Table 1: Standard Charges,,,,,,,,,,,,,,,
Last Updated 03/09/2022,,,,,,,,,,,,,,,
Facility ID,Charge Code, Description,NDC/Supply ID,CPT(R)/HCPCS Code, Revenue Code,Gross charge/ unit,Cash Price,Min Allowable,Max Allowable,Aetna Rental Network (IP/OP),Health Alliance Carle EP (IP/OP),Healthlink (IP/OP),HFN Zelis Platinum (IP/OP),HFN/Zelis PPO (IP/OP),Multiplan/ PHCS (OP)
Carle BroMenn Medical Center,8010110,PRIVATE ROOM,,,110,"$2,000.00 ","$2,000.00 ",$600.00 ,"$1,820.00 ","$1,400.00 ",$600.00 ,"$1,300.00 ","$1,440.00 ","$1,820.00 ","$1,500.00 "
Carle BroMenn Medical Center,8011110,PRIVATE ROOM,,,110,"$1,590.00 ","$1,590.00 ",$477.00 ,"$1,446.90 ","$1,113.00 ",$477.00 ,"$1,033.50 ","$1,144.80 ","$1,446.90 ","$1,192.50 "
Carle BroMenn Medical Center,8012110,PRIVATE ROOM CBMC ACUTE REHAB,,,110,"$1,200.00 ","$1,200.00 ",$360.00 ,"$1,092.00 ",$840.00 ,$360.00 ,$780.00 ,$864.00 ,"$1,092.00 ",$900.00 
Carle BroMenn Medical Center,8014110,PRIVATE ROOM,,,110,"$2,678.00 ","$2,678.00 ",$803.40 ,"$2,436.98 ","$1,874.60 ",$803.40 ,"$1,740.70 ","$1,928.16 ","$2,436.98 ","$2,008.50 "
Carle BroMenn Medical Center,8016110,PRIVATE ROOM CBMC ADDICTION RECOVERY,,,110,"$1,260.00 ","$1,260.00 ",$378.00 ,"$1,146.60 ",$882.00 ,$378.00 ,$819.00 ,$907.20 ,"$1,146.60 ",$945.00 
Carle BroMenn Medical Center,8000120,SWINGBED SEMI-PRIVATE,,,120,$220.00 ,$220.00 ,$66.00 ,$200.20 ,$154.00 ,$66.00 ,$143.00 ,$158.40 ,$200.20 ,$165.00 
Carle BroMenn Medical Center,8010120,SEMI-PRIVATE CBMC ADDICTION RECOVERY,,,120,"$1,260.00 ","$1,260.00 ",$378.00 ,"$1,146.60 ",$882.00 ,$378.00 ,$819.00 ,$907.20 ,"$1,146.60 ",$945.00 
Carle BroMenn Medical Center,8011120,SEMI-PRIVATE,,,120,"$2,000.00 ","$2,000.00 ",$600.00 ,"$1,820.00 ","$1,400.00 ",$600.00 ,"$1,300.00 ","$1,440.00 ","$1,820.00 ","$1,500.00 "
Carle BroMenn Medical Center,8012120,SEMI-PRIVATE OB,,,120,"$1,493.00 ","$1,493.00 ",$447.90 ,"$1,358.63 ","$1,045.10 ",$447.90 ,$970.45 ,"$1,074.96 ","$1,358.63 ","$1,119.75 "
Carle BroMenn Medical Center,8015120,SEMI-PRIVATE CBMC ACUTE REHAB,,,120,"$1,200.00 ","$1,200.00 ",$360.00 ,"$1,092.00 ",$840.00 ,$360.00 ,$780.00 ,$864.00 ,"$1,092.00 ",$900.00 
Carle BroMenn Medical Center,8019120,L1 SEMI PRV FLR,,,120,"$1,733.00 ","$1,733.00 ",$519.90 ,"$1,577.03 ","$1,213.10 ",$519.90 ,"$1,126.45 ","$1,247.76 ","$1,577.03 ","$1,299.75 "
Carle BroMenn Medical Center,8001170,LVL 2 NICU/NEONATE/PEDS,,,170,"$2,063.00 ","$2,063.00 ",$618.90 ,"$1,877.33 ","$1,444.10 ",$618.90 ,"$1,340.95 ","$1,485.36 ","$1,877.33 ","$1,547.25 "
Carle BroMenn Medical Center,8002170,LVL 3 NICU/NEONATE/PEDS,,,170,"$3,390.00 ","$3,390.00 ","$1,017.00 ","$3,084.90 ","$2,373.00 ","$1,017.00 ","$2,203.50 ","$2,440.80 ","$3,084.90 ","$2,542.50 "
Carle BroMenn Medical Center,8012170,L2 NICU/NURSERY/PEDS ROOM,,,170,"$5,000.00 ","$5,000.00 ","$1,500.00 ","$4,550.00 ","$3,500.00 ","$1,500.00 ","$3,250.00 ","$3,600.00 ","$4,550.00 ","$3,750.00 "
Carle BroMenn Medical Center,8018170,NURSERY ROOM CHARGE,,,170,"$3,500.00 ","$3,500.00 ","$1,050.00 ","$3,185.00 ","$2,450.00 ","$1,050.00 ","$2,275.00 ","$2,520.00 ","$3,185.00 ","$2,625.00 "
Carle BroMenn Medical Center,8019170,TRANSITION NURSERY,,,170,"$1,785.00 ","$1,785.00 ",$535.50 ,"$1,624.35 ","$1,249.50 ",$535.50 ,"$1,160.25 ","$1,285.20 ","$1,624.35 ","$1,338.75 "
Carle BroMenn Medical Center,8000200,ICU,,,200,"$4,000.00 ","$4,000.00 ","$1,200.00 ","$3,640.00 ","$2,800.00 ","$1,200.00 ","$2,600.00 ","$2,880.00 ","$3,640.00 ","$3,000.00 "
Carle BroMenn Medical Center,8011200,L1 CVCU INTNSV,,,200,"$4,410.00 ","$4,410.00 ","$1,323.00 ","$4,013.10 ","$3,087.00 ","$1,323.00 ","$2,866.50 ","$3,175.20 ","$4,013.10 ","$3,307.50 "
Carle BroMenn Medical Center,8012200,L2 CVCU INTNSV,,,200,"$6,195.00 ","$6,195.00 ","$1,858.50 ","$5,637.45 ","$4,336.50 ","$1,858.50 ","$4,026.75 ","$4,460.40 ","$5,637.45 ","$4,646.25 "
Carle BroMenn Medical Center,8013200,L3 CVCU INTNSV,,,200,"$8,910.00 ","$8,910.00 ","$2,673.00 ","$8,108.10 ","$6,237.00 ","$2,673.00 ","$5,791.50 ","$6,415.20 ","$8,108.10 ","$6,682.50 "
Carle BroMenn Medical Center,8014200,L1 SICU INTNSV,,,200,"$4,680.00 ","$4,680.00 ","$1,404.00 ","$4,258.80 ","$3,276.00 ","$1,404.00 ","$3,042.00 ","$3,369.60 ","$4,258.80 ","$3,510.00 "
Carle BroMenn Medical Center,8015200,L2 SICU INTNSV,,,200,"$6,413.00 ","$6,413.00 ","$1,923.90 ","$5,835.83 ","$4,489.10 ","$1,923.90 ","$4,168.45 ","$4,617.36 ","$5,835.83 ","$4,809.75 "
Carle BroMenn Medical Center,8016200,L3 SICU INTNSV,,,200,"$9,255.00 ","$9,255.00 ","$2,776.50 ","$8,422.05 ","$6,478.50 ","$2,776.50 ","$6,015.75 ","$6,663.60 ","$8,422.05 ","$6,941.25 "
Carle BroMenn Medical Center,8017200,L1 IMCU INTNSV,,,200,"$4,680.00 ","$4,680.00 ","$1,404.00 ","$4,258.80 ","$3,276.00 ","$1,404.00 ","$3,042.00 ","$3,369.60 ","$4,258.80 ","$3,510.00 "
Carle BroMenn Medical Center,8018200,L1 PAR INTNSV,,,200,"$4,680.00 ","$4,680.00 ","$1,404.00 ","$4,258.80 ","$3,276.00 ","$1,404.00 ","$3,042.00 ","$3,369.60 ","$4,258.80 ","$3,510.00 "
Carle BroMenn Medical Center,8019200,L2 IMCU INTNSV,,,200,"$6,413.00 ","$6,413.00 ","$1,923.90 ","$5,835.83 ","$4,489.10 ","$1,923.90 ","$4,168.45 ","$4,617.36 ","$5,835.83 ","$4,809.75 "
Carle BroMenn Medical Center,8019201,L3 IMCU INTNSV,,,200,"$9,255.00 ","$9,255.00 ","$2,776.50 ","$8,422.05 ","$6,478.50 ","$2,776.50 ","$6,015.75 ","$6,663.60 ","$8,422.05 ","$6,941.25 "
Carle BroMenn Medical Center,8030050,NITROUS OXIDE,,,250,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8160003,ANESTHESIA MEDICATION,,,250,$143.00 ,$143.00 ,$42.90 ,$130.13 ,$100.10 ,$42.90 ,$92.95 ,$102.96 ,$130.13 ,$107.25 
Carle BroMenn Medical Center,8160005,OR ANESTHESIA MEDICATIONS 1,,,250,$146.00 ,$146.00 ,$43.80 ,$132.86 ,$102.20 ,$43.80 ,$94.90 ,$105.12 ,$132.86 ,$109.50 
Carle BroMenn Medical Center,8160013,SEVOFLURANE,,,250,$1.00 ,$1.00 ,$0.30 ,$0.91 ,$0.70 ,$0.30 ,$0.65 ,$0.72 ,$0.91 ,$0.75 
Carle BroMenn Medical Center,8160014,ISOFLURANE,,,250,$24.00 ,$24.00 ,$7.20 ,$21.84 ,$16.80 ,$7.20 ,$15.60 ,$17.28 ,$21.84 ,$18.00 
Carle BroMenn Medical Center,8160015,NITROUS OXIDE,,,250,$1.00 ,$1.00 ,$0.30 ,$0.91 ,$0.70 ,$0.30 ,$0.65 ,$0.72 ,$0.91 ,$0.75 
Carle BroMenn Medical Center,8160017,DESFLURANE,,,250,$2.14 ,$2.14 ,$0.64 ,$1.95 ,$1.50 ,$0.64 ,$1.39 ,$1.54 ,$1.95 ,$1.61 
Carle BroMenn Medical Center,8160018,BCCS SURG DRUG BUNDLE 1,,,250,"$1,900.00 ","$1,900.00 ",$570.00 ,"$1,729.00 ","$1,330.00 ",$570.00 ,"$1,235.00 ","$1,368.00 ","$1,729.00 ","$1,425.00 "
Carle BroMenn Medical Center,8160019,BCCS SURG DRUG BUNDLE 2,,,250,$955.00 ,$955.00 ,$286.50 ,$869.05 ,$668.50 ,$286.50 ,$620.75 ,$687.60 ,$869.05 ,$716.25 
Carle BroMenn Medical Center,8299605,"MEDICATION THERAPY, FACE TO FACE, 1ST 15 MIN NEW PATIENT",,99605,250,$64.00 ,$64.00 ,$19.20 ,$58.24 ,$44.80 ,$19.20 ,$41.60 ,$46.08 ,$58.24 ,$48.00 
Carle BroMenn Medical Center,8299606,"MEDICATION THERAPY, FACE TO FACE, 1ST 15 MIN ESTABLISHED PT",,99606,250,$64.00 ,$64.00 ,$19.20 ,$58.24 ,$44.80 ,$19.20 ,$41.60 ,$46.08 ,$58.24 ,$48.00 
Carle BroMenn Medical Center,8299607,"MEDICATION THERAPY, FACE TO FACE, EA ADDITIONAL 15 MIN",,99607,250,$64.00 ,$64.00 ,$19.20 ,$58.24 ,$44.80 ,$19.20 ,$41.60 ,$46.08 ,$58.24 ,$48.00 
Carle BroMenn Medical Center,8650041,NEO NITRIC OXIDE THERAPY/HOUR,,,250,$420.00 ,$420.00 ,$126.00 ,$382.20 ,$294.00 ,$126.00 ,$273.00 ,$302.40 ,$382.20 ,$315.00 
Carle BroMenn Medical Center,8670001,BENZOIN,,,250,$5.00 ,$5.00 ,$1.50 ,$4.55 ,$3.50 ,$1.50 ,$3.25 ,$3.60 ,$4.55 ,$3.75 
Carle BroMenn Medical Center,8670006,500 ML/1000 U HEPARIN,,,250,$17.00 ,$17.00 ,$5.10 ,$15.47 ,$11.90 ,$5.10 ,$11.05 ,$12.24 ,$15.47 ,$12.75 
Carle BroMenn Medical Center,8670026,ATROPINE/ATNOVENT,,,250,$6.00 ,$6.00 ,$1.80 ,$5.46 ,$4.20 ,$1.80 ,$3.90 ,$4.32 ,$5.46 ,$4.50 
Carle BroMenn Medical Center,8670030,BRETHINE,,,250,$9.00 ,$9.00 ,$2.70 ,$8.19 ,$6.30 ,$2.70 ,$5.85 ,$6.48 ,$8.19 ,$6.75 
Carle BroMenn Medical Center,8670031,BRONKOSOL,,,250,$5.00 ,$5.00 ,$1.50 ,$4.55 ,$3.50 ,$1.50 ,$3.25 ,$3.60 ,$4.55 ,$3.75 
Carle BroMenn Medical Center,8670032,BRONKOSOL,,,250,$9.00 ,$9.00 ,$2.70 ,$8.19 ,$6.30 ,$2.70 ,$5.85 ,$6.48 ,$8.19 ,$6.75 
Carle BroMenn Medical Center,8670104,INHAL-AID,,,250,$71.00 ,$71.00 ,$21.30 ,$64.61 ,$49.70 ,$21.30 ,$46.15 ,$51.12 ,$64.61 ,$53.25 
Carle BroMenn Medical Center,8670105,INHAL-AID,,,250,$72.00 ,$72.00 ,$21.60 ,$65.52 ,$50.40 ,$21.60 ,$46.80 ,$51.84 ,$65.52 ,$54.00 
Carle BroMenn Medical Center,8670106,INSPIR-EASE,,,250,$42.00 ,$42.00 ,$12.60 ,$38.22 ,$29.40 ,$12.60 ,$27.30 ,$30.24 ,$38.22 ,$31.50 
Carle BroMenn Medical Center,8670107,INTAL,,,250,$6.00 ,$6.00 ,$1.80 ,$5.46 ,$4.20 ,$1.80 ,$3.90 ,$4.32 ,$5.46 ,$4.50 
Carle BroMenn Medical Center,8670123,MUCOMYST,,,250,$20.00 ,$20.00 ,$6.00 ,$18.20 ,$14.00 ,$6.00 ,$13.00 ,$14.40 ,$18.20 ,$15.00 
Carle BroMenn Medical Center,8670124,MUCOMYST-BOTTLE,,,250,$38.00 ,$38.00 ,$11.40 ,$34.58 ,$26.60 ,$11.40 ,$24.70 ,$27.36 ,$34.58 ,$28.50 
Carle BroMenn Medical Center,8670144,ROBINUL,,,250,$26.00 ,$26.00 ,$7.80 ,$23.66 ,$18.20 ,$7.80 ,$16.90 ,$18.72 ,$23.66 ,$19.50 
Carle BroMenn Medical Center,8670181,VENTOLIN/ALBUTEROL,,,250,$5.00 ,$5.00 ,$1.50 ,$4.55 ,$3.50 ,$1.50 ,$3.25 ,$3.60 ,$4.55 ,$3.75 
Carle BroMenn Medical Center,8980250,"acamprosate 333 mg tablet,delayed release",68382056928,,250,$10.52 ,$10.52 ,$3.16 ,$9.57 ,$7.36 ,$3.16 ,$6.84 ,$7.57 ,$9.57 ,$7.89 
Carle BroMenn Medical Center,8980250,acetaminophen 120 mg rectal suppository,45802073200,J3490,250,$0.82 ,$0.82 ,$0.25 ,$0.75 ,$0.57 ,$0.25 ,$0.53 ,$0.59 ,$0.75 ,$0.62 
Carle BroMenn Medical Center,8980250,acetaminophen 120 mg rectal suppository,45802073230,J3490,250,$0.82 ,$0.82 ,$0.25 ,$0.75 ,$0.57 ,$0.25 ,$0.53 ,$0.59 ,$0.75 ,$0.62 
Carle BroMenn Medical Center,8980250,acetaminophen 160 mg/5 mL (5 mL) oral suspension,121178100,,250,$1.95 ,$1.95 ,$0.59 ,$1.77 ,$1.37 ,$0.59 ,$1.27 ,$1.40 ,$1.77 ,$1.46 
Carle BroMenn Medical Center,8980250,acetaminophen 160 mg/5 mL (5 mL) oral suspension,121178105,,250,$1.95 ,$1.95 ,$0.59 ,$1.77 ,$1.37 ,$0.59 ,$1.27 ,$1.40 ,$1.77 ,$1.46 
Carle BroMenn Medical Center,8980250,acetaminophen 300 mg-codeine 30 mg tablet,406048423,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,acetaminophen 300 mg-codeine 30 mg tablet,406048462,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,acetaminophen 300 mg-codeine 30 mg/12.5 mL (12.5 mL) oral solution,121100800,,250,$12.82 ,$12.82 ,$3.85 ,$11.67 ,$8.97 ,$3.85 ,$8.33 ,$9.23 ,$11.67 ,$9.62 
Carle BroMenn Medical Center,8980250,acetaminophen 300 mg-codeine 30 mg/12.5 mL (12.5 mL) oral solution,121100812,,250,$12.82 ,$12.82 ,$3.85 ,$11.67 ,$8.97 ,$3.85 ,$8.33 ,$9.23 ,$11.67 ,$9.62 
Carle BroMenn Medical Center,8980250,acetaminophen 300 mg-codeine 30 mg/12.5 mL (12.5 mL) oral solution,50383033912,,250,$13.16 ,$13.16 ,$3.95 ,$11.98 ,$9.21 ,$3.95 ,$8.55 ,$9.48 ,$11.98 ,$9.87 
Carle BroMenn Medical Center,8980250,acetaminophen 300 mg-codeine 30 mg/12.5 mL (12.5 mL) oral solution,50383033913,,250,$13.16 ,$13.16 ,$3.95 ,$11.98 ,$9.21 ,$3.95 ,$8.55 ,$9.48 ,$11.98 ,$9.87 
Carle BroMenn Medical Center,8980250,acetaminophen 32 mg/mL oral syringe  (FOR ORAL USE ONLY),68094058658,,250,$9.51 ,$9.51 ,$2.85 ,$8.65 ,$6.66 ,$2.85 ,$6.18 ,$6.85 ,$8.65 ,$7.13 
Carle BroMenn Medical Center,8980250,acetaminophen 325 mg rectal suppository,51672211600,,250,$1.12 ,$1.12 ,$0.34 ,$1.02 ,$0.78 ,$0.34 ,$0.73 ,$0.81 ,$1.02 ,$0.84 
Carle BroMenn Medical Center,8980250,acetaminophen 325 mg rectal suppository,51672211602,,250,$1.12 ,$1.12 ,$0.34 ,$1.02 ,$0.78 ,$0.34 ,$0.73 ,$0.81 ,$1.02 ,$0.84 
Carle BroMenn Medical Center,8980250,acetaminophen 325 mg tablet,904677361,J3490,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,acetaminophen 325 mg tablet,50580045811,J3490,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,acetaminophen 325 mg tablet,69618001001,J3490,250,$2.40 ,$2.40 ,$0.72 ,$2.18 ,$1.68 ,$0.72 ,$1.56 ,$1.73 ,$2.18 ,$1.80 
Carle BroMenn Medical Center,8980250,acetaminophen 325 mg/10.15 mL oral solution,121131400,,250,$3.06 ,$3.06 ,$0.92 ,$2.78 ,$2.14 ,$0.92 ,$1.99 ,$2.20 ,$2.78 ,$2.30 
Carle BroMenn Medical Center,8980250,acetaminophen 325 mg/10.15 mL oral solution,121131411,,250,$3.06 ,$3.06 ,$0.92 ,$2.78 ,$2.14 ,$0.92 ,$1.99 ,$2.20 ,$2.78 ,$2.30 
Carle BroMenn Medical Center,8980250,acetaminophen 325 mg/10.15 mL oral solution,60687057142,,250,$2.69 ,$2.69 ,$0.81 ,$2.45 ,$1.88 ,$0.81 ,$1.75 ,$1.94 ,$2.45 ,$2.02 
Carle BroMenn Medical Center,8980250,acetaminophen 325 mg/10.15 mL oral solution,60687057156,,250,$2.69 ,$2.69 ,$0.81 ,$2.45 ,$1.88 ,$0.81 ,$1.75 ,$1.94 ,$2.45 ,$2.02 
Carle BroMenn Medical Center,8980250,acetaminophen 325 mg/10.15 mL oral solution,66689005501,,250,$3.57 ,$3.57 ,$1.07 ,$3.25 ,$2.50 ,$1.07 ,$2.32 ,$2.57 ,$3.25 ,$2.68 
Carle BroMenn Medical Center,8980250,acetaminophen 325 mg/10.15 mL oral solution,66689005599,,250,$3.57 ,$3.57 ,$1.07 ,$3.25 ,$2.50 ,$1.07 ,$2.32 ,$2.57 ,$3.25 ,$2.68 
Carle BroMenn Medical Center,8980250,acetaminophen 500 mg tablet,904672059,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,acetaminophen 500 mg tablet,904673059,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,acetaminophen 500 mg tablet,904673061,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,acetaminophen 500 mg tablet,50580041202,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,acetaminophen 500 mg tablet,50580045711,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,acetaminophen 650 mg rectal suppository,45802073033,,250,$0.60 ,$0.60 ,$0.18 ,$0.55 ,$0.42 ,$0.18 ,$0.39 ,$0.43 ,$0.55 ,$0.45 
Carle BroMenn Medical Center,8980250,acetaminophen 650 mg/20.3 mL oral solution,904682076,,250,$2.97 ,$2.97 ,$0.89 ,$2.70 ,$2.08 ,$0.89 ,$1.93 ,$2.14 ,$2.70 ,$2.23 
Carle BroMenn Medical Center,8980250,acetaminophen 80 mg rectal suppository,51672211400,,250,$1.12 ,$1.12 ,$0.34 ,$1.02 ,$0.78 ,$0.34 ,$0.73 ,$0.81 ,$1.02 ,$0.84 
Carle BroMenn Medical Center,8980250,acetaminophen 80 mg rectal suppository,51672211402,,250,$1.12 ,$1.12 ,$0.34 ,$1.02 ,$0.78 ,$0.34 ,$0.73 ,$0.81 ,$1.02 ,$0.84 
Carle BroMenn Medical Center,8980250,acetaZOLAMIDE 250 mg tablet,527105001,,250,$17.68 ,$17.68 ,$5.30 ,$16.09 ,$12.38 ,$5.30 ,$11.49 ,$12.73 ,$16.09 ,$13.26 
Carle BroMenn Medical Center,8980250,acetaZOLAMIDE 250 mg tablet,23155028801,,250,$4.29 ,$4.29 ,$1.29 ,$3.90 ,$3.00 ,$1.29 ,$2.79 ,$3.09 ,$3.90 ,$3.22 
Carle BroMenn Medical Center,8980250,acetaZOLAMIDE 250 mg tablet,64380083406,,250,$15.23 ,$15.23 ,$4.57 ,$13.86 ,$10.66 ,$4.57 ,$9.90 ,$10.97 ,$13.86 ,$11.42 
Carle BroMenn Medical Center,8980250,activated charcoaL 25 gram/120 mL oral suspension,574012104,,250,$80.06 ,$80.06 ,$24.02 ,$72.85 ,$56.04 ,$24.02 ,$52.04 ,$57.64 ,$72.85 ,$60.05 
Carle BroMenn Medical Center,8980250,activated charcoaL 25 gram/120 mL oral suspension,574012174,,250,$80.06 ,$80.06 ,$24.02 ,$72.85 ,$56.04 ,$24.02 ,$52.04 ,$57.64 ,$72.85 ,$60.05 
Carle BroMenn Medical Center,8980250,activated charcoaL 25 gram/120 mL oral suspension,574052104,,250,$80.06 ,$80.06 ,$24.02 ,$72.85 ,$56.04 ,$24.02 ,$52.04 ,$57.64 ,$72.85 ,$60.05 
Carle BroMenn Medical Center,8980250,activated charcoaL 25 gram/120 mL oral suspension,574052174,,250,$80.06 ,$80.06 ,$24.02 ,$72.85 ,$56.04 ,$24.02 ,$52.04 ,$57.64 ,$72.85 ,$60.05 
Carle BroMenn Medical Center,8980250,activated charcoaL 25 gram/120 mL oral suspension,66689020204,,250,$140.45 ,$140.45 ,$42.14 ,$127.81 ,$98.32 ,$42.14 ,$91.29 ,$101.12 ,$127.81 ,$105.34 
Carle BroMenn Medical Center,8980250,activated charcoal-sorbitoL 25 gram/120 mL oral suspension,574012004,,250,$80.06 ,$80.06 ,$24.02 ,$72.85 ,$56.04 ,$24.02 ,$52.04 ,$57.64 ,$72.85 ,$60.05 
Carle BroMenn Medical Center,8980250,activated charcoal-sorbitoL 25 gram/120 mL oral suspension,574052004,,250,$80.06 ,$80.06 ,$24.02 ,$72.85 ,$56.04 ,$24.02 ,$52.04 ,$57.64 ,$72.85 ,$60.05 
Carle BroMenn Medical Center,8980250,acyclovir 200 mg capsule,904578961,,250,$9.46 ,$9.46 ,$2.84 ,$8.61 ,$6.62 ,$2.84 ,$6.15 ,$6.81 ,$8.61 ,$7.10 
Carle BroMenn Medical Center,8980250,acyclovir 200 mg/5 mL oral suspension,472008216,,250,$12.39 ,$12.39 ,$3.72 ,$11.27 ,$8.67 ,$3.72 ,$8.05 ,$8.92 ,$11.27 ,$9.29 
Carle BroMenn Medical Center,8980250,acyclovir 200 mg/5 mL oral suspension,50383081016,,250,$12.39 ,$12.39 ,$3.72 ,$11.27 ,$8.67 ,$3.72 ,$8.05 ,$8.92 ,$11.27 ,$9.29 
Carle BroMenn Medical Center,8980250,acyclovir 800 mg tablet,60505530701,,250,$21.98 ,$21.98 ,$6.59 ,$20.00 ,$15.39 ,$6.59 ,$14.29 ,$15.83 ,$20.00 ,$16.49 
Carle BroMenn Medical Center,8980250,albuterol sulfate HFA 90 mcg/actuation aerosol inhaler,93317431,,250,$365.89 ,$365.89 ,$109.77 ,$332.96 ,$256.12 ,$109.77 ,$237.83 ,$263.44 ,$332.96 ,$274.42 
Carle BroMenn Medical Center,8980250,albuterol sulfate HFA 90 mcg/actuation aerosol inhaler,173068224,,250,$144.33 ,$144.33 ,$43.30 ,$131.34 ,$101.03 ,$43.30 ,$93.81 ,$103.92 ,$131.34 ,$108.25 
Carle BroMenn Medical Center,8980250,albuterol sulfate HFA 90 mcg/actuation aerosol inhaler,781729685,,250,$230.56 ,$230.56 ,$69.17 ,$209.81 ,$161.39 ,$69.17 ,$149.86 ,$166.00 ,$209.81 ,$172.92 
Carle BroMenn Medical Center,8980250,albuterol sulfate HFA 90 mcg/actuation aerosol inhaler,59310057922,J3490,250,$417.07 ,$417.07 ,$125.12 ,$379.53 ,$291.95 ,$125.12 ,$271.10 ,$300.29 ,$379.53 ,$312.80 
Carle BroMenn Medical Center,8980250,albuterol sulfate HFA 90 mcg/actuation aerosol inhaler,68180096301,,250,$365.89 ,$365.89 ,$109.77 ,$332.96 ,$256.12 ,$109.77 ,$237.83 ,$263.44 ,$332.96 ,$274.42 
Carle BroMenn Medical Center,8980250,allopurinoL 100 mg tablet,29300034901,,250,$4.58 ,$4.58 ,$1.37 ,$4.17 ,$3.21 ,$1.37 ,$2.98 ,$3.30 ,$4.17 ,$3.44 
Carle BroMenn Medical Center,8980250,allopurinoL 100 mg tablet,51079020501,,250,$4.09 ,$4.09 ,$1.23 ,$3.72 ,$2.86 ,$1.23 ,$2.66 ,$2.94 ,$3.72 ,$3.07 
Carle BroMenn Medical Center,8980250,allopurinoL 100 mg tablet,51079020520,,250,$4.09 ,$4.09 ,$1.23 ,$3.72 ,$2.86 ,$1.23 ,$2.66 ,$2.94 ,$3.72 ,$3.07 
Carle BroMenn Medical Center,8980250,allopurinoL 100 mg tablet,63739041010,,250,$3.72 ,$3.72 ,$1.12 ,$3.39 ,$2.60 ,$1.12 ,$2.42 ,$2.68 ,$3.39 ,$2.79 
Carle BroMenn Medical Center,8980250,allopurinoL 300 mg tablet,62584071301,,250,$6.72 ,$6.72 ,$2.02 ,$6.12 ,$4.70 ,$2.02 ,$4.37 ,$4.84 ,$6.12 ,$5.04 
Carle BroMenn Medical Center,8980250,allopurinoL 300 mg tablet,62584071311,,250,$6.72 ,$6.72 ,$2.02 ,$6.12 ,$4.70 ,$2.02 ,$4.37 ,$4.84 ,$6.12 ,$5.04 
Carle BroMenn Medical Center,8980250,allopurinoL 300 mg tablet,63739079610,,250,$5.17 ,$5.17 ,$1.55 ,$4.70 ,$3.62 ,$1.55 ,$3.36 ,$3.72 ,$4.70 ,$3.88 
Carle BroMenn Medical Center,8980250,ALPRAZolam 0.25 mg tablet,228202710,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,ALPRAZolam 0.25 mg tablet,51991070401,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,ALPRAZolam 0.25 mg tablet,59762371901,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,ALPRAZolam 0.5 mg tablet,228202910,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,ALPRAZolam 0.5 mg tablet,51991070501,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,ALPRAZolam 0.5 mg tablet,59762372001,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,ALPRAZolam 0.5 mg tablet,65862067701,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,ALPRAZolam 1 mg tablet,904586061,,250,$6.51 ,$6.51 ,$1.95 ,$5.92 ,$4.56 ,$1.95 ,$4.23 ,$4.69 ,$5.92 ,$4.88 
Carle BroMenn Medical Center,8980250,ALPRAZolam 1 mg tablet,59762372101,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,aluminum-mag hydroxide-simethicone 200 mg-200 mg-20 mg/5 mL oral susp,121176130,,250,$5.29 ,$5.29 ,$1.59 ,$4.81 ,$3.70 ,$1.59 ,$3.44 ,$3.81 ,$4.81 ,$3.97 
Carle BroMenn Medical Center,8980250,aluminum-mag hydroxide-simethicone 200 mg-200 mg-20 mg/5 mL oral susp,904572114,,250,$17.47 ,$17.47 ,$5.24 ,$15.90 ,$12.23 ,$5.24 ,$11.36 ,$12.58 ,$15.90 ,$13.10 
Carle BroMenn Medical Center,8980250,aluminum-mag hydroxide-simethicone 200 mg-200 mg-20 mg/5 mL oral susp,46122043340,,250,$17.47 ,$17.47 ,$5.24 ,$15.90 ,$12.23 ,$5.24 ,$11.36 ,$12.58 ,$15.90 ,$13.10 
Carle BroMenn Medical Center,8980250,aluminum-mag hydroxide-simethicone 200 mg-200 mg-20 mg/5 mL oral susp,57896062912,,250,$17.47 ,$17.47 ,$5.24 ,$15.90 ,$12.23 ,$5.24 ,$11.36 ,$12.58 ,$15.90 ,$13.10 
Carle BroMenn Medical Center,8980250,aluminum-mag hydroxide-simethicone 200 mg-200 mg-20 mg/5 mL oral susp,87701042974,,250,$17.47 ,$17.47 ,$5.24 ,$15.90 ,$12.23 ,$5.24 ,$11.36 ,$12.58 ,$15.90 ,$13.10 
Carle BroMenn Medical Center,8980250,amantadine HCL 100 mg capsule,62332024631,,250,$11.36 ,$11.36 ,$3.41 ,$10.34 ,$7.95 ,$3.41 ,$7.38 ,$8.18 ,$10.34 ,$8.52 
Carle BroMenn Medical Center,8980250,amantadine HCL 100 mg capsule,68382051201,,250,$11.74 ,$11.74 ,$3.52 ,$10.68 ,$8.22 ,$3.52 ,$7.63 ,$8.45 ,$10.68 ,$8.81 
Carle BroMenn Medical Center,8980250,aMILoride 5 mg tablet,574029201,,250,$3.57 ,$3.57 ,$1.07 ,$3.25 ,$2.50 ,$1.07 ,$2.32 ,$2.57 ,$3.25 ,$2.68 
Carle BroMenn Medical Center,8980250,amino acid 5 % in 20 % dextrose intravenous solution,338110104,,250,$570.39 ,$570.39 ,$171.12 ,$519.05 ,$399.27 ,$171.12 ,$370.75 ,$410.68 ,$519.05 ,$427.79 
Carle BroMenn Medical Center,8980250,amino acid 5 % in 20 % dextrose intravenous solution,338113803,,250,$325.95 ,$325.95 ,$97.79 ,$296.61 ,$228.17 ,$97.79 ,$211.87 ,$234.68 ,$296.61 ,$244.46 
Carle BroMenn Medical Center,8980250,aminocaproic acid 250 mg/mL intravenous solution,409434673,,250,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980250,aminocaproic acid 250 mg/mL intravenous solution,517912001,,250,$97.81 ,$97.81 ,$29.34 ,$89.01 ,$68.47 ,$29.34 ,$63.58 ,$70.42 ,$89.01 ,$73.36 
Carle BroMenn Medical Center,8980250,aminocaproic acid 250 mg/mL intravenous solution,517912025,,250,$97.81 ,$97.81 ,$29.34 ,$89.01 ,$68.47 ,$29.34 ,$63.58 ,$70.42 ,$89.01 ,$73.36 
Carle BroMenn Medical Center,8980250,amiodarone 200 mg tablet,245014789,,250,$35.95 ,$35.95 ,$10.79 ,$32.71 ,$25.17 ,$10.79 ,$23.37 ,$25.88 ,$32.71 ,$26.96 
Carle BroMenn Medical Center,8980250,amiodarone 200 mg tablet,904655661,,250,$5.08 ,$5.08 ,$1.52 ,$4.62 ,$3.56 ,$1.52 ,$3.30 ,$3.66 ,$4.62 ,$3.81 
Carle BroMenn Medical Center,8980250,amiodarone 200 mg tablet,60687043701,,250,$5.15 ,$5.15 ,$1.55 ,$4.69 ,$3.61 ,$1.55 ,$3.35 ,$3.71 ,$4.69 ,$3.86 
Carle BroMenn Medical Center,8980250,amiodarone 200 mg tablet,60687043711,,250,$5.15 ,$5.15 ,$1.55 ,$4.69 ,$3.61 ,$1.55 ,$3.35 ,$3.71 ,$4.69 ,$3.86 
Carle BroMenn Medical Center,8980250,amiodarone 200 mg tablet,65862073260,,250,$18.09 ,$18.09 ,$5.43 ,$16.46 ,$12.66 ,$5.43 ,$11.76 ,$13.02 ,$16.46 ,$13.57 
Carle BroMenn Medical Center,8980250,amiodarone 200 mg tablet,68084037101,,250,$5.15 ,$5.15 ,$1.55 ,$4.69 ,$3.61 ,$1.55 ,$3.35 ,$3.71 ,$4.69 ,$3.86 
Carle BroMenn Medical Center,8980250,amitriptyline 10 mg tablet,16729017101,,250,$3.81 ,$3.81 ,$1.14 ,$3.47 ,$2.67 ,$1.14 ,$2.48 ,$2.74 ,$3.47 ,$2.86 
Carle BroMenn Medical Center,8980250,amitriptyline 10 mg tablet,51079013101,,250,$3.81 ,$3.81 ,$1.14 ,$3.47 ,$2.67 ,$1.14 ,$2.48 ,$2.74 ,$3.47 ,$2.86 
Carle BroMenn Medical Center,8980250,amitriptyline 10 mg tablet,51079013120,,250,$3.81 ,$3.81 ,$1.14 ,$3.47 ,$2.67 ,$1.14 ,$2.48 ,$2.74 ,$3.47 ,$2.86 
Carle BroMenn Medical Center,8980250,amitriptyline 25 mg tablet,60687043301,,250,$4.73 ,$4.73 ,$1.42 ,$4.30 ,$3.31 ,$1.42 ,$3.07 ,$3.41 ,$4.30 ,$3.55 
Carle BroMenn Medical Center,8980250,amitriptyline 25 mg tablet,60687043311,,250,$4.73 ,$4.73 ,$1.42 ,$4.30 ,$3.31 ,$1.42 ,$3.07 ,$3.41 ,$4.30 ,$3.55 
Carle BroMenn Medical Center,8980250,amLODIPine 10 mg tablet,904637161,,250,$12.84 ,$12.84 ,$3.85 ,$11.68 ,$8.99 ,$3.85 ,$8.35 ,$9.24 ,$11.68 ,$9.63 
Carle BroMenn Medical Center,8980250,amLODIPine 10 mg tablet,60687049601,,250,$3.21 ,$3.21 ,$0.96 ,$2.92 ,$2.25 ,$0.96 ,$2.09 ,$2.31 ,$2.92 ,$2.41 
Carle BroMenn Medical Center,8980250,amLODIPine 10 mg tablet,60687049611,,250,$3.21 ,$3.21 ,$0.96 ,$2.92 ,$2.25 ,$0.96 ,$2.09 ,$2.31 ,$2.92 ,$2.41 
Carle BroMenn Medical Center,8980250,amLODIPine 10 mg tablet,63739063110,,250,$2.87 ,$2.87 ,$0.86 ,$2.61 ,$2.01 ,$0.86 ,$1.87 ,$2.07 ,$2.61 ,$2.15 
Carle BroMenn Medical Center,8980250,amLODIPine 5 mg tablet,904637061,,250,$9.99 ,$9.99 ,$3.00 ,$9.09 ,$6.99 ,$3.00 ,$6.49 ,$7.19 ,$9.09 ,$7.49 
Carle BroMenn Medical Center,8980250,amLODIPine 5 mg tablet,60687048811,,250,$3.21 ,$3.21 ,$0.96 ,$2.92 ,$2.25 ,$0.96 ,$2.09 ,$2.31 ,$2.92 ,$2.41 
Carle BroMenn Medical Center,8980250,ammonia aromatic 15 % (w/v) solution for inhalation,16784014012,J3490,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,ammonia aromatic 15 % (w/v) solution for inhalation,39822990001,J3490,250,$0.75 ,$0.75 ,$0.23 ,$0.68 ,$0.53 ,$0.23 ,$0.49 ,$0.54 ,$0.68 ,$0.56 
Carle BroMenn Medical Center,8980250,ammonia aromatic 15 % (w/v) solution for inhalation,67777025101,J3490,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,amoxicillin 250 mg capsule,57237003001,,250,$3.50 ,$3.50 ,$1.05 ,$3.19 ,$2.45 ,$1.05 ,$2.28 ,$2.52 ,$3.19 ,$2.63 
Carle BroMenn Medical Center,8980250,amoxicillin 400 mg/5 mL oral suspension,143988750,,250,$9.84 ,$9.84 ,$2.95 ,$8.95 ,$6.89 ,$2.95 ,$6.40 ,$7.08 ,$8.95 ,$7.38 
Carle BroMenn Medical Center,8980250,amoxicillin 400 mg/5 mL oral suspension,143988775,,250,$9.84 ,$9.84 ,$2.95 ,$8.95 ,$6.89 ,$2.95 ,$6.40 ,$7.08 ,$8.95 ,$7.38 
Carle BroMenn Medical Center,8980250,amoxicillin 400 mg/5 mL oral suspension,781615757,,250,$9.84 ,$9.84 ,$2.95 ,$8.95 ,$6.89 ,$2.95 ,$6.40 ,$7.08 ,$8.95 ,$7.38 
Carle BroMenn Medical Center,8980250,amoxicillin 400 mg-potassium clavulanate 57 mg/5 mL oral suspension,65862053475,,250,$25.15 ,$25.15 ,$7.55 ,$22.89 ,$17.61 ,$7.55 ,$16.35 ,$18.11 ,$22.89 ,$18.86 
Carle BroMenn Medical Center,8980250,amoxicillin 400 mg-potassium clavulanate 57 mg/5 mL oral suspension,66685101201,,250,$25.15 ,$25.15 ,$7.55 ,$22.89 ,$17.61 ,$7.55 ,$16.35 ,$18.11 ,$22.89 ,$18.86 
Carle BroMenn Medical Center,8980250,amoxicillin 500 mg capsule,781261301,,250,$4.35 ,$4.35 ,$1.31 ,$3.96 ,$3.05 ,$1.31 ,$2.83 ,$3.13 ,$3.96 ,$3.26 
Carle BroMenn Medical Center,8980250,amoxicillin 500 mg capsule,781261305,,250,$4.11 ,$4.11 ,$1.23 ,$3.74 ,$2.88 ,$1.23 ,$2.67 ,$2.96 ,$3.74 ,$3.08 
Carle BroMenn Medical Center,8980250,amoxicillin 500 mg capsule,16714029903,,250,$2.83 ,$2.83 ,$0.85 ,$2.58 ,$1.98 ,$0.85 ,$1.84 ,$2.04 ,$2.58 ,$2.12 
Carle BroMenn Medical Center,8980250,amoxicillin 500 mg-potassium clavulanate 125 mg tablet,65862050220,,250,$19.97 ,$19.97 ,$5.99 ,$18.17 ,$13.98 ,$5.99 ,$12.98 ,$14.38 ,$18.17 ,$14.98 
Carle BroMenn Medical Center,8980250,amoxicillin 600 mg-potassium clavulanate 42.9 mg/5 mL oral suspension,781613957,,250,$27.10 ,$27.10 ,$8.13 ,$24.66 ,$18.97 ,$8.13 ,$17.62 ,$19.51 ,$24.66 ,$20.33 
Carle BroMenn Medical Center,8980250,amoxicillin 600 mg-potassium clavulanate 42.9 mg/5 mL oral suspension,16714029401,,250,$14.59 ,$14.59 ,$4.38 ,$13.28 ,$10.21 ,$4.38 ,$9.48 ,$10.50 ,$13.28 ,$10.94 
Carle BroMenn Medical Center,8980250,amoxicillin 875 mg-potassium clavulanate 125 mg tablet,93227534,,250,$25.83 ,$25.83 ,$7.75 ,$23.51 ,$18.08 ,$7.75 ,$16.79 ,$18.60 ,$23.51 ,$19.37 
Carle BroMenn Medical Center,8980250,amoxicillin 875 mg-potassium clavulanate 125 mg tablet,781185220,,250,$25.83 ,$25.83 ,$7.75 ,$23.51 ,$18.08 ,$7.75 ,$16.79 ,$18.60 ,$23.51 ,$19.37 
Carle BroMenn Medical Center,8980250,amoxicillin 875 mg-potassium clavulanate 125 mg tablet,65862050320,,250,$25.83 ,$25.83 ,$7.75 ,$23.51 ,$18.08 ,$7.75 ,$16.79 ,$18.60 ,$23.51 ,$19.37 
Carle BroMenn Medical Center,8980250,"amoxicillin-potassium clavulanate 1,000 mg-62.5 mg tablet,ext.rel 12hr",781194382,,250,$35.00 ,$35.00 ,$10.50 ,$31.85 ,$24.50 ,$10.50 ,$22.75 ,$25.20 ,$31.85 ,$26.25 
Carle BroMenn Medical Center,8980250,anagrelide 0.5 mg capsule,13668045301,,250,$47.22 ,$47.22 ,$14.17 ,$42.97 ,$33.05 ,$14.17 ,$30.69 ,$34.00 ,$42.97 ,$35.42 
Carle BroMenn Medical Center,8980250,ARIPiprazole 10 mg tablet,16729028001,,250,$120.41 ,$120.41 ,$36.12 ,$109.57 ,$84.29 ,$36.12 ,$78.27 ,$86.70 ,$109.57 ,$90.31 
Carle BroMenn Medical Center,8980250,ARIPiprazole 10 mg tablet,62332009930,,250,$120.15 ,$120.15 ,$36.05 ,$109.34 ,$84.11 ,$36.05 ,$78.10 ,$86.51 ,$109.34 ,$90.11 
Carle BroMenn Medical Center,8980250,ARIPiprazole 2 mg tablet,16729027801,,250,$120.41 ,$120.41 ,$36.12 ,$109.57 ,$84.29 ,$36.12 ,$78.27 ,$86.70 ,$109.57 ,$90.31 
Carle BroMenn Medical Center,8980250,ARIPiprazole 2 mg tablet,62332009731,,250,$120.41 ,$120.41 ,$36.12 ,$109.57 ,$84.29 ,$36.12 ,$78.27 ,$86.70 ,$109.57 ,$90.31 
Carle BroMenn Medical Center,8980250,ARIPiprazole 5 mg tablet,16729027901,,250,$120.41 ,$120.41 ,$36.12 ,$109.57 ,$84.29 ,$36.12 ,$78.27 ,$86.70 ,$109.57 ,$90.31 
Carle BroMenn Medical Center,8980250,ARIPiprazole 5 mg tablet,62332009830,,250,$120.15 ,$120.15 ,$36.05 ,$109.34 ,$84.11 ,$36.05 ,$78.10 ,$86.51 ,$109.34 ,$90.11 
Carle BroMenn Medical Center,8980250,ARIPiprazole 5 mg tablet,62332009831,,250,$120.41 ,$120.41 ,$36.12 ,$109.57 ,$84.29 ,$36.12 ,$78.27 ,$86.70 ,$109.57 ,$90.31 
Carle BroMenn Medical Center,8980250,ascorbic acid (vitamin C) 500 mg tablet,904052360,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,ascorbic acid (vitamin C) 500 mg tablet,904052361,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,asenapine 5 mg sublingual tablet,456240560,,250,$92.21 ,$92.21 ,$27.66 ,$83.91 ,$64.55 ,$27.66 ,$59.94 ,$66.39 ,$83.91 ,$69.16 
Carle BroMenn Medical Center,8980250,asenapine 5 mg sublingual tablet,59762201206,,250,$83.80 ,$83.80 ,$25.14 ,$76.26 ,$58.66 ,$25.14 ,$54.47 ,$60.34 ,$76.26 ,$62.85 
Carle BroMenn Medical Center,8980250,"aspirin 25 mg-dipyridamole 200 mg capsule,ext.release 12 hr multiphase",43598033960,,250,$37.39 ,$37.39 ,$11.22 ,$34.02 ,$26.17 ,$11.22 ,$24.30 ,$26.92 ,$34.02 ,$28.04 
Carle BroMenn Medical Center,8980250,"aspirin 25 mg-dipyridamole 200 mg capsule,ext.release 12 hr multiphase",65162059606,,250,$37.39 ,$37.39 ,$11.22 ,$34.02 ,$26.17 ,$11.22 ,$24.30 ,$26.92 ,$34.02 ,$28.04 
Carle BroMenn Medical Center,8980250,aspirin 300 mg rectal suppository,574703412,,250,$2.04 ,$2.04 ,$0.61 ,$1.86 ,$1.43 ,$0.61 ,$1.33 ,$1.47 ,$1.86 ,$1.53 
Carle BroMenn Medical Center,8980250,aspirin 325 mg tablet,536105429,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,aspirin 325 mg tablet,57896090101,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,aspirin 325 mg tablet,66553000101,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,aspirin 81 mg chewable tablet,904679489,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,aspirin 81 mg chewable tablet,66553000201,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,"aspirin 81 mg tablet,delayed release",536123441,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,"aspirin 81 mg tablet,delayed release",46122059848,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,"aspirin 81 mg tablet,delayed release",63739021202,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,"aspirin 81 mg tablet,delayed release",63739021210,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,"aspirin 81 mg tablet,delayed release",69618006602,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,"aspirin 81 mg tablet,delayed release",71399862702,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,atenoloL 100 mg tablet,51079068501,,250,$9.29 ,$9.29 ,$2.79 ,$8.45 ,$6.50 ,$2.79 ,$6.04 ,$6.69 ,$8.45 ,$6.97 
Carle BroMenn Medical Center,8980250,atenoloL 100 mg tablet,51079068520,,250,$9.29 ,$9.29 ,$2.79 ,$8.45 ,$6.50 ,$2.79 ,$6.04 ,$6.69 ,$8.45 ,$6.97 
Carle BroMenn Medical Center,8980250,atenoloL 25 mg tablet,51079075901,,250,$6.06 ,$6.06 ,$1.82 ,$5.51 ,$4.24 ,$1.82 ,$3.94 ,$4.36 ,$5.51 ,$4.55 
Carle BroMenn Medical Center,8980250,atenoloL 25 mg tablet,51079075920,,250,$6.06 ,$6.06 ,$1.82 ,$5.51 ,$4.24 ,$1.82 ,$3.94 ,$4.36 ,$5.51 ,$4.55 
Carle BroMenn Medical Center,8980250,atenoloL 50 mg tablet,51079068401,,250,$6.49 ,$6.49 ,$1.95 ,$5.91 ,$4.54 ,$1.95 ,$4.22 ,$4.67 ,$5.91 ,$4.87 
Carle BroMenn Medical Center,8980250,atenoloL 50 mg tablet,51079068420,,250,$6.49 ,$6.49 ,$1.95 ,$5.91 ,$4.54 ,$1.95 ,$4.22 ,$4.67 ,$5.91 ,$4.87 
Carle BroMenn Medical Center,8980250,atomoxetine 40 mg capsule,55111052130,,250,$62.28 ,$62.28 ,$18.68 ,$56.67 ,$43.60 ,$18.68 ,$40.48 ,$44.84 ,$56.67 ,$46.71 
Carle BroMenn Medical Center,8980250,atorvastatin 10 mg tablet,51079020801,,250,$4.04 ,$4.04 ,$1.21 ,$3.68 ,$2.83 ,$1.21 ,$2.63 ,$2.91 ,$3.68 ,$3.03 
Carle BroMenn Medical Center,8980250,atorvastatin 10 mg tablet,51079020820,,250,$4.04 ,$4.04 ,$1.21 ,$3.68 ,$2.83 ,$1.21 ,$2.63 ,$2.91 ,$3.68 ,$3.03 
Carle BroMenn Medical Center,8980250,atorvastatin 10 mg tablet,68084009701,,250,$5.27 ,$5.27 ,$1.58 ,$4.80 ,$3.69 ,$1.58 ,$3.43 ,$3.79 ,$4.80 ,$3.95 
Carle BroMenn Medical Center,8980250,atorvastatin 10 mg tablet,68084009711,,250,$5.27 ,$5.27 ,$1.58 ,$4.80 ,$3.69 ,$1.58 ,$3.43 ,$3.79 ,$4.80 ,$3.95 
Carle BroMenn Medical Center,8980250,atorvastatin 40 mg tablet,50268009511,,250,$4.77 ,$4.77 ,$1.43 ,$4.34 ,$3.34 ,$1.43 ,$3.10 ,$3.43 ,$4.34 ,$3.58 
Carle BroMenn Medical Center,8980250,atorvastatin 40 mg tablet,50268009515,,250,$4.77 ,$4.77 ,$1.43 ,$4.34 ,$3.34 ,$1.43 ,$3.10 ,$3.43 ,$4.34 ,$3.58 
Carle BroMenn Medical Center,8980250,atorvastatin 40 mg tablet,51079021001,,250,$4.78 ,$4.78 ,$1.43 ,$4.35 ,$3.35 ,$1.43 ,$3.11 ,$3.44 ,$4.35 ,$3.59 
Carle BroMenn Medical Center,8980250,atorvastatin 40 mg tablet,51079021020,,250,$4.78 ,$4.78 ,$1.43 ,$4.35 ,$3.35 ,$1.43 ,$3.11 ,$3.44 ,$4.35 ,$3.59 
Carle BroMenn Medical Center,8980250,atorvastatin 40 mg tablet,68084009901,,250,$6.32 ,$6.32 ,$1.90 ,$5.75 ,$4.42 ,$1.90 ,$4.11 ,$4.55 ,$5.75 ,$4.74 
Carle BroMenn Medical Center,8980250,atorvastatin 40 mg tablet,68084009911,,250,$6.32 ,$6.32 ,$1.90 ,$5.75 ,$4.42 ,$1.90 ,$4.11 ,$4.55 ,$5.75 ,$4.74 
Carle BroMenn Medical Center,8980250,atorvastatin 80 mg tablet,904629304,,250,$11.38 ,$11.38 ,$3.41 ,$10.36 ,$7.97 ,$3.41 ,$7.40 ,$8.19 ,$10.36 ,$8.54 
Carle BroMenn Medical Center,8980250,atorvastatin 80 mg tablet,68084059025,,250,$11.47 ,$11.47 ,$3.44 ,$10.44 ,$8.03 ,$3.44 ,$7.46 ,$8.26 ,$10.44 ,$8.60 
Carle BroMenn Medical Center,8980250,atorvastatin 80 mg tablet,68084059095,,250,$11.47 ,$11.47 ,$3.44 ,$10.44 ,$8.03 ,$3.44 ,$7.46 ,$8.26 ,$10.44 ,$8.60 
Carle BroMenn Medical Center,8980250,atovaquone 750 mg/5 mL oral suspension,65162069388,,250,$197.97 ,$197.97 ,$59.39 ,$180.15 ,$138.58 ,$59.39 ,$128.68 ,$142.54 ,$180.15 ,$148.48 
Carle BroMenn Medical Center,8980250,atovaquone 750 mg/5 mL oral suspension,70748029901,,250,$197.97 ,$197.97 ,$59.39 ,$180.15 ,$138.58 ,$59.39 ,$128.68 ,$142.54 ,$180.15 ,$148.48 
Carle BroMenn Medical Center,8980250,atropine 1 % eye drops,17478021502,,250,$244.00 ,$244.00 ,$73.20 ,$222.04 ,$170.80 ,$73.20 ,$158.60 ,$175.68 ,$222.04 ,$183.00 
Carle BroMenn Medical Center,8980250,azithromycin 200 mg/5 mL oral suspension,93202623,,250,$61.12 ,$61.12 ,$18.34 ,$55.62 ,$42.78 ,$18.34 ,$39.73 ,$44.01 ,$55.62 ,$45.84 
Carle BroMenn Medical Center,8980250,azithromycin 200 mg/5 mL oral suspension,42806014932,,250,$61.12 ,$61.12 ,$18.34 ,$55.62 ,$42.78 ,$18.34 ,$39.73 ,$44.01 ,$55.62 ,$45.84 
Carle BroMenn Medical Center,8980250,azithromycin 250 mg tablet,50111078751,,250,$35.39 ,$35.39 ,$10.62 ,$32.20 ,$24.77 ,$10.62 ,$23.00 ,$25.48 ,$32.20 ,$26.54 
Carle BroMenn Medical Center,8980250,azithromycin 250 mg tablet,50111078766,,250,$35.39 ,$35.39 ,$10.62 ,$32.20 ,$24.77 ,$10.62 ,$23.00 ,$25.48 ,$32.20 ,$26.54 
Carle BroMenn Medical Center,8980250,azithromycin 250 mg tablet,59762306002,,250,$35.36 ,$35.36 ,$10.61 ,$32.18 ,$24.75 ,$10.61 ,$22.98 ,$25.46 ,$32.18 ,$26.52 
Carle BroMenn Medical Center,8980250,azithromycin 250 mg tablet,60687028211,,250,$21.97 ,$21.97 ,$6.59 ,$19.99 ,$15.38 ,$6.59 ,$14.28 ,$15.82 ,$19.99 ,$16.48 
Carle BroMenn Medical Center,8980250,azithromycin 250 mg tablet,65862064163,,250,$35.39 ,$35.39 ,$10.62 ,$32.20 ,$24.77 ,$10.62 ,$23.00 ,$25.48 ,$32.20 ,$26.54 
Carle BroMenn Medical Center,8980250,azithromycin 250 mg tablet,65862064169,,250,$35.39 ,$35.39 ,$10.62 ,$32.20 ,$24.77 ,$10.62 ,$23.00 ,$25.48 ,$32.20 ,$26.54 
Carle BroMenn Medical Center,8980250,aztreonam 1 gram solution for injection,63323040120,,250,$265.83 ,$265.83 ,$79.75 ,$241.91 ,$186.08 ,$79.75 ,$172.79 ,$191.40 ,$241.91 ,$199.37 
Carle BroMenn Medical Center,8980250,aztreonam 2 gram solution for injection,63323040220,,250,$474.02 ,$474.02 ,$142.21 ,$431.36 ,$331.81 ,$142.21 ,$308.11 ,$341.29 ,$431.36 ,$355.52 
Carle BroMenn Medical Center,8980250,aztreonam 2 gram solution for injection,63323040224,,250,$369.51 ,$369.51 ,$110.85 ,$336.25 ,$258.66 ,$110.85 ,$240.18 ,$266.05 ,$336.25 ,$277.13 
Carle BroMenn Medical Center,8980250,"bacitracin 500 unit/gram topical ointment,bacitracin zinc 500 unit/gram topical ointment",51672207502,,250,$42.45 ,$42.45 ,$12.74 ,$38.63 ,$29.72 ,$12.74 ,$27.59 ,$30.56 ,$38.63 ,$31.84 
Carle BroMenn Medical Center,8980250,"bacitracin zinc 500 unit/gram topical packet,bacitracin 500 unit/gram topical packet",45802006070,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,"bacitracin-polymyxin B 500 unit-10,000 unit/gram eye ointment",24208055555,,250,$137.80 ,$137.80 ,$41.34 ,$125.40 ,$96.46 ,$41.34 ,$89.57 ,$99.22 ,$125.40 ,$103.35 
Carle BroMenn Medical Center,8980250,"bacitracin-polymyxin B 500 unit-10,000 unit/gram topical ointment,bacitracin zinc 500 unit-polymyxin B 10,000 unit/gram topical ointment",81079888,,250,$29.20 ,$29.20 ,$8.76 ,$26.57 ,$20.44 ,$8.76 ,$18.98 ,$21.02 ,$26.57 ,$21.90 
Carle BroMenn Medical Center,8980250,"bacitracin-polymyxin B 500 unit-10,000 unit/gram topical ointment,bacitracin zinc 500 unit-polymyxin B 10,000 unit/gram topical ointment",810079887,,250,$48.01 ,$48.01 ,$14.40 ,$43.69 ,$33.61 ,$14.40 ,$31.21 ,$34.57 ,$43.69 ,$36.01 
Carle BroMenn Medical Center,8980250,"bacitracin-polymyxin B 500 unit-10,000 unit/gram topical ointment,bacitracin zinc 500 unit-polymyxin B 10,000 unit/gram topical ointment",51672204402,,250,$39.25 ,$39.25 ,$11.78 ,$35.72 ,$27.48 ,$11.78 ,$25.51 ,$28.26 ,$35.72 ,$29.44 
Carle BroMenn Medical Center,8980250,baclofen 10 mg tablet,63739047910,,250,$4.92 ,$4.92 ,$1.48 ,$4.48 ,$3.44 ,$1.48 ,$3.20 ,$3.54 ,$4.48 ,$3.69 
Carle BroMenn Medical Center,8980250,baclofen 10 mg tablet,68084085501,,250,$5.77 ,$5.77 ,$1.73 ,$5.25 ,$4.04 ,$1.73 ,$3.75 ,$4.15 ,$5.25 ,$4.33 
Carle BroMenn Medical Center,8980250,baclofen 10 mg tablet,68084085511,,250,$5.77 ,$5.77 ,$1.73 ,$5.25 ,$4.04 ,$1.73 ,$3.75 ,$4.15 ,$5.25 ,$4.33 
Carle BroMenn Medical Center,8980250,baclofen 20 mg tablet,29300034401,,250,$26.11 ,$26.11 ,$7.83 ,$23.76 ,$18.28 ,$7.83 ,$16.97 ,$18.80 ,$23.76 ,$19.58 
Carle BroMenn Medical Center,8980250,baclofen 20 mg tablet,70710128601,,250,$26.11 ,$26.11 ,$7.83 ,$23.76 ,$18.28 ,$7.83 ,$16.97 ,$18.80 ,$23.76 ,$19.58 
Carle BroMenn Medical Center,8980250,balanced salt solution combination no.2 intraocular irrigation,65079515,,250,$74.82 ,$74.82 ,$22.45 ,$68.09 ,$52.37 ,$22.45 ,$48.63 ,$53.87 ,$68.09 ,$56.12 
Carle BroMenn Medical Center,8980250,balanced salt solution non-surgical no.3 eye wash,65053001,J3490,250,$126.38 ,$126.38 ,$37.91 ,$115.01 ,$88.47 ,$37.91 ,$82.15 ,$90.99 ,$115.01 ,$94.79 
Carle BroMenn Medical Center,8980250,balsam peru-castor oiL topical ointment,75834013960,,250,$195.72 ,$195.72 ,$58.72 ,$178.11 ,$137.00 ,$58.72 ,$127.22 ,$140.92 ,$178.11 ,$146.79 
Carle BroMenn Medical Center,8980250,baricitinib 2 mg tablet,2418230,,250,$341.13 ,$341.13 ,$102.34 ,$310.43 ,$238.79 ,$102.34 ,$221.73 ,$245.61 ,$310.43 ,$255.85 
Carle BroMenn Medical Center,8980250,"barium sulfate 0.1 % (w/v), 0.1 % (w/w) oral suspension",32909092603,,250,$954.37 ,$954.37 ,$286.31 ,$868.48 ,$668.06 ,$286.31 ,$620.34 ,$687.15 ,$868.48 ,$715.78 
Carle BroMenn Medical Center,8980250,"barium sulfate 105 % (w/v), 58 % (w/w) oral suspension",32909016802,,250,$65.94 ,$65.94 ,$19.78 ,$60.01 ,$46.16 ,$19.78 ,$42.86 ,$47.48 ,$60.01 ,$49.46 
Carle BroMenn Medical Center,8980250,"barium sulfate 40 % (w/v), 29% (w/w) oral suspension",32909012207,,250,$15.10 ,$15.10 ,$4.53 ,$13.74 ,$10.57 ,$4.53 ,$9.82 ,$10.87 ,$13.74 ,$11.33 
Carle BroMenn Medical Center,8980250,"barium sulfate 40 % (w/v), 30 % (w/w) oral suspension",32909011500,,250,$5.59 ,$5.59 ,$1.68 ,$5.09 ,$3.91 ,$1.68 ,$3.63 ,$4.02 ,$5.09 ,$4.19 
Carle BroMenn Medical Center,8980250,barium sulfate 60 % (w/v) oral suspension,32909018602,,250,$14.21 ,$14.21 ,$4.26 ,$12.93 ,$9.95 ,$4.26 ,$9.24 ,$10.23 ,$12.93 ,$10.66 
Carle BroMenn Medical Center,8980250,barium sulfate 60 % (w/v) oral suspension,32909018702,,250,$2.37 ,$2.37 ,$0.71 ,$2.16 ,$1.66 ,$0.71 ,$1.54 ,$1.71 ,$2.16 ,$1.78 
Carle BroMenn Medical Center,8980250,beclomethasone diprop 40 mcg/actuation HFA breath activated aerosol,59310030240,,250,"$1,137.76 ","$1,137.76 ",$341.33 ,"$1,035.36 ",$796.43 ,$341.33 ,$739.54 ,$819.19 ,"$1,035.36 ",$853.32 
Carle BroMenn Medical Center,8980250,belladonna alkaloids-opium 16.2 mg-60 mg rectal suppository,574704001,,250,$127.58 ,$127.58 ,$38.27 ,$116.10 ,$89.31 ,$38.27 ,$82.93 ,$91.86 ,$116.10 ,$95.69 
Carle BroMenn Medical Center,8980250,belladonna alkaloids-opium 16.2 mg-60 mg rectal suppository,574704004,,250,$186.12 ,$186.12 ,$55.84 ,$169.37 ,$130.28 ,$55.84 ,$120.98 ,$134.01 ,$169.37 ,$139.59 
Carle BroMenn Medical Center,8980250,belladonna alkaloids-opium 16.2 mg-60 mg rectal suppository,574704012,,250,$127.58 ,$127.58 ,$38.27 ,$116.10 ,$89.31 ,$38.27 ,$82.93 ,$91.86 ,$116.10 ,$95.69 
Carle BroMenn Medical Center,8980250,benzocaine 10 % mucosal gel,10310022240,,250,$24.24 ,$24.24 ,$7.27 ,$22.06 ,$16.97 ,$7.27 ,$15.76 ,$17.45 ,$22.06 ,$18.18 
Carle BroMenn Medical Center,8980250,benzocaine 15 mg-menthoL 3.6 mg lozenges,904625549,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,benzocaine 20 % mucosal aerosol spray,283067902,,250,$17.47 ,$17.47 ,$5.24 ,$15.90 ,$12.23 ,$5.24 ,$11.36 ,$12.58 ,$15.90 ,$13.10 
Carle BroMenn Medical Center,8980250,benzocaine 20 % topical aerosol,63736037882,,250,$29.38 ,$29.38 ,$8.81 ,$26.74 ,$20.57 ,$8.81 ,$19.10 ,$21.15 ,$26.74 ,$22.04 
Carle BroMenn Medical Center,8980250,benzocaine 20 % topical ointment,63736003751,,250,$28.92 ,$28.92 ,$8.68 ,$26.32 ,$20.24 ,$8.68 ,$18.80 ,$20.82 ,$26.32 ,$21.69 
Carle BroMenn Medical Center,8980250,benzocaine 20 %-menthoL 0.5 % topical aerosol,16864068002,,250,$33.16 ,$33.16 ,$9.95 ,$30.18 ,$23.21 ,$9.95 ,$21.55 ,$23.88 ,$30.18 ,$24.87 
Carle BroMenn Medical Center,8980250,benzonatate 100 mg capsule,904656461,,250,$5.09 ,$5.09 ,$1.53 ,$4.63 ,$3.56 ,$1.53 ,$3.31 ,$3.66 ,$4.63 ,$3.82 
Carle BroMenn Medical Center,8980250,benzonatate 100 mg capsule,51224001050,,250,$13.99 ,$13.99 ,$4.20 ,$12.73 ,$9.79 ,$4.20 ,$9.09 ,$10.07 ,$12.73 ,$10.49 
Carle BroMenn Medical Center,8980250,benzonatate 100 mg capsule,60687034611,,250,$5.73 ,$5.73 ,$1.72 ,$5.21 ,$4.01 ,$1.72 ,$3.72 ,$4.13 ,$5.21 ,$4.30 
Carle BroMenn Medical Center,8980250,benzonatate 100 mg capsule,68084021401,,250,$5.73 ,$5.73 ,$1.72 ,$5.21 ,$4.01 ,$1.72 ,$3.72 ,$4.13 ,$5.21 ,$4.30 
Carle BroMenn Medical Center,8980250,benzonatate 100 mg capsule,68084021411,,250,$5.73 ,$5.73 ,$1.72 ,$5.21 ,$4.01 ,$1.72 ,$3.72 ,$4.13 ,$5.21 ,$4.30 
Carle BroMenn Medical Center,8980250,benztropine 0.5 mg tablet,60687035601,,250,$5.07 ,$5.07 ,$1.52 ,$4.61 ,$3.55 ,$1.52 ,$3.30 ,$3.65 ,$4.61 ,$3.80 
Carle BroMenn Medical Center,8980250,benztropine 0.5 mg tablet,60687035611,,250,$5.07 ,$5.07 ,$1.52 ,$4.61 ,$3.55 ,$1.52 ,$3.30 ,$3.65 ,$4.61 ,$3.80 
Carle BroMenn Medical Center,8980250,bethanechol chloride 10 mg tablet,68084036501,,250,$8.39 ,$8.39 ,$2.52 ,$7.63 ,$5.87 ,$2.52 ,$5.45 ,$6.04 ,$7.63 ,$6.29 
Carle BroMenn Medical Center,8980250,bethanechol chloride 10 mg tablet,68084036511,,250,$8.39 ,$8.39 ,$2.52 ,$7.63 ,$5.87 ,$2.52 ,$5.45 ,$6.04 ,$7.63 ,$6.29 
Carle BroMenn Medical Center,8980250,bethanechol chloride 25 mg tablet,832051201,,250,$14.77 ,$14.77 ,$4.43 ,$13.44 ,$10.34 ,$4.43 ,$9.60 ,$10.63 ,$13.44 ,$11.08 
Carle BroMenn Medical Center,8980250,bethanechol chloride 25 mg tablet,832051289,,250,$14.77 ,$14.77 ,$4.43 ,$13.44 ,$10.34 ,$4.43 ,$9.60 ,$10.63 ,$13.44 ,$11.08 
Carle BroMenn Medical Center,8980250,bisacodyL 10 mg rectal suppository,574705012,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,bisacodyL 10 mg rectal suppository,574705050,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,"bisacodyL 5 mg tablet,delayed release",904640761,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,"bisacodyL 5 mg tablet,delayed release",81421002004,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,bismuth subsalicylate 262 mg chewable tablet,536102107,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,bismuth subsalicylate 262 mg chewable tablet,904131546,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,brimonidine 0.2 % eye drops,61314014305,,250,$173.12 ,$173.12 ,$51.94 ,$157.54 ,$121.18 ,$51.94 ,$112.53 ,$124.65 ,$157.54 ,$129.84 
Carle BroMenn Medical Center,8980250,brivaracetam 50 mg tablet,50474057066,,250,$93.18 ,$93.18 ,$27.95 ,$84.79 ,$65.23 ,$27.95 ,$60.57 ,$67.09 ,$84.79 ,$69.89 
Carle BroMenn Medical Center,8980250,brivaracetam 50 mg/5 mL intravenous solution,50474097063,,250,$398.53 ,$398.53 ,$119.56 ,$362.66 ,$278.97 ,$119.56 ,$259.04 ,$286.94 ,$362.66 ,$298.90 
Carle BroMenn Medical Center,8980250,brivaracetam 50 mg/5 mL intravenous solution,50474097075,,250,$398.53 ,$398.53 ,$119.56 ,$362.66 ,$278.97 ,$119.56 ,$259.04 ,$286.94 ,$362.66 ,$298.90 
Carle BroMenn Medical Center,8980250,bromocriptine 2.5 mg tablet,574010603,,250,$21.61 ,$21.61 ,$6.48 ,$19.67 ,$15.13 ,$6.48 ,$14.05 ,$15.56 ,$19.67 ,$16.21 
Carle BroMenn Medical Center,8980250,bromocriptine 2.5 mg tablet,63304096230,,250,$21.61 ,$21.61 ,$6.48 ,$19.67 ,$15.13 ,$6.48 ,$14.05 ,$15.56 ,$19.67 ,$16.21 
Carle BroMenn Medical Center,8980250,bumetanide 0.25 mg/mL injection solution,409141210,,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,bumetanide 0.25 mg/mL injection solution,409141240,,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,bumetanide 0.25 mg/mL injection solution,641600701,,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,bumetanide 0.25 mg/mL injection solution,641600710,,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,bumetanide 0.25 mg/mL injection solution,641600810,,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,bumetanide 1 mg tablet,42799012001,,250,$14.77 ,$14.77 ,$4.43 ,$13.44 ,$10.34 ,$4.43 ,$9.60 ,$10.63 ,$13.44 ,$11.08 
Carle BroMenn Medical Center,8980250,bupivacaine (PF) 0.25 % (2.5 mg/mL) injection solution,409115919,J3490,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,bupivacaine (PF) 0.25 % (2.5 mg/mL) injection solution,55150016710,J3490,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,bupivacaine (PF) 0.25 % (2.5 mg/mL) injection solution,55150016830,J3490,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,bupivacaine (PF) 0.5 % (5 mg/mL) injection solution,409116219,J3490,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,bupivacaine (PF) 0.5 % (5 mg/mL) injection solution,55150017030,J3490,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,bupivacaine (PF) 0.75 % (7.5 mg/mL) in 8.25 % dextrose injection,409361301,,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,bupivacaine (PF) 0.75 % (7.5 mg/mL) in 8.25 % dextrose injection,409361311,,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,bupivacaine (PF) 0.75 % (7.5 mg/mL) injection solution,63323047217,J3490,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,bupivacaine (PF) 0.75 % (7.5 mg/mL) injection solution,63323047237,J3490,250,$49.15 ,$49.15 ,$14.75 ,$44.73 ,$34.41 ,$14.75 ,$31.95 ,$35.39 ,$44.73 ,$36.86 
Carle BroMenn Medical Center,8980250,bupivacaine HCl 0.25 % (2.5 mg/mL) injection solution,409116018,,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,bupivacaine HCl 0.25 % (2.5 mg/mL) injection solution,55150024950,,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,bupivacaine HCl 0.5 % (5 mg/mL) injection solution,409116301,J3490,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,bupivacaine HCl 0.5 % (5 mg/mL) injection solution,409161050,J3490,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,bupivacaine HCl 0.5 % (5 mg/mL) injection solution,55150025050,J3490,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,bupivacaine HCl 0.5 % (5 mg/mL) injection solution,63323046757,J3490,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,"bupivacaine-epinephrine (PF) 0.5 %-1:200,000 injection solution",63323046237,,250,$66.61 ,$66.61 ,$19.98 ,$60.62 ,$46.63 ,$19.98 ,$43.30 ,$47.96 ,$60.62 ,$49.96 
Carle BroMenn Medical Center,8980250,"bupivacaine-epinephrine 0.25 %-1:200,000 injection solution",63323046157,,250,$97.39 ,$97.39 ,$29.22 ,$88.62 ,$68.17 ,$29.22 ,$63.30 ,$70.12 ,$88.62 ,$73.04 
Carle BroMenn Medical Center,8980250,"bupivacaine-epinephrine 0.5 %-1:200,000 injection solution",63323046301,,250,$104.09 ,$104.09 ,$31.23 ,$94.72 ,$72.86 ,$31.23 ,$67.66 ,$74.94 ,$94.72 ,$78.07 
Carle BroMenn Medical Center,8980250,"bupivacaine-epinephrine 0.5 %-1:200,000 injection solution",63323046357,,250,$104.09 ,$104.09 ,$31.23 ,$94.72 ,$72.86 ,$31.23 ,$67.66 ,$74.94 ,$94.72 ,$78.07 
Carle BroMenn Medical Center,8980250,buPROPion HCL 75 mg tablet,60505015801,,250,$6.03 ,$6.03 ,$1.81 ,$5.49 ,$4.22 ,$1.81 ,$3.92 ,$4.34 ,$5.49 ,$4.52 
Carle BroMenn Medical Center,8980250,"buPROPion HCL SR 100 mg tablet,12 hr sustained-release",43547028810,,250,$11.37 ,$11.37 ,$3.41 ,$10.35 ,$7.96 ,$3.41 ,$7.39 ,$8.19 ,$10.35 ,$8.53 
Carle BroMenn Medical Center,8980250,"buPROPion HCL SR 100 mg tablet,12 hr sustained-release",70436005801,,250,$10.20 ,$10.20 ,$3.06 ,$9.28 ,$7.14 ,$3.06 ,$6.63 ,$7.34 ,$9.28 ,$7.65 
Carle BroMenn Medical Center,8980250,"buPROPion HCL XL 150 mg 24 hr tablet, extended release",187073030,,250,$230.17 ,$230.17 ,$69.05 ,$209.45 ,$161.12 ,$69.05 ,$149.61 ,$165.72 ,$209.45 ,$172.63 
Carle BroMenn Medical Center,8980250,"buPROPion HCL XL 150 mg 24 hr tablet, extended release",16729044315,,250,$26.42 ,$26.42 ,$7.93 ,$24.04 ,$18.49 ,$7.93 ,$17.17 ,$19.02 ,$24.04 ,$19.82 
Carle BroMenn Medical Center,8980250,"buPROPion HCL XL 150 mg 24 hr tablet, extended release",64679010202,,250,$3.47 ,$3.47 ,$1.04 ,$3.16 ,$2.43 ,$1.04 ,$2.26 ,$2.50 ,$3.16 ,$2.60 
Carle BroMenn Medical Center,8980250,"buPROPion HCL XL 150 mg 24 hr tablet, extended release",68001026104,,250,$24.57 ,$24.57 ,$7.37 ,$22.36 ,$17.20 ,$7.37 ,$15.97 ,$17.69 ,$22.36 ,$18.43 
Carle BroMenn Medical Center,8980250,"buPROPion HCL XL 150 mg 24 hr tablet, extended release",68001032205,,250,$24.57 ,$24.57 ,$7.37 ,$22.36 ,$17.20 ,$7.37 ,$15.97 ,$17.69 ,$22.36 ,$18.43 
Carle BroMenn Medical Center,8980250,"buPROPion HCL XL 150 mg 24 hr tablet, extended release",68180031906,,250,$24.57 ,$24.57 ,$7.37 ,$22.36 ,$17.20 ,$7.37 ,$15.97 ,$17.69 ,$22.36 ,$18.43 
Carle BroMenn Medical Center,8980250,"buPROPion HCL XL 150 mg 24 hr tablet, extended release",68180031909,,250,$24.57 ,$24.57 ,$7.37 ,$22.36 ,$17.20 ,$7.37 ,$15.97 ,$17.69 ,$22.36 ,$18.43 
Carle BroMenn Medical Center,8980250,"buPROPion HCL XL 150 mg 24 hr tablet, extended release",68382035306,,250,$24.57 ,$24.57 ,$7.37 ,$22.36 ,$17.20 ,$7.37 ,$15.97 ,$17.69 ,$22.36 ,$18.43 
Carle BroMenn Medical Center,8980250,busPIRone 15 mg tablet,93100301,,250,$11.74 ,$11.74 ,$3.52 ,$10.68 ,$8.22 ,$3.52 ,$7.63 ,$8.45 ,$10.68 ,$8.81 
Carle BroMenn Medical Center,8980250,busPIRone 15 mg tablet,29300024601,,250,$11.74 ,$11.74 ,$3.52 ,$10.68 ,$8.22 ,$3.52 ,$7.63 ,$8.45 ,$10.68 ,$8.81 
Carle BroMenn Medical Center,8980250,busPIRone 15 mg tablet,69584009310,,250,$11.74 ,$11.74 ,$3.52 ,$10.68 ,$8.22 ,$3.52 ,$7.63 ,$8.45 ,$10.68 ,$8.81 
Carle BroMenn Medical Center,8980250,busPIRone 5 mg tablet,51079098501,,250,$5.92 ,$5.92 ,$1.78 ,$5.39 ,$4.14 ,$1.78 ,$3.85 ,$4.26 ,$5.39 ,$4.44 
Carle BroMenn Medical Center,8980250,busPIRone 5 mg tablet,51079098520,,250,$5.92 ,$5.92 ,$1.78 ,$5.39 ,$4.14 ,$1.78 ,$3.85 ,$4.26 ,$5.39 ,$4.44 
Carle BroMenn Medical Center,8980250,butalbitaL 50 mg-acetaminophen 325 mg-caffeine 40 mg-codeine 30 mg cap,591322001,,250,$11.60 ,$11.60 ,$3.48 ,$10.56 ,$8.12 ,$3.48 ,$7.54 ,$8.35 ,$10.56 ,$8.70 
Carle BroMenn Medical Center,8980250,butalbital-acetaminophen-caffeine 50 mg-325 mg-40 mg tablet,527169501,,250,$12.53 ,$12.53 ,$3.76 ,$11.40 ,$8.77 ,$3.76 ,$8.14 ,$9.02 ,$11.40 ,$9.40 
Carle BroMenn Medical Center,8980250,butalbital-acetaminophen-caffeine 50 mg-325 mg-40 mg tablet,10702025301,,250,$12.53 ,$12.53 ,$3.76 ,$11.40 ,$8.77 ,$3.76 ,$8.14 ,$9.02 ,$11.40 ,$9.40 
Carle BroMenn Medical Center,8980250,butamben-tetracaine-benzocaine 2 %-2 %-14 % (200 mg/sec) topical spray,10223020103,,250,$691.91 ,$691.91 ,$207.57 ,$629.64 ,$484.34 ,$207.57 ,$449.74 ,$498.18 ,$629.64 ,$518.93 
Carle BroMenn Medical Center,8980250,caffeine-sodium benzoate 250 mg/mL(125 mg/mL caffeine) injection soln,517250210,,250,$164.66 ,$164.66 ,$49.40 ,$149.84 ,$115.26 ,$49.40 ,$107.03 ,$118.56 ,$149.84 ,$123.50 
Carle BroMenn Medical Center,8980250,calcitrioL 0.25 mcg capsule,60687034511,,250,$5.90 ,$5.90 ,$1.77 ,$5.37 ,$4.13 ,$1.77 ,$3.84 ,$4.25 ,$5.37 ,$4.43 
Carle BroMenn Medical Center,8980250,calcitrioL 0.25 mcg capsule,69452020720,,250,$7.97 ,$7.97 ,$2.39 ,$7.25 ,$5.58 ,$2.39 ,$5.18 ,$5.74 ,$7.25 ,$5.98 
Carle BroMenn Medical Center,8980250,calcium acetate(phosphate binders) 667 mg capsule,781208102,,250,$6.01 ,$6.01 ,$1.80 ,$5.47 ,$4.21 ,$1.80 ,$3.91 ,$4.33 ,$5.47 ,$4.51 
Carle BroMenn Medical Center,8980250,calcium acetate(phosphate binders) 667 mg capsule,23155053102,,250,$7.12 ,$7.12 ,$2.14 ,$6.48 ,$4.98 ,$2.14 ,$4.63 ,$5.13 ,$6.48 ,$5.34 
Carle BroMenn Medical Center,8980250,calcium acetate(phosphate binders) 667 mg capsule,69097086283,,250,$5.69 ,$5.69 ,$1.71 ,$5.18 ,$3.98 ,$1.71 ,$3.70 ,$4.10 ,$5.18 ,$4.27 
Carle BroMenn Medical Center,8980250,calcium carbonate 200 mg calcium (500 mg) chewable tablet,904641292,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,calcium carbonate 200 mg calcium (500 mg) chewable tablet,66553000401,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,calcium carbonate 200 mg calcium (500 mg) chewable tablet,69618002015,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,"calcium carbonate 500 mg/5 mL calcium (1,250 mg/5 mL) oral suspension",121076616,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,calcium chloride 100 mg/mL (10 %) intravenous solution,517671001,,250,$144.59 ,$144.59 ,$43.38 ,$131.58 ,$101.21 ,$43.38 ,$93.98 ,$104.10 ,$131.58 ,$108.44 
Carle BroMenn Medical Center,8980250,calcium chloride 100 mg/mL (10 %) intravenous syringe,76329330401,,250,$66.26 ,$66.26 ,$19.88 ,$60.30 ,$46.38 ,$19.88 ,$43.07 ,$47.71 ,$60.30 ,$49.70 
Carle BroMenn Medical Center,8980250,calcium citrate 315 mg calcium-vitamin D3 6.25 mcg (250 unit) tablet,87701040774,,250,$2.68 ,$2.68 ,$0.80 ,$2.44 ,$1.88 ,$0.80 ,$1.74 ,$1.93 ,$2.44 ,$2.01 
Carle BroMenn Medical Center,8980250,capsaicin 0.025 % topical cream,536252525,,250,$61.47 ,$61.47 ,$18.44 ,$55.94 ,$43.03 ,$18.44 ,$39.96 ,$44.26 ,$55.94 ,$46.10 
Carle BroMenn Medical Center,8980250,captopriL 12.5 mg tablet,69292052201,,250,$7.92 ,$7.92 ,$2.38 ,$7.21 ,$5.54 ,$2.38 ,$5.15 ,$5.70 ,$7.21 ,$5.94 
Carle BroMenn Medical Center,8980250,carbachoL 0.01 % intraocular solution,65002315,,250,$247.09 ,$247.09 ,$74.13 ,$224.85 ,$172.96 ,$74.13 ,$160.61 ,$177.90 ,$224.85 ,$185.32 
Carle BroMenn Medical Center,8980250,carBAMazepine 100 mg chewable tablet,904385461,,250,$5.31 ,$5.31 ,$1.59 ,$4.83 ,$3.72 ,$1.59 ,$3.45 ,$3.82 ,$4.83 ,$3.98 
Carle BroMenn Medical Center,8980250,carBAMazepine 100 mg chewable tablet,60687047911,,250,$5.06 ,$5.06 ,$1.52 ,$4.60 ,$3.54 ,$1.52 ,$3.29 ,$3.64 ,$4.60 ,$3.80 
Carle BroMenn Medical Center,8980250,carBAMazepine 100 mg/5 mL oral suspension,51672404709,,250,$12.72 ,$12.72 ,$3.82 ,$11.58 ,$8.90 ,$3.82 ,$8.27 ,$9.16 ,$11.58 ,$9.54 
Carle BroMenn Medical Center,8980250,carBAMazepine 200 mg tablet,904617261,,250,$7.54 ,$7.54 ,$2.26 ,$6.86 ,$5.28 ,$2.26 ,$4.90 ,$5.43 ,$6.86 ,$5.66 
Carle BroMenn Medical Center,8980250,carBAMazepine 200 mg tablet,75834022101,,250,$9.78 ,$9.78 ,$2.93 ,$8.90 ,$6.85 ,$2.93 ,$6.36 ,$7.04 ,$8.90 ,$7.34 
Carle BroMenn Medical Center,8980250,"carBAMazepine ER 100 mg capsule,extended release mphase12hr",66993040732,,250,$11.48 ,$11.48 ,$3.44 ,$10.45 ,$8.04 ,$3.44 ,$7.46 ,$8.27 ,$10.45 ,$8.61 
Carle BroMenn Medical Center,8980250,"carBAMazepine ER 200 mg capsule,extended release mphase12hr",54092017212,,250,$12.24 ,$12.24 ,$3.67 ,$11.14 ,$8.57 ,$3.67 ,$7.96 ,$8.81 ,$11.14 ,$9.18 
Carle BroMenn Medical Center,8980250,"carBAMazepine ER 200 mg capsule,extended release mphase12hr",66993040832,,250,$11.48 ,$11.48 ,$3.44 ,$10.45 ,$8.04 ,$3.44 ,$7.46 ,$8.27 ,$10.45 ,$8.61 
Carle BroMenn Medical Center,8980250,carbamide peroxide 6.5 % ear drops,904662735,,250,$17.47 ,$17.47 ,$5.24 ,$15.90 ,$12.23 ,$5.24 ,$11.36 ,$12.58 ,$15.90 ,$13.10 
Carle BroMenn Medical Center,8980250,carbidopa 10 mg-levodopa 100 mg tablet,228253810,,250,$5.93 ,$5.93 ,$1.78 ,$5.40 ,$4.15 ,$1.78 ,$3.85 ,$4.27 ,$5.40 ,$4.45 
Carle BroMenn Medical Center,8980250,carbidopa 10 mg-levodopa 100 mg tablet,62756051788,,250,$5.63 ,$5.63 ,$1.69 ,$5.12 ,$3.94 ,$1.69 ,$3.66 ,$4.05 ,$5.12 ,$4.22 
Carle BroMenn Medical Center,8980250,carbidopa 25 mg-levodopa 100 mg tablet,904623761,,250,$5.11 ,$5.11 ,$1.53 ,$4.65 ,$3.58 ,$1.53 ,$3.32 ,$3.68 ,$4.65 ,$3.83 
Carle BroMenn Medical Center,8980250,carbidopa 25 mg-levodopa 100 mg tablet,51862085601,,250,$6.39 ,$6.39 ,$1.92 ,$5.81 ,$4.47 ,$1.92 ,$4.15 ,$4.60 ,$5.81 ,$4.79 
Carle BroMenn Medical Center,8980250,carbidopa 25 mg-levodopa 250 mg tablet,904623861,,250,$6.32 ,$6.32 ,$1.90 ,$5.75 ,$4.42 ,$1.90 ,$4.11 ,$4.55 ,$5.75 ,$4.74 
Carle BroMenn Medical Center,8980250,carbidopa 31.25 mg-levodopa 125 mg-entacapone 200 mg tablet,781564101,,250,$19.81 ,$19.81 ,$5.94 ,$18.03 ,$13.87 ,$5.94 ,$12.88 ,$14.26 ,$18.03 ,$14.86 
Carle BroMenn Medical Center,8980250,"carbidopa ER 25 mg-levodopa 100 mg tablet,extended release",51079097820,,250,$6.67 ,$6.67 ,$2.00 ,$6.07 ,$4.67 ,$2.00 ,$4.34 ,$4.80 ,$6.07 ,$5.00 
Carle BroMenn Medical Center,8980250,"carbidopa ER 25 mg-levodopa 100 mg tablet,extended release",68001017100,,250,$6.93 ,$6.93 ,$2.08 ,$6.31 ,$4.85 ,$2.08 ,$4.50 ,$4.99 ,$6.31 ,$5.20 
Carle BroMenn Medical Center,8980250,"carbidopa ER 50 mg-levodopa 200 mg tablet,extended release",51079092301,,250,$10.45 ,$10.45 ,$3.14 ,$9.51 ,$7.32 ,$3.14 ,$6.79 ,$7.52 ,$9.51 ,$7.84 
Carle BroMenn Medical Center,8980250,"carbidopa ER 50 mg-levodopa 200 mg tablet,extended release",68001017200,,250,$11.18 ,$11.18 ,$3.35 ,$10.17 ,$7.83 ,$3.35 ,$7.27 ,$8.05 ,$10.17 ,$8.39 
Carle BroMenn Medical Center,8980250,carboprost tromethamine 250 mcg/mL intramuscular solution,9085608,,250,"$1,618.20 ","$1,618.20 ",$485.46 ,"$1,472.56 ","$1,132.74 ",$485.46 ,"$1,051.83 ","$1,165.10 ","$1,472.56 ","$1,213.65 "
Carle BroMenn Medical Center,8980250,carboprost tromethamine 250 mcg/mL intramuscular solution,69784024001,,250,"$1,461.90 ","$1,461.90 ",$438.57 ,"$1,330.33 ","$1,023.33 ",$438.57 ,$950.24 ,"$1,052.57 ","$1,330.33 ","$1,096.43 "
Carle BroMenn Medical Center,8980250,carboprost tromethamine 250 mcg/mL intramuscular solution,69784024010,,250,"$1,461.90 ","$1,461.90 ",$438.57 ,"$1,330.33 ","$1,023.33 ",$438.57 ,$950.24 ,"$1,052.57 ","$1,330.33 ","$1,096.43 "
Carle BroMenn Medical Center,8980250,cardioplegic solution 16 mEq/L (potassium) for perfusion,409796905,,250,$389.97 ,$389.97 ,$116.99 ,$354.87 ,$272.98 ,$116.99 ,$253.48 ,$280.78 ,$354.87 ,$292.48 
Carle BroMenn Medical Center,8980250,carvediloL 12.5 mg tablet,904630261,,250,$12.12 ,$12.12 ,$3.64 ,$11.03 ,$8.48 ,$3.64 ,$7.88 ,$8.73 ,$11.03 ,$9.09 
Carle BroMenn Medical Center,8980250,carvediloL 12.5 mg tablet,51079093101,,250,$12.27 ,$12.27 ,$3.68 ,$11.17 ,$8.59 ,$3.68 ,$7.98 ,$8.83 ,$11.17 ,$9.20 
Carle BroMenn Medical Center,8980250,carvediloL 12.5 mg tablet,51079093120,,250,$12.27 ,$12.27 ,$3.68 ,$11.17 ,$8.59 ,$3.68 ,$7.98 ,$8.83 ,$11.17 ,$9.20 
Carle BroMenn Medical Center,8980250,carvediloL 12.5 mg tablet,65862014401,,250,$11.41 ,$11.41 ,$3.42 ,$10.38 ,$7.99 ,$3.42 ,$7.42 ,$8.22 ,$10.38 ,$8.56 
Carle BroMenn Medical Center,8980250,carvediloL 25 mg tablet,904630361,,250,$12.12 ,$12.12 ,$3.64 ,$11.03 ,$8.48 ,$3.64 ,$7.88 ,$8.73 ,$11.03 ,$9.09 
Carle BroMenn Medical Center,8980250,carvediloL 25 mg tablet,51079093201,,250,$12.27 ,$12.27 ,$3.68 ,$11.17 ,$8.59 ,$3.68 ,$7.98 ,$8.83 ,$11.17 ,$9.20 
Carle BroMenn Medical Center,8980250,carvediloL 25 mg tablet,51079093220,,250,$12.27 ,$12.27 ,$3.68 ,$11.17 ,$8.59 ,$3.68 ,$7.98 ,$8.83 ,$11.17 ,$9.20 
Carle BroMenn Medical Center,8980250,carvediloL 3.125 mg tablet,904630061,,250,$12.12 ,$12.12 ,$3.64 ,$11.03 ,$8.48 ,$3.64 ,$7.88 ,$8.73 ,$11.03 ,$9.09 
Carle BroMenn Medical Center,8980250,carvediloL 6.25 mg tablet,904630161,,250,$12.12 ,$12.12 ,$3.64 ,$11.03 ,$8.48 ,$3.64 ,$7.88 ,$8.73 ,$11.03 ,$9.09 
Carle BroMenn Medical Center,8980250,carvediloL 6.25 mg tablet,51079093001,,250,$12.27 ,$12.27 ,$3.68 ,$11.17 ,$8.59 ,$3.68 ,$7.98 ,$8.83 ,$11.17 ,$9.20 
Carle BroMenn Medical Center,8980250,carvediloL 6.25 mg tablet,51079093020,,250,$12.27 ,$12.27 ,$3.68 ,$11.17 ,$8.59 ,$3.68 ,$7.98 ,$8.83 ,$11.17 ,$9.20 
Carle BroMenn Medical Center,8980250,carvediloL 6.25 mg tablet,68084085401,,250,$11.41 ,$11.41 ,$3.42 ,$10.38 ,$7.99 ,$3.42 ,$7.42 ,$8.22 ,$10.38 ,$8.56 
Carle BroMenn Medical Center,8980250,carvediloL 6.25 mg tablet,68084085411,,250,$11.41 ,$11.41 ,$3.42 ,$10.38 ,$7.99 ,$3.42 ,$7.42 ,$8.22 ,$10.38 ,$8.56 
Carle BroMenn Medical Center,8980250,cefdinir 250 mg/5 mL oral suspension,65862021960,,250,$35.90 ,$35.90 ,$10.77 ,$32.67 ,$25.13 ,$10.77 ,$23.34 ,$25.85 ,$32.67 ,$26.93 
Carle BroMenn Medical Center,8980250,cefdinir 250 mg/5 mL oral suspension,68180072304,,250,$35.94 ,$35.94 ,$10.78 ,$32.71 ,$25.16 ,$10.78 ,$23.36 ,$25.88 ,$32.71 ,$26.96 
Carle BroMenn Medical Center,8980250,cefdinir 300 mg capsule,16714039102,,250,$10.95 ,$10.95 ,$3.29 ,$9.96 ,$7.67 ,$3.29 ,$7.12 ,$7.88 ,$9.96 ,$8.21 
Carle BroMenn Medical Center,8980250,cefdinir 300 mg capsule,67877054360,,250,$26.02 ,$26.02 ,$7.81 ,$23.68 ,$18.21 ,$7.81 ,$16.91 ,$18.73 ,$23.68 ,$19.52 
Carle BroMenn Medical Center,8980250,cefdinir 300 mg capsule,68001036206,,250,$26.05 ,$26.05 ,$7.82 ,$23.71 ,$18.24 ,$7.82 ,$16.93 ,$18.76 ,$23.71 ,$19.54 
Carle BroMenn Medical Center,8980250,cefuroxime axetil 250 mg tablet,67877021520,,250,$27.97 ,$27.97 ,$8.39 ,$25.45 ,$19.58 ,$8.39 ,$18.18 ,$20.14 ,$25.45 ,$20.98 
Carle BroMenn Medical Center,8980250,celecoxib 100 mg capsule,59762151601,,250,$23.87 ,$23.87 ,$7.16 ,$21.72 ,$16.71 ,$7.16 ,$15.52 ,$17.19 ,$21.72 ,$17.90 
Carle BroMenn Medical Center,8980250,celecoxib 200 mg capsule,59762151701,,250,$34.68 ,$34.68 ,$10.40 ,$31.56 ,$24.28 ,$10.40 ,$22.54 ,$24.97 ,$31.56 ,$26.01 
Carle BroMenn Medical Center,8980250,celecoxib 200 mg capsule,62332014231,,250,$34.66 ,$34.66 ,$10.40 ,$31.54 ,$24.26 ,$10.40 ,$22.53 ,$24.96 ,$31.54 ,$26.00 
Carle BroMenn Medical Center,8980250,cephalexin 250 mg capsule,93314501,,250,$5.56 ,$5.56 ,$1.67 ,$5.06 ,$3.89 ,$1.67 ,$3.61 ,$4.00 ,$5.06 ,$4.17 
Carle BroMenn Medical Center,8980250,cephalexin 250 mg capsule,60687015201,,250,$5.65 ,$5.65 ,$1.70 ,$5.14 ,$3.96 ,$1.70 ,$3.67 ,$4.07 ,$5.14 ,$4.24 
Carle BroMenn Medical Center,8980250,cephalexin 250 mg capsule,60687015211,,250,$5.65 ,$5.65 ,$1.70 ,$5.14 ,$3.96 ,$1.70 ,$3.67 ,$4.07 ,$5.14 ,$4.24 
Carle BroMenn Medical Center,8980250,cephalexin 500 mg capsule,50268015211,,250,$8.02 ,$8.02 ,$2.41 ,$7.30 ,$5.61 ,$2.41 ,$5.21 ,$5.77 ,$7.30 ,$6.02 
Carle BroMenn Medical Center,8980250,cephalexin 500 mg capsule,50268015215,,250,$8.02 ,$8.02 ,$2.41 ,$7.30 ,$5.61 ,$2.41 ,$5.21 ,$5.77 ,$7.30 ,$6.02 
Carle BroMenn Medical Center,8980250,cephalexin 500 mg capsule,60687016311,,250,$8.63 ,$8.63 ,$2.59 ,$7.85 ,$6.04 ,$2.59 ,$5.61 ,$6.21 ,$7.85 ,$6.47 
Carle BroMenn Medical Center,8980250,cephalexin 500 mg capsule,68180012201,,250,$8.74 ,$8.74 ,$2.62 ,$7.95 ,$6.12 ,$2.62 ,$5.68 ,$6.29 ,$7.95 ,$6.56 
Carle BroMenn Medical Center,8980250,cetirizine 1 mg/mL oral solution,45802062626,,250,$12.30 ,$12.30 ,$3.69 ,$11.19 ,$8.61 ,$3.69 ,$8.00 ,$8.86 ,$11.19 ,$9.23 
Carle BroMenn Medical Center,8980250,cetirizine 1 mg/mL oral solution,45802097426,,250,$3.50 ,$3.50 ,$1.05 ,$3.19 ,$2.45 ,$1.05 ,$2.28 ,$2.52 ,$3.19 ,$2.63 
Carle BroMenn Medical Center,8980250,chlordiazePOXIDE 25 mg capsule,555015902,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,chlordiazePOXIDE 25 mg capsule,51079014120,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,chlordiazePOXIDE 5 mg capsule,555015802,,250,$3.97 ,$3.97 ,$1.19 ,$3.61 ,$2.78 ,$1.19 ,$2.58 ,$2.86 ,$3.61 ,$2.98 
Carle BroMenn Medical Center,8980250,chlordiazePOXIDE 5 mg capsule,51079037420,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,chlorhexidine gluconate 0.12 % mouthwash,116200116,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,chlorhexidine gluconate 0.12 % mouthwash,121089300,,250,$12.26 ,$12.26 ,$3.68 ,$11.16 ,$8.58 ,$3.68 ,$7.97 ,$8.83 ,$11.16 ,$9.20 
Carle BroMenn Medical Center,8980250,chlorhexidine gluconate 0.12 % mouthwash,121089315,,250,$12.26 ,$12.26 ,$3.68 ,$11.16 ,$8.58 ,$3.68 ,$7.97 ,$8.83 ,$11.16 ,$9.20 
Carle BroMenn Medical Center,8980250,chlorhexidine gluconate 0.12 % mouthwash,121089316,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,chlorhexidine gluconate 0.12 % mouthwash,9999066794,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,chlorhexidine gluconate 0.12 % mouthwash,69339013815,,250,$12.95 ,$12.95 ,$3.89 ,$11.78 ,$9.07 ,$3.89 ,$8.42 ,$9.32 ,$11.78 ,$9.71 
Carle BroMenn Medical Center,8980250,chlorothiazide 250 mg/5 mL oral suspension,65649031112,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,chlorthalidone 25 mg tablet,57664064888,,250,$7.95 ,$7.95 ,$2.39 ,$7.23 ,$5.57 ,$2.39 ,$5.17 ,$5.72 ,$7.23 ,$5.96 
Carle BroMenn Medical Center,8980250,chlorthalidone 25 mg tablet,66689034599,,250,$7.95 ,$7.95 ,$2.39 ,$7.23 ,$5.57 ,$2.39 ,$5.17 ,$5.72 ,$7.23 ,$5.96 
Carle BroMenn Medical Center,8980250,"cholecalciferol (vitamin D3) 125 mcg (5,000 unit) tablet",50268086611,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,"cholecalciferol (vitamin D3) 125 mcg (5,000 unit) tablet",50268086615,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,"cholecalciferol (vitamin D3) 125 mcg (5,000 unit) tablet",79854007941,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,"cholecalciferol (vitamin D3) 125 mcg (5,000 unit) tablet",87701040752,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,"cholecalciferol (vitamin D3) 25 mcg (1,000 unit) tablet",904582461,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,"cholecalciferol (vitamin D3) 25 mcg (1,000 unit) tablet",20555003300,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,"cholecalciferol (vitamin D3) 25 mcg (1,000 unit) tablet",48433010401,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,"cholecalciferol (vitamin D3) 25 mcg (1,000 unit) tablet",80681016800,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,"cholecalciferol (vitamin D3) 25 mcg (1,000 unit) tablet",80681016900,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,cholestyramine (with sugar) 4 gram powder for susp in a packet,185094098,,250,$18.03 ,$18.03 ,$5.41 ,$16.41 ,$12.62 ,$5.41 ,$11.72 ,$12.98 ,$16.41 ,$13.52 
Carle BroMenn Medical Center,8980250,cholestyramine (with sugar) 4 gram powder for susp in a packet,49884046564,,250,$18.03 ,$18.03 ,$5.41 ,$16.41 ,$12.62 ,$5.41 ,$11.72 ,$12.98 ,$16.41 ,$13.52 
Carle BroMenn Medical Center,8980250,chondroitin-sod hyaluron 4 %-3 % (40 mg-30 mg/mL) intraocular syringe,8065183905,,250,$794.49 ,$794.49 ,$238.35 ,$722.99 ,$556.14 ,$238.35 ,$516.42 ,$572.03 ,$722.99 ,$595.87 
Carle BroMenn Medical Center,8980250,cilostazoL 100 mg tablet,93206406,,250,$10.83 ,$10.83 ,$3.25 ,$9.86 ,$7.58 ,$3.25 ,$7.04 ,$7.80 ,$9.86 ,$8.12 
Carle BroMenn Medical Center,8980250,"ciprofloxacin 0.3 %-dexamethasone 0.1 % ear drops,suspension",65853302,,250,"$1,413.90 ","$1,413.90 ",$424.17 ,"$1,286.65 ",$989.73 ,$424.17 ,$919.04 ,"$1,018.01 ","$1,286.65 ","$1,060.43 "
Carle BroMenn Medical Center,8980250,"ciprofloxacin 0.3 %-dexamethasone 0.1 % ear drops,suspension",781618667,,250,"$1,326.84 ","$1,326.84 ",$398.05 ,"$1,207.42 ",$928.79 ,$398.05 ,$862.45 ,$955.32 ,"$1,207.42 ",$995.13 
Carle BroMenn Medical Center,8980250,"ciprofloxacin 0.3 %-dexamethasone 0.1 % ear drops,suspension",43598032675,,250,"$1,274.59 ","$1,274.59 ",$382.38 ,"$1,159.88 ",$892.21 ,$382.38 ,$828.48 ,$917.70 ,"$1,159.88 ",$955.94 
Carle BroMenn Medical Center,8980250,ciprofloxacin 250 mg tablet,143992701,,250,$23.74 ,$23.74 ,$7.12 ,$21.60 ,$16.62 ,$7.12 ,$15.43 ,$17.09 ,$21.60 ,$17.81 
Carle BroMenn Medical Center,8980250,ciprofloxacin 250 mg tablet,55111012601,,250,$23.00 ,$23.00 ,$6.90 ,$20.93 ,$16.10 ,$6.90 ,$14.95 ,$16.56 ,$20.93 ,$17.25 
Carle BroMenn Medical Center,8980250,ciprofloxacin 500 mg tablet,143992801,,250,$26.94 ,$26.94 ,$8.08 ,$24.52 ,$18.86 ,$8.08 ,$17.51 ,$19.40 ,$24.52 ,$20.21 
Carle BroMenn Medical Center,8980250,ciprofloxacin 500 mg tablet,904637861,,250,$3.95 ,$3.95 ,$1.19 ,$3.59 ,$2.77 ,$1.19 ,$2.57 ,$2.84 ,$3.59 ,$2.96 
Carle BroMenn Medical Center,8980250,ciprofloxacin 500 mg tablet,16571041250,,250,$25.31 ,$25.31 ,$7.59 ,$23.03 ,$17.72 ,$7.59 ,$16.45 ,$18.22 ,$23.03 ,$18.98 
Carle BroMenn Medical Center,8980250,ciprofloxacin 500 mg tablet,16714065202,,250,$26.95 ,$26.95 ,$8.09 ,$24.52 ,$18.87 ,$8.09 ,$17.52 ,$19.40 ,$24.52 ,$20.21 
Carle BroMenn Medical Center,8980250,ciprofloxacin 500 mg tablet,16714065204,,250,$25.86 ,$25.86 ,$7.76 ,$23.53 ,$18.10 ,$7.76 ,$16.81 ,$18.62 ,$23.53 ,$19.40 
Carle BroMenn Medical Center,8980250,ciprofloxacin 500 mg tablet,55111012701,,250,$26.32 ,$26.32 ,$7.90 ,$23.95 ,$18.42 ,$7.90 ,$17.11 ,$18.95 ,$23.95 ,$19.74 
Carle BroMenn Medical Center,8980250,ciprofloxacin 500 mg tablet,63739055910,,250,$3.33 ,$3.33 ,$1.00 ,$3.03 ,$2.33 ,$1.00 ,$2.16 ,$2.40 ,$3.03 ,$2.50 
Carle BroMenn Medical Center,8980250,cisatracurium 2 mg/mL intravenous solution,74437805,,250,$144.45 ,$144.45 ,$43.34 ,$131.45 ,$101.12 ,$43.34 ,$93.89 ,$104.00 ,$131.45 ,$108.34 
Carle BroMenn Medical Center,8980250,cisatracurium 2 mg/mL intravenous solution,74438010,,250,$227.07 ,$227.07 ,$68.12 ,$206.63 ,$158.95 ,$68.12 ,$147.60 ,$163.49 ,$206.63 ,$170.30 
Carle BroMenn Medical Center,8980250,cisatracurium 2 mg/mL intravenous solution,409554701,,250,$132.73 ,$132.73 ,$39.82 ,$120.78 ,$92.91 ,$39.82 ,$86.27 ,$95.57 ,$120.78 ,$99.55 
Carle BroMenn Medical Center,8980250,cisatracurium 2 mg/mL intravenous solution,409554710,,250,$132.73 ,$132.73 ,$39.82 ,$120.78 ,$92.91 ,$39.82 ,$86.27 ,$95.57 ,$120.78 ,$99.55 
Carle BroMenn Medical Center,8980250,cisatracurium 2 mg/mL intravenous solution,409708301,,250,$195.58 ,$195.58 ,$58.67 ,$177.98 ,$136.91 ,$58.67 ,$127.13 ,$140.82 ,$177.98 ,$146.69 
Carle BroMenn Medical Center,8980250,cisatracurium 2 mg/mL intravenous solution,409708310,,250,$195.58 ,$195.58 ,$58.67 ,$177.98 ,$136.91 ,$58.67 ,$127.13 ,$140.82 ,$177.98 ,$146.69 
Carle BroMenn Medical Center,8980250,cisatracurium 2 mg/mL intravenous solution,71288071410,,250,$181.61 ,$181.61 ,$54.48 ,$165.27 ,$127.13 ,$54.48 ,$118.05 ,$130.76 ,$165.27 ,$136.21 
Carle BroMenn Medical Center,8980250,cisatracurium 2 mg/mL intravenous solution,71288071411,,250,$181.61 ,$181.61 ,$54.48 ,$165.27 ,$127.13 ,$54.48 ,$118.05 ,$130.76 ,$165.27 ,$136.21 
Carle BroMenn Medical Center,8980250,cisatracurium concentrate 10 mg/mL (ICU USE ONLY) intravenous solution,74438220,,250,"$2,109.20 ","$2,109.20 ",$632.76 ,"$1,919.37 ","$1,476.44 ",$632.76 ,"$1,370.98 ","$1,518.62 ","$1,919.37 ","$1,581.90 "
Carle BroMenn Medical Center,8980250,cisatracurium concentrate 10 mg/mL (ICU USE ONLY) intravenous solution,409110301,,250,"$1,924.12 ","$1,924.12 ",$577.24 ,"$1,750.95 ","$1,346.88 ",$577.24 ,"$1,250.68 ","$1,385.37 ","$1,750.95 ","$1,443.09 "
Carle BroMenn Medical Center,8980250,cisatracurium concentrate 10 mg/mL (ICU USE ONLY) intravenous solution,409110311,,250,"$1,924.12 ","$1,924.12 ",$577.24 ,"$1,750.95 ","$1,346.88 ",$577.24 ,"$1,250.68 ","$1,385.37 ","$1,750.95 ","$1,443.09 "
Carle BroMenn Medical Center,8980250,cisatracurium concentrate 10 mg/mL (ICU USE ONLY) intravenous solution,409367001,,250,"$1,924.12 ","$1,924.12 ",$577.24 ,"$1,750.95 ","$1,346.88 ",$577.24 ,"$1,250.68 ","$1,385.37 ","$1,750.95 ","$1,443.09 "
Carle BroMenn Medical Center,8980250,cisatracurium concentrate 10 mg/mL (ICU USE ONLY) intravenous solution,409367010,,250,"$1,924.12 ","$1,924.12 ",$577.24 ,"$1,750.95 ","$1,346.88 ",$577.24 ,"$1,250.68 ","$1,385.37 ","$1,750.95 ","$1,443.09 "
Carle BroMenn Medical Center,8980250,cisatracurium concentrate 10 mg/mL (ICU USE ONLY) intravenous solution,781315380,,250,"$2,022.83 ","$2,022.83 ",$606.85 ,"$1,840.78 ","$1,415.98 ",$606.85 ,"$1,314.84 ","$1,456.44 ","$1,840.78 ","$1,517.12 "
Carle BroMenn Medical Center,8980250,cisatracurium concentrate 10 mg/mL (ICU USE ONLY) intravenous solution,781315395,,250,"$2,022.83 ","$2,022.83 ",$606.85 ,"$1,840.78 ","$1,415.98 ",$606.85 ,"$1,314.84 ","$1,456.44 ","$1,840.78 ","$1,517.12 "
Carle BroMenn Medical Center,8980250,cisatracurium concentrate 10 mg/mL (ICU USE ONLY) intravenous solution,63323041820,,250,"$1,924.12 ","$1,924.12 ",$577.24 ,"$1,750.95 ","$1,346.88 ",$577.24 ,"$1,250.68 ","$1,385.37 ","$1,750.95 ","$1,443.09 "
Carle BroMenn Medical Center,8980250,cisatracurium concentrate 10 mg/mL (ICU USE ONLY) intravenous solution,70069015101,,250,"$1,924.12 ","$1,924.12 ",$577.24 ,"$1,750.95 ","$1,346.88 ",$577.24 ,"$1,250.68 ","$1,385.37 ","$1,750.95 ","$1,443.09 "
Carle BroMenn Medical Center,8980250,cisatracurium concentrate 10 mg/mL (ICU USE ONLY) intravenous solution,70069015110,,250,"$1,924.12 ","$1,924.12 ",$577.24 ,"$1,750.95 ","$1,346.88 ",$577.24 ,"$1,250.68 ","$1,385.37 ","$1,750.95 ","$1,443.09 "
Carle BroMenn Medical Center,8980250,citalopram 20 mg tablet,904608561,,250,$14.88 ,$14.88 ,$4.46 ,$13.54 ,$10.42 ,$4.46 ,$9.67 ,$10.71 ,$13.54 ,$11.16 
Carle BroMenn Medical Center,8980250,citalopram 40 mg tablet,13668001101,,250,$15.28 ,$15.28 ,$4.58 ,$13.90 ,$10.70 ,$4.58 ,$9.93 ,$11.00 ,$13.90 ,$11.46 
Carle BroMenn Medical Center,8980250,clarithromycin 250 mg tablet,781196160,,250,$29.20 ,$29.20 ,$8.76 ,$26.57 ,$20.44 ,$8.76 ,$18.98 ,$21.02 ,$26.57 ,$21.90 
Carle BroMenn Medical Center,8980250,clindamycin 150 mg/mL injection solution,25021011502,,250,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980250,clindamycin 150 mg/mL injection solution,25021011504,,250,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980250,clindamycin 300 mg/50 mL in 5 % dextrose intravenous piggyback,338341050,,250,$52.87 ,$52.87 ,$15.86 ,$48.11 ,$37.01 ,$15.86 ,$34.37 ,$38.07 ,$48.11 ,$39.65 
Carle BroMenn Medical Center,8980250,clindamycin 600 mg/50 mL in 5 % dextrose intravenous piggyback,338361224,,250,$77.90 ,$77.90 ,$23.37 ,$70.89 ,$54.53 ,$23.37 ,$50.64 ,$56.09 ,$70.89 ,$58.43 
Carle BroMenn Medical Center,8980250,clindamycin 900 mg/50 mL in 5 % dextrose intravenous piggyback,338381424,,250,$94.48 ,$94.48 ,$28.34 ,$85.98 ,$66.14 ,$28.34 ,$61.41 ,$68.03 ,$85.98 ,$70.86 
Carle BroMenn Medical Center,8980250,clindamycin 900 mg/50 mL in 5 % dextrose intravenous piggyback,338381450,,250,$126.03 ,$126.03 ,$37.81 ,$114.69 ,$88.22 ,$37.81 ,$81.92 ,$90.74 ,$114.69 ,$94.52 
Carle BroMenn Medical Center,8980250,clindamycin HCL 150 mg capsule,904595961,,250,$9.14 ,$9.14 ,$2.74 ,$8.32 ,$6.40 ,$2.74 ,$5.94 ,$6.58 ,$8.32 ,$6.86 
Carle BroMenn Medical Center,8980250,clindamycin HCL 150 mg capsule,68084024301,,250,$8.17 ,$8.17 ,$2.45 ,$7.43 ,$5.72 ,$2.45 ,$5.31 ,$5.88 ,$7.43 ,$6.13 
Carle BroMenn Medical Center,8980250,clobetasoL 0.05 % topical cream,168016315,,250,$618.55 ,$618.55 ,$185.57 ,$562.88 ,$432.99 ,$185.57 ,$402.06 ,$445.36 ,$562.88 ,$463.91 
Carle BroMenn Medical Center,8980250,clobetasoL 0.05 % topical cream,42291007615,,250,$618.55 ,$618.55 ,$185.57 ,$562.88 ,$432.99 ,$185.57 ,$402.06 ,$445.36 ,$562.88 ,$463.91 
Carle BroMenn Medical Center,8980250,clobetasoL 0.05 % topical cream,42291007630,,250,"$1,215.98 ","$1,215.98 ",$364.79 ,"$1,106.54 ",$851.19 ,$364.79 ,$790.39 ,$875.51 ,"$1,106.54 ",$911.99 
Carle BroMenn Medical Center,8980250,clobetasoL 0.05 % topical cream,64980044115,,250,$618.55 ,$618.55 ,$185.57 ,$562.88 ,$432.99 ,$185.57 ,$402.06 ,$445.36 ,$562.88 ,$463.91 
Carle BroMenn Medical Center,8980250,clonazePAM 0.25 mg disintegrating tablet,555009596,,250,$10.71 ,$10.71 ,$3.21 ,$9.75 ,$7.50 ,$3.21 ,$6.96 ,$7.71 ,$9.75 ,$8.03 
Carle BroMenn Medical Center,8980250,clonazePAM 0.25 mg disintegrating tablet,49884030702,,250,$10.71 ,$10.71 ,$3.21 ,$9.75 ,$7.50 ,$3.21 ,$6.96 ,$7.71 ,$9.75 ,$8.03 
Carle BroMenn Medical Center,8980250,clonazePAM 0.25 mg disintegrating tablet,49884030752,,250,$10.71 ,$10.71 ,$3.21 ,$9.75 ,$7.50 ,$3.21 ,$6.96 ,$7.71 ,$9.75 ,$8.03 
Carle BroMenn Medical Center,8980250,clonazePAM 0.5 mg tablet,16729013600,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,clonazePAM 0.5 mg tablet,60687054401,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,clonazePAM 0.5 mg tablet,60687054411,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,clonazePAM 1 mg tablet,93321201,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,clonazePAM 1 mg tablet,60687055501,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,clonazePAM 1 mg tablet,60687055511,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,cloNIDine 0.1 mg/24 hr weekly transdermal patch,378087199,,250,$124.08 ,$124.08 ,$37.22 ,$112.91 ,$86.86 ,$37.22 ,$80.65 ,$89.34 ,$112.91 ,$93.06 
Carle BroMenn Medical Center,8980250,cloNIDine 0.1 mg/24 hr weekly transdermal patch,591350804,,250,$124.08 ,$124.08 ,$37.22 ,$112.91 ,$86.86 ,$37.22 ,$80.65 ,$89.34 ,$112.91 ,$93.06 
Carle BroMenn Medical Center,8980250,cloNIDine 0.1 mg/24 hr weekly transdermal patch,591350854,,250,$124.08 ,$124.08 ,$37.22 ,$112.91 ,$86.86 ,$37.22 ,$80.65 ,$89.34 ,$112.91 ,$93.06 
Carle BroMenn Medical Center,8980250,cloNIDine 0.2 mg/24 hr weekly transdermal patch,591350954,,250,$203.33 ,$203.33 ,$61.00 ,$185.03 ,$142.33 ,$61.00 ,$132.16 ,$146.40 ,$185.03 ,$152.50 
Carle BroMenn Medical Center,8980250,cloNIDine 0.3 mg/24 hr weekly transdermal patch,591351054,,250,$278.91 ,$278.91 ,$83.67 ,$253.81 ,$195.24 ,$83.67 ,$181.29 ,$200.82 ,$253.81 ,$209.18 
Carle BroMenn Medical Center,8980250,cloNIDine 0.3 mg/24 hr weekly transdermal patch,51862045501,,250,$279.22 ,$279.22 ,$83.77 ,$254.09 ,$195.45 ,$83.77 ,$181.49 ,$201.04 ,$254.09 ,$209.42 
Carle BroMenn Medical Center,8980250,cloNIDine 0.3 mg/24 hr weekly transdermal patch,51862045504,,250,$279.22 ,$279.22 ,$83.77 ,$254.09 ,$195.45 ,$83.77 ,$181.49 ,$201.04 ,$254.09 ,$209.42 
Carle BroMenn Medical Center,8980250,cloNIDine HCL 0.1 mg tablet,60687011311,,250,$4.03 ,$4.03 ,$1.21 ,$3.67 ,$2.82 ,$1.21 ,$2.62 ,$2.90 ,$3.67 ,$3.02 
Carle BroMenn Medical Center,8980250,cloNIDine HCL 0.1 mg tablet,68001023700,,250,$3.54 ,$3.54 ,$1.06 ,$3.22 ,$2.48 ,$1.06 ,$2.30 ,$2.55 ,$3.22 ,$2.66 
Carle BroMenn Medical Center,8980250,cloNIDine HCL 0.2 mg tablet,60687012401,,250,$4.03 ,$4.03 ,$1.21 ,$3.67 ,$2.82 ,$1.21 ,$2.62 ,$2.90 ,$3.67 ,$3.02 
Carle BroMenn Medical Center,8980250,cloNIDine HCL 0.2 mg tablet,60687012411,,250,$4.03 ,$4.03 ,$1.21 ,$3.67 ,$2.82 ,$1.21 ,$2.62 ,$2.90 ,$3.67 ,$3.02 
Carle BroMenn Medical Center,8980250,clopidogreL 75 mg tablet,904629461,,250,$22.66 ,$22.66 ,$6.80 ,$20.62 ,$15.86 ,$6.80 ,$14.73 ,$16.32 ,$20.62 ,$17.00 
Carle BroMenn Medical Center,8980250,clopidogreL 75 mg tablet,68084053601,,250,$32.00 ,$32.00 ,$9.60 ,$29.12 ,$22.40 ,$9.60 ,$20.80 ,$23.04 ,$29.12 ,$24.00 
Carle BroMenn Medical Center,8980250,clopidogreL 75 mg tablet,68084053611,,250,$32.00 ,$32.00 ,$9.60 ,$29.12 ,$22.40 ,$9.60 ,$20.80 ,$23.04 ,$29.12 ,$24.00 
Carle BroMenn Medical Center,8980250,clorazepate dipotassium 7.5 mg tablet,378004001,,250,$15.58 ,$15.58 ,$4.67 ,$14.18 ,$10.91 ,$4.67 ,$10.13 ,$11.22 ,$14.18 ,$11.69 
Carle BroMenn Medical Center,8980250,clotrimazole 10 mg troche,54414622,,250,$17.31 ,$17.31 ,$5.19 ,$15.75 ,$12.12 ,$5.19 ,$11.25 ,$12.46 ,$15.75 ,$12.98 
Carle BroMenn Medical Center,8980250,clotrimazole 10 mg troche,54814622,,250,$18.34 ,$18.34 ,$5.50 ,$16.69 ,$12.84 ,$5.50 ,$11.92 ,$13.20 ,$16.69 ,$13.76 
Carle BroMenn Medical Center,8980250,clotrimazole 10 mg troche,574010770,,250,$9.82 ,$9.82 ,$2.95 ,$8.94 ,$6.87 ,$2.95 ,$6.38 ,$7.07 ,$8.94 ,$7.37 
Carle BroMenn Medical Center,8980250,clotrimazole 2 % vaginal cream,51672206200,,250,$72.18 ,$72.18 ,$21.65 ,$65.68 ,$50.53 ,$21.65 ,$46.92 ,$51.97 ,$65.68 ,$54.14 
Carle BroMenn Medical Center,8980250,cloZAPine 25 mg tablet,51079092101,,250,$8.50 ,$8.50 ,$2.55 ,$7.74 ,$5.95 ,$2.55 ,$5.53 ,$6.12 ,$7.74 ,$6.38 
Carle BroMenn Medical Center,8980250,cloZAPine 25 mg tablet,51079092120,,250,$8.50 ,$8.50 ,$2.55 ,$7.74 ,$5.95 ,$2.55 ,$5.53 ,$6.12 ,$7.74 ,$6.38 
Carle BroMenn Medical Center,8980250,codeine 10 mg-guaifenesin 100 mg/5 mL oral liquid,121155000,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,codeine 10 mg-guaifenesin 100 mg/5 mL oral liquid,121155010,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,codeine sulfate 30 mg tablet,54024424,,250,$9.46 ,$9.46 ,$2.84 ,$8.61 ,$6.62 ,$2.84 ,$6.15 ,$6.81 ,$8.61 ,$7.10 
Carle BroMenn Medical Center,8980250,colchicine 0.6 mg tablet,591256230,,250,$36.84 ,$36.84 ,$11.05 ,$33.52 ,$25.79 ,$11.05 ,$23.95 ,$26.52 ,$33.52 ,$27.63 
Carle BroMenn Medical Center,8980250,colchicine 0.6 mg tablet,60687038911,,250,$47.18 ,$47.18 ,$14.15 ,$42.93 ,$33.03 ,$14.15 ,$30.67 ,$33.97 ,$42.93 ,$35.39 
Carle BroMenn Medical Center,8980250,colchicine 0.6 mg tablet,60687038921,,250,$47.18 ,$47.18 ,$14.15 ,$42.93 ,$33.03 ,$14.15 ,$30.67 ,$33.97 ,$42.93 ,$35.39 
Carle BroMenn Medical Center,8980250,colchicine 0.6 mg tablet,99999470206,,250,$27.66 ,$27.66 ,$8.30 ,$25.17 ,$19.36 ,$8.30 ,$17.98 ,$19.92 ,$25.17 ,$20.75 
Carle BroMenn Medical Center,8980250,collagenase clostridium histolyticum 250 unit/gram topical ointment,50484001030,,250,"$1,481.60 ","$1,481.60 ",$444.48 ,"$1,348.26 ","$1,037.12 ",$444.48 ,$963.04 ,"$1,066.75 ","$1,348.26 ","$1,111.20 "
Carle BroMenn Medical Center,8980250,compounding vehicle suspension sugar-free no.20 oral,574030316,,250,$133.62 ,$133.62 ,$40.09 ,$121.59 ,$93.53 ,$40.09 ,$86.85 ,$96.21 ,$121.59 ,$100.22 
Carle BroMenn Medical Center,8980250,compounding vehicle syrup no.23,574030416,,250,$133.62 ,$133.62 ,$40.09 ,$121.59 ,$93.53 ,$40.09 ,$86.85 ,$96.21 ,$121.59 ,$100.22 
Carle BroMenn Medical Center,8980250,conjugated estrogens 0.3 mg tablet,46110081,,250,$34.19 ,$34.19 ,$10.26 ,$31.11 ,$23.93 ,$10.26 ,$22.22 ,$24.62 ,$31.11 ,$25.64 
Carle BroMenn Medical Center,8980250,conjugated estrogens 0.625 mg/gram vaginal cream,46087221,,250,"$2,280.14 ","$2,280.14 ",$684.04 ,"$2,074.93 ","$1,596.10 ",$684.04 ,"$1,482.09 ","$1,641.70 ","$2,074.93 ","$1,710.11 "
Carle BroMenn Medical Center,8980250,cyanocobalamin (vit B-12) 500 mcg tablet,50268085411,,250,$3.81 ,$3.81 ,$1.14 ,$3.47 ,$2.67 ,$1.14 ,$2.48 ,$2.74 ,$3.47 ,$2.86 
Carle BroMenn Medical Center,8980250,cyanocobalamin (vit B-12) 500 mcg tablet,50268085415,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,cyanocobalamin (vit B-12) 500 mcg tablet,77333093710,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,cyanocobalamin (vit B-12) 500 mcg tablet,77333093725,,250,$3.23 ,$3.23 ,$0.97 ,$2.94 ,$2.26 ,$0.97 ,$2.10 ,$2.33 ,$2.94 ,$2.42 
Carle BroMenn Medical Center,8980250,cyclobenzaprine 10 mg tablet,591565801,,250,$7.68 ,$7.68 ,$2.30 ,$6.99 ,$5.38 ,$2.30 ,$4.99 ,$5.53 ,$6.99 ,$5.76 
Carle BroMenn Medical Center,8980250,cyclobenzaprine 10 mg tablet,43547040010,,250,$7.73 ,$7.73 ,$2.32 ,$7.03 ,$5.41 ,$2.32 ,$5.02 ,$5.57 ,$7.03 ,$5.80 
Carle BroMenn Medical Center,8980250,cyclobenzaprine 10 mg tablet,63739053110,,250,$2.77 ,$2.77 ,$0.83 ,$2.52 ,$1.94 ,$0.83 ,$1.80 ,$1.99 ,$2.52 ,$2.08 
Carle BroMenn Medical Center,8980250,cyclobenzaprine 5 mg tablet,43547039910,,250,$9.98 ,$9.98 ,$2.99 ,$9.08 ,$6.99 ,$2.99 ,$6.49 ,$7.19 ,$9.08 ,$7.49 
Carle BroMenn Medical Center,8980250,cyclobenzaprine 5 mg tablet,50268019011,,250,$8.06 ,$8.06 ,$2.42 ,$7.33 ,$5.64 ,$2.42 ,$5.24 ,$5.80 ,$7.33 ,$6.05 
Carle BroMenn Medical Center,8980250,cyclobenzaprine 5 mg tablet,69097084507,,250,$9.98 ,$9.98 ,$2.99 ,$9.08 ,$6.99 ,$2.99 ,$6.49 ,$7.19 ,$9.08 ,$7.49 
Carle BroMenn Medical Center,8980250,cyclopentolate 1 % eye drops,17478010002,,250,$89.46 ,$89.46 ,$26.84 ,$81.41 ,$62.62 ,$26.84 ,$58.15 ,$64.41 ,$81.41 ,$67.10 
Carle BroMenn Medical Center,8980250,cyclopentolate 1 % eye drops,61314039601,,250,$99.26 ,$99.26 ,$29.78 ,$90.33 ,$69.48 ,$29.78 ,$64.52 ,$71.47 ,$90.33 ,$74.45 
Carle BroMenn Medical Center,8980250,cycloSPORINE 0.05 % eye drops in a dropperette,23916330,,250,$51.19 ,$51.19 ,$15.36 ,$46.58 ,$35.83 ,$15.36 ,$33.27 ,$36.86 ,$46.58 ,$38.39 
Carle BroMenn Medical Center,8980250,cyproheptadine 4 mg tablet,50742019001,,250,$7.30 ,$7.30 ,$2.19 ,$6.64 ,$5.11 ,$2.19 ,$4.75 ,$5.26 ,$6.64 ,$5.48 
Carle BroMenn Medical Center,8980250,cyproheptadine 4 mg tablet,70710111001,,250,$7.30 ,$7.30 ,$2.19 ,$6.64 ,$5.11 ,$2.19 ,$4.75 ,$5.26 ,$6.64 ,$5.48 
Carle BroMenn Medical Center,8980250,dabigatran etexilate 150 mg capsule,597036082,,250,$41.53 ,$41.53 ,$12.46 ,$37.79 ,$29.07 ,$12.46 ,$26.99 ,$29.90 ,$37.79 ,$31.15 
Carle BroMenn Medical Center,8980250,dabigatran etexilate 75 mg capsule,597035556,,250,$41.53 ,$41.53 ,$12.46 ,$37.79 ,$29.07 ,$12.46 ,$26.99 ,$29.90 ,$37.79 ,$31.15 
Carle BroMenn Medical Center,8980250,dantrolene 20 mg intravenous solution,27505000367,,250,$416.14 ,$416.14 ,$124.84 ,$378.69 ,$291.30 ,$124.84 ,$270.49 ,$299.62 ,$378.69 ,$312.11 
Carle BroMenn Medical Center,8980250,dantrolene 25 mg capsule,527321937,,250,$7.31 ,$7.31 ,$2.19 ,$6.65 ,$5.12 ,$2.19 ,$4.75 ,$5.26 ,$6.65 ,$5.48 
Carle BroMenn Medical Center,8980250,dapsone 25 mg tablet,13925050430,,250,$13.82 ,$13.82 ,$4.15 ,$12.58 ,$9.67 ,$4.15 ,$8.98 ,$9.95 ,$12.58 ,$10.37 
Carle BroMenn Medical Center,8980250,dapsone 25 mg tablet,29033003630,,250,$13.82 ,$13.82 ,$4.15 ,$12.58 ,$9.67 ,$4.15 ,$8.98 ,$9.95 ,$12.58 ,$10.37 
Carle BroMenn Medical Center,8980250,demeclocycline 150 mg tablet,62584015901,,250,$45.36 ,$45.36 ,$13.61 ,$41.28 ,$31.75 ,$13.61 ,$29.48 ,$32.66 ,$41.28 ,$34.02 
Carle BroMenn Medical Center,8980250,demeclocycline 150 mg tablet,62584015911,,250,$45.36 ,$45.36 ,$13.61 ,$41.28 ,$31.75 ,$13.61 ,$29.48 ,$32.66 ,$41.28 ,$34.02 
Carle BroMenn Medical Center,8980250,demeclocycline 150 mg tablet,65162055410,,250,$41.05 ,$41.05 ,$12.32 ,$37.36 ,$28.74 ,$12.32 ,$26.68 ,$29.56 ,$37.36 ,$30.79 
Carle BroMenn Medical Center,8980250,desflurane 100 % inhalation liquid,10019064164,,250,$916.81 ,$916.81 ,$275.04 ,$834.30 ,$641.77 ,$275.04 ,$595.93 ,$660.10 ,$834.30 ,$687.61 
Carle BroMenn Medical Center,8980250,desipramine 25 mg tablet,50742011301,,250,$11.67 ,$11.67 ,$3.50 ,$10.62 ,$8.17 ,$3.50 ,$7.59 ,$8.40 ,$10.62 ,$8.75 
Carle BroMenn Medical Center,8980250,desmopressin 0.1 mg tablet,68001032500,,250,$26.65 ,$26.65 ,$8.00 ,$24.25 ,$18.66 ,$8.00 ,$17.32 ,$19.19 ,$24.25 ,$19.99 
Carle BroMenn Medical Center,8980250,desmopressin 10 mcg/spray (0.1 mL) nasal spray (non-refrigerated),47335078891,,250,"$1,168.50 ","$1,168.50 ",$350.55 ,"$1,063.34 ",$817.95 ,$350.55 ,$759.53 ,$841.32 ,"$1,063.34 ",$876.38 
Carle BroMenn Medical Center,8980250,desmopressin 10 mcg/spray (0.1 mL) nasal spray (non-refrigerated),69918050105,,250,"$1,122.59 ","$1,122.59 ",$336.78 ,"$1,021.56 ",$785.81 ,$336.78 ,$729.68 ,$808.26 ,"$1,021.56 ",$841.94 
Carle BroMenn Medical Center,8980250,desonide 0.05 % topical cream,45802042235,,250,$121.63 ,$121.63 ,$36.49 ,$110.68 ,$85.14 ,$36.49 ,$79.06 ,$87.57 ,$110.68 ,$91.22 
Carle BroMenn Medical Center,8980250,desonide 0.05 % topical cream,72578008601,,250,$395.14 ,$395.14 ,$118.54 ,$359.58 ,$276.60 ,$118.54 ,$256.84 ,$284.50 ,$359.58 ,$296.36 
Carle BroMenn Medical Center,8980250,"desvenlafaxine succinate ER 100 mg tablet,extended release 24 hr",54040113,,250,$49.98 ,$49.98 ,$14.99 ,$45.48 ,$34.99 ,$14.99 ,$32.49 ,$35.99 ,$45.48 ,$37.49 
Carle BroMenn Medical Center,8980250,"desvenlafaxine succinate ER 100 mg tablet,extended release 24 hr",51991031233,,250,$48.29 ,$48.29 ,$14.49 ,$43.94 ,$33.80 ,$14.49 ,$31.39 ,$34.77 ,$43.94 ,$36.22 
Carle BroMenn Medical Center,8980250,"desvenlafaxine succinate ER 50 mg tablet,extended release 24 hr",54040013,,250,$49.98 ,$49.98 ,$14.99 ,$45.48 ,$34.99 ,$14.99 ,$32.49 ,$35.99 ,$45.48 ,$37.49 
Carle BroMenn Medical Center,8980250,dexAMETHasone sodium phosphate 0.1 % eye drops,24208072002,,250,$322.38 ,$322.38 ,$96.71 ,$293.37 ,$225.67 ,$96.71 ,$209.55 ,$232.11 ,$293.37 ,$241.79 
Carle BroMenn Medical Center,8980250,dexmedeTOMIDine 100 mcg/mL intravenous solution,143953225,,250,$125.74 ,$125.74 ,$37.72 ,$114.42 ,$88.02 ,$37.72 ,$81.73 ,$90.53 ,$114.42 ,$94.31 
Carle BroMenn Medical Center,8980250,dexmedeTOMIDine 100 mcg/mL intravenous solution,42023014625,,250,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980250,dexmedeTOMIDine 100 mcg/mL intravenous solution,55150020902,,250,$325.03 ,$325.03 ,$97.51 ,$295.78 ,$227.52 ,$97.51 ,$211.27 ,$234.02 ,$295.78 ,$243.77 
Carle BroMenn Medical Center,8980250,dexmedeTOMIDine 100 mcg/mL intravenous solution,70860060503,,250,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980250,dexmedeTOMIDine 100 mcg/mL intravenous solution,70860060541,,250,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980250,dextroamphetamine-amphetamine 10 mg tablet,185084201,,250,$12.65 ,$12.65 ,$3.80 ,$11.51 ,$8.86 ,$3.80 ,$8.22 ,$9.11 ,$11.51 ,$9.49 
Carle BroMenn Medical Center,8980250,dextroamphetamine-amphetamine 10 mg tablet,555097202,,250,$12.65 ,$12.65 ,$3.80 ,$11.51 ,$8.86 ,$3.80 ,$8.22 ,$9.11 ,$11.51 ,$9.49 
Carle BroMenn Medical Center,8980250,dextroamphetamine-amphetamine 10 mg tablet,13107007001,,250,$12.65 ,$12.65 ,$3.80 ,$11.51 ,$8.86 ,$3.80 ,$8.22 ,$9.11 ,$11.51 ,$9.49 
Carle BroMenn Medical Center,8980250,dextroamphetamine-amphetamine 5 mg tablet,406889101,,250,$12.65 ,$12.65 ,$3.80 ,$11.51 ,$8.86 ,$3.80 ,$8.22 ,$9.11 ,$11.51 ,$9.49 
Carle BroMenn Medical Center,8980250,dextroamphetamine-amphetamine 5 mg tablet,555097102,,250,$12.65 ,$12.65 ,$3.80 ,$11.51 ,$8.86 ,$3.80 ,$8.22 ,$9.11 ,$11.51 ,$9.49 
Carle BroMenn Medical Center,8980250,dextromethorphan-guaifenesin 10 mg-100 mg/5 mL oral syrup,121063800,,250,$3.49 ,$3.49 ,$1.05 ,$3.18 ,$2.44 ,$1.05 ,$2.27 ,$2.51 ,$3.18 ,$2.62 
Carle BroMenn Medical Center,8980250,dextromethorphan-guaifenesin 10 mg-100 mg/5 mL oral syrup,121063805,,250,$3.49 ,$3.49 ,$1.05 ,$3.18 ,$2.44 ,$1.05 ,$2.27 ,$2.51 ,$3.18 ,$2.62 
Carle BroMenn Medical Center,8980250,dextrose 10% in water (D10W) IV Soln,264752000,J7060,250,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980250,dextrose 2.45 gram-sod citrate 2.2 gram-citric ac 800 mg/100 mL soln,14537096775,,250,$146.97 ,$146.97 ,$44.09 ,$133.74 ,$102.88 ,$44.09 ,$95.53 ,$105.82 ,$133.74 ,$110.23 
Carle BroMenn Medical Center,8980250,dextrose 25 % in water (D25W) intravenous syringe,409177510,,250,$70.50 ,$70.50 ,$21.15 ,$64.16 ,$49.35 ,$21.15 ,$45.83 ,$50.76 ,$64.16 ,$52.88 
Carle BroMenn Medical Center,8980250,dextrose 40 % oral gel,574006915,,250,$5.51 ,$5.51 ,$1.65 ,$5.01 ,$3.86 ,$1.65 ,$3.58 ,$3.97 ,$5.01 ,$4.13 
Carle BroMenn Medical Center,8980250,dextrose 40 % oral gel,574006930,J3490,250,$5.51 ,$5.51 ,$1.65 ,$5.01 ,$3.86 ,$1.65 ,$3.58 ,$3.97 ,$5.01 ,$4.13 
Carle BroMenn Medical Center,8980250,dextrose 50 % in water (D50W) intravenous syringe,409490234,J3490,250,$69.17 ,$69.17 ,$20.75 ,$62.94 ,$48.42 ,$20.75 ,$44.96 ,$49.80 ,$62.94 ,$51.88 
Carle BroMenn Medical Center,8980250,dextrose 50 % in water (D50W) intravenous syringe,409490264,J3490,250,$69.17 ,$69.17 ,$20.75 ,$62.94 ,$48.42 ,$20.75 ,$44.96 ,$49.80 ,$62.94 ,$51.88 
Carle BroMenn Medical Center,8980250,"dextrose 50 % in water (D50W) intravenous syringe,dextrose 50 % in water (D50W) intravenous solution",409490264,J3490,250,$69.17 ,$69.17 ,$20.75 ,$62.94 ,$48.42 ,$20.75 ,$44.96 ,$49.80 ,$62.94 ,$51.88 
Carle BroMenn Medical Center,8980250,diazePAM 10 mg tablet,172392760,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,diazePAM 10 mg tablet,51079028601,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,diazePAM 10 mg tablet,51079028620,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,diazePAM 2 mg tablet,172392560,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,diazePAM 2 mg tablet,51079028401,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,diazePAM 2 mg tablet,51079028420,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,diazePAM 5 mg tablet,904588061,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,diazePAM 5 mg tablet,51079028501,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,diazePAM 5 mg tablet,51079028520,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,dibucaine 1 % topical ointment,536121195,,250,$35.44 ,$35.44 ,$10.63 ,$32.25 ,$24.81 ,$10.63 ,$23.04 ,$25.52 ,$32.25 ,$26.58 
Carle BroMenn Medical Center,8980250,diclofenac 1 % topical gel,67815202,,250,$59.37 ,$59.37 ,$17.81 ,$54.03 ,$41.56 ,$17.81 ,$38.59 ,$42.75 ,$54.03 ,$44.53 
Carle BroMenn Medical Center,8980250,diclofenac 1 % topical gel,45802016000,,250,$251.17 ,$251.17 ,$75.35 ,$228.56 ,$175.82 ,$75.35 ,$163.26 ,$180.84 ,$228.56 ,$188.38 
Carle BroMenn Medical Center,8980250,diclofenac 1 % topical gel,45802095301,,250,$84.98 ,$84.98 ,$25.49 ,$77.33 ,$59.49 ,$25.49 ,$55.24 ,$61.19 ,$77.33 ,$63.74 
Carle BroMenn Medical Center,8980250,diclofenac 1 % topical gel,69097052444,,250,$254.44 ,$254.44 ,$76.33 ,$231.54 ,$178.11 ,$76.33 ,$165.39 ,$183.20 ,$231.54 ,$190.83 
Carle BroMenn Medical Center,8980250,"diclofenac sodium 50 mg tablet,delayed release",16571020210,,250,$9.19 ,$9.19 ,$2.76 ,$8.36 ,$6.43 ,$2.76 ,$5.97 ,$6.62 ,$8.36 ,$6.89 
Carle BroMenn Medical Center,8980250,dicyclomine 10 mg capsule,143312601,,250,$4.87 ,$4.87 ,$1.46 ,$4.43 ,$3.41 ,$1.46 ,$3.17 ,$3.51 ,$4.43 ,$3.65 
Carle BroMenn Medical Center,8980250,dicyclomine 10 mg capsule,378161001,,250,$3.56 ,$3.56 ,$1.07 ,$3.24 ,$2.49 ,$1.07 ,$2.31 ,$2.56 ,$3.24 ,$2.67 
Carle BroMenn Medical Center,8980250,dicyclomine 10 mg capsule,60687036901,,250,$5.40 ,$5.40 ,$1.62 ,$4.91 ,$3.78 ,$1.62 ,$3.51 ,$3.89 ,$4.91 ,$4.05 
Carle BroMenn Medical Center,8980250,dicyclomine 10 mg capsule,60687036911,,250,$5.40 ,$5.40 ,$1.62 ,$4.91 ,$3.78 ,$1.62 ,$3.51 ,$3.89 ,$4.91 ,$4.05 
Carle BroMenn Medical Center,8980250,dicyclomine 20 mg tablet,527128201,,250,$5.04 ,$5.04 ,$1.51 ,$4.59 ,$3.53 ,$1.51 ,$3.28 ,$3.63 ,$4.59 ,$3.78 
Carle BroMenn Medical Center,8980250,dicyclomine 20 mg tablet,60687038001,,250,$4.87 ,$4.87 ,$1.46 ,$4.43 ,$3.41 ,$1.46 ,$3.17 ,$3.51 ,$4.43 ,$3.65 
Carle BroMenn Medical Center,8980250,dicyclomine 20 mg tablet,60687038011,,250,$4.87 ,$4.87 ,$1.46 ,$4.43 ,$3.41 ,$1.46 ,$3.17 ,$3.51 ,$4.43 ,$3.65 
Carle BroMenn Medical Center,8980250,digoxin 125 mcg (0.125 mg) tablet,143124001,,250,$13.05 ,$13.05 ,$3.92 ,$11.88 ,$9.14 ,$3.92 ,$8.48 ,$9.40 ,$11.88 ,$9.79 
Carle BroMenn Medical Center,8980250,digoxin 250 mcg/mL (0.25 mg/mL) injection solution,641141031,J1160,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,digoxin 250 mcg/mL (0.25 mg/mL) injection solution,641141035,J1160,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,digoxin 250 mcg/mL (0.25 mg/mL) injection solution,781305972,J1160,250,$46.91 ,$46.91 ,$14.07 ,$42.69 ,$32.84 ,$14.07 ,$30.49 ,$33.78 ,$42.69 ,$35.18 
Carle BroMenn Medical Center,8980250,digoxin 250 mcg/mL (0.25 mg/mL) injection solution,781305995,J1160,250,$46.91 ,$46.91 ,$14.07 ,$42.69 ,$32.84 ,$14.07 ,$30.49 ,$33.78 ,$42.69 ,$35.18 
Carle BroMenn Medical Center,8980250,dilTIAZem 30 mg tablet,68682000610,,250,$6.99 ,$6.99 ,$2.10 ,$6.36 ,$4.89 ,$2.10 ,$4.54 ,$5.03 ,$6.36 ,$5.24 
Carle BroMenn Medical Center,8980250,dilTIAZem 5 mg/mL intravenous solution,641601301,,250,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980250,dilTIAZem 5 mg/mL intravenous solution,641601310,,250,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980250,dilTIAZem 5 mg/mL intravenous solution,641601501,,250,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980250,dilTIAZem 5 mg/mL intravenous solution,641601510,,250,$92.71 ,$92.71 ,$27.81 ,$84.37 ,$64.90 ,$27.81 ,$60.26 ,$66.75 ,$84.37 ,$69.53 
Carle BroMenn Medical Center,8980250,dilTIAZem 5 mg/mL intravenous solution,17478093710,,250,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980250,dilTIAZem 5 mg/mL intravenous solution,70860030105,,250,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980250,dilTIAZem 5 mg/mL intravenous solution,70860030141,,250,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980250,dilTIAZem 5 mg/mL intravenous solution,70860030143,,250,$103.04 ,$103.04 ,$30.91 ,$93.77 ,$72.13 ,$30.91 ,$66.98 ,$74.19 ,$93.77 ,$77.28 
Carle BroMenn Medical Center,8980250,dilTIAZem 60 mg tablet,68682000710,,250,$9.63 ,$9.63 ,$2.89 ,$8.76 ,$6.74 ,$2.89 ,$6.26 ,$6.93 ,$8.76 ,$7.22 
Carle BroMenn Medical Center,8980250,"dilTIAZem CD 120 mg capsule,extended release 24 hr",60687019501,,250,$4.35 ,$4.35 ,$1.31 ,$3.96 ,$3.05 ,$1.31 ,$2.83 ,$3.13 ,$3.96 ,$3.26 
Carle BroMenn Medical Center,8980250,"dilTIAZem CD 120 mg capsule,extended release 24 hr",60687019511,,250,$4.35 ,$4.35 ,$1.31 ,$3.96 ,$3.05 ,$1.31 ,$2.83 ,$3.13 ,$3.96 ,$3.26 
Carle BroMenn Medical Center,8980250,"dilTIAZem CD 180 mg capsule,extended release 24 hr",60687020601,,250,$4.71 ,$4.71 ,$1.41 ,$4.29 ,$3.30 ,$1.41 ,$3.06 ,$3.39 ,$4.29 ,$3.53 
Carle BroMenn Medical Center,8980250,"dilTIAZem CD 180 mg capsule,extended release 24 hr",60687020611,,250,$4.71 ,$4.71 ,$1.41 ,$4.29 ,$3.30 ,$1.41 ,$3.06 ,$3.39 ,$4.29 ,$3.53 
Carle BroMenn Medical Center,8980250,"dilTIAZem CD 240 mg capsule,extended release 24 hr",60687021701,,250,$6.08 ,$6.08 ,$1.82 ,$5.53 ,$4.26 ,$1.82 ,$3.95 ,$4.38 ,$5.53 ,$4.56 
Carle BroMenn Medical Center,8980250,"dilTIAZem CD 240 mg capsule,extended release 24 hr",60687021711,,250,$6.08 ,$6.08 ,$1.82 ,$5.53 ,$4.26 ,$1.82 ,$3.95 ,$4.38 ,$5.53 ,$4.56 
Carle BroMenn Medical Center,8980250,"dilTIAZem CD 300 mg capsule,extended release 24 hr",24979002907,,250,$11.16 ,$11.16 ,$3.35 ,$10.16 ,$7.81 ,$3.35 ,$7.25 ,$8.04 ,$10.16 ,$8.37 
Carle BroMenn Medical Center,8980250,"dilTIAZem CD 300 mg capsule,extended release 24 hr",60687022801,,250,$14.82 ,$14.82 ,$4.45 ,$13.49 ,$10.37 ,$4.45 ,$9.63 ,$10.67 ,$13.49 ,$11.12 
Carle BroMenn Medical Center,8980250,"dilTIAZem CD 300 mg capsule,extended release 24 hr",60687022811,,250,$14.82 ,$14.82 ,$4.45 ,$13.49 ,$10.37 ,$4.45 ,$9.63 ,$10.67 ,$13.49 ,$11.12 
Carle BroMenn Medical Center,8980250,diphenhydrAMINE 12.5 mg/5 mL oral liquid,904674172,,250,$1.88 ,$1.88 ,$0.56 ,$1.71 ,$1.32 ,$0.56 ,$1.22 ,$1.35 ,$1.71 ,$1.41 
Carle BroMenn Medical Center,8980250,diphenhydrAMINE 12.5 mg/5 mL oral liquid,904698520,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,diphenhydrAMINE 12.5 mg/5 mL oral liquid,50580053404,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,diphenhydrAMINE 12.5 mg/5 mL oral liquid,69339015201,,250,$2.04 ,$2.04 ,$0.61 ,$1.86 ,$1.43 ,$0.61 ,$1.33 ,$1.47 ,$1.86 ,$1.53 
Carle BroMenn Medical Center,8980250,diphenhydrAMINE 12.5 mg/5 mL oral liquid,69339015219,,250,$1.88 ,$1.88 ,$0.56 ,$1.71 ,$1.32 ,$0.56 ,$1.22 ,$1.35 ,$1.71 ,$1.41 
Carle BroMenn Medical Center,8980250,diphenhydrAMINE 25 mg capsule,904530660,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,diphenhydrAMINE 25 mg capsule,904530661,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,diphenhydrAMINE 25 mg capsule,69618002401,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,diphenhydramine-zinc acetate 2 %-0.1 % topical cream,24385021003,,250,$29.57 ,$29.57 ,$8.87 ,$26.91 ,$20.70 ,$8.87 ,$19.22 ,$21.29 ,$26.91 ,$22.18 
Carle BroMenn Medical Center,8980250,diphenhydramine-zinc acetate 2 %-0.1 % topical cream,45802035803,,250,$25.17 ,$25.17 ,$7.55 ,$22.90 ,$17.62 ,$7.55 ,$16.36 ,$18.12 ,$22.90 ,$18.88 
Carle BroMenn Medical Center,8980250,diphenoxylate-atropine 2.5 mg-0.025 mg tablet,59762106101,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,diphenoxylate-atropine 2.5 mg-0.025 mg tablet,60687056901,,250,$10.09 ,$10.09 ,$3.03 ,$9.18 ,$7.06 ,$3.03 ,$6.56 ,$7.26 ,$9.18 ,$7.57 
Carle BroMenn Medical Center,8980250,diphenoxylate-atropine 2.5 mg-0.025 mg tablet,60687056911,,250,$10.09 ,$10.09 ,$3.03 ,$9.18 ,$7.06 ,$3.03 ,$6.56 ,$7.26 ,$9.18 ,$7.57 
Carle BroMenn Medical Center,8980250,diphenoxylate-atropine 2.5 mg-0.025 mg tablet,62559049001,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,dipyridamole 25 mg tablet,64980013301,,250,$8.95 ,$8.95 ,$2.69 ,$8.14 ,$6.27 ,$2.69 ,$5.82 ,$6.44 ,$8.14 ,$6.71 
Carle BroMenn Medical Center,8980250,"divalproex 125 mg capsule,delayed release sprinkle",55111053201,,250,$7.55 ,$7.55 ,$2.27 ,$6.87 ,$5.29 ,$2.27 ,$4.91 ,$5.44 ,$6.87 ,$5.66 
Carle BroMenn Medical Center,8980250,"divalproex 125 mg capsule,delayed release sprinkle",68084031301,,250,$8.94 ,$8.94 ,$2.68 ,$8.14 ,$6.26 ,$2.68 ,$5.81 ,$6.44 ,$8.14 ,$6.71 
Carle BroMenn Medical Center,8980250,"divalproex 125 mg capsule,delayed release sprinkle",68084031311,,250,$8.94 ,$8.94 ,$2.68 ,$8.14 ,$6.26 ,$2.68 ,$5.81 ,$6.44 ,$8.14 ,$6.71 
Carle BroMenn Medical Center,8980250,"divalproex ER 250 mg tablet,extended release 24 hr",904636361,,250,$9.56 ,$9.56 ,$2.87 ,$8.70 ,$6.69 ,$2.87 ,$6.21 ,$6.88 ,$8.70 ,$7.17 
Carle BroMenn Medical Center,8980250,"divalproex ER 250 mg tablet,extended release 24 hr",68084031001,,250,$13.73 ,$13.73 ,$4.12 ,$12.49 ,$9.61 ,$4.12 ,$8.92 ,$9.89 ,$12.49 ,$10.30 
Carle BroMenn Medical Center,8980250,"divalproex ER 250 mg tablet,extended release 24 hr",68084031011,,250,$13.73 ,$13.73 ,$4.12 ,$12.49 ,$9.61 ,$4.12 ,$8.92 ,$9.89 ,$12.49 ,$10.30 
Carle BroMenn Medical Center,8980250,"divalproex ER 500 mg tablet,extended release 24 hr",904636461,,250,$13.84 ,$13.84 ,$4.15 ,$12.59 ,$9.69 ,$4.15 ,$9.00 ,$9.96 ,$12.59 ,$10.38 
Carle BroMenn Medical Center,8980250,"divalproex ER 500 mg tablet,extended release 24 hr",51079076701,,250,$21.32 ,$21.32 ,$6.40 ,$19.40 ,$14.92 ,$6.40 ,$13.86 ,$15.35 ,$19.40 ,$15.99 
Carle BroMenn Medical Center,8980250,"divalproex ER 500 mg tablet,extended release 24 hr",51079076708,,250,$21.32 ,$21.32 ,$6.40 ,$19.40 ,$14.92 ,$6.40 ,$13.86 ,$15.35 ,$19.40 ,$15.99 
Carle BroMenn Medical Center,8980250,"divalproex ER 500 mg tablet,extended release 24 hr",65862059501,,250,$21.32 ,$21.32 ,$6.40 ,$19.40 ,$14.92 ,$6.40 ,$13.86 ,$15.35 ,$19.40 ,$15.99 
Carle BroMenn Medical Center,8980250,docusate sodium 100 mg capsule,904645561,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,docusate sodium 100 mg capsule,904699860,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,docusate sodium 100 mg capsule,904711561,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,docusate sodium 100 mg capsule,60687012901,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,docusate sodium 100 mg capsule,60687012911,,250,$3.08 ,$3.08 ,$0.92 ,$2.80 ,$2.16 ,$0.92 ,$2.00 ,$2.22 ,$2.80 ,$2.31 
Carle BroMenn Medical Center,8980250,docusate sodium 100 mg capsule,63739047840,,250,$2.47 ,$2.47 ,$0.74 ,$2.25 ,$1.73 ,$0.74 ,$1.61 ,$1.78 ,$2.25 ,$1.85 
Carle BroMenn Medical Center,8980250,docusate sodium 50 mg/5 mL oral liquid,121054410,,250,$0.98 ,$0.98 ,$0.29 ,$0.89 ,$0.69 ,$0.29 ,$0.64 ,$0.71 ,$0.89 ,$0.74 
Carle BroMenn Medical Center,8980250,docusate sodium 50 mg/5 mL oral liquid,50383077116,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,dofetilide 125 mcg capsule,47335006186,,250,$38.12 ,$38.12 ,$11.44 ,$34.69 ,$26.68 ,$11.44 ,$24.78 ,$27.45 ,$34.69 ,$28.59 
Carle BroMenn Medical Center,8980250,dofetilide 250 mcg capsule,16714084101,,250,$31.09 ,$31.09 ,$9.33 ,$28.29 ,$21.76 ,$9.33 ,$20.21 ,$22.38 ,$28.29 ,$23.32 
Carle BroMenn Medical Center,8980250,dofetilide 250 mcg capsule,47335006286,,250,$38.12 ,$38.12 ,$11.44 ,$34.69 ,$26.68 ,$11.44 ,$24.78 ,$27.45 ,$34.69 ,$28.59 
Carle BroMenn Medical Center,8980250,donepeziL 10 mg tablet,60687030301,,250,$5.95 ,$5.95 ,$1.79 ,$5.41 ,$4.17 ,$1.79 ,$3.87 ,$4.28 ,$5.41 ,$4.46 
Carle BroMenn Medical Center,8980250,donepeziL 10 mg tablet,60687030311,,250,$5.95 ,$5.95 ,$1.79 ,$5.41 ,$4.17 ,$1.79 ,$3.87 ,$4.28 ,$5.41 ,$4.46 
Carle BroMenn Medical Center,8980250,donepeziL 5 mg tablet,904647761,,250,$3.09 ,$3.09 ,$0.93 ,$2.81 ,$2.16 ,$0.93 ,$2.01 ,$2.22 ,$2.81 ,$2.32 
Carle BroMenn Medical Center,8980250,donepeziL 5 mg tablet,60687029201,,250,$5.95 ,$5.95 ,$1.79 ,$5.41 ,$4.17 ,$1.79 ,$3.87 ,$4.28 ,$5.41 ,$4.46 
Carle BroMenn Medical Center,8980250,donepeziL 5 mg tablet,60687029211,,250,$5.95 ,$5.95 ,$1.79 ,$5.41 ,$4.17 ,$1.79 ,$3.87 ,$4.28 ,$5.41 ,$4.46 
Carle BroMenn Medical Center,8980250,dorzolamide 2 % eye drops,42571014126,,250,$332.26 ,$332.26 ,$99.68 ,$302.36 ,$232.58 ,$99.68 ,$215.97 ,$239.23 ,$302.36 ,$249.20 
Carle BroMenn Medical Center,8980250,dorzolamide 2 % eye drops,50383023210,,250,$332.26 ,$332.26 ,$99.68 ,$302.36 ,$232.58 ,$99.68 ,$215.97 ,$239.23 ,$302.36 ,$249.20 
Carle BroMenn Medical Center,8980250,doxazosin 1 mg tablet,60505009300,,250,$8.62 ,$8.62 ,$2.59 ,$7.84 ,$6.03 ,$2.59 ,$5.60 ,$6.21 ,$7.84 ,$6.47 
Carle BroMenn Medical Center,8980250,doxazosin 2 mg tablet,60505009400,,250,$8.62 ,$8.62 ,$2.59 ,$7.84 ,$6.03 ,$2.59 ,$5.60 ,$6.21 ,$7.84 ,$6.47 
Carle BroMenn Medical Center,8980250,doxazosin 4 mg tablet,60505009500,,250,$8.93 ,$8.93 ,$2.68 ,$8.13 ,$6.25 ,$2.68 ,$5.80 ,$6.43 ,$8.13 ,$6.70 
Carle BroMenn Medical Center,8980250,doxepin 25 mg capsule,51079043701,,250,$6.26 ,$6.26 ,$1.88 ,$5.70 ,$4.38 ,$1.88 ,$4.07 ,$4.51 ,$5.70 ,$4.70 
Carle BroMenn Medical Center,8980250,doxepin 25 mg capsule,51079043720,,250,$6.26 ,$6.26 ,$1.88 ,$5.70 ,$4.38 ,$1.88 ,$4.07 ,$4.51 ,$5.70 ,$4.70 
Carle BroMenn Medical Center,8980250,doxepin 50 mg capsule,904697261,,250,$8.55 ,$8.55 ,$2.57 ,$7.78 ,$5.99 ,$2.57 ,$5.56 ,$6.16 ,$7.78 ,$6.41 
Carle BroMenn Medical Center,8980250,doxepin 50 mg capsule,51079043801,,250,$7.77 ,$7.77 ,$2.33 ,$7.07 ,$5.44 ,$2.33 ,$5.05 ,$5.59 ,$7.07 ,$5.83 
Carle BroMenn Medical Center,8980250,doxepin 50 mg capsule,51079043820,,250,$7.77 ,$7.77 ,$2.33 ,$7.07 ,$5.44 ,$2.33 ,$5.05 ,$5.59 ,$7.07 ,$5.83 
Carle BroMenn Medical Center,8980250,doxycycline hyclate 100 mg capsule,143314250,,250,$27.51 ,$27.51 ,$8.25 ,$25.03 ,$19.26 ,$8.25 ,$17.88 ,$19.81 ,$25.03 ,$20.63 
Carle BroMenn Medical Center,8980250,doxycycline hyclate 100 mg capsule,143980350,,250,$27.51 ,$27.51 ,$8.25 ,$25.03 ,$19.26 ,$8.25 ,$17.88 ,$19.81 ,$25.03 ,$20.63 
Carle BroMenn Medical Center,8980250,doxycycline hyclate 100 mg capsule,69238110002,,250,$41.81 ,$41.81 ,$12.54 ,$38.05 ,$29.27 ,$12.54 ,$27.18 ,$30.10 ,$38.05 ,$31.36 
Carle BroMenn Medical Center,8980250,doxycycline hyclate 100 mg intravenous powder for solution,143938101,,250,$181.84 ,$181.84 ,$54.55 ,$165.47 ,$127.29 ,$54.55 ,$118.20 ,$130.92 ,$165.47 ,$136.38 
Carle BroMenn Medical Center,8980250,doxycycline hyclate 100 mg intravenous powder for solution,143938110,,250,$181.84 ,$181.84 ,$54.55 ,$165.47 ,$127.29 ,$54.55 ,$118.20 ,$130.92 ,$165.47 ,$136.38 
Carle BroMenn Medical Center,8980250,doxycycline hyclate 100 mg intravenous powder for solution,63323013002,,250,$211.31 ,$211.31 ,$63.39 ,$192.29 ,$147.92 ,$63.39 ,$137.35 ,$152.14 ,$192.29 ,$158.48 
Carle BroMenn Medical Center,8980250,doxycycline hyclate 100 mg intravenous powder for solution,63323013011,,250,$211.31 ,$211.31 ,$63.39 ,$192.29 ,$147.92 ,$63.39 ,$137.35 ,$152.14 ,$192.29 ,$158.48 
Carle BroMenn Medical Center,8980250,doxycycline hyclate 100 mg intravenous powder for solution,63323013017,,250,$181.50 ,$181.50 ,$54.45 ,$165.17 ,$127.05 ,$54.45 ,$117.98 ,$130.68 ,$165.17 ,$136.13 
Carle BroMenn Medical Center,8980250,doxycycline hyclate 100 mg intravenous powder for solution,67457043700,,250,$140.90 ,$140.90 ,$42.27 ,$128.22 ,$98.63 ,$42.27 ,$91.59 ,$101.45 ,$128.22 ,$105.68 
Carle BroMenn Medical Center,8980250,doxycycline hyclate 100 mg intravenous powder for solution,67457043710,,250,$140.90 ,$140.90 ,$42.27 ,$128.22 ,$98.63 ,$42.27 ,$91.59 ,$101.45 ,$128.22 ,$105.68 
Carle BroMenn Medical Center,8980250,doxycycline hyclate 100 mg intravenous powder for solution,68382091001,,250,$204.80 ,$204.80 ,$61.44 ,$186.37 ,$143.36 ,$61.44 ,$133.12 ,$147.46 ,$186.37 ,$153.60 
Carle BroMenn Medical Center,8980250,doxycycline hyclate 100 mg intravenous powder for solution,68382091010,,250,$204.80 ,$204.80 ,$61.44 ,$186.37 ,$143.36 ,$61.44 ,$133.12 ,$147.46 ,$186.37 ,$153.60 
Carle BroMenn Medical Center,8980250,"DULoxetine 20 mg capsule,delayed release",60505299506,,250,$32.64 ,$32.64 ,$9.79 ,$29.70 ,$22.85 ,$9.79 ,$21.22 ,$23.50 ,$29.70 ,$24.48 
Carle BroMenn Medical Center,8980250,"DULoxetine 20 mg capsule,delayed release",67877026360,,250,$31.75 ,$31.75 ,$9.53 ,$28.89 ,$22.23 ,$9.53 ,$20.64 ,$22.86 ,$28.89 ,$23.81 
Carle BroMenn Medical Center,8980250,"DULoxetine 30 mg capsule,delayed release",43547038003,,250,$35.59 ,$35.59 ,$10.68 ,$32.39 ,$24.91 ,$10.68 ,$23.13 ,$25.62 ,$32.39 ,$26.69 
Carle BroMenn Medical Center,8980250,"DULoxetine 30 mg capsule,delayed release",51991074790,,250,$34.54 ,$34.54 ,$10.36 ,$31.43 ,$24.18 ,$10.36 ,$22.45 ,$24.87 ,$31.43 ,$25.91 
Carle BroMenn Medical Center,8980250,"DULoxetine 30 mg capsule,delayed release",67877026490,,250,$35.40 ,$35.40 ,$10.62 ,$32.21 ,$24.78 ,$10.62 ,$23.01 ,$25.49 ,$32.21 ,$26.55 
Carle BroMenn Medical Center,8980250,"DULoxetine 30 mg capsule,delayed release",68001041405,,250,$35.60 ,$35.60 ,$10.68 ,$32.40 ,$24.92 ,$10.68 ,$23.14 ,$25.63 ,$32.40 ,$26.70 
Carle BroMenn Medical Center,8980250,"DULoxetine 60 mg capsule,delayed release",43547038103,,250,$35.59 ,$35.59 ,$10.68 ,$32.39 ,$24.91 ,$10.68 ,$23.13 ,$25.62 ,$32.39 ,$26.69 
Carle BroMenn Medical Center,8980250,"DULoxetine 60 mg capsule,delayed release",51991074890,,250,$34.54 ,$34.54 ,$10.36 ,$31.43 ,$24.18 ,$10.36 ,$22.45 ,$24.87 ,$31.43 ,$25.91 
Carle BroMenn Medical Center,8980250,"DULoxetine 60 mg capsule,delayed release",67877026590,,250,$35.40 ,$35.40 ,$10.62 ,$32.21 ,$24.78 ,$10.62 ,$23.01 ,$25.49 ,$32.21 ,$26.55 
Carle BroMenn Medical Center,8980250,"DULoxetine 60 mg capsule,delayed release",68001041504,,250,$35.60 ,$35.60 ,$10.68 ,$32.40 ,$24.92 ,$10.68 ,$23.14 ,$25.63 ,$32.40 ,$26.70 
Carle BroMenn Medical Center,8980250,dutasteride 0.5 mg capsule,31722013130,,250,$29.33 ,$29.33 ,$8.80 ,$26.69 ,$20.53 ,$8.80 ,$19.06 ,$21.12 ,$26.69 ,$22.00 
Carle BroMenn Medical Center,8980250,electrolyte-A intravenous solution,338022104,,250,$104.77 ,$104.77 ,$31.43 ,$95.34 ,$73.34 ,$31.43 ,$68.10 ,$75.43 ,$95.34 ,$78.58 
Carle BroMenn Medical Center,8980250,electrolyte-S (pH 7.4) intravenous solution,264770700,,250,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980250,enalapril maleate 10 mg tablet,904561061,,250,$9.88 ,$9.88 ,$2.96 ,$8.99 ,$6.92 ,$2.96 ,$6.42 ,$7.11 ,$8.99 ,$7.41 
Carle BroMenn Medical Center,8980250,enalapril maleate 2.5 mg tablet,904560961,,250,$9.12 ,$9.12 ,$2.74 ,$8.30 ,$6.38 ,$2.74 ,$5.93 ,$6.57 ,$8.30 ,$6.84 
Carle BroMenn Medical Center,8980250,enalapril maleate 5 mg tablet,904550261,,250,$9.53 ,$9.53 ,$2.86 ,$8.67 ,$6.67 ,$2.86 ,$6.19 ,$6.86 ,$8.67 ,$7.15 
Carle BroMenn Medical Center,8980250,enalaprilat 1.25 mg/mL intravenous solution,143978601,,250,$63.66 ,$63.66 ,$19.10 ,$57.93 ,$44.56 ,$19.10 ,$41.38 ,$45.84 ,$57.93 ,$47.75 
Carle BroMenn Medical Center,8980250,enalaprilat 1.25 mg/mL intravenous solution,143978610,,250,$63.66 ,$63.66 ,$19.10 ,$57.93 ,$44.56 ,$19.10 ,$41.38 ,$45.84 ,$57.93 ,$47.75 
Carle BroMenn Medical Center,8980250,enalaprilat 1.25 mg/mL intravenous solution,143978701,,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,enalaprilat 1.25 mg/mL intravenous solution,143978710,,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,entacapone 200 mg tablet,781557801,,250,$20.74 ,$20.74 ,$6.22 ,$18.87 ,$14.52 ,$6.22 ,$13.48 ,$14.93 ,$18.87 ,$15.56 
Carle BroMenn Medical Center,8980250,entacapone 200 mg tablet,65862065401,,250,$23.48 ,$23.48 ,$7.04 ,$21.37 ,$16.44 ,$7.04 ,$15.26 ,$16.91 ,$21.37 ,$17.61 
Carle BroMenn Medical Center,8980250,"EPINEPHrine 0.3 mg/0.3 mL injection, auto-injector",49502010202,J3490,250,$778.39 ,$778.39 ,$233.52 ,$708.33 ,$544.87 ,$233.52 ,$505.95 ,$560.44 ,$708.33 ,$583.79 
Carle BroMenn Medical Center,8980250,eplerenone 25 mg tablet,16729029315,,250,$22.55 ,$22.55 ,$6.77 ,$20.52 ,$15.79 ,$6.77 ,$14.66 ,$16.24 ,$20.52 ,$16.91 
Carle BroMenn Medical Center,8980250,eplerenone 25 mg tablet,59762171002,,250,$21.74 ,$21.74 ,$6.52 ,$19.78 ,$15.22 ,$6.52 ,$14.13 ,$15.65 ,$19.78 ,$16.31 
Carle BroMenn Medical Center,8980250,erythromycin 5 mg/gram (0.5 %) eye ointment,574402435,,250,$107.66 ,$107.66 ,$32.30 ,$97.97 ,$75.36 ,$32.30 ,$69.98 ,$77.52 ,$97.97 ,$80.75 
Carle BroMenn Medical Center,8980250,erythromycin 5 mg/gram (0.5 %) eye ointment,17478007031,J3490,250,$62.96 ,$62.96 ,$18.89 ,$57.29 ,$44.07 ,$18.89 ,$40.92 ,$45.33 ,$57.29 ,$47.22 
Carle BroMenn Medical Center,8980250,erythromycin 5 mg/gram (0.5 %) eye ointment,17478007035,J3490,250,$97.02 ,$97.02 ,$29.11 ,$88.29 ,$67.91 ,$29.11 ,$63.06 ,$69.85 ,$88.29 ,$72.77 
Carle BroMenn Medical Center,8980250,erythromycin ethylsuccinate 200 mg/5 mL oral powder for suspension,24338013402,,250,$85.82 ,$85.82 ,$25.75 ,$78.10 ,$60.07 ,$25.75 ,$55.78 ,$61.79 ,$78.10 ,$64.37 
Carle BroMenn Medical Center,8980250,erythromycin ethylsuccinate 200 mg/5 mL oral powder for suspension,24338013610,,250,$76.31 ,$76.31 ,$22.89 ,$69.44 ,$53.42 ,$22.89 ,$49.60 ,$54.94 ,$69.44 ,$57.23 
Carle BroMenn Medical Center,8980250,erythromycin ethylsuccinate 200 mg/5 mL oral powder for suspension,52536013413,,250,$75.17 ,$75.17 ,$22.55 ,$68.40 ,$52.62 ,$22.55 ,$48.86 ,$54.12 ,$68.40 ,$56.38 
Carle BroMenn Medical Center,8980250,esmoloL 100 mg/10 mL (10 mg/mL) intravenous solution,25021031410,,250,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980250,esmoloL 100 mg/10 mL (10 mg/mL) intravenous solution,55150019410,,250,$54.62 ,$54.62 ,$16.39 ,$49.70 ,$38.23 ,$16.39 ,$35.50 ,$39.33 ,$49.70 ,$40.97 
Carle BroMenn Medical Center,8980250,esmoloL 100 mg/10 mL (10 mg/mL) intravenous solution,63323065210,,250,$103.85 ,$103.85 ,$31.16 ,$94.50 ,$72.70 ,$31.16 ,$67.50 ,$74.77 ,$94.50 ,$77.89 
Carle BroMenn Medical Center,8980250,esmolol 100 mg/10 mL (10 mg/mL) IV,25021031410,,250,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980250,esmolol 100 mg/10 mL (10 mg/mL) IV,55150019410,,250,$54.62 ,$54.62 ,$16.39 ,$49.70 ,$38.23 ,$16.39 ,$35.50 ,$39.33 ,$49.70 ,$40.97 
Carle BroMenn Medical Center,8980250,esmolol 100 mg/10 mL (10 mg/mL) IV,63323065210,,250,$103.85 ,$103.85 ,$31.16 ,$94.50 ,$72.70 ,$31.16 ,$67.50 ,$74.77 ,$94.50 ,$77.89 
Carle BroMenn Medical Center,8980250,"esmoloL 2,000 mg/100 mL (20 mg/mL) in sodium chloride (iso-osmotic) IV",10019007587,,250,"$3,522.75 ","$3,522.75 ","$1,056.83 ","$3,205.70 ","$2,465.93 ","$1,056.83 ","$2,289.79 ","$2,536.38 ","$3,205.70 ","$2,642.06 "
Carle BroMenn Medical Center,8980250,"esmoloL 2,000 mg/100 mL (20 mg/mL) in sodium chloride (iso-osmotic) IV",25021030982,,250,"$2,433.25 ","$2,433.25 ",$729.98 ,"$2,214.26 ","$1,703.28 ",$729.98 ,"$1,581.61 ","$1,751.94 ","$2,214.26 ","$1,824.94 "
Carle BroMenn Medical Center,8980250,estradioL 0.05 mg/24 hr weekly transdermal patch,378335099,,250,$89.38 ,$89.38 ,$26.81 ,$81.34 ,$62.57 ,$26.81 ,$58.10 ,$64.35 ,$81.34 ,$67.04 
Carle BroMenn Medical Center,8980250,estradioL 0.1 mg/24 hr weekly transdermal patch,378335216,,250,$89.38 ,$89.38 ,$26.81 ,$81.34 ,$62.57 ,$26.81 ,$58.10 ,$64.35 ,$81.34 ,$67.04 
Carle BroMenn Medical Center,8980250,estradioL 0.1 mg/24 hr weekly transdermal patch,378335299,,250,$89.38 ,$89.38 ,$26.81 ,$81.34 ,$62.57 ,$26.81 ,$58.10 ,$64.35 ,$81.34 ,$67.04 
Carle BroMenn Medical Center,8980250,estradioL 1 mg tablet,378145401,,250,$4.10 ,$4.10 ,$1.23 ,$3.73 ,$2.87 ,$1.23 ,$2.67 ,$2.95 ,$3.73 ,$3.08 
Carle BroMenn Medical Center,8980250,estradioL 1 mg tablet,42806008801,,250,$5.50 ,$5.50 ,$1.65 ,$5.01 ,$3.85 ,$1.65 ,$3.58 ,$3.96 ,$5.01 ,$4.13 
Carle BroMenn Medical Center,8980250,estradioL 1 mg tablet,51862033301,,250,$5.50 ,$5.50 ,$1.65 ,$5.01 ,$3.85 ,$1.65 ,$3.58 ,$3.96 ,$5.01 ,$4.13 
Carle BroMenn Medical Center,8980250,ethambutoL 400 mg tablet,68084028001,,250,$9.90 ,$9.90 ,$2.97 ,$9.01 ,$6.93 ,$2.97 ,$6.44 ,$7.13 ,$9.01 ,$7.43 
Carle BroMenn Medical Center,8980250,ethambutoL 400 mg tablet,68084028011,,250,$9.90 ,$9.90 ,$2.97 ,$9.01 ,$6.93 ,$2.97 ,$6.44 ,$7.13 ,$9.01 ,$7.43 
Carle BroMenn Medical Center,8980250,ethambutoL 400 mg tablet,68850001202,,250,$6.87 ,$6.87 ,$2.06 ,$6.25 ,$4.81 ,$2.06 ,$4.47 ,$4.95 ,$6.25 ,$5.15 
Carle BroMenn Medical Center,8980250,ethanol (ethyl alcohol) 98 % injection solution,17478050305,,250,"$2,076.70 ","$2,076.70 ",$623.01 ,"$1,889.80 ","$1,453.69 ",$623.01 ,"$1,349.86 ","$1,495.22 ","$1,889.80 ","$1,557.53 "
Carle BroMenn Medical Center,8980250,etomidate 2 mg/mL intravenous solution,143950701,,250,$50.31 ,$50.31 ,$15.09 ,$45.78 ,$35.22 ,$15.09 ,$32.70 ,$36.22 ,$45.78 ,$37.73 
Carle BroMenn Medical Center,8980250,etomidate 2 mg/mL intravenous solution,409669502,,250,$48.21 ,$48.21 ,$14.46 ,$43.87 ,$33.75 ,$14.46 ,$31.34 ,$34.71 ,$43.87 ,$36.16 
Carle BroMenn Medical Center,8980250,etomidate 2 mg/mL intravenous solution,55150022220,,250,$68.00 ,$68.00 ,$20.40 ,$61.88 ,$47.60 ,$20.40 ,$44.20 ,$48.96 ,$61.88 ,$51.00 
Carle BroMenn Medical Center,8980250,etomidate 2 mg/mL intravenous solution,65219044702,,250,$47.75 ,$47.75 ,$14.33 ,$43.45 ,$33.43 ,$14.33 ,$31.04 ,$34.38 ,$43.45 ,$35.81 
Carle BroMenn Medical Center,8980250,etomidate 2 mg/mL intravenous solution,65219044720,,250,$47.75 ,$47.75 ,$14.33 ,$43.45 ,$33.43 ,$14.33 ,$31.04 ,$34.38 ,$43.45 ,$35.81 
Carle BroMenn Medical Center,8980250,etomidate 2 mg/mL intravenous solution,72266014701,,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,etomidate 2 mg/mL intravenous solution,72266014710,,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,famotidine (PF) 20 mg/2 mL intravenous solution,63323073911,J3490,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,famotidine (PF) 20 mg/2 mL intravenous solution,63323073912,J3490,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,famotidine (PF) 20 mg/2 mL intravenous solution,63323073916,J3490,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,famotidine (PF) 20 mg/2 mL intravenous solution,67457043300,J3490,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,famotidine (PF) 20 mg/2 mL intravenous solution,67457043322,J3490,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,famotidine 20 mg tablet,60687059501,,250,$3.45 ,$3.45 ,$1.04 ,$3.14 ,$2.42 ,$1.04 ,$2.24 ,$2.48 ,$3.14 ,$2.59 
Carle BroMenn Medical Center,8980250,famotidine 20 mg tablet,60687059511,,250,$3.45 ,$3.45 ,$1.04 ,$3.14 ,$2.42 ,$1.04 ,$2.24 ,$2.48 ,$3.14 ,$2.59 
Carle BroMenn Medical Center,8980250,famotidine 20 mg tablet,62332000131,,250,$10.39 ,$10.39 ,$3.12 ,$9.45 ,$7.27 ,$3.12 ,$6.75 ,$7.48 ,$9.45 ,$7.79 
Carle BroMenn Medical Center,8980250,famotidine 20 mg tablet,63739064510,,250,$2.81 ,$2.81 ,$0.84 ,$2.56 ,$1.97 ,$0.84 ,$1.83 ,$2.02 ,$2.56 ,$2.11 
Carle BroMenn Medical Center,8980250,famotidine 20 mg tablet,65862085901,,250,$13.62 ,$13.62 ,$4.09 ,$12.39 ,$9.53 ,$4.09 ,$8.85 ,$9.81 ,$12.39 ,$10.22 
Carle BroMenn Medical Center,8980250,famotidine 20 mg tablet,68001039700,,250,$13.62 ,$13.62 ,$4.09 ,$12.39 ,$9.53 ,$4.09 ,$8.85 ,$9.81 ,$12.39 ,$10.22 
Carle BroMenn Medical Center,8980250,fat emulsion-soybean oiL-mct-olive oil-fish oiL 20 % intravenous,63323082000,C9399,250,$157.05 ,$157.05 ,$47.12 ,$142.92 ,$109.94 ,$47.12 ,$102.08 ,$113.08 ,$142.92 ,$117.79 
Carle BroMenn Medical Center,8980250,fat emulsion-soybean oiL-mct-olive oil-fish oiL 20 % intravenous,63323082001,C9399,250,$157.05 ,$157.05 ,$47.12 ,$142.92 ,$109.94 ,$47.12 ,$102.08 ,$113.08 ,$142.92 ,$117.79 
Carle BroMenn Medical Center,8980250,fat emulsion-soybean oiL-mct-olive oil-fish oiL 20 % intravenous,63323082003,C9399,250,$242.02 ,$242.02 ,$72.61 ,$220.24 ,$169.41 ,$72.61 ,$157.31 ,$174.25 ,$220.24 ,$181.52 
Carle BroMenn Medical Center,8980250,fat emulsion-soybean oiL-mct-olive oil-fish oiL 20 % intravenous,63323082004,C9399,250,$192.55 ,$192.55 ,$57.77 ,$175.22 ,$134.79 ,$57.77 ,$125.16 ,$138.64 ,$175.22 ,$144.41 
Carle BroMenn Medical Center,8980250,fat emulsion-soybean oiL-mct-olive oil-fish oiL 20 % intravenous,63323082005,C9399,250,$445.72 ,$445.72 ,$133.72 ,$405.61 ,$312.00 ,$133.72 ,$289.72 ,$320.92 ,$405.61 ,$334.29 
Carle BroMenn Medical Center,8980250,fat emulsion-soybean oiL-mct-olive oil-fish oiL 20 % intravenous,63323082010,C9399,250,$445.72 ,$445.72 ,$133.72 ,$405.61 ,$312.00 ,$133.72 ,$289.72 ,$320.92 ,$405.61 ,$334.29 
Carle BroMenn Medical Center,8980250,febuxostat 40 mg tablet,72205002830,,250,$43.38 ,$43.38 ,$13.01 ,$39.48 ,$30.37 ,$13.01 ,$28.20 ,$31.23 ,$39.48 ,$32.54 
Carle BroMenn Medical Center,8980250,fenofibrate 160 mg tablet,115552210,,250,$13.40 ,$13.40 ,$4.02 ,$12.19 ,$9.38 ,$4.02 ,$8.71 ,$9.65 ,$12.19 ,$10.05 
Carle BroMenn Medical Center,8980250,fenofibrate 160 mg tablet,42858066045,,250,$15.75 ,$15.75 ,$4.73 ,$14.33 ,$11.03 ,$4.73 ,$10.24 ,$11.34 ,$14.33 ,$11.81 
Carle BroMenn Medical Center,8980250,fenofibrate 160 mg tablet,70756021590,,250,$13.40 ,$13.40 ,$4.02 ,$12.19 ,$9.38 ,$4.02 ,$8.71 ,$9.65 ,$12.19 ,$10.05 
Carle BroMenn Medical Center,8980250,fenofibrate 54 mg tablet,63304090090,,250,$6.02 ,$6.02 ,$1.81 ,$5.48 ,$4.21 ,$1.81 ,$3.91 ,$4.33 ,$5.48 ,$4.52 
Carle BroMenn Medical Center,8980250,fenofibrate 54 mg tablet,70756021490,,250,$6.02 ,$6.02 ,$1.81 ,$5.48 ,$4.21 ,$1.81 ,$3.91 ,$4.33 ,$5.48 ,$4.52 
Carle BroMenn Medical Center,8980250,fentaNYL 100 mcg/hr transdermal patch,406900076,,250,$197.25 ,$197.25 ,$59.18 ,$179.50 ,$138.08 ,$59.18 ,$128.21 ,$142.02 ,$179.50 ,$147.94 
Carle BroMenn Medical Center,8980250,fentaNYL 50 mcg/hr transdermal patch,406915076,,250,$102.75 ,$102.75 ,$30.83 ,$93.50 ,$71.93 ,$30.83 ,$66.79 ,$73.98 ,$93.50 ,$77.06 
Carle BroMenn Medical Center,8980250,fentaNYL 50 mcg/hr transdermal patch,47781042647,,250,$146.58 ,$146.58 ,$43.97 ,$133.39 ,$102.61 ,$43.97 ,$95.28 ,$105.54 ,$133.39 ,$109.94 
Carle BroMenn Medical Center,8980250,fentaNYL 50 mcg/hr transdermal patch,60505708200,,250,$146.58 ,$146.58 ,$43.97 ,$133.39 ,$102.61 ,$43.97 ,$95.28 ,$105.54 ,$133.39 ,$109.94 
Carle BroMenn Medical Center,8980250,fentaNYL 50 mcg/hr transdermal patch,60505708202,,250,$146.58 ,$146.58 ,$43.97 ,$133.39 ,$102.61 ,$43.97 ,$95.28 ,$105.54 ,$133.39 ,$109.94 
Carle BroMenn Medical Center,8980250,fentaNYL 75 mcg/hr transdermal patch,406907576,,250,$151.23 ,$151.23 ,$45.37 ,$137.62 ,$105.86 ,$45.37 ,$98.30 ,$108.89 ,$137.62 ,$113.42 
Carle BroMenn Medical Center,8980250,fentaNYL 75 mcg/hr transdermal patch,406917576,,250,$151.23 ,$151.23 ,$45.37 ,$137.62 ,$105.86 ,$45.37 ,$98.30 ,$108.89 ,$137.62 ,$113.42 
Carle BroMenn Medical Center,8980250,ferric subsulfate 259 mg/g topical solution,59365606500,,250,$56.39 ,$56.39 ,$16.92 ,$51.31 ,$39.47 ,$16.92 ,$36.65 ,$40.60 ,$51.31 ,$42.29 
Carle BroMenn Medical Center,8980250,ferrous sulfate 15 mg iron (75 mg)/mL oral drops,54838001150,,250,$40.46 ,$40.46 ,$12.14 ,$36.82 ,$28.32 ,$12.14 ,$26.30 ,$29.13 ,$36.82 ,$30.35 
Carle BroMenn Medical Center,8980250,ferrous sulfate 220 mg (44 mg iron)/5 mL oral elixir,50383077816,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,ferrous sulfate 220 mg (44 mg iron)/5 mL oral elixir,54838000180,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,ferrous sulfate 325 mg (65 mg iron) tablet,904759161,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,finasteride 5 mg tablet,60687042811,,250,$9.69 ,$9.69 ,$2.91 ,$8.82 ,$6.78 ,$2.91 ,$6.30 ,$6.98 ,$8.82 ,$7.27 
Carle BroMenn Medical Center,8980250,flecainide 100 mg tablet,50268032111,,250,$29.06 ,$29.06 ,$8.72 ,$26.44 ,$20.34 ,$8.72 ,$18.89 ,$20.92 ,$26.44 ,$21.80 
Carle BroMenn Medical Center,8980250,flecainide 100 mg tablet,50268032115,,250,$29.06 ,$29.06 ,$8.72 ,$26.44 ,$20.34 ,$8.72 ,$18.89 ,$20.92 ,$26.44 ,$21.80 
Carle BroMenn Medical Center,8980250,flecainide 50 mg tablet,54001020,,250,$11.74 ,$11.74 ,$3.52 ,$10.68 ,$8.22 ,$3.52 ,$7.63 ,$8.45 ,$10.68 ,$8.81 
Carle BroMenn Medical Center,8980250,flecainide 50 mg tablet,62559038001,,250,$10.44 ,$10.44 ,$3.13 ,$9.50 ,$7.31 ,$3.13 ,$6.79 ,$7.52 ,$9.50 ,$7.83 
Carle BroMenn Medical Center,8980250,fluconazole 100 mg tablet,55111014430,,250,$38.79 ,$38.79 ,$11.64 ,$35.30 ,$27.15 ,$11.64 ,$25.21 ,$27.93 ,$35.30 ,$29.09 
Carle BroMenn Medical Center,8980250,fluconazole 100 mg tablet,62559099130,,250,$38.79 ,$38.79 ,$11.64 ,$35.30 ,$27.15 ,$11.64 ,$25.21 ,$27.93 ,$35.30 ,$29.09 
Carle BroMenn Medical Center,8980250,fluconazole 100 mg tablet,67405060203,,250,$38.79 ,$38.79 ,$11.64 ,$35.30 ,$27.15 ,$11.64 ,$25.21 ,$27.93 ,$35.30 ,$29.09 
Carle BroMenn Medical Center,8980250,fluconazole 100 mg tablet,70710113803,,250,$38.79 ,$38.79 ,$11.64 ,$35.30 ,$27.15 ,$11.64 ,$25.21 ,$27.93 ,$35.30 ,$29.09 
Carle BroMenn Medical Center,8980250,fluconazole 150 mg tablet,62559099212,,250,$57.06 ,$57.06 ,$17.12 ,$51.92 ,$39.94 ,$17.12 ,$37.09 ,$41.08 ,$51.92 ,$42.80 
Carle BroMenn Medical Center,8980250,fluconazole 150 mg tablet,68001025320,,250,$57.19 ,$57.19 ,$17.16 ,$52.04 ,$40.03 ,$17.16 ,$37.17 ,$41.18 ,$52.04 ,$42.89 
Carle BroMenn Medical Center,8980250,fluconazole 150 mg tablet,68001025321,,250,$57.19 ,$57.19 ,$17.16 ,$52.04 ,$40.03 ,$17.16 ,$37.17 ,$41.18 ,$52.04 ,$42.89 
Carle BroMenn Medical Center,8980250,fluconazole 150 mg tablet,68462011940,,250,$57.19 ,$57.19 ,$17.16 ,$52.04 ,$40.03 ,$17.16 ,$37.17 ,$41.18 ,$52.04 ,$42.89 
Carle BroMenn Medical Center,8980250,fluconazole 150 mg tablet,68462011944,,250,$57.19 ,$57.19 ,$17.16 ,$52.04 ,$40.03 ,$17.16 ,$37.17 ,$41.18 ,$52.04 ,$42.89 
Carle BroMenn Medical Center,8980250,fluconazole 150 mg tablet,70710113907,,250,$56.92 ,$56.92 ,$17.08 ,$51.80 ,$39.84 ,$17.08 ,$37.00 ,$40.98 ,$51.80 ,$42.69 
Carle BroMenn Medical Center,8980250,fluconazole 150 mg tablet,70710113908,,250,$56.92 ,$56.92 ,$17.08 ,$51.80 ,$39.84 ,$17.08 ,$37.00 ,$40.98 ,$51.80 ,$42.69 
Carle BroMenn Medical Center,8980250,fludrocortisone 0.1 mg tablet,50268033011,,250,$9.78 ,$9.78 ,$2.93 ,$8.90 ,$6.85 ,$2.93 ,$6.36 ,$7.04 ,$8.90 ,$7.34 
Carle BroMenn Medical Center,8980250,fludrocortisone 0.1 mg tablet,50268033015,,250,$9.78 ,$9.78 ,$2.93 ,$8.90 ,$6.85 ,$2.93 ,$6.36 ,$7.04 ,$8.90 ,$7.34 
Carle BroMenn Medical Center,8980250,flumazeniL 0.1 mg/mL intravenous solution,143978401,,250,$50.69 ,$50.69 ,$15.21 ,$46.13 ,$35.48 ,$15.21 ,$32.95 ,$36.50 ,$46.13 ,$38.02 
Carle BroMenn Medical Center,8980250,flumazeniL 0.1 mg/mL intravenous solution,36000014810,,250,$48.80 ,$48.80 ,$14.64 ,$44.41 ,$34.16 ,$14.64 ,$31.72 ,$35.14 ,$44.41 ,$36.60 
Carle BroMenn Medical Center,8980250,fluocinonide 0.05 % topical cream,93026215,,250,$233.26 ,$233.26 ,$69.98 ,$212.27 ,$163.28 ,$69.98 ,$151.62 ,$167.95 ,$212.27 ,$174.95 
Carle BroMenn Medical Center,8980250,fluorescein 1 mg eye strips,17238090030,,250,$3.18 ,$3.18 ,$0.95 ,$2.89 ,$2.23 ,$0.95 ,$2.07 ,$2.29 ,$2.89 ,$2.39 
Carle BroMenn Medical Center,8980250,fluorescein 500 mg/5 mL (10 %) intravenous solution,65009265,,250,$340.17 ,$340.17 ,$102.05 ,$309.55 ,$238.12 ,$102.05 ,$221.11 ,$244.92 ,$309.55 ,$255.13 
Carle BroMenn Medical Center,8980250,fluorescein 500 mg/5 mL (10 %) intravenous solution,17478025310,,250,$268.94 ,$268.94 ,$80.68 ,$244.74 ,$188.26 ,$80.68 ,$174.81 ,$193.64 ,$244.74 ,$201.71 
Carle BroMenn Medical Center,8980250,FLUoxetine 10 mg capsule,904578461,,250,$13.60 ,$13.60 ,$4.08 ,$12.38 ,$9.52 ,$4.08 ,$8.84 ,$9.79 ,$12.38 ,$10.20 
Carle BroMenn Medical Center,8980250,FLUoxetine 10 mg capsule,68001039900,,250,$14.44 ,$14.44 ,$4.33 ,$13.14 ,$10.11 ,$4.33 ,$9.39 ,$10.40 ,$13.14 ,$10.83 
Carle BroMenn Medical Center,8980250,FLUoxetine 20 mg capsule,904578561,,250,$13.91 ,$13.91 ,$4.17 ,$12.66 ,$9.74 ,$4.17 ,$9.04 ,$10.02 ,$12.66 ,$10.43 
Carle BroMenn Medical Center,8980250,FLUoxetine 20 mg capsule,68001040000,,250,$14.76 ,$14.76 ,$4.43 ,$13.43 ,$10.33 ,$4.43 ,$9.59 ,$10.63 ,$13.43 ,$11.07 
Carle BroMenn Medical Center,8980250,FLUoxetine 20 mg/5 mL (4 mg/mL) oral solution,54838052340,,250,$24.15 ,$24.15 ,$7.25 ,$21.98 ,$16.91 ,$7.25 ,$15.70 ,$17.39 ,$21.98 ,$18.11 
Carle BroMenn Medical Center,8980250,FLUoxetine 40 mg capsule,68084010101,,250,$19.23 ,$19.23 ,$5.77 ,$17.50 ,$13.46 ,$5.77 ,$12.50 ,$13.85 ,$17.50 ,$14.42 
Carle BroMenn Medical Center,8980250,FLUoxetine 40 mg capsule,68084010111,,250,$19.23 ,$19.23 ,$5.77 ,$17.50 ,$13.46 ,$5.77 ,$12.50 ,$13.85 ,$17.50 ,$14.42 
Carle BroMenn Medical Center,8980250,fluPHENAZine 1 mg tablet,527178801,,250,$22.80 ,$22.80 ,$6.84 ,$20.75 ,$15.96 ,$6.84 ,$14.82 ,$16.42 ,$20.75 ,$17.10 
Carle BroMenn Medical Center,8980250,fluticasone fur. 100 mcg-umeclid 62.5 mcg-vilant 25 mcg inhalat.powder,173088714,,250,"$2,056.94 ","$2,056.94 ",$617.08 ,"$1,871.82 ","$1,439.86 ",$617.08 ,"$1,337.01 ","$1,481.00 ","$1,871.82 ","$1,542.71 "
Carle BroMenn Medical Center,8980250,fluticasone furoate 100 mcg-vilanteroL 25 mcg/dose inhalation powder,173085914,,250,"$1,100.69 ","$1,100.69 ",$330.21 ,"$1,001.63 ",$770.48 ,$330.21 ,$715.45 ,$792.50 ,"$1,001.63 ",$825.52 
Carle BroMenn Medical Center,8980250,fluticasone furoate 200 mcg-vilanteroL 25 mcg/dose inhalation powder,173088214,,250,$39.31 ,$39.31 ,$11.79 ,$35.77 ,$27.52 ,$11.79 ,$25.55 ,$28.30 ,$35.77 ,$29.48 
Carle BroMenn Medical Center,8980250,"fluticasone propionate 50 mcg/actuation nasal spray,suspension",50383070016,,250,$413.90 ,$413.90 ,$124.17 ,$376.65 ,$289.73 ,$124.17 ,$269.04 ,$298.01 ,$376.65 ,$310.43 
Carle BroMenn Medical Center,8980250,"fluticasone propionate 50 mcg/actuation nasal spray,suspension",60505082901,,250,$418.30 ,$418.30 ,$125.49 ,$380.65 ,$292.81 ,$125.49 ,$271.90 ,$301.18 ,$380.65 ,$313.73 
Carle BroMenn Medical Center,8980250,fluvoxaMINE 50 mg tablet,62559015901,,250,$14.31 ,$14.31 ,$4.29 ,$13.02 ,$10.02 ,$4.29 ,$9.30 ,$10.30 ,$13.02 ,$10.73 
Carle BroMenn Medical Center,8980250,folic acid 1 mg tablet,62584089701,,250,$3.22 ,$3.22 ,$0.97 ,$2.93 ,$2.25 ,$0.97 ,$2.09 ,$2.32 ,$2.93 ,$2.42 
Carle BroMenn Medical Center,8980250,folic acid 1 mg tablet,62584089711,,250,$3.22 ,$3.22 ,$0.97 ,$2.93 ,$2.25 ,$0.97 ,$2.09 ,$2.32 ,$2.93 ,$2.42 
Carle BroMenn Medical Center,8980250,folic acid 400 mcg tablet,536384401,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,folic acid 400 mcg tablet,50268034615,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,folic acid 400 mcg tablet,80681009900,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,folic acid 5 mg/mL injection solution,39822110001,,250,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980250,folic acid 5 mg/mL injection solution,63323018410,,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,furosemide 20 mg tablet,51079007201,,250,$3.02 ,$3.02 ,$0.91 ,$2.75 ,$2.11 ,$0.91 ,$1.96 ,$2.17 ,$2.75 ,$2.27 
Carle BroMenn Medical Center,8980250,furosemide 20 mg tablet,51079007220,,250,$3.02 ,$3.02 ,$0.91 ,$2.75 ,$2.11 ,$0.91 ,$1.96 ,$2.17 ,$2.75 ,$2.27 
Carle BroMenn Medical Center,8980250,furosemide 40 mg tablet,51079007301,,250,$3.11 ,$3.11 ,$0.93 ,$2.83 ,$2.18 ,$0.93 ,$2.02 ,$2.24 ,$2.83 ,$2.33 
Carle BroMenn Medical Center,8980250,furosemide 40 mg tablet,51079007320,,250,$3.11 ,$3.11 ,$0.93 ,$2.83 ,$2.18 ,$0.93 ,$2.02 ,$2.24 ,$2.83 ,$2.33 
Carle BroMenn Medical Center,8980250,furosemide 80 mg tablet,51079052701,,250,$4.43 ,$4.43 ,$1.33 ,$4.03 ,$3.10 ,$1.33 ,$2.88 ,$3.19 ,$4.03 ,$3.32 
Carle BroMenn Medical Center,8980250,furosemide 80 mg tablet,51079052720,,250,$4.43 ,$4.43 ,$1.33 ,$4.03 ,$3.10 ,$1.33 ,$2.88 ,$3.19 ,$4.03 ,$3.32 
Carle BroMenn Medical Center,8980250,furosemide 80 mg tablet,69315011801,,250,$4.37 ,$4.37 ,$1.31 ,$3.98 ,$3.06 ,$1.31 ,$2.84 ,$3.15 ,$3.98 ,$3.28 
Carle BroMenn Medical Center,8980250,gabapentin 100 mg capsule,904666561,,250,$2.98 ,$2.98 ,$0.89 ,$2.71 ,$2.09 ,$0.89 ,$1.94 ,$2.15 ,$2.71 ,$2.24 
Carle BroMenn Medical Center,8980250,gabapentin 100 mg capsule,60687058001,,250,$5.05 ,$5.05 ,$1.52 ,$4.60 ,$3.54 ,$1.52 ,$3.28 ,$3.64 ,$4.60 ,$3.79 
Carle BroMenn Medical Center,8980250,gabapentin 100 mg capsule,60687058011,,250,$5.05 ,$5.05 ,$1.52 ,$4.60 ,$3.54 ,$1.52 ,$3.28 ,$3.64 ,$4.60 ,$3.79 
Carle BroMenn Medical Center,8980250,gabapentin 100 mg capsule,68084078301,,250,$5.05 ,$5.05 ,$1.52 ,$4.60 ,$3.54 ,$1.52 ,$3.28 ,$3.64 ,$4.60 ,$3.79 
Carle BroMenn Medical Center,8980250,gabapentin 300 mg capsule,904666661,,250,$3.24 ,$3.24 ,$0.97 ,$2.95 ,$2.27 ,$0.97 ,$2.11 ,$2.33 ,$2.95 ,$2.43 
Carle BroMenn Medical Center,8980250,gabapentin 300 mg capsule,60687059101,,250,$8.75 ,$8.75 ,$2.63 ,$7.96 ,$6.13 ,$2.63 ,$5.69 ,$6.30 ,$7.96 ,$6.56 
Carle BroMenn Medical Center,8980250,gabapentin 300 mg capsule,60687059111,,250,$8.75 ,$8.75 ,$2.63 ,$7.96 ,$6.13 ,$2.63 ,$5.69 ,$6.30 ,$7.96 ,$6.56 
Carle BroMenn Medical Center,8980250,gabapentin 400 mg capsule,904666761,,250,$3.48 ,$3.48 ,$1.04 ,$3.17 ,$2.44 ,$1.04 ,$2.26 ,$2.51 ,$3.17 ,$2.61 
Carle BroMenn Medical Center,8980250,galantamine 4 mg tablet,57237004960,,250,$17.16 ,$17.16 ,$5.15 ,$15.62 ,$12.01 ,$5.15 ,$11.15 ,$12.36 ,$15.62 ,$12.87 
Carle BroMenn Medical Center,8980250,galantamine 4 mg tablet,65862045860,,250,$17.16 ,$17.16 ,$5.15 ,$15.62 ,$12.01 ,$5.15 ,$11.15 ,$12.36 ,$15.62 ,$12.87 
Carle BroMenn Medical Center,8980250,gemfibroziL 600 mg tablet,60687022401,,250,$13.12 ,$13.12 ,$3.94 ,$11.94 ,$9.18 ,$3.94 ,$8.53 ,$9.45 ,$11.94 ,$9.84 
Carle BroMenn Medical Center,8980250,gemfibroziL 600 mg tablet,60687022411,,250,$13.12 ,$13.12 ,$3.94 ,$11.94 ,$9.18 ,$3.94 ,$8.53 ,$9.45 ,$11.94 ,$9.84 
Carle BroMenn Medical Center,8980250,gentamicin 0.1 % topical cream,45802005611,,250,$481.19 ,$481.19 ,$144.36 ,$437.88 ,$336.83 ,$144.36 ,$312.77 ,$346.46 ,$437.88 ,$360.89 
Carle BroMenn Medical Center,8980250,gentamicin 0.1 % topical cream,45802005635,,250,$251.08 ,$251.08 ,$75.32 ,$228.48 ,$175.76 ,$75.32 ,$163.20 ,$180.78 ,$228.48 ,$188.31 
Carle BroMenn Medical Center,8980250,gentamicin 0.1 % topical cream,52565008515,,250,$251.08 ,$251.08 ,$75.32 ,$228.48 ,$175.76 ,$75.32 ,$163.20 ,$180.78 ,$228.48 ,$188.31 
Carle BroMenn Medical Center,8980250,gentamicin 0.3 % (3 mg/gram) eye ointment,17478028435,,250,$179.80 ,$179.80 ,$53.94 ,$163.62 ,$125.86 ,$53.94 ,$116.87 ,$129.46 ,$163.62 ,$134.85 
Carle BroMenn Medical Center,8980250,gentamicin 0.3 % eye drops,60758018805,,250,$110.35 ,$110.35 ,$33.11 ,$100.42 ,$77.25 ,$33.11 ,$71.73 ,$79.45 ,$100.42 ,$82.76 
Carle BroMenn Medical Center,8980250,gentamicin 0.3 % eye drops,61314063305,,250,$122.09 ,$122.09 ,$36.63 ,$111.10 ,$85.46 ,$36.63 ,$79.36 ,$87.90 ,$111.10 ,$91.57 
Carle BroMenn Medical Center,8980250,glipiZIDE 10 mg tablet,60505014200,,250,$5.45 ,$5.45 ,$1.64 ,$4.96 ,$3.82 ,$1.64 ,$3.54 ,$3.92 ,$4.96 ,$4.09 
Carle BroMenn Medical Center,8980250,glipiZIDE 5 mg tablet,51079081001,,250,$4.08 ,$4.08 ,$1.22 ,$3.71 ,$2.86 ,$1.22 ,$2.65 ,$2.94 ,$3.71 ,$3.06 
Carle BroMenn Medical Center,8980250,glipiZIDE 5 mg tablet,51079081020,,250,$4.08 ,$4.08 ,$1.22 ,$3.71 ,$2.86 ,$1.22 ,$2.65 ,$2.94 ,$3.71 ,$3.06 
Carle BroMenn Medical Center,8980250,glipiZIDE 5 mg tablet,60505014100,,250,$4.03 ,$4.03 ,$1.21 ,$3.67 ,$2.82 ,$1.21 ,$2.62 ,$2.90 ,$3.67 ,$3.02 
Carle BroMenn Medical Center,8980250,glucose 4 gram chewable tablet,38396051963,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,glucose 4 gram chewable tablet,56151161011,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,glucose 4 gram chewable tablet,80681010000,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,glucose 4 gram chewable tablet,87701042600,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,glucose 4 gram chewable tablet,87701042601,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,glycerin 99.5 % topical solution,395103116,,250,$13.98 ,$13.98 ,$4.19 ,$12.72 ,$9.79 ,$4.19 ,$9.09 ,$10.07 ,$12.72 ,$10.49 
Carle BroMenn Medical Center,8980250,glycerin 99.5 % topical solution,395103196,,250,$17.47 ,$17.47 ,$5.24 ,$15.90 ,$12.23 ,$5.24 ,$11.36 ,$12.58 ,$15.90 ,$13.10 
Carle BroMenn Medical Center,8980250,glycerin 99.5 % topical solution,87701040072,,250,$13.98 ,$13.98 ,$4.19 ,$12.72 ,$9.79 ,$4.19 ,$9.09 ,$10.07 ,$12.72 ,$10.49 
Carle BroMenn Medical Center,8980250,glycopyrrolate 0.2 mg/mL injection solution,517460525,J3490,250,$323.50 ,$323.50 ,$97.05 ,$294.39 ,$226.45 ,$97.05 ,$210.28 ,$232.92 ,$294.39 ,$242.63 
Carle BroMenn Medical Center,8980250,glycopyrrolate 0.2 mg/mL injection solution,781382571,J3490,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,glycopyrrolate 0.2 mg/mL injection solution,781382975,J3490,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,glycopyrrolate 0.2 mg/mL injection solution,781382996,J3490,250,$83.43 ,$83.43 ,$25.03 ,$75.92 ,$58.40 ,$25.03 ,$54.23 ,$60.07 ,$75.92 ,$62.57 
Carle BroMenn Medical Center,8980250,glycopyrrolate 0.2 mg/mL injection solution,16729047108,J3490,250,$45.97 ,$45.97 ,$13.79 ,$41.83 ,$32.18 ,$13.79 ,$29.88 ,$33.10 ,$41.83 ,$34.48 
Carle BroMenn Medical Center,8980250,glycopyrrolate 0.2 mg/mL injection solution,16729047163,J3490,250,$45.97 ,$45.97 ,$13.79 ,$41.83 ,$32.18 ,$13.79 ,$29.88 ,$33.10 ,$41.83 ,$34.48 
Carle BroMenn Medical Center,8980250,glycopyrrolate 0.2 mg/mL injection solution,16729047303,J3490,250,$190.72 ,$190.72 ,$57.22 ,$173.56 ,$133.50 ,$57.22 ,$123.97 ,$137.32 ,$173.56 ,$143.04 
Carle BroMenn Medical Center,8980250,glycopyrrolate 0.2 mg/mL injection solution,16729047331,J3490,250,$190.72 ,$190.72 ,$57.22 ,$173.56 ,$133.50 ,$57.22 ,$123.97 ,$137.32 ,$173.56 ,$143.04 
Carle BroMenn Medical Center,8980250,glycopyrrolate 0.2 mg/mL injection solution,63323057801,J3490,250,$58.57 ,$58.57 ,$17.57 ,$53.30 ,$41.00 ,$17.57 ,$38.07 ,$42.17 ,$53.30 ,$43.93 
Carle BroMenn Medical Center,8980250,glycopyrrolate 0.2 mg/mL injection solution,63323057805,J3490,250,$212.22 ,$212.22 ,$63.67 ,$193.12 ,$148.55 ,$63.67 ,$137.94 ,$152.80 ,$193.12 ,$159.17 
Carle BroMenn Medical Center,8980250,glycopyrrolate 0.2 mg/mL injection solution,70069001301,J3490,250,$83.13 ,$83.13 ,$24.94 ,$75.65 ,$58.19 ,$24.94 ,$54.03 ,$59.85 ,$75.65 ,$62.35 
Carle BroMenn Medical Center,8980250,glycopyrrolate 0.2 mg/mL injection solution,70069001325,J3490,250,$83.13 ,$83.13 ,$24.94 ,$75.65 ,$58.19 ,$24.94 ,$54.03 ,$59.85 ,$75.65 ,$62.35 
Carle BroMenn Medical Center,8980250,glycopyrrolate 1 mg tablet,13107001401,,250,$8.45 ,$8.45 ,$2.54 ,$7.69 ,$5.92 ,$2.54 ,$5.49 ,$6.08 ,$7.69 ,$6.34 
Carle BroMenn Medical Center,8980250,guaiFENesin 100 mg/5 mL oral liquid,121174400,,250,$0.84 ,$0.84 ,$0.25 ,$0.76 ,$0.59 ,$0.25 ,$0.55 ,$0.60 ,$0.76 ,$0.63 
Carle BroMenn Medical Center,8980250,guaiFENesin 100 mg/5 mL oral liquid,121174405,,250,$0.84 ,$0.84 ,$0.25 ,$0.76 ,$0.59 ,$0.25 ,$0.55 ,$0.60 ,$0.76 ,$0.63 
Carle BroMenn Medical Center,8980250,guaiFENesin 100 mg/5 mL oral liquid,50383006305,,250,$0.76 ,$0.76 ,$0.23 ,$0.69 ,$0.53 ,$0.23 ,$0.49 ,$0.55 ,$0.69 ,$0.57 
Carle BroMenn Medical Center,8980250,"guaiFENesin ER 600 mg tablet, extended release 12 hr",904671839,,250,$1.50 ,$1.50 ,$0.45 ,$1.37 ,$1.05 ,$0.45 ,$0.98 ,$1.08 ,$1.37 ,$1.13 
Carle BroMenn Medical Center,8980250,"guaiFENesin ER 600 mg tablet, extended release 12 hr",68084057201,,250,$1.40 ,$1.40 ,$0.42 ,$1.27 ,$0.98 ,$0.42 ,$0.91 ,$1.01 ,$1.27 ,$1.05 
Carle BroMenn Medical Center,8980250,"guaiFENesin ER 600 mg tablet, extended release 12 hr",68084057211,,250,$1.40 ,$1.40 ,$0.42 ,$1.27 ,$0.98 ,$0.42 ,$0.91 ,$1.01 ,$1.27 ,$1.05 
Carle BroMenn Medical Center,8980250,guanFACINE 1 mg tablet,591044401,,250,$6.39 ,$6.39 ,$1.92 ,$5.81 ,$4.47 ,$1.92 ,$4.15 ,$4.60 ,$5.81 ,$4.79 
Carle BroMenn Medical Center,8980250,guar gum oral packet,43900097647,,250,$0.68 ,$0.68 ,$0.20 ,$0.62 ,$0.48 ,$0.20 ,$0.44 ,$0.49 ,$0.62 ,$0.51 
Carle BroMenn Medical Center,8980250,haloperidoL 1 mg tablet,51079073401,,250,$4.62 ,$4.62 ,$1.39 ,$4.20 ,$3.23 ,$1.39 ,$3.00 ,$3.33 ,$4.20 ,$3.47 
Carle BroMenn Medical Center,8980250,haloperidoL 1 mg tablet,51079073420,,250,$4.62 ,$4.62 ,$1.39 ,$4.20 ,$3.23 ,$1.39 ,$3.00 ,$3.33 ,$4.20 ,$3.47 
Carle BroMenn Medical Center,8980250,haloperidoL 5 mg tablet,832154011,,250,$7.10 ,$7.10 ,$2.13 ,$6.46 ,$4.97 ,$2.13 ,$4.62 ,$5.11 ,$6.46 ,$5.33 
Carle BroMenn Medical Center,8980250,haloperidoL 5 mg tablet,51079073601,,250,$7.42 ,$7.42 ,$2.23 ,$6.75 ,$5.19 ,$2.23 ,$4.82 ,$5.34 ,$6.75 ,$5.57 
Carle BroMenn Medical Center,8980250,haloperidoL 5 mg tablet,51079073620,,250,$7.42 ,$7.42 ,$2.23 ,$6.75 ,$5.19 ,$2.23 ,$4.82 ,$5.34 ,$6.75 ,$5.57 
Carle BroMenn Medical Center,8980250,hydrALAZINE 10 mg tablet,904644061,,250,$2.91 ,$2.91 ,$0.87 ,$2.65 ,$2.04 ,$0.87 ,$1.89 ,$2.10 ,$2.65 ,$2.18 
Carle BroMenn Medical Center,8980250,hydrALAZINE 25 mg tablet,904644161,,250,$3.02 ,$3.02 ,$0.91 ,$2.75 ,$2.11 ,$0.91 ,$1.96 ,$2.17 ,$2.75 ,$2.27 
Carle BroMenn Medical Center,8980250,hydrALAZINE 25 mg tablet,23155000201,,250,$2.67 ,$2.67 ,$0.80 ,$2.43 ,$1.87 ,$0.80 ,$1.74 ,$1.92 ,$2.43 ,$2.00 
Carle BroMenn Medical Center,8980250,hydrALAZINE 25 mg tablet,51079007501,,250,$4.70 ,$4.70 ,$1.41 ,$4.28 ,$3.29 ,$1.41 ,$3.06 ,$3.38 ,$4.28 ,$3.53 
Carle BroMenn Medical Center,8980250,hydrALAZINE 25 mg tablet,51079007520,,250,$4.70 ,$4.70 ,$1.41 ,$4.28 ,$3.29 ,$1.41 ,$3.06 ,$3.38 ,$4.28 ,$3.53 
Carle BroMenn Medical Center,8980250,hydrALAZINE 25 mg tablet,62584073301,,250,$3.51 ,$3.51 ,$1.05 ,$3.19 ,$2.46 ,$1.05 ,$2.28 ,$2.53 ,$3.19 ,$2.63 
Carle BroMenn Medical Center,8980250,hydrALAZINE 25 mg tablet,62584073311,,250,$3.51 ,$3.51 ,$1.05 ,$3.19 ,$2.46 ,$1.05 ,$2.28 ,$2.53 ,$3.19 ,$2.63 
Carle BroMenn Medical Center,8980250,hydroCHLOROthiazide 12.5 mg tablet,16729018201,,250,$4.31 ,$4.31 ,$1.29 ,$3.92 ,$3.02 ,$1.29 ,$2.80 ,$3.10 ,$3.92 ,$3.23 
Carle BroMenn Medical Center,8980250,hydroCHLOROthiazide 12.5 mg tablet,69315015501,,250,$3.11 ,$3.11 ,$0.93 ,$2.83 ,$2.18 ,$0.93 ,$2.02 ,$2.24 ,$2.83 ,$2.33 
Carle BroMenn Medical Center,8980250,hydroCHLOROthiazide 25 mg tablet,16729018301,,250,$2.73 ,$2.73 ,$0.82 ,$2.48 ,$1.91 ,$0.82 ,$1.77 ,$1.97 ,$2.48 ,$2.05 
Carle BroMenn Medical Center,8980250,hydroCHLOROthiazide 25 mg tablet,60687059301,,250,$3.50 ,$3.50 ,$1.05 ,$3.19 ,$2.45 ,$1.05 ,$2.28 ,$2.52 ,$3.19 ,$2.63 
Carle BroMenn Medical Center,8980250,hydroCHLOROthiazide 25 mg tablet,60687059311,,250,$3.50 ,$3.50 ,$1.05 ,$3.19 ,$2.45 ,$1.05 ,$2.28 ,$2.52 ,$3.19 ,$2.63 
Carle BroMenn Medical Center,8980250,HYDROcodone 10 mg-acetaminophen 325 mg tablet,406012501,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,HYDROcodone 10 mg-acetaminophen 325 mg tablet,406012523,,250,$10.30 ,$10.30 ,$3.09 ,$9.37 ,$7.21 ,$3.09 ,$6.70 ,$7.42 ,$9.37 ,$7.73 
Carle BroMenn Medical Center,8980250,HYDROcodone 10 mg-acetaminophen 325 mg tablet,406012562,,250,$10.30 ,$10.30 ,$3.09 ,$9.37 ,$7.21 ,$3.09 ,$6.70 ,$7.42 ,$9.37 ,$7.73 
Carle BroMenn Medical Center,8980250,HYDROcodone 10 mg-acetaminophen 325 mg tablet,60687041801,,250,$9.79 ,$9.79 ,$2.94 ,$8.91 ,$6.85 ,$2.94 ,$6.36 ,$7.05 ,$8.91 ,$7.34 
Carle BroMenn Medical Center,8980250,HYDROcodone 10 mg-acetaminophen 325 mg tablet,60687041811,,250,$9.79 ,$9.79 ,$2.94 ,$8.91 ,$6.85 ,$2.94 ,$6.36 ,$7.05 ,$8.91 ,$7.34 
Carle BroMenn Medical Center,8980250,HYDROcodone 5 mg-acetaminophen 325 mg tablet,406012323,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,HYDROcodone 5 mg-acetaminophen 325 mg tablet,406012362,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,HYDROcodone 5 mg-acetaminophen 325 mg tablet,904682461,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,HYDROcodone 5 mg-acetaminophen 325 mg tablet,68084089501,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,HYDROcodone 7.5 mg-acetaminophen 325 mg tablet,60687040701,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,HYDROcodone 7.5 mg-acetaminophen 325 mg tablet,60687040711,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,HYDROcodone 7.5 mg-acetaminophen 325 mg tablet,68084086301,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,HYDROcodone 7.5 mg-acetaminophen 325 mg/15 mL oral solution,66689002316,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,HYDROcodone 7.5 mg-acetaminophen 325 mg/15 mL oral solution,71930002743,,250,$11.18 ,$11.18 ,$3.35 ,$10.17 ,$7.83 ,$3.35 ,$7.27 ,$8.05 ,$10.17 ,$8.39 
Carle BroMenn Medical Center,8980250,hydrocortisone 1 % topical cream,45802043803,,250,$25.17 ,$25.17 ,$7.55 ,$22.90 ,$17.62 ,$7.55 ,$16.36 ,$18.12 ,$22.90 ,$18.88 
Carle BroMenn Medical Center,8980250,hydrocortisone 1 % topical cream,61269034356,,250,$17.47 ,$17.47 ,$5.24 ,$15.90 ,$12.23 ,$5.24 ,$11.36 ,$12.58 ,$15.90 ,$13.10 
Carle BroMenn Medical Center,8980250,hydrocortisone 10 mg tablet,42543014101,,250,$5.00 ,$5.00 ,$1.50 ,$4.55 ,$3.50 ,$1.50 ,$3.25 ,$3.60 ,$4.55 ,$3.75 
Carle BroMenn Medical Center,8980250,hydrocortisone 10 mg tablet,59762007401,,250,$5.00 ,$5.00 ,$1.50 ,$4.55 ,$3.50 ,$1.50 ,$3.25 ,$3.60 ,$4.55 ,$3.75 
Carle BroMenn Medical Center,8980250,hydrocortisone acetate 25 mg rectal suppository,42494030100,,250,$87.48 ,$87.48 ,$26.24 ,$79.61 ,$61.24 ,$26.24 ,$56.86 ,$62.99 ,$79.61 ,$65.61 
Carle BroMenn Medical Center,8980250,hydrocortisone acetate 25 mg rectal suppository,42494030112,,250,$87.48 ,$87.48 ,$26.24 ,$79.61 ,$61.24 ,$26.24 ,$56.86 ,$62.99 ,$79.61 ,$65.61 
Carle BroMenn Medical Center,8980250,HYDROmorphone 1 mg/mL oral liquid,42858030416,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,HYDROmorphone 2 mg tablet,42858030125,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,HYDROmorphone 4 mg tablet,42858030201,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,HYDROmorphone 4 mg tablet,42858030225,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,"hydroxocobalamin 1,000 mcg/mL intramuscular solution",591288830,,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,hydroxocobalamin 5 gram intravenous solution,11704037001,,250,"$3,571.67 ","$3,571.67 ","$1,071.50 ","$3,250.22 ","$2,500.17 ","$1,071.50 ","$2,321.59 ","$2,571.60 ","$3,250.22 ","$2,678.75 "
Carle BroMenn Medical Center,8980250,hydrOXYchloroQUINE 200 mg tablet,43598072101,,250,$21.38 ,$21.38 ,$6.41 ,$19.46 ,$14.97 ,$6.41 ,$13.90 ,$15.39 ,$19.46 ,$16.04 
Carle BroMenn Medical Center,8980250,hydrOXYchloroQUINE 200 mg tablet,68084026901,,250,$22.79 ,$22.79 ,$6.84 ,$20.74 ,$15.95 ,$6.84 ,$14.81 ,$16.41 ,$20.74 ,$17.09 
Carle BroMenn Medical Center,8980250,hydrOXYchloroQUINE 200 mg tablet,68084026911,,250,$22.79 ,$22.79 ,$6.84 ,$20.74 ,$15.95 ,$6.84 ,$14.81 ,$16.41 ,$20.74 ,$17.09 
Carle BroMenn Medical Center,8980250,hydrOXYchloroQUINE 200 mg tablet,76385014401,,250,$8.30 ,$8.30 ,$2.49 ,$7.55 ,$5.81 ,$2.49 ,$5.40 ,$5.98 ,$7.55 ,$6.23 
Carle BroMenn Medical Center,8980250,hydrOXYzine HCL 10 mg tablet,68084025301,,250,$3.62 ,$3.62 ,$1.09 ,$3.29 ,$2.53 ,$1.09 ,$2.35 ,$2.61 ,$3.29 ,$2.72 
Carle BroMenn Medical Center,8980250,hydrOXYzine HCL 10 mg tablet,68084025311,,250,$3.62 ,$3.62 ,$1.09 ,$3.29 ,$2.53 ,$1.09 ,$2.35 ,$2.61 ,$3.29 ,$2.72 
Carle BroMenn Medical Center,8980250,hydrOXYzine HCL 25 mg tablet,93506101,,250,$6.59 ,$6.59 ,$1.98 ,$6.00 ,$4.61 ,$1.98 ,$4.28 ,$4.74 ,$6.00 ,$4.94 
Carle BroMenn Medical Center,8980250,hydrOXYzine HCL 25 mg tablet,904661761,,250,$3.75 ,$3.75 ,$1.13 ,$3.41 ,$2.63 ,$1.13 ,$2.44 ,$2.70 ,$3.41 ,$2.81 
Carle BroMenn Medical Center,8980250,hydrOXYzine HCL 25 mg tablet,68084025401,,250,$4.17 ,$4.17 ,$1.25 ,$3.79 ,$2.92 ,$1.25 ,$2.71 ,$3.00 ,$3.79 ,$3.13 
Carle BroMenn Medical Center,8980250,hydrOXYzine HCL 25 mg tablet,68084025411,,250,$4.17 ,$4.17 ,$1.25 ,$3.79 ,$2.92 ,$1.25 ,$2.71 ,$3.00 ,$3.79 ,$3.13 
Carle BroMenn Medical Center,8980250,hyoscyamine 0.125 mg sublingual tablet,42192033901,,250,$6.29 ,$6.29 ,$1.89 ,$5.72 ,$4.40 ,$1.89 ,$4.09 ,$4.53 ,$5.72 ,$4.72 
Carle BroMenn Medical Center,8980250,hypromellose 2.5 % eye drops,17478006412,,250,$17.47 ,$17.47 ,$5.24 ,$15.90 ,$12.23 ,$5.24 ,$11.36 ,$12.58 ,$15.90 ,$13.10 
Carle BroMenn Medical Center,8980250,ibuprofen 100 mg/5 mL oral suspension,121091405,,250,$2.44 ,$2.44 ,$0.73 ,$2.22 ,$1.71 ,$0.73 ,$1.59 ,$1.76 ,$2.22 ,$1.83 
Carle BroMenn Medical Center,8980250,ibuprofen 100 mg/5 mL oral suspension,573029030,,250,$0.60 ,$0.60 ,$0.18 ,$0.55 ,$0.42 ,$0.18 ,$0.39 ,$0.43 ,$0.55 ,$0.45 
Carle BroMenn Medical Center,8980250,ibuprofen 100 mg/5 mL oral suspension,24385000926,,250,$0.80 ,$0.80 ,$0.24 ,$0.73 ,$0.56 ,$0.24 ,$0.52 ,$0.58 ,$0.73 ,$0.60 
Carle BroMenn Medical Center,8980250,ibuprofen 100 mg/5 mL oral suspension,24385037226,,250,$0.80 ,$0.80 ,$0.24 ,$0.73 ,$0.56 ,$0.24 ,$0.52 ,$0.58 ,$0.73 ,$0.60 
Carle BroMenn Medical Center,8980250,ibuprofen 100 mg/5 mL oral suspension,51672213008,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,ibuprofen 100 mg/5 mL oral suspension,68094049458,,250,$4.49 ,$4.49 ,$1.35 ,$4.09 ,$3.14 ,$1.35 ,$2.92 ,$3.23 ,$4.09 ,$3.37 
Carle BroMenn Medical Center,8980250,ibuprofen 100 mg/5 mL oral suspension,68094049461,,250,$2.44 ,$2.44 ,$0.73 ,$2.22 ,$1.71 ,$0.73 ,$1.59 ,$1.76 ,$2.22 ,$1.83 
Carle BroMenn Medical Center,8980250,ibuprofen 200 mg tablet,904791461,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,ibuprofen 400 mg tablet,904585361,,250,$3.34 ,$3.34 ,$1.00 ,$3.04 ,$2.34 ,$1.00 ,$2.17 ,$2.40 ,$3.04 ,$2.51 
Carle BroMenn Medical Center,8980250,ibuprofen 400 mg tablet,60687044611,,250,$3.54 ,$3.54 ,$1.06 ,$3.22 ,$2.48 ,$1.06 ,$2.30 ,$2.55 ,$3.22 ,$2.66 
Carle BroMenn Medical Center,8980250,ibuprofen 400 mg tablet,63739067210,,250,$2.68 ,$2.68 ,$0.80 ,$2.44 ,$1.88 ,$0.80 ,$1.74 ,$1.93 ,$2.44 ,$2.01 
Carle BroMenn Medical Center,8980250,ibuprofen 600 mg tablet,904585461,,250,$3.75 ,$3.75 ,$1.13 ,$3.41 ,$2.63 ,$1.13 ,$2.44 ,$2.70 ,$3.41 ,$2.81 
Carle BroMenn Medical Center,8980250,ibuprofen 600 mg tablet,60687045701,,250,$4.02 ,$4.02 ,$1.21 ,$3.66 ,$2.81 ,$1.21 ,$2.61 ,$2.89 ,$3.66 ,$3.02 
Carle BroMenn Medical Center,8980250,ibuprofen 600 mg tablet,60687045711,,250,$4.02 ,$4.02 ,$1.21 ,$3.66 ,$2.81 ,$1.21 ,$2.61 ,$2.89 ,$3.66 ,$3.02 
Carle BroMenn Medical Center,8980250,ibuprofen 800 mg tablet,904585561,,250,$4.19 ,$4.19 ,$1.26 ,$3.81 ,$2.93 ,$1.26 ,$2.72 ,$3.02 ,$3.81 ,$3.14 
Carle BroMenn Medical Center,8980250,ibuprofen 800 mg tablet,60687046801,,250,$4.32 ,$4.32 ,$1.30 ,$3.93 ,$3.02 ,$1.30 ,$2.81 ,$3.11 ,$3.93 ,$3.24 
Carle BroMenn Medical Center,8980250,ibuprofen 800 mg tablet,60687046811,,250,$4.32 ,$4.32 ,$1.30 ,$3.93 ,$3.02 ,$1.30 ,$2.81 ,$3.11 ,$3.93 ,$3.24 
Carle BroMenn Medical Center,8980250,idaruCIZUmab 2.5 gram/50 mL intravenous solution,597019705,,250,"$12,002.11 ","$12,002.11 ","$3,600.63 ","$10,921.92 ","$8,401.48 ","$3,600.63 ","$7,801.37 ","$8,641.52 ","$10,921.92 ","$9,001.58 "
Carle BroMenn Medical Center,8980250,imipramine 10 mg tablet,69315013301,,250,$4.33 ,$4.33 ,$1.30 ,$3.94 ,$3.03 ,$1.30 ,$2.81 ,$3.12 ,$3.94 ,$3.25 
Carle BroMenn Medical Center,8980250,imipramine 25 mg tablet,69315013401,,250,$5.68 ,$5.68 ,$1.70 ,$5.17 ,$3.98 ,$1.70 ,$3.69 ,$4.09 ,$5.17 ,$4.26 
Carle BroMenn Medical Center,8980250,indapamide 2.5 mg tablet,62559051101,,250,$9.55 ,$9.55 ,$2.87 ,$8.69 ,$6.69 ,$2.87 ,$6.21 ,$6.88 ,$8.69 ,$7.16 
Carle BroMenn Medical Center,8980250,indigotindisulfonate sodium 8 mg/mL (0.8 %) injection solution,517037501,,250,"$1,090.98 ","$1,090.98 ",$327.29 ,$992.79 ,$763.69 ,$327.29 ,$709.14 ,$785.51 ,$992.79 ,$818.24 
Carle BroMenn Medical Center,8980250,indigotindisulfonate sodium 8 mg/mL (0.8 %) injection solution,517037505,,250,"$1,090.98 ","$1,090.98 ",$327.29 ,$992.79 ,$763.69 ,$327.29 ,$709.14 ,$785.51 ,$992.79 ,$818.24 
Carle BroMenn Medical Center,8980250,indocyanine green 25 mg solution for injection,70100042401,,250,$545.79 ,$545.79 ,$163.74 ,$496.67 ,$382.05 ,$163.74 ,$354.76 ,$392.97 ,$496.67 ,$409.34 
Carle BroMenn Medical Center,8980250,indocyanine green 25 mg solution for injection,70100042402,,250,$545.79 ,$545.79 ,$163.74 ,$496.67 ,$382.05 ,$163.74 ,$354.76 ,$392.97 ,$496.67 ,$409.34 
Carle BroMenn Medical Center,8980250,indomethacin 1 mg intravenous solution,63323065903,,250,"$3,021.91 ","$3,021.91 ",$906.57 ,"$2,749.94 ","$2,115.34 ",$906.57 ,"$1,964.24 ","$2,175.78 ","$2,749.94 ","$2,266.43 "
Carle BroMenn Medical Center,8980250,indomethacin 25 mg capsule,50268043011,,250,$4.33 ,$4.33 ,$1.30 ,$3.94 ,$3.03 ,$1.30 ,$2.81 ,$3.12 ,$3.94 ,$3.25 
Carle BroMenn Medical Center,8980250,indomethacin 25 mg capsule,68462040601,,250,$4.20 ,$4.20 ,$1.26 ,$3.82 ,$2.94 ,$1.26 ,$2.73 ,$3.02 ,$3.82 ,$3.15 
Carle BroMenn Medical Center,8980250,iodine strong (Lugols) 5 % oral solution,395277516,,250,$17.47 ,$17.47 ,$5.24 ,$15.90 ,$12.23 ,$5.24 ,$11.36 ,$12.58 ,$15.90 ,$13.10 
Carle BroMenn Medical Center,8980250,iodine strong (Lugols) 5 % oral solution,48433023015,,250,$8.59 ,$8.59 ,$2.58 ,$7.82 ,$6.01 ,$2.58 ,$5.58 ,$6.18 ,$7.82 ,$6.44 
Carle BroMenn Medical Center,8980250,ipratropium 0.5 mg-albuteroL 3 mg (2.5 mg base)/3 mL nebulization soln,487020101,,250,$5.13 ,$5.13 ,$1.54 ,$4.67 ,$3.59 ,$1.54 ,$3.33 ,$3.69 ,$4.67 ,$3.85 
Carle BroMenn Medical Center,8980250,ipratropium 0.5 mg-albuteroL 3 mg (2.5 mg base)/3 mL nebulization soln,60687040579,,250,$5.20 ,$5.20 ,$1.56 ,$4.73 ,$3.64 ,$1.56 ,$3.38 ,$3.74 ,$4.73 ,$3.90 
Carle BroMenn Medical Center,8980250,ipratropium 0.5 mg-albuteroL 3 mg (2.5 mg base)/3 mL nebulization soln,60687040583,,250,$5.20 ,$5.20 ,$1.56 ,$4.73 ,$3.64 ,$1.56 ,$3.38 ,$3.74 ,$4.73 ,$3.90 
Carle BroMenn Medical Center,8980250,ipratropium 0.5 mg-albuteroL 3 mg (2.5 mg base)/3 mL nebulization soln,76204060001,,250,$13.02 ,$13.02 ,$3.91 ,$11.85 ,$9.11 ,$3.91 ,$8.46 ,$9.37 ,$11.85 ,$9.77 
Carle BroMenn Medical Center,8980250,ipratropium bromide 21 mcg (0.03 %) nasal spray,54004544,,250,$541.31 ,$541.31 ,$162.39 ,$492.59 ,$378.92 ,$162.39 ,$351.85 ,$389.74 ,$492.59 ,$405.98 
Carle BroMenn Medical Center,8980250,ipratropium bromide 21 mcg (0.03 %) nasal spray,24208039830,,250,$233.61 ,$233.61 ,$70.08 ,$212.59 ,$163.53 ,$70.08 ,$151.85 ,$168.20 ,$212.59 ,$175.21 
Carle BroMenn Medical Center,8980250,ipratropium bromide 21 mcg (0.03 %) nasal spray,60505082601,,250,$541.31 ,$541.31 ,$162.39 ,$492.59 ,$378.92 ,$162.39 ,$351.85 ,$389.74 ,$492.59 ,$405.98 
Carle BroMenn Medical Center,8980250,isavuconazonium sulfate 186 mg capsule,469052014,,250,$809.03 ,$809.03 ,$242.71 ,$736.22 ,$566.32 ,$242.71 ,$525.87 ,$582.50 ,$736.22 ,$606.77 
Carle BroMenn Medical Center,8980250,isoniazid 300 mg tablet,555007102,,250,$3.77 ,$3.77 ,$1.13 ,$3.43 ,$2.64 ,$1.13 ,$2.45 ,$2.71 ,$3.43 ,$2.83 
Carle BroMenn Medical Center,8980250,isoproterenoL 0.2 mg/mL injection solution,548950100,,250,"$1,098.59 ","$1,098.59 ",$329.58 ,$999.72 ,$769.01 ,$329.58 ,$714.08 ,$790.98 ,$999.72 ,$823.94 
Carle BroMenn Medical Center,8980250,isoproterenoL 0.2 mg/mL injection solution,548950200,,250,"$1,182.47 ","$1,182.47 ",$354.74 ,"$1,076.05 ",$827.73 ,$354.74 ,$768.61 ,$851.38 ,"$1,076.05 ",$886.85 
Carle BroMenn Medical Center,8980250,isoproterenoL 0.2 mg/mL injection solution,14789001101,,250,"$2,580.47 ","$2,580.47 ",$774.14 ,"$2,348.23 ","$1,806.33 ",$774.14 ,"$1,677.31 ","$1,857.94 ","$2,348.23 ","$1,935.35 "
Carle BroMenn Medical Center,8980250,isoproterenoL 0.2 mg/mL injection solution,14789001107,,250,"$2,580.47 ","$2,580.47 ",$774.14 ,"$2,348.23 ","$1,806.33 ",$774.14 ,"$1,677.31 ","$1,857.94 ","$2,348.23 ","$1,935.35 "
Carle BroMenn Medical Center,8980250,isoproterenoL 0.2 mg/mL injection solution,69097052235,,250,"$6,114.61 ","$6,114.61 ","$1,834.38 ","$5,564.30 ","$4,280.23 ","$1,834.38 ","$3,974.50 ","$4,402.52 ","$5,564.30 ","$4,585.96 "
Carle BroMenn Medical Center,8980250,isosorbide dinitrate 10 mg tablet,68084008201,,250,$8.16 ,$8.16 ,$2.45 ,$7.43 ,$5.71 ,$2.45 ,$5.30 ,$5.88 ,$7.43 ,$6.12 
Carle BroMenn Medical Center,8980250,isosorbide dinitrate 10 mg tablet,68084008211,,250,$8.16 ,$8.16 ,$2.45 ,$7.43 ,$5.71 ,$2.45 ,$5.30 ,$5.88 ,$7.43 ,$6.12 
Carle BroMenn Medical Center,8980250,isosorbide dinitrate 20 mg tablet,68084008301,,250,$8.62 ,$8.62 ,$2.59 ,$7.84 ,$6.03 ,$2.59 ,$5.60 ,$6.21 ,$7.84 ,$6.47 
Carle BroMenn Medical Center,8980250,isosorbide dinitrate 20 mg tablet,68084008311,,250,$8.62 ,$8.62 ,$2.59 ,$7.84 ,$6.03 ,$2.59 ,$5.60 ,$6.21 ,$7.84 ,$6.47 
Carle BroMenn Medical Center,8980250,"isosorbide mononitrate ER 30 mg tablet,extended release 24 hr",904644961,,250,$10.07 ,$10.07 ,$3.02 ,$9.16 ,$7.05 ,$3.02 ,$6.55 ,$7.25 ,$9.16 ,$7.55 
Carle BroMenn Medical Center,8980250,"isosorbide mononitrate ER 30 mg tablet,extended release 24 hr",50268045111,,250,$9.99 ,$9.99 ,$3.00 ,$9.09 ,$6.99 ,$3.00 ,$6.49 ,$7.19 ,$9.09 ,$7.49 
Carle BroMenn Medical Center,8980250,"isosorbide mononitrate ER 30 mg tablet,extended release 24 hr",68084059101,,250,$10.14 ,$10.14 ,$3.04 ,$9.23 ,$7.10 ,$3.04 ,$6.59 ,$7.30 ,$9.23 ,$7.61 
Carle BroMenn Medical Center,8980250,"isosorbide mononitrate ER 30 mg tablet,extended release 24 hr",68084059111,,250,$10.14 ,$10.14 ,$3.04 ,$9.23 ,$7.10 ,$3.04 ,$6.59 ,$7.30 ,$9.23 ,$7.61 
Carle BroMenn Medical Center,8980250,"isosorbide mononitrate ER 60 mg tablet,extended release 24 hr",68084059201,,250,$11.92 ,$11.92 ,$3.58 ,$10.85 ,$8.34 ,$3.58 ,$7.75 ,$8.58 ,$10.85 ,$8.94 
Carle BroMenn Medical Center,8980250,"isosorbide mononitrate ER 60 mg tablet,extended release 24 hr",68084059211,,250,$11.92 ,$11.92 ,$3.58 ,$10.85 ,$8.34 ,$3.58 ,$7.75 ,$8.58 ,$10.85 ,$8.94 
Carle BroMenn Medical Center,8980250,itraconazole 10 mg/mL oral solution,65162008774,,250,$149.46 ,$149.46 ,$44.84 ,$136.01 ,$104.62 ,$44.84 ,$97.15 ,$107.61 ,$136.01 ,$112.10 
Carle BroMenn Medical Center,8980250,itraconazole 100 mg capsule,50268045011,,250,$27.95 ,$27.95 ,$8.39 ,$25.43 ,$19.57 ,$8.39 ,$18.17 ,$20.12 ,$25.43 ,$20.96 
Carle BroMenn Medical Center,8980250,itraconazole 100 mg capsule,50268045012,,250,$27.95 ,$27.95 ,$8.39 ,$25.43 ,$19.57 ,$8.39 ,$18.17 ,$20.12 ,$25.43 ,$20.96 
Carle BroMenn Medical Center,8980250,ketamine 10 mg/mL injection solution,67457018100,,250,$146.20 ,$146.20 ,$43.86 ,$133.04 ,$102.34 ,$43.86 ,$95.03 ,$105.26 ,$133.04 ,$109.65 
Carle BroMenn Medical Center,8980250,ketamine 10 mg/mL injection solution,67457018120,,250,$146.20 ,$146.20 ,$43.86 ,$133.04 ,$102.34 ,$43.86 ,$95.03 ,$105.26 ,$133.04 ,$109.65 
Carle BroMenn Medical Center,8980250,"ketamine 50 mg/5 mL (10 mg/mL) in sodium chlor,iso-osmotic inj syringe",69374098255,,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,ketamine 50 mg/mL injection solution,409205310,,250,$145.61 ,$145.61 ,$43.68 ,$132.51 ,$101.93 ,$43.68 ,$94.65 ,$104.84 ,$132.51 ,$109.21 
Carle BroMenn Medical Center,8980250,ketamine 50 mg/mL injection solution,67457000100,,250,$145.61 ,$145.61 ,$43.68 ,$132.51 ,$101.93 ,$43.68 ,$94.65 ,$104.84 ,$132.51 ,$109.21 
Carle BroMenn Medical Center,8980250,ketamine 50 mg/mL injection solution,67457000110,,250,$145.61 ,$145.61 ,$43.68 ,$132.51 ,$101.93 ,$43.68 ,$94.65 ,$104.84 ,$132.51 ,$109.21 
Carle BroMenn Medical Center,8980250,ketorolac 0.5 % eye drops,61314012605,,250,$512.60 ,$512.60 ,$153.78 ,$466.47 ,$358.82 ,$153.78 ,$333.19 ,$369.07 ,$466.47 ,$384.45 
Carle BroMenn Medical Center,8980250,labetaloL 100 mg tablet,49884012201,,250,$5.47 ,$5.47 ,$1.64 ,$4.98 ,$3.83 ,$1.64 ,$3.56 ,$3.94 ,$4.98 ,$4.10 
Carle BroMenn Medical Center,8980250,labetaloL 100 mg tablet,60687043901,,250,$4.87 ,$4.87 ,$1.46 ,$4.43 ,$3.41 ,$1.46 ,$3.17 ,$3.51 ,$4.43 ,$3.65 
Carle BroMenn Medical Center,8980250,labetaloL 100 mg tablet,60687043911,,250,$4.87 ,$4.87 ,$1.46 ,$4.43 ,$3.41 ,$1.46 ,$3.17 ,$3.51 ,$4.43 ,$3.65 
Carle BroMenn Medical Center,8980250,labetaloL 100 mg tablet,68001038100,,250,$4.72 ,$4.72 ,$1.42 ,$4.30 ,$3.30 ,$1.42 ,$3.07 ,$3.40 ,$4.30 ,$3.54 
Carle BroMenn Medical Center,8980250,labetaloL 200 mg tablet,60687045001,,250,$5.59 ,$5.59 ,$1.68 ,$5.09 ,$3.91 ,$1.68 ,$3.63 ,$4.02 ,$5.09 ,$4.19 
Carle BroMenn Medical Center,8980250,labetaloL 200 mg tablet,60687045011,,250,$5.59 ,$5.59 ,$1.68 ,$5.09 ,$3.91 ,$1.68 ,$3.63 ,$4.02 ,$5.09 ,$4.19 
Carle BroMenn Medical Center,8980250,labetaloL 5 mg/mL intravenous solution,143962201,J3490,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,labetaloL 5 mg/mL intravenous solution,143962301,J3490,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,labetaloL 5 mg/mL intravenous solution,409226720,J3490,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,lacosamide 200 mg/20 mL intravenous solution,131181067,,250,$177.63 ,$177.63 ,$53.29 ,$161.64 ,$124.34 ,$53.29 ,$115.46 ,$127.89 ,$161.64 ,$133.22 
Carle BroMenn Medical Center,8980250,lacosamide 50 mg tablet,131247760,,250,$54.15 ,$54.15 ,$16.25 ,$49.28 ,$37.91 ,$16.25 ,$35.20 ,$38.99 ,$49.28 ,$40.61 
Carle BroMenn Medical Center,8980250,lactulose 10 gram/15 mL oral solution,121057732,,250,$17.47 ,$17.47 ,$5.24 ,$15.90 ,$12.23 ,$5.24 ,$11.36 ,$12.58 ,$15.90 ,$13.10 
Carle BroMenn Medical Center,8980250,lactulose 10 gram/15 mL oral solution,45963043864,,250,$17.47 ,$17.47 ,$5.24 ,$15.90 ,$12.23 ,$5.24 ,$11.36 ,$12.58 ,$15.90 ,$13.10 
Carle BroMenn Medical Center,8980250,lactulose 20 gram/30 mL oral solution,121115400,,250,$6.10 ,$6.10 ,$1.83 ,$5.55 ,$4.27 ,$1.83 ,$3.97 ,$4.39 ,$5.55 ,$4.58 
Carle BroMenn Medical Center,8980250,lactulose 20 gram/30 mL oral solution,121115430,,250,$6.10 ,$6.10 ,$1.83 ,$5.55 ,$4.27 ,$1.83 ,$3.97 ,$4.39 ,$5.55 ,$4.58 
Carle BroMenn Medical Center,8980250,lactulose 20 gram/30 mL oral solution,50383077930,,250,$16.17 ,$16.17 ,$4.85 ,$14.71 ,$11.32 ,$4.85 ,$10.51 ,$11.64 ,$14.71 ,$12.13 
Carle BroMenn Medical Center,8980250,lamoTRIgine 100 mg tablet,68084031901,,250,$3.40 ,$3.40 ,$1.02 ,$3.09 ,$2.38 ,$1.02 ,$2.21 ,$2.45 ,$3.09 ,$2.55 
Carle BroMenn Medical Center,8980250,lamoTRIgine 100 mg tablet,68084031911,,250,$3.40 ,$3.40 ,$1.02 ,$3.09 ,$2.38 ,$1.02 ,$2.21 ,$2.45 ,$3.09 ,$2.55 
Carle BroMenn Medical Center,8980250,lamoTRIgine 100 mg tablet,68382000801,,250,$26.33 ,$26.33 ,$7.90 ,$23.96 ,$18.43 ,$7.90 ,$17.11 ,$18.96 ,$23.96 ,$19.75 
Carle BroMenn Medical Center,8980250,lamoTRIgine 25 mg tablet,904700761,,250,$3.28 ,$3.28 ,$0.98 ,$2.98 ,$2.30 ,$0.98 ,$2.13 ,$2.36 ,$2.98 ,$2.46 
Carle BroMenn Medical Center,8980250,lamoTRIgine 25 mg tablet,68084031801,,250,$3.37 ,$3.37 ,$1.01 ,$3.07 ,$2.36 ,$1.01 ,$2.19 ,$2.43 ,$3.07 ,$2.53 
Carle BroMenn Medical Center,8980250,lamoTRIgine 25 mg tablet,68084031811,,250,$3.37 ,$3.37 ,$1.01 ,$3.07 ,$2.36 ,$1.01 ,$2.19 ,$2.43 ,$3.07 ,$2.53 
Carle BroMenn Medical Center,8980250,latanoprost 0.005 % eye drops,61314054701,,250,$463.67 ,$463.67 ,$139.10 ,$421.94 ,$324.57 ,$139.10 ,$301.39 ,$333.84 ,$421.94 ,$347.75 
Carle BroMenn Medical Center,8980250,latanoprost 0.005 % eye drops,70069042101,,250,$463.67 ,$463.67 ,$139.10 ,$421.94 ,$324.57 ,$139.10 ,$301.39 ,$333.84 ,$421.94 ,$347.75 
Carle BroMenn Medical Center,8980250,leflunomide 10 mg tablet,60505250201,,250,$67.91 ,$67.91 ,$20.37 ,$61.80 ,$47.54 ,$20.37 ,$44.14 ,$48.90 ,$61.80 ,$50.93 
Carle BroMenn Medical Center,8980250,leflunomide 10 mg tablet,62332006130,,250,$67.91 ,$67.91 ,$20.37 ,$61.80 ,$47.54 ,$20.37 ,$44.14 ,$48.90 ,$61.80 ,$50.93 
Carle BroMenn Medical Center,8980250,leflunomide 10 mg tablet,70710115703,,250,$67.91 ,$67.91 ,$20.37 ,$61.80 ,$47.54 ,$20.37 ,$44.14 ,$48.90 ,$61.80 ,$50.93 
Carle BroMenn Medical Center,8980250,leucovorin calcium 5 mg tablet,54449613,,250,$11.88 ,$11.88 ,$3.56 ,$10.81 ,$8.32 ,$3.56 ,$7.72 ,$8.55 ,$10.81 ,$8.91 
Carle BroMenn Medical Center,8980250,leucovorin calcium 5 mg tablet,555048401,,250,$13.33 ,$13.33 ,$4.00 ,$12.13 ,$9.33 ,$4.00 ,$8.66 ,$9.60 ,$12.13 ,$10.00 
Carle BroMenn Medical Center,8980250,levETIRAcetam 100 mg/mL oral solution,121079916,,250,$10.72 ,$10.72 ,$3.22 ,$9.76 ,$7.50 ,$3.22 ,$6.97 ,$7.72 ,$9.76 ,$8.04 
Carle BroMenn Medical Center,8980250,levETIRAcetam 100 mg/mL oral solution,31722057447,,250,$10.72 ,$10.72 ,$3.22 ,$9.76 ,$7.50 ,$3.22 ,$6.97 ,$7.72 ,$9.76 ,$8.04 
Carle BroMenn Medical Center,8980250,levETIRAcetam 500 mg tablet,904605261,,250,$17.07 ,$17.07 ,$5.12 ,$15.53 ,$11.95 ,$5.12 ,$11.10 ,$12.29 ,$15.53 ,$12.80 
Carle BroMenn Medical Center,8980250,levETIRAcetam 500 mg tablet,31722053705,,250,$18.71 ,$18.71 ,$5.61 ,$17.03 ,$13.10 ,$5.61 ,$12.16 ,$13.47 ,$17.03 ,$14.03 
Carle BroMenn Medical Center,8980250,levETIRAcetam 500 mg tablet,51079082101,,250,$18.71 ,$18.71 ,$5.61 ,$17.03 ,$13.10 ,$5.61 ,$12.16 ,$13.47 ,$17.03 ,$14.03 
Carle BroMenn Medical Center,8980250,levETIRAcetam 500 mg tablet,51079082120,,250,$18.71 ,$18.71 ,$5.61 ,$17.03 ,$13.10 ,$5.61 ,$12.16 ,$13.47 ,$17.03 ,$14.03 
Carle BroMenn Medical Center,8980250,levETIRAcetam 500 mg tablet,63739041110,,250,$3.38 ,$3.38 ,$1.01 ,$3.08 ,$2.37 ,$1.01 ,$2.20 ,$2.43 ,$3.08 ,$2.54 
Carle BroMenn Medical Center,8980250,levETIRAcetam 500 mg tablet,68084087001,,250,$5.68 ,$5.68 ,$1.70 ,$5.17 ,$3.98 ,$1.70 ,$3.69 ,$4.09 ,$5.17 ,$4.26 
Carle BroMenn Medical Center,8980250,levETIRAcetam 500 mg tablet,68084087011,,250,$5.68 ,$5.68 ,$1.70 ,$5.17 ,$3.98 ,$1.70 ,$3.69 ,$4.09 ,$5.17 ,$4.26 
Carle BroMenn Medical Center,8980250,levoFLOXacin 250 mg tablet,904635161,,250,$59.69 ,$59.69 ,$17.91 ,$54.32 ,$41.78 ,$17.91 ,$38.80 ,$42.98 ,$54.32 ,$44.77 
Carle BroMenn Medical Center,8980250,levoFLOXacin 250 mg tablet,31722072150,,250,$66.99 ,$66.99 ,$20.10 ,$60.96 ,$46.89 ,$20.10 ,$43.54 ,$48.23 ,$60.96 ,$50.24 
Carle BroMenn Medical Center,8980250,levoFLOXacin 250 mg tablet,65862053650,,250,$66.99 ,$66.99 ,$20.10 ,$60.96 ,$46.89 ,$20.10 ,$43.54 ,$48.23 ,$60.96 ,$50.24 
Carle BroMenn Medical Center,8980250,levoFLOXacin 750 mg tablet,31722072320,,250,$134.56 ,$134.56 ,$40.37 ,$122.45 ,$94.19 ,$40.37 ,$87.46 ,$96.88 ,$122.45 ,$100.92 
Carle BroMenn Medical Center,8980250,levoFLOXacin 750 mg tablet,65862053820,,250,$134.42 ,$134.42 ,$40.33 ,$122.32 ,$94.09 ,$40.33 ,$87.37 ,$96.78 ,$122.32 ,$100.82 
Carle BroMenn Medical Center,8980250,levomefolate calcium 15 mg tablet,76439035890,,250,$16.14 ,$16.14 ,$4.84 ,$14.69 ,$11.30 ,$4.84 ,$10.49 ,$11.62 ,$14.69 ,$12.11 
Carle BroMenn Medical Center,8980250,levomefolate calcium 7.5 mg tablet,76439035930,,250,$16.14 ,$16.14 ,$4.84 ,$14.69 ,$11.30 ,$4.84 ,$10.49 ,$11.62 ,$14.69 ,$12.11 
Carle BroMenn Medical Center,8980250,levothyroxine 100 mcg intravenous powder for solution,70860045110,,250,$519.04 ,$519.04 ,$155.71 ,$472.33 ,$363.33 ,$155.71 ,$337.38 ,$373.71 ,$472.33 ,$389.28 
Carle BroMenn Medical Center,8980250,levothyroxine 100 mcg tablet,60687049701,,250,$5.70 ,$5.70 ,$1.71 ,$5.19 ,$3.99 ,$1.71 ,$3.71 ,$4.10 ,$5.19 ,$4.28 
Carle BroMenn Medical Center,8980250,levothyroxine 100 mcg tablet,60687049711,,250,$5.70 ,$5.70 ,$1.71 ,$5.19 ,$3.99 ,$1.71 ,$3.71 ,$4.10 ,$5.19 ,$4.28 
Carle BroMenn Medical Center,8980250,levothyroxine 112 mcg tablet,60687050801,,250,$6.14 ,$6.14 ,$1.84 ,$5.59 ,$4.30 ,$1.84 ,$3.99 ,$4.42 ,$5.59 ,$4.61 
Carle BroMenn Medical Center,8980250,levothyroxine 112 mcg tablet,60687050811,,250,$6.14 ,$6.14 ,$1.84 ,$5.59 ,$4.30 ,$1.84 ,$3.99 ,$4.42 ,$5.59 ,$4.61 
Carle BroMenn Medical Center,8980250,levothyroxine 125 mcg tablet,51079044301,,250,$5.67 ,$5.67 ,$1.70 ,$5.16 ,$3.97 ,$1.70 ,$3.69 ,$4.08 ,$5.16 ,$4.25 
Carle BroMenn Medical Center,8980250,levothyroxine 125 mcg tablet,51079044320,,250,$5.67 ,$5.67 ,$1.70 ,$5.16 ,$3.97 ,$1.70 ,$3.69 ,$4.08 ,$5.16 ,$4.25 
Carle BroMenn Medical Center,8980250,levothyroxine 125 mcg tablet,60687051911,,250,$6.30 ,$6.30 ,$1.89 ,$5.73 ,$4.41 ,$1.89 ,$4.10 ,$4.54 ,$5.73 ,$4.73 
Carle BroMenn Medical Center,8980250,levothyroxine 137 mcg tablet,60687056301,,250,$6.33 ,$6.33 ,$1.90 ,$5.76 ,$4.43 ,$1.90 ,$4.11 ,$4.56 ,$5.76 ,$4.75 
Carle BroMenn Medical Center,8980250,levothyroxine 137 mcg tablet,60687056311,,250,$6.33 ,$6.33 ,$1.90 ,$5.76 ,$4.43 ,$1.90 ,$4.11 ,$4.56 ,$5.76 ,$4.75 
Carle BroMenn Medical Center,8980250,levothyroxine 150 mcg tablet,51079044501,,250,$5.77 ,$5.77 ,$1.73 ,$5.25 ,$4.04 ,$1.73 ,$3.75 ,$4.15 ,$5.25 ,$4.33 
Carle BroMenn Medical Center,8980250,levothyroxine 150 mcg tablet,51079044520,,250,$5.77 ,$5.77 ,$1.73 ,$5.25 ,$4.04 ,$1.73 ,$3.75 ,$4.15 ,$5.25 ,$4.33 
Carle BroMenn Medical Center,8980250,levothyroxine 150 mcg tablet,60687053001,,250,$6.41 ,$6.41 ,$1.92 ,$5.83 ,$4.49 ,$1.92 ,$4.17 ,$4.62 ,$5.83 ,$4.81 
Carle BroMenn Medical Center,8980250,levothyroxine 150 mcg tablet,60687053011,,250,$6.41 ,$6.41 ,$1.92 ,$5.83 ,$4.49 ,$1.92 ,$4.17 ,$4.62 ,$5.83 ,$4.81 
Carle BroMenn Medical Center,8980250,levothyroxine 150 mcg tablet,68180097301,,250,$5.49 ,$5.49 ,$1.65 ,$5.00 ,$3.84 ,$1.65 ,$3.57 ,$3.95 ,$5.00 ,$4.12 
Carle BroMenn Medical Center,8980250,levothyroxine 200 mcg tablet,69238184001,,250,$6.09 ,$6.09 ,$1.83 ,$5.54 ,$4.26 ,$1.83 ,$3.96 ,$4.38 ,$5.54 ,$4.57 
Carle BroMenn Medical Center,8980250,levothyroxine 25 mcg tablet,51079044401,,250,$4.54 ,$4.54 ,$1.36 ,$4.13 ,$3.18 ,$1.36 ,$2.95 ,$3.27 ,$4.13 ,$3.41 
Carle BroMenn Medical Center,8980250,levothyroxine 25 mcg tablet,51079044420,,250,$4.54 ,$4.54 ,$1.36 ,$4.13 ,$3.18 ,$1.36 ,$2.95 ,$3.27 ,$4.13 ,$3.41 
Carle BroMenn Medical Center,8980250,levothyroxine 25 mcg tablet,60687045301,,250,$4.93 ,$4.93 ,$1.48 ,$4.49 ,$3.45 ,$1.48 ,$3.20 ,$3.55 ,$4.49 ,$3.70 
Carle BroMenn Medical Center,8980250,levothyroxine 25 mcg tablet,60687045311,,250,$4.93 ,$4.93 ,$1.48 ,$4.49 ,$3.45 ,$1.48 ,$3.20 ,$3.55 ,$4.49 ,$3.70 
Carle BroMenn Medical Center,8980250,levothyroxine 50 mcg tablet,51079044001,,250,$4.85 ,$4.85 ,$1.46 ,$4.41 ,$3.40 ,$1.46 ,$3.15 ,$3.49 ,$4.41 ,$3.64 
Carle BroMenn Medical Center,8980250,levothyroxine 50 mcg tablet,51079044020,,250,$4.85 ,$4.85 ,$1.46 ,$4.41 ,$3.40 ,$1.46 ,$3.15 ,$3.49 ,$4.41 ,$3.64 
Carle BroMenn Medical Center,8980250,levothyroxine 50 mcg tablet,60687046401,,250,$4.96 ,$4.96 ,$1.49 ,$4.51 ,$3.47 ,$1.49 ,$3.22 ,$3.57 ,$4.51 ,$3.72 
Carle BroMenn Medical Center,8980250,levothyroxine 50 mcg tablet,60687046411,,250,$4.96 ,$4.96 ,$1.49 ,$4.51 ,$3.47 ,$1.49 ,$3.22 ,$3.57 ,$4.51 ,$3.72 
Carle BroMenn Medical Center,8980250,levothyroxine 75 mcg tablet,51079044101,,250,$5.11 ,$5.11 ,$1.53 ,$4.65 ,$3.58 ,$1.53 ,$3.32 ,$3.68 ,$4.65 ,$3.83 
Carle BroMenn Medical Center,8980250,levothyroxine 75 mcg tablet,51079044120,,250,$5.11 ,$5.11 ,$1.53 ,$4.65 ,$3.58 ,$1.53 ,$3.32 ,$3.68 ,$4.65 ,$3.83 
Carle BroMenn Medical Center,8980250,levothyroxine 75 mcg tablet,60687047501,,250,$5.62 ,$5.62 ,$1.69 ,$5.11 ,$3.93 ,$1.69 ,$3.65 ,$4.05 ,$5.11 ,$4.22 
Carle BroMenn Medical Center,8980250,levothyroxine 75 mcg tablet,60687047511,,250,$5.62 ,$5.62 ,$1.69 ,$5.11 ,$3.93 ,$1.69 ,$3.65 ,$4.05 ,$5.11 ,$4.22 
Carle BroMenn Medical Center,8980250,levothyroxine 88 mcg tablet,60687048601,,250,$5.59 ,$5.59 ,$1.68 ,$5.09 ,$3.91 ,$1.68 ,$3.63 ,$4.02 ,$5.09 ,$4.19 
Carle BroMenn Medical Center,8980250,levothyroxine 88 mcg tablet,60687048611,,250,$5.59 ,$5.59 ,$1.68 ,$5.09 ,$3.91 ,$1.68 ,$3.63 ,$4.02 ,$5.09 ,$4.19 
Carle BroMenn Medical Center,8980250,"lidocaine 1 %-epinephrine 1:100,000 injection solution",409317802,J3490,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,"lidocaine 1 %-epinephrine 1:100,000 injection solution",63323048217,J3490,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,"lidocaine 1 %-epinephrine 1:100,000 injection solution",63323048227,J3490,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,"lidocaine 1 %-epinephrine 1:100,000 injection solution",63323048241,J3490,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,lidocaine 2 % mucosal jelly in applicator,25021067377,,250,$37.85 ,$37.85 ,$11.36 ,$34.44 ,$26.50 ,$11.36 ,$24.60 ,$27.25 ,$34.44 ,$28.39 
Carle BroMenn Medical Center,8980250,lidocaine 2 % mucosal jelly in applicator,76329301305,,250,$38.17 ,$38.17 ,$11.45 ,$34.73 ,$26.72 ,$11.45 ,$24.81 ,$27.48 ,$34.73 ,$28.63 
Carle BroMenn Medical Center,8980250,Lidocaine 2 % Mucosal Soln,50383077515,,250,$7.36 ,$7.36 ,$2.21 ,$6.70 ,$5.15 ,$2.21 ,$4.78 ,$5.30 ,$6.70 ,$5.52 
Carle BroMenn Medical Center,8980250,Lidocaine 2 % Mucosal Soln,50383077517,,250,$7.36 ,$7.36 ,$2.21 ,$6.70 ,$5.15 ,$2.21 ,$4.78 ,$5.30 ,$6.70 ,$5.52 
Carle BroMenn Medical Center,8980250,lidocaine 4 % topical cream,24357070105,,250,$38.42 ,$38.42 ,$11.53 ,$34.96 ,$26.89 ,$11.53 ,$24.97 ,$27.66 ,$34.96 ,$28.82 
Carle BroMenn Medical Center,8980250,lidocaine 4 % topical cream,24357070106,,250,$38.42 ,$38.42 ,$11.53 ,$34.96 ,$26.89 ,$11.53 ,$24.97 ,$27.66 ,$34.96 ,$28.82 
Carle BroMenn Medical Center,8980250,lidocaine 4 % topical cream,39328002405,,250,$60.54 ,$60.54 ,$18.16 ,$55.09 ,$42.38 ,$18.16 ,$39.35 ,$43.59 ,$55.09 ,$45.41 
Carle BroMenn Medical Center,8980250,lidocaine 4 % topical patch,536120215,,250,$9.34 ,$9.34 ,$2.80 ,$8.50 ,$6.54 ,$2.80 ,$6.07 ,$6.72 ,$8.50 ,$7.01 
Carle BroMenn Medical Center,8980250,lidocaine 4 % topical patch,41167005840,,250,$15.44 ,$15.44 ,$4.63 ,$14.05 ,$10.81 ,$4.63 ,$10.04 ,$11.12 ,$14.05 ,$11.58 
Carle BroMenn Medical Center,8980250,lidocaine 4 % topical patch,46122045021,,250,$10.34 ,$10.34 ,$3.10 ,$9.41 ,$7.24 ,$3.10 ,$6.72 ,$7.44 ,$9.41 ,$7.76 
Carle BroMenn Medical Center,8980250,lidocaine 4 % topical patch,46581083006,,250,$9.12 ,$9.12 ,$2.74 ,$8.30 ,$6.38 ,$2.74 ,$5.93 ,$6.57 ,$8.30 ,$6.84 
Carle BroMenn Medical Center,8980250,lidocaine 4 % topical patch,87701043001,,250,$7.32 ,$7.32 ,$2.20 ,$6.66 ,$5.12 ,$2.20 ,$4.76 ,$5.27 ,$6.66 ,$5.49 
Carle BroMenn Medical Center,8980250,lidocaine 4 %-racepinephrine 0.05 %-tetracaine 0.5 % topical gel,5446060701,,250,$20.96 ,$20.96 ,$6.29 ,$19.07 ,$14.67 ,$6.29 ,$13.62 ,$15.09 ,$19.07 ,$15.72 
Carle BroMenn Medical Center,8980250,lidocaine HCL 2 % mucosal jelly,17478071110,,250,$52.39 ,$52.39 ,$15.72 ,$47.67 ,$36.67 ,$15.72 ,$34.05 ,$37.72 ,$47.67 ,$39.29 
Carle BroMenn Medical Center,8980250,lidocaine HCL 2 % mucosal jelly,17478071131,,250,$52.39 ,$52.39 ,$15.72 ,$47.67 ,$36.67 ,$15.72 ,$34.05 ,$37.72 ,$47.67 ,$39.29 
Carle BroMenn Medical Center,8980250,lidocaine HCL 2 % mucosal solution,54350049,,250,$17.47 ,$17.47 ,$5.24 ,$15.90 ,$12.23 ,$5.24 ,$11.36 ,$12.58 ,$15.90 ,$13.10 
Carle BroMenn Medical Center,8980250,lidocaine HCL 2 % mucosal solution,121090315,,250,$13.30 ,$13.30 ,$3.99 ,$12.10 ,$9.31 ,$3.99 ,$8.65 ,$9.58 ,$12.10 ,$9.98 
Carle BroMenn Medical Center,8980250,lidocaine HCL 2 % mucosal solution,121090340,,250,$13.30 ,$13.30 ,$3.99 ,$12.10 ,$9.31 ,$3.99 ,$8.65 ,$9.58 ,$12.10 ,$9.98 
Carle BroMenn Medical Center,8980250,lidocaine HCL 2 % mucosal solution,50383077504,,250,$17.47 ,$17.47 ,$5.24 ,$15.90 ,$12.23 ,$5.24 ,$11.36 ,$12.58 ,$15.90 ,$13.10 
Carle BroMenn Medical Center,8980250,lidocaine HCL 2 % mucosal solution,50383077515,,250,$7.36 ,$7.36 ,$2.21 ,$6.70 ,$5.15 ,$2.21 ,$4.78 ,$5.30 ,$6.70 ,$5.52 
Carle BroMenn Medical Center,8980250,lidocaine HCL 2 % mucosal solution,50383077517,,250,$7.36 ,$7.36 ,$2.21 ,$6.70 ,$5.15 ,$2.21 ,$4.78 ,$5.30 ,$6.70 ,$5.52 
Carle BroMenn Medical Center,8980250,lidocaine HCL 4 % (40 mg/mL) mucosal solution,54350547,,250,$244.65 ,$244.65 ,$73.40 ,$222.63 ,$171.26 ,$73.40 ,$159.02 ,$176.15 ,$222.63 ,$183.49 
Carle BroMenn Medical Center,8980250,lidocaine HCL 4 % (40 mg/mL) mucosal solution,527600480,,250,$322.24 ,$322.24 ,$96.67 ,$293.24 ,$225.57 ,$96.67 ,$209.46 ,$232.01 ,$293.24 ,$241.68 
Carle BroMenn Medical Center,8980250,lidocaine HCL 4 % laryngotracheal solution,76329630005,,250,$195.32 ,$195.32 ,$58.60 ,$177.74 ,$136.72 ,$58.60 ,$126.96 ,$140.63 ,$177.74 ,$146.49 
Carle BroMenn Medical Center,8980250,"lidocaine-epinephrine (PF) 1.5 %-1:200,000 injection solution",409120970,,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,"lidocaine-epinephrine (PF) 1.5 %-1:200,000 injection solution",63323048807,,250,$98.38 ,$98.38 ,$29.51 ,$89.53 ,$68.87 ,$29.51 ,$63.95 ,$70.83 ,$89.53 ,$73.79 
Carle BroMenn Medical Center,8980250,"lidocaine-epinephrine (PF) 2 %-1:200,000 injection solution",409318301,,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,"lidocaine-epinephrine (PF) 2 %-1:200,000 injection solution",409318311,,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,"lidocaine-epinephrine (PF) 2 %-1:200,000 injection solution",63323048921,,250,$92.91 ,$92.91 ,$27.87 ,$84.55 ,$65.04 ,$27.87 ,$60.39 ,$66.90 ,$84.55 ,$69.68 
Carle BroMenn Medical Center,8980250,"lidocaine-epinephrine 0.5 %-1:200,000 injection solution",409317701,,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,"lidocaine-epinephrine 0.5 %-1:200,000 injection solution",409317716,,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,"lidocaine-epinephrine 0.5 %-1:200,000 injection solution",63323048101,,250,$46.18 ,$46.18 ,$13.85 ,$42.02 ,$32.33 ,$13.85 ,$30.02 ,$33.25 ,$42.02 ,$34.64 
Carle BroMenn Medical Center,8980250,"lidocaine-epinephrine 0.5 %-1:200,000 injection solution",63323048157,,250,$46.18 ,$46.18 ,$13.85 ,$42.02 ,$32.33 ,$13.85 ,$30.02 ,$33.25 ,$42.02 ,$34.64 
Carle BroMenn Medical Center,8980250,linaCLOtide 145 mcg capsule,456120130,,250,$73.57 ,$73.57 ,$22.07 ,$66.95 ,$51.50 ,$22.07 ,$47.82 ,$52.97 ,$66.95 ,$55.18 
Carle BroMenn Medical Center,8980250,linaGLIPtin 5 mg tablet,597014061,,250,$76.11 ,$76.11 ,$22.83 ,$69.26 ,$53.28 ,$22.83 ,$49.47 ,$54.80 ,$69.26 ,$57.08 
Carle BroMenn Medical Center,8980250,linezolid 600 mg tablet,67877041984,,250,$650.97 ,$650.97 ,$195.29 ,$592.38 ,$455.68 ,$195.29 ,$423.13 ,$468.70 ,$592.38 ,$488.23 
Carle BroMenn Medical Center,8980250,liothyronine 25 mcg tablet,42794001912,,250,$7.46 ,$7.46 ,$2.24 ,$6.79 ,$5.22 ,$2.24 ,$4.85 ,$5.37 ,$6.79 ,$5.60 
Carle BroMenn Medical Center,8980250,liothyronine 5 mcg tablet,42794001802,,250,$6.02 ,$6.02 ,$1.81 ,$5.48 ,$4.21 ,$1.81 ,$3.91 ,$4.33 ,$5.48 ,$4.52 
Carle BroMenn Medical Center,8980250,"lipase 3,000-protease 9,500-amylase 15,000 unit capsule, delayed rel",32120370,,250,$10.71 ,$10.71 ,$3.21 ,$9.75 ,$7.50 ,$3.21 ,$6.96 ,$7.71 ,$9.75 ,$8.03 
Carle BroMenn Medical Center,8980250,"lipase-protease-amylase 12,000-38,000-60,000 unit capsule,delayed rel",32121201,,250,$22.17 ,$22.17 ,$6.65 ,$20.17 ,$15.52 ,$6.65 ,$14.41 ,$15.96 ,$20.17 ,$16.63 
Carle BroMenn Medical Center,8980250,"lipase-protease-amylase 24,000-76,000-120,000 unit capsule,delayed rel",32122401,,250,$37.68 ,$37.68 ,$11.30 ,$34.29 ,$26.38 ,$11.30 ,$24.49 ,$27.13 ,$34.29 ,$28.26 
Carle BroMenn Medical Center,8980250,"lipase-protease-amylase 6,000-19,000-30,000 unit capsule,delayed rel",32120601,,250,$12.26 ,$12.26 ,$3.68 ,$11.16 ,$8.58 ,$3.68 ,$7.97 ,$8.83 ,$11.16 ,$9.20 
Carle BroMenn Medical Center,8980250,lisinopriL 10 mg tablet,904679861,,250,$2.63 ,$2.63 ,$0.79 ,$2.39 ,$1.84 ,$0.79 ,$1.71 ,$1.89 ,$2.39 ,$1.97 
Carle BroMenn Medical Center,8980250,lisinopriL 10 mg tablet,60687032501,,250,$3.03 ,$3.03 ,$0.91 ,$2.76 ,$2.12 ,$0.91 ,$1.97 ,$2.18 ,$2.76 ,$2.27 
Carle BroMenn Medical Center,8980250,lisinopriL 10 mg tablet,60687032511,,250,$3.03 ,$3.03 ,$0.91 ,$2.76 ,$2.12 ,$0.91 ,$1.97 ,$2.18 ,$2.76 ,$2.27 
Carle BroMenn Medical Center,8980250,lisinopriL 2.5 mg tablet,591040501,,250,$5.31 ,$5.31 ,$1.59 ,$4.83 ,$3.72 ,$1.59 ,$3.45 ,$3.82 ,$4.83 ,$3.98 
Carle BroMenn Medical Center,8980250,lisinopriL 2.5 mg tablet,68001033200,,250,$5.35 ,$5.35 ,$1.61 ,$4.87 ,$3.75 ,$1.61 ,$3.48 ,$3.85 ,$4.87 ,$4.01 
Carle BroMenn Medical Center,8980250,lisinopriL 2.5 mg tablet,68180051201,,250,$5.35 ,$5.35 ,$1.61 ,$4.87 ,$3.75 ,$1.61 ,$3.48 ,$3.85 ,$4.87 ,$4.01 
Carle BroMenn Medical Center,8980250,lisinopriL 20 mg tablet,904679961,,250,$2.71 ,$2.71 ,$0.81 ,$2.47 ,$1.90 ,$0.81 ,$1.76 ,$1.95 ,$2.47 ,$2.03 
Carle BroMenn Medical Center,8980250,lisinopriL 20 mg tablet,60687033301,,250,$3.03 ,$3.03 ,$0.91 ,$2.76 ,$2.12 ,$0.91 ,$1.97 ,$2.18 ,$2.76 ,$2.27 
Carle BroMenn Medical Center,8980250,lisinopriL 20 mg tablet,60687033311,,250,$3.03 ,$3.03 ,$0.91 ,$2.76 ,$2.12 ,$0.91 ,$1.97 ,$2.18 ,$2.76 ,$2.27 
Carle BroMenn Medical Center,8980250,lisinopriL 40 mg tablet,904680061,,250,$2.38 ,$2.38 ,$0.71 ,$2.17 ,$1.67 ,$0.71 ,$1.55 ,$1.71 ,$2.17 ,$1.79 
Carle BroMenn Medical Center,8980250,lisinopriL 40 mg tablet,68084019901,,250,$5.18 ,$5.18 ,$1.55 ,$4.71 ,$3.63 ,$1.55 ,$3.37 ,$3.73 ,$4.71 ,$3.89 
Carle BroMenn Medical Center,8980250,lisinopriL 40 mg tablet,68084019911,,250,$5.18 ,$5.18 ,$1.55 ,$4.71 ,$3.63 ,$1.55 ,$3.37 ,$3.73 ,$4.71 ,$3.89 
Carle BroMenn Medical Center,8980250,lisinopriL 5 mg tablet,904679761,,250,$2.69 ,$2.69 ,$0.81 ,$2.45 ,$1.88 ,$0.81 ,$1.75 ,$1.94 ,$2.45 ,$2.02 
Carle BroMenn Medical Center,8980250,lisinopriL 5 mg tablet,68084019601,,250,$6.39 ,$6.39 ,$1.92 ,$5.81 ,$4.47 ,$1.92 ,$4.15 ,$4.60 ,$5.81 ,$4.79 
Carle BroMenn Medical Center,8980250,lisinopriL 5 mg tablet,68084019611,,250,$6.39 ,$6.39 ,$1.92 ,$5.81 ,$4.47 ,$1.92 ,$4.15 ,$4.60 ,$5.81 ,$4.79 
Carle BroMenn Medical Center,8980250,lithium carbonate 150 mg capsule,54852625,,250,$3.21 ,$3.21 ,$0.96 ,$2.92 ,$2.25 ,$0.96 ,$2.09 ,$2.31 ,$2.92 ,$2.41 
Carle BroMenn Medical Center,8980250,"lithium carbonate ER 300 mg tablet,extended release",68084064001,,250,$4.56 ,$4.56 ,$1.37 ,$4.15 ,$3.19 ,$1.37 ,$2.96 ,$3.28 ,$4.15 ,$3.42 
Carle BroMenn Medical Center,8980250,"lithium carbonate ER 300 mg tablet,extended release",68084064011,,250,$4.56 ,$4.56 ,$1.37 ,$4.15 ,$3.19 ,$1.37 ,$2.96 ,$3.28 ,$4.15 ,$3.42 
Carle BroMenn Medical Center,8980250,"lithium carbonate ER 450 mg tablet,extended release",68084065501,,250,$5.85 ,$5.85 ,$1.76 ,$5.32 ,$4.10 ,$1.76 ,$3.80 ,$4.21 ,$5.32 ,$4.39 
Carle BroMenn Medical Center,8980250,"lithium carbonate ER 450 mg tablet,extended release",68084065511,,250,$5.85 ,$5.85 ,$1.76 ,$5.32 ,$4.10 ,$1.76 ,$3.80 ,$4.21 ,$5.32 ,$4.39 
Carle BroMenn Medical Center,8980250,lithium citrate 8 mEq/5 mL oral solution,54352763,,250,$17.47 ,$17.47 ,$5.24 ,$15.90 ,$12.23 ,$5.24 ,$11.36 ,$12.58 ,$15.90 ,$13.10 
Carle BroMenn Medical Center,8980250,loperamide 2 mg capsule,93031101,,250,$8.69 ,$8.69 ,$2.61 ,$7.91 ,$6.08 ,$2.61 ,$5.65 ,$6.26 ,$7.91 ,$6.52 
Carle BroMenn Medical Center,8980250,loperamide 2 mg capsule,60687022901,,250,$6.42 ,$6.42 ,$1.93 ,$5.84 ,$4.49 ,$1.93 ,$4.17 ,$4.62 ,$5.84 ,$4.82 
Carle BroMenn Medical Center,8980250,loperamide 2 mg capsule,60687022911,,250,$6.42 ,$6.42 ,$1.93 ,$5.84 ,$4.49 ,$1.93 ,$4.17 ,$4.62 ,$5.84 ,$4.82 
Carle BroMenn Medical Center,8980250,loratadine 10 mg tablet,51079024601,,250,$1.20 ,$1.20 ,$0.36 ,$1.09 ,$0.84 ,$0.36 ,$0.78 ,$0.86 ,$1.09 ,$0.90 
Carle BroMenn Medical Center,8980250,loratadine 10 mg tablet,51079024620,,250,$1.20 ,$1.20 ,$0.36 ,$1.09 ,$0.84 ,$0.36 ,$0.78 ,$0.86 ,$1.09 ,$0.90 
Carle BroMenn Medical Center,8980250,loratadine 10 mg tablet,68001043816,,250,$0.98 ,$0.98 ,$0.29 ,$0.89 ,$0.69 ,$0.29 ,$0.64 ,$0.71 ,$0.89 ,$0.74 
Carle BroMenn Medical Center,8980250,loratadine 10 mg tablet,68001043896,,250,$0.98 ,$0.98 ,$0.29 ,$0.89 ,$0.69 ,$0.29 ,$0.64 ,$0.71 ,$0.89 ,$0.74 
Carle BroMenn Medical Center,8980250,loratadine 10 mg tablet,68084024801,,250,$0.98 ,$0.98 ,$0.29 ,$0.89 ,$0.69 ,$0.29 ,$0.64 ,$0.71 ,$0.89 ,$0.74 
Carle BroMenn Medical Center,8980250,loratadine 10 mg tablet,68084024811,,250,$0.98 ,$0.98 ,$0.29 ,$0.89 ,$0.69 ,$0.29 ,$0.64 ,$0.71 ,$0.89 ,$0.74 
Carle BroMenn Medical Center,8980250,loratadine 5 mg/5 mL oral solution,46122042326,,250,$9.38 ,$9.38 ,$2.81 ,$8.54 ,$6.57 ,$2.81 ,$6.10 ,$6.75 ,$8.54 ,$7.04 
Carle BroMenn Medical Center,8980250,loratadine 5 mg/5 mL oral solution,54838055840,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,LORazepam 0.5 mg tablet,904600761,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,LORazepam 0.5 mg tablet,60687040101,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,LORazepam 0.5 mg tablet,60687040111,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,LORazepam 1 mg tablet,591024101,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,LORazepam 1 mg tablet,904600861,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,LORazepam 1 mg tablet,60687035511,,250,$3.13 ,$3.13 ,$0.94 ,$2.85 ,$2.19 ,$0.94 ,$2.03 ,$2.25 ,$2.85 ,$2.35 
Carle BroMenn Medical Center,8980250,LORazepam 2 mg tablet,904600961,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,LORazepam 2 mg/mL oral concentrate,54353244,,250,$16.31 ,$16.31 ,$4.89 ,$14.84 ,$11.42 ,$4.89 ,$10.60 ,$11.74 ,$14.84 ,$12.23 
Carle BroMenn Medical Center,8980250,LORazepam 2 mg/mL oral concentrate,121077001,,250,$14.71 ,$14.71 ,$4.41 ,$13.39 ,$10.30 ,$4.41 ,$9.56 ,$10.59 ,$13.39 ,$11.03 
Carle BroMenn Medical Center,8980250,losartan 100 mg tablet,68084034801,,250,$16.66 ,$16.66 ,$5.00 ,$15.16 ,$11.66 ,$5.00 ,$10.83 ,$12.00 ,$15.16 ,$12.50 
Carle BroMenn Medical Center,8980250,losartan 100 mg tablet,68084034811,,250,$16.66 ,$16.66 ,$5.00 ,$15.16 ,$11.66 ,$5.00 ,$10.83 ,$12.00 ,$15.16 ,$12.50 
Carle BroMenn Medical Center,8980250,losartan 25 mg tablet,63739067310,,250,$5.12 ,$5.12 ,$1.54 ,$4.66 ,$3.58 ,$1.54 ,$3.33 ,$3.69 ,$4.66 ,$3.84 
Carle BroMenn Medical Center,8980250,losartan 25 mg tablet,68084034601,,250,$10.15 ,$10.15 ,$3.05 ,$9.24 ,$7.11 ,$3.05 ,$6.60 ,$7.31 ,$9.24 ,$7.61 
Carle BroMenn Medical Center,8980250,losartan 25 mg tablet,68084034611,,250,$10.15 ,$10.15 ,$3.05 ,$9.24 ,$7.11 ,$3.05 ,$6.60 ,$7.31 ,$9.24 ,$7.61 
Carle BroMenn Medical Center,8980250,losartan 50 mg tablet,68084034701,,250,$12.82 ,$12.82 ,$3.85 ,$11.67 ,$8.97 ,$3.85 ,$8.33 ,$9.23 ,$11.67 ,$9.62 
Carle BroMenn Medical Center,8980250,losartan 50 mg tablet,68084034711,,250,$12.82 ,$12.82 ,$3.85 ,$11.67 ,$8.97 ,$3.85 ,$8.33 ,$9.23 ,$11.67 ,$9.62 
Carle BroMenn Medical Center,8980250,lubiprostone 24 mcg capsule,254302902,,250,$31.53 ,$31.53 ,$9.46 ,$28.69 ,$22.07 ,$9.46 ,$20.49 ,$22.70 ,$28.69 ,$23.65 
Carle BroMenn Medical Center,8980250,lubiprostone 24 mcg capsule,64764024060,,250,$34.13 ,$34.13 ,$10.24 ,$31.06 ,$23.89 ,$10.24 ,$22.18 ,$24.57 ,$31.06 ,$25.60 
Carle BroMenn Medical Center,8980250,lubiprostone 8 mcg capsule,64764008060,,250,$34.13 ,$34.13 ,$10.24 ,$31.06 ,$23.89 ,$10.24 ,$22.18 ,$24.57 ,$31.06 ,$25.60 
Carle BroMenn Medical Center,8980250,lurasidone 20 mg tablet,63402030230,,250,$196.65 ,$196.65 ,$59.00 ,$178.95 ,$137.66 ,$59.00 ,$127.82 ,$141.59 ,$178.95 ,$147.49 
Carle BroMenn Medical Center,8980250,lurasidone 40 mg tablet,63402030430,,250,$196.65 ,$196.65 ,$59.00 ,$178.95 ,$137.66 ,$59.00 ,$127.82 ,$141.59 ,$178.95 ,$147.49 
Carle BroMenn Medical Center,8980250,lurasidone 80 mg tablet,63402030830,,250,$196.65 ,$196.65 ,$59.00 ,$178.95 ,$137.66 ,$59.00 ,$127.82 ,$141.59 ,$178.95 ,$147.49 
Carle BroMenn Medical Center,8980250,magnesium citrate oral solution,869069338,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,magnesium citrate oral solution,904678744,,250,$2.90 ,$2.90 ,$0.87 ,$2.64 ,$2.03 ,$0.87 ,$1.89 ,$2.09 ,$2.64 ,$2.18 
Carle BroMenn Medical Center,8980250,magnesium hydroxide 400 mg/5 mL oral suspension,121043130,,250,$1.64 ,$1.64 ,$0.49 ,$1.49 ,$1.15 ,$0.49 ,$1.07 ,$1.18 ,$1.49 ,$1.23 
Carle BroMenn Medical Center,8980250,magnesium hydroxide 400 mg/5 mL oral suspension,60687042945,,250,$3.36 ,$3.36 ,$1.01 ,$3.06 ,$2.35 ,$1.01 ,$2.18 ,$2.42 ,$3.06 ,$2.52 
Carle BroMenn Medical Center,8980250,magnesium hydroxide 400 mg/5 mL oral suspension,66689005399,,250,$3.70 ,$3.70 ,$1.11 ,$3.37 ,$2.59 ,$1.11 ,$2.41 ,$2.66 ,$3.37 ,$2.78 
Carle BroMenn Medical Center,8980250,magnesium sulfate (laxative) 495 mg/5 gram oral granules,87701043017,,250,$17.47 ,$17.47 ,$5.24 ,$15.90 ,$12.23 ,$5.24 ,$11.36 ,$12.58 ,$15.90 ,$13.10 
Carle BroMenn Medical Center,8980250,meclizine 12.5 mg tablet,68084049011,,250,$5.63 ,$5.63 ,$1.69 ,$5.12 ,$3.94 ,$1.69 ,$3.66 ,$4.05 ,$5.12 ,$4.22 
Carle BroMenn Medical Center,8980250,meclizine 25 mg tablet,16571066101,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,meclizine 25 mg tablet,68084049101,,250,$1.20 ,$1.20 ,$0.36 ,$1.09 ,$0.84 ,$0.36 ,$0.78 ,$0.86 ,$1.09 ,$0.90 
Carle BroMenn Medical Center,8980250,meclizine 25 mg tablet,68084049111,,250,$1.20 ,$1.20 ,$0.36 ,$1.09 ,$0.84 ,$0.36 ,$0.78 ,$0.86 ,$1.09 ,$0.90 
Carle BroMenn Medical Center,8980250,medroxyPROGESTERone 2.5 mg tablet,555087202,,250,$3.79 ,$3.79 ,$1.14 ,$3.45 ,$2.65 ,$1.14 ,$2.46 ,$2.73 ,$3.45 ,$2.84 
Carle BroMenn Medical Center,8980250,medroxyPROGESTERone 2.5 mg tablet,59762005501,,250,$3.79 ,$3.79 ,$1.14 ,$3.45 ,$2.65 ,$1.14 ,$2.46 ,$2.73 ,$3.45 ,$2.84 
Carle BroMenn Medical Center,8980250,megestroL 20 mg tablet,49884028901,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,megestroL 400 mg/10 mL (40 mg/mL) oral suspension,49884090738,,250,$76.83 ,$76.83 ,$23.05 ,$69.92 ,$53.78 ,$23.05 ,$49.94 ,$55.32 ,$69.92 ,$57.62 
Carle BroMenn Medical Center,8980250,megestroL 400 mg/10 mL (40 mg/mL) oral suspension,60432012608,,250,$76.83 ,$76.83 ,$23.05 ,$69.92 ,$53.78 ,$23.05 ,$49.94 ,$55.32 ,$69.92 ,$57.62 
Carle BroMenn Medical Center,8980250,melatonin 3 mg tablet,10006070031,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,melatonin 3 mg tablet,20555003600,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,melatonin 3 mg tablet,20555003601,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,melatonin 3 mg tablet,68094011061,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,meloxicam 15 mg tablet,50268052611,,250,$24.06 ,$24.06 ,$7.22 ,$21.89 ,$16.84 ,$7.22 ,$15.64 ,$17.32 ,$21.89 ,$18.05 
Carle BroMenn Medical Center,8980250,meloxicam 15 mg tablet,50268052615,,250,$24.06 ,$24.06 ,$7.22 ,$21.89 ,$16.84 ,$7.22 ,$15.64 ,$17.32 ,$21.89 ,$18.05 
Carle BroMenn Medical Center,8980250,meloxicam 15 mg tablet,68382005101,,250,$24.91 ,$24.91 ,$7.47 ,$22.67 ,$17.44 ,$7.47 ,$16.19 ,$17.94 ,$22.67 ,$18.68 
Carle BroMenn Medical Center,8980250,memantine 10 mg tablet,904650661,,250,$6.78 ,$6.78 ,$2.03 ,$6.17 ,$4.75 ,$2.03 ,$4.41 ,$4.88 ,$6.17 ,$5.09 
Carle BroMenn Medical Center,8980250,memantine 10 mg tablet,60687018411,,250,$6.06 ,$6.06 ,$1.82 ,$5.51 ,$4.24 ,$1.82 ,$3.94 ,$4.36 ,$5.51 ,$4.55 
Carle BroMenn Medical Center,8980250,memantine 10 mg tablet,60687018457,,250,$6.06 ,$6.06 ,$1.82 ,$5.51 ,$4.24 ,$1.82 ,$3.94 ,$4.36 ,$5.51 ,$4.55 
Carle BroMenn Medical Center,8980250,memantine 5 mg tablet,60687017311,,250,$6.06 ,$6.06 ,$1.82 ,$5.51 ,$4.24 ,$1.82 ,$3.94 ,$4.36 ,$5.51 ,$4.55 
Carle BroMenn Medical Center,8980250,memantine 5 mg tablet,60687017357,,250,$6.06 ,$6.06 ,$1.82 ,$5.51 ,$4.24 ,$1.82 ,$3.94 ,$4.36 ,$5.51 ,$4.55 
Carle BroMenn Medical Center,8980250,mesalamine 4 gram/60 mL enema,45802009851,,250,$115.57 ,$115.57 ,$34.67 ,$105.17 ,$80.90 ,$34.67 ,$75.12 ,$83.21 ,$105.17 ,$86.68 
Carle BroMenn Medical Center,8980250,mesalamine 400 mg capsule (with delayed release tablets inside),93590786,,250,$22.94 ,$22.94 ,$6.88 ,$20.88 ,$16.06 ,$6.88 ,$14.91 ,$16.52 ,$20.88 ,$17.21 
Carle BroMenn Medical Center,8980250,"mesalamine CR 250 mg capsule,controlled release",54092018981,,250,$19.31 ,$19.31 ,$5.79 ,$17.57 ,$13.52 ,$5.79 ,$12.55 ,$13.90 ,$17.57 ,$14.48 
Carle BroMenn Medical Center,8980250,metFORMIN 500 mg tablet,904668961,,250,$2.69 ,$2.69 ,$0.81 ,$2.45 ,$1.88 ,$0.81 ,$1.75 ,$1.94 ,$2.45 ,$2.02 
Carle BroMenn Medical Center,8980250,metFORMIN 500 mg tablet,904716261,,250,$2.69 ,$2.69 ,$0.81 ,$2.45 ,$1.88 ,$0.81 ,$1.75 ,$1.94 ,$2.45 ,$2.02 
Carle BroMenn Medical Center,8980250,metFORMIN 500 mg tablet,60687015501,,250,$5.60 ,$5.60 ,$1.68 ,$5.10 ,$3.92 ,$1.68 ,$3.64 ,$4.03 ,$5.10 ,$4.20 
Carle BroMenn Medical Center,8980250,metFORMIN 500 mg tablet,60687015511,,250,$5.60 ,$5.60 ,$1.68 ,$5.10 ,$3.92 ,$1.68 ,$3.64 ,$4.03 ,$5.10 ,$4.20 
Carle BroMenn Medical Center,8980250,"metFORMIN ER 750 mg tablet,extended release 24 hr",76385012901,,250,$7.91 ,$7.91 ,$2.37 ,$7.20 ,$5.54 ,$2.37 ,$5.14 ,$5.70 ,$7.20 ,$5.93 
Carle BroMenn Medical Center,8980250,methadone 10 mg tablet,904653061,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,methadone 10 mg tablet,68084073801,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,methadone 10 mg/mL injection solution,67457021720,J1230,250,$141.65 ,$141.65 ,$42.50 ,$128.90 ,$99.16 ,$42.50 ,$92.07 ,$101.99 ,$128.90 ,$106.24 
Carle BroMenn Medical Center,8980250,methadone 10 mg/mL oral concentrate,406052710,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,methadone 5 mg tablet,406575501,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,methadone 5 mg tablet,60687021401,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,methadone 5 mg tablet,60687021411,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,methadone 5 mg/5 mL oral solution,54355563,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,methIMAzole 5 mg tablet,23155007001,,250,$3.17 ,$3.17 ,$0.95 ,$2.88 ,$2.22 ,$0.95 ,$2.06 ,$2.28 ,$2.88 ,$2.38 
Carle BroMenn Medical Center,8980250,methIMAzole 5 mg tablet,60687035701,,250,$5.13 ,$5.13 ,$1.54 ,$4.67 ,$3.59 ,$1.54 ,$3.33 ,$3.69 ,$4.67 ,$3.85 
Carle BroMenn Medical Center,8980250,methIMAzole 5 mg tablet,60687035711,,250,$5.13 ,$5.13 ,$1.54 ,$4.67 ,$3.59 ,$1.54 ,$3.33 ,$3.69 ,$4.67 ,$3.85 
Carle BroMenn Medical Center,8980250,methyldopa 500 mg tablet,51079020120,,250,$5.47 ,$5.47 ,$1.64 ,$4.98 ,$3.83 ,$1.64 ,$3.56 ,$3.94 ,$4.98 ,$4.10 
Carle BroMenn Medical Center,8980250,methylergonovine 0.2 mg tablet,54063905,,250,$243.45 ,$243.45 ,$73.04 ,$221.54 ,$170.42 ,$73.04 ,$158.24 ,$175.28 ,$221.54 ,$182.59 
Carle BroMenn Medical Center,8980250,methylphenidate 10 mg tablet,31722017401,,250,$9.56 ,$9.56 ,$2.87 ,$8.70 ,$6.69 ,$2.87 ,$6.21 ,$6.88 ,$8.70 ,$7.17 
Carle BroMenn Medical Center,8980250,methylphenidate 5 mg tablet,115180001,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,methylphenidate 5 mg tablet,10702010001,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,methylphenidate 5 mg tablet,31722017301,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,metoclopramide 10 mg tablet,93220305,,250,$3.55 ,$3.55 ,$1.07 ,$3.23 ,$2.49 ,$1.07 ,$2.31 ,$2.56 ,$3.23 ,$2.66 
Carle BroMenn Medical Center,8980250,metoclopramide 10 mg tablet,51079088801,,250,$6.79 ,$6.79 ,$2.04 ,$6.18 ,$4.75 ,$2.04 ,$4.41 ,$4.89 ,$6.18 ,$5.09 
Carle BroMenn Medical Center,8980250,metoclopramide 10 mg tablet,51079088820,,250,$6.79 ,$6.79 ,$2.04 ,$6.18 ,$4.75 ,$2.04 ,$4.41 ,$4.89 ,$6.18 ,$5.09 
Carle BroMenn Medical Center,8980250,metoclopramide 5 mg/5 mL oral solution,121057616,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,metoclopramide 5 mg/5 mL oral solution,62559019016,,250,$13.10 ,$13.10 ,$3.93 ,$11.92 ,$9.17 ,$3.93 ,$8.52 ,$9.43 ,$11.92 ,$9.83 
Carle BroMenn Medical Center,8980250,metOLazone 2.5 mg tablet,185505001,,250,$11.99 ,$11.99 ,$3.60 ,$10.91 ,$8.39 ,$3.60 ,$7.79 ,$8.63 ,$10.91 ,$8.99 
Carle BroMenn Medical Center,8980250,metOLazone 2.5 mg tablet,527221537,,250,$13.74 ,$13.74 ,$4.12 ,$12.50 ,$9.62 ,$4.12 ,$8.93 ,$9.89 ,$12.50 ,$10.31 
Carle BroMenn Medical Center,8980250,metOLazone 5 mg tablet,185005501,,250,$13.31 ,$13.31 ,$3.99 ,$12.11 ,$9.32 ,$3.99 ,$8.65 ,$9.58 ,$12.11 ,$9.98 
Carle BroMenn Medical Center,8980250,"metoprolol succinate ER 100 mg tablet,extended release 24 hr",60687041301,,250,$10.14 ,$10.14 ,$3.04 ,$9.23 ,$7.10 ,$3.04 ,$6.59 ,$7.30 ,$9.23 ,$7.61 
Carle BroMenn Medical Center,8980250,"metoprolol succinate ER 100 mg tablet,extended release 24 hr",60687041311,,250,$10.14 ,$10.14 ,$3.04 ,$9.23 ,$7.10 ,$3.04 ,$6.59 ,$7.30 ,$9.23 ,$7.61 
Carle BroMenn Medical Center,8980250,"metoprolol succinate ER 100 mg tablet,extended release 24 hr",68084067301,,250,$10.14 ,$10.14 ,$3.04 ,$9.23 ,$7.10 ,$3.04 ,$6.59 ,$7.30 ,$9.23 ,$7.61 
Carle BroMenn Medical Center,8980250,"metoprolol succinate ER 25 mg tablet,extended release 24 hr",904632261,,250,$8.10 ,$8.10 ,$2.43 ,$7.37 ,$5.67 ,$2.43 ,$5.27 ,$5.83 ,$7.37 ,$6.08 
Carle BroMenn Medical Center,8980250,"metoprolol succinate ER 25 mg tablet,extended release 24 hr",24979003701,,250,$3.67 ,$3.67 ,$1.10 ,$3.34 ,$2.57 ,$1.10 ,$2.39 ,$2.64 ,$3.34 ,$2.75 
Carle BroMenn Medical Center,8980250,"metoprolol succinate ER 25 mg tablet,extended release 24 hr",50268054011,,250,$7.47 ,$7.47 ,$2.24 ,$6.80 ,$5.23 ,$2.24 ,$4.86 ,$5.38 ,$6.80 ,$5.60 
Carle BroMenn Medical Center,8980250,"metoprolol succinate ER 25 mg tablet,extended release 24 hr",50268054015,,250,$7.47 ,$7.47 ,$2.24 ,$6.80 ,$5.23 ,$2.24 ,$4.86 ,$5.38 ,$6.80 ,$5.60 
Carle BroMenn Medical Center,8980250,"metoprolol succinate ER 25 mg tablet,extended release 24 hr",60687039001,,250,$7.53 ,$7.53 ,$2.26 ,$6.85 ,$5.27 ,$2.26 ,$4.89 ,$5.42 ,$6.85 ,$5.65 
Carle BroMenn Medical Center,8980250,"metoprolol succinate ER 25 mg tablet,extended release 24 hr",60687039011,,250,$7.53 ,$7.53 ,$2.26 ,$6.85 ,$5.27 ,$2.26 ,$4.89 ,$5.42 ,$6.85 ,$5.65 
Carle BroMenn Medical Center,8980250,"metoprolol succinate ER 25 mg tablet,extended release 24 hr",68084065901,,250,$7.53 ,$7.53 ,$2.26 ,$6.85 ,$5.27 ,$2.26 ,$4.89 ,$5.42 ,$6.85 ,$5.65 
Carle BroMenn Medical Center,8980250,"metoprolol succinate ER 50 mg tablet,extended release 24 hr",904632361,,250,$8.10 ,$8.10 ,$2.43 ,$7.37 ,$5.67 ,$2.43 ,$5.27 ,$5.83 ,$7.37 ,$6.08 
Carle BroMenn Medical Center,8980250,"metoprolol succinate ER 50 mg tablet,extended release 24 hr",60687040211,,250,$7.53 ,$7.53 ,$2.26 ,$6.85 ,$5.27 ,$2.26 ,$4.89 ,$5.42 ,$6.85 ,$5.65 
Carle BroMenn Medical Center,8980250,metoprolol tartrate 100 mg tablet,62584026701,,250,$3.16 ,$3.16 ,$0.95 ,$2.88 ,$2.21 ,$0.95 ,$2.05 ,$2.28 ,$2.88 ,$2.37 
Carle BroMenn Medical Center,8980250,metoprolol tartrate 100 mg tablet,62584026711,,250,$3.16 ,$3.16 ,$0.95 ,$2.88 ,$2.21 ,$0.95 ,$2.05 ,$2.28 ,$2.88 ,$2.37 
Carle BroMenn Medical Center,8980250,metoprolol tartrate 25 mg tablet,51079025501,,250,$3.46 ,$3.46 ,$1.04 ,$3.15 ,$2.42 ,$1.04 ,$2.25 ,$2.49 ,$3.15 ,$2.60 
Carle BroMenn Medical Center,8980250,metoprolol tartrate 25 mg tablet,51079025520,,250,$3.46 ,$3.46 ,$1.04 ,$3.15 ,$2.42 ,$1.04 ,$2.25 ,$2.49 ,$3.15 ,$2.60 
Carle BroMenn Medical Center,8980250,metoprolol tartrate 25 mg tablet,62584026501,,250,$2.83 ,$2.83 ,$0.85 ,$2.58 ,$1.98 ,$0.85 ,$1.84 ,$2.04 ,$2.58 ,$2.12 
Carle BroMenn Medical Center,8980250,metoprolol tartrate 25 mg tablet,62584026511,,250,$2.83 ,$2.83 ,$0.85 ,$2.58 ,$1.98 ,$0.85 ,$1.84 ,$2.04 ,$2.58 ,$2.12 
Carle BroMenn Medical Center,8980250,metoprolol tartrate 5 mg/5 mL intravenous solution,36000003310,J3490,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,metoprolol tartrate 5 mg/5 mL intravenous solution,70860030005,J3490,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,metoprolol tartrate 5 mg/5 mL intravenous solution,72611074001,J3490,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,metoprolol tartrate 50 mg tablet,51079080101,,250,$5.00 ,$5.00 ,$1.50 ,$4.55 ,$3.50 ,$1.50 ,$3.25 ,$3.60 ,$4.55 ,$3.75 
Carle BroMenn Medical Center,8980250,metoprolol tartrate 50 mg tablet,51079080120,,250,$5.00 ,$5.00 ,$1.50 ,$4.55 ,$3.50 ,$1.50 ,$3.25 ,$3.60 ,$4.55 ,$3.75 
Carle BroMenn Medical Center,8980250,metoprolol tartrate 50 mg tablet,62584026601,,250,$2.95 ,$2.95 ,$0.89 ,$2.68 ,$2.07 ,$0.89 ,$1.92 ,$2.12 ,$2.68 ,$2.21 
Carle BroMenn Medical Center,8980250,metoprolol tartrate 50 mg tablet,62584026611,,250,$2.95 ,$2.95 ,$0.89 ,$2.68 ,$2.07 ,$0.89 ,$1.92 ,$2.12 ,$2.68 ,$2.21 
Carle BroMenn Medical Center,8980250,metroNIDAZOLE 0.75 % topical cream,168032346,,250,$420.03 ,$420.03 ,$126.01 ,$382.23 ,$294.02 ,$126.01 ,$273.02 ,$302.42 ,$382.23 ,$315.02 
Carle BroMenn Medical Center,8980250,metroNIDAZOLE 250 mg tablet,60687052611,,250,$4.62 ,$4.62 ,$1.39 ,$4.20 ,$3.23 ,$1.39 ,$3.00 ,$3.33 ,$4.20 ,$3.47 
Carle BroMenn Medical Center,8980250,metroNIDAZOLE 500 mg tablet,60687055001,,250,$6.62 ,$6.62 ,$1.99 ,$6.02 ,$4.63 ,$1.99 ,$4.30 ,$4.77 ,$6.02 ,$4.97 
Carle BroMenn Medical Center,8980250,metroNIDAZOLE 500 mg tablet,60687055011,,250,$6.62 ,$6.62 ,$1.99 ,$6.02 ,$4.63 ,$1.99 ,$4.30 ,$4.77 ,$6.02 ,$4.97 
Carle BroMenn Medical Center,8980250,metroNIDAZOLE 500 mg tablet,68001036500,,250,$5.72 ,$5.72 ,$1.72 ,$5.21 ,$4.00 ,$1.72 ,$3.72 ,$4.12 ,$5.21 ,$4.29 
Carle BroMenn Medical Center,8980250,metroNIDAZOLE 500 mg/100 mL-sodium chloride(iso) intravenous piggyback,264553532,,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,metroNIDAZOLE 500 mg/100 mL-sodium chloride(iso) intravenous piggyback,338105548,,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,metroNIDAZOLE 500 mg/100 mL-sodium chloride(iso) intravenous piggyback,338954124,,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,metroNIDAZOLE 500 mg/100 mL-sodium chloride(iso) intravenous piggyback,409781124,,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,metroNIDAZOLE in sodium chloride (iso-osm) 500 mg/100 mL,9999501129,,250,$34.95 ,$34.95 ,$10.49 ,$31.80 ,$24.47 ,$10.49 ,$22.72 ,$25.16 ,$31.80 ,$26.21 
Carle BroMenn Medical Center,8980250,mexiletine 150 mg capsule,93873901,,250,$14.15 ,$14.15 ,$4.25 ,$12.88 ,$9.91 ,$4.25 ,$9.20 ,$10.19 ,$12.88 ,$10.61 
Carle BroMenn Medical Center,8980250,mexiletine 150 mg capsule,527410737,,250,$14.15 ,$14.15 ,$4.25 ,$12.88 ,$9.91 ,$4.25 ,$9.20 ,$10.19 ,$12.88 ,$10.61 
Carle BroMenn Medical Center,8980250,mexiletine 200 mg capsule,527410837,,250,$16.44 ,$16.44 ,$4.93 ,$14.96 ,$11.51 ,$4.93 ,$10.69 ,$11.84 ,$14.96 ,$12.33 
Carle BroMenn Medical Center,8980250,miconazole nitrate 2 % topical cream,472073556,,250,$21.43 ,$21.43 ,$6.43 ,$19.50 ,$15.00 ,$6.43 ,$13.93 ,$15.43 ,$19.50 ,$16.07 
Carle BroMenn Medical Center,8980250,miconazole nitrate 2 % topical cream,536113428,,250,$34.23 ,$34.23 ,$10.27 ,$31.15 ,$23.96 ,$10.27 ,$22.25 ,$24.65 ,$31.15 ,$25.67 
Carle BroMenn Medical Center,8980250,miconazole nitrate 2 % topical cream,51672200102,,250,$45.40 ,$45.40 ,$13.62 ,$41.31 ,$31.78 ,$13.62 ,$29.51 ,$32.69 ,$41.31 ,$34.05 
Carle BroMenn Medical Center,8980250,midazolam (PF) 1 mg/mL injection solution,409230504,J2250,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,midazolam (PF) 1 mg/mL injection solution,409230505,J2250,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,midodrine 2.5 mg tablet,49884081401,,250,$7.93 ,$7.93 ,$2.38 ,$7.22 ,$5.55 ,$2.38 ,$5.15 ,$5.71 ,$7.22 ,$5.95 
Carle BroMenn Medical Center,8980250,midodrine 2.5 mg tablet,68382073701,,250,$7.96 ,$7.96 ,$2.39 ,$7.24 ,$5.57 ,$2.39 ,$5.17 ,$5.73 ,$7.24 ,$5.97 
Carle BroMenn Medical Center,8980250,midodrine 5 mg tablet,51079045301,,250,$14.96 ,$14.96 ,$4.49 ,$13.61 ,$10.47 ,$4.49 ,$9.72 ,$10.77 ,$13.61 ,$11.22 
Carle BroMenn Medical Center,8980250,midodrine 5 mg tablet,51079045320,,250,$14.96 ,$14.96 ,$4.49 ,$13.61 ,$10.47 ,$4.49 ,$9.72 ,$10.77 ,$13.61 ,$11.22 
Carle BroMenn Medical Center,8980250,midodrine 5 mg tablet,68382073801,,250,$13.65 ,$13.65 ,$4.10 ,$12.42 ,$9.56 ,$4.10 ,$8.87 ,$9.83 ,$12.42 ,$10.24 
Carle BroMenn Medical Center,8980250,"mineral oil, light sterile",63323025410,,250,$106.20 ,$106.20 ,$31.86 ,$96.64 ,$74.34 ,$31.86 ,$69.03 ,$76.46 ,$96.64 ,$79.65 
Carle BroMenn Medical Center,8980250,minoxidiL 2.5 mg tablet,68084020401,,250,$10.23 ,$10.23 ,$3.07 ,$9.31 ,$7.16 ,$3.07 ,$6.65 ,$7.37 ,$9.31 ,$7.67 
Carle BroMenn Medical Center,8980250,minoxidiL 2.5 mg tablet,68084020411,,250,$10.23 ,$10.23 ,$3.07 ,$9.31 ,$7.16 ,$3.07 ,$6.65 ,$7.37 ,$9.31 ,$7.67 
Carle BroMenn Medical Center,8980250,mirtazapine 15 mg tablet,904651961,,250,$15.65 ,$15.65 ,$4.70 ,$14.24 ,$10.96 ,$4.70 ,$10.17 ,$11.27 ,$14.24 ,$11.74 
Carle BroMenn Medical Center,8980250,mirtazapine 15 mg tablet,13107003134,,250,$14.91 ,$14.91 ,$4.47 ,$13.57 ,$10.44 ,$4.47 ,$9.69 ,$10.74 ,$13.57 ,$11.18 
Carle BroMenn Medical Center,8980250,mirtazapine 15 mg tablet,68084011901,,250,$7.20 ,$7.20 ,$2.16 ,$6.55 ,$5.04 ,$2.16 ,$4.68 ,$5.18 ,$6.55 ,$5.40 
Carle BroMenn Medical Center,8980250,mirtazapine 15 mg tablet,68084011911,,250,$7.20 ,$7.20 ,$2.16 ,$6.55 ,$5.04 ,$2.16 ,$4.68 ,$5.18 ,$6.55 ,$5.40 
Carle BroMenn Medical Center,8980250,mirtazapine 30 mg tablet,68084012001,,250,$8.33 ,$8.33 ,$2.50 ,$7.58 ,$5.83 ,$2.50 ,$5.41 ,$6.00 ,$7.58 ,$6.25 
Carle BroMenn Medical Center,8980250,mirtazapine 30 mg tablet,68084012011,,250,$8.33 ,$8.33 ,$2.50 ,$7.58 ,$5.83 ,$2.50 ,$5.41 ,$6.00 ,$7.58 ,$6.25 
Carle BroMenn Medical Center,8980250,miSOPROStoL 100 mcg tablet,43386016006,,250,$6.90 ,$6.90 ,$2.07 ,$6.28 ,$4.83 ,$2.07 ,$4.49 ,$4.97 ,$6.28 ,$5.18 
Carle BroMenn Medical Center,8980250,miSOPROStoL 100 mcg tablet,59762500701,,250,$6.17 ,$6.17 ,$1.85 ,$5.61 ,$4.32 ,$1.85 ,$4.01 ,$4.44 ,$5.61 ,$4.63 
Carle BroMenn Medical Center,8980250,miSOPROStoL 200 mcg tablet,43386016101,,250,$8.99 ,$8.99 ,$2.70 ,$8.18 ,$6.29 ,$2.70 ,$5.84 ,$6.47 ,$8.18 ,$6.74 
Carle BroMenn Medical Center,8980250,miSOPROStoL 200 mcg tablet,43386016106,,250,$8.99 ,$8.99 ,$2.70 ,$8.18 ,$6.29 ,$2.70 ,$5.84 ,$6.47 ,$8.18 ,$6.74 
Carle BroMenn Medical Center,8980250,miSOPROStoL 200 mcg tablet,59762500801,,250,$7.92 ,$7.92 ,$2.38 ,$7.21 ,$5.54 ,$2.38 ,$5.15 ,$5.70 ,$7.21 ,$5.94 
Carle BroMenn Medical Center,8980250,miSOPROStoL 200 mcg tablet,59762500802,,250,$7.92 ,$7.92 ,$2.38 ,$7.21 ,$5.54 ,$2.38 ,$5.15 ,$5.70 ,$7.21 ,$5.94 
Carle BroMenn Medical Center,8980250,modafiniL 100 mg tablet,60505252603,,250,$102.81 ,$102.81 ,$30.84 ,$93.56 ,$71.97 ,$30.84 ,$66.83 ,$74.02 ,$93.56 ,$77.11 
Carle BroMenn Medical Center,8980250,mometasone 220 mcg/actuation(14 doses) breath activated powder inhaler,85134106,,250,$434.55 ,$434.55 ,$130.37 ,$395.44 ,$304.19 ,$130.37 ,$282.46 ,$312.88 ,$395.44 ,$325.91 
Carle BroMenn Medical Center,8980250,mometasone 220 mcg/actuation(14 doses) breath activated powder inhaler,78206011403,,250,$434.55 ,$434.55 ,$130.37 ,$395.44 ,$304.19 ,$130.37 ,$282.46 ,$312.88 ,$395.44 ,$325.91 
Carle BroMenn Medical Center,8980250,montelukast 10 mg tablet,904680861,,250,$4.18 ,$4.18 ,$1.25 ,$3.80 ,$2.93 ,$1.25 ,$2.72 ,$3.01 ,$3.80 ,$3.14 
Carle BroMenn Medical Center,8980250,montelukast 4 mg chewable tablet,31722072730,,250,$27.95 ,$27.95 ,$8.39 ,$25.43 ,$19.57 ,$8.39 ,$18.17 ,$20.12 ,$25.43 ,$20.96 
Carle BroMenn Medical Center,8980250,montelukast 4 mg chewable tablet,42291062230,,250,$3.51 ,$3.51 ,$1.05 ,$3.19 ,$2.46 ,$1.05 ,$2.28 ,$2.53 ,$3.19 ,$2.63 
Carle BroMenn Medical Center,8980250,morphine 10 mg/5 mL oral solution,54023763,,250,$9.46 ,$9.46 ,$2.84 ,$8.61 ,$6.62 ,$2.84 ,$6.15 ,$6.81 ,$8.61 ,$7.10 
Carle BroMenn Medical Center,8980250,morphine 10 mg/5 mL oral solution,9999023763,,250,$9.46 ,$9.46 ,$2.84 ,$8.61 ,$6.62 ,$2.84 ,$6.15 ,$6.81 ,$8.61 ,$7.10 
Carle BroMenn Medical Center,8980250,morphine 10 mg/5 mL oral solution,68094000162,,250,$16.48 ,$16.48 ,$4.94 ,$15.00 ,$11.54 ,$4.94 ,$10.71 ,$11.87 ,$15.00 ,$12.36 
Carle BroMenn Medical Center,8980250,morphine 15 mg immediate release tablet,54023524,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,morphine concentrate 100 mg/5 mL (20 mg/mL) oral solution,54040444,,250,$11.88 ,$11.88 ,$3.56 ,$10.81 ,$8.32 ,$3.56 ,$7.72 ,$8.55 ,$10.81 ,$8.91 
Carle BroMenn Medical Center,8980250,morphine concentrate 100 mg/5 mL (20 mg/mL) oral solution,54051741,,250,$11.88 ,$11.88 ,$3.56 ,$10.81 ,$8.32 ,$3.56 ,$7.72 ,$8.55 ,$10.81 ,$8.91 
Carle BroMenn Medical Center,8980250,morphine concentrate 100 mg/5 mL (20 mg/mL) oral solution,54051744,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,morphine concentrate 100 mg/5 mL (20 mg/mL) oral solution,406800330,,250,$11.34 ,$11.34 ,$3.40 ,$10.32 ,$7.94 ,$3.40 ,$7.37 ,$8.16 ,$10.32 ,$8.51 
Carle BroMenn Medical Center,8980250,"morphine ER 15 mg tablet,extended release",406831523,,250,$13.38 ,$13.38 ,$4.01 ,$12.18 ,$9.37 ,$4.01 ,$8.70 ,$9.63 ,$12.18 ,$10.04 
Carle BroMenn Medical Center,8980250,"morphine ER 15 mg tablet,extended release",406831562,,250,$13.38 ,$13.38 ,$4.01 ,$12.18 ,$9.37 ,$4.01 ,$8.70 ,$9.63 ,$12.18 ,$10.04 
Carle BroMenn Medical Center,8980250,"morphine ER 15 mg tablet,extended release",68084015701,,250,$13.25 ,$13.25 ,$3.98 ,$12.06 ,$9.28 ,$3.98 ,$8.61 ,$9.54 ,$12.06 ,$9.94 
Carle BroMenn Medical Center,8980250,"morphine ER 15 mg tablet,extended release",68084015711,,250,$13.25 ,$13.25 ,$3.98 ,$12.06 ,$9.28 ,$3.98 ,$8.61 ,$9.54 ,$12.06 ,$9.94 
Carle BroMenn Medical Center,8980250,"morphine ER 30 mg tablet,extended release",68084015801,,250,$20.17 ,$20.17 ,$6.05 ,$18.35 ,$14.12 ,$6.05 ,$13.11 ,$14.52 ,$18.35 ,$15.13 
Carle BroMenn Medical Center,8980250,"morphine ER 30 mg tablet,extended release",68084015811,,250,$17.84 ,$17.84 ,$5.35 ,$16.23 ,$12.49 ,$5.35 ,$11.60 ,$12.84 ,$16.23 ,$13.38 
Carle BroMenn Medical Center,8980250,moxifloxacin 0.5 % eye drops,60505058204,,250,$800.82 ,$800.82 ,$240.25 ,$728.75 ,$560.57 ,$240.25 ,$520.53 ,$576.59 ,$728.75 ,$600.62 
Carle BroMenn Medical Center,8980250,moxifloxacin 0.5 % eye drops,65862084003,,250,$800.82 ,$800.82 ,$240.25 ,$728.75 ,$560.57 ,$240.25 ,$520.53 ,$576.59 ,$728.75 ,$600.62 
Carle BroMenn Medical Center,8980250,moxifloxacin 0.5 % eye drops,68180042201,,250,$800.82 ,$800.82 ,$240.25 ,$728.75 ,$560.57 ,$240.25 ,$520.53 ,$576.59 ,$728.75 ,$600.62 
Carle BroMenn Medical Center,8980250,moxifloxacin 400 mg tablet,13668020130,,250,$103.33 ,$103.33 ,$31.00 ,$94.03 ,$72.33 ,$31.00 ,$67.16 ,$74.40 ,$94.03 ,$77.50 
Carle BroMenn Medical Center,8980250,multivit and minerals-ferrous gluconate 9 mg iron/15 mL oral liquid,69618000858,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,mupirocin 2 % topical ointment,50268057260,,250,$26.09 ,$26.09 ,$7.83 ,$23.74 ,$18.26 ,$7.83 ,$16.96 ,$18.78 ,$23.74 ,$19.57 
Carle BroMenn Medical Center,8980250,mupirocin 2 % topical ointment,51672131200,,250,$137.43 ,$137.43 ,$41.23 ,$125.06 ,$96.20 ,$41.23 ,$89.33 ,$98.95 ,$125.06 ,$103.07 
Carle BroMenn Medical Center,8980250,"mvi,adult no.4 with vit K 3300 unit-150 mcg/10 mL intravenous solution",54643564901,,250,$111.95 ,$111.95 ,$33.59 ,$101.87 ,$78.37 ,$33.59 ,$72.77 ,$80.60 ,$101.87 ,$83.96 
Carle BroMenn Medical Center,8980250,"mvi,adult no.4 with vit K 3300 unit-150 mcg/10 mL intravenous solution",54643786201,,250,$80.40 ,$80.40 ,$24.12 ,$73.16 ,$56.28 ,$24.12 ,$52.26 ,$57.89 ,$73.16 ,$60.30 
Carle BroMenn Medical Center,8980250,nadoloL 40 mg tablet,68001031800,,250,$21.03 ,$21.03 ,$6.31 ,$19.14 ,$14.72 ,$6.31 ,$13.67 ,$15.14 ,$19.14 ,$15.77 
Carle BroMenn Medical Center,8980250,nafcillin 1 gram solution for injection,55150012215,,250,$119.34 ,$119.34 ,$35.80 ,$108.60 ,$83.54 ,$35.80 ,$77.57 ,$85.92 ,$108.60 ,$89.51 
Carle BroMenn Medical Center,8980250,nafcillin 10 gram solution for injection,44567022301,,250,$874.91 ,$874.91 ,$262.47 ,$796.17 ,$612.44 ,$262.47 ,$568.69 ,$629.94 ,$796.17 ,$656.18 
Carle BroMenn Medical Center,8980250,nafcillin 10 gram solution for injection,55150012499,,250,$707.15 ,$707.15 ,$212.15 ,$643.51 ,$495.01 ,$212.15 ,$459.65 ,$509.15 ,$643.51 ,$530.36 
Carle BroMenn Medical Center,8980250,nafcillin 10 gram solution for injection,63323033060,,250,$855.62 ,$855.62 ,$256.69 ,$778.61 ,$598.93 ,$256.69 ,$556.15 ,$616.05 ,$778.61 ,$641.72 
Carle BroMenn Medical Center,8980250,nafcillin 2 gram intravenous solution,781922515,,250,$231.16 ,$231.16 ,$69.35 ,$210.36 ,$161.81 ,$69.35 ,$150.25 ,$166.44 ,$210.36 ,$173.37 
Carle BroMenn Medical Center,8980250,nafcillin 2 gram intravenous solution,781922592,,250,$222.46 ,$222.46 ,$66.74 ,$202.44 ,$155.72 ,$66.74 ,$144.60 ,$160.17 ,$202.44 ,$166.85 
Carle BroMenn Medical Center,8980250,nafcillin 2 gram solution for injection,55150012315,,250,$195.83 ,$195.83 ,$58.75 ,$178.21 ,$137.08 ,$58.75 ,$127.29 ,$141.00 ,$178.21 ,$146.87 
Carle BroMenn Medical Center,8980250,nafcillin 2 gram solution for injection,63323032820,,250,$225.62 ,$225.62 ,$67.69 ,$205.31 ,$157.93 ,$67.69 ,$146.65 ,$162.45 ,$205.31 ,$169.22 
Carle BroMenn Medical Center,8980250,nafcillin 2 gram solution for injection,63323032821,,250,$225.62 ,$225.62 ,$67.69 ,$205.31 ,$157.93 ,$67.69 ,$146.65 ,$162.45 ,$205.31 ,$169.22 
Carle BroMenn Medical Center,8980250,naproxen 250 mg tablet,50268059415,,250,$5.96 ,$5.96 ,$1.79 ,$5.42 ,$4.17 ,$1.79 ,$3.87 ,$4.29 ,$5.42 ,$4.47 
Carle BroMenn Medical Center,8980250,"neomycin 3.5 mg/g-polymyxin B 10,000 unit/g-dexameth 0.1 % eye oint",24208079535,,250,$101.95 ,$101.95 ,$30.59 ,$92.77 ,$71.37 ,$30.59 ,$66.27 ,$73.40 ,$92.77 ,$76.46 
Carle BroMenn Medical Center,8980250,"neomycin 3.5 mg/g-polymyxin B 10,000 unit/g-dexameth 0.1 % eye oint",61314063136,,250,$200.38 ,$200.38 ,$60.11 ,$182.35 ,$140.27 ,$60.11 ,$130.25 ,$144.27 ,$182.35 ,$150.29 
Carle BroMenn Medical Center,8980250,neomycin 500 mg tablet,93117701,,250,$8.69 ,$8.69 ,$2.61 ,$7.91 ,$6.08 ,$2.61 ,$5.65 ,$6.26 ,$7.91 ,$6.52 
Carle BroMenn Medical Center,8980250,neomycin 500 mg tablet,39822031005,,250,$10.23 ,$10.23 ,$3.07 ,$9.31 ,$7.16 ,$3.07 ,$6.65 ,$7.37 ,$9.31 ,$7.67 
Carle BroMenn Medical Center,8980250,"neomycin-bacitracn Zn-polymyxn 3.5 mg-400 unit-5,000 unit top oint pkt",45802014370,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,"neomycin-polymyxin-dexameth 3.5 mg/mL-10,000 unit/mL-0.1% eye drops",24208083060,,250,$113.52 ,$113.52 ,$34.06 ,$103.30 ,$79.46 ,$34.06 ,$73.79 ,$81.73 ,$103.30 ,$85.14 
Carle BroMenn Medical Center,8980250,niCARdipine 25 mg/10 mL intravenous solution,143968901,,250,$213.16 ,$213.16 ,$63.95 ,$193.98 ,$149.21 ,$63.95 ,$138.55 ,$153.48 ,$193.98 ,$159.87 
Carle BroMenn Medical Center,8980250,niCARdipine 25 mg/10 mL intravenous solution,143968910,,250,$213.16 ,$213.16 ,$63.95 ,$193.98 ,$149.21 ,$63.95 ,$138.55 ,$153.48 ,$193.98 ,$159.87 
Carle BroMenn Medical Center,8980250,niCARdipine 40 mg/200 mL(0.2 mg/ml) in sod chlor(iso) intravenous soln,10122032501,,250,"$1,423.48 ","$1,423.48 ",$427.04 ,"$1,295.37 ",$996.44 ,$427.04 ,$925.26 ,"$1,024.91 ","$1,295.37 ","$1,067.61 "
Carle BroMenn Medical Center,8980250,niCARdipine 40 mg/200 mL(0.2 mg/ml) in sod chlor(iso) intravenous soln,43066001610,,250,"$1,423.48 ","$1,423.48 ",$427.04 ,"$1,295.37 ",$996.44 ,$427.04 ,$925.26 ,"$1,024.91 ","$1,295.37 ","$1,067.61 "
Carle BroMenn Medical Center,8980250,nicotine (polacrilex) 4 mg gum,536137223,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,nicotine (polacrilex) 4 mg gum,536303006,,250,$0.72 ,$0.72 ,$0.22 ,$0.66 ,$0.50 ,$0.22 ,$0.47 ,$0.52 ,$0.66 ,$0.54 
Carle BroMenn Medical Center,8980250,nicotine (polacrilex) 4 mg gum,536303023,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,nicotine 14 mg/24 hr daily transdermal patch,536589588,,250,$3.00 ,$3.00 ,$0.90 ,$2.73 ,$2.10 ,$0.90 ,$1.95 ,$2.16 ,$2.73 ,$2.25 
Carle BroMenn Medical Center,8980250,nicotine 14 mg/24 hr daily transdermal patch,43598044771,,250,$12.31 ,$12.31 ,$3.69 ,$11.20 ,$8.62 ,$3.69 ,$8.00 ,$8.86 ,$11.20 ,$9.23 
Carle BroMenn Medical Center,8980250,nicotine 14 mg/24 hr daily transdermal patch,46122035274,,250,$3.50 ,$3.50 ,$1.05 ,$3.19 ,$2.45 ,$1.05 ,$2.28 ,$2.52 ,$3.19 ,$2.63 
Carle BroMenn Medical Center,8980250,nicotine 14 mg/24 hr daily transdermal patch,60505706200,,250,$3.20 ,$3.20 ,$0.96 ,$2.91 ,$2.24 ,$0.96 ,$2.08 ,$2.30 ,$2.91 ,$2.40 
Carle BroMenn Medical Center,8980250,nicotine 14 mg/24 hr daily transdermal patch,60505708900,,250,$3.20 ,$3.20 ,$0.96 ,$2.91 ,$2.24 ,$0.96 ,$2.08 ,$2.30 ,$2.91 ,$2.40 
Carle BroMenn Medical Center,8980250,nicotine 14 mg/24 hr daily transdermal patch,87701042789,,250,$3.00 ,$3.00 ,$0.90 ,$2.73 ,$2.10 ,$0.90 ,$1.95 ,$2.16 ,$2.73 ,$2.25 
Carle BroMenn Medical Center,8980250,nicotine 21 mg/24 hr daily transdermal patch,536589688,,250,$3.00 ,$3.00 ,$0.90 ,$2.73 ,$2.10 ,$0.90 ,$1.95 ,$2.16 ,$2.73 ,$2.25 
Carle BroMenn Medical Center,8980250,nicotine 21 mg/24 hr daily transdermal patch,43598044828,,250,$2.69 ,$2.69 ,$0.81 ,$2.45 ,$1.88 ,$0.81 ,$1.75 ,$1.94 ,$2.45 ,$2.02 
Carle BroMenn Medical Center,8980250,nicotine 21 mg/24 hr daily transdermal patch,43598044871,,250,$3.00 ,$3.00 ,$0.90 ,$2.73 ,$2.10 ,$0.90 ,$1.95 ,$2.16 ,$2.73 ,$2.25 
Carle BroMenn Medical Center,8980250,nicotine 21 mg/24 hr daily transdermal patch,46122035374,,250,$3.50 ,$3.50 ,$1.05 ,$3.19 ,$2.45 ,$1.05 ,$2.28 ,$2.52 ,$3.19 ,$2.63 
Carle BroMenn Medical Center,8980250,nicotine 21 mg/24 hr daily transdermal patch,60505706300,,250,$3.60 ,$3.60 ,$1.08 ,$3.28 ,$2.52 ,$1.08 ,$2.34 ,$2.59 ,$3.28 ,$2.70 
Carle BroMenn Medical Center,8980250,nicotine 21 mg/24 hr daily transdermal patch,60505709000,,250,$3.60 ,$3.60 ,$1.08 ,$3.28 ,$2.52 ,$1.08 ,$2.34 ,$2.59 ,$3.28 ,$2.70 
Carle BroMenn Medical Center,8980250,nicotine 21 mg/24 hr daily transdermal patch,87701042790,,250,$3.00 ,$3.00 ,$0.90 ,$2.73 ,$2.10 ,$0.90 ,$1.95 ,$2.16 ,$2.73 ,$2.25 
Carle BroMenn Medical Center,8980250,nicotine 7 mg/24 hr daily transdermal patch,43598044671,,250,$3.00 ,$3.00 ,$0.90 ,$2.73 ,$2.10 ,$0.90 ,$1.95 ,$2.16 ,$2.73 ,$2.25 
Carle BroMenn Medical Center,8980250,nicotine 7 mg/24 hr daily transdermal patch,43598044674,,250,$2.99 ,$2.99 ,$0.90 ,$2.72 ,$2.09 ,$0.90 ,$1.94 ,$2.15 ,$2.72 ,$2.24 
Carle BroMenn Medical Center,8980250,nicotine 7 mg/24 hr daily transdermal patch,60505706100,,250,$2.70 ,$2.70 ,$0.81 ,$2.46 ,$1.89 ,$0.81 ,$1.76 ,$1.94 ,$2.46 ,$2.03 
Carle BroMenn Medical Center,8980250,nicotine 7 mg/24 hr daily transdermal patch,60505708800,,250,$2.70 ,$2.70 ,$0.81 ,$2.46 ,$1.89 ,$0.81 ,$1.76 ,$1.94 ,$2.46 ,$2.03 
Carle BroMenn Medical Center,8980250,NIFEdipine 10 mg capsule,43386044024,,250,$8.33 ,$8.33 ,$2.50 ,$7.58 ,$5.83 ,$2.50 ,$5.41 ,$6.00 ,$7.58 ,$6.25 
Carle BroMenn Medical Center,8980250,NIFEdipine 10 mg capsule,60687042501,,250,$8.03 ,$8.03 ,$2.41 ,$7.31 ,$5.62 ,$2.41 ,$5.22 ,$5.78 ,$7.31 ,$6.02 
Carle BroMenn Medical Center,8980250,NIFEdipine 10 mg capsule,60687042511,,250,$8.03 ,$8.03 ,$2.41 ,$7.31 ,$5.62 ,$2.41 ,$5.22 ,$5.78 ,$7.31 ,$6.02 
Carle BroMenn Medical Center,8980250,NIFEdipine 10 mg capsule,69315021101,,250,$7.31 ,$7.31 ,$2.19 ,$6.65 ,$5.12 ,$2.19 ,$4.75 ,$5.26 ,$6.65 ,$5.48 
Carle BroMenn Medical Center,8980250,"NIFEdipine ER 30 mg tablet,extended release 24 hr",50268059711,,250,$8.44 ,$8.44 ,$2.53 ,$7.68 ,$5.91 ,$2.53 ,$5.49 ,$6.08 ,$7.68 ,$6.33 
Carle BroMenn Medical Center,8980250,"NIFEdipine ER 30 mg tablet,extended release 24 hr",50268059715,,250,$8.44 ,$8.44 ,$2.53 ,$7.68 ,$5.91 ,$2.53 ,$5.49 ,$6.08 ,$7.68 ,$6.33 
Carle BroMenn Medical Center,8980250,"NIFEdipine ER 30 mg tablet,extended release 24 hr",68084059701,,250,$10.66 ,$10.66 ,$3.20 ,$9.70 ,$7.46 ,$3.20 ,$6.93 ,$7.68 ,$9.70 ,$8.00 
Carle BroMenn Medical Center,8980250,"NIFEdipine ER 30 mg tablet,extended release 24 hr",68084059711,,250,$10.66 ,$10.66 ,$3.20 ,$9.70 ,$7.46 ,$3.20 ,$6.93 ,$7.68 ,$9.70 ,$8.00 
Carle BroMenn Medical Center,8980250,"NIFEdipine ER 60 mg tablet,extended release 24 hr",50742026101,,250,$13.01 ,$13.01 ,$3.90 ,$11.84 ,$9.11 ,$3.90 ,$8.46 ,$9.37 ,$11.84 ,$9.76 
Carle BroMenn Medical Center,8980250,niMODipine 30 mg capsule,23155051200,,250,$9.04 ,$9.04 ,$2.71 ,$8.23 ,$6.33 ,$2.71 ,$5.88 ,$6.51 ,$8.23 ,$6.78 
Carle BroMenn Medical Center,8980250,niMODipine 30 mg capsule,23155051211,,250,$9.04 ,$9.04 ,$2.71 ,$8.23 ,$6.33 ,$2.71 ,$5.88 ,$6.51 ,$8.23 ,$6.78 
Carle BroMenn Medical Center,8980250,niMODipine 30 mg capsule,69452020907,,250,$75.47 ,$75.47 ,$22.64 ,$68.68 ,$52.83 ,$22.64 ,$49.06 ,$54.34 ,$68.68 ,$56.60 
Carle BroMenn Medical Center,8980250,niMODipine 30 mg capsule,69452020913,,250,$75.47 ,$75.47 ,$22.64 ,$68.68 ,$52.83 ,$22.64 ,$49.06 ,$54.34 ,$68.68 ,$56.60 
Carle BroMenn Medical Center,8980250,niMODipine 60 mg/10 mL oral syringe (FOR ORAL USE ONLY),24338026010,,250,$361.76 ,$361.76 ,$108.53 ,$329.20 ,$253.23 ,$108.53 ,$235.14 ,$260.47 ,$329.20 ,$271.32 
Carle BroMenn Medical Center,8980250,niMODipine 60 mg/10 mL oral syringe (FOR ORAL USE ONLY),24338026012,,250,$361.76 ,$361.76 ,$108.53 ,$329.20 ,$253.23 ,$108.53 ,$235.14 ,$260.47 ,$329.20 ,$271.32 
Carle BroMenn Medical Center,8980250,nitrofurantoin monohydrate/macrocrystals 100 mg capsule,185012201,,250,$17.28 ,$17.28 ,$5.18 ,$15.72 ,$12.10 ,$5.18 ,$11.23 ,$12.44 ,$15.72 ,$12.96 
Carle BroMenn Medical Center,8980250,nitroglycerin 0.1 mg/hr transdermal 24 hour patch,378910216,,250,$10.99 ,$10.99 ,$3.30 ,$10.00 ,$7.69 ,$3.30 ,$7.14 ,$7.91 ,$10.00 ,$8.24 
Carle BroMenn Medical Center,8980250,nitroglycerin 0.1 mg/hr transdermal 24 hour patch,378910293,,250,$10.99 ,$10.99 ,$3.30 ,$10.00 ,$7.69 ,$3.30 ,$7.14 ,$7.91 ,$10.00 ,$8.24 
Carle BroMenn Medical Center,8980250,nitroglycerin 0.2 mg/hr transdermal 24 hour patch,378910416,,250,$11.19 ,$11.19 ,$3.36 ,$10.18 ,$7.83 ,$3.36 ,$7.27 ,$8.06 ,$10.18 ,$8.39 
Carle BroMenn Medical Center,8980250,nitroglycerin 0.2 mg/hr transdermal 24 hour patch,378910493,,250,$11.19 ,$11.19 ,$3.36 ,$10.18 ,$7.83 ,$3.36 ,$7.27 ,$8.06 ,$10.18 ,$8.39 
Carle BroMenn Medical Center,8980250,nitroglycerin 0.2 mg/hr transdermal 24 hour patch,68382030901,,250,$11.19 ,$11.19 ,$3.36 ,$10.18 ,$7.83 ,$3.36 ,$7.27 ,$8.06 ,$10.18 ,$8.39 
Carle BroMenn Medical Center,8980250,nitroglycerin 0.4 mg sublingual tablet,43598043611,,250,$7.06 ,$7.06 ,$2.12 ,$6.42 ,$4.94 ,$2.12 ,$4.59 ,$5.08 ,$6.42 ,$5.30 
Carle BroMenn Medical Center,8980250,nitroglycerin 0.4 mg sublingual tablet,43598043635,,250,$7.06 ,$7.06 ,$2.12 ,$6.42 ,$4.94 ,$2.12 ,$4.59 ,$5.08 ,$6.42 ,$5.30 
Carle BroMenn Medical Center,8980250,nitroglycerin 0.4 mg sublingual tablet,68462063925,,250,$7.12 ,$7.12 ,$2.14 ,$6.48 ,$4.98 ,$2.14 ,$4.63 ,$5.13 ,$6.48 ,$5.34 
Carle BroMenn Medical Center,8980250,nitroglycerin 0.4 mg/hr transdermal 24 hour patch,378911216,,250,$12.46 ,$12.46 ,$3.74 ,$11.34 ,$8.72 ,$3.74 ,$8.10 ,$8.97 ,$11.34 ,$9.35 
Carle BroMenn Medical Center,8980250,nitroglycerin 0.4 mg/hr transdermal 24 hour patch,378911293,,250,$12.46 ,$12.46 ,$3.74 ,$11.34 ,$8.72 ,$3.74 ,$8.10 ,$8.97 ,$11.34 ,$9.35 
Carle BroMenn Medical Center,8980250,nitroglycerin 0.6 mg/hr transdermal 24 hour patch,378911693,,250,$13.50 ,$13.50 ,$4.05 ,$12.29 ,$9.45 ,$4.05 ,$8.78 ,$9.72 ,$12.29 ,$10.13 
Carle BroMenn Medical Center,8980250,nitroglycerin 2 % transdermal ointment,281032608,,250,$15.17 ,$15.17 ,$4.55 ,$13.80 ,$10.62 ,$4.55 ,$9.86 ,$10.92 ,$13.80 ,$11.38 
Carle BroMenn Medical Center,8980250,nitroglycerin 50 mg/250 mL (200 mcg/mL) in 5 % dextrose intravenous,338104902,,250,$153.27 ,$153.27 ,$45.98 ,$139.48 ,$107.29 ,$45.98 ,$99.63 ,$110.35 ,$139.48 ,$114.95 
Carle BroMenn Medical Center,8980250,norepinephrine bitartrate 1 mg/mL intravenous solution,409337504,,250,$176.24 ,$176.24 ,$52.87 ,$160.38 ,$123.37 ,$52.87 ,$114.56 ,$126.89 ,$160.38 ,$132.18 
Carle BroMenn Medical Center,8980250,norepinephrine bitartrate 1 mg/mL intravenous solution,703115301,,250,$160.80 ,$160.80 ,$48.24 ,$146.33 ,$112.56 ,$48.24 ,$104.52 ,$115.78 ,$146.33 ,$120.60 
Carle BroMenn Medical Center,8980250,norepinephrine bitartrate 1 mg/mL intravenous solution,703115303,,250,$160.80 ,$160.80 ,$48.24 ,$146.33 ,$112.56 ,$48.24 ,$104.52 ,$115.78 ,$146.33 ,$120.60 
Carle BroMenn Medical Center,8980250,norepinephrine bitartrate 1 mg/mL intravenous solution,703115381,,250,$160.80 ,$160.80 ,$48.24 ,$146.33 ,$112.56 ,$48.24 ,$104.52 ,$115.78 ,$146.33 ,$120.60 
Carle BroMenn Medical Center,8980250,norepinephrine bitartrate 1 mg/mL intravenous solution,703115383,,250,$160.80 ,$160.80 ,$48.24 ,$146.33 ,$112.56 ,$48.24 ,$104.52 ,$115.78 ,$146.33 ,$120.60 
Carle BroMenn Medical Center,8980250,norepinephrine bitartrate 1 mg/mL intravenous solution,781375575,,250,$167.41 ,$167.41 ,$50.22 ,$152.34 ,$117.19 ,$50.22 ,$108.82 ,$120.54 ,$152.34 ,$125.56 
Carle BroMenn Medical Center,8980250,norepinephrine bitartrate 1 mg/mL intravenous solution,781375595,,250,$167.41 ,$167.41 ,$50.22 ,$152.34 ,$117.19 ,$50.22 ,$108.82 ,$120.54 ,$152.34 ,$125.56 
Carle BroMenn Medical Center,8980250,norepinephrine bitartrate 1 mg/mL intravenous solution,25021031604,,250,$95.99 ,$95.99 ,$28.80 ,$87.35 ,$67.19 ,$28.80 ,$62.39 ,$69.11 ,$87.35 ,$71.99 
Carle BroMenn Medical Center,8980250,norepinephrine bitartrate 1 mg/mL intravenous solution,63323094004,,250,$108.28 ,$108.28 ,$32.48 ,$98.53 ,$75.80 ,$32.48 ,$70.38 ,$77.96 ,$98.53 ,$81.21 
Carle BroMenn Medical Center,8980250,norepinephrine bitartrate 1 mg/mL intravenous solution,63323094021,,250,$108.28 ,$108.28 ,$32.48 ,$98.53 ,$75.80 ,$32.48 ,$70.38 ,$77.96 ,$98.53 ,$81.21 
Carle BroMenn Medical Center,8980250,norepinephrine bitartrate 1 mg/mL intravenous solution,67457085200,,250,$161.97 ,$161.97 ,$48.59 ,$147.39 ,$113.38 ,$48.59 ,$105.28 ,$116.62 ,$147.39 ,$121.48 
Carle BroMenn Medical Center,8980250,norepinephrine bitartrate 1 mg/mL intravenous solution,67457085204,,250,$161.97 ,$161.97 ,$48.59 ,$147.39 ,$113.38 ,$48.59 ,$105.28 ,$116.62 ,$147.39 ,$121.48 
Carle BroMenn Medical Center,8980250,nortriptyline 10 mg capsule,51672400105,,250,$2.93 ,$2.93 ,$0.88 ,$2.67 ,$2.05 ,$0.88 ,$1.90 ,$2.11 ,$2.67 ,$2.20 
Carle BroMenn Medical Center,8980250,nortriptyline 10 mg capsule,60687028101,,250,$4.39 ,$4.39 ,$1.32 ,$3.99 ,$3.07 ,$1.32 ,$2.85 ,$3.16 ,$3.99 ,$3.29 
Carle BroMenn Medical Center,8980250,nortriptyline 10 mg capsule,60687028111,,250,$4.39 ,$4.39 ,$1.32 ,$3.99 ,$3.07 ,$1.32 ,$2.85 ,$3.16 ,$3.99 ,$3.29 
Carle BroMenn Medical Center,8980250,nortriptyline 25 mg capsule,50268060411,,250,$5.08 ,$5.08 ,$1.52 ,$4.62 ,$3.56 ,$1.52 ,$3.30 ,$3.66 ,$4.62 ,$3.81 
Carle BroMenn Medical Center,8980250,nortriptyline 25 mg capsule,50268060415,,250,$5.08 ,$5.08 ,$1.52 ,$4.62 ,$3.56 ,$1.52 ,$3.30 ,$3.66 ,$4.62 ,$3.81 
Carle BroMenn Medical Center,8980250,nortriptyline 50 mg capsule,50268060511,,250,$5.26 ,$5.26 ,$1.58 ,$4.79 ,$3.68 ,$1.58 ,$3.42 ,$3.79 ,$4.79 ,$3.95 
Carle BroMenn Medical Center,8980250,"nystatin 100,000 unit/gram topical cream",713067831,,250,$143.30 ,$143.30 ,$42.99 ,$130.40 ,$100.31 ,$42.99 ,$93.15 ,$103.18 ,$130.40 ,$107.48 
Carle BroMenn Medical Center,8980250,"nystatin 100,000 unit/gram topical powder",574200815,,250,$148.96 ,$148.96 ,$44.69 ,$135.55 ,$104.27 ,$44.69 ,$96.82 ,$107.25 ,$135.55 ,$111.72 
Carle BroMenn Medical Center,8980250,"nystatin 100,000 unit/gram topical powder",832046515,,250,$195.51 ,$195.51 ,$58.65 ,$177.91 ,$136.86 ,$58.65 ,$127.08 ,$140.77 ,$177.91 ,$146.63 
Carle BroMenn Medical Center,8980250,"nystatin 100,000 unit/gram topical powder",16714076901,,250,$117.99 ,$117.99 ,$35.40 ,$107.37 ,$82.59 ,$35.40 ,$76.69 ,$84.95 ,$107.37 ,$88.49 
Carle BroMenn Medical Center,8980250,"nystatin 100,000 unit/mL oral suspension",60432053716,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,"nystatin 100,000 unit/mL oral suspension",66689003701,,250,$9.51 ,$9.51 ,$2.85 ,$8.65 ,$6.66 ,$2.85 ,$6.18 ,$6.85 ,$8.65 ,$7.13 
Carle BroMenn Medical Center,8980250,"nystatin 100,000 unit/mL oral suspension",66689003750,,250,$9.51 ,$9.51 ,$2.85 ,$8.65 ,$6.66 ,$2.85 ,$6.18 ,$6.85 ,$8.65 ,$7.13 
Carle BroMenn Medical Center,8980250,"nystatin 100,000 unit/mL oral suspension",66689003799,,250,$7.04 ,$7.04 ,$2.11 ,$6.41 ,$4.93 ,$2.11 ,$4.58 ,$5.07 ,$6.41 ,$5.28 
Carle BroMenn Medical Center,8980250,ofloxacin 0.3 % eye drops,17478071310,,250,$118.55 ,$118.55 ,$35.57 ,$107.88 ,$82.99 ,$35.57 ,$77.06 ,$85.36 ,$107.88 ,$88.91 
Carle BroMenn Medical Center,8980250,ofloxacin 0.3 % eye drops,60505056001,,250,$209.14 ,$209.14 ,$62.74 ,$190.32 ,$146.40 ,$62.74 ,$135.94 ,$150.58 ,$190.32 ,$156.86 
Carle BroMenn Medical Center,8980250,ofloxacin 0.3 % eye drops,64980051505,,250,$348.80 ,$348.80 ,$104.64 ,$317.41 ,$244.16 ,$104.64 ,$226.72 ,$251.14 ,$317.41 ,$261.60 
Carle BroMenn Medical Center,8980250,OLANZapine 10 mg disintegrating tablet,55111026379,,250,$16.54 ,$16.54 ,$4.96 ,$15.05 ,$11.58 ,$4.96 ,$10.75 ,$11.91 ,$15.05 ,$12.41 
Carle BroMenn Medical Center,8980250,OLANZapine 10 mg disintegrating tablet,55111026381,,250,$16.54 ,$16.54 ,$4.96 ,$15.05 ,$11.58 ,$4.96 ,$10.75 ,$11.91 ,$15.05 ,$12.41 
Carle BroMenn Medical Center,8980250,OLANZapine 10 mg disintegrating tablet,59746030712,,250,$81.56 ,$81.56 ,$24.47 ,$74.22 ,$57.09 ,$24.47 ,$53.01 ,$58.72 ,$74.22 ,$61.17 
Carle BroMenn Medical Center,8980250,OLANZapine 10 mg disintegrating tablet,59746030732,,250,$81.56 ,$81.56 ,$24.47 ,$74.22 ,$57.09 ,$24.47 ,$53.01 ,$58.72 ,$74.22 ,$61.17 
Carle BroMenn Medical Center,8980250,OLANZapine 5 mg disintegrating tablet,49884032055,,250,$58.11 ,$58.11 ,$17.43 ,$52.88 ,$40.68 ,$17.43 ,$37.77 ,$41.84 ,$52.88 ,$43.58 
Carle BroMenn Medical Center,8980250,OLANZapine 5 mg disintegrating tablet,59746030612,,250,$58.11 ,$58.11 ,$17.43 ,$52.88 ,$40.68 ,$17.43 ,$37.77 ,$41.84 ,$52.88 ,$43.58 
Carle BroMenn Medical Center,8980250,OLANZapine 5 mg disintegrating tablet,59746030632,,250,$58.11 ,$58.11 ,$17.43 ,$52.88 ,$40.68 ,$17.43 ,$37.77 ,$41.84 ,$52.88 ,$43.58 
Carle BroMenn Medical Center,8980250,OLANZapine 5 mg disintegrating tablet,60505327500,,250,$58.11 ,$58.11 ,$17.43 ,$52.88 ,$40.68 ,$17.43 ,$37.77 ,$41.84 ,$52.88 ,$43.58 
Carle BroMenn Medical Center,8980250,OLANZapine 5 mg tablet,60505311100,,250,$54.41 ,$54.41 ,$16.32 ,$49.51 ,$38.09 ,$16.32 ,$35.37 ,$39.18 ,$49.51 ,$40.81 
Carle BroMenn Medical Center,8980250,oseltamivir 6 mg/mL oral suspension,93818064,,250,$90.97 ,$90.97 ,$27.29 ,$82.78 ,$63.68 ,$27.29 ,$59.13 ,$65.50 ,$82.78 ,$68.23 
Carle BroMenn Medical Center,8980250,oseltamivir 6 mg/mL oral suspension,27241013909,,250,$86.55 ,$86.55 ,$25.97 ,$78.76 ,$60.59 ,$25.97 ,$56.26 ,$62.32 ,$78.76 ,$64.91 
Carle BroMenn Medical Center,8980250,oseltamivir 6 mg/mL oral suspension,42291056760,,250,$65.34 ,$65.34 ,$19.60 ,$59.46 ,$45.74 ,$19.60 ,$42.47 ,$47.04 ,$59.46 ,$49.01 
Carle BroMenn Medical Center,8980250,oseltamivir 6 mg/mL oral suspension,68180067801,,250,$86.40 ,$86.40 ,$25.92 ,$78.62 ,$60.48 ,$25.92 ,$56.16 ,$62.21 ,$78.62 ,$64.80 
Carle BroMenn Medical Center,8980250,oseltamivir 75 mg capsule,47781047013,,250,$62.25 ,$62.25 ,$18.68 ,$56.65 ,$43.58 ,$18.68 ,$40.46 ,$44.82 ,$56.65 ,$46.69 
Carle BroMenn Medical Center,8980250,oseltamivir 75 mg capsule,64380079901,,250,$62.25 ,$62.25 ,$18.68 ,$56.65 ,$43.58 ,$18.68 ,$40.46 ,$44.82 ,$56.65 ,$46.69 
Carle BroMenn Medical Center,8980250,oseltamivir 75 mg capsule,68180067711,,250,$62.25 ,$62.25 ,$18.68 ,$56.65 ,$43.58 ,$18.68 ,$40.46 ,$44.82 ,$56.65 ,$46.69 
Carle BroMenn Medical Center,8980250,oxybutynin chloride 5 mg tablet,904282161,,250,$5.22 ,$5.22 ,$1.57 ,$4.75 ,$3.65 ,$1.57 ,$3.39 ,$3.76 ,$4.75 ,$3.92 
Carle BroMenn Medical Center,8980250,oxybutynin chloride 5 mg tablet,64980043101,,250,$5.87 ,$5.87 ,$1.76 ,$5.34 ,$4.11 ,$1.76 ,$3.82 ,$4.23 ,$5.34 ,$4.40 
Carle BroMenn Medical Center,8980250,oxybutynin chloride 5 mg tablet,68084040001,,250,$4.67 ,$4.67 ,$1.40 ,$4.25 ,$3.27 ,$1.40 ,$3.04 ,$3.36 ,$4.25 ,$3.50 
Carle BroMenn Medical Center,8980250,oxybutynin chloride 5 mg tablet,68084040011,,250,$4.67 ,$4.67 ,$1.40 ,$4.25 ,$3.27 ,$1.40 ,$3.04 ,$3.36 ,$4.25 ,$3.50 
Carle BroMenn Medical Center,8980250,oxyCODONE 15 mg tablet,68084018401,,250,$13.37 ,$13.37 ,$4.01 ,$12.17 ,$9.36 ,$4.01 ,$8.69 ,$9.63 ,$12.17 ,$10.03 
Carle BroMenn Medical Center,8980250,oxyCODONE 15 mg tablet,68084097501,,250,$13.37 ,$13.37 ,$4.01 ,$12.17 ,$9.36 ,$4.01 ,$8.69 ,$9.63 ,$12.17 ,$10.03 
Carle BroMenn Medical Center,8980250,oxyCODONE 15 mg tablet,68084097511,,250,$13.37 ,$13.37 ,$4.01 ,$12.17 ,$9.36 ,$4.01 ,$8.69 ,$9.63 ,$12.17 ,$10.03 
Carle BroMenn Medical Center,8980250,oxyCODONE 20 mg/mL oral concentrate,406855730,,250,$71.57 ,$71.57 ,$21.47 ,$65.13 ,$50.10 ,$21.47 ,$46.52 ,$51.53 ,$65.13 ,$53.68 
Carle BroMenn Medical Center,8980250,oxyCODONE 5 mg tablet,406055223,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,oxyCODONE 5 mg tablet,406055262,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,oxyCODONE 5 mg tablet,904696661,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,oxyCODONE 5 mg tablet,68084035401,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,oxyCODONE 5 mg tablet,68084035411,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,"oxyCODONE ER 10 mg tablet,crush resistant,extended release 12 hr",59011041020,,250,$29.62 ,$29.62 ,$8.89 ,$26.95 ,$20.73 ,$8.89 ,$19.25 ,$21.33 ,$26.95 ,$22.22 
Carle BroMenn Medical Center,8980250,"oxyCODONE ER 20 mg tablet,crush resistant,extended release 12 hr",59011042020,,250,$46.14 ,$46.14 ,$13.84 ,$41.99 ,$32.30 ,$13.84 ,$29.99 ,$33.22 ,$41.99 ,$34.61 
Carle BroMenn Medical Center,8980250,"oxyCODONE ER 40 mg tablet,crush resistant,extended release 12 hr",59011044020,,250,$71.52 ,$71.52 ,$21.46 ,$65.08 ,$50.06 ,$21.46 ,$46.49 ,$51.49 ,$65.08 ,$53.64 
Carle BroMenn Medical Center,8980250,oxyCODONE-acetaminophen 10 mg-325 mg tablet,406052362,,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,oxyCODONE-acetaminophen 10 mg-325 mg tablet,68084071001,,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,oxyCODONE-acetaminophen 10 mg-325 mg tablet,68084071011,,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,oxyCODONE-acetaminophen 5 mg-325 mg tablet,904709361,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,oxyCODONE-acetaminophen 5 mg-325 mg tablet,68084035501,,250,$11.11 ,$11.11 ,$3.33 ,$10.11 ,$7.78 ,$3.33 ,$7.22 ,$8.00 ,$10.11 ,$8.33 
Carle BroMenn Medical Center,8980250,oxyCODONE-acetaminophen 5 mg-325 mg tablet,68084035511,,250,$11.11 ,$11.11 ,$3.33 ,$10.11 ,$7.78 ,$3.33 ,$7.22 ,$8.00 ,$10.11 ,$8.33 
Carle BroMenn Medical Center,8980250,oxymetazoline 0.05 % nasal mist,573119120,,250,$31.35 ,$31.35 ,$9.41 ,$28.53 ,$21.95 ,$9.41 ,$20.38 ,$22.57 ,$28.53 ,$23.51 
Carle BroMenn Medical Center,8980250,oxymetazoline 0.05 % nasal spray,904571135,J3490,250,$17.47 ,$17.47 ,$5.24 ,$15.90 ,$12.23 ,$5.24 ,$11.36 ,$12.58 ,$15.90 ,$13.10 
Carle BroMenn Medical Center,8980250,oxymetazoline 0.05 % nasal spray,23900001252,,250,$31.35 ,$31.35 ,$9.41 ,$28.53 ,$21.95 ,$9.41 ,$20.38 ,$22.57 ,$28.53 ,$23.51 
Carle BroMenn Medical Center,8980250,oxymetazoline 0.05 % nasal spray,46122016510,,250,$38.42 ,$38.42 ,$11.53 ,$34.96 ,$26.89 ,$11.53 ,$24.97 ,$27.66 ,$34.96 ,$28.82 
Carle BroMenn Medical Center,8980250,oxymetazoline 0.05 % nasal spray,87701089900,,250,$38.42 ,$38.42 ,$11.53 ,$34.96 ,$26.89 ,$11.53 ,$24.97 ,$27.66 ,$34.96 ,$28.82 
Carle BroMenn Medical Center,8980250,"paliperidone ER 1.5 mg tablet,extended release 24 hr",47335074483,,250,$115.12 ,$115.12 ,$34.54 ,$104.76 ,$80.58 ,$34.54 ,$74.83 ,$82.89 ,$104.76 ,$86.34 
Carle BroMenn Medical Center,8980250,"paliperidone ER 1.5 mg tablet,extended release 24 hr",65162028003,,250,$115.24 ,$115.24 ,$34.57 ,$104.87 ,$80.67 ,$34.57 ,$74.91 ,$82.97 ,$104.87 ,$86.43 
Carle BroMenn Medical Center,8980250,"paliperidone ER 3 mg tablet,extended release 24 hr",378397993,,250,$115.12 ,$115.12 ,$34.54 ,$104.76 ,$80.58 ,$34.54 ,$74.83 ,$82.89 ,$104.76 ,$86.34 
Carle BroMenn Medical Center,8980250,"paliperidone ER 3 mg tablet,extended release 24 hr",16714086701,,250,$113.77 ,$113.77 ,$34.13 ,$103.53 ,$79.64 ,$34.13 ,$73.95 ,$81.91 ,$103.53 ,$85.33 
Carle BroMenn Medical Center,8980250,"paliperidone ER 3 mg tablet,extended release 24 hr",47335076583,,250,$115.12 ,$115.12 ,$34.54 ,$104.76 ,$80.58 ,$34.54 ,$74.83 ,$82.89 ,$104.76 ,$86.34 
Carle BroMenn Medical Center,8980250,"pantoprazole 20 mg tablet,delayed release",60687058501,,250,$20.04 ,$20.04 ,$6.01 ,$18.24 ,$14.03 ,$6.01 ,$13.03 ,$14.43 ,$18.24 ,$15.03 
Carle BroMenn Medical Center,8980250,"pantoprazole 20 mg tablet,delayed release",60687058511,,250,$20.04 ,$20.04 ,$6.01 ,$18.24 ,$14.03 ,$6.01 ,$13.03 ,$14.43 ,$18.24 ,$15.03 
Carle BroMenn Medical Center,8980250,"pantoprazole 20 mg tablet,delayed release",65862055990,,250,$26.58 ,$26.58 ,$7.97 ,$24.19 ,$18.61 ,$7.97 ,$17.28 ,$19.14 ,$24.19 ,$19.94 
Carle BroMenn Medical Center,8980250,"pantoprazole 40 mg tablet,delayed release",904647461,,250,$21.37 ,$21.37 ,$6.41 ,$19.45 ,$14.96 ,$6.41 ,$13.89 ,$15.39 ,$19.45 ,$16.03 
Carle BroMenn Medical Center,8980250,"pantoprazole 40 mg tablet,delayed release",904687045,,250,$3.43 ,$3.43 ,$1.03 ,$3.12 ,$2.40 ,$1.03 ,$2.23 ,$2.47 ,$3.12 ,$2.57 
Carle BroMenn Medical Center,8980250,"pantoprazole 40 mg tablet,delayed release",13668042990,,250,$21.34 ,$21.34 ,$6.40 ,$19.42 ,$14.94 ,$6.40 ,$13.87 ,$15.36 ,$19.42 ,$16.01 
Carle BroMenn Medical Center,8980250,"pantoprazole 40 mg tablet,delayed release",35573042851,,250,$4.44 ,$4.44 ,$1.33 ,$4.04 ,$3.11 ,$1.33 ,$2.89 ,$3.20 ,$4.04 ,$3.33 
Carle BroMenn Medical Center,8980250,"pantoprazole 40 mg tablet,delayed release",35573042880,,250,$4.44 ,$4.44 ,$1.33 ,$4.04 ,$3.11 ,$1.33 ,$2.89 ,$3.20 ,$4.04 ,$3.33 
Carle BroMenn Medical Center,8980250,"pantoprazole 40 mg tablet,delayed release",50268063911,,250,$21.10 ,$21.10 ,$6.33 ,$19.20 ,$14.77 ,$6.33 ,$13.72 ,$15.19 ,$19.20 ,$15.83 
Carle BroMenn Medical Center,8980250,"pantoprazole 40 mg tablet,delayed release",51079005101,,250,$26.58 ,$26.58 ,$7.97 ,$24.19 ,$18.61 ,$7.97 ,$17.28 ,$19.14 ,$24.19 ,$19.94 
Carle BroMenn Medical Center,8980250,"pantoprazole 40 mg tablet,delayed release",51079005120,,250,$26.58 ,$26.58 ,$7.97 ,$24.19 ,$18.61 ,$7.97 ,$17.28 ,$19.14 ,$24.19 ,$19.94 
Carle BroMenn Medical Center,8980250,"pantoprazole 40 mg tablet,delayed release",65862056090,,250,$26.58 ,$26.58 ,$7.97 ,$24.19 ,$18.61 ,$7.97 ,$17.28 ,$19.14 ,$24.19 ,$19.94 
Carle BroMenn Medical Center,8980250,"pantoprazole 40 mg tablet,delayed release",68084081309,,250,$4.47 ,$4.47 ,$1.34 ,$4.07 ,$3.13 ,$1.34 ,$2.91 ,$3.22 ,$4.07 ,$3.35 
Carle BroMenn Medical Center,8980250,"pantoprazole 40 mg tablet,delayed release",68084081311,,250,$4.47 ,$4.47 ,$1.34 ,$4.07 ,$3.13 ,$1.34 ,$2.91 ,$3.22 ,$4.07 ,$3.35 
Carle BroMenn Medical Center,8980250,PARoxetine 20 mg tablet,904567761,,250,$16.02 ,$16.02 ,$4.81 ,$14.58 ,$11.21 ,$4.81 ,$10.41 ,$11.53 ,$14.58 ,$12.02 
Carle BroMenn Medical Center,8980250,PARoxetine 40 mg tablet,68084004701,,250,$16.47 ,$16.47 ,$4.94 ,$14.99 ,$11.53 ,$4.94 ,$10.71 ,$11.86 ,$14.99 ,$12.35 
Carle BroMenn Medical Center,8980250,pediatric multivitamin no.189-ferrous sulfate 11 mg/mL oral drops,87040501,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,pediatric multivitamin no.192 250 mcg-50 mg-10 mcg/mL oral drops,87040203,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,"pediatric mv no.180-iron,carbonyl 8 mg-vit K 10 mcg chewable tablet",5423720,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,peg 3350-electrolytes 236 gram-22.74 gram-6.74 gram-5.86 gram solution,10572010001,,250,$76.89 ,$76.89 ,$23.07 ,$69.97 ,$53.82 ,$23.07 ,$49.98 ,$55.36 ,$69.97 ,$57.67 
Carle BroMenn Medical Center,8980250,peg 3350-electrolytes 236 gram-22.74 gram-6.74 gram-5.86 gram solution,52268010001,,250,$76.89 ,$76.89 ,$23.07 ,$69.97 ,$53.82 ,$23.07 ,$49.98 ,$55.36 ,$69.97 ,$57.67 
Carle BroMenn Medical Center,8980250,"peg 400-hypromellose-glycerin 1 %-0.2 %-0.2 % eye drops,dextran 70-hypromellose 0.1 %-0.3 % eye drops,polyvinyl alcohol-povidone 0.5 %-0.6 % eye drops,polyvinyl alcohol 1.4 % eye drops,peg 400-propylene glycol 0.4 %-0.3 % eye drops",17478006012,,250,$46.63 ,$46.63 ,$13.99 ,$42.43 ,$32.64 ,$13.99 ,$30.31 ,$33.57 ,$42.43 ,$34.97 
Carle BroMenn Medical Center,8980250,"peg 400-hypromellose-glycerin 1 %-0.2 %-0.2 % eye drops,dextran 70-hypromellose 0.1 %-0.3 % eye drops,polyvinyl alcohol-povidone 0.5 %-0.6 % eye drops,polyvinyl alcohol 1.4 % eye drops,peg 400-propylene glycol 0.4 %-0.3 % eye drops",24385000605,,250,$37.20 ,$37.20 ,$11.16 ,$33.85 ,$26.04 ,$11.16 ,$24.18 ,$26.78 ,$33.85 ,$27.90 
Carle BroMenn Medical Center,8980250,"peg 400-hypromellose-glycerin 1 %-0.2 %-0.2 % eye drops,dextran 70-hypromellose 0.1 %-0.3 % eye drops,polyvinyl alcohol-povidone 0.5 %-0.6 % eye drops,polyvinyl alcohol 1.4 % eye drops,peg 400-propylene glycol 0.4 %-0.3 % eye drops",57896018105,,250,$17.47 ,$17.47 ,$5.24 ,$15.90 ,$12.23 ,$5.24 ,$11.36 ,$12.58 ,$15.90 ,$13.10 
Carle BroMenn Medical Center,8980250,"peg 400-hypromellose-glycerin 1 %-0.2 %-0.2 % eye drops,dextran 70-hypromellose 0.1 %-0.3 % eye drops,polyvinyl alcohol-povidone 0.5 %-0.6 % eye drops,polyvinyl alcohol 1.4 % eye drops,peg 400-propylene glycol 0.4 %-0.3 % eye drops",57896018405,,250,$17.47 ,$17.47 ,$5.24 ,$15.90 ,$12.23 ,$5.24 ,$11.36 ,$12.58 ,$15.90 ,$13.10 
Carle BroMenn Medical Center,8980250,"peg 400-hypromellose-glycerin 1 %-0.2 %-0.2 % eye drops,dextran 70-hypromellose 0.1 %-0.3 % eye drops,polyvinyl alcohol-povidone 0.5 %-0.6 % eye drops,polyvinyl alcohol 1.4 % eye drops,peg 400-propylene glycol 0.4 %-0.3 % eye drops",78112073645,,250,$29.25 ,$29.25 ,$8.78 ,$26.62 ,$20.48 ,$8.78 ,$19.01 ,$21.06 ,$26.62 ,$21.94 
Carle BroMenn Medical Center,8980250,"peg 400-hypromellose-glycerin 1 %-0.2 %-0.2 % eye drops,dextran 70-hypromellose 0.1 %-0.3 % eye drops,polyvinyl alcohol-povidone 0.5 %-0.6 % eye drops,polyvinyl alcohol 1.4 % eye drops,peg 400-propylene glycol 0.4 %-0.3 % eye drops",87701010406,,250,$22.62 ,$22.62 ,$6.79 ,$20.58 ,$15.83 ,$6.79 ,$14.70 ,$16.29 ,$20.58 ,$16.97 
Carle BroMenn Medical Center,8980250,peg3350 100 gram-sod sulf 7.5 gram-NaCl-KCl-ascorbate-C oral pwdr pack,65649020175,,250,$506.90 ,$506.90 ,$152.07 ,$461.28 ,$354.83 ,$152.07 ,$329.49 ,$364.97 ,$461.28 ,$380.18 
Carle BroMenn Medical Center,8980250,peg-electrolyte solution 420 gram oral solution,10572030201,,250,$132.81 ,$132.81 ,$39.84 ,$120.86 ,$92.97 ,$39.84 ,$86.33 ,$95.62 ,$120.86 ,$99.61 
Carle BroMenn Medical Center,8980250,peg-electrolyte solution 420 gram oral solution,52268030201,,250,$132.81 ,$132.81 ,$39.84 ,$120.86 ,$92.97 ,$39.84 ,$86.33 ,$95.62 ,$120.86 ,$99.61 
Carle BroMenn Medical Center,8980250,penicillin V potassium 250 mg tablet,143983701,,250,$6.29 ,$6.29 ,$1.89 ,$5.72 ,$4.40 ,$1.89 ,$4.09 ,$4.53 ,$5.72 ,$4.72 
Carle BroMenn Medical Center,8980250,penicillin V potassium 250 mg tablet,16714023401,,250,$4.46 ,$4.46 ,$1.34 ,$4.06 ,$3.12 ,$1.34 ,$2.90 ,$3.21 ,$4.06 ,$3.35 
Carle BroMenn Medical Center,8980250,pentamidine 300 mg solution for inhalation,63323087715,J2545,250,$709.10 ,$709.10 ,$212.73 ,$645.28 ,$496.37 ,$212.73 ,$460.92 ,$510.55 ,$645.28 ,$531.83 
Carle BroMenn Medical Center,8980250,pentamidine 300 mg solution for injection,13925051510,,250,$905.20 ,$905.20 ,$271.56 ,$823.73 ,$633.64 ,$271.56 ,$588.38 ,$651.74 ,$823.73 ,$678.90 
Carle BroMenn Medical Center,8980250,"pentoxifylline ER 400 mg tablet,extended release",904544861,,250,$9.31 ,$9.31 ,$2.79 ,$8.47 ,$6.52 ,$2.79 ,$6.05 ,$6.70 ,$8.47 ,$6.98 
Carle BroMenn Medical Center,8980250,"pentoxifylline ER 400 mg tablet,extended release",60505003306,,250,$7.65 ,$7.65 ,$2.30 ,$6.96 ,$5.36 ,$2.30 ,$4.97 ,$5.51 ,$6.96 ,$5.74 
Carle BroMenn Medical Center,8980250,permethrin 1 % topical liquid,46122010846,,250,$60.84 ,$60.84 ,$18.25 ,$55.36 ,$42.59 ,$18.25 ,$39.55 ,$43.80 ,$55.36 ,$45.63 
Carle BroMenn Medical Center,8980250,permethrin 5 % topical cream,21922002107,,250,$570.94 ,$570.94 ,$171.28 ,$519.56 ,$399.66 ,$171.28 ,$371.11 ,$411.08 ,$519.56 ,$428.21 
Carle BroMenn Medical Center,8980250,permethrin 5 % topical cream,45802026937,,250,$574.58 ,$574.58 ,$172.37 ,$522.87 ,$402.21 ,$172.37 ,$373.48 ,$413.70 ,$522.87 ,$430.94 
Carle BroMenn Medical Center,8980250,phenazopyridine 200 mg tablet,51293081101,,250,$20.97 ,$20.97 ,$6.29 ,$19.08 ,$14.68 ,$6.29 ,$13.63 ,$15.10 ,$19.08 ,$15.73 
Carle BroMenn Medical Center,8980250,phenazopyridine 200 mg tablet,65162068210,,250,$20.97 ,$20.97 ,$6.29 ,$19.08 ,$14.68 ,$6.29 ,$13.63 ,$15.10 ,$19.08 ,$15.73 
Carle BroMenn Medical Center,8980250,phenazopyridine 200 mg tablet,69367016304,,250,$20.97 ,$20.97 ,$6.29 ,$19.08 ,$14.68 ,$6.29 ,$13.63 ,$15.10 ,$19.08 ,$15.73 
Carle BroMenn Medical Center,8980250,phenoL 1.4 % mucosal aerosol spray,536122858,,250,$21.01 ,$21.01 ,$6.30 ,$19.12 ,$14.71 ,$6.30 ,$13.66 ,$15.13 ,$19.12 ,$15.76 
Carle BroMenn Medical Center,8980250,phenoL 1.4 % mucosal aerosol spray,536242558,,250,$19.98 ,$19.98 ,$5.99 ,$18.18 ,$13.99 ,$5.99 ,$12.99 ,$14.39 ,$18.18 ,$14.99 
Carle BroMenn Medical Center,8980250,phenoL 1.4 % mucosal aerosol spray,904630521,,250,$17.92 ,$17.92 ,$5.38 ,$16.31 ,$12.54 ,$5.38 ,$11.65 ,$12.90 ,$16.31 ,$13.44 
Carle BroMenn Medical Center,8980250,phenoL 89 % topical swab,884629730,,250,$27.25 ,$27.25 ,$8.18 ,$24.80 ,$19.08 ,$8.18 ,$17.71 ,$19.62 ,$24.80 ,$20.44 
Carle BroMenn Medical Center,8980250,phenylephrine 0.125 % nasal drops,56184012105,,250,$25.85 ,$25.85 ,$7.76 ,$23.52 ,$18.10 ,$7.76 ,$16.80 ,$18.61 ,$23.52 ,$19.39 
Carle BroMenn Medical Center,8980250,phenylephrine 0.5 % nasal spray,225080547,,250,$25.59 ,$25.59 ,$7.68 ,$23.29 ,$17.91 ,$7.68 ,$16.63 ,$18.42 ,$23.29 ,$19.19 
Carle BroMenn Medical Center,8980250,phenylephrine 0.5 % nasal spray,69536005015,,250,$25.59 ,$25.59 ,$7.68 ,$23.29 ,$17.91 ,$7.68 ,$16.63 ,$18.42 ,$23.29 ,$19.19 
Carle BroMenn Medical Center,8980250,phenylephrine 1 % nasal spray,69536010015,,250,$28.38 ,$28.38 ,$8.51 ,$25.83 ,$19.87 ,$8.51 ,$18.45 ,$20.43 ,$25.83 ,$21.29 
Carle BroMenn Medical Center,8980250,phenylephrine 10 % eye drops,17478020605,,250,$17.47 ,$17.47 ,$5.24 ,$15.90 ,$12.23 ,$5.24 ,$11.36 ,$12.58 ,$15.90 ,$13.10 
Carle BroMenn Medical Center,8980250,phenylephrine 10 mg/mL injection solution,999501721,,250,$140.29 ,$140.29 ,$42.09 ,$127.66 ,$98.20 ,$42.09 ,$91.19 ,$101.01 ,$127.66 ,$105.22 
Carle BroMenn Medical Center,8980250,phenytoin 125 mg/5 mL oral suspension,51672406901,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,phenytoin sodium extended 100 mg capsule,904618761,,250,$5.74 ,$5.74 ,$1.72 ,$5.22 ,$4.02 ,$1.72 ,$3.73 ,$4.13 ,$5.22 ,$4.31 
Carle BroMenn Medical Center,8980250,phenytoin sodium extended 100 mg capsule,68084037601,,250,$5.32 ,$5.32 ,$1.60 ,$4.84 ,$3.72 ,$1.60 ,$3.46 ,$3.83 ,$4.84 ,$3.99 
Carle BroMenn Medical Center,8980250,phenytoin sodium extended 100 mg capsule,68084037611,,250,$5.32 ,$5.32 ,$1.60 ,$4.84 ,$3.72 ,$1.60 ,$3.46 ,$3.83 ,$4.84 ,$3.99 
Carle BroMenn Medical Center,8980250,physostigmine 1 mg/mL injection solution,17478051002,,250,$475.11 ,$475.11 ,$142.53 ,$432.35 ,$332.58 ,$142.53 ,$308.82 ,$342.08 ,$432.35 ,$356.33 
Carle BroMenn Medical Center,8980250,pilocarpine 2 % eye drops,70069019101,,250,$462.95 ,$462.95 ,$138.89 ,$421.28 ,$324.07 ,$138.89 ,$300.92 ,$333.32 ,$421.28 ,$347.21 
Carle BroMenn Medical Center,8980250,pilocarpine 5 mg tablet,527131301,,250,$10.78 ,$10.78 ,$3.23 ,$9.81 ,$7.55 ,$3.23 ,$7.01 ,$7.76 ,$9.81 ,$8.09 
Carle BroMenn Medical Center,8980250,polyethylene glycol 3350 17 gram oral powder packet,11523723401,,250,$1.76 ,$1.76 ,$0.53 ,$1.60 ,$1.23 ,$0.53 ,$1.14 ,$1.27 ,$1.60 ,$1.32 
Carle BroMenn Medical Center,8980250,polyethylene glycol 3350 17 gram oral powder packet,11523726808,,250,$1.60 ,$1.60 ,$0.48 ,$1.46 ,$1.12 ,$0.48 ,$1.04 ,$1.15 ,$1.46 ,$1.20 
Carle BroMenn Medical Center,8980250,polyethylene glycol 3350 17 gram oral powder packet,41100080676,,250,$1.41 ,$1.41 ,$0.42 ,$1.28 ,$0.99 ,$0.42 ,$0.92 ,$1.02 ,$1.28 ,$1.06 
Carle BroMenn Medical Center,8980250,polyethylene glycol 3350 17 gram oral powder packet,62559015710,,250,$2.34 ,$2.34 ,$0.70 ,$2.13 ,$1.64 ,$0.70 ,$1.52 ,$1.68 ,$2.13 ,$1.76 
Carle BroMenn Medical Center,8980250,polyethylene glycol 3350 17 gram oral powder packet,62559015717,,250,$2.34 ,$2.34 ,$0.70 ,$2.13 ,$1.64 ,$0.70 ,$1.52 ,$1.68 ,$2.13 ,$1.76 
Carle BroMenn Medical Center,8980250,polyethylene glycol 3350 17 gram/dose oral powder,41100082073,,250,$17.47 ,$17.47 ,$5.24 ,$15.90 ,$12.23 ,$5.24 ,$11.36 ,$12.58 ,$15.90 ,$13.10 
Carle BroMenn Medical Center,8980250,"polymyxin B sulfate 10,000 unit-trimethoprim 1 mg/mL eye drops",61314062810,,250,$102.15 ,$102.15 ,$30.65 ,$92.96 ,$71.51 ,$30.65 ,$66.40 ,$73.55 ,$92.96 ,$76.61 
Carle BroMenn Medical Center,8980250,polyvinyl alcohol-povidone (PF) 1.4 %-0.6 % eye drops in a dropperette,23050601,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,polyvinyl alcohol-povidone (PF) 1.4 %-0.6 % eye drops in a dropperette,23050650,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,poractant alfa 120 mg/1.5 mL intratracheal suspension,10122051001,,250,"$2,082.46 ","$2,082.46 ",$624.74 ,"$1,895.04 ","$1,457.72 ",$624.74 ,"$1,353.60 ","$1,499.37 ","$1,895.04 ","$1,561.85 "
Carle BroMenn Medical Center,8980250,poractant alfa 240 mg/3 mL intratracheal suspension,10122051003,,250,"$4,098.46 ","$4,098.46 ","$1,229.54 ","$3,729.60 ","$2,868.92 ","$1,229.54 ","$2,664.00 ","$2,950.89 ","$3,729.60 ","$3,073.85 "
Carle BroMenn Medical Center,8980250,"posaconazole 100 mg tablet,delayed release",60687052321,,250,$206.25 ,$206.25 ,$61.88 ,$187.69 ,$144.38 ,$61.88 ,$134.06 ,$148.50 ,$187.69 ,$154.69 
Carle BroMenn Medical Center,8980250,"posaconazole 100 mg tablet,delayed release",70748025807,,250,$267.18 ,$267.18 ,$80.15 ,$243.13 ,$187.03 ,$80.15 ,$173.67 ,$192.37 ,$243.13 ,$200.39 
Carle BroMenn Medical Center,8980250,potassium acetate 2 mEq/mL intravenous solution,409818301,,250,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980250,potassium acetate 2 mEq/mL intravenous solution,409818311,,250,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980250,potassium acetate 2 mEq/mL intravenous solution,51754200104,,250,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980250,potassium bicarbonate-citric acid 25 mEq effervescent tablet,51801000130,,250,$4.15 ,$4.15 ,$1.25 ,$3.78 ,$2.91 ,$1.25 ,$2.70 ,$2.99 ,$3.78 ,$3.11 
Carle BroMenn Medical Center,8980250,"potassium chloride ER 10 mEq tablet,extended release(part/cryst)",245531701,,250,$5.21 ,$5.21 ,$1.56 ,$4.74 ,$3.65 ,$1.56 ,$3.39 ,$3.75 ,$4.74 ,$3.91 
Carle BroMenn Medical Center,8980250,"potassium chloride ER 10 mEq tablet,extended release(part/cryst)",245531789,,250,$5.21 ,$5.21 ,$1.56 ,$4.74 ,$3.65 ,$1.56 ,$3.39 ,$3.75 ,$4.74 ,$3.91 
Carle BroMenn Medical Center,8980250,"potassium chloride ER 10 mEq tablet,extended release(part/cryst)",68084063201,,250,$5.69 ,$5.69 ,$1.71 ,$5.18 ,$3.98 ,$1.71 ,$3.70 ,$4.10 ,$5.18 ,$4.27 
Carle BroMenn Medical Center,8980250,"potassium chloride ER 10 mEq tablet,extended release(part/cryst)",68084063211,,250,$5.69 ,$5.69 ,$1.71 ,$5.18 ,$3.98 ,$1.71 ,$3.70 ,$4.10 ,$5.18 ,$4.27 
Carle BroMenn Medical Center,8980250,"potassium chloride ER 20 mEq tablet,extended release(part/cryst)",245531901,,250,$5.50 ,$5.50 ,$1.65 ,$5.01 ,$3.85 ,$1.65 ,$3.58 ,$3.96 ,$5.01 ,$4.13 
Carle BroMenn Medical Center,8980250,"potassium chloride ER 20 mEq tablet,extended release(part/cryst)",245531989,,250,$5.50 ,$5.50 ,$1.65 ,$5.01 ,$3.85 ,$1.65 ,$3.58 ,$3.96 ,$5.01 ,$4.13 
Carle BroMenn Medical Center,8980250,"potassium chloride ER 20 mEq tablet,extended release(part/cryst)",68084036009,,250,$6.05 ,$6.05 ,$1.82 ,$5.51 ,$4.24 ,$1.82 ,$3.93 ,$4.36 ,$5.51 ,$4.54 
Carle BroMenn Medical Center,8980250,"potassium chloride ER 20 mEq tablet,extended release(part/cryst)",68084036011,,250,$6.05 ,$6.05 ,$1.82 ,$5.51 ,$4.24 ,$1.82 ,$3.93 ,$4.36 ,$5.51 ,$4.54 
Carle BroMenn Medical Center,8980250,"potassium citrate ER 10 mEq (1,080 mg) tablet,extended release",591272901,,250,$13.70 ,$13.70 ,$4.11 ,$12.47 ,$9.59 ,$4.11 ,$8.91 ,$9.86 ,$12.47 ,$10.28 
Carle BroMenn Medical Center,8980250,"potassium citrate ER 10 mEq (1,080 mg) tablet,extended release",62559029101,,250,$13.77 ,$13.77 ,$4.13 ,$12.53 ,$9.64 ,$4.13 ,$8.95 ,$9.91 ,$12.53 ,$10.33 
Carle BroMenn Medical Center,8980250,potassium iodide 1 gram/mL oral solution,71740011230,,250,"$2,222.82 ","$2,222.82 ",$666.85 ,"$2,022.77 ","$1,555.97 ",$666.85 ,"$1,444.83 ","$1,600.43 ","$2,022.77 ","$1,667.12 "
Carle BroMenn Medical Center,8980250,potassium phosphates-mbasic and dibasic 3 mmol/mL intravenous solution,409729501,,250,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980250,potassium phosphates-mbasic and dibasic 3 mmol/mL intravenous solution,409729511,,250,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980250,"potassium, sodium phosphates 280 mg-160 mg-250 mg oral powder packet",60258000601,,250,$5.37 ,$5.37 ,$1.61 ,$4.89 ,$3.76 ,$1.61 ,$3.49 ,$3.87 ,$4.89 ,$4.03 
Carle BroMenn Medical Center,8980250,"potassium, sodium phosphates 280 mg-160 mg-250 mg oral powder packet",71351001099,,250,$4.48 ,$4.48 ,$1.34 ,$4.08 ,$3.14 ,$1.34 ,$2.91 ,$3.23 ,$4.08 ,$3.36 
Carle BroMenn Medical Center,8980250,povidone-iodine 10 % topical solution,52380190502,,250,$17.47 ,$17.47 ,$5.24 ,$15.90 ,$12.23 ,$5.24 ,$11.36 ,$12.58 ,$15.90 ,$13.10 
Carle BroMenn Medical Center,8980250,povidone-iodine 10 % topical solution,67618015005,,250,$17.47 ,$17.47 ,$5.24 ,$15.90 ,$12.23 ,$5.24 ,$11.36 ,$12.58 ,$15.90 ,$13.10 
Carle BroMenn Medical Center,8980250,povidone-iodine 5 % eye solution,65041130,,250,$93.95 ,$93.95 ,$28.19 ,$85.49 ,$65.77 ,$28.19 ,$61.07 ,$67.64 ,$85.49 ,$70.46 
Carle BroMenn Medical Center,8980250,pramipexole 0.125 mg tablet,13668009190,,250,$16.08 ,$16.08 ,$4.82 ,$14.63 ,$11.26 ,$4.82 ,$10.45 ,$11.58 ,$14.63 ,$12.06 
Carle BroMenn Medical Center,8980250,pramipexole 0.25 mg tablet,60687057001,,250,$4.01 ,$4.01 ,$1.20 ,$3.65 ,$2.81 ,$1.20 ,$2.61 ,$2.89 ,$3.65 ,$3.01 
Carle BroMenn Medical Center,8980250,pramipexole 0.25 mg tablet,60687057011,,250,$4.01 ,$4.01 ,$1.20 ,$3.65 ,$2.81 ,$1.20 ,$2.61 ,$2.89 ,$3.65 ,$3.01 
Carle BroMenn Medical Center,8980250,pramipexole 1 mg tablet,13668009490,,250,$16.08 ,$16.08 ,$4.82 ,$14.63 ,$11.26 ,$4.82 ,$10.45 ,$11.58 ,$14.63 ,$12.06 
Carle BroMenn Medical Center,8980250,prasugreL 10 mg tablet,2512301,,250,$72.41 ,$72.41 ,$21.72 ,$65.89 ,$50.69 ,$21.72 ,$47.07 ,$52.14 ,$65.89 ,$54.31 
Carle BroMenn Medical Center,8980250,prasugreL 10 mg tablet,2512377,,250,$72.41 ,$72.41 ,$21.72 ,$65.89 ,$50.69 ,$21.72 ,$47.07 ,$52.14 ,$65.89 ,$54.31 
Carle BroMenn Medical Center,8980250,prasugreL 10 mg tablet,16729027310,,250,$65.92 ,$65.92 ,$19.78 ,$59.99 ,$46.14 ,$19.78 ,$42.85 ,$47.46 ,$59.99 ,$49.44 
Carle BroMenn Medical Center,8980250,prasugreL 10 mg tablet,60505464303,,250,$65.92 ,$65.92 ,$19.78 ,$59.99 ,$46.14 ,$19.78 ,$42.85 ,$47.46 ,$59.99 ,$49.44 
Carle BroMenn Medical Center,8980250,prasugreL 10 mg tablet,65862083030,,250,$65.92 ,$65.92 ,$19.78 ,$59.99 ,$46.14 ,$19.78 ,$42.85 ,$47.46 ,$59.99 ,$49.44 
Carle BroMenn Medical Center,8980250,pravastatin 20 mg tablet,904589261,,250,$13.96 ,$13.96 ,$4.19 ,$12.70 ,$9.77 ,$4.19 ,$9.07 ,$10.05 ,$12.70 ,$10.47 
Carle BroMenn Medical Center,8980250,pravastatin 40 mg tablet,60505017009,,250,$24.67 ,$24.67 ,$7.40 ,$22.45 ,$17.27 ,$7.40 ,$16.04 ,$17.76 ,$22.45 ,$18.50 
Carle BroMenn Medical Center,8980250,pravastatin 40 mg tablet,60687019001,,250,$24.56 ,$24.56 ,$7.37 ,$22.35 ,$17.19 ,$7.37 ,$15.96 ,$17.68 ,$22.35 ,$18.42 
Carle BroMenn Medical Center,8980250,pravastatin 40 mg tablet,60687019011,,250,$24.56 ,$24.56 ,$7.37 ,$22.35 ,$17.19 ,$7.37 ,$15.96 ,$17.68 ,$22.35 ,$18.42 
Carle BroMenn Medical Center,8980250,prazosin 1 mg capsule,70954001910,,250,$6.50 ,$6.50 ,$1.95 ,$5.92 ,$4.55 ,$1.95 ,$4.23 ,$4.68 ,$5.92 ,$4.88 
Carle BroMenn Medical Center,8980250,prazosin 2 mg capsule,70954002010,,250,$8.49 ,$8.49 ,$2.55 ,$7.73 ,$5.94 ,$2.55 ,$5.52 ,$6.11 ,$7.73 ,$6.37 
Carle BroMenn Medical Center,8980250,prazosin 5 mg capsule,70954002110,,250,$12.50 ,$12.50 ,$3.75 ,$11.38 ,$8.75 ,$3.75 ,$8.13 ,$9.00 ,$11.38 ,$9.38 
Carle BroMenn Medical Center,8980250,"prednisoLONE acetate 1 % eye drops,suspension",60758011905,,250,$267.02 ,$267.02 ,$80.11 ,$242.99 ,$186.91 ,$80.11 ,$173.56 ,$192.25 ,$242.99 ,$200.27 
Carle BroMenn Medical Center,8980250,"prednisoLONE acetate 1 % eye drops,suspension",61314063705,,250,$17.47 ,$17.47 ,$5.24 ,$15.90 ,$12.23 ,$5.24 ,$11.36 ,$12.58 ,$15.90 ,$13.10 
Carle BroMenn Medical Center,8980250,pregabalin 100 mg capsule,60687050601,,250,$12.20 ,$12.20 ,$3.66 ,$11.10 ,$8.54 ,$3.66 ,$7.93 ,$8.78 ,$11.10 ,$9.15 
Carle BroMenn Medical Center,8980250,pregabalin 100 mg capsule,60687050611,,250,$12.20 ,$12.20 ,$3.66 ,$11.10 ,$8.54 ,$3.66 ,$7.93 ,$8.78 ,$11.10 ,$9.15 
Carle BroMenn Medical Center,8980250,pregabalin 25 mg capsule,60687047301,,250,$12.20 ,$12.20 ,$3.66 ,$11.10 ,$8.54 ,$3.66 ,$7.93 ,$8.78 ,$11.10 ,$9.15 
Carle BroMenn Medical Center,8980250,pregabalin 25 mg capsule,60687047311,,250,$12.20 ,$12.20 ,$3.66 ,$11.10 ,$8.54 ,$3.66 ,$7.93 ,$8.78 ,$11.10 ,$9.15 
Carle BroMenn Medical Center,8980250,pregabalin 50 mg capsule,60687048401,,250,$12.20 ,$12.20 ,$3.66 ,$11.10 ,$8.54 ,$3.66 ,$7.93 ,$8.78 ,$11.10 ,$9.15 
Carle BroMenn Medical Center,8980250,pregabalin 50 mg capsule,60687048411,,250,$12.20 ,$12.20 ,$3.66 ,$11.10 ,$8.54 ,$3.66 ,$7.93 ,$8.78 ,$11.10 ,$9.15 
Carle BroMenn Medical Center,8980250,pregabalin 75 mg capsule,31722061290,,250,$41.63 ,$41.63 ,$12.49 ,$37.88 ,$29.14 ,$12.49 ,$27.06 ,$29.97 ,$37.88 ,$31.22 
Carle BroMenn Medical Center,8980250,pregabalin 75 mg capsule,60687049501,,250,$12.20 ,$12.20 ,$3.66 ,$11.10 ,$8.54 ,$3.66 ,$7.93 ,$8.78 ,$11.10 ,$9.15 
Carle BroMenn Medical Center,8980250,pregabalin 75 mg capsule,60687049511,,250,$12.20 ,$12.20 ,$3.66 ,$11.10 ,$8.54 ,$3.66 ,$7.93 ,$8.78 ,$11.10 ,$9.15 
Carle BroMenn Medical Center,8980250,pregabalin 75 mg capsule,72205001390,,250,$39.98 ,$39.98 ,$11.99 ,$36.38 ,$27.99 ,$11.99 ,$25.99 ,$28.79 ,$36.38 ,$29.99 
Carle BroMenn Medical Center,8980250,prenatal vits no.130-ferrous fum 27 mg iron-folic acid 800 mcg tablet,904531360,,250,$2.68 ,$2.68 ,$0.80 ,$2.44 ,$1.88 ,$0.80 ,$1.74 ,$1.93 ,$2.44 ,$2.01 
Carle BroMenn Medical Center,8980250,primidone 50 mg tablet,527130101,,250,$4.67 ,$4.67 ,$1.40 ,$4.25 ,$3.27 ,$1.40 ,$3.04 ,$3.36 ,$4.25 ,$3.50 
Carle BroMenn Medical Center,8980250,primidone 50 mg tablet,68084020211,,250,$6.03 ,$6.03 ,$1.81 ,$5.49 ,$4.22 ,$1.81 ,$3.92 ,$4.34 ,$5.49 ,$4.52 
Carle BroMenn Medical Center,8980250,probenecid 500 mg tablet,591534701,,250,$6.91 ,$6.91 ,$2.07 ,$6.29 ,$4.84 ,$2.07 ,$4.49 ,$4.98 ,$6.29 ,$5.18 
Carle BroMenn Medical Center,8980250,prochlorperazine 25 mg rectal suppository,574722612,,250,$52.19 ,$52.19 ,$15.66 ,$47.49 ,$36.53 ,$15.66 ,$33.92 ,$37.58 ,$47.49 ,$39.14 
Carle BroMenn Medical Center,8980250,progesterone micronized 100 mg capsule,17478076610,,250,$12.12 ,$12.12 ,$3.64 ,$11.03 ,$8.48 ,$3.64 ,$7.88 ,$8.73 ,$11.03 ,$9.09 
Carle BroMenn Medical Center,8980250,promethazine 12.5 mg rectal suppository,713053606,,250,$70.12 ,$70.12 ,$21.04 ,$63.81 ,$49.08 ,$21.04 ,$45.58 ,$50.49 ,$63.81 ,$52.59 
Carle BroMenn Medical Center,8980250,promethazine 12.5 mg rectal suppository,713053612,,250,$70.12 ,$70.12 ,$21.04 ,$63.81 ,$49.08 ,$21.04 ,$45.58 ,$50.49 ,$63.81 ,$52.59 
Carle BroMenn Medical Center,8980250,promethazine 25 mg rectal suppository,713052606,,250,$70.12 ,$70.12 ,$21.04 ,$63.81 ,$49.08 ,$21.04 ,$45.58 ,$50.49 ,$63.81 ,$52.59 
Carle BroMenn Medical Center,8980250,promethazine 25 mg rectal suppository,713052612,,250,$70.12 ,$70.12 ,$21.04 ,$63.81 ,$49.08 ,$21.04 ,$45.58 ,$50.49 ,$63.81 ,$52.59 
Carle BroMenn Medical Center,8980250,promethazine 25 mg tablet,904646161,,250,$6.77 ,$6.77 ,$2.03 ,$6.16 ,$4.74 ,$2.03 ,$4.40 ,$4.87 ,$6.16 ,$5.08 
Carle BroMenn Medical Center,8980250,propafenone 150 mg tablet,62559023001,,250,$9.95 ,$9.95 ,$2.99 ,$9.05 ,$6.97 ,$2.99 ,$6.47 ,$7.16 ,$9.05 ,$7.46 
Carle BroMenn Medical Center,8980250,"propafenone ER 225 mg capsule,extended release 12 hr",68462040860,,250,$35.78 ,$35.78 ,$10.73 ,$32.56 ,$25.05 ,$10.73 ,$23.26 ,$25.76 ,$32.56 ,$26.84 
Carle BroMenn Medical Center,8980250,"propafenone ER 325 mg capsule,extended release 12 hr",68462040960,,250,$43.15 ,$43.15 ,$12.95 ,$39.27 ,$30.21 ,$12.95 ,$28.05 ,$31.07 ,$39.27 ,$32.36 
Carle BroMenn Medical Center,8980250,"propafenone ER 425 mg capsule,extended release 12 hr",68462041060,,250,$43.15 ,$43.15 ,$12.95 ,$39.27 ,$30.21 ,$12.95 ,$28.05 ,$31.07 ,$39.27 ,$32.36 
Carle BroMenn Medical Center,8980250,"propafenone ER 425 mg capsule,extended release 12 hr",69680013260,,250,$10.25 ,$10.25 ,$3.08 ,$9.33 ,$7.18 ,$3.08 ,$6.66 ,$7.38 ,$9.33 ,$7.69 
Carle BroMenn Medical Center,8980250,proparacaine 0.5 % eye drops,61314001601,,250,$17.47 ,$17.47 ,$5.24 ,$15.90 ,$12.23 ,$5.24 ,$11.36 ,$12.58 ,$15.90 ,$13.10 
Carle BroMenn Medical Center,8980250,Propofol 10 mg/mL IV,641619501,,250,$108.16 ,$108.16 ,$32.45 ,$98.43 ,$75.71 ,$32.45 ,$70.30 ,$77.88 ,$98.43 ,$81.12 
Carle BroMenn Medical Center,8980250,Propofol 10 mg/mL IV,63323026950,,250,$108.16 ,$108.16 ,$32.45 ,$98.43 ,$75.71 ,$32.45 ,$70.30 ,$77.88 ,$98.43 ,$81.12 
Carle BroMenn Medical Center,8980250,Propofol 10 mg/mL IV,63323026959,,250,$45.30 ,$45.30 ,$13.59 ,$41.22 ,$31.71 ,$13.59 ,$29.45 ,$32.62 ,$41.22 ,$33.98 
Carle BroMenn Medical Center,8980250,propranoloL 10 mg tablet,904655061,,250,$3.97 ,$3.97 ,$1.19 ,$3.61 ,$2.78 ,$1.19 ,$2.58 ,$2.86 ,$3.61 ,$2.98 
Carle BroMenn Medical Center,8980250,propranoloL 20 mg tablet,378018301,,250,$4.71 ,$4.71 ,$1.41 ,$4.29 ,$3.30 ,$1.41 ,$3.06 ,$3.39 ,$4.29 ,$3.53 
Carle BroMenn Medical Center,8980250,propranoloL 20 mg tablet,603548321,,250,$4.71 ,$4.71 ,$1.41 ,$4.29 ,$3.30 ,$1.41 ,$3.06 ,$3.39 ,$4.29 ,$3.53 
Carle BroMenn Medical Center,8980250,propranoloL 20 mg tablet,50268070115,,250,$5.16 ,$5.16 ,$1.55 ,$4.70 ,$3.61 ,$1.55 ,$3.35 ,$3.72 ,$4.70 ,$3.87 
Carle BroMenn Medical Center,8980250,propranoloL 40 mg tablet,378018401,,250,$5.67 ,$5.67 ,$1.70 ,$5.16 ,$3.97 ,$1.70 ,$3.69 ,$4.08 ,$5.16 ,$4.25 
Carle BroMenn Medical Center,8980250,propranoloL 40 mg tablet,50268070215,,250,$5.37 ,$5.37 ,$1.61 ,$4.89 ,$3.76 ,$1.61 ,$3.49 ,$3.87 ,$4.89 ,$4.03 
Carle BroMenn Medical Center,8980250,"propranoloL ER 60 mg capsule,24 hr,extended release",228277811,,250,$11.92 ,$11.92 ,$3.58 ,$10.85 ,$8.34 ,$3.58 ,$7.75 ,$8.58 ,$10.85 ,$8.94 
Carle BroMenn Medical Center,8980250,"propranoloL ER 80 mg capsule,24 hr,extended release",527411737,,250,$13.55 ,$13.55 ,$4.07 ,$12.33 ,$9.49 ,$4.07 ,$8.81 ,$9.76 ,$12.33 ,$10.16 
Carle BroMenn Medical Center,8980250,propylthiouraciL 50 mg tablet,228234810,,250,$6.52 ,$6.52 ,$1.96 ,$5.93 ,$4.56 ,$1.96 ,$4.24 ,$4.69 ,$5.93 ,$4.89 
Carle BroMenn Medical Center,8980250,"pseudoephedrine ER 120 mg tablet,extended release",904675415,,250,$0.66 ,$0.66 ,$0.20 ,$0.60 ,$0.46 ,$0.20 ,$0.43 ,$0.48 ,$0.60 ,$0.50 
Carle BroMenn Medical Center,8980250,pyrazinamide 500 mg tablet,61748001206,,250,$30.25 ,$30.25 ,$9.08 ,$27.53 ,$21.18 ,$9.08 ,$19.66 ,$21.78 ,$27.53 ,$22.69 
Carle BroMenn Medical Center,8980250,pyridostigmine bromide 5 mg/mL injection solution,781304095,,250,$226.88 ,$226.88 ,$68.06 ,$206.46 ,$158.82 ,$68.06 ,$147.47 ,$163.35 ,$206.46 ,$170.16 
Carle BroMenn Medical Center,8980250,pyridostigmine bromide 60 mg tablet,71930002890,,250,$8.03 ,$8.03 ,$2.41 ,$7.31 ,$5.62 ,$2.41 ,$5.22 ,$5.78 ,$7.31 ,$6.02 
Carle BroMenn Medical Center,8980250,pyridoxine (vitamin B6) 50 mg tablet,77333094010,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,QUEtiapine 200 mg tablet,904664161,,250,$7.64 ,$7.64 ,$2.29 ,$6.95 ,$5.35 ,$2.29 ,$4.97 ,$5.50 ,$6.95 ,$5.73 
Carle BroMenn Medical Center,8980250,QUEtiapine 25 mg tablet,904663861,,250,$3.95 ,$3.95 ,$1.19 ,$3.59 ,$2.77 ,$1.19 ,$2.57 ,$2.84 ,$3.59 ,$2.96 
Carle BroMenn Medical Center,8980250,QUEtiapine 25 mg tablet,50268063011,,250,$19.64 ,$19.64 ,$5.89 ,$17.87 ,$13.75 ,$5.89 ,$12.77 ,$14.14 ,$17.87 ,$14.73 
Carle BroMenn Medical Center,8980250,QUEtiapine 25 mg tablet,50268063015,,250,$19.64 ,$19.64 ,$5.89 ,$17.87 ,$13.75 ,$5.89 ,$12.77 ,$14.14 ,$17.87 ,$14.73 
Carle BroMenn Medical Center,8980250,QUEtiapine 25 mg tablet,60687032701,,250,$19.93 ,$19.93 ,$5.98 ,$18.14 ,$13.95 ,$5.98 ,$12.95 ,$14.35 ,$18.14 ,$14.95 
Carle BroMenn Medical Center,8980250,QUEtiapine 25 mg tablet,60687032711,,250,$19.93 ,$19.93 ,$5.98 ,$18.14 ,$13.95 ,$5.98 ,$12.95 ,$14.35 ,$18.14 ,$14.95 
Carle BroMenn Medical Center,8980250,raltegravir 100 mg chewable tablet,6047761,,250,$38.52 ,$38.52 ,$11.56 ,$35.05 ,$26.96 ,$11.56 ,$25.04 ,$27.73 ,$35.05 ,$28.89 
Carle BroMenn Medical Center,8980250,raltegravir 25 mg chewable tablet,6047361,,250,$11.96 ,$11.96 ,$3.59 ,$10.88 ,$8.37 ,$3.59 ,$7.77 ,$8.61 ,$10.88 ,$8.97 
Carle BroMenn Medical Center,8980250,raltegravir 400 mg tablet,6022761,,250,$129.61 ,$129.61 ,$38.88 ,$117.95 ,$90.73 ,$38.88 ,$84.25 ,$93.32 ,$117.95 ,$97.21 
Carle BroMenn Medical Center,8980250,"ranolazine ER 500 mg tablet,extended release,12 hr",27241012502,,250,$31.73 ,$31.73 ,$9.52 ,$28.87 ,$22.21 ,$9.52 ,$20.62 ,$22.85 ,$28.87 ,$23.80 
Carle BroMenn Medical Center,8980250,"ranolazine ER 500 mg tablet,extended release,12 hr",60687054921,,250,$10.16 ,$10.16 ,$3.05 ,$9.25 ,$7.11 ,$3.05 ,$6.60 ,$7.32 ,$9.25 ,$7.62 
Carle BroMenn Medical Center,8980250,rasagiline 0.5 mg tablet,23155074603,,250,$18.36 ,$18.36 ,$5.51 ,$16.71 ,$12.85 ,$5.51 ,$11.93 ,$13.22 ,$16.71 ,$13.77 
Carle BroMenn Medical Center,8980250,rasagiline 0.5 mg tablet,47781068330,,250,$95.55 ,$95.55 ,$28.67 ,$86.95 ,$66.89 ,$28.67 ,$62.11 ,$68.80 ,$86.95 ,$71.66 
Carle BroMenn Medical Center,8980250,remdesivir 100 mg intravenous powder for solution,61958290101,,250,"$2,971.91 ","$2,971.91 ",$891.57 ,"$2,704.44 ","$2,080.34 ",$891.57 ,"$1,931.74 ","$2,139.78 ","$2,704.44 ","$2,228.93 "
Carle BroMenn Medical Center,8980250,remifentaniL 1 mg intravenous solution,63323072301,,250,$398.24 ,$398.24 ,$119.47 ,$362.40 ,$278.77 ,$119.47 ,$258.86 ,$286.73 ,$362.40 ,$298.68 
Carle BroMenn Medical Center,8980250,remifentaniL 1 mg intravenous solution,63323072303,,250,$398.24 ,$398.24 ,$119.47 ,$362.40 ,$278.77 ,$119.47 ,$258.86 ,$286.73 ,$362.40 ,$298.68 
Carle BroMenn Medical Center,8980250,remifentaniL 2 mg intravenous solution,63323072401,,250,$662.34 ,$662.34 ,$198.70 ,$602.73 ,$463.64 ,$198.70 ,$430.52 ,$476.88 ,$602.73 ,$496.76 
Carle BroMenn Medical Center,8980250,repaglinide 0.5 mg tablet,574024001,,250,$3.45 ,$3.45 ,$1.04 ,$3.14 ,$2.42 ,$1.04 ,$2.24 ,$2.48 ,$3.14 ,$2.59 
Carle BroMenn Medical Center,8980250,rifAMPin 300 mg capsule,60687058601,,250,$8.68 ,$8.68 ,$2.60 ,$7.90 ,$6.08 ,$2.60 ,$5.64 ,$6.25 ,$7.90 ,$6.51 
Carle BroMenn Medical Center,8980250,rifAMPin 300 mg capsule,60687058611,,250,$8.68 ,$8.68 ,$2.60 ,$7.90 ,$6.08 ,$2.60 ,$5.64 ,$6.25 ,$7.90 ,$6.51 
Carle BroMenn Medical Center,8980250,rifAMPin 300 mg capsule,61748001830,,250,$11.73 ,$11.73 ,$3.52 ,$10.67 ,$8.21 ,$3.52 ,$7.62 ,$8.45 ,$10.67 ,$8.80 
Carle BroMenn Medical Center,8980250,rifAMPin 300 mg capsule,68084035801,,250,$8.68 ,$8.68 ,$2.60 ,$7.90 ,$6.08 ,$2.60 ,$5.64 ,$6.25 ,$7.90 ,$6.51 
Carle BroMenn Medical Center,8980250,rifAMPin 600 mg intravenous solution,67457044560,,250,$961.73 ,$961.73 ,$288.52 ,$875.17 ,$673.21 ,$288.52 ,$625.12 ,$692.45 ,$875.17 ,$721.30 
Carle BroMenn Medical Center,8980250,rifAXIMin 200 mg tablet,65649030103,,250,$109.42 ,$109.42 ,$32.83 ,$99.57 ,$76.59 ,$32.83 ,$71.12 ,$78.78 ,$99.57 ,$82.07 
Carle BroMenn Medical Center,8980250,rifAXIMin 550 mg tablet,65649030303,,250,$201.18 ,$201.18 ,$60.35 ,$183.07 ,$140.83 ,$60.35 ,$130.77 ,$144.85 ,$183.07 ,$150.89 
Carle BroMenn Medical Center,8980250,risperiDONE 0.5 mg tablet,904635861,,250,$20.65 ,$20.65 ,$6.20 ,$18.79 ,$14.46 ,$6.20 ,$13.42 ,$14.87 ,$18.79 ,$15.49 
Carle BroMenn Medical Center,8980250,risperiDONE 1 mg tablet,904635961,,250,$23.60 ,$23.60 ,$7.08 ,$21.48 ,$16.52 ,$7.08 ,$15.34 ,$16.99 ,$21.48 ,$17.70 
Carle BroMenn Medical Center,8980250,risperiDONE 1 mg tablet,68084027201,,250,$23.49 ,$23.49 ,$7.05 ,$21.38 ,$16.44 ,$7.05 ,$15.27 ,$16.91 ,$21.38 ,$17.62 
Carle BroMenn Medical Center,8980250,risperiDONE 1 mg tablet,68084027211,,250,$23.49 ,$23.49 ,$7.05 ,$21.38 ,$16.44 ,$7.05 ,$15.27 ,$16.91 ,$21.38 ,$17.62 
Carle BroMenn Medical Center,8980250,ritonavir 100 mg tablet,54040713,,250,$40.55 ,$40.55 ,$12.17 ,$36.90 ,$28.39 ,$12.17 ,$26.36 ,$29.20 ,$36.90 ,$30.41 
Carle BroMenn Medical Center,8980250,rivaroxaban 10 mg tablet,50458058001,,250,$77.10 ,$77.10 ,$23.13 ,$70.16 ,$53.97 ,$23.13 ,$50.12 ,$55.51 ,$70.16 ,$57.83 
Carle BroMenn Medical Center,8980250,rivaroxaban 10 mg tablet,50458058010,,250,$77.10 ,$77.10 ,$23.13 ,$70.16 ,$53.97 ,$23.13 ,$50.12 ,$55.51 ,$70.16 ,$57.83 
Carle BroMenn Medical Center,8980250,rivaroxaban 2.5 mg tablet,50458057710,,250,$42.63 ,$42.63 ,$12.79 ,$38.79 ,$29.84 ,$12.79 ,$27.71 ,$30.69 ,$38.79 ,$31.97 
Carle BroMenn Medical Center,8980250,rivastigmine 1.5 mg capsule,51991079306,,250,$24.05 ,$24.05 ,$7.22 ,$21.89 ,$16.84 ,$7.22 ,$15.63 ,$17.32 ,$21.89 ,$18.04 
Carle BroMenn Medical Center,8980250,rivastigmine 1.5 mg capsule,55111035260,,250,$22.11 ,$22.11 ,$6.63 ,$20.12 ,$15.48 ,$6.63 ,$14.37 ,$15.92 ,$20.12 ,$16.58 
Carle BroMenn Medical Center,8980250,rivastigmine 13.3 mg/24 hour transdermal patch,378907216,,250,$67.29 ,$67.29 ,$20.19 ,$61.23 ,$47.10 ,$20.19 ,$43.74 ,$48.45 ,$61.23 ,$50.47 
Carle BroMenn Medical Center,8980250,rivastigmine 13.3 mg/24 hour transdermal patch,781731331,,250,$67.29 ,$67.29 ,$20.19 ,$61.23 ,$47.10 ,$20.19 ,$43.74 ,$48.45 ,$61.23 ,$50.47 
Carle BroMenn Medical Center,8980250,rivastigmine 13.3 mg/24 hour transdermal patch,781731358,,250,$67.29 ,$67.29 ,$20.19 ,$61.23 ,$47.10 ,$20.19 ,$43.74 ,$48.45 ,$61.23 ,$50.47 
Carle BroMenn Medical Center,8980250,rivastigmine 4.6 mg/24 hour transdermal patch,781730431,,250,$67.29 ,$67.29 ,$20.19 ,$61.23 ,$47.10 ,$20.19 ,$43.74 ,$48.45 ,$61.23 ,$50.47 
Carle BroMenn Medical Center,8980250,rivastigmine 9.5 mg/24 hour transdermal patch,378907193,,250,$67.29 ,$67.29 ,$20.19 ,$61.23 ,$47.10 ,$20.19 ,$43.74 ,$48.45 ,$61.23 ,$50.47 
Carle BroMenn Medical Center,8980250,rocuronium 10 mg/mL intravenous solution,143925001,,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,rocuronium 10 mg/mL intravenous solution,143925010,,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,rocuronium 10 mg/mL intravenous solution,39822420001,,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,rocuronium 10 mg/mL intravenous solution,39822420002,,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,rocuronium 10 mg/mL intravenous solution,43066000710,,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,rocuronium 10 mg/mL intravenous solution,55150022505,,250,$64.51 ,$64.51 ,$19.35 ,$58.70 ,$45.16 ,$19.35 ,$41.93 ,$46.45 ,$58.70 ,$48.38 
Carle BroMenn Medical Center,8980250,roflumilast 500 mcg tablet,310009530,,250,$65.01 ,$65.01 ,$19.50 ,$59.16 ,$45.51 ,$19.50 ,$42.26 ,$46.81 ,$59.16 ,$48.76 
Carle BroMenn Medical Center,8980250,rOPINIRole 0.25 mg tablet,60687057701,,250,$5.41 ,$5.41 ,$1.62 ,$4.92 ,$3.79 ,$1.62 ,$3.52 ,$3.90 ,$4.92 ,$4.06 
Carle BroMenn Medical Center,8980250,rOPINIRole 0.25 mg tablet,60687057711,,250,$5.41 ,$5.41 ,$1.62 ,$4.92 ,$3.79 ,$1.62 ,$3.52 ,$3.90 ,$4.92 ,$4.06 
Carle BroMenn Medical Center,8980250,rOPINIRole 0.25 mg tablet,62332003031,,250,$13.98 ,$13.98 ,$4.19 ,$12.72 ,$9.79 ,$4.19 ,$9.09 ,$10.07 ,$12.72 ,$10.49 
Carle BroMenn Medical Center,8980250,rOPINIRole 0.5 mg tablet,62332003131,,250,$13.98 ,$13.98 ,$4.19 ,$12.72 ,$9.79 ,$4.19 ,$9.09 ,$10.07 ,$12.72 ,$10.49 
Carle BroMenn Medical Center,8980250,rOPINIRole 1 mg tablet,904637461,,250,$5.50 ,$5.50 ,$1.65 ,$5.01 ,$3.85 ,$1.65 ,$3.58 ,$3.96 ,$5.01 ,$4.13 
Carle BroMenn Medical Center,8980250,rOPINIRole 1 mg tablet,62332003231,,250,$13.98 ,$13.98 ,$4.19 ,$12.72 ,$9.79 ,$4.19 ,$9.09 ,$10.07 ,$12.72 ,$10.49 
Carle BroMenn Medical Center,8980250,rOPINIRole 2 mg tablet,62332003331,,250,$13.98 ,$13.98 ,$4.19 ,$12.72 ,$9.79 ,$4.19 ,$9.09 ,$10.07 ,$12.72 ,$10.49 
Carle BroMenn Medical Center,8980250,rosuvastatin 10 mg tablet,27808015601,,250,$39.46 ,$39.46 ,$11.84 ,$35.91 ,$27.62 ,$11.84 ,$25.65 ,$28.41 ,$35.91 ,$29.60 
Carle BroMenn Medical Center,8980250,rosuvastatin 20 mg tablet,27808015701,,250,$39.46 ,$39.46 ,$11.84 ,$35.91 ,$27.62 ,$11.84 ,$25.65 ,$28.41 ,$35.91 ,$29.60 
Carle BroMenn Medical Center,8980250,rosuvastatin 40 mg tablet,27808015801,,250,$39.46 ,$39.46 ,$11.84 ,$35.91 ,$27.62 ,$11.84 ,$25.65 ,$28.41 ,$35.91 ,$29.60 
Carle BroMenn Medical Center,8980250,sacubitriL 24 mg-valsartan 26 mg tablet,78065920,,250,$48.95 ,$48.95 ,$14.69 ,$44.54 ,$34.27 ,$14.69 ,$31.82 ,$35.24 ,$44.54 ,$36.71 
Carle BroMenn Medical Center,8980250,sacubitriL 49 mg-valsartan 51 mg tablet,78077720,,250,$48.95 ,$48.95 ,$14.69 ,$44.54 ,$34.27 ,$14.69 ,$31.82 ,$35.24 ,$44.54 ,$36.71 
Carle BroMenn Medical Center,8980250,sacubitriL 97 mg-valsartan 103 mg tablet,78069620,,250,$48.95 ,$48.95 ,$14.69 ,$44.54 ,$34.27 ,$14.69 ,$31.82 ,$35.24 ,$44.54 ,$36.71 
Carle BroMenn Medical Center,8980250,saliva substitute combo no.9 mouthwash,48582080220,,250,$24.19 ,$24.19 ,$7.26 ,$22.01 ,$16.93 ,$7.26 ,$15.72 ,$17.42 ,$22.01 ,$18.14 
Carle BroMenn Medical Center,8980250,scopolamine 1 mg over 3 days transdermal patch,10019055304,,250,$97.59 ,$97.59 ,$29.28 ,$88.81 ,$68.31 ,$29.28 ,$63.43 ,$70.26 ,$88.81 ,$73.19 
Carle BroMenn Medical Center,8980250,scopolamine 1 mg over 3 days transdermal patch,10019055390,,250,$97.59 ,$97.59 ,$29.28 ,$88.81 ,$68.31 ,$29.28 ,$63.43 ,$70.26 ,$88.81 ,$73.19 
Carle BroMenn Medical Center,8980250,scopolamine 1 mg over 3 days transdermal patch,45802058001,,250,$88.65 ,$88.65 ,$26.60 ,$80.67 ,$62.06 ,$26.60 ,$57.62 ,$63.83 ,$80.67 ,$66.49 
Carle BroMenn Medical Center,8980250,scopolamine 1 mg over 3 days transdermal patch,45802058046,,250,$88.65 ,$88.65 ,$26.60 ,$80.67 ,$62.06 ,$26.60 ,$57.62 ,$63.83 ,$80.67 ,$66.49 
Carle BroMenn Medical Center,8980250,selegiline 5 mg capsule,60505005501,,250,$13.06 ,$13.06 ,$3.92 ,$11.88 ,$9.14 ,$3.92 ,$8.49 ,$9.40 ,$11.88 ,$9.80 
Carle BroMenn Medical Center,8980250,sennosides 8.6 mg tablet,904652261,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,sennosides 8.6 mg tablet,904672559,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,sennosides 8.6 mg tablet,16103036308,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,sennosides 8.6 mg tablet,57896045101,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,sennosides 8.6 mg tablet,87701043173,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,sennosides 8.6 mg-docusate sodium 50 mg tablet,536124801,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,sennosides 8.6 mg-docusate sodium 50 mg tablet,904672361,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,sennosides 8.6 mg-docusate sodium 50 mg tablet,904672461,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,sennosides 8.6 mg-docusate sodium 50 mg tablet,57896045501,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,sennosides 8.6 mg-docusate sodium 50 mg tablet,60687062201,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,sennosides 8.6 mg-docusate sodium 50 mg tablet,60687062211,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,sertraline 100 mg tablet,60687025301,,250,$4.80 ,$4.80 ,$1.44 ,$4.37 ,$3.36 ,$1.44 ,$3.12 ,$3.46 ,$4.37 ,$3.60 
Carle BroMenn Medical Center,8980250,sertraline 100 mg tablet,60687025311,,250,$4.80 ,$4.80 ,$1.44 ,$4.37 ,$3.36 ,$1.44 ,$3.12 ,$3.46 ,$4.37 ,$3.60 
Carle BroMenn Medical Center,8980250,sertraline 25 mg tablet,60687023101,,250,$4.20 ,$4.20 ,$1.26 ,$3.82 ,$2.94 ,$1.26 ,$2.73 ,$3.02 ,$3.82 ,$3.15 
Carle BroMenn Medical Center,8980250,sertraline 25 mg tablet,60687023111,,250,$4.20 ,$4.20 ,$1.26 ,$3.82 ,$2.94 ,$1.26 ,$2.73 ,$3.02 ,$3.82 ,$3.15 
Carle BroMenn Medical Center,8980250,sertraline 50 mg tablet,16729021615,,250,$15.60 ,$15.60 ,$4.68 ,$14.20 ,$10.92 ,$4.68 ,$10.14 ,$11.23 ,$14.20 ,$11.70 
Carle BroMenn Medical Center,8980250,sertraline 50 mg tablet,60687024201,,250,$4.20 ,$4.20 ,$1.26 ,$3.82 ,$2.94 ,$1.26 ,$2.73 ,$3.02 ,$3.82 ,$3.15 
Carle BroMenn Medical Center,8980250,sertraline 50 mg tablet,60687024211,,250,$4.20 ,$4.20 ,$1.26 ,$3.82 ,$2.94 ,$1.26 ,$2.73 ,$3.02 ,$3.82 ,$3.15 
Carle BroMenn Medical Center,8980250,sertraline 50 mg tablet,65862001230,,250,$15.60 ,$15.60 ,$4.68 ,$14.20 ,$10.92 ,$4.68 ,$10.14 ,$11.23 ,$14.20 ,$11.70 
Carle BroMenn Medical Center,8980250,sevelamer carbonate 800 mg tablet,24979018646,,250,$12.66 ,$12.66 ,$3.80 ,$11.52 ,$8.86 ,$3.80 ,$8.23 ,$9.12 ,$11.52 ,$9.50 
Carle BroMenn Medical Center,8980250,sevelamer carbonate 800 mg tablet,65162005827,,250,$29.48 ,$29.48 ,$8.84 ,$26.83 ,$20.64 ,$8.84 ,$19.16 ,$21.23 ,$26.83 ,$22.11 
Carle BroMenn Medical Center,8980250,sevoflurane inhalation liquid,74445604,,250,"$1,116.96 ","$1,116.96 ",$335.09 ,"$1,016.43 ",$781.87 ,$335.09 ,$726.02 ,$804.21 ,"$1,016.43 ",$837.72 
Carle BroMenn Medical Center,8980250,sevoflurane inhalation liquid,66794001525,,250,$714.72 ,$714.72 ,$214.42 ,$650.40 ,$500.30 ,$214.42 ,$464.57 ,$514.60 ,$650.40 ,$536.04 
Carle BroMenn Medical Center,8980250,silver nitrate applicators 75 %-25 % topical stick,12870000101,,250,$5.88 ,$5.88 ,$1.76 ,$5.35 ,$4.12 ,$1.76 ,$3.82 ,$4.23 ,$5.35 ,$4.41 
Carle BroMenn Medical Center,8980250,silver sulfADIAZINE 1 % topical cream,43598021025,,250,$55.88 ,$55.88 ,$16.76 ,$50.85 ,$39.12 ,$16.76 ,$36.32 ,$40.23 ,$50.85 ,$41.91 
Carle BroMenn Medical Center,8980250,silver sulfADIAZINE 1 % topical cream,61570013125,,250,$55.88 ,$55.88 ,$16.76 ,$50.85 ,$39.12 ,$16.76 ,$36.32 ,$40.23 ,$50.85 ,$41.91 
Carle BroMenn Medical Center,8980250,"simethicone 40 mg/0.6 mL oral drops,suspension",536130375,,250,$17.47 ,$17.47 ,$5.24 ,$15.90 ,$12.23 ,$5.24 ,$11.36 ,$12.58 ,$15.90 ,$13.10 
Carle BroMenn Medical Center,8980250,"simethicone 40 mg/0.6 mL oral drops,suspension",536222075,,250,$44.53 ,$44.53 ,$13.36 ,$40.52 ,$31.17 ,$13.36 ,$28.94 ,$32.06 ,$40.52 ,$33.40 
Carle BroMenn Medical Center,8980250,"simethicone 40 mg/0.6 mL oral drops,suspension",904589430,,250,$23.93 ,$23.93 ,$7.18 ,$21.78 ,$16.75 ,$7.18 ,$15.55 ,$17.23 ,$21.78 ,$17.95 
Carle BroMenn Medical Center,8980250,"simethicone 40 mg/0.6 mL oral drops,suspension",46122054703,,250,$61.64 ,$61.64 ,$18.49 ,$56.09 ,$43.15 ,$18.49 ,$40.07 ,$44.38 ,$56.09 ,$46.23 
Carle BroMenn Medical Center,8980250,"simethicone 40 mg/0.6 mL oral drops,suspension",69618005951,,250,$20.79 ,$20.79 ,$6.24 ,$18.92 ,$14.55 ,$6.24 ,$13.51 ,$14.97 ,$18.92 ,$15.59 
Carle BroMenn Medical Center,8980250,simethicone 80 mg chewable tablet,904506860,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,simethicone 80 mg chewable tablet,24385011878,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,SITagliptin 100 mg tablet,6027701,,250,$77.70 ,$77.70 ,$23.31 ,$70.71 ,$54.39 ,$23.31 ,$50.51 ,$55.94 ,$70.71 ,$58.28 
Carle BroMenn Medical Center,8980250,SITagliptin 100 mg tablet,6027728,,250,$77.70 ,$77.70 ,$23.31 ,$70.71 ,$54.39 ,$23.31 ,$50.51 ,$55.94 ,$70.71 ,$58.28 
Carle BroMenn Medical Center,8980250,SITagliptin 25 mg tablet,6022128,,250,$77.70 ,$77.70 ,$23.31 ,$70.71 ,$54.39 ,$23.31 ,$50.51 ,$55.94 ,$70.71 ,$58.28 
Carle BroMenn Medical Center,8980250,SITagliptin 50 mg tablet,6011228,,250,$77.70 ,$77.70 ,$23.31 ,$70.71 ,$54.39 ,$23.31 ,$50.51 ,$55.94 ,$70.71 ,$58.28 
Carle BroMenn Medical Center,8980250,sodium acetate 2 mEq/mL intravenous solution,409729973,,250,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980250,sodium acetate 2 mEq/mL intravenous solution,409729983,,250,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980250,sodium bicarbonate (bulk) powder,395268594,,250,$51.92 ,$51.92 ,$15.58 ,$47.25 ,$36.34 ,$15.58 ,$33.75 ,$37.38 ,$47.25 ,$38.94 
Carle BroMenn Medical Center,8980250,sodium bicarbonate 1 mEq/mL (8.4 %) intravenous solution,409662514,,250,$103.04 ,$103.04 ,$30.91 ,$93.77 ,$72.13 ,$30.91 ,$66.98 ,$74.19 ,$93.77 ,$77.28 
Carle BroMenn Medical Center,8980250,sodium bicarbonate 1 mEq/mL (8.4 %) intravenous solution,409662522,,250,$103.04 ,$103.04 ,$30.91 ,$93.77 ,$72.13 ,$30.91 ,$66.98 ,$74.19 ,$93.77 ,$77.28 
Carle BroMenn Medical Center,8980250,sodium bicarbonate 1 mEq/mL (8.4 %) intravenous solution,51754500105,,250,$96.06 ,$96.06 ,$28.82 ,$87.41 ,$67.24 ,$28.82 ,$62.44 ,$69.16 ,$87.41 ,$72.05 
Carle BroMenn Medical Center,8980250,sodium bicarbonate 1 mEq/mL (8.4 %) intravenous solution,63323008950,,250,$174.05 ,$174.05 ,$52.22 ,$158.39 ,$121.84 ,$52.22 ,$113.13 ,$125.32 ,$158.39 ,$130.54 
Carle BroMenn Medical Center,8980250,sodium bicarbonate 10 mEq/10 mL (8.4 %) intravenous syringe,409490034,,250,$101.53 ,$101.53 ,$30.46 ,$92.39 ,$71.07 ,$30.46 ,$65.99 ,$73.10 ,$92.39 ,$76.15 
Carle BroMenn Medical Center,8980250,sodium bicarbonate 4.2 % (0.5 mEq/mL) intravenous syringe,409553434,,250,$78.89 ,$78.89 ,$23.67 ,$71.79 ,$55.22 ,$23.67 ,$51.28 ,$56.80 ,$71.79 ,$59.17 
Carle BroMenn Medical Center,8980250,sodium bicarbonate 4.2 % intravenous solution,409555502,,250,$110.49 ,$110.49 ,$33.15 ,$100.55 ,$77.34 ,$33.15 ,$71.82 ,$79.55 ,$100.55 ,$82.87 
Carle BroMenn Medical Center,8980250,sodium bicarbonate 650 mg tablet,77333083110,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,sodium bicarbonate 650 mg tablet,77333083125,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,sodium bicarbonate 8.4 % (1 mEq/mL) intravenous syringe,409663734,,250,$79.06 ,$79.06 ,$23.72 ,$71.94 ,$55.34 ,$23.72 ,$51.39 ,$56.92 ,$71.94 ,$59.30 
Carle BroMenn Medical Center,8980250,sodium bicarbonate 8.4 % (1 mEq/mL) intravenous syringe,76329335201,,250,$97.68 ,$97.68 ,$29.30 ,$88.89 ,$68.38 ,$29.30 ,$63.49 ,$70.33 ,$88.89 ,$73.26 
Carle BroMenn Medical Center,8980250,sodium chloride 0.65 % nasal spray aerosol,904386575,,250,$17.47 ,$17.47 ,$5.24 ,$15.90 ,$12.23 ,$5.24 ,$11.36 ,$12.58 ,$15.90 ,$13.10 
Carle BroMenn Medical Center,8980250,sodium chloride 0.9 % for nebulization,378698789,,250,$6.73 ,$6.73 ,$2.02 ,$6.12 ,$4.71 ,$2.02 ,$4.37 ,$4.85 ,$6.12 ,$5.05 
Carle BroMenn Medical Center,8980250,sodium chloride 0.9 % for nebulization,487930133,,250,$3.03 ,$3.03 ,$0.91 ,$2.76 ,$2.12 ,$0.91 ,$1.97 ,$2.18 ,$2.76 ,$2.27 
Carle BroMenn Medical Center,8980250,sodium chloride 1 gram tablet,223176002,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,sodium chloride 1 gram tablet,69367022001,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,sodium chloride 4 mEq/mL intravenous solution,409114102,,250,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980250,sodium chloride 4 mEq/mL intravenous solution,63323008861,,250,$117.01 ,$117.01 ,$35.10 ,$106.48 ,$81.91 ,$35.10 ,$76.06 ,$84.25 ,$106.48 ,$87.76 
Carle BroMenn Medical Center,8980250,sodium chloride 4 mEq/mL intravenous solution,63323009301,,250,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980250,sodium chloride 4 mEq/mL intravenous solution,63323009330,,250,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980250,sodium citrate 4 gram/100 mL (4 %) solution,942950410,,250,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980250,sodium citrate-citric acid 500 mg-334 mg/5 mL oral solution,121059530,,250,$12.40 ,$12.40 ,$3.72 ,$11.28 ,$8.68 ,$3.72 ,$8.06 ,$8.93 ,$11.28 ,$9.30 
Carle BroMenn Medical Center,8980250,sodium hyaluronate 10 mg/mL intraocular syringe,8065183055,,250,$755.96 ,$755.96 ,$226.79 ,$687.92 ,$529.17 ,$226.79 ,$491.37 ,$544.29 ,$687.92 ,$566.97 
Carle BroMenn Medical Center,8980250,sodium hyaluronate 10 mg/mL(mw 2.4-3.6 million)intra-articular syringe,55566410001,J7323,250,"$1,549.84 ","$1,549.84 ",$464.95 ,"$1,410.35 ","$1,084.89 ",$464.95 ,"$1,007.40 ","$1,115.88 ","$1,410.35 ","$1,162.38 "
Carle BroMenn Medical Center,8980250,sodium nitrite 30 mg/mL intravenous solution,60267031110,,250,$626.14 ,$626.14 ,$187.84 ,$569.79 ,$438.30 ,$187.84 ,$406.99 ,$450.82 ,$569.79 ,$469.61 
Carle BroMenn Medical Center,8980250,sodium nitroprusside 25 mg/mL intravenous solution,14789001202,J3490,250,$511.43 ,$511.43 ,$153.43 ,$465.40 ,$358.00 ,$153.43 ,$332.43 ,$368.23 ,$465.40 ,$383.57 
Carle BroMenn Medical Center,8980250,sodium nitroprusside 25 mg/mL intravenous solution,70069026101,J3490,250,$180.45 ,$180.45 ,$54.14 ,$164.21 ,$126.32 ,$54.14 ,$117.29 ,$129.92 ,$164.21 ,$135.34 
Carle BroMenn Medical Center,8980250,sodium phosphate 3 mmol/mL intravenous solution,409739172,,250,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980250,sodium phosphate 3 mmol/mL intravenous solution,409739182,,250,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980250,sodium phosphate 3 mmol/mL intravenous solution,63323017005,,250,$147.68 ,$147.68 ,$44.30 ,$134.39 ,$103.38 ,$44.30 ,$95.99 ,$106.33 ,$134.39 ,$110.76 
Carle BroMenn Medical Center,8980250,sodium phosphate 3 mmol/mL intravenous solution,63323017015,,250,$111.80 ,$111.80 ,$33.54 ,$101.74 ,$78.26 ,$33.54 ,$72.67 ,$80.50 ,$101.74 ,$83.85 
Carle BroMenn Medical Center,8980250,sodium phosphates 19 gram-7 gram/118 mL enema,132020140,,250,$2.42 ,$2.42 ,$0.73 ,$2.20 ,$1.69 ,$0.73 ,$1.57 ,$1.74 ,$2.20 ,$1.82 
Carle BroMenn Medical Center,8980250,sodium polystyrene sulfonate 15 gram-sorbitoL 20 gram/60 mL oral susp,46287000660,,250,$113.61 ,$113.61 ,$34.08 ,$103.39 ,$79.53 ,$34.08 ,$73.85 ,$81.80 ,$103.39 ,$85.21 
Carle BroMenn Medical Center,8980250,sodium polystyrene sulfonate oral powder,10702003615,,250,$65.31 ,$65.31 ,$19.59 ,$59.43 ,$45.72 ,$19.59 ,$42.45 ,$47.02 ,$59.43 ,$48.98 
Carle BroMenn Medical Center,8980250,sodium tetradecyl sulfate 1 % (10 mg/mL) intravenous solution,67457016202,,250,$474.21 ,$474.21 ,$142.26 ,$431.53 ,$331.95 ,$142.26 ,$308.24 ,$341.43 ,$431.53 ,$355.66 
Carle BroMenn Medical Center,8980250,sodium tetradecyl sulfate 3 % (30 mg/mL) intravenous solution,24201020101,,250,$467.91 ,$467.91 ,$140.37 ,$425.80 ,$327.54 ,$140.37 ,$304.14 ,$336.90 ,$425.80 ,$350.93 
Carle BroMenn Medical Center,8980250,sodium tetradecyl sulfate 3 % (30 mg/mL) intravenous solution,24201020105,,250,$467.91 ,$467.91 ,$140.37 ,$425.80 ,$327.54 ,$140.37 ,$304.14 ,$336.90 ,$425.80 ,$350.93 
Carle BroMenn Medical Center,8980250,sodium tetradecyl sulfate 3 % (30 mg/mL) intravenous solution,67457016302,,250,$474.21 ,$474.21 ,$142.26 ,$431.53 ,$331.95 ,$142.26 ,$308.24 ,$341.43 ,$431.53 ,$355.66 
Carle BroMenn Medical Center,8980250,solifenacin 5 mg tablet,67877052730,,250,$54.02 ,$54.02 ,$16.21 ,$49.16 ,$37.81 ,$16.21 ,$35.11 ,$38.89 ,$49.16 ,$40.52 
Carle BroMenn Medical Center,8980250,solifenacin 5 mg tablet,72205002030,,250,$56.86 ,$56.86 ,$17.06 ,$51.74 ,$39.80 ,$17.06 ,$36.96 ,$40.94 ,$51.74 ,$42.65 
Carle BroMenn Medical Center,8980250,sorbitoL 70 % solution,46287050001,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,sorbitoL 70 % solution,46287050030,,250,$4.12 ,$4.12 ,$1.24 ,$3.75 ,$2.88 ,$1.24 ,$2.68 ,$2.97 ,$3.75 ,$3.09 
Carle BroMenn Medical Center,8980250,sotaloL 120 mg tablet,76385011501,,250,$18.26 ,$18.26 ,$5.48 ,$16.62 ,$12.78 ,$5.48 ,$11.87 ,$13.15 ,$16.62 ,$13.70 
Carle BroMenn Medical Center,8980250,sotaloL 80 mg tablet,60505008000,,250,$14.27 ,$14.27 ,$4.28 ,$12.99 ,$9.99 ,$4.28 ,$9.28 ,$10.27 ,$12.99 ,$10.70 
Carle BroMenn Medical Center,8980250,spironolactone 25 mg tablet,51079010301,,250,$4.32 ,$4.32 ,$1.30 ,$3.93 ,$3.02 ,$1.30 ,$2.81 ,$3.11 ,$3.93 ,$3.24 
Carle BroMenn Medical Center,8980250,spironolactone 25 mg tablet,51079010320,,250,$4.32 ,$4.32 ,$1.30 ,$3.93 ,$3.02 ,$1.30 ,$2.81 ,$3.11 ,$3.93 ,$3.24 
Carle BroMenn Medical Center,8980250,spironolactone 25 mg tablet,60687046501,,250,$3.39 ,$3.39 ,$1.02 ,$3.08 ,$2.37 ,$1.02 ,$2.20 ,$2.44 ,$3.08 ,$2.54 
Carle BroMenn Medical Center,8980250,spironolactone 25 mg tablet,60687046511,,250,$3.39 ,$3.39 ,$1.02 ,$3.08 ,$2.37 ,$1.02 ,$2.20 ,$2.44 ,$3.08 ,$2.54 
Carle BroMenn Medical Center,8980250,spironolactone 25 mg tablet,63739054410,,250,$4.32 ,$4.32 ,$1.30 ,$3.93 ,$3.02 ,$1.30 ,$2.81 ,$3.11 ,$3.93 ,$3.24 
Carle BroMenn Medical Center,8980250,sterile talc 3 gram intrapleural aerosol powder,62327033343,,250,$664.79 ,$664.79 ,$199.44 ,$604.96 ,$465.35 ,$199.44 ,$432.11 ,$478.65 ,$604.96 ,$498.59 
Carle BroMenn Medical Center,8980250,"succinylcholine (PF) 20 mg/mL in sodium chlor,iso injection solution",69374030005,,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,"succinylcholine (PF) 20 mg/mL in sodium chlor,iso injection solution,succinylcholine(PF)100 mg/5 mL (20 mg/mL)-NaCl,iso intravenous syringe",69374030005,,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,"succinylcholine (PF) 20 mg/mL in sodium chlor,iso injection solution,succinylcholine(PF)100 mg/5 mL (20 mg/mL)-NaCl,iso intravenous syringe",69374092005,,250,$90.70 ,$90.70 ,$27.21 ,$82.54 ,$63.49 ,$27.21 ,$58.96 ,$65.30 ,$82.54 ,$68.03 
Carle BroMenn Medical Center,8980250,"succinylcholine(PF)100 mg/5 mL (20 mg/mL)-NaCl,iso intravenous syringe",69374092005,,250,$90.70 ,$90.70 ,$27.21 ,$82.54 ,$63.49 ,$27.21 ,$58.96 ,$65.30 ,$82.54 ,$68.03 
Carle BroMenn Medical Center,8980250,sucralfate 100 mg/mL oral suspension,50268073211,,250,$59.09 ,$59.09 ,$17.73 ,$53.77 ,$41.36 ,$17.73 ,$38.41 ,$42.54 ,$53.77 ,$44.32 
Carle BroMenn Medical Center,8980250,sucralfate 100 mg/mL oral suspension,50268073212,,250,$59.09 ,$59.09 ,$17.73 ,$53.77 ,$41.36 ,$17.73 ,$38.41 ,$42.54 ,$53.77 ,$44.32 
Carle BroMenn Medical Center,8980250,sucralfate 100 mg/mL oral suspension,58914017014,,250,$45.34 ,$45.34 ,$13.60 ,$41.26 ,$31.74 ,$13.60 ,$29.47 ,$32.64 ,$41.26 ,$34.01 
Carle BroMenn Medical Center,8980250,sucralfate 100 mg/mL oral suspension,66689079001,,250,$67.62 ,$67.62 ,$20.29 ,$61.53 ,$47.33 ,$20.29 ,$43.95 ,$48.69 ,$61.53 ,$50.72 
Carle BroMenn Medical Center,8980250,sucralfate 100 mg/mL oral suspension,66689079050,,250,$67.62 ,$67.62 ,$20.29 ,$61.53 ,$47.33 ,$20.29 ,$43.95 ,$48.69 ,$61.53 ,$50.72 
Carle BroMenn Medical Center,8980250,sugammadex 100 mg/mL intravenous solution,6542302,,250,$652.11 ,$652.11 ,$195.63 ,$593.42 ,$456.48 ,$195.63 ,$423.87 ,$469.52 ,$593.42 ,$489.08 
Carle BroMenn Medical Center,8980250,sugammadex 100 mg/mL intravenous solution,6542312,,250,$652.11 ,$652.11 ,$195.63 ,$593.42 ,$456.48 ,$195.63 ,$423.87 ,$469.52 ,$593.42 ,$489.08 
Carle BroMenn Medical Center,8980250,sugammadex 100 mg/mL intravenous solution,6542505,,250,"$1,163.28 ","$1,163.28 ",$348.98 ,"$1,058.58 ",$814.30 ,$348.98 ,$756.13 ,$837.56 ,"$1,058.58 ",$872.46 
Carle BroMenn Medical Center,8980250,sugammadex 100 mg/mL intravenous solution,6542515,,250,"$1,163.28 ","$1,163.28 ",$348.98 ,"$1,058.58 ",$814.30 ,$348.98 ,$756.13 ,$837.56 ,"$1,058.58 ",$872.46 
Carle BroMenn Medical Center,8980250,sulfacetamide sodium 10 % eye drops,61314070101,,250,$280.30 ,$280.30 ,$84.09 ,$255.07 ,$196.21 ,$84.09 ,$182.20 ,$201.82 ,$255.07 ,$210.23 
Carle BroMenn Medical Center,8980250,sulfamethoxazole 200 mg-trimethoprim 40 mg/5 mL oral suspension,121085320,,250,$45.11 ,$45.11 ,$13.53 ,$41.05 ,$31.58 ,$13.53 ,$29.32 ,$32.48 ,$41.05 ,$33.83 
Carle BroMenn Medical Center,8980250,sulfamethoxazole 200 mg-trimethoprim 40 mg/5 mL oral suspension,121085416,,250,$20.67 ,$20.67 ,$6.20 ,$18.81 ,$14.47 ,$6.20 ,$13.44 ,$14.88 ,$18.81 ,$15.50 
Carle BroMenn Medical Center,8980250,sulfamethoxazole 200 mg-trimethoprim 40 mg/5 mL oral suspension,50383082316,,250,$33.12 ,$33.12 ,$9.94 ,$30.14 ,$23.18 ,$9.94 ,$21.53 ,$23.85 ,$30.14 ,$24.84 
Carle BroMenn Medical Center,8980250,sulfamethoxazole 400 mg-trimethoprim 80 mg/5 mL intravenous solution,703951403,,250,$122.54 ,$122.54 ,$36.76 ,$111.51 ,$85.78 ,$36.76 ,$79.65 ,$88.23 ,$111.51 ,$91.91 
Carle BroMenn Medical Center,8980250,sulfamethoxazole 400 mg-trimethoprim 80 mg/5 mL intravenous solution,70069036201,,250,$123.47 ,$123.47 ,$37.04 ,$112.36 ,$86.43 ,$37.04 ,$80.26 ,$88.90 ,$112.36 ,$92.60 
Carle BroMenn Medical Center,8980250,sulfamethoxazole 400 mg-trimethoprim 80 mg/5 mL intravenous solution,70069036210,,250,$123.47 ,$123.47 ,$37.04 ,$112.36 ,$86.43 ,$37.04 ,$80.26 ,$88.90 ,$112.36 ,$92.60 
Carle BroMenn Medical Center,8980250,sulfamethoxazole 800 mg-trimethoprim 160 mg tablet,904272561,,250,$4.07 ,$4.07 ,$1.22 ,$3.70 ,$2.85 ,$1.22 ,$2.65 ,$2.93 ,$3.70 ,$3.05 
Carle BroMenn Medical Center,8980250,sulfamethoxazole 800 mg-trimethoprim 160 mg tablet,60687053101,,250,$3.70 ,$3.70 ,$1.11 ,$3.37 ,$2.59 ,$1.11 ,$2.41 ,$2.66 ,$3.37 ,$2.78 
Carle BroMenn Medical Center,8980250,sulfamethoxazole 800 mg-trimethoprim 160 mg tablet,60687053111,,250,$3.70 ,$3.70 ,$1.11 ,$3.37 ,$2.59 ,$1.11 ,$2.41 ,$2.66 ,$3.37 ,$2.78 
Carle BroMenn Medical Center,8980250,sulfaSALAzine 500 mg tablet,591079601,,250,$3.52 ,$3.52 ,$1.06 ,$3.20 ,$2.46 ,$1.06 ,$2.29 ,$2.53 ,$3.20 ,$2.64 
Carle BroMenn Medical Center,8980250,sulfaSALAzine 500 mg tablet,59762500005,,250,$3.46 ,$3.46 ,$1.04 ,$3.15 ,$2.42 ,$1.04 ,$2.25 ,$2.49 ,$3.15 ,$2.60 
Carle BroMenn Medical Center,8980250,SUMAtriptan 50 mg tablet,65862014736,,250,$96.14 ,$96.14 ,$28.84 ,$87.49 ,$67.30 ,$28.84 ,$62.49 ,$69.22 ,$87.49 ,$72.11 
Carle BroMenn Medical Center,8980250,surgical lubricant jelly topical,281020502,,250,$22.94 ,$22.94 ,$6.88 ,$20.88 ,$16.06 ,$6.88 ,$14.91 ,$16.52 ,$20.88 ,$17.21 
Carle BroMenn Medical Center,8980250,tamsulosin 0.4 mg capsule,904640161,,250,$21.94 ,$21.94 ,$6.58 ,$19.97 ,$15.36 ,$6.58 ,$14.26 ,$15.80 ,$19.97 ,$16.46 
Carle BroMenn Medical Center,8980250,tamsulosin 0.4 mg capsule,50268074011,,250,$4.54 ,$4.54 ,$1.36 ,$4.13 ,$3.18 ,$1.36 ,$2.95 ,$3.27 ,$4.13 ,$3.41 
Carle BroMenn Medical Center,8980250,tamsulosin 0.4 mg capsule,50268074015,,250,$4.54 ,$4.54 ,$1.36 ,$4.13 ,$3.18 ,$1.36 ,$2.95 ,$3.27 ,$4.13 ,$3.41 
Carle BroMenn Medical Center,8980250,terbinafine HCL 1 % topical cream,363208001,,250,$17.47 ,$17.47 ,$5.24 ,$15.90 ,$12.23 ,$5.24 ,$11.36 ,$12.58 ,$15.90 ,$13.10 
Carle BroMenn Medical Center,8980250,terbinafine HCL 1 % topical cream,49348079072,,250,$77.88 ,$77.88 ,$23.36 ,$70.87 ,$54.52 ,$23.36 ,$50.62 ,$56.07 ,$70.87 ,$58.41 
Carle BroMenn Medical Center,8980250,terbinafine HCL 1 % topical cream,51672208002,,250,$73.51 ,$73.51 ,$22.05 ,$66.89 ,$51.46 ,$22.05 ,$47.78 ,$52.93 ,$66.89 ,$55.13 
Carle BroMenn Medical Center,8980250,terbutaline 2.5 mg tablet,115261101,,250,$27.20 ,$27.20 ,$8.16 ,$24.75 ,$19.04 ,$8.16 ,$17.68 ,$19.58 ,$24.75 ,$20.40 
Carle BroMenn Medical Center,8980250,terbutaline 2.5 mg tablet,62559072101,,250,$27.20 ,$27.20 ,$8.16 ,$24.75 ,$19.04 ,$8.16 ,$17.68 ,$19.58 ,$24.75 ,$20.40 
Carle BroMenn Medical Center,8980250,tetracaine HCl (PF) 0.5 % eye drops,65074114,,250,$77.46 ,$77.46 ,$23.24 ,$70.49 ,$54.22 ,$23.24 ,$50.35 ,$55.77 ,$70.49 ,$58.10 
Carle BroMenn Medical Center,8980250,tetracaine HCl (PF) 1 % (10 mg/mL) injection solution,17478004532,,250,$462.00 ,$462.00 ,$138.60 ,$420.42 ,$323.40 ,$138.60 ,$300.30 ,$332.64 ,$420.42 ,$346.50 
Carle BroMenn Medical Center,8980250,tetrahydrozoline 0.05 % eye drops,536121794,,250,$17.47 ,$17.47 ,$5.24 ,$15.90 ,$12.23 ,$5.24 ,$11.36 ,$12.58 ,$15.90 ,$13.10 
Carle BroMenn Medical Center,8980250,theophylline 80 mg/15 mL oral solution,27808003301,,250,$17.84 ,$17.84 ,$5.35 ,$16.23 ,$12.49 ,$5.35 ,$11.60 ,$12.84 ,$16.23 ,$13.38 
Carle BroMenn Medical Center,8980250,thiamine mononitrate (vitamin B1) 100 mg tablet,48433010801,,250,$3.08 ,$3.08 ,$0.92 ,$2.80 ,$2.16 ,$0.92 ,$2.00 ,$2.22 ,$2.80 ,$2.31 
Carle BroMenn Medical Center,8980250,thiamine mononitrate (vitamin B1) 100 mg tablet,50268085111,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,thiamine mononitrate (vitamin B1) 100 mg tablet,50268085115,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,thiamine mononitrate (vitamin B1) 100 mg tablet,54629005701,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,thiamine mononitrate (vitamin B1) 100 mg tablet,77333093425,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,"thrombin (bovine) 5,000 unit topical solution",60793021505,,250,$311.11 ,$311.11 ,$93.33 ,$283.11 ,$217.78 ,$93.33 ,$202.22 ,$224.00 ,$283.11 ,$233.33 
Carle BroMenn Medical Center,8980250,"thrombin (bovine) 5,000 unit topical solution",60793031501,,250,$311.11 ,$311.11 ,$93.33 ,$283.11 ,$217.78 ,$93.33 ,$202.22 ,$224.00 ,$283.11 ,$233.33 
Carle BroMenn Medical Center,8980250,"thrombin (bovine) 5,000 unit topical spray syringe",60793070505,,250,$317.20 ,$317.20 ,$95.16 ,$288.65 ,$222.04 ,$95.16 ,$206.18 ,$228.38 ,$288.65 ,$237.90 
Carle BroMenn Medical Center,8980250,thyroid (pork) 60 mg tablet,42192033001,,250,$7.17 ,$7.17 ,$2.15 ,$6.52 ,$5.02 ,$2.15 ,$4.66 ,$5.16 ,$6.52 ,$5.38 
Carle BroMenn Medical Center,8980250,ticagrelor 90 mg tablet,186077739,,250,$37.05 ,$37.05 ,$11.12 ,$33.72 ,$25.94 ,$11.12 ,$24.08 ,$26.68 ,$33.72 ,$27.79 
Carle BroMenn Medical Center,8980250,timoloL maleate 0.25 % eye drops,60758080205,,250,$24.34 ,$24.34 ,$7.30 ,$22.15 ,$17.04 ,$7.30 ,$15.82 ,$17.52 ,$22.15 ,$18.26 
Carle BroMenn Medical Center,8980250,timoloL maleate 0.25 % eye drops,61314022605,,250,$90.80 ,$90.80 ,$27.24 ,$82.63 ,$63.56 ,$27.24 ,$59.02 ,$65.38 ,$82.63 ,$68.10 
Carle BroMenn Medical Center,8980250,timoloL maleate 0.5 % eye drops,17478028810,,250,$100.19 ,$100.19 ,$30.06 ,$91.17 ,$70.13 ,$30.06 ,$65.12 ,$72.14 ,$91.17 ,$75.14 
Carle BroMenn Medical Center,8980250,timoloL maleate 0.5 % eye drops,60758080105,,250,$41.68 ,$41.68 ,$12.50 ,$37.93 ,$29.18 ,$12.50 ,$27.09 ,$30.01 ,$37.93 ,$31.26 
Carle BroMenn Medical Center,8980250,tiotropium bromide 18 mcg capsule with inhalation device,597007575,,250,$634.23 ,$634.23 ,$190.27 ,$577.15 ,$443.96 ,$190.27 ,$412.25 ,$456.65 ,$577.15 ,$475.67 
Carle BroMenn Medical Center,8980250,tiotropium bromide 2.5 mcg/actuation mist for inhalation,597010051,,250,$440.37 ,$440.37 ,$132.11 ,$400.74 ,$308.26 ,$132.11 ,$286.24 ,$317.07 ,$400.74 ,$330.28 
Carle BroMenn Medical Center,8980250,tiZANidine 4 mg tablet,68084064501,,250,$9.39 ,$9.39 ,$2.82 ,$8.54 ,$6.57 ,$2.82 ,$6.10 ,$6.76 ,$8.54 ,$7.04 
Carle BroMenn Medical Center,8980250,tiZANidine 4 mg tablet,68084064511,,250,$9.39 ,$9.39 ,$2.82 ,$8.54 ,$6.57 ,$2.82 ,$6.10 ,$6.76 ,$8.54 ,$7.04 
Carle BroMenn Medical Center,8980250,tobramycin 0.3 % eye drops,70069013101,,250,$17.47 ,$17.47 ,$5.24 ,$15.90 ,$12.23 ,$5.24 ,$11.36 ,$12.58 ,$15.90 ,$13.10 
Carle BroMenn Medical Center,8980250,"tobramycin 0.3 %-dexamethasone 0.1 % eye drops,suspension",24208029505,,250,$588.00 ,$588.00 ,$176.40 ,$535.08 ,$411.60 ,$176.40 ,$382.20 ,$423.36 ,$535.08 ,$441.00 
Carle BroMenn Medical Center,8980250,"tobramycin 0.3 %-dexamethasone 0.1 % eye drops,suspension",61314064705,,250,$698.72 ,$698.72 ,$209.62 ,$635.84 ,$489.10 ,$209.62 ,$454.17 ,$503.08 ,$635.84 ,$524.04 
Carle BroMenn Medical Center,8980250,tolterodine 1 mg tablet,59762017006,,250,$17.75 ,$17.75 ,$5.33 ,$16.15 ,$12.43 ,$5.33 ,$11.54 ,$12.78 ,$16.15 ,$13.31 
Carle BroMenn Medical Center,8980250,tolterodine 2 mg tablet,33342009809,,250,$18.16 ,$18.16 ,$5.45 ,$16.53 ,$12.71 ,$5.45 ,$11.80 ,$13.08 ,$16.53 ,$13.62 
Carle BroMenn Medical Center,8980250,tolterodine 2 mg tablet,59762080002,,250,$18.16 ,$18.16 ,$5.45 ,$16.53 ,$12.71 ,$5.45 ,$11.80 ,$13.08 ,$16.53 ,$13.62 
Carle BroMenn Medical Center,8980250,"tolterodine ER 2 mg capsule,extended release 24 hr",43975032203,,250,$36.28 ,$36.28 ,$10.88 ,$33.01 ,$25.40 ,$10.88 ,$23.58 ,$26.12 ,$33.01 ,$27.21 
Carle BroMenn Medical Center,8980250,"tolterodine ER 2 mg capsule,extended release 24 hr",59762004701,,250,$41.56 ,$41.56 ,$12.47 ,$37.82 ,$29.09 ,$12.47 ,$27.01 ,$29.92 ,$37.82 ,$31.17 
Carle BroMenn Medical Center,8980250,"tolterodine ER 4 mg capsule,extended release 24 hr",93716456,,250,$36.28 ,$36.28 ,$10.88 ,$33.01 ,$25.40 ,$10.88 ,$23.58 ,$26.12 ,$33.01 ,$27.21 
Carle BroMenn Medical Center,8980250,"tolterodine ER 4 mg capsule,extended release 24 hr",13668019030,,250,$41.56 ,$41.56 ,$12.47 ,$37.82 ,$29.09 ,$12.47 ,$27.01 ,$29.92 ,$37.82 ,$31.17 
Carle BroMenn Medical Center,8980250,topiramate 25 mg tablet,68084034201,,250,$12.12 ,$12.12 ,$3.64 ,$11.03 ,$8.48 ,$3.64 ,$7.88 ,$8.73 ,$11.03 ,$9.09 
Carle BroMenn Medical Center,8980250,topiramate 25 mg tablet,68084034211,,250,$12.12 ,$12.12 ,$3.64 ,$11.03 ,$8.48 ,$3.64 ,$7.88 ,$8.73 ,$11.03 ,$9.09 
Carle BroMenn Medical Center,8980250,torsemide 10 mg tablet,50111091601,,250,$5.61 ,$5.61 ,$1.68 ,$5.11 ,$3.93 ,$1.68 ,$3.65 ,$4.04 ,$5.11 ,$4.21 
Carle BroMenn Medical Center,8980250,torsemide 10 mg tablet,50268075511,,250,$5.65 ,$5.65 ,$1.70 ,$5.14 ,$3.96 ,$1.70 ,$3.67 ,$4.07 ,$5.14 ,$4.24 
Carle BroMenn Medical Center,8980250,torsemide 10 mg tablet,50268075515,,250,$5.65 ,$5.65 ,$1.70 ,$5.14 ,$3.96 ,$1.70 ,$3.67 ,$4.07 ,$5.14 ,$4.24 
Carle BroMenn Medical Center,8980250,torsemide 10 mg tablet,65862012601,,250,$5.61 ,$5.61 ,$1.68 ,$5.11 ,$3.93 ,$1.68 ,$3.65 ,$4.04 ,$5.11 ,$4.21 
Carle BroMenn Medical Center,8980250,torsemide 20 mg tablet,50268075611,,250,$6.19 ,$6.19 ,$1.86 ,$5.63 ,$4.33 ,$1.86 ,$4.02 ,$4.46 ,$5.63 ,$4.64 
Carle BroMenn Medical Center,8980250,torsemide 20 mg tablet,50268075615,,250,$6.19 ,$6.19 ,$1.86 ,$5.63 ,$4.33 ,$1.86 ,$4.02 ,$4.46 ,$5.63 ,$4.64 
Carle BroMenn Medical Center,8980250,torsemide 20 mg tablet,68084053901,,250,$6.23 ,$6.23 ,$1.87 ,$5.67 ,$4.36 ,$1.87 ,$4.05 ,$4.49 ,$5.67 ,$4.67 
Carle BroMenn Medical Center,8980250,trace elements Cr-Cu-Mn-Se-Zn 10 mcg-1 mg-0.5 mg-60 mcg-5mg/mL IV soln,517820125,,250,$125.89 ,$125.89 ,$37.77 ,$114.56 ,$88.12 ,$37.77 ,$81.83 ,$90.64 ,$114.56 ,$94.42 
Carle BroMenn Medical Center,8980250,trace elements Zn 3 mg-Cu 0.3 mg-Mn 55 mcg-Se 60 mcg/mL IV solution,517930501,,250,$184.30 ,$184.30 ,$55.29 ,$167.71 ,$129.01 ,$55.29 ,$119.80 ,$132.70 ,$167.71 ,$138.23 
Carle BroMenn Medical Center,8980250,trace elements Zn 3 mg-Cu 0.3 mg-Mn 55 mcg-Se 60 mcg/mL IV solution,517930525,,250,$184.30 ,$184.30 ,$55.29 ,$167.71 ,$129.01 ,$55.29 ,$119.80 ,$132.70 ,$167.71 ,$138.23 
Carle BroMenn Medical Center,8980250,traMADoL 50 mg tablet,51079099101,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,traMADoL 50 mg tablet,51079099120,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,traMADoL 50 mg tablet,57664037708,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,traMADoL 50 mg tablet,65162062710,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,traMADoL 50 mg tablet,68084080801,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,traMADoL 50 mg tablet,68084080811,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,"tranexamic acid 1,000 mg/10 mL (100 mg/mL) intravenous solution",23155016631,,250,$118.76 ,$118.76 ,$35.63 ,$108.07 ,$83.13 ,$35.63 ,$77.19 ,$85.51 ,$108.07 ,$89.07 
Carle BroMenn Medical Center,8980250,"tranexamic acid 1,000 mg/10 mL (100 mg/mL) intravenous solution",23155016641,,250,$118.76 ,$118.76 ,$35.63 ,$108.07 ,$83.13 ,$35.63 ,$77.19 ,$85.51 ,$108.07 ,$89.07 
Carle BroMenn Medical Center,8980250,"tranexamic acid 1,000 mg/10 mL (100 mg/mL) intravenous solution",23155052441,,250,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980250,"tranexamic acid 1,000 mg/10 mL (100 mg/mL) intravenous solution",39822100001,,250,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980250,tranexamic acid 650 mg tablet,69918030130,,250,$44.65 ,$44.65 ,$13.40 ,$40.63 ,$31.26 ,$13.40 ,$29.02 ,$32.15 ,$40.63 ,$33.49 
Carle BroMenn Medical Center,8980250,traZODone 100 mg tablet,60687045401,,250,$3.36 ,$3.36 ,$1.01 ,$3.06 ,$2.35 ,$1.01 ,$2.18 ,$2.42 ,$3.06 ,$2.52 
Carle BroMenn Medical Center,8980250,traZODone 100 mg tablet,60687045411,,250,$3.36 ,$3.36 ,$1.01 ,$3.06 ,$2.35 ,$1.01 ,$2.18 ,$2.42 ,$3.06 ,$2.52 
Carle BroMenn Medical Center,8980250,traZODone 50 mg tablet,904686861,,250,$3.02 ,$3.02 ,$0.91 ,$2.75 ,$2.11 ,$0.91 ,$1.96 ,$2.17 ,$2.75 ,$2.27 
Carle BroMenn Medical Center,8980250,traZODone 50 mg tablet,60687044301,,250,$3.06 ,$3.06 ,$0.92 ,$2.78 ,$2.14 ,$0.92 ,$1.99 ,$2.20 ,$2.78 ,$2.30 
Carle BroMenn Medical Center,8980250,traZODone 50 mg tablet,60687044311,,250,$3.06 ,$3.06 ,$0.92 ,$2.78 ,$2.14 ,$0.92 ,$1.99 ,$2.20 ,$2.78 ,$2.30 
Carle BroMenn Medical Center,8980250,triamcinolone acetonide 0.1 % topical cream,168000480,J3490,250,$52.39 ,$52.39 ,$15.72 ,$47.67 ,$36.67 ,$15.72 ,$34.05 ,$37.72 ,$47.67 ,$39.29 
Carle BroMenn Medical Center,8980250,triamcinolone acetonide 0.1 % topical cream,33342032980,,250,$76.60 ,$76.60 ,$22.98 ,$69.71 ,$53.62 ,$22.98 ,$49.79 ,$55.15 ,$69.71 ,$57.45 
Carle BroMenn Medical Center,8980250,triamcinolone acetonide 0.1 % topical cream,45802006405,,250,$128.87 ,$128.87 ,$38.66 ,$117.27 ,$90.21 ,$38.66 ,$83.77 ,$92.79 ,$117.27 ,$96.65 
Carle BroMenn Medical Center,8980250,triamcinolone acetonide 0.1 % topical cream,45802006436,,250,$58.91 ,$58.91 ,$17.67 ,$53.61 ,$41.24 ,$17.67 ,$38.29 ,$42.42 ,$53.61 ,$44.18 
Carle BroMenn Medical Center,8980250,triamcinolone acetonide 0.5 % topical cream,168000215,,250,$68.10 ,$68.10 ,$20.43 ,$61.97 ,$47.67 ,$20.43 ,$44.27 ,$49.03 ,$61.97 ,$51.08 
Carle BroMenn Medical Center,8980250,triamcinolone acetonide 0.5 % topical cream,67877031815,,250,$69.50 ,$69.50 ,$20.85 ,$63.25 ,$48.65 ,$20.85 ,$45.18 ,$50.04 ,$63.25 ,$52.13 
Carle BroMenn Medical Center,8980250,triamterene 37.5 mg-hydrochlorothiazide 25 mg capsule,527163201,,250,$4.26 ,$4.26 ,$1.28 ,$3.88 ,$2.98 ,$1.28 ,$2.77 ,$3.07 ,$3.88 ,$3.20 
Carle BroMenn Medical Center,8980250,triamterene 37.5 mg-hydrochlorothiazide 25 mg capsule,72578009001,,250,$4.06 ,$4.06 ,$1.22 ,$3.69 ,$2.84 ,$1.22 ,$2.64 ,$2.92 ,$3.69 ,$3.05 
Carle BroMenn Medical Center,8980250,trihexyphenidyL 2 mg tablet,591533501,,250,$3.18 ,$3.18 ,$0.95 ,$2.89 ,$2.23 ,$0.95 ,$2.07 ,$2.29 ,$2.89 ,$2.39 
Carle BroMenn Medical Center,8980250,trihexyphenidyL 5 mg tablet,591533701,,250,$4.03 ,$4.03 ,$1.21 ,$3.67 ,$2.82 ,$1.21 ,$2.62 ,$2.90 ,$3.67 ,$3.02 
Carle BroMenn Medical Center,8980250,tropicamide 1 % eye drops,17478010212,,250,$17.47 ,$17.47 ,$5.24 ,$15.90 ,$12.23 ,$5.24 ,$11.36 ,$12.58 ,$15.90 ,$13.10 
Carle BroMenn Medical Center,8980250,tropicamide 1 % eye drops,61314035502,,250,$17.47 ,$17.47 ,$5.24 ,$15.90 ,$12.23 ,$5.24 ,$11.36 ,$12.58 ,$15.90 ,$13.10 
Carle BroMenn Medical Center,8980250,ulipristaL 30 mg tablet,50102091101,,250,$158.30 ,$158.30 ,$47.49 ,$144.05 ,$110.81 ,$47.49 ,$102.90 ,$113.98 ,$144.05 ,$118.73 
Carle BroMenn Medical Center,8980250,ulipristaL 30 mg tablet,73302045601,,250,$170.90 ,$170.90 ,$51.27 ,$155.52 ,$119.63 ,$51.27 ,$111.09 ,$123.05 ,$155.52 ,$128.18 
Carle BroMenn Medical Center,8980250,ultrasound coupling gel topical,8556830060,,250,$18.05 ,$18.05 ,$5.42 ,$16.43 ,$12.64 ,$5.42 ,$11.73 ,$13.00 ,$16.43 ,$13.54 
Carle BroMenn Medical Center,8980250,umeclidinium 62.5 mcg/actuation blister powder for inhalation,173087306,,250,$548.66 ,$548.66 ,$164.60 ,$499.28 ,$384.06 ,$164.60 ,$356.63 ,$395.04 ,$499.28 ,$411.50 
Carle BroMenn Medical Center,8980250,umeclidinium 62.5 mcg-vilanteroL 25 mcg/actuation powdr for inhalation,173086906,,250,$778.41 ,$778.41 ,$233.52 ,$708.35 ,$544.89 ,$233.52 ,$505.97 ,$560.46 ,$708.35 ,$583.81 
Carle BroMenn Medical Center,8980250,ursodioL 300 mg capsule,591315901,,250,$33.88 ,$33.88 ,$10.16 ,$30.83 ,$23.72 ,$10.16 ,$22.02 ,$24.39 ,$30.83 ,$25.41 
Carle BroMenn Medical Center,8980250,ursodioL 300 mg capsule,42806050301,,250,$33.88 ,$33.88 ,$10.16 ,$30.83 ,$23.72 ,$10.16 ,$22.02 ,$24.39 ,$30.83 ,$25.41 
Carle BroMenn Medical Center,8980250,valACYclovir 500 mg tablet,378427593,,250,$33.43 ,$33.43 ,$10.03 ,$30.42 ,$23.40 ,$10.03 ,$21.73 ,$24.07 ,$30.42 ,$25.07 
Carle BroMenn Medical Center,8980250,valACYclovir 500 mg tablet,31722070490,,250,$33.43 ,$33.43 ,$10.03 ,$30.42 ,$23.40 ,$10.03 ,$21.73 ,$24.07 ,$30.42 ,$25.07 
Carle BroMenn Medical Center,8980250,valACYclovir 500 mg tablet,50268078811,,250,$29.05 ,$29.05 ,$8.72 ,$26.44 ,$20.34 ,$8.72 ,$18.88 ,$20.92 ,$26.44 ,$21.79 
Carle BroMenn Medical Center,8980250,valGANciclovir 450 mg tablet,31722083260,,250,$233.54 ,$233.54 ,$70.06 ,$212.52 ,$163.48 ,$70.06 ,$151.80 ,$168.15 ,$212.52 ,$175.16 
Carle BroMenn Medical Center,8980250,valproate sodium 500 mg/5 mL (100 mg/mL) intravenous solution,143978501,J3490,250,$155.69 ,$155.69 ,$46.71 ,$141.68 ,$108.98 ,$46.71 ,$101.20 ,$112.10 ,$141.68 ,$116.77 
Carle BroMenn Medical Center,8980250,valproate sodium 500 mg/5 mL (100 mg/mL) intravenous solution,143978510,J3490,250,$155.69 ,$155.69 ,$46.71 ,$141.68 ,$108.98 ,$46.71 ,$101.20 ,$112.10 ,$141.68 ,$116.77 
Carle BroMenn Medical Center,8980250,valproate sodium 500 mg/5 mL (100 mg/mL) intravenous solution,63323049401,J3490,250,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980250,valproate sodium 500 mg/5 mL (100 mg/mL) intravenous solution,63323049416,J3490,250,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980250,valproate sodium 500 mg/5 mL (100 mg/mL) intravenous solution,63323049441,J3490,250,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980250,valproic acid (as sodium salt) 250 mg/5 mL oral solution,121067516,,250,$11.38 ,$11.38 ,$3.41 ,$10.36 ,$7.97 ,$3.41 ,$7.40 ,$8.19 ,$10.36 ,$8.54 
Carle BroMenn Medical Center,8980250,valproic acid (as sodium salt) 250 mg/5 mL oral solution,60432062116,,250,$11.41 ,$11.41 ,$3.42 ,$10.38 ,$7.99 ,$3.42 ,$7.42 ,$8.22 ,$10.38 ,$8.56 
Carle BroMenn Medical Center,8980250,valproic acid 250 mg capsule,832031011,,250,$7.13 ,$7.13 ,$2.14 ,$6.49 ,$4.99 ,$2.14 ,$4.63 ,$5.13 ,$6.49 ,$5.35 
Carle BroMenn Medical Center,8980250,valproic acid 250 mg capsule,69452015020,,250,$6.24 ,$6.24 ,$1.87 ,$5.68 ,$4.37 ,$1.87 ,$4.06 ,$4.49 ,$5.68 ,$4.68 
Carle BroMenn Medical Center,8980250,valsartan 160 mg tablet,59746036290,,250,$25.39 ,$25.39 ,$7.62 ,$23.10 ,$17.77 ,$7.62 ,$16.50 ,$18.28 ,$23.10 ,$19.04 
Carle BroMenn Medical Center,8980250,valsartan 40 mg tablet,59746036030,,250,$20.27 ,$20.27 ,$6.08 ,$18.45 ,$14.19 ,$6.08 ,$13.18 ,$14.59 ,$18.45 ,$15.20 
Carle BroMenn Medical Center,8980250,valsartan 80 mg tablet,33342006310,,250,$11.37 ,$11.37 ,$3.41 ,$10.35 ,$7.96 ,$3.41 ,$7.39 ,$8.19 ,$10.35 ,$8.53 
Carle BroMenn Medical Center,8980250,valsartan 80 mg tablet,59746036190,,250,$23.78 ,$23.78 ,$7.13 ,$21.64 ,$16.65 ,$7.13 ,$15.46 ,$17.12 ,$21.64 ,$17.84 
Carle BroMenn Medical Center,8980250,vancomycin 50 mg/mL oral solution,65628020605,,250,$23.55 ,$23.55 ,$7.07 ,$21.43 ,$16.49 ,$7.07 ,$15.31 ,$16.96 ,$21.43 ,$17.66 
Carle BroMenn Medical Center,8980250,varenicline 1 mg tablet,69046956,,250,$42.32 ,$42.32 ,$12.70 ,$38.51 ,$29.62 ,$12.70 ,$27.51 ,$30.47 ,$38.51 ,$31.74 
Carle BroMenn Medical Center,8980250,vasopressin 20 unit/mL intravenous solution,42023016401,J3490,250,"$1,251.68 ","$1,251.68 ",$375.50 ,"$1,139.03 ",$876.18 ,$375.50 ,$813.59 ,$901.21 ,"$1,139.03 ",$938.76 
Carle BroMenn Medical Center,8980250,vasopressin 20 unit/mL intravenous solution,42023016425,J3490,250,"$1,251.68 ","$1,251.68 ",$375.50 ,"$1,139.03 ",$876.18 ,$375.50 ,$813.59 ,$901.21 ,"$1,139.03 ",$938.76 
Carle BroMenn Medical Center,8980250,vecuronium bromide 10 mg intravenous solution,55150023501,,250,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980250,vecuronium bromide 10 mg intravenous solution,55150023510,,250,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980250,vecuronium bromide 10 mg intravenous solution,63323078110,,250,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980250,venlafaxine 25 mg tablet,50268079811,,250,$11.94 ,$11.94 ,$3.58 ,$10.87 ,$8.36 ,$3.58 ,$7.76 ,$8.60 ,$10.87 ,$8.96 
Carle BroMenn Medical Center,8980250,venlafaxine 25 mg tablet,57664039288,,250,$11.38 ,$11.38 ,$3.41 ,$10.36 ,$7.97 ,$3.41 ,$7.40 ,$8.19 ,$10.36 ,$8.54 
Carle BroMenn Medical Center,8980250,venlafaxine 37.5 mg tablet,68084084401,,250,$11.65 ,$11.65 ,$3.50 ,$10.60 ,$8.16 ,$3.50 ,$7.57 ,$8.39 ,$10.60 ,$8.74 
Carle BroMenn Medical Center,8980250,venlafaxine 37.5 mg tablet,68084084411,,250,$11.65 ,$11.65 ,$3.50 ,$10.60 ,$8.16 ,$3.50 ,$7.57 ,$8.39 ,$10.60 ,$8.74 
Carle BroMenn Medical Center,8980250,"venlafaxine ER 150 mg capsule,extended release 24 hr",904647061,,250,$5.60 ,$5.60 ,$1.68 ,$5.10 ,$3.92 ,$1.68 ,$3.64 ,$4.03 ,$5.10 ,$4.20 
Carle BroMenn Medical Center,8980250,"venlafaxine ER 150 mg capsule,extended release 24 hr",68084071301,,250,$23.64 ,$23.64 ,$7.09 ,$21.51 ,$16.55 ,$7.09 ,$15.37 ,$17.02 ,$21.51 ,$17.73 
Carle BroMenn Medical Center,8980250,"venlafaxine ER 37.5 mg capsule,extended release 24 hr",904646861,,250,$5.20 ,$5.20 ,$1.56 ,$4.73 ,$3.64 ,$1.56 ,$3.38 ,$3.74 ,$4.73 ,$3.90 
Carle BroMenn Medical Center,8980250,"venlafaxine ER 37.5 mg capsule,extended release 24 hr",68084069801,,250,$19.77 ,$19.77 ,$5.93 ,$17.99 ,$13.84 ,$5.93 ,$12.85 ,$14.23 ,$17.99 ,$14.83 
Carle BroMenn Medical Center,8980250,"venlafaxine ER 37.5 mg capsule,extended release 24 hr",68084069811,,250,$19.77 ,$19.77 ,$5.93 ,$17.99 ,$13.84 ,$5.93 ,$12.85 ,$14.23 ,$17.99 ,$14.83 
Carle BroMenn Medical Center,8980250,"venlafaxine ER 75 mg capsule,extended release 24 hr",904646961,,250,$5.25 ,$5.25 ,$1.58 ,$4.78 ,$3.68 ,$1.58 ,$3.41 ,$3.78 ,$4.78 ,$3.94 
Carle BroMenn Medical Center,8980250,verapamiL 120 mg tablet,904292461,,250,$5.83 ,$5.83 ,$1.75 ,$5.31 ,$4.08 ,$1.75 ,$3.79 ,$4.20 ,$5.31 ,$4.37 
Carle BroMenn Medical Center,8980250,verapamiL 2.5 mg/mL intravenous solution,43066003101,J3490,250,$73.24 ,$73.24 ,$21.97 ,$66.65 ,$51.27 ,$21.97 ,$47.61 ,$52.73 ,$66.65 ,$54.93 
Carle BroMenn Medical Center,8980250,verapamiL 2.5 mg/mL intravenous solution,70069027101,J3490,250,$76.15 ,$76.15 ,$22.85 ,$69.30 ,$53.31 ,$22.85 ,$49.50 ,$54.83 ,$69.30 ,$57.11 
Carle BroMenn Medical Center,8980250,verapamiL 2.5 mg/mL intravenous solution,70069027105,J3490,250,$76.15 ,$76.15 ,$22.85 ,$69.30 ,$53.31 ,$22.85 ,$49.50 ,$54.83 ,$69.30 ,$57.11 
Carle BroMenn Medical Center,8980250,verapamiL 80 mg tablet,904292061,,250,$4.99 ,$4.99 ,$1.50 ,$4.54 ,$3.49 ,$1.50 ,$3.24 ,$3.59 ,$4.54 ,$3.74 
Carle BroMenn Medical Center,8980250,verapamiL 80 mg tablet,23155002601,,250,$3.77 ,$3.77 ,$1.13 ,$3.43 ,$2.64 ,$1.13 ,$2.45 ,$2.71 ,$3.43 ,$2.83 
Carle BroMenn Medical Center,8980250,vitamin B comp no.3-folic acid 1 mg-vit C 60 mg-biotin 300 mcg tablet,60258016101,,250,$3.40 ,$3.40 ,$1.02 ,$3.09 ,$2.38 ,$1.02 ,$2.21 ,$2.45 ,$3.09 ,$2.55 
Carle BroMenn Medical Center,8980250,"vitamin B complex no.2 ER 100 mg tablet,extended release",31604001637,,250,$3.32 ,$3.32 ,$1.00 ,$3.02 ,$2.32 ,$1.00 ,$2.16 ,$2.39 ,$3.02 ,$2.49 
Carle BroMenn Medical Center,8980250,"vitamin B complex no.2 ER 100 mg tablet,extended release",87701040728,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,vitamins A and D-white petrolatum-lanolin topical ointment,41100081124,,250,$26.52 ,$26.52 ,$7.96 ,$24.13 ,$18.56 ,$7.96 ,$17.24 ,$19.09 ,$24.13 ,$19.89 
Carle BroMenn Medical Center,8980250,vitamins A and D-white petrolatum-lanolin topical ointment,45802039504,,250,$25.20 ,$25.20 ,$7.56 ,$22.93 ,$17.64 ,$7.56 ,$16.38 ,$18.14 ,$22.93 ,$18.90 
Carle BroMenn Medical Center,8980250,voriconazole 200 mg tablet,43547037803,,250,$184.01 ,$184.01 ,$55.20 ,$167.45 ,$128.81 ,$55.20 ,$119.61 ,$132.49 ,$167.45 ,$138.01 
Carle BroMenn Medical Center,8980250,voriconazole 200 mg tablet,68462057330,,250,$286.46 ,$286.46 ,$85.94 ,$260.68 ,$200.52 ,$85.94 ,$186.20 ,$206.25 ,$260.68 ,$214.85 
Carle BroMenn Medical Center,8980250,voriconazole 200 mg/5 mL (40 mg/mL) oral suspension,43386003860,,250,$416.46 ,$416.46 ,$124.94 ,$378.98 ,$291.52 ,$124.94 ,$270.70 ,$299.85 ,$378.98 ,$312.35 
Carle BroMenn Medical Center,8980250,vortioxetine 10 mg tablet,64764073030,,250,$67.37 ,$67.37 ,$20.21 ,$61.31 ,$47.16 ,$20.21 ,$43.79 ,$48.51 ,$61.31 ,$50.53 
Carle BroMenn Medical Center,8980250,warfarin 1 mg tablet,832121101,,250,$5.20 ,$5.20 ,$1.56 ,$4.73 ,$3.64 ,$1.56 ,$3.38 ,$3.74 ,$4.73 ,$3.90 
Carle BroMenn Medical Center,8980250,warfarin 1 mg tablet,832121189,,250,$5.20 ,$5.20 ,$1.56 ,$4.73 ,$3.64 ,$1.56 ,$3.38 ,$3.74 ,$4.73 ,$3.90 
Carle BroMenn Medical Center,8980250,warfarin 1 mg tablet,9999470207,,250,$3.77 ,$3.77 ,$1.13 ,$3.43 ,$2.64 ,$1.13 ,$2.45 ,$2.71 ,$3.43 ,$2.83 
Carle BroMenn Medical Center,8980250,warfarin 10 mg tablet,832121901,,250,$6.76 ,$6.76 ,$2.03 ,$6.15 ,$4.73 ,$2.03 ,$4.39 ,$4.87 ,$6.15 ,$5.07 
Carle BroMenn Medical Center,8980250,warfarin 10 mg tablet,832121989,,250,$6.76 ,$6.76 ,$2.03 ,$6.15 ,$4.73 ,$2.03 ,$4.39 ,$4.87 ,$6.15 ,$5.07 
Carle BroMenn Medical Center,8980250,warfarin 2 mg tablet,832121200,,250,$5.32 ,$5.32 ,$1.60 ,$4.84 ,$3.72 ,$1.60 ,$3.46 ,$3.83 ,$4.84 ,$3.99 
Carle BroMenn Medical Center,8980250,warfarin 2 mg tablet,832121201,,250,$5.32 ,$5.32 ,$1.60 ,$4.84 ,$3.72 ,$1.60 ,$3.46 ,$3.83 ,$4.84 ,$3.99 
Carle BroMenn Medical Center,8980250,warfarin 2 mg tablet,832121289,,250,$5.32 ,$5.32 ,$1.60 ,$4.84 ,$3.72 ,$1.60 ,$3.46 ,$3.83 ,$4.84 ,$3.99 
Carle BroMenn Medical Center,8980250,warfarin 2 mg tablet,62584098401,,250,$5.20 ,$5.20 ,$1.56 ,$4.73 ,$3.64 ,$1.56 ,$3.38 ,$3.74 ,$4.73 ,$3.90 
Carle BroMenn Medical Center,8980250,warfarin 2.5 mg tablet,832121300,,250,$5.41 ,$5.41 ,$1.62 ,$4.92 ,$3.79 ,$1.62 ,$3.52 ,$3.90 ,$4.92 ,$4.06 
Carle BroMenn Medical Center,8980250,warfarin 2.5 mg tablet,832121301,,250,$5.41 ,$5.41 ,$1.62 ,$4.92 ,$3.79 ,$1.62 ,$3.52 ,$3.90 ,$4.92 ,$4.06 
Carle BroMenn Medical Center,8980250,warfarin 3 mg tablet,832121401,,250,$5.41 ,$5.41 ,$1.62 ,$4.92 ,$3.79 ,$1.62 ,$3.52 ,$3.90 ,$4.92 ,$4.06 
Carle BroMenn Medical Center,8980250,warfarin 4 mg tablet,832121501,,250,$5.41 ,$5.41 ,$1.62 ,$4.92 ,$3.79 ,$1.62 ,$3.52 ,$3.90 ,$4.92 ,$4.06 
Carle BroMenn Medical Center,8980250,warfarin 4 mg tablet,832121589,,250,$5.41 ,$5.41 ,$1.62 ,$4.92 ,$3.79 ,$1.62 ,$3.52 ,$3.90 ,$4.92 ,$4.06 
Carle BroMenn Medical Center,8980250,warfarin 4 mg tablet,51672403101,,250,$5.40 ,$5.40 ,$1.62 ,$4.91 ,$3.78 ,$1.62 ,$3.51 ,$3.89 ,$4.91 ,$4.05 
Carle BroMenn Medical Center,8980250,warfarin 5 mg tablet,832121601,,250,$5.53 ,$5.53 ,$1.66 ,$5.03 ,$3.87 ,$1.66 ,$3.59 ,$3.98 ,$5.03 ,$4.15 
Carle BroMenn Medical Center,8980250,warfarin 6 mg tablet,832121701,,250,$6.46 ,$6.46 ,$1.94 ,$5.88 ,$4.52 ,$1.94 ,$4.20 ,$4.65 ,$5.88 ,$4.85 
Carle BroMenn Medical Center,8980250,warfarin 7.5 mg tablet,832121801,,250,$6.63 ,$6.63 ,$1.99 ,$6.03 ,$4.64 ,$1.99 ,$4.31 ,$4.77 ,$6.03 ,$4.97 
Carle BroMenn Medical Center,8980250,warfarin 7.5 mg tablet,832121889,,250,$6.63 ,$6.63 ,$1.99 ,$6.03 ,$4.64 ,$1.99 ,$4.31 ,$4.77 ,$6.03 ,$4.97 
Carle BroMenn Medical Center,8980250,"water for injection, bacteriostatic injection solution",409397701,J3490,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,"water for injection, bacteriostatic injection solution",409397703,J3490,250,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980250,"water for injection, sterile intravenous solution",264785000,,250,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980250,"water for injection, sterile intravenous solution",990799009,,250,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980250,"water for irrigation, sterile solution",264210110,,250,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980250,white petrolatum 42 % topical ointment,536114397,,250,$41.33 ,$41.33 ,$12.40 ,$37.61 ,$28.93 ,$12.40 ,$26.86 ,$29.76 ,$37.61 ,$31.00 
Carle BroMenn Medical Center,8980250,white petrolatum 42 % topical ointment,536114398,,250,$88.05 ,$88.05 ,$26.42 ,$80.13 ,$61.64 ,$26.42 ,$57.23 ,$63.40 ,$80.13 ,$66.04 
Carle BroMenn Medical Center,8980250,white petrolatum-mineral oiL 56.8 %-42.5 % eye ointment,23031204,,250,$63.18 ,$63.18 ,$18.95 ,$57.49 ,$44.23 ,$18.95 ,$41.07 ,$45.49 ,$57.49 ,$47.39 
Carle BroMenn Medical Center,8980250,white petrolatum-mineral oiL 83 %-15 % eye ointment,904648838,,250,$28.76 ,$28.76 ,$8.63 ,$26.17 ,$20.13 ,$8.63 ,$18.69 ,$20.71 ,$26.17 ,$21.57 
Carle BroMenn Medical Center,8980250,white petrolatum-mineral oiL 83 %-15 % eye ointment,17478006235,,250,$48.01 ,$48.01 ,$14.40 ,$43.69 ,$33.61 ,$14.40 ,$31.21 ,$34.57 ,$43.69 ,$36.01 
Carle BroMenn Medical Center,8980250,white petrolatum-mineral oiL 94 %-3 % eye ointment,65051801,,250,$43.22 ,$43.22 ,$12.97 ,$39.33 ,$30.25 ,$12.97 ,$28.09 ,$31.12 ,$39.33 ,$32.42 
Carle BroMenn Medical Center,8980250,"witch hazel 50 % topical pads,glycerin-witch hazel 12.5 %-50 % topical pads",4138800732,,250,$166.77 ,$166.77 ,$50.03 ,$151.76 ,$116.74 ,$50.03 ,$108.40 ,$120.07 ,$151.76 ,$125.08 
Carle BroMenn Medical Center,8980250,"witch hazel 50 % topical pads,glycerin-witch hazel 12.5 %-50 % topical pads",50289325001,,250,$155.13 ,$155.13 ,$46.54 ,$141.17 ,$108.59 ,$46.54 ,$100.83 ,$111.69 ,$141.17 ,$116.35 
Carle BroMenn Medical Center,8980250,zidovudine 10 mg/mL oral syrup,49702021248,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,zidovudine 10 mg/mL oral syrup,65862004824,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,zidovudine 100 mg capsule,65862010701,,250,$11.74 ,$11.74 ,$3.52 ,$10.68 ,$8.22 ,$3.52 ,$7.63 ,$8.45 ,$10.68 ,$8.81 
Carle BroMenn Medical Center,8980250,zinc chloride 1 mg/mL intravenous solution,409409001,,250,$105.17 ,$105.17 ,$31.55 ,$95.70 ,$73.62 ,$31.55 ,$68.36 ,$75.72 ,$95.70 ,$78.88 
Carle BroMenn Medical Center,8980250,zinc oxide-white petrolatum 15 %-49 % topical ointment,43553325604,,250,$56.77 ,$56.77 ,$17.03 ,$51.66 ,$39.74 ,$17.03 ,$36.90 ,$40.87 ,$51.66 ,$42.58 
Carle BroMenn Medical Center,8980250,zinc sulfate 50 mg zinc (220 mg) capsule,77333098310,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,zinc sulfate 50 mg zinc (220 mg) capsule,77333098325,,250,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980250,ziprasidone 20 mg capsule,55111025660,,250,$39.17 ,$39.17 ,$11.75 ,$35.64 ,$27.42 ,$11.75 ,$25.46 ,$28.20 ,$35.64 ,$29.38 
Carle BroMenn Medical Center,8980250,ziprasidone 40 mg capsule,781216660,,250,$39.17 ,$39.17 ,$11.75 ,$35.64 ,$27.42 ,$11.75 ,$25.46 ,$28.20 ,$35.64 ,$29.38 
Carle BroMenn Medical Center,8980250,ziprasidone 40 mg capsule,55111025760,,250,$39.17 ,$39.17 ,$11.75 ,$35.64 ,$27.42 ,$11.75 ,$25.46 ,$28.20 ,$35.64 ,$29.38 
Carle BroMenn Medical Center,8980250,ziprasidone 40 mg capsule,63739000532,,250,$17.89 ,$17.89 ,$5.37 ,$16.28 ,$12.52 ,$5.37 ,$11.63 ,$12.88 ,$16.28 ,$13.42 
Carle BroMenn Medical Center,8980250,ziprasidone 60 mg capsule,781216760,,250,$45.80 ,$45.80 ,$13.74 ,$41.68 ,$32.06 ,$13.74 ,$29.77 ,$32.98 ,$41.68 ,$34.35 
Carle BroMenn Medical Center,8980250,ziprasidone 60 mg capsule,16714083701,,250,$7.77 ,$7.77 ,$2.33 ,$7.07 ,$5.44 ,$2.33 ,$5.05 ,$5.59 ,$7.07 ,$5.83 
Carle BroMenn Medical Center,8980250,zolpidem 5 mg tablet,904608261,,250,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980250,zolpidem 5 mg tablet,68084018901,,250,$12.84 ,$12.84 ,$3.85 ,$11.68 ,$8.99 ,$3.85 ,$8.35 ,$9.24 ,$11.68 ,$9.63 
Carle BroMenn Medical Center,8980250,zolpidem 5 mg tablet,68084018911,,250,$12.84 ,$12.84 ,$3.85 ,$11.68 ,$8.99 ,$3.85 ,$8.35 ,$9.24 ,$11.68 ,$9.63 
Carle BroMenn Medical Center,8980250,zonisamide 100 mg capsule,60687023001,,250,$6.54 ,$6.54 ,$1.96 ,$5.95 ,$4.58 ,$1.96 ,$4.25 ,$4.71 ,$5.95 ,$4.91 
Carle BroMenn Medical Center,8980250,zonisamide 100 mg capsule,60687023011,,250,$6.54 ,$6.54 ,$1.96 ,$5.95 ,$4.58 ,$1.96 ,$4.25 ,$4.71 ,$5.95 ,$4.91 
Carle BroMenn Medical Center,8980250,zonisamide 100 mg capsule,68001024400,,250,$12.54 ,$12.54 ,$3.76 ,$11.41 ,$8.78 ,$3.76 ,$8.15 ,$9.03 ,$11.41 ,$9.41 
Carle BroMenn Medical Center,8980250,zonisamide 25 mg capsule,68462012801,,250,$4.89 ,$4.89 ,$1.47 ,$4.45 ,$3.42 ,$1.47 ,$3.18 ,$3.52 ,$4.45 ,$3.67 
Carle BroMenn Medical Center,8201254,OPTISON PERFLUTREN MCR 3ML,,Q9956,255,"$1,400.00 ","$1,400.00 ",$420.00 ,"$1,274.00 ",$980.00 ,$420.00 ,$910.00 ,"$1,008.00 ","$1,274.00 ","$1,050.00 "
Carle BroMenn Medical Center,8201255,DEFINITY 1ML,,Q9957,255,$312.00 ,$312.00 ,$93.60 ,$283.92 ,$218.40 ,$93.60 ,$202.80 ,$224.64 ,$283.92 ,$234.00 
Carle BroMenn Medical Center,8409576,PROHANCE PER ML,,A9576,255,$80.00 ,$80.00 ,$24.00 ,$72.80 ,$56.00 ,$24.00 ,$52.00 ,$57.60 ,$72.80 ,$60.00 
Carle BroMenn Medical Center,8409579,CONTRAST MATERIAL PER ML,,A9579,255,$28.00 ,$28.00 ,$8.40 ,$25.48 ,$19.60 ,$8.40 ,$18.20 ,$20.16 ,$25.48 ,$21.00 
Carle BroMenn Medical Center,8409585,GADAVIST (GADOBUTROL) INJECTION,,A9585,255,$2.00 ,$2.00 ,$0.60 ,$1.82 ,$1.40 ,$0.60 ,$1.30 ,$1.44 ,$1.82 ,$1.50 
Carle BroMenn Medical Center,8980255,barium sulfate 2 % (w/v) oral suspension,32909074103,,255,$19.81 ,$19.81 ,$5.94 ,$18.03 ,$13.87 ,$5.94 ,$12.88 ,$14.26 ,$18.03 ,$14.86 
Carle BroMenn Medical Center,8980255,barium sulfate 2 % (w/v) oral suspension,32909075603,,255,$15.15 ,$15.15 ,$4.55 ,$13.79 ,$10.61 ,$4.55 ,$9.85 ,$10.91 ,$13.79 ,$11.36 
Carle BroMenn Medical Center,8980255,"barium sulfate 40 % (w/v), 30% (w/w) oral paste",32909012522,,255,$14.07 ,$14.07 ,$4.22 ,$12.80 ,$9.85 ,$4.22 ,$9.15 ,$10.13 ,$12.80 ,$10.55 
Carle BroMenn Medical Center,8980255,barium sulfate 700 mg tablet,10361077831,,255,$15.27 ,$15.27 ,$4.58 ,$13.90 ,$10.69 ,$4.58 ,$9.93 ,$10.99 ,$13.90 ,$11.45 
Carle BroMenn Medical Center,8980255,barium sulfate 81 % (w/w) oral powder,32909010510,,255,$3.30 ,$3.30 ,$0.99 ,$3.00 ,$2.31 ,$0.99 ,$2.15 ,$2.38 ,$3.00 ,$2.48 
Carle BroMenn Medical Center,8980255,barium sulfate 98 % oral powder for suspension,32909076401,,255,$33.42 ,$33.42 ,$10.03 ,$30.41 ,$23.39 ,$10.03 ,$21.72 ,$24.06 ,$30.41 ,$25.07 
Carle BroMenn Medical Center,8980255,iodixanoL 320 mg iodine/mL intravenous solution,407222316,Q9967,255,$483.90 ,$483.90 ,$145.17 ,$440.35 ,$338.73 ,$145.17 ,$314.54 ,$348.41 ,$440.35 ,$362.93 
Carle BroMenn Medical Center,8980255,iodixanoL 320 mg iodine/mL intravenous solution,407222317,Q9967,255,$483.90 ,$483.90 ,$145.17 ,$440.35 ,$338.73 ,$145.17 ,$314.54 ,$348.41 ,$440.35 ,$362.93 
Carle BroMenn Medical Center,8980255,iohexoL 180 mg iodine/mL intrathecal solution,407141110,Q9965,255,$68.60 ,$68.60 ,$20.58 ,$62.43 ,$48.02 ,$20.58 ,$44.59 ,$49.39 ,$62.43 ,$51.45 
Carle BroMenn Medical Center,8980255,iohexoL 180 mg iodine/mL intrathecal solution,407141120,Q9965,255,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980255,iohexoL 240 mg iodine/mL intravenous solution,407141230,Q9966,255,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980255,iohexoL 240 mg iodine/mL intravenous solution,407141250,Q9966,255,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980255,iohexoL 300 mg iodine/mL intravenous solution,407141361,Q9967,255,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980255,iohexoL 300 mg iodine/mL intravenous solution,407141363,Q9967,255,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980255,iohexoL 300 mg iodine/mL intravenous solution,407141365,Q9967,255,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980255,iohexoL 300 mg iodine/mL intravenous solution,407141390,Q9967,255,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980255,iohexoL 350 mg iodine/mL intravenous solution,407141489,Q9967,255,$355.80 ,$355.80 ,$106.74 ,$323.78 ,$249.06 ,$106.74 ,$231.27 ,$256.18 ,$323.78 ,$266.85 
Carle BroMenn Medical Center,8980255,iohexoL 350 mg iodine/mL intravenous solution,407141491,Q9967,255,$706.46 ,$706.46 ,$211.94 ,$642.88 ,$494.52 ,$211.94 ,$459.20 ,$508.65 ,$642.88 ,$529.85 
Carle BroMenn Medical Center,8980255,iohexoL 350 mg iodine/mL intravenous solution,9999042888,Q9967,255,$72.87 ,$72.87 ,$21.86 ,$66.31 ,$51.01 ,$21.86 ,$47.37 ,$52.47 ,$66.31 ,$54.65 
Carle BroMenn Medical Center,8980255,perflutren lipid microspheres 1.1 mg/mL intravenous suspension,11994001104,,255,$679.96 ,$679.96 ,$203.99 ,$618.76 ,$475.97 ,$203.99 ,$441.97 ,$489.57 ,$618.76 ,$509.97 
Carle BroMenn Medical Center,8980258,potassium chloride 10 mEq/L in dextrose 5 %-0.45 % sodium chloride IV,264763400,,258,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980258,potassium chloride 20 mEq/L in D5-0.9 % sodium chloride intravenous,264765200,,258,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980258,potassium chloride 20 mEq/L in dextrose 5 %-0.45 % sodium chloride IV,264763500,,258,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980258,potassium chloride 20 mEq/L in dextrose 5 %-0.45 % sodium chloride IV,990790209,,258,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980258,potassium chloride 20 mEq/L-lactated ringers-5 % dextrose intravenous,338081104,J7120,258,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980258,potassium chloride 20 mEq/L-lactated ringers-5 % dextrose intravenous,990711109,J7120,258,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980258,potassium chloride 40 mEq/L in D5-0.9 % sodium chloride intravenous,338080704,,258,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980258,potassium chloride 40 mEq/L in D5-0.9 % sodium chloride intravenous,409710909,,258,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980258,potassium chloride 40 mEq/L in D5-0.9 % sodium chloride intravenous,990710909,,258,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980258,potassium chloride 40 mEq/L in dextrose 5 %-0.45 % sodium chloride IV,264763800,,258,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980258,potassium chloride 40 mEq/L in dextrose 5 %-0.45 % sodium chloride IV,990790409,,258,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980258,sodium chloride 0.9 % irrigation solution,264220100,,258,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980258,sodium chloride 0.9 % irrigation solution,264220110,,258,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980258,sodium chloride 0.9 % irrigation solution,264738860,,258,$116.41 ,$116.41 ,$34.92 ,$105.93 ,$81.49 ,$34.92 ,$75.67 ,$83.82 ,$105.93 ,$87.31 
Carle BroMenn Medical Center,8980258,sodium chloride 0.9 % irrigation solution,338004747,,258,$116.41 ,$116.41 ,$34.92 ,$105.93 ,$81.49 ,$34.92 ,$75.67 ,$83.82 ,$105.93 ,$87.31 
Carle BroMenn Medical Center,8980258,sodium chloride 0.9 % irrigation solution,338004802,,258,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980258,sodium chloride 0.9 % irrigation solution,338004804,,258,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980259,acarbose 50 mg tablet,54014125,,259,$6.89 ,$6.89 ,$2.07 ,$6.27 ,$4.82 ,$2.07 ,$4.48 ,$4.96 ,$6.27 ,$5.17 
Carle BroMenn Medical Center,8980259,"alfuzosin ER 10 mg tablet,extended release 24 hr",378500577,,259,$21.97 ,$21.97 ,$6.59 ,$19.99 ,$15.38 ,$6.59 ,$14.28 ,$15.82 ,$19.99 ,$16.48 
Carle BroMenn Medical Center,8980259,"alfuzosin ER 10 mg tablet,extended release 24 hr",47335095688,,259,$21.97 ,$21.97 ,$6.59 ,$19.99 ,$15.38 ,$6.59 ,$14.28 ,$15.82 ,$19.99 ,$16.48 
Carle BroMenn Medical Center,8980259,amantadine HCL 50 mg/5 mL oral solution,121064616,,259,$11.41 ,$11.41 ,$3.42 ,$10.38 ,$7.99 ,$3.42 ,$7.42 ,$8.22 ,$10.38 ,$8.56 
Carle BroMenn Medical Center,8980259,amantadine HCL 50 mg/5 mL oral solution,50383080716,,259,$11.41 ,$11.41 ,$3.42 ,$10.38 ,$7.99 ,$3.42 ,$7.42 ,$8.22 ,$10.38 ,$8.56 
Carle BroMenn Medical Center,8980259,amitriptyline 50 mg tablet,60687044401,,259,$5.57 ,$5.57 ,$1.67 ,$5.07 ,$3.90 ,$1.67 ,$3.62 ,$4.01 ,$5.07 ,$4.18 
Carle BroMenn Medical Center,8980259,amitriptyline 50 mg tablet,60687044411,,259,$5.57 ,$5.57 ,$1.67 ,$5.07 ,$3.90 ,$1.67 ,$3.62 ,$4.01 ,$5.07 ,$4.18 
Carle BroMenn Medical Center,8980259,amLODIPine 2.5 mg tablet,904636961,,259,$9.75 ,$9.75 ,$2.93 ,$8.87 ,$6.83 ,$2.93 ,$6.34 ,$7.02 ,$8.87 ,$7.31 
Carle BroMenn Medical Center,8980259,amLODIPine 2.5 mg tablet,67877019790,,259,$10.46 ,$10.46 ,$3.14 ,$9.52 ,$7.32 ,$3.14 ,$6.80 ,$7.53 ,$9.52 ,$7.85 
Carle BroMenn Medical Center,8980259,amoxicillin 875 mg tablet,143928501,,259,$6.39 ,$6.39 ,$1.92 ,$5.81 ,$4.47 ,$1.92 ,$4.15 ,$4.60 ,$5.81 ,$4.79 
Carle BroMenn Medical Center,8980259,amoxicillin 875 mg tablet,57237002920,,259,$6.59 ,$6.59 ,$1.98 ,$6.00 ,$4.61 ,$1.98 ,$4.28 ,$4.74 ,$6.00 ,$4.94 
Carle BroMenn Medical Center,8980259,"aspirin 325 mg tablet,delayed release",69618001501,,259,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980259,aspirin-acetaminophen-caffeine 250 mg-250 mg-65 mg tablet,904513559,,259,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980259,benzocaine 20 % mucosal gel,283087131,,259,$53.78 ,$53.78 ,$16.13 ,$48.94 ,$37.65 ,$16.13 ,$34.96 ,$38.72 ,$48.94 ,$40.34 
Carle BroMenn Medical Center,8980259,benztropine 1 mg tablet,904679061,,259,$5.07 ,$5.07 ,$1.52 ,$4.61 ,$3.55 ,$1.52 ,$3.30 ,$3.65 ,$4.61 ,$3.80 
Carle BroMenn Medical Center,8980259,benztropine 1 mg tablet,60687036801,,259,$5.07 ,$5.07 ,$1.52 ,$4.61 ,$3.55 ,$1.52 ,$3.30 ,$3.65 ,$4.61 ,$3.80 
Carle BroMenn Medical Center,8980259,benztropine 1 mg tablet,60687036811,,259,$5.07 ,$5.07 ,$1.52 ,$4.61 ,$3.55 ,$1.52 ,$3.30 ,$3.65 ,$4.61 ,$3.80 
Carle BroMenn Medical Center,8980259,"budesonide DR - ER 3 mg capsule,delayed,extended release",574985510,J3490,259,$14.77 ,$14.77 ,$4.43 ,$13.44 ,$10.34 ,$4.43 ,$9.60 ,$10.63 ,$13.44 ,$11.08 
Carle BroMenn Medical Center,8980259,bumetanide 0.5 mg tablet,42799011901,,259,$13.53 ,$13.53 ,$4.06 ,$12.31 ,$9.47 ,$4.06 ,$8.79 ,$9.74 ,$12.31 ,$10.15 
Carle BroMenn Medical Center,8980259,"buPROPion HCL SR 150 mg tablet,12 hr sustained-release",904658561,,259,$5.61 ,$5.61 ,$1.68 ,$5.11 ,$3.93 ,$1.68 ,$3.65 ,$4.04 ,$5.11 ,$4.21 
Carle BroMenn Medical Center,8980259,"buPROPion HCL SR 150 mg tablet,12 hr sustained-release",43547028910,,259,$11.37 ,$11.37 ,$3.41 ,$10.35 ,$7.96 ,$3.41 ,$7.39 ,$8.19 ,$10.35 ,$8.53 
Carle BroMenn Medical Center,8980259,"buPROPion HCL SR 150 mg tablet,12 hr sustained-release",68084070825,,259,$5.75 ,$5.75 ,$1.73 ,$5.23 ,$4.03 ,$1.73 ,$3.74 ,$4.14 ,$5.23 ,$4.31 
Carle BroMenn Medical Center,8980259,"buPROPion HCL SR 150 mg tablet,12 hr sustained-release",68084070895,,259,$5.75 ,$5.75 ,$1.73 ,$5.23 ,$4.03 ,$1.73 ,$3.74 ,$4.14 ,$5.23 ,$4.31 
Carle BroMenn Medical Center,8980259,caffeine 200 mg tablet,10135017575,,259,$2.58 ,$2.58 ,$0.77 ,$2.35 ,$1.81 ,$0.77 ,$1.68 ,$1.86 ,$2.35 ,$1.94 
Carle BroMenn Medical Center,8980259,caffeine 200 mg tablet,46017001808,,259,$3.45 ,$3.45 ,$1.04 ,$3.14 ,$2.42 ,$1.04 ,$2.24 ,$2.48 ,$3.14 ,$2.59 
Carle BroMenn Medical Center,8980259,caffeine 200 mg tablet,46017001816,,259,$3.45 ,$3.45 ,$1.04 ,$3.14 ,$2.42 ,$1.04 ,$2.24 ,$2.48 ,$3.14 ,$2.59 
Carle BroMenn Medical Center,8980259,caffeine 200 mg tablet,46122045773,,259,$3.49 ,$3.49 ,$1.05 ,$3.18 ,$2.44 ,$1.05 ,$2.27 ,$2.51 ,$3.18 ,$2.62 
Carle BroMenn Medical Center,8980259,calcitonin (salmon) 200 unit/actuation nasal spray,49884016111,,259,$573.37 ,$573.37 ,$172.01 ,$521.77 ,$401.36 ,$172.01 ,$372.69 ,$412.83 ,$521.77 ,$430.03 
Carle BroMenn Medical Center,8980259,calcitonin (salmon) 200 unit/actuation nasal spray,60505082306,,259,$573.37 ,$573.37 ,$172.01 ,$521.77 ,$401.36 ,$172.01 ,$372.69 ,$412.83 ,$521.77 ,$430.03 
Carle BroMenn Medical Center,8980259,"calcium acetate-aluminum 952 mg-1,347 mg topical powder in packet",51224016212,,259,$1.59 ,$1.59 ,$0.48 ,$1.45 ,$1.11 ,$0.48 ,$1.03 ,$1.14 ,$1.45 ,$1.19 
Carle BroMenn Medical Center,8980259,"calcium acetate-aluminum 952 mg-1,347 mg topical powder in packet",51224016299,,259,$1.04 ,$1.04 ,$0.31 ,$0.95 ,$0.73 ,$0.31 ,$0.68 ,$0.75 ,$0.95 ,$0.78 
Carle BroMenn Medical Center,8980259,"calcium carbonate 500 mg calcium (1,250 mg) tablet",904188361,,259,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980259,calcium polycarbophiL 625 mg tablet,536430611,,259,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980259,calcium polycarbophiL 625 mg tablet,904250091,,259,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980259,calcium polycarbophiL 625 mg tablet,24385012576,,259,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980259,calcium polycarbophiL 625 mg tablet,87701070558,,259,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980259,captopriL 50 mg tablet,69292052601,,259,$12.73 ,$12.73 ,$3.82 ,$11.58 ,$8.91 ,$3.82 ,$8.27 ,$9.17 ,$11.58 ,$9.55 
Carle BroMenn Medical Center,8980259,cefpodoxime 200 mg tablet,781543920,,259,$37.75 ,$37.75 ,$11.33 ,$34.35 ,$26.43 ,$11.33 ,$24.54 ,$27.18 ,$34.35 ,$28.31 
Carle BroMenn Medical Center,8980259,cefpodoxime 200 mg tablet,65862009620,,259,$37.75 ,$37.75 ,$11.33 ,$34.35 ,$26.43 ,$11.33 ,$24.54 ,$27.18 ,$34.35 ,$28.31 
Carle BroMenn Medical Center,8980259,cephalexin 250 mg/5 mL oral suspension,93417773,,259,$174.61 ,$174.61 ,$52.38 ,$158.90 ,$122.23 ,$52.38 ,$113.50 ,$125.72 ,$158.90 ,$130.96 
Carle BroMenn Medical Center,8980259,cephalexin 250 mg/5 mL oral suspension,68180044101,,259,$15.37 ,$15.37 ,$4.61 ,$13.99 ,$10.76 ,$4.61 ,$9.99 ,$11.07 ,$13.99 ,$11.53 
Carle BroMenn Medical Center,8980259,cetirizine 10 mg tablet,51079059701,,259,$13.95 ,$13.95 ,$4.19 ,$12.69 ,$9.77 ,$4.19 ,$9.07 ,$10.04 ,$12.69 ,$10.46 
Carle BroMenn Medical Center,8980259,cetirizine 10 mg tablet,51079059720,,259,$3.49 ,$3.49 ,$1.05 ,$3.18 ,$2.44 ,$1.05 ,$2.27 ,$2.51 ,$3.18 ,$2.62 
Carle BroMenn Medical Center,8980259,citalopram 10 mg tablet,904608461,,259,$13.64 ,$13.64 ,$4.09 ,$12.41 ,$9.55 ,$4.09 ,$8.87 ,$9.82 ,$12.41 ,$10.23 
Carle BroMenn Medical Center,8980259,clindamycin 75 mg/5 mL oral solution,65862059601,,259,$367.83 ,$367.83 ,$110.35 ,$334.73 ,$257.48 ,$110.35 ,$239.09 ,$264.84 ,$334.73 ,$275.87 
Carle BroMenn Medical Center,8980259,clomiPRAMINE 25 mg capsule,832063011,,259,$47.50 ,$47.50 ,$14.25 ,$43.23 ,$33.25 ,$14.25 ,$30.88 ,$34.20 ,$43.23 ,$35.63 
Carle BroMenn Medical Center,8980259,cloNIDine HCL 0.3 mg tablet,68001023900,,259,$4.77 ,$4.77 ,$1.43 ,$4.34 ,$3.34 ,$1.43 ,$3.10 ,$3.43 ,$4.34 ,$3.58 
Carle BroMenn Medical Center,8980259,clopidogreL 300 mg tablet,904646707,,259,$75.58 ,$75.58 ,$22.67 ,$68.78 ,$52.91 ,$22.67 ,$49.13 ,$54.42 ,$68.78 ,$56.69 
Carle BroMenn Medical Center,8980259,clopidogreL 300 mg tablet,68084075225,,259,$101.37 ,$101.37 ,$30.41 ,$92.25 ,$70.96 ,$30.41 ,$65.89 ,$72.99 ,$92.25 ,$76.03 
Carle BroMenn Medical Center,8980259,clopidogreL 300 mg tablet,68084075295,,259,$101.37 ,$101.37 ,$30.41 ,$92.25 ,$70.96 ,$30.41 ,$65.89 ,$72.99 ,$92.25 ,$76.03 
Carle BroMenn Medical Center,8980259,clopidogreL 300 mg tablet,69367019430,,259,$105.60 ,$105.60 ,$31.68 ,$96.10 ,$73.92 ,$31.68 ,$68.64 ,$76.03 ,$96.10 ,$79.20 
Carle BroMenn Medical Center,8980259,clotrimazole-betamethasone 1 %-0.05 % topical cream,472037915,,259,$201.52 ,$201.52 ,$60.46 ,$183.38 ,$141.06 ,$60.46 ,$130.99 ,$145.09 ,$183.38 ,$151.14 
Carle BroMenn Medical Center,8980259,clotrimazole-betamethasone 1 %-0.05 % topical cream,68462029817,,259,$282.89 ,$282.89 ,$84.87 ,$257.43 ,$198.02 ,$84.87 ,$183.88 ,$203.68 ,$257.43 ,$212.17 
Carle BroMenn Medical Center,8980259,cloZAPine 100 mg tablet,378086001,,259,$18.26 ,$18.26 ,$5.48 ,$16.62 ,$12.78 ,$5.48 ,$11.87 ,$13.15 ,$16.62 ,$13.70 
Carle BroMenn Medical Center,8980259,cloZAPine 100 mg tablet,51079092201,,259,$18.30 ,$18.30 ,$5.49 ,$16.65 ,$12.81 ,$5.49 ,$11.90 ,$13.18 ,$16.65 ,$13.73 
Carle BroMenn Medical Center,8980259,cloZAPine 100 mg tablet,51079092220,,259,$18.30 ,$18.30 ,$5.49 ,$16.65 ,$12.81 ,$5.49 ,$11.90 ,$13.18 ,$16.65 ,$13.73 
Carle BroMenn Medical Center,8980259,colestipoL 1 gram tablet,115521116,,259,$13.87 ,$13.87 ,$4.16 ,$12.62 ,$9.71 ,$4.16 ,$9.02 ,$9.99 ,$12.62 ,$10.40 
Carle BroMenn Medical Center,8980259,colestipoL 1 gram tablet,59762045001,,259,$14.10 ,$14.10 ,$4.23 ,$12.83 ,$9.87 ,$4.23 ,$9.17 ,$10.15 ,$12.83 ,$10.58 
Carle BroMenn Medical Center,8980259,conjugated estrogens 0.625 mg tablet,46110281,,259,$34.19 ,$34.19 ,$10.26 ,$31.11 ,$23.93 ,$10.26 ,$22.22 ,$24.62 ,$31.11 ,$25.64 
Carle BroMenn Medical Center,8980259,dexAMETHasone 1 mg/mL drops (concentrate),54317644,,259,$194.16 ,$194.16 ,$58.25 ,$176.69 ,$135.91 ,$58.25 ,$126.20 ,$139.80 ,$176.69 ,$145.62 
Carle BroMenn Medical Center,8980259,"diclofenac sodium 75 mg tablet,delayed release",68001028106,,259,$10.60 ,$10.60 ,$3.18 ,$9.65 ,$7.42 ,$3.18 ,$6.89 ,$7.63 ,$9.65 ,$7.95 
Carle BroMenn Medical Center,8980259,digoxin 250 mcg (0.25 mg) tablet,904592261,,259,$10.18 ,$10.18 ,$3.05 ,$9.26 ,$7.13 ,$3.05 ,$6.62 ,$7.33 ,$9.26 ,$7.64 
Carle BroMenn Medical Center,8980259,"dinoprostone ER 10 mg vaginal insert,controlled release",55566280000,,259,"$1,927.52 ","$1,927.52 ",$578.26 ,"$1,754.04 ","$1,349.26 ",$578.26 ,"$1,252.89 ","$1,387.81 ","$1,754.04 ","$1,445.64 "
Carle BroMenn Medical Center,8980259,"dinoprostone ER 10 mg vaginal insert,controlled release",55566280001,,259,"$1,927.52 ","$1,927.52 ",$578.26 ,"$1,754.04 ","$1,349.26 ",$578.26 ,"$1,252.89 ","$1,387.81 ","$1,754.04 ","$1,445.64 "
Carle BroMenn Medical Center,8980259,"divalproex 250 mg tablet,delayed release",832712301,,259,$7.33 ,$7.33 ,$2.20 ,$6.67 ,$5.13 ,$2.20 ,$4.76 ,$5.28 ,$6.67 ,$5.50 
Carle BroMenn Medical Center,8980259,"divalproex 250 mg tablet,delayed release",832712389,,259,$7.33 ,$7.33 ,$2.20 ,$6.67 ,$5.13 ,$2.20 ,$4.76 ,$5.28 ,$6.67 ,$5.50 
Carle BroMenn Medical Center,8980259,"divalproex 250 mg tablet,delayed release",904686061,,259,$3.44 ,$3.44 ,$1.03 ,$3.13 ,$2.41 ,$1.03 ,$2.24 ,$2.48 ,$3.13 ,$2.58 
Carle BroMenn Medical Center,8980259,"divalproex 250 mg tablet,delayed release",68084077601,,259,$10.54 ,$10.54 ,$3.16 ,$9.59 ,$7.38 ,$3.16 ,$6.85 ,$7.59 ,$9.59 ,$7.91 
Carle BroMenn Medical Center,8980259,"divalproex 500 mg tablet,delayed release",832712401,,259,$8.96 ,$8.96 ,$2.69 ,$8.15 ,$6.27 ,$2.69 ,$5.82 ,$6.45 ,$8.15 ,$6.72 
Carle BroMenn Medical Center,8980259,"divalproex 500 mg tablet,delayed release",832712489,,259,$8.96 ,$8.96 ,$2.69 ,$8.15 ,$6.27 ,$2.69 ,$5.82 ,$6.45 ,$8.15 ,$6.72 
Carle BroMenn Medical Center,8980259,doxepin 10 mg capsule,51079043601,,259,$5.31 ,$5.31 ,$1.59 ,$4.83 ,$3.72 ,$1.59 ,$3.45 ,$3.82 ,$4.83 ,$3.98 
Carle BroMenn Medical Center,8980259,doxepin 10 mg capsule,51079043620,,259,$5.31 ,$5.31 ,$1.59 ,$4.83 ,$3.72 ,$1.59 ,$3.45 ,$3.82 ,$4.83 ,$3.98 
Carle BroMenn Medical Center,8980259,doxylamine succinate 25 mg tablet,41167000623,,259,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980259,doxylamine succinate 25 mg tablet,70030013186,,259,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980259,"ergocalciferol (vitamin D2) 1,250 mcg (50,000 unit) capsule",62332046431,,259,$5.68 ,$5.68 ,$1.70 ,$5.17 ,$3.98 ,$1.70 ,$3.69 ,$4.09 ,$5.17 ,$4.26 
Carle BroMenn Medical Center,8980259,"ergocalciferol (vitamin D2) 1,250 mcg (50,000 unit) capsule",69452015120,,259,$5.68 ,$5.68 ,$1.70 ,$5.17 ,$3.98 ,$1.70 ,$3.69 ,$4.09 ,$5.17 ,$4.26 
Carle BroMenn Medical Center,8980259,"erythromycin 250 mg tablet,delayed release",52536018003,,259,$37.51 ,$37.51 ,$11.25 ,$34.13 ,$26.26 ,$11.25 ,$24.38 ,$27.01 ,$34.13 ,$28.13 
Carle BroMenn Medical Center,8980259,escitalopram 10 mg tablet,904642661,,259,$22.75 ,$22.75 ,$6.83 ,$20.70 ,$15.93 ,$6.83 ,$14.79 ,$16.38 ,$20.70 ,$17.06 
Carle BroMenn Medical Center,8980259,escitalopram 10 mg tablet,68084061701,,259,$22.46 ,$22.46 ,$6.74 ,$20.44 ,$15.72 ,$6.74 ,$14.60 ,$16.17 ,$20.44 ,$16.85 
Carle BroMenn Medical Center,8980259,escitalopram 10 mg tablet,68084061711,,259,$22.46 ,$22.46 ,$6.74 ,$20.44 ,$15.72 ,$6.74 ,$14.60 ,$16.17 ,$20.44 ,$16.85 
Carle BroMenn Medical Center,8980259,estradioL 0.5 mg tablet,42806008701,,259,$4.90 ,$4.90 ,$1.47 ,$4.46 ,$3.43 ,$1.47 ,$3.19 ,$3.53 ,$4.46 ,$3.68 
Carle BroMenn Medical Center,8980259,ethacrynic acid 25 mg tablet,42799040501,,259,$91.98 ,$91.98 ,$27.59 ,$83.70 ,$64.39 ,$27.59 ,$59.79 ,$66.23 ,$83.70 ,$68.99 
Carle BroMenn Medical Center,8980259,ezetimibe 10 mg tablet,781569031,,259,$14.52 ,$14.52 ,$4.36 ,$13.21 ,$10.16 ,$4.36 ,$9.44 ,$10.45 ,$13.21 ,$10.89 
Carle BroMenn Medical Center,8980259,ezetimibe 10 mg tablet,67877049030,,259,$44.14 ,$44.14 ,$13.24 ,$40.17 ,$30.90 ,$13.24 ,$28.69 ,$31.78 ,$40.17 ,$33.11 
Carle BroMenn Medical Center,8980259,famotidine 40 mg/5 mL (8 mg/mL) oral suspension,9999045055,,259,$26.80 ,$26.80 ,$8.04 ,$24.39 ,$18.76 ,$8.04 ,$17.42 ,$19.30 ,$24.39 ,$20.10 
Carle BroMenn Medical Center,8980259,fentaNYL 12 mcg/hr transdermal patch,378911998,,259,$81.55 ,$81.55 ,$24.47 ,$74.21 ,$57.09 ,$24.47 ,$53.01 ,$58.72 ,$74.21 ,$61.16 
Carle BroMenn Medical Center,8980259,fentaNYL 12 mcg/hr transdermal patch,406901276,,259,$81.55 ,$81.55 ,$24.47 ,$74.21 ,$57.09 ,$24.47 ,$53.01 ,$58.72 ,$74.21 ,$61.16 
Carle BroMenn Medical Center,8980259,fentaNYL 12 mcg/hr transdermal patch,406911276,,259,$81.55 ,$81.55 ,$24.47 ,$74.21 ,$57.09 ,$24.47 ,$53.01 ,$58.72 ,$74.21 ,$61.16 
Carle BroMenn Medical Center,8980259,fentaNYL 25 mcg/hr transdermal patch,406902576,,259,$60.96 ,$60.96 ,$18.29 ,$55.47 ,$42.67 ,$18.29 ,$39.62 ,$43.89 ,$55.47 ,$45.72 
Carle BroMenn Medical Center,8980259,fentaNYL 25 mcg/hr transdermal patch,406912576,,259,$60.96 ,$60.96 ,$18.29 ,$55.47 ,$42.67 ,$18.29 ,$39.62 ,$43.89 ,$55.47 ,$45.72 
Carle BroMenn Medical Center,8980259,flucytosine 500 mg capsule,42494034001,,259,$563.97 ,$563.97 ,$169.19 ,$513.21 ,$394.78 ,$169.19 ,$366.58 ,$406.06 ,$513.21 ,$422.98 
Carle BroMenn Medical Center,8980259,flucytosine 500 mg capsule,42794001008,,259,$256.07 ,$256.07 ,$76.82 ,$233.02 ,$179.25 ,$76.82 ,$166.45 ,$184.37 ,$233.02 ,$192.05 
Carle BroMenn Medical Center,8980259,furosemide 10 mg/mL oral solution,54329446,,259,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980259,glimepiride 1 mg tablet,16729000101,,259,$4.20 ,$4.20 ,$1.26 ,$3.82 ,$2.94 ,$1.26 ,$2.73 ,$3.02 ,$3.82 ,$3.15 
Carle BroMenn Medical Center,8980259,glimepiride 2 mg tablet,68084032601,,259,$6.44 ,$6.44 ,$1.93 ,$5.86 ,$4.51 ,$1.93 ,$4.19 ,$4.64 ,$5.86 ,$4.83 
Carle BroMenn Medical Center,8980259,glimepiride 2 mg tablet,68084032611,,259,$6.44 ,$6.44 ,$1.93 ,$5.86 ,$4.51 ,$1.93 ,$4.19 ,$4.64 ,$5.86 ,$4.83 
Carle BroMenn Medical Center,8980259,"glipiZIDE ER 2.5 mg tablet, extended release 24 hr",59651026830,,259,$4.23 ,$4.23 ,$1.27 ,$3.85 ,$2.96 ,$1.27 ,$2.75 ,$3.05 ,$3.85 ,$3.17 
Carle BroMenn Medical Center,8980259,"glipiZIDE ER 2.5 mg tablet, extended release 24 hr",59762054001,,259,$4.23 ,$4.23 ,$1.27 ,$3.85 ,$2.96 ,$1.27 ,$2.75 ,$3.05 ,$3.85 ,$3.17 
Carle BroMenn Medical Center,8980259,"glipiZIDE ER 2.5 mg tablet, extended release 24 hr",64980027903,,259,$4.23 ,$4.23 ,$1.27 ,$3.85 ,$2.96 ,$1.27 ,$2.75 ,$3.05 ,$3.85 ,$3.17 
Carle BroMenn Medical Center,8980259,"glipiZIDE ER 2.5 mg tablet, extended release 24 hr",65862088830,,259,$4.23 ,$4.23 ,$1.27 ,$3.85 ,$2.96 ,$1.27 ,$2.75 ,$3.05 ,$3.85 ,$3.17 
Carle BroMenn Medical Center,8980259,glycerin (adult) rectal suppository,132007912,,259,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980259,glycerin (adult) rectal suppository,132007924,,259,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980259,glycerin (child) rectal suppository,132008112,,259,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980259,guaiFENesin 200 mg tablet,904515460,,259,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980259,hydrocortisone 2.5 % topical cream,45802000403,,259,$66.61 ,$66.61 ,$19.98 ,$60.62 ,$46.63 ,$19.98 ,$43.30 ,$47.96 ,$60.62 ,$49.96 
Carle BroMenn Medical Center,8980259,hydrocortisone 2.5 % topical cream,51672300302,,259,$56.63 ,$56.63 ,$16.99 ,$51.53 ,$39.64 ,$16.99 ,$36.81 ,$40.77 ,$51.53 ,$42.47 
Carle BroMenn Medical Center,8980259,Insulin Regular human 100 unit/mL Sub-Q,2821517,,259,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980259,ketoconazole 2 % shampoo,45802046564,,259,$161.89 ,$161.89 ,$48.57 ,$147.32 ,$113.32 ,$48.57 ,$105.23 ,$116.56 ,$147.32 ,$121.42 
Carle BroMenn Medical Center,8980259,ketotifen 0.025 % (0.035 %) eye drops,17478071710,,259,$74.45 ,$74.45 ,$22.34 ,$67.75 ,$52.12 ,$22.34 ,$48.39 ,$53.60 ,$67.75 ,$55.84 
Carle BroMenn Medical Center,8980259,"lactase 3,000 unit tablet",904522452,,259,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980259,Lactobacillus rhamnosus GG 10 billion cell capsule,49100038164,,259,$1.25 ,$1.25 ,$0.38 ,$1.14 ,$0.88 ,$0.38 ,$0.81 ,$0.90 ,$1.14 ,$0.94 
Carle BroMenn Medical Center,8980259,Lactobacillus rhamnosus GG 10 billion cell capsule,49100040007,,259,$1.60 ,$1.60 ,$0.48 ,$1.46 ,$1.12 ,$0.48 ,$1.04 ,$1.15 ,$1.46 ,$1.20 
Carle BroMenn Medical Center,8980259,lanolin alcohols-mineral oil-w.petrolatum-ceresin topical cream,904775127,,259,$32.57 ,$32.57 ,$9.77 ,$29.64 ,$22.80 ,$9.77 ,$21.17 ,$23.45 ,$29.64 ,$24.43 
Carle BroMenn Medical Center,8980259,lanolin alcohols-mineral oil-w.petrolatum-ceresin topical cream,72140000022,,259,$50.85 ,$50.85 ,$15.26 ,$46.27 ,$35.60 ,$15.26 ,$33.05 ,$36.61 ,$46.27 ,$38.14 
Carle BroMenn Medical Center,8980259,lanolin alcohols-mineral oil-w.petrolatum-ceresin topical cream,80681015500,,259,$21.26 ,$21.26 ,$6.38 ,$19.35 ,$14.88 ,$6.38 ,$13.82 ,$15.31 ,$19.35 ,$15.95 
Carle BroMenn Medical Center,8980259,lithium carbonate 300 mg capsule,54852725,,259,$3.31 ,$3.31 ,$0.99 ,$3.01 ,$2.32 ,$0.99 ,$2.15 ,$2.38 ,$3.01 ,$2.48 
Carle BroMenn Medical Center,8980259,magnesium oxide 400 mg (241.3 mg magnesium) tablet,10006070028,,259,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980259,magnesium oxide 400 mg (241.3 mg magnesium) tablet,64980033901,,259,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980259,magnesium oxide 400 mg (241.3 mg magnesium) tablet,64980033990,,259,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980259,meloxicam 7.5 mg tablet,50268052511,,259,$16.77 ,$16.77 ,$5.03 ,$15.26 ,$11.74 ,$5.03 ,$10.90 ,$12.07 ,$15.26 ,$12.58 
Carle BroMenn Medical Center,8980259,meloxicam 7.5 mg tablet,50268052515,,259,$16.77 ,$16.77 ,$5.03 ,$15.26 ,$11.74 ,$5.03 ,$10.90 ,$12.07 ,$15.26 ,$12.58 
Carle BroMenn Medical Center,8980259,metaxalone 800 mg tablet,55111065001,,259,$25.12 ,$25.12 ,$7.54 ,$22.86 ,$17.58 ,$7.54 ,$16.33 ,$18.09 ,$22.86 ,$18.84 
Carle BroMenn Medical Center,8980259,metFORMIN 850 mg tablet,23155010301,,259,$2.67 ,$2.67 ,$0.80 ,$2.43 ,$1.87 ,$0.80 ,$1.74 ,$1.92 ,$2.43 ,$2.00 
Carle BroMenn Medical Center,8980259,metFORMIN 850 mg tablet,70010006401,,259,$7.91 ,$7.91 ,$2.37 ,$7.20 ,$5.54 ,$2.37 ,$5.14 ,$5.70 ,$7.20 ,$5.93 
Carle BroMenn Medical Center,8980259,"metFORMIN ER 500 mg tablet,extended release 24 hr",51224000750,,259,$5.80 ,$5.80 ,$1.74 ,$5.28 ,$4.06 ,$1.74 ,$3.77 ,$4.18 ,$5.28 ,$4.35 
Carle BroMenn Medical Center,8980259,"metFORMIN ER 500 mg tablet,extended release 24 hr",70010049101,,259,$6.30 ,$6.30 ,$1.89 ,$5.73 ,$4.41 ,$1.89 ,$4.10 ,$4.54 ,$5.73 ,$4.73 
Carle BroMenn Medical Center,8980259,methyl salicylate 15 %-menthol 10 % topical cream,45802017453,,259,$22.79 ,$22.79 ,$6.84 ,$20.74 ,$15.95 ,$6.84 ,$14.81 ,$16.41 ,$20.74 ,$17.09 
Carle BroMenn Medical Center,8980259,metoclopramide 5 mg tablet,93220401,,259,$3.88 ,$3.88 ,$1.16 ,$3.53 ,$2.72 ,$1.16 ,$2.52 ,$2.79 ,$3.53 ,$2.91 
Carle BroMenn Medical Center,8980259,metoclopramide 5 mg tablet,51079088601,,259,$6.54 ,$6.54 ,$1.96 ,$5.95 ,$4.58 ,$1.96 ,$4.25 ,$4.71 ,$5.95 ,$4.91 
Carle BroMenn Medical Center,8980259,metoclopramide 5 mg tablet,51079088620,,259,$6.54 ,$6.54 ,$1.96 ,$5.95 ,$4.58 ,$1.96 ,$4.25 ,$4.71 ,$5.95 ,$4.91 
Carle BroMenn Medical Center,8980259,metroNIDAZOLE 0.75 % vaginal gel,781707787,,259,$733.06 ,$733.06 ,$219.92 ,$667.08 ,$513.14 ,$219.92 ,$476.49 ,$527.80 ,$667.08 ,$549.80 
Carle BroMenn Medical Center,8980259,metroNIDAZOLE 0.75 % vaginal gel,45802013970,,259,$733.06 ,$733.06 ,$219.92 ,$667.08 ,$513.14 ,$219.92 ,$476.49 ,$527.80 ,$667.08 ,$549.80 
Carle BroMenn Medical Center,8980259,miconazole nitrate 2 % vaginal cream,472073063,,259,$67.40 ,$67.40 ,$20.22 ,$61.33 ,$47.18 ,$20.22 ,$43.81 ,$48.53 ,$61.33 ,$50.55 
Carle BroMenn Medical Center,8980259,midazolam 2 mg/mL oral syrup,54356699,,259,$68.65 ,$68.65 ,$20.60 ,$62.47 ,$48.06 ,$20.60 ,$44.62 ,$49.43 ,$62.47 ,$51.49 
Carle BroMenn Medical Center,8980259,midazolam 2 mg/mL oral syrup,574015004,,259,$26.69 ,$26.69 ,$8.01 ,$24.29 ,$18.68 ,$8.01 ,$17.35 ,$19.22 ,$24.29 ,$20.02 
Carle BroMenn Medical Center,8980259,mineral oil oral,46122039516,,259,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980259,mineral oil oral,48433020230,,259,$1.39 ,$1.39 ,$0.42 ,$1.26 ,$0.97 ,$0.42 ,$0.90 ,$1.00 ,$1.26 ,$1.04 
Carle BroMenn Medical Center,8980259,mineral oil oral,87701042917,,259,$17.47 ,$17.47 ,$5.24 ,$15.90 ,$12.23 ,$5.24 ,$11.36 ,$12.58 ,$15.90 ,$13.10 
Carle BroMenn Medical Center,8980259,modafiniL 200 mg tablet,60505252703,,259,$150.16 ,$150.16 ,$45.05 ,$136.65 ,$105.11 ,$45.05 ,$97.60 ,$108.12 ,$136.65 ,$112.62 
Carle BroMenn Medical Center,8980259,modafiniL 200 mg tablet,65862060201,,259,$150.30 ,$150.30 ,$45.09 ,$136.77 ,$105.21 ,$45.09 ,$97.70 ,$108.22 ,$136.77 ,$112.73 
Carle BroMenn Medical Center,8980259,modified lanolin 100 % topical cream,44677010020,,259,$45.40 ,$45.40 ,$13.62 ,$41.31 ,$31.78 ,$13.62 ,$29.51 ,$32.69 ,$41.31 ,$34.05 
Carle BroMenn Medical Center,8980259,modified lanolin 100 % topical cream,44677010202,,259,$18.17 ,$18.17 ,$5.45 ,$16.53 ,$12.72 ,$5.45 ,$11.81 ,$13.08 ,$16.53 ,$13.63 
Carle BroMenn Medical Center,8980259,nadoloL 20 mg tablet,68001031700,,259,$18.15 ,$18.15 ,$5.45 ,$16.52 ,$12.71 ,$5.45 ,$11.80 ,$13.07 ,$16.52 ,$13.61 
Carle BroMenn Medical Center,8980259,naltrexone 50 mg tablet,406117003,,259,$22.25 ,$22.25 ,$6.68 ,$20.25 ,$15.58 ,$6.68 ,$14.46 ,$16.02 ,$20.25 ,$16.69 
Carle BroMenn Medical Center,8980259,naltrexone 50 mg tablet,16729008110,,259,$22.23 ,$22.23 ,$6.67 ,$20.23 ,$15.56 ,$6.67 ,$14.45 ,$16.01 ,$20.23 ,$16.67 
Carle BroMenn Medical Center,8980259,naphazoline 0.025 %-pheniramine 0.3 % eye drops,65008515,,259,$55.97 ,$55.97 ,$16.79 ,$50.93 ,$39.18 ,$16.79 ,$36.38 ,$40.30 ,$50.93 ,$41.98 
Carle BroMenn Medical Center,8980259,naproxen 375 mg tablet,50268059515,,259,$6.93 ,$6.93 ,$2.08 ,$6.31 ,$4.85 ,$2.08 ,$4.50 ,$4.99 ,$6.31 ,$5.20 
Carle BroMenn Medical Center,8980259,nebivoloL 2.5 mg tablet,456140230,,259,$30.26 ,$30.26 ,$9.08 ,$27.54 ,$21.18 ,$9.08 ,$19.67 ,$21.79 ,$27.54 ,$22.70 
Carle BroMenn Medical Center,8980259,nebivoloL 5 mg tablet,456140563,,259,$30.68 ,$30.68 ,$9.20 ,$27.92 ,$21.48 ,$9.20 ,$19.94 ,$22.09 ,$27.92 ,$23.01 
Carle BroMenn Medical Center,8980259,"neomycin-polymyxin-hydrocort 3.5 mg-10,000 unit/mL-1 % ear drops,susp",24208063562,,259,$490.14 ,$490.14 ,$147.04 ,$446.03 ,$343.10 ,$147.04 ,$318.59 ,$352.90 ,$446.03 ,$367.61 
Carle BroMenn Medical Center,8980259,nicotine (polacrilex) 2 mg gum,536136223,,259,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980259,nicotine (polacrilex) 2 mg gum,536302923,,259,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980259,nitroglycerin 0.3 mg/hr transdermal 24 hour patch,50742051501,,259,$173.01 ,$173.01 ,$51.90 ,$157.44 ,$121.11 ,$51.90 ,$112.46 ,$124.57 ,$157.44 ,$129.76 
Carle BroMenn Medical Center,8980259,nitroglycerin 0.3 mg/hr transdermal 24 hour patch,50742051530,,259,$173.01 ,$173.01 ,$51.90 ,$157.44 ,$121.11 ,$51.90 ,$112.46 ,$124.57 ,$157.44 ,$129.76 
Carle BroMenn Medical Center,8980259,"nystatin-triamcinolone 100,000 unit/g-0.1 % topical cream",45802088094,,259,$185.51 ,$185.51 ,$55.65 ,$168.81 ,$129.86 ,$55.65 ,$120.58 ,$133.57 ,$168.81 ,$139.13 
Carle BroMenn Medical Center,8980259,"nystatin-triamcinolone 100,000 unit/g-0.1 % topical cream",68180054502,,259,$764.29 ,$764.29 ,$229.29 ,$695.50 ,$535.00 ,$229.29 ,$496.79 ,$550.29 ,$695.50 ,$573.22 
Carle BroMenn Medical Center,8980259,"nystatin-triamcinolone 100,000 unit/g-0.1 % topical cream",68462031435,,259,$764.29 ,$764.29 ,$229.29 ,$695.50 ,$535.00 ,$229.29 ,$496.79 ,$550.29 ,$695.50 ,$573.22 
Carle BroMenn Medical Center,8980259,OLANZapine 2.5 mg tablet,60505311000,,259,$47.34 ,$47.34 ,$14.20 ,$43.08 ,$33.14 ,$14.20 ,$30.77 ,$34.08 ,$43.08 ,$35.51 
Carle BroMenn Medical Center,8980259,OLANZapine 2.5 mg tablet,68084052501,,259,$47.25 ,$47.25 ,$14.18 ,$43.00 ,$33.08 ,$14.18 ,$30.71 ,$34.02 ,$43.00 ,$35.44 
Carle BroMenn Medical Center,8980259,OLANZapine 2.5 mg tablet,68084052511,,259,$47.25 ,$47.25 ,$14.18 ,$43.00 ,$33.08 ,$14.18 ,$30.71 ,$34.02 ,$43.00 ,$35.44 
Carle BroMenn Medical Center,8980259,OXcarbazepine 150 mg tablet,62756018388,,259,$9.07 ,$9.07 ,$2.72 ,$8.25 ,$6.35 ,$2.72 ,$5.90 ,$6.53 ,$8.25 ,$6.80 
Carle BroMenn Medical Center,8980259,OXcarbazepine 150 mg tablet,68084084501,,259,$9.36 ,$9.36 ,$2.81 ,$8.52 ,$6.55 ,$2.81 ,$6.08 ,$6.74 ,$8.52 ,$7.02 
Carle BroMenn Medical Center,8980259,OXcarbazepine 150 mg tablet,68084084511,,259,$9.36 ,$9.36 ,$2.81 ,$8.52 ,$6.55 ,$2.81 ,$6.08 ,$6.74 ,$8.52 ,$7.02 
Carle BroMenn Medical Center,8980259,OXcarbazepine 300 mg tablet,68084085301,,259,$15.17 ,$15.17 ,$4.55 ,$13.80 ,$10.62 ,$4.55 ,$9.86 ,$10.92 ,$13.80 ,$11.38 
Carle BroMenn Medical Center,8980259,OXcarbazepine 300 mg tablet,68084085311,,259,$15.17 ,$15.17 ,$4.55 ,$13.80 ,$10.62 ,$4.55 ,$9.86 ,$10.92 ,$13.80 ,$11.38 
Carle BroMenn Medical Center,8980259,OXcarbazepine 300 mg tablet,68462013801,,259,$14.49 ,$14.49 ,$4.35 ,$13.19 ,$10.14 ,$4.35 ,$9.42 ,$10.43 ,$13.19 ,$10.87 
Carle BroMenn Medical Center,8980259,"oxybutynin chloride ER 5 mg tablet,extended release 24 hr",62175027037,,259,$16.65 ,$16.65 ,$5.00 ,$15.15 ,$11.66 ,$5.00 ,$10.82 ,$11.99 ,$15.15 ,$12.49 
Carle BroMenn Medical Center,8980259,"oxybutynin chloride ER 5 mg tablet,extended release 24 hr",63739054833,,259,$18.53 ,$18.53 ,$5.56 ,$16.86 ,$12.97 ,$5.56 ,$12.04 ,$13.34 ,$16.86 ,$13.90 
Carle BroMenn Medical Center,8980259,"oxyCODONE ER 15 mg tablet,crush resistant,extended release 12 hr",59011041520,,259,$38.63 ,$38.63 ,$11.59 ,$35.15 ,$27.04 ,$11.59 ,$25.11 ,$27.81 ,$35.15 ,$28.97 
Carle BroMenn Medical Center,8980259,PARoxetine 10 mg tablet,50268064015,,259,$5.89 ,$5.89 ,$1.77 ,$5.36 ,$4.12 ,$1.77 ,$3.83 ,$4.24 ,$5.36 ,$4.42 
Carle BroMenn Medical Center,8980259,penicillin V potassium 250 mg/5 mL oral solution,93412773,,259,$9.96 ,$9.96 ,$2.99 ,$9.06 ,$6.97 ,$2.99 ,$6.47 ,$7.17 ,$9.06 ,$7.47 
Carle BroMenn Medical Center,8980259,penicillin V potassium 250 mg/5 mL oral solution,93412774,J3490,259,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980259,pentosan polysulfate sodium 100 mg capsule,50458009801,,259,$48.40 ,$48.40 ,$14.52 ,$44.04 ,$33.88 ,$14.52 ,$31.46 ,$34.85 ,$44.04 ,$36.30 
Carle BroMenn Medical Center,8980259,phenazopyridine 100 mg tablet,51293061101,,259,$14.91 ,$14.91 ,$4.47 ,$13.57 ,$10.44 ,$4.47 ,$9.69 ,$10.74 ,$13.57 ,$11.18 
Carle BroMenn Medical Center,8980259,phenazopyridine 100 mg tablet,69367016204,,259,$14.91 ,$14.91 ,$4.47 ,$13.57 ,$10.44 ,$4.47 ,$9.69 ,$10.74 ,$13.57 ,$11.18 
Carle BroMenn Medical Center,8980259,PHENobarbitaL 32.4 mg tablet,904657561,,259,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980259,phenylephrine 0.25 %-cocoa butter 88.44 % rectal suppository,536118612,,259,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980259,phenylephrine 0.25 %-mineral oil 14 %-petrolatm 74.9 % rectal ointment,536128806,,259,$19.76 ,$19.76 ,$5.93 ,$17.98 ,$13.83 ,$5.93 ,$12.84 ,$14.23 ,$17.98 ,$14.82 
Carle BroMenn Medical Center,8980259,phenylephrine 0.25 %-mineral oil 14 %-petrolatm 74.9 % rectal ointment,45802018816,,259,$31.03 ,$31.03 ,$9.31 ,$28.24 ,$21.72 ,$9.31 ,$20.17 ,$22.34 ,$28.24 ,$23.27 
Carle BroMenn Medical Center,8980259,phenylephrine 0.25 %-mineral oil 14 %-petrolatm 74.9 % rectal ointment,46122010346,,259,$63.21 ,$63.21 ,$18.96 ,$57.52 ,$44.25 ,$18.96 ,$41.09 ,$45.51 ,$57.52 ,$47.41 
Carle BroMenn Medical Center,8980259,phenylephrine 2.5 % eye drops,17478020102,,259,$17.47 ,$17.47 ,$5.24 ,$15.90 ,$12.23 ,$5.24 ,$11.36 ,$12.58 ,$15.90 ,$13.10 
Carle BroMenn Medical Center,8980259,phenytoin sodium extended 30 mg capsule,71374066,,259,$9.21 ,$9.21 ,$2.76 ,$8.38 ,$6.45 ,$2.76 ,$5.99 ,$6.63 ,$8.38 ,$6.91 
Carle BroMenn Medical Center,8980259,phytonadione (vitamin K1) 5 mg tablet,16714097301,,259,$233.22 ,$233.22 ,$69.97 ,$212.23 ,$163.25 ,$69.97 ,$151.59 ,$167.92 ,$212.23 ,$174.92 
Carle BroMenn Medical Center,8980259,phytonadione (vitamin K1) 5 mg tablet,69238105103,,259,$242.60 ,$242.60 ,$72.78 ,$220.77 ,$169.82 ,$72.78 ,$157.69 ,$174.67 ,$220.77 ,$181.95 
Carle BroMenn Medical Center,8980259,pioglitazone 15 mg tablet,781542031,,259,$32.67 ,$32.67 ,$9.80 ,$29.73 ,$22.87 ,$9.80 ,$21.24 ,$23.52 ,$29.73 ,$24.50 
Carle BroMenn Medical Center,8980259,potassium chloride 20 mEq/15 mL oral liquid,121168040,,259,$73.21 ,$73.21 ,$21.96 ,$66.62 ,$51.25 ,$21.96 ,$47.59 ,$52.71 ,$66.62 ,$54.91 
Carle BroMenn Medical Center,8980259,potassium chloride 20 mEq/15 mL oral liquid,66689004701,,259,$108.65 ,$108.65 ,$32.60 ,$98.87 ,$76.06 ,$32.60 ,$70.62 ,$78.23 ,$98.87 ,$81.49 
Carle BroMenn Medical Center,8980259,pravastatin 10 mg tablet,904589161,,259,$15.81 ,$15.81 ,$4.74 ,$14.39 ,$11.07 ,$4.74 ,$10.28 ,$11.38 ,$14.39 ,$11.86 
Carle BroMenn Medical Center,8980259,pravastatin 10 mg tablet,60687016901,,259,$17.24 ,$17.24 ,$5.17 ,$15.69 ,$12.07 ,$5.17 ,$11.21 ,$12.41 ,$15.69 ,$12.93 
Carle BroMenn Medical Center,8980259,pravastatin 10 mg tablet,60687016911,,259,$17.24 ,$17.24 ,$5.17 ,$15.69 ,$12.07 ,$5.17 ,$11.21 ,$12.41 ,$15.69 ,$12.93 
Carle BroMenn Medical Center,8980259,prednisoLONE sodium phosphate 1 % eye drops,24208071510,,259,$17.47 ,$17.47 ,$5.24 ,$15.90 ,$12.23 ,$5.24 ,$11.36 ,$12.58 ,$15.90 ,$13.10 
Carle BroMenn Medical Center,8980259,pseudoephedrine 30 mg tablet,904505359,,259,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980259,ramelteon 8 mg tablet,64764080530,,259,$64.95 ,$64.95 ,$19.49 ,$59.10 ,$45.47 ,$19.49 ,$42.22 ,$46.76 ,$59.10 ,$48.71 
Carle BroMenn Medical Center,8980259,ramelteon 8 mg tablet,70710134403,,259,$59.46 ,$59.46 ,$17.84 ,$54.11 ,$41.62 ,$17.84 ,$38.65 ,$42.81 ,$54.11 ,$44.60 
Carle BroMenn Medical Center,8980259,risperiDONE 0.25 mg tablet,68084027001,,259,$20.47 ,$20.47 ,$6.14 ,$18.63 ,$14.33 ,$6.14 ,$13.31 ,$14.74 ,$18.63 ,$15.35 
Carle BroMenn Medical Center,8980259,risperiDONE 1 mg/mL oral solution,54006344,,259,$39.52 ,$39.52 ,$11.86 ,$35.96 ,$27.66 ,$11.86 ,$25.69 ,$28.45 ,$35.96 ,$29.64 
Carle BroMenn Medical Center,8980259,rivaroxaban 15 mg tablet,50458057801,,259,$77.10 ,$77.10 ,$23.13 ,$70.16 ,$53.97 ,$23.13 ,$50.12 ,$55.51 ,$70.16 ,$57.83 
Carle BroMenn Medical Center,8980259,rivaroxaban 15 mg tablet,50458057810,,259,$77.10 ,$77.10 ,$23.13 ,$70.16 ,$53.97 ,$23.13 ,$50.12 ,$55.51 ,$70.16 ,$57.83 
Carle BroMenn Medical Center,8980259,rivaroxaban 20 mg tablet,50458057901,,259,$77.10 ,$77.10 ,$23.13 ,$70.16 ,$53.97 ,$23.13 ,$50.12 ,$55.51 ,$70.16 ,$57.83 
Carle BroMenn Medical Center,8980259,rivaroxaban 20 mg tablet,50458057910,,259,$77.10 ,$77.10 ,$23.13 ,$70.16 ,$53.97 ,$23.13 ,$50.12 ,$55.51 ,$70.16 ,$57.83 
Carle BroMenn Medical Center,8980259,rivaroxaban 20 mg tablet,50458057930,,259,$77.10 ,$77.10 ,$23.13 ,$70.16 ,$53.97 ,$23.13 ,$50.12 ,$55.51 ,$70.16 ,$57.83 
Carle BroMenn Medical Center,8980259,rizatriptan 10 mg disintegrating tablet,65862062690,,259,$124.53 ,$124.53 ,$37.36 ,$113.32 ,$87.17 ,$37.36 ,$80.94 ,$89.66 ,$113.32 ,$93.40 
Carle BroMenn Medical Center,8980259,salmeteroL 50 mcg/dose blister powder for inhalation,173052000,,259,"$1,793.11 ","$1,793.11 ",$537.93 ,"$1,631.73 ","$1,255.18 ",$537.93 ,"$1,165.52 ","$1,291.04 ","$1,631.73 ","$1,344.83 "
Carle BroMenn Medical Center,8980259,simethicone 125 mg capsule,87701043013,,259,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980259,sodium chloride 3 % for nebulization,378699789,J3490,259,$6.52 ,$6.52 ,$1.96 ,$5.93 ,$4.56 ,$1.96 ,$4.24 ,$4.69 ,$5.93 ,$4.89 
Carle BroMenn Medical Center,8980259,sodium chloride 5 % eye drops,536125494,,259,$32.05 ,$32.05 ,$9.62 ,$29.17 ,$22.44 ,$9.62 ,$20.83 ,$23.08 ,$29.17 ,$24.04 
Carle BroMenn Medical Center,8980259,sodium chloride 5 % eye drops,17478062312,,259,$89.32 ,$89.32 ,$26.80 ,$81.28 ,$62.52 ,$26.80 ,$58.06 ,$64.31 ,$81.28 ,$66.99 
Carle BroMenn Medical Center,8980259,sodium chloride-aloe vera nasal gel,225052547,,259,$20.32 ,$20.32 ,$6.10 ,$18.49 ,$14.22 ,$6.10 ,$13.21 ,$14.63 ,$18.49 ,$15.24 
Carle BroMenn Medical Center,8980259,sodium hypochlorite 0.25 % solution,39328006325,,259,$83.33 ,$83.33 ,$25.00 ,$75.83 ,$58.33 ,$25.00 ,$54.16 ,$60.00 ,$75.83 ,$62.50 
Carle BroMenn Medical Center,8980259,sucralfate 1 gram tablet,51079075301,,259,$4.10 ,$4.10 ,$1.23 ,$3.73 ,$2.87 ,$1.23 ,$2.67 ,$2.95 ,$3.73 ,$3.08 
Carle BroMenn Medical Center,8980259,sucralfate 1 gram tablet,51079075320,,259,$4.10 ,$4.10 ,$1.23 ,$3.73 ,$2.87 ,$1.23 ,$2.67 ,$2.95 ,$3.73 ,$3.08 
Carle BroMenn Medical Center,8980259,sucralfate 1 gram tablet,59762040101,,259,$5.63 ,$5.63 ,$1.69 ,$5.12 ,$3.94 ,$1.69 ,$3.66 ,$4.05 ,$5.12 ,$4.22 
Carle BroMenn Medical Center,8980259,SUMAtriptan 25 mg tablet,16714079601,,259,$12.24 ,$12.24 ,$3.67 ,$11.14 ,$8.57 ,$3.67 ,$7.96 ,$8.81 ,$11.14 ,$9.18 
Carle BroMenn Medical Center,8980259,SUMAtriptan 25 mg tablet,55111029109,,259,$102.83 ,$102.83 ,$30.85 ,$93.58 ,$71.98 ,$30.85 ,$66.84 ,$74.04 ,$93.58 ,$77.12 
Carle BroMenn Medical Center,8980259,temazepam 7.5 mg capsule,406996001,,259,$45.28 ,$45.28 ,$13.58 ,$41.20 ,$31.70 ,$13.58 ,$29.43 ,$32.60 ,$41.20 ,$33.96 
Carle BroMenn Medical Center,8980259,temazepam 7.5 mg capsule,904643604,,259,$26.70 ,$26.70 ,$8.01 ,$24.30 ,$18.69 ,$8.01 ,$17.36 ,$19.22 ,$24.30 ,$20.03 
Carle BroMenn Medical Center,8980259,temazepam 7.5 mg capsule,68084054911,,259,$39.72 ,$39.72 ,$11.92 ,$36.15 ,$27.80 ,$11.92 ,$25.82 ,$28.60 ,$36.15 ,$29.79 
Carle BroMenn Medical Center,8980259,temazepam 7.5 mg capsule,68084054921,,259,$39.72 ,$39.72 ,$11.92 ,$36.15 ,$27.80 ,$11.92 ,$25.82 ,$28.60 ,$36.15 ,$29.79 
Carle BroMenn Medical Center,8980259,thyroid (pork) 30 mg tablet,456045801,,259,$6.98 ,$6.98 ,$2.09 ,$6.35 ,$4.89 ,$2.09 ,$4.54 ,$5.03 ,$6.35 ,$5.24 
Carle BroMenn Medical Center,8980259,tobramycin-dexamethasone 0.3 %-0.1 % eye ointment,65064835,,259,"$1,137.60 ","$1,137.60 ",$341.28 ,"$1,035.22 ",$796.32 ,$341.28 ,$739.44 ,$819.07 ,"$1,035.22 ",$853.20 
Carle BroMenn Medical Center,8980259,topiramate 100 mg tablet,68084034401,,259,$29.85 ,$29.85 ,$8.96 ,$27.16 ,$20.90 ,$8.96 ,$19.40 ,$21.49 ,$27.16 ,$22.39 
Carle BroMenn Medical Center,8980259,topiramate 100 mg tablet,68084034411,,259,$29.85 ,$29.85 ,$8.96 ,$27.16 ,$20.90 ,$8.96 ,$19.40 ,$21.49 ,$27.16 ,$22.39 
Carle BroMenn Medical Center,8980259,topiramate 100 mg tablet,68382014014,,259,$32.52 ,$32.52 ,$9.76 ,$29.59 ,$22.76 ,$9.76 ,$21.14 ,$23.41 ,$29.59 ,$24.39 
Carle BroMenn Medical Center,8980259,triamcinolone acetonide 0.1 % dental paste,51672126705,,259,$396.52 ,$396.52 ,$118.96 ,$360.83 ,$277.56 ,$118.96 ,$257.74 ,$285.49 ,$360.83 ,$297.39 
Carle BroMenn Medical Center,8980259,triamterene 37.5 mg-hydrochlorothiazide 25 mg tablet,60505265601,,259,$4.16 ,$4.16 ,$1.25 ,$3.79 ,$2.91 ,$1.25 ,$2.70 ,$3.00 ,$3.79 ,$3.12 
Carle BroMenn Medical Center,8980259,varenicline 0.5 mg tablet,69046856,,259,$42.32 ,$42.32 ,$12.70 ,$38.51 ,$29.62 ,$12.70 ,$27.51 ,$30.47 ,$38.51 ,$31.74 
Carle BroMenn Medical Center,8980259,verapamiL 40 mg tablet,591040401,,259,$3.62 ,$3.62 ,$1.09 ,$3.29 ,$2.53 ,$1.09 ,$2.35 ,$2.61 ,$3.29 ,$2.72 
Carle BroMenn Medical Center,8980259,"verapamiL ER (SR) 120 mg tablet,extended release",68462029201,,259,$7.33 ,$7.33 ,$2.20 ,$6.67 ,$5.13 ,$2.20 ,$4.76 ,$5.28 ,$6.67 ,$5.50 
Carle BroMenn Medical Center,8980259,"verapamiL ER (SR) 180 mg tablet,extended release",68462029301,,259,$9.04 ,$9.04 ,$2.71 ,$8.23 ,$6.33 ,$2.71 ,$5.88 ,$6.51 ,$8.23 ,$6.78 
Carle BroMenn Medical Center,8980259,"verapamiL ER (SR) 240 mg tablet,extended release",75834015901,,259,$9.95 ,$9.95 ,$2.99 ,$9.05 ,$6.97 ,$2.99 ,$6.47 ,$7.16 ,$9.05 ,$7.46 
Carle BroMenn Medical Center,8980259,"vitamin E (dl, acetate) 180 mg (400 unit) capsule",904027460,,259,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980259,"vitamin E (dl, acetate) 180 mg (400 unit) capsule",77333095110,,259,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980259,"vitamin E (dl, acetate) 180 mg (400 unit) capsule",77333095125,,259,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980259,voriconazole 50 mg tablet,68462057230,,259,$77.73 ,$77.73 ,$23.32 ,$70.73 ,$54.41 ,$23.32 ,$50.52 ,$55.97 ,$70.73 ,$58.30 
Carle BroMenn Medical Center,8030001,ACTIVATED CLOTTING TIME,,,270,$23.00 ,$23.00 ,$6.90 ,$20.93 ,$16.10 ,$6.90 ,$14.95 ,$16.56 ,$20.93 ,$17.25 
Carle BroMenn Medical Center,8030002,ACUTE DIALYSIS,,,270,"$1,328.00 ","$1,328.00 ",$398.40 ,"$1,208.48 ",$929.60 ,$398.40 ,$863.20 ,$956.16 ,"$1,208.48 ",$996.00 
Carle BroMenn Medical Center,8030003,ANTEPARTUM SUPPLY CHARGE,,,270,$74.00 ,$74.00 ,$22.20 ,$67.34 ,$51.80 ,$22.20 ,$48.10 ,$53.28 ,$67.34 ,$55.50 
Carle BroMenn Medical Center,8030004,BLOOD/FLUID WARMER,,,270,$465.00 ,$465.00 ,$139.50 ,$423.15 ,$325.50 ,$139.50 ,$302.25 ,$334.80 ,$423.15 ,$348.75 
Carle BroMenn Medical Center,8030005,CARDIAC PROFILE/Q-VIEW,,,270,$210.00 ,$210.00 ,$63.00 ,$191.10 ,$147.00 ,$63.00 ,$136.50 ,$151.20 ,$191.10 ,$157.50 
Carle BroMenn Medical Center,8030006,CERCLAGE SUPPLY,,,270,$203.00 ,$203.00 ,$60.90 ,$184.73 ,$142.10 ,$60.90 ,$131.95 ,$146.16 ,$184.73 ,$152.25 
Carle BroMenn Medical Center,8030007,C-SECTION SUPPLY CHARGE,,,270,$995.00 ,$995.00 ,$298.50 ,$905.45 ,$696.50 ,$298.50 ,$646.75 ,$716.40 ,$905.45 ,$746.25 
Carle BroMenn Medical Center,8030008,EPIDURAL ANESTHESIA SUPPLIES,,,270,$161.00 ,$161.00 ,$48.30 ,$146.51 ,$112.70 ,$48.30 ,$104.65 ,$115.92 ,$146.51 ,$120.75 
Carle BroMenn Medical Center,8030009,GENERAL ANESTHESIA SUPPLIES,,,270,$266.00 ,$266.00 ,$79.80 ,$242.06 ,$186.20 ,$79.80 ,$172.90 ,$191.52 ,$242.06 ,$199.50 
Carle BroMenn Medical Center,8030010,L & D DAILY SUPPLY CHARGE,,,270,$128.00 ,$128.00 ,$38.40 ,$116.48 ,$89.60 ,$38.40 ,$83.20 ,$92.16 ,$116.48 ,$96.00 
Carle BroMenn Medical Center,8030014,CLIP FILSHIE,244757,,270,$330.00 ,$330.00 ,$99.00 ,$300.30 ,$231.00 ,$99.00 ,$214.50 ,$237.60 ,$300.30 ,$247.50 
Carle BroMenn Medical Center,8030016,PHOTOTHERAPY,,,270,$29.00 ,$29.00 ,$8.70 ,$26.39 ,$20.30 ,$8.70 ,$18.85 ,$20.88 ,$26.39 ,$21.75 
Carle BroMenn Medical Center,8030017,POSTPARTUM TUBAL SUPPLY,,,270,$101.00 ,$101.00 ,$30.30 ,$91.91 ,$70.70 ,$30.30 ,$65.65 ,$72.72 ,$91.91 ,$75.75 
Carle BroMenn Medical Center,8030019,SPINAL ANESTHESIA SUPPLIES,,,270,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8030021,VAGINAL DELIVERY POOL SUPPLY,,,270,$417.00 ,$417.00 ,$125.10 ,$379.47 ,$291.90 ,$125.10 ,$271.05 ,$300.24 ,$379.47 ,$312.75 
Carle BroMenn Medical Center,8030022,GYN SUPPLY,,,270,$147.00 ,$147.00 ,$44.10 ,$133.77 ,$102.90 ,$44.10 ,$95.55 ,$105.84 ,$133.77 ,$110.25 
Carle BroMenn Medical Center,8030023,MINI LARYNGOSCOPE HANDLE,,,270,$68.00 ,$68.00 ,$20.40 ,$61.88 ,$47.60 ,$20.40 ,$44.20 ,$48.96 ,$61.88 ,$51.00 
Carle BroMenn Medical Center,8030024,LARYNGOSCOPE BLADE MILLER SIZE 00,,,270,$30.00 ,$30.00 ,$9.00 ,$27.30 ,$21.00 ,$9.00 ,$19.50 ,$21.60 ,$27.30 ,$22.50 
Carle BroMenn Medical Center,8030025,LARYNGOSCOPE BLADE MILLER SIZE 0,,,270,$30.00 ,$30.00 ,$9.00 ,$27.30 ,$21.00 ,$9.00 ,$19.50 ,$21.60 ,$27.30 ,$22.50 
Carle BroMenn Medical Center,8030026,LARYNGOSCOPE BLADE MILLER SIZE 1,,,270,$30.00 ,$30.00 ,$9.00 ,$27.30 ,$21.00 ,$9.00 ,$19.50 ,$21.60 ,$27.30 ,$22.50 
Carle BroMenn Medical Center,8030027,LARYNGOSCOPE BLADE MILLER SIZE 2,,,270,$30.00 ,$30.00 ,$9.00 ,$27.30 ,$21.00 ,$9.00 ,$19.50 ,$21.60 ,$27.30 ,$22.50 
Carle BroMenn Medical Center,8030030,L&D TRIAGE SUPPLY,,,270,$39.00 ,$39.00 ,$11.70 ,$35.49 ,$27.30 ,$11.70 ,$25.35 ,$28.08 ,$35.49 ,$29.25 
Carle BroMenn Medical Center,8030038,DISPOSABLE BRONCH SCOPE 2.2MM 06540300100,,,270,$939.00 ,$939.00 ,$281.70 ,$854.49 ,$657.30 ,$281.70 ,$610.35 ,$676.08 ,$854.49 ,$704.25 
Carle BroMenn Medical Center,8030039,DISPOSABLE BRONCH SCOPE 2.8MM 065414001000,,,270,"$1,031.00 ","$1,031.00 ",$309.30 ,$938.21 ,$721.70 ,$309.30 ,$670.15 ,$742.32 ,$938.21 ,$773.25 
Carle BroMenn Medical Center,8030048,NITROUS ANALGESIA SUPPLY PACKAGE,,,270,$72.00 ,$72.00 ,$21.60 ,$65.52 ,$50.40 ,$21.60 ,$46.80 ,$51.84 ,$65.52 ,$54.00 
Carle BroMenn Medical Center,8030052,32FR CHEST TUBE (204525),,,270,$33.00 ,$33.00 ,$9.90 ,$30.03 ,$23.10 ,$9.90 ,$21.45 ,$23.76 ,$30.03 ,$24.75 
Carle BroMenn Medical Center,8030053,PROLACT CREAM,,,270,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8030054,20 FR COOK THAL-QUICK CHEST TUBE TRAY (454420),,,270,$542.00 ,$542.00 ,$162.60 ,$493.22 ,$379.40 ,$162.60 ,$352.30 ,$390.24 ,$493.22 ,$406.50 
Carle BroMenn Medical Center,8030055,16 FR COOK THAL-QUICK CHEST TUBE SET (454419),,,270,$443.00 ,$443.00 ,$132.90 ,$403.13 ,$310.10 ,$132.90 ,$287.95 ,$318.96 ,$403.13 ,$332.25 
Carle BroMenn Medical Center,8030056,7 FR TRIPLE LUMAN (226778),,,270,$365.00 ,$365.00 ,$109.50 ,$332.15 ,$255.50 ,$109.50 ,$237.25 ,$262.80 ,$332.15 ,$273.75 
Carle BroMenn Medical Center,8030057,8.5 QUAD LUMAN (226780),,,270,$298.00 ,$298.00 ,$89.40 ,$271.18 ,$208.60 ,$89.40 ,$193.70 ,$214.56 ,$271.18 ,$223.50 
Carle BroMenn Medical Center,8030058,COPE MANDRIL (452877),,,270,$111.00 ,$111.00 ,$33.30 ,$101.01 ,$77.70 ,$33.30 ,$72.15 ,$79.92 ,$101.01 ,$83.25 
Carle BroMenn Medical Center,8030059,CHOICE PT FLOPPY (LS) (617644),,,270,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8030060,A-LINE KIT (210190),,,270,$84.00 ,$84.00 ,$25.20 ,$76.44 ,$58.80 ,$25.20 ,$54.60 ,$60.48 ,$76.44 ,$63.00 
Carle BroMenn Medical Center,8030061,12 FR MAHURKAR TRIPLE LUMAN CATH TRAY (204614),,,270,$412.00 ,$412.00 ,$123.60 ,$374.92 ,$288.40 ,$123.60 ,$267.80 ,$296.64 ,$374.92 ,$309.00 
Carle BroMenn Medical Center,8030062,13 FR 15 CM TRIALYSIS CATH POWER INJECTABLE CATH (623665),,,270,$875.00 ,$875.00 ,$262.50 ,$796.25 ,$612.50 ,$262.50 ,$568.75 ,$630.00 ,$796.25 ,$656.25 
Carle BroMenn Medical Center,8030063,SENSATION PLUS 40CC BALLOON CATHETER KIT (618707),,,270,"$3,527.00 ","$3,527.00 ","$1,058.10 ","$3,209.57 ","$2,468.90 ","$1,058.10 ","$2,292.55 ","$2,539.44 ","$3,209.57 ","$2,645.25 "
Carle BroMenn Medical Center,8030064,SENSATION PLUS 50CC BALLOON CATHETER KIT (619270),,,270,"$3,524.00 ","$3,524.00 ","$1,057.20 ","$3,206.84 ","$2,466.80 ","$1,057.20 ","$2,290.60 ","$2,537.28 ","$3,206.84 ","$2,643.00 "
Carle BroMenn Medical Center,8030065,STARTUP KIT (626270),,,270,$650.00 ,$650.00 ,$195.00 ,$591.50 ,$455.00 ,$195.00 ,$422.50 ,$468.00 ,$591.50 ,$487.50 
Carle BroMenn Medical Center,8030066,ICY CATHETER (626268),,,270,"$2,932.00 ","$2,932.00 ",$879.60 ,"$2,668.12 ","$2,052.40 ",$879.60 ,"$1,905.80 ","$2,111.04 ","$2,668.12 ","$2,199.00 "
Carle BroMenn Medical Center,8030067,QUATRO CATHETER (626269),,,270,"$3,282.00 ","$3,282.00 ",$984.60 ,"$2,986.62 ","$2,297.40 ",$984.60 ,"$2,133.30 ","$2,363.04 ","$2,986.62 ","$2,461.50 "
Carle BroMenn Medical Center,8030068,PROCEDURE TRAY (227025),,,270,$215.00 ,$215.00 ,$64.50 ,$195.65 ,$150.50 ,$64.50 ,$139.75 ,$154.80 ,$195.65 ,$161.25 
Carle BroMenn Medical Center,8030069,PROCEDURE TRAY (226990),,,270,$359.00 ,$359.00 ,$107.70 ,$326.69 ,$251.30 ,$107.70 ,$233.35 ,$258.48 ,$326.69 ,$269.25 
Carle BroMenn Medical Center,8030070,DISPOSABLE LARGE (690180),,,270,"$1,050.00 ","$1,050.00 ",$315.00 ,$955.50 ,$735.00 ,$315.00 ,$682.50 ,$756.00 ,$955.50 ,$787.50 
Carle BroMenn Medical Center,8030071,DISPOSABLE REGULAR (609180),,,270,$908.00 ,$908.00 ,$272.40 ,$826.28 ,$635.60 ,$272.40 ,$590.20 ,$653.76 ,$826.28 ,$681.00 
Carle BroMenn Medical Center,8030072,CODMAN EDS3 CSF DRAINAGE KIT (306327),,,270,$616.00 ,$616.00 ,$184.80 ,$560.56 ,$431.20 ,$184.80 ,$400.40 ,$443.52 ,$560.56 ,$462.00 
Carle BroMenn Medical Center,8030073,LUMBAR PUNCTURE TRAY (226925),,,270,$20.00 ,$20.00 ,$6.00 ,$18.20 ,$14.00 ,$6.00 ,$13.00 ,$14.40 ,$18.20 ,$15.00 
Carle BroMenn Medical Center,8030074,SUNDANCE PILLOWS (628183),,,270,$194.00 ,$194.00 ,$58.20 ,$176.54 ,$135.80 ,$58.20 ,$126.10 ,$139.68 ,$176.54 ,$145.50 
Carle BroMenn Medical Center,8030075,AG STERNAL DRESSING FOR OPEN HEART 4X12IN (334793),,,270,$95.00 ,$95.00 ,$28.50 ,$86.45 ,$66.50 ,$28.50 ,$61.75 ,$68.40 ,$86.45 ,$71.25 
Carle BroMenn Medical Center,8030076,COMFORT GLIDE AIR SHEETS (628105),,,270,$389.00 ,$389.00 ,$116.70 ,$353.99 ,$272.30 ,$116.70 ,$252.85 ,$280.08 ,$353.99 ,$291.75 
Carle BroMenn Medical Center,8030077,30 DEGREE FOAM WEDGE (628106),,,270,$128.00 ,$128.00 ,$38.40 ,$116.48 ,$89.60 ,$38.40 ,$83.20 ,$92.16 ,$116.48 ,$96.00 
Carle BroMenn Medical Center,8030078,28FR CHEST TUBE (204575),,,270,$33.00 ,$33.00 ,$9.90 ,$30.03 ,$23.10 ,$9.90 ,$21.45 ,$23.76 ,$30.03 ,$24.75 
Carle BroMenn Medical Center,8030084,THAL-QUICK CHEST TUBE TRAY,,,270,$554.00 ,$554.00 ,$166.20 ,$504.14 ,$387.80 ,$166.20 ,$360.10 ,$398.88 ,$504.14 ,$415.50 
Carle BroMenn Medical Center,8030087,SMART GUARD,,,270,$85.00 ,$85.00 ,$25.50 ,$77.35 ,$59.50 ,$25.50 ,$55.25 ,$61.20 ,$77.35 ,$63.75 
Carle BroMenn Medical Center,8030088,LUMBAR CATHETER ACCESSORY KIT,,A4550,270,$518.00 ,$518.00 ,$155.40 ,$471.38 ,$362.60 ,$155.40 ,$336.70 ,$372.96 ,$471.38 ,$388.50 
Carle BroMenn Medical Center,8030091,EBB BALLOON,,,270,"$1,266.00 ","$1,266.00 ",$379.80 ,"$1,152.06 ",$886.20 ,$379.80 ,$822.90 ,$911.52 ,"$1,152.06 ",$949.50 
Carle BroMenn Medical Center,8030099,CATH ARROW 4 LUMEN CY,,C1751,270,$318.00 ,$318.00 ,$95.40 ,$289.38 ,$222.60 ,$95.40 ,$206.70 ,$228.96 ,$289.38 ,$238.50 
Carle BroMenn Medical Center,8030157,ARTIC SUN PADS UNIVERSAL,,,270,"$1,043.00 ","$1,043.00 ",$312.90 ,$949.13 ,$730.10 ,$312.90 ,$677.95 ,$750.96 ,$949.13 ,$782.25 
Carle BroMenn Medical Center,8030184,5.0MM AMBU BRONCH,,,270,$807.00 ,$807.00 ,$242.10 ,$734.37 ,$564.90 ,$242.10 ,$524.55 ,$581.04 ,$734.37 ,$605.25 
Carle BroMenn Medical Center,8030185,5.8MM AMBU BRONCH,,,270,$933.00 ,$933.00 ,$279.90 ,$849.03 ,$653.10 ,$279.90 ,$606.45 ,$671.76 ,$849.03 ,$699.75 
Carle BroMenn Medical Center,8030186,5.0MM GLIDESCOPE,,,270,$404.00 ,$404.00 ,$121.20 ,$367.64 ,$282.80 ,$121.20 ,$262.60 ,$290.88 ,$367.64 ,$303.00 
Carle BroMenn Medical Center,8030187,5.8MM GLIDESCOPE,,,270,$936.00 ,$936.00 ,$280.80 ,$851.76 ,$655.20 ,$280.80 ,$608.40 ,$673.92 ,$851.76 ,$702.00 
Carle BroMenn Medical Center,8030188,PERCUTANEOUS TRACH,,,270,"$1,305.00 ","$1,305.00 ",$391.50 ,"$1,187.55 ",$913.50 ,$391.50 ,$848.25 ,$939.60 ,"$1,187.55 ",$978.75 
Carle BroMenn Medical Center,8030189,CRANIAL ACCESS KIT,,,270,$977.00 ,$977.00 ,$293.10 ,$889.07 ,$683.90 ,$293.10 ,$635.05 ,$703.44 ,$889.07 ,$732.75 
Carle BroMenn Medical Center,8030190,VENTRICULAR CATHETER BACTISEAL 35CM,,,270,"$1,353.00 ","$1,353.00 ",$405.90 ,"$1,231.23 ",$947.10 ,$405.90 ,$879.45 ,$974.16 ,"$1,231.23 ","$1,014.75 "
Carle BroMenn Medical Center,8030191,METABOLT KIT CODMAN,,,270,"$3,213.00 ","$3,213.00 ",$963.90 ,"$2,923.83 ","$2,249.10 ",$963.90 ,"$2,088.45 ","$2,313.36 ","$2,923.83 ","$2,409.75 "
Carle BroMenn Medical Center,8030192,FLOTRAC ART LINE,,,270,$930.00 ,$930.00 ,$279.00 ,$846.30 ,$651.00 ,$279.00 ,$604.50 ,$669.60 ,$846.30 ,$697.50 
Carle BroMenn Medical Center,8030193,CLEAR SIGHT CUFF SMALL,,,270,$930.00 ,$930.00 ,$279.00 ,$846.30 ,$651.00 ,$279.00 ,$604.50 ,$669.60 ,$846.30 ,$697.50 
Carle BroMenn Medical Center,8030194,CLEARSIGHT CUFF MEDIUM,,,270,$930.00 ,$930.00 ,$279.00 ,$846.30 ,$651.00 ,$279.00 ,$604.50 ,$669.60 ,$846.30 ,$697.50 
Carle BroMenn Medical Center,8030195,CLEARSIGHT CUFF LARGE,,,270,$930.00 ,$930.00 ,$279.00 ,$846.30 ,$651.00 ,$279.00 ,$604.50 ,$669.60 ,$846.30 ,$697.50 
Carle BroMenn Medical Center,8030197,ARCTIC SUN (SM),,,270,"$3,468.00 ","$3,468.00 ","$1,040.40 ","$3,155.88 ","$2,427.60 ","$1,040.40 ","$2,254.20 ","$2,496.96 ","$3,155.88 ","$2,601.00 "
Carle BroMenn Medical Center,8030198,ARCTIC SUN (LG),,,270,"$3,468.00 ","$3,468.00 ","$1,040.40 ","$3,155.88 ","$2,427.60 ","$1,040.40 ","$2,254.20 ","$2,496.96 ","$3,155.88 ","$2,601.00 "
Carle BroMenn Medical Center,8030199,TRIALYSIS CATHETER,,,270,$446.00 ,$446.00 ,$133.80 ,$405.86 ,$312.20 ,$133.80 ,$289.90 ,$321.12 ,$405.86 ,$334.50 
Carle BroMenn Medical Center,8030200,16CM CENTRAL LINE,,,270,$389.00 ,$389.00 ,$116.70 ,$353.99 ,$272.30 ,$116.70 ,$252.85 ,$280.08 ,$353.99 ,$291.75 
Carle BroMenn Medical Center,8030201,BELMONT TUBING,,,270,$453.00 ,$453.00 ,$135.90 ,$412.23 ,$317.10 ,$135.90 ,$294.45 ,$326.16 ,$412.23 ,$339.75 
Carle BroMenn Medical Center,8030202,PRISMAX DISPOSABLE FILTER,,,270,$729.00 ,$729.00 ,$218.70 ,$663.39 ,$510.30 ,$218.70 ,$473.85 ,$524.88 ,$663.39 ,$546.75 
Carle BroMenn Medical Center,8030203,THERMAX BLOOD WARMER,,,270,$40.00 ,$40.00 ,$12.00 ,$36.40 ,$28.00 ,$12.00 ,$26.00 ,$28.80 ,$36.40 ,$30.00 
Carle BroMenn Medical Center,8030204,COMFORT GLIDE SHEET,,,270,$338.00 ,$338.00 ,$101.40 ,$307.58 ,$236.60 ,$101.40 ,$219.70 ,$243.36 ,$307.58 ,$253.50 
Carle BroMenn Medical Center,8030205,PUPILLOMETER SMARTGUARD,,,270,$82.00 ,$82.00 ,$24.60 ,$74.62 ,$57.40 ,$24.60 ,$53.30 ,$59.04 ,$74.62 ,$61.50 
Carle BroMenn Medical Center,8031011,LABOR CHECK SUPPLY,,,270,$38.00 ,$38.00 ,$11.40 ,$34.58 ,$26.60 ,$11.40 ,$24.70 ,$27.36 ,$34.58 ,$28.50 
Carle BroMenn Medical Center,8031013,NEWBORN NURSERY CARE SUPPLY,,,270,$307.00 ,$307.00 ,$92.10 ,$279.37 ,$214.90 ,$92.10 ,$199.55 ,$221.04 ,$279.37 ,$230.25 
Carle BroMenn Medical Center,8031014,NEWBORN RESUSCITATION SUPPLY,,,270,$320.00 ,$320.00 ,$96.00 ,$291.20 ,$224.00 ,$96.00 ,$208.00 ,$230.40 ,$291.20 ,$240.00 
Carle BroMenn Medical Center,8031015,IV SUPPLY CHARGE,,,270,$70.00 ,$70.00 ,$21.00 ,$63.70 ,$49.00 ,$21.00 ,$45.50 ,$50.40 ,$63.70 ,$52.50 
Carle BroMenn Medical Center,8031016,NEWBORN IV START,,,270,$22.00 ,$22.00 ,$6.60 ,$20.02 ,$15.40 ,$6.60 ,$14.30 ,$15.84 ,$20.02 ,$16.50 
Carle BroMenn Medical Center,8038000,CARTRIDGE -LAB TEST- HAND UNIT,,,270,$22.00 ,$22.00 ,$6.60 ,$20.02 ,$15.40 ,$6.60 ,$14.30 ,$15.84 ,$20.02 ,$16.50 
Carle BroMenn Medical Center,8038001,CARTRIDGE-CHEM 4+ TEST,,,270,$29.00 ,$29.00 ,$8.70 ,$26.39 ,$20.30 ,$8.70 ,$18.85 ,$20.88 ,$26.39 ,$21.75 
Carle BroMenn Medical Center,8038002,CARTRIDGE-CHEM 6+ TEST,,,270,$33.00 ,$33.00 ,$9.90 ,$30.03 ,$23.10 ,$9.90 ,$21.45 ,$23.76 ,$30.03 ,$24.75 
Carle BroMenn Medical Center,8038003,CARTRIDGE-CHEM 8+ TEST,,,270,$38.00 ,$38.00 ,$11.40 ,$34.58 ,$26.60 ,$11.40 ,$24.70 ,$27.36 ,$34.58 ,$28.50 
Carle BroMenn Medical Center,8038004,CARTRIDGE-TROPONIN TEST,,,270,$59.00 ,$59.00 ,$17.70 ,$53.69 ,$41.30 ,$17.70 ,$38.35 ,$42.48 ,$53.69 ,$44.25 
Carle BroMenn Medical Center,8040004,PROLACT 8,,,270,$814.00 ,$814.00 ,$244.20 ,$740.74 ,$569.80 ,$244.20 ,$529.10 ,$586.08 ,$740.74 ,$610.50 
Carle BroMenn Medical Center,8040005,PROLACT 4 PER BOTTLE,,,270,$214.00 ,$214.00 ,$64.20 ,$194.74 ,$149.80 ,$64.20 ,$139.10 ,$154.08 ,$194.74 ,$160.50 
Carle BroMenn Medical Center,8040007,PROLACT 10 PER BOTTLE,,,270,"$1,014.00 ","$1,014.00 ",$304.20 ,$922.74 ,$709.80 ,$304.20 ,$659.10 ,$730.08 ,$922.74 ,$760.50 
Carle BroMenn Medical Center,8100027,TUBE T DEAVER 12F,244536,,270,$36.90 ,$36.90 ,$11.07 ,$33.58 ,$25.83 ,$11.07 ,$23.99 ,$26.57 ,$33.58 ,$27.68 
Carle BroMenn Medical Center,8100027,TUBE T DEAVER 14F,244537,,270,$36.90 ,$36.90 ,$11.07 ,$33.58 ,$25.83 ,$11.07 ,$23.99 ,$26.57 ,$33.58 ,$27.68 
Carle BroMenn Medical Center,8100027,TUBE T DEAVER 18F,244538,,270,$36.00 ,$36.00 ,$10.80 ,$32.76 ,$25.20 ,$10.80 ,$23.40 ,$25.92 ,$32.76 ,$27.00 
Carle BroMenn Medical Center,8130006,PERIPHERAL NERVE BLOCK TRAY BRAUN,,,270,$173.00 ,$173.00 ,$51.90 ,$157.43 ,$121.10 ,$51.90 ,$112.45 ,$124.56 ,$157.43 ,$129.75 
Carle BroMenn Medical Center,8130007,OR ANES SUPPLIES ART LINE ARROW,,,270,$146.00 ,$146.00 ,$43.80 ,$132.86 ,$102.20 ,$43.80 ,$94.90 ,$105.12 ,$132.86 ,$109.50 
Carle BroMenn Medical Center,8130008,OR ANES SUPPLIES ART LINE ANGIOCATH,,,270,$119.00 ,$119.00 ,$35.70 ,$108.29 ,$83.30 ,$35.70 ,$77.35 ,$85.68 ,$108.29 ,$89.25 
Carle BroMenn Medical Center,8130009,OR ANES SUPPLISE ART LINE ARGON,,,270,$221.00 ,$221.00 ,$66.30 ,$201.11 ,$154.70 ,$66.30 ,$143.65 ,$159.12 ,$201.11 ,$165.75 
Carle BroMenn Medical Center,8130010,OR ANES SUPPLIES CVP 7FR,,,270,$370.00 ,$370.00 ,$111.00 ,$336.70 ,$259.00 ,$111.00 ,$240.50 ,$266.40 ,$336.70 ,$277.50 
Carle BroMenn Medical Center,8130011,OR ANES SUPPLIES CVP 9FR,,,270,$180.00 ,$180.00 ,$54.00 ,$163.80 ,$126.00 ,$54.00 ,$117.00 ,$129.60 ,$163.80 ,$135.00 
Carle BroMenn Medical Center,8130012,OR ANES SUPPLIES SNAP IN TRIPLE LUMEN,,,270,$173.00 ,$173.00 ,$51.90 ,$157.43 ,$121.10 ,$51.90 ,$112.45 ,$124.56 ,$157.43 ,$129.75 
Carle BroMenn Medical Center,8130013,OR ANES GLIDESCOPE 0 - 2.5,,,270,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8130014,OR ANES GLIDESCOPE 3 -4,,,270,$94.00 ,$94.00 ,$28.20 ,$85.54 ,$65.80 ,$28.20 ,$61.10 ,$67.68 ,$85.54 ,$70.50 
Carle BroMenn Medical Center,8130015,KING VIDEO LARYNGOSCOPE CHANNELED BLADE,,,270,$174.00 ,$174.00 ,$52.20 ,$158.34 ,$121.80 ,$52.20 ,$113.10 ,$125.28 ,$158.34 ,$130.50 
Carle BroMenn Medical Center,8130016,LUMBAR DRAINAGE SET,,,270,$692.00 ,$692.00 ,$207.60 ,$629.72 ,$484.40 ,$207.60 ,$449.80 ,$498.24 ,$629.72 ,$519.00 
Carle BroMenn Medical Center,8130018,EDWARDS MONITORING FINGER CUFF SUPPLY,,,270,$930.00 ,$930.00 ,$279.00 ,$846.30 ,$651.00 ,$279.00 ,$604.50 ,$669.60 ,$846.30 ,$697.50 
Carle BroMenn Medical Center,8130026,EPIDURAL STEROID INJECTION SUPPLY,,,270,$47.00 ,$47.00 ,$14.10 ,$42.77 ,$32.90 ,$14.10 ,$30.55 ,$33.84 ,$42.77 ,$35.25 
Carle BroMenn Medical Center,8130027,LARYNGOSCOPE BLADE,,,270,$30.00 ,$30.00 ,$9.00 ,$27.30 ,$21.00 ,$9.00 ,$19.50 ,$21.60 ,$27.30 ,$22.50 
Carle BroMenn Medical Center,8130028,DISPOSABLE LARYNGOSCOPE BLADE,,,270,$41.00 ,$41.00 ,$12.30 ,$37.31 ,$28.70 ,$12.30 ,$26.65 ,$29.52 ,$37.31 ,$30.75 
Carle BroMenn Medical Center,8130029,CARDIAC OUTPUT A-LINE TRANSDUCER,,,270,$930.00 ,$930.00 ,$279.00 ,$846.30 ,$651.00 ,$279.00 ,$604.50 ,$669.60 ,$846.30 ,$697.50 
Carle BroMenn Medical Center,8130030,CEREBRAL/TISSUE OXIMETRY PATCHES,,,270,$255.00 ,$255.00 ,$76.50 ,$232.05 ,$178.50 ,$76.50 ,$165.75 ,$183.60 ,$232.05 ,$191.25 
Carle BroMenn Medical Center,8140002,CARTRIDGE-CHEM 6+ TEST,,,270,$33.00 ,$33.00 ,$9.90 ,$30.03 ,$23.10 ,$9.90 ,$21.45 ,$23.76 ,$30.03 ,$24.75 
Carle BroMenn Medical Center,8140010,DAVINCI ALL STAPLER 45 SHEATH,189054,,270,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8140010,DAVINCI ALL TIP COVER ACCESSRY,1224,,270,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8140010,DAVINCI XI 5MM-8MM SEAL,210974,,270,$54.00 ,$54.00 ,$16.20 ,$49.14 ,$37.80 ,$16.20 ,$35.10 ,$38.88 ,$49.14 ,$40.50 
Carle BroMenn Medical Center,8140010,DAVINCI XI 60MM STAPLER,226293,,270,"$1,590.00 ","$1,590.00 ",$477.00 ,"$1,446.90 ","$1,113.00 ",$477.00 ,"$1,033.50 ","$1,144.80 ","$1,446.90 ","$1,192.50 "
Carle BroMenn Medical Center,8140010,DAVINCI XI INSTR ARM DRAPE,210969,,270,$156.00 ,$156.00 ,$46.80 ,$141.96 ,$109.20 ,$46.80 ,$101.40 ,$112.32 ,$141.96 ,$117.00 
Carle BroMenn Medical Center,8140010,DAVINCI XI OBTURATOR OPTI,210972,,270,$90.00 ,$90.00 ,$27.00 ,$81.90 ,$63.00 ,$27.00 ,$58.50 ,$64.80 ,$81.90 ,$67.50 
Carle BroMenn Medical Center,8140010,DAVINCI XI RELOAD 60MM BLUE,226295,,270,$690.00 ,$690.00 ,$207.00 ,$627.90 ,$483.00 ,$207.00 ,$448.50 ,$496.80 ,$627.90 ,$517.50 
Carle BroMenn Medical Center,8140010,DAVINCI XI RELOAD 60MM GREEN,226296,,270,$690.00 ,$690.00 ,$207.00 ,$627.90 ,$483.00 ,$207.00 ,$448.50 ,$496.80 ,$627.90 ,$517.50 
Carle BroMenn Medical Center,8140010,DAVINCI XI STAPLER BLUE RELOAD,210966,,270,$540.00 ,$540.00 ,$162.00 ,$491.40 ,$378.00 ,$162.00 ,$351.00 ,$388.80 ,$491.40 ,$405.00 
Carle BroMenn Medical Center,8140010,DAVINCI XI STAPLER CANN REDUCE,210965,,270,$75.00 ,$75.00 ,$22.50 ,$68.25 ,$52.50 ,$22.50 ,$48.75 ,$54.00 ,$68.25 ,$56.25 
Carle BroMenn Medical Center,8140010,DAVINCI XI STAPLER GREENRELOAD,210967,,270,$540.00 ,$540.00 ,$162.00 ,$491.40 ,$378.00 ,$162.00 ,$351.00 ,$388.80 ,$491.40 ,$405.00 
Carle BroMenn Medical Center,8140010,DAVINCI XI STAPLER RELOAD WHT BX/,213591,,270,$540.00 ,$540.00 ,$162.00 ,$491.40 ,$378.00 ,$162.00 ,$351.00 ,$388.80 ,$491.40 ,$405.00 
Carle BroMenn Medical Center,8140010,DAVINCI XI STAPLER SEAL,210964,,270,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8140010,DAVINCI XI VESSEL SEALER,210968,,270,"$1,785.00 ","$1,785.00 ",$535.50 ,"$1,624.35 ","$1,249.50 ",$535.50 ,"$1,160.25 ","$1,285.20 ","$1,624.35 ","$1,338.75 "
Carle BroMenn Medical Center,8140010,DAVINCI XI VESSEL SEALER 2,223236,,270,"$1,875.00 ","$1,875.00 ",$562.50 ,"$1,706.25 ","$1,312.50 ",$562.50 ,"$1,218.75 ","$1,350.00 ","$1,706.25 ","$1,406.25 "
Carle BroMenn Medical Center,8140010,PACK ROBOTIC BRO CUSTOM 2/CA,254593,,270,$217.89 ,$217.89 ,$65.37 ,$198.28 ,$152.52 ,$65.37 ,$141.63 ,$156.88 ,$198.28 ,$163.42 
Carle BroMenn Medical Center,8140010,SYS RUMI 2 KOH-EFFICIENT 4CM,244773,,270,$501.31 ,$501.31 ,$150.39 ,$456.19 ,$350.92 ,$150.39 ,$325.85 ,$360.94 ,$456.19 ,$375.98 
Carle BroMenn Medical Center,8140010,TIP SACROCOLPOPEXY LG 3.8X11.4 3,245177,,270,$282.20 ,$282.20 ,$84.66 ,$256.80 ,$197.54 ,$84.66 ,$183.43 ,$203.18 ,$256.80 ,$211.65 
Carle BroMenn Medical Center,8140021,OR ANESTHESIA SUPPLIES CVP,,,270,$323.00 ,$323.00 ,$96.90 ,$293.93 ,$226.10 ,$96.90 ,$209.95 ,$232.56 ,$293.93 ,$242.25 
Carle BroMenn Medical Center,8140022,OR ANESTHESIA SUPPLIES ART LINE,,,270,$278.00 ,$278.00 ,$83.40 ,$252.98 ,$194.60 ,$83.40 ,$180.70 ,$200.16 ,$252.98 ,$208.50 
Carle BroMenn Medical Center,8140023,OR ANESTHESIA SUPPLIES SWAN-GANZ,,,270,$690.00 ,$690.00 ,$207.00 ,$627.90 ,$483.00 ,$207.00 ,$448.50 ,$496.80 ,$627.90 ,$517.50 
Carle BroMenn Medical Center,8140024,DASC ANESTHESIA SUPPLIES CVP,,,270,$413.00 ,$413.00 ,$123.90 ,$375.83 ,$289.10 ,$123.90 ,$268.45 ,$297.36 ,$375.83 ,$309.75 
Carle BroMenn Medical Center,8140025,DASC ANESTHESIA SUPPLIES ART LINE,,,270,$345.00 ,$345.00 ,$103.50 ,$313.95 ,$241.50 ,$103.50 ,$224.25 ,$248.40 ,$313.95 ,$258.75 
Carle BroMenn Medical Center,8140026,DASC ANESTHESIA SUPPLIES SWAN-GANZ,,,270,$953.00 ,$953.00 ,$285.90 ,$867.23 ,$667.10 ,$285.90 ,$619.45 ,$686.16 ,$867.23 ,$714.75 
Carle BroMenn Medical Center,8140027,DASC EPIDURAL NERVE BLOCK TRAY,,,270,$128.00 ,$128.00 ,$38.40 ,$116.48 ,$89.60 ,$38.40 ,$83.20 ,$92.16 ,$116.48 ,$96.00 
Carle BroMenn Medical Center,8140028,DASC PERIPHERAL NERVE BLOCK TRAY,,,270,$319.00 ,$319.00 ,$95.70 ,$290.29 ,$223.30 ,$95.70 ,$207.35 ,$229.68 ,$290.29 ,$239.25 
Carle BroMenn Medical Center,8140029,OXYGEN,,,270,$13.00 ,$13.00 ,$3.90 ,$11.83 ,$9.10 ,$3.90 ,$8.45 ,$9.36 ,$11.83 ,$9.75 
Carle BroMenn Medical Center,8140050,AIRWAY LMA UNIQUE DISP 3,244843,,270,$18.00 ,$18.00 ,$5.40 ,$16.38 ,$12.60 ,$5.40 ,$11.70 ,$12.96 ,$16.38 ,$13.50 
Carle BroMenn Medical Center,8140050,AIRWAY LMA UNIQUE DISP 4,244842,,270,$18.00 ,$18.00 ,$5.40 ,$16.38 ,$12.60 ,$5.40 ,$11.70 ,$12.96 ,$16.38 ,$13.50 
Carle BroMenn Medical Center,8140050,AIRWAY LMA UNIQUE DISP 5,244844,,270,$18.00 ,$18.00 ,$5.40 ,$16.38 ,$12.60 ,$5.40 ,$11.70 ,$12.96 ,$16.38 ,$13.50 
Carle BroMenn Medical Center,8140052,ANESTHESIA SUPPLIES,,,270,$274.00 ,$274.00 ,$82.20 ,$249.34 ,$191.80 ,$82.20 ,$178.10 ,$197.28 ,$249.34 ,$205.50 
Carle BroMenn Medical Center,8140054,ADAPTER 14MM,244706,,270,$3.33 ,$3.33 ,$1.00 ,$3.03 ,$2.33 ,$1.00 ,$2.16 ,$2.40 ,$3.03 ,$2.50 
Carle BroMenn Medical Center,8140054,ADAPTER DRAIN OSTOMY,244136,,270,$2.12 ,$2.12 ,$0.64 ,$1.93 ,$1.48 ,$0.64 ,$1.38 ,$1.53 ,$1.93 ,$1.59 
Carle BroMenn Medical Center,8140054,ADAPTER GOLDBERG URET 14X15,244779,,270,$99.96 ,$99.96 ,$29.99 ,$90.96 ,$69.97 ,$29.99 ,$64.97 ,$71.97 ,$90.96 ,$74.97 
Carle BroMenn Medical Center,8140054,ADAPTER UROLOK II W/BALL-FIT 10/B,236857,,270,$42.95 ,$42.95 ,$12.89 ,$39.08 ,$30.07 ,$12.89 ,$27.92 ,$30.92 ,$39.08 ,$32.21 
Carle BroMenn Medical Center,8140054,ADAPTOR SPIKE,245066,,270,$4.51 ,$4.51 ,$1.35 ,$4.10 ,$3.16 ,$1.35 ,$2.93 ,$3.25 ,$4.10 ,$3.38 
Carle BroMenn Medical Center,8140054,ADHESIVE DERMABOND MINI 12/BX,248937,,270,$30.96 ,$30.96 ,$9.29 ,$28.17 ,$21.67 ,$9.29 ,$20.12 ,$22.29 ,$28.17 ,$23.22 
Carle BroMenn Medical Center,8140054,ADHESIVE LIQUIBAND EXCEED 0.8G 6,245085,,270,$75.00 ,$75.00 ,$22.50 ,$68.25 ,$52.50 ,$22.50 ,$48.75 ,$54.00 ,$68.25 ,$56.25 
Carle BroMenn Medical Center,8140054,ADHESIVE MASTISOL 0.225OZ,228984,,270,$4.97 ,$4.97 ,$1.49 ,$4.52 ,$3.48 ,$1.49 ,$3.23 ,$3.58 ,$4.52 ,$3.73 
Carle BroMenn Medical Center,8140054,ADHESIVE SKIN HISTOACRYL,11276,,270,$54.68 ,$54.68 ,$16.40 ,$49.76 ,$38.28 ,$16.40 ,$35.54 ,$39.37 ,$49.76 ,$41.01 
Carle BroMenn Medical Center,8140054,ADHESIVE SURGICAL MASTISOL,11267,,270,$4.68 ,$4.68 ,$1.40 ,$4.26 ,$3.28 ,$1.40 ,$3.04 ,$3.37 ,$4.26 ,$3.51 
Carle BroMenn Medical Center,8140054,ADHESIVE TOPICAL SKN DERMABOND,244398,,270,$51.95 ,$51.95 ,$15.59 ,$47.27 ,$36.37 ,$15.59 ,$33.77 ,$37.40 ,$47.27 ,$38.96 
Carle BroMenn Medical Center,8140054,ALCOHOL RUBBING,244019,,270,$4.51 ,$4.51 ,$1.35 ,$4.10 ,$3.16 ,$1.35 ,$2.93 ,$3.25 ,$4.10 ,$3.38 
Carle BroMenn Medical Center,8140054,ANCHOR CLIK X 2 PER EA,239212,,270,"$1,012.50 ","$1,012.50 ",$303.75 ,$921.38 ,$708.75 ,$303.75 ,$658.13 ,$729.00 ,$921.38 ,$759.38 
Carle BroMenn Medical Center,8140054,APPLICATOR CHLORAPREP 10.5ML W/TE,9655,,270,$10.06 ,$10.06 ,$3.02 ,$9.15 ,$7.04 ,$3.02 ,$6.54 ,$7.24 ,$9.15 ,$7.55 
Carle BroMenn Medical Center,8140054,APPLICATOR CHLORAPREP ORG 26ML W/,316,,270,$18.33 ,$18.33 ,$5.50 ,$16.68 ,$12.83 ,$5.50 ,$11.91 ,$13.20 ,$16.68 ,$13.75 
Carle BroMenn Medical Center,8140054,APPLICATOR COTTON TIP STL 6IN,244110,,270,$0.09 ,$0.09 ,$0.03 ,$0.08 ,$0.06 ,$0.03 ,$0.06 ,$0.06 ,$0.08 ,$0.07 
Carle BroMenn Medical Center,8140054,APPLICATOR DUAL VISTASEAL,253695,,270,$139.35 ,$139.35 ,$41.81 ,$126.81 ,$97.55 ,$41.81 ,$90.58 ,$100.33 ,$126.81 ,$104.51 
Carle BroMenn Medical Center,8140054,APPLICATOR DUPLOSPRAY MIS 20MM TI,245070,,270,$256.01 ,$256.01 ,$76.80 ,$232.97 ,$179.21 ,$76.80 ,$166.41 ,$184.33 ,$232.97 ,$192.01 
Carle BroMenn Medical Center,8140054,APPLICATOR DURAPREP,244348,,270,$10.80 ,$10.80 ,$3.24 ,$9.83 ,$7.56 ,$3.24 ,$7.02 ,$7.78 ,$9.83 ,$8.10 
Carle BroMenn Medical Center,8140054,APPLICATOR ENDOSCOPIC SURGIFLO,230132,,270,$148.23 ,$148.23 ,$44.47 ,$134.89 ,$103.76 ,$44.47 ,$96.35 ,$106.73 ,$134.89 ,$111.17 
Carle BroMenn Medical Center,8140054,APPLICATOR FLOSEAL ENDOSCOPIC,245244,,270,$169.67 ,$169.67 ,$50.90 ,$154.40 ,$118.77 ,$50.90 ,$110.29 ,$122.16 ,$154.40 ,$127.25 
Carle BroMenn Medical Center,8140054,APPLICATOR LAPAROSCOPIC 45CM,254177,,270,$189.09 ,$189.09 ,$56.73 ,$172.07 ,$132.36 ,$56.73 ,$122.91 ,$136.14 ,$172.07 ,$141.82 
Carle BroMenn Medical Center,8140054,APPLIER ENDO CLIP L 12MM 3/BX,242485,,270,"$2,381.40 ","$2,381.40 ",$714.42 ,"$2,167.07 ","$1,666.98 ",$714.42 ,"$1,547.91 ","$1,714.61 ","$2,167.07 ","$1,786.05 "
Carle BroMenn Medical Center,8140054,APPLIER ENDO CLIP M/L 10MM 3/BX,242489,,270,$203.12 ,$203.12 ,$60.94 ,$184.84 ,$142.18 ,$60.94 ,$132.03 ,$146.25 ,$184.84 ,$152.34 
Carle BroMenn Medical Center,8140054,APPLIER ENDO CLIP M/L 5MM 3/BX,242490,,270,"$2,976.78 ","$2,976.78 ",$893.03 ,"$2,708.87 ","$2,083.75 ",$893.03 ,"$1,934.91 ","$2,143.28 ","$2,708.87 ","$2,232.59 "
Carle BroMenn Medical Center,8140054,APPLIER LIGACIP MEDIUM 6/BX,242520,,270,$141.93 ,$141.93 ,$42.58 ,$129.16 ,$99.35 ,$42.58 ,$92.25 ,$102.19 ,$129.16 ,$106.45 
Carle BroMenn Medical Center,8140054,APPLIER LIGACLIP LARGE 6/BX,242486,,270,$123.71 ,$123.71 ,$37.11 ,$112.58 ,$86.60 ,$37.11 ,$80.41 ,$89.07 ,$112.58 ,$92.78 
Carle BroMenn Medical Center,8140054,APPLIER LIGACLIP MED 11 6/bx,1138,,270,$123.58 ,$123.58 ,$37.07 ,$112.46 ,$86.51 ,$37.07 ,$80.33 ,$88.98 ,$112.46 ,$92.69 
Carle BroMenn Medical Center,8140054,APPLIER LIGACLIP SMALL 6/BX,242491,,270,$121.82 ,$121.82 ,$36.55 ,$110.86 ,$85.27 ,$36.55 ,$79.18 ,$87.71 ,$110.86 ,$91.37 
Carle BroMenn Medical Center,8140054,ASSEMBLY BLADE DISP FOR CTRS,244657,,270,$720.00 ,$720.00 ,$216.00 ,$655.20 ,$504.00 ,$216.00 ,$468.00 ,$518.40 ,$655.20 ,$540.00 
Carle BroMenn Medical Center,8140054,ASSEMBLY SUCT STRYKEFLOW2 DISP 6,245217,,270,$162.23 ,$162.23 ,$48.67 ,$147.63 ,$113.56 ,$48.67 ,$105.45 ,$116.81 ,$147.63 ,$121.67 
Carle BroMenn Medical Center,8140054,ATTACH ACCUVAC SMOKE EVAC,244777,,270,$27.66 ,$27.66 ,$8.30 ,$25.17 ,$19.36 ,$8.30 ,$17.98 ,$19.92 ,$25.17 ,$20.75 
Carle BroMenn Medical Center,8140054,AWL TAPERED 3.8MM DISP,237482,,270,$144.78 ,$144.78 ,$43.43 ,$131.75 ,$101.35 ,$43.43 ,$94.11 ,$104.24 ,$131.75 ,$108.59 
Carle BroMenn Medical Center,8140054,BAG DRAIN BILE 19OZ T-TUBE,244257,,270,$24.15 ,$24.15 ,$7.25 ,$21.98 ,$16.91 ,$7.25 ,$15.70 ,$17.39 ,$21.98 ,$18.11 
Carle BroMenn Medical Center,8140054,BAG DRAIN UROL F/GE-OEC UROVIEW 2,245053,,270,$18.96 ,$18.96 ,$5.69 ,$17.25 ,$13.27 ,$5.69 ,$12.32 ,$13.65 ,$17.25 ,$14.22 
Carle BroMenn Medical Center,8140054,BAG EDS3 COLLECTION,872,,270,$117.95 ,$117.95 ,$35.39 ,$107.33 ,$82.57 ,$35.39 ,$76.67 ,$84.92 ,$107.33 ,$88.46 
Carle BroMenn Medical Center,8140054,BAG ENDOCATCH II 15MM,206160,,270,$300.00 ,$300.00 ,$90.00 ,$273.00 ,$210.00 ,$90.00 ,$195.00 ,$216.00 ,$273.00 ,$225.00 
Carle BroMenn Medical Center,8140054,BAG LEG FABRIC STRAP FLIP-FLO,244981,,270,$7.35 ,$7.35 ,$2.21 ,$6.69 ,$5.15 ,$2.21 ,$4.78 ,$5.29 ,$6.69 ,$5.51 
Carle BroMenn Medical Center,8140054,BAG PRES INFUSOR 3000ML NYL 25/CA,244740,,270,$21.38 ,$21.38 ,$6.41 ,$19.46 ,$14.97 ,$6.41 ,$13.90 ,$15.39 ,$19.46 ,$16.04 
Carle BroMenn Medical Center,8140054,BAG PRES INFUSOR DISP 1000ML INFU,244195,,270,$16.83 ,$16.83 ,$5.05 ,$15.32 ,$11.78 ,$5.05 ,$10.94 ,$12.12 ,$15.32 ,$12.62 
Carle BroMenn Medical Center,8140054,BAG SPONGE COUNTER,244394,,270,$1.44 ,$1.44 ,$0.43 ,$1.31 ,$1.01 ,$0.43 ,$0.94 ,$1.04 ,$1.31 ,$1.08 
Carle BroMenn Medical Center,8140054,BAG URIN DRAIN CTR 4000ML,244856,,270,$12.20 ,$12.20 ,$3.66 ,$11.10 ,$8.54 ,$3.66 ,$7.93 ,$8.78 ,$11.10 ,$9.15 
Carle BroMenn Medical Center,8140054,BALL COTTON STERILE 5PK,244135,,270,$0.27 ,$0.27 ,$0.08 ,$0.25 ,$0.19 ,$0.08 ,$0.18 ,$0.19 ,$0.25 ,$0.20 
Carle BroMenn Medical Center,8140054,BALLOON CRE 15-18 FIXED WIRE 6F 8,244941,,270,$484.38 ,$484.38 ,$145.31 ,$440.79 ,$339.07 ,$145.31 ,$314.85 ,$348.75 ,$440.79 ,$363.29 
Carle BroMenn Medical Center,8140054,BALLOON NC TREK RX 2.5X15,238163,,270,$240.00 ,$240.00 ,$72.00 ,$218.40 ,$168.00 ,$72.00 ,$156.00 ,$172.80 ,$218.40 ,$180.00 
Carle BroMenn Medical Center,8140054,BALLOON NC TREK RX 2.5X20,238164,,270,$240.00 ,$240.00 ,$72.00 ,$218.40 ,$168.00 ,$72.00 ,$156.00 ,$172.80 ,$218.40 ,$180.00 
Carle BroMenn Medical Center,8140054,BALLOON SENSATION PLUS 50CC,180947,,270,"$3,198.00 ","$3,198.00 ",$959.40 ,"$2,910.18 ","$2,238.60 ",$959.40 ,"$2,078.70 ","$2,302.56 ","$2,910.18 ","$2,398.50 "
Carle BroMenn Medical Center,8140054,BALLOON SINUPLASTY KIT 6MM BX/5,205534,,270,"$6,318.00 ","$6,318.00 ","$1,895.40 ","$5,749.38 ","$4,422.60 ","$1,895.40 ","$4,106.70 ","$4,548.96 ","$5,749.38 ","$4,738.50 "
Carle BroMenn Medical Center,8140054,BALLOON SINUS 7X16 INCREMENTS OF,197922,,270,"$2,343.00 ","$2,343.00 ",$702.90 ,"$2,132.13 ","$1,640.10 ",$702.90 ,"$1,522.95 ","$1,686.96 ","$2,132.13 ","$1,757.25 "
Carle BroMenn Medical Center,8140054,BALLOON UROMAX ULT 18X6X10X75 HYD,236677,,270,$727.80 ,$727.80 ,$218.34 ,$662.30 ,$509.46 ,$218.34 ,$473.07 ,$524.02 ,$662.30 ,$545.85 
Carle BroMenn Medical Center,8140054,BALLOON UROMAX ULT 21X7X10X75 HYD,239626,,270,$680.07 ,$680.07 ,$204.02 ,$618.86 ,$476.05 ,$204.02 ,$442.05 ,$489.65 ,$618.86 ,$510.05 
Carle BroMenn Medical Center,8140054,BALLOON UROMAX ULTRA 15X5X4X75 HY,236661,,270,"$1,242.60 ","$1,242.60 ",$372.78 ,"$1,130.77 ",$869.82 ,$372.78 ,$807.69 ,$894.67 ,"$1,130.77 ",$931.95 
Carle BroMenn Medical Center,8140054,BALLOON UROMAX ULTRA 18X6X4X75 HY,236676,,270,$727.80 ,$727.80 ,$218.34 ,$662.30 ,$509.46 ,$218.34 ,$473.07 ,$524.02 ,$662.30 ,$545.85 
Carle BroMenn Medical Center,8140054,BAND FIXATE TISS,238321,,270,"$2,400.00 ","$2,400.00 ",$720.00 ,"$2,184.00 ","$1,680.00 ",$720.00 ,"$1,560.00 ","$1,728.00 ","$2,184.00 ","$1,800.00 "
Carle BroMenn Medical Center,8140054,BANDAGE ACE 2IN STERILE,244372,,270,$1.38 ,$1.38 ,$0.41 ,$1.26 ,$0.97 ,$0.41 ,$0.90 ,$0.99 ,$1.26 ,$1.04 
Carle BroMenn Medical Center,8140054,BANDAGE ACE 2IN STERILE,580,,270,$2.10 ,$2.10 ,$0.63 ,$1.91 ,$1.47 ,$0.63 ,$1.37 ,$1.51 ,$1.91 ,$1.58 
Carle BroMenn Medical Center,8140054,BANDAGE ACE 3IN NS,244934,,270,$1.10 ,$1.10 ,$0.33 ,$1.00 ,$0.77 ,$0.33 ,$0.72 ,$0.79 ,$1.00 ,$0.83 
Carle BroMenn Medical Center,8140054,BANDAGE ACE 3IN NS VELCRO,52,,270,$1.11 ,$1.11 ,$0.33 ,$1.01 ,$0.78 ,$0.33 ,$0.72 ,$0.80 ,$1.01 ,$0.83 
Carle BroMenn Medical Center,8140054,BANDAGE ACE 3IN STERILE,244741,,270,$1.65 ,$1.65 ,$0.50 ,$1.50 ,$1.16 ,$0.50 ,$1.07 ,$1.19 ,$1.50 ,$1.24 
Carle BroMenn Medical Center,8140054,BANDAGE ACE 4IN NS VELCRO,53,,270,$1.44 ,$1.44 ,$0.43 ,$1.31 ,$1.01 ,$0.43 ,$0.94 ,$1.04 ,$1.31 ,$1.08 
Carle BroMenn Medical Center,8140054,BANDAGE ACE 4IN STERILE,244373,,270,$2.21 ,$2.21 ,$0.66 ,$2.01 ,$1.55 ,$0.66 ,$1.44 ,$1.59 ,$2.01 ,$1.66 
Carle BroMenn Medical Center,8140054,BANDAGE ACE 6IN NS,244933,,270,$2.09 ,$2.09 ,$0.63 ,$1.90 ,$1.46 ,$0.63 ,$1.36 ,$1.50 ,$1.90 ,$1.57 
Carle BroMenn Medical Center,8140054,BANDAGE ACE 6IN NS VELCRO,54,,270,$2.11 ,$2.11 ,$0.63 ,$1.92 ,$1.48 ,$0.63 ,$1.37 ,$1.52 ,$1.92 ,$1.58 
Carle BroMenn Medical Center,8140054,BANDAGE ACE 6IN STERILE,244374,,270,$2.85 ,$2.85 ,$0.86 ,$2.59 ,$2.00 ,$0.86 ,$1.85 ,$2.05 ,$2.59 ,$2.14 
Carle BroMenn Medical Center,8140054,BANDAGE ACE 6IN STERILE,582,,270,$3.00 ,$3.00 ,$0.90 ,$2.73 ,$2.10 ,$0.90 ,$1.95 ,$2.16 ,$2.73 ,$2.25 
Carle BroMenn Medical Center,8140054,BANDAGE ACE 6IN X 10YD BX/10,169762,,270,$3.85 ,$3.85 ,$1.16 ,$3.50 ,$2.70 ,$1.16 ,$2.50 ,$2.77 ,$3.50 ,$2.89 
Carle BroMenn Medical Center,8140054,BANDAGE ADH SHR-GRD LF 2X4IN,244174,,270,$0.35 ,$0.35 ,$0.11 ,$0.32 ,$0.25 ,$0.11 ,$0.23 ,$0.25 ,$0.32 ,$0.26 
Carle BroMenn Medical Center,8140054,BANDAGE ADH SHR-GRD SPOT 7/8IN,244107,,270,$0.08 ,$0.08 ,$0.02 ,$0.07 ,$0.06 ,$0.02 ,$0.05 ,$0.06 ,$0.07 ,$0.06 
Carle BroMenn Medical Center,8140054,BANDAGE BANDAID 1INX3IN 50/BX,109995,,270,$0.04 ,$0.04 ,$0.01 ,$0.04 ,$0.03 ,$0.01 ,$0.03 ,$0.03 ,$0.04 ,$0.03 
Carle BroMenn Medical Center,8140054,BANDAGE BLKEE LTE STL6INX4.5YD,244172,,270,$3.13 ,$3.13 ,$0.94 ,$2.85 ,$2.19 ,$0.94 ,$2.03 ,$2.25 ,$2.85 ,$2.35 
Carle BroMenn Medical Center,8140054,BANDAGE BULKEE II 4.5X147 STL,244233,,270,$3.53 ,$3.53 ,$1.06 ,$3.21 ,$2.47 ,$1.06 ,$2.29 ,$2.54 ,$3.21 ,$2.65 
Carle BroMenn Medical Center,8140054,BANDAGE CONFORM 3IN STRL KRLX,244234,,270,$1.15 ,$1.15 ,$0.35 ,$1.05 ,$0.81 ,$0.35 ,$0.75 ,$0.83 ,$1.05 ,$0.86 
Carle BroMenn Medical Center,8140054,BANDAGE CONFORM LTE 3IN STRL,244222,,270,$1.83 ,$1.83 ,$0.55 ,$1.67 ,$1.28 ,$0.55 ,$1.19 ,$1.32 ,$1.67 ,$1.37 
Carle BroMenn Medical Center,8140054,BANDAGE ESMARK 4IN STERILE,245216,,270,$16.90 ,$16.90 ,$5.07 ,$15.38 ,$11.83 ,$5.07 ,$10.99 ,$12.17 ,$15.38 ,$12.68 
Carle BroMenn Medical Center,8140054,BANDAGE ESMARK STRL 6INX9FT,245264,,270,$25.62 ,$25.62 ,$7.69 ,$23.31 ,$17.93 ,$7.69 ,$16.65 ,$18.45 ,$23.31 ,$19.22 
Carle BroMenn Medical Center,8140054,BANDAGE GAUZE TUBE 1.5INX50YD CTN,245056,,270,$62.22 ,$62.22 ,$18.67 ,$56.62 ,$43.55 ,$18.67 ,$40.44 ,$44.80 ,$56.62 ,$46.67 
Carle BroMenn Medical Center,8140054,BANDAGE SHR-GRD 1X3,244228,,270,$0.08 ,$0.08 ,$0.02 ,$0.07 ,$0.06 ,$0.02 ,$0.05 ,$0.06 ,$0.07 ,$0.06 
Carle BroMenn Medical Center,8140054,BARRER INTERCEED 4X3IN 10/CA HEMO,219955,,270,$450.00 ,$450.00 ,$135.00 ,$409.50 ,$315.00 ,$135.00 ,$292.50 ,$324.00 ,$409.50 ,$337.50 
Carle BroMenn Medical Center,8140054,BARRIER SEPRAFILM 6X5IN,2547,,270,$894.59 ,$894.59 ,$268.38 ,$814.08 ,$626.21 ,$268.38 ,$581.48 ,$644.10 ,$814.08 ,$670.94 
Carle BroMenn Medical Center,8140054,BASIN SNGL BRO,244039,,270,$14.04 ,$14.04 ,$4.21 ,$12.78 ,$9.83 ,$4.21 ,$9.13 ,$10.11 ,$12.78 ,$10.53 
Carle BroMenn Medical Center,8140054,BASKET DAKOTA 1.9F 11MMX120CM,239343,,270,$3.33 ,$3.33 ,$1.00 ,$3.03 ,$2.33 ,$1.00 ,$2.16 ,$2.40 ,$3.03 ,$2.50 
Carle BroMenn Medical Center,8140054,BELT SIZE LARGE INTERSTIM,242427,,270,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8140054,BENZOIN TINCTURE CAPSUL,244097,,270,$1.24 ,$1.24 ,$0.37 ,$1.13 ,$0.87 ,$0.37 ,$0.81 ,$0.89 ,$1.13 ,$0.93 
Carle BroMenn Medical Center,8140054,BINDER ABD 10IN UNIV,244148,,270,$22.05 ,$22.05 ,$6.62 ,$20.07 ,$15.44 ,$6.62 ,$14.33 ,$15.88 ,$20.07 ,$16.54 
Carle BroMenn Medical Center,8140054,BINDER UNIV ABD 12IN 26-70 ADJ,244186,,270,$48.42 ,$48.42 ,$14.53 ,$44.06 ,$33.89 ,$14.53 ,$31.47 ,$34.86 ,$44.06 ,$36.32 
Carle BroMenn Medical Center,8140054,BINDER UNIV ABD 15IN 5PANEL 70,245012,,270,$61.71 ,$61.71 ,$18.51 ,$56.16 ,$43.20 ,$18.51 ,$40.11 ,$44.43 ,$56.16 ,$46.28 
Carle BroMenn Medical Center,8140054,BIOSURE PK 7X25MM,250621,,270,$686.40 ,$686.40 ,$205.92 ,$624.62 ,$480.48 ,$205.92 ,$446.16 ,$494.21 ,$624.62 ,$514.80 
Carle BroMenn Medical Center,8140054,BIT DRILL 1.1MM/KWIRE ATTCHMNT,215827,,270,$188.10 ,$188.10 ,$56.43 ,$171.17 ,$131.67 ,$56.43 ,$122.27 ,$135.43 ,$171.17 ,$141.08 
Carle BroMenn Medical Center,8140054,BIT DRILL 1.8X 100MM,6285,,270,$333.90 ,$333.90 ,$100.17 ,$303.85 ,$233.73 ,$100.17 ,$217.04 ,$240.41 ,$303.85 ,$250.43 
Carle BroMenn Medical Center,8140054,BIT DRILL 11MM,242224,,270,$701.40 ,$701.40 ,$210.42 ,$638.27 ,$490.98 ,$210.42 ,$455.91 ,$505.01 ,$638.27 ,$526.05 
Carle BroMenn Medical Center,8140054,BIT DRILL 2.0MM,233360,,270,$726.18 ,$726.18 ,$217.85 ,$660.82 ,$508.33 ,$217.85 ,$472.02 ,$522.85 ,$660.82 ,$544.64 
Carle BroMenn Medical Center,8140054,BIT DRILL 2.0X 140MM,6286,,270,$333.90 ,$333.90 ,$100.17 ,$303.85 ,$233.73 ,$100.17 ,$217.04 ,$240.41 ,$303.85 ,$250.43 
Carle BroMenn Medical Center,8140054,BIT DRILL 2.2MM,233883,,270,$279.00 ,$279.00 ,$83.70 ,$253.89 ,$195.30 ,$83.70 ,$181.35 ,$200.88 ,$253.89 ,$209.25 
Carle BroMenn Medical Center,8140054,BIT DRILL 2.5MM,5277,,270,$297.00 ,$297.00 ,$89.10 ,$270.27 ,$207.90 ,$89.10 ,$193.05 ,$213.84 ,$270.27 ,$222.75 
Carle BroMenn Medical Center,8140054,BIT DRILL 2.5MMX110MM QC GOLD 310,3002,,270,$162.30 ,$162.30 ,$48.69 ,$147.69 ,$113.61 ,$48.69 ,$105.50 ,$116.86 ,$147.69 ,$121.73 
Carle BroMenn Medical Center,8140054,BIT DRILL 2.5X180MM,4351,,270,$183.00 ,$183.00 ,$54.90 ,$166.53 ,$128.10 ,$54.90 ,$118.95 ,$131.76 ,$166.53 ,$137.25 
Carle BroMenn Medical Center,8140054,BIT DRILL 2.5X205MM,233608,,270,$296.64 ,$296.64 ,$88.99 ,$269.94 ,$207.65 ,$88.99 ,$192.82 ,$213.58 ,$269.94 ,$222.48 
Carle BroMenn Medical Center,8140054,BIT DRILL 2.5X70MM,237198,,270,$297.00 ,$297.00 ,$89.10 ,$270.27 ,$207.90 ,$89.10 ,$193.05 ,$213.84 ,$270.27 ,$222.75 
Carle BroMenn Medical Center,8140054,BIT DRILL 2.7MM QC,3435,,270,$259.20 ,$259.20 ,$77.76 ,$235.87 ,$181.44 ,$77.76 ,$168.48 ,$186.62 ,$235.87 ,$194.40 
Carle BroMenn Medical Center,8140054,BIT DRILL 2.8X165MM QC,3003,,270,$202.50 ,$202.50 ,$60.75 ,$184.28 ,$141.75 ,$60.75 ,$131.63 ,$145.80 ,$184.28 ,$151.88 
Carle BroMenn Medical Center,8140054,BIT DRILL 2X125MM QC,3001,,270,$183.00 ,$183.00 ,$54.90 ,$166.53 ,$128.10 ,$54.90 ,$118.95 ,$131.76 ,$166.53 ,$137.25 
Carle BroMenn Medical Center,8140054,BIT DRILL 3.2MM QC,3332,,270,$159.90 ,$159.90 ,$47.97 ,$145.51 ,$111.93 ,$47.97 ,$103.94 ,$115.13 ,$145.51 ,$119.93 
Carle BroMenn Medical Center,8140054,BIT DRILL 300MM QC CALIB 4.3MM,8413,,270,$419.10 ,$419.10 ,$125.73 ,$381.38 ,$293.37 ,$125.73 ,$272.42 ,$301.75 ,$381.38 ,$314.33 
Carle BroMenn Medical Center,8140054,BIT DRILL 4.2MM EX,6234,,270,$490.20 ,$490.20 ,$147.06 ,$446.08 ,$343.14 ,$147.06 ,$318.63 ,$352.94 ,$446.08 ,$367.65 
Carle BroMenn Medical Center,8140054,BIT DRILL 4.2MM EX CALIBRATED,6235,,270,$643.50 ,$643.50 ,$193.05 ,$585.59 ,$450.45 ,$193.05 ,$418.28 ,$463.32 ,$585.59 ,$482.63 
Carle BroMenn Medical Center,8140054,BIT DRILL 4.3MM LONG CALIBRATD,241602,,270,$306.54 ,$306.54 ,$91.96 ,$278.95 ,$214.58 ,$91.96 ,$199.25 ,$220.71 ,$278.95 ,$229.91 
Carle BroMenn Medical Center,8140054,BIT DRILL 4.3X180MM QC,3436,,270,$276.00 ,$276.00 ,$82.80 ,$251.16 ,$193.20 ,$82.80 ,$179.40 ,$198.72 ,$251.16 ,$207.00 
Carle BroMenn Medical Center,8140054,BIT DRILL 4.5MM QUICK COUP 145,3333,,270,$159.90 ,$159.90 ,$47.97 ,$145.51 ,$111.93 ,$47.97 ,$103.94 ,$115.13 ,$145.51 ,$119.93 
Carle BroMenn Medical Center,8140054,BIT DRILL 5.0X230MM AO STERILE,243023,,270,$597.30 ,$597.30 ,$179.19 ,$543.54 ,$418.11 ,$179.19 ,$388.25 ,$430.06 ,$543.54 ,$447.98 
Carle BroMenn Medical Center,8140054,BIT DRILL AO 2.6X135MM SCALED,243582,,270,$371.64 ,$371.64 ,$111.49 ,$338.19 ,$260.15 ,$111.49 ,$241.57 ,$267.58 ,$338.19 ,$278.73 
Carle BroMenn Medical Center,8140054,BIT DRILL CALIBD 2.7MM,239070,,270,$312.00 ,$312.00 ,$93.60 ,$283.92 ,$218.40 ,$93.60 ,$202.80 ,$224.64 ,$283.92 ,$234.00 
Carle BroMenn Medical Center,8140054,BIT DRILL CALIBD LNG 4.3MM,239126,,270,$306.54 ,$306.54 ,$91.96 ,$278.95 ,$214.58 ,$91.96 ,$199.25 ,$220.71 ,$278.95 ,$229.91 
Carle BroMenn Medical Center,8140054,BIT DRILL CANN 4.5MM MAGNAFX,236856,,270,"$1,522.77 ","$1,522.77 ",$456.83 ,"$1,385.72 ","$1,065.94 ",$456.83 ,$989.80 ,"$1,096.39 ","$1,385.72 ","$1,142.08 "
Carle BroMenn Medical Center,8140054,BIT DRILL CMPHSV REV 3.2MM,237368,,270,$447.00 ,$447.00 ,$134.10 ,$406.77 ,$312.90 ,$134.10 ,$290.55 ,$321.84 ,$406.77 ,$335.25 
Carle BroMenn Medical Center,8140054,BIT DRILL FREEHAND 4.3MM,239146,,270,$286.77 ,$286.77 ,$86.03 ,$260.96 ,$200.74 ,$86.03 ,$186.40 ,$206.47 ,$260.96 ,$215.08 
Carle BroMenn Medical Center,8140054,BIT DRILL INSTRUMENT 2.4MM,11419,,270,$924.00 ,$924.00 ,$277.20 ,$840.84 ,$646.80 ,$277.20 ,$600.60 ,$665.28 ,$840.84 ,$693.00 
Carle BroMenn Medical Center,8140054,BIT DRILL INSTRUMENT 3.2MM,242227,,270,$947.10 ,$947.10 ,$284.13 ,$861.86 ,$662.97 ,$284.13 ,$615.62 ,$681.91 ,$861.86 ,$710.33 
Carle BroMenn Medical Center,8140054,BIT DRILL LG 2.5X120MM,237260,,270,$342.00 ,$342.00 ,$102.60 ,$311.22 ,$239.40 ,$102.60 ,$222.30 ,$246.24 ,$311.22 ,$256.50 
Carle BroMenn Medical Center,8140054,BIT DRILL MAX TORQ 3.7,235374,,270,"$1,020.00 ","$1,020.00 ",$306.00 ,$928.20 ,$714.00 ,$306.00 ,$663.00 ,$734.40 ,$928.20 ,$765.00 
Carle BroMenn Medical Center,8140054,BIT DRILL MAX TORQ 4.7,235375,,270,"$1,167.00 ","$1,167.00 ",$350.10 ,"$1,061.97 ",$816.90 ,$350.10 ,$758.55 ,$840.24 ,"$1,061.97 ",$875.25 
Carle BroMenn Medical Center,8140054,BIT DRILL MINIQUICK 1.1MM,237298,,270,$147.00 ,$147.00 ,$44.10 ,$133.77 ,$102.90 ,$44.10 ,$95.55 ,$105.84 ,$133.77 ,$110.25 
Carle BroMenn Medical Center,8140054,BIT DRILL NCB 4.3X195MM,247882,,270,$306.54 ,$306.54 ,$91.96 ,$278.95 ,$214.58 ,$91.96 ,$199.25 ,$220.71 ,$278.95 ,$229.91 
Carle BroMenn Medical Center,8140054,BIT DRILL QC 1.5X110MM,12337,,270,$162.30 ,$162.30 ,$48.69 ,$147.69 ,$113.61 ,$48.69 ,$105.50 ,$116.86 ,$147.69 ,$121.73 
Carle BroMenn Medical Center,8140054,BIT DRILL QC 2.5X110MM,233606,,270,$207.66 ,$207.66 ,$62.30 ,$188.97 ,$145.36 ,$62.30 ,$134.98 ,$149.52 ,$188.97 ,$155.75 
Carle BroMenn Medical Center,8140054,BIT DRILL QC 3.5X110MM,233607,,270,$207.66 ,$207.66 ,$62.30 ,$188.97 ,$145.36 ,$62.30 ,$134.98 ,$149.52 ,$188.97 ,$155.75 
Carle BroMenn Medical Center,8140054,BIT DRILL QC CANN 5.0X300MM,12344,,270,$981.60 ,$981.60 ,$294.48 ,$893.26 ,$687.12 ,$294.48 ,$638.04 ,$706.75 ,$893.26 ,$736.20 
Carle BroMenn Medical Center,8140054,BIT DRILL QC STL 2.5X110MM,237678,,270,$273.30 ,$273.30 ,$81.99 ,$248.70 ,$191.31 ,$81.99 ,$177.65 ,$196.78 ,$248.70 ,$204.98 
Carle BroMenn Medical Center,8140054,BIT DRILL QR 2.3MM,240964,,270,$408.00 ,$408.00 ,$122.40 ,$371.28 ,$285.60 ,$122.40 ,$265.20 ,$293.76 ,$371.28 ,$306.00 
Carle BroMenn Medical Center,8140054,BIT DRILL QR 2.8MM,240849,,270,$417.00 ,$417.00 ,$125.10 ,$379.47 ,$291.90 ,$125.10 ,$271.05 ,$300.24 ,$379.47 ,$312.75 
Carle BroMenn Medical Center,8140054,BIT DRILL REVOLUTION 10MM HELIX,250351,,270,$176.64 ,$176.64 ,$52.99 ,$160.74 ,$123.65 ,$52.99 ,$114.82 ,$127.18 ,$160.74 ,$132.48 
Carle BroMenn Medical Center,8140054,BIT DRILL SHLDR CMPHSV REV 2.7,237340,,270,$585.00 ,$585.00 ,$175.50 ,$532.35 ,$409.50 ,$175.50 ,$380.25 ,$421.20 ,$532.35 ,$438.75 
Carle BroMenn Medical Center,8140054,BIT DRILL SHT 2.5MM,237524,,270,$255.00 ,$255.00 ,$76.50 ,$232.05 ,$178.50 ,$76.50 ,$165.75 ,$183.60 ,$232.05 ,$191.25 
Carle BroMenn Medical Center,8140054,BIT DRILL SURGIBIT QC 2MM,240970,,270,$387.00 ,$387.00 ,$116.10 ,$352.17 ,$270.90 ,$116.10 ,$251.55 ,$278.64 ,$352.17 ,$290.25 
Carle BroMenn Medical Center,8140054,BIT DRILL T2 AO 4.2X130MM,243015,,270,$597.30 ,$597.30 ,$179.19 ,$543.54 ,$418.11 ,$179.19 ,$388.25 ,$430.06 ,$543.54 ,$447.98 
Carle BroMenn Medical Center,8140054,BIT DRILL T2 AO 4.2X340MM,243014,,270,$597.30 ,$597.30 ,$179.19 ,$543.54 ,$418.11 ,$179.19 ,$388.25 ,$430.06 ,$543.54 ,$447.98 
Carle BroMenn Medical Center,8140054,BIT DRILL VP XT,251999,,270,"$1,650.00 ","$1,650.00 ",$495.00 ,"$1,501.50 ","$1,155.00 ",$495.00 ,"$1,072.50 ","$1,188.00 ","$1,501.50 ","$1,237.50 "
Carle BroMenn Medical Center,8140054,BIT DRILL VUEPOINT II,251995,,270,$219.00 ,$219.00 ,$65.70 ,$199.29 ,$153.30 ,$65.70 ,$142.35 ,$157.68 ,$199.29 ,$164.25 
Carle BroMenn Medical Center,8140054,BIT DRILL WIRE PASS 1.5 MD,244675,,270,$155.25 ,$155.25 ,$46.58 ,$141.28 ,$108.68 ,$46.58 ,$100.91 ,$111.78 ,$141.28 ,$116.44 
Carle BroMenn Medical Center,8140054,BIT DRL 3.5X110MM QC,3004,,270,$174.00 ,$174.00 ,$52.20 ,$158.34 ,$121.80 ,$52.20 ,$113.10 ,$125.28 ,$158.34 ,$130.50 
Carle BroMenn Medical Center,8140054,BIT INFINITY DRILL 2.4MM,243573,,270,"$1,200.00 ","$1,200.00 ",$360.00 ,"$1,092.00 ",$840.00 ,$360.00 ,$780.00 ,$864.00 ,"$1,092.00 ",$900.00 
Carle BroMenn Medical Center,8140054,BIT PERFORATOR LG 14MMX3MM,245219,,270,$564.75 ,$564.75 ,$169.43 ,$513.92 ,$395.33 ,$169.43 ,$367.09 ,$406.62 ,$513.92 ,$423.56 
Carle BroMenn Medical Center,8140054,BITE BLOCK LG SCOPE SAVER GRN 50/,249523,,270,$8.25 ,$8.25 ,$2.48 ,$7.51 ,$5.78 ,$2.48 ,$5.36 ,$5.94 ,$7.51 ,$6.19 
Carle BroMenn Medical Center,8140054,BLADE AGRSV MD 25X9,244702,,270,$97.50 ,$97.50 ,$29.25 ,$88.73 ,$68.25 ,$29.25 ,$63.38 ,$70.20 ,$88.73 ,$73.13 
Carle BroMenn Medical Center,8140054,BLADE CCA RECIP SIDE D,244502,,270,$90.00 ,$90.00 ,$27.00 ,$81.90 ,$63.00 ,$27.00 ,$58.50 ,$64.80 ,$81.90 ,$67.50 
Carle BroMenn Medical Center,8140054,BLADE DERMA SHAVE BIOP FLEX,244572,,270,$189.00 ,$189.00 ,$56.70 ,$171.99 ,$132.30 ,$56.70 ,$122.85 ,$136.08 ,$171.99 ,$141.75 
Carle BroMenn Medical Center,8140054,BLADE DERMATOME 8800,600,,270,$85.65 ,$85.65 ,$25.70 ,$77.94 ,$59.96 ,$25.70 ,$55.67 ,$61.67 ,$77.94 ,$64.24 
Carle BroMenn Medical Center,8140054,BLADE DUAL CUT SAG 18X90X1.27,244697,,270,$147.48 ,$147.48 ,$44.24 ,$134.21 ,$103.24 ,$44.24 ,$95.86 ,$106.19 ,$134.21 ,$110.61 
Carle BroMenn Medical Center,8140054,BLADE DUAL CUT SAG 25X90X1.27,250841,,270,$147.48 ,$147.48 ,$44.24 ,$134.21 ,$103.24 ,$44.24 ,$95.86 ,$106.19 ,$134.21 ,$110.61 
Carle BroMenn Medical Center,8140054,BLADE ELECTRODE STD 6.5IN,248938,,270,$12.24 ,$12.24 ,$3.67 ,$11.14 ,$8.57 ,$3.67 ,$7.96 ,$8.81 ,$11.14 ,$9.18 
Carle BroMenn Medical Center,8140054,BLADE INFER TURBINATE 2MM,245237,,270,$0.67 ,$0.67 ,$0.20 ,$0.61 ,$0.47 ,$0.20 ,$0.44 ,$0.48 ,$0.61 ,$0.50 
Carle BroMenn Medical Center,8140054,BLADE LAMELLAR 60D BVL 60D BLK BE,245037,,270,$46.09 ,$46.09 ,$13.83 ,$41.94 ,$32.26 ,$13.83 ,$29.96 ,$33.18 ,$41.94 ,$34.57 
Carle BroMenn Medical Center,8140054,BLADE LNG MD 25X9MM,244678,,270,$97.50 ,$97.50 ,$29.25 ,$88.73 ,$68.25 ,$29.25 ,$63.38 ,$70.20 ,$88.73 ,$73.13 
Carle BroMenn Medical Center,8140054,BLADE MINI 64,244616,,270,$4.44 ,$4.44 ,$1.33 ,$4.04 ,$3.11 ,$1.33 ,$2.89 ,$3.20 ,$4.04 ,$3.33 
Carle BroMenn Medical Center,8140054,BLADE MVR 23GA 8065912301,4062,,270,$126.54 ,$126.54 ,$37.96 ,$115.15 ,$88.58 ,$37.96 ,$82.25 ,$91.11 ,$115.15 ,$94.91 
Carle BroMenn Medical Center,8140054,BLADE MYRINGOTOMY LANCE TIP,244589,,270,$15.09 ,$15.09 ,$4.53 ,$13.73 ,$10.56 ,$4.53 ,$9.81 ,$10.86 ,$13.73 ,$11.32 
Carle BroMenn Medical Center,8140054,BLADE OPTHALMIC BEAVER 3/CA,11036,,270,$29.90 ,$29.90 ,$8.97 ,$27.21 ,$20.93 ,$8.97 ,$19.44 ,$21.53 ,$27.21 ,$22.43 
Carle BroMenn Medical Center,8140054,BLADE PAT RMR PILOT H 51MM SS,236899,,270,$429.00 ,$429.00 ,$128.70 ,$390.39 ,$300.30 ,$128.70 ,$278.85 ,$308.88 ,$390.39 ,$321.75 
Carle BroMenn Medical Center,8140054,BLADE PRECISN MED NRW 18.5X7,249495,,270,$97.50 ,$97.50 ,$29.25 ,$88.73 ,$68.25 ,$29.25 ,$63.38 ,$70.20 ,$88.73 ,$73.13 
Carle BroMenn Medical Center,8140054,BLADE REVISION TKA,206419,,270,$83.04 ,$83.04 ,$24.91 ,$75.57 ,$58.13 ,$24.91 ,$53.98 ,$59.79 ,$75.57 ,$62.28 
Carle BroMenn Medical Center,8140054,BLADE RMR PAT PILOT H 29MM SS,237017,,270,$429.00 ,$429.00 ,$128.70 ,$390.39 ,$300.30 ,$128.70 ,$278.85 ,$308.88 ,$390.39 ,$321.75 
Carle BroMenn Medical Center,8140054,BLADE RMR PAT PILOT H 32MM SS,236883,,270,$429.00 ,$429.00 ,$128.70 ,$390.39 ,$300.30 ,$128.70 ,$278.85 ,$308.88 ,$390.39 ,$321.75 
Carle BroMenn Medical Center,8140054,BLADE RMR PAT PILOT H 35MM SS,237014,,270,$429.00 ,$429.00 ,$128.70 ,$390.39 ,$300.30 ,$128.70 ,$278.85 ,$308.88 ,$390.39 ,$321.75 
Carle BroMenn Medical Center,8140054,BLADE RMR PAT PILOT H 38MM,238991,,270,$429.00 ,$429.00 ,$128.70 ,$390.39 ,$300.30 ,$128.70 ,$278.85 ,$308.88 ,$390.39 ,$321.75 
Carle BroMenn Medical Center,8140054,BLADE SAG 21X90X1.19MM,244975,,270,$175.89 ,$175.89 ,$52.77 ,$160.06 ,$123.12 ,$52.77 ,$114.33 ,$126.64 ,$160.06 ,$131.92 
Carle BroMenn Medical Center,8140054,BLADE SAG NRW THICK OFST 12.4 73.,244849,,270,$75.00 ,$75.00 ,$22.50 ,$68.25 ,$52.50 ,$22.50 ,$48.75 ,$54.00 ,$68.25 ,$56.25 
Carle BroMenn Medical Center,8140054,BLADE SAW GIGLI RND 300MM 10/BX,249744,,270,$54.38 ,$54.38 ,$16.31 ,$49.49 ,$38.07 ,$16.31 ,$35.35 ,$39.15 ,$49.49 ,$40.79 
Carle BroMenn Medical Center,8140054,BLADE SS STL #10 SOUTHMEDIC PERSO,244154,,270,$0.91 ,$0.91 ,$0.27 ,$0.83 ,$0.64 ,$0.27 ,$0.59 ,$0.66 ,$0.83 ,$0.68 
Carle BroMenn Medical Center,8140054,BLADE SS STL #11 SOUTHMEDIC PERSO,244727,,270,$0.97 ,$0.97 ,$0.29 ,$0.88 ,$0.68 ,$0.29 ,$0.63 ,$0.70 ,$0.88 ,$0.73 
Carle BroMenn Medical Center,8140054,BLADE SS STL #15 SOUTHMEDIC PERSO,244157,,270,$0.91 ,$0.91 ,$0.27 ,$0.83 ,$0.64 ,$0.27 ,$0.59 ,$0.66 ,$0.83 ,$0.68 
Carle BroMenn Medical Center,8140054,BLADE SS STL #20 SOUTHMEDIC PERSO,244151,,270,$0.91 ,$0.91 ,$0.27 ,$0.83 ,$0.64 ,$0.27 ,$0.59 ,$0.66 ,$0.83 ,$0.68 
Carle BroMenn Medical Center,8140054,BLADE STERNAL REPEAT 44.5X40MM,245140,,270,$0.67 ,$0.67 ,$0.20 ,$0.61 ,$0.47 ,$0.20 ,$0.44 ,$0.48 ,$0.61 ,$0.50 
Carle BroMenn Medical Center,8140054,BLADE STERNAL SAW 30.5X1MM,245097,,270,$87.60 ,$87.60 ,$26.28 ,$79.72 ,$61.32 ,$26.28 ,$56.94 ,$63.07 ,$79.72 ,$65.70 
Carle BroMenn Medical Center,8140054,BLADE STR DBL BVL 180D CTNG BEAVE,245025,,270,$15.21 ,$15.21 ,$4.56 ,$13.84 ,$10.65 ,$4.56 ,$9.89 ,$10.95 ,$13.84 ,$11.41 
Carle BroMenn Medical Center,8140054,BLADE STRAIGHT SHOT TIP 4.0 5 PER,2521,,270,$791.40 ,$791.40 ,$237.42 ,$720.17 ,$553.98 ,$237.42 ,$514.41 ,$569.81 ,$720.17 ,$593.55 
Carle BroMenn Medical Center,8140054,BLADE SURG CLIPPER PROF F/9681,244121,,270,$6.57 ,$6.57 ,$1.97 ,$5.98 ,$4.60 ,$1.97 ,$4.27 ,$4.73 ,$5.98 ,$4.93 
Carle BroMenn Medical Center,8140054,BLADE TOMCAT SHAVER 4MM,245234,,270,$121.73 ,$121.73 ,$36.52 ,$110.77 ,$85.21 ,$36.52 ,$79.12 ,$87.65 ,$110.77 ,$91.30 
Carle BroMenn Medical Center,8140054,BLADE TRICUT ANG NONROTG27.5CM,244659,,270,$1.11 ,$1.11 ,$0.33 ,$1.01 ,$0.78 ,$0.33 ,$0.72 ,$0.80 ,$1.01 ,$0.83 
Carle BroMenn Medical Center,8140054,BLADE TRICUT CUTTER 2.9MM,244645,,270,$789.00 ,$789.00 ,$236.70 ,$717.99 ,$552.30 ,$236.70 ,$512.85 ,$568.08 ,$717.99 ,$591.75 
Carle BroMenn Medical Center,8140054,BLADE TRUNCATED HEMI 62MM EXPLANT,247120,,270,"$2,550.00 ","$2,550.00 ",$765.00 ,"$2,320.50 ","$1,785.00 ",$765.00 ,"$1,657.50 ","$1,836.00 ","$2,320.50 ","$1,912.50 "
Carle BroMenn Medical Center,8140054,BLANKET WARMER  LOWER BODY,244026,,270,$14.97 ,$14.97 ,$4.49 ,$13.62 ,$10.48 ,$4.49 ,$9.73 ,$10.78 ,$13.62 ,$11.23 
Carle BroMenn Medical Center,8140054,BLANKET WARMER SM UPPER BODY,244029,,270,$14.97 ,$14.97 ,$4.49 ,$13.62 ,$10.48 ,$4.49 ,$9.73 ,$10.78 ,$13.62 ,$11.23 
Carle BroMenn Medical Center,8140054,BOLSTER SUTURE RETENTION TUBE,244014,,270,$6.33 ,$6.33 ,$1.90 ,$5.76 ,$4.43 ,$1.90 ,$4.11 ,$4.56 ,$5.76 ,$4.75 
Carle BroMenn Medical Center,8140054,BOWL SMART MIXING CPS EMPTY,237352,,270,$135.00 ,$135.00 ,$40.50 ,$122.85 ,$94.50 ,$40.50 ,$87.75 ,$97.20 ,$122.85 ,$101.25 
Carle BroMenn Medical Center,8140054,BRA COMPRSS VEST BGE 30-32 SM,244811,,270,$197.40 ,$197.40 ,$59.22 ,$179.63 ,$138.18 ,$59.22 ,$128.31 ,$142.13 ,$179.63 ,$148.05 
Carle BroMenn Medical Center,8140054,BRA COMPRSS VEST BGE 38-40 LG,244812,,270,$197.40 ,$197.40 ,$59.22 ,$179.63 ,$138.18 ,$59.22 ,$128.31 ,$142.13 ,$179.63 ,$148.05 
Carle BroMenn Medical Center,8140054,BRA COMPRSS VEST BGE MD,244803,,270,$197.40 ,$197.40 ,$59.22 ,$179.63 ,$138.18 ,$59.22 ,$128.31 ,$142.13 ,$179.63 ,$148.05 
Carle BroMenn Medical Center,8140054,BRA COMPRSS VEST BGE XL,244801,,270,$190.59 ,$190.59 ,$57.18 ,$173.44 ,$133.41 ,$57.18 ,$123.88 ,$137.22 ,$173.44 ,$142.94 
Carle BroMenn Medical Center,8140054,BRA COMPRSS VEST BGE XXL,244031,,270,$197.40 ,$197.40 ,$59.22 ,$179.63 ,$138.18 ,$59.22 ,$128.31 ,$142.13 ,$179.63 ,$148.05 
Carle BroMenn Medical Center,8140054,BRACE SHLDR PAD II LG 7X18IN,245201,,270,$133.89 ,$133.89 ,$40.17 ,$121.84 ,$93.72 ,$40.17 ,$87.03 ,$96.40 ,$121.84 ,$100.42 
Carle BroMenn Medical Center,8140054,BRACE SHLDR PAD II MD 7X17IN,245200,,270,$133.89 ,$133.89 ,$40.17 ,$121.84 ,$93.72 ,$40.17 ,$87.03 ,$96.40 ,$121.84 ,$100.42 
Carle BroMenn Medical Center,8140054,BRACE SHLDR PAD II SM 7X16IN,245199,,270,$133.89 ,$133.89 ,$40.17 ,$121.84 ,$93.72 ,$40.17 ,$87.03 ,$96.40 ,$121.84 ,$100.42 
Carle BroMenn Medical Center,8140054,BRIEF STRETCH MESH SMLSS XL,244198,,270,$2.03 ,$2.03 ,$0.61 ,$1.85 ,$1.42 ,$0.61 ,$1.32 ,$1.46 ,$1.85 ,$1.52 
Carle BroMenn Medical Center,8140054,BRUSH CYTOBRUSH PLUS STL GENTLE T,244798,,270,$2.10 ,$2.10 ,$0.63 ,$1.91 ,$1.47 ,$0.63 ,$1.37 ,$1.51 ,$1.91 ,$1.58 
Carle BroMenn Medical Center,8140054,BULB EVACUATOR SIL 400CC,244819,,270,$43.88 ,$43.88 ,$13.16 ,$39.93 ,$30.72 ,$13.16 ,$28.52 ,$31.59 ,$39.93 ,$32.91 
Carle BroMenn Medical Center,8140054,BULB LIGHTED RET. INVUITY,207842,,270,"$1,185.00 ","$1,185.00 ",$355.50 ,"$1,078.35 ",$829.50 ,$355.50 ,$770.25 ,$853.20 ,"$1,078.35 ",$888.75 
Carle BroMenn Medical Center,8140054,BUR 12CM SD BALL 3MM DIAM MR8 PMV,240314,,270,$645.00 ,$645.00 ,$193.50 ,$586.95 ,$451.50 ,$193.50 ,$419.25 ,$464.40 ,$586.95 ,$483.75 
Carle BroMenn Medical Center,8140054,BUR 14CM BALL 3MM DIAM MR8 PMT,240316,,270,$553.50 ,$553.50 ,$166.05 ,$503.69 ,$387.45 ,$166.05 ,$359.78 ,$398.52 ,$503.69 ,$415.13 
Carle BroMenn Medical Center,8140054,BUR 14CM BALL 4MM DIAM MR8 PMT,240319,,270,$516.60 ,$516.60 ,$154.98 ,$470.11 ,$361.62 ,$154.98 ,$335.79 ,$371.95 ,$470.11 ,$387.45 
Carle BroMenn Medical Center,8140054,BUR 14CM BALL 5MM DIAM MR8 PMT,240324,,270,$529.20 ,$529.20 ,$158.76 ,$481.57 ,$370.44 ,$158.76 ,$343.98 ,$381.02 ,$481.57 ,$396.90 
Carle BroMenn Medical Center,8140054,BUR 14CM BALL DMD CRSE 4MM DIA MR,240321,,270,$580.50 ,$580.50 ,$174.15 ,$528.26 ,$406.35 ,$174.15 ,$377.33 ,$417.96 ,$528.26 ,$435.38 
Carle BroMenn Medical Center,8140054,BUR 14CM BALL DMD XCRS 4MM DIA MR,240322,,270,$587.25 ,$587.25 ,$176.18 ,$534.40 ,$411.08 ,$176.18 ,$381.71 ,$422.82 ,$534.40 ,$440.44 
Carle BroMenn Medical Center,8140054,BUR 14CM BALL DMD XCRS 5MM DIA MR,240326,,270,$587.25 ,$587.25 ,$176.18 ,$534.40 ,$411.08 ,$176.18 ,$381.71 ,$422.82 ,$534.40 ,$440.44 
Carle BroMenn Medical Center,8140054,BUR 14CM BALL DMND 3MM DIAM MR8 P,240317,,270,$580.50 ,$580.50 ,$174.15 ,$528.26 ,$406.35 ,$174.15 ,$377.33 ,$417.96 ,$528.26 ,$435.38 
Carle BroMenn Medical Center,8140054,BUR 14CM BALL DMND 4MM DIAM MR8 P,240320,,270,$587.25 ,$587.25 ,$176.18 ,$534.40 ,$411.08 ,$176.18 ,$381.71 ,$422.82 ,$534.40 ,$440.44 
Carle BroMenn Medical Center,8140054,BUR 14CM BALL DMND 5MM DIAM MR8 P,240325,,270,$587.25 ,$587.25 ,$176.18 ,$534.40 ,$411.08 ,$176.18 ,$381.71 ,$422.82 ,$534.40 ,$440.44 
Carle BroMenn Medical Center,8140054,BUR 14CM BALL SYM-TRI 3MM DIAM MR,240318,,270,$639.00 ,$639.00 ,$191.70 ,$581.49 ,$447.30 ,$191.70 ,$415.35 ,$460.08 ,$581.49 ,$479.25 
Carle BroMenn Medical Center,8140054,BUR 14CM BALL SYM-TRI 4MM DIAM MR,240323,,270,$596.40 ,$596.40 ,$178.92 ,$542.72 ,$417.48 ,$178.92 ,$387.66 ,$429.41 ,$542.72 ,$447.30 
Carle BroMenn Medical Center,8140054,BUR 14CM BALL SYM-TRI 5MM DIAM MR,240327,,270,$639.00 ,$639.00 ,$191.70 ,$581.49 ,$447.30 ,$191.70 ,$415.35 ,$460.08 ,$581.49 ,$479.25 
Carle BroMenn Medical Center,8140054,BUR 14CM SP BALL 3MM DIAM MR8 PMV,240315,,270,$645.00 ,$645.00 ,$193.50 ,$586.95 ,$451.50 ,$193.50 ,$419.25 ,$464.40 ,$586.95 ,$483.75 
Carle BroMenn Medical Center,8140054,BUR 14CM TELESCP BALL 3MM DIAM MR,240313,,270,$506.25 ,$506.25 ,$151.88 ,$460.69 ,$354.38 ,$151.88 ,$329.06 ,$364.50 ,$460.69 ,$379.69 
Carle BroMenn Medical Center,8140054,BUR 15CM BALL 4MM DIAM MR8 PMT,240328,,270,$553.50 ,$553.50 ,$166.05 ,$503.69 ,$387.45 ,$166.05 ,$359.78 ,$398.52 ,$503.69 ,$415.13 
Carle BroMenn Medical Center,8140054,BUR 15CM BALL SYM-TRI 4MM MR8 PMT,240329,,270,$639.00 ,$639.00 ,$191.70 ,$581.49 ,$447.30 ,$191.70 ,$415.35 ,$460.08 ,$581.49 ,$479.25 
Carle BroMenn Medical Center,8140054,BUR 15CM MATCH HEAD 2.2MM DIAM MR,240330,,270,$499.50 ,$499.50 ,$149.85 ,$454.55 ,$349.65 ,$149.85 ,$324.68 ,$359.64 ,$454.55 ,$374.63 
Carle BroMenn Medical Center,8140054,BUR 2.0MM ROUND DIAMOND,163342,,270,$471.00 ,$471.00 ,$141.30 ,$428.61 ,$329.70 ,$141.30 ,$306.15 ,$339.12 ,$428.61 ,$353.25 
Carle BroMenn Medical Center,8140054,BUR 6 FLUTES 4MM BARREL,245162,,270,$60.86 ,$60.86 ,$18.26 ,$55.38 ,$42.60 ,$18.26 ,$39.56 ,$43.82 ,$55.38 ,$45.65 
Carle BroMenn Medical Center,8140054,BUR 7CM TWIST DRILL 1.5X12MM MR8,240294,,270,$605.25 ,$605.25 ,$181.58 ,$550.78 ,$423.68 ,$181.58 ,$393.41 ,$435.78 ,$550.78 ,$453.94 
Carle BroMenn Medical Center,8140054,BUR 7CM TWIST DRILL 1.5X8MM MR8 P,240295,,270,$375.75 ,$375.75 ,$112.73 ,$341.93 ,$263.03 ,$112.73 ,$244.24 ,$270.54 ,$341.93 ,$281.81 
Carle BroMenn Medical Center,8140054,BUR 9CM BALL 3MM DIAM MR8 PMT,240296,,270,$528.75 ,$528.75 ,$158.63 ,$481.16 ,$370.13 ,$158.63 ,$343.69 ,$380.70 ,$481.16 ,$396.56 
Carle BroMenn Medical Center,8140054,BUR 9CM BALL 4MM DIAM MR8 PMT,240300,,270,$528.75 ,$528.75 ,$158.63 ,$481.16 ,$370.13 ,$158.63 ,$343.69 ,$380.70 ,$481.16 ,$396.56 
Carle BroMenn Medical Center,8140054,BUR 9CM BALL 5MM DIAM MR8 PMT,240305,,270,$528.75 ,$528.75 ,$158.63 ,$481.16 ,$370.13 ,$158.63 ,$343.69 ,$380.70 ,$481.16 ,$396.56 
Carle BroMenn Medical Center,8140054,BUR 9CM BALL DMD CRS 4MM DIAM MR8,240302,,270,$587.25 ,$587.25 ,$176.18 ,$534.40 ,$411.08 ,$176.18 ,$381.71 ,$422.82 ,$534.40 ,$440.44 
Carle BroMenn Medical Center,8140054,BUR 9CM BALL DMD CRS 5MM DIAM MR8,240307,,270,$587.25 ,$587.25 ,$176.18 ,$534.40 ,$411.08 ,$176.18 ,$381.71 ,$422.82 ,$534.40 ,$440.44 
Carle BroMenn Medical Center,8140054,BUR 9CM BALL DMD XCRS 4MM DIAM MR,240303,,270,$587.25 ,$587.25 ,$176.18 ,$534.40 ,$411.08 ,$176.18 ,$381.71 ,$422.82 ,$534.40 ,$440.44 
Carle BroMenn Medical Center,8140054,BUR 9CM BALL DMD XCRS 5MM DIAM MR,240308,,270,$587.25 ,$587.25 ,$176.18 ,$534.40 ,$411.08 ,$176.18 ,$381.71 ,$422.82 ,$534.40 ,$440.44 
Carle BroMenn Medical Center,8140054,BUR 9CM BALL DMND 3MM DIAM MR8 PM,240297,,270,$587.25 ,$587.25 ,$176.18 ,$534.40 ,$411.08 ,$176.18 ,$381.71 ,$422.82 ,$534.40 ,$440.44 
Carle BroMenn Medical Center,8140054,BUR 9CM BALL DMND 4MM DIAM MR8 PM,240301,,270,$587.25 ,$587.25 ,$176.18 ,$534.40 ,$411.08 ,$176.18 ,$381.71 ,$422.82 ,$534.40 ,$440.44 
Carle BroMenn Medical Center,8140054,BUR 9CM BALL DMND 5MM DIAM MR8 PM,240306,,270,$587.25 ,$587.25 ,$176.18 ,$534.40 ,$411.08 ,$176.18 ,$381.71 ,$422.82 ,$534.40 ,$440.44 
Carle BroMenn Medical Center,8140054,BUR 9CM BALL DMND CRS 3MM DIAM MR,240298,,270,$587.25 ,$587.25 ,$176.18 ,$534.40 ,$411.08 ,$176.18 ,$381.71 ,$422.82 ,$534.40 ,$440.44 
Carle BroMenn Medical Center,8140054,BUR 9CM BALL SYM-TRI 3MM DIAM MR8,240299,,270,$639.00 ,$639.00 ,$191.70 ,$581.49 ,$447.30 ,$191.70 ,$415.35 ,$460.08 ,$581.49 ,$479.25 
Carle BroMenn Medical Center,8140054,BUR 9CM BALL SYM-TRI 4MM DIAM MR8,240304,,270,$639.00 ,$639.00 ,$191.70 ,$581.49 ,$447.30 ,$191.70 ,$415.35 ,$460.08 ,$581.49 ,$479.25 
Carle BroMenn Medical Center,8140054,BUR 9CM BALL SYM-TRI 5MM DIAM MR8,240309,,270,$639.00 ,$639.00 ,$191.70 ,$581.49 ,$447.30 ,$191.70 ,$415.35 ,$460.08 ,$581.49 ,$479.25 
Carle BroMenn Medical Center,8140054,BUR 9CM MTL CUT 3MM DIAM CRBID MR,240310,,270,$726.75 ,$726.75 ,$218.03 ,$661.34 ,$508.73 ,$218.03 ,$472.39 ,$523.26 ,$661.34 ,$545.06 
Carle BroMenn Medical Center,8140054,BUR BARREL 6 FLUTE 5.5MM,658,,270,$121.73 ,$121.73 ,$36.52 ,$110.77 ,$85.21 ,$36.52 ,$79.12 ,$87.65 ,$110.77 ,$91.30 
Carle BroMenn Medical Center,8140054,BUR BARREL 6FLTD 5.5MM,248939,,270,$125.33 ,$125.33 ,$37.60 ,$114.05 ,$87.73 ,$37.60 ,$81.46 ,$90.24 ,$114.05 ,$94.00 
Carle BroMenn Medical Center,8140054,BUR EGG 4MM,609,,270,$134.52 ,$134.52 ,$40.36 ,$122.41 ,$94.16 ,$40.36 ,$87.44 ,$96.85 ,$122.41 ,$100.89 
Carle BroMenn Medical Center,8140054,BUR F2/7CM TAPER 2.3MM DIAM MR8 P,240311,,270,$416.25 ,$416.25 ,$124.88 ,$378.79 ,$291.38 ,$124.88 ,$270.56 ,$299.70 ,$378.79 ,$312.19 
Carle BroMenn Medical Center,8140054,BUR F3/9CM TAPER 3.0MM DIAM MR8 P,240312,,270,$499.50 ,$499.50 ,$149.85 ,$454.55 ,$349.65 ,$149.85 ,$324.68 ,$359.64 ,$454.55 ,$374.63 
Carle BroMenn Medical Center,8140054,BUR FLUTE ROUND 4.0MM,163338,,270,$731.79 ,$731.79 ,$219.54 ,$665.93 ,$512.25 ,$219.54 ,$475.66 ,$526.89 ,$665.93 ,$548.84 
Carle BroMenn Medical Center,8140054,BUR FLUTE ROUND 6.0MM,163339,,270,$715.35 ,$715.35 ,$214.61 ,$650.97 ,$500.75 ,$214.61 ,$464.98 ,$515.05 ,$650.97 ,$536.51 
Carle BroMenn Medical Center,8140054,BUR PRECISION RND 3MM,245032,,270,$625.32 ,$625.32 ,$187.60 ,$569.04 ,$437.72 ,$187.60 ,$406.46 ,$450.23 ,$569.04 ,$468.99 
Carle BroMenn Medical Center,8140054,BUR PRECISION RND 4MM,245034,,270,$787.17 ,$787.17 ,$236.15 ,$716.32 ,$551.02 ,$236.15 ,$511.66 ,$566.76 ,$716.32 ,$590.38 
Carle BroMenn Medical Center,8140054,BUR PRECISION RND 5MM,245033,,270,$787.17 ,$787.17 ,$236.15 ,$716.32 ,$551.02 ,$236.15 ,$511.66 ,$566.76 ,$716.32 ,$590.38 
Carle BroMenn Medical Center,8140054,BUR RND 2 FLUTE 2MM,245039,,270,$625.32 ,$625.32 ,$187.60 ,$569.04 ,$437.72 ,$187.60 ,$406.46 ,$450.23 ,$569.04 ,$468.99 
Carle BroMenn Medical Center,8140054,BUR RND CUT 3MM,245096,,270,$541.77 ,$541.77 ,$162.53 ,$493.01 ,$379.24 ,$162.53 ,$352.15 ,$390.07 ,$493.01 ,$406.33 
Carle BroMenn Medical Center,8140054,BUR RND CUT 4MM SS,244705,,270,$144.00 ,$144.00 ,$43.20 ,$131.04 ,$100.80 ,$43.20 ,$93.60 ,$103.68 ,$131.04 ,$108.00 
Carle BroMenn Medical Center,8140054,BUR RND DMND 3MM,244690,,270,$446.67 ,$446.67 ,$134.00 ,$406.47 ,$312.67 ,$134.00 ,$290.34 ,$321.60 ,$406.47 ,$335.00 
Carle BroMenn Medical Center,8140054,BUR RND DMND 4MM,244691,,270,$446.67 ,$446.67 ,$134.00 ,$406.47 ,$312.67 ,$134.00 ,$290.34 ,$321.60 ,$406.47 ,$335.00 
Carle BroMenn Medical Center,8140054,BUR RND DMND 5MM,244694,,270,$446.67 ,$446.67 ,$134.00 ,$406.47 ,$312.67 ,$134.00 ,$290.34 ,$321.60 ,$406.47 ,$335.00 
Carle BroMenn Medical Center,8140054,BUR RND DMND EXT 4MM,245193,,270,$402.45 ,$402.45 ,$120.74 ,$366.23 ,$281.72 ,$120.74 ,$261.59 ,$289.76 ,$366.23 ,$301.84 
Carle BroMenn Medical Center,8140054,BUR RND DMND XCOARSE 4MM,244636,,270,$353.07 ,$353.07 ,$105.92 ,$321.29 ,$247.15 ,$105.92 ,$229.50 ,$254.21 ,$321.29 ,$264.80 
Carle BroMenn Medical Center,8140054,BUR RND SS FAST CTNG 4MM,250085,,270,$140.31 ,$140.31 ,$42.09 ,$127.68 ,$98.22 ,$42.09 ,$91.20 ,$101.02 ,$127.68 ,$105.23 
Carle BroMenn Medical Center,8140054,BUR RND SS FAST CTNG 5.5MM,244672,,270,$101.13 ,$101.13 ,$30.34 ,$92.03 ,$70.79 ,$30.34 ,$65.73 ,$72.81 ,$92.03 ,$75.85 
Carle BroMenn Medical Center,8140054,BUR SM TEAR CROSS RASP,110203,,270,$283.65 ,$283.65 ,$85.10 ,$258.12 ,$198.56 ,$85.10 ,$184.37 ,$204.23 ,$258.12 ,$212.74 
Carle BroMenn Medical Center,8140054,BUR SWANSON PILOT POINT 4MM,244546,,270,$156.84 ,$156.84 ,$47.05 ,$142.72 ,$109.79 ,$47.05 ,$101.95 ,$112.92 ,$142.72 ,$117.63 
Carle BroMenn Medical Center,8140054,CABLE OR SPECTRA EXT 2X8,239496,,270,$3.00 ,$3.00 ,$0.90 ,$2.73 ,$2.10 ,$0.90 ,$1.95 ,$2.16 ,$2.73 ,$2.25 
Carle BroMenn Medical Center,8140054,CABLE PACING STD BGE DISP 6FT,249749,,270,$302.24 ,$302.24 ,$90.67 ,$275.04 ,$211.57 ,$90.67 ,$196.46 ,$217.61 ,$275.04 ,$226.68 
Carle BroMenn Medical Center,8140054,CANISTER SUCT W/LID 1200CC,244141,,270,$3.34 ,$3.34 ,$1.00 ,$3.04 ,$2.34 ,$1.00 ,$2.17 ,$2.40 ,$3.04 ,$2.51 
Carle BroMenn Medical Center,8140054,CANISTER SUCT W/LID 3000CC,244140,,270,$4.61 ,$4.61 ,$1.38 ,$4.20 ,$3.23 ,$1.38 ,$3.00 ,$3.32 ,$4.20 ,$3.46 
Carle BroMenn Medical Center,8140054,CANISTER SUCTION D AND C,1023,,270,$40.97 ,$40.97 ,$12.29 ,$37.28 ,$28.68 ,$12.29 ,$26.63 ,$29.50 ,$37.28 ,$30.73 
Carle BroMenn Medical Center,8140054,CANNULA 1 WAY VLV BLNT 3MM 2.5,244543,,270,$0.08 ,$0.08 ,$0.02 ,$0.07 ,$0.06 ,$0.02 ,$0.05 ,$0.06 ,$0.07 ,$0.06 
Carle BroMenn Medical Center,8140054,CANNULA ARTERIOTOMY 1MM 1.8IN,244701,,270,$0.17 ,$0.17 ,$0.05 ,$0.15 ,$0.12 ,$0.05 ,$0.11 ,$0.12 ,$0.15 ,$0.13 
Carle BroMenn Medical Center,8140054,CANNULA BLDLS OPTCL 11MM STD,245058,,270,$206.70 ,$206.70 ,$62.01 ,$188.10 ,$144.69 ,$62.01 ,$134.36 ,$148.82 ,$188.10 ,$155.03 
Carle BroMenn Medical Center,8140054,CANNULA BUTTON PASSPORT ARTHEX,215430,,270,$96.00 ,$96.00 ,$28.80 ,$87.36 ,$67.20 ,$28.80 ,$62.40 ,$69.12 ,$87.36 ,$72.00 
Carle BroMenn Medical Center,8140054,CANNULA CRYSTAL PART THREADED,221533,,270,$75.00 ,$75.00 ,$22.50 ,$68.25 ,$52.50 ,$22.50 ,$48.75 ,$54.00 ,$68.25 ,$56.25 
Carle BroMenn Medical Center,8140054,CANNULA DELIVERY 11G,251059,,270,"$1,050.00 ","$1,050.00 ",$315.00 ,$955.50 ,$735.00 ,$315.00 ,$682.50 ,$756.00 ,$955.50 ,$787.50 
Carle BroMenn Medical Center,8140054,CANNULA EXTDBL POLYTIP 38G,245077,,270,$0.67 ,$0.67 ,$0.20 ,$0.61 ,$0.47 ,$0.20 ,$0.44 ,$0.48 ,$0.61 ,$0.50 
Carle BroMenn Medical Center,8140054,CANNULA KII 12X100MM,1200,,270,$41.25 ,$41.25 ,$12.38 ,$37.54 ,$28.88 ,$12.38 ,$26.81 ,$29.70 ,$37.54 ,$30.94 
Carle BroMenn Medical Center,8140054,CANNULA KII 5X100MM,1198,,270,$24.00 ,$24.00 ,$7.20 ,$21.84 ,$16.80 ,$7.20 ,$15.60 ,$17.28 ,$21.84 ,$18.00 
Carle BroMenn Medical Center,8140054,CANNULA PAL 4X10 22CM MERCEDES,250937,,270,$181.50 ,$181.50 ,$54.45 ,$165.17 ,$127.05 ,$54.45 ,$117.98 ,$130.68 ,$165.17 ,$136.13 
Carle BroMenn Medical Center,8140054,CANNULA PAL 4X10 30CM MERCEDES,250601,,270,$165.00 ,$165.00 ,$49.50 ,$150.15 ,$115.50 ,$49.50 ,$107.25 ,$118.80 ,$150.15 ,$123.75 
Carle BroMenn Medical Center,8140054,CANNULA PAL 5X10 22CM MERCEDES,250938,,270,$165.00 ,$165.00 ,$49.50 ,$150.15 ,$115.50 ,$49.50 ,$107.25 ,$118.80 ,$150.15 ,$123.75 
Carle BroMenn Medical Center,8140054,CANNULA POLYTIP 25GA-38GA,51749,,270,$134.40 ,$134.40 ,$40.32 ,$122.30 ,$94.08 ,$40.32 ,$87.36 ,$96.77 ,$122.30 ,$100.80 
Carle BroMenn Medical Center,8140054,CANNULA RF CRV 10CMX10MM 20G PREM,257570,,270,$57.00 ,$57.00 ,$17.10 ,$51.87 ,$39.90 ,$17.10 ,$37.05 ,$41.04 ,$51.87 ,$42.75 
Carle BroMenn Medical Center,8140054,CANNULA SELF DRILL 5.5MMX45,247118,,270,"$1,350.00 ","$1,350.00 ",$405.00 ,"$1,228.50 ",$945.00 ,$405.00 ,$877.50 ,$972.00 ,"$1,228.50 ","$1,012.50 "
Carle BroMenn Medical Center,8140054,CANNULA SUCT IRR 23GX1.5MM FLEX-T,245146,,270,$0.67 ,$0.67 ,$0.20 ,$0.61 ,$0.47 ,$0.20 ,$0.44 ,$0.48 ,$0.61 ,$0.50 
Carle BroMenn Medical Center,8140054,CANNULA TWISTIN 7MMX7CM PURPLE,235476,,270,$75.00 ,$75.00 ,$22.50 ,$68.25 ,$52.50 ,$22.50 ,$48.75 ,$54.00 ,$68.25 ,$56.25 
Carle BroMenn Medical Center,8140054,CANNULA TWIST-IN 8.25MMX7CM,667,,270,$62.50 ,$62.50 ,$18.75 ,$56.88 ,$43.75 ,$18.75 ,$40.63 ,$45.00 ,$56.88 ,$46.88 
Carle BroMenn Medical Center,8140054,CANNULA UNIV STD FIX 5MM,245045,,270,$87.57 ,$87.57 ,$26.27 ,$79.69 ,$61.30 ,$26.27 ,$56.92 ,$63.05 ,$79.69 ,$65.68 
Carle BroMenn Medical Center,8140054,CANNULA VLVD ENTRY SYS 25G 4MM,245192,,270,$0.28 ,$0.28 ,$0.08 ,$0.25 ,$0.20 ,$0.08 ,$0.18 ,$0.20 ,$0.25 ,$0.21 
Carle BroMenn Medical Center,8140054,CARTRIDGE MAESTRO OIL,244794,,270,$66.14 ,$66.14 ,$19.84 ,$60.19 ,$46.30 ,$19.84 ,$42.99 ,$47.62 ,$60.19 ,$49.61 
Carle BroMenn Medical Center,8140054,CASSETTE CORE IRRIGATION,163346,,270,$139.24 ,$139.24 ,$41.77 ,$126.71 ,$97.47 ,$41.77 ,$90.51 ,$100.25 ,$126.71 ,$104.43 
Carle BroMenn Medical Center,8140054,CATCH ENDO 10MM 10/BX,1165,,270,$108.00 ,$108.00 ,$32.40 ,$98.28 ,$75.60 ,$32.40 ,$70.20 ,$77.76 ,$98.28 ,$81.00 
Carle BroMenn Medical Center,8140054,CATH 3-WAY 22FR 30CC,244389,,270,$51.72 ,$51.72 ,$15.52 ,$47.07 ,$36.20 ,$15.52 ,$33.62 ,$37.24 ,$47.07 ,$38.79 
Carle BroMenn Medical Center,8140054,CATH ASCENDA 4 LAYER 114.3CM,239586,,270,"$2,700.00 ","$2,700.00 ",$810.00 ,"$2,457.00 ","$1,890.00 ",$810.00 ,"$1,755.00 ","$1,944.00 ","$2,457.00 ","$2,025.00 "
Carle BroMenn Medical Center,8140054,CATH CHOLANGIOGRAM 4.5FR TAUT,234450,,270,$151.50 ,$151.50 ,$45.45 ,$137.87 ,$106.05 ,$45.45 ,$98.48 ,$109.08 ,$137.87 ,$113.63 
Carle BroMenn Medical Center,8140054,CATH DRAIN 24FR MALECOT,720,,270,$73.32 ,$73.32 ,$22.00 ,$66.72 ,$51.32 ,$22.00 ,$47.66 ,$52.79 ,$66.72 ,$54.99 
Carle BroMenn Medical Center,8140054,CATH FOLEY 16FR 30CC 3 WAY,245261,,270,$24.96 ,$24.96 ,$7.49 ,$22.71 ,$17.47 ,$7.49 ,$16.22 ,$17.97 ,$22.71 ,$18.72 
Carle BroMenn Medical Center,8140054,CATH FOLEY 18FR 5CC LATEX,84,,270,$5.82 ,$5.82 ,$1.75 ,$5.30 ,$4.07 ,$1.75 ,$3.78 ,$4.19 ,$5.30 ,$4.37 
Carle BroMenn Medical Center,8140054,CATH FOLEY 2WAY LF SIL 12F 5C SUR,244959,,270,$11.20 ,$11.20 ,$3.36 ,$10.19 ,$7.84 ,$3.36 ,$7.28 ,$8.06 ,$10.19 ,$8.40 
Carle BroMenn Medical Center,8140054,CATH FOLEY 2WAY LF SIL 16F 5C SUR,244960,,270,$10.68 ,$10.68 ,$3.20 ,$9.72 ,$7.48 ,$3.20 ,$6.94 ,$7.69 ,$9.72 ,$8.01 
Carle BroMenn Medical Center,8140054,CATH FOLEY 2WAY LF SIL 18F 5C SUR,244961,,270,$11.20 ,$11.20 ,$3.36 ,$10.19 ,$7.84 ,$3.36 ,$7.28 ,$8.06 ,$10.19 ,$8.40 
Carle BroMenn Medical Center,8140054,CATH FOLEY BARDEX 30CC 2WY 14F LU,244955,,270,$11.16 ,$11.16 ,$3.35 ,$10.16 ,$7.81 ,$3.35 ,$7.25 ,$8.04 ,$10.16 ,$8.37 
Carle BroMenn Medical Center,8140054,CATH FOLEY BARDEX 30CC 2WY 16F LU,244954,,270,$11.72 ,$11.72 ,$3.52 ,$10.67 ,$8.20 ,$3.52 ,$7.62 ,$8.44 ,$10.67 ,$8.79 
Carle BroMenn Medical Center,8140054,CATH FOLEY BARDEX 30CC 2WY 18F LU,244956,,270,$11.16 ,$11.16 ,$3.35 ,$10.16 ,$7.81 ,$3.35 ,$7.25 ,$8.04 ,$10.16 ,$8.37 
Carle BroMenn Medical Center,8140054,CATH FOLEY BARDEX 30CC 2WY 20F LU,244957,,270,$11.16 ,$11.16 ,$3.35 ,$10.16 ,$7.81 ,$3.35 ,$7.25 ,$8.04 ,$10.16 ,$8.37 
Carle BroMenn Medical Center,8140054,CATH FOLEY BARDEX 30CC 2WY 22F LU,244698,,270,$11.72 ,$11.72 ,$3.52 ,$10.67 ,$8.20 ,$3.52 ,$7.62 ,$8.44 ,$10.67 ,$8.79 
Carle BroMenn Medical Center,8140054,CATH FOLEY BARDEX 30CC 2WY 26F LU,244958,,270,$11.72 ,$11.72 ,$3.52 ,$10.67 ,$8.20 ,$3.52 ,$7.62 ,$8.44 ,$10.67 ,$8.79 
Carle BroMenn Medical Center,8140054,CATH FOLEY BARDEX 5CC 12F LUBRICA,244725,,270,$10.11 ,$10.11 ,$3.03 ,$9.20 ,$7.08 ,$3.03 ,$6.57 ,$7.28 ,$9.20 ,$7.58 
Carle BroMenn Medical Center,8140054,CATH FOLEY BARDEX 5CC 14F LUBRICA,244721,,270,$9.63 ,$9.63 ,$2.89 ,$8.76 ,$6.74 ,$2.89 ,$6.26 ,$6.93 ,$8.76 ,$7.22 
Carle BroMenn Medical Center,8140054,CATH FOLEY BARDEX 5CC 16F LUBRICA,244726,,270,$10.11 ,$10.11 ,$3.03 ,$9.20 ,$7.08 ,$3.03 ,$6.57 ,$7.28 ,$9.20 ,$7.58 
Carle BroMenn Medical Center,8140054,CATH FOLEY BARDEX 5CC 20F LUBRICA,244638,,270,$10.11 ,$10.11 ,$3.03 ,$9.20 ,$7.08 ,$3.03 ,$6.57 ,$7.28 ,$9.20 ,$7.58 
Carle BroMenn Medical Center,8140054,CATH FOLEY BARDEX 5CC 22F LUBRICA,244639,,270,$10.11 ,$10.11 ,$3.03 ,$9.20 ,$7.08 ,$3.03 ,$6.57 ,$7.28 ,$9.20 ,$7.58 
Carle BroMenn Medical Center,8140054,CATH FOLEY BARDEX 5CC 24F LUBRICA,244700,,270,$10.11 ,$10.11 ,$3.03 ,$9.20 ,$7.08 ,$3.03 ,$6.57 ,$7.28 ,$9.20 ,$7.58 
Carle BroMenn Medical Center,8140054,CATH FOLEY BARDEX 5CC 26F LUBRICA,244655,,270,$10.11 ,$10.11 ,$3.03 ,$9.20 ,$7.08 ,$3.03 ,$6.57 ,$7.28 ,$9.20 ,$7.58 
Carle BroMenn Medical Center,8140054,CATH FOLEY CARSON 5CC 2WY 12F,244523,,270,$23.79 ,$23.79 ,$7.14 ,$21.65 ,$16.65 ,$7.14 ,$15.46 ,$17.13 ,$21.65 ,$17.84 
Carle BroMenn Medical Center,8140054,CATH FOLEY CARSON 5CC 2WY 14F,244259,,270,$24.27 ,$24.27 ,$7.28 ,$22.09 ,$16.99 ,$7.28 ,$15.78 ,$17.47 ,$22.09 ,$18.20 
Carle BroMenn Medical Center,8140054,CATH FOLEY CARSON 5CC 2WY 16F,244265,,270,$24.27 ,$24.27 ,$7.28 ,$22.09 ,$16.99 ,$7.28 ,$15.78 ,$17.47 ,$22.09 ,$18.20 
Carle BroMenn Medical Center,8140054,CATH FOLEY CARSON 5CC 2WY 18F,244260,,270,$23.79 ,$23.79 ,$7.14 ,$21.65 ,$16.65 ,$7.14 ,$15.46 ,$17.13 ,$21.65 ,$17.84 
Carle BroMenn Medical Center,8140054,CATH FOLEY CARSON 5CC 2WY 20F,244262,,270,$24.27 ,$24.27 ,$7.28 ,$22.09 ,$16.99 ,$7.28 ,$15.78 ,$17.47 ,$22.09 ,$18.20 
Carle BroMenn Medical Center,8140054,CATH FOLEY CARSON 5CC 2WY 22F,244264,,270,$24.27 ,$24.27 ,$7.28 ,$22.09 ,$16.99 ,$7.28 ,$15.78 ,$17.47 ,$22.09 ,$18.20 
Carle BroMenn Medical Center,8140054,CATH FOLEY CARSON 5CC 2WY 24F,244623,,270,$25.46 ,$25.46 ,$7.64 ,$23.17 ,$17.82 ,$7.64 ,$16.55 ,$18.33 ,$23.17 ,$19.10 
Carle BroMenn Medical Center,8140054,CATH FOLEY IRR 3WAY 30CC 24F,244953,,270,$24.96 ,$24.96 ,$7.49 ,$22.71 ,$17.47 ,$7.49 ,$16.22 ,$17.97 ,$22.71 ,$18.72 
Carle BroMenn Medical Center,8140054,CATH FOLEY PED SIL 8F 3CC,245231,,270,$11.20 ,$11.20 ,$3.36 ,$10.19 ,$7.84 ,$3.36 ,$7.28 ,$8.06 ,$10.19 ,$8.40 
Carle BroMenn Medical Center,8140054,CATH FOLEY SILICON 5CC 14FR,245262,,270,$10.68 ,$10.68 ,$3.20 ,$9.72 ,$7.48 ,$3.20 ,$6.94 ,$7.69 ,$9.72 ,$8.01 
Carle BroMenn Medical Center,8140054,CATH FOLEY SILICONE 20FR 5CC,232214,,270,$9.36 ,$9.36 ,$2.81 ,$8.52 ,$6.55 ,$2.81 ,$6.08 ,$6.74 ,$8.52 ,$7.02 
Carle BroMenn Medical Center,8140054,CATH LAP CHOLANGIOGRAM 23CM ORDER,244976,,270,$450.00 ,$450.00 ,$135.00 ,$409.50 ,$315.00 ,$135.00 ,$292.50 ,$324.00 ,$409.50 ,$337.50 
Carle BroMenn Medical Center,8140054,CATH LOCK DRAIN 12FX30CMX.038 RES,238085,,270,$179.55 ,$179.55 ,$53.87 ,$163.39 ,$125.69 ,$53.87 ,$116.71 ,$129.28 ,$163.39 ,$134.66 
Carle BroMenn Medical Center,8140054,CATH LUMBOPERITONEAL SYS,244671,,270,$3.33 ,$3.33 ,$1.00 ,$3.03 ,$2.33 ,$1.00 ,$2.16 ,$2.40 ,$3.03 ,$2.50 
Carle BroMenn Medical Center,8140054,CATH NEPHROMAX HP 30X10 PTFE,236958,,270,$715.86 ,$715.86 ,$214.76 ,$651.43 ,$501.10 ,$214.76 ,$465.31 ,$515.42 ,$651.43 ,$536.90 
Carle BroMenn Medical Center,8140054,CATH OCCLUDER 34X11.5X7X65,237002,,270,$424.74 ,$424.74 ,$127.42 ,$386.51 ,$297.32 ,$127.42 ,$276.08 ,$305.81 ,$386.51 ,$318.56 
Carle BroMenn Medical Center,8140054,CATH SUCT CNTRL VALVE STR 14F,244182,,270,$1.77 ,$1.77 ,$0.53 ,$1.61 ,$1.24 ,$0.53 ,$1.15 ,$1.27 ,$1.61 ,$1.33 
Carle BroMenn Medical Center,8140054,CATH THOR 32F RT ANG,244609,,270,$17.74 ,$17.74 ,$5.32 ,$16.14 ,$12.42 ,$5.32 ,$11.53 ,$12.77 ,$16.14 ,$13.31 
Carle BroMenn Medical Center,8140054,CATH THOR STR STL PVC 40F TAPER T,244643,,270,$12.16 ,$12.16 ,$3.65 ,$11.07 ,$8.51 ,$3.65 ,$7.90 ,$8.76 ,$11.07 ,$9.12 
Carle BroMenn Medical Center,8140054,CATH THORACIC SOFT 28F RT ANGL,244352,,270,$22.76 ,$22.76 ,$6.83 ,$20.71 ,$15.93 ,$6.83 ,$14.79 ,$16.39 ,$20.71 ,$17.07 
Carle BroMenn Medical Center,8140054,CATH THORACIC SOFT 32FR STRGHT TA,247024,,270,$11.87 ,$11.87 ,$3.56 ,$10.80 ,$8.31 ,$3.56 ,$7.72 ,$8.55 ,$10.80 ,$8.90 
Carle BroMenn Medical Center,8140054,CATH WORD BARTHOLIN GLAND 10/12FR,244724,,270,$91.73 ,$91.73 ,$27.52 ,$83.47 ,$64.21 ,$27.52 ,$59.62 ,$66.05 ,$83.47 ,$68.80 
Carle BroMenn Medical Center,8140054,CATHETER AIP VNTRCL BACTISEAL,236779,,270,"$1,242.90 ","$1,242.90 ",$372.87 ,"$1,131.04 ",$870.03 ,$372.87 ,$807.89 ,$894.89 ,"$1,131.04 ",$932.18 
Carle BroMenn Medical Center,8140054,CATHETER CHOL 4.5F,244640,,270,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8140054,CATHETER FOLEY 16F 5CC 3-WAY,244421,,270,$23.70 ,$23.70 ,$7.11 ,$21.57 ,$16.59 ,$7.11 ,$15.41 ,$17.06 ,$21.57 ,$17.78 
Carle BroMenn Medical Center,8140054,CATHETER GUIDE 70 DEGREE INCREMEN,4024,,270,"$1,110.00 ","$1,110.00 ",$333.00 ,"$1,010.10 ",$777.00 ,$333.00 ,$721.50 ,$799.20 ,"$1,010.10 ",$832.50 
Carle BroMenn Medical Center,8140054,CATHETER LUMBAR CLOSED TIP,224797,,270,$478.50 ,$478.50 ,$143.55 ,$435.44 ,$334.95 ,$143.55 ,$311.03 ,$344.52 ,$435.44 ,$358.88 
Carle BroMenn Medical Center,8140054,CATHETER PASSER 38CM,248338,,270,$294.00 ,$294.00 ,$88.20 ,$267.54 ,$205.80 ,$88.20 ,$191.10 ,$211.68 ,$267.54 ,$220.50 
Carle BroMenn Medical Center,8140054,CATHETER PERIT OPEN END 90CM,244885,,270,$3.33 ,$3.33 ,$1.00 ,$3.03 ,$2.33 ,$1.00 ,$2.16 ,$2.40 ,$3.03 ,$2.50 
Carle BroMenn Medical Center,8140054,CATHETER RAD ART 20G,244413,,270,$24.72 ,$24.72 ,$7.42 ,$22.50 ,$17.30 ,$7.42 ,$16.07 ,$17.80 ,$22.50 ,$18.54 
Carle BroMenn Medical Center,8140054,CATHETER URETERAL OPEN TP 5FR 10/,88610,,270,$33.82 ,$33.82 ,$10.15 ,$30.78 ,$23.67 ,$10.15 ,$21.98 ,$24.35 ,$30.78 ,$25.37 
Carle BroMenn Medical Center,8140054,CATHETERFOLEY 18F 5CC 3-WAY,245013,,270,$25.36 ,$25.36 ,$7.61 ,$23.08 ,$17.75 ,$7.61 ,$16.48 ,$18.26 ,$23.08 ,$19.02 
Carle BroMenn Medical Center,8140054,CATHETERFOLEY 20F 5CC 3-WAY,244610,,270,$24.18 ,$24.18 ,$7.25 ,$22.00 ,$16.93 ,$7.25 ,$15.72 ,$17.41 ,$22.00 ,$18.14 
Carle BroMenn Medical Center,8140054,CATHETERFOLEY 22F 5CC 3-WAY,244637,,270,$24.18 ,$24.18 ,$7.25 ,$22.00 ,$16.93 ,$7.25 ,$15.72 ,$17.41 ,$22.00 ,$18.14 
Carle BroMenn Medical Center,8140054,CATHETERFOLEY 24F 5CC 3-WAY,244611,,270,$24.18 ,$24.18 ,$7.25 ,$22.00 ,$16.93 ,$7.25 ,$15.72 ,$17.41 ,$22.00 ,$18.14 
Carle BroMenn Medical Center,8140054,CAUTERY HIGH TEMP 2IN DISP,244771,,270,$43.19 ,$43.19 ,$12.96 ,$39.30 ,$30.23 ,$12.96 ,$28.07 ,$31.10 ,$39.30 ,$32.39 
Carle BroMenn Medical Center,8140054,CAUTERY HIGH TEMP FINE TEMP,244573,,270,$26.10 ,$26.10 ,$7.83 ,$23.75 ,$18.27 ,$7.83 ,$16.97 ,$18.79 ,$23.75 ,$19.58 
Carle BroMenn Medical Center,8140054,CAUTERY NDL TIP,244521,,270,$5.22 ,$5.22 ,$1.57 ,$4.75 ,$3.65 ,$1.57 ,$3.39 ,$3.76 ,$4.75 ,$3.92 
Carle BroMenn Medical Center,8140054,CLAMP OSTOMY,244164,,270,$1.00 ,$1.00 ,$0.30 ,$0.91 ,$0.70 ,$0.30 ,$0.65 ,$0.72 ,$0.91 ,$0.75 
Carle BroMenn Medical Center,8140054,CLAMP RAPORT BIOP 10MM STL,244488,,270,$52.77 ,$52.77 ,$15.83 ,$48.02 ,$36.94 ,$15.83 ,$34.30 ,$37.99 ,$48.02 ,$39.58 
Carle BroMenn Medical Center,8140054,CLAMP VASC SM MINI STR RED VASCU-,244797,,270,$0.67 ,$0.67 ,$0.20 ,$0.61 ,$0.47 ,$0.20 ,$0.44 ,$0.48 ,$0.61 ,$0.50 
Carle BroMenn Medical Center,8140054,CLEANER CAUTERY TIP 2X2,245215,,270,$2.08 ,$2.08 ,$0.62 ,$1.89 ,$1.46 ,$0.62 ,$1.35 ,$1.50 ,$1.89 ,$1.56 
Carle BroMenn Medical Center,8140054,CLEANSER IRRISEPT,245099,,270,$195.00 ,$195.00 ,$58.50 ,$177.45 ,$136.50 ,$58.50 ,$126.75 ,$140.40 ,$177.45 ,$146.25 
Carle BroMenn Medical Center,8140054,CLIP HEM O LOK ML,10358,,270,$78.43 ,$78.43 ,$23.53 ,$71.37 ,$54.90 ,$23.53 ,$50.98 ,$56.47 ,$71.37 ,$58.82 
Carle BroMenn Medical Center,8140054,CLIP HEMOLOK MLX LG LF 6/EA,245029,,270,$6.54 ,$6.54 ,$1.96 ,$5.95 ,$4.58 ,$1.96 ,$4.25 ,$4.71 ,$5.95 ,$4.91 
Carle BroMenn Medical Center,8140054,CLIP HORIZON LGTNG LG,245223,,270,$2.56 ,$2.56 ,$0.77 ,$2.33 ,$1.79 ,$0.77 ,$1.66 ,$1.84 ,$2.33 ,$1.92 
Carle BroMenn Medical Center,8140054,CLIP HORIZON LGTNG SM WD 24/EA,244714,,270,$4.14 ,$4.14 ,$1.24 ,$3.77 ,$2.90 ,$1.24 ,$2.69 ,$2.98 ,$3.77 ,$3.11 
Carle BroMenn Medical Center,8140054,CLIP HORIZON TITANIUM MEDIUM,244405,,270,$30.72 ,$30.72 ,$9.22 ,$27.96 ,$21.50 ,$9.22 ,$19.97 ,$22.12 ,$27.96 ,$23.04 
Carle BroMenn Medical Center,8140054,CLIP HORIZON TITANIUM SMALL,244379,,270,$24.24 ,$24.24 ,$7.27 ,$22.06 ,$16.97 ,$7.27 ,$15.76 ,$17.45 ,$22.06 ,$18.18 
Carle BroMenn Medical Center,8140054,CLIP LIGACLIP TI LG LT400,244586,,270,$12.19 ,$12.19 ,$3.66 ,$11.09 ,$8.53 ,$3.66 ,$7.92 ,$8.78 ,$11.09 ,$9.14 
Carle BroMenn Medical Center,8140054,CLIP RESOLUTION 235CM 20/BX,248531,,270,$456.89 ,$456.89 ,$137.07 ,$415.77 ,$319.82 ,$137.07 ,$296.98 ,$328.96 ,$415.77 ,$342.67 
Carle BroMenn Medical Center,8140054,CLIP SCALP RANEY DISP STL,244665,,270,$57.47 ,$57.47 ,$17.24 ,$52.30 ,$40.23 ,$17.24 ,$37.36 ,$41.38 ,$52.30 ,$43.10 
Carle BroMenn Medical Center,8140054,CLIP SOFT FIBRA ATRAUMAX 12MM MAM,250257,,270,$48.00 ,$48.00 ,$14.40 ,$43.68 ,$33.60 ,$14.40 ,$31.20 ,$34.56 ,$43.68 ,$36.00 
Carle BroMenn Medical Center,8140054,CLIP TUBAL FILSHIE,69654,,270,$330.00 ,$330.00 ,$99.00 ,$300.30 ,$231.00 ,$99.00 ,$214.50 ,$237.60 ,$300.30 ,$247.50 
Carle BroMenn Medical Center,8140054,CLOSURE ZIP16 SURG SKIN 16CM,244877,,270,$277.88 ,$277.88 ,$83.36 ,$252.87 ,$194.52 ,$83.36 ,$180.62 ,$200.07 ,$252.87 ,$208.41 
Carle BroMenn Medical Center,8140054,CLOSURE ZIP24 SURG SKIN 24CM,249751,,270,$407.77 ,$407.77 ,$122.33 ,$371.07 ,$285.44 ,$122.33 ,$265.05 ,$293.59 ,$371.07 ,$305.83 
Carle BroMenn Medical Center,8140054,COAGULATOR SUCTION,244409,,270,$33.15 ,$33.15 ,$9.95 ,$30.17 ,$23.21 ,$9.95 ,$21.55 ,$23.87 ,$30.17 ,$24.86 
Carle BroMenn Medical Center,8140054,COAGULATOR SUCTION 6IN 10FR,223972,,270,$29.21 ,$29.21 ,$8.76 ,$26.58 ,$20.45 ,$8.76 ,$18.99 ,$21.03 ,$26.58 ,$21.91 
Carle BroMenn Medical Center,8140054,CONE FISCHER BIOP EXCISR LG,244713,,270,$70.22 ,$70.22 ,$21.07 ,$63.90 ,$49.15 ,$21.07 ,$45.64 ,$50.56 ,$63.90 ,$52.67 
Carle BroMenn Medical Center,8140054,CONNECTOR ACCU-FLO STR PLAS,244660,,270,$443.43 ,$443.43 ,$133.03 ,$403.52 ,$310.40 ,$133.03 ,$288.23 ,$319.27 ,$403.52 ,$332.57 
Carle BroMenn Medical Center,8140054,CONNECTOR BLAKE CARDIO 2.1 19F,244684,,270,$60.47 ,$60.47 ,$18.14 ,$55.03 ,$42.33 ,$18.14 ,$39.31 ,$43.54 ,$55.03 ,$45.35 
Carle BroMenn Medical Center,8140054,CONNECTOR EQUAL WYE 3/8X3/8,244588,,270,$18.53 ,$18.53 ,$5.56 ,$16.86 ,$12.97 ,$5.56 ,$12.04 ,$13.34 ,$16.86 ,$13.90 
Carle BroMenn Medical Center,8140054,CONNECTOR TUBING 5 IN 1 STL,244092,,270,$2.90 ,$2.90 ,$0.87 ,$2.64 ,$2.03 ,$0.87 ,$1.89 ,$2.09 ,$2.64 ,$2.18 
Carle BroMenn Medical Center,8140054,CONTAINER AVITINE HEMO 1/2GRAM,244745,,270,$282.00 ,$282.00 ,$84.60 ,$256.62 ,$197.40 ,$84.60 ,$183.30 ,$203.04 ,$256.62 ,$211.50 
Carle BroMenn Medical Center,8140054,CONTAINER DENTURE NO LBL CLR 8OZ,244224,,270,$0.28 ,$0.28 ,$0.08 ,$0.25 ,$0.20 ,$0.08 ,$0.18 ,$0.20 ,$0.25 ,$0.21 
Carle BroMenn Medical Center,8140054,CONTAINER SPCMN 4OZ STL,244160,,270,$1.43 ,$1.43 ,$0.43 ,$1.30 ,$1.00 ,$0.43 ,$0.93 ,$1.03 ,$1.30 ,$1.07 
Carle BroMenn Medical Center,8140054,CONTAINER SPCMN TRNSLNT 172OZ,244007,,270,$8.99 ,$8.99 ,$2.70 ,$8.18 ,$6.29 ,$2.70 ,$5.84 ,$6.47 ,$8.18 ,$6.74 
Carle BroMenn Medical Center,8140054,CONTAINER SPECIMEN 32OZ GRAD 100/,244006,,270,$2.75 ,$2.75 ,$0.83 ,$2.50 ,$1.93 ,$0.83 ,$1.79 ,$1.98 ,$2.50 ,$2.06 
Carle BroMenn Medical Center,8140054,CORD CAUTERY BIP STL,244034,,270,$10.23 ,$10.23 ,$3.07 ,$9.31 ,$7.16 ,$3.07 ,$6.65 ,$7.37 ,$9.31 ,$7.67 
Carle BroMenn Medical Center,8140054,COUNTER NDL FOAM MAGNET 40CT,249770,,270,$4.20 ,$4.20 ,$1.26 ,$3.82 ,$2.94 ,$1.26 ,$2.73 ,$3.02 ,$3.82 ,$3.15 
Carle BroMenn Medical Center,8140054,COUNTERSINK 7.0,235378,,270,"$1,167.00 ","$1,167.00 ",$350.10 ,"$1,061.97 ",$816.90 ,$350.10 ,$758.55 ,$840.24 ,"$1,061.97 ",$875.25 
Carle BroMenn Medical Center,8140054,COVER BLU STL .035IN K-WIRE/STEIN,244818,,270,$0.28 ,$0.28 ,$0.08 ,$0.25 ,$0.20 ,$0.08 ,$0.18 ,$0.20 ,$0.25 ,$0.21 
Carle BroMenn Medical Center,8140054,COVER COMFORT SNGL USE DISP,245186,,270,$0.67 ,$0.67 ,$0.20 ,$0.61 ,$0.47 ,$0.20 ,$0.44 ,$0.48 ,$0.61 ,$0.50 
Carle BroMenn Medical Center,8140054,COVER GAMMA PROBE CORDLESS CA/50,203404,,270,$16.32 ,$16.32 ,$4.90 ,$14.85 ,$11.42 ,$4.90 ,$10.61 ,$11.75 ,$14.85 ,$12.24 
Carle BroMenn Medical Center,8140054,COVER GRN STL .062IN K-WIRE/STEIN,244839,,270,$5.50 ,$5.50 ,$1.65 ,$5.01 ,$3.85 ,$1.65 ,$3.58 ,$3.96 ,$5.01 ,$4.13 
Carle BroMenn Medical Center,8140054,COVER LIGHT HNDL BLU STL,248536,,270,$3.25 ,$3.25 ,$0.98 ,$2.96 ,$2.28 ,$0.98 ,$2.11 ,$2.34 ,$2.96 ,$2.44 
Carle BroMenn Medical Center,8140054,COVER LOCKING 6MM,243138,,270,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8140054,COVER MAYO STAND,244342,,270,$2.25 ,$2.25 ,$0.68 ,$2.05 ,$1.58 ,$0.68 ,$1.46 ,$1.62 ,$2.05 ,$1.69 
Carle BroMenn Medical Center,8140054,COVER MAYO STAND 29.5X55IN,245093,,270,$3.87 ,$3.87 ,$1.16 ,$3.52 ,$2.71 ,$1.16 ,$2.52 ,$2.79 ,$3.52 ,$2.90 
Carle BroMenn Medical Center,8140054,COVER POSNR STEEP TREND DISP,245179,,270,$55.77 ,$55.77 ,$16.73 ,$50.75 ,$39.04 ,$16.73 ,$36.25 ,$40.15 ,$50.75 ,$41.83 
Carle BroMenn Medical Center,8140054,COVER RIGID LIGHT HNDL,244984,,270,$2.92 ,$2.92 ,$0.88 ,$2.66 ,$2.04 ,$0.88 ,$1.90 ,$2.10 ,$2.66 ,$2.19 
Carle BroMenn Medical Center,8140054,COVER WHT STL .045X1.1MM KWIRE/ST,244830,,270,$7.61 ,$7.61 ,$2.28 ,$6.93 ,$5.33 ,$2.28 ,$4.95 ,$5.48 ,$6.93 ,$5.71 
Carle BroMenn Medical Center,8140054,CUFF CLEARSIGHT LARGE FLOTRAC,244004,,270,$930.00 ,$930.00 ,$279.00 ,$846.30 ,$651.00 ,$279.00 ,$604.50 ,$669.60 ,$846.30 ,$697.50 
Carle BroMenn Medical Center,8140054,CUFF DBSPW/PLC 24IN STL DISP,239134,,270,$106.22 ,$106.22 ,$31.87 ,$96.66 ,$74.35 ,$31.87 ,$69.04 ,$76.48 ,$96.66 ,$79.67 
Carle BroMenn Medical Center,8140054,CUFF S HOSE SB 42IN DISP W/PLC,237503,,270,$82.06 ,$82.06 ,$24.62 ,$74.67 ,$57.44 ,$24.62 ,$53.34 ,$59.08 ,$74.67 ,$61.55 
Carle BroMenn Medical Center,8140054,CUFF SINGLE HOSE SB 18IN STL,236832,,270,$57.91 ,$57.91 ,$17.37 ,$52.70 ,$40.54 ,$17.37 ,$37.64 ,$41.70 ,$52.70 ,$43.43 
Carle BroMenn Medical Center,8140054,CUFF SPSB PLC STL DISP 12,237491,,270,$51.80 ,$51.80 ,$15.54 ,$47.14 ,$36.26 ,$15.54 ,$33.67 ,$37.30 ,$47.14 ,$38.85 
Carle BroMenn Medical Center,8140054,CUFF TOURN SPSB 24IN W/PLC,239399,,270,$65.18 ,$65.18 ,$19.55 ,$59.31 ,$45.63 ,$19.55 ,$42.37 ,$46.93 ,$59.31 ,$48.89 
Carle BroMenn Medical Center,8140054,CUFF TOURNIQUET 18IN 10/BX,1050,,270,$62.86 ,$62.86 ,$18.86 ,$57.20 ,$44.00 ,$18.86 ,$40.86 ,$45.26 ,$57.20 ,$47.15 
Carle BroMenn Medical Center,8140054,CUFF TOURNIQUET 24IN 10/BX,1051,,270,$27.06 ,$27.06 ,$8.12 ,$24.62 ,$18.94 ,$8.12 ,$17.59 ,$19.48 ,$24.62 ,$20.30 
Carle BroMenn Medical Center,8140054,CUFF TOURNIQUET 34IN,237484,,270,$76.24 ,$76.24 ,$22.87 ,$69.38 ,$53.37 ,$22.87 ,$49.56 ,$54.89 ,$69.38 ,$57.18 
Carle BroMenn Medical Center,8140054,CUFF TOURNIQUET 42IN 10/BX,1054,,270,$86.72 ,$86.72 ,$26.02 ,$78.92 ,$60.70 ,$26.02 ,$56.37 ,$62.44 ,$78.92 ,$65.04 
Carle BroMenn Medical Center,8140054,CURETTE CRVD OPEN TIP LF 11MM,244699,,270,$8.92 ,$8.92 ,$2.68 ,$8.12 ,$6.24 ,$2.68 ,$5.80 ,$6.42 ,$8.12 ,$6.69 
Carle BroMenn Medical Center,8140054,CURETTE STR REG TIP 7MM,244833,,270,$9.54 ,$9.54 ,$2.86 ,$8.68 ,$6.68 ,$2.86 ,$6.20 ,$6.87 ,$8.68 ,$7.16 
Carle BroMenn Medical Center,8140054,CURETTE STR/REG TIP 8MM,244829,,270,$9.14 ,$9.14 ,$2.74 ,$8.32 ,$6.40 ,$2.74 ,$5.94 ,$6.58 ,$8.32 ,$6.86 
Carle BroMenn Medical Center,8140054,CURETTE VAC RIGID STR 14MM CLR,245175,,270,$10.56 ,$10.56 ,$3.17 ,$9.61 ,$7.39 ,$3.17 ,$6.86 ,$7.60 ,$9.61 ,$7.92 
Carle BroMenn Medical Center,8140054,CURETTE VACUUM 7MM CURVED,244370,,270,$8.93 ,$8.93 ,$2.68 ,$8.13 ,$6.25 ,$2.68 ,$5.80 ,$6.43 ,$8.13 ,$6.70 
Carle BroMenn Medical Center,8140054,CUSHION LG PRONE VIEW INSRT,244644,,270,$80.25 ,$80.25 ,$24.08 ,$73.03 ,$56.18 ,$24.08 ,$52.16 ,$57.78 ,$73.03 ,$60.19 
Carle BroMenn Medical Center,8140054,CUSHION PRONE VIEW INSRT SM,245127,,270,$80.25 ,$80.25 ,$24.08 ,$73.03 ,$56.18 ,$24.08 ,$52.16 ,$57.78 ,$73.03 ,$60.19 
Carle BroMenn Medical Center,8140054,CUTTER AGGRESSIVE PLUS 5MM,245169,,270,$121.73 ,$121.73 ,$36.52 ,$110.77 ,$85.21 ,$36.52 ,$79.12 ,$87.65 ,$110.77 ,$91.30 
Carle BroMenn Medical Center,8140054,CUTTER AGRSV + FORML 4MM,244718,,270,$121.73 ,$121.73 ,$36.52 ,$110.77 ,$85.21 ,$36.52 ,$79.12 ,$87.65 ,$110.77 ,$91.30 
Carle BroMenn Medical Center,8140054,CUTTER FAST FIX KNOT PUSHER,110170,,270,$450.99 ,$450.99 ,$135.30 ,$410.40 ,$315.69 ,$135.30 ,$293.14 ,$324.71 ,$410.40 ,$338.24 
Carle BroMenn Medical Center,8140054,CUTTER RESECTOR 5MM,245218,,270,$121.73 ,$121.73 ,$36.52 ,$110.77 ,$85.21 ,$36.52 ,$79.12 ,$87.65 ,$110.77 ,$91.30 
Carle BroMenn Medical Center,8140054,CUTTER RESECTOR FORML 4MM,245132,,270,$162.07 ,$162.07 ,$48.62 ,$147.48 ,$113.45 ,$48.62 ,$105.35 ,$116.69 ,$147.48 ,$121.55 
Carle BroMenn Medical Center,8140054,CUTTER RESECTOR FORML 5.5MM,245133,,270,$121.73 ,$121.73 ,$36.52 ,$110.77 ,$85.21 ,$36.52 ,$79.12 ,$87.65 ,$110.77 ,$91.30 
Carle BroMenn Medical Center,8140054,DAVINCI XI COLUMN DRAPE BX/20,211107,,270,$54.00 ,$54.00 ,$16.20 ,$49.14 ,$37.80 ,$16.20 ,$35.10 ,$38.88 ,$49.14 ,$40.50 
Carle BroMenn Medical Center,8140054,DECANTER BAG,560,,270,$1.95 ,$1.95 ,$0.59 ,$1.77 ,$1.37 ,$0.59 ,$1.27 ,$1.40 ,$1.77 ,$1.46 
Carle BroMenn Medical Center,8140054,DEPRESSOR ADLT TONGUE STL 6IN,244105,,270,$0.16 ,$0.16 ,$0.05 ,$0.15 ,$0.11 ,$0.05 ,$0.10 ,$0.12 ,$0.15 ,$0.12 
Carle BroMenn Medical Center,8140054,DERMACARRIER 1.5 TO 1 SKIN CRAFT,769,,270,$62.85 ,$62.85 ,$18.86 ,$57.19 ,$44.00 ,$18.86 ,$40.85 ,$45.25 ,$57.19 ,$47.14 
Carle BroMenn Medical Center,8140054,DERMACARRIER 3 TO 1 SKIN GRAFT CA,237069,,270,$0.17 ,$0.17 ,$0.05 ,$0.15 ,$0.12 ,$0.05 ,$0.11 ,$0.12 ,$0.15 ,$0.13 
Carle BroMenn Medical Center,8140054,DERMACARRIER 9 TO 1 SKIN GRAFT CA,237081,,270,$0.17 ,$0.17 ,$0.05 ,$0.15 ,$0.12 ,$0.05 ,$0.11 ,$0.12 ,$0.15 ,$0.13 
Carle BroMenn Medical Center,8140054,DEVICE LAPARASCOPE PLUME FILTR,249497,,270,$64.50 ,$64.50 ,$19.35 ,$58.70 ,$45.15 ,$19.35 ,$41.93 ,$46.44 ,$58.70 ,$48.38 
Carle BroMenn Medical Center,8140054,DEVICE LAPSNC GAS CONDITIONING,244821,,270,$255.00 ,$255.00 ,$76.50 ,$232.05 ,$178.50 ,$76.50 ,$165.75 ,$183.60 ,$232.05 ,$191.25 
Carle BroMenn Medical Center,8140054,DEVICE PICO 4IN X 12IN use #33465,177904,,270,$674.60 ,$674.60 ,$202.38 ,$613.89 ,$472.22 ,$202.38 ,$438.49 ,$485.71 ,$613.89 ,$505.95 
Carle BroMenn Medical Center,8140054,DEVICE PICO NEG PRES 4X12IN BROME,244042,,270,$726.00 ,$726.00 ,$217.80 ,$660.66 ,$508.20 ,$217.80 ,$471.90 ,$522.72 ,$660.66 ,$544.50 
Carle BroMenn Medical Center,8140054,DEVICE PNEUVIEW XE SMK ELMIN,245178,,270,$0.22 ,$0.22 ,$0.07 ,$0.20 ,$0.15 ,$0.07 ,$0.14 ,$0.16 ,$0.20 ,$0.17 
Carle BroMenn Medical Center,8140054,DEVICE REACH TISS REMVL 3/BX MYOS,244037,,270,"$3,835.00 ","$3,835.00 ","$1,150.50 ","$3,489.85 ","$2,684.50 ","$1,150.50 ","$2,492.75 ","$2,761.20 ","$3,489.85 ","$2,876.25 "
Carle BroMenn Medical Center,8140054,DEVICE RX LOCK & CAP OLYMPS 10/BX,247170,,270,$27.10 ,$27.10 ,$8.13 ,$24.66 ,$18.97 ,$8.13 ,$17.62 ,$19.51 ,$24.66 ,$20.33 
Carle BroMenn Medical Center,8140054,DEVICE SE INFL ACCLARENT,245142,,270,$223.65 ,$223.65 ,$67.10 ,$203.52 ,$156.56 ,$67.10 ,$145.37 ,$161.03 ,$203.52 ,$167.74 
Carle BroMenn Medical Center,8140054,DEVICE SUTURE CAPTURING 25CM,244676,,270,"$1,467.28 ","$1,467.28 ",$440.18 ,"$1,335.22 ","$1,027.10 ",$440.18 ,$953.73 ,"$1,056.44 ","$1,335.22 ","$1,100.46 "
Carle BroMenn Medical Center,8140054,DEVICE TRACKER POINTER AXIEM,4340,,270,"$1,704.00 ","$1,704.00 ",$511.20 ,"$1,550.64 ","$1,192.80 ",$511.20 ,"$1,107.60 ","$1,226.88 ","$1,550.64 ","$1,278.00 "
Carle BroMenn Medical Center,8140054,DEVICE VASOVIEW SYSTEM EVH ORDER,204386,,270,"$4,172.31 ","$4,172.31 ","$1,251.69 ","$3,796.80 ","$2,920.62 ","$1,251.69 ","$2,712.00 ","$3,004.06 ","$3,796.80 ","$3,129.23 "
Carle BroMenn Medical Center,8140054,DEVIDE RAPID RHINO 5.5CM UNI NASA,249746,,270,$112.50 ,$112.50 ,$33.75 ,$102.38 ,$78.75 ,$33.75 ,$73.13 ,$81.00 ,$102.38 ,$84.38 
Carle BroMenn Medical Center,8140054,DIFFUSER,244793,,270,$38.04 ,$38.04 ,$11.41 ,$34.62 ,$26.63 ,$11.41 ,$24.73 ,$27.39 ,$34.62 ,$28.53 
Carle BroMenn Medical Center,8140054,DILATOR S CURVE 37CM 8-20FR URETH,251296,,270,$514.95 ,$514.95 ,$154.49 ,$468.60 ,$360.47 ,$154.49 ,$334.72 ,$370.76 ,$468.60 ,$386.21 
Carle BroMenn Medical Center,8140054,DILATOR URETRERAL AQ,250606,,270,$459.00 ,$459.00 ,$137.70 ,$417.69 ,$321.30 ,$137.70 ,$298.35 ,$330.48 ,$417.69 ,$344.25 
Carle BroMenn Medical Center,8140054,DISH PETRI STERILE,250411,,270,$5.47 ,$5.47 ,$1.64 ,$4.98 ,$3.83 ,$1.64 ,$3.56 ,$3.94 ,$4.98 ,$4.10 
Carle BroMenn Medical Center,8140054,DISSECTOR ENDO LAP 5MM,245255,,270,$661.50 ,$661.50 ,$198.45 ,$601.97 ,$463.05 ,$198.45 ,$429.98 ,$476.28 ,$601.97 ,$496.13 
Carle BroMenn Medical Center,8140054,DISSECTOR KITTNER SECTO 7.9X16,244861,,270,$16.31 ,$16.31 ,$4.89 ,$14.84 ,$11.42 ,$4.89 ,$10.60 ,$11.74 ,$14.84 ,$12.23 
Carle BroMenn Medical Center,8140054,DRAIN 1/8 SIL RND W/TROCAR,248470,,270,$28.50 ,$28.50 ,$8.55 ,$25.94 ,$19.95 ,$8.55 ,$18.53 ,$20.52 ,$25.94 ,$21.38 
Carle BroMenn Medical Center,8140054,DRAIN 10F RND HBLSS FLUTE/TROC,245007,,270,$76.20 ,$76.20 ,$22.86 ,$69.34 ,$53.34 ,$22.86 ,$49.53 ,$54.86 ,$69.34 ,$57.15 
Carle BroMenn Medical Center,8140054,DRAIN 10MM FLT FULL PERF,244739,,270,$19.50 ,$19.50 ,$5.85 ,$17.75 ,$13.65 ,$5.85 ,$12.68 ,$14.04 ,$17.75 ,$14.63 
Carle BroMenn Medical Center,8140054,DRAIN 15F RND FULL FLUTE,245204,,270,$61.50 ,$61.50 ,$18.45 ,$55.97 ,$43.05 ,$18.45 ,$39.98 ,$44.28 ,$55.97 ,$46.13 
Carle BroMenn Medical Center,8140054,DRAIN 15F RND FULL FLUTE/TROC,245006,,270,$75.45 ,$75.45 ,$22.64 ,$68.66 ,$52.82 ,$22.64 ,$49.04 ,$54.32 ,$68.66 ,$56.59 
Carle BroMenn Medical Center,8140054,DRAIN 19F RND HBLSS FULL FLUTE,244783,,270,$60.90 ,$60.90 ,$18.27 ,$55.42 ,$42.63 ,$18.27 ,$39.59 ,$43.85 ,$55.42 ,$45.68 
Carle BroMenn Medical Center,8140054,DRAIN 24F RND HBLSS FULL FLUTE,245238,,270,$60.90 ,$60.90 ,$18.27 ,$55.42 ,$42.63 ,$18.27 ,$39.59 ,$43.85 ,$55.42 ,$45.68 
Carle BroMenn Medical Center,8140054,DRAIN 7MM FLAT3/4 PERF,245004,,270,$19.50 ,$19.50 ,$5.85 ,$17.75 ,$13.65 ,$5.85 ,$12.68 ,$14.04 ,$17.75 ,$14.63 
Carle BroMenn Medical Center,8140054,DRAIN 7MM FLT FULL PERF,244642,,270,$19.50 ,$19.50 ,$5.85 ,$17.75 ,$13.65 ,$5.85 ,$12.68 ,$14.04 ,$17.75 ,$14.63 
Carle BroMenn Medical Center,8140054,DRAIN BIFUR T-TUBE 100CC RESER,244569,,270,$19.37 ,$19.37 ,$5.81 ,$17.63 ,$13.56 ,$5.81 ,$12.59 ,$13.95 ,$17.63 ,$14.53 
Carle BroMenn Medical Center,8140054,DRAIN BLAKE WND FULL RND 19F W/TR,244814,,270,$60.90 ,$60.90 ,$18.27 ,$55.42 ,$42.63 ,$18.27 ,$39.59 ,$43.85 ,$55.42 ,$45.68 
Carle BroMenn Medical Center,8140054,DRAIN CHEST PLEUR EVAC/OASIS,244247,,270,$92.73 ,$92.73 ,$27.82 ,$84.38 ,$64.91 ,$27.82 ,$60.27 ,$66.77 ,$84.38 ,$69.55 
Carle BroMenn Medical Center,8140054,DRAIN MALECOT 4WING 22F,244261,,270,$73.32 ,$73.32 ,$22.00 ,$66.72 ,$51.32 ,$22.00 ,$47.66 ,$52.79 ,$66.72 ,$54.99 
Carle BroMenn Medical Center,8140054,DRAIN PENROSE .25X12IN,244857,,270,$3.69 ,$3.69 ,$1.11 ,$3.36 ,$2.58 ,$1.11 ,$2.40 ,$2.66 ,$3.36 ,$2.77 
Carle BroMenn Medical Center,8140054,DRAIN PENROSE .5X12IN,244982,,270,$3.64 ,$3.64 ,$1.09 ,$3.31 ,$2.55 ,$1.09 ,$2.37 ,$2.62 ,$3.31 ,$2.73 
Carle BroMenn Medical Center,8140054,DRAIN PENROSE 1X18IN,244858,,270,$4.22 ,$4.22 ,$1.27 ,$3.84 ,$2.95 ,$1.27 ,$2.74 ,$3.04 ,$3.84 ,$3.17 
Carle BroMenn Medical Center,8140054,DRAIN RND CHANNEL 28F,247028,,270,$108.00 ,$108.00 ,$32.40 ,$98.28 ,$75.60 ,$32.40 ,$70.20 ,$77.76 ,$98.28 ,$81.00 
Carle BroMenn Medical Center,8140054,DRAPE BEACHCHAIR SPLIT 172X100 CI,245086,,270,$54.00 ,$54.00 ,$16.20 ,$49.14 ,$37.80 ,$16.20 ,$35.10 ,$38.88 ,$49.14 ,$40.50 
Carle BroMenn Medical Center,8140054,DRAPE BILAT EXTRM 86X138X107.5,244577,,270,$20.90 ,$20.90 ,$6.27 ,$19.02 ,$14.63 ,$6.27 ,$13.59 ,$15.05 ,$19.02 ,$15.68 
Carle BroMenn Medical Center,8140054,DRAPE CAMERA SNAP KOVER 36X30 BAN,245048,,270,$3.39 ,$3.39 ,$1.02 ,$3.08 ,$2.37 ,$1.02 ,$2.20 ,$2.44 ,$3.08 ,$2.54 
Carle BroMenn Medical Center,8140054,DRAPE CAMERA UNIV STL 7X96 BANDED,245049,,270,$5.04 ,$5.04 ,$1.51 ,$4.59 ,$3.53 ,$1.51 ,$3.28 ,$3.63 ,$4.59 ,$3.78 
Carle BroMenn Medical Center,8140054,DRAPE C-ARM KOVER STL 42X72IN BAN,245051,,270,$10.86 ,$10.86 ,$3.26 ,$9.88 ,$7.60 ,$3.26 ,$7.06 ,$7.82 ,$9.88 ,$8.15 
Carle BroMenn Medical Center,8140054,DRAPE C-ARMOR,244824,,270,$125.00 ,$125.00 ,$37.50 ,$113.75 ,$87.50 ,$37.50 ,$81.25 ,$90.00 ,$113.75 ,$93.75 
Carle BroMenn Medical Center,8140054,DRAPE CRANIOTOMY SURG 77X134IN OV,245087,,270,$44.83 ,$44.83 ,$13.45 ,$40.80 ,$31.38 ,$13.45 ,$29.14 ,$32.28 ,$40.80 ,$33.62 
Carle BroMenn Medical Center,8140054,DRAPE DINAMIC OR DISP DBL WD,244875,,270,$0.28 ,$0.28 ,$0.08 ,$0.25 ,$0.20 ,$0.08 ,$0.18 ,$0.20 ,$0.25 ,$0.21 
Carle BroMenn Medical Center,8140054,DRAPE DINAMIC OR DISP TRPL WD,244876,,270,$0.33 ,$0.33 ,$0.10 ,$0.30 ,$0.23 ,$0.10 ,$0.21 ,$0.24 ,$0.30 ,$0.25 
Carle BroMenn Medical Center,8140054,DRAPE EXTRM FULL FABRIC,244859,,270,$15.68 ,$15.68 ,$4.70 ,$14.27 ,$10.98 ,$4.70 ,$10.19 ,$11.29 ,$14.27 ,$11.76 
Carle BroMenn Medical Center,8140054,DRAPE FEML ANGIO SURG 84X124IN DU,245088,,270,$15.12 ,$15.12 ,$4.54 ,$13.76 ,$10.58 ,$4.54 ,$9.83 ,$10.89 ,$13.76 ,$11.34 
Carle BroMenn Medical Center,8140054,DRAPE FLUID CONTROL SHOULDER 10 P,256472,,270,$52.82 ,$52.82 ,$15.85 ,$48.07 ,$36.97 ,$15.85 ,$34.33 ,$38.03 ,$48.07 ,$39.62 
Carle BroMenn Medical Center,8140054,DRAPE FLUID WARMER DISC 44X66 W/P,244682,,270,$130.62 ,$130.62 ,$39.19 ,$118.86 ,$91.43 ,$39.19 ,$84.90 ,$94.05 ,$118.86 ,$97.97 
Carle BroMenn Medical Center,8140054,DRAPE HALF SHEET 40X57IN CONVERTO,244519,,270,$2.55 ,$2.55 ,$0.77 ,$2.32 ,$1.79 ,$0.77 ,$1.66 ,$1.84 ,$2.32 ,$1.91 
Carle BroMenn Medical Center,8140054,DRAPE HDUTY ARTHRO 87X114IN ARMBO,245089,,270,$74.99 ,$74.99 ,$22.50 ,$68.24 ,$52.49 ,$22.50 ,$48.74 ,$53.99 ,$68.24 ,$56.24 
Carle BroMenn Medical Center,8140054,DRAPE HDUTY SHLDR 59.5X112IN DUAL,245091,,270,$28.32 ,$28.32 ,$8.50 ,$25.77 ,$19.82 ,$8.50 ,$18.41 ,$20.39 ,$25.77 ,$21.24 
Carle BroMenn Medical Center,8140054,DRAPE HDUTY SHLDR 99X59IN FLUID C,245090,,270,$63.81 ,$63.81 ,$19.14 ,$58.07 ,$44.67 ,$19.14 ,$41.48 ,$45.94 ,$58.07 ,$47.86 
Carle BroMenn Medical Center,8140054,DRAPE HEAD CVR,244995,,270,$0.08 ,$0.08 ,$0.02 ,$0.07 ,$0.06 ,$0.02 ,$0.05 ,$0.06 ,$0.07 ,$0.06 
Carle BroMenn Medical Center,8140054,DRAPE INCISE IOBAN PREP 13X13,244615,,270,$9.82 ,$9.82 ,$2.95 ,$8.94 ,$6.87 ,$2.95 ,$6.38 ,$7.07 ,$8.94 ,$7.37 
Carle BroMenn Medical Center,8140054,DRAPE IOBAN 23X17,244354,,270,$0.36 ,$0.36 ,$0.11 ,$0.33 ,$0.25 ,$0.11 ,$0.23 ,$0.26 ,$0.33 ,$0.27 
Carle BroMenn Medical Center,8140054,DRAPE IOBAN INCISE 23 X 33IN,244353,,270,$27.53 ,$27.53 ,$8.26 ,$25.05 ,$19.27 ,$8.26 ,$17.89 ,$19.82 ,$25.05 ,$20.65 
Carle BroMenn Medical Center,8140054,DRAPE KINEVO MICROSCOPE,223701,,270,$85.96 ,$85.96 ,$25.79 ,$78.22 ,$60.17 ,$25.79 ,$55.87 ,$61.89 ,$78.22 ,$64.47 
Carle BroMenn Medical Center,8140054,DRAPE LAP 77X122X106IN,244578,,270,$12.44 ,$12.44 ,$3.73 ,$11.32 ,$8.71 ,$3.73 ,$8.09 ,$8.96 ,$11.32 ,$9.33 
Carle BroMenn Medical Center,8140054,DRAPE LEICA MSCP W/ANGL 54X150,244878,,270,$41.16 ,$41.16 ,$12.35 ,$37.46 ,$28.81 ,$12.35 ,$26.75 ,$29.64 ,$37.46 ,$30.87 
Carle BroMenn Medical Center,8140054,DRAPE MAGNETIC INSTR 16X20IN,244985,,270,$34.93 ,$34.93 ,$10.48 ,$31.79 ,$24.45 ,$10.48 ,$22.70 ,$25.15 ,$31.79 ,$26.20 
Carle BroMenn Medical Center,8140054,DRAPE MAJOR ABD 77X123.5IN ARMBOA,252600,,270,$26.13 ,$26.13 ,$7.84 ,$23.78 ,$18.29 ,$7.84 ,$16.98 ,$18.81 ,$23.78 ,$19.60 
Carle BroMenn Medical Center,8140054,DRAPE NEONATAL 44X60IN,244872,,270,$6.77 ,$6.77 ,$2.03 ,$6.16 ,$4.74 ,$2.03 ,$4.40 ,$4.87 ,$6.16 ,$5.08 
Carle BroMenn Medical Center,8140054,DRAPE OPEN HEART DBL BASIN BRO,245101,,270,$264.15 ,$264.15 ,$79.25 ,$240.38 ,$184.91 ,$79.25 ,$171.70 ,$190.19 ,$240.38 ,$198.11 
Carle BroMenn Medical Center,8140054,DRAPE SHEET THREE QUARTER,244263,,270,$3.80 ,$3.80 ,$1.14 ,$3.46 ,$2.66 ,$1.14 ,$2.47 ,$2.74 ,$3.46 ,$2.85 
Carle BroMenn Medical Center,8140054,DRAPE SPLIT SHEET ADH REINF,244403,,270,$13.58 ,$13.58 ,$4.07 ,$12.36 ,$9.51 ,$4.07 ,$8.83 ,$9.78 ,$12.36 ,$10.19 
Carle BroMenn Medical Center,8140054,DRAPE STERI SHOULDER 89CMX76CM 5,250483,,270,$31.13 ,$31.13 ,$9.34 ,$28.33 ,$21.79 ,$9.34 ,$20.23 ,$22.41 ,$28.33 ,$23.35 
Carle BroMenn Medical Center,8140054,DRAPE SURGICAL SMART KINEVO 5/PK,247201,,270,$85.96 ,$85.96 ,$25.79 ,$78.22 ,$60.17 ,$25.79 ,$55.87 ,$61.89 ,$78.22 ,$64.47 
Carle BroMenn Medical Center,8140054,DRAPE TABLE TRAUMA 90X65IN,245246,,270,$6.18 ,$6.18 ,$1.85 ,$5.62 ,$4.33 ,$1.85 ,$4.02 ,$4.45 ,$5.62 ,$4.64 
Carle BroMenn Medical Center,8140054,DRAPE TIBURON HAND LF 77X147,245030,,270,$18.21 ,$18.21 ,$5.46 ,$16.57 ,$12.75 ,$5.46 ,$11.84 ,$13.11 ,$16.57 ,$13.66 
Carle BroMenn Medical Center,8140054,DRAPE TOWEL W/ADHN 19X30,244860,,270,$1.91 ,$1.91 ,$0.57 ,$1.74 ,$1.34 ,$0.57 ,$1.24 ,$1.38 ,$1.74 ,$1.43 
Carle BroMenn Medical Center,8140054,DRAPE TRANSVERSE LAPAROTOMY,244345,,270,$13.59 ,$13.59 ,$4.08 ,$12.37 ,$9.51 ,$4.08 ,$8.83 ,$9.78 ,$12.37 ,$10.19 
Carle BroMenn Medical Center,8140054,DRAPE TREMANO BEACH CHAIR,243966,,270,$225.00 ,$225.00 ,$67.50 ,$204.75 ,$157.50 ,$67.50 ,$146.25 ,$162.00 ,$204.75 ,$168.75 
Carle BroMenn Medical Center,8140054,DRAPE TUBE OR ARM IMAGING STL,244795,,270,$0.17 ,$0.17 ,$0.05 ,$0.15 ,$0.12 ,$0.05 ,$0.11 ,$0.12 ,$0.15 ,$0.13 
Carle BroMenn Medical Center,8140054,DRAPE U ORTHO 60X72IN,244033,,270,$4.72 ,$4.72 ,$1.42 ,$4.30 ,$3.30 ,$1.42 ,$3.07 ,$3.40 ,$4.30 ,$3.54 
Carle BroMenn Medical Center,8140054,DRAPE UNDER BUTT 40X44.5IN,245092,,270,$7.75 ,$7.75 ,$2.33 ,$7.05 ,$5.43 ,$2.33 ,$5.04 ,$5.58 ,$7.05 ,$5.81 
Carle BroMenn Medical Center,8140054,DRAPE XRAY UNIV CASS STL 20X40,245050,,270,$3.06 ,$3.06 ,$0.92 ,$2.78 ,$2.14 ,$0.92 ,$1.99 ,$2.20 ,$2.78 ,$2.30 
Carle BroMenn Medical Center,8140054,DRAPE ZEISS MSCP MD STL 454X15,245057,,270,$37.32 ,$37.32 ,$11.20 ,$33.96 ,$26.12 ,$11.20 ,$24.26 ,$26.87 ,$33.96 ,$27.99 
Carle BroMenn Medical Center,8140054,DRAPE ZEISS MSCP MD STL 48X102,245052,,270,$32.87 ,$32.87 ,$9.86 ,$29.91 ,$23.01 ,$9.86 ,$21.37 ,$23.67 ,$29.91 ,$24.65 
Carle BroMenn Medical Center,8140054,DRESSING ACTICOAT FLEX 7 30/CA,793,,270,$41.45 ,$41.45 ,$12.44 ,$37.72 ,$29.02 ,$12.44 ,$26.94 ,$29.84 ,$37.72 ,$31.09 
Carle BroMenn Medical Center,8140054,DRESSING ADAPTIC 3 X 8 NON-ADHERI,158,,270,$1.18 ,$1.18 ,$0.35 ,$1.07 ,$0.83 ,$0.35 ,$0.77 ,$0.85 ,$1.07 ,$0.89 
Carle BroMenn Medical Center,8140054,DRESSING ADAPTIC 3X8,232098,,270,$3.06 ,$3.06 ,$0.92 ,$2.78 ,$2.14 ,$0.92 ,$1.99 ,$2.20 ,$2.78 ,$2.30 
Carle BroMenn Medical Center,8140054,DRESSING AQUACEL AG 3.5X10,232118,,270,$92.86 ,$92.86 ,$27.86 ,$84.50 ,$65.00 ,$27.86 ,$60.36 ,$66.86 ,$84.50 ,$69.65 
Carle BroMenn Medical Center,8140054,DRESSING AQUACEL AG 3.5X9.75 HYDR,244753,,270,$89.53 ,$89.53 ,$26.86 ,$81.47 ,$62.67 ,$26.86 ,$58.19 ,$64.46 ,$81.47 ,$67.15 
Carle BroMenn Medical Center,8140054,DRESSING AQUACEL AG SURG 12IN,245182,,270,$97.33 ,$97.33 ,$29.20 ,$88.57 ,$68.13 ,$29.20 ,$63.26 ,$70.08 ,$88.57 ,$73.00 
Carle BroMenn Medical Center,8140054,DRESSING BIOPATCH 1IN,244099,,270,$16.49 ,$16.49 ,$4.95 ,$15.01 ,$11.54 ,$4.95 ,$10.72 ,$11.87 ,$15.01 ,$12.37 
Carle BroMenn Medical Center,8140054,DRESSING COVADERM 4X10,232104,,270,$6.06 ,$6.06 ,$1.82 ,$5.51 ,$4.24 ,$1.82 ,$3.94 ,$4.36 ,$5.51 ,$4.55 
Carle BroMenn Medical Center,8140054,DRESSING COVRSITE PLUS 6X6,232230,,270,$3.51 ,$3.51 ,$1.05 ,$3.19 ,$2.46 ,$1.05 ,$2.28 ,$2.53 ,$3.19 ,$2.63 
Carle BroMenn Medical Center,8140054,DRESSING CURAD GAUZE OIL 3X8 EMUL,244117,,270,$1.40 ,$1.40 ,$0.42 ,$1.27 ,$0.98 ,$0.42 ,$0.91 ,$1.01 ,$1.27 ,$1.05 
Carle BroMenn Medical Center,8140054,DRESSING CURAD XEROFORM 5X9,245001,,270,$2.96 ,$2.96 ,$0.89 ,$2.69 ,$2.07 ,$0.89 ,$1.92 ,$2.13 ,$2.69 ,$2.22 
Carle BroMenn Medical Center,8140054,DRESSING CURAD XEROFRM STL 1X8,245000,,270,$2.36 ,$2.36 ,$0.71 ,$2.15 ,$1.65 ,$0.71 ,$1.53 ,$1.70 ,$2.15 ,$1.77 
Carle BroMenn Medical Center,8140054,DRESSING GAUZE COVR SPONGE 4X4,232114,,270,$0.31 ,$0.31 ,$0.09 ,$0.28 ,$0.22 ,$0.09 ,$0.20 ,$0.22 ,$0.28 ,$0.23 
Carle BroMenn Medical Center,8140054,DRESSING GAUZE NS 4PLY 2INX100,244996,,270,$0.14 ,$0.14 ,$0.04 ,$0.13 ,$0.10 ,$0.04 ,$0.09 ,$0.10 ,$0.13 ,$0.11 
Carle BroMenn Medical Center,8140054,DRESSING GAUZE SPONGE N/S 2X2,232100,,270,$4.11 ,$4.11 ,$1.23 ,$3.74 ,$2.88 ,$1.23 ,$2.67 ,$2.96 ,$3.74 ,$3.08 
Carle BroMenn Medical Center,8140054,DRESSING IV TEGADERM 4X6,170,,270,$3.05 ,$3.05 ,$0.92 ,$2.78 ,$2.14 ,$0.92 ,$1.98 ,$2.20 ,$2.78 ,$2.29 
Carle BroMenn Medical Center,8140054,DRESSING MEDIFIX RETN 2INX11YD AD,244951,,270,$0.07 ,$0.07 ,$0.02 ,$0.06 ,$0.05 ,$0.02 ,$0.05 ,$0.05 ,$0.06 ,$0.05 
Carle BroMenn Medical Center,8140054,DRESSING MEPILEX 4X10,244161,,270,$15.56 ,$15.56 ,$4.67 ,$14.16 ,$10.89 ,$4.67 ,$10.11 ,$11.20 ,$14.16 ,$11.67 
Carle BroMenn Medical Center,8140054,DRESSING MEPILEX AG 10X25CM BORDE,245171,,270,$70.76 ,$70.76 ,$21.23 ,$64.39 ,$49.53 ,$21.23 ,$45.99 ,$50.95 ,$64.39 ,$53.07 
Carle BroMenn Medical Center,8140054,DRESSING MEPILEX AG 3X3IN BORDER,244168,,270,$4.51 ,$4.51 ,$1.35 ,$4.10 ,$3.16 ,$1.35 ,$2.93 ,$3.25 ,$4.10 ,$3.38 
Carle BroMenn Medical Center,8140054,DRESSING MEPILEX AG 4X4IN BORDER,244171,,270,$8.60 ,$8.60 ,$2.58 ,$7.83 ,$6.02 ,$2.58 ,$5.59 ,$6.19 ,$7.83 ,$6.45 
Carle BroMenn Medical Center,8140054,DRESSING MEPILEX BORDER 4X12,248971,,270,$16.76 ,$16.76 ,$5.03 ,$15.25 ,$11.73 ,$5.03 ,$10.89 ,$12.07 ,$15.25 ,$12.57 
Carle BroMenn Medical Center,8140054,DRESSING MEPILEX BORDER 4X12 use,196961,,270,$17.65 ,$17.65 ,$5.30 ,$16.06 ,$12.36 ,$5.30 ,$11.47 ,$12.71 ,$16.06 ,$13.24 
Carle BroMenn Medical Center,8140054,DRESSING MEPILEX BORDER 4X4IN,232109,,270,$8.74 ,$8.74 ,$2.62 ,$7.95 ,$6.12 ,$2.62 ,$5.68 ,$6.29 ,$7.95 ,$6.56 
Carle BroMenn Medical Center,8140054,DRESSING MEPILEX BORDER 7X7 SACRU,232099,,270,$3.84 ,$3.84 ,$1.15 ,$3.49 ,$2.69 ,$1.15 ,$2.50 ,$2.76 ,$3.49 ,$2.88 
Carle BroMenn Medical Center,8140054,DRESSING MEPILEX BORDERLITE2X5 AD,162,,270,$31.90 ,$31.90 ,$9.57 ,$29.03 ,$22.33 ,$9.57 ,$20.74 ,$22.97 ,$29.03 ,$23.93 
Carle BroMenn Medical Center,8140054,DRESSING MEPILEX SACR 6.3X7.9 FOA,244210,,270,$19.43 ,$19.43 ,$5.83 ,$17.68 ,$13.60 ,$5.83 ,$12.63 ,$13.99 ,$17.68 ,$14.57 
Carle BroMenn Medical Center,8140054,DRESSING NASAL MEROCEL STD 8CM,244032,,270,$0.33 ,$0.33 ,$0.10 ,$0.30 ,$0.23 ,$0.10 ,$0.21 ,$0.24 ,$0.30 ,$0.25 
Carle BroMenn Medical Center,8140054,DRESSING OIL EMULS CURAD 3X3,244113,,270,$0.61 ,$0.61 ,$0.18 ,$0.56 ,$0.43 ,$0.18 ,$0.40 ,$0.44 ,$0.56 ,$0.46 
Carle BroMenn Medical Center,8140054,DRESSING OPTIFOAM BASC ADH 4X5,245173,,270,$4.18 ,$4.18 ,$1.25 ,$3.80 ,$2.93 ,$1.25 ,$2.72 ,$3.01 ,$3.80 ,$3.14 
Carle BroMenn Medical Center,8140054,DRESSING OWENS 3X8IN,245250,,270,$5.31 ,$5.31 ,$1.59 ,$4.83 ,$3.72 ,$1.59 ,$3.45 ,$3.82 ,$4.83 ,$3.98 
Carle BroMenn Medical Center,8140054,DRESSING PETRL OVERWRAP 3X18 CURA,244191,,270,$3.27 ,$3.27 ,$0.98 ,$2.98 ,$2.29 ,$0.98 ,$2.13 ,$2.35 ,$2.98 ,$2.45 
Carle BroMenn Medical Center,8140054,DRESSING PETRL OVERWRAP 3X9 CURAD,244192,,270,$2.39 ,$2.39 ,$0.72 ,$2.17 ,$1.67 ,$0.72 ,$1.55 ,$1.72 ,$2.17 ,$1.79 
Carle BroMenn Medical Center,8140054,DRESSING PREVENA 20CM KIT,208330,,270,"$1,485.00 ","$1,485.00 ",$445.50 ,"$1,351.35 ","$1,039.50 ",$445.50 ,$965.25 ,"$1,069.20 ","$1,351.35 ","$1,113.75 "
Carle BroMenn Medical Center,8140054,DRESSING PRINEO DERMABOND 22CM,244400,,270,$232.52 ,$232.52 ,$69.76 ,$211.59 ,$162.76 ,$69.76 ,$151.14 ,$167.41 ,$211.59 ,$174.39 
Carle BroMenn Medical Center,8140054,DRESSING SPONGE GAUZE 4X4 STR,230083,,270,$0.92 ,$0.92 ,$0.28 ,$0.84 ,$0.64 ,$0.28 ,$0.60 ,$0.66 ,$0.84 ,$0.69 
Carle BroMenn Medical Center,8140054,DRESSING SURGIFOAM 2X6 12-7 12 PE,240107,,270,$12.39 ,$12.39 ,$3.72 ,$11.27 ,$8.67 ,$3.72 ,$8.05 ,$8.92 ,$11.27 ,$9.29 
Carle BroMenn Medical Center,8140054,DRESSING TEGADERM 1.75 X 1.75 400,67623,,270,$0.60 ,$0.60 ,$0.18 ,$0.55 ,$0.42 ,$0.18 ,$0.39 ,$0.43 ,$0.55 ,$0.45 
Carle BroMenn Medical Center,8140054,DRESSING TEGADERM 2.25X2.75,244091,,270,$0.60 ,$0.60 ,$0.18 ,$0.55 ,$0.42 ,$0.18 ,$0.39 ,$0.43 ,$0.55 ,$0.45 
Carle BroMenn Medical Center,8140054,DRESSING TEGADERM 2X3 100/BX,169,,270,$0.33 ,$0.33 ,$0.10 ,$0.30 ,$0.23 ,$0.10 ,$0.21 ,$0.24 ,$0.30 ,$0.25 
Carle BroMenn Medical Center,8140054,DRESSING TEGADERM 4 X 4.75,244248,,270,$1.75 ,$1.75 ,$0.53 ,$1.59 ,$1.23 ,$0.53 ,$1.14 ,$1.26 ,$1.59 ,$1.31 
Carle BroMenn Medical Center,8140054,DRESSING TEGADERM 4 X 4.75 50/BX,1056,,270,$7.07 ,$7.07 ,$2.12 ,$6.43 ,$4.95 ,$2.12 ,$4.60 ,$5.09 ,$6.43 ,$5.30 
Carle BroMenn Medical Center,8140054,DRESSING TEGADERM 8X12,244279,,270,$5.01 ,$5.01 ,$1.50 ,$4.56 ,$3.51 ,$1.50 ,$3.26 ,$3.61 ,$4.56 ,$3.76 
Carle BroMenn Medical Center,8140054,DRESSING TEGADERM CHG 4X4.75IN,244178,,270,$18.54 ,$18.54 ,$5.56 ,$16.87 ,$12.98 ,$5.56 ,$12.05 ,$13.35 ,$16.87 ,$13.91 
Carle BroMenn Medical Center,8140054,DRESSING TEGADERM TRANS 4X10,244127,,270,$3.11 ,$3.11 ,$0.93 ,$2.83 ,$2.18 ,$0.93 ,$2.02 ,$2.24 ,$2.83 ,$2.33 
Carle BroMenn Medical Center,8140054,DRESSING TEGADERM TRANS 6X8,244236,,270,$3.54 ,$3.54 ,$1.06 ,$3.22 ,$2.48 ,$1.06 ,$2.30 ,$2.55 ,$3.22 ,$2.66 
Carle BroMenn Medical Center,8140054,DRESSING TELFA 3 X 8,171,,270,$0.16 ,$0.16 ,$0.05 ,$0.15 ,$0.11 ,$0.05 ,$0.10 ,$0.12 ,$0.15 ,$0.12 
Carle BroMenn Medical Center,8140054,DRESSING TUBULAR SPANDAGE SZ 1 1/,244011,,270,$32.69 ,$32.69 ,$9.81 ,$29.75 ,$22.88 ,$9.81 ,$21.25 ,$23.54 ,$29.75 ,$24.52 
Carle BroMenn Medical Center,8140054,DRESSING WOUND VAC MEDIUM,529,,270,$117.41 ,$117.41 ,$35.22 ,$106.84 ,$82.19 ,$35.22 ,$76.32 ,$84.54 ,$106.84 ,$88.06 
Carle BroMenn Medical Center,8140054,DRESSING XEROFORM 5 X 9,232091,,270,$1.20 ,$1.20 ,$0.36 ,$1.09 ,$0.84 ,$0.36 ,$0.78 ,$0.86 ,$1.09 ,$0.90 
Carle BroMenn Medical Center,8140054,DRILL 2.0 MM FBD20,247876,,270,$297.00 ,$297.00 ,$89.10 ,$270.27 ,$207.90 ,$89.10 ,$193.05 ,$213.84 ,$270.27 ,$222.75 
Carle BroMenn Medical Center,8140054,DRILL BIT 1.5MM/MINI QC 48MM,215830,,270,$188.10 ,$188.10 ,$56.43 ,$171.17 ,$131.67 ,$56.43 ,$122.27 ,$135.43 ,$171.17 ,$141.08 
Carle BroMenn Medical Center,8140054,DRILL CANN +3.5MM AO FITTING,247608,,270,$752.40 ,$752.40 ,$225.72 ,$684.68 ,$526.68 ,$225.72 ,$489.06 ,$541.73 ,$684.68 ,$564.30 
Carle BroMenn Medical Center,8140054,DRILL CANN +4.9MM LARGE AO FIT,247611,,270,$616.68 ,$616.68 ,$185.00 ,$561.18 ,$431.68 ,$185.00 ,$400.84 ,$444.01 ,$561.18 ,$462.51 
Carle BroMenn Medical Center,8140054,DRILL DISP FLEX 15MM,239201,,270,$429.00 ,$429.00 ,$128.70 ,$390.39 ,$300.30 ,$128.70 ,$278.85 ,$308.88 ,$390.39 ,$321.75 
Carle BroMenn Medical Center,8140054,DRILL DISP FLEX 30MM,237573,,270,$429.00 ,$429.00 ,$128.70 ,$390.39 ,$300.30 ,$128.70 ,$278.85 ,$308.88 ,$390.39 ,$321.75 
Carle BroMenn Medical Center,8140054,DRILL OID TROCAR EXPRESS,177341,,270,"$1,080.00 ","$1,080.00 ",$324.00 ,$982.80 ,$756.00 ,$324.00 ,$702.00 ,$777.60 ,$982.80 ,$810.00 
Carle BroMenn Medical Center,8140054,DRILL OVERDRILL AO 3.5X12MM,251474,,270,$371.64 ,$371.64 ,$111.49 ,$338.19 ,$260.15 ,$111.49 ,$241.57 ,$267.58 ,$338.19 ,$278.73 
Carle BroMenn Medical Center,8140054,DRILL TW F/COLE RAD 4.0,242688,,270,$583.20 ,$583.20 ,$174.96 ,$530.71 ,$408.24 ,$174.96 ,$379.08 ,$419.90 ,$530.71 ,$437.40 
Carle BroMenn Medical Center,8140054,DRIVER HEXALOBE T8 STICK,251393,,270,$336.00 ,$336.00 ,$100.80 ,$305.76 ,$235.20 ,$100.80 ,$218.40 ,$241.92 ,$305.76 ,$252.00 
Carle BroMenn Medical Center,8140054,DRIVER HIGH TORQUE,225357,,270,$447.00 ,$447.00 ,$134.10 ,$406.77 ,$312.90 ,$134.10 ,$290.55 ,$321.84 ,$406.77 ,$335.25 
Carle BroMenn Medical Center,8140054,DRIVER UNIVERSAL REMOVAL T20,243556,,270,$450.00 ,$450.00 ,$135.00 ,$409.50 ,$315.00 ,$135.00 ,$292.50 ,$324.00 ,$409.50 ,$337.50 
Carle BroMenn Medical Center,8140054,ELECTRODE 6IN COAT ULTRACLEAN,800,,270,$11.34 ,$11.34 ,$3.40 ,$10.32 ,$7.94 ,$3.40 ,$7.37 ,$8.16 ,$10.32 ,$8.51 
Carle BroMenn Medical Center,8140054,ELECTRODE ATRICURE RADIO CLAMP,3744,,270,"$8,250.00 ","$8,250.00 ","$2,475.00 ","$7,507.50 ","$5,775.00 ","$2,475.00 ","$5,362.50 ","$5,940.00 ","$7,507.50 ","$6,187.50 "
Carle BroMenn Medical Center,8140054,ELECTRODE BALL ROLLER 5MM,110181,,270,$404.40 ,$404.40 ,$121.32 ,$368.00 ,$283.08 ,$121.32 ,$262.86 ,$291.17 ,$368.00 ,$303.30 
Carle BroMenn Medical Center,8140054,ELECTRODE BLDE CTD 2.5IN,244601,,270,$21.00 ,$21.00 ,$6.30 ,$19.11 ,$14.70 ,$6.30 ,$13.65 ,$15.12 ,$19.11 ,$15.75 
Carle BroMenn Medical Center,8140054,ELECTRODE COAGTG 24F,244499,,270,$405.88 ,$405.88 ,$121.76 ,$369.35 ,$284.12 ,$121.76 ,$263.82 ,$292.23 ,$369.35 ,$304.41 
Carle BroMenn Medical Center,8140054,ELECTRODE CONE BIOPSY MEDIUM,107021,,270,$70.22 ,$70.22 ,$21.07 ,$63.90 ,$49.15 ,$21.07 ,$45.64 ,$50.56 ,$63.90 ,$52.67 
Carle BroMenn Medical Center,8140054,ELECTRODE CONE BIOPSY SMALL 5/BX,230456,,270,$57.60 ,$57.60 ,$17.28 ,$52.42 ,$40.32 ,$17.28 ,$37.44 ,$41.47 ,$52.42 ,$43.20 
Carle BroMenn Medical Center,8140054,ELECTRODE EDGE CTD 4IN SNGL,245206,,270,$26.85 ,$26.85 ,$8.06 ,$24.43 ,$18.80 ,$8.06 ,$17.45 ,$19.33 ,$24.43 ,$20.14 
Carle BroMenn Medical Center,8140054,ELECTRODE EXTD BLDE 4IN,248974,,270,$13.77 ,$13.77 ,$4.13 ,$12.53 ,$9.64 ,$4.13 ,$8.95 ,$9.91 ,$12.53 ,$10.33 
Carle BroMenn Medical Center,8140054,ELECTRODE EXTD CTD BLDE 6.5IN,244600,,270,$23.55 ,$23.55 ,$7.07 ,$21.43 ,$16.49 ,$7.07 ,$15.31 ,$16.96 ,$21.43 ,$17.66 
Carle BroMenn Medical Center,8140054,ELECTRODE INSUL CTD BLDE 2.7,244693,,270,"$1,023.00 ","$1,023.00 ",$306.90 ,$930.93 ,$716.10 ,$306.90 ,$664.95 ,$736.56 ,$930.93 ,$767.25 
Carle BroMenn Medical Center,8140054,ELECTRODE INSUL CTD NDL 2.84I 50/,244602,,270,$20.79 ,$20.79 ,$6.24 ,$18.92 ,$14.55 ,$6.24 ,$13.51 ,$14.97 ,$18.92 ,$15.59 
Carle BroMenn Medical Center,8140054,ELECTRODE LAP WIRE L-HOOK 36CM CL,245064,,270,$300.30 ,$300.30 ,$90.09 ,$273.27 ,$210.21 ,$90.09 ,$195.20 ,$216.22 ,$273.27 ,$225.23 
Carle BroMenn Medical Center,8140054,ELECTRODE LAP WIRE L-HOOK 45CM CL,245065,,270,$326.88 ,$326.88 ,$98.06 ,$297.46 ,$228.82 ,$98.06 ,$212.47 ,$235.35 ,$297.46 ,$245.16 
Carle BroMenn Medical Center,8140054,ELECTRODE LEEP BALL 3MMX12CM,244708,,270,$48.00 ,$48.00 ,$14.40 ,$43.68 ,$33.60 ,$14.40 ,$31.20 ,$34.56 ,$43.68 ,$36.00 
Carle BroMenn Medical Center,8140054,ELECTRODE LEEP BALL 5MMX12CM,244641,,270,$65.44 ,$65.44 ,$19.63 ,$59.55 ,$45.81 ,$19.63 ,$42.54 ,$47.12 ,$59.55 ,$49.08 
Carle BroMenn Medical Center,8140054,ELECTRODE LOOP LLETZ 15X12,245207,,270,$65.49 ,$65.49 ,$19.65 ,$59.60 ,$45.84 ,$19.65 ,$42.57 ,$47.15 ,$59.60 ,$49.12 
Carle BroMenn Medical Center,8140054,ELECTRODE LOOP LLETZ 20X12,245208,,270,$65.43 ,$65.43 ,$19.63 ,$59.54 ,$45.80 ,$19.63 ,$42.53 ,$47.11 ,$59.54 ,$49.07 
Carle BroMenn Medical Center,8140054,ELECTRODE LOOP LLETZ 20X15,251693,,270,$62.94 ,$62.94 ,$18.88 ,$57.28 ,$44.06 ,$18.88 ,$40.91 ,$45.32 ,$57.28 ,$47.21 
Carle BroMenn Medical Center,8140054,ELECTRODE LOOP SNGL 24F ANGD 6 PE,244516,,270,$404.40 ,$404.40 ,$121.32 ,$368.00 ,$283.08 ,$121.32 ,$262.86 ,$291.17 ,$368.00 ,$303.30 
Carle BroMenn Medical Center,8140054,ELECTRODE LOOP SNGL 27F CONCL,244515,,270,$0.56 ,$0.56 ,$0.17 ,$0.51 ,$0.39 ,$0.17 ,$0.36 ,$0.40 ,$0.51 ,$0.42 
Carle BroMenn Medical Center,8140054,ELECTRODE NDL EZ CLEAN 2.75IN,244947,,270,$10.28 ,$10.28 ,$3.08 ,$9.35 ,$7.20 ,$3.08 ,$6.68 ,$7.40 ,$9.35 ,$7.71 
Carle BroMenn Medical Center,8140054,ELECTRODE NON-REM POLYHESIVE 9 50,244570,,270,$17.37 ,$17.37 ,$5.21 ,$15.81 ,$12.16 ,$5.21 ,$11.29 ,$12.51 ,$15.81 ,$13.03 
Carle BroMenn Medical Center,8140054,ELECTRODE QUIK-COMBO CNCTR 2PK,244094,,270,$80.16 ,$80.16 ,$24.05 ,$72.95 ,$56.11 ,$24.05 ,$52.10 ,$57.72 ,$72.95 ,$60.12 
Carle BroMenn Medical Center,8140054,ELECTRODE ROLLER YLW 24FX3MM,244808,,270,$550.05 ,$550.05 ,$165.02 ,$500.55 ,$385.04 ,$165.02 ,$357.53 ,$396.04 ,$500.55 ,$412.54 
Carle BroMenn Medical Center,8140054,ELECTRODE TUNG LOOP 10X10,244711,,270,$3.18 ,$3.18 ,$0.95 ,$2.89 ,$2.23 ,$0.95 ,$2.07 ,$2.29 ,$2.89 ,$2.39 
Carle BroMenn Medical Center,8140054,ELECTRODE VAPOUR COOLPULSE 90,239556,,270,"$1,029.00 ","$1,029.00 ",$308.70 ,$936.39 ,$720.30 ,$308.70 ,$668.85 ,$740.88 ,$936.39 ,$771.75 
Carle BroMenn Medical Center,8140054,ELECTROSE BLADE 15CM 6IN SINGLE U,244802,,270,$18.24 ,$18.24 ,$5.47 ,$16.60 ,$12.77 ,$5.47 ,$11.86 ,$13.13 ,$16.60 ,$13.68 
Carle BroMenn Medical Center,8140054,ELECTROSE BLADE 20CM 8IN SINGLE U,244807,,270,$0.13 ,$0.13 ,$0.04 ,$0.12 ,$0.09 ,$0.04 ,$0.08 ,$0.09 ,$0.12 ,$0.10 
Carle BroMenn Medical Center,8140054,ENDOBUTTON CL ULTRA PAC 1.2MM,237508,,270,"$1,063.92 ","$1,063.92 ",$319.18 ,$968.17 ,$744.74 ,$319.18 ,$691.55 ,$766.02 ,$968.17 ,$797.94 
Carle BroMenn Medical Center,8140054,EVACUATOR 400CC3/16 PVC TROCAR,245003,,270,$33.75 ,$33.75 ,$10.13 ,$30.71 ,$23.63 ,$10.13 ,$21.94 ,$24.30 ,$30.71 ,$25.31 
Carle BroMenn Medical Center,8140054,EVACUATOR 400CC3/32 PVC TROCAR,245002,,270,$33.75 ,$33.75 ,$10.13 ,$30.71 ,$23.63 ,$10.13 ,$21.94 ,$24.30 ,$30.71 ,$25.31 
Carle BroMenn Medical Center,8140054,EVACUATOR SIL BULB GRENAD100CC,245005,,270,$22.35 ,$22.35 ,$6.71 ,$20.34 ,$15.65 ,$6.71 ,$14.53 ,$16.09 ,$20.34 ,$16.76 
Carle BroMenn Medical Center,8140054,EVACUATOR UROVAC BLADDER,236754,,270,$0.33 ,$0.33 ,$0.10 ,$0.30 ,$0.23 ,$0.10 ,$0.21 ,$0.24 ,$0.30 ,$0.25 
Carle BroMenn Medical Center,8140054,EXTENDER ARGON TIP LAP SHRP 28,244822,,270,$187.62 ,$187.62 ,$56.29 ,$170.73 ,$131.33 ,$56.29 ,$121.95 ,$135.09 ,$170.73 ,$140.72 
Carle BroMenn Medical Center,8140054,EXTENSION GUIDEWIRE DOC 145CM 18I,179197,,270,$255.00 ,$255.00 ,$76.50 ,$232.05 ,$178.50 ,$76.50 ,$165.75 ,$183.60 ,$232.05 ,$191.25 
Carle BroMenn Medical Center,8140054,EXTRACTOR BAL RX 9-12MM ABOVE,247177,,270,$427.86 ,$427.86 ,$128.36 ,$389.35 ,$299.50 ,$128.36 ,$278.11 ,$308.06 ,$389.35 ,$320.90 
Carle BroMenn Medical Center,8140054,FELT PTFE PLED 4.8X9.5MM 250 UNIT,245205,,270,$39.74 ,$39.74 ,$11.92 ,$36.16 ,$27.82 ,$11.92 ,$25.83 ,$28.61 ,$36.16 ,$29.81 
Carle BroMenn Medical Center,8140054,FILTER SEECLEAR XCL PINK,245139,,270,$115.20 ,$115.20 ,$34.56 ,$104.83 ,$80.64 ,$34.56 ,$74.88 ,$82.94 ,$104.83 ,$86.40 
Carle BroMenn Medical Center,8140054,FORCEP GRASP TRPD RETRVL20X2.8,237118,,270,"$1,213.56 ","$1,213.56 ",$364.07 ,"$1,104.34 ",$849.49 ,$364.07 ,$788.81 ,$873.76 ,"$1,104.34 ",$910.17 
Carle BroMenn Medical Center,8140054,FORCEPS 25GA,10455,,270,$343.05 ,$343.05 ,$102.92 ,$312.18 ,$240.14 ,$102.92 ,$222.98 ,$247.00 ,$312.18 ,$257.29 
Carle BroMenn Medical Center,8140054,FORCEPS BIOP 2.4MMX240CM,247178,,270,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8140054,FORCEPS HALO PKS CUT 5MMX33CM,249750,,270,"$2,232.00 ","$2,232.00 ",$669.60 ,"$2,031.12 ","$1,562.40 ",$669.60 ,"$1,450.80 ","$1,607.04 ","$2,031.12 ","$1,674.00 "
Carle BroMenn Medical Center,8140054,FORCEPS LG RDL 240CM NDL 40/BX,247189,,270,$25.22 ,$25.22 ,$7.57 ,$22.95 ,$17.65 ,$7.57 ,$16.39 ,$18.16 ,$22.95 ,$18.92 
Carle BroMenn Medical Center,8140054,FORCEPS MAXGRIP 25 PLUS 27GA BX/6,203408,,270,$358.05 ,$358.05 ,$107.42 ,$325.83 ,$250.64 ,$107.42 ,$232.73 ,$257.80 ,$325.83 ,$268.54 
Carle BroMenn Medical Center,8140054,FORCEPS NON-RET GRASP 3F 120CM,238089,,270,$520.20 ,$520.20 ,$156.06 ,$473.38 ,$364.14 ,$156.06 ,$338.13 ,$374.54 ,$473.38 ,$390.15 
Carle BroMenn Medical Center,8140054,FORCEPS PIRANHA 3F 1X115,236720,,270,$980.25 ,$980.25 ,$294.08 ,$892.03 ,$686.18 ,$294.08 ,$637.16 ,$705.78 ,$892.03 ,$735.19 
Carle BroMenn Medical Center,8140054,FORCEPS PK MOLLY CUT 3MMX33CM,244827,,270,$0.67 ,$0.67 ,$0.20 ,$0.61 ,$0.47 ,$0.20 ,$0.44 ,$0.48 ,$0.61 ,$0.50 
Carle BroMenn Medical Center,8140054,FORCEPS PKS SEAL OPEN CRVD JAW,244789,,270,"$1,525.69 ","$1,525.69 ",$457.71 ,"$1,388.38 ","$1,067.98 ",$457.71 ,$991.70 ,"$1,098.50 ","$1,388.38 ","$1,144.27 "
Carle BroMenn Medical Center,8140054,FORMULA PRO-ADVANCE 2OZ SIMILAC,249742,,270,$3.54 ,$3.54 ,$1.06 ,$3.22 ,$2.48 ,$1.06 ,$2.30 ,$2.55 ,$3.22 ,$2.66 
Carle BroMenn Medical Center,8140054,GAUZE BORDERED 4X10,245157,,270,$2.64 ,$2.64 ,$0.79 ,$2.40 ,$1.85 ,$0.79 ,$1.72 ,$1.90 ,$2.40 ,$1.98 
Carle BroMenn Medical Center,8140054,GAUZE BORDERED STL 6X6IN,244179,,270,$2.32 ,$2.32 ,$0.70 ,$2.11 ,$1.62 ,$0.70 ,$1.51 ,$1.67 ,$2.11 ,$1.74 
Carle BroMenn Medical Center,8140054,GAUZE ROLL KERLIX 4.5IN 100 ROLLS,220,,270,$1.70 ,$1.70 ,$0.51 ,$1.55 ,$1.19 ,$0.51 ,$1.11 ,$1.22 ,$1.55 ,$1.28 
Carle BroMenn Medical Center,8140054,GENERATOR PULSE EXTRL 2 PORT H,239331,,270,$3.33 ,$3.33 ,$1.00 ,$3.03 ,$2.33 ,$1.00 ,$2.16 ,$2.40 ,$3.03 ,$2.50 
Carle BroMenn Medical Center,8140054,GLOVE BIOGEL SUPER-SENS 8,248975,,270,$4.03 ,$4.03 ,$1.21 ,$3.67 ,$2.82 ,$1.21 ,$2.62 ,$2.90 ,$3.67 ,$3.02 
Carle BroMenn Medical Center,8140054,GLOVE BIOGEL SURGL M PF 6.5,244484,,270,$3.93 ,$3.93 ,$1.18 ,$3.58 ,$2.75 ,$1.18 ,$2.55 ,$2.83 ,$3.58 ,$2.95 
Carle BroMenn Medical Center,8140054,GLOVE BIOGEL SURGL M PF 8,247025,,270,$4.03 ,$4.03 ,$1.21 ,$3.67 ,$2.82 ,$1.21 ,$2.62 ,$2.90 ,$3.67 ,$3.02 
Carle BroMenn Medical Center,8140054,GLOVE BIOGEL SZ 7.5,232166,,270,$5.61 ,$5.61 ,$1.68 ,$5.11 ,$3.93 ,$1.68 ,$3.65 ,$4.04 ,$5.11 ,$4.21 
Carle BroMenn Medical Center,8140054,GLOVE EXAM XPROT 7-7.5 ANS,244545,,270,$1.17 ,$1.17 ,$0.35 ,$1.06 ,$0.82 ,$0.35 ,$0.76 ,$0.84 ,$1.06 ,$0.88 
Carle BroMenn Medical Center,8140054,GLOVE PROTEXIS HYDROGEL 6 STL LAT,244187,,270,$2.40 ,$2.40 ,$0.72 ,$2.18 ,$1.68 ,$0.72 ,$1.56 ,$1.73 ,$2.18 ,$1.80 
Carle BroMenn Medical Center,8140054,GLOVE PROTEXIS HYDROGEL 7 STL LAT,244189,,270,$2.40 ,$2.40 ,$0.72 ,$2.18 ,$1.68 ,$0.72 ,$1.56 ,$1.73 ,$2.18 ,$1.80 
Carle BroMenn Medical Center,8140054,GLOVE PROTEXIS HYDROGEL 8 STL LAT,244020,,270,$2.40 ,$2.40 ,$0.72 ,$2.18 ,$1.68 ,$0.72 ,$1.56 ,$1.73 ,$2.18 ,$1.80 
Carle BroMenn Medical Center,8140054,GLOVE PROTEXIS HYDROGEL 9 STL LAT,245018,,270,$2.51 ,$2.51 ,$0.75 ,$2.28 ,$1.76 ,$0.75 ,$1.63 ,$1.81 ,$2.28 ,$1.88 
Carle BroMenn Medical Center,8140054,GLOVE PROTEXIS HYDROGEL5.5 STL LA,245017,,270,$2.58 ,$2.58 ,$0.77 ,$2.35 ,$1.81 ,$0.77 ,$1.68 ,$1.86 ,$2.35 ,$1.94 
Carle BroMenn Medical Center,8140054,GLOVE PROTEXIS HYDROGEL6.5 STL LA,244188,,270,$2.51 ,$2.51 ,$0.75 ,$2.28 ,$1.76 ,$0.75 ,$1.63 ,$1.81 ,$2.28 ,$1.88 
Carle BroMenn Medical Center,8140054,GLOVE PROTEXIS HYDROGEL7.5 STL LA,244190,,270,$2.40 ,$2.40 ,$0.72 ,$2.18 ,$1.68 ,$0.72 ,$1.56 ,$1.73 ,$2.18 ,$1.80 
Carle BroMenn Medical Center,8140054,GLOVE PROTEXIS HYDROGEL8.5 STL LA,244021,,270,$2.51 ,$2.51 ,$0.75 ,$2.28 ,$1.76 ,$0.75 ,$1.63 ,$1.81 ,$2.28 ,$1.88 
Carle BroMenn Medical Center,8140054,GLOVE PROTEXIS MICRO STL SZ6.5 LA,245021,,270,$2.33 ,$2.33 ,$0.70 ,$2.12 ,$1.63 ,$0.70 ,$1.51 ,$1.68 ,$2.12 ,$1.75 
Carle BroMenn Medical Center,8140054,GLOVE PROTEXIS MICRO STL SZ7.5 LA,245022,,270,$2.33 ,$2.33 ,$0.70 ,$2.12 ,$1.63 ,$0.70 ,$1.51 ,$1.68 ,$2.12 ,$1.75 
Carle BroMenn Medical Center,8140054,GLOVE PROTEXIS MICRO STL SZ8.5 LA,245024,,270,$2.33 ,$2.33 ,$0.70 ,$2.12 ,$1.63 ,$0.70 ,$1.51 ,$1.68 ,$2.12 ,$1.75 
Carle BroMenn Medical Center,8140054,GLOVE PROTEXIS MICRO STRL SZ 6 LA,245020,,270,$2.33 ,$2.33 ,$0.70 ,$2.12 ,$1.63 ,$0.70 ,$1.51 ,$1.68 ,$2.12 ,$1.75 
Carle BroMenn Medical Center,8140054,GLOVE PROTEXIS MICRO STRL SZ 7 LA,244395,,270,$2.27 ,$2.27 ,$0.68 ,$2.07 ,$1.59 ,$0.68 ,$1.48 ,$1.63 ,$2.07 ,$1.70 
Carle BroMenn Medical Center,8140054,GLOVE PROTEXIS MICRO STRL SZ 8 LA,245023,,270,$2.33 ,$2.33 ,$0.70 ,$2.12 ,$1.63 ,$0.70 ,$1.51 ,$1.68 ,$2.12 ,$1.75 
Carle BroMenn Medical Center,8140054,GLOVE PROTEXIS NEOPRN PF SZ 6,245008,,270,$3.49 ,$3.49 ,$1.05 ,$3.18 ,$2.44 ,$1.05 ,$2.27 ,$2.51 ,$3.18 ,$2.62 
Carle BroMenn Medical Center,8140054,GLOVE PROTEXIS NEOPRN PF SZ 7 50,245009,,270,$3.49 ,$3.49 ,$1.05 ,$3.18 ,$2.44 ,$1.05 ,$2.27 ,$2.51 ,$3.18 ,$2.62 
Carle BroMenn Medical Center,8140054,GLOVE PROTEXIS NEOPRN PF SZ 8 200,244166,,270,$3.27 ,$3.27 ,$0.98 ,$2.98 ,$2.29 ,$0.98 ,$2.13 ,$2.35 ,$2.98 ,$2.45 
Carle BroMenn Medical Center,8140054,GLOVE PROTEXIS NEOPRN PF SZ 9,245190,,270,$3.41 ,$3.41 ,$1.02 ,$3.10 ,$2.39 ,$1.02 ,$2.22 ,$2.46 ,$3.10 ,$2.56 
Carle BroMenn Medical Center,8140054,GLOVE PROTEXIS NEOPRN PF SZ6.5,244184,,270,$3.49 ,$3.49 ,$1.05 ,$3.18 ,$2.44 ,$1.05 ,$2.27 ,$2.51 ,$3.18 ,$2.62 
Carle BroMenn Medical Center,8140054,GLOVE PROTEXIS NEOPRN PF SZ7.5,244185,,270,$3.27 ,$3.27 ,$0.98 ,$2.98 ,$2.29 ,$0.98 ,$2.13 ,$2.35 ,$2.98 ,$2.45 
Carle BroMenn Medical Center,8140054,GLOVE PROTEXIS NEOPRN PF SZ8.5,245027,,270,$3.49 ,$3.49 ,$1.05 ,$3.18 ,$2.44 ,$1.05 ,$2.27 ,$2.51 ,$3.18 ,$2.62 
Carle BroMenn Medical Center,8140054,GLOVE PROTEXIS PI LF  9,244397,,270,$4.09 ,$4.09 ,$1.23 ,$3.72 ,$2.86 ,$1.23 ,$2.66 ,$2.94 ,$3.72 ,$3.07 
Carle BroMenn Medical Center,8140054,GLOVE PROTEXIS PI LF 6,244396,,270,$4.19 ,$4.19 ,$1.26 ,$3.81 ,$2.93 ,$1.26 ,$2.72 ,$3.02 ,$3.81 ,$3.14 
Carle BroMenn Medical Center,8140054,GLOVE PROTEXIS PI LF 6.5,244118,,270,$3.93 ,$3.93 ,$1.18 ,$3.58 ,$2.75 ,$1.18 ,$2.55 ,$2.83 ,$3.58 ,$2.95 
Carle BroMenn Medical Center,8140054,GLOVE PROTEXIS PI LF 7,244252,,270,$4.19 ,$4.19 ,$1.26 ,$3.81 ,$2.93 ,$1.26 ,$2.72 ,$3.02 ,$3.81 ,$3.14 
Carle BroMenn Medical Center,8140054,GLOVE PROTEXIS PI LF 7.5,244119,,270,$3.93 ,$3.93 ,$1.18 ,$3.58 ,$2.75 ,$1.18 ,$2.55 ,$2.83 ,$3.58 ,$2.95 
Carle BroMenn Medical Center,8140054,GLOVE PROTEXIS PI LF 8,244120,,270,$3.93 ,$3.93 ,$1.18 ,$3.58 ,$2.75 ,$1.18 ,$2.55 ,$2.83 ,$3.58 ,$2.95 
Carle BroMenn Medical Center,8140054,GLOVE PROTEXIS PI LF 8.5,244253,,270,$4.19 ,$4.19 ,$1.26 ,$3.81 ,$2.93 ,$1.26 ,$2.72 ,$3.02 ,$3.81 ,$3.14 
Carle BroMenn Medical Center,8140054,GLOVE PROTEXIS PI SZ 6 BLUE NEU-T,244527,,270,$3.59 ,$3.59 ,$1.08 ,$3.27 ,$2.51 ,$1.08 ,$2.33 ,$2.58 ,$3.27 ,$2.69 
Carle BroMenn Medical Center,8140054,GLOVE PROTEXIS PI SZ 6.5 BLUE NEU,245240,,270,$3.36 ,$3.36 ,$1.01 ,$3.06 ,$2.35 ,$1.01 ,$2.18 ,$2.42 ,$3.06 ,$2.52 
Carle BroMenn Medical Center,8140054,GLOVE PROTEXIS PI SZ 7.0 BLUE,245248,,270,$3.36 ,$3.36 ,$1.01 ,$3.06 ,$2.35 ,$1.01 ,$2.18 ,$2.42 ,$3.06 ,$2.52 
Carle BroMenn Medical Center,8140054,GLOVE PROTEXIS PI SZ 7.5 BLUE NEU,244528,,270,$3.50 ,$3.50 ,$1.05 ,$3.19 ,$2.45 ,$1.05 ,$2.28 ,$2.52 ,$3.19 ,$2.63 
Carle BroMenn Medical Center,8140054,GLOVE PROTEXIS PI SZ 8 BLUE NEU-T,244766,,270,$3.36 ,$3.36 ,$1.01 ,$3.06 ,$2.35 ,$1.01 ,$2.18 ,$2.42 ,$3.06 ,$2.52 
Carle BroMenn Medical Center,8140054,GLOVE PROTEXIS PI SZ 8.5 BLUE NEU,244529,,270,$3.50 ,$3.50 ,$1.05 ,$3.19 ,$2.45 ,$1.05 ,$2.28 ,$2.52 ,$3.19 ,$2.63 
Carle BroMenn Medical Center,8140054,GLOVE PROTEXIS PI SZ 9 BLUE NEU-T,244770,,270,$3.36 ,$3.36 ,$1.01 ,$3.06 ,$2.35 ,$1.01 ,$2.18 ,$2.42 ,$3.06 ,$2.52 
Carle BroMenn Medical Center,8140054,GLOVE SENSICARE LTX PF 7.5,244778,,270,$101.79 ,$101.79 ,$30.54 ,$92.63 ,$71.25 ,$30.54 ,$66.16 ,$73.29 ,$92.63 ,$76.34 
Carle BroMenn Medical Center,8140054,GLOVE SENSICARE LTX PF 8 RADION-X,245214,,270,$101.79 ,$101.79 ,$30.54 ,$92.63 ,$71.25 ,$30.54 ,$66.16 ,$73.29 ,$92.63 ,$76.34 
Carle BroMenn Medical Center,8140054,GLOVE SURG SYN STL LF 7.5 GAMMEX,244853,,270,$3.96 ,$3.96 ,$1.19 ,$3.60 ,$2.77 ,$1.19 ,$2.57 ,$2.85 ,$3.60 ,$2.97 
Carle BroMenn Medical Center,8140054,GLOVE SURG TRIUMPH LTX 7,248978,,270,$0.85 ,$0.85 ,$0.26 ,$0.77 ,$0.60 ,$0.26 ,$0.55 ,$0.61 ,$0.77 ,$0.64 
Carle BroMenn Medical Center,8140054,GLOVE SURG TRIUMPH LTX 7.5,244030,,270,$2.10 ,$2.10 ,$0.63 ,$1.91 ,$1.47 ,$0.63 ,$1.37 ,$1.51 ,$1.91 ,$1.58 
Carle BroMenn Medical Center,8140054,GLOVE ULTRAFREE MAX SIZE  9 PROTE,251518,,270,$3.06 ,$3.06 ,$0.92 ,$2.78 ,$2.14 ,$0.92 ,$1.99 ,$2.20 ,$2.78 ,$2.30 
Carle BroMenn Medical Center,8140054,GLOVE ULTRAFREE MAX SIZE 6.5 PROT,245081,,270,$3.06 ,$3.06 ,$0.92 ,$2.78 ,$2.14 ,$0.92 ,$1.99 ,$2.20 ,$2.78 ,$2.30 
Carle BroMenn Medical Center,8140054,GLOVE ULTRAFREE MAX SIZE 7 PROTEX,245082,,270,$3.06 ,$3.06 ,$0.92 ,$2.78 ,$2.14 ,$0.92 ,$1.99 ,$2.20 ,$2.78 ,$2.30 
Carle BroMenn Medical Center,8140054,GLOVE ULTRAFREE MAX SIZE 7.5 PROT,245083,,270,$3.06 ,$3.06 ,$0.92 ,$2.78 ,$2.14 ,$0.92 ,$1.99 ,$2.20 ,$2.78 ,$2.30 
Carle BroMenn Medical Center,8140054,GLOVE ULTRAFREE MAX SIZE 8 PROTEX,244402,,270,$3.06 ,$3.06 ,$0.92 ,$2.78 ,$2.14 ,$0.92 ,$1.99 ,$2.20 ,$2.78 ,$2.30 
Carle BroMenn Medical Center,8140054,GLOVE ULTRAFREE MAX SIZE 8.5 PROT,245084,,270,$3.06 ,$3.06 ,$0.92 ,$2.78 ,$2.14 ,$0.92 ,$1.99 ,$2.20 ,$2.78 ,$2.30 
Carle BroMenn Medical Center,8140054,GOWN ASTOUND XL AAMI 3,206,,270,$5.48 ,$5.48 ,$1.64 ,$4.99 ,$3.84 ,$1.64 ,$3.56 ,$3.95 ,$4.99 ,$4.11 
Carle BroMenn Medical Center,8140054,GOWN IMPRV BLU W/THUMB HK UNIV PE,244948,,270,$2.96 ,$2.96 ,$0.89 ,$2.69 ,$2.07 ,$0.89 ,$1.92 ,$2.13 ,$2.69 ,$2.22 
Carle BroMenn Medical Center,8140054,GOWN SMART XL XL,244153,,270,$10.49 ,$10.49 ,$3.15 ,$9.55 ,$7.34 ,$3.15 ,$6.82 ,$7.55 ,$9.55 ,$7.87 
Carle BroMenn Medical Center,8140054,GOWN SMARTGOWN LG AAMI 4 RAGLAN,244211,,270,$9.71 ,$9.71 ,$2.91 ,$8.84 ,$6.80 ,$2.91 ,$6.31 ,$6.99 ,$8.84 ,$7.28 
Carle BroMenn Medical Center,8140054,GOWN SMARTGOWN XL XLONG AAMI 4,244378,,270,$11.99 ,$11.99 ,$3.60 ,$10.91 ,$8.39 ,$3.60 ,$7.79 ,$8.63 ,$10.91 ,$8.99 
Carle BroMenn Medical Center,8140054,GOWN SMARTGOWN XXXL AAMI 4,244404,,270,$16.95 ,$16.95 ,$5.09 ,$15.42 ,$11.87 ,$5.09 ,$11.02 ,$12.20 ,$15.42 ,$12.71 
Carle BroMenn Medical Center,8140054,GOWN SURG FABRIC REINF LG,244938,,270,$5.80 ,$5.80 ,$1.74 ,$5.28 ,$4.06 ,$1.74 ,$3.77 ,$4.18 ,$5.28 ,$4.35 
Carle BroMenn Medical Center,8140054,GOWN SURG L DISP REINF XL STL,244935,,270,$6.25 ,$6.25 ,$1.88 ,$5.69 ,$4.38 ,$1.88 ,$4.06 ,$4.50 ,$5.69 ,$4.69 
Carle BroMenn Medical Center,8140054,GRASPER BABCOCK 5MM,244501,,270,$159.00 ,$159.00 ,$47.70 ,$144.69 ,$111.30 ,$47.70 ,$103.35 ,$114.48 ,$144.69 ,$119.25 
Carle BroMenn Medical Center,8140054,GRASPER BABCOCK W/HANDLE,244620,,270,$166.25 ,$166.25 ,$49.88 ,$151.29 ,$116.38 ,$49.88 ,$108.06 ,$119.70 ,$151.29 ,$124.69 
Carle BroMenn Medical Center,8140054,GRASPER MINILAP ALG PERCU 2.3,245136,,270,$600.00 ,$600.00 ,$180.00 ,$546.00 ,$420.00 ,$180.00 ,$390.00 ,$432.00 ,$546.00 ,$450.00 
Carle BroMenn Medical Center,8140054,GRID BIOPSY ACCU GRID 4.65IN,234404,,270,$59.94 ,$59.94 ,$17.98 ,$54.55 ,$41.96 ,$17.98 ,$38.96 ,$43.16 ,$54.55 ,$44.96 
Carle BroMenn Medical Center,8140054,GUIDE ACCURA LOCATOR,250860,,270,$20.00 ,$20.00 ,$6.00 ,$18.20 ,$14.00 ,$6.00 ,$13.00 ,$14.40 ,$18.20 ,$15.00 
Carle BroMenn Medical Center,8140054,GUIDE SET TRUMATCH RESECT LT,240016,,270,"$3,000.00 ","$3,000.00 ",$900.00 ,"$2,730.00 ","$2,100.00 ",$900.00 ,"$1,950.00 ","$2,160.00 ","$2,730.00 ","$2,250.00 "
Carle BroMenn Medical Center,8140054,GUIDE SET TRUMATCH RESECT RT,239966,,270,"$3,000.00 ","$3,000.00 ",$900.00 ,"$2,730.00 ","$2,100.00 ",$900.00 ,"$1,950.00 ","$2,160.00 ","$2,730.00 ","$2,250.00 "
Carle BroMenn Medical Center,8140054,GUIDE TRUMATCH SHLDR APG,247868,,270,"$2,850.00 ","$2,850.00 ",$855.00 ,"$2,593.50 ","$1,995.00 ",$855.00 ,"$1,852.50 ","$2,052.00 ","$2,593.50 ","$2,137.50 "
Carle BroMenn Medical Center,8140054,GUIDE WIRE 3.2MM 400MM,6293,,270,$216.60 ,$216.60 ,$64.98 ,$197.11 ,$151.62 ,$64.98 ,$140.79 ,$155.95 ,$197.11 ,$162.45 
Carle BroMenn Medical Center,8140054,GUIDEPIN METAGLENE DIA 2.5MM,10671,,270,$207.00 ,$207.00 ,$62.10 ,$188.37 ,$144.90 ,$62.10 ,$134.55 ,$149.04 ,$188.37 ,$155.25 
Carle BroMenn Medical Center,8140054,GUIDEPIN PARTIAL 1.6MMX6IN,233446,,270,$247.20 ,$247.20 ,$74.16 ,$224.95 ,$173.04 ,$74.16 ,$160.68 ,$177.98 ,$224.95 ,$185.40 
Carle BroMenn Medical Center,8140054,GUIDEPIN PTHR TROC 3.2MMX9IN MAGN,236904,,270,$49.44 ,$49.44 ,$14.83 ,$44.99 ,$34.61 ,$14.83 ,$32.14 ,$35.60 ,$44.99 ,$37.08 
Carle BroMenn Medical Center,8140054,GUIDEPIN SMOOTH 1.6MMX6IN,233445,,270,$162.18 ,$162.18 ,$48.65 ,$147.58 ,$113.53 ,$48.65 ,$105.42 ,$116.77 ,$147.58 ,$121.64 
Carle BroMenn Medical Center,8140054,GUIDEPIN THR 3.2X508MM,237187,,270,$355.98 ,$355.98 ,$106.79 ,$323.94 ,$249.19 ,$106.79 ,$231.39 ,$256.31 ,$323.94 ,$266.99 
Carle BroMenn Medical Center,8140054,GUIDEPIN TROC PTHR 3.2MMX12IN MAG,237009,,270,$247.20 ,$247.20 ,$74.16 ,$224.95 ,$173.04 ,$74.16 ,$160.68 ,$177.98 ,$224.95 ,$185.40 
Carle BroMenn Medical Center,8140054,GUIDEROD 3.0 X 1000 BALL TIP 7163,5000,,270,$908.82 ,$908.82 ,$272.65 ,$827.03 ,$636.17 ,$272.65 ,$590.73 ,$654.35 ,$827.03 ,$681.62 
Carle BroMenn Medical Center,8140054,GUIDEWIRE AMPLATZ STF .038 STR,236863,,270,$76.36 ,$76.36 ,$22.91 ,$69.49 ,$53.45 ,$22.91 ,$49.63 ,$54.98 ,$69.49 ,$57.27 
Carle BroMenn Medical Center,8140054,GUIDEWIRE AMPLATZ XTRSTF 260 3MM,177352,,270,$84.54 ,$84.54 ,$25.36 ,$76.93 ,$59.18 ,$25.36 ,$54.95 ,$60.87 ,$76.93 ,$63.41 
Carle BroMenn Medical Center,8140054,GUIDEWIRE BALL NOSE 3MMX100CM,237440,,270,$396.00 ,$396.00 ,$118.80 ,$360.36 ,$277.20 ,$118.80 ,$257.40 ,$285.12 ,$360.36 ,$297.00 
Carle BroMenn Medical Center,8140054,GUIDEWIRE BULLETT TIP 3.0MM,247393,,270,$336.21 ,$336.21 ,$100.86 ,$305.95 ,$235.35 ,$100.86 ,$218.54 ,$242.07 ,$305.95 ,$252.16 
Carle BroMenn Medical Center,8140054,GUIDEWIRE IRONMAN 3CMX14INX190,179504,,270,$240.00 ,$240.00 ,$72.00 ,$218.40 ,$168.00 ,$72.00 ,$156.00 ,$172.80 ,$218.40 ,$180.00 
Carle BroMenn Medical Center,8140054,GUIDEWIRE LUNDERQUIST XTRA STF,3797,,270,$469.06 ,$469.06 ,$140.72 ,$426.84 ,$328.34 ,$140.72 ,$304.89 ,$337.72 ,$426.84 ,$351.80 
Carle BroMenn Medical Center,8140054,GUIDEWIRE MOVE J .035X150CM PTFE,236751,,270,$52.47 ,$52.47 ,$15.74 ,$47.75 ,$36.73 ,$15.74 ,$34.11 ,$37.78 ,$47.75 ,$39.35 
Carle BroMenn Medical Center,8140054,GUIDEWIRE MOVE STR 0.035X150CM PT,236831,,270,$40.53 ,$40.53 ,$12.16 ,$36.88 ,$28.37 ,$12.16 ,$26.34 ,$29.18 ,$36.88 ,$30.40 
Carle BroMenn Medical Center,8140054,GUIDEWIRE ORTH 3MM 800MM BALL TIP,243013,,270,$452.58 ,$452.58 ,$135.77 ,$411.85 ,$316.81 ,$135.77 ,$294.18 ,$325.86 ,$411.85 ,$339.44 
Carle BroMenn Medical Center,8140054,GUIDEWIRE POLARUS SS .059X5IN,249297,,270,$48.00 ,$48.00 ,$14.40 ,$43.68 ,$33.60 ,$14.40 ,$31.20 ,$34.56 ,$43.68 ,$36.00 
Carle BroMenn Medical Center,8140054,GUIDEWIRE SENSOR STR .035 150 PTF,237067,,270,$121.70 ,$121.70 ,$36.51 ,$110.75 ,$85.19 ,$36.51 ,$79.11 ,$87.62 ,$110.75 ,$91.28 
Carle BroMenn Medical Center,8140054,GUIDEWIRE SINUS RELIEVA VIGOR INC,4026,,270,"$1,287.00 ","$1,287.00 ",$386.10 ,"$1,171.17 ",$900.90 ,$386.10 ,$836.55 ,$926.64 ,"$1,171.17 ",$965.25 
Carle BroMenn Medical Center,8140054,GUIDEWIRE SS .062X9IN,4269,,270,$78.00 ,$78.00 ,$23.40 ,$70.98 ,$54.60 ,$23.40 ,$50.70 ,$56.16 ,$70.98 ,$58.50 
Carle BroMenn Medical Center,8140054,GUIDEWIRE STORQ STR .035X180CM,236787,,270,$0.67 ,$0.67 ,$0.20 ,$0.61 ,$0.47 ,$0.20 ,$0.44 ,$0.48 ,$0.61 ,$0.50 
Carle BroMenn Medical Center,8140054,GUIDEWIRE STORQ STR .035X300CM,236788,,270,$198.00 ,$198.00 ,$59.40 ,$180.18 ,$138.60 ,$59.40 ,$128.70 ,$142.56 ,$180.18 ,$148.50 
Carle BroMenn Medical Center,8140054,GUIDEWIRE T2 SMTH TIP 3X800,243016,,270,$618.75 ,$618.75 ,$185.63 ,$563.06 ,$433.13 ,$185.63 ,$402.19 ,$445.50 ,$563.06 ,$464.06 
Carle BroMenn Medical Center,8140054,GUIDEWIRE THREAD TRCR 2.8X300,12341,,270,$103.20 ,$103.20 ,$30.96 ,$93.91 ,$72.24 ,$30.96 ,$67.08 ,$74.30 ,$93.91 ,$77.40 
Carle BroMenn Medical Center,8140054,GUIDEWIRE THREADED 1.9MM,247117,,270,$90.00 ,$90.00 ,$27.00 ,$81.90 ,$63.00 ,$27.00 ,$58.50 ,$64.80 ,$81.90 ,$67.50 
Carle BroMenn Medical Center,8140054,GUIDEWIRE UNTHREADED +1.4X150,243583,,270,$379.62 ,$379.62 ,$113.89 ,$345.45 ,$265.73 ,$113.89 ,$246.75 ,$273.33 ,$345.45 ,$284.72 
Carle BroMenn Medical Center,8140054,GUIDEWIRE UNTHREADED +3.2X230,247610,,270,$148.50 ,$148.50 ,$44.55 ,$135.14 ,$103.95 ,$44.55 ,$96.53 ,$106.92 ,$135.14 ,$111.38 
Carle BroMenn Medical Center,8140054,GUIDEWIRE ZIP HDS ANG .035X150,238264,,270,$109.76 ,$109.76 ,$32.93 ,$99.88 ,$76.83 ,$32.93 ,$71.34 ,$79.03 ,$99.88 ,$82.32 
Carle BroMenn Medical Center,8140054,GUIDEWIRE ZIP HDS STR .035X150 5/,195710,,270,$189.24 ,$189.24 ,$56.77 ,$172.21 ,$132.47 ,$56.77 ,$123.01 ,$136.25 ,$172.21 ,$141.93 
Carle BroMenn Medical Center,8140054,GUIDEWIRE ZIP STF STR .035X150,238265,,270,$159.88 ,$159.88 ,$47.96 ,$145.49 ,$111.92 ,$47.96 ,$103.92 ,$115.11 ,$145.49 ,$119.91 
Carle BroMenn Medical Center,8140054,HANDLE BLE 20GA,244852,,270,$0.56 ,$0.56 ,$0.17 ,$0.51 ,$0.39 ,$0.17 ,$0.36 ,$0.40 ,$0.51 ,$0.42 
Carle BroMenn Medical Center,8140054,HANDPIECE W/COAXIAL BONE INTERPUL,244841,,270,$89.93 ,$89.93 ,$26.98 ,$81.84 ,$62.95 ,$26.98 ,$58.45 ,$64.75 ,$81.84 ,$67.45 
Carle BroMenn Medical Center,8140054,HANDSET ARGON PLUS,244717,,270,$250.40 ,$250.40 ,$75.12 ,$227.86 ,$175.28 ,$75.12 ,$162.76 ,$180.29 ,$227.86 ,$187.80 
Carle BroMenn Medical Center,8140054,HEAD FEM OXINIUM 12/14 32MM -3,236983,,270,$3.33 ,$3.33 ,$1.00 ,$3.03 ,$2.33 ,$1.00 ,$2.16 ,$2.40 ,$3.03 ,$2.50 
Carle BroMenn Medical Center,8140054,HEMOSTATIC INTERCEED 4X3IN use #3,1580,,270,$811.44 ,$811.44 ,$243.43 ,$738.41 ,$568.01 ,$243.43 ,$527.44 ,$584.24 ,$738.41 ,$608.58 
Carle BroMenn Medical Center,8140054,HOLDER LIMB ADJ ADLT 48,249743,,270,$9.81 ,$9.81 ,$2.94 ,$8.93 ,$6.87 ,$2.94 ,$6.38 ,$7.06 ,$8.93 ,$7.36 
Carle BroMenn Medical Center,8140054,HOLDER TRACH TUBE MEDC ADLT,244197,,270,$8.94 ,$8.94 ,$2.68 ,$8.14 ,$6.26 ,$2.68 ,$5.81 ,$6.44 ,$8.14 ,$6.71 
Carle BroMenn Medical Center,8140054,HOLDER TUBE,244887,,270,$1.24 ,$1.24 ,$0.37 ,$1.13 ,$0.87 ,$0.37 ,$0.81 ,$0.89 ,$1.13 ,$0.93 
Carle BroMenn Medical Center,8140054,HOOD FLYTE STERI-SHEILD,245187,,270,$71.73 ,$71.73 ,$21.52 ,$65.27 ,$50.21 ,$21.52 ,$46.62 ,$51.65 ,$65.27 ,$53.80 
Carle BroMenn Medical Center,8140054,HOOD STERI-SHIELD T-4 36/PK,244574,,270,$71.74 ,$71.74 ,$21.52 ,$65.28 ,$50.22 ,$21.52 ,$46.63 ,$51.65 ,$65.28 ,$53.81 
Carle BroMenn Medical Center,8140054,IMMOBILIZER CANVAS KNEE BLU LG,244663,,270,$62.79 ,$62.79 ,$18.84 ,$57.14 ,$43.95 ,$18.84 ,$40.81 ,$45.21 ,$57.14 ,$47.09 
Carle BroMenn Medical Center,8140054,IMMOBILIZER CANVAS KNEE BLU MD,244888,,270,$62.79 ,$62.79 ,$18.84 ,$57.14 ,$43.95 ,$18.84 ,$40.81 ,$45.21 ,$57.14 ,$47.09 
Carle BroMenn Medical Center,8140054,IMMOBILIZER CANVAS KNEE BLU SM,245241,,270,$62.79 ,$62.79 ,$18.84 ,$57.14 ,$43.95 ,$18.84 ,$40.81 ,$45.21 ,$57.14 ,$47.09 
Carle BroMenn Medical Center,8140054,IMMOBILIZER KNEE CANVAS XL,244629,,270,$62.79 ,$62.79 ,$18.84 ,$57.14 ,$43.95 ,$18.84 ,$40.81 ,$45.21 ,$57.14 ,$47.09 
Carle BroMenn Medical Center,8140054,IMMOBILIZER SHLDR ELAS LG,244132,,270,$17.43 ,$17.43 ,$5.23 ,$15.86 ,$12.20 ,$5.23 ,$11.33 ,$12.55 ,$15.86 ,$13.07 
Carle BroMenn Medical Center,8140054,IMMOBILIZER SHLDR ELAS MD,244146,,270,$18.90 ,$18.90 ,$5.67 ,$17.20 ,$13.23 ,$5.67 ,$12.29 ,$13.61 ,$17.20 ,$14.18 
Carle BroMenn Medical Center,8140054,IMMOBILIZER SHLDR ELAS SM,244624,,270,$17.43 ,$17.43 ,$5.23 ,$15.86 ,$12.20 ,$5.23 ,$11.33 ,$12.55 ,$15.86 ,$13.07 
Carle BroMenn Medical Center,8140054,IMMOBILIZER SHLDR ELAS XL,244147,,270,$18.90 ,$18.90 ,$5.67 ,$17.20 ,$13.23 ,$5.67 ,$12.29 ,$13.61 ,$17.20 ,$14.18 
Carle BroMenn Medical Center,8140054,INFLATOR ENCORE 26 UROL SNGL,237283,,270,$98.94 ,$98.94 ,$29.68 ,$90.04 ,$69.26 ,$29.68 ,$64.31 ,$71.24 ,$90.04 ,$74.21 
Carle BroMenn Medical Center,8140054,INJECTOR UTER HUMI,244594,,270,$148.59 ,$148.59 ,$44.58 ,$135.22 ,$104.01 ,$44.58 ,$96.58 ,$106.98 ,$135.22 ,$111.44 
Carle BroMenn Medical Center,8140054,INSERT SOFT/SOFT 30MM,244762,,270,$34.50 ,$34.50 ,$10.35 ,$31.40 ,$24.15 ,$10.35 ,$22.43 ,$24.84 ,$31.40 ,$25.88 
Carle BroMenn Medical Center,8140054,INSERT SUTURE FOR RETRACTOR,2646,,270,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8140054,INSTR PIN THR,237570,,270,$771.00 ,$771.00 ,$231.30 ,$701.61 ,$539.70 ,$231.30 ,$501.15 ,$555.12 ,$701.61 ,$578.25 
Carle BroMenn Medical Center,8140054,INSTR PIN THR HIGH PERFORMANCE ST,237111,,270,$771.00 ,$771.00 ,$231.30 ,$701.61 ,$539.70 ,$231.30 ,$501.15 ,$555.12 ,$701.61 ,$578.25 
Carle BroMenn Medical Center,8140054,INTRD CHKFL 16P-38-35-RB,244533,,270,$383.97 ,$383.97 ,$115.19 ,$349.41 ,$268.78 ,$115.19 ,$249.58 ,$276.46 ,$349.41 ,$287.98 
Carle BroMenn Medical Center,8140054,INTRODUCER SHEATH 18FR 30CM,3554,,270,$374.61 ,$374.61 ,$112.38 ,$340.90 ,$262.23 ,$112.38 ,$243.50 ,$269.72 ,$340.90 ,$280.96 
Carle BroMenn Medical Center,8140054,IODINE SCRUB PROVIDONE 4OZ LF,244183,,270,$1.74 ,$1.74 ,$0.52 ,$1.58 ,$1.22 ,$0.52 ,$1.13 ,$1.25 ,$1.58 ,$1.31 
Carle BroMenn Medical Center,8140054,IRRIGATOR HYDRO-SURG W/TIP,244945,,270,$266.90 ,$266.90 ,$80.07 ,$242.88 ,$186.83 ,$80.07 ,$173.49 ,$192.17 ,$242.88 ,$200.18 
Carle BroMenn Medical Center,8140054,IRRISEPT 450ML CA/12,223785,,270,$181.80 ,$181.80 ,$54.54 ,$165.44 ,$127.26 ,$54.54 ,$118.17 ,$130.90 ,$165.44 ,$136.35 
Carle BroMenn Medical Center,8140054,JELLY SURGILUBE FLIP 56.75GR,244213,,270,$4.99 ,$4.99 ,$1.50 ,$4.54 ,$3.49 ,$1.50 ,$3.24 ,$3.59 ,$4.54 ,$3.74 
Carle BroMenn Medical Center,8140054,JELLY SURGILUBE FOIL PK 3GR,249739,,270,$0.31 ,$0.31 ,$0.09 ,$0.28 ,$0.22 ,$0.09 ,$0.20 ,$0.22 ,$0.28 ,$0.23 
Carle BroMenn Medical Center,8140054,KIT 25GA ENTRY SYSTEM,4370,,270,$318.75 ,$318.75 ,$95.63 ,$290.06 ,$223.13 ,$95.63 ,$207.19 ,$229.50 ,$290.06 ,$239.06 
Carle BroMenn Medical Center,8140054,KIT ABG 3CC LL,244150,,270,$0.71 ,$0.71 ,$0.21 ,$0.65 ,$0.50 ,$0.21 ,$0.46 ,$0.51 ,$0.65 ,$0.53 
Carle BroMenn Medical Center,8140054,KIT ANTIFOG ENDOMATE,248532,,270,$4.26 ,$4.26 ,$1.28 ,$3.88 ,$2.98 ,$1.28 ,$2.77 ,$3.07 ,$3.88 ,$3.20 
Carle BroMenn Medical Center,8140054,KIT AXIUM TRIAL LEAD 5MMX50CM SLI,238977,,270,"$6,595.95 ","$6,595.95 ","$1,978.79 ","$6,002.31 ","$4,617.17 ","$1,978.79 ","$4,287.37 ","$4,749.08 ","$6,002.31 ","$4,946.96 "
Carle BroMenn Medical Center,8140054,KIT BEAD RESORB 3.5/4.5MM 10GR RA,240836,,270,"$2,550.00 ","$2,550.00 ",$765.00 ,"$2,320.50 ","$1,785.00 ",$765.00 ,"$1,657.50 ","$1,836.00 ","$2,320.50 ","$1,912.50 "
Carle BroMenn Medical Center,8140054,KIT BIO-TENODESIS DISP STL 5PK,236894,,270,$585.00 ,$585.00 ,$175.50 ,$532.35 ,$409.50 ,$175.50 ,$380.25 ,$421.20 ,$532.35 ,$438.75 
Carle BroMenn Medical Center,8140054,KIT CEMENT MIXING SMART MIX,235,,270,$261.41 ,$261.41 ,$78.42 ,$237.88 ,$182.99 ,$78.42 ,$169.92 ,$188.22 ,$237.88 ,$196.06 
Carle BroMenn Medical Center,8140054,KIT CLEARVIEW BLOWER MISTER,223649,,270,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8140054,KIT CLOSURE WND 5MM & 10/12MM ORD,244722,,270,$579.96 ,$579.96 ,$173.99 ,$527.76 ,$405.97 ,$173.99 ,$376.97 ,$417.57 ,$527.76 ,$434.97 
Carle BroMenn Medical Center,8140054,KIT CVC QL PRES INJ 8.5FX8IN,244972,,270,$394.46 ,$394.46 ,$118.34 ,$358.96 ,$276.12 ,$118.34 ,$256.40 ,$284.01 ,$358.96 ,$295.85 
Carle BroMenn Medical Center,8140054,KIT CVC RPAQUE 8.5FR 18 ARROWG+AR,249740,,270,$376.82 ,$376.82 ,$113.05 ,$342.91 ,$263.77 ,$113.05 ,$244.93 ,$271.31 ,$342.91 ,$282.62 
Carle BroMenn Medical Center,8140054,KIT DRILL QUIXOTE MINI 1.8MM,247618,,270,$600.00 ,$600.00 ,$180.00 ,$546.00 ,$420.00 ,$180.00 ,$390.00 ,$432.00 ,$546.00 ,$450.00 
Carle BroMenn Medical Center,8140054,KIT DX FIBERTAK DISP,252585,,270,$825.00 ,$825.00 ,$247.50 ,$750.75 ,$577.50 ,$247.50 ,$536.25 ,$594.00 ,$750.75 ,$618.75 
Carle BroMenn Medical Center,8140054,KIT FALOPE-RING APPLC W/TROCAR,244749,,270,"$7,752.00 ","$7,752.00 ","$2,325.60 ","$7,054.32 ","$5,426.40 ","$2,325.60 ","$5,038.80 ","$5,581.44 ","$7,054.32 ","$5,814.00 "
Carle BroMenn Medical Center,8140054,KIT FEMORAL BONE CEMENT PREP,241520,,270,$384.00 ,$384.00 ,$115.20 ,$349.44 ,$268.80 ,$115.20 ,$249.60 ,$276.48 ,$349.44 ,$288.00 
Carle BroMenn Medical Center,8140054,KIT FRAGMATOME ACCESS,3648,,270,$210.90 ,$210.90 ,$63.27 ,$191.92 ,$147.63 ,$63.27 ,$137.09 ,$151.85 ,$191.92 ,$158.18 
Carle BroMenn Medical Center,8140054,KIT GAS CONSTELATION AUTOFILL BX/,205828,,270,$191.88 ,$191.88 ,$57.56 ,$174.61 ,$134.32 ,$57.56 ,$124.72 ,$138.15 ,$174.61 ,$143.91 
Carle BroMenn Medical Center,8140054,KIT HEARTSTRING 3.8,223691,,270,"$1,674.84 ","$1,674.84 ",$502.45 ,"$1,524.10 ","$1,172.39 ",$502.45 ,"$1,088.65 ","$1,205.88 ","$1,524.10 ","$1,256.13 "
Carle BroMenn Medical Center,8140054,KIT HEMOVAC EVACUATOR 3/16IN,232176,,270,$34.09 ,$34.09 ,$10.23 ,$31.02 ,$23.86 ,$10.23 ,$22.16 ,$24.54 ,$31.02 ,$25.57 
Carle BroMenn Medical Center,8140054,KIT MINISTICK MAX 4F NIT TUNG GDW,239203,,270,$48.00 ,$48.00 ,$14.40 ,$43.68 ,$33.60 ,$14.40 ,$31.20 ,$34.56 ,$43.68 ,$36.00 
Carle BroMenn Medical Center,8140054,KIT NDL GUIDE 18G,244681,,270,$96.33 ,$96.33 ,$28.90 ,$87.66 ,$67.43 ,$28.90 ,$62.61 ,$69.36 ,$87.66 ,$72.25 
Carle BroMenn Medical Center,8140054,KIT NEEDLE BIOPSY,4280,,270,"$2,265.00 ","$2,265.00 ",$679.50 ,"$2,061.15 ","$1,585.50 ",$679.50 ,"$1,472.25 ","$1,630.80 ","$2,061.15 ","$1,698.75 "
Carle BroMenn Medical Center,8140054,KIT NEEDLE CRV INSERTION 4IN,243408,,270,$225.00 ,$225.00 ,$67.50 ,$204.75 ,$157.50 ,$67.50 ,$146.25 ,$162.00 ,$204.75 ,$168.75 
Carle BroMenn Medical Center,8140054,KIT NOVASURE DISP DEVICE,244692,,270,"$3,460.00 ","$3,460.00 ","$1,038.00 ","$3,148.60 ","$2,422.00 ","$1,038.00 ","$2,249.00 ","$2,491.20 ","$3,148.60 ","$2,595.00 "
Carle BroMenn Medical Center,8140054,KIT PENILE ACCESSORY 700 BUNDLED,236672,,270,"$2,820.00 ","$2,820.00 ",$846.00 ,"$2,566.20 ","$1,974.00 ",$846.00 ,"$1,833.00 ","$2,030.40 ","$2,566.20 ","$2,115.00 "
Carle BroMenn Medical Center,8140054,KIT PERCU ACCESS,236635,,270,$405.66 ,$405.66 ,$121.70 ,$369.15 ,$283.96 ,$121.70 ,$263.68 ,$292.08 ,$369.15 ,$304.25 
Carle BroMenn Medical Center,8140054,KIT PREP FEM CMNT STL,236625,,270,$384.00 ,$384.00 ,$115.20 ,$349.44 ,$268.80 ,$115.20 ,$249.60 ,$276.48 ,$349.44 ,$288.00 
Carle BroMenn Medical Center,8140054,KIT PREP W/RESTRICTORS MUST ORDER,236948,,270,$285.00 ,$285.00 ,$85.50 ,$259.35 ,$199.50 ,$85.50 ,$185.25 ,$205.20 ,$259.35 ,$213.75 
Carle BroMenn Medical Center,8140054,KIT PROCLAIM TUNNEL TOOL,238980,,270,"$1,099.80 ","$1,099.80 ",$329.94 ,"$1,000.82 ",$769.86 ,$329.94 ,$714.87 ,$791.86 ,"$1,000.82 ",$824.85 
Carle BroMenn Medical Center,8140054,KIT PULSAVAC PLUS SHOWER,860,,270,$90.00 ,$90.00 ,$27.00 ,$81.90 ,$63.00 ,$27.00 ,$58.50 ,$64.80 ,$81.90 ,$67.50 
Carle BroMenn Medical Center,8140054,KIT PUSHLOCK INSERTION 2.9MM,237621,,270,$660.00 ,$660.00 ,$198.00 ,$600.60 ,$462.00 ,$198.00 ,$429.00 ,$475.20 ,$600.60 ,$495.00 
Carle BroMenn Medical Center,8140054,KIT REMOTE CONTROL FREELINK,258004,,270,"$2,700.00 ","$2,700.00 ",$810.00 ,"$2,457.00 ","$1,890.00 ",$810.00 ,"$1,755.00 ","$1,944.00 ","$2,457.00 ","$2,025.00 "
Carle BroMenn Medical Center,8140054,KIT SHLDR SUSP W/COHESIVE WRAP,247929,,270,$101.40 ,$101.40 ,$30.42 ,$92.27 ,$70.98 ,$30.42 ,$65.91 ,$73.01 ,$92.27 ,$76.05 
Carle BroMenn Medical Center,8140054,KIT THD SLIDE ONE STL PROC,245011,,270,$0.33 ,$0.33 ,$0.10 ,$0.30 ,$0.23 ,$0.10 ,$0.21 ,$0.24 ,$0.30 ,$0.25 
Carle BroMenn Medical Center,8140054,KIT TOWER CEMENT SMARTMIX,252893,,270,$285.00 ,$285.00 ,$85.50 ,$259.35 ,$199.50 ,$85.50 ,$185.25 ,$205.20 ,$259.35 ,$213.75 
Carle BroMenn Medical Center,8140054,KIT TRAJECTORY GUIDE,4281,,270,"$4,446.00 ","$4,446.00 ","$1,333.80 ","$4,045.86 ","$3,112.20 ","$1,333.80 ","$2,889.90 ","$3,201.12 ","$4,045.86 ","$3,334.50 "
Carle BroMenn Medical Center,8140054,KIT TROCAR FLEXIPATH 15MM,244647,,270,$951.46 ,$951.46 ,$285.44 ,$865.83 ,$666.02 ,$285.44 ,$618.45 ,$685.05 ,$865.83 ,$713.60 
Carle BroMenn Medical Center,8140054,KIT UNIV MAMMARY FILL,237257,,270,$0.56 ,$0.56 ,$0.17 ,$0.51 ,$0.39 ,$0.17 ,$0.36 ,$0.40 ,$0.51 ,$0.42 
Carle BroMenn Medical Center,8140054,KIT UROMAX ULTRA HP 21X7X4X75 BAL,236640,,270,$756.42 ,$756.42 ,$226.93 ,$688.34 ,$529.49 ,$226.93 ,$491.67 ,$544.62 ,$688.34 ,$567.32 
Carle BroMenn Medical Center,8140054,KNIFE COLD STL,244496,,270,$0.56 ,$0.56 ,$0.17 ,$0.51 ,$0.39 ,$0.17 ,$0.36 ,$0.40 ,$0.51 ,$0.42 
Carle BroMenn Medical Center,8140054,KNIFE COLD STR STL,244614,,270,$0.56 ,$0.56 ,$0.17 ,$0.51 ,$0.39 ,$0.17 ,$0.36 ,$0.40 ,$0.51 ,$0.42 
Carle BroMenn Medical Center,8140054,KNIFE MVR SCLERAL 25GA,244786,,270,$0.56 ,$0.56 ,$0.17 ,$0.51 ,$0.39 ,$0.17 ,$0.36 ,$0.40 ,$0.51 ,$0.42 
Carle BroMenn Medical Center,8140054,KWIRE .062 1.66MM SS,5245,,270,$114.00 ,$114.00 ,$34.20 ,$103.74 ,$79.80 ,$34.20 ,$74.10 ,$82.08 ,$103.74 ,$85.50 
Carle BroMenn Medical Center,8140054,KWIRE SS 2X152MM,237159,,270,$114.00 ,$114.00 ,$34.20 ,$103.74 ,$79.80 ,$34.20 ,$74.10 ,$82.08 ,$103.74 ,$85.50 
Carle BroMenn Medical Center,8140054,KWIRE THREADED 1.6MMX150MM 10/TP,3000,,270,$37.26 ,$37.26 ,$11.18 ,$33.91 ,$26.08 ,$11.18 ,$24.22 ,$26.83 ,$33.91 ,$27.95 
Carle BroMenn Medical Center,8140054,KWIRE TROCAR POINT 1.25X150MM PK/,2998,,270,$19.98 ,$19.98 ,$5.99 ,$18.18 ,$13.99 ,$5.99 ,$12.99 ,$14.39 ,$18.18 ,$14.99 
Carle BroMenn Medical Center,8140054,KWIRE TROCAR POINT 1.6X150MM 10/T,83304,,270,$19.98 ,$19.98 ,$5.99 ,$18.18 ,$13.99 ,$5.99 ,$12.99 ,$14.39 ,$18.18 ,$14.99 
Carle BroMenn Medical Center,8140054,KWIRE TROCAR PT 2END 1.25X150,237018,,270,$23.58 ,$23.58 ,$7.07 ,$21.46 ,$16.51 ,$7.07 ,$15.33 ,$16.98 ,$21.46 ,$17.69 
Carle BroMenn Medical Center,8140054,LEGGING ATHROMBIC BARIATRIC,244200,,270,$56.58 ,$56.58 ,$16.97 ,$51.49 ,$39.61 ,$16.97 ,$36.78 ,$40.74 ,$51.49 ,$42.44 
Carle BroMenn Medical Center,8140054,LEGGING ATHROMBIC REGULAR,244199,,270,$29.82 ,$29.82 ,$8.95 ,$27.14 ,$20.87 ,$8.95 ,$19.38 ,$21.47 ,$27.14 ,$22.37 
Carle BroMenn Medical Center,8140054,LEGGING SURG 31X48IN,245094,,270,$9.79 ,$9.79 ,$2.94 ,$8.91 ,$6.85 ,$2.94 ,$6.36 ,$7.05 ,$8.91 ,$7.34 
Carle BroMenn Medical Center,8140054,LEGION PS HI FLEX XLPE SZ 7-8 13M,242633,,270,"$4,000.50 ","$4,000.50 ","$1,200.15 ","$3,640.46 ","$2,800.35 ","$1,200.15 ","$2,600.33 ","$2,880.36 ","$3,640.46 ","$3,000.38 "
Carle BroMenn Medical Center,8140054,LGN PS HIGH FLEX XLPE SZ7-8 15,247870,,270,"$4,000.50 ","$4,000.50 ","$1,200.15 ","$3,640.46 ","$2,800.35 ","$1,200.15 ","$2,600.33 ","$2,880.36 ","$3,640.46 ","$3,000.38 "
Carle BroMenn Medical Center,8140054,LIGASURE 23CM MARYLAND TIP,223234,,270,"$2,192.57 ","$2,192.57 ",$657.77 ,"$1,995.24 ","$1,534.80 ",$657.77 ,"$1,425.17 ","$1,578.65 ","$1,995.24 ","$1,644.43 "
Carle BroMenn Medical Center,8140054,LIGASURE IMPACT OPEN SEALER DV,240259,,270,"$2,858.97 ","$2,858.97 ",$857.69 ,"$2,601.66 ","$2,001.28 ",$857.69 ,"$1,858.33 ","$2,058.46 ","$2,601.66 ","$2,144.23 "
Carle BroMenn Medical Center,8140054,LIGASURE LAP 5MM 37CM,245075,,270,"$2,217.24 ","$2,217.24 ",$665.17 ,"$2,017.69 ","$1,552.07 ",$665.17 ,"$1,441.21 ","$1,596.41 ","$2,017.69 ","$1,662.93 "
Carle BroMenn Medical Center,8140054,LOCATOR NERVE VARI-STIM III,920,,270,$167.93 ,$167.93 ,$50.38 ,$152.82 ,$117.55 ,$50.38 ,$109.15 ,$120.91 ,$152.82 ,$125.95 
Carle BroMenn Medical Center,8140054,LOOP MINI VESSEL BLU 2/PK,244987,,270,$1.83 ,$1.83 ,$0.55 ,$1.67 ,$1.28 ,$0.55 ,$1.19 ,$1.32 ,$1.67 ,$1.37 
Carle BroMenn Medical Center,8140054,LOOP VESSEL YLW MAXI CARD MEDICHO,244998,,270,$4.76 ,$4.76 ,$1.43 ,$4.33 ,$3.33 ,$1.43 ,$3.09 ,$3.43 ,$4.33 ,$3.57 
Carle BroMenn Medical Center,8140054,MANAGER MYPTM PERSONAL THRPY,248339,,270,"$2,250.00 ","$2,250.00 ",$675.00 ,"$2,047.50 ","$1,575.00 ",$675.00 ,"$1,462.50 ","$1,620.00 ","$2,047.50 ","$1,687.50 "
Carle BroMenn Medical Center,8140054,MANIFOLD 4 PORT,245156,,270,$47.25 ,$47.25 ,$14.18 ,$43.00 ,$33.08 ,$14.18 ,$30.71 ,$34.02 ,$43.00 ,$35.44 
Carle BroMenn Medical Center,8140054,MANIPULATOR RUMI KOH-EFF 2.5CM BX,38540,,270,$370.72 ,$370.72 ,$111.22 ,$337.36 ,$259.50 ,$111.22 ,$240.97 ,$266.92 ,$337.36 ,$278.04 
Carle BroMenn Medical Center,8140054,MARKER FIDUCIAL 100 F/IGS,244823,,270,$13.18 ,$13.18 ,$3.95 ,$11.99 ,$9.23 ,$3.95 ,$8.57 ,$9.49 ,$11.99 ,$9.89 
Carle BroMenn Medical Center,8140054,MARKER MARGIN MAP SPCMN 10MM,244952,,270,$48.30 ,$48.30 ,$14.49 ,$43.95 ,$33.81 ,$14.49 ,$31.40 ,$34.78 ,$43.95 ,$36.23 
Carle BroMenn Medical Center,8140054,MARKER MARGIN MAP SPCMN 5MM,244977,,270,$0.22 ,$0.22 ,$0.07 ,$0.20 ,$0.15 ,$0.07 ,$0.14 ,$0.16 ,$0.20 ,$0.17 
Carle BroMenn Medical Center,8140054,MARKER SKIN W/RULER & LABEL,244180,,270,$3.10 ,$3.10 ,$0.93 ,$2.82 ,$2.17 ,$0.93 ,$2.02 ,$2.23 ,$2.82 ,$2.33 
Carle BroMenn Medical Center,8140054,MARKER SKIN W/RULER FINE TIP,244986,,270,$3.49 ,$3.49 ,$1.05 ,$3.18 ,$2.44 ,$1.05 ,$2.27 ,$2.51 ,$3.18 ,$2.62 
Carle BroMenn Medical Center,8140054,MASK SURE SEAL LARYN 1.0 W/CP SIL,244880,,270,$18.00 ,$18.00 ,$5.40 ,$16.38 ,$12.60 ,$5.40 ,$11.70 ,$12.96 ,$16.38 ,$13.50 
Carle BroMenn Medical Center,8140054,MASK SURE SEAL LARYN 1.5 W/CP SIL,244881,,270,$18.00 ,$18.00 ,$5.40 ,$16.38 ,$12.60 ,$5.40 ,$11.70 ,$12.96 ,$16.38 ,$13.50 
Carle BroMenn Medical Center,8140054,MASK SURE SEAL LARYN 2.0 W/CP SIL,244882,,270,$18.45 ,$18.45 ,$5.54 ,$16.79 ,$12.92 ,$5.54 ,$11.99 ,$13.28 ,$16.79 ,$13.84 
Carle BroMenn Medical Center,8140054,MASK SURE SEAL LARYN 2.5 W/CP SIL,244883,,270,$18.45 ,$18.45 ,$5.54 ,$16.79 ,$12.92 ,$5.54 ,$11.99 ,$13.28 ,$16.79 ,$13.84 
Carle BroMenn Medical Center,8140054,MILL BONE FINE DISP,244772,,270,$976.36 ,$976.36 ,$292.91 ,$888.49 ,$683.45 ,$292.91 ,$634.63 ,$702.98 ,$888.49 ,$732.27 
Carle BroMenn Medical Center,8140054,MIXER KYPHON CMNT,244748,,270,$176.88 ,$176.88 ,$53.06 ,$160.96 ,$123.82 ,$53.06 ,$114.97 ,$127.35 ,$160.96 ,$132.66 
Carle BroMenn Medical Center,8140054,MIXER MIX EVAC III 10/PK,244703,,270,"$1,272.60 ","$1,272.60 ",$381.78 ,"$1,158.07 ",$890.82 ,$381.78 ,$827.19 ,$916.27 ,"$1,158.07 ",$954.45 
Carle BroMenn Medical Center,8140054,NANOSCOPE AR-3210-0040,242708,,270,"$1,977.00 ","$1,977.00 ",$593.10 ,"$1,799.07 ","$1,383.90 ",$593.10 ,"$1,285.05 ","$1,423.44 ","$1,799.07 ","$1,482.75 "
Carle BroMenn Medical Center,8140054,NAVIGATOR 11/13F 36CM,237375,,270,$329.31 ,$329.31 ,$98.79 ,$299.67 ,$230.52 ,$98.79 ,$214.05 ,$237.10 ,$299.67 ,$246.98 
Carle BroMenn Medical Center,8140054,NEEDLE 25GA X 1 1/2 BD DISP,109649,,270,$0.09 ,$0.09 ,$0.03 ,$0.08 ,$0.06 ,$0.03 ,$0.06 ,$0.06 ,$0.08 ,$0.07 
Carle BroMenn Medical Center,8140054,NEEDLE 25GA X 1 1/2 BD DISP,234265,,270,$0.09 ,$0.09 ,$0.03 ,$0.08 ,$0.06 ,$0.03 ,$0.06 ,$0.06 ,$0.08 ,$0.07 
Carle BroMenn Medical Center,8140054,NEEDLE 4 FACET TIP 13G 6/BX,244707,,270,$150.30 ,$150.30 ,$45.09 ,$136.77 ,$105.21 ,$45.09 ,$97.70 ,$108.22 ,$136.77 ,$112.73 
Carle BroMenn Medical Center,8140054,NEEDLE ACCESS INTRO 18G 20CM,236893,,270,$93.06 ,$93.06 ,$27.92 ,$84.68 ,$65.14 ,$27.92 ,$60.49 ,$67.00 ,$84.68 ,$69.80 
Carle BroMenn Medical Center,8140054,NEEDLE ASPIRATION ENDO CYST TOPEL,1602,,270,$708.00 ,$708.00 ,$212.40 ,$644.28 ,$495.60 ,$212.40 ,$460.20 ,$509.76 ,$644.28 ,$531.00 
Carle BroMenn Medical Center,8140054,NEEDLE BIOP TRUCUT 14GX6IN,244587,,270,$101.87 ,$101.87 ,$30.56 ,$92.70 ,$71.31 ,$30.56 ,$66.22 ,$73.35 ,$92.70 ,$76.40 
Carle BroMenn Medical Center,8140054,NEEDLE BLUNT FILL,244095,,270,$0.20 ,$0.20 ,$0.06 ,$0.18 ,$0.14 ,$0.06 ,$0.13 ,$0.14 ,$0.18 ,$0.15 
Carle BroMenn Medical Center,8140054,NEEDLE BSDN-18-7,244511,,270,$12.81 ,$12.81 ,$3.84 ,$11.66 ,$8.97 ,$3.84 ,$8.33 ,$9.22 ,$11.66 ,$9.61 
Carle BroMenn Medical Center,8140054,NEEDLE BULLET TIP 8GAX15CM,247603,,270,$125.10 ,$125.10 ,$37.53 ,$113.84 ,$87.57 ,$37.53 ,$81.32 ,$90.07 ,$113.84 ,$93.83 
Carle BroMenn Medical Center,8140054,NEEDLE CHIBA 22GAX8IN,10428,,270,$15.06 ,$15.06 ,$4.52 ,$13.70 ,$10.54 ,$4.52 ,$9.79 ,$10.84 ,$13.70 ,$11.30 
Carle BroMenn Medical Center,8140054,NEEDLE COUDE EPIDURAL 14G 4IN 10,255579,,270,$148.29 ,$148.29 ,$44.49 ,$134.94 ,$103.80 ,$44.49 ,$96.39 ,$106.77 ,$134.94 ,$111.22 
Carle BroMenn Medical Center,8140054,NEEDLE CURVED TAPERS 26MM X.5 CIR,252120,,270,$57.00 ,$57.00 ,$17.10 ,$51.87 ,$39.90 ,$17.10 ,$37.05 ,$41.04 ,$51.87 ,$42.75 
Carle BroMenn Medical Center,8140054,NEEDLE EPDRL TUOHY 18GX3.5IN,244597,,270,$10.91 ,$10.91 ,$3.27 ,$9.93 ,$7.64 ,$3.27 ,$7.09 ,$7.86 ,$9.93 ,$8.18 
Carle BroMenn Medical Center,8140054,NEEDLE FAST-FIX 360 CRVD,3749,,270,"$1,380.00 ","$1,380.00 ",$414.00 ,"$1,255.80 ",$966.00 ,$414.00 ,$897.00 ,$993.60 ,"$1,255.80 ","$1,035.00 "
Carle BroMenn Medical Center,8140054,NEEDLE FLTR FML LL 19GX1IN 100/CA,244612,,270,$1.20 ,$1.20 ,$0.36 ,$1.09 ,$0.84 ,$0.36 ,$0.78 ,$0.86 ,$1.09 ,$0.90 
Carle BroMenn Medical Center,8140054,NEEDLE FORAMEN 20GX5IN 2/PK INTER,242434,,270,$180.00 ,$180.00 ,$54.00 ,$163.80 ,$126.00 ,$54.00 ,$117.00 ,$129.60 ,$163.80 ,$135.00 
Carle BroMenn Medical Center,8140054,NEEDLE FORAMEN 20GX5IN 6/BX USE #,219250,,270,$120.00 ,$120.00 ,$36.00 ,$109.20 ,$84.00 ,$36.00 ,$78.00 ,$86.40 ,$109.20 ,$90.00 
Carle BroMenn Medical Center,8140054,NEEDLE HYPO 25GA 5/8IN BD,244281,,270,$0.09 ,$0.09 ,$0.03 ,$0.08 ,$0.06 ,$0.03 ,$0.06 ,$0.06 ,$0.08 ,$0.07 
Carle BroMenn Medical Center,8140054,NEEDLE HYPO 27GA 1.5IN MONOJCT 10,11047,,270,$0.08 ,$0.08 ,$0.02 ,$0.07 ,$0.06 ,$0.02 ,$0.05 ,$0.06 ,$0.07 ,$0.06 
Carle BroMenn Medical Center,8140054,NEEDLE HYPO A BEVEL 22GX1.5,244978,,270,$0.16 ,$0.16 ,$0.05 ,$0.15 ,$0.11 ,$0.05 ,$0.10 ,$0.12 ,$0.15 ,$0.12 
Carle BroMenn Medical Center,8140054,NEEDLE HYPO A BEVEL 27X1.5IN SOFT,249748,,270,$0.16 ,$0.16 ,$0.05 ,$0.15 ,$0.11 ,$0.05 ,$0.10 ,$0.12 ,$0.15 ,$0.12 
Carle BroMenn Medical Center,8140054,NEEDLE HYPO SPEC RW 16GX1IN PRECI,244650,,270,$0.15 ,$0.15 ,$0.05 ,$0.14 ,$0.11 ,$0.05 ,$0.10 ,$0.11 ,$0.14 ,$0.11 
Carle BroMenn Medical Center,8140054,NEEDLE INJ 4F STL,244542,,270,$361.50 ,$361.50 ,$108.45 ,$328.97 ,$253.05 ,$108.45 ,$234.98 ,$260.28 ,$328.97 ,$271.13 
Carle BroMenn Medical Center,8140054,NEEDLE INJETAK ADJ TIP 35CM 0-,245046,,270,$0.03 ,$0.03 ,$0.01 ,$0.03 ,$0.02 ,$0.01 ,$0.02 ,$0.02 ,$0.03 ,$0.02 
Carle BroMenn Medical Center,8140054,NEEDLE MAYO CIR 1/2IN TAPER,244696,,270,$0.02 ,$0.02 ,$0.01 ,$0.02 ,$0.01 ,$0.01 ,$0.01 ,$0.01 ,$0.02 ,$0.02 
Carle BroMenn Medical Center,8140054,NEEDLE MULTIFIRE SCORPION BX/5,79194,,270,$510.00 ,$510.00 ,$153.00 ,$464.10 ,$357.00 ,$153.00 ,$331.50 ,$367.20 ,$464.10 ,$382.50 
Carle BroMenn Medical Center,8140054,NEEDLE OVUM ASPIRATION SINGLE,250607,,270,$71.91 ,$71.91 ,$21.57 ,$65.44 ,$50.34 ,$21.57 ,$46.74 ,$51.78 ,$65.44 ,$53.93 
Carle BroMenn Medical Center,8140054,NEEDLE PORT CLOS TN VIC 0 27IN,244613,,270,$66.01 ,$66.01 ,$19.80 ,$60.07 ,$46.21 ,$19.80 ,$42.91 ,$47.53 ,$60.07 ,$49.51 
Carle BroMenn Medical Center,8140054,NEEDLE RETROBULB 22D 25GX1.5IN,244962,,270,$12.73 ,$12.73 ,$3.82 ,$11.58 ,$8.91 ,$3.82 ,$8.27 ,$9.17 ,$11.58 ,$9.55 
Carle BroMenn Medical Center,8140054,NEEDLE SAFETY 22GAX1.5IN 100/BX,9608,,270,$0.44 ,$0.44 ,$0.13 ,$0.40 ,$0.31 ,$0.13 ,$0.29 ,$0.32 ,$0.40 ,$0.33 
Carle BroMenn Medical Center,8140054,NEEDLE SAFETY 25GX1.5IN ECLIPSE,244018,,270,$0.44 ,$0.44 ,$0.13 ,$0.40 ,$0.31 ,$0.13 ,$0.29 ,$0.32 ,$0.40 ,$0.33 
Carle BroMenn Medical Center,8140054,NEEDLE SCLERO FLEX YLW25X5X230 5/,244946,,270,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8140054,NEEDLE SPARE INSRTN 4IN,239041,,270,$120.00 ,$120.00 ,$36.00 ,$109.20 ,$84.00 ,$36.00 ,$78.00 ,$86.40 ,$109.20 ,$90.00 
Carle BroMenn Medical Center,8140054,NEEDLE SPINAL 18GA X 3.5IN,244292,,270,$4.59 ,$4.59 ,$1.38 ,$4.18 ,$3.21 ,$1.38 ,$2.98 ,$3.30 ,$4.18 ,$3.44 
Carle BroMenn Medical Center,8140054,NEEDLE SPINAL 22GA X 3.5IN,244316,,270,$4.45 ,$4.45 ,$1.34 ,$4.05 ,$3.12 ,$1.34 ,$2.89 ,$3.20 ,$4.05 ,$3.34 
Carle BroMenn Medical Center,8140054,NEEDLE SPINOCAN SPINAL 22GX5IN,250409,,270,$7.88 ,$7.88 ,$2.36 ,$7.17 ,$5.52 ,$2.36 ,$5.12 ,$5.67 ,$7.17 ,$5.91 
Carle BroMenn Medical Center,8140054,NEEDLE SPNL CLR HUB 25GX3.5IN,245195,,270,$3.52 ,$3.52 ,$1.06 ,$3.20 ,$2.46 ,$1.06 ,$2.29 ,$2.53 ,$3.20 ,$2.64 
Carle BroMenn Medical Center,8140054,NEEDLE SPNL LNG BLK 22GX5IN,244506,,270,$12.48 ,$12.48 ,$3.74 ,$11.36 ,$8.74 ,$3.74 ,$8.11 ,$8.99 ,$11.36 ,$9.36 
Carle BroMenn Medical Center,8140054,NEEDLE SPNL SPINOCAN 20GX3.5IN,244036,,270,$3.61 ,$3.61 ,$1.08 ,$3.29 ,$2.53 ,$1.08 ,$2.35 ,$2.60 ,$3.29 ,$2.71 
Carle BroMenn Medical Center,8140054,NEEDLE SPNL STL YLW 20GX3IN,244607,,270,$5.25 ,$5.25 ,$1.58 ,$4.78 ,$3.68 ,$1.58 ,$3.41 ,$3.78 ,$4.78 ,$3.94 
Carle BroMenn Medical Center,8140054,NEEDLE SURGICAL 3/8 CUTTING SZ,245265,,270,$8.45 ,$8.45 ,$2.54 ,$7.69 ,$5.92 ,$2.54 ,$5.49 ,$6.08 ,$7.69 ,$6.34 
Carle BroMenn Medical Center,8140054,NEEDLE SURGINEEDLE 120MM,244731,,270,$134.66 ,$134.66 ,$40.40 ,$122.54 ,$94.26 ,$40.40 ,$87.53 ,$96.96 ,$122.54 ,$101.00 
Carle BroMenn Medical Center,8140054,NEEDLE TW BIOP CHOL 22GX6IN,244648,,270,$16.92 ,$16.92 ,$5.08 ,$15.40 ,$11.84 ,$5.08 ,$11.00 ,$12.18 ,$15.40 ,$12.69 
Carle BroMenn Medical Center,8140054,NEEDLE TW REG BVL 19GX1.5IN,244256,,270,$0.08 ,$0.08 ,$0.02 ,$0.07 ,$0.06 ,$0.02 ,$0.05 ,$0.06 ,$0.07 ,$0.06 
Carle BroMenn Medical Center,8140054,NEUROSTIMULATOR EXTRL WIRELESS,237715,,270,$900.00 ,$900.00 ,$270.00 ,$819.00 ,$630.00 ,$270.00 ,$585.00 ,$648.00 ,$819.00 ,$675.00 
Carle BroMenn Medical Center,8140054,OINTMENT VASELINE .06OZ BULK,244165,,270,$0.84 ,$0.84 ,$0.25 ,$0.76 ,$0.59 ,$0.25 ,$0.55 ,$0.60 ,$0.76 ,$0.63 
Carle BroMenn Medical Center,8140054,OSTEOTOME 12MM WIDE REV INST,243969,,270,$720.00 ,$720.00 ,$216.00 ,$655.20 ,$504.00 ,$216.00 ,$468.00 ,$518.40 ,$655.20 ,$540.00 
Carle BroMenn Medical Center,8140054,PACK ARTHROSCOPY BRO,245102,,270,$96.36 ,$96.36 ,$28.91 ,$87.69 ,$67.45 ,$28.91 ,$62.63 ,$69.38 ,$87.69 ,$72.27 
Carle BroMenn Medical Center,8140054,PACK CERV BRO,245103,,270,$344.67 ,$344.67 ,$103.40 ,$313.65 ,$241.27 ,$103.40 ,$224.04 ,$248.16 ,$313.65 ,$258.50 
Carle BroMenn Medical Center,8140054,PACK COSTELLATION TUBING VFC,2539,,270,$184.50 ,$184.50 ,$55.35 ,$167.90 ,$129.15 ,$55.35 ,$119.93 ,$132.84 ,$167.90 ,$138.38 
Carle BroMenn Medical Center,8140054,PACK CRANI BRO,245104,,270,$373.92 ,$373.92 ,$112.18 ,$340.27 ,$261.74 ,$112.18 ,$243.05 ,$269.22 ,$340.27 ,$280.44 
Carle BroMenn Medical Center,8140054,PACK CV UNIV DRAPING,245095,,270,$68.24 ,$68.24 ,$20.47 ,$62.10 ,$47.77 ,$20.47 ,$44.36 ,$49.13 ,$62.10 ,$51.18 
Carle BroMenn Medical Center,8140054,PACK CYSTO BRO,245105,,270,$59.34 ,$59.34 ,$17.80 ,$54.00 ,$41.54 ,$17.80 ,$38.57 ,$42.72 ,$54.00 ,$44.51 
Carle BroMenn Medical Center,8140054,PACK D&C BRO,245106,,270,$35.67 ,$35.67 ,$10.70 ,$32.46 ,$24.97 ,$10.70 ,$23.19 ,$25.68 ,$32.46 ,$26.75 
Carle BroMenn Medical Center,8140054,PACK DENTAL BRO,245107,,270,$59.16 ,$59.16 ,$17.75 ,$53.84 ,$41.41 ,$17.75 ,$38.45 ,$42.60 ,$53.84 ,$44.37 
Carle BroMenn Medical Center,8140054,PACK ENDO CHOLE BRO,245108,,270,$225.96 ,$225.96 ,$67.79 ,$205.62 ,$158.17 ,$67.79 ,$146.87 ,$162.69 ,$205.62 ,$169.47 
Carle BroMenn Medical Center,8140054,PACK FUSION ACCESSORY BRO CUSTOM,254592,,270,$196.44 ,$196.44 ,$58.93 ,$178.76 ,$137.51 ,$58.93 ,$127.69 ,$141.44 ,$178.76 ,$147.33 
Carle BroMenn Medical Center,8140054,PACK GEN CLOSING BRO,245109,,270,$141.63 ,$141.63 ,$42.49 ,$128.88 ,$99.14 ,$42.49 ,$92.06 ,$101.97 ,$128.88 ,$106.22 
Carle BroMenn Medical Center,8140054,PACK GEN SURG EUR,245121,,270,$73.77 ,$73.77 ,$22.13 ,$67.13 ,$51.64 ,$22.13 ,$47.95 ,$53.11 ,$67.13 ,$55.33 
Carle BroMenn Medical Center,8140054,PACK HEAD & NECK BRO,245110,,270,$171.54 ,$171.54 ,$51.46 ,$156.10 ,$120.08 ,$51.46 ,$111.50 ,$123.51 ,$156.10 ,$128.66 
Carle BroMenn Medical Center,8140054,PACK HIP DRAPE W/POUCH,244381,,270,$37.05 ,$37.05 ,$11.12 ,$33.72 ,$25.94 ,$11.12 ,$24.08 ,$26.68 ,$33.72 ,$27.79 
Carle BroMenn Medical Center,8140054,PACK HIP PINNING BRO,245111,,270,$257.52 ,$257.52 ,$77.26 ,$234.34 ,$180.26 ,$77.26 ,$167.39 ,$185.41 ,$234.34 ,$193.14 
Carle BroMenn Medical Center,8140054,PACK LAPROSCOPIC BRO,245112,,270,$99.27 ,$99.27 ,$29.78 ,$90.34 ,$69.49 ,$29.78 ,$64.53 ,$71.47 ,$90.34 ,$74.45 
Carle BroMenn Medical Center,8140054,PACK LUMBAR BRO,245120,,270,$359.16 ,$359.16 ,$107.75 ,$326.84 ,$251.41 ,$107.75 ,$233.45 ,$258.60 ,$326.84 ,$269.37 
Carle BroMenn Medical Center,8140054,PACK MAJOR BRO,245113,,270,$199.41 ,$199.41 ,$59.82 ,$181.46 ,$139.59 ,$59.82 ,$129.62 ,$143.58 ,$181.46 ,$149.56 
Carle BroMenn Medical Center,8140054,PACK MINOR BRO,245114,,270,$188.22 ,$188.22 ,$56.47 ,$171.28 ,$131.75 ,$56.47 ,$122.34 ,$135.52 ,$171.28 ,$141.17 
Carle BroMenn Medical Center,8140054,PACK OPEN HEART TABLE BRO,244040,,270,$506.04 ,$506.04 ,$151.81 ,$460.50 ,$354.23 ,$151.81 ,$328.93 ,$364.35 ,$460.50 ,$379.53 
Carle BroMenn Medical Center,8140054,PACK ORTHO BRO,245115,,270,$239.88 ,$239.88 ,$71.96 ,$218.29 ,$167.92 ,$71.96 ,$155.92 ,$172.71 ,$218.29 ,$179.91 
Carle BroMenn Medical Center,8140054,PACK SHLDR BRO,245116,,270,$316.08 ,$316.08 ,$94.82 ,$287.63 ,$221.26 ,$94.82 ,$205.45 ,$227.58 ,$287.63 ,$237.06 
Carle BroMenn Medical Center,8140054,PACK T&A BRO,244041,,270,$37.77 ,$37.77 ,$11.33 ,$34.37 ,$26.44 ,$11.33 ,$24.55 ,$27.19 ,$34.37 ,$28.33 
Carle BroMenn Medical Center,8140054,PACK TOTAL HIP BRO,245117,,270,$347.43 ,$347.43 ,$104.23 ,$316.16 ,$243.20 ,$104.23 ,$225.83 ,$250.15 ,$316.16 ,$260.57 
Carle BroMenn Medical Center,8140054,PACK TOTAL KNEE BRO CONSTELLATION,245118,,270,$324.15 ,$324.15 ,$97.25 ,$294.98 ,$226.91 ,$97.25 ,$210.70 ,$233.39 ,$294.98 ,$243.11 
Carle BroMenn Medical Center,8140054,PACK TOTAL+ PAK 20G CONSTELLATION,244805,,270,$0.56 ,$0.56 ,$0.17 ,$0.51 ,$0.39 ,$0.17 ,$0.36 ,$0.40 ,$0.51 ,$0.42 
Carle BroMenn Medical Center,8140054,PACK TOTAL+ PAK+ 25G,244806,,270,$0.56 ,$0.56 ,$0.17 ,$0.51 ,$0.39 ,$0.17 ,$0.36 ,$0.40 ,$0.51 ,$0.42 
Carle BroMenn Medical Center,8140054,PACK UNIVERSAL DRAPE,271,,270,$45.97 ,$45.97 ,$13.79 ,$41.83 ,$32.18 ,$13.79 ,$29.88 ,$33.10 ,$41.83 ,$34.48 
Carle BroMenn Medical Center,8140054,PACK VAG HYST BRO,245119,,270,$136.65 ,$136.65 ,$41.00 ,$124.35 ,$95.66 ,$41.00 ,$88.82 ,$98.39 ,$124.35 ,$102.49 
Carle BroMenn Medical Center,8140054,PACK VASOVIEW ACCESSORY,245138,,270,$378.21 ,$378.21 ,$113.46 ,$344.17 ,$264.75 ,$113.46 ,$245.84 ,$272.31 ,$344.17 ,$283.66 
Carle BroMenn Medical Center,8140054,PACKING NASAL MEROGEL 4X4,244680,,270,$1.67 ,$1.67 ,$0.50 ,$1.52 ,$1.17 ,$0.50 ,$1.09 ,$1.20 ,$1.52 ,$1.25 
Carle BroMenn Medical Center,8140054,PAD ABD STL LF 8X10IN,244106,,270,$0.66 ,$0.66 ,$0.20 ,$0.60 ,$0.46 ,$0.20 ,$0.43 ,$0.48 ,$0.60 ,$0.50 
Carle BroMenn Medical Center,8140054,PAD ABDOMINAL SURGIPAD 8X7-1/2 ST,440,,270,$0.39 ,$0.39 ,$0.12 ,$0.35 ,$0.27 ,$0.12 ,$0.25 ,$0.28 ,$0.35 ,$0.29 
Carle BroMenn Medical Center,8140054,PAD ADH TAPE REMOVER,244096,,270,$0.09 ,$0.09 ,$0.03 ,$0.08 ,$0.06 ,$0.03 ,$0.06 ,$0.06 ,$0.08 ,$0.07 
Carle BroMenn Medical Center,8140054,PAD ADLT REM POLYHESIVE II PT RET,244169,,270,$15.12 ,$15.12 ,$4.54 ,$13.76 ,$10.58 ,$4.54 ,$9.83 ,$10.89 ,$13.76 ,$11.34 
Carle BroMenn Medical Center,8140054,PAD EYE STL 1-5/8X2-5/8IN,244215,,270,$0.51 ,$0.51 ,$0.15 ,$0.46 ,$0.36 ,$0.15 ,$0.33 ,$0.37 ,$0.46 ,$0.38 
Carle BroMenn Medical Center,8140054,PAD GROUNDING 10 CORD BO SUB USE,244388,,270,$23.94 ,$23.94 ,$7.18 ,$21.79 ,$16.76 ,$7.18 ,$15.56 ,$17.24 ,$21.79 ,$17.96 
Carle BroMenn Medical Center,8140054,PAD NAIL POLISH REMOVER,244196,,270,$0.05 ,$0.05 ,$0.02 ,$0.05 ,$0.04 ,$0.02 ,$0.03 ,$0.04 ,$0.05 ,$0.04 
Carle BroMenn Medical Center,8140054,PAD NONADHER 3X4 STL,244231,,270,$0.42 ,$0.42 ,$0.13 ,$0.38 ,$0.29 ,$0.13 ,$0.27 ,$0.30 ,$0.38 ,$0.32 
Carle BroMenn Medical Center,8140054,PAD NONADHER 3X8 STL,244232,,270,$0.82 ,$0.82 ,$0.25 ,$0.75 ,$0.57 ,$0.25 ,$0.53 ,$0.59 ,$0.75 ,$0.62 
Carle BroMenn Medical Center,8140054,PAD OB NS INDV WRAPPED 2.75X10,244022,,270,$0.26 ,$0.26 ,$0.08 ,$0.24 ,$0.18 ,$0.08 ,$0.17 ,$0.19 ,$0.24 ,$0.20 
Carle BroMenn Medical Center,8140054,PAD POST PERONEAL DISPOSABLE,239056,,270,$282.27 ,$282.27 ,$84.68 ,$256.87 ,$197.59 ,$84.68 ,$183.48 ,$203.23 ,$256.87 ,$211.70 
Carle BroMenn Medical Center,8140054,PAD PT PROTECTIVE STL F/DE MAYO P,245059,,270,$103.50 ,$103.50 ,$31.05 ,$94.19 ,$72.45 ,$31.05 ,$67.28 ,$74.52 ,$94.19 ,$77.63 
Carle BroMenn Medical Center,8140054,PADDING CAST 6INX4YDS,244816,,270,$24.58 ,$24.58 ,$7.37 ,$22.37 ,$17.21 ,$7.37 ,$15.98 ,$17.70 ,$22.37 ,$18.44 
Carle BroMenn Medical Center,8140054,PADDING CAST WEBRIL 3IN STRL,585,,270,$5.85 ,$5.85 ,$1.76 ,$5.32 ,$4.10 ,$1.76 ,$3.80 ,$4.21 ,$5.32 ,$4.39 
Carle BroMenn Medical Center,8140054,PADDING CAST WEBRIL 4IN STRL,586,,270,$6.41 ,$6.41 ,$1.92 ,$5.83 ,$4.49 ,$1.92 ,$4.17 ,$4.62 ,$5.83 ,$4.81 
Carle BroMenn Medical Center,8140054,PADDING CAST WEBRIL 6IN STRL,587,,270,$9.00 ,$9.00 ,$2.70 ,$8.19 ,$6.30 ,$2.70 ,$5.85 ,$6.48 ,$8.19 ,$6.75 
Carle BroMenn Medical Center,8140054,PADDING UNDERCAST 6IN WEBRIL 6/BG,11059,,270,$3.96 ,$3.96 ,$1.19 ,$3.60 ,$2.77 ,$1.19 ,$2.57 ,$2.85 ,$3.60 ,$2.97 
Carle BroMenn Medical Center,8140054,PADDING WEBRIL II STL 2INX4YD CAS,244992,,270,$3.05 ,$3.05 ,$0.92 ,$2.78 ,$2.14 ,$0.92 ,$1.98 ,$2.20 ,$2.78 ,$2.29 
Carle BroMenn Medical Center,8140054,PADDING WEBRIL II STL 3INX4YD,244993,,270,$9.64 ,$9.64 ,$2.89 ,$8.77 ,$6.75 ,$2.89 ,$6.27 ,$6.94 ,$8.77 ,$7.23 
Carle BroMenn Medical Center,8140054,PADDING WEBRIL II STL 4INX4YD CAS,244994,,270,$6.70 ,$6.70 ,$2.01 ,$6.10 ,$4.69 ,$2.01 ,$4.36 ,$4.82 ,$6.10 ,$5.03 
Carle BroMenn Medical Center,8140054,PASSER CATH MLBL 55CM LNG,244517,,270,$622.75 ,$622.75 ,$186.83 ,$566.70 ,$435.93 ,$186.83 ,$404.79 ,$448.38 ,$566.70 ,$467.06 
Carle BroMenn Medical Center,8140054,PASSER SHUNT 36CM,723,,270,$325.80 ,$325.80 ,$97.74 ,$296.48 ,$228.06 ,$97.74 ,$211.77 ,$234.58 ,$296.48 ,$244.35 
Carle BroMenn Medical Center,8140054,PATTIES  SURGICAL .25 X .25IN,990,,270,$66.90 ,$66.90 ,$20.07 ,$60.88 ,$46.83 ,$20.07 ,$43.49 ,$48.17 ,$60.88 ,$50.18 
Carle BroMenn Medical Center,8140054,PATTIES SURGICAL 0.5X1IN,235589,,270,$32.48 ,$32.48 ,$9.74 ,$29.56 ,$22.74 ,$9.74 ,$21.11 ,$23.39 ,$29.56 ,$24.36 
Carle BroMenn Medical Center,8140054,PATTY SURG XRAY .5X3IN 10/PK,244592,,270,$60.11 ,$60.11 ,$18.03 ,$54.70 ,$42.08 ,$18.03 ,$39.07 ,$43.28 ,$54.70 ,$45.08 
Carle BroMenn Medical Center,8140054,PATTY SURG XRAY 1X3IN 10/PK,244593,,270,$63.05 ,$63.05 ,$18.92 ,$57.38 ,$44.14 ,$18.92 ,$40.98 ,$45.40 ,$57.38 ,$47.29 
Carle BroMenn Medical Center,8140054,PATTY SURG XRAY.25X3IN 10/PK,244622,,270,$21.26 ,$21.26 ,$6.38 ,$19.35 ,$14.88 ,$6.38 ,$13.82 ,$15.31 ,$19.35 ,$15.95 
Carle BroMenn Medical Center,8140054,PATTY SURG XRAY.5X.5IN 10/PK,244590,,270,$54.24 ,$54.24 ,$16.27 ,$49.36 ,$37.97 ,$16.27 ,$35.26 ,$39.05 ,$49.36 ,$40.68 
Carle BroMenn Medical Center,8140054,PATTY SURG XRAY.5X1IN 10/PK,244591,,270,$56.60 ,$56.60 ,$16.98 ,$51.51 ,$39.62 ,$16.98 ,$36.79 ,$40.75 ,$51.51 ,$42.45 
Carle BroMenn Medical Center,8140054,PENCIL BIPOLAR ST 25GA,8272,,270,$118.80 ,$118.80 ,$35.64 ,$108.11 ,$83.16 ,$35.64 ,$77.22 ,$85.54 ,$108.11 ,$89.10 
Carle BroMenn Medical Center,8140054,PENCIL ELECTROSURG VALLEYLAB,244377,,270,$16.14 ,$16.14 ,$4.84 ,$14.69 ,$11.30 ,$4.84 ,$10.49 ,$11.62 ,$14.69 ,$12.11 
Carle BroMenn Medical Center,8140054,PENCIL SMOKE EVAC COATED PB 10 PE,216964,,270,$85.50 ,$85.50 ,$25.65 ,$77.81 ,$59.85 ,$25.65 ,$55.58 ,$61.56 ,$77.81 ,$64.13 
Carle BroMenn Medical Center,8140054,PENCIL SMOKE EVACUATOR NEPTUNE,235484,,270,$85.50 ,$85.50 ,$25.65 ,$77.81 ,$59.85 ,$25.65 ,$55.58 ,$61.56 ,$77.81 ,$64.13 
Carle BroMenn Medical Center,8140054,PERI-STRIPS DRY PSD7506-E,3591,,270,$441.00 ,$441.00 ,$132.30 ,$401.31 ,$308.70 ,$132.30 ,$286.65 ,$317.52 ,$401.31 ,$330.75 
Carle BroMenn Medical Center,8140054,PEROXIDE HYDROGEN 3% 4OZ MEDICHOI,244115,,270,$1.43 ,$1.43 ,$0.43 ,$1.30 ,$1.00 ,$0.43 ,$0.93 ,$1.03 ,$1.30 ,$1.07 
Carle BroMenn Medical Center,8140054,PIK ILLUM MEMB 25G W/CONSTELLATIO,245062,,270,$0.28 ,$0.28 ,$0.08 ,$0.25 ,$0.20 ,$0.08 ,$0.18 ,$0.20 ,$0.25 ,$0.21 
Carle BroMenn Medical Center,8140054,PILLOW HEADREST ELVTR 7IN GENTLE,244503,,270,$52.02 ,$52.02 ,$15.61 ,$47.34 ,$36.41 ,$15.61 ,$33.81 ,$37.45 ,$47.34 ,$39.02 
Carle BroMenn Medical Center,8140054,PIN CLAW II TEM FIX PIN,198231,,270,$204.00 ,$204.00 ,$61.20 ,$185.64 ,$142.80 ,$61.20 ,$132.60 ,$146.88 ,$185.64 ,$153.00 
Carle BroMenn Medical Center,8140054,PIN DRILL ACL CLSD EYELET 4MM TIG,238273,,270,$375.00 ,$375.00 ,$112.50 ,$341.25 ,$262.50 ,$112.50 ,$243.75 ,$270.00 ,$341.25 ,$281.25 
Carle BroMenn Medical Center,8140054,PIN RIM SPEED 65MM STERILE,237179,,270,$1.11 ,$1.11 ,$0.33 ,$1.01 ,$0.78 ,$0.33 ,$0.72 ,$0.80 ,$1.01 ,$0.83 
Carle BroMenn Medical Center,8140054,PIN SKULL DISPOSABLE,2548,,270,$147.00 ,$147.00 ,$44.10 ,$133.77 ,$102.90 ,$44.10 ,$95.55 ,$105.84 ,$133.77 ,$110.25 
Carle BroMenn Medical Center,8140054,PIN STEINMANN 3.2MM,248343,,270,$447.00 ,$447.00 ,$134.10 ,$406.77 ,$312.90 ,$134.10 ,$290.55 ,$321.84 ,$406.77 ,$335.25 
Carle BroMenn Medical Center,8140054,PIN STEINMANN 9IN COMPREHENSIVE R,237341,,270,$468.00 ,$468.00 ,$140.40 ,$425.88 ,$327.60 ,$140.40 ,$304.20 ,$336.96 ,$425.88 ,$351.00 
Carle BroMenn Medical Center,8140054,PITCHER 1200CC LF STL,244979,,270,$3.95 ,$3.95 ,$1.19 ,$3.59 ,$2.77 ,$1.19 ,$2.57 ,$2.84 ,$3.59 ,$2.96 
Carle BroMenn Medical Center,8140054,PLANER MODULAR CALCAR SML,243968,,270,"$1,381.50 ","$1,381.50 ",$414.45 ,"$1,257.17 ",$967.05 ,$414.45 ,$897.98 ,$994.68 ,"$1,257.17 ","$1,036.13 "
Carle BroMenn Medical Center,8140054,PLANNER SP2 PAT LG,236827,,270,$297.00 ,$297.00 ,$89.10 ,$270.27 ,$207.90 ,$89.10 ,$193.05 ,$213.84 ,$270.27 ,$222.75 
Carle BroMenn Medical Center,8140054,PLANNER SP2 PAT MED,236780,,270,$297.00 ,$297.00 ,$89.10 ,$270.27 ,$207.90 ,$89.10 ,$193.05 ,$213.84 ,$270.27 ,$222.75 
Carle BroMenn Medical Center,8140054,PLANNER SP2 PAT SM,236823,,270,$297.00 ,$297.00 ,$89.10 ,$270.27 ,$207.90 ,$89.10 ,$193.05 ,$213.84 ,$270.27 ,$222.75 
Carle BroMenn Medical Center,8140054,PLASTER CAST 2IN 12/DZ FAST SETTI,244272,,270,$1.97 ,$1.97 ,$0.59 ,$1.79 ,$1.38 ,$0.59 ,$1.28 ,$1.42 ,$1.79 ,$1.48 
Carle BroMenn Medical Center,8140054,PLASTER CAST 3IN 12/BX FAST SETTI,244273,,270,$2.35 ,$2.35 ,$0.71 ,$2.14 ,$1.65 ,$0.71 ,$1.53 ,$1.69 ,$2.14 ,$1.76 
Carle BroMenn Medical Center,8140054,PLEDGETS FELT 250 PER CASE,247034,,270,$43.50 ,$43.50 ,$13.05 ,$39.59 ,$30.45 ,$13.05 ,$28.28 ,$31.32 ,$39.59 ,$32.63 
Carle BroMenn Medical Center,8140054,PLUG FOLEY CATH STL W/CAP,250195,,270,$1.03 ,$1.03 ,$0.31 ,$0.94 ,$0.72 ,$0.31 ,$0.67 ,$0.74 ,$0.94 ,$0.77 
Carle BroMenn Medical Center,8140054,PORT GEL LAPARSCOPIC HAND ASSIST,11049,,270,"$1,575.00 ","$1,575.00 ",$472.50 ,"$1,433.25 ","$1,102.50 ",$472.50 ,"$1,023.75 ","$1,134.00 ","$1,433.25 ","$1,181.25 "
Carle BroMenn Medical Center,8140054,POSITIONER ABUCT PILLOW MD CHRONO,244223,,270,$43.96 ,$43.96 ,$13.19 ,$40.00 ,$30.77 ,$13.19 ,$28.57 ,$31.65 ,$40.00 ,$32.97 
Carle BroMenn Medical Center,8140054,POSITIONER TREND STEEP HUGUVAC,248979,,270,"$5,247.00 ","$5,247.00 ","$1,574.10 ","$4,774.77 ","$3,672.90 ","$1,574.10 ","$3,410.55 ","$3,777.84 ","$4,774.77 ","$3,935.25 "
Carle BroMenn Medical Center,8140054,POSITIONER URCHIN EVO CONVALUTED,245028,,270,$3.33 ,$3.33 ,$1.00 ,$3.03 ,$2.33 ,$1.00 ,$2.16 ,$2.40 ,$3.03 ,$2.50 
Carle BroMenn Medical Center,8140054,POUCH ACTIVE LIFE .75-2.25,244134,,270,$1.09 ,$1.09 ,$0.33 ,$0.99 ,$0.76 ,$0.33 ,$0.71 ,$0.78 ,$0.99 ,$0.82 
Carle BroMenn Medical Center,8140054,POUCH ANTIBIOTIC INTERSTIM TYRX,238833,,270,"$2,985.00 ","$2,985.00 ",$895.50 ,"$2,716.35 ","$2,089.50 ",$895.50 ,"$1,940.25 ","$2,149.20 ","$2,716.35 ","$2,238.75 "
Carle BroMenn Medical Center,8140054,POUCH INSTR 6.75X12IN,244756,,270,$9.73 ,$9.73 ,$2.92 ,$8.85 ,$6.81 ,$2.92 ,$6.32 ,$7.01 ,$8.85 ,$7.30 
Carle BroMenn Medical Center,8140054,POUCH RELIACATCH SPCMN 10MM,245078,,270,$524.73 ,$524.73 ,$157.42 ,$477.50 ,$367.31 ,$157.42 ,$341.07 ,$377.81 ,$477.50 ,$393.55 
Carle BroMenn Medical Center,8140054,POUCH RELIACATCH SPCMN 12MM,245079,,270,$141.75 ,$141.75 ,$42.53 ,$128.99 ,$99.23 ,$42.53 ,$92.14 ,$102.06 ,$128.99 ,$106.31 
Carle BroMenn Medical Center,8140054,POUCH UROSTOMY TRNSPRNT 2.75IN,244167,,270,$1.54 ,$1.54 ,$0.46 ,$1.40 ,$1.08 ,$0.46 ,$1.00 ,$1.11 ,$1.40 ,$1.16 
Carle BroMenn Medical Center,8140054,PREFILTER STACKHOUSE CHRCL,244804,,270,$0.28 ,$0.28 ,$0.08 ,$0.25 ,$0.20 ,$0.08 ,$0.18 ,$0.20 ,$0.25 ,$0.21 
Carle BroMenn Medical Center,8140054,PROBE CRYO ABLAT MLBL 10CM,244774,,270,$1.11 ,$1.11 ,$0.33 ,$1.01 ,$0.78 ,$0.33 ,$0.72 ,$0.80 ,$1.01 ,$0.83 
Carle BroMenn Medical Center,8140054,PROBE HK 3.5MM,245235,,270,$3.33 ,$3.33 ,$1.00 ,$3.03 ,$2.33 ,$1.00 ,$2.16 ,$2.40 ,$3.03 ,$2.50 
Carle BroMenn Medical Center,8140054,PROBE ILLUM 25G RFID X1 LASER,244832,,270,$0.56 ,$0.56 ,$0.17 ,$0.51 ,$0.39 ,$0.17 ,$0.36 ,$0.40 ,$0.51 ,$0.42 
Carle BroMenn Medical Center,8140054,PROBE LITHOTRIPSY 3.4MM SHOCK PUL,250106,,270,"$1,983.20 ","$1,983.20 ",$594.96 ,"$1,804.71 ","$1,388.24 ",$594.96 ,"$1,289.08 ","$1,427.90 ","$1,804.71 ","$1,487.40 "
Carle BroMenn Medical Center,8140054,PROBE SERFAS ENERGY,235483,,270,$507.39 ,$507.39 ,$152.22 ,$461.72 ,$355.17 ,$152.22 ,$329.80 ,$365.32 ,$461.72 ,$380.54 
Carle BroMenn Medical Center,8140054,PROBE SUPER ENERGY 90-S 3.5,244836,,270,$3.33 ,$3.33 ,$1.00 ,$3.03 ,$2.33 ,$1.00 ,$2.16 ,$2.40 ,$3.03 ,$2.50 
Carle BroMenn Medical Center,8140054,PROBE ULTRASONIC TIP,2012,,270,$701.25 ,$701.25 ,$210.38 ,$638.14 ,$490.88 ,$210.38 ,$455.81 ,$504.90 ,$638.14 ,$525.94 
Carle BroMenn Medical Center,8140054,PROBE YSI 400 SER GP 9F ESOPH/REC,249754,,270,$0.17 ,$0.17 ,$0.05 ,$0.15 ,$0.12 ,$0.05 ,$0.11 ,$0.12 ,$0.15 ,$0.13 
Carle BroMenn Medical Center,8140054,PROGRAMMER PT THRPY MGR RS2,238934,,270,"$3,735.00 ","$3,735.00 ","$1,120.50 ","$3,398.85 ","$2,614.50 ","$1,120.50 ","$2,427.75 ","$2,689.20 ","$3,398.85 ","$2,801.25 "
Carle BroMenn Medical Center,8140054,PROGRAMMER RECHARGE MGR RS2,238935,,270,"$5,100.00 ","$5,100.00 ","$1,530.00 ","$4,641.00 ","$3,570.00 ","$1,530.00 ","$3,315.00 ","$3,672.00 ","$4,641.00 ","$3,825.00 "
Carle BroMenn Medical Center,8140054,PROTACK 5MM 6/BX,244568,,270,"$2,081.69 ","$2,081.69 ",$624.51 ,"$1,894.34 ","$1,457.18 ",$624.51 ,"$1,353.10 ","$1,498.82 ","$1,894.34 ","$1,561.27 "
Carle BroMenn Medical Center,8140054,PROTECTOR CORNEAL CROUCH,244534,,270,$0.33 ,$0.33 ,$0.10 ,$0.30 ,$0.23 ,$0.10 ,$0.21 ,$0.24 ,$0.30 ,$0.25 
Carle BroMenn Medical Center,8140054,PROTECTOR ORTHO ALEXIS MD/LG,245198,,270,$675.00 ,$675.00 ,$202.50 ,$614.25 ,$472.50 ,$202.50 ,$438.75 ,$486.00 ,$614.25 ,$506.25 
Carle BroMenn Medical Center,8140054,PROTECTOR ORTHO ALEXIS SM/MD,245242,,270,$615.00 ,$615.00 ,$184.50 ,$559.65 ,$430.50 ,$184.50 ,$399.75 ,$442.80 ,$559.65 ,$461.25 
Carle BroMenn Medical Center,8140054,PROTECTOR WOUND LARGE BX/5,203530,,270,$129.00 ,$129.00 ,$38.70 ,$117.39 ,$90.30 ,$38.70 ,$83.85 ,$92.88 ,$117.39 ,$96.75 
Carle BroMenn Medical Center,8140054,PROTECTOR WOUND MEDIUM BX/5,203529,,270,$84.00 ,$84.00 ,$25.20 ,$76.44 ,$58.80 ,$25.20 ,$54.60 ,$60.48 ,$76.44 ,$63.00 
Carle BroMenn Medical Center,8140054,PROTECTOR WOUND MEDIUM LID 3/BX A,234267,,270,"$1,000.00 ","$1,000.00 ",$300.00 ,$910.00 ,$700.00 ,$300.00 ,$650.00 ,$720.00 ,$910.00 ,$750.00 
Carle BroMenn Medical Center,8140054,PROTECTOR WOUND SMALL BX/5,203528,,270,$84.00 ,$84.00 ,$25.20 ,$76.44 ,$58.80 ,$25.20 ,$54.60 ,$60.48 ,$76.44 ,$63.00 
Carle BroMenn Medical Center,8140054,PUNCH AORTIC ROTARY LONG 4.0MM 6/,244760,,270,$75.00 ,$75.00 ,$22.50 ,$68.25 ,$52.50 ,$22.50 ,$48.75 ,$54.00 ,$68.25 ,$56.25 
Carle BroMenn Medical Center,8140054,PUNCH AORTIC ROTARY LONG 5.0MM,244750,,270,$0.56 ,$0.56 ,$0.17 ,$0.51 ,$0.39 ,$0.17 ,$0.36 ,$0.40 ,$0.51 ,$0.42 
Carle BroMenn Medical Center,8140054,PUNCH PUSHLOCK DISP 3.5MM,110230,,270,$225.00 ,$225.00 ,$67.50 ,$204.75 ,$157.50 ,$67.50 ,$146.25 ,$162.00 ,$204.75 ,$168.75 
Carle BroMenn Medical Center,8140054,RASP HELIO AM 3.2X18.3MM,245220,,270,$431.82 ,$431.82 ,$129.55 ,$392.96 ,$302.27 ,$129.55 ,$280.68 ,$310.91 ,$392.96 ,$323.87 
Carle BroMenn Medical Center,8140054,RASP HELIOCOIDAL MD 3.2,244742,,270,$411.39 ,$411.39 ,$123.42 ,$374.36 ,$287.97 ,$123.42 ,$267.40 ,$296.20 ,$374.36 ,$308.54 
Carle BroMenn Medical Center,8140054,REAMER 3MM CALIBRATED,247607,,270,$473.10 ,$473.10 ,$141.93 ,$430.52 ,$331.17 ,$141.93 ,$307.52 ,$340.63 ,$430.52 ,$354.83 
Carle BroMenn Medical Center,8140054,REAMER GFORCE 7MM,198220,,270,"$1,956.00 ","$1,956.00 ",$586.80 ,"$1,779.96 ","$1,369.20 ",$586.80 ,"$1,271.40 ","$1,408.32 ","$1,779.96 ","$1,467.00 "
Carle BroMenn Medical Center,8140054,REAMER SRG MOD TRNKL FIT MDLR SHF,243012,,270,$712.50 ,$712.50 ,$213.75 ,$648.38 ,$498.75 ,$213.75 ,$463.13 ,$513.00 ,$648.38 ,$534.38 
Carle BroMenn Medical Center,8140054,REDUCER FITTING 7/8-1/4IN STL,245225,,270,$33.09 ,$33.09 ,$9.93 ,$30.11 ,$23.16 ,$9.93 ,$21.51 ,$23.82 ,$30.11 ,$24.82 
Carle BroMenn Medical Center,8140054,RELOAD 30MM TA WHITE VASCULAR 12/,242460,,270,$263.79 ,$263.79 ,$79.14 ,$240.05 ,$184.65 ,$79.14 ,$171.46 ,$189.93 ,$240.05 ,$197.84 
Carle BroMenn Medical Center,8140054,RELOAD 35MM WHITE 12/BX,242471,,270,$641.55 ,$641.55 ,$192.47 ,$583.81 ,$449.09 ,$192.47 ,$417.01 ,$461.92 ,$583.81 ,$481.16 
Carle BroMenn Medical Center,8140054,RELOAD 45MM BLUE 12/BX,242473,,270,$458.09 ,$458.09 ,$137.43 ,$416.86 ,$320.66 ,$137.43 ,$297.76 ,$329.82 ,$416.86 ,$343.57 
Carle BroMenn Medical Center,8140054,RELOAD 45MM GREEN 12/BX,242478,,270,$458.09 ,$458.09 ,$137.43 ,$416.86 ,$320.66 ,$137.43 ,$297.76 ,$329.82 ,$416.86 ,$343.57 
Carle BroMenn Medical Center,8140054,RELOAD 45MM WHITE 12/BX,242458,,270,$458.09 ,$458.09 ,$137.43 ,$416.86 ,$320.66 ,$137.43 ,$297.76 ,$329.82 ,$416.86 ,$343.57 
Carle BroMenn Medical Center,8140054,RELOAD 55MM GIA BLUE 12/BX,242466,,270,$308.91 ,$308.91 ,$92.67 ,$281.11 ,$216.24 ,$92.67 ,$200.79 ,$222.42 ,$281.11 ,$231.68 
Carle BroMenn Medical Center,8140054,RELOAD 60MM BLUE 12/BX,242606,,270,$495.33 ,$495.33 ,$148.60 ,$450.75 ,$346.73 ,$148.60 ,$321.96 ,$356.64 ,$450.75 ,$371.50 
Carle BroMenn Medical Center,8140054,RELOAD 60MM GIA BLUE 12/BX,242459,,270,$262.93 ,$262.93 ,$78.88 ,$239.27 ,$184.05 ,$78.88 ,$170.90 ,$189.31 ,$239.27 ,$197.20 
Carle BroMenn Medical Center,8140054,RELOAD 60MM GREEN 12/BX,242607,,270,$495.33 ,$495.33 ,$148.60 ,$450.75 ,$346.73 ,$148.60 ,$321.96 ,$356.64 ,$450.75 ,$371.50 
Carle BroMenn Medical Center,8140054,RELOAD 60MM TA GREEN 12/BX,242462,,270,$271.48 ,$271.48 ,$81.44 ,$247.05 ,$190.04 ,$81.44 ,$176.46 ,$195.47 ,$247.05 ,$203.61 
Carle BroMenn Medical Center,8140054,RELOAD 60MM WHITE 12/BX,242469,,270,$495.33 ,$495.33 ,$148.60 ,$450.75 ,$346.73 ,$148.60 ,$321.96 ,$356.64 ,$450.75 ,$371.50 
Carle BroMenn Medical Center,8140054,RELOAD 75MM GIA BLUE 12/BX,242467,,270,$457.64 ,$457.64 ,$137.29 ,$416.45 ,$320.35 ,$137.29 ,$297.47 ,$329.50 ,$416.45 ,$343.23 
Carle BroMenn Medical Center,8140054,RELOAD 75MM GIA GREEN 12/BX,242468,,270,$451.15 ,$451.15 ,$135.35 ,$410.55 ,$315.81 ,$135.35 ,$293.25 ,$324.83 ,$410.55 ,$338.36 
Carle BroMenn Medical Center,8140054,RELOAD ENDO GIA ROTIC 30 2.5MM,244688,,270,"$1,228.95 ","$1,228.95 ",$368.69 ,"$1,118.34 ",$860.27 ,$368.69 ,$798.82 ,$884.84 ,"$1,118.34 ",$921.71 
Carle BroMenn Medical Center,8140054,RELOAD ENDO GIA ROTIC 45 2.0MM,244361,,270,"$1,323.51 ","$1,323.51 ",$397.05 ,"$1,204.39 ",$926.46 ,$397.05 ,$860.28 ,$952.93 ,"$1,204.39 ",$992.63 
Carle BroMenn Medical Center,8140054,RELOAD GRAY 45MM 12/BX,242477,,270,$457.20 ,$457.20 ,$137.16 ,$416.05 ,$320.04 ,$137.16 ,$297.18 ,$329.18 ,$416.05 ,$342.90 
Carle BroMenn Medical Center,8140054,RELOAD MF ENDO HERNIA 4.8MM,244854,,270,$481.30 ,$481.30 ,$144.39 ,$437.98 ,$336.91 ,$144.39 ,$312.85 ,$346.54 ,$437.98 ,$360.98 
Carle BroMenn Medical Center,8140054,RELOAD RELIATACK STD 10 TACK,245144,,270,$0.56 ,$0.56 ,$0.17 ,$0.51 ,$0.39 ,$0.17 ,$0.36 ,$0.40 ,$0.51 ,$0.42 
Carle BroMenn Medical Center,8140054,RELOAD TA 60-4.8,244732,,270,$542.96 ,$542.96 ,$162.89 ,$494.09 ,$380.07 ,$162.89 ,$352.92 ,$390.93 ,$494.09 ,$407.22 
Carle BroMenn Medical Center,8140054,RELOAD TA 90-4.8,244734,,270,$529.71 ,$529.71 ,$158.91 ,$482.04 ,$370.80 ,$158.91 ,$344.31 ,$381.39 ,$482.04 ,$397.28 
Carle BroMenn Medical Center,8140054,RELOAD TRI-STAPLE 2.0 RADMT,245067,,270,"$1,991.13 ","$1,991.13 ",$597.34 ,"$1,811.93 ","$1,393.79 ",$597.34 ,"$1,294.23 ","$1,433.61 ","$1,811.93 ","$1,493.35 "
Carle BroMenn Medical Center,8140054,RELOAD TRI-STAPLE 2.0 RADXT,245068,,270,"$2,289.81 ","$2,289.81 ",$686.94 ,"$2,083.73 ","$1,602.87 ",$686.94 ,"$1,488.38 ","$1,648.66 ","$2,083.73 ","$1,717.36 "
Carle BroMenn Medical Center,8140054,REMOVER LOTION DURAPREP,244357,,270,$9.99 ,$9.99 ,$3.00 ,$9.09 ,$6.99 ,$3.00 ,$6.49 ,$7.19 ,$9.09 ,$7.49 
Carle BroMenn Medical Center,8140054,REMOVER STAPLE SKIN PREM,244225,,270,$39.66 ,$39.66 ,$11.90 ,$36.09 ,$27.76 ,$11.90 ,$25.78 ,$28.56 ,$36.09 ,$29.75 
Carle BroMenn Medical Center,8140054,RESERVOIR RPLCMNT BACKFLUSH,244689,,270,$0.33 ,$0.33 ,$0.10 ,$0.30 ,$0.23 ,$0.10 ,$0.21 ,$0.24 ,$0.30 ,$0.25 
Carle BroMenn Medical Center,8140054,RESTRAINT HEAD UNIV ADJ STRAP,244826,,270,$0.33 ,$0.33 ,$0.10 ,$0.30 ,$0.23 ,$0.10 ,$0.21 ,$0.24 ,$0.30 ,$0.25 
Carle BroMenn Medical Center,8140054,RETAINER GLASSMAN VISCERA LG FISH,244668,,270,$85.20 ,$85.20 ,$25.56 ,$77.53 ,$59.64 ,$25.56 ,$55.38 ,$61.34 ,$77.53 ,$63.90 
Carle BroMenn Medical Center,8140054,RETRACTOR 28.5X19CM,244571,,270,$337.02 ,$337.02 ,$101.11 ,$306.69 ,$235.91 ,$101.11 ,$219.06 ,$242.65 ,$306.69 ,$252.77 
Carle BroMenn Medical Center,8140054,RETRACTOR C SECTION 11X17CM XL,250768,,270,$162.00 ,$162.00 ,$48.60 ,$147.42 ,$113.40 ,$48.60 ,$105.30 ,$116.64 ,$147.42 ,$121.50 
Carle BroMenn Medical Center,8140054,RETRACTOR CSECTION 9X14CM 5/BX,250767,,270,$129.00 ,$129.00 ,$38.70 ,$117.39 ,$90.30 ,$38.70 ,$83.85 ,$92.88 ,$117.39 ,$96.75 
Carle BroMenn Medical Center,8140054,RETRACTOR DURAHOOK 6MM,244595,,270,$70.30 ,$70.30 ,$21.09 ,$63.97 ,$49.21 ,$21.09 ,$45.70 ,$50.62 ,$63.97 ,$52.73 
Carle BroMenn Medical Center,8140054,RETRACTOR ENDO 10MM,244433,,270,$678.90 ,$678.90 ,$203.67 ,$617.80 ,$475.23 ,$203.67 ,$441.29 ,$488.81 ,$617.80 ,$509.18 
Carle BroMenn Medical Center,8140054,RETRACTOR OCTOPUS,2589,,270,"$3,660.00 ","$3,660.00 ","$1,098.00 ","$3,330.60 ","$2,562.00 ","$1,098.00 ","$2,379.00 ","$2,635.20 ","$3,330.60 ","$2,745.00 "
Carle BroMenn Medical Center,8140054,ROD REAMING 2.5MM 950MM EX,6660,,270,$258.00 ,$258.00 ,$77.40 ,$234.78 ,$180.60 ,$77.40 ,$167.70 ,$185.76 ,$234.78 ,$193.50 
Carle BroMenn Medical Center,8140054,ROUTER DURAGUARD LG,245222,,270,$383.28 ,$383.28 ,$114.98 ,$348.78 ,$268.30 ,$114.98 ,$249.13 ,$275.96 ,$348.78 ,$287.46 
Carle BroMenn Medical Center,8140054,ROUTER DURAGUARD MD,245221,,270,$383.28 ,$383.28 ,$114.98 ,$348.78 ,$268.30 ,$114.98 ,$249.13 ,$275.96 ,$348.78 ,$287.46 
Carle BroMenn Medical Center,8140054,SCALPEL HARMNC 5MMX36CM ERGO ADAP,245031,,270,"$1,352.81 ","$1,352.81 ",$405.84 ,"$1,231.06 ",$946.97 ,$405.84 ,$879.33 ,$974.02 ,"$1,231.06 ","$1,014.61 "
Carle BroMenn Medical Center,8140054,SCOPE FLEX INTUB 3.5MMX65CM,245155,,270,$817.13 ,$817.13 ,$245.14 ,$743.59 ,$571.99 ,$245.14 ,$531.13 ,$588.33 ,$743.59 ,$612.85 
Carle BroMenn Medical Center,8140054,SCOPE LITHOVUE DISP,224023,,270,"$4,500.00 ","$4,500.00 ","$1,350.00 ","$4,095.00 ","$3,150.00 ","$1,350.00 ","$2,925.00 ","$3,240.00 ","$4,095.00 ","$3,375.00 "
Carle BroMenn Medical Center,8140054,SCOTCHCAST 4IN ROLL,49,,270,$9.31 ,$9.31 ,$2.79 ,$8.47 ,$6.52 ,$2.79 ,$6.05 ,$6.70 ,$8.47 ,$6.98 
Carle BroMenn Medical Center,8140054,SCRAPER RETRACTABLE DDMS 25GA,245060,,270,$0.67 ,$0.67 ,$0.20 ,$0.61 ,$0.47 ,$0.20 ,$0.44 ,$0.48 ,$0.61 ,$0.50 
Carle BroMenn Medical Center,8140054,SCREW G7 LPR DOME 6.5X25MM,237863,,270,$75.00 ,$75.00 ,$22.50 ,$68.25 ,$52.50 ,$22.50 ,$48.75 ,$54.00 ,$68.25 ,$56.25 
Carle BroMenn Medical Center,8140054,SCREW G7 LPR DOME 6.5X35MM,238314,,270,$75.00 ,$75.00 ,$22.50 ,$68.25 ,$52.50 ,$22.50 ,$48.75 ,$54.00 ,$68.25 ,$56.25 
Carle BroMenn Medical Center,8140054,SCREW SELF DRILL SA 3.5X13 2PK,241128,,270,$495.00 ,$495.00 ,$148.50 ,$450.45 ,$346.50 ,$148.50 ,$321.75 ,$356.40 ,$450.45 ,$371.25 
Carle BroMenn Medical Center,8140054,SCRUB HIBICLENS 4OZ,244850,,270,$8.61 ,$8.61 ,$2.58 ,$7.84 ,$6.03 ,$2.58 ,$5.60 ,$6.20 ,$7.84 ,$6.46 
Carle BroMenn Medical Center,8140054,SEAL MYOSURE 10/BX,120411,,270,$30.00 ,$30.00 ,$9.00 ,$27.30 ,$21.00 ,$9.00 ,$19.50 ,$21.60 ,$27.30 ,$22.50 
Carle BroMenn Medical Center,8140054,SEALANT  DURASEAL EXACT 5ML,3786,,270,"$3,146.56 ","$3,146.56 ",$943.97 ,"$2,863.37 ","$2,202.59 ",$943.97 ,"$2,045.26 ","$2,265.52 ","$2,863.37 ","$2,359.92 "
Carle BroMenn Medical Center,8140054,SEALANT FIBRIN VISTASEAL 10ML,253691,,270,"$1,518.42 ","$1,518.42 ",$455.53 ,"$1,381.76 ","$1,062.89 ",$455.53 ,$986.97 ,"$1,093.26 ","$1,381.76 ","$1,138.82 "
Carle BroMenn Medical Center,8140054,SEALANT FIBRIN VISTASEAL 4ML,253690,,270,$660.18 ,$660.18 ,$198.05 ,$600.76 ,$462.13 ,$198.05 ,$429.12 ,$475.33 ,$600.76 ,$495.14 
Carle BroMenn Medical Center,8140054,SEALANT HEMOSTATIC TISSEEL 4ML,245243,,270,$440.94 ,$440.94 ,$132.28 ,$401.26 ,$308.66 ,$132.28 ,$286.61 ,$317.48 ,$401.26 ,$330.71 
Carle BroMenn Medical Center,8140054,SEALANT TISSEEL FRZN 10ML,245145,,270,"$1,082.10 ","$1,082.10 ",$324.63 ,$984.71 ,$757.47 ,$324.63 ,$703.37 ,$779.11 ,$984.71 ,$811.58 
Carle BroMenn Medical Center,8140054,SEALER AQUAMANTYS 6.0 BIP,244788,,270,"$2,004.45 ","$2,004.45 ",$601.34 ,"$1,824.05 ","$1,403.12 ",$601.34 ,"$1,302.89 ","$1,443.20 ","$1,824.05 ","$1,503.34 "
Carle BroMenn Medical Center,8140054,SEALER TISSUE ENSEAL X1,894,,270,"$1,466.04 ","$1,466.04 ",$439.81 ,"$1,334.10 ","$1,026.23 ",$439.81 ,$952.93 ,"$1,055.55 ","$1,334.10 ","$1,099.53 "
Carle BroMenn Medical Center,8140054,SENSOR ACUMEN IQ 5/CA,243891,,270,"$1,230.00 ","$1,230.00 ",$369.00 ,"$1,119.30 ",$861.00 ,$369.00 ,$799.50 ,$885.60 ,"$1,119.30 ",$922.50 
Carle BroMenn Medical Center,8140054,SEPRAFILM 3X5 SHEET,244729,,270,"$2,412.05 ","$2,412.05 ",$723.62 ,"$2,194.97 ","$1,688.44 ",$723.62 ,"$1,567.83 ","$1,736.68 ","$2,194.97 ","$1,809.04 "
Carle BroMenn Medical Center,8140054,SET 360 SPRAY ENDO APPLC,245071,,270,$344.43 ,$344.43 ,$103.33 ,$313.43 ,$241.10 ,$103.33 ,$223.88 ,$247.99 ,$313.43 ,$258.32 
Carle BroMenn Medical Center,8140054,SET ARTHROSCOPY PUMP TU,244944,,270,$189.74 ,$189.74 ,$56.92 ,$172.66 ,$132.82 ,$56.92 ,$123.33 ,$136.61 ,$172.66 ,$142.31 
Carle BroMenn Medical Center,8140054,SET CATH HERMETIC VNTRCL,236744,,270,$357.36 ,$357.36 ,$107.21 ,$325.20 ,$250.15 ,$107.21 ,$232.28 ,$257.30 ,$325.20 ,$268.02 
Carle BroMenn Medical Center,8140054,SET CATHETER 24FR NEPHROSTOMY RE-,1216,,270,$214.77 ,$214.77 ,$64.43 ,$195.44 ,$150.34 ,$64.43 ,$139.60 ,$154.63 ,$195.44 ,$161.08 
Carle BroMenn Medical Center,8140054,SET COLLAR ASPEN VISTA TX ADLT,244212,,270,$141.00 ,$141.00 ,$42.30 ,$128.31 ,$98.70 ,$42.30 ,$91.65 ,$101.52 ,$128.31 ,$105.75 
Carle BroMenn Medical Center,8140054,SET COLLECTION STERILE 6FT,232575,,270,$20.84 ,$20.84 ,$6.25 ,$18.96 ,$14.59 ,$6.25 ,$13.55 ,$15.00 ,$18.96 ,$15.63 
Carle BroMenn Medical Center,8140054,SET CYSTOSCOPY/IRRIGATION,244123,,270,$12.64 ,$12.64 ,$3.79 ,$11.50 ,$8.85 ,$3.79 ,$8.22 ,$9.10 ,$11.50 ,$9.48 
Carle BroMenn Medical Center,8140054,SET HEYMAN FOLLOWER 10-24F,244670,,270,$821.34 ,$821.34 ,$246.40 ,$747.42 ,$574.94 ,$246.40 ,$533.87 ,$591.36 ,$747.42 ,$616.01 
Carle BroMenn Medical Center,8140054,SET LENS SUPERVIEW DISP,244630,,270,$405.37 ,$405.37 ,$121.61 ,$368.89 ,$283.76 ,$121.61 ,$263.49 ,$291.87 ,$368.89 ,$304.03 
Carle BroMenn Medical Center,8140054,SET SHEATH 8/10 DILATOR,236596,,270,$147.93 ,$147.93 ,$44.38 ,$134.62 ,$103.55 ,$44.38 ,$96.15 ,$106.51 ,$134.62 ,$110.95 
Carle BroMenn Medical Center,8140054,SET SHEATH ACCESS 11/13F 28CM,239354,,270,$0.67 ,$0.67 ,$0.20 ,$0.61 ,$0.47 ,$0.20 ,$0.44 ,$0.48 ,$0.61 ,$0.50 
Carle BroMenn Medical Center,8140054,SET SIZER CIRCULAR STAPLER 1/BX,242479,,270,$396.63 ,$396.63 ,$118.99 ,$360.93 ,$277.64 ,$118.99 ,$257.81 ,$285.57 ,$360.93 ,$297.47 
Carle BroMenn Medical Center,8140054,SET SUCT TU QC CRTG,245154,,270,"$2,196.00 ","$2,196.00 ",$658.80 ,"$1,998.36 ","$1,537.20 ",$658.80 ,"$1,427.40 ","$1,581.12 ","$1,998.36 ","$1,647.00 "
Carle BroMenn Medical Center,8140054,SET TISSEEL AEROSOL SPRAY,245247,,270,$177.82 ,$177.82 ,$53.35 ,$161.82 ,$124.47 ,$53.35 ,$115.58 ,$128.03 ,$161.82 ,$133.37 
Carle BroMenn Medical Center,8140054,SET TU I/FLOW AQUILEX,245042,,270,$300.00 ,$300.00 ,$90.00 ,$273.00 ,$210.00 ,$90.00 ,$195.00 ,$216.00 ,$273.00 ,$225.00 
Carle BroMenn Medical Center,8140054,SET TU O/FLOW AQUILEX 10/BX,245041,,270,$30.00 ,$30.00 ,$9.00 ,$27.30 ,$21.00 ,$9.00 ,$19.50 ,$21.60 ,$27.30 ,$22.50 
Carle BroMenn Medical Center,8140054,SET TUBE AIRSEAL TRILUMEN FLTR CA,208432,,270,$262.65 ,$262.65 ,$78.80 ,$239.01 ,$183.86 ,$78.80 ,$170.72 ,$189.11 ,$239.01 ,$196.99 
Carle BroMenn Medical Center,8140054,SET TUBE/CORD FLYING LEADS,237694,,270,$141.92 ,$141.92 ,$42.58 ,$129.15 ,$99.34 ,$42.58 ,$92.25 ,$102.18 ,$129.15 ,$106.44 
Carle BroMenn Medical Center,8140054,SET TUBING IV EXTENSION 30IN MACR,498,,270,$2.12 ,$2.12 ,$0.64 ,$1.93 ,$1.48 ,$0.64 ,$1.38 ,$1.53 ,$1.93 ,$1.59 
Carle BroMenn Medical Center,8140054,SET TUR Y,244038,,270,$41.10 ,$41.10 ,$12.33 ,$37.40 ,$28.77 ,$12.33 ,$26.72 ,$29.59 ,$37.40 ,$30.83 
Carle BroMenn Medical Center,8140054,SET URET DILATOR S-CRV 073701,244999,,270,"$1,049.94 ","$1,049.94 ",$314.98 ,$955.45 ,$734.96 ,$314.98 ,$682.46 ,$755.96 ,$955.45 ,$787.46 
Carle BroMenn Medical Center,8140054,SHEAR CRV HARMONIC PISTOL 36CM,892,,270,"$1,421.57 ","$1,421.57 ",$426.47 ,"$1,293.63 ",$995.10 ,$426.47 ,$924.02 ,"$1,023.53 ","$1,293.63 ","$1,066.18 "
Carle BroMenn Medical Center,8140054,SHEAR ENDO 5MM,244685,,270,$552.33 ,$552.33 ,$165.70 ,$502.62 ,$386.63 ,$165.70 ,$359.01 ,$397.68 ,$502.62 ,$414.25 
Carle BroMenn Medical Center,8140054,SHEAR FOCUS HARMONIC 9CM,245044,,270,$192.80 ,$192.80 ,$57.84 ,$175.45 ,$134.96 ,$57.84 ,$125.32 ,$138.82 ,$175.45 ,$144.60 
Carle BroMenn Medical Center,8140054,SHEATH AXIUM BIG CRV 22CM,237719,,270,"$1,616.55 ","$1,616.55 ",$484.97 ,"$1,471.06 ","$1,131.59 ",$484.97 ,"$1,050.76 ","$1,163.92 ","$1,471.06 ","$1,212.41 "
Carle BroMenn Medical Center,8140054,SHEATH FORTE XE URET 2 35CM,244710,,270,$285.00 ,$285.00 ,$85.50 ,$259.35 ,$199.50 ,$85.50 ,$185.25 ,$205.20 ,$259.35 ,$213.75 
Carle BroMenn Medical Center,8140054,SHEATH HD URET ACCESS 12/14F 3,239722,,270,$360.60 ,$360.60 ,$108.18 ,$328.15 ,$252.42 ,$108.18 ,$234.39 ,$259.63 ,$328.15 ,$270.45 
Carle BroMenn Medical Center,8140054,SHEATH HD URET ACS 11/13F 36CM,238652,,270,$3.33 ,$3.33 ,$1.00 ,$3.03 ,$2.33 ,$1.00 ,$2.16 ,$2.40 ,$3.03 ,$2.50 
Carle BroMenn Medical Center,8140054,SHEATH INTRD 405120 10F,244522,,270,$115.50 ,$115.50 ,$34.65 ,$105.11 ,$80.85 ,$34.65 ,$75.08 ,$83.16 ,$105.11 ,$86.63 
Carle BroMenn Medical Center,8140054,SHIELD EYE SOFGUARD FLEX EDGE,245259,,270,$6.33 ,$6.33 ,$1.90 ,$5.76 ,$4.43 ,$1.90 ,$4.11 ,$4.56 ,$5.76 ,$4.75 
Carle BroMenn Medical Center,8140054,SIZER INSPIRA XFPR 580CC,237662,,270,$600.00 ,$600.00 ,$180.00 ,$546.00 ,$420.00 ,$180.00 ,$390.00 ,$432.00 ,$546.00 ,$450.00 
Carle BroMenn Medical Center,8140054,SIZER INSPIRA XFPR 615CC,237889,,270,$3.33 ,$3.33 ,$1.00 ,$3.03 ,$2.33 ,$1.00 ,$2.16 ,$2.40 ,$3.03 ,$2.50 
Carle BroMenn Medical Center,8140054,SIZER SIL BRST MPR 210MM NATRELLE,238915,,270,$600.00 ,$600.00 ,$180.00 ,$546.00 ,$420.00 ,$180.00 ,$390.00 ,$432.00 ,$546.00 ,$450.00 
Carle BroMenn Medical Center,8140054,SIZER SIL BRST MPR 255MM NATRELLE,238860,,270,$600.00 ,$600.00 ,$180.00 ,$546.00 ,$420.00 ,$180.00 ,$390.00 ,$432.00 ,$546.00 ,$450.00 
Carle BroMenn Medical Center,8140054,SIZER SIL BRST MPR 310CC NATRELLE,239264,,270,$600.00 ,$600.00 ,$180.00 ,$546.00 ,$420.00 ,$180.00 ,$390.00 ,$432.00 ,$546.00 ,$450.00 
Carle BroMenn Medical Center,8140054,SLEEVE CONVERTER STERILE,244406,,270,$1.87 ,$1.87 ,$0.56 ,$1.70 ,$1.31 ,$0.56 ,$1.22 ,$1.35 ,$1.70 ,$1.40 
Carle BroMenn Medical Center,8140054,SLING ARM W/FOAM STRAP LG,244138,,270,$11.82 ,$11.82 ,$3.55 ,$10.76 ,$8.27 ,$3.55 ,$7.68 ,$8.51 ,$10.76 ,$8.87 
Carle BroMenn Medical Center,8140054,SLING ARM W/FOAM STRAP MD,244137,,270,$11.82 ,$11.82 ,$3.55 ,$10.76 ,$8.27 ,$3.55 ,$7.68 ,$8.51 ,$10.76 ,$8.87 
Carle BroMenn Medical Center,8140054,SLING ARM W/FOAM STRAP SM,244139,,270,$10.89 ,$10.89 ,$3.27 ,$9.91 ,$7.62 ,$3.27 ,$7.08 ,$7.84 ,$9.91 ,$8.17 
Carle BroMenn Medical Center,8140054,SLING ARM W/FOAM STRAP XL,245159,,270,$10.89 ,$10.89 ,$3.27 ,$9.91 ,$7.62 ,$3.27 ,$7.08 ,$7.84 ,$9.91 ,$8.17 
Carle BroMenn Medical Center,8140054,SNARE CAPTIVATOR SM HEXA STF,248535,,270,$40.42 ,$40.42 ,$12.13 ,$36.78 ,$28.29 ,$12.13 ,$26.27 ,$29.10 ,$36.78 ,$30.32 
Carle BroMenn Medical Center,8140054,SNARE SENSATION ST STD OVAL 40,248311,,270,$26.24 ,$26.24 ,$7.87 ,$23.88 ,$18.37 ,$7.87 ,$17.06 ,$18.89 ,$23.88 ,$19.68 
Carle BroMenn Medical Center,8140054,SOCK SPECIMEN MEDIVAC 9IN STANDAR,226213,,270,$2.96 ,$2.96 ,$0.89 ,$2.69 ,$2.07 ,$0.89 ,$1.92 ,$2.13 ,$2.69 ,$2.22 
Carle BroMenn Medical Center,8140054,SOL .9 NACL  250ML,244131,,270,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8140054,SOL .9 NACL  500ML,244125,,270,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8140054,SOL .9 NACL 1000ML,244203,,270,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8140054,SOL BUTLER CLR DIP LIQ 16OZ,244997,,270,$39.00 ,$39.00 ,$11.70 ,$35.49 ,$27.30 ,$11.70 ,$25.35 ,$28.08 ,$35.49 ,$29.25 
Carle BroMenn Medical Center,8140054,SOL D5 .225 NACL  500ML,244205,,270,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8140054,SOL D5 .45 NACL 1000ML,244149,,270,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8140054,SOL D5 1000ML,244204,,270,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8140054,SOL D5 LR 1000ML,244208,,270,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8140054,SOL ELECTRO LUBE ANTI STICK,244764,,270,$89.25 ,$89.25 ,$26.78 ,$81.22 ,$62.48 ,$26.78 ,$58.01 ,$64.26 ,$81.22 ,$66.94 
Carle BroMenn Medical Center,8140054,SOL IRR .9 NACL 3000ML,244128,,270,$41.88 ,$41.88 ,$12.56 ,$38.11 ,$29.32 ,$12.56 ,$27.22 ,$30.15 ,$38.11 ,$31.41 
Carle BroMenn Medical Center,8140054,SOL IRR .9NACL 1000ML,244098,,270,$11.25 ,$11.25 ,$3.38 ,$10.24 ,$7.88 ,$3.38 ,$7.31 ,$8.10 ,$10.24 ,$8.44 
Carle BroMenn Medical Center,8140054,SOL IRR 1.5 GLYCINE 3000ML,244144,,270,$20.33 ,$20.33 ,$6.10 ,$18.50 ,$14.23 ,$6.10 ,$13.21 ,$14.64 ,$18.50 ,$15.25 
Carle BroMenn Medical Center,8140054,SOL IRR STL H20 3000ML,244143,,270,$41.42 ,$41.42 ,$12.43 ,$37.69 ,$28.99 ,$12.43 ,$26.92 ,$29.82 ,$37.69 ,$31.07 
Carle BroMenn Medical Center,8140054,SOL IRR WATER 1000ML,244243,,270,$11.25 ,$11.25 ,$3.38 ,$10.24 ,$7.88 ,$3.38 ,$7.31 ,$8.10 ,$10.24 ,$8.44 
Carle BroMenn Medical Center,8140054,SOL LR  500ML,244156,,270,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8140054,SOL LR 1000ML,244207,,270,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8140054,SOL LR 3000ML,244209,,270,$20.70 ,$20.70 ,$6.21 ,$18.84 ,$14.49 ,$6.21 ,$13.46 ,$14.90 ,$18.84 ,$15.53 
Carle BroMenn Medical Center,8140054,SOL NACL 0.9 INJ 100ML,244155,,270,$3.57 ,$3.57 ,$1.07 ,$3.25 ,$2.50 ,$1.07 ,$2.32 ,$2.57 ,$3.25 ,$2.68 
Carle BroMenn Medical Center,8140054,SOL NORMOSOL-R PH 7/4 1000ML,244206,,270,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8140054,SOL POVIDONE IODINE 4OZ PAINT,244114,,270,$9.99 ,$9.99 ,$3.00 ,$9.09 ,$6.99 ,$3.00 ,$6.49 ,$7.19 ,$9.09 ,$7.49 
Carle BroMenn Medical Center,8140054,SPECIMEN CONVERTER M PORTAL,244541,,270,$2.87 ,$2.87 ,$0.86 ,$2.61 ,$2.01 ,$0.86 ,$1.87 ,$2.07 ,$2.61 ,$2.15 
Carle BroMenn Medical Center,8140054,SPECULUM SIGMOID W/OBTUR 19MM,244579,,270,$20.63 ,$20.63 ,$6.19 ,$18.77 ,$14.44 ,$6.19 ,$13.41 ,$14.85 ,$18.77 ,$15.47 
Carle BroMenn Medical Center,8140054,SPHERE PASSIVE ELECTRODE 12/PK,235937,,270,$93.77 ,$93.77 ,$28.13 ,$85.33 ,$65.64 ,$28.13 ,$60.95 ,$67.51 ,$85.33 ,$70.33 
Carle BroMenn Medical Center,8140054,SPHINCTEROTOME HYD 4.4F 20X260,247185,,270,"$1,202.67 ","$1,202.67 ",$360.80 ,"$1,094.43 ",$841.87 ,$360.80 ,$781.74 ,$865.92 ,"$1,094.43 ",$902.00 
Carle BroMenn Medical Center,8140054,SPLINT 5X30 ONE STEP,244025,,270,$42.00 ,$42.00 ,$12.60 ,$38.22 ,$29.40 ,$12.60 ,$27.30 ,$30.24 ,$38.22 ,$31.50 
Carle BroMenn Medical Center,8140054,SPLINT NASAL EXTRL MD 65X35MM,244531,,270,$173.40 ,$173.40 ,$52.02 ,$157.79 ,$121.38 ,$52.02 ,$112.71 ,$124.85 ,$157.79 ,$130.05 
Carle BroMenn Medical Center,8140054,SPLINT NASAL EXTRL SM 58X30MM,244530,,270,$0.67 ,$0.67 ,$0.20 ,$0.61 ,$0.47 ,$0.20 ,$0.44 ,$0.48 ,$0.61 ,$0.50 
Carle BroMenn Medical Center,8140054,SPLINT NASAL POSISEPX 0.6X2 BX/5,206810,,270,$420.00 ,$420.00 ,$126.00 ,$382.20 ,$294.00 ,$126.00 ,$273.00 ,$302.40 ,$382.20 ,$315.00 
Carle BroMenn Medical Center,8140054,SPLINT ONE-STEP 3X12IN SCOTCH,244250,,270,$14.48 ,$14.48 ,$4.34 ,$13.18 ,$10.14 ,$4.34 ,$9.41 ,$10.43 ,$13.18 ,$10.86 
Carle BroMenn Medical Center,8140054,SPLINT ONE-STEP 4X15IN SCOTCH,244249,,270,$14.32 ,$14.32 ,$4.30 ,$13.03 ,$10.02 ,$4.30 ,$9.31 ,$10.31 ,$13.03 ,$10.74 
Carle BroMenn Medical Center,8140054,SPLINT ONE-STEP 4X30IN SCOTCH,244251,,270,$32.53 ,$32.53 ,$9.76 ,$29.60 ,$22.77 ,$9.76 ,$21.14 ,$23.42 ,$29.60 ,$24.40 
Carle BroMenn Medical Center,8140054,SPLINT SEPTAL DOYLE,985,,270,$138.87 ,$138.87 ,$41.66 ,$126.37 ,$97.21 ,$41.66 ,$90.27 ,$99.99 ,$126.37 ,$104.15 
Carle BroMenn Medical Center,8140054,SPLINT THERMAL NASAL SNGL MD,244767,,270,$0.33 ,$0.33 ,$0.10 ,$0.30 ,$0.23 ,$0.10 ,$0.21 ,$0.24 ,$0.30 ,$0.25 
Carle BroMenn Medical Center,8140054,SPLINT WRIST BLK LT MD,244949,,270,$40.38 ,$40.38 ,$12.11 ,$36.75 ,$28.27 ,$12.11 ,$26.25 ,$29.07 ,$36.75 ,$30.29 
Carle BroMenn Medical Center,8140054,SPLINT WRIST BLK RT MD,244950,,270,$40.38 ,$40.38 ,$12.11 ,$36.75 ,$28.27 ,$12.11 ,$26.25 ,$29.07 ,$36.75 ,$30.29 
Carle BroMenn Medical Center,8140054,SPLINT WRIST FOREARM LH/SM,245160,,270,$27.12 ,$27.12 ,$8.14 ,$24.68 ,$18.98 ,$8.14 ,$17.63 ,$19.53 ,$24.68 ,$20.34 
Carle BroMenn Medical Center,8140054,SPLINT WRIST SMALL RIGHT,245266,,270,$27.12 ,$27.12 ,$8.14 ,$24.68 ,$18.98 ,$8.14 ,$17.63 ,$19.53 ,$24.68 ,$20.34 
Carle BroMenn Medical Center,8140054,SPLINT WRIST/FOREARM BLU LG LT,245202,,270,$14.49 ,$14.49 ,$4.35 ,$13.19 ,$10.14 ,$4.35 ,$9.42 ,$10.43 ,$13.19 ,$10.87 
Carle BroMenn Medical Center,8140054,SPLINT WRIST/FOREARM BLU LG RT,245203,,270,$14.49 ,$14.49 ,$4.35 ,$13.19 ,$10.14 ,$4.35 ,$9.42 ,$10.43 ,$13.19 ,$10.87 
Carle BroMenn Medical Center,8140054,SPONGE 2X2 8PLY STL 2/PK,244214,,270,$0.20 ,$0.20 ,$0.06 ,$0.18 ,$0.14 ,$0.06 ,$0.13 ,$0.14 ,$0.18 ,$0.15 
Carle BroMenn Medical Center,8140054,SPONGE 4X4 12PLY NS 200/PK,244939,,270,$28.74 ,$28.74 ,$8.62 ,$26.15 ,$20.12 ,$8.62 ,$18.68 ,$20.69 ,$26.15 ,$21.56 
Carle BroMenn Medical Center,8140054,SPONGE AVANT GAUZE DRAIN 4X4 2/PK,244218,,270,$17.96 ,$17.96 ,$5.39 ,$16.34 ,$12.57 ,$5.39 ,$11.67 ,$12.93 ,$16.34 ,$13.47 
Carle BroMenn Medical Center,8140054,SPONGE BULKEE LTE 2INX3.5YD,244111,,270,$1.87 ,$1.87 ,$0.56 ,$1.70 ,$1.31 ,$0.56 ,$1.22 ,$1.35 ,$1.70 ,$1.40 
Carle BroMenn Medical Center,8140054,SPONGE DELICOT RPAQUE 50X9MM,243889,,270,$4.11 ,$4.11 ,$1.23 ,$3.74 ,$2.88 ,$1.23 ,$2.67 ,$2.96 ,$3.74 ,$3.08 
Carle BroMenn Medical Center,8140054,SPONGE DELICOT RPAQUE 60X13MM,243890,,270,$4.19 ,$4.19 ,$1.26 ,$3.81 ,$2.93 ,$1.26 ,$2.72 ,$3.02 ,$3.81 ,$3.14 
Carle BroMenn Medical Center,8140054,SPONGE DRAIN 6-PLY 4 X 4,418,,270,$0.39 ,$0.39 ,$0.12 ,$0.35 ,$0.27 ,$0.12 ,$0.25 ,$0.28 ,$0.35 ,$0.29 
Carle BroMenn Medical Center,8140054,SPONGE ENDO KITTNER 5MM,244626,,270,$51.40 ,$51.40 ,$15.42 ,$46.77 ,$35.98 ,$15.42 ,$33.41 ,$37.01 ,$46.77 ,$38.55 
Carle BroMenn Medical Center,8140054,SPONGE FLUFF 6X6.75 STL 10S,244221,,270,$6.09 ,$6.09 ,$1.83 ,$5.54 ,$4.26 ,$1.83 ,$3.96 ,$4.38 ,$5.54 ,$4.57 
Carle BroMenn Medical Center,8140054,SPONGE GAUZE 2 X 2 8-PLY STERILE,9753,,270,$0.07 ,$0.07 ,$0.02 ,$0.06 ,$0.05 ,$0.02 ,$0.05 ,$0.05 ,$0.06 ,$0.05 
Carle BroMenn Medical Center,8140054,SPONGE GAUZE 2X2 2/PACK,839,,270,$0.07 ,$0.07 ,$0.02 ,$0.06 ,$0.05 ,$0.02 ,$0.05 ,$0.05 ,$0.06 ,$0.05 
Carle BroMenn Medical Center,8140054,SPONGE GAUZE 4 X 4 TRAY 8-PLY,411,,270,$1.09 ,$1.09 ,$0.33 ,$0.99 ,$0.76 ,$0.33 ,$0.71 ,$0.78 ,$0.99 ,$0.82 
Carle BroMenn Medical Center,8140054,SPONGE GAUZE 4X4 12PLY STL 10S,244226,,270,$2.59 ,$2.59 ,$0.78 ,$2.36 ,$1.81 ,$0.78 ,$1.68 ,$1.86 ,$2.36 ,$1.94 
Carle BroMenn Medical Center,8140054,SPONGE GAUZE 8 X 4 12-PLY STERILE,412,,270,$0.47 ,$0.47 ,$0.14 ,$0.43 ,$0.33 ,$0.14 ,$0.31 ,$0.34 ,$0.43 ,$0.35 
Carle BroMenn Medical Center,8140054,SPONGE INSTR WIPE 3.62X3IN MEROCE,244817,,270,$7.40 ,$7.40 ,$2.22 ,$6.73 ,$5.18 ,$2.22 ,$4.81 ,$5.33 ,$6.73 ,$5.55 
Carle BroMenn Medical Center,8140054,SPONGE KERLIX FLUFF 6 X 6,414,,270,$1.36 ,$1.36 ,$0.41 ,$1.24 ,$0.95 ,$0.41 ,$0.88 ,$0.98 ,$1.24 ,$1.02 
Carle BroMenn Medical Center,8140054,SPONGE LAP 18 X 18,244175,,270,$0.80 ,$0.80 ,$0.24 ,$0.73 ,$0.56 ,$0.24 ,$0.52 ,$0.58 ,$0.73 ,$0.60 
Carle BroMenn Medical Center,8140054,SPONGE LAP 18 X 4,244202,,270,$0.36 ,$0.36 ,$0.11 ,$0.33 ,$0.25 ,$0.11 ,$0.23 ,$0.26 ,$0.33 ,$0.27 
Carle BroMenn Medical Center,8140054,SPONGE LAP XRAY DETECT 18X36IN,244988,,270,$1.60 ,$1.60 ,$0.48 ,$1.46 ,$1.12 ,$0.48 ,$1.04 ,$1.15 ,$1.46 ,$1.20 
Carle BroMenn Medical Center,8140054,SPONGE PATTY MEROCEL 1.3X1.3CM,244820,,270,$0.03 ,$0.03 ,$0.01 ,$0.03 ,$0.02 ,$0.01 ,$0.02 ,$0.02 ,$0.03 ,$0.02 
Carle BroMenn Medical Center,8140054,SPONGE PATTY MEROCEL 1.3X2.5CM,244810,,270,$0.03 ,$0.03 ,$0.01 ,$0.03 ,$0.02 ,$0.01 ,$0.02 ,$0.02 ,$0.03 ,$0.02 
Carle BroMenn Medical Center,8140054,SPONGE PATTY MEROCEL 1.3X7.6CM 10,244825,,270,$78.95 ,$78.95 ,$23.69 ,$71.84 ,$55.27 ,$23.69 ,$51.32 ,$56.84 ,$71.84 ,$59.21 
Carle BroMenn Medical Center,8140054,SPONGE TONSIL STL 1IN,244862,,270,$7.90 ,$7.90 ,$2.37 ,$7.19 ,$5.53 ,$2.37 ,$5.14 ,$5.69 ,$7.19 ,$5.93 
Carle BroMenn Medical Center,8140054,SPONGE XRAY DETECT LF STL 4X4 RAY,244173,,270,$0.34 ,$0.34 ,$0.10 ,$0.31 ,$0.24 ,$0.10 ,$0.22 ,$0.24 ,$0.31 ,$0.26 
Carle BroMenn Medical Center,8140054,SPRAY TIP VISTASEAL LAP,229953,,270,$189.09 ,$189.09 ,$56.73 ,$172.07 ,$132.36 ,$56.73 ,$122.91 ,$136.14 ,$172.07 ,$141.82 
Carle BroMenn Medical Center,8140054,STAPLER 25MM POWERED 3/BX,242487,,270,"$1,118.21 ","$1,118.21 ",$335.46 ,"$1,017.57 ",$782.75 ,$335.46 ,$726.84 ,$805.11 ,"$1,017.57 ",$838.66 
Carle BroMenn Medical Center,8140054,STAPLER 29MM POWERED 3/BX,242488,,270,"$1,118.21 ","$1,118.21 ",$335.46 ,"$1,017.57 ",$782.75 ,$335.46 ,$726.84 ,$805.11 ,"$1,017.57 ",$838.66 
Carle BroMenn Medical Center,8140054,STAPLER 35MM POWER VASCULAR 3/BX,242476,,270,$866.83 ,$866.83 ,$260.05 ,$788.82 ,$606.78 ,$260.05 ,$563.44 ,$624.12 ,$788.82 ,$650.12 
Carle BroMenn Medical Center,8140054,STAPLER 45MM COMPACT 3/BX,242470,,270,$866.83 ,$866.83 ,$260.05 ,$788.82 ,$606.78 ,$260.05 ,$563.44 ,$624.12 ,$788.82 ,$650.12 
Carle BroMenn Medical Center,8140054,STAPLER 45MM STANDARD 3/BX,242472,,270,$866.83 ,$866.83 ,$260.05 ,$788.82 ,$606.78 ,$260.05 ,$563.44 ,$624.12 ,$788.82 ,$650.12 
Carle BroMenn Medical Center,8140054,STAPLER 55MM GIA CUTTER BLUE 3/bx,242464,,270,$219.88 ,$219.88 ,$65.96 ,$200.09 ,$153.92 ,$65.96 ,$142.92 ,$158.31 ,$200.09 ,$164.91 
Carle BroMenn Medical Center,8140054,STAPLER 60MM COMPACT 3/BX,242475,,270,"$1,040.19 ","$1,040.19 ",$312.06 ,$946.57 ,$728.13 ,$312.06 ,$676.12 ,$748.94 ,$946.57 ,$780.14 
Carle BroMenn Medical Center,8140054,STAPLER 60MM STANDARD 3/BX,242474,,270,"$1,040.19 ","$1,040.19 ",$312.06 ,$946.57 ,$728.13 ,$312.06 ,$676.12 ,$748.94 ,$946.57 ,$780.14 
Carle BroMenn Medical Center,8140054,STAPLER 60MM TA BLUE 3/BX,242457,,270,"$1,045.44 ","$1,045.44 ",$313.63 ,$951.35 ,$731.81 ,$313.63 ,$679.54 ,$752.72 ,$951.35 ,$784.08 
Carle BroMenn Medical Center,8140054,STAPLER 60MM TA GREEN 3/BX,242461,,270,"$1,216.16 ","$1,216.16 ",$364.85 ,"$1,106.71 ",$851.31 ,$364.85 ,$790.50 ,$875.64 ,"$1,106.71 ",$912.12 
Carle BroMenn Medical Center,8140054,STAPLER 75MM GIA CUTTER BLUE 3/BX,242465,,270,"$1,763.31 ","$1,763.31 ",$528.99 ,"$1,604.61 ","$1,234.32 ",$528.99 ,"$1,146.15 ","$1,269.58 ","$1,604.61 ","$1,322.48 "
Carle BroMenn Medical Center,8140054,STAPLER 75MM GIA CUTTER GREEN 3/B,242463,,270,"$1,807.39 ","$1,807.39 ",$542.22 ,"$1,644.72 ","$1,265.17 ",$542.22 ,"$1,174.80 ","$1,301.32 ","$1,644.72 ","$1,355.54 "
Carle BroMenn Medical Center,8140054,STAPLER CONTOUR CRVD BLUE CUTTER,245128,,270,"$1,349.55 ","$1,349.55 ",$404.87 ,"$1,228.09 ",$944.69 ,$404.87 ,$877.21 ,$971.68 ,"$1,228.09 ","$1,012.16 "
Carle BroMenn Medical Center,8140054,STAPLER CONTOUR CRVD GREEN CUTTER,244407,,270,"$1,349.55 ","$1,349.55 ",$404.87 ,"$1,228.09 ",$944.69 ,$404.87 ,$877.21 ,$971.68 ,"$1,228.09 ","$1,012.16 "
Carle BroMenn Medical Center,8140054,STAPLER ENDO UNIV 65,245161,,270,"$1,492.59 ","$1,492.59 ",$447.78 ,"$1,358.26 ","$1,044.81 ",$447.78 ,$970.18 ,"$1,074.66 ","$1,358.26 ","$1,119.44 "
Carle BroMenn Medical Center,8140054,STAPLER MF ENDO HERNIA 4.8MM,244855,,270,$896.06 ,$896.06 ,$268.82 ,$815.41 ,$627.24 ,$268.82 ,$582.44 ,$645.16 ,$815.41 ,$672.05 
Carle BroMenn Medical Center,8140054,STAPLER MF TA 60-4.8 TI GREEN,244733,,270,"$1,071.58 ","$1,071.58 ",$321.47 ,$975.14 ,$750.11 ,$321.47 ,$696.53 ,$771.54 ,$975.14 ,$803.69 
Carle BroMenn Medical Center,8140054,STAPLER MF TA 90-4.8 SS,244735,,270,"$1,216.16 ","$1,216.16 ",$364.85 ,"$1,106.71 ",$851.31 ,$364.85 ,$790.50 ,$875.64 ,"$1,106.71 ",$912.12 
Carle BroMenn Medical Center,8140054,STAPLER PROXIMATE 30MM VASC 3/BX,1180,,270,$234.53 ,$234.53 ,$70.36 ,$213.42 ,$164.17 ,$70.36 ,$152.44 ,$168.86 ,$213.42 ,$175.90 
Carle BroMenn Medical Center,8140054,STAPLER PURSTRING 65 3/BX,244580,,270,$526.23 ,$526.23 ,$157.87 ,$478.87 ,$368.36 ,$157.87 ,$342.05 ,$378.89 ,$478.87 ,$394.67 
Carle BroMenn Medical Center,8140054,STAPLER SKIN 35 WIDE 6/BX,444,,270,$22.18 ,$22.18 ,$6.65 ,$20.18 ,$15.53 ,$6.65 ,$14.42 ,$15.97 ,$20.18 ,$16.64 
Carle BroMenn Medical Center,8140054,STAPLER SKIN 35 WIDE MTRC 12/BX,248081,,270,$70.50 ,$70.50 ,$21.15 ,$64.16 ,$49.35 ,$21.15 ,$45.83 ,$50.76 ,$64.16 ,$52.88 
Carle BroMenn Medical Center,8140054,STAPLER SKIN 35MM REGULAR 6/BX,242492,,270,$18.30 ,$18.30 ,$5.49 ,$16.65 ,$12.81 ,$5.49 ,$11.90 ,$13.18 ,$16.65 ,$13.73 
Carle BroMenn Medical Center,8140054,STAPLER SKIN 35MM WIDE 6/BX,242484,,270,$18.30 ,$18.30 ,$5.49 ,$16.65 ,$12.81 ,$5.49 ,$11.90 ,$13.18 ,$16.65 ,$13.73 
Carle BroMenn Medical Center,8140054,STAPLER SKIN INSORB ABSORB STL,244835,,270,$129.99 ,$129.99 ,$39.00 ,$118.29 ,$90.99 ,$39.00 ,$84.49 ,$93.59 ,$118.29 ,$97.49 
Carle BroMenn Medical Center,8140054,STAPLER SKIN PRECISE DISP DS15,248080,,270,$15.65 ,$15.65 ,$4.70 ,$14.24 ,$10.96 ,$4.70 ,$10.17 ,$11.27 ,$14.24 ,$11.74 
Carle BroMenn Medical Center,8140054,STAPLER SNGL USE 28X4.8MM,244787,,270,"$2,698.53 ","$2,698.53 ",$809.56 ,"$2,455.66 ","$1,888.97 ",$809.56 ,"$1,754.04 ","$1,942.94 ","$2,455.66 ","$2,023.90 "
Carle BroMenn Medical Center,8140054,STAPLER VERSATACK MF 4.0MM 6/BX,206912,,270,$931.26 ,$931.26 ,$279.38 ,$847.45 ,$651.88 ,$279.38 ,$605.32 ,$670.51 ,$847.45 ,$698.45 
Carle BroMenn Medical Center,8140054,STATLOCK FOLEY ANCHORING DEV,244100,,270,$8.88 ,$8.88 ,$2.66 ,$8.08 ,$6.22 ,$2.66 ,$5.77 ,$6.39 ,$8.08 ,$6.66 
Carle BroMenn Medical Center,8140054,STAY ELSTC LNG,244886,,270,$30.23 ,$30.23 ,$9.07 ,$27.51 ,$21.16 ,$9.07 ,$19.65 ,$21.77 ,$27.51 ,$22.67 
Carle BroMenn Medical Center,8140054,STENT CONTOUR VL 4.8X22-30 W/O,236735,,270,$331.74 ,$331.74 ,$99.52 ,$301.88 ,$232.22 ,$99.52 ,$215.63 ,$238.85 ,$301.88 ,$248.81 
Carle BroMenn Medical Center,8140054,STENT CONTOUR VL 6X22-30 W/O,237070,,270,$331.74 ,$331.74 ,$99.52 ,$301.88 ,$232.22 ,$99.52 ,$215.63 ,$238.85 ,$301.88 ,$248.81 
Carle BroMenn Medical Center,8140054,STENT PERCUFLEX+ 6F 24CM,236757,,270,$331.74 ,$331.74 ,$99.52 ,$301.88 ,$232.22 ,$99.52 ,$215.63 ,$238.85 ,$301.88 ,$248.81 
Carle BroMenn Medical Center,8140054,STERIDRAPE APERT 16X16IN SM,244412,,270,$2.99 ,$2.99 ,$0.90 ,$2.72 ,$2.09 ,$0.90 ,$1.94 ,$2.15 ,$2.72 ,$2.24 
Carle BroMenn Medical Center,8140054,STERIDRAPE INCISE LG 32X17,244851,,270,$6.89 ,$6.89 ,$2.07 ,$6.27 ,$4.82 ,$2.07 ,$4.48 ,$4.96 ,$6.27 ,$5.17 
Carle BroMenn Medical Center,8140054,STERIDRAPE INSTRUMENT POUCH,248973,,270,$5.38 ,$5.38 ,$1.61 ,$4.90 ,$3.77 ,$1.61 ,$3.50 ,$3.87 ,$4.90 ,$4.04 
Carle BroMenn Medical Center,8140054,STERIDRAPE IOBAN LRG ISOLATION,244318,,270,$59.46 ,$59.46 ,$17.84 ,$54.11 ,$41.62 ,$17.84 ,$38.65 ,$42.81 ,$54.11 ,$44.60 
Carle BroMenn Medical Center,8140054,STERIDRAPE LARGE TOWEL 17 X 23,244344,,270,$2.37 ,$2.37 ,$0.71 ,$2.16 ,$1.66 ,$0.71 ,$1.54 ,$1.71 ,$2.16 ,$1.78 
Carle BroMenn Medical Center,8140054,STERIDRAPE SMALL TOWEL 17 X 11,244343,,270,$1.64 ,$1.64 ,$0.49 ,$1.49 ,$1.15 ,$0.49 ,$1.07 ,$1.18 ,$1.49 ,$1.23 
Carle BroMenn Medical Center,8140054,STERIDRAPE U-SHAPE 48X53IN,244575,,270,$8.18 ,$8.18 ,$2.45 ,$7.44 ,$5.73 ,$2.45 ,$5.32 ,$5.89 ,$7.44 ,$6.14 
Carle BroMenn Medical Center,8140054,STERISTRIP 0.25IN X 4IN,244240,,270,$2.29 ,$2.29 ,$0.69 ,$2.08 ,$1.60 ,$0.69 ,$1.49 ,$1.65 ,$2.08 ,$1.72 
Carle BroMenn Medical Center,8140054,STERISTRIP 0.25IN X 4IN,423,,270,$2.31 ,$2.31 ,$0.69 ,$2.10 ,$1.62 ,$0.69 ,$1.50 ,$1.66 ,$2.10 ,$1.73 
Carle BroMenn Medical Center,8140054,STERISTRIP 0.5 X 4IN,244088,,270,$2.29 ,$2.29 ,$0.69 ,$2.08 ,$1.60 ,$0.69 ,$1.49 ,$1.65 ,$2.08 ,$1.72 
Carle BroMenn Medical Center,8140054,STERISTRIP 0.5 X 4IN,422,,270,$2.31 ,$2.31 ,$0.69 ,$2.10 ,$1.62 ,$0.69 ,$1.50 ,$1.66 ,$2.10 ,$1.73 
Carle BroMenn Medical Center,8140054,STERISTRIP 1X5IN,244576,,270,$4.50 ,$4.50 ,$1.35 ,$4.10 ,$3.15 ,$1.35 ,$2.93 ,$3.24 ,$4.10 ,$3.38 
Carle BroMenn Medical Center,8140054,STERISTRIP AM 0.25X3IN,244980,,270,$1.52 ,$1.52 ,$0.46 ,$1.38 ,$1.06 ,$0.46 ,$0.99 ,$1.09 ,$1.38 ,$1.14 
Carle BroMenn Medical Center,8140054,STIMULATOR EXTERNAL TEMP INTERSTI,219246,,270,"$1,200.00 ","$1,200.00 ",$360.00 ,"$1,092.00 ",$840.00 ,$360.00 ,$780.00 ,$864.00 ,"$1,092.00 ",$900.00 
Carle BroMenn Medical Center,8140054,STOCKINETTE DBL PLY STL 6X54IN,244989,,270,$14.89 ,$14.89 ,$4.47 ,$13.55 ,$10.42 ,$4.47 ,$9.68 ,$10.72 ,$13.55 ,$11.17 
Carle BroMenn Medical Center,8140054,STOCKINETTE DBL PLY STL 8X48IN,244751,,270,$18.43 ,$18.43 ,$5.53 ,$16.77 ,$12.90 ,$5.53 ,$11.98 ,$13.27 ,$16.77 ,$13.82 
Carle BroMenn Medical Center,8140054,STOCKINETTE IMPRV STL LF 12X48,245239,,270,$16.16 ,$16.16 ,$4.85 ,$14.71 ,$11.31 ,$4.85 ,$10.50 ,$11.64 ,$14.71 ,$12.12 
Carle BroMenn Medical Center,8140054,STOCKING ANTIEMB LG REG KNEE ULTR,244103,,270,$7.89 ,$7.89 ,$2.37 ,$7.18 ,$5.52 ,$2.37 ,$5.13 ,$5.68 ,$7.18 ,$5.92 
Carle BroMenn Medical Center,8140054,STOCKING ANTIEMB MD REG KNEE ULTR,244102,,270,$7.89 ,$7.89 ,$2.37 ,$7.18 ,$5.52 ,$2.37 ,$5.13 ,$5.68 ,$7.18 ,$5.92 
Carle BroMenn Medical Center,8140054,STOCKING ANTIEMB XL REG KNEE ULTR,244104,,270,$7.89 ,$7.89 ,$2.37 ,$7.18 ,$5.52 ,$2.37 ,$5.13 ,$5.68 ,$7.18 ,$5.92 
Carle BroMenn Medical Center,8140054,STOPCOCK 3-WAY TRNSPRNT,244936,,270,$1.88 ,$1.88 ,$0.56 ,$1.71 ,$1.32 ,$0.56 ,$1.22 ,$1.35 ,$1.71 ,$1.41 
Carle BroMenn Medical Center,8140054,STOPCOCK 4WAY 3GANG LG BORE,244483,,270,$15.62 ,$15.62 ,$4.69 ,$14.21 ,$10.93 ,$4.69 ,$10.15 ,$11.25 ,$14.21 ,$11.72 
Carle BroMenn Medical Center,8140054,STOPCOCK DISCOFIX 4WAY D500,244027,,270,$1.44 ,$1.44 ,$0.43 ,$1.31 ,$1.01 ,$0.43 ,$0.94 ,$1.04 ,$1.31 ,$1.08 
Carle BroMenn Medical Center,8140054,STRAP ANKLE DISTRACTOR,247887,,270,$193.50 ,$193.50 ,$58.05 ,$176.09 ,$135.45 ,$58.05 ,$125.78 ,$139.32 ,$176.09 ,$145.13 
Carle BroMenn Medical Center,8140054,STRAP CHIN HEAD F/BEACH CHAIR,249752,,270,$112.46 ,$112.46 ,$33.74 ,$102.34 ,$78.72 ,$33.74 ,$73.10 ,$80.97 ,$102.34 ,$84.35 
Carle BroMenn Medical Center,8140054,STRAP PERSONAL STIRRUP 19X3.5 WIT,4141,,270,$11.61 ,$11.61 ,$3.48 ,$10.57 ,$8.13 ,$3.48 ,$7.55 ,$8.36 ,$10.57 ,$8.71 
Carle BroMenn Medical Center,8140054,STRIP PACKING IODOFORM 0.25IN,306,,270,$4.45 ,$4.45 ,$1.34 ,$4.05 ,$3.12 ,$1.34 ,$2.89 ,$3.20 ,$4.05 ,$3.34 
Carle BroMenn Medical Center,8140054,STRIP PACKING IODOFORM 0.5IN,305,,270,$5.33 ,$5.33 ,$1.60 ,$4.85 ,$3.73 ,$1.60 ,$3.46 ,$3.84 ,$4.85 ,$4.00 
Carle BroMenn Medical Center,8140054,STRIP PKG IODOFORM .25X5YD,244220,,270,$9.71 ,$9.71 ,$2.91 ,$8.84 ,$6.80 ,$2.91 ,$6.31 ,$6.99 ,$8.84 ,$7.28 
Carle BroMenn Medical Center,8140054,STRIP PKG IODOFORM .5X5YD,244230,,270,$10.68 ,$10.68 ,$3.20 ,$9.72 ,$7.48 ,$3.20 ,$6.94 ,$7.69 ,$9.72 ,$8.01 
Carle BroMenn Medical Center,8140054,STRIP PKG IODOFORM 1X5YD,244229,,270,$16.44 ,$16.44 ,$4.93 ,$14.96 ,$11.51 ,$4.93 ,$10.69 ,$11.84 ,$14.96 ,$12.33 
Carle BroMenn Medical Center,8140054,STRIP PKG IODOFORM 2X5YD,244219,,270,$19.41 ,$19.41 ,$5.82 ,$17.66 ,$13.59 ,$5.82 ,$12.62 ,$13.98 ,$17.66 ,$14.56 
Carle BroMenn Medical Center,8140054,STRIP PKG PLN .25X5YD,244217,,270,$9.62 ,$9.62 ,$2.89 ,$8.75 ,$6.73 ,$2.89 ,$6.25 ,$6.93 ,$8.75 ,$7.22 
Carle BroMenn Medical Center,8140054,STRIP PKG PLN .5X5YD,244227,,270,$10.15 ,$10.15 ,$3.05 ,$9.24 ,$7.11 ,$3.05 ,$6.60 ,$7.31 ,$9.24 ,$7.61 
Carle BroMenn Medical Center,8140054,STRIP PKG PLN 1INX5YD,244216,,270,$13.74 ,$13.74 ,$4.12 ,$12.50 ,$9.62 ,$4.12 ,$8.93 ,$9.89 ,$12.50 ,$10.31 
Carle BroMenn Medical Center,8140054,STRIP PKG PLN 2INX5YD,245158,,270,$23.58 ,$23.58 ,$7.07 ,$21.46 ,$16.51 ,$7.07 ,$15.33 ,$16.98 ,$21.46 ,$17.69 
Carle BroMenn Medical Center,8140054,STYLET BENT,243399,,270,$69.00 ,$69.00 ,$20.70 ,$62.79 ,$48.30 ,$20.70 ,$44.85 ,$49.68 ,$62.79 ,$51.75 
Carle BroMenn Medical Center,8140054,SUCTION SIGMOID 18F W/TUBE,244608,,270,$6.15 ,$6.15 ,$1.85 ,$5.60 ,$4.31 ,$1.85 ,$4.00 ,$4.43 ,$5.60 ,$4.61 
Carle BroMenn Medical Center,8140054,SUCTION YANKAUER REG CAPACITY,244142,,270,$1.15 ,$1.15 ,$0.35 ,$1.05 ,$0.81 ,$0.35 ,$0.75 ,$0.83 ,$1.05 ,$0.86 
Carle BroMenn Medical Center,8140054,SUPPORT ATHLETIC LARGE,244359,,270,$9.60 ,$9.60 ,$2.88 ,$8.74 ,$6.72 ,$2.88 ,$6.24 ,$6.91 ,$8.74 ,$7.20 
Carle BroMenn Medical Center,8140054,SUPPORT ATHLETIC MED ADLT,244258,,270,$19.86 ,$19.86 ,$5.96 ,$18.07 ,$13.90 ,$5.96 ,$12.91 ,$14.30 ,$18.07 ,$14.90 
Carle BroMenn Medical Center,8140054,SUPPORT FACIAL ELASTIC MEDIUM,244056,,270,$56.22 ,$56.22 ,$16.87 ,$51.16 ,$39.35 ,$16.87 ,$36.54 ,$40.48 ,$51.16 ,$42.17 
Carle BroMenn Medical Center,8140054,SURGICEL 2X14IN,244865,,270,$171.02 ,$171.02 ,$51.31 ,$155.63 ,$119.71 ,$51.31 ,$111.16 ,$123.13 ,$155.63 ,$128.27 
Carle BroMenn Medical Center,8140054,SURGICEL 2X3IN,244866,,270,$100.82 ,$100.82 ,$30.25 ,$91.75 ,$70.57 ,$30.25 ,$65.53 ,$72.59 ,$91.75 ,$75.62 
Carle BroMenn Medical Center,8140054,SURGICEL FIBRILLAR 2X4IN,244606,,270,$306.56 ,$306.56 ,$91.97 ,$278.97 ,$214.59 ,$91.97 ,$199.26 ,$220.72 ,$278.97 ,$229.92 
Carle BroMenn Medical Center,8140054,SURGICEL FIBRILLAR 4X4IN,244619,,270,$383.19 ,$383.19 ,$114.96 ,$348.70 ,$268.23 ,$114.96 ,$249.07 ,$275.90 ,$348.70 ,$287.39 
Carle BroMenn Medical Center,8140054,SURGIFOAM HEMOSTAT 100,245213,,270,$61.41 ,$61.41 ,$18.42 ,$55.88 ,$42.99 ,$18.42 ,$39.92 ,$44.22 ,$55.88 ,$46.06 
Carle BroMenn Medical Center,8140054,SURGIFOAM HEMOSTAT 12-7,248977,,270,$12.27 ,$12.27 ,$3.68 ,$11.17 ,$8.59 ,$3.68 ,$7.98 ,$8.83 ,$11.17 ,$9.20 
Carle BroMenn Medical Center,8140054,SUTURELASSO QK PASS CRV 45D RT,239584,,270,$480.00 ,$480.00 ,$144.00 ,$436.80 ,$336.00 ,$144.00 ,$312.00 ,$345.60 ,$436.80 ,$360.00 
Carle BroMenn Medical Center,8140054,SWAB GEL AMIES NO CHARCOL SNGL 50,244889,,270,$44.79 ,$44.79 ,$13.44 ,$40.76 ,$31.35 ,$13.44 ,$29.11 ,$32.25 ,$40.76 ,$33.59 
Carle BroMenn Medical Center,8140054,SWAB LIQ STUARTS DUAL RED CAP 50/,244890,,270,$1.10 ,$1.10 ,$0.33 ,$1.00 ,$0.77 ,$0.33 ,$0.72 ,$0.79 ,$1.00 ,$0.83 
Carle BroMenn Medical Center,8140054,SWAB PROCTO 16 STL,244845,,270,$14.95 ,$14.95 ,$4.49 ,$13.60 ,$10.47 ,$4.49 ,$9.72 ,$10.76 ,$13.60 ,$11.21 
Carle BroMenn Medical Center,8140054,SWABSTICK SNGL 10% PVP-I,244181,,270,$0.66 ,$0.66 ,$0.20 ,$0.60 ,$0.46 ,$0.20 ,$0.43 ,$0.48 ,$0.60 ,$0.50 
Carle BroMenn Medical Center,8140054,SYRINGE 10ML LL,244024,,270,$0.21 ,$0.21 ,$0.06 ,$0.19 ,$0.15 ,$0.06 ,$0.14 ,$0.15 ,$0.19 ,$0.16 
Carle BroMenn Medical Center,8140054,SYRINGE 10ML NACL FLUSH 30/BX,244101,,270,$0.60 ,$0.60 ,$0.18 ,$0.55 ,$0.42 ,$0.18 ,$0.39 ,$0.43 ,$0.55 ,$0.45 
Carle BroMenn Medical Center,8140054,SYRINGE 1ML LEUR LOK,244324,,270,$0.69 ,$0.69 ,$0.21 ,$0.63 ,$0.48 ,$0.21 ,$0.45 ,$0.50 ,$0.63 ,$0.52 
Carle BroMenn Medical Center,8140054,SYRINGE 1ML TB SAFETY 27X 1/2 100,244322,,270,$0.80 ,$0.80 ,$0.24 ,$0.73 ,$0.56 ,$0.24 ,$0.52 ,$0.58 ,$0.73 ,$0.60 
Carle BroMenn Medical Center,8140054,SYRINGE 20ML LL,244193,,270,$0.48 ,$0.48 ,$0.14 ,$0.44 ,$0.34 ,$0.14 ,$0.31 ,$0.35 ,$0.44 ,$0.36 
Carle BroMenn Medical Center,8140054,SYRINGE 30ML LEUR LOCK,244194,,270,$0.57 ,$0.57 ,$0.17 ,$0.52 ,$0.40 ,$0.17 ,$0.37 ,$0.41 ,$0.52 ,$0.43 
Carle BroMenn Medical Center,8140054,SYRINGE 3ML 18G BLUNT FILL NDL,244152,,270,$0.27 ,$0.27 ,$0.08 ,$0.25 ,$0.19 ,$0.08 ,$0.18 ,$0.19 ,$0.25 ,$0.20 
Carle BroMenn Medical Center,8140054,SYRINGE 3ML LL,248970,,270,$0.12 ,$0.12 ,$0.04 ,$0.11 ,$0.08 ,$0.04 ,$0.08 ,$0.09 ,$0.11 ,$0.09 
Carle BroMenn Medical Center,8140054,SYRINGE 50ML LL,244241,,270,$0.87 ,$0.87 ,$0.26 ,$0.79 ,$0.61 ,$0.26 ,$0.57 ,$0.63 ,$0.79 ,$0.65 
Carle BroMenn Medical Center,8140054,SYRINGE 5ML LL,244112,,270,$0.19 ,$0.19 ,$0.06 ,$0.17 ,$0.13 ,$0.06 ,$0.12 ,$0.14 ,$0.17 ,$0.14 
Carle BroMenn Medical Center,8140054,SYRINGE 60ML SLIPTIP,244238,,270,$0.90 ,$0.90 ,$0.27 ,$0.82 ,$0.63 ,$0.27 ,$0.59 ,$0.65 ,$0.82 ,$0.68 
Carle BroMenn Medical Center,8140054,SYRINGE ALLIANCE INFL,247157,,270,$86.53 ,$86.53 ,$25.96 ,$78.74 ,$60.57 ,$25.96 ,$56.24 ,$62.30 ,$78.74 ,$64.90 
Carle BroMenn Medical Center,8140054,SYRINGE ANGIO 150CC 50/CA,244873,,270,$16.96 ,$16.96 ,$5.09 ,$15.43 ,$11.87 ,$5.09 ,$11.02 ,$12.21 ,$15.43 ,$12.72 
Carle BroMenn Medical Center,8140054,SYRINGE BULB IRR 60CC,249769,,270,$3.79 ,$3.79 ,$1.14 ,$3.45 ,$2.65 ,$1.14 ,$2.46 ,$2.73 ,$3.45 ,$2.84 
Carle BroMenn Medical Center,8140054,SYRINGE COAPTITE BULK AGNT 1ML,244763,,270,"$1,096.98 ","$1,096.98 ",$329.09 ,$998.25 ,$767.89 ,$329.09 ,$713.04 ,$789.83 ,$998.25 ,$822.74 
Carle BroMenn Medical Center,8140054,SYRINGE CONTROL 10ML LL,244129,,270,$1.89 ,$1.89 ,$0.57 ,$1.72 ,$1.32 ,$0.57 ,$1.23 ,$1.36 ,$1.72 ,$1.42 
Carle BroMenn Medical Center,8140054,SYRINGE EAR/ULCER BULB 3OZ,244109,,270,$3.10 ,$3.10 ,$0.93 ,$2.82 ,$2.17 ,$0.93 ,$2.02 ,$2.23 ,$2.82 ,$2.33 
Carle BroMenn Medical Center,8140054,SYRINGE EPDRL 7CC PUISATOR PLS,244520,,270,$8.52 ,$8.52 ,$2.56 ,$7.75 ,$5.96 ,$2.56 ,$5.54 ,$6.13 ,$7.75 ,$6.39 
Carle BroMenn Medical Center,8140054,SYRINGE IMBIBE 20CC,247604,,270,$685.50 ,$685.50 ,$205.65 ,$623.81 ,$479.85 ,$205.65 ,$445.58 ,$493.56 ,$623.81 ,$514.13 
Carle BroMenn Medical Center,8140054,SYRINGE INFL XPANDER W/LOCK,244730,,270,$0.67 ,$0.67 ,$0.20 ,$0.61 ,$0.47 ,$0.20 ,$0.44 ,$0.48 ,$0.61 ,$0.50 
Carle BroMenn Medical Center,8140054,SYRINGE INS U-100 1ML 30GX5MM,244937,,270,$0.96 ,$0.96 ,$0.29 ,$0.87 ,$0.67 ,$0.29 ,$0.62 ,$0.69 ,$0.87 ,$0.72 
Carle BroMenn Medical Center,8140054,SYRINGE INSLN 0.5ML 31GX6MM,245076,,270,$0.78 ,$0.78 ,$0.23 ,$0.71 ,$0.55 ,$0.23 ,$0.51 ,$0.56 ,$0.71 ,$0.59 
Carle BroMenn Medical Center,8140054,SYRINGE LUER-LOK W/O NDL 10ML,244162,,270,$0.04 ,$0.04 ,$0.01 ,$0.04 ,$0.03 ,$0.01 ,$0.03 ,$0.03 ,$0.04 ,$0.03 
Carle BroMenn Medical Center,8140054,SYRINGE PLAS LS 8ML,256479,,270,$4.97 ,$4.97 ,$1.49 ,$4.52 ,$3.48 ,$1.49 ,$3.23 ,$3.58 ,$4.52 ,$3.73 
Carle BroMenn Medical Center,8140054,SYRINGE PROLARYN + 1CC INJ IMP,244743,,270,"$1,875.00 ","$1,875.00 ",$562.50 ,"$1,706.25 ","$1,312.50 ",$562.50 ,"$1,218.75 ","$1,350.00 ","$1,706.25 ","$1,406.25 "
Carle BroMenn Medical Center,8140054,SYRINGE PROLARYN GEL VOICE 1CC,244765,,270,"$1,875.00 ","$1,875.00 ",$562.50 ,"$1,706.25 ","$1,312.50 ",$562.50 ,"$1,218.75 ","$1,350.00 ","$1,706.25 ","$1,406.25 "
Carle BroMenn Medical Center,8140054,SYRINGE SAFETY 3CC 22G X 1.5IN EC,458,,270,$0.57 ,$0.57 ,$0.17 ,$0.52 ,$0.40 ,$0.17 ,$0.37 ,$0.41 ,$0.52 ,$0.43 
Carle BroMenn Medical Center,8140054,SYRINGE TB 1ML 25GX5/8IN VANISHPO,244023,,270,$0.96 ,$0.96 ,$0.29 ,$0.87 ,$0.67 ,$0.29 ,$0.62 ,$0.69 ,$0.87 ,$0.72 
Carle BroMenn Medical Center,8140054,SYRINGE TOOMEY 70CC IRRIGATION 50,250484,,270,$2.88 ,$2.88 ,$0.86 ,$2.62 ,$2.02 ,$0.86 ,$1.87 ,$2.07 ,$2.62 ,$2.16 
Carle BroMenn Medical Center,8140054,SYRINGE TOOMEY W/CATH & TIP,244093,,270,$0.85 ,$0.85 ,$0.26 ,$0.77 ,$0.60 ,$0.26 ,$0.55 ,$0.61 ,$0.77 ,$0.64 
Carle BroMenn Medical Center,8140054,SYS ACCESS KII BLD THR 8X100,244974,,270,$54.00 ,$54.00 ,$16.20 ,$49.14 ,$37.80 ,$16.20 ,$35.10 ,$38.88 ,$49.14 ,$40.50 
Carle BroMenn Medical Center,8140054,SYS ALEXIS KII FIOS SM 2.5-6CM AL,245043,,270,$600.00 ,$600.00 ,$180.00 ,$546.00 ,$420.00 ,$180.00 ,$390.00 ,$432.00 ,$546.00 ,$450.00 
Carle BroMenn Medical Center,8140054,SYS CLEARMIX SNGL/DBL MIXING,237755,,270,$342.00 ,$342.00 ,$102.60 ,$311.22 ,$239.40 ,$102.60 ,$222.30 ,$246.24 ,$311.22 ,$256.50 
Carle BroMenn Medical Center,8140054,SYS CLEARMIX TRIPLE MIXING,239339,,270,$420.00 ,$420.00 ,$126.00 ,$382.20 ,$294.00 ,$126.00 ,$273.00 ,$302.40 ,$382.20 ,$315.00 
Carle BroMenn Medical Center,8140054,SYS DURASEAL DURAL SEALANT 5ML,245125,,270,"$3,058.83 ","$3,058.83 ",$917.65 ,"$2,783.54 ","$2,141.18 ",$917.65 ,"$1,988.24 ","$2,202.36 ","$2,783.54 ","$2,294.12 "
Carle BroMenn Medical Center,8140054,SYS INZI RETRVL UNIV 5MM,245184,,270,$108.00 ,$108.00 ,$32.40 ,$98.28 ,$75.60 ,$32.40 ,$70.20 ,$77.76 ,$98.28 ,$81.00 
Carle BroMenn Medical Center,8140054,SYS KII OPTCL BAL BLNT 5X100MM,245183,,270,$51.00 ,$51.00 ,$15.30 ,$46.41 ,$35.70 ,$15.30 ,$33.15 ,$36.72 ,$46.41 ,$38.25 
Carle BroMenn Medical Center,8140054,SYS KII Z-THR 12X100MM,253773,,270,$84.00 ,$84.00 ,$25.20 ,$76.44 ,$58.80 ,$25.20 ,$54.60 ,$60.48 ,$76.44 ,$63.00 
Carle BroMenn Medical Center,8140054,SYS RUMI 2 KOH-EFFICIENT 3.5CM,244769,,270,$501.31 ,$501.31 ,$150.39 ,$456.19 ,$350.92 ,$150.39 ,$325.85 ,$360.94 ,$456.19 ,$375.98 
Carle BroMenn Medical Center,8140054,SYS RUMI 2 KOH-EFFICIENT 3CM,244768,,270,$501.31 ,$501.31 ,$150.39 ,$456.19 ,$350.92 ,$150.39 ,$325.85 ,$360.94 ,$456.19 ,$375.98 
Carle BroMenn Medical Center,8140054,SYS SAPS SNGL ACTION BX,236641,,270,$138.97 ,$138.97 ,$41.69 ,$126.46 ,$97.28 ,$41.69 ,$90.33 ,$100.06 ,$126.46 ,$104.23 
Carle BroMenn Medical Center,8140054,SYS WND CLOSURE 12X15MM XL 10,244784,,270,$607.20 ,$607.20 ,$182.16 ,$552.55 ,$425.04 ,$182.16 ,$394.68 ,$437.18 ,$552.55 ,$455.40 
Carle BroMenn Medical Center,8140054,SYSTEM ANTIFOG SEE SHARP,244399,,270,$1.40 ,$1.40 ,$0.42 ,$1.27 ,$0.98 ,$0.42 ,$0.91 ,$1.01 ,$1.27 ,$1.05 
Carle BroMenn Medical Center,8140054,SYSTEM EXTERNAL CSF DRAIN W/ANTI,871,,270,$609.45 ,$609.45 ,$182.84 ,$554.60 ,$426.62 ,$182.84 ,$396.14 ,$438.80 ,$554.60 ,$457.09 
Carle BroMenn Medical Center,8140054,SYSTEM EXTERNAL CSF DRAIN W/ANTI-,227154,,270,$598.23 ,$598.23 ,$179.47 ,$544.39 ,$418.76 ,$179.47 ,$388.85 ,$430.73 ,$544.39 ,$448.67 
Carle BroMenn Medical Center,8140054,TACK CONGRUENT TEMP PLATE 3IN,4275,,270,$165.00 ,$165.00 ,$49.50 ,$150.15 ,$115.50 ,$49.50 ,$107.25 ,$118.80 ,$150.15 ,$123.75 
Carle BroMenn Medical Center,8140054,TACKER SORBAFIX ABSORB 30LOAD,245135,,270,"$1,230.00 ","$1,230.00 ",$369.00 ,"$1,119.30 ",$861.00 ,$369.00 ,$799.50 ,$885.60 ,"$1,119.30 ",$922.50 
Carle BroMenn Medical Center,8140054,TAPE COTTON UMBILICAL,244347,,270,$3.22 ,$3.22 ,$0.97 ,$2.93 ,$2.25 ,$0.97 ,$2.09 ,$2.32 ,$2.93 ,$2.42 
Carle BroMenn Medical Center,8140054,TAPE FOAM 4IN ROLL SELFADH,250485,,270,$25.68 ,$25.68 ,$7.70 ,$23.37 ,$17.98 ,$7.70 ,$16.69 ,$18.49 ,$23.37 ,$19.26 
Carle BroMenn Medical Center,8140054,TAPE MEDIPORE 2IN,244360,,270,$9.39 ,$9.39 ,$2.82 ,$8.54 ,$6.57 ,$2.82 ,$6.10 ,$6.76 ,$8.54 ,$7.04 
Carle BroMenn Medical Center,8140054,TAPE MEDIPORE 4IN,475,,270,$18.94 ,$18.94 ,$5.68 ,$17.24 ,$13.26 ,$5.68 ,$12.31 ,$13.64 ,$17.24 ,$14.21 
Carle BroMenn Medical Center,8140054,TAPE MICROFOAM SURG 3INX5.5YD,244133,,270,$8.66 ,$8.66 ,$2.60 ,$7.88 ,$6.06 ,$2.60 ,$5.63 ,$6.24 ,$7.88 ,$6.50 
Carle BroMenn Medical Center,8140054,TAPE MICROFOAM SURG 4INX5.5YD,244163,,270,$12.99 ,$12.99 ,$3.90 ,$11.82 ,$9.09 ,$3.90 ,$8.44 ,$9.35 ,$11.82 ,$9.74 
Carle BroMenn Medical Center,8140054,TAPE MICROPORE SURG 3INX10YD,244246,,270,$2.42 ,$2.42 ,$0.73 ,$2.20 ,$1.69 ,$0.73 ,$1.57 ,$1.74 ,$2.20 ,$1.82 
Carle BroMenn Medical Center,8140054,TAPE PAPER MICROPORE .5IN,244244,,270,$0.40 ,$0.40 ,$0.12 ,$0.36 ,$0.28 ,$0.12 ,$0.26 ,$0.29 ,$0.36 ,$0.30 
Carle BroMenn Medical Center,8140054,TAPE PAPER MICROPORE 1IN,244245,,270,$0.80 ,$0.80 ,$0.24 ,$0.73 ,$0.56 ,$0.24 ,$0.52 ,$0.58 ,$0.73 ,$0.60 
Carle BroMenn Medical Center,8140054,TAPE PAPER MICROPORE 2IN,244124,,270,$1.61 ,$1.61 ,$0.48 ,$1.47 ,$1.13 ,$0.48 ,$1.05 ,$1.16 ,$1.47 ,$1.21 
Carle BroMenn Medical Center,8140054,TAPE RETRACT-O-TAPE 12IN 18GA,244669,,270,$60.11 ,$60.11 ,$18.03 ,$54.70 ,$42.08 ,$18.03 ,$39.07 ,$43.28 ,$54.70 ,$45.08 
Carle BroMenn Medical Center,8140054,TAPE SCOTCHCAST+ WHT 2INX4YD,244581,,270,$15.79 ,$15.79 ,$4.74 ,$14.37 ,$11.05 ,$4.74 ,$10.26 ,$11.37 ,$14.37 ,$11.84 
Carle BroMenn Medical Center,8140054,TAPE SCOTCHCAST+ WHT 3INX4YD,244582,,270,$22.49 ,$22.49 ,$6.75 ,$20.47 ,$15.74 ,$6.75 ,$14.62 ,$16.19 ,$20.47 ,$16.87 
Carle BroMenn Medical Center,8140054,TAPE SCOTCHCAST+ WHT 4INX4YD,244583,,270,$27.44 ,$27.44 ,$8.23 ,$24.97 ,$19.21 ,$8.23 ,$17.84 ,$19.76 ,$24.97 ,$20.58 
Carle BroMenn Medical Center,8140054,TAPE SCOTCHCAST+ WHT 5INX4YD,244584,,270,$29.50 ,$29.50 ,$8.85 ,$26.85 ,$20.65 ,$8.85 ,$19.18 ,$21.24 ,$26.85 ,$22.13 
Carle BroMenn Medical Center,8140054,TAPE SILK DURAPORE .5IN,244130,,270,$0.70 ,$0.70 ,$0.21 ,$0.64 ,$0.49 ,$0.21 ,$0.46 ,$0.50 ,$0.64 ,$0.53 
Carle BroMenn Medical Center,8140054,TAPE SILK DURAPORE 1IN,244237,,270,$1.39 ,$1.39 ,$0.42 ,$1.26 ,$0.97 ,$0.42 ,$0.90 ,$1.00 ,$1.26 ,$1.04 
Carle BroMenn Medical Center,8140054,TAPE SILK DURAPORE 2IN,244239,,270,$2.78 ,$2.78 ,$0.83 ,$2.53 ,$1.95 ,$0.83 ,$1.81 ,$2.00 ,$2.53 ,$2.09 
Carle BroMenn Medical Center,8140054,TAPE SILK DURAPORE 3IN,244242,,270,$4.18 ,$4.18 ,$1.25 ,$3.80 ,$2.93 ,$1.25 ,$2.72 ,$3.01 ,$3.80 ,$3.14 
Carle BroMenn Medical Center,8140054,TAPE TRANSPORE WHT 1NX10YD,244108,,270,$1.57 ,$1.57 ,$0.47 ,$1.43 ,$1.10 ,$0.47 ,$1.02 ,$1.13 ,$1.43 ,$1.18 
Carle BroMenn Medical Center,8140054,TAPE TRANSPORE WHT 2INX10YD,244177,,270,$3.14 ,$3.14 ,$0.94 ,$2.86 ,$2.20 ,$0.94 ,$2.04 ,$2.26 ,$2.86 ,$2.36 
Carle BroMenn Medical Center,8140054,TAPE UMBI COTTON 30IN U11T,244424,,270,$3.73 ,$3.73 ,$1.12 ,$3.39 ,$2.61 ,$1.12 ,$2.42 ,$2.69 ,$3.39 ,$2.80 
Carle BroMenn Medical Center,8140054,TAPE XBRAID 2.3 ANCHOR 2.0MM ICON,247602,,270,"$1,425.00 ","$1,425.00 ",$427.50 ,"$1,296.75 ",$997.50 ,$427.50 ,$926.25 ,"$1,026.00 ","$1,296.75 ","$1,068.75 "
Carle BroMenn Medical Center,8140054,THERMOMETER CRYSTALLINE II DISPEN,244005,,270,$2.40 ,$2.40 ,$0.72 ,$2.18 ,$1.68 ,$0.72 ,$1.56 ,$1.73 ,$2.18 ,$1.80 
Carle BroMenn Medical Center,8140054,THUNDERBEAT PISTOL GRIP 5X35,245180,,270,"$1,445.71 ","$1,445.71 ",$433.71 ,"$1,315.60 ","$1,012.00 ",$433.71 ,$939.71 ,"$1,040.91 ","$1,315.60 ","$1,084.28 "
Carle BroMenn Medical Center,8140054,TIP ASP EXT MICRO CRVD 36KHZ,245150,,270,"$3,618.00 ","$3,618.00 ","$1,085.40 ","$3,292.38 ","$2,532.60 ","$1,085.40 ","$2,351.70 ","$2,604.96 ","$3,292.38 ","$2,713.50 "
Carle BroMenn Medical Center,8140054,TIP ASP EXT SHEAR CRVD 36KHZ,245151,,270,"$4,890.00 ","$4,890.00 ","$1,467.00 ","$4,449.90 ","$3,423.00 ","$1,467.00 ","$3,178.50 ","$3,520.80 ","$4,449.90 ","$3,667.50 "
Carle BroMenn Medical Center,8140054,TIP CANNULA SOFT 27GA,10445,,270,$54.08 ,$54.08 ,$16.22 ,$49.21 ,$37.86 ,$16.22 ,$35.15 ,$38.94 ,$49.21 ,$40.56 
Carle BroMenn Medical Center,8140054,TIP COAXIAL BONE CLNG,244840,,270,$30.90 ,$30.90 ,$9.27 ,$28.12 ,$21.63 ,$9.27 ,$20.09 ,$22.25 ,$28.12 ,$23.18 
Carle BroMenn Medical Center,8140054,TIP CUSA EXT STD 36KHZ CRVD,244686,,270,"$2,802.00 ","$2,802.00 ",$840.60 ,"$2,549.82 ","$1,961.40 ",$840.60 ,"$1,821.30 ","$2,017.44 ","$2,549.82 ","$2,101.50 "
Carle BroMenn Medical Center,8140054,TIP DUPLOTIP SNAP 5MMX32CM,244605,,270,$188.33 ,$188.33 ,$56.50 ,$171.38 ,$131.83 ,$56.50 ,$122.41 ,$135.60 ,$171.38 ,$141.25 
Carle BroMenn Medical Center,8140054,TIP EXT MICRO PLUS CRVD 36KHZ,245152,,270,"$4,929.00 ","$4,929.00 ","$1,478.70 ","$4,485.39 ","$3,450.30 ","$1,478.70 ","$3,203.85 ","$3,548.88 ","$4,485.39 ","$3,696.75 "
Carle BroMenn Medical Center,8140054,TIP FEM CANAL IRR/SUCTION,244604,,270,$26.67 ,$26.67 ,$8.00 ,$24.27 ,$18.67 ,$8.00 ,$17.34 ,$19.20 ,$24.27 ,$20.00 
Carle BroMenn Medical Center,8140054,TIP MICROVAC SUCT MLBL 13F,245147,,270,$0.28 ,$0.28 ,$0.08 ,$0.25 ,$0.20 ,$0.08 ,$0.18 ,$0.20 ,$0.25 ,$0.21 
Carle BroMenn Medical Center,8140054,TIP NANOGRASPER 70MM DISP,242709,,270,$795.00 ,$795.00 ,$238.50 ,$723.45 ,$556.50 ,$238.50 ,$516.75 ,$572.40 ,$723.45 ,$596.25 
Carle BroMenn Medical Center,8140054,TIP RUMI 3.75CM,4289,,270,$147.00 ,$147.00 ,$44.10 ,$133.77 ,$102.90 ,$44.10 ,$95.55 ,$105.84 ,$133.77 ,$110.25 
Carle BroMenn Medical Center,8140054,TIP RUMI LAVENDER,244785,,270,$206.72 ,$206.72 ,$62.02 ,$188.12 ,$144.70 ,$62.02 ,$134.37 ,$148.84 ,$188.12 ,$155.04 
Carle BroMenn Medical Center,8140054,TIP RUMI ORANGE 6.7MM X 12CM BX/5,38544,,270,$180.68 ,$180.68 ,$54.20 ,$164.42 ,$126.48 ,$54.20 ,$117.44 ,$130.09 ,$164.42 ,$135.51 
Carle BroMenn Medical Center,8140054,TIP RUMI STL BLU 6.7MMX8CM,246640,,270,$244.33 ,$244.33 ,$73.30 ,$222.34 ,$171.03 ,$73.30 ,$158.81 ,$175.92 ,$222.34 ,$183.25 
Carle BroMenn Medical Center,8140054,TIP RUMI STL GRN 6.7MMX10CM,244673,,270,$224.88 ,$224.88 ,$67.46 ,$204.64 ,$157.42 ,$67.46 ,$146.17 ,$161.91 ,$204.64 ,$168.66 
Carle BroMenn Medical Center,8140054,TIP RUMI STL WHT 6.7MMX6CM,249745,,270,$244.33 ,$244.33 ,$73.30 ,$222.34 ,$171.03 ,$73.30 ,$158.81 ,$175.92 ,$222.34 ,$183.25 
Carle BroMenn Medical Center,8140054,TIP SACROCOLPOPEXY SM 3.2X9CM 3/B,245194,,270,$282.20 ,$282.20 ,$84.66 ,$256.80 ,$197.54 ,$84.66 ,$183.43 ,$203.18 ,$256.80 ,$211.65 
Carle BroMenn Medical Center,8140054,TIP SUCT YANKAUER CLR BULB,244411,,270,$1.37 ,$1.37 ,$0.41 ,$1.25 ,$0.96 ,$0.41 ,$0.89 ,$0.99 ,$1.25 ,$1.03 
Carle BroMenn Medical Center,8140054,TIP SUCT YANKAUER VENT/BULBOUS,244116,,270,$1.03 ,$1.03 ,$0.31 ,$0.94 ,$0.72 ,$0.31 ,$0.67 ,$0.74 ,$0.94 ,$0.77 
Carle BroMenn Medical Center,8140054,TOOL STRAW TUNNELING 28CM,253094,,270,$300.00 ,$300.00 ,$90.00 ,$273.00 ,$210.00 ,$90.00 ,$195.00 ,$216.00 ,$273.00 ,$225.00 
Carle BroMenn Medical Center,8140054,TOOL STRAW TUNNELING REG,237226,,270,$3.33 ,$3.33 ,$1.00 ,$3.03 ,$2.33 ,$1.00 ,$2.16 ,$2.40 ,$3.03 ,$2.50 
Carle BroMenn Medical Center,8140054,TOOL TUNNELING 35CM,239300,,270,$225.00 ,$225.00 ,$67.50 ,$204.75 ,$157.50 ,$67.50 ,$146.25 ,$162.00 ,$204.75 ,$168.75 
Carle BroMenn Medical Center,8140054,TOOL TUNNELING LNG,239064,,270,$300.00 ,$300.00 ,$90.00 ,$273.00 ,$210.00 ,$90.00 ,$195.00 ,$216.00 ,$273.00 ,$225.00 
Carle BroMenn Medical Center,8140054,TORUNIQUET DLP 7IN 5 TUBES 40 PER,247032,,270,$18.00 ,$18.00 ,$5.40 ,$16.38 ,$12.60 ,$5.40 ,$11.70 ,$12.96 ,$16.38 ,$13.50 
Carle BroMenn Medical Center,8140054,TOWEL BLUE SURGICAL 16X26 4/PK,244159,,270,$1.27 ,$1.27 ,$0.38 ,$1.16 ,$0.89 ,$0.38 ,$0.83 ,$0.91 ,$1.16 ,$0.95 
Carle BroMenn Medical Center,8140054,TOWEL WHITE SURGICAL 16X26 2PK,244815,,270,$1.55 ,$1.55 ,$0.47 ,$1.41 ,$1.09 ,$0.47 ,$1.01 ,$1.12 ,$1.41 ,$1.16 
Carle BroMenn Medical Center,8140054,TRACH TUBE SZ 4,245251,,270,$94.05 ,$94.05 ,$28.22 ,$85.59 ,$65.84 ,$28.22 ,$61.13 ,$67.72 ,$85.59 ,$70.54 
Carle BroMenn Medical Center,8140054,TRACKER INSTRUMENT,204393,,270,$436.23 ,$436.23 ,$130.87 ,$396.97 ,$305.36 ,$130.87 ,$283.55 ,$314.09 ,$396.97 ,$327.17 
Carle BroMenn Medical Center,8140054,TRAP BERKELEY SAFETOUCH TISS,236819,,270,$27.96 ,$27.96 ,$8.39 ,$25.44 ,$19.57 ,$8.39 ,$18.17 ,$20.13 ,$25.44 ,$20.97 
Carle BroMenn Medical Center,8140054,TRAP MUCUS SPCMN 80CC,244035,,270,$3.14 ,$3.14 ,$0.94 ,$2.86 ,$2.20 ,$0.94 ,$2.04 ,$2.26 ,$2.86 ,$2.36 
Carle BroMenn Medical Center,8140054,TRAP POLYP,8443,,270,$24.00 ,$24.00 ,$7.20 ,$21.84 ,$16.80 ,$7.20 ,$15.60 ,$17.28 ,$21.84 ,$18.00 
Carle BroMenn Medical Center,8140054,TRAP POLYP MULTI CHAMBER 4 5/CA,251906,,270,$99.00 ,$99.00 ,$29.70 ,$90.09 ,$69.30 ,$29.70 ,$64.35 ,$71.28 ,$90.09 ,$74.25 
Carle BroMenn Medical Center,8140054,TRAY FOL LUBRI-SIL URINE 10F,245069,,270,$70.56 ,$70.56 ,$21.17 ,$64.21 ,$49.39 ,$21.17 ,$45.86 ,$50.80 ,$64.21 ,$52.92 
Carle BroMenn Medical Center,8140054,TRAY FOLEY LUBRI-SIL TEMP 16F,244254,,270,$96.93 ,$96.93 ,$29.08 ,$88.21 ,$67.85 ,$29.08 ,$63.00 ,$69.79 ,$88.21 ,$72.70 
Carle BroMenn Medical Center,8140054,TRAY HUMERAL +6 +5,246791,,270,"$3,450.00 ","$3,450.00 ","$1,035.00 ","$3,139.50 ","$2,415.00 ","$1,035.00 ","$2,242.50 ","$2,484.00 ","$3,139.50 ","$2,587.50 "
Carle BroMenn Medical Center,8140054,TRAY KYPHOPAK EXPRESS II 10MM,244759,,270,"$8,161.02 ","$8,161.02 ","$2,448.31 ","$7,426.53 ","$5,712.71 ","$2,448.31 ","$5,304.66 ","$5,875.93 ","$7,426.53 ","$6,120.77 "
Carle BroMenn Medical Center,8140054,TRAY KYPHOPAK FIRST FX,244838,,270,"$8,977.50 ","$8,977.50 ","$2,693.25 ","$8,169.53 ","$6,284.25 ","$2,693.25 ","$5,835.38 ","$6,463.80 ","$8,169.53 ","$6,733.13 "
Carle BroMenn Medical Center,8140054,TRAY LUBRI-SIL URINE 16F,244122,,270,$60.27 ,$60.27 ,$18.08 ,$54.85 ,$42.19 ,$18.08 ,$39.18 ,$43.39 ,$54.85 ,$45.20 
Carle BroMenn Medical Center,8140054,TRAY LUMBAR PUNC ADLT 20G,244235,,270,$43.89 ,$43.89 ,$13.17 ,$39.94 ,$30.72 ,$13.17 ,$28.53 ,$31.60 ,$39.94 ,$32.92 
Carle BroMenn Medical Center,8140054,TRAY SKIN SCRUB PREM WET,244983,,270,$23.96 ,$23.96 ,$7.19 ,$21.80 ,$16.77 ,$7.19 ,$15.57 ,$17.25 ,$21.80 ,$17.97 
Carle BroMenn Medical Center,8140054,TRAY SUPRAPUBIC,244661,,270,$295.88 ,$295.88 ,$88.76 ,$269.25 ,$207.12 ,$88.76 ,$192.32 ,$213.03 ,$269.25 ,$221.91 
Carle BroMenn Medical Center,8140054,TRAY UROL HEYMAN SYS STL,244255,,270,$668.52 ,$668.52 ,$200.56 ,$608.35 ,$467.96 ,$200.56 ,$434.54 ,$481.33 ,$608.35 ,$501.39 
Carle BroMenn Medical Center,8140054,TROCAR AIRSEAL 12MMX120MM CA/6,208335,,270,$262.65 ,$262.65 ,$78.80 ,$239.01 ,$183.86 ,$78.80 ,$170.72 ,$189.11 ,$239.01 ,$196.99 
Carle BroMenn Medical Center,8140054,TROCAR AIRSEAL 5MMX120MM,245026,,270,$460.89 ,$460.89 ,$138.27 ,$419.41 ,$322.62 ,$138.27 ,$299.58 ,$331.84 ,$419.41 ,$345.67 
Carle BroMenn Medical Center,8140054,TROCAR AIRSEAL 8MMX120MM CA/6,208333,,270,$253.38 ,$253.38 ,$76.01 ,$230.58 ,$177.37 ,$76.01 ,$164.70 ,$182.43 ,$230.58 ,$190.04 
Carle BroMenn Medical Center,8140054,TROCAR BLDLS OPTICAL STD 11MM,245141,,270,$428.88 ,$428.88 ,$128.66 ,$390.28 ,$300.22 ,$128.66 ,$278.77 ,$308.79 ,$390.28 ,$321.66 
Carle BroMenn Medical Center,8140054,TROCAR BLDLS STD FIX 8MM,245080,,270,$350.18 ,$350.18 ,$105.05 ,$318.66 ,$245.13 ,$105.05 ,$227.62 ,$252.13 ,$318.66 ,$262.64 
Carle BroMenn Medical Center,8140054,TROCAR BLE STD FIX 12MM,245061,,270,$355.11 ,$355.11 ,$106.53 ,$323.15 ,$248.58 ,$106.53 ,$230.82 ,$255.68 ,$323.15 ,$266.33 
Carle BroMenn Medical Center,8140054,TROCAR BLE STD FIX 5MM,245063,,270,$348.09 ,$348.09 ,$104.43 ,$316.76 ,$243.66 ,$104.43 ,$226.26 ,$250.62 ,$316.76 ,$261.07 
Carle BroMenn Medical Center,8140054,TROCAR BLUNT STD SMTH 12MM,245054,,270,$458.10 ,$458.10 ,$137.43 ,$416.87 ,$320.67 ,$137.43 ,$297.77 ,$329.83 ,$416.87 ,$343.58 
Carle BroMenn Medical Center,8140054,TROCAR HASSON 12X100MM SM CONE BL,1146,,270,$63.00 ,$63.00 ,$18.90 ,$57.33 ,$44.10 ,$18.90 ,$40.95 ,$45.36 ,$57.33 ,$47.25 
Carle BroMenn Medical Center,8140054,TROCAR KII BLADED 5X100MM,1203,,270,$54.00 ,$54.00 ,$16.20 ,$49.14 ,$37.80 ,$16.20 ,$35.10 ,$38.88 ,$49.14 ,$40.50 
Carle BroMenn Medical Center,8140054,TROCAR KII NO-BLADE 11X100MM,1141,,270,$63.00 ,$63.00 ,$18.90 ,$57.33 ,$44.10 ,$18.90 ,$40.95 ,$45.36 ,$57.33 ,$47.25 
Carle BroMenn Medical Center,8140054,TROCAR KII NO-BLADE 12X100MM,1142,,270,$63.00 ,$63.00 ,$18.90 ,$57.33 ,$44.10 ,$18.90 ,$40.95 ,$45.36 ,$57.33 ,$47.25 
Carle BroMenn Medical Center,8140054,TROCAR KII NO-BLADE 12X150MM,918,,270,$63.00 ,$63.00 ,$18.90 ,$57.33 ,$44.10 ,$18.90 ,$40.95 ,$45.36 ,$57.33 ,$47.25 
Carle BroMenn Medical Center,8140054,TROCAR KII NO-BLADE 5X100MM NO BA,1143,,270,$51.00 ,$51.00 ,$15.30 ,$46.41 ,$35.70 ,$15.30 ,$33.15 ,$36.72 ,$46.41 ,$38.25 
Carle BroMenn Medical Center,8140054,TROCAR KII NO-BLADE 5X150MM,1140,,270,$51.00 ,$51.00 ,$15.30 ,$46.41 ,$35.70 ,$15.30 ,$33.15 ,$36.72 ,$46.41 ,$38.25 
Carle BroMenn Medical Center,8140054,TROCAR KII NO-BLADE 8X100MM,1145,,270,$54.00 ,$54.00 ,$16.20 ,$49.14 ,$37.80 ,$16.20 ,$35.10 ,$38.88 ,$49.14 ,$40.50 
Carle BroMenn Medical Center,8140054,TROCAR SPLIT 10CM STL,244846,,270,"$1,291.68 ","$1,291.68 ",$387.50 ,"$1,175.43 ",$904.18 ,$387.50 ,$839.59 ,$930.01 ,"$1,175.43 ",$968.76 
Carle BroMenn Medical Center,8140054,TROCAR THORACOPORT 11.5MM,245072,,270,$0.28 ,$0.28 ,$0.08 ,$0.25 ,$0.20 ,$0.08 ,$0.18 ,$0.20 ,$0.25 ,$0.21 
Carle BroMenn Medical Center,8140054,TROCAR V2 BLDLS OPTCL 5MM STD,245010,,270,$177.06 ,$177.06 ,$53.12 ,$161.12 ,$123.94 ,$53.12 ,$115.09 ,$127.48 ,$161.12 ,$132.80 
Carle BroMenn Medical Center,8140054,TROCAR V2 BLDLS OPTCL STD 12MM,245196,,270,$256.92 ,$256.92 ,$77.08 ,$233.80 ,$179.84 ,$77.08 ,$167.00 ,$184.98 ,$233.80 ,$192.69 
Carle BroMenn Medical Center,8140054,TROCAR V2 BLDLSS OPT 12MM LNG,245035,,270,$516.14 ,$516.14 ,$154.84 ,$469.69 ,$361.30 ,$154.84 ,$335.49 ,$371.62 ,$469.69 ,$387.11 
Carle BroMenn Medical Center,8140054,TROCAR V2 BLDLSS OPT 5MM LNG,245019,,270,$388.04 ,$388.04 ,$116.41 ,$353.12 ,$271.63 ,$116.41 ,$252.23 ,$279.39 ,$353.12 ,$291.03 
Carle BroMenn Medical Center,8140054,TROCAR VERSAPORT BLDL 10-15MM,245267,,270,$483.99 ,$483.99 ,$145.20 ,$440.43 ,$338.79 ,$145.20 ,$314.59 ,$348.47 ,$440.43 ,$362.99 
Carle BroMenn Medical Center,8140054,TUBE CHEST DRAIN 28F STR 23IN,244715,,270,$0.33 ,$0.33 ,$0.10 ,$0.30 ,$0.23 ,$0.10 ,$0.21 ,$0.24 ,$0.30 ,$0.25 
Carle BroMenn Medical Center,8140054,TUBE IRRIGATION TUBE,235406,,270,$303.00 ,$303.00 ,$90.90 ,$275.73 ,$212.10 ,$90.90 ,$196.95 ,$218.16 ,$275.73 ,$227.25 
Carle BroMenn Medical Center,8140054,TUBE NG FEEDING 5FR 20IN INDWELL,9891,,270,$12.03 ,$12.03 ,$3.61 ,$10.95 ,$8.42 ,$3.61 ,$7.82 ,$8.66 ,$10.95 ,$9.02 
Carle BroMenn Medical Center,8140054,TUBE NG SALEM 14FR,244145,,270,$9.04 ,$9.04 ,$2.71 ,$8.23 ,$6.33 ,$2.71 ,$5.88 ,$6.51 ,$8.23 ,$6.78 
Carle BroMenn Medical Center,8140054,TUBE NG SALEM 16FR,244090,,270,$17.85 ,$17.85 ,$5.36 ,$16.24 ,$12.50 ,$5.36 ,$11.60 ,$12.85 ,$16.24 ,$13.39 
Carle BroMenn Medical Center,8140054,TUBE NG SALEM 18FR,244089,,270,$12.48 ,$12.48 ,$3.74 ,$11.36 ,$8.74 ,$3.74 ,$8.11 ,$8.99 ,$11.36 ,$9.36 
Carle BroMenn Medical Center,8140054,TUBE SET HIGH FLOW PNEUMOCLEAR 10,247033,,270,$48.60 ,$48.60 ,$14.58 ,$44.23 ,$34.02 ,$14.58 ,$31.59 ,$34.99 ,$44.23 ,$36.45 
Carle BroMenn Medical Center,8140054,TUBE TRACH CUFF XLT DIST 6,245129,,270,$176.70 ,$176.70 ,$53.01 ,$160.80 ,$123.69 ,$53.01 ,$114.86 ,$127.22 ,$160.80 ,$132.53 
Carle BroMenn Medical Center,8140054,TUBE TRACH CUFF XLT DIST 8,245130,,270,$176.70 ,$176.70 ,$53.01 ,$160.80 ,$123.69 ,$53.01 ,$114.86 ,$127.22 ,$160.80 ,$132.53 
Carle BroMenn Medical Center,8140054,TUBE TRACH SHILEY 10CFS UNCUFF,244716,,270,$96.39 ,$96.39 ,$28.92 ,$87.71 ,$67.47 ,$28.92 ,$62.65 ,$69.40 ,$87.71 ,$72.29 
Carle BroMenn Medical Center,8140054,TUBE TRACH SHILEY 10DCT CUFF,244268,,270,$96.39 ,$96.39 ,$28.92 ,$87.71 ,$67.47 ,$28.92 ,$62.65 ,$69.40 ,$87.71 ,$72.29 
Carle BroMenn Medical Center,8140054,TUBE TRACH SHILEY 4CFS UNCUFF,244269,,270,$94.05 ,$94.05 ,$28.22 ,$85.59 ,$65.84 ,$28.22 ,$61.13 ,$67.72 ,$85.59 ,$70.54 
Carle BroMenn Medical Center,8140054,TUBE TRACH SHILEY 4LPC CUFF,244349,,270,$119.70 ,$119.70 ,$35.91 ,$108.93 ,$83.79 ,$35.91 ,$77.81 ,$86.18 ,$108.93 ,$89.78 
Carle BroMenn Medical Center,8140054,TUBE TRACH SHILEY 6CFS UNCUFF,244270,,270,$94.05 ,$94.05 ,$28.22 ,$85.59 ,$65.84 ,$28.22 ,$61.13 ,$67.72 ,$85.59 ,$70.54 
Carle BroMenn Medical Center,8140054,TUBE TRACH SHILEY 6DCT CUFF,244266,,270,$94.05 ,$94.05 ,$28.22 ,$85.59 ,$65.84 ,$28.22 ,$61.13 ,$67.72 ,$85.59 ,$70.54 
Carle BroMenn Medical Center,8140054,TUBE TRACH SHILEY 6LPC CUFF,244598,,270,$119.70 ,$119.70 ,$35.91 ,$108.93 ,$83.79 ,$35.91 ,$77.81 ,$86.18 ,$108.93 ,$89.78 
Carle BroMenn Medical Center,8140054,TUBE TRACH SHILEY 8 CUFF,244267,,270,$133.02 ,$133.02 ,$39.91 ,$121.05 ,$93.11 ,$39.91 ,$86.46 ,$95.77 ,$121.05 ,$99.77 
Carle BroMenn Medical Center,8140054,TUBE TRACH SHILEY 8 UNCUFF,244271,,270,$122.97 ,$122.97 ,$36.89 ,$111.90 ,$86.08 ,$36.89 ,$79.93 ,$88.54 ,$111.90 ,$92.23 
Carle BroMenn Medical Center,8140054,TUBE TRACH SHILEY 8LPC CUFF,244599,,270,$119.70 ,$119.70 ,$35.91 ,$108.93 ,$83.79 ,$35.91 ,$77.81 ,$86.18 ,$108.93 ,$89.78 
Carle BroMenn Medical Center,8140054,TUBE TRACH UNCUF XLT DIST 8,245232,,270,$176.70 ,$176.70 ,$53.01 ,$160.80 ,$123.69 ,$53.01 ,$114.86 ,$127.22 ,$160.80 ,$132.53 
Carle BroMenn Medical Center,8140054,TUBE TRACH UNCUF XLT PROX 8,245233,,270,$176.70 ,$176.70 ,$53.01 ,$160.80 ,$123.69 ,$53.01 ,$114.86 ,$127.22 ,$160.80 ,$132.53 
Carle BroMenn Medical Center,8140054,TUBE TRACH UNCUFF XLONG 6.0,244368,,270,$176.70 ,$176.70 ,$53.01 ,$160.80 ,$123.69 ,$53.01 ,$114.86 ,$127.22 ,$160.80 ,$132.53 
Carle BroMenn Medical Center,8140054,TUBE TRIUNE VENT SIL 1.3X5X5MM,244782,,270,$0.67 ,$0.67 ,$0.20 ,$0.61 ,$0.47 ,$0.20 ,$0.44 ,$0.48 ,$0.61 ,$0.50 
Carle BroMenn Medical Center,8140054,TUBING AUTOFUSE ASP STL,244791,,270,$0.33 ,$0.33 ,$0.10 ,$0.30 ,$0.23 ,$0.10 ,$0.21 ,$0.24 ,$0.30 ,$0.25 
Carle BroMenn Medical Center,8140054,TUBING CROSSFLOW INFLOW CASS,245036,,270,$179.67 ,$179.67 ,$53.90 ,$163.50 ,$125.77 ,$53.90 ,$116.79 ,$129.36 ,$163.50 ,$134.75 
Carle BroMenn Medical Center,8140054,TUBING CUSA DISP STL 36,244687,,270,$0.56 ,$0.56 ,$0.17 ,$0.51 ,$0.39 ,$0.17 ,$0.36 ,$0.40 ,$0.51 ,$0.42 
Carle BroMenn Medical Center,8140054,TUBING HP W/ADAPTOR 48IN,244621,,270,$0.03 ,$0.03 ,$0.01 ,$0.03 ,$0.02 ,$0.01 ,$0.02 ,$0.02 ,$0.03 ,$0.02 
Carle BroMenn Medical Center,8140054,TUBING INSUF 10FT W/.1MIC FLTR,244990,,270,$21.86 ,$21.86 ,$6.56 ,$19.89 ,$15.30 ,$6.56 ,$14.21 ,$15.74 ,$19.89 ,$16.40 
Carle BroMenn Medical Center,8140054,TUBING IRRIG CV LOW-PRFL 5PK MR8,240332,,270,$120.00 ,$120.00 ,$36.00 ,$109.20 ,$84.00 ,$36.00 ,$78.00 ,$86.40 ,$109.20 ,$90.00 
Carle BroMenn Medical Center,8140054,TUBING IRRIG CV LOW-PRFL EA MR8 P,240333,,270,$180.00 ,$180.00 ,$54.00 ,$163.80 ,$126.00 ,$54.00 ,$117.00 ,$129.60 ,$163.80 ,$135.00 
Carle BroMenn Medical Center,8140054,TUBING IRRIG ON-DRILL 5PK MR8 PMX,240331,,270,$164.97 ,$164.97 ,$49.49 ,$150.12 ,$115.48 ,$49.49 ,$107.23 ,$118.78 ,$150.12 ,$123.73 
Carle BroMenn Medical Center,8140054,TUBING IRRIG ON-DRILL EA MR8 PMX,240334,,270,$180.00 ,$180.00 ,$54.00 ,$163.80 ,$126.00 ,$54.00 ,$117.00 ,$129.60 ,$163.80 ,$135.00 
Carle BroMenn Medical Center,8140054,TUBING PAL ASPIRATION CONNECT,250935,,270,$42.90 ,$42.90 ,$12.87 ,$39.04 ,$30.03 ,$12.87 ,$27.89 ,$30.89 ,$39.04 ,$32.18 
Carle BroMenn Medical Center,8140054,TUBING PRES 72IN M/M CNCT 20 PER,244796,,270,$8.55 ,$8.55 ,$2.57 ,$7.78 ,$5.99 ,$2.57 ,$5.56 ,$6.16 ,$7.78 ,$6.41 
Carle BroMenn Medical Center,8140054,TUBING SUCTION .25INX12FT W/CONNE,244158,,270,$2.04 ,$2.04 ,$0.61 ,$1.86 ,$1.43 ,$0.61 ,$1.33 ,$1.47 ,$1.86 ,$1.53 
Carle BroMenn Medical Center,8140054,TUBING SUCTION 3/16INX18IN W/CONN,244170,,270,$0.69 ,$0.69 ,$0.21 ,$0.63 ,$0.48 ,$0.21 ,$0.45 ,$0.50 ,$0.63 ,$0.52 
Carle BroMenn Medical Center,8140054,TUBING TBG SILICON 30IN,245149,,270,$29.62 ,$29.62 ,$8.89 ,$26.95 ,$20.73 ,$8.89 ,$19.25 ,$21.33 ,$26.95 ,$22.22 
Carle BroMenn Medical Center,8140054,TUBING VAC STL 7/8INX6FT,244991,,270,$27.02 ,$27.02 ,$8.11 ,$24.59 ,$18.91 ,$8.11 ,$17.56 ,$19.45 ,$24.59 ,$20.27 
Carle BroMenn Medical Center,8140054,TULIP CREO AMP POLYAX THREADED,241409,,270,"$1,200.00 ","$1,200.00 ",$360.00 ,"$1,092.00 ",$840.00 ,$360.00 ,$780.00 ,$864.00 ,"$1,092.00 ",$900.00 
Carle BroMenn Medical Center,8140054,UNDERPAD SUPERSORB 30X36IN,244940,,270,$4.10 ,$4.10 ,$1.23 ,$3.73 ,$2.87 ,$1.23 ,$2.67 ,$2.95 ,$3.73 ,$3.08 
Carle BroMenn Medical Center,8140054,VACURETTE 6MM FLEX TIP,236903,,270,$0.33 ,$0.33 ,$0.10 ,$0.30 ,$0.23 ,$0.10 ,$0.21 ,$0.24 ,$0.30 ,$0.25 
Carle BroMenn Medical Center,8140054,VACURETTE CRVD 14MM,236732,,270,$16.62 ,$16.62 ,$4.99 ,$15.12 ,$11.63 ,$4.99 ,$10.80 ,$11.97 ,$15.12 ,$12.47 
Carle BroMenn Medical Center,8140054,VACURETTE D/C CURVED 10MM,234828,,270,$14.24 ,$14.24 ,$4.27 ,$12.96 ,$9.97 ,$4.27 ,$9.26 ,$10.25 ,$12.96 ,$10.68 
Carle BroMenn Medical Center,8140054,VACURETTE D/C CURVED 12MM,234830,,270,$14.24 ,$14.24 ,$4.27 ,$12.96 ,$9.97 ,$4.27 ,$9.26 ,$10.25 ,$12.96 ,$10.68 
Carle BroMenn Medical Center,8140054,VACURETTE D/C CURVED 8MM,234822,,270,$12.99 ,$12.99 ,$3.90 ,$11.82 ,$9.09 ,$3.90 ,$8.44 ,$9.35 ,$11.82 ,$9.74 
Carle BroMenn Medical Center,8140054,VACURETTE D/C CURVED 9MM,234827,,270,$14.24 ,$14.24 ,$4.27 ,$12.96 ,$9.97 ,$4.27 ,$9.26 ,$10.25 ,$12.96 ,$10.68 
Carle BroMenn Medical Center,8140054,VACURETTE D/C STRAIGHT 10MM,234824,,270,$13.50 ,$13.50 ,$4.05 ,$12.29 ,$9.45 ,$4.05 ,$8.78 ,$9.72 ,$12.29 ,$10.13 
Carle BroMenn Medical Center,8140054,VACURETTE D/C STRAIGHT 11MM,234825,,270,$14.57 ,$14.57 ,$4.37 ,$13.26 ,$10.20 ,$4.37 ,$9.47 ,$10.49 ,$13.26 ,$10.93 
Carle BroMenn Medical Center,8140054,VACURETTE D/C STRAIGHT 12MM,236731,,270,$25.49 ,$25.49 ,$7.65 ,$23.20 ,$17.84 ,$7.65 ,$16.57 ,$18.35 ,$23.20 ,$19.12 
Carle BroMenn Medical Center,8140054,VACURETTE D/C STRAIGHT 9MM,234823,,270,$14.24 ,$14.24 ,$4.27 ,$12.96 ,$9.97 ,$4.27 ,$9.26 ,$10.25 ,$12.96 ,$10.68 
Carle BroMenn Medical Center,8140054,VALVE BRONCH BIOPSY 20/BX,65,,270,$16.95 ,$16.95 ,$5.09 ,$15.42 ,$11.87 ,$5.09 ,$11.02 ,$12.20 ,$15.42 ,$12.71 
Carle BroMenn Medical Center,8140054,VIAL MASTISOL 2/3CC,244848,,270,$5.04 ,$5.04 ,$1.51 ,$4.59 ,$3.53 ,$1.51 ,$3.28 ,$3.63 ,$4.59 ,$3.78 
Carle BroMenn Medical Center,8140054,WAND COBLATION EVAC 70 XTRA,244755,,270,$834.00 ,$834.00 ,$250.20 ,$758.94 ,$583.80 ,$250.20 ,$542.10 ,$600.48 ,$758.94 ,$625.50 
Carle BroMenn Medical Center,8140054,WAND REFLEX ULTRA 45 W/CABLE,244667,,270,$756.00 ,$756.00 ,$226.80 ,$687.96 ,$529.20 ,$226.80 ,$491.40 ,$544.32 ,$687.96 ,$567.00 
Carle BroMenn Medical Center,8140054,WAND REFLEX ULTRA 55 W/CABLE,244666,,270,$3.33 ,$3.33 ,$1.00 ,$3.03 ,$2.33 ,$1.00 ,$2.16 ,$2.40 ,$3.03 ,$2.50 
Carle BroMenn Medical Center,8140054,WAX BONE 2.5GM,244585,,270,$12.78 ,$12.78 ,$3.83 ,$11.63 ,$8.95 ,$3.83 ,$8.31 ,$9.20 ,$11.63 ,$9.59 
Carle BroMenn Medical Center,8140054,WIRE GUIDE BENTSON 145CM MOVABLE,244043,,270,$90.00 ,$90.00 ,$27.00 ,$81.90 ,$63.00 ,$27.00 ,$58.50 ,$64.80 ,$81.90 ,$67.50 
Carle BroMenn Medical Center,8140054,WIRE K W/TRCR POINT 1.00X150MM,215838,,270,$199.80 ,$199.80 ,$59.94 ,$181.82 ,$139.86 ,$59.94 ,$129.87 ,$143.86 ,$181.82 ,$149.85 
Carle BroMenn Medical Center,8140054,WIRE OLIVE SMOOTH 1.3MM,244049,,270,$315.00 ,$315.00 ,$94.50 ,$286.65 ,$220.50 ,$94.50 ,$204.75 ,$226.80 ,$286.65 ,$236.25 
Carle BroMenn Medical Center,8140054,WIRE PACING TEMP UNI 53CMX.5MM,249753,,270,$93.75 ,$93.75 ,$28.13 ,$85.31 ,$65.63 ,$28.13 ,$60.94 ,$67.50 ,$85.31 ,$70.31 
Carle BroMenn Medical Center,8140054,WRAP ALLOWRAP 2X4CM DS WET,246788,,270,"$6,140.55 ","$6,140.55 ","$1,842.17 ","$5,587.90 ","$4,298.39 ","$1,842.17 ","$3,991.36 ","$4,421.20 ","$5,587.90 ","$4,605.41 "
Carle BroMenn Medical Center,8140054,WRAP COBAN 4IN STERILE TAN 5 YARD,244408,,270,$5.38 ,$5.38 ,$1.61 ,$4.90 ,$3.77 ,$1.61 ,$3.50 ,$3.87 ,$4.90 ,$4.04 
Carle BroMenn Medical Center,8140054,WRENCH HEX TORQUE 7.6CM,239564,,270,$120.00 ,$120.00 ,$36.00 ,$109.20 ,$84.00 ,$36.00 ,$78.00 ,$86.40 ,$109.20 ,$90.00 
Carle BroMenn Medical Center,8140054,WRENCH TORQUE 36KHZ CUSA,244679,,270,$285.00 ,$285.00 ,$85.50 ,$259.35 ,$199.50 ,$85.50 ,$185.25 ,$205.20 ,$259.35 ,$213.75 
Carle BroMenn Medical Center,8140054,WRENCH TORQUE 4IN,238284,,270,$156.00 ,$156.00 ,$46.80 ,$141.96 ,$109.20 ,$46.80 ,$101.40 ,$112.32 ,$141.96 ,$117.00 
Carle BroMenn Medical Center,8140054,WRENCH TORQUE CUSA CLARITY,245153,,270,$456.00 ,$456.00 ,$136.80 ,$414.96 ,$319.20 ,$136.80 ,$296.40 ,$328.32 ,$414.96 ,$342.00 
Carle BroMenn Medical Center,8140058,OXYGEN,,,270,$13.00 ,$13.00 ,$3.90 ,$11.83 ,$9.10 ,$3.90 ,$8.45 ,$9.36 ,$11.83 ,$9.75 
Carle BroMenn Medical Center,8140059,OXYGEN,,,270,$13.00 ,$13.00 ,$3.90 ,$11.83 ,$9.10 ,$3.90 ,$8.45 ,$9.36 ,$11.83 ,$9.75 
Carle BroMenn Medical Center,8140060,OXYGEN,,,270,$13.00 ,$13.00 ,$3.90 ,$11.83 ,$9.10 ,$3.90 ,$8.45 ,$9.36 ,$11.83 ,$9.75 
Carle BroMenn Medical Center,8140062,DEVICE COR-KNOT COMBO KIT 6/BX,197543,,270,"$2,172.00 ","$2,172.00 ",$651.60 ,"$1,976.52 ","$1,520.40 ",$651.60 ,"$1,411.80 ","$1,563.84 ","$1,976.52 ","$1,629.00 "
Carle BroMenn Medical Center,8140062,DEVICE SUT V-LOC 0 VLOCN2146 12/C,245100,,270,$79.56 ,$79.56 ,$23.87 ,$72.40 ,$55.69 ,$23.87 ,$51.71 ,$57.28 ,$72.40 ,$59.67 
Carle BroMenn Medical Center,8140062,FIBERWIRE 1/2 CIRCLE CONV CUT,131334,,270,$120.00 ,$120.00 ,$36.00 ,$109.20 ,$84.00 ,$36.00 ,$78.00 ,$86.40 ,$109.20 ,$90.00 
Carle BroMenn Medical Center,8140062,FIBERWIRE REVERSE CUT NEEDLE 2/5,131147,,270,$66.00 ,$66.00 ,$19.80 ,$60.06 ,$46.20 ,$19.80 ,$42.90 ,$47.52 ,$60.06 ,$49.50 
Carle BroMenn Medical Center,8140062,LOAD COR-KNOT QUICK BX/12,52774,,270,$126.00 ,$126.00 ,$37.80 ,$114.66 ,$88.20 ,$37.80 ,$81.90 ,$90.72 ,$114.66 ,$94.50 
Carle BroMenn Medical Center,8140062,NEEDLE KEITH STRAIGHT 18272DG BX/,211309,,270,$17.75 ,$17.75 ,$5.33 ,$16.15 ,$12.43 ,$5.33 ,$11.54 ,$12.78 ,$16.15 ,$13.31 
Carle BroMenn Medical Center,8140062,NEEDLE SURGINEEDLE 150MM LNG,253037,,270,$115.71 ,$115.71 ,$34.71 ,$105.30 ,$81.00 ,$34.71 ,$75.21 ,$83.31 ,$105.30 ,$86.78 
Carle BroMenn Medical Center,8140062,SUT 2-0 PROLENE CT-1,11121,,270,$6.23 ,$6.23 ,$1.87 ,$5.67 ,$4.36 ,$1.87 ,$4.05 ,$4.49 ,$5.67 ,$4.67 
Carle BroMenn Medical Center,8140062,SUT 3-0  CHROMIC RB-1,11150,,270,$7.62 ,$7.62 ,$2.29 ,$6.93 ,$5.33 ,$2.29 ,$4.95 ,$5.49 ,$6.93 ,$5.72 
Carle BroMenn Medical Center,8140062,SUT 3-0 PROLENE SH,11123,,270,$8.42 ,$8.42 ,$2.53 ,$7.66 ,$5.89 ,$2.53 ,$5.47 ,$6.06 ,$7.66 ,$6.32 
Carle BroMenn Medical Center,8140062,SUT 5-0 CHROMIC RB-1,11157,,270,$7.86 ,$7.86 ,$2.36 ,$7.15 ,$5.50 ,$2.36 ,$5.11 ,$5.66 ,$7.15 ,$5.90 
Carle BroMenn Medical Center,8140062,SUT 5-0 PROLENE PS-2,244334,,270,$11.42 ,$11.42 ,$3.43 ,$10.39 ,$7.99 ,$3.43 ,$7.42 ,$8.22 ,$10.39 ,$8.57 
Carle BroMenn Medical Center,8140062,SUT 6-0 PROLENE RB-2 8714H,11129,,270,$14.55 ,$14.55 ,$4.37 ,$13.24 ,$10.19 ,$4.37 ,$9.46 ,$10.48 ,$13.24 ,$10.91 
Carle BroMenn Medical Center,8140062,SUT 7-0 PROLENE BV-1,11132,,270,$31.09 ,$31.09 ,$9.33 ,$28.29 ,$21.76 ,$9.33 ,$20.21 ,$22.38 ,$28.29 ,$23.32 
Carle BroMenn Medical Center,8140062,SUT SPIRAL STRAT PDO CT1 36X36 SX,245249,,270,$59.49 ,$59.49 ,$17.85 ,$54.14 ,$41.64 ,$17.85 ,$38.67 ,$42.83 ,$54.14 ,$44.62 
Carle BroMenn Medical Center,8140062,SUT WIRE DBL STERNOTOMY 6 49MM,244752,,270,$0.28 ,$0.28 ,$0.08 ,$0.25 ,$0.20 ,$0.08 ,$0.18 ,$0.20 ,$0.25 ,$0.21 
Carle BroMenn Medical Center,8140062,SUTURE 0 CHROMIC CT-1 812H,244548,,270,$7.73 ,$7.73 ,$2.32 ,$7.03 ,$5.41 ,$2.32 ,$5.02 ,$5.57 ,$7.03 ,$5.80 
Carle BroMenn Medical Center,8140062,SUTURE 0 CHROMIC LIGAPAK L114G,244547,,270,$8.96 ,$8.96 ,$2.69 ,$8.15 ,$6.27 ,$2.69 ,$5.82 ,$6.45 ,$8.15 ,$6.72 
Carle BroMenn Medical Center,8140062,SUTURE 0 ETHIBOND CT-1 18IN,244328,,270,$4.11 ,$4.11 ,$1.23 ,$3.74 ,$2.88 ,$1.23 ,$2.67 ,$2.96 ,$3.74 ,$3.08 
Carle BroMenn Medical Center,8140062,SUTURE 0 ETHIBOND CT-1 18IN MS,244300,,270,$27.44 ,$27.44 ,$8.23 ,$24.97 ,$19.21 ,$8.23 ,$17.84 ,$19.76 ,$24.97 ,$20.58 
Carle BroMenn Medical Center,8140062,SUTURE 0 ETHILON TP-1 L880G,244712,,270,$8.42 ,$8.42 ,$2.53 ,$7.66 ,$5.89 ,$2.53 ,$5.47 ,$6.06 ,$7.66 ,$6.32 
Carle BroMenn Medical Center,8140062,SUTURE 0 MONOCRYL UR-5 Y378H,244653,,270,$6.77 ,$6.77 ,$2.03 ,$6.16 ,$4.74 ,$2.03 ,$4.40 ,$4.87 ,$6.16 ,$5.08 
Carle BroMenn Medical Center,8140062,SUTURE 0 NUROLON CR/CT-1 BLK,244331,,270,$26.64 ,$26.64 ,$7.99 ,$24.24 ,$18.65 ,$7.99 ,$17.32 ,$19.18 ,$24.24 ,$19.98 
Carle BroMenn Medical Center,8140062,SUTURE 0 NUROLON MO-6 C545D,244627,,270,$30.59 ,$30.59 ,$9.18 ,$27.84 ,$21.41 ,$9.18 ,$19.88 ,$22.02 ,$27.84 ,$22.94 
Carle BroMenn Medical Center,8140062,SUTURE 0 PDO TAP 1/2 CIR QUILL SR,245137,,270,$0.28 ,$0.28 ,$0.08 ,$0.25 ,$0.20 ,$0.08 ,$0.18 ,$0.20 ,$0.25 ,$0.21 
Carle BroMenn Medical Center,8140062,SUTURE 0 PDS ENDO LOOP,244383,,270,$91.39 ,$91.39 ,$27.42 ,$83.16 ,$63.97 ,$27.42 ,$59.40 ,$65.80 ,$83.16 ,$68.54 
Carle BroMenn Medical Center,8140062,SUTURE 0 PDS II CT-1 Z346H,244628,,270,$6.78 ,$6.78 ,$2.03 ,$6.17 ,$4.75 ,$2.03 ,$4.41 ,$4.88 ,$6.17 ,$5.09 
Carle BroMenn Medical Center,8140062,SUTURE 0 PDS II CT-2 Z334H,244634,,270,$6.74 ,$6.74 ,$2.02 ,$6.13 ,$4.72 ,$2.02 ,$4.38 ,$4.85 ,$6.13 ,$5.06 
Carle BroMenn Medical Center,8140062,SUTURE 0 PLAIN CT-3 N864H,244646,,270,$7.23 ,$7.23 ,$2.17 ,$6.58 ,$5.06 ,$2.17 ,$4.70 ,$5.21 ,$6.58 ,$5.42 
Carle BroMenn Medical Center,8140062,SUTURE 0 PROLENE CT-1 30IN,244303,,270,$6.07 ,$6.07 ,$1.82 ,$5.52 ,$4.25 ,$1.82 ,$3.95 ,$4.37 ,$5.52 ,$4.55 
Carle BroMenn Medical Center,8140062,SUTURE 0 PROLENE CT-1 C821G C821G,244560,,270,$39.77 ,$39.77 ,$11.93 ,$36.19 ,$27.84 ,$11.93 ,$25.85 ,$28.63 ,$36.19 ,$29.83 
Carle BroMenn Medical Center,8140062,SUTURE 0 PROLENE CT-2 30IN,244369,,270,$6.30 ,$6.30 ,$1.89 ,$5.73 ,$4.41 ,$1.89 ,$4.10 ,$4.54 ,$5.73 ,$4.73 
Carle BroMenn Medical Center,8140062,SUTURE 0 PROLENE MO-6 CR/8 C845G,245254,,270,$36.84 ,$36.84 ,$11.05 ,$33.52 ,$25.79 ,$11.05 ,$23.95 ,$26.52 ,$33.52 ,$27.63 
Carle BroMenn Medical Center,8140062,SUTURE 0 PROLENE V-34 30IN  8444H,1332,,270,$8.08 ,$8.08 ,$2.42 ,$7.35 ,$5.66 ,$2.42 ,$5.25 ,$5.82 ,$7.35 ,$6.06 
Carle BroMenn Medical Center,8140062,SUTURE 0 SILK 18IN BLACK 6STR A18,245122,,270,$2.34 ,$2.34 ,$0.70 ,$2.13 ,$1.64 ,$0.70 ,$1.52 ,$1.68 ,$2.13 ,$1.76 
Carle BroMenn Medical Center,8140062,SUTURE 0 SILK CT-1 424H,244544,,270,$3.17 ,$3.17 ,$0.95 ,$2.88 ,$2.22 ,$0.95 ,$2.06 ,$2.28 ,$2.88 ,$2.38 
Carle BroMenn Medical Center,8140062,SUTURE 0 SILK KS 624H,244863,,270,$3.99 ,$3.99 ,$1.20 ,$3.63 ,$2.79 ,$1.20 ,$2.59 ,$2.87 ,$3.63 ,$2.99 
Carle BroMenn Medical Center,8140062,SUTURE 0 SILK SH 30IN,244335,,270,$3.18 ,$3.18 ,$0.95 ,$2.89 ,$2.23 ,$0.95 ,$2.07 ,$2.29 ,$2.89 ,$2.39 
Carle BroMenn Medical Center,8140062,SUTURE 0 VICRYL 18IN J646H J646H,245283,,270,$5.66 ,$5.66 ,$1.70 ,$5.15 ,$3.96 ,$1.70 ,$3.68 ,$4.08 ,$5.15 ,$4.25 
Carle BroMenn Medical Center,8140062,SUTURE 0 VICRYL 36IN CT VIOLET,248867,,270,$3.90 ,$3.90 ,$1.17 ,$3.55 ,$2.73 ,$1.17 ,$2.54 ,$2.81 ,$3.55 ,$2.93 
Carle BroMenn Medical Center,8140062,SUTURE 0 VICRYL CP-1 27IN  J267H,1269,,270,$4.13 ,$4.13 ,$1.24 ,$3.76 ,$2.89 ,$1.24 ,$2.68 ,$2.97 ,$3.76 ,$3.10 
Carle BroMenn Medical Center,8140062,SUTURE 0 VICRYL CP-2 GS J870H,244781,,270,$4.09 ,$4.09 ,$1.23 ,$3.72 ,$2.86 ,$1.23 ,$2.66 ,$2.94 ,$3.72 ,$3.07 
Carle BroMenn Medical Center,8140062,SUTURE 0 VICRYL CT-1 36IN,244317,,270,$3.91 ,$3.91 ,$1.17 ,$3.56 ,$2.74 ,$1.17 ,$2.54 ,$2.82 ,$3.56 ,$2.93 
Carle BroMenn Medical Center,8140062,SUTURE 0 VICRYL CT-1 J340H,244426,,270,$3.75 ,$3.75 ,$1.13 ,$3.41 ,$2.63 ,$1.13 ,$2.44 ,$2.70 ,$3.41 ,$2.81 
Carle BroMenn Medical Center,8140062,SUTURE 0 VICRYL CT-1 J346H,244425,,270,$3.83 ,$3.83 ,$1.15 ,$3.49 ,$2.68 ,$1.15 ,$2.49 ,$2.76 ,$3.49 ,$2.87 
Carle BroMenn Medical Center,8140062,SUTURE 0 VICRYL CT-1 J740D,244492,,270,$28.20 ,$28.20 ,$8.46 ,$25.66 ,$19.74 ,$8.46 ,$18.33 ,$20.30 ,$25.66 ,$21.15 
Carle BroMenn Medical Center,8140062,SUTURE 0 VICRYL CT-2 J334H,244489,,270,$3.78 ,$3.78 ,$1.13 ,$3.44 ,$2.65 ,$1.13 ,$2.46 ,$2.72 ,$3.44 ,$2.84 
Carle BroMenn Medical Center,8140062,SUTURE 0 VICRYL CT-2 J727D,244518,,270,$28.14 ,$28.14 ,$8.44 ,$25.61 ,$19.70 ,$8.44 ,$18.29 ,$20.26 ,$25.61 ,$21.11 
Carle BroMenn Medical Center,8140062,SUTURE 0 VICRYL UNDYED REEL J287G,244776,,270,$5.19 ,$5.19 ,$1.56 ,$4.72 ,$3.63 ,$1.56 ,$3.37 ,$3.74 ,$4.72 ,$3.89 
Carle BroMenn Medical Center,8140062,SUTURE 0 VICRYL UR-5 J376H J376H,245252,,270,$4.53 ,$4.53 ,$1.36 ,$4.12 ,$3.17 ,$1.36 ,$2.94 ,$3.26 ,$4.12 ,$3.40 
Carle BroMenn Medical Center,8140062,SUTURE 0 VICRYL UR-6 27IN,244294,,270,$4.57 ,$4.57 ,$1.37 ,$4.16 ,$3.20 ,$1.37 ,$2.97 ,$3.29 ,$4.16 ,$3.43 
Carle BroMenn Medical Center,8140062,SUTURE 0 VLOC ABS GREEN 12IN VLOC,244813,,270,$65.46 ,$65.46 ,$19.64 ,$59.57 ,$45.82 ,$19.64 ,$42.55 ,$47.13 ,$59.57 ,$49.10 
Carle BroMenn Medical Center,8140062,SUTURE 0 VLOC ABS GREEN 9IN VLOCL,245040,,270,$88.92 ,$88.92 ,$26.68 ,$80.92 ,$62.24 ,$26.68 ,$57.80 ,$64.02 ,$80.92 ,$66.69 
Carle BroMenn Medical Center,8140062,SUTURE 0 VLOC GS-21 NOABS 18IN VL,244874,,270,$78.12 ,$78.12 ,$23.44 ,$71.09 ,$54.68 ,$23.44 ,$50.78 ,$56.25 ,$71.09 ,$58.59 
Carle BroMenn Medical Center,8140062,SUTURE 0 XBRAID WHIPSTITCH,247601,,270,$183.00 ,$183.00 ,$54.90 ,$166.53 ,$128.10 ,$54.90 ,$118.95 ,$131.76 ,$166.53 ,$137.25 
Carle BroMenn Medical Center,8140062,SUTURE 0-0 ETHIBOND GRN BR,245212,,270,$2.41 ,$2.41 ,$0.72 ,$2.19 ,$1.69 ,$0.72 ,$1.57 ,$1.74 ,$2.19 ,$1.81 
Carle BroMenn Medical Center,8140062,SUTURE 1 CHROMIC CTX 36IN BRWN 90,244549,,270,$8.25 ,$8.25 ,$2.48 ,$7.51 ,$5.78 ,$2.48 ,$5.36 ,$5.94 ,$7.51 ,$6.19 
Carle BroMenn Medical Center,8140062,SUTURE 1 NUROLON OS-8 C595T,244967,,270,$17.67 ,$17.67 ,$5.30 ,$16.08 ,$12.37 ,$5.30 ,$11.49 ,$12.72 ,$16.08 ,$13.25 
Carle BroMenn Medical Center,8140062,SUTURE 1 PDS CTX 36IN,244285,,270,$7.28 ,$7.28 ,$2.18 ,$6.62 ,$5.10 ,$2.18 ,$4.73 ,$5.24 ,$6.62 ,$5.46 
Carle BroMenn Medical Center,8140062,SUTURE 1 PDS TP-1 96IN,244332,,270,$12.50 ,$12.50 ,$3.75 ,$11.38 ,$8.75 ,$3.75 ,$8.13 ,$9.00 ,$11.38 ,$9.38 
Carle BroMenn Medical Center,8140062,SUTURE 1 PROLENE CT-1 8425H 8425H,248866,,270,$6.17 ,$6.17 ,$1.85 ,$5.61 ,$4.32 ,$1.85 ,$4.01 ,$4.44 ,$5.61 ,$4.63 
Carle BroMenn Medical Center,8140062,SUTURE 1 SILK SUTUREUPAK SA87G,244561,,270,$5.97 ,$5.97 ,$1.79 ,$5.43 ,$4.18 ,$1.79 ,$3.88 ,$4.30 ,$5.43 ,$4.48 
Carle BroMenn Medical Center,8140062,SUTURE 1 VICRYL BR CT J281H,244968,,270,$3.74 ,$3.74 ,$1.12 ,$3.40 ,$2.62 ,$1.12 ,$2.43 ,$2.69 ,$3.40 ,$2.81 
Carle BroMenn Medical Center,8140062,SUTURE 1 VICRYL CT J359H,244658,,270,$4.37 ,$4.37 ,$1.31 ,$3.98 ,$3.06 ,$1.31 ,$2.84 ,$3.15 ,$3.98 ,$3.28 
Carle BroMenn Medical Center,8140062,SUTURE 1 VICRYL CT-1 J947H,244635,,270,$4.07 ,$4.07 ,$1.22 ,$3.70 ,$2.85 ,$1.22 ,$2.65 ,$2.93 ,$3.70 ,$3.05 
Carle BroMenn Medical Center,8140062,SUTURE 1 VICRYL CT-1 JJ40G,244969,,270,$28.98 ,$28.98 ,$8.69 ,$26.37 ,$20.29 ,$8.69 ,$18.84 ,$20.87 ,$26.37 ,$21.74 
Carle BroMenn Medical Center,8140062,SUTURE 1 VICRYL CTX J977H,244509,,270,$4.12 ,$4.12 ,$1.24 ,$3.75 ,$2.88 ,$1.24 ,$2.68 ,$2.97 ,$3.75 ,$3.09 
Carle BroMenn Medical Center,8140062,SUTURE 1 VICRYL TP-1 J650G,244869,,270,$33.78 ,$33.78 ,$10.13 ,$30.74 ,$23.65 ,$10.13 ,$21.96 ,$24.32 ,$30.74 ,$25.34 
Carle BroMenn Medical Center,8140062,SUTURE 1 VICRYL UND CP-1 CTD J268,245286,,270,$4.01 ,$4.01 ,$1.20 ,$3.65 ,$2.81 ,$1.20 ,$2.61 ,$2.89 ,$3.65 ,$3.01 
Carle BroMenn Medical Center,8140062,SUTURE 1 VICRYL UND OS-8 CTD J699,245285,,270,$5.75 ,$5.75 ,$1.73 ,$5.23 ,$4.03 ,$1.73 ,$3.74 ,$4.14 ,$5.23 ,$4.31 
Carle BroMenn Medical Center,8140062,SUTURE 1 VICRYL V-34 J519H,244495,,270,$6.24 ,$6.24 ,$1.87 ,$5.68 ,$4.37 ,$1.87 ,$4.06 ,$4.49 ,$5.68 ,$4.68 
Carle BroMenn Medical Center,8140062,SUTURE 1 VICRYL VILBR CT-1 J341H,245284,,270,$3.74 ,$3.74 ,$1.12 ,$3.40 ,$2.62 ,$1.12 ,$2.43 ,$2.69 ,$3.40 ,$2.81 
Carle BroMenn Medical Center,8140062,SUTURE 1 VICRYL0-0 CS1606 DARM V4,244430,,270,$52.37 ,$52.37 ,$15.71 ,$47.66 ,$36.66 ,$15.71 ,$34.04 ,$37.71 ,$47.66 ,$39.28 
Carle BroMenn Medical Center,8140062,SUTURE 1-0 PROLENE CT 30IN 8435H,245271,,270,$6.17 ,$6.17 ,$1.85 ,$5.61 ,$4.32 ,$1.85 ,$4.01 ,$4.44 ,$5.61 ,$4.63 
Carle BroMenn Medical Center,8140062,SUTURE 10-0 ETHILON CS160-6,244302,,270,$53.49 ,$53.49 ,$16.05 ,$48.68 ,$37.44 ,$16.05 ,$34.77 ,$38.51 ,$48.68 ,$40.12 
Carle BroMenn Medical Center,8140062,SUTURE 2 ETHIBOND OS-4 30IN,244338,,270,$6.05 ,$6.05 ,$1.82 ,$5.51 ,$4.24 ,$1.82 ,$3.93 ,$4.36 ,$5.51 ,$4.54 
Carle BroMenn Medical Center,8140062,SUTURE 2 ETHIBOND V-37 MX69G,244508,,270,$38.36 ,$38.36 ,$11.51 ,$34.91 ,$26.85 ,$11.51 ,$24.93 ,$27.62 ,$34.91 ,$28.77 
Carle BroMenn Medical Center,8140062,SUTURE 2 ETHILON 20IN 460T,245276,,270,$5.24 ,$5.24 ,$1.57 ,$4.77 ,$3.67 ,$1.57 ,$3.41 ,$3.77 ,$4.77 ,$3.93 
Carle BroMenn Medical Center,8140062,SUTURE 2 FIBERWIRE TAPER 38IN INC,1496,,270,$66.00 ,$66.00 ,$19.80 ,$60.06 ,$46.20 ,$19.80 ,$42.90 ,$47.52 ,$60.06 ,$49.50 
Carle BroMenn Medical Center,8140062,SUTURE 2 PROLENE TP-1 60IN,244375,,270,$9.20 ,$9.20 ,$2.76 ,$8.37 ,$6.44 ,$2.76 ,$5.98 ,$6.62 ,$8.37 ,$6.90 
Carle BroMenn Medical Center,8140062,SUTURE 2 SILK 60IN,244288,,270,$3.50 ,$3.50 ,$1.05 ,$3.19 ,$2.45 ,$1.05 ,$2.28 ,$2.52 ,$3.19 ,$2.63 
Carle BroMenn Medical Center,8140062,SUTURE 2 VICRYL TP-1 27IN,244350,,270,$17.09 ,$17.09 ,$5.13 ,$15.55 ,$11.96 ,$5.13 ,$11.11 ,$12.30 ,$15.55 ,$12.82 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 CHROMIC CT-1 811H,244550,,270,$7.50 ,$7.50 ,$2.25 ,$6.83 ,$5.25 ,$2.25 ,$4.88 ,$5.40 ,$6.83 ,$5.63 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 CHROMIC LIGAPAK L113G,244416,,270,$9.05 ,$9.05 ,$2.72 ,$8.24 ,$6.34 ,$2.72 ,$5.88 ,$6.52 ,$8.24 ,$6.79 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 CHROMIC SH 27IN G123H,244274,,270,$7.10 ,$7.10 ,$2.13 ,$6.46 ,$4.97 ,$2.13 ,$4.62 ,$5.11 ,$6.46 ,$5.33 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 ETHIBND V-5 10X52 30IN,1442,,270,$126.00 ,$126.00 ,$37.80 ,$114.66 ,$88.20 ,$37.80 ,$81.90 ,$90.72 ,$114.66 ,$94.50 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 ETHIBND V-5 PXX52 D-AR,244321,,270,$178.53 ,$178.53 ,$53.56 ,$162.46 ,$124.97 ,$53.56 ,$116.04 ,$128.54 ,$162.46 ,$133.90 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 ETHIBOND CT-2 30IN,244387,,270,$3.99 ,$3.99 ,$1.20 ,$3.63 ,$2.79 ,$1.20 ,$2.59 ,$2.87 ,$3.63 ,$2.99 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 ETHIBOND SH 30IN X833H,245256,,270,$4.86 ,$4.86 ,$1.46 ,$4.42 ,$3.40 ,$1.46 ,$3.16 ,$3.50 ,$4.42 ,$3.65 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 ETHIBOND SH GRN BR,247031,,270,$9.67 ,$9.67 ,$2.90 ,$8.80 ,$6.77 ,$2.90 ,$6.29 ,$6.96 ,$8.80 ,$7.25 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 ETHIBOND V-7 10X72 D-A,244963,,270,$138.59 ,$138.59 ,$41.58 ,$126.12 ,$97.01 ,$41.58 ,$90.08 ,$99.78 ,$126.12 ,$103.94 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 ETHIBOND V-7 PXX77 D-A,244728,,270,$194.73 ,$194.73 ,$58.42 ,$177.20 ,$136.31 ,$58.42 ,$126.57 ,$140.21 ,$177.20 ,$146.05 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 ETHILON FS 18IN,244282,,270,$4.81 ,$4.81 ,$1.44 ,$4.38 ,$3.37 ,$1.44 ,$3.13 ,$3.46 ,$4.38 ,$3.61 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 MONO QUILL 30X30,245268,,270,$91.38 ,$91.38 ,$27.41 ,$83.16 ,$63.97 ,$27.41 ,$59.40 ,$65.79 ,$83.16 ,$68.54 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 MONOCRYL CT-1 Y945H Y9,244736,,270,$5.88 ,$5.88 ,$1.76 ,$5.35 ,$4.12 ,$1.76 ,$3.82 ,$4.23 ,$5.35 ,$4.41 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 PDS II CT-1 Z339H,244420,,270,$6.29 ,$6.29 ,$1.89 ,$5.72 ,$4.40 ,$1.89 ,$4.09 ,$4.53 ,$5.72 ,$4.72 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 PDS II CT-2 Z333H,244555,,270,$6.60 ,$6.60 ,$1.98 ,$6.01 ,$4.62 ,$1.98 ,$4.29 ,$4.75 ,$6.01 ,$4.95 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 PDS SH 27IN,244325,,270,$6.39 ,$6.39 ,$1.92 ,$5.81 ,$4.47 ,$1.92 ,$4.15 ,$4.60 ,$5.81 ,$4.79 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 PROLENE CT-2 8411H,244631,,270,$6.30 ,$6.30 ,$1.89 ,$5.73 ,$4.41 ,$1.89 ,$4.10 ,$4.54 ,$5.73 ,$4.73 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 PROLENE MH DARM 8843H,244867,,270,$15.31 ,$15.31 ,$4.59 ,$13.93 ,$10.72 ,$4.59 ,$9.95 ,$11.02 ,$13.93 ,$11.48 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 PROLENE MO-6 8417H,245290,,270,$7.90 ,$7.90 ,$2.37 ,$7.19 ,$5.53 ,$2.37 ,$5.14 ,$5.69 ,$7.19 ,$5.93 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 PROLENE SH 36IN,244304,,270,$14.00 ,$14.00 ,$4.20 ,$12.74 ,$9.80 ,$4.20 ,$9.10 ,$10.08 ,$12.74 ,$10.50 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 SILK 12-18 LABYRNTH 36,244012,,270,$3.59 ,$3.59 ,$1.08 ,$3.27 ,$2.51 ,$1.08 ,$2.33 ,$2.58 ,$3.27 ,$2.69 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 SILK 18IN SA65H SA65H,245279,,270,$5.50 ,$5.50 ,$1.65 ,$5.01 ,$3.85 ,$1.65 ,$3.58 ,$3.96 ,$5.01 ,$4.13 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 SILK 30IN TIE,244311,,270,$5.90 ,$5.90 ,$1.77 ,$5.37 ,$4.13 ,$1.77 ,$3.84 ,$4.25 ,$5.37 ,$4.43 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 SILK CR SH 8PK,244380,,270,$25.51 ,$25.51 ,$7.65 ,$23.21 ,$17.86 ,$7.65 ,$16.58 ,$18.37 ,$23.21 ,$19.13 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 SILK CT2 C026D,245278,,270,$21.75 ,$21.75 ,$6.53 ,$19.79 ,$15.23 ,$6.53 ,$14.14 ,$15.66 ,$19.79 ,$16.31 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 SILK FS 685G,244563,,270,$3.93 ,$3.93 ,$1.18 ,$3.58 ,$2.75 ,$1.18 ,$2.55 ,$2.83 ,$3.58 ,$2.95 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 SILK SH 18IN MS,244336,,270,$21.82 ,$21.82 ,$6.55 ,$19.86 ,$15.27 ,$6.55 ,$14.18 ,$15.71 ,$19.86 ,$16.37 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 SILK SH 18IN MS  C012D,1411,,270,$21.41 ,$21.41 ,$6.42 ,$19.48 ,$14.99 ,$6.42 ,$13.92 ,$15.42 ,$19.48 ,$16.06 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 SILK SH 30IN K833H,244289,,270,$3.03 ,$3.03 ,$0.91 ,$2.76 ,$2.12 ,$0.91 ,$1.97 ,$2.18 ,$2.76 ,$2.27 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 SILK X-1 737H,244964,,270,$4.04 ,$4.04 ,$1.21 ,$3.68 ,$2.83 ,$1.21 ,$2.63 ,$2.91 ,$3.68 ,$3.03 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 TICRON 5 BLU HGS-21,245224,,270,$21.86 ,$21.86 ,$6.56 ,$19.89 ,$15.30 ,$6.56 ,$14.21 ,$15.74 ,$19.89 ,$16.40 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 VICRYL CP-1 27IN  J266,1281,,270,$3.93 ,$3.93 ,$1.18 ,$3.58 ,$2.75 ,$1.18 ,$2.55 ,$2.83 ,$3.58 ,$2.95 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 VICRYL CP-1 J466H,244427,,270,$3.97 ,$3.97 ,$1.19 ,$3.61 ,$2.78 ,$1.19 ,$2.58 ,$2.86 ,$3.61 ,$2.98 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 VICRYL CR/SH J775D,52606,,270,$26.35 ,$26.35 ,$7.91 ,$23.98 ,$18.45 ,$7.91 ,$17.13 ,$18.97 ,$23.98 ,$19.76 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 VICRYL CT UD BR 18 J11,245211,,270,$20.39 ,$20.39 ,$6.12 ,$18.55 ,$14.27 ,$6.12 ,$13.25 ,$14.68 ,$18.55 ,$15.29 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 VICRYL CT-1 27IN,244319,,270,$3.70 ,$3.70 ,$1.11 ,$3.37 ,$2.59 ,$1.11 ,$2.41 ,$2.66 ,$3.37 ,$2.78 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 VICRYL CT-1 J339H,244491,,270,$3.70 ,$3.70 ,$1.11 ,$3.37 ,$2.59 ,$1.11 ,$2.41 ,$2.66 ,$3.37 ,$2.78 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 VICRYL CT-1 J839D,244656,,270,$27.51 ,$27.51 ,$8.25 ,$25.03 ,$19.26 ,$8.25 ,$17.88 ,$19.81 ,$25.03 ,$20.63 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 VICRYL CT-1 J945H,244632,,270,$3.98 ,$3.98 ,$1.19 ,$3.62 ,$2.79 ,$1.19 ,$2.59 ,$2.87 ,$3.62 ,$2.99 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 VICRYL CT2  J269H,9099,,270,$4.71 ,$4.71 ,$1.41 ,$4.29 ,$3.30 ,$1.41 ,$3.06 ,$3.39 ,$4.29 ,$3.53 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 VICRYL CT-2 18IN,244355,,270,$27.36 ,$27.36 ,$8.21 ,$24.90 ,$19.15 ,$8.21 ,$17.78 ,$19.70 ,$24.90 ,$20.52 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 VICRYL CT-2 27IN,244384,,270,$3.78 ,$3.78 ,$1.13 ,$3.44 ,$2.65 ,$1.13 ,$2.46 ,$2.72 ,$3.44 ,$2.84 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 VICRYL DYED 27IN,244295,,270,$3.59 ,$3.59 ,$1.08 ,$3.27 ,$2.51 ,$1.08 ,$2.33 ,$2.58 ,$3.27 ,$2.69 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 VICRYL FS-1 27IN,244386,,270,$5.30 ,$5.30 ,$1.59 ,$4.82 ,$3.71 ,$1.59 ,$3.45 ,$3.82 ,$4.82 ,$3.98 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 VICRYL REEL,244410,,270,$5.30 ,$5.30 ,$1.59 ,$4.82 ,$3.71 ,$1.59 ,$3.45 ,$3.82 ,$4.82 ,$3.98 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 VICRYL SH 27IN,244299,,270,$3.70 ,$3.70 ,$1.11 ,$3.37 ,$2.59 ,$1.11 ,$2.41 ,$2.66 ,$3.37 ,$2.78 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 VICRYL UR-6 27IN,244309,,270,$4.64 ,$4.64 ,$1.39 ,$4.22 ,$3.25 ,$1.39 ,$3.02 ,$3.34 ,$4.22 ,$3.48 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 VLOC ABS GREEN 12IN VL,244831,,270,$65.46 ,$65.46 ,$19.64 ,$59.57 ,$45.82 ,$19.64 ,$42.55 ,$47.13 ,$59.57 ,$49.10 
Carle BroMenn Medical Center,8140062,SUTURE 2-0 VLOC ABS VIOL 9IN VLOC,244834,,270,$62.34 ,$62.34 ,$18.70 ,$56.73 ,$43.64 ,$18.70 ,$40.52 ,$44.88 ,$56.73 ,$46.76 
Carle BroMenn Medical Center,8140062,SUTURE 3-0 CHROMIC FS-2 27IN 636H,244340,,270,$7.31 ,$7.31 ,$2.19 ,$6.65 ,$5.12 ,$2.19 ,$4.75 ,$5.26 ,$6.65 ,$5.48 
Carle BroMenn Medical Center,8140062,SUTURE 3-0 CHROMIC SH 27IN,244275,,270,$7.20 ,$7.20 ,$2.16 ,$6.55 ,$5.04 ,$2.16 ,$4.68 ,$5.18 ,$6.55 ,$5.40 
Carle BroMenn Medical Center,8140062,SUTURE 3-0 CHROMICLIGAPAK L112G,244551,,270,$8.42 ,$8.42 ,$2.53 ,$7.66 ,$5.89 ,$2.53 ,$5.47 ,$6.06 ,$7.66 ,$6.32 
Carle BroMenn Medical Center,8140062,SUTURE 3-0 ETHILON FS1 18IN,244341,,270,$4.91 ,$4.91 ,$1.47 ,$4.47 ,$3.44 ,$1.47 ,$3.19 ,$3.54 ,$4.47 ,$3.68 
Carle BroMenn Medical Center,8140062,SUTURE 3-0 ETHILON FS1 18IN 663G,197025,,270,$4.86 ,$4.86 ,$1.46 ,$4.42 ,$3.40 ,$1.46 ,$3.16 ,$3.50 ,$4.42 ,$3.65 
Carle BroMenn Medical Center,8140062,SUTURE 3-0 ETHLN 18IN PS-1,244327,,270,$10.69 ,$10.69 ,$3.21 ,$9.73 ,$7.48 ,$3.21 ,$6.95 ,$7.70 ,$9.73 ,$8.02 
Carle BroMenn Medical Center,8140062,SUTURE 3-0 MONO B/S CP1 497G,245280,,270,$5.15 ,$5.15 ,$1.55 ,$4.69 ,$3.61 ,$1.55 ,$3.35 ,$3.71 ,$4.69 ,$3.86 
Carle BroMenn Medical Center,8140062,SUTURE 3-0 MONOCRYL CT1 CLEAR BX/,212831,,270,$6.41 ,$6.41 ,$1.92 ,$5.83 ,$4.49 ,$1.92 ,$4.17 ,$4.62 ,$5.83 ,$4.81 
Carle BroMenn Medical Center,8140062,SUTURE 3-0 MONOCRYL PS-2 Y427H,244633,,270,$14.30 ,$14.30 ,$4.29 ,$13.01 ,$10.01 ,$4.29 ,$9.30 ,$10.30 ,$13.01 ,$10.73 
Carle BroMenn Medical Center,8140062,SUTURE 3-0 MONOCRYL RB-1 27IN,12124,,270,$5.84 ,$5.84 ,$1.75 ,$5.31 ,$4.09 ,$1.75 ,$3.80 ,$4.20 ,$5.31 ,$4.38 
Carle BroMenn Medical Center,8140062,SUTURE 3-0 MONOCRYL RB-1 Y305H,244704,,270,$5.84 ,$5.84 ,$1.75 ,$5.31 ,$4.09 ,$1.75 ,$3.80 ,$4.20 ,$5.31 ,$4.38 
Carle BroMenn Medical Center,8140062,SUTURE 3-0 NUROLON FSL C566D,244966,,270,$38.62 ,$38.62 ,$11.59 ,$35.14 ,$27.03 ,$11.59 ,$25.10 ,$27.81 ,$35.14 ,$28.97 
Carle BroMenn Medical Center,8140062,SUTURE 3-0 NUROLON SH C513D,244554,,270,$28.44 ,$28.44 ,$8.53 ,$25.88 ,$19.91 ,$8.53 ,$18.49 ,$20.48 ,$25.88 ,$21.33 
Carle BroMenn Medical Center,8140062,SUTURE 3-0 PDS II PS2 CLEAR MO Z4,245257,,270,$13.07 ,$13.07 ,$3.92 ,$11.89 ,$9.15 ,$3.92 ,$8.50 ,$9.41 ,$11.89 ,$9.80 
Carle BroMenn Medical Center,8140062,SUTURE 3-0 PDS II SH X316H,244532,,270,$6.34 ,$6.34 ,$1.90 ,$5.77 ,$4.44 ,$1.90 ,$4.12 ,$4.56 ,$5.77 ,$4.76 
Carle BroMenn Medical Center,8140062,SUTURE 3-0 PLAIN CT-1 842H,244556,,270,$7.98 ,$7.98 ,$2.39 ,$7.26 ,$5.59 ,$2.39 ,$5.19 ,$5.75 ,$7.26 ,$5.99 
Carle BroMenn Medical Center,8140062,SUTURE 3-0 PLAIN FS-2 27IN  H822H,1396,,270,$7.55 ,$7.55 ,$2.27 ,$6.87 ,$5.29 ,$2.27 ,$4.91 ,$5.44 ,$6.87 ,$5.66 
Carle BroMenn Medical Center,8140062,SUTURE 3-0 PROLENE FS-2 8665G,244723,,270,$7.41 ,$7.41 ,$2.22 ,$6.74 ,$5.19 ,$2.22 ,$4.82 ,$5.34 ,$6.74 ,$5.56 
Carle BroMenn Medical Center,8140062,SUTURE 3-0 PROLENE PS-1 8663G,244558,,270,$13.82 ,$13.82 ,$4.15 ,$12.58 ,$9.67 ,$4.15 ,$8.98 ,$9.95 ,$12.58 ,$10.37 
Carle BroMenn Medical Center,8140062,SUTURE 3-0 PROLENE SH 36IN,244305,,270,$14.24 ,$14.24 ,$4.27 ,$12.96 ,$9.97 ,$4.27 ,$9.26 ,$10.25 ,$12.96 ,$10.68 
Carle BroMenn Medical Center,8140062,SUTURE 3-0 PROLENE SH 48IN,244367,,270,$15.94 ,$15.94 ,$4.78 ,$14.51 ,$11.16 ,$4.78 ,$10.36 ,$11.48 ,$14.51 ,$11.96 
Carle BroMenn Medical Center,8140062,SUTURE 3-0 SILK 30IN TIE,244290,,270,$7.68 ,$7.68 ,$2.30 ,$6.99 ,$5.38 ,$2.30 ,$4.99 ,$5.53 ,$6.99 ,$5.76 
Carle BroMenn Medical Center,8140062,SUTURE 3-0 SILK A184H,244564,,270,$4.38 ,$4.38 ,$1.31 ,$3.99 ,$3.07 ,$1.31 ,$2.85 ,$3.15 ,$3.99 ,$3.29 
Carle BroMenn Medical Center,8140062,SUTURE 3-0 SILK FS-1 18IN,244942,,270,$3.96 ,$3.96 ,$1.19 ,$3.60 ,$2.77 ,$1.19 ,$2.57 ,$2.85 ,$3.60 ,$2.97 
Carle BroMenn Medical Center,8140062,SUTURE 3-0 SILK RB-1 30IN K872H,60785,,270,$3.98 ,$3.98 ,$1.19 ,$3.62 ,$2.79 ,$1.19 ,$2.59 ,$2.87 ,$3.62 ,$2.99 
Carle BroMenn Medical Center,8140062,SUTURE 3-0 SILK SH 30IN,244291,,270,$3.04 ,$3.04 ,$0.91 ,$2.77 ,$2.13 ,$0.91 ,$1.98 ,$2.19 ,$2.77 ,$2.28 
Carle BroMenn Medical Center,8140062,SUTURE 3-0 SILK SH/CR-8,244301,,270,$21.68 ,$21.68 ,$6.50 ,$19.73 ,$15.18 ,$6.50 ,$14.09 ,$15.61 ,$19.73 ,$16.26 
Carle BroMenn Medical Center,8140062,SUTURE 3-0 VICRYL,244391,,270,$9.90 ,$9.90 ,$2.97 ,$9.01 ,$6.93 ,$2.97 ,$6.44 ,$7.13 ,$9.01 ,$7.43 
Carle BroMenn Medical Center,8140062,SUTURE 3-0 VICRYL CT UD BR J110T,245210,,270,$20.01 ,$20.01 ,$6.00 ,$18.21 ,$14.01 ,$6.00 ,$13.01 ,$14.41 ,$18.21 ,$15.01 
Carle BroMenn Medical Center,8140062,SUTURE 3-0 VICRYL CT-1 27IN,244385,,270,$3.88 ,$3.88 ,$1.16 ,$3.53 ,$2.72 ,$1.16 ,$2.52 ,$2.79 ,$3.53 ,$2.91 
Carle BroMenn Medical Center,8140062,SUTURE 3-0 VICRYL CT-1 J258H,244566,,270,$3.71 ,$3.71 ,$1.11 ,$3.38 ,$2.60 ,$1.11 ,$2.41 ,$2.67 ,$3.38 ,$2.78 
Carle BroMenn Medical Center,8140062,SUTURE 3-0 VICRYL CT-1 J344H,244505,,270,$4.00 ,$4.00 ,$1.20 ,$3.64 ,$2.80 ,$1.20 ,$2.60 ,$2.88 ,$3.64 ,$3.00 
Carle BroMenn Medical Center,8140062,SUTURE 3-0 VICRYL CT-2 J332H,244654,,270,$4.10 ,$4.10 ,$1.23 ,$3.73 ,$2.87 ,$1.23 ,$2.67 ,$2.95 ,$3.73 ,$3.08 
Carle BroMenn Medical Center,8140062,SUTURE 3-0 VICRYL J644H,245272,,270,$5.66 ,$5.66 ,$1.70 ,$5.15 ,$3.96 ,$1.70 ,$3.68 ,$4.08 ,$5.15 ,$4.25 
Carle BroMenn Medical Center,8140062,SUTURE 3-0 VICRYL PS-2,244008,,270,$9.72 ,$9.72 ,$2.92 ,$8.85 ,$6.80 ,$2.92 ,$6.32 ,$7.00 ,$8.85 ,$7.29 
Carle BroMenn Medical Center,8140062,SUTURE 3-0 VICRYL RB-1 J305H,244497,,270,$3.98 ,$3.98 ,$1.19 ,$3.62 ,$2.79 ,$1.19 ,$2.59 ,$2.87 ,$3.62 ,$2.99 
Carle BroMenn Medical Center,8140062,SUTURE 3-0 VICRYL REEL,244390,,270,$5.21 ,$5.21 ,$1.56 ,$4.74 ,$3.65 ,$1.56 ,$3.39 ,$3.75 ,$4.74 ,$3.91 
Carle BroMenn Medical Center,8140062,SUTURE 3-0 VICRYL SH 27IN,244320,,270,$3.71 ,$3.71 ,$1.11 ,$3.38 ,$2.60 ,$1.11 ,$2.41 ,$2.67 ,$3.38 ,$2.78 
Carle BroMenn Medical Center,8140062,SUTURE 3-0 VICRYL SH 27IN J316H,244428,,270,$3.71 ,$3.71 ,$1.11 ,$3.38 ,$2.60 ,$1.11 ,$2.41 ,$2.67 ,$3.38 ,$2.78 
Carle BroMenn Medical Center,8140062,SUTURE 3-0 VICRYL SH J864D,244603,,270,$28.32 ,$28.32 ,$8.50 ,$25.77 ,$19.82 ,$8.50 ,$18.41 ,$20.39 ,$25.77 ,$21.24 
Carle BroMenn Medical Center,8140062,SUTURE 3-0 VICRYL UND CTD FS-2 J4,245287,,270,$5.16 ,$5.16 ,$1.55 ,$4.70 ,$3.61 ,$1.55 ,$3.35 ,$3.72 ,$4.70 ,$3.87 
Carle BroMenn Medical Center,8140062,SUTURE 3-0 VICRYL VIL BR SH J527H,245273,,270,$7.47 ,$7.47 ,$2.24 ,$6.80 ,$5.23 ,$2.24 ,$4.86 ,$5.38 ,$6.80 ,$5.60 
Carle BroMenn Medical Center,8140062,SUTURE 3-0 VLOC 9IN DYED COVIDIEN,255781,,270,$21.42 ,$21.42 ,$6.43 ,$19.49 ,$14.99 ,$6.43 ,$13.92 ,$15.42 ,$19.49 ,$16.07 
Carle BroMenn Medical Center,8140062,SUTURE 3-0 VLOC 9IN UNDYED COVIDI,254227,,270,$29.64 ,$29.64 ,$8.89 ,$26.97 ,$20.75 ,$8.89 ,$19.27 ,$21.34 ,$26.97 ,$22.23 
Carle BroMenn Medical Center,8140062,SUTURE 3-0 VLOC ABS VIOL 6IN VLOC,245185,,270,$88.92 ,$88.92 ,$26.68 ,$80.92 ,$62.24 ,$26.68 ,$57.80 ,$64.02 ,$80.92 ,$66.69 
Carle BroMenn Medical Center,8140062,SUTURE 4-0 CHROMIC P-3 18IN,244298,,270,$14.73 ,$14.73 ,$4.42 ,$13.40 ,$10.31 ,$4.42 ,$9.57 ,$10.61 ,$13.40 ,$11.05 
Carle BroMenn Medical Center,8140062,SUTURE 4-0 CHROMIC PS-2,244276,,270,$14.91 ,$14.91 ,$4.47 ,$13.57 ,$10.44 ,$4.47 ,$9.69 ,$10.74 ,$13.57 ,$11.18 
Carle BroMenn Medical Center,8140062,SUTURE 4-0 CHROMIC RB-1 27IN,244277,,270,$8.11 ,$8.11 ,$2.43 ,$7.38 ,$5.68 ,$2.43 ,$5.27 ,$5.84 ,$7.38 ,$6.08 
Carle BroMenn Medical Center,8140062,SUTURE 4-0 CHROMIC SH,244278,,270,$7.47 ,$7.47 ,$2.24 ,$6.80 ,$5.23 ,$2.24 ,$4.86 ,$5.38 ,$6.80 ,$5.60 
Carle BroMenn Medical Center,8140062,SUTURE 4-0 ETHILON P-3 BLACK,244283,,270,$10.29 ,$10.29 ,$3.09 ,$9.36 ,$7.20 ,$3.09 ,$6.69 ,$7.41 ,$9.36 ,$7.72 
Carle BroMenn Medical Center,8140062,SUTURE 4-0 ETHILON PC-3 18IN 1864,244504,,270,$10.76 ,$10.76 ,$3.23 ,$9.79 ,$7.53 ,$3.23 ,$6.99 ,$7.75 ,$9.79 ,$8.07 
Carle BroMenn Medical Center,8140062,SUTURE 4-0 ETHILON PS-2 1667H,244486,,270,$9.80 ,$9.80 ,$2.94 ,$8.92 ,$6.86 ,$2.94 ,$6.37 ,$7.06 ,$8.92 ,$7.35 
Carle BroMenn Medical Center,8140062,SUTURE 4-0 ETHILON PS-2 BLACK,244313,,270,$9.80 ,$9.80 ,$2.94 ,$8.92 ,$6.86 ,$2.94 ,$6.37 ,$7.06 ,$8.92 ,$7.35 
Carle BroMenn Medical Center,8140062,SUTURE 4-0 FIBERWIRE,206184,,270,$66.00 ,$66.00 ,$19.80 ,$60.06 ,$46.20 ,$19.80 ,$42.90 ,$47.52 ,$60.06 ,$49.50 
Carle BroMenn Medical Center,8140062,SUTURE 4-0 MONOCRYL P-3 18IN Y494,244315,,270,$15.03 ,$15.03 ,$4.51 ,$13.68 ,$10.52 ,$4.51 ,$9.77 ,$10.82 ,$13.68 ,$11.27 
Carle BroMenn Medical Center,8140062,SUTURE 4-0 MONOCRYL PS2 Y496G,244329,,270,$14.06 ,$14.06 ,$4.22 ,$12.79 ,$9.84 ,$4.22 ,$9.14 ,$10.12 ,$12.79 ,$10.55 
Carle BroMenn Medical Center,8140062,SUTURE 4-0 MONOCRYL TAPER RB-1 Y3,245230,,270,$5.68 ,$5.68 ,$1.70 ,$5.17 ,$3.98 ,$1.70 ,$3.69 ,$4.09 ,$5.17 ,$4.26 
Carle BroMenn Medical Center,8140062,SUTURE 4-0 NUROLON RB-1 18IN N124,244371,,270,$35.52 ,$35.52 ,$10.66 ,$32.32 ,$24.86 ,$10.66 ,$23.09 ,$25.57 ,$32.32 ,$26.64 
Carle BroMenn Medical Center,8140062,SUTURE 4-0 NUROLONG RB-1 C554D,244507,,270,$32.83 ,$32.83 ,$9.85 ,$29.88 ,$22.98 ,$9.85 ,$21.34 ,$23.64 ,$29.88 ,$24.62 
Carle BroMenn Medical Center,8140062,SUTURE 4-0 PDS CLEAR PS-2,244333,,270,$14.13 ,$14.13 ,$4.24 ,$12.86 ,$9.89 ,$4.24 ,$9.18 ,$10.17 ,$12.86 ,$10.60 
Carle BroMenn Medical Center,8140062,SUTURE 4-0 PDS RB-1 27IN,244362,,270,$6.35 ,$6.35 ,$1.91 ,$5.78 ,$4.45 ,$1.91 ,$4.13 ,$4.57 ,$5.78 ,$4.76 
Carle BroMenn Medical Center,8140062,SUTURE 4-0 PLAIN SC-1 18IN,244363,,270,$7.89 ,$7.89 ,$2.37 ,$7.18 ,$5.52 ,$2.37 ,$5.13 ,$5.68 ,$7.18 ,$5.92 
Carle BroMenn Medical Center,8140062,SUTURE 4-0 PROLENE BB DARM 8581H,244720,,270,$15.35 ,$15.35 ,$4.61 ,$13.97 ,$10.75 ,$4.61 ,$9.98 ,$11.05 ,$13.97 ,$11.51 
Carle BroMenn Medical Center,8140062,SUTURE 4-0 PROLENE P-3 18IN,244339,,270,$14.18 ,$14.18 ,$4.25 ,$12.90 ,$9.93 ,$4.25 ,$9.22 ,$10.21 ,$12.90 ,$10.64 
Carle BroMenn Medical Center,8140062,SUTURE 4-0 PROLENE PS-2 8682G,244490,,270,$14.06 ,$14.06 ,$4.22 ,$12.79 ,$9.84 ,$4.22 ,$9.14 ,$10.12 ,$12.79 ,$10.55 
Carle BroMenn Medical Center,8140062,SUTURE 4-0 PROLENE RB-1 DARM 8557,244559,,270,$15.45 ,$15.45 ,$4.64 ,$14.06 ,$10.82 ,$4.64 ,$10.04 ,$11.12 ,$14.06 ,$11.59 
Carle BroMenn Medical Center,8140062,SUTURE 4-0 PROLENE SH 36IN,244310,,270,$15.43 ,$15.43 ,$4.63 ,$14.04 ,$10.80 ,$4.63 ,$10.03 ,$11.11 ,$14.04 ,$11.57 
Carle BroMenn Medical Center,8140062,SUTURE 4-0 SILK CR/8 18IN C014D,245288,,270,$21.09 ,$21.09 ,$6.33 ,$19.19 ,$14.76 ,$6.33 ,$13.71 ,$15.18 ,$19.19 ,$15.82 
Carle BroMenn Medical Center,8140062,SUTURE 4-0 SILK CR/8 30IN C018D,245289,,270,$23.80 ,$23.80 ,$7.14 ,$21.66 ,$16.66 ,$7.14 ,$15.47 ,$17.14 ,$21.66 ,$17.85 
Carle BroMenn Medical Center,8140062,SUTURE 4-0 SILK FS-2 683G,244562,,270,$4.36 ,$4.36 ,$1.31 ,$3.97 ,$3.05 ,$1.31 ,$2.83 ,$3.14 ,$3.97 ,$3.27 
Carle BroMenn Medical Center,8140062,SUTURE 4-0 SILK PS-2 1677G,244432,,270,$8.48 ,$8.48 ,$2.54 ,$7.72 ,$5.94 ,$2.54 ,$5.51 ,$6.11 ,$7.72 ,$6.36 
Carle BroMenn Medical Center,8140062,SUTURE 4-0 SILK RB-1 C054D,244431,,270,$27.12 ,$27.12 ,$8.14 ,$24.68 ,$18.98 ,$8.14 ,$17.63 ,$19.53 ,$24.68 ,$20.34 
Carle BroMenn Medical Center,8140062,SUTURE 4-0 SILK RB-1 K871H,244423,,270,$3.92 ,$3.92 ,$1.18 ,$3.57 ,$2.74 ,$1.18 ,$2.55 ,$2.82 ,$3.57 ,$2.94 
Carle BroMenn Medical Center,8140062,SUTURE 4-0 SILK SA63H SA63H,245291,,270,$5.50 ,$5.50 ,$1.65 ,$5.01 ,$3.85 ,$1.65 ,$3.58 ,$3.96 ,$5.01 ,$4.13 
Carle BroMenn Medical Center,8140062,SUTURE 4-0 SILK SUTUREUPAK SA83H,247027,,270,$5.78 ,$5.78 ,$1.73 ,$5.26 ,$4.05 ,$1.73 ,$3.76 ,$4.16 ,$5.26 ,$4.34 
Carle BroMenn Medical Center,8140062,SUTURE 4-0 SILK T-5 18IN N272H,245263,,270,$5.60 ,$5.60 ,$1.68 ,$5.10 ,$3.92 ,$1.68 ,$3.64 ,$4.03 ,$5.10 ,$4.20 
Carle BroMenn Medical Center,8140062,SUTURE 4-0 SILK TF CR C084D,244965,,270,$28.91 ,$28.91 ,$8.67 ,$26.31 ,$20.24 ,$8.67 ,$18.79 ,$20.82 ,$26.31 ,$21.68 
Carle BroMenn Medical Center,8140062,SUTURE 4-0 VCRYL CTD FS2 UNDBR 36,244013,,270,$5.93 ,$5.93 ,$1.78 ,$5.40 ,$4.15 ,$1.78 ,$3.85 ,$4.27 ,$5.40 ,$4.45 
Carle BroMenn Medical Center,8140062,SUTURE 4-0 VICRYL FS-1 J441H,245281,,270,$5.15 ,$5.15 ,$1.55 ,$4.69 ,$3.61 ,$1.55 ,$3.35 ,$3.71 ,$4.69 ,$3.86 
Carle BroMenn Medical Center,8140062,SUTURE 4-0 VICRYL P-2 J504G,244510,,270,$13.21 ,$13.21 ,$3.96 ,$12.02 ,$9.25 ,$3.96 ,$8.59 ,$9.51 ,$12.02 ,$9.91 
Carle BroMenn Medical Center,8140062,SUTURE 4-0 VICRYL P-3 J494G,244314,,270,$10.76 ,$10.76 ,$3.23 ,$9.79 ,$7.53 ,$3.23 ,$6.99 ,$7.75 ,$9.79 ,$8.07 
Carle BroMenn Medical Center,8140062,SUTURE 4-0 VICRYL PS-2,244358,,270,$9.97 ,$9.97 ,$2.99 ,$9.07 ,$6.98 ,$2.99 ,$6.48 ,$7.18 ,$9.07 ,$7.48 
Carle BroMenn Medical Center,8140062,SUTURE 4-0 VICRYL PS-2 18IN,247745,,270,$9.80 ,$9.80 ,$2.94 ,$8.92 ,$6.86 ,$2.94 ,$6.37 ,$7.06 ,$8.92 ,$7.35 
Carle BroMenn Medical Center,8140062,SUTURE 4-0 VICRYL RB-1 UNDYED,244337,,270,$3.83 ,$3.83 ,$1.15 ,$3.49 ,$2.68 ,$1.15 ,$2.49 ,$2.76 ,$3.49 ,$2.87 
Carle BroMenn Medical Center,8140062,SUTURE 4-0 VICRYL SH 27IN,244346,,270,$3.70 ,$3.70 ,$1.11 ,$3.37 ,$2.59 ,$1.11 ,$2.41 ,$2.66 ,$3.37 ,$2.78 
Carle BroMenn Medical Center,8140062,SUTURE 4-0 VICRYL SH J315H,244429,,270,$3.85 ,$3.85 ,$1.16 ,$3.50 ,$2.70 ,$1.16 ,$2.50 ,$2.77 ,$3.50 ,$2.89 
Carle BroMenn Medical Center,8140062,SUTURE 4-0 VICRYL TIE 54IN REEL J,1315,,270,$5.09 ,$5.09 ,$1.53 ,$4.63 ,$3.56 ,$1.53 ,$3.31 ,$3.66 ,$4.63 ,$3.82 
Carle BroMenn Medical Center,8140062,SUTURE 5 ETHIBOND V-37 MB66G,244651,,270,$38.72 ,$38.72 ,$11.62 ,$35.24 ,$27.10 ,$11.62 ,$25.17 ,$27.88 ,$35.24 ,$29.04 
Carle BroMenn Medical Center,8140062,SUTURE 5 TICRON HOS-14 30IN,244293,,270,$33.98 ,$33.98 ,$10.19 ,$30.92 ,$23.79 ,$10.19 ,$22.09 ,$24.47 ,$30.92 ,$25.49 
Carle BroMenn Medical Center,8140062,SUTURE 5-0 CHROMIC P-3 18IN,244280,,270,$15.08 ,$15.08 ,$4.52 ,$13.72 ,$10.56 ,$4.52 ,$9.80 ,$10.86 ,$13.72 ,$11.31 
Carle BroMenn Medical Center,8140062,SUTURE 5-0 ETHILON P-3 BLACK,244330,,270,$9.18 ,$9.18 ,$2.75 ,$8.35 ,$6.43 ,$2.75 ,$5.97 ,$6.61 ,$8.35 ,$6.89 
Carle BroMenn Medical Center,8140062,SUTURE 5-0 ETHILON P-3 CLEAR,244323,,270,$10.86 ,$10.86 ,$3.26 ,$9.88 ,$7.60 ,$3.26 ,$7.06 ,$7.82 ,$9.88 ,$8.15 
Carle BroMenn Medical Center,8140062,SUTURE 5-0 ETHILON PS-2 18IN,244351,,270,$9.89 ,$9.89 ,$2.97 ,$9.00 ,$6.92 ,$2.97 ,$6.43 ,$7.12 ,$9.00 ,$7.42 
Carle BroMenn Medical Center,8140062,SUTURE 5-0 MONOCRYL P-3 Y493G,244498,,270,$15.25 ,$15.25 ,$4.58 ,$13.88 ,$10.68 ,$4.58 ,$9.91 ,$10.98 ,$13.88 ,$11.44 
Carle BroMenn Medical Center,8140062,SUTURE 5-0 MONOCRYL PC-1 Y834G,244971,,270,$15.88 ,$15.88 ,$4.76 ,$14.45 ,$11.12 ,$4.76 ,$10.32 ,$11.43 ,$14.45 ,$11.91 
Carle BroMenn Medical Center,8140062,SUTURE 5-0 PDS P-3 18IN,244286,,270,$14.55 ,$14.55 ,$4.37 ,$13.24 ,$10.19 ,$4.37 ,$9.46 ,$10.48 ,$13.24 ,$10.91 
Carle BroMenn Medical Center,8140062,SUTURE 5-0 PLAIN P-3 18IN,244364,,270,$14.36 ,$14.36 ,$4.31 ,$13.07 ,$10.05 ,$4.31 ,$9.33 ,$10.34 ,$13.07 ,$10.77 
Carle BroMenn Medical Center,8140062,SUTURE 5-0 PLAIN PC-1,244943,,270,$15.82 ,$15.82 ,$4.75 ,$14.40 ,$11.07 ,$4.75 ,$10.28 ,$11.39 ,$14.40 ,$11.87 
Carle BroMenn Medical Center,8140062,SUTURE 5-0 PROLENE 30IN RB2,244376,,270,$15.27 ,$15.27 ,$4.58 ,$13.90 ,$10.69 ,$4.58 ,$9.93 ,$10.99 ,$13.90 ,$11.45 
Carle BroMenn Medical Center,8140062,SUTURE 5-0 PROLENE BV1,64393,,270,$58.58 ,$58.58 ,$17.57 ,$53.31 ,$41.01 ,$17.57 ,$38.08 ,$42.18 ,$53.31 ,$43.94 
Carle BroMenn Medical Center,8140062,SUTURE 5-0 PROLENE C-1 36IN,244306,,270,$36.28 ,$36.28 ,$10.88 ,$33.01 ,$25.40 ,$10.88 ,$23.58 ,$26.12 ,$33.01 ,$27.21 
Carle BroMenn Medical Center,8140062,SUTURE 5-0 PROLENE C-1 36IN MS,244393,,270,$154.23 ,$154.23 ,$46.27 ,$140.35 ,$107.96 ,$46.27 ,$100.25 ,$111.05 ,$140.35 ,$115.67 
Carle BroMenn Medical Center,8140062,SUTURE 5-0 PROLENE P-3 18IN BL,244287,,270,$12.31 ,$12.31 ,$3.69 ,$11.20 ,$8.62 ,$3.69 ,$8.00 ,$8.86 ,$11.20 ,$9.23 
Carle BroMenn Medical Center,8140062,SUTURE 5-0 SILK BLK BRAID D9474,244761,,270,$95.36 ,$95.36 ,$28.61 ,$86.78 ,$66.75 ,$28.61 ,$61.98 ,$68.66 ,$86.78 ,$71.52 
Carle BroMenn Medical Center,8140062,SUTURE 5-0 SILK P-3 640G,244864,,270,$9.76 ,$9.76 ,$2.93 ,$8.88 ,$6.83 ,$2.93 ,$6.34 ,$7.03 ,$8.88 ,$7.32 
Carle BroMenn Medical Center,8140062,SUTURE 5-0 SILK RB1 K870H,245277,,270,$3.98 ,$3.98 ,$1.19 ,$3.62 ,$2.79 ,$1.19 ,$2.59 ,$2.87 ,$3.62 ,$2.99 
Carle BroMenn Medical Center,8140062,SUTURE 5-0 VICRYL P-1 J490G,244366,,270,$11.30 ,$11.30 ,$3.39 ,$10.28 ,$7.91 ,$3.39 ,$7.35 ,$8.14 ,$10.28 ,$8.48 
Carle BroMenn Medical Center,8140062,SUTURE 5-0 VICRYL P-2 J503G J503G,245282,,270,$12.41 ,$12.41 ,$3.72 ,$11.29 ,$8.69 ,$3.72 ,$8.07 ,$8.94 ,$11.29 ,$9.31 
Carle BroMenn Medical Center,8140062,SUTURE 5-0 VICRYL P-3 18IN,244312,,270,$10.55 ,$10.55 ,$3.17 ,$9.60 ,$7.39 ,$3.17 ,$6.86 ,$7.60 ,$9.60 ,$7.91 
Carle BroMenn Medical Center,8140062,SUTURE 5-0 VICRYL RB-1 UNDYED,178417,,270,$4.93 ,$4.93 ,$1.48 ,$4.49 ,$3.45 ,$1.48 ,$3.20 ,$3.55 ,$4.49 ,$3.70 
Carle BroMenn Medical Center,8140062,SUTURE 5-0 VICRYL S-14 J591G J591,245260,,270,$34.35 ,$34.35 ,$10.31 ,$31.26 ,$24.05 ,$10.31 ,$22.33 ,$24.73 ,$31.26 ,$25.76 
Carle BroMenn Medical Center,8140062,SUTURE 5-0 VICRYL TF 27IN  J433H,1320,,270,$4.84 ,$4.84 ,$1.45 ,$4.40 ,$3.39 ,$1.45 ,$3.15 ,$3.48 ,$4.40 ,$3.63 
Carle BroMenn Medical Center,8140062,SUTURE 6-0 CHROMIC G-1 796G,244514,,270,$21.73 ,$21.73 ,$6.52 ,$19.77 ,$15.21 ,$6.52 ,$14.12 ,$15.65 ,$19.77 ,$16.30 
Carle BroMenn Medical Center,8140062,SUTURE 6-0 CHROMIC PS-3 GUT 12/BX,244662,,270,$14.96 ,$14.96 ,$4.49 ,$13.61 ,$10.47 ,$4.49 ,$9.72 ,$10.77 ,$13.61 ,$11.22 
Carle BroMenn Medical Center,8140062,SUTURE 6-0 ETHILN BLK MONO P3,244382,,270,$9.20 ,$9.20 ,$2.76 ,$8.37 ,$6.44 ,$2.76 ,$5.98 ,$6.62 ,$8.37 ,$6.90 
Carle BroMenn Medical Center,8140062,SUTURE 6-0 ETHILON P-2 18IN 697H,244552,,270,$5.30 ,$5.30 ,$1.59 ,$4.82 ,$3.71 ,$1.59 ,$3.45 ,$3.82 ,$4.82 ,$3.98 
Carle BroMenn Medical Center,8140062,SUTURE 6-0 PDS II TF Z432H,244871,,270,$8.96 ,$8.96 ,$2.69 ,$8.15 ,$6.27 ,$2.69 ,$5.82 ,$6.45 ,$8.15 ,$6.72 
Carle BroMenn Medical Center,8140062,SUTURE 6-0 PLAIN G-1 18IN,244326,,270,$40.21 ,$40.21 ,$12.06 ,$36.59 ,$28.15 ,$12.06 ,$26.14 ,$28.95 ,$36.59 ,$30.16 
Carle BroMenn Medical Center,8140062,SUTURE 6-0 PROLENE C-1 30IN,244307,,270,$38.09 ,$38.09 ,$11.43 ,$34.66 ,$26.66 ,$11.43 ,$24.76 ,$27.42 ,$34.66 ,$28.57 
Carle BroMenn Medical Center,8140062,SUTURE 6-0 PROLENE C-1 3OIN MS DO,1359,,270,$160.00 ,$160.00 ,$48.00 ,$145.60 ,$112.00 ,$48.00 ,$104.00 ,$115.20 ,$145.60 ,$120.00 
Carle BroMenn Medical Center,8140062,SUTURE 6-0 PROLENE CC 24IN DOUBLE,1360,,270,$38.43 ,$38.43 ,$11.53 ,$34.97 ,$26.90 ,$11.53 ,$24.98 ,$27.67 ,$34.97 ,$28.82 
Carle BroMenn Medical Center,8140062,SUTURE 6-0 PROLENE CC M8807,245269,,270,$184.58 ,$184.58 ,$55.37 ,$167.97 ,$129.21 ,$55.37 ,$119.98 ,$132.90 ,$167.97 ,$138.44 
Carle BroMenn Medical Center,8140062,SUTURE 6-0 PROLENE P-1 8697G,244557,,270,$15.83 ,$15.83 ,$4.75 ,$14.41 ,$11.08 ,$4.75 ,$10.29 ,$11.40 ,$14.41 ,$11.87 
Carle BroMenn Medical Center,8140062,SUTURE 6-0 PROLENE P-3,244365,,270,$15.30 ,$15.30 ,$4.59 ,$13.92 ,$10.71 ,$4.59 ,$9.95 ,$11.02 ,$13.92 ,$11.48 
Carle BroMenn Medical Center,8140062,SUTURE 6-0 PROLENE RB-2 DARM 8711,244415,,270,$14.68 ,$14.68 ,$4.40 ,$13.36 ,$10.28 ,$4.40 ,$9.54 ,$10.57 ,$13.36 ,$11.01 
Carle BroMenn Medical Center,8140062,SUTURE 6-0 VICRYL P-3 J492H,244868,,270,$10.99 ,$10.99 ,$3.30 ,$10.00 ,$7.69 ,$3.30 ,$7.14 ,$7.91 ,$10.00 ,$8.24 
Carle BroMenn Medical Center,8140062,SUTURE 6-0 VICRYL S-14 DARM J590G,244565,,270,$37.84 ,$37.84 ,$11.35 ,$34.43 ,$26.49 ,$11.35 ,$24.60 ,$27.24 ,$34.43 ,$28.38 
Carle BroMenn Medical Center,8140062,SUTURE 7-0 CHROMIC TG140-8 1797G,245253,,270,$61.28 ,$61.28 ,$18.38 ,$55.76 ,$42.90 ,$18.38 ,$39.83 ,$44.12 ,$55.76 ,$45.96 
Carle BroMenn Medical Center,8140062,SUTURE 7-0 PROLENE BV-1 DARM 8304,247018,,270,$45.85 ,$45.85 ,$13.76 ,$41.72 ,$32.10 ,$13.76 ,$29.80 ,$33.01 ,$41.72 ,$34.39 
Carle BroMenn Medical Center,8140062,SUTURE 7-0 PROLENE BV1756 DARM M8,244649,,270,$136.26 ,$136.26 ,$40.88 ,$124.00 ,$95.38 ,$40.88 ,$88.57 ,$98.11 ,$124.00 ,$102.20 
Carle BroMenn Medical Center,8140062,SUTURE 7-0 PROLENE CC DARM 8704H,244422,,270,$48.20 ,$48.20 ,$14.46 ,$43.86 ,$33.74 ,$14.46 ,$31.33 ,$34.70 ,$43.86 ,$36.15 
Carle BroMenn Medical Center,8140062,SUTURE 7-0 PROLENE CC DARM M8704,244870,,270,$208.96 ,$208.96 ,$62.69 ,$190.15 ,$146.27 ,$62.69 ,$135.82 ,$150.45 ,$190.15 ,$156.72 
Carle BroMenn Medical Center,8140062,SUTURE 7-0 VICRYL TG160-8 18IN,244296,,270,$34.86 ,$34.86 ,$10.46 ,$31.72 ,$24.40 ,$10.46 ,$22.66 ,$25.10 ,$31.72 ,$26.15 
Carle BroMenn Medical Center,8140062,SUTURE 8-0 ETHILON BV130-5 5IN,244284,,270,$37.05 ,$37.05 ,$11.12 ,$33.72 ,$25.94 ,$11.12 ,$24.08 ,$26.68 ,$33.72 ,$27.79 
Carle BroMenn Medical Center,8140062,SUTURE 8-0 ETHILON TG100-8 1714G,245270,,270,$30.61 ,$30.61 ,$9.18 ,$27.86 ,$21.43 ,$9.18 ,$19.90 ,$22.04 ,$27.86 ,$22.96 
Carle BroMenn Medical Center,8140062,SUTURE 8-0 PROLENE BV1305 DARM M8,244596,,270,$252.36 ,$252.36 ,$75.71 ,$229.65 ,$176.65 ,$75.71 ,$164.03 ,$181.70 ,$229.65 ,$189.27 
Carle BroMenn Medical Center,8140062,SUTURE 8-0 VICRYL TG140-8 DARM J5,244567,,270,$34.32 ,$34.32 ,$10.30 ,$31.23 ,$24.02 ,$10.30 ,$22.31 ,$24.71 ,$31.23 ,$25.74 
Carle BroMenn Medical Center,8140062,SUTURE BOOT ORIGINAL 513  1001-51,206159,,270,$8.04 ,$8.04 ,$2.41 ,$7.32 ,$5.63 ,$2.41 ,$5.23 ,$5.79 ,$7.32 ,$6.03 
Carle BroMenn Medical Center,8140062,SUTURE CAPIO POLY BRAID,244028,,270,$0.28 ,$0.28 ,$0.08 ,$0.25 ,$0.20 ,$0.08 ,$0.18 ,$0.20 ,$0.25 ,$0.21 
Carle BroMenn Medical Center,8140062,SUTURE CLIP LAPRA-TY,244356,,270,$183.68 ,$183.68 ,$55.10 ,$167.15 ,$128.58 ,$55.10 ,$119.39 ,$132.25 ,$167.15 ,$137.76 
Carle BroMenn Medical Center,8140062,SUTURE ENDOLOOP COATED VICRYL,10434,,270,$91.39 ,$91.39 ,$27.42 ,$83.16 ,$63.97 ,$27.42 ,$59.40 ,$65.80 ,$83.16 ,$68.54 
Carle BroMenn Medical Center,8140062,SUTURE ETHILON 5-0 S-24 BLK,245236,,270,$31.07 ,$31.07 ,$9.32 ,$28.27 ,$21.75 ,$9.32 ,$20.20 ,$22.37 ,$28.27 ,$23.30 
Carle BroMenn Medical Center,8140062,SUTURE ETHILON 6-0 P-1 689G,244553,,270,$11.43 ,$11.43 ,$3.43 ,$10.40 ,$8.00 ,$3.43 ,$7.43 ,$8.23 ,$10.40 ,$8.57 
Carle BroMenn Medical Center,8140062,SUTURE ETHILON 6-0 PC-1 1956G,244418,,270,$10.68 ,$10.68 ,$3.20 ,$9.72 ,$7.48 ,$3.20 ,$6.94 ,$7.69 ,$9.72 ,$8.01 
Carle BroMenn Medical Center,8140062,SUTURE ETHILON 9-0 BV130-3 281,244500,,270,$39.14 ,$39.14 ,$11.74 ,$35.62 ,$27.40 ,$11.74 ,$25.44 ,$28.18 ,$35.62 ,$29.36 
Carle BroMenn Medical Center,8140062,SUTURE ETHILON LR DA MONO 489T,245209,,270,$8.98 ,$8.98 ,$2.69 ,$8.17 ,$6.29 ,$2.69 ,$5.84 ,$6.47 ,$8.17 ,$6.74 
Carle BroMenn Medical Center,8140062,SUTURE FIBERLOOP #2,228983,,270,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8140062,SUTURE GORE-TEX CV-2 THX-26 SA,236669,,270,$73.33 ,$73.33 ,$22.00 ,$66.73 ,$51.33 ,$22.00 ,$47.66 ,$52.80 ,$66.73 ,$55.00 
Carle BroMenn Medical Center,8140062,SUTURE LASSO QK PASS 45D LT,239524,,270,$480.00 ,$480.00 ,$144.00 ,$436.80 ,$336.00 ,$144.00 ,$312.00 ,$345.60 ,$436.80 ,$360.00 
Carle BroMenn Medical Center,8140062,SUTURE LASSO STR 90D CRVD,237389,,270,$480.00 ,$480.00 ,$144.00 ,$436.80 ,$336.00 ,$144.00 ,$312.00 ,$345.60 ,$436.80 ,$360.00 
Carle BroMenn Medical Center,8140062,SUTURE MERS 5MM BP-1 DARM RS21,244419,,270,$79.50 ,$79.50 ,$23.85 ,$72.35 ,$55.65 ,$23.85 ,$51.68 ,$57.24 ,$72.35 ,$59.63 
Carle BroMenn Medical Center,8140062,SUTURE MONODEK CAPIO  48IN,223565,,270,$118.44 ,$118.44 ,$35.53 ,$107.78 ,$82.91 ,$35.53 ,$76.99 ,$85.28 ,$107.78 ,$88.83 
Carle BroMenn Medical Center,8140062,SUTURE NICELOOP GREEN SZ 5 BRD,243976,,270,$204.00 ,$204.00 ,$61.20 ,$185.64 ,$142.80 ,$61.20 ,$132.60 ,$146.88 ,$185.64 ,$153.00 
Carle BroMenn Medical Center,8140062,SUTURE NICELOOP WHITE SZ 5 BRD,243977,,270,$204.00 ,$204.00 ,$61.20 ,$185.64 ,$142.80 ,$61.20 ,$132.60 ,$146.88 ,$185.64 ,$153.00 
Carle BroMenn Medical Center,8140062,SUTURE PASSER FIRSTPASS ST STANDA,242984,,270,$510.00 ,$510.00 ,$153.00 ,$464.10 ,$357.00 ,$153.00 ,$331.50 ,$367.20 ,$464.10 ,$382.50 
Carle BroMenn Medical Center,8140062,SUTURE SILK 4-0 LIGAPAK LA53G,247030,,270,$4.17 ,$4.17 ,$1.25 ,$3.79 ,$2.92 ,$1.25 ,$2.71 ,$3.00 ,$3.79 ,$3.13 
Carle BroMenn Medical Center,8140062,SUTURE STEEL 6 CCS M654G,244414,,270,$39.44 ,$39.44 ,$11.83 ,$35.89 ,$27.61 ,$11.83 ,$25.64 ,$28.40 ,$35.89 ,$29.58 
Carle BroMenn Medical Center,8140062,SUTURE STRAT 0 PDS CT-2 9IN,229610,,270,$78.33 ,$78.33 ,$23.50 ,$71.28 ,$54.83 ,$23.50 ,$50.91 ,$56.40 ,$71.28 ,$58.75 
Carle BroMenn Medical Center,8140062,SUTURE STRAT 1 CTX SPIRAL STRATAF,244401,,270,$61.45 ,$61.45 ,$18.44 ,$55.92 ,$43.02 ,$18.44 ,$39.94 ,$44.24 ,$55.92 ,$46.09 
Carle BroMenn Medical Center,8140062,SUTURE STRAT 1 PDS CT-1 60CM 12 P,258061,,270,$79.40 ,$79.40 ,$23.82 ,$72.25 ,$55.58 ,$23.82 ,$51.61 ,$57.17 ,$72.25 ,$59.55 
Carle BroMenn Medical Center,8140062,SUTURE STRAT 1 PDS OS-6 0 SPIRAL,244879,,270,$61.52 ,$61.52 ,$18.46 ,$55.98 ,$43.06 ,$18.46 ,$39.99 ,$44.29 ,$55.98 ,$46.14 
Carle BroMenn Medical Center,8140062,SUTURE STRAT 2-0 MONO + 45CM SPIR,245074,,270,$58.46 ,$58.46 ,$17.54 ,$53.20 ,$40.92 ,$17.54 ,$38.00 ,$42.09 ,$53.20 ,$43.85 
Carle BroMenn Medical Center,8140062,SUTURE STRAT 3-0 MONO + 20CM SPIR,245073,,270,$75.26 ,$75.26 ,$22.58 ,$68.49 ,$52.68 ,$22.58 ,$48.92 ,$54.19 ,$68.49 ,$56.45 
Carle BroMenn Medical Center,8140062,SUTURE TAPE 1.7MM WH/BL CC NDL,243099,,270,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8140062,SUTURE TIES 0 SILK 30IN MS,244308,,270,$3.51 ,$3.51 ,$1.05 ,$3.19 ,$2.46 ,$1.05 ,$2.28 ,$2.53 ,$3.19 ,$2.63 
Carle BroMenn Medical Center,8140062,SUTURE VICRYL O  TIES MULTIPAK,244392,,270,$18.92 ,$18.92 ,$5.68 ,$17.22 ,$13.24 ,$5.68 ,$12.30 ,$13.62 ,$17.22 ,$14.19 
Carle BroMenn Medical Center,8140062,SUTURE4-0  MONOCRYL PS-2 Y426H Y4,244970,,270,$14.45 ,$14.45 ,$4.34 ,$13.15 ,$10.12 ,$4.34 ,$9.39 ,$10.40 ,$13.15 ,$10.84 
Carle BroMenn Medical Center,8140062,TAPE SUTURE 1.3MM W NEEDLE MUST O,227388,,270,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8140070,OR ANESTHESIA SUPPLIES 2,,,270,$154.00 ,$154.00 ,$46.20 ,$140.14 ,$107.80 ,$46.20 ,$100.10 ,$110.88 ,$140.14 ,$115.50 
Carle BroMenn Medical Center,8140071,OR ANESTHESIA SUPPLIES 3,,,270,$22.00 ,$22.00 ,$6.60 ,$20.02 ,$15.40 ,$6.60 ,$14.30 ,$15.84 ,$20.02 ,$16.50 
Carle BroMenn Medical Center,8140072,DASC ANESTHESIA SUPPLIES 2,,,270,$191.00 ,$191.00 ,$57.30 ,$173.81 ,$133.70 ,$57.30 ,$124.15 ,$137.52 ,$173.81 ,$143.25 
Carle BroMenn Medical Center,8140073,DASC ANESTHESIA SUPPLIES 3,,,270,$27.00 ,$27.00 ,$8.10 ,$24.57 ,$18.90 ,$8.10 ,$17.55 ,$19.44 ,$24.57 ,$20.25 
Carle BroMenn Medical Center,8140074,DHC ANESTHESIA SUPPLIES 2,,,270,$22.00 ,$22.00 ,$6.60 ,$20.02 ,$15.40 ,$6.60 ,$14.30 ,$15.84 ,$20.02 ,$16.50 
Carle BroMenn Medical Center,8140075,TRAY EPDRL TUOHY WNGD 18GX3.5,256478,,270,$41.59 ,$41.59 ,$12.48 ,$37.85 ,$29.11 ,$12.48 ,$27.03 ,$29.94 ,$37.85 ,$31.19 
Carle BroMenn Medical Center,8140075,TRAY EPDRL TUOHY WNGD 20GX3.5,256477,,270,$38.96 ,$38.96 ,$11.69 ,$35.45 ,$27.27 ,$11.69 ,$25.32 ,$28.05 ,$35.45 ,$29.22 
Carle BroMenn Medical Center,8140080,OR ANESTHESIA SUPPLIES 1,,,270,$275.00 ,$275.00 ,$82.50 ,$250.25 ,$192.50 ,$82.50 ,$178.75 ,$198.00 ,$250.25 ,$206.25 
Carle BroMenn Medical Center,8140081,DHC ANESTHESIA SUPPLIES 1,,,270,$289.00 ,$289.00 ,$86.70 ,$262.99 ,$202.30 ,$86.70 ,$187.85 ,$208.08 ,$262.99 ,$216.75 
Carle BroMenn Medical Center,8140082,DASC ANESTHESIA SUPPLIES 1,,,270,$356.00 ,$356.00 ,$106.80 ,$323.96 ,$249.20 ,$106.80 ,$231.40 ,$256.32 ,$323.96 ,$267.00 
Carle BroMenn Medical Center,8140119,Trimano Beach Chair,,,270,$900.00 ,$900.00 ,$270.00 ,$819.00 ,$630.00 ,$270.00 ,$585.00 ,$648.00 ,$819.00 ,$675.00 
Carle BroMenn Medical Center,8140120,OMNIGUIDE LASER,,,270,"$3,150.00 ","$3,150.00 ",$945.00 ,"$2,866.50 ","$2,205.00 ",$945.00 ,"$2,047.50 ","$2,268.00 ","$2,866.50 ","$2,362.50 "
Carle BroMenn Medical Center,8140121,OMNIGUIDE HAND PIECE ENT,,,270,"$1,410.00 ","$1,410.00 ",$423.00 ,"$1,283.10 ",$987.00 ,$423.00 ,$916.50 ,"$1,015.20 ","$1,283.10 ","$1,057.50 "
Carle BroMenn Medical Center,8140122,IMPERIUM 500 FIBER,,,270,"$4,230.00 ","$4,230.00 ","$1,269.00 ","$3,849.30 ","$2,961.00 ","$1,269.00 ","$2,749.50 ","$3,045.60 ","$3,849.30 ","$3,172.50 "
Carle BroMenn Medical Center,8170126,ANESTHESIA EEG PROBE,,,270,$146.00 ,$146.00 ,$43.80 ,$132.86 ,$102.20 ,$43.80 ,$94.90 ,$105.12 ,$132.86 ,$109.50 
Carle BroMenn Medical Center,8200001,VAGINAL DILATOR #3,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200002,VAGINAL DILATOR #4,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200003,VAGINAL DILATOR #5,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200004,VAGINAL DILATOR #6,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200005,VAGINAL DILATOR #7,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200006,VAGINAL DILATOR #8,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200007,VAGINAL DILATOR #2,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200008,LAUNDRY AID SUNGUARD 1OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200018,VAGINAL DILATOR #1,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200106,HEALING CAP,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200108,TANSMITTER CABLE COCHLEA,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200110,VAGINAL DILATOR SM,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200112,VAGINAL DILATOR XS,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200114,VAGINAL DILATOR #2,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200181,CREAM EYE TREATMENT SOOTHING DEPUFFING,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200448,TURFTOE FULL INSOLE ULTRA LITE SHOCK ABSORBER,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200449,TURFTOE HALF INSOLE ULTRA LITE SHOCK ABSORBER,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200450,VEST MALE COMPRESION BEIGE,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200604,HEAT WRAP BACK LG/XL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200632,NOSE GUARD / FACE SHEILD,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200634,MALE COMPRESSION VEST,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200635,DILATOR VAGINAL SMALL SILICONE,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200636,DILATOR VAGINAL MEDIUM SILICONE,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200637,DILATOR VAGINAL LARGE SILICONE,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200646,MALE COMPRESSION VEST CONTOUR MD 11XL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200647,MALE COMPRESSION VEST CONTOUR MD 11L,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200648,MALE COMPRESSION VEST CONTOUR MD 11XXL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200649,INSOLE FULL ULTRA LT SHCK ABSRB,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200657,VOLBELLA,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201281,THERMAL SPRING WATER 1.7,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201282,SURGRAS CLNS BAR,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201283,PEROXIDE WASH 10,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201284,SKINCARE LIPS 0.16OZ TUBE,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201285,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201286,LIP REPAIR CREAM,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201287,THERMAL SPRING WATER 10.1,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201288,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201289,SKINCARE TONER ASTRT LOTN,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201290,SKINCARE FOAMNG GEL 5.1OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201291,SKINCARE DEEP CLNSE FOAM,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201292,SKINCARE K ACNE TRTMNT FL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201293,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201294,SKINCARE MINERAL FACE PRIMER,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201295,SKINCARE REVITALIZING TONER 240 ML,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201296,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201297,FACIAL RPLCE HEAD NOR,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201298,FACIAL RPLCE HEAD SEN,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201299,FACIAL RPLCE HEAD DEL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201300,FACIAL SPOT BRUSH,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201301,SKINCARE ANTIBAC ACNE WSH,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201302,SKINCARE EYES 0.5 OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201303,SKINCARE MICRO EXFOLIATING,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201304,SKINCARE EPIDERMAL RCVRY,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201305,SUNSCREEN SPF40,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201306,SKINCARE CONDTN SOL 6 OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201307,SKINCARE MINERAL ULTRA BRUSH,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201308,SKINCARE PUR ENZYME,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201309,SKINCARE COLLAGENIST PWDER,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201310,LIGHT DAILY LOTION,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201311,FACIAL CLEANSING SPOT THERAPY K,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201312,SKINCARE FACE CARE,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201313,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201314,SKINCARE RETINOL 60 1-OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201315,FACIAL FACE&BODY SYSTEM GRAY,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201316,FACIAL FACE&BODY SYSTEM PINK,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201317,SKINCARE EYES 0.5 OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201318,SKINCARE FACE CARE DRY,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201319,SUNSCREEN DAILY MOIST,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201320,SKINCARE HYDRO EMULSION,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201321,SKINCARE PURIFY CLEANSER,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201322,SKINCARE AGE DEFENSE,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201323,LIP BALM,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201324,FACIAL DEEP CLEANSING BRUSH HEAD,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201325,FACIAL SKIN SYSTEM TRAVEL SZ WHITE,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201326,FACIAL FACE&BODY SYSTEM WHITE,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201327,DAILY SUN DEFENSE SPF20,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201328,SUNSCREEN SPF 30,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201329,SKINCARE PRESSED BASE ALL COLO,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201330,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201331,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201332,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201333,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201334,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201335,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201336,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201337,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201338,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201339,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201340,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201341,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201342,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201343,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201344,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201345,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201346,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201347,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201348,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201349,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201350,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201351,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201352,AFTER SHAVE SOLUTION,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201353,SUNSCREEN SPF 50,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201354,REDNESS NEUTRALIZER,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201355,POWDER INSUFFLATOR,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201356,DERMAL FILLER,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201357,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201358,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201359,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201360,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201361,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201362,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201363,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201364,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201365,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201366,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201367,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201368,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201369,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201370,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201371,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201372,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201373,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201374,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201375,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201376,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201377,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201378,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201379,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201380,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201381,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201382,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201383,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201384,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201385,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201386,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201387,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201388,VITAMIN C CREAM,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201389,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201390,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201391,BODY LOTION 6.8OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201392,SYNDET CLEANS GEL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201393,SKINCARE TX PADS 15,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201394,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201395,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201396,SKINCARE GNTL SOOTH OINTM,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201397,FACIAL GLYCARE PERFT GEL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201398,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201400,FACIAL CLEANERS I,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201401,BALM 6.8 OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201402,SKINCARE TX PADS 20,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201403,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201404,SKINCARE BLEMISH STICK ALL COL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201405,LIP BALM,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201406,SKINCARE CAMOUFLAGE ALL COLORS,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201407,DERMAL FILLER,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201408,DERMAL FILLER,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201409,EYEPATCH BOX,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201410,BREAST BINDER 2X,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201411,BREAST BINDER 3X,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201412,BREAST BINDER LG,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201413,BREAST BINDER XL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201414,BREAST BINDER STRAPS ONE SIZE,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201415,GIRDLE ABDOMINOPLASTY MED WHITE,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201416,"GIRDLE, RUBENESQUE,ZIP,WHILE-LARGE",,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201417,LONG ARM SLEEVE W LACE SM,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201418,LONG ARM SLEEVE W LACE XS WHITE (L933),,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201419,LONG ARM SLEEVE W/LACE MED WHITE L933,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201420,"ABDOMINAL GARMENT, ZIP RUBEN, WHITE,4XL",,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201421,BRA COTTON KNIT MED WHITE,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201422,BRA COTTON KNIT SM WHITE,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201423,BRA COTTON KNIT XS WHITE,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201424,BRA SPORT COTTON SM WHITE,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201425,BRA SPORT COTTON XS WHITE,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201426,GIRDLE BELOW KNEE ZIPPERED MED,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201427,GIRDLE BELOW KNEE ZIPPERED WT 2X,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201428,GIRDLE BELOW KNEE ZIPPERED WT 3X,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201429,GIRDLE BELOW KNEE ZIPPERED XL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201430,GIRDLE BELOW KNEE ZIPPERED XS,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201431,GIRDLE BELOW KNEE ZIPPPERED SM,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201432,"DESIGN VERONIQUE GIRDLE, BELOW KNEE, ZIPPERED, WHITE, 4X",,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201433,DOME NONSLIP COMPRESSION GRMT CLSD EAR LG,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201434,DOME NONSLIP COMPRESSION GRMT CLSD EAR MED,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201435,DOME NONSLIP COMPRESSION GRMT CLSD EAR SM,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201436,DORSOCERVICAL MALE GARMENT  XL WHITE,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201437,DORSOCERVICAL MALE GARMENT LG WHITE,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201438,EARRINGS PRESSURE,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201440,TOE SEPARATOR SMALL 11605,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201441,TOPICAL GEL 6G TUBE,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201442,HEAT WRAP NCK SHLD WRST,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201443,LAUNDRY AID SUNGUARD 1OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201444,DIGITAL PADS LG OR XL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201445,HEAT WRAP BACK SM/MED,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201446,DIGITAL CAPS MINI,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201447,TOE SPREADER MED 11515,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201448,HAMMER TOE CORRECTOR,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201449,SKINCARE 5 GEL 2-OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201450,SKINCARE 10 GEL 2-OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201451,THERMO SPRING WATER 5.1,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201452,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201453,LIP CONDITIONER,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201454,FOOT GEL CUSHION,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201455,METATARSAL GEL STRAP L-XL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201456,METATARSAL GEL STRAP S-M,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201457,GLOVE GEL GLOVE SM RT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201458,ACNE CLEANSER 6.7,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201459,VAGINAL DILATOR XS,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201460,VAGINAL DILATOR SM,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201461,SURGRAS SHOWER CR,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201462,VAGINAL DILATOR MED,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201463,SKINCARE MOIST CLEANSR 10,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201464,VAGINAL DILATOR LARGE,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201465,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201466,BUNION RELIEF GEL SKN S M,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201467,SKINCARE TX PADS 10,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201468,BUNION RELIEF GEL SKN L X,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201469,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201470,WRAP BREAST 3 IN,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201471,COTTON BRA SZ 38,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201472,SZ 32 COTTON BRA,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201473,SZ 34 COTTON BRA,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201474,SZ 40 COTTON BRA,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201475,SZ 42 COTTON BRA,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201476,SZ 44 COTTON BRA,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201477,SZ 46 COTTON BRA,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201478,SKINCARE ACTIVE MATTE MOI,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201479,SKINCARE TONER 6.76 OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201480,EXTRA MILD PROTECTION 2OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201481,SZ 36 COTTON BRA,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201482,BUNION GEL SLEEVE SM  MED,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201483,SKINCARE 1.35 OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201484,SKINCARE MILK 6.76 OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201485,FACIAL CLEANERS 2,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201486,FACIAL SHIELD SPF 20 2 OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201487,BATH OIL 6.8 OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201488,SKINCARE VRY DRY BIOLIPID,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201489,FACIAL SHIELD SPF 30 2 OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201490,BUNION GEL SLEEVE LG XL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201491,SKINCARE UV SPF 30,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201492,SKINCARE FACE CRM 20,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201493,GENTLE MOIST EMULSION 2OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201494,ANTIBACTERIAL PROTECTION 1OZ.,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201495,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201496,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201497,SKINCARE FACIAL MOISTUR,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201498,CATHETER BARTHOLIN GLAND WORD,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201499,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201500,"HAMMER TOE CREST, FELT, SMALL, RT",,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201501,"HAMMER TOE CREST, FELT, MEDIUM, RT",,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201502,"HAMMER TOE CREST, FELT, LARGE, RT",,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201503,"HAMMER TOE CREST, FELT, SMALL, LT",,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201504,"HAMMER TOE CREST, FELT, MEDIUM, LT",,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201505,"HAMMER TOE CREST, FELT, LARGE, LT",,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201506,FACIAL TREATMENT 2OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201507,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201508,PSORENT SOLUTN,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201509,CHIN NECK STRAP MED COSC,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201510,TUMMY TUCK PRSSR GAR SZ30,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201511,SKINCARE LHA PREPEEL SOLU,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201512,SKINCARE LHA CLEANSING GE,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201513,SKINCARE LHA POSTPEEL KIT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201514,TUMMY TUCK PRSSRE GARMENT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201515,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201516,TUMMY TUCK CMPN BRF SZ 32,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201517,TUMMY TUCK CMPN BRF SZ 34,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201518,TUMMY TUCK CMPN BRF SZ 36,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201519,TUMMY TUCK CMPN BRF SZ 38,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201520,SKINCARE CONDITION GEL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201521,SKINCARE CONDITION CREAM,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201522,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201523,FACIAL TREATMENT 2OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201524,FACIAL REPLENISH HYDRT CRM,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201525,SKINCARE C-RECOVERY TX,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201526,VAGINAL DILATOR #2,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201527,RETINOL 30 1 OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201528,SKINCARE CONDITION GEL PL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201529,EARRINGS PRESSURE AVERAGE,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201530,FACIAL CLEANSER,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201531,BRA LG,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201532,BRA MED,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201533,BRA SMALL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201534,BRA XL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201535,BRA LACE SUPPORT 40C BLCK,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201536,BRA LACE SUPPORT 38C BLCK,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201537,BRA LACE SUPPORT 36C BLCK,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201538,BRA LACE SUPPORT 34C BLCK,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201539,BRA LACE SPPRT 44C WHITE,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201540,BRA LACE SPPRT 42C WHITE,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201541,EXTRA RICH MOISTURIZR 1OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201542,SKINCARE POTENT-C 10.5 CONC,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201543,VAGINAL DILATOR #3,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201544,ABDOMINOPLASTY GIRDLE XLG,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201545,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201546,SKINCARE LHA SERUM,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201547,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201548,SKINCARE HYDRATING SERUM,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201549,COMPRESSION VEST MALE LG,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201550,COMPRESSION VEST MALE XL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201551,VEST MALE MED,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201552,VEST MALE SMALL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201553,VAGINAL DILATORS #4,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201554,BINDER DBL PNL 9IN MED,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201555,BINDER DBL PNL 9IN LG,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201556,BINDER DBL PNL 9IN XL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201557,ABDOMINAL BRIEF NON ZIP X,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201558,ABDOMINAL BRIEF NONZIP LG,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201559,ABDOMINAL BRIEF NONZP MED,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201560,ABDOMINAL BRIEF NONZIP SM,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201561,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201562,VIT C FIRM CREAM,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201563,GIRDLE LARGE,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201564,GIRDLE MEDIUM,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201565,GIRDLE SMALL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201566,SKINCARE LHA PREPEEL KIT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201567,VAGINAL DIALTORS #5,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201568,COMPRESSION VEST MALE XXL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201569,LONGLINE BRA W CUPS XS,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201570,CMPRSN BRA LNGLN W/CP 2XL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201571,LONGLINE BRA W CUPS LG,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201572,COMPRESSN VEST SHORT XS,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201573,LONGLINE BRA W CUPS XL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201574,ABD VEST GARMENT MALE,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201575,TRAM FLAP GIRDLE SZ X,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201576,XS SHORTLINE BRA W CUPS,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201577,SM SHORTLINE BRA W CUPS,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201578,MED SHORTLINE BRA W CUPS,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201579,LG SHORTLINE BRA W CUPS,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201580,XL SHORTLINE BRA W CUPS,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201581,XXL SHORTLINE BRA W CUPS,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201582,LONGLINE BRA W CUPS SM,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201583,LONGLINE BRA W CUPS MED,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201584,BINDER DBL PNL 9IN XXL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201585,BINDER DBL PNL 9IN 3XL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201586,ABDOMINAL BRIEF NONZIP 2X,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201587,TRAM FLAP GIRDLE XS 750,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201588,TRAM FLAP GIRDLE SM 750,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201589,TRAM FLAP GIRDLE MD 750,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201590,TRAM FLAP GIRDLE LG 750,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201591,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201592,TORSO BRIEF NON ZIP MED,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201593,TORSO BRIEF NON ZIP SMALL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201594,TORSO BRIEF NON ZIP XS,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201595,TORSO BRIEF NON ZIP XL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201596,TORSO BRIEF NON ZIP LARGE,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201597,BRA W CPS 4XL WHT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201598,BRA W CPS 5XL WHT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201599,BRA W CPS 3XL BLK,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201600,BRA W CPS 4XL BLK,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201601,BRA W CPS 5XL BLK,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201602,LONG ARM SLEEVE W LACE XL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201603,LONG ARM SLEEVE W LACE LG,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201604,GIRDLE ABV KNE FEMALE MED,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201605,GIRDLE ABV KNEE FEMALE LG,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201606,GIRDLE ABV KNEE FEMALE XS,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201607,GIRDLE ABV KNEE FEMALE SM,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201608,GIRDLE ABV KNEE FEMALE XL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201609,GIRDLE ABV KNEE NONZIP SM,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201610,GIRDLE ABV KNEE NONZIP XL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201611,GIRDLE ABV KNEE NONZIP LG,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201612,GIRDLE ABV KNEE NONZIP MD,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201613,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201614,VAGINAL DILATORS #6,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201615,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201616,SLING GIRDLE LARGE,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201617,SLING GIRDLE MEDIUM,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201618,SLING GIRDLE SMALL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201619,LONG ARM SLEEVE W LACE 2X,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201620,GIRDLE BELOW KNEE ZIPPERED WT LG,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201621,ABDOMINAL BRIEF NONZP 3XL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201622,ABDOMINAL BRIEF NONZP 4XL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201623,TRAM FLAP GIRDLE 2X 750,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201624,COMPRESSION GARMET LG MT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201625,TORSO BRIEF NON ZIP XXL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201626,COMPRESSION GARMET MED M,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201627,VAGINAL DILATOR #7,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201628,GIRDLE ABV KNE FEMALE XXL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201629,GIRDLE ABV KNEE NONZIP 2X,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201630,BREAST FORM PER PAIR SMAL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201631,BREAST FORM PR PAIR LARGE,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201632,GRDL ABV KNE XL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201633,LONG ARM SLEEVE W LACE 3X,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201634,LONG ARM SLEEVE W LACE 4X,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201635,BINDER DBL PNL 9 IN 4XL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201636,TRAM FLAP GIRDLE 3X 750,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201637,TRAM FLAP GIRDLE 4X 750,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201638,VAGINAL DILATORS-SET OF 4,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201639,TORSO BRIEF NON ZIP 4X LG,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201640,TORSO BRIEF NON ZIP 3X LG,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201641,GIRDLE XSMALL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201642,GIRDLE SMALL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201643,GIRDLE MEDIUM,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201644,GIRDLE LARGE,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201645,GIRDLE X-LARGE,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201646,GIRDLE XXLARGE,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201647,VAGINAL DILATOR #8,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201648,GIRDLE ABV KNEE ZIP 4X,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201649,GRIDLE ABV KNEE ZIP 3X,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201650,GIRDLE ABV KNEE NONZIP 3X,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201651,GIRDLE ABV KNEE NONZIP 4X,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201652,ZIPRD RUBN BDY GRDL SZ MD,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201653,ZIPRD RUBN BDY GRDL SZ L,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201654,DERMAL FILLER,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201655,GIRDLE LGLE ABDMNL BEST,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201656,ABDMINL GARMENT ZIP MD840,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201657,FULL FOAM SHORT DROP,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201658,ABDMNL GARMENT 4XL MALE 743,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201659,ABDMINL GARMENT ZIP 3X 840,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201660,ABDMINL GARMENT ZIP 4X 840,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201661,DERMAL FILLER,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201662,DERMAL FILLER,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201663,DERMAL FILLER,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201664,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201666,ABDOMINOPLASTY GIRDLE SML,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201670,FACIAL SKIN SYSTEM TRAVEL SZ PINK,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201671,FACIAL SKIN SYSTEM TRAVEL SZ YELLOW,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201672,FACIAL SKIN SYSTEM TRAVEL SZ BLUE,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201673,FACIAL SKIN SYSTEM TRAVEL SZ LAVENDAR,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201676,HYDRATING B5 GEL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201684,HAMMER TOE CREST MD RT EA,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201690,RETINOL 15 1 OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201691,WRAP BREAST 9 IN,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201692,FULL FOAM DROP LOCK K,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201693,AUGMENTATION BRA MED,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201694,WOMENS SUPPORT BRA LARGE,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201695,WOMENS SUPPORT BRA SMALL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201696,WOMENS SUPPORT BRA XL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201697,WOMANS SPPRT BRA XSM W/2,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201698,WOMENS SUPPORT BRA MED,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201699,VEST X-SMALL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201700,VEST SMALL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201701,VEST MEDIUM,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201702,VEST LARGE,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201703,VEST XL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201704,VEST XXL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201705,VEST 3X,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201706,SUPPORT BRA WOMENS 2X,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201707,SUNSCREEN SPF 15 3.4 OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201708,FOOT COVER MD GEL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201709,FOOT COVER LG GEL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201710,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201711,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201712,DIGITAL CAPS SM  MD 10205,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201713,SUNSCREEN SPF-60 1.7 OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8201714,HEAT WRAP KNEE/ELBOW,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8202292,SKINCARE LOTION,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8202334,ABOVE KNEE BODY GIRDLE ZIPPERED,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8202335,ABOVE KNEE BODY GIRDLE ZIPPERED XXXL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8202608,BRA SCOOPNECK,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8202609,BRA COMFORT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299070,MISC SUPPLIES,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299612,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299613,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299622,TUBING PUMP INFUSION,,,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299623,CATHETER SNGL SENSOR AIR CHARGED,,,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299624,CATHETER ABD SENSOR AIR CHARGED,,,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299628,SKINCARE PRODUCT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299785,JUVEDERM ULTRA XC 1.0ML,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299786,VOLUMA,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299788,BRA SUPPORT WOMENS,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299789,JUVEDERM ULTRA 0.55ML,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299790,JUVEDERM ULTRA XC 0.55ML,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299791,JUVEDERM ULTRA PLUS XC 0.55ML,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299792,JUVEDERM ULTRA PLUS XC 1.0ML,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299793,JUVEDERM VOLBELLA 1.0ML,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299794,SKINCARE TOTAL CLEANSER FACIAL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299795,SKINCARE TOTAL FILLER PUR -6,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299796,SKINCARE TOTAL CR?ME RETINAL-A,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299797,SKINCARE TOTAL MASQUE 2OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299798,SKINCARE TOTAL MASQUE 6OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299799,SKINCARE LOTION ACNE 1.7 OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299800,SKINCARE LOTION ACNE 4.0 OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299801,SKINCARE MASQUE ACNE 2.0 OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299802,SKINCARE PAD SALICYLIC CLARIFY,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299803,SKINCARE SERUM INTENSE 1OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299804,SKINCARE SERUM INTENSE 2OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299805,SKINCARE CR?ME INTENSE EYE,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299806,SKINCARE POWDER INTENSE EXFL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299807,SKINCARE CLEANSER STEM CELL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299808,SKINCARE SERUM STEM CELL 1OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299809,SKINCARE CR?ME STEM CELL 1.7OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299810,SKINCARE CLEANSER BALANCE,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299811,SKINCARE CR?ME BIOPEPTIDE 2OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299812,SKINCARE CR?ME BIOPEPTIDE 4OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299813,SKINCARE CLEANSER FACIAL 6OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299814,SKINCARE CLEANSER FACIAL 12OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299815,SKINCARE SERUM ANTI-AGING 4OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299816,SKINCARE SERUM A C E ANTIOXDNT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299817,SKINCARE MOISTURIZER INTENSE,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299818,SKINCARE CR?ME REPAIR 2.0 OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299819,SKINCARE CR?ME REPAIR 5.0OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299820,SKINCARE MASQUE ENZYME 6.0 OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299821,SKINCARE MASQUE ENZYME 2.0 OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299822,SKINCARE MASQUE OVERNIGHT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299823,SKINCARE MOISTRIZR SPF32 3.2OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299824,SKINCARE MOISTRIZR SPF32 6.0OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299825,SKINCARE MOISTRIZR SPF30 3.2OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299826,SKINCARE MOISTRIZR SPF30 6.0OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299827,SKINCARE CLEANSER FACIAL 4.0OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299828,SKINCARE BOOSTER RETINOL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299829,SKINCARE SERUM YOUTH,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299830,SKINCARE CR?ME BRIGHTENING,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299831,SKINCARE CR?ME RETINOL 1.0OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299832,SKINCARE CR?ME YOUTH REPAIR,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299833,SKINCARE GEL EYE COLLAGEN .5OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299834,SKINCARE MASQUE OVERNIGHT RTNL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299835,SKINCARE MASQUE RESTORING,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299836,SKINCARE MOISTRIZR SPF50 2.0OZ,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299837,SKINCARE SOLUTION DEGREASING,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299838,SKINCARE KIT O2 LIFT TREATMENT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299839,SKINCARE SOLUTION FACE LIFT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299840,SKINCARE PEEL LIGHTENING LIFT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299841,SKINCARE PEEL WRINKLE LIFT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299842,SKINCARE PEEL PERFECTION LIFT,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299843,SKINCARE ENHANCER HYALURONIC,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299844,SKINCARE ENHANCER KOJIC ACID,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299845,SKINCARE ENHANCER RETINOL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299846,SKINCARE ENHANCER STEM CELL,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299847,SKINCARE ENHANCER VITAMIN C,,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8336525,PALL FILTER,,,270,$79.00 ,$79.00 ,$23.70 ,$71.89 ,$55.30 ,$23.70 ,$51.35 ,$56.88 ,$71.89 ,$59.25 
Carle BroMenn Medical Center,8610005,CPM DAILY RENTAL,,,270,$77.00 ,$77.00 ,$23.10 ,$70.07 ,$53.90 ,$23.10 ,$50.05 ,$55.44 ,$70.07 ,$57.75 
Carle BroMenn Medical Center,8670002,"12"" M-F ADAPTER TUBING",,,270,$11.00 ,$11.00 ,$3.30 ,$10.01 ,$7.70 ,$3.30 ,$7.15 ,$7.92 ,$10.01 ,$8.25 
Carle BroMenn Medical Center,8670003,14 FRENCH STYLET,,,270,$23.00 ,$23.00 ,$6.90 ,$20.93 ,$16.10 ,$6.90 ,$14.95 ,$16.56 ,$20.93 ,$17.25 
Carle BroMenn Medical Center,8670004,2X2 GAUZE,,,270,$2.00 ,$2.00 ,$0.60 ,$1.82 ,$1.40 ,$0.60 ,$1.30 ,$1.44 ,$1.82 ,$1.50 
Carle BroMenn Medical Center,8670005,3.0 SILK SUTURE,,,270,$14.00 ,$14.00 ,$4.20 ,$12.74 ,$9.80 ,$4.20 ,$9.10 ,$10.08 ,$12.74 ,$10.50 
Carle BroMenn Medical Center,8670011,ADJ TORSION STYLE MECHANISM,,,270,$77.00 ,$77.00 ,$23.10 ,$70.07 ,$53.90 ,$23.10 ,$50.05 ,$55.44 ,$70.07 ,$57.75 
Carle BroMenn Medical Center,8670012,ADULT MASK,,,270,$5.00 ,$5.00 ,$1.50 ,$4.55 ,$3.50 ,$1.50 ,$3.25 ,$3.60 ,$4.55 ,$3.75 
Carle BroMenn Medical Center,8670014,AFO ORTHOSIS FLOOR-REACT,,,270,$142.00 ,$142.00 ,$42.60 ,$129.22 ,$99.40 ,$42.60 ,$92.30 ,$102.24 ,$129.22 ,$106.50 
Carle BroMenn Medical Center,8670015,AFO/ADULT,,,270,$163.00 ,$163.00 ,$48.90 ,$148.33 ,$114.10 ,$48.90 ,$105.95 ,$117.36 ,$148.33 ,$122.25 
Carle BroMenn Medical Center,8670016,AFO/CHILD,,,270,$142.00 ,$142.00 ,$42.60 ,$129.22 ,$99.40 ,$42.60 ,$92.30 ,$102.24 ,$129.22 ,$106.50 
Carle BroMenn Medical Center,8670017,AFO/CHILD - HINGED BRACE,,,270,$142.00 ,$142.00 ,$42.60 ,$129.22 ,$99.40 ,$42.60 ,$92.30 ,$102.24 ,$129.22 ,$106.50 
Carle BroMenn Medical Center,8670019,AFO/SMO,,,270,$142.00 ,$142.00 ,$42.60 ,$129.22 ,$99.40 ,$42.60 ,$92.30 ,$102.24 ,$129.22 ,$106.50 
Carle BroMenn Medical Center,8670020,ALUP/MET,,,270,$5.00 ,$5.00 ,$1.50 ,$4.55 ,$3.50 ,$1.50 ,$3.25 ,$3.60 ,$4.55 ,$3.75 
Carle BroMenn Medical Center,8670021,"ANKLE FOOT ORTHOSIS""HINGED""",,,270,$163.00 ,$163.00 ,$48.90 ,$148.33 ,$114.10 ,$48.90 ,$105.95 ,$117.36 ,$148.33 ,$122.25 
Carle BroMenn Medical Center,8670023,ARMBOARD,,,270,$32.00 ,$32.00 ,$9.60 ,$29.12 ,$22.40 ,$9.60 ,$20.80 ,$23.04 ,$29.12 ,$24.00 
Carle BroMenn Medical Center,8670039,CLAMSHELL WRIST FX. ORTHOSIS,,,270,$126.00 ,$126.00 ,$37.80 ,$114.66 ,$88.20 ,$37.80 ,$81.90 ,$90.72 ,$114.66 ,$94.50 
Carle BroMenn Medical Center,8670044,CPAP PRONGS,,,270,$68.00 ,$68.00 ,$20.40 ,$61.88 ,$47.60 ,$20.40 ,$44.20 ,$48.96 ,$61.88 ,$51.00 
Carle BroMenn Medical Center,8670045,CPM DAILY RENTAL,,,270,$77.00 ,$77.00 ,$23.10 ,$70.07 ,$53.90 ,$23.10 ,$50.05 ,$55.44 ,$70.07 ,$57.75 
Carle BroMenn Medical Center,8670061,EAR MOLD IMPRESSION -EXPEDITED,,,270,$109.00 ,$109.00 ,$32.70 ,$99.19 ,$76.30 ,$32.70 ,$70.85 ,$78.48 ,$99.19 ,$81.75 
Carle BroMenn Medical Center,8670065,ELBOW HINGED SPLINT  (2 HINGES,,,270,$323.00 ,$323.00 ,$96.90 ,$293.93 ,$226.10 ,$96.90 ,$209.95 ,$232.56 ,$293.93 ,$242.25 
Carle BroMenn Medical Center,8670068,ET TUBE,,,270,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8670071,FEMORAL A-LINE KIT,,,270,$59.00 ,$59.00 ,$17.70 ,$53.69 ,$41.30 ,$17.70 ,$38.35 ,$42.48 ,$53.69 ,$44.25 
Carle BroMenn Medical Center,8670075,FLEX PROBE,,,270,$101.00 ,$101.00 ,$30.30 ,$91.91 ,$70.70 ,$30.30 ,$65.65 ,$72.72 ,$91.91 ,$75.75 
Carle BroMenn Medical Center,8670077,FOOT DROP SPLINT,,,270,$103.00 ,$103.00 ,$30.90 ,$93.73 ,$72.10 ,$30.90 ,$66.95 ,$74.16 ,$93.73 ,$77.25 
Carle BroMenn Medical Center,8670086,GLOVES,,,270,$6.00 ,$6.00 ,$1.80 ,$5.46 ,$4.20 ,$1.80 ,$3.90 ,$4.32 ,$5.46 ,$4.50 
Carle BroMenn Medical Center,8670103,INCENTIVE SPIROMETER,,,270,$23.00 ,$23.00 ,$6.90 ,$20.93 ,$16.10 ,$6.90 ,$14.95 ,$16.56 ,$20.93 ,$17.25 
Carle BroMenn Medical Center,8670122,MONITORING SYSTEM,,,270,$65.00 ,$65.00 ,$19.50 ,$59.15 ,$45.50 ,$19.50 ,$42.25 ,$46.80 ,$59.15 ,$48.75 
Carle BroMenn Medical Center,8670125,NASAL CANNULA,,,270,$5.00 ,$5.00 ,$1.50 ,$4.55 ,$3.50 ,$1.50 ,$3.25 ,$3.60 ,$4.55 ,$3.75 
Carle BroMenn Medical Center,8670128,NORMAL SALINE,,,270,$4.00 ,$4.00 ,$1.20 ,$3.64 ,$2.80 ,$1.20 ,$2.60 ,$2.88 ,$3.64 ,$3.00 
Carle BroMenn Medical Center,8670131,PEAK FLOWMETER-ONLY,,,270,$69.00 ,$69.00 ,$20.70 ,$62.79 ,$48.30 ,$20.70 ,$44.85 ,$49.68 ,$62.79 ,$51.75 
Carle BroMenn Medical Center,8670132,PEDIATRIC ELBOW,,,270,$87.00 ,$87.00 ,$26.10 ,$79.17 ,$60.90 ,$26.10 ,$56.55 ,$62.64 ,$79.17 ,$65.25 
Carle BroMenn Medical Center,8670139,PULSAVAC KIT,,,270,$154.00 ,$154.00 ,$46.20 ,$140.14 ,$107.80 ,$46.20 ,$100.10 ,$110.88 ,$140.14 ,$115.50 
Carle BroMenn Medical Center,8670160,SI BELT REGULAR/LARGE (BACK MA,,,270,$26.00 ,$26.00 ,$7.80 ,$23.66 ,$18.20 ,$7.80 ,$16.90 ,$18.72 ,$23.66 ,$19.50 
Carle BroMenn Medical Center,8670161,SI BELTS SAUNDERS,,,270,$26.00 ,$26.00 ,$7.80 ,$23.66 ,$18.20 ,$7.80 ,$16.90 ,$18.72 ,$23.66 ,$19.50 
Carle BroMenn Medical Center,8670162,SI LOC (LARGE/XLARGE),,,270,$36.00 ,$36.00 ,$10.80 ,$32.76 ,$25.20 ,$10.80 ,$23.40 ,$25.92 ,$32.76 ,$27.00 
Carle BroMenn Medical Center,8670163,SI LOC (SMALL/MED.),,,270,$33.00 ,$33.00 ,$9.90 ,$30.03 ,$23.10 ,$9.90 ,$21.45 ,$23.76 ,$30.03 ,$24.75 
Carle BroMenn Medical Center,8670166,SPRING WIRE GUIDE,,,270,$35.00 ,$35.00 ,$10.50 ,$31.85 ,$24.50 ,$10.50 ,$22.75 ,$25.20 ,$31.85 ,$26.25 
Carle BroMenn Medical Center,8670169,STELLAR SI BELT,,,270,$33.00 ,$33.00 ,$9.90 ,$30.03 ,$23.10 ,$9.90 ,$21.45 ,$23.76 ,$30.03 ,$24.75 
Carle BroMenn Medical Center,8670170,STERILE GOWN,,,270,$23.00 ,$23.00 ,$6.90 ,$20.93 ,$16.10 ,$6.90 ,$14.95 ,$16.56 ,$20.93 ,$17.25 
Carle BroMenn Medical Center,8670172,STOPCOCK DOUBLE W/LL,,,270,$11.00 ,$11.00 ,$3.30 ,$10.01 ,$7.70 ,$3.30 ,$7.15 ,$7.92 ,$10.01 ,$8.25 
Carle BroMenn Medical Center,8670180,VAPO/EPI,,,270,$11.00 ,$11.00 ,$3.30 ,$10.01 ,$7.70 ,$3.30 ,$7.15 ,$7.92 ,$10.01 ,$8.25 
Carle BroMenn Medical Center,8670200,MISCELLANEOUS SUPPLIES,,,270,$120.00 ,$120.00 ,$36.00 ,$109.20 ,$84.00 ,$36.00 ,$78.00 ,$86.40 ,$109.20 ,$90.00 
Carle BroMenn Medical Center,8730001,CARTRIDGE-CHEM 8+ TEST,,,270,$38.00 ,$38.00 ,$11.40 ,$34.58 ,$26.60 ,$11.40 ,$24.70 ,$27.36 ,$34.58 ,$28.50 
Carle BroMenn Medical Center,8730002,ACTIVATED CLOTTING TIME,,,270,$23.00 ,$23.00 ,$6.90 ,$20.93 ,$16.10 ,$6.90 ,$14.95 ,$16.56 ,$20.93 ,$17.25 
Carle BroMenn Medical Center,8730003,SI BELTS SAUNDERS,,,270,$29.00 ,$29.00 ,$8.70 ,$26.39 ,$20.30 ,$8.70 ,$18.85 ,$20.88 ,$26.39 ,$21.75 
Carle BroMenn Medical Center,8730004,PULSAVAC KIT,,,270,$173.00 ,$173.00 ,$51.90 ,$157.43 ,$121.10 ,$51.90 ,$112.45 ,$124.56 ,$157.43 ,$129.75 
Carle BroMenn Medical Center,8730005,SI BELT REGULAR/LARGE (BACK MA,,,270,$29.00 ,$29.00 ,$8.70 ,$26.39 ,$20.30 ,$8.70 ,$18.85 ,$20.88 ,$26.39 ,$21.75 
Carle BroMenn Medical Center,8730008,AFO/ADULT,,,270,$180.00 ,$180.00 ,$54.00 ,$163.80 ,$126.00 ,$54.00 ,$117.00 ,$129.60 ,$163.80 ,$135.00 
Carle BroMenn Medical Center,8730009,AFO/CHILD,,,270,$158.00 ,$158.00 ,$47.40 ,$143.78 ,$110.60 ,$47.40 ,$102.70 ,$113.76 ,$143.78 ,$118.50 
Carle BroMenn Medical Center,8730010,AFO/CHILD - HINGED BRACE,,,270,$158.00 ,$158.00 ,$47.40 ,$143.78 ,$110.60 ,$47.40 ,$102.70 ,$113.76 ,$143.78 ,$118.50 
Carle BroMenn Medical Center,8730011,AFO/SMO,,,270,$158.00 ,$158.00 ,$47.40 ,$143.78 ,$110.60 ,$47.40 ,$102.70 ,$113.76 ,$143.78 ,$118.50 
Carle BroMenn Medical Center,8730012,"ANKLE FOOT ORTHOSIS""HINGED""",,,270,$180.00 ,$180.00 ,$54.00 ,$163.80 ,$126.00 ,$54.00 ,$117.00 ,$129.60 ,$163.80 ,$135.00 
Carle BroMenn Medical Center,8730013,AFO ORTHOSIS FLOOR-REACT,,,270,$158.00 ,$158.00 ,$47.40 ,$143.78 ,$110.60 ,$47.40 ,$102.70 ,$113.76 ,$143.78 ,$118.50 
Carle BroMenn Medical Center,8730025,ELBOW HINGED SPLINT  (2 HINGES,,,270,$353.00 ,$353.00 ,$105.90 ,$321.23 ,$247.10 ,$105.90 ,$229.45 ,$254.16 ,$321.23 ,$264.75 
Carle BroMenn Medical Center,8730037,STELLAR SI BELT,,,270,$37.00 ,$37.00 ,$11.10 ,$33.67 ,$25.90 ,$11.10 ,$24.05 ,$26.64 ,$33.67 ,$27.75 
Carle BroMenn Medical Center,8730038,SI LOC (SMALL/MED.),,,270,$37.00 ,$37.00 ,$11.10 ,$33.67 ,$25.90 ,$11.10 ,$24.05 ,$26.64 ,$33.67 ,$27.75 
Carle BroMenn Medical Center,8730039,SI LOC (LARGE/XLARGE),,,270,$40.00 ,$40.00 ,$12.00 ,$36.40 ,$28.00 ,$12.00 ,$26.00 ,$28.80 ,$36.40 ,$30.00 
Carle BroMenn Medical Center,8730044,"CMC STABILIZATION ""Y"" SPLINT",,,270,$53.00 ,$53.00 ,$15.90 ,$48.23 ,$37.10 ,$15.90 ,$34.45 ,$38.16 ,$48.23 ,$39.75 
Carle BroMenn Medical Center,8730049,CLAMSHELL WRIST FX. ORTHOSIS,,,270,$143.00 ,$143.00 ,$42.90 ,$130.13 ,$100.10 ,$42.90 ,$92.95 ,$102.96 ,$130.13 ,$107.25 
Carle BroMenn Medical Center,8730051,PEDIATRIC ELBOW,,,270,$98.00 ,$98.00 ,$29.40 ,$89.18 ,$68.60 ,$29.40 ,$63.70 ,$70.56 ,$89.18 ,$73.50 
Carle BroMenn Medical Center,8730052,ADJ TORSION STYLE MECHANISM,,,270,$86.00 ,$86.00 ,$25.80 ,$78.26 ,$60.20 ,$25.80 ,$55.90 ,$61.92 ,$78.26 ,$64.50 
Carle BroMenn Medical Center,8730060,CPM DAILY RENTAL,,,270,$86.00 ,$86.00 ,$25.80 ,$78.26 ,$60.20 ,$25.80 ,$55.90 ,$61.92 ,$78.26 ,$64.50 
Carle BroMenn Medical Center,8730062,CPM DAILY RENTAL,,,270,$86.00 ,$86.00 ,$25.80 ,$78.26 ,$60.20 ,$25.80 ,$55.90 ,$61.92 ,$78.26 ,$64.50 
Carle BroMenn Medical Center,8730237,"REACHER 26"" STANDARD",,,270,$31.00 ,$31.00 ,$9.30 ,$28.21 ,$21.70 ,$9.30 ,$20.15 ,$22.32 ,$28.21 ,$23.25 
Carle BroMenn Medical Center,8730238,PROGRESSIVE THERAPUTTY,,,270,$14.00 ,$14.00 ,$4.20 ,$12.74 ,$9.80 ,$4.20 ,$9.10 ,$10.08 ,$12.74 ,$10.50 
Carle BroMenn Medical Center,8730239,BATH SPONGE,,,270,$8.00 ,$8.00 ,$2.40 ,$7.28 ,$5.60 ,$2.40 ,$5.20 ,$5.76 ,$7.28 ,$6.00 
Carle BroMenn Medical Center,8730240,DRESSING STICK,,,270,$8.00 ,$8.00 ,$2.40 ,$7.28 ,$5.60 ,$2.40 ,$5.20 ,$5.76 ,$7.28 ,$6.00 
Carle BroMenn Medical Center,8730241,LEG LIFTER RIGID,,,270,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8730242,"SHOE HORN 24""",,,270,$16.00 ,$16.00 ,$4.80 ,$14.56 ,$11.20 ,$4.80 ,$10.40 ,$11.52 ,$14.56 ,$12.00 
Carle BroMenn Medical Center,8730243,SHOE LACES (ELASTIC) PR.,,,270,$7.00 ,$7.00 ,$2.10 ,$6.37 ,$4.90 ,$2.10 ,$4.55 ,$5.04 ,$6.37 ,$5.25 
Carle BroMenn Medical Center,8730244,SOCK AID CORD STYLE,,,270,$17.00 ,$17.00 ,$5.10 ,$15.47 ,$11.90 ,$5.10 ,$11.05 ,$12.24 ,$15.47 ,$12.75 
Carle BroMenn Medical Center,8730245,SOCK AID TERRY CLOTH,,,270,$25.00 ,$25.00 ,$7.50 ,$22.75 ,$17.50 ,$7.50 ,$16.25 ,$18.00 ,$22.75 ,$18.75 
Carle BroMenn Medical Center,8730246,THIGH LIFTER,,,270,$35.00 ,$35.00 ,$10.50 ,$31.85 ,$24.50 ,$10.50 ,$22.75 ,$25.20 ,$31.85 ,$26.25 
Carle BroMenn Medical Center,8730247,TOILET AID,,,270,$19.00 ,$19.00 ,$5.70 ,$17.29 ,$13.30 ,$5.70 ,$12.35 ,$13.68 ,$17.29 ,$14.25 
Carle BroMenn Medical Center,8730248,WASH MITT (PLAIN TERRY),,,270,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8800012,SPLINT FINGER/THUMB,,,270,$13.00 ,$13.00 ,$3.90 ,$11.83 ,$9.10 ,$3.90 ,$8.45 ,$9.36 ,$11.83 ,$9.75 
Carle BroMenn Medical Center,8800013,TRAY -STRAIGHT CATHETER,,,270,$8.00 ,$8.00 ,$2.40 ,$7.28 ,$5.60 ,$2.40 ,$5.20 ,$5.76 ,$7.28 ,$6.00 
Carle BroMenn Medical Center,8800014,STYLET INTUBATING,,,270,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8800015,CATHETER-FOLEY,,,270,$16.00 ,$16.00 ,$4.80 ,$14.56 ,$11.20 ,$4.80 ,$10.40 ,$11.52 ,$14.56 ,$12.00 
Carle BroMenn Medical Center,8800016,ELETROSURG PENCIL,,,270,$17.00 ,$17.00 ,$5.10 ,$15.47 ,$11.90 ,$5.10 ,$11.05 ,$12.24 ,$15.47 ,$12.75 
Carle BroMenn Medical Center,8800017,IODOFOAM PACKING,,,270,$19.00 ,$19.00 ,$5.70 ,$17.29 ,$13.30 ,$5.70 ,$12.35 ,$13.68 ,$17.29 ,$14.25 
Carle BroMenn Medical Center,8800018,SUTURE PACKAGE,,,270,$20.00 ,$20.00 ,$6.00 ,$18.20 ,$14.00 ,$6.00 ,$13.00 ,$14.40 ,$18.20 ,$15.00 
Carle BroMenn Medical Center,8800020,MUCUS TRAP W/CATH,,,270,$20.00 ,$20.00 ,$6.00 ,$18.20 ,$14.00 ,$6.00 ,$13.00 ,$14.40 ,$18.20 ,$15.00 
Carle BroMenn Medical Center,8800021,ELECTOSURG PAD,,,270,$20.00 ,$20.00 ,$6.00 ,$18.20 ,$14.00 ,$6.00 ,$13.00 ,$14.40 ,$18.20 ,$15.00 
Carle BroMenn Medical Center,8800023,SALEM NG TUBE,,,270,$23.00 ,$23.00 ,$6.90 ,$20.93 ,$16.10 ,$6.90 ,$14.95 ,$16.56 ,$20.93 ,$17.25 
Carle BroMenn Medical Center,8800024,FEMALE CATH KIT,,,270,$23.00 ,$23.00 ,$6.90 ,$20.93 ,$16.10 ,$6.90 ,$14.95 ,$16.56 ,$20.93 ,$17.25 
Carle BroMenn Medical Center,8800025,ARCH BAR WIRE,,,270,$24.00 ,$24.00 ,$7.20 ,$21.84 ,$16.80 ,$7.20 ,$15.60 ,$17.28 ,$21.84 ,$18.00 
Carle BroMenn Medical Center,8800026,RIB BELT-FEMALE,,,270,$29.00 ,$29.00 ,$8.70 ,$26.39 ,$20.30 ,$8.70 ,$18.85 ,$20.88 ,$26.39 ,$21.75 
Carle BroMenn Medical Center,8800027,SUBCLAVIAN DSG SET,,,270,$30.00 ,$30.00 ,$9.00 ,$27.30 ,$21.00 ,$9.00 ,$19.50 ,$21.60 ,$27.30 ,$22.50 
Carle BroMenn Medical Center,8800028,FLUID WARMER INJECTION SET,,,270,$30.00 ,$30.00 ,$9.00 ,$27.30 ,$21.00 ,$9.00 ,$19.50 ,$21.60 ,$27.30 ,$22.50 
Carle BroMenn Medical Center,8800029,CERVICAL COLLAR,,,270,$31.00 ,$31.00 ,$9.30 ,$28.21 ,$21.70 ,$9.30 ,$20.15 ,$22.32 ,$28.21 ,$23.25 
Carle BroMenn Medical Center,8800030,BAIR HUGGER FULL BODY,,,270,$32.00 ,$32.00 ,$9.60 ,$29.12 ,$22.40 ,$9.60 ,$20.80 ,$23.04 ,$29.12 ,$24.00 
Carle BroMenn Medical Center,8800031,SUPPORT ARTERIAL WRIST,,,270,$32.00 ,$32.00 ,$9.60 ,$29.12 ,$22.40 ,$9.60 ,$20.80 ,$23.04 ,$29.12 ,$24.00 
Carle BroMenn Medical Center,8800032,RESTRAINTS,,,270,$32.00 ,$32.00 ,$9.60 ,$29.12 ,$22.40 ,$9.60 ,$20.80 ,$23.04 ,$29.12 ,$24.00 
Carle BroMenn Medical Center,8800033,POST OP SHOE,,,270,$33.00 ,$33.00 ,$9.90 ,$30.03 ,$23.10 ,$9.90 ,$21.45 ,$23.76 ,$30.03 ,$24.75 
Carle BroMenn Medical Center,8800035,TRAY -SUTURE/STAPLE,,,270,$33.00 ,$33.00 ,$9.90 ,$30.03 ,$23.10 ,$9.90 ,$21.45 ,$23.76 ,$30.03 ,$24.75 
Carle BroMenn Medical Center,8800036,OPTHETIC BURRS,,,270,$35.00 ,$35.00 ,$10.50 ,$31.85 ,$24.50 ,$10.50 ,$22.75 ,$25.20 ,$31.85 ,$26.25 
Carle BroMenn Medical Center,8800037,CARTRIDGE -CHEM8+ TEST,,,270,$38.00 ,$38.00 ,$11.40 ,$34.58 ,$26.60 ,$11.40 ,$24.70 ,$27.36 ,$34.58 ,$28.50 
Carle BroMenn Medical Center,8800038,CVP MONITOR,,,270,$36.00 ,$36.00 ,$10.80 ,$32.76 ,$25.20 ,$10.80 ,$23.40 ,$25.92 ,$32.76 ,$27.00 
Carle BroMenn Medical Center,8800039,TRAY -FOLEY CATHETER,,,270,$40.00 ,$40.00 ,$12.00 ,$36.40 ,$28.00 ,$12.00 ,$26.00 ,$28.80 ,$36.40 ,$30.00 
Carle BroMenn Medical Center,8800040,SPLINT-CLAVICLE ADULT,,,270,$41.00 ,$41.00 ,$12.30 ,$37.31 ,$28.70 ,$12.30 ,$26.65 ,$29.52 ,$37.31 ,$30.75 
Carle BroMenn Medical Center,8800041,ARTERY CATH SET,,,270,$41.00 ,$41.00 ,$12.30 ,$37.31 ,$28.70 ,$12.30 ,$26.65 ,$29.52 ,$37.31 ,$30.75 
Carle BroMenn Medical Center,8800042,SPLINT-VELCRO FOREARM,,,270,$44.00 ,$44.00 ,$13.20 ,$40.04 ,$30.80 ,$13.20 ,$28.60 ,$31.68 ,$40.04 ,$33.00 
Carle BroMenn Medical Center,8800043,STIFF NECK COLLAR,,,270,$47.00 ,$47.00 ,$14.10 ,$42.77 ,$32.90 ,$14.10 ,$30.55 ,$33.84 ,$42.77 ,$35.25 
Carle BroMenn Medical Center,8800044,CATH-THORACIC,,,270,$47.00 ,$47.00 ,$14.10 ,$42.77 ,$32.90 ,$14.10 ,$30.55 ,$33.84 ,$42.77 ,$35.25 
Carle BroMenn Medical Center,8800045,TRANSDUCER KIT 42584,,,270,$50.00 ,$50.00 ,$15.00 ,$45.50 ,$35.00 ,$15.00 ,$32.50 ,$36.00 ,$45.50 ,$37.50 
Carle BroMenn Medical Center,8800046,STAPLES,,,270,$53.00 ,$53.00 ,$15.90 ,$48.23 ,$37.10 ,$15.90 ,$34.45 ,$38.16 ,$48.23 ,$39.75 
Carle BroMenn Medical Center,8800047,RESTRAINT VEST,,,270,$53.00 ,$53.00 ,$15.90 ,$48.23 ,$37.10 ,$15.90 ,$34.45 ,$38.16 ,$48.23 ,$39.75 
Carle BroMenn Medical Center,8800048,ANUS SCOPE,,,270,$53.00 ,$53.00 ,$15.90 ,$48.23 ,$37.10 ,$15.90 ,$34.45 ,$38.16 ,$48.23 ,$39.75 
Carle BroMenn Medical Center,8800049,DISPOSABLE OXISENSOR,,,270,$53.00 ,$53.00 ,$15.90 ,$48.23 ,$37.10 ,$15.90 ,$34.45 ,$38.16 ,$48.23 ,$39.75 
Carle BroMenn Medical Center,8800050,SPLINT ARM PLASTER,,,270,$53.00 ,$53.00 ,$15.90 ,$48.23 ,$37.10 ,$15.90 ,$34.45 ,$38.16 ,$48.23 ,$39.75 
Carle BroMenn Medical Center,8800051,TRAY -SPINAL PUNCTURE- ADULT,,,270,$67.00 ,$67.00 ,$20.10 ,$60.97 ,$46.90 ,$20.10 ,$43.55 ,$48.24 ,$60.97 ,$50.25 
Carle BroMenn Medical Center,8800052,HIGH PRESSURE IRRIGATION SET,,,270,$55.00 ,$55.00 ,$16.50 ,$50.05 ,$38.50 ,$16.50 ,$35.75 ,$39.60 ,$50.05 ,$41.25 
Carle BroMenn Medical Center,8800053,CARTRIDGE -TROPONIN TEST,,,270,$59.00 ,$59.00 ,$17.70 ,$53.69 ,$41.30 ,$17.70 ,$38.35 ,$42.48 ,$53.69 ,$44.25 
Carle BroMenn Medical Center,8800054,SPLINT-A/C SHOULDER IMMOB,,,270,$59.00 ,$59.00 ,$17.70 ,$53.69 ,$41.30 ,$17.70 ,$38.35 ,$42.48 ,$53.69 ,$44.25 
Carle BroMenn Medical Center,8800055,IV SOLUTION,,,270,$59.00 ,$59.00 ,$17.70 ,$53.69 ,$41.30 ,$17.70 ,$38.35 ,$42.48 ,$53.69 ,$44.25 
Carle BroMenn Medical Center,8800056,IV D5W 50 ML,,,270,$59.00 ,$59.00 ,$17.70 ,$53.69 ,$41.30 ,$17.70 ,$38.35 ,$42.48 ,$53.69 ,$44.25 
Carle BroMenn Medical Center,8800057,SPLINT-THUMB SPICA,,,270,$62.00 ,$62.00 ,$18.60 ,$56.42 ,$43.40 ,$18.60 ,$40.30 ,$44.64 ,$56.42 ,$46.50 
Carle BroMenn Medical Center,8800058,AMBU BAG,,,270,$62.00 ,$62.00 ,$18.60 ,$56.42 ,$43.40 ,$18.60 ,$40.30 ,$44.64 ,$56.42 ,$46.50 
Carle BroMenn Medical Center,8800059,URINE METER/FOLEY TRAY,,,270,$62.00 ,$62.00 ,$18.60 ,$56.42 ,$43.40 ,$18.60 ,$40.30 ,$44.64 ,$56.42 ,$46.50 
Carle BroMenn Medical Center,8800060,TRAY -SPINAL PUNCTURE,,,270,$86.00 ,$86.00 ,$25.80 ,$78.26 ,$60.20 ,$25.80 ,$55.90 ,$61.92 ,$78.26 ,$64.50 
Carle BroMenn Medical Center,8800061,SPLINT ARM PLASTIC,,,270,$65.00 ,$65.00 ,$19.50 ,$59.15 ,$45.50 ,$19.50 ,$42.25 ,$46.80 ,$59.15 ,$48.75 
Carle BroMenn Medical Center,8800062,CANE,,,270,$68.00 ,$68.00 ,$20.40 ,$61.88 ,$47.60 ,$20.40 ,$44.20 ,$48.96 ,$61.88 ,$51.00 
Carle BroMenn Medical Center,8800063,CRUTCH PAIR,,,270,$69.00 ,$69.00 ,$20.70 ,$62.79 ,$48.30 ,$20.70 ,$44.85 ,$49.68 ,$62.79 ,$51.75 
Carle BroMenn Medical Center,8800064,SPLINT FOREARM METAL,,,270,$73.00 ,$73.00 ,$21.90 ,$66.43 ,$51.10 ,$21.90 ,$47.45 ,$52.56 ,$66.43 ,$54.75 
Carle BroMenn Medical Center,8800065,ARROW HIGH FLO TUBING,,,270,$73.00 ,$73.00 ,$21.90 ,$66.43 ,$51.10 ,$21.90 ,$47.45 ,$52.56 ,$66.43 ,$54.75 
Carle BroMenn Medical Center,8800066,BLOOD TUBING SET,,,270,$73.00 ,$73.00 ,$21.90 ,$66.43 ,$51.10 ,$21.90 ,$47.45 ,$52.56 ,$66.43 ,$54.75 
Carle BroMenn Medical Center,8800067,PRESSURE BAG,,,270,$73.00 ,$73.00 ,$21.90 ,$66.43 ,$51.10 ,$21.90 ,$47.45 ,$52.56 ,$66.43 ,$54.75 
Carle BroMenn Medical Center,8800068,SPLINT LEG PLASTER,,,270,$73.00 ,$73.00 ,$21.90 ,$66.43 ,$51.10 ,$21.90 ,$47.45 ,$52.56 ,$66.43 ,$54.75 
Carle BroMenn Medical Center,8800069,BLANKETROL PAD,,,270,$79.00 ,$79.00 ,$23.70 ,$71.89 ,$55.30 ,$23.70 ,$51.35 ,$56.88 ,$71.89 ,$59.25 
Carle BroMenn Medical Center,8800070,"FLUID WARMER, LEVEL I",,,270,$79.00 ,$79.00 ,$23.70 ,$71.89 ,$55.30 ,$23.70 ,$51.35 ,$56.88 ,$71.89 ,$59.25 
Carle BroMenn Medical Center,8800071,MORGAN LENS,,,270,$83.00 ,$83.00 ,$24.90 ,$75.53 ,$58.10 ,$24.90 ,$53.95 ,$59.76 ,$75.53 ,$62.25 
Carle BroMenn Medical Center,8800072,TRAY -SPINAL PUNCTURE- PEDS,,,270,$83.00 ,$83.00 ,$24.90 ,$75.53 ,$58.10 ,$24.90 ,$53.95 ,$59.76 ,$75.53 ,$62.25 
Carle BroMenn Medical Center,8800073,TRAY -THORA/PARACENTESIS,,,270,$83.00 ,$83.00 ,$24.90 ,$75.53 ,$58.10 ,$24.90 ,$53.95 ,$59.76 ,$75.53 ,$62.25 
Carle BroMenn Medical Center,8800074,CAST ARM PLASTER,,,270,$86.00 ,$86.00 ,$25.80 ,$78.26 ,$60.20 ,$25.80 ,$55.90 ,$61.92 ,$78.26 ,$64.50 
Carle BroMenn Medical Center,8800075,PEAK FLOW,,,270,$86.00 ,$86.00 ,$25.80 ,$78.26 ,$60.20 ,$25.80 ,$55.90 ,$61.92 ,$78.26 ,$64.50 
Carle BroMenn Medical Center,8800076,BLANKETROL PROBE,,,270,$86.00 ,$86.00 ,$25.80 ,$78.26 ,$60.20 ,$25.80 ,$55.90 ,$61.92 ,$78.26 ,$64.50 
Carle BroMenn Medical Center,8800077,PACER ELECTRODES,,,270,$86.00 ,$86.00 ,$25.80 ,$78.26 ,$60.20 ,$25.80 ,$55.90 ,$61.92 ,$78.26 ,$64.50 
Carle BroMenn Medical Center,8800078,CAST ARM PLASTIC,,,270,$94.00 ,$94.00 ,$28.20 ,$85.54 ,$65.80 ,$28.20 ,$61.10 ,$67.68 ,$85.54 ,$70.50 
Carle BroMenn Medical Center,8800079,CARTRIDGE -BNP TEST,,,270,$94.00 ,$94.00 ,$28.20 ,$85.54 ,$65.80 ,$28.20 ,$61.10 ,$67.68 ,$85.54 ,$70.50 
Carle BroMenn Medical Center,8800080,SPLINT LEG PLASTIC,,,270,$94.00 ,$94.00 ,$28.20 ,$85.54 ,$65.80 ,$28.20 ,$61.10 ,$67.68 ,$85.54 ,$70.50 
Carle BroMenn Medical Center,8800081,CATH CD FOLEY,,,270,$101.00 ,$101.00 ,$30.30 ,$91.91 ,$70.70 ,$30.30 ,$65.65 ,$72.72 ,$91.91 ,$75.75 
Carle BroMenn Medical Center,8800082,SURGICEL 1/2X2,,,270,$101.00 ,$101.00 ,$30.30 ,$91.91 ,$70.70 ,$30.30 ,$65.65 ,$72.72 ,$91.91 ,$75.75 
Carle BroMenn Medical Center,8800083,END TIDAL DETECTOR,,,270,$109.00 ,$109.00 ,$32.70 ,$99.19 ,$76.30 ,$32.70 ,$70.85 ,$78.48 ,$99.19 ,$81.75 
Carle BroMenn Medical Center,8800084,RHINO ROCKET,,,270,$109.00 ,$109.00 ,$32.70 ,$99.19 ,$76.30 ,$32.70 ,$70.85 ,$78.48 ,$99.19 ,$81.75 
Carle BroMenn Medical Center,8800085,TRANSPORT MONITOR/ELEC,,,270,$113.00 ,$113.00 ,$33.90 ,$102.83 ,$79.10 ,$33.90 ,$73.45 ,$81.36 ,$102.83 ,$84.75 
Carle BroMenn Medical Center,8800086,BUCKS TRACTION BOOT,,,270,$116.00 ,$116.00 ,$34.80 ,$105.56 ,$81.20 ,$34.80 ,$75.40 ,$83.52 ,$105.56 ,$87.00 
Carle BroMenn Medical Center,8800087,TRAY-TROCAR/CHEST,,,270,$120.00 ,$120.00 ,$36.00 ,$109.20 ,$84.00 ,$36.00 ,$78.00 ,$86.40 ,$109.20 ,$90.00 
Carle BroMenn Medical Center,8800088,CENTRAL VEIN CATH KIT,,,270,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8800089,CAST AIR,,,270,$135.00 ,$135.00 ,$40.50 ,$122.85 ,$94.50 ,$40.50 ,$87.75 ,$97.20 ,$122.85 ,$101.25 
Carle BroMenn Medical Center,8800090,TRAY -TRIPLE LUMEN CATHETER,,,270,$323.00 ,$323.00 ,$96.90 ,$293.93 ,$226.10 ,$96.90 ,$209.95 ,$232.56 ,$293.93 ,$242.25 
Carle BroMenn Medical Center,8800091,NEEDLE INTRAOSSEOUS,,,270,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8800092,TRAY -PERITONEAL LAVAGE,,,270,$161.00 ,$161.00 ,$48.30 ,$146.51 ,$112.70 ,$48.30 ,$104.65 ,$115.92 ,$146.51 ,$120.75 
Carle BroMenn Medical Center,8800093,WALKER,,,270,$165.00 ,$165.00 ,$49.50 ,$150.15 ,$115.50 ,$49.50 ,$107.25 ,$118.80 ,$150.15 ,$123.75 
Carle BroMenn Medical Center,8800094,EASI LAVAGE KIT,,,270,$173.00 ,$173.00 ,$51.90 ,$157.43 ,$121.10 ,$51.90 ,$112.45 ,$124.56 ,$157.43 ,$129.75 
Carle BroMenn Medical Center,8800095,CAST LEG PLASTIC,,,270,$176.00 ,$176.00 ,$52.80 ,$160.16 ,$123.20 ,$52.80 ,$114.40 ,$126.72 ,$160.16 ,$132.00 
Carle BroMenn Medical Center,8800096,CAST LEG PLASTER,,,270,$184.00 ,$184.00 ,$55.20 ,$167.44 ,$128.80 ,$55.20 ,$119.60 ,$132.48 ,$167.44 ,$138.00 
Carle BroMenn Medical Center,8800097,SPLINT-KNEE IMMOBILIZER,,,270,$188.00 ,$188.00 ,$56.40 ,$171.08 ,$131.60 ,$56.40 ,$122.20 ,$135.36 ,$171.08 ,$141.00 
Carle BroMenn Medical Center,8800098,SHILEY TRACH,,,270,$203.00 ,$203.00 ,$60.90 ,$184.73 ,$142.10 ,$60.90 ,$131.95 ,$146.16 ,$184.73 ,$152.25 
Carle BroMenn Medical Center,8800099,INTRODUCER,,,270,$236.00 ,$236.00 ,$70.80 ,$214.76 ,$165.20 ,$70.80 ,$153.40 ,$169.92 ,$214.76 ,$177.00 
Carle BroMenn Medical Center,8800100,ASPEN COLLAR,,,270,$248.00 ,$248.00 ,$74.40 ,$225.68 ,$173.60 ,$74.40 ,$161.20 ,$178.56 ,$225.68 ,$186.00 
Carle BroMenn Medical Center,8800101,TENS UNITS,,,270,$263.00 ,$263.00 ,$78.90 ,$239.33 ,$184.10 ,$78.90 ,$170.95 ,$189.36 ,$239.33 ,$197.25 
Carle BroMenn Medical Center,8800102,CV CATH,,,270,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8800103,AUTOTRANSFUSER,,,270,$274.00 ,$274.00 ,$82.20 ,$249.34 ,$191.80 ,$82.20 ,$178.10 ,$197.28 ,$249.34 ,$205.50 
Carle BroMenn Medical Center,8800104,"FLUID WARMER, TUBING",,,270,$281.00 ,$281.00 ,$84.30 ,$255.71 ,$196.70 ,$84.30 ,$182.65 ,$202.32 ,$255.71 ,$210.75 
Carle BroMenn Medical Center,8800105,DELIVERY PACK-VAGINAL,,,270,$296.00 ,$296.00 ,$88.80 ,$269.36 ,$207.20 ,$88.80 ,$192.40 ,$213.12 ,$269.36 ,$222.00 
Carle BroMenn Medical Center,8800106,DRAINAGE UNIT CHEST,,,270,$323.00 ,$323.00 ,$96.90 ,$293.93 ,$226.10 ,$96.90 ,$209.95 ,$232.56 ,$293.93 ,$242.25 
Carle BroMenn Medical Center,8800111,ANKLE STIRRUP UNIVERSAL,,,270,$71.00 ,$71.00 ,$21.30 ,$64.61 ,$49.70 ,$21.30 ,$46.15 ,$51.12 ,$64.61 ,$53.25 
Carle BroMenn Medical Center,8800112,"CAST BOOT LARGE 12 3/4""",,,270,$29.00 ,$29.00 ,$8.70 ,$26.39 ,$20.30 ,$8.70 ,$18.85 ,$20.88 ,$26.39 ,$21.75 
Carle BroMenn Medical Center,8800113,"CAST BOOT MEDIUM 11""",,,270,$29.00 ,$29.00 ,$8.70 ,$26.39 ,$20.30 ,$8.70 ,$18.85 ,$20.88 ,$26.39 ,$21.75 
Carle BroMenn Medical Center,8800114,"CAST BOOT SMALL 9 1/2""",,,270,$29.00 ,$29.00 ,$8.70 ,$26.39 ,$20.30 ,$8.70 ,$18.85 ,$20.88 ,$26.39 ,$21.75 
Carle BroMenn Medical Center,8800115,CATH COUDE FOLEY 12FR 5CC,,,270,$41.00 ,$41.00 ,$12.30 ,$37.31 ,$28.70 ,$12.30 ,$26.65 ,$29.52 ,$37.31 ,$30.75 
Carle BroMenn Medical Center,8800116,CATH COUDE FOLEY14FR 5CC,,,270,$48.00 ,$48.00 ,$14.40 ,$43.68 ,$33.60 ,$14.40 ,$31.20 ,$34.56 ,$43.68 ,$36.00 
Carle BroMenn Medical Center,8800117,CATH COUDE FOLEY 16FR 5CC,,,270,$48.00 ,$48.00 ,$14.40 ,$43.68 ,$33.60 ,$14.40 ,$31.20 ,$34.56 ,$43.68 ,$36.00 
Carle BroMenn Medical Center,8800118,CATH COUDE FOLEY 18FR 5CC,,,270,$48.00 ,$48.00 ,$14.40 ,$43.68 ,$33.60 ,$14.40 ,$31.20 ,$34.56 ,$43.68 ,$36.00 
Carle BroMenn Medical Center,8800119,CATH FOLEY HOLDER,,,270,$18.00 ,$18.00 ,$5.40 ,$16.38 ,$12.60 ,$5.40 ,$11.70 ,$12.96 ,$16.38 ,$13.50 
Carle BroMenn Medical Center,8800120,CATH FOLEY 10FR 3CC SILICONE,,,270,$29.00 ,$29.00 ,$8.70 ,$26.39 ,$20.30 ,$8.70 ,$18.85 ,$20.88 ,$26.39 ,$21.75 
Carle BroMenn Medical Center,8800121,CATH FOLEY 16FR 5CC HYDROMER,,,270,$14.00 ,$14.00 ,$4.20 ,$12.74 ,$9.80 ,$4.20 ,$9.10 ,$10.08 ,$12.74 ,$10.50 
Carle BroMenn Medical Center,8800122,CATH FOLEY 18FR 5CC,,,270,$14.00 ,$14.00 ,$4.20 ,$12.74 ,$9.80 ,$4.20 ,$9.10 ,$10.08 ,$12.74 ,$10.50 
Carle BroMenn Medical Center,8800123,CATH FOLEY 20FR 5CC,,,270,$14.00 ,$14.00 ,$4.20 ,$12.74 ,$9.80 ,$4.20 ,$9.10 ,$10.08 ,$12.74 ,$10.50 
Carle BroMenn Medical Center,8800124,CATH FOLEY 22FR 5CC,,,270,$14.00 ,$14.00 ,$4.20 ,$12.74 ,$9.80 ,$4.20 ,$9.10 ,$10.08 ,$12.74 ,$10.50 
Carle BroMenn Medical Center,8800125,CATH FOLEY 24FR 30CC,,,270,$26.00 ,$26.00 ,$7.80 ,$23.66 ,$18.20 ,$7.80 ,$16.90 ,$18.72 ,$23.66 ,$19.50 
Carle BroMenn Medical Center,8800126,CATH FOLEY 28FR 30CC,,,270,$14.00 ,$14.00 ,$4.20 ,$12.74 ,$9.80 ,$4.20 ,$9.10 ,$10.08 ,$12.74 ,$10.50 
Carle BroMenn Medical Center,8800128,CRUTCHES YOUTH,,,270,$54.00 ,$54.00 ,$16.20 ,$49.14 ,$37.80 ,$16.20 ,$35.10 ,$38.88 ,$49.14 ,$40.50 
Carle BroMenn Medical Center,8800135,STRIP PACKING IODOFORM 0.5IN,,,270,$12.00 ,$12.00 ,$3.60 ,$10.92 ,$8.40 ,$3.60 ,$7.80 ,$8.64 ,$10.92 ,$9.00 
Carle BroMenn Medical Center,8800136,"PACKING STRIP IODOPHOR 1/4""",,,270,$11.00 ,$11.00 ,$3.30 ,$10.01 ,$7.70 ,$3.30 ,$7.15 ,$7.92 ,$10.01 ,$8.25 
Carle BroMenn Medical Center,8800137,"PACKING STRIP IODOPHOR 2"" *",,,270,$18.00 ,$18.00 ,$5.40 ,$16.38 ,$12.60 ,$5.40 ,$11.70 ,$12.96 ,$16.38 ,$13.50 
Carle BroMenn Medical Center,8800138,STRIP PACKING PLAIN 0.5IN,,,270,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8800139,"PACKING STRIP PLAIN 1/4"" *",,,270,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8800141,SHOE POST-OP MEN LRG SZ 11-13,,,270,$32.00 ,$32.00 ,$9.60 ,$29.12 ,$22.40 ,$9.60 ,$20.80 ,$23.04 ,$29.12 ,$24.00 
Carle BroMenn Medical Center,8800145,SLING ARM LARGE PROCARE,,,270,$21.00 ,$21.00 ,$6.30 ,$19.11 ,$14.70 ,$6.30 ,$13.65 ,$15.12 ,$19.11 ,$15.75 
Carle BroMenn Medical Center,8800146,SLING ARM MEDIUM PROCARE,,,270,$20.00 ,$20.00 ,$6.00 ,$18.20 ,$14.00 ,$6.00 ,$13.00 ,$14.40 ,$18.20 ,$15.00 
Carle BroMenn Medical Center,8800147,SLING ARM SMALL PROCARE,,,270,$20.00 ,$20.00 ,$6.00 ,$18.20 ,$14.00 ,$6.00 ,$13.00 ,$14.40 ,$18.20 ,$15.00 
Carle BroMenn Medical Center,8800148,"SPLINT KNEE 20""",,,270,$74.00 ,$74.00 ,$22.20 ,$67.34 ,$51.80 ,$22.20 ,$48.10 ,$53.28 ,$67.34 ,$55.50 
Carle BroMenn Medical Center,8800149,"SPLINT KNEE 24""",,,270,$94.00 ,$94.00 ,$28.20 ,$85.54 ,$65.80 ,$28.20 ,$61.10 ,$67.68 ,$85.54 ,$70.50 
Carle BroMenn Medical Center,8800151,STAPLER SKIN 35 WIDE,,,270,$41.00 ,$41.00 ,$12.30 ,$37.31 ,$28.70 ,$12.30 ,$26.65 ,$29.52 ,$37.31 ,$30.75 
Carle BroMenn Medical Center,8800152,REMOVER SKIN STAPLE,,,270,$11.00 ,$11.00 ,$3.30 ,$10.01 ,$7.70 ,$3.30 ,$7.15 ,$7.92 ,$10.01 ,$8.25 
Carle BroMenn Medical Center,8800154,MUCUS TRAP W/CATH 10FR,,,270,$8.00 ,$8.00 ,$2.40 ,$7.28 ,$5.60 ,$2.40 ,$5.20 ,$5.76 ,$7.28 ,$6.00 
Carle BroMenn Medical Center,8800163,SALEM (NG) TUBE 16FR,,,270,$25.00 ,$25.00 ,$7.50 ,$22.75 ,$17.50 ,$7.50 ,$16.25 ,$18.00 ,$22.75 ,$18.75 
Carle BroMenn Medical Center,8800164,SALEM (NG) TUBE 18FR,,,270,$25.00 ,$25.00 ,$7.50 ,$22.75 ,$17.50 ,$7.50 ,$16.25 ,$18.00 ,$22.75 ,$18.75 
Carle BroMenn Medical Center,8800166,PAD DEFIB/PACING PEDIATRIC,,,270,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8800167,X-SMALL ARM SLING V#79-84112,,,270,$21.00 ,$21.00 ,$6.30 ,$19.11 ,$14.70 ,$6.30 ,$13.65 ,$15.12 ,$19.11 ,$15.75 
Carle BroMenn Medical Center,8800168,FLUID WARMING TUBING,,,270,$300.00 ,$300.00 ,$90.00 ,$273.00 ,$210.00 ,$90.00 ,$195.00 ,$216.00 ,$273.00 ,$225.00 
Carle BroMenn Medical Center,8800169,FLUID WARMER EXT. TUBING,,,270,$34.00 ,$34.00 ,$10.20 ,$30.94 ,$23.80 ,$10.20 ,$22.10 ,$24.48 ,$30.94 ,$25.50 
Carle BroMenn Medical Center,8800170,INCISION & DRAINAGE KIT R/O#DYNJ,,,270,$31.00 ,$31.00 ,$9.30 ,$28.21 ,$21.70 ,$9.30 ,$20.15 ,$22.32 ,$28.21 ,$23.25 
Carle BroMenn Medical Center,8800171,DRAIN CHEST PLEUR EVAC,,,270,$173.00 ,$173.00 ,$51.90 ,$157.43 ,$121.10 ,$51.90 ,$112.45 ,$124.56 ,$157.43 ,$129.75 
Carle BroMenn Medical Center,8800172,QUAD LUMEN TRAY CENTRAL VENOUS,,,270,$480.00 ,$480.00 ,$144.00 ,$436.80 ,$336.00 ,$144.00 ,$312.00 ,$345.60 ,$436.80 ,$360.00 
Carle BroMenn Medical Center,8800179,TUM E VAC,,,270,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8800184,ARCTIC SUN GEL PAD SMALL,,,270,"$3,030.00 ","$3,030.00 ",$909.00 ,"$2,757.30 ","$2,121.00 ",$909.00 ,"$1,969.50 ","$2,181.60 ","$2,757.30 ","$2,272.50 "
Carle BroMenn Medical Center,8800185,ARCTIC SUN GEL PAD LARGE,,,270,"$3,030.00 ","$3,030.00 ",$909.00 ,"$2,757.30 ","$2,121.00 ",$909.00 ,"$1,969.50 ","$2,181.60 ","$2,757.30 ","$2,272.50 "
Carle BroMenn Medical Center,8800186,ARCTIC SUN GEL PAD UNIVERSAL,,,270,$909.00 ,$909.00 ,$272.70 ,$827.19 ,$636.30 ,$272.70 ,$590.85 ,$654.48 ,$827.19 ,$681.75 
Carle BroMenn Medical Center,8902476,SHI6CFS T/R TRACH 6CFS 6.4MM EA,,A7520,270,$530.00 ,$530.00 ,$159.00 ,$482.30 ,$371.00 ,$159.00 ,$344.50 ,$381.60 ,$482.30 ,$397.50 
Carle BroMenn Medical Center,8902477,SHI4CFS T/R 4CFS CUFFLESS TRACH TUBE,,A7520,270,$530.00 ,$530.00 ,$159.00 ,$482.30 ,$371.00 ,$159.00 ,$344.50 ,$381.60 ,$482.30 ,$397.50 
Carle BroMenn Medical Center,8902485,"*SPECIAL ORDER ITEM, ROUTINE",,A9999,270,$314.00 ,$314.00 ,$94.20 ,$285.74 ,$219.80 ,$94.20 ,$204.10 ,$226.08 ,$285.74 ,$235.50 
Carle BroMenn Medical Center,8902486,*ROUTINE SUPPLIES,,A9999,270,$314.00 ,$314.00 ,$94.20 ,$285.74 ,$219.80 ,$94.20 ,$204.10 ,$226.08 ,$285.74 ,$235.50 
Carle BroMenn Medical Center,8902487,*TRACH SUPPLIES,,A9999,270,$314.00 ,$314.00 ,$94.20 ,$285.74 ,$219.80 ,$94.20 ,$204.10 ,$226.08 ,$285.74 ,$235.50 
Carle BroMenn Medical Center,8902488,*O2 SUPPLIES,,A9999,270,$314.00 ,$314.00 ,$94.20 ,$285.74 ,$219.80 ,$94.20 ,$204.10 ,$226.08 ,$285.74 ,$235.50 
Carle BroMenn Medical Center,8902489,*TUBE FEEDING SUPPLIES,,A9999,270,$314.00 ,$314.00 ,$94.20 ,$285.74 ,$219.80 ,$94.20 ,$204.10 ,$226.08 ,$285.74 ,$235.50 
Carle BroMenn Medical Center,8902490,*IV SUPPLIES,,A9999,270,$314.00 ,$314.00 ,$94.20 ,$285.74 ,$219.80 ,$94.20 ,$204.10 ,$226.08 ,$285.74 ,$235.50 
Carle BroMenn Medical Center,8902491,*OSTOMY SUPPLIES,,A9999,270,$314.00 ,$314.00 ,$94.20 ,$285.74 ,$219.80 ,$94.20 ,$204.10 ,$226.08 ,$285.74 ,$235.50 
Carle BroMenn Medical Center,8902492,*FOLEY CATHETER SUPPLIES,,A9999,270,$314.00 ,$314.00 ,$94.20 ,$285.74 ,$219.80 ,$94.20 ,$204.10 ,$226.08 ,$285.74 ,$235.50 
Carle BroMenn Medical Center,8902493,MMM5122Z MISC TEMPADOT SINGLE-USE THERM.,,A9999,270,$314.00 ,$314.00 ,$94.20 ,$285.74 ,$219.80 ,$94.20 ,$204.10 ,$226.08 ,$285.74 ,$235.50 
Carle BroMenn Medical Center,8902494,"NON171335H MISC TAPE MEASURE PAPER 36""",,A9999,270,$314.00 ,$314.00 ,$94.20 ,$285.74 ,$219.80 ,$94.20 ,$204.10 ,$226.08 ,$285.74 ,$235.50 
Carle BroMenn Medical Center,8902495,"MDS202075H MISC TONGUE BLADE 6"" STERILE",,A9999,270,$314.00 ,$314.00 ,$94.20 ,$285.74 ,$219.80 ,$94.20 ,$204.10 ,$226.08 ,$285.74 ,$235.50 
Carle BroMenn Medical Center,8902496,MISC DENTIPS TREATED,,A9999,270,$314.00 ,$314.00 ,$94.20 ,$285.74 ,$219.80 ,$94.20 ,$204.10 ,$226.08 ,$285.74 ,$235.50 
Carle BroMenn Medical Center,8902497,NON24274WH MISC APRON PULL OVER 28X46,,A9999,270,$314.00 ,$314.00 ,$94.20 ,$285.74 ,$219.80 ,$94.20 ,$204.10 ,$226.08 ,$285.74 ,$235.50 
Carle BroMenn Medical Center,8902498,MDS96502 MISC TOOTHETTES,,A9999,270,$314.00 ,$314.00 ,$94.20 ,$285.74 ,$219.80 ,$94.20 ,$204.10 ,$226.08 ,$285.74 ,$235.50 
Carle BroMenn Medical Center,8902499,NON27236H MISC GOWN ISOLATION WATER REPEL,,A9999,270,$314.00 ,$314.00 ,$94.20 ,$285.74 ,$219.80 ,$94.20 ,$204.10 ,$226.08 ,$285.74 ,$235.50 
Carle BroMenn Medical Center,8902500,"MSC097030H MISC EPI-CLENZ GEL, 4 OZ BOTTLE",,A9999,270,$314.00 ,$314.00 ,$94.20 ,$285.74 ,$219.80 ,$94.20 ,$204.10 ,$226.08 ,$285.74 ,$235.50 
Carle BroMenn Medical Center,8902501,MDS096504H MISC DENTIPS TREATED,,A9999,270,$314.00 ,$314.00 ,$94.20 ,$285.74 ,$219.80 ,$94.20 ,$204.10 ,$226.08 ,$285.74 ,$235.50 
Carle BroMenn Medical Center,8902502,NON27279XL MISC GOWN IMPERVIOUS (MRSA),,A9999,270,$314.00 ,$314.00 ,$94.20 ,$285.74 ,$219.80 ,$94.20 ,$204.10 ,$226.08 ,$285.74 ,$235.50 
Carle BroMenn Medical Center,8902503,MDS709110H MISC SHARPS CONTAINER 1 QUART RED,,A9999,270,$314.00 ,$314.00 ,$94.20 ,$285.74 ,$219.80 ,$94.20 ,$204.10 ,$226.08 ,$285.74 ,$235.50 
Carle BroMenn Medical Center,8902504,DYNJ04058H WD SKIN STAPLE REMOVER S,,A9999,270,$314.00 ,$314.00 ,$94.20 ,$285.74 ,$219.80 ,$94.20 ,$204.10 ,$226.08 ,$285.74 ,$235.50 
Carle BroMenn Medical Center,8902505,MDS131020H MISC PENLIGHT DISPOSABLE,,A9999,270,$314.00 ,$314.00 ,$94.20 ,$285.74 ,$219.80 ,$94.20 ,$204.10 ,$226.08 ,$285.74 ,$235.50 
Carle BroMenn Medical Center,8902506,NON25600Z WD BANDAGE 1X3 100/BX,,A9999,270,$314.00 ,$314.00 ,$94.20 ,$285.74 ,$219.80 ,$94.20 ,$204.10 ,$226.08 ,$285.74 ,$235.50 
Carle BroMenn Medical Center,8902507,MISC PICC LINE DRESSING KIT,,A9999,270,$314.00 ,$314.00 ,$94.20 ,$285.74 ,$219.80 ,$94.20 ,$204.10 ,$226.08 ,$285.74 ,$235.50 
Carle BroMenn Medical Center,8902508,MISC CENTRAL LINE AND DRESSING KIT,,A9999,270,$314.00 ,$314.00 ,$94.20 ,$285.74 ,$219.80 ,$94.20 ,$204.10 ,$226.08 ,$285.74 ,$235.50 
Carle BroMenn Medical Center,8902509,MISC CENTRAL LINE REPAIR KIT,,A9999,270,$314.00 ,$314.00 ,$94.20 ,$285.74 ,$219.80 ,$94.20 ,$204.10 ,$226.08 ,$285.74 ,$235.50 
Carle BroMenn Medical Center,8902510,3MSR-3 WD 3M STAPLE REMOVER KIT,,A9999,270,$314.00 ,$314.00 ,$94.20 ,$285.74 ,$219.80 ,$94.20 ,$204.10 ,$226.08 ,$285.74 ,$235.50 
Carle BroMenn Medical Center,8902511,"MSC094109H MISC CLEANSER, FOAMING 9OZ",,A9999,270,$314.00 ,$314.00 ,$94.20 ,$285.74 ,$219.80 ,$94.20 ,$204.10 ,$226.08 ,$285.74 ,$235.50 
Carle BroMenn Medical Center,8902512,MSC094308H MISC CLEANSING LOTION 8OZ EA,,A9999,270,$314.00 ,$314.00 ,$94.20 ,$285.74 ,$219.80 ,$94.20 ,$204.10 ,$226.08 ,$285.74 ,$235.50 
Carle BroMenn Medical Center,8902513,MRSA MISC MRSA DEDICATED EQUIPMENT KIT,,A9999,270,$314.00 ,$314.00 ,$94.20 ,$285.74 ,$219.80 ,$94.20 ,$204.10 ,$226.08 ,$285.74 ,$235.50 
Carle BroMenn Medical Center,8902554,AQUACEL SURGICAL DRESSING COVER 3.5X,,A9999,270,$314.00 ,$314.00 ,$94.20 ,$285.74 ,$219.80 ,$94.20 ,$204.10 ,$226.08 ,$285.74 ,$235.50 
Carle BroMenn Medical Center,8902987,TRAY SUTURE REMOVAL (MZMDS701550),,A4550,270,$518.00 ,$518.00 ,$155.40 ,$471.38 ,$362.60 ,$155.40 ,$336.70 ,$372.96 ,$471.38 ,$388.50 
Carle BroMenn Medical Center,8903058,TRAY SUTURE REMOVAL (KN66200),,A4550,270,$518.00 ,$518.00 ,$155.40 ,$471.38 ,$362.60 ,$155.40 ,$336.70 ,$372.96 ,$471.38 ,$388.50 
Carle BroMenn Medical Center,8903208,BLOOD COLLECTION SET 23G X 3/4 IN WINGED SAFETY (KN225307),,A4215,270,$31.00 ,$31.00 ,$9.30 ,$28.21 ,$21.70 ,$9.30 ,$20.15 ,$22.32 ,$28.21 ,$23.25 
Carle BroMenn Medical Center,8903376,TRACH CUFFED SHILEY SIZE 6 XLT 6.0MM DISTAL EXTENS (2M60XLTCD),,A7521,270,$627.00 ,$627.00 ,$188.10 ,$570.57 ,$438.90 ,$188.10 ,$407.55 ,$451.44 ,$570.57 ,$470.25 
Carle BroMenn Medical Center,8903489,BLOOD COLLECTION SET 21G X 3/4 IN WINGED SAFETY (KN225299),,A4215,270,$31.00 ,$31.00 ,$9.30 ,$28.21 ,$21.70 ,$9.30 ,$20.15 ,$22.32 ,$28.21 ,$23.25 
Carle BroMenn Medical Center,8903490,BLOOD COLLECTION SET 25G X 3/4 IN WINGED SAFETY (KN225315),,A4215,270,$31.00 ,$31.00 ,$9.30 ,$28.21 ,$21.70 ,$9.30 ,$20.15 ,$22.32 ,$28.21 ,$23.25 
Carle BroMenn Medical Center,8903573,IV STOPCOCK 3-WAY W/LEUR LOCK (PHK69),,A9999,270,$314.00 ,$314.00 ,$94.20 ,$285.74 ,$219.80 ,$94.20 ,$204.10 ,$226.08 ,$285.74 ,$235.50 
Carle BroMenn Medical Center,8903577,BED WEDGE 12 IN X 24 X 26 WHITE (DU8028W),,E0190,270,$596.00 ,$596.00 ,$178.80 ,$542.36 ,$417.20 ,$178.80 ,$387.40 ,$429.12 ,$542.36 ,$447.00 
Carle BroMenn Medical Center,8903643,PORT-A-CATH ACCESS KIT (NB12-0021),,A4215,270,$31.00 ,$31.00 ,$9.30 ,$28.21 ,$21.70 ,$9.30 ,$20.15 ,$22.32 ,$28.21 ,$23.25 
Carle BroMenn Medical Center,8903673,TRACH VALVE SPEAKING SWALLOWIN PASSY-MUIR (PFPMV2001),,L8501,270,$501.00 ,$501.00 ,$150.30 ,$455.91 ,$350.70 ,$150.30 ,$325.65 ,$360.72 ,$455.91 ,$375.75 
Carle BroMenn Medical Center,8903892,TRACH TUBE  CANNULA DISPOSABLE SIZE 8 CUFFLESS SHILEY (2M8DCFS),,A7520,270,$530.00 ,$530.00 ,$159.00 ,$482.30 ,$371.00 ,$159.00 ,$344.50 ,$381.60 ,$482.30 ,$397.50 
Carle BroMenn Medical Center,8904247,"TRAY SUTURE REMOVAL PRESOURCE 4.5""LITTAUER SCISSORS CARDINAL (5524000005)",,A4550,270,$518.00 ,$518.00 ,$155.40 ,$471.38 ,$362.60 ,$155.40 ,$336.70 ,$372.96 ,$471.38 ,$388.50 
Carle BroMenn Medical Center,8910001,PROFORE/PROFORE LITE,,,270,$75.00 ,$75.00 ,$22.50 ,$68.25 ,$52.50 ,$22.50 ,$48.75 ,$54.00 ,$68.25 ,$56.25 
Carle BroMenn Medical Center,8910002,UNNA BOOT,,,270,$83.00 ,$83.00 ,$24.90 ,$75.53 ,$58.10 ,$24.90 ,$53.95 ,$59.76 ,$75.53 ,$62.25 
Carle BroMenn Medical Center,8910004,"HAMMER TOE CREST, FELT, MEDIUM, RT",,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8910005,"HAMMER TOE CREST, FELT, LARGE, RT",,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8910006,"HAMMER TOE CREST, FELT, MEDIUM, LT",,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8910007,"HAMMER TOE CREST, FELT, LARGE, LT",,99070,270,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8920042,CATHETER OPTI-Q 52509-11,,,270,$653.00 ,$653.00 ,$195.90 ,$594.23 ,$457.10 ,$195.90 ,$424.45 ,$470.16 ,$594.23 ,$489.75 
Carle BroMenn Medical Center,8920043,CATH PULMONARY ARTERY 8F,,,270,$548.00 ,$548.00 ,$164.40 ,$498.68 ,$383.60 ,$164.40 ,$356.20 ,$394.56 ,$498.68 ,$411.00 
Carle BroMenn Medical Center,8920045,CVVHD PRE-DILUTION SET,,,270,$585.00 ,$585.00 ,$175.50 ,$532.35 ,$409.50 ,$175.50 ,$380.25 ,$421.20 ,$532.35 ,$438.75 
Carle BroMenn Medical Center,8920046,DIAL DRAIN BAG,,,270,$14.00 ,$14.00 ,$4.20 ,$12.74 ,$9.80 ,$4.20 ,$9.10 ,$10.08 ,$12.74 ,$10.50 
Carle BroMenn Medical Center,8920047,HALO VEST AIR SHORT,,,270,"$4,605.00 ","$4,605.00 ","$1,381.50 ","$4,190.55 ","$3,223.50 ","$1,381.50 ","$2,993.25 ","$3,315.60 ","$4,190.55 ","$3,453.75 "
Carle BroMenn Medical Center,8920048,HALO VEST AIR TALL,,,270,"$4,605.00 ","$4,605.00 ","$1,381.50 ","$4,190.55 ","$3,223.50 ","$1,381.50 ","$2,993.25 ","$3,315.60 ","$4,190.55 ","$3,453.75 "
Carle BroMenn Medical Center,8920049,HALO CROWN SMALL,,,270,"$2,453.00 ","$2,453.00 ",$735.90 ,"$2,232.23 ","$1,717.10 ",$735.90 ,"$1,594.45 ","$1,766.16 ","$2,232.23 ","$1,839.75 "
Carle BroMenn Medical Center,8920050,HALO CROWN LARGE,,,270,"$2,453.00 ","$2,453.00 ",$735.90 ,"$2,232.23 ","$1,717.10 ",$735.90 ,"$1,594.45 ","$1,766.16 ","$2,232.23 ","$1,839.75 "
Carle BroMenn Medical Center,8920051,HALO EXTRA LINER SHORT,,,270,$420.00 ,$420.00 ,$126.00 ,$382.20 ,$294.00 ,$126.00 ,$273.00 ,$302.40 ,$382.20 ,$315.00 
Carle BroMenn Medical Center,8920052,HALO EXTRA LINER TALL,,,270,$420.00 ,$420.00 ,$126.00 ,$382.20 ,$294.00 ,$126.00 ,$273.00 ,$302.40 ,$382.20 ,$315.00 
Carle BroMenn Medical Center,8920053,HALO SKULL PINS,,,270,$825.00 ,$825.00 ,$247.50 ,$750.75 ,$577.50 ,$247.50 ,$536.25 ,$594.00 ,$750.75 ,$618.75 
Carle BroMenn Medical Center,8920054,SOL INPERSOL 1.5 2000ML,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920055,SOL INPERSOL4.25 2000ML,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920056,SOL DIANEAL 2.5% 2000ML,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920057,SOL .9 NACL IRR 1000ML,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920058,SOL .9 NACL IRR 1500ML,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920059,SOL .9 NACK IRR 250ML,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920060,SOL .9 NACL IRR 500ML,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920061,SOL .9 NACL IRR. 3000ML,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920062,SOL .9 NACL 100ML SGL,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920063,SOL .9 NACL 100 DF SGL,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920064,SOL .9 NACL 1000ML,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920065,SOL .9 NACL 250ML,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920066,SOL .9 NACL 50ML SGL,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920067,SOL .9 NACL 50PF SGL,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920068,SOL .9 NACL 500ML,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920069,SOL. DIALYSATE PREMIX,,,270,$116.00 ,$116.00 ,$34.80 ,$105.56 ,$81.20 ,$34.80 ,$75.40 ,$83.52 ,$105.56 ,$87.00 
Carle BroMenn Medical Center,8920070,SOL D 10 W 1000ML,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920071,SOL D 10 W 500ML,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920072,SOL D 5 1/4S10KCL 1000ML,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920073,SOL D 5 L R 1000ML,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920074,SOL D5W.P 1000ML,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920075,SOL D5W 100PF SINGLE,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920076,SOL D5W 50ML ADVANTAGE,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920077,SOL D5W 100ML ADVANTAGE,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920078,SOL D 5 W 1000ML,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920079,SOL D 5 W 20 KCL 1000ML,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920080,SOL D 5 W 250ML,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920081,SOL D 5 W 40 KCL 1000ML,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920082,SOL D5W DO PF SGL,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920083,SOL D5W NSS 20 M 1000ML,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920084,"SOL D5W, NSS 40M 1000ML",,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920085,SOL .9NACL 20KCL 1000ML,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920086,SOL D 5 W 500ML,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920087,SOL D 5 1/2 S 1000ML,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920088,SOL D 5 1/2 S 30 KCL 1000ML,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920089,SOL D 5 1/2 S 40 KCL 1000ML,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920090,SOL D 5 1/2 S 500ML,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920091,SOL D 5 1/2 10KCL 1000ML,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920092,SOL D 5 1/2 20KCL 1000ML,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920093,SOL D 5 1/4 S 1000ML,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920094,SOL D 5 1/4 S 250ML,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920095,SOL D 5 1/4 S 500ML,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920096,SOL D 5 1/4S20KCL 1000ML,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920097,SOL D 5 1/4S30KCL 1000ML,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920098,SOL D 5 1/4S40KCL 1000ML,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920099,SOL DEXTROSE 100ML SGL,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920100,SOL DEXTROSE 50ML SGL,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920101,SOL DOPAMINE 250ML,,,270,$109.00 ,$109.00 ,$32.70 ,$99.19 ,$76.30 ,$32.70 ,$70.85 ,$78.48 ,$99.19 ,$81.75 
Carle BroMenn Medical Center,8920102,SOL GLYCINE 3000,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920103,SOL HEPARIN 500ML,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920104,SOL D5LR 20KCL 1000ML,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920105,SOL 5DLR 40KCL 1000ML,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920106,SOL LAC. RINGER 1000ML,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920107,SOL LAC. RINGER 500ML,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920108,SOL LIDOCAINE .4 D 5 500ML,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920109,SOL MANNITOL 20% 500ML,,,270,$143.00 ,$143.00 ,$42.90 ,$130.13 ,$100.10 ,$42.90 ,$92.95 ,$102.96 ,$130.13 ,$107.25 
Carle BroMenn Medical Center,8920110,SOL MANNITOL  5% 1000ML,,,270,$188.00 ,$188.00 ,$56.40 ,$171.08 ,$131.60 ,$56.40 ,$122.20 ,$135.36 ,$171.08 ,$141.00 
Carle BroMenn Medical Center,8920111,SOL NORMOSOL M D5 1000,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920112,SOL NORM R 1000ML,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920113,SOL RINGERS IRR 1000ML,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920114,SOL STRL. WATER 1000ML,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920116,SOL STRL. H20 1000 IRR,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920117,SOL STRL. H20 1500 IRR,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920118,SOL STRL. H20 250 IRR,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920119,SOL STRL H20 500 IRR,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920120,SOL 0.45 NACL 1000ML,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920121,SOL 10% LMD D 5 500ML,,,270,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8920122,SOL 10% LMD S .09 500ML,,,270,$229.00 ,$229.00 ,$68.70 ,$208.39 ,$160.30 ,$68.70 ,$148.85 ,$164.88 ,$208.39 ,$171.75 
Carle BroMenn Medical Center,8920124,CV CATH TRAY GROSHONG 8F,,,270,"$1,013.00 ","$1,013.00 ",$303.90 ,$921.83 ,$709.10 ,$303.90 ,$658.45 ,$729.36 ,$921.83 ,$759.75 
Carle BroMenn Medical Center,8920125,CV CATH 9.5FR GROSHONG,,,270,"$1,193.00 ","$1,193.00 ",$357.90 ,"$1,085.63 ",$835.10 ,$357.90 ,$775.45 ,$858.96 ,"$1,085.63 ",$894.75 
Carle BroMenn Medical Center,8920126,GASTROSTOMY TUBE MOSS 18F-CPD,,,270,$735.00 ,$735.00 ,$220.50 ,$668.85 ,$514.50 ,$220.50 ,$477.75 ,$529.20 ,$668.85 ,$551.25 
Carle BroMenn Medical Center,8920127,GASTROSTOMY TUBE MOSS 18F,,,270,"$1,088.00 ","$1,088.00 ",$326.40 ,$990.08 ,$761.60 ,$326.40 ,$707.20 ,$783.36 ,$990.08 ,$816.00 
Carle BroMenn Medical Center,8920128,TRACH SET PERCUTANEIOUS,,,270,$915.00 ,$915.00 ,$274.50 ,$832.65 ,$640.50 ,$274.50 ,$594.75 ,$658.80 ,$832.65 ,$686.25 
Carle BroMenn Medical Center,8920129,CATHETER OPTI-Q 52509-11,,,270,$863.00 ,$863.00 ,$258.90 ,$785.33 ,$604.10 ,$258.90 ,$560.95 ,$621.36 ,$785.33 ,$647.25 
Carle BroMenn Medical Center,8920136,CRANIAL ACCESS KIT,,,270,$855.00 ,$855.00 ,$256.50 ,$778.05 ,$598.50 ,$256.50 ,$555.75 ,$615.60 ,$778.05 ,$641.25 
Carle BroMenn Medical Center,8920137,SUBDURAL MICROSENSOR KIT,,,270,"$1,635.00 ","$1,635.00 ",$490.50 ,"$1,487.85 ","$1,144.50 ",$490.50 ,"$1,062.75 ","$1,177.20 ","$1,487.85 ","$1,226.25 "
Carle BroMenn Medical Center,8920143,UROLOGIST TRAY,,,270,$645.00 ,$645.00 ,$193.50 ,$586.95 ,$451.50 ,$193.50 ,$419.25 ,$464.40 ,$586.95 ,$483.75 
Carle BroMenn Medical Center,8940001,HIBICLENS 4OZ BOTTLE,,,270,$35.00 ,$35.00 ,$10.50 ,$31.85 ,$24.50 ,$10.50 ,$22.75 ,$25.20 ,$31.85 ,$26.25 
Carle BroMenn Medical Center,8940002,PROCEDURE TRAY,,,270,$161.00 ,$161.00 ,$48.30 ,$146.51 ,$112.70 ,$48.30 ,$104.65 ,$115.92 ,$146.51 ,$120.75 
Carle BroMenn Medical Center,8940024,CATH PICC 4 FR SINGLE LUMEN KIT,,C1751,270,$318.00 ,$318.00 ,$95.40 ,$289.38 ,$222.60 ,$95.40 ,$206.70 ,$228.96 ,$289.38 ,$238.50 
Carle BroMenn Medical Center,8940025,CATH PICC 5 FR DUAL LUMEN KIT,,C1751,270,$318.00 ,$318.00 ,$95.40 ,$289.38 ,$222.60 ,$95.40 ,$206.70 ,$228.96 ,$289.38 ,$238.50 
Carle BroMenn Medical Center,8940035,MIDLINE 3 FRENCH SINGLE LUMEN,,,270,$504.00 ,$504.00 ,$151.20 ,$458.64 ,$352.80 ,$151.20 ,$327.60 ,$362.88 ,$458.64 ,$378.00 
Carle BroMenn Medical Center,8940036,MIDLINE 4 FRENCH DUAL LUMEN,,,270,"$1,483.00 ","$1,483.00 ",$444.90 ,"$1,349.53 ","$1,038.10 ",$444.90 ,$963.95 ,"$1,067.76 ","$1,349.53 ","$1,112.25 "
Carle BroMenn Medical Center,8950001,ACTIVATED CLOTTING TIME,,,270,$23.00 ,$23.00 ,$6.90 ,$20.93 ,$16.10 ,$6.90 ,$14.95 ,$16.56 ,$20.93 ,$17.25 
Carle BroMenn Medical Center,8950002,ACUTE DIALYSIS,,,270,"$1,328.00 ","$1,328.00 ",$398.40 ,"$1,208.48 ",$929.60 ,$398.40 ,$863.20 ,$956.16 ,"$1,208.48 ",$996.00 
Carle BroMenn Medical Center,8950004,THERAPEUTIC PHLEBOTOMY,,,270,$113.00 ,$113.00 ,$33.90 ,$102.83 ,$79.10 ,$33.90 ,$73.45 ,$81.36 ,$102.83 ,$84.75 
Carle BroMenn Medical Center,8950005,Capd (pd Modality),,,270,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8950006,Capd (single Exchange),,,270,$79.00 ,$79.00 ,$23.70 ,$71.89 ,$55.30 ,$23.70 ,$51.35 ,$56.88 ,$71.89 ,$59.25 
Carle BroMenn Medical Center,8950007,Ccpd,,,270,$206.00 ,$206.00 ,$61.80 ,$187.46 ,$144.20 ,$61.80 ,$133.90 ,$148.32 ,$187.46 ,$154.50 
Carle BroMenn Medical Center,8970040,BIOPSY FULL CORE BIOPINCE 18GA 10CM,,,270,$218.00 ,$218.00 ,$65.40 ,$198.38 ,$152.60 ,$65.40 ,$141.70 ,$156.96 ,$198.38 ,$163.50 
Carle BroMenn Medical Center,8970041,BIOPNCE FU 18G X 11.8CM,,,270,$218.00 ,$218.00 ,$65.40 ,$198.38 ,$152.60 ,$65.40 ,$141.70 ,$156.96 ,$198.38 ,$163.50 
Carle BroMenn Medical Center,8970042,INSTRUMENT TRUCORE II BIOPSY,,,270,$235.00 ,$235.00 ,$70.50 ,$213.85 ,$164.50 ,$70.50 ,$152.75 ,$169.20 ,$213.85 ,$176.25 
Carle BroMenn Medical Center,8970043,NEEDLE COAXIAL 17G X 6.8CM,,,270,$87.00 ,$87.00 ,$26.10 ,$79.17 ,$60.90 ,$26.10 ,$56.55 ,$62.64 ,$79.17 ,$65.25 
Carle BroMenn Medical Center,8970044,NEEDLE COAXIAL 17G X 11.8CM,,,270,$87.00 ,$87.00 ,$26.10 ,$79.17 ,$60.90 ,$26.10 ,$56.55 ,$62.64 ,$79.17 ,$65.25 
Carle BroMenn Medical Center,8970045,NEEDLE INTRODUCER CO-AXIAL TRU-CORE 19GA 11.4CM,,,270,$87.00 ,$87.00 ,$26.10 ,$79.17 ,$60.90 ,$26.10 ,$56.55 ,$62.64 ,$79.17 ,$65.25 
Carle BroMenn Medical Center,8970046,NDL SPNL 3.5IN 25GA BD,,,270,$26.00 ,$26.00 ,$7.80 ,$23.66 ,$18.20 ,$7.80 ,$16.90 ,$18.72 ,$23.66 ,$19.50 
Carle BroMenn Medical Center,8970047,NEEDLE 22G X 1 1/2IN NONSFTY,,,270,$1.00 ,$1.00 ,$0.30 ,$0.91 ,$0.70 ,$0.30 ,$0.65 ,$0.72 ,$0.91 ,$0.75 
Carle BroMenn Medical Center,8970048,DISH PETRI,,,270,$9.00 ,$9.00 ,$2.70 ,$8.19 ,$6.30 ,$2.70 ,$5.85 ,$6.48 ,$8.19 ,$6.75 
Carle BroMenn Medical Center,8970049,GLOVE SURGICAL ESTEEM SZ7.0 ST,,,270,$9.00 ,$9.00 ,$2.70 ,$8.19 ,$6.30 ,$2.70 ,$5.85 ,$6.48 ,$8.19 ,$6.75 
Carle BroMenn Medical Center,8970050,GLOVE SURGICAL ESTEEM SZ7.5 ST,,,270,$9.00 ,$9.00 ,$2.70 ,$8.19 ,$6.30 ,$2.70 ,$5.85 ,$6.48 ,$8.19 ,$6.75 
Carle BroMenn Medical Center,8970051,GLOVE SURGICAL ESTEEM SZ8.0 ST,,,270,$9.00 ,$9.00 ,$2.70 ,$8.19 ,$6.30 ,$2.70 ,$5.85 ,$6.48 ,$8.19 ,$6.75 
Carle BroMenn Medical Center,8970052,NEEDLE 25 X 1 1/4,,,270,$1.00 ,$1.00 ,$0.30 ,$0.91 ,$0.70 ,$0.30 ,$0.65 ,$0.72 ,$0.91 ,$0.75 
Carle BroMenn Medical Center,8970053,NDL SPNL 2IN 25GA BD MED QCK,,,270,$18.00 ,$18.00 ,$5.40 ,$16.38 ,$12.60 ,$5.40 ,$11.70 ,$12.96 ,$16.38 ,$13.50 
Carle BroMenn Medical Center,8970054,SYRINGE LEUR SLIP 20ML,,,270,$1.00 ,$1.00 ,$0.30 ,$0.91 ,$0.70 ,$0.30 ,$0.65 ,$0.72 ,$0.91 ,$0.75 
Carle BroMenn Medical Center,8970055,TEMNO EVOLTION 18X11CM W/INTRO,,,270,$197.00 ,$197.00 ,$59.10 ,$179.27 ,$137.90 ,$59.10 ,$128.05 ,$141.84 ,$179.27 ,$147.75 
Carle BroMenn Medical Center,8970056,TEMNO EVOLTION 18X15CM W/INTRO,,,270,$197.00 ,$197.00 ,$59.10 ,$179.27 ,$137.90 ,$59.10 ,$128.05 ,$141.84 ,$179.27 ,$147.75 
Carle BroMenn Medical Center,8970057,TEMNO EVOLTION 20X11CM W/INTRO,,,270,$231.00 ,$231.00 ,$69.30 ,$210.21 ,$161.70 ,$69.30 ,$150.15 ,$166.32 ,$210.21 ,$173.25 
Carle BroMenn Medical Center,8970058,TEMNO EVOLTION 20X15CM W/INTRO,,,270,$231.00 ,$231.00 ,$69.30 ,$210.21 ,$161.70 ,$69.30 ,$150.15 ,$166.32 ,$210.21 ,$173.25 
Carle BroMenn Medical Center,8970059,ICEPACK INSTANT 6X10IN,,,270,$2.00 ,$2.00 ,$0.60 ,$1.82 ,$1.40 ,$0.60 ,$1.30 ,$1.44 ,$1.82 ,$1.50 
Carle BroMenn Medical Center,8970060,TEMNO EVOLUTION 16X11 W/INTRO,,,270,$213.00 ,$213.00 ,$63.90 ,$193.83 ,$149.10 ,$63.90 ,$138.45 ,$153.36 ,$193.83 ,$159.75 
Carle BroMenn Medical Center,8970061,TEMNO EVOLUTION 16X15 W/INTRO,,,270,$197.00 ,$197.00 ,$59.10 ,$179.27 ,$137.90 ,$59.10 ,$128.05 ,$141.84 ,$179.27 ,$147.75 
Carle BroMenn Medical Center,8970062,NEEDLE SPINAL 22GA X 3.5IN á,,,270,$8.00 ,$8.00 ,$2.40 ,$7.28 ,$5.60 ,$2.40 ,$5.20 ,$5.76 ,$7.28 ,$6.00 
Carle BroMenn Medical Center,8970064,SYRINGE 20ML LL,,,270,$1.00 ,$1.00 ,$0.30 ,$0.91 ,$0.70 ,$0.30 ,$0.65 ,$0.72 ,$0.91 ,$0.75 
Carle BroMenn Medical Center,8970065,CONTAINER SPECIMEN STERILECLIKSEAL,,,270,$2.00 ,$2.00 ,$0.60 ,$1.82 ,$1.40 ,$0.60 ,$1.30 ,$1.44 ,$1.82 ,$1.50 
Carle BroMenn Medical Center,8970066,SPONGE GAUZE 4 X 4,,,270,$2.00 ,$2.00 ,$0.60 ,$1.82 ,$1.40 ,$0.60 ,$1.30 ,$1.44 ,$1.82 ,$1.50 
Carle BroMenn Medical Center,8970067,JAR FORMALIN/PATH,,,270,$3.00 ,$3.00 ,$0.90 ,$2.73 ,$2.10 ,$0.90 ,$1.95 ,$2.16 ,$2.73 ,$2.25 
Carle BroMenn Medical Center,8970069,APPLICATOR CHLORAPREP ONESTEP,,,270,$5.00 ,$5.00 ,$1.50 ,$4.55 ,$3.50 ,$1.50 ,$3.25 ,$3.60 ,$4.55 ,$3.75 
Carle BroMenn Medical Center,8970070,RESERVOIR JACKSON-PRATT 100ML á,,,270,$20.00 ,$20.00 ,$6.00 ,$18.20 ,$14.00 ,$6.00 ,$13.00 ,$14.40 ,$18.20 ,$15.00 
Carle BroMenn Medical Center,8970071,TOWEL WHITE SURGICAL,,,270,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8970072,SOL IRR .9 NACL 500ML,,,270,$6.00 ,$6.00 ,$1.80 ,$5.46 ,$4.20 ,$1.80 ,$3.90 ,$4.32 ,$5.46 ,$4.50 
Carle BroMenn Medical Center,8970073,SOL .9 NS 20ML/IV,,,270,$6.00 ,$6.00 ,$1.80 ,$5.46 ,$4.20 ,$1.80 ,$3.90 ,$4.32 ,$5.46 ,$4.50 
Carle BroMenn Medical Center,8970074,SYRINGE PREFLL 3ML NACL FLUSH/ 2.5ML OF 0.9% SOD CHL,,,270,$1.00 ,$1.00 ,$0.30 ,$0.91 ,$0.70 ,$0.30 ,$0.65 ,$0.72 ,$0.91 ,$0.75 
Carle BroMenn Medical Center,8970077,NEEDLE SPINAL 22GA 2.5IN,,,270,$9.00 ,$9.00 ,$2.70 ,$8.19 ,$6.30 ,$2.70 ,$5.85 ,$6.48 ,$8.19 ,$6.75 
Carle BroMenn Medical Center,8970078,GEL AQUASONIC 20GM STERILE,,,270,$6.00 ,$6.00 ,$1.80 ,$5.46 ,$4.20 ,$1.80 ,$3.90 ,$4.32 ,$5.46 ,$4.50 
Carle BroMenn Medical Center,8970079,STERIDRAPE LARGE TOWEL 17 X 23,,,270,$5.00 ,$5.00 ,$1.50 ,$4.55 ,$3.50 ,$1.50 ,$3.25 ,$3.60 ,$4.55 ,$3.75 
Carle BroMenn Medical Center,8970080,COOK MEINEEDLE BIOPSY CHIBA 22GA 15CM,,,270,$43.00 ,$43.00 ,$12.90 ,$39.13 ,$30.10 ,$12.90 ,$27.95 ,$30.96 ,$39.13 ,$32.25 
Carle BroMenn Medical Center,8970081,COOK MEINEEDLE BIOPSY CHIBA 22GA 20CM,,,270,$50.00 ,$50.00 ,$15.00 ,$45.50 ,$35.00 ,$15.00 ,$32.50 ,$36.00 ,$45.50 ,$37.50 
Carle BroMenn Medical Center,8970085,OWENS & GLOVE POTEXIS PI LF 6.5,,,270,$9.00 ,$9.00 ,$2.70 ,$8.19 ,$6.30 ,$2.70 ,$5.85 ,$6.48 ,$8.19 ,$6.75 
Carle BroMenn Medical Center,8970270,CABLE TEMP PACING 6FT 5/BX,180864,,270,$72.58 ,$72.58 ,$21.77 ,$66.05 ,$50.81 ,$21.77 ,$47.18 ,$52.26 ,$66.05 ,$54.44 
Carle BroMenn Medical Center,8970270,CATHETER IMPRESS PIG 5F .038 90CM,239735,,270,$33.00 ,$33.00 ,$9.90 ,$30.03 ,$23.10 ,$9.90 ,$21.45 ,$23.76 ,$30.03 ,$24.75 
Carle BroMenn Medical Center,8970270,CATHETER SWAN GANZ 8FR,241043,,270,$998.01 ,$998.01 ,$299.40 ,$908.19 ,$698.61 ,$299.40 ,$648.71 ,$718.57 ,$908.19 ,$748.51 
Carle BroMenn Medical Center,8970270,FLOSEAL 5ML FOR DR. ALLY/ BROMENN,824,,270,$673.75 ,$673.75 ,$202.13 ,$613.11 ,$471.63 ,$202.13 ,$437.94 ,$485.10 ,$613.11 ,$505.31 
Carle BroMenn Medical Center,8970270,KIT MAC CVC 9FX11.5CM,259337,,270,$404.00 ,$404.00 ,$121.20 ,$367.64 ,$282.80 ,$121.20 ,$262.60 ,$290.88 ,$367.64 ,$303.00 
Carle BroMenn Medical Center,8970270,KIT PERICARDIOCENTESIS 6F PIG HI,214566,,270,$299.25 ,$299.25 ,$89.78 ,$272.32 ,$209.48 ,$89.78 ,$194.51 ,$215.46 ,$272.32 ,$224.44 
Carle BroMenn Medical Center,8970270,SEALANT HEMOSTAT SURGIFLO 8ML,230131,,270,$524.62 ,$524.62 ,$157.39 ,$477.40 ,$367.23 ,$157.39 ,$341.00 ,$377.73 ,$477.40 ,$393.47 
Carle BroMenn Medical Center,8979086,NON-IONIC DYE ANGIO,,,270,$293.00 ,$293.00 ,$87.90 ,$266.63 ,$205.10 ,$87.90 ,$190.45 ,$210.96 ,$266.63 ,$219.75 
Carle BroMenn Medical Center,8979283,"ATHERECTOMY SYSTEM, ROTA-WIRE",,C1769,270,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8979549,OSTEOCOOL RENTAL,,,270,"$3,375.00 ","$3,375.00 ","$1,012.50 ","$3,071.25 ","$2,362.50 ","$1,012.50 ","$2,193.75 ","$2,430.00 ","$3,071.25 ","$2,531.25 "
Carle BroMenn Medical Center,8030044,POSITIONER MEDIUM WITH COVER 01581400239,,E0190,271,$596.00 ,$596.00 ,$178.80 ,$542.36 ,$417.20 ,$178.80 ,$387.40 ,$429.12 ,$542.36 ,$447.00 
Carle BroMenn Medical Center,8030045,POSITIONER LARGE WITH COVER 01581400200,,E0190,271,$596.00 ,$596.00 ,$178.80 ,$542.36 ,$417.20 ,$178.80 ,$387.40 ,$429.12 ,$542.36 ,$447.00 
Carle BroMenn Medical Center,8030090,SUNDANCE PILLOW,,E0190,271,$596.00 ,$596.00 ,$178.80 ,$542.36 ,$417.20 ,$178.80 ,$387.40 ,$429.12 ,$542.36 ,$447.00 
Carle BroMenn Medical Center,8299625,PATCH GEL EMG,,A4556,271,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8030032,CATHETER COOL LINE 626267,,A4719,272,"$1,573.00 ","$1,573.00 ",$471.90 ,"$1,431.43 ","$1,101.10 ",$471.90 ,"$1,022.45 ","$1,132.56 ","$1,431.43 ","$1,179.75 "
Carle BroMenn Medical Center,8030046,NOURISH,,B4149,272,$26.00 ,$26.00 ,$7.80 ,$23.66 ,$18.20 ,$7.80 ,$16.90 ,$18.72 ,$23.66 ,$19.50 
Carle BroMenn Medical Center,8030051,ADULT NASAL TUBE RETAINING SYSTEM BRIDLE PRO 18FR,,B9998,272,$313.00 ,$313.00 ,$93.90 ,$284.83 ,$219.10 ,$93.90 ,$203.45 ,$225.36 ,$284.83 ,$234.75 
Carle BroMenn Medical Center,8030079,MINI ONE BUTTON BALLOON 14FR,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8030080,MINI ONE BUTTON BALLOON 16FR,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8030081,MINI ONE BUTTON BALLOON 18FR,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8030082,MINI ONE BUTTON BALLOON 20FR,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8030083,MINI ONE BUTTON BALLOON 24FR,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8030160,CATH SWAN GANZ,,,272,$806.00 ,$806.00 ,$241.80 ,$733.46 ,$564.20 ,$241.80 ,$523.90 ,$580.32 ,$733.46 ,$604.50 
Carle BroMenn Medical Center,8030162,CHEST TUBE INSERTION SUPPLIES,,,272,$228.00 ,$228.00 ,$68.40 ,$207.48 ,$159.60 ,$68.40 ,$148.20 ,$164.16 ,$207.48 ,$171.00 
Carle BroMenn Medical Center,8030163,CRRT-PRISMA PRE-SET MEMBRANE,,,272,$257.00 ,$257.00 ,$77.10 ,$233.87 ,$179.90 ,$77.10 ,$167.05 ,$185.04 ,$233.87 ,$192.75 
Carle BroMenn Medical Center,8030164,DIALYSIS CATHETER,,,272,$227.00 ,$227.00 ,$68.10 ,$206.57 ,$158.90 ,$68.10 ,$147.55 ,$163.44 ,$206.57 ,$170.25 
Carle BroMenn Medical Center,8030165,ESOPHAGEAL DOPPLER PROBE DISP,,,272,$388.00 ,$388.00 ,$116.40 ,$353.08 ,$271.60 ,$116.40 ,$252.20 ,$279.36 ,$353.08 ,$291.00 
Carle BroMenn Medical Center,8030166,FECAL MANAGEMENT SYSTEM,,,272,$330.00 ,$330.00 ,$99.00 ,$300.30 ,$231.00 ,$99.00 ,$214.50 ,$237.60 ,$300.30 ,$247.50 
Carle BroMenn Medical Center,8030167,FLEXISEAL FMS KIT CONVOTEC,,,272,$465.00 ,$465.00 ,$139.50 ,$423.15 ,$325.50 ,$139.50 ,$302.25 ,$334.80 ,$423.15 ,$348.75 
Carle BroMenn Medical Center,8030168,PERCUTANEOUS TRACH INTRO SET,,,272,$439.00 ,$439.00 ,$131.70 ,$399.49 ,$307.30 ,$131.70 ,$285.35 ,$316.08 ,$399.49 ,$329.25 
Carle BroMenn Medical Center,8030169,PREVENA 125 THERAPY UNIT KIT,,,272,"$1,337.00 ","$1,337.00 ",$401.10 ,"$1,216.67 ",$935.90 ,$401.10 ,$869.05 ,$962.64 ,"$1,216.67 ","$1,002.75 "
Carle BroMenn Medical Center,8030170,QUATTRO CATH KIT HYPOTHERMIA,,,272,"$1,800.00 ","$1,800.00 ",$540.00 ,"$1,638.00 ","$1,260.00 ",$540.00 ,"$1,170.00 ","$1,296.00 ","$1,638.00 ","$1,350.00 "
Carle BroMenn Medical Center,8030171,SAFEGUARD PRESSURE BANDAGE,,,272,$119.00 ,$119.00 ,$35.70 ,$108.29 ,$83.30 ,$35.70 ,$77.35 ,$85.68 ,$108.29 ,$89.25 
Carle BroMenn Medical Center,8030172,START UP KIT HYPOTHERMIA,,,272,$614.00 ,$614.00 ,$184.20 ,$558.74 ,$429.80 ,$184.20 ,$399.10 ,$442.08 ,$558.74 ,$460.50 
Carle BroMenn Medical Center,8030173,SUPPLIES CHEST TUBE,,,272,$228.00 ,$228.00 ,$68.40 ,$207.48 ,$159.60 ,$68.40 ,$148.20 ,$164.16 ,$207.48 ,$171.00 
Carle BroMenn Medical Center,8030174,TIGER 2 NASAL J TUBE,,,272,$612.00 ,$612.00 ,$183.60 ,$556.92 ,$428.40 ,$183.60 ,$397.80 ,$440.64 ,$556.92 ,$459.00 
Carle BroMenn Medical Center,8030175,TRAY DIALYSIS INSERTION 322,,,272,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8030176,TRAY DIALYSIS INSERTION 328,,,272,$160.00 ,$160.00 ,$48.00 ,$145.60 ,$112.00 ,$48.00 ,$104.00 ,$115.20 ,$145.60 ,$120.00 
Carle BroMenn Medical Center,8030177,VENTRICULOSTOMY INSERT SUPPLIES,,,272,"$1,682.00 ","$1,682.00 ",$504.60 ,"$1,530.62 ","$1,177.40 ",$504.60 ,"$1,093.30 ","$1,211.04 ","$1,530.62 ","$1,261.50 "
Carle BroMenn Medical Center,8030178,POWER PICC 4FR SINGLE W 3CG,,C1751,272,$243.00 ,$243.00 ,$72.90 ,$221.13 ,$170.10 ,$72.90 ,$157.95 ,$174.96 ,$221.13 ,$182.25 
Carle BroMenn Medical Center,8030179,POWER PICC 5FR DUAL W 3CG,,C1751,272,$632.00 ,$632.00 ,$189.60 ,$575.12 ,$442.40 ,$189.60 ,$410.80 ,$455.04 ,$575.12 ,$474.00 
Carle BroMenn Medical Center,8030180,POWER PICC 5FR TRIPLE W 3CG,,C1751,272,"$2,365.00 ","$2,365.00 ",$709.50 ,"$2,152.15 ","$1,655.50 ",$709.50 ,"$1,537.25 ","$1,702.80 ","$2,152.15 ","$1,773.75 "
Carle BroMenn Medical Center,8030181,POWER MIDLINE 3FR SINGLE,,C1751,272,"$1,123.00 ","$1,123.00 ",$336.90 ,"$1,021.93 ",$786.10 ,$336.90 ,$729.95 ,$808.56 ,"$1,021.93 ",$842.25 
Carle BroMenn Medical Center,8030182,POWER PICC 4FR DUAL W 3CG,,C1751,272,$761.00 ,$761.00 ,$228.30 ,$692.51 ,$532.70 ,$228.30 ,$494.65 ,$547.92 ,$692.51 ,$570.75 
Carle BroMenn Medical Center,8030196,MIDLINE 4 FR DOUBLE LUMEN MAX BARRIER TRAY,,C1751,272,$507.00 ,$507.00 ,$152.10 ,$461.37 ,$354.90 ,$152.10 ,$329.55 ,$365.04 ,$461.37 ,$380.25 
Carle BroMenn Medical Center,8130003,NEEDLE SPINAL PEN POINT 25GX5 (620573),,A4215,272,$31.00 ,$31.00 ,$9.30 ,$28.21 ,$21.70 ,$9.30 ,$20.15 ,$22.32 ,$28.21 ,$23.25 
Carle BroMenn Medical Center,8130004,NEEDLE SPNL 3.5IN 27GA BD MED (610822),,A4215,272,$31.00 ,$31.00 ,$9.30 ,$28.21 ,$21.70 ,$9.30 ,$20.15 ,$22.32 ,$28.21 ,$23.25 
Carle BroMenn Medical Center,8130005,NEEDLE SPINAL 22GA X 3.5IN (212100),,A4215,272,$31.00 ,$31.00 ,$9.30 ,$28.21 ,$21.70 ,$9.30 ,$20.15 ,$22.32 ,$28.21 ,$23.25 
Carle BroMenn Medical Center,8140083,DISPOSABLE URETEROSCOPE,,,272,"$4,545.00 ","$4,545.00 ","$1,363.50 ","$4,135.95 ","$3,181.50 ","$1,363.50 ","$2,954.25 ","$3,272.40 ","$4,135.95 ","$3,408.75 "
Carle BroMenn Medical Center,8140085,EOPA 20F ARETERIAL CANNULA,,,272,$374.85 ,$374.85 ,$112.46 ,$341.11 ,$262.40 ,$112.46 ,$243.65 ,$269.89 ,$341.11 ,$281.14 
Carle BroMenn Medical Center,8140086,ARTERIAL SOFT FLOW STRAIGHT CANNULA,,,272,$374.85 ,$374.85 ,$112.46 ,$341.11 ,$262.40 ,$112.46 ,$243.65 ,$269.89 ,$341.11 ,$281.14 
Carle BroMenn Medical Center,8140087,FEMORAL ARTERIAL CANNULA,,,272,$976.50 ,$976.50 ,$292.95 ,$888.62 ,$683.55 ,$292.95 ,$634.73 ,$703.08 ,$888.62 ,$732.38 
Carle BroMenn Medical Center,8140088,VENOUS CANNULA,,,272,$148.50 ,$148.50 ,$44.55 ,$135.14 ,$103.95 ,$44.55 ,$96.53 ,$106.92 ,$135.14 ,$111.38 
Carle BroMenn Medical Center,8140089,MULTIFEM VENOUS CANNULA,,,272,"$1,351.50 ","$1,351.50 ",$405.45 ,"$1,229.87 ",$946.05 ,$405.45 ,$878.48 ,$973.08 ,"$1,229.87 ","$1,013.63 "
Carle BroMenn Medical Center,8140090,PRESSURE DOMES,,,272,$47.85 ,$47.85 ,$14.36 ,$43.54 ,$33.50 ,$14.36 ,$31.10 ,$34.45 ,$43.54 ,$35.89 
Carle BroMenn Medical Center,8140091,CONNECTORS AND TUBING,,,272,$29.85 ,$29.85 ,$8.96 ,$27.16 ,$20.90 ,$8.96 ,$19.40 ,$21.49 ,$27.16 ,$22.39 
Carle BroMenn Medical Center,8140092,ADULT CPB SMART CIRCUIT,,,272,"$3,825.00 ","$3,825.00 ","$1,147.50 ","$3,480.75 ","$2,677.50 ","$1,147.50 ","$2,486.25 ","$2,754.00 ","$3,480.75 ","$2,868.75 "
Carle BroMenn Medical Center,8140093,AFFINITY CENTRIFUGAL PUMPHEAD,,,272,"$1,350.00 ","$1,350.00 ",$405.00 ,"$1,228.50 ",$945.00 ,$405.00 ,$877.50 ,$972.00 ,"$1,228.50 ","$1,012.50 "
Carle BroMenn Medical Center,8140094,ECMO TUBING PACK,,,272,"$3,825.00 ","$3,825.00 ","$1,147.50 ","$3,480.75 ","$2,677.50 ","$1,147.50 ","$2,486.25 ","$2,754.00 ","$3,480.75 ","$2,868.75 "
Carle BroMenn Medical Center,8140095,QUADDROX D OXYGENATOR,,,272,"$3,750.00 ","$3,750.00 ","$1,125.00 ","$3,412.50 ","$2,625.00 ","$1,125.00 ","$2,437.50 ","$2,700.00 ","$3,412.50 ","$2,812.50 "
Carle BroMenn Medical Center,8140096,AUTOTRANSFUSION PROCEDURE KIT,,,272,$975.00 ,$975.00 ,$292.50 ,$887.25 ,$682.50 ,$292.50 ,$633.75 ,$702.00 ,$887.25 ,$731.25 
Carle BroMenn Medical Center,8140097,EL 240 RESERVOIR,,,272,$300.00 ,$300.00 ,$90.00 ,$273.00 ,$210.00 ,$90.00 ,$195.00 ,$216.00 ,$273.00 ,$225.00 
Carle BroMenn Medical Center,8140098,SUCTION ASSEMBLY,,,272,$75.00 ,$75.00 ,$22.50 ,$68.25 ,$52.50 ,$22.50 ,$48.75 ,$54.00 ,$68.25 ,$56.25 
Carle BroMenn Medical Center,8140099,CORONARY OSTIA CANNULA,,,272,$598.50 ,$598.50 ,$179.55 ,$544.64 ,$418.95 ,$179.55 ,$389.03 ,$430.92 ,$544.64 ,$448.88 
Carle BroMenn Medical Center,8140100,ARISS CARDIOPLEGIA SWITCH,,,272,$298.50 ,$298.50 ,$89.55 ,$271.64 ,$208.95 ,$89.55 ,$194.03 ,$214.92 ,$271.64 ,$223.88 
Carle BroMenn Medical Center,8140101,CARIOPLEGIA SET,,,272,$298.50 ,$298.50 ,$89.55 ,$271.64 ,$208.95 ,$89.55 ,$194.03 ,$214.92 ,$271.64 ,$223.88 
Carle BroMenn Medical Center,8140102,MISC ACCESSORIES,,,272,$148.50 ,$148.50 ,$44.55 ,$135.14 ,$103.95 ,$44.55 ,$96.53 ,$106.92 ,$135.14 ,$111.38 
Carle BroMenn Medical Center,8140103,CARDIOPLEGIA CANNULA,,,272,$598.50 ,$598.50 ,$179.55 ,$544.64 ,$418.95 ,$179.55 ,$389.03 ,$430.92 ,$544.64 ,$448.88 
Carle BroMenn Medical Center,8140104,MISTER-BLOWER,,,272,$298.50 ,$298.50 ,$89.55 ,$271.64 ,$208.95 ,$89.55 ,$194.03 ,$214.92 ,$271.64 ,$223.88 
Carle BroMenn Medical Center,8140105,FEMORAL INSERTION KIT,,,272,$298.50 ,$298.50 ,$89.55 ,$271.64 ,$208.95 ,$89.55 ,$194.03 ,$214.92 ,$271.64 ,$223.88 
Carle BroMenn Medical Center,8140106,BLOOD COLLECTION BAG WITH CPD,,,272,$29.85 ,$29.85 ,$8.96 ,$27.16 ,$20.90 ,$8.96 ,$19.40 ,$21.49 ,$27.16 ,$22.39 
Carle BroMenn Medical Center,8140107,Hc 200 Micron,,,272,$675.00 ,$675.00 ,$202.50 ,$614.25 ,$472.50 ,$202.50 ,$438.75 ,$486.00 ,$614.25 ,$506.25 
Carle BroMenn Medical Center,8140108,Hc 365 Micron,,,272,$675.00 ,$675.00 ,$202.50 ,$614.25 ,$472.50 ,$202.50 ,$438.75 ,$486.00 ,$614.25 ,$506.25 
Carle BroMenn Medical Center,8140109,Hc 550 Micron,,,272,$900.00 ,$900.00 ,$270.00 ,$819.00 ,$630.00 ,$270.00 ,$585.00 ,$648.00 ,$819.00 ,$675.00 
Carle BroMenn Medical Center,8140110,Hc 1000 Micron,,,272,"$2,550.00 ","$2,550.00 ",$765.00 ,"$2,320.50 ","$1,785.00 ",$765.00 ,"$1,657.50 ","$1,836.00 ","$2,320.50 ","$1,912.50 "
Carle BroMenn Medical Center,8140111,Hc Expedia,,,272,"$3,450.00 ","$3,450.00 ","$1,035.00 ","$3,139.50 ","$2,415.00 ","$1,035.00 ","$2,242.50 ","$2,484.00 ","$3,139.50 ","$2,587.50 "
Carle BroMenn Medical Center,8140112,Hc Xps,,,272,"$3,450.00 ","$3,450.00 ","$1,035.00 ","$3,139.50 ","$2,415.00 ","$1,035.00 ","$2,242.50 ","$2,484.00 ","$3,139.50 ","$2,587.50 "
Carle BroMenn Medical Center,8140113,Hc Holmium/green Light Laser,,,272,"$1,890.00 ","$1,890.00 ",$567.00 ,"$1,719.90 ","$1,323.00 ",$567.00 ,"$1,228.50 ","$1,360.80 ","$1,719.90 ","$1,417.50 "
Carle BroMenn Medical Center,8140114,Hc Intra-operative Nerve Monitoring,,,272,"$1,425.00 ","$1,425.00 ",$427.50 ,"$1,296.75 ",$997.50 ,$427.50 ,$926.25 ,"$1,026.00 ","$1,296.75 ","$1,068.75 "
Carle BroMenn Medical Center,8140115,Hc Hummingbird Tapered Tip Probe,,,272,$255.00 ,$255.00 ,$76.50 ,$232.05 ,$178.50 ,$76.50 ,$165.75 ,$183.60 ,$232.05 ,$191.25 
Carle BroMenn Medical Center,8140116,Hc Unilateral/bilateral Lithotripsy,,,272,"$5,070.00 ","$5,070.00 ","$1,521.00 ","$4,613.70 ","$3,549.00 ","$1,521.00 ","$3,295.50 ","$3,650.40 ","$4,613.70 ","$3,802.50 "
Carle BroMenn Medical Center,8140117,CELL SAVER PACK,,,272,"$3,792.00 ","$3,792.00 ","$1,137.60 ","$3,450.72 ","$2,654.40 ","$1,137.60 ","$2,464.80 ","$2,730.24 ","$3,450.72 ","$2,844.00 "
Carle BroMenn Medical Center,8170001,EPIDURAL NERVE BLOCK TRAY,,,272,$146.00 ,$146.00 ,$43.80 ,$132.86 ,$102.20 ,$43.80 ,$94.90 ,$105.12 ,$132.86 ,$109.50 
Carle BroMenn Medical Center,8170010,PERIPHERAL NERVE BLOCK TRAY,,,272,$529.00 ,$529.00 ,$158.70 ,$481.39 ,$370.30 ,$158.70 ,$343.85 ,$380.88 ,$481.39 ,$396.75 
Carle BroMenn Medical Center,8170029,CATHETER -BALLOON DILATION,,C1726,272,$274.00 ,$274.00 ,$82.20 ,$249.34 ,$191.80 ,$82.20 ,$178.10 ,$197.28 ,$249.34 ,$205.50 
Carle BroMenn Medical Center,8170030,CATHETER -BALLOON DILATION,,C1726,272,$274.00 ,$274.00 ,$82.20 ,$249.34 ,$191.80 ,$82.20 ,$178.10 ,$197.28 ,$249.34 ,$205.50 
Carle BroMenn Medical Center,8170031,CATHETER -BILIARY DILATATION,,C1726,272,$274.00 ,$274.00 ,$82.20 ,$249.34 ,$191.80 ,$82.20 ,$178.10 ,$197.28 ,$249.34 ,$205.50 
Carle BroMenn Medical Center,8170032,"CATHETER,BALLOON, NON-VASCULAR",,C1726,272,$274.00 ,$274.00 ,$82.20 ,$249.34 ,$191.80 ,$82.20 ,$178.10 ,$197.28 ,$249.34 ,$205.50 
Carle BroMenn Medical Center,8170038,CATH EMBOLECTOMY 3FR X 80CM,245245,C1757,272,$159.42 ,$159.42 ,$47.83 ,$145.07 ,$111.59 ,$47.83 ,$103.62 ,$114.78 ,$145.07 ,$119.57 
Carle BroMenn Medical Center,8170038,CATH FLEXIMA NEPH 8X25 REG,236660,C1757,272,$240.75 ,$240.75 ,$72.23 ,$219.08 ,$168.53 ,$72.23 ,$156.49 ,$173.34 ,$219.08 ,$180.56 
Carle BroMenn Medical Center,8170038,CATH FOG 3F 40CM,244847,C1757,272,$200.34 ,$200.34 ,$60.10 ,$182.31 ,$140.24 ,$60.10 ,$130.22 ,$144.24 ,$182.31 ,$150.26 
Carle BroMenn Medical Center,8170038,CATH FOG 4F 40CM,244535,C1757,272,$163.41 ,$163.41 ,$49.02 ,$148.70 ,$114.39 ,$49.02 ,$106.22 ,$117.66 ,$148.70 ,$122.56 
Carle BroMenn Medical Center,8170038,CATHETER FOG EMBOLEC 4F 80MM,244493,C1757,272,$200.34 ,$200.34 ,$60.10 ,$182.31 ,$140.24 ,$60.10 ,$130.22 ,$144.24 ,$182.31 ,$150.26 
Carle BroMenn Medical Center,8170038,CATHETER FOG EMBOLEC 6F 80MM,244494,C1757,272,$159.42 ,$159.42 ,$47.83 ,$145.07 ,$111.59 ,$47.83 ,$103.62 ,$114.78 ,$145.07 ,$119.57 
Carle BroMenn Medical Center,8170038,CATHETERFOG EMBOLEC 5F 80MM,244487,C1757,272,$159.42 ,$159.42 ,$47.83 ,$145.07 ,$111.59 ,$47.83 ,$103.62 ,$114.78 ,$145.07 ,$119.57 
Carle BroMenn Medical Center,8170039,CATH URET FLEX TIP 5F 70CM,244674,C1758,272,$48.56 ,$48.56 ,$14.57 ,$44.19 ,$33.99 ,$14.57 ,$31.56 ,$34.96 ,$44.19 ,$36.42 
Carle BroMenn Medical Center,8170039,CATH URET GUID BERN 5F 65CM IMAGE,237351,C1758,272,$52.49 ,$52.49 ,$15.75 ,$47.77 ,$36.74 ,$15.75 ,$34.12 ,$37.79 ,$47.77 ,$39.37 
Carle BroMenn Medical Center,8170039,CATH URET GUID C2 5F 65CM IMAGER,237350,C1758,272,$52.49 ,$52.49 ,$15.75 ,$47.77 ,$36.74 ,$15.75 ,$34.12 ,$37.79 ,$47.77 ,$39.37 
Carle BroMenn Medical Center,8170039,CATH URET POLYU 6F X70CM WHSTL,244539,C1758,272,$36.78 ,$36.78 ,$11.03 ,$33.47 ,$25.75 ,$11.03 ,$23.91 ,$26.48 ,$33.47 ,$27.59 
Carle BroMenn Medical Center,8170039,CATH URET POLYU 8F 5FX70CM,244540,C1758,272,$43.92 ,$43.92 ,$13.18 ,$39.97 ,$30.74 ,$13.18 ,$28.55 ,$31.62 ,$39.97 ,$32.94 
Carle BroMenn Medical Center,8170039,CATH URET RED RBR 20F,244738,C1758,272,$1.06 ,$1.06 ,$0.32 ,$0.96 ,$0.74 ,$0.32 ,$0.69 ,$0.76 ,$0.96 ,$0.80 
Carle BroMenn Medical Center,8170039,CATH URET RR ALLL PURP 10F,245014,C1758,272,$2.28 ,$2.28 ,$0.68 ,$2.07 ,$1.60 ,$0.68 ,$1.48 ,$1.64 ,$2.07 ,$1.71 
Carle BroMenn Medical Center,8170039,CATH URET RR ALLL PURP 14F,245015,C1758,272,$2.37 ,$2.37 ,$0.71 ,$2.16 ,$1.66 ,$0.71 ,$1.54 ,$1.71 ,$2.16 ,$1.78 
Carle BroMenn Medical Center,8170039,CATH URET RR ALLL PURP 16F,245016,C1758,272,$2.28 ,$2.28 ,$0.68 ,$2.07 ,$1.60 ,$0.68 ,$1.48 ,$1.64 ,$2.07 ,$1.71 
Carle BroMenn Medical Center,8170039,CATH WHISTLE 5FR LEFT,244297,C1758,272,$36.78 ,$36.78 ,$11.03 ,$33.47 ,$25.75 ,$11.03 ,$23.91 ,$26.48 ,$33.47 ,$27.59 
Carle BroMenn Medical Center,8170039,CATHETER URETERAL 6FR,1833,C1758,272,$31.41 ,$31.41 ,$9.42 ,$28.58 ,$21.99 ,$9.42 ,$20.42 ,$22.62 ,$28.58 ,$23.56 
Carle BroMenn Medical Center,8170039,STENT PERCUFLEX+ 6F 28CM,236764,C1758,272,$331.74 ,$331.74 ,$99.52 ,$301.88 ,$232.22 ,$99.52 ,$215.63 ,$238.85 ,$301.88 ,$248.81 
Carle BroMenn Medical Center,8170047,GUIDE WIRE,,C1769,272,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8170050,BASKET BAGLEY 1.9X120,239008,C1773,272,$937.65 ,$937.65 ,$281.30 ,$853.26 ,$656.36 ,$281.30 ,$609.47 ,$675.11 ,$853.26 ,$703.24 
Carle BroMenn Medical Center,8170050,BASKET SEGURA 4WR O 2.4X120X16,236918,C1773,272,$544.05 ,$544.05 ,$163.22 ,$495.09 ,$380.84 ,$163.22 ,$353.63 ,$391.72 ,$495.09 ,$408.04 
Carle BroMenn Medical Center,8170050,BASKET SEGURA 4WR O 3X120X16,236674,C1773,272,$544.05 ,$544.05 ,$163.22 ,$495.09 ,$380.84 ,$163.22 ,$353.63 ,$391.72 ,$495.09 ,$408.04 
Carle BroMenn Medical Center,8170050,BASKET SEGURA 4WR O 4.5X90X20,236718,C1773,272,$544.05 ,$544.05 ,$163.22 ,$495.09 ,$380.84 ,$163.22 ,$353.63 ,$391.72 ,$495.09 ,$408.04 
Carle BroMenn Medical Center,8170050,BASKET ZEROTIP 1.9X120CM,237062,C1773,272,$620.40 ,$620.40 ,$186.12 ,$564.56 ,$434.28 ,$186.12 ,$403.26 ,$446.69 ,$564.56 ,$465.30 
Carle BroMenn Medical Center,8170050,BASKET ZEROTIP 3F 120X16,238090,C1773,272,$520.89 ,$520.89 ,$156.27 ,$474.01 ,$364.62 ,$156.27 ,$338.58 ,$375.04 ,$474.01 ,$390.67 
Carle BroMenn Medical Center,8170050,BASKET ZEROTIP 4WR O 2.4X120,236721,C1773,272,$549.99 ,$549.99 ,$165.00 ,$500.49 ,$384.99 ,$165.00 ,$357.49 ,$395.99 ,$500.49 ,$412.49 
Carle BroMenn Medical Center,8170050,RETRIEVER COIL NITL UROL 3F 10 ST,239019,C1773,272,$703.92 ,$703.92 ,$211.18 ,$640.57 ,$492.74 ,$211.18 ,$457.55 ,$506.82 ,$640.57 ,$527.94 
Carle BroMenn Medical Center,8170050,RETRIEVER SUTURE HEWSON 6/BX,3699,C1773,272,$311.04 ,$311.04 ,$93.31 ,$283.05 ,$217.73 ,$93.31 ,$202.18 ,$223.95 ,$283.05 ,$233.28 
Carle BroMenn Medical Center,8170084,BAHA DRILL,,,272,"$3,300.00 ","$3,300.00 ",$990.00 ,"$3,003.00 ","$2,310.00 ",$990.00 ,"$2,145.00 ","$2,376.00 ","$3,003.00 ","$2,475.00 "
Carle BroMenn Medical Center,8179041,CLOSURE DEVICE -VASCULAR,,C1760,272,$248.00 ,$248.00 ,$74.40 ,$225.68 ,$173.60 ,$74.40 ,$161.20 ,$178.56 ,$225.68 ,$186.00 
Carle BroMenn Medical Center,8179047,GUIDE WIRE,,C1769,272,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8179050,RETRIEVAL DEVICE,,C1773,272,$233.00 ,$233.00 ,$69.90 ,$212.03 ,$163.10 ,$69.90 ,$151.45 ,$167.76 ,$212.03 ,$174.75 
Carle BroMenn Medical Center,8179118,SHEATH BRITE TIP 7F 11CM,110114,C1894,272,$89.67 ,$89.67 ,$26.90 ,$81.60 ,$62.77 ,$26.90 ,$58.29 ,$64.56 ,$81.60 ,$67.25 
Carle BroMenn Medical Center,8201843,Y-PORT 20 IN FEEDING TUBE,,B9998,272,$313.00 ,$313.00 ,$93.90 ,$284.83 ,$219.10 ,$93.90 ,$203.45 ,$225.36 ,$284.83 ,$234.75 
Carle BroMenn Medical Center,8201844,Y-PORT 24 IN FEEDING TUBE,,B9998,272,$313.00 ,$313.00 ,$93.90 ,$284.83 ,$219.10 ,$93.90 ,$203.45 ,$225.36 ,$284.83 ,$234.75 
Carle BroMenn Medical Center,8201845,C-CLAMP FOR FEED TUBE,,B9998,272,$313.00 ,$313.00 ,$93.90 ,$284.83 ,$219.10 ,$93.90 ,$203.45 ,$225.36 ,$284.83 ,$234.75 
Carle BroMenn Medical Center,8201846,Y-PORT ADAPTER FEED TUBE,,B9998,272,$313.00 ,$313.00 ,$93.90 ,$284.83 ,$219.10 ,$93.90 ,$203.45 ,$225.36 ,$284.83 ,$234.75 
Carle BroMenn Medical Center,8202333,TUBE FEEDING MICKEY,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299693,TUBE FEEDING MICKEY 14FR,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299694,TUBE FEEDING MINI ONE 20FR 3.5,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299695,BALLOON STOMA MEASURE MINI ONE,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299696,SET IP DILATOR MINI ONE,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299707,TUBE FEEDING MINI ONE 18FR 2.0,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299708,TUBE FEEDING MINI ONE 18FR 4.0,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299717,TUBE FEEDING MINI ONE 12FR 0.8,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299718,TUBE FEEDING MINI ONE 12FR 2.3,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299719,TUBE FEEDING MINI ONE 12FR 2.7,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299720,TUBE FEEDING MINI ONE 14FR 0.8,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299721,TUBE FEEDING MINI ONE 14FR 1.2,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299722,TUBE FEEDING MINI ONE 14FR 2.3,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299723,TUBE FEEDING MINI ONE 14FR 2.7,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299724,TUBE FEEDING MINI ONE 14FR 3.5,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299725,TUBE FEEDING MINI ONE 14FR 4,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299726,TUBE FEEDING MINI ONE 14FR 4.4,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299727,TUBE FEEDING MINI ONE 14FR 5,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299728,TUBE FEEDING MINI ONE 14FR 5.5,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299729,TUBE FEEDING MINI ONE 14FR 6,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299730,TUBE FEEDING MINI ONE 14FR 6.5,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299731,TUBE FEEDING MINI ONE 16FR 1,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299732,TUBE FEEDING MINI ONE 16FR 1.2,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299733,TUBE FEEDING MINI ONE 16FR 1.5,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299734,TUBE FEEDING MINI ONE 16FR 1.7,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299735,TUBE FEEDING MINI ONE 16FR 2,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299736,TUBE FEEDING MINI ONE 16FR 2.3,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299737,TUBE FEEDING MINI ONE 16FR 2.5,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299738,TUBE FEEDING MINI ONE 16FR 2.7,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299739,TUBE FEEDING MINI ONE 16FR 3,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299740,TUBE FEEDING MINI ONE 16FR 3.5,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299741,TUBE FEEDING MINI ONE 16FR 4,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299742,TUBE FEEDING MINI ONE 16FR 4.4,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299743,TUBE FEEDING MINI ONE 18FR 1,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299744,TUBE FEEDING MINI ONE 18FR 1.2,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299745,TUBE FEEDING MINI ONE 18FR 1.5,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299746,TUBE FEEDING MINI ONE 18FR 1.7,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299747,TUBE FEEDING MINI ONE 18FR 2.3,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299748,TUBE FEEDING MINI ONE 18FR 2.5,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299749,TUBE FEEDING MINI ONE 18FR 2.7,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299750,TUBE FEEDING MINI ONE 18FR 3,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299751,TUBE FEEDING MINI ONE 18FR 3.5,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299752,TUBE FEEDING MINI ONE 18FR 4.4,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299753,TUBE FEEDING MINI ONE 18FR 5,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299754,TUBE FEEDING MINI ONE 18FR 6,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299755,TUBE FEEDING MINI ONE 20FR 1,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299756,TUBE FEEDING MINI ONE 20FR 1.2,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299757,TUBE FEEDING MINI ONE 20FR 1.5,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299758,TUBE FEEDING MINI ONE 20FR 1.7,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299759,TUBE FEEDING MINI ONE 20FR 2,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299760,TUBE FEEDING MINI ONE 20FR 2.3,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299761,TUBE FEEDING MINI ONE 20FR 4.4,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299762,TUBE FEEDING MINI ONE 24FR 1.5,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299763,TUBE FEEDING MINI ONE 24FR 1.7,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299764,TUBE FEEDING MINI ONE 24FR 2,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299765,TUBE FEEDING MINI ONE 24FR 2.3,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299766,TUBE FEEDING MINI ONE 24FR 2.7,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299767,TUBE FEEDING MINI ONE 24FR 4.4,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8299778,MICROCANNULAS 25G40XL EASYGUIDE NEEDLE,,A4215,272,$31.00 ,$31.00 ,$9.30 ,$28.21 ,$21.70 ,$9.30 ,$20.15 ,$22.32 ,$28.21 ,$23.25 
Carle BroMenn Medical Center,8650030,IS TREATMENT,,,272,$83.00 ,$83.00 ,$24.90 ,$75.53 ,$58.10 ,$24.90 ,$53.95 ,$59.76 ,$75.53 ,$62.25 
Carle BroMenn Medical Center,8800110,NEE /SYRINGE PRESSU MONITORING,,A9279,272,$266.00 ,$266.00 ,$79.80 ,$242.06 ,$186.20 ,$79.80 ,$172.90 ,$191.52 ,$242.06 ,$199.50 
Carle BroMenn Medical Center,8914102,OASIS WOUND MATRIX /SQCM,,Q4102,272,$25.00 ,$25.00 ,$7.50 ,$22.75 ,$17.50 ,$7.50 ,$16.25 ,$18.00 ,$22.75 ,$18.75 
Carle BroMenn Medical Center,8920179,DERMACLOSE,,,272,"$2,570.00 ","$2,570.00 ",$771.00 ,"$2,338.70 ","$1,799.00 ",$771.00 ,"$1,670.50 ","$1,850.40 ","$2,338.70 ","$1,927.50 "
Carle BroMenn Medical Center,8940004,CATHETER -REPAIR MATERIAL,,,272,$64.00 ,$64.00 ,$19.20 ,$58.24 ,$44.80 ,$19.20 ,$41.60 ,$46.08 ,$58.24 ,$48.00 
Carle BroMenn Medical Center,8940005,SITE RITE,,,272,$25.00 ,$25.00 ,$7.50 ,$22.75 ,$17.50 ,$7.50 ,$16.25 ,$18.00 ,$22.75 ,$18.75 
Carle BroMenn Medical Center,8940006,CATHETER - PICC 4,,C1751,272,$318.00 ,$318.00 ,$95.40 ,$289.38 ,$222.60 ,$95.40 ,$206.70 ,$228.96 ,$289.38 ,$238.50 
Carle BroMenn Medical Center,8940007,CATHETER - PICC 5,,C1751,272,$318.00 ,$318.00 ,$95.40 ,$289.38 ,$222.60 ,$95.40 ,$206.70 ,$228.96 ,$289.38 ,$238.50 
Carle BroMenn Medical Center,8940008,CATHETER - PICC 6,,C1751,272,$318.00 ,$318.00 ,$95.40 ,$289.38 ,$222.60 ,$95.40 ,$206.70 ,$228.96 ,$289.38 ,$238.50 
Carle BroMenn Medical Center,8940009,INTRODUCER,,C1894,272,$143.00 ,$143.00 ,$42.90 ,$130.13 ,$100.10 ,$42.90 ,$92.95 ,$102.96 ,$130.13 ,$107.25 
Carle BroMenn Medical Center,8940018,CATHETER - TRIPLE LUMEN,,C1751,272,$318.00 ,$318.00 ,$95.40 ,$289.38 ,$222.60 ,$95.40 ,$206.70 ,$228.96 ,$289.38 ,$238.50 
Carle BroMenn Medical Center,8940020,3CG - 4,,C1751,272,$318.00 ,$318.00 ,$95.40 ,$289.38 ,$222.60 ,$95.40 ,$206.70 ,$228.96 ,$289.38 ,$238.50 
Carle BroMenn Medical Center,8940021,3CG - 5,,C1751,272,$318.00 ,$318.00 ,$95.40 ,$289.38 ,$222.60 ,$95.40 ,$206.70 ,$228.96 ,$289.38 ,$238.50 
Carle BroMenn Medical Center,8940022,3CG - 5T,,C1751,272,$318.00 ,$318.00 ,$95.40 ,$289.38 ,$222.60 ,$95.40 ,$206.70 ,$228.96 ,$289.38 ,$238.50 
Carle BroMenn Medical Center,8940023,CART COVER,,,272,$50.00 ,$50.00 ,$15.00 ,$45.50 ,$35.00 ,$15.00 ,$32.50 ,$36.00 ,$45.50 ,$37.50 
Carle BroMenn Medical Center,8940033,PICC 3 FRENCH SINGLE LUMEN 3CG,,C1751,272,$318.00 ,$318.00 ,$95.40 ,$289.38 ,$222.60 ,$95.40 ,$206.70 ,$228.96 ,$289.38 ,$238.50 
Carle BroMenn Medical Center,8940034,PICC 4 FRENCH DUAL LUMEN 3CG,,C1751,272,$318.00 ,$318.00 ,$95.40 ,$289.38 ,$222.60 ,$95.40 ,$206.70 ,$228.96 ,$289.38 ,$238.50 
Carle BroMenn Medical Center,8970003,G-J TUBE LOW PROFILE,,B4088,272,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8970173,NON-VASCULAR PROC SUPPLIES,,C1729,272,"$2,018.90 ","$2,018.90 ",$605.67 ,"$1,837.20 ","$1,413.23 ",$605.67 ,"$1,312.29 ","$1,453.61 ","$1,837.20 ","$1,514.18 "
Carle BroMenn Medical Center,8979170,CATHETER -BALLOON DILATION,,C1726,272,$274.00 ,$274.00 ,$82.20 ,$249.34 ,$191.80 ,$82.20 ,$178.10 ,$197.28 ,$249.34 ,$205.50 
Carle BroMenn Medical Center,8979172,CATHETER -DRAINAGE,,C1729,272,"$2,018.90 ","$2,018.90 ",$605.67 ,"$1,837.20 ","$1,413.23 ",$605.67 ,"$1,312.29 ","$1,453.61 ","$1,837.20 ","$1,514.18 "
Carle BroMenn Medical Center,8979173,CATHETER -DRAINAGE,,C1729,272,"$2,018.90 ","$2,018.90 ",$605.67 ,"$1,837.20 ","$1,413.23 ",$605.67 ,"$1,312.29 ","$1,453.61 ","$1,837.20 ","$1,514.18 "
Carle BroMenn Medical Center,8979174,CATHETER -DRAINAGE,,C1729,272,"$2,018.90 ","$2,018.90 ",$605.67 ,"$1,837.20 ","$1,413.23 ",$605.67 ,"$1,312.29 ","$1,453.61 ","$1,837.20 ","$1,514.18 "
Carle BroMenn Medical Center,8979175,8.3 RING BILIARY CATHETER,,C1729,272,"$2,018.90 ","$2,018.90 ",$605.67 ,"$1,837.20 ","$1,413.23 ",$605.67 ,"$1,312.29 ","$1,453.61 ","$1,837.20 ","$1,514.18 "
Carle BroMenn Medical Center,8979176,10.2FR BILIARY CATHETER (BCL),,C1729,272,"$2,018.90 ","$2,018.90 ",$605.67 ,"$1,837.20 ","$1,413.23 ",$605.67 ,"$1,312.29 ","$1,453.61 ","$1,837.20 ","$1,514.18 "
Carle BroMenn Medical Center,8979177,18FR BILIARY CATHETER (BCL),,C1729,272,"$2,018.90 ","$2,018.90 ",$605.67 ,"$1,837.20 ","$1,413.23 ",$605.67 ,"$1,312.29 ","$1,453.61 ","$1,837.20 ","$1,514.18 "
Carle BroMenn Medical Center,8979178,18X145 TDOC GUIDEWIRE,,C1729,272,"$2,018.90 ","$2,018.90 ",$605.67 ,"$1,837.20 ","$1,413.23 ",$605.67 ,"$1,312.29 ","$1,453.61 ","$1,837.20 ","$1,514.18 "
Carle BroMenn Medical Center,8979179,10.2FR BILIARY CATHETER (BCL),,C1729,272,"$2,018.90 ","$2,018.90 ",$605.67 ,"$1,837.20 ","$1,413.23 ",$605.67 ,"$1,312.29 ","$1,453.61 ","$1,837.20 ","$1,514.18 "
Carle BroMenn Medical Center,8979180,12FR BILIARY CATHETER (BCL),,C1729,272,"$2,018.90 ","$2,018.90 ",$605.67 ,"$1,837.20 ","$1,413.23 ",$605.67 ,"$1,312.29 ","$1,453.61 ","$1,837.20 ","$1,514.18 "
Carle BroMenn Medical Center,8979181,8.5FR CLB-RH BILIARY CATH,,C1729,272,"$2,018.90 ","$2,018.90 ",$605.67 ,"$1,837.20 ","$1,413.23 ",$605.67 ,"$1,312.29 ","$1,453.61 ","$1,837.20 ","$1,514.18 "
Carle BroMenn Medical Center,8979182,10.2FR CLB-RH BILIARY CATH,,C1729,272,"$2,018.90 ","$2,018.90 ",$605.67 ,"$1,837.20 ","$1,413.23 ",$605.67 ,"$1,312.29 ","$1,453.61 ","$1,837.20 ","$1,514.18 "
Carle BroMenn Medical Center,8979207,CATHETER -INFUSION,,C1751,272,$318.00 ,$318.00 ,$95.40 ,$289.38 ,$222.60 ,$95.40 ,$206.70 ,$228.96 ,$289.38 ,$238.50 
Carle BroMenn Medical Center,8979208,CATHETER -INFUSION,,C1751,272,$318.00 ,$318.00 ,$95.40 ,$289.38 ,$222.60 ,$95.40 ,$206.70 ,$228.96 ,$289.38 ,$238.50 
Carle BroMenn Medical Center,8979209,5F DUAL LUMEN PICC LINE,,C1751,272,$318.00 ,$318.00 ,$95.40 ,$289.38 ,$222.60 ,$95.40 ,$206.70 ,$228.96 ,$289.38 ,$238.50 
Carle BroMenn Medical Center,8979210,4FR SINGLE LUMEN PICC KIT,,C1751,272,$318.00 ,$318.00 ,$95.40 ,$289.38 ,$222.60 ,$95.40 ,$206.70 ,$228.96 ,$289.38 ,$238.50 
Carle BroMenn Medical Center,8979211,4FR PICC LINE KIT,,C1751,272,$318.00 ,$318.00 ,$95.40 ,$289.38 ,$222.60 ,$95.40 ,$206.70 ,$228.96 ,$289.38 ,$238.50 
Carle BroMenn Medical Center,8979212,5FR PICC LINE KIT,,C1751,272,$318.00 ,$318.00 ,$95.40 ,$289.38 ,$222.60 ,$95.40 ,$206.70 ,$228.96 ,$289.38 ,$238.50 
Carle BroMenn Medical Center,8979213,CATHETER -INFUSION,,C1751,272,$318.00 ,$318.00 ,$95.40 ,$289.38 ,$222.60 ,$95.40 ,$206.70 ,$228.96 ,$289.38 ,$238.50 
Carle BroMenn Medical Center,8979214,CATHETER -HEMODIALYSIS/PERITON,,C1752,272,$585.00 ,$585.00 ,$175.50 ,$532.35 ,$409.50 ,$175.50 ,$380.25 ,$421.20 ,$532.35 ,$438.75 
Carle BroMenn Medical Center,8979228,CLOSURE DEVICE -VASCULAR,,C1760,272,$248.00 ,$248.00 ,$74.40 ,$225.68 ,$173.60 ,$74.40 ,$161.20 ,$178.56 ,$225.68 ,$186.00 
Carle BroMenn Medical Center,8979229,CLOSURE DEVICE -VASCULAR,,C1760,272,$248.00 ,$248.00 ,$74.40 ,$225.68 ,$173.60 ,$74.40 ,$161.20 ,$178.56 ,$225.68 ,$186.00 
Carle BroMenn Medical Center,8979230,CLOSURE DEVICE -VASCULAR,,C1760,272,$248.00 ,$248.00 ,$74.40 ,$225.68 ,$173.60 ,$74.40 ,$161.20 ,$178.56 ,$225.68 ,$186.00 
Carle BroMenn Medical Center,8979231,CLOSURE DEVICE -VASCULAR,,C1760,272,$248.00 ,$248.00 ,$74.40 ,$225.68 ,$173.60 ,$74.40 ,$161.20 ,$178.56 ,$225.68 ,$186.00 
Carle BroMenn Medical Center,8979232,6FR ANGIOSEAL,,C1760,272,$248.00 ,$248.00 ,$74.40 ,$225.68 ,$173.60 ,$74.40 ,$161.20 ,$178.56 ,$225.68 ,$186.00 
Carle BroMenn Medical Center,8979233,8FR ANGIOSEAL,,C1760,272,$248.00 ,$248.00 ,$74.40 ,$225.68 ,$173.60 ,$74.40 ,$161.20 ,$178.56 ,$225.68 ,$186.00 
Carle BroMenn Medical Center,8979234,CLOSURE DEVICE -VASCULAR,,C1760,272,$248.00 ,$248.00 ,$74.40 ,$225.68 ,$173.60 ,$74.40 ,$161.20 ,$178.56 ,$225.68 ,$186.00 
Carle BroMenn Medical Center,8979242,GUIDE WIRE,,C1769,272,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8979243,"GUIDE WIRE,PERC TRANSLUMINAL",,C1769,272,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8979244,"GUIDE WIRE,IRONMAN,BMW,ALLSTAR",,C1769,272,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8979245,"GUIDE WIRE,CHOICE,LUGE,PATRIOT",,C1769,272,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8979246,GUIDE WIRE,,C1769,272,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8979247,GUIDE WIRE,,C1769,272,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8979248,GUIDE WIRE,,C1769,272,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8979249,GUIDE WIRE,,C1769,272,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8979250,GUIDE WIRE,,C1769,272,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8979251,18-60 COPE MANDRIL,,C1769,272,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8979252,GUIDEWIRE TDOC 35-145,,C1769,272,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8979253,.035-150CM 3CM ANGLD GLIDEWIRE,,C1769,272,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8979254,018-150 ANGLED GUIDEWIRE,,C1769,272,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8979255,AMPLATZ .035-260CM 6CM WIRE,,C1769,272,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8979256,.035-150-3CM ST GLUIDEWIRE,,C1769,272,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8979257,154CM OCCLUDING WIRE,,C1769,272,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8979258,DASHER 14 STEERABLE GUIDEWIRE,,C1769,272,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8979259,.014 300CM SHAPEABLE TIP,,C1769,272,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8979260,TAPER-16 GUIDEWIRE,,C1769,272,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8979261,0.25 X 150 ANGLED GUIDEWIRE,,C1769,272,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8979262,.035X150CM 3CM SS GUIDEWIRE,,C1769,272,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8979263,.035X260CM 3CM ANGLD GDWIRE,,C1769,272,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8979264,.035X150CM 8CM ANGLD GDWIRE,,C1769,272,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8979265,.035X145CM 6CM ANGLD GDWIRE,,C1769,272,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8979266,.035X145CM 3.5CM AMPLATZ WIRE,,C1769,272,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8979267,.025X260 ST GUIDEWIRE,,C1769,272,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8979268,.018-200CM V-18 CONTROL WIRE,,C1769,272,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8979269,SEEKER 16 GUIDEWIRE,,C1769,272,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8979270,21-1458 TSCF GUIDEWIRE,,C1769,272,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8979271,35-145-15 TSCF GUIDEWIRE,,C1769,272,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8979272,35-145 TSCM GUIDEWIRE,,C1769,272,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8979273,35-145 TSFB GUIDEWIRE,,C1769,272,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8979274,35-260 TSFB GUIDEWIRE,,C1769,272,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8979275,THSCF-35 ROSEN GUIDEWIRE,,C1769,272,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8979276,35-145-THG HSF RING TORQUE,,C1769,272,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8979277,35-260 TDOC GUIDEWIRE,,C1769,272,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8979278,.018-180X5CM TAPER-4CM TP WIRE,,C1769,272,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8979279,.032 X 150CM GUIDEWIRE,,C1769,272,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8979280,.014 182CM CHOICE FL GUIDEWIRE,,C1769,272,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8979281,GUIDE WIRE,,C1769,272,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8979286,RETRIEVAL DEVICE,,C1773,272,$233.00 ,$233.00 ,$69.90 ,$212.03 ,$163.10 ,$69.90 ,$151.45 ,$167.76 ,$212.03 ,$174.75 
Carle BroMenn Medical Center,8979287,RETRIEVAL DEVICE,,C1773,272,$233.00 ,$233.00 ,$69.90 ,$212.03 ,$163.10 ,$69.90 ,$151.45 ,$167.76 ,$212.03 ,$174.75 
Carle BroMenn Medical Center,8979288,RETRIEVAL DEVICE,,C1773,272,$233.00 ,$233.00 ,$69.90 ,$212.03 ,$163.10 ,$69.90 ,$151.45 ,$167.76 ,$212.03 ,$174.75 
Carle BroMenn Medical Center,8979289,RETRIEVAL DEVICE,,C1773,272,$233.00 ,$233.00 ,$69.90 ,$212.03 ,$163.10 ,$69.90 ,$151.45 ,$167.76 ,$212.03 ,$174.75 
Carle BroMenn Medical Center,8979290,RETRIEVAL DEVICE,,C1773,272,$233.00 ,$233.00 ,$69.90 ,$212.03 ,$163.10 ,$69.90 ,$151.45 ,$167.76 ,$212.03 ,$174.75 
Carle BroMenn Medical Center,8979291,RETRIEVAL DEVICE,,C1773,272,$233.00 ,$233.00 ,$69.90 ,$212.03 ,$163.10 ,$69.90 ,$151.45 ,$167.76 ,$212.03 ,$174.75 
Carle BroMenn Medical Center,8979455,CATH SOFT-VU SOS OMNI1 5F 80CM 2S,238268,C1887,272,$50.10 ,$50.10 ,$15.03 ,$45.59 ,$35.07 ,$15.03 ,$32.57 ,$36.07 ,$45.59 ,$37.58 
Carle BroMenn Medical Center,8979455,CATHETER HEADWAY 17 STR 150CM,232625,C1887,272,"$2,106.00 ","$2,106.00 ",$631.80 ,"$1,916.46 ","$1,474.20 ",$631.80 ,"$1,368.90 ","$1,516.32 ","$1,916.46 ","$1,579.50 "
Carle BroMenn Medical Center,8979455,MICROCATHETER HDWY 21 STR 156,225612,C1887,272,"$2,808.00 ","$2,808.00 ",$842.40 ,"$2,555.28 ","$1,965.60 ",$842.40 ,"$1,825.20 ","$2,021.76 ","$2,555.28 ","$2,106.00 "
Carle BroMenn Medical Center,8979455,MICROCATHETER HDWY17 45DEG 150,225611,C1887,272,"$2,268.00 ","$2,268.00 ",$680.40 ,"$2,063.88 ","$1,587.60 ",$680.40 ,"$1,474.20 ","$1,632.96 ","$2,063.88 ","$1,701.00 "
Carle BroMenn Medical Center,8979455,SHEATH BRITE TIP 9F 11CM,237068,C1887,272,$39.00 ,$39.00 ,$11.70 ,$35.49 ,$27.30 ,$11.70 ,$25.35 ,$28.08 ,$35.49 ,$29.25 
Carle BroMenn Medical Center,8979497,SHEATH PRELUDE SNAP 6FX13CM GREEN,240959,C1894,272,$103.50 ,$103.50 ,$31.05 ,$94.19 ,$72.45 ,$31.05 ,$67.28 ,$74.52 ,$94.19 ,$77.63 
Carle BroMenn Medical Center,8979497,SHEATH PRELUDE SNAP 8FRX13CM BLUE,240961,C1894,272,$103.50 ,$103.50 ,$31.05 ,$94.19 ,$72.45 ,$31.05 ,$67.28 ,$74.52 ,$94.19 ,$77.63 
Carle BroMenn Medical Center,8979532,LIVER ACCESS & BIOPSY SET,,,272,"$1,358.00 ","$1,358.00 ",$407.40 ,"$1,235.78 ",$950.60 ,$407.40 ,$882.70 ,$977.76 ,"$1,235.78 ","$1,018.50 "
Carle BroMenn Medical Center,8980272,"water for injection, sterile injection solution",409488710,,272,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980272,"water for injection, sterile injection solution",409488717,,272,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980272,"water for injection, sterile injection solution",409488750,,272,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980272,"water for injection, sterile injection solution",517300525,,272,$84.18 ,$84.18 ,$25.25 ,$76.60 ,$58.93 ,$25.25 ,$54.72 ,$60.61 ,$76.60 ,$63.14 
Carle BroMenn Medical Center,8980272,"water for injection, sterile injection solution",63323018510,,272,$52.17 ,$52.17 ,$15.65 ,$47.47 ,$36.52 ,$15.65 ,$33.91 ,$37.56 ,$47.47 ,$39.13 
Carle BroMenn Medical Center,8670007,"BANDAGE 2"" EA.",,,273,$4.00 ,$4.00 ,$1.20 ,$3.64 ,$2.80 ,$1.20 ,$2.60 ,$2.88 ,$3.64 ,$3.00 
Carle BroMenn Medical Center,8670008,"BANDAGE 3"" EA.",,,273,$5.00 ,$5.00 ,$1.50 ,$4.55 ,$3.50 ,$1.50 ,$3.25 ,$3.60 ,$4.55 ,$3.75 
Carle BroMenn Medical Center,8670009,"BANDAGE 4"" EA.",,,273,$7.00 ,$7.00 ,$2.10 ,$6.37 ,$4.90 ,$2.10 ,$4.55 ,$5.04 ,$6.37 ,$5.25 
Carle BroMenn Medical Center,8670010,"BANDAGE 6"" EA.",,,273,$9.00 ,$9.00 ,$2.70 ,$8.19 ,$6.30 ,$2.70 ,$5.85 ,$6.48 ,$8.19 ,$6.75 
Carle BroMenn Medical Center,8670024,BANDAGE 10 CM. EA.,,,273,$5.00 ,$5.00 ,$1.50 ,$4.55 ,$3.50 ,$1.50 ,$3.25 ,$3.60 ,$4.55 ,$3.75 
Carle BroMenn Medical Center,8670025,BANDAGE 15 CM. EA.,,,273,$6.00 ,$6.00 ,$1.80 ,$5.46 ,$4.20 ,$1.80 ,$3.90 ,$4.32 ,$5.46 ,$4.50 
Carle BroMenn Medical Center,8670029,WALKING BOOT EA.,,,273,$173.00 ,$173.00 ,$51.90 ,$157.43 ,$121.10 ,$51.90 ,$112.45 ,$124.56 ,$157.43 ,$129.75 
Carle BroMenn Medical Center,8670033,CANE BRONZE W/ORTHO GRIP,,,273,$23.00 ,$23.00 ,$6.90 ,$20.93 ,$16.10 ,$6.90 ,$14.95 ,$16.56 ,$20.93 ,$17.25 
Carle BroMenn Medical Center,8670034,CANE QUAD SMALL/LARGE BASE,,,273,$46.00 ,$46.00 ,$13.80 ,$41.86 ,$32.20 ,$13.80 ,$29.90 ,$33.12 ,$41.86 ,$34.50 
Carle BroMenn Medical Center,8670035,CANE STANDARD,,,273,$25.00 ,$25.00 ,$7.50 ,$22.75 ,$17.50 ,$7.50 ,$16.25 ,$18.00 ,$22.75 ,$18.75 
Carle BroMenn Medical Center,8670036,CERVICAL ROLL,,,273,$30.00 ,$30.00 ,$9.00 ,$27.30 ,$21.00 ,$9.00 ,$19.50 ,$21.60 ,$27.30 ,$22.50 
Carle BroMenn Medical Center,8670037,CERVICAL ROLL REGULAR,,,273,$23.00 ,$23.00 ,$6.90 ,$20.93 ,$16.10 ,$6.90 ,$14.95 ,$16.56 ,$20.93 ,$17.25 
Carle BroMenn Medical Center,8670038,CERVICAL TRACTION KIT,,,273,$21.00 ,$21.00 ,$6.30 ,$19.11 ,$14.70 ,$6.30 ,$13.65 ,$15.12 ,$19.11 ,$15.75 
Carle BroMenn Medical Center,8670041,"BANDAGE 1"" PER ROLL",,,273,$2.00 ,$2.00 ,$0.60 ,$1.82 ,$1.40 ,$0.60 ,$1.30 ,$1.44 ,$1.82 ,$1.50 
Carle BroMenn Medical Center,8670042,"BANDAGE 2"" PER ROLL",,,273,$6.00 ,$6.00 ,$1.80 ,$5.46 ,$4.20 ,$1.80 ,$3.90 ,$4.32 ,$5.46 ,$4.50 
Carle BroMenn Medical Center,8670043,"COVER ROLL 2"" BX",,,273,$11.00 ,$11.00 ,$3.30 ,$10.01 ,$7.70 ,$3.30 ,$7.15 ,$7.92 ,$10.01 ,$8.25 
Carle BroMenn Medical Center,8670046,CPM SLINGSET EA,,,273,$69.00 ,$69.00 ,$20.70 ,$62.79 ,$48.30 ,$20.70 ,$44.85 ,$49.68 ,$62.79 ,$51.75 
Carle BroMenn Medical Center,8670047,CRUTCHES PR,,,273,$52.00 ,$52.00 ,$15.60 ,$47.32 ,$36.40 ,$15.60 ,$33.80 ,$37.44 ,$47.32 ,$39.00 
Carle BroMenn Medical Center,8670064,EARHOOKS - 6/PK,,,273,$65.00 ,$65.00 ,$19.50 ,$59.15 ,$45.50 ,$19.50 ,$42.25 ,$46.80 ,$59.15 ,$48.75 
Carle BroMenn Medical Center,8670066,ELECTRODES  FOR E-STIM EA,,,273,$14.00 ,$14.00 ,$4.20 ,$12.74 ,$9.80 ,$4.20 ,$9.10 ,$10.08 ,$12.74 ,$10.50 
Carle BroMenn Medical Center,8670067,ELECTRODE-STIM OVAL 2X4 EA,,,273,$14.00 ,$14.00 ,$4.20 ,$12.74 ,$9.80 ,$4.20 ,$9.10 ,$10.08 ,$12.74 ,$10.50 
Carle BroMenn Medical Center,8670069,EXTNSR PATELLAR STAB KNEE WRAP,,,273,$39.00 ,$39.00 ,$11.70 ,$35.49 ,$27.30 ,$11.70 ,$25.35 ,$28.08 ,$35.49 ,$29.25 
Carle BroMenn Medical Center,8670072,FIBROMYALGIA BOOK,,,273,$6.00 ,$6.00 ,$1.80 ,$5.46 ,$4.20 ,$1.80 ,$3.90 ,$4.32 ,$5.46 ,$4.50 
Carle BroMenn Medical Center,8670079,GAIT BELT 48 INCH,,,273,$8.00 ,$8.00 ,$2.40 ,$7.28 ,$5.60 ,$2.40 ,$5.20 ,$5.76 ,$7.28 ,$6.00 
Carle BroMenn Medical Center,8670080,GAIT BELT 60 INCH,,,273,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8670081,GAIT BELT 72 INCH,,,273,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8670082,ELBOW BRACE,,,273,$11.00 ,$11.00 ,$3.30 ,$10.01 ,$7.70 ,$3.30 ,$7.15 ,$7.92 ,$10.01 ,$8.25 
Carle BroMenn Medical Center,8670083,GLOVE EDEMA EA,,,273,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8670084,GLOVE GEL EA,,,273,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8670085,GLOVE EA,,,273,$26.00 ,$26.00 ,$7.80 ,$23.66 ,$18.20 ,$7.80 ,$16.90 ,$18.72 ,$23.66 ,$19.50 
Carle BroMenn Medical Center,8670087,"GREY  FOAM 1/2"" SHEET PER SHEET",,,273,$8.00 ,$8.00 ,$2.40 ,$7.28 ,$5.60 ,$2.40 ,$5.20 ,$5.76 ,$7.28 ,$6.00 
Carle BroMenn Medical Center,8670088,"GREY FOAM 1/4"" SHEET PER SHEET",,,273,$6.00 ,$6.00 ,$1.80 ,$5.46 ,$4.20 ,$1.80 ,$3.90 ,$4.32 ,$5.46 ,$4.50 
Carle BroMenn Medical Center,8670089,HALF LUMBAR ROLL,,,273,$17.00 ,$17.00 ,$5.10 ,$15.47 ,$11.90 ,$5.10 ,$11.05 ,$12.24 ,$15.47 ,$12.75 
Carle BroMenn Medical Center,8670092,HAND EXERCISER EA,,,273,$16.00 ,$16.00 ,$4.80 ,$14.56 ,$11.20 ,$4.80 ,$10.40 ,$11.52 ,$14.56 ,$12.00 
Carle BroMenn Medical Center,8670100,HEMI ARM SLING,,,273,$77.00 ,$77.00 ,$23.10 ,$70.07 ,$53.90 ,$23.10 ,$50.05 ,$55.44 ,$70.07 ,$57.75 
Carle BroMenn Medical Center,8670101,HOME PULLEY MET EA,,,273,$45.00 ,$45.00 ,$13.50 ,$40.95 ,$31.50 ,$13.50 ,$29.25 ,$32.40 ,$40.95 ,$33.75 
Carle BroMenn Medical Center,8670102,HOME PULLEY EACH,,,273,$24.00 ,$24.00 ,$7.20 ,$21.84 ,$16.80 ,$7.20 ,$15.60 ,$17.28 ,$21.84 ,$18.00 
Carle BroMenn Medical Center,8670108,ADHESIVE LOTION,,,273,$14.00 ,$14.00 ,$4.20 ,$12.74 ,$9.80 ,$4.20 ,$9.10 ,$10.08 ,$12.74 ,$10.50 
Carle BroMenn Medical Center,8670109,BANDAGE 10M PER YD.,,,273,$2.00 ,$2.00 ,$0.60 ,$1.82 ,$1.40 ,$0.60 ,$1.30 ,$1.44 ,$1.82 ,$1.50 
Carle BroMenn Medical Center,8670110,KIDNEY LARGE EA,,,273,$5.00 ,$5.00 ,$1.50 ,$4.55 ,$3.50 ,$1.50 ,$3.25 ,$3.60 ,$4.55 ,$3.75 
Carle BroMenn Medical Center,8670111,KIDNEY SMALL EA,,,273,$3.00 ,$3.00 ,$0.90 ,$2.73 ,$2.10 ,$0.90 ,$1.95 ,$2.16 ,$2.73 ,$2.25 
Carle BroMenn Medical Center,8670112,KNEE BRACE LG PULLOVER,,,273,$29.00 ,$29.00 ,$8.70 ,$26.39 ,$20.30 ,$8.70 ,$18.85 ,$20.88 ,$26.39 ,$21.75 
Carle BroMenn Medical Center,8670113,KT MEDICAL GLOVE,,,273,$32.00 ,$32.00 ,$9.60 ,$29.12 ,$22.40 ,$9.60 ,$20.80 ,$23.04 ,$29.12 ,$24.00 
Carle BroMenn Medical Center,8670114,LUMBAR ROLL,,,273,$23.00 ,$23.00 ,$6.90 ,$20.93 ,$16.10 ,$6.90 ,$14.95 ,$16.56 ,$20.93 ,$17.25 
Carle BroMenn Medical Center,8670115,LUMBAR SACRAL SADDLE,,,273,$33.00 ,$33.00 ,$9.90 ,$30.03 ,$23.10 ,$9.90 ,$21.45 ,$23.76 ,$30.03 ,$24.75 
Carle BroMenn Medical Center,8670116,"LUMBAR SUPPORT 28-37""",,,273,$41.00 ,$41.00 ,$12.30 ,$37.31 ,$28.70 ,$12.30 ,$26.65 ,$29.52 ,$37.31 ,$30.75 
Carle BroMenn Medical Center,8670118,MANAGING BACK PAIN,,,273,$6.00 ,$6.00 ,$1.80 ,$5.46 ,$4.20 ,$1.80 ,$3.90 ,$4.32 ,$5.46 ,$4.50 
Carle BroMenn Medical Center,8670120,BANDAGE 4CM ROLL,,,273,$2.00 ,$2.00 ,$0.60 ,$1.82 ,$1.40 ,$0.60 ,$1.30 ,$1.44 ,$1.82 ,$1.50 
Carle BroMenn Medical Center,8670121,BANDAGE 6CM ROLL,,,273,$2.00 ,$2.00 ,$0.60 ,$1.82 ,$1.40 ,$0.60 ,$1.30 ,$1.44 ,$1.82 ,$1.50 
Carle BroMenn Medical Center,8670126,NECK EXERCISER STP,,,273,$22.00 ,$22.00 ,$6.60 ,$20.02 ,$15.40 ,$6.60 ,$14.30 ,$15.84 ,$20.02 ,$16.50 
Carle BroMenn Medical Center,8670127,NEONATAL KIT,,,273,$134.00 ,$134.00 ,$40.20 ,$121.94 ,$93.80 ,$40.20 ,$87.10 ,$96.48 ,$121.94 ,$100.50 
Carle BroMenn Medical Center,8670134,PLATFORM  CRX. ATTACHMENT EA,,,273,$74.00 ,$74.00 ,$22.20 ,$67.34 ,$51.80 ,$22.20 ,$48.10 ,$53.28 ,$67.34 ,$55.50 
Carle BroMenn Medical Center,8670138,BANDAGE SYSTEM BX,,,273,$36.00 ,$36.00 ,$10.80 ,$32.76 ,$25.20 ,$10.80 ,$23.40 ,$25.92 ,$32.76 ,$27.00 
Carle BroMenn Medical Center,8670145,BANDAGE 10CM EA,,,273,$13.00 ,$13.00 ,$3.90 ,$11.83 ,$9.10 ,$3.90 ,$8.45 ,$9.36 ,$11.83 ,$9.75 
Carle BroMenn Medical Center,8670146,BANDAGE 12CM EA,,,273,$20.00 ,$20.00 ,$6.00 ,$18.20 ,$14.00 ,$6.00 ,$13.00 ,$14.40 ,$18.20 ,$15.00 
Carle BroMenn Medical Center,8670147,BANDAGE 6CM EA,,,273,$9.00 ,$9.00 ,$2.70 ,$8.19 ,$6.30 ,$2.70 ,$5.85 ,$6.48 ,$8.19 ,$6.75 
Carle BroMenn Medical Center,8670148,BANDAGE 8CM EA,,,273,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8670149,BANDAGE SOFT 10CM/BOX,,,273,$13.00 ,$13.00 ,$3.90 ,$11.83 ,$9.10 ,$3.90 ,$8.45 ,$9.36 ,$11.83 ,$9.75 
Carle BroMenn Medical Center,8670150,BANDAGE SOFT 15CM/BOX,,,273,$20.00 ,$20.00 ,$6.00 ,$18.20 ,$14.00 ,$6.00 ,$13.00 ,$14.40 ,$18.20 ,$15.00 
Carle BroMenn Medical Center,8670151,SACRAL SADDLE,,,273,$33.00 ,$33.00 ,$9.90 ,$30.03 ,$23.10 ,$9.90 ,$21.45 ,$23.76 ,$30.03 ,$24.75 
Carle BroMenn Medical Center,8670152,SCAR PATCH-LARGE,,,273,$16.00 ,$16.00 ,$4.80 ,$14.56 ,$11.20 ,$4.80 ,$10.40 ,$11.52 ,$14.56 ,$12.00 
Carle BroMenn Medical Center,8670153,SCAR PATCH-MEDIUM,,,273,$12.00 ,$12.00 ,$3.60 ,$10.92 ,$8.40 ,$3.60 ,$7.80 ,$8.64 ,$10.92 ,$9.00 
Carle BroMenn Medical Center,8670154,SCAR PATCH-SMALL,,,273,$8.00 ,$8.00 ,$2.40 ,$7.28 ,$5.60 ,$2.40 ,$5.20 ,$5.76 ,$7.28 ,$6.00 
Carle BroMenn Medical Center,8670155,"CASTING TAPE 2""",,,273,$5.00 ,$5.00 ,$1.50 ,$4.55 ,$3.50 ,$1.50 ,$3.25 ,$3.60 ,$4.55 ,$3.75 
Carle BroMenn Medical Center,8670156,"CASTING TAPE 3""",,,273,$6.00 ,$6.00 ,$1.80 ,$5.46 ,$4.20 ,$1.80 ,$3.90 ,$4.32 ,$5.46 ,$4.50 
Carle BroMenn Medical Center,8670157,"CASTING TAPE 4""",,,273,$8.00 ,$8.00 ,$2.40 ,$7.28 ,$5.60 ,$2.40 ,$5.20 ,$5.76 ,$7.28 ,$6.00 
Carle BroMenn Medical Center,8670158,"CASTING TAPE 5""",,,273,$8.00 ,$8.00 ,$2.40 ,$7.28 ,$5.60 ,$2.40 ,$5.20 ,$5.76 ,$7.28 ,$6.00 
Carle BroMenn Medical Center,8670159,SEX AND BACK PAIN BOOK,,,273,$6.00 ,$6.00 ,$1.80 ,$5.46 ,$4.20 ,$1.80 ,$3.90 ,$4.32 ,$5.46 ,$4.50 
Carle BroMenn Medical Center,8670164,SLING ARM COMFORT,,,273,$8.00 ,$8.00 ,$2.40 ,$7.28 ,$5.60 ,$2.40 ,$5.20 ,$5.76 ,$7.28 ,$6.00 
Carle BroMenn Medical Center,8670165,LUMBAR SUPPORT BRACE,,,273,$56.00 ,$56.00 ,$16.80 ,$50.96 ,$39.20 ,$16.80 ,$36.40 ,$40.32 ,$50.96 ,$42.00 
Carle BroMenn Medical Center,8670174,BANDAGE 6/20M YD,,,273,$3.00 ,$3.00 ,$0.90 ,$2.73 ,$2.10 ,$0.90 ,$1.95 ,$2.16 ,$2.73 ,$2.25 
Carle BroMenn Medical Center,8670175,BANDAGE 7/20M YD,,,273,$3.00 ,$3.00 ,$0.90 ,$2.73 ,$2.10 ,$0.90 ,$1.95 ,$2.16 ,$2.73 ,$2.25 
Carle BroMenn Medical Center,8670176,BANDAGE 9/20M YD,,,273,$3.00 ,$3.00 ,$0.90 ,$2.73 ,$2.10 ,$0.90 ,$1.95 ,$2.16 ,$2.73 ,$2.25 
Carle BroMenn Medical Center,8670177,GAUZE 2IN. ROLL,,,273,$3.00 ,$3.00 ,$0.90 ,$2.73 ,$2.10 ,$0.90 ,$1.95 ,$2.16 ,$2.73 ,$2.25 
Carle BroMenn Medical Center,8670182,WALKER ADULT FOLDING,,,273,$96.00 ,$96.00 ,$28.80 ,$87.36 ,$67.20 ,$28.80 ,$62.40 ,$69.12 ,$87.36 ,$72.00 
Carle BroMenn Medical Center,8670183,WALKER WHEELS 5 INCHES PER PAI,,,273,$48.00 ,$48.00 ,$14.40 ,$43.68 ,$33.60 ,$14.40 ,$31.20 ,$34.56 ,$43.68 ,$36.00 
Carle BroMenn Medical Center,8670184,WORK BOOK WITHOUT TEARS,,,273,$8.00 ,$8.00 ,$2.40 ,$7.28 ,$5.60 ,$2.40 ,$5.20 ,$5.76 ,$7.28 ,$6.00 
Carle BroMenn Medical Center,8670185,ANCHOR BELT,,,273,$41.00 ,$41.00 ,$12.30 ,$37.31 ,$28.70 ,$12.30 ,$26.65 ,$29.52 ,$37.31 ,$30.75 
Carle BroMenn Medical Center,8670187,COMPRESSION BANDAGE,,,273,$29.00 ,$29.00 ,$8.70 ,$26.39 ,$20.30 ,$8.70 ,$18.85 ,$20.88 ,$26.39 ,$21.75 
Carle BroMenn Medical Center,8670188,COMPRESSION BANDAGE,,,273,$27.00 ,$27.00 ,$8.10 ,$24.57 ,$18.90 ,$8.10 ,$17.55 ,$19.44 ,$24.57 ,$20.25 
Carle BroMenn Medical Center,8670189,BANDAGE 12CM X 10M,,,273,$22.00 ,$22.00 ,$6.60 ,$20.02 ,$15.40 ,$6.60 ,$14.30 ,$15.84 ,$20.02 ,$16.50 
Carle BroMenn Medical Center,8670190,BANDAGE 10CM X 10M,,,273,$20.00 ,$20.00 ,$6.00 ,$18.20 ,$14.00 ,$6.00 ,$13.00 ,$14.40 ,$18.20 ,$15.00 
Carle BroMenn Medical Center,8670202,TAKE HOME SUPPLIES - HIGH TAX,,,273,$233.00 ,$233.00 ,$69.90 ,$212.03 ,$163.10 ,$69.90 ,$151.45 ,$167.76 ,$212.03 ,$174.75 
Carle BroMenn Medical Center,8730065,WALKER WHEELS 5 INCHES PER PAI,,,273,$53.00 ,$53.00 ,$15.90 ,$48.23 ,$37.10 ,$15.90 ,$34.45 ,$38.16 ,$48.23 ,$39.75 
Carle BroMenn Medical Center,8730066,"BANDAGE 2"" EA.",,,273,$5.00 ,$5.00 ,$1.50 ,$4.55 ,$3.50 ,$1.50 ,$3.25 ,$3.60 ,$4.55 ,$3.75 
Carle BroMenn Medical Center,8730067,"BANDAGE 3"" EA.",,,273,$7.00 ,$7.00 ,$2.10 ,$6.37 ,$4.90 ,$2.10 ,$4.55 ,$5.04 ,$6.37 ,$5.25 
Carle BroMenn Medical Center,8730068,"BANDAGE 4"" EA.",,,273,$8.00 ,$8.00 ,$2.40 ,$7.28 ,$5.60 ,$2.40 ,$5.20 ,$5.76 ,$7.28 ,$6.00 
Carle BroMenn Medical Center,8730069,"BANDAGE 6"" EA.",,,273,$11.00 ,$11.00 ,$3.30 ,$10.01 ,$7.70 ,$3.30 ,$7.15 ,$7.92 ,$10.01 ,$8.25 
Carle BroMenn Medical Center,8730070,BANDAGE 10 CM. EA.,,,273,$6.00 ,$6.00 ,$1.80 ,$5.46 ,$4.20 ,$1.80 ,$3.90 ,$4.32 ,$5.46 ,$4.50 
Carle BroMenn Medical Center,8730071,BANDAGE 15 CM. EA.,,,273,$8.00 ,$8.00 ,$2.40 ,$7.28 ,$5.60 ,$2.40 ,$5.20 ,$5.76 ,$7.28 ,$6.00 
Carle BroMenn Medical Center,8730072,WALKING BOOT EA.,,,273,$191.00 ,$191.00 ,$57.30 ,$173.81 ,$133.70 ,$57.30 ,$124.15 ,$137.52 ,$173.81 ,$143.25 
Carle BroMenn Medical Center,8730073,CANE BRONZE W/ORTHO GRIP EA.,,,273,$26.00 ,$26.00 ,$7.80 ,$23.66 ,$18.20 ,$7.80 ,$16.90 ,$18.72 ,$23.66 ,$19.50 
Carle BroMenn Medical Center,8730074,CANE QUAD SMALL/LARGE BASE,,,273,$50.00 ,$50.00 ,$15.00 ,$45.50 ,$35.00 ,$15.00 ,$32.50 ,$36.00 ,$45.50 ,$37.50 
Carle BroMenn Medical Center,8730075,CANE STANDARD,,,273,$28.00 ,$28.00 ,$8.40 ,$25.48 ,$19.60 ,$8.40 ,$18.20 ,$20.16 ,$25.48 ,$21.00 
Carle BroMenn Medical Center,8730076,CERVICAL ROLL,,,273,$33.00 ,$33.00 ,$9.90 ,$30.03 ,$23.10 ,$9.90 ,$21.45 ,$23.76 ,$30.03 ,$24.75 
Carle BroMenn Medical Center,8730077,CERVICAL ROLL REGULAR,,,273,$26.00 ,$26.00 ,$7.80 ,$23.66 ,$18.20 ,$7.80 ,$16.90 ,$18.72 ,$23.66 ,$19.50 
Carle BroMenn Medical Center,8730078,CERVICAL TRACTION KIT,,,273,$23.00 ,$23.00 ,$6.90 ,$20.93 ,$16.10 ,$6.90 ,$14.95 ,$16.56 ,$20.93 ,$17.25 
Carle BroMenn Medical Center,8730079,"BANDAGE 1"" PER ROLL",,,273,$4.00 ,$4.00 ,$1.20 ,$3.64 ,$2.80 ,$1.20 ,$2.60 ,$2.88 ,$3.64 ,$3.00 
Carle BroMenn Medical Center,8730080,"BANDAGE 2"" PER ROLL",,,273,$8.00 ,$8.00 ,$2.40 ,$7.28 ,$5.60 ,$2.40 ,$5.20 ,$5.76 ,$7.28 ,$6.00 
Carle BroMenn Medical Center,8730081,"COVER ROLL 2"" BX",,,273,$13.00 ,$13.00 ,$3.90 ,$11.83 ,$9.10 ,$3.90 ,$8.45 ,$9.36 ,$11.83 ,$9.75 
Carle BroMenn Medical Center,8730082,CPM SLINGSET EA,,,273,$75.00 ,$75.00 ,$22.50 ,$68.25 ,$52.50 ,$22.50 ,$48.75 ,$54.00 ,$68.25 ,$56.25 
Carle BroMenn Medical Center,8730083,CRUTCHES PR,,,273,$57.00 ,$57.00 ,$17.10 ,$51.87 ,$39.90 ,$17.10 ,$37.05 ,$41.04 ,$51.87 ,$42.75 
Carle BroMenn Medical Center,8730084,PLATFORM  CRX. ATTACHMENT EA,,,273,$83.00 ,$83.00 ,$24.90 ,$75.53 ,$58.10 ,$24.90 ,$53.95 ,$59.76 ,$75.53 ,$62.25 
Carle BroMenn Medical Center,8730085,ELECTRODES  FOR E-STIM EA,,,273,$16.00 ,$16.00 ,$4.80 ,$14.56 ,$11.20 ,$4.80 ,$10.40 ,$11.52 ,$14.56 ,$12.00 
Carle BroMenn Medical Center,8730086,ELECTRODE-STIM OVAL 2X4 EA,,,273,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8730087,FIBROMYALGIA BOOK,,,273,$8.00 ,$8.00 ,$2.40 ,$7.28 ,$5.60 ,$2.40 ,$5.20 ,$5.76 ,$7.28 ,$6.00 
Carle BroMenn Medical Center,8730088,GAIT BELT 48 INCH,,,273,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8730089,GAIT BELT 60 INCH,,,273,$11.00 ,$11.00 ,$3.30 ,$10.01 ,$7.70 ,$3.30 ,$7.15 ,$7.92 ,$10.01 ,$8.25 
Carle BroMenn Medical Center,8730090,GAIT BELT 72 INCH,,,273,$11.00 ,$11.00 ,$3.30 ,$10.01 ,$7.70 ,$3.30 ,$7.15 ,$7.92 ,$10.01 ,$8.25 
Carle BroMenn Medical Center,8730091,GLOVE EDEMA EA,,,273,$11.00 ,$11.00 ,$3.30 ,$10.01 ,$7.70 ,$3.30 ,$7.15 ,$7.92 ,$10.01 ,$8.25 
Carle BroMenn Medical Center,8730092,GLOVE GEL EA,,,273,$17.00 ,$17.00 ,$5.10 ,$15.47 ,$11.90 ,$5.10 ,$11.05 ,$12.24 ,$15.47 ,$12.75 
Carle BroMenn Medical Center,8730093,GLOVE EA,,,273,$29.00 ,$29.00 ,$8.70 ,$26.39 ,$20.30 ,$8.70 ,$18.85 ,$20.88 ,$26.39 ,$21.75 
Carle BroMenn Medical Center,8730094,"GREY  FOAM 1/2"" SHEET PER SHEET",,,273,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8730095,"GREY FOAM 1/4"" SHEET PER SHEET",,,273,$8.00 ,$8.00 ,$2.40 ,$7.28 ,$5.60 ,$2.40 ,$5.20 ,$5.76 ,$7.28 ,$6.00 
Carle BroMenn Medical Center,8730096,HAND EXERCISER EA,,,273,$18.00 ,$18.00 ,$5.40 ,$16.38 ,$12.60 ,$5.40 ,$11.70 ,$12.96 ,$16.38 ,$13.50 
Carle BroMenn Medical Center,8730097,HOME PULLEY MET EA,,,273,$49.00 ,$49.00 ,$14.70 ,$44.59 ,$34.30 ,$14.70 ,$31.85 ,$35.28 ,$44.59 ,$36.75 
Carle BroMenn Medical Center,8730098,HOME PULLEY EA,,,273,$27.00 ,$27.00 ,$8.10 ,$24.57 ,$18.90 ,$8.10 ,$17.55 ,$19.44 ,$24.57 ,$20.25 
Carle BroMenn Medical Center,8730099,ADHESIVE LOTION,,,273,$16.00 ,$16.00 ,$4.80 ,$14.56 ,$11.20 ,$4.80 ,$10.40 ,$11.52 ,$14.56 ,$12.00 
Carle BroMenn Medical Center,8730100,BANDAGE 10M PER YD.,,,273,$4.00 ,$4.00 ,$1.20 ,$3.64 ,$2.80 ,$1.20 ,$2.60 ,$2.88 ,$3.64 ,$3.00 
Carle BroMenn Medical Center,8730101,BANDAGE 10M PER YD.,,,273,$7.00 ,$7.00 ,$2.10 ,$6.37 ,$4.90 ,$2.10 ,$4.55 ,$5.04 ,$6.37 ,$5.25 
Carle BroMenn Medical Center,8730102,KIDNEY LARGE EA,,,273,$6.00 ,$6.00 ,$1.80 ,$5.46 ,$4.20 ,$1.80 ,$3.90 ,$4.32 ,$5.46 ,$4.50 
Carle BroMenn Medical Center,8730103,KIDNEY SMALL EA,,,273,$5.00 ,$5.00 ,$1.50 ,$4.55 ,$3.50 ,$1.50 ,$3.25 ,$3.60 ,$4.55 ,$3.75 
Carle BroMenn Medical Center,8730104,KNEE BRACE LG PULLOVER,,,273,$32.00 ,$32.00 ,$9.60 ,$29.12 ,$22.40 ,$9.60 ,$20.80 ,$23.04 ,$29.12 ,$24.00 
Carle BroMenn Medical Center,8730105,LUMBAR ROLL,,,273,$25.00 ,$25.00 ,$7.50 ,$22.75 ,$17.50 ,$7.50 ,$16.25 ,$18.00 ,$22.75 ,$18.75 
Carle BroMenn Medical Center,8730106,LUMBAR SACRAL SADDLE,,,273,$37.00 ,$37.00 ,$11.10 ,$33.67 ,$25.90 ,$11.10 ,$24.05 ,$26.64 ,$33.67 ,$27.75 
Carle BroMenn Medical Center,8730107,"LUMBAR SUPPORT 28-37""",,,273,$44.00 ,$44.00 ,$13.20 ,$40.04 ,$30.80 ,$13.20 ,$28.60 ,$31.68 ,$40.04 ,$33.00 
Carle BroMenn Medical Center,8730108,MANAGING BACK PAIN,,,273,$8.00 ,$8.00 ,$2.40 ,$7.28 ,$5.60 ,$2.40 ,$5.20 ,$5.76 ,$7.28 ,$6.00 
Carle BroMenn Medical Center,8730109,BANDAGE 4CM ROLL,,,273,$3.00 ,$3.00 ,$0.90 ,$2.73 ,$2.10 ,$0.90 ,$1.95 ,$2.16 ,$2.73 ,$2.25 
Carle BroMenn Medical Center,8730110,BANDAGE 6CM ROLL,,,273,$4.00 ,$4.00 ,$1.20 ,$3.64 ,$2.80 ,$1.20 ,$2.60 ,$2.88 ,$3.64 ,$3.00 
Carle BroMenn Medical Center,8730111,NECK EXERCISER STP,,,273,$24.00 ,$24.00 ,$7.20 ,$21.84 ,$16.80 ,$7.20 ,$15.60 ,$17.28 ,$21.84 ,$18.00 
Carle BroMenn Medical Center,8730112,BANDAGE SYSTEM BX,,,273,$40.00 ,$40.00 ,$12.00 ,$36.40 ,$28.00 ,$12.00 ,$26.00 ,$28.80 ,$36.40 ,$30.00 
Carle BroMenn Medical Center,8730113,BANDAGE SOFT 10CM/BOX,,,273,$14.00 ,$14.00 ,$4.20 ,$12.74 ,$9.80 ,$4.20 ,$9.10 ,$10.08 ,$12.74 ,$10.50 
Carle BroMenn Medical Center,8730114,BANDAGE 10CM EA,,,273,$14.00 ,$14.00 ,$4.20 ,$12.74 ,$9.80 ,$4.20 ,$9.10 ,$10.08 ,$12.74 ,$10.50 
Carle BroMenn Medical Center,8730115,BANDAGE 12CM EA,,,273,$23.00 ,$23.00 ,$6.90 ,$20.93 ,$16.10 ,$6.90 ,$14.95 ,$16.56 ,$20.93 ,$17.25 
Carle BroMenn Medical Center,8730116,BANDAGE 6CM EA,,,273,$11.00 ,$11.00 ,$3.30 ,$10.01 ,$7.70 ,$3.30 ,$7.15 ,$7.92 ,$10.01 ,$8.25 
Carle BroMenn Medical Center,8730117,BANDAGE 8CM EA,,,273,$11.00 ,$11.00 ,$3.30 ,$10.01 ,$7.70 ,$3.30 ,$7.15 ,$7.92 ,$10.01 ,$8.25 
Carle BroMenn Medical Center,8730118,BANDAGE SOFT 15CM/BOX,,,273,$23.00 ,$23.00 ,$6.90 ,$20.93 ,$16.10 ,$6.90 ,$14.95 ,$16.56 ,$20.93 ,$17.25 
Carle BroMenn Medical Center,8730119,"CASTING TAPE 2""",,,273,$7.00 ,$7.00 ,$2.10 ,$6.37 ,$4.90 ,$2.10 ,$4.55 ,$5.04 ,$6.37 ,$5.25 
Carle BroMenn Medical Center,8730120,"CASTING TAPE 3""",,,273,$8.00 ,$8.00 ,$2.40 ,$7.28 ,$5.60 ,$2.40 ,$5.20 ,$5.76 ,$7.28 ,$6.00 
Carle BroMenn Medical Center,8730121,"CASTING TAPE 4""",,,273,$9.00 ,$9.00 ,$2.70 ,$8.19 ,$6.30 ,$2.70 ,$5.85 ,$6.48 ,$8.19 ,$6.75 
Carle BroMenn Medical Center,8730122,"CASTING TAPE 5""",,,273,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8730123,SEX AND BACK PAIN BOOK,,,273,$8.00 ,$8.00 ,$2.40 ,$7.28 ,$5.60 ,$2.40 ,$5.20 ,$5.76 ,$7.28 ,$6.00 
Carle BroMenn Medical Center,8730124,SLING ARM COMFORT,,,273,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8730125,FOOT DROP SPLINT,,,273,$113.00 ,$113.00 ,$33.90 ,$102.83 ,$79.10 ,$33.90 ,$73.45 ,$81.36 ,$102.83 ,$84.75 
Carle BroMenn Medical Center,8730126,LUMBAR SUPPORT BRACE,,,273,$62.00 ,$62.00 ,$18.60 ,$56.42 ,$43.40 ,$18.60 ,$40.30 ,$44.64 ,$56.42 ,$46.50 
Carle BroMenn Medical Center,8730127,BANDAGE 6/20M YD,,,273,$5.00 ,$5.00 ,$1.50 ,$4.55 ,$3.50 ,$1.50 ,$3.25 ,$3.60 ,$4.55 ,$3.75 
Carle BroMenn Medical Center,8730128,BANDAGE 7/20M YD,,,273,$5.00 ,$5.00 ,$1.50 ,$4.55 ,$3.50 ,$1.50 ,$3.25 ,$3.60 ,$4.55 ,$3.75 
Carle BroMenn Medical Center,8730129,BANDAGE 9/20M YD,,,273,$5.00 ,$5.00 ,$1.50 ,$4.55 ,$3.50 ,$1.50 ,$3.25 ,$3.60 ,$4.55 ,$3.75 
Carle BroMenn Medical Center,8730130,GAUZE 2IN. ROLL,,,273,$5.00 ,$5.00 ,$1.50 ,$4.55 ,$3.50 ,$1.50 ,$3.25 ,$3.60 ,$4.55 ,$3.75 
Carle BroMenn Medical Center,8730131,WALKER ADULT FOLDING,,,273,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8730132,ANCHOR BELT,,,273,$45.00 ,$45.00 ,$13.50 ,$40.95 ,$31.50 ,$13.50 ,$29.25 ,$32.40 ,$40.95 ,$33.75 
Carle BroMenn Medical Center,8730133,SCAR PATCH-SMALL,,,273,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8730134,SCAR PATCH-MEDIUM,,,273,$14.00 ,$14.00 ,$4.20 ,$12.74 ,$9.80 ,$4.20 ,$9.10 ,$10.08 ,$12.74 ,$10.50 
Carle BroMenn Medical Center,8730135,SCAR PATCH-LARGE,,,273,$18.00 ,$18.00 ,$5.40 ,$16.38 ,$12.60 ,$5.40 ,$11.70 ,$12.96 ,$16.38 ,$13.50 
Carle BroMenn Medical Center,8730136,WORK BOOK WITHOUT TEARS,,,273,$9.00 ,$9.00 ,$2.70 ,$8.19 ,$6.30 ,$2.70 ,$5.85 ,$6.48 ,$8.19 ,$6.75 
Carle BroMenn Medical Center,8730137,HALF LUMBAR ROLL,,,273,$20.00 ,$20.00 ,$6.00 ,$18.20 ,$14.00 ,$6.00 ,$13.00 ,$14.40 ,$18.20 ,$15.00 
Carle BroMenn Medical Center,8730138,EXTNSR PATELLAR STAB KNEE WRAP,,,273,$43.00 ,$43.00 ,$12.90 ,$39.13 ,$30.10 ,$12.90 ,$27.95 ,$30.96 ,$39.13 ,$32.25 
Carle BroMenn Medical Center,8730139,NEONATAL KIT,,,273,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8730140,HEMI ARM SLING,,,273,$86.00 ,$86.00 ,$25.80 ,$78.26 ,$60.20 ,$25.80 ,$55.90 ,$61.92 ,$78.26 ,$64.50 
Carle BroMenn Medical Center,8730141,ELBOW BRACE,,,273,$13.00 ,$13.00 ,$3.90 ,$11.83 ,$9.10 ,$3.90 ,$8.45 ,$9.36 ,$11.83 ,$9.75 
Carle BroMenn Medical Center,8730142,KT MEDICAL GLOVE,,,273,$35.00 ,$35.00 ,$10.50 ,$31.85 ,$24.50 ,$10.50 ,$22.75 ,$25.20 ,$31.85 ,$26.25 
Carle BroMenn Medical Center,8030040,3.5 BIVONA FLEXEND STRAIGHT CUFFLESS 60PFSS35,,A7520,274,$530.00 ,$530.00 ,$159.00 ,$482.30 ,$371.00 ,$159.00 ,$344.50 ,$381.60 ,$482.30 ,$397.50 
Carle BroMenn Medical Center,8030041,3.5 BIVONA FLEXEND WITH TTS CUFF 67PFS35,,A7521,274,$627.00 ,$627.00 ,$188.10 ,$570.57 ,$438.90 ,$188.10 ,$407.55 ,$451.44 ,$570.57 ,$470.25 
Carle BroMenn Medical Center,8030042,4.0 BIVONA FLEXEND WITH TTS CUFF 67PFS40,,A7521,274,$627.00 ,$627.00 ,$188.10 ,$570.57 ,$438.90 ,$188.10 ,$407.55 ,$451.44 ,$570.57 ,$470.25 
Carle BroMenn Medical Center,8201079,TUBE TRACH SHILEY XLT CUFFLESS,,A7520,274,$530.00 ,$530.00 ,$159.00 ,$482.30 ,$371.00 ,$159.00 ,$344.50 ,$381.60 ,$482.30 ,$397.50 
Carle BroMenn Medical Center,8201833,TRACHEOTOMY TUBE 6CFS,,A7520,274,$530.00 ,$530.00 ,$159.00 ,$482.30 ,$371.00 ,$159.00 ,$344.50 ,$381.60 ,$482.30 ,$397.50 
Carle BroMenn Medical Center,8201834,TRACHEOTOMY TUBE 6CFN,,A7520,274,$530.00 ,$530.00 ,$159.00 ,$482.30 ,$371.00 ,$159.00 ,$344.50 ,$381.60 ,$482.30 ,$397.50 
Carle BroMenn Medical Center,8670018,AFO/REG STYLE,,L1960,274,$345.00 ,$345.00 ,$103.50 ,$313.95 ,$241.50 ,$103.50 ,$224.25 ,$248.40 ,$313.95 ,$258.75 
Carle BroMenn Medical Center,8670040,"CMC STABILIZATION ""Y"" SPLINT",,L3919,274,$165.00 ,$165.00 ,$49.50 ,$150.15 ,$115.50 ,$49.50 ,$107.25 ,$118.80 ,$150.15 ,$123.75 
Carle BroMenn Medical Center,8670048,CUSTOM ORTHOTIC  -LARGE,,L3000,274,$232.00 ,$232.00 ,$69.60 ,$211.12 ,$162.40 ,$69.60 ,$150.80 ,$167.04 ,$211.12 ,$174.00 
Carle BroMenn Medical Center,8670049,CUSTOM ORTHOTIC  -MEDIUM,,L3000,274,$232.00 ,$232.00 ,$69.60 ,$211.12 ,$162.40 ,$69.60 ,$150.80 ,$167.04 ,$211.12 ,$174.00 
Carle BroMenn Medical Center,8670050,CUSTOM ORTHOTIC  -SMALL,,L3000,274,$232.00 ,$232.00 ,$69.60 ,$211.12 ,$162.40 ,$69.60 ,$150.80 ,$167.04 ,$211.12 ,$174.00 
Carle BroMenn Medical Center,8670051,CUSTOM ORTHOTIC-LARGE,,L3000,274,$232.00 ,$232.00 ,$69.60 ,$211.12 ,$162.40 ,$69.60 ,$150.80 ,$167.04 ,$211.12 ,$174.00 
Carle BroMenn Medical Center,8670052,CUSTOM ORTHOTIC-MEDIUM,,L3000,274,$232.00 ,$232.00 ,$69.60 ,$211.12 ,$162.40 ,$69.60 ,$150.80 ,$167.04 ,$211.12 ,$174.00 
Carle BroMenn Medical Center,8670053,CUSTOM ORTHOTIC-SMALL,,L3000,274,$232.00 ,$232.00 ,$69.60 ,$211.12 ,$162.40 ,$69.60 ,$150.80 ,$167.04 ,$211.12 ,$174.00 
Carle BroMenn Medical Center,8670054,DAFO W/ FREE MED LAT STAB,,L1960,274,$345.00 ,$345.00 ,$103.50 ,$313.95 ,$241.50 ,$103.50 ,$224.25 ,$248.40 ,$313.95 ,$258.75 
Carle BroMenn Medical Center,8670055,DAFO W/FREE PLANTAR FLEXION,,L1960,274,$345.00 ,$345.00 ,$103.50 ,$313.95 ,$241.50 ,$103.50 ,$224.25 ,$248.40 ,$313.95 ,$258.75 
Carle BroMenn Medical Center,8670056,DIGIT ARTHR DYN MCP EXT SPLINT,,L3806,274,$255.00 ,$255.00 ,$76.50 ,$232.05 ,$178.50 ,$76.50 ,$165.75 ,$183.60 ,$232.05 ,$191.25 
Carle BroMenn Medical Center,8670057,DURAN STATIC DORSAL BLOCKING,,L3808,274,$259.00 ,$259.00 ,$77.70 ,$235.69 ,$181.30 ,$77.70 ,$168.35 ,$186.48 ,$235.69 ,$194.25 
Carle BroMenn Medical Center,8670058,DYNAMIC SUP./PRO.SPLINT,,L3764,274,$450.00 ,$450.00 ,$135.00 ,$409.50 ,$315.00 ,$135.00 ,$292.50 ,$324.00 ,$409.50 ,$337.50 
Carle BroMenn Medical Center,8670059,DYNAMIC WRIST SPLINT,,L3905,274,$410.00 ,$410.00 ,$123.00 ,$373.10 ,$287.00 ,$123.00 ,$266.50 ,$295.20 ,$373.10 ,$307.50 
Carle BroMenn Medical Center,8670070,FB DYNAMIC MP FLEXION SPLINT,,L3806,274,$255.00 ,$255.00 ,$76.50 ,$232.05 ,$178.50 ,$76.50 ,$165.75 ,$183.60 ,$232.05 ,$191.25 
Carle BroMenn Medical Center,8670073,FINGER GUTTER SPLINT,,L3933,274,$131.00 ,$131.00 ,$39.30 ,$119.21 ,$91.70 ,$39.30 ,$85.15 ,$94.32 ,$119.21 ,$98.25 
Carle BroMenn Medical Center,8670074,FINGERTIP PROTECTOR,,L3933,274,$131.00 ,$131.00 ,$39.30 ,$119.21 ,$91.70 ,$39.30 ,$85.15 ,$94.32 ,$119.21 ,$98.25 
Carle BroMenn Medical Center,8670076,FOOT DROP MODERATE CONTROL,,L1960,274,$345.00 ,$345.00 ,$103.50 ,$313.95 ,$241.50 ,$103.50 ,$224.25 ,$248.40 ,$313.95 ,$258.75 
Carle BroMenn Medical Center,8670078,FOREARM BASE THUMB SPICA GAUNT,,L3808,274,$259.00 ,$259.00 ,$77.70 ,$235.69 ,$181.30 ,$77.70 ,$168.35 ,$186.48 ,$235.69 ,$194.25 
Carle BroMenn Medical Center,8670090,HAND ARTHRP DYN MCP EXT SPLNT,,L3806,274,$255.00 ,$255.00 ,$76.50 ,$232.05 ,$178.50 ,$76.50 ,$165.75 ,$183.60 ,$232.05 ,$191.25 
Carle BroMenn Medical Center,8670091,HAND BASED THUMB SPICA (WHFO),,L3913,274,$165.00 ,$165.00 ,$49.50 ,$150.15 ,$115.50 ,$49.50 ,$107.25 ,$118.80 ,$150.15 ,$123.75 
Carle BroMenn Medical Center,8670093,HB DYNAMIC IP EXTENSION SPLINT,,L3921,274,$188.00 ,$188.00 ,$56.40 ,$171.08 ,$131.60 ,$56.40 ,$122.20 ,$135.36 ,$171.08 ,$141.00 
Carle BroMenn Medical Center,8670094,HB DYNAMIC IP FLEXION SPLINT,,L3921,274,$188.00 ,$188.00 ,$56.40 ,$171.08 ,$131.60 ,$56.40 ,$122.20 ,$135.36 ,$171.08 ,$141.00 
Carle BroMenn Medical Center,8670095,HB MP/IP EXTNSION BLOCK SPLINT,,L3913,274,$165.00 ,$165.00 ,$49.50 ,$150.15 ,$115.50 ,$49.50 ,$107.25 ,$118.80 ,$150.15 ,$123.75 
Carle BroMenn Medical Center,8670096,HB PALMER RESTING SPLINT,,L3913,274,$165.00 ,$165.00 ,$49.50 ,$150.15 ,$115.50 ,$49.50 ,$107.25 ,$118.80 ,$150.15 ,$123.75 
Carle BroMenn Medical Center,8670097,HB PST-DUPYTRNS FNGR EXT SPLNT,,L3913,274,$165.00 ,$165.00 ,$49.50 ,$150.15 ,$115.50 ,$49.50 ,$107.25 ,$118.80 ,$150.15 ,$123.75 
Carle BroMenn Medical Center,8670098,FB STATIC PROGR IP FLEXN SPLNT,,L3935,274,$186.00 ,$186.00 ,$55.80 ,$169.26 ,$130.20 ,$55.80 ,$120.90 ,$133.92 ,$169.26 ,$139.50 
Carle BroMenn Medical Center,8670099,HB ULNAR/RADIAL GUTTER SPLINT,,L3913,274,$165.00 ,$165.00 ,$49.50 ,$150.15 ,$115.50 ,$49.50 ,$107.25 ,$118.80 ,$150.15 ,$123.75 
Carle BroMenn Medical Center,8670117,MALLET SPLINT,,L3933,274,$131.00 ,$131.00 ,$39.30 ,$119.21 ,$91.70 ,$39.30 ,$85.15 ,$94.32 ,$119.21 ,$98.25 
Carle BroMenn Medical Center,8670135,POST DUYPTRNS RELEASE-FING EXT,,L3808,274,$259.00 ,$259.00 ,$77.70 ,$235.69 ,$181.30 ,$77.70 ,$168.35 ,$186.48 ,$235.69 ,$194.25 
Carle BroMenn Medical Center,8670141,RA RESTING HAND,,L3808,274,$259.00 ,$259.00 ,$77.70 ,$235.69 ,$181.30 ,$77.70 ,$168.35 ,$186.48 ,$235.69 ,$194.25 
Carle BroMenn Medical Center,8670142,RADIAL N DYN MCP EXTNSN SPLINT,,L3806,274,$255.00 ,$255.00 ,$76.50 ,$232.05 ,$178.50 ,$76.50 ,$165.75 ,$183.60 ,$232.05 ,$191.25 
Carle BroMenn Medical Center,8670143,RESTING PAN,,L3808,274,$259.00 ,$259.00 ,$77.70 ,$235.69 ,$181.30 ,$77.70 ,$168.35 ,$186.48 ,$235.69 ,$194.25 
Carle BroMenn Medical Center,8670167,STATIC LONG ARM ELBOW SPLINT,,L3702,274,$287.00 ,$287.00 ,$86.10 ,$261.17 ,$200.90 ,$86.10 ,$186.55 ,$206.64 ,$261.17 ,$215.25 
Carle BroMenn Medical Center,8670168,STATIC-PROGRESSIVE  WRIST BASE,,L3905,274,$410.00 ,$410.00 ,$123.00 ,$373.10 ,$287.00 ,$123.00 ,$266.50 ,$295.20 ,$373.10 ,$307.50 
Carle BroMenn Medical Center,8670173,SUGAR TONG SPLINT,,L3763,274,$390.00 ,$390.00 ,$117.00 ,$354.90 ,$273.00 ,$117.00 ,$253.50 ,$280.80 ,$354.90 ,$292.50 
Carle BroMenn Medical Center,8670178,UE LONG ARM ELBOW FX SPLINT,,L3702,274,$287.00 ,$287.00 ,$86.10 ,$261.17 ,$200.90 ,$86.10 ,$186.55 ,$206.64 ,$261.17 ,$215.25 
Carle BroMenn Medical Center,8670179,"ULNAR N. ANTI - CLAW ""8""",,L3913,274,$165.00 ,$165.00 ,$49.50 ,$150.15 ,$115.50 ,$49.50 ,$107.25 ,$118.80 ,$150.15 ,$123.75 
Carle BroMenn Medical Center,8670186,WRST GAUNT MOLD VOLR/DRSL/THMB,,L3906,274,$259.00 ,$259.00 ,$77.70 ,$235.69 ,$181.30 ,$77.70 ,$168.35 ,$186.48 ,$235.69 ,$194.25 
Carle BroMenn Medical Center,8670205,HB STATIC PROGR IP EXTSN SPLNT,,L3933,274,$131.00 ,$131.00 ,$39.30 ,$119.21 ,$91.70 ,$39.30 ,$85.15 ,$94.32 ,$119.21 ,$98.25 
Carle BroMenn Medical Center,8670206,TRACHEO-ESOPH VOICE PROSTHESIS,,L8509,274,$338.00 ,$338.00 ,$101.40 ,$307.58 ,$236.60 ,$101.40 ,$219.70 ,$243.36 ,$307.58 ,$253.50 
Carle BroMenn Medical Center,8670207,DAFO W/ PLANTAR FLEXION RESIST,,L1960,274,$345.00 ,$345.00 ,$103.50 ,$313.95 ,$241.50 ,$103.50 ,$224.25 ,$248.40 ,$313.95 ,$258.75 
Carle BroMenn Medical Center,8670208,DAFO W/ PLANTAR FLEXION STOP,,L1960,274,$345.00 ,$345.00 ,$103.50 ,$313.95 ,$241.50 ,$103.50 ,$224.25 ,$248.40 ,$313.95 ,$258.75 
Carle BroMenn Medical Center,8670212,EO W/O JNTS CF,,L3702,274,$287.00 ,$287.00 ,$86.10 ,$261.17 ,$200.90 ,$86.10 ,$186.55 ,$206.64 ,$261.17 ,$215.25 
Carle BroMenn Medical Center,8670214,EWHO W/O JNTS CF,,L3763,274,$390.00 ,$390.00 ,$117.00 ,$354.90 ,$273.00 ,$117.00 ,$253.50 ,$280.80 ,$354.90 ,$292.50 
Carle BroMenn Medical Center,8670215,EWHO W/JNTS CF,,L3764,274,$450.00 ,$450.00 ,$135.00 ,$409.50 ,$315.00 ,$135.00 ,$292.50 ,$324.00 ,$409.50 ,$337.50 
Carle BroMenn Medical Center,8670218,WHFO W/JNT CUSTOM FAB,,L3806,274,$255.00 ,$255.00 ,$76.50 ,$232.05 ,$178.50 ,$76.50 ,$165.75 ,$183.60 ,$232.05 ,$191.25 
Carle BroMenn Medical Center,8670219,WHFO RIGID W/O JNTS,,L3808,274,$259.00 ,$259.00 ,$77.70 ,$235.69 ,$181.30 ,$77.70 ,$168.35 ,$186.48 ,$235.69 ,$194.25 
Carle BroMenn Medical Center,8670220,WHO W/NONTORSION JNT CF,,L3905,274,$410.00 ,$410.00 ,$123.00 ,$373.10 ,$287.00 ,$123.00 ,$266.50 ,$295.20 ,$373.10 ,$307.50 
Carle BroMenn Medical Center,8670221,WHO W/O JNTS CF,,L3906,274,$259.00 ,$259.00 ,$77.70 ,$235.69 ,$181.30 ,$77.70 ,$168.35 ,$186.48 ,$235.69 ,$194.25 
Carle BroMenn Medical Center,8670223,HFO W/O JNT CF,,L3913,274,$165.00 ,$165.00 ,$49.50 ,$150.15 ,$115.50 ,$49.50 ,$107.25 ,$118.80 ,$150.15 ,$123.75 
Carle BroMenn Medical Center,8670224,HO W/O JNTS CF,,L3919,274,$165.00 ,$165.00 ,$49.50 ,$150.15 ,$115.50 ,$49.50 ,$107.25 ,$118.80 ,$150.15 ,$123.75 
Carle BroMenn Medical Center,8670225,HFO W/JNTS CF,,L3921,274,$188.00 ,$188.00 ,$56.40 ,$171.08 ,$131.60 ,$56.40 ,$122.20 ,$135.36 ,$171.08 ,$141.00 
Carle BroMenn Medical Center,8670228,FO W/O JOINTS CF,,L3933,274,$131.00 ,$131.00 ,$39.30 ,$119.21 ,$91.70 ,$39.30 ,$85.15 ,$94.32 ,$119.21 ,$98.25 
Carle BroMenn Medical Center,8670229,FO NONTORSION JNT CF,,L3935,274,$186.00 ,$186.00 ,$55.80 ,$169.26 ,$130.20 ,$55.80 ,$120.90 ,$133.92 ,$169.26 ,$139.50 
Carle BroMenn Medical Center,8680030,GLOVE FINGER FLEXION,,L3912,274,$58.00 ,$58.00 ,$17.40 ,$52.78 ,$40.60 ,$17.40 ,$37.70 ,$41.76 ,$52.78 ,$43.50 
Carle BroMenn Medical Center,8680040,RADIUS/ULNAR FX ORTHOSIS,,L3982,274,$116.00 ,$116.00 ,$34.80 ,$105.56 ,$81.20 ,$34.80 ,$75.40 ,$83.52 ,$105.56 ,$87.00 
Carle BroMenn Medical Center,8680202,PROCESSING UNIT ONLY,,L8627,274,"$14,745.00 ","$14,745.00 ","$4,423.50 ","$13,417.95 ","$10,321.50 ","$4,423.50 ","$9,584.25 ","$10,616.40 ","$13,417.95 ","$11,058.75 "
Carle BroMenn Medical Center,8680203,BTE CONTROLLER ONLY,,L8628,274,"$4,140.00 ","$4,140.00 ","$1,242.00 ","$3,767.40 ","$2,898.00 ","$1,242.00 ","$2,691.00 ","$2,980.80 ","$3,767.40 ","$3,105.00 "
Carle BroMenn Medical Center,8680204,TRANSMITTING COIL/CABLE,,L8629,274,$390.00 ,$390.00 ,$117.00 ,$354.90 ,$273.00 ,$117.00 ,$253.50 ,$280.80 ,$354.90 ,$292.50 
Carle BroMenn Medical Center,8680205,HEADPIECE,,L8629,274,$390.00 ,$390.00 ,$117.00 ,$354.90 ,$273.00 ,$117.00 ,$253.50 ,$280.80 ,$354.90 ,$292.50 
Carle BroMenn Medical Center,8680206,CABLE/COIL,,L8629,274,$390.00 ,$390.00 ,$117.00 ,$354.90 ,$273.00 ,$117.00 ,$253.50 ,$280.80 ,$354.90 ,$292.50 
Carle BroMenn Medical Center,8680207,PROCESSOR & BTE CONTROLLER,,L8629,274,$390.00 ,$390.00 ,$117.00 ,$354.90 ,$273.00 ,$117.00 ,$253.50 ,$280.80 ,$354.90 ,$292.50 
Carle BroMenn Medical Center,8680209,AUD OSSEO DEVICE BODY WORN,,L8692,274,$259.00 ,$259.00 ,$77.70 ,$235.69 ,$181.30 ,$77.70 ,$168.35 ,$186.48 ,$235.69 ,$194.25 
Carle BroMenn Medical Center,8730014,AFO/REG STYLE,,L1960,274,$345.00 ,$345.00 ,$103.50 ,$313.95 ,$241.50 ,$103.50 ,$224.25 ,$248.40 ,$313.95 ,$258.75 
Carle BroMenn Medical Center,8730015,CUSTOM ORTHOTIC-SMALL,,L3000,274,$232.00 ,$232.00 ,$69.60 ,$211.12 ,$162.40 ,$69.60 ,$150.80 ,$167.04 ,$211.12 ,$174.00 
Carle BroMenn Medical Center,8730016,CUSTOM ORTHOTIC-MEDIUM,,L3000,274,$232.00 ,$232.00 ,$69.60 ,$211.12 ,$162.40 ,$69.60 ,$150.80 ,$167.04 ,$211.12 ,$174.00 
Carle BroMenn Medical Center,8730017,CUSTOM ORTHOTIC-LARGE,,L3000,274,$232.00 ,$232.00 ,$69.60 ,$211.12 ,$162.40 ,$69.60 ,$150.80 ,$167.04 ,$211.12 ,$174.00 
Carle BroMenn Medical Center,8730018,DAFO W/ FREE MED LAT STAB,,L1960,274,$345.00 ,$345.00 ,$103.50 ,$313.95 ,$241.50 ,$103.50 ,$224.25 ,$248.40 ,$313.95 ,$258.75 
Carle BroMenn Medical Center,8730019,DAFO W/FREE PLANTAR FLEXION,,L1960,274,$345.00 ,$345.00 ,$103.50 ,$313.95 ,$241.50 ,$103.50 ,$224.25 ,$248.40 ,$313.95 ,$258.75 
Carle BroMenn Medical Center,8730020,DAFO W/PLANTAR FLEXION RESIST,,L1960,274,$345.00 ,$345.00 ,$103.50 ,$313.95 ,$241.50 ,$103.50 ,$224.25 ,$248.40 ,$313.95 ,$258.75 
Carle BroMenn Medical Center,8730021,DAFO W/PLANTAR FLEXION STOP,,L1960,274,$345.00 ,$345.00 ,$103.50 ,$313.95 ,$241.50 ,$103.50 ,$224.25 ,$248.40 ,$313.95 ,$258.75 
Carle BroMenn Medical Center,8730022,DURAN STATIC DORSAL BLOCKING,,L3808,274,$259.00 ,$259.00 ,$77.70 ,$235.69 ,$181.30 ,$77.70 ,$168.35 ,$186.48 ,$235.69 ,$194.25 
Carle BroMenn Medical Center,8730023,FOOT DROP MODERATE CONTROL,,L1960,274,$345.00 ,$345.00 ,$103.50 ,$313.95 ,$241.50 ,$103.50 ,$224.25 ,$248.40 ,$313.95 ,$258.75 
Carle BroMenn Medical Center,8730024,HB ULNAR/RADIAL GUTTER SPLINT,,L3913,274,$165.00 ,$165.00 ,$49.50 ,$150.15 ,$115.50 ,$49.50 ,$107.25 ,$118.80 ,$150.15 ,$123.75 
Carle BroMenn Medical Center,8730026,FOREARM BASE THUMB SPICA GAUNT,,L3808,274,$259.00 ,$259.00 ,$77.70 ,$235.69 ,$181.30 ,$77.70 ,$168.35 ,$186.48 ,$235.69 ,$194.25 
Carle BroMenn Medical Center,8730027,RESTING PAN,,L3808,274,$259.00 ,$259.00 ,$77.70 ,$235.69 ,$181.30 ,$77.70 ,$168.35 ,$186.48 ,$235.69 ,$194.25 
Carle BroMenn Medical Center,8730028,HAND BASED THUMB SPICA(WHFO),,L3808,274,$259.00 ,$259.00 ,$77.70 ,$235.69 ,$181.30 ,$77.70 ,$168.35 ,$186.48 ,$235.69 ,$194.25 
Carle BroMenn Medical Center,8730029,WRST GAUNT MOLD VOLR/DRSL/THMB,,L3906,274,$259.00 ,$259.00 ,$77.70 ,$235.69 ,$181.30 ,$77.70 ,$168.35 ,$186.48 ,$235.69 ,$194.25 
Carle BroMenn Medical Center,8730030,POST DUYPTRNS RELEASE-FING EXT,,L3808,274,$259.00 ,$259.00 ,$77.70 ,$235.69 ,$181.30 ,$77.70 ,$168.35 ,$186.48 ,$235.69 ,$194.25 
Carle BroMenn Medical Center,8730031,DYNAMIC SUP./PRO.SPLINT,,L3764,274,$450.00 ,$450.00 ,$135.00 ,$409.50 ,$315.00 ,$135.00 ,$292.50 ,$324.00 ,$409.50 ,$337.50 
Carle BroMenn Medical Center,8730032,STATIC-PROGRESSIVE  WRIST BASE,,L3905,274,$410.00 ,$410.00 ,$123.00 ,$373.10 ,$287.00 ,$123.00 ,$266.50 ,$295.20 ,$373.10 ,$307.50 
Carle BroMenn Medical Center,8730033,UE LONG ARM ELBOW FX SPLINT,,L3702,274,$287.00 ,$287.00 ,$86.10 ,$261.17 ,$200.90 ,$86.10 ,$186.55 ,$206.64 ,$261.17 ,$215.25 
Carle BroMenn Medical Center,8730034,SUGAR TONG SPLINT,,L3763,274,$390.00 ,$390.00 ,$117.00 ,$354.90 ,$273.00 ,$117.00 ,$253.50 ,$280.80 ,$354.90 ,$292.50 
Carle BroMenn Medical Center,8730035,FINGER GUTTER SPLINT,,L3933,274,$131.00 ,$131.00 ,$39.30 ,$119.21 ,$91.70 ,$39.30 ,$85.15 ,$94.32 ,$119.21 ,$98.25 
Carle BroMenn Medical Center,8730036,HB MP/IP EXTNSION BLOCK SPLINT,,L3913,274,$165.00 ,$165.00 ,$49.50 ,$150.15 ,$115.50 ,$49.50 ,$107.25 ,$118.80 ,$150.15 ,$123.75 
Carle BroMenn Medical Center,8730040,MALLET SPLINT,,L3933,274,$131.00 ,$131.00 ,$39.30 ,$119.21 ,$91.70 ,$39.30 ,$85.15 ,$94.32 ,$119.21 ,$98.25 
Carle BroMenn Medical Center,8730041,FINGERTIP PROTECTOR,,L3933,274,$131.00 ,$131.00 ,$39.30 ,$119.21 ,$91.70 ,$39.30 ,$85.15 ,$94.32 ,$119.21 ,$98.25 
Carle BroMenn Medical Center,8730042,RADIAL N DYN MCP EXTNSN SPLINT,,L3806,274,$255.00 ,$255.00 ,$76.50 ,$232.05 ,$178.50 ,$76.50 ,$165.75 ,$183.60 ,$232.05 ,$191.25 
Carle BroMenn Medical Center,8730043,HAND ARTHRP DYN MCP EXT SPLNT,,L3806,274,$255.00 ,$255.00 ,$76.50 ,$232.05 ,$178.50 ,$76.50 ,$165.75 ,$183.60 ,$232.05 ,$191.25 
Carle BroMenn Medical Center,8730045,RA RESTING HAND,,L3808,274,$259.00 ,$259.00 ,$77.70 ,$235.69 ,$181.30 ,$77.70 ,$168.35 ,$186.48 ,$235.69 ,$194.25 
Carle BroMenn Medical Center,8730046,HB PST-DUPYTRNS FNGR EXT SPLNT,,L3913,274,$165.00 ,$165.00 ,$49.50 ,$150.15 ,$115.50 ,$49.50 ,$107.25 ,$118.80 ,$150.15 ,$123.75 
Carle BroMenn Medical Center,8730047,"ULNAR N. ANTI - CLAW ""8""",,L3913,274,$165.00 ,$165.00 ,$49.50 ,$150.15 ,$115.50 ,$49.50 ,$107.25 ,$118.80 ,$150.15 ,$123.75 
Carle BroMenn Medical Center,8730048,HB PALMER RESTING SPLINT,,L3913,274,$165.00 ,$165.00 ,$49.50 ,$150.15 ,$115.50 ,$49.50 ,$107.25 ,$118.80 ,$150.15 ,$123.75 
Carle BroMenn Medical Center,8730050,STATIC LONG ARM ELBOW SPLINT,,L3702,274,$287.00 ,$287.00 ,$86.10 ,$261.17 ,$200.90 ,$86.10 ,$186.55 ,$206.64 ,$261.17 ,$215.25 
Carle BroMenn Medical Center,8730053,FB DYNAMIC MP FLEXION SPLINT,,L3806,274,$255.00 ,$255.00 ,$76.50 ,$232.05 ,$178.50 ,$76.50 ,$165.75 ,$183.60 ,$232.05 ,$191.25 
Carle BroMenn Medical Center,8730054,DIGIT ARTHR DYN MCP EXT SPLINT,,L3806,274,$255.00 ,$255.00 ,$76.50 ,$232.05 ,$178.50 ,$76.50 ,$165.75 ,$183.60 ,$232.05 ,$191.25 
Carle BroMenn Medical Center,8730055,HB DYNAMIC IP EXTENSION SPLINT,,L3921,274,$188.00 ,$188.00 ,$56.40 ,$171.08 ,$131.60 ,$56.40 ,$122.20 ,$135.36 ,$171.08 ,$141.00 
Carle BroMenn Medical Center,8730056,HB DYNAMIC IP FLEXION SPLINT,,L3921,274,$188.00 ,$188.00 ,$56.40 ,$171.08 ,$131.60 ,$56.40 ,$122.20 ,$135.36 ,$171.08 ,$141.00 
Carle BroMenn Medical Center,8730057,HB STATIC PROGRSV IP EXT SPLNT,,L3935,274,$186.00 ,$186.00 ,$55.80 ,$169.26 ,$130.20 ,$55.80 ,$120.90 ,$133.92 ,$169.26 ,$139.50 
Carle BroMenn Medical Center,8730058,HB STATIC PROGR IP FLEXN SPLNT,,L3933,274,$131.00 ,$131.00 ,$39.30 ,$119.21 ,$91.70 ,$39.30 ,$85.15 ,$94.32 ,$119.21 ,$98.25 
Carle BroMenn Medical Center,8730059,DYNAMIC WRIST SPLINT,,L3905,274,$410.00 ,$410.00 ,$123.00 ,$373.10 ,$287.00 ,$123.00 ,$266.50 ,$295.20 ,$373.10 ,$307.50 
Carle BroMenn Medical Center,8730226,GLOVE FINGER FLEXION,,L3912,274,$58.00 ,$58.00 ,$17.40 ,$52.78 ,$40.60 ,$17.40 ,$37.70 ,$41.76 ,$52.78 ,$43.50 
Carle BroMenn Medical Center,8730236,RADIUS/ULNAR FX ORTHOSIS,,L3982,274,$116.00 ,$116.00 ,$34.80 ,$105.56 ,$81.20 ,$34.80 ,$75.40 ,$83.52 ,$105.56 ,$87.00 
Carle BroMenn Medical Center,8730249,TRACHEO-ESOPH VOICE PROSTHESIS,,L8509,274,$338.00 ,$338.00 ,$101.40 ,$307.58 ,$236.60 ,$101.40 ,$219.70 ,$243.36 ,$307.58 ,$253.50 
Carle BroMenn Medical Center,8730251,TRACHEOSTOMY SPEAKING VALVE,,L8501,274,$501.00 ,$501.00 ,$150.30 ,$455.91 ,$350.70 ,$150.30 ,$325.65 ,$360.72 ,$455.91 ,$375.75 
Carle BroMenn Medical Center,8902671,SHI8CFS TRACH 8CFS 7.6MM ID 12.2MM OD 81MM L. SHILEY EACH,,A7520,274,$530.00 ,$530.00 ,$159.00 ,$482.30 ,$371.00 ,$159.00 ,$344.50 ,$381.60 ,$482.30 ,$397.50 
Carle BroMenn Medical Center,8902887,PASPMV2000 TRACH SPEAK VALVE,,L8501,274,$501.00 ,$501.00 ,$150.30 ,$455.91 ,$350.70 ,$150.30 ,$325.65 ,$360.72 ,$455.91 ,$375.75 
Carle BroMenn Medical Center,8903306,BIV60P035 TRACH BIVONA 3.5 PEDS,,A7520,274,$530.00 ,$530.00 ,$159.00 ,$482.30 ,$371.00 ,$159.00 ,$344.50 ,$381.60 ,$482.30 ,$397.50 
Carle BroMenn Medical Center,8903307,BIV67SN035 67SN035 3.5 NEONATAL,,A7521,274,$627.00 ,$627.00 ,$188.10 ,$570.57 ,$438.90 ,$188.10 ,$407.55 ,$451.44 ,$570.57 ,$470.25 
Carle BroMenn Medical Center,8903308,BIV67SP035 TRACH BIVONA 67SP035 3.5,,A7521,274,$627.00 ,$627.00 ,$188.10 ,$570.57 ,$438.90 ,$188.10 ,$407.55 ,$451.44 ,$570.57 ,$470.25 
Carle BroMenn Medical Center,8179054,LEAD PMK TEMPORARY ATRIAL 6492,244891,C1779,275,$0.28 ,$0.28 ,$0.08 ,$0.25 ,$0.20 ,$0.08 ,$0.18 ,$0.20 ,$0.25 ,$0.21 
Carle BroMenn Medical Center,8030028,SHERLOCK 5FR DL,,C1751,278,$318.00 ,$318.00 ,$95.40 ,$289.38 ,$222.60 ,$95.40 ,$206.70 ,$228.96 ,$289.38 ,$238.50 
Carle BroMenn Medical Center,8030029,SHERLOCK 5FR TL,,C1751,278,$318.00 ,$318.00 ,$95.40 ,$289.38 ,$222.60 ,$95.40 ,$206.70 ,$228.96 ,$289.38 ,$238.50 
Carle BroMenn Medical Center,8030031,KIT COOL GUARD START UP 626270,,C1752,278,$577.00 ,$577.00 ,$173.10 ,$525.07 ,$403.90 ,$173.10 ,$375.05 ,$415.44 ,$525.07 ,$432.75 
Carle BroMenn Medical Center,8030033,CATHETER ICY 626268,,C1752,278,"$2,606.00 ","$2,606.00 ",$781.80 ,"$2,371.46 ","$1,824.20 ",$781.80 ,"$1,693.90 ","$1,876.32 ","$2,371.46 ","$1,954.50 "
Carle BroMenn Medical Center,8030034,CATHETER TRIALYSIS 3 LUMEN 15CM 623665,,C1752,278,$585.00 ,$585.00 ,$175.50 ,$532.35 ,$409.50 ,$175.50 ,$380.25 ,$421.20 ,$532.35 ,$438.75 
Carle BroMenn Medical Center,8030035,SHERLOCK CATHETER 5 FR DUAL LINE 9295108D,,C1751,278,$318.00 ,$318.00 ,$95.40 ,$289.38 ,$222.60 ,$95.40 ,$206.70 ,$228.96 ,$289.38 ,$238.50 
Carle BroMenn Medical Center,8030036,SHERLOCK CATHETER 5 FR TRIPLE LINE 9395108QD,,C1751,278,$318.00 ,$318.00 ,$95.40 ,$289.38 ,$222.60 ,$95.40 ,$206.70 ,$228.96 ,$289.38 ,$238.50 
Carle BroMenn Medical Center,8030037,3CG CUSTOM KIT 5FR TRIPLE LINE CK000162,,C1751,278,$318.00 ,$318.00 ,$95.40 ,$289.38 ,$222.60 ,$95.40 ,$206.70 ,$228.96 ,$289.38 ,$238.50 
Carle BroMenn Medical Center,8030047,MULTI-LUMEN HEMODIALYSIS CATH KIT FOR HIGH VOLUME INFUSIONS,,C1752,278,$585.00 ,$585.00 ,$175.50 ,$532.35 ,$409.50 ,$175.50 ,$380.25 ,$421.20 ,$532.35 ,$438.75 
Carle BroMenn Medical Center,8030049,PRESSURE INJECTABLE MULTILUMEN CVC KIT 7FR 3LUM 16CM,,C1751,278,$318.00 ,$318.00 ,$95.40 ,$289.38 ,$222.60 ,$95.40 ,$206.70 ,$228.96 ,$289.38 ,$238.50 
Carle BroMenn Medical Center,8030085,3FR SINGLE LUMEN BASIC PEDIATRIC PICC LINE,,C1751,278,$318.00 ,$318.00 ,$95.40 ,$289.38 ,$222.60 ,$95.40 ,$206.70 ,$228.96 ,$289.38 ,$238.50 
Carle BroMenn Medical Center,8030086,4FR DUAL LUMEN BASIC PEDIATRIC PICC LINE,,C1751,278,$318.00 ,$318.00 ,$95.40 ,$289.38 ,$222.60 ,$95.40 ,$206.70 ,$228.96 ,$289.38 ,$238.50 
Carle BroMenn Medical Center,8030089,ACCUDRAIN W ANTI-REFLUX,,C1729,278,"$2,018.90 ","$2,018.90 ",$605.67 ,"$1,837.20 ","$1,413.23 ",$605.67 ,"$1,312.29 ","$1,453.61 ","$1,837.20 ","$1,514.18 "
Carle BroMenn Medical Center,8030100,CATH ARROW 3 LUMEN CV (C1751),,C1751,278,$318.00 ,$318.00 ,$95.40 ,$289.38 ,$222.60 ,$95.40 ,$206.70 ,$228.96 ,$289.38 ,$238.50 
Carle BroMenn Medical Center,8030161,CENTRAL LINE CATH INSERT BUCKT,,C1751,278,$318.00 ,$318.00 ,$95.40 ,$289.38 ,$222.60 ,$95.40 ,$206.70 ,$228.96 ,$289.38 ,$238.50 
Carle BroMenn Medical Center,8100038,IMPLANTABLE TISSUE MARKER,,A4648,278,$149.00 ,$149.00 ,$44.70 ,$135.59 ,$104.30 ,$44.70 ,$96.85 ,$107.28 ,$135.59 ,$111.75 
Carle BroMenn Medical Center,8100039,IMPLANTABLE TISSUE MARKER,,A4648,278,$149.00 ,$149.00 ,$44.70 ,$135.59 ,$104.30 ,$44.70 ,$96.85 ,$107.28 ,$135.59 ,$111.75 
Carle BroMenn Medical Center,8170033,DHC STENT-BILIARY,,C1729,278,"$2,018.90 ","$2,018.90 ",$605.67 ,"$1,837.20 ","$1,413.23 ",$605.67 ,"$1,312.29 ","$1,453.61 ","$1,837.20 ","$1,514.18 "
Carle BroMenn Medical Center,8170033,STENT BILIARY PRELOAD 5FX3CM ADVA,240293,C1729,278,$501.12 ,$501.12 ,$150.34 ,$456.02 ,$350.78 ,$150.34 ,$325.73 ,$360.81 ,$456.02 ,$375.84 
Carle BroMenn Medical Center,8170033,STENT BILIARY PRELOAD 5FX5CM ADVA,240336,C1729,278,$501.12 ,$501.12 ,$150.34 ,$456.02 ,$350.78 ,$150.34 ,$325.73 ,$360.81 ,$456.02 ,$375.84 
Carle BroMenn Medical Center,8170033,STENT BILIARY PRELOAD 5FX7CM ADVA,240337,C1729,278,$501.12 ,$501.12 ,$150.34 ,$456.02 ,$350.78 ,$150.34 ,$325.73 ,$360.81 ,$456.02 ,$375.84 
Carle BroMenn Medical Center,8170041,CLOSURE DEVICE -VASCULAR,,C1760,278,$248.00 ,$248.00 ,$74.40 ,$225.68 ,$173.60 ,$74.40 ,$161.20 ,$178.56 ,$225.68 ,$186.00 
Carle BroMenn Medical Center,8170045,KIT BASIC EVAL PACK INTERSTIM,242436,C1767,278,"$1,680.00 ","$1,680.00 ",$504.00 ,"$1,528.80 ","$1,176.00 ",$504.00 ,"$1,092.00 ","$1,209.60 ","$1,528.80 ","$1,260.00 "
Carle BroMenn Medical Center,8170045,KIT REVISION INTERSTIM,242435,C1767,278,"$1,185.00 ","$1,185.00 ",$355.50 ,"$1,078.35 ",$829.50 ,$355.50 ,$770.25 ,$853.20 ,"$1,078.35 ",$888.75 
Carle BroMenn Medical Center,8170045,NEUROSTIMULATOR 51X43MM IPG INTER,12448,C1767,278,"$35,040.00 ","$35,040.00 ","$10,512.00 ","$31,886.40 ","$24,528.00 ","$10,512.00 ","$22,776.00 ","$25,228.80 ","$31,886.40 ","$26,280.00 "
Carle BroMenn Medical Center,8170045,NEUROSTIMULATOR MRI MICRO INTERST,242425,C1767,278,"$35,040.00 ","$35,040.00 ","$10,512.00 ","$31,886.40 ","$24,528.00 ","$10,512.00 ","$22,776.00 ","$25,228.80 ","$31,886.40 ","$26,280.00 "
Carle BroMenn Medical Center,8170051,ATTUNE CRS FEMORAL LT SZ8 CEM,247397,C1776,278,"$12,926.07 ","$12,926.07 ","$3,877.82 ","$11,762.72 ","$9,048.25 ","$3,877.82 ","$8,401.95 ","$9,306.77 ","$11,762.72 ","$9,694.55 "
Carle BroMenn Medical Center,8170051,ATTUNE FEM POR CR RT SZ 5,247866,C1776,278,"$4,323.00 ","$4,323.00 ","$1,296.90 ","$3,933.93 ","$3,026.10 ","$1,296.90 ","$2,809.95 ","$3,112.56 ","$3,933.93 ","$3,242.25 "
Carle BroMenn Medical Center,8170051,AUGMENT ATTUNE DIST FEM SZ8 12,247398,C1776,278,"$2,320.35 ","$2,320.35 ",$696.11 ,"$2,111.52 ","$1,624.25 ",$696.11 ,"$1,508.23 ","$1,670.65 ","$2,111.52 ","$1,740.26 "
Carle BroMenn Medical Center,8170051,AUGMENT ATTUNE FEM DIST 4 12MM,242647,C1776,278,"$2,320.35 ","$2,320.35 ",$696.11 ,"$2,111.52 ","$1,624.25 ",$696.11 ,"$1,508.23 ","$1,670.65 ","$2,111.52 ","$1,740.26 "
Carle BroMenn Medical Center,8170051,AUGMENT DIST FEM SZ 6 16MM,242894,C1776,278,"$2,320.35 ","$2,320.35 ",$696.11 ,"$2,111.52 ","$1,624.25 ",$696.11 ,"$1,508.23 ","$1,670.65 ","$2,111.52 ","$1,740.26 "
Carle BroMenn Medical Center,8170051,AUGMENT FEM DISTAL NEXGEN 10MM,243095,C1776,278,"$3,498.00 ","$3,498.00 ","$1,049.40 ","$3,183.18 ","$2,448.60 ","$1,049.40 ","$2,273.70 ","$2,518.56 ","$3,183.18 ","$2,623.50 "
Carle BroMenn Medical Center,8170051,CENT INVIS DIST SZ 12MM,247122,C1776,278,$323.40 ,$323.40 ,$97.02 ,$294.29 ,$226.38 ,$97.02 ,$210.21 ,$232.85 ,$294.29 ,$242.55 
Carle BroMenn Medical Center,8170051,CUP BIMENTUM PFR 61MM PRESSFIT,243404,C1776,278,"$5,238.00 ","$5,238.00 ","$1,571.40 ","$4,766.58 ","$3,666.60 ","$1,571.40 ","$3,404.70 ","$3,771.36 ","$4,766.58 ","$3,928.50 "
Carle BroMenn Medical Center,8170051,CUP VCARE CERV 34MM MD,245134,C1776,278,$237.42 ,$237.42 ,$71.23 ,$216.05 ,$166.19 ,$71.23 ,$154.32 ,$170.94 ,$216.05 ,$178.07 
Carle BroMenn Medical Center,8170051,FEM PSN REV CMT CCR PLS SZ 7R,246793,C1776,278,"$25,162.50 ","$25,162.50 ","$7,548.75 ","$22,897.88 ","$17,613.75 ","$7,548.75 ","$16,355.63 ","$18,117.00 ","$22,897.88 ","$18,871.88 "
Carle BroMenn Medical Center,8170051,FEMUR ATTUNE NAR POR CR LT SZ6,243401,C1776,278,"$4,323.00 ","$4,323.00 ","$1,296.90 ","$3,933.93 ","$3,026.10 ","$1,296.90 ","$2,809.95 ","$3,112.56 ","$3,933.93 ","$3,242.25 "
Carle BroMenn Medical Center,8170051,FEMUR ATTUNE POR CR LT SZ5,242898,C1776,278,"$4,323.00 ","$4,323.00 ","$1,296.90 ","$3,933.93 ","$3,026.10 ","$1,296.90 ","$2,809.95 ","$3,112.56 ","$3,933.93 ","$3,242.25 "
Carle BroMenn Medical Center,8170051,FEMUR ATTUNE POR CR LT SZ8,243402,C1776,278,"$4,110.00 ","$4,110.00 ","$1,233.00 ","$3,740.10 ","$2,877.00 ","$1,233.00 ","$2,671.50 ","$2,959.20 ","$3,740.10 ","$3,082.50 "
Carle BroMenn Medical Center,8170051,FEMUR ATTUNE PS NRW CMNTD RT 5,239896,C1776,278,"$3,723.00 ","$3,723.00 ","$1,116.90 ","$3,387.93 ","$2,606.10 ","$1,116.90 ","$2,419.95 ","$2,680.56 ","$3,387.93 ","$2,792.25 "
Carle BroMenn Medical Center,8170051,FEMUR PS CMNTD STD 5 RT PERSONA,239812,C1776,278,"$4,200.00 ","$4,200.00 ","$1,260.00 ","$3,822.00 ","$2,940.00 ","$1,260.00 ","$2,730.00 ","$3,024.00 ","$3,822.00 ","$3,150.00 "
Carle BroMenn Medical Center,8170051,HEAD BIOLOX DELTA FEM 36X+3.5,243553,C1776,278,"$2,250.00 ","$2,250.00 ",$675.00 ,"$2,047.50 ","$1,575.00 ",$675.00 ,"$1,462.50 ","$1,620.00 ","$2,047.50 ","$1,687.50 "
Carle BroMenn Medical Center,8170051,HEAD FEM 6 DEG 28MM MD+,243411,C1776,278,$900.00 ,$900.00 ,$270.00 ,$819.00 ,$630.00 ,$270.00 ,$585.00 ,$648.00 ,$819.00 ,$675.00 
Carle BroMenn Medical Center,8170051,HEAD HUMERAL 52X19 HIGH OFFSET AE,247871,C1776,278,"$6,756.00 ","$6,756.00 ","$2,026.80 ","$6,147.96 ","$4,729.20 ","$2,026.80 ","$4,391.40 ","$4,864.32 ","$6,147.96 ","$5,067.00 "
Carle BroMenn Medical Center,8170051,HEAD HUML STD 52X15MM GLOBAL UNIT,239927,C1776,278,"$3,000.00 ","$3,000.00 ",$900.00 ,"$2,730.00 ","$2,100.00 ",$900.00 ,"$1,950.00 ","$2,160.00 ","$2,730.00 ","$2,250.00 "
Carle BroMenn Medical Center,8170051,HEAD TANDEM BIPOLAR COCR 43X28,247121,C1776,278,"$2,773.44 ","$2,773.44 ",$832.03 ,"$2,523.83 ","$1,941.41 ",$832.03 ,"$1,802.74 ","$1,996.88 ","$2,523.83 ","$2,080.08 "
Carle BroMenn Medical Center,8170051,HEAD TANDEM BIPOLAR COCR 47X28,247616,C1776,278,"$2,773.44 ","$2,773.44 ",$832.03 ,"$2,523.83 ","$1,941.41 ",$832.03 ,"$1,802.74 ","$1,996.88 ","$2,523.83 ","$2,080.08 "
Carle BroMenn Medical Center,8170051,HIP CORAIL AMT SZ 13 HIGH COL,243967,C1776,278,"$6,000.00 ","$6,000.00 ","$1,800.00 ","$5,460.00 ","$4,200.00 ","$1,800.00 ","$3,900.00 ","$4,320.00 ","$5,460.00 ","$4,500.00 "
Carle BroMenn Medical Center,8170051,HIP HEAD ARTICULEZE M 28MM 1.5,5135,C1776,278,$900.00 ,$900.00 ,$270.00 ,$819.00 ,$630.00 ,$270.00 ,$585.00 ,$648.00 ,$819.00 ,$675.00 
Carle BroMenn Medical Center,8170051,HIP HEAD SLF-CNTR BI-PLR 28X42,4628,C1776,278,"$1,350.00 ","$1,350.00 ",$405.00 ,"$1,228.50 ",$945.00 ,$405.00 ,$877.50 ,$972.00 ,"$1,228.50 ","$1,012.50 "
Carle BroMenn Medical Center,8170051,HIP LINER ACTB GG NTRL 48X32MM VI,242778,C1776,278,"$3,300.00 ","$3,300.00 ",$990.00 ,"$3,003.00 ","$2,310.00 ",$990.00 ,"$2,145.00 ","$2,376.00 ","$3,003.00 ","$2,475.00 "
Carle BroMenn Medical Center,8170051,HIP PINACL DUAL MOBILITY 60/51 PI,247127,C1776,278,"$5,244.00 ","$5,244.00 ","$1,573.20 ","$4,772.04 ","$3,670.80 ","$1,573.20 ","$3,408.60 ","$3,775.68 ","$4,772.04 ","$3,933.00 "
Carle BroMenn Medical Center,8170051,HIP STEM CORAIL REVISION HO14,247126,C1776,278,"$19,638.96 ","$19,638.96 ","$5,891.69 ","$17,871.45 ","$13,747.27 ","$5,891.69 ","$12,765.32 ","$14,140.05 ","$17,871.45 ","$14,729.22 "
Carle BroMenn Medical Center,8170051,HIP STEM FEM 125X12MM 12/14 VRSYS,247873,C1776,278,"$6,000.00 ","$6,000.00 ","$1,800.00 ","$5,460.00 ","$4,200.00 ","$1,800.00 ","$3,900.00 ","$4,320.00 ","$5,460.00 ","$4,500.00 "
Carle BroMenn Medical Center,8170051,HIP STEM METAL TAPER 16MM STD OFF,246796,C1776,278,"$6,000.00 ","$6,000.00 ","$1,800.00 ","$5,460.00 ","$4,200.00 ","$1,800.00 ","$3,900.00 ","$4,320.00 ","$5,460.00 ","$4,500.00 "
Carle BroMenn Medical Center,8170051,HIP STEM SUMMIT STD CMNTD 3,237143,C1776,278,"$4,200.00 ","$4,200.00 ","$1,260.00 ","$3,822.00 ","$2,940.00 ","$1,260.00 ","$2,730.00 ","$3,024.00 ","$3,822.00 ","$3,150.00 "
Carle BroMenn Medical Center,8170051,HUMERAL BEARING 36MM STD VITE,243974,C1776,278,"$3,900.00 ","$3,900.00 ","$1,170.00 ","$3,549.00 ","$2,730.00 ","$1,170.00 ","$2,535.00 ","$2,808.00 ","$3,549.00 ","$2,925.00 "
Carle BroMenn Medical Center,8170051,HUMERAL TRAY +6 STD,243975,C1776,278,"$3,450.00 ","$3,450.00 ","$1,035.00 ","$3,139.50 ","$2,415.00 ","$1,035.00 ","$2,242.50 ","$2,484.00 ","$3,139.50 ","$2,587.50 "
Carle BroMenn Medical Center,8170051,IMPLANT FEMOR NEXGEN LCCK SET D L,243096,C1776,278,"$22,390.50 ","$22,390.50 ","$6,717.15 ","$20,375.36 ","$15,673.35 ","$6,717.15 ","$14,553.83 ","$16,121.16 ","$20,375.36 ","$16,792.88 "
Carle BroMenn Medical Center,8170051,IMPLANT NEXGEN PROLONG 20MM CD FE,243097,C1776,278,"$2,400.00 ","$2,400.00 ",$720.00 ,"$2,184.00 ","$1,680.00 ",$720.00 ,"$1,560.00 ","$1,728.00 ","$2,184.00 ","$1,800.00 "
Carle BroMenn Medical Center,8170051,INSERT ATTUNE CR RP SZ 5 5MM,242899,C1776,278,"$2,757.00 ","$2,757.00 ",$827.10 ,"$2,508.87 ","$1,929.90 ",$827.10 ,"$1,792.05 ","$1,985.04 ","$2,508.87 ","$2,067.75 "
Carle BroMenn Medical Center,8170051,INSERT ATTUNE CR RP SZ 5 6MM,247867,C1776,278,"$2,757.00 ","$2,757.00 ",$827.10 ,"$2,508.87 ","$1,929.90 ",$827.10 ,"$1,792.05 ","$1,985.04 ","$2,508.87 ","$2,067.75 "
Carle BroMenn Medical Center,8170051,INSERT ATTUNE CR RP SZ4 12MM,243400,C1776,278,"$2,757.00 ","$2,757.00 ",$827.10 ,"$2,508.87 ","$1,929.90 ",$827.10 ,"$1,792.05 ","$1,985.04 ","$2,508.87 ","$2,067.75 "
Carle BroMenn Medical Center,8170051,INSERT ATTUNE CR RP SZ8 8MM,243403,C1776,278,"$2,757.00 ","$2,757.00 ",$827.10 ,"$2,508.87 ","$1,929.90 ",$827.10 ,"$1,792.05 ","$1,985.04 ","$2,508.87 ","$2,067.75 "
Carle BroMenn Medical Center,8170051,INSERT ATTUNE CRS RP SZ 6 6MM,242895,C1776,278,"$5,600.46 ","$5,600.46 ","$1,680.14 ","$5,096.42 ","$3,920.32 ","$1,680.14 ","$3,640.30 ","$4,032.33 ","$5,096.42 ","$4,200.35 "
Carle BroMenn Medical Center,8170051,INSERT ATTUNE CRS RP SZ 7 12MM,247395,C1776,278,"$5,600.46 ","$5,600.46 ","$1,680.14 ","$5,096.42 ","$3,920.32 ","$1,680.14 ","$3,640.30 ","$4,032.33 ","$5,096.42 ","$4,200.35 "
Carle BroMenn Medical Center,8170051,INSERT SIGMA SZ2 7MM LM/RL,242646,C1776,278,"$1,350.00 ","$1,350.00 ",$405.00 ,"$1,228.50 ",$945.00 ,$405.00 ,$877.50 ,$972.00 ,"$1,228.50 ","$1,012.50 "
Carle BroMenn Medical Center,8170051,INSERT TIB PS EF 6-9 11MM LT PERS,239891,C1776,278,"$2,400.00 ","$2,400.00 ",$720.00 ,"$2,184.00 ","$1,680.00 ",$720.00 ,"$1,560.00 ","$1,728.00 ","$2,184.00 ","$1,800.00 "
Carle BroMenn Medical Center,8170051,INSERT VEGA PS GLIDE T5 12MM,247392,C1776,278,"$3,750.00 ","$3,750.00 ","$1,125.00 ","$3,412.50 ","$2,625.00 ","$1,125.00 ","$2,437.50 ","$2,700.00 ","$3,412.50 ","$2,812.50 "
Carle BroMenn Medical Center,8170051,INTERBODY 14X13X6MM 7DEG STRL,243136,C1776,278,"$2,100.00 ","$2,100.00 ",$630.00 ,"$1,911.00 ","$1,470.00 ",$630.00 ,"$1,365.00 ","$1,512.00 ","$1,911.00 ","$1,575.00 "
Carle BroMenn Medical Center,8170051,KNEE ARTC 6-9 CD 10MM LT PRSNA PO,242649,C1776,278,"$3,150.00 ","$3,150.00 ",$945.00 ,"$2,866.50 ","$2,205.00 ",$945.00 ,"$2,047.50 ","$2,268.00 ","$2,866.50 ","$2,362.50 "
Carle BroMenn Medical Center,8170051,KNEE PERSONA TRI ASF 12MM R 35 CD,247119,C1776,278,"$2,400.00 ","$2,400.00 ",$720.00 ,"$2,184.00 ","$1,680.00 ",$720.00 ,"$1,560.00 ","$1,728.00 ","$2,184.00 ","$1,800.00 "
Carle BroMenn Medical Center,8170051,KNEE PSN ASF PS 10MM VE L 6-9 EF,243554,C1776,278,"$3,150.00 ","$3,150.00 ",$945.00 ,"$2,866.50 ","$2,205.00 ",$945.00 ,"$2,047.50 ","$2,268.00 ","$2,866.50 ","$2,362.50 "
Carle BroMenn Medical Center,8170051,KNEE PSN ASF PS 11MM L 10-12 GH V,242650,C1776,278,"$3,150.00 ","$3,150.00 ",$945.00 ,"$2,866.50 ","$2,205.00 ",$945.00 ,"$2,047.50 ","$2,268.00 ","$2,866.50 ","$2,362.50 "
Carle BroMenn Medical Center,8170051,KNEE PSN ASF PS 11MM VE L 1011 EF,242777,C1776,278,"$3,150.00 ","$3,150.00 ",$945.00 ,"$2,866.50 ","$2,205.00 ",$945.00 ,"$2,047.50 ","$2,268.00 ","$2,866.50 ","$2,362.50 "
Carle BroMenn Medical Center,8170051,KNEE PSN ASF PS 12MM VE R 6-9 EF,243555,C1776,278,"$3,150.00 ","$3,150.00 ",$945.00 ,"$2,866.50 ","$2,205.00 ",$945.00 ,"$2,047.50 ","$2,268.00 ","$2,866.50 ","$2,362.50 "
Carle BroMenn Medical Center,8170051,KNEE PSN ASF PS 13MM VE L 1012,243098,C1776,278,"$3,150.00 ","$3,150.00 ",$945.00 ,"$2,866.50 ","$2,205.00 ",$945.00 ,"$2,047.50 ","$2,268.00 ","$2,866.50 ","$2,362.50 "
Carle BroMenn Medical Center,8170051,KNEE PSN ASF PS 13MM VE L 6-9 EF,243140,C1776,278,"$3,150.00 ","$3,150.00 ",$945.00 ,"$2,866.50 ","$2,205.00 ",$945.00 ,"$2,047.50 ","$2,268.00 ","$2,866.50 ","$2,362.50 "
Carle BroMenn Medical Center,8170051,KNEE PSN ASF PS 16MM VE 10-12 GH,247619,C1776,278,"$3,150.00 ","$3,150.00 ",$945.00 ,"$2,866.50 ","$2,205.00 ",$945.00 ,"$2,047.50 ","$2,268.00 ","$2,866.50 ","$2,362.50 "
Carle BroMenn Medical Center,8170051,KNEE SURFACE 10MM PSN 6-9 EFRT VI,246795,C1776,278,"$3,150.00 ","$3,150.00 ",$945.00 ,"$2,866.50 ","$2,205.00 ",$945.00 ,"$2,047.50 ","$2,268.00 ","$2,866.50 ","$2,362.50 "
Carle BroMenn Medical Center,8170051,LINER 10DEGREE 36MM XL 62X10.9 LO,243552,C1776,278,"$2,550.00 ","$2,550.00 ",$765.00 ,"$2,320.50 ","$1,785.00 ",$765.00 ,"$1,657.50 ","$1,836.00 ","$2,320.50 ","$1,912.50 "
Carle BroMenn Medical Center,8170051,LINER BIMENTUM PFR PE 61X28MM,243405,C1776,278,"$3,312.00 ","$3,312.00 ",$993.60 ,"$3,013.92 ","$2,318.40 ",$993.60 ,"$2,152.80 ","$2,384.64 ","$3,013.92 ","$2,484.00 "
Carle BroMenn Medical Center,8170051,LINER G7 VIT E HIGH WALL 36MME,243410,C1776,278,"$3,300.00 ","$3,300.00 ",$990.00 ,"$3,003.00 ","$2,310.00 ",$990.00 ,"$2,145.00 ","$2,376.00 ","$3,003.00 ","$2,475.00 "
Carle BroMenn Medical Center,8170051,PATELLA PERSONA 32MM,239484,C1776,278,$900.00 ,$900.00 ,$270.00 ,$819.00 ,$630.00 ,$270.00 ,$585.00 ,$648.00 ,$819.00 ,$675.00 
Carle BroMenn Medical Center,8170051,RESTRICTOR CEMENT SZ 3,242896,C1776,278,$180.00 ,$180.00 ,$54.00 ,$163.80 ,$126.00 ,$54.00 ,$117.00 ,$129.60 ,$163.80 ,$135.00 
Carle BroMenn Medical Center,8170051,RESTRICTOR CEMENT SZ 5,242897,C1776,278,$180.00 ,$180.00 ,$54.00 ,$163.80 ,$126.00 ,$54.00 ,$117.00 ,$129.60 ,$163.80 ,$135.00 
Carle BroMenn Medical Center,8170051,SHELL G7 OSSEOTI 3H 52MM E,243409,C1776,278,"$9,240.00 ","$9,240.00 ","$2,772.00 ","$8,408.40 ","$6,468.00 ","$2,772.00 ","$6,006.00 ","$6,652.80 ","$8,408.40 ","$6,930.00 "
Carle BroMenn Medical Center,8170051,SHELL TRIDENT II CLUSTERHL 56F PS,246786,C1776,278,"$3,000.00 ","$3,000.00 ",$900.00 ,"$2,730.00 ","$2,100.00 ",$900.00 ,"$1,950.00 ","$2,160.00 ","$2,730.00 ","$2,250.00 "
Carle BroMenn Medical Center,8170051,SHOULDER 36MM COMP RVRS GLNSP STD,243972,C1776,278,"$3,450.00 ","$3,450.00 ","$1,035.00 ","$3,139.50 ","$2,415.00 ","$1,035.00 ","$2,242.50 ","$2,484.00 ","$3,139.50 ","$2,587.50 "
Carle BroMenn Medical Center,8170051,SLEEVE ATTUNE FEM M/L 45MM FLL,242648,C1776,278,"$6,288.66 ","$6,288.66 ","$1,886.60 ","$5,722.68 ","$4,402.06 ","$1,886.60 ","$4,087.63 ","$4,527.84 ","$5,722.68 ","$4,716.50 "
Carle BroMenn Medical Center,8170051,SLEEVE ATUN FEM M/L 35MM FULL,242893,C1776,278,"$6,288.66 ","$6,288.66 ","$1,886.60 ","$5,722.68 ","$4,402.06 ","$1,886.60 ","$4,087.63 ","$4,527.84 ","$5,722.68 ","$4,716.50 "
Carle BroMenn Medical Center,8170051,SLEEVE SROM PROX ZTT 20F LG 10 PE,245098,C1776,278,$11.40 ,$11.40 ,$3.42 ,$10.37 ,$7.98 ,$3.42 ,$7.41 ,$8.21 ,$10.37 ,$8.55 
Carle BroMenn Medical Center,8170051,SPACER RISE 7-13X8X22MM,247116,C1776,278,"$19,200.00 ","$19,200.00 ","$5,760.00 ","$17,472.00 ","$13,440.00 ","$5,760.00 ","$12,480.00 ","$13,824.00 ","$17,472.00 ","$14,400.00 "
Carle BroMenn Medical Center,8170051,SPACER RISE 8X22MM 11-17 15 DEG,243093,C1776,278,"$19,200.00 ","$19,200.00 ","$5,760.00 ","$17,472.00 ","$13,440.00 ","$5,760.00 ","$12,480.00 ","$13,824.00 ","$17,472.00 ","$14,400.00 "
Carle BroMenn Medical Center,8170051,STEM ATTUNE CEMENTED 14X80MM,247125,C1776,278,"$1,999.50 ","$1,999.50 ",$599.85 ,"$1,819.55 ","$1,399.65 ",$599.85 ,"$1,299.68 ","$1,439.64 ","$1,819.55 ","$1,499.63 "
Carle BroMenn Medical Center,8170051,STEM COMPR PRIMARY 11MM MINI,246792,C1776,278,"$8,250.00 ","$8,250.00 ","$2,475.00 ","$7,507.50 ","$5,775.00 ","$2,475.00 ","$5,362.50 ","$5,940.00 ","$7,507.50 ","$6,187.50 "
Carle BroMenn Medical Center,8170051,STEM FRACTURE 8X122 COMP PPS,243973,C1776,278,"$10,200.00 ","$10,200.00 ","$3,060.00 ","$9,282.00 ","$7,140.00 ","$3,060.00 ","$6,630.00 ","$7,344.00 ","$9,282.00 ","$7,650.00 "
Carle BroMenn Medical Center,8170051,STEM GLOBAL UNITE STD 10,238282,C1776,278,"$9,000.00 ","$9,000.00 ","$2,700.00 ","$8,190.00 ","$6,300.00 ","$2,700.00 ","$5,850.00 ","$6,480.00 ","$8,190.00 ","$6,750.00 "
Carle BroMenn Medical Center,8170051,STEM HUMERAL 5B FLEX STD PTC,247872,C1776,278,"$6,897.00 ","$6,897.00 ","$2,069.10 ","$6,276.27 ","$4,827.90 ","$2,069.10 ","$4,483.05 ","$4,965.84 ","$6,276.27 ","$5,172.75 "
Carle BroMenn Medical Center,8170051,STEM PSN REV STR SPLINE 13X135,246794,C1776,278,"$5,692.50 ","$5,692.50 ","$1,707.75 ","$5,180.18 ","$3,984.75 ","$1,707.75 ","$3,700.13 ","$4,098.60 ","$5,180.18 ","$4,269.38 "
Carle BroMenn Medical Center,8170051,TIBIA STEM CMNTD C 5D RT,239692,C1776,278,"$3,000.00 ","$3,000.00 ",$900.00 ,"$2,730.00 ","$2,100.00 ",$900.00 ,"$1,950.00 ","$2,160.00 ","$2,730.00 ","$2,250.00 "
Carle BroMenn Medical Center,8170051,WEDGE AUGM DIST 2 4MM RT PFC SIGM,239887,C1776,278,"$1,949.40 ","$1,949.40 ",$584.82 ,"$1,773.95 ","$1,364.58 ",$584.82 ,"$1,267.11 ","$1,403.57 ","$1,773.95 ","$1,462.05 "
Carle BroMenn Medical Center,8170051,WEDGE EVANS ALLOGRAFT 10X22X20,247605,C1776,278,"$5,153.85 ","$5,153.85 ","$1,546.16 ","$4,690.00 ","$3,607.70 ","$1,546.16 ","$3,350.00 ","$3,710.77 ","$4,690.00 ","$3,865.39 "
Carle BroMenn Medical Center,8170053,CABLE 2.16MM INTERSTIM SURESCN RE,242421,C1778,278,$750.00 ,$750.00 ,$225.00 ,$682.50 ,$525.00 ,$225.00 ,$487.50 ,$540.00 ,$682.50 ,$562.50 
Carle BroMenn Medical Center,8170053,CABLE 4.32MM INTERSTIM SURESCN RE,242422,C1778,278,$750.00 ,$750.00 ,$225.00 ,$682.50 ,$525.00 ,$225.00 ,$487.50 ,$540.00 ,$682.50 ,$562.50 
Carle BroMenn Medical Center,8170053,CABLE PATIENT URO STIMULATOR,219247,C1778,278,$120.00 ,$120.00 ,$36.00 ,$109.20 ,$84.00 ,$36.00 ,$78.00 ,$86.40 ,$109.20 ,$90.00 
Carle BroMenn Medical Center,8170053,KIT MRI LEAD 2.16X28 INTERSTIM RE,242423,C1778,278,"$13,662.00 ","$13,662.00 ","$4,098.60 ","$12,432.42 ","$9,563.40 ","$4,098.60 ","$8,880.30 ","$9,836.64 ","$12,432.42 ","$10,246.50 "
Carle BroMenn Medical Center,8170053,KIT MRI LEAD 2.16X33 INTERSTIM RE,242430,C1778,278,"$13,662.00 ","$13,662.00 ","$4,098.60 ","$12,432.42 ","$9,563.40 ","$4,098.60 ","$8,880.30 ","$9,836.64 ","$12,432.42 ","$10,246.50 "
Carle BroMenn Medical Center,8170053,KIT MRI LEAD 2.16X41 INTERSTIM RE,242431,C1778,278,"$13,662.00 ","$13,662.00 ","$4,098.60 ","$12,432.42 ","$9,563.40 ","$4,098.60 ","$8,880.30 ","$9,836.64 ","$12,432.42 ","$10,246.50 "
Carle BroMenn Medical Center,8170053,KIT MRI LEAD 4.32X33 INTERSTIM RE,242432,C1778,278,"$13,662.00 ","$13,662.00 ","$4,098.60 ","$12,432.42 ","$9,563.40 ","$4,098.60 ","$8,880.30 ","$9,836.64 ","$12,432.42 ","$10,246.50 "
Carle BroMenn Medical Center,8170053,KIT MRI LEAD 4.32X41 INTERSTIM RE,242433,C1778,278,"$13,662.00 ","$13,662.00 ","$4,098.60 ","$12,432.42 ","$9,563.40 ","$4,098.60 ","$8,880.30 ","$9,836.64 ","$12,432.42 ","$10,246.50 "
Carle BroMenn Medical Center,8170063,KIT REMOTE CTL FREELINK WAVEWRITE,238937,C1787,278,"$2,700.00 ","$2,700.00 ",$810.00 ,"$2,457.00 ","$1,890.00 ",$810.00 ,"$1,755.00 ","$1,944.00 ","$2,457.00 ","$2,025.00 "
Carle BroMenn Medical Center,8170063,PROGRAMMER PATIENT INTERSTIM W/ C,139656,C1787,278,"$5,850.00 ","$5,850.00 ","$1,755.00 ","$5,323.50 ","$4,095.00 ","$1,755.00 ","$3,802.50 ","$4,212.00 ","$5,323.50 ","$4,387.50 "
Carle BroMenn Medical Center,8170066,OR STENT-BILIARY,,C1729,278,"$2,018.90 ","$2,018.90 ",$605.67 ,"$1,837.20 ","$1,413.23 ",$605.67 ,"$1,312.29 ","$1,453.61 ","$1,837.20 ","$1,514.18 "
Carle BroMenn Medical Center,8170081,KIT CHARGING SYSTEM,8910,C1820,278,"$5,250.00 ","$5,250.00 ","$1,575.00 ","$4,777.50 ","$3,675.00 ","$1,575.00 ","$3,412.50 ","$3,780.00 ","$4,777.50 ","$3,937.50 "
Carle BroMenn Medical Center,8170081,KIT RECHARGER INTERSTIM,242426,C1820,278,"$4,050.00 ","$4,050.00 ","$1,215.00 ","$3,685.50 ","$2,835.00 ","$1,215.00 ","$2,632.50 ","$2,916.00 ","$3,685.50 ","$3,037.50 "
Carle BroMenn Medical Center,8170603,ANCHOR QUICK 2.4MM CP-2,1697,C1713,278,"$1,515.00 ","$1,515.00 ",$454.50 ,"$1,378.65 ","$1,060.50 ",$454.50 ,$984.75 ,"$1,090.80 ","$1,378.65 ","$1,136.25 "
Carle BroMenn Medical Center,8170603,ANCHOR SUT BIOCORK 5.5MM W/3 SUT,237124,C1713,278,"$1,020.00 ","$1,020.00 ",$306.00 ,$928.20 ,$714.00 ,$306.00 ,$663.00 ,$734.40 ,$928.20 ,$765.00 
Carle BroMenn Medical Center,8170603,ANCHOR SUT CRKSCRW FTHR 5.5,239048,C1713,278,$0.67 ,$0.67 ,$0.20 ,$0.61 ,$0.47 ,$0.20 ,$0.44 ,$0.48 ,$0.61 ,$0.50 
Carle BroMenn Medical Center,8170603,CABLE WITH CRIMP,4548,C1713,278,$741.06 ,$741.06 ,$222.32 ,$674.36 ,$518.74 ,$222.32 ,$481.69 ,$533.56 ,$674.36 ,$555.80 
Carle BroMenn Medical Center,8170603,CAP END T2 SCN FULLY THREADED,243022,C1713,278,$638.55 ,$638.55 ,$191.57 ,$581.08 ,$446.99 ,$191.57 ,$415.06 ,$459.76 ,$581.08 ,$478.91 
Carle BroMenn Medical Center,8170603,CAP LOCKING CREO THREADED,241410,C1713,278,$210.00 ,$210.00 ,$63.00 ,$191.10 ,$147.00 ,$63.00 ,$136.50 ,$151.20 ,$191.10 ,$157.50 
Carle BroMenn Medical Center,8170603,CAP NAIL 14MM TI-6AL-4V CEPHALOME,247878,C1713,278,$573.51 ,$573.51 ,$172.05 ,$521.89 ,$401.46 ,$172.05 ,$372.78 ,$412.93 ,$521.89 ,$430.13 
Carle BroMenn Medical Center,8170603,CROSSLINK ROD TO ROD M,243590,C1713,278,"$3,744.00 ","$3,744.00 ","$1,123.20 ","$3,407.04 ","$2,620.80 ","$1,123.20 ","$2,433.60 ","$2,695.68 ","$3,407.04 ","$2,808.00 "
Carle BroMenn Medical Center,8170603,INSERT CLAMP FIBRA #5 90MM,244754,C1713,278,$55.50 ,$55.50 ,$16.65 ,$50.51 ,$38.85 ,$16.65 ,$36.08 ,$39.96 ,$50.51 ,$41.63 
Carle BroMenn Medical Center,8170603,KIT ANTEROMEDIALIZATION DISP,237569,C1713,278,"$1,497.00 ","$1,497.00 ",$449.10 ,"$1,362.27 ","$1,047.90 ",$449.10 ,$973.05 ,"$1,077.84 ","$1,362.27 ","$1,122.75 "
Carle BroMenn Medical Center,8170603,KWIRE .9MX152MM DUAL-TROCAR,245131,C1713,278,$18.75 ,$18.75 ,$5.63 ,$17.06 ,$13.13 ,$5.63 ,$12.19 ,$13.50 ,$17.06 ,$14.06 
Carle BroMenn Medical Center,8170603,KWIRE DUAL-TROCAR .045 6IN,244677,C1713,278,$18.75 ,$18.75 ,$5.63 ,$17.06 ,$13.13 ,$5.63 ,$12.19 ,$13.50 ,$17.06 ,$14.06 
Carle BroMenn Medical Center,8170603,KWIRE DUAL-TROCAR .062X6IN,244747,C1713,278,$19.69 ,$19.69 ,$5.91 ,$17.92 ,$13.78 ,$5.91 ,$12.80 ,$14.18 ,$17.92 ,$14.77 
Carle BroMenn Medical Center,8170603,NAIL LONG ZNAIL CPM 11.5X42 LT CE,247880,C1713,278,"$6,387.66 ","$6,387.66 ","$1,916.30 ","$5,812.77 ","$4,471.36 ","$1,916.30 ","$4,151.98 ","$4,599.12 ","$5,812.77 ","$4,790.75 "
Carle BroMenn Medical Center,8170603,NAIL META TIBIAL 10MMX30CM,248082,C1713,278,"$7,951.83 ","$7,951.83 ","$2,385.55 ","$7,236.17 ","$5,566.28 ","$2,385.55 ","$5,168.69 ","$5,725.32 ","$7,236.17 ","$5,963.87 "
Carle BroMenn Medical Center,8170603,NAIL T2 ANKLE 10X200MM RT TRIGEN,243018,C1713,278,"$9,400.95 ","$9,400.95 ","$2,820.29 ","$8,554.86 ","$6,580.67 ","$2,820.29 ","$6,110.62 ","$6,768.68 ","$8,554.86 ","$7,050.71 "
Carle BroMenn Medical Center,8170603,NAIL TFNA 125 DEG 10X170MM,6449,C1713,278,"$4,498.11 ","$4,498.11 ","$1,349.43 ","$4,093.28 ","$3,148.68 ","$1,349.43 ","$2,923.77 ","$3,238.64 ","$4,093.28 ","$3,373.58 "
Carle BroMenn Medical Center,8170603,NAIL Z CPM SHORT 14.5MMX21.5CM 13,247394,C1713,278,"$4,251.84 ","$4,251.84 ","$1,275.55 ","$3,869.17 ","$2,976.29 ","$1,275.55 ","$2,763.70 ","$3,061.32 ","$3,869.17 ","$3,188.88 "
Carle BroMenn Medical Center,8170603,PIN 12MM DISTRACTION,41,C1713,278,$63.00 ,$63.00 ,$18.90 ,$57.33 ,$44.10 ,$18.90 ,$40.95 ,$45.36 ,$57.33 ,$47.25 
Carle BroMenn Medical Center,8170603,PIN 2.0MM,247881,C1713,278,$267.00 ,$267.00 ,$80.10 ,$242.97 ,$186.90 ,$80.10 ,$173.55 ,$192.24 ,$242.97 ,$200.25 
Carle BroMenn Medical Center,8170603,PIN FIX ANCHORAGE,243574,C1713,278,$323.76 ,$323.76 ,$97.13 ,$294.62 ,$226.63 ,$97.13 ,$210.44 ,$233.11 ,$294.62 ,$242.82 
Carle BroMenn Medical Center,8170603,PIN HALF APEX SLF 5MM 180X50MM,233311,C1713,278,$269.10 ,$269.10 ,$80.73 ,$244.88 ,$188.37 ,$80.73 ,$174.92 ,$193.75 ,$244.88 ,$201.83 
Carle BroMenn Medical Center,8170603,PIN NON-RIMMED SPEED 65MM STL,237577,C1713,278,$1.11 ,$1.11 ,$0.33 ,$1.01 ,$0.78 ,$0.33 ,$0.72 ,$0.80 ,$1.01 ,$0.83 
Carle BroMenn Medical Center,8170603,PIN PERCU 100MM,244790,C1713,278,$921.00 ,$921.00 ,$276.30 ,$838.11 ,$644.70 ,$276.30 ,$598.65 ,$663.12 ,$838.11 ,$690.75 
Carle BroMenn Medical Center,8170603,PIN PERCU 150MM STL DISP,244775,C1713,278,$921.00 ,$921.00 ,$276.30 ,$838.11 ,$644.70 ,$276.30 ,$598.65 ,$663.12 ,$838.11 ,$690.75 
Carle BroMenn Medical Center,8170603,PLATE 1/3 TUBLR 81MM 7H,2982,C1713,278,$516.84 ,$516.84 ,$155.05 ,$470.32 ,$361.79 ,$155.05 ,$335.95 ,$372.12 ,$470.32 ,$387.63 
Carle BroMenn Medical Center,8170603,PLATE 2H ANTERIOR 6MM,243139,C1713,278,"$1,800.00 ","$1,800.00 ",$540.00 ,"$1,638.00 ","$1,260.00 ",$540.00 ,"$1,170.00 ","$1,296.00 ","$1,638.00 ","$1,350.00 "
Carle BroMenn Medical Center,8170603,PLATE 43MM LEVEL 2,242900,C1713,278,"$2,700.00 ","$2,700.00 ",$810.00 ,"$2,457.00 ","$1,890.00 ",$810.00 ,"$1,755.00 ","$1,944.00 ","$2,457.00 ","$2,025.00 "
Carle BroMenn Medical Center,8170603,PLATE ATL VISION ELITE 60MM,244047,C1713,278,"$3,300.00 ","$3,300.00 ",$990.00 ,"$3,003.00 ","$2,310.00 ",$990.00 ,"$2,145.00 ","$2,376.00 ","$3,003.00 ","$2,475.00 "
Carle BroMenn Medical Center,8170603,PLATE ATLANTIS 23MM VISION ELITE,242983,C1713,278,"$2,700.00 ","$2,700.00 ",$810.00 ,"$2,457.00 ","$1,890.00 ",$810.00 ,"$1,755.00 ","$1,944.00 ","$2,457.00 ","$2,025.00 "
Carle BroMenn Medical Center,8170603,PLATE CALCANEUS MESH MEDIUM,243575,C1713,278,"$2,139.00 ","$2,139.00 ",$641.70 ,"$1,946.49 ","$1,497.30 ",$641.70 ,"$1,390.35 ","$1,540.08 ","$1,946.49 ","$1,604.25 "
Carle BroMenn Medical Center,8170603,PLATE CLAVICLE 8H STR RT NRW PROF,247598,C1713,278,"$3,678.00 ","$3,678.00 ","$1,103.40 ","$3,346.98 ","$2,574.60 ","$1,103.40 ","$2,390.70 ","$2,648.16 ","$3,346.98 ","$2,758.50 "
Carle BroMenn Medical Center,8170603,PLATE HELIX LVL1 20MM,243025,C1713,278,"$1,440.00 ","$1,440.00 ",$432.00 ,"$1,310.40 ","$1,008.00 ",$432.00 ,$936.00 ,"$1,036.80 ","$1,310.40 ","$1,080.00 "
Carle BroMenn Medical Center,8170603,PLATE HOOK COMPRESSION LFT 5H,244048,C1713,278,"$3,450.00 ","$3,450.00 ","$1,035.00 ","$3,139.50 ","$2,415.00 ","$1,035.00 ","$2,242.50 ","$2,484.00 ","$3,139.50 ","$2,587.50 "
Carle BroMenn Medical Center,8170603,PLATE LOCKING MEDIAL 12 HOLE,3107,C1713,278,"$3,504.00 ","$3,504.00 ","$1,051.20 ","$3,188.64 ","$2,452.80 ","$1,051.20 ","$2,277.60 ","$2,522.88 ","$3,188.64 ","$2,628.00 "
Carle BroMenn Medical Center,8170603,PLATE LVL 1 NEURO 2H 17MM ULTRAON,242634,C1713,278,$138.00 ,$138.00 ,$41.40 ,$125.58 ,$96.60 ,$41.40 ,$89.70 ,$99.36 ,$125.58 ,$103.50 
Carle BroMenn Medical Center,8170603,PLATE OLECRANON 3H LT STANDARD,247599,C1713,278,"$3,804.00 ","$3,804.00 ","$1,141.20 ","$3,461.64 ","$2,662.80 ","$1,141.20 ","$2,472.60 ","$2,738.88 ","$3,461.64 ","$2,853.00 "
Carle BroMenn Medical Center,8170603,PLATE PRX HUM HI LT 3H 80MM,243992,C1713,278,"$4,257.00 ","$4,257.00 ","$1,277.10 ","$3,873.87 ","$2,979.90 ","$1,277.10 ","$2,767.05 ","$3,065.04 ","$3,873.87 ","$3,192.75 "
Carle BroMenn Medical Center,8170603,PLATE VA CONDYLAR 12H RT,228496,C1713,278,"$6,339.60 ","$6,339.60 ","$1,901.88 ","$5,769.04 ","$4,437.72 ","$1,901.88 ","$4,120.74 ","$4,564.51 ","$5,769.04 ","$4,754.70 "
Carle BroMenn Medical Center,8170603,PLATE VA CONDYLAR 14H LT,228499,C1713,278,"$6,764.40 ","$6,764.40 ","$2,029.32 ","$6,155.60 ","$4,735.08 ","$2,029.32 ","$4,396.86 ","$4,870.37 ","$6,155.60 ","$5,073.30 "
Carle BroMenn Medical Center,8170603,PLATE ZEVO LVL 4 78MM,242707,C1713,278,"$3,600.00 ","$3,600.00 ","$1,080.00 ","$3,276.00 ","$2,520.00 ","$1,080.00 ","$2,340.00 ","$2,592.00 ","$3,276.00 ","$2,700.00 "
Carle BroMenn Medical Center,8170603,ROD CREO CURVED 5.5X65MM,247130,C1713,278,$630.00 ,$630.00 ,$189.00 ,$573.30 ,$441.00 ,$189.00 ,$409.50 ,$453.60 ,$573.30 ,$472.50 
Carle BroMenn Medical Center,8170603,ROD LOOP OSTOMY 65MM,244652,C1713,278,$4.37 ,$4.37 ,$1.31 ,$3.98 ,$3.06 ,$1.31 ,$2.84 ,$3.15 ,$3.98 ,$3.28 
Carle BroMenn Medical Center,8170603,ROD VERTEX INFINITY 3.5X240MM CHR,243589,C1713,278,$600.00 ,$600.00 ,$180.00 ,$546.00 ,$420.00 ,$180.00 ,$390.00 ,$432.00 ,$546.00 ,$450.00 
Carle BroMenn Medical Center,8170603,SCREW 2.7MM NON LOCK 14MM,233859,C1713,278,$198.00 ,$198.00 ,$59.40 ,$180.18 ,$138.60 ,$59.40 ,$128.70 ,$142.56 ,$180.18 ,$148.50 
Carle BroMenn Medical Center,8170603,SCREW 3.5 HEX LOCK CMP 4.75X30,246789,C1713,278,$165.00 ,$165.00 ,$49.50 ,$150.15 ,$115.50 ,$49.50 ,$107.25 ,$118.80 ,$150.15 ,$123.75 
Carle BroMenn Medical Center,8170603,SCREW 3.5 HEX NONLOCK,246790,C1713,278,$165.00 ,$165.00 ,$49.50 ,$150.15 ,$115.50 ,$49.50 ,$107.25 ,$118.80 ,$150.15 ,$123.75 
Carle BroMenn Medical Center,8170603,SCREW 3.5MM CORT 50MM,233540,C1713,278,$73.20 ,$73.20 ,$21.96 ,$66.61 ,$51.24 ,$21.96 ,$47.58 ,$52.70 ,$66.61 ,$54.90 
Carle BroMenn Medical Center,8170603,SCREW 3.5MM CORT LOCK 36MM,243997,C1713,278,$396.00 ,$396.00 ,$118.80 ,$360.36 ,$277.20 ,$118.80 ,$257.40 ,$285.12 ,$360.36 ,$297.00 
Carle BroMenn Medical Center,8170603,SCREW 3.5MM CORT LOCK 38MM,243994,C1713,278,$396.00 ,$396.00 ,$118.80 ,$360.36 ,$277.20 ,$118.80 ,$257.40 ,$285.12 ,$360.36 ,$297.00 
Carle BroMenn Medical Center,8170603,SCREW 3.5MM CORT LOCK 42MM,243995,C1713,278,$396.00 ,$396.00 ,$118.80 ,$360.36 ,$277.20 ,$118.80 ,$257.40 ,$285.12 ,$360.36 ,$297.00 
Carle BroMenn Medical Center,8170603,SCREW 3.5MM CORT LOCK 42MM,243996,C1713,278,$396.00 ,$396.00 ,$118.80 ,$360.36 ,$277.20 ,$118.80 ,$257.40 ,$285.12 ,$360.36 ,$297.00 
Carle BroMenn Medical Center,8170603,SCREW 3.5MM CORT LOCK 52MM,243993,C1713,278,$396.00 ,$396.00 ,$118.80 ,$360.36 ,$277.20 ,$118.80 ,$257.40 ,$285.12 ,$360.36 ,$297.00 
Carle BroMenn Medical Center,8170603,SCREW 3.5MM VARIABLE SLF 14MM,243137,C1713,278,$300.00 ,$300.00 ,$90.00 ,$273.00 ,$210.00 ,$90.00 ,$195.00 ,$216.00 ,$273.00 ,$225.00 
Carle BroMenn Medical Center,8170603,SCREW 3DI NONLOCK 3.5X32MM,198535,C1713,278,$315.00 ,$315.00 ,$94.50 ,$286.65 ,$220.50 ,$94.50 ,$204.75 ,$226.80 ,$286.65 ,$236.25 
Carle BroMenn Medical Center,8170603,SCREW 3DI NONLOCK 3.5X42MM,198540,C1713,278,$315.00 ,$315.00 ,$94.50 ,$286.65 ,$220.50 ,$94.50 ,$204.75 ,$226.80 ,$286.65 ,$236.25 
Carle BroMenn Medical Center,8170603,SCREW 45MM 5MM TI LCK FT T2 STRL,243011,C1713,278,$620.40 ,$620.40 ,$186.12 ,$564.56 ,$434.28 ,$186.12 ,$403.26 ,$446.69 ,$564.56 ,$465.30 
Carle BroMenn Medical Center,8170603,SCREW 5.0MM VA LOCK X 36MM,64310,C1713,278,$554.40 ,$554.40 ,$166.32 ,$504.50 ,$388.08 ,$166.32 ,$360.36 ,$399.17 ,$504.50 ,$415.80 
Carle BroMenn Medical Center,8170603,SCREW 5.0MM VA LOCK X 38MM,64311,C1713,278,$554.40 ,$554.40 ,$166.32 ,$504.50 ,$388.08 ,$166.32 ,$360.36 ,$399.17 ,$504.50 ,$415.80 
Carle BroMenn Medical Center,8170603,SCREW 5.0MM VA LOCK X 40MM,64312,C1713,278,$554.40 ,$554.40 ,$166.32 ,$504.50 ,$388.08 ,$166.32 ,$360.36 ,$399.17 ,$504.50 ,$415.80 
Carle BroMenn Medical Center,8170603,SCREW 5.0MM VA LOCK X 60MM,64319,C1713,278,$554.40 ,$554.40 ,$166.32 ,$504.50 ,$388.08 ,$166.32 ,$360.36 ,$399.17 ,$504.50 ,$415.80 
Carle BroMenn Medical Center,8170603,SCREW 5.0MM VA LOCK X 70MM,213574,C1713,278,$554.40 ,$554.40 ,$166.32 ,$504.50 ,$388.08 ,$166.32 ,$360.36 ,$399.17 ,$504.50 ,$415.80 
Carle BroMenn Medical Center,8170603,SCREW 5.0MM VA LOCK X 80MM,213576,C1713,278,$554.40 ,$554.40 ,$166.32 ,$504.50 ,$388.08 ,$166.32 ,$360.36 ,$399.17 ,$504.50 ,$415.80 
Carle BroMenn Medical Center,8170603,SCREW 5.0MM VA LOCK X 85MM,213577,C1713,278,$554.40 ,$554.40 ,$166.32 ,$504.50 ,$388.08 ,$166.32 ,$360.36 ,$399.17 ,$504.50 ,$415.80 
Carle BroMenn Medical Center,8170603,SCREW 5.0MM VA LOCK X 90MM,213578,C1713,278,$554.40 ,$554.40 ,$166.32 ,$504.50 ,$388.08 ,$166.32 ,$360.36 ,$399.17 ,$504.50 ,$415.80 
Carle BroMenn Medical Center,8170603,SCREW BONE 3.5X14,242962,C1713,278,$937.20 ,$937.20 ,$281.16 ,$852.85 ,$656.04 ,$281.16 ,$609.18 ,$674.78 ,$852.85 ,$702.90 
Carle BroMenn Medical Center,8170603,SCREW BONE MOD SHANK 6.5X45MM REL,245229,C1713,278,$750.00 ,$750.00 ,$225.00 ,$682.50 ,$525.00 ,$225.00 ,$487.50 ,$540.00 ,$682.50 ,$562.50 
Carle BroMenn Medical Center,8170603,SCREW BONE T10 FULL 3.5X18MM,247614,C1713,278,$250.74 ,$250.74 ,$75.22 ,$228.17 ,$175.52 ,$75.22 ,$162.98 ,$180.53 ,$228.17 ,$188.06 
Carle BroMenn Medical Center,8170603,SCREW BONE T10 FULL 3.5X20MM,247615,C1713,278,$250.74 ,$250.74 ,$75.22 ,$228.17 ,$175.52 ,$75.22 ,$162.98 ,$180.53 ,$228.17 ,$188.06 
Carle BroMenn Medical Center,8170603,SCREW CANN 7.3X85MM 16MM THRD 4MM,12252,C1713,278,$850.02 ,$850.02 ,$255.01 ,$773.52 ,$595.01 ,$255.01 ,$552.51 ,$612.01 ,$773.52 ,$637.52 
Carle BroMenn Medical Center,8170603,SCREW CANN 7.3X90MM 16MM THRD,12253,C1713,278,$850.02 ,$850.02 ,$255.01 ,$773.52 ,$595.01 ,$255.01 ,$552.51 ,$612.01 ,$773.52 ,$637.52 
Carle BroMenn Medical Center,8170603,SCREW CANN BONE 6.5X30MM PINNACLE,5292,C1713,278,$231.00 ,$231.00 ,$69.30 ,$210.21 ,$161.70 ,$69.30 ,$150.15 ,$166.32 ,$210.21 ,$173.25 
Carle BroMenn Medical Center,8170603,SCREW CANN BONE 6.5X35MM PINNACLE,5293,C1713,278,$231.00 ,$231.00 ,$69.30 ,$210.21 ,$161.70 ,$69.30 ,$150.15 ,$166.32 ,$210.21 ,$173.25 
Carle BroMenn Medical Center,8170603,SCREW CANN LONG THREAD 4.0X38M,247600,C1713,278,$654.72 ,$654.72 ,$196.42 ,$595.80 ,$458.30 ,$196.42 ,$425.57 ,$471.40 ,$595.80 ,$491.04 
Carle BroMenn Medical Center,8170603,SCREW CORT 3.5X44MM SLFTAP LOW PR,243406,C1713,278,$109.80 ,$109.80 ,$32.94 ,$99.92 ,$76.86 ,$32.94 ,$71.37 ,$79.06 ,$99.92 ,$82.35 
Carle BroMenn Medical Center,8170603,SCREW CORT 4.5X32MM SS,3199,C1713,278,$72.57 ,$72.57 ,$21.77 ,$66.04 ,$50.80 ,$21.77 ,$47.17 ,$52.25 ,$66.04 ,$54.43 
Carle BroMenn Medical Center,8170603,SCREW CORT ST 5X42MM NCB,247885,C1713,278,$464.76 ,$464.76 ,$139.43 ,$422.93 ,$325.33 ,$139.43 ,$302.09 ,$334.63 ,$422.93 ,$348.57 
Carle BroMenn Medical Center,8170603,SCREW CORT ST 5X46MM NCB,247886,C1713,278,$464.76 ,$464.76 ,$139.43 ,$422.93 ,$325.33 ,$139.43 ,$302.09 ,$334.63 ,$422.93 ,$348.57 
Carle BroMenn Medical Center,8170603,SCREW CORT ST 5X48MM NCB,247884,C1713,278,$464.76 ,$464.76 ,$139.43 ,$422.93 ,$325.33 ,$139.43 ,$302.09 ,$334.63 ,$422.93 ,$348.57 
Carle BroMenn Medical Center,8170603,SCREW CORT ST 5X50MM NCB,247883,C1713,278,$464.76 ,$464.76 ,$139.43 ,$422.93 ,$325.33 ,$139.43 ,$302.09 ,$334.63 ,$422.93 ,$348.57 
Carle BroMenn Medical Center,8170603,SCREW CORT ZNAIL 5.0X52.5 FA,247877,C1713,278,$553.74 ,$553.74 ,$166.12 ,$503.90 ,$387.62 ,$166.12 ,$359.93 ,$398.69 ,$503.90 ,$415.31 
Carle BroMenn Medical Center,8170603,SCREW CREO AMP 55X40MM MODULAR,247128,C1713,278,"$1,200.00 ","$1,200.00 ",$360.00 ,"$1,092.00 ",$840.00 ,$360.00 ,$780.00 ,$864.00 ,"$1,092.00 ",$900.00 
Carle BroMenn Medical Center,8170603,SCREW CREO AMP 55X45MM MODULAR,242298,C1713,278,"$1,200.00 ","$1,200.00 ",$360.00 ,"$1,092.00 ",$840.00 ,$360.00 ,$780.00 ,$864.00 ,"$1,092.00 ",$900.00 
Carle BroMenn Medical Center,8170603,SCREW CREO AMP 55X50MM MODULAR,247129,C1713,278,"$1,200.00 ","$1,200.00 ",$360.00 ,"$1,092.00 ",$840.00 ,$360.00 ,$780.00 ,$864.00 ,"$1,092.00 ",$900.00 
Carle BroMenn Medical Center,8170603,SCREW FIX 4.0X15 SELF TAP,243407,C1713,278,$495.00 ,$495.00 ,$148.50 ,$450.45 ,$346.50 ,$148.50 ,$321.75 ,$356.40 ,$450.45 ,$371.25 
Carle BroMenn Medical Center,8170603,SCREW FML PERSONA 25X25MM 2/PK,239683,C1713,278,$510.00 ,$510.00 ,$153.00 ,$464.10 ,$357.00 ,$153.00 ,$331.50 ,$367.20 ,$464.10 ,$382.50 
Carle BroMenn Medical Center,8170603,SCREW HEADLESS +5MMX50MM COMPRESS,247609,C1713,278,$915.60 ,$915.60 ,$274.68 ,$833.20 ,$640.92 ,$274.68 ,$595.14 ,$659.23 ,$833.20 ,$686.70 
Carle BroMenn Medical Center,8170603,SCREW HEADLESS +5X40MM COMPRESSIO,247613,C1713,278,$913.44 ,$913.44 ,$274.03 ,$831.23 ,$639.41 ,$274.03 ,$593.74 ,$657.68 ,$831.23 ,$685.08 
Carle BroMenn Medical Center,8170603,SCREW HEADLESS +7X55 SHORT THR CO,247612,C1713,278,"$1,474.44 ","$1,474.44 ",$442.33 ,"$1,341.74 ","$1,032.11 ",$442.33 ,$958.39 ,"$1,061.60 ","$1,341.74 ","$1,105.83 "
Carle BroMenn Medical Center,8170603,SCREW HELIX STP VA 4.5X19MM REVOL,248085,C1713,278,$285.00 ,$285.00 ,$85.50 ,$259.35 ,$199.50 ,$85.50 ,$185.25 ,$205.20 ,$259.35 ,$213.75 
Carle BroMenn Medical Center,8170603,SCREW HEXALOBE NLOCK 3.5X12MM,247857,C1713,278,$228.00 ,$228.00 ,$68.40 ,$207.48 ,$159.60 ,$68.40 ,$148.20 ,$164.16 ,$207.48 ,$171.00 
Carle BroMenn Medical Center,8170603,SCREW HEXALOBE NLOCK 3.5X16MM,240853,C1713,278,$228.00 ,$228.00 ,$68.40 ,$207.48 ,$159.60 ,$68.40 ,$148.20 ,$164.16 ,$207.48 ,$171.00 
Carle BroMenn Medical Center,8170603,SCREW HEXALOBE NLOCK 3.5X18MM,240851,C1713,278,$228.00 ,$228.00 ,$68.40 ,$207.48 ,$159.60 ,$68.40 ,$148.20 ,$164.16 ,$207.48 ,$171.00 
Carle BroMenn Medical Center,8170603,SCREW HEXALOBE NLOCK 3.5X20MM,240965,C1713,278,$228.00 ,$228.00 ,$68.40 ,$207.48 ,$159.60 ,$68.40 ,$148.20 ,$164.16 ,$207.48 ,$171.00 
Carle BroMenn Medical Center,8170603,SCREW HEXALOBE NLOCK 3.5X24MM,240967,C1713,278,$228.00 ,$228.00 ,$68.40 ,$207.48 ,$159.60 ,$68.40 ,$148.20 ,$164.16 ,$207.48 ,$171.00 
Carle BroMenn Medical Center,8170603,SCREW HEXALOBE NLOCK 3.5X30MM,247863,C1713,278,$228.00 ,$228.00 ,$68.40 ,$207.48 ,$159.60 ,$68.40 ,$148.20 ,$164.16 ,$207.48 ,$171.00 
Carle BroMenn Medical Center,8170603,SCREW LAG 10.5X130MM TI-6AL-4V,247879,C1713,278,"$1,542.54 ","$1,542.54 ",$462.76 ,"$1,403.71 ","$1,079.78 ",$462.76 ,"$1,002.65 ","$1,110.63 ","$1,403.71 ","$1,156.91 "
Carle BroMenn Medical Center,8170603,SCREW LAG TFNA 95MM FENEST,6762,C1713,278,"$1,939.80 ","$1,939.80 ",$581.94 ,"$1,765.22 ","$1,357.86 ",$581.94 ,"$1,260.87 ","$1,396.66 ","$1,765.22 ","$1,454.85 "
Carle BroMenn Medical Center,8170603,SCREW LOCK 3.5 HEX 4.75X25,243970,C1713,278,$165.00 ,$165.00 ,$49.50 ,$150.15 ,$115.50 ,$49.50 ,$107.25 ,$118.80 ,$150.15 ,$123.75 
Carle BroMenn Medical Center,8170603,SCREW LOCK HEXALOBE 2.7X14MM,240972,C1713,278,$384.00 ,$384.00 ,$115.20 ,$349.44 ,$268.80 ,$115.20 ,$249.60 ,$276.48 ,$349.44 ,$288.00 
Carle BroMenn Medical Center,8170603,SCREW LOCK HEXALOBE 2.7X16MM,240968,C1713,278,$384.00 ,$384.00 ,$115.20 ,$349.44 ,$268.80 ,$115.20 ,$249.60 ,$276.48 ,$349.44 ,$288.00 
Carle BroMenn Medical Center,8170603,SCREW LOCK MINI GORILLA 2.5X10,244051,C1713,278,$502.20 ,$502.20 ,$150.66 ,$457.00 ,$351.54 ,$150.66 ,$326.43 ,$361.58 ,$457.00 ,$376.65 
Carle BroMenn Medical Center,8170603,SCREW LOCK MINI GORILLA 2.5X12,244052,C1713,278,$502.20 ,$502.20 ,$150.66 ,$457.00 ,$351.54 ,$150.66 ,$326.43 ,$361.58 ,$457.00 ,$376.65 
Carle BroMenn Medical Center,8170603,SCREW LOCK MINI GORILLA 2.5X30,244053,C1713,278,$502.20 ,$502.20 ,$150.66 ,$457.00 ,$351.54 ,$150.66 ,$326.43 ,$361.58 ,$457.00 ,$376.65 
Carle BroMenn Medical Center,8170603,SCREW LOCK MINI GORILLA 2.5X8,244050,C1713,278,$502.20 ,$502.20 ,$150.66 ,$457.00 ,$351.54 ,$150.66 ,$326.43 ,$361.58 ,$457.00 ,$376.65 
Carle BroMenn Medical Center,8170603,SCREW LOCK T10 FULL 3.5X18MM,243576,C1713,278,$461.16 ,$461.16 ,$138.35 ,$419.66 ,$322.81 ,$138.35 ,$299.75 ,$332.04 ,$419.66 ,$345.87 
Carle BroMenn Medical Center,8170603,SCREW LOCK T10 FULL 3.5X26MM,243577,C1713,278,$461.16 ,$461.16 ,$138.35 ,$419.66 ,$322.81 ,$138.35 ,$299.75 ,$332.04 ,$419.66 ,$345.87 
Carle BroMenn Medical Center,8170603,SCREW LOCK T10 FULL 3.5X30MM,243578,C1713,278,$461.16 ,$461.16 ,$138.35 ,$419.66 ,$322.81 ,$138.35 ,$299.75 ,$332.04 ,$419.66 ,$345.87 
Carle BroMenn Medical Center,8170603,SCREW LOCK T10 FULL 3.5X32M,243579,C1713,278,$461.16 ,$461.16 ,$138.35 ,$419.66 ,$322.81 ,$138.35 ,$299.75 ,$332.04 ,$419.66 ,$345.87 
Carle BroMenn Medical Center,8170603,SCREW LOCK T10 FULL 3.5X34,243580,C1713,278,$461.16 ,$461.16 ,$138.35 ,$419.66 ,$322.81 ,$138.35 ,$299.75 ,$332.04 ,$419.66 ,$345.87 
Carle BroMenn Medical Center,8170603,SCREW LOCK T10 FULL 3.5X36,243581,C1713,278,$461.16 ,$461.16 ,$138.35 ,$419.66 ,$322.81 ,$138.35 ,$299.75 ,$332.04 ,$419.66 ,$345.87 
Carle BroMenn Medical Center,8170603,SCREW LOCK T2 F/T 5MMX25MM,243021,C1713,278,$627.00 ,$627.00 ,$188.10 ,$570.57 ,$438.90 ,$188.10 ,$407.55 ,$451.44 ,$570.57 ,$470.25 
Carle BroMenn Medical Center,8170603,SCREW LOCK T2 F/T 5MMX65MM,243024,C1713,278,$620.40 ,$620.40 ,$186.12 ,$564.56 ,$434.28 ,$186.12 ,$403.26 ,$446.69 ,$564.56 ,$465.30 
Carle BroMenn Medical Center,8170603,SCREW LOCKING HEX 2.7X10MM,247858,C1713,278,$384.00 ,$384.00 ,$115.20 ,$349.44 ,$268.80 ,$115.20 ,$249.60 ,$276.48 ,$349.44 ,$288.00 
Carle BroMenn Medical Center,8170603,SCREW LOCKING HEX 2.7X18MM,247859,C1713,278,$384.00 ,$384.00 ,$115.20 ,$349.44 ,$268.80 ,$115.20 ,$249.60 ,$276.48 ,$349.44 ,$288.00 
Carle BroMenn Medical Center,8170603,SCREW LOCKING HEX 2.7X20MM,247860,C1713,278,$384.00 ,$384.00 ,$115.20 ,$349.44 ,$268.80 ,$115.20 ,$249.60 ,$276.48 ,$349.44 ,$288.00 
Carle BroMenn Medical Center,8170603,SCREW MAX TORQ SHORT 7.0MMX75 SEL,235247,C1713,278,"$1,635.00 ","$1,635.00 ",$490.50 ,"$1,487.85 ","$1,144.50 ",$490.50 ,"$1,062.75 ","$1,177.20 ","$1,487.85 ","$1,226.25 "
Carle BroMenn Medical Center,8170603,SCREW MINI GORILLA 2.5X10 NLCK,244054,C1713,278,$375.00 ,$375.00 ,$112.50 ,$341.25 ,$262.50 ,$112.50 ,$243.75 ,$270.00 ,$341.25 ,$281.25 
Carle BroMenn Medical Center,8170603,SCREW MINI GORILLA 2.5X12 NLCK,244055,C1713,278,$375.00 ,$375.00 ,$112.50 ,$341.25 ,$262.50 ,$112.50 ,$243.75 ,$270.00 ,$341.25 ,$281.25 
Carle BroMenn Medical Center,8170603,SCREW MULTI AXIAL 3.5X20MM,247389,C1713,278,"$1,440.00 ","$1,440.00 ",$432.00 ,"$1,310.40 ","$1,008.00 ",$432.00 ,$936.00 ,"$1,036.80 ","$1,310.40 ","$1,080.00 "
Carle BroMenn Medical Center,8170603,SCREW MULTI AXIAL 3.5X22MM,247390,C1713,278,"$1,440.00 ","$1,440.00 ",$432.00 ,"$1,310.40 ","$1,008.00 ",$432.00 ,$936.00 ,"$1,036.80 ","$1,310.40 ","$1,080.00 "
Carle BroMenn Medical Center,8170603,SCREW MULTI AXIAL 4.0X26MM,243586,C1713,278,"$2,250.00 ","$2,250.00 ",$675.00 ,"$2,047.50 ","$1,575.00 ",$675.00 ,"$1,462.50 ","$1,620.00 ","$2,047.50 ","$1,687.50 "
Carle BroMenn Medical Center,8170603,SCREW MULTI AXIAL 4.5X26MM,243588,C1713,278,"$2,250.00 ","$2,250.00 ",$675.00 ,"$2,047.50 ","$1,575.00 ",$675.00 ,"$1,462.50 ","$1,620.00 ","$2,047.50 ","$1,687.50 "
Carle BroMenn Medical Center,8170603,SCREW MULTI AXIAL 4.5X28MM,243587,C1713,278,"$2,250.00 ","$2,250.00 ",$675.00 ,"$2,047.50 ","$1,575.00 ",$675.00 ,"$1,462.50 ","$1,620.00 ","$2,047.50 ","$1,687.50 "
Carle BroMenn Medical Center,8170603,SCREW NAIL STR DRV 5X36,6730,C1713,278,$633.60 ,$633.60 ,$190.08 ,$576.58 ,$443.52 ,$190.08 ,$411.84 ,$456.19 ,$576.58 ,$475.20 
Carle BroMenn Medical Center,8170603,SCREW NONLOCK 3.5 HEX 4.75X15,243971,C1713,278,$165.00 ,$165.00 ,$49.50 ,$150.15 ,$115.50 ,$49.50 ,$107.25 ,$118.80 ,$150.15 ,$123.75 
Carle BroMenn Medical Center,8170603,SCREW NONLOCK HEX 3.0X14MM,247861,C1713,278,$228.00 ,$228.00 ,$68.40 ,$207.48 ,$159.60 ,$68.40 ,$148.20 ,$164.16 ,$207.48 ,$171.00 
Carle BroMenn Medical Center,8170603,SCREW NONLOCK HEX 3.0X40MM,247862,C1713,278,$228.00 ,$228.00 ,$68.40 ,$207.48 ,$159.60 ,$68.40 ,$148.20 ,$164.16 ,$207.48 ,$171.00 
Carle BroMenn Medical Center,8170603,SCREW NONLOCK HEX 3.5X32MM,247864,C1713,278,$228.00 ,$228.00 ,$68.40 ,$207.48 ,$159.60 ,$68.40 ,$148.20 ,$164.16 ,$207.48 ,$171.00 
Carle BroMenn Medical Center,8170603,SCREW NONLOCK HEX 3.5X36MM,247903,C1713,278,$228.00 ,$228.00 ,$68.40 ,$207.48 ,$159.60 ,$68.40 ,$148.20 ,$164.16 ,$207.48 ,$171.00 
Carle BroMenn Medical Center,8170603,SCREW NONSTANDARD MAS 3.5X10MM,243584,C1713,278,"$2,550.00 ","$2,550.00 ",$765.00 ,"$2,320.50 ","$1,785.00 ",$765.00 ,"$1,657.50 ","$1,836.00 ","$2,320.50 ","$1,912.50 "
Carle BroMenn Medical Center,8170603,SCREW PEEK INTERFERENCE 7X25MM,10555,C1713,278,"$1,500.00 ","$1,500.00 ",$450.00 ,"$1,365.00 ","$1,050.00 ",$450.00 ,$975.00 ,"$1,080.00 ","$1,365.00 ","$1,125.00 "
Carle BroMenn Medical Center,8170603,SCREW SELF DRILL 4.0X13MM,246787,C1713,278,$495.00 ,$495.00 ,$148.50 ,$450.45 ,$346.50 ,$148.50 ,$321.75 ,$356.40 ,$450.45 ,$371.25 
Carle BroMenn Medical Center,8170603,SCREW SELF TAP FIX 4X14,242963,C1713,278,$495.00 ,$495.00 ,$148.50 ,$450.45 ,$346.50 ,$148.50 ,$321.75 ,$356.40 ,$450.45 ,$371.25 
Carle BroMenn Medical Center,8170603,SCREW SELF TAP VAR 4X14,242964,C1713,278,$495.00 ,$495.00 ,$148.50 ,$450.45 ,$346.50 ,$148.50 ,$321.75 ,$356.40 ,$450.45 ,$371.25 
Carle BroMenn Medical Center,8170603,SCREW SHAFT T2 5MMX40MM,243020,C1713,278,$671.55 ,$671.55 ,$201.47 ,$611.11 ,$470.09 ,$201.47 ,$436.51 ,$483.52 ,$611.11 ,$503.66 
Carle BroMenn Medical Center,8170603,SCREW SHANK CANN 6.5X40MM SPHEREX,242901,C1713,278,$945.00 ,$945.00 ,$283.50 ,$859.95 ,$661.50 ,$283.50 ,$614.25 ,$680.40 ,$859.95 ,$708.75 
Carle BroMenn Medical Center,8170603,SCREW SHANK NCANN 6.5X45MM SPHERX,249187,C1713,278,$945.00 ,$945.00 ,$283.50 ,$859.95 ,$661.50 ,$283.50 ,$614.25 ,$680.40 ,$859.95 ,$708.75 
Carle BroMenn Medical Center,8170603,SCREW SHANK RELINO MOD 5.5X60,243049,C1713,278,$750.00 ,$750.00 ,$225.00 ,$682.50 ,$525.00 ,$225.00 ,$487.50 ,$540.00 ,$682.50 ,$562.50 
Carle BroMenn Medical Center,8170603,SCREW T2 COMPRSS ANKLE T2,243017,C1713,278,$756.60 ,$756.60 ,$226.98 ,$688.51 ,$529.62 ,$226.98 ,$491.79 ,$544.75 ,$688.51 ,$567.45 
Carle BroMenn Medical Center,8170603,SCREW TI CORTEX X 60MM,213482,C1713,278,$84.96 ,$84.96 ,$25.49 ,$77.31 ,$59.47 ,$25.49 ,$55.22 ,$61.17 ,$77.31 ,$63.72 
Carle BroMenn Medical Center,8170603,SCREW TRIGEN LOWPRO 5X25MM,248083,C1713,278,$952.29 ,$952.29 ,$285.69 ,$866.58 ,$666.60 ,$285.69 ,$618.99 ,$685.65 ,$866.58 ,$714.22 
Carle BroMenn Medical Center,8170603,SCREW TRIGEN LOWPRO 5X32.5MM,248084,C1713,278,$952.29 ,$952.29 ,$285.69 ,$866.58 ,$666.60 ,$285.69 ,$618.99 ,$685.65 ,$866.58 ,$714.22 
Carle BroMenn Medical Center,8170603,SCREW VA SD XTEND 4.2X12MM,245227,C1713,278,"$1,860.00 ","$1,860.00 ",$558.00 ,"$1,692.60 ","$1,302.00 ",$558.00 ,"$1,209.00 ","$1,339.20 ","$1,692.60 ","$1,395.00 "
Carle BroMenn Medical Center,8170603,SCREW VERTEX INFINITY 3.5X26MM,243585,C1713,278,"$2,250.00 ","$2,250.00 ",$675.00 ,"$2,047.50 ","$1,575.00 ",$675.00 ,"$1,462.50 ","$1,620.00 ","$2,047.50 ","$1,687.50 "
Carle BroMenn Medical Center,8170603,SCREW ZEVO SD VARI 3.5X15MM,242704,C1713,278,$495.00 ,$495.00 ,$148.50 ,$450.45 ,$346.50 ,$148.50 ,$321.75 ,$356.40 ,$450.45 ,$371.25 
Carle BroMenn Medical Center,8170603,SCREW ZEVO SD VARI 3.5X17MM,242703,C1713,278,$495.00 ,$495.00 ,$148.50 ,$450.45 ,$346.50 ,$148.50 ,$321.75 ,$356.40 ,$450.45 ,$371.25 
Carle BroMenn Medical Center,8170603,SCREW ZEVO VAR ST 4X17MM,242706,C1713,278,$495.00 ,$495.00 ,$148.50 ,$450.45 ,$346.50 ,$148.50 ,$321.75 ,$356.40 ,$450.45 ,$371.25 
Carle BroMenn Medical Center,8170603,STAPLE NITINOL 12X12,235219,C1713,278,"$3,534.00 ","$3,534.00 ","$1,060.20 ","$3,215.94 ","$2,473.80 ","$1,060.20 ","$2,297.10 ","$2,544.48 ","$3,215.94 ","$2,650.50 "
Carle BroMenn Medical Center,8170603,WIRE 2.0MM,241384,C1713,278,$75.90 ,$75.90 ,$22.77 ,$69.07 ,$53.13 ,$22.77 ,$49.34 ,$54.65 ,$69.07 ,$56.93 
Carle BroMenn Medical Center,8170603,WIRE CLAW II THREADED,198232,C1713,278,$69.00 ,$69.00 ,$20.70 ,$62.79 ,$48.30 ,$20.70 ,$44.85 ,$49.68 ,$62.79 ,$51.75 
Carle BroMenn Medical Center,8170603,WIRE FX 3MM 285MM KRSH SS ORTH ST,243010,C1713,278,$369.00 ,$369.00 ,$110.70 ,$335.79 ,$258.30 ,$110.70 ,$239.85 ,$265.68 ,$335.79 ,$276.75 
Carle BroMenn Medical Center,8179013,CEMENT BONE 40GM GENTAMIACIN 5450,4015,,278,$660.00 ,$660.00 ,$198.00 ,$600.60 ,$462.00 ,$198.00 ,$429.00 ,$475.20 ,$600.60 ,$495.00 
Carle BroMenn Medical Center,8179013,CEMENT BONE BIOMET R 1X40,239338,,278,$240.00 ,$240.00 ,$72.00 ,$218.40 ,$168.00 ,$72.00 ,$156.00 ,$172.80 ,$218.40 ,$180.00 
Carle BroMenn Medical Center,8179013,CEMENT BONE HV ANTIBIO 40GR PALAC,245123,,278,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01 
Carle BroMenn Medical Center,8179013,CEMENT BONE HV-R 20G,244737,,278,$287.43 ,$287.43 ,$86.23 ,$261.56 ,$201.20 ,$86.23 ,$186.83 ,$206.95 ,$261.56 ,$215.57 
Carle BroMenn Medical Center,8179013,CEMENT BONE REFOBACIN R 40GR W/GE,239334,,278,$900.00 ,$900.00 ,$270.00 ,$819.00 ,$630.00 ,$270.00 ,$585.00 ,$648.00 ,$819.00 ,$675.00 
Carle BroMenn Medical Center,8179013,SCREW VA LCK 2.7X16MM T8,213586,,278,$433.80 ,$433.80 ,$130.14 ,$394.76 ,$303.66 ,$130.14 ,$281.97 ,$312.34 ,$394.76 ,$325.35 
Carle BroMenn Medical Center,8179013,SCREW VA LCK 2.7X34MM T8,213633,,278,$433.80 ,$433.80 ,$130.14 ,$394.76 ,$303.66 ,$130.14 ,$281.97 ,$312.34 ,$394.76 ,$325.35 
Carle BroMenn Medical Center,8179035,CATH ANGIO .038IN 5FR 100CM,3990,C1751,278,$151.95 ,$151.95 ,$45.59 ,$138.27 ,$106.37 ,$45.59 ,$98.77 ,$109.40 ,$138.27 ,$113.96 
Carle BroMenn Medical Center,8179035,CATH ANGIO .038IN 5FR 65CM,3989,C1751,278,$151.95 ,$151.95 ,$45.59 ,$138.27 ,$106.37 ,$45.59 ,$98.77 ,$109.40 ,$138.27 ,$113.96 
Carle BroMenn Medical Center,8179035,CATH INSYTE AUTOGUARD 18GA,234438,C1751,278,$4.88 ,$4.88 ,$1.46 ,$4.44 ,$3.42 ,$1.46 ,$3.17 ,$3.51 ,$4.44 ,$3.66 
Carle BroMenn Medical Center,8179035,CATH IV 18X1.25 JELCO,245275,C1751,278,$5.61 ,$5.61 ,$1.68 ,$5.11 ,$3.93 ,$1.68 ,$3.65 ,$4.04 ,$5.11 ,$4.21 
Carle BroMenn Medical Center,8179035,CATH IV 20GX1.75 JELCO,245274,C1751,278,$5.61 ,$5.61 ,$1.68 ,$5.11 ,$3.93 ,$1.68 ,$3.65 ,$4.04 ,$5.11 ,$4.21 
Carle BroMenn Medical Center,8179035,CATH IV 22GA 1IN JELCO TFLN BLU R,244009,C1751,278,$9.36 ,$9.36 ,$2.81 ,$8.52 ,$6.55 ,$2.81 ,$6.08 ,$6.74 ,$8.52 ,$7.02 
Carle BroMenn Medical Center,8179035,CATHETER ANGIO 5FR .052IN PGTL,4009,C1751,278,$271.53 ,$271.53 ,$81.46 ,$247.09 ,$190.07 ,$81.46 ,$176.49 ,$195.50 ,$247.09 ,$203.65 
Carle BroMenn Medical Center,8179035,CATHETER IV INSYTE 14GX1.75,244126,C1751,278,$4.83 ,$4.83 ,$1.45 ,$4.40 ,$3.38 ,$1.45 ,$3.14 ,$3.48 ,$4.40 ,$3.62 
Carle BroMenn Medical Center,8179035,CATHETER IV INSYTE 16GX1.77,244512,C1751,278,$4.83 ,$4.83 ,$1.45 ,$4.40 ,$3.38 ,$1.45 ,$3.14 ,$3.48 ,$4.40 ,$3.62 
Carle BroMenn Medical Center,8179035,CATHETER IV INSYTE 20GX1.16,244513,C1751,278,$4.83 ,$4.83 ,$1.45 ,$4.40 ,$3.38 ,$1.45 ,$3.14 ,$3.48 ,$4.40 ,$3.62 
Carle BroMenn Medical Center,8179035,CATHETER IV INSYTE 20GX1.88,244625,C1751,278,$4.83 ,$4.83 ,$1.45 ,$4.40 ,$3.38 ,$1.45 ,$3.14 ,$3.48 ,$4.40 ,$3.62 
Carle BroMenn Medical Center,8179042,ALLOGRAFT BONE CANN CHIPS 15CC AL,2600,C1762,278,$510.00 ,$510.00 ,$153.00 ,$464.10 ,$357.00 ,$153.00 ,$331.50 ,$367.20 ,$464.10 ,$382.50 
Carle BroMenn Medical Center,8179042,ALLOGRAFT BONE CANN CHIPS 30CC AL,197343,C1762,278,$825.00 ,$825.00 ,$247.50 ,$750.75 ,$577.50 ,$247.50 ,$536.25 ,$594.00 ,$750.75 ,$618.75 
Carle BroMenn Medical Center,8179042,ALLOGRAFT BONE CANN CHIPS 5CC ALL,197342,C1762,278,$375.00 ,$375.00 ,$112.50 ,$341.25 ,$262.50 ,$112.50 ,$243.75 ,$270.00 ,$341.25 ,$281.25 
Carle BroMenn Medical Center,8179042,ALLOGRAFT BONE CEMENT KYPHON,3992,C1762,278,$525.00 ,$525.00 ,$157.50 ,$477.75 ,$367.50 ,$157.50 ,$341.25 ,$378.00 ,$477.75 ,$393.75 
Carle BroMenn Medical Center,8179042,ALLOGRAFT INFUSE XSMALL,4017,C1762,278,"$5,715.00 ","$5,715.00 ","$1,714.50 ","$5,200.65 ","$4,000.50 ","$1,714.50 ","$3,714.75 ","$4,114.80 ","$5,200.65 ","$4,286.25 "
Carle BroMenn Medical Center,8179042,BONE GRAFT 5MM LORDOSED SRV FEE C,243094,C1762,278,"$3,000.00 ","$3,000.00 ",$900.00 ,"$2,730.00 ","$2,100.00 ",$900.00 ,"$1,950.00 ","$2,160.00 ","$2,730.00 ","$2,250.00 "
Carle BroMenn Medical Center,8179042,GRAFT BP SUTURABLE 6X8CM,237628,C1762,278,"$1,468.11 ","$1,468.11 ",$440.43 ,"$1,335.98 ","$1,027.68 ",$440.43 ,$954.27 ,"$1,057.04 ","$1,335.98 ","$1,101.08 "
Carle BroMenn Medical Center,8179042,GRAFT DISTAFLO FLX SM 6X50 STD,244792,C1762,278,"$13,275.00 ","$13,275.00 ","$3,982.50 ","$12,080.25 ","$9,292.50 ","$3,982.50 ","$8,628.75 ","$9,558.00 ","$12,080.25 ","$9,956.25 "
Carle BroMenn Medical Center,8179042,GRAFT DISTAFLO FLX SM 8X50 STD,245181,C1762,278,"$13,275.00 ","$13,275.00 ","$3,982.50 ","$12,080.25 ","$9,292.50 ","$3,982.50 ","$8,628.75 ","$9,558.00 ","$12,080.25 ","$9,956.25 "
Carle BroMenn Medical Center,8179042,GRAFT DURAGEN 5X5CM,244884,C1762,278,"$6,417.15 ","$6,417.15 ","$1,925.15 ","$5,839.61 ","$4,492.01 ","$1,925.15 ","$4,171.15 ","$4,620.35 ","$5,839.61 ","$4,812.86 "
Carle BroMenn Medical Center,8179042,GRAFT FEM HEMI FRZD 166-202MM,238864,C1762,278,$3.33 ,$3.33 ,$1.00 ,$3.03 ,$2.33 ,$1.00 ,$2.16 ,$2.40 ,$3.03 ,$2.50 
Carle BroMenn Medical Center,8179042,GRAFT FIB FRZD 99-125MM,238818,C1762,278,$3.33 ,$3.33 ,$1.00 ,$3.03 ,$2.33 ,$1.00 ,$2.16 ,$2.40 ,$3.03 ,$2.50 
Carle BroMenn Medical Center,8179042,GRAFT MAGNIFUSE PI 1.75X10CM,237392,C1762,278,"$10,830.00 ","$10,830.00 ","$3,249.00 ","$9,855.30 ","$7,581.00 ","$3,249.00 ","$7,039.50 ","$7,797.60 ","$9,855.30 ","$8,122.50 "
Carle BroMenn Medical Center,8179042,GRAFT MAGNIFUSE PI 1.75X5CM,237394,C1762,278,"$7,445.64 ","$7,445.64 ","$2,233.69 ","$6,775.53 ","$5,211.95 ","$2,233.69 ","$4,839.67 ","$5,360.86 ","$6,775.53 ","$5,584.23 "
Carle BroMenn Medical Center,8179042,GRAFT PATCH DURA GUARD 8X6CM,1611,C1762,278,"$1,305.00 ","$1,305.00 ",$391.50 ,"$1,187.55 ",$913.50 ,$391.50 ,$848.25 ,$939.60 ,"$1,187.55 ",$978.75 
Carle BroMenn Medical Center,8179042,GRAFT TISSUE PATCH 15X20X2,2569,C1762,278,"$4,344.00 ","$4,344.00 ","$1,303.20 ","$3,953.04 ","$3,040.80 ","$1,303.20 ","$2,823.60 ","$3,127.68 ","$3,953.04 ","$3,258.00 "
Carle BroMenn Medical Center,8179042,GRAFT VENAFLO II 6MMX50CM STR,244758,C1762,278,"$6,483.00 ","$6,483.00 ","$1,944.90 ","$5,899.53 ","$4,538.10 ","$1,944.90 ","$4,213.95 ","$4,667.76 ","$5,899.53 ","$4,862.25 "
Carle BroMenn Medical Center,8179042,HARVESTER COLINK 8MM BONE GRFT,247123,C1762,278,"$1,635.00 ","$1,635.00 ",$490.50 ,"$1,487.85 ","$1,144.50 ",$490.50 ,"$1,062.75 ","$1,177.20 ","$1,487.85 ","$1,226.25 "
Carle BroMenn Medical Center,8179042,MATRIX BIO4 VIABLE BONE 5CC,243019,C1762,278,"$7,312.50 ","$7,312.50 ","$2,193.75 ","$6,654.38 ","$5,118.75 ","$2,193.75 ","$4,753.13 ","$5,265.00 ","$6,654.38 ","$5,484.38 "
Carle BroMenn Medical Center,8179042,PASTE ORTHOBLAST II 3CC DBM,238607,C1762,278,"$1,379.40 ","$1,379.40 ",$413.82 ,"$1,255.25 ",$965.58 ,$413.82 ,$896.61 ,$993.17 ,"$1,255.25 ","$1,034.55 "
Carle BroMenn Medical Center,8179042,PASTE ORTHOBLAST II 8CC DBM,238608,C1762,278,"$3,511.14 ","$3,511.14 ","$1,053.34 ","$3,195.14 ","$2,457.80 ","$1,053.34 ","$2,282.24 ","$2,528.02 ","$3,195.14 ","$2,633.36 "
Carle BroMenn Medical Center,8179055,BAG VICRYL MESH SPLEEN,10418,C1781,278,"$2,057.58 ","$2,057.58 ",$617.27 ,"$1,872.40 ","$1,440.31 ",$617.27 ,"$1,337.43 ","$1,481.46 ","$1,872.40 ","$1,543.19 "
Carle BroMenn Medical Center,8179055,MESH 3D LIGHT LARGE LEFT 4.1X6.2,236141,C1781,278,$603.90 ,$603.90 ,$181.17 ,$549.55 ,$422.73 ,$181.17 ,$392.54 ,$434.81 ,$549.55 ,$452.93 
Carle BroMenn Medical Center,8179055,MESH 3D LIGHT LARGE RIGHT,236139,C1781,278,$603.90 ,$603.90 ,$181.17 ,$549.55 ,$422.73 ,$181.17 ,$392.54 ,$434.81 ,$549.55 ,$452.93 
Carle BroMenn Medical Center,8179055,MESH 3DMAX LARGE LEFT 4X6 1/CA,67598,C1781,278,$484.80 ,$484.80 ,$145.44 ,$441.17 ,$339.36 ,$145.44 ,$315.12 ,$349.06 ,$441.17 ,$363.60 
Carle BroMenn Medical Center,8179055,MESH 3DMAX LARGE RIGHT 4X6 1/CA,67597,C1781,278,$484.80 ,$484.80 ,$145.44 ,$441.17 ,$339.36 ,$145.44 ,$315.12 ,$349.06 ,$441.17 ,$363.60 
Carle BroMenn Medical Center,8179055,MESH COMPOSIX ECHO 7.2X9.2IN,245188,C1781,278,"$3,984.30 ","$3,984.30 ","$1,195.29 ","$3,625.71 ","$2,789.01 ","$1,195.29 ","$2,589.80 ","$2,868.70 ","$3,625.71 ","$2,988.23 "
Carle BroMenn Medical Center,8179055,MESH COMPOSIX ECHO PS 6.2X10.2,245189,C1781,278,"$4,092.00 ","$4,092.00 ","$1,227.60 ","$3,723.72 ","$2,864.40 ","$1,227.60 ","$2,659.80 ","$2,946.24 ","$3,723.72 ","$3,069.00 "
Carle BroMenn Medical Center,8179055,MESH COMPOSIX LP 8X10IN,244828,C1781,278,"$4,699.05 ","$4,699.05 ","$1,409.72 ","$4,276.14 ","$3,289.34 ","$1,409.72 ","$3,054.38 ","$3,383.32 ","$4,276.14 ","$3,524.29 "
Carle BroMenn Medical Center,8179055,MESH DART SM 1X1.35IN,245038,C1781,278,$243.45 ,$243.45 ,$73.04 ,$221.54 ,$170.42 ,$73.04 ,$158.24 ,$175.28 ,$221.54 ,$182.59 
Carle BroMenn Medical Center,8179055,MESH ECHO POSITION 10.2X13.2IN,245174,C1781,278,"$6,710.10 ","$6,710.10 ","$2,013.03 ","$6,106.19 ","$4,697.07 ","$2,013.03 ","$4,361.57 ","$4,831.27 ","$6,106.19 ","$5,032.58 "
Carle BroMenn Medical Center,8179055,MESH ECHO POSITIONING 6.2X8CM,245176,C1781,278,"$3,484.50 ","$3,484.50 ","$1,045.35 ","$3,170.90 ","$2,439.15 ","$1,045.35 ","$2,264.93 ","$2,508.84 ","$3,170.90 ","$2,613.38 "
Carle BroMenn Medical Center,8179055,MESH FLT SHEET 3X6IN 3/CA,236280,C1781,278,$106.65 ,$106.65 ,$32.00 ,$97.05 ,$74.66 ,$32.00 ,$69.32 ,$76.79 ,$97.05 ,$79.99 
Carle BroMenn Medical Center,8179055,MESH GALAFLEX SCAFFOLD 15X20CM,242985,C1781,278,"$6,600.00 ","$6,600.00 ","$1,980.00 ","$6,006.00 ","$4,620.00 ","$1,980.00 ","$4,290.00 ","$4,752.00 ","$6,006.00 ","$4,950.00 "
Carle BroMenn Medical Center,8179055,MESH HERNIA OVAL XL 19.6X24.6,245172,C1781,278,"$5,063.70 ","$5,063.70 ","$1,519.11 ","$4,607.97 ","$3,544.59 ","$1,519.11 ","$3,291.41 ","$3,645.86 ","$4,607.97 ","$3,797.78 "
Carle BroMenn Medical Center,8179055,MESH HERNIA PATCH MD VENTRALEX us,3971,C1781,278,"$1,327.50 ","$1,327.50 ",$398.25 ,"$1,208.03 ",$929.25 ,$398.25 ,$862.88 ,$955.80 ,"$1,208.03 ",$995.63 
Carle BroMenn Medical Center,8179055,MESH HERNIA PATCH SM VENTRALEX us,3970,C1781,278,"$1,226.40 ","$1,226.40 ",$367.92 ,"$1,116.02 ",$858.48 ,$367.92 ,$797.16 ,$883.01 ,"$1,116.02 ",$919.80 
Carle BroMenn Medical Center,8179055,MESH HERNIA VENTRELEX ST LG,197336,C1781,278,"$1,665.00 ","$1,665.00 ",$499.50 ,"$1,515.15 ","$1,165.50 ",$499.50 ,"$1,082.25 ","$1,198.80 ","$1,515.15 ","$1,248.75 "
Carle BroMenn Medical Center,8179055,MESH HERNIA VENTRELEX ST MD,197335,C1781,278,"$1,278.00 ","$1,278.00 ",$383.40 ,"$1,162.98 ",$894.60 ,$383.40 ,$830.70 ,$920.16 ,"$1,162.98 ",$958.50 
Carle BroMenn Medical Center,8179055,MESH HERNIA VENTRELEX ST SM,197334,C1781,278,"$1,057.50 ","$1,057.50 ",$317.25 ,$962.33 ,$740.25 ,$317.25 ,$687.38 ,$761.40 ,$962.33 ,$793.13 
Carle BroMenn Medical Center,8179055,MESH LG DART 1.3X1.55IN,244973,C1781,278,$691.20 ,$691.20 ,$207.36 ,$628.99 ,$483.84 ,$207.36 ,$449.28 ,$497.66 ,$628.99 ,$518.40 
Carle BroMenn Medical Center,8179055,MESH LIGHT MD LT 7.9X13.4CM 3DMAX,244800,C1781,278,$683.70 ,$683.70 ,$205.11 ,$622.17 ,$478.59 ,$205.11 ,$444.41 ,$492.26 ,$622.17 ,$512.78 
Carle BroMenn Medical Center,8179055,MESH LIGHT MD RT 7.9X13.4CM 3DMAX,244799,C1781,278,$683.70 ,$683.70 ,$205.11 ,$622.17 ,$478.59 ,$205.11 ,$444.41 ,$492.26 ,$622.17 ,$512.78 
Carle BroMenn Medical Center,8179055,MESH LP PROGRIP 10X15CM,244837,C1781,278,"$1,646.85 ","$1,646.85 ",$494.06 ,"$1,498.63 ","$1,152.80 ",$494.06 ,"$1,070.45 ","$1,185.73 ","$1,498.63 ","$1,235.14 "
Carle BroMenn Medical Center,8179055,MESH PELVIC 24X3CM RESTORELLE,238720,C1781,278,"$2,634.00 ","$2,634.00 ",$790.20 ,"$2,396.94 ","$1,843.80 ",$790.20 ,"$1,712.10 ","$1,896.48 ","$2,396.94 ","$1,975.50 "
Carle BroMenn Medical Center,8179055,MESH PLUG LARGE PERLIX HERNIA 1.6,197338,C1781,278,$544.50 ,$544.50 ,$163.35 ,$495.50 ,$381.15 ,$163.35 ,$353.93 ,$392.04 ,$495.50 ,$408.38 
Carle BroMenn Medical Center,8179055,MESH PLUG MEDIUM Use Lawson # 622,197337,C1781,278,$864.48 ,$864.48 ,$259.34 ,$786.68 ,$605.14 ,$259.34 ,$561.91 ,$622.43 ,$786.68 ,$648.36 
Carle BroMenn Medical Center,8179055,MESH PLUS MEDIUM PERLIX HERNIA 1.,101895,C1781,278,$547.20 ,$547.20 ,$164.16 ,$497.95 ,$383.04 ,$164.16 ,$355.68 ,$393.98 ,$497.95 ,$410.40 
Carle BroMenn Medical Center,8179055,MESH PROLENE HERNIA SYSTEM EXT,248747,C1781,278,$727.16 ,$727.16 ,$218.15 ,$661.72 ,$509.01 ,$218.15 ,$472.65 ,$523.56 ,$661.72 ,$545.37 
Carle BroMenn Medical Center,8179055,MESH VENTRALEX HERNIA PATCH LG us,3972,C1781,278,"$1,689.00 ","$1,689.00 ",$506.70 ,"$1,536.99 ","$1,182.30 ",$506.70 ,"$1,097.85 ","$1,216.08 ","$1,536.99 ","$1,266.75 "
Carle BroMenn Medical Center,8179055,MESH VENTRALIGHT ECHO 4.5 CIRC 1/,205704,C1781,278,"$1,592.85 ","$1,592.85 ",$477.86 ,"$1,449.49 ","$1,115.00 ",$477.86 ,"$1,035.35 ","$1,146.85 ","$1,449.49 ","$1,194.64 "
Carle BroMenn Medical Center,8179055,MESH VENTRALIGHT ECHO 6X8 1/CA,205706,C1781,278,"$2,753.85 ","$2,753.85 ",$826.16 ,"$2,506.00 ","$1,927.70 ",$826.16 ,"$1,790.00 ","$1,982.77 ","$2,506.00 ","$2,065.39 "
Carle BroMenn Medical Center,8179055,MESH VENTRALIGHT ECHO 7X9,245170,C1781,278,"$3,729.30 ","$3,729.30 ","$1,118.79 ","$3,393.66 ","$2,610.51 ","$1,118.79 ","$2,424.05 ","$2,685.10 ","$3,393.66 ","$2,796.98 "
Carle BroMenn Medical Center,8179055,MESH VENTRALIGHT ECHO 8X10 1/CA,201478,C1781,278,"$4,593.45 ","$4,593.45 ","$1,378.04 ","$4,180.04 ","$3,215.42 ","$1,378.04 ","$2,985.74 ","$3,307.28 ","$4,180.04 ","$3,445.09 "
Carle BroMenn Medical Center,8179055,MESH VENTRIO LG OVAL 14X18CM 1/CS,245164,C1781,278,"$3,322.80 ","$3,322.80 ",$996.84 ,"$3,023.75 ","$2,325.96 ",$996.84 ,"$2,159.82 ","$2,392.42 ","$3,023.75 ","$2,492.10 "
Carle BroMenn Medical Center,8179055,MESH VENTRIO OVAL 16X31.2CM,245168,C1781,278,"$5,446.80 ","$5,446.80 ","$1,634.04 ","$4,956.59 ","$3,812.76 ","$1,634.04 ","$3,540.42 ","$3,921.70 ","$4,956.59 ","$4,085.10 "
Carle BroMenn Medical Center,8179055,MESH VENTRIO SM OVAL 8X12CM 1/CS,245163,C1781,278,"$1,776.30 ","$1,776.30 ",$532.89 ,"$1,616.43 ","$1,243.41 ",$532.89 ,"$1,154.60 ","$1,278.94 ","$1,616.43 ","$1,332.23 "
Carle BroMenn Medical Center,8179055,MESH VENTRIO XL OVAL 1/CS,245165,C1781,278,"$5,334.60 ","$5,334.60 ","$1,600.38 ","$4,854.49 ","$3,734.22 ","$1,600.38 ","$3,467.49 ","$3,840.91 ","$4,854.49 ","$4,000.95 "
Carle BroMenn Medical Center,8179055,MESH VENTRIO XL OVAL 19.6CM 1/CS,245167,C1781,278,"$4,502.40 ","$4,502.40 ","$1,350.72 ","$4,097.18 ","$3,151.68 ","$1,350.72 ","$2,926.56 ","$3,241.73 ","$4,097.18 ","$3,376.80 "
Carle BroMenn Medical Center,8179055,MESH VENTRIO XL OVAL 27.4CM,245166,C1781,278,"$6,670.20 ","$6,670.20 ","$2,001.06 ","$6,069.88 ","$4,669.14 ","$2,001.06 ","$4,335.63 ","$4,802.54 ","$6,069.88 ","$5,002.65 "
Carle BroMenn Medical Center,8179055,MESH Y LITE VERTESSA 26X4X3 3 PER,247377,C1781,278,"$2,547.00 ","$2,547.00 ",$764.10 ,"$2,317.77 ","$1,782.90 ",$764.10 ,"$1,655.55 ","$1,833.84 ","$2,317.77 ","$1,910.25 "
Carle BroMenn Medical Center,8179055,MESH Y UPSYLON,245197,C1781,278,"$2,830.50 ","$2,830.50 ",$849.15 ,"$2,575.76 ","$1,981.35 ",$849.15 ,"$1,839.83 ","$2,037.96 ","$2,575.76 ","$2,122.88 "
Carle BroMenn Medical Center,8179055,SYSTEM OPTIFIX AT30,252804,C1781,278,$796.50 ,$796.50 ,$238.95 ,$724.82 ,$557.55 ,$238.95 ,$517.73 ,$573.48 ,$724.82 ,$597.38 
Carle BroMenn Medical Center,8179064,PORT PWR MRI PLAS 8F,237555,C1788,278,$840.00 ,$840.00 ,$252.00 ,$764.40 ,$588.00 ,$252.00 ,$546.00 ,$604.80 ,$764.40 ,$630.00 
Carle BroMenn Medical Center,8200136,FIDUCIAL MARKER 3 PACK,,A4648,278,$149.00 ,$149.00 ,$44.70 ,$135.59 ,$104.30 ,$44.70 ,$96.85 ,$107.28 ,$135.59 ,$111.75 
Carle BroMenn Medical Center,8201044,FIDUCIAL MARKERS 1 PACK,,A4648,278,$149.00 ,$149.00 ,$44.70 ,$135.59 ,$104.30 ,$44.70 ,$96.85 ,$107.28 ,$135.59 ,$111.75 
Carle BroMenn Medical Center,8201045,FIDUCIAL MARKER 3 PACK,,A4648,278,$149.00 ,$149.00 ,$44.70 ,$135.59 ,$104.30 ,$44.70 ,$96.85 ,$107.28 ,$135.59 ,$111.75 
Carle BroMenn Medical Center,8401717,"BRACHTX, NON-STR, HDR IR-192",,C1717,278,"$2,095.00 ","$2,095.00 ",$628.50 ,"$1,906.45 ","$1,466.50 ",$628.50 ,"$1,361.75 ","$1,508.40 ","$1,906.45 ","$1,571.25 "
Carle BroMenn Medical Center,8402638,I-125 STRANDED,,A4648,278,$465.00 ,$465.00 ,$139.50 ,$423.15 ,$325.50 ,$139.50 ,$302.25 ,$334.80 ,$423.15 ,$348.75 
Carle BroMenn Medical Center,8402640,PALLADIUM-103 STRANDED,,C2640,278,$465.00 ,$465.00 ,$139.50 ,$423.15 ,$325.50 ,$139.50 ,$302.25 ,$334.80 ,$423.15 ,$348.75 
Carle BroMenn Medical Center,8404648,"GOLD TISSUE MARKER, IMPLANTABLE, EACH",,A4648,278,$149.00 ,$149.00 ,$44.70 ,$135.59 ,$104.30 ,$44.70 ,$96.85 ,$107.28 ,$135.59 ,$111.75 
Carle BroMenn Medical Center,8414648,BREAST LOCALIZATION NEEDLE,,C1819,278,$104.00 ,$104.00 ,$31.20 ,$94.64 ,$72.80 ,$31.20 ,$67.60 ,$74.88 ,$94.64 ,$78.00 
Carle BroMenn Medical Center,8970007,GUIDE WIRE,,C1769,278,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8970018,CATHETER MACLOC 8.5F 5SH,,C1729,278,"$2,018.90 ","$2,018.90 ",$605.67 ,"$1,837.20 ","$1,413.23 ",$605.67 ,"$1,312.29 ","$1,453.61 ","$1,837.20 ","$1,514.18 "
Carle BroMenn Medical Center,8970023,CATHETER MACLOC 10.2F 5SH,,C1729,278,"$2,018.90 ","$2,018.90 ",$605.67 ,"$1,837.20 ","$1,413.23 ",$605.67 ,"$1,312.29 ","$1,453.61 ","$1,837.20 ","$1,514.18 "
Carle BroMenn Medical Center,8970024,CATHETER  MACLOC 12F  5SH,,C1729,278,"$2,018.90 ","$2,018.90 ",$605.67 ,"$1,837.20 ","$1,413.23 ",$605.67 ,"$1,312.29 ","$1,453.61 ","$1,837.20 ","$1,514.18 "
Carle BroMenn Medical Center,8970032,CATHETER CENTESIS 5F 15CM 19GA 17CM ECHO,,C1729,278,"$2,018.90 ","$2,018.90 ",$605.67 ,"$1,837.20 ","$1,413.23 ",$605.67 ,"$1,312.29 ","$1,453.61 ","$1,837.20 ","$1,514.18 "
Carle BroMenn Medical Center,8970104,CATHETER CENTESIS 5F 10CM 19GA 12CM ECHO,,C1729,278,"$2,018.90 ","$2,018.90 ",$605.67 ,"$1,837.20 ","$1,413.23 ",$605.67 ,"$1,312.29 ","$1,453.61 ","$1,837.20 ","$1,514.18 "
Carle BroMenn Medical Center,8972616,Y90 DOSE,,C2616,278,"$40,613.00 ","$40,613.00 ","$12,183.90 ","$36,957.83 ","$28,429.10 ","$12,183.90 ","$26,398.45 ","$29,241.36 ","$36,957.83 ","$30,459.75 "
Carle BroMenn Medical Center,8979235,"VASCULAR CLOSURE DEV, PERCLOSE",,C1760,278,$248.00 ,$248.00 ,$74.40 ,$225.68 ,$173.60 ,$74.40 ,$161.20 ,$178.56 ,$225.68 ,$186.00 
Carle BroMenn Medical Center,8979236,"VASC CLOSURE,ANGIOSEAL,6FR/8FR",,C1760,278,$248.00 ,$248.00 ,$74.40 ,$225.68 ,$173.60 ,$74.40 ,$161.20 ,$178.56 ,$225.68 ,$186.00 
Carle BroMenn Medical Center,8979237,"CLOSURE DEVICE, VASOSEAL",,C1760,278,$248.00 ,$248.00 ,$74.40 ,$225.68 ,$173.60 ,$74.40 ,$161.20 ,$178.56 ,$225.68 ,$186.00 
Carle BroMenn Medical Center,8979238,"CLOSURE DEVICE,VASCULAR,INSERT",,C1760,278,$248.00 ,$248.00 ,$74.40 ,$225.68 ,$173.60 ,$74.40 ,$161.20 ,$178.56 ,$225.68 ,$186.00 
Carle BroMenn Medical Center,8979282,"GUIDE WIRE,CROSS IT,WIGGLEWIRE",,C1769,278,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8979297,PORT 8F SMARTPORT PLASTIC,240912,C1788,278,$540.00 ,$540.00 ,$162.00 ,$491.40 ,$378.00 ,$162.00 ,$351.00 ,$388.80 ,$491.40 ,$405.00 
Carle BroMenn Medical Center,8979547,WIRELESS PRESSURE SENSOR,,C2624,278,"$76,193.00 ","$76,193.00 ","$22,857.90 ","$69,335.63 ","$53,335.10 ","$22,857.90 ","$49,525.45 ","$54,858.96 ","$69,335.63 ","$57,144.75 "
Carle BroMenn Medical Center,8200009,RADIATION IMPLANT BRIEF SMALL,,A9999,290,$314.00 ,$314.00 ,$94.20 ,$285.74 ,$219.80 ,$94.20 ,$204.10 ,$226.08 ,$285.74 ,$235.50 
Carle BroMenn Medical Center,8200010,RADIATION IMPLANT BRIEF MED,,A9999,290,$314.00 ,$314.00 ,$94.20 ,$285.74 ,$219.80 ,$94.20 ,$204.10 ,$226.08 ,$285.74 ,$235.50 
Carle BroMenn Medical Center,8200011,RADIATION IMPLANT BRIEF LARGE,,A9999,290,$314.00 ,$314.00 ,$94.20 ,$285.74 ,$219.80 ,$94.20 ,$204.10 ,$226.08 ,$285.74 ,$235.50 
Carle BroMenn Medical Center,8200013,RADIATION IMPLANT BRIEF 1X-LARGE,,A9999,290,$314.00 ,$314.00 ,$94.20 ,$285.74 ,$219.80 ,$94.20 ,$204.10 ,$226.08 ,$285.74 ,$235.50 
Carle BroMenn Medical Center,8200014,RADIATION IMPLANT BRIEF 2X-LARGE,,A9999,290,$314.00 ,$314.00 ,$94.20 ,$285.74 ,$219.80 ,$94.20 ,$204.10 ,$226.08 ,$285.74 ,$235.50 
Carle BroMenn Medical Center,8200015,RADIATION IMPLANT BRIEF 3X-LARGE,,A9999,290,$314.00 ,$314.00 ,$94.20 ,$285.74 ,$219.80 ,$94.20 ,$204.10 ,$226.08 ,$285.74 ,$235.50 
Carle BroMenn Medical Center,8200016,RADIATION IMPLANT BRIEF 4X-LARGE,,A9999,290,$314.00 ,$314.00 ,$94.20 ,$285.74 ,$219.80 ,$94.20 ,$204.10 ,$226.08 ,$285.74 ,$235.50 
Carle BroMenn Medical Center,8200017,RADIATION IMPLANT BRIEF 5X-LARGE,,A9999,290,$314.00 ,$314.00 ,$94.20 ,$285.74 ,$219.80 ,$94.20 ,$204.10 ,$226.08 ,$285.74 ,$235.50 
Carle BroMenn Medical Center,8201074,EAR BAND IT-SMALL,,A9999,290,$314.00 ,$314.00 ,$94.20 ,$285.74 ,$219.80 ,$94.20 ,$204.10 ,$226.08 ,$285.74 ,$235.50 
Carle BroMenn Medical Center,8920150,BARIATRIC BED PLATFORM 2,,,291,$323.00 ,$323.00 ,$96.90 ,$293.93 ,$226.10 ,$96.90 ,$209.95 ,$232.56 ,$293.93 ,$242.25 
Carle BroMenn Medical Center,8920151,BARIATRIC TRAPEZE,,,291,$54.00 ,$54.00 ,$16.20 ,$49.14 ,$37.80 ,$16.20 ,$35.10 ,$38.88 ,$49.14 ,$40.50 
Carle BroMenn Medical Center,8920152,BARIATRIC SCALE,,,291,$54.00 ,$54.00 ,$16.20 ,$49.14 ,$37.80 ,$16.20 ,$35.10 ,$38.88 ,$49.14 ,$40.50 
Carle BroMenn Medical Center,8920153,LOWBOY BARIATRIC,,,291,$221.00 ,$221.00 ,$66.30 ,$201.11 ,$154.70 ,$66.30 ,$143.65 ,$159.12 ,$201.11 ,$165.75 
Carle BroMenn Medical Center,8920154,LOWBOY MATTRESS,,,291,$28.00 ,$28.00 ,$8.40 ,$25.48 ,$19.60 ,$8.40 ,$18.20 ,$20.16 ,$25.48 ,$21.00 
Carle BroMenn Medical Center,8920155,BARIATRIC BIGTURN,,,291,$195.00 ,$195.00 ,$58.50 ,$177.45 ,$136.50 ,$58.50 ,$126.75 ,$140.40 ,$177.45 ,$146.25 
Carle BroMenn Medical Center,8920156,BARIATRIC MIGHTY AIR,,,291,$195.00 ,$195.00 ,$58.50 ,$177.45 ,$136.50 ,$58.50 ,$126.75 ,$140.40 ,$177.45 ,$146.25 
Carle BroMenn Medical Center,8920157,BARIATRIC WALKER,,,291,$11.00 ,$11.00 ,$3.30 ,$10.01 ,$7.70 ,$3.30 ,$7.15 ,$7.92 ,$10.01 ,$8.25 
Carle BroMenn Medical Center,8920158,BARIATRIC BEDSIDE RECLINER,,,291,$218.00 ,$218.00 ,$65.40 ,$198.38 ,$152.60 ,$65.40 ,$141.70 ,$156.96 ,$198.38 ,$163.50 
Carle BroMenn Medical Center,8920159,BARIATRIC AIR TRANSFER,,,291,$109.00 ,$109.00 ,$32.70 ,$99.19 ,$76.30 ,$32.70 ,$70.85 ,$78.48 ,$99.19 ,$81.75 
Carle BroMenn Medical Center,8920161,SIZEWISE BARIATIRC SHUTTLE B SERIES ADVANCED,,,291,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8920162,SIZEWISE BARIATRIC SHUTTLE B SERIES ADVANCED POWER DRIVE,,,291,$83.00 ,$83.00 ,$24.90 ,$75.53 ,$58.10 ,$24.90 ,$53.95 ,$59.76 ,$75.53 ,$62.25 
Carle BroMenn Medical Center,8920163,PLATINUM 6000,,,291,$65.00 ,$65.00 ,$19.50 ,$59.15 ,$45.50 ,$19.50 ,$42.25 ,$46.80 ,$59.15 ,$48.75 
Carle BroMenn Medical Center,8920164,SW PULSATE SYSTEM,,,291,$230.00 ,$230.00 ,$69.00 ,$209.30 ,$161.00 ,$69.00 ,$149.50 ,$165.60 ,$209.30 ,$172.50 
Carle BroMenn Medical Center,8920165,SW ALTERNATE SYSTEM,,,291,$230.00 ,$230.00 ,$69.00 ,$209.30 ,$161.00 ,$69.00 ,$149.50 ,$165.60 ,$209.30 ,$172.50 
Carle BroMenn Medical Center,8920166,ENVISION LOW AIR LOSS,,,291,$248.00 ,$248.00 ,$74.40 ,$225.68 ,$173.60 ,$74.40 ,$161.20 ,$178.56 ,$225.68 ,$186.00 
Carle BroMenn Medical Center,8920167,CLINITRON,,,291,$356.00 ,$356.00 ,$106.80 ,$323.96 ,$249.20 ,$106.80 ,$231.40 ,$256.32 ,$323.96 ,$267.00 
Carle BroMenn Medical Center,8920168,HILLROM CLINITRON TRAPEZE,,,291,$47.00 ,$47.00 ,$14.10 ,$42.77 ,$32.90 ,$14.10 ,$30.55 ,$33.84 ,$42.77 ,$35.25 
Carle BroMenn Medical Center,8920169,ACELITY WOUND VAC,,,291,$315.00 ,$315.00 ,$94.50 ,$286.65 ,$220.50 ,$94.50 ,$204.75 ,$226.80 ,$286.65 ,$236.25 
Carle BroMenn Medical Center,8920170,ENCLOSURE BED,,,291,$291.00 ,$291.00 ,$87.30 ,$264.81 ,$203.70 ,$87.30 ,$189.15 ,$209.52 ,$264.81 ,$218.25 
Carle BroMenn Medical Center,8920171,LOWBOY STANDARD,,,291,$113.00 ,$113.00 ,$33.90 ,$102.83 ,$79.10 ,$33.90 ,$73.45 ,$81.36 ,$102.83 ,$84.75 
Carle BroMenn Medical Center,8920172,BUNDLED PKG REHAB PLATFORM FLEX W/AIR,,,291,$546.00 ,$546.00 ,$163.80 ,$496.86 ,$382.20 ,$163.80 ,$354.90 ,$393.12 ,$496.86 ,$409.50 
Carle BroMenn Medical Center,8920173,BUNDLED PKG REHAB PLATFORM W/SCALE FOAM,,,291,$386.00 ,$386.00 ,$115.80 ,$351.26 ,$270.20 ,$115.80 ,$250.90 ,$277.92 ,$351.26 ,$289.50 
Carle BroMenn Medical Center,8920174,LOWBOY FLOOR SAFETY PADS,,8920174,291,$28.00 ,$28.00 ,$8.40 ,$25.48 ,$19.60 ,$8.40 ,$18.20 ,$20.16 ,$25.48 ,$21.00 
Carle BroMenn Medical Center,8920175,BARI DROP ARM COMMODE,,,291,$58.00 ,$58.00 ,$17.40 ,$52.78 ,$40.60 ,$17.40 ,$37.70 ,$41.76 ,$52.78 ,$43.50 
Carle BroMenn Medical Center,8920176,STANDARD SHUTTLE B ADV,,,291,$221.00 ,$221.00 ,$66.30 ,$201.11 ,$154.70 ,$66.30 ,$143.65 ,$159.12 ,$201.11 ,$165.75 
Carle BroMenn Medical Center,8920177,SIZEWISE TRAPEZE,,,291,$56.00 ,$56.00 ,$16.80 ,$50.96 ,$39.20 ,$16.80 ,$36.40 ,$40.32 ,$50.96 ,$42.00 
Carle BroMenn Medical Center,8920178,SIZEWIZE EVOLUTION,,,291,$201.00 ,$201.00 ,$60.30 ,$182.91 ,$140.70 ,$60.30 ,$130.65 ,$144.72 ,$182.91 ,$150.75 
Carle BroMenn Medical Center,8920181,BARI SHOWER CHAIR,,,291,$58.00 ,$58.00 ,$17.40 ,$52.78 ,$40.60 ,$17.40 ,$37.70 ,$41.76 ,$52.78 ,$43.50 
Carle BroMenn Medical Center,8920182,HILLROM SENTINEL II BARIATRIC LOW BED,,,291,$411.00 ,$411.00 ,$123.30 ,$374.01 ,$287.70 ,$123.30 ,$267.15 ,$295.92 ,$374.01 ,$308.25 
Carle BroMenn Medical Center,8920183,HILLROM SENTINEL II BARIATRIC LOW BED/TRAPEZE,,,291,$479.00 ,$479.00 ,$143.70 ,$435.89 ,$335.30 ,$143.70 ,$311.35 ,$344.88 ,$435.89 ,$359.25 
Carle BroMenn Medical Center,8920184,HILLROM POSEY BEDS 8070 & CANOPY,,,291,$271.00 ,$271.00 ,$81.30 ,$246.61 ,$189.70 ,$81.30 ,$176.15 ,$195.12 ,$246.61 ,$203.25 
Carle BroMenn Medical Center,8920185,HILLROM COMPELLA W/P530 CLRT,,,291,$410.00 ,$410.00 ,$123.00 ,$373.10 ,$287.00 ,$123.00 ,$266.50 ,$295.20 ,$373.10 ,$307.50 
Carle BroMenn Medical Center,8920186,HILLROM COMPELLA W/P530 CLRT/TRAPEZE,,,291,$443.00 ,$443.00 ,$132.90 ,$403.13 ,$310.10 ,$132.90 ,$287.95 ,$318.96 ,$403.13 ,$332.25 
Carle BroMenn Medical Center,8920187,HILLROM CLINITRON RITE HITE AIR FLUIDIZED THERAPY,,,291,$391.00 ,$391.00 ,$117.30 ,$355.81 ,$273.70 ,$117.30 ,$254.15 ,$281.52 ,$355.81 ,$293.25 
Carle BroMenn Medical Center,8920188,"HILLROM SPIRIT SELECT LOW BED W/TEMPUR MATTRESS 84""",,,291,$194.00 ,$194.00 ,$58.20 ,$176.54 ,$135.80 ,$58.20 ,$126.10 ,$139.68 ,$176.54 ,$145.50 
Carle BroMenn Medical Center,8920189,HILLROM TCB SERIAL H349AL1802 TOTAL CARE BARIATIC PLUS,,,291,$320.00 ,$320.00 ,$96.00 ,$291.20 ,$224.00 ,$96.00 ,$208.00 ,$230.40 ,$291.20 ,$240.00 
Carle BroMenn Medical Center,8920190,HILLROM ENVELLA P0819A,,,291,$617.00 ,$617.00 ,$185.10 ,$561.47 ,$431.90 ,$185.10 ,$401.05 ,$444.24 ,$561.47 ,$462.75 
Carle BroMenn Medical Center,8920191,HILLROM ENVELLA W/ TRAPEZE,,,291,$333.00 ,$333.00 ,$99.90 ,$303.03 ,$233.10 ,$99.90 ,$216.45 ,$239.76 ,$303.03 ,$249.75 
Carle BroMenn Medical Center,8920192,HILLROM ADVANTA W/P500,,,291,$181.00 ,$181.00 ,$54.30 ,$164.71 ,$126.70 ,$54.30 ,$117.65 ,$130.32 ,$164.71 ,$135.75 
Carle BroMenn Medical Center,8920193,HILLROM VCP500 VERSACARE P500 BED,,,291,$207.00 ,$207.00 ,$62.10 ,$188.37 ,$144.90 ,$62.10 ,$134.55 ,$149.04 ,$188.37 ,$155.25 
Carle BroMenn Medical Center,8920194,AGILITI LOW BED HARMONY LOW BED (HLB) LOW BED,,,291,$96.00 ,$96.00 ,$28.80 ,$87.36 ,$67.20 ,$28.80 ,$62.40 ,$69.12 ,$87.36 ,$72.00 
Carle BroMenn Medical Center,8920195,AGILITI TIW POSEY 8070 CANOPY AND BED,,,291,$127.00 ,$127.00 ,$38.10 ,$115.57 ,$88.90 ,$38.10 ,$82.55 ,$91.44 ,$115.57 ,$95.25 
Carle BroMenn Medical Center,8920196,AGILITI STRETCHAIR (SHUTTLE CHAIR),,,291,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8920197,HILLROM COMPELLA W/P530 CLRT/VITALGO,,,291,$912.00 ,$912.00 ,$273.60 ,$829.92 ,$638.40 ,$273.60 ,$592.80 ,$656.64 ,$829.92 ,$684.00 
Carle BroMenn Medical Center,8920198,AGILITI TOTAL VITALGO BARIATRIC BED,,,291,$502.00 ,$502.00 ,$150.60 ,$456.82 ,$351.40 ,$150.60 ,$326.30 ,$361.44 ,$456.82 ,$376.50 
Carle BroMenn Medical Center,8200173,KIT MINI ONE BUTTON,,B4088,294,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8200273,TRACH TUBE BOVINA TTS SZ 6 CUFFED,,A7521,294,$627.00 ,$627.00 ,$188.10 ,$570.57 ,$438.90 ,$188.10 ,$407.55 ,$451.44 ,$570.57 ,$470.25 
Carle BroMenn Medical Center,8201055,TRACHEOTOMY TUBE 6DCFN,,A7520,294,$530.00 ,$530.00 ,$159.00 ,$482.30 ,$371.00 ,$159.00 ,$344.50 ,$381.60 ,$482.30 ,$397.50 
Carle BroMenn Medical Center,8201056,TRACHEOTOMY TUBE 8CFS,,A7520,294,$530.00 ,$530.00 ,$159.00 ,$482.30 ,$371.00 ,$159.00 ,$344.50 ,$381.60 ,$482.30 ,$397.50 
Carle BroMenn Medical Center,8201057,TRACHEOTOMY TUBE 4CFS,,A7520,294,$530.00 ,$530.00 ,$159.00 ,$482.30 ,$371.00 ,$159.00 ,$344.50 ,$381.60 ,$482.30 ,$397.50 
Carle BroMenn Medical Center,8201058,TRACH TUBE SHILEY 60XLTD,,A7520,294,$530.00 ,$530.00 ,$159.00 ,$482.30 ,$371.00 ,$159.00 ,$344.50 ,$381.60 ,$482.30 ,$397.50 
Carle BroMenn Medical Center,8201059,TRACHEOTOMY TUBE 4LPC,,A7521,294,$627.00 ,$627.00 ,$188.10 ,$570.57 ,$438.90 ,$188.10 ,$407.55 ,$451.44 ,$570.57 ,$470.25 
Carle BroMenn Medical Center,8201060,TRACHEOTOMY TUBE 6LPC,,A7521,294,$627.00 ,$627.00 ,$188.10 ,$570.57 ,$438.90 ,$188.10 ,$407.55 ,$451.44 ,$570.57 ,$470.25 
Carle BroMenn Medical Center,8201061,TRACHEOSTOMY TUBE 8LPC,,A7521,294,$627.00 ,$627.00 ,$188.10 ,$570.57 ,$438.90 ,$188.10 ,$407.55 ,$451.44 ,$570.57 ,$470.25 
Carle BroMenn Medical Center,8201062,TRACHEOTOMY TUBE 60XLTCD,,A7521,294,$627.00 ,$627.00 ,$188.10 ,$570.57 ,$438.90 ,$188.10 ,$407.55 ,$451.44 ,$570.57 ,$470.25 
Carle BroMenn Medical Center,8201063,TRACH TUBE ADULT 8MM 11OD,,A7521,294,$627.00 ,$627.00 ,$188.10 ,$570.57 ,$438.90 ,$188.10 ,$407.55 ,$451.44 ,$570.57 ,$470.25 
Carle BroMenn Medical Center,8202296,KIT GASTRO ENTRISTAR,,99070,294,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8980294,racepinephrine 2.25 % solution for nebulization,487278401,J7699,294,$113.15 ,$113.15 ,$33.95 ,$102.97 ,$79.21 ,$33.95 ,$73.55 ,$81.47 ,$102.97 ,$84.86 
Carle BroMenn Medical Center,8021416,CAPILLARY BLOOD COLL (FINGER/HEEL STICK),,36416,300,$23.00 ,$23.00 ,$6.90 ,$20.93 ,$16.10 ,$6.90 ,$14.95 ,$16.56 ,$20.93 ,$17.25 
Carle BroMenn Medical Center,8026415,VENIPUNCTURE,,36415,300,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8080001,URINE PH (DIPSTICK NON AUTOMATED),,81002,300,$37.00 ,$37.00 ,$11.10 ,$33.67 ,$25.90 ,$11.10 ,$24.05 ,$26.64 ,$33.67 ,$27.75 
Carle BroMenn Medical Center,8080047,"BASIC METABOLIC PANEL, CALCIUM IONIZED",,80047,300,$728.00 ,$728.00 ,$218.40 ,$662.48 ,$509.60 ,$218.40 ,$473.20 ,$524.16 ,$662.48 ,$546.00 
Carle BroMenn Medical Center,8081002,BEDSIDE URINE TEST STRIP,,81002,300,$37.00 ,$37.00 ,$11.10 ,$33.67 ,$25.90 ,$11.10 ,$24.05 ,$26.64 ,$33.67 ,$27.75 
Carle BroMenn Medical Center,8081025,BEDSIDE URINE PREGNANCY,,81025,300,$90.00 ,$90.00 ,$27.00 ,$81.90 ,$63.00 ,$27.00 ,$58.50 ,$64.80 ,$81.90 ,$67.50 
Carle BroMenn Medical Center,8082930,OCCULT BLOOD & PH - GASTRIC,,82930,300,$36.00 ,$36.00 ,$10.80 ,$32.76 ,$25.20 ,$10.80 ,$23.40 ,$25.92 ,$32.76 ,$27.00 
Carle BroMenn Medical Center,8120001,METBLC PNL IONIZED CA OR CHEM8+,,80047,300,$728.00 ,$728.00 ,$218.40 ,$662.48 ,$509.60 ,$218.40 ,$473.20 ,$524.16 ,$662.48 ,$546.00 
Carle BroMenn Medical Center,8200115,POST COITAL MUCOUS EXAM,,Q0115,300,$40.00 ,$40.00 ,$12.00 ,$36.40 ,$28.00 ,$12.00 ,$26.00 ,$28.80 ,$36.40 ,$30.00 
Carle BroMenn Medical Center,8200602,SEND OUT SHIPPING FEE,,99000,300,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8200603,SEND OUT PROCESSING/HANDLING FEE,,99001,300,$44.00 ,$44.00 ,$13.20 ,$40.04 ,$30.80 ,$13.20 ,$28.60 ,$31.68 ,$40.04 ,$33.00 
Carle BroMenn Medical Center,8200621,"BLOOD TYPING, ABO",,86900,300,$25.00 ,$25.00 ,$7.50 ,$22.75 ,$17.50 ,$7.50 ,$16.25 ,$18.00 ,$22.75 ,$18.75 
Carle BroMenn Medical Center,8200622,"BLOOD TYPING, RH",,86901,300,$22.00 ,$22.00 ,$6.60 ,$20.02 ,$15.40 ,$6.60 ,$14.30 ,$15.84 ,$20.02 ,$16.50 
Carle BroMenn Medical Center,8209612,CATH URINE SPECIMEN COLLECTION,,P9612,300,$21.00 ,$21.00 ,$6.30 ,$19.11 ,$14.70 ,$6.30 ,$13.65 ,$15.12 ,$19.11 ,$15.75 
Carle BroMenn Medical Center,8236415,VENIPUNCTURE,,36415,300,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8236416,COLLECTION CAPILLARY BLOOD SPECIMEN,,36416,300,$23.00 ,$23.00 ,$6.90 ,$20.93 ,$16.10 ,$6.90 ,$14.95 ,$16.56 ,$20.93 ,$17.25 
Carle BroMenn Medical Center,8280047,CHG BASIC METABOLIC PANEL CALCIUM IONIZED,,80047,300,$728.00 ,$728.00 ,$218.40 ,$662.48 ,$509.60 ,$218.40 ,$473.20 ,$524.16 ,$662.48 ,$546.00 
Carle BroMenn Medical Center,8281002,URINE PROTEIN,,81002,300,$37.00 ,$37.00 ,$11.10 ,$33.67 ,$25.90 ,$11.10 ,$24.05 ,$26.64 ,$33.67 ,$27.75 
Carle BroMenn Medical Center,8281003,"URINALYSIS, AUTO, W/O SCOPE",,81003,300,$53.00 ,$53.00 ,$15.90 ,$48.23 ,$37.10 ,$15.90 ,$34.45 ,$38.16 ,$48.23 ,$39.75 
Carle BroMenn Medical Center,8281025,URINE PREGNANCY,,81025,300,$90.00 ,$90.00 ,$27.00 ,$81.90 ,$63.00 ,$27.00 ,$58.50 ,$64.80 ,$81.90 ,$67.50 
Carle BroMenn Medical Center,8282271,GASTRIC OCCULT BLOOD,,82271,300,$38.00 ,$38.00 ,$11.40 ,$34.58 ,$26.60 ,$11.40 ,$24.70 ,$27.36 ,$34.58 ,$28.50 
Carle BroMenn Medical Center,8282375,ASSAY BLOOD CARBON MONOXIDE,,82375,300,$108.00 ,$108.00 ,$32.40 ,$98.28 ,$75.60 ,$32.40 ,$70.20 ,$77.76 ,$98.28 ,$81.00 
Carle BroMenn Medical Center,8286308,MONO TEST,,86308,300,$19.00 ,$19.00 ,$5.70 ,$17.29 ,$13.30 ,$5.70 ,$12.35 ,$13.68 ,$17.29 ,$14.25 
Carle BroMenn Medical Center,8286900,"BLOOD TYPING, ABO",,86900,300,$81.00 ,$81.00 ,$24.30 ,$73.71 ,$56.70 ,$24.30 ,$52.65 ,$58.32 ,$73.71 ,$60.75 
Carle BroMenn Medical Center,8286901,"BLOOD TYPING, RH (D)",,86901,300,$77.00 ,$77.00 ,$23.10 ,$70.07 ,$53.90 ,$23.10 ,$50.05 ,$55.44 ,$70.07 ,$57.75 
Carle BroMenn Medical Center,8289259,"CRYOPRESERVATION, SPERM",,89259,300,$300.00 ,$300.00 ,$90.00 ,$273.00 ,$210.00 ,$90.00 ,$195.00 ,$216.00 ,$273.00 ,$225.00 
Carle BroMenn Medical Center,8289261,"SPERM ISOLATION, COMPLEX",,89261,300,$520.00 ,$520.00 ,$156.00 ,$473.20 ,$364.00 ,$156.00 ,$338.00 ,$374.40 ,$473.20 ,$390.00 
Carle BroMenn Medical Center,8289300,POST COITAL TEST,,89300,300,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8289310,"SEMEN ANALYSIS,MOTIL & COUNT W/O HUHNER",,89310,300,$125.00 ,$125.00 ,$37.50 ,$113.75 ,$87.50 ,$37.50 ,$81.25 ,$90.00 ,$113.75 ,$93.75 
Carle BroMenn Medical Center,8289322,"SEMEN ANALYSIS, STRICT MORPHOLOGIC CRITERIA",,89322,300,$245.00 ,$245.00 ,$73.50 ,$222.95 ,$171.50 ,$73.50 ,$159.25 ,$176.40 ,$222.95 ,$183.75 
Carle BroMenn Medical Center,8289330,"SPERM EVAL; CERV MUCUS PENETRATION TEST, W OR W/O SPINNBARKEIT TEST",,89330,300,$240.00 ,$240.00 ,$72.00 ,$218.40 ,$168.00 ,$72.00 ,$156.00 ,$172.80 ,$218.40 ,$180.00 
Carle BroMenn Medical Center,8289331,RETROGRADE EJACULATION ANALYSIS,,89331,300,$205.00 ,$205.00 ,$61.50 ,$186.55 ,$143.50 ,$61.50 ,$133.25 ,$147.60 ,$186.55 ,$153.75 
Carle BroMenn Medical Center,8289353,THAWING CRYOPRESRVED; SPERM,,89353,300,$520.00 ,$520.00 ,$156.00 ,$473.20 ,$364.00 ,$156.00 ,$338.00 ,$374.40 ,$473.20 ,$390.00 
Carle BroMenn Medical Center,8289356,THAWING CRYOPRESRVED; OOCYTE,,89356,300,$350.00 ,$350.00 ,$105.00 ,$318.50 ,$245.00 ,$105.00 ,$227.50 ,$252.00 ,$318.50 ,$262.50 
Carle BroMenn Medical Center,8299000,"SPECIMEN HANDLING,DR OFF->LAB",,99000,300,$36.00 ,$36.00 ,$10.80 ,$32.76 ,$25.20 ,$10.80 ,$23.40 ,$25.92 ,$32.76 ,$27.00 
Carle BroMenn Medical Center,8299001,"SPECIMEN HANDLING,PT->LAB",,99001,300,$36.00 ,$36.00 ,$10.80 ,$32.76 ,$25.20 ,$10.80 ,$23.40 ,$25.92 ,$32.76 ,$27.00 
Carle BroMenn Medical Center,8300002,CMP PANEL,,80053,300,$88.00 ,$88.00 ,$26.40 ,$80.08 ,$61.60 ,$26.40 ,$57.20 ,$63.36 ,$80.08 ,$66.00 
Carle BroMenn Medical Center,8300003,CBC W/AUTO DIFF,,85025,300,$66.00 ,$66.00 ,$19.80 ,$60.06 ,$46.20 ,$19.80 ,$42.90 ,$47.52 ,$60.06 ,$49.50 
Carle BroMenn Medical Center,8300004,TSH,,84443,300,$120.00 ,$120.00 ,$36.00 ,$109.20 ,$84.00 ,$36.00 ,$78.00 ,$86.40 ,$109.20 ,$90.00 
Carle BroMenn Medical Center,8300006,CBC W/AUTOMATED DIFFERENTIAL,,85025,300,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8300007,HEPATITIS B SURFACE ANTIGEN,,87340,300,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8300008,RUBELLA IGG SCREEN,,86762,300,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8300009,LABORATORY TEST,,86592,300,$40.00 ,$40.00 ,$12.00 ,$36.40 ,$28.00 ,$12.00 ,$26.00 ,$28.80 ,$36.40 ,$30.00 
Carle BroMenn Medical Center,8300010,ANTIBODY SCREENING,,86850,300,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8300011,"BLOOD TYPING, ABO",,86900,300,$66.00 ,$66.00 ,$19.80 ,$60.06 ,$46.20 ,$19.80 ,$42.90 ,$47.52 ,$60.06 ,$49.50 
Carle BroMenn Medical Center,8300012,"BLOOD TYPING, RH",,86901,300,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8336416,CAPILLARY SPECIMEN COLLECTION,,36416,300,$20.00 ,$20.00 ,$6.00 ,$18.20 ,$14.00 ,$6.00 ,$13.00 ,$14.40 ,$18.20 ,$15.00 
Carle BroMenn Medical Center,8340009,CMP WISHBONE ANIMAL,,8340009,300,$13.00 ,$13.00 ,$3.90 ,$11.83 ,$9.10 ,$3.90 ,$8.45 ,$9.36 ,$11.83 ,$9.75 
Carle BroMenn Medical Center,8340016,ETHANOL BLOOD CHAIN CUSTODY,,80320,300,$230.00 ,$230.00 ,$69.00 ,$209.30 ,$161.00 ,$69.00 ,$149.50 ,$165.60 ,$209.30 ,$172.50 
Carle BroMenn Medical Center,8340019,GLUCOSE,,82947,300,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8340023,HISTOLOGY TECHNICAL FEE,,8340023,300,$12.00 ,$12.00 ,$3.60 ,$10.92 ,$8.40 ,$3.60 ,$7.80 ,$8.64 ,$10.92 ,$9.00 
Carle BroMenn Medical Center,8340024,HU-tTG IGA TO PROMETHUS,,83520,300,$255.00 ,$255.00 ,$76.50 ,$232.05 ,$178.50 ,$76.50 ,$165.75 ,$183.60 ,$232.05 ,$191.25 
Carle BroMenn Medical Center,8340029,PROCAINAMIDE-PRONESTYL,,80192,300,$175.00 ,$175.00 ,$52.50 ,$159.25 ,$122.50 ,$52.50 ,$113.75 ,$126.00 ,$159.25 ,$131.25 
Carle BroMenn Medical Center,8340038,SYNOVIAL FLUID URIC ACID,,84560,300,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8340043,VET PANEL,,8340043,300,$21.00 ,$21.00 ,$6.30 ,$19.11 ,$14.70 ,$6.30 ,$13.65 ,$15.12 ,$19.11 ,$15.75 
Carle BroMenn Medical Center,8340044,ACL COLLECTION FEE,,8340044,300,$7.40 ,$7.40 ,$2.22 ,$6.73 ,$5.18 ,$2.22 ,$4.81 ,$5.33 ,$6.73 ,$5.55 
Carle BroMenn Medical Center,8380051,ELECTROLYTE PANEL,,80051,300,$63.70 ,$63.70 ,$19.11 ,$57.97 ,$44.59 ,$19.11 ,$41.41 ,$45.86 ,$57.97 ,$47.78 
Carle BroMenn Medical Center,8380058,HEPATIC FUNCTION PANEL,,80076,300,$87.75 ,$87.75 ,$26.33 ,$79.85 ,$61.43 ,$26.33 ,$57.04 ,$63.18 ,$79.85 ,$65.81 
Carle BroMenn Medical Center,8380069,RENAL FUNCTION PANEL,,80069,300,$104.00 ,$104.00 ,$31.20 ,$94.64 ,$72.80 ,$31.20 ,$67.60 ,$74.88 ,$94.64 ,$78.00 
Carle BroMenn Medical Center,8380127,PARATHORMONE (PTH),,83970,300,$198.25 ,$198.25 ,$59.48 ,$180.41 ,$138.78 ,$59.48 ,$128.86 ,$142.74 ,$180.41 ,$148.69 
Carle BroMenn Medical Center,8380170,DRUG ASSAY -GENTAMYCIN,,80170,300,$123.50 ,$123.50 ,$37.05 ,$112.39 ,$86.45 ,$37.05 ,$80.28 ,$88.92 ,$112.39 ,$92.63 
Carle BroMenn Medical Center,8380200,DRUG ASSAY -TOBRAMYCIN,,80200,300,$107.25 ,$107.25 ,$32.18 ,$97.60 ,$75.08 ,$32.18 ,$69.71 ,$77.22 ,$97.60 ,$80.44 
Carle BroMenn Medical Center,8380202,DRUG ASSAY -VANCOMYCIN,,80202,300,$107.25 ,$107.25 ,$32.18 ,$97.60 ,$75.08 ,$32.18 ,$69.71 ,$77.22 ,$97.60 ,$80.44 
Carle BroMenn Medical Center,8380223,"TRIIODOTHYRONINE T3, TOTAL  REF",,84480,300,$68.25 ,$68.25 ,$20.48 ,$62.11 ,$47.78 ,$20.48 ,$44.36 ,$49.14 ,$62.11 ,$51.19 
Carle BroMenn Medical Center,8380228,KETONE-SERUM,,82009,300,$28.60 ,$28.60 ,$8.58 ,$26.03 ,$20.02 ,$8.58 ,$18.59 ,$20.59 ,$26.03 ,$21.45 
Carle BroMenn Medical Center,8380247,INFECTIOUS AGENT IMMUNOASSAY,,86318,300,$101.00 ,$101.00 ,$30.30 ,$91.91 ,$70.70 ,$30.30 ,$65.65 ,$72.72 ,$91.91 ,$75.75 
Carle BroMenn Medical Center,8380255,"ALCOHOL EMPLOYMENT, BREATH",,82075,300,$62.00 ,$62.00 ,$18.60 ,$56.42 ,$43.40 ,$18.60 ,$40.30 ,$44.64 ,$56.42 ,$46.50 
Carle BroMenn Medical Center,8380602,"IRON, LIVER TISSUE",,83540,300,$51.00 ,$51.00 ,$15.30 ,$46.41 ,$35.70 ,$15.30 ,$33.15 ,$36.72 ,$46.41 ,$38.25 
Carle BroMenn Medical Center,8380604,"MYCOPHENOLIC ACID, S  REF",,80180,300,$152.75 ,$152.75 ,$45.83 ,$139.00 ,$106.93 ,$45.83 ,$99.29 ,$109.98 ,$139.00 ,$114.56 
Carle BroMenn Medical Center,8380636,"PREALBUMIN (PAB), SERUM  REF",,84134,300,$73.00 ,$73.00 ,$21.90 ,$66.43 ,$51.10 ,$21.90 ,$47.45 ,$52.56 ,$66.43 ,$54.75 
Carle BroMenn Medical Center,8381000,URINALYSIS AUTO W/MICROSCOPY,,81001,300,$35.10 ,$35.10 ,$10.53 ,$31.94 ,$24.57 ,$10.53 ,$22.82 ,$25.27 ,$31.94 ,$26.33 
Carle BroMenn Medical Center,8381001,URINALYSIS -GLUCOSE,,81002,300,$49.00 ,$49.00 ,$14.70 ,$44.59 ,$34.30 ,$14.70 ,$31.85 ,$35.28 ,$44.59 ,$36.75 
Carle BroMenn Medical Center,8381002,URINALYSIS -MICROSCOPIC ONLY,,81015,300,$26.65 ,$26.65 ,$8.00 ,$24.25 ,$18.66 ,$8.00 ,$17.32 ,$19.19 ,$24.25 ,$19.99 
Carle BroMenn Medical Center,8381003,CLINITEST,,81002,300,$57.00 ,$57.00 ,$17.10 ,$51.87 ,$39.90 ,$17.10 ,$37.05 ,$41.04 ,$51.87 ,$42.75 
Carle BroMenn Medical Center,8381004,URINALYSIS AUTO W/O MICROSCOPY,,81003,300,$25.35 ,$25.35 ,$7.61 ,$23.07 ,$17.75 ,$7.61 ,$16.48 ,$18.25 ,$23.07 ,$19.01 
Carle BroMenn Medical Center,8381009,URINALYSIS -SPECIFIC GRAVITY,,81002,300,$20.80 ,$20.80 ,$6.24 ,$18.93 ,$14.56 ,$6.24 ,$13.52 ,$14.98 ,$18.93 ,$15.60 
Carle BroMenn Medical Center,8381010,LEUKOCYTE ESTERASE FLD,,81002,300,$88.00 ,$88.00 ,$26.40 ,$80.08 ,$61.60 ,$26.40 ,$57.20 ,$63.36 ,$80.08 ,$66.00 
Carle BroMenn Medical Center,8381016,SOLUBLE FIBRIN MONOMER  REF,,85366,300,$39.00 ,$39.00 ,$11.70 ,$35.49 ,$27.30 ,$11.70 ,$25.35 ,$28.08 ,$35.49 ,$29.25 
Carle BroMenn Medical Center,8381041,"ISOAGGLUTININ TITER, ANTI-A  REF",,86886,300,$117.00 ,$117.00 ,$35.10 ,$106.47 ,$81.90 ,$35.10 ,$76.05 ,$84.24 ,$106.47 ,$87.75 
Carle BroMenn Medical Center,8381050,VOL MEASURE -TIMED COLLCTN EA,,81050,300,$20.15 ,$20.15 ,$6.05 ,$18.34 ,$14.11 ,$6.05 ,$13.10 ,$14.51 ,$18.34 ,$15.11 
Carle BroMenn Medical Center,8381056,"EVEROLIMUS, B REF",,80169,300,$18.00 ,$18.00 ,$5.40 ,$16.38 ,$12.60 ,$5.40 ,$11.70 ,$12.96 ,$16.38 ,$13.50 
Carle BroMenn Medical Center,8381079,"PROTEIN S AG, P REF",,85306,300,$126.75 ,$126.75 ,$38.03 ,$115.34 ,$88.73 ,$38.03 ,$82.39 ,$91.26 ,$115.34 ,$95.06 
Carle BroMenn Medical Center,8381086,PSEUDOCHOLIN. DIB. INHIB.  REF,,82638,300,$31.00 ,$31.00 ,$9.30 ,$28.21 ,$21.70 ,$9.30 ,$20.15 ,$22.32 ,$28.21 ,$23.25 
Carle BroMenn Medical Center,8381088,"POTASSIUM, PLASMA REF",,84132,300,$2.00 ,$2.00 ,$0.60 ,$1.82 ,$1.40 ,$0.60 ,$1.30 ,$1.44 ,$1.82 ,$1.50 
Carle BroMenn Medical Center,8381117,"THROMBIN TIME (BOVINE), P REF",,85670,300,$152.75 ,$152.75 ,$45.83 ,$139.00 ,$106.93 ,$45.83 ,$99.29 ,$109.98 ,$139.00 ,$114.56 
Carle BroMenn Medical Center,8381119,LABORATORY SERVICES,,86701,300,$66.00 ,$66.00 ,$19.80 ,$60.06 ,$46.20 ,$19.80 ,$42.90 ,$47.52 ,$60.06 ,$49.50 
Carle BroMenn Medical Center,8381139,"PORPHYRINS, FECES  REF",,84126,300,$136.00 ,$136.00 ,$40.80 ,$123.76 ,$95.20 ,$40.80 ,$88.40 ,$97.92 ,$123.76 ,$102.00 
Carle BroMenn Medical Center,8381489,ESR (PHOTOMETRIC),,85652,300,$46.15 ,$46.15 ,$13.85 ,$42.00 ,$32.31 ,$13.85 ,$30.00 ,$33.23 ,$42.00 ,$34.61 
Carle BroMenn Medical Center,8381505,"HEPTOGLOBIN, QUANTIATIVE  REF",,83010,300,$81.25 ,$81.25 ,$24.38 ,$73.94 ,$56.88 ,$24.38 ,$52.81 ,$58.50 ,$73.94 ,$60.94 
Carle BroMenn Medical Center,8381519,UA-DIPSTICK ONLY (ITC LAB),,81003,300,$57.00 ,$57.00 ,$17.10 ,$51.87 ,$39.90 ,$17.10 ,$37.05 ,$41.04 ,$51.87 ,$42.75 
Carle BroMenn Medical Center,8381545,PROTHROMBIN TIME-SUBSTITUTION/IMMED,,85611,300,$40.00 ,$40.00 ,$12.00 ,$36.40 ,$28.00 ,$12.00 ,$26.00 ,$28.80 ,$36.40 ,$30.00 
Carle BroMenn Medical Center,8381547,PROTHROMBIN TIME-SUBSTITUTION/INCUBATED,,85611,300,$47.00 ,$47.00 ,$14.10 ,$42.77 ,$32.90 ,$14.10 ,$30.55 ,$33.84 ,$42.77 ,$35.25 
Carle BroMenn Medical Center,8381548,"THROMBOPLASTIN TIME, PTL (PTT)-SUBSTITUTION/IMMED",,85732,300,$53.00 ,$53.00 ,$15.90 ,$48.23 ,$37.10 ,$15.90 ,$34.45 ,$38.16 ,$48.23 ,$39.75 
Carle BroMenn Medical Center,8381549,"THROMBOPLASTIN TIME, PTL (PTT)-INCUBATED",,85730,300,$88.00 ,$88.00 ,$26.40 ,$80.08 ,$61.60 ,$26.40 ,$57.20 ,$63.36 ,$80.08 ,$66.00 
Carle BroMenn Medical Center,8381550,"THROMBOPLASTIN TIME, PTL (PTT)-SUBSTITUTION/INCUBATED",,85732,300,$53.00 ,$53.00 ,$15.90 ,$48.23 ,$37.10 ,$15.90 ,$34.45 ,$38.16 ,$48.23 ,$39.75 
Carle BroMenn Medical Center,8381596,PROTEIN ELECTROPHORESIS  REF,,84165,300,$71.50 ,$71.50 ,$21.45 ,$65.07 ,$50.05 ,$21.45 ,$46.48 ,$51.48 ,$65.07 ,$53.63 
Carle BroMenn Medical Center,8381624,ELECTROLYTE  REF,,80051,300,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8381639,LABORATORY TEST    REF,,86593,300,$31.20 ,$31.20 ,$9.36 ,$28.39 ,$21.84 ,$9.36 ,$20.28 ,$22.46 ,$28.39 ,$23.40 
Carle BroMenn Medical Center,8381640,PROTHROMBIN TIME-SUBSTITUTION/IMM,,85611,300,$40.00 ,$40.00 ,$12.00 ,$36.40 ,$28.00 ,$12.00 ,$26.00 ,$28.80 ,$36.40 ,$30.00 
Carle BroMenn Medical Center,8381696,CRYO QC FOR MRV BLOOD CENTER,,99001,300,$42.00 ,$42.00 ,$12.60 ,$38.22 ,$29.40 ,$12.60 ,$27.30 ,$30.24 ,$38.22 ,$31.50 
Carle BroMenn Medical Center,8381832,HIV-1 ANTIBODY,,86701,300,$59.15 ,$59.15 ,$17.75 ,$53.83 ,$41.41 ,$17.75 ,$38.45 ,$42.59 ,$53.83 ,$44.36 
Carle BroMenn Medical Center,8381840,"APTT MIX 1:1, REF",,85732,300,$123.50 ,$123.50 ,$37.05 ,$112.39 ,$86.45 ,$37.05 ,$80.28 ,$88.92 ,$112.39 ,$92.63 
Carle BroMenn Medical Center,8381878,"VDRL, SERUM, REF",,86592,300,$48.10 ,$48.10 ,$14.43 ,$43.77 ,$33.67 ,$14.43 ,$31.27 ,$34.63 ,$43.77 ,$36.08 
Carle BroMenn Medical Center,8381914,"OSMOLALITY, SERUM, REF",,83930,300,$56.00 ,$56.00 ,$16.80 ,$50.96 ,$39.20 ,$16.80 ,$36.40 ,$40.32 ,$50.96 ,$42.00 
Carle BroMenn Medical Center,8382015,"ACETYLCHOLINESTERASE, AF   REF",,82013,300,$155.00 ,$155.00 ,$46.50 ,$141.05 ,$108.50 ,$46.50 ,$100.75 ,$111.60 ,$141.05 ,$116.25 
Carle BroMenn Medical Center,8382216,RPR(DX)REFL FTA,,86592,300,$36.40 ,$36.40 ,$10.92 ,$33.12 ,$25.48 ,$10.92 ,$23.66 ,$26.21 ,$33.12 ,$27.30 
Carle BroMenn Medical Center,8382249,PROTEIN ELECTRO.,,84165,300,$88.00 ,$88.00 ,$26.40 ,$80.08 ,$61.60 ,$26.40 ,$57.20 ,$63.36 ,$80.08 ,$66.00 
Carle BroMenn Medical Center,8382295,PREALBUMIN,,84134,300,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8382373,ASSAY C-D TRANSFER MEASURE REF,,82373,300,$21.00 ,$21.00 ,$6.30 ,$19.11 ,$14.70 ,$6.30 ,$13.65 ,$15.12 ,$19.11 ,$15.75 
Carle BroMenn Medical Center,8382391,CERULOPLASMIN,,82390,300,$176.00 ,$176.00 ,$52.80 ,$160.16 ,$123.20 ,$52.80 ,$114.40 ,$126.72 ,$160.16 ,$132.00 
Carle BroMenn Medical Center,8382395,"FECAL FAT, QUAL",,82705,300,$6.00 ,$6.00 ,$1.80 ,$5.46 ,$4.20 ,$1.80 ,$3.90 ,$4.32 ,$5.46 ,$4.50 
Carle BroMenn Medical Center,8382396,"CULT,FUNGUS,OTHER",,87102,300,$3.00 ,$3.00 ,$0.90 ,$2.73 ,$2.10 ,$0.90 ,$1.95 ,$2.16 ,$2.73 ,$2.25 
Carle BroMenn Medical Center,8382397,"CULT,FUNGUS,OTHER",,87206,300,$3.00 ,$3.00 ,$0.90 ,$2.73 ,$2.10 ,$0.90 ,$1.95 ,$2.16 ,$2.73 ,$2.25 
Carle BroMenn Medical Center,8382408,"PROTEIN C, ANTIGEN",,85302,300,$51.00 ,$51.00 ,$15.30 ,$46.41 ,$35.70 ,$15.30 ,$33.15 ,$36.72 ,$46.41 ,$38.25 
Carle BroMenn Medical Center,8382409,"PROTEIN S AG, TOTAL",,85305,300,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8382410,TRANSFERRIN,,84466,300,$81.25 ,$81.25 ,$24.38 ,$73.94 ,$56.88 ,$24.38 ,$52.81 ,$58.50 ,$73.94 ,$60.94 
Carle BroMenn Medical Center,8382413,CERULOPLASMIN REF,,82390,300,$78.00 ,$78.00 ,$23.40 ,$70.98 ,$54.60 ,$23.40 ,$50.70 ,$56.16 ,$70.98 ,$58.50 
Carle BroMenn Medical Center,8382443,"CHOLESTEROL, SERUM, TOTAL REF",,82465,300,$23.00 ,$23.00 ,$6.90 ,$20.93 ,$16.10 ,$6.90 ,$14.95 ,$16.56 ,$20.93 ,$17.25 
Carle BroMenn Medical Center,8382457,"CREATININE CLEARANCE, 24 HR REF",,82575,300,$13.00 ,$13.00 ,$3.90 ,$11.83 ,$9.10 ,$3.90 ,$8.45 ,$9.36 ,$11.83 ,$9.75 
Carle BroMenn Medical Center,8382465,"CHOLESTEROL, SERUM, TOTAL",,82465,300,$48.10 ,$48.10 ,$14.43 ,$43.77 ,$33.67 ,$14.43 ,$31.27 ,$34.63 ,$43.77 ,$36.08 
Carle BroMenn Medical Center,8382497,"T3 TOTAL, S REF",,84480,300,$6.00 ,$6.00 ,$1.80 ,$5.46 ,$4.20 ,$1.80 ,$3.90 ,$4.32 ,$5.46 ,$4.50 
Carle BroMenn Medical Center,8382500,IGF BINDING PROTEIN 3,,82397,300,$215.00 ,$215.00 ,$64.50 ,$195.65 ,$150.50 ,$64.50 ,$139.75 ,$154.80 ,$195.65 ,$161.25 
Carle BroMenn Medical Center,8382516,LEGIONELLA PNEUMOPHILA SMEAR,,87278,300,$110.00 ,$110.00 ,$33.00 ,$100.10 ,$77.00 ,$33.00 ,$71.50 ,$79.20 ,$100.10 ,$82.50 
Carle BroMenn Medical Center,8382517,GIARDIA SCREEN,,87329,300,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8382519,COVID 19 NON CDC,,U0002,300,$153.00 ,$153.00 ,$45.90 ,$139.23 ,$107.10 ,$45.90 ,$99.45 ,$110.16 ,$139.23 ,$114.75 
Carle BroMenn Medical Center,8382552,CK MB FRACTION,,82553,300,$120.25 ,$120.25 ,$36.08 ,$109.43 ,$84.18 ,$36.08 ,$78.16 ,$86.58 ,$109.43 ,$90.19 
Carle BroMenn Medical Center,8382563,ACETAMINOPHEN W SALICYLATE,,80329,300,$184.00 ,$184.00 ,$55.20 ,$167.44 ,$128.80 ,$55.20 ,$119.60 ,$132.48 ,$167.44 ,$138.00 
Carle BroMenn Medical Center,8382575,CREATININE CLEARANCE,,82575,300,$110.50 ,$110.50 ,$33.15 ,$100.56 ,$77.35 ,$33.15 ,$71.83 ,$79.56 ,$100.56 ,$82.88 
Carle BroMenn Medical Center,8382589,AMYLASE URINE,,82150,300,$195.00 ,$195.00 ,$58.50 ,$177.45 ,$136.50 ,$58.50 ,$126.75 ,$140.40 ,$177.45 ,$146.25 
Carle BroMenn Medical Center,8382619,SEMEN ANALYSIS FERTILITY,,89322,300,$220.00 ,$220.00 ,$66.00 ,$200.20 ,$154.00 ,$66.00 ,$143.00 ,$158.40 ,$200.20 ,$165.00 
Carle BroMenn Medical Center,8382621,ACTH STIMULATION PANEL,,80400,300,$325.00 ,$325.00 ,$97.50 ,$295.75 ,$227.50 ,$97.50 ,$211.25 ,$234.00 ,$295.75 ,$243.75 
Carle BroMenn Medical Center,8382630,NEONATAL SCREEN,,84030,300,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8382631,REPEAT NEONATAL SCREEN,,84030,300,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8382641,DRUG ASSAY -DIGOXIN,,80162,300,$81.25 ,$81.25 ,$24.38 ,$73.94 ,$56.88 ,$24.38 ,$52.81 ,$58.50 ,$73.94 ,$60.94 
Carle BroMenn Medical Center,8382642,PROTEIN URINE,,81003,300,$39.00 ,$39.00 ,$11.70 ,$35.49 ,$27.30 ,$11.70 ,$25.35 ,$28.08 ,$35.49 ,$29.25 
Carle BroMenn Medical Center,8382644,DIFFERENTIAL ADSORP OF SERUM,,86978,300,$195.00 ,$195.00 ,$58.50 ,$177.45 ,$136.50 ,$58.50 ,$126.75 ,$140.40 ,$177.45 ,$146.25 
Carle BroMenn Medical Center,8382645,DILUTION OF SERUM,,86976,300,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8382647,RETICULOCYTE SEPARATION,,86972,300,$370.00 ,$370.00 ,$111.00 ,$336.70 ,$259.00 ,$111.00 ,$240.50 ,$266.40 ,$336.70 ,$277.50 
Carle BroMenn Medical Center,8382648,PRETREAT OF RBC WITH CHEM,,86970,300,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8382649,RH PHENOTYPE COMPLETE,,86906,300,$185.00 ,$185.00 ,$55.50 ,$168.35 ,$129.50 ,$55.50 ,$120.25 ,$133.20 ,$168.35 ,$138.75 
Carle BroMenn Medical Center,8382650,SCREEN DONR USING PT SPECIMEN,,86904,300,$195.00 ,$195.00 ,$58.50 ,$177.45 ,$136.50 ,$58.50 ,$126.75 ,$140.40 ,$177.45 ,$146.25 
Carle BroMenn Medical Center,8382653,Ab ID EACH SELECTED REAGANT,,86885,300,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8382654,PH ANALYSIS ARTERIAL BLOOD,,82800,300,$86.00 ,$86.00 ,$25.80 ,$78.26 ,$60.20 ,$25.80 ,$55.90 ,$61.92 ,$78.26 ,$64.50 
Carle BroMenn Medical Center,8382657,GAMMAHYDROXYBUTRIC ACID BLD,,80307,300,$285.00 ,$285.00 ,$85.50 ,$259.35 ,$199.50 ,$85.50 ,$185.25 ,$205.20 ,$259.35 ,$213.75 
Carle BroMenn Medical Center,8382662,DRUG SCN DRUG CLASS A  DRGCOM,,80307,300,$35.00 ,$35.00 ,$10.50 ,$31.85 ,$24.50 ,$10.50 ,$22.75 ,$25.20 ,$31.85 ,$26.25 
Carle BroMenn Medical Center,8382663,CC PATH CONSULT,,88321,300,$400.00 ,$400.00 ,$120.00 ,$364.00 ,$280.00 ,$120.00 ,$260.00 ,$288.00 ,$364.00 ,$300.00 
Carle BroMenn Medical Center,8382688,OPIATES CONF GC/MS UR,,80361,300,$190.00 ,$190.00 ,$57.00 ,$172.90 ,$133.00 ,$57.00 ,$123.50 ,$136.80 ,$172.90 ,$142.50 
Carle BroMenn Medical Center,8382690,SALIVA CORTISOL,,82530,300,$128.00 ,$128.00 ,$38.40 ,$116.48 ,$89.60 ,$38.40 ,$83.20 ,$92.16 ,$116.48 ,$96.00 
Carle BroMenn Medical Center,8382697,CSF IGG ALBUMIN INDEX,,82784,300,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8382698,GTT ADD GLUCOSE,,82947,300,$75.00 ,$75.00 ,$22.50 ,$68.25 ,$52.50 ,$22.50 ,$48.75 ,$54.00 ,$68.25 ,$56.25 
Carle BroMenn Medical Center,8382701,"TOXOPLASMA,IGG (TORCH)",,86777,300,$135.00 ,$135.00 ,$40.50 ,$122.85 ,$94.50 ,$40.50 ,$87.75 ,$97.20 ,$122.85 ,$101.25 
Carle BroMenn Medical Center,8382705,FECAL FAT/LIPIDS QUALTATVE REF,,82705,300,$51.00 ,$51.00 ,$15.30 ,$46.41 ,$35.70 ,$15.30 ,$33.15 ,$36.72 ,$46.41 ,$38.25 
Carle BroMenn Medical Center,8382723,ALBUMIN PERITONEAL FLUID,,82042,300,$44.00 ,$44.00 ,$13.20 ,$40.04 ,$30.80 ,$13.20 ,$28.60 ,$31.68 ,$40.04 ,$33.00 
Carle BroMenn Medical Center,8382724,ALCOHOL METABOLITES URINE,,80321,300,$170.00 ,$170.00 ,$51.00 ,$154.70 ,$119.00 ,$51.00 ,$110.50 ,$122.40 ,$154.70 ,$127.50 
Carle BroMenn Medical Center,8382728,BENZODIAZEPINES CONF URINE,,80346,300,$170.00 ,$170.00 ,$51.00 ,$154.70 ,$119.00 ,$51.00 ,$110.50 ,$122.40 ,$154.70 ,$127.50 
Carle BroMenn Medical Center,8382729,CANDIDA SP DNA,,87480,300,$54.00 ,$54.00 ,$16.20 ,$49.14 ,$37.80 ,$16.20 ,$35.10 ,$38.88 ,$49.14 ,$40.50 
Carle BroMenn Medical Center,8382731,FETAL FIBRONECTIN,,82731,300,$435.50 ,$435.50 ,$130.65 ,$396.31 ,$304.85 ,$130.65 ,$283.08 ,$313.56 ,$396.31 ,$326.63 
Carle BroMenn Medical Center,8382732,CHLAMYDOPHILA PNEUMONIAE,,87486,300,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8382733,DEXAMETHASONE,,82542,300,$177.00 ,$177.00 ,$53.10 ,$161.07 ,$123.90 ,$53.10 ,$115.05 ,$127.44 ,$161.07 ,$132.75 
Carle BroMenn Medical Center,8382734,GARNERELLA VAGINALIS DNA,,87510,300,$54.00 ,$54.00 ,$16.20 ,$49.14 ,$37.80 ,$16.20 ,$35.10 ,$38.88 ,$49.14 ,$40.50 
Carle BroMenn Medical Center,8382736,GASTROINTESTINAL PATH PANEL,,87506,300,$800.00 ,$800.00 ,$240.00 ,$728.00 ,$560.00 ,$240.00 ,$520.00 ,$576.00 ,$728.00 ,$600.00 
Carle BroMenn Medical Center,8382737,GLUTAMIC ACID DECARBOXYLASE 65,,86341,300,$148.00 ,$148.00 ,$44.40 ,$134.68 ,$103.60 ,$44.40 ,$96.20 ,$106.56 ,$134.68 ,$111.00 
Carle BroMenn Medical Center,8382740,ISLET CELL AB SCREEN,,86341,300,$97.00 ,$97.00 ,$29.10 ,$88.27 ,$67.90 ,$29.10 ,$63.05 ,$69.84 ,$88.27 ,$72.75 
Carle BroMenn Medical Center,8382741,LD PERITONEAL FLUID,,83615,300,$28.00 ,$28.00 ,$8.40 ,$25.48 ,$19.60 ,$8.40 ,$18.20 ,$20.16 ,$25.48 ,$21.00 
Carle BroMenn Medical Center,8382744,PROLACTIN DILUTED,,84146,300,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8382749,PROLACTIN UNDILUTED,,84146,300,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8382755,THYROID CANCER MONITOR,,86800,300,$256.00 ,$256.00 ,$76.80 ,$232.96 ,$179.20 ,$76.80 ,$166.40 ,$184.32 ,$232.96 ,$192.00 
Carle BroMenn Medical Center,8382756,TRICHOMONIS VAGINALIS  MALE,,87661,300,$224.00 ,$224.00 ,$67.20 ,$203.84 ,$156.80 ,$67.20 ,$145.60 ,$161.28 ,$203.84 ,$168.00 
Carle BroMenn Medical Center,8382757,TRICHOMONIS VAGINALIS DNA,,87660,300,$54.00 ,$54.00 ,$16.20 ,$49.14 ,$37.80 ,$16.20 ,$35.10 ,$38.88 ,$49.14 ,$40.50 
Carle BroMenn Medical Center,8382758,UMBILICAL DRUG SCREEN,,80307,300,$254.00 ,$254.00 ,$76.20 ,$231.14 ,$177.80 ,$76.20 ,$165.10 ,$182.88 ,$231.14 ,$190.50 
Carle BroMenn Medical Center,8382929,AB ID; PLT IMMGLB ASY REF,,86023,300,$256.75 ,$256.75 ,$77.03 ,$233.64 ,$179.73 ,$77.03 ,$166.89 ,$184.86 ,$233.64 ,$192.56 
Carle BroMenn Medical Center,8382940,PREALBUMIN,,84134,300,$87.75 ,$87.75 ,$26.33 ,$79.85 ,$61.43 ,$26.33 ,$57.04 ,$63.18 ,$79.85 ,$65.81 
Carle BroMenn Medical Center,8382950,"GLUCOSE, POST GLUCOSE DOSE",,82950,300,$44.20 ,$44.20 ,$13.26 ,$40.22 ,$30.94 ,$13.26 ,$28.73 ,$31.82 ,$40.22 ,$33.15 
Carle BroMenn Medical Center,8382953,"GTT, THREE SPECIMENS",,82951,300,$53.95 ,$53.95 ,$16.19 ,$49.09 ,$37.77 ,$16.19 ,$35.07 ,$38.84 ,$49.09 ,$40.46 
Carle BroMenn Medical Center,8382954,"GTT, EA ADDL BEYOND THREE",,82952,300,$31.85 ,$31.85 ,$9.56 ,$28.98 ,$22.30 ,$9.56 ,$20.70 ,$22.93 ,$28.98 ,$23.89 
Carle BroMenn Medical Center,8382977,"GLUTAMYLTRANSFERASE, GAMMA",,82977,300,$63.70 ,$63.70 ,$19.11 ,$57.97 ,$44.59 ,$19.11 ,$41.41 ,$45.86 ,$57.97 ,$47.78 
Carle BroMenn Medical Center,8383010,"HAPTOGLOBIN, QUANTITATIVE",,83010,300,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8383160,URINE PREGNANCY TEST,,81025,300,$71.50 ,$71.50 ,$21.45 ,$65.07 ,$50.05 ,$21.45 ,$46.48 ,$51.48 ,$65.07 ,$53.63 
Carle BroMenn Medical Center,8383439,"TRIIODOTHYRONINE T3, TOTAL",,84480,300,$183.00 ,$183.00 ,$54.90 ,$166.53 ,$128.10 ,$54.90 ,$118.95 ,$131.76 ,$166.53 ,$137.25 
Carle BroMenn Medical Center,8383540,IRON,,83540,300,$74.75 ,$74.75 ,$22.43 ,$68.02 ,$52.33 ,$22.43 ,$48.59 ,$53.82 ,$68.02 ,$56.06 
Carle BroMenn Medical Center,8383550,IRON BINDING CAPACITY,,83550,300,$53.95 ,$53.95 ,$16.19 ,$49.09 ,$37.77 ,$16.19 ,$35.07 ,$38.84 ,$49.09 ,$40.46 
Carle BroMenn Medical Center,8383632,"INSULIN-LIKE GROWTH FACTOR 1, S  REF",,84305,300,$37.70 ,$37.70 ,$11.31 ,$34.31 ,$26.39 ,$11.31 ,$24.51 ,$27.14 ,$34.31 ,$28.28 
Carle BroMenn Medical Center,8383690,LIPASE,,83690,300,$81.25 ,$81.25 ,$24.38 ,$73.94 ,$56.88 ,$24.38 ,$52.81 ,$58.50 ,$73.94 ,$60.94 
Carle BroMenn Medical Center,8383703,LIPID PROFILE,,80061,300,$113.75 ,$113.75 ,$34.13 ,$103.51 ,$79.63 ,$34.13 ,$73.94 ,$81.90 ,$103.51 ,$85.31 
Carle BroMenn Medical Center,8383725,DRUG ASSAY -LITHIUM,,80178,300,$61.10 ,$61.10 ,$18.33 ,$55.60 ,$42.77 ,$18.33 ,$39.72 ,$43.99 ,$55.60 ,$45.83 
Carle BroMenn Medical Center,8383873,"MYELIN BASIC PROTEIN, CSF  REF",,83873,300,$63.70 ,$63.70 ,$19.11 ,$57.97 ,$44.59 ,$19.11 ,$41.41 ,$45.86 ,$57.97 ,$47.78 
Carle BroMenn Medical Center,8383916,OLIGOCLONAL BANDS,,83916,300,$149.50 ,$149.50 ,$44.85 ,$136.05 ,$104.65 ,$44.85 ,$97.18 ,$107.64 ,$136.05 ,$112.13 
Carle BroMenn Medical Center,8383930,"OSMOLALITY, BLOOD",,83930,300,$53.95 ,$53.95 ,$16.19 ,$49.09 ,$37.77 ,$16.19 ,$35.07 ,$38.84 ,$49.09 ,$40.46 
Carle BroMenn Medical Center,8383970,"PARATHYROID HORMONE,INTACT REF",,83970,300,$198.25 ,$198.25 ,$59.48 ,$180.41 ,$138.78 ,$59.48 ,$128.86 ,$142.74 ,$180.41 ,$148.69 
Carle BroMenn Medical Center,8384030,"PHENYLALANINE (PKU), BLOOD REF",,84030,300,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8384140,"POTASSIUM, SERUM",,84132,300,$48.10 ,$48.10 ,$14.43 ,$43.77 ,$33.67 ,$14.43 ,$31.27 ,$34.63 ,$43.77 ,$36.08 
Carle BroMenn Medical Center,8384142,DRUG ASSAY -PROCAINAMIDE +,,80192,300,$135.00 ,$135.00 ,$40.50 ,$122.85 ,$94.50 ,$40.50 ,$87.75 ,$97.20 ,$122.85 ,$101.25 
Carle BroMenn Medical Center,8384165,PROTEIN ELP FRACT&QUANT SERUM,,84165,300,$183.00 ,$183.00 ,$54.90 ,$166.53 ,$128.10 ,$54.90 ,$118.95 ,$131.76 ,$166.53 ,$137.25 
Carle BroMenn Medical Center,8384210,PYRUVIC ACID   REF,,84210,300,$30.00 ,$30.00 ,$9.00 ,$27.30 ,$21.00 ,$9.00 ,$19.50 ,$21.60 ,$27.30 ,$22.50 
Carle BroMenn Medical Center,8384220,PYRUVATE KINASE            REF,,84220,300,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8384316,"SPECIFIC GRAVITY, BODY FLUID",,84315,300,$29.25 ,$29.25 ,$8.78 ,$26.62 ,$20.48 ,$8.78 ,$19.01 ,$21.06 ,$26.62 ,$21.94 
Carle BroMenn Medical Center,8384420,DRUG ASSAY -THEOPHYLLINE,,80198,300,$87.75 ,$87.75 ,$26.33 ,$79.85 ,$61.43 ,$26.33 ,$57.04 ,$63.18 ,$79.85 ,$65.81 
Carle BroMenn Medical Center,8384450,"TRANSFERASE, ASPARTATE AMINO",,84450,300,$48.75 ,$48.75 ,$14.63 ,$44.36 ,$34.13 ,$14.63 ,$31.69 ,$35.10 ,$44.36 ,$36.56 
Carle BroMenn Medical Center,8384550,"URIC ACID, BLOOD",,84550,300,$48.10 ,$48.10 ,$14.43 ,$43.77 ,$33.67 ,$14.43 ,$31.27 ,$34.63 ,$43.77 ,$36.08 
Carle BroMenn Medical Center,8385000,BLEEDING TIME,,85002,300,$91.00 ,$91.00 ,$27.30 ,$82.81 ,$63.70 ,$27.30 ,$59.15 ,$65.52 ,$82.81 ,$68.25 
Carle BroMenn Medical Center,8385003,APT TEST FOR FETAL HGB,,83033,300,$66.00 ,$66.00 ,$19.80 ,$60.06 ,$46.20 ,$19.80 ,$42.90 ,$47.52 ,$60.06 ,$49.50 
Carle BroMenn Medical Center,8385306,PROTEIN S ANTIGEN FREE,,85306,300,$280.00 ,$280.00 ,$84.00 ,$254.80 ,$196.00 ,$84.00 ,$182.00 ,$201.60 ,$254.80 ,$210.00 
Carle BroMenn Medical Center,8385362,FIBRIN DEGREDATION PRODUCTS,,85362,300,$97.50 ,$97.50 ,$29.25 ,$88.73 ,$68.25 ,$29.25 ,$63.38 ,$70.20 ,$88.73 ,$73.13 
Carle BroMenn Medical Center,8385460,"FMH SCREEN, ROSETTE",,85461,300,$74.75 ,$74.75 ,$22.43 ,$68.02 ,$52.33 ,$22.43 ,$48.59 ,$53.82 ,$68.02 ,$56.06 
Carle BroMenn Medical Center,8385545,KLEIHAUER-BETKE TEST,,85460,300,$107.25 ,$107.25 ,$32.18 ,$97.60 ,$75.08 ,$32.18 ,$69.71 ,$77.22 ,$97.60 ,$80.44 
Carle BroMenn Medical Center,8385635,REPTILASE TEST (VENOM TIME),,85635,300,$82.00 ,$82.00 ,$24.60 ,$74.62 ,$57.40 ,$24.60 ,$53.30 ,$59.04 ,$74.62 ,$61.50 
Carle BroMenn Medical Center,8385641,"RETICULOCYTE COUNT, AUTOMATED",,85045,300,$48.75 ,$48.75 ,$14.63 ,$44.36 ,$34.13 ,$14.63 ,$31.69 ,$35.10 ,$44.36 ,$36.56 
Carle BroMenn Medical Center,8385651,ESR WESTERGREN,,85652,300,$85.00 ,$85.00 ,$25.50 ,$77.35 ,$59.50 ,$25.50 ,$55.25 ,$61.20 ,$77.35 ,$63.75 
Carle BroMenn Medical Center,8385670,THROMBIN TIME,,85670,300,$72.00 ,$72.00 ,$21.60 ,$65.52 ,$50.40 ,$21.60 ,$46.80 ,$51.84 ,$65.52 ,$54.00 
Carle BroMenn Medical Center,8385720,"THROMBOPLSTN TIME,PTL(PTT) REF",,85730,300,$65.00 ,$65.00 ,$19.50 ,$59.15 ,$45.50 ,$19.50 ,$42.25 ,$46.80 ,$59.15 ,$48.75 
Carle BroMenn Medical Center,8385730,"THROMBOPLASTIN TIME, PTL (PTT)",,85730,300,$65.00 ,$65.00 ,$19.50 ,$59.15 ,$45.50 ,$19.50 ,$42.25 ,$46.80 ,$59.15 ,$48.75 
Carle BroMenn Medical Center,8385732,CORRECTION STUDIES,,85732,300,$62.00 ,$62.00 ,$18.60 ,$56.42 ,$43.40 ,$18.60 ,$40.30 ,$44.64 ,$56.42 ,$46.50 
Carle BroMenn Medical Center,8385810,"VISCOSITY, SERUM           REF",,85810,300,$104.00 ,$104.00 ,$31.20 ,$94.64 ,$72.80 ,$31.20 ,$67.60 ,$74.88 ,$94.64 ,$78.00 
Carle BroMenn Medical Center,8386019,ANTIGEN TYPING,,86905,300,$91.00 ,$91.00 ,$27.30 ,$82.81 ,$63.70 ,$27.30 ,$59.15 ,$65.52 ,$82.81 ,$68.25 
Carle BroMenn Medical Center,8386025,"INDIRECT, TITER",,86886,300,$133.25 ,$133.25 ,$39.98 ,$121.26 ,$93.28 ,$39.98 ,$86.61 ,$95.94 ,$121.26 ,$99.94 
Carle BroMenn Medical Center,8386049,LABORATORY TEST,,G0432,300,$186.00 ,$186.00 ,$55.80 ,$169.26 ,$130.20 ,$55.80 ,$120.90 ,$133.92 ,$169.26 ,$139.50 
Carle BroMenn Medical Center,8386080,"BLOOD TYPING, ABO",,86900,300,$60.45 ,$60.45 ,$18.14 ,$55.01 ,$42.32 ,$18.14 ,$39.29 ,$43.52 ,$55.01 ,$45.34 
Carle BroMenn Medical Center,8386100,"BLOOD TYPING, RH",,86901,300,$60.45 ,$60.45 ,$18.14 ,$55.01 ,$42.32 ,$18.14 ,$39.29 ,$43.52 ,$55.01 ,$45.34 
Carle BroMenn Medical Center,8386101,BONE BANK PROCESSING,,86999,300,$410.00 ,$410.00 ,$123.00 ,$373.10 ,$287.00 ,$123.00 ,$266.50 ,$295.20 ,$373.10 ,$307.50 
Carle BroMenn Medical Center,8386149,ACTIVATED PROTEIN C RESISTANCE,,85307,300,$246.00 ,$246.00 ,$73.80 ,$223.86 ,$172.20 ,$73.80 ,$159.90 ,$177.12 ,$223.86 ,$184.50 
Carle BroMenn Medical Center,8386203,FROZEN PLASMA PREP,,86927,300,$132.00 ,$132.00 ,$39.60 ,$120.12 ,$92.40 ,$39.60 ,$85.80 ,$95.04 ,$120.12 ,$99.00 
Carle BroMenn Medical Center,8386300,MONO TEST,,86308,300,$65.00 ,$65.00 ,$19.50 ,$59.15 ,$45.50 ,$19.50 ,$42.25 ,$46.80 ,$59.15 ,$48.75 
Carle BroMenn Medical Center,8386305,LABORATORY TEST FOR ANTIBODY,,86701,300,$107.00 ,$107.00 ,$32.10 ,$97.37 ,$74.90 ,$32.10 ,$69.55 ,$77.04 ,$97.37 ,$80.25 
Carle BroMenn Medical Center,8386307,HEPATITIS B SURFACE ANTIBODY,,86706,300,$151.00 ,$151.00 ,$45.30 ,$137.41 ,$105.70 ,$45.30 ,$98.15 ,$108.72 ,$137.41 ,$113.25 
Carle BroMenn Medical Center,8386340,TRANSFERRIN,,84466,300,$164.00 ,$164.00 ,$49.20 ,$149.24 ,$114.80 ,$49.20 ,$106.60 ,$118.08 ,$149.24 ,$123.00 
Carle BroMenn Medical Center,8386415,LABORATORY TEST,,86592,300,$48.10 ,$48.10 ,$14.43 ,$43.77 ,$33.67 ,$14.43 ,$31.27 ,$34.63 ,$43.77 ,$36.08 
Carle BroMenn Medical Center,8386416,LABORATORY TEST,,86593,300,$76.00 ,$76.00 ,$22.80 ,$69.16 ,$53.20 ,$22.80 ,$49.40 ,$54.72 ,$69.16 ,$57.00 
Carle BroMenn Medical Center,8386418,LABORATORY TEST REF,,86592,300,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8386706,HEPATITIS B SURFACE AB REF,,86706,300,$74.75 ,$74.75 ,$22.43 ,$68.02 ,$52.33 ,$22.43 ,$48.59 ,$53.82 ,$68.02 ,$56.06 
Carle BroMenn Medical Center,8386902,ANTIGEN TYPING EA ANTIGEN TEST,,86902,300,$113.75 ,$113.75 ,$34.13 ,$103.51 ,$79.63 ,$34.13 ,$73.94 ,$81.90 ,$103.51 ,$85.31 
Carle BroMenn Medical Center,8386903,ANTIGEN TYPING,,86902,300,$214.00 ,$214.00 ,$64.20 ,$194.74 ,$149.80 ,$64.20 ,$139.10 ,$154.08 ,$194.74 ,$160.50 
Carle BroMenn Medical Center,8386905,BLOOD TYPNG RBC AG N ABO/RH RF,,86905,300,$70.00 ,$70.00 ,$21.00 ,$63.70 ,$49.00 ,$21.00 ,$45.50 ,$50.40 ,$63.70 ,$52.50 
Carle BroMenn Medical Center,8386920,COMPATIBILITY IMMEDIATE SPIN,,86920,300,$250.25 ,$250.25 ,$75.08 ,$227.73 ,$175.18 ,$75.08 ,$162.66 ,$180.18 ,$227.73 ,$187.69 
Carle BroMenn Medical Center,8386922,COMPATABILITY AHG,,86922,300,$211.25 ,$211.25 ,$63.38 ,$192.24 ,$147.88 ,$63.38 ,$137.31 ,$152.10 ,$192.24 ,$158.44 
Carle BroMenn Medical Center,8386945,IRRAD. BLOOD PROD. CCB REF,,86945,300,$63.00 ,$63.00 ,$18.90 ,$57.33 ,$44.10 ,$18.90 ,$40.95 ,$45.36 ,$57.33 ,$47.25 
Carle BroMenn Medical Center,8386965,PLTLTS/BLOOD PRODUCT POOLING,,86965,300,$149.50 ,$149.50 ,$44.85 ,$136.05 ,$104.65 ,$44.85 ,$97.18 ,$107.64 ,$136.05 ,$112.13 
Carle BroMenn Medical Center,8386985,SPLITTING OF BLOOD/BLOOD PRDCT,,86985,300,$152.75 ,$152.75 ,$45.83 ,$139.00 ,$106.93 ,$45.83 ,$99.29 ,$109.98 ,$139.00 ,$114.56 
Carle BroMenn Medical Center,8386987,L-P PLT FILTER,,86999,300,$287.00 ,$287.00 ,$86.10 ,$261.17 ,$200.90 ,$86.10 ,$186.55 ,$206.64 ,$261.17 ,$215.25 
Carle BroMenn Medical Center,8387002,URINE CULTURE PRESUMPTIVE ID,,87088,300,$140.00 ,$140.00 ,$42.00 ,$127.40 ,$98.00 ,$42.00 ,$91.00 ,$100.80 ,$127.40 ,$105.00 
Carle BroMenn Medical Center,8387040,"BACTERIAL CULTURE, BLOOD",,87040,300,$167.00 ,$167.00 ,$50.10 ,$151.97 ,$116.90 ,$50.10 ,$108.55 ,$120.24 ,$151.97 ,$125.25 
Carle BroMenn Medical Center,8387046,ENT PATH CULT / ADNL PATHOGENS,,87046,300,$44.20 ,$44.20 ,$13.26 ,$40.22 ,$30.94 ,$13.26 ,$28.73 ,$31.82 ,$40.22 ,$33.15 
Carle BroMenn Medical Center,8387050,BLOOD CULTURE,,87040,300,$84.50 ,$84.50 ,$25.35 ,$76.90 ,$59.15 ,$25.35 ,$54.93 ,$60.84 ,$76.90 ,$63.38 
Carle BroMenn Medical Center,8387075,BACT CULT ANY SRC ANAEROBIC,,87075,300,$100.75 ,$100.75 ,$30.23 ,$91.68 ,$70.53 ,$30.23 ,$65.49 ,$72.54 ,$91.68 ,$75.56 
Carle BroMenn Medical Center,8387095,ENTERIC PATHOGENS CULTURE,,87045,300,$91.00 ,$91.00 ,$27.30 ,$82.81 ,$63.70 ,$27.30 ,$59.15 ,$65.52 ,$82.81 ,$68.25 
Carle BroMenn Medical Center,8387102,"FUNGAL CULT, OTHER SRC, ISOLAT",,87102,300,$65.00 ,$65.00 ,$19.50 ,$59.15 ,$45.50 ,$19.50 ,$42.25 ,$46.80 ,$59.15 ,$48.75 
Carle BroMenn Medical Center,8387103,"FUNGAL CULTURE, BLOOD",,87103,300,$104.00 ,$104.00 ,$31.20 ,$94.64 ,$72.80 ,$31.20 ,$67.60 ,$74.88 ,$94.64 ,$78.00 
Carle BroMenn Medical Center,8387105,"FUNGAL CULTURE, ENVIRONMENTAL",,87102,300,$135.00 ,$135.00 ,$40.50 ,$122.85 ,$94.50 ,$40.50 ,$87.75 ,$97.20 ,$122.85 ,$101.25 
Carle BroMenn Medical Center,8387110,URINE CULTURE,,87086,300,$55.90 ,$55.90 ,$16.77 ,$50.87 ,$39.13 ,$16.77 ,$36.34 ,$40.25 ,$50.87 ,$41.93 
Carle BroMenn Medical Center,8387116,"CULT, TUBRCL/ACID-FAST BACILLI",,87116,300,$74.75 ,$74.75 ,$22.43 ,$68.02 ,$52.33 ,$22.43 ,$48.59 ,$53.82 ,$68.02 ,$56.06 
Carle BroMenn Medical Center,8387118,AFB ISOLATE IDENTIFICATION,,87118,300,$139.00 ,$139.00 ,$41.70 ,$126.49 ,$97.30 ,$41.70 ,$90.35 ,$100.08 ,$126.49 ,$104.25 
Carle BroMenn Medical Center,8387145,CULTURE                    REF,,87110,300,$264.00 ,$264.00 ,$79.20 ,$240.24 ,$184.80 ,$79.20 ,$171.60 ,$190.08 ,$240.24 ,$198.00 
Carle BroMenn Medical Center,8387169,"MACROSCOPIC EXAM, PARASITE",,87169,300,$43.00 ,$43.00 ,$12.90 ,$39.13 ,$30.10 ,$12.90 ,$27.95 ,$30.96 ,$39.13 ,$32.25 
Carle BroMenn Medical Center,8387171,HOMOGENIZATN TISSUE FR CULTURE,,87176,300,$97.00 ,$97.00 ,$29.10 ,$88.27 ,$67.90 ,$29.10 ,$63.05 ,$69.84 ,$88.27 ,$72.75 
Carle BroMenn Medical Center,8387187,SERUM BACTERICIDAL TITER,,87197,300,$98.00 ,$98.00 ,$29.40 ,$89.18 ,$68.60 ,$29.40 ,$63.70 ,$70.56 ,$89.18 ,$73.50 
Carle BroMenn Medical Center,8387205,"SMEAR, PRIMARY SRCE RTN STAIN",,87205,300,$32.50 ,$32.50 ,$9.75 ,$29.58 ,$22.75 ,$9.75 ,$21.13 ,$23.40 ,$29.58 ,$24.38 
Carle BroMenn Medical Center,8387206,"SMEAR, PRIMARY SRC FLRSNT/AF",,87206,300,$33.15 ,$33.15 ,$9.95 ,$30.17 ,$23.21 ,$9.95 ,$21.55 ,$23.87 ,$30.17 ,$24.86 
Carle BroMenn Medical Center,8387380,HEP D VIRUS AG      REF,,87380,300,$76.00 ,$76.00 ,$22.80 ,$69.16 ,$53.20 ,$22.80 ,$49.40 ,$54.72 ,$69.16 ,$57.00 
Carle BroMenn Medical Center,8387425,ROTOVIRUS ANTIGEN,,87425,300,$91.00 ,$91.00 ,$27.30 ,$82.81 ,$63.70 ,$27.30 ,$59.15 ,$65.52 ,$82.81 ,$68.25 
Carle BroMenn Medical Center,8387997,MICROSCOPIC EXAM,,87999,300,$43.00 ,$43.00 ,$12.90 ,$39.13 ,$30.10 ,$12.90 ,$27.95 ,$30.96 ,$39.13 ,$32.25 
Carle BroMenn Medical Center,8388006,DIRECTED DONOR CONSULT,,86999,300,$95.00 ,$95.00 ,$28.50 ,$86.45 ,$66.50 ,$28.50 ,$61.75 ,$68.40 ,$86.45 ,$71.25 
Carle BroMenn Medical Center,8389051,"CELL CT & DIFF, MISC. FLUID",,89051,300,$63.70 ,$63.70 ,$19.11 ,$57.97 ,$44.59 ,$19.11 ,$41.41 ,$45.86 ,$57.97 ,$47.78 
Carle BroMenn Medical Center,8389053,CELL CT & DIFF MISC FLUID REF,,89051,300,$78.40 ,$78.40 ,$23.52 ,$71.34 ,$54.88 ,$23.52 ,$50.96 ,$56.45 ,$71.34 ,$58.80 
Carle BroMenn Medical Center,8389190,NASAL SMEAR EOS,,89190,300,$59.00 ,$59.00 ,$17.70 ,$53.69 ,$41.30 ,$17.70 ,$38.35 ,$42.48 ,$53.69 ,$44.25 
Carle BroMenn Medical Center,8389802,PROCESSING AND HANDLING,,99001,300,$38.00 ,$38.00 ,$11.40 ,$34.58 ,$26.60 ,$11.40 ,$24.70 ,$27.36 ,$34.58 ,$28.50 
Carle BroMenn Medical Center,8399001,CLINICAL TRIAL PROCESSING (INPT),,99001,300,$7.00 ,$7.00 ,$2.10 ,$6.37 ,$4.90 ,$2.10 ,$4.55 ,$5.04 ,$6.37 ,$5.25 
Carle BroMenn Medical Center,8399006,HOME VENI PUNCTURE,,36415,300,$27.00 ,$27.00 ,$8.10 ,$24.57 ,$18.90 ,$8.10 ,$17.55 ,$19.44 ,$24.57 ,$20.25 
Carle BroMenn Medical Center,8399008,VENIPUNCTURE FOR LAB SPECIMEN,,36415,300,$9.75 ,$9.75 ,$2.93 ,$8.87 ,$6.83 ,$2.93 ,$6.34 ,$7.02 ,$8.87 ,$7.31 
Carle BroMenn Medical Center,8399018,VENIPUNCTURE FOR LAB SPECIMEN,,36415,300,$25.00 ,$25.00 ,$7.50 ,$22.75 ,$17.50 ,$7.50 ,$16.25 ,$18.00 ,$22.75 ,$18.75 
Carle BroMenn Medical Center,8809612,CATH URINE SPECIMEN COLLECTION,,P9612,300,$21.00 ,$21.00 ,$6.30 ,$19.11 ,$14.70 ,$6.30 ,$13.65 ,$15.12 ,$19.11 ,$15.75 
Carle BroMenn Medical Center,8836415,VENI PUNCTURE,,36415,300,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8028720,BILIRUBIN TOTAL TRANSCUTANEOUS,,88720,301,$50.00 ,$50.00 ,$15.00 ,$45.50 ,$35.00 ,$15.00 ,$32.50 ,$36.00 ,$45.50 ,$37.50 
Carle BroMenn Medical Center,8082270,OCCULT BLOOD - FECES,,82270,301,$42.00 ,$42.00 ,$12.60 ,$38.22 ,$29.40 ,$12.60 ,$27.30 ,$30.24 ,$38.22 ,$31.50 
Carle BroMenn Medical Center,8082330,IONIZED CALCIUM,,82330,301,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8082374,TCO2,,82374,301,$86.00 ,$86.00 ,$25.80 ,$78.26 ,$60.20 ,$25.80 ,$55.90 ,$61.92 ,$78.26 ,$64.50 
Carle BroMenn Medical Center,8082435,CHLORIDE,,82435,301,$62.00 ,$62.00 ,$18.60 ,$56.42 ,$43.40 ,$18.60 ,$40.30 ,$44.64 ,$56.42 ,$46.50 
Carle BroMenn Medical Center,8082565,CREATININE,,82565,301,$85.80 ,$85.80 ,$25.74 ,$78.08 ,$60.06 ,$25.74 ,$55.77 ,$61.78 ,$78.08 ,$64.35 
Carle BroMenn Medical Center,8082947,BLOOD GLUCOSE LEVEL,,82947,301,$46.00 ,$46.00 ,$13.80 ,$41.86 ,$32.20 ,$13.80 ,$29.90 ,$33.12 ,$41.86 ,$34.50 
Carle BroMenn Medical Center,8082962,GLUCOSE BLOOD TEST,,82962,301,$31.00 ,$31.00 ,$9.30 ,$28.21 ,$21.70 ,$9.30 ,$20.15 ,$22.32 ,$28.21 ,$23.25 
Carle BroMenn Medical Center,8084112,AMNISURE,,84112,301,$158.00 ,$158.00 ,$47.40 ,$143.78 ,$110.60 ,$47.40 ,$102.70 ,$113.76 ,$143.78 ,$118.50 
Carle BroMenn Medical Center,8084132,POTASSIUM,,84132,301,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8084295,SODIUM,,84295,301,$98.00 ,$98.00 ,$29.40 ,$89.18 ,$68.60 ,$29.40 ,$63.70 ,$70.56 ,$89.18 ,$73.50 
Carle BroMenn Medical Center,8084484,ISTAT TROPONIN,,84484,301,$180.00 ,$180.00 ,$54.00 ,$163.80 ,$126.00 ,$54.00 ,$117.00 ,$129.60 ,$163.80 ,$135.00 
Carle BroMenn Medical Center,8084520,BUN,,84520,301,$87.10 ,$87.10 ,$26.13 ,$79.26 ,$60.97 ,$26.13 ,$56.62 ,$62.71 ,$79.26 ,$65.33 
Carle BroMenn Medical Center,8120002,ASSAY OF BLOOD CHLORIDE,,82435,301,$62.00 ,$62.00 ,$18.60 ,$56.42 ,$43.40 ,$18.60 ,$40.30 ,$44.64 ,$56.42 ,$46.50 
Carle BroMenn Medical Center,8120003,"ASSAY, GLUCOSE, BLOOD QUANT",,82947,301,$46.00 ,$46.00 ,$13.80 ,$41.86 ,$32.20 ,$13.80 ,$29.90 ,$33.12 ,$41.86 ,$34.50 
Carle BroMenn Medical Center,8120004,NATRIURETIC PEPTIDE,,83880,301,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8120005,ASSAY OF SERUM POTASSIUM,,84132,301,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8120006,ASSAY OF SERUM SODIUM,,84295,301,$98.00 ,$98.00 ,$29.40 ,$89.18 ,$68.60 ,$29.40 ,$63.70 ,$70.56 ,$89.18 ,$73.50 
Carle BroMenn Medical Center,8120007,"ASSAY OF TROPONIN, QUANT",,84484,301,$180.00 ,$180.00 ,$54.00 ,$163.80 ,$126.00 ,$54.00 ,$117.00 ,$129.60 ,$163.80 ,$135.00 
Carle BroMenn Medical Center,8120008,ASSAY OF UREA NITROGEN,,84520,301,$87.10 ,$87.10 ,$26.13 ,$79.26 ,$60.97 ,$26.13 ,$56.62 ,$62.71 ,$79.26 ,$65.33 
Carle BroMenn Medical Center,8200433,LABORATORY TEST,,G0433,301,$48.00 ,$48.00 ,$14.40 ,$43.68 ,$33.60 ,$14.40 ,$31.20 ,$34.56 ,$43.68 ,$36.00 
Carle BroMenn Medical Center,8210114,FERN TEST,,Q0114,301,$84.00 ,$84.00 ,$25.20 ,$76.44 ,$58.80 ,$25.20 ,$54.60 ,$60.48 ,$76.44 ,$63.00 
Carle BroMenn Medical Center,8280051,ELECTROLYTE PANEL,,80051,301,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8280305,"DRUG TEST(S), PRSMP, ANY NM DRG CLS/DVCS/PRCS DRCT OPTICAL OBS ONLY",,80305,301,$65.00 ,$65.00 ,$19.50 ,$59.15 ,$45.50 ,$19.50 ,$42.25 ,$46.80 ,$59.15 ,$48.75 
Carle BroMenn Medical Center,8280307,DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,,80307,301,$820.00 ,$820.00 ,$246.00 ,$746.20 ,$574.00 ,$246.00 ,$533.00 ,$590.40 ,$746.20 ,$615.00 
Carle BroMenn Medical Center,8282043,"MICROALBUMIN, URINE, QUANT",,82043,301,$160.00 ,$160.00 ,$48.00 ,$145.60 ,$112.00 ,$48.00 ,$104.00 ,$115.20 ,$145.60 ,$120.00 
Carle BroMenn Medical Center,8282075,ALCOHOL BREATH,,82075,301,$62.00 ,$62.00 ,$18.60 ,$56.42 ,$43.40 ,$18.60 ,$40.30 ,$44.64 ,$56.42 ,$46.50 
Carle BroMenn Medical Center,8282270,"G BLOOD OCCULT,BY PEROXID,FECES,SINGLE, COLORECTAL SCREEN",,82270,301,$42.00 ,$42.00 ,$12.60 ,$38.22 ,$29.40 ,$12.60 ,$27.30 ,$30.24 ,$38.22 ,$31.50 
Carle BroMenn Medical Center,8282272,"BLOOD OCCULT,BY PEROXID, FECES, 1-3 SIMULT, NON CA SCREEN",,82272,301,$47.00 ,$47.00 ,$14.10 ,$42.77 ,$32.90 ,$14.10 ,$30.55 ,$33.84 ,$42.77 ,$35.25 
Carle BroMenn Medical Center,8282330,"ASSAY OF CALCIUM, IONIZED",,82330,301,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8282435,ASSAY OF BLOOD CHLORIDE,,82435,301,$62.00 ,$62.00 ,$18.60 ,$56.42 ,$43.40 ,$18.60 ,$40.30 ,$44.64 ,$56.42 ,$46.50 
Carle BroMenn Medical Center,8282438,ASSAY OTHER FLUID CHLORIDES,,82438,301,$64.00 ,$64.00 ,$19.20 ,$58.24 ,$44.80 ,$19.20 ,$41.60 ,$46.08 ,$58.24 ,$48.00 
Carle BroMenn Medical Center,8282565,ASSAY OF CREATININE,,82565,301,$85.80 ,$85.80 ,$25.74 ,$78.08 ,$60.06 ,$25.74 ,$55.77 ,$61.78 ,$78.08 ,$64.35 
Carle BroMenn Medical Center,8282670,ASSAY OF ESTRADIOL,,82670,301,$290.00 ,$290.00 ,$87.00 ,$263.90 ,$203.00 ,$87.00 ,$188.50 ,$208.80 ,$263.90 ,$217.50 
Carle BroMenn Medical Center,8282803,"BLOOD GASES: PH, PO2 & PCO2",,82803,301,$190.00 ,$190.00 ,$57.00 ,$172.90 ,$133.00 ,$57.00 ,$123.50 ,$136.80 ,$172.90 ,$142.50 
Carle BroMenn Medical Center,8282947,"ASSAY QUANTITATIVE,BLOOD GLUCOSE",,82947,301,$46.00 ,$46.00 ,$13.80 ,$41.86 ,$32.20 ,$13.80 ,$29.90 ,$33.12 ,$41.86 ,$34.50 
Carle BroMenn Medical Center,8282962,GLUCOSE BLOOD TEST,,82962,301,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8283001,FSH,,83001,301,$210.00 ,$210.00 ,$63.00 ,$191.10 ,$147.00 ,$63.00 ,$136.50 ,$151.20 ,$191.10 ,$157.50 
Carle BroMenn Medical Center,8283002,GONADOTROPIN (LH),,83002,301,$240.00 ,$240.00 ,$72.00 ,$218.40 ,$168.00 ,$72.00 ,$156.00 ,$172.80 ,$218.40 ,$180.00 
Carle BroMenn Medical Center,8283036,"HEMOGLOBIN, GLYCATED (A1C)",,83036,301,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8283605,LACTIC ACID,,83605,301,$175.00 ,$175.00 ,$52.50 ,$159.25 ,$122.50 ,$52.50 ,$113.75 ,$126.00 ,$159.25 ,$131.25 
Carle BroMenn Medical Center,8283655,ASSAY OF LEAD,,83655,301,$74.00 ,$74.00 ,$22.20 ,$67.34 ,$51.80 ,$22.20 ,$48.10 ,$53.28 ,$67.34 ,$55.50 
Carle BroMenn Medical Center,8283880,B-TYPE NATIURETIC PEPTIDE ISTAT (POC),,83880,301,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8283986,PH BODY FLUID NOS,,83986,301,$76.00 ,$76.00 ,$22.80 ,$69.16 ,$53.20 ,$22.80 ,$49.40 ,$54.72 ,$69.16 ,$57.00 
Carle BroMenn Medical Center,8284112,"PLACENTAL ALPHA MICROGLOBULIN,CERVICOVAGINAL QUALITATIVE",,84112,301,$158.00 ,$158.00 ,$47.40 ,$143.78 ,$110.60 ,$47.40 ,$102.70 ,$113.76 ,$143.78 ,$118.50 
Carle BroMenn Medical Center,8284132,ASSAY OF SERUM POTASSIUM,,84132,301,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8284144,ASSAY OF PROGESTERONE,,84144,301,$280.00 ,$280.00 ,$84.00 ,$254.80 ,$196.00 ,$84.00 ,$182.00 ,$201.60 ,$254.80 ,$210.00 
Carle BroMenn Medical Center,8284295,ASSAY OF SERUM SODIUM,,84295,301,$98.00 ,$98.00 ,$29.40 ,$89.18 ,$68.60 ,$29.40 ,$63.70 ,$70.56 ,$89.18 ,$73.50 
Carle BroMenn Medical Center,8284484,"CHG ASSAY OF TROPONIN, QUANT",,84484,301,$180.00 ,$180.00 ,$54.00 ,$163.80 ,$126.00 ,$54.00 ,$117.00 ,$129.60 ,$163.80 ,$135.00 
Carle BroMenn Medical Center,8284520,"ASSAY UREA NITROGEN, QUAN",,84520,301,$87.10 ,$87.10 ,$26.13 ,$79.26 ,$60.97 ,$26.13 ,$56.62 ,$62.71 ,$79.26 ,$65.33 
Carle BroMenn Medical Center,8284702,"CHORIONIC GONADOTROPIN, QUANT",,84702,301,$205.00 ,$205.00 ,$61.50 ,$186.55 ,$143.50 ,$61.50 ,$133.25 ,$147.60 ,$186.55 ,$153.75 
Carle BroMenn Medical Center,8288720,BILIRUBIN TOTAL TRANSCUTANEOUS,,88720,301,$50.00 ,$50.00 ,$15.00 ,$45.50 ,$35.00 ,$15.00 ,$32.50 ,$36.00 ,$45.50 ,$37.50 
Carle BroMenn Medical Center,8340000,ANTI CBIR 1,,83520,301,$255.00 ,$255.00 ,$76.50 ,$232.05 ,$178.50 ,$76.50 ,$165.75 ,$183.60 ,$232.05 ,$191.25 
Carle BroMenn Medical Center,8340001,ANTI-OMPC ELISA IGA,,83520,301,$255.00 ,$255.00 ,$76.50 ,$232.05 ,$178.50 ,$76.50 ,$165.75 ,$183.60 ,$232.05 ,$191.25 
Carle BroMenn Medical Center,8340032,REFLEX HU AB WESTERN BLOT,,84181,301,$370.00 ,$370.00 ,$111.00 ,$336.70 ,$259.00 ,$111.00 ,$240.50 ,$266.40 ,$336.70 ,$277.50 
Carle BroMenn Medical Center,8340033,RIBOSOMAL PORTEIN AB,,83516,301,$205.00 ,$205.00 ,$61.50 ,$186.55 ,$143.50 ,$61.50 ,$133.25 ,$147.60 ,$186.55 ,$153.75 
Carle BroMenn Medical Center,8340036,STACHYBOTRYS IGA,,83520,301,$86.00 ,$86.00 ,$25.80 ,$78.26 ,$60.20 ,$25.80 ,$55.90 ,$61.92 ,$78.26 ,$64.50 
Carle BroMenn Medical Center,8340042,URINE REDUCING SUBSTANCE,,81002,301,$43.00 ,$43.00 ,$12.90 ,$39.13 ,$30.10 ,$12.90 ,$27.95 ,$30.96 ,$39.13 ,$32.25 
Carle BroMenn Medical Center,8380013,ASSAY CITRATE REF,,82507,301,$120.00 ,$120.00 ,$36.00 ,$109.20 ,$84.00 ,$36.00 ,$78.00 ,$86.40 ,$109.20 ,$90.00 
Carle BroMenn Medical Center,8380024,ASSAY OF CREATININE,,82565,301,$85.80 ,$85.80 ,$25.74 ,$78.08 ,$60.06 ,$25.74 ,$55.77 ,$61.78 ,$78.08 ,$64.35 
Carle BroMenn Medical Center,8380037,IMMUNOGLOB FREE LIGHT CHAINS,,83883,301,$126.00 ,$126.00 ,$37.80 ,$114.66 ,$88.20 ,$37.80 ,$81.90 ,$90.72 ,$114.66 ,$94.50 
Carle BroMenn Medical Center,8380049,BASIC METABOLIC PANEL,,80048,301,$84.50 ,$84.50 ,$25.35 ,$76.90 ,$59.15 ,$25.35 ,$54.93 ,$60.84 ,$76.90 ,$63.38 
Carle BroMenn Medical Center,8380050,GENERAL HEALTH PANEL,,80050,301,$282.75 ,$282.75 ,$84.83 ,$257.30 ,$197.93 ,$84.83 ,$183.79 ,$203.58 ,$257.30 ,$212.06 
Carle BroMenn Medical Center,8380054,COMPREHENSIVE METABOLIC PANEL,,80053,301,$113.75 ,$113.75 ,$34.13 ,$103.51 ,$79.63 ,$34.13 ,$73.94 ,$81.90 ,$103.51 ,$85.31 
Carle BroMenn Medical Center,8380055,OBSTETRIC PANEL,,80055,301,$409.50 ,$409.50 ,$122.85 ,$372.65 ,$286.65 ,$122.85 ,$266.18 ,$294.84 ,$372.65 ,$307.13 
Carle BroMenn Medical Center,8380074,HEPATITIS ACUTE PANEL,,80074,301,$289.25 ,$289.25 ,$86.78 ,$263.22 ,$202.48 ,$86.78 ,$188.01 ,$208.26 ,$263.22 ,$216.94 
Carle BroMenn Medical Center,8380080,DRUG ASSAY,,80299,301,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8380081,OBSTETRIC PANEL,,80081,301,$447.00 ,$447.00 ,$134.10 ,$406.77 ,$312.90 ,$134.10 ,$290.55 ,$321.84 ,$406.77 ,$335.25 
Carle BroMenn Medical Center,8380085,RAPAMYCIN REF,,80195,301,$123.50 ,$123.50 ,$37.05 ,$112.39 ,$86.45 ,$37.05 ,$80.28 ,$88.92 ,$112.39 ,$92.63 
Carle BroMenn Medical Center,8380088,DRUG ASSAY -OXCARBAZEPINE  REF,,83789,301,$85.00 ,$85.00 ,$25.50 ,$77.35 ,$59.50 ,$25.50 ,$55.25 ,$61.20 ,$77.35 ,$63.75 
Carle BroMenn Medical Center,8380089,ASSAY FELBAMATE REF,,80299,301,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8380090,"RIBOSOME P AB, IGG, S     REF",,83516,301,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8380092,NMO EVAL W/REFLEX S [60796],,83520,301,$244.00 ,$244.00 ,$73.20 ,$222.04 ,$170.80 ,$73.20 ,$158.60 ,$175.68 ,$222.04 ,$183.00 
Carle BroMenn Medical Center,8380100,"PHENOLPHTHALEIN, STOOL",,84999,301,$79.00 ,$79.00 ,$23.70 ,$71.89 ,$55.30 ,$23.70 ,$51.35 ,$56.88 ,$71.89 ,$59.25 
Carle BroMenn Medical Center,8380124,"PHENOBARBITAL, UR REF",,80184,301,$120.25 ,$120.25 ,$36.08 ,$109.43 ,$84.18 ,$36.08 ,$78.16 ,$86.58 ,$109.43 ,$90.19 
Carle BroMenn Medical Center,8380134,NBS-CYCSTIC FIBROSIS SCRN  REF,,83516,301,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8380142,"PREGNENOLONE, S  REF",,84140,301,$13.00 ,$13.00 ,$3.90 ,$11.83 ,$9.10 ,$3.90 ,$8.45 ,$9.36 ,$11.83 ,$9.75 
Carle BroMenn Medical Center,8380144,"ALPHA-FETOPROTEIN, SERUM   REF",,82105,301,$123.50 ,$123.50 ,$37.05 ,$112.39 ,$86.45 ,$37.05 ,$80.28 ,$88.92 ,$112.39 ,$92.63 
Carle BroMenn Medical Center,8380145,COLLAGEN CROSS LINK REF,,82523,301,$110.00 ,$110.00 ,$33.00 ,$100.10 ,$77.00 ,$33.00 ,$71.50 ,$79.20 ,$100.10 ,$82.50 
Carle BroMenn Medical Center,8380148,PROCALCITONIN,,84145,301,$172.25 ,$172.25 ,$51.68 ,$156.75 ,$120.58 ,$51.68 ,$111.96 ,$124.02 ,$156.75 ,$129.19 
Carle BroMenn Medical Center,8380150,"AMIKACIN,  REF",,80150,301,$266.50 ,$266.50 ,$79.95 ,$242.52 ,$186.55 ,$79.95 ,$173.23 ,$191.88 ,$242.52 ,$199.88 
Carle BroMenn Medical Center,8380156,DRUG ASSY-CARBAMAZEPN FREE REF,,80157,301,$38.00 ,$38.00 ,$11.40 ,$34.58 ,$26.60 ,$11.40 ,$24.70 ,$27.36 ,$34.58 ,$28.50 
Carle BroMenn Medical Center,8380158,DRUG ASSY-CARBAMAZAPN TOTL REF,,80156,301,$48.00 ,$48.00 ,$14.40 ,$43.68 ,$33.60 ,$14.40 ,$31.20 ,$34.56 ,$43.68 ,$36.00 
Carle BroMenn Medical Center,8380164,DRUG ASSY-VALPROIC ACID FRE RF,,80164,301,$68.00 ,$68.00 ,$20.40 ,$61.88 ,$47.60 ,$20.40 ,$44.20 ,$48.96 ,$61.88 ,$51.00 
Carle BroMenn Medical Center,8380165,DRUG ASSY-VALPROIC ACID TOT RF,,80164,301,$33.00 ,$33.00 ,$9.90 ,$30.03 ,$23.10 ,$9.90 ,$21.45 ,$23.76 ,$30.03 ,$24.75 
Carle BroMenn Medical Center,8380168,ETHOSUXIMIDE   REF,,80168,301,$69.00 ,$69.00 ,$20.70 ,$62.79 ,$48.30 ,$20.70 ,$44.85 ,$49.68 ,$62.79 ,$51.75 
Carle BroMenn Medical Center,8380176,ASSAY LIDOCAINE,,80176,301,$165.75 ,$165.75 ,$49.73 ,$150.83 ,$116.03 ,$49.73 ,$107.74 ,$119.34 ,$150.83 ,$124.31 
Carle BroMenn Medical Center,8380188,PRIMIDONE REF,,80188,301,$143.00 ,$143.00 ,$42.90 ,$130.13 ,$100.10 ,$42.90 ,$92.95 ,$102.96 ,$130.13 ,$107.25 
Carle BroMenn Medical Center,8380197,DRUG ASSAY-TACROLIMS TROUGH RF,,80197,301,$83.00 ,$83.00 ,$24.90 ,$75.53 ,$58.10 ,$24.90 ,$53.95 ,$59.76 ,$75.53 ,$62.25 
Carle BroMenn Medical Center,8380201,DRUG ASSAY -TOPIRAMATE     REF,,80201,301,$79.00 ,$79.00 ,$23.70 ,$71.89 ,$55.30 ,$23.70 ,$51.35 ,$56.88 ,$71.89 ,$59.25 
Carle BroMenn Medical Center,8380215,"TROPONIN, QUANTITATIVE   REF",,84484,301,$180.00 ,$180.00 ,$54.00 ,$163.80 ,$126.00 ,$54.00 ,$117.00 ,$129.60 ,$163.80 ,$135.00 
Carle BroMenn Medical Center,8380218,"MICROALBUMIN, URINE    REF",,82043,301,$65.00 ,$65.00 ,$19.50 ,$59.15 ,$45.50 ,$19.50 ,$42.25 ,$46.80 ,$59.15 ,$48.75 
Carle BroMenn Medical Center,8380229,GASTRIC OCCULT BLOOD,,82271,301,$33.15 ,$33.15 ,$9.95 ,$30.17 ,$23.21 ,$9.95 ,$21.55 ,$23.87 ,$30.17 ,$24.86 
Carle BroMenn Medical Center,8380230,"PREG, QUAL-SERUM",,84703,301,$74.75 ,$74.75 ,$22.43 ,$68.02 ,$52.33 ,$22.43 ,$48.59 ,$53.82 ,$68.02 ,$56.06 
Carle BroMenn Medical Center,8380232,BLOOD GASES ISTAT G3 PLUS,,82803,301,$287.00 ,$287.00 ,$86.10 ,$261.17 ,$200.90 ,$86.10 ,$186.55 ,$206.64 ,$261.17 ,$215.25 
Carle BroMenn Medical Center,8380283,CARBON DIOXIDE (BICARBONATE)  REF,,82374,301,$86.00 ,$86.00 ,$25.80 ,$78.26 ,$60.20 ,$25.80 ,$55.90 ,$61.92 ,$78.26 ,$64.50 
Carle BroMenn Medical Center,8380298,DRUG ASSAY -GABAPENTIN     REF,,80299,301,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8380299,"CLOMIPRAMINE, S    REF",,80299,301,$114.00 ,$114.00 ,$34.20 ,$103.74 ,$79.80 ,$34.20 ,$74.10 ,$82.08 ,$103.74 ,$85.50 
Carle BroMenn Medical Center,8380300,DRUG ASSAY -LAMOTRIGINE    REF,,80299,301,$28.00 ,$28.00 ,$8.40 ,$25.48 ,$19.60 ,$8.40 ,$18.20 ,$20.16 ,$25.48 ,$21.00 
Carle BroMenn Medical Center,8380306,"COBALT, BLOOD REF",,83018,301,$49.00 ,$49.00 ,$14.70 ,$44.59 ,$34.30 ,$14.70 ,$31.85 ,$35.28 ,$44.59 ,$36.75 
Carle BroMenn Medical Center,8380311,TISSUE TRANSGLUT. IGA,,83516,301,$110.00 ,$110.00 ,$33.00 ,$100.10 ,$77.00 ,$33.00 ,$71.50 ,$79.20 ,$100.10 ,$82.50 
Carle BroMenn Medical Center,8380323,PH URINE,,83986,301,$29.00 ,$29.00 ,$8.70 ,$26.39 ,$20.30 ,$8.70 ,$18.85 ,$20.88 ,$26.39 ,$21.75 
Carle BroMenn Medical Center,8380324,CALCIUM URINE,,82340,301,$78.00 ,$78.00 ,$23.40 ,$70.98 ,$54.60 ,$23.40 ,$50.70 ,$56.16 ,$70.98 ,$58.50 
Carle BroMenn Medical Center,8380325,OXALATE URINE,,83945,301,$78.00 ,$78.00 ,$23.40 ,$70.98 ,$54.60 ,$23.40 ,$50.70 ,$56.16 ,$70.98 ,$58.50 
Carle BroMenn Medical Center,8380326,URIC ACID URINE,,84560,301,$104.00 ,$104.00 ,$31.20 ,$94.64 ,$72.80 ,$31.20 ,$67.60 ,$74.88 ,$94.64 ,$78.00 
Carle BroMenn Medical Center,8380327,CITRATE URINE,,82507,301,$107.25 ,$107.25 ,$32.18 ,$97.60 ,$75.08 ,$32.18 ,$69.71 ,$77.22 ,$97.60 ,$80.44 
Carle BroMenn Medical Center,8380328,SODIUM URINE,,84300,301,$40.00 ,$40.00 ,$12.00 ,$36.40 ,$28.00 ,$12.00 ,$26.00 ,$28.80 ,$36.40 ,$30.00 
Carle BroMenn Medical Center,8380329,PHOSPHORUS URINE,,84105,301,$104.00 ,$104.00 ,$31.20 ,$94.64 ,$72.80 ,$31.20 ,$67.60 ,$74.88 ,$94.64 ,$78.00 
Carle BroMenn Medical Center,8380330,MAGNESIUM URINE,,83735,301,$91.00 ,$91.00 ,$27.30 ,$82.81 ,$63.70 ,$27.30 ,$59.15 ,$65.52 ,$82.81 ,$68.25 
Carle BroMenn Medical Center,8380331,AMMONIUM URINE,,82140,301,$84.00 ,$84.00 ,$25.20 ,$76.44 ,$58.80 ,$25.20 ,$54.60 ,$60.48 ,$76.44 ,$63.00 
Carle BroMenn Medical Center,8380332,POTASSIUM URINE,,84133,301,$40.00 ,$40.00 ,$12.00 ,$36.40 ,$28.00 ,$12.00 ,$26.00 ,$28.80 ,$36.40 ,$30.00 
Carle BroMenn Medical Center,8380333,CREATININE URINE,,82570,301,$8.25 ,$8.25 ,$2.48 ,$7.51 ,$5.78 ,$2.48 ,$5.36 ,$5.94 ,$7.51 ,$6.19 
Carle BroMenn Medical Center,8380335,"LACTOFERRIN, FECAL, QUAL.",,83630,301,$120.25 ,$120.25 ,$36.08 ,$109.43 ,$84.18 ,$36.08 ,$78.16 ,$86.58 ,$109.43 ,$90.19 
Carle BroMenn Medical Center,8380339,ENZYME ACTIVITY NES NONRAD (TPMT ENZ-PROMETH),,82657,301,$162.50 ,$162.50 ,$48.75 ,$147.88 ,$113.75 ,$48.75 ,$105.63 ,$117.00 ,$147.88 ,$121.88 
Carle BroMenn Medical Center,8380347,IMMUNOASSAY ANALYTE QT (SGI-PROMETH),,83520,301,$20.00 ,$20.00 ,$6.00 ,$18.20 ,$14.00 ,$6.00 ,$13.00 ,$14.40 ,$18.20 ,$15.00 
Carle BroMenn Medical Center,8380348,IMMUNOASSAY ANALYTE QT (SGI-PROMETH),,83520,301,$20.00 ,$20.00 ,$6.00 ,$18.20 ,$14.00 ,$6.00 ,$13.00 ,$14.40 ,$18.20 ,$15.00 
Carle BroMenn Medical Center,8380349,CHEMILUMINESCENT ASSAY (SGI-PROMETH),,82397,301,$28.00 ,$28.00 ,$8.40 ,$25.48 ,$19.60 ,$8.40 ,$18.20 ,$20.16 ,$25.48 ,$21.00 
Carle BroMenn Medical Center,8380356,IMMUNOASSAY ANALYTE QT (CROHN'S RFLX-PROMETH),,83520,301,$12.00 ,$12.00 ,$3.60 ,$10.92 ,$8.40 ,$3.60 ,$7.80 ,$8.64 ,$10.92 ,$9.00 
Carle BroMenn Medical Center,8380360,IMMUNOASSAY ANALYTE QT (CROHN'S-PROMETH),,83520,301,$20.00 ,$20.00 ,$6.00 ,$18.20 ,$14.00 ,$6.00 ,$13.00 ,$14.40 ,$18.20 ,$15.00 
Carle BroMenn Medical Center,8380365,"DEAMINATED GLIADIN PEPTIDE AB, IGA/IGG (CELIAC-PROME)",,82397,301,$28.00 ,$28.00 ,$8.40 ,$25.48 ,$19.60 ,$8.40 ,$18.20 ,$20.16 ,$25.48 ,$21.00 
Carle BroMenn Medical Center,8380366,"ANTI-HUMAN TTG, ELISA (CELIAC-PROMETH)",,82397,301,$36.00 ,$36.00 ,$10.80 ,$32.76 ,$25.20 ,$10.80 ,$23.40 ,$25.92 ,$32.76 ,$27.00 
Carle BroMenn Medical Center,8380368,TOTAL IGA (CELIAC-PROMETH),,82784,301,$20.00 ,$20.00 ,$6.00 ,$18.20 ,$14.00 ,$6.00 ,$13.00 ,$14.40 ,$18.20 ,$15.00 
Carle BroMenn Medical Center,8380371,"IMMUNOGLOBULIN A (IGA), S      REF",,82784,301,$9.00 ,$9.00 ,$2.70 ,$8.19 ,$6.30 ,$2.70 ,$5.85 ,$6.48 ,$8.19 ,$6.75 
Carle BroMenn Medical Center,8380373,"GLIADIN(DEAMIDATED) AB, IGA, S  REF",,83516,301,$84.50 ,$84.50 ,$25.35 ,$76.90 ,$59.15 ,$25.35 ,$54.93 ,$60.84 ,$76.90 ,$63.38 
Carle BroMenn Medical Center,8380374,"GLIADIN(DEAMIDATED) AB, IGG, S  REF",,83516,301,$84.50 ,$84.50 ,$25.35 ,$76.90 ,$59.15 ,$25.35 ,$54.93 ,$60.84 ,$76.90 ,$63.38 
Carle BroMenn Medical Center,8380377,"RENIN ACTIVITY, P    REF",,84244,301,$133.25 ,$133.25 ,$39.98 ,$121.26 ,$93.28 ,$39.98 ,$86.61 ,$95.94 ,$121.26 ,$99.94 
Carle BroMenn Medical Center,8380381,"CENTROMERE AB, IGG, S    REF",,83516,301,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8380383,"IMMUNOGLOBULIN E (IGE), S    REF",,82785,301,$9.00 ,$9.00 ,$2.70 ,$8.19 ,$6.30 ,$2.70 ,$5.85 ,$6.48 ,$8.19 ,$6.75 
Carle BroMenn Medical Center,8380385,"HEMOGLOBIN ELECTROPH, B    REF",,83020,301,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8380386,HEMOGLOBIN A2 AND F    REF,,83021,301,$16.00 ,$16.00 ,$4.80 ,$14.56 ,$11.20 ,$4.80 ,$10.40 ,$11.52 ,$14.56 ,$12.00 
Carle BroMenn Medical Center,8380387,"HB VARIANT BY MASS SPEC, B    REF",,83789,301,$84.00 ,$84.00 ,$25.20 ,$76.44 ,$58.80 ,$25.20 ,$54.60 ,$60.48 ,$76.44 ,$63.00 
Carle BroMenn Medical Center,8380388,IEF CONFIRMS    REF,,82664,301,$42.00 ,$42.00 ,$12.60 ,$38.22 ,$29.40 ,$12.60 ,$27.30 ,$30.24 ,$38.22 ,$31.50 
Carle BroMenn Medical Center,8380397,"ALDOLASE, S    REF",,82085,301,$10.22 ,$10.22 ,$3.07 ,$9.30 ,$7.15 ,$3.07 ,$6.64 ,$7.36 ,$9.30 ,$7.67 
Carle BroMenn Medical Center,8380401,DEHYDROEPIANDROSTERONE SULFATE  REF,,82627,301,$8.00 ,$8.00 ,$2.40 ,$7.28 ,$5.60 ,$2.40 ,$5.20 ,$5.76 ,$7.28 ,$6.00 
Carle BroMenn Medical Center,8380404,"TESTOSTERONE, TOTAL, S    REF",,84403,301,$81.25 ,$81.25 ,$24.38 ,$73.94 ,$56.88 ,$24.38 ,$52.81 ,$58.50 ,$73.94 ,$60.94 
Carle BroMenn Medical Center,8380405,"PSEUDOCHOLINESTERASE, TOTAL, S  REF",,82480,301,$9.00 ,$9.00 ,$2.70 ,$8.19 ,$6.30 ,$2.70 ,$5.85 ,$6.48 ,$8.19 ,$6.75 
Carle BroMenn Medical Center,8380406,"ACETYLCHOLINESTERASE, RBC    REF",,82482,301,$30.00 ,$30.00 ,$9.00 ,$27.30 ,$21.00 ,$9.00 ,$19.50 ,$21.60 ,$27.30 ,$22.50 
Carle BroMenn Medical Center,8380408,"CORTISOL, FREE, URINE      REF",,82530,301,$123.50 ,$123.50 ,$37.05 ,$112.39 ,$86.45 ,$37.05 ,$80.28 ,$88.92 ,$112.39 ,$92.63 
Carle BroMenn Medical Center,8380409,"ALDOSTERONE, S    REF",,82088,301,$247.00 ,$247.00 ,$74.10 ,$224.77 ,$172.90 ,$74.10 ,$160.55 ,$177.84 ,$224.77 ,$185.25 
Carle BroMenn Medical Center,8380410,PORPHOBILINOGEN URINE QNT     REF,,84110,301,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8380411,"COPPER, 24 HR, U    REF",,82525,301,$22.00 ,$22.00 ,$6.60 ,$20.02 ,$15.40 ,$6.60 ,$14.30 ,$15.84 ,$20.02 ,$16.50 
Carle BroMenn Medical Center,8380412,"MERCURY, URINE (24HR)      REF",,83825,301,$100.75 ,$100.75 ,$30.23 ,$91.68 ,$70.53 ,$30.23 ,$65.49 ,$72.54 ,$91.68 ,$75.56 
Carle BroMenn Medical Center,8380413,KIDNEY STONE ANALYSIS    REF,,82365,301,$17.00 ,$17.00 ,$5.10 ,$15.47 ,$11.90 ,$5.10 ,$11.05 ,$12.24 ,$15.47 ,$12.75 
Carle BroMenn Medical Center,8380414,"LEAD, URINE (24HR)         REF",,82365,301,$11.00 ,$11.00 ,$3.30 ,$10.01 ,$7.70 ,$3.30 ,$7.15 ,$7.92 ,$10.01 ,$8.25 
Carle BroMenn Medical Center,8380415,"THALLIUM, 24 HR, U    REF",,83789,301,$14.00 ,$14.00 ,$4.20 ,$12.74 ,$9.80 ,$4.20 ,$9.10 ,$10.08 ,$12.74 ,$10.50 
Carle BroMenn Medical Center,8380416,"ARSENIC, 24 HR, U    REF",,82175,301,$97.50 ,$97.50 ,$29.25 ,$88.73 ,$68.25 ,$29.25 ,$63.38 ,$70.20 ,$88.73 ,$73.13 
Carle BroMenn Medical Center,8380417,"INSULIN, S    REF",,83525,301,$8.00 ,$8.00 ,$2.40 ,$7.28 ,$5.60 ,$2.40 ,$5.20 ,$5.76 ,$7.28 ,$6.00 
Carle BroMenn Medical Center,8380419,OXALATE URINE (24HR) REF,,83945,301,$14.00 ,$14.00 ,$4.20 ,$12.74 ,$9.80 ,$4.20 ,$9.10 ,$10.08 ,$12.74 ,$10.50 
Carle BroMenn Medical Center,8380420,"CADMIUM, URINE (24HR)      REF",,82300,301,$12.00 ,$12.00 ,$3.60 ,$10.92 ,$8.40 ,$3.60 ,$7.80 ,$8.64 ,$10.92 ,$9.00 
Carle BroMenn Medical Center,8380421,"LACTATE DEHYDROGENASE (LD), S    REF",,83615,301,$10.54 ,$10.54 ,$3.16 ,$9.59 ,$7.38 ,$3.16 ,$6.85 ,$7.59 ,$9.59 ,$7.91 
Carle BroMenn Medical Center,8380422,"LD ISOENZYMES, S    REF",,83625,301,$14.00 ,$14.00 ,$4.20 ,$12.74 ,$9.80 ,$4.20 ,$9.10 ,$10.08 ,$12.74 ,$10.50 
Carle BroMenn Medical Center,8380423,"GROWTH HORMONE, S    REF",,83003,301,$14.00 ,$14.00 ,$4.20 ,$12.74 ,$9.80 ,$4.20 ,$9.10 ,$10.08 ,$12.74 ,$10.50 
Carle BroMenn Medical Center,8380424,"T4 (THYROXINE), TOTAL ONLY, S    REF",,84436,301,$9.00 ,$9.00 ,$2.70 ,$8.19 ,$6.30 ,$2.70 ,$5.85 ,$6.48 ,$8.19 ,$6.75 
Carle BroMenn Medical Center,8380425,"STRIATIONAL MUSCLE AB, S     REF",,83520,301,$12.00 ,$12.00 ,$3.60 ,$10.92 ,$8.40 ,$3.60 ,$7.80 ,$8.64 ,$10.92 ,$9.00 
Carle BroMenn Medical Center,8380426,"CAFFEINE, S    REF",,80155,301,$18.00 ,$18.00 ,$5.40 ,$16.38 ,$12.60 ,$5.40 ,$11.70 ,$12.96 ,$16.38 ,$13.50 
Carle BroMenn Medical Center,8380429,"CARNITINE, FRACTIONATED    REF",,82379,301,$17.00 ,$17.00 ,$5.10 ,$15.47 ,$11.90 ,$5.10 ,$11.05 ,$12.24 ,$15.47 ,$12.75 
Carle BroMenn Medical Center,8380430,"C-PEPTIDE, S    REF",,84681,301,$10.57 ,$10.57 ,$3.17 ,$9.62 ,$7.40 ,$3.17 ,$6.87 ,$7.61 ,$9.62 ,$7.93 
Carle BroMenn Medical Center,8380431,"1,25-DIHYDROXYVITAMIN D, S    REF",,82652,301,$14.00 ,$14.00 ,$4.20 ,$12.74 ,$9.80 ,$4.20 ,$9.10 ,$10.08 ,$12.74 ,$10.50 
Carle BroMenn Medical Center,8380436,ALPHASUBUNIT PITUIT TUMOR MRKR  REF,,83520,301,$11.00 ,$11.00 ,$3.30 ,$10.01 ,$7.70 ,$3.30 ,$7.15 ,$7.92 ,$10.01 ,$8.25 
Carle BroMenn Medical Center,8380440,"17-HYDROXYPROGESTERONE, S    REF",,83498,301,$201.50 ,$201.50 ,$60.45 ,$183.37 ,$141.05 ,$60.45 ,$130.98 ,$145.08 ,$183.37 ,$151.13 
Carle BroMenn Medical Center,8380441,"BETA-2-MICROGLOBULIN, S    REF",,82232,301,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8380442,"5-HYDROXYINDOLEACETIC ACID, U  REF",,83497,301,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8380443,TOTAL IGG                   REF,,82784,301,$4.00 ,$4.00 ,$1.20 ,$3.64 ,$2.80 ,$1.20 ,$2.60 ,$2.88 ,$3.64 ,$3.00 
Carle BroMenn Medical Center,8380444,"IGG SUBCLASSES, S       REF",,82787,301,$4.00 ,$4.00 ,$1.20 ,$3.64 ,$2.80 ,$1.20 ,$2.60 ,$2.88 ,$3.64 ,$3.00 
Carle BroMenn Medical Center,8380445,"AMINO ACIDS, QN, P           REF",,82139,301,$106.00 ,$106.00 ,$31.80 ,$96.46 ,$74.20 ,$31.80 ,$68.90 ,$76.32 ,$96.46 ,$79.50 
Carle BroMenn Medical Center,8380449,"NORDOXEPIN, S    REF",,80299,301,$9.00 ,$9.00 ,$2.70 ,$8.19 ,$6.30 ,$2.70 ,$5.85 ,$6.48 ,$8.19 ,$6.75 
Carle BroMenn Medical Center,8380450,"CITRATE EXCRETION, U    REF",,82507,301,$14.00 ,$14.00 ,$4.20 ,$12.74 ,$9.80 ,$4.20 ,$9.10 ,$10.08 ,$12.74 ,$10.50 
Carle BroMenn Medical Center,8380451,"GLUCAGON, P    REF",,82943,301,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8380452,"T3 (TRIIODOTHYRONINE), FREE, S  REF",,84481,301,$100.75 ,$100.75 ,$30.23 ,$91.68 ,$70.53 ,$30.23 ,$65.49 ,$72.54 ,$91.68 ,$75.56 
Carle BroMenn Medical Center,8380453,"MPO AB AND PR3 AB, S    REF",,83516,301,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8380467,"PHENYTOIN, FREE, S    REF",,80186,301,$11.00 ,$11.00 ,$3.30 ,$10.01 ,$7.70 ,$3.30 ,$7.15 ,$7.92 ,$10.01 ,$8.25 
Carle BroMenn Medical Center,8380468,"PHENYTOIN, TOTAL, S    REF",,80185,301,$11.00 ,$11.00 ,$3.30 ,$10.01 ,$7.70 ,$3.30 ,$7.15 ,$7.92 ,$10.01 ,$8.25 
Carle BroMenn Medical Center,8380469,"LEAD, B    REF",,83655,301,$6.00 ,$6.00 ,$1.80 ,$5.46 ,$4.20 ,$1.80 ,$3.90 ,$4.32 ,$5.46 ,$4.50 
Carle BroMenn Medical Center,8380480,"ALPHA-1-ANTITRYPSIN, S    REF",,82103,301,$81.25 ,$81.25 ,$24.38 ,$73.94 ,$56.88 ,$24.38 ,$52.81 ,$58.50 ,$73.94 ,$60.94 
Carle BroMenn Medical Center,8380489,PANCREASTATIN    REF,,83519,301,$110.00 ,$110.00 ,$33.00 ,$100.10 ,$77.00 ,$33.00 ,$71.50 ,$79.20 ,$100.10 ,$82.50 
Carle BroMenn Medical Center,8380491,"FOLATE, RBC    REF",,82747,301,$33.00 ,$33.00 ,$9.90 ,$30.03 ,$23.10 ,$9.90 ,$21.45 ,$23.76 ,$30.03 ,$24.75 
Carle BroMenn Medical Center,8380492,"AMINO ACIDS, QN, RANDOM, U    REF",,82139,301,$284.00 ,$284.00 ,$85.20 ,$258.44 ,$198.80 ,$85.20 ,$184.60 ,$204.48 ,$258.44 ,$213.00 
Carle BroMenn Medical Center,8380493,"PYRIDOXAL 5-PHOSPHATE (PLP), P  REF",,84207,301,$119.00 ,$119.00 ,$35.70 ,$108.29 ,$83.30 ,$35.70 ,$77.35 ,$85.68 ,$108.29 ,$89.25 
Carle BroMenn Medical Center,8380494,"PYRIDOXIC ACID (PA), P    REF",,82542,301,$77.00 ,$77.00 ,$23.10 ,$70.07 ,$53.90 ,$23.10 ,$50.05 ,$55.44 ,$70.07 ,$57.75 
Carle BroMenn Medical Center,8380495,"ERYTHROPOIETIN (EPO), S    REF",,82668,301,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8380499,"GALACTOSE-1-PHOSPHATE, RBC    REF",,84378,301,$40.00 ,$40.00 ,$12.00 ,$36.40 ,$28.00 ,$12.00 ,$26.00 ,$28.80 ,$36.40 ,$30.00 
Carle BroMenn Medical Center,8380501,"MYELOPEROXIDASE AB, S    REF",,83516,301,$12.00 ,$12.00 ,$3.60 ,$10.92 ,$8.40 ,$3.60 ,$7.80 ,$8.64 ,$10.92 ,$9.00 
Carle BroMenn Medical Center,8380507,"MAG AB, DUAL ELISA, S     REF",,83520,301,$69.00 ,$69.00 ,$20.70 ,$62.79 ,$48.30 ,$20.70 ,$44.85 ,$49.68 ,$62.79 ,$51.75 
Carle BroMenn Medical Center,8380508,"TACROLIMUS, B    REF",,80197,301,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8380509,"CK ISOENZYME ELECTROPH, S    REF",,82552,301,$13.00 ,$13.00 ,$3.90 ,$11.83 ,$9.10 ,$3.90 ,$8.45 ,$9.36 ,$11.83 ,$9.75 
Carle BroMenn Medical Center,8380510,TOTAL CK ACTIVITY    REF,,82550,301,$4.00 ,$4.00 ,$1.20 ,$3.64 ,$2.80 ,$1.20 ,$2.60 ,$2.88 ,$3.64 ,$3.00 
Carle BroMenn Medical Center,8380514,"LAMOTRIGINE, S    REF",,80175,301,$110.50 ,$110.50 ,$33.15 ,$100.56 ,$77.35 ,$33.15 ,$71.83 ,$79.56 ,$100.56 ,$82.88 
Carle BroMenn Medical Center,8380515,"THIAMIN (VITAMIN B1), WB    REF",,84425,301,$14.00 ,$14.00 ,$4.20 ,$12.74 ,$9.80 ,$4.20 ,$9.10 ,$10.08 ,$12.74 ,$10.50 
Carle BroMenn Medical Center,8380517,"PORPHYRINS, TOTAL, P    REF",,84311,301,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8380522,CEA (VISTA),,82378,301,$195.00 ,$195.00 ,$58.50 ,$177.45 ,$136.50 ,$58.50 ,$126.75 ,$140.40 ,$177.45 ,$146.25 
Carle BroMenn Medical Center,8380523,"AFP SINGLE MKR SCRN, MATNL, S   REF",,82105,301,$8.00 ,$8.00 ,$2.40 ,$7.28 ,$5.60 ,$2.40 ,$5.20 ,$5.76 ,$7.28 ,$6.00 
Carle BroMenn Medical Center,8380526,"ESTRONE, S    REF",,82679,301,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8380546,"A1AT PHENOTYPE, S    REF",,82104,301,$32.00 ,$32.00 ,$9.60 ,$29.12 ,$22.40 ,$9.60 ,$20.80 ,$23.04 ,$29.12 ,$24.00 
Carle BroMenn Medical Center,8380547,ALPHA-1-ANTITRYPSIN PHENOTYPE   REF,,82104,301,$156.00 ,$156.00 ,$46.80 ,$141.96 ,$109.20 ,$46.80 ,$101.40 ,$112.32 ,$141.96 ,$117.00 
Carle BroMenn Medical Center,8380548,"ALPHA-1-ANTITRYPSIN, S    REF",,82103,301,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8380559,"STRIATED MUSCLE AB, S    REF",,83520,301,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8380560,P/Q-TYPE CALCIUM CHANNEL AB    REF,,83519,301,$11.00 ,$11.00 ,$3.30 ,$10.01 ,$7.70 ,$3.30 ,$7.15 ,$7.92 ,$10.01 ,$8.25 
Carle BroMenn Medical Center,8380561,N-TYPE CALCIUM CHANNEL AB    REF,,83519,301,$11.00 ,$11.00 ,$3.30 ,$10.01 ,$7.70 ,$3.30 ,$7.15 ,$7.92 ,$10.01 ,$8.25 
Carle BroMenn Medical Center,8380562,ACH RECEP (MUSCLE) BINDING AB  REF,,83519,301,$11.00 ,$11.00 ,$3.30 ,$10.01 ,$7.70 ,$3.30 ,$7.15 ,$7.92 ,$10.01 ,$8.25 
Carle BroMenn Medical Center,8380563,"ACHR GANGLIONIC NEURONAL AB, S  REF",,83519,301,$14.00 ,$14.00 ,$4.20 ,$12.74 ,$9.80 ,$4.20 ,$9.10 ,$10.08 ,$12.74 ,$10.50 
Carle BroMenn Medical Center,8380564,"NEURONAL (V-G) K+ CHNL AB, S    REF",,83519,301,$35.00 ,$35.00 ,$10.50 ,$31.85 ,$24.50 ,$10.50 ,$22.75 ,$25.20 ,$31.85 ,$26.25 
Carle BroMenn Medical Center,8380566,"CRMP-5-IGG WESTERN BLOT, S    REF",,84182,301,$131.00 ,$131.00 ,$39.30 ,$119.21 ,$91.70 ,$39.30 ,$85.15 ,$94.32 ,$119.21 ,$98.25 
Carle BroMenn Medical Center,8380567,"PARANEOPLASTIC AUTOAB WBLOT,S   REF",,84182,301,$34.00 ,$34.00 ,$10.20 ,$30.94 ,$23.80 ,$10.20 ,$22.10 ,$24.48 ,$30.94 ,$25.50 
Carle BroMenn Medical Center,8380568,ACH RECEPTOR (MUSCLE) MOD AB    REF,,83519,301,$26.00 ,$26.00 ,$7.80 ,$23.66 ,$18.20 ,$7.80 ,$16.90 ,$18.72 ,$23.66 ,$19.50 
Carle BroMenn Medical Center,8380569,"AMPHIPHYSIN WESTERN BLOT, S    REF",,84182,301,$164.00 ,$164.00 ,$49.20 ,$149.24 ,$114.80 ,$49.20 ,$106.60 ,$118.08 ,$149.24 ,$123.00 
Carle BroMenn Medical Center,8380584,"SIROLIMUS, B    REF",,80195,301,$14.00 ,$14.00 ,$4.20 ,$12.74 ,$9.80 ,$4.20 ,$9.10 ,$10.08 ,$12.74 ,$10.50 
Carle BroMenn Medical Center,8380585,"CARBAMAZEPINE, FREE, S    REF",,80157,301,$13.00 ,$13.00 ,$3.90 ,$11.83 ,$9.10 ,$3.90 ,$8.45 ,$9.36 ,$11.83 ,$9.75 
Carle BroMenn Medical Center,8380586,"CARBAMAZEPINE, TOTAL, S    REF",,80156,301,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8380587,"VALPROIC ACID, FREE, TOTAL, S   REF",,80164,301,$13.00 ,$13.00 ,$3.90 ,$11.83 ,$9.10 ,$3.90 ,$8.45 ,$9.36 ,$11.83 ,$9.75 
Carle BroMenn Medical Center,8380591,TOTAL PSA    REF,,84153,301,$113.75 ,$113.75 ,$34.13 ,$103.51 ,$79.63 ,$34.13 ,$73.94 ,$81.90 ,$103.51 ,$85.31 
Carle BroMenn Medical Center,8380592,FREE PSA    REF,,84154,301,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8380594,"SODIUM, U    REF",,84300,301,$4.00 ,$4.00 ,$1.20 ,$3.64 ,$2.80 ,$1.20 ,$2.60 ,$2.88 ,$3.64 ,$3.00 
Carle BroMenn Medical Center,8380595,"POTASSIUM, U    REF",,84133,301,$3.00 ,$3.00 ,$0.90 ,$2.73 ,$2.10 ,$0.90 ,$1.95 ,$2.16 ,$2.73 ,$2.25 
Carle BroMenn Medical Center,8380596,"CALCIUM, U    REF",,82340,301,$5.00 ,$5.00 ,$1.50 ,$4.55 ,$3.50 ,$1.50 ,$3.25 ,$3.60 ,$4.55 ,$3.75 
Carle BroMenn Medical Center,8380597,"MAGNESIUM, U    REF",,83735,301,$5.00 ,$5.00 ,$1.50 ,$4.55 ,$3.50 ,$1.50 ,$3.25 ,$3.60 ,$4.55 ,$3.75 
Carle BroMenn Medical Center,8380598,"CHLORIDE, U    REF",,82436,301,$81.25 ,$81.25 ,$24.38 ,$73.94 ,$56.88 ,$24.38 ,$52.81 ,$58.50 ,$73.94 ,$60.94 
Carle BroMenn Medical Center,8380599,"PHOSPHORUS, U    REF",,84105,301,$4.00 ,$4.00 ,$1.20 ,$3.64 ,$2.80 ,$1.20 ,$2.60 ,$2.88 ,$3.64 ,$3.00 
Carle BroMenn Medical Center,8380601,BOTULINUM TOXIN TYPE A AB  REF,,84182,301,$189.00 ,$189.00 ,$56.70 ,$171.99 ,$132.30 ,$56.70 ,$122.85 ,$136.08 ,$171.99 ,$141.75 
Carle BroMenn Medical Center,8380603,"ITRACONAZOLE, S   REF",,80189,301,$18.00 ,$18.00 ,$5.40 ,$16.38 ,$12.60 ,$5.40 ,$11.70 ,$12.96 ,$16.38 ,$13.50 
Carle BroMenn Medical Center,8380616,"IMMUNOGLOB; IGA, D, G, OR M, EACH   REF",,82784,301,$68.25 ,$68.25 ,$20.48 ,$62.11 ,$47.78 ,$20.48 ,$44.36 ,$49.14 ,$62.11 ,$51.19 
Carle BroMenn Medical Center,8380619,"PROTEIN, TOTAL, OTHER SOURCE REF",,84157,301,$32.50 ,$32.50 ,$9.75 ,$29.58 ,$22.75 ,$9.75 ,$21.13 ,$23.40 ,$29.58 ,$24.38 
Carle BroMenn Medical Center,8380620,FECAL OCCULT BLOOD,,82274,301,$94.25 ,$94.25 ,$28.28 ,$85.77 ,$65.98 ,$28.28 ,$61.26 ,$67.86 ,$85.77 ,$70.69 
Carle BroMenn Medical Center,8380628,"PSA, DIAGNOSTIC (VISTA)",,84153,301,$113.75 ,$113.75 ,$34.13 ,$103.51 ,$79.63 ,$34.13 ,$73.94 ,$81.90 ,$103.51 ,$85.31 
Carle BroMenn Medical Center,8380629,"PSA, SCREENING (VISTA)",,G0103,301,$186.00 ,$186.00 ,$55.80 ,$169.26 ,$130.20 ,$55.80 ,$120.90 ,$133.92 ,$169.26 ,$139.50 
Carle BroMenn Medical Center,8380637,PROCALCITONIN   REF,,84145,301,$95.00 ,$95.00 ,$28.50 ,$86.45 ,$66.50 ,$28.50 ,$61.75 ,$68.40 ,$86.45 ,$71.25 
Carle BroMenn Medical Center,8380700,"SULFATE, U    REF",,84392,301,$4.00 ,$4.00 ,$1.20 ,$3.64 ,$2.80 ,$1.20 ,$2.60 ,$2.88 ,$3.64 ,$3.00 
Carle BroMenn Medical Center,8380701,"CITRATE EXCRETION, U    REF",,82507,301,$19.00 ,$19.00 ,$5.70 ,$17.29 ,$13.30 ,$5.70 ,$12.35 ,$13.68 ,$17.29 ,$14.25 
Carle BroMenn Medical Center,8380702,"OXALATE, U    REF",,83945,301,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8380703,"PH, U   REF",,83986,301,$3.00 ,$3.00 ,$0.90 ,$2.73 ,$2.10 ,$0.90 ,$1.95 ,$2.16 ,$2.73 ,$2.25 
Carle BroMenn Medical Center,8380704,"URIC ACID, U    REF",,84560,301,$4.00 ,$4.00 ,$1.20 ,$3.64 ,$2.80 ,$1.20 ,$2.60 ,$2.88 ,$3.64 ,$3.00 
Carle BroMenn Medical Center,8380705,"CREATININE, U    REF",,82570,301,$4.00 ,$4.00 ,$1.20 ,$3.64 ,$2.80 ,$1.20 ,$2.60 ,$2.88 ,$3.64 ,$3.00 
Carle BroMenn Medical Center,8380706,"OSMOLALITY,U    REF",,83935,301,$5.00 ,$5.00 ,$1.50 ,$4.55 ,$3.50 ,$1.50 ,$3.25 ,$3.60 ,$4.55 ,$3.75 
Carle BroMenn Medical Center,8380708,"ACYLCARNITINES, QUANT, P    REF",,82017,301,$24.00 ,$24.00 ,$7.20 ,$21.84 ,$16.80 ,$7.20 ,$15.60 ,$17.28 ,$21.84 ,$18.00 
Carle BroMenn Medical Center,8380710,"TIAGABINE, S    REF",,80199,301,$56.00 ,$56.00 ,$16.80 ,$50.96 ,$39.20 ,$16.80 ,$36.40 ,$40.32 ,$50.96 ,$42.00 
Carle BroMenn Medical Center,8380711,"14-3-3 PROTEIN, CSF    REF",,83520,301,$88.00 ,$88.00 ,$26.40 ,$80.08 ,$61.60 ,$26.40 ,$57.20 ,$63.36 ,$80.08 ,$66.00 
Carle BroMenn Medical Center,8380712,"MERCURY OCCUP MONITOR, U    REF",,83825,301,$19.00 ,$19.00 ,$5.70 ,$17.29 ,$13.30 ,$5.70 ,$12.35 ,$13.68 ,$17.29 ,$14.25 
Carle BroMenn Medical Center,8380713,"PROTEINASE 3 AB (PR3), S    REF",,83516,301,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8380714,"BONE ALKALINE PHOSPHATASE, S   REF",,84080,301,$97.50 ,$97.50 ,$29.25 ,$88.73 ,$68.25 ,$29.25 ,$63.38 ,$70.20 ,$88.73 ,$73.13 
Carle BroMenn Medical Center,8380716,"METANEPHRINES, FRACT, 24H, U    REF",,83835,301,$16.00 ,$16.00 ,$4.80 ,$14.56 ,$11.20 ,$4.80 ,$10.40 ,$11.52 ,$14.56 ,$12.00 
Carle BroMenn Medical Center,8380717,"LEVETIRACETAM, S    REF",,80177,301,$16.00 ,$16.00 ,$4.80 ,$14.56 ,$11.20 ,$4.80 ,$10.40 ,$11.52 ,$14.56 ,$12.00 
Carle BroMenn Medical Center,8380720,"BETA-CROSSLAPS (B-CTX), S    REF",,82523,301,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8380728,"IGFBP-3, S    REF",,83520,301,$13.00 ,$13.00 ,$3.90 ,$11.83 ,$9.10 ,$3.90 ,$8.45 ,$9.36 ,$11.83 ,$9.75 
Carle BroMenn Medical Center,8380734,"MYASTHENIA GRAVIS EVAL, PED.    REF",,83519,301,$28.00 ,$28.00 ,$8.40 ,$25.48 ,$19.60 ,$8.40 ,$18.20 ,$20.16 ,$25.48 ,$21.00 
Carle BroMenn Medical Center,8380735,"CRYOGLOBULIN, S    REF",,82595,301,$8.00 ,$8.00 ,$2.40 ,$7.28 ,$5.60 ,$2.40 ,$5.20 ,$5.76 ,$7.28 ,$6.00 
Carle BroMenn Medical Center,8380736,"CRYOFIBRINOGEN, P    REF",,82585,301,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8380737,"TESTOSTERONE, TOTAL, S    REF",,84403,301,$7.00 ,$7.00 ,$2.10 ,$6.37 ,$4.90 ,$2.10 ,$4.55 ,$5.04 ,$6.37 ,$5.25 
Carle BroMenn Medical Center,8380738,"TESTOSTERONE, FREE, BIOAVAIL, S  REF",,84402,301,$7.00 ,$7.00 ,$2.10 ,$6.37 ,$4.90 ,$2.10 ,$4.55 ,$5.04 ,$6.37 ,$5.25 
Carle BroMenn Medical Center,8380745,"CORTISOL, SALIVA    REF",,82533,301,$14.00 ,$14.00 ,$4.20 ,$12.74 ,$9.80 ,$4.20 ,$9.10 ,$10.08 ,$12.74 ,$10.50 
Carle BroMenn Medical Center,8380746,MAG AB WESTERN BLOT REF,,84181,301,$90.00 ,$90.00 ,$27.00 ,$81.90 ,$63.00 ,$27.00 ,$58.50 ,$64.80 ,$81.90 ,$67.50 
Carle BroMenn Medical Center,8380747,"ESTRADIOL, S    REF",,82670,301,$11.00 ,$11.00 ,$3.30 ,$10.01 ,$7.70 ,$3.30 ,$7.15 ,$7.92 ,$10.01 ,$8.25 
Carle BroMenn Medical Center,8380781,CREATINE    REF,,82540,301,$31.00 ,$31.00 ,$9.30 ,$28.21 ,$21.70 ,$9.30 ,$20.15 ,$22.32 ,$28.21 ,$23.25 
Carle BroMenn Medical Center,8380782,CREATININE    REF,,82570,301,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8380783,GUANIDINOACETATE    REF,,83789,301,$117.00 ,$117.00 ,$35.10 ,$106.47 ,$81.90 ,$35.10 ,$76.05 ,$84.24 ,$106.47 ,$87.75 
Carle BroMenn Medical Center,8380788,"INHIBIN B, S           REF",,83520,301,$97.50 ,$97.50 ,$29.25 ,$88.73 ,$68.25 ,$29.25 ,$63.38 ,$70.20 ,$88.73 ,$73.13 
Carle BroMenn Medical Center,8380808,"GLIADIN (DEAMIDATED) AB EVAL, S  REF",,83516,301,$8.00 ,$8.00 ,$2.40 ,$7.28 ,$5.60 ,$2.40 ,$5.20 ,$5.76 ,$7.28 ,$6.00 
Carle BroMenn Medical Center,8380819,ALKALINE PHOSPHATASE S REF,,84075,301,$68.25 ,$68.25 ,$20.48 ,$62.11 ,$47.78 ,$20.48 ,$44.36 ,$49.14 ,$62.11 ,$51.19 
Carle BroMenn Medical Center,8380820,ALKALINE PHOS ISOENZYMES S REF,,84080,301,$19.00 ,$19.00 ,$5.70 ,$17.29 ,$13.30 ,$5.70 ,$12.35 ,$13.68 ,$17.29 ,$14.25 
Carle BroMenn Medical Center,8380849,DISACCHARIDASE ANALYSIS    REF,,82657,301,$28.00 ,$28.00 ,$8.40 ,$25.48 ,$19.60 ,$8.40 ,$18.20 ,$20.16 ,$25.48 ,$21.00 
Carle BroMenn Medical Center,8380850,MUSK ANTIBODY    REF,,83516,301,$341.00 ,$341.00 ,$102.30 ,$310.31 ,$238.70 ,$102.30 ,$221.65 ,$245.52 ,$310.31 ,$255.75 
Carle BroMenn Medical Center,8380852,PIVKA-II    REF,,83520,301,$109.00 ,$109.00 ,$32.70 ,$99.19 ,$76.30 ,$32.70 ,$70.85 ,$78.48 ,$99.19 ,$81.75 
Carle BroMenn Medical Center,8380853,MYOSITIS ANTIBODY PANEL    REF,,83516,301,$11.00 ,$11.00 ,$3.30 ,$10.01 ,$7.70 ,$3.30 ,$7.15 ,$7.92 ,$10.01 ,$8.25 
Carle BroMenn Medical Center,8380859,"BILE ACIDS, FRACTIONATED    REF",,83789,301,$328.25 ,$328.25 ,$98.48 ,$298.71 ,$229.78 ,$98.48 ,$213.36 ,$236.34 ,$298.71 ,$246.19 
Carle BroMenn Medical Center,8380864,"BERYLLIUM, BLOOD    REF",,83018,301,$56.00 ,$56.00 ,$16.80 ,$50.96 ,$39.20 ,$16.80 ,$36.40 ,$40.32 ,$50.96 ,$42.00 
Carle BroMenn Medical Center,8380865,"BENZENE AS PHENOL, OCC EXP, U  REF",,84600,301,$43.00 ,$43.00 ,$12.90 ,$39.13 ,$30.10 ,$12.90 ,$27.95 ,$30.96 ,$39.13 ,$32.25 
Carle BroMenn Medical Center,8380912,"ACTH, PLASMA                  REF",,82024,301,$240.50 ,$240.50 ,$72.15 ,$218.86 ,$168.35 ,$72.15 ,$156.33 ,$173.16 ,$218.86 ,$180.38 
Carle BroMenn Medical Center,8380914,ACETYCHOLINE RECEP BINDING AB  REF,,83519,301,$115.05 ,$115.05 ,$34.52 ,$104.70 ,$80.54 ,$34.52 ,$74.78 ,$82.84 ,$104.70 ,$86.29 
Carle BroMenn Medical Center,8380915,TOPIRAMATE            REF,,80201,301,$94.25 ,$94.25 ,$28.28 ,$85.77 ,$65.98 ,$28.28 ,$61.26 ,$67.86 ,$85.77 ,$70.69 
Carle BroMenn Medical Center,8380916,"ZINC PROTOPORPHYRIN, BLOOD   REF",,84202,301,$17.00 ,$17.00 ,$5.10 ,$15.47 ,$11.90 ,$5.10 ,$11.05 ,$12.24 ,$15.47 ,$12.75 
Carle BroMenn Medical Center,8380917,MERCURY BLOOD          REF,,83825,301,$120.25 ,$120.25 ,$36.08 ,$109.43 ,$84.18 ,$36.08 ,$78.16 ,$86.58 ,$109.43 ,$90.19 
Carle BroMenn Medical Center,8380918,OXCARBAZINE METAB (MHC)      REF,,80183,301,$113.75 ,$113.75 ,$34.13 ,$103.51 ,$79.63 ,$34.13 ,$73.94 ,$81.90 ,$103.51 ,$85.31 
Carle BroMenn Medical Center,8380919,"CADMIUM, BLOOD          REF",,82300,301,$172.25 ,$172.25 ,$51.68 ,$156.75 ,$120.58 ,$51.68 ,$111.96 ,$124.02 ,$156.75 ,$129.19 
Carle BroMenn Medical Center,8380920,"ARSENIC, BLOOD      REF",,82175,301,$11.00 ,$11.00 ,$3.30 ,$10.01 ,$7.70 ,$3.30 ,$7.15 ,$7.92 ,$10.01 ,$8.25 
Carle BroMenn Medical Center,8380921,T-UPTAKE                  REF,,84479,301,$48.10 ,$48.10 ,$14.43 ,$43.77 ,$33.67 ,$14.43 ,$31.27 ,$34.63 ,$43.77 ,$36.08 
Carle BroMenn Medical Center,8380922,VITAMIN A          REF,,84590,301,$22.00 ,$22.00 ,$6.60 ,$20.02 ,$15.40 ,$6.60 ,$14.30 ,$15.84 ,$20.02 ,$16.50 
Carle BroMenn Medical Center,8380923,VITAMIN E          REF,,84446,301,$22.00 ,$22.00 ,$6.60 ,$20.02 ,$15.40 ,$6.60 ,$14.30 ,$15.84 ,$20.02 ,$16.50 
Carle BroMenn Medical Center,8380926,GASTRIN                    REF,,82941,301,$107.25 ,$107.25 ,$32.18 ,$97.60 ,$75.08 ,$32.18 ,$69.71 ,$77.22 ,$97.60 ,$80.44 
Carle BroMenn Medical Center,8380927,"MYOGLOBIN, URINE           REF",,83874,301,$87.75 ,$87.75 ,$26.33 ,$79.85 ,$61.43 ,$26.33 ,$57.04 ,$63.18 ,$79.85 ,$65.81 
Carle BroMenn Medical Center,8380928,THYROTROPIN RECEP AB     REF,,83520,301,$17.00 ,$17.00 ,$5.10 ,$15.47 ,$11.90 ,$5.10 ,$11.05 ,$12.24 ,$15.47 ,$12.75 
Carle BroMenn Medical Center,8380929,"ZINC, SERUM     REF",,84630,301,$84.50 ,$84.50 ,$25.35 ,$76.90 ,$59.15 ,$25.35 ,$54.93 ,$60.84 ,$76.90 ,$63.38 
Carle BroMenn Medical Center,8380930,"TSI, SERUM     REF",,84445,301,$51.00 ,$51.00 ,$15.30 ,$46.41 ,$35.70 ,$15.30 ,$33.15 ,$36.72 ,$46.41 ,$38.25 
Carle BroMenn Medical Center,8380931,"CHROMIUM, SERUM     REF",,82495,301,$21.00 ,$21.00 ,$6.30 ,$19.11 ,$14.70 ,$6.30 ,$13.65 ,$15.12 ,$19.11 ,$15.75 
Carle BroMenn Medical Center,8380932,"CALCITONIN, SERUM    REF",,82308,301,$14.00 ,$14.00 ,$4.20 ,$12.74 ,$9.80 ,$4.20 ,$9.10 ,$10.08 ,$12.74 ,$10.50 
Carle BroMenn Medical Center,8380933,"COBALT, SERUM     REF",,83789,301,$32.00 ,$32.00 ,$9.60 ,$29.12 ,$22.40 ,$9.60 ,$20.80 ,$23.04 ,$29.12 ,$24.00 
Carle BroMenn Medical Center,8380934,"COPPER, SERUM    REF",,82525,301,$12.00 ,$12.00 ,$3.60 ,$10.92 ,$8.40 ,$3.60 ,$7.80 ,$8.64 ,$10.92 ,$9.00 
Carle BroMenn Medical Center,8380939,"GABAPENTIN, S       REF",,80171,301,$107.25 ,$107.25 ,$32.18 ,$97.60 ,$75.08 ,$32.18 ,$69.71 ,$77.22 ,$97.60 ,$80.44 
Carle BroMenn Medical Center,8380940,"SEROTONIN, BLOOD           REF",,84260,301,$13.00 ,$13.00 ,$3.90 ,$11.83 ,$9.10 ,$3.90 ,$8.45 ,$9.36 ,$11.83 ,$9.75 
Carle BroMenn Medical Center,8380941,"ZONISAMIDE, S     REF",,80203,301,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8380944,"ANDROSTENEDIONE, S     REF",,82157,301,$14.00 ,$14.00 ,$4.20 ,$12.74 ,$9.80 ,$4.20 ,$9.10 ,$10.08 ,$12.74 ,$10.50 
Carle BroMenn Medical Center,8380945,"PANCREATIC AMYLASE, SERUM    REF",,82150,301,$13.00 ,$13.00 ,$3.90 ,$11.83 ,$9.10 ,$3.90 ,$8.45 ,$9.36 ,$11.83 ,$9.75 
Carle BroMenn Medical Center,8380948,"PARIETAL CELL AB, IGG, S   REF",,83516,301,$12.00 ,$12.00 ,$3.60 ,$10.92 ,$8.40 ,$3.60 ,$7.80 ,$8.64 ,$10.92 ,$9.00 
Carle BroMenn Medical Center,8380949,"ETHOSUXIMIDE, S    REF",,80168,301,$16.00 ,$16.00 ,$4.80 ,$14.56 ,$11.20 ,$4.80 ,$10.40 ,$11.52 ,$14.56 ,$12.00 
Carle BroMenn Medical Center,8380950,"MYOGLOBIN, SERUM    REF",,83874,301,$11.00 ,$11.00 ,$3.30 ,$10.01 ,$7.70 ,$3.30 ,$7.15 ,$7.92 ,$10.01 ,$8.25 
Carle BroMenn Medical Center,8380951,"SEX HORMONE BINDING GLOBULIN, S  REF",,84270,301,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8380952,"VASOACT INTEST POLYPEPTIDE, P   REF",,84586,301,$18.00 ,$18.00 ,$5.40 ,$16.38 ,$12.60 ,$5.40 ,$11.70 ,$12.96 ,$16.38 ,$13.50 
Carle BroMenn Medical Center,8380954,"PANCREATIC POLYPEPTIDE, PL   REF",,83519,301,$18.00 ,$18.00 ,$5.40 ,$16.38 ,$12.60 ,$5.40 ,$11.70 ,$12.96 ,$16.38 ,$13.50 
Carle BroMenn Medical Center,8380956,"TRYPTASE, S        REF",,83520,301,$113.75 ,$113.75 ,$34.13 ,$103.51 ,$79.63 ,$34.13 ,$73.94 ,$81.90 ,$103.51 ,$85.31 
Carle BroMenn Medical Center,8380957,CAROTENE    REF,,82380,301,$172.25 ,$172.25 ,$51.68 ,$156.75 ,$120.58 ,$51.68 ,$111.96 ,$124.02 ,$156.75 ,$129.19 
Carle BroMenn Medical Center,8380958,"G-6-PD QNT, ERYTHROCYTES   REF",,82955,301,$68.25 ,$68.25 ,$20.48 ,$62.11 ,$47.78 ,$20.48 ,$44.36 ,$49.14 ,$62.11 ,$51.19 
Carle BroMenn Medical Center,8380959,"MOTILIN, S        REF",,83519,301,$142.00 ,$142.00 ,$42.60 ,$129.22 ,$99.40 ,$42.60 ,$92.30 ,$102.24 ,$129.22 ,$106.50 
Carle BroMenn Medical Center,8380962,SUBSTANCE P             REF,,83519,301,$95.00 ,$95.00 ,$28.50 ,$86.45 ,$66.50 ,$28.50 ,$61.75 ,$68.40 ,$86.45 ,$71.25 
Carle BroMenn Medical Center,8380963,"FELBAMATE, S         REF",,80167,301,$19.00 ,$19.00 ,$5.70 ,$17.29 ,$13.30 ,$5.70 ,$12.35 ,$13.68 ,$17.29 ,$14.25 
Carle BroMenn Medical Center,8380966,"DHEA, SERUM    REF",,82626,301,$17.00 ,$17.00 ,$5.10 ,$15.47 ,$11.90 ,$5.10 ,$11.05 ,$12.24 ,$15.47 ,$12.75 
Carle BroMenn Medical Center,8380968,"LIPOPROTEIN (A), S          REF",,83695,301,$81.25 ,$81.25 ,$24.38 ,$73.94 ,$56.88 ,$24.38 ,$52.81 ,$58.50 ,$73.94 ,$60.94 
Carle BroMenn Medical Center,8380969,NIACIN VITAMIN B3    REF,,84591,301,$54.00 ,$54.00 ,$16.20 ,$49.14 ,$37.80 ,$16.20 ,$35.10 ,$38.88 ,$49.14 ,$40.50 
Carle BroMenn Medical Center,8380970,"ANTIMULLERIAN HORMONE (AMH), S  REF",,83520,301,$165.75 ,$165.75 ,$49.73 ,$150.83 ,$116.03 ,$49.73 ,$107.74 ,$119.34 ,$150.83 ,$124.31 
Carle BroMenn Medical Center,8380971,"FRUCTOSAMINE, S          REF",,82985,301,$113.75 ,$113.75 ,$34.13 ,$103.51 ,$79.63 ,$34.13 ,$73.94 ,$81.90 ,$103.51 ,$85.31 
Carle BroMenn Medical Center,8380972,NATRIURETIC PEPTIDE REF,,83880,301,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8380980,"ANGIOTENSIN CONV ENZ (ACE), CSF REF",,82164,301,$43.00 ,$43.00 ,$12.90 ,$39.13 ,$30.10 ,$12.90 ,$27.95 ,$30.96 ,$39.13 ,$32.25 
Carle BroMenn Medical Center,8380981,"THYROGLOBULIN, TUMOR MARKER, S  REF",,84432,301,$9.00 ,$9.00 ,$2.70 ,$8.19 ,$6.30 ,$2.70 ,$5.85 ,$6.48 ,$8.19 ,$6.75 
Carle BroMenn Medical Center,8380993,AMIKACIN LEVEL,,80150,301,$266.50 ,$266.50 ,$79.95 ,$242.52 ,$186.55 ,$79.95 ,$173.23 ,$191.88 ,$242.52 ,$199.88 
Carle BroMenn Medical Center,8380999,THROMBOPOIETIN (TPO)  REF,,83520,301,$57.00 ,$57.00 ,$17.10 ,$51.87 ,$39.90 ,$17.10 ,$37.05 ,$41.04 ,$51.87 ,$42.75 
Carle BroMenn Medical Center,8381006,:MYOGLOBIN,,83874,301,$97.50 ,$97.50 ,$29.25 ,$88.73 ,$68.25 ,$29.25 ,$63.38 ,$70.20 ,$88.73 ,$73.13 
Carle BroMenn Medical Center,8381034,"PSA, ULTRASENSITIVE  REF",,84153,301,$78.00 ,$78.00 ,$23.40 ,$70.98 ,$54.60 ,$23.40 ,$50.70 ,$56.16 ,$70.98 ,$58.50 
Carle BroMenn Medical Center,8381043,"OXALATE, PLASMA  REF",,83945,301,$89.00 ,$89.00 ,$26.70 ,$80.99 ,$62.30 ,$26.70 ,$57.85 ,$64.08 ,$80.99 ,$66.75 
Carle BroMenn Medical Center,8381045,"APOLIPOPROTINE B, S  REF",,82172,301,$94.25 ,$94.25 ,$28.28 ,$85.77 ,$65.98 ,$28.28 ,$61.26 ,$67.86 ,$85.77 ,$70.69 
Carle BroMenn Medical Center,8381046,"HDL CHOLESTEROL, CDC, S  REF",,83718,301,$11.00 ,$11.00 ,$3.30 ,$10.01 ,$7.70 ,$3.30 ,$7.15 ,$7.92 ,$10.01 ,$8.25 
Carle BroMenn Medical Center,8381067,METHOTREXATE REF,,83520,301,$24.00 ,$24.00 ,$7.20 ,$21.84 ,$16.80 ,$7.20 ,$15.60 ,$17.28 ,$21.84 ,$18.00 
Carle BroMenn Medical Center,8381087,"TC (TRIIODOTHYRONINE), FREE",,84481,301,$161.00 ,$161.00 ,$48.30 ,$146.51 ,$112.70 ,$48.30 ,$104.65 ,$115.92 ,$146.51 ,$120.75 
Carle BroMenn Medical Center,8381089,SODIUM REF,,84295,301,$2.00 ,$2.00 ,$0.60 ,$1.82 ,$1.40 ,$0.60 ,$1.30 ,$1.44 ,$1.82 ,$1.50 
Carle BroMenn Medical Center,8381090,CHLORIDE REF,,82435,301,$2.00 ,$2.00 ,$0.60 ,$1.82 ,$1.40 ,$0.60 ,$1.30 ,$1.44 ,$1.82 ,$1.50 
Carle BroMenn Medical Center,8381093,ACH RECEPTOR (MUSCLE) MOD AB-RFLX  REF,,83519,301,$164.00 ,$164.00 ,$49.20 ,$149.24 ,$114.80 ,$49.20 ,$106.60 ,$118.08 ,$149.24 ,$123.00 
Carle BroMenn Medical Center,8381131,"MAGNESIUM, RBC  REF",,83735,301,$91.00 ,$91.00 ,$27.30 ,$82.81 ,$63.70 ,$27.30 ,$59.15 ,$65.52 ,$82.81 ,$68.25 
Carle BroMenn Medical Center,8381134,"CREATININE, S  REF",,82565,301,$85.80 ,$85.80 ,$25.74 ,$78.08 ,$60.06 ,$25.74 ,$55.77 ,$61.78 ,$78.08 ,$64.35 
Carle BroMenn Medical Center,8381141,"C1 ESTERASE INHIBITOR AG, S  REF",,83883,301,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8381142,"C1 ESTERASE INHIB, FUNCTIONAL ASSAY, S  REF",,83520,301,$22.00 ,$22.00 ,$6.60 ,$20.02 ,$15.40 ,$6.60 ,$14.30 ,$15.84 ,$20.02 ,$16.50 
Carle BroMenn Medical Center,8381143,"INTERLEUKIN-6 (IL-6), S  REF",,83520,301,$113.00 ,$113.00 ,$33.90 ,$102.83 ,$79.10 ,$33.90 ,$73.45 ,$81.36 ,$102.83 ,$84.75 
Carle BroMenn Medical Center,8381144,"HISTONE AUTOANTIBODIES, S  REF",,83516,301,$71.50 ,$71.50 ,$21.45 ,$65.07 ,$50.05 ,$21.45 ,$46.48 ,$51.48 ,$65.07 ,$53.63 
Carle BroMenn Medical Center,8381248,"ALCOHOL, SERUM",,80307,301,$353.00 ,$353.00 ,$105.90 ,$321.23 ,$247.10 ,$105.90 ,$229.45 ,$254.16 ,$321.23 ,$264.75 
Carle BroMenn Medical Center,8381284,"ANTIDEPRESSANTS, SEROTONERGIC CLASS; 1 OR 2   REF",,80332,301,$11.70 ,$11.70 ,$3.51 ,$10.65 ,$8.19 ,$3.51 ,$7.61 ,$8.42 ,$10.65 ,$8.78 
Carle BroMenn Medical Center,8381288,"ANTIDEPRESSANTS, TRICYCLIC, OTHER CYCLICALS; 3-5   REF",,80336,301,$139.75 ,$139.75 ,$41.93 ,$127.17 ,$97.83 ,$41.93 ,$90.84 ,$100.62 ,$127.17 ,$104.81 
Carle BroMenn Medical Center,8381289,"ANTIDEPRESSANTS, TRICYCLIC, OTHER CYCLICALS; 6 OR MORE   REF",,80337,301,$11.70 ,$11.70 ,$3.51 ,$10.65 ,$8.19 ,$3.51 ,$7.61 ,$8.42 ,$10.65 ,$8.78 
Carle BroMenn Medical Center,8381305,"ANTIDEPRESSANTS, NOS   REF",,80338,301,$11.70 ,$11.70 ,$3.51 ,$10.65 ,$8.19 ,$3.51 ,$7.61 ,$8.42 ,$10.65 ,$8.78 
Carle BroMenn Medical Center,8381314,BENZODIAZEPINES; 1-12   REF,,80346,301,$133.25 ,$133.25 ,$39.98 ,$121.26 ,$93.28 ,$39.98 ,$86.61 ,$95.94 ,$121.26 ,$99.94 
Carle BroMenn Medical Center,8381320,BUPRENORPHINE   REF,,80348,301,$170.00 ,$170.00 ,$51.00 ,$154.70 ,$119.00 ,$51.00 ,$110.50 ,$122.40 ,$154.70 ,$127.50 
Carle BroMenn Medical Center,8381335,FENTANYL   REF,,80354,301,$170.00 ,$170.00 ,$51.00 ,$154.70 ,$119.00 ,$51.00 ,$110.50 ,$122.40 ,$154.70 ,$127.50 
Carle BroMenn Medical Center,8381339,METHADONE   REF,,80358,301,$11.70 ,$11.70 ,$3.51 ,$10.65 ,$8.19 ,$3.51 ,$7.61 ,$8.42 ,$10.65 ,$8.78 
Carle BroMenn Medical Center,8381343,METHYLPHENIDATE   REF,,80360,301,$110.50 ,$110.50 ,$33.15 ,$100.56 ,$77.35 ,$33.15 ,$71.83 ,$79.56 ,$100.56 ,$82.88 
Carle BroMenn Medical Center,8381346,OPIOIDS AND OPIATE ANALOGS; 3 OR 4   REF,,80363,301,$11.70 ,$11.70 ,$3.51 ,$10.65 ,$8.19 ,$3.51 ,$7.61 ,$8.42 ,$10.65 ,$8.78 
Carle BroMenn Medical Center,8381348,OXYCODONE   REF,,80365,301,$11.70 ,$11.70 ,$3.51 ,$10.65 ,$8.19 ,$3.51 ,$7.61 ,$8.42 ,$10.65 ,$8.78 
Carle BroMenn Medical Center,8381352,SEDATIVE HYPNOTICS (NON-BENZODIAZEPINES)   REF,,80368,301,$11.70 ,$11.70 ,$3.51 ,$10.65 ,$8.19 ,$3.51 ,$7.61 ,$8.42 ,$10.65 ,$8.78 
Carle BroMenn Medical Center,8381354,SKELETAL MUSCLE RELAXANTS; 3 OR MORE   REF,,80370,301,$11.70 ,$11.70 ,$3.51 ,$10.65 ,$8.19 ,$3.51 ,$7.61 ,$8.42 ,$10.65 ,$8.78 
Carle BroMenn Medical Center,8381357,TRAMADOL   REF,,80373,301,$170.00 ,$170.00 ,$51.00 ,$154.70 ,$119.00 ,$51.00 ,$110.50 ,$122.40 ,$154.70 ,$127.50 
Carle BroMenn Medical Center,8381361,"DRUGS, SUBSTANCES, DEFIN, QL OR QNT, NOS; 7 OR MORE   REF",,80377,301,$55.90 ,$55.90 ,$16.77 ,$50.87 ,$39.13 ,$16.77 ,$36.34 ,$40.25 ,$50.87 ,$41.93 
Carle BroMenn Medical Center,8381363,"DRUG SCREEN, SNGL CLASS LIST A; INST IA OR EIA SYSTEM, PER DOS",,80307,301,$98.00 ,$98.00 ,$29.40 ,$89.18 ,$68.60 ,$29.40 ,$63.70 ,$70.56 ,$89.18 ,$73.50 
Carle BroMenn Medical Center,8381365,SALICYLATE,,80307,301,$302.00 ,$302.00 ,$90.60 ,$274.82 ,$211.40 ,$90.60 ,$196.30 ,$217.44 ,$274.82 ,$226.50 
Carle BroMenn Medical Center,8381366,ACETAMINOPHEN,,80307,301,$416.00 ,$416.00 ,$124.80 ,$378.56 ,$291.20 ,$124.80 ,$270.40 ,$299.52 ,$378.56 ,$312.00 
Carle BroMenn Medical Center,8381371,CPT-CORDSTAT 13 DRUG PANEL   REF,,80307,301,$8.00 ,$8.00 ,$2.40 ,$7.28 ,$5.60 ,$2.40 ,$5.20 ,$5.76 ,$7.28 ,$6.00 
Carle BroMenn Medical Center,8381377,CPT-CORDSTAT 13 DRUG PANEL   REF,,80307,301,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8381378,CPT-CORDSTAT 13 DRUG+ETOH PANEL   REF,,80307,301,$9.00 ,$9.00 ,$2.70 ,$8.19 ,$6.30 ,$2.70 ,$5.85 ,$6.48 ,$8.19 ,$6.75 
Carle BroMenn Medical Center,8381379,CPT-CORDSTAT 13 DRUG+ETOH PANEL   REF,,80307,301,$131.00 ,$131.00 ,$39.30 ,$119.21 ,$91.70 ,$39.30 ,$85.15 ,$94.32 ,$119.21 ,$98.25 
Carle BroMenn Medical Center,8381383,CORDSTAT ETOH   REF,,80307,301,$26.00 ,$26.00 ,$7.80 ,$23.66 ,$18.20 ,$7.80 ,$16.90 ,$18.72 ,$23.66 ,$19.50 
Carle BroMenn Medical Center,8381384,CPT-LACTOSTAT 13 DRUG PANEL   REF,,80307,301,$11.00 ,$11.00 ,$3.30 ,$10.01 ,$7.70 ,$3.30 ,$7.15 ,$7.92 ,$10.01 ,$8.25 
Carle BroMenn Medical Center,8381385,CPT-LACTOSTAT 13 DRUG PANEL   REF,,80307,301,$147.00 ,$147.00 ,$44.10 ,$133.77 ,$102.90 ,$44.10 ,$95.55 ,$105.84 ,$133.77 ,$110.25 
Carle BroMenn Medical Center,8381386,CPT-MECSTAT 13 DRUG PANEL   REF,,80307,301,$7.00 ,$7.00 ,$2.10 ,$6.37 ,$4.90 ,$2.10 ,$4.55 ,$5.04 ,$6.37 ,$5.25 
Carle BroMenn Medical Center,8381387,CPT-MECSTAT 13 DRUG PANEL   REF,,80307,301,$95.00 ,$95.00 ,$28.50 ,$86.45 ,$66.50 ,$28.50 ,$61.75 ,$68.40 ,$86.45 ,$71.25 
Carle BroMenn Medical Center,8381388,CPT-MECSTAT 13 DRUG+ETOH PANEL   REF,,80307,301,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8381389,CPT-MECSTAT 13 DRUG+ETOH PANEL   REF,,80307,301,$139.00 ,$139.00 ,$41.70 ,$126.49 ,$97.30 ,$41.70 ,$90.35 ,$100.08 ,$126.49 ,$104.25 
Carle BroMenn Medical Center,8381390,CPT-MECSTAT ETOH   REF,,80307,301,$44.00 ,$44.00 ,$13.20 ,$40.04 ,$30.80 ,$13.20 ,$28.60 ,$31.68 ,$40.04 ,$33.00 
Carle BroMenn Medical Center,8381391,"BENZODIAZEPINES CONFIRM, U REF   REF",,G0480,301,$49.00 ,$49.00 ,$14.70 ,$44.59 ,$34.30 ,$14.70 ,$31.85 ,$35.28 ,$44.59 ,$36.75 
Carle BroMenn Medical Center,8381393,"DOXEPIN AND NORDOXEPIN, S   REF",,G0480,301,$19.00 ,$19.00 ,$5.70 ,$17.29 ,$13.30 ,$5.70 ,$12.35 ,$13.68 ,$17.29 ,$14.25 
Carle BroMenn Medical Center,8381394,"AMITRIPTYLINE AND NORTRIPTYLINE, S   REF",,80335,301,$139.75 ,$139.75 ,$41.93 ,$127.17 ,$97.83 ,$41.93 ,$90.84 ,$100.62 ,$127.17 ,$104.81 
Carle BroMenn Medical Center,8381395,"NORTRIPTYLINE, S   REF",,G0480,301,$23.00 ,$23.00 ,$6.90 ,$20.93 ,$16.10 ,$6.90 ,$14.95 ,$16.56 ,$20.93 ,$17.25 
Carle BroMenn Medical Center,8381396,PENTOBARBITAL   REF,,G0480,301,$89.00 ,$89.00 ,$26.70 ,$80.99 ,$62.30 ,$26.70 ,$57.85 ,$64.08 ,$80.99 ,$66.75 
Carle BroMenn Medical Center,8381397,"DIHYDROTESTOSTERONE, S   REF",,G0480,301,$19.00 ,$19.00 ,$5.70 ,$17.29 ,$13.30 ,$5.70 ,$12.35 ,$13.68 ,$17.29 ,$14.25 
Carle BroMenn Medical Center,8381398,"NICOTINE AND METABOLITES, S   REF",,G0480,301,$19.00 ,$19.00 ,$5.70 ,$17.29 ,$13.30 ,$5.70 ,$12.35 ,$13.68 ,$17.29 ,$14.25 
Carle BroMenn Medical Center,8381399,"NICOTINE AND METABOLITES, U   REF",,G0480,301,$20.00 ,$20.00 ,$6.00 ,$18.20 ,$14.00 ,$6.00 ,$13.00 ,$14.40 ,$18.20 ,$15.00 
Carle BroMenn Medical Center,8381409,"VALPROIC ACID, FREE, S   REF",,80165,301,$13.00 ,$13.00 ,$3.90 ,$11.83 ,$9.10 ,$3.90 ,$8.45 ,$9.36 ,$11.83 ,$9.75 
Carle BroMenn Medical Center,8381410,"COBALT, S  REF",,83018,301,$32.00 ,$32.00 ,$9.60 ,$29.12 ,$22.40 ,$9.60 ,$20.80 ,$23.04 ,$29.12 ,$24.00 
Carle BroMenn Medical Center,8381415,RECEPTOR ASSAY; NON-ENDOCRINE   REF,,84238,301,$224.25 ,$224.25 ,$67.28 ,$204.07 ,$156.98 ,$67.28 ,$145.76 ,$161.46 ,$204.07 ,$168.19 
Carle BroMenn Medical Center,8381416,TRIGLYCERIDES   REF,,84478,301,$36.40 ,$36.40 ,$10.92 ,$33.12 ,$25.48 ,$10.92 ,$23.66 ,$26.21 ,$33.12 ,$27.30 
Carle BroMenn Medical Center,8381424,MUSK ANTIBODY    REF,,83519,301,$671.00 ,$671.00 ,$201.30 ,$610.61 ,$469.70 ,$201.30 ,$436.15 ,$483.12 ,$610.61 ,$503.25 
Carle BroMenn Medical Center,8381425,"CPT-TSTTF TESTOS TOTAL, FREE  REF",,84403,301,$18.00 ,$18.00 ,$5.40 ,$16.38 ,$12.60 ,$5.40 ,$11.70 ,$12.96 ,$16.38 ,$13.50 
Carle BroMenn Medical Center,8381426,"CPT-TTTBF TESTOS TOTAL, BIO, FREE  REF",,84403,301,$5.00 ,$5.00 ,$1.50 ,$4.55 ,$3.50 ,$1.50 ,$3.25 ,$3.60 ,$4.55 ,$3.75 
Carle BroMenn Medical Center,8381428,DESIPRAMINE  REF,,80335,301,$139.75 ,$139.75 ,$41.93 ,$127.17 ,$97.83 ,$41.93 ,$90.84 ,$100.62 ,$127.17 ,$104.81 
Carle BroMenn Medical Center,8381429,IMIPRAMINE    REF,,80335,301,$172.00 ,$172.00 ,$51.60 ,$156.52 ,$120.40 ,$51.60 ,$111.80 ,$123.84 ,$156.52 ,$129.00 
Carle BroMenn Medical Center,8381440,"THYROXINE, TOTAL  REF",,84436,301,$8.00 ,$8.00 ,$2.40 ,$7.28 ,$5.60 ,$2.40 ,$5.20 ,$5.76 ,$7.28 ,$6.00 
Carle BroMenn Medical Center,8381441,THYROXINE BINDING CAPACITY  REF,,84479,301,$8.00 ,$8.00 ,$2.40 ,$7.28 ,$5.60 ,$2.40 ,$5.20 ,$5.76 ,$7.28 ,$6.00 
Carle BroMenn Medical Center,8381443,NBS-GALACTOSEMIA SCRN  REF,,82776,301,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8381445,NBS-LSD SCRN  REF,,83798,301,$7.00 ,$7.00 ,$2.10 ,$6.37 ,$4.90 ,$2.10 ,$4.55 ,$5.04 ,$6.37 ,$5.25 
Carle BroMenn Medical Center,8381458,DHEA SULFATE,,82626,301,$236.00 ,$236.00 ,$70.80 ,$214.76 ,$165.20 ,$70.80 ,$153.40 ,$169.92 ,$214.76 ,$177.00 
Carle BroMenn Medical Center,8381461,IMMUNOGLOBULIN E (IGE),,82785,301,$158.00 ,$158.00 ,$47.40 ,$143.78 ,$110.60 ,$47.40 ,$102.70 ,$113.76 ,$143.78 ,$118.50 
Carle BroMenn Medical Center,8381462,INSULIN,,83525,301,$107.00 ,$107.00 ,$32.10 ,$97.37 ,$74.90 ,$32.10 ,$69.55 ,$77.04 ,$97.37 ,$80.25 
Carle BroMenn Medical Center,8381463,C-PEPTIDE,,84681,301,$173.00 ,$173.00 ,$51.90 ,$157.43 ,$121.10 ,$51.90 ,$112.45 ,$124.56 ,$157.43 ,$129.75 
Carle BroMenn Medical Center,8381477,"A1AT PROTEOTYPE S/Z, LC-MS/MS  REF",,82542,301,$54.00 ,$54.00 ,$16.20 ,$49.14 ,$37.80 ,$16.20 ,$35.10 ,$38.88 ,$49.14 ,$40.50 
Carle BroMenn Medical Center,8381487,"HEMOSIDERIN, U  REF",,83070,301,$87.75 ,$87.75 ,$26.33 ,$79.85 ,$61.43 ,$26.33 ,$57.04 ,$63.18 ,$79.85 ,$65.81 
Carle BroMenn Medical Center,8381514,COMPREHENSIVE METABOLIC PANEL (ITC LAB),,80053,301,$255.00 ,$255.00 ,$76.50 ,$232.05 ,$178.50 ,$76.50 ,$165.75 ,$183.60 ,$232.05 ,$191.25 
Carle BroMenn Medical Center,8381520,"CALCIUM, INOIZED, S  REF",,82330,301,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8381524,THIOPURINE METABOLITES (PROMETHEUS) REF,,82542,301,$133.00 ,$133.00 ,$39.90 ,$121.03 ,$93.10 ,$39.90 ,$86.45 ,$95.76 ,$121.03 ,$99.75 
Carle BroMenn Medical Center,8381525,TPMT ENZYME (PROMETHEUS) REF,,82542,301,$54.00 ,$54.00 ,$16.20 ,$49.14 ,$37.80 ,$16.20 ,$35.10 ,$38.88 ,$49.14 ,$40.50 
Carle BroMenn Medical Center,8381530,"AMMONIUM, 24 HR, U  REF",,82140,301,$11.00 ,$11.00 ,$3.30 ,$10.01 ,$7.70 ,$3.30 ,$7.15 ,$7.92 ,$10.01 ,$8.25 
Carle BroMenn Medical Center,8381531,"UREA NITROGEN, U  REF",,84540,301,$87.75 ,$87.75 ,$26.33 ,$79.85 ,$61.43 ,$26.33 ,$57.04 ,$63.18 ,$79.85 ,$65.81 
Carle BroMenn Medical Center,8381535,NBS-AMINO/FATTY/ORGANIC ACIDS SCRN REF,,83789,301,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8381537,"COENZYME Q10, RED AND TOT, P   REF",,82542,301,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8381538,"DRUG SCREEN PANEL, URINE",,80307,301,$55.25 ,$55.25 ,$16.58 ,$50.28 ,$38.68 ,$16.58 ,$35.91 ,$39.78 ,$50.28 ,$41.44 
Carle BroMenn Medical Center,8381543,"CARBON MONOXIDE, B  REF",,82375,301,$108.00 ,$108.00 ,$32.40 ,$98.28 ,$75.60 ,$32.40 ,$70.20 ,$77.76 ,$98.28 ,$81.00 
Carle BroMenn Medical Center,8381563,"CEA, PANCREATIC CYST  REF",,82378,301,$79.00 ,$79.00 ,$23.70 ,$71.89 ,$55.30 ,$23.70 ,$51.35 ,$56.88 ,$71.89 ,$59.25 
Carle BroMenn Medical Center,8381565,SOLUBLE TRANSFERRIN RECEPTOR  REF,,84238,301,$18.00 ,$18.00 ,$5.40 ,$16.38 ,$12.60 ,$5.40 ,$11.70 ,$12.96 ,$16.38 ,$13.50 
Carle BroMenn Medical Center,8381566,"TC (TRIIODOTHYRONINE), REVERSE  REF",,84482,301,$17.00 ,$17.00 ,$5.10 ,$15.47 ,$11.90 ,$5.10 ,$11.05 ,$12.24 ,$15.47 ,$12.75 
Carle BroMenn Medical Center,8381579,"IMMUNOGLOBULIN M (IGM), S  REF",,82784,301,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8381580,GAMMAGLOBULIN IGA/IGD/IGG/IGM,,82784,301,$176.00 ,$176.00 ,$52.80 ,$160.16 ,$123.20 ,$52.80 ,$114.40 ,$126.72 ,$160.16 ,$132.00 
Carle BroMenn Medical Center,8381591,"CALPROTECTIN, FECAL",,83993,301,$186.00 ,$186.00 ,$55.80 ,$169.26 ,$130.20 ,$55.80 ,$120.90 ,$133.92 ,$169.26 ,$139.50 
Carle BroMenn Medical Center,8381602,DRUG SCREEN COMPREHENSIVE,,80307,301,$175.50 ,$175.50 ,$52.65 ,$159.71 ,$122.85 ,$52.65 ,$114.08 ,$126.36 ,$159.71 ,$131.63 
Carle BroMenn Medical Center,8381618,"PROTEIN TOTAL, U, REF",,84156,301,$3.00 ,$3.00 ,$0.90 ,$2.73 ,$2.10 ,$0.90 ,$1.95 ,$2.16 ,$2.73 ,$2.25 
Carle BroMenn Medical Center,8381619,"PROTEIN ELECTROPHORESIS, U, REF",,84166,301,$13.00 ,$13.00 ,$3.90 ,$11.83 ,$9.10 ,$3.90 ,$8.45 ,$9.36 ,$11.83 ,$9.75 
Carle BroMenn Medical Center,8381656,"PH, FECAL, REF",,83986,301,$71.50 ,$71.50 ,$21.45 ,$65.07 ,$50.05 ,$21.45 ,$46.48 ,$51.48 ,$65.07 ,$53.63 
Carle BroMenn Medical Center,8381697,"AMYLASE, BF, REF",,82150,301,$60.16 ,$60.16 ,$18.05 ,$54.75 ,$42.11 ,$18.05 ,$39.10 ,$43.32 ,$54.75 ,$45.12 
Carle BroMenn Medical Center,8381703,"PROSTATE SPECIFIC ANTIGEN, S",,84153,301,$17.00 ,$17.00 ,$5.10 ,$15.47 ,$11.90 ,$5.10 ,$11.05 ,$12.24 ,$15.47 ,$12.75 
Carle BroMenn Medical Center,8381704,"FREE PSA, S",,84154,301,$17.00 ,$17.00 ,$5.10 ,$15.47 ,$11.90 ,$5.10 ,$11.05 ,$12.24 ,$15.47 ,$12.75 
Carle BroMenn Medical Center,8381729,"INTERLEUKIN 6, P",,83520,301,$223.60 ,$223.60 ,$67.08 ,$203.48 ,$156.52 ,$67.08 ,$145.34 ,$160.99 ,$203.48 ,$167.70 
Carle BroMenn Medical Center,8381737,"NICOTINE AND METABOLITES, QU, REF",,80323,301,$120.25 ,$120.25 ,$36.08 ,$109.43 ,$84.18 ,$36.08 ,$78.16 ,$86.58 ,$109.43 ,$90.19 
Carle BroMenn Medical Center,8381740,"ASSAY OF SERUM ALBUMIN, REF",,82040,301,$46.15 ,$46.15 ,$13.85 ,$42.00 ,$32.31 ,$13.85 ,$30.00 ,$33.23 ,$42.00 ,$34.61 
Carle BroMenn Medical Center,8381741,"OTHER SOURCE ALBUMIN QUAN EA, REF",,82042,301,$38.35 ,$38.35 ,$11.51 ,$34.90 ,$26.85 ,$11.51 ,$24.93 ,$27.61 ,$34.90 ,$28.76 
Carle BroMenn Medical Center,8381761,"IMMUNOGLOBULIN A (IGA), S",,82784,301,$7.00 ,$7.00 ,$2.10 ,$6.37 ,$4.90 ,$2.10 ,$4.55 ,$5.04 ,$6.37 ,$5.25 
Carle BroMenn Medical Center,8381762,"ALPHA-GALACTOSIDASE, LEUKOCYTES, REF",,82657,301,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8381777,"BLD UREA NITROG, BF, REF",,84520,301,$87.10 ,$87.10 ,$26.13 ,$79.26 ,$60.97 ,$26.13 ,$56.62 ,$62.71 ,$79.26 ,$65.33 
Carle BroMenn Medical Center,8381782,"CARBOXY-THC CONFIRMATION, REF",,80349,301,$169.00 ,$169.00 ,$50.70 ,$153.79 ,$118.30 ,$50.70 ,$109.85 ,$121.68 ,$153.79 ,$126.75 
Carle BroMenn Medical Center,8381784,"AMPHETAMINES CONFIRMATION,  REF",,80324,301,$175.50 ,$175.50 ,$52.65 ,$159.71 ,$122.85 ,$52.65 ,$114.08 ,$126.36 ,$159.71 ,$131.63 
Carle BroMenn Medical Center,8381785,"METHYLENEDIOXYAPHETAMINES, REF",,80359,301,$20.00 ,$20.00 ,$6.00 ,$18.20 ,$14.00 ,$6.00 ,$13.00 ,$14.40 ,$18.20 ,$15.00 
Carle BroMenn Medical Center,8381786,"COCAINE AND METABOLITE CONF, REF",,80353,301,$211.25 ,$211.25 ,$63.38 ,$192.24 ,$147.88 ,$63.38 ,$137.31 ,$152.10 ,$192.24 ,$158.44 
Carle BroMenn Medical Center,8381787,"OPIATES 1 OR MORE, REF",,80361,301,$31.00 ,$31.00 ,$9.30 ,$28.21 ,$21.70 ,$9.30 ,$20.15 ,$22.32 ,$28.21 ,$23.25 
Carle BroMenn Medical Center,8381788,"OXYCODONE, REF",,80365,301,$25.00 ,$25.00 ,$7.50 ,$22.75 ,$17.50 ,$7.50 ,$16.25 ,$18.00 ,$22.75 ,$18.75 
Carle BroMenn Medical Center,8381793,HEMOGLOBIN ELECTROPHORESIS,,83020,301,$123.00 ,$123.00 ,$36.90 ,$111.93 ,$86.10 ,$36.90 ,$79.95 ,$88.56 ,$111.93 ,$92.25 
Carle BroMenn Medical Center,8381796,BILLING BENZENE CPT 82570-90,,82570,301,$22.00 ,$22.00 ,$6.60 ,$20.02 ,$15.40 ,$6.60 ,$14.30 ,$15.84 ,$20.02 ,$16.50 
Carle BroMenn Medical Center,8381798,"CREATININE CONC, REF",,82570,301,$6.00 ,$6.00 ,$1.80 ,$5.46 ,$4.20 ,$1.80 ,$3.90 ,$4.32 ,$5.46 ,$4.50 
Carle BroMenn Medical Center,8381806,"CALCIUM, IONIZED",,82330,301,$84.50 ,$84.50 ,$25.35 ,$76.90 ,$59.15 ,$25.35 ,$54.93 ,$60.84 ,$76.90 ,$63.38 
Carle BroMenn Medical Center,8381808,"CHYMOTRIPSIN, STOOL, REF",,84311,301,$132.60 ,$132.60 ,$39.78 ,$120.67 ,$92.82 ,$39.78 ,$86.19 ,$95.47 ,$120.67 ,$99.45 
Carle BroMenn Medical Center,8381827,"PORPHOBILINOGEN DEAMINASE (PBGD), WHOLE BLOOD, REF",,82657,301,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8381829,"TESTOSTERONE, FREE, S, REF",,84402,301,$65.00 ,$65.00 ,$19.50 ,$59.15 ,$45.50 ,$19.50 ,$42.25 ,$46.80 ,$59.15 ,$48.75 
Carle BroMenn Medical Center,8381830,"TESTOSTERONE, BIOAVAIL, S REF",,84410,301,$11.00 ,$11.00 ,$3.30 ,$10.01 ,$7.70 ,$3.30 ,$7.15 ,$7.92 ,$10.01 ,$8.25 
Carle BroMenn Medical Center,8381836,"REDUCING SUBSTANCE, FECES, REF",,84376,301,$71.50 ,$71.50 ,$21.45 ,$65.07 ,$50.05 ,$21.45 ,$46.48 ,$51.48 ,$65.07 ,$53.63 
Carle BroMenn Medical Center,8381846,"CLOMIPRAMINE, S, REF",,80335,301,$139.75 ,$139.75 ,$41.93 ,$127.17 ,$97.83 ,$41.93 ,$90.84 ,$100.62 ,$127.17 ,$104.81 
Carle BroMenn Medical Center,8381851,ASSAY OF PROGESTERONE  REF,,83498,301,$248.00 ,$248.00 ,$74.40 ,$225.68 ,$173.60 ,$74.40 ,$161.20 ,$178.56 ,$225.68 ,$186.00 
Carle BroMenn Medical Center,8381852,"DIURETIC SCREEN, URINE  REF",,80377,301,$68.80 ,$68.80 ,$20.64 ,$62.61 ,$48.16 ,$20.64 ,$44.72 ,$49.54 ,$62.61 ,$51.60 
Carle BroMenn Medical Center,8381864,"BETA-HCG QUANTITATIVE, S, REF",,84702,301,$113.75 ,$113.75 ,$34.13 ,$103.51 ,$79.63 ,$34.13 ,$73.94 ,$81.90 ,$103.51 ,$85.31 
Carle BroMenn Medical Center,8381867,"DIHYDROTESTOSTERONE, S, REF",,82642,301,$19.00 ,$19.00 ,$5.70 ,$17.29 ,$13.30 ,$5.70 ,$12.35 ,$13.68 ,$17.29 ,$14.25 
Carle BroMenn Medical Center,8381879,ADMARK PHOSPHO-TAU/TOTAL-TAU/A BETA 42,,83520,301,$873.00 ,$873.00 ,$261.90 ,$794.43 ,$611.10 ,$261.90 ,$567.45 ,$628.56 ,$794.43 ,$654.75 
Carle BroMenn Medical Center,8381903,"VOLTAGE-GATED CALCIUM CHANNEL (VGCC), AB, REF",,83519,301,$201.50 ,$201.50 ,$60.45 ,$183.37 ,$141.05 ,$60.45 ,$130.98 ,$145.08 ,$183.37 ,$151.13 
Carle BroMenn Medical Center,8381915,"OSMOLALITY, URINE, REF",,83935,301,$53.00 ,$53.00 ,$15.90 ,$48.23 ,$37.10 ,$15.90 ,$34.45 ,$38.16 ,$48.23 ,$39.75 
Carle BroMenn Medical Center,8381919,"COPEPTIN PRO-AVP, P, REF",,84588,301,$57.00 ,$57.00 ,$17.10 ,$51.87 ,$39.90 ,$17.10 ,$37.05 ,$41.04 ,$51.87 ,$42.75 
Carle BroMenn Medical Center,8381934,"MERCURY/CREATININE RATIO, U, REF",,83825,301,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8381935,"ARYLSULFATASE A, LEUKOCYTES, REF",,82657,301,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8381937,"B-TYPE NAT PEPTIDE (BNP) S, REF",,83880,301,$172.25 ,$172.25 ,$51.68 ,$156.75 ,$120.58 ,$51.68 ,$111.96 ,$124.02 ,$156.75 ,$129.19 
Carle BroMenn Medical Center,8381947,"OXALATE, SERUM/PLASMA REF",,83945,301,$96.00 ,$96.00 ,$28.80 ,$87.36 ,$67.20 ,$28.80 ,$62.40 ,$69.12 ,$87.36 ,$72.00 
Carle BroMenn Medical Center,8381953,"LSD CONFIRMATION, U, REF",,80323,301,$148.00 ,$148.00 ,$44.40 ,$134.68 ,$103.60 ,$44.40 ,$96.20 ,$106.56 ,$134.68 ,$111.00 
Carle BroMenn Medical Center,8381989,"BARBITUATES, CONFIRMATION",,80345,301,$11.70 ,$11.70 ,$3.51 ,$10.65 ,$8.19 ,$3.51 ,$7.61 ,$8.42 ,$10.65 ,$8.78 
Carle BroMenn Medical Center,8382009,B-HYDROXYBUTYRATE,,82010,301,$98.00 ,$98.00 ,$29.40 ,$89.18 ,$68.60 ,$29.40 ,$63.70 ,$70.56 ,$89.18 ,$73.50 
Carle BroMenn Medical Center,8382011,ACYLCARNITINE PROFILE      REF,,82016,301,$6.00 ,$6.00 ,$1.80 ,$5.46 ,$4.20 ,$1.80 ,$3.90 ,$4.32 ,$5.46 ,$4.50 
Carle BroMenn Medical Center,8382014,ACETYCHOLINE RECEPTOR ASSAY RF,,83519,301,$183.00 ,$183.00 ,$54.90 ,$166.53 ,$128.10 ,$54.90 ,$118.95 ,$131.76 ,$166.53 ,$137.25 
Carle BroMenn Medical Center,8382017,"ACYLCARNITINE, PLASMAREF REF",,82017,301,$49.00 ,$49.00 ,$14.70 ,$44.59 ,$34.30 ,$14.70 ,$31.85 ,$35.28 ,$44.59 ,$36.75 
Carle BroMenn Medical Center,8382024,"ACTH, PLASMA               REF",,82024,301,$24.00 ,$24.00 ,$7.20 ,$21.84 ,$16.80 ,$7.20 ,$15.60 ,$17.28 ,$21.84 ,$18.00 
Carle BroMenn Medical Center,8382035,ALBUMIN BODY FLUID,,82042,301,$66.00 ,$66.00 ,$19.80 ,$60.06 ,$46.20 ,$19.80 ,$42.90 ,$47.52 ,$60.06 ,$49.50 
Carle BroMenn Medical Center,8382037,ALBUMIN -SYNOVIAL FLUID,,82042,301,$76.00 ,$76.00 ,$22.80 ,$69.16 ,$53.20 ,$22.80 ,$49.40 ,$54.72 ,$69.16 ,$57.00 
Carle BroMenn Medical Center,8382039,LEAD                       REF,,83655,301,$91.00 ,$91.00 ,$27.30 ,$82.81 ,$63.70 ,$27.30 ,$59.15 ,$65.52 ,$82.81 ,$68.25 
Carle BroMenn Medical Center,8382040,"ALBUMIN, SERUM",,82040,301,$46.15 ,$46.15 ,$13.85 ,$42.00 ,$32.31 ,$13.85 ,$30.00 ,$33.23 ,$42.00 ,$34.61 
Carle BroMenn Medical Center,8382043,"MICROALBUMIN, URINE, QUANT",,82043,301,$65.00 ,$65.00 ,$19.50 ,$59.15 ,$45.50 ,$19.50 ,$42.25 ,$46.80 ,$59.15 ,$48.75 
Carle BroMenn Medical Center,8382058,VITAMIN D3 (25-HYDROXY)    REF,,82306,301,$221.00 ,$221.00 ,$66.30 ,$201.11 ,$154.70 ,$66.30 ,$143.65 ,$159.12 ,$201.11 ,$165.75 
Carle BroMenn Medical Center,8382059,VITA-D 25 HYDROXY SRM,,82306,301,$142.00 ,$142.00 ,$42.60 ,$129.22 ,$99.40 ,$42.60 ,$92.30 ,$102.24 ,$129.22 ,$106.50 
Carle BroMenn Medical Center,8382060,VITAMIN E (TOCOPHEROL)     REF,,84446,301,$107.25 ,$107.25 ,$32.18 ,$97.60 ,$75.08 ,$32.18 ,$69.71 ,$77.22 ,$97.60 ,$80.44 
Carle BroMenn Medical Center,8382065,ASSAY OF SERUM ALBUMMIN    REF,,82040,301,$28.00 ,$28.00 ,$8.40 ,$25.48 ,$19.60 ,$8.40 ,$18.20 ,$20.16 ,$25.48 ,$21.00 
Carle BroMenn Medical Center,8382070,CANNABINOIDS CONF UR REF,,82542,301,$107.00 ,$107.00 ,$32.10 ,$97.37 ,$74.90 ,$32.10 ,$69.55 ,$77.04 ,$97.37 ,$80.25 
Carle BroMenn Medical Center,8382085,ALDOLASE     REF,,82085,301,$71.50 ,$71.50 ,$21.45 ,$65.07 ,$50.05 ,$21.45 ,$46.48 ,$51.48 ,$65.07 ,$53.63 
Carle BroMenn Medical Center,8382087,CYCLOSPORINE ASSAY,,80158,301,$192.00 ,$192.00 ,$57.60 ,$174.72 ,$134.40 ,$57.60 ,$124.80 ,$138.24 ,$174.72 ,$144.00 
Carle BroMenn Medical Center,8382088,"ALDOSTERONE, URINE (24H) REF",,82088,301,$79.00 ,$79.00 ,$23.70 ,$71.89 ,$55.30 ,$23.70 ,$51.35 ,$56.88 ,$71.89 ,$59.25 
Carle BroMenn Medical Center,8382096,PANCREATIC POLYPEPTIDE     REF,,83519,301,$86.00 ,$86.00 ,$25.80 ,$78.26 ,$60.20 ,$25.80 ,$55.90 ,$61.92 ,$78.26 ,$64.50 
Carle BroMenn Medical Center,8382103,"ALPHA-1-ANTITRYPSIN, RAND, F   REF",,82103,301,$9.00 ,$9.00 ,$2.70 ,$8.19 ,$6.30 ,$2.70 ,$5.85 ,$6.48 ,$8.19 ,$6.75 
Carle BroMenn Medical Center,8382105,"ALPHA-FETOPROTEIN, SERUM",,82105,301,$195.00 ,$195.00 ,$58.50 ,$177.45 ,$136.50 ,$58.50 ,$126.75 ,$140.40 ,$177.45 ,$146.25 
Carle BroMenn Medical Center,8382106,"ALPHA FETOPROTEIN, AF    REF",,82106,301,$21.00 ,$21.00 ,$6.30 ,$19.11 ,$14.70 ,$6.30 ,$13.65 ,$15.12 ,$19.11 ,$15.75 
Carle BroMenn Medical Center,8382107,"ALPHA-FETOPROTEIN, SERUM   REF",,82105,301,$98.00 ,$98.00 ,$29.40 ,$89.18 ,$68.60 ,$29.40 ,$63.70 ,$70.56 ,$89.18 ,$73.50 
Carle BroMenn Medical Center,8382112,ALPHA FETOPROTEIN AMNIOTIC REF,,82106,301,$165.75 ,$165.75 ,$49.73 ,$150.83 ,$116.03 ,$49.73 ,$107.74 ,$119.34 ,$150.83 ,$124.31 
Carle BroMenn Medical Center,8382128,AMINO ACID QUAL PLASMA REF,,82128,301,$90.00 ,$90.00 ,$27.00 ,$81.90 ,$63.00 ,$27.00 ,$58.50 ,$64.80 ,$81.90 ,$67.50 
Carle BroMenn Medical Center,8382134,CYSTINE-QUANTITATIVE-URINE REF,,82131,301,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8382135,"AMINOLEVULINIC ACID, URINE REF",,82135,301,$120.25 ,$120.25 ,$36.08 ,$109.43 ,$84.18 ,$36.08 ,$78.16 ,$86.58 ,$109.43 ,$90.19 
Carle BroMenn Medical Center,8382136,"AMINO ACIDS,2-5 QNT. REF",,82136,301,$148.00 ,$148.00 ,$44.40 ,$134.68 ,$103.60 ,$44.40 ,$96.20 ,$106.56 ,$134.68 ,$111.00 
Carle BroMenn Medical Center,8382137,"AMINOLEVULINIC ACID, URINE REF",,82135,301,$148.00 ,$148.00 ,$44.40 ,$134.68 ,$103.60 ,$44.40 ,$96.20 ,$106.56 ,$134.68 ,$111.00 
Carle BroMenn Medical Center,8382140,AMMONIA,,82140,301,$87.75 ,$87.75 ,$26.33 ,$79.85 ,$61.43 ,$26.33 ,$57.04 ,$63.18 ,$79.85 ,$65.81 
Carle BroMenn Medical Center,8382142,AMINO ACID PROFILE         REF,,82128,301,$6.00 ,$6.00 ,$1.80 ,$5.46 ,$4.20 ,$1.80 ,$3.90 ,$4.32 ,$5.46 ,$4.50 
Carle BroMenn Medical Center,8382150,AMYLASE,,82150,301,$84.50 ,$84.50 ,$25.35 ,$76.90 ,$59.15 ,$25.35 ,$54.93 ,$60.84 ,$76.90 ,$63.38 
Carle BroMenn Medical Center,8382155,AMINO ACIDS 6/>QUANT EA/SPC RF,,82139,301,$275.00 ,$275.00 ,$82.50 ,$250.25 ,$192.50 ,$82.50 ,$178.75 ,$198.00 ,$250.25 ,$206.25 
Carle BroMenn Medical Center,8382157,ANDROSTENEDIONE REF,,82157,301,$178.75 ,$178.75 ,$53.63 ,$162.66 ,$125.13 ,$53.63 ,$116.19 ,$128.70 ,$162.66 ,$134.06 
Carle BroMenn Medical Center,8382159,AMYLASE ISOENZYMES REF,,82150,301,$20.00 ,$20.00 ,$6.00 ,$18.20 ,$14.00 ,$6.00 ,$13.00 ,$14.40 ,$18.20 ,$15.00 
Carle BroMenn Medical Center,8382163,"OH-PROGESTERONE, 17-ALPHA  REF",,83498,301,$103.00 ,$103.00 ,$30.90 ,$93.73 ,$72.10 ,$30.90 ,$66.95 ,$74.16 ,$93.73 ,$77.25 
Carle BroMenn Medical Center,8382164,"ANGIOTENSIN CONVERT. ENZYME, S  REF",,82164,301,$10.05 ,$10.05 ,$3.02 ,$9.15 ,$7.04 ,$3.02 ,$6.53 ,$7.24 ,$9.15 ,$7.54 
Carle BroMenn Medical Center,8382170,"PROT ELE PHO OTHR(CSF,URINE)QN",,84166,301,$132.00 ,$132.00 ,$39.60 ,$120.12 ,$92.40 ,$39.60 ,$85.80 ,$95.04 ,$120.12 ,$99.00 
Carle BroMenn Medical Center,8382172,"APOLIPOPROTEIN A1 AND B, P  REF",,82172,301,$107.25 ,$107.25 ,$32.18 ,$97.60 ,$75.08 ,$32.18 ,$69.71 ,$77.22 ,$97.60 ,$80.44 
Carle BroMenn Medical Center,8382175,"ARSENIC, BLOOD             REF",,82175,301,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8382176,"ARSENIC, URINE (24HR)      REF",,82175,301,$64.00 ,$64.00 ,$19.20 ,$58.24 ,$44.80 ,$19.20 ,$41.60 ,$46.08 ,$58.24 ,$48.00 
Carle BroMenn Medical Center,8382212,"INFLIXIMAB QANT W/REFLEX TO AB TO INFILXIMAB, S, REF",,80230,301,$276.25 ,$276.25 ,$82.88 ,$251.39 ,$193.38 ,$82.88 ,$179.56 ,$198.90 ,$251.39 ,$207.19 
Carle BroMenn Medical Center,8382226,CEA,,82378,301,$117.00 ,$117.00 ,$35.10 ,$106.47 ,$81.90 ,$35.10 ,$76.05 ,$84.24 ,$106.47 ,$87.75 
Carle BroMenn Medical Center,8382232,BETA-2 MICROGLOBULIN       REF,,82232,301,$120.25 ,$120.25 ,$36.08 ,$109.43 ,$84.18 ,$36.08 ,$78.16 ,$86.58 ,$109.43 ,$90.19 
Carle BroMenn Medical Center,8382235,"MERCURY, URINE(24HR)",,83825,301,$79.00 ,$79.00 ,$23.70 ,$71.89 ,$55.30 ,$23.70 ,$51.35 ,$56.88 ,$71.89 ,$59.25 
Carle BroMenn Medical Center,8382236,"TISS TRANSGLUTAMIN AB, IGG, S   REF",,83516,301,$84.50 ,$84.50 ,$25.35 ,$76.90 ,$59.15 ,$25.35 ,$54.93 ,$60.84 ,$76.90 ,$63.38 
Carle BroMenn Medical Center,8382239,"BILE ACIDS, TOTAL  REF",,82239,301,$31.00 ,$31.00 ,$9.30 ,$28.21 ,$21.70 ,$9.30 ,$20.15 ,$22.32 ,$28.21 ,$23.25 
Carle BroMenn Medical Center,8382247,"BILIRUBIN, TOTAL",,82247,301,$48.75 ,$48.75 ,$14.63 ,$44.36 ,$34.13 ,$14.63 ,$31.69 ,$35.10 ,$44.36 ,$36.56 
Carle BroMenn Medical Center,8382248,"BILIRUBIN, DIRECT",,82248,301,$35.10 ,$35.10 ,$10.53 ,$31.94 ,$24.57 ,$10.53 ,$22.82 ,$25.27 ,$31.94 ,$26.33 
Carle BroMenn Medical Center,8382250,STONE ANALYSIS,,82365,301,$84.50 ,$84.50 ,$25.35 ,$76.90 ,$59.15 ,$25.35 ,$54.93 ,$60.84 ,$76.90 ,$63.38 
Carle BroMenn Medical Center,8382255,METHYLMALONIC ACID,,83921,301,$107.25 ,$107.25 ,$32.18 ,$97.60 ,$75.08 ,$32.18 ,$69.71 ,$77.22 ,$97.60 ,$80.44 
Carle BroMenn Medical Center,8382259,KAPPA/LAMBDA W/RATIO,,83883,301,$84.50 ,$84.50 ,$25.35 ,$76.90 ,$59.15 ,$25.35 ,$54.93 ,$60.84 ,$76.90 ,$63.38 
Carle BroMenn Medical Center,8382261,IMMUNOGLOBULIN A,,82784,301,$56.55 ,$56.55 ,$16.97 ,$51.46 ,$39.59 ,$16.97 ,$36.76 ,$40.72 ,$51.46 ,$42.41 
Carle BroMenn Medical Center,8382263,"TACROLIMUS, LC/MS/MS",,80197,301,$133.25 ,$133.25 ,$39.98 ,$121.26 ,$93.28 ,$39.98 ,$86.61 ,$95.94 ,$121.26 ,$99.94 
Carle BroMenn Medical Center,8382264,LEVETIRACETAM,,80177,301,$113.75 ,$113.75 ,$34.13 ,$103.51 ,$79.63 ,$34.13 ,$73.94 ,$81.90 ,$103.51 ,$85.31 
Carle BroMenn Medical Center,8382267,IMMUNOGLOBULIN G,,82784,301,$68.25 ,$68.25 ,$20.48 ,$62.11 ,$47.78 ,$20.48 ,$44.36 ,$49.14 ,$62.11 ,$51.19 
Carle BroMenn Medical Center,8382270,OCCULT BLOOD,,82270,301,$40.95 ,$40.95 ,$12.29 ,$37.26 ,$28.67 ,$12.29 ,$26.62 ,$29.48 ,$37.26 ,$30.71 
Carle BroMenn Medical Center,8382272,OCCULT BLOOD -SINGLE SPECIMEN,,82272,301,$35.00 ,$35.00 ,$10.50 ,$31.85 ,$24.50 ,$10.50 ,$22.75 ,$25.20 ,$31.85 ,$26.25 
Carle BroMenn Medical Center,8382282,"CORTISOL, TOTAL",,82533,301,$100.75 ,$100.75 ,$30.23 ,$91.68 ,$70.53 ,$30.23 ,$65.49 ,$72.54 ,$91.68 ,$75.56 
Carle BroMenn Medical Center,8382284,VITAMIN A (RETINOL),,84590,301,$91.00 ,$91.00 ,$27.30 ,$82.81 ,$63.70 ,$27.30 ,$59.15 ,$65.52 ,$82.81 ,$68.25 
Carle BroMenn Medical Center,8382285,IMMUNOGLOBULIN M,,82784,301,$68.25 ,$68.25 ,$20.48 ,$62.11 ,$47.78 ,$20.48 ,$44.36 ,$49.14 ,$62.11 ,$51.19 
Carle BroMenn Medical Center,8382286,"VITAMIN B1,THIAMINE",,84425,301,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8382294,"AFP,TUMOR (CHIRON)",,82105,301,$123.50 ,$123.50 ,$37.05 ,$112.39 ,$86.45 ,$37.05 ,$80.28 ,$88.92 ,$112.39 ,$92.63 
Carle BroMenn Medical Center,8382296,"CALPROTECTIN,STOOL",,83993,301,$182.00 ,$182.00 ,$54.60 ,$165.62 ,$127.40 ,$54.60 ,$118.30 ,$131.04 ,$165.62 ,$136.50 
Carle BroMenn Medical Center,8382300,"CADMIUM, BLOOD             REF",,82300,301,$59.00 ,$59.00 ,$17.70 ,$53.69 ,$41.30 ,$17.70 ,$38.35 ,$42.48 ,$53.69 ,$44.25 
Carle BroMenn Medical Center,8382301,"CADMIUM, URINE (24HR)      REF",,82300,301,$59.00 ,$59.00 ,$17.70 ,$53.69 ,$41.30 ,$17.70 ,$38.35 ,$42.48 ,$53.69 ,$44.25 
Carle BroMenn Medical Center,8382306,25 OH VITAMIN D TOTAL,,82306,301,$221.00 ,$221.00 ,$66.30 ,$201.11 ,$154.70 ,$66.30 ,$143.65 ,$159.12 ,$201.11 ,$165.75 
Carle BroMenn Medical Center,8382308,FECAL OCCULT BLOOD,,82272,301,$47.00 ,$47.00 ,$14.10 ,$42.77 ,$32.90 ,$14.10 ,$30.55 ,$33.84 ,$42.77 ,$35.25 
Carle BroMenn Medical Center,8382309,CALCIUM (PTH-INTACT) REF,,82310,301,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8382310,"CALCIUM, TOTAL",,82310,301,$48.10 ,$48.10 ,$14.43 ,$43.77 ,$33.67 ,$14.43 ,$31.27 ,$34.63 ,$43.77 ,$36.08 
Carle BroMenn Medical Center,8382311,"CALCIUM, IONIZED",,82330,301,$151.00 ,$151.00 ,$45.30 ,$137.41 ,$105.70 ,$45.30 ,$98.15 ,$108.72 ,$137.41 ,$113.25 
Carle BroMenn Medical Center,8382312,"ALCOHOL, SERUM",,80320,301,$149.50 ,$149.50 ,$44.85 ,$136.05 ,$104.65 ,$44.85 ,$97.18 ,$107.64 ,$136.05 ,$112.13 
Carle BroMenn Medical Center,8382313,ACETAMINOPHEN,,80329,301,$104.00 ,$104.00 ,$31.20 ,$94.64 ,$72.80 ,$31.20 ,$67.60 ,$74.88 ,$94.64 ,$78.00 
Carle BroMenn Medical Center,8382315,CALCITONIN                 REF,,82308,301,$67.00 ,$67.00 ,$20.10 ,$60.97 ,$46.90 ,$20.10 ,$43.55 ,$48.24 ,$60.97 ,$50.25 
Carle BroMenn Medical Center,8382316,SALICYLATE,,80329,301,$84.50 ,$84.50 ,$25.35 ,$76.90 ,$59.15 ,$25.35 ,$54.93 ,$60.84 ,$76.90 ,$63.38 
Carle BroMenn Medical Center,8382326,PROM,,84112,301,$158.00 ,$158.00 ,$47.40 ,$143.78 ,$110.60 ,$47.40 ,$102.70 ,$113.76 ,$143.78 ,$118.50 
Carle BroMenn Medical Center,8382330,GASTRIC BLOOD/PH,,83986,301,$76.00 ,$76.00 ,$22.80 ,$69.16 ,$53.20 ,$22.80 ,$49.40 ,$54.72 ,$69.16 ,$57.00 
Carle BroMenn Medical Center,8382340,"CALCIUM, URINE",,82340,301,$113.00 ,$113.00 ,$33.90 ,$102.83 ,$79.10 ,$33.90 ,$73.45 ,$81.36 ,$102.83 ,$84.75 
Carle BroMenn Medical Center,8382345,"CARNITINE,TOTAL&FREE,QUANT REF",,82379,301,$173.00 ,$173.00 ,$51.90 ,$157.43 ,$121.10 ,$51.90 ,$112.45 ,$124.56 ,$157.43 ,$129.75 
Carle BroMenn Medical Center,8382350,"HEPATITIS ACUTE PANEL, REF",,80074,301,$37.00 ,$37.00 ,$11.10 ,$33.67 ,$25.90 ,$11.10 ,$24.05 ,$26.64 ,$33.67 ,$27.75 
Carle BroMenn Medical Center,8382365,KIDNEY STONE ANALYSIS      REF,,82365,301,$62.00 ,$62.00 ,$18.60 ,$56.42 ,$43.40 ,$18.60 ,$40.30 ,$44.64 ,$56.42 ,$46.50 
Carle BroMenn Medical Center,8382368,SARS-COV-2 IGG,,86769,301,$47.45 ,$47.45 ,$14.24 ,$43.18 ,$33.22 ,$14.24 ,$30.84 ,$34.16 ,$43.18 ,$35.59 
Carle BroMenn Medical Center,8382371,"DHEA-SULFATE, REF",,82627,301,$165.75 ,$165.75 ,$49.73 ,$150.83 ,$116.03 ,$49.73 ,$107.74 ,$119.34 ,$150.83 ,$124.31 
Carle BroMenn Medical Center,8382372,CHEMILUMINESCENT ASSAY     REF,,82397,301,$118.00 ,$118.00 ,$35.40 ,$107.38 ,$82.60 ,$35.40 ,$76.70 ,$84.96 ,$107.38 ,$88.50 
Carle BroMenn Medical Center,8382374,CARBON DIOXIDE (BICARBONATE),,82374,301,$40.95 ,$40.95 ,$12.29 ,$37.26 ,$28.67 ,$12.29 ,$26.62 ,$29.48 ,$37.26 ,$30.71 
Carle BroMenn Medical Center,8382375,"VITAMIN E, REF",,84446,301,$26.00 ,$26.00 ,$7.80 ,$23.66 ,$18.20 ,$7.80 ,$16.90 ,$18.72 ,$23.66 ,$19.50 
Carle BroMenn Medical Center,8382377,"SARS-COV-2 (COVID-19) AB, IGG, S",,86769,301,$47.45 ,$47.45 ,$14.24 ,$43.18 ,$33.22 ,$14.24 ,$30.84 ,$34.16 ,$43.18 ,$35.59 
Carle BroMenn Medical Center,8382379,"CARNITINE, FRACTIONATED    REF",,82379,301,$173.00 ,$173.00 ,$51.90 ,$157.43 ,$121.10 ,$51.90 ,$112.45 ,$124.56 ,$157.43 ,$129.75 
Carle BroMenn Medical Center,8382380,CAROTENE      REF,,82380,301,$55.00 ,$55.00 ,$16.50 ,$50.05 ,$38.50 ,$16.50 ,$35.75 ,$39.60 ,$50.05 ,$41.25 
Carle BroMenn Medical Center,8382382,OSMOLALITY (U),,83935,301,$18.00 ,$18.00 ,$5.40 ,$16.38 ,$12.60 ,$5.40 ,$11.70 ,$12.96 ,$16.38 ,$13.50 
Carle BroMenn Medical Center,8382383,"VITAMIN D,1,25",,82652,301,$29.00 ,$29.00 ,$8.70 ,$26.39 ,$20.30 ,$8.70 ,$18.85 ,$20.88 ,$26.39 ,$21.75 
Carle BroMenn Medical Center,8382384,"CATECHOLAMINES FRC, UR REF",,82384,301,$188.50 ,$188.50 ,$56.55 ,$171.54 ,$131.95 ,$56.55 ,$122.53 ,$135.72 ,$171.54 ,$141.38 
Carle BroMenn Medical Center,8382386,"FOLATE, RBC",,82747,301,$107.25 ,$107.25 ,$32.18 ,$97.60 ,$75.08 ,$32.18 ,$69.71 ,$77.22 ,$97.60 ,$80.44 
Carle BroMenn Medical Center,8382390,"VITAMIN K, PLASMA",,84597,301,$69.00 ,$69.00 ,$20.70 ,$62.79 ,$48.30 ,$20.70 ,$44.85 ,$49.68 ,$62.79 ,$51.75 
Carle BroMenn Medical Center,8382399,METANPH.24 HR URINE,,83835,301,$211.25 ,$211.25 ,$63.38 ,$192.24 ,$147.88 ,$63.38 ,$137.31 ,$152.10 ,$192.24 ,$158.44 
Carle BroMenn Medical Center,8382400,"CATECHOLAMINES,FRACTIONATD REF",,82384,301,$188.50 ,$188.50 ,$56.55 ,$171.54 ,$131.95 ,$56.55 ,$122.53 ,$135.72 ,$171.54 ,$141.38 
Carle BroMenn Medical Center,8382402,ALK PHOS ISOENZYMES,,84075,301,$4.00 ,$4.00 ,$1.20 ,$3.64 ,$2.80 ,$1.20 ,$2.60 ,$2.88 ,$3.64 ,$3.00 
Carle BroMenn Medical Center,8382403,ALK PHOS ISOENZYMES,,84080,301,$91.00 ,$91.00 ,$27.30 ,$82.81 ,$63.70 ,$27.30 ,$59.15 ,$65.52 ,$82.81 ,$68.25 
Carle BroMenn Medical Center,8382412,PRA LC/MS/MS,,84244,301,$26.00 ,$26.00 ,$7.80 ,$23.66 ,$18.20 ,$7.80 ,$16.90 ,$18.72 ,$23.66 ,$19.50 
Carle BroMenn Medical Center,8382418,MASS SPECTROMTRY-EA SPECIMN RF,,83789,301,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8382419,"CREATININE, I-STAT",,82565,301,$85.80 ,$85.80 ,$25.74 ,$78.08 ,$60.06 ,$25.74 ,$55.77 ,$61.78 ,$78.08 ,$64.35 
Carle BroMenn Medical Center,8382420,GLUTAMC ACID DECRBXYLSE AB REF,,83519,301,$166.00 ,$166.00 ,$49.80 ,$151.06 ,$116.20 ,$49.80 ,$107.90 ,$119.52 ,$151.06 ,$124.50 
Carle BroMenn Medical Center,8382423,"BUPROPION AND METABOLITE, S, REF",,80338,301,$14.40 ,$14.40 ,$4.32 ,$13.10 ,$10.08 ,$4.32 ,$9.36 ,$10.37 ,$13.10 ,$10.80 
Carle BroMenn Medical Center,8382425,DRUG ASSAY -ZONISAMIDE,,80299,301,$32.00 ,$32.00 ,$9.60 ,$29.12 ,$22.40 ,$9.60 ,$20.80 ,$23.04 ,$29.12 ,$24.00 
Carle BroMenn Medical Center,8382435,"CHLORIDE, BLOOD",,82435,301,$39.65 ,$39.65 ,$11.90 ,$36.08 ,$27.76 ,$11.90 ,$25.77 ,$28.55 ,$36.08 ,$29.74 
Carle BroMenn Medical Center,8382436,"CHLORIDE, URINE",,82436,301,$47.00 ,$47.00 ,$14.10 ,$42.77 ,$32.90 ,$14.10 ,$30.55 ,$33.84 ,$42.77 ,$35.25 
Carle BroMenn Medical Center,8382438,"CHLORIDE, STOOL",,82438,301,$49.00 ,$49.00 ,$14.70 ,$44.59 ,$34.30 ,$14.70 ,$31.85 ,$35.28 ,$44.59 ,$36.75 
Carle BroMenn Medical Center,8382446,"BETA-GALACTOSIDASE, LEUKOCYTES, REF",,82657,301,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8382449,"PANCREATIC ELASTASE, F REF",,83520,301,$57.00 ,$57.00 ,$17.10 ,$51.87 ,$39.90 ,$17.10 ,$37.05 ,$41.04 ,$51.87 ,$42.75 
Carle BroMenn Medical Center,8382462,"IGF BINDING PROTEIN-1, REF",,83519,301,$65.00 ,$65.00 ,$19.50 ,$59.15 ,$45.50 ,$19.50 ,$42.25 ,$46.80 ,$59.15 ,$48.75 
Carle BroMenn Medical Center,8382463,"THIOPURINE METHYLTRANSFERACE ACTIVITY PROFILE, REF",,82657,301,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8382466,"CHOLESTROL, BODY FLUID",,84999,301,$91.00 ,$91.00 ,$27.30 ,$82.81 ,$63.70 ,$27.30 ,$59.15 ,$65.52 ,$82.81 ,$68.25 
Carle BroMenn Medical Center,8382469,"COPPER, RBC",,82525,301,$19.00 ,$19.00 ,$5.70 ,$17.29 ,$13.30 ,$5.70 ,$12.35 ,$13.68 ,$17.29 ,$14.25 
Carle BroMenn Medical Center,8382471,INHIBIN B,,82397,301,$85.00 ,$85.00 ,$25.50 ,$77.35 ,$59.50 ,$25.50 ,$55.25 ,$61.20 ,$77.35 ,$63.75 
Carle BroMenn Medical Center,8382479,"SEX HORMONE BINDING GLOBULIN, S",,84270,301,$18.00 ,$18.00 ,$5.40 ,$16.38 ,$12.60 ,$5.40 ,$11.70 ,$12.96 ,$16.38 ,$13.50 
Carle BroMenn Medical Center,8382480,"CHOLINESTERASE, PLASMA REF",,82480,301,$62.40 ,$62.40 ,$18.72 ,$56.78 ,$43.68 ,$18.72 ,$40.56 ,$44.93 ,$56.78 ,$46.80 
Carle BroMenn Medical Center,8382482,"CHOLINESTERASE, RBC REF",,82482,301,$62.40 ,$62.40 ,$18.72 ,$56.78 ,$43.68 ,$18.72 ,$40.56 ,$44.93 ,$56.78 ,$46.80 
Carle BroMenn Medical Center,8382487,NBS-SICKLE CELL SCRN  REF,,83021,301,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8382492,"DRUG ASSAY-CAFFEINE, SERUM REF",,80299,301,$42.00 ,$42.00 ,$12.60 ,$38.22 ,$29.40 ,$12.60 ,$27.30 ,$30.24 ,$38.22 ,$31.50 
Carle BroMenn Medical Center,8382493,DRUG ASSY-TIAGABNE/GABITRL REF,,80299,301,$62.00 ,$62.00 ,$18.60 ,$56.42 ,$43.40 ,$18.60 ,$40.30 ,$44.64 ,$56.42 ,$46.50 
Carle BroMenn Medical Center,8382498,"SUCCINYLACETONE, QUANT, UR, REF",,83921,301,$132.00 ,$132.00 ,$39.60 ,$120.12 ,$92.40 ,$39.60 ,$85.80 ,$95.04 ,$120.12 ,$99.00 
Carle BroMenn Medical Center,8382502,ANTI-MULLERIAN HORMONE,,82397,301,$204.00 ,$204.00 ,$61.20 ,$185.64 ,$142.80 ,$61.20 ,$132.60 ,$146.88 ,$185.64 ,$153.00 
Carle BroMenn Medical Center,8382504,H PYLORI BREATH TEST,,83013,301,$350.00 ,$350.00 ,$105.00 ,$318.50 ,$245.00 ,$105.00 ,$227.50 ,$252.00 ,$318.50 ,$262.50 
Carle BroMenn Medical Center,8382505,LEVETIRACETAM (KEPPRA)     REF,,80299,301,$102.00 ,$102.00 ,$30.60 ,$92.82 ,$71.40 ,$30.60 ,$66.30 ,$73.44 ,$92.82 ,$76.50 
Carle BroMenn Medical Center,8382511,THYROXINE-BINDING GLOBULIN,,84442,301,$165.00 ,$165.00 ,$49.50 ,$150.15 ,$115.50 ,$49.50 ,$107.25 ,$118.80 ,$150.15 ,$123.75 
Carle BroMenn Medical Center,8382522,"PTH RELATED PROTEIN, REF",,83519,301,$162.50 ,$162.50 ,$48.75 ,$147.88 ,$113.75 ,$48.75 ,$105.63 ,$117.00 ,$147.88 ,$121.88 
Carle BroMenn Medical Center,8382523,N-TELOPEPTIDE (NTX) UR  REF,,82523,301,$65.00 ,$65.00 ,$19.50 ,$59.15 ,$45.50 ,$19.50 ,$42.25 ,$46.80 ,$59.15 ,$48.75 
Carle BroMenn Medical Center,8382525,"COPPER, PLASMA             REF",,82525,301,$89.00 ,$89.00 ,$26.70 ,$80.99 ,$62.30 ,$26.70 ,$57.85 ,$64.08 ,$80.99 ,$66.75 
Carle BroMenn Medical Center,8382530,"CORTISOL, FREE, URINE      REF",,82530,301,$33.00 ,$33.00 ,$9.90 ,$30.03 ,$23.10 ,$9.90 ,$21.45 ,$23.76 ,$30.03 ,$24.75 
Carle BroMenn Medical Center,8382533,"CORTISOL, TOTAL            REF",,82533,301,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8382550,CREATINE KINASE CK/CPK/TOTAL,,82550,301,$74.75 ,$74.75 ,$22.43 ,$68.02 ,$52.33 ,$22.43 ,$48.59 ,$53.82 ,$68.02 ,$56.06 
Carle BroMenn Medical Center,8382551,"PANCREATIC ELASTASE-1, FECAL",,83520,301,$135.00 ,$135.00 ,$40.50 ,$122.85 ,$94.50 ,$40.50 ,$87.75 ,$97.20 ,$122.85 ,$101.25 
Carle BroMenn Medical Center,8382553,CK ISOENZYMES              REF,,82552,301,$91.00 ,$91.00 ,$27.30 ,$82.81 ,$63.70 ,$27.30 ,$59.15 ,$65.52 ,$82.81 ,$68.25 
Carle BroMenn Medical Center,8382555,CK TOTAL,,82550,301,$85.00 ,$85.00 ,$25.50 ,$77.35 ,$59.50 ,$25.50 ,$55.25 ,$61.20 ,$77.35 ,$63.75 
Carle BroMenn Medical Center,8382556,CK TOTAL  REF,,82550,301,$74.75 ,$74.75 ,$22.43 ,$68.02 ,$52.33 ,$22.43 ,$48.59 ,$53.82 ,$68.02 ,$56.06 
Carle BroMenn Medical Center,8382562,"BENZODIAZEPINES CONFIRMATION, U, REF",,80347,301,$55.00 ,$55.00 ,$16.50 ,$50.05 ,$38.50 ,$16.50 ,$35.75 ,$39.60 ,$50.05 ,$41.25 
Carle BroMenn Medical Center,8382565,"CREATININE, BLOOD",,82565,301,$48.75 ,$48.75 ,$14.63 ,$44.36 ,$34.13 ,$14.63 ,$31.69 ,$35.10 ,$44.36 ,$36.56 
Carle BroMenn Medical Center,8382570,"CREATININE, OTHER SOURCE",,82570,301,$51.35 ,$51.35 ,$15.41 ,$46.73 ,$35.95 ,$15.41 ,$33.38 ,$36.97 ,$46.73 ,$38.51 
Carle BroMenn Medical Center,8382571,"CREATININE, URINE, RANDOM  REF",,82570,301,$38.00 ,$38.00 ,$11.40 ,$34.58 ,$26.60 ,$11.40 ,$24.70 ,$27.36 ,$34.58 ,$28.50 
Carle BroMenn Medical Center,8382573,CREATININE UR   REF,,82570,301,$38.00 ,$38.00 ,$11.40 ,$34.58 ,$26.60 ,$11.40 ,$24.70 ,$27.36 ,$34.58 ,$28.50 
Carle BroMenn Medical Center,8382580,"RHEUMATOID FACTOR,  IGG, S REF",,83520,301,$18.00 ,$18.00 ,$5.40 ,$16.38 ,$12.60 ,$5.40 ,$11.70 ,$12.96 ,$16.38 ,$13.50 
Carle BroMenn Medical Center,8382583,"NICOTINE AND METABOLITES, REF",,80323,301,$148.00 ,$148.00 ,$44.40 ,$134.68 ,$103.60 ,$44.40 ,$96.20 ,$106.56 ,$134.68 ,$111.00 
Carle BroMenn Medical Center,8382584,CARBOXYHEMOGLOBIN,,82375,301,$108.00 ,$108.00 ,$32.40 ,$98.28 ,$75.60 ,$32.40 ,$70.20 ,$77.76 ,$98.28 ,$81.00 
Carle BroMenn Medical Center,8382585,"CRYOFIBRINOGEN, PLASMA     REF",,82585,301,$52.00 ,$52.00 ,$15.60 ,$47.32 ,$36.40 ,$15.60 ,$33.80 ,$37.44 ,$47.32 ,$39.00 
Carle BroMenn Medical Center,8382590,"ALPHA-MANNOSIDASE, LEUKOCYTES, REF",,82657,301,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8382595,"CRYOGLOBULIN, SERUM        REF",,82595,301,$71.50 ,$71.50 ,$21.45 ,$65.07 ,$50.05 ,$21.45 ,$46.48 ,$51.48 ,$65.07 ,$53.63 
Carle BroMenn Medical Center,8382600,CYANIDE                    REF,,82600,301,$90.00 ,$90.00 ,$27.00 ,$81.90 ,$63.00 ,$27.00 ,$58.50 ,$64.80 ,$81.90 ,$67.50 
Carle BroMenn Medical Center,8382601,"BENZODIAZEPINES, QUANT, U",,80346,301,$14.00 ,$14.00 ,$4.20 ,$12.74 ,$9.80 ,$4.20 ,$9.10 ,$10.08 ,$12.74 ,$10.50 
Carle BroMenn Medical Center,8382606,THC -QUANT- CONFIRMATION   REF,,82542,301,$127.00 ,$127.00 ,$38.10 ,$115.57 ,$88.90 ,$38.10 ,$82.55 ,$91.44 ,$115.57 ,$95.25 
Carle BroMenn Medical Center,8382607,VITAMIN B12,,82607,301,$91.00 ,$91.00 ,$27.30 ,$82.81 ,$63.70 ,$27.30 ,$59.15 ,$65.52 ,$82.81 ,$68.25 
Carle BroMenn Medical Center,8382623,FECAL FAT QUALITATIVE,,82705,301,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8382626,DHEA UNCONJUGATED          REF,,82626,301,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8382627,DHEA SULPHATE   REF,,82627,301,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8382646,DRUG ASSAY -PRIMIDONE,,80188,301,$117.00 ,$117.00 ,$35.10 ,$106.47 ,$81.90 ,$35.10 ,$76.05 ,$84.24 ,$106.47 ,$87.75 
Carle BroMenn Medical Center,8382652,"VITAMIN D 1,25-DIHYDROXY   REF",,82652,301,$286.00 ,$286.00 ,$85.80 ,$260.26 ,$200.20 ,$85.80 ,$185.90 ,$205.92 ,$260.26 ,$214.50 
Carle BroMenn Medical Center,8382655,DRUG ASSAY -PHENYTOIN,,80185,301,$97.50 ,$97.50 ,$29.25 ,$88.73 ,$68.25 ,$29.25 ,$63.38 ,$70.20 ,$88.73 ,$73.13 
Carle BroMenn Medical Center,8382656,DRUG ASSAY -PHENOBARBITAL,,80184,301,$91.00 ,$91.00 ,$27.30 ,$82.81 ,$63.70 ,$27.30 ,$59.15 ,$65.52 ,$82.81 ,$68.25 
Carle BroMenn Medical Center,8382658,GAMMAHYDROXYBUTRIC ACID UR,,80307,301,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8382659,DRUG ASSAY -CARBAMAZEPINE TOTL,,80156,301,$91.00 ,$91.00 ,$27.30 ,$82.81 ,$63.70 ,$27.30 ,$59.15 ,$65.52 ,$82.81 ,$68.25 
Carle BroMenn Medical Center,8382660,METHOTREXATE,,80299,301,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8382661,LACOSAMIDE,,80299,301,$190.00 ,$190.00 ,$57.00 ,$172.90 ,$133.00 ,$57.00 ,$123.50 ,$136.80 ,$172.90 ,$142.50 
Carle BroMenn Medical Center,8382668,ERYTHROPOIETIN             REF,,82668,301,$113.75 ,$113.75 ,$34.13 ,$103.51 ,$79.63 ,$34.13 ,$73.94 ,$81.90 ,$103.51 ,$85.31 
Carle BroMenn Medical Center,8382672,ESTROGEN TOTAL   REF,,82672,301,$26.00 ,$26.00 ,$7.80 ,$23.66 ,$18.20 ,$7.80 ,$16.90 ,$18.72 ,$23.66 ,$19.50 
Carle BroMenn Medical Center,8382674,ENZYME ACTIVITY NES NONRAD REF,,82657,301,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8382677,"ESTRIOL, UNCONJUGATED",,82677,301,$151.00 ,$151.00 ,$45.30 ,$137.41 ,$105.70 ,$45.30 ,$98.15 ,$108.72 ,$137.41 ,$113.25 
Carle BroMenn Medical Center,8382678,ENZYME ACTIVITY NES NONRAD REF,,82657,301,$164.00 ,$164.00 ,$49.20 ,$149.24 ,$114.80 ,$49.20 ,$106.60 ,$118.08 ,$149.24 ,$123.00 
Carle BroMenn Medical Center,8382689,OPIATES CONFIRMATION QUANT,,80361,301,$235.00 ,$235.00 ,$70.50 ,$213.85 ,$164.50 ,$70.50 ,$152.75 ,$169.20 ,$213.85 ,$176.25 
Carle BroMenn Medical Center,8382692,HGH PRSH CHOGR 6M MCPTP (6MP),,82542,301,$245.00 ,$245.00 ,$73.50 ,$222.95 ,$171.50 ,$73.50 ,$159.25 ,$176.40 ,$222.95 ,$183.75 
Carle BroMenn Medical Center,8382693,ETHYLENE GLYCOL            REF,,82693,301,$91.00 ,$91.00 ,$27.30 ,$82.81 ,$63.70 ,$27.30 ,$59.15 ,$65.52 ,$82.81 ,$68.25 
Carle BroMenn Medical Center,8382695,HGH PRSH CHOGR 6M THIO (TPMTEA,,82542,301,$245.00 ,$245.00 ,$73.50 ,$222.95 ,$171.50 ,$73.50 ,$159.25 ,$176.40 ,$222.95 ,$183.75 
Carle BroMenn Medical Center,8382696,HGH PSH LQID CHRGR 6 THIO (6MP,,82542,301,$245.00 ,$245.00 ,$73.50 ,$222.95 ,$171.50 ,$73.50 ,$159.25 ,$176.40 ,$222.95 ,$183.75 
Carle BroMenn Medical Center,8382699,HGB FRACT/QUA CHROMA (HGBE),,83021,301,$170.00 ,$170.00 ,$51.00 ,$154.70 ,$119.00 ,$51.00 ,$110.50 ,$122.40 ,$154.70 ,$127.50 
Carle BroMenn Medical Center,8382710,FECAL FAT/LIPIDS QUANTITTVE RF,,82710,301,$117.00 ,$117.00 ,$35.10 ,$106.47 ,$81.90 ,$35.10 ,$76.05 ,$84.24 ,$106.47 ,$87.75 
Carle BroMenn Medical Center,8382725,FATTY ACIDS NON ESTERIFIED REF,,82725,301,$68.00 ,$68.00 ,$20.40 ,$61.88 ,$47.60 ,$20.40 ,$44.20 ,$48.96 ,$61.88 ,$51.00 
Carle BroMenn Medical Center,8382726,"FATTY ACID PROFILE, PEROXISOMAL   REF",,82726,301,$41.00 ,$41.00 ,$12.30 ,$37.31 ,$28.70 ,$12.30 ,$26.65 ,$29.52 ,$37.31 ,$30.75 
Carle BroMenn Medical Center,8382735,"FLUORIDE, P  REF",,82735,301,$70.00 ,$70.00 ,$21.00 ,$63.70 ,$49.00 ,$21.00 ,$45.50 ,$50.40 ,$63.70 ,$52.50 
Carle BroMenn Medical Center,8382739,INFLIXIMAB ADAIBD,,83520,301,$425.00 ,$425.00 ,$127.50 ,$386.75 ,$297.50 ,$127.50 ,$276.25 ,$306.00 ,$386.75 ,$318.75 
Carle BroMenn Medical Center,8382743,"FOLIC ACID (FOLATE), SERUM",,82746,301,$91.00 ,$91.00 ,$27.30 ,$82.81 ,$63.70 ,$27.30 ,$59.15 ,$65.52 ,$82.81 ,$68.25 
Carle BroMenn Medical Center,8382747,"FOLIC ACID (FOLATE), RBC   REF",,82747,301,$20.00 ,$20.00 ,$6.00 ,$18.20 ,$14.00 ,$6.00 ,$13.00 ,$14.40 ,$18.20 ,$15.00 
Carle BroMenn Medical Center,8382748,VIT K,,84597,301,$228.88 ,$228.88 ,$68.66 ,$208.28 ,$160.22 ,$68.66 ,$148.77 ,$164.79 ,$208.28 ,$171.66 
Carle BroMenn Medical Center,8382754,THN LYR ANLTE NOT EW SPEC (PG),,83516,301,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8382760,GALACTOSEMIA SCREEN        REF,,82760,301,$5.00 ,$5.00 ,$1.50 ,$4.55 ,$3.50 ,$1.50 ,$3.25 ,$3.60 ,$4.55 ,$3.75 
Carle BroMenn Medical Center,8382775,ASSAY GALACTOSE TRANSFERASE-RE,,82775,301,$227.00 ,$227.00 ,$68.10 ,$206.57 ,$158.90 ,$68.10 ,$147.55 ,$163.44 ,$206.57 ,$170.25 
Carle BroMenn Medical Center,8382780,GAMMAGLOBULIN IGG TOTAL    REF,,82784,301,$11.00 ,$11.00 ,$3.30 ,$10.01 ,$7.70 ,$3.30 ,$7.15 ,$7.92 ,$10.01 ,$8.25 
Carle BroMenn Medical Center,8382783,GAMMAGLOBULIN REF,,82785,301,$100.75 ,$100.75 ,$30.23 ,$91.68 ,$70.53 ,$30.23 ,$65.49 ,$72.54 ,$91.68 ,$75.56 
Carle BroMenn Medical Center,8382784,GAMMAGLOBULIN IGA/IGD/IGG/IGM,,82784,301,$151.00 ,$151.00 ,$45.30 ,$137.41 ,$105.70 ,$45.30 ,$98.15 ,$108.72 ,$137.41 ,$113.25 
Carle BroMenn Medical Center,8382787,GAMMAGLOBULIN IGE          REF,,82785,301,$20.00 ,$20.00 ,$6.00 ,$18.20 ,$14.00 ,$6.00 ,$13.00 ,$14.40 ,$18.20 ,$15.00 
Carle BroMenn Medical Center,8382790,IMMUNOGLOBULIN SUBCLASSES  REF,,82787,301,$48.75 ,$48.75 ,$14.63 ,$44.36 ,$34.13 ,$14.63 ,$31.69 ,$35.10 ,$44.36 ,$36.56 
Carle BroMenn Medical Center,8382791,"METHYLMALONIC ACID, QN, U   REF",,83921,301,$34.00 ,$34.00 ,$10.20 ,$30.94 ,$23.80 ,$10.20 ,$22.10 ,$24.48 ,$30.94 ,$25.50 
Carle BroMenn Medical Center,8382820,H PYLORI BREATH TEST,,83013,301,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8382833,COPPER,,82525,301,$74.75 ,$74.75 ,$22.43 ,$68.02 ,$52.33 ,$22.43 ,$48.59 ,$53.82 ,$68.02 ,$56.06 
Carle BroMenn Medical Center,8382943,"GLUCAGON, P  REF",,82943,301,$21.00 ,$21.00 ,$6.30 ,$19.11 ,$14.70 ,$6.30 ,$13.65 ,$15.12 ,$19.11 ,$15.75 
Carle BroMenn Medical Center,8382944,HOMOCYSTEINE ASSAY,,83090,301,$158.00 ,$158.00 ,$47.40 ,$143.78 ,$110.60 ,$47.40 ,$102.70 ,$113.76 ,$143.78 ,$118.50 
Carle BroMenn Medical Center,8382945,GLUCOSE BODY FLUID REF,,82945,301,$29.25 ,$29.25 ,$8.78 ,$26.62 ,$20.48 ,$8.78 ,$19.01 ,$21.06 ,$26.62 ,$21.94 
Carle BroMenn Medical Center,8382946,GASTRIN                    REF,,82941,301,$132.00 ,$132.00 ,$39.60 ,$120.12 ,$92.40 ,$39.60 ,$85.80 ,$95.04 ,$120.12 ,$99.00 
Carle BroMenn Medical Center,8382947,"GLUCOSE, QUANTITATIVE",,82947,301,$48.75 ,$48.75 ,$14.63 ,$44.36 ,$34.13 ,$14.63 ,$31.69 ,$35.10 ,$44.36 ,$36.56 
Carle BroMenn Medical Center,8382949,GLUCOSE MISC REF,,82947,301,$46.00 ,$46.00 ,$13.80 ,$41.86 ,$32.20 ,$13.80 ,$29.90 ,$33.12 ,$41.86 ,$34.50 
Carle BroMenn Medical Center,8382951,GLUCOSE 2 HR PP,,82947,301,$46.00 ,$46.00 ,$13.80 ,$41.86 ,$32.20 ,$13.80 ,$29.90 ,$33.12 ,$41.86 ,$34.50 
Carle BroMenn Medical Center,8382955,"G6PD, QUANTITATIVE         REF",,82955,301,$32.00 ,$32.00 ,$9.60 ,$29.12 ,$22.40 ,$9.60 ,$20.80 ,$23.04 ,$29.12 ,$24.00 
Carle BroMenn Medical Center,8382960,G6PD SCREEN,,82960,301,$56.00 ,$56.00 ,$16.80 ,$50.96 ,$39.20 ,$16.80 ,$36.40 ,$40.32 ,$50.96 ,$42.00 
Carle BroMenn Medical Center,8382961,G6PD SCREEN                REF,,82960,301,$8.00 ,$8.00 ,$2.40 ,$7.28 ,$5.60 ,$2.40 ,$5.20 ,$5.76 ,$7.28 ,$6.00 
Carle BroMenn Medical Center,8382985,GLYCATD PROTEIN -FRUCTOSAMN RF,,82985,301,$18.00 ,$18.00 ,$5.40 ,$16.38 ,$12.60 ,$5.40 ,$11.70 ,$12.96 ,$16.38 ,$13.50 
Carle BroMenn Medical Center,8383003,HUMAN GROWTH HORMONE       REF,,83003,301,$100.75 ,$100.75 ,$30.23 ,$91.68 ,$70.53 ,$30.23 ,$65.49 ,$72.54 ,$91.68 ,$75.56 
Carle BroMenn Medical Center,8383014,FERRITIN,,82728,301,$94.25 ,$94.25 ,$28.28 ,$85.77 ,$65.98 ,$28.28 ,$61.26 ,$67.86 ,$85.77 ,$70.69 
Carle BroMenn Medical Center,8383016,GASTRIN                    REF,,82941,301,$28.00 ,$28.00 ,$8.40 ,$25.48 ,$19.60 ,$8.40 ,$18.20 ,$20.16 ,$25.48 ,$21.00 
Carle BroMenn Medical Center,8383019,HGB CHROMATOGRAPHY         REF,,83021,301,$21.00 ,$21.00 ,$6.30 ,$19.11 ,$14.70 ,$6.30 ,$13.65 ,$15.12 ,$19.11 ,$15.75 
Carle BroMenn Medical Center,8383025,"HEMOGLOBIN, GLYCATED (A1C)",,83036,301,$63.70 ,$63.70 ,$19.11 ,$57.97 ,$44.59 ,$19.11 ,$41.41 ,$45.86 ,$57.97 ,$47.78 
Carle BroMenn Medical Center,8383051,"HEMOGLOBIN, PLASMA",,83051,301,$113.75 ,$113.75 ,$34.13 ,$103.51 ,$79.63 ,$34.13 ,$73.94 ,$81.90 ,$103.51 ,$85.31 
Carle BroMenn Medical Center,8383068,"HEMOGLOBIN, UNSTABLE, B    REF",,83068,301,$83.00 ,$83.00 ,$24.90 ,$75.53 ,$58.10 ,$24.90 ,$53.95 ,$59.76 ,$75.53 ,$62.25 
Carle BroMenn Medical Center,8383069,"HEMOGLOBIN, URINE          REF",,83069,301,$52.00 ,$52.00 ,$15.60 ,$47.32 ,$36.40 ,$15.60 ,$33.80 ,$37.44 ,$47.32 ,$39.00 
Carle BroMenn Medical Center,8383070,HEMOSIDERIN URINE QUALITATIVE,,83070,301,$39.00 ,$39.00 ,$11.70 ,$35.49 ,$27.30 ,$11.70 ,$25.35 ,$28.08 ,$35.49 ,$29.25 
Carle BroMenn Medical Center,8383088,ASSAY HISTAMINE,,83088,301,$113.00 ,$113.00 ,$33.90 ,$102.83 ,$79.10 ,$33.90 ,$73.45 ,$81.36 ,$102.83 ,$84.75 
Carle BroMenn Medical Center,8383090,HOMOCYSTINE LEVEL REF,,83090,301,$104.00 ,$104.00 ,$31.20 ,$94.64 ,$72.80 ,$31.20 ,$67.60 ,$74.88 ,$94.64 ,$78.00 
Carle BroMenn Medical Center,8383103,"FENTANYL AND ACETYL FENTANYL,REF",,á80354,301,$170.00 ,$170.00 ,$51.00 ,$154.70 ,$119.00 ,$51.00 ,$110.50 ,$122.40 ,$154.70 ,$127.50 
Carle BroMenn Medical Center,8383112,"ALDOSTERONE, SERUM         REF",,82088,301,$22.00 ,$22.00 ,$6.60 ,$20.02 ,$15.40 ,$6.60 ,$14.30 ,$15.84 ,$20.02 ,$16.50 
Carle BroMenn Medical Center,8383120,"CATECHOLAMINE FRACT, FREE, U   REF",,82384,301,$19.00 ,$19.00 ,$5.70 ,$17.29 ,$13.30 ,$5.70 ,$12.35 ,$13.68 ,$17.29 ,$14.25 
Carle BroMenn Medical Center,8383140,"VMA, URINE (ADULT)",,84585,301,$139.75 ,$139.75 ,$41.93 ,$127.17 ,$97.83 ,$41.93 ,$90.84 ,$100.62 ,$127.17 ,$104.81 
Carle BroMenn Medical Center,8383150,"HOMOVANILLIC ACID(HVA), 24HR, U  REF",,83150,301,$30.00 ,$30.00 ,$9.00 ,$27.30 ,$21.00 ,$9.00 ,$19.50 ,$21.60 ,$27.30 ,$22.50 
Carle BroMenn Medical Center,8383180,"CORTISOL, TOTAL",,82533,301,$100.75 ,$100.75 ,$30.23 ,$91.68 ,$70.53 ,$30.23 ,$65.49 ,$72.54 ,$91.68 ,$75.56 
Carle BroMenn Medical Center,8383246,ASSAY  -ESTRADIOL,,82670,301,$146.25 ,$146.25 ,$43.88 ,$133.09 ,$102.38 ,$43.88 ,$95.06 ,$105.30 ,$133.09 ,$109.69 
Carle BroMenn Medical Center,8383304,LUTEINIZING HORMONE (LH),,83002,301,$136.50 ,$136.50 ,$40.95 ,$124.22 ,$95.55 ,$40.95 ,$88.73 ,$98.28 ,$124.22 ,$102.38 
Carle BroMenn Medical Center,8383311,FOLLICLE STIMULATING HORMONE,,83001,301,$139.75 ,$139.75 ,$41.93 ,$127.17 ,$97.83 ,$41.93 ,$90.84 ,$100.62 ,$127.17 ,$104.81 
Carle BroMenn Medical Center,8383350,PROGESTRONE,,84144,301,$156.00 ,$156.00 ,$46.80 ,$141.96 ,$109.20 ,$46.80 ,$101.40 ,$112.32 ,$141.96 ,$117.00 
Carle BroMenn Medical Center,8383360,"RENIN ACTIVITY, PLASMA     REF",,84244,301,$62.00 ,$62.00 ,$18.60 ,$56.42 ,$43.40 ,$18.60 ,$40.30 ,$44.64 ,$56.42 ,$46.50 
Carle BroMenn Medical Center,8383390,INSULIN                    REF,,83525,301,$91.00 ,$91.00 ,$27.30 ,$82.81 ,$63.70 ,$27.30 ,$59.15 ,$65.52 ,$82.81 ,$68.25 
Carle BroMenn Medical Center,8383405,TESTOSTERONE,,84403,301,$243.00 ,$243.00 ,$72.90 ,$221.13 ,$170.10 ,$72.90 ,$157.95 ,$174.96 ,$221.13 ,$182.25 
Carle BroMenn Medical Center,8383455,T-4,,84436,301,$48.10 ,$48.10 ,$14.43 ,$43.77 ,$33.67 ,$14.43 ,$31.27 ,$34.63 ,$43.77 ,$36.08 
Carle BroMenn Medical Center,8383480,TSH,,84443,301,$104.00 ,$104.00 ,$31.20 ,$94.64 ,$72.80 ,$31.20 ,$67.60 ,$74.88 ,$94.64 ,$78.00 
Carle BroMenn Medical Center,8383493,HYDRXYINDOLCTEIC ACID 5HIAA RF,,83497,301,$97.50 ,$97.50 ,$29.25 ,$88.73 ,$68.25 ,$29.25 ,$63.38 ,$70.20 ,$88.73 ,$73.13 
Carle BroMenn Medical Center,8383494,"TISS TRANSGLUTAMIN AB, IGA, S   REF",,83516,301,$84.50 ,$84.50 ,$25.35 ,$76.90 ,$59.15 ,$25.35 ,$54.93 ,$60.84 ,$76.90 ,$63.38 
Carle BroMenn Medical Center,8383496,"OH-PROGESTERONE, 17-ALPHA  REF",,83498,301,$31.00 ,$31.00 ,$9.30 ,$28.21 ,$21.70 ,$9.30 ,$20.15 ,$22.32 ,$28.21 ,$23.25 
Carle BroMenn Medical Center,8383498,ANGIOTENSIN I-CONV ENZYME  REF,,82164,301,$107.25 ,$107.25 ,$32.18 ,$97.60 ,$75.08 ,$32.18 ,$69.71 ,$77.22 ,$97.60 ,$80.44 
Carle BroMenn Medical Center,8383499,NBS-CONGEN ADRENAL HYPERPL SCRN  REF,,83498,301,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8383510,"PANCREATIC ELASTASE, F     REF",,82656,301,$182.00 ,$182.00 ,$54.60 ,$165.62 ,$127.40 ,$54.60 ,$118.30 ,$131.04 ,$165.62 ,$136.50 
Carle BroMenn Medical Center,8383513,ASSAY -ENDOCRINE HORMONE REF,,82397,301,$154.00 ,$154.00 ,$46.20 ,$140.14 ,$107.80 ,$46.20 ,$100.10 ,$110.88 ,$140.14 ,$115.50 
Carle BroMenn Medical Center,8383518,SUBSTANCE-P,,83520,301,$122.00 ,$122.00 ,$36.60 ,$111.02 ,$85.40 ,$36.60 ,$79.30 ,$87.84 ,$111.02 ,$91.50 
Carle BroMenn Medical Center,8383524,GLOMERULAR BASE MEM AB     REF,,83520,301,$117.00 ,$117.00 ,$35.10 ,$106.47 ,$81.90 ,$35.10 ,$76.05 ,$84.24 ,$106.47 ,$87.75 
Carle BroMenn Medical Center,8383531,GLIADIN ANTIBODIES,,83516,301,$7.00 ,$7.00 ,$2.10 ,$6.37 ,$4.90 ,$2.10 ,$4.55 ,$5.04 ,$6.37 ,$5.25 
Carle BroMenn Medical Center,8383533,"RIBOSOMAL P AB, REF",,83516,301,$36.00 ,$36.00 ,$10.80 ,$32.76 ,$25.20 ,$10.80 ,$23.40 ,$25.92 ,$32.76 ,$27.00 
Carle BroMenn Medical Center,8383534,B-NATRIURETIC PEPTIDE,,83880,301,$172.25 ,$172.25 ,$51.68 ,$156.75 ,$120.58 ,$51.68 ,$111.96 ,$124.02 ,$156.75 ,$129.19 
Carle BroMenn Medical Center,8383546,CYSTIC FIBROSIS            REF,,83516,301,$13.00 ,$13.00 ,$3.90 ,$11.83 ,$9.10 ,$3.90 ,$8.45 ,$9.36 ,$11.83 ,$9.75 
Carle BroMenn Medical Center,8383555,IMMUNO ASSAY MOTILIN,,83519,301,$122.00 ,$122.00 ,$36.60 ,$111.02 ,$85.40 ,$36.60 ,$79.30 ,$87.84 ,$111.02 ,$91.50 
Carle BroMenn Medical Center,8383576,IMMUNOASSAY ANALYTE QUANT  REF,,83520,301,$104.00 ,$104.00 ,$31.20 ,$94.64 ,$72.80 ,$31.20 ,$67.60 ,$74.88 ,$94.64 ,$78.00 
Carle BroMenn Medical Center,8383600,LACTIC ACID (LACTATE)      REF,,83605,301,$11.00 ,$11.00 ,$3.30 ,$10.01 ,$7.70 ,$3.30 ,$7.15 ,$7.92 ,$10.01 ,$8.25 
Carle BroMenn Medical Center,8383605,LACTIC ACID,,83605,301,$84.50 ,$84.50 ,$25.35 ,$76.90 ,$59.15 ,$25.35 ,$54.93 ,$60.84 ,$76.90 ,$63.38 
Carle BroMenn Medical Center,8383610,"HEMOGLOBIN, GLYCATED (A1C) REF",,83036,301,$17.00 ,$17.00 ,$5.10 ,$15.47 ,$11.90 ,$5.10 ,$11.05 ,$12.24 ,$15.47 ,$12.75 
Carle BroMenn Medical Center,8383615,LACTATE DEHYDROGENASE (LD/LDH),,83615,301,$53.95 ,$53.95 ,$16.19 ,$49.09 ,$37.77 ,$16.19 ,$35.07 ,$38.84 ,$49.09 ,$40.46 
Carle BroMenn Medical Center,8383616,LACTATE DEHYDROGENASE TOTL REF,,83615,301,$44.85 ,$44.85 ,$13.46 ,$40.81 ,$31.40 ,$13.46 ,$29.15 ,$32.29 ,$40.81 ,$33.64 
Carle BroMenn Medical Center,8383625,LD ISOENZYMES              REF,,83625,301,$78.00 ,$78.00 ,$23.40 ,$70.98 ,$54.60 ,$23.40 ,$50.70 ,$56.16 ,$70.98 ,$58.50 
Carle BroMenn Medical Center,8383626,"PHENCYCLIDINE CONF, URREF REF",,83992,301,$328.25 ,$328.25 ,$98.48 ,$298.71 ,$229.78 ,$98.48 ,$213.36 ,$236.34 ,$298.71 ,$246.19 
Carle BroMenn Medical Center,8383631,"LDL CHOLESTEROL, DIRECT",,83721,301,$88.00 ,$88.00 ,$26.40 ,$80.08 ,$61.60 ,$26.40 ,$57.20 ,$63.36 ,$80.08 ,$66.00 
Carle BroMenn Medical Center,8383650,ASSAY OF MYOGLOBIN REF,,83874,301,$125.00 ,$125.00 ,$37.50 ,$113.75 ,$87.50 ,$37.50 ,$81.25 ,$90.00 ,$113.75 ,$93.75 
Carle BroMenn Medical Center,8383655,"LEAD, BLOOD                REF",,83655,301,$18.00 ,$18.00 ,$5.40 ,$16.38 ,$12.60 ,$5.40 ,$11.70 ,$12.96 ,$16.38 ,$13.50 
Carle BroMenn Medical Center,8383660,"LEAD, URINE (24HR)         REF",,83655,301,$67.00 ,$67.00 ,$20.10 ,$60.97 ,$46.90 ,$20.10 ,$43.55 ,$48.24 ,$60.97 ,$50.25 
Carle BroMenn Medical Center,8383661,L/S RATIO,,83661,301,$497.25 ,$497.25 ,$149.18 ,$452.50 ,$348.08 ,$149.18 ,$323.21 ,$358.02 ,$452.50 ,$372.94 
Carle BroMenn Medical Center,8383680,"METANEPHRINES, PLASMA REF",,83835,301,$211.25 ,$211.25 ,$63.38 ,$192.24 ,$147.88 ,$63.38 ,$137.31 ,$152.10 ,$192.24 ,$158.44 
Carle BroMenn Medical Center,8383685,DRUG ASSAY -LIDOCAINE,,80176,301,$117.00 ,$117.00 ,$35.10 ,$106.47 ,$81.90 ,$35.10 ,$76.05 ,$84.24 ,$106.47 ,$87.75 
Carle BroMenn Medical Center,8383695,LIPOPROTEIN ASSAY REF,,83695,301,$74.00 ,$74.00 ,$22.20 ,$67.34 ,$51.80 ,$22.20 ,$48.10 ,$53.28 ,$67.34 ,$55.50 
Carle BroMenn Medical Center,8383701,LIPOPROTEIN BLD HR FRACTION-RE,,83701,301,$29.00 ,$29.00 ,$8.70 ,$26.39 ,$20.30 ,$8.70 ,$18.85 ,$20.88 ,$26.39 ,$21.75 
Carle BroMenn Medical Center,8383718,HDL CHOLESTEROL,,83718,301,$74.75 ,$74.75 ,$22.43 ,$68.02 ,$52.33 ,$22.43 ,$48.59 ,$53.82 ,$68.02 ,$56.06 
Carle BroMenn Medical Center,8383721,DIRECT LDL,,83721,301,$50.00 ,$50.00 ,$15.00 ,$45.50 ,$35.00 ,$15.00 ,$32.50 ,$36.00 ,$45.50 ,$37.50 
Carle BroMenn Medical Center,8383730,"METHYLMALONIC ACID, QN, S   REF",,83921,301,$22.00 ,$22.00 ,$6.60 ,$20.02 ,$15.40 ,$6.60 ,$14.30 ,$15.84 ,$20.02 ,$16.50 
Carle BroMenn Medical Center,8383735,MAGNESIUM,,83735,301,$68.25 ,$68.25 ,$20.48 ,$62.11 ,$47.78 ,$20.48 ,$44.36 ,$49.14 ,$62.11 ,$51.19 
Carle BroMenn Medical Center,8383736,"MAGNESIUM, URINE",,83735,301,$101.00 ,$101.00 ,$30.30 ,$91.91 ,$70.70 ,$30.30 ,$65.65 ,$72.72 ,$91.91 ,$75.75 
Carle BroMenn Medical Center,8383830,"MERCURY, URINE (24HR)      REF",,83825,301,$49.00 ,$49.00 ,$14.70 ,$44.59 ,$34.30 ,$14.70 ,$31.85 ,$35.28 ,$44.59 ,$36.75 
Carle BroMenn Medical Center,8383831,MERCURY BLOOD   REF,,83825,301,$48.00 ,$48.00 ,$14.40 ,$43.68 ,$33.60 ,$14.40 ,$31.20 ,$34.56 ,$43.68 ,$36.00 
Carle BroMenn Medical Center,8383835,"METANEPHRINES, URINE(24HR) REF",,83835,301,$30.00 ,$30.00 ,$9.00 ,$27.30 ,$21.00 ,$9.00 ,$19.50 ,$21.60 ,$27.30 ,$22.50 
Carle BroMenn Medical Center,8383872,"MUCIN, SYNOVIAL FLUID(ROPES TE",,83872,301,$49.00 ,$49.00 ,$14.70 ,$44.59 ,$34.30 ,$14.70 ,$31.85 ,$35.28 ,$44.59 ,$36.75 
Carle BroMenn Medical Center,8383874,"MYOGLOBIN, SERUM           REF",,83874,301,$37.00 ,$37.00 ,$11.10 ,$33.67 ,$25.90 ,$11.10 ,$24.05 ,$26.64 ,$33.67 ,$27.75 
Carle BroMenn Medical Center,8383883,"ALBUMIN, CSF",,82042,301,$66.00 ,$66.00 ,$19.80 ,$60.06 ,$46.20 ,$19.80 ,$42.90 ,$47.52 ,$60.06 ,$49.50 
Carle BroMenn Medical Center,8383915,NUCLEOTIDASE-5 REF,,83915,301,$57.00 ,$57.00 ,$17.10 ,$51.87 ,$39.90 ,$17.10 ,$37.05 ,$41.04 ,$51.87 ,$42.75 
Carle BroMenn Medical Center,8383918,"ORGANIC ACIDS, QUANT EACH  REF",,83918,301,$201.50 ,$201.50 ,$60.45 ,$183.37 ,$141.05 ,$60.45 ,$130.98 ,$145.08 ,$183.37 ,$151.13 
Carle BroMenn Medical Center,8383919,METHYLMALONIC ACID         REF,,83921,301,$48.00 ,$48.00 ,$14.40 ,$43.68 ,$33.60 ,$14.40 ,$31.20 ,$34.56 ,$43.68 ,$36.00 
Carle BroMenn Medical Center,8383920,"ORGANIC ACIDS, QUAL, URINE REF",,83919,301,$56.00 ,$56.00 ,$16.80 ,$50.96 ,$39.20 ,$16.80 ,$36.40 ,$40.32 ,$50.96 ,$42.00 
Carle BroMenn Medical Center,8383921,ORGANIC ACID SINGLE QUANT REF,,83921,301,$273.00 ,$273.00 ,$81.90 ,$248.43 ,$191.10 ,$81.90 ,$177.45 ,$196.56 ,$248.43 ,$204.75 
Carle BroMenn Medical Center,8383931,"OSMOLALITY, STOOL",,84999,301,$95.00 ,$95.00 ,$28.50 ,$86.45 ,$66.50 ,$28.50 ,$61.75 ,$68.40 ,$86.45 ,$71.25 
Carle BroMenn Medical Center,8383932,OSMOLALITY -BODY FLUID,,84999,301,$82.00 ,$82.00 ,$24.60 ,$74.62 ,$57.40 ,$24.60 ,$53.30 ,$59.04 ,$74.62 ,$61.50 
Carle BroMenn Medical Center,8383935,"OSMOLALITY, URINE",,83935,301,$53.95 ,$53.95 ,$16.19 ,$49.09 ,$37.77 ,$16.19 ,$35.07 ,$38.84 ,$49.09 ,$40.46 
Carle BroMenn Medical Center,8383937,"OSTEOCALCIN, SERUM       REF",,83937,301,$20.00 ,$20.00 ,$6.00 ,$18.20 ,$14.00 ,$6.00 ,$13.00 ,$14.40 ,$18.20 ,$15.00 
Carle BroMenn Medical Center,8383945,OXALATE URINE (24HR) REF,,83945,301,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8383951,DES-GAMMA-CARBOXY-PROTHROMBIN,,83951,301,$158.00 ,$158.00 ,$47.40 ,$143.78 ,$110.60 ,$47.40 ,$102.70 ,$113.76 ,$143.78 ,$118.50 
Carle BroMenn Medical Center,8383986,"PH, BODY FLUID, EXCEPT BLOOD",,83986,301,$72.00 ,$72.00 ,$21.60 ,$65.52 ,$50.40 ,$21.60 ,$46.80 ,$51.84 ,$65.52 ,$54.00 
Carle BroMenn Medical Center,8383992,PHENCYCLIDINE (PCP)   REF,,83992,301,$22.75 ,$22.75 ,$6.83 ,$20.70 ,$15.93 ,$6.83 ,$14.79 ,$16.38 ,$20.70 ,$17.06 
Carle BroMenn Medical Center,8383993,CALPROTECTIN FECAL REF,,83993,301,$136.00 ,$136.00 ,$40.80 ,$123.76 ,$95.20 ,$40.80 ,$88.40 ,$97.92 ,$123.76 ,$102.00 
Carle BroMenn Medical Center,8384039,"ALKALINE PHOSPHATASE,TOTAL REF",,84075,301,$49.00 ,$49.00 ,$14.70 ,$44.59 ,$34.30 ,$14.70 ,$31.85 ,$35.28 ,$44.59 ,$36.75 
Carle BroMenn Medical Center,8384045,"PHENYTOIN, FREE            REF",,80186,301,$100.75 ,$100.75 ,$30.23 ,$91.68 ,$70.53 ,$30.23 ,$65.49 ,$72.54 ,$91.68 ,$75.56 
Carle BroMenn Medical Center,8384046,"PHENYTOIN, TOTAL           REF",,80185,301,$16.00 ,$16.00 ,$4.80 ,$14.56 ,$11.20 ,$4.80 ,$10.40 ,$11.52 ,$14.56 ,$12.00 
Carle BroMenn Medical Center,8384064,PSA TOTAL,,84153,301,$175.00 ,$175.00 ,$52.50 ,$159.25 ,$122.50 ,$52.50 ,$113.75 ,$126.00 ,$159.25 ,$131.25 
Carle BroMenn Medical Center,8384067,PROSTATIC ACID PHOSPHATASE REF,,84066,301,$91.00 ,$91.00 ,$27.30 ,$82.81 ,$63.70 ,$27.30 ,$59.15 ,$65.52 ,$82.81 ,$68.25 
Carle BroMenn Medical Center,8384075,ALKALINE PHOSPHATASE,,84075,301,$44.20 ,$44.20 ,$13.26 ,$40.22 ,$30.94 ,$13.26 ,$28.73 ,$31.82 ,$40.22 ,$33.15 
Carle BroMenn Medical Center,8384080,ALK PHOS ISOENZYMES        REF,,84080,301,$43.00 ,$43.00 ,$12.90 ,$39.13 ,$30.10 ,$12.90 ,$27.95 ,$30.96 ,$39.13 ,$32.25 
Carle BroMenn Medical Center,8384081,PHOPHATIDYLGLYCEROL (IA MTHD),,84081,301,$403.00 ,$403.00 ,$120.90 ,$366.73 ,$282.10 ,$120.90 ,$261.95 ,$290.16 ,$366.73 ,$302.25 
Carle BroMenn Medical Center,8384100,PHOSPHORUS INORGAN (PHOSPHATE),,84100,301,$51.35 ,$51.35 ,$15.41 ,$46.73 ,$35.95 ,$15.41 ,$33.38 ,$36.97 ,$46.73 ,$38.51 
Carle BroMenn Medical Center,8384105,"PHOSPHORUS, URINE",,84105,301,$167.00 ,$167.00 ,$50.10 ,$151.97 ,$116.90 ,$50.10 ,$108.55 ,$120.24 ,$151.97 ,$125.25 
Carle BroMenn Medical Center,8384110,"PORPHOBILINOGEN, U           REF",,84110,301,$100.75 ,$100.75 ,$30.23 ,$91.68 ,$70.53 ,$30.23 ,$65.49 ,$72.54 ,$91.68 ,$75.56 
Carle BroMenn Medical Center,8384112,AMNISURE ROM,,84112,301,$85.00 ,$85.00 ,$25.50 ,$77.35 ,$59.50 ,$25.50 ,$55.25 ,$61.20 ,$77.35 ,$63.75 
Carle BroMenn Medical Center,8384123,"PORPHYRINS FRACT, URINE    REF",,84120,301,$136.50 ,$136.50 ,$40.95 ,$124.22 ,$95.55 ,$40.95 ,$88.73 ,$98.28 ,$124.22 ,$102.38 
Carle BroMenn Medical Center,8384132,POTASSIUM BODY FLUID,,84999,301,$91.00 ,$91.00 ,$27.30 ,$82.81 ,$63.70 ,$27.30 ,$59.15 ,$65.52 ,$82.81 ,$68.25 
Carle BroMenn Medical Center,8384133,"POTASSIUM, URINE",,84133,301,$40.95 ,$40.95 ,$12.29 ,$37.26 ,$28.67 ,$12.29 ,$26.62 ,$29.48 ,$37.26 ,$30.71 
Carle BroMenn Medical Center,8384139,PORPHYRIN FRAC RANDOM UR   REF,,84120,301,$26.00 ,$26.00 ,$7.80 ,$23.66 ,$18.20 ,$7.80 ,$16.90 ,$18.72 ,$23.66 ,$19.50 
Carle BroMenn Medical Center,8384146,PROLACTIN,,84146,301,$143.00 ,$143.00 ,$42.90 ,$130.13 ,$100.10 ,$42.90 ,$92.95 ,$102.96 ,$130.13 ,$107.25 
Carle BroMenn Medical Center,8384147,ASSAY PROLACTIN,,84146,301,$68.25 ,$68.25 ,$20.48 ,$62.11 ,$47.78 ,$20.48 ,$44.36 ,$49.14 ,$62.11 ,$51.19 
Carle BroMenn Medical Center,8384152,PSA TOTAL REF,,84153,301,$10.25 ,$10.25 ,$3.08 ,$9.33 ,$7.18 ,$3.08 ,$6.66 ,$7.38 ,$9.33 ,$7.69 
Carle BroMenn Medical Center,8384153,"PSA, SCREENING",,G0103,301,$185.00 ,$185.00 ,$55.50 ,$168.35 ,$129.50 ,$55.50 ,$120.25 ,$133.20 ,$168.35 ,$138.75 
Carle BroMenn Medical Center,8384154,PSA FREE,,84154,301,$113.75 ,$113.75 ,$34.13 ,$103.51 ,$79.63 ,$34.13 ,$73.94 ,$81.90 ,$103.51 ,$85.31 
Carle BroMenn Medical Center,8384155,"PROTEIN, TOTAL, SERUM",,84155,301,$48.10 ,$48.10 ,$14.43 ,$43.77 ,$33.67 ,$14.43 ,$31.27 ,$34.63 ,$43.77 ,$36.08 
Carle BroMenn Medical Center,8384156,"PROTEIN, TOTAL, URINE",,84156,301,$53.95 ,$53.95 ,$16.19 ,$49.09 ,$37.77 ,$16.19 ,$35.07 ,$38.84 ,$49.09 ,$40.46 
Carle BroMenn Medical Center,8384157,"PROTEIN, TOTAL, OTHER SOURCE",,84157,301,$51.35 ,$51.35 ,$15.41 ,$46.73 ,$35.95 ,$15.41 ,$33.38 ,$36.97 ,$46.73 ,$38.51 
Carle BroMenn Medical Center,8384158,PROTEIN TOTAL UR REF,,84156,301,$53.95 ,$53.95 ,$16.19 ,$49.09 ,$37.77 ,$16.19 ,$35.07 ,$38.84 ,$49.09 ,$40.46 
Carle BroMenn Medical Center,8384167,PROTEIN ELP FRACT&QT W/CONC REF,,84166,301,$97.50 ,$97.50 ,$29.25 ,$88.73 ,$68.25 ,$29.25 ,$63.38 ,$70.20 ,$88.73 ,$73.13 
Carle BroMenn Medical Center,8384181,"PROTEIN, WESTERN BLOT      REF",,84181,301,$242.00 ,$242.00 ,$72.60 ,$220.22 ,$169.40 ,$72.60 ,$157.30 ,$174.24 ,$220.22 ,$181.50 
Carle BroMenn Medical Center,8384202,PROTOPORPHYRIN  -ZINC-     REF,,84202,301,$18.00 ,$18.00 ,$5.40 ,$16.38 ,$12.60 ,$5.40 ,$11.70 ,$12.96 ,$16.38 ,$13.50 
Carle BroMenn Medical Center,8384206,PROINSULIN                 REF,,84206,301,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8384207,VITAMIN B6                 REF,,84207,301,$172.25 ,$172.25 ,$51.68 ,$156.75 ,$120.58 ,$51.68 ,$111.96 ,$124.02 ,$156.75 ,$129.19 
Carle BroMenn Medical Center,8384236,ACETYLCHLNE RCPTR BLCKNG AB RF,,83519,301,$115.05 ,$115.05 ,$34.52 ,$104.70 ,$80.54 ,$34.52 ,$74.78 ,$82.84 ,$104.70 ,$86.29 
Carle BroMenn Medical Center,8384238,ACETYLCHLN RCPTR MODULAT AB RF,,83519,301,$135.20 ,$135.20 ,$40.56 ,$123.03 ,$94.64 ,$40.56 ,$87.88 ,$97.34 ,$123.03 ,$101.40 
Carle BroMenn Medical Center,8384252,VITAMIN B2-RIBOFLAVIN REF,,84252,301,$34.00 ,$34.00 ,$10.20 ,$30.94 ,$23.80 ,$10.20 ,$22.10 ,$24.48 ,$30.94 ,$25.50 
Carle BroMenn Medical Center,8384260,"SEROTONIN, BLOOD           REF",,84260,301,$143.00 ,$143.00 ,$42.90 ,$130.13 ,$100.10 ,$42.90 ,$92.95 ,$102.96 ,$130.13 ,$107.25 
Carle BroMenn Medical Center,8384270,ASSAY SEX HORMONE GLOBUL REF,,84270,301,$162.50 ,$162.50 ,$48.75 ,$147.88 ,$113.75 ,$48.75 ,$105.63 ,$117.00 ,$147.88 ,$121.88 
Carle BroMenn Medical Center,8384295,SODIUM SERUM PLASM/WHOLE BLOOD,,84295,301,$51.35 ,$51.35 ,$15.41 ,$46.73 ,$35.95 ,$15.41 ,$33.38 ,$36.97 ,$46.73 ,$38.51 
Carle BroMenn Medical Center,8384296,"SODIUM, BODY FLUID",,84302,301,$43.00 ,$43.00 ,$12.90 ,$39.13 ,$30.10 ,$12.90 ,$27.95 ,$30.96 ,$39.13 ,$32.25 
Carle BroMenn Medical Center,8384300,"SODIUM, URINE",,84300,301,$44.20 ,$44.20 ,$13.26 ,$40.22 ,$30.94 ,$13.26 ,$28.73 ,$31.82 ,$40.22 ,$33.15 
Carle BroMenn Medical Center,8384302,"SODIUM, RANDOM, F   REF",,84302,301,$74.75 ,$74.75 ,$22.43 ,$68.02 ,$52.33 ,$22.43 ,$48.59 ,$53.82 ,$68.02 ,$56.06 
Carle BroMenn Medical Center,8384309,SPECTROPHOTOMETRY -ANALYTE REF,,84311,301,$48.10 ,$48.10 ,$14.43 ,$43.77 ,$33.67 ,$14.43 ,$31.27 ,$34.63 ,$43.77 ,$36.08 
Carle BroMenn Medical Center,8384311,NBS-BIOTINIDASE DEFIC SCRN  REF,,82261,301,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8384312,ASSAY -BIOTINIDASE         REF,,82261,301,$106.00 ,$106.00 ,$31.80 ,$96.46 ,$74.20 ,$31.80 ,$68.90 ,$76.32 ,$96.46 ,$79.50 
Carle BroMenn Medical Center,8384313,HEXO A + TOTAL SERUM REF,,83080,301,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8384317,"PHOSPHORUS, RANDOM URINE",,84105,301,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8384330,GLUCOSE BLOOD,,82947,301,$46.00 ,$46.00 ,$13.80 ,$41.86 ,$32.20 ,$13.80 ,$29.90 ,$33.12 ,$41.86 ,$34.50 
Carle BroMenn Medical Center,8384376,SUGARS; SNGL QUAL EA   REF,,84376,301,$88.00 ,$88.00 ,$26.40 ,$80.08 ,$61.60 ,$26.40 ,$57.20 ,$63.36 ,$80.08 ,$66.00 
Carle BroMenn Medical Center,8384379,"SUGARS, MULT QUANT EACH    REF",,84379,301,$21.00 ,$21.00 ,$6.30 ,$19.11 ,$14.70 ,$6.30 ,$13.65 ,$15.12 ,$19.11 ,$15.75 
Carle BroMenn Medical Center,8384392,SULPHATE URINE,,84392,301,$28.00 ,$28.00 ,$8.40 ,$25.48 ,$19.60 ,$8.40 ,$18.20 ,$20.16 ,$25.48 ,$21.00 
Carle BroMenn Medical Center,8384402,"TESTOSTERONE, FREE, S    REF",,84402,301,$9.00 ,$9.00 ,$2.70 ,$8.19 ,$6.30 ,$2.70 ,$5.85 ,$6.48 ,$8.19 ,$6.75 
Carle BroMenn Medical Center,8384403,ASSAY TOTAL TESTOSTERONE REF,,84403,301,$142.00 ,$142.00 ,$42.60 ,$129.22 ,$99.40 ,$42.60 ,$92.30 ,$102.24 ,$129.22 ,$106.50 
Carle BroMenn Medical Center,8384425,VITAMIN B-1 (THIAMINE)     REF,,84425,301,$69.00 ,$69.00 ,$20.70 ,$62.79 ,$48.30 ,$20.70 ,$44.85 ,$49.68 ,$62.79 ,$51.75 
Carle BroMenn Medical Center,8384433,"THYROGLOBULIN, QUANT.      REF",,84432,301,$97.50 ,$97.50 ,$29.25 ,$88.73 ,$68.25 ,$29.25 ,$63.38 ,$70.20 ,$88.73 ,$73.13 
Carle BroMenn Medical Center,8384436,"THYROXINE, TOTAL (T4)      REF",,84436,301,$9.00 ,$9.00 ,$2.70 ,$8.19 ,$6.30 ,$2.70 ,$5.85 ,$6.48 ,$8.19 ,$6.75 
Carle BroMenn Medical Center,8384438,"THYROXINE, FREE (T4)",,84439,301,$61.10 ,$61.10 ,$18.33 ,$55.60 ,$42.77 ,$18.33 ,$39.72 ,$43.99 ,$55.60 ,$45.83 
Carle BroMenn Medical Center,8384439,T4 (THYROXIN T4) FREE,,84439,301,$85.00 ,$85.00 ,$25.50 ,$77.35 ,$59.50 ,$25.50 ,$55.25 ,$61.20 ,$77.35 ,$63.75 
Carle BroMenn Medical Center,8384443,NBS-HYPYOTHYROIDISM SCRN  REF,,84443,301,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8384445,TSI (THYROID STIM. IMMUREF REF,,84445,301,$175.50 ,$175.50 ,$52.65 ,$159.71 ,$122.85 ,$52.65 ,$114.08 ,$126.36 ,$159.71 ,$131.63 
Carle BroMenn Medical Center,8384448,SPECTROPHOTOMETRY,,84311,301,$56.00 ,$56.00 ,$16.80 ,$50.96 ,$39.20 ,$16.80 ,$36.40 ,$40.32 ,$50.96 ,$42.00 
Carle BroMenn Medical Center,8384460,"TRANSFERASE, ALANINE AMINO",,84460,301,$48.10 ,$48.10 ,$14.43 ,$43.77 ,$33.67 ,$14.43 ,$31.27 ,$34.63 ,$43.77 ,$36.08 
Carle BroMenn Medical Center,8384472,ESTRIOL ASSAY              REF,,82677,301,$68.25 ,$68.25 ,$20.48 ,$62.11 ,$47.78 ,$20.48 ,$44.36 ,$49.14 ,$62.11 ,$51.19 
Carle BroMenn Medical Center,8384474,"NEPHELOMETRY, EACH ANALYTE REF",,83883,301,$84.50 ,$84.50 ,$25.35 ,$76.90 ,$59.15 ,$25.35 ,$54.93 ,$60.84 ,$76.90 ,$63.38 
Carle BroMenn Medical Center,8384476,TRIGLYCERIDES,,84478,301,$14.00 ,$14.00 ,$4.20 ,$12.74 ,$9.80 ,$4.20 ,$9.10 ,$10.08 ,$12.74 ,$10.50 
Carle BroMenn Medical Center,8384478,TRIGLYCERIDES,,84478,301,$46.20 ,$46.20 ,$13.86 ,$42.04 ,$32.34 ,$13.86 ,$30.03 ,$33.26 ,$42.04 ,$34.65 
Carle BroMenn Medical Center,8384479,THYROID HORMONE(T3) UPTAKE REF,,84479,301,$8.00 ,$8.00 ,$2.40 ,$7.28 ,$5.60 ,$2.40 ,$5.20 ,$5.76 ,$7.28 ,$6.00 
Carle BroMenn Medical Center,8384481,"TRIIODOTHYRONINE T3, FREE  REF",,84481,301,$13.00 ,$13.00 ,$3.90 ,$11.83 ,$9.10 ,$3.90 ,$8.45 ,$9.36 ,$11.83 ,$9.75 
Carle BroMenn Medical Center,8384483,CHEMILUMINESCENT ASSAY   REF,,82397,301,$13.00 ,$13.00 ,$3.90 ,$11.83 ,$9.10 ,$3.90 ,$8.45 ,$9.36 ,$11.83 ,$9.75 
Carle BroMenn Medical Center,8384484,"TROPONIN, QUANTITATIVE",,84484,301,$100.75 ,$100.75 ,$30.23 ,$91.68 ,$70.53 ,$30.23 ,$65.49 ,$72.54 ,$91.68 ,$75.56 
Carle BroMenn Medical Center,8384520,"UREA NITROGEN, QUANTITATIVE",,84520,301,$46.15 ,$46.15 ,$13.85 ,$42.00 ,$32.31 ,$13.85 ,$30.00 ,$33.23 ,$42.00 ,$34.61 
Carle BroMenn Medical Center,8384521,BUN BODY FLUID,,84520,301,$87.10 ,$87.10 ,$26.13 ,$79.26 ,$60.97 ,$26.13 ,$56.62 ,$62.71 ,$79.26 ,$65.33 
Carle BroMenn Medical Center,8384540,"UREA NITROGEN, URINE",,84540,301,$45.00 ,$45.00 ,$13.50 ,$40.95 ,$31.50 ,$13.50 ,$29.25 ,$32.40 ,$40.95 ,$33.75 
Carle BroMenn Medical Center,8384560,"URIC ACID, OTHER SOURCE",,84560,301,$117.00 ,$117.00 ,$35.10 ,$106.47 ,$81.90 ,$35.10 ,$76.05 ,$84.24 ,$106.47 ,$87.75 
Carle BroMenn Medical Center,8384561,"URIC ACID, RANDOM URINE",,84560,301,$117.00 ,$117.00 ,$35.10 ,$106.47 ,$81.90 ,$35.10 ,$76.05 ,$84.24 ,$106.47 ,$87.75 
Carle BroMenn Medical Center,8384575,"VITAMIN K, SERUM       REF",,84597,301,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8384584,VASOACTVE INTESTNAL PEPTDE REF,,84586,301,$84.00 ,$84.00 ,$25.20 ,$76.44 ,$58.80 ,$25.20 ,$54.60 ,$60.48 ,$76.44 ,$63.00 
Carle BroMenn Medical Center,8384585,VANILLYMANDELIC ACID       REF,,84585,301,$47.00 ,$47.00 ,$14.10 ,$42.77 ,$32.90 ,$14.10 ,$30.55 ,$33.84 ,$42.77 ,$35.25 
Carle BroMenn Medical Center,8384586,DRUG ASSAY -VALPROIC ACID,,80164,301,$81.25 ,$81.25 ,$24.38 ,$73.94 ,$56.88 ,$24.38 ,$52.81 ,$58.50 ,$73.94 ,$60.94 
Carle BroMenn Medical Center,8384588,"ARGININE VASOPRESSIN, P   REFF",,84588,301,$172.25 ,$172.25 ,$51.68 ,$156.75 ,$120.58 ,$51.68 ,$111.96 ,$124.02 ,$156.75 ,$129.19 
Carle BroMenn Medical Center,8384595,VITAMIN A (RETINOL)        REF,,84590,301,$65.00 ,$65.00 ,$19.50 ,$59.15 ,$45.50 ,$19.50 ,$42.25 ,$46.80 ,$59.15 ,$48.75 
Carle BroMenn Medical Center,8384630,ZINC REF,,84630,301,$67.00 ,$67.00 ,$20.10 ,$60.97 ,$46.90 ,$20.10 ,$43.55 ,$48.24 ,$60.97 ,$50.25 
Carle BroMenn Medical Center,8384645,"NEPHELOMETRY, EACH ANALYTE REF",,83883,301,$10.58 ,$10.58 ,$3.17 ,$9.63 ,$7.41 ,$3.17 ,$6.88 ,$7.62 ,$9.63 ,$7.94 
Carle BroMenn Medical Center,8384680,"L/S RATIO, AMNIO REF",,83661,301,$149.50 ,$149.50 ,$44.85 ,$136.05 ,$104.65 ,$44.85 ,$97.18 ,$107.64 ,$136.05 ,$112.13 
Carle BroMenn Medical Center,8384681,C-PEPTIDE                  REF,,84681,301,$126.75 ,$126.75 ,$38.03 ,$115.34 ,$88.73 ,$38.03 ,$82.39 ,$91.26 ,$115.34 ,$95.06 
Carle BroMenn Medical Center,8384701,HCG TEST      REF,,84702,301,$31.00 ,$31.00 ,$9.30 ,$28.21 ,$21.70 ,$9.30 ,$20.15 ,$22.32 ,$28.21 ,$23.25 
Carle BroMenn Medical Center,8384702,"GONADOTROPIN, CHORIONIC (HCG)",,84702,301,$113.75 ,$113.75 ,$34.13 ,$103.51 ,$79.63 ,$34.13 ,$73.94 ,$81.90 ,$103.51 ,$85.31 
Carle BroMenn Medical Center,8386130,COPPER  -URINE (24HR) REF,,82525,301,$74.75 ,$74.75 ,$22.43 ,$68.02 ,$52.33 ,$22.43 ,$48.59 ,$53.82 ,$68.02 ,$56.06 
Carle BroMenn Medical Center,8386208,CYCLOSPORINE REF,,80158,301,$139.75 ,$139.75 ,$41.93 ,$127.17 ,$97.83 ,$41.93 ,$90.84 ,$100.62 ,$127.17 ,$104.81 
Carle BroMenn Medical Center,8386326,"ALPHA-1-ANTITRYPSIN, TOTAL",,82103,301,$139.00 ,$139.00 ,$41.70 ,$126.49 ,$97.30 ,$41.70 ,$90.35 ,$100.08 ,$126.49 ,$104.25 
Carle BroMenn Medical Center,8386425,PROTEIN ELP FRACT&QUANT OTH FL,,84166,301,$170.00 ,$170.00 ,$51.00 ,$154.70 ,$119.00 ,$51.00 ,$110.50 ,$122.40 ,$154.70 ,$127.50 
Carle BroMenn Medical Center,8388274,MOL HYB INTPH 25-99CELLS REF,,88274,301,$568.00 ,$568.00 ,$170.40 ,$516.88 ,$397.60 ,$170.40 ,$369.20 ,$408.96 ,$516.88 ,$426.00 
Carle BroMenn Medical Center,8389072,GLUCOSE BODY FLUID (CSF),,82945,301,$53.95 ,$53.95 ,$16.19 ,$49.09 ,$37.77 ,$16.19 ,$35.07 ,$38.84 ,$49.09 ,$40.46 
Carle BroMenn Medical Center,8478267,H. PYLORI C14 TEST SPEC COLLCT,,78267,301,$35.00 ,$35.00 ,$10.50 ,$31.85 ,$24.50 ,$10.50 ,$22.75 ,$25.20 ,$31.85 ,$26.25 
Carle BroMenn Medical Center,8478268,H. PYLORI C14 BREATH TEST,,78268,301,$255.00 ,$255.00 ,$76.50 ,$232.05 ,$178.50 ,$76.50 ,$165.75 ,$183.60 ,$232.05 ,$191.25 
Carle BroMenn Medical Center,8650003,ABG ANALYSIS ONLY,,82803,301,$190.00 ,$190.00 ,$57.00 ,$172.90 ,$133.00 ,$57.00 ,$123.50 ,$136.80 ,$172.90 ,$142.50 
Carle BroMenn Medical Center,8650031,I-STAT,,82803,301,$190.00 ,$190.00 ,$57.00 ,$172.90 ,$133.00 ,$57.00 ,$123.50 ,$136.80 ,$172.90 ,$142.50 
Carle BroMenn Medical Center,8650036,NEO ABG ANALYSIS ONLY,,82803,301,$190.00 ,$190.00 ,$57.00 ,$172.90 ,$133.00 ,$57.00 ,$123.50 ,$136.80 ,$172.90 ,$142.50 
Carle BroMenn Medical Center,8652375,CARBON MONOXIDE STUDY,,82375,301,$108.00 ,$108.00 ,$32.40 ,$98.28 ,$75.60 ,$32.40 ,$70.20 ,$77.76 ,$98.28 ,$81.00 
Carle BroMenn Medical Center,8652803,BLOOD GAS,,82803,301,$190.00 ,$190.00 ,$57.00 ,$172.90 ,$133.00 ,$57.00 ,$123.50 ,$136.80 ,$172.90 ,$142.50 
Carle BroMenn Medical Center,8652810,"BLOOD GASES, O2 SAT ONLY",,82810,301,$82.00 ,$82.00 ,$24.60 ,$74.62 ,$57.40 ,$24.60 ,$53.30 ,$59.04 ,$74.62 ,$61.50 
Carle BroMenn Medical Center,8658051,ELECTROLYTE PANEL,,80051,301,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8026580,SKIN TEST TB INTRADERMAL,,86580,302,$84.00 ,$84.00 ,$25.20 ,$76.44 ,$58.80 ,$25.20 ,$54.60 ,$60.48 ,$76.44 ,$63.00 
Carle BroMenn Medical Center,8200608,"HB CORE, TOTAL",,86704,302,$62.00 ,$62.00 ,$18.60 ,$56.42 ,$43.40 ,$18.60 ,$40.30 ,$44.64 ,$56.42 ,$46.50 
Carle BroMenn Medical Center,8200609,HCV AB,,86803,302,$115.00 ,$115.00 ,$34.50 ,$104.65 ,$80.50 ,$34.50 ,$74.75 ,$82.80 ,$104.65 ,$86.25 
Carle BroMenn Medical Center,8200610,AB HIV1/HIV2,,86703,302,$95.00 ,$95.00 ,$28.50 ,$86.45 ,$66.50 ,$28.50 ,$61.75 ,$68.40 ,$86.45 ,$71.25 
Carle BroMenn Medical Center,8200616,CMV TOTAL,,86644,302,$88.00 ,$88.00 ,$26.40 ,$80.08 ,$61.60 ,$26.40 ,$57.20 ,$63.36 ,$80.08 ,$66.00 
Carle BroMenn Medical Center,8200617,HTLV 1/2 AB W/REFX WBQ,,86790,302,$91.00 ,$91.00 ,$27.30 ,$82.81 ,$63.70 ,$27.30 ,$59.15 ,$65.52 ,$82.81 ,$68.25 
Carle BroMenn Medical Center,8200619,T. CRUZI,,86753,302,$43.00 ,$43.00 ,$12.90 ,$39.13 ,$30.10 ,$12.90 ,$27.95 ,$30.96 ,$39.13 ,$32.25 
Carle BroMenn Medical Center,8200623,HEP B CORE REFLUX,,86705,302,$91.00 ,$91.00 ,$27.30 ,$82.81 ,$63.70 ,$27.30 ,$59.15 ,$65.52 ,$82.81 ,$68.25 
Carle BroMenn Medical Center,8286580,SKIN TEST TB INTRADERMAL,,86580,302,$84.00 ,$84.00 ,$25.20 ,$76.44 ,$58.80 ,$25.20 ,$54.60 ,$60.48 ,$76.44 ,$63.00 
Carle BroMenn Medical Center,8286644,CMV ANTIBODY,,86644,302,$175.00 ,$175.00 ,$52.50 ,$159.25 ,$122.50 ,$52.50 ,$113.75 ,$126.00 ,$159.25 ,$131.25 
Carle BroMenn Medical Center,8286645,"CMV ANTIBODY, IGM",,86645,302,$205.00 ,$205.00 ,$61.50 ,$186.55 ,$143.50 ,$61.50 ,$133.25 ,$147.60 ,$186.55 ,$153.75 
Carle BroMenn Medical Center,8286703,"HIV-1/HIV-2, SINGLE ASSAY",,86703,302,$125.00 ,$125.00 ,$37.50 ,$113.75 ,$87.50 ,$37.50 ,$81.25 ,$90.00 ,$113.75 ,$93.75 
Carle BroMenn Medical Center,8286704,"HEP B CORE AB TEST, TOTAL",,86704,302,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8286705,"HEP B CORE AB TEST, IGM",,86705,302,$215.00 ,$215.00 ,$64.50 ,$195.65 ,$150.50 ,$64.50 ,$139.75 ,$154.80 ,$195.65 ,$161.25 
Carle BroMenn Medical Center,8286762,RUBELLA,,86762,302,$170.00 ,$170.00 ,$51.00 ,$154.70 ,$119.00 ,$51.00 ,$110.50 ,$122.40 ,$154.70 ,$127.50 
Carle BroMenn Medical Center,8286787,VARICELLA-ZOSTER,,86787,302,$185.00 ,$185.00 ,$55.50 ,$168.35 ,$129.50 ,$55.50 ,$120.25 ,$133.20 ,$168.35 ,$138.75 
Carle BroMenn Medical Center,8286803,HEPATITIS C AB TEST,,86803,302,$225.00 ,$225.00 ,$67.50 ,$204.75 ,$157.50 ,$67.50 ,$146.25 ,$162.00 ,$204.75 ,$168.75 
Carle BroMenn Medical Center,8340011,CRYPTOCOCCAL AG TITER,,86406,302,$310.00 ,$310.00 ,$93.00 ,$282.10 ,$217.00 ,$93.00 ,$201.50 ,$223.20 ,$282.10 ,$232.50 
Carle BroMenn Medical Center,8380005,"TUMOR ANTIGEN, CA 125 II   REF",,86304,302,$156.00 ,$156.00 ,$46.80 ,$141.96 ,$109.20 ,$46.80 ,$101.40 ,$112.32 ,$141.96 ,$117.00 
Carle BroMenn Medical Center,8380131,CHROMATIN ANTIBODY-EACH AB REF,,86235,302,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8380140,LABRATORY TEST REF,,86703,302,$117.00 ,$117.00 ,$35.10 ,$106.47 ,$81.90 ,$35.10 ,$76.05 ,$84.24 ,$106.47 ,$87.75 
Carle BroMenn Medical Center,8380257,HSV 1/2 IGM TITER   REF,,86696,302,$25.00 ,$25.00 ,$7.50 ,$22.75 ,$17.50 ,$7.50 ,$16.25 ,$18.00 ,$22.75 ,$18.75 
Carle BroMenn Medical Center,8380350,C-REACTIVE PROTEIN (SGI-PROMETH),,86140,302,$22.00 ,$22.00 ,$6.60 ,$20.02 ,$15.40 ,$6.60 ,$14.30 ,$15.84 ,$20.02 ,$16.50 
Carle BroMenn Medical Center,8380372,"ENDOMYSIAL ABS, S         REF",,86255,302,$94.25 ,$94.25 ,$28.28 ,$85.77 ,$65.98 ,$28.28 ,$61.26 ,$67.86 ,$85.77 ,$70.69 
Carle BroMenn Medical Center,8380375,"BRUCELLA AB SCREEN, IGG, IGM S  REF",,86622,302,$8.00 ,$8.00 ,$2.40 ,$7.28 ,$5.60 ,$2.40 ,$5.20 ,$5.76 ,$7.28 ,$6.00 
Carle BroMenn Medical Center,8380376,"BRUCELLA TOTAL AB, AGGL, S    REF",,86622,302,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8380378,"ANTINUCLEAR AB, S    REF",,86038,302,$6.00 ,$6.00 ,$1.80 ,$5.46 ,$4.20 ,$1.80 ,$3.90 ,$4.32 ,$5.46 ,$4.50 
Carle BroMenn Medical Center,8380379,"CYCLIC CITRULL PEPTIDE AB, S    REF",,86200,302,$78.00 ,$78.00 ,$23.40 ,$70.98 ,$54.60 ,$23.40 ,$50.70 ,$56.16 ,$70.98 ,$58.50 
Carle BroMenn Medical Center,8380380,"DNA DOUBLE-STRANDED AB, IGG, S  REF",,86225,302,$21.00 ,$21.00 ,$6.30 ,$19.11 ,$14.70 ,$6.30 ,$13.65 ,$15.12 ,$19.11 ,$15.75 
Carle BroMenn Medical Center,8380382,"LEGIONELLA PNEUMOPHILA AB, S    REF",,86713,302,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8380384,"COMPLEMENT, TOTAL, S    REF",,86162,302,$123.50 ,$123.50 ,$37.05 ,$112.39 ,$86.45 ,$37.05 ,$80.28 ,$88.92 ,$112.39 ,$92.63 
Carle BroMenn Medical Center,8380396,"HEPATITIS B CORE TOTAL AB, S    REF",,86704,302,$17.00 ,$17.00 ,$5.10 ,$15.47 ,$11.90 ,$5.10 ,$11.05 ,$12.24 ,$15.47 ,$12.75 
Carle BroMenn Medical Center,8380407,PLATELET AB S   REF,,86022,302,$36.00 ,$36.00 ,$10.80 ,$32.76 ,$25.20 ,$10.80 ,$23.40 ,$25.92 ,$32.76 ,$27.00 
Carle BroMenn Medical Center,8380418,INSULIN ANTIBODIES         REF,,86337,302,$16.00 ,$16.00 ,$4.80 ,$14.56 ,$11.20 ,$4.80 ,$10.40 ,$11.52 ,$14.56 ,$12.00 
Carle BroMenn Medical Center,8380427,"ASPERGILLUS FUMIGATUS, IGG AB   REF",,86606,302,$64.70 ,$64.70 ,$19.41 ,$58.88 ,$45.29 ,$19.41 ,$42.06 ,$46.58 ,$58.88 ,$48.53 
Carle BroMenn Medical Center,8380428,"M. FAENI-T. VULGARIS, IGG AB    REF",,86671,302,$11.00 ,$11.00 ,$3.30 ,$10.01 ,$7.70 ,$3.30 ,$7.15 ,$7.92 ,$10.01 ,$8.25 
Carle BroMenn Medical Center,8380438,"LYME DISEASE SEROLOGY, S    REF",,86618,302,$9.00 ,$9.00 ,$2.70 ,$8.19 ,$6.30 ,$2.70 ,$5.85 ,$6.48 ,$8.19 ,$6.75 
Carle BroMenn Medical Center,8380439,"LYME DISEASE AB, IGG,IGM, WB, S REF",,86617,302,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8380446,"CARBOHYDRATE AG 19-9, S        REF",,86301,302,$13.00 ,$13.00 ,$3.90 ,$11.83 ,$9.10 ,$3.90 ,$8.45 ,$9.36 ,$11.83 ,$9.75 
Carle BroMenn Medical Center,8380454,"CYTOPLASMIC NEUTROPHILIC AB, S  REF",,86255,302,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8380455,"HTLV-I/-II AB SCREEN, S    REF",,86687,302,$17.00 ,$17.00 ,$5.10 ,$15.47 ,$11.90 ,$5.10 ,$11.05 ,$12.24 ,$15.47 ,$12.75 
Carle BroMenn Medical Center,8380456,"HTLV-I/-II AB CONFIRMATION, S    REF",,86689,302,$156.00 ,$156.00 ,$46.80 ,$141.96 ,$109.20 ,$46.80 ,$101.40 ,$112.32 ,$141.96 ,$117.00 
Carle BroMenn Medical Center,8380466,"ASPERGILLUS FUMIGATUS, IGG AB  REF",,86606,302,$11.00 ,$11.00 ,$3.30 ,$10.01 ,$7.70 ,$3.30 ,$7.15 ,$7.92 ,$10.01 ,$8.25 
Carle BroMenn Medical Center,8380485,"HIV-1 AB CONFIRM W BLOT, S    REF",,86689,302,$156.00 ,$156.00 ,$46.80 ,$141.96 ,$109.20 ,$46.80 ,$101.40 ,$112.32 ,$141.96 ,$117.00 
Carle BroMenn Medical Center,8380486,"HIV-1 AB CONFIRM BY IFA, S    REF",,86689,302,$107.00 ,$107.00 ,$32.10 ,$97.37 ,$74.90 ,$32.10 ,$69.55 ,$77.04 ,$97.37 ,$80.25 
Carle BroMenn Medical Center,8380487,"HIV-2 AB EVAL, S    REF",,86702,302,$93.00 ,$93.00 ,$27.90 ,$84.63 ,$65.10 ,$27.90 ,$60.45 ,$66.96 ,$84.63 ,$69.75 
Carle BroMenn Medical Center,8380488,"HIV 2 AB, IMMUNOBLOT    REF",,86689,302,$46.00 ,$46.00 ,$13.80 ,$41.86 ,$32.20 ,$13.80 ,$29.90 ,$33.12 ,$41.86 ,$34.50 
Carle BroMenn Medical Center,8380496,"COXSACKIE B(1-6) ANTIBODIES, S  REF",,86658,302,$11.00 ,$11.00 ,$3.30 ,$10.01 ,$7.70 ,$3.30 ,$7.15 ,$7.92 ,$10.01 ,$8.25 
Carle BroMenn Medical Center,8380497,"COXSACKIE A ANTIBODIES, S    REF",,86658,302,$11.00 ,$11.00 ,$3.30 ,$10.01 ,$7.70 ,$3.30 ,$7.15 ,$7.92 ,$10.01 ,$8.25 
Carle BroMenn Medical Center,8380498,"ECHOVIRUS ANTIBODIES, S    REF",,86658,302,$12.00 ,$12.00 ,$3.60 ,$10.92 ,$8.40 ,$3.60 ,$7.80 ,$8.64 ,$10.92 ,$9.00 
Carle BroMenn Medical Center,8380502,"POLIOVIRUS (TYPES 1-3) AB, S    REF",,86658,302,$26.00 ,$26.00 ,$7.80 ,$23.66 ,$18.20 ,$7.80 ,$16.90 ,$18.72 ,$23.66 ,$19.50 
Carle BroMenn Medical Center,8380503,"DENGUE FEVER ABS (IGG,IGM)    REF",,86790,302,$52.00 ,$52.00 ,$15.60 ,$47.32 ,$36.40 ,$15.60 ,$33.80 ,$37.44 ,$47.32 ,$39.00 
Carle BroMenn Medical Center,8380511,"HEPATITIS BE AB, S    REF",,86707,302,$18.00 ,$18.00 ,$5.40 ,$16.38 ,$12.60 ,$5.40 ,$11.70 ,$12.96 ,$16.38 ,$13.50 
Carle BroMenn Medical Center,8380512,"MUMPS AB, IGM, S    REF",,86735,302,$11.00 ,$11.00 ,$3.30 ,$10.01 ,$7.70 ,$3.30 ,$7.15 ,$7.92 ,$10.01 ,$8.25 
Carle BroMenn Medical Center,8380513,"RUBEOLA (MEASLES) AB, IGM, S    REF",,86765,302,$11.00 ,$11.00 ,$3.30 ,$10.01 ,$7.70 ,$3.30 ,$7.15 ,$7.92 ,$10.01 ,$8.25 
Carle BroMenn Medical Center,8380516,"INHIBIN A, TUMOR MARKER, S    REF",,86336,302,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8380521,T CELLS ABSOLUTE CD4 COUNT   REF,,86361,302,$100.75 ,$100.75 ,$30.23 ,$91.68 ,$70.53 ,$30.23 ,$65.49 ,$72.54 ,$91.68 ,$75.56 
Carle BroMenn Medical Center,8380525,BR CARCINOMA AG(CA 27.29)    REF,,86300,302,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8380549,"BARTONELLA AB PANEL, IGG, IGM  REF",,86611,302,$10.36 ,$10.36 ,$3.11 ,$9.43 ,$7.25 ,$3.11 ,$6.73 ,$7.46 ,$9.43 ,$7.77 
Carle BroMenn Medical Center,8380550,"ANNA-1, S    REF",,86256,302,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8380551,"ANNA-2, S    REF",,86256,302,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8380552,"ANNA-3, S    REF",,86256,302,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8380553,"AGNA-1, S    REF",,86256,302,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8380554,"PCA-1, S    REF",,86256,302,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8380555,"PCA-2, S    REF",,86256,302,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8380556,"PCA-TR, S    REF",,86256,302,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8380557,"AMPHIPHYSIN AB, S    REF",,86256,302,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8380558,"CRMP-5-IGG, S    REF",,86256,302,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8380565,"GAD65 AB ASSAY, S    REF",,86341,302,$16.00 ,$16.00 ,$4.80 ,$14.56 ,$11.20 ,$4.80 ,$10.40 ,$11.52 ,$14.56 ,$12.00 
Carle BroMenn Medical Center,8380571,"TOXOPLASMA AB, IGM, S    REF",,86778,302,$107.25 ,$107.25 ,$32.18 ,$97.60 ,$75.08 ,$32.18 ,$69.71 ,$77.22 ,$97.60 ,$80.44 
Carle BroMenn Medical Center,8380572,"TOXOPLASMA AB, IGG, S    REF",,86777,302,$8.00 ,$8.00 ,$2.40 ,$7.28 ,$5.60 ,$2.40 ,$5.20 ,$5.76 ,$7.28 ,$6.00 
Carle BroMenn Medical Center,8380583,"THYROPEROXIDASE AB, S    REF",,86376,302,$8.00 ,$8.00 ,$2.40 ,$7.28 ,$5.60 ,$2.40 ,$5.20 ,$5.76 ,$7.28 ,$6.00 
Carle BroMenn Medical Center,8380589,FOOD-GRAIN PANEL    REF,,86003,302,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8380590,MOLD PANEL    REF,,86003,302,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8380605,"BETA-2 TRANSFERRIN, BF    REF",,86335,302,$54.00 ,$54.00 ,$16.20 ,$49.14 ,$37.80 ,$16.20 ,$35.10 ,$38.88 ,$49.14 ,$40.50 
Carle BroMenn Medical Center,8380612,"SIN NOMBRE IGG CONFRM,IBL  REF",,86790,302,$48.00 ,$48.00 ,$14.40 ,$43.68 ,$33.60 ,$14.40 ,$31.20 ,$34.56 ,$43.68 ,$36.00 
Carle BroMenn Medical Center,8380613,"SIN NOMBRE IGM CNFRM,ELISA REF",,86790,302,$34.00 ,$34.00 ,$10.20 ,$30.94 ,$23.80 ,$10.20 ,$22.10 ,$24.48 ,$30.94 ,$25.50 
Carle BroMenn Medical Center,8380630,CA125 (VISTA),,86304,302,$217.00 ,$217.00 ,$65.10 ,$197.47 ,$151.90 ,$65.10 ,$141.05 ,$156.24 ,$197.47 ,$162.75 
Carle BroMenn Medical Center,8380680,TB QUANTIFERON,,86480,302,$340.00 ,$340.00 ,$102.00 ,$309.40 ,$238.00 ,$102.00 ,$221.00 ,$244.80 ,$309.40 ,$255.00 
Carle BroMenn Medical Center,8380707,"SS-A/RO & B/LA AB, IGG, S    REF",,86235,302,$6.00 ,$6.00 ,$1.80 ,$5.46 ,$4.20 ,$1.80 ,$3.90 ,$4.32 ,$5.46 ,$4.50 
Carle BroMenn Medical Center,8380718,"Q FEVER AB, IGG AND IGM, S    REF",,86638,302,$23.00 ,$23.00 ,$6.90 ,$20.93 ,$16.10 ,$6.90 ,$14.95 ,$16.56 ,$20.93 ,$17.25 
Carle BroMenn Medical Center,8380729,"HEPATITIS A TOTAL AB, S    REF",,86708,302,$9.00 ,$9.00 ,$2.70 ,$8.19 ,$6.30 ,$2.70 ,$5.85 ,$6.48 ,$8.19 ,$6.75 
Carle BroMenn Medical Center,8380730,ALLRG SPC IGE QNT/SMQT EA REF,,86003,302,$41.33 ,$41.33 ,$12.40 ,$37.61 ,$28.93 ,$12.40 ,$26.86 ,$29.76 ,$37.61 ,$31.00 
Carle BroMenn Medical Center,8380741,"LYME DISEASE AB, WBLOT, CSF    REF",,86617,302,$8.00 ,$8.00 ,$2.40 ,$7.28 ,$5.60 ,$2.40 ,$5.20 ,$5.76 ,$7.28 ,$6.00 
Carle BroMenn Medical Center,8380742,"CYCLIC CITRULL PEPTIDE AB, S    REF",,86200,302,$7.00 ,$7.00 ,$2.10 ,$6.37 ,$4.90 ,$2.10 ,$4.55 ,$5.04 ,$6.37 ,$5.25 
Carle BroMenn Medical Center,8380743,"WEST NILE VIRUS AB, IGG, S    REF",,86789,302,$7.00 ,$7.00 ,$2.10 ,$6.37 ,$4.90 ,$2.10 ,$4.55 ,$5.04 ,$6.37 ,$5.25 
Carle BroMenn Medical Center,8380744,"WEST NILE VIRUS AB, IGM, S    REF",,86788,302,$9.00 ,$9.00 ,$2.70 ,$8.19 ,$6.30 ,$2.70 ,$5.85 ,$6.48 ,$8.19 ,$6.75 
Carle BroMenn Medical Center,8380749,"PARVOVIRUS B19 AB, IGG, S  REF",,86747,302,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8380750,CD3 (T CELLS)    REF,,86359,302,$17.00 ,$17.00 ,$5.10 ,$15.47 ,$11.90 ,$5.10 ,$11.05 ,$12.24 ,$15.47 ,$12.75 
Carle BroMenn Medical Center,8380751,CD4 (HELPER CELLS)    REF,,86360,302,$18.00 ,$18.00 ,$5.40 ,$16.38 ,$12.60 ,$5.40 ,$11.70 ,$12.96 ,$16.38 ,$13.50 
Carle BroMenn Medical Center,8380752,"THYROGLOBULIN ANTIBODY, S    REF",,86800,302,$10.92 ,$10.92 ,$3.28 ,$9.94 ,$7.64 ,$3.28 ,$7.10 ,$7.86 ,$9.94 ,$8.19 
Carle BroMenn Medical Center,8380755,"EBV VCA IGM, IGG AB, S    REF",,86665,302,$5.00 ,$5.00 ,$1.50 ,$4.55 ,$3.50 ,$1.50 ,$3.25 ,$3.60 ,$4.55 ,$3.75 
Carle BroMenn Medical Center,8380756,"EBNA AB, S    REF",,86664,302,$4.00 ,$4.00 ,$1.20 ,$3.64 ,$2.80 ,$1.20 ,$2.60 ,$2.88 ,$3.64 ,$3.00 
Carle BroMenn Medical Center,8380757,LABORATORY SERVICE      REF,,86695,302,$4.00 ,$4.00 ,$1.20 ,$3.64 ,$2.80 ,$1.20 ,$2.60 ,$2.88 ,$3.64 ,$3.00 
Carle BroMenn Medical Center,8380758,LABORATORY SERVICE      REF,,86696,302,$5.00 ,$5.00 ,$1.50 ,$4.55 ,$3.50 ,$1.50 ,$3.25 ,$3.60 ,$4.55 ,$3.75 
Carle BroMenn Medical Center,8380763,"ANTISTREP-O TITER, S    REF",,86060,302,$4.00 ,$4.00 ,$1.20 ,$3.64 ,$2.80 ,$1.20 ,$2.60 ,$2.88 ,$3.64 ,$3.00 
Carle BroMenn Medical Center,8380764,"ANTI-DNASE B TITER, S    REF",,86215,302,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8380765,"CYTOMEGALOVIRUS AB, IGM, S    REF",,86645,302,$104.00 ,$104.00 ,$31.20 ,$94.64 ,$72.80 ,$31.20 ,$67.60 ,$74.88 ,$94.64 ,$78.00 
Carle BroMenn Medical Center,8380767,"CALIF ENCEP AB, IGG, IGM     REF",,86651,302,$18.00 ,$18.00 ,$5.40 ,$16.38 ,$12.60 ,$5.40 ,$11.70 ,$12.96 ,$16.38 ,$13.50 
Carle BroMenn Medical Center,8380768,"E. EQUINE ENCEPH AB, IGG, IGM   REF",,86652,302,$18.00 ,$18.00 ,$5.40 ,$16.38 ,$12.60 ,$5.40 ,$11.70 ,$12.96 ,$16.38 ,$13.50 
Carle BroMenn Medical Center,8380769,"ST. LOUIS ENCEPH AB, IGG, IGM  REF",,86653,302,$18.00 ,$18.00 ,$5.40 ,$16.38 ,$12.60 ,$5.40 ,$11.70 ,$12.96 ,$16.38 ,$13.50 
Carle BroMenn Medical Center,8380770,"W. EQUINE ENCEPH AB, IGG, IGM   REF",,86654,302,$18.00 ,$18.00 ,$5.40 ,$16.38 ,$12.60 ,$5.40 ,$11.70 ,$12.96 ,$16.38 ,$13.50 
Carle BroMenn Medical Center,8380771,"WEST NILE VIRUS AB, IGG    REF",,86789,302,$97.50 ,$97.50 ,$29.25 ,$88.73 ,$68.25 ,$29.25 ,$63.38 ,$70.20 ,$88.73 ,$73.13 
Carle BroMenn Medical Center,8380772,"WEST NILE VIRUS AB, IGM    REF",,86788,302,$97.50 ,$97.50 ,$29.25 ,$88.73 ,$68.25 ,$29.25 ,$63.38 ,$70.20 ,$88.73 ,$73.13 
Carle BroMenn Medical Center,8380776,LABORATORY SERVICE      REF,,86694,302,$11.00 ,$11.00 ,$3.30 ,$10.01 ,$7.70 ,$3.30 ,$7.15 ,$7.92 ,$10.01 ,$8.25 
Carle BroMenn Medical Center,8380777,LABORATORY SERVICE      REF,,86694,302,$13.00 ,$13.00 ,$3.90 ,$11.83 ,$9.10 ,$3.90 ,$8.45 ,$9.36 ,$11.83 ,$9.75 
Carle BroMenn Medical Center,8380779,"WEST NILE VIRUS AB, IGG, CSF    REF",,86789,302,$7.00 ,$7.00 ,$2.10 ,$6.37 ,$4.90 ,$2.10 ,$4.55 ,$5.04 ,$6.37 ,$5.25 
Carle BroMenn Medical Center,8380780,"WEST NILE VIRUS AB, IGM, CSF    REF",,86788,302,$8.00 ,$8.00 ,$2.40 ,$7.28 ,$5.60 ,$2.40 ,$5.20 ,$5.76 ,$7.28 ,$6.00 
Carle BroMenn Medical Center,8380801,"BETA 2 GP1 AB PANEL, S    REF",,86146,302,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8380802,CELIAC ASSOC. HLA-DQ TYPING    REF,,86816,302,$111.00 ,$111.00 ,$33.30 ,$101.01 ,$77.70 ,$33.30 ,$72.15 ,$79.92 ,$101.01 ,$83.25 
Carle BroMenn Medical Center,8380823,"CALIFORNIA IGG, IGM    REF",,86651,302,$10.28 ,$10.28 ,$3.08 ,$9.35 ,$7.20 ,$3.08 ,$6.68 ,$7.40 ,$9.35 ,$7.71 
Carle BroMenn Medical Center,8380824,"EASTERN EQUINE IGG, IGM    REF",,86652,302,$10.28 ,$10.28 ,$3.08 ,$9.35 ,$7.20 ,$3.08 ,$6.68 ,$7.40 ,$9.35 ,$7.71 
Carle BroMenn Medical Center,8380825,"ST. LOUIS IGG, IGM    REF",,86653,302,$10.28 ,$10.28 ,$3.08 ,$9.35 ,$7.20 ,$3.08 ,$6.68 ,$7.40 ,$9.35 ,$7.71 
Carle BroMenn Medical Center,8380826,WESTERN EQUINE IGG    REF,,86654,302,$10.28 ,$10.28 ,$3.08 ,$9.35 ,$7.20 ,$3.08 ,$6.68 ,$7.40 ,$9.35 ,$7.71 
Carle BroMenn Medical Center,8380827,"LCM IGG, IGM    REF",,86727,302,$10.03 ,$10.03 ,$3.01 ,$9.13 ,$7.02 ,$3.01 ,$6.52 ,$7.22 ,$9.13 ,$7.52 
Carle BroMenn Medical Center,8380828,"MEASLES (RUBEOLA) IGG, IGM IFA  REF",,86765,302,$10.04 ,$10.04 ,$3.01 ,$9.14 ,$7.03 ,$3.01 ,$6.53 ,$7.23 ,$9.14 ,$7.53 
Carle BroMenn Medical Center,8380829,"MUMPS AB IGG,IGM IFA    REF",,86735,302,$10.17 ,$10.17 ,$3.05 ,$9.25 ,$7.12 ,$3.05 ,$6.61 ,$7.32 ,$9.25 ,$7.63 
Carle BroMenn Medical Center,8380830,"HSV 1 IGG INDEX, IGM IFA    REF",,86695,302,$10.28 ,$10.28 ,$3.08 ,$9.35 ,$7.20 ,$3.08 ,$6.68 ,$7.40 ,$9.35 ,$7.71 
Carle BroMenn Medical Center,8380831,"HSV 2 IGG INDEX, IGM IFA    REF",,86696,302,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8380832,ADENOVIRUS AB    REF,,86603,302,$10.03 ,$10.03 ,$3.01 ,$9.13 ,$7.02 ,$3.01 ,$6.52 ,$7.22 ,$9.13 ,$7.52 
Carle BroMenn Medical Center,8380833,"INFLUENZA A,B AB    REF",,86710,302,$10.56 ,$10.56 ,$3.17 ,$9.61 ,$7.39 ,$3.17 ,$6.86 ,$7.60 ,$9.61 ,$7.92 
Carle BroMenn Medical Center,8380834,VARICELLA-ZOSTER VIR AB    REF,,86787,302,$100.75 ,$100.75 ,$30.23 ,$91.68 ,$70.53 ,$30.23 ,$65.49 ,$72.54 ,$91.68 ,$75.56 
Carle BroMenn Medical Center,8380835,ENTEROVIRUS ABS    REF,,86658,302,$10.15 ,$10.15 ,$3.05 ,$9.24 ,$7.11 ,$3.05 ,$6.60 ,$7.31 ,$9.24 ,$7.61 
Carle BroMenn Medical Center,8380836,"CYTOMEG IGG, ELISA (CSF)    REF",,86644,302,$7.00 ,$7.00 ,$2.10 ,$6.37 ,$4.90 ,$2.10 ,$4.55 ,$5.04 ,$6.37 ,$5.25 
Carle BroMenn Medical Center,8380837,"CYTOMEG IGM, ELISA (CSF)    REF",,86645,302,$8.00 ,$8.00 ,$2.40 ,$7.28 ,$5.60 ,$2.40 ,$5.20 ,$5.76 ,$7.28 ,$6.00 
Carle BroMenn Medical Center,8380838,WEST NILE VIRUS IGG    REF,,86789,302,$7.00 ,$7.00 ,$2.10 ,$6.37 ,$4.90 ,$2.10 ,$4.55 ,$5.04 ,$6.37 ,$5.25 
Carle BroMenn Medical Center,8380839,WEST NILE VIRUS IGM    REF,,86788,302,$8.00 ,$8.00 ,$2.40 ,$7.28 ,$5.60 ,$2.40 ,$5.20 ,$5.76 ,$7.28 ,$6.00 
Carle BroMenn Medical Center,8380840,"POLIOVIRUS (TYPES 1-3) AB, CSF  REF",,86658,302,$26.00 ,$26.00 ,$7.80 ,$23.66 ,$18.20 ,$7.80 ,$16.90 ,$18.72 ,$23.66 ,$19.50 
Carle BroMenn Medical Center,8380841,RICKETTSIA ABS    REF,,86757,302,$19.00 ,$19.00 ,$5.70 ,$17.29 ,$13.30 ,$5.70 ,$12.35 ,$13.68 ,$17.29 ,$14.25 
Carle BroMenn Medical Center,8380842,COX. BURNETII (Q FEVER) ABS    REF,,86638,302,$12.00 ,$12.00 ,$3.60 ,$10.92 ,$8.40 ,$3.60 ,$7.80 ,$8.64 ,$10.92 ,$9.00 
Carle BroMenn Medical Center,8380843,Q FEVER TITER(S)    REF,,86638,302,$49.00 ,$49.00 ,$14.70 ,$44.59 ,$34.30 ,$14.70 ,$31.85 ,$35.28 ,$44.59 ,$36.75 
Carle BroMenn Medical Center,8380844,RMSF IGG TITER    REF,,86757,302,$94.25 ,$94.25 ,$28.28 ,$85.77 ,$65.98 ,$28.28 ,$61.26 ,$67.86 ,$85.77 ,$70.69 
Carle BroMenn Medical Center,8380845,RMSF IGM TITER    REF,,86757,302,$97.50 ,$97.50 ,$29.25 ,$88.73 ,$68.25 ,$29.25 ,$63.38 ,$70.20 ,$88.73 ,$73.13 
Carle BroMenn Medical Center,8380846,R. TYPHI IGG TITER    REF,,86757,302,$55.00 ,$55.00 ,$16.50 ,$50.05 ,$38.50 ,$16.50 ,$35.75 ,$39.60 ,$50.05 ,$41.25 
Carle BroMenn Medical Center,8380847,R. TYPHI IGM TITER    REF,,86757,302,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8380851,"POLIOVIRUS 1,2,3 ABS    REF",,86382,302,$64.00 ,$64.00 ,$19.20 ,$58.24 ,$44.80 ,$19.20 ,$41.60 ,$46.08 ,$58.24 ,$48.00 
Carle BroMenn Medical Center,8380860,LABORATORY SERVICE      REF,,86780,302,$33.00 ,$33.00 ,$9.90 ,$30.03 ,$23.10 ,$9.90 ,$21.45 ,$23.76 ,$30.03 ,$24.75 
Carle BroMenn Medical Center,8380863,RABIES TITER-RESPONSE    REF,,86382,302,$67.00 ,$67.00 ,$20.10 ,$60.97 ,$46.90 ,$20.10 ,$43.55 ,$48.24 ,$60.97 ,$50.25 
Carle BroMenn Medical Center,8380911,FOOD PANEL       REF,,86003,302,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8380913,CHROMOGRANIN A               REF,,86316,302,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8380925,SCL 70 ANTIBODY               REF,,86235,302,$133.25 ,$133.25 ,$39.98 ,$121.26 ,$93.28 ,$39.98 ,$86.61 ,$95.94 ,$121.26 ,$99.94 
Carle BroMenn Medical Center,8380936,SM ABS    REF,,86235,302,$9.00 ,$9.00 ,$2.70 ,$8.19 ,$6.30 ,$2.70 ,$5.85 ,$6.48 ,$8.19 ,$6.75 
Carle BroMenn Medical Center,8380937,RNP ABS    REF,,86235,302,$9.00 ,$9.00 ,$2.70 ,$8.19 ,$6.30 ,$2.70 ,$5.85 ,$6.48 ,$8.19 ,$6.75 
Carle BroMenn Medical Center,8380938,JO 1 ABS     REF,,86235,302,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8380942,"EBG IGG AB TO EARLY AG, S      REF",,86663,302,$21.00 ,$21.00 ,$6.30 ,$19.11 ,$14.70 ,$6.30 ,$13.65 ,$15.12 ,$19.11 ,$15.75 
Carle BroMenn Medical Center,8380943,"TETANUS TOXOID IGG AB, S     REF",,86774,302,$14.00 ,$14.00 ,$4.20 ,$12.74 ,$9.80 ,$4.20 ,$9.10 ,$10.08 ,$12.74 ,$10.50 
Carle BroMenn Medical Center,8380947,FOOD NUT PANEL #1    REF,,86003,302,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8380953,"GRANULOCYTE ABS, S       REF",,86021,302,$56.00 ,$56.00 ,$16.80 ,$50.96 ,$39.20 ,$16.80 ,$36.40 ,$40.32 ,$50.96 ,$42.00 
Carle BroMenn Medical Center,8380955,"LIVER/KIDNEY MICROSOME ABS, S    REF",,86376,302,$13.00 ,$13.00 ,$3.90 ,$11.83 ,$9.10 ,$3.90 ,$8.45 ,$9.36 ,$11.83 ,$9.75 
Carle BroMenn Medical Center,8380960,IFN-B NEUTRALIZATION TEST VIRAL  REF,,86382,302,$633.00 ,$633.00 ,$189.90 ,$576.03 ,$443.10 ,$189.90 ,$411.45 ,$455.76 ,$576.03 ,$474.75 
Carle BroMenn Medical Center,8380964,"CANCER AG 15-3, S          REF",,86300,302,$13.00 ,$13.00 ,$3.90 ,$11.83 ,$9.10 ,$3.90 ,$8.45 ,$9.36 ,$11.83 ,$9.75 
Carle BroMenn Medical Center,8380973,"SMOOTH MUSCLE ABS, S        REF",,86255,302,$113.75 ,$113.75 ,$34.13 ,$103.51 ,$79.63 ,$34.13 ,$73.94 ,$81.90 ,$103.51 ,$85.31 
Carle BroMenn Medical Center,8380978,CHLAMYDIA AB           REF,,86631,302,$81.25 ,$81.25 ,$24.38 ,$73.94 ,$56.88 ,$24.38 ,$52.81 ,$58.50 ,$73.94 ,$60.94 
Carle BroMenn Medical Center,8380979,"CHLAMYDIA AB, IGM     REF",,86632,302,$84.50 ,$84.50 ,$25.35 ,$76.90 ,$59.15 ,$25.35 ,$54.93 ,$60.84 ,$76.90 ,$63.38 
Carle BroMenn Medical Center,8380982,"THYROGLOBULIN AB SCREEN, S   REF",,86800,302,$9.00 ,$9.00 ,$2.70 ,$8.19 ,$6.30 ,$2.70 ,$5.85 ,$6.48 ,$8.19 ,$6.75 
Carle BroMenn Medical Center,8380983,ANTI-PHOSPHATIDLYSERINE AB   REF,,86148,302,$107.25 ,$107.25 ,$32.18 ,$97.60 ,$75.08 ,$32.18 ,$69.71 ,$77.22 ,$97.60 ,$80.44 
Carle BroMenn Medical Center,8381031,T/B CELL QUANT NK CELLS REF,,86357,302,$16.00 ,$16.00 ,$4.80 ,$14.56 ,$11.20 ,$4.80 ,$10.40 ,$11.52 ,$14.56 ,$12.00 
Carle BroMenn Medical Center,8381033,"COMPLEMENT C1Q, S  REF",,86160,302,$14.00 ,$14.00 ,$4.20 ,$12.74 ,$9.80 ,$4.20 ,$9.10 ,$10.08 ,$12.74 ,$10.50 
Carle BroMenn Medical Center,8381036,"IMMUNODIFFUSEION OUCHTERLONY, REF",,86331,302,$58.00 ,$58.00 ,$17.40 ,$52.78 ,$40.60 ,$17.40 ,$37.70 ,$41.76 ,$52.78 ,$43.50 
Carle BroMenn Medical Center,8381042,"FRANCISELLA TULARENSIS ANTIBODY, IGM/IGA  REF",,86668,302,$37.00 ,$37.00 ,$11.10 ,$33.67 ,$25.90 ,$11.10 ,$24.05 ,$26.64 ,$33.67 ,$27.75 
Carle BroMenn Medical Center,8381044,CD20 TOTAL COUNT  REF,,86356,302,$70.00 ,$70.00 ,$21.00 ,$63.70 ,$49.00 ,$21.00 ,$45.50 ,$50.40 ,$63.70 ,$52.50 
Carle BroMenn Medical Center,8381094,DIRECT BACTERIAL AG-PARTICLE AGGLUT.EACH,,86403,302,$45.00 ,$45.00 ,$13.50 ,$40.95 ,$31.50 ,$13.50 ,$29.25 ,$32.40 ,$40.95 ,$33.75 
Carle BroMenn Medical Center,8381100,"COCCIDIOIDES AB SCREEN, CSF  REF",,86635,302,$58.00 ,$58.00 ,$17.40 ,$52.78 ,$40.60 ,$17.40 ,$37.70 ,$41.76 ,$52.78 ,$43.50 
Carle BroMenn Medical Center,8381101,"COCCIDIOIDES AB SCREEN, SERUM  REF",,86635,302,$22.00 ,$22.00 ,$6.60 ,$20.02 ,$15.40 ,$6.60 ,$14.30 ,$15.84 ,$20.02 ,$16.50 
Carle BroMenn Medical Center,8381120,LABORATORY SERVICES,,86702,302,$101.00 ,$101.00 ,$30.30 ,$91.91 ,$70.70 ,$30.30 ,$65.65 ,$72.72 ,$91.91 ,$75.75 
Carle BroMenn Medical Center,8381121,"FL NONINF AGENT AB; SCRN, EA   REF",,86255,302,$284.00 ,$284.00 ,$85.20 ,$258.44 ,$198.80 ,$85.20 ,$184.60 ,$204.48 ,$258.44 ,$213.00 
Carle BroMenn Medical Center,8381122,"FL NONINF AGENT AB; TITER, EA   REF",,86256,302,$74.75 ,$74.75 ,$22.43 ,$68.02 ,$52.33 ,$22.43 ,$48.59 ,$53.82 ,$68.02 ,$56.06 
Carle BroMenn Medical Center,8381127,CHIKUNGUNYA IGG-IGM SCREEN  REF,,86790,302,$66.00 ,$66.00 ,$19.80 ,$60.06 ,$46.20 ,$19.80 ,$42.90 ,$47.52 ,$60.06 ,$49.50 
Carle BroMenn Medical Center,8381128,CHIKUNGUNYA IGG TITRATION  REF,,86790,302,$71.00 ,$71.00 ,$21.30 ,$64.61 ,$49.70 ,$21.30 ,$46.15 ,$51.12 ,$64.61 ,$53.25 
Carle BroMenn Medical Center,8381129,CHIKUNGUNYA IGM TITRATION  REF,,86790,302,$74.00 ,$74.00 ,$22.20 ,$67.34 ,$51.80 ,$22.20 ,$48.10 ,$53.28 ,$67.34 ,$55.50 
Carle BroMenn Medical Center,8381230,"ISLET ANTIGETN 2 (IA-2) AB, S  REF",,86341,302,$18.00 ,$18.00 ,$5.40 ,$16.38 ,$12.60 ,$5.40 ,$11.70 ,$12.96 ,$16.38 ,$13.50 
Carle BroMenn Medical Center,8381247,HU ANTIBODY SCREEN WITH REFLEX  REF,,86255,302,$94.25 ,$94.25 ,$28.28 ,$85.77 ,$65.98 ,$28.28 ,$61.26 ,$67.86 ,$85.77 ,$70.69 
Carle BroMenn Medical Center,8381417,"FL NONINF AGENT AB; SCRN, EA   REF",,86255,302,$126.00 ,$126.00 ,$37.80 ,$114.66 ,$88.20 ,$37.80 ,$81.90 ,$90.72 ,$114.66 ,$94.50 
Carle BroMenn Medical Center,8381418,COCCIDIODES    REF,,86635,302,$64.70 ,$64.70 ,$19.41 ,$58.88 ,$45.29 ,$19.41 ,$42.06 ,$46.58 ,$58.88 ,$48.53 
Carle BroMenn Medical Center,8381439,DENGUE VIRUS NS1 ANTIGEN  REF,,86790,302,$63.00 ,$63.00 ,$18.90 ,$57.33 ,$44.10 ,$18.90 ,$40.95 ,$45.36 ,$57.33 ,$47.25 
Carle BroMenn Medical Center,8381453,"B CELLS, TOTAL COUNT  REF",,86355,302,$119.88 ,$119.88 ,$35.96 ,$109.09 ,$83.92 ,$35.96 ,$77.92 ,$86.31 ,$109.09 ,$89.91 
Carle BroMenn Medical Center,8381455,HEPATITIS A TOTAL AB,,86708,302,$101.00 ,$101.00 ,$30.30 ,$91.91 ,$70.70 ,$30.30 ,$65.65 ,$72.72 ,$91.91 ,$75.75 
Carle BroMenn Medical Center,8381456,HEPATITIS B CORE TOTAL AB,,86704,302,$113.00 ,$113.00 ,$33.90 ,$102.83 ,$79.10 ,$33.90 ,$73.45 ,$81.36 ,$102.83 ,$84.75 
Carle BroMenn Medical Center,8381457,THYROGLOBULIN AB,,86800,302,$101.00 ,$101.00 ,$30.30 ,$91.91 ,$70.70 ,$30.30 ,$65.65 ,$72.72 ,$91.91 ,$75.75 
Carle BroMenn Medical Center,8381459,THYROPEROXIDASE AB,,86376,302,$135.00 ,$135.00 ,$40.50 ,$122.85 ,$94.50 ,$40.50 ,$87.75 ,$97.20 ,$122.85 ,$101.25 
Carle BroMenn Medical Center,8381460,CARBOHYDRATE ANTIGEN 19-9,,86301,302,$173.00 ,$173.00 ,$51.90 ,$157.43 ,$121.10 ,$51.90 ,$112.45 ,$124.56 ,$157.43 ,$129.75 
Carle BroMenn Medical Center,8381466,DS-DNA AB BY CRITHIDIA IFA  REF,,86255,302,$23.00 ,$23.00 ,$6.90 ,$20.93 ,$16.10 ,$6.90 ,$14.95 ,$16.56 ,$20.93 ,$17.25 
Carle BroMenn Medical Center,8381469,"DIPHTHERIA TOXOID IGG AB, S   REF",,86317,302,$123.50 ,$123.50 ,$37.05 ,$112.39 ,$86.45 ,$37.05 ,$80.28 ,$88.92 ,$112.39 ,$92.63 
Carle BroMenn Medical Center,8381470,"TETANUS TOXOID IGG AB, S     REF",,86317,302,$123.50 ,$123.50 ,$37.05 ,$112.39 ,$86.45 ,$37.05 ,$80.28 ,$88.92 ,$112.39 ,$92.63 
Carle BroMenn Medical Center,8381533,BACTERIUM ANTIBODY         REF,,86609,302,$6.00 ,$6.00 ,$1.80 ,$5.46 ,$4.20 ,$1.80 ,$3.90 ,$4.32 ,$5.46 ,$4.50 
Carle BroMenn Medical Center,8381540,"CHIKUNGUNYA IGG, IGM ABS  REF",,86790,302,$63.00 ,$63.00 ,$18.90 ,$57.33 ,$44.10 ,$18.90 ,$40.95 ,$45.36 ,$57.33 ,$47.25 
Carle BroMenn Medical Center,8381551,BLASTOMYCES AB IMMUNODIFFUSION  REF,,86612,302,$64.70 ,$64.70 ,$19.41 ,$58.88 ,$45.29 ,$19.41 ,$42.06 ,$46.58 ,$58.88 ,$48.53 
Carle BroMenn Medical Center,8381554,"KIT ASP816VAL MUTATION ANALYSIS, B  REF",,86612,302,$96.00 ,$96.00 ,$28.80 ,$87.36 ,$67.20 ,$28.80 ,$62.40 ,$69.12 ,$87.36 ,$72.00 
Carle BroMenn Medical Center,8381562,ALLRG SPC IGE ALPHA-GAL PANEL  REF,,86003,302,$12.00 ,$12.00 ,$3.60 ,$10.92 ,$8.40 ,$3.60 ,$7.80 ,$8.64 ,$10.92 ,$9.00 
Carle BroMenn Medical Center,8381564,UNFRAC HEPARIN DEP PLATELET AB  REF,,86022,302,$231.00 ,$231.00 ,$69.30 ,$210.21 ,$161.70 ,$69.30 ,$150.15 ,$166.32 ,$210.21 ,$173.25 
Carle BroMenn Medical Center,8381567,"RUBELLA AB, IGG (TRCHG)  REF",,86762,302,$12.00 ,$12.00 ,$3.60 ,$10.92 ,$8.40 ,$3.60 ,$7.80 ,$8.64 ,$10.92 ,$9.00 
Carle BroMenn Medical Center,8381568,"CYTOMEGALOVIURS AB, IGG (TRCHG)  REF",,86644,302,$12.00 ,$12.00 ,$3.60 ,$10.92 ,$8.40 ,$3.60 ,$7.80 ,$8.64 ,$10.92 ,$9.00 
Carle BroMenn Medical Center,8381605,NMO/AQP4-IGG FACS  REF,,86255,302,$95.00 ,$95.00 ,$28.50 ,$86.45 ,$66.50 ,$28.50 ,$61.75 ,$68.40 ,$86.45 ,$71.25 
Carle BroMenn Medical Center,8381606,NMO/AQP4-IGG FACS TITER  REF,,86256,302,$38.00 ,$38.00 ,$11.40 ,$34.58 ,$26.60 ,$11.40 ,$24.70 ,$27.36 ,$34.58 ,$28.50 
Carle BroMenn Medical Center,8381616,STREPTOZYME TITER  REF,,86406,302,$74.75 ,$74.75 ,$22.43 ,$68.02 ,$52.33 ,$22.43 ,$48.59 ,$53.82 ,$68.02 ,$56.06 
Carle BroMenn Medical Center,8381620,"IMMUNOFIXATION, U, REF",,86335,302,$21.00 ,$21.00 ,$6.30 ,$19.11 ,$14.70 ,$6.30 ,$13.65 ,$15.12 ,$19.11 ,$15.75 
Carle BroMenn Medical Center,8381653,"EMA TITER, S (IGA) REF",,86256,302,$49.00 ,$49.00 ,$14.70 ,$44.59 ,$34.30 ,$14.70 ,$31.85 ,$35.28 ,$44.59 ,$36.75 
Carle BroMenn Medical Center,8381669,"ECHINOCOCCUS ANTIBODY IGG, SERUM, REF",,86682,302,$169.00 ,$169.00 ,$50.70 ,$153.79 ,$118.30 ,$50.70 ,$109.85 ,$121.68 ,$153.79 ,$126.75 
Carle BroMenn Medical Center,8381682,"DEMENTIA-AUTOIMMUNE EVALUATION, CSF, REF",,86255,302,$116.00 ,$116.00 ,$34.80 ,$105.56 ,$81.20 ,$34.80 ,$75.40 ,$83.52 ,$105.56 ,$87.00 
Carle BroMenn Medical Center,8381693,"LYME DISEASE ANTIBODY, IGM",,86618,302,$214.00 ,$214.00 ,$64.20 ,$194.74 ,$149.80 ,$64.20 ,$139.10 ,$154.08 ,$194.74 ,$160.50 
Carle BroMenn Medical Center,8381695,"LYME DISEASE ANTIBODY, IGG",,86618,302,$198.00 ,$198.00 ,$59.40 ,$180.18 ,$138.60 ,$59.40 ,$128.70 ,$142.56 ,$180.18 ,$148.50 
Carle BroMenn Medical Center,8381705,"(-2) PROPSA, S",,86316,302,$47.00 ,$47.00 ,$14.10 ,$42.77 ,$32.90 ,$14.10 ,$30.55 ,$33.84 ,$42.77 ,$35.25 
Carle BroMenn Medical Center,8381726,"HEPATITIS D TOTAL AB, S",,86692,302,$36.00 ,$36.00 ,$10.80 ,$32.76 ,$25.20 ,$10.80 ,$23.40 ,$25.92 ,$32.76 ,$27.00 
Carle BroMenn Medical Center,8381727,LABORATORY TEST,,86780,302,$126.00 ,$126.00 ,$37.80 ,$114.66 ,$88.20 ,$37.80 ,$81.90 ,$90.72 ,$114.66 ,$94.50 
Carle BroMenn Medical Center,8381739,"LYME CNS INFECTION IGG SCREEN, CSF, REF",,86618,302,$12.00 ,$12.00 ,$3.60 ,$10.92 ,$8.40 ,$3.60 ,$7.80 ,$8.64 ,$10.92 ,$9.00 
Carle BroMenn Medical Center,8381742,"LYME DISEASE ANTIBODY, REF",,86618,302,$126.75 ,$126.75 ,$38.03 ,$115.34 ,$88.73 ,$38.03 ,$82.39 ,$91.26 ,$115.34 ,$95.06 
Carle BroMenn Medical Center,8381772,"PARANEOPLASTIC AUTOANTIBODY EVAL, CSF, REF",,86255,302,$116.00 ,$116.00 ,$34.80 ,$105.56 ,$81.20 ,$34.80 ,$75.40 ,$83.52 ,$105.56 ,$87.00 
Carle BroMenn Medical Center,8381792,"MYOCARDIAL ABS, S, REF",,86255,302,$116.00 ,$116.00 ,$34.80 ,$105.56 ,$81.20 ,$34.80 ,$75.40 ,$83.52 ,$105.56 ,$87.00 
Carle BroMenn Medical Center,8381800,"NMDA RECEPTOR ANTIBODY TEST, REF",,86255,302,$116.00 ,$116.00 ,$34.80 ,$105.56 ,$81.20 ,$34.80 ,$75.40 ,$83.52 ,$105.56 ,$87.00 
Carle BroMenn Medical Center,8381805,"SPOTTED FEVER AB, REF",,86757,302,$101.00 ,$101.00 ,$30.30 ,$91.91 ,$70.70 ,$30.30 ,$65.65 ,$72.72 ,$91.91 ,$75.75 
Carle BroMenn Medical Center,8381816,"TAU PROTEIN, REF",,86317,302,$152.00 ,$152.00 ,$45.60 ,$138.32 ,$106.40 ,$45.60 ,$98.80 ,$109.44 ,$138.32 ,$114.00 
Carle BroMenn Medical Center,8381818,"(CSF) TAU, REF CASE WESTERN",,86317,302,$152.00 ,$152.00 ,$45.60 ,$138.32 ,$106.40 ,$45.60 ,$98.80 ,$109.44 ,$138.32 ,$114.00 
Carle BroMenn Medical Center,8381824,"MOG FACS, S, REF",,86255,302,$116.00 ,$116.00 ,$34.80 ,$105.56 ,$81.20 ,$34.80 ,$75.40 ,$83.52 ,$105.56 ,$87.00 
Carle BroMenn Medical Center,8381833,HIV-2 ANTIBODY,,86702,302,$61.75 ,$61.75 ,$18.53 ,$56.19 ,$43.23 ,$18.53 ,$40.14 ,$44.46 ,$56.19 ,$46.31 
Carle BroMenn Medical Center,8381849,"CHLAMYDIA IGM ANTIBODY, REF",,86632,302,$104.00 ,$104.00 ,$31.20 ,$94.64 ,$72.80 ,$31.20 ,$67.60 ,$74.88 ,$94.64 ,$78.00 
Carle BroMenn Medical Center,8381854,"AGGLUTININS, FEBRILE, EACH ANTIGEN",,86000,302,$79.00 ,$79.00 ,$23.70 ,$71.89 ,$55.30 ,$23.70 ,$51.35 ,$56.88 ,$71.89 ,$59.25 
Carle BroMenn Medical Center,8381856,"AC/HS TOXOPLASMOSIS TESTING, REF",,86406,302,$92.00 ,$92.00 ,$27.60 ,$83.72 ,$64.40 ,$27.60 ,$59.80 ,$66.24 ,$83.72 ,$69.00 
Carle BroMenn Medical Center,8381858,"PRENATAL ZIKA VIRUS MAC-ELISA, IGM,S, REF",,86794,302,$110.00 ,$110.00 ,$33.00 ,$100.10 ,$77.00 ,$33.00 ,$71.50 ,$79.20 ,$100.10 ,$82.50 
Carle BroMenn Medical Center,8381862,"SRP IFA SCREEN, S, REF",,86255,302,$116.00 ,$116.00 ,$34.80 ,$105.56 ,$81.20 ,$34.80 ,$75.40 ,$83.52 ,$105.56 ,$87.00 
Carle BroMenn Medical Center,8381870,"NUCLEAR ANTIGEN ANTIBODY, REF",,86235,302,$16.00 ,$16.00 ,$4.80 ,$14.56 ,$11.20 ,$4.80 ,$10.40 ,$11.52 ,$14.56 ,$12.00 
Carle BroMenn Medical Center,8381880,"ANTI-NEURONAL NUCLEAR AB, TYPE 1, REF",,86255,302,$116.00 ,$116.00 ,$34.80 ,$105.56 ,$81.20 ,$34.80 ,$75.40 ,$83.52 ,$105.56 ,$87.00 
Carle BroMenn Medical Center,8381908,"OVARIAN ANTIBODY SCREEN, REF",,86255,302,$116.00 ,$116.00 ,$34.80 ,$105.56 ,$81.20 ,$34.80 ,$75.40 ,$83.52 ,$105.56 ,$87.00 
Carle BroMenn Medical Center,8381909,"GALACTOSE-ALPHA-1, 3-GALACTOSE (ALPHA-GAL), IGE, REF",,86008,302,$41.33 ,$41.33 ,$12.40 ,$37.61 ,$28.93 ,$12.40 ,$26.86 ,$29.76 ,$37.61 ,$31.00 
Carle BroMenn Medical Center,8381926,"HTLV-1/-11 AB, SCREEN, S, REF",,86790,302,$97.50 ,$97.50 ,$29.25 ,$88.73 ,$68.25 ,$29.25 ,$63.38 ,$70.20 ,$88.73 ,$73.13 
Carle BroMenn Medical Center,8381939,HC TB QUANTIFERON-PLUS,,86481,302,$309.00 ,$309.00 ,$92.70 ,$281.19 ,$216.30 ,$92.70 ,$200.85 ,$222.48 ,$281.19 ,$231.75 
Carle BroMenn Medical Center,8381940,"SACCHAROMYCES CER AB, IGA, REF",,86671,302,$266.50 ,$266.50 ,$79.95 ,$242.52 ,$186.55 ,$79.95 ,$173.23 ,$191.88 ,$242.52 ,$199.88 
Carle BroMenn Medical Center,8381954,"FLUORESCENT AB SCREEN, REF",,86255,302,$116.00 ,$116.00 ,$34.80 ,$105.56 ,$81.20 ,$34.80 ,$75.40 ,$83.52 ,$105.56 ,$87.00 
Carle BroMenn Medical Center,8381969,"F. TULARENSIS AB, S",,86668,302,$42.00 ,$42.00 ,$12.60 ,$38.22 ,$29.40 ,$12.60 ,$27.30 ,$30.24 ,$38.22 ,$31.50 
Carle BroMenn Medical Center,8382100,OLIGOCLONAL BANDS,,86335,302,$274.00 ,$274.00 ,$82.20 ,$249.34 ,$191.80 ,$82.20 ,$178.10 ,$197.28 ,$249.34 ,$205.50 
Carle BroMenn Medical Center,8382156,IMMUNFIX E-PHORSIS/URINE/CSF,,86335,302,$233.00 ,$233.00 ,$69.90 ,$212.03 ,$163.10 ,$69.90 ,$151.45 ,$167.76 ,$212.03 ,$174.75 
Carle BroMenn Medical Center,8382165,HEPARIN DEPENDENT PLATELET ABS,,86022,302,$353.00 ,$353.00 ,$105.90 ,$321.23 ,$247.10 ,$105.90 ,$229.45 ,$254.16 ,$321.23 ,$264.75 
Carle BroMenn Medical Center,8382192,GLOMERULAR BASEMENT MEMBRANE AB IGG REF,,86255,302,$116.00 ,$116.00 ,$34.80 ,$105.56 ,$81.20 ,$34.80 ,$75.40 ,$83.52 ,$105.56 ,$87.00 
Carle BroMenn Medical Center,8382196,"LRP4 AUTOANTIBODY TEST, REF",,86255,302,$116.00 ,$116.00 ,$34.80 ,$105.56 ,$81.20 ,$34.80 ,$75.40 ,$83.52 ,$105.56 ,$87.00 
Carle BroMenn Medical Center,8382222,HEP A IGM AB,,86709,302,$91.00 ,$91.00 ,$27.30 ,$82.81 ,$63.70 ,$27.30 ,$59.15 ,$65.52 ,$82.81 ,$68.25 
Carle BroMenn Medical Center,8382225,HEP B SURFACE AB QN,,86317,302,$152.00 ,$152.00 ,$45.60 ,$138.32 ,$106.40 ,$45.60 ,$98.80 ,$109.44 ,$138.32 ,$114.00 
Carle BroMenn Medical Center,8382256,"MEASLES AB IGG,EIA",,86765,302,$78.00 ,$78.00 ,$23.40 ,$70.98 ,$54.60 ,$23.40 ,$50.70 ,$56.16 ,$70.98 ,$58.50 
Carle BroMenn Medical Center,8382260,QUANTIFERON(R) PL 4T,,86480,302,$68.25 ,$68.25 ,$20.48 ,$62.11 ,$47.78 ,$20.48 ,$44.36 ,$49.14 ,$62.11 ,$51.19 
Carle BroMenn Medical Center,8382298,"LYMPHOCYTE SUBSET PANEL 4 - CD4/CD8 - BRONCH, REF",,86356,302,$7.00 ,$7.00 ,$2.10 ,$6.37 ,$4.90 ,$2.10 ,$4.55 ,$5.04 ,$6.37 ,$5.25 
Carle BroMenn Medical Center,8382303,"CELIAC DISEASE PANEL, REF",,86255,302,$116.00 ,$116.00 ,$34.80 ,$105.56 ,$81.20 ,$34.80 ,$75.40 ,$83.52 ,$105.56 ,$87.00 
Carle BroMenn Medical Center,8382320,COXSACKIE A AB PANEL    REF,,86658,302,$62.00 ,$62.00 ,$18.60 ,$56.42 ,$43.40 ,$18.60 ,$40.30 ,$44.64 ,$56.42 ,$46.50 
Carle BroMenn Medical Center,8382325,COXSACKIE B(1-6)AB REF,,86658,302,$62.00 ,$62.00 ,$18.60 ,$56.42 ,$43.40 ,$18.60 ,$40.30 ,$44.64 ,$56.42 ,$46.50 
Carle BroMenn Medical Center,8382346,"CENTROMERE AB, REF",,86235,302,$19.00 ,$19.00 ,$5.70 ,$17.29 ,$13.30 ,$5.70 ,$12.35 ,$13.68 ,$17.29 ,$14.25 
Carle BroMenn Medical Center,8382349,"T. PALLIDIUM AB, PA, REF",,86780,302,$49.40 ,$49.40 ,$14.82 ,$44.95 ,$34.58 ,$14.82 ,$32.11 ,$35.57 ,$44.95 ,$37.05 
Carle BroMenn Medical Center,8382351,ANTISTREPTOLYSIN O,,86060,302,$100.75 ,$100.75 ,$30.23 ,$91.68 ,$70.53 ,$30.23 ,$65.49 ,$72.54 ,$91.68 ,$75.56 
Carle BroMenn Medical Center,8382363,"SERUM IMMUNOFIXATION, REF",,86334,302,$136.50 ,$136.50 ,$40.95 ,$124.22 ,$95.55 ,$40.95 ,$88.73 ,$98.28 ,$124.22 ,$102.38 
Carle BroMenn Medical Center,8382376,"HEP B CORE AB, TOTAL, REF",,86704,302,$13.00 ,$13.00 ,$3.90 ,$11.83 ,$9.10 ,$3.90 ,$8.45 ,$9.36 ,$11.83 ,$9.75 
Carle BroMenn Medical Center,8382392,"CHROMOGRANIN A, ECL",,86316,302,$65.00 ,$65.00 ,$19.50 ,$59.15 ,$45.50 ,$19.50 ,$42.25 ,$46.80 ,$59.15 ,$48.75 
Carle BroMenn Medical Center,8382401,CA27.29 CHIRON/BAYER,,86300,302,$11.00 ,$11.00 ,$3.30 ,$10.01 ,$7.70 ,$3.30 ,$7.15 ,$7.92 ,$10.01 ,$8.25 
Carle BroMenn Medical Center,8382405,CYCLIC CITRUL PEPTIDE AB REF,,86200,302,$111.00 ,$111.00 ,$33.30 ,$101.01 ,$77.70 ,$33.30 ,$72.15 ,$79.92 ,$101.01 ,$83.25 
Carle BroMenn Medical Center,8382414,"IMMUNOFIX, UR",,86335,302,$13.00 ,$13.00 ,$3.90 ,$11.83 ,$9.10 ,$3.90 ,$8.45 ,$9.36 ,$11.83 ,$9.75 
Carle BroMenn Medical Center,8382439,"ANTI-DSDNA, REFLUS, TITER, REF",,86255,302,$116.00 ,$116.00 ,$34.80 ,$105.56 ,$81.20 ,$34.80 ,$75.40 ,$83.52 ,$105.56 ,$87.00 
Carle BroMenn Medical Center,8382444,ANA TITER & PATTERN REF,,86039,302,$149.50 ,$149.50 ,$44.85 ,$136.05 ,$104.65 ,$44.85 ,$97.18 ,$107.64 ,$136.05 ,$112.13 
Carle BroMenn Medical Center,8382451,"STREPTOCOCCUS PNEUMONIAE S, REF",,86317,302,$152.00 ,$152.00 ,$45.60 ,$138.32 ,$106.40 ,$45.60 ,$98.80 ,$109.44 ,$138.32 ,$114.00 
Carle BroMenn Medical Center,8382470,INHIBIN A,,86336,302,$53.00 ,$53.00 ,$15.90 ,$48.23 ,$37.10 ,$15.90 ,$34.45 ,$38.16 ,$48.23 ,$39.75 
Carle BroMenn Medical Center,8382486,"PHOSPHATIDYLSERINE AB, REF",,86148,302,$19.00 ,$19.00 ,$5.70 ,$17.29 ,$13.30 ,$5.70 ,$12.35 ,$13.68 ,$17.29 ,$14.25 
Carle BroMenn Medical Center,8382526,"THSD7, REF",,86255,302,$116.00 ,$116.00 ,$34.80 ,$105.56 ,$81.20 ,$34.80 ,$75.40 ,$83.52 ,$105.56 ,$87.00 
Carle BroMenn Medical Center,8382528,"LYMPHOCYTE SUBSET PANEL 5, REF",,86361,302,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8382548,"LYMPHOCYTE SUBSET PANEL 4, B",,86360,302,$166.00 ,$166.00 ,$49.80 ,$151.06 ,$116.20 ,$49.80 ,$107.90 ,$119.52 ,$151.06 ,$124.50 
Carle BroMenn Medical Center,8382559,"GABA-BR AB, IGG BY IFA W/REFLUX TO TITER, REF",,86255,302,$116.00 ,$116.00 ,$34.80 ,$105.56 ,$81.20 ,$34.80 ,$75.40 ,$83.52 ,$105.56 ,$87.00 
Carle BroMenn Medical Center,8382568,"ALLERGEN SPECIFIC IGE, EACH, REF",,86003,302,$39.00 ,$39.00 ,$11.70 ,$35.49 ,$27.30 ,$11.70 ,$25.35 ,$28.08 ,$35.49 ,$29.25 
Carle BroMenn Medical Center,8382574,ASPERGILLUS FUMIGATUS,,86606,302,$76.80 ,$76.80 ,$23.04 ,$69.89 ,$53.76 ,$23.04 ,$49.92 ,$55.30 ,$69.89 ,$57.60 
Carle BroMenn Medical Center,8382604,"CPT-CARDIOLIPIN AB, EACH IG CLASS",,86147,302,$20.00 ,$20.00 ,$6.00 ,$18.20 ,$14.00 ,$6.00 ,$13.00 ,$14.40 ,$18.20 ,$15.00 
Carle BroMenn Medical Center,8382632,INFLUENZA B,,87275,302,$110.00 ,$110.00 ,$33.00 ,$100.10 ,$77.00 ,$33.00 ,$71.50 ,$79.20 ,$100.10 ,$82.50 
Carle BroMenn Medical Center,8382635,INFLUENZA A,,87276,302,$110.00 ,$110.00 ,$33.00 ,$100.10 ,$77.00 ,$33.00 ,$71.50 ,$79.20 ,$100.10 ,$82.50 
Carle BroMenn Medical Center,8382665,ANTI CENTROMERE B ANTIBODY,,82397,302,$110.00 ,$110.00 ,$33.00 ,$100.10 ,$77.00 ,$33.00 ,$71.50 ,$79.20 ,$100.10 ,$82.50 
Carle BroMenn Medical Center,8382702,TOXOPLASMA IGG AB (TOXO),,86777,302,$165.00 ,$165.00 ,$49.50 ,$150.15 ,$115.50 ,$49.50 ,$107.25 ,$118.80 ,$150.15 ,$123.75 
Carle BroMenn Medical Center,8382718,ACL CGLIGGP,,83516,302,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8382722,ACL CTTABGP,,83516,302,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8382730,"EXTRAC NUCLEAR AG AB, EA    REF",,86235,302,$133.25 ,$133.25 ,$39.98 ,$121.26 ,$93.28 ,$39.98 ,$86.61 ,$95.94 ,$121.26 ,$99.94 
Carle BroMenn Medical Center,8382792,"INTRINSIC FACTOR BLOCKING AB, S  REF",,86340,302,$13.00 ,$13.00 ,$3.90 ,$11.83 ,$9.10 ,$3.90 ,$8.45 ,$9.36 ,$11.83 ,$9.75 
Carle BroMenn Medical Center,8382927,HELICOBACTOR PYLORI AB REF,,86677,302,$26.00 ,$26.00 ,$7.80 ,$23.66 ,$18.20 ,$7.80 ,$16.90 ,$18.72 ,$23.66 ,$19.50 
Carle BroMenn Medical Center,8382995,IMMUNOFIXATN ELECTROPHORSS REF,,86335,302,$159.25 ,$159.25 ,$47.78 ,$144.92 ,$111.48 ,$47.78 ,$103.51 ,$114.66 ,$144.92 ,$119.44 
Carle BroMenn Medical Center,8383005,"TUMOR ANTIGEN, CA 19-9     REF",,86301,302,$126.75 ,$126.75 ,$38.03 ,$115.34 ,$88.73 ,$38.03 ,$82.39 ,$91.26 ,$115.34 ,$95.06 
Carle BroMenn Medical Center,8383006,TUMOR AG OTHR-CHROMOGRANIN REF,,86316,302,$28.00 ,$28.00 ,$8.40 ,$25.48 ,$19.60 ,$8.40 ,$18.20 ,$20.16 ,$25.48 ,$21.00 
Carle BroMenn Medical Center,8383131,CHLAMYDIA DETECTION,,86631,302,$72.00 ,$72.00 ,$21.60 ,$65.52 ,$50.40 ,$21.60 ,$46.80 ,$51.84 ,$65.52 ,$54.00 
Carle BroMenn Medical Center,8383545,C1 ESTERSE INHIBITR FUNCTNL RF,,86161,302,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8383571,JO-1 ANTIBODY,,86235,302,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8383755,C1 ESTERASE INHIBITOR TOTL REF,,86160,302,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8384060,"PHOSPHATASE, ACID, TOTAL   REF",,84060,302,$9.00 ,$9.00 ,$2.70 ,$8.19 ,$6.30 ,$2.70 ,$5.85 ,$6.48 ,$8.19 ,$6.75 
Carle BroMenn Medical Center,8385426,TUBERCULSIS TEST;CELL IMMUN RF,,86480,302,$28.00 ,$28.00 ,$8.40 ,$25.48 ,$19.60 ,$8.40 ,$18.20 ,$20.16 ,$25.48 ,$21.00 
Carle BroMenn Medical Center,8386001,ALLERGEN SPECIFIC IGG,,86001,302,$71.50 ,$71.50 ,$21.45 ,$65.07 ,$50.05 ,$21.45 ,$46.48 ,$51.48 ,$65.07 ,$53.63 
Carle BroMenn Medical Center,8386011,"LYME DISEASE SEROLOGY, CSF REF",,86618,302,$12.00 ,$12.00 ,$3.60 ,$10.92 ,$8.40 ,$3.60 ,$7.80 ,$8.64 ,$10.92 ,$9.00 
Carle BroMenn Medical Center,8386020,ANTIBODY SCREENING,,86850,302,$126.75 ,$126.75 ,$38.03 ,$115.34 ,$88.73 ,$38.03 ,$82.39 ,$91.26 ,$115.34 ,$95.06 
Carle BroMenn Medical Center,8386021,ANTIBODY IDENTIFICATION PANEL,,86870,302,$334.75 ,$334.75 ,$100.43 ,$304.62 ,$234.33 ,$100.43 ,$217.59 ,$241.02 ,$304.62 ,$251.06 
Carle BroMenn Medical Center,8386024,PLATELET ANTIBODIES        REF,,86022,302,$178.75 ,$178.75 ,$53.63 ,$162.66 ,$125.13 ,$53.63 ,$116.19 ,$128.70 ,$162.66 ,$134.06 
Carle BroMenn Medical Center,8386026,ANTIBODY ELUTION,,86860,302,$182.00 ,$182.00 ,$54.60 ,$165.62 ,$127.40 ,$54.60 ,$118.30 ,$131.04 ,$165.62 ,$136.50 
Carle BroMenn Medical Center,8386027,PROTEINASE-3 ANTIBODY      REF,,86021,302,$84.50 ,$84.50 ,$25.35 ,$76.90 ,$59.15 ,$25.35 ,$54.93 ,$60.84 ,$76.90 ,$63.38 
Carle BroMenn Medical Center,8386030,"ANTI-NATIVE DNA AB, IFA",,86225,302,$186.00 ,$186.00 ,$55.80 ,$169.26 ,$130.20 ,$55.80 ,$120.90 ,$133.92 ,$169.26 ,$139.50 
Carle BroMenn Medical Center,8386038,ANTINUCLEAR ANTIBDIES(ANA) REF,,86038,302,$91.00 ,$91.00 ,$27.30 ,$82.81 ,$63.70 ,$27.30 ,$59.15 ,$65.52 ,$82.81 ,$68.25 
Carle BroMenn Medical Center,8386039,ANTINUCLEAR ANTIBODIES     REF,,86038,302,$14.00 ,$14.00 ,$4.20 ,$12.74 ,$9.80 ,$4.20 ,$9.10 ,$10.08 ,$12.74 ,$10.50 
Carle BroMenn Medical Center,8386045,MYELOPEROXIDASE ANTIBODY   REF,,86021,302,$84.50 ,$84.50 ,$25.35 ,$76.90 ,$59.15 ,$25.35 ,$54.93 ,$60.84 ,$76.90 ,$63.38 
Carle BroMenn Medical Center,8386050,ANTINUCLEAR ANTIBODY SCREEN,,86038,302,$167.00 ,$167.00 ,$50.10 ,$151.97 ,$116.90 ,$50.10 ,$108.55 ,$120.24 ,$151.97 ,$125.25 
Carle BroMenn Medical Center,8386051,ANTINUCLEAR ANTIBODY PROFILE,,86039,302,$68.25 ,$68.25 ,$20.48 ,$62.11 ,$47.78 ,$20.48 ,$44.36 ,$49.14 ,$62.11 ,$51.19 
Carle BroMenn Medical Center,8386060,ANTISTREPTOLYSIN O (ASO) TITER,,86060,302,$164.00 ,$164.00 ,$49.20 ,$149.24 ,$114.80 ,$49.20 ,$106.60 ,$118.08 ,$149.24 ,$123.00 
Carle BroMenn Medical Center,8386064,ANA TITER & PATTERN        REF,,86039,302,$23.00 ,$23.00 ,$6.90 ,$20.93 ,$16.10 ,$6.90 ,$14.95 ,$16.56 ,$20.93 ,$17.25 
Carle BroMenn Medical Center,8386074,MEASELS IGG AB,,86765,302,$129.00 ,$129.00 ,$38.70 ,$117.39 ,$90.30 ,$38.70 ,$83.85 ,$92.88 ,$117.39 ,$96.75 
Carle BroMenn Medical Center,8386138,"CRP, HIGH SENSITIVITY",,86141,302,$107.00 ,$107.00 ,$32.10 ,$97.37 ,$74.90 ,$32.10 ,$69.55 ,$77.04 ,$97.37 ,$80.25 
Carle BroMenn Medical Center,8386139,"ENA ANTIBODY, EACH AB      REF",,86235,302,$53.00 ,$53.00 ,$15.90 ,$48.23 ,$37.10 ,$15.90 ,$34.45 ,$38.16 ,$48.23 ,$39.75 
Carle BroMenn Medical Center,8386140,C-REACTIVE PROTEIN,,86140,302,$55.90 ,$55.90 ,$16.77 ,$50.87 ,$39.13 ,$16.77 ,$36.34 ,$40.25 ,$50.87 ,$41.93 
Carle BroMenn Medical Center,8386146,"BETA-2 GLYCOPROTEIN,ABS EA REF",,86146,302,$78.00 ,$78.00 ,$23.40 ,$70.98 ,$54.60 ,$23.40 ,$50.70 ,$56.16 ,$70.98 ,$58.50 
Carle BroMenn Medical Center,8386147,CARDIOLIPIN ANTIBODIES     REF,,86147,302,$120.25 ,$120.25 ,$36.08 ,$109.43 ,$84.18 ,$36.08 ,$78.16 ,$86.58 ,$109.43 ,$90.19 
Carle BroMenn Medical Center,8386150,COLD AGGLUTININ TITER      REF,,86157,302,$49.40 ,$49.40 ,$14.82 ,$44.95 ,$34.58 ,$14.82 ,$32.11 ,$35.57 ,$44.95 ,$37.05 
Carle BroMenn Medical Center,8386158,INHIBIN A                  REF,,86336,302,$97.50 ,$97.50 ,$29.25 ,$88.73 ,$68.25 ,$29.25 ,$63.38 ,$70.20 ,$88.73 ,$73.13 
Carle BroMenn Medical Center,8386160,"COMPLEMENT ANTIGEN, EACH COMP.",,86160,302,$148.00 ,$148.00 ,$44.40 ,$134.68 ,$103.60 ,$44.40 ,$96.20 ,$106.56 ,$134.68 ,$111.00 
Carle BroMenn Medical Center,8386161,"COMPLEMENT;AG,FNCTNL ACTIV REF",,86161,302,$104.00 ,$104.00 ,$31.20 ,$94.64 ,$72.80 ,$31.20 ,$67.60 ,$74.88 ,$94.64 ,$78.00 
Carle BroMenn Medical Center,8386162,COMPLEMENT C3C REF,,86160,302,$74.75 ,$74.75 ,$22.43 ,$68.02 ,$52.33 ,$22.43 ,$48.59 ,$53.82 ,$68.02 ,$56.06 
Carle BroMenn Medical Center,8386163,COMPLEMENT C4C REF,,86160,302,$74.75 ,$74.75 ,$22.43 ,$68.02 ,$52.33 ,$22.43 ,$48.59 ,$53.82 ,$68.02 ,$56.06 
Carle BroMenn Medical Center,8386164,COMPLEMENT TOTAL (CH50)    REF,,86162,302,$32.00 ,$32.00 ,$9.60 ,$29.12 ,$22.40 ,$9.60 ,$20.80 ,$23.04 ,$29.12 ,$24.00 
Carle BroMenn Medical Center,8386165,COMPLEMENT ANTIGEN REF,,86160,302,$18.00 ,$18.00 ,$5.40 ,$16.38 ,$12.60 ,$5.40 ,$11.70 ,$12.96 ,$16.38 ,$13.50 
Carle BroMenn Medical Center,8386188,ANTIBODY -VIRUS            REF,,86790,302,$89.00 ,$89.00 ,$26.70 ,$80.99 ,$62.30 ,$26.70 ,$57.85 ,$64.08 ,$80.99 ,$66.75 
Carle BroMenn Medical Center,8386215,DNASE-B ANTIBODY           REF,,86215,302,$81.25 ,$81.25 ,$24.38 ,$73.94 ,$56.88 ,$24.38 ,$52.81 ,$58.50 ,$73.94 ,$60.94 
Carle BroMenn Medical Center,8386225,DNA ANTIBODY   REF,,86225,302,$104.00 ,$104.00 ,$31.20 ,$94.64 ,$72.80 ,$31.20 ,$67.60 ,$74.88 ,$94.64 ,$78.00 
Carle BroMenn Medical Center,8386235,SM (SMITH)ANTIBODY-EACH AB REF,,86235,302,$33.00 ,$33.00 ,$9.90 ,$30.03 ,$23.10 ,$9.90 ,$21.45 ,$23.76 ,$30.03 ,$24.75 
Carle BroMenn Medical Center,8386236,ENA ANTIBODY-EACH ANTIBODY REF,,86235,302,$82.00 ,$82.00 ,$24.60 ,$74.62 ,$57.40 ,$24.60 ,$53.30 ,$59.04 ,$74.62 ,$61.50 
Carle BroMenn Medical Center,8386237,SM/RNP ANTIBODY TEST REF,,86235,302,$25.00 ,$25.00 ,$7.50 ,$22.75 ,$17.50 ,$7.50 ,$16.25 ,$18.00 ,$22.75 ,$18.75 
Carle BroMenn Medical Center,8386238,SJOGREN'S ANTIBODY-EACH AB REF,,86235,302,$133.25 ,$133.25 ,$39.98 ,$121.26 ,$93.28 ,$39.98 ,$86.61 ,$95.94 ,$121.26 ,$99.94 
Carle BroMenn Medical Center,8386239,SJOGREN'S ANTIBODY-EACH AB REF,,86235,302,$9.00 ,$9.00 ,$2.70 ,$8.19 ,$6.30 ,$2.70 ,$5.85 ,$6.48 ,$8.19 ,$6.75 
Carle BroMenn Medical Center,8386240,SM ANTIBODY TEST REF,,86235,302,$25.00 ,$25.00 ,$7.50 ,$22.75 ,$17.50 ,$7.50 ,$16.25 ,$18.00 ,$22.75 ,$18.75 
Carle BroMenn Medical Center,8386241,LUPUS PANEL-CENTROMERE ANTIBOD,,86255,302,$116.00 ,$116.00 ,$34.80 ,$105.56 ,$81.20 ,$34.80 ,$75.40 ,$83.52 ,$105.56 ,$87.00 
Carle BroMenn Medical Center,8386242,"CYTOPLASMIC NEUTROPHILIC AB, S  REF",,86255,302,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8386243,LUPUS PANEL-MITOCHONDRIAL AB,,86255,302,$116.00 ,$116.00 ,$34.80 ,$105.56 ,$81.20 ,$34.80 ,$75.40 ,$83.52 ,$105.56 ,$87.00 
Carle BroMenn Medical Center,8386244,PARIETAL CELL AB SCREEN REF,,86255,302,$49.00 ,$49.00 ,$14.70 ,$44.59 ,$34.30 ,$14.70 ,$31.85 ,$35.28 ,$44.59 ,$36.75 
Carle BroMenn Medical Center,8386245,LUPUS PANEL-RETICULIN ANTIBODY,,86255,302,$116.00 ,$116.00 ,$34.80 ,$105.56 ,$81.20 ,$34.80 ,$75.40 ,$83.52 ,$105.56 ,$87.00 
Carle BroMenn Medical Center,8386246,LUPUS PANEL-SKELETAL MUSCLE AB,,86255,302,$116.00 ,$116.00 ,$34.80 ,$105.56 ,$81.20 ,$34.80 ,$75.40 ,$83.52 ,$105.56 ,$87.00 
Carle BroMenn Medical Center,8386247,LUPUS PANEL-ANTI-SMOOTH MUSCLE,,86255,302,$116.00 ,$116.00 ,$34.80 ,$105.56 ,$81.20 ,$34.80 ,$75.40 ,$83.52 ,$105.56 ,$87.00 
Carle BroMenn Medical Center,8386250,DIRECT COMBS,,86880,302,$74.75 ,$74.75 ,$22.43 ,$68.02 ,$52.33 ,$22.43 ,$48.59 ,$53.82 ,$68.02 ,$56.06 
Carle BroMenn Medical Center,8386251,NMO/AQP4-IGG CBA  REF,,86255,302,$74.00 ,$74.00 ,$22.20 ,$67.34 ,$51.80 ,$22.20 ,$48.10 ,$53.28 ,$67.34 ,$55.50 
Carle BroMenn Medical Center,8386253,CELIAC DISEASE,,86255,302,$116.00 ,$116.00 ,$34.80 ,$105.56 ,$81.20 ,$34.80 ,$75.40 ,$83.52 ,$105.56 ,$87.00 
Carle BroMenn Medical Center,8386254,"FL NONINF AGENT AB; SCRN, EA   REF",,86255,302,$113.75 ,$113.75 ,$34.13 ,$103.51 ,$79.63 ,$34.13 ,$73.94 ,$81.90 ,$103.51 ,$85.31 
Carle BroMenn Medical Center,8386255,ISLET CELL ANTIBODY        REF,,86341,302,$8.00 ,$8.00 ,$2.40 ,$7.28 ,$5.60 ,$2.40 ,$5.20 ,$5.76 ,$7.28 ,$6.00 
Carle BroMenn Medical Center,8386257,MUMPS ANTIBODY    REF,,86735,302,$78.00 ,$78.00 ,$23.40 ,$70.98 ,$54.60 ,$23.40 ,$50.70 ,$56.16 ,$70.98 ,$58.50 
Carle BroMenn Medical Center,8386259,RETICULIN ABS              REF,,86255,302,$143.00 ,$143.00 ,$42.90 ,$130.13 ,$100.10 ,$42.90 ,$92.95 ,$102.96 ,$130.13 ,$107.25 
Carle BroMenn Medical Center,8386267,PARIETAL CELL AB TITER,,86256,302,$49.00 ,$49.00 ,$14.70 ,$44.59 ,$34.30 ,$14.70 ,$31.85 ,$35.28 ,$44.59 ,$36.75 
Carle BroMenn Medical Center,8386272,ENDOMYSIUM AB IGA W/REFLX TTRF,,86255,302,$40.00 ,$40.00 ,$12.00 ,$36.40 ,$28.00 ,$12.00 ,$26.00 ,$28.80 ,$36.40 ,$30.00 
Carle BroMenn Medical Center,8386273,FLUORESCNT ANTIBDY TITR-EA REF,,86256,302,$37.00 ,$37.00 ,$11.10 ,$33.67 ,$25.90 ,$11.10 ,$24.05 ,$26.64 ,$33.67 ,$27.75 
Carle BroMenn Medical Center,8386281,HEPATITIS C VIRUS ANTIBODY,,86803,302,$87.75 ,$87.75 ,$26.33 ,$79.85 ,$61.43 ,$26.33 ,$57.04 ,$63.18 ,$79.85 ,$65.81 
Carle BroMenn Medical Center,8386283,TUMOR AG IMMUNOASSAY       REF,,86316,302,$126.75 ,$126.75 ,$38.03 ,$115.34 ,$88.73 ,$38.03 ,$82.39 ,$91.26 ,$115.34 ,$95.06 
Carle BroMenn Medical Center,8386292,HEPATITIS A IGM ANTIBODY,,86709,302,$123.50 ,$123.50 ,$37.05 ,$112.39 ,$86.45 ,$37.05 ,$80.28 ,$88.92 ,$112.39 ,$92.63 
Carle BroMenn Medical Center,8386294,HEPATITIS B CORE IGM ANTIBODY,,86705,302,$87.75 ,$87.75 ,$26.33 ,$79.85 ,$61.43 ,$26.33 ,$57.04 ,$63.18 ,$79.85 ,$65.81 
Carle BroMenn Medical Center,8386306,CYTOMEGALOVIRUS (CMV) REF,,86644,302,$87.75 ,$87.75 ,$26.33 ,$79.85 ,$61.43 ,$26.33 ,$57.04 ,$63.18 ,$79.85 ,$65.81 
Carle BroMenn Medical Center,8386312,HCV CONFIRMATION BY SIA    REF,,86804,302,$89.00 ,$89.00 ,$26.70 ,$80.99 ,$62.30 ,$26.70 ,$57.85 ,$64.08 ,$80.99 ,$66.75 
Carle BroMenn Medical Center,8386315,HTLV I/II W.BLOT REF,,86689,302,$224.25 ,$224.25 ,$67.28 ,$204.07 ,$156.98 ,$67.28 ,$145.76 ,$161.46 ,$204.07 ,$168.19 
Carle BroMenn Medical Center,8386317,"S.PNEUMO IGG AB,23 SEROTYPES, S  REF",,86317,302,$1.00 ,$1.00 ,$0.30 ,$0.91 ,$0.70 ,$0.30 ,$0.65 ,$0.72 ,$0.91 ,$0.75 
Carle BroMenn Medical Center,8386318,CARDIOLIPIN ANTIBODIES     REF,,86147,302,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8386320,"IMMUNOFIXATION/IMMUNOTYPING, SERUM",,86334,302,$243.00 ,$243.00 ,$72.90 ,$221.13 ,$170.10 ,$72.90 ,$157.95 ,$174.96 ,$221.13 ,$182.25 
Carle BroMenn Medical Center,8386336,"TUMOR AG, CA 27.29 (CHIRON) RF",,86300,302,$126.75 ,$126.75 ,$38.03 ,$115.34 ,$88.73 ,$38.03 ,$82.39 ,$91.26 ,$115.34 ,$95.06 
Carle BroMenn Medical Center,8386337,"TUMOR ANTIGEN, CA 15-3     REF",,86300,302,$7.00 ,$7.00 ,$2.10 ,$6.37 ,$4.90 ,$2.10 ,$4.55 ,$5.04 ,$6.37 ,$5.25 
Carle BroMenn Medical Center,8386338,IMMUNODIFFUSION NOS,,86329,302,$54.00 ,$54.00 ,$16.20 ,$49.14 ,$37.80 ,$16.20 ,$35.10 ,$38.88 ,$49.14 ,$40.50 
Carle BroMenn Medical Center,8386342,LEGIONELLA ANTIBODY REF,,86713,302,$18.00 ,$18.00 ,$5.40 ,$16.38 ,$12.60 ,$5.40 ,$11.70 ,$12.96 ,$16.38 ,$13.50 
Carle BroMenn Medical Center,8386343,LEUCOCYTE HISTAMIN RELEASE,,86343,302,$46.00 ,$46.00 ,$13.80 ,$41.86 ,$32.20 ,$13.80 ,$29.90 ,$33.12 ,$41.86 ,$34.50 
Carle BroMenn Medical Center,8386346,ISLET CELL ANTIBODY TITER  REF,,86341,302,$95.00 ,$95.00 ,$28.50 ,$86.45 ,$66.50 ,$28.50 ,$61.75 ,$68.40 ,$86.45 ,$71.25 
Carle BroMenn Medical Center,8386349,INTRINSIC FACTOR BLOCK AB  REF,,86340,302,$113.75 ,$113.75 ,$34.13 ,$103.51 ,$79.63 ,$34.13 ,$73.94 ,$81.90 ,$103.51 ,$85.31 
Carle BroMenn Medical Center,8386353,LYMHOCYTE TRANSFORMATION REF,,86353,302,$342.00 ,$342.00 ,$102.60 ,$311.22 ,$239.40 ,$102.60 ,$222.30 ,$246.24 ,$311.22 ,$256.50 
Carle BroMenn Medical Center,8386357,NK CELLS TOTAL COUNT REF,,86357,302,$113.75 ,$113.75 ,$34.13 ,$103.51 ,$79.63 ,$34.13 ,$73.94 ,$81.90 ,$103.51 ,$85.31 
Carle BroMenn Medical Center,8386362,RHEUMATOID FACTOR QUANTITATIVE,,86431,302,$95.00 ,$95.00 ,$28.50 ,$86.45 ,$66.50 ,$28.50 ,$61.75 ,$68.40 ,$86.45 ,$71.25 
Carle BroMenn Medical Center,8386363,FL NONINF AGENT AB TITER,,86256,302,$158.00 ,$158.00 ,$47.40 ,$143.78 ,$110.60 ,$47.40 ,$102.70 ,$113.76 ,$143.78 ,$118.50 
Carle BroMenn Medical Center,8386375,MICROSOMAL ABS EACH REF,,86376,302,$87.75 ,$87.75 ,$26.33 ,$79.85 ,$61.43 ,$26.33 ,$57.04 ,$63.18 ,$79.85 ,$65.81 
Carle BroMenn Medical Center,8386376,PEROXIDASE ANTIBODY        REF,,86376,302,$23.00 ,$23.00 ,$6.90 ,$20.93 ,$16.10 ,$6.90 ,$14.95 ,$16.56 ,$20.93 ,$17.25 
Carle BroMenn Medical Center,8386379,NK CELLS  -TOTAL COUNT,,86357,302,$359.00 ,$359.00 ,$107.70 ,$326.69 ,$251.30 ,$107.70 ,$233.35 ,$258.48 ,$326.69 ,$269.25 
Carle BroMenn Medical Center,8386382,VIRAL NUTRALIZATION TEST REF,,86382,302,$117.00 ,$117.00 ,$35.10 ,$106.47 ,$81.90 ,$35.10 ,$76.05 ,$84.24 ,$106.47 ,$87.75 
Carle BroMenn Medical Center,8386386,INSULIN ANTIBODIES         REF,,86337,302,$164.00 ,$164.00 ,$49.20 ,$149.24 ,$114.80 ,$49.20 ,$106.60 ,$118.08 ,$149.24 ,$123.00 
Carle BroMenn Medical Center,8386389,T CELL TOTAL COUNT REF,,86359,302,$119.88 ,$119.88 ,$35.96 ,$109.09 ,$83.92 ,$35.96 ,$77.92 ,$86.31 ,$109.09 ,$89.91 
Carle BroMenn Medical Center,8386391,T CELL ABSOLUTE COUNT REF,,86360,302,$119.92 ,$119.92 ,$35.98 ,$109.13 ,$83.94 ,$35.98 ,$77.95 ,$86.34 ,$109.13 ,$89.94 
Carle BroMenn Medical Center,8386393,IMM ASSAY INF AG AB REF,,86317,302,$152.00 ,$152.00 ,$45.60 ,$138.32 ,$106.40 ,$45.60 ,$98.80 ,$109.44 ,$138.32 ,$114.00 
Carle BroMenn Medical Center,8386398,MUMPS ANTIBODY IGM         REF,,86735,302,$97.50 ,$97.50 ,$29.25 ,$88.73 ,$68.25 ,$29.25 ,$63.38 ,$70.20 ,$88.73 ,$73.13 
Carle BroMenn Medical Center,8386403,PARTICLE AGGLUTINATION SCREEN,,86317,302,$101.00 ,$101.00 ,$30.30 ,$91.91 ,$70.70 ,$30.30 ,$65.65 ,$72.72 ,$91.91 ,$75.75 
Carle BroMenn Medical Center,8386413,MYCOPLASMA IGM AB BY EIA,,86738,302,$161.00 ,$161.00 ,$48.30 ,$146.51 ,$112.70 ,$48.30 ,$104.65 ,$115.92 ,$146.51 ,$120.75 
Carle BroMenn Medical Center,8386420,VARICELLA AB IGG ANTIBODY,,86787,302,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8386421,T CELLS; ABS CD4&CD8 COUNT W/R,,86360,302,$384.00 ,$384.00 ,$115.20 ,$349.44 ,$268.80 ,$115.20 ,$249.60 ,$276.48 ,$349.44 ,$288.00 
Carle BroMenn Medical Center,8386422,"T CELLS, TOTAL COUNT",,86359,302,$309.00 ,$309.00 ,$92.70 ,$281.19 ,$216.30 ,$92.70 ,$200.85 ,$222.48 ,$281.19 ,$231.75 
Carle BroMenn Medical Center,8386423,B CELLS TOTAL COUNT,,86355,302,$359.00 ,$359.00 ,$107.70 ,$326.69 ,$251.30 ,$107.70 ,$233.35 ,$258.48 ,$326.69 ,$269.25 
Carle BroMenn Medical Center,8386424,IMMUNOFIXATION ELP -FLUIDS,,86335,302,$233.00 ,$233.00 ,$69.90 ,$212.03 ,$163.10 ,$69.90 ,$151.45 ,$167.76 ,$212.03 ,$174.75 
Carle BroMenn Medical Center,8386431,"RHEUMATOID FACTOR, QUANT.  REF",,86431,302,$55.90 ,$55.90 ,$16.77 ,$50.87 ,$39.13 ,$16.77 ,$36.34 ,$40.25 ,$50.87 ,$41.93 
Carle BroMenn Medical Center,8386435,RUBELLA IGG SCREEN,,86762,302,$107.25 ,$107.25 ,$32.18 ,$97.60 ,$75.08 ,$32.18 ,$69.71 ,$77.22 ,$97.60 ,$80.44 
Carle BroMenn Medical Center,8386450,COCCI ID-IGG             REF,,86635,302,$27.00 ,$27.00 ,$8.10 ,$24.57 ,$18.90 ,$8.10 ,$17.55 ,$19.44 ,$24.57 ,$20.25 
Carle BroMenn Medical Center,8386455,COCCI ID-IGM             REF,,86635,302,$27.00 ,$27.00 ,$8.10 ,$24.57 ,$18.90 ,$8.10 ,$17.55 ,$19.44 ,$24.57 ,$20.25 
Carle BroMenn Medical Center,8386470,CHLAMYDIA ABS (IGG/A)      REF,,86631,302,$42.00 ,$42.00 ,$12.60 ,$38.22 ,$29.40 ,$12.60 ,$27.30 ,$30.24 ,$38.22 ,$31.50 
Carle BroMenn Medical Center,8386480,LAB SERVICE,,86632,302,$45.00 ,$45.00 ,$13.50 ,$40.95 ,$31.50 ,$13.50 ,$29.25 ,$32.40 ,$40.95 ,$33.75 
Carle BroMenn Medical Center,8386495,MEASLES IGM AB REF,,86765,302,$90.46 ,$90.46 ,$27.14 ,$82.32 ,$63.32 ,$27.14 ,$58.80 ,$65.13 ,$82.32 ,$67.85 
Carle BroMenn Medical Center,8386500,LAB SERVICE,,86694,302,$152.75 ,$152.75 ,$45.83 ,$139.00 ,$106.93 ,$45.83 ,$99.29 ,$109.98 ,$139.00 ,$114.56 
Carle BroMenn Medical Center,8386530,LABORATORY TEST REF,,86689,302,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8386550,RICKETTTSIA ANTIBODYREF REF,,86757,302,$61.75 ,$61.75 ,$18.53 ,$56.19 ,$43.23 ,$18.53 ,$40.14 ,$44.46 ,$56.19 ,$46.31 
Carle BroMenn Medical Center,8386586,"CRYPTOCOCCUS AG, SERUM     REF",,86403,302,$75.00 ,$75.00 ,$22.50 ,$68.25 ,$52.50 ,$22.50 ,$48.75 ,$54.00 ,$68.25 ,$56.25 
Carle BroMenn Medical Center,8386587,"CRYPTOCOCCUS AG, CSF     REF",,86403,302,$31.00 ,$31.00 ,$9.30 ,$28.21 ,$21.70 ,$9.30 ,$20.15 ,$22.32 ,$28.21 ,$23.25 
Carle BroMenn Medical Center,8386594,BARTONELLA AB TITER REF,,86611,302,$59.00 ,$59.00 ,$17.70 ,$53.69 ,$41.30 ,$17.70 ,$38.35 ,$42.48 ,$53.69 ,$44.25 
Carle BroMenn Medical Center,8386595,EHRILICHIA ANTIBODY        REF,,86666,302,$113.75 ,$113.75 ,$34.13 ,$103.51 ,$79.63 ,$34.13 ,$73.94 ,$81.90 ,$103.51 ,$85.31 
Carle BroMenn Medical Center,8386606,ASPERGILLUS AB REF,,86606,302,$64.70 ,$64.70 ,$19.41 ,$58.88 ,$45.29 ,$19.41 ,$42.06 ,$46.58 ,$58.88 ,$48.53 
Carle BroMenn Medical Center,8386609,PNEUMOCOCCAL IGG ANTIBODY  REF,,86609,302,$32.00 ,$32.00 ,$9.60 ,$29.12 ,$22.40 ,$9.60 ,$20.80 ,$23.04 ,$29.12 ,$24.00 
Carle BroMenn Medical Center,8386611,BARTONELLA ANTIBODIES      REF,,86611,302,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8386612,"BLASTOMYCES AB, SERUM      REF",,86612,302,$26.00 ,$26.00 ,$7.80 ,$23.66 ,$18.20 ,$7.80 ,$16.90 ,$18.72 ,$23.66 ,$19.50 
Carle BroMenn Medical Center,8386613,"BLASTOMYCES AB, CSF      REF",,86612,302,$34.00 ,$34.00 ,$10.20 ,$30.94 ,$23.80 ,$10.20 ,$22.10 ,$24.48 ,$30.94 ,$25.50 
Carle BroMenn Medical Center,8386617,LYME AB CONFIRMTION W BLOT REF,,86617,302,$126.75 ,$126.75 ,$38.03 ,$115.34 ,$88.73 ,$38.03 ,$82.39 ,$91.26 ,$115.34 ,$95.06 
Carle BroMenn Medical Center,8386618,LYME AB SCREEN TOTAL       REF,,86618,302,$38.00 ,$38.00 ,$11.40 ,$34.58 ,$26.60 ,$11.40 ,$24.70 ,$27.36 ,$34.58 ,$28.50 
Carle BroMenn Medical Center,8386628,CANDIDA AB REF,,86628,302,$51.00 ,$51.00 ,$15.30 ,$46.41 ,$35.70 ,$15.30 ,$33.15 ,$36.72 ,$46.41 ,$38.25 
Carle BroMenn Medical Center,8386630,LAB SERVICE,,86696,302,$107.25 ,$107.25 ,$32.18 ,$97.60 ,$75.08 ,$32.18 ,$69.71 ,$77.22 ,$97.60 ,$80.44 
Carle BroMenn Medical Center,8386631,LAB TEST      REF,,86631,302,$35.00 ,$35.00 ,$10.50 ,$31.85 ,$24.50 ,$10.50 ,$22.75 ,$25.20 ,$31.85 ,$26.25 
Carle BroMenn Medical Center,8386632,LAB TEST      REF,,86632,302,$38.00 ,$38.00 ,$11.40 ,$34.58 ,$26.60 ,$11.40 ,$24.70 ,$27.36 ,$34.58 ,$28.50 
Carle BroMenn Medical Center,8386634,IMMUNOFIX CRYOGLOBULIN    REF,,86334,302,$82.00 ,$82.00 ,$24.60 ,$74.62 ,$57.40 ,$24.60 ,$53.30 ,$59.04 ,$74.62 ,$61.50 
Carle BroMenn Medical Center,8386635,"COCCIDIODES AB, SERUM      REF",,86635,302,$9.00 ,$9.00 ,$2.70 ,$8.19 ,$6.30 ,$2.70 ,$5.85 ,$6.48 ,$8.19 ,$6.75 
Carle BroMenn Medical Center,8386636,"COCCIDIODES AB, CSF    REF",,86635,302,$27.00 ,$27.00 ,$8.10 ,$24.57 ,$18.90 ,$8.10 ,$17.55 ,$19.44 ,$24.57 ,$20.25 
Carle BroMenn Medical Center,8386638,COXIELLA BURNETII AB       REF,,86638,302,$53.00 ,$53.00 ,$15.90 ,$48.23 ,$37.10 ,$15.90 ,$34.45 ,$38.16 ,$48.23 ,$39.75 
Carle BroMenn Medical Center,8386644,CMV IGG ANTIBODY BY EIA    REF,,86644,302,$19.00 ,$19.00 ,$5.70 ,$17.29 ,$13.30 ,$5.70 ,$12.35 ,$13.68 ,$17.29 ,$14.25 
Carle BroMenn Medical Center,8386645,CMV IGM ANTIBODY BY EIA    REF,,86645,302,$33.00 ,$33.00 ,$9.90 ,$30.03 ,$23.10 ,$9.90 ,$21.45 ,$23.76 ,$30.03 ,$24.75 
Carle BroMenn Medical Center,8386646,CMV IGG ANTIBODY,,86644,302,$132.00 ,$132.00 ,$39.60 ,$120.12 ,$92.40 ,$39.60 ,$85.80 ,$95.04 ,$120.12 ,$99.00 
Carle BroMenn Medical Center,8386647,CMV IGM ANTIBODY,,86645,302,$161.00 ,$161.00 ,$48.30 ,$146.51 ,$112.70 ,$48.30 ,$104.65 ,$115.92 ,$146.51 ,$120.75 
Carle BroMenn Medical Center,8386648,"DIPHTHERIA TOXOID IGG AB, S   REF",,86648,302,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8386651,ENCEPHALITS AB CA(LA CROSSE)RF,,86651,302,$20.00 ,$20.00 ,$6.00 ,$18.20 ,$14.00 ,$6.00 ,$13.00 ,$14.40 ,$18.20 ,$15.00 
Carle BroMenn Medical Center,8386652,ENCEPHALITIS AB EAST EQUINE RF,,86652,302,$20.00 ,$20.00 ,$6.00 ,$18.20 ,$14.00 ,$6.00 ,$13.00 ,$14.40 ,$18.20 ,$15.00 
Carle BroMenn Medical Center,8386653,ENCEPHALITIS AB ST LOUIS   REF,,86653,302,$20.00 ,$20.00 ,$6.00 ,$18.20 ,$14.00 ,$6.00 ,$13.00 ,$14.40 ,$18.20 ,$15.00 
Carle BroMenn Medical Center,8386654,ENCEPHALITS AB WEST EQUINE REF,,86654,302,$20.00 ,$20.00 ,$6.00 ,$18.20 ,$14.00 ,$6.00 ,$13.00 ,$14.40 ,$18.20 ,$15.00 
Carle BroMenn Medical Center,8386658,ENTEROVIRUS ANTIBODY       REF,,86658,302,$68.25 ,$68.25 ,$20.48 ,$62.11 ,$47.78 ,$20.48 ,$44.36 ,$49.14 ,$62.11 ,$51.19 
Carle BroMenn Medical Center,8386663,EBV EARLY ANTIGEN ANTIBODY REF,,86663,302,$97.50 ,$97.50 ,$29.25 ,$88.73 ,$68.25 ,$29.25 ,$63.38 ,$70.20 ,$88.73 ,$73.13 
Carle BroMenn Medical Center,8386664,EBV NUCLEAR ANTIGEN        REF,,86664,302,$113.75 ,$113.75 ,$34.13 ,$103.51 ,$79.63 ,$34.13 ,$73.94 ,$81.90 ,$103.51 ,$85.31 
Carle BroMenn Medical Center,8386665,EBV VIRAL CAPSID (IGG)     REF,,86665,302,$91.00 ,$91.00 ,$27.30 ,$82.81 ,$63.70 ,$27.30 ,$59.15 ,$65.52 ,$82.81 ,$68.25 
Carle BroMenn Medical Center,8386666,EBV VIRAL CAPSID (IGM)     REF,,86665,302,$91.00 ,$91.00 ,$27.30 ,$82.81 ,$63.70 ,$27.30 ,$59.15 ,$65.52 ,$82.81 ,$68.25 
Carle BroMenn Medical Center,8386671,FUNGUS ANTIBODY REF,,86671,302,$266.50 ,$266.50 ,$79.95 ,$242.52 ,$186.55 ,$79.95 ,$173.23 ,$191.88 ,$242.52 ,$199.88 
Carle BroMenn Medical Center,8386677,HELICOBACTER PYLORI ANTIBODY,,86677,302,$224.00 ,$224.00 ,$67.20 ,$203.84 ,$156.80 ,$67.20 ,$145.60 ,$161.28 ,$203.84 ,$168.00 
Carle BroMenn Medical Center,8386682,HELMINTH ANTIBODY          REF,,86682,302,$256.75 ,$256.75 ,$77.03 ,$233.64 ,$179.73 ,$77.03 ,$166.89 ,$184.86 ,$233.64 ,$192.56 
Carle BroMenn Medical Center,8386684,"H INFLUENZAE B AB, IGG, S     REF",,86684,302,$16.00 ,$16.00 ,$4.80 ,$14.56 ,$11.20 ,$4.80 ,$10.40 ,$11.52 ,$14.56 ,$12.00 
Carle BroMenn Medical Center,8386685,VZV ANTIBODY IGM BY EIA    REF,,86787,302,$19.00 ,$19.00 ,$5.70 ,$17.29 ,$13.30 ,$5.70 ,$12.35 ,$13.68 ,$17.29 ,$14.25 
Carle BroMenn Medical Center,8386689,LABORATRY TEST FOR ANTIBDY REF,,86689,302,$23.00 ,$23.00 ,$6.90 ,$20.93 ,$16.10 ,$6.90 ,$14.95 ,$16.56 ,$20.93 ,$17.25 
Carle BroMenn Medical Center,8386692,HEPATITIS DELTA AG ANTIBDY REF,,86692,302,$108.00 ,$108.00 ,$32.40 ,$98.28 ,$75.60 ,$32.40 ,$70.20 ,$77.76 ,$98.28 ,$81.00 
Carle BroMenn Medical Center,8386694,LAB SERVICE,,86694,302,$107.25 ,$107.25 ,$32.18 ,$97.60 ,$75.08 ,$32.18 ,$69.71 ,$77.22 ,$97.60 ,$80.44 
Carle BroMenn Medical Center,8386695,LAB SERVICE,,86695,302,$97.50 ,$97.50 ,$29.25 ,$88.73 ,$68.25 ,$29.25 ,$63.38 ,$70.20 ,$88.73 ,$73.13 
Carle BroMenn Medical Center,8386696,"HISTOPLASMA AB, CSF       REF",,86698,302,$11.00 ,$11.00 ,$3.30 ,$10.01 ,$7.70 ,$3.30 ,$7.15 ,$7.92 ,$10.01 ,$8.25 
Carle BroMenn Medical Center,8386697,"HISTOPLASMA AB, SERUM      REF",,86698,302,$7.00 ,$7.00 ,$2.10 ,$6.37 ,$4.90 ,$2.10 ,$4.55 ,$5.04 ,$6.37 ,$5.25 
Carle BroMenn Medical Center,8386698,"HISTOPLASMA AB SCREEN, SERUM REF",,86698,302,$64.70 ,$64.70 ,$19.41 ,$58.88 ,$45.29 ,$19.41 ,$42.06 ,$46.58 ,$58.88 ,$48.53 
Carle BroMenn Medical Center,8386702,LABORATORY TEST,,86702,302,$21.00 ,$21.00 ,$6.30 ,$19.11 ,$14.70 ,$6.30 ,$13.65 ,$15.12 ,$19.11 ,$15.75 
Carle BroMenn Medical Center,8386703,LAB SERVICE,,86703,302,$117.00 ,$117.00 ,$35.10 ,$106.47 ,$81.90 ,$35.10 ,$76.05 ,$84.24 ,$106.47 ,$87.75 
Carle BroMenn Medical Center,8386704,HEPATITIS B CORE AB TOTAL  REF,,86704,302,$84.50 ,$84.50 ,$25.35 ,$76.90 ,$59.15 ,$25.35 ,$54.93 ,$60.84 ,$76.90 ,$63.38 
Carle BroMenn Medical Center,8386707,HEPATITIS BE ANTIBODY      REF,,86707,302,$48.00 ,$48.00 ,$14.40 ,$43.68 ,$33.60 ,$14.40 ,$31.20 ,$34.56 ,$43.68 ,$36.00 
Carle BroMenn Medical Center,8386708,HEPATITIS A ANTIBODY TOTAL REF,,86708,302,$74.75 ,$74.75 ,$22.43 ,$68.02 ,$52.33 ,$22.43 ,$48.59 ,$53.82 ,$68.02 ,$56.06 
Carle BroMenn Medical Center,8386709,HEPATITIS A IGM TITER      REF,,86709,302,$16.00 ,$16.00 ,$4.80 ,$14.56 ,$11.20 ,$4.80 ,$10.40 ,$11.52 ,$14.56 ,$12.00 
Carle BroMenn Medical Center,8386710,INFLUENZA VIRUS ANTIBODY   REF,,86710,302,$91.00 ,$91.00 ,$27.30 ,$82.81 ,$63.70 ,$27.30 ,$59.15 ,$65.52 ,$82.81 ,$68.25 
Carle BroMenn Medical Center,8386720,"LEPTOSPIRA AB, S  REF",,86720,302,$54.00 ,$54.00 ,$16.20 ,$49.14 ,$37.80 ,$16.20 ,$35.10 ,$38.88 ,$49.14 ,$40.50 
Carle BroMenn Medical Center,8386723,FLUORESCNT ANTIBDY TITR-EA REF,,86256,302,$20.00 ,$20.00 ,$6.00 ,$18.20 ,$14.00 ,$6.00 ,$13.00 ,$14.40 ,$18.20 ,$15.00 
Carle BroMenn Medical Center,8386735,MUMPS ANTIBODY IGG,,86735,302,$123.00 ,$123.00 ,$36.90 ,$111.93 ,$86.10 ,$36.90 ,$79.95 ,$88.56 ,$111.93 ,$92.25 
Carle BroMenn Medical Center,8386738,MYCOPLSMA IGG ABS          REF,,86738,302,$81.25 ,$81.25 ,$24.38 ,$73.94 ,$56.88 ,$24.38 ,$52.81 ,$58.50 ,$73.94 ,$60.94 
Carle BroMenn Medical Center,8386747,PAROVIRUS B19 ANTIBODY     REF,,86747,302,$20.00 ,$20.00 ,$6.00 ,$18.20 ,$14.00 ,$6.00 ,$13.00 ,$14.40 ,$18.20 ,$15.00 
Carle BroMenn Medical Center,8386753,"E. HISTOLYTICA AB, EIA     REF",,86753,302,$59.00 ,$59.00 ,$17.70 ,$53.69 ,$41.30 ,$17.70 ,$38.35 ,$42.48 ,$53.69 ,$44.25 
Carle BroMenn Medical Center,8386757,RICKETTSIA ANTIBODY        REF,,86757,302,$61.75 ,$61.75 ,$18.53 ,$56.19 ,$43.23 ,$18.53 ,$40.14 ,$44.46 ,$56.19 ,$46.31 
Carle BroMenn Medical Center,8386762,RUBELLA IGG AB BY EIA      REF,,86762,302,$87.75 ,$87.75 ,$26.33 ,$79.85 ,$61.43 ,$26.33 ,$57.04 ,$63.18 ,$79.85 ,$65.81 
Carle BroMenn Medical Center,8386763,RUBELLA IGM TITER          REF,,86762,302,$31.00 ,$31.00 ,$9.30 ,$28.21 ,$21.70 ,$9.30 ,$20.15 ,$22.32 ,$28.21 ,$23.25 
Carle BroMenn Medical Center,8386765,MEASLES IGG ANTIBODY REF,,86765,302,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8386774,TETANUS ANTITOXOID AB      REF,,86774,302,$59.00 ,$59.00 ,$17.70 ,$53.69 ,$41.30 ,$17.70 ,$38.35 ,$42.48 ,$53.69 ,$44.25 
Carle BroMenn Medical Center,8386777,TOXOPL IGG AB BY EIA       REF,,86777,302,$21.00 ,$21.00 ,$6.30 ,$19.11 ,$14.70 ,$6.30 ,$13.65 ,$15.12 ,$19.11 ,$15.75 
Carle BroMenn Medical Center,8386778,TOXOPL IGM AB BY EIA       REF,,86778,302,$33.00 ,$33.00 ,$9.90 ,$30.03 ,$23.10 ,$9.90 ,$21.45 ,$23.76 ,$30.03 ,$24.75 
Carle BroMenn Medical Center,8386780,LABORATORY SERVICE      REF,,86780,302,$28.00 ,$28.00 ,$8.40 ,$25.48 ,$19.60 ,$8.40 ,$18.20 ,$20.16 ,$25.48 ,$21.00 
Carle BroMenn Medical Center,8386781,LABORATORY TEST REF,,86780,302,$22.00 ,$22.00 ,$6.60 ,$20.02 ,$15.40 ,$6.60 ,$14.30 ,$15.84 ,$20.02 ,$16.50 
Carle BroMenn Medical Center,8386784,"TRICHINELLA AB, S           REF",,86784,302,$13.00 ,$13.00 ,$3.90 ,$11.83 ,$9.10 ,$3.90 ,$8.45 ,$9.36 ,$11.83 ,$9.75 
Carle BroMenn Medical Center,8386787,"VARICELLA-ZOSTER AB, IGM, S    REF",,86787,302,$11.00 ,$11.00 ,$3.30 ,$10.01 ,$7.70 ,$3.30 ,$7.15 ,$7.92 ,$10.01 ,$8.25 
Carle BroMenn Medical Center,8386790,VIRUS AB NOS,,86790,302,$88.00 ,$88.00 ,$26.40 ,$80.08 ,$61.60 ,$26.40 ,$57.20 ,$63.36 ,$80.08 ,$66.00 
Carle BroMenn Medical Center,8386800,THYROGLOBULIN ANTIBODY     REF,,86800,302,$97.50 ,$97.50 ,$29.25 ,$88.73 ,$68.25 ,$29.25 ,$63.38 ,$70.20 ,$88.73 ,$73.13 
Carle BroMenn Medical Center,8386810,HLA TYPING A/B/C/-1 ANTIGN REF,,86812,302,$159.25 ,$159.25 ,$47.78 ,$144.92 ,$111.48 ,$47.78 ,$103.51 ,$114.66 ,$144.92 ,$119.44 
Carle BroMenn Medical Center,8386812,HLA-B27 ANTIGEN,,86812,302,$156.00 ,$156.00 ,$46.80 ,$141.96 ,$109.20 ,$46.80 ,$101.40 ,$112.32 ,$141.96 ,$117.00 
Carle BroMenn Medical Center,8386860,"ANTIBODY ELUTION (RBC), EACH REF",,86860,302,$224.00 ,$224.00 ,$67.20 ,$203.84 ,$156.80 ,$67.20 ,$145.60 ,$161.28 ,$203.84 ,$168.00 
Carle BroMenn Medical Center,8386870,"ANTIBODY ID, RBC, EACH PANEL REF",,86870,302,$412.00 ,$412.00 ,$123.60 ,$374.92 ,$288.40 ,$123.60 ,$267.80 ,$296.64 ,$374.92 ,$309.00 
Carle BroMenn Medical Center,8386880,"DIRECT COOMS (DAT), EACH REF",,86880,302,$92.00 ,$92.00 ,$27.60 ,$83.72 ,$64.40 ,$27.60 ,$59.80 ,$66.24 ,$83.72 ,$69.00 
Carle BroMenn Medical Center,8386923,COMPATIBILITY TEST -EACH UNIT,,86923,302,$170.00 ,$170.00 ,$51.00 ,$154.70 ,$119.00 ,$51.00 ,$110.50 ,$122.40 ,$154.70 ,$127.50 
Carle BroMenn Medical Center,8386988,CMV-NEGATIVE,,86644,302,$34.00 ,$34.00 ,$10.20 ,$30.94 ,$23.80 ,$10.20 ,$22.10 ,$24.48 ,$30.94 ,$25.50 
Carle BroMenn Medical Center,8085014,HCT,,85014,305,$50.00 ,$50.00 ,$15.00 ,$45.50 ,$35.00 ,$15.00 ,$32.50 ,$36.00 ,$45.50 ,$37.50 
Carle BroMenn Medical Center,8085347,ISTAT ACT,,85347,305,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8085610,PT,,85610,305,$94.00 ,$94.00 ,$28.20 ,$85.54 ,$65.80 ,$28.20 ,$61.10 ,$67.68 ,$85.54 ,$70.50 
Carle BroMenn Medical Center,8120009,HEMATOCRIT,,85014,305,$50.00 ,$50.00 ,$15.00 ,$45.50 ,$35.00 ,$15.00 ,$32.50 ,$36.00 ,$45.50 ,$37.50 
Carle BroMenn Medical Center,8120010,ACT-K,,85347,305,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8285014,HEMATOCRIT,,85014,305,$50.00 ,$50.00 ,$15.00 ,$45.50 ,$35.00 ,$15.00 ,$32.50 ,$36.00 ,$45.50 ,$37.50 
Carle BroMenn Medical Center,8285018,HEMOGLOBIN,,85018,305,$43.00 ,$43.00 ,$12.90 ,$39.13 ,$30.10 ,$12.90 ,$27.95 ,$30.96 ,$39.13 ,$32.25 
Carle BroMenn Medical Center,8285347,"COAGULATION TIME, ACTIVATED",,85347,305,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8285379,D-DIMER (POC),,85379,305,$165.00 ,$165.00 ,$49.50 ,$150.15 ,$115.50 ,$49.50 ,$107.25 ,$118.80 ,$150.15 ,$123.75 
Carle BroMenn Medical Center,8285610,PROTHROMBIN TIME,,85610,305,$94.00 ,$94.00 ,$28.20 ,$85.54 ,$65.80 ,$28.20 ,$61.10 ,$67.68 ,$85.54 ,$70.50 
Carle BroMenn Medical Center,8340051,COMPLETE BLOOD COUNT DOG,,8340051,305,$9.50 ,$9.50 ,$2.85 ,$8.65 ,$6.65 ,$2.85 ,$6.18 ,$6.84 ,$8.65 ,$7.13 
Carle BroMenn Medical Center,8380141,MICROHEMATOCRIT -SPUN,,85013,305,$26.00 ,$26.00 ,$7.80 ,$23.66 ,$18.20 ,$7.80 ,$16.90 ,$18.72 ,$23.66 ,$19.50 
Carle BroMenn Medical Center,8380338,POC PROTHROMBIN TIME,,85610,305,$82.00 ,$82.00 ,$24.60 ,$74.62 ,$57.40 ,$24.60 ,$53.30 ,$59.04 ,$74.62 ,$61.50 
Carle BroMenn Medical Center,8380447,"RISTOCETIN COFACTOR, P  REF",,85245,305,$143.00 ,$143.00 ,$42.90 ,$130.13 ,$100.10 ,$42.90 ,$92.95 ,$102.96 ,$130.13 ,$107.25 
Carle BroMenn Medical Center,8380570,PHOSPHOLIPID NEUT; HEXAGONAL REF,,85598,305,$110.50 ,$110.50 ,$33.15 ,$100.56 ,$77.35 ,$33.15 ,$71.83 ,$79.56 ,$100.56 ,$82.88 
Carle BroMenn Medical Center,8380909,CLOTTING FACTOR V REF,,85220,305,$107.25 ,$107.25 ,$32.18 ,$97.60 ,$75.08 ,$32.18 ,$69.71 ,$77.22 ,$97.60 ,$80.44 
Carle BroMenn Medical Center,8380924,"VON WILLEBRAND FACTOR AG, P  REF",,85246,305,$12.00 ,$12.00 ,$3.60 ,$10.92 ,$8.40 ,$3.60 ,$7.80 ,$8.64 ,$10.92 ,$9.00 
Carle BroMenn Medical Center,8380967,"HEPARIN ANTI-XA ASSAY, P REF",,85520,305,$30.00 ,$30.00 ,$9.00 ,$27.30 ,$21.00 ,$9.00 ,$19.50 ,$21.60 ,$27.30 ,$22.50 
Carle BroMenn Medical Center,8380985,PROTHROMBIN TIME   REF,,85610,305,$94.00 ,$94.00 ,$28.20 ,$85.54 ,$65.80 ,$28.20 ,$61.10 ,$67.68 ,$85.54 ,$70.50 
Carle BroMenn Medical Center,8380992,PLATELET FUNCTION,,85576,305,$205.00 ,$205.00 ,$61.50 ,$186.55 ,$143.50 ,$61.50 ,$133.25 ,$147.60 ,$186.55 ,$153.75 
Carle BroMenn Medical Center,8381011,TEG COAG TIME; ACTIVATED,,85347,305,$47.00 ,$47.00 ,$14.10 ,$42.77 ,$32.90 ,$14.10 ,$30.55 ,$33.84 ,$42.77 ,$35.25 
Carle BroMenn Medical Center,8381012,TEG FIBRINOGEN; ACTIVITY,,85384,305,$113.00 ,$113.00 ,$33.90 ,$102.83 ,$79.10 ,$33.90 ,$73.45 ,$81.36 ,$102.83 ,$84.75 
Carle BroMenn Medical Center,8381013,TEG FIBRINOLYSIS OR COAG SCRN INTERP & RPT,,85390,305,$126.00 ,$126.00 ,$37.80 ,$114.66 ,$88.20 ,$37.80 ,$81.90 ,$90.72 ,$114.66 ,$94.50 
Carle BroMenn Medical Center,8381014,"TEG PLATELET AGGREGATION, EA",,85576,305,$205.00 ,$205.00 ,$61.50 ,$186.55 ,$143.50 ,$61.50 ,$133.25 ,$147.60 ,$186.55 ,$153.75 
Carle BroMenn Medical Center,8381194,HC ADAMTS13 ACTIVITY REF,,85397,305,$129.00 ,$129.00 ,$38.70 ,$117.39 ,$90.30 ,$38.70 ,$83.85 ,$92.88 ,$117.39 ,$96.75 
Carle BroMenn Medical Center,8381195,ADAMTS14 INHIBITOR REF,,85335,305,$215.00 ,$215.00 ,$64.50 ,$195.65 ,$150.50 ,$64.50 ,$139.75 ,$154.80 ,$195.65 ,$161.25 
Carle BroMenn Medical Center,8381447,"COAG FACTOR VIII ACTIVITY ASSAY, P  REF",,85240,305,$198.25 ,$198.25 ,$59.48 ,$180.41 ,$138.78 ,$59.48 ,$128.86 ,$142.74 ,$180.41 ,$148.69 
Carle BroMenn Medical Center,8381448,"VON WILLEBRAND FACTOR ACTIVITY, P  REF",,85397,305,$119.00 ,$119.00 ,$35.70 ,$108.29 ,$83.30 ,$35.70 ,$77.35 ,$85.68 ,$108.29 ,$89.25 
Carle BroMenn Medical Center,8381449,BETHESDA UNITS  REF,,85335,305,$89.00 ,$89.00 ,$26.70 ,$80.99 ,$62.30 ,$26.70 ,$57.85 ,$64.08 ,$80.99 ,$66.75 
Carle BroMenn Medical Center,8381450,"COAG FACTOR VIII ASSAY INHIB SCRN, P  REF",,85335,305,$180.00 ,$180.00 ,$54.00 ,$163.80 ,$126.00 ,$54.00 ,$117.00 ,$129.60 ,$163.80 ,$135.00 
Carle BroMenn Medical Center,8381451,SPECIAL COAG INTERPRETATION  REF,,85390,305,$98.00 ,$98.00 ,$29.40 ,$89.18 ,$68.60 ,$29.40 ,$63.70 ,$70.56 ,$89.18 ,$73.50 
Carle BroMenn Medical Center,8381515,CBC (ITC LAB),,85027,305,$98.00 ,$98.00 ,$29.40 ,$89.18 ,$68.60 ,$29.40 ,$63.70 ,$70.56 ,$89.18 ,$73.50 
Carle BroMenn Medical Center,8381546,PROTHROMBIN TIME-INCUBATED,,85610,305,$82.00 ,$82.00 ,$24.60 ,$74.62 ,$57.40 ,$24.60 ,$53.30 ,$59.04 ,$74.62 ,$61.50 
Carle BroMenn Medical Center,8381839,"STACLOT APTT, REF",,85598,305,$136.00 ,$136.00 ,$40.80 ,$123.76 ,$95.20 ,$40.80 ,$88.40 ,$97.92 ,$123.76 ,$102.00 
Carle BroMenn Medical Center,8381946,"RETICULOCYTE COUNT, AUTOMATED",,85046,305,$91.00 ,$91.00 ,$27.30 ,$82.81 ,$63.70 ,$27.30 ,$59.15 ,$65.52 ,$82.81 ,$68.25 
Carle BroMenn Medical Center,8382404,DRVVT CONFIRM,,85597,305,$94.25 ,$94.25 ,$28.28 ,$85.77 ,$65.98 ,$28.28 ,$61.26 ,$67.86 ,$85.77 ,$70.69 
Carle BroMenn Medical Center,8382422,"ANTI-XA, PLASMA",,85520,305,$120.00 ,$120.00 ,$36.00 ,$109.20 ,$84.00 ,$36.00 ,$78.00 ,$86.40 ,$109.20 ,$90.00 
Carle BroMenn Medical Center,8382513,HC PLAT FUNCT COLLAGEN,,85576,305,$245.00 ,$245.00 ,$73.50 ,$222.95 ,$171.50 ,$73.50 ,$159.25 ,$176.40 ,$222.95 ,$183.75 
Carle BroMenn Medical Center,8382620,RETICULACYTE COUNT MANUAL,,85044,305,$64.00 ,$64.00 ,$19.20 ,$58.24 ,$44.80 ,$19.20 ,$41.60 ,$46.08 ,$58.24 ,$48.00 
Carle BroMenn Medical Center,8382640,DILUTED RUSSELL VIP VEN (LUP),,85613,305,$90.00 ,$90.00 ,$27.00 ,$81.90 ,$63.00 ,$27.00 ,$58.50 ,$64.80 ,$81.90 ,$67.50 
Carle BroMenn Medical Center,8385001,LUPUS ANTICOAGULANT,,85613,305,$129.00 ,$129.00 ,$38.70 ,$117.39 ,$90.30 ,$38.70 ,$83.85 ,$92.88 ,$117.39 ,$96.75 
Carle BroMenn Medical Center,8385004,AUTOMATED DIFFERENTIAL WBC,,85004,305,$52.00 ,$52.00 ,$15.60 ,$47.32 ,$36.40 ,$15.60 ,$33.80 ,$37.44 ,$47.32 ,$39.00 
Carle BroMenn Medical Center,8385005,HEMATOCRIT                 REF,,85014,305,$4.00 ,$4.00 ,$1.20 ,$3.64 ,$2.80 ,$1.20 ,$2.60 ,$2.88 ,$3.64 ,$3.00 
Carle BroMenn Medical Center,8385009,MAN DIFF WBC COUNT BUFFY COAT,,85009,305,$35.00 ,$35.00 ,$10.50 ,$31.85 ,$24.50 ,$10.50 ,$22.75 ,$25.20 ,$31.85 ,$26.25 
Carle BroMenn Medical Center,8385012,URINE EOS,,85999,305,$101.00 ,$101.00 ,$30.30 ,$91.91 ,$70.70 ,$30.30 ,$65.65 ,$72.72 ,$91.91 ,$75.75 
Carle BroMenn Medical Center,8385013,SPUN MICROHEMATOCRIT,,85013,305,$43.00 ,$43.00 ,$12.90 ,$39.13 ,$30.10 ,$12.90 ,$27.95 ,$30.96 ,$39.13 ,$32.25 
Carle BroMenn Medical Center,8385016,CBC W/AUTOMATED DIFFERENTIAL,,85025,305,$47.45 ,$47.45 ,$14.24 ,$43.18 ,$33.22 ,$14.24 ,$30.84 ,$34.16 ,$43.18 ,$35.59 
Carle BroMenn Medical Center,8385017,CBC W/O DIFFERENTIAL,,85027,305,$39.65 ,$39.65 ,$11.90 ,$36.08 ,$27.76 ,$11.90 ,$25.77 ,$28.55 ,$36.08 ,$29.74 
Carle BroMenn Medical Center,8385020,RED BLOOD CELL COUNT ONLY,,85041,305,$22.10 ,$22.10 ,$6.63 ,$20.11 ,$15.47 ,$6.63 ,$14.37 ,$15.91 ,$20.11 ,$16.58 
Carle BroMenn Medical Center,8385030,WHITE CELL COUNT,,85048,305,$32.50 ,$32.50 ,$9.75 ,$29.58 ,$22.75 ,$9.75 ,$21.13 ,$23.40 ,$29.58 ,$24.38 
Carle BroMenn Medical Center,8385031,HEMOGLOBIN                 REF,,85018,305,$4.00 ,$4.00 ,$1.20 ,$3.64 ,$2.80 ,$1.20 ,$2.60 ,$2.88 ,$3.64 ,$3.00 
Carle BroMenn Medical Center,8385032,MANUAL BLOOD CELL COUNT   REF,,85032,305,$38.00 ,$38.00 ,$11.40 ,$34.58 ,$26.60 ,$11.40 ,$24.70 ,$27.36 ,$34.58 ,$28.50 
Carle BroMenn Medical Center,8385042,MANUAL DIFFERENTIAL WBC COUNT,,85007,305,$30.55 ,$30.55 ,$9.17 ,$27.80 ,$21.39 ,$9.17 ,$19.86 ,$22.00 ,$27.80 ,$22.91 
Carle BroMenn Medical Center,8385050,HEMOGLOBIN,,85018,305,$20.80 ,$20.80 ,$6.24 ,$18.93 ,$14.56 ,$6.24 ,$13.52 ,$14.98 ,$18.93 ,$15.60 
Carle BroMenn Medical Center,8385055,HEMATOCRIT,,85014,305,$20.80 ,$20.80 ,$6.24 ,$18.93 ,$14.56 ,$6.24 ,$13.52 ,$14.98 ,$18.93 ,$15.60 
Carle BroMenn Medical Center,8385095,RED BLOOD CELL COUNT       REF,,85041,305,$5.00 ,$5.00 ,$1.50 ,$4.55 ,$3.50 ,$1.50 ,$3.25 ,$3.60 ,$4.55 ,$3.75 
Carle BroMenn Medical Center,8385109,"FACTOR XIII, FUNCTIONAL    REF",,85290,305,$101.00 ,$101.00 ,$30.30 ,$91.91 ,$70.70 ,$30.30 ,$65.65 ,$72.72 ,$91.91 ,$75.75 
Carle BroMenn Medical Center,8385165,"VW FACTOR, MULTIMETRIC     REF",,85247,305,$214.50 ,$214.50 ,$64.35 ,$195.20 ,$150.15 ,$64.35 ,$139.43 ,$154.44 ,$195.20 ,$160.88 
Carle BroMenn Medical Center,8385171,VW FACTOR ANTIGEN REF,,85246,305,$144.00 ,$144.00 ,$43.20 ,$131.04 ,$100.80 ,$43.20 ,$93.60 ,$103.68 ,$131.04 ,$108.00 
Carle BroMenn Medical Center,8385172,"VWF, RISTOCETIN COFACTOR   REF",,85245,305,$157.00 ,$157.00 ,$47.10 ,$142.87 ,$109.90 ,$47.10 ,$102.05 ,$113.04 ,$142.87 ,$117.75 
Carle BroMenn Medical Center,8385210,CLOTTING FACTOR II,,85210,305,$123.00 ,$123.00 ,$36.90 ,$111.93 ,$86.10 ,$36.90 ,$79.95 ,$88.56 ,$111.93 ,$92.25 
Carle BroMenn Medical Center,8385220,CLOTTING FACTOR V,,85220,305,$167.00 ,$167.00 ,$50.10 ,$151.97 ,$116.90 ,$50.10 ,$108.55 ,$120.24 ,$151.97 ,$125.25 
Carle BroMenn Medical Center,8385230,CLOTTING FACTOR VII,,85230,305,$208.00 ,$208.00 ,$62.40 ,$189.28 ,$145.60 ,$62.40 ,$135.20 ,$149.76 ,$189.28 ,$156.00 
Carle BroMenn Medical Center,8385240,CLOTTING FACTOR VIII,,85240,305,$296.00 ,$296.00 ,$88.80 ,$269.36 ,$207.20 ,$88.80 ,$192.40 ,$213.12 ,$269.36 ,$222.00 
Carle BroMenn Medical Center,8385242,CLOTTING FACTOR IX REF,,85250,305,$126.75 ,$126.75 ,$38.03 ,$115.34 ,$88.73 ,$38.03 ,$82.39 ,$91.26 ,$115.34 ,$95.06 
Carle BroMenn Medical Center,8385245,"VWF, RISTOCETIN COFACTOR   REF",,85245,305,$80.00 ,$80.00 ,$24.00 ,$72.80 ,$56.00 ,$24.00 ,$52.00 ,$57.60 ,$72.80 ,$60.00 
Carle BroMenn Medical Center,8385246,VW FACTOR ANTIGEN          REF,,85246,305,$152.75 ,$152.75 ,$45.83 ,$139.00 ,$106.93 ,$45.83 ,$99.29 ,$109.98 ,$139.00 ,$114.56 
Carle BroMenn Medical Center,8385247,"VON WILLEBRAND FACTOR MULTIMER, P  REF",,85247,305,$29.00 ,$29.00 ,$8.70 ,$26.39 ,$20.30 ,$8.70 ,$18.85 ,$20.88 ,$26.39 ,$21.75 
Carle BroMenn Medical Center,8385250,CLOTTING FACTOR IX,,85250,305,$180.00 ,$180.00 ,$54.00 ,$163.80 ,$126.00 ,$54.00 ,$117.00 ,$129.60 ,$163.80 ,$135.00 
Carle BroMenn Medical Center,8385260,CLOTTING FACTOR X,,85260,305,$173.00 ,$173.00 ,$51.90 ,$157.43 ,$121.10 ,$51.90 ,$112.45 ,$124.56 ,$157.43 ,$129.75 
Carle BroMenn Medical Center,8385261,CLOTTING FACTOR X REF,,85260,305,$185.25 ,$185.25 ,$55.58 ,$168.58 ,$129.68 ,$55.58 ,$120.41 ,$133.38 ,$168.58 ,$138.94 
Carle BroMenn Medical Center,8385270,CLOTTING FACTOR XI ACTIVTY REF,,85270,305,$214.50 ,$214.50 ,$64.35 ,$195.20 ,$150.15 ,$64.35 ,$139.43 ,$154.44 ,$195.20 ,$160.88 
Carle BroMenn Medical Center,8385280,CLOTTING FACTOR XII ACTIV REF,,85280,305,$250.25 ,$250.25 ,$75.08 ,$227.73 ,$175.18 ,$75.08 ,$162.66 ,$180.18 ,$227.73 ,$187.69 
Carle BroMenn Medical Center,8385291,FACTR XIII SOLUBILTY SCREEN RF,,85291,305,$88.00 ,$88.00 ,$26.40 ,$80.08 ,$61.60 ,$26.40 ,$57.20 ,$63.36 ,$80.08 ,$66.00 
Carle BroMenn Medical Center,8385300,ANTITHROMBIN ACTIVITY REF,,85300,305,$104.00 ,$104.00 ,$31.20 ,$94.64 ,$72.80 ,$31.20 ,$67.60 ,$74.88 ,$94.64 ,$78.00 
Carle BroMenn Medical Center,8385303,PROTEIN C ACTIVITY REF,,85303,305,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8385307,ANTITHROMBINE III ACTIVITY,,85300,305,$123.50 ,$123.50 ,$37.05 ,$112.39 ,$86.45 ,$37.05 ,$80.28 ,$88.92 ,$112.39 ,$92.63 
Carle BroMenn Medical Center,8385310,"PROTEIN C, ACTIVITY",,85303,305,$221.00 ,$221.00 ,$66.30 ,$201.11 ,$154.70 ,$66.30 ,$143.65 ,$159.12 ,$201.11 ,$165.75 
Carle BroMenn Medical Center,8385350,EOSINOPHIL COUNT,,85999,305,$69.00 ,$69.00 ,$20.70 ,$62.79 ,$48.30 ,$20.70 ,$44.85 ,$49.68 ,$62.79 ,$51.75 
Carle BroMenn Medical Center,8385375,FIBRINOGEN,,85384,305,$91.00 ,$91.00 ,$27.30 ,$82.81 ,$63.70 ,$27.30 ,$59.15 ,$65.52 ,$82.81 ,$68.25 
Carle BroMenn Medical Center,8385392,"D-DIMER, ULTRASENSITIVE",,85379,305,$84.50 ,$84.50 ,$25.35 ,$76.90 ,$59.15 ,$25.35 ,$54.93 ,$60.84 ,$76.90 ,$63.38 
Carle BroMenn Medical Center,8385410,ALPHA-2 ANTIPLASMIN ACTVIT REF,,85410,305,$149.00 ,$149.00 ,$44.70 ,$135.59 ,$104.30 ,$44.70 ,$96.85 ,$107.28 ,$135.59 ,$111.75 
Carle BroMenn Medical Center,8385420,PLASMINOGEN ACTIVITY       REF,,85420,305,$117.00 ,$117.00 ,$35.10 ,$106.47 ,$81.90 ,$35.10 ,$76.05 ,$84.24 ,$106.47 ,$87.75 
Carle BroMenn Medical Center,8385421,PLASMINOGEN ANTIGEN        REF,,85421,305,$103.00 ,$103.00 ,$30.90 ,$93.73 ,$72.10 ,$30.90 ,$66.95 ,$74.16 ,$93.73 ,$77.25 
Carle BroMenn Medical Center,8385520,HEPARIN ASSAY              REF,,85520,305,$51.00 ,$51.00 ,$15.30 ,$46.41 ,$35.70 ,$15.30 ,$33.15 ,$36.72 ,$46.41 ,$38.25 
Carle BroMenn Medical Center,8385538,LYSOZYME/MURAMIDASE        REF,,85549,305,$126.75 ,$126.75 ,$38.03 ,$115.34 ,$88.73 ,$38.03 ,$82.39 ,$91.26 ,$115.34 ,$95.06 
Carle BroMenn Medical Center,8385540,LEUKOCYTE ALKALINE PHOSPHATASE,,85540,305,$91.00 ,$91.00 ,$27.30 ,$82.81 ,$63.70 ,$27.30 ,$59.15 ,$65.52 ,$82.81 ,$68.25 
Carle BroMenn Medical Center,8385549,"LYSOZYME (MURAMIDASE), PL  REF",,85549,305,$13.00 ,$13.00 ,$3.90 ,$11.83 ,$9.10 ,$3.90 ,$8.45 ,$9.36 ,$11.83 ,$9.75 
Carle BroMenn Medical Center,8385557,"OSMOTIC FRAG,RBC,INCUBATED REF",,85557,305,$123.00 ,$123.00 ,$36.90 ,$111.93 ,$86.10 ,$36.90 ,$79.95 ,$88.56 ,$111.93 ,$92.25 
Carle BroMenn Medical Center,8385595,PLATELET PROFILE,,85049,305,$33.15 ,$33.15 ,$9.95 ,$30.17 ,$23.21 ,$9.95 ,$21.55 ,$23.87 ,$30.17 ,$24.86 
Carle BroMenn Medical Center,8385597,PLATELET NEUTRALIZATION REF,,85597,305,$68.25 ,$68.25 ,$20.48 ,$62.11 ,$47.78 ,$20.48 ,$44.36 ,$49.14 ,$62.11 ,$51.19 
Carle BroMenn Medical Center,8385600,PLATELET AGGREGATION,,85576,305,$120.25 ,$120.25 ,$36.08 ,$109.43 ,$84.18 ,$36.08 ,$78.16 ,$86.58 ,$109.43 ,$90.19 
Carle BroMenn Medical Center,8385610,PROTHROMBIN TIME,,85610,305,$51.35 ,$51.35 ,$15.41 ,$46.73 ,$35.95 ,$15.41 ,$33.38 ,$36.97 ,$46.73 ,$38.51 
Carle BroMenn Medical Center,8385660,"HEMOGLOBIN S, SCRN, B    REF",,85660,305,$65.00 ,$65.00 ,$19.50 ,$59.15 ,$45.50 ,$19.50 ,$42.25 ,$46.80 ,$59.15 ,$48.75 
Carle BroMenn Medical Center,8385661,SICKLE CELL SCREEN,,85660,305,$126.75 ,$126.75 ,$38.03 ,$115.34 ,$88.73 ,$38.03 ,$82.39 ,$91.26 ,$115.34 ,$95.06 
Carle BroMenn Medical Center,8655347,"COAGULATION TIME, ACTIVATED",,85347,305,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8200607,HBSAG,,87340,306,$53.00 ,$53.00 ,$15.90 ,$48.23 ,$37.10 ,$15.90 ,$34.45 ,$38.16 ,$48.23 ,$39.75 
Carle BroMenn Medical Center,8200612,IAD NA CHLAMYDIA TRACH,,87491,306,$120.00 ,$120.00 ,$36.00 ,$109.20 ,$84.00 ,$36.00 ,$78.00 ,$86.40 ,$109.20 ,$90.00 
Carle BroMenn Medical Center,8200613,IAD NA NG,,87591,306,$135.00 ,$135.00 ,$40.50 ,$122.85 ,$94.50 ,$40.50 ,$87.75 ,$97.20 ,$122.85 ,$101.25 
Carle BroMenn Medical Center,8200614,IAN NA AMP PROBE,,87801,306,$66.00 ,$66.00 ,$19.80 ,$60.06 ,$46.20 ,$19.80 ,$42.90 ,$47.52 ,$60.06 ,$49.50 
Carle BroMenn Medical Center,8200620,WEST NILE VIRUS NAT,,87798,306,$47.00 ,$47.00 ,$14.10 ,$42.77 ,$32.90 ,$14.10 ,$30.55 ,$33.84 ,$42.77 ,$35.25 
Carle BroMenn Medical Center,8200626,HIV 1&2 REFLUX,,87340,306,$53.00 ,$53.00 ,$15.90 ,$48.23 ,$37.10 ,$15.90 ,$34.45 ,$38.16 ,$48.23 ,$39.75 
Carle BroMenn Medical Center,8210112,POTASSIUM HYDROXIDE PREPS,,Q0112,306,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8287101,CULTURE FUNGI-SKIN HAIR NAILS,,87101,306,$84.00 ,$84.00 ,$25.20 ,$76.44 ,$58.80 ,$25.20 ,$54.60 ,$60.48 ,$76.44 ,$63.00 
Carle BroMenn Medical Center,8287210,"G SMEAR,STAIN,WET MNT,INTERP",,87210,306,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8287220,G TISSUE EXAM BY KOH,,87220,306,$65.00 ,$65.00 ,$19.50 ,$59.15 ,$45.50 ,$19.50 ,$42.25 ,$46.80 ,$59.15 ,$48.75 
Carle BroMenn Medical Center,8287340,"HEPATITIS B SURFACE AG, EIA",,87340,306,$165.00 ,$165.00 ,$49.50 ,$150.15 ,$115.50 ,$49.50 ,$107.25 ,$118.80 ,$150.15 ,$123.75 
Carle BroMenn Medical Center,8287491,"CHYLMD TRACH, DNA, AMP PROBE",,87491,306,$320.00 ,$320.00 ,$96.00 ,$291.20 ,$224.00 ,$96.00 ,$208.00 ,$230.40 ,$291.20 ,$240.00 
Carle BroMenn Medical Center,8287502,INFECT AGENT DNA/RNA INFLUENZA 1ST 2 TYPES,,87502,306,$305.00 ,$305.00 ,$91.50 ,$277.55 ,$213.50 ,$91.50 ,$198.25 ,$219.60 ,$277.55 ,$228.75 
Carle BroMenn Medical Center,8287591,"N.GONORRHOEAE, DNA, AMP PROB",,87591,306,$320.00 ,$320.00 ,$96.00 ,$291.20 ,$224.00 ,$96.00 ,$208.00 ,$230.40 ,$291.20 ,$240.00 
Carle BroMenn Medical Center,8287634,IADNA DNA/RNA RSV AMPLIFIED PROBE TECHNIQUE,,87634,306,$600.00 ,$600.00 ,$180.00 ,$546.00 ,$420.00 ,$180.00 ,$390.00 ,$432.00 ,$546.00 ,$450.00 
Carle BroMenn Medical Center,8287635,SARS-COV-2 COVID-19 AMP PRB,,87635,306,$125.00 ,$125.00 ,$37.50 ,$113.75 ,$87.50 ,$37.50 ,$81.25 ,$90.00 ,$113.75 ,$93.75 
Carle BroMenn Medical Center,8287651,STRA-GROUP A STREP (POC),,87651,306,$360.00 ,$360.00 ,$108.00 ,$327.60 ,$252.00 ,$108.00 ,$234.00 ,$259.20 ,$327.60 ,$270.00 
Carle BroMenn Medical Center,8287798,"DETECT AGENT NOS, DNA, AMP",,87798,306,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8287801,RSV RNA,,87801,306,$730.00 ,$730.00 ,$219.00 ,$664.30 ,$511.00 ,$219.00 ,$474.50 ,$525.60 ,$664.30 ,$547.50 
Carle BroMenn Medical Center,8287804,"DETECT AGENT,IMMUN,DIR OBS,INFLUENZA",,87804,306,$74.00 ,$74.00 ,$22.20 ,$67.34 ,$51.80 ,$22.20 ,$48.10 ,$53.28 ,$67.34 ,$55.50 
Carle BroMenn Medical Center,8287807,"DETECT AGENT,IMMUN,DIR OBS, RSV",,87807,306,$74.00 ,$74.00 ,$22.20 ,$67.34 ,$51.80 ,$22.20 ,$48.10 ,$53.28 ,$67.34 ,$55.50 
Carle BroMenn Medical Center,8287808,TRICHOMONAS RAPID ANTIGEN TEST,,87808,306,$115.00 ,$115.00 ,$34.50 ,$104.65 ,$80.50 ,$34.50 ,$74.75 ,$82.80 ,$104.65 ,$86.25 
Carle BroMenn Medical Center,8287880,STREP A ASSAY W/OPTIC,,87880,306,$74.75 ,$74.75 ,$22.43 ,$68.02 ,$52.33 ,$22.43 ,$48.59 ,$53.82 ,$68.02 ,$56.06 
Carle BroMenn Medical Center,8287905,BACTERIAL VAGINOSIS SCREEN,,87905,306,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8340014,CULTURE OTHER-SPECIFY SOURCE,,87070,306,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8340015,CULTURE THROAT-BETA STREP ONLY,,87081,306,$115.00 ,$115.00 ,$34.50 ,$104.65 ,$80.50 ,$34.50 ,$74.75 ,$82.80 ,$104.65 ,$86.25 
Carle BroMenn Medical Center,8340018,GC-REFLEX FOR GCCHLAM,,87590,306,$210.00 ,$210.00 ,$63.00 ,$191.10 ,$147.00 ,$63.00 ,$136.50 ,$151.20 ,$191.10 ,$157.50 
Carle BroMenn Medical Center,8340062,VET SUSCEPTIBILITY,,8340062,306,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8380023,INFEC AGEN DETEC AMPLI PROBE,,U0005,306,$90.00 ,$90.00 ,$27.00 ,$81.90 ,$63.00 ,$27.00 ,$58.50 ,$64.80 ,$81.90 ,$67.50 
Carle BroMenn Medical Center,8380133,CRYPTOCOCCUS AG SCREEN CSF REF,,87327,306,$87.75 ,$87.75 ,$26.33 ,$79.85 ,$61.43 ,$26.33 ,$57.04 ,$63.18 ,$79.85 ,$65.81 
Carle BroMenn Medical Center,8380135,CYTOMEG DNA - QUANT,,87497,306,$479.00 ,$479.00 ,$143.70 ,$435.89 ,$335.30 ,$143.70 ,$311.35 ,$344.88 ,$435.89 ,$359.25 
Carle BroMenn Medical Center,8380139,INFECTIOUS AGENT DETECTION,,87427,306,$71.50 ,$71.50 ,$21.45 ,$65.07 ,$50.05 ,$21.45 ,$46.48 ,$51.48 ,$65.07 ,$53.63 
Carle BroMenn Medical Center,8380143,ENTEROVIRUS BY PCR,,87498,306,$224.00 ,$224.00 ,$67.20 ,$203.84 ,$156.80 ,$67.20 ,$145.60 ,$161.28 ,$203.84 ,$168.00 
Carle BroMenn Medical Center,8380146,AMPL PROBE EA ORG,,87798,306,$268.00 ,$268.00 ,$80.40 ,$243.88 ,$187.60 ,$80.40 ,$174.20 ,$192.96 ,$243.88 ,$201.00 
Carle BroMenn Medical Center,8380149,AMP PROB TECH EA ORGANISM,,87150,306,$113.00 ,$113.00 ,$33.90 ,$102.83 ,$79.10 ,$33.90 ,$73.45 ,$81.36 ,$102.83 ,$84.75 
Carle BroMenn Medical Center,8380234,INFLUENZA A,,87400,306,$91.00 ,$91.00 ,$27.30 ,$82.81 ,$63.70 ,$27.30 ,$59.15 ,$65.52 ,$82.81 ,$68.25 
Carle BroMenn Medical Center,8380235,INFLUENZA B,,87400,306,$91.00 ,$91.00 ,$27.30 ,$82.81 ,$63.70 ,$27.30 ,$59.15 ,$65.52 ,$82.81 ,$68.25 
Carle BroMenn Medical Center,8380240,"BETA STREP, RAPID",,87430,306,$110.00 ,$110.00 ,$33.00 ,$100.10 ,$77.00 ,$33.00 ,$71.50 ,$79.20 ,$100.10 ,$82.50 
Carle BroMenn Medical Center,8380242,UPPER RESIRATORY CULTURE,,87081,306,$97.00 ,$97.00 ,$29.10 ,$88.27 ,$67.90 ,$29.10 ,$63.05 ,$69.84 ,$88.27 ,$72.75 
Carle BroMenn Medical Center,8380248,PHENOTYPIC MIC SENSITIVITY,,87186,306,$101.00 ,$101.00 ,$30.30 ,$91.91 ,$70.70 ,$30.30 ,$65.65 ,$72.72 ,$91.91 ,$75.75 
Carle BroMenn Medical Center,8380250,BORDETELLA PERTUSSIS/PARAPERTUSSIS PCR MML REF,,87801,306,$54.00 ,$54.00 ,$16.20 ,$49.14 ,$37.80 ,$16.20 ,$35.10 ,$38.88 ,$49.14 ,$40.50 
Carle BroMenn Medical Center,8380286,"WET MOUNT, INFECTIOUS AGENT  REF",,87210,306,$37.05 ,$37.05 ,$11.12 ,$33.72 ,$25.94 ,$11.12 ,$24.08 ,$26.68 ,$33.72 ,$27.79 
Carle BroMenn Medical Center,8380305,MRSA AMPI PROBE,,87641,306,$214.50 ,$214.50 ,$64.35 ,$195.20 ,$150.15 ,$64.35 ,$139.43 ,$154.44 ,$195.20 ,$160.88 
Carle BroMenn Medical Center,8380313,MTB COMPLEX DIRECT,,87798,306,$31.00 ,$31.00 ,$9.30 ,$28.21 ,$21.70 ,$9.30 ,$20.15 ,$22.32 ,$28.21 ,$23.25 
Carle BroMenn Medical Center,8380334,FLU A PANEL BY PCR,,87798,306,$230.00 ,$230.00 ,$69.00 ,$209.30 ,$161.00 ,$69.00 ,$149.50 ,$165.60 ,$209.30 ,$172.50 
Carle BroMenn Medical Center,8380437,"HBS ANTIGEN CONFIRMATION, S    REF",,87341,306,$106.00 ,$106.00 ,$31.80 ,$96.46 ,$74.20 ,$31.80 ,$68.90 ,$76.32 ,$96.46 ,$79.50 
Carle BroMenn Medical Center,8380490,"VIRAL CULTURE, NON-RESPIR    REF",,87252,306,$17.00 ,$17.00 ,$5.10 ,$15.47 ,$11.90 ,$5.10 ,$11.05 ,$12.24 ,$15.47 ,$12.75 
Carle BroMenn Medical Center,8380504,"HEPATITIS BE AG, S    REF",,87350,306,$14.00 ,$14.00 ,$4.20 ,$12.74 ,$9.80 ,$4.20 ,$9.10 ,$10.08 ,$12.74 ,$10.50 
Carle BroMenn Medical Center,8380524,VARICELLA-ZOSTER VIRUS PCR    REF,,87798,306,$291.20 ,$291.20 ,$87.36 ,$264.99 ,$203.84 ,$87.36 ,$189.28 ,$209.66 ,$264.99 ,$218.40 
Carle BroMenn Medical Center,8380535,"CYCLOSPORA, CONCENTRATION    REF",,87015,306,$13.00 ,$13.00 ,$3.90 ,$11.83 ,$9.10 ,$3.90 ,$8.45 ,$9.36 ,$11.83 ,$9.75 
Carle BroMenn Medical Center,8380536,CYCLOSPORA STAIN    REF,,87207,306,$12.00 ,$12.00 ,$3.60 ,$10.92 ,$8.40 ,$3.60 ,$7.80 ,$8.64 ,$10.92 ,$9.00 
Carle BroMenn Medical Center,8380617,HIV-1 RNA,,87536,306,$693.00 ,$693.00 ,$207.90 ,$630.63 ,$485.10 ,$207.90 ,$450.45 ,$498.96 ,$630.63 ,$519.75 
Carle BroMenn Medical Center,8380618,RNA QUANT BY PCR,,87522,306,$353.00 ,$353.00 ,$105.90 ,$321.23 ,$247.10 ,$105.90 ,$229.45 ,$254.16 ,$321.23 ,$264.75 
Carle BroMenn Medical Center,8380621,LAB/PATH TESTING,,87633,306,"$2,287.00 ","$2,287.00 ",$686.10 ,"$2,081.17 ","$1,600.90 ",$686.10 ,"$1,486.55 ","$1,646.64 ","$2,081.17 ","$1,715.25 "
Carle BroMenn Medical Center,8380641,CPT-RAPID GROWER DISC DIF 87184-90 U OF TEXAS,,87184,306,$57.00 ,$57.00 ,$17.10 ,$51.87 ,$39.90 ,$17.10 ,$37.05 ,$41.04 ,$51.87 ,$42.75 
Carle BroMenn Medical Center,8380642,CPT-RAPID GROWER MIC SENSI 87186-90 U OF TEXAS,,87186,306,$57.00 ,$57.00 ,$17.10 ,$51.87 ,$39.90 ,$17.10 ,$37.05 ,$41.04 ,$51.87 ,$42.75 
Carle BroMenn Medical Center,8380643,CPT-NOCARDIA/ACTINOMYCES DISC DIFFUS U OF TEXAS,,87184,306,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8380644,CPT-NORCARDIA/ACTINOMYCETES MIC SENSIT U OF TEXAS,,87186,306,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8380645,CPT-M MARINUM MIC SENSI 87186-90 U OF TEXAS,,87186,306,$95.00 ,$95.00 ,$28.50 ,$86.45 ,$66.50 ,$28.50 ,$61.75 ,$68.40 ,$86.45 ,$71.25 
Carle BroMenn Medical Center,8380646,CPT-M KANSASII MIC SENSI 87186-90 U OF TEXAS,,87186,306,$69.00 ,$69.00 ,$20.70 ,$62.79 ,$48.30 ,$20.70 ,$44.85 ,$49.68 ,$62.79 ,$51.75 
Carle BroMenn Medical Center,8380651,"VIRAL CULTURE, RESPIRATORY REF",,87252,306,$21.00 ,$21.00 ,$6.30 ,$19.11 ,$14.70 ,$6.30 ,$13.65 ,$15.12 ,$19.11 ,$15.75 
Carle BroMenn Medical Center,8380653,SMEAR-COMPLEX STAIN REF,,87209,306,$152.75 ,$152.75 ,$45.83 ,$139.00 ,$106.93 ,$45.83 ,$99.29 ,$109.98 ,$139.00 ,$114.56 
Carle BroMenn Medical Center,8380677,"M. TUBERCULOSIS COMPLEX, PCR REF",,87556,306,$78.00 ,$78.00 ,$23.40 ,$70.98 ,$54.60 ,$23.40 ,$50.70 ,$56.16 ,$70.98 ,$58.50 
Carle BroMenn Medical Center,8380682,"CPT-AMP PROBE, EACH ORG-ADENOVIRUS",,87798,306,$227.00 ,$227.00 ,$68.10 ,$206.57 ,$158.90 ,$68.10 ,$147.55 ,$163.44 ,$206.57 ,$170.25 
Carle BroMenn Medical Center,8380683,"CPT-AMP PROBE, EACH ORG-CORONAV. 229E",,87798,306,$208.00 ,$208.00 ,$62.40 ,$189.28 ,$145.60 ,$62.40 ,$135.20 ,$149.76 ,$189.28 ,$156.00 
Carle BroMenn Medical Center,8380684,CPT AMP PROBE EACH ORG CORONAV HKU1,,87798,306,$227.00 ,$227.00 ,$68.10 ,$206.57 ,$158.90 ,$68.10 ,$147.55 ,$163.44 ,$206.57 ,$170.25 
Carle BroMenn Medical Center,8380685,"CPT-AMP PROBE, EACH ORG-CORONAV. NL63",,87798,306,$227.00 ,$227.00 ,$68.10 ,$206.57 ,$158.90 ,$68.10 ,$147.55 ,$163.44 ,$206.57 ,$170.25 
Carle BroMenn Medical Center,8380686,"CPT-AMP PROBE, EACH ORG-CORONAV. OC43",,87798,306,$227.00 ,$227.00 ,$68.10 ,$206.57 ,$158.90 ,$68.10 ,$147.55 ,$163.44 ,$206.57 ,$170.25 
Carle BroMenn Medical Center,8380687,"CPT-AMP PROBE, EACH ORG-METAPNEUM",,87798,306,$227.00 ,$227.00 ,$68.10 ,$206.57 ,$158.90 ,$68.10 ,$147.55 ,$163.44 ,$206.57 ,$170.25 
Carle BroMenn Medical Center,8380688,"CPT-AMP PROBE, EACH ORG-RHINO/ENTERO",,87798,306,$227.00 ,$227.00 ,$68.10 ,$206.57 ,$158.90 ,$68.10 ,$147.55 ,$163.44 ,$206.57 ,$170.25 
Carle BroMenn Medical Center,8380689,"CPT-INFLUENZA A VIRUS, FIRST 2 OR SUB-TYPES",,87502,306,$198.00 ,$198.00 ,$59.40 ,$180.18 ,$138.60 ,$59.40 ,$128.70 ,$142.56 ,$180.18 ,$148.50 
Carle BroMenn Medical Center,8380690,"CPT-INFLUENZA A H3 VIRUS, FIRST 2 OR SUB-TYPES",,87503,306,$48.00 ,$48.00 ,$14.40 ,$43.68 ,$33.60 ,$14.40 ,$31.20 ,$34.56 ,$43.68 ,$36.00 
Carle BroMenn Medical Center,8380691,"CPT-INFLUENZA A 2009 VIRUS, FIRST 2 OR SUB-TYPES",,87503,306,$48.00 ,$48.00 ,$14.40 ,$43.68 ,$33.60 ,$14.40 ,$31.20 ,$34.56 ,$43.68 ,$36.00 
Carle BroMenn Medical Center,8380692,"CPT-INFLUENZA A H1 VIRUS, FIRST 2 OR SUB-TYPES",,87503,306,$48.00 ,$48.00 ,$14.40 ,$43.68 ,$33.60 ,$14.40 ,$31.20 ,$34.56 ,$43.68 ,$36.00 
Carle BroMenn Medical Center,8380693,"CPT-AMP PROBE, EACH ORG-PIV1",,87798,306,$227.00 ,$227.00 ,$68.10 ,$206.57 ,$158.90 ,$68.10 ,$147.55 ,$163.44 ,$206.57 ,$170.25 
Carle BroMenn Medical Center,8380694,"CPT-AMP PROBE, EACH ORG-PIV2",,87798,306,$227.00 ,$227.00 ,$68.10 ,$206.57 ,$158.90 ,$68.10 ,$147.55 ,$163.44 ,$206.57 ,$170.25 
Carle BroMenn Medical Center,8380695,"CPT-AMP PROBE, EACH ORG-PIV3",,87798,306,$227.00 ,$227.00 ,$68.10 ,$206.57 ,$158.90 ,$68.10 ,$147.55 ,$163.44 ,$206.57 ,$170.25 
Carle BroMenn Medical Center,8380696,"CPT-AMP PROBE, EACH ORG-PIV4",,87798,306,$227.00 ,$227.00 ,$68.10 ,$206.57 ,$158.90 ,$68.10 ,$147.55 ,$163.44 ,$206.57 ,$170.25 
Carle BroMenn Medical Center,8380697,"CPT-AMP PROBE, EACH ORG-RSV",,87798,306,$227.00 ,$227.00 ,$68.10 ,$206.57 ,$158.90 ,$68.10 ,$147.55 ,$163.44 ,$206.57 ,$170.25 
Carle BroMenn Medical Center,8380698,"CPT-AMP PROBE, EACH ORG-PERTUSSIS",,87798,306,$227.00 ,$227.00 ,$68.10 ,$206.57 ,$158.90 ,$68.10 ,$147.55 ,$163.44 ,$206.57 ,$170.25 
Carle BroMenn Medical Center,8380699,CPT-AMP PROBE-CHLAMYDIAá PNEUMONIAE,,87486,306,$129.00 ,$129.00 ,$38.70 ,$117.39 ,$90.30 ,$38.70 ,$83.85 ,$92.88 ,$117.39 ,$96.75 
Carle BroMenn Medical Center,8380709,"HEP B VIRUS DNA QNT BY BDNA, S  REF",,87517,306,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8380715,"EPS-BARR VIRUS PCR, REF",,87799,306,$52.00 ,$52.00 ,$15.60 ,$47.32 ,$36.40 ,$15.60 ,$33.80 ,$37.44 ,$47.32 ,$39.00 
Carle BroMenn Medical Center,8380719,PARVOVIRUS B19 BY RAPID PCR    REF,,87798,306,$24.00 ,$24.00 ,$7.20 ,$21.84 ,$16.80 ,$7.20 ,$15.60 ,$17.28 ,$21.84 ,$18.00 
Carle BroMenn Medical Center,8380727,"BK VIRUS PCR, QUANT, P    REF",,87799,306,$260.00 ,$260.00 ,$78.00 ,$236.60 ,$182.00 ,$78.00 ,$169.00 ,$187.20 ,$236.60 ,$195.00 
Carle BroMenn Medical Center,8380748,"EHRLICHIA/ANAPLASMA PCR, B    REF",,87798,306,$11.00 ,$11.00 ,$3.30 ,$10.01 ,$7.70 ,$3.30 ,$7.15 ,$7.92 ,$10.01 ,$8.25 
Carle BroMenn Medical Center,8380759,"HEPATITIS C AMPLIF, RT-PCR    REF",,87521,306,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8380760,HEPATITIS C GENOTYPING    REF,,87902,306,$34.00 ,$34.00 ,$10.20 ,$30.94 ,$23.80 ,$10.20 ,$22.10 ,$24.48 ,$30.94 ,$25.50 
Carle BroMenn Medical Center,8380766,"WEST NILE VIRUS PCR, P    REF",,87798,306,$171.00 ,$171.00 ,$51.30 ,$155.61 ,$119.70 ,$51.30 ,$111.15 ,$123.12 ,$155.61 ,$128.25 
Carle BroMenn Medical Center,8380778,"HBV DNA DETECT/QNT, PCR, S    REF",,87517,306,$59.00 ,$59.00 ,$17.70 ,$53.69 ,$41.30 ,$17.70 ,$38.35 ,$42.48 ,$53.69 ,$44.25 
Carle BroMenn Medical Center,8380789,LABORATORY TEST REF,,87901,306,$259.00 ,$259.00 ,$77.70 ,$235.69 ,$181.30 ,$77.70 ,$168.35 ,$186.48 ,$235.69 ,$194.25 
Carle BroMenn Medical Center,8380790,LABORATORY TEST REF,,87900,306,$158.00 ,$158.00 ,$47.40 ,$143.78 ,$110.60 ,$47.40 ,$102.70 ,$113.76 ,$143.78 ,$118.50 
Carle BroMenn Medical Center,8380821,LEGIONELLA PCR    REF,,87798,306,$173.00 ,$173.00 ,$51.90 ,$157.43 ,$121.10 ,$51.90 ,$112.45 ,$124.56 ,$157.43 ,$129.75 
Carle BroMenn Medical Center,8380822,"MVISTA HISTOPLASMA AG, S    REF",,87385,306,$75.00 ,$75.00 ,$22.50 ,$68.25 ,$52.50 ,$22.50 ,$48.75 ,$54.00 ,$68.25 ,$56.25 
Carle BroMenn Medical Center,8380848,MVISTA BLASTOMYCES QUANT AG    REF,,87449,306,$75.00 ,$75.00 ,$22.50 ,$68.25 ,$52.50 ,$22.50 ,$48.75 ,$54.00 ,$68.25 ,$56.25 
Carle BroMenn Medical Center,8380861,MYCOPLASMA HOMINIS PCR    REF,,87798,306,$236.00 ,$236.00 ,$70.80 ,$214.76 ,$165.20 ,$70.80 ,$153.40 ,$169.92 ,$214.76 ,$177.00 
Carle BroMenn Medical Center,8380862,"UREAPLASMA SP, MOL DET, PCR    REF",,87798,306,$236.00 ,$236.00 ,$70.80 ,$214.76 ,$165.20 ,$70.80 ,$153.40 ,$169.92 ,$214.76 ,$177.00 
Carle BroMenn Medical Center,8380946,ASPERGILLUS (GALACTOMANNAN) AG REF,,87305,306,$30.00 ,$30.00 ,$9.00 ,$27.30 ,$21.00 ,$9.00 ,$19.50 ,$21.60 ,$27.30 ,$22.50 
Carle BroMenn Medical Center,8380961,IFN-B TISSUE CULTURE    REF,,87253,306,$282.00 ,$282.00 ,$84.60 ,$256.62 ,$197.40 ,$84.60 ,$183.30 ,$203.04 ,$256.62 ,$211.50 
Carle BroMenn Medical Center,8380977,CYCLOSPORA STAIN           REF,,87207,306,$12.00 ,$12.00 ,$3.60 ,$10.92 ,$8.40 ,$3.60 ,$7.80 ,$8.64 ,$10.92 ,$9.00 
Carle BroMenn Medical Center,8380991,CPT-AMP PROBE-MYCO PNEUMONIAE,,87581,306,$151.00 ,$151.00 ,$45.30 ,$137.41 ,$105.70 ,$45.30 ,$98.15 ,$108.72 ,$137.41 ,$113.25 
Carle BroMenn Medical Center,8381015,"CULTURE REFER FOR ID, MYCOBACTERIUM  REF",,87153,306,$159.00 ,$159.00 ,$47.70 ,$144.69 ,$111.30 ,$47.70 ,$103.35 ,$114.48 ,$144.69 ,$119.25 
Carle BroMenn Medical Center,8381017,"CULTURE, TYPING; IMMUNOFLUORESCENT METHOD",,87140,306,$40.95 ,$40.95 ,$12.29 ,$37.26 ,$28.67 ,$12.29 ,$26.62 ,$29.48 ,$37.26 ,$30.71 
Carle BroMenn Medical Center,8381035,BACTERIAL DETECTION BY PCR  REF,,87801,306,$174.00 ,$174.00 ,$52.20 ,$158.34 ,$121.80 ,$52.20 ,$113.10 ,$125.28 ,$158.34 ,$130.50 
Carle BroMenn Medical Center,8381059,BORDETELLA by PCR,,87798,306,$27.00 ,$27.00 ,$8.10 ,$24.57 ,$18.90 ,$8.10 ,$17.55 ,$19.44 ,$24.57 ,$20.25 
Carle BroMenn Medical Center,8381068,CPT-ID BY NUCLEIC ACID PROBE (U OF TEXAS),,87150,306,$55.00 ,$55.00 ,$16.50 ,$50.05 ,$38.50 ,$16.50 ,$35.75 ,$39.60 ,$50.05 ,$41.25 
Carle BroMenn Medical Center,8381070,SUSCEPTIBILTY STUDY EA AGNT RF,,87188,306,$21.00 ,$21.00 ,$6.30 ,$19.11 ,$14.70 ,$6.30 ,$13.65 ,$15.12 ,$19.11 ,$15.75 
Carle BroMenn Medical Center,8381071,SUSCEPTIBILTY STUDY EA AGNT RF,,87188,306,$21.00 ,$21.00 ,$6.30 ,$19.11 ,$14.70 ,$6.30 ,$13.65 ,$15.12 ,$19.11 ,$15.75 
Carle BroMenn Medical Center,8381072,SUSCEPTIBILTY STUDY EA AGNT RF,,87188,306,$28.00 ,$28.00 ,$8.40 ,$25.48 ,$19.60 ,$8.40 ,$18.20 ,$20.16 ,$25.48 ,$21.00 
Carle BroMenn Medical Center,8381073,SUSCEPTIBILTY STUDY EA AGNT RF,,87188,306,$26.00 ,$26.00 ,$7.80 ,$23.66 ,$18.20 ,$7.80 ,$16.90 ,$18.72 ,$23.66 ,$19.50 
Carle BroMenn Medical Center,8381074,"SUSCEPTIBILITY STUDY, PER PLATE RF",,87186,306,$167.00 ,$167.00 ,$50.10 ,$151.97 ,$116.90 ,$50.10 ,$108.55 ,$120.24 ,$151.97 ,$125.25 
Carle BroMenn Medical Center,8381075,AFB IDENTIFICATION BY NUCLEIC ACID SEQ. RF,,87153,306,$183.00 ,$183.00 ,$54.90 ,$166.53 ,$128.10 ,$54.90 ,$118.95 ,$131.76 ,$166.53 ,$137.25 
Carle BroMenn Medical Center,8381080,"VIRAL CULTURE AND ID, REF",,87253,306,$140.00 ,$140.00 ,$42.00 ,$127.40 ,$98.00 ,$42.00 ,$91.00 ,$100.80 ,$127.40 ,$105.00 
Carle BroMenn Medical Center,8381081,CPT-87798-GPP-INF. AGENT DETC. BY AMP. PROBE,,87798,306,$129.00 ,$129.00 ,$38.70 ,$117.39 ,$90.30 ,$38.70 ,$83.85 ,$92.88 ,$117.39 ,$96.75 
Carle BroMenn Medical Center,8381082,"CPT-87493-GPP-C DIFF, TOXIN GENE, AMP PROBE",,87493,306,$165.75 ,$165.75 ,$49.73 ,$150.83 ,$116.03 ,$49.73 ,$107.74 ,$119.34 ,$150.83 ,$124.31 
Carle BroMenn Medical Center,8381097,CPT-AFB MIC SUSCEPT 87186-90 (NAT'L JEWISH) 1/1,,87186,306,$28.00 ,$28.00 ,$8.40 ,$25.48 ,$19.60 ,$8.40 ,$18.20 ,$20.16 ,$25.48 ,$21.00 
Carle BroMenn Medical Center,8381098,CPT-AFB MIC SUSCEPT 87186-90 (NAT'L JEWISH) 1/1,,87186,306,$25.00 ,$25.00 ,$7.50 ,$22.75 ,$17.50 ,$7.50 ,$16.25 ,$18.00 ,$22.75 ,$18.75 
Carle BroMenn Medical Center,8381099,"CPT-HBRP AMPLIFIED PROBE, EACH",,87798,306,$117.00 ,$117.00 ,$35.10 ,$106.47 ,$81.90 ,$35.10 ,$76.05 ,$84.24 ,$106.47 ,$87.75 
Carle BroMenn Medical Center,8381104,"CPT-HBRPB AMPLIFIED PROBE, EACH REF",,87798,306,$72.00 ,$72.00 ,$21.60 ,$65.52 ,$50.40 ,$21.60 ,$46.80 ,$51.84 ,$65.52 ,$54.00 
Carle BroMenn Medical Center,8381108,CPT-HPAGS HISTO ANTIGEN DETECTION REF,,87385,306,$75.00 ,$75.00 ,$22.50 ,$68.25 ,$52.50 ,$22.50 ,$48.75 ,$54.00 ,$68.25 ,$56.25 
Carle BroMenn Medical Center,8381109,CPT-HPAGU HISTO ANTIGEN DETECTION REF,,87385,306,$75.00 ,$75.00 ,$22.50 ,$68.25 ,$52.50 ,$22.50 ,$48.75 ,$54.00 ,$68.25 ,$56.25 
Carle BroMenn Medical Center,8381110,CPT-LCMV-CMV AMPLIFIED PROBE REF,,87496,306,$45.00 ,$45.00 ,$13.50 ,$40.95 ,$31.50 ,$13.50 ,$29.25 ,$32.40 ,$40.95 ,$33.75 
Carle BroMenn Medical Center,8381114,CPT-UCMV AMPLIFIED PROBEááá REF,,87496,306,$45.00 ,$45.00 ,$13.50 ,$40.95 ,$31.50 ,$13.50 ,$29.25 ,$32.40 ,$40.95 ,$33.75 
Carle BroMenn Medical Center,8381124,LABORATORY SERVICE,,87899,306,$101.00 ,$101.00 ,$30.30 ,$91.91 ,$70.70 ,$30.30 ,$65.65 ,$72.72 ,$91.91 ,$75.75 
Carle BroMenn Medical Center,8381130,"CHIKUNGUNYA VIRUS RNA, QUAL  REF",,87798,306,$161.00 ,$161.00 ,$48.30 ,$146.51 ,$112.70 ,$48.30 ,$104.65 ,$115.92 ,$146.51 ,$120.75 
Carle BroMenn Medical Center,8381135,ID BY NUCLEIC ACID PROBE (EACH),,87150,306,$92.95 ,$92.95 ,$27.89 ,$84.58 ,$65.07 ,$27.89 ,$60.42 ,$66.92 ,$84.58 ,$69.71 
Carle BroMenn Medical Center,8381137,"HISTOOPLASMA AG, RESULT  REF",,87385,306,$56.00 ,$56.00 ,$16.80 ,$50.96 ,$39.20 ,$16.80 ,$36.40 ,$40.32 ,$50.96 ,$42.00 
Carle BroMenn Medical Center,8381145,"BK VIRUS QUANTITATIVE, PCR, U  REF",,87799,306,$45.00 ,$45.00 ,$13.50 ,$40.95 ,$31.50 ,$13.50 ,$29.25 ,$32.40 ,$40.95 ,$33.75 
Carle BroMenn Medical Center,8381146,LEGIONELLA CULTURE  REF,,87081,306,$97.00 ,$97.00 ,$29.10 ,$88.27 ,$67.90 ,$29.10 ,$63.05 ,$69.84 ,$88.27 ,$72.75 
Carle BroMenn Medical Center,8381147,"HERPES SIMPLEX (HSV) PCR, B  REV",,87529,306,$37.00 ,$37.00 ,$11.10 ,$33.67 ,$25.90 ,$11.10 ,$24.05 ,$26.64 ,$33.67 ,$27.75 
Carle BroMenn Medical Center,8381148,PNEUMOCYSTIS JIROVECI PCR  REF,,87798,306,$114.00 ,$114.00 ,$34.20 ,$103.74 ,$79.80 ,$34.20 ,$74.10 ,$82.08 ,$103.74 ,$85.50 
Carle BroMenn Medical Center,8381151,IDENT-BACTERIAL IDENTIFICATION REF,,87077,306,$46.15 ,$46.15 ,$13.85 ,$42.00 ,$32.31 ,$13.85 ,$30.00 ,$33.23 ,$42.00 ,$34.61 
Carle BroMenn Medical Center,8381198,PNEUMOCYSTIS JIROVECI PCR  REF,,87799,306,$202.00 ,$202.00 ,$60.60 ,$183.82 ,$141.40 ,$60.60 ,$131.30 ,$145.44 ,$183.82 ,$151.50 
Carle BroMenn Medical Center,8381231,"CPT-RPP-RESPIRATORY VIRUS, PROBE, 12-25 TARGETS",,0202U,306,"$1,046.00 ","$1,046.00 ",$313.80 ,$951.86 ,$732.20 ,$313.80 ,$679.90 ,$753.12 ,$951.86 ,$784.50 
Carle BroMenn Medical Center,8381233,CPT-HPV HIGH RISK TYPES,,87624,306,$221.00 ,$221.00 ,$66.30 ,$201.11 ,$154.70 ,$66.30 ,$143.65 ,$159.12 ,$201.11 ,$165.75 
Carle BroMenn Medical Center,8381423,LEGIONELLA PCR    REF,,87801,306,$225.00 ,$225.00 ,$67.50 ,$204.75 ,$157.50 ,$67.50 ,$146.25 ,$162.00 ,$204.75 ,$168.75 
Carle BroMenn Medical Center,8381454,MYCOPLASMA PNEUMONIAE DNA,,87581,306,$274.00 ,$274.00 ,$82.20 ,$249.34 ,$191.80 ,$82.20 ,$178.10 ,$197.28 ,$249.34 ,$205.50 
Carle BroMenn Medical Center,8381464,CPT-AFB 10 DURG MIC PLUS 87181-90 (NAT'L JEWISH)  REF,,87181,306,$76.00 ,$76.00 ,$22.80 ,$69.16 ,$53.20 ,$22.80 ,$49.40 ,$54.72 ,$69.16 ,$57.00 
Carle BroMenn Medical Center,8381465,CPT-AFB 10 DRUG MIC RIF/ETHAM. 87186-90 (NAT'L JEWISH)  REF,,87186,306,$76.00 ,$76.00 ,$22.80 ,$69.16 ,$53.20 ,$22.80 ,$49.40 ,$54.72 ,$69.16 ,$57.00 
Carle BroMenn Medical Center,8381467,BORDETELLA PERTUSSIS DNA,,87798,306,$249.00 ,$249.00 ,$74.70 ,$226.59 ,$174.30 ,$74.70 ,$161.85 ,$179.28 ,$226.59 ,$186.75 
Carle BroMenn Medical Center,8381471,HELICOBACTER PYLORI CULTURE AND SUSC   REF,,87081,306,$97.00 ,$97.00 ,$29.10 ,$88.27 ,$67.90 ,$29.10 ,$63.05 ,$69.84 ,$88.27 ,$72.75 
Carle BroMenn Medical Center,8381476,"CMV DNA DETEC/QUANT, P  REF",,87497,306,$30.00 ,$30.00 ,$9.00 ,$27.30 ,$21.00 ,$9.00 ,$19.50 ,$21.60 ,$27.30 ,$22.50 
Carle BroMenn Medical Center,8381493,"VIRUS ISOL; SHELL VIAL TECHNIQUE, EACH VIRUS  REF",,87254,306,$133.25 ,$133.25 ,$39.98 ,$121.26 ,$93.28 ,$39.98 ,$86.61 ,$95.94 ,$121.26 ,$99.94 
Carle BroMenn Medical Center,8381516,MALARIA ANTIGEN (ITC LAB),,87899,306,$46.00 ,$46.00 ,$13.80 ,$41.86 ,$32.20 ,$13.80 ,$29.90 ,$33.12 ,$41.86 ,$34.50 
Carle BroMenn Medical Center,8381517,CPT-EBOLA ZAIRE VIRUS DNA (ITC LAB),,87150,306,$110.00 ,$110.00 ,$33.00 ,$100.10 ,$77.00 ,$33.00 ,$71.50 ,$79.20 ,$100.10 ,$82.50 
Carle BroMenn Medical Center,8381518,RESPIRATORY PATHOGENS PANEL (ITC LAB),,87633,306,"$2,287.00 ","$2,287.00 ",$686.10 ,"$2,081.17 ","$1,600.90 ",$686.10 ,"$1,486.55 ","$1,646.64 ","$2,081.17 ","$1,715.25 "
Carle BroMenn Medical Center,8381521,MALARIA ANTIGEN,,87899,306,$76.00 ,$76.00 ,$22.80 ,$69.16 ,$53.20 ,$22.80 ,$49.40 ,$54.72 ,$69.16 ,$57.00 
Carle BroMenn Medical Center,8381539,HCV GENOTYPE RESOLUTION REF,,87902,306,$39.00 ,$39.00 ,$11.70 ,$35.49 ,$27.30 ,$11.70 ,$25.35 ,$28.08 ,$35.49 ,$29.25 
Carle BroMenn Medical Center,8381555,HCV RNA GENOTYPE 3 NS5A DRUG RESIST  REF,,87902,306,$361.00 ,$361.00 ,$108.30 ,$328.51 ,$252.70 ,$108.30 ,$234.65 ,$259.92 ,$328.51 ,$270.75 
Carle BroMenn Medical Center,8381558,HCV RNA GENOTYPE 1 NS5A DRUG RESIST  REF,,87902,306,$414.00 ,$414.00 ,$124.20 ,$376.74 ,$289.80 ,$124.20 ,$269.10 ,$298.08 ,$376.74 ,$310.50 
Carle BroMenn Medical Center,8381570,LABORATORY SERVICE,,87538,306,$191.00 ,$191.00 ,$57.30 ,$173.81 ,$133.70 ,$57.30 ,$124.15 ,$137.52 ,$173.81 ,$143.25 
Carle BroMenn Medical Center,8381571,"HIV-1/2 AG AND AB SCREEN, S  REF",,87389,306,$74.75 ,$74.75 ,$22.43 ,$68.02 ,$52.33 ,$22.43 ,$48.59 ,$53.82 ,$68.02 ,$56.06 
Carle BroMenn Medical Center,8381577,"HERPES SIMPLEX VIRUS, PCR  REF",,87529,306,$23.00 ,$23.00 ,$6.90 ,$20.93 ,$16.10 ,$6.90 ,$14.95 ,$16.56 ,$20.93 ,$17.25 
Carle BroMenn Medical Center,8381578,"TOXOPLASMA GONDII, PCS  REF",,87798,306,$45.00 ,$45.00 ,$13.50 ,$40.95 ,$31.50 ,$13.50 ,$29.25 ,$32.40 ,$40.95 ,$33.75 
Carle BroMenn Medical Center,8381584,HIV-DNA/RNA QUALITIVE DETECT BY PCR  REF,,87535,306,$165.75 ,$165.75 ,$49.73 ,$150.83 ,$116.03 ,$49.73 ,$107.74 ,$119.34 ,$150.83 ,$124.31 
Carle BroMenn Medical Center,8381595,CPT-HCVGE 87902 BILLING,,87902,306,"$1,241.00 ","$1,241.00 ",$372.30 ,"$1,129.31 ",$868.70 ,$372.30 ,$806.65 ,$893.52 ,"$1,129.31 ",$930.75 
Carle BroMenn Medical Center,8381633,TRICHOMONAS RAPID ANTIGEN TEST,,87808,306,$104.00 ,$104.00 ,$31.20 ,$94.64 ,$72.80 ,$31.20 ,$67.60 ,$74.88 ,$94.64 ,$78.00 
Carle BroMenn Medical Center,8381634,BACTERIAL VAGINOSIS SCREEN,,87905,306,$117.00 ,$117.00 ,$35.10 ,$106.47 ,$81.90 ,$35.10 ,$76.05 ,$84.24 ,$106.47 ,$87.75 
Carle BroMenn Medical Center,8381646,MICROSPORIDIA SPECIES PCR,,87798,306,$98.00 ,$98.00 ,$29.40 ,$89.18 ,$68.60 ,$29.40 ,$63.70 ,$70.56 ,$89.18 ,$73.50 
Carle BroMenn Medical Center,8381694,"CPT-MENINGITIS PANEL, CSF",,87483,306,"$1,676.00 ","$1,676.00 ",$502.80 ,"$1,525.16 ","$1,173.20 ",$502.80 ,"$1,089.40 ","$1,206.72 ","$1,525.16 ","$1,257.00 "
Carle BroMenn Medical Center,8381698,CPT-INFLUENZA AND RSV PANEL,,87631,306,$806.00 ,$806.00 ,$241.80 ,$733.46 ,$564.20 ,$241.80 ,$523.90 ,$580.32 ,$733.46 ,$604.50 
Carle BroMenn Medical Center,8381699,"CPT-RSV AMPLIFIED PROBE, EACH ORGANISM",,87798,306,$227.00 ,$227.00 ,$68.10 ,$206.57 ,$158.90 ,$68.10 ,$147.55 ,$163.44 ,$206.57 ,$170.25 
Carle BroMenn Medical Center,8381728,"ASPERGILLUS AG, BAL, REF",,87305,306,$30.00 ,$30.00 ,$9.00 ,$27.30 ,$21.00 ,$9.00 ,$19.50 ,$21.60 ,$27.30 ,$22.50 
Carle BroMenn Medical Center,8381735,IADNA DNA/RNA RSV AMPLIFIED PROBE TECHNIQUE,,87634,306,$365.00 ,$365.00 ,$109.50 ,$332.15 ,$255.50 ,$109.50 ,$237.25 ,$262.80 ,$332.15 ,$273.75 
Carle BroMenn Medical Center,8381746,"MUMPS RNA, QUANT PCR, REF",,87798,306,$568.75 ,$568.75 ,$170.63 ,$517.56 ,$398.13 ,$170.63 ,$369.69 ,$409.50 ,$517.56 ,$426.56 
Carle BroMenn Medical Center,8381760,"FUNGITELL, S, REF",,87449,306,$82.00 ,$82.00 ,$24.60 ,$74.62 ,$57.40 ,$24.60 ,$53.30 ,$59.04 ,$74.62 ,$61.50 
Carle BroMenn Medical Center,8381763,"BETA STREP GROUP B BY PCR, PRENATAL",,87150,306,$287.00 ,$287.00 ,$86.10 ,$261.17 ,$200.90 ,$86.10 ,$186.55 ,$206.64 ,$261.17 ,$215.25 
Carle BroMenn Medical Center,8381764,"BETA STREP GROUP B BY PCR, LABOR & DELIVERY",,87653,306,$287.00 ,$287.00 ,$86.10 ,$261.17 ,$200.90 ,$86.10 ,$186.55 ,$206.64 ,$261.17 ,$215.25 
Carle BroMenn Medical Center,8381765,"T.VAGINALIS, AMPLIFIED RNA, REF",,87661,306,$79.00 ,$79.00 ,$23.70 ,$71.89 ,$55.30 ,$23.70 ,$51.35 ,$56.88 ,$71.89 ,$59.25 
Carle BroMenn Medical Center,8381766,"GI PATHOGEN, AMPLIFIED PROBE, REF",,87507,306,"$1,293.50 ","$1,293.50 ",$388.05 ,"$1,177.09 ",$905.45 ,$388.05 ,$840.78 ,$931.32 ,"$1,177.09 ",$970.13 
Carle BroMenn Medical Center,8381771,CRYPTOCOCCAL ANTIGEN OR TITER,,87899,306,$132.00 ,$132.00 ,$39.60 ,$120.12 ,$92.40 ,$39.60 ,$85.80 ,$95.04 ,$120.12 ,$99.00 
Carle BroMenn Medical Center,8381803,"ENTEROVIRUS PCR, REF",,87498,306,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8381857,"ZIKA VIRUS, PCR, SERUM, REF",,87662,306,$170.00 ,$170.00 ,$51.00 ,$154.70 ,$119.00 ,$51.00 ,$110.50 ,$122.40 ,$154.70 ,$127.50 
Carle BroMenn Medical Center,8381871,"BABESIA SPECIES, PCR, B, REF",,87798,306,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8381910,"MENINGITIS/ENCEPH PATHOGEN PANEL, PCR, CSF, REF",,87483,306,$585.00 ,$585.00 ,$175.50 ,$532.35 ,$409.50 ,$175.50 ,$380.25 ,$421.20 ,$532.35 ,$438.75 
Carle BroMenn Medical Center,8381933,HEP C VIRAL DNA DRUG RESISTANCE REF,,87902,306,$393.00 ,$393.00 ,$117.90 ,$357.63 ,$275.10 ,$117.90 ,$255.45 ,$282.96 ,$357.63 ,$294.75 
Carle BroMenn Medical Center,8381963,C. DIFFICILE TOXIN EIA,,87324,306,$76.05 ,$76.05 ,$22.82 ,$69.21 ,$53.24 ,$22.82 ,$49.43 ,$54.76 ,$69.21 ,$57.04 
Carle BroMenn Medical Center,8382089,LABORATORY TEST REF,,87901,306,$763.00 ,$763.00 ,$228.90 ,$694.33 ,$534.10 ,$228.90 ,$495.95 ,$549.36 ,$694.33 ,$572.25 
Carle BroMenn Medical Center,8382191,LABORATORY TEST REF,,87491,306,$107.25 ,$107.25 ,$32.18 ,$97.60 ,$75.08 ,$32.18 ,$69.71 ,$77.22 ,$97.60 ,$80.44 
Carle BroMenn Medical Center,8382215,"HIV1/2 AG/AB,4 W/RFL",,87389,306,$92.00 ,$92.00 ,$27.60 ,$83.72 ,$64.40 ,$27.60 ,$59.80 ,$66.24 ,$83.72 ,$69.00 
Carle BroMenn Medical Center,8382220,"CT/GC RNA,TMA,UROGEN",,87591,306,$107.25 ,$107.25 ,$32.18 ,$97.60 ,$75.08 ,$32.18 ,$69.71 ,$77.22 ,$97.60 ,$80.44 
Carle BroMenn Medical Center,8382227,OVA AND PARASITE,,87177,306,$58.50 ,$58.50 ,$17.55 ,$53.24 ,$40.95 ,$17.55 ,$38.03 ,$42.12 ,$53.24 ,$43.88 
Carle BroMenn Medical Center,8382304,COVID,,87635,306,$113.00 ,$113.00 ,$33.90 ,$102.83 ,$79.10 ,$33.90 ,$73.45 ,$81.36 ,$102.83 ,$84.75 
Carle BroMenn Medical Center,8382307,RSV Antigen,,87420,306,$136.00 ,$136.00 ,$40.80 ,$123.76 ,$95.20 ,$40.80 ,$88.40 ,$97.92 ,$123.76 ,$102.00 
Carle BroMenn Medical Center,8382327,STREP SCREEN,,87651,306,$97.50 ,$97.50 ,$29.25 ,$88.73 ,$68.25 ,$29.25 ,$63.38 ,$70.20 ,$88.73 ,$73.13 
Carle BroMenn Medical Center,8382348,"HC HPV DNA, HIGH RISK, REF",,87624,306,$175.50 ,$175.50 ,$52.65 ,$159.71 ,$122.85 ,$52.65 ,$114.08 ,$126.36 ,$159.71 ,$131.63 
Carle BroMenn Medical Center,8382378,"SARS-COV-2-RNA, PCR",,87635,306,$99.45 ,$99.45 ,$29.84 ,$90.50 ,$69.62 ,$29.84 ,$64.64 ,$71.60 ,$90.50 ,$74.59 
Carle BroMenn Medical Center,8382393,HCV GENOTYPE LIPA(R),,87902,306,$705.25 ,$705.25 ,$211.58 ,$641.78 ,$493.68 ,$211.58 ,$458.41 ,$507.78 ,$641.78 ,$528.94 
Carle BroMenn Medical Center,8382394,TVAG RNA QL TMA,,87661,306,$71.00 ,$71.00 ,$21.30 ,$64.61 ,$49.70 ,$21.30 ,$46.15 ,$51.12 ,$64.61 ,$53.25 
Carle BroMenn Medical Center,8382398,"HIV-1 RNA,QN,RT PCR",,87536,306,$331.50 ,$331.50 ,$99.45 ,$301.67 ,$232.05 ,$99.45 ,$215.48 ,$238.68 ,$301.67 ,$248.63 
Carle BroMenn Medical Center,8382468,HISTOPLASMA QN AG,,87385,306,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8382514,YERSINIA CULTURE,,87046,306,$110.00 ,$110.00 ,$33.00 ,$100.10 ,$77.00 ,$33.00 ,$71.50 ,$79.20 ,$100.10 ,$82.50 
Carle BroMenn Medical Center,8382515,PINWORM EXAMINATION,,87172,306,$140.00 ,$140.00 ,$42.00 ,$127.40 ,$98.00 ,$42.00 ,$91.00 ,$100.80 ,$127.40 ,$105.00 
Carle BroMenn Medical Center,8382518,H PYLORI AG QUAL-STOOL,,87338,306,$155.00 ,$155.00 ,$46.50 ,$141.05 ,$108.50 ,$46.50 ,$100.75 ,$111.60 ,$141.05 ,$116.25 
Carle BroMenn Medical Center,8382521,LEGIONELLA ANTIGEN URINE,,87899,306,$125.00 ,$125.00 ,$37.50 ,$113.75 ,$87.50 ,$37.50 ,$81.25 ,$90.00 ,$113.75 ,$93.75 
Carle BroMenn Medical Center,8382535,SARS-COV-2/FLU/RSV,,0241U,306,$440.00 ,$440.00 ,$132.00 ,$400.40 ,$308.00 ,$132.00 ,$286.00 ,$316.80 ,$400.40 ,$330.00 
Carle BroMenn Medical Center,8382538,LABORATORY TEST REF,,87901,306,$343.00 ,$343.00 ,$102.90 ,$312.13 ,$240.10 ,$102.90 ,$222.95 ,$246.96 ,$312.13 ,$257.25 
Carle BroMenn Medical Center,8382622,HIV AG AB,,87806,306,$103.00 ,$103.00 ,$30.90 ,$93.73 ,$72.10 ,$30.90 ,$66.95 ,$74.16 ,$93.73 ,$77.25 
Carle BroMenn Medical Center,8382625,HIV AG AB SINGLE RESULT,,87389,306,$116.00 ,$116.00 ,$34.80 ,$105.56 ,$81.20 ,$34.80 ,$75.40 ,$83.52 ,$105.56 ,$87.00 
Carle BroMenn Medical Center,8382719,ACL CGPCRY,,87798,306,$170.00 ,$170.00 ,$51.00 ,$154.70 ,$119.00 ,$51.00 ,$110.50 ,$122.40 ,$154.70 ,$127.50 
Carle BroMenn Medical Center,8382720,ACL CGPEDH,,87798,306,$170.00 ,$170.00 ,$51.00 ,$154.70 ,$119.00 ,$51.00 ,$110.50 ,$122.40 ,$154.70 ,$127.50 
Carle BroMenn Medical Center,8382721,ACL CGPRGRL,,87798,306,$170.00 ,$170.00 ,$51.00 ,$154.70 ,$119.00 ,$51.00 ,$110.50 ,$122.40 ,$154.70 ,$127.50 
Carle BroMenn Medical Center,8382738,HPB DNA LOW RISK,,87623,306,$173.00 ,$173.00 ,$51.90 ,$157.43 ,$121.10 ,$51.90 ,$112.45 ,$124.56 ,$157.43 ,$129.75 
Carle BroMenn Medical Center,8382751,SARS COVID 19 ANTIGEN,,87811,306,$82.00 ,$82.00 ,$24.60 ,$74.62 ,$57.40 ,$24.60 ,$53.30 ,$59.04 ,$74.62 ,$61.50 
Carle BroMenn Medical Center,8382884,1-3-B-3-GLUCAN IFI,,87449,306,$500.00 ,$500.00 ,$150.00 ,$455.00 ,$350.00 ,$150.00 ,$325.00 ,$360.00 ,$455.00 ,$375.00 
Carle BroMenn Medical Center,8382885,ASPERGILLUS AG EIA,,87305,306,$210.00 ,$210.00 ,$63.00 ,$191.10 ,$147.00 ,$63.00 ,$136.50 ,$151.20 ,$191.10 ,$157.50 
Carle BroMenn Medical Center,8382931,CONCENTRATION-INFECT AGNTS REF,,87015,306,$40.95 ,$40.95 ,$12.29 ,$37.26 ,$28.67 ,$12.29 ,$26.62 ,$29.48 ,$37.26 ,$30.71 
Carle BroMenn Medical Center,8382932,MICRO SPECIAL STAIN       -REF,,87207,306,$36.40 ,$36.40 ,$10.92 ,$33.12 ,$25.48 ,$10.92 ,$23.66 ,$26.21 ,$33.12 ,$27.30 
Carle BroMenn Medical Center,8383187,SARS-COV-2/FLU,,0240U,306,$113.00 ,$113.00 ,$33.90 ,$102.83 ,$79.10 ,$33.90 ,$73.45 ,$81.36 ,$102.83 ,$84.75 
Carle BroMenn Medical Center,8383587,LABORATORY TEST REF,,87904,306,$146.00 ,$146.00 ,$43.80 ,$132.86 ,$102.20 ,$43.80 ,$94.90 ,$105.12 ,$132.86 ,$109.50 
Carle BroMenn Medical Center,8383588,LABORATORY TEST REF,,87903,306,$793.00 ,$793.00 ,$237.90 ,$721.63 ,$555.10 ,$237.90 ,$515.45 ,$570.96 ,$721.63 ,$594.75 
Carle BroMenn Medical Center,8384434,ASPERGILLUS ANTIGEN        REF,,87305,306,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8384447,LAB SERVICE,,87449,306,$214.50 ,$214.50 ,$64.35 ,$195.20 ,$150.15 ,$64.35 ,$139.43 ,$154.44 ,$195.20 ,$160.88 
Carle BroMenn Medical Center,8384613,SENSITIVITY STUDIES REF,,87184,306,$81.00 ,$81.00 ,$24.30 ,$73.71 ,$56.70 ,$24.30 ,$52.65 ,$58.32 ,$73.71 ,$60.75 
Carle BroMenn Medical Center,8384615,SENSITIVITY STUDIES     REF,,87186,306,$146.00 ,$146.00 ,$43.80 ,$132.86 ,$102.20 ,$43.80 ,$94.90 ,$105.12 ,$132.86 ,$109.50 
Carle BroMenn Medical Center,8385535,LABORATORY TEST REF,,87900,306,$123.00 ,$123.00 ,$36.90 ,$111.93 ,$86.10 ,$36.90 ,$79.95 ,$88.56 ,$111.93 ,$92.25 
Carle BroMenn Medical Center,8385550,"SMEAR, MALRIA/BLOOD PARASITE",,87207,306,$306.00 ,$306.00 ,$91.80 ,$278.46 ,$214.20 ,$91.80 ,$198.90 ,$220.32 ,$278.46 ,$229.50 
Carle BroMenn Medical Center,8385556,LABORATORY TEST REF,,87900,306,$123.00 ,$123.00 ,$36.90 ,$111.93 ,$86.10 ,$36.90 ,$79.95 ,$88.56 ,$111.93 ,$92.25 
Carle BroMenn Medical Center,8385560,INFECTIOUS AGENT DETECTION,,87529,306,$334.00 ,$334.00 ,$100.20 ,$303.94 ,$233.80 ,$100.20 ,$217.10 ,$240.48 ,$303.94 ,$250.50 
Carle BroMenn Medical Center,8386076,"VIRUS ISOLTN,SHELL VIALMTHD RF",,87254,306,$89.00 ,$89.00 ,$26.70 ,$80.99 ,$62.30 ,$26.70 ,$57.85 ,$64.08 ,$80.99 ,$66.75 
Carle BroMenn Medical Center,8386287,HEPATITIS B SURFACE ANTIGEN,,87340,306,$63.05 ,$63.05 ,$18.92 ,$57.38 ,$44.14 ,$18.92 ,$40.98 ,$45.40 ,$57.38 ,$47.29 
Carle BroMenn Medical Center,8386308,INFECTIOUS AGNT ANTIGN FLU A/B,,87804,306,$101.00 ,$101.00 ,$30.30 ,$91.91 ,$70.70 ,$30.30 ,$65.65 ,$72.72 ,$91.91 ,$75.75 
Carle BroMenn Medical Center,8386540,SUSCEPTIBILTY STUDY EA AGNT RF,,87188,306,$25.00 ,$25.00 ,$7.50 ,$22.75 ,$17.50 ,$7.50 ,$16.25 ,$18.00 ,$22.75 ,$18.75 
Carle BroMenn Medical Center,8386683,HEPATITIS BE ANTIGEN       REF,,87350,306,$81.25 ,$81.25 ,$24.38 ,$73.94 ,$56.88 ,$24.38 ,$52.81 ,$58.50 ,$73.94 ,$60.94 
Carle BroMenn Medical Center,8387001,"SUSCEPTIBILITY, DISK DIFFUSION",,87184,306,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8387003,"FUNGAL IDENTIFICATION, YEAST",,87106,306,$63.05 ,$63.05 ,$18.92 ,$57.38 ,$44.14 ,$18.92 ,$40.98 ,$45.40 ,$57.38 ,$47.29 
Carle BroMenn Medical Center,8387006,"SUSCEPTIBILTY,DISK DIFFUSN REF",,87184,306,$121.00 ,$121.00 ,$36.30 ,$110.11 ,$84.70 ,$36.30 ,$78.65 ,$87.12 ,$110.11 ,$90.75 
Carle BroMenn Medical Center,8387007,SENSITIVITY STUDIES        REF,,87186,306,$151.00 ,$151.00 ,$45.30 ,$137.41 ,$105.70 ,$45.30 ,$98.15 ,$108.72 ,$137.41 ,$113.25 
Carle BroMenn Medical Center,8387010,"TISSUE EXAM, KOH MOUNT",,87220,306,$57.20 ,$57.20 ,$17.16 ,$52.05 ,$40.04 ,$17.16 ,$37.18 ,$41.18 ,$52.05 ,$42.90 
Carle BroMenn Medical Center,8387015,"CONCENTRATION, CYCLOSPORA    REF",,87015,306,$13.00 ,$13.00 ,$3.90 ,$11.83 ,$9.10 ,$3.90 ,$8.45 ,$9.36 ,$11.83 ,$9.75 
Carle BroMenn Medical Center,8387017,"CONCENTRATION, INFECT AGENTS",,87015,306,$86.00 ,$86.00 ,$25.80 ,$78.26 ,$60.20 ,$25.80 ,$55.90 ,$61.92 ,$78.26 ,$64.50 
Carle BroMenn Medical Center,8387060,UPPER RESPIRATORY CULTURE,,87070,306,$74.75 ,$74.75 ,$22.43 ,$68.02 ,$52.33 ,$22.43 ,$48.59 ,$53.82 ,$68.02 ,$56.06 
Carle BroMenn Medical Center,8387066,BACT CULT QUANT AEROBIC W/ISO,,87071,306,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8387067,BACT CULT QUANT ANA W/ISO,,87073,306,$132.00 ,$132.00 ,$39.60 ,$120.12 ,$92.40 ,$39.60 ,$85.80 ,$95.04 ,$120.12 ,$99.00 
Carle BroMenn Medical Center,8387068,BACT CULT DEF ID AEROBIC,,87077,306,$155.00 ,$155.00 ,$46.50 ,$141.05 ,$108.50 ,$46.50 ,$100.75 ,$111.60 ,$141.05 ,$116.25 
Carle BroMenn Medical Center,8387070,BACT CULT ISOL/PRESMPTV ID OTH,,87070,306,$74.75 ,$74.75 ,$22.43 ,$68.02 ,$52.33 ,$22.43 ,$48.59 ,$53.82 ,$68.02 ,$56.06 
Carle BroMenn Medical Center,8387071,ENVIRONMENTAL CULT/BACT,,87070,306,$74.75 ,$74.75 ,$22.43 ,$68.02 ,$52.33 ,$22.43 ,$48.59 ,$53.82 ,$68.02 ,$56.06 
Carle BroMenn Medical Center,8387077,BACT CULT DEF ID ANAEROBIC,,87076,306,$135.00 ,$135.00 ,$40.50 ,$122.85 ,$94.50 ,$40.50 ,$87.75 ,$97.20 ,$122.85 ,$101.25 
Carle BroMenn Medical Center,8387081,BACT CULTURE SCREENING ONLY,,87081,306,$53.95 ,$53.95 ,$16.19 ,$49.09 ,$37.77 ,$16.19 ,$35.07 ,$38.84 ,$49.09 ,$40.46 
Carle BroMenn Medical Center,8387084,BACT CULTURE SCREENNG ONLY REF,,87081,306,$97.00 ,$97.00 ,$29.10 ,$88.27 ,$67.90 ,$29.10 ,$63.05 ,$69.84 ,$88.27 ,$72.75 
Carle BroMenn Medical Center,8387085,BACT CULTURE SCREENING ONLY,,87081,306,$113.00 ,$113.00 ,$33.90 ,$102.83 ,$79.10 ,$33.90 ,$73.45 ,$81.36 ,$102.83 ,$84.75 
Carle BroMenn Medical Center,8387086,UREA TEST FOR H. PYLORI,,87077,306,$98.00 ,$98.00 ,$29.40 ,$89.18 ,$68.60 ,$29.40 ,$63.70 ,$70.56 ,$89.18 ,$73.50 
Carle BroMenn Medical Center,8387087,VRE  SCREEN,,87081,306,$95.00 ,$95.00 ,$28.50 ,$86.45 ,$66.50 ,$28.50 ,$61.75 ,$68.40 ,$86.45 ,$71.25 
Carle BroMenn Medical Center,8387098,"FUNGUS CULT, DERMAL",,87101,306,$91.00 ,$91.00 ,$27.30 ,$82.81 ,$63.70 ,$27.30 ,$59.15 ,$65.52 ,$82.81 ,$68.25 
Carle BroMenn Medical Center,8387107,"FUNGAL IDENTIFICATION, MOLD",,87107,306,$135.00 ,$135.00 ,$40.50 ,$122.85 ,$94.50 ,$40.50 ,$87.75 ,$97.20 ,$122.85 ,$101.25 
Carle BroMenn Medical Center,8387109,MYCOPLASMA CULTURE         REF,,87109,306,$19.00 ,$19.00 ,$5.70 ,$17.29 ,$13.30 ,$5.70 ,$12.35 ,$13.68 ,$17.29 ,$14.25 
Carle BroMenn Medical Center,8387120,SENSITIVITY STUDIES,,87186,306,$58.50 ,$58.50 ,$17.55 ,$53.24 ,$40.95 ,$17.55 ,$38.03 ,$42.12 ,$53.24 ,$43.88 
Carle BroMenn Medical Center,8387139,CULTURE TYPING; IMMUNOFL REF,,87140,306,$50.40 ,$50.40 ,$15.12 ,$45.86 ,$35.28 ,$15.12 ,$32.76 ,$36.29 ,$45.86 ,$37.80 
Carle BroMenn Medical Center,8387143,AFB CHROMATOGRAPHY REF,,87143,306,$181.00 ,$181.00 ,$54.30 ,$164.71 ,$126.70 ,$54.30 ,$117.65 ,$130.32 ,$164.71 ,$135.75 
Carle BroMenn Medical Center,8387149,CULTURE IMMUNOFL TYPING    REF,,87140,306,$36.00 ,$36.00 ,$10.80 ,$32.76 ,$25.20 ,$10.80 ,$23.40 ,$25.92 ,$32.76 ,$27.00 
Carle BroMenn Medical Center,8387152,CULTURE TYPE ID BY PFGE,,87152,306,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8387155,CMV RAPID CULTURE          REF,,87254,306,$23.00 ,$23.00 ,$6.90 ,$20.93 ,$16.10 ,$6.90 ,$14.95 ,$16.56 ,$20.93 ,$17.25 
Carle BroMenn Medical Center,8387168,MACROSCOPIC EXAM  -ARTHROPOD,,87168,306,$43.00 ,$43.00 ,$12.90 ,$39.13 ,$30.10 ,$12.90 ,$27.95 ,$30.96 ,$39.13 ,$32.25 
Carle BroMenn Medical Center,8387172,PIMWORM EXAM,,87172,306,$41.00 ,$41.00 ,$12.30 ,$37.31 ,$28.70 ,$12.30 ,$26.65 ,$29.52 ,$37.31 ,$30.75 
Carle BroMenn Medical Center,8387177,OVA AND PARASITE EXAM,,87177,306,$110.00 ,$110.00 ,$33.00 ,$100.10 ,$77.00 ,$33.00 ,$71.50 ,$79.20 ,$100.10 ,$82.50 
Carle BroMenn Medical Center,8387178,"AFB ID, DNA, PROBE TECH",,87149,306,$167.00 ,$167.00 ,$50.10 ,$151.97 ,$116.90 ,$50.10 ,$108.55 ,$120.24 ,$151.97 ,$125.25 
Carle BroMenn Medical Center,8387179,BETA LACTAMASE DETECTION,,87185,306,$31.85 ,$31.85 ,$9.56 ,$28.98 ,$22.30 ,$9.56 ,$20.70 ,$22.93 ,$28.98 ,$23.89 
Carle BroMenn Medical Center,8387183,MIN BACTERIACIDAL LEVEL,,87187,306,$69.00 ,$69.00 ,$20.70 ,$62.79 ,$48.30 ,$20.70 ,$44.85 ,$49.68 ,$62.79 ,$51.75 
Carle BroMenn Medical Center,8387186,"SUSCEP;MIC,EA PLATE REF",,87186,306,$202.00 ,$202.00 ,$60.60 ,$183.82 ,$141.40 ,$60.60 ,$131.30 ,$145.44 ,$183.82 ,$151.50 
Carle BroMenn Medical Center,8387192,LABORATORY TEST REF,,87900,306,$123.00 ,$123.00 ,$36.90 ,$111.93 ,$86.10 ,$36.90 ,$79.95 ,$88.56 ,$111.93 ,$92.25 
Carle BroMenn Medical Center,8387198,"VIRS ISOL,DEF IDBYNEUTRALZ REF",,87253,306,$442.00 ,$442.00 ,$132.60 ,$402.22 ,$309.40 ,$132.60 ,$287.30 ,$318.24 ,$402.22 ,$331.50 
Carle BroMenn Medical Center,8387209,SMEAR -COMPLEX STAIN,,87209,306,$170.00 ,$170.00 ,$51.00 ,$154.70 ,$119.00 ,$51.00 ,$110.50 ,$122.40 ,$154.70 ,$127.50 
Carle BroMenn Medical Center,8387211,MICRO SPECIAL STAIN,,87207,306,$299.00 ,$299.00 ,$89.70 ,$272.09 ,$209.30 ,$89.70 ,$194.35 ,$215.28 ,$272.09 ,$224.25 
Carle BroMenn Medical Center,8387212,"WET MOUNT, PRIMARY SOURCE",,87210,306,$91.00 ,$91.00 ,$27.30 ,$82.81 ,$63.70 ,$27.30 ,$59.15 ,$65.52 ,$82.81 ,$68.25 
Carle BroMenn Medical Center,8387251,"TISSUE CULTURE, VIRUS ISOL REF",,87252,306,$143.00 ,$143.00 ,$42.90 ,$130.13 ,$100.10 ,$42.90 ,$92.95 ,$102.96 ,$130.13 ,$107.25 
Carle BroMenn Medical Center,8387252,CMV CONVENTIONAL CULTURE   REF,,87252,306,$111.00 ,$111.00 ,$33.30 ,$101.01 ,$77.70 ,$33.30 ,$72.15 ,$79.92 ,$101.01 ,$83.25 
Carle BroMenn Medical Center,8387255,HSV CULT ID W/IMMUNOSTAIN,,87254,306,$102.00 ,$102.00 ,$30.60 ,$92.82 ,$71.40 ,$30.60 ,$66.30 ,$73.44 ,$92.82 ,$76.50 
Carle BroMenn Medical Center,8387271,CYTOMEGALOVIRUS DFA        REF,,87271,306,$94.00 ,$94.00 ,$28.20 ,$85.54 ,$65.80 ,$28.20 ,$61.10 ,$67.68 ,$85.54 ,$70.50 
Carle BroMenn Medical Center,8387272,CRYPTOSPORIDIUM ANTIGEN REF,,87272,306,$88.00 ,$88.00 ,$26.40 ,$80.08 ,$61.60 ,$26.40 ,$57.20 ,$63.36 ,$80.08 ,$66.00 
Carle BroMenn Medical Center,8387279,PARAINFLUENZA ANTIGEN TEST REF,,87279,306,$66.00 ,$66.00 ,$19.80 ,$60.06 ,$46.20 ,$19.80 ,$42.90 ,$47.52 ,$60.06 ,$49.50 
Carle BroMenn Medical Center,8387281,PNEUMOCYSTIS CARINII IMMFL TCH,,87281,306,$85.00 ,$85.00 ,$25.50 ,$77.35 ,$59.50 ,$25.50 ,$55.25 ,$61.20 ,$77.35 ,$63.75 
Carle BroMenn Medical Center,8387324,CLOSTRIDIUM DIFFICILE TOXIN A,,87324,306,$129.00 ,$129.00 ,$38.70 ,$117.39 ,$90.30 ,$38.70 ,$83.85 ,$92.88 ,$117.39 ,$96.75 
Carle BroMenn Medical Center,8387327,CRYPTOCOCCUS AG SCRN SERUM REF,,87327,306,$8.00 ,$8.00 ,$2.40 ,$7.28 ,$5.60 ,$2.40 ,$5.20 ,$5.76 ,$7.28 ,$6.00 
Carle BroMenn Medical Center,8387328,CRYPTOSPORIDIUM ANTIGEN,,87328,306,$129.00 ,$129.00 ,$38.70 ,$117.39 ,$90.30 ,$38.70 ,$83.85 ,$92.88 ,$117.39 ,$96.75 
Carle BroMenn Medical Center,8387329,GIARDIA ANTIGEN,,87329,306,$113.00 ,$113.00 ,$33.90 ,$102.83 ,$79.10 ,$33.90 ,$73.45 ,$81.36 ,$102.83 ,$84.75 
Carle BroMenn Medical Center,8387338,"H.PYLORI ANTIGEN, STOOL",,87338,306,$139.00 ,$139.00 ,$41.70 ,$126.49 ,$97.30 ,$41.70 ,$90.35 ,$100.08 ,$126.49 ,$104.25 
Carle BroMenn Medical Center,8387340,HBSAG CONFRM BY IMMUNOASSY REF,,87340,306,$48.00 ,$48.00 ,$14.40 ,$43.68 ,$33.60 ,$14.40 ,$31.20 ,$34.56 ,$43.68 ,$36.00 
Carle BroMenn Medical Center,8387341,HBSAG CONFRM BY NEUTRALIZTN RF,,87341,306,$45.00 ,$45.00 ,$13.50 ,$40.95 ,$31.50 ,$13.50 ,$29.25 ,$32.40 ,$40.95 ,$33.75 
Carle BroMenn Medical Center,8387350,DARK FIELD EXAM,,87164,306,$85.00 ,$85.00 ,$25.50 ,$77.35 ,$59.50 ,$25.50 ,$55.25 ,$61.20 ,$77.35 ,$63.75 
Carle BroMenn Medical Center,8387385,HISTOPLASMA ANTIGEN        REF,,87385,306,$113.75 ,$113.75 ,$34.13 ,$103.51 ,$79.63 ,$34.13 ,$73.94 ,$81.90 ,$103.51 ,$85.31 
Carle BroMenn Medical Center,8387390,LABORATORY TEST REF,,87390,306,$120.00 ,$120.00 ,$36.00 ,$109.20 ,$84.00 ,$36.00 ,$78.00 ,$86.40 ,$109.20 ,$90.00 
Carle BroMenn Medical Center,8387420,RESPIRATORY SYNCYTIAL VIRUS,,87807,306,$81.25 ,$81.25 ,$24.38 ,$73.94 ,$56.88 ,$24.38 ,$52.81 ,$58.50 ,$73.94 ,$60.94 
Carle BroMenn Medical Center,8387447,LAB SERVICE,,87449,306,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8387449,LAB SERVICE,,87899,306,$28.60 ,$28.60 ,$8.58 ,$26.03 ,$20.02 ,$8.58 ,$18.59 ,$20.59 ,$26.03 ,$21.45 
Carle BroMenn Medical Center,8387451,GIARDIA/CRYPTOSPORIDIUM SCREEN,,87451,306,$101.00 ,$101.00 ,$30.30 ,$91.91 ,$70.70 ,$30.30 ,$65.65 ,$72.72 ,$91.91 ,$75.75 
Carle BroMenn Medical Center,8387486,INFCT AGNT DETECTN DIR PRBE RF,,87486,306,$160.00 ,$160.00 ,$48.00 ,$145.60 ,$112.00 ,$48.00 ,$104.00 ,$115.20 ,$145.60 ,$120.00 
Carle BroMenn Medical Center,8387491,LABORATORY TEST,,87491,306,$93.60 ,$93.60 ,$28.08 ,$85.18 ,$65.52 ,$28.08 ,$60.84 ,$67.39 ,$85.18 ,$70.20 
Carle BroMenn Medical Center,8387493,C DIFF TOXIN BY PCR,,87493,306,$306.00 ,$306.00 ,$91.80 ,$278.46 ,$214.20 ,$91.80 ,$198.90 ,$220.32 ,$278.46 ,$229.50 
Carle BroMenn Medical Center,8387497,"CMV DNA QUANT, PCR         REF",,87497,306,$612.00 ,$612.00 ,$183.60 ,$556.92 ,$428.40 ,$183.60 ,$397.80 ,$440.64 ,$556.92 ,$459.00 
Carle BroMenn Medical Center,8387502,HUMAN INFLUENZA A,,87502,306,$321.00 ,$321.00 ,$96.30 ,$292.11 ,$224.70 ,$96.30 ,$208.65 ,$231.12 ,$292.11 ,$240.75 
Carle BroMenn Medical Center,8387503,FLU A SUBTYPES,,87503,306,$54.00 ,$54.00 ,$16.20 ,$49.14 ,$37.80 ,$16.20 ,$35.10 ,$38.88 ,$49.14 ,$40.50 
Carle BroMenn Medical Center,8387517,HEPATITIS B VIRUS-DNA QUANT RF,,87517,306,$232.00 ,$232.00 ,$69.60 ,$211.12 ,$162.40 ,$69.60 ,$150.80 ,$167.04 ,$211.12 ,$174.00 
Carle BroMenn Medical Center,8387521,"HCV RNA BY PCR, QUAL       REF",,87521,306,$90.00 ,$90.00 ,$27.00 ,$81.90 ,$63.00 ,$27.00 ,$58.50 ,$64.80 ,$81.90 ,$67.50 
Carle BroMenn Medical Center,8387522,HCV RNA BY PCR QUANT       REF,,87522,306,$260.00 ,$260.00 ,$78.00 ,$236.60 ,$182.00 ,$78.00 ,$169.00 ,$187.20 ,$236.60 ,$195.00 
Carle BroMenn Medical Center,8387529,HSV AMPLIFIED PROBE   REF,,87529,306,$214.50 ,$214.50 ,$64.35 ,$195.20 ,$150.15 ,$64.35 ,$139.43 ,$154.44 ,$195.20 ,$160.88 
Carle BroMenn Medical Center,8387530,HSV DNA QUANTIFICATION     REF,,87530,306,$170.00 ,$170.00 ,$51.00 ,$154.70 ,$119.00 ,$51.00 ,$110.50 ,$122.40 ,$154.70 ,$127.50 
Carle BroMenn Medical Center,8387535,LABORATORY TEST REF,,87535,306,$204.00 ,$204.00 ,$61.20 ,$185.64 ,$142.80 ,$61.20 ,$132.60 ,$146.88 ,$185.64 ,$153.00 
Carle BroMenn Medical Center,8387536,LABORATORY TEST REF,,87536,306,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8387556,M.TUBERCULOSIS AMPL PROBE  REF,,87556,306,$109.00 ,$109.00 ,$32.70 ,$99.19 ,$76.30 ,$32.70 ,$70.85 ,$78.48 ,$99.19 ,$81.75 
Carle BroMenn Medical Center,8387581,MYCOPLSMA PNEUMNIA AMP PRBE RF,,87581,306,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8387591,LABORATORY TEST,,87591,306,$93.60 ,$93.60 ,$28.08 ,$85.18 ,$65.52 ,$28.08 ,$60.84 ,$67.39 ,$85.18 ,$70.20 
Carle BroMenn Medical Center,8387633,LAB/PATH TESTING,,87633,306,"$1,293.50 ","$1,293.50 ",$388.05 ,"$1,177.09 ",$905.45 ,$388.05 ,$840.78 ,$931.32 ,"$1,177.09 ",$970.13 
Carle BroMenn Medical Center,8387640,STAPH AUREUS AMP PROBE,,87640,306,$287.00 ,$287.00 ,$86.10 ,$261.17 ,$200.90 ,$86.10 ,$186.55 ,$206.64 ,$261.17 ,$215.25 
Carle BroMenn Medical Center,8387641,STAPH AUREUS-METHICILLN RESIST,,87641,306,$287.00 ,$287.00 ,$86.10 ,$261.17 ,$200.90 ,$86.10 ,$186.55 ,$206.64 ,$261.17 ,$215.25 
Carle BroMenn Medical Center,8387801,INF AGNT AG NUCL ACID MULT ORG AMP PROB REF,,87801,306,$152.75 ,$152.75 ,$45.83 ,$139.00 ,$106.93 ,$45.83 ,$99.29 ,$109.98 ,$139.00 ,$114.56 
Carle BroMenn Medical Center,8387880,"STREPTOCOCCUS, GROUP A",,87880,306,$74.75 ,$74.75 ,$22.43 ,$68.02 ,$52.33 ,$22.43 ,$48.59 ,$53.82 ,$68.02 ,$56.06 
Carle BroMenn Medical Center,8387901,LABORATORY TEST REF,,87901,306,$763.00 ,$763.00 ,$228.90 ,$694.33 ,$534.10 ,$228.90 ,$495.95 ,$549.36 ,$694.33 ,$572.25 
Carle BroMenn Medical Center,8387902,HEPATITS C VIRS RNA GENOTYP RF,,87902,306,$221.00 ,$221.00 ,$66.30 ,$201.11 ,$154.70 ,$66.30 ,$143.65 ,$159.12 ,$201.11 ,$165.75 
Carle BroMenn Medical Center,8388144,GENET VIRUS ISO HSV REF,,87255,306,$172.25 ,$172.25 ,$51.68 ,$156.75 ,$120.58 ,$51.68 ,$111.96 ,$124.02 ,$156.75 ,$129.19 
Carle BroMenn Medical Center,8389321,"SEMEN ANAL, SPERM DETECTION",,89321,306,$87.75 ,$87.75 ,$26.33 ,$79.85 ,$61.43 ,$26.33 ,$57.04 ,$63.18 ,$79.85 ,$65.81 
Carle BroMenn Medical Center,8389401,"HIV-1 RNA QUANT, BY PCR",,87536,306,$312.00 ,$312.00 ,$93.60 ,$283.92 ,$218.40 ,$93.60 ,$202.80 ,$224.64 ,$283.92 ,$234.00 
Carle BroMenn Medical Center,8396935,FUNGAL SCRAPING & INTERP,,87106,306,$95.00 ,$95.00 ,$28.50 ,$86.45 ,$66.50 ,$28.50 ,$61.75 ,$68.40 ,$86.45 ,$71.25 
Carle BroMenn Medical Center,8382639,URINE FOR EOSINOPHILS,,85999,307,$71.00 ,$71.00 ,$21.30 ,$64.61 ,$49.70 ,$21.30 ,$46.15 ,$51.12 ,$64.61 ,$53.25 
Carle BroMenn Medical Center,8289335,CRYOPRESERVE TESTICULAR TISS,,89335,309,$420.00 ,$420.00 ,$126.00 ,$382.20 ,$294.00 ,$126.00 ,$273.00 ,$302.40 ,$382.20 ,$315.00 
Carle BroMenn Medical Center,8289342,STORAGE/YEAR; EMBRYO(S),,89342,309,$385.00 ,$385.00 ,$115.50 ,$350.35 ,$269.50 ,$115.50 ,$250.25 ,$277.20 ,$350.35 ,$288.75 
Carle BroMenn Medical Center,8289344,STORAGE/YEAR; REPROD TISSUE,,89344,309,$385.00 ,$385.00 ,$115.50 ,$350.35 ,$269.50 ,$115.50 ,$250.25 ,$277.20 ,$350.35 ,$288.75 
Carle BroMenn Medical Center,8289346,STORAGE/YEAR; OOCYTE,,89346,309,$385.00 ,$385.00 ,$115.50 ,$350.35 ,$269.50 ,$115.50 ,$250.25 ,$277.20 ,$350.35 ,$288.75 
Carle BroMenn Medical Center,8289352,THAWING CRYOPRESRVED; EMBRYO,,89352,309,$450.00 ,$450.00 ,$135.00 ,$409.50 ,$315.00 ,$135.00 ,$292.50 ,$324.00 ,$409.50 ,$337.50 
Carle BroMenn Medical Center,8380627,"CRYSTALS, TISSUE",,89060,309,$98.00 ,$98.00 ,$29.40 ,$89.18 ,$68.60 ,$29.40 ,$63.70 ,$70.56 ,$89.18 ,$73.50 
Carle BroMenn Medical Center,8389052,"CELL COUNT, MISC BODY FLUID",,89050,309,$51.35 ,$51.35 ,$15.41 ,$46.73 ,$35.95 ,$15.41 ,$33.38 ,$36.97 ,$46.73 ,$38.51 
Carle BroMenn Medical Center,8389060,CRYSTAL ID BY LIGHT MICROSCOPY,,89060,309,$43.55 ,$43.55 ,$13.07 ,$39.63 ,$30.49 ,$13.07 ,$28.31 ,$31.36 ,$39.63 ,$32.66 
Carle BroMenn Medical Center,8108001,"CYTOPATHOLOGY, CONCEN TECH",,88108,310,$146.00 ,$146.00 ,$43.80 ,$132.86 ,$102.20 ,$43.80 ,$94.90 ,$105.12 ,$132.86 ,$109.50 
Carle BroMenn Medical Center,8108002,EVAL ASPIRATE INTERP & REPORT,,88173,310,$221.00 ,$221.00 ,$66.30 ,$201.11 ,$154.70 ,$66.30 ,$143.65 ,$159.12 ,$201.11 ,$165.75 
Carle BroMenn Medical Center,8210111,WET MOUNTS/ W PREPARATIONS,,Q0111,310,$65.00 ,$65.00 ,$19.50 ,$59.15 ,$45.50 ,$19.50 ,$42.25 ,$46.80 ,$59.15 ,$48.75 
Carle BroMenn Medical Center,8289250,CULTURE/FERTILIZATION OF OOCYTE,,89250,310,$450.00 ,$450.00 ,$135.00 ,$409.50 ,$315.00 ,$135.00 ,$292.50 ,$324.00 ,$409.50 ,$337.50 
Carle BroMenn Medical Center,8289253,EMBRYO HATCHING,,89253,310,$450.00 ,$450.00 ,$135.00 ,$409.50 ,$315.00 ,$135.00 ,$292.50 ,$324.00 ,$409.50 ,$337.50 
Carle BroMenn Medical Center,8289254,OOCYTE IDENTIFICATION,,89254,310,$350.00 ,$350.00 ,$105.00 ,$318.50 ,$245.00 ,$105.00 ,$227.50 ,$252.00 ,$318.50 ,$262.50 
Carle BroMenn Medical Center,8289255,PREPARE EMBRYO FOR TRANSFER,,89255,310,"$1,190.00 ","$1,190.00 ",$357.00 ,"$1,082.90 ",$833.00 ,$357.00 ,$773.50 ,$856.80 ,"$1,082.90 ",$892.50 
Carle BroMenn Medical Center,8289257,SPERM IDENTIFICATION,,89257,310,$600.00 ,$600.00 ,$180.00 ,$546.00 ,$420.00 ,$180.00 ,$390.00 ,$432.00 ,$546.00 ,$450.00 
Carle BroMenn Medical Center,8289258,"CRYOPRESERVATION, EMBRYO",,89258,310,$600.00 ,$600.00 ,$180.00 ,$546.00 ,$420.00 ,$180.00 ,$390.00 ,$432.00 ,$546.00 ,$450.00 
Carle BroMenn Medical Center,8289264,SPERM TISSUE IDENTIFY,,89264,310,$670.00 ,$670.00 ,$201.00 ,$609.70 ,$469.00 ,$201.00 ,$435.50 ,$482.40 ,$609.70 ,$502.50 
Carle BroMenn Medical Center,8289268,INSEMINATION OF OOCYTES,,89268,310,$450.00 ,$450.00 ,$135.00 ,$409.50 ,$315.00 ,$135.00 ,$292.50 ,$324.00 ,$409.50 ,$337.50 
Carle BroMenn Medical Center,8289272,EXTENDED CULTURE OF OOCYTES,,89272,310,$450.00 ,$450.00 ,$135.00 ,$409.50 ,$315.00 ,$135.00 ,$292.50 ,$324.00 ,$409.50 ,$337.50 
Carle BroMenn Medical Center,8289280,"ASSIST OOCYTE FERTILIZATION, MICROTECHNIQUE, LESS/EQUAL 10 OOCYTES",,89280,310,"$1,120.00 ","$1,120.00 ",$336.00 ,"$1,019.20 ",$784.00 ,$336.00 ,$728.00 ,$806.40 ,"$1,019.20 ",$840.00 
Carle BroMenn Medical Center,8289281,"ASSIST OOCYTE FERTILIZATION, MICROTECHNIQUE, GREATER 10 OOCYTES",,89281,310,"$1,400.00 ","$1,400.00 ",$420.00 ,"$1,274.00 ",$980.00 ,$420.00 ,$910.00 ,"$1,008.00 ","$1,274.00 ","$1,050.00 "
Carle BroMenn Medical Center,8289290,"BIOPSY, OOCYTE POLAR BODY LESS EQUAL 5 EMBRYO",,89290,310,"$1,190.00 ","$1,190.00 ",$357.00 ,"$1,082.90 ",$833.00 ,$357.00 ,$773.50 ,$856.80 ,"$1,082.90 ",$892.50 
Carle BroMenn Medical Center,8289337,CRYOPRESERVATION MATURE OOCYTE(S),,89337,310,$600.00 ,$600.00 ,$180.00 ,$546.00 ,$420.00 ,$180.00 ,$390.00 ,$432.00 ,$546.00 ,$450.00 
Carle BroMenn Medical Center,8289398,UNLISTED REPRODUCTIVE MEDICINE LAB PROCEDURE,,89398,310,$600.00 ,$600.00 ,$180.00 ,$546.00 ,$420.00 ,$180.00 ,$390.00 ,$432.00 ,$546.00 ,$450.00 
Carle BroMenn Medical Center,8380287,LAB/PATH TESTING,,81382,310,$258.00 ,$258.00 ,$77.40 ,$234.78 ,$180.60 ,$77.40 ,$167.70 ,$185.76 ,$234.78 ,$193.50 
Carle BroMenn Medical Center,8380288,LAB/PATH TESTING,,81401,310,$258.00 ,$258.00 ,$77.40 ,$234.78 ,$180.60 ,$77.40 ,$167.70 ,$185.76 ,$234.78 ,$193.50 
Carle BroMenn Medical Center,8380289,LAB/PATH TESTING,,81479,310,$9.00 ,$9.00 ,$2.70 ,$8.19 ,$6.30 ,$2.70 ,$5.85 ,$6.48 ,$8.19 ,$6.75 
Carle BroMenn Medical Center,8380290,LAB/PATH TESTING,,81335,310,$312.00 ,$312.00 ,$93.60 ,$283.92 ,$218.40 ,$93.60 ,$202.80 ,$224.64 ,$283.92 ,$234.00 
Carle BroMenn Medical Center,8380291,LAB/PATH TESTING,,81240,310,$617.00 ,$617.00 ,$185.10 ,$561.47 ,$431.90 ,$185.10 ,$401.05 ,$444.24 ,$561.47 ,$462.75 
Carle BroMenn Medical Center,8380292,LAB/PATH TESTING,,81241,310,$403.00 ,$403.00 ,$120.90 ,$366.73 ,$282.10 ,$120.90 ,$261.95 ,$290.16 ,$366.73 ,$302.25 
Carle BroMenn Medical Center,8380293,LAB/PATH TESTING,,81220,310,$334.00 ,$334.00 ,$100.20 ,$303.94 ,$233.80 ,$100.20 ,$217.10 ,$240.48 ,$303.94 ,$250.50 
Carle BroMenn Medical Center,8380294,LAB/PATH TESTING,,81221,310,$170.00 ,$170.00 ,$51.00 ,$154.70 ,$119.00 ,$51.00 ,$110.50 ,$122.40 ,$154.70 ,$127.50 
Carle BroMenn Medical Center,8380295,LAB/PATH TESTING,,81222,310,$249.00 ,$249.00 ,$74.70 ,$226.59 ,$174.30 ,$74.70 ,$161.85 ,$179.28 ,$226.59 ,$186.75 
Carle BroMenn Medical Center,8380296,LAB/PATH TESTING,,81223,310,$485.00 ,$485.00 ,$145.50 ,$441.35 ,$339.50 ,$145.50 ,$315.25 ,$349.20 ,$441.35 ,$363.75 
Carle BroMenn Medical Center,8380297,LAB/PATH TESTING,,81224,310,$410.00 ,$410.00 ,$123.00 ,$373.10 ,$287.00 ,$123.00 ,$266.50 ,$295.20 ,$373.10 ,$307.50 
Carle BroMenn Medical Center,8380622,LAB/PATH TESTING,,81401,310,$96.00 ,$96.00 ,$28.80 ,$87.36 ,$67.20 ,$28.80 ,$62.40 ,$69.12 ,$87.36 ,$72.00 
Carle BroMenn Medical Center,8380623,LAB/PATH TESTING,,81403,310,$96.00 ,$96.00 ,$28.80 ,$87.36 ,$67.20 ,$28.80 ,$62.40 ,$69.12 ,$87.36 ,$72.00 
Carle BroMenn Medical Center,8380624,LAB/PATH TESTING,,81404,310,$46.00 ,$46.00 ,$13.80 ,$41.86 ,$32.20 ,$13.80 ,$29.90 ,$33.12 ,$41.86 ,$34.50 
Carle BroMenn Medical Center,8380625,LAB/PATH TESTING,,81403,310,$186.00 ,$186.00 ,$55.80 ,$169.26 ,$130.20 ,$55.80 ,$120.90 ,$133.92 ,$169.26 ,$139.50 
Carle BroMenn Medical Center,8380626,LAB/PATH TESTING,,81511,310,$35.00 ,$35.00 ,$10.50 ,$31.85 ,$24.50 ,$10.50 ,$22.75 ,$25.20 ,$31.85 ,$26.25 
Carle BroMenn Medical Center,8380638,CPT-MOLEC PATH-L 1-RDSTR ENZYME DIGEST U OF TEXAS,,81400,310,$55.00 ,$55.00 ,$16.50 ,$50.05 ,$38.50 ,$16.50 ,$35.75 ,$39.60 ,$50.05 ,$41.25 
Carle BroMenn Medical Center,8380639,CPT-MOLECULAR PATHOLOGY PROCEDURE U OF TEXAS,,81479,310,$55.00 ,$55.00 ,$16.50 ,$50.05 ,$38.50 ,$16.50 ,$35.75 ,$39.60 ,$50.05 ,$41.25 
Carle BroMenn Medical Center,8380654,CGH MICROARRAY ANALY SNP REF,,81229,310,$663.00 ,$663.00 ,$198.90 ,$603.33 ,$464.10 ,$198.90 ,$430.95 ,$477.36 ,$603.33 ,$497.25 
Carle BroMenn Medical Center,8381040,HLA A29 TYPING  REF,,81374,310,$69.00 ,$69.00 ,$20.70 ,$62.79 ,$48.30 ,$20.70 ,$44.85 ,$49.68 ,$62.79 ,$51.75 
Carle BroMenn Medical Center,8381085,IMMUNOCHEM ANTIBODY PRIMARY REF,,88343,310,$246.35 ,$246.35 ,$73.91 ,$224.18 ,$172.45 ,$73.91 ,$160.13 ,$177.37 ,$224.18 ,$184.76 
Carle BroMenn Medical Center,8381092,MATERNIT21  REF,,81420,310,$347.00 ,$347.00 ,$104.10 ,$315.77 ,$242.90 ,$104.10 ,$225.55 ,$249.84 ,$315.77 ,$260.25 
Carle BroMenn Medical Center,8381125,"DECALCIFICATION , REF",,88311,310,$116.00 ,$116.00 ,$34.80 ,$105.56 ,$81.20 ,$34.80 ,$75.40 ,$83.52 ,$105.56 ,$87.00 
Carle BroMenn Medical Center,8381206,LAB/PATH TESTING,,81206,310,$296.00 ,$296.00 ,$88.80 ,$269.36 ,$207.20 ,$88.80 ,$192.40 ,$213.12 ,$269.36 ,$222.00 
Carle BroMenn Medical Center,8381210,BRAF GENE ANALYSIS REF,,81210,310,$325.00 ,$325.00 ,$97.50 ,$295.75 ,$227.50 ,$97.50 ,$211.25 ,$234.00 ,$295.75 ,$243.75 
Carle BroMenn Medical Center,8381220,CFTR GENE ANALYSIS   REF,,81220,310,"$1,244.75 ","$1,244.75 ",$373.43 ,"$1,132.72 ",$871.33 ,$373.43 ,$809.09 ,$896.22 ,"$1,132.72 ",$933.56 
Carle BroMenn Medical Center,8381222,CFTR GENE ; DEL/DUP VARIANTS  REF,,81222,310,$437.00 ,$437.00 ,$131.10 ,$397.67 ,$305.90 ,$131.10 ,$284.05 ,$314.64 ,$397.67 ,$327.75 
Carle BroMenn Medical Center,8381223,LAB/PATH TESTING,,81223,310,$699.00 ,$699.00 ,$209.70 ,$636.09 ,$489.30 ,$209.70 ,$454.35 ,$503.28 ,$636.09 ,$524.25 
Carle BroMenn Medical Center,8381232,"CPT-GPP-GI PATHOGEN, PROBE, 12-25  TARGETS",,0097U,310,"$1,046.00 ","$1,046.00 ",$313.80 ,$951.86 ,$732.20 ,$313.80 ,$679.90 ,$753.12 ,$951.86 ,$784.50 
Carle BroMenn Medical Center,8381235,LAB/PATH TESTING,,81235,310,$518.70 ,$518.70 ,$155.61 ,$472.02 ,$363.09 ,$155.61 ,$337.16 ,$373.46 ,$472.02 ,$389.03 
Carle BroMenn Medical Center,8381241,LAB/PATH TESTING,,81241,310,$85.00 ,$85.00 ,$25.50 ,$77.35 ,$59.50 ,$25.50 ,$55.25 ,$61.20 ,$77.35 ,$63.75 
Carle BroMenn Medical Center,8381243,LAB/PATH TESTING,,81243,310,$154.00 ,$154.00 ,$46.20 ,$140.14 ,$107.80 ,$46.20 ,$100.10 ,$110.88 ,$140.14 ,$115.50 
Carle BroMenn Medical Center,8381244,LAB/PATH TESTING,,81244,310,$132.00 ,$132.00 ,$39.60 ,$120.12 ,$92.40 ,$39.60 ,$85.80 ,$95.04 ,$120.12 ,$99.00 
Carle BroMenn Medical Center,8381256,LAB/PATH TESTING,,81256,310,$126.00 ,$126.00 ,$37.80 ,$114.66 ,$88.20 ,$37.80 ,$81.90 ,$90.72 ,$114.66 ,$94.50 
Carle BroMenn Medical Center,8381257,LAB/PATH TESTING,,81257,310,$96.00 ,$96.00 ,$28.80 ,$87.36 ,$67.20 ,$28.80 ,$62.40 ,$69.12 ,$87.36 ,$72.00 
Carle BroMenn Medical Center,8381265,LAB/PATH TESTING,,81265,310,$328.00 ,$328.00 ,$98.40 ,$298.48 ,$229.60 ,$98.40 ,$213.20 ,$236.16 ,$298.48 ,$246.00 
Carle BroMenn Medical Center,8381270,LAB/PATH TESTING,,81270,310,$164.00 ,$164.00 ,$49.20 ,$149.24 ,$114.80 ,$49.20 ,$106.60 ,$118.08 ,$149.24 ,$123.00 
Carle BroMenn Medical Center,8381291,LAB/PATH TESTING,,81291,310,$73.00 ,$73.00 ,$21.90 ,$66.43 ,$51.10 ,$21.90 ,$47.45 ,$52.56 ,$66.43 ,$54.75 
Carle BroMenn Medical Center,8381301,CPT-HNPCC SCREEN  MML   REF,,81301,310,$184.00 ,$184.00 ,$55.20 ,$167.44 ,$128.80 ,$55.20 ,$119.60 ,$132.48 ,$167.44 ,$138.00 
Carle BroMenn Medical Center,8381332,CPT-SERPINA 1 (A1AT DEFIC) REF,,81332,310,$29.00 ,$29.00 ,$8.70 ,$26.39 ,$20.30 ,$8.70 ,$18.85 ,$20.88 ,$26.39 ,$21.75 
Carle BroMenn Medical Center,8381340,CPT-TRB T CELL RECEP GENE REARR  REF,,81340,310,$128.00 ,$128.00 ,$38.40 ,$116.48 ,$89.60 ,$38.40 ,$83.20 ,$92.16 ,$116.48 ,$96.00 
Carle BroMenn Medical Center,8381342,CPT-TRG T CELL RECEP GENE REARR  REF,,81342,310,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8381375,LAB/PATH TESTING,,81375,310,$211.00 ,$211.00 ,$63.30 ,$192.01 ,$147.70 ,$63.30 ,$137.15 ,$151.92 ,$192.01 ,$158.25 
Carle BroMenn Medical Center,8381376,LAB/PATH TESTING,,81376,310,$91.00 ,$91.00 ,$27.30 ,$82.81 ,$63.70 ,$27.30 ,$59.15 ,$65.52 ,$82.81 ,$68.25 
Carle BroMenn Medical Center,8381381,LAB/PATH TESTING,,81381,310,$328.00 ,$328.00 ,$98.40 ,$298.48 ,$229.60 ,$98.40 ,$213.20 ,$236.16 ,$298.48 ,$246.00 
Carle BroMenn Medical Center,8381382,LAB/PATH TESTING,,81382,310,$295.75 ,$295.75 ,$88.73 ,$269.13 ,$207.03 ,$88.73 ,$192.24 ,$212.94 ,$269.13 ,$221.81 
Carle BroMenn Medical Center,8381406,LAB/PATH TESTING,,81406,310,"$1,018.40 ","$1,018.40 ",$305.52 ,$926.74 ,$712.88 ,$305.52 ,$661.96 ,$733.25 ,$926.74 ,$763.80 
Carle BroMenn Medical Center,8381444,NBS-SCID SCRN  REF,,81479,310,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8381527,"IMMFL ST; ADDNL AB, EACH (CROHN-PROM) REF",,88350,310,$74.00 ,$74.00 ,$22.20 ,$67.34 ,$51.80 ,$22.20 ,$48.10 ,$53.28 ,$67.34 ,$55.50 
Carle BroMenn Medical Center,8381529,"IMMFL ST; ADDNL AB, EACH (SGI-PROM)  REF",,88350,310,$74.00 ,$74.00 ,$22.20 ,$67.34 ,$51.80 ,$22.20 ,$48.10 ,$53.28 ,$67.34 ,$55.50 
Carle BroMenn Medical Center,8381536,IMMUNOFLUORESCENCE EA ADDT ANTIBODY STAIN REF,,88350,310,$91.00 ,$91.00 ,$27.30 ,$82.81 ,$63.70 ,$27.30 ,$59.15 ,$65.52 ,$82.81 ,$68.25 
Carle BroMenn Medical Center,8381587,"PROTHROMBIN G20210A MUTATION, B  REF",,81240,310,$367.25 ,$367.25 ,$110.18 ,$334.20 ,$257.08 ,$110.18 ,$238.71 ,$264.42 ,$334.20 ,$275.44 
Carle BroMenn Medical Center,8381706,"MTHFR (677C AND 1298C) MUTATIONS, B",,81291,310,$498.00 ,$498.00 ,$149.40 ,$453.18 ,$348.60 ,$149.40 ,$323.70 ,$358.56 ,$453.18 ,$373.50 
Carle BroMenn Medical Center,8381707,"FACTOR V LEIDEN (1691G>A) MUTATION, B",,81241,310,$649.00 ,$649.00 ,$194.70 ,$590.59 ,$454.30 ,$194.70 ,$421.85 ,$467.28 ,$590.59 ,$486.75 
Carle BroMenn Medical Center,8381757,Hc Hla B27 Antigen,,81374,310,$302.00 ,$302.00 ,$90.60 ,$274.82 ,$211.40 ,$90.60 ,$196.30 ,$217.44 ,$274.82 ,$226.50 
Carle BroMenn Medical Center,8381855,"SMA CARRIER SCREEN, REF",,81401,310,$142.00 ,$142.00 ,$42.60 ,$129.22 ,$99.40 ,$42.60 ,$92.30 ,$102.24 ,$129.22 ,$106.50 
Carle BroMenn Medical Center,8381868,"SMA CARRIER SCREEN, REF",,81329,310,$142.00 ,$142.00 ,$42.60 ,$129.22 ,$99.40 ,$42.60 ,$92.30 ,$102.24 ,$129.22 ,$106.50 
Carle BroMenn Medical Center,8381875,MPL EXON 10 MUTATION,,81339,310,$517.00 ,$517.00 ,$155.10 ,$470.47 ,$361.90 ,$155.10 ,$336.05 ,$372.24 ,$470.47 ,$387.75 
Carle BroMenn Medical Center,8381976,"BRAF GENE ANALYSIS, V600 VARIANT(S)",,81210,310,$737.00 ,$737.00 ,$221.10 ,$670.67 ,$515.90 ,$221.10 ,$479.05 ,$530.64 ,$670.67 ,$552.75 
Carle BroMenn Medical Center,8381977,MSI ANALYSIS,,81301,310,"$1,468.00 ","$1,468.00 ",$440.40 ,"$1,335.88 ","$1,027.60 ",$440.40 ,$954.20 ,"$1,056.96 ","$1,335.88 ","$1,101.00 "
Carle BroMenn Medical Center,8382369,SARS-COV-2 BY NUCLEIC ACID,,U0003,310,$180.00 ,$180.00 ,$54.00 ,$163.80 ,$126.00 ,$54.00 ,$117.00 ,$129.60 ,$163.80 ,$135.00 
Carle BroMenn Medical Center,8382387,FACTOR V (LEIDEN),,81241,310,$455.00 ,$455.00 ,$136.50 ,$414.05 ,$318.50 ,$136.50 ,$295.75 ,$327.60 ,$414.05 ,$341.25 
Carle BroMenn Medical Center,8382389,PROTHROMBIN GENE,,81240,310,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8382407,LIVER FIBROSIS,,81596,310,$175.00 ,$175.00 ,$52.50 ,$159.25 ,$122.50 ,$52.50 ,$113.75 ,$126.00 ,$159.25 ,$131.25 
Carle BroMenn Medical Center,8382421,"FIBROTEST-ACTITEST, S REF",,81596,310,$183.00 ,$183.00 ,$54.90 ,$166.53 ,$128.10 ,$54.90 ,$118.95 ,$131.76 ,$166.53 ,$137.25 
Carle BroMenn Medical Center,8382494,"HLA-DR-DQ DisAssoc Typing LowRes, REF",,81376,310,$32.00 ,$32.00 ,$9.60 ,$29.12 ,$22.40 ,$9.60 ,$20.80 ,$23.04 ,$29.12 ,$24.00 
Carle BroMenn Medical Center,8382554,"JAK-2 V617 MUTATION,  B",,81270,310,$205.00 ,$205.00 ,$61.50 ,$186.55 ,$143.50 ,$61.50 ,$133.25 ,$147.60 ,$186.55 ,$153.75 
Carle BroMenn Medical Center,8382636,PATH CONSULT MAYO COMPREHENSIV,,88325,310,$500.00 ,$500.00 ,$150.00 ,$455.00 ,$350.00 ,$150.00 ,$325.00 ,$360.00 ,$455.00 ,$375.00 
Carle BroMenn Medical Center,8382637,PATH CONSULTATION MAYO,,88321,310,$500.00 ,$500.00 ,$150.00 ,$455.00 ,$350.00 ,$150.00 ,$325.00 ,$360.00 ,$455.00 ,$375.00 
Carle BroMenn Medical Center,8383116,SARS-COV-2/FLU A/ FLU B PCR,,87636,310,$360.00 ,$360.00 ,$108.00 ,$327.60 ,$252.00 ,$108.00 ,$234.00 ,$259.20 ,$327.60 ,$270.00 
Carle BroMenn Medical Center,8385630,LEVEL IV  -SURGICAL PATH REF,,88305,310,$304.00 ,$304.00 ,$91.20 ,$276.64 ,$212.80 ,$91.20 ,$197.60 ,$218.88 ,$276.64 ,$228.00 
Carle BroMenn Medical Center,8386711,LAB/PATH TESTING,,86711,310,$38.35 ,$38.35 ,$11.51 ,$34.90 ,$26.85 ,$11.51 ,$24.93 ,$27.61 ,$34.90 ,$28.76 
Carle BroMenn Medical Center,8387140,DRA/LEGIONELLA PNEUMOPHILA,,87300,310,$88.00 ,$88.00 ,$26.40 ,$80.08 ,$61.60 ,$26.40 ,$57.20 ,$63.36 ,$80.08 ,$66.00 
Carle BroMenn Medical Center,8388106,"CYTOPATH FLUIDS/WASHINGS/BRUSHINGS, SMEARS W/INTERP",,88104,310,$139.75 ,$139.75 ,$41.93 ,$127.17 ,$97.83 ,$41.93 ,$90.84 ,$100.62 ,$127.17 ,$104.81 
Carle BroMenn Medical Center,8388141,"CYTOPATH, CV, INTERPRET",,88141,310,$205.00 ,$205.00 ,$61.50 ,$186.55 ,$143.50 ,$61.50 ,$133.25 ,$147.60 ,$186.55 ,$153.75 
Carle BroMenn Medical Center,8388150,DX CYTOPATH-B CX/VAG,,88164,310,$85.00 ,$85.00 ,$25.50 ,$77.35 ,$59.50 ,$25.50 ,$55.25 ,$61.20 ,$77.35 ,$63.75 
Carle BroMenn Medical Center,8388172,"EVAL. FOR ADEQUACY, INITIAL",,88172,310,$266.50 ,$266.50 ,$79.95 ,$242.52 ,$186.55 ,$79.95 ,$173.23 ,$191.88 ,$242.52 ,$199.88 
Carle BroMenn Medical Center,8388173,FNA EVA INTER-REPORT,,88173,310,$214.50 ,$214.50 ,$64.35 ,$195.20 ,$150.15 ,$64.35 ,$139.43 ,$154.44 ,$195.20 ,$160.88 
Carle BroMenn Medical Center,8388264,CHROM ANALYSIS; 20-25 CELLS RF,,88264,310,$760.50 ,$760.50 ,$228.15 ,$692.06 ,$532.35 ,$228.15 ,$494.33 ,$547.56 ,$692.06 ,$570.38 
Carle BroMenn Medical Center,8388267,CHROMO ANA AMNIO FLUID REF,,88267,310,"$1,212.25 ","$1,212.25 ",$363.68 ,"$1,103.15 ",$848.58 ,$363.68 ,$787.96 ,$872.82 ,"$1,103.15 ",$909.19 
Carle BroMenn Medical Center,8388283,CHRM ANALYS ADNL SPEC BNDNG RF,,88283,310,$133.00 ,$133.00 ,$39.90 ,$121.03 ,$93.10 ,$39.90 ,$86.45 ,$95.76 ,$121.03 ,$99.75 
Carle BroMenn Medical Center,8388289,CHROM ADNL HI RES STUDY    REF,,88289,310,$40.00 ,$40.00 ,$12.00 ,$36.40 ,$28.00 ,$12.00 ,$26.00 ,$28.80 ,$36.40 ,$30.00 
Carle BroMenn Medical Center,8388307,SURGICAL PATHOLOGY LEVEL-V REF,,88307,310,$533.00 ,$533.00 ,$159.90 ,$485.03 ,$373.10 ,$159.90 ,$346.45 ,$383.76 ,$485.03 ,$399.75 
Carle BroMenn Medical Center,8388319,DETERMINATIVE HISTO/CYTO TO ID,,88319,310,$354.25 ,$354.25 ,$106.28 ,$322.37 ,$247.98 ,$106.28 ,$230.26 ,$255.06 ,$322.37 ,$265.69 
Carle BroMenn Medical Center,8388333,INTRAOPERATIVE CYTOPATHOLOGY,,88333,310,$695.50 ,$695.50 ,$208.65 ,$632.91 ,$486.85 ,$208.65 ,$452.08 ,$500.76 ,$632.91 ,$521.63 
Carle BroMenn Medical Center,8388350,IMMUNOFLOURESCENCE EA ADDT SINGLE ANTIBODY STAIN,,88350,310,$573.00 ,$573.00 ,$171.90 ,$521.43 ,$401.10 ,$171.90 ,$372.45 ,$412.56 ,$521.43 ,$429.75 
Carle BroMenn Medical Center,8388360,IN SITU HYBRIDIZATN EA PRBE RF,,88365,310,$123.50 ,$123.50 ,$37.05 ,$112.39 ,$86.45 ,$37.05 ,$80.28 ,$88.92 ,$112.39 ,$92.63 
Carle BroMenn Medical Center,8388400,SURGICAL PATHOLOGY LEVEL -1,,88300,310,$94.25 ,$94.25 ,$28.28 ,$85.77 ,$65.98 ,$28.28 ,$61.26 ,$67.86 ,$85.77 ,$70.69 
Carle BroMenn Medical Center,8388402,SURGICAL PATHOLOGY LEVEL-II,,88302,310,$126.75 ,$126.75 ,$38.03 ,$115.34 ,$88.73 ,$38.03 ,$82.39 ,$91.26 ,$115.34 ,$95.06 
Carle BroMenn Medical Center,8388403,LEVEL IV  -SURGICAL PATH,,88305,310,$466.00 ,$466.00 ,$139.80 ,$424.06 ,$326.20 ,$139.80 ,$302.90 ,$335.52 ,$424.06 ,$349.50 
Carle BroMenn Medical Center,8388404,SURGI-PATHO LEVEL-III,,88304,310,$214.50 ,$214.50 ,$64.35 ,$195.20 ,$150.15 ,$64.35 ,$139.43 ,$154.44 ,$195.20 ,$160.88 
Carle BroMenn Medical Center,8388405,SURGICALPATHOLOGY LEVEL-IV,,88305,310,$214.50 ,$214.50 ,$64.35 ,$195.20 ,$150.15 ,$64.35 ,$139.43 ,$154.44 ,$195.20 ,$160.88 
Carle BroMenn Medical Center,8388407,SURGICL PATHOLOGY LEVEL-V,,88307,310,$789.75 ,$789.75 ,$236.93 ,$718.67 ,$552.83 ,$236.93 ,$513.34 ,$568.62 ,$718.67 ,$592.31 
Carle BroMenn Medical Center,8388409,SURGICAL PATHOLOGYLEVEL-VI,,88309,310,$841.75 ,$841.75 ,$252.53 ,$765.99 ,$589.23 ,$252.53 ,$547.14 ,$606.06 ,$765.99 ,$631.31 
Carle BroMenn Medical Center,8388411,DECALCIFICATION PROCEDURE,,88311,310,$97.50 ,$97.50 ,$29.25 ,$88.73 ,$68.25 ,$29.25 ,$63.38 ,$70.20 ,$88.73 ,$73.13 
Carle BroMenn Medical Center,8388431,"FROZEN SECTION, 1ST TISS BLOCK",,88331,310,$461.50 ,$461.50 ,$138.45 ,$419.97 ,$323.05 ,$138.45 ,$299.98 ,$332.28 ,$419.97 ,$346.13 
Carle BroMenn Medical Center,8388432,"FROZEN SECTION, ADL TISS BLOCK",,88332,310,$247.00 ,$247.00 ,$74.10 ,$224.77 ,$172.90 ,$74.10 ,$160.55 ,$177.84 ,$224.77 ,$185.25 
Carle BroMenn Medical Center,8388443,IMMUNOCHEM ANTIBODY ADDITIONAL,,88343,310,$303.20 ,$303.20 ,$90.96 ,$275.91 ,$212.24 ,$90.96 ,$197.08 ,$218.30 ,$275.91 ,$227.40 
Carle BroMenn Medical Center,8388449,ELECTRON MICROSCPY DX,,88348,310,"$2,281.00 ","$2,281.00 ",$684.30 ,"$2,075.71 ","$1,596.70 ",$684.30 ,"$1,482.65 ","$1,642.32 ","$2,075.71 ","$1,710.75 "
Carle BroMenn Medical Center,8389006,CYTOGENETICS INTERP/REPORT,,88289,310,$155.00 ,$155.00 ,$46.50 ,$141.05 ,$108.50 ,$46.50 ,$100.75 ,$111.60 ,$141.05 ,$116.25 
Carle BroMenn Medical Center,8389180,BRONCIAL SPECIMENS W/STAIN,,88162,310,$195.00 ,$195.00 ,$58.50 ,$177.45 ,$136.50 ,$58.50 ,$126.75 ,$140.40 ,$177.45 ,$146.25 
Carle BroMenn Medical Center,8210091,OBTAINING SCREEN PAP SMEAR,,Q0091,311,$24.00 ,$24.00 ,$7.20 ,$21.84 ,$16.80 ,$7.20 ,$15.60 ,$17.28 ,$21.84 ,$18.00 
Carle BroMenn Medical Center,8340025,PAP CYTOLOGY CERVIX/VAGINAL,,88164,311,$160.00 ,$160.00 ,$48.00 ,$145.60 ,$112.00 ,$48.00 ,$104.00 ,$115.20 ,$145.60 ,$120.00 
Carle BroMenn Medical Center,8380224,"FLOW CYTOM,CELL CYCLE OR DNA ANALYSIS  REF",,88182,311,$19.00 ,$19.00 ,$5.70 ,$17.29 ,$13.30 ,$5.70 ,$12.35 ,$13.68 ,$17.29 ,$14.25 
Carle BroMenn Medical Center,8380258,SOLID TISSUE BIOPSY   REF,,88233,311,$203.00 ,$203.00 ,$60.90 ,$184.73 ,$142.10 ,$60.90 ,$131.95 ,$146.16 ,$184.73 ,$152.25 
Carle BroMenn Medical Center,8380259,CRYOPRESERVATION  REF,,88240,311,$17.00 ,$17.00 ,$5.10 ,$15.47 ,$11.90 ,$5.10 ,$11.05 ,$12.24 ,$15.47 ,$12.75 
Carle BroMenn Medical Center,8380260,AMNIOTIC FL CULT/GENETIC   REF,,88235,311,$334.75 ,$334.75 ,$100.43 ,$304.62 ,$234.33 ,$100.43 ,$217.59 ,$241.02 ,$304.62 ,$251.06 
Carle BroMenn Medical Center,8380261,CRYOPRESERVATION   REF,,88240,311,$22.00 ,$22.00 ,$6.60 ,$20.02 ,$15.40 ,$6.60 ,$14.30 ,$15.84 ,$20.02 ,$16.50 
Carle BroMenn Medical Center,8380302,"CYTOGENETICS, DNA PROBE    REF",,88271,311,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8380303,"CYTOGENETICS, 100-300      REF",,88275,311,$116.00 ,$116.00 ,$34.80 ,$105.56 ,$81.20 ,$34.80 ,$75.40 ,$83.52 ,$105.56 ,$87.00 
Carle BroMenn Medical Center,8380304,CYTO/MOLECULAR REPORT      REF,,88291,311,$215.00 ,$215.00 ,$64.50 ,$195.65 ,$150.50 ,$64.50 ,$139.75 ,$154.80 ,$195.65 ,$161.25 
Carle BroMenn Medical Center,8380389,"HGB F, RED CELL DISTRIB, B    REF",,88184,311,$103.00 ,$103.00 ,$30.90 ,$93.73 ,$72.10 ,$30.90 ,$66.95 ,$74.16 ,$93.73 ,$77.25 
Carle BroMenn Medical Center,8380398,"CHROMOSOME, AMNIO CULT       REF",,88235,311,$126.00 ,$126.00 ,$37.80 ,$114.66 ,$88.20 ,$37.80 ,$81.90 ,$90.72 ,$114.66 ,$94.50 
Carle BroMenn Medical Center,8380399,"CHROM ANAL, ADDNL KARYOTYPE  REF",,88280,311,$182.00 ,$182.00 ,$54.60 ,$165.62 ,$127.40 ,$54.60 ,$118.30 ,$131.04 ,$165.62 ,$136.50 
Carle BroMenn Medical Center,8380400,UNLISTED CYTOGENETIC STUDY    REF,,88299,311,$106.00 ,$106.00 ,$31.80 ,$96.46 ,$74.20 ,$31.80 ,$68.90 ,$76.32 ,$96.46 ,$79.50 
Carle BroMenn Medical Center,8380402,TISS CULT NEOPL BN MAR/BLD REF,,88237,311,$266.50 ,$266.50 ,$79.95 ,$242.52 ,$186.55 ,$79.95 ,$173.23 ,$191.88 ,$242.52 ,$199.88 
Carle BroMenn Medical Center,8380403,UNLISETD CYTOGENETIC STUDY    REF,,88299,311,$115.00 ,$115.00 ,$34.50 ,$104.65 ,$80.50 ,$34.50 ,$74.75 ,$82.80 ,$104.65 ,$86.25 
Carle BroMenn Medical Center,8380432,"CHROMOSOME, TISSUE CULTURE   REF",,88233,311,$167.00 ,$167.00 ,$50.10 ,$151.97 ,$116.90 ,$50.10 ,$108.55 ,$120.24 ,$151.97 ,$125.25 
Carle BroMenn Medical Center,8380433,UNLISETD CYTOGENETIC STUDY    REF,,88299,311,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8380434,MOLEC CYTOGEN; DNA PROBE      REF,,88271,311,$39.00 ,$39.00 ,$11.70 ,$35.49 ,$27.30 ,$11.70 ,$25.35 ,$28.08 ,$35.49 ,$29.25 
Carle BroMenn Medical Center,8380435,"MOL CYT INTPH ISH,100-300 CELLS  REF",,88275,311,$107.00 ,$107.00 ,$32.10 ,$97.37 ,$74.90 ,$32.10 ,$69.55 ,$77.04 ,$97.37 ,$80.25 
Carle BroMenn Medical Center,8380505,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$27.00 ,$27.00 ,$8.10 ,$24.57 ,$18.90 ,$8.10 ,$17.55 ,$19.44 ,$24.57 ,$20.25 
Carle BroMenn Medical Center,8380506,MOL CYT INTPH ISH 100-300 CELLS REF,,88275,311,$51.00 ,$51.00 ,$15.30 ,$46.41 ,$35.70 ,$15.30 ,$33.15 ,$36.72 ,$46.41 ,$38.25 
Carle BroMenn Medical Center,8380533,MOLEC CYTOGEN; DNA PROBE      REF,,88271,311,$32.00 ,$32.00 ,$9.60 ,$29.12 ,$22.40 ,$9.60 ,$20.80 ,$23.04 ,$29.12 ,$24.00 
Carle BroMenn Medical Center,8380534,"MOL CYT INTPH ISH,100-300 CELLS  REF",,88275,311,$89.00 ,$89.00 ,$26.70 ,$80.99 ,$62.30 ,$26.70 ,$57.85 ,$64.08 ,$80.99 ,$66.75 
Carle BroMenn Medical Center,8380593,"UROVYSION, BLADDER CANCER    REF",,88120,311,$190.00 ,$190.00 ,$57.00 ,$172.90 ,$133.00 ,$57.00 ,$123.50 ,$136.80 ,$172.90 ,$142.50 
Carle BroMenn Medical Center,8380607,FLOW CYTOM;FIRST MARKER    REF,,88184,311,$24.00 ,$24.00 ,$7.20 ,$21.84 ,$16.80 ,$7.20 ,$15.60 ,$17.28 ,$21.84 ,$18.00 
Carle BroMenn Medical Center,8380608,FLOW CYTOM; EACH ADDTNL REF,,88185,311,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8380610,FLOW CYTOM; FIRST MARKER REF,,88184,311,$16.00 ,$16.00 ,$4.80 ,$14.56 ,$11.20 ,$4.80 ,$10.40 ,$11.52 ,$14.56 ,$12.00 
Carle BroMenn Medical Center,8380655,"TISSUE CULTURE, CHROM ANAL, B REF",,88230,311,$115.00 ,$115.00 ,$34.50 ,$104.65 ,$80.50 ,$34.50 ,$74.75 ,$82.80 ,$104.65 ,$86.25 
Carle BroMenn Medical Center,8380656,"CYTOGENETIC STUDY, CHROM ANAL, B REF",,88299,311,$115.00 ,$115.00 ,$34.50 ,$104.65 ,$80.50 ,$34.50 ,$74.75 ,$82.80 ,$104.65 ,$86.25 
Carle BroMenn Medical Center,8380657,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$4.00 ,$4.00 ,$1.20 ,$3.64 ,$2.80 ,$1.20 ,$2.60 ,$2.88 ,$3.64 ,$3.00 
Carle BroMenn Medical Center,8380658,"MOL CYT INTPH ISH, 100-300 CELLS REF",,88275,311,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8380659,"MOL CYT INTPH ISH, 100-300 CELLS",,88271,311,$12.00 ,$12.00 ,$3.60 ,$10.92 ,$8.40 ,$3.60 ,$7.80 ,$8.64 ,$10.92 ,$9.00 
Carle BroMenn Medical Center,8380660,"MOL CYT INTPH ISH, 100-300 CELLS REF",,88275,311,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8380661,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$12.00 ,$12.00 ,$3.60 ,$10.92 ,$8.40 ,$3.60 ,$7.80 ,$8.64 ,$10.92 ,$9.00 
Carle BroMenn Medical Center,8380662,"MOL CYT INTPH ISH, 100-300 CELLS REF",,88275,311,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8380663,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$12.00 ,$12.00 ,$3.60 ,$10.92 ,$8.40 ,$3.60 ,$7.80 ,$8.64 ,$10.92 ,$9.00 
Carle BroMenn Medical Center,8380664,"MOL CYT INTPH ISH, 100-300 CELLS REF",,88275,311,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8380665,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$12.00 ,$12.00 ,$3.60 ,$10.92 ,$8.40 ,$3.60 ,$7.80 ,$8.64 ,$10.92 ,$9.00 
Carle BroMenn Medical Center,8380666,"MOL CYT INTPH ISH, 100-300 CELLS REF",,88275,311,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8380667,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$12.00 ,$12.00 ,$3.60 ,$10.92 ,$8.40 ,$3.60 ,$7.80 ,$8.64 ,$10.92 ,$9.00 
Carle BroMenn Medical Center,8380668,"MOL CYT INTPH ISH, 100-300 CELLS REF",,88275,311,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8380669,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$12.00 ,$12.00 ,$3.60 ,$10.92 ,$8.40 ,$3.60 ,$7.80 ,$8.64 ,$10.92 ,$9.00 
Carle BroMenn Medical Center,8380670,"MOL CYT INTPH ISH, 100-300 CELLS REF",,88275,311,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8380671,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$12.00 ,$12.00 ,$3.60 ,$10.92 ,$8.40 ,$3.60 ,$7.80 ,$8.64 ,$10.92 ,$9.00 
Carle BroMenn Medical Center,8380672,"MOL CYT INTPH ISH, 100-300 CELLS REF",,88275,311,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8380673,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$12.00 ,$12.00 ,$3.60 ,$10.92 ,$8.40 ,$3.60 ,$7.80 ,$8.64 ,$10.92 ,$9.00 
Carle BroMenn Medical Center,8380674,"MOL CYT INTPH ISH, 100-300 CELLS REF",,88275,311,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8380675,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$12.00 ,$12.00 ,$3.60 ,$10.92 ,$8.40 ,$3.60 ,$7.80 ,$8.64 ,$10.92 ,$9.00 
Carle BroMenn Medical Center,8380676,"MOL CYT INTPH ISH, 100-300 CELLS REF",,88275,311,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8380731,MOLEC CYTOGEN; DNA PROBE      REF,,88271,311,$21.00 ,$21.00 ,$6.30 ,$19.11 ,$14.70 ,$6.30 ,$13.65 ,$15.12 ,$19.11 ,$15.75 
Carle BroMenn Medical Center,8380732,"MOL CYT INTPH ISH,100-300 CELLS  REF",,88275,311,$32.00 ,$32.00 ,$9.60 ,$29.12 ,$22.40 ,$9.60 ,$20.80 ,$23.04 ,$29.12 ,$24.00 
Carle BroMenn Medical Center,8380733,"CRYOPR, FRZ, STORE, EA CELL LINE REF",,88240,311,$8.00 ,$8.00 ,$2.40 ,$7.28 ,$5.60 ,$2.40 ,$5.20 ,$5.76 ,$7.28 ,$6.00 
Carle BroMenn Medical Center,8380739,FLOW CYTOM; FIRST MARKER      REF,,88184,311,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8380740,FLOW CYTOM; EACH ADDNL MARKER REF,,88185,311,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8380753,MOLEC CYTOGEN; DNA PROBE      REF,,88271,311,$25.00 ,$25.00 ,$7.50 ,$22.75 ,$17.50 ,$7.50 ,$16.25 ,$18.00 ,$22.75 ,$18.75 
Carle BroMenn Medical Center,8380754,"MOL CYT INTPH ISH,100-300 CELLS  REF",,88275,311,$70.00 ,$70.00 ,$21.00 ,$63.70 ,$49.00 ,$21.00 ,$45.50 ,$50.40 ,$63.70 ,$52.50 
Carle BroMenn Medical Center,8380761,MOLEC CYTOGEN; DNA PROBE      REF,,88271,311,$39.00 ,$39.00 ,$11.70 ,$35.49 ,$27.30 ,$11.70 ,$25.35 ,$28.08 ,$35.49 ,$29.25 
Carle BroMenn Medical Center,8380762,"MOL CYT INTPH ISH,100-300 CELLS  REF",,88275,311,$79.00 ,$79.00 ,$23.70 ,$71.89 ,$55.30 ,$23.70 ,$51.35 ,$56.88 ,$71.89 ,$59.25 
Carle BroMenn Medical Center,8380774,MOLEC CYTOGEN; DNA PROBE      REF,,88271,311,$18.00 ,$18.00 ,$5.40 ,$16.38 ,$12.60 ,$5.40 ,$11.70 ,$12.96 ,$16.38 ,$13.50 
Carle BroMenn Medical Center,8380775,"MOL CYT INTPH ISH,100-300 CELLS  REF",,88275,311,$50.00 ,$50.00 ,$15.00 ,$45.50 ,$35.00 ,$15.00 ,$32.50 ,$36.00 ,$45.50 ,$37.50 
Carle BroMenn Medical Center,8380866,MOLEC CYTOGEN; DNA PROBE      REF,,88271,311,$45.00 ,$45.00 ,$13.50 ,$40.95 ,$31.50 ,$13.50 ,$29.25 ,$32.40 ,$40.95 ,$33.75 
Carle BroMenn Medical Center,8380867,"MOL CYT INTPH ISH,100-300 CELLS  REF",,88275,311,$58.00 ,$58.00 ,$17.40 ,$52.78 ,$40.60 ,$17.40 ,$37.70 ,$41.76 ,$52.78 ,$43.50 
Carle BroMenn Medical Center,8380868,MOLEC CYTOGEN; DNA PROBE      REF,,88271,311,$33.00 ,$33.00 ,$9.90 ,$30.03 ,$23.10 ,$9.90 ,$21.45 ,$23.76 ,$30.03 ,$24.75 
Carle BroMenn Medical Center,8380869,"MOL CYT INTPH ISH,100-300 CELLS  REF",,88275,311,$40.00 ,$40.00 ,$12.00 ,$36.40 ,$28.00 ,$12.00 ,$26.00 ,$28.80 ,$36.40 ,$30.00 
Carle BroMenn Medical Center,8380870,MOLEC CYTOGEN; DNA PROBE      REF,,88271,311,$22.00 ,$22.00 ,$6.60 ,$20.02 ,$15.40 ,$6.60 ,$14.30 ,$15.84 ,$20.02 ,$16.50 
Carle BroMenn Medical Center,8380871,"MOL CYT INTPH ISH,100-300 CELLS  REF",,88275,311,$28.00 ,$28.00 ,$8.40 ,$25.48 ,$19.60 ,$8.40 ,$18.20 ,$20.16 ,$25.48 ,$21.00 
Carle BroMenn Medical Center,8380872,MOLEC CYTOGEN; DNA PROBE      REF,,88271,311,$18.00 ,$18.00 ,$5.40 ,$16.38 ,$12.60 ,$5.40 ,$11.70 ,$12.96 ,$16.38 ,$13.50 
Carle BroMenn Medical Center,8380873,"MOL CYT INTPH ISH,100-300 CELLS  REF",,88275,311,$22.00 ,$22.00 ,$6.60 ,$20.02 ,$15.40 ,$6.60 ,$14.30 ,$15.84 ,$20.02 ,$16.50 
Carle BroMenn Medical Center,8380874,MOLEC CYTOGEN; DNA PROBE      REF,,88271,311,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8380875,"MOL CYT INTPH ISH,100-300 CELLS  REF",,88275,311,$18.00 ,$18.00 ,$5.40 ,$16.38 ,$12.60 ,$5.40 ,$11.70 ,$12.96 ,$16.38 ,$13.50 
Carle BroMenn Medical Center,8380876,MOLEC CYTOGEN; DNA PROBE      REF,,88271,311,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8380877,"MOL CYT INTPH ISH,100-300 CELLS  REF",,88275,311,$18.00 ,$18.00 ,$5.40 ,$16.38 ,$12.60 ,$5.40 ,$11.70 ,$12.96 ,$16.38 ,$13.50 
Carle BroMenn Medical Center,8380878,MOLEC CYTOGEN; DNA PROBE      REF,,88271,311,$14.00 ,$14.00 ,$4.20 ,$12.74 ,$9.80 ,$4.20 ,$9.10 ,$10.08 ,$12.74 ,$10.50 
Carle BroMenn Medical Center,8380879,"MOL CYT INTPH ISH,100-300 CELLS  REF",,88275,311,$17.00 ,$17.00 ,$5.10 ,$15.47 ,$11.90 ,$5.10 ,$11.05 ,$12.24 ,$15.47 ,$12.75 
Carle BroMenn Medical Center,8380880,MOLEC CYTOGEN; DNA PROBE      REF,,88271,311,$13.00 ,$13.00 ,$3.90 ,$11.83 ,$9.10 ,$3.90 ,$8.45 ,$9.36 ,$11.83 ,$9.75 
Carle BroMenn Medical Center,8380881,"MOL CYT INTPH ISH,100-300 CELLS  REF",,88275,311,$17.00 ,$17.00 ,$5.10 ,$15.47 ,$11.90 ,$5.10 ,$11.05 ,$12.24 ,$15.47 ,$12.75 
Carle BroMenn Medical Center,8380882,MOLEC CYTOGEN; DNA PROBE      REF,,88271,311,$13.00 ,$13.00 ,$3.90 ,$11.83 ,$9.10 ,$3.90 ,$8.45 ,$9.36 ,$11.83 ,$9.75 
Carle BroMenn Medical Center,8380883,"MOL CYT INTPH ISH,100-300 CELLS  REF",,88275,311,$16.00 ,$16.00 ,$4.80 ,$14.56 ,$11.20 ,$4.80 ,$10.40 ,$11.52 ,$14.56 ,$12.00 
Carle BroMenn Medical Center,8380884,MOLEC CYTOGEN; DNA PROBE      REF,,88271,311,$14.00 ,$14.00 ,$4.20 ,$12.74 ,$9.80 ,$4.20 ,$9.10 ,$10.08 ,$12.74 ,$10.50 
Carle BroMenn Medical Center,8380885,"MOL CYT INTPH ISH,100-300 CELLS  REF",,88275,311,$16.00 ,$16.00 ,$4.80 ,$14.56 ,$11.20 ,$4.80 ,$10.40 ,$11.52 ,$14.56 ,$12.00 
Carle BroMenn Medical Center,8380886,MOLEC CYTOGEN; DNA PROBE      REF,,88271,311,$13.00 ,$13.00 ,$3.90 ,$11.83 ,$9.10 ,$3.90 ,$8.45 ,$9.36 ,$11.83 ,$9.75 
Carle BroMenn Medical Center,8380887,"MOL CYT INTPH ISH,100-300 CELLS  REF",,88275,311,$16.00 ,$16.00 ,$4.80 ,$14.56 ,$11.20 ,$4.80 ,$10.40 ,$11.52 ,$14.56 ,$12.00 
Carle BroMenn Medical Center,8380888,MOLEC CYTOGEN; DNA PROBE      REF,,88271,311,$17.00 ,$17.00 ,$5.10 ,$15.47 ,$11.90 ,$5.10 ,$11.05 ,$12.24 ,$15.47 ,$12.75 
Carle BroMenn Medical Center,8380889,"MOL CYT INTPH ISH,100-300 CELLS  REF",,88275,311,$16.00 ,$16.00 ,$4.80 ,$14.56 ,$11.20 ,$4.80 ,$10.40 ,$11.52 ,$14.56 ,$12.00 
Carle BroMenn Medical Center,8380890,MOLEC CYTOGEN; DNA PROBE      REF,,88271,311,$13.00 ,$13.00 ,$3.90 ,$11.83 ,$9.10 ,$3.90 ,$8.45 ,$9.36 ,$11.83 ,$9.75 
Carle BroMenn Medical Center,8380891,"MOL CYT INTPH ISH,100-300 CELLS  REF",,88275,311,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8380892,MOLEC CYTOGEN; DNA PROBE      REF,,88271,311,$13.00 ,$13.00 ,$3.90 ,$11.83 ,$9.10 ,$3.90 ,$8.45 ,$9.36 ,$11.83 ,$9.75 
Carle BroMenn Medical Center,8380893,"MOL CYT INTPH ISH,100-300 CELLS  REF",,88275,311,$16.00 ,$16.00 ,$4.80 ,$14.56 ,$11.20 ,$4.80 ,$10.40 ,$11.52 ,$14.56 ,$12.00 
Carle BroMenn Medical Center,8380894,MOLEC CYTOGEN; DNA PROBE      REF,,88271,311,$12.00 ,$12.00 ,$3.60 ,$10.92 ,$8.40 ,$3.60 ,$7.80 ,$8.64 ,$10.92 ,$9.00 
Carle BroMenn Medical Center,8380895,"MOL CYT INTPH ISH,100-300 CELLS  REF",,88275,311,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8380896,MOLEC CYTOGEN; DNA PROBE      REF,,88271,311,$13.00 ,$13.00 ,$3.90 ,$11.83 ,$9.10 ,$3.90 ,$8.45 ,$9.36 ,$11.83 ,$9.75 
Carle BroMenn Medical Center,8380897,"MOL CYT INTPH ISH,100-300 CELLS  REF",,88275,311,$16.00 ,$16.00 ,$4.80 ,$14.56 ,$11.20 ,$4.80 ,$10.40 ,$11.52 ,$14.56 ,$12.00 
Carle BroMenn Medical Center,8380898,MOLEC CYTOGEN; DNA PROBE      REF,,88271,311,$12.00 ,$12.00 ,$3.60 ,$10.92 ,$8.40 ,$3.60 ,$7.80 ,$8.64 ,$10.92 ,$9.00 
Carle BroMenn Medical Center,8380899,"MOL CYT INTPH ISH,100-300 CELLS  REF",,88275,311,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8380900,MOLEC CYTOGEN; DNA PROBE      REF,,88271,311,$13.00 ,$13.00 ,$3.90 ,$11.83 ,$9.10 ,$3.90 ,$8.45 ,$9.36 ,$11.83 ,$9.75 
Carle BroMenn Medical Center,8380901,"MOL CYT INTPH ISH,100-300 CELLS  REF",,88275,311,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8380902,MOLEC CYTOGEN; DNA PROBE      REF,,88271,311,$12.00 ,$12.00 ,$3.60 ,$10.92 ,$8.40 ,$3.60 ,$7.80 ,$8.64 ,$10.92 ,$9.00 
Carle BroMenn Medical Center,8380903,"MOL CYT INTPH ISH,100-300 CELLS  REF",,88275,311,$16.00 ,$16.00 ,$4.80 ,$14.56 ,$11.20 ,$4.80 ,$10.40 ,$11.52 ,$14.56 ,$12.00 
Carle BroMenn Medical Center,8380904,MOLEC CYTOGEN; DNA PROBE      REF,,88271,311,$13.00 ,$13.00 ,$3.90 ,$11.83 ,$9.10 ,$3.90 ,$8.45 ,$9.36 ,$11.83 ,$9.75 
Carle BroMenn Medical Center,8380905,"MOL CYT INTPH ISH,100-300 CELLS  REF",,88275,311,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8380906,MOLEC CYTOGEN; DNA PROBE      REF,,88271,311,$12.00 ,$12.00 ,$3.60 ,$10.92 ,$8.40 ,$3.60 ,$7.80 ,$8.64 ,$10.92 ,$9.00 
Carle BroMenn Medical Center,8380907,"MOL CYT INTPH ISH,100-300 CELLS  REF",,88275,311,$17.00 ,$17.00 ,$5.10 ,$15.47 ,$11.90 ,$5.10 ,$11.05 ,$12.24 ,$15.47 ,$12.75 
Carle BroMenn Medical Center,8381078,"MOLEC CYTOGEN, HYBRIDIZATN  REF",,88273,311,$55.00 ,$55.00 ,$16.50 ,$50.05 ,$38.50 ,$16.50 ,$35.75 ,$39.60 ,$50.05 ,$41.25 
Carle BroMenn Medical Center,8381091,CYTOGENETIC STUDY  REF,,88299,311,$21.00 ,$21.00 ,$6.30 ,$19.11 ,$14.70 ,$6.30 ,$13.65 ,$15.12 ,$19.11 ,$15.75 
Carle BroMenn Medical Center,8381113,LEUKEMIA LYMPHOMA CD45,,88184,311,$321.00 ,$321.00 ,$96.30 ,$292.11 ,$224.70 ,$96.30 ,$208.65 ,$231.12 ,$292.11 ,$240.75 
Carle BroMenn Medical Center,8381419,FLOW CYTOM; EA ADDNL MARKER  REF,,88185,311,$39.65 ,$39.65 ,$11.90 ,$36.08 ,$27.76 ,$11.90 ,$25.77 ,$28.55 ,$36.08 ,$29.74 
Carle BroMenn Medical Center,8381420,TISSUE CULTURE; SKIN OR SOLID TISSUE    REF,,88233,311,$994.50 ,$994.50 ,$298.35 ,$905.00 ,$696.15 ,$298.35 ,$646.43 ,$716.04 ,$905.00 ,$745.88 
Carle BroMenn Medical Center,8381421,"MOLEC CYTOGEN; DNA PROBE, EA    REF",,88271,311,$107.25 ,$107.25 ,$32.18 ,$97.60 ,$75.08 ,$32.18 ,$69.71 ,$77.22 ,$97.60 ,$80.44 
Carle BroMenn Medical Center,8381659,"ONCO CHROMOSOME ANALYSIS, REF",,88237,311,$328.00 ,$328.00 ,$98.40 ,$298.48 ,$229.60 ,$98.40 ,$213.20 ,$236.16 ,$298.48 ,$246.00 
Carle BroMenn Medical Center,8382268,MOLEC CYTOGEN; DNA PROBE   REF,,88271,311,$127.00 ,$127.00 ,$38.10 ,$115.57 ,$88.90 ,$38.10 ,$82.55 ,$91.44 ,$115.57 ,$95.25 
Carle BroMenn Medical Center,8382560,"CYTOGENETICS, 100-300, REF",,88275,311,$16.00 ,$16.00 ,$4.80 ,$14.56 ,$11.20 ,$4.80 ,$10.40 ,$11.52 ,$14.56 ,$12.00 
Carle BroMenn Medical Center,8382561,"CYTOGENETICS DNA PROBE, REF",,88271,311,$38.00 ,$38.00 ,$11.40 ,$34.58 ,$26.60 ,$11.40 ,$24.70 ,$27.36 ,$34.58 ,$28.50 
Carle BroMenn Medical Center,8382566,CPT-MOLECULAR CYTOGENETICS PROBE,,88271,311,$67.00 ,$67.00 ,$20.10 ,$60.97 ,$46.90 ,$20.10 ,$43.55 ,$48.24 ,$60.97 ,$50.25 
Carle BroMenn Medical Center,8382567,"FISH, CML/ALL, BCR/ABL TRANSLOCATION 9,22",,88275,311,$67.00 ,$67.00 ,$20.10 ,$60.97 ,$46.90 ,$20.10 ,$43.55 ,$48.24 ,$60.97 ,$50.25 
Carle BroMenn Medical Center,8382596,"CPT-CYTOGENETICS, 100-300, REF",,88275,311,$122.00 ,$122.00 ,$36.60 ,$111.02 ,$85.40 ,$36.60 ,$79.30 ,$87.84 ,$111.02 ,$91.50 
Carle BroMenn Medical Center,8382597,"CPT-CYTOGENETICS DNA PROBE, REF",,88271,311,$51.00 ,$51.00 ,$15.30 ,$46.41 ,$35.70 ,$15.30 ,$33.15 ,$36.72 ,$46.41 ,$38.25 
Carle BroMenn Medical Center,8382795,MOL CYTOGEN; DNA PROBE REF,,88271,311,$77.00 ,$77.00 ,$23.10 ,$70.07 ,$53.90 ,$23.10 ,$50.05 ,$55.44 ,$70.07 ,$57.75 
Carle BroMenn Medical Center,8382802,MOL CYTOGEN; HYBRIDIZ REF,,88273,311,$171.00 ,$171.00 ,$51.30 ,$155.61 ,$119.70 ,$51.30 ,$111.15 ,$123.12 ,$155.61 ,$128.25 
Carle BroMenn Medical Center,8383556,FLOW CYTOMTRY INTERPRETATN REF,,88189,311,$136.50 ,$136.50 ,$40.95 ,$124.22 ,$95.55 ,$40.95 ,$88.73 ,$98.28 ,$124.22 ,$102.38 
Carle BroMenn Medical Center,8383596,MOLEC CYTOGEN; DNA PROBE   REF,,88271,311,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8383597,MOL CYT INTRPH IS HYBRID   REF,,88275,311,$146.00 ,$146.00 ,$43.80 ,$132.86 ,$102.20 ,$43.80 ,$94.90 ,$105.12 ,$132.86 ,$109.50 
Carle BroMenn Medical Center,8383629,MOLEC CYTOGEN; HYBRIDIZATN REF,,88273,311,$217.75 ,$217.75 ,$65.33 ,$198.15 ,$152.43 ,$65.33 ,$141.54 ,$156.78 ,$198.15 ,$163.31 
Carle BroMenn Medical Center,8383865,TISS CULT NON-NEOPL LYMPH  REF,,88230,311,$867.75 ,$867.75 ,$260.33 ,$789.65 ,$607.43 ,$260.33 ,$564.04 ,$624.78 ,$789.65 ,$650.81 
Carle BroMenn Medical Center,8383870,TISSUE CULTURE   REF,,88230,311,$155.00 ,$155.00 ,$46.50 ,$141.05 ,$108.50 ,$46.50 ,$100.75 ,$111.60 ,$141.05 ,$116.25 
Carle BroMenn Medical Center,8384038,TISS CULT NON-NEOPL LYMPH  REF,,88230,311,$152.00 ,$152.00 ,$45.60 ,$138.32 ,$106.40 ,$45.60 ,$98.80 ,$109.44 ,$138.32 ,$114.00 
Carle BroMenn Medical Center,8384441,"CHROMOSOME, AMNIO CULT REF",,88235,311,$180.00 ,$180.00 ,$54.00 ,$163.80 ,$126.00 ,$54.00 ,$117.00 ,$129.60 ,$163.80 ,$135.00 
Carle BroMenn Medical Center,8386095,CYTO VAG/CER W/MANU W/PHY SUP,,G0145,311,$249.00 ,$249.00 ,$74.70 ,$226.59 ,$174.30 ,$74.70 ,$161.85 ,$179.28 ,$226.59 ,$186.75 
Carle BroMenn Medical Center,8386096,"DIAG CYTOL-ML; AUTO, MNL RESCN",,88175,311,$243.00 ,$243.00 ,$72.90 ,$221.13 ,$170.10 ,$72.90 ,$157.95 ,$174.96 ,$221.13 ,$182.25 
Carle BroMenn Medical Center,8386131,FLOW CYTOMTRY-EA ADNL MARKR RF,,88185,311,$10.00 ,$10.00 ,$3.00 ,$9.10 ,$7.00 ,$3.00 ,$6.50 ,$7.20 ,$9.10 ,$7.50 
Carle BroMenn Medical Center,8386411,FLOW CYTOMTRY-EA ADNL MARKR RF,,88185,311,$63.00 ,$63.00 ,$18.90 ,$57.33 ,$44.10 ,$18.90 ,$40.95 ,$45.36 ,$57.33 ,$47.25 
Carle BroMenn Medical Center,8388001,"CYTOPATH, CONC, SMEAR  REF",,88108,311,$146.00 ,$146.00 ,$43.80 ,$132.86 ,$102.20 ,$43.80 ,$94.90 ,$105.12 ,$132.86 ,$109.50 
Carle BroMenn Medical Center,8388012,DNA CONTENT,,88182,311,$253.50 ,$253.50 ,$76.05 ,$230.69 ,$177.45 ,$76.05 ,$164.78 ,$182.52 ,$230.69 ,$190.13 
Carle BroMenn Medical Center,8388108,"CYTOPATHOLOGY, CONCENTRATION T",,88108,311,$290.00 ,$290.00 ,$87.00 ,$263.90 ,$203.00 ,$87.00 ,$188.50 ,$208.80 ,$263.90 ,$217.50 
Carle BroMenn Medical Center,8388109,CHROMOSOME ANALYSIS REF,,88262,311,$155.00 ,$155.00 ,$46.50 ,$141.05 ,$108.50 ,$46.50 ,$100.75 ,$111.60 ,$141.05 ,$116.25 
Carle BroMenn Medical Center,8388112,CYTO LIQUID-BASED MONO LAYER,,88112,311,$214.50 ,$214.50 ,$64.35 ,$195.20 ,$150.15 ,$64.35 ,$139.43 ,$154.44 ,$195.20 ,$160.88 
Carle BroMenn Medical Center,8388120,"UROVYSION (FISH, BLADDER CANCER)",,88120,311,$290.00 ,$290.00 ,$87.00 ,$263.90 ,$203.00 ,$87.00 ,$188.50 ,$208.80 ,$263.90 ,$217.50 
Carle BroMenn Medical Center,8388142,DX CYTO PATH-ML CX /VAG,,88142,311,$167.00 ,$167.00 ,$50.10 ,$151.97 ,$116.90 ,$50.10 ,$108.55 ,$120.24 ,$151.97 ,$125.25 
Carle BroMenn Medical Center,8388145,TOUCH PREP CYTOLOGY,,88161,311,$152.75 ,$152.75 ,$45.83 ,$139.00 ,$106.93 ,$45.83 ,$99.29 ,$109.98 ,$139.00 ,$114.56 
Carle BroMenn Medical Center,8388156,SCREEN CYTO ML CX /VAG PAP,,G0123,311,$192.00 ,$192.00 ,$57.60 ,$174.72 ,$134.40 ,$57.60 ,$124.80 ,$138.24 ,$174.72 ,$144.00 
Carle BroMenn Medical Center,8388161,MISC CYTOLOGY,,88108,311,$146.00 ,$146.00 ,$43.80 ,$132.86 ,$102.20 ,$43.80 ,$94.90 ,$105.12 ,$132.86 ,$109.50 
Carle BroMenn Medical Center,8388177,"CYTOPATHOLOGY, FNA EVAL, IMMD STUDY",,88177,311,$172.25 ,$172.25 ,$51.68 ,$156.75 ,$120.58 ,$51.68 ,$111.96 ,$124.02 ,$156.75 ,$129.19 
Carle BroMenn Medical Center,8388184,FLOW CYTOMETRY  -FIRST MARKER,,88184,311,$624.00 ,$624.00 ,$187.20 ,$567.84 ,$436.80 ,$187.20 ,$405.60 ,$449.28 ,$567.84 ,$468.00 
Carle BroMenn Medical Center,8388185,FLOW  CYTOMETRY EA ADD MARKER,,88185,311,$186.00 ,$186.00 ,$55.80 ,$169.26 ,$130.20 ,$55.80 ,$120.90 ,$133.92 ,$169.26 ,$139.50 
Carle BroMenn Medical Center,8388233,TISSUE CULTURE -SKIN BIOPSY RF,,88233,311,$118.00 ,$118.00 ,$35.40 ,$107.38 ,$82.60 ,$35.40 ,$76.70 ,$84.96 ,$107.38 ,$88.50 
Carle BroMenn Medical Center,8388235,CHROMO AMNIO FLD CULTURE REF,,88235,311,$412.00 ,$412.00 ,$123.60 ,$374.92 ,$288.40 ,$123.60 ,$267.80 ,$296.64 ,$374.92 ,$309.00 
Carle BroMenn Medical Center,8388237,TISS CULT NEOPL BN MAR/BLD REF,,88237,311,$355.00 ,$355.00 ,$106.50 ,$323.05 ,$248.50 ,$106.50 ,$230.75 ,$255.60 ,$323.05 ,$266.25 
Carle BroMenn Medical Center,8388268,CHROM ANALYSIS W/BANDING   REF,,88262,311,$118.00 ,$118.00 ,$35.40 ,$107.38 ,$82.60 ,$35.40 ,$76.70 ,$84.96 ,$107.38 ,$88.50 
Carle BroMenn Medical Center,8388269,"CHROM ANALYSIS, IN SITU     REF",,88269,311,$334.75 ,$334.75 ,$100.43 ,$304.62 ,$234.33 ,$100.43 ,$217.59 ,$241.02 ,$304.62 ,$251.06 
Carle BroMenn Medical Center,8388270,CHROM 2 CARYOTYPES;BANDING REF,,88262,311,$266.50 ,$266.50 ,$79.95 ,$242.52 ,$186.55 ,$79.95 ,$173.23 ,$191.88 ,$242.52 ,$199.88 
Carle BroMenn Medical Center,8388271,MOLEC CYTOGEN; DNA PROBE   REF,,88271,311,$113.00 ,$113.00 ,$33.90 ,$102.83 ,$79.10 ,$33.90 ,$73.45 ,$81.36 ,$102.83 ,$84.75 
Carle BroMenn Medical Center,8388273,MOLEC CYTOGEN; HYBRIDIZATN REF,,88273,311,$197.00 ,$197.00 ,$59.10 ,$179.27 ,$137.90 ,$59.10 ,$128.05 ,$141.84 ,$179.27 ,$147.75 
Carle BroMenn Medical Center,8388280,CHROMO ANA AMNIO FLUID REF,,88280,311,$33.00 ,$33.00 ,$9.90 ,$30.03 ,$23.10 ,$9.90 ,$21.45 ,$23.76 ,$30.03 ,$24.75 
Carle BroMenn Medical Center,8388291,CYTO/MOLE GENE INTER REF,,88291,311,$135.00 ,$135.00 ,$40.50 ,$122.85 ,$94.50 ,$40.50 ,$87.75 ,$97.20 ,$122.85 ,$101.25 
Carle BroMenn Medical Center,8389007,CYTO/MOLE GENETICS INTER REF,,88291,311,$118.00 ,$118.00 ,$35.40 ,$107.38 ,$82.60 ,$35.40 ,$76.70 ,$84.96 ,$107.38 ,$88.50 
Carle BroMenn Medical Center,8389345,FLOW CYTOMETRY;FIRST MARKR REF,,88184,311,$78.00 ,$78.00 ,$23.40 ,$70.98 ,$54.60 ,$23.40 ,$50.70 ,$56.16 ,$70.98 ,$58.50 
Carle BroMenn Medical Center,8108003,SURG PATH GROSS ONLY,,88300,312,$109.00 ,$109.00 ,$32.70 ,$99.19 ,$76.30 ,$32.70 ,$70.85 ,$78.48 ,$99.19 ,$81.75 
Carle BroMenn Medical Center,8108004,SURG PATH MICRO ID,,88302,312,$180.00 ,$180.00 ,$54.00 ,$163.80 ,$126.00 ,$54.00 ,$117.00 ,$129.60 ,$163.80 ,$135.00 
Carle BroMenn Medical Center,8108005,SURGICAL PATH ROUTINE,,88304,312,$248.00 ,$248.00 ,$74.40 ,$225.68 ,$173.60 ,$74.40 ,$161.20 ,$178.56 ,$225.68 ,$186.00 
Carle BroMenn Medical Center,8108006,SURG PATH-SKIN MICROSCOPC EXAM,,88305,312,$304.00 ,$304.00 ,$91.20 ,$276.64 ,$212.80 ,$91.20 ,$197.60 ,$218.88 ,$276.64 ,$228.00 
Carle BroMenn Medical Center,8108007,"LEVEL IV SURG PATH,GROSS&MICRO",,88305,312,$304.00 ,$304.00 ,$91.20 ,$276.64 ,$212.80 ,$91.20 ,$197.60 ,$218.88 ,$276.64 ,$228.00 
Carle BroMenn Medical Center,8108008,SURG PATH COMPL SPEC(S),,88307,312,$533.00 ,$533.00 ,$159.90 ,$485.03 ,$373.10 ,$159.90 ,$346.45 ,$383.76 ,$485.03 ,$399.75 
Carle BroMenn Medical Center,8108009,SURG PATH COMPLEX DX,,88309,312,$615.00 ,$615.00 ,$184.50 ,$559.65 ,$430.50 ,$184.50 ,$399.75 ,$442.80 ,$559.65 ,$461.25 
Carle BroMenn Medical Center,8108010,DECAL. PROCEDURE,,88311,312,$116.00 ,$116.00 ,$34.80 ,$105.56 ,$81.20 ,$34.80 ,$75.40 ,$83.52 ,$105.56 ,$87.00 
Carle BroMenn Medical Center,8108011,SPECIAL STAINS GROUP 1,,88312,312,$158.00 ,$158.00 ,$47.40 ,$143.78 ,$110.60 ,$47.40 ,$102.70 ,$113.76 ,$143.78 ,$118.50 
Carle BroMenn Medical Center,8108012,SPECIAL STAIN GROUP 2,,88313,312,$203.00 ,$203.00 ,$60.90 ,$184.73 ,$142.10 ,$60.90 ,$131.95 ,$146.16 ,$184.73 ,$152.25 
Carle BroMenn Medical Center,8108013,IMMUNOCHEM ANTIBODY,,88342,312,$356.00 ,$356.00 ,$106.80 ,$323.96 ,$249.20 ,$106.80 ,$231.40 ,$256.32 ,$323.96 ,$267.00 
Carle BroMenn Medical Center,8380237,MORPH ANALYSIS IN SITU HYBRIDZTN EA PROBE CMPTR ASST,,88367,312,$857.00 ,$857.00 ,$257.10 ,$779.87 ,$599.90 ,$257.10 ,$557.05 ,$617.04 ,$779.87 ,$642.75 
Carle BroMenn Medical Center,8380238,MORPH ANALYSIS IN SITU HYBRIDZTN EA PROBE MANUAL,,88368,312,$699.00 ,$699.00 ,$209.70 ,$636.09 ,$489.30 ,$209.70 ,$454.35 ,$503.28 ,$636.09 ,$524.25 
Carle BroMenn Medical Center,8380476,MLH1 IHC    REF,,88342,312,$45.00 ,$45.00 ,$13.50 ,$40.95 ,$31.50 ,$13.50 ,$29.25 ,$32.40 ,$40.95 ,$33.75 
Carle BroMenn Medical Center,8380477,MSH2 IHC    REF,,88342,312,$48.00 ,$48.00 ,$14.40 ,$43.68 ,$33.60 ,$14.40 ,$31.20 ,$34.56 ,$43.68 ,$36.00 
Carle BroMenn Medical Center,8380478,MSH6 IHC    REF,,88342,312,$45.00 ,$45.00 ,$13.50 ,$40.95 ,$31.50 ,$13.50 ,$29.25 ,$32.40 ,$40.95 ,$33.75 
Carle BroMenn Medical Center,8380479,PMS2 IHC    REF,,88342,312,$46.00 ,$46.00 ,$13.80 ,$41.86 ,$32.20 ,$13.80 ,$29.90 ,$33.12 ,$41.86 ,$34.50 
Carle BroMenn Medical Center,8380519,"CPT-MICRODISECTION, MANUAL        MML",,88381,312,$32.00 ,$32.00 ,$9.60 ,$29.12 ,$22.40 ,$9.60 ,$20.80 ,$23.04 ,$29.12 ,$24.00 
Carle BroMenn Medical Center,8381234,IHC EA ADDTL SINGLE AB STAIN PROCEDURE REF,,88341,312,$312.00 ,$312.00 ,$93.60 ,$283.92 ,$218.40 ,$93.60 ,$202.80 ,$224.64 ,$283.92 ,$234.00 
Carle BroMenn Medical Center,8381237,IN SITU HYBRID EA ADDTL SINGLE PROBE REF,,88364,312,$123.50 ,$123.50 ,$37.05 ,$112.39 ,$86.45 ,$37.05 ,$80.28 ,$88.92 ,$112.39 ,$92.63 
Carle BroMenn Medical Center,8381240,"MORPH ANALY, IN SITU HYBRID, COMP ASST, EA MULTIPLEX REF",,88374,312,$247.00 ,$247.00 ,$74.10 ,$224.77 ,$172.90 ,$74.10 ,$160.55 ,$177.84 ,$224.77 ,$185.25 
Carle BroMenn Medical Center,8381522,ANTI-ENDOMYSIAL (EMA) IGA AB (CELIAC-PROMETH) REF,,88346,312,$240.50 ,$240.50 ,$72.15 ,$218.86 ,$168.35 ,$72.15 ,$156.33 ,$173.16 ,$218.86 ,$180.38 
Carle BroMenn Medical Center,8381523,ANTI-ENDOMYSIAL (EMA) IGA AB (CELIAC-PROMETH)  REF,,88346,312,$74.00 ,$74.00 ,$22.20 ,$67.34 ,$51.80 ,$22.20 ,$48.10 ,$53.28 ,$67.34 ,$55.50 
Carle BroMenn Medical Center,8381526,IMMFL ST; SINGLE AG PER SPEC (CROHN-PROM) REF,,88346,312,$74.00 ,$74.00 ,$22.20 ,$67.34 ,$51.80 ,$22.20 ,$48.10 ,$53.28 ,$67.34 ,$55.50 
Carle BroMenn Medical Center,8381528,IMMFL ST; SINGLE AB PER SPEC (SGI-PROM) REF,,88346,312,$74.00 ,$74.00 ,$22.20 ,$67.34 ,$51.80 ,$22.20 ,$48.10 ,$53.28 ,$67.34 ,$55.50 
Carle BroMenn Medical Center,8381678,"IHC EA ADDTL SINGLE AB STAIN PROCEDURE, REF",,88341,312,$384.00 ,$384.00 ,$115.20 ,$349.44 ,$268.80 ,$115.20 ,$249.60 ,$276.48 ,$349.44 ,$288.00 
Carle BroMenn Medical Center,8381680,"MORPH ANALY, IN SITU HYBRID, COMP ASST, EA MULTIPLEX, REF",,88374,312,$304.00 ,$304.00 ,$91.20 ,$276.64 ,$212.80 ,$91.20 ,$197.60 ,$218.88 ,$276.64 ,$228.00 
Carle BroMenn Medical Center,8381681,"IN SITU HYBRID, EA ADDTL SINGLE PROBE, REF",,88364,312,$152.00 ,$152.00 ,$45.60 ,$138.32 ,$106.40 ,$45.60 ,$98.80 ,$109.44 ,$138.32 ,$114.00 
Carle BroMenn Medical Center,8385585,TUMOR IMMUNOCHEM MANUAL    REF,,88360,312,$507.00 ,$507.00 ,$152.10 ,$461.37 ,$354.90 ,$152.10 ,$329.55 ,$365.04 ,$461.37 ,$380.25 
Carle BroMenn Medical Center,8385665,SPECIAL STAINS GROUP I     REF,,88312,312,$158.00 ,$158.00 ,$47.40 ,$143.78 ,$110.60 ,$47.40 ,$102.70 ,$113.76 ,$143.78 ,$118.50 
Carle BroMenn Medical Center,8385667,SPECIAL STAINS GROUP II    REF,,88313,312,$203.00 ,$203.00 ,$60.90 ,$184.73 ,$142.10 ,$60.90 ,$131.95 ,$146.16 ,$184.73 ,$152.25 
Carle BroMenn Medical Center,8386427,TUMOR IMMUNOCHEM MANUAL,,88360,312,$580.00 ,$580.00 ,$174.00 ,$527.80 ,$406.00 ,$174.00 ,$377.00 ,$417.60 ,$527.80 ,$435.00 
Carle BroMenn Medical Center,8388312,SPECIAL STAINS -GROUP I,,88312,312,$214.50 ,$214.50 ,$64.35 ,$195.20 ,$150.15 ,$64.35 ,$139.43 ,$154.44 ,$195.20 ,$160.88 
Carle BroMenn Medical Center,8388313,SPECIAL STAINS -GROUP II,,88313,312,$126.75 ,$126.75 ,$38.03 ,$115.34 ,$88.73 ,$38.03 ,$82.39 ,$91.26 ,$115.34 ,$95.06 
Carle BroMenn Medical Center,8388323,TECHNICL PREP-PATH CONSULT REF,,88323,312,$299.00 ,$299.00 ,$89.70 ,$272.09 ,$209.30 ,$89.70 ,$194.35 ,$215.28 ,$272.09 ,$224.25 
Carle BroMenn Medical Center,8388334,INTRAOPERATIVE PATHOLOGY EXAM,,88334,312,$211.25 ,$211.25 ,$63.38 ,$192.24 ,$147.88 ,$63.38 ,$137.31 ,$152.10 ,$192.24 ,$158.44 
Carle BroMenn Medical Center,8388341,IHC EA ADDTL SINGLE AB STAIN PROCEDURE,,88341,312,$128.70 ,$128.70 ,$38.61 ,$117.12 ,$90.09 ,$38.61 ,$83.66 ,$92.66 ,$117.12 ,$96.53 
Carle BroMenn Medical Center,8388344,IHC EA MULTIPLEX AB STAIN PROCEDURE,,88344,312,$876.00 ,$876.00 ,$262.80 ,$797.16 ,$613.20 ,$262.80 ,$569.40 ,$630.72 ,$797.16 ,$657.00 
Carle BroMenn Medical Center,8388346,IMMUNOFL STDY DIRECT EA AB REF,,88346,312,$296.00 ,$296.00 ,$88.80 ,$269.36 ,$207.20 ,$88.80 ,$192.40 ,$213.12 ,$269.36 ,$222.00 
Carle BroMenn Medical Center,8388361,TUMOR IMM HISTOCHEM W/COMPUTER,,88361,312,"$1,216.00 ","$1,216.00 ",$364.80 ,"$1,106.56 ",$851.20 ,$364.80 ,$790.40 ,$875.52 ,"$1,106.56 ",$912.00 
Carle BroMenn Medical Center,8388364,IN SITU HYBRID EA ADDTL SINGLE PROBE,,88364,312,$693.00 ,$693.00 ,$207.90 ,$630.63 ,$485.10 ,$207.90 ,$450.45 ,$498.96 ,$630.63 ,$519.75 
Carle BroMenn Medical Center,8388366,IN SITU HYBRID EA MULTIPLEX PROBE STAIN,,88366,312,$813.00 ,$813.00 ,$243.90 ,$739.83 ,$569.10 ,$243.90 ,$528.45 ,$585.36 ,$739.83 ,$609.75 
Carle BroMenn Medical Center,8388367,MORPHOMETRIC ANALYSIS -EACH,,88367,312,$562.25 ,$562.25 ,$168.68 ,$511.65 ,$393.58 ,$168.68 ,$365.46 ,$404.82 ,$511.65 ,$421.69 
Carle BroMenn Medical Center,8388368,MORPHOMETRIC ANALYSIS -EACH,,88368,312,$266.50 ,$266.50 ,$79.95 ,$242.52 ,$186.55 ,$79.95 ,$173.23 ,$191.88 ,$242.52 ,$199.88 
Carle BroMenn Medical Center,8388369,"MORPH ANALY, IN SITU HYBRID, MANUAL, EA ADDTL SINGLE PROBE",,88369,312,$466.00 ,$466.00 ,$139.80 ,$424.06 ,$326.20 ,$139.80 ,$302.90 ,$335.52 ,$424.06 ,$349.50 
Carle BroMenn Medical Center,8388373,"MORPH ANALY, IN SITU HYBRID, COMP ASST, EA ADDTL STAIN",,88373,312,$397.00 ,$397.00 ,$119.10 ,$361.27 ,$277.90 ,$119.10 ,$258.05 ,$285.84 ,$361.27 ,$297.75 
Carle BroMenn Medical Center,8388374,"MORPH ANALY, IN SITU HYBRID, COMP ASST, EA MULTIPLEX",,88374,312,"$1,336.00 ","$1,336.00 ",$400.80 ,"$1,215.76 ",$935.20 ,$400.80 ,$868.40 ,$961.92 ,"$1,215.76 ","$1,002.00 "
Carle BroMenn Medical Center,8388377,"MORPH ANALY, IN SITU HYBRID, MANUAL, EA MULTIPLEX",,88377,312,"$1,455.00 ","$1,455.00 ",$436.50 ,"$1,324.05 ","$1,018.50 ",$436.50 ,$945.75 ,"$1,047.60 ","$1,324.05 ","$1,091.25 "
Carle BroMenn Medical Center,8388381,MICRODISSECTION MANUAL,,88381,312,$233.00 ,$233.00 ,$69.90 ,$212.03 ,$163.10 ,$69.90 ,$151.45 ,$167.76 ,$212.03 ,$174.75 
Carle BroMenn Medical Center,8388399,UNLISTED PATH,,88399,312,$39.65 ,$39.65 ,$11.90 ,$36.08 ,$27.76 ,$11.90 ,$25.77 ,$28.55 ,$36.08 ,$29.74 
Carle BroMenn Medical Center,8388413,SPECIAL STAINS -GROUP II,,88313,312,$258.00 ,$258.00 ,$77.40 ,$234.78 ,$180.60 ,$77.40 ,$167.70 ,$185.76 ,$234.78 ,$193.50 
Carle BroMenn Medical Center,8388423,MICRO SLIDE PREPR FOR CONSULT,,88323,312,$325.00 ,$325.00 ,$97.50 ,$295.75 ,$227.50 ,$97.50 ,$211.25 ,$234.00 ,$295.75 ,$243.75 
Carle BroMenn Medical Center,8388442,IMMUNOCHEM ANTIBODY,,88342,312,$158.60 ,$158.60 ,$47.58 ,$144.33 ,$111.02 ,$47.58 ,$103.09 ,$114.19 ,$144.33 ,$118.95 
Carle BroMenn Medical Center,8388446,IMMUNOFL STDY DIRECT EA AB,,88346,312,$699.00 ,$699.00 ,$209.70 ,$636.09 ,$489.30 ,$209.70 ,$454.35 ,$503.28 ,$636.09 ,$524.25 
Carle BroMenn Medical Center,8389210,TUMR IMMUNOHISTOCHM W/CMPTR RF,,88361,312,$559.00 ,$559.00 ,$167.70 ,$508.69 ,$391.30 ,$167.70 ,$363.35 ,$402.48 ,$508.69 ,$419.25 
Carle BroMenn Medical Center,8389256,MORPHOMETRIC ANALYSIS-EACH REF,,88368,312,$183.00 ,$183.00 ,$54.90 ,$166.53 ,$128.10 ,$54.90 ,$118.95 ,$131.76 ,$166.53 ,$137.25 
Carle BroMenn Medical Center,8389350,IMMUNOCHEM ANTIBODY       REF,,88342,312,$356.00 ,$356.00 ,$106.80 ,$323.96 ,$249.20 ,$106.80 ,$231.40 ,$256.32 ,$323.96 ,$267.00 
Carle BroMenn Medical Center,8381196,"PROSTATE NEEDLE BX SPECIMENS, ANY METHOD",,G0416,314,$819.00 ,$819.00 ,$245.70 ,$745.29 ,$573.30 ,$245.70 ,$532.35 ,$589.68 ,$745.29 ,$614.25 
Carle BroMenn Medical Center,8107013,FEMUR XRAYS 2 VIEWS,,73550,320,$325.00 ,$325.00 ,$97.50 ,$295.75 ,$227.50 ,$97.50 ,$211.25 ,$234.00 ,$295.75 ,$243.75 
Carle BroMenn Medical Center,8107098,C-ARM/FLUORO,,76000,320,$780.00 ,$780.00 ,$234.00 ,$709.80 ,$546.00 ,$234.00 ,$507.00 ,$561.60 ,$709.80 ,$585.00 
Carle BroMenn Medical Center,8107107,FLUORO GDNC -CNTRL VN ACC DVC,,77001,320,$490.00 ,$490.00 ,$147.00 ,$445.90 ,$343.00 ,$147.00 ,$318.50 ,$352.80 ,$445.90 ,$367.50 
Carle BroMenn Medical Center,8107108,FLUORO GDNC -CNTRL VN ACC DVC,,77001,320,$490.00 ,$490.00 ,$147.00 ,$445.90 ,$343.00 ,$147.00 ,$318.50 ,$352.80 ,$445.90 ,$367.50 
Carle BroMenn Medical Center,8107109,FLUORO GUIDANCE -NEEDLE PLCMNT,,77002,320,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8107110,FLUORO GUIDNC ASP/BX/DRAINAGE,,77002,320,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8107111,FLUORO SPINE/PARASPINAL DX/TX,,77003,320,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8270250,G X-RAY SKULL <4 VW,,70250,320,$420.00 ,$420.00 ,$126.00 ,$382.20 ,$294.00 ,$126.00 ,$273.00 ,$302.40 ,$382.20 ,$315.00 
Carle BroMenn Medical Center,8270350,G X-RAY HEAD FOR ORTHODONTIA,,70350,320,$300.00 ,$300.00 ,$90.00 ,$273.00 ,$210.00 ,$90.00 ,$195.00 ,$216.00 ,$273.00 ,$225.00 
Carle BroMenn Medical Center,8270355,G PANORAMIC X-RAY OF JAWS,,70355,320,$330.00 ,$330.00 ,$99.00 ,$300.30 ,$231.00 ,$99.00 ,$214.50 ,$237.60 ,$300.30 ,$247.50 
Carle BroMenn Medical Center,8270380,X-RAY SALIVARY GLAND,,70380,320,$565.00 ,$565.00 ,$169.50 ,$514.15 ,$395.50 ,$169.50 ,$367.25 ,$406.80 ,$514.15 ,$423.75 
Carle BroMenn Medical Center,8274740,X-RAY HYSTEROSALPINGOGRAM,,74740,320,"$1,245.00 ","$1,245.00 ",$373.50 ,"$1,132.95 ",$871.50 ,$373.50 ,$809.25 ,$896.40 ,"$1,132.95 ",$933.75 
Carle BroMenn Medical Center,8277002,FLUOROSCOPIC GUIDANCE NEEDLE PLACEMENT,,77002,320,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8277003,FLUORSCOPIC GUIDANCE SPINAL INJECTION,,77003,320,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8400017,BODY COMPOSITION SCANNING,,,320,$40.00 ,$40.00 ,$12.00 ,$36.40 ,$28.00 ,$12.00 ,$26.00 ,$28.80 ,$36.40 ,$30.00 
Carle BroMenn Medical Center,8405710,ANGIO EXTREMITY UNILAT S&I,,75710,320,"$2,415.00 ","$2,415.00 ",$724.50 ,"$2,197.65 ","$1,690.50 ",$724.50 ,"$1,569.75 ","$1,738.80 ","$2,197.65 ","$1,811.25 "
Carle BroMenn Medical Center,8427096,GD SI JOINT INJECTION,,27096,320,"$1,807.00 ","$1,807.00 ",$542.10 ,"$1,644.37 ","$1,264.90 ",$542.10 ,"$1,174.55 ","$1,301.04 ","$1,644.37 ","$1,355.25 "
Carle BroMenn Medical Center,8447531,NJX CHOLANGIO PRQ W/IMG GID RS&I EXISTING ACCESS,,47531,320,"$1,655.00 ","$1,655.00 ",$496.50 ,"$1,506.05 ","$1,158.50 ",$496.50 ,"$1,075.75 ","$1,191.60 ","$1,506.05 ","$1,241.25 "
Carle BroMenn Medical Center,8451100,ASPIRATION - BLADDER,,51100,320,$908.00 ,$908.00 ,$272.40 ,$826.28 ,$635.60 ,$272.40 ,$590.20 ,$653.76 ,$826.28 ,$681.00 
Carle BroMenn Medical Center,8462323,INJ DX/THER SBST INTRLMNR LMBR/SAC W/ IMG GDN,,62323,320,"$1,170.00 ","$1,170.00 ",$351.00 ,"$1,064.70 ",$819.00 ,$351.00 ,$760.50 ,$842.40 ,"$1,064.70 ",$877.50 
Carle BroMenn Medical Center,8470015,"CISTERNOGRAPHY,POS CONTRAST",,70015,320,"$3,185.00 ","$3,185.00 ",$955.50 ,"$2,898.35 ","$2,229.50 ",$955.50 ,"$2,070.25 ","$2,293.20 ","$2,898.35 ","$2,388.75 "
Carle BroMenn Medical Center,8470030,EYE/ORBIT XRAY,,70030,320,$398.00 ,$398.00 ,$119.40 ,$362.18 ,$278.60 ,$119.40 ,$258.70 ,$286.56 ,$362.18 ,$298.50 
Carle BroMenn Medical Center,8470100,MANDIBLE XRAYS <4 VIEWS,,70100,320,$300.00 ,$300.00 ,$90.00 ,$273.00 ,$210.00 ,$90.00 ,$195.00 ,$216.00 ,$273.00 ,$225.00 
Carle BroMenn Medical Center,8470110,MANDIBLE XRAYS 4/> VIEWS,,70110,320,$505.00 ,$505.00 ,$151.50 ,$459.55 ,$353.50 ,$151.50 ,$328.25 ,$363.60 ,$459.55 ,$378.75 
Carle BroMenn Medical Center,8470120,MASTOID XRAYS <3 VIEWS,,70120,320,$545.00 ,$545.00 ,$163.50 ,$495.95 ,$381.50 ,$163.50 ,$354.25 ,$392.40 ,$495.95 ,$408.75 
Carle BroMenn Medical Center,8470130,X-RAY MASTOIDS 3+ VW,,70130,320,$615.00 ,$615.00 ,$184.50 ,$559.65 ,$430.50 ,$184.50 ,$399.75 ,$442.80 ,$559.65 ,$461.25 
Carle BroMenn Medical Center,8470134,"XRAY INTERNAL AUDITORY MEATI, COMPLETE",,70134,320,$488.00 ,$488.00 ,$146.40 ,$444.08 ,$341.60 ,$146.40 ,$317.20 ,$351.36 ,$444.08 ,$366.00 
Carle BroMenn Medical Center,8470140,FACIAL BONES XRAYS <3 VIEWS,,70140,320,$405.00 ,$405.00 ,$121.50 ,$368.55 ,$283.50 ,$121.50 ,$263.25 ,$291.60 ,$368.55 ,$303.75 
Carle BroMenn Medical Center,8470150,FACIAL BONES XRAYS 3/> VIEWS,,70150,320,$620.00 ,$620.00 ,$186.00 ,$564.20 ,$434.00 ,$186.00 ,$403.00 ,$446.40 ,$564.20 ,$465.00 
Carle BroMenn Medical Center,8470160,NASAL BONES XRAYS 3/> VIEWS,,70160,320,$330.00 ,$330.00 ,$99.00 ,$300.30 ,$231.00 ,$99.00 ,$214.50 ,$237.60 ,$300.30 ,$247.50 
Carle BroMenn Medical Center,8470190,OPTIC FORAMINA XRAYS,,70190,320,$263.00 ,$263.00 ,$78.90 ,$239.33 ,$184.10 ,$78.90 ,$170.95 ,$189.36 ,$239.33 ,$197.25 
Carle BroMenn Medical Center,8470200,ORBITS XRAYS 4/> VIEWS,,70200,320,$620.00 ,$620.00 ,$186.00 ,$564.20 ,$434.00 ,$186.00 ,$403.00 ,$446.40 ,$564.20 ,$465.00 
Carle BroMenn Medical Center,8470210,SINUS/PARANASAL XRAYS <3 VIEWS,,70210,320,$330.00 ,$330.00 ,$99.00 ,$300.30 ,$231.00 ,$99.00 ,$214.50 ,$237.60 ,$300.30 ,$247.50 
Carle BroMenn Medical Center,8470220,SINUS/PARANASAL XRAYS 3/> VWS,,70220,320,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8470240,SELLA TURCICA XRAYS,,70240,320,$300.00 ,$300.00 ,$90.00 ,$273.00 ,$210.00 ,$90.00 ,$195.00 ,$216.00 ,$273.00 ,$225.00 
Carle BroMenn Medical Center,8470250,SKULL XRAYS <4 VIEWS,,70250,320,$420.00 ,$420.00 ,$126.00 ,$382.20 ,$294.00 ,$126.00 ,$273.00 ,$302.40 ,$382.20 ,$315.00 
Carle BroMenn Medical Center,8470260,SKULL XRAYS 4/> VIEWS,,70260,320,$620.00 ,$620.00 ,$186.00 ,$564.20 ,$434.00 ,$186.00 ,$403.00 ,$446.40 ,$564.20 ,$465.00 
Carle BroMenn Medical Center,8470320,TEETH XRAY - FULL MOUTH,,70320,320,$195.00 ,$195.00 ,$58.50 ,$177.45 ,$136.50 ,$58.50 ,$126.75 ,$140.40 ,$177.45 ,$146.25 
Carle BroMenn Medical Center,8470328,TMJ XRAYS -UNILATERAL,,70328,320,$338.00 ,$338.00 ,$101.40 ,$307.58 ,$236.60 ,$101.40 ,$219.70 ,$243.36 ,$307.58 ,$253.50 
Carle BroMenn Medical Center,8470330,TMJ XRAYS -BILATERAL,,70330,320,$375.00 ,$375.00 ,$112.50 ,$341.25 ,$262.50 ,$112.50 ,$243.75 ,$270.00 ,$341.25 ,$281.25 
Carle BroMenn Medical Center,8470350,CEPHALOGRAM ORTHODONTIC,,70350,320,$300.00 ,$300.00 ,$90.00 ,$273.00 ,$210.00 ,$90.00 ,$195.00 ,$216.00 ,$273.00 ,$225.00 
Carle BroMenn Medical Center,8470355,ORTHOPANTOGRAM,,70355,320,$330.00 ,$330.00 ,$99.00 ,$300.30 ,$231.00 ,$99.00 ,$214.50 ,$237.60 ,$300.30 ,$247.50 
Carle BroMenn Medical Center,8470360,NECK TISSUE XRAY,,70360,320,$330.00 ,$330.00 ,$99.00 ,$300.30 ,$231.00 ,$99.00 ,$214.50 ,$237.60 ,$300.30 ,$247.50 
Carle BroMenn Medical Center,8470380,GD SALIVA GLAND/DUCT,,70380,320,$565.00 ,$565.00 ,$169.50 ,$514.15 ,$395.50 ,$169.50 ,$367.25 ,$406.80 ,$514.15 ,$423.75 
Carle BroMenn Medical Center,8471045,RADIOLOGIC EXAM CHEST SINGLE VIEW,,71045,320,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8471046,RADIOLOGIC EXAM CHEST 2 VIEWS,,71046,320,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8471047,RADIOLOGIC EXAM CHEST 3 VIEWS,,71047,320,$300.00 ,$300.00 ,$90.00 ,$273.00 ,$210.00 ,$90.00 ,$195.00 ,$216.00 ,$273.00 ,$225.00 
Carle BroMenn Medical Center,8471048,RADIOLOGIC EXAM CHEST 4+ VIEWS,,71048,320,$330.00 ,$330.00 ,$99.00 ,$300.30 ,$231.00 ,$99.00 ,$214.50 ,$237.60 ,$300.30 ,$247.50 
Carle BroMenn Medical Center,8471100,RIB XRAY UNILATERAL 2 VIEWS,,71100,320,$290.00 ,$290.00 ,$87.00 ,$263.90 ,$203.00 ,$87.00 ,$188.50 ,$208.80 ,$263.90 ,$217.50 
Carle BroMenn Medical Center,8471101,RIB XRAY UNI W/PA CHEST 3/> VW,,71101,320,$488.00 ,$488.00 ,$146.40 ,$444.08 ,$341.60 ,$146.40 ,$317.20 ,$351.36 ,$444.08 ,$366.00 
Carle BroMenn Medical Center,8471110,RIB XRAYS BILATERAL 3 VIEWS,,71110,320,$505.00 ,$505.00 ,$151.50 ,$459.55 ,$353.50 ,$151.50 ,$328.25 ,$363.60 ,$459.55 ,$378.75 
Carle BroMenn Medical Center,8471111,RIB XRAY BIL W/PA CHEST 4/>VWS,,71111,320,$540.00 ,$540.00 ,$162.00 ,$491.40 ,$378.00 ,$162.00 ,$351.00 ,$388.80 ,$491.40 ,$405.00 
Carle BroMenn Medical Center,8471120,STERNUM XRAYS 2/> VIEWS,,71120,320,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8471130,STERNOCLAVICULAR XRAYS 3/> VWS,,71130,320,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8472020,SPINE XRAY SINGLE VIEW,,72020,320,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8472040,CERVICAL SPINE XRAYS 2-3 VIEWS,,72040,320,$330.00 ,$330.00 ,$99.00 ,$300.30 ,$231.00 ,$99.00 ,$214.50 ,$237.60 ,$300.30 ,$247.50 
Carle BroMenn Medical Center,8472050,CERVICAL SPINE XRAYS 4/> VIEWS,,72050,320,$620.00 ,$620.00 ,$186.00 ,$564.20 ,$434.00 ,$186.00 ,$403.00 ,$446.40 ,$564.20 ,$465.00 
Carle BroMenn Medical Center,8472052,CERV SPINE XRAYS W/OBL/FLX/EXT,,72052,320,$505.00 ,$505.00 ,$151.50 ,$459.55 ,$353.50 ,$151.50 ,$328.25 ,$363.60 ,$459.55 ,$378.75 
Carle BroMenn Medical Center,8472070,THORACIC SPINE XRAYS 2 VIEWS,,72070,320,$505.00 ,$505.00 ,$151.50 ,$459.55 ,$353.50 ,$151.50 ,$328.25 ,$363.60 ,$459.55 ,$378.75 
Carle BroMenn Medical Center,8472072,THORACIC SPINE XRAYS 3 VIEWS,,72072,320,$620.00 ,$620.00 ,$186.00 ,$564.20 ,$434.00 ,$186.00 ,$403.00 ,$446.40 ,$564.20 ,$465.00 
Carle BroMenn Medical Center,8472074,THORACIC SPINE XRAYS 4/> VIEWS,,72074,320,$565.00 ,$565.00 ,$169.50 ,$514.15 ,$395.50 ,$169.50 ,$367.25 ,$406.80 ,$514.15 ,$423.75 
Carle BroMenn Medical Center,8472080,THORACOLUMBAR XRAYS 2 VIEWS,,72080,320,$398.00 ,$398.00 ,$119.40 ,$362.18 ,$278.60 ,$119.40 ,$258.70 ,$286.56 ,$362.18 ,$298.50 
Carle BroMenn Medical Center,8472081,CHG RADEX ENTIR THRC LMBR CRV SAC SPI W/SKULL 1 VW,,72081,320,$503.00 ,$503.00 ,$150.90 ,$457.73 ,$352.10 ,$150.90 ,$326.95 ,$362.16 ,$457.73 ,$377.25 
Carle BroMenn Medical Center,8472082,CHG RADEX ENTIR THRC LMBR CRV SAC SPI W/SKULL 2/3 VW,,72082,320,$620.00 ,$620.00 ,$186.00 ,$564.20 ,$434.00 ,$186.00 ,$403.00 ,$446.40 ,$564.20 ,$465.00 
Carle BroMenn Medical Center,8472083,CHG RADEX ENTIR THRC LMBR CRV SAC SPI W/SKULL 4/5 VW,,72083,320,$983.00 ,$983.00 ,$294.90 ,$894.53 ,$688.10 ,$294.90 ,$638.95 ,$707.76 ,$894.53 ,$737.25 
Carle BroMenn Medical Center,8472084,CHG RADEX ENTIR THRC LMBR CRV SAC SPI W/SKULL 6/> VW,,72084,320,"$1,170.00 ","$1,170.00 ",$351.00 ,"$1,064.70 ",$819.00 ,$351.00 ,$760.50 ,$842.40 ,"$1,064.70 ",$877.50 
Carle BroMenn Medical Center,8472100,LUMBOSACRAL XRAYS 2-3 VIEWS,,72100,320,$505.00 ,$505.00 ,$151.50 ,$459.55 ,$353.50 ,$151.50 ,$328.25 ,$363.60 ,$459.55 ,$378.75 
Carle BroMenn Medical Center,8472110,LUMBOSACRAL XRAYS 4/> VIEWS,,72110,320,$505.00 ,$505.00 ,$151.50 ,$459.55 ,$353.50 ,$151.50 ,$328.25 ,$363.60 ,$459.55 ,$378.75 
Carle BroMenn Medical Center,8472114,LUMBOSACRAL XRAYS W/BENDING VW,,72114,320,$505.00 ,$505.00 ,$151.50 ,$459.55 ,$353.50 ,$151.50 ,$328.25 ,$363.60 ,$459.55 ,$378.75 
Carle BroMenn Medical Center,8472120,LUMBOSACRAL BENDING VIEWS ONLY,,72120,320,$330.00 ,$330.00 ,$99.00 ,$300.30 ,$231.00 ,$99.00 ,$214.50 ,$237.60 ,$300.30 ,$247.50 
Carle BroMenn Medical Center,8472170,PELVIS XRAYS 1-2 VIEWS,,72170,320,$505.00 ,$505.00 ,$151.50 ,$459.55 ,$353.50 ,$151.50 ,$328.25 ,$363.60 ,$459.55 ,$378.75 
Carle BroMenn Medical Center,8472190,PELVIS XRAYS 3/> VIEWS,,72190,320,$505.00 ,$505.00 ,$151.50 ,$459.55 ,$353.50 ,$151.50 ,$328.25 ,$363.60 ,$459.55 ,$378.75 
Carle BroMenn Medical Center,8472200,SACROILIAC JOINTS XRAYS <3 VWS,,72200,320,$495.00 ,$495.00 ,$148.50 ,$450.45 ,$346.50 ,$148.50 ,$321.75 ,$356.40 ,$450.45 ,$371.25 
Carle BroMenn Medical Center,8472202,SACROILIAC JOINTS 3 OR MORE VIEWS,,72202,320,$505.00 ,$505.00 ,$151.50 ,$459.55 ,$353.50 ,$151.50 ,$328.25 ,$363.60 ,$459.55 ,$378.75 
Carle BroMenn Medical Center,8472220,SACRUM & COCCYX XRAYS 2/> VWS,,72220,320,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8472240,MYELOGRAM - CERVICAL SPINE S&I,,72240,320,"$2,670.00 ","$2,670.00 ",$801.00 ,"$2,429.70 ","$1,869.00 ",$801.00 ,"$1,735.50 ","$1,922.40 ","$2,429.70 ","$2,002.50 "
Carle BroMenn Medical Center,8472255,MYELOGRAM -THORACIC SPINE S&I,,72255,320,"$1,275.00 ","$1,275.00 ",$382.50 ,"$1,160.25 ",$892.50 ,$382.50 ,$828.75 ,$918.00 ,"$1,160.25 ",$956.25 
Carle BroMenn Medical Center,8472265,MYELOGRAM -LUMBAR SPINE S&I,,72265,320,"$2,025.00 ","$2,025.00 ",$607.50 ,"$1,842.75 ","$1,417.50 ",$607.50 ,"$1,316.25 ","$1,458.00 ","$1,842.75 ","$1,518.75 "
Carle BroMenn Medical Center,8472270,MYELOGRAM 2-3 REGIONS S&I,,72270,320,"$2,250.00 ","$2,250.00 ",$675.00 ,"$2,047.50 ","$1,575.00 ",$675.00 ,"$1,462.50 ","$1,620.00 ","$2,047.50 ","$1,687.50 "
Carle BroMenn Medical Center,8472295,DISKOGRAPHY - LUMBAR S&I,,72295,320,"$6,485.00 ","$6,485.00 ","$1,945.50 ","$5,901.35 ","$4,539.50 ","$1,945.50 ","$4,215.25 ","$4,669.20 ","$5,901.35 ","$4,863.75 "
Carle BroMenn Medical Center,8473000,CLAVICLE XRAYS,,73000,320,$330.00 ,$330.00 ,$99.00 ,$300.30 ,$231.00 ,$99.00 ,$214.50 ,$237.60 ,$300.30 ,$247.50 
Carle BroMenn Medical Center,8473010,SCAPULA XRAYS,,73010,320,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8473020,SHOULDER XRAY 1 VIEW,,73020,320,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8473030,SHOULDER XRAYS 2/> VIEWS,,73030,320,$330.00 ,$330.00 ,$99.00 ,$300.30 ,$231.00 ,$99.00 ,$214.50 ,$237.60 ,$300.30 ,$247.50 
Carle BroMenn Medical Center,8473040,ARTHROGRAM -SHOULDER S&I,,73040,320,"$1,015.00 ","$1,015.00 ",$304.50 ,$923.65 ,$710.50 ,$304.50 ,$659.75 ,$730.80 ,$923.65 ,$761.25 
Carle BroMenn Medical Center,8473050,A-C JOINT XRAYS BILAT W/WO WTS,,73050,320,$330.00 ,$330.00 ,$99.00 ,$300.30 ,$231.00 ,$99.00 ,$214.50 ,$237.60 ,$300.30 ,$247.50 
Carle BroMenn Medical Center,8473060,HUMERUS XRAYS 2/> VIEWS,,73060,320,$330.00 ,$330.00 ,$99.00 ,$300.30 ,$231.00 ,$99.00 ,$214.50 ,$237.60 ,$300.30 ,$247.50 
Carle BroMenn Medical Center,8473070,ELBOW XRAYS 2 VIEWS,,73070,320,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8473080,ELBOW XRAYS 3/> VIEWS,,73080,320,$330.00 ,$330.00 ,$99.00 ,$300.30 ,$231.00 ,$99.00 ,$214.50 ,$237.60 ,$300.30 ,$247.50 
Carle BroMenn Medical Center,8473085,ARTHROGRAM OF ELBOW,,73085,320,"$1,620.00 ","$1,620.00 ",$486.00 ,"$1,474.20 ","$1,134.00 ",$486.00 ,"$1,053.00 ","$1,166.40 ","$1,474.20 ","$1,215.00 "
Carle BroMenn Medical Center,8473090,FOREARM XRAYS 2 VIEWS,,73090,320,$330.00 ,$330.00 ,$99.00 ,$300.30 ,$231.00 ,$99.00 ,$214.50 ,$237.60 ,$300.30 ,$247.50 
Carle BroMenn Medical Center,8473092,ARM XRAY INFANT 2/> VIEWS,,73092,320,$360.00 ,$360.00 ,$108.00 ,$327.60 ,$252.00 ,$108.00 ,$234.00 ,$259.20 ,$327.60 ,$270.00 
Carle BroMenn Medical Center,8473100,WRIST XRAYS 2 VIEWS,,73100,320,$190.00 ,$190.00 ,$57.00 ,$172.90 ,$133.00 ,$57.00 ,$123.50 ,$136.80 ,$172.90 ,$142.50 
Carle BroMenn Medical Center,8473110,WRIST XRAYS 3/> VIEWS,,73110,320,$385.00 ,$385.00 ,$115.50 ,$350.35 ,$269.50 ,$115.50 ,$250.25 ,$277.20 ,$350.35 ,$288.75 
Carle BroMenn Medical Center,8473115,WRIST ARTHROGRAPHY S&I,,73115,320,"$1,740.00 ","$1,740.00 ",$522.00 ,"$1,583.40 ","$1,218.00 ",$522.00 ,"$1,131.00 ","$1,252.80 ","$1,583.40 ","$1,305.00 "
Carle BroMenn Medical Center,8473120,HAND XRAYS 2 VIEWS,,73120,320,$380.00 ,$380.00 ,$114.00 ,$345.80 ,$266.00 ,$114.00 ,$247.00 ,$273.60 ,$345.80 ,$285.00 
Carle BroMenn Medical Center,8473130,HAND XRAYS 3/> VIEWS,,73130,320,$385.00 ,$385.00 ,$115.50 ,$350.35 ,$269.50 ,$115.50 ,$250.25 ,$277.20 ,$350.35 ,$288.75 
Carle BroMenn Medical Center,8473140,FINGER(S) XRAYS 2/> VIEWS,,73140,320,$330.00 ,$330.00 ,$99.00 ,$300.30 ,$231.00 ,$99.00 ,$214.50 ,$237.60 ,$300.30 ,$247.50 
Carle BroMenn Medical Center,8473501,CHG RADEX HIP UNILATERAL WITH PELVIS 1 VIEW,,73501,320,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8473502,CHG RADEX HIP UNILATERAL WITH PELVIS 2-3 VIEWS,,73502,320,$330.00 ,$330.00 ,$99.00 ,$300.30 ,$231.00 ,$99.00 ,$214.50 ,$237.60 ,$300.30 ,$247.50 
Carle BroMenn Medical Center,8473503,CHG RADEX HIP UNILATERAL WITH PELVIS MINIMUM 4 VIEWS,,73503,320,$653.00 ,$653.00 ,$195.90 ,$594.23 ,$457.10 ,$195.90 ,$424.45 ,$470.16 ,$594.23 ,$489.75 
Carle BroMenn Medical Center,8473510,HIP XRAYS 2/> VIEWS,,73510,320,$345.00 ,$345.00 ,$103.50 ,$313.95 ,$241.50 ,$103.50 ,$224.25 ,$248.40 ,$313.95 ,$258.75 
Carle BroMenn Medical Center,8473521,CHG RADEX HIPS BILATERAL WITH PELVIS 2 VIEWS,,73521,320,$620.00 ,$620.00 ,$186.00 ,$564.20 ,$434.00 ,$186.00 ,$403.00 ,$446.40 ,$564.20 ,$465.00 
Carle BroMenn Medical Center,8473522,CHG RADEX HIPS BILATERAL WITH PELVIS 3-4 VIEWS,,73522,320,$505.00 ,$505.00 ,$151.50 ,$459.55 ,$353.50 ,$151.50 ,$328.25 ,$363.60 ,$459.55 ,$378.75 
Carle BroMenn Medical Center,8473523,CHG RADEX HIPS BILATERAL WITH PELVIS MINIMUM 5 VIEWS,,73523,320,"$1,155.00 ","$1,155.00 ",$346.50 ,"$1,051.05 ",$808.50 ,$346.50 ,$750.75 ,$831.60 ,"$1,051.05 ",$866.25 
Carle BroMenn Medical Center,8473525,HIP ARTHROGRAPHY S&I,,73525,320,"$1,635.00 ","$1,635.00 ",$490.50 ,"$1,487.85 ","$1,144.50 ",$490.50 ,"$1,062.75 ","$1,177.20 ","$1,487.85 ","$1,226.25 "
Carle BroMenn Medical Center,8473550,FEMUR XRAYS 2 VIEWS,,73550,320,$325.00 ,$325.00 ,$97.50 ,$295.75 ,$227.50 ,$97.50 ,$211.25 ,$234.00 ,$295.75 ,$243.75 
Carle BroMenn Medical Center,8473551,CHG RADIOLOGIC EXAMINATION FEMUR 1 VIEW,,73551,320,$215.00 ,$215.00 ,$64.50 ,$195.65 ,$150.50 ,$64.50 ,$139.75 ,$154.80 ,$195.65 ,$161.25 
Carle BroMenn Medical Center,8473552,CHG RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,,73552,320,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8473560,KNEE XRAYS 1-2 VIEWS,,73560,320,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8473562,KNEE XRAYS 3 VIEWS,,73562,320,$305.00 ,$305.00 ,$91.50 ,$277.55 ,$213.50 ,$91.50 ,$198.25 ,$219.60 ,$277.55 ,$228.75 
Carle BroMenn Medical Center,8473564,KNEE XRAYS 4/> VIEWS,,73564,320,$620.00 ,$620.00 ,$186.00 ,$564.20 ,$434.00 ,$186.00 ,$403.00 ,$446.40 ,$564.20 ,$465.00 
Carle BroMenn Medical Center,8473565,KNEES XRAY AP STANDING,,73565,320,$320.00 ,$320.00 ,$96.00 ,$291.20 ,$224.00 ,$96.00 ,$208.00 ,$230.40 ,$291.20 ,$240.00 
Carle BroMenn Medical Center,8473580,ARTHROGRAM OF KNEE JOINT,,73580,320,"$1,830.00 ","$1,830.00 ",$549.00 ,"$1,665.30 ","$1,281.00 ",$549.00 ,"$1,189.50 ","$1,317.60 ","$1,665.30 ","$1,372.50 "
Carle BroMenn Medical Center,8473590,LOWER LEG XRAYS 2 VIEWS,,73590,320,$330.00 ,$330.00 ,$99.00 ,$300.30 ,$231.00 ,$99.00 ,$214.50 ,$237.60 ,$300.30 ,$247.50 
Carle BroMenn Medical Center,8473592,LEG XRAY INFANT 2/> VIEWS,,73592,320,$325.00 ,$325.00 ,$97.50 ,$295.75 ,$227.50 ,$97.50 ,$211.25 ,$234.00 ,$295.75 ,$243.75 
Carle BroMenn Medical Center,8473600,ANKLE XRAYS 2 VIEWS,,73600,320,$330.00 ,$330.00 ,$99.00 ,$300.30 ,$231.00 ,$99.00 ,$214.50 ,$237.60 ,$300.30 ,$247.50 
Carle BroMenn Medical Center,8473610,ANKLE XRAYS 3/> VIEWS,,73610,320,$330.00 ,$330.00 ,$99.00 ,$300.30 ,$231.00 ,$99.00 ,$214.50 ,$237.60 ,$300.30 ,$247.50 
Carle BroMenn Medical Center,8473615,ANKLE ARTHROGRAPHY S&I,,73615,320,"$1,740.00 ","$1,740.00 ",$522.00 ,"$1,583.40 ","$1,218.00 ",$522.00 ,"$1,131.00 ","$1,252.80 ","$1,583.40 ","$1,305.00 "
Carle BroMenn Medical Center,8473620,FOOT XRAYS 2 VIEWS,,73620,320,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8473630,FOOT XRAYS 3/> VIEWS,,73630,320,$330.00 ,$330.00 ,$99.00 ,$300.30 ,$231.00 ,$99.00 ,$214.50 ,$237.60 ,$300.30 ,$247.50 
Carle BroMenn Medical Center,8473650,HEEL XRAYS 2/> VIEWS,,73650,320,$330.00 ,$330.00 ,$99.00 ,$300.30 ,$231.00 ,$99.00 ,$214.50 ,$237.60 ,$300.30 ,$247.50 
Carle BroMenn Medical Center,8473660,TOE(S) XRAYS 2/> VIEWS,,73660,320,$330.00 ,$330.00 ,$99.00 ,$300.30 ,$231.00 ,$99.00 ,$214.50 ,$237.60 ,$300.30 ,$247.50 
Carle BroMenn Medical Center,8474018,RADIOLOGIC EXAM ABDOMEN 1 VIEW,,74018,320,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8474019,RADIOLOGIC EXAM ABDOMEN 2 VIEWS,,74019,320,$325.00 ,$325.00 ,$97.50 ,$295.75 ,$227.50 ,$97.50 ,$211.25 ,$234.00 ,$295.75 ,$243.75 
Carle BroMenn Medical Center,8474021,RADIOLOGIC EXAM ABDOMEN 3+ VIEWS,,74021,320,$510.00 ,$510.00 ,$153.00 ,$464.10 ,$357.00 ,$153.00 ,$331.50 ,$367.20 ,$464.10 ,$382.50 
Carle BroMenn Medical Center,8474022,ABDOMEN XRAYS W/PA CHEST XRAY,,74022,320,$505.00 ,$505.00 ,$151.50 ,$459.55 ,$353.50 ,$151.50 ,$328.25 ,$363.60 ,$459.55 ,$378.75 
Carle BroMenn Medical Center,8474190,PERITONEOGRAM S&I,,74190,320,$690.00 ,$690.00 ,$207.00 ,$627.90 ,$483.00 ,$207.00 ,$448.50 ,$496.80 ,$627.90 ,$517.50 
Carle BroMenn Medical Center,8474220,ESOPHAGUS XRAYS,,74220,320,$620.00 ,$620.00 ,$186.00 ,$564.20 ,$434.00 ,$186.00 ,$403.00 ,$446.40 ,$564.20 ,$465.00 
Carle BroMenn Medical Center,8474221,RADIOLOGIC EXAM ESOPHAGUS DOUBLE CONTRAST STUDY,,74221,320,$743.00 ,$743.00 ,$222.90 ,$676.13 ,$520.10 ,$222.90 ,$482.95 ,$534.96 ,$676.13 ,$557.25 
Carle BroMenn Medical Center,8474230,SWALLOWING FUNCTION XRAY,,74230,320,$620.00 ,$620.00 ,$186.00 ,$564.20 ,$434.00 ,$186.00 ,$403.00 ,$446.40 ,$564.20 ,$465.00 
Carle BroMenn Medical Center,8474235,RMVL FB ESOPH W/BALLOON CATH,,74235,320,"$1,125.00 ","$1,125.00 ",$337.50 ,"$1,023.75 ",$787.50 ,$337.50 ,$731.25 ,$810.00 ,"$1,023.75 ",$843.75 
Carle BroMenn Medical Center,8474240,UPPER GI (STOMACH) XRAYS,,74240,320,$645.00 ,$645.00 ,$193.50 ,$586.95 ,$451.50 ,$193.50 ,$419.25 ,$464.40 ,$586.95 ,$483.75 
Carle BroMenn Medical Center,8474241,UPPER GI (STOMACH) XRAYS W/KUB,,74241,320,$983.00 ,$983.00 ,$294.90 ,$894.53 ,$688.10 ,$294.90 ,$638.95 ,$707.76 ,$894.53 ,$737.25 
Carle BroMenn Medical Center,8474245,UPPER GI W/SML INTESTINE XRAYS,,74245,320,"$1,245.00 ","$1,245.00 ",$373.50 ,"$1,132.95 ",$871.50 ,$373.50 ,$809.25 ,$896.40 ,"$1,132.95 ",$933.75 
Carle BroMenn Medical Center,8474246,UPPER GI XRAYS W/AIR CONTRAST,,74246,320,$500.00 ,$500.00 ,$150.00 ,$455.00 ,$350.00 ,$150.00 ,$325.00 ,$360.00 ,$455.00 ,$375.00 
Carle BroMenn Medical Center,8474247,UPPER GI XRAYS W/AIR CONTRAST W/KUB,,74247,320,"$1,170.00 ","$1,170.00 ",$351.00 ,"$1,064.70 ",$819.00 ,$351.00 ,$760.50 ,$842.40 ,"$1,064.70 ",$877.50 
Carle BroMenn Medical Center,8474248,RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY,,74248,320,$500.00 ,$500.00 ,$150.00 ,$455.00 ,$350.00 ,$150.00 ,$325.00 ,$360.00 ,$455.00 ,$375.00 
Carle BroMenn Medical Center,8474249,UPPER GI XRAYS W/AIR&SM INTEST,,74249,320,"$1,178.00 ","$1,178.00 ",$353.40 ,"$1,071.98 ",$824.60 ,$353.40 ,$765.70 ,$848.16 ,"$1,071.98 ",$883.50 
Carle BroMenn Medical Center,8474250,SMALL INTESTINE XRAYS,,74250,320,$620.00 ,$620.00 ,$186.00 ,$564.20 ,$434.00 ,$186.00 ,$403.00 ,$446.40 ,$564.20 ,$465.00 
Carle BroMenn Medical Center,8474251,SMALL INTESTINE XRAYS -EC TUBE,,74251,320,$698.00 ,$698.00 ,$209.40 ,$635.18 ,$488.60 ,$209.40 ,$453.70 ,$502.56 ,$635.18 ,$523.50 
Carle BroMenn Medical Center,8474260,DUODENOGRAPHY HYPOTONIC,,74260,320,$608.00 ,$608.00 ,$182.40 ,$553.28 ,$425.60 ,$182.40 ,$395.20 ,$437.76 ,$553.28 ,$456.00 
Carle BroMenn Medical Center,8474270,RAD EXAM COLON CONTRAST ENEMA,,74270,320,$620.00 ,$620.00 ,$186.00 ,$564.20 ,$434.00 ,$186.00 ,$403.00 ,$446.40 ,$564.20 ,$465.00 
Carle BroMenn Medical Center,8474280,COLON XRAYS W/AIR CONTRAST,,74280,320,$690.00 ,$690.00 ,$207.00 ,$627.90 ,$483.00 ,$207.00 ,$448.50 ,$496.80 ,$627.90 ,$517.50 
Carle BroMenn Medical Center,8474290,CHOLECYSTOGRAM (GALLBLADDER),,74290,320,$445.00 ,$445.00 ,$133.50 ,$404.95 ,$311.50 ,$133.50 ,$289.25 ,$320.40 ,$404.95 ,$333.75 
Carle BroMenn Medical Center,8474300,CHOLANGIOGRPHY -INTRAOPERATIVE,,74300,320,$520.00 ,$520.00 ,$156.00 ,$473.20 ,$364.00 ,$156.00 ,$338.00 ,$374.40 ,$473.20 ,$390.00 
Carle BroMenn Medical Center,8474328,ENDO CATH BILIARY DUCT S&I,,74328,320,$850.00 ,$850.00 ,$255.00 ,$773.50 ,$595.00 ,$255.00 ,$552.50 ,$612.00 ,$773.50 ,$637.50 
Carle BroMenn Medical Center,8474329,ENDO CATH PANCREATIC DUCT S&I,,74329,320,$925.00 ,$925.00 ,$277.50 ,$841.75 ,$647.50 ,$277.50 ,$601.25 ,$666.00 ,$841.75 ,$693.75 
Carle BroMenn Medical Center,8474330,ENDO CATH BILIARY/PANCR DUCT,,74330,320,"$1,165.00 ","$1,165.00 ",$349.50 ,"$1,060.15 ",$815.50 ,$349.50 ,$757.25 ,$838.80 ,"$1,060.15 ",$873.75 
Carle BroMenn Medical Center,8474340,INSERTION LONG GI TUBE S&I,,74340,320,$650.00 ,$650.00 ,$195.00 ,$591.50 ,$455.00 ,$195.00 ,$422.50 ,$468.00 ,$591.50 ,$487.50 
Carle BroMenn Medical Center,8474355,PERC PLCMNT ENTEROCLYSIS TUBE,,74355,320,$495.00 ,$495.00 ,$148.50 ,$450.45 ,$346.50 ,$148.50 ,$321.75 ,$356.40 ,$450.45 ,$371.25 
Carle BroMenn Medical Center,8474360,DILATION STRICTURE/OBSTRUCTION,,74360,320,$570.00 ,$570.00 ,$171.00 ,$518.70 ,$399.00 ,$171.00 ,$370.50 ,$410.40 ,$518.70 ,$427.50 
Carle BroMenn Medical Center,8474363,PERC DILATN BILIARY STRICTURE,,74363,320,"$1,343.00 ","$1,343.00 ",$402.90 ,"$1,222.13 ",$940.10 ,$402.90 ,$872.95 ,$966.96 ,"$1,222.13 ","$1,007.25 "
Carle BroMenn Medical Center,8474400,IVP (INTRAVENOUS PYELOGRAM),,74400,320,"$1,180.00 ","$1,180.00 ",$354.00 ,"$1,073.80 ",$826.00 ,$354.00 ,$767.00 ,$849.60 ,"$1,073.80 ",$885.00 
Carle BroMenn Medical Center,8474420,PYELOGRAPHY RETROGRADE,,74420,320,"$1,355.00 ","$1,355.00 ",$406.50 ,"$1,233.05 ",$948.50 ,$406.50 ,$880.75 ,$975.60 ,"$1,233.05 ","$1,016.25 "
Carle BroMenn Medical Center,8474425,PYELOGRAPHY ANTEGRADE,,74425,320,"$1,410.00 ","$1,410.00 ",$423.00 ,"$1,283.10 ",$987.00 ,$423.00 ,$916.50 ,"$1,015.20 ","$1,283.10 ","$1,057.50 "
Carle BroMenn Medical Center,8474430,CYSTOGRAPHY S&I (MIN 3 VIEWS),,74430,320,"$1,130.00 ","$1,130.00 ",$339.00 ,"$1,028.30 ",$791.00 ,$339.00 ,$734.50 ,$813.60 ,"$1,028.30 ",$847.50 
Carle BroMenn Medical Center,8474450,URETHROCYSTOGRAPHY S&I,,74450,320,"$1,085.00 ","$1,085.00 ",$325.50 ,$987.35 ,$759.50 ,$325.50 ,$705.25 ,$781.20 ,$987.35 ,$813.75 
Carle BroMenn Medical Center,8474455,URETHROCYSTOGRAPHY VOIDING S&I,,74455,320,"$1,190.00 ","$1,190.00 ",$357.00 ,"$1,082.90 ",$833.00 ,$357.00 ,$773.50 ,$856.80 ,"$1,082.90 ",$892.50 
Carle BroMenn Medical Center,8474485,DILAT NEPHRSTMY/URETER/URETHRA,,74485,320,"$4,910.00 ","$4,910.00 ","$1,473.00 ","$4,468.10 ","$3,437.00 ","$1,473.00 ","$3,191.50 ","$3,535.20 ","$4,468.10 ","$3,682.50 "
Carle BroMenn Medical Center,8474710,PELVIMETRY XRAYS,,74710,320,$380.00 ,$380.00 ,$114.00 ,$345.80 ,$266.00 ,$114.00 ,$247.00 ,$273.60 ,$345.80 ,$285.00 
Carle BroMenn Medical Center,8474740,HYSTEROSALPINGOGRAPHY S & I,,74740,320,"$1,245.00 ","$1,245.00 ",$373.50 ,"$1,132.95 ",$871.50 ,$373.50 ,$809.25 ,$896.40 ,"$1,132.95 ",$933.75 
Carle BroMenn Medical Center,8474775,PERINEOGRAM,,74775,320,$435.00 ,$435.00 ,$130.50 ,$395.85 ,$304.50 ,$130.50 ,$282.75 ,$313.20 ,$395.85 ,$326.25 
Carle BroMenn Medical Center,8475605,AORTOGRAPHY THORACIC,,75605,320,"$3,210.00 ","$3,210.00 ",$963.00 ,"$2,921.10 ","$2,247.00 ",$963.00 ,"$2,086.50 ","$2,311.20 ","$2,921.10 ","$2,407.50 "
Carle BroMenn Medical Center,8475625,AORTOGRAPHY ABDOMINAL S & I,,75625,320,"$6,950.00 ","$6,950.00 ","$2,085.00 ","$6,324.50 ","$4,865.00 ","$2,085.00 ","$4,517.50 ","$5,004.00 ","$6,324.50 ","$5,212.50 "
Carle BroMenn Medical Center,8475630,AORTOGR. ABD/ILEOFEM S & I,,75630,320,"$3,503.00 ","$3,503.00 ","$1,050.90 ","$3,187.73 ","$2,452.10 ","$1,050.90 ","$2,276.95 ","$2,522.16 ","$3,187.73 ","$2,627.25 "
Carle BroMenn Medical Center,8475705,ANGIO SPINE SELCTV EA VSL,,75705,320,"$4,193.00 ","$4,193.00 ","$1,257.90 ","$3,815.63 ","$2,935.10 ","$1,257.90 ","$2,725.45 ","$3,018.96 ","$3,815.63 ","$3,144.75 "
Carle BroMenn Medical Center,8475710,ANGIO EXTREMITY UNILAT S&I,,75710,320,"$2,415.00 ","$2,415.00 ",$724.50 ,"$2,197.65 ","$1,690.50 ",$724.50 ,"$1,569.75 ","$1,738.80 ","$2,197.65 ","$1,811.25 "
Carle BroMenn Medical Center,8475716,ANGIO EXTREMITY BILAT  S&I,,75716,320,"$3,285.00 ","$3,285.00 ",$985.50 ,"$2,989.35 ","$2,299.50 ",$985.50 ,"$2,135.25 ","$2,365.20 ","$2,989.35 ","$2,463.75 "
Carle BroMenn Medical Center,8475726,ANGIO VISCERAL EA VESSEL S&I,,75726,320,"$4,193.00 ","$4,193.00 ","$1,257.90 ","$3,815.63 ","$2,935.10 ","$1,257.90 ","$2,725.45 ","$3,018.96 ","$3,815.63 ","$3,144.75 "
Carle BroMenn Medical Center,8475736,ANGIO PELVIC S&I,,75736,320,"$7,290.00 ","$7,290.00 ","$2,187.00 ","$6,633.90 ","$5,103.00 ","$2,187.00 ","$4,738.50 ","$5,248.80 ","$6,633.90 ","$5,467.50 "
Carle BroMenn Medical Center,8475741,ANGIOGR PULM UNI S&I,,75741,320,"$2,235.00 ","$2,235.00 ",$670.50 ,"$2,033.85 ","$1,564.50 ",$670.50 ,"$1,452.75 ","$1,609.20 ","$2,033.85 ","$1,676.25 "
Carle BroMenn Medical Center,8475743,ANGIOGR PULM BIL S&I,,75743,320,"$3,630.00 ","$3,630.00 ","$1,089.00 ","$3,303.30 ","$2,541.00 ","$1,089.00 ","$2,359.50 ","$2,613.60 ","$3,303.30 ","$2,722.50 "
Carle BroMenn Medical Center,8475746,ANGIOGRAPHY PULMONARY S&I,,75746,320,"$2,010.00 ","$2,010.00 ",$603.00 ,"$1,829.10 ","$1,407.00 ",$603.00 ,"$1,306.50 ","$1,447.20 ","$1,829.10 ","$1,507.50 "
Carle BroMenn Medical Center,8475756,ANGIO INT MAMMARY S & I,,75756,320,"$2,055.00 ","$2,055.00 ",$616.50 ,"$1,870.05 ","$1,438.50 ",$616.50 ,"$1,335.75 ","$1,479.60 ","$1,870.05 ","$1,541.25 "
Carle BroMenn Medical Center,8475774,ANGIO EA ADNL. AFTER BASIC,,75774,320,"$2,805.00 ","$2,805.00 ",$841.50 ,"$2,552.55 ","$1,963.50 ",$841.50 ,"$1,823.25 ","$2,019.60 ","$2,552.55 ","$2,103.75 "
Carle BroMenn Medical Center,8475809,NONVASCULAR SHUNT EVALUATION,,75809,320,$665.00 ,$665.00 ,$199.50 ,$605.15 ,$465.50 ,$199.50 ,$432.25 ,$478.80 ,$605.15 ,$498.75 
Carle BroMenn Medical Center,8475820,VENOGRAPHY UNI EXTREMITY S&I,,75820,320,"$2,540.00 ","$2,540.00 ",$762.00 ,"$2,311.40 ","$1,778.00 ",$762.00 ,"$1,651.00 ","$1,828.80 ","$2,311.40 ","$1,905.00 "
Carle BroMenn Medical Center,8475822,VENOGRAPHY BILAT EXTREMITY S&I,,75822,320,"$2,785.00 ","$2,785.00 ",$835.50 ,"$2,534.35 ","$1,949.50 ",$835.50 ,"$1,810.25 ","$2,005.20 ","$2,534.35 ","$2,088.75 "
Carle BroMenn Medical Center,8475825,VENOGRPHY INFERIOR CAVAL,,75825,320,"$5,110.00 ","$5,110.00 ","$1,533.00 ","$4,650.10 ","$3,577.00 ","$1,533.00 ","$3,321.50 ","$3,679.20 ","$4,650.10 ","$3,832.50 "
Carle BroMenn Medical Center,8475827,VENOGRAPHY CAVAL SUP S&I,,75827,320,"$1,785.00 ","$1,785.00 ",$535.50 ,"$1,624.35 ","$1,249.50 ",$535.50 ,"$1,160.25 ","$1,285.20 ","$1,624.35 ","$1,338.75 "
Carle BroMenn Medical Center,8475831,VENOGRAPHY RENAL UNI S&I,,75831,320,"$2,198.00 ","$2,198.00 ",$659.40 ,"$2,000.18 ","$1,538.60 ",$659.40 ,"$1,428.70 ","$1,582.56 ","$2,000.18 ","$1,648.50 "
Carle BroMenn Medical Center,8475885,PORTOGRPHY/HEMODYNAM EVAL,,75885,320,"$2,235.00 ","$2,235.00 ",$670.50 ,"$2,033.85 ","$1,564.50 ",$670.50 ,"$1,452.75 ","$1,609.20 ","$2,033.85 ","$1,676.25 "
Carle BroMenn Medical Center,8475889,VENOGRAPH/HEMODYNAM EVAL,,75889,320,"$2,430.00 ","$2,430.00 ",$729.00 ,"$2,211.30 ","$1,701.00 ",$729.00 ,"$1,579.50 ","$1,749.60 ","$2,211.30 ","$1,822.50 "
Carle BroMenn Medical Center,8475891,VENO W/O HEMODYNAM EVAL S&I,,75891,320,"$2,055.00 ","$2,055.00 ",$616.50 ,"$1,870.05 ","$1,438.50 ",$616.50 ,"$1,335.75 ","$1,479.60 ","$1,870.05 ","$1,541.25 "
Carle BroMenn Medical Center,8475894,TRNSCATH EMBLZTN S&I,,75894,320,"$3,578.00 ","$3,578.00 ","$1,073.40 ","$3,255.98 ","$2,504.60 ","$1,073.40 ","$2,325.70 ","$2,576.16 ","$3,255.98 ","$2,683.50 "
Carle BroMenn Medical Center,8475898,ANGIOGRAM FOLLOW-UP,,75898,320,"$1,140.00 ","$1,140.00 ",$342.00 ,"$1,037.40 ",$798.00 ,$342.00 ,$741.00 ,$820.80 ,"$1,037.40 ",$855.00 
Carle BroMenn Medical Center,8475984,GD KIDNEY NEPHRO TUBE PLACEMENT,,75984,320,$505.00 ,$505.00 ,$151.50 ,$459.55 ,$353.50 ,$151.50 ,$328.25 ,$363.60 ,$459.55 ,$378.75 
Carle BroMenn Medical Center,8475989,GUIDANCE FOR DRAINAGE PROC S&I,,75989,320,$960.00 ,$960.00 ,$288.00 ,$873.60 ,$672.00 ,$288.00 ,$624.00 ,$691.20 ,$873.60 ,$720.00 
Carle BroMenn Medical Center,8476000,FLUOROSCOPY UP TO 1 HR,,76000,320,$570.00 ,$570.00 ,$171.00 ,$518.70 ,$399.00 ,$171.00 ,$370.50 ,$410.40 ,$518.70 ,$427.50 
Carle BroMenn Medical Center,8476001,FLUOROSCOPY >1 HOUR,,76001,320,$983.00 ,$983.00 ,$294.90 ,$894.53 ,$688.10 ,$294.90 ,$638.95 ,$707.76 ,$894.53 ,$737.25 
Carle BroMenn Medical Center,8476010,NOSE-RECTUM 1 VIEW FB -CHILD,,76010,320,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8476080,FISTULA/SINUS TRACT STUDY S&I,,76080,320,"$1,085.00 ","$1,085.00 ",$325.50 ,$987.35 ,$759.50 ,$325.50 ,$705.25 ,$781.20 ,$987.35 ,$813.75 
Carle BroMenn Medical Center,8476098,XRAY EXAM BREAST SURGICAL SPEC,,76098,320,$600.00 ,$600.00 ,$180.00 ,$546.00 ,$420.00 ,$180.00 ,$390.00 ,$432.00 ,$546.00 ,$450.00 
Carle BroMenn Medical Center,8476100,XRAY SNGL BODY PLANE SCTN,,76100,320,$770.00 ,$770.00 ,$231.00 ,$700.70 ,$539.00 ,$231.00 ,$500.50 ,$554.40 ,$700.70 ,$577.50 
Carle BroMenn Medical Center,8476101,XRAY CMPLX MOTION BODY SCTN UNILAT,,76101,320,$518.00 ,$518.00 ,$155.40 ,$471.38 ,$362.60 ,$155.40 ,$336.70 ,$372.96 ,$471.38 ,$388.50 
Carle BroMenn Medical Center,8476102,XRAY CMPLX MOTION BODY SCTN BILAT,,76102,320,$773.00 ,$773.00 ,$231.90 ,$703.43 ,$541.10 ,$231.90 ,$502.45 ,$556.56 ,$703.43 ,$579.75 
Carle BroMenn Medical Center,8476120,"CINE/VIDEORADIOLOGY,EXC WHERE SPEC INCL",,76120,320,$525.00 ,$525.00 ,$157.50 ,$477.75 ,$367.50 ,$157.50 ,$341.25 ,$378.00 ,$477.75 ,$393.75 
Carle BroMenn Medical Center,8476145,MEDICAL PHYSICS DOSE EVAL RADIATION EXPOS W/RPRT,,76145,320,$580.00 ,$580.00 ,$174.00 ,$527.80 ,$406.00 ,$174.00 ,$377.00 ,$417.60 ,$527.80 ,$435.00 
Carle BroMenn Medical Center,8476496,UNLISTED FLUROSCOPY PROCEDURE,,76496,320,$280.00 ,$280.00 ,$84.00 ,$254.80 ,$196.00 ,$84.00 ,$182.00 ,$201.60 ,$254.80 ,$210.00 
Carle BroMenn Medical Center,8476499,UNLISTED DX RADIOGRAPHIC PROCEDURE,,76499,320,$330.00 ,$330.00 ,$99.00 ,$300.30 ,$231.00 ,$99.00 ,$214.50 ,$237.60 ,$300.30 ,$247.50 
Carle BroMenn Medical Center,8477001,FLUORO GDNC CNTRL VN ACC DVC,,77001,320,$490.00 ,$490.00 ,$147.00 ,$445.90 ,$343.00 ,$147.00 ,$318.50 ,$352.80 ,$445.90 ,$367.50 
Carle BroMenn Medical Center,8477002,FLUORO GUIDNC ASP/BX/DRAINAGE,,77002,320,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8477003,FLUORO SPINE/PARASP DX/TX,,77003,320,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8477053,MAMMOGRAPHY DUCTOGRAM SINGLE,,77053,320,$840.00 ,$840.00 ,$252.00 ,$764.40 ,$588.00 ,$252.00 ,$546.00 ,$604.80 ,$764.40 ,$630.00 
Carle BroMenn Medical Center,8477054,MAMMOGRAPHY DUCTOGRAM MULTIPLE,,77054,320,$965.00 ,$965.00 ,$289.50 ,$878.15 ,$675.50 ,$289.50 ,$627.25 ,$694.80 ,$878.15 ,$723.75 
Carle BroMenn Medical Center,8477071,MANUAL APPL STRESS JOINT RADIOGRAPHY,,77071,320,$281.00 ,$281.00 ,$84.30 ,$255.71 ,$196.70 ,$84.30 ,$182.65 ,$202.32 ,$255.71 ,$210.75 
Carle BroMenn Medical Center,8477072,BONE AGE XRAY STUDY,,77072,320,$505.00 ,$505.00 ,$151.50 ,$459.55 ,$353.50 ,$151.50 ,$328.25 ,$363.60 ,$459.55 ,$378.75 
Carle BroMenn Medical Center,8477073,BONE LENGTH STUDIES,,77073,320,$430.00 ,$430.00 ,$129.00 ,$391.30 ,$301.00 ,$129.00 ,$279.50 ,$309.60 ,$391.30 ,$322.50 
Carle BroMenn Medical Center,8477074,OSSEOUS SURVEY LIMITED,,77074,320,$505.00 ,$505.00 ,$151.50 ,$459.55 ,$353.50 ,$151.50 ,$328.25 ,$363.60 ,$459.55 ,$378.75 
Carle BroMenn Medical Center,8477075,OSSEOUS SURVEY COMPLETE,,77075,320,$530.00 ,$530.00 ,$159.00 ,$482.30 ,$371.00 ,$159.00 ,$344.50 ,$381.60 ,$482.30 ,$397.50 
Carle BroMenn Medical Center,8477076,OSSEOUS SURVEY INFANT,,77076,320,$488.00 ,$488.00 ,$146.40 ,$444.08 ,$341.60 ,$146.40 ,$317.20 ,$351.36 ,$444.08 ,$366.00 
Carle BroMenn Medical Center,8477077,JOINT SURVEY 1/MORE JOINTS,,77077,320,$505.00 ,$505.00 ,$151.50 ,$459.55 ,$353.50 ,$151.50 ,$328.25 ,$363.60 ,$459.55 ,$378.75 
Carle BroMenn Medical Center,8477080,DUAL ENERGY BONE DENSITOMETRY,,77080,320,$620.00 ,$620.00 ,$186.00 ,$564.20 ,$434.00 ,$186.00 ,$403.00 ,$446.40 ,$564.20 ,$465.00 
Carle BroMenn Medical Center,8477081,"DEXA,BONE DENSITY, 1 OR > SITE, APNDCLR SKELTN",,77081,320,$345.00 ,$345.00 ,$103.50 ,$313.95 ,$241.50 ,$103.50 ,$224.25 ,$248.40 ,$313.95 ,$258.75 
Carle BroMenn Medical Center,8477085,"DEXA, BONE DENSITY, AXIAL SKELETON",,77085,320,$475.00 ,$475.00 ,$142.50 ,$432.25 ,$332.50 ,$142.50 ,$308.75 ,$342.00 ,$432.25 ,$356.25 
Carle BroMenn Medical Center,8477086,"DEXA, VERTEBRAL FX ASSESSMENT",,77086,320,$215.00 ,$215.00 ,$64.50 ,$195.65 ,$150.50 ,$64.50 ,$139.75 ,$154.80 ,$195.65 ,$161.25 
Carle BroMenn Medical Center,8970121,RADIOLOGIC EXAM CHEST SINGLE VIEW,,71045,320,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8971003,FLUOR SPINE/PARASPINAL DX/TX,,77003,320,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8971450,URETHROCYSTOGRM RETROGRADE S&I,,74450,320,"$1,085.00 ","$1,085.00 ",$325.50 ,$987.35 ,$759.50 ,$325.50 ,$705.25 ,$781.20 ,$987.35 ,$813.75 
Carle BroMenn Medical Center,8971496,FLUROSCOPY VASCULAR PROCEDURE,,76496,320,$280.00 ,$280.00 ,$84.00 ,$254.80 ,$196.00 ,$84.00 ,$182.00 ,$201.60 ,$254.80 ,$210.00 
Carle BroMenn Medical Center,8971822,VENOGRAM EXTREMITY BIL S&I,,75822,320,"$2,785.00 ","$2,785.00 ",$835.50 ,"$2,534.35 ","$1,949.50 ",$835.50 ,"$1,810.25 ","$2,005.20 ","$2,534.35 ","$2,088.75 "
Carle BroMenn Medical Center,8971860,VENOGRAM SINUS/JUGULAR S&I,,75860,320,"$1,935.00 ","$1,935.00 ",$580.50 ,"$1,760.85 ","$1,354.50 ",$580.50 ,"$1,257.75 ","$1,393.20 ","$1,760.85 ","$1,451.25 "
Carle BroMenn Medical Center,8971872,"VENOGRAM, EPIDURAL S&I",,75872,320,"$1,350.00 ","$1,350.00 ",$405.00 ,"$1,228.50 ",$945.00 ,$405.00 ,$877.50 ,$972.00 ,"$1,228.50 ","$1,012.50 "
Carle BroMenn Medical Center,8971880,VENOGRAM ORBITAL S&I,,75880,320,"$1,215.00 ","$1,215.00 ",$364.50 ,"$1,105.65 ",$850.50 ,$364.50 ,$789.75 ,$874.80 ,"$1,105.65 ",$911.25 
Carle BroMenn Medical Center,8971894,TRANSCATH EMBOLIZATION S&I,,75894,320,"$3,578.00 ","$3,578.00 ","$1,073.40 ","$3,255.98 ","$2,504.60 ","$1,073.40 ","$2,325.70 ","$2,576.16 ","$3,255.98 ","$2,683.50 "
Carle BroMenn Medical Center,8971898,ANGIOGRAM FOLLOW-UP,,75898,320,"$1,140.00 ","$1,140.00 ",$342.00 ,"$1,037.40 ",$798.00 ,$342.00 ,$741.00 ,$820.80 ,"$1,037.40 ",$855.00 
Carle BroMenn Medical Center,8971984,CHANGE PERC DRAIN CATH S&I,,75984,320,$505.00 ,$505.00 ,$151.50 ,$459.55 ,$353.50 ,$151.50 ,$328.25 ,$363.60 ,$459.55 ,$378.75 
Carle BroMenn Medical Center,8972265,MYELOGRAM -LUMBAR SPINE S&I,,72265,320,"$2,025.00 ","$2,025.00 ",$607.50 ,"$1,842.75 ","$1,417.50 ",$607.50 ,"$1,316.25 ","$1,458.00 ","$1,842.75 ","$1,518.75 "
Carle BroMenn Medical Center,8972295,DISKOGRAPHY -LUMBAR  S&I,,72295,320,"$6,485.00 ","$6,485.00 ","$1,945.50 ","$5,901.35 ","$4,539.50 ","$1,945.50 ","$4,215.25 ","$4,669.20 ","$5,901.35 ","$4,863.75 "
Carle BroMenn Medical Center,8974018,RADIOLOGIC EXAM ABDOMEN 1 VIEW,,74018,320,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8974190,PERITONEOGRAM S&I,,74190,320,$690.00 ,$690.00 ,$207.00 ,$627.90 ,$483.00 ,$207.00 ,$448.50 ,$496.80 ,$627.90 ,$517.50 
Carle BroMenn Medical Center,8974290,CHOLECYSTOGRAM (GALLBLADDER),,74290,320,$445.00 ,$445.00 ,$133.50 ,$404.95 ,$311.50 ,$133.50 ,$289.25 ,$320.40 ,$404.95 ,$333.75 
Carle BroMenn Medical Center,8974340,INTRO LONG GI TUBE X-RAY GUIDE,,74340,320,$650.00 ,$650.00 ,$195.00 ,$591.50 ,$455.00 ,$195.00 ,$422.50 ,$468.00 ,$591.50 ,$487.50 
Carle BroMenn Medical Center,8974355,PLCMNT ENTEROCLYSIS TUBE S&I,,74355,320,$495.00 ,$495.00 ,$148.50 ,$450.45 ,$346.50 ,$148.50 ,$321.75 ,$356.40 ,$450.45 ,$371.25 
Carle BroMenn Medical Center,8974363,DILATE BILIARY DUCT STRICT S&I,,74363,320,"$1,343.00 ","$1,343.00 ",$402.90 ,"$1,222.13 ",$940.10 ,$402.90 ,$872.95 ,$966.96 ,"$1,222.13 ","$1,007.25 "
Carle BroMenn Medical Center,8974425,ANTEGRADE UROGRAPHY S&I,,74425,320,"$1,410.00 ","$1,410.00 ",$423.00 ,"$1,283.10 ",$987.00 ,$423.00 ,$916.50 ,"$1,015.20 ","$1,283.10 ","$1,057.50 "
Carle BroMenn Medical Center,8974430,CYSTOGRAPHY S&I,,74430,320,"$1,130.00 ","$1,130.00 ",$339.00 ,"$1,028.30 ",$791.00 ,$339.00 ,$734.50 ,$813.60 ,"$1,028.30 ",$847.50 
Carle BroMenn Medical Center,8974470,RENAL CYST STUDY -TRNSLMBR S&I,,74470,320,$720.00 ,$720.00 ,$216.00 ,$655.20 ,$504.00 ,$216.00 ,$468.00 ,$518.40 ,$655.20 ,$540.00 
Carle BroMenn Medical Center,8974485,DILATE NEPH/URETER/URETHRA S&I,,74485,320,"$4,910.00 ","$4,910.00 ","$1,473.00 ","$4,468.10 ","$3,437.00 ","$1,473.00 ","$3,191.50 ","$3,535.20 ","$4,468.10 ","$3,682.50 "
Carle BroMenn Medical Center,8975605,"AORTOGRAPHY, THORACIC S&I",,75605,320,"$3,210.00 ","$3,210.00 ",$963.00 ,"$2,921.10 ","$2,247.00 ",$963.00 ,"$2,086.50 ","$2,311.20 ","$2,921.10 ","$2,407.50 "
Carle BroMenn Medical Center,8975625,"AORTOGRAPHY, ABDOMINAL S&I",,75625,320,"$6,950.00 ","$6,950.00 ","$2,085.00 ","$6,324.50 ","$4,865.00 ","$2,085.00 ","$4,517.50 ","$5,004.00 ","$6,324.50 ","$5,212.50 "
Carle BroMenn Medical Center,8975630,AORTOGR. ABD/ILEOFEM S & I,,75630,320,"$3,503.00 ","$3,503.00 ","$1,050.90 ","$3,187.73 ","$2,452.10 ","$1,050.90 ","$2,276.95 ","$2,522.16 ","$3,187.73 ","$2,627.25 "
Carle BroMenn Medical Center,8975705,ANGIO SPINAL S&I,,75705,320,"$4,193.00 ","$4,193.00 ","$1,257.90 ","$3,815.63 ","$2,935.10 ","$1,257.90 ","$2,725.45 ","$3,018.96 ","$3,815.63 ","$3,144.75 "
Carle BroMenn Medical Center,8975710,"ANGIO EXTREMITY, UNI S & I",,75710,320,"$2,415.00 ","$2,415.00 ",$724.50 ,"$2,197.65 ","$1,690.50 ",$724.50 ,"$1,569.75 ","$1,738.80 ","$2,197.65 ","$1,811.25 "
Carle BroMenn Medical Center,8975711,"ANGIO EXTREMITY, UNI S & I",,75710,320,"$2,415.00 ","$2,415.00 ",$724.50 ,"$2,197.65 ","$1,690.50 ",$724.50 ,"$1,569.75 ","$1,738.80 ","$2,197.65 ","$1,811.25 "
Carle BroMenn Medical Center,8975716,ANGIO EXTREMITY BILAT  S&I,,75716,320,"$3,285.00 ","$3,285.00 ",$985.50 ,"$2,989.35 ","$2,299.50 ",$985.50 ,"$2,135.25 ","$2,365.20 ","$2,989.35 ","$2,463.75 "
Carle BroMenn Medical Center,8975726,ANGIO VISCERAL ARTERY S&I,,75726,320,"$4,193.00 ","$4,193.00 ","$1,257.90 ","$3,815.63 ","$2,935.10 ","$1,257.90 ","$2,725.45 ","$3,018.96 ","$3,815.63 ","$3,144.75 "
Carle BroMenn Medical Center,8975731,ANGIO ADRENAL UNILATERAL S&I,,75731,320,"$2,813.00 ","$2,813.00 ",$843.90 ,"$2,559.83 ","$1,969.10 ",$843.90 ,"$1,828.45 ","$2,025.36 ","$2,559.83 ","$2,109.75 "
Carle BroMenn Medical Center,8975733,ANGIO ADRENAL BILATERAL S&I,,75733,320,"$2,580.00 ","$2,580.00 ",$774.00 ,"$2,347.80 ","$1,806.00 ",$774.00 ,"$1,677.00 ","$1,857.60 ","$2,347.80 ","$1,935.00 "
Carle BroMenn Medical Center,8975736,ANGIO PELVIC ARTERY S&I,,75736,320,"$7,290.00 ","$7,290.00 ","$2,187.00 ","$6,633.90 ","$5,103.00 ","$2,187.00 ","$4,738.50 ","$5,248.80 ","$6,633.90 ","$5,467.50 "
Carle BroMenn Medical Center,8975741,ANGIO PULMONARY UNI S&I,,75741,320,"$2,235.00 ","$2,235.00 ",$670.50 ,"$2,033.85 ","$1,564.50 ",$670.50 ,"$1,452.75 ","$1,609.20 ","$2,033.85 ","$1,676.25 "
Carle BroMenn Medical Center,8975743,ANGIO PULMONARY BILAT S&I,,75743,320,"$3,630.00 ","$3,630.00 ","$1,089.00 ","$3,303.30 ","$2,541.00 ","$1,089.00 ","$2,359.50 ","$2,613.60 ","$3,303.30 ","$2,722.50 "
Carle BroMenn Medical Center,8975746,ANGIO PULMONARY NONSELECT S&I,,75746,320,"$2,010.00 ","$2,010.00 ",$603.00 ,"$1,829.10 ","$1,407.00 ",$603.00 ,"$1,306.50 ","$1,447.20 ","$1,829.10 ","$1,507.50 "
Carle BroMenn Medical Center,8975756,ANGIO INTERNAL MAMMARY S&I,,75756,320,"$2,055.00 ","$2,055.00 ",$616.50 ,"$1,870.05 ","$1,438.50 ",$616.50 ,"$1,335.75 ","$1,479.60 ","$1,870.05 ","$1,541.25 "
Carle BroMenn Medical Center,8975774,ANGIO EA ADNL AFTER BASIC S&I,,75774,320,"$2,805.00 ","$2,805.00 ",$841.50 ,"$2,552.55 ","$1,963.50 ",$841.50 ,"$1,823.25 ","$2,019.60 ","$2,552.55 ","$2,103.75 "
Carle BroMenn Medical Center,8975801,"LYMPHANGIOGRM, EXTRMTY UNI S&I",,75801,320,$720.00 ,$720.00 ,$216.00 ,$655.20 ,$504.00 ,$216.00 ,$468.00 ,$518.40 ,$655.20 ,$540.00 
Carle BroMenn Medical Center,8975803,"LYMPHANGIOGRM, EXTRMTY BIL S&I",,75803,320,"$1,140.00 ","$1,140.00 ",$342.00 ,"$1,037.40 ",$798.00 ,$342.00 ,$741.00 ,$820.80 ,"$1,037.40 ",$855.00 
Carle BroMenn Medical Center,8975805,"LYMPHANGIOGRM, PELV/ABD UNI",,75805,320,"$1,140.00 ","$1,140.00 ",$342.00 ,"$1,037.40 ",$798.00 ,$342.00 ,$741.00 ,$820.80 ,"$1,037.40 ",$855.00 
Carle BroMenn Medical Center,8975807,"LYMPHANGIOGRM, PELV/ABD BIL",,75807,320,"$1,935.00 ","$1,935.00 ",$580.50 ,"$1,760.85 ","$1,354.50 ",$580.50 ,"$1,257.75 ","$1,393.20 ","$1,760.85 ","$1,451.25 "
Carle BroMenn Medical Center,8975809,NONVASCULAR SHUNT EVALUATION,,75809,320,$665.00 ,$665.00 ,$199.50 ,$605.15 ,$465.50 ,$199.50 ,$432.25 ,$478.80 ,$605.15 ,$498.75 
Carle BroMenn Medical Center,8975810,SPLENOPORTOGRAPHY S&I,,75810,320,"$1,845.00 ","$1,845.00 ",$553.50 ,"$1,678.95 ","$1,291.50 ",$553.50 ,"$1,199.25 ","$1,328.40 ","$1,678.95 ","$1,383.75 "
Carle BroMenn Medical Center,8975820,"VENOGRAM, EXTREMITY - UNILAT",,75820,320,"$2,540.00 ","$2,540.00 ",$762.00 ,"$2,311.40 ","$1,778.00 ",$762.00 ,"$1,651.00 ","$1,828.80 ","$2,311.40 ","$1,905.00 "
Carle BroMenn Medical Center,8975822,VENOGRAM EXTREMITY BIL S&I,,75822,320,"$2,785.00 ","$2,785.00 ",$835.50 ,"$2,534.35 ","$1,949.50 ",$835.50 ,"$1,810.25 ","$2,005.20 ","$2,534.35 ","$2,088.75 "
Carle BroMenn Medical Center,8975825,VENOGRAM IVC S&I,,75825,320,"$5,110.00 ","$5,110.00 ","$1,533.00 ","$4,650.10 ","$3,577.00 ","$1,533.00 ","$3,321.50 ","$3,679.20 ","$4,650.10 ","$3,832.50 "
Carle BroMenn Medical Center,8975827,VENOGRAM SVC S&I,,75827,320,"$1,785.00 ","$1,785.00 ",$535.50 ,"$1,624.35 ","$1,249.50 ",$535.50 ,"$1,160.25 ","$1,285.20 ","$1,624.35 ","$1,338.75 "
Carle BroMenn Medical Center,8975831,VENOGRAM RENAL UNILATERAL S&I,,75831,320,"$2,198.00 ","$2,198.00 ",$659.40 ,"$2,000.18 ","$1,538.60 ",$659.40 ,"$1,428.70 ","$1,582.56 ","$2,000.18 ","$1,648.50 "
Carle BroMenn Medical Center,8975833,VENOGRAM RENAL BILATERAL S&I,,75833,320,"$3,698.00 ","$3,698.00 ","$1,109.40 ","$3,365.18 ","$2,588.60 ","$1,109.40 ","$2,403.70 ","$2,662.56 ","$3,365.18 ","$2,773.50 "
Carle BroMenn Medical Center,8975840,"VENOGRAM, ADRENAL UNI S&I",,75840,320,"$1,935.00 ","$1,935.00 ",$580.50 ,"$1,760.85 ","$1,354.50 ",$580.50 ,"$1,257.75 ","$1,393.20 ","$1,760.85 ","$1,451.25 "
Carle BroMenn Medical Center,8975842,"VENOGRAM, ADRENAL BILAT S&I",,75842,320,"$3,218.00 ","$3,218.00 ",$965.40 ,"$2,928.38 ","$2,252.60 ",$965.40 ,"$2,091.70 ","$2,316.96 ","$2,928.38 ","$2,413.50 "
Carle BroMenn Medical Center,8975860,VENOGRAM SINUS/JUGULAR S&I,,75860,320,"$1,935.00 ","$1,935.00 ",$580.50 ,"$1,760.85 ","$1,354.50 ",$580.50 ,"$1,257.75 ","$1,393.20 ","$1,760.85 ","$1,451.25 "
Carle BroMenn Medical Center,8975870,VENOGRAM SUP SAGITL SINUS S&I,,75870,320,"$1,463.00 ","$1,463.00 ",$438.90 ,"$1,331.33 ","$1,024.10 ",$438.90 ,$950.95 ,"$1,053.36 ","$1,331.33 ","$1,097.25 "
Carle BroMenn Medical Center,8975872,"VENOGRAM, EPIDURAL S&I",,75872,320,"$1,350.00 ","$1,350.00 ",$405.00 ,"$1,228.50 ",$945.00 ,$405.00 ,$877.50 ,$972.00 ,"$1,228.50 ","$1,012.50 "
Carle BroMenn Medical Center,8975880,VENOGRAM ORBITAL S&I,,75880,320,"$1,215.00 ","$1,215.00 ",$364.50 ,"$1,105.65 ",$850.50 ,$364.50 ,$789.75 ,$874.80 ,"$1,105.65 ",$911.25 
Carle BroMenn Medical Center,8975885,PORTOGRAM W/HEMODYNAMICS S&I,,75885,320,"$2,235.00 ","$2,235.00 ",$670.50 ,"$2,033.85 ","$1,564.50 ",$670.50 ,"$1,452.75 ","$1,609.20 ","$2,033.85 ","$1,676.25 "
Carle BroMenn Medical Center,8975887,PORTOGRAM W/O HEMODYNAMICS S&I,,75887,320,"$1,995.00 ","$1,995.00 ",$598.50 ,"$1,815.45 ","$1,396.50 ",$598.50 ,"$1,296.75 ","$1,436.40 ","$1,815.45 ","$1,496.25 "
Carle BroMenn Medical Center,8975889,HEP VENOGRM W/HEMODYNAMICS S&I,,75889,320,"$2,430.00 ","$2,430.00 ",$729.00 ,"$2,211.30 ","$1,701.00 ",$729.00 ,"$1,579.50 ","$1,749.60 ","$2,211.30 ","$1,822.50 "
Carle BroMenn Medical Center,8975891,HEP VENOGRM W/O HEMODYNMCS S&I,,75891,320,"$2,055.00 ","$2,055.00 ",$616.50 ,"$1,870.05 ","$1,438.50 ",$616.50 ,"$1,335.75 ","$1,479.60 ","$1,870.05 ","$1,541.25 "
Carle BroMenn Medical Center,8975893,VENOUS SMPLNG W/WO ANGIO S&I,,75893,320,"$3,218.00 ","$3,218.00 ",$965.40 ,"$2,928.38 ","$2,252.60 ",$965.40 ,"$2,091.70 ","$2,316.96 ","$2,928.38 ","$2,413.50 "
Carle BroMenn Medical Center,8975894,TRANSCATH EMBOLIZATION S&I,,75894,320,"$3,578.00 ","$3,578.00 ","$1,073.40 ","$3,255.98 ","$2,504.60 ","$1,073.40 ","$2,325.70 ","$2,576.16 ","$3,255.98 ","$2,683.50 "
Carle BroMenn Medical Center,8975898,ANGIOGRAM FOLLOW-UP,,75898,320,"$1,140.00 ","$1,140.00 ",$342.00 ,"$1,037.40 ",$798.00 ,$342.00 ,$741.00 ,$820.80 ,"$1,037.40 ",$855.00 
Carle BroMenn Medical Center,8975901,RMV PERICTH OBSTR MTL CVC S&I,,75901,320,$833.00 ,$833.00 ,$249.90 ,$758.03 ,$583.10 ,$249.90 ,$541.45 ,$599.76 ,$758.03 ,$624.75 
Carle BroMenn Medical Center,8975902,RMV INTRACTH OBST MTL CVC S&I,,75902,320,"$1,335.00 ","$1,335.00 ",$400.50 ,"$1,214.85 ",$934.50 ,$400.50 ,$867.75 ,$961.20 ,"$1,214.85 ","$1,001.25 "
Carle BroMenn Medical Center,8975956,ENDOVACULAR REPAIR S & I,,75956,320,"$4,013.00 ","$4,013.00 ","$1,203.90 ","$3,651.83 ","$2,809.10 ","$1,203.90 ","$2,608.45 ","$2,889.36 ","$3,651.83 ","$3,009.75 "
Carle BroMenn Medical Center,8975957,ENDOVASCULAR REPAIR S & I,,75957,320,"$3,323.00 ","$3,323.00 ",$996.90 ,"$3,023.93 ","$2,326.10 ",$996.90 ,"$2,159.95 ","$2,392.56 ","$3,023.93 ","$2,492.25 "
Carle BroMenn Medical Center,8975958,PLCMNT PROXIMAL EXTNSN PRSTHS,,75958,320,"$1,673.00 ","$1,673.00 ",$501.90 ,"$1,522.43 ","$1,171.10 ",$501.90 ,"$1,087.45 ","$1,204.56 ","$1,522.43 ","$1,254.75 "
Carle BroMenn Medical Center,8975959,PLCMNT DISTAL EXTNSN PRSTHS,,75959,320,"$2,993.00 ","$2,993.00 ",$897.90 ,"$2,723.63 ","$2,095.10 ",$897.90 ,"$1,945.45 ","$2,154.96 ","$2,723.63 ","$2,244.75 "
Carle BroMenn Medical Center,8975970,TRANSCATHETER BIOPSY S&I,,75970,320,"$2,423.00 ","$2,423.00 ",$726.90 ,"$2,204.93 ","$1,696.10 ",$726.90 ,"$1,574.95 ","$1,744.56 ","$2,204.93 ","$1,817.25 "
Carle BroMenn Medical Center,8975984,CHANGE PERC DRAIN CATH S&I,,75984,320,$505.00 ,$505.00 ,$151.50 ,$459.55 ,$353.50 ,$151.50 ,$328.25 ,$363.60 ,$459.55 ,$378.75 
Carle BroMenn Medical Center,8975989,GUIDANCE FOR DRAINAGE PROC S&I,,75989,320,$960.00 ,$960.00 ,$288.00 ,$873.60 ,$672.00 ,$288.00 ,$624.00 ,$691.20 ,$873.60 ,$720.00 
Carle BroMenn Medical Center,8976080,ABSCESS/FISTULA/TRACT STDY S&I,,76080,320,"$1,085.00 ","$1,085.00 ",$325.50 ,$987.35 ,$759.50 ,$325.50 ,$705.25 ,$781.20 ,$987.35 ,$813.75 
Carle BroMenn Medical Center,8976496,FLUOROSCOPY -NONVASC PROCEDURE,,76496,320,$280.00 ,$280.00 ,$84.00 ,$254.80 ,$196.00 ,$84.00 ,$182.00 ,$201.60 ,$254.80 ,$210.00 
Carle BroMenn Medical Center,8977001,FLUORO GDNC -CNTRL VN ACC DVC,,77001,320,$490.00 ,$490.00 ,$147.00 ,$445.90 ,$343.00 ,$147.00 ,$318.50 ,$352.80 ,$445.90 ,$367.50 
Carle BroMenn Medical Center,8977002,FLUORO GUIDNC ASP/BX/DRAINAGE,,77002,320,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8977003,FLUORO SPINE/PARASPINAL DX/TX,,77003,320,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8977601,FLUOROSCOPY  -IR PROCEDURE,,76000,320,$570.00 ,$570.00 ,$171.00 ,$518.70 ,$399.00 ,$171.00 ,$370.50 ,$410.40 ,$518.70 ,$427.50 
Carle BroMenn Medical Center,8978016,FLUORO OCCL BALLOON PLCMNT,,76496,320,$280.00 ,$280.00 ,$84.00 ,$254.80 ,$196.00 ,$84.00 ,$182.00 ,$201.60 ,$254.80 ,$210.00 
Carle BroMenn Medical Center,8978017,FLUORO SHEATH EXCHANGE,,76496,320,$280.00 ,$280.00 ,$84.00 ,$254.80 ,$196.00 ,$84.00 ,$182.00 ,$201.60 ,$254.80 ,$210.00 
Carle BroMenn Medical Center,8978018,FLUORO GUIDNC BILLARY BX,,76496,320,$280.00 ,$280.00 ,$84.00 ,$254.80 ,$196.00 ,$84.00 ,$182.00 ,$201.60 ,$254.80 ,$210.00 
Carle BroMenn Medical Center,8978019,FLUORO GUIDNC STONE CLEARANCE,,76496,320,$280.00 ,$280.00 ,$84.00 ,$254.80 ,$196.00 ,$84.00 ,$182.00 ,$201.60 ,$254.80 ,$210.00 
Carle BroMenn Medical Center,8978020,FLUORO GUIDNC STONE CLEAR & THORMBECTOMY,,76496,320,$280.00 ,$280.00 ,$84.00 ,$254.80 ,$196.00 ,$84.00 ,$182.00 ,$201.60 ,$254.80 ,$210.00 
Carle BroMenn Medical Center,8978021,FLUORO GUIDNC DUODENAL ANGIOPLSTY,,76496,320,$280.00 ,$280.00 ,$84.00 ,$254.80 ,$196.00 ,$84.00 ,$182.00 ,$201.60 ,$254.80 ,$210.00 
Carle BroMenn Medical Center,8978022,FLUORO GUIDNC EMBOLIZATION,,76496,320,$280.00 ,$280.00 ,$84.00 ,$254.80 ,$196.00 ,$84.00 ,$182.00 ,$201.60 ,$254.80 ,$210.00 
Carle BroMenn Medical Center,8978023,PERCUT EXLCUD LIMB ROUX-EN-Y BYPSS CNTST STUDY,,76496,320,$280.00 ,$280.00 ,$84.00 ,$254.80 ,$196.00 ,$84.00 ,$182.00 ,$201.60 ,$254.80 ,$210.00 
Carle BroMenn Medical Center,8978024,FLUORO NEPHROURETRL CATH ILIAL CONDUIT,,76496,320,$280.00 ,$280.00 ,$84.00 ,$254.80 ,$196.00 ,$84.00 ,$182.00 ,$201.60 ,$254.80 ,$210.00 
Carle BroMenn Medical Center,8978025,FLUORO GUIDNC STONE SWEEP & PLASTY,,76496,320,$280.00 ,$280.00 ,$84.00 ,$254.80 ,$196.00 ,$84.00 ,$182.00 ,$201.60 ,$254.80 ,$210.00 
Carle BroMenn Medical Center,8978026,FLUORO FOR EMBOLIZATION OF FISTULA,,76496,320,$280.00 ,$280.00 ,$84.00 ,$254.80 ,$196.00 ,$84.00 ,$182.00 ,$201.60 ,$254.80 ,$210.00 
Carle BroMenn Medical Center,8978027,FLUORO FOR IRRGTN & ASPRTN ABSCESS TRACT,,76496,320,$280.00 ,$280.00 ,$84.00 ,$254.80 ,$196.00 ,$84.00 ,$182.00 ,$201.60 ,$254.80 ,$210.00 
Carle BroMenn Medical Center,8978028,FLUORO ASPRTN ABSCESS TRCT & CATH REPO,,76496,320,$280.00 ,$280.00 ,$84.00 ,$254.80 ,$196.00 ,$84.00 ,$182.00 ,$201.60 ,$254.80 ,$210.00 
Carle BroMenn Medical Center,8978029,FLUORO EVAL & ASP MTL FROM PRTNL DIAL CATH,,76496,320,$280.00 ,$280.00 ,$84.00 ,$254.80 ,$196.00 ,$84.00 ,$182.00 ,$201.60 ,$254.80 ,$210.00 
Carle BroMenn Medical Center,8978030,FLUORO REPOSITION PERITONEAL CATH,,76496,320,$280.00 ,$280.00 ,$84.00 ,$254.80 ,$196.00 ,$84.00 ,$182.00 ,$201.60 ,$254.80 ,$210.00 
Carle BroMenn Medical Center,8978031,FLUORO CATH EVAL,,76496,320,$280.00 ,$280.00 ,$84.00 ,$254.80 ,$196.00 ,$84.00 ,$182.00 ,$201.60 ,$254.80 ,$210.00 
Carle BroMenn Medical Center,8978032,FLUORO RMVL PERTNAL DIALYSIS CATH,,76496,320,$280.00 ,$280.00 ,$84.00 ,$254.80 ,$196.00 ,$84.00 ,$182.00 ,$201.60 ,$254.80 ,$210.00 
Carle BroMenn Medical Center,8978033,FLUORO GUIDE FOR BCR,,76496,320,$280.00 ,$280.00 ,$84.00 ,$254.80 ,$196.00 ,$84.00 ,$182.00 ,$201.60 ,$254.80 ,$210.00 
Carle BroMenn Medical Center,8978034,FLUORO GUIDE CHNG CHEST TUBE UNILAT,,76496,320,$280.00 ,$280.00 ,$84.00 ,$254.80 ,$196.00 ,$84.00 ,$182.00 ,$201.60 ,$254.80 ,$210.00 
Carle BroMenn Medical Center,8978035,FLUORO GUIDE CHNG CHEST TUBE BILAT,,76496,320,$280.00 ,$280.00 ,$84.00 ,$254.80 ,$196.00 ,$84.00 ,$182.00 ,$201.60 ,$254.80 ,$210.00 
Carle BroMenn Medical Center,8978036,PERITONEAL-VENOUS SHUNT MAINT S&I,,76496,320,$280.00 ,$280.00 ,$84.00 ,$254.80 ,$196.00 ,$84.00 ,$182.00 ,$201.60 ,$254.80 ,$210.00 
Carle BroMenn Medical Center,8026405,CHEMO INTRALESIONAL 1-7 LESNS,,96405,330,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8026406,CHEMO INTRALESIONAL >7 LESIONS,,96406,330,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8026450,CHEMO -CENTRAL NERVOUS SYSTEM,,96450,330,$480.00 ,$480.00 ,$144.00 ,$436.80 ,$336.00 ,$144.00 ,$312.00 ,$345.60 ,$436.80 ,$360.00 
Carle BroMenn Medical Center,8026521,REFILL & MAINT PORTABLE PUMP,,96521,330,$750.00 ,$750.00 ,$225.00 ,$682.50 ,$525.00 ,$225.00 ,$487.50 ,$540.00 ,$682.50 ,$562.50 
Carle BroMenn Medical Center,8026522,REFILL & MAINT IMPLNTD PUMP,,96522,330,$638.00 ,$638.00 ,$191.40 ,$580.58 ,$446.60 ,$191.40 ,$414.70 ,$459.36 ,$580.58 ,$478.50 
Carle BroMenn Medical Center,8109050,REFILLING & MAINT PORTABLE PUM,,96521,330,$750.00 ,$750.00 ,$225.00 ,$682.50 ,$525.00 ,$225.00 ,$487.50 ,$540.00 ,$682.50 ,$562.50 
Carle BroMenn Medical Center,8109051,REFILL & MAINT IMPL PUMP/RESRV,,96522,330,$638.00 ,$638.00 ,$191.40 ,$580.58 ,$446.60 ,$191.40 ,$414.70 ,$459.36 ,$580.58 ,$478.50 
Carle BroMenn Medical Center,8796521,REFILLING & MAINT PORTABLE PUM,,96521,330,$750.00 ,$750.00 ,$225.00 ,$682.50 ,$525.00 ,$225.00 ,$487.50 ,$540.00 ,$682.50 ,$562.50 
Carle BroMenn Medical Center,8796522,REFILL & MAINT IMPL PUMP/RESRV,,96522,330,$638.00 ,$638.00 ,$191.40 ,$580.58 ,$446.60 ,$191.40 ,$414.70 ,$459.36 ,$580.58 ,$478.50 
Carle BroMenn Medical Center,8026401,CHEMO ADMIN NON-HORMONAL,,96401,331,$410.00 ,$410.00 ,$123.00 ,$373.10 ,$287.00 ,$123.00 ,$266.50 ,$295.20 ,$373.10 ,$307.50 
Carle BroMenn Medical Center,8026402,CHEMO ADMIN HORMONAL,,96402,331,$296.00 ,$296.00 ,$88.80 ,$269.36 ,$207.20 ,$88.80 ,$192.40 ,$213.12 ,$269.36 ,$222.00 
Carle BroMenn Medical Center,8026409,CHEMO IV PUSH SNGL/INTL DRUG,,96409,331,$860.00 ,$860.00 ,$258.00 ,$782.60 ,$602.00 ,$258.00 ,$559.00 ,$619.20 ,$782.60 ,$645.00 
Carle BroMenn Medical Center,8026411,CHEMO IV PUSH -EA ADNL,,96411,331,$605.00 ,$605.00 ,$181.50 ,$550.55 ,$423.50 ,$181.50 ,$393.25 ,$435.60 ,$550.55 ,$453.75 
Carle BroMenn Medical Center,8296401,CHEMO ANTI-NEOPL SQ/IM,,96401,331,$410.00 ,$410.00 ,$123.00 ,$373.10 ,$287.00 ,$123.00 ,$266.50 ,$295.20 ,$373.10 ,$307.50 
Carle BroMenn Medical Center,8296402,CHEMO HORMON ANTINEOPL SQ/IM,,96402,331,$296.00 ,$296.00 ,$88.80 ,$269.36 ,$207.20 ,$88.80 ,$192.40 ,$213.12 ,$269.36 ,$222.00 
Carle BroMenn Medical Center,8296409,CHEMO IV PUSH SNGL DRUG,,96409,331,$860.00 ,$860.00 ,$258.00 ,$782.60 ,$602.00 ,$258.00 ,$559.00 ,$619.20 ,$782.60 ,$645.00 
Carle BroMenn Medical Center,8296411,CHEMO IV PUSH ADDL DRUG,,96411,331,$605.00 ,$605.00 ,$181.50 ,$550.55 ,$423.50 ,$181.50 ,$393.25 ,$435.60 ,$550.55 ,$453.75 
Carle BroMenn Medical Center,8296446,"CHEM, PERITONEAL CAVITY VIA INDWELLING PORT/CATH",,96446,331,$405.00 ,$405.00 ,$121.50 ,$368.55 ,$283.50 ,$121.50 ,$263.25 ,$291.60 ,$368.55 ,$303.75 
Carle BroMenn Medical Center,8296450,CHEMOTHERAPY INTO CNS,,96450,331,$480.00 ,$480.00 ,$144.00 ,$436.80 ,$336.00 ,$144.00 ,$312.00 ,$345.60 ,$436.80 ,$360.00 
Carle BroMenn Medical Center,8296542,CHEMO INJ SUBARACHNOID/INTRAVENT VIA SUBQ RESERVOIR,,96542,331,$260.00 ,$260.00 ,$78.00 ,$236.60 ,$182.00 ,$78.00 ,$169.00 ,$187.20 ,$236.60 ,$195.00 
Carle BroMenn Medical Center,8496450,CHEMO -CENTRAL NERVOUS SYSTEM,,96450,331,$480.00 ,$480.00 ,$144.00 ,$436.80 ,$336.00 ,$144.00 ,$312.00 ,$345.60 ,$436.80 ,$360.00 
Carle BroMenn Medical Center,8261796,"STEREOTACTIC RADIOSURGERY, CRANIAL SIMPLE, SINGLE",,61796,333,"$9,150.00 ","$9,150.00 ","$2,745.00 ","$8,326.50 ","$6,405.00 ","$2,745.00 ","$5,947.50 ","$6,588.00 ","$8,326.50 ","$6,862.50 "
Carle BroMenn Medical Center,8261797,"STEREOTACTIC RADIOSURGERY, CRANIAL SIMPLE, EA ADD",,61797,333,"$2,020.00 ","$2,020.00 ",$606.00 ,"$1,838.20 ","$1,414.00 ",$606.00 ,"$1,313.00 ","$1,454.40 ","$1,838.20 ","$1,515.00 "
Carle BroMenn Medical Center,8261798,"STEREOTACTIC RADIOSURGERY, CRANIAL COMPLEX, SINGLE",,61798,333,"$10,610.00 ","$10,610.00 ","$3,183.00 ","$9,655.10 ","$7,427.00 ","$3,183.00 ","$6,896.50 ","$7,639.20 ","$9,655.10 ","$7,957.50 "
Carle BroMenn Medical Center,8261799,"STEREOTACTIC RADIOSURGERY, CRANIAL COMPLEX, EA ADD",,61799,333,"$2,770.00 ","$2,770.00 ",$831.00 ,"$2,520.70 ","$1,939.00 ",$831.00 ,"$1,800.50 ","$1,994.40 ","$2,520.70 ","$2,077.50 "
Carle BroMenn Medical Center,8261800,APPLY STEREOTACTIC HEADFRAME FOR RADIOSURGERY,,61800,333,"$1,200.00 ","$1,200.00 ",$360.00 ,"$1,092.00 ",$840.00 ,$360.00 ,$780.00 ,$864.00 ,"$1,092.00 ",$900.00 
Carle BroMenn Medical Center,8400339,SRS LN ACCLRTR 1RST SESSION,,G0339,333,"$9,548.00 ","$9,548.00 ","$2,864.40 ","$8,688.68 ","$6,683.60 ","$2,864.40 ","$6,206.20 ","$6,874.56 ","$8,688.68 ","$7,161.00 "
Carle BroMenn Medical Center,8400340,SRS LN ACCLRTR 2ND-5TH SESSION,,G0340,333,"$7,148.00 ","$7,148.00 ","$2,144.40 ","$6,504.68 ","$5,003.60 ","$2,144.40 ","$4,646.20 ","$5,146.56 ","$6,504.68 ","$5,361.00 "
Carle BroMenn Medical Center,8477280,SIMULATN-AIDED FLD SET SIMPLE,,77280,333,$998.00 ,$998.00 ,$299.40 ,$908.18 ,$698.60 ,$299.40 ,$648.70 ,$718.56 ,$908.18 ,$748.50 
Carle BroMenn Medical Center,8477285,SIMULATN-AIDED FLD SET INTERM,,77285,333,"$1,635.00 ","$1,635.00 ",$490.50 ,"$1,487.85 ","$1,144.50 ",$490.50 ,"$1,062.75 ","$1,177.20 ","$1,487.85 ","$1,226.25 "
Carle BroMenn Medical Center,8477290,SIMULATN-AIDED FLD SET COMPLX,,77290,333,"$2,130.00 ","$2,130.00 ",$639.00 ,"$1,938.30 ","$1,491.00 ",$639.00 ,"$1,384.50 ","$1,533.60 ","$1,938.30 ","$1,597.50 "
Carle BroMenn Medical Center,8477293,RESPIRATORY MOTION MANAGEMENT SIMULATION,,77293,333,"$2,093.00 ","$2,093.00 ",$627.90 ,"$1,904.63 ","$1,465.10 ",$627.90 ,"$1,360.45 ","$1,506.96 ","$1,904.63 ","$1,569.75 "
Carle BroMenn Medical Center,8477295,SIMUL-AIDED FLD SET 3D RECON,,77295,333,"$6,075.00 ","$6,075.00 ","$1,822.50 ","$5,528.25 ","$4,252.50 ","$1,822.50 ","$3,948.75 ","$4,374.00 ","$5,528.25 ","$4,556.25 "
Carle BroMenn Medical Center,8477300,RADIATN DOSIMETRY CALCULATION,,77300,333,$660.00 ,$660.00 ,$198.00 ,$600.60 ,$462.00 ,$198.00 ,$429.00 ,$475.20 ,$600.60 ,$495.00 
Carle BroMenn Medical Center,8477301,INTNSTY MODULATD RAD THRPY PLN,,77301,333,"$6,075.00 ","$6,075.00 ","$1,822.50 ","$5,528.25 ","$4,252.50 ","$1,822.50 ","$3,948.75 ","$4,374.00 ","$5,528.25 ","$4,556.25 "
Carle BroMenn Medical Center,8477306,TELETHRPY ISODOSE PLAN SIMPLE,,77306,333,"$1,178.00 ","$1,178.00 ",$353.40 ,"$1,071.98 ",$824.60 ,$353.40 ,$765.70 ,$848.16 ,"$1,071.98 ",$883.50 
Carle BroMenn Medical Center,8477307,TELETHRPY ISODOSE PLAN COMPLEX,,77307,333,"$1,635.00 ","$1,635.00 ",$490.50 ,"$1,487.85 ","$1,144.50 ",$490.50 ,"$1,062.75 ","$1,177.20 ","$1,487.85 ","$1,226.25 "
Carle BroMenn Medical Center,8477316,BRACHYTHRPY ISODOSE PLAN SIMPLE,,77316,333,$698.00 ,$698.00 ,$209.40 ,$635.18 ,$488.60 ,$209.40 ,$453.70 ,$502.56 ,$635.18 ,$523.50 
Carle BroMenn Medical Center,8477317,BRACHYTHRPY ISODOSE PLAN INTERMEDIATE,,77317,333,$848.00 ,$848.00 ,$254.40 ,$771.68 ,$593.60 ,$254.40 ,$551.20 ,$610.56 ,$771.68 ,$636.00 
Carle BroMenn Medical Center,8477318,BRACHYTHRPY ISODOSE PLAN COMPLEX,,77318,333,"$1,673.00 ","$1,673.00 ",$501.90 ,"$1,522.43 ","$1,171.10 ",$501.90 ,"$1,087.45 ","$1,204.56 ","$1,522.43 ","$1,254.75 "
Carle BroMenn Medical Center,8477321,SPECIAL TELETHERAPY PORT PLAN,,77321,333,"$1,875.00 ","$1,875.00 ",$562.50 ,"$1,706.25 ","$1,312.50 ",$562.50 ,"$1,218.75 ","$1,350.00 ","$1,706.25 ","$1,406.25 "
Carle BroMenn Medical Center,8477331,SPECIAL DOSIMETRY,,77331,333,$660.00 ,$660.00 ,$198.00 ,$600.60 ,$462.00 ,$198.00 ,$429.00 ,$475.20 ,$600.60 ,$495.00 
Carle BroMenn Medical Center,8477332,TREATMENT DEVICE(S) SIMPLE,,77332,333,$713.00 ,$713.00 ,$213.90 ,$648.83 ,$499.10 ,$213.90 ,$463.45 ,$513.36 ,$648.83 ,$534.75 
Carle BroMenn Medical Center,8477333,TREATMENT DEVICE(S) NTERMED,,77333,333,$818.00 ,$818.00 ,$245.40 ,$744.38 ,$572.60 ,$245.40 ,$531.70 ,$588.96 ,$744.38 ,$613.50 
Carle BroMenn Medical Center,8477334,TREATMENT DEVICE(S) COMPLEX,,77334,333,"$1,635.00 ","$1,635.00 ",$490.50 ,"$1,487.85 ","$1,144.50 ",$490.50 ,"$1,062.75 ","$1,177.20 ","$1,487.85 ","$1,226.25 "
Carle BroMenn Medical Center,8477336,RADIATION PHYSICS SUPPORT,,77336,333,$623.00 ,$623.00 ,$186.90 ,$566.93 ,$436.10 ,$186.90 ,$404.95 ,$448.56 ,$566.93 ,$467.25 
Carle BroMenn Medical Center,8477338,DESIGN MLC DEVICE FOR IMRT,,77338,333,"$1,253.00 ","$1,253.00 ",$375.90 ,"$1,140.23 ",$877.10 ,$375.90 ,$814.45 ,$902.16 ,"$1,140.23 ",$939.75 
Carle BroMenn Medical Center,8477370,RADIATION PHYSICS CONSULT,,77370,333,$915.00 ,$915.00 ,$274.50 ,$832.65 ,$640.50 ,$274.50 ,$594.75 ,$658.80 ,$832.65 ,$686.25 
Carle BroMenn Medical Center,8477372,RADIATION DELIVERY SRS; LINEAR ACCELERATOR BASED,,77372,333,"$15,278.00 ","$15,278.00 ","$4,583.40 ","$13,902.98 ","$10,694.60 ","$4,583.40 ","$9,930.70 ","$11,000.16 ","$13,902.98 ","$11,458.50 "
Carle BroMenn Medical Center,8477373,SRS FRACTIONATED TXMNT PER SESSION,,77373,333,"$8,828.00 ","$8,828.00 ","$2,648.40 ","$8,033.48 ","$6,179.60 ","$2,648.40 ","$5,738.20 ","$6,356.16 ","$8,033.48 ","$6,621.00 "
Carle BroMenn Medical Center,8477385,IMRT SIMPLE,,77385,333,"$2,633.00 ","$2,633.00 ",$789.90 ,"$2,396.03 ","$1,843.10 ",$789.90 ,"$1,711.45 ","$1,895.76 ","$2,396.03 ","$1,974.75 "
Carle BroMenn Medical Center,8477386,IMRT COMPLEX,,77386,333,"$4,268.00 ","$4,268.00 ","$1,280.40 ","$3,883.88 ","$2,987.60 ","$1,280.40 ","$2,774.20 ","$3,072.96 ","$3,883.88 ","$3,201.00 "
Carle BroMenn Medical Center,8477387,GUIDE LCLZTN TARGET VOL RAD TX DELV,,77387,333,"$1,455.00 ","$1,455.00 ",$436.50 ,"$1,324.05 ","$1,018.50 ",$436.50 ,$945.75 ,"$1,047.60 ","$1,324.05 ","$1,091.25 "
Carle BroMenn Medical Center,8477399,UNLISTED/IMAGE FUSION RADIATN ONCOLOGY,,77399,333,$803.00 ,$803.00 ,$240.90 ,$730.73 ,$562.10 ,$240.90 ,$521.95 ,$578.16 ,$730.73 ,$602.25 
Carle BroMenn Medical Center,8477402,RAD TRTMNT SIMPLE UP TO 5MEV,,77402,333,$600.00 ,$600.00 ,$180.00 ,$546.00 ,$420.00 ,$180.00 ,$390.00 ,$432.00 ,$546.00 ,$450.00 
Carle BroMenn Medical Center,8477407,RAD TRTMNT INTRMD UP TO 5MEV,,77407,333,$660.00 ,$660.00 ,$198.00 ,$600.60 ,$462.00 ,$198.00 ,$429.00 ,$475.20 ,$600.60 ,$495.00 
Carle BroMenn Medical Center,8477412,RAD TRTMNT COMPLX UP TO 5MEV,,77412,333,"$1,118.00 ","$1,118.00 ",$335.40 ,"$1,017.38 ",$782.60 ,$335.40 ,$726.70 ,$804.96 ,"$1,017.38 ",$838.50 
Carle BroMenn Medical Center,8477417,RADIATION THERAPY PORT FILM(S),,77417,333,$251.00 ,$251.00 ,$75.30 ,$228.41 ,$175.70 ,$75.30 ,$163.15 ,$180.72 ,$228.41 ,$188.25 
Carle BroMenn Medical Center,8477419,SRS LN ACCLRTR FIRST SSN,,G0339,333,"$9,548.00 ","$9,548.00 ","$2,864.40 ","$8,688.68 ","$6,683.60 ","$2,864.40 ","$6,206.20 ","$6,874.56 ","$8,688.68 ","$7,161.00 "
Carle BroMenn Medical Center,8477420,SRS LN ACCLRTR 2ND-5TH SSN EA,,G0340,333,"$7,148.00 ","$7,148.00 ","$2,144.40 ","$6,504.68 ","$5,003.60 ","$2,144.40 ","$4,646.20 ","$5,146.56 ","$6,504.68 ","$5,361.00 "
Carle BroMenn Medical Center,8477470,SPECIAL TREATMENT PROCEDURE,,77470,333,"$2,633.00 ","$2,633.00 ",$789.90 ,"$2,396.03 ","$1,843.10 ",$789.90 ,"$1,711.45 ","$1,895.76 ","$2,396.03 ","$1,974.75 "
Carle BroMenn Medical Center,8977290,SIMULATN-AIDED FLD SET COMPLX,,77290,333,"$2,130.00 ","$2,130.00 ",$639.00 ,"$1,938.30 ","$1,491.00 ",$639.00 ,"$1,384.50 ","$1,533.60 ","$1,938.30 ","$1,597.50 "
Carle BroMenn Medical Center,8977300,CALCULATIONS -RADIATION TRTMNT,,77300,333,$660.00 ,$660.00 ,$198.00 ,$600.60 ,$462.00 ,$198.00 ,$429.00 ,$475.20 ,$600.60 ,$495.00 
Carle BroMenn Medical Center,8026413,CHEMO IV INFUSION -UP TO 1HR,,96413,335,$945.00 ,$945.00 ,$283.50 ,$859.95 ,$661.50 ,$283.50 ,$614.25 ,$680.40 ,$859.95 ,$708.75 
Carle BroMenn Medical Center,8026416,INIT PROLONG CHEMO REQ PUMP,,96416,335,$465.00 ,$465.00 ,$139.50 ,$423.15 ,$325.50 ,$139.50 ,$302.25 ,$334.80 ,$423.15 ,$348.75 
Carle BroMenn Medical Center,8026417,CHEMO IV INFUSN SEQTNTL -UP TO 1HR,,96417,335,$525.00 ,$525.00 ,$157.50 ,$477.75 ,$367.50 ,$157.50 ,$341.25 ,$378.00 ,$477.75 ,$393.75 
Carle BroMenn Medical Center,8029415,CHEMO IV INFUSION -EA ADNL HR,,96415,335,$410.00 ,$410.00 ,$123.00 ,$373.10 ,$287.00 ,$123.00 ,$266.50 ,$295.20 ,$373.10 ,$307.50 
Carle BroMenn Medical Center,8200498,"CHEMO PROLONG VIA PUMP;INCL SET UP, RMV, PUMP",,G0498,335,$475.00 ,$475.00 ,$142.50 ,$432.25 ,$332.50 ,$142.50 ,$308.75 ,$342.00 ,$432.25 ,$356.25 
Carle BroMenn Medical Center,8296413,CHEMO IV INFUSION 1 HR,,96413,335,$945.00 ,$945.00 ,$283.50 ,$859.95 ,$661.50 ,$283.50 ,$614.25 ,$680.40 ,$859.95 ,$708.75 
Carle BroMenn Medical Center,8296415,CHEMO IV INFUSION ADDL HR,,96415,335,$410.00 ,$410.00 ,$123.00 ,$373.10 ,$287.00 ,$123.00 ,$266.50 ,$295.20 ,$373.10 ,$307.50 
Carle BroMenn Medical Center,8296416,CHEMO PROLONG INFUSE W/PUMP,,96416,335,$465.00 ,$465.00 ,$139.50 ,$423.15 ,$325.50 ,$139.50 ,$302.25 ,$334.80 ,$423.15 ,$348.75 
Carle BroMenn Medical Center,8296417,CHEMO IV INFUS EACH ADDL SEQ,,96417,335,$525.00 ,$525.00 ,$157.50 ,$477.75 ,$367.50 ,$157.50 ,$341.25 ,$378.00 ,$477.75 ,$393.75 
Carle BroMenn Medical Center,8478012,THYROID UPTAKE MEASUREMENT,,78012,340,$428.00 ,$428.00 ,$128.40 ,$389.48 ,$299.60 ,$128.40 ,$278.20 ,$308.16 ,$389.48 ,$321.00 
Carle BroMenn Medical Center,8478013,THYROID IMAGING W/BLOOD FLOW,,78013,340,"$1,335.00 ","$1,335.00 ",$400.50 ,"$1,214.85 ",$934.50 ,$400.50 ,$867.75 ,$961.20 ,"$1,214.85 ","$1,001.25 "
Carle BroMenn Medical Center,8478014,THYROID IMAGING W/BLOOD FLOW,,78014,340,"$1,080.00 ","$1,080.00 ",$324.00 ,$982.80 ,$756.00 ,$324.00 ,$702.00 ,$777.60 ,$982.80 ,$810.00 
Carle BroMenn Medical Center,8478015,THYROID CA METS IMAGING LIMITD,,78015,340,"$1,050.00 ","$1,050.00 ",$315.00 ,$955.50 ,$735.00 ,$315.00 ,$682.50 ,$756.00 ,$955.50 ,$787.50 
Carle BroMenn Medical Center,8478185,SPLEEN IMAGING,,78185,340,$713.00 ,$713.00 ,$213.90 ,$648.83 ,$499.10 ,$213.90 ,$463.45 ,$513.36 ,$648.83 ,$534.75 
Carle BroMenn Medical Center,8478201,LIVER IMAGING STATIC,,78201,340,"$1,635.00 ","$1,635.00 ",$490.50 ,"$1,487.85 ","$1,144.50 ",$490.50 ,"$1,062.75 ","$1,177.20 ","$1,487.85 ","$1,226.25 "
Carle BroMenn Medical Center,8478202,LIVER IMAGING W/VASCLR FLOW,,78202,340,"$2,813.00 ","$2,813.00 ",$843.90 ,"$2,559.83 ","$1,969.10 ",$843.90 ,"$1,828.45 ","$2,025.36 ","$2,559.83 ","$2,109.75 "
Carle BroMenn Medical Center,8478205,LIVER IMAGING (SPECT),,78205,340,"$2,003.00 ","$2,003.00 ",$600.90 ,"$1,822.73 ","$1,402.10 ",$600.90 ,"$1,301.95 ","$1,442.16 ","$1,822.73 ","$1,502.25 "
Carle BroMenn Medical Center,8478206,LIVER IMAGING (SPECT); W/VASCULAR FLOW,,78206,340,"$3,308.00 ","$3,308.00 ",$992.40 ,"$3,010.28 ","$2,315.60 ",$992.40 ,"$2,150.20 ","$2,381.76 ","$3,010.28 ","$2,481.00 "
Carle BroMenn Medical Center,8478215,LIVER & SPLEEN IMAGING;STATIC,,78215,340,"$1,535.00 ","$1,535.00 ",$460.50 ,"$1,396.85 ","$1,074.50 ",$460.50 ,$997.75 ,"$1,105.20 ","$1,396.85 ","$1,151.25 "
Carle BroMenn Medical Center,8478226,HEPATOBILIARY SYST IMAGING W/GLBLDR,,78226,340,"$2,085.00 ","$2,085.00 ",$625.50 ,"$1,897.35 ","$1,459.50 ",$625.50 ,"$1,355.25 ","$1,501.20 ","$1,897.35 ","$1,563.75 "
Carle BroMenn Medical Center,8478227,HEPATOBILIARY SYST IMGNG W/GLBLDR W/RX,,78227,340,"$2,085.00 ","$2,085.00 ",$625.50 ,"$1,897.35 ","$1,459.50 ",$625.50 ,"$1,355.25 ","$1,501.20 ","$1,897.35 ","$1,563.75 "
Carle BroMenn Medical Center,8478262,GASTROESOPHAGEAL REFLUX STUDY,,78262,340,"$1,275.00 ","$1,275.00 ",$382.50 ,"$1,160.25 ",$892.50 ,$382.50 ,$828.75 ,$918.00 ,"$1,160.25 ",$956.25 
Carle BroMenn Medical Center,8478264,GASTRIC EMPTYING STUDY,,78264,340,"$1,330.00 ","$1,330.00 ",$399.00 ,"$1,210.30 ",$931.00 ,$399.00 ,$864.50 ,$957.60 ,"$1,210.30 ",$997.50 
Carle BroMenn Medical Center,8478265,CHG GASTRIC EMPTYNG IMAG STD W/SM BWL TRANSIT,,78265,340,"$2,295.00 ","$2,295.00 ",$688.50 ,"$2,088.45 ","$1,606.50 ",$688.50 ,"$1,491.75 ","$1,652.40 ","$2,088.45 ","$1,721.25 "
Carle BroMenn Medical Center,8478266,CHG GSTRC EMPTNG IMAG STD W/SM BWL COL TRNST MLT DAY,,78266,340,"$3,233.00 ","$3,233.00 ",$969.90 ,"$2,942.03 ","$2,263.10 ",$969.90 ,"$2,101.45 ","$2,327.76 ","$2,942.03 ","$2,424.75 "
Carle BroMenn Medical Center,8478270,VIT B12 ABSORB STDY WO INT FCT,,78270,340,$630.00 ,$630.00 ,$189.00 ,$573.30 ,$441.00 ,$189.00 ,$409.50 ,$453.60 ,$573.30 ,$472.50 
Carle BroMenn Medical Center,8478278,GI BLOOD LOSS IMAGING,,78278,340,$595.00 ,$595.00 ,$178.50 ,$541.45 ,$416.50 ,$178.50 ,$386.75 ,$428.40 ,$541.45 ,$446.25 
Carle BroMenn Medical Center,8478300,BONE/JOINT IMAGING -LTD AREA,,78300,340,"$1,505.00 ","$1,505.00 ",$451.50 ,"$1,369.55 ","$1,053.50 ",$451.50 ,$978.25 ,"$1,083.60 ","$1,369.55 ","$1,128.75 "
Carle BroMenn Medical Center,8478305,BONE/JOINT IMAGING -MULT AREAS,,78305,340,"$1,373.00 ","$1,373.00 ",$411.90 ,"$1,249.43 ",$961.10 ,$411.90 ,$892.45 ,$988.56 ,"$1,249.43 ","$1,029.75 "
Carle BroMenn Medical Center,8478306,BONE/JOINT IMAGING -WHOLE BODY,,78306,340,"$1,690.00 ","$1,690.00 ",$507.00 ,"$1,537.90 ","$1,183.00 ",$507.00 ,"$1,098.50 ","$1,216.80 ","$1,537.90 ","$1,267.50 "
Carle BroMenn Medical Center,8478429,MYOCRD IMG PET METAB EVAL SINGLE STUDY CNCRNT CT,,78429,340,"$2,460.00 ","$2,460.00 ",$738.00 ,"$2,238.60 ","$1,722.00 ",$738.00 ,"$1,599.00 ","$1,771.20 ","$2,238.60 ","$1,845.00 "
Carle BroMenn Medical Center,8478430,MYOCRD IMG PET PRFUJ 1STD REST/STRESS CNCRNT CT,,78430,340,"$2,830.00 ","$2,830.00 ",$849.00 ,"$2,575.30 ","$1,981.00 ",$849.00 ,"$1,839.50 ","$2,037.60 ","$2,575.30 ","$2,122.50 "
Carle BroMenn Medical Center,8478431,MYOCRD IMG PET PRFUJ MLT STD RST&STRS CNCRNT CT,,78431,340,"$4,410.00 ","$4,410.00 ","$1,323.00 ","$4,013.10 ","$3,087.00 ","$1,323.00 ","$2,866.50 ","$3,175.20 ","$4,013.10 ","$3,307.50 "
Carle BroMenn Medical Center,8478432,MYOCRD IMG PET PRFUJ W/METAB DUAL RADIOTRACER,,78432,340,"$5,390.00 ","$5,390.00 ","$1,617.00 ","$4,904.90 ","$3,773.00 ","$1,617.00 ","$3,503.50 ","$3,880.80 ","$4,904.90 ","$4,042.50 "
Carle BroMenn Medical Center,8478433,MYOCRD IMG PET PRFUJ W/METAB 2RTRACER CNCRNT CT,,78433,340,"$5,390.00 ","$5,390.00 ","$1,617.00 ","$4,904.90 ","$3,773.00 ","$1,617.00 ","$3,503.50 ","$3,880.80 ","$4,904.90 ","$4,042.50 "
Carle BroMenn Medical Center,8478434,AQMBF PET REST AND PHARMACOLOGIC STRESS,,78434,340,"$1,875.00 ","$1,875.00 ",$562.50 ,"$1,706.25 ","$1,312.50 ",$562.50 ,"$1,218.75 ","$1,350.00 ","$1,706.25 ","$1,406.25 "
Carle BroMenn Medical Center,8478466,MYOCAR IMAGING INFARCT AVID PL,,78466,340,"$1,215.00 ","$1,215.00 ",$364.50 ,"$1,105.65 ",$850.50 ,$364.50 ,$789.75 ,$874.80 ,"$1,105.65 ",$911.25 
Carle BroMenn Medical Center,8478472,CARDIAC GATED BLOOD POOL IMAGN,,78472,340,"$1,480.00 ","$1,480.00 ",$444.00 ,"$1,346.80 ","$1,036.00 ",$444.00 ,$962.00 ,"$1,065.60 ","$1,346.80 ","$1,110.00 "
Carle BroMenn Medical Center,8478473,CARDIAC GATED BLOOD POOL IMAGN,,78473,340,"$1,815.00 ","$1,815.00 ",$544.50 ,"$1,651.65 ","$1,270.50 ",$544.50 ,"$1,179.75 ","$1,306.80 ","$1,651.65 ","$1,361.25 "
Carle BroMenn Medical Center,8478494,HEART IMAGE SPECT,,78494,340,$938.00 ,$938.00 ,$281.40 ,$853.58 ,$656.60 ,$281.40 ,$609.70 ,$675.36 ,$853.58 ,$703.50 
Carle BroMenn Medical Center,8478580,LUNG PERFUSION IMAGING,,78580,340,"$1,935.00 ","$1,935.00 ",$580.50 ,"$1,760.85 ","$1,354.50 ",$580.50 ,"$1,257.75 ","$1,393.20 ","$1,760.85 ","$1,451.25 "
Carle BroMenn Medical Center,8478582,PULM VENT AND PERFUSION IMAGING,,78582,340,"$1,200.00 ","$1,200.00 ",$360.00 ,"$1,092.00 ",$840.00 ,$360.00 ,$780.00 ,$864.00 ,"$1,092.00 ",$900.00 
Carle BroMenn Medical Center,8478597,QUANT DIFF PULM PRFSN STUDY,,78597,340,"$1,425.00 ","$1,425.00 ",$427.50 ,"$1,296.75 ",$997.50 ,$427.50 ,$926.25 ,"$1,026.00 ","$1,296.75 ","$1,068.75 "
Carle BroMenn Medical Center,8478598,QUANT DIFF PULM PRFUSION & VENTLAJ W/WO IMAGING,,78598,340,"$3,005.00 ","$3,005.00 ",$901.50 ,"$2,734.55 ","$2,103.50 ",$901.50 ,"$1,953.25 ","$2,163.60 ","$2,734.55 ","$2,253.75 "
Carle BroMenn Medical Center,8478601,BRAIN IMAGING LESS THAN 4 STATIC VIEWS W/VAS FLOW,,78601,340,$840.00 ,$840.00 ,$252.00 ,$764.40 ,$588.00 ,$252.00 ,$546.00 ,$604.80 ,$764.40 ,$630.00 
Carle BroMenn Medical Center,8478605,BRAIN IMAGING COMPLETE STATIC,,78605,340,$878.00 ,$878.00 ,$263.40 ,$798.98 ,$614.60 ,$263.40 ,$570.70 ,$632.16 ,$798.98 ,$658.50 
Carle BroMenn Medical Center,8478610,BRAIN IMAGING VASC FLOW ONLY,,78610,340,$990.00 ,$990.00 ,$297.00 ,$900.90 ,$693.00 ,$297.00 ,$643.50 ,$712.80 ,$900.90 ,$742.50 
Carle BroMenn Medical Center,8478645,CEREBROSPINAL FLUID FLOW IMAGING; SHUNT,,78645,340,$683.00 ,$683.00 ,$204.90 ,$621.53 ,$478.10 ,$204.90 ,$443.95 ,$491.76 ,$621.53 ,$512.25 
Carle BroMenn Medical Center,8478740,URETERAL REFLUX STDY W/RADIOPH,,78740,340,"$1,610.00 ","$1,610.00 ",$483.00 ,"$1,465.10 ","$1,127.00 ",$483.00 ,"$1,046.50 ","$1,159.20 ","$1,465.10 ","$1,207.50 "
Carle BroMenn Medical Center,8478800,TUMOR LOCALIZATION LIMITED AREA,,78800,340,"$2,090.00 ","$2,090.00 ",$627.00 ,"$1,901.90 ","$1,463.00 ",$627.00 ,"$1,358.50 ","$1,504.80 ","$1,901.90 ","$1,567.50 "
Carle BroMenn Medical Center,8478801,TUMOR LOCALIZATION MULT AREAS,,78801,340,"$1,613.00 ","$1,613.00 ",$483.90 ,"$1,467.83 ","$1,129.10 ",$483.90 ,"$1,048.45 ","$1,161.36 ","$1,467.83 ","$1,209.75 "
Carle BroMenn Medical Center,8478805,LOCALIZE INFLAM PROC LMTD AREA,,78805,340,"$1,433.00 ","$1,433.00 ",$429.90 ,"$1,304.03 ","$1,003.10 ",$429.90 ,$931.45 ,"$1,031.76 ","$1,304.03 ","$1,074.75 "
Carle BroMenn Medical Center,8478806,LOCALIZED INFLA WHOLE BODY,,78806,340,"$1,635.00 ","$1,635.00 ",$490.50 ,"$1,487.85 ","$1,144.50 ",$490.50 ,"$1,062.75 ","$1,177.20 ","$1,487.85 ","$1,226.25 "
Carle BroMenn Medical Center,8478807,LOCALIZE ABSCESS (SPECT),,78807,340,"$1,725.00 ","$1,725.00 ",$517.50 ,"$1,569.75 ","$1,207.50 ",$517.50 ,"$1,121.25 ","$1,242.00 ","$1,569.75 ","$1,293.75 "
Carle BroMenn Medical Center,8478830,RP LOCLZJ TUM SPECT W/CT 1 AREA 1 DAY IMAGING,,78830,340,"$2,239.00 ","$2,239.00 ",$671.70 ,"$2,037.49 ","$1,567.30 ",$671.70 ,"$1,455.35 ","$1,612.08 ","$2,037.49 ","$1,679.25 "
Carle BroMenn Medical Center,8478831,RP LOCLZJ TUM SPECT 2 AREA 1D IMG/1 AREA IMG>2+D,,78831,340,"$2,500.00 ","$2,500.00 ",$750.00 ,"$2,275.00 ","$1,750.00 ",$750.00 ,"$1,625.00 ","$1,800.00 ","$2,275.00 ","$1,875.00 "
Carle BroMenn Medical Center,8478832,RP LOCLZJ TUM SPECT CT 2AREA 1D IMG/1 AR IMG>2+D,,78832,340,"$3,184.00 ","$3,184.00 ",$955.20 ,"$2,897.44 ","$2,228.80 ",$955.20 ,"$2,069.60 ","$2,292.48 ","$2,897.44 ","$2,388.00 "
Carle BroMenn Medical Center,8478835,RADIOPHARMACEUTICAL QUANTIFICATION MEAS 1 AREA,,78835,340,$375.00 ,$375.00 ,$112.50 ,$341.25 ,$262.50 ,$112.50 ,$243.75 ,$270.00 ,$341.25 ,$281.25 
Carle BroMenn Medical Center,8479445,RADIOPHARM TX INTRA ART PARTICLT ADMIN,,79445,340,"$1,485.00 ","$1,485.00 ",$445.50 ,"$1,351.35 ","$1,039.50 ",$445.50 ,$965.25 ,"$1,069.20 ","$1,351.35 ","$1,113.75 "
Carle BroMenn Medical Center,8971440,"NUCLEAR THERAPY, INTRA-ARTICULAR",,79440,340,"$1,335.00 ","$1,335.00 ",$400.50 ,"$1,214.85 ",$934.50 ,$400.50 ,$867.75 ,$961.20 ,"$1,214.85 ","$1,001.25 "
Carle BroMenn Medical Center,8971445,"RADIOPHARM TX, INTRA-ARTERIAL",,79445,340,"$1,485.00 ","$1,485.00 ",$445.50 ,"$1,351.35 ","$1,039.50 ",$445.50 ,$965.25 ,"$1,069.20 ","$1,351.35 ","$1,113.75 "
Carle BroMenn Medical Center,8478018,WHOLE BODY IMAGING,,78018,341,"$1,880.00 ","$1,880.00 ",$564.00 ,"$1,710.80 ","$1,316.00 ",$564.00 ,"$1,222.00 ","$1,353.60 ","$1,710.80 ","$1,410.00 "
Carle BroMenn Medical Center,8478020,THYROID CA METS UPDATE,,78020,341,$341.00 ,$341.00 ,$102.30 ,$310.31 ,$238.70 ,$102.30 ,$221.65 ,$245.52 ,$310.31 ,$255.75 
Carle BroMenn Medical Center,8478070,PARATHYROID IMAGING,,78070,341,"$1,105.00 ","$1,105.00 ",$331.50 ,"$1,005.55 ",$773.50 ,$331.50 ,$718.25 ,$795.60 ,"$1,005.55 ",$828.75 
Carle BroMenn Medical Center,8478071,PARATHYROID IMAGING W/SPECT,,78071,341,"$1,420.00 ","$1,420.00 ",$426.00 ,"$1,292.20 ",$994.00 ,$426.00 ,$923.00 ,"$1,022.40 ","$1,292.20 ","$1,065.00 "
Carle BroMenn Medical Center,8478072,PARATHYROID IMAGING W/SPECT AND ANTMCL LCLZN CT,,78072,341,"$1,700.00 ","$1,700.00 ",$510.00 ,"$1,547.00 ","$1,190.00 ",$510.00 ,"$1,105.00 ","$1,224.00 ","$1,547.00 ","$1,275.00 "
Carle BroMenn Medical Center,8478102,BONE MARROW IMAGING LIMITED AREA,,78102,341,$683.00 ,$683.00 ,$204.90 ,$621.53 ,$478.10 ,$204.90 ,$443.95 ,$491.76 ,$621.53 ,$512.25 
Carle BroMenn Medical Center,8478104,BONE MARROW IMAGING WHOLE BODY,,78104,341,$960.00 ,$960.00 ,$288.00 ,$873.60 ,$672.00 ,$288.00 ,$624.00 ,$691.20 ,$873.60 ,$720.00 
Carle BroMenn Medical Center,8478195,LYMPHOSCINTIGRAPHY,,78195,341,$835.00 ,$835.00 ,$250.50 ,$759.85 ,$584.50 ,$250.50 ,$542.75 ,$601.20 ,$759.85 ,$626.25 
Carle BroMenn Medical Center,8478282,GI PROTEIN LOSS EXAM,,78282,341,"$1,193.00 ","$1,193.00 ",$357.90 ,"$1,085.63 ",$835.10 ,$357.90 ,$775.45 ,$858.96 ,"$1,085.63 ",$894.75 
Carle BroMenn Medical Center,8478290,INTESTINE IMAGING (MECKEL'S),,78290,341,"$1,465.00 ","$1,465.00 ",$439.50 ,"$1,333.15 ","$1,025.50 ",$439.50 ,$952.25 ,"$1,054.80 ","$1,333.15 ","$1,098.75 "
Carle BroMenn Medical Center,8478291,PERITONEAL-VENOUS SHUNT EVAL,,78291,341,$840.00 ,$840.00 ,$252.00 ,$764.40 ,$588.00 ,$252.00 ,$546.00 ,$604.80 ,$764.40 ,$630.00 
Carle BroMenn Medical Center,8478315,BONE/JOINT IMAGING -3 PHASE,,78315,341,"$1,810.00 ","$1,810.00 ",$543.00 ,"$1,647.10 ","$1,267.00 ",$543.00 ,"$1,176.50 ","$1,303.20 ","$1,647.10 ","$1,357.50 "
Carle BroMenn Medical Center,8478320,BONE/JOINT IMAGING(SPECT),,78320,341,"$2,325.00 ","$2,325.00 ",$697.50 ,"$2,115.75 ","$1,627.50 ",$697.50 ,"$1,511.25 ","$1,674.00 ","$2,115.75 ","$1,743.75 "
Carle BroMenn Medical Center,8478445,NON-CARDIAC VASCULAR FLOW IMAGING,,78445,341,"$1,193.00 ","$1,193.00 ",$357.90 ,"$1,085.63 ",$835.10 ,$357.90 ,$775.45 ,$858.96 ,"$1,085.63 ",$894.75 
Carle BroMenn Medical Center,8478451,HT MUSCLE IMAGE SPECT SINGLE,,78451,341,"$2,235.00 ","$2,235.00 ",$670.50 ,"$2,033.85 ","$1,564.50 ",$670.50 ,"$1,452.75 ","$1,609.20 ","$2,033.85 ","$1,676.25 "
Carle BroMenn Medical Center,8478452,HT MUSCLE IMAGE SPECT MULT,,78452,341,"$3,390.00 ","$3,390.00 ","$1,017.00 ","$3,084.90 ","$2,373.00 ","$1,017.00 ","$2,203.50 ","$2,440.80 ","$3,084.90 ","$2,542.50 "
Carle BroMenn Medical Center,8478453,HT MUSCLE IMAGE PLANAR SINGLE,,78453,341,"$2,453.00 ","$2,453.00 ",$735.90 ,"$2,232.23 ","$1,717.10 ",$735.90 ,"$1,594.45 ","$1,766.16 ","$2,232.23 ","$1,839.75 "
Carle BroMenn Medical Center,8478454,HT MUSC IMAGE PLANAR MULT,,78454,341,"$3,345.00 ","$3,345.00 ","$1,003.50 ","$3,043.95 ","$2,341.50 ","$1,003.50 ","$2,174.25 ","$2,408.40 ","$3,043.95 ","$2,508.75 "
Carle BroMenn Medical Center,8478469,MYOCAR IMAGING INFARCT AVID SP,,78469,341,"$2,481.00 ","$2,481.00 ",$744.30 ,"$2,257.71 ","$1,736.70 ",$744.30 ,"$1,612.65 ","$1,786.32 ","$2,257.71 ","$1,860.75 "
Carle BroMenn Medical Center,8478630,CSF FLUID SCAN CISTERNOGRAPHY,,78630,341,"$1,530.00 ","$1,530.00 ",$459.00 ,"$1,392.30 ","$1,071.00 ",$459.00 ,$994.50 ,"$1,101.60 ","$1,392.30 ","$1,147.50 "
Carle BroMenn Medical Center,8478700,KIDNEY IMAGING,,78700,341,"$1,028.00 ","$1,028.00 ",$308.40 ,$935.48 ,$719.60 ,$308.40 ,$668.20 ,$740.16 ,$935.48 ,$771.00 
Carle BroMenn Medical Center,8478707,KIDNEY IMAGING W/FLOW W/O PHRM,,78707,341,"$2,020.00 ","$2,020.00 ",$606.00 ,"$1,838.20 ","$1,414.00 ",$606.00 ,"$1,313.00 ","$1,454.40 ","$1,838.20 ","$1,515.00 "
Carle BroMenn Medical Center,8478708,KIDNEY IMAGING W/FLOW & PHARM,,78708,341,"$1,440.00 ","$1,440.00 ",$432.00 ,"$1,310.40 ","$1,008.00 ",$432.00 ,$936.00 ,"$1,036.80 ","$1,310.40 ","$1,080.00 "
Carle BroMenn Medical Center,8478709,KIDNEY IMAGING W/FLOW W/WO PHA,,78709,341,"$1,420.00 ","$1,420.00 ",$426.00 ,"$1,292.20 ",$994.00 ,$426.00 ,$923.00 ,"$1,022.40 ","$1,292.20 ","$1,065.00 "
Carle BroMenn Medical Center,8478802,TUMOR IMAGING WHOLE BODY,,78802,341,"$3,350.00 ","$3,350.00 ","$1,005.00 ","$3,048.50 ","$2,345.00 ","$1,005.00 ","$2,177.50 ","$2,412.00 ","$3,048.50 ","$2,512.50 "
Carle BroMenn Medical Center,8478803,TUMOR LOCALIZATION SPECT,,78803,341,"$2,635.00 ","$2,635.00 ",$790.50 ,"$2,397.85 ","$1,844.50 ",$790.50 ,"$1,712.75 ","$1,897.20 ","$2,397.85 ","$1,976.25 "
Carle BroMenn Medical Center,8478804,TUMOR LOCALIZATION WHOLE BODY MULT DAY IMAGING,,78804,341,"$4,500.00 ","$4,500.00 ","$1,350.00 ","$4,095.00 ","$3,150.00 ","$1,350.00 ","$2,925.00 ","$3,240.00 ","$4,095.00 ","$3,375.00 "
Carle BroMenn Medical Center,8978291,PERITONEAL-VENOUS SHUNT PATENCY TEST,,78291,341,$840.00 ,$840.00 ,$252.00 ,$764.40 ,$588.00 ,$252.00 ,$546.00 ,$604.80 ,$764.40 ,$630.00 
Carle BroMenn Medical Center,8477750,INFUSE/INSTILL RADIOELEMNT SOL,,77750,342,$900.00 ,$900.00 ,$270.00 ,$819.00 ,$630.00 ,$270.00 ,$585.00 ,$648.00 ,$819.00 ,$675.00 
Carle BroMenn Medical Center,8477761,RAD SRC APPL INTRACAV SIMPLE,,77761,342,"$1,418.00 ","$1,418.00 ",$425.40 ,"$1,290.38 ",$992.60 ,$425.40 ,$921.70 ,"$1,020.96 ","$1,290.38 ","$1,063.50 "
Carle BroMenn Medical Center,8477762,RAD SRC APPL INTRACAV INTERMD,,77762,342,"$1,808.00 ","$1,808.00 ",$542.40 ,"$1,645.28 ","$1,265.60 ",$542.40 ,"$1,175.20 ","$1,301.76 ","$1,645.28 ","$1,356.00 "
Carle BroMenn Medical Center,8477763,RAD SRC APPL INTRACAV COMPLEX,,77763,342,"$2,108.00 ","$2,108.00 ",$632.40 ,"$1,918.28 ","$1,475.60 ",$632.40 ,"$1,370.20 ","$1,517.76 ","$1,918.28 ","$1,581.00 "
Carle BroMenn Medical Center,8477767,HDR RDNCL SKN SURF BRACHYTX LES </2CM/1 CHAN,,77767,342,"$1,598.00 ","$1,598.00 ",$479.40 ,"$1,454.18 ","$1,118.60 ",$479.40 ,"$1,038.70 ","$1,150.56 ","$1,454.18 ","$1,198.50 "
Carle BroMenn Medical Center,8477768,HDR RDNCL SK SRF BRCHYTX LES >2CM&2CHAN/MLT LES,,77768,342,"$2,633.00 ","$2,633.00 ",$789.90 ,"$2,396.03 ","$1,843.10 ",$789.90 ,"$1,711.45 ","$1,895.76 ","$2,396.03 ","$1,974.75 "
Carle BroMenn Medical Center,8477770,HDR RDNCL NTRSTL/INTRCAV BRACHYTX 1 CHANNEL,,77770,342,"$1,950.00 ","$1,950.00 ",$585.00 ,"$1,774.50 ","$1,365.00 ",$585.00 ,"$1,267.50 ","$1,404.00 ","$1,774.50 ","$1,462.50 "
Carle BroMenn Medical Center,8477771,HDR RDNCL NTRSTL/INTRCAV BRACHYTX 2-12 CHANNEL,,77771,342,"$3,188.00 ","$3,188.00 ",$956.40 ,"$2,901.08 ","$2,231.60 ",$956.40 ,"$2,072.20 ","$2,295.36 ","$2,901.08 ","$2,391.00 "
Carle BroMenn Medical Center,8477772,HDR RDNCL NTRSTL/INTRCAV BRACHYTX >12 CHANNELS,,77772,342,"$5,918.00 ","$5,918.00 ","$1,775.40 ","$5,385.38 ","$4,142.60 ","$1,775.40 ","$3,846.70 ","$4,260.96 ","$5,385.38 ","$4,438.50 "
Carle BroMenn Medical Center,8477778,RAD SRC APP INTERSTITIAL CMPLX,,77778,342,"$3,435.00 ","$3,435.00 ","$1,030.50 ","$3,125.85 ","$2,404.50 ","$1,030.50 ","$2,232.75 ","$2,473.20 ","$3,125.85 ","$2,576.25 "
Carle BroMenn Medical Center,8477789,RAD SOURCE APPLICATN SURFACE,,77789,342,$383.00 ,$383.00 ,$114.90 ,$348.53 ,$268.10 ,$114.90 ,$248.95 ,$275.76 ,$348.53 ,$287.25 
Carle BroMenn Medical Center,8477790,RAD SRC SUPRVSN/HANDLNG/LOADNG,,77790,342,$443.00 ,$443.00 ,$132.90 ,$403.13 ,$310.10 ,$132.90 ,$287.95 ,$318.96 ,$403.13 ,$332.25 
Carle BroMenn Medical Center,8479005,RAD THERAPY ORAL ADMINISTRATN,,79005,342,"$1,015.00 ","$1,015.00 ",$304.50 ,$923.65 ,$710.50 ,$304.50 ,$659.75 ,$730.80 ,$923.65 ,$761.25 
Carle BroMenn Medical Center,8479101,RADPHARM TRPY BY IV,,79101,342,$938.00 ,$938.00 ,$281.40 ,$853.58 ,$656.60 ,$281.40 ,$609.70 ,$675.36 ,$853.58 ,$703.50 
Carle BroMenn Medical Center,8479200,RADPHARM TRPY BY INTRACAV ADMIN,,79200,342,"$1,110.00 ","$1,110.00 ",$333.00 ,"$1,010.10 ",$777.00 ,$333.00 ,$721.50 ,$799.20 ,"$1,010.10 ",$832.50 
Carle BroMenn Medical Center,8479403,RADPHARM TRPY BY RADLABLD MONOCLNL ANTBDY IV,,79403,342,"$1,350.00 ","$1,350.00 ",$405.00 ,"$1,228.50 ",$945.00 ,$405.00 ,$877.50 ,$972.00 ,"$1,228.50 ","$1,012.50 "
Carle BroMenn Medical Center,8977778,"INTERSTITIONAL RAD SOURCE APPLCTN, COMPLX",,77778,342,"$3,435.00 ","$3,435.00 ","$1,030.50 ","$3,125.85 ","$2,404.50 ","$1,030.50 ","$2,232.75 ","$2,473.20 ","$3,125.85 ","$2,576.25 "
Carle BroMenn Medical Center,8409500,TC 99M SESTAMIBI UP TO 40MCI,,A9500,343,$527.00 ,$527.00 ,$158.10 ,$479.57 ,$368.90 ,$158.10 ,$342.55 ,$379.44 ,$479.57 ,$395.25 
Carle BroMenn Medical Center,8409502,TC 99M TETROFOSMIN UP TO 40MCI,,A9502,343,$416.00 ,$416.00 ,$124.80 ,$378.56 ,$291.20 ,$124.80 ,$270.40 ,$299.52 ,$378.56 ,$312.00 
Carle BroMenn Medical Center,8409503,TC 99M MEDRONATE UP TO 30MCI,,A9503,343,$217.00 ,$217.00 ,$65.10 ,$197.47 ,$151.90 ,$65.10 ,$141.05 ,$156.24 ,$197.47 ,$162.75 
Carle BroMenn Medical Center,8409505,THALLIUM -PER MILLICURIE,,A9505,343,$93.00 ,$93.00 ,$27.90 ,$84.63 ,$65.10 ,$27.90 ,$60.45 ,$66.96 ,$84.63 ,$69.75 
Carle BroMenn Medical Center,8409507,111IN CAPROMAB PENDETIDE PER SD,,A9507,343,"$2,910.00 ","$2,910.00 ",$873.00 ,"$2,648.10 ","$2,037.00 ",$873.00 ,"$1,891.50 ","$2,095.20 ","$2,648.10 ","$2,182.50 "
Carle BroMenn Medical Center,8409508,MIBG PER DOSE,,A9508,343,"$3,128.00 ","$3,128.00 ",$938.40 ,"$2,846.48 ","$2,189.60 ",$938.40 ,"$2,033.20 ","$2,252.16 ","$2,846.48 ","$2,346.00 "
Carle BroMenn Medical Center,8409512,TC 99M PERTECHNETATE PER MCI,,A9512,343,$20.00 ,$20.00 ,$6.00 ,$18.20 ,$14.00 ,$6.00 ,$13.00 ,$14.40 ,$18.20 ,$15.00 
Carle BroMenn Medical Center,8409513,"LUTETIUM LU 177, DOTATATE, THERAPEUTIC, 1MCI",,A9513,343,$848.00 ,$848.00 ,$254.40 ,$771.68 ,$593.60 ,$254.40 ,$551.20 ,$610.56 ,$771.68 ,$636.00 
Carle BroMenn Medical Center,8409516,I-123 SODIUM IODIDE CAP 100UCI,,A9516,343,$197.00 ,$197.00 ,$59.10 ,$179.27 ,$137.90 ,$59.10 ,$128.05 ,$141.84 ,$179.27 ,$147.75 
Carle BroMenn Medical Center,8409521,TC 99M EXAMETAZIME UP TO 25MCI,,A9521,343,"$3,308.00 ","$3,308.00 ",$992.40 ,"$3,010.28 ","$2,315.60 ",$992.40 ,"$2,150.20 ","$2,381.76 ","$3,010.28 ","$2,481.00 "
Carle BroMenn Medical Center,8409524,"IODAINATED I-131 SERUM ALBUMIN, 5 MCI",,A9524,343,"$4,500.00 ","$4,500.00 ","$1,350.00 ","$4,095.00 ","$3,150.00 ","$1,350.00 ","$2,925.00 ","$3,240.00 ","$4,095.00 ","$3,375.00 "
Carle BroMenn Medical Center,8409537,TC 99M MEBROFENIN UP TO 15MCI,,A9537,343,$209.00 ,$209.00 ,$62.70 ,$190.19 ,$146.30 ,$62.70 ,$135.85 ,$150.48 ,$190.19 ,$156.75 
Carle BroMenn Medical Center,8409538,TC 99M PYROPHOSPHATE UP TO 25 MCI,,A9538,343,$86.00 ,$86.00 ,$25.80 ,$78.26 ,$60.20 ,$25.80 ,$55.90 ,$61.92 ,$78.26 ,$64.50 
Carle BroMenn Medical Center,8409539,DTPA,,A9539,343,$24.00 ,$24.00 ,$7.20 ,$21.84 ,$16.80 ,$7.20 ,$15.60 ,$17.28 ,$21.84 ,$18.00 
Carle BroMenn Medical Center,8409540,99M MAA UP TO 10MCI STDY DS,,A9540,343,$264.00 ,$264.00 ,$79.20 ,$240.24 ,$184.80 ,$79.20 ,$171.60 ,$190.08 ,$240.24 ,$198.00 
Carle BroMenn Medical Center,8409541,TC 99M SUPFUR COLLOID EA 20MCI,,A9541,343,$458.00 ,$458.00 ,$137.40 ,$416.78 ,$320.60 ,$137.40 ,$297.70 ,$329.76 ,$416.78 ,$343.50 
Carle BroMenn Medical Center,8409542,IN-111 IBRITUMOMAB TIUXETAN,,A9542,343,"$6,720.00 ","$6,720.00 ","$2,016.00 ","$6,115.20 ","$4,704.00 ","$2,016.00 ","$4,368.00 ","$4,838.40 ","$6,115.20 ","$5,040.00 "
Carle BroMenn Medical Center,8409547,IN-111 OXYQUINOLINE 0.5 MCI,,A9547,343,$863.00 ,$863.00 ,$258.90 ,$785.33 ,$604.10 ,$258.90 ,$560.95 ,$621.36 ,$785.33 ,$647.25 
Carle BroMenn Medical Center,8409548,"111 IN DTPA, PER 0.5 MCI",,A9548,343,"$3,320.00 ","$3,320.00 ",$996.00 ,"$3,021.20 ","$2,324.00 ",$996.00 ,"$2,158.00 ","$2,390.40 ","$3,021.20 ","$2,490.00 "
Carle BroMenn Medical Center,8409552,F-18 FDG PER DOSE UP TO 45MCI,,A9552,343,$419.00 ,$419.00 ,$125.70 ,$381.29 ,$293.30 ,$125.70 ,$272.35 ,$301.68 ,$381.29 ,$314.25 
Carle BroMenn Medical Center,8409556,GALLIUM PER MCI,,A9556,343,$56.00 ,$56.00 ,$16.80 ,$50.96 ,$39.20 ,$16.80 ,$36.40 ,$40.32 ,$50.96 ,$42.00 
Carle BroMenn Medical Center,8409557,TC99 BICISATE UD,,A9557,343,"$1,193.00 ","$1,193.00 ",$357.90 ,"$1,085.63 ",$835.10 ,$357.90 ,$775.45 ,$858.96 ,"$1,085.63 ",$894.75 
Carle BroMenn Medical Center,8409558,XENON XE-133 GAS PER 10MCI,,A9558,343,$143.00 ,$143.00 ,$42.90 ,$130.13 ,$100.10 ,$42.90 ,$92.95 ,$102.96 ,$130.13 ,$107.25 
Carle BroMenn Medical Center,8409560,TC 99M LABELED RBC'S PER 30MCI,,A9560,343,"$3,390.00 ","$3,390.00 ","$1,017.00 ","$3,084.90 ","$2,373.00 ","$1,017.00 ","$2,203.50 ","$2,440.80 ","$3,084.90 ","$2,542.50 "
Carle BroMenn Medical Center,8409562,TC 99M MERTIATIDE UP TO 15MCI,,A9562,343,$631.00 ,$631.00 ,$189.30 ,$574.21 ,$441.70 ,$189.30 ,$410.15 ,$454.32 ,$574.21 ,$473.25 
Carle BroMenn Medical Center,8409566,TC 99M FANOLESOMAB UP TO 25MCI,,A9566,343,"$7,403.00 ","$7,403.00 ","$2,220.90 ","$6,736.73 ","$5,182.10 ","$2,220.90 ","$4,811.95 ","$5,330.16 ","$6,736.73 ","$5,552.25 "
Carle BroMenn Medical Center,8409567,TECHNETIUM TC-99M AEROSOL,,A9567,343,$223.00 ,$223.00 ,$66.90 ,$202.93 ,$156.10 ,$66.90 ,$144.95 ,$160.56 ,$202.93 ,$167.25 
Carle BroMenn Medical Center,8409569,CERETEC AUTO WBCS/STUDY DOSE,,A9569,343,"$3,390.00 ","$3,390.00 ","$1,017.00 ","$3,084.90 ","$2,373.00 ","$1,017.00 ","$2,203.50 ","$2,440.80 ","$3,084.90 ","$2,542.50 "
Carle BroMenn Medical Center,8409570,IN-111 WBC OXINE STUDY SD,,A9570,343,"$6,600.00 ","$6,600.00 ","$1,980.00 ","$6,006.00 ","$4,620.00 ","$1,980.00 ","$4,290.00 ","$4,752.00 ","$6,006.00 ","$4,950.00 "
Carle BroMenn Medical Center,8409572,INDIUM IN-111 PENTETREOTIDE,,A9572,343,"$4,395.00 ","$4,395.00 ","$1,318.50 ","$3,999.45 ","$3,076.50 ","$1,318.50 ","$2,856.75 ","$3,164.40 ","$3,999.45 ","$3,296.25 "
Carle BroMenn Medical Center,8409582,INJ IOBENGUANE I-123 15 MLC,,A9582,343,"$6,240.00 ","$6,240.00 ","$1,872.00 ","$5,678.40 ","$4,368.00 ","$1,872.00 ","$4,056.00 ","$4,492.80 ","$5,678.40 ","$4,680.00 "
Carle BroMenn Medical Center,8409584,"I-123 IOFLUPANE, DIAG, PER STUDY DOSE UP TO 5 MCI",,A9584,343,"$7,380.00 ","$7,380.00 ","$2,214.00 ","$6,715.80 ","$5,166.00 ","$2,214.00 ","$4,797.00 ","$5,313.60 ","$6,715.80 ","$5,535.00 "
Carle BroMenn Medical Center,8409588,AXUMIN EA 1 MCI,,A9588,343,"$1,470.00 ","$1,470.00 ",$441.00 ,"$1,337.70 ","$1,029.00 ",$441.00 ,$955.50 ,"$1,058.40 ","$1,337.70 ","$1,102.50 "
Carle BroMenn Medical Center,8409592,"COPPER CU-64, DOTATATE, DIAGNOSTIC, 1 MILLICURIE",,A9592,343,"$11,100.00 ","$11,100.00 ","$3,330.00 ","$10,101.00 ","$7,770.00 ","$3,330.00 ","$7,215.00 ","$7,992.00 ","$10,101.00 ","$8,325.00 "
Carle BroMenn Medical Center,8414641,LYMPHOSEEK (TC99M TILMANOCEPT),,A9520,343,$960.00 ,$960.00 ,$288.00 ,$873.60 ,$672.00 ,$288.00 ,$624.00 ,$691.20 ,$873.60 ,$720.00 
Carle BroMenn Medical Center,8419502,TC 99M TETROFOSMIN UP TO 40MCI,,A9502,343,$416.00 ,$416.00 ,$124.80 ,$378.56 ,$291.20 ,$124.80 ,$270.40 ,$299.52 ,$378.56 ,$312.00 
Carle BroMenn Medical Center,8419503,TC 99M MEDRONATE UP TO 30MCI,,A9503,343,$217.00 ,$217.00 ,$65.10 ,$197.47 ,$151.90 ,$65.10 ,$141.05 ,$156.24 ,$197.47 ,$162.75 
Carle BroMenn Medical Center,8419508,131 IOBENGUANE SULFATE,,A9508,343,"$3,128.00 ","$3,128.00 ",$938.40 ,"$2,846.48 ","$2,189.60 ",$938.40 ,"$2,033.20 ","$2,252.16 ","$2,846.48 ","$2,346.00 "
Carle BroMenn Medical Center,8419512,TC 99M PERTECHNETATE PER MCI,,A9512,343,$20.00 ,$20.00 ,$6.00 ,$18.20 ,$14.00 ,$6.00 ,$13.00 ,$14.40 ,$18.20 ,$15.00 
Carle BroMenn Medical Center,8419516,I-123 SODIUM IODIDE CAP 100UCI,,A9516,343,$197.00 ,$197.00 ,$59.10 ,$179.27 ,$137.90 ,$59.10 ,$128.05 ,$141.84 ,$179.27 ,$147.75 
Carle BroMenn Medical Center,8419521,TC 99M EXAMETAZIME UP TO 25MCI,,A9521,343,"$3,308.00 ","$3,308.00 ",$992.40 ,"$3,010.28 ","$2,315.60 ",$992.40 ,"$2,150.20 ","$2,381.76 ","$3,010.28 ","$2,481.00 "
Carle BroMenn Medical Center,8419537,TC 99M MEBROFENIN UP TO 15MCI,,A9537,343,$209.00 ,$209.00 ,$62.70 ,$190.19 ,$146.30 ,$62.70 ,$135.85 ,$150.48 ,$190.19 ,$156.75 
Carle BroMenn Medical Center,8419540,Tc 99m Maa Up To 10mci Stdy Ds,,A9540,343,$264.00 ,$264.00 ,$79.20 ,$240.24 ,$184.80 ,$79.20 ,$171.60 ,$190.08 ,$240.24 ,$198.00 
Carle BroMenn Medical Center,8419541,TC 99M SUPFUR COLLOID EA 20MCI,,A9541,343,$458.00 ,$458.00 ,$137.40 ,$416.78 ,$320.60 ,$137.40 ,$297.70 ,$329.76 ,$416.78 ,$343.50 
Carle BroMenn Medical Center,8419556,"FDG 2-(F-18) , UP TO 45 MCI",,A9556,343,$56.00 ,$56.00 ,$16.80 ,$50.96 ,$39.20 ,$16.80 ,$36.40 ,$40.32 ,$50.96 ,$42.00 
Carle BroMenn Medical Center,8419558,XENON XE-133 GAS PER 10MCI,,A9558,343,$143.00 ,$143.00 ,$42.90 ,$130.13 ,$100.10 ,$42.90 ,$92.95 ,$102.96 ,$130.13 ,$107.25 
Carle BroMenn Medical Center,8429512,TC 99M PERTECHNETATE PER MCI,,A9512,343,$20.00 ,$20.00 ,$6.00 ,$18.20 ,$14.00 ,$6.00 ,$13.00 ,$14.40 ,$18.20 ,$15.00 
Carle BroMenn Medical Center,8429541,TC 99M SUPFUR COLLOID EA 20MCI,,A9541,343,$458.00 ,$458.00 ,$137.40 ,$416.78 ,$320.60 ,$137.40 ,$297.70 ,$329.76 ,$416.78 ,$343.50 
Carle BroMenn Medical Center,8270486,"G CT SCAN,MAXILLOFACIAL AREA,W/O CONTRAST",,70486,350,"$1,103.70 ","$1,103.70 ",$331.11 ,"$1,004.37 ",$772.59 ,$331.11 ,$717.41 ,$794.66 ,"$1,004.37 ",$827.78 
Carle BroMenn Medical Center,8276376,G 3D RENDER W/O IMAGE POSTPROCESS,,76376,350,$870.00 ,$870.00 ,$261.00 ,$791.70 ,$609.00 ,$261.00 ,$565.50 ,$626.40 ,$791.70 ,$652.50 
Carle BroMenn Medical Center,8276377,3D RENDERING W/POST-PROCESSING,,76377,350,$690.00 ,$690.00 ,$207.00 ,$627.90 ,$483.00 ,$207.00 ,$448.50 ,$496.80 ,$627.90 ,$517.50 
Carle BroMenn Medical Center,8400042,"CEREBRAL PERFUSION STUDY, CT W/ CONTRAST",,0042T,350,"$2,890.00 ","$2,890.00 ",$867.00 ,"$2,629.90 ","$2,023.00 ",$867.00 ,"$1,878.50 ","$2,080.80 ","$2,629.90 ","$2,167.50 "
Carle BroMenn Medical Center,8400288,CT ANGIOGRAPHY -AORTA,,G0288,350,"$1,890.00 ","$1,890.00 ",$567.00 ,"$1,719.90 ","$1,323.00 ",$567.00 ,"$1,228.50 ","$1,360.80 ","$1,719.90 ","$1,417.50 "
Carle BroMenn Medical Center,8400297,LDCT FOR LUNG SCREENING,,G0297,350,"$3,090.00 ","$3,090.00 ",$927.00 ,"$2,811.90 ","$2,163.00 ",$927.00 ,"$2,008.50 ","$2,224.80 ","$2,811.90 ","$2,317.50 "
Carle BroMenn Medical Center,8400554,B1 STR & FX RSK ANALYSIS,,0554T,350,$960.00 ,$960.00 ,$288.00 ,$873.60 ,$672.00 ,$288.00 ,$624.00 ,$691.20 ,$873.60 ,$720.00 
Carle BroMenn Medical Center,8400558,CT SCAN F/BIOMCHN CT ALYS,,0558T,350,"$1,890.00 ","$1,890.00 ",$567.00 ,"$1,719.90 ","$1,323.00 ",$567.00 ,"$1,228.50 ","$1,360.80 ","$1,719.90 ","$1,417.50 "
Carle BroMenn Medical Center,8400559,ANTMC MDL 3D PRINT 1ST CMPNT,,0559T,350,"$1,845.00 ","$1,845.00 ",$553.50 ,"$1,678.95 ","$1,291.50 ",$553.50 ,"$1,199.25 ","$1,328.40 ","$1,678.95 ","$1,383.75 "
Carle BroMenn Medical Center,8400560,ANTMC MDL 3D PRINT EA ADDL,,0560T,350,$848.00 ,$848.00 ,$254.40 ,$771.68 ,$593.60 ,$254.40 ,$551.20 ,$610.56 ,$771.68 ,$636.00 
Carle BroMenn Medical Center,8400561,ANTMC GUIDE 3D PRINT 1ST GD,,0561T,350,"$2,693.00 ","$2,693.00 ",$807.90 ,"$2,450.63 ","$1,885.10 ",$807.90 ,"$1,750.45 ","$1,938.96 ","$2,450.63 ","$2,019.75 "
Carle BroMenn Medical Center,8400562,ANTMC GUIDE 3D PRINT EA ADDL,,0562T,350,"$1,313.00 ","$1,313.00 ",$393.90 ,"$1,194.83 ",$919.10 ,$393.90 ,$853.45 ,$945.36 ,"$1,194.83 ",$984.75 
Carle BroMenn Medical Center,8470450,CT HEAD/BRAIN W/O CONTRAST,,70450,350,"$2,640.00 ","$2,640.00 ",$792.00 ,"$2,402.40 ","$1,848.00 ",$792.00 ,"$1,716.00 ","$1,900.80 ","$2,402.40 ","$1,980.00 "
Carle BroMenn Medical Center,8470460,CT HEAD/BRAIN W/CONTRAST,,70460,350,"$2,460.00 ","$2,460.00 ",$738.00 ,"$2,238.60 ","$1,722.00 ",$738.00 ,"$1,599.00 ","$1,771.20 ","$2,238.60 ","$1,845.00 "
Carle BroMenn Medical Center,8470470,CT HEAD/BRAIN W/O & W/CONTRAST,,70470,350,"$2,830.00 ","$2,830.00 ",$849.00 ,"$2,575.30 ","$1,981.00 ",$849.00 ,"$1,839.50 ","$2,037.60 ","$2,575.30 ","$2,122.50 "
Carle BroMenn Medical Center,8470480,CT ORB/PIT/PF/IAC W/O CONTRAST,,70480,350,"$2,620.00 ","$2,620.00 ",$786.00 ,"$2,384.20 ","$1,834.00 ",$786.00 ,"$1,703.00 ","$1,886.40 ","$2,384.20 ","$1,965.00 "
Carle BroMenn Medical Center,8470481,CT ORB/PIT/PF/IAC W/CONTRAST,,70481,350,"$2,420.00 ","$2,420.00 ",$726.00 ,"$2,202.20 ","$1,694.00 ",$726.00 ,"$1,573.00 ","$1,742.40 ","$2,202.20 ","$1,815.00 "
Carle BroMenn Medical Center,8470482,CT ORB/PIT/PF/IAC W/O&W/CNTRST,,70482,350,"$2,780.00 ","$2,780.00 ",$834.00 ,"$2,529.80 ","$1,946.00 ",$834.00 ,"$1,807.00 ","$2,001.60 ","$2,529.80 ","$2,085.00 "
Carle BroMenn Medical Center,8470486,CT MAXILLOFACIAL W/O CONTRAST,,70486,350,"$2,470.00 ","$2,470.00 ",$741.00 ,"$2,247.70 ","$1,729.00 ",$741.00 ,"$1,605.50 ","$1,778.40 ","$2,247.70 ","$1,852.50 "
Carle BroMenn Medical Center,8470487,CT MAXILLOFACIAL W/CONTRAST,,70487,350,"$3,010.00 ","$3,010.00 ",$903.00 ,"$2,739.10 ","$2,107.00 ",$903.00 ,"$1,956.50 ","$2,167.20 ","$2,739.10 ","$2,257.50 "
Carle BroMenn Medical Center,8470488,CT MAXILLOFACIAL W/O & W/ CONTRAST,,70488,350,"$3,220.00 ","$3,220.00 ",$966.00 ,"$2,930.20 ","$2,254.00 ",$966.00 ,"$2,093.00 ","$2,318.40 ","$2,930.20 ","$2,415.00 "
Carle BroMenn Medical Center,8470490,CT SOFT TISSUE NECK W/O CNTRST,,70490,350,"$2,110.00 ","$2,110.00 ",$633.00 ,"$1,920.10 ","$1,477.00 ",$633.00 ,"$1,371.50 ","$1,519.20 ","$1,920.10 ","$1,582.50 "
Carle BroMenn Medical Center,8470491,CT SOFT TISSUE NECK W/CONTRAST,,70491,350,"$3,050.00 ","$3,050.00 ",$915.00 ,"$2,775.50 ","$2,135.00 ",$915.00 ,"$1,982.50 ","$2,196.00 ","$2,775.50 ","$2,287.50 "
Carle BroMenn Medical Center,8470492,CT SOFT TISSUE NECK W/ & W/O CONTRAST,,70492,350,"$3,060.00 ","$3,060.00 ",$918.00 ,"$2,784.60 ","$2,142.00 ",$918.00 ,"$1,989.00 ","$2,203.20 ","$2,784.60 ","$2,295.00 "
Carle BroMenn Medical Center,8470496,CT ANGIOGRAPHY  -HEAD,,70496,350,"$2,580.00 ","$2,580.00 ",$774.00 ,"$2,347.80 ","$1,806.00 ",$774.00 ,"$1,677.00 ","$1,857.60 ","$2,347.80 ","$1,935.00 "
Carle BroMenn Medical Center,8470498,CT ANGIOGRAPHY  -NECK,,70498,350,"$3,460.00 ","$3,460.00 ","$1,038.00 ","$3,148.60 ","$2,422.00 ","$1,038.00 ","$2,249.00 ","$2,491.20 ","$3,148.60 ","$2,595.00 "
Carle BroMenn Medical Center,8471250,CT CHEST W/O CONTRAST,,71250,350,"$2,710.00 ","$2,710.00 ",$813.00 ,"$2,466.10 ","$1,897.00 ",$813.00 ,"$1,761.50 ","$1,951.20 ","$2,466.10 ","$2,032.50 "
Carle BroMenn Medical Center,8471260,CT CHEST W/CONTRAST,,71260,350,"$3,450.00 ","$3,450.00 ","$1,035.00 ","$3,139.50 ","$2,415.00 ","$1,035.00 ","$2,242.50 ","$2,484.00 ","$3,139.50 ","$2,587.50 "
Carle BroMenn Medical Center,8471270,CT CHEST W & W/O CONTRAST,,71270,350,"$3,890.00 ","$3,890.00 ","$1,167.00 ","$3,539.90 ","$2,723.00 ","$1,167.00 ","$2,528.50 ","$2,800.80 ","$3,539.90 ","$2,917.50 "
Carle BroMenn Medical Center,8471271,COMPUTED TOMOGRAPHY THORAX LW DOSE LNG CA SCR C-,,71271,350,$530.00 ,$530.00 ,$159.00 ,$482.30 ,$371.00 ,$159.00 ,$344.50 ,$381.60 ,$482.30 ,$397.50 
Carle BroMenn Medical Center,8471275,CT ANGIOGRAPHY -CHEST,,71275,350,"$3,500.00 ","$3,500.00 ","$1,050.00 ","$3,185.00 ","$2,450.00 ","$1,050.00 ","$2,275.00 ","$2,520.00 ","$3,185.00 ","$2,625.00 "
Carle BroMenn Medical Center,8472125,CT CERVICAL SPINE W/O CONTRAST,,72125,350,"$3,060.00 ","$3,060.00 ",$918.00 ,"$2,784.60 ","$2,142.00 ",$918.00 ,"$1,989.00 ","$2,203.20 ","$2,784.60 ","$2,295.00 "
Carle BroMenn Medical Center,8472126,CT CERVICAL SPINE W/CONTRAST,,72126,350,"$3,450.00 ","$3,450.00 ","$1,035.00 ","$3,139.50 ","$2,415.00 ","$1,035.00 ","$2,242.50 ","$2,484.00 ","$3,139.50 ","$2,587.50 "
Carle BroMenn Medical Center,8472127,CT NECK SPINE W/O & W/DYE,,72127,350,"$4,680.00 ","$4,680.00 ","$1,404.00 ","$4,258.80 ","$3,276.00 ","$1,404.00 ","$3,042.00 ","$3,369.60 ","$4,258.80 ","$3,510.00 "
Carle BroMenn Medical Center,8472128,CT THORACIC SPINE W/O CONTRAST,,72128,350,"$2,520.00 ","$2,520.00 ",$756.00 ,"$2,293.20 ","$1,764.00 ",$756.00 ,"$1,638.00 ","$1,814.40 ","$2,293.20 ","$1,890.00 "
Carle BroMenn Medical Center,8472129,CT THORACIC SPINE W/CONTRAST,,72129,350,"$2,780.00 ","$2,780.00 ",$834.00 ,"$2,529.80 ","$1,946.00 ",$834.00 ,"$1,807.00 ","$2,001.60 ","$2,529.80 ","$2,085.00 "
Carle BroMenn Medical Center,8472130,CT THORACIC SPINE W/O&W/CNTRST,,72130,350,"$3,010.00 ","$3,010.00 ",$903.00 ,"$2,739.10 ","$2,107.00 ",$903.00 ,"$1,956.50 ","$2,167.20 ","$2,739.10 ","$2,257.50 "
Carle BroMenn Medical Center,8472131,CT LUMBAR SPINE W/O CONTRAST,,72131,350,"$2,580.00 ","$2,580.00 ",$774.00 ,"$2,347.80 ","$1,806.00 ",$774.00 ,"$1,677.00 ","$1,857.60 ","$2,347.80 ","$1,935.00 "
Carle BroMenn Medical Center,8472132,CT LUMBAR SPINE W/CONTRAST,,72132,350,"$3,600.00 ","$3,600.00 ","$1,080.00 ","$3,276.00 ","$2,520.00 ","$1,080.00 ","$2,340.00 ","$2,592.00 ","$3,276.00 ","$2,700.00 "
Carle BroMenn Medical Center,8472133,CT LUMBAR SPINE W/O & W/CNTRST,,72133,350,"$3,840.00 ","$3,840.00 ","$1,152.00 ","$3,494.40 ","$2,688.00 ","$1,152.00 ","$2,496.00 ","$2,764.80 ","$3,494.40 ","$2,880.00 "
Carle BroMenn Medical Center,8472191,CT ANGIOGRAPHY PELVIS,,72191,350,"$3,000.00 ","$3,000.00 ",$900.00 ,"$2,730.00 ","$2,100.00 ",$900.00 ,"$1,950.00 ","$2,160.00 ","$2,730.00 ","$2,250.00 "
Carle BroMenn Medical Center,8472192,CT PELVIS W/O CONTRAST,,72192,350,"$2,870.00 ","$2,870.00 ",$861.00 ,"$2,611.70 ","$2,009.00 ",$861.00 ,"$1,865.50 ","$2,066.40 ","$2,611.70 ","$2,152.50 "
Carle BroMenn Medical Center,8472193,CT PELVIS W/CONTRAST,,72193,350,"$3,500.00 ","$3,500.00 ","$1,050.00 ","$3,185.00 ","$2,450.00 ","$1,050.00 ","$2,275.00 ","$2,520.00 ","$3,185.00 ","$2,625.00 "
Carle BroMenn Medical Center,8472194,CT PELVIS W/O & W/CONTRAST,,72194,350,"$3,170.00 ","$3,170.00 ",$951.00 ,"$2,884.70 ","$2,219.00 ",$951.00 ,"$2,060.50 ","$2,282.40 ","$2,884.70 ","$2,377.50 "
Carle BroMenn Medical Center,8473200,CT UPPER EXTREMITY W/O CONTRST,,73200,350,"$2,820.00 ","$2,820.00 ",$846.00 ,"$2,566.20 ","$1,974.00 ",$846.00 ,"$1,833.00 ","$2,030.40 ","$2,566.20 ","$2,115.00 "
Carle BroMenn Medical Center,8473201,CT UPPER EXTREMITY W/CONTRAST,,73201,350,"$2,530.00 ","$2,530.00 ",$759.00 ,"$2,302.30 ","$1,771.00 ",$759.00 ,"$1,644.50 ","$1,821.60 ","$2,302.30 ","$1,897.50 "
Carle BroMenn Medical Center,8473202,CT UPPR EXT W/O & W/ CONTRAST,,73202,350,"$3,440.00 ","$3,440.00 ","$1,032.00 ","$3,130.40 ","$2,408.00 ","$1,032.00 ","$2,236.00 ","$2,476.80 ","$3,130.40 ","$2,580.00 "
Carle BroMenn Medical Center,8473206,CT ANGIOGRAPHY UPPER EXTRMITY,,73206,350,"$3,230.00 ","$3,230.00 ",$969.00 ,"$2,939.30 ","$2,261.00 ",$969.00 ,"$2,099.50 ","$2,325.60 ","$2,939.30 ","$2,422.50 "
Carle BroMenn Medical Center,8473700,CT LOWER EXTREMITY W/O CONTRST,,73700,350,"$2,440.00 ","$2,440.00 ",$732.00 ,"$2,220.40 ","$1,708.00 ",$732.00 ,"$1,586.00 ","$1,756.80 ","$2,220.40 ","$1,830.00 "
Carle BroMenn Medical Center,8473701,CT LOWER EXTREMITY W/CONTRAST,,73701,350,"$2,240.00 ","$2,240.00 ",$672.00 ,"$2,038.40 ","$1,568.00 ",$672.00 ,"$1,456.00 ","$1,612.80 ","$2,038.40 ","$1,680.00 "
Carle BroMenn Medical Center,8473702,CT LOWER EXTREMITY W/ WO CONTRAST,,73702,350,"$2,410.00 ","$2,410.00 ",$723.00 ,"$2,193.10 ","$1,687.00 ",$723.00 ,"$1,566.50 ","$1,735.20 ","$2,193.10 ","$1,807.50 "
Carle BroMenn Medical Center,8473706,CT ANGIOGRAPHY LWR EXT W/CONTRAST,,73706,350,"$2,690.00 ","$2,690.00 ",$807.00 ,"$2,447.90 ","$1,883.00 ",$807.00 ,"$1,748.50 ","$1,936.80 ","$2,447.90 ","$2,017.50 "
Carle BroMenn Medical Center,8474150,CT ABDOMEN W/O CONTRAST,,74150,350,"$2,880.00 ","$2,880.00 ",$864.00 ,"$2,620.80 ","$2,016.00 ",$864.00 ,"$1,872.00 ","$2,073.60 ","$2,620.80 ","$2,160.00 "
Carle BroMenn Medical Center,8474160,CT ABDOMEN W/CONTRAST,,74160,350,"$3,460.00 ","$3,460.00 ","$1,038.00 ","$3,148.60 ","$2,422.00 ","$1,038.00 ","$2,249.00 ","$2,491.20 ","$3,148.60 ","$2,595.00 "
Carle BroMenn Medical Center,8474170,CT ABDOMEN W&W/O CONTRAST,,74170,350,"$3,810.00 ","$3,810.00 ","$1,143.00 ","$3,467.10 ","$2,667.00 ","$1,143.00 ","$2,476.50 ","$2,743.20 ","$3,467.10 ","$2,857.50 "
Carle BroMenn Medical Center,8474174,CT ANGIOGRAPHY ABD & PELVIS W/CONTRAST,,74174,350,"$3,610.00 ","$3,610.00 ","$1,083.00 ","$3,285.10 ","$2,527.00 ","$1,083.00 ","$2,346.50 ","$2,599.20 ","$3,285.10 ","$2,707.50 "
Carle BroMenn Medical Center,8474175,CT ANGIOGRAPHY ABDOMEN W/CONTRAST,,74175,350,"$3,810.00 ","$3,810.00 ","$1,143.00 ","$3,467.10 ","$2,667.00 ","$1,143.00 ","$2,476.50 ","$2,743.20 ","$3,467.10 ","$2,857.50 "
Carle BroMenn Medical Center,8474176,CT ABD & PELVIS W/O CONTRAST,,74176,350,"$4,300.00 ","$4,300.00 ","$1,290.00 ","$3,913.00 ","$3,010.00 ","$1,290.00 ","$2,795.00 ","$3,096.00 ","$3,913.00 ","$3,225.00 "
Carle BroMenn Medical Center,8474177,CT ABD & PELVIS W/ CONTRAST,,74177,350,"$5,210.00 ","$5,210.00 ","$1,563.00 ","$4,741.10 ","$3,647.00 ","$1,563.00 ","$3,386.50 ","$3,751.20 ","$4,741.10 ","$3,907.50 "
Carle BroMenn Medical Center,8474178,CT ABD & PELVIS W/ & W/O CONTRAST,,74178,350,"$5,750.00 ","$5,750.00 ","$1,725.00 ","$5,232.50 ","$4,025.00 ","$1,725.00 ","$3,737.50 ","$4,140.00 ","$5,232.50 ","$4,312.50 "
Carle BroMenn Medical Center,8474262,"CT COLONOGRAPHY, W / DYE",,74262,350,"$1,430.00 ","$1,430.00 ",$429.00 ,"$1,301.30 ","$1,001.00 ",$429.00 ,$929.50 ,"$1,029.60 ","$1,301.30 ","$1,072.50 "
Carle BroMenn Medical Center,8474263,"CT COLONOGRAPHY, SCREEN",,74263,350,"$1,420.00 ","$1,420.00 ",$426.00 ,"$1,292.20 ",$994.00 ,$426.00 ,$923.00 ,"$1,022.40 ","$1,292.20 ","$1,065.00 "
Carle BroMenn Medical Center,8475571,CT HRT W/O DYE W/CA TEST,,75571,350,$510.00 ,$510.00 ,$153.00 ,$464.10 ,$357.00 ,$153.00 ,$331.50 ,$367.20 ,$464.10 ,$382.50 
Carle BroMenn Medical Center,8475635,CT ANGIO ABD AORTA & RUNOFF,,75635,350,"$3,320.00 ","$3,320.00 ",$996.00 ,"$3,021.20 ","$2,324.00 ",$996.00 ,"$2,158.00 ","$2,390.40 ","$3,021.20 ","$2,490.00 "
Carle BroMenn Medical Center,8476376,3D RENDERING W/O POST-PROCESS,,76376,350,"$1,240.00 ","$1,240.00 ",$372.00 ,"$1,128.40 ",$868.00 ,$372.00 ,$806.00 ,$892.80 ,"$1,128.40 ",$930.00 
Carle BroMenn Medical Center,8476377,3D RENDERING W/POST-PROCESSING,,76377,350,"$1,650.00 ","$1,650.00 ",$495.00 ,"$1,501.50 ","$1,155.00 ",$495.00 ,"$1,072.50 ","$1,188.00 ","$1,501.50 ","$1,237.50 "
Carle BroMenn Medical Center,8476380,CT LIMITED/LOCALIZED FOLLOW-UP,,76380,350,"$1,330.00 ","$1,330.00 ",$399.00 ,"$1,210.30 ",$931.00 ,$399.00 ,$864.50 ,$957.60 ,"$1,210.30 ",$997.50 
Carle BroMenn Medical Center,8476497,UNLISTED CT PROCEDURE,,76497,350,"$2,530.00 ","$2,530.00 ",$759.00 ,"$2,302.30 ","$1,771.00 ",$759.00 ,"$1,644.50 ","$1,821.60 ","$2,302.30 ","$1,897.50 "
Carle BroMenn Medical Center,8477011,CT STEREOTACTIC LOCALIZATION,,77011,350,"$2,110.00 ","$2,110.00 ",$633.00 ,"$1,920.10 ","$1,477.00 ",$633.00 ,"$1,371.50 ","$1,519.20 ","$1,920.10 ","$1,582.50 "
Carle BroMenn Medical Center,8477012,CT GUIDANCE NEEDLE PLCMNT S&I,,77012,350,"$2,940.00 ","$2,940.00 ",$882.00 ,"$2,675.40 ","$2,058.00 ",$882.00 ,"$1,911.00 ","$2,116.80 ","$2,675.40 ","$2,205.00 "
Carle BroMenn Medical Center,8477013,CT GUIDNCE VISCERAL TISS ABLTN,,77013,350,"$2,480.00 ","$2,480.00 ",$744.00 ,"$2,256.80 ","$1,736.00 ",$744.00 ,"$1,612.00 ","$1,785.60 ","$2,256.80 ","$1,860.00 "
Carle BroMenn Medical Center,8477014,CT PLACEMNT RAD THERAPY FIELDS,,77014,350,"$1,070.00 ","$1,070.00 ",$321.00 ,$973.70 ,$749.00 ,$321.00 ,$695.50 ,$770.40 ,$973.70 ,$802.50 
Carle BroMenn Medical Center,8971377,3D RENDERING W/POST-PROCESSING,,76377,350,$690.00 ,$690.00 ,$207.00 ,$627.90 ,$483.00 ,$207.00 ,$448.50 ,$496.80 ,$627.90 ,$517.50 
Carle BroMenn Medical Center,8972377,3D RENDERING W/POST-PROCESSING,,76377,350,$690.00 ,$690.00 ,$207.00 ,$627.90 ,$483.00 ,$207.00 ,$448.50 ,$496.80 ,$627.90 ,$517.50 
Carle BroMenn Medical Center,8974150,CT ABDOMEN W/O CONTRAST,,74150,350,"$1,103.70 ","$1,103.70 ",$331.11 ,"$1,004.37 ",$772.59 ,$331.11 ,$717.41 ,$794.66 ,"$1,004.37 ",$827.78 
Carle BroMenn Medical Center,8977012,CT GUIDANCE NEEDLE PLCMNT S&I,,77012,350,"$1,891.50 ","$1,891.50 ",$567.45 ,"$1,721.27 ","$1,324.05 ",$567.45 ,"$1,229.48 ","$1,361.88 ","$1,721.27 ","$1,418.63 "
Carle BroMenn Medical Center,8474261,"CT COLONOGRAPHY, W/O DYE",,74261,352,"$1,100.00 ","$1,100.00 ",$330.00 ,"$1,001.00 ",$770.00 ,$330.00 ,$715.00 ,$792.00 ,"$1,001.00 ",$825.00 
Carle BroMenn Medical Center,8475572,CT HRT W/3D IMAGE,,75572,352,"$1,280.00 ","$1,280.00 ",$384.00 ,"$1,164.80 ",$896.00 ,$384.00 ,$832.00 ,$921.60 ,"$1,164.80 ",$960.00 
Carle BroMenn Medical Center,8475573,"CT HRT W/3D IMAGE, CONGEN",,75573,352,"$1,060.00 ","$1,060.00 ",$318.00 ,$964.60 ,$742.00 ,$318.00 ,$689.00 ,$763.20 ,$964.60 ,$795.00 
Carle BroMenn Medical Center,8475574,CT ANGIO HRT W/3D IMAGE,,75574,352,"$1,280.00 ","$1,280.00 ",$384.00 ,"$1,164.80 ",$896.00 ,$384.00 ,$832.00 ,$921.60 ,"$1,164.80 ",$960.00 
Carle BroMenn Medical Center,8020015,ECMO INITIATION VENO-VENOUS,,,360,"$4,508.00 ","$4,508.00 ","$1,352.40 ","$4,102.28 ","$3,155.60 ","$1,352.40 ","$2,930.20 ","$3,245.76 ","$4,102.28 ","$3,381.00 "
Carle BroMenn Medical Center,8020016,ECMO INITIATION VENO-ARTERIAL,,,360,"$4,830.00 ","$4,830.00 ","$1,449.00 ","$4,395.30 ","$3,381.00 ","$1,449.00 ","$3,139.50 ","$3,477.60 ","$4,395.30 ","$3,622.50 "
Carle BroMenn Medical Center,8020017,INTRAAORTIC BALLOON PUMP (IABP) BEDSIDE,,,360,"$2,325.00 ","$2,325.00 ",$697.50 ,"$2,115.75 ","$1,627.50 ",$697.50 ,"$1,511.25 ","$1,674.00 ","$2,115.75 ","$1,743.75 "
Carle BroMenn Medical Center,8023000,BRONCHOSCOPY,,,360,"$1,688.00 ","$1,688.00 ",$506.40 ,"$1,536.08 ","$1,181.60 ",$506.40 ,"$1,097.20 ","$1,215.36 ","$1,536.08 ","$1,266.00 "
Carle BroMenn Medical Center,8027065,OR LEVEL-IV(D&C)PER MINUTE,,,360,$49.00 ,$49.00 ,$14.70 ,$44.59 ,$34.30 ,$14.70 ,$31.85 ,$35.28 ,$44.59 ,$36.75 
Carle BroMenn Medical Center,8027066,OR LEVEL III(TUBALS)/MINUTE,,,360,$47.00 ,$47.00 ,$14.10 ,$42.77 ,$32.90 ,$14.10 ,$30.55 ,$33.84 ,$42.77 ,$35.25 
Carle BroMenn Medical Center,8027067,OR LEVEL II(C-SECTION)/MINUTE,,,360,$37.00 ,$37.00 ,$11.10 ,$33.67 ,$25.90 ,$11.10 ,$24.05 ,$26.64 ,$33.67 ,$27.75 
Carle BroMenn Medical Center,8028851,RMVL PERCT RT HEART VENTRICULAR ASSIST DEVICE,,,360,"$3,195.00 ","$3,195.00 ",$958.50 ,"$2,907.45 ","$2,236.50 ",$958.50 ,"$2,076.75 ","$2,300.40 ","$2,907.45 ","$2,396.25 "
Carle BroMenn Medical Center,8100050,OR L1 BASE OPERATING ROOM CHARGE,,,360,$885.00 ,$885.00 ,$265.50 ,$805.35 ,$619.50 ,$265.50 ,$575.25 ,$637.20 ,$805.35 ,$663.75 
Carle BroMenn Medical Center,8100065,AURA LASER ROOM,,,360,$683.00 ,$683.00 ,$204.90 ,$621.53 ,$478.10 ,$204.90 ,$443.95 ,$491.76 ,$621.53 ,$512.25 
Carle BroMenn Medical Center,8100075,LASER LITHOTRIPSY,,,360,"$1,403.00 ","$1,403.00 ",$420.90 ,"$1,276.73 ",$982.10 ,$420.90 ,$911.95 ,"$1,010.16 ","$1,276.73 ","$1,052.25 "
Carle BroMenn Medical Center,8100077,PROSTATE LASER,,,360,"$1,148.00 ","$1,148.00 ",$344.40 ,"$1,044.68 ",$803.60 ,$344.40 ,$746.20 ,$826.56 ,"$1,044.68 ",$861.00 
Carle BroMenn Medical Center,8100079,OMNIGUIDE LASER,,,360,$915.00 ,$915.00 ,$274.50 ,$832.65 ,$640.50 ,$274.50 ,$594.75 ,$658.80 ,$832.65 ,$686.25 
Carle BroMenn Medical Center,8100080,ARGON BEAM COAGULATOR,,,360,$705.00 ,$705.00 ,$211.50 ,$641.55 ,$493.50 ,$211.50 ,$458.25 ,$507.60 ,$641.55 ,$528.75 
Carle BroMenn Medical Center,8100081,UHS ESWL STORZ TABLE,,,360,"$1,148.00 ","$1,148.00 ",$344.40 ,"$1,044.68 ",$803.60 ,$344.40 ,$746.20 ,$826.56 ,"$1,044.68 ",$861.00 
Carle BroMenn Medical Center,8100089,INSERT VENOUS CENTRAL LINE,,,360,$770.00 ,$770.00 ,$231.00 ,$700.70 ,$539.00 ,$231.00 ,$500.50 ,$554.40 ,$700.70 ,$577.50 
Carle BroMenn Medical Center,8100090,INTRAOP MONITOR SERVICE / CASE,,,360,"$1,335.00 ","$1,335.00 ",$400.50 ,"$1,214.85 ",$934.50 ,$400.50 ,$867.75 ,$961.20 ,"$1,214.85 ","$1,001.25 "
Carle BroMenn Medical Center,8100092,PERFUSION FIRST 15 MINS,,,360,$880.00 ,$880.00 ,$264.00 ,$800.80 ,$616.00 ,$264.00 ,$572.00 ,$633.60 ,$800.80 ,$660.00 
Carle BroMenn Medical Center,8100093,PERFUSION ADDL 1 MIN,,,360,$40.00 ,$40.00 ,$12.00 ,$36.40 ,$28.00 ,$12.00 ,$26.00 ,$28.80 ,$36.40 ,$30.00 
Carle BroMenn Medical Center,8102050,OR L2 BASE OPERATING ROOM CHARGE,,,360,$850.00 ,$850.00 ,$255.00 ,$773.50 ,$595.00 ,$255.00 ,$552.50 ,$612.00 ,$773.50 ,$637.50 
Carle BroMenn Medical Center,8103050,OR L3 BASE OPERATING ROOM CHARGE,,,360,$743.00 ,$743.00 ,$222.90 ,$676.13 ,$520.10 ,$222.90 ,$482.95 ,$534.96 ,$676.13 ,$557.25 
Carle BroMenn Medical Center,8103104,DHC BRONCH BASE OPERATING ROOM CHARGE,,,360,$848.00 ,$848.00 ,$254.40 ,$771.68 ,$593.60 ,$254.40 ,$551.20 ,$610.56 ,$771.68 ,$636.00 
Carle BroMenn Medical Center,8103105,DHC BRONCH PER MIN OPERATING ROOM CHARGE,,,360,$116.00 ,$116.00 ,$34.80 ,$105.56 ,$81.20 ,$34.80 ,$75.40 ,$83.52 ,$105.56 ,$87.00 
Carle BroMenn Medical Center,8104050,OR L4 BASE OPERATING ROOM CHARGE,,,360,$728.00 ,$728.00 ,$218.40 ,$662.48 ,$509.60 ,$218.40 ,$473.20 ,$524.16 ,$662.48 ,$546.00 
Carle BroMenn Medical Center,8105050,OR L1 PER MIN OPERATING ROOM CHARGE,,,360,$86.00 ,$86.00 ,$25.80 ,$78.26 ,$60.20 ,$25.80 ,$55.90 ,$61.92 ,$78.26 ,$64.50 
Carle BroMenn Medical Center,8106050,OR L2 PER MIN OPERATING ROOM CHARGE,,,360,$74.00 ,$74.00 ,$22.20 ,$67.34 ,$51.80 ,$22.20 ,$48.10 ,$53.28 ,$67.34 ,$55.50 
Carle BroMenn Medical Center,8107050,OR L3 PER MIN OPERATING ROOM CHARGE,,,360,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8108050,OR L4 PER MIN OPERATING ROOM CHARGE,,,360,$46.00 ,$46.00 ,$13.80 ,$41.86 ,$32.20 ,$13.80 ,$29.90 ,$33.12 ,$41.86 ,$34.50 
Carle BroMenn Medical Center,8108051,OR L5 BASE OPERATING ROOM CHARGE,,,360,$450.00 ,$450.00 ,$135.00 ,$409.50 ,$315.00 ,$135.00 ,$292.50 ,$324.00 ,$409.50 ,$337.50 
Carle BroMenn Medical Center,8108052,OR L5 PER MIN OPERATING ROOM CHARGE,,,360,$26.00 ,$26.00 ,$7.80 ,$23.66 ,$18.20 ,$7.80 ,$16.90 ,$18.72 ,$23.66 ,$19.50 
Carle BroMenn Medical Center,8120033,NERVE BLOCK EA ADDL LEVEL,,,360,$240.00 ,$240.00 ,$72.00 ,$218.40 ,$168.00 ,$72.00 ,$156.00 ,$172.80 ,$218.40 ,$180.00 
Carle BroMenn Medical Center,8180003,UHS CRYO ENDOCARE PROSTATE,,,360,"$1,823.00 ","$1,823.00 ",$546.90 ,"$1,658.93 ","$1,276.10 ",$546.90 ,"$1,184.95 ","$1,312.56 ","$1,658.93 ","$1,367.25 "
Carle BroMenn Medical Center,8462264,"LYSIS,PERQ,EPIDURAL ADHESIONS,1 DAY",,62264,360,"$1,658.00 ","$1,658.00 ",$497.40 ,"$1,508.78 ","$1,160.60 ",$497.40 ,"$1,077.70 ","$1,193.76 ","$1,508.78 ","$1,243.50 "
Carle BroMenn Medical Center,8730147,BRONCHOSCOPY,,,360,"$1,598.00 ","$1,598.00 ",$479.40 ,"$1,454.18 ","$1,118.60 ",$479.40 ,"$1,038.70 ","$1,150.56 ","$1,454.18 ","$1,198.50 "
Carle BroMenn Medical Center,8970254,ENDOVASC RPR ILIAC ART BIFUR UNILAT,,0254T,360,"$5,963.00 ","$5,963.00 ","$1,788.90 ","$5,426.33 ","$4,174.10 ","$1,788.90 ","$3,875.95 ","$4,293.36 ","$5,426.33 ","$4,472.25 "
Carle BroMenn Medical Center,8970399,PERC INSRTN CARDIAC SUP SYSTEM,,33999,360,"$13,283.00 ","$13,283.00 ","$3,984.90 ","$12,087.53 ","$9,298.10 ","$3,984.90 ","$8,633.95 ","$9,563.76 ","$12,087.53 ","$9,962.25 "
Carle BroMenn Medical Center,8970543,TA MV RPR W/ARTIF CHORD TEND,,0543T,360,"$18,435.00 ","$18,435.00 ","$5,530.50 ","$16,775.85 ","$12,904.50 ","$5,530.50 ","$11,982.75 ","$13,273.20 ","$16,775.85 ","$13,826.25 "
Carle BroMenn Medical Center,8970544,TCAT MV ANNULUS RCNSTJ,,0544T,360,"$20,205.00 ","$20,205.00 ","$6,061.50 ","$18,386.55 ","$14,143.50 ","$6,061.50 ","$13,133.25 ","$14,547.60 ","$18,386.55 ","$15,153.75 "
Carle BroMenn Medical Center,8970545,TCAT TV ANNULUS RCNSTJ,,0545T,360,"$23,040.00 ","$23,040.00 ","$6,912.00 ","$20,966.40 ","$16,128.00 ","$6,912.00 ","$14,976.00 ","$16,588.80 ","$20,966.40 ","$17,280.00 "
Carle BroMenn Medical Center,8970553,PERQ TCAT ILIAC ANAST IMPLT,,0553T,360,"$13,440.00 ","$13,440.00 ","$4,032.00 ","$12,230.40 ","$9,408.00 ","$4,032.00 ","$8,736.00 ","$9,676.80 ","$12,230.40 ","$10,080.00 "
Carle BroMenn Medical Center,8971210,INS/RPL TEMP ELECTR/PCMKR,,33210,360,"$6,385.00 ","$6,385.00 ","$1,915.50 ","$5,810.35 ","$4,469.50 ","$1,915.50 ","$4,150.25 ","$4,597.20 ","$5,810.35 ","$4,788.75 "
Carle BroMenn Medical Center,8971240,INSRT DUAL CHMBR ICD GENERATOR,,33240,360,"$17,513.00 ","$17,513.00 ","$5,253.90 ","$15,936.83 ","$12,259.10 ","$5,253.90 ","$11,383.45 ","$12,609.36 ","$15,936.83 ","$13,134.75 "
Carle BroMenn Medical Center,8971249,INS/RPOS DUAL CHMB PCG LDS&GEN,,33249,360,"$46,073.00 ","$46,073.00 ","$13,821.90 ","$41,926.43 ","$32,251.10 ","$13,821.90 ","$29,947.45 ","$33,172.56 ","$41,926.43 ","$34,554.75 "
Carle BroMenn Medical Center,8971782,INSERTION TIPS (INTRAHEP SHNT),,37182,360,"$7,050.00 ","$7,050.00 ","$2,115.00 ","$6,415.50 ","$4,935.00 ","$2,115.00 ","$4,582.50 ","$5,076.00 ","$6,415.50 ","$5,287.50 "
Carle BroMenn Medical Center,8972550,INSERTN TUNNELED PLEURAL CATH,,32550,360,"$5,000.00 ","$5,000.00 ","$1,500.00 ","$4,550.00 ","$3,500.00 ","$1,500.00 ","$3,250.00 ","$3,600.00 ","$4,550.00 ","$3,750.00 "
Carle BroMenn Medical Center,8973099,PROCEDURE - CARDIAC,,33999,360,"$13,283.00 ","$13,283.00 ","$3,984.90 ","$12,087.53 ","$9,298.10 ","$3,984.90 ","$8,633.95 ","$9,563.76 ","$12,087.53 ","$9,962.25 "
Carle BroMenn Medical Center,8973206,INS/RPLC PERM PACEMAKER ATRIAL,,33206,360,"$12,630.00 ","$12,630.00 ","$3,789.00 ","$11,493.30 ","$8,841.00 ","$3,789.00 ","$8,209.50 ","$9,093.60 ","$11,493.30 ","$9,472.50 "
Carle BroMenn Medical Center,8973207,INS/RPLC PERM PACEMAKER VNTRCL,,33207,360,"$13,373.00 ","$13,373.00 ","$4,011.90 ","$12,169.43 ","$9,361.10 ","$4,011.90 ","$8,692.45 ","$9,628.56 ","$12,169.43 ","$10,029.75 "
Carle BroMenn Medical Center,8973208,INSRT/RPLC PERM PACEMAKER AV,,33208,360,"$15,383.00 ","$15,383.00 ","$4,614.90 ","$13,998.53 ","$10,768.10 ","$4,614.90 ","$9,998.95 ","$11,075.76 ","$13,998.53 ","$11,537.25 "
Carle BroMenn Medical Center,8973210,INS/RPL TEMP ELECTR/PCMKR,,33210,360,"$6,385.00 ","$6,385.00 ","$1,915.50 ","$5,810.35 ","$4,469.50 ","$1,915.50 ","$4,150.25 ","$4,597.20 ","$5,810.35 ","$4,788.75 "
Carle BroMenn Medical Center,8973211,INS/RPL TEMP TRNSVN DUAL,,33211,360,"$5,663.00 ","$5,663.00 ","$1,698.90 ","$5,153.33 ","$3,964.10 ","$1,698.90 ","$3,680.95 ","$4,077.36 ","$5,153.33 ","$4,247.25 "
Carle BroMenn Medical Center,8973212,INS/RPL PACEMKR PULSE GENERATR,,33212,360,"$6,473.00 ","$6,473.00 ","$1,941.90 ","$5,890.43 ","$4,531.10 ","$1,941.90 ","$4,207.45 ","$4,660.56 ","$5,890.43 ","$4,854.75 "
Carle BroMenn Medical Center,8973213,INS/RPL PCMKR PULSE GEN DUAL,,33213,360,"$8,273.00 ","$8,273.00 ","$2,481.90 ","$7,528.43 ","$5,791.10 ","$2,481.90 ","$5,377.45 ","$5,956.56 ","$7,528.43 ","$6,204.75 "
Carle BroMenn Medical Center,8973214,UPGRADE PACEMAKER SYSTEM,,33214,360,"$14,498.00 ","$14,498.00 ","$4,349.40 ","$13,193.18 ","$10,148.60 ","$4,349.40 ","$9,423.70 ","$10,438.56 ","$13,193.18 ","$10,873.50 "
Carle BroMenn Medical Center,8973215,REPSTN PREV IMPL PCR/ICD LEAD,,33215,360,"$4,163.00 ","$4,163.00 ","$1,248.90 ","$3,788.33 ","$2,914.10 ","$1,248.90 ","$2,705.95 ","$2,997.36 ","$3,788.33 ","$3,122.25 "
Carle BroMenn Medical Center,8973216,INSRT TRNV ELCTRD - SC PCR/ICD,,33216,360,"$5,700.00 ","$5,700.00 ","$1,710.00 ","$5,187.00 ","$3,990.00 ","$1,710.00 ","$3,705.00 ","$4,104.00 ","$5,187.00 ","$4,275.00 "
Carle BroMenn Medical Center,8973217,INSRT TRNV ELCTRD - DC PCR/ICD,,33217,360,"$9,398.00 ","$9,398.00 ","$2,819.40 ","$8,552.18 ","$6,578.60 ","$2,819.40 ","$6,108.70 ","$6,766.56 ","$8,552.18 ","$7,048.50 "
Carle BroMenn Medical Center,8973218,RPR PCMKR/PCG ICD ELECTRODE-SC,,33218,360,"$4,088.00 ","$4,088.00 ","$1,226.40 ","$3,720.08 ","$2,861.60 ","$1,226.40 ","$2,657.20 ","$2,943.36 ","$3,720.08 ","$3,066.00 "
Carle BroMenn Medical Center,8973220,RPR PCMKR/PCG ICD ELECTRD -DC,,33220,360,"$5,093.00 ","$5,093.00 ","$1,527.90 ","$4,634.63 ","$3,565.10 ","$1,527.90 ","$3,310.45 ","$3,666.96 ","$4,634.63 ","$3,819.75 "
Carle BroMenn Medical Center,8973221,INSRTN PCMKR PLS GEN W/MULT LEADS,,33221,360,"$21,773.00 ","$21,773.00 ","$6,531.90 ","$19,813.43 ","$15,241.10 ","$6,531.90 ","$14,152.45 ","$15,676.56 ","$19,813.43 ","$16,329.75 "
Carle BroMenn Medical Center,8973222,REV/RELOC SKIN PKT FOR PACEMKR,,33222,360,"$2,550.00 ","$2,550.00 ",$765.00 ,"$2,320.50 ","$1,785.00 ",$765.00 ,"$1,657.50 ","$1,836.00 ","$2,320.50 ","$1,912.50 "
Carle BroMenn Medical Center,8973223,REVSN/RELOC SKIN PCKT PCG ICD,,33223,360,"$2,805.00 ","$2,805.00 ",$841.50 ,"$2,552.55 ","$1,963.50 ",$841.50 ,"$1,823.25 ","$2,019.60 ","$2,552.55 ","$2,103.75 "
Carle BroMenn Medical Center,8973224,INSRT LT VNT LEAD -PR PLCD PCR,,33224,360,"$13,493.00 ","$13,493.00 ","$4,047.90 ","$12,278.63 ","$9,445.10 ","$4,047.90 ","$8,770.45 ","$9,714.96 ","$12,278.63 ","$10,119.75 "
Carle BroMenn Medical Center,8973225,INSRT LT VENT PACING ELECTRODE,,33225,360,"$7,035.00 ","$7,035.00 ","$2,110.50 ","$6,401.85 ","$4,924.50 ","$2,110.50 ","$4,572.75 ","$5,065.20 ","$6,401.85 ","$5,276.25 "
Carle BroMenn Medical Center,8973226,REPOSTN PREV IMPLANTED LV LEAD,,33226,360,"$4,163.00 ","$4,163.00 ","$1,248.90 ","$3,788.33 ","$2,914.10 ","$1,248.90 ","$2,705.95 ","$2,997.36 ","$3,788.33 ","$3,122.25 "
Carle BroMenn Medical Center,8973227,RMVL PERM PCMKR W/RPLCMNT SNGL LEAD,,33227,360,"$10,433.00 ","$10,433.00 ","$3,129.90 ","$9,494.03 ","$7,303.10 ","$3,129.90 ","$6,781.45 ","$7,511.76 ","$9,494.03 ","$7,824.75 "
Carle BroMenn Medical Center,8973228,RMVL PERM PCMKR W/RPLCMNT DUAL LEAD,,33228,360,"$7,688.00 ","$7,688.00 ","$2,306.40 ","$6,996.08 ","$5,381.60 ","$2,306.40 ","$4,997.20 ","$5,535.36 ","$6,996.08 ","$5,766.00 "
Carle BroMenn Medical Center,8973229,RMVL PERM PCMKR W/RPLCMNT MULT LEAD,,33229,360,"$13,688.00 ","$13,688.00 ","$4,106.40 ","$12,456.08 ","$9,581.60 ","$4,106.40 ","$8,897.20 ","$9,855.36 ","$12,456.08 ","$10,266.00 "
Carle BroMenn Medical Center,8973230,INSRT ICD GENRTR W/EXST DUAL LEADS,,33230,360,"$29,738.00 ","$29,738.00 ","$8,921.40 ","$27,061.58 ","$20,816.60 ","$8,921.40 ","$19,329.70 ","$21,411.36 ","$27,061.58 ","$22,303.50 "
Carle BroMenn Medical Center,8973231,INSRT ICD GENRTR W/EXST MULT LEADS,,33231,360,"$24,758.00 ","$24,758.00 ","$7,427.40 ","$22,529.78 ","$17,330.60 ","$7,427.40 ","$16,092.70 ","$17,825.76 ","$22,529.78 ","$18,568.50 "
Carle BroMenn Medical Center,8973233,RMV PERM PCMKR PULSE GENERATOR,,33233,360,"$5,700.00 ","$5,700.00 ","$1,710.00 ","$5,187.00 ","$3,990.00 ","$1,710.00 ","$3,705.00 ","$4,104.00 ","$5,187.00 ","$4,275.00 "
Carle BroMenn Medical Center,8973234,RMVL TRNSVNS PCMKR ELCTRODE(S),,33234,360,"$4,478.00 ","$4,478.00 ","$1,343.40 ","$4,074.98 ","$3,134.60 ","$1,343.40 ","$2,910.70 ","$3,224.16 ","$4,074.98 ","$3,358.50 "
Carle BroMenn Medical Center,8973235,RMVL TRNSVNS PCMKR ELCTRODE(S),,33235,360,"$4,478.00 ","$4,478.00 ","$1,343.40 ","$4,074.98 ","$3,134.60 ","$1,343.40 ","$2,910.70 ","$3,224.16 ","$4,074.98 ","$3,358.50 "
Carle BroMenn Medical Center,8973240,INSRT SINGLE CHMBR ICD GENRATR,,33240,360,"$17,513.00 ","$17,513.00 ","$5,253.90 ","$15,936.83 ","$12,259.10 ","$5,253.90 ","$11,383.45 ","$12,609.36 ","$15,936.83 ","$13,134.75 "
Carle BroMenn Medical Center,8973241,REMOVE PCD PULSE GENERATOR,,33241,360,"$4,478.00 ","$4,478.00 ","$1,343.40 ","$4,074.98 ","$3,134.60 ","$1,343.40 ","$2,910.70 ","$3,224.16 ","$4,074.98 ","$3,358.50 "
Carle BroMenn Medical Center,8973244,RMVL AICD - TRANSVENOUS EXCISN,,33244,360,"$4,478.00 ","$4,478.00 ","$1,343.40 ","$4,074.98 ","$3,134.60 ","$1,343.40 ","$2,910.70 ","$3,224.16 ","$4,074.98 ","$3,358.50 "
Carle BroMenn Medical Center,8973249,INS/RPOS SNGL CHMBR PCG LD&GEN,,33249,360,"$46,073.00 ","$46,073.00 ","$13,821.90 ","$41,926.43 ","$32,251.10 ","$13,821.90 ","$29,947.45 ","$33,172.56 ","$41,926.43 ","$34,554.75 "
Carle BroMenn Medical Center,8973262,RMVL PCD W/RPLC SNGL LEAD,,33262,360,"$34,073.00 ","$34,073.00 ","$10,221.90 ","$31,006.43 ","$23,851.10 ","$10,221.90 ","$22,147.45 ","$24,532.56 ","$31,006.43 ","$25,554.75 "
Carle BroMenn Medical Center,8973263,RMVL PCD W/ RPLC DUAL LEAD,,33263,360,"$33,818.00 ","$33,818.00 ","$10,145.40 ","$30,774.38 ","$23,672.60 ","$10,145.40 ","$21,981.70 ","$24,348.96 ","$30,774.38 ","$25,363.50 "
Carle BroMenn Medical Center,8973264,RMVL PCD W/RPLC MULT LEAD,,33264,360,"$24,900.00 ","$24,900.00 ","$7,470.00 ","$22,659.00 ","$17,430.00 ","$7,470.00 ","$16,185.00 ","$17,928.00 ","$22,659.00 ","$18,675.00 "
Carle BroMenn Medical Center,8973340,PERQ CLSR TCAT L ATR APNDGE W/ENDOCARDIAL IMPLNT,,33340,360,"$5,190.00 ","$5,190.00 ","$1,557.00 ","$4,722.90 ","$3,633.00 ","$1,557.00 ","$3,373.50 ","$3,736.80 ","$4,722.90 ","$3,892.50 "
Carle BroMenn Medical Center,8973362,TRNSCATH AORTIC VALVE RPLCMNT - OPEN FEM,,33362,360,"$9,630.00 ","$9,630.00 ","$2,889.00 ","$8,763.30 ","$6,741.00 ","$2,889.00 ","$6,259.50 ","$6,933.60 ","$8,763.30 ","$7,222.50 "
Carle BroMenn Medical Center,8973363,TRNSCATH AORTIC VALVE RPLCMNT - OPEN AUX,,33363,360,"$12,030.00 ","$12,030.00 ","$3,609.00 ","$10,947.30 ","$8,421.00 ","$3,609.00 ","$7,819.50 ","$8,661.60 ","$10,947.30 ","$9,022.50 "
Carle BroMenn Medical Center,8973364,TRNSCATH AORTIC VALVE RPLCMNT - OPEN ILLIAC,,33364,360,"$12,158.00 ","$12,158.00 ","$3,647.40 ","$11,063.78 ","$8,510.60 ","$3,647.40 ","$7,902.70 ","$8,753.76 ","$11,063.78 ","$9,118.50 "
Carle BroMenn Medical Center,8973365,TRNSCATH AORTIC VALVE RPLCMNT - TRNSAORTIC,,33365,360,"$13,335.00 ","$13,335.00 ","$4,000.50 ","$12,134.85 ","$9,334.50 ","$4,000.50 ","$8,667.75 ","$9,601.20 ","$12,134.85 ","$10,001.25 "
Carle BroMenn Medical Center,8973366,TRNSCATH AORTIC VALUE RPLCMENT - TRNSAPICAL,,33366,360,"$15,135.00 ","$15,135.00 ","$4,540.50 ","$13,772.85 ","$10,594.50 ","$4,540.50 ","$9,837.75 ","$10,897.20 ","$13,772.85 ","$11,351.25 "
Carle BroMenn Medical Center,8973367,PERCUT CARDPULM BYPS SUPPORT,,33367,360,"$4,943.00 ","$4,943.00 ","$1,482.90 ","$4,498.13 ","$3,460.10 ","$1,482.90 ","$3,212.95 ","$3,558.96 ","$4,498.13 ","$3,707.25 "
Carle BroMenn Medical Center,8973368,CENTRAL CARDPULM BYPS SUPPORT,,33368,360,"$5,978.00 ","$5,978.00 ","$1,793.40 ","$5,439.98 ","$4,184.60 ","$1,793.40 ","$3,885.70 ","$4,304.16 ","$5,439.98 ","$4,483.50 "
Carle BroMenn Medical Center,8973369,CNTRL ARTRL & VNUS CNNULTN CARDPULM BYPS SPPRT,,33369,360,"$7,905.00 ","$7,905.00 ","$2,371.50 ","$7,193.55 ","$5,533.50 ","$2,371.50 ","$5,138.25 ","$5,691.60 ","$7,193.55 ","$5,928.75 "
Carle BroMenn Medical Center,8973401,PR MEDIASTINOSCOPY INCLUDES MEDIASTINAL MASS BIOPSY,,39401,360,"$7,920.00 ","$7,920.00 ","$2,376.00 ","$7,207.20 ","$5,544.00 ","$2,376.00 ","$5,148.00 ","$5,702.40 ","$7,207.20 ","$5,940.00 "
Carle BroMenn Medical Center,8973402,PR MEDIASTINOSCOPY WITH LYMPH NODE BIOPSY/IES,,39402,360,"$7,920.00 ","$7,920.00 ","$2,376.00 ","$7,207.20 ","$5,544.00 ","$2,376.00 ","$5,148.00 ","$5,702.40 ","$7,207.20 ","$5,940.00 "
Carle BroMenn Medical Center,8973418,TCAT MITRAL VALVE REPAIR INITIAL PROSTHESIS,,33418,360,"$33,750.00 ","$33,750.00 ","$10,125.00 ","$30,712.50 ","$23,625.00 ","$10,125.00 ","$21,937.50 ","$24,300.00 ","$30,712.50 ","$25,312.50 "
Carle BroMenn Medical Center,8973419,TCAT MITRAL VALVE REPAIR ADDL PROSTHESIS,,33419,360,"$11,250.00 ","$11,250.00 ","$3,375.00 ","$10,237.50 ","$7,875.00 ","$3,375.00 ","$7,312.50 ","$8,100.00 ","$10,237.50 ","$8,437.50 "
Carle BroMenn Medical Center,8973477,PR TCAT PULMONARY VALVE IMPLANTATION PRQ APPROACH,,33477,360,"$10,620.00 ","$10,620.00 ","$3,186.00 ","$9,664.20 ","$7,434.00 ","$3,186.00 ","$6,903.00 ","$7,646.40 ","$9,664.20 ","$7,965.00 "
Carle BroMenn Medical Center,8973946,ECMO INITIATION VENO-VENOUS,,33946,360,"$4,508.00 ","$4,508.00 ","$1,352.40 ","$4,102.28 ","$3,155.60 ","$1,352.40 ","$2,930.20 ","$3,245.76 ","$4,102.28 ","$3,381.00 "
Carle BroMenn Medical Center,8973947,ECMO INITIATION VENO-ARTERIAL,,33947,360,"$4,110.00 ","$4,110.00 ","$1,233.00 ","$3,740.10 ","$2,877.00 ","$1,233.00 ","$2,671.50 ","$2,959.20 ","$3,740.10 ","$3,082.50 "
Carle BroMenn Medical Center,8973952,"ECMO INSERTION PERIPHERAL CANNULA(E) PERCUT, AGE 6 +",,33952,360,"$2,933.00 ","$2,933.00 ",$879.90 ,"$2,669.03 ","$2,053.10 ",$879.90 ,"$1,906.45 ","$2,111.76 ","$2,669.03 ","$2,199.75 "
Carle BroMenn Medical Center,8973999,PROCEDURE - CARDIAC,,33999,360,"$13,283.00 ","$13,283.00 ","$3,984.90 ","$12,087.53 ","$9,298.10 ","$3,984.90 ","$8,633.95 ","$9,563.76 ","$12,087.53 ","$9,962.25 "
Carle BroMenn Medical Center,8974705,EVASC RPR DPLMNT AORTO-BI-ILIAC NDGFT,,34705,360,"$22,800.00 ","$22,800.00 ","$6,840.00 ","$20,748.00 ","$15,960.00 ","$6,840.00 ","$14,820.00 ","$16,416.00 ","$20,748.00 ","$17,100.00 "
Carle BroMenn Medical Center,8974709,PLACEMENT XTN PROSTH FOR ENDOVASCULAR RPR,,34709,360,"$7,500.00 ","$7,500.00 ","$2,250.00 ","$6,825.00 ","$5,250.00 ","$2,250.00 ","$4,875.00 ","$5,400.00 ","$6,825.00 ","$5,625.00 "
Carle BroMenn Medical Center,8974713,PERQ ACCESS & CLOSURE FEM ART FOR DELIVERY NDGFT,,34713,360,"$4,882.00 ","$4,882.00 ","$1,464.60 ","$4,442.62 ","$3,417.40 ","$1,464.60 ","$3,173.30 ","$3,515.04 ","$4,442.62 ","$3,661.50 "
Carle BroMenn Medical Center,8977182,INSERTION TIPS (INTRAHEP SHNT),,37182,360,"$7,050.00 ","$7,050.00 ","$2,115.00 ","$6,415.50 ","$4,935.00 ","$2,115.00 ","$4,582.50 ","$5,076.00 ","$6,415.50 ","$5,287.50 "
Carle BroMenn Medical Center,8977183,REVISION TIPS (INTRAHEP SHNT),,37183,360,"$7,433.00 ","$7,433.00 ","$2,229.90 ","$6,764.03 ","$5,203.10 ","$2,229.90 ","$4,831.45 ","$5,351.76 ","$6,764.03 ","$5,574.75 "
Carle BroMenn Medical Center,8977215,TRANSCATH PLCMNT CAROTID STENT,,37215,360,"$8,265.00 ","$8,265.00 ","$2,479.50 ","$7,521.15 ","$5,785.50 ","$2,479.50 ","$5,372.25 ","$5,950.80 ","$7,521.15 ","$6,198.75 "
Carle BroMenn Medical Center,8979756,TRANSCATH MITRAL VALVE REPAIR VIA CORONARY SINUS,,0345T,360,"$11,603.00 ","$11,603.00 ","$3,480.90 ","$10,558.73 ","$8,122.10 ","$3,480.90 ","$7,541.95 ","$8,354.16 ","$10,558.73 ","$8,702.25 "
Carle BroMenn Medical Center,8979758,TRANSCATHETER RENAL SYMPATH DENERVATION BILATERAL,,0339T,360,"$3,473.00 ","$3,473.00 ","$1,041.90 ","$3,160.43 ","$2,431.10 ","$1,041.90 ","$2,257.45 ","$2,500.56 ","$3,160.43 ","$2,604.75 "
Carle BroMenn Medical Center,8020003,RESEVOIR TAPS,,,361,$833.00 ,$833.00 ,$249.90 ,$758.03 ,$583.10 ,$249.90 ,$541.45 ,$599.76 ,$758.03 ,$624.75 
Carle BroMenn Medical Center,8020006,"CATH UMBILICAL ARTERY, NEWBORN",,,361,$465.00 ,$465.00 ,$139.50 ,$423.15 ,$325.50 ,$139.50 ,$302.25 ,$334.80 ,$423.15 ,$348.75 
Carle BroMenn Medical Center,8020007,"CATH UMBILICAL VEIN, NEWBORN",,,361,$413.00 ,$413.00 ,$123.90 ,$375.83 ,$289.10 ,$123.90 ,$268.45 ,$297.36 ,$375.83 ,$309.75 
Carle BroMenn Medical Center,8020011,PERCUTANEOUS REMOVAL IABP,,,361,$630.00 ,$630.00 ,$189.00 ,$573.30 ,$441.00 ,$189.00 ,$409.50 ,$453.60 ,$573.30 ,$472.50 
Carle BroMenn Medical Center,8020012,BX OR EXC LYMPH NODE,,,361,"$2,490.00 ","$2,490.00 ",$747.00 ,"$2,265.90 ","$1,743.00 ",$747.00 ,"$1,618.50 ","$1,792.80 ","$2,265.90 ","$1,867.50 "
Carle BroMenn Medical Center,8020013,BX RECTUM,,,361,"$3,353.00 ","$3,353.00 ","$1,005.90 ","$3,051.23 ","$2,347.10 ","$1,005.90 ","$2,179.45 ","$2,414.16 ","$3,051.23 ","$2,514.75 "
Carle BroMenn Medical Center,8020018,THORACOTOMY W/CARDIAC MASSAGE,,,361,"$6,713.00 ","$6,713.00 ","$2,013.90 ","$6,108.83 ","$4,699.10 ","$2,013.90 ","$4,363.45 ","$4,833.36 ","$6,108.83 ","$5,034.75 "
Carle BroMenn Medical Center,8020037,WOUND EXPLORATION,,,361,"$3,780.00 ","$3,780.00 ","$1,134.00 ","$3,439.80 ","$2,646.00 ","$1,134.00 ","$2,457.00 ","$2,721.60 ","$3,439.80 ","$2,835.00 "
Carle BroMenn Medical Center,8020038,"ARTHROCENTESIS, ASP/INJ JOINT/BURSA W/O US GUIDE",,,361,$785.00 ,$785.00 ,$235.50 ,$714.35 ,$549.50 ,$235.50 ,$510.25 ,$565.20 ,$714.35 ,$588.75 
Carle BroMenn Medical Center,8023001,APPLICATION OF HALO  -CRANIAL,,,361,$848.00 ,$848.00 ,$254.40 ,$771.68 ,$593.60 ,$254.40 ,$551.20 ,$610.56 ,$771.68 ,$636.00 
Carle BroMenn Medical Center,8023002,CENTRAL LINE INSERTION,,,361,"$1,388.00 ","$1,388.00 ",$416.40 ,"$1,263.08 ",$971.60 ,$416.40 ,$902.20 ,$999.36 ,"$1,263.08 ","$1,041.00 "
Carle BroMenn Medical Center,8023003,INSERTION - CHEST TUBE,,,361,"$1,080.00 ","$1,080.00 ",$324.00 ,$982.80 ,$756.00 ,$324.00 ,$702.00 ,$777.60 ,$982.80 ,$810.00 
Carle BroMenn Medical Center,8023004,PARACENTESIS,,,361,$780.00 ,$780.00 ,$234.00 ,$709.80 ,$546.00 ,$234.00 ,$507.00 ,$561.60 ,$709.80 ,$585.00 
Carle BroMenn Medical Center,8023005,PLEURODESIS,,,361,$840.00 ,$840.00 ,$252.00 ,$764.40 ,$588.00 ,$252.00 ,$546.00 ,$604.80 ,$764.40 ,$630.00 
Carle BroMenn Medical Center,8023006,THORACENTESIS/PARACENTESIS,,,361,$840.00 ,$840.00 ,$252.00 ,$764.40 ,$588.00 ,$252.00 ,$546.00 ,$604.80 ,$764.40 ,$630.00 
Carle BroMenn Medical Center,8023007,TRACHEOSTOMY,,,361,"$1,290.00 ","$1,290.00 ",$387.00 ,"$1,173.90 ",$903.00 ,$387.00 ,$838.50 ,$928.80 ,"$1,173.90 ",$967.50 
Carle BroMenn Medical Center,8023008,VENTRICULOSTOMY,,,361,$945.00 ,$945.00 ,$283.50 ,$859.95 ,$661.50 ,$283.50 ,$614.25 ,$680.40 ,$859.95 ,$708.75 
Carle BroMenn Medical Center,8023010,LARYNGOSCOPY,,,361,$945.00 ,$945.00 ,$283.50 ,$859.95 ,$661.50 ,$283.50 ,$614.25 ,$680.40 ,$859.95 ,$708.75 
Carle BroMenn Medical Center,8023011,ENDOSCOPY,,,361,"$1,560.00 ","$1,560.00 ",$468.00 ,"$1,419.60 ","$1,092.00 ",$468.00 ,"$1,014.00 ","$1,123.20 ","$1,419.60 ","$1,170.00 "
Carle BroMenn Medical Center,8023012,ARTERIAL LINE INSERTION,,,361,"$1,388.00 ","$1,388.00 ",$416.40 ,"$1,263.08 ",$971.60 ,$416.40 ,$902.20 ,$999.36 ,"$1,263.08 ","$1,041.00 "
Carle BroMenn Medical Center,8023013,OPEN ABDOMNIAL PROC,,,361,"$2,730.00 ","$2,730.00 ",$819.00 ,"$2,484.30 ","$1,911.00 ",$819.00 ,"$1,774.50 ","$1,965.60 ","$2,484.30 ","$2,047.50 "
Carle BroMenn Medical Center,8023014,PICC INSERTION,,,361,"$1,515.00 ","$1,515.00 ",$454.50 ,"$1,378.65 ","$1,060.50 ",$454.50 ,$984.75 ,"$1,090.80 ","$1,378.65 ","$1,136.25 "
Carle BroMenn Medical Center,8023658,RPLC NON-TNNLD CVC W/O PRT/PMP,,36580,361,"$2,070.00 ","$2,070.00 ",$621.00 ,"$1,883.70 ","$1,449.00 ",$621.00 ,"$1,345.50 ","$1,490.40 ","$1,883.70 ","$1,552.50 "
Carle BroMenn Medical Center,8024405,INJ ANES/STEROID GRTR OCCPITAL NRV,,,361,$900.00 ,$900.00 ,$270.00 ,$819.00 ,$630.00 ,$270.00 ,$585.00 ,$648.00 ,$819.00 ,$675.00 
Carle BroMenn Medical Center,8024649,PROC ROOM DERMACLOSE PLACEMENT,,,361,"$1,185.00 ","$1,185.00 ",$355.50 ,"$1,078.35 ",$829.50 ,$355.50 ,$770.25 ,$853.20 ,"$1,078.35 ",$888.75 
Carle BroMenn Medical Center,8025900,REDUCTION RECTAL PROLAPSE,,,361,"$3,176.00 ","$3,176.00 ",$952.80 ,"$2,890.16 ","$2,223.20 ",$952.80 ,"$2,064.40 ","$2,286.72 ","$2,890.16 ","$2,382.00 "
Carle BroMenn Medical Center,8026465,NJX NONCMPND SCLEROSANT SINGLE INCMPTNT VEIN,,36465,361,"$1,133.00 ","$1,133.00 ",$339.90 ,"$1,031.03 ",$793.10 ,$339.90 ,$736.45 ,$815.76 ,"$1,031.03 ",$849.75 
Carle BroMenn Medical Center,8026466,NJX NONCMPND SCLEROSANT MULTIPLE INCMPTNT VEINS,,36466,361,"$1,133.00 ","$1,133.00 ",$339.90 ,"$1,031.03 ",$793.10 ,$339.90 ,$736.45 ,$815.76 ,"$1,031.03 ",$849.75 
Carle BroMenn Medical Center,8026482,ENDOVEN ABLTI THER CHEM ADHESIVE 1ST VEIN,,36482,361,"$3,218.00 ","$3,218.00 ",$965.40 ,"$2,928.38 ","$2,252.60 ",$965.40 ,"$2,091.70 ","$2,316.96 ","$2,928.38 ","$2,413.50 "
Carle BroMenn Medical Center,8026483,ENDOVEN ABLTI THER CHEM ADHESIVE SBSQ VEIN,,36483,361,$240.00 ,$240.00 ,$72.00 ,$218.40 ,$168.00 ,$72.00 ,$156.00 ,$172.80 ,$218.40 ,$180.00 
Carle BroMenn Medical Center,8026569,INSERT PICC >= AGE 5 WO IMAGE,,36569,361,"$1,845.00 ","$1,845.00 ",$553.50 ,"$1,678.95 ","$1,291.50 ",$553.50 ,"$1,199.25 ","$1,328.40 ","$1,678.95 ","$1,383.75 "
Carle BroMenn Medical Center,8026572,INSERTION PICC W/RS&I < 5 YR,,36572,361,$893.00 ,$893.00 ,$267.90 ,$812.63 ,$625.10 ,$267.90 ,$580.45 ,$642.96 ,$812.63 ,$669.75 
Carle BroMenn Medical Center,8026573,INSERTION PICC W/RS&I 5 YR/>,,36573,361,"$2,242.00 ","$2,242.00 ",$672.60 ,"$2,040.22 ","$1,569.40 ",$672.60 ,"$1,457.30 ","$1,614.24 ","$2,040.22 ","$1,681.50 "
Carle BroMenn Medical Center,8026575,REPAIR CV CATH W/O SUBQ PORT OR PUMP,,36575,361,"$1,845.00 ","$1,845.00 ",$553.50 ,"$1,678.95 ","$1,291.50 ",$553.50 ,"$1,199.25 ","$1,328.40 ","$1,678.95 ","$1,383.75 "
Carle BroMenn Medical Center,8026600,ARTERIAL BLOOD COLLECTION,,36600,361,$44.00 ,$44.00 ,$13.20 ,$40.04 ,$30.80 ,$13.20 ,$28.60 ,$31.68 ,$40.04 ,$33.00 
Carle BroMenn Medical Center,8027705,PROCEDURE ROOM,,,361,$218.00 ,$218.00 ,$65.40 ,$198.38 ,$152.60 ,$65.40 ,$141.70 ,$156.96 ,$198.38 ,$163.50 
Carle BroMenn Medical Center,8028222,DIAGNOSTIC BONE MARROW BIOPSIES & ASPIRATIONS,,38222,361,"$1,620.00 ","$1,620.00 ",$486.00 ,"$1,474.20 ","$1,134.00 ",$486.00 ,"$1,053.00 ","$1,166.40 ","$1,474.20 ","$1,215.00 "
Carle BroMenn Medical Center,8062328,DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT,,,361,"$1,748.00 ","$1,748.00 ",$524.40 ,"$1,590.68 ","$1,223.60 ",$524.40 ,"$1,136.20 ","$1,258.56 ","$1,590.68 ","$1,311.00 "
Carle BroMenn Medical Center,8062329,THERAPEUTIC SPINAL PNXR DRAINAGE CSF W/FLUOR/CT,,,361,"$2,183.00 ","$2,183.00 ",$654.90 ,"$1,986.53 ","$1,528.10 ",$654.90 ,"$1,418.95 ","$1,571.76 ","$1,986.53 ","$1,637.25 "
Carle BroMenn Medical Center,8100088,INSERTION FOLEY CATHETER,,51702,361,$185.00 ,$185.00 ,$55.50 ,$168.35 ,$129.50 ,$55.50 ,$120.25 ,$133.20 ,$168.35 ,$138.75 
Carle BroMenn Medical Center,8100091,INSERT CVC/TEMP DIALYSIS CATH,,36556,361,"$2,465.00 ","$2,465.00 ",$739.50 ,"$2,243.15 ","$1,725.50 ",$739.50 ,"$1,602.25 ","$1,774.80 ","$2,243.15 ","$1,848.75 "
Carle BroMenn Medical Center,8103079,EVAL CV DVC W/INJECTN & FLUORO,,36598,361,$595.00 ,$595.00 ,$178.50 ,$541.45 ,$416.50 ,$178.50 ,$386.75 ,$428.40 ,$541.45 ,$446.25 
Carle BroMenn Medical Center,8109052,IRRIGATN IMPLNTD VEN ACC DVC,,96523,361,$190.00 ,$190.00 ,$57.00 ,$172.90 ,$133.00 ,$57.00 ,$123.50 ,$136.80 ,$172.90 ,$142.50 
Carle BroMenn Medical Center,8120030,INJECT EPIDURAL BLD/CLOT PATCH,,,361,$728.00 ,$728.00 ,$218.40 ,$662.48 ,$509.60 ,$218.40 ,$473.20 ,$524.16 ,$662.48 ,$546.00 
Carle BroMenn Medical Center,8120031,INJECTN -NERVE BLOCK FOR PAIN,,,361,$983.00 ,$983.00 ,$294.90 ,$894.53 ,$688.10 ,$294.90 ,$638.95 ,$707.76 ,$894.53 ,$737.25 
Carle BroMenn Medical Center,8120032,JOINT MANIPULATION,,,361,$578.00 ,$578.00 ,$173.40 ,$525.98 ,$404.60 ,$173.40 ,$375.70 ,$416.16 ,$525.98 ,$433.50 
Carle BroMenn Medical Center,8130001,POS OP PAIN EPIDU/SPINAL INJ,,,361,"$1,050.00 ","$1,050.00 ",$315.00 ,$955.50 ,$735.00 ,$315.00 ,$682.50 ,$756.00 ,$955.50 ,$787.50 
Carle BroMenn Medical Center,8130002,POS OP PAIN NERVE BLOCK,,,361,$803.00 ,$803.00 ,$240.90 ,$730.73 ,$562.10 ,$240.90 ,$521.95 ,$578.16 ,$730.73 ,$602.25 
Carle BroMenn Medical Center,8400200,SACROPLASTY UNILATERAL,,0200T,361,"$4,245.00 ","$4,245.00 ","$1,273.50 ","$3,862.95 ","$2,971.50 ","$1,273.50 ","$2,759.25 ","$3,056.40 ","$3,862.95 ","$3,183.75 "
Carle BroMenn Medical Center,8400201,SACROPLASTY BILATERAL,,0201T,361,"$4,268.00 ","$4,268.00 ","$1,280.40 ","$3,883.88 ","$2,987.60 ","$1,280.40 ","$2,774.20 ","$3,072.96 ","$3,883.88 ","$3,201.00 "
Carle BroMenn Medical Center,8422513,PERQ VERT AGMNTJ CAVITY CRTJ UNI/BI CANNULATION,,22513,361,"$9,795.00 ","$9,795.00 ","$2,938.50 ","$8,913.45 ","$6,856.50 ","$2,938.50 ","$6,366.75 ","$7,052.40 ","$8,913.45 ","$7,346.25 "
Carle BroMenn Medical Center,8433010,PERICARIOCENTESIS,,33010,361,"$1,193.00 ","$1,193.00 ",$357.90 ,"$1,085.63 ",$835.10 ,$357.90 ,$775.45 ,$858.96 ,"$1,085.63 ",$894.75 
Carle BroMenn Medical Center,8433017,PERQ PRCRD DRG 6YR+ W/O CONGENITAL CAR ANOMALY,,33017,361,"$4,748.00 ","$4,748.00 ","$1,424.40 ","$4,320.68 ","$3,323.60 ","$1,424.40 ","$3,086.20 ","$3,418.56 ","$4,320.68 ","$3,561.00 "
Carle BroMenn Medical Center,8436002,THROMBIN INJCT PSEUODOANEURYSM,,36002,361,$920.00 ,$920.00 ,$276.00 ,$837.20 ,$644.00 ,$276.00 ,$598.00 ,$662.40 ,$837.20 ,$690.00 
Carle BroMenn Medical Center,8460300,US THYROID CYST ASP,,60300,361,$578.50 ,$578.50 ,$173.55 ,$526.44 ,$404.95 ,$173.55 ,$376.03 ,$416.52 ,$526.44 ,$433.88 
Carle BroMenn Medical Center,8720077,DECLOT VASCULAR ACCESS DVC/CTH,,36593,361,$760.00 ,$760.00 ,$228.00 ,$691.60 ,$532.00 ,$228.00 ,$494.00 ,$547.20 ,$691.60 ,$570.00 
Carle BroMenn Medical Center,8730148,CENTRAL LINE INSERTION,,,361,"$1,313.00 ","$1,313.00 ",$393.90 ,"$1,194.83 ",$919.10 ,$393.90 ,$853.45 ,$945.36 ,"$1,194.83 ",$984.75 
Carle BroMenn Medical Center,8730149,THORACENTESIS/PARACENTESIS,,,361,$788.00 ,$788.00 ,$236.40 ,$717.08 ,$551.60 ,$236.40 ,$512.20 ,$567.36 ,$717.08 ,$591.00 
Carle BroMenn Medical Center,8796523,IRRIGATN IMPLNTD VEN ACC DVC,,96523,361,$190.00 ,$190.00 ,$57.00 ,$172.90 ,$133.00 ,$57.00 ,$123.50 ,$136.80 ,$172.90 ,$142.50 
Carle BroMenn Medical Center,8970075,STENT PLACMNT VERT/INTRATHOR CAROTID,,0075T,361,"$7,995.00 ","$7,995.00 ","$2,398.50 ","$7,275.45 ","$5,596.50 ","$2,398.50 ","$5,196.75 ","$5,756.40 ","$7,275.45 ","$5,996.25 "
Carle BroMenn Medical Center,8970076,STENT PLACMNT VERT/INTRATHOR CAROTID,,0076T,361,"$2,115.00 ","$2,115.00 ",$634.50 ,"$1,924.65 ","$1,480.50 ",$634.50 ,"$1,374.75 ","$1,522.80 ","$1,924.65 ","$1,586.25 "
Carle BroMenn Medical Center,8970082,"ABDOMINAL PARACENTESIS, W/O IMAGING",,49082,361,$965.00 ,$965.00 ,$289.50 ,$878.15 ,$675.50 ,$289.50 ,$627.25 ,$694.80 ,$878.15 ,$723.75 
Carle BroMenn Medical Center,8970083,"ABDOMINAL PARACENTESIS, W/ IMAGING",,49083,361,"$3,003.00 ","$3,003.00 ",$900.90 ,"$2,732.73 ","$2,102.10 ",$900.90 ,"$1,951.95 ","$2,162.16 ","$2,732.73 ","$2,252.25 "
Carle BroMenn Medical Center,8970084,PERITONEAL LAVAGE W/WO IMAGING,,49084,361,"$2,730.00 ","$2,730.00 ",$819.00 ,"$2,484.30 ","$1,911.00 ",$819.00 ,"$1,774.50 ","$1,965.60 ","$2,484.30 ","$2,047.50 "
Carle BroMenn Medical Center,8970100,"THYROID BIOPSY, PERC CORE NDL",,60100,361,"$1,183.00 ","$1,183.00 ",$354.90 ,"$1,076.53 ",$828.10 ,$354.90 ,$768.95 ,$851.76 ,"$1,076.53 ",$887.25 
Carle BroMenn Medical Center,8970120,REMOVE FOREIGN BODY SIMPLE,,10120,361,$780.00 ,$780.00 ,$234.00 ,$709.80 ,$546.00 ,$234.00 ,$507.00 ,$561.60 ,$709.80 ,$585.00 
Carle BroMenn Medical Center,8970123,TRANSCATH INSERT OR REPLACE LEADLESS PM VENTR,,0387T,361,"$11,475.00 ","$11,475.00 ","$3,442.50 ","$10,442.25 ","$8,032.50 ","$3,442.50 ","$7,458.75 ","$8,262.00 ","$10,442.25 ","$8,606.25 "
Carle BroMenn Medical Center,8970140,INCISION/DRAINAGE FLUID,,10140,361,"$3,160.00 ","$3,160.00 ",$948.00 ,"$2,875.60 ","$2,212.00 ",$948.00 ,"$2,054.00 ","$2,275.20 ","$2,875.60 ","$2,370.00 "
Carle BroMenn Medical Center,8970146,FINE NEEDLE ASPIRATION BX W/CT GDN EA ADDL,,10010,361,$728.00 ,$728.00 ,$218.40 ,$662.48 ,$509.60 ,$218.40 ,$473.20 ,$524.16 ,$662.48 ,$546.00 
Carle BroMenn Medical Center,8970160,PUNCTR/ASPRTN FLUID,,10160,361,$605.00 ,$605.00 ,$181.50 ,$550.55 ,$423.50 ,$181.50 ,$393.25 ,$435.60 ,$550.55 ,$453.75 
Carle BroMenn Medical Center,8970180,I&D COMPLEX POSTOP WOUND INF,,10180,361,"$4,505.00 ","$4,505.00 ","$1,351.50 ","$4,099.55 ","$3,153.50 ","$1,351.50 ","$2,928.25 ","$3,243.60 ","$4,099.55 ","$3,378.75 "
Carle BroMenn Medical Center,8970199,CHANGE CHEST TUBE BILATERAL,,32999,361,$760.00 ,$760.00 ,$228.00 ,$691.60 ,$532.00 ,$228.00 ,$494.00 ,$547.20 ,$691.60 ,$570.00 
Carle BroMenn Medical Center,8970200,"RENAL BIOPSY, PERCUTANEOUS",,50200,361,"$1,170.00 ","$1,170.00 ",$351.00 ,"$1,064.70 ",$819.00 ,$351.00 ,$760.50 ,$842.40 ,"$1,064.70 ",$877.50 
Carle BroMenn Medical Center,8970201,PERQ SACRAL AUGMT BILAT INJ,,0201T,361,"$4,268.00 ","$4,268.00 ","$1,280.40 ","$3,883.88 ","$2,987.60 ","$1,280.40 ","$2,774.20 ","$3,072.96 ","$3,883.88 ","$3,201.00 "
Carle BroMenn Medical Center,8970205,INIRS EA VESSEL ADD-ON,,0205T,361,"$4,298.00 ","$4,298.00 ","$1,289.40 ","$3,911.18 ","$3,008.60 ","$1,289.40 ","$2,793.70 ","$3,094.56 ","$3,911.18 ","$3,223.50 "
Carle BroMenn Medical Center,8970206,"MUSCLE BIOPSY, PERCUTANEOUS",,20206,361,"$2,574.00 ","$2,574.00 ",$772.20 ,"$2,342.34 ","$1,801.80 ",$772.20 ,"$1,673.10 ","$1,853.28 ","$2,342.34 ","$1,930.50 "
Carle BroMenn Medical Center,8970220,"BONE BIOPSY, SUPERFICIAL",,20220,361,"$1,715.00 ","$1,715.00 ",$514.50 ,"$1,560.65 ","$1,200.50 ",$514.50 ,"$1,114.75 ","$1,234.80 ","$1,560.65 ","$1,286.25 "
Carle BroMenn Medical Center,8970225,"BONE BIOPSY, DEEP",,20225,361,"$2,307.50 ","$2,307.50 ",$692.25 ,"$2,099.83 ","$1,615.25 ",$692.25 ,"$1,499.88 ","$1,661.40 ","$2,099.83 ","$1,730.63 "
Carle BroMenn Medical Center,8970234,RENAL ARTERY ATHERECTOMY,,0234T,361,"$10,935.00 ","$10,935.00 ","$3,280.50 ","$9,950.85 ","$7,654.50 ","$3,280.50 ","$7,107.75 ","$7,873.20 ","$9,950.85 ","$8,201.25 "
Carle BroMenn Medical Center,8970235,VISCERAL ARTERY ATHERECTOMY,,0235T,361,"$9,180.00 ","$9,180.00 ","$2,754.00 ","$8,353.80 ","$6,426.00 ","$2,754.00 ","$5,967.00 ","$6,609.60 ","$8,353.80 ","$6,885.00 "
Carle BroMenn Medical Center,8970236,ABDOMINAL AORTA ATHERECTOMY,,0236T,361,"$8,528.00 ","$8,528.00 ","$2,558.40 ","$7,760.48 ","$5,969.60 ","$2,558.40 ","$5,543.20 ","$6,140.16 ","$7,760.48 ","$6,396.00 "
Carle BroMenn Medical Center,8970237,BRACHIOCEPHALIC ART ATHERECTMY,,0237T,361,"$8,528.00 ","$8,528.00 ","$2,558.40 ","$7,760.48 ","$5,969.60 ","$2,558.40 ","$5,543.20 ","$6,140.16 ","$7,760.48 ","$6,396.00 "
Carle BroMenn Medical Center,8970238,ILIAC ARTERY ATHERECTOMY,,0238T,361,"$12,000.00 ","$12,000.00 ","$3,600.00 ","$10,920.00 ","$8,400.00 ","$3,600.00 ","$7,800.00 ","$8,640.00 ","$10,920.00 ","$9,000.00 "
Carle BroMenn Medical Center,8970250,"BIOPSY VERTEBRAL BODY, OPEN; THORACIC",,20250,361,"$4,088.00 ","$4,088.00 ","$1,226.40 ","$3,720.08 ","$2,861.60 ","$1,226.40 ","$2,657.20 ","$2,943.36 ","$3,720.08 ","$3,066.00 "
Carle BroMenn Medical Center,8970299,PROCEDURE -VASC INJECTION,,36299,361,"$1,566.00 ","$1,566.00 ",$469.80 ,"$1,425.06 ","$1,096.20 ",$469.80 ,"$1,017.90 ","$1,127.52 ","$1,425.06 ","$1,174.50 "
Carle BroMenn Medical Center,8970382,REMV & REPLACE URETERAL STENT,,50382,361,"$2,843.00 ","$2,843.00 ",$852.90 ,"$2,587.13 ","$1,990.10 ",$852.90 ,"$1,847.95 ","$2,046.96 ","$2,587.13 ","$2,132.25 "
Carle BroMenn Medical Center,8970384,REMOVAL OF URETERAL STENT,,50384,361,"$3,038.00 ","$3,038.00 ",$911.40 ,"$2,764.58 ","$2,126.60 ",$911.40 ,"$1,974.70 ","$2,187.36 ","$2,764.58 ","$2,278.50 "
Carle BroMenn Medical Center,8970385,REMV & REPLACE URETERAL STENT,,50385,361,"$2,933.00 ","$2,933.00 ",$879.90 ,"$2,669.03 ","$2,053.10 ",$879.90 ,"$1,906.45 ","$2,111.76 ","$2,669.03 ","$2,199.75 "
Carle BroMenn Medical Center,8970386,REMOVAL OF URETERAL STENT,,50386,361,"$2,205.00 ","$2,205.00 ",$661.50 ,"$2,006.55 ","$1,543.50 ",$661.50 ,"$1,433.25 ","$1,587.60 ","$2,006.55 ","$1,653.75 "
Carle BroMenn Medical Center,8970387,CHANGE URETERAL STENT,,50387,361,"$1,688.00 ","$1,688.00 ",$506.40 ,"$1,536.08 ","$1,181.60 ",$506.40 ,"$1,097.20 ","$1,215.36 ","$1,536.08 ","$1,266.00 "
Carle BroMenn Medical Center,8970389,REMVL NEPHROSTMY TUBE W/FLUORO,,50389,361,"$1,340.00 ","$1,340.00 ",$402.00 ,"$1,219.40 ",$938.00 ,$402.00 ,$871.00 ,$964.80 ,"$1,219.40 ","$1,005.00 "
Carle BroMenn Medical Center,8970390,ASP/INJCT RENAL CYST/PELVIS,,50390,361,"$1,355.00 ","$1,355.00 ",$406.50 ,"$1,233.05 ",$948.50 ,$406.50 ,$880.75 ,$975.60 ,"$1,233.05 ","$1,016.25 "
Carle BroMenn Medical Center,8970391,INSTILL TX AGENT -RENAL PELVIS/URETER,,50391,361,$765.00 ,$765.00 ,$229.50 ,$696.15 ,$535.50 ,$229.50 ,$497.25 ,$550.80 ,$696.15 ,$573.75 
Carle BroMenn Medical Center,8970395,DILATE NEPHROSTOMY TRACT,,50395,361,"$3,503.00 ","$3,503.00 ","$1,050.90 ","$3,187.73 ","$2,452.10 ","$1,050.90 ","$2,276.95 ","$2,522.16 ","$3,187.73 ","$2,627.25 "
Carle BroMenn Medical Center,8970396,KIDNEY PRESSURE MEASUREMENTS,,50396,361,"$1,223.00 ","$1,223.00 ",$366.90 ,"$1,112.93 ",$856.10 ,$366.90 ,$794.95 ,$880.56 ,"$1,112.93 ",$917.25 
Carle BroMenn Medical Center,8970405,"IMG GUIDE CATH FLD CLCTN VISCERAL, PERQ",,49405,361,"$4,342.00 ","$4,342.00 ","$1,302.60 ","$3,951.22 ","$3,039.40 ","$1,302.60 ","$2,822.30 ","$3,126.24 ","$3,951.22 ","$3,256.50 "
Carle BroMenn Medical Center,8970406,"IMG GUIDE CATH FLD CLCTN PERI/RETRO, PERQ",,49406,361,"$2,230.00 ","$2,230.00 ",$669.00 ,"$2,029.30 ","$1,561.00 ",$669.00 ,"$1,449.50 ","$1,605.60 ","$2,029.30 ","$1,672.50 "
Carle BroMenn Medical Center,8970407,"IMG GUIDE CATH FLD CLCTN PERI/RETRO, TRNSVG/TRNSRCTL",,49407,361,"$4,342.00 ","$4,342.00 ","$1,302.60 ","$3,951.22 ","$3,039.40 ","$1,302.60 ","$2,822.30 ","$3,126.24 ","$3,951.22 ","$3,256.50 "
Carle BroMenn Medical Center,8970430,NJX PX ANTEGRDE NFROSGRM &/URTRGRM NEW ACCESS,,50430,361,"$1,110.00 ","$1,110.00 ",$333.00 ,"$1,010.10 ",$777.00 ,$333.00 ,$721.50 ,$799.20 ,"$1,010.10 ",$832.50 
Carle BroMenn Medical Center,8970431,NJX PX ANTEGRDE NFROSGRM &/URTRGRM EXSTNG ACESS,,50431,361,"$1,485.00 ","$1,485.00 ",$445.50 ,"$1,351.35 ","$1,039.50 ",$445.50 ,$965.25 ,"$1,069.20 ","$1,351.35 ","$1,113.75 "
Carle BroMenn Medical Center,8970432,PLMT NEPHROSTOMY CATH PRQ NEW ACCESS RS&I,,50432,361,"$3,615.00 ","$3,615.00 ","$1,084.50 ","$3,289.65 ","$2,530.50 ","$1,084.50 ","$2,349.75 ","$2,602.80 ","$3,289.65 ","$2,711.25 "
Carle BroMenn Medical Center,8970433,PLMT NEPHROURETERAL CATH PRQ NEW ACCESS RS&I,,50433,361,"$4,530.00 ","$4,530.00 ","$1,359.00 ","$4,122.30 ","$3,171.00 ","$1,359.00 ","$2,944.50 ","$3,261.60 ","$4,122.30 ","$3,397.50 "
Carle BroMenn Medical Center,8970434,CONVERT NEPHROSTOMY CATH TO NEPHROURTRL CATH PRQ,,50434,361,"$2,663.00 ","$2,663.00 ",$798.90 ,"$2,423.33 ","$1,864.10 ",$798.90 ,"$1,730.95 ","$1,917.36 ","$2,423.33 ","$1,997.25 "
Carle BroMenn Medical Center,8970435,EXCHANGE NEPHROSTOMY CATHETER PRQ W/IMG GID RS&I,,50435,361,"$1,485.00 ","$1,485.00 ",$445.50 ,"$1,351.35 ","$1,039.50 ",$445.50 ,$965.25 ,"$1,069.20 ","$1,351.35 ","$1,113.75 "
Carle BroMenn Medical Center,8970436,DLYD CRTN EXIT SITE CATH,,49436,361,"$3,105.00 ","$3,105.00 ",$931.50 ,"$2,825.55 ","$2,173.50 ",$931.50 ,"$2,018.25 ","$2,235.60 ","$2,825.55 ","$2,328.75 "
Carle BroMenn Medical Center,8970453,DILTN ESOPH OVER GUIDE WIRE,,43453,361,"$2,408.00 ","$2,408.00 ",$722.40 ,"$2,191.28 ","$1,685.60 ",$722.40 ,"$1,565.20 ","$1,733.76 ","$2,191.28 ","$1,806.00 "
Carle BroMenn Medical Center,8970501,INJECTION FOR SINOGRAM,,20501,361,$430.00 ,$430.00 ,$129.00 ,$391.30 ,$301.00 ,$129.00 ,$279.50 ,$309.60 ,$391.30 ,$322.50 
Carle BroMenn Medical Center,8970520,REMOVAL OF FOREIGN BODY,,20520,361,"$1,155.00 ","$1,155.00 ",$346.50 ,"$1,051.05 ",$808.50 ,$346.50 ,$750.75 ,$831.60 ,"$1,051.05 ",$866.25 
Carle BroMenn Medical Center,8970575,REPAIR CVC W/O PORT/PUMP,,36575,361,"$1,845.00 ","$1,845.00 ",$553.50 ,"$1,678.95 ","$1,291.50 ",$553.50 ,"$1,199.25 ","$1,328.40 ","$1,678.95 ","$1,383.75 "
Carle BroMenn Medical Center,8970589,RMVL TNNLD CVC W/O PORT/PUMP,,36589,361,"$1,845.00 ","$1,845.00 ",$553.50 ,"$1,678.95 ","$1,291.50 ",$553.50 ,"$1,199.25 ","$1,328.40 ","$1,678.95 ","$1,383.75 "
Carle BroMenn Medical Center,8970592,RADIOFREQUENCY ABLATION -RENAL,,50592,361,"$9,997.00 ","$9,997.00 ","$2,999.10 ","$9,097.27 ","$6,997.90 ","$2,999.10 ","$6,498.05 ","$7,197.84 ","$9,097.27 ","$7,497.75 "
Carle BroMenn Medical Center,8970605,INJ WRIST JOINT,,20605,361,$830.00 ,$830.00 ,$249.00 ,$755.30 ,$581.00 ,$249.00 ,$539.50 ,$597.60 ,$755.30 ,$622.50 
Carle BroMenn Medical Center,8970606,PR ENDOLUMINAL BX URTR &/RNL PELVIS NONENDOSCOPIC,,50606,361,"$1,920.00 ","$1,920.00 ",$576.00 ,"$1,747.20 ","$1,344.00 ",$576.00 ,"$1,248.00 ","$1,382.40 ","$1,747.20 ","$1,440.00 "
Carle BroMenn Medical Center,8970610,INJ MAJOR JOINT,,20610,361,$630.00 ,$630.00 ,$189.00 ,$573.30 ,$441.00 ,$189.00 ,$409.50 ,$453.60 ,$573.30 ,$472.50 
Carle BroMenn Medical Center,8970611,ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US,,20611,361,$760.00 ,$760.00 ,$228.00 ,$691.60 ,$532.00 ,$228.00 ,$494.00 ,$547.20 ,$691.60 ,$570.00 
Carle BroMenn Medical Center,8970615,ASPIR/INJEC BONE CYST,,20615,361,$422.50 ,$422.50 ,$126.75 ,$384.48 ,$295.75 ,$126.75 ,$274.63 ,$304.20 ,$384.48 ,$316.88 
Carle BroMenn Medical Center,8970684,INJECT FOR URETERO/PYELOGRAPHY,,50684,361,$443.00 ,$443.00 ,$132.90 ,$403.13 ,$310.10 ,$132.90 ,$287.95 ,$318.96 ,$403.13 ,$332.25 
Carle BroMenn Medical Center,8970688,CHANGE URETER TUBE/STENT,,50688,361,"$1,515.00 ","$1,515.00 ",$454.50 ,"$1,378.65 ","$1,060.50 ",$454.50 ,$984.75 ,"$1,090.80 ","$1,378.65 ","$1,136.25 "
Carle BroMenn Medical Center,8970690,INJCT ILEAL COND/URETROPYELGRM,,50690,361,"$1,055.00 ","$1,055.00 ",$316.50 ,$960.05 ,$738.50 ,$316.50 ,$685.75 ,$759.60 ,$960.05 ,$791.25 
Carle BroMenn Medical Center,8970693,PR PLMT URTRL STENT PRQ PRE-EXISTING NFROS TRACT,,50693,361,"$3,375.00 ","$3,375.00 ","$1,012.50 ","$3,071.25 ","$2,362.50 ","$1,012.50 ","$2,193.75 ","$2,430.00 ","$3,071.25 ","$2,531.25 "
Carle BroMenn Medical Center,8970694,PR PLMT URTRL STNT PRQ NEW ACESS W/O SEP NFROS CATH,,50694,361,"$4,410.00 ","$4,410.00 ","$1,323.00 ","$4,013.10 ","$3,087.00 ","$1,323.00 ","$2,866.50 ","$3,175.20 ","$4,013.10 ","$3,307.50 "
Carle BroMenn Medical Center,8970695,PR PLMT URTRL STENT PRQ NEW ACCESS W/SEP NFROS CATH,,50695,361,"$4,530.00 ","$4,530.00 ","$1,359.00 ","$4,122.30 ","$3,171.00 ","$1,359.00 ","$2,944.50 ","$3,261.60 ","$4,122.30 ","$3,397.50 "
Carle BroMenn Medical Center,8970699,PROCEDURE -ENDOCRINE SYSTEM,,60699,361,"$6,402.50 ","$6,402.50 ","$1,920.75 ","$5,826.28 ","$4,481.75 ","$1,920.75 ","$4,161.63 ","$4,609.80 ","$5,826.28 ","$4,801.88 "
Carle BroMenn Medical Center,8970705,PR URETERAL EMBOLIZATION/OCCLUSION W/IMG GID RS&I,,50705,361,"$2,453.00 ","$2,453.00 ",$735.90 ,"$2,232.23 ","$1,717.10 ",$735.90 ,"$1,594.45 ","$1,766.16 ","$2,232.23 ","$1,839.75 "
Carle BroMenn Medical Center,8970706,PR BALLOON DILAT URETERAL STRICTURE W/IMG GID RS&I,,50706,361,"$2,295.00 ","$2,295.00 ",$688.50 ,"$2,088.45 ","$1,606.50 ",$688.50 ,"$1,491.75 ","$1,652.40 ","$2,088.45 ","$1,721.25 "
Carle BroMenn Medical Center,8970982,ABLTN BONE TUMOR(S) RFQ PERCT W/CT GUIDE,,20982,361,"$9,023.00 ","$9,023.00 ","$2,706.90 ","$8,210.93 ","$6,316.10 ","$2,706.90 ","$5,864.95 ","$6,496.56 ","$8,210.93 ","$6,767.25 "
Carle BroMenn Medical Center,8970999,RMVL CHEST TUBE,,32999,361,$760.00 ,$760.00 ,$228.00 ,$691.60 ,$532.00 ,$228.00 ,$494.00 ,$547.20 ,$691.60 ,$570.00 
Carle BroMenn Medical Center,8971006,FINE NEEDLE ASPIRATION BX W/US GDN EA ADDL,,10006,361,$560.00 ,$560.00 ,$168.00 ,$509.60 ,$392.00 ,$168.00 ,$364.00 ,$403.20 ,$509.60 ,$420.00 
Carle BroMenn Medical Center,8971009,FINE NEEDLE ASPIRATION BX W/CT GDN 1ST LESION,,10009,361,"$1,560.00 ","$1,560.00 ",$468.00 ,"$1,419.60 ","$1,092.00 ",$468.00 ,"$1,014.00 ","$1,123.20 ","$1,419.60 ","$1,170.00 "
Carle BroMenn Medical Center,8971010,CATHETER PLACEMENT IN SVC/IVC,,36010,361,$923.00 ,$923.00 ,$276.90 ,$839.93 ,$646.10 ,$276.90 ,$599.95 ,$664.56 ,$839.93 ,$692.25 
Carle BroMenn Medical Center,8971011,SELECT CATH - 1ST ORDER VEIN,,36011,361,$893.00 ,$893.00 ,$267.90 ,$812.63 ,$625.10 ,$267.90 ,$580.45 ,$642.96 ,$812.63 ,$669.75 
Carle BroMenn Medical Center,8971012,SELECT CATH - 2ND ORDER/>VEIN,,36012,361,$983.00 ,$983.00 ,$294.90 ,$894.53 ,$688.10 ,$294.90 ,$638.95 ,$707.76 ,$894.53 ,$737.25 
Carle BroMenn Medical Center,8971030,IMG GD FLUID CLCTN DRAIN BY CATH SOFT TISSUE PERCUT,,10030,361,"$1,891.50 ","$1,891.50 ",$567.45 ,"$1,721.27 ","$1,324.05 ",$567.45 ,"$1,229.48 ","$1,361.88 ","$1,721.27 ","$1,418.63 "
Carle BroMenn Medical Center,8971042,"DEBRIDEMENT, SKIN, SUB-Q TISSUE; 1RST 20 SQ CM OR <",,11042,361,$965.00 ,$965.00 ,$289.50 ,$878.15 ,$675.50 ,$289.50 ,$627.25 ,$694.80 ,$878.15 ,$723.75 
Carle BroMenn Medical Center,8971043,"DEBRIDEMENT, MUSC/FASCIA; 1RST 20 SQ CM OR <",,11043,361,"$1,495.00 ","$1,495.00 ",$448.50 ,"$1,360.45 ","$1,046.50 ",$448.50 ,$971.75 ,"$1,076.40 ","$1,360.45 ","$1,121.25 "
Carle BroMenn Medical Center,8971044,"DEBRIDEMENT, BONE; 1RST 20 SQ CM OR <",,11044,361,"$4,080.00 ","$4,080.00 ","$1,224.00 ","$3,712.80 ","$2,856.00 ","$1,224.00 ","$2,652.00 ","$2,937.60 ","$3,712.80 ","$3,060.00 "
Carle BroMenn Medical Center,8971045,"DEBRIDEMENT, SUBQ; EA ADD 20 SQ CM OR PART OF",,11045,361,$410.00 ,$410.00 ,$123.00 ,$373.10 ,$287.00 ,$123.00 ,$266.50 ,$295.20 ,$373.10 ,$307.50 
Carle BroMenn Medical Center,8971046,"DEBRIDEMENT, MUSC/FASCIA; EA ADD 20 SQ CM OR PART OF",,11046,361,$410.00 ,$410.00 ,$123.00 ,$373.10 ,$287.00 ,$123.00 ,$266.50 ,$295.20 ,$373.10 ,$307.50 
Carle BroMenn Medical Center,8971047,"DEBRIDEMENT, BONE; EA ADD 20 SQ CM OR PART OF",,11047,361,"$1,410.00 ","$1,410.00 ",$423.00 ,"$1,283.10 ",$987.00 ,$423.00 ,$916.50 ,"$1,015.20 ","$1,283.10 ","$1,057.50 "
Carle BroMenn Medical Center,8971060,DRAIN SKIN ABSCESS SIMPLE,,10060,361,$675.00 ,$675.00 ,$202.50 ,$614.25 ,$472.50 ,$202.50 ,$438.75 ,$486.00 ,$614.25 ,$506.25 
Carle BroMenn Medical Center,8971082,RMVL NON-BIODEGRADALBE DRUG DELV IMPLNT,,11982,361,$165.00 ,$165.00 ,$49.50 ,$150.15 ,$115.50 ,$49.50 ,$107.25 ,$118.80 ,$150.15 ,$123.75 
Carle BroMenn Medical Center,8971100,INTRO NDL/CATH CAROTID/VERT,,36100,361,$780.00 ,$780.00 ,$234.00 ,$709.80 ,$546.00 ,$234.00 ,$507.00 ,$561.60 ,$709.80 ,$585.00 
Carle BroMenn Medical Center,8971101,ASPIRATION -BLADDER,,51101,361,$720.00 ,$720.00 ,$216.00 ,$655.20 ,$504.00 ,$216.00 ,$468.00 ,$518.40 ,$655.20 ,$540.00 
Carle BroMenn Medical Center,8971102,ASPIRATE BLADDER W/CATH INSERT,,51102,361,"$1,345.00 ","$1,345.00 ",$403.50 ,"$1,223.95 ",$941.50 ,$403.50 ,$874.25 ,$968.40 ,"$1,223.95 ","$1,008.75 "
Carle BroMenn Medical Center,8971105,FINE NEEDLE ASPIRATION BX W/US GDN 1ST LSN,,10005,361,"$1,200.00 ","$1,200.00 ",$360.00 ,"$1,092.00 ",$840.00 ,$360.00 ,$780.00 ,$864.00 ,"$1,092.00 ",$900.00 
Carle BroMenn Medical Center,8971140,INTRO NDL/INTRACATH EXT ARTERY,,36140,361,$728.00 ,$728.00 ,$218.40 ,$662.48 ,$509.60 ,$218.40 ,$473.20 ,$524.16 ,$662.48 ,$546.00 
Carle BroMenn Medical Center,8971160,INTRO NDL/CATH AORTA -TRNSLMBR,,36160,361,"$1,163.00 ","$1,163.00 ",$348.90 ,"$1,058.33 ",$814.10 ,$348.90 ,$755.95 ,$837.36 ,"$1,058.33 ",$872.25 
Carle BroMenn Medical Center,8971184,PERCUTANEOUS THROMBECTOMY PRIM,,37184,361,"$6,968.00 ","$6,968.00 ","$2,090.40 ","$6,340.88 ","$4,877.60 ","$2,090.40 ","$4,529.20 ","$5,016.96 ","$6,340.88 ","$5,226.00 "
Carle BroMenn Medical Center,8971185,PERCUTANEOUS THROMBECTOMY,,37185,361,"$5,820.00 ","$5,820.00 ","$1,746.00 ","$5,296.20 ","$4,074.00 ","$1,746.00 ","$3,783.00 ","$4,190.40 ","$5,296.20 ","$4,365.00 "
Carle BroMenn Medical Center,8971186,THROMBECTOMY,,37186,361,"$2,610.00 ","$2,610.00 ",$783.00 ,"$2,375.10 ","$1,827.00 ",$783.00 ,"$1,696.50 ","$1,879.20 ","$2,375.10 ","$1,957.50 "
Carle BroMenn Medical Center,8971187,VENOUS THROMBECTOMY,,37187,361,"$5,775.00 ","$5,775.00 ","$1,732.50 ","$5,255.25 ","$4,042.50 ","$1,732.50 ","$3,753.75 ","$4,158.00 ","$5,255.25 ","$4,331.25 "
Carle BroMenn Medical Center,8971188,VENOUS THROMBECTOMY,,37188,361,"$5,948.00 ","$5,948.00 ","$1,784.40 ","$5,412.68 ","$4,163.60 ","$1,784.40 ","$3,866.20 ","$4,282.56 ","$5,412.68 ","$4,461.00 "
Carle BroMenn Medical Center,8971197,TRNSCATH RETRIEVL FOREIGN BODY,,37197,361,"$5,705.00 ","$5,705.00 ","$1,711.50 ","$5,191.55 ","$3,993.50 ","$1,711.50 ","$3,708.25 ","$4,107.60 ","$5,191.55 ","$4,278.75 "
Carle BroMenn Medical Center,8971200,NON-SELECTIVE CATH - AORTA,,36200,361,"$1,275.00 ","$1,275.00 ",$382.50 ,"$1,160.25 ",$892.50 ,$382.50 ,$828.75 ,$918.00 ,"$1,160.25 ",$956.25 
Carle BroMenn Medical Center,8971211,TRANSCATH ART INF THROMBOLYSIS -INIT,,37211,361,"$4,658.00 ","$4,658.00 ","$1,397.40 ","$4,238.78 ","$3,260.60 ","$1,397.40 ","$3,027.70 ","$3,353.76 ","$4,238.78 ","$3,493.50 "
Carle BroMenn Medical Center,8971212,TRANSCATH VENOUS INF THROMBOLYSIS -INIT,,37212,361,"$4,658.00 ","$4,658.00 ","$1,397.40 ","$4,238.78 ","$3,260.60 ","$1,397.40 ","$3,027.70 ","$3,353.76 ","$4,238.78 ","$3,493.50 "
Carle BroMenn Medical Center,8971213,TRANSCATH INF THROMBOLYSIS - SUBSEQ,,37213,361,"$4,373.00 ","$4,373.00 ","$1,311.90 ","$3,979.43 ","$3,061.10 ","$1,311.90 ","$2,842.45 ","$3,148.56 ","$3,979.43 ","$3,279.75 "
Carle BroMenn Medical Center,8971214,TRANSCATH INF THROMBOLYSIS - CESSATN,,37214,361,"$3,450.00 ","$3,450.00 ","$1,035.00 ","$3,139.50 ","$2,415.00 ","$1,035.00 ","$2,242.50 ","$2,484.00 ","$3,139.50 ","$2,587.50 "
Carle BroMenn Medical Center,8971215,SELECT CATH - 1ST ORDER ARTERY,,36215,361,"$1,733.00 ","$1,733.00 ",$519.90 ,"$1,577.03 ","$1,213.10 ",$519.90 ,"$1,126.45 ","$1,247.76 ","$1,577.03 ","$1,299.75 "
Carle BroMenn Medical Center,8971216,SELECT CATH - 2ND ORDER ARTERY,,36216,361,"$1,733.00 ","$1,733.00 ",$519.90 ,"$1,577.03 ","$1,213.10 ",$519.90 ,"$1,126.45 ","$1,247.76 ","$1,577.03 ","$1,299.75 "
Carle BroMenn Medical Center,8971217,SELECT CATH - 3RD ORDER ARTERY,,36217,361,"$1,995.00 ","$1,995.00 ",$598.50 ,"$1,815.45 ","$1,396.50 ",$598.50 ,"$1,296.75 ","$1,436.40 ","$1,815.45 ","$1,496.25 "
Carle BroMenn Medical Center,8971218,SELECT CATH ADNL 2ND/3RD ORDER,,36218,361,$945.00 ,$945.00 ,$283.50 ,$859.95 ,$661.50 ,$283.50 ,$614.25 ,$680.40 ,$859.95 ,$708.75 
Carle BroMenn Medical Center,8971225,BONE BIOPSY DEEP,,20225,361,"$2,307.50 ","$2,307.50 ",$692.25 ,"$2,099.83 ","$1,615.25 ",$692.25 ,"$1,499.88 ","$1,661.40 ","$2,099.83 ","$1,730.63 "
Carle BroMenn Medical Center,8971236,OPEN/PERQ PLC STENT 1RST ARTERY,,37236,361,"$20,340.00 ","$20,340.00 ","$6,102.00 ","$18,509.40 ","$14,238.00 ","$6,102.00 ","$13,221.00 ","$14,644.80 ","$18,509.40 ","$15,255.00 "
Carle BroMenn Medical Center,8971237,OPEN/PERQ PLC STENT EA ADD ARTERY,,37237,361,"$9,848.00 ","$9,848.00 ","$2,954.40 ","$8,961.68 ","$6,893.60 ","$2,954.40 ","$6,401.20 ","$7,090.56 ","$8,961.68 ","$7,386.00 "
Carle BroMenn Medical Center,8971238,"OPEN/PERQ PLC STENT SAME, INITIAL VEIN",,37238,361,"$20,340.00 ","$20,340.00 ","$6,102.00 ","$18,509.40 ","$14,238.00 ","$6,102.00 ","$13,221.00 ","$14,644.80 ","$18,509.40 ","$15,255.00 "
Carle BroMenn Medical Center,8971239,OPEN/PERQ PLC STENT EA ADD VEIN,,37239,361,"$9,848.00 ","$9,848.00 ","$2,954.40 ","$8,961.68 ","$6,893.60 ","$2,954.40 ","$6,401.20 ","$7,090.56 ","$8,961.68 ","$7,386.00 "
Carle BroMenn Medical Center,8971245,SELECT CATH 1ST ORDER ARTERY,,36245,361,"$2,130.00 ","$2,130.00 ",$639.00 ,"$1,938.30 ","$1,491.00 ",$639.00 ,"$1,384.50 ","$1,533.60 ","$1,938.30 ","$1,597.50 "
Carle BroMenn Medical Center,8971246,SELECT CATH 2ND ORDER ARTERY,,36246,361,"$2,420.00 ","$2,420.00 ",$726.00 ,"$2,202.20 ","$1,694.00 ",$726.00 ,"$1,573.00 ","$1,742.40 ","$2,202.20 ","$1,815.00 "
Carle BroMenn Medical Center,8971247,SLECT CATH 3RD ORDER ARTERY,,36247,361,"$2,048.00 ","$2,048.00 ",$614.40 ,"$1,863.68 ","$1,433.60 ",$614.40 ,"$1,331.20 ","$1,474.56 ","$1,863.68 ","$1,536.00 "
Carle BroMenn Medical Center,8971248,SELECT CATH 2ND/3RD ORD ARTERY,,36248,361,$578.00 ,$578.00 ,$173.40 ,$525.98 ,$404.60 ,$173.40 ,$375.70 ,$416.16 ,$525.98 ,$433.50 
Carle BroMenn Medical Center,8971252,"CATH RENAL SELECTIVE W/ S&I, BILAT",,36252,361,"$4,590.00 ","$4,590.00 ","$1,377.00 ","$4,176.90 ","$3,213.00 ","$1,377.00 ","$2,983.50 ","$3,304.80 ","$4,176.90 ","$3,442.50 "
Carle BroMenn Medical Center,8971269,"SPINAL CORD BIOPSY, PERCUT NDL",,62269,361,$975.00 ,$975.00 ,$292.50 ,$887.25 ,$682.50 ,$292.50 ,$633.75 ,$702.00 ,$887.25 ,$731.25 
Carle BroMenn Medical Center,8971270,LUMBAR PUNCTURE,,62270,361,"$1,035.00 ","$1,035.00 ",$310.50 ,$941.85 ,$724.50 ,$310.50 ,$672.75 ,$745.20 ,$941.85 ,$776.25 
Carle BroMenn Medical Center,8971299,PROCEDURE -VASC INJECTION,,36299,361,"$1,566.00 ","$1,566.00 ",$469.80 ,"$1,425.06 ","$1,096.20 ",$469.80 ,"$1,017.90 ","$1,127.52 ","$1,425.06 ","$1,174.50 "
Carle BroMenn Medical Center,8971400,BX SALIVARY GLAND; NEEDLE,,42400,361,"$1,455.00 ","$1,455.00 ",$436.50 ,"$1,324.05 ","$1,018.50 ",$436.50 ,$945.75 ,"$1,047.60 ","$1,324.05 ","$1,091.25 "
Carle BroMenn Medical Center,8971406,"IMG GUIDE CATH FLD CLCTN PERI/RETRO, PERQ",,49406,361,"$2,230.00 ","$2,230.00 ",$669.00 ,"$2,029.30 ","$1,561.00 ",$669.00 ,"$1,449.50 ","$1,605.60 ","$2,029.30 ","$1,672.50 "
Carle BroMenn Medical Center,8971419,INSRTN PERITNL CATH W/PORT,,49419,361,"$6,660.00 ","$6,660.00 ","$1,998.00 ","$6,060.60 ","$4,662.00 ","$1,998.00 ","$4,329.00 ","$4,795.20 ","$6,060.60 ","$4,995.00 "
Carle BroMenn Medical Center,8971425,INSRTN PERITONEAL-VENOUS SHUNT,,49425,361,"$5,730.00 ","$5,730.00 ","$1,719.00 ","$5,214.30 ","$4,011.00 ","$1,719.00 ","$3,724.50 ","$4,125.60 ","$5,214.30 ","$4,297.50 "
Carle BroMenn Medical Center,8971500,INTUBATION -ENDOTRACHEAL EMERG,,31500,361,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8971554,THORACENTESIS W/O IMAGING,,32554,361,"$1,795.00 ","$1,795.00 ",$538.50 ,"$1,633.45 ","$1,256.50 ",$538.50 ,"$1,166.75 ","$1,292.40 ","$1,633.45 ","$1,346.25 "
Carle BroMenn Medical Center,8971555,THORACENTESIS W/IMAGING,,32555,361,"$2,105.00 ","$2,105.00 ",$631.50 ,"$1,915.55 ","$1,473.50 ",$631.50 ,"$1,368.25 ","$1,515.60 ","$1,915.55 ","$1,578.75 "
Carle BroMenn Medical Center,8971556,PERC PLEURAL DRAINAGE W/O IMAGING,,32556,361,"$1,830.00 ","$1,830.00 ",$549.00 ,"$1,665.30 ","$1,281.00 ",$549.00 ,"$1,189.50 ","$1,317.60 ","$1,665.30 ","$1,372.50 "
Carle BroMenn Medical Center,8971557,PERC PLEURAL DRAINAGE W/IMAGING,,32557,361,"$1,845.00 ","$1,845.00 ",$553.50 ,"$1,678.95 ","$1,291.50 ",$553.50 ,"$1,199.25 ","$1,328.40 ","$1,678.95 ","$1,383.75 "
Carle BroMenn Medical Center,8971576,REPAIR CVC W/PORT/PUMP,,36576,361,"$1,140.00 ","$1,140.00 ",$342.00 ,"$1,037.40 ",$798.00 ,$342.00 ,$741.00 ,$820.80 ,"$1,037.40 ",$855.00 
Carle BroMenn Medical Center,8971600,INJECTION FOR CYSTOGRAM/VCUG,,51600,361,$645.00 ,$645.00 ,$193.50 ,$586.95 ,$451.50 ,$193.50 ,$419.25 ,$464.40 ,$586.95 ,$483.75 
Carle BroMenn Medical Center,8971602,EXCISION CH WAL TUM W/RIB W/O MEDSTNL LYMPHADEC,,21602,361,"$5,468.00 ","$5,468.00 ","$1,640.40 ","$4,975.88 ","$3,827.60 ","$1,640.40 ","$3,554.20 ","$3,936.96 ","$4,975.88 ","$4,101.00 "
Carle BroMenn Medical Center,8971603,EXCISION CH WAL TUM W/RIB W/MEDSTNL LYMPHADEC,,21603,361,"$6,075.00 ","$6,075.00 ","$1,822.50 ","$5,528.25 ","$4,252.50 ","$1,822.50 ","$3,948.75 ","$4,374.00 ","$5,528.25 ","$4,556.25 "
Carle BroMenn Medical Center,8971606,ARTHROCENTESIS ASPIR&/INJ INTERM JT/BURS W/US,,20606,361,"$1,041.00 ","$1,041.00 ",$312.30 ,$947.31 ,$728.70 ,$312.30 ,$676.65 ,$749.52 ,$947.31 ,$780.75 
Carle BroMenn Medical Center,8971610,INJECTION FOR URETHROCYSTOGRAM,,51610,361,$395.00 ,$395.00 ,$118.50 ,$359.45 ,$276.50 ,$118.50 ,$256.75 ,$284.40 ,$359.45 ,$296.25 
Carle BroMenn Medical Center,8971623,TEMP BALLOON OCCL HD/NECK ART,,61623,361,"$8,100.00 ","$8,100.00 ","$2,430.00 ","$7,371.00 ","$5,670.00 ","$2,430.00 ","$5,265.00 ","$5,832.00 ","$7,371.00 ","$6,075.00 "
Carle BroMenn Medical Center,8971624,TRANSCATH OCCL/EMBOL CNS,,61624,361,"$3,390.00 ","$3,390.00 ","$1,017.00 ","$3,084.90 ","$2,373.00 ","$1,017.00 ","$2,203.50 ","$2,440.80 ","$3,084.90 ","$2,542.50 "
Carle BroMenn Medical Center,8971626,TRANSCATH OCCL/EMBOL HEAD/NECK,,61626,361,"$12,675.00 ","$12,675.00 ","$3,802.50 ","$11,534.25 ","$8,872.50 ","$3,802.50 ","$8,238.75 ","$9,126.00 ","$11,534.25 ","$9,506.25 "
Carle BroMenn Medical Center,8971630,PTA INTRACRANIAL VESSEL,,61630,361,"$7,800.00 ","$7,800.00 ","$2,340.00 ","$7,098.00 ","$5,460.00 ","$2,340.00 ","$5,070.00 ","$5,616.00 ","$7,098.00 ","$5,850.00 "
Carle BroMenn Medical Center,8971635,TRNSCTH PLCMNT STENT INTRACRAN,,61635,361,"$8,325.00 ","$8,325.00 ","$2,497.50 ","$7,575.75 ","$5,827.50 ","$2,497.50 ","$5,411.25 ","$5,994.00 ","$7,575.75 ","$6,243.75 "
Carle BroMenn Medical Center,8971640,DILATION INTRACRAN VASOSPASM,,61640,361,"$8,723.00 ","$8,723.00 ","$2,616.90 ","$7,937.93 ","$6,106.10 ","$2,616.90 ","$5,669.95 ","$6,280.56 ","$7,937.93 ","$6,542.25 "
Carle BroMenn Medical Center,8971641,DILATN INTRACRAN VASOSPSM ADNL,,61641,361,"$6,848.00 ","$6,848.00 ","$2,054.40 ","$6,231.68 ","$4,793.60 ","$2,054.40 ","$4,451.20 ","$4,930.56 ","$6,231.68 ","$5,136.00 "
Carle BroMenn Medical Center,8971642,DILATN INTRACRAN VASOSPSM ADNL,,61642,361,"$7,478.00 ","$7,478.00 ","$2,243.40 ","$6,804.98 ","$5,234.60 ","$2,243.40 ","$4,860.70 ","$5,384.16 ","$6,804.98 ","$5,608.50 "
Carle BroMenn Medical Center,8971645,PERCUT ART THRMBCTOMY INTRCRNL,,61645,361,"$11,085.00 ","$11,085.00 ","$3,325.50 ","$10,087.35 ","$7,759.50 ","$3,325.50 ","$7,205.25 ","$7,981.20 ","$10,087.35 ","$8,313.75 "
Carle BroMenn Medical Center,8971700,IRRIGATION OF BLADDER,,51700,361,$780.00 ,$780.00 ,$234.00 ,$709.80 ,$546.00 ,$234.00 ,$507.00 ,$561.60 ,$709.80 ,$585.00 
Carle BroMenn Medical Center,8971705,"CHANGE CYSTOSTOMY TUBE, SIMPLE",,51705,361,$780.00 ,$780.00 ,$234.00 ,$709.80 ,$546.00 ,$234.00 ,$507.00 ,$561.60 ,$709.80 ,$585.00 
Carle BroMenn Medical Center,8971710,"CHANGE CYSTOSTOMY TUBE, COMPL",,51710,361,"$1,245.00 ","$1,245.00 ",$373.50 ,"$1,132.95 ",$871.50 ,$373.50 ,$809.25 ,$896.40 ,"$1,132.95 ",$933.75 
Carle BroMenn Medical Center,8971774,ANGIO EA ADNL AFTER BASIC S&I,,75774,361,"$2,805.00 ","$2,805.00 ",$841.50 ,"$2,552.55 ","$1,963.50 ",$841.50 ,"$1,823.25 ","$2,019.60 ","$2,552.55 ","$2,103.75 "
Carle BroMenn Medical Center,8971937,US GUIDED VASC ACCESS,,76937,361,$315.00 ,$315.00 ,$94.50 ,$286.65 ,$220.50 ,$94.50 ,$204.75 ,$226.80 ,$286.65 ,$236.25 
Carle BroMenn Medical Center,8971942,US GUIDED NDL PLACEMENT,,76942,361,$535.00 ,$535.00 ,$160.50 ,$486.85 ,$374.50 ,$160.50 ,$347.75 ,$385.20 ,$486.85 ,$401.25 
Carle BroMenn Medical Center,8971976,RMVL IMPLNT CNTRCPTV CPSLS,,11976,361,$815.00 ,$815.00 ,$244.50 ,$741.65 ,$570.50 ,$244.50 ,$529.75 ,$586.80 ,$741.65 ,$611.25 
Carle BroMenn Medical Center,8971982,ABLTN BONE TUMOR(S) RFQ PERCT W/CT GUIDE,,20982,361,"$9,023.00 ","$9,023.00 ","$2,706.90 ","$8,210.93 ","$6,316.10 ","$2,706.90 ","$5,864.95 ","$6,496.56 ","$8,210.93 ","$6,767.25 "
Carle BroMenn Medical Center,8971999,CHANGE CHEST TUBE UNILATERAL,,32999,361,$760.00 ,$760.00 ,$228.00 ,$691.60 ,$532.00 ,$228.00 ,$494.00 ,$547.20 ,$691.60 ,$570.00 
Carle BroMenn Medical Center,8972020,TREATMENT OF SPLIT WOUND,,12020,361,"$1,630.00 ","$1,630.00 ",$489.00 ,"$1,483.30 ","$1,141.00 ",$489.00 ,"$1,059.50 ","$1,173.60 ","$1,483.30 ","$1,222.50 "
Carle BroMenn Medical Center,8972030,IMG GD FLUID CLCTN DRAIN BY CATH SOFT TISSUE PERCUT,,10030,361,"$1,891.50 ","$1,891.50 ",$567.45 ,"$1,721.27 ","$1,324.05 ",$567.45 ,"$1,229.48 ","$1,361.88 ","$1,721.27 ","$1,418.63 "
Carle BroMenn Medical Center,8972031,"LAYR CLOS WND TRUNK,ARM,LEG <2.5 CM",,12031,361,"$1,110.00 ","$1,110.00 ",$333.00 ,"$1,010.10 ",$777.00 ,$333.00 ,$721.50 ,$799.20 ,"$1,010.10 ",$832.50 
Carle BroMenn Medical Center,8972032,"RPR INTRMD WND SCLP, AXL, TRNK, EXT 2.6 TO 7.5CM",,12032,361,"$1,290.00 ","$1,290.00 ",$387.00 ,"$1,173.90 ",$903.00 ,$387.00 ,$838.50 ,$928.80 ,"$1,173.90 ",$967.50 
Carle BroMenn Medical Center,8972060,DRAIN SKIN ABSCESS SIMPLE,,10060,361,$675.00 ,$675.00 ,$202.50 ,$614.25 ,$472.50 ,$202.50 ,$438.75 ,$486.00 ,$614.25 ,$506.25 
Carle BroMenn Medical Center,8972100,"THYROID BIOPSY, PERC CORE NDL",,60100,361,"$1,183.00 ","$1,183.00 ",$354.90 ,"$1,076.53 ",$828.10 ,$354.90 ,$768.95 ,$851.76 ,"$1,076.53 ",$887.25 
Carle BroMenn Medical Center,8972140,INCISION/DRAINAGE FLUID,,10140,361,"$3,160.00 ","$3,160.00 ",$948.00 ,"$2,875.60 ","$2,212.00 ",$948.00 ,"$2,054.00 ","$2,275.20 ","$2,875.60 ","$2,370.00 "
Carle BroMenn Medical Center,8972160,PUNCTR/ASPRTN FLUID,,10160,361,$605.00 ,$605.00 ,$181.50 ,$550.55 ,$423.50 ,$181.50 ,$393.25 ,$435.60 ,$550.55 ,$453.75 
Carle BroMenn Medical Center,8972200,PERQ SACRAL AUGMT UNILAT INJ,,0200T,361,"$4,245.00 ","$4,245.00 ","$1,273.50 ","$3,862.95 ","$2,971.50 ","$1,273.50 ","$2,759.25 ","$3,056.40 ","$3,862.95 ","$3,183.75 "
Carle BroMenn Medical Center,8972206,"MUSCLE BIOPSY, PERCUTANEOUS",,20206,361,"$2,574.00 ","$2,574.00 ",$772.20 ,"$2,342.34 ","$1,801.80 ",$772.20 ,"$1,673.10 ","$1,853.28 ","$2,342.34 ","$1,930.50 "
Carle BroMenn Medical Center,8972225,VERTEBRAL ANGIOGRPHY W/WO ARCH -UNI,,36225,361,"$7,073.00 ","$7,073.00 ","$2,121.90 ","$6,436.43 ","$4,951.10 ","$2,121.90 ","$4,597.45 ","$5,092.56 ","$6,436.43 ","$5,304.75 "
Carle BroMenn Medical Center,8972250,CHEMICAL CAUTERIZATION GRANULATION TISSUE,,17250,361,$415.00 ,$415.00 ,$124.50 ,$377.65 ,$290.50 ,$124.50 ,$269.75 ,$298.80 ,$377.65 ,$311.25 
Carle BroMenn Medical Center,8972269,"SPINAL CORD BIOPSY, PERCUT NDL",,62269,361,$975.00 ,$975.00 ,$292.50 ,$887.25 ,$682.50 ,$292.50 ,$633.75 ,$702.00 ,$887.25 ,$731.25 
Carle BroMenn Medical Center,8972270,LUMBAR PUNCTURE,,62270,361,"$1,035.00 ","$1,035.00 ",$310.50 ,$941.85 ,$724.50 ,$310.50 ,$672.75 ,$745.20 ,$941.85 ,$776.25 
Carle BroMenn Medical Center,8972284,INJECTION -MYELOGRAPHY- SPINAL,,62284,361,$580.00 ,$580.00 ,$174.00 ,$527.80 ,$406.00 ,$174.00 ,$377.00 ,$417.60 ,$527.80 ,$435.00 
Carle BroMenn Medical Center,8972290,INJECTION -DISKOGRAPHY -LUMBAR,,62290,361,"$1,385.00 ","$1,385.00 ",$415.50 ,"$1,260.35 ",$969.50 ,$415.50 ,$900.25 ,$997.20 ,"$1,260.35 ","$1,038.75 "
Carle BroMenn Medical Center,8972400,"BIOPSY, PLEURA",,32400,361,"$2,925.00 ","$2,925.00 ",$877.50 ,"$2,661.75 ","$2,047.50 ",$877.50 ,"$1,901.25 ","$2,106.00 ","$2,661.75 ","$2,193.75 "
Carle BroMenn Medical Center,8972405,"BIOPSY, LUNG/MEDIASTINUM",,32405,361,"$2,040.00 ","$2,040.00 ",$612.00 ,"$1,856.40 ","$1,428.00 ",$612.00 ,"$1,326.00 ","$1,468.80 ","$1,856.40 ","$1,530.00 "
Carle BroMenn Medical Center,8972408,CORE NEEDLE BX LUNG/MEDIASTINUM PERQ W/IMG,,32408,361,"$3,495.00 ","$3,495.00 ","$1,048.50 ","$3,180.45 ","$2,446.50 ","$1,048.50 ","$2,271.75 ","$2,516.40 ","$3,180.45 ","$2,621.25 "
Carle BroMenn Medical Center,8972551,TUBE THORACOSTOMY,,32551,361,"$1,400.00 ","$1,400.00 ",$420.00 ,"$1,274.00 ",$980.00 ,$420.00 ,$910.00 ,"$1,008.00 ","$1,274.00 ","$1,050.00 "
Carle BroMenn Medical Center,8972552,RMV TUNNLD PLEURAL CATH W/CUFF,,32552,361,$570.00 ,$570.00 ,$171.00 ,$518.70 ,$399.00 ,$171.00 ,$370.50 ,$410.40 ,$518.70 ,$427.50 
Carle BroMenn Medical Center,8972554,THORACENTESIS W/O IMAGING,,32554,361,"$1,795.00 ","$1,795.00 ",$538.50 ,"$1,633.45 ","$1,256.50 ",$538.50 ,"$1,166.75 ","$1,292.40 ","$1,633.45 ","$1,346.25 "
Carle BroMenn Medical Center,8972555,THORACENTESIS W/IMAGING,,32555,361,"$2,105.00 ","$2,105.00 ",$631.50 ,"$1,915.55 ","$1,473.50 ",$631.50 ,"$1,368.25 ","$1,515.60 ","$1,915.55 ","$1,578.75 "
Carle BroMenn Medical Center,8972556,PERC PLEURAL DRAINAGE W/O IMAGING,,32556,361,"$1,830.00 ","$1,830.00 ",$549.00 ,"$1,665.30 ","$1,281.00 ",$549.00 ,"$1,189.50 ","$1,317.60 ","$1,665.30 ","$1,372.50 "
Carle BroMenn Medical Center,8972557,PERC PLEURAL DRAINAGE W/IMAGING,,32557,361,"$1,845.00 ","$1,845.00 ",$553.50 ,"$1,678.95 ","$1,291.50 ",$553.50 ,"$1,199.25 ","$1,328.40 ","$1,678.95 ","$1,383.75 "
Carle BroMenn Medical Center,8972560,INSTILL AGENT FOR PLEURODESIS (VIA CHEST TUBE/CATH),,32560,361,$975.00 ,$975.00 ,$292.50 ,$887.25 ,$682.50 ,$292.50 ,$633.75 ,$702.00 ,$887.25 ,$731.25 
Carle BroMenn Medical Center,8972624,TRANSCATH OCCL/EMBOL CNS,,61624,361,"$3,390.00 ","$3,390.00 ","$1,017.00 ","$3,084.90 ","$2,373.00 ","$1,017.00 ","$2,203.50 ","$2,440.80 ","$3,084.90 ","$2,542.50 "
Carle BroMenn Medical Center,8972626,TRANSCATH OCCL/EMBOL HEAD/NECK,,61626,361,"$12,675.00 ","$12,675.00 ","$3,802.50 ","$11,534.25 ","$8,872.50 ","$3,802.50 ","$8,238.75 ","$9,126.00 ","$11,534.25 ","$9,506.25 "
Carle BroMenn Medical Center,8972999,PROCEDURE -LUNGS/PLEURA,,32999,361,$760.00 ,$760.00 ,$228.00 ,$691.60 ,$532.00 ,$228.00 ,$494.00 ,$547.20 ,$691.60 ,$570.00 
Carle BroMenn Medical Center,8973010,PERICARDIOCENTESIS,,33010,361,"$1,193.00 ","$1,193.00 ",$357.90 ,"$1,085.63 ",$835.10 ,$357.90 ,$775.45 ,$858.96 ,"$1,085.63 ",$894.75 
Carle BroMenn Medical Center,8973011,"PERICARDIOCENTESIS, SUBSQ",,33011,361,"$1,140.00 ","$1,140.00 ",$342.00 ,"$1,037.40 ",$798.00 ,$342.00 ,$741.00 ,$820.80 ,"$1,037.40 ",$855.00 
Carle BroMenn Medical Center,8973015,TUBE PERICARDIOSTOMY,,33015,361,"$5,040.00 ","$5,040.00 ","$1,512.00 ","$4,586.40 ","$3,528.00 ","$1,512.00 ","$3,276.00 ","$3,628.80 ","$4,586.40 ","$3,780.00 "
Carle BroMenn Medical Center,8973016,PERICARDIOCENTESIS W/IMG GUIDANCE WHEN PERFORMED,,33016,361,"$1,545.00 ","$1,545.00 ",$463.50 ,"$1,405.95 ","$1,081.50 ",$463.50 ,"$1,004.25 ","$1,112.40 ","$1,405.95 ","$1,158.75 "
Carle BroMenn Medical Center,8973017,PERQ PRCRD DRG 6YR+ W/O CONGENITAL CAR ANOMALY,,33017,361,"$4,748.00 ","$4,748.00 ","$1,424.40 ","$4,320.68 ","$3,323.60 ","$1,424.40 ","$3,086.20 ","$3,418.56 ","$4,320.68 ","$3,561.00 "
Carle BroMenn Medical Center,8973018,PERQ PRCRD DRG 0-5YR/ANY AGE W/CGEN CAR ANOMALY,,33018,361,"$5,040.00 ","$5,040.00 ","$1,512.00 ","$4,586.40 ","$3,528.00 ","$1,512.00 ","$3,276.00 ","$3,628.80 ","$4,586.40 ","$3,780.00 "
Carle BroMenn Medical Center,8973019,PERQ PERICARDIAL DRG W/INSJ NDWELLG CATH W/CT,,33019,361,"$4,035.00 ","$4,035.00 ","$1,210.50 ","$3,671.85 ","$2,824.50 ","$1,210.50 ","$2,622.75 ","$2,905.20 ","$3,671.85 ","$3,026.25 "
Carle BroMenn Medical Center,8973030,IMG GD FLUID CLCTN DRAIN BY CATH SOFT TISSUE PERCUT,,10030,361,"$1,891.50 ","$1,891.50 ",$567.45 ,"$1,721.27 ","$1,324.05 ",$567.45 ,"$1,229.48 ","$1,361.88 ","$1,721.27 ","$1,418.63 "
Carle BroMenn Medical Center,8973060,DRAIN SKIN ABSCESS SIMPLE,,10060,361,$675.00 ,$675.00 ,$202.50 ,$614.25 ,$472.50 ,$202.50 ,$438.75 ,$486.00 ,$614.25 ,$506.25 
Carle BroMenn Medical Center,8973160,PUNCTR/ASPRTN FLUID,,10160,361,$605.00 ,$605.00 ,$181.50 ,$550.55 ,$423.50 ,$181.50 ,$393.25 ,$435.60 ,$550.55 ,$453.75 
Carle BroMenn Medical Center,8973200,"RENAL BIOPSY, PERCUTANEOUS",,50200,361,"$1,170.00 ","$1,170.00 ",$351.00 ,"$1,064.70 ",$819.00 ,$351.00 ,$760.50 ,$842.40 ,"$1,064.70 ",$877.50 
Carle BroMenn Medical Center,8973274,TCAT INSJ/RPL PERM LEADLESS PACEMAKER RV W/IMG,,33274,361,"$30,350.00 ","$30,350.00 ","$9,105.00 ","$27,618.50 ","$21,245.00 ","$9,105.00 ","$19,727.50 ","$21,852.00 ","$27,618.50 ","$22,762.50 "
Carle BroMenn Medical Center,8973299,PROCEDURE -VASC INJECTION,,36299,361,"$1,566.00 ","$1,566.00 ",$469.80 ,"$1,425.06 ","$1,096.20 ",$469.80 ,"$1,017.90 ","$1,127.52 ","$1,425.06 ","$1,174.50 "
Carle BroMenn Medical Center,8973315,TUBE PERICARDIOSTOMY,,33015,361,"$5,040.00 ","$5,040.00 ","$1,512.00 ","$4,586.40 ","$3,528.00 ","$1,512.00 ","$3,276.00 ","$3,628.80 ","$4,586.40 ","$3,780.00 "
Carle BroMenn Medical Center,8973400,BX SALIVARY GLAND; NEEDLE,,42400,361,"$1,455.00 ","$1,455.00 ",$436.50 ,"$1,324.05 ","$1,018.50 ",$436.50 ,$945.75 ,"$1,047.60 ","$1,324.05 ","$1,091.25 "
Carle BroMenn Medical Center,8973762,PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC,,43762,361,$500.00 ,$500.00 ,$150.00 ,$455.00 ,$350.00 ,$150.00 ,$325.00 ,$360.00 ,$455.00 ,$375.00 
Carle BroMenn Medical Center,8973910,"MEDIASTINOTOMY W/EXPL/DRAIN/RMVL FB/BX, TRANSTHOR W/STERNOTOMY",,39010,361,"$7,245.00 ","$7,245.00 ","$2,173.50 ","$6,592.95 ","$5,071.50 ","$2,173.50 ","$4,709.25 ","$5,216.40 ","$6,592.95 ","$5,433.75 "
Carle BroMenn Medical Center,8974002,PROCEDURE - ABD/PERIT/OMNTM,,49999,361,"$1,550.00 ","$1,550.00 ",$465.00 ,"$1,410.50 ","$1,085.00 ",$465.00 ,"$1,007.50 ","$1,116.00 ","$1,410.50 ","$1,162.50 "
Carle BroMenn Medical Center,8974003,BALLOON COMPRESSION RHIZOTOMY,,64999,361,$578.50 ,$578.50 ,$173.55 ,$526.44 ,$404.95 ,$173.55 ,$376.03 ,$416.52 ,$526.44 ,$433.88 
Carle BroMenn Medical Center,8974082,"ABDOMINAL PARACENTESIS, W/O IMAGING",,49082,361,$965.00 ,$965.00 ,$289.50 ,$878.15 ,$675.50 ,$289.50 ,$627.25 ,$694.80 ,$878.15 ,$723.75 
Carle BroMenn Medical Center,8974083,"ABDOMINAL PARACENTESIS, W/ IMAGING",,49083,361,"$3,003.00 ","$3,003.00 ",$900.90 ,"$2,732.73 ","$2,102.10 ",$900.90 ,"$1,951.95 ","$2,162.16 ","$2,732.73 ","$2,252.25 "
Carle BroMenn Medical Center,8974084,PERITONEAL LAVAGE W/WO IMAGING,,49084,361,"$2,730.00 ","$2,730.00 ",$819.00 ,"$2,484.30 ","$1,911.00 ",$819.00 ,"$1,774.50 ","$1,965.60 ","$2,484.30 ","$2,047.50 "
Carle BroMenn Medical Center,8974102,"BIOPSY, PANCREAS",,48102,361,"$2,265.90 ","$2,265.90 ",$679.77 ,"$2,061.97 ","$1,586.13 ",$679.77 ,"$1,472.84 ","$1,631.45 ","$2,061.97 ","$1,699.43 "
Carle BroMenn Medical Center,8974180,"BIOPSY, ABD/RETROPERITONL MASS",,49180,361,"$2,756.00 ","$2,756.00 ",$826.80 ,"$2,507.96 ","$1,929.20 ",$826.80 ,"$1,791.40 ","$1,984.32 ","$2,507.96 ","$2,067.00 "
Carle BroMenn Medical Center,8974280,"BIOPSY, ABD/RETROPERITONL MASS",,49180,361,"$2,756.00 ","$2,756.00 ",$826.80 ,"$2,507.96 ","$1,929.20 ",$826.80 ,"$1,791.40 ","$1,984.32 ","$2,507.96 ","$2,067.00 "
Carle BroMenn Medical Center,8974382,RADIOFREQUENCY ABLATION -LIVER,,47382,361,"$9,997.00 ","$9,997.00 ","$2,999.10 ","$9,097.27 ","$6,997.90 ","$2,999.10 ","$6,498.05 ","$7,197.84 ","$9,097.27 ","$7,497.75 "
Carle BroMenn Medical Center,8974400,INJCT AIR/CNTRST PERITNEAL CAV,,49400,361,$638.00 ,$638.00 ,$191.40 ,$580.58 ,$446.60 ,$191.40 ,$414.70 ,$459.36 ,$580.58 ,$478.50 
Carle BroMenn Medical Center,8974418,INSRTN PERITONL CATH W/O PORT,,49418,361,"$8,170.50 ","$8,170.50 ","$2,451.15 ","$7,435.16 ","$5,719.35 ","$2,451.15 ","$5,310.83 ","$5,882.76 ","$7,435.16 ","$6,127.88 "
Carle BroMenn Medical Center,8974421,INSERTION -ABDOMINAL DRAIN,,49421,361,"$3,600.00 ","$3,600.00 ","$1,080.00 ","$3,276.00 ","$2,520.00 ","$1,080.00 ","$2,340.00 ","$2,592.00 ","$3,276.00 ","$2,700.00 "
Carle BroMenn Medical Center,8974423,CHANGE DRAINAGE CATHETER,,49423,361,"$3,605.00 ","$3,605.00 ","$1,081.50 ","$3,280.55 ","$2,523.50 ","$1,081.50 ","$2,343.25 ","$2,595.60 ","$3,280.55 ","$2,703.75 "
Carle BroMenn Medical Center,8974424,INJECT DRAINAGE CATHETER,,49424,361,$515.00 ,$515.00 ,$154.50 ,$468.65 ,$360.50 ,$154.50 ,$334.75 ,$370.80 ,$468.65 ,$386.25 
Carle BroMenn Medical Center,8974426,RVSN PERITONEAL-VENOUS SHUNT,,49426,361,"$5,063.00 ","$5,063.00 ","$1,518.90 ","$4,607.33 ","$3,544.10 ","$1,518.90 ","$3,290.95 ","$3,645.36 ","$4,607.33 ","$3,797.25 "
Carle BroMenn Medical Center,8974427,INJECTION PROCEDURE SHUNT EVAL,,49427,361,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8974428,LIGATION PERITONEAL-VENOUS SHUNT,,49428,361,"$3,863.00 ","$3,863.00 ","$1,158.90 ","$3,515.33 ","$2,704.10 ","$1,158.90 ","$2,510.95 ","$2,781.36 ","$3,515.33 ","$2,897.25 "
Carle BroMenn Medical Center,8974429,RMVL PERITONEAL-VENOUS SHUNT,,49429,361,"$3,578.00 ","$3,578.00 ","$1,073.40 ","$3,255.98 ","$2,504.60 ","$1,073.40 ","$2,325.70 ","$2,576.16 ","$3,255.98 ","$2,683.50 "
Carle BroMenn Medical Center,8974435,INSRT SUBQ EXT INTRAPERIT CATH,,49435,361,"$2,070.00 ","$2,070.00 ",$621.00 ,"$1,883.70 ","$1,449.00 ",$621.00 ,"$1,345.50 ","$1,490.40 ","$1,883.70 ","$1,552.50 "
Carle BroMenn Medical Center,8974440,GASTROSTOMY TUBE PLACEMENT,,49440,361,"$2,762.50 ","$2,762.50 ",$828.75 ,"$2,513.88 ","$1,933.75 ",$828.75 ,"$1,795.63 ","$1,989.00 ","$2,513.88 ","$2,071.88 "
Carle BroMenn Medical Center,8974441,INSERT DUODEN/JEJUNOSTOMY TUBE,,49441,361,"$2,340.00 ","$2,340.00 ",$702.00 ,"$2,129.40 ","$1,638.00 ",$702.00 ,"$1,521.00 ","$1,684.80 ","$2,129.40 ","$1,755.00 "
Carle BroMenn Medical Center,8974442,INSERT CECOSTOMY/COLONIC TUBE,,49442,361,"$1,673.00 ","$1,673.00 ",$501.90 ,"$1,522.43 ","$1,171.10 ",$501.90 ,"$1,087.45 ","$1,204.56 ","$1,522.43 ","$1,254.75 "
Carle BroMenn Medical Center,8974446,CONVERT G-TUBE TO G-J-TUBE,,49446,361,"$2,340.00 ","$2,340.00 ",$702.00 ,"$2,129.40 ","$1,638.00 ",$702.00 ,"$1,521.00 ","$1,684.80 ","$2,129.40 ","$1,755.00 "
Carle BroMenn Medical Center,8974450,REPLAC GASTROSTMY/COLONIC TUBE,,49450,361,"$2,100.00 ","$2,100.00 ",$630.00 ,"$1,911.00 ","$1,470.00 ",$630.00 ,"$1,365.00 ","$1,512.00 ","$1,911.00 ","$1,575.00 "
Carle BroMenn Medical Center,8974451,REPLAC DUODEN/JEJUNOSTOMY TUBE,,49451,361,"$1,735.00 ","$1,735.00 ",$520.50 ,"$1,578.85 ","$1,214.50 ",$520.50 ,"$1,127.75 ","$1,249.20 ","$1,578.85 ","$1,301.25 "
Carle BroMenn Medical Center,8974452,REPLAC GASTRO-JEJUNOSTOMY TUBE,,49452,361,"$1,760.00 ","$1,760.00 ",$528.00 ,"$1,601.60 ","$1,232.00 ",$528.00 ,"$1,144.00 ","$1,267.20 ","$1,601.60 ","$1,320.00 "
Carle BroMenn Medical Center,8974460,REMV OBSTRCT FRM GI-OSTMY TUBE,,49460,361,$930.00 ,$930.00 ,$279.00 ,$846.30 ,$651.00 ,$279.00 ,$604.50 ,$669.60 ,$846.30 ,$697.50 
Carle BroMenn Medical Center,8974465,EVALUATN GI-OSTOMY TUBE,,49465,361,$655.00 ,$655.00 ,$196.50 ,$596.05 ,$458.50 ,$196.50 ,$425.75 ,$471.60 ,$596.05 ,$491.25 
Carle BroMenn Medical Center,8974490,PERCUTANEOUS CHOLECYSTOSTOMY,,47490,361,"$5,928.00 ","$5,928.00 ","$1,778.40 ","$5,394.48 ","$4,149.60 ","$1,778.40 ","$3,853.20 ","$4,268.16 ","$5,394.48 ","$4,446.00 "
Carle BroMenn Medical Center,8974500,INTRODUCTION LONG GI TUBE,,44500,361,"$1,534.00 ","$1,534.00 ",$460.20 ,"$1,395.94 ","$1,073.80 ",$460.20 ,$997.10 ,"$1,104.48 ","$1,395.94 ","$1,150.50 "
Carle BroMenn Medical Center,8974531,NJX CHOLANGIO PRQ W/IMG GID RS&I EXISTING ACCESS,,47531,361,"$1,655.00 ","$1,655.00 ",$496.50 ,"$1,506.05 ","$1,158.50 ",$496.50 ,"$1,075.75 ","$1,191.60 ","$1,506.05 ","$1,241.25 "
Carle BroMenn Medical Center,8974533,PRQ PLMT BILIARY DRG CATH W/IMG GID RS&I EXTERNL,,47533,361,"$4,665.00 ","$4,665.00 ","$1,399.50 ","$4,245.15 ","$3,265.50 ","$1,399.50 ","$3,032.25 ","$3,358.80 ","$4,245.15 ","$3,498.75 "
Carle BroMenn Medical Center,8974534,PRQ PLMT BILIARY DRG CATH W/IMG GID RS&I INT-EXT,,47534,361,"$4,665.00 ","$4,665.00 ","$1,399.50 ","$4,245.15 ","$3,265.50 ","$1,399.50 ","$3,032.25 ","$3,358.80 ","$4,245.15 ","$3,498.75 "
Carle BroMenn Medical Center,8974535,CONV EXT BIL DRG CATH TO INT-EXT BIL DRG CATH,,47535,361,"$5,483.00 ","$5,483.00 ","$1,644.90 ","$4,989.53 ","$3,838.10 ","$1,644.90 ","$3,563.95 ","$3,947.76 ","$4,989.53 ","$4,112.25 "
Carle BroMenn Medical Center,8974536,EXCHANGE BILIARY DRG CATHETER PRQ W/IMG GID RS&I,,47536,361,"$4,665.00 ","$4,665.00 ","$1,399.50 ","$4,245.15 ","$3,265.50 ","$1,399.50 ","$3,032.25 ","$3,358.80 ","$4,245.15 ","$3,498.75 "
Carle BroMenn Medical Center,8974537,REMOVAL BILIARY DRG CATHETER REQ FLUOR GID RS&I,,47537,361,"$1,890.00 ","$1,890.00 ",$567.00 ,"$1,719.90 ","$1,323.00 ",$567.00 ,"$1,228.50 ","$1,360.80 ","$1,719.90 ","$1,417.50 "
Carle BroMenn Medical Center,8974538,PLMT BILE DUCT STENT PRQ EXISTING ACCESS,,47538,361,"$8,798.00 ","$8,798.00 ","$2,639.40 ","$8,006.18 ","$6,158.60 ","$2,639.40 ","$5,718.70 ","$6,334.56 ","$8,006.18 ","$6,598.50 "
Carle BroMenn Medical Center,8974539,PLMT BILE DUCT STENT PRQ NEW ACCESS W/O SEP CATH,,47539,361,"$10,343.00 ","$10,343.00 ","$3,102.90 ","$9,412.13 ","$7,240.10 ","$3,102.90 ","$6,722.95 ","$7,446.96 ","$9,412.13 ","$7,757.25 "
Carle BroMenn Medical Center,8974540,PLMT BILE DUCT STENT PRQ NEW ACCESS W/SEP CATH,,47540,361,"$10,343.00 ","$10,343.00 ","$3,102.90 ","$9,412.13 ","$7,240.10 ","$3,102.90 ","$6,722.95 ","$7,446.96 ","$9,412.13 ","$7,757.25 "
Carle BroMenn Medical Center,8974541,PLMT ACCESS THRU BILIARY TREE INTO SMALL BWL NEW,,47541,361,"$5,483.00 ","$5,483.00 ","$1,644.90 ","$4,989.53 ","$3,838.10 ","$1,644.90 ","$3,563.95 ","$3,947.76 ","$4,989.53 ","$4,112.25 "
Carle BroMenn Medical Center,8974542,BALLOON DILAT BILIARY DUCT/AMPULLA PRQ EACH DUCT,,47542,361,"$1,740.00 ","$1,740.00 ",$522.00 ,"$1,583.40 ","$1,218.00 ",$522.00 ,"$1,131.00 ","$1,252.80 ","$1,583.40 ","$1,305.00 "
Carle BroMenn Medical Center,8974543,ENDOLUMINAL BX BILIARY TREE PRQ ANY METH SNG/MLT,,47543,361,"$2,183.00 ","$2,183.00 ",$654.90 ,"$1,986.53 ","$1,528.10 ",$654.90 ,"$1,418.95 ","$1,571.76 ","$1,986.53 ","$1,637.25 "
Carle BroMenn Medical Center,8974544,REMOVAL BILIARY DUCT &/GLBLDR CALCULI PERQ RS&I,,47544,361,"$2,730.00 ","$2,730.00 ",$819.00 ,"$2,484.30 ","$1,911.00 ",$819.00 ,"$1,774.50 ","$1,965.60 ","$2,484.30 ","$2,047.50 "
Carle BroMenn Medical Center,8974553,BILIARY BIOPSY -SINGLE OR MULT,,47553,361,"$4,260.00 ","$4,260.00 ","$1,278.00 ","$3,876.60 ","$2,982.00 ","$1,278.00 ","$2,769.00 ","$3,067.20 ","$3,876.60 ","$3,195.00 "
Carle BroMenn Medical Center,8974555,DILATION BILE DUCT W/O STENT,,47555,361,"$2,340.00 ","$2,340.00 ",$702.00 ,"$2,129.40 ","$1,638.00 ",$702.00 ,"$1,521.00 ","$1,684.80 ","$2,129.40 ","$1,755.00 "
Carle BroMenn Medical Center,8974556,DILATION BILE DUCT W/STENT,,47556,361,"$3,465.00 ","$3,465.00 ","$1,039.50 ","$3,153.15 ","$2,425.50 ","$1,039.50 ","$2,252.25 ","$2,494.80 ","$3,153.15 ","$2,598.75 "
Carle BroMenn Medical Center,8974700,"BIOPSY, LIVER",,47000,361,"$2,596.10 ","$2,596.10 ",$778.83 ,"$2,362.45 ","$1,817.27 ",$778.83 ,"$1,687.47 ","$1,869.19 ","$2,362.45 ","$1,947.08 "
Carle BroMenn Medical Center,8974710,"BIOPSY, LIVER",,47000,361,"$2,596.10 ","$2,596.10 ",$778.83 ,"$2,362.45 ","$1,817.27 ",$778.83 ,"$1,687.47 ","$1,869.19 ","$2,362.45 ","$1,947.08 "
Carle BroMenn Medical Center,8974752,NASO-/ORO-GASTRIC TUBE PLCMNT,,43752,361,$510.00 ,$510.00 ,$153.00 ,$464.10 ,$357.00 ,$153.00 ,$331.50 ,$367.20 ,$464.10 ,$382.50 
Carle BroMenn Medical Center,8974761,REPOSITION FEEDING TUBE,,43761,361,$668.00 ,$668.00 ,$200.40 ,$607.88 ,$467.60 ,$200.40 ,$434.20 ,$480.96 ,$607.88 ,$501.00 
Carle BroMenn Medical Center,8974918,SCLEROTHERAPY FLUID COLLECITON PRQ W/IMG GID,,49185,361,"$5,910.00 ","$5,910.00 ","$1,773.00 ","$5,378.10 ","$4,137.00 ","$1,773.00 ","$3,841.50 ","$4,255.20 ","$5,378.10 ","$4,432.50 "
Carle BroMenn Medical Center,8975080,PERC RENL CALCLS RMVL UP TO 2CM,,50080,361,"$7,613.00 ","$7,613.00 ","$2,283.90 ","$6,927.83 ","$5,329.10 ","$2,283.90 ","$4,948.45 ","$5,481.36 ","$6,927.83 ","$5,709.75 "
Carle BroMenn Medical Center,8975081,PERC RENL CALCLS RMVL OVER 2CM,,50081,361,"$11,160.00 ","$11,160.00 ","$3,348.00 ","$10,155.60 ","$7,812.00 ","$3,348.00 ","$7,254.00 ","$8,035.20 ","$10,155.60 ","$8,370.00 "
Carle BroMenn Medical Center,8975100,ASPIRATION -BLADDER,,51100,361,$908.00 ,$908.00 ,$272.40 ,$826.28 ,$635.60 ,$272.40 ,$590.20 ,$653.76 ,$826.28 ,$681.00 
Carle BroMenn Medical Center,8975102,"BIOPSY, PANCREAS",,48102,361,"$2,265.90 ","$2,265.90 ",$679.77 ,"$2,061.97 ","$1,586.13 ",$679.77 ,"$1,472.84 ","$1,631.45 ","$2,061.97 ","$1,699.43 "
Carle BroMenn Medical Center,8975700,"PROSTATE BIOPSY, NEEDLE/PUNCH",,55700,361,"$2,684.50 ","$2,684.50 ",$805.35 ,"$2,442.90 ","$1,879.15 ",$805.35 ,"$1,744.93 ","$1,932.84 ","$2,442.90 ","$2,013.38 "
Carle BroMenn Medical Center,8975999,PROCEDURE -FEMALE GENITAL SYSTM (NON-OB),,58999,361,"$2,085.00 ","$2,085.00 ",$625.50 ,"$1,897.35 ","$1,459.50 ",$625.50 ,"$1,355.25 ","$1,501.20 ","$1,897.35 ","$1,563.75 "
Carle BroMenn Medical Center,8976000,INTRO NEEDLE/INTRACATH   -VEIN,,36000,361,$170.00 ,$170.00 ,$51.00 ,$154.70 ,$119.00 ,$51.00 ,$110.50 ,$122.40 ,$154.70 ,$127.50 
Carle BroMenn Medical Center,8976002,THROMBIN INJCT PSEUODOANEURYSM,,36002,361,$920.00 ,$920.00 ,$276.00 ,$837.20 ,$644.00 ,$276.00 ,$598.00 ,$662.40 ,$837.20 ,$690.00 
Carle BroMenn Medical Center,8976005,INJECT FOR EXTREMITY VENOGRAM,,36005,361,$840.00 ,$840.00 ,$252.00 ,$764.40 ,$588.00 ,$252.00 ,$546.00 ,$604.80 ,$764.40 ,$630.00 
Carle BroMenn Medical Center,8976010,CATHETER PLACEMENT IN SVC/IVC,,36010,361,$923.00 ,$923.00 ,$276.90 ,$839.93 ,$646.10 ,$276.90 ,$599.95 ,$664.56 ,$839.93 ,$692.25 
Carle BroMenn Medical Center,8976011,SELECT CATH - 1ST ORDER VEIN,,36011,361,$893.00 ,$893.00 ,$267.90 ,$812.63 ,$625.10 ,$267.90 ,$580.45 ,$642.96 ,$812.63 ,$669.75 
Carle BroMenn Medical Center,8976012,SELECT CATH - 2ND ORDER/>VEIN,,36012,361,$983.00 ,$983.00 ,$294.90 ,$894.53 ,$688.10 ,$294.90 ,$638.95 ,$707.76 ,$894.53 ,$737.25 
Carle BroMenn Medical Center,8976013,CATH PLCMNT RT HRT/MN PLM ART,,36013,361,"$1,163.00 ","$1,163.00 ",$348.90 ,"$1,058.33 ",$814.10 ,$348.90 ,$755.95 ,$837.36 ,"$1,058.33 ",$872.25 
Carle BroMenn Medical Center,8976014,CATH PLCMNT LT/RT PULM ARTERY,,36014,361,"$1,380.00 ","$1,380.00 ",$414.00 ,"$1,255.80 ",$966.00 ,$414.00 ,$897.00 ,$993.60 ,"$1,255.80 ","$1,035.00 "
Carle BroMenn Medical Center,8976015,CATH PLCMNT SEGMNTL PULM ART,,36015,361,"$1,298.00 ","$1,298.00 ",$389.40 ,"$1,181.18 ",$908.60 ,$389.40 ,$843.70 ,$934.56 ,"$1,181.18 ",$973.50 
Carle BroMenn Medical Center,8976100,INTRO NDL/CATH CAROTID/VERT,,36100,361,$780.00 ,$780.00 ,$234.00 ,$709.80 ,$546.00 ,$234.00 ,$507.00 ,$561.60 ,$709.80 ,$585.00 
Carle BroMenn Medical Center,8976105,INJECT FOR EXTREMITY VENOGRAM,,36005,361,$840.00 ,$840.00 ,$252.00 ,$764.40 ,$588.00 ,$252.00 ,$546.00 ,$604.80 ,$764.40 ,$630.00 
Carle BroMenn Medical Center,8976140,INTRO NDL/INTRACATH EXT ARTERY,,36140,361,$728.00 ,$728.00 ,$218.40 ,$662.48 ,$509.60 ,$218.40 ,$473.20 ,$524.16 ,$662.48 ,$546.00 
Carle BroMenn Medical Center,8976160,INTRO NDL/CATH AORTA -TRNSLMBR,,36160,361,"$1,163.00 ","$1,163.00 ",$348.90 ,"$1,058.33 ",$814.10 ,$348.90 ,$755.95 ,$837.36 ,"$1,058.33 ",$872.25 
Carle BroMenn Medical Center,8976200,NON-SELECTIVE CATH - AORTA,,36200,361,"$1,275.00 ","$1,275.00 ",$382.50 ,"$1,160.25 ",$892.50 ,$382.50 ,$828.75 ,$918.00 ,"$1,160.25 ",$956.25 
Carle BroMenn Medical Center,8976215,SELECT CATH - 1ST ORDER ARTERY,,36215,361,"$1,733.00 ","$1,733.00 ",$519.90 ,"$1,577.03 ","$1,213.10 ",$519.90 ,"$1,126.45 ","$1,247.76 ","$1,577.03 ","$1,299.75 "
Carle BroMenn Medical Center,8976216,SELECT CATH - 2ND ORDER ARTERY,,36216,361,"$1,733.00 ","$1,733.00 ",$519.90 ,"$1,577.03 ","$1,213.10 ",$519.90 ,"$1,126.45 ","$1,247.76 ","$1,577.03 ","$1,299.75 "
Carle BroMenn Medical Center,8976217,SELECT CATH - 3RD ORDER ARTERY,,36217,361,"$1,995.00 ","$1,995.00 ",$598.50 ,"$1,815.45 ","$1,396.50 ",$598.50 ,"$1,296.75 ","$1,436.40 ","$1,815.45 ","$1,496.25 "
Carle BroMenn Medical Center,8976218,SELECT CATH ADNL 2ND/3RD ORDER,,36218,361,$945.00 ,$945.00 ,$283.50 ,$859.95 ,$661.50 ,$283.50 ,$614.25 ,$680.40 ,$859.95 ,$708.75 
Carle BroMenn Medical Center,8976221,ANGIO CERVICOCEREBRAL (ARCH),,36221,361,"$4,290.00 ","$4,290.00 ","$1,287.00 ","$3,903.90 ","$3,003.00 ","$1,287.00 ","$2,788.50 ","$3,088.80 ","$3,903.90 ","$3,217.50 "
Carle BroMenn Medical Center,8976222,CERVICAL CAROTID ANGIO W/WO ARCH -UNI,,36222,361,"$7,635.00 ","$7,635.00 ","$2,290.50 ","$6,947.85 ","$5,344.50 ","$2,290.50 ","$4,962.75 ","$5,497.20 ","$6,947.85 ","$5,726.25 "
Carle BroMenn Medical Center,8976223,CEREBRL ANGIO W/WO EXT CAROTD/ARCH -UNI,,36223,361,"$10,530.00 ","$10,530.00 ","$3,159.00 ","$9,582.30 ","$7,371.00 ","$3,159.00 ","$6,844.50 ","$7,581.60 ","$9,582.30 ","$7,897.50 "
Carle BroMenn Medical Center,8976224,CEREBRL ANGIO W/WO EXT CAROTD/ARCH -UNI,,36224,361,"$12,458.00 ","$12,458.00 ","$3,737.40 ","$11,336.78 ","$8,720.60 ","$3,737.40 ","$8,097.70 ","$8,969.76 ","$11,336.78 ","$9,343.50 "
Carle BroMenn Medical Center,8976225,VERTEBRAL ANGIOGRPHY W/WO ARCH -UNI,,36225,361,"$7,073.00 ","$7,073.00 ","$2,121.90 ","$6,436.43 ","$4,951.10 ","$2,121.90 ","$4,597.45 ","$5,092.56 ","$6,436.43 ","$5,304.75 "
Carle BroMenn Medical Center,8976226,VERTEBRAL ANGIOGRPHY W/WO ARCH -UNI,,36226,361,"$8,460.00 ","$8,460.00 ","$2,538.00 ","$7,698.60 ","$5,922.00 ","$2,538.00 ","$5,499.00 ","$6,091.20 ","$7,698.60 ","$6,345.00 "
Carle BroMenn Medical Center,8976227,EXTERNAL CAROTID ANGIOGRPHY -UNI,,36227,361,"$5,933.00 ","$5,933.00 ","$1,779.90 ","$5,399.03 ","$4,153.10 ","$1,779.90 ","$3,856.45 ","$4,271.76 ","$5,399.03 ","$4,449.75 "
Carle BroMenn Medical Center,8976228,CEREBRAL OR VERTEBRAL ANGIOGRPHY -UNI,,36228,361,"$4,298.00 ","$4,298.00 ","$1,289.40 ","$3,911.18 ","$3,008.60 ","$1,289.40 ","$2,793.70 ","$3,094.56 ","$3,911.18 ","$3,223.50 "
Carle BroMenn Medical Center,8976245,SELECT CATH - 1ST ORDER ARTERY,,36245,361,"$2,130.00 ","$2,130.00 ",$639.00 ,"$1,938.30 ","$1,491.00 ",$639.00 ,"$1,384.50 ","$1,533.60 ","$1,938.30 ","$1,597.50 "
Carle BroMenn Medical Center,8976246,SELECT CATH - 2ND ORDER ARTERY,,36246,361,"$2,420.00 ","$2,420.00 ",$726.00 ,"$2,202.20 ","$1,694.00 ",$726.00 ,"$1,573.00 ","$1,742.40 ","$2,202.20 ","$1,815.00 "
Carle BroMenn Medical Center,8976247,SELECT CATH - 3RD ORDER ARTERY,,36247,361,"$2,048.00 ","$2,048.00 ",$614.40 ,"$1,863.68 ","$1,433.60 ",$614.40 ,"$1,331.20 ","$1,474.56 ","$1,863.68 ","$1,536.00 "
Carle BroMenn Medical Center,8976248,SELECT CATH ADNL 2ND/3RD ORDER,,36248,361,$578.00 ,$578.00 ,$173.40 ,$525.98 ,$404.60 ,$173.40 ,$375.70 ,$416.16 ,$525.98 ,$433.50 
Carle BroMenn Medical Center,8976251,"CATH RENAL SELECTIVE W/ S&I, UNILAT",,36251,361,"$4,545.00 ","$4,545.00 ","$1,363.50 ","$4,135.95 ","$3,181.50 ","$1,363.50 ","$2,954.25 ","$3,272.40 ","$4,135.95 ","$3,408.75 "
Carle BroMenn Medical Center,8976252,"CATH RENAL SELECTIVE W/ S&I, BILAT",,36252,361,"$4,590.00 ","$4,590.00 ","$1,377.00 ","$4,176.90 ","$3,213.00 ","$1,377.00 ","$2,983.50 ","$3,304.80 ","$4,176.90 ","$3,442.50 "
Carle BroMenn Medical Center,8976253,"CATH RENAL SUPERSELCTIVE W/ S&I, UNILAT",,36253,361,"$6,900.00 ","$6,900.00 ","$2,070.00 ","$6,279.00 ","$4,830.00 ","$2,070.00 ","$4,485.00 ","$4,968.00 ","$6,279.00 ","$5,175.00 "
Carle BroMenn Medical Center,8976254,"CATH RENAL SUPERSELCTIVE W/ S&I, BILAT",,36254,361,"$5,310.00 ","$5,310.00 ","$1,593.00 ","$4,832.10 ","$3,717.00 ","$1,593.00 ","$3,451.50 ","$3,823.20 ","$4,832.10 ","$3,982.50 "
Carle BroMenn Medical Center,8976299,INJ FOR VENOGRAPHY (NONEXTRM),,36299,361,"$1,566.00 ","$1,566.00 ",$469.80 ,"$1,425.06 ","$1,096.20 ",$469.80 ,"$1,017.90 ","$1,127.52 ","$1,425.06 ","$1,174.50 "
Carle BroMenn Medical Center,8976465,NJX NONCMPND SCLEROSANT SINGLE INCMPTNT VEIN,,36465,361,"$1,133.00 ","$1,133.00 ",$339.90 ,"$1,031.03 ",$793.10 ,$339.90 ,$736.45 ,$815.76 ,"$1,031.03 ",$849.75 
Carle BroMenn Medical Center,8976466,NJX NONCMPND SCLEROSANT MULTIPLE INCMPTNT VEINS,,36466,361,"$1,133.00 ","$1,133.00 ",$339.90 ,"$1,031.03 ",$793.10 ,$339.90 ,$736.45 ,$815.76 ,"$1,031.03 ",$849.75 
Carle BroMenn Medical Center,8976473,ENDOVEN ABLTJ INCMPTNT VEIN MCHNCHEM 1ST VEIN,,36473,361,"$5,753.00 ","$5,753.00 ","$1,725.90 ","$5,235.23 ","$4,027.10 ","$1,725.90 ","$3,739.45 ","$4,142.16 ","$5,235.23 ","$4,314.75 "
Carle BroMenn Medical Center,8976474,ENDOVEN ABLTJ INCMPTNT VEIN MCHNCHEM SBSQ VEINS,,36474,361,"$1,155.00 ","$1,155.00 ",$346.50 ,"$1,051.05 ",$808.50 ,$346.50 ,$750.75 ,$831.60 ,"$1,051.05 ",$866.25 
Carle BroMenn Medical Center,8976481,CATHETER PLCMNT IN PORTAL VEIN,,36481,361,"$1,358.00 ","$1,358.00 ",$407.40 ,"$1,235.78 ",$950.60 ,$407.40 ,$882.70 ,$977.76 ,"$1,235.78 ","$1,018.50 "
Carle BroMenn Medical Center,8976482,ENDOVEN ABLTI THER CHEM ADHESIVE 1ST VEIN,,36482,361,"$3,218.00 ","$3,218.00 ",$965.40 ,"$2,928.38 ","$2,252.60 ",$965.40 ,"$2,091.70 ","$2,316.96 ","$2,928.38 ","$2,413.50 "
Carle BroMenn Medical Center,8976483,ENDOVEN ABLTI THER CHEM ADHESIVE SBSQ VEIN,,36483,361,$240.00 ,$240.00 ,$72.00 ,$218.40 ,$168.00 ,$72.00 ,$156.00 ,$172.80 ,$218.40 ,$180.00 
Carle BroMenn Medical Center,8976499,PROCEDURE -NERVOUS SYSTEM,,64999,361,$578.50 ,$578.50 ,$173.55 ,$526.44 ,$404.95 ,$173.55 ,$376.03 ,$416.52 ,$526.44 ,$433.88 
Carle BroMenn Medical Center,8976500,VENOUS CATH FOR ORGAN BLD SMPL,,36500,361,$758.00 ,$758.00 ,$227.40 ,$689.78 ,$530.60 ,$227.40 ,$492.70 ,$545.76 ,$689.78 ,$568.50 
Carle BroMenn Medical Center,8976555,INSRTN NON-TUNNELED CVC <5YO,,36555,361,"$2,453.00 ","$2,453.00 ",$735.90 ,"$2,232.23 ","$1,717.10 ",$735.90 ,"$1,594.45 ","$1,766.16 ","$2,232.23 ","$1,839.75 "
Carle BroMenn Medical Center,8976556,INSRTN NON-TUNNELED CVC >5YO,,36556,361,"$2,690.00 ","$2,690.00 ",$807.00 ,"$2,447.90 ","$1,883.00 ",$807.00 ,"$1,748.50 ","$1,936.80 ","$2,447.90 ","$2,017.50 "
Carle BroMenn Medical Center,8976557,INSRTN TUNNLD CVC W/O PORT/PMP,,36557,361,"$3,218.00 ","$3,218.00 ",$965.40 ,"$2,928.38 ","$2,252.60 ",$965.40 ,"$2,091.70 ","$2,316.96 ","$2,928.38 ","$2,413.50 "
Carle BroMenn Medical Center,8976558,INSRTN TUNNLD CVC W/O PORT/PMP,,36558,361,"$2,220.00 ","$2,220.00 ",$666.00 ,"$2,020.20 ","$1,554.00 ",$666.00 ,"$1,443.00 ","$1,598.40 ","$2,020.20 ","$1,665.00 "
Carle BroMenn Medical Center,8976560,INSRTN TUNNLD CVC W/PORT <5YO,,36560,361,"$3,578.00 ","$3,578.00 ","$1,073.40 ","$3,255.98 ","$2,504.60 ","$1,073.40 ","$2,325.70 ","$2,576.16 ","$3,255.98 ","$2,683.50 "
Carle BroMenn Medical Center,8976561,INSRTN TUNNLD CVC W/PORT >5YO,,36561,361,"$5,430.00 ","$5,430.00 ","$1,629.00 ","$4,941.30 ","$3,801.00 ","$1,629.00 ","$3,529.50 ","$3,909.60 ","$4,941.30 ","$4,072.50 "
Carle BroMenn Medical Center,8976563,INSERTION TUNNELED CVC W/PUMP,,36563,361,"$4,755.00 ","$4,755.00 ","$1,426.50 ","$4,327.05 ","$3,328.50 ","$1,426.50 ","$3,090.75 ","$3,423.60 ","$4,327.05 ","$3,566.25 "
Carle BroMenn Medical Center,8976565,INSRTN TUNNLD CVC 2 CATH/2ACC,,36565,361,"$3,068.00 ","$3,068.00 ",$920.40 ,"$2,791.88 ","$2,147.60 ",$920.40 ,"$1,994.20 ","$2,208.96 ","$2,791.88 ","$2,301.00 "
Carle BroMenn Medical Center,8976566,INSRTN TUNNLD CVC 2 CATH/2ACC,,36566,361,"$8,993.00 ","$8,993.00 ","$2,697.90 ","$8,183.63 ","$6,295.10 ","$2,697.90 ","$5,845.45 ","$6,474.96 ","$8,183.63 ","$6,744.75 "
Carle BroMenn Medical Center,8976568,INSERTION PICC < 5 YRS OLD,,36568,361,"$1,290.00 ","$1,290.00 ",$387.00 ,"$1,173.90 ",$903.00 ,$387.00 ,$838.50 ,$928.80 ,"$1,173.90 ",$967.50 
Carle BroMenn Medical Center,8976569,INSERTION PICC > 5 YRS OLD,,36569,361,"$1,845.00 ","$1,845.00 ",$553.50 ,"$1,678.95 ","$1,291.50 ",$553.50 ,"$1,199.25 ","$1,328.40 ","$1,678.95 ","$1,383.75 "
Carle BroMenn Medical Center,8976570,PERIPH INSRTN CVC W/PORT <5YO,,36570,361,"$2,505.00 ","$2,505.00 ",$751.50 ,"$2,279.55 ","$1,753.50 ",$751.50 ,"$1,628.25 ","$1,803.60 ","$2,279.55 ","$1,878.75 "
Carle BroMenn Medical Center,8976571,PERIPH INSRTN CVC W/PORT >5YO,,36571,361,"$2,235.00 ","$2,235.00 ",$670.50 ,"$2,033.85 ","$1,564.50 ",$670.50 ,"$1,452.75 ","$1,609.20 ","$2,033.85 ","$1,676.25 "
Carle BroMenn Medical Center,8976572,INSERTION PICC W/RS&I < 5 YR,,36572,361,$893.00 ,$893.00 ,$267.90 ,$812.63 ,$625.10 ,$267.90 ,$580.45 ,$642.96 ,$812.63 ,$669.75 
Carle BroMenn Medical Center,8976573,INSERTION PICC W/RS&I 5 YR/>,,36573,361,"$2,242.00 ","$2,242.00 ",$672.60 ,"$2,040.22 ","$1,569.40 ",$672.60 ,"$1,457.30 ","$1,614.24 ","$2,040.22 ","$1,681.50 "
Carle BroMenn Medical Center,8976575,REPAIR CVC W/O PORT/PUMP,,36575,361,"$1,845.00 ","$1,845.00 ",$553.50 ,"$1,678.95 ","$1,291.50 ",$553.50 ,"$1,199.25 ","$1,328.40 ","$1,678.95 ","$1,383.75 "
Carle BroMenn Medical Center,8976576,REPAIR CVC W/PORT/PUMP,,36576,361,"$1,140.00 ","$1,140.00 ",$342.00 ,"$1,037.40 ",$798.00 ,$342.00 ,$741.00 ,$820.80 ,"$1,037.40 ",$855.00 
Carle BroMenn Medical Center,8976578,REPLACE CVC CATHETER ONLY,,36578,361,"$6,345.00 ","$6,345.00 ","$1,903.50 ","$5,773.95 ","$4,441.50 ","$1,903.50 ","$4,124.25 ","$4,568.40 ","$5,773.95 ","$4,758.75 "
Carle BroMenn Medical Center,8976580,RPLC NON-TNNLD CVC W/O PRT/PMP,,36580,361,"$2,070.00 ","$2,070.00 ",$621.00 ,"$1,883.70 ","$1,449.00 ",$621.00 ,"$1,345.50 ","$1,490.40 ","$1,883.70 ","$1,552.50 "
Carle BroMenn Medical Center,8976581,RPLC TUNNLD CVC W/O PORT/PUMP,,36581,361,"$1,973.00 ","$1,973.00 ",$591.90 ,"$1,795.43 ","$1,381.10 ",$591.90 ,"$1,282.45 ","$1,420.56 ","$1,795.43 ","$1,479.75 "
Carle BroMenn Medical Center,8976582,REPLACE TUNNLD CVC W/PORT,,36582,361,"$4,163.00 ","$4,163.00 ","$1,248.90 ","$3,788.33 ","$2,914.10 ","$1,248.90 ","$2,705.95 ","$2,997.36 ","$3,788.33 ","$3,122.25 "
Carle BroMenn Medical Center,8976583,REPLACE TUNNLD CVC W/PUMP,,36583,361,"$3,210.00 ","$3,210.00 ",$963.00 ,"$2,921.10 ","$2,247.00 ",$963.00 ,"$2,086.50 ","$2,311.20 ","$2,921.10 ","$2,407.50 "
Carle BroMenn Medical Center,8976584,REPLACE PICC W/O PORT/PUMP,,36584,361,"$2,453.00 ","$2,453.00 ",$735.90 ,"$2,232.23 ","$1,717.10 ",$735.90 ,"$1,594.45 ","$1,766.16 ","$2,232.23 ","$1,839.75 "
Carle BroMenn Medical Center,8976585,RPLC PERIPH INSRTD CVC W/PORT,,36585,361,"$2,205.00 ","$2,205.00 ",$661.50 ,"$2,006.55 ","$1,543.50 ",$661.50 ,"$1,433.25 ","$1,587.60 ","$2,006.55 ","$1,653.75 "
Carle BroMenn Medical Center,8976589,RMVL TNNLD CVC W/O PORT/PUMP,,36589,361,"$1,845.00 ","$1,845.00 ",$553.50 ,"$1,678.95 ","$1,291.50 ",$553.50 ,"$1,199.25 ","$1,328.40 ","$1,678.95 ","$1,383.75 "
Carle BroMenn Medical Center,8976590,RMVL TUNNLD CVC W/PORT/PUMP,,36590,361,"$2,760.00 ","$2,760.00 ",$828.00 ,"$2,511.60 ","$1,932.00 ",$828.00 ,"$1,794.00 ","$1,987.20 ","$2,511.60 ","$2,070.00 "
Carle BroMenn Medical Center,8976593,DECLOT VASCULAR ACCESS DVC/CTH,,36593,361,$760.00 ,$760.00 ,$228.00 ,$691.60 ,$532.00 ,$228.00 ,$494.00 ,$547.20 ,$691.60 ,$570.00 
Carle BroMenn Medical Center,8976595,RMVL PERICATH OBST MTL FRM CVC,,36595,361,"$2,115.00 ","$2,115.00 ",$634.50 ,"$1,924.65 ","$1,480.50 ",$634.50 ,"$1,374.75 ","$1,522.80 ","$1,924.65 ","$1,586.25 "
Carle BroMenn Medical Center,8976596,RMVL INTRACATH OBST MTL FR CVC,,36596,361,"$1,140.00 ","$1,140.00 ",$342.00 ,"$1,037.40 ",$798.00 ,$342.00 ,$741.00 ,$820.80 ,"$1,037.40 ",$855.00 
Carle BroMenn Medical Center,8976597,REPOSITION PREV PLCD CVC CATH,,36597,361,"$2,050.00 ","$2,050.00 ",$615.00 ,"$1,865.50 ","$1,435.00 ",$615.00 ,"$1,332.50 ","$1,476.00 ","$1,865.50 ","$1,537.50 "
Carle BroMenn Medical Center,8976598,EVAL CV DVC W/INJECTN & FLUORO,,36598,361,$595.00 ,$595.00 ,$178.50 ,$541.45 ,$416.50 ,$178.50 ,$386.75 ,$428.40 ,$541.45 ,$446.25 
Carle BroMenn Medical Center,8976620,ARTERIAL CATH SMPL/MONTR/TRNSF,,36620,361,"$1,585.00 ","$1,585.00 ",$475.50 ,"$1,442.35 ","$1,109.50 ",$475.50 ,"$1,030.25 ","$1,141.20 ","$1,442.35 ","$1,188.75 "
Carle BroMenn Medical Center,8976650,PR EVASC INTRACRANIAL PROLNG ADMN RX AGENT ART 1ST,,61650,361,"$7,095.00 ","$7,095.00 ","$2,128.50 ","$6,456.45 ","$4,966.50 ","$2,128.50 ","$4,611.75 ","$5,108.40 ","$6,456.45 ","$5,321.25 "
Carle BroMenn Medical Center,8976651,PR EVASC INTRACRANIAL PROLNG ADMN RX AGENT ART ADDL,,61651,361,"$3,015.00 ","$3,015.00 ",$904.50 ,"$2,743.65 ","$2,110.50 ",$904.50 ,"$1,959.75 ","$2,170.80 ","$2,743.65 ","$2,261.25 "
Carle BroMenn Medical Center,8976901,INTRO CATH DIALYSIS CIRCUIT DX ANGRPH FLUOR S&I,,36901,361,"$2,453.00 ","$2,453.00 ",$735.90 ,"$2,232.23 ","$1,717.10 ",$735.90 ,"$1,594.45 ","$1,766.16 ","$2,232.23 ","$1,839.75 "
Carle BroMenn Medical Center,8976902,INTRO CATH DIALYSIS CIRCUIT W/TRLUML BALO ANGIOP,,36902,361,"$9,990.00 ","$9,990.00 ","$2,997.00 ","$9,090.90 ","$6,993.00 ","$2,997.00 ","$6,493.50 ","$7,192.80 ","$9,090.90 ","$7,492.50 "
Carle BroMenn Medical Center,8976903,INTRO CATH DIALYSIS CIRCUIT W/TCAT PLMT IV STENT,,36903,361,"$20,168.00 ","$20,168.00 ","$6,050.40 ","$18,352.88 ","$14,117.60 ","$6,050.40 ","$13,109.20 ","$14,520.96 ","$18,352.88 ","$15,126.00 "
Carle BroMenn Medical Center,8976904,PERQ THRMBC/NFS DIALYSIS CIRCUIT IMG DX ANGRPH,,36904,361,"$11,745.00 ","$11,745.00 ","$3,523.50 ","$10,687.95 ","$8,221.50 ","$3,523.50 ","$7,634.25 ","$8,456.40 ","$10,687.95 ","$8,808.75 "
Carle BroMenn Medical Center,8976905,PERQ THRMBC/NFS DIAL CIRCUIT TRLUML BALO ANGIOP,,36905,361,"$20,168.00 ","$20,168.00 ","$6,050.40 ","$18,352.88 ","$14,117.60 ","$6,050.40 ","$13,109.20 ","$14,520.96 ","$18,352.88 ","$15,126.00 "
Carle BroMenn Medical Center,8976906,PERQ THRMBC/NFS DIAL CIRCUIT TCAT PLMT IV STENT,,36906,361,"$30,563.00 ","$30,563.00 ","$9,168.90 ","$27,812.33 ","$21,394.10 ","$9,168.90 ","$19,865.95 ","$22,005.36 ","$27,812.33 ","$22,922.25 "
Carle BroMenn Medical Center,8976907,TRLUML BALO ANGIOP CTR DIALYSIS SEG W/IMG S&I,,36907,361,"$1,230.00 ","$1,230.00 ",$369.00 ,"$1,119.30 ",$861.00 ,$369.00 ,$799.50 ,$885.60 ,"$1,119.30 ",$922.50 
Carle BroMenn Medical Center,8976908,TCAT PLMT IV STENT CTR DIALYSIS SEG W/IMG S&I,,36908,361,"$2,985.00 ","$2,985.00 ",$895.50 ,"$2,716.35 ","$2,089.50 ",$895.50 ,"$1,940.25 ","$2,149.20 ","$2,716.35 ","$2,238.75 "
Carle BroMenn Medical Center,8976909,DIALYIS CIRCUIT VASC EMBOLI OCCLS EVASC IMG S&I,,36909,361,"$2,843.00 ","$2,843.00 ",$852.90 ,"$2,587.13 ","$1,990.10 ",$852.90 ,"$1,847.95 ","$2,046.96 ","$2,587.13 ","$2,132.25 "
Carle BroMenn Medical Center,8977140,INTRO NDL/INTRACATH EXT ARTERY,,36140,361,$728.00 ,$728.00 ,$218.40 ,$662.48 ,$509.60 ,$218.40 ,$473.20 ,$524.16 ,$662.48 ,$546.00 
Carle BroMenn Medical Center,8977184,PERCUTANEOUS THROMBECTOMY PRIM,,37184,361,"$6,968.00 ","$6,968.00 ","$2,090.40 ","$6,340.88 ","$4,877.60 ","$2,090.40 ","$4,529.20 ","$5,016.96 ","$6,340.88 ","$5,226.00 "
Carle BroMenn Medical Center,8977185,PERCUTANEOUS THROMBECTOMY,,37185,361,"$5,820.00 ","$5,820.00 ","$1,746.00 ","$5,296.20 ","$4,074.00 ","$1,746.00 ","$3,783.00 ","$4,190.40 ","$5,296.20 ","$4,365.00 "
Carle BroMenn Medical Center,8977186,THROMBECTOMY,,37186,361,"$2,610.00 ","$2,610.00 ",$783.00 ,"$2,375.10 ","$1,827.00 ",$783.00 ,"$1,696.50 ","$1,879.20 ","$2,375.10 ","$1,957.50 "
Carle BroMenn Medical Center,8977187,VENOUS THROMBECTOMY,,37187,361,"$5,775.00 ","$5,775.00 ","$1,732.50 ","$5,255.25 ","$4,042.50 ","$1,732.50 ","$3,753.75 ","$4,158.00 ","$5,255.25 ","$4,331.25 "
Carle BroMenn Medical Center,8977188,VENOUS THROMBECTOMY,,37188,361,"$5,948.00 ","$5,948.00 ","$1,784.40 ","$5,412.68 ","$4,163.60 ","$1,784.40 ","$3,866.20 ","$4,282.56 ","$5,412.68 ","$4,461.00 "
Carle BroMenn Medical Center,8977191,PLACEMENT IVC FILTER W/ S&I,,37191,361,"$6,773.00 ","$6,773.00 ","$2,031.90 ","$6,163.43 ","$4,741.10 ","$2,031.90 ","$4,402.45 ","$4,876.56 ","$6,163.43 ","$5,079.75 "
Carle BroMenn Medical Center,8977192,REPOSITION IVC FILTER W/ S&I,,37192,361,"$6,645.00 ","$6,645.00 ","$1,993.50 ","$6,046.95 ","$4,651.50 ","$1,993.50 ","$4,319.25 ","$4,784.40 ","$6,046.95 ","$4,983.75 "
Carle BroMenn Medical Center,8977193,REMOVAL IVC FILTER W/ S&I,,37193,361,"$8,843.00 ","$8,843.00 ","$2,652.90 ","$8,047.13 ","$6,190.10 ","$2,652.90 ","$5,747.95 ","$6,366.96 ","$8,047.13 ","$6,632.25 "
Carle BroMenn Medical Center,8977195,THROMBYLS CEREBRAL BY IV INF,,37195,361,$458.00 ,$458.00 ,$137.40 ,$416.78 ,$320.60 ,$137.40 ,$297.70 ,$329.76 ,$416.78 ,$343.50 
Carle BroMenn Medical Center,8977197,TRNSCATH RETRIEVL FOREIGN BODY,,37197,361,"$5,705.00 ","$5,705.00 ","$1,711.50 ","$5,191.55 ","$3,993.50 ","$1,711.50 ","$3,708.25 ","$4,107.60 ","$5,191.55 ","$4,278.75 "
Carle BroMenn Medical Center,8977200,TRANSCATHETER BIOPSY,,37200,361,"$3,593.00 ","$3,593.00 ","$1,077.90 ","$3,269.63 ","$2,515.10 ","$1,077.90 ","$2,335.45 ","$2,586.96 ","$3,269.63 ","$2,694.75 "
Carle BroMenn Medical Center,8977211,TRANSCATH ART INF THROMBOLYSIS -INIT,,37211,361,"$4,658.00 ","$4,658.00 ","$1,397.40 ","$4,238.78 ","$3,260.60 ","$1,397.40 ","$3,027.70 ","$3,353.76 ","$4,238.78 ","$3,493.50 "
Carle BroMenn Medical Center,8977212,TRANSCATH VENOUS INF THROMBOLYSIS -INIT,,37212,361,"$4,658.00 ","$4,658.00 ","$1,397.40 ","$4,238.78 ","$3,260.60 ","$1,397.40 ","$3,027.70 ","$3,353.76 ","$4,238.78 ","$3,493.50 "
Carle BroMenn Medical Center,8977213,TRANSCATH INF THROMBOLYSIS - SUBSEQ,,37213,361,"$4,373.00 ","$4,373.00 ","$1,311.90 ","$3,979.43 ","$3,061.10 ","$1,311.90 ","$2,842.45 ","$3,148.56 ","$3,979.43 ","$3,279.75 "
Carle BroMenn Medical Center,8977214,TRANSCATH INF THROMBOLYSIS - CESSATN,,37214,361,"$3,450.00 ","$3,450.00 ","$1,035.00 ","$3,139.50 ","$2,415.00 ","$1,035.00 ","$2,242.50 ","$2,484.00 ","$3,139.50 ","$2,587.50 "
Carle BroMenn Medical Center,8977216,TRANSCATH PLCMNT CAROTID STENT,,37216,361,"$8,348.00 ","$8,348.00 ","$2,504.40 ","$7,596.68 ","$5,843.60 ","$2,504.40 ","$5,426.20 ","$6,010.56 ","$7,596.68 ","$6,261.00 "
Carle BroMenn Medical Center,8977217,TRANSCATH PLCMNT CAROTID STENT,,37217,361,"$9,098.00 ","$9,098.00 ","$2,729.40 ","$8,279.18 ","$6,368.60 ","$2,729.40 ","$5,913.70 ","$6,550.56 ","$8,279.18 ","$6,823.50 "
Carle BroMenn Medical Center,8977218,TRANSCATH STENT PLACMT ANTEGRADE CAROTID/INNOM,,37218,361,"$6,848.00 ","$6,848.00 ","$2,054.40 ","$6,231.68 ","$4,793.60 ","$2,054.40 ","$4,451.20 ","$4,930.56 ","$6,231.68 ","$5,136.00 "
Carle BroMenn Medical Center,8977220,ILIAC ARTERY ANGIOPLASTY,,37220,361,"$8,678.00 ","$8,678.00 ","$2,603.40 ","$7,896.98 ","$6,074.60 ","$2,603.40 ","$5,640.70 ","$6,248.16 ","$7,896.98 ","$6,508.50 "
Carle BroMenn Medical Center,8977221,ILIAC ARTERY STENT/PTA,,37221,361,"$19,665.00 ","$19,665.00 ","$5,899.50 ","$17,895.15 ","$13,765.50 ","$5,899.50 ","$12,782.25 ","$14,158.80 ","$17,895.15 ","$14,748.75 "
Carle BroMenn Medical Center,8977222,ADNL ILIAC ARTERY ANGIOPLASTY,,37222,361,"$6,983.00 ","$6,983.00 ","$2,094.90 ","$6,354.53 ","$4,888.10 ","$2,094.90 ","$4,538.95 ","$5,027.76 ","$6,354.53 ","$5,237.25 "
Carle BroMenn Medical Center,8977223,ADNL ILIAC ARTERY STENT/PTA,,37223,361,"$17,918.00 ","$17,918.00 ","$5,375.40 ","$16,305.38 ","$12,542.60 ","$5,375.40 ","$11,646.70 ","$12,900.96 ","$16,305.38 ","$13,438.50 "
Carle BroMenn Medical Center,8977224,FEM/POP ARTERY ANGIOPLSTY,,37224,361,"$9,218.00 ","$9,218.00 ","$2,765.40 ","$8,388.38 ","$6,452.60 ","$2,765.40 ","$5,991.70 ","$6,636.96 ","$8,388.38 ","$6,913.50 "
Carle BroMenn Medical Center,8977225,FEM/POP ART ATHERECTOMY/PTA,,37225,361,"$15,773.00 ","$15,773.00 ","$4,731.90 ","$14,353.43 ","$11,041.10 ","$4,731.90 ","$10,252.45 ","$11,356.56 ","$14,353.43 ","$11,829.75 "
Carle BroMenn Medical Center,8977226,FEM/POP ARTERY STENT/PTA,,37226,361,"$26,363.00 ","$26,363.00 ","$7,908.90 ","$23,990.33 ","$18,454.10 ","$7,908.90 ","$17,135.95 ","$18,981.36 ","$23,990.33 ","$19,772.25 "
Carle BroMenn Medical Center,8977227,FEM/POP ART STENT/ARTHRECT/PTA,,37227,361,"$23,910.00 ","$23,910.00 ","$7,173.00 ","$21,758.10 ","$16,737.00 ","$7,173.00 ","$15,541.50 ","$17,215.20 ","$21,758.10 ","$17,932.50 "
Carle BroMenn Medical Center,8977228,TIB/PERONEAL ARTERY ANGIOPLSTY,,37228,361,"$14,865.00 ","$14,865.00 ","$4,459.50 ","$13,527.15 ","$10,405.50 ","$4,459.50 ","$9,662.25 ","$10,702.80 ","$13,527.15 ","$11,148.75 "
Carle BroMenn Medical Center,8977229,TIB/PERONEAL ARTERY ATHRECTMY,,37229,361,"$23,910.00 ","$23,910.00 ","$7,173.00 ","$21,758.10 ","$16,737.00 ","$7,173.00 ","$15,541.50 ","$17,215.20 ","$21,758.10 ","$17,932.50 "
Carle BroMenn Medical Center,8977230,TIB/PERONEAL ARTERY STENT/PTA,,37230,361,"$19,425.00 ","$19,425.00 ","$5,827.50 ","$17,676.75 ","$13,597.50 ","$5,827.50 ","$12,626.25 ","$13,986.00 ","$17,676.75 ","$14,568.75 "
Carle BroMenn Medical Center,8977231,TIB/PERNL ART STENT/ATHERECTMY,,37231,361,"$27,450.00 ","$27,450.00 ","$8,235.00 ","$24,979.50 ","$19,215.00 ","$8,235.00 ","$17,842.50 ","$19,764.00 ","$24,979.50 ","$20,587.50 "
Carle BroMenn Medical Center,8977232,ADNL TIB/PERONL ART ANGIOPLSTY,,37232,361,"$7,005.00 ","$7,005.00 ","$2,101.50 ","$6,374.55 ","$4,903.50 ","$2,101.50 ","$4,553.25 ","$5,043.60 ","$6,374.55 ","$5,253.75 "
Carle BroMenn Medical Center,8977233,ADNL TIB/PERONEAL ATHERECTOMY,,37233,361,"$13,688.00 ","$13,688.00 ","$4,106.40 ","$12,456.08 ","$9,581.60 ","$4,106.40 ","$8,897.20 ","$9,855.36 ","$12,456.08 ","$10,266.00 "
Carle BroMenn Medical Center,8977234,ADNL TIB/PERONEAL STENT/PTA,,37234,361,"$17,100.00 ","$17,100.00 ","$5,130.00 ","$15,561.00 ","$11,970.00 ","$5,130.00 ","$11,115.00 ","$12,312.00 ","$15,561.00 ","$12,825.00 "
Carle BroMenn Medical Center,8977235,ADNL TIB/PERONL STENT/ATHRCTMY,,37235,361,"$25,118.00 ","$25,118.00 ","$7,535.40 ","$22,857.38 ","$17,582.60 ","$7,535.40 ","$16,326.70 ","$18,084.96 ","$22,857.38 ","$18,838.50 "
Carle BroMenn Medical Center,8977236,OPEN/PERQ PLC STENT 1RST ARTERY,,37236,361,"$20,340.00 ","$20,340.00 ","$6,102.00 ","$18,509.40 ","$14,238.00 ","$6,102.00 ","$13,221.00 ","$14,644.80 ","$18,509.40 ","$15,255.00 "
Carle BroMenn Medical Center,8977237,OPEN/PERQ PLC STENT EA ADD ARTERY,,37237,361,"$9,848.00 ","$9,848.00 ","$2,954.40 ","$8,961.68 ","$6,893.60 ","$2,954.40 ","$6,401.20 ","$7,090.56 ","$8,961.68 ","$7,386.00 "
Carle BroMenn Medical Center,8977238,"OPEN/PERQ PLC STENT SAME, INITIAL VEIN",,37238,361,"$20,340.00 ","$20,340.00 ","$6,102.00 ","$18,509.40 ","$14,238.00 ","$6,102.00 ","$13,221.00 ","$14,644.80 ","$18,509.40 ","$15,255.00 "
Carle BroMenn Medical Center,8977239,OPEN/PERQ PLC STENT EA ADD VEIN,,37239,361,"$9,848.00 ","$9,848.00 ","$2,954.40 ","$8,961.68 ","$6,893.60 ","$2,954.40 ","$6,401.20 ","$7,090.56 ","$8,961.68 ","$7,386.00 "
Carle BroMenn Medical Center,8977241,VASC EMBOLIZE/OCCLUDE VENOUS,,37241,361,"$24,285.00 ","$24,285.00 ","$7,285.50 ","$22,099.35 ","$16,999.50 ","$7,285.50 ","$15,785.25 ","$17,485.20 ","$22,099.35 ","$18,213.75 "
Carle BroMenn Medical Center,8977242,VASC EMBOLIZE/OCCLUDE ARTERY,,37242,361,"$21,623.00 ","$21,623.00 ","$6,486.90 ","$19,676.93 ","$15,136.10 ","$6,486.90 ","$14,054.95 ","$15,568.56 ","$19,676.93 ","$16,217.25 "
Carle BroMenn Medical Center,8977243,VASC EMBOLIZE/OCCLUDE ORGAN,,37243,361,"$18,383.00 ","$18,383.00 ","$5,514.90 ","$16,728.53 ","$12,868.10 ","$5,514.90 ","$11,948.95 ","$13,235.76 ","$16,728.53 ","$13,787.25 "
Carle BroMenn Medical Center,8977244,VASC EMBOLIZE/OCCLUDE HEM OR LYMPH EXTRAVASATION,,37244,361,"$18,383.00 ","$18,383.00 ","$5,514.90 ","$16,728.53 ","$12,868.10 ","$5,514.90 ","$11,948.95 ","$13,235.76 ","$16,728.53 ","$13,787.25 "
Carle BroMenn Medical Center,8977246,TRLML BALO ANGIOP OPEN/PERQ IMG S&I 1ST ART,,37246,361,"$9,990.00 ","$9,990.00 ","$2,997.00 ","$9,090.90 ","$6,993.00 ","$2,997.00 ","$6,493.50 ","$7,192.80 ","$9,090.90 ","$7,492.50 "
Carle BroMenn Medical Center,8977247,TRLML BALO ANGIOP OPEN/PERQ IMG S&I EA ADDL ART,,37247,361,"$5,880.00 ","$5,880.00 ","$1,764.00 ","$5,350.80 ","$4,116.00 ","$1,764.00 ","$3,822.00 ","$4,233.60 ","$5,350.80 ","$4,410.00 "
Carle BroMenn Medical Center,8977248,TRLML BALO ANGIOP OPEN/PERQ W/IMG S&I 1ST VEIN,,37248,361,"$9,990.00 ","$9,990.00 ","$2,997.00 ","$9,090.90 ","$6,993.00 ","$2,997.00 ","$6,493.50 ","$7,192.80 ","$9,090.90 ","$7,492.50 "
Carle BroMenn Medical Center,8977249,TRLML BALO ANGIOP OPEN/PERQ W/IMG S&I ADDL VEIN,,37249,361,"$5,003.00 ","$5,003.00 ","$1,500.90 ","$4,552.73 ","$3,502.10 ","$1,500.90 ","$3,251.95 ","$3,602.16 ","$4,552.73 ","$3,752.25 "
Carle BroMenn Medical Center,8977252,PR INTRAVASCULAR US NONCORONARY RS&I INTIAL VESSEL,,37252,361,"$4,538.00 ","$4,538.00 ","$1,361.40 ","$4,129.58 ","$3,176.60 ","$1,361.40 ","$2,949.70 ","$3,267.36 ","$4,129.58 ","$3,403.50 "
Carle BroMenn Medical Center,8977253,PR INTRAVASCULAR US NONCORONARY RS&I ADDL VESSEL,,37253,361,"$2,040.00 ","$2,040.00 ",$612.00 ,"$1,856.40 ","$1,428.00 ",$612.00 ,"$1,326.00 ","$1,468.80 ","$1,856.40 ","$1,530.00 "
Carle BroMenn Medical Center,8977425,"CHOLEDOCHOTOMY/STOMY W/EXPL, DRN, RMVL CALC",,47425,361,"$6,660.00 ","$6,660.00 ","$1,998.00 ","$6,060.60 ","$4,662.00 ","$1,998.00 ","$4,329.00 ","$4,795.20 ","$6,060.60 ","$4,995.00 "
Carle BroMenn Medical Center,8977597,SELECTIVE DEBRIDEMENT < 20SQ CM,,97597,361,$415.00 ,$415.00 ,$124.50 ,$377.65 ,$290.50 ,$124.50 ,$269.75 ,$298.80 ,$377.65 ,$311.25 
Carle BroMenn Medical Center,8977598,SELECTIVE DEBRIDEMENT > 20 SQ CM,,97598,361,$280.00 ,$280.00 ,$84.00 ,$254.80 ,$196.00 ,$84.00 ,$182.00 ,$201.60 ,$254.80 ,$210.00 
Carle BroMenn Medical Center,8977999,PROCEDURE -SKIN/MUC MEMB/SUBQ,,17999,361,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8978006,EMBOLIZATION PANCREATICO CUTNUS FISTULA,,49999,361,"$1,550.00 ","$1,550.00 ",$465.00 ,"$1,410.50 ","$1,085.00 ",$465.00 ,"$1,007.50 ","$1,116.00 ","$1,410.50 ","$1,162.50 "
Carle BroMenn Medical Center,8978007,IRRIGATE & ASPIRATE ABSCESS TRACT,,49999,361,"$1,550.00 ","$1,550.00 ",$465.00 ,"$1,410.50 ","$1,085.00 ",$465.00 ,"$1,007.50 ","$1,116.00 ","$1,410.50 ","$1,162.50 "
Carle BroMenn Medical Center,8978008,ASPIRATE ABSCESS TRACT & REPOSTN CATH,,49999,361,"$1,550.00 ","$1,550.00 ",$465.00 ,"$1,410.50 ","$1,085.00 ",$465.00 ,"$1,007.50 ","$1,116.00 ","$1,410.50 ","$1,162.50 "
Carle BroMenn Medical Center,8978009,EVAL & ASP FIBRUS MTL FRM PERITNL DIALYSIS CATH,,49999,361,"$1,550.00 ","$1,550.00 ",$465.00 ,"$1,410.50 ","$1,085.00 ",$465.00 ,"$1,007.50 ","$1,116.00 ","$1,410.50 ","$1,162.50 "
Carle BroMenn Medical Center,8978010,PERITNL CATH REPOSITION,,49999,361,"$1,550.00 ","$1,550.00 ",$465.00 ,"$1,410.50 ","$1,085.00 ",$465.00 ,"$1,007.50 ","$1,116.00 ","$1,410.50 ","$1,162.50 "
Carle BroMenn Medical Center,8978221,BONE MARROW BIOPSY,,38221,361,"$1,228.50 ","$1,228.50 ",$368.55 ,"$1,117.94 ",$859.95 ,$368.55 ,$798.53 ,$884.52 ,"$1,117.94 ",$921.38 
Carle BroMenn Medical Center,8978222,DIAGNOSTIC BONE MARROW BIOPSIES & ASPIRATIONS,,38222,361,"$1,620.00 ","$1,620.00 ",$486.00 ,"$1,474.20 ","$1,134.00 ",$486.00 ,"$1,053.00 ","$1,166.40 ","$1,474.20 ","$1,215.00 "
Carle BroMenn Medical Center,8978505,"BIOPSY, LYMPH NODE",,38505,361,"$2,756.00 ","$2,756.00 ",$826.80 ,"$2,507.96 ","$1,929.20 ",$826.80 ,"$1,791.40 ","$1,984.32 ","$2,507.96 ","$2,067.00 "
Carle BroMenn Medical Center,8978515,"BIOPSY, LYMPH NODE",,38505,361,"$2,756.00 ","$2,756.00 ",$826.80 ,"$2,507.96 ","$1,929.20 ",$826.80 ,"$1,791.40 ","$1,984.32 ","$2,507.96 ","$2,067.00 "
Carle BroMenn Medical Center,8978790,INJECTION FOR LYMPHANGIOGRAPHY,,38790,361,$660.00 ,$660.00 ,$198.00 ,$600.60 ,$462.00 ,$198.00 ,$429.00 ,$475.20 ,$600.60 ,$495.00 
Carle BroMenn Medical Center,8979526,OCLUS DEVIC PLACMNT POST PROC,,G0269,361,$540.00 ,$540.00 ,$162.00 ,$491.40 ,$378.00 ,$162.00 ,$351.00 ,$388.80 ,$491.40 ,$405.00 
Carle BroMenn Medical Center,8979527,OLSV DEVIC PLACMNT,,G0269,361,$540.00 ,$540.00 ,$162.00 ,$491.40 ,$378.00 ,$162.00 ,$351.00 ,$388.80 ,$491.40 ,$405.00 
Carle BroMenn Medical Center,8979999,PROCEDURE -SKIN/MUC MEMB/SUBQ,,17999,361,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8100060,ARGON LASER ROOM,,,369,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8100061,DYE ARGON LASER ROOM,,,369,$330.00 ,$330.00 ,$99.00 ,$300.30 ,$231.00 ,$99.00 ,$214.50 ,$237.60 ,$300.30 ,$247.50 
Carle BroMenn Medical Center,8100062,YAG LASER ROOM,,,369,$525.00 ,$525.00 ,$157.50 ,$477.75 ,$367.50 ,$157.50 ,$341.25 ,$378.00 ,$477.75 ,$393.75 
Carle BroMenn Medical Center,8029151,"MOD SED SAME PHYS/QHP, PT <5YRS, INITL 15 MIN",,99151,370,$345.00 ,$345.00 ,$103.50 ,$313.95 ,$241.50 ,$103.50 ,$224.25 ,$248.40 ,$313.95 ,$258.75 
Carle BroMenn Medical Center,8029152,"MOD SED SAME PHYS/QHP, PT 5YRS OR >, INITL 15 MIN",,99152,370,$345.00 ,$345.00 ,$103.50 ,$313.95 ,$241.50 ,$103.50 ,$224.25 ,$248.40 ,$313.95 ,$258.75 
Carle BroMenn Medical Center,8029153,"MOD SED SAME PHYS/QHP, EA ADD 15 MIN",,99153,370,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8029155,"MOD SED OTHER PHYS/QHP, PT <5YRS, INITL 15 MIN",,99155,370,$198.00 ,$198.00 ,$59.40 ,$180.18 ,$138.60 ,$59.40 ,$128.70 ,$142.56 ,$180.18 ,$148.50 
Carle BroMenn Medical Center,8029156,"MOD SED OTHER PHYS/QHP, PT 5YRS OR >, INITL 15 MIN",,99156,370,$198.00 ,$198.00 ,$59.40 ,$180.18 ,$138.60 ,$59.40 ,$128.70 ,$142.56 ,$180.18 ,$148.50 
Carle BroMenn Medical Center,8029157,"MOD SED OTHER PHYS/QHP, EA ADD 15 MIN",,99157,370,$148.00 ,$148.00 ,$44.40 ,$134.68 ,$103.60 ,$44.40 ,$96.20 ,$106.56 ,$134.68 ,$111.00 
Carle BroMenn Medical Center,8100082,MODERATE SEDATION INITIAL,,,370,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01 
Carle BroMenn Medical Center,8100083,MODERATE SEDATION INITIAL,,,370,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01 
Carle BroMenn Medical Center,8100084,MODERATE SEDATION INITIAL,,,370,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01 
Carle BroMenn Medical Center,8100085,MODERATE SEDATION SUBSEQUENT,,,370,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01 
Carle BroMenn Medical Center,8100086,MODERATE SEDATION SUBSEQUENT,,,370,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01 
Carle BroMenn Medical Center,8100087,MODERATE SEDATION SUBSEQUENT,,,370,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01 
Carle BroMenn Medical Center,8130019,ANES EA ADD MIN SPI/CAU/EPI,,,370,$13.00 ,$13.00 ,$3.90 ,$11.83 ,$9.10 ,$3.90 ,$8.45 ,$9.36 ,$11.83 ,$9.75 
Carle BroMenn Medical Center,8130020,ANESTHESIA 1ST 15 MIN GENERAL,,,370,$255.00 ,$255.00 ,$76.50 ,$232.05 ,$178.50 ,$76.50 ,$165.75 ,$183.60 ,$232.05 ,$191.25 
Carle BroMenn Medical Center,8130021,ANESTHESIA EA ADD MIN MAC,,,370,$8.25 ,$8.25 ,$2.48 ,$7.51 ,$5.78 ,$2.48 ,$5.36 ,$5.94 ,$7.51 ,$6.19 
Carle BroMenn Medical Center,8130022,ANESTHESIA EACH ADD MIN GEN,,,370,$13.00 ,$13.00 ,$3.90 ,$11.83 ,$9.10 ,$3.90 ,$8.45 ,$9.36 ,$11.83 ,$9.75 
Carle BroMenn Medical Center,8130023,MONITORED ANESTH CARE FIRST 15,,,370,$205.00 ,$205.00 ,$61.50 ,$186.55 ,$143.50 ,$61.50 ,$133.25 ,$147.60 ,$186.55 ,$153.75 
Carle BroMenn Medical Center,8130024,IV BLOCK/BIER BLOCK,,,370,$325.00 ,$325.00 ,$97.50 ,$295.75 ,$227.50 ,$97.50 ,$211.25 ,$234.00 ,$295.75 ,$243.75 
Carle BroMenn Medical Center,8130025,ANEST SPINAL CAUDEL EPI FST 15,,,370,$175.00 ,$175.00 ,$52.50 ,$159.25 ,$122.50 ,$52.50 ,$113.75 ,$126.00 ,$159.25 ,$131.25 
Carle BroMenn Medical Center,8255500,MOD SED ENDO SERVICE PT > 5 YRS INITIAL 15 MIN,,G0500,370,$345.00 ,$345.00 ,$103.50 ,$313.95 ,$241.50 ,$103.50 ,$224.25 ,$248.40 ,$313.95 ,$258.75 
Carle BroMenn Medical Center,8299151,"MOD SED SAME PHYS/QHP, PT <5YRS, INITL 15 MIN",,99151,370,$345.00 ,$345.00 ,$103.50 ,$313.95 ,$241.50 ,$103.50 ,$224.25 ,$248.40 ,$313.95 ,$258.75 
Carle BroMenn Medical Center,8299152,"MOD SED SAME PHYS/QHP, PT 5YRS OR >, INITL 15 MIN",,99152,370,$345.00 ,$345.00 ,$103.50 ,$313.95 ,$241.50 ,$103.50 ,$224.25 ,$248.40 ,$313.95 ,$258.75 
Carle BroMenn Medical Center,8299153,"MOD SED SAME PHYS/QHP, EA ADD 15 MIN",,99153,370,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8299155,"MOD SED OTHER PHYS/QHP, PT <5YRS, INITL 15 MIN",,99155,370,$198.00 ,$198.00 ,$59.40 ,$180.18 ,$138.60 ,$59.40 ,$128.70 ,$142.56 ,$180.18 ,$148.50 
Carle BroMenn Medical Center,8299156,"MOD SED OTHER PHYS/QHP, PT 5YRS OR >, INITL 15 MIN",,99156,370,$198.00 ,$198.00 ,$59.40 ,$180.18 ,$138.60 ,$59.40 ,$128.70 ,$142.56 ,$180.18 ,$148.50 
Carle BroMenn Medical Center,8299157,"MOD SED OTHER PHYS/QHP, EA ADD 15 MIN",,99157,370,$148.00 ,$148.00 ,$44.40 ,$134.68 ,$103.60 ,$44.40 ,$96.20 ,$106.56 ,$134.68 ,$111.00 
Carle BroMenn Medical Center,8499151,"MOD SED SAME PHYS/QHP, PT <5YRS, INITL 15 MIN",,99151,370,$290.00 ,$290.00 ,$87.00 ,$263.90 ,$203.00 ,$87.00 ,$188.50 ,$208.80 ,$263.90 ,$217.50 
Carle BroMenn Medical Center,8499152,"MOD SED SAME PHYS/QHP, PT 5YRS OR >, INITL 15 MIN",,99152,370,$345.00 ,$345.00 ,$103.50 ,$313.95 ,$241.50 ,$103.50 ,$224.25 ,$248.40 ,$313.95 ,$258.75 
Carle BroMenn Medical Center,8499153,"MOD SED SAME PHYS/QHP, EA ADD 15 MIN",,99153,370,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8899151,"MOD SED SAME PHYS/QHP, PT <5YRS, INITL 15 MIN",,99151,370,$345.00 ,$345.00 ,$103.50 ,$313.95 ,$241.50 ,$103.50 ,$224.25 ,$248.40 ,$313.95 ,$258.75 
Carle BroMenn Medical Center,8899152,"MOD SED SAME PHYS/QHP, PT 5YRS OR >, INITL 15 MIN",,99152,370,$345.00 ,$345.00 ,$103.50 ,$313.95 ,$241.50 ,$103.50 ,$224.25 ,$248.40 ,$313.95 ,$258.75 
Carle BroMenn Medical Center,8899153,"MOD SED SAME PHYS/QHP, EA ADD 15 MIN",,99153,370,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8899155,"MOD SED OTHER PHYS/QHP, PT <5YRS, INITL 15 MIN",,99155,370,$198.00 ,$198.00 ,$59.40 ,$180.18 ,$138.60 ,$59.40 ,$128.70 ,$142.56 ,$180.18 ,$148.50 
Carle BroMenn Medical Center,8899156,"MOD SED OTHER PHYS/QHP, PT 5YRS OR >, INITL 15 MIN",,99156,370,$198.00 ,$198.00 ,$59.40 ,$180.18 ,$138.60 ,$59.40 ,$128.70 ,$142.56 ,$180.18 ,$148.50 
Carle BroMenn Medical Center,8899157,"MOD SED OTHER PHYS/QHP, EA ADD 15 MIN",,99157,370,$148.00 ,$148.00 ,$44.40 ,$134.68 ,$103.60 ,$44.40 ,$96.20 ,$106.56 ,$134.68 ,$111.00 
Carle BroMenn Medical Center,8979537,"MOD SED SAME PHYS/QHP, PT <5YRS, INITL 15 MIN",,99151,370,$345.00 ,$345.00 ,$103.50 ,$313.95 ,$241.50 ,$103.50 ,$224.25 ,$248.40 ,$313.95 ,$258.75 
Carle BroMenn Medical Center,8979538,"MOD SED SAME PHYS/QHP, PT 5YRS OR >, INITL 15 MIN",,99152,370,$345.00 ,$345.00 ,$103.50 ,$313.95 ,$241.50 ,$103.50 ,$224.25 ,$248.40 ,$313.95 ,$258.75 
Carle BroMenn Medical Center,8979539,"MOD SED SAME PHYS/QHP, EA ADD 15 MIN",,99153,370,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8979540,"MOD SED OTHER PHYS/QHP, PT <5YRS, INITL 15 MIN",,99155,370,$198.00 ,$198.00 ,$59.40 ,$180.18 ,$138.60 ,$59.40 ,$128.70 ,$142.56 ,$180.18 ,$148.50 
Carle BroMenn Medical Center,8979541,"MOD SED OTHER PHYS/QHP, PT 5YRS OR >, INITL 15 MIN",,99156,370,$198.00 ,$198.00 ,$59.40 ,$180.18 ,$138.60 ,$59.40 ,$128.70 ,$142.56 ,$180.18 ,$148.50 
Carle BroMenn Medical Center,8979542,"MOD SED OTHER PHYS/QHP, EA ADD 15 MIN",,99157,370,$148.00 ,$148.00 ,$44.40 ,$134.68 ,$103.60 ,$44.40 ,$96.20 ,$106.56 ,$134.68 ,$111.00 
Carle BroMenn Medical Center,8380314,CRYO AHF 5 UNIT POOL,,P9012,390,$224.00 ,$224.00 ,$67.20 ,$203.84 ,$156.80 ,$67.20 ,$145.60 ,$161.28 ,$203.84 ,$168.00 
Carle BroMenn Medical Center,8380975,AUTOLOGOUS L-P RED BLOOD CELLS,,P9016,390,$252.00 ,$252.00 ,$75.60 ,$229.32 ,$176.40 ,$75.60 ,$163.80 ,$181.44 ,$229.32 ,$189.00 
Carle BroMenn Medical Center,8380976,FRESH FROZEN PLASMA PER UNIT,,P9059,390,$42.00 ,$42.00 ,$12.60 ,$38.22 ,$29.40 ,$12.60 ,$27.30 ,$30.24 ,$38.22 ,$31.50 
Carle BroMenn Medical Center,8386002,CRYO-POOR PLASMA,,P9044,390,$42.00 ,$42.00 ,$12.60 ,$38.22 ,$29.40 ,$12.60 ,$27.30 ,$30.24 ,$38.22 ,$31.50 
Carle BroMenn Medical Center,8386007,LP SINGLE DONOR PLATELETS PHER,,P9035,390,$357.00 ,$357.00 ,$107.10 ,$324.87 ,$249.90 ,$107.10 ,$232.05 ,$257.04 ,$324.87 ,$267.75 
Carle BroMenn Medical Center,8386012,LP IRRAD SNGL DONOR PLTLTS PHR,,P9037,390,$392.00 ,$392.00 ,$117.60 ,$356.72 ,$274.40 ,$117.60 ,$254.80 ,$282.24 ,$356.72 ,$294.00 
Carle BroMenn Medical Center,8386017,NEONATAL WHOLE BLOOD,,86999,390,$271.00 ,$271.00 ,$81.30 ,$246.61 ,$189.70 ,$81.30 ,$176.15 ,$195.12 ,$246.61 ,$203.25 
Carle BroMenn Medical Center,8386033,IRRAD LEUKOCYTES REDUCED RBC'S,,P9040,390,$192.00 ,$192.00 ,$57.60 ,$174.72 ,$134.40 ,$57.60 ,$124.80 ,$138.24 ,$174.72 ,$144.00 
Carle BroMenn Medical Center,8386034,IRRAD RED BLOOD CELLS PER UNIT,,P9038,390,$611.00 ,$611.00 ,$183.30 ,$556.01 ,$427.70 ,$183.30 ,$397.15 ,$439.92 ,$556.01 ,$458.25 
Carle BroMenn Medical Center,8386035,IRRAD SINGLE DONOR PLTLTS PHER,,P9036,390,"$1,399.00 ","$1,399.00 ",$419.70 ,"$1,273.09 ",$979.30 ,$419.70 ,$909.35 ,"$1,007.28 ","$1,273.09 ","$1,049.25 "
Carle BroMenn Medical Center,8386036,IRRADIATION PLATELETS PER UNIT,,P9032,390,$198.00 ,$198.00 ,$59.40 ,$180.18 ,$138.60 ,$59.40 ,$128.70 ,$142.56 ,$180.18 ,$148.50 
Carle BroMenn Medical Center,8386102,LEUKO-REDUCED RED BLOOD CELLS,,P9016,390,$156.00 ,$156.00 ,$46.80 ,$141.96 ,$109.20 ,$46.80 ,$101.40 ,$112.32 ,$141.96 ,$117.00 
Carle BroMenn Medical Center,8386112,SINGLE DONOR PLATLETS PHERESIS,,P9034,390,"$1,279.00 ","$1,279.00 ",$383.70 ,"$1,163.89 ",$895.30 ,$383.70 ,$831.35 ,$920.88 ,"$1,163.89 ",$959.25 
Carle BroMenn Medical Center,8386129,GRANULOCYTES,,,390,"$1,449.00 ","$1,449.00 ",$434.70 ,"$1,318.59 ","$1,014.30 ",$434.70 ,$941.85 ,"$1,043.28 ","$1,318.59 ","$1,086.75 "
Carle BroMenn Medical Center,8386134,WHOLE BLOOD PER UNIT,,P9010,390,$217.00 ,$217.00 ,$65.10 ,$197.47 ,$151.90 ,$65.10 ,$141.05 ,$156.24 ,$197.47 ,$162.75 
Carle BroMenn Medical Center,8386201,CRYOPRECIPITATE PER UNIT,,P9012,390,$45.00 ,$45.00 ,$13.50 ,$40.95 ,$31.50 ,$13.50 ,$29.25 ,$32.40 ,$40.95 ,$33.75 
Carle BroMenn Medical Center,8386388,FRESH FROZEN PLASMA PER UNIT,,P9017,390,$52.00 ,$52.00 ,$15.60 ,$47.32 ,$36.40 ,$15.60 ,$33.80 ,$37.44 ,$47.32 ,$39.00 
Carle BroMenn Medical Center,8386426,PACKED RED BLOOD CELLS EA UNIT,,P9021,390,$328.00 ,$328.00 ,$98.40 ,$298.48 ,$229.60 ,$98.40 ,$213.20 ,$236.16 ,$298.48 ,$246.00 
Carle BroMenn Medical Center,8386890,AUTOLOGOUS BLOOD COLL & STORG,,86890,390,$186.00 ,$186.00 ,$55.80 ,$169.26 ,$130.20 ,$55.80 ,$120.90 ,$133.92 ,$169.26 ,$139.50 
Carle BroMenn Medical Center,8388008,AUTOLOGOUS DONOR PACKED RBC'S,,P9021,390,$252.00 ,$252.00 ,$75.60 ,$229.32 ,$176.40 ,$75.60 ,$163.80 ,$181.44 ,$229.32 ,$189.00 
Carle BroMenn Medical Center,8388009,DESIGNATED DONOR SURCHARGE,,,390,$98.00 ,$98.00 ,$29.40 ,$89.18 ,$68.60 ,$29.40 ,$63.70 ,$70.56 ,$89.18 ,$73.50 
Carle BroMenn Medical Center,8389073,PLATELET PHERESIS PATH REDUCED,,P9073,390,"$1,392.00 ","$1,392.00 ",$417.60 ,"$1,266.72 ",$974.40 ,$417.60 ,$904.80 ,"$1,002.24 ","$1,266.72 ","$1,044.00 "
Carle BroMenn Medical Center,8336430,ADMINISTER TRANSFUSION,,36430,391,$617.00 ,$617.00 ,$185.10 ,$561.47 ,$431.90 ,$185.10 ,$401.05 ,$444.24 ,$561.47 ,$462.75 
Carle BroMenn Medical Center,8292228,"REMOTE IMAGE RETINA, MONITOR/MANAGE ACTIVE DISEASE",,92228,400,$230.00 ,$230.00 ,$69.00 ,$209.30 ,$161.00 ,$69.00 ,$149.50 ,$165.60 ,$209.30 ,$172.50 
Carle BroMenn Medical Center,8400279,BREAST TOMOSYNTHESIS UNILATERAL OR BILATERAL,,G0279,401,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8477056,MAMMOGRAPHY BILATERAL,,77056,401,$340.00 ,$340.00 ,$102.00 ,$309.40 ,$238.00 ,$102.00 ,$221.00 ,$244.80 ,$309.40 ,$255.00 
Carle BroMenn Medical Center,8477061,DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,,G0279,401,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8477062,DIGITAL BREAST TOMOSYNTHESIS BILATERAL,,G0279,401,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8477065,DIAGNOSTIC MAMMOGRAPHY UNILAT W/CAD,,77065,401,$260.00 ,$260.00 ,$78.00 ,$236.60 ,$182.00 ,$78.00 ,$169.00 ,$187.20 ,$236.60 ,$195.00 
Carle BroMenn Medical Center,8477066,DIAGNOSTIC MAMMOGRAPHY BILAT W/CAD,,77066,401,$370.00 ,$370.00 ,$111.00 ,$336.70 ,$259.00 ,$111.00 ,$240.50 ,$266.40 ,$336.70 ,$277.50 
Carle BroMenn Medical Center,8026512,OPHTH US B W/NON-QUANT A,,76512,402,$315.00 ,$315.00 ,$94.50 ,$286.65 ,$220.50 ,$94.50 ,$204.75 ,$226.80 ,$286.65 ,$236.25 
Carle BroMenn Medical Center,8026815,OB SONO LIMITED,,76815,402,$735.00 ,$735.00 ,$220.50 ,$668.85 ,$514.50 ,$220.50 ,$477.75 ,$529.20 ,$668.85 ,$551.25 
Carle BroMenn Medical Center,8026817,OB SONO TRANSVAGINAL,,76817,402,$870.00 ,$870.00 ,$261.00 ,$791.70 ,$609.00 ,$261.00 ,$565.50 ,$626.40 ,$791.70 ,$652.50 
Carle BroMenn Medical Center,8026819,FETAL BIOPH PROF W/O STRESS/NS,,76819,402,$639.00 ,$639.00 ,$191.70 ,$581.49 ,$447.30 ,$191.70 ,$415.35 ,$460.08 ,$581.49 ,$479.25 
Carle BroMenn Medical Center,8130017,ULTRASND GUIDANCE NEEDLE PLACEMENT,,76942,402,$535.00 ,$535.00 ,$160.50 ,$486.85 ,$374.50 ,$160.50 ,$347.75 ,$385.20 ,$486.85 ,$401.25 
Carle BroMenn Medical Center,8206857,FOLLICLES SONO (REPRO MED),,76857,402,$560.00 ,$560.00 ,$168.00 ,$509.60 ,$392.00 ,$168.00 ,$364.00 ,$403.20 ,$509.60 ,$420.00 
Carle BroMenn Medical Center,8276512,OPHTH US B W/NON-QUANT A,,76512,402,$315.00 ,$315.00 ,$94.50 ,$286.65 ,$220.50 ,$94.50 ,$204.75 ,$226.80 ,$286.65 ,$236.25 
Carle BroMenn Medical Center,8276513,US EYE ANTERIOR,,76513,402,$435.00 ,$435.00 ,$130.50 ,$395.85 ,$304.50 ,$130.50 ,$282.75 ,$313.20 ,$395.85 ,$326.25 
Carle BroMenn Medical Center,8276514,OPHTHALMIC ULTRASOUND ECHOGRAPHY DX CORNEAL PACHYMETRY,,76514,402,$84.00 ,$84.00 ,$25.20 ,$76.44 ,$58.80 ,$25.20 ,$54.60 ,$60.48 ,$76.44 ,$63.00 
Carle BroMenn Medical Center,8276519,OPHTHALMIC BIOMETRY ULTRASOUND ECHOGRAPHY A-SCAN W/INTRAOCULAR LENS POWER CALCULATION,,76519,402,$650.00 ,$650.00 ,$195.00 ,$591.50 ,$455.00 ,$195.00 ,$422.50 ,$468.00 ,$591.50 ,$487.50 
Carle BroMenn Medical Center,8276604,ULTRASOUND -CHEST,,76604,402,$710.00 ,$710.00 ,$213.00 ,$646.10 ,$497.00 ,$213.00 ,$461.50 ,$511.20 ,$646.10 ,$532.50 
Carle BroMenn Medical Center,8276642,US BREAST UNILATERAL LIMITED,,76642,402,$460.00 ,$460.00 ,$138.00 ,$418.60 ,$322.00 ,$138.00 ,$299.00 ,$331.20 ,$418.60 ,$345.00 
Carle BroMenn Medical Center,8276705,ULTRASOUND ABDMNL LIMITED W/O CONTRAST,,76705,402,$710.00 ,$710.00 ,$213.00 ,$646.10 ,$497.00 ,$213.00 ,$461.50 ,$511.20 ,$646.10 ,$532.50 
Carle BroMenn Medical Center,8276706,US ABD AORTA REAL TIME SCREEN STUDY AAA,,76706,402,$850.00 ,$850.00 ,$255.00 ,$773.50 ,$595.00 ,$255.00 ,$552.50 ,$612.00 ,$773.50 ,$637.50 
Carle BroMenn Medical Center,8276775,ULTRASOUND RETRPRTNL LIMITED,,76775,402,$710.00 ,$710.00 ,$213.00 ,$646.10 ,$497.00 ,$213.00 ,$461.50 ,$511.20 ,$646.10 ,$532.50 
Carle BroMenn Medical Center,8276815,OB SONO LIMITED,,76815,402,$735.00 ,$735.00 ,$220.50 ,$668.85 ,$514.50 ,$220.50 ,$477.75 ,$529.20 ,$668.85 ,$551.25 
Carle BroMenn Medical Center,8276817,OB SONO TRANSVAGINAL,,76817,402,$870.00 ,$870.00 ,$261.00 ,$791.70 ,$609.00 ,$261.00 ,$565.50 ,$626.40 ,$791.70 ,$652.50 
Carle BroMenn Medical Center,8276818,FETAL BIOPHYSICAL PROFILE W/NS,,76818,402,$790.00 ,$790.00 ,$237.00 ,$718.90 ,$553.00 ,$237.00 ,$513.50 ,$568.80 ,$718.90 ,$592.50 
Carle BroMenn Medical Center,8276831,"SONO EXAM, HYSTEROSONOGRAPHY",,76831,402,$890.00 ,$890.00 ,$267.00 ,$809.90 ,$623.00 ,$267.00 ,$578.50 ,$640.80 ,$809.90 ,$667.50 
Carle BroMenn Medical Center,8276857,ULTRASOUND PELVIS LIMITED,,76857,402,$560.00 ,$560.00 ,$168.00 ,$509.60 ,$392.00 ,$168.00 ,$364.00 ,$403.20 ,$509.60 ,$420.00 
Carle BroMenn Medical Center,8276872,"RASOUND, TRANSRECTAL",,76872,402,$790.00 ,$790.00 ,$237.00 ,$718.90 ,$553.00 ,$237.00 ,$513.50 ,$568.80 ,$718.90 ,$592.50 
Carle BroMenn Medical Center,8276873,RASOUND PROSTATE VOL STDY BRCYTHRPY PLN,,76873,402,$710.00 ,$710.00 ,$213.00 ,$646.10 ,$497.00 ,$213.00 ,$461.50 ,$511.20 ,$646.10 ,$532.50 
Carle BroMenn Medical Center,8276881,ULTRASOUND EXTREMITY COMPLETE,,76881,402,$445.00 ,$445.00 ,$133.50 ,$404.95 ,$311.50 ,$133.50 ,$289.25 ,$320.40 ,$404.95 ,$333.75 
Carle BroMenn Medical Center,8276882,ULTRASOUND EXTREMITY LIMITED,,76882,402,$235.00 ,$235.00 ,$70.50 ,$213.85 ,$164.50 ,$70.50 ,$152.75 ,$169.20 ,$213.85 ,$176.25 
Carle BroMenn Medical Center,8276937,US GUIDED VASC ACCESS,,76937,402,$315.00 ,$315.00 ,$94.50 ,$286.65 ,$220.50 ,$94.50 ,$204.75 ,$226.80 ,$286.65 ,$236.25 
Carle BroMenn Medical Center,8276942,SONO GUIDE NEEDLE BIOPSY,,76942,402,$535.00 ,$535.00 ,$160.50 ,$486.85 ,$374.50 ,$160.50 ,$347.75 ,$385.20 ,$486.85 ,$401.25 
Carle BroMenn Medical Center,8276946,SONO GUIDE AMNIOCENTESIS,,76946,402,$420.00 ,$420.00 ,$126.00 ,$382.20 ,$294.00 ,$126.00 ,$273.00 ,$302.40 ,$382.20 ,$315.00 
Carle BroMenn Medical Center,8276977,"SONO BONE DENSITY MEASURE,PERIPHERAL",,76977,402,$280.00 ,$280.00 ,$84.00 ,$254.80 ,$196.00 ,$84.00 ,$182.00 ,$201.60 ,$254.80 ,$210.00 
Carle BroMenn Medical Center,8276999,UNLISTED ULTRASOUND PROCEDURE,,76999,402,$420.00 ,$420.00 ,$126.00 ,$382.20 ,$294.00 ,$126.00 ,$273.00 ,$302.40 ,$382.20 ,$315.00 
Carle BroMenn Medical Center,8291200,LIVER ELASTOGRAPHY W/O IMAG W/I&R,,91200,402,$380.00 ,$380.00 ,$114.00 ,$345.80 ,$266.00 ,$114.00 ,$247.00 ,$273.60 ,$345.80 ,$285.00 
Carle BroMenn Medical Center,8400365,VESSEL MAPPING HEMODIALYSIS ACCESS,,G0365,402,"$1,178.00 ","$1,178.00 ",$353.40 ,"$1,071.98 ",$824.60 ,$353.40 ,$765.70 ,$848.16 ,"$1,071.98 ",$883.50 
Carle BroMenn Medical Center,8476506,ECHOENCEPHALOGRAPHY,,76506,402,$615.00 ,$615.00 ,$184.50 ,$559.65 ,$430.50 ,$184.50 ,$399.75 ,$442.80 ,$559.65 ,$461.25 
Carle BroMenn Medical Center,8476519,ECHOGRAPHY A-SCAN,,76519,402,$405.00 ,$405.00 ,$121.50 ,$368.55 ,$283.50 ,$121.50 ,$263.25 ,$291.60 ,$368.55 ,$303.75 
Carle BroMenn Medical Center,8476536,ULTRASOUND -THYROID,,76536,402,$870.00 ,$870.00 ,$261.00 ,$791.70 ,$609.00 ,$261.00 ,$565.50 ,$626.40 ,$791.70 ,$652.50 
Carle BroMenn Medical Center,8476604,ULTRASOUND   -CHEST,,76604,402,$710.00 ,$710.00 ,$213.00 ,$646.10 ,$497.00 ,$213.00 ,$461.50 ,$511.20 ,$646.10 ,$532.50 
Carle BroMenn Medical Center,8476641,US BREAST UNILATERAL  COMPLETE,,76641,402,$695.00 ,$695.00 ,$208.50 ,$632.45 ,$486.50 ,$208.50 ,$451.75 ,$500.40 ,$632.45 ,$521.25 
Carle BroMenn Medical Center,8476642,US BREAST UNILATERAL LIMITED,,76642,402,$460.00 ,$460.00 ,$138.00 ,$418.60 ,$322.00 ,$138.00 ,$299.00 ,$331.20 ,$418.60 ,$345.00 
Carle BroMenn Medical Center,8476700,ULTRASOUND ABDMNL COMPLETE W/O CONTRAST,,76700,402,$770.00 ,$770.00 ,$231.00 ,$700.70 ,$539.00 ,$231.00 ,$500.50 ,$554.40 ,$700.70 ,$577.50 
Carle BroMenn Medical Center,8476705,ULTRASOUND ABDMNL LIMITED W/O CONTRAST,,76705,402,$710.00 ,$710.00 ,$213.00 ,$646.10 ,$497.00 ,$213.00 ,$461.50 ,$511.20 ,$646.10 ,$532.50 
Carle BroMenn Medical Center,8476706,US ABD AORTA REAL TIME SCREEN STUDY AAA,,76706,402,$850.00 ,$850.00 ,$255.00 ,$773.50 ,$595.00 ,$255.00 ,$552.50 ,$612.00 ,$773.50 ,$637.50 
Carle BroMenn Medical Center,8476770,ULTRASOUND RETRPRTNL COMPLETE,,76770,402,$870.00 ,$870.00 ,$261.00 ,$791.70 ,$609.00 ,$261.00 ,$565.50 ,$626.40 ,$791.70 ,$652.50 
Carle BroMenn Medical Center,8476775,ULTRASOUND RETRPRTNL LIMITED,,76775,402,$710.00 ,$710.00 ,$213.00 ,$646.10 ,$497.00 ,$213.00 ,$461.50 ,$511.20 ,$646.10 ,$532.50 
Carle BroMenn Medical Center,8476776,ULTRASOUND TRNSPLNTD KIDNEY,,76776,402,$953.00 ,$953.00 ,$285.90 ,$867.23 ,$667.10 ,$285.90 ,$619.45 ,$686.16 ,$867.23 ,$714.75 
Carle BroMenn Medical Center,8476800,ULTRASOUND SPINAL CANAL/CONTENTS,,76800,402,$375.00 ,$375.00 ,$112.50 ,$341.25 ,$262.50 ,$112.50 ,$243.75 ,$270.00 ,$341.25 ,$281.25 
Carle BroMenn Medical Center,8476801,ROUTINE OB SONO <14 WKS,,76801,402,$870.00 ,$870.00 ,$261.00 ,$791.70 ,$609.00 ,$261.00 ,$565.50 ,$626.40 ,$791.70 ,$652.50 
Carle BroMenn Medical Center,8476802,OB SONO ADNL GESTATION,,76802,402,$440.00 ,$440.00 ,$132.00 ,$400.40 ,$308.00 ,$132.00 ,$286.00 ,$316.80 ,$400.40 ,$330.00 
Carle BroMenn Medical Center,8476805,ROUTINE SCRN OB SONO > 14 WKS,,76805,402,$870.00 ,$870.00 ,$261.00 ,$791.70 ,$609.00 ,$261.00 ,$565.50 ,$626.40 ,$791.70 ,$652.50 
Carle BroMenn Medical Center,8476810,RTN OB SONO > 14 WK MULT GEST,,76810,402,$775.00 ,$775.00 ,$232.50 ,$705.25 ,$542.50 ,$232.50 ,$503.75 ,$558.00 ,$705.25 ,$581.25 
Carle BroMenn Medical Center,8476811,HIGH RISK OB SONO SINGLE OR 1RST GEST,,76811,402,$710.00 ,$710.00 ,$213.00 ,$646.10 ,$497.00 ,$213.00 ,$461.50 ,$511.20 ,$646.10 ,$532.50 
Carle BroMenn Medical Center,8476812,HIGH RISK OB SONO MULT GEST,,76812,402,$725.00 ,$725.00 ,$217.50 ,$659.75 ,$507.50 ,$217.50 ,$471.25 ,$522.00 ,$659.75 ,$543.75 
Carle BroMenn Medical Center,8476813,US PREG UTER NUCHAL MEAS 1ST TRIMSTR,,76813,402,$758.00 ,$758.00 ,$227.40 ,$689.78 ,$530.60 ,$227.40 ,$492.70 ,$545.76 ,$689.78 ,$568.50 
Carle BroMenn Medical Center,8476814,US PREG UTER NUCHAL MEAS 1ST TRIM EA ADD GEST,,76814,402,$326.00 ,$326.00 ,$97.80 ,$296.66 ,$228.20 ,$97.80 ,$211.90 ,$234.72 ,$296.66 ,$244.50 
Carle BroMenn Medical Center,8476815,OB SONO LIMITED,,76815,402,$735.00 ,$735.00 ,$220.50 ,$668.85 ,$514.50 ,$220.50 ,$477.75 ,$529.20 ,$668.85 ,$551.25 
Carle BroMenn Medical Center,8476816,OB SONO FOLLOW-UP TRANSABD,,76816,402,$825.00 ,$825.00 ,$247.50 ,$750.75 ,$577.50 ,$247.50 ,$536.25 ,$594.00 ,$750.75 ,$618.75 
Carle BroMenn Medical Center,8476817,OB SONO TRANSVAGINAL,,76817,402,$870.00 ,$870.00 ,$261.00 ,$791.70 ,$609.00 ,$261.00 ,$565.50 ,$626.40 ,$791.70 ,$652.50 
Carle BroMenn Medical Center,8476818,FETAL BIOPHYSICAL PROFILE W/NS,,76818,402,$747.00 ,$747.00 ,$224.10 ,$679.77 ,$522.90 ,$224.10 ,$485.55 ,$537.84 ,$679.77 ,$560.25 
Carle BroMenn Medical Center,8476819,FETAL BIOPH PROF W/O STRESS/NS,,76819,402,$639.00 ,$639.00 ,$191.70 ,$581.49 ,$447.30 ,$191.70 ,$415.35 ,$460.08 ,$581.49 ,$479.25 
Carle BroMenn Medical Center,8476820,DOPPLER -FETAL UMBILICAL ARTRY,,76820,402,$675.00 ,$675.00 ,$202.50 ,$614.25 ,$472.50 ,$202.50 ,$438.75 ,$486.00 ,$614.25 ,$506.25 
Carle BroMenn Medical Center,8476821,DOPPLER MID CEREBRAL ARTERY,,76821,402,$720.00 ,$720.00 ,$216.00 ,$655.20 ,$504.00 ,$216.00 ,$468.00 ,$518.40 ,$655.20 ,$540.00 
Carle BroMenn Medical Center,8476825,FETAL ECHOCARDIOGRAPHY,,76825,402,"$1,078.00 ","$1,078.00 ",$323.40 ,$980.98 ,$754.60 ,$323.40 ,$700.70 ,$776.16 ,$980.98 ,$808.50 
Carle BroMenn Medical Center,8476826,FETAL ECHOCARD F/U OR REPEAT,,76826,402,$810.00 ,$810.00 ,$243.00 ,$737.10 ,$567.00 ,$243.00 ,$526.50 ,$583.20 ,$737.10 ,$607.50 
Carle BroMenn Medical Center,8476827,FETAL DOPPLER ECHOCARD COMPLT,,76827,402,$592.00 ,$592.00 ,$177.60 ,$538.72 ,$414.40 ,$177.60 ,$384.80 ,$426.24 ,$538.72 ,$444.00 
Carle BroMenn Medical Center,8476828,FETAL DOPPLER ECHOCARD F/U-RPT,,76828,402,$720.00 ,$720.00 ,$216.00 ,$655.20 ,$504.00 ,$216.00 ,$468.00 ,$518.40 ,$655.20 ,$540.00 
Carle BroMenn Medical Center,8476830,ULTRASOUND TRANSVAGINAL,,76830,402,$870.00 ,$870.00 ,$261.00 ,$791.70 ,$609.00 ,$261.00 ,$565.50 ,$626.40 ,$791.70 ,$652.50 
Carle BroMenn Medical Center,8476831,"SONO EXAM, HYSTEROSONOGRAPHY",,76831,402,$890.00 ,$890.00 ,$267.00 ,$809.90 ,$623.00 ,$267.00 ,$578.50 ,$640.80 ,$809.90 ,$667.50 
Carle BroMenn Medical Center,8476856,ULTRASOUND PELVIS COMPLETE,,76856,402,$870.00 ,$870.00 ,$261.00 ,$791.70 ,$609.00 ,$261.00 ,$565.50 ,$626.40 ,$791.70 ,$652.50 
Carle BroMenn Medical Center,8476857,ULTRASOUND PELVIS LIMITED,,76857,402,$560.00 ,$560.00 ,$168.00 ,$509.60 ,$392.00 ,$168.00 ,$364.00 ,$403.20 ,$509.60 ,$420.00 
Carle BroMenn Medical Center,8476870,ULTRASOUNDSCROTUM,,76870,402,$870.00 ,$870.00 ,$261.00 ,$791.70 ,$609.00 ,$261.00 ,$565.50 ,$626.40 ,$791.70 ,$652.50 
Carle BroMenn Medical Center,8476872,ULTRASOUND PROSTATE,,76872,402,$790.00 ,$790.00 ,$237.00 ,$718.90 ,$553.00 ,$237.00 ,$513.50 ,$568.80 ,$718.90 ,$592.50 
Carle BroMenn Medical Center,8476873,US PROSTATE VOLUME STUDY,,76873,402,$715.00 ,$715.00 ,$214.50 ,$650.65 ,$500.50 ,$214.50 ,$464.75 ,$514.80 ,$650.65 ,$536.25 
Carle BroMenn Medical Center,8476882,ULTRASOUND EXTREMITY LIMITED,,76882,402,$235.00 ,$235.00 ,$70.50 ,$213.85 ,$164.50 ,$70.50 ,$152.75 ,$169.20 ,$213.85 ,$176.25 
Carle BroMenn Medical Center,8476883,ULTRASOUND EXTREMITY COMPLETE,,76881,402,$445.00 ,$445.00 ,$133.50 ,$404.95 ,$311.50 ,$133.50 ,$289.25 ,$320.40 ,$404.95 ,$333.75 
Carle BroMenn Medical Center,8476885,ULTRASND INFANT HIPS W/MANIP,,76885,402,$460.00 ,$460.00 ,$138.00 ,$418.60 ,$322.00 ,$138.00 ,$299.00 ,$331.20 ,$418.60 ,$345.00 
Carle BroMenn Medical Center,8476886,"US INFANT HIPS, LIMITED, STATIC",,76886,402,$460.00 ,$460.00 ,$138.00 ,$418.60 ,$322.00 ,$138.00 ,$299.00 ,$331.20 ,$418.60 ,$345.00 
Carle BroMenn Medical Center,8476930,US GUIDE/PERICARDIOCENTESIS,,76930,402,$495.00 ,$495.00 ,$148.50 ,$450.45 ,$346.50 ,$148.50 ,$321.75 ,$356.40 ,$450.45 ,$371.25 
Carle BroMenn Medical Center,8476936,ULTRASOUND COMPRESSION REPAIR,,76936,402,"$1,625.00 ","$1,625.00 ",$487.50 ,"$1,478.75 ","$1,137.50 ",$487.50 ,"$1,056.25 ","$1,170.00 ","$1,478.75 ","$1,218.75 "
Carle BroMenn Medical Center,8476937,US GUIDED VASC ACCESS,,76937,402,$315.00 ,$315.00 ,$94.50 ,$286.65 ,$220.50 ,$94.50 ,$204.75 ,$226.80 ,$286.65 ,$236.25 
Carle BroMenn Medical Center,8476940,ULTRASOUND GUIDANCE TISSUE ABLATION,,76940,402,$730.00 ,$730.00 ,$219.00 ,$664.30 ,$511.00 ,$219.00 ,$474.50 ,$525.60 ,$664.30 ,$547.50 
Carle BroMenn Medical Center,8476942,ULTRASND GUIDANCE ASP/BX/DRAIN,,76942,402,$535.00 ,$535.00 ,$160.50 ,$486.85 ,$374.50 ,$160.50 ,$347.75 ,$385.20 ,$486.85 ,$401.25 
Carle BroMenn Medical Center,8476946,ULTRASOUND GUIDANCE FOR AMNIO,,76946,402,$420.00 ,$420.00 ,$126.00 ,$382.20 ,$294.00 ,$126.00 ,$273.00 ,$302.40 ,$382.20 ,$315.00 
Carle BroMenn Medical Center,8476948,SONO GUIDE OVA ASPIRATION,,76948,402,"$1,155.00 ","$1,155.00 ",$346.50 ,"$1,051.05 ",$808.50 ,$346.50 ,$750.75 ,$831.60 ,"$1,051.05 ",$866.25 
Carle BroMenn Medical Center,8476965,ULTRASND GUIDNC INTERSTITL APP,,76965,402,$750.00 ,$750.00 ,$225.00 ,$682.50 ,$525.00 ,$225.00 ,$487.50 ,$540.00 ,$682.50 ,$562.50 
Carle BroMenn Medical Center,8476970,ULTRASND F/U STUDY,,76970,402,$300.00 ,$300.00 ,$90.00 ,$273.00 ,$210.00 ,$90.00 ,$195.00 ,$216.00 ,$273.00 ,$225.00 
Carle BroMenn Medical Center,8476978,ULTRASOUND TRGT DYNAMIC MICROBUBBLE 1ST LESION,,76978,402,$930.00 ,$930.00 ,$279.00 ,$846.30 ,$651.00 ,$279.00 ,$604.50 ,$669.60 ,$846.30 ,$697.50 
Carle BroMenn Medical Center,8476979,ULTRASOUND TRGT DYNAMIC MICROBUBBLE EA ADDL LES,,76979,402,$465.00 ,$465.00 ,$139.50 ,$423.15 ,$325.50 ,$139.50 ,$302.25 ,$334.80 ,$423.15 ,$348.75 
Carle BroMenn Medical Center,8476981,ULTRASOUND ELASTOGRAPHY PARENCHYMA,,76981,402,$308.00 ,$308.00 ,$92.40 ,$280.28 ,$215.60 ,$92.40 ,$200.20 ,$221.76 ,$280.28 ,$231.00 
Carle BroMenn Medical Center,8476982,ULTRASOUND ELASTOGRAPHY FIRST TARGET LESION,,76982,402,$308.00 ,$308.00 ,$92.40 ,$280.28 ,$215.60 ,$92.40 ,$200.20 ,$221.76 ,$280.28 ,$231.00 
Carle BroMenn Medical Center,8476983,ULTRASOUND ELASTOGRAPHY EA ADDL TAGET LESION,,76983,402,$233.00 ,$233.00 ,$69.90 ,$212.03 ,$163.10 ,$69.90 ,$151.45 ,$167.76 ,$212.03 ,$174.75 
Carle BroMenn Medical Center,8476998,ULTRASOUND GUIDANCE -INTRAOP,,76998,402,$740.00 ,$740.00 ,$222.00 ,$673.40 ,$518.00 ,$222.00 ,$481.00 ,$532.80 ,$673.40 ,$555.00 
Carle BroMenn Medical Center,8476999,ULTRASOUND -SOFT TISSUE BACK,,76999,402,$420.00 ,$420.00 ,$126.00 ,$382.20 ,$294.00 ,$126.00 ,$273.00 ,$302.40 ,$382.20 ,$315.00 
Carle BroMenn Medical Center,8876512,US OPHTHALMIC,,76512,402,$315.00 ,$315.00 ,$94.50 ,$286.65 ,$220.50 ,$94.50 ,$204.75 ,$226.80 ,$286.65 ,$236.25 
Carle BroMenn Medical Center,8876536,US HEAD/NECK SOFT TISSUES,,76536,402,$870.00 ,$870.00 ,$261.00 ,$791.70 ,$609.00 ,$261.00 ,$565.50 ,$626.40 ,$791.70 ,$652.50 
Carle BroMenn Medical Center,8876604,US CHEST,,76604,402,$710.00 ,$710.00 ,$213.00 ,$646.10 ,$497.00 ,$213.00 ,$461.50 ,$511.20 ,$646.10 ,$532.50 
Carle BroMenn Medical Center,8876642,US BREAST UNILATERAL LIMITED,,76642,402,$460.00 ,$460.00 ,$138.00 ,$418.60 ,$322.00 ,$138.00 ,$299.00 ,$331.20 ,$418.60 ,$345.00 
Carle BroMenn Medical Center,8876705,US LIMITED ABDOMINAL AREA,,76705,402,$710.00 ,$710.00 ,$213.00 ,$646.10 ,$497.00 ,$213.00 ,$461.50 ,$511.20 ,$646.10 ,$532.50 
Carle BroMenn Medical Center,8876775,US AAA LIMITED,,76775,402,$710.00 ,$710.00 ,$213.00 ,$646.10 ,$497.00 ,$213.00 ,$461.50 ,$511.20 ,$646.10 ,$532.50 
Carle BroMenn Medical Center,8876815,LIMITED US PREGNANT UTERUS,,76815,402,$735.00 ,$735.00 ,$220.50 ,$668.85 ,$514.50 ,$220.50 ,$477.75 ,$529.20 ,$668.85 ,$551.25 
Carle BroMenn Medical Center,8876817,US PREG UTERUS TRANSVAG,,76817,402,$870.00 ,$870.00 ,$261.00 ,$791.70 ,$609.00 ,$261.00 ,$565.50 ,$626.40 ,$791.70 ,$652.50 
Carle BroMenn Medical Center,8876857,LIMITED US PELVIC (NON-OB),,76857,402,$560.00 ,$560.00 ,$168.00 ,$509.60 ,$392.00 ,$168.00 ,$364.00 ,$403.20 ,$509.60 ,$420.00 
Carle BroMenn Medical Center,8876870,US SCROTUM AND CONTENTS,,76870,402,$870.00 ,$870.00 ,$261.00 ,$791.70 ,$609.00 ,$261.00 ,$565.50 ,$626.40 ,$791.70 ,$652.50 
Carle BroMenn Medical Center,8876882,US EXTREMITY LIMITED,,76882,402,$235.00 ,$235.00 ,$70.50 ,$213.85 ,$164.50 ,$70.50 ,$152.75 ,$169.20 ,$213.85 ,$176.25 
Carle BroMenn Medical Center,8876886,"US INFANT HIPS, LIMITED, STATIC",,76886,402,$460.00 ,$460.00 ,$138.00 ,$418.60 ,$322.00 ,$138.00 ,$299.00 ,$331.20 ,$418.60 ,$345.00 
Carle BroMenn Medical Center,8876937,US GUIDED VASC ACCESS,,76937,402,$315.00 ,$315.00 ,$94.50 ,$286.65 ,$220.50 ,$94.50 ,$204.75 ,$226.80 ,$286.65 ,$236.25 
Carle BroMenn Medical Center,8876942,US GUIDE NEEDLE PLCMNT,,76942,402,$535.00 ,$535.00 ,$160.50 ,$486.85 ,$374.50 ,$160.50 ,$347.75 ,$385.20 ,$486.85 ,$401.25 
Carle BroMenn Medical Center,8876999,PROCEDURE - ULTRASOUND,,76999,402,$420.00 ,$420.00 ,$126.00 ,$382.20 ,$294.00 ,$126.00 ,$273.00 ,$302.40 ,$382.20 ,$315.00 
Carle BroMenn Medical Center,8970642,US GUIDED NDL PLACMENT,,76942,402,$535.00 ,$535.00 ,$160.50 ,$486.85 ,$374.50 ,$160.50 ,$347.75 ,$385.20 ,$486.85 ,$401.25 
Carle BroMenn Medical Center,8970937,US GUIDED VASC ACCESS,,76937,402,$315.00 ,$315.00 ,$94.50 ,$286.65 ,$220.50 ,$94.50 ,$204.75 ,$226.80 ,$286.65 ,$236.25 
Carle BroMenn Medical Center,8971604,US CHEST INCL MEDIATSTINUM,,76604,402,$710.00 ,$710.00 ,$213.00 ,$646.10 ,$497.00 ,$213.00 ,$461.50 ,$511.20 ,$646.10 ,$532.50 
Carle BroMenn Medical Center,8971775,ULTRASOUND RETRPRTNL LIMITED,,76775,402,$710.00 ,$710.00 ,$213.00 ,$646.10 ,$497.00 ,$213.00 ,$461.50 ,$511.20 ,$646.10 ,$532.50 
Carle BroMenn Medical Center,8971908,"BRST BX W/PLC LCL DVC US GUIDE, 1RST LSN",,19083,402,"$4,080.00 ","$4,080.00 ","$1,224.00 ","$3,712.80 ","$2,856.00 ","$1,224.00 ","$2,652.00 ","$2,937.60 ","$3,712.80 ","$3,060.00 "
Carle BroMenn Medical Center,8976536,ULTRASOUND -THYROID,,76536,402,$870.00 ,$870.00 ,$261.00 ,$791.70 ,$609.00 ,$261.00 ,$565.50 ,$626.40 ,$791.70 ,$652.50 
Carle BroMenn Medical Center,8976604,US CHEST INCL MEDIATSTINUM,,76604,402,$710.00 ,$710.00 ,$213.00 ,$646.10 ,$497.00 ,$213.00 ,$461.50 ,$511.20 ,$646.10 ,$532.50 
Carle BroMenn Medical Center,8976700,US ABDOMEN COMPLETE,,76700,402,$770.00 ,$770.00 ,$231.00 ,$700.70 ,$539.00 ,$231.00 ,$500.50 ,$554.40 ,$700.70 ,$577.50 
Carle BroMenn Medical Center,8976705,ULTRASOUND -ABDOMEN- LIMITED W/O CONTRAST,,76705,402,$710.00 ,$710.00 ,$213.00 ,$646.10 ,$497.00 ,$213.00 ,$461.50 ,$511.20 ,$646.10 ,$532.50 
Carle BroMenn Medical Center,8976775,ULTRASOUND RETRPRTNL LIMITED,,76775,402,$710.00 ,$710.00 ,$213.00 ,$646.10 ,$497.00 ,$213.00 ,$461.50 ,$511.20 ,$646.10 ,$532.50 
Carle BroMenn Medical Center,8976857,US PELVIS LTD,,76857,402,$560.00 ,$560.00 ,$168.00 ,$509.60 ,$392.00 ,$168.00 ,$364.00 ,$403.20 ,$509.60 ,$420.00 
Carle BroMenn Medical Center,8976882,US EXT NONVASC LIMITED,,76882,402,$235.00 ,$235.00 ,$70.50 ,$213.85 ,$164.50 ,$70.50 ,$152.75 ,$169.20 ,$213.85 ,$176.25 
Carle BroMenn Medical Center,8976930,US GUIDE/PERICARDIOCENTESIS,,76930,402,$495.00 ,$495.00 ,$148.50 ,$450.45 ,$346.50 ,$148.50 ,$321.75 ,$356.40 ,$450.45 ,$371.25 
Carle BroMenn Medical Center,8976932,US GUID/ENDOMYOCARDIAL BIOPSY,,76932,402,$803.00 ,$803.00 ,$240.90 ,$730.73 ,$562.10 ,$240.90 ,$521.95 ,$578.16 ,$730.73 ,$602.25 
Carle BroMenn Medical Center,8976936,US GUIDE COMPRESSION REPAIR PSEUDOANEURYSM,,76936,402,"$1,625.00 ","$1,625.00 ",$487.50 ,"$1,478.75 ","$1,137.50 ",$487.50 ,"$1,056.25 ","$1,170.00 ","$1,478.75 ","$1,218.75 "
Carle BroMenn Medical Center,8976937,US GUIDED VASC ACCESS,,76937,402,$315.00 ,$315.00 ,$94.50 ,$286.65 ,$220.50 ,$94.50 ,$204.75 ,$226.80 ,$286.65 ,$236.25 
Carle BroMenn Medical Center,8976940,ULTRASOUND GUIDANCE TISSUE ABLATION,,76940,402,$730.00 ,$730.00 ,$219.00 ,$664.30 ,$511.00 ,$219.00 ,$474.50 ,$525.60 ,$664.30 ,$547.50 
Carle BroMenn Medical Center,8976942,US GUIDED NDL PLACMENT,,76942,402,$535.00 ,$535.00 ,$160.50 ,$486.85 ,$374.50 ,$160.50 ,$347.75 ,$385.20 ,$486.85 ,$401.25 
Carle BroMenn Medical Center,8976978,ULTRASOUND TRGT DYNAMIC MICROBUBBLE 1ST LESION,,76978,402,$930.00 ,$930.00 ,$279.00 ,$846.30 ,$651.00 ,$279.00 ,$604.50 ,$669.60 ,$846.30 ,$697.50 
Carle BroMenn Medical Center,8976979,ULTRASOUND TRGT DYNAMIC MICROBUBBLE EA ADDL LES,,76979,402,$465.00 ,$465.00 ,$139.50 ,$423.15 ,$325.50 ,$139.50 ,$302.25 ,$334.80 ,$423.15 ,$348.75 
Carle BroMenn Medical Center,8976981,ULTRASOUND ELASTOGRAPHY PARENCHYMA,,76981,402,$308.00 ,$308.00 ,$92.40 ,$280.28 ,$215.60 ,$92.40 ,$200.20 ,$221.76 ,$280.28 ,$231.00 
Carle BroMenn Medical Center,8976982,ULTRASOUND ELASTOGRAPHY FIRST TARGET LESION,,76982,402,$308.00 ,$308.00 ,$92.40 ,$280.28 ,$215.60 ,$92.40 ,$200.20 ,$221.76 ,$280.28 ,$231.00 
Carle BroMenn Medical Center,8976983,ULTRASOUND ELASTOGRAPHY EA ADDL TAGET LESION,,76983,402,$233.00 ,$233.00 ,$69.90 ,$212.03 ,$163.10 ,$69.90 ,$151.45 ,$167.76 ,$212.03 ,$174.75 
Carle BroMenn Medical Center,8976998,ULTRASOUND GUIDANCE -INTRAOP,,76998,402,$740.00 ,$740.00 ,$222.00 ,$673.40 ,$518.00 ,$222.00 ,$481.00 ,$532.80 ,$673.40 ,$555.00 
Carle BroMenn Medical Center,8976999,PROCEDURE - ULTRASOUND,,76999,402,$420.00 ,$420.00 ,$126.00 ,$382.20 ,$294.00 ,$126.00 ,$273.00 ,$302.40 ,$382.20 ,$315.00 
Carle BroMenn Medical Center,8977323,US BIOPSY SOFT TISSUE KNEE OR THIGH,,27323,402,"$1,860.00 ","$1,860.00 ",$558.00 ,"$1,692.60 ","$1,302.00 ",$558.00 ,"$1,209.00 ","$1,339.20 ","$1,692.60 ","$1,395.00 "
Carle BroMenn Medical Center,8977705,ULTRASOUND -ABDOMEN- LIMITED,,76705,402,$710.00 ,$710.00 ,$213.00 ,$646.10 ,$497.00 ,$213.00 ,$461.50 ,$511.20 ,$646.10 ,$532.50 
Carle BroMenn Medical Center,8477063,SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL,,77063,403,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8477067,SCREENING MAMMOGRAPHY BILAT W/CAD,,77067,403,$425.00 ,$425.00 ,$127.50 ,$386.75 ,$297.50 ,$127.50 ,$276.25 ,$306.00 ,$386.75 ,$318.75 
Carle BroMenn Medical Center,8478608,PET/CT METABOLIC EVALUATION,,78608,404,"$6,495.00 ","$6,495.00 ","$1,948.50 ","$5,910.45 ","$4,546.50 ","$1,948.50 ","$4,221.75 ","$4,676.40 ","$5,910.45 ","$4,871.25 "
Carle BroMenn Medical Center,8478814,PET SCAN LIMITED AREA,,78814,404,"$6,495.00 ","$6,495.00 ","$1,948.50 ","$5,910.45 ","$4,546.50 ","$1,948.50 ","$4,221.75 ","$4,676.40 ","$5,910.45 ","$4,871.25 "
Carle BroMenn Medical Center,8478815,PET SCAN SKULL BASE TO MIDTHIGH,,78815,404,"$6,495.00 ","$6,495.00 ","$1,948.50 ","$5,910.45 ","$4,546.50 ","$1,948.50 ","$4,221.75 ","$4,676.40 ","$5,910.45 ","$4,871.25 "
Carle BroMenn Medical Center,8478816,PET/CT SCAN WHOLE BODY,,78816,404,"$6,495.00 ","$6,495.00 ","$1,948.50 ","$5,910.45 ","$4,546.50 ","$1,948.50 ","$4,221.75 ","$4,676.40 ","$5,910.45 ","$4,871.25 "
Carle BroMenn Medical Center,8024760,"PULSE OXIMETRY, SINGLE DETERM",,94760,410,$48.00 ,$48.00 ,$14.40 ,$43.68 ,$33.60 ,$14.40 ,$31.20 ,$34.56 ,$43.68 ,$36.00 
Carle BroMenn Medical Center,8294640,AIRWAY INHALATION TREATMENT,,94640,410,$90.00 ,$90.00 ,$27.00 ,$81.90 ,$63.00 ,$27.00 ,$58.50 ,$64.80 ,$81.90 ,$67.50 
Carle BroMenn Medical Center,8294644,"CONTINUOUS INHALATION TX, 1ST HR",,94644,410,$252.00 ,$252.00 ,$75.60 ,$229.32 ,$176.40 ,$75.60 ,$163.80 ,$181.44 ,$229.32 ,$189.00 
Carle BroMenn Medical Center,8294664,"DEMO &/OR EVAL,PT USE,AEROSOL DEVICE",,94664,410,$110.00 ,$110.00 ,$33.00 ,$100.10 ,$77.00 ,$33.00 ,$71.50 ,$79.20 ,$100.10 ,$82.50 
Carle BroMenn Medical Center,8294667,"CHEST WALL MANIPULATION,INITIAL",,94667,410,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8650001,21% AEROSOL / PER DAY,,,410,$540.00 ,$540.00 ,$162.00 ,$491.40 ,$378.00 ,$162.00 ,$351.00 ,$388.80 ,$491.40 ,$405.00 
Carle BroMenn Medical Center,8650002,21% AEROSOL/SHIFT,,,410,$73.00 ,$73.00 ,$21.90 ,$66.43 ,$51.10 ,$21.90 ,$47.45 ,$52.56 ,$66.43 ,$54.75 
Carle BroMenn Medical Center,8650004,AEROSOL / PER DAY,,94799,410,$803.00 ,$803.00 ,$240.90 ,$730.73 ,$562.10 ,$240.90 ,$521.95 ,$578.16 ,$730.73 ,$602.25 
Carle BroMenn Medical Center,8650005,AEROSOL/SHIFT,,,410,$113.00 ,$113.00 ,$33.90 ,$102.83 ,$79.10 ,$33.90 ,$73.45 ,$81.36 ,$102.83 ,$84.75 
Carle BroMenn Medical Center,8650006,BEDSIDE PULM/MECH,,,410,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8650007,BEDSIDE SPIROMETRY-LAP,,94010,410,$165.00 ,$165.00 ,$49.50 ,$150.15 ,$115.50 ,$49.50 ,$107.25 ,$118.80 ,$150.15 ,$123.75 
Carle BroMenn Medical Center,8650008,BI PAP / PER DAY,,94660,410,$365.00 ,$365.00 ,$109.50 ,$332.15 ,$255.50 ,$109.50 ,$237.25 ,$262.80 ,$332.15 ,$273.75 
Carle BroMenn Medical Center,8650009,BI PAP TREATMENT,,,410,$398.00 ,$398.00 ,$119.40 ,$362.18 ,$278.60 ,$119.40 ,$258.70 ,$286.56 ,$362.18 ,$298.50 
Carle BroMenn Medical Center,8650010,BI PAP/SHIFT,,,410,$244.00 ,$244.00 ,$73.20 ,$222.04 ,$170.80 ,$73.20 ,$158.60 ,$175.68 ,$222.04 ,$183.00 
Carle BroMenn Medical Center,8650011,CAL-SWAN,,94799,410,$109.00 ,$109.00 ,$32.70 ,$99.19 ,$76.30 ,$32.70 ,$70.85 ,$78.48 ,$99.19 ,$81.75 
Carle BroMenn Medical Center,8650012,CARDIAC OUTPUT PROFILE,,,410,$191.00 ,$191.00 ,$57.30 ,$173.81 ,$133.70 ,$57.30 ,$124.15 ,$137.52 ,$173.81 ,$143.25 
Carle BroMenn Medical Center,8650013,CARDIAC PROFILE,,,410,$214.00 ,$214.00 ,$64.20 ,$194.74 ,$149.80 ,$64.20 ,$139.10 ,$154.08 ,$194.74 ,$160.50 
Carle BroMenn Medical Center,8650014,CAT SCAN VENT,,,410,$735.00 ,$735.00 ,$220.50 ,$668.85 ,$514.50 ,$220.50 ,$477.75 ,$529.20 ,$668.85 ,$551.25 
Carle BroMenn Medical Center,8650015,CBG,,82803,410,$353.00 ,$353.00 ,$105.90 ,$321.23 ,$247.10 ,$105.90 ,$229.45 ,$254.16 ,$321.23 ,$264.75 
Carle BroMenn Medical Center,8650016,CHEST PHYSIOTHERAPY,,94669,410,$103.00 ,$103.00 ,$30.90 ,$93.73 ,$72.10 ,$30.90 ,$66.95 ,$74.16 ,$93.73 ,$77.25 
Carle BroMenn Medical Center,8650017,CO2 MONITOR,,,410,$158.00 ,$158.00 ,$47.40 ,$143.78 ,$110.60 ,$47.40 ,$102.70 ,$113.76 ,$143.78 ,$118.50 
Carle BroMenn Medical Center,8650018,CONSULT/INSTRUCT,,,410,$143.00 ,$143.00 ,$42.90 ,$130.13 ,$100.10 ,$42.90 ,$92.95 ,$102.96 ,$130.13 ,$107.25 
Carle BroMenn Medical Center,8650019,CONSULT/INSTRUCT-OUT,,,410,$86.00 ,$86.00 ,$25.80 ,$78.26 ,$60.20 ,$25.80 ,$55.90 ,$61.92 ,$78.26 ,$64.50 
Carle BroMenn Medical Center,8650020,CPAP / PER DAY,,94660,410,$365.00 ,$365.00 ,$109.50 ,$332.15 ,$255.50 ,$109.50 ,$237.25 ,$262.80 ,$332.15 ,$273.75 
Carle BroMenn Medical Center,8650021,CPAP/SHIFT,,,410,$244.00 ,$244.00 ,$73.20 ,$222.04 ,$170.80 ,$73.20 ,$158.60 ,$175.68 ,$222.04 ,$183.00 
Carle BroMenn Medical Center,8650022,CPT PER BED,,94669,410,$103.00 ,$103.00 ,$30.90 ,$93.73 ,$72.10 ,$30.90 ,$66.95 ,$74.16 ,$93.73 ,$77.25 
Carle BroMenn Medical Center,8650024,HELIOX THERAPY PER HOUR,,,410,$68.00 ,$68.00 ,$20.40 ,$61.88 ,$47.60 ,$20.40 ,$44.20 ,$48.96 ,$61.88 ,$51.00 
Carle BroMenn Medical Center,8650025,INSERTION  -ARTERIAL LINE,,36620,410,$510.00 ,$510.00 ,$153.00 ,$464.10 ,$357.00 ,$153.00 ,$331.50 ,$367.20 ,$464.10 ,$382.50 
Carle BroMenn Medical Center,8650026,INTRAPULMONARY PERCUSSIVE VENT-INITIAL,,94667,410,$109.00 ,$109.00 ,$32.70 ,$99.19 ,$76.30 ,$32.70 ,$70.85 ,$78.48 ,$99.19 ,$81.75 
Carle BroMenn Medical Center,8650028,IPPB TREATMENT,,,410,$120.00 ,$120.00 ,$36.00 ,$109.20 ,$84.00 ,$36.00 ,$78.00 ,$86.40 ,$109.20 ,$90.00 
Carle BroMenn Medical Center,8650029,IS INSTRUCT,,94799,410,$180.00 ,$180.00 ,$54.00 ,$163.80 ,$126.00 ,$54.00 ,$117.00 ,$129.60 ,$163.80 ,$135.00 
Carle BroMenn Medical Center,8650032,JET VENT & VENT MGMNT -DAILY,,94002,410,"$2,730.00 ","$2,730.00 ",$819.00 ,"$2,484.30 ","$1,911.00 ",$819.00 ,"$1,774.50 ","$1,965.60 ","$2,484.30 ","$2,047.50 "
Carle BroMenn Medical Center,8650033,MDI TREATMENT,,94640,410,$90.00 ,$90.00 ,$27.00 ,$81.90 ,$63.00 ,$27.00 ,$58.50 ,$64.80 ,$81.90 ,$67.50 
Carle BroMenn Medical Center,8650034,MET MEAS. SCREEN IN,,,410,$458.00 ,$458.00 ,$137.40 ,$416.78 ,$320.60 ,$137.40 ,$297.70 ,$329.76 ,$416.78 ,$343.50 
Carle BroMenn Medical Center,8650035,MET MEAS. SCREEN OUT,,,410,$458.00 ,$458.00 ,$137.40 ,$416.78 ,$320.60 ,$137.40 ,$297.70 ,$329.76 ,$416.78 ,$343.50 
Carle BroMenn Medical Center,8650037,NEO CHEST PHYSIOTHERAPY,,94667,410,$113.00 ,$113.00 ,$33.90 ,$102.83 ,$79.10 ,$33.90 ,$73.45 ,$81.36 ,$102.83 ,$84.75 
Carle BroMenn Medical Center,8650038,NEO CORD PH,,83986,410,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8650039,NEO DELIVERY,,,410,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8650040,NEO NEBULIZER TREATMENT,,94640,410,$143.00 ,$143.00 ,$42.90 ,$130.13 ,$100.10 ,$42.90 ,$92.95 ,$102.96 ,$130.13 ,$107.25 
Carle BroMenn Medical Center,8650042,NEO OXYGEN / PER DAY,,94799,410,$555.00 ,$555.00 ,$166.50 ,$505.05 ,$388.50 ,$166.50 ,$360.75 ,$399.60 ,$505.05 ,$416.25 
Carle BroMenn Medical Center,8650043,NEO OXYGEN/SHIFT,,,410,$109.00 ,$109.00 ,$32.70 ,$99.19 ,$76.30 ,$32.70 ,$70.85 ,$78.48 ,$99.19 ,$81.75 
Carle BroMenn Medical Center,8650044,NEO TCM -EAR OXIMETRY/PER DAY,,,410,$653.00 ,$653.00 ,$195.90 ,$594.23 ,$457.10 ,$195.90 ,$424.45 ,$470.16 ,$594.23 ,$489.75 
Carle BroMenn Medical Center,8650045,NEO TRANSPORT-OUT,,,410,$214.00 ,$214.00 ,$64.20 ,$194.74 ,$149.80 ,$64.20 ,$139.10 ,$154.08 ,$194.74 ,$160.50 
Carle BroMenn Medical Center,8650046,NEO VENT / PER DAY,,,410,"$2,310.00 ","$2,310.00 ",$693.00 ,"$2,102.10 ","$1,617.00 ",$693.00 ,"$1,501.50 ","$1,663.20 ","$2,102.10 ","$1,732.50 "
Carle BroMenn Medical Center,8650047,NEO VENT TRANSPORT,,,410,$214.00 ,$214.00 ,$64.20 ,$194.74 ,$149.80 ,$64.20 ,$139.10 ,$154.08 ,$194.74 ,$160.50 
Carle BroMenn Medical Center,8650048,NEO VENT / PER DAY,,94002,410,"$2,280.00 ","$2,280.00 ",$684.00 ,"$2,074.80 ","$1,596.00 ",$684.00 ,"$1,482.00 ","$1,641.60 ","$2,074.80 ","$1,710.00 "
Carle BroMenn Medical Center,8650049,NEO VENT-CPAP/SHIFT,,,410,$503.00 ,$503.00 ,$150.90 ,$457.73 ,$352.10 ,$150.90 ,$326.95 ,$362.16 ,$457.73 ,$377.25 
Carle BroMenn Medical Center,8650050,NOVA PROFILE ANALYSIS,,,410,$203.00 ,$203.00 ,$60.90 ,$184.73 ,$142.10 ,$60.90 ,$131.95 ,$146.16 ,$184.73 ,$152.25 
Carle BroMenn Medical Center,8650051,OSA  C-PAP,,94660,410,$365.00 ,$365.00 ,$109.50 ,$332.15 ,$255.50 ,$109.50 ,$237.25 ,$262.80 ,$332.15 ,$273.75 
Carle BroMenn Medical Center,8650053,OXYGEN/SHIFT,,,410,$65.00 ,$65.00 ,$19.50 ,$59.15 ,$45.50 ,$19.50 ,$42.25 ,$46.80 ,$59.15 ,$48.75 
Carle BroMenn Medical Center,8650054,PAR VENT AND TRANS,,,410,$840.00 ,$840.00 ,$252.00 ,$764.40 ,$588.00 ,$252.00 ,$546.00 ,$604.80 ,$764.40 ,$630.00 
Carle BroMenn Medical Center,8650055,PED TENT/SHIFT,,,410,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8650056,PULM MECHANICS,,,410,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8650059,RT TRACH CHANGE,,,410,$330.00 ,$330.00 ,$99.00 ,$300.30 ,$231.00 ,$99.00 ,$214.50 ,$237.60 ,$300.30 ,$247.50 
Carle BroMenn Medical Center,8650060,RT USN TREATMENT,,,410,$86.00 ,$86.00 ,$25.80 ,$78.26 ,$60.20 ,$25.80 ,$55.90 ,$61.92 ,$78.26 ,$64.50 
Carle BroMenn Medical Center,8650061,SHUNT & CARDIAC PROFILE,,,410,$263.00 ,$263.00 ,$78.90 ,$239.33 ,$184.10 ,$78.90 ,$170.95 ,$189.36 ,$239.33 ,$197.25 
Carle BroMenn Medical Center,8650062,SHUNT STUDY,,,410,$214.00 ,$214.00 ,$64.20 ,$194.74 ,$149.80 ,$64.20 ,$139.10 ,$154.08 ,$194.74 ,$160.50 
Carle BroMenn Medical Center,8650064,SPUTUM INDUCTION,,94640,410,$154.00 ,$154.00 ,$46.20 ,$140.14 ,$107.80 ,$46.20 ,$100.10 ,$110.88 ,$140.14 ,$115.50 
Carle BroMenn Medical Center,8650065,TCM -EAR OXIMETRY/PER DAY,,94761,410,$74.00 ,$74.00 ,$22.20 ,$67.34 ,$51.80 ,$22.20 ,$48.10 ,$53.28 ,$67.34 ,$55.50 
Carle BroMenn Medical Center,8650066,TCM-OX/SHIFT,,,410,$143.00 ,$143.00 ,$42.90 ,$130.13 ,$100.10 ,$42.90 ,$92.95 ,$102.96 ,$130.13 ,$107.25 
Carle BroMenn Medical Center,8650067,THERAPIST TIME,,,410,$236.00 ,$236.00 ,$70.80 ,$214.76 ,$165.20 ,$70.80 ,$153.40 ,$169.92 ,$214.76 ,$177.00 
Carle BroMenn Medical Center,8650068,THERAPIST TIME 1/2 HR,,,410,$206.00 ,$206.00 ,$61.80 ,$187.46 ,$144.20 ,$61.80 ,$133.90 ,$148.32 ,$187.46 ,$154.50 
Carle BroMenn Medical Center,8650069,TRANSPORT OUT 1 HR,,,410,$214.00 ,$214.00 ,$64.20 ,$194.74 ,$149.80 ,$64.20 ,$139.10 ,$154.08 ,$194.74 ,$160.50 
Carle BroMenn Medical Center,8650070,TRANSP-OUT 1 HR,,,410,$214.00 ,$214.00 ,$64.20 ,$194.74 ,$149.80 ,$64.20 ,$139.10 ,$154.08 ,$194.74 ,$160.50 
Carle BroMenn Medical Center,8650071,USN TX,,,410,$86.00 ,$86.00 ,$25.80 ,$78.26 ,$60.20 ,$25.80 ,$55.90 ,$61.92 ,$78.26 ,$64.50 
Carle BroMenn Medical Center,8650073,VENT/SHIFT,,,410,$503.00 ,$503.00 ,$150.90 ,$457.73 ,$352.10 ,$150.90 ,$326.95 ,$362.16 ,$457.73 ,$377.25 
Carle BroMenn Medical Center,8650076,RCVRY CPAP,,94660,410,$365.00 ,$365.00 ,$109.50 ,$332.15 ,$255.50 ,$109.50 ,$237.25 ,$262.80 ,$332.15 ,$273.75 
Carle BroMenn Medical Center,8650079,INTRAPULMONARY PERCUSSIVE VENT - SUBSEQUENT,,94668,410,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8650080,NEO CPAP / PER DAY,,,410,$365.00 ,$365.00 ,$109.50 ,$332.15 ,$255.50 ,$109.50 ,$237.25 ,$262.80 ,$332.15 ,$273.75 
Carle BroMenn Medical Center,8651002,VENT MANAGEMENT -HOURLY,,94002,410,"$1,700.00 ","$1,700.00 ",$510.00 ,"$1,547.00 ","$1,190.00 ",$510.00 ,"$1,105.00 ","$1,224.00 ","$1,547.00 ","$1,275.00 "
Carle BroMenn Medical Center,8651642,PENTAMIDANE TREATMENT W/ INSTR,,94642,410,$120.00 ,$120.00 ,$36.00 ,$109.20 ,$84.00 ,$36.00 ,$78.00 ,$86.40 ,$109.20 ,$90.00 
Carle BroMenn Medical Center,8651664,NEBULIZER TREAT-OUT,,94664,410,$110.00 ,$110.00 ,$33.00 ,$100.10 ,$77.00 ,$33.00 ,$71.50 ,$79.20 ,$100.10 ,$82.50 
Carle BroMenn Medical Center,8651667,CPT-OUT,,94667,410,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8652664,SPUTUM INDUCTION,,94664,410,$110.00 ,$110.00 ,$33.00 ,$100.10 ,$77.00 ,$33.00 ,$71.50 ,$79.20 ,$100.10 ,$82.50 
Carle BroMenn Medical Center,8652667,"MANIP CHEST WALL - WITH DVC, INITIAL TXMNT",,94667,410,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8652668,"MANIP CHEST WALL - WITH DVC, SUBSQ TXMNT",,94668,410,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8652950,CPR,,92950,410,"$1,445.00 ","$1,445.00 ",$433.50 ,"$1,314.95 ","$1,011.50 ",$433.50 ,$939.25 ,"$1,040.40 ","$1,314.95 ","$1,083.75 "
Carle BroMenn Medical Center,8654002,VENT / PER DAY,,94002,410,"$1,700.00 ","$1,700.00 ",$510.00 ,"$1,547.00 ","$1,190.00 ",$510.00 ,"$1,105.00 ","$1,224.00 ","$1,547.00 ","$1,275.00 "
Carle BroMenn Medical Center,8654003,MECH. VENTILATOR SUBSEQUENT DAY,,94003,410,"$1,320.00 ","$1,320.00 ",$396.00 ,"$1,201.20 ",$924.00 ,$396.00 ,$858.00 ,$950.40 ,"$1,201.20 ",$990.00 
Carle BroMenn Medical Center,8654640,NEBULIZER TREATMENT,,94640,410,$90.00 ,$90.00 ,$27.00 ,$81.90 ,$63.00 ,$27.00 ,$58.50 ,$64.80 ,$81.90 ,$67.50 
Carle BroMenn Medical Center,8654642,PENTAMIDANE TREATMENT,,94642,410,$120.00 ,$120.00 ,$36.00 ,$109.20 ,$84.00 ,$36.00 ,$78.00 ,$86.40 ,$109.20 ,$90.00 
Carle BroMenn Medical Center,8654644,CONTINUOUS NEB FIRST HOUR,,94644,410,$252.00 ,$252.00 ,$75.60 ,$229.32 ,$176.40 ,$75.60 ,$163.80 ,$181.44 ,$229.32 ,$189.00 
Carle BroMenn Medical Center,8654645,CONTINUOUS NEB EACH ADD HOUR,,94645,410,$192.00 ,$192.00 ,$57.60 ,$174.72 ,$134.40 ,$57.60 ,$124.80 ,$138.24 ,$174.72 ,$144.00 
Carle BroMenn Medical Center,8654660,CPAP TREATMENT,,94660,410,$365.00 ,$365.00 ,$109.50 ,$332.15 ,$255.50 ,$109.50 ,$237.25 ,$262.80 ,$332.15 ,$273.75 
Carle BroMenn Medical Center,8654680,CO-OX SAT MV02-OUT,,94680,410,$158.00 ,$158.00 ,$47.40 ,$143.78 ,$110.60 ,$47.40 ,$102.70 ,$113.76 ,$143.78 ,$118.50 
Carle BroMenn Medical Center,8660237,15'ENDURANCE/STRENGTH EXERCISE,,G0237,410,$120.00 ,$120.00 ,$36.00 ,$109.20 ,$84.00 ,$36.00 ,$78.00 ,$86.40 ,$109.20 ,$90.00 
Carle BroMenn Medical Center,8660238,"EDUCATION/INSTRUCTION, 15 MIN",,G0238,410,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8660239,"PHYS & EXERCISE CONDITION, GRP",,G0239,410,$135.00 ,$135.00 ,$40.50 ,$122.85 ,$94.50 ,$40.50 ,$87.75 ,$97.20 ,$122.85 ,$101.25 
Carle BroMenn Medical Center,8664799,PULMONARY REHAB PH3 MONTHLY,,94799,410,$57.86 ,$57.86 ,$17.36 ,$52.65 ,$40.50 ,$17.36 ,$37.61 ,$41.66 ,$52.65 ,$43.40 
Carle BroMenn Medical Center,8667750,6 MINUTE WALK TEST,,97750,410,$140.00 ,$140.00 ,$42.00 ,$127.40 ,$98.00 ,$42.00 ,$91.00 ,$100.80 ,$127.40 ,$105.00 
Carle BroMenn Medical Center,8669211,ASSESS/EVAL W/WO 6 MINUTE WALK,,G0463,410,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8669799,PULMONARY REHAB PH3 WEEKLY,,94799,410,$14.86 ,$14.86 ,$4.46 ,$13.52 ,$10.40 ,$4.46 ,$9.66 ,$10.70 ,$13.52 ,$11.15 
Carle BroMenn Medical Center,8299183,HYPERBARIC OXYGEN TX,,G0277,413,$700.00 ,$700.00 ,$210.00 ,$637.00 ,$490.00 ,$210.00 ,$455.00 ,$504.00 ,$637.00 ,$525.00 
Carle BroMenn Medical Center,8919183,"HYPERBARIC OXYGEN TX PER 30""",,G0277,413,$700.00 ,$700.00 ,$210.00 ,$637.00 ,$490.00 ,$210.00 ,$455.00 ,$504.00 ,$637.00 ,$525.00 
Carle BroMenn Medical Center,8610003,CANCELLATION-24 HOURS OR LESS,,,420,$285.00 ,$285.00 ,$85.50 ,$259.35 ,$199.50 ,$85.50 ,$185.25 ,$205.20 ,$259.35 ,$213.75 
Carle BroMenn Medical Center,8610004,CANCELLATION-25 TO 48 HOURS,,,420,$143.00 ,$143.00 ,$42.90 ,$130.13 ,$100.10 ,$42.90 ,$92.95 ,$102.96 ,$130.13 ,$107.25 
Carle BroMenn Medical Center,8610006,DRIVERS EVALUATION,,,420,$315.00 ,$315.00 ,$94.50 ,$286.65 ,$220.50 ,$94.50 ,$204.75 ,$226.80 ,$286.65 ,$236.25 
Carle BroMenn Medical Center,8610014,PT EVAL/ASSESSMENT ON/LOC CODE 11,,96112,420,$18.13 ,$18.13 ,$5.44 ,$16.50 ,$12.69 ,$5.44 ,$11.78 ,$13.05 ,$16.50 ,$13.60 
Carle BroMenn Medical Center,8610015,PT EVAL/ASSESSMENT OFF/LOC CODE 12,,96112,420,$18.13 ,$18.13 ,$5.44 ,$16.50 ,$12.69 ,$5.44 ,$11.78 ,$13.05 ,$16.50 ,$13.60 
Carle BroMenn Medical Center,8610016,PT EVAL/ASSESSMENT OFF/LOC CODE 99,,96112,420,$18.13 ,$18.13 ,$5.44 ,$16.50 ,$12.69 ,$5.44 ,$11.78 ,$13.05 ,$16.50 ,$13.60 
Carle BroMenn Medical Center,8610017,PT SERVICES ON/LOC CODE 11,,97110,420,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8610018,PT SERVICES OFF/LOC CODE 12,,97110,420,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8610019,PT SERVICES OFF/LOC CODE 99,,97110,420,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8610020,PT IFSP MTG/DEV ON/LOC CODE 11,,99499,420,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8610021,PT IFSP MTG/DEV OFF/LOC CODE 12,,99499,420,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8610022,PT IFSP MTG/DEV OFF/LOC CODE 99,,99499,420,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8610025,PT EVAL - MOD COMPLEXITY,,97162,420,$315.00 ,$315.00 ,$94.50 ,$286.65 ,$220.50 ,$94.50 ,$204.75 ,$226.80 ,$286.65 ,$236.25 
Carle BroMenn Medical Center,8610026,PT EVAL - HIGH COMPLEXITY,,97163,420,$385.00 ,$385.00 ,$115.50 ,$350.35 ,$269.50 ,$115.50 ,$250.25 ,$277.20 ,$350.35 ,$288.75 
Carle BroMenn Medical Center,8610281,ELECTRICAL STIM FOR ULCERS,,G0281,420,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8610282,ELECTRICAL STIM FOR WOUNDS,,G0282,420,$74.00 ,$74.00 ,$22.20 ,$67.34 ,$51.80 ,$22.20 ,$48.10 ,$53.28 ,$67.34 ,$55.50 
Carle BroMenn Medical Center,8610283,ELECTRICAL STIMULATION,,G0283,420,$79.00 ,$79.00 ,$23.70 ,$71.89 ,$55.30 ,$23.70 ,$51.35 ,$56.88 ,$71.89 ,$59.25 
Carle BroMenn Medical Center,8610500,15' INDIVIDUAL SERVICE COORDIN,,T1017,420,$40.00 ,$40.00 ,$12.00 ,$36.40 ,$28.00 ,$12.00 ,$26.00 ,$28.80 ,$36.40 ,$30.00 
Carle BroMenn Medical Center,8610501,15' ASSESSMENT-ONSITE,,W8754,420,$40.00 ,$40.00 ,$12.00 ,$36.40 ,$28.00 ,$12.00 ,$26.00 ,$28.80 ,$36.40 ,$30.00 
Carle BroMenn Medical Center,8610901,BIOFEEDBACK-SPEC MUSCLE GRPS,,90901,420,$158.00 ,$158.00 ,$47.40 ,$143.78 ,$110.60 ,$47.40 ,$102.70 ,$113.76 ,$143.78 ,$118.50 
Carle BroMenn Medical Center,8610911,BIOFEEDBACK-PERINEAL MUSCLES,,90911,420,$266.00 ,$266.00 ,$79.80 ,$242.06 ,$186.20 ,$79.80 ,$172.90 ,$191.52 ,$242.06 ,$199.50 
Carle BroMenn Medical Center,8611022,LIQUID WHIRLPOOL,,97022,420,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8611105,SPLINT APP LNG ARM STAT 8-30',,29105,420,$290.00 ,$290.00 ,$87.00 ,$263.90 ,$203.00 ,$87.00 ,$188.50 ,$208.80 ,$263.90 ,$217.50 
Carle BroMenn Medical Center,8611110,15' INDIVIDUAL THERAPY-ONSITE,,97110,420,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8611125,SPLINT APP SHT ARM STAT 31-45',,29125,420,$295.00 ,$295.00 ,$88.50 ,$268.45 ,$206.50 ,$88.50 ,$191.75 ,$212.40 ,$268.45 ,$221.25 
Carle BroMenn Medical Center,8611130,SPLINT APP FINGER STAT 8-15',,29130,420,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8611131,SPLINT APP FINGER DYN 8-30',,29131,420,$275.00 ,$275.00 ,$82.50 ,$250.25 ,$192.50 ,$82.50 ,$178.75 ,$198.00 ,$250.25 ,$206.25 
Carle BroMenn Medical Center,8611260,"46-60"" STRAPPING ELBOW/WRIST",,29260,420,$365.00 ,$365.00 ,$109.50 ,$332.15 ,$255.50 ,$109.50 ,$237.25 ,$262.80 ,$332.15 ,$273.75 
Carle BroMenn Medical Center,8611280,"31-45"" STRAPPING HAND/FINGER",,29280,420,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8611499,15' IFSP DEVELOPMENT-ONSITE,,99499,420,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8611505,"SPLINT APP LONG LEG 61""-75""",,29505,420,$520.00 ,$520.00 ,$156.00 ,$473.20 ,$364.00 ,$156.00 ,$338.00 ,$374.40 ,$473.20 ,$390.00 
Carle BroMenn Medical Center,8611515,"SPLINT APP SHORT LEG 61""-75""",,29515,420,$520.00 ,$520.00 ,$156.00 ,$473.20 ,$364.00 ,$156.00 ,$338.00 ,$374.40 ,$473.20 ,$390.00 
Carle BroMenn Medical Center,8611540,"31""-60"" ORTH CUST FT/ANKL STRP",,29540,420,$375.00 ,$375.00 ,$112.50 ,$341.25 ,$262.50 ,$112.50 ,$243.75 ,$270.00 ,$341.25 ,$281.25 
Carle BroMenn Medical Center,8611602,"8-30"" NONSELECTIVE DEBRIDEMENT",,97602,420,$190.00 ,$190.00 ,$57.00 ,$172.90 ,$133.00 ,$57.00 ,$123.50 ,$136.80 ,$172.90 ,$142.50 
Carle BroMenn Medical Center,8611750,FUNCTIONAL TESTS & MEASURES,,97750,420,$140.00 ,$140.00 ,$42.00 ,$127.40 ,$98.00 ,$42.00 ,$91.00 ,$100.80 ,$127.40 ,$105.00 
Carle BroMenn Medical Center,8612022,WHIRLPOOL,,97022,420,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8612110,15' THERAPEUTIC EXERCISE,,97110,420,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8612125,SPLINT APP SHT ARM STAT 46-60',,29125,420,$355.00 ,$355.00 ,$106.50 ,$323.05 ,$248.50 ,$106.50 ,$230.75 ,$255.60 ,$323.05 ,$266.25 
Carle BroMenn Medical Center,8612201,ATC EVALUATION,,G0463,420,$185.00 ,$185.00 ,$55.50 ,$168.35 ,$129.50 ,$55.50 ,$120.25 ,$133.20 ,$168.35 ,$138.75 
Carle BroMenn Medical Center,8612260,"8-15"" STRAPPING ELBOW/WRIST",,29260,420,$190.00 ,$190.00 ,$57.00 ,$172.90 ,$133.00 ,$57.00 ,$123.50 ,$136.80 ,$172.90 ,$142.50 
Carle BroMenn Medical Center,8612280,"46-60"" STRAPPING HAND/FINGER",,29280,420,$345.00 ,$345.00 ,$103.50 ,$313.95 ,$241.50 ,$103.50 ,$224.25 ,$248.40 ,$313.95 ,$258.75 
Carle BroMenn Medical Center,8612505,"SPLINT APP LONG LEG 8""-30""",,29505,420,$295.00 ,$295.00 ,$88.50 ,$268.45 ,$206.50 ,$88.50 ,$191.75 ,$212.40 ,$268.45 ,$221.25 
Carle BroMenn Medical Center,8612515,"SPLINT APP SHORT LEG 8""-30""",,29515,420,$230.00 ,$230.00 ,$69.00 ,$209.30 ,$161.00 ,$69.00 ,$149.50 ,$165.60 ,$209.30 ,$172.50 
Carle BroMenn Medical Center,8612540,"8""-15"" ORTH CUST FT/ANKL STRP",,29540,420,$125.00 ,$125.00 ,$37.50 ,$113.75 ,$87.50 ,$37.50 ,$81.25 ,$90.00 ,$113.75 ,$93.75 
Carle BroMenn Medical Center,8612760,"ORTHOTIC MGMT & TRAINING 15""",,97760,420,$175.00 ,$175.00 ,$52.50 ,$159.25 ,$122.50 ,$52.50 ,$113.75 ,$126.00 ,$159.25 ,$131.25 
Carle BroMenn Medical Center,8613125,SPLINT APP SHT ARM STAT 8-15',,29125,420,$255.00 ,$255.00 ,$76.50 ,$232.05 ,$178.50 ,$76.50 ,$165.75 ,$183.60 ,$232.05 ,$191.25 
Carle BroMenn Medical Center,8613260,"31-45"" STRAPPING ELBOW/WRIST",,29260,420,$310.00 ,$310.00 ,$93.00 ,$282.10 ,$217.00 ,$93.00 ,$201.50 ,$223.20 ,$282.10 ,$232.50 
Carle BroMenn Medical Center,8613280,"8-15"" STRAPPING HAND/FINGER",,29280,420,$190.00 ,$190.00 ,$57.00 ,$172.90 ,$133.00 ,$57.00 ,$123.50 ,$136.80 ,$172.90 ,$142.50 
Carle BroMenn Medical Center,8615150,GROUP PT 31'-45',,97150,420,$115.00 ,$115.00 ,$34.50 ,$104.65 ,$80.50 ,$34.50 ,$74.75 ,$82.80 ,$104.65 ,$86.25 
Carle BroMenn Medical Center,8615992,"CANALITH REPOSITIONING PROCEDURE, PER DAY",,95992,420,$120.00 ,$120.00 ,$36.00 ,$109.20 ,$84.00 ,$36.00 ,$78.00 ,$86.40 ,$109.20 ,$90.00 
Carle BroMenn Medical Center,8616020,DRSG/DEBRID SMALL AREA,,16020,420,$580.00 ,$580.00 ,$174.00 ,$527.80 ,$406.00 ,$174.00 ,$377.00 ,$417.60 ,$527.80 ,$435.00 
Carle BroMenn Medical Center,8616025,DRSG/DEBRID MEDIUM SIZE AREA,,16025,420,$620.00 ,$620.00 ,$186.00 ,$564.20 ,$434.00 ,$186.00 ,$403.00 ,$446.40 ,$564.20 ,$465.00 
Carle BroMenn Medical Center,8616030,DRSG/DEBRID LARGE AREA,,16030,420,$790.00 ,$790.00 ,$237.00 ,$718.90 ,$553.00 ,$237.00 ,$513.50 ,$568.80 ,$718.90 ,$592.50 
Carle BroMenn Medical Center,8616150,"GROUP PT 46""-60""",,97150,420,$175.00 ,$175.00 ,$52.50 ,$159.25 ,$122.50 ,$52.50 ,$113.75 ,$126.00 ,$159.25 ,$131.25 
Carle BroMenn Medical Center,8617012,PELVIC & CERVICAL TRACTION,,97012,420,$76.00 ,$76.00 ,$22.80 ,$69.16 ,$53.20 ,$22.80 ,$49.40 ,$54.72 ,$69.16 ,$57.00 
Carle BroMenn Medical Center,8617014,ELECTRIC STIMULATION THERAPY,,97014,420,$75.00 ,$75.00 ,$22.50 ,$68.25 ,$52.50 ,$22.50 ,$48.75 ,$54.00 ,$68.25 ,$56.25 
Carle BroMenn Medical Center,8617016,COMPRESSION PUMP,,97016,420,$71.00 ,$71.00 ,$21.30 ,$64.61 ,$49.70 ,$21.30 ,$46.15 ,$51.12 ,$64.61 ,$53.25 
Carle BroMenn Medical Center,8617018,PARAFFIN,,97018,420,$74.00 ,$74.00 ,$22.20 ,$67.34 ,$51.80 ,$22.20 ,$48.10 ,$53.28 ,$67.34 ,$55.50 
Carle BroMenn Medical Center,8617022,DRY WHIRLPOOL,,97022,420,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8617026,"INFRARED 15""",,97026,420,$57.00 ,$57.00 ,$17.10 ,$51.87 ,$39.90 ,$17.10 ,$37.05 ,$41.04 ,$51.87 ,$42.75 
Carle BroMenn Medical Center,8617032,15' EMS 1:1,,97032,420,$89.00 ,$89.00 ,$26.70 ,$80.99 ,$62.30 ,$26.70 ,$57.85 ,$64.08 ,$80.99 ,$66.75 
Carle BroMenn Medical Center,8617033,15' IONTO 1:1,,97033,420,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8617034,15' CONTRAST BATH 1:1,,97034,420,$73.00 ,$73.00 ,$21.90 ,$66.43 ,$51.10 ,$21.90 ,$47.45 ,$52.56 ,$66.43 ,$54.75 
Carle BroMenn Medical Center,8617035,15' ULTRASOUND 1:1,,97035,420,$72.00 ,$72.00 ,$21.60 ,$65.52 ,$50.40 ,$21.60 ,$46.80 ,$51.84 ,$65.52 ,$54.00 
Carle BroMenn Medical Center,8617110,15' INDIVIDUAL THERAPY-OFFSITE,,97110,420,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8617112,15' NEUROMUSCULAR RE-EDUCATION,,97112,420,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8617113,15' AQUATIC THERAPY,,97113,420,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8617116,15' GAIT TRAINING,,97116,420,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8617129,THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES,,97129,420,$185.00 ,$185.00 ,$55.50 ,$168.35 ,$129.50 ,$55.50 ,$120.25 ,$133.20 ,$168.35 ,$138.75 
Carle BroMenn Medical Center,8617130,THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES,,97130,420,$185.00 ,$185.00 ,$55.50 ,$168.35 ,$129.50 ,$55.50 ,$120.25 ,$133.20 ,$168.35 ,$138.75 
Carle BroMenn Medical Center,8617139,THERAPEUTIC PROCEDURE,,97139,420,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8617140,15' MANUAL THERAPY,,97140,420,$125.00 ,$125.00 ,$37.50 ,$113.75 ,$87.50 ,$37.50 ,$81.25 ,$90.00 ,$113.75 ,$93.75 
Carle BroMenn Medical Center,8617150,15' GROUP THERAPY,,97150,420,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8617530,15' FUNCT THERAPY ACTIVITY,,97530,420,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8617533,15' SENSORY INTEGRATION,,97533,420,$154.00 ,$154.00 ,$46.20 ,$140.14 ,$107.80 ,$46.20 ,$100.10 ,$110.88 ,$140.14 ,$115.50 
Carle BroMenn Medical Center,8617535,15' ADL TRAINING,,97535,420,$135.00 ,$135.00 ,$40.50 ,$122.85 ,$94.50 ,$40.50 ,$87.75 ,$97.20 ,$122.85 ,$101.25 
Carle BroMenn Medical Center,8617537,15'  WORK & COMMUNITY RE-ENTRY,,97537,420,$109.00 ,$109.00 ,$32.70 ,$99.19 ,$76.30 ,$32.70 ,$70.85 ,$78.48 ,$99.19 ,$81.75 
Carle BroMenn Medical Center,8617542,15'  WHEELCHAIR MGMT TRAINING,,97542,420,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8617545,WORK CONDITIONING INITIAL 2 HR,,97545,420,$4.10 ,$4.10 ,$1.23 ,$3.73 ,$2.87 ,$1.23 ,$2.67 ,$2.95 ,$3.73 ,$3.08 
Carle BroMenn Medical Center,8617546,WORK CONDITIONING ADDTL HR,,97546,420,$4.10 ,$4.10 ,$1.23 ,$3.73 ,$2.87 ,$1.23 ,$2.67 ,$2.95 ,$3.73 ,$3.08 
Carle BroMenn Medical Center,8617597,SELECTIVE DEBRIDEMNT < 20SQ CM,,97597,420,$415.00 ,$415.00 ,$124.50 ,$377.65 ,$290.50 ,$124.50 ,$269.75 ,$298.80 ,$377.65 ,$311.25 
Carle BroMenn Medical Center,8617598,SELECTIVE DEBRDEMNT > 20 SQ CM,,97598,420,$280.00 ,$280.00 ,$84.00 ,$254.80 ,$196.00 ,$84.00 ,$182.00 ,$201.60 ,$254.80 ,$210.00 
Carle BroMenn Medical Center,8617602,"31-60"" NONSELECTIVE DEBRIDEMNT",,97602,420,$710.00 ,$710.00 ,$213.00 ,$646.10 ,$497.00 ,$213.00 ,$461.50 ,$511.20 ,$646.10 ,$532.50 
Carle BroMenn Medical Center,8617750,FUNCTIONAL CAPACITY EVALUATION,,97750,420,$140.00 ,$140.00 ,$42.00 ,$127.40 ,$98.00 ,$42.00 ,$91.00 ,$100.80 ,$127.40 ,$105.00 
Carle BroMenn Medical Center,8617760,"ORTHOTIC MGMNT & TRAINING 15""",,97760,420,$175.00 ,$175.00 ,$52.50 ,$159.25 ,$122.50 ,$52.50 ,$113.75 ,$126.00 ,$159.25 ,$131.25 
Carle BroMenn Medical Center,8617761,PROSTHETIC TRAINING 15',,97761,420,$125.00 ,$125.00 ,$37.50 ,$113.75 ,$87.50 ,$37.50 ,$81.25 ,$90.00 ,$113.75 ,$93.75 
Carle BroMenn Medical Center,8617763,ORTHOTICS/PROSTH MGMT &/TRAINJ SBSQ ENCTR 15 MIN,,97763,420,$125.00 ,$125.00 ,$37.50 ,$113.75 ,$87.50 ,$37.50 ,$81.25 ,$90.00 ,$113.75 ,$93.75 
Carle BroMenn Medical Center,8618150,"GROUP PT 61""-120""",,97150,420,$225.00 ,$225.00 ,$67.50 ,$204.75 ,$157.50 ,$67.50 ,$146.25 ,$162.00 ,$204.75 ,$168.75 
Carle BroMenn Medical Center,8619105,SPLINT APP LNG ARM STAT 31-60',,29105,420,$355.00 ,$355.00 ,$106.50 ,$323.05 ,$248.50 ,$106.50 ,$230.75 ,$255.60 ,$323.05 ,$266.25 
Carle BroMenn Medical Center,8619125,SPLINT APP SHT ARM STAT 16-30',,29125,420,$275.00 ,$275.00 ,$82.50 ,$250.25 ,$192.50 ,$82.50 ,$178.75 ,$198.00 ,$250.25 ,$206.25 
Carle BroMenn Medical Center,8619130,SPLINT APP FINGER STAT 16-30',,29130,420,$230.00 ,$230.00 ,$69.00 ,$209.30 ,$161.00 ,$69.00 ,$149.50 ,$165.60 ,$209.30 ,$172.50 
Carle BroMenn Medical Center,8619131,SPLINT APP FINGER DYN 31-60',,29131,420,$310.00 ,$310.00 ,$93.00 ,$282.10 ,$217.00 ,$93.00 ,$201.50 ,$223.20 ,$282.10 ,$232.50 
Carle BroMenn Medical Center,8619150,"GROUP PT 8""-30""",,97150,420,$79.00 ,$79.00 ,$23.70 ,$71.89 ,$55.30 ,$23.70 ,$51.35 ,$56.88 ,$71.89 ,$59.25 
Carle BroMenn Medical Center,8619201,ATC EVALUATION,,G0463,420,$170.00 ,$170.00 ,$51.00 ,$154.70 ,$119.00 ,$51.00 ,$110.50 ,$122.40 ,$154.70 ,$127.50 
Carle BroMenn Medical Center,8619220,STRAPPING LOW BACK,,29799,420,$255.00 ,$255.00 ,$76.50 ,$232.05 ,$178.50 ,$76.50 ,$165.75 ,$183.60 ,$232.05 ,$191.25 
Carle BroMenn Medical Center,8619240,STRAPPING SHOULDER,,29240,420,$170.00 ,$170.00 ,$51.00 ,$154.70 ,$119.00 ,$51.00 ,$110.50 ,$122.40 ,$154.70 ,$127.50 
Carle BroMenn Medical Center,8619260,"16-30"" STRAPPING ELBOW/WRIST",,29260,420,$230.00 ,$230.00 ,$69.00 ,$209.30 ,$161.00 ,$69.00 ,$149.50 ,$165.60 ,$209.30 ,$172.50 
Carle BroMenn Medical Center,8619280,"16-30"" STRAPPING HAND/FINGER",,29280,420,$230.00 ,$230.00 ,$69.00 ,$209.30 ,$161.00 ,$69.00 ,$149.50 ,$165.60 ,$209.30 ,$172.50 
Carle BroMenn Medical Center,8619366,"PT CHG TEAM CONF WITH PT/FAMILY PRSNT, EA 30 MIN",,99366,420,$190.00 ,$190.00 ,$57.00 ,$172.90 ,$133.00 ,$57.00 ,$123.50 ,$136.80 ,$172.90 ,$142.50 
Carle BroMenn Medical Center,8619368,"PT CHG TEAM CONF W/O PT/FAMILY PRSNT, EA 30 MIN",,99368,420,$195.00 ,$195.00 ,$58.50 ,$177.45 ,$136.50 ,$58.50 ,$126.75 ,$140.40 ,$177.45 ,$146.25 
Carle BroMenn Medical Center,8619499,15' IFSP DEVELOPMENT-OFFSITE,,99499,420,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8619505,"SPLINT APP LONG LEG 31""-60""",,29505,420,$345.00 ,$345.00 ,$103.50 ,$313.95 ,$241.50 ,$103.50 ,$224.25 ,$248.40 ,$313.95 ,$258.75 
Carle BroMenn Medical Center,8619515,"SPLINT APP SHORT LEG 31""-60""",,29515,420,$325.00 ,$325.00 ,$97.50 ,$295.75 ,$227.50 ,$97.50 ,$211.25 ,$234.00 ,$295.75 ,$243.75 
Carle BroMenn Medical Center,8619520,STRAPPING HIP,,29520,420,$169.00 ,$169.00 ,$50.70 ,$153.79 ,$118.30 ,$50.70 ,$109.85 ,$121.68 ,$153.79 ,$126.75 
Carle BroMenn Medical Center,8619530,STRAPPING KNEE,,29530,420,$185.00 ,$185.00 ,$55.50 ,$168.35 ,$129.50 ,$55.50 ,$120.25 ,$133.20 ,$168.35 ,$138.75 
Carle BroMenn Medical Center,8619540,"16""-30"" ORTH CUST FT/ANKL STRP",,29540,420,$250.00 ,$250.00 ,$75.00 ,$227.50 ,$175.00 ,$75.00 ,$162.50 ,$180.00 ,$227.50 ,$187.50 
Carle BroMenn Medical Center,8619550,STRAPPING TOE,,29550,420,$180.00 ,$180.00 ,$54.00 ,$163.80 ,$126.00 ,$54.00 ,$117.00 ,$129.60 ,$163.80 ,$135.00 
Carle BroMenn Medical Center,8619581,APPLY MULTI-LAY CMPRSSN; LEG (BELOW KNEE) INCL ANKLE/FT,,29581,420,$415.00 ,$415.00 ,$124.50 ,$377.65 ,$290.50 ,$124.50 ,$269.75 ,$298.80 ,$377.65 ,$311.25 
Carle BroMenn Medical Center,8619584,APPLY MULTI-LAY CMPRSSN; UPPER ARM THRU HAND/FINGERS,,29584,420,$420.00 ,$420.00 ,$126.00 ,$382.20 ,$294.00 ,$126.00 ,$273.00 ,$302.40 ,$382.20 ,$315.00 
Carle BroMenn Medical Center,8620003,CANCELLATION-24 HOURS OR LESS,,,420,$285.00 ,$285.00 ,$85.50 ,$259.35 ,$199.50 ,$85.50 ,$185.25 ,$205.20 ,$259.35 ,$213.75 
Carle BroMenn Medical Center,8620005,CANCELLATION-25 TO 48 HOURS,,,420,$143.00 ,$143.00 ,$42.90 ,$130.13 ,$100.10 ,$42.90 ,$92.95 ,$102.96 ,$130.13 ,$107.25 
Carle BroMenn Medical Center,8620007,DRIVERS EVALUATION,,,420,$315.00 ,$315.00 ,$94.50 ,$286.65 ,$220.50 ,$94.50 ,$204.75 ,$226.80 ,$286.65 ,$236.25 
Carle BroMenn Medical Center,8621110,15' INDIVIDUAL THERAPY-OFFSITE,,97110,420,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8627210,15' INDIVIDUAL THERAPY-ONSITE,,97110,420,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8655992,CANALITH REPOSITIONING,,95992,420,$120.00 ,$120.00 ,$36.00 ,$109.20 ,$84.00 ,$36.00 ,$78.00 ,$86.40 ,$109.20 ,$90.00 
Carle BroMenn Medical Center,8719366,"PT CHG TEAM CONF WITH PT/FAMILY PRSNT, EA 30 MIN",,99366,420,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8719368,"PT CHG TEAM CONF W/O PT/FAMILY PRSNT, EA 30 MIN",,99368,420,$195.00 ,$195.00 ,$58.50 ,$177.45 ,$136.50 ,$58.50 ,$126.75 ,$140.40 ,$177.45 ,$146.25 
Carle BroMenn Medical Center,8720001,DRSG/DEBRID SMALL AREA  GP,,16020,420,$580.00 ,$580.00 ,$174.00 ,$527.80 ,$406.00 ,$174.00 ,$377.00 ,$417.60 ,$527.80 ,$435.00 
Carle BroMenn Medical Center,8720003,DRSG/DEBRID MEDIUM SIZE AREA  GP,,16025,420,$620.00 ,$620.00 ,$186.00 ,$564.20 ,$434.00 ,$186.00 ,$403.00 ,$446.40 ,$564.20 ,$465.00 
Carle BroMenn Medical Center,8720005,DRSG/DEBRID LARGE AREA GP,,16030,420,$790.00 ,$790.00 ,$237.00 ,$718.90 ,$553.00 ,$237.00 ,$513.50 ,$568.80 ,$718.90 ,$592.50 
Carle BroMenn Medical Center,8720007,SPLINT APP LNG ARM STAT 31-60' GP,,29105,420,$370.00 ,$370.00 ,$111.00 ,$336.70 ,$259.00 ,$111.00 ,$240.50 ,$266.40 ,$336.70 ,$277.50 
Carle BroMenn Medical Center,8720008,SPLINT APP LNG ARM STAT 8-30' GP,,29105,420,$300.00 ,$300.00 ,$90.00 ,$273.00 ,$210.00 ,$90.00 ,$195.00 ,$216.00 ,$273.00 ,$225.00 
Carle BroMenn Medical Center,8720011,SPLINT APP SHT ARM STAT 16-30' GP,,29125,420,$265.00 ,$265.00 ,$79.50 ,$241.15 ,$185.50 ,$79.50 ,$172.25 ,$190.80 ,$241.15 ,$198.75 
Carle BroMenn Medical Center,8720012,SPLINT APP SHT ARM STAT 8-15' GP,,29125,420,$265.00 ,$265.00 ,$79.50 ,$241.15 ,$185.50 ,$79.50 ,$172.25 ,$190.80 ,$241.15 ,$198.75 
Carle BroMenn Medical Center,8720013,SPLINT APP SHT ARM STAT 31-45' GP,,29125,420,$305.00 ,$305.00 ,$91.50 ,$277.55 ,$213.50 ,$91.50 ,$198.25 ,$219.60 ,$277.55 ,$228.75 
Carle BroMenn Medical Center,8720014,SPLINT APP SHT ARM STAT 46-60' GP,,29125,420,$370.00 ,$370.00 ,$111.00 ,$336.70 ,$259.00 ,$111.00 ,$240.50 ,$266.40 ,$336.70 ,$277.50 
Carle BroMenn Medical Center,8720023,SPLINT APP FINGER STAT 8-15' GP,,29130,420,$155.00 ,$155.00 ,$46.50 ,$141.05 ,$108.50 ,$46.50 ,$100.75 ,$111.60 ,$141.05 ,$116.25 
Carle BroMenn Medical Center,8720024,SPLINT APP FINGER STAT 16-30' GP,,29130,420,$235.00 ,$235.00 ,$70.50 ,$213.85 ,$164.50 ,$70.50 ,$152.75 ,$169.20 ,$213.85 ,$176.25 
Carle BroMenn Medical Center,8720027,SPLINT APP FINGER DYN 31-60' GP,,29131,420,$325.00 ,$325.00 ,$97.50 ,$295.75 ,$227.50 ,$97.50 ,$211.25 ,$234.00 ,$295.75 ,$243.75 
Carle BroMenn Medical Center,8720028,SPLINT APP FINGER DYN 8-30' GP,,29131,420,$285.00 ,$285.00 ,$85.50 ,$259.35 ,$199.50 ,$85.50 ,$185.25 ,$205.20 ,$259.35 ,$213.75 
Carle BroMenn Medical Center,8720033,STRAPPING SHOULDER GP,,29240,420,$170.00 ,$170.00 ,$51.00 ,$154.70 ,$119.00 ,$51.00 ,$110.50 ,$122.40 ,$154.70 ,$127.50 
Carle BroMenn Medical Center,8720035,"8-15"" STRAPPING ELBOW/WRIST GP",,29260,420,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8720036,"16-30"" STRAPPING ELBOW/WRIST GP",,29260,420,$235.00 ,$235.00 ,$70.50 ,$213.85 ,$164.50 ,$70.50 ,$152.75 ,$169.20 ,$213.85 ,$176.25 
Carle BroMenn Medical Center,8720037,"31-45"" STRAPPING ELBOW/WRIST GP",,29260,420,$325.00 ,$325.00 ,$97.50 ,$295.75 ,$227.50 ,$97.50 ,$211.25 ,$234.00 ,$295.75 ,$243.75 
Carle BroMenn Medical Center,8720038,"46-60"" STRAPPING ELBOW/WRIST GP",,29260,420,$385.00 ,$385.00 ,$115.50 ,$350.35 ,$269.50 ,$115.50 ,$250.25 ,$277.20 ,$350.35 ,$288.75 
Carle BroMenn Medical Center,8720043,"8-15"" STRAPPING HAND/FINGER GP",,29280,420,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8720044,"16-30"" STRAPPING HAND/FINGER GP",,29280,420,$235.00 ,$235.00 ,$70.50 ,$213.85 ,$164.50 ,$70.50 ,$152.75 ,$169.20 ,$213.85 ,$176.25 
Carle BroMenn Medical Center,8720045,"31-45"" STRAPPING HAND/FINGER GP",,29280,420,$280.00 ,$280.00 ,$84.00 ,$254.80 ,$196.00 ,$84.00 ,$182.00 ,$201.60 ,$254.80 ,$210.00 
Carle BroMenn Medical Center,8720046,"46-60"" STRAPPING HAND/FINGER GP",,29280,420,$360.00 ,$360.00 ,$108.00 ,$327.60 ,$252.00 ,$108.00 ,$234.00 ,$259.20 ,$327.60 ,$270.00 
Carle BroMenn Medical Center,8720051,SPLINT APP LONG LEG 61'-75' GP,,29505,420,$530.00 ,$530.00 ,$159.00 ,$482.30 ,$371.00 ,$159.00 ,$344.50 ,$381.60 ,$482.30 ,$397.50 
Carle BroMenn Medical Center,8720052,SPLINT APP LONG LEG 31'-60' GP,,29505,420,$360.00 ,$360.00 ,$108.00 ,$327.60 ,$252.00 ,$108.00 ,$234.00 ,$259.20 ,$327.60 ,$270.00 
Carle BroMenn Medical Center,8720053,SPLINT APP LONG LEG 8'-30' GP,,29505,420,$305.00 ,$305.00 ,$91.50 ,$277.55 ,$213.50 ,$91.50 ,$198.25 ,$219.60 ,$277.55 ,$228.75 
Carle BroMenn Medical Center,8720057,SPLINT APP SHORT LEG 61'-75' GP,,29515,420,$530.00 ,$530.00 ,$159.00 ,$482.30 ,$371.00 ,$159.00 ,$344.50 ,$381.60 ,$482.30 ,$397.50 
Carle BroMenn Medical Center,8720058,SPLINT APP SHORT LEG 8'-30' GP,,29515,420,$235.00 ,$235.00 ,$70.50 ,$213.85 ,$164.50 ,$70.50 ,$152.75 ,$169.20 ,$213.85 ,$176.25 
Carle BroMenn Medical Center,8720059,SPLINT APP SHORT LEG 31'-60' GP,,29515,420,$345.00 ,$345.00 ,$103.50 ,$313.95 ,$241.50 ,$103.50 ,$224.25 ,$248.40 ,$313.95 ,$258.75 
Carle BroMenn Medical Center,8720063,STRAPPING HIP GP,,29520,420,$169.00 ,$169.00 ,$50.70 ,$153.79 ,$118.30 ,$50.70 ,$109.85 ,$121.68 ,$153.79 ,$126.75 
Carle BroMenn Medical Center,8720065,STRAPPING KNEE GP,,29530,420,$185.00 ,$185.00 ,$55.50 ,$168.35 ,$129.50 ,$55.50 ,$120.25 ,$133.20 ,$168.35 ,$138.75 
Carle BroMenn Medical Center,8720067,8'-15' ORTH CUST FT/ANKL STRP GP,,29540,420,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8720068,16'-30' ORTH CUST FT/ANKL STRP GP,,29540,420,$255.00 ,$255.00 ,$76.50 ,$232.05 ,$178.50 ,$76.50 ,$165.75 ,$183.60 ,$232.05 ,$191.25 
Carle BroMenn Medical Center,8720069,31'-60' ORTH CUST FT/ANKL STRP GP,,29540,420,$400.00 ,$400.00 ,$120.00 ,$364.00 ,$280.00 ,$120.00 ,$260.00 ,$288.00 ,$364.00 ,$300.00 
Carle BroMenn Medical Center,8720073,STRAPPING TOE GP,,29550,420,$180.00 ,$180.00 ,$54.00 ,$163.80 ,$126.00 ,$54.00 ,$117.00 ,$129.60 ,$163.80 ,$135.00 
Carle BroMenn Medical Center,8720085,BIOFEEDBACK-SPEC MUSCLE GRPS GP,,90901,420,$158.00 ,$158.00 ,$47.40 ,$143.78 ,$110.60 ,$47.40 ,$102.70 ,$113.76 ,$143.78 ,$118.50 
Carle BroMenn Medical Center,8720087,BIOFEEDBACK-PERINEAL MUSCLES GP,,90911,420,$266.00 ,$266.00 ,$79.80 ,$242.06 ,$186.20 ,$79.80 ,$172.90 ,$191.52 ,$242.06 ,$199.50 
Carle BroMenn Medical Center,8720182,ELECTRIC STIMULATION THERAPY,,97014,420,$75.00 ,$75.00 ,$22.50 ,$68.25 ,$52.50 ,$22.50 ,$48.75 ,$54.00 ,$68.25 ,$56.25 
Carle BroMenn Medical Center,8720190,PELVIC & CERVICAL TRACTION GP,,97012,420,$76.00 ,$76.00 ,$22.80 ,$69.16 ,$53.20 ,$22.80 ,$49.40 ,$54.72 ,$69.16 ,$57.00 
Carle BroMenn Medical Center,8720192,COMPRESSION PUMP (VASOPNEUMATIC DVCS) GP,,97016,420,$71.00 ,$71.00 ,$21.30 ,$64.61 ,$49.70 ,$21.30 ,$46.15 ,$51.12 ,$64.61 ,$53.25 
Carle BroMenn Medical Center,8720194,PARAFFIN BATH GP,,97018,420,$74.00 ,$74.00 ,$22.20 ,$67.34 ,$51.80 ,$22.20 ,$48.10 ,$53.28 ,$67.34 ,$55.50 
Carle BroMenn Medical Center,8720196,DRY WHIRLPOOL GP,,97022,420,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8720198,LIQUID WHIRLPOOL GP,,97022,420,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8720201,"INFRARED 15"" GP",,97026,420,$57.00 ,$57.00 ,$17.10 ,$51.87 ,$39.90 ,$17.10 ,$37.05 ,$41.04 ,$51.87 ,$42.75 
Carle BroMenn Medical Center,8720204,15' EMS 1:1 GP,,97032,420,$89.00 ,$89.00 ,$26.70 ,$80.99 ,$62.30 ,$26.70 ,$57.85 ,$64.08 ,$80.99 ,$66.75 
Carle BroMenn Medical Center,8720207,15' IONTO 1:1 GP,,97033,420,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8720209,15' CONTRAST BATH 1:1 GP,,97034,420,$73.00 ,$73.00 ,$21.90 ,$66.43 ,$51.10 ,$21.90 ,$47.45 ,$52.56 ,$66.43 ,$54.75 
Carle BroMenn Medical Center,8720211,15' ULTRASOUND 1:1 GP,,97035,420,$72.00 ,$72.00 ,$21.60 ,$65.52 ,$50.40 ,$21.60 ,$46.80 ,$51.84 ,$65.52 ,$54.00 
Carle BroMenn Medical Center,8720220,15' THERAPEUTIC EXERCISE GP,,97110,420,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8720223,15' INDIVIDUAL THERAPEUTIC PROC-ONSITE,,97110,420,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8720224,15' INDIVIDUAL THERAPEUTIC PROC-OFFSITE,,97110,420,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8720225,15' NEUROMUSCULAR RE-EDUCATION GP,,97112,420,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8720228,15' AQUATIC THERAPY GP,,97113,420,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8720230,15' GAIT TRAINING GP,,97116,420,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8720232,THERAPEUTIC PROCEDURE GP,,97139,420,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8720235,15' MANUAL THERAPY GP,,97140,420,$125.00 ,$125.00 ,$37.50 ,$113.75 ,$87.50 ,$37.50 ,$81.25 ,$90.00 ,$113.75 ,$93.75 
Carle BroMenn Medical Center,8720240,15' GROUP THERAPY SE,,97150,420,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8720242,GROUP PT 8'-30' GP,,97150,420,$94.00 ,$94.00 ,$28.20 ,$85.54 ,$65.80 ,$28.20 ,$61.10 ,$67.68 ,$85.54 ,$70.50 
Carle BroMenn Medical Center,8720244,GROUP PT 31'-45' GP,,97150,420,$120.00 ,$120.00 ,$36.00 ,$109.20 ,$84.00 ,$36.00 ,$78.00 ,$86.40 ,$109.20 ,$90.00 
Carle BroMenn Medical Center,8720246,GROUP PT 46'-60' GP,,97150,420,$190.00 ,$190.00 ,$57.00 ,$172.90 ,$133.00 ,$57.00 ,$123.50 ,$136.80 ,$172.90 ,$142.50 
Carle BroMenn Medical Center,8720248,GROUP PT 61'-120' GP,,97150,420,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8720252,15' FUNCT THERAPY ACTIVITY GP,,97530,420,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8720258,15' SENSORY INTEGRATION GP,,97533,420,$154.00 ,$154.00 ,$46.20 ,$140.14 ,$107.80 ,$46.20 ,$100.10 ,$110.88 ,$140.14 ,$115.50 
Carle BroMenn Medical Center,8720261,15' ADL TRAINING GP,,97535,420,$135.00 ,$135.00 ,$40.50 ,$122.85 ,$94.50 ,$40.50 ,$87.75 ,$97.20 ,$122.85 ,$101.25 
Carle BroMenn Medical Center,8720264,15'  WORK & COMMUNITY RE-ENTRY GP,,97537,420,$109.00 ,$109.00 ,$32.70 ,$99.19 ,$76.30 ,$32.70 ,$70.85 ,$78.48 ,$99.19 ,$81.75 
Carle BroMenn Medical Center,8720270,15'  WHEELCHAIR MGMT TRAINING GP,,97542,420,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8720272,WORK CONDITIONING INITIAL 2 HR GP,,97545,420,$4.10 ,$4.10 ,$1.23 ,$3.73 ,$2.87 ,$1.23 ,$2.67 ,$2.95 ,$3.73 ,$3.08 
Carle BroMenn Medical Center,8720274,WORK CONDITIONING ADDTL HR GP,,97546,420,$4.10 ,$4.10 ,$1.23 ,$3.73 ,$2.87 ,$1.23 ,$2.67 ,$2.95 ,$3.73 ,$3.08 
Carle BroMenn Medical Center,8720276,ORTHOTICS/PROSTH MGMT &/TRAINJ SBSQ ENCTR 15 MIN GP,,97763,420,$125.00 ,$125.00 ,$37.50 ,$113.75 ,$87.50 ,$37.50 ,$81.25 ,$90.00 ,$113.75 ,$93.75 
Carle BroMenn Medical Center,8720280,SELECTIVE DEBRIDEMNT < 20SQ CM GP,,97597,420,$415.00 ,$415.00 ,$124.50 ,$377.65 ,$290.50 ,$124.50 ,$269.75 ,$298.80 ,$377.65 ,$311.25 
Carle BroMenn Medical Center,8720282,SELECTIVE DEBRIDEMNT > 20SQ CM GP,,97598,420,$280.00 ,$280.00 ,$84.00 ,$254.80 ,$196.00 ,$84.00 ,$182.00 ,$201.60 ,$254.80 ,$210.00 
Carle BroMenn Medical Center,8720284,"8-30"" NONSELECTIVE DEBRIDEMENT GP",,97602,420,$205.00 ,$205.00 ,$61.50 ,$186.55 ,$143.50 ,$61.50 ,$133.25 ,$147.60 ,$186.55 ,$153.75 
Carle BroMenn Medical Center,8720286,"31-60"" NONSELECTIVE DEBRIDEMNT GP",,97602,420,$740.00 ,$740.00 ,$222.00 ,$673.40 ,$518.00 ,$222.00 ,$481.00 ,$532.80 ,$673.40 ,$555.00 
Carle BroMenn Medical Center,8720300,FUNCTIONAL CAPACITY EVALUATION GP,,97750,420,$140.00 ,$140.00 ,$42.00 ,$127.40 ,$98.00 ,$42.00 ,$91.00 ,$100.80 ,$127.40 ,$105.00 
Carle BroMenn Medical Center,8720302,FUNCTIONAL TESTS & MEASURES GP,,97750,420,$140.00 ,$140.00 ,$42.00 ,$127.40 ,$98.00 ,$42.00 ,$91.00 ,$100.80 ,$127.40 ,$105.00 
Carle BroMenn Medical Center,8720306,"ORTHOTIC MGMNT & TRAINING 15"" GP",,97760,420,$175.00 ,$175.00 ,$52.50 ,$159.25 ,$122.50 ,$52.50 ,$113.75 ,$126.00 ,$159.25 ,$131.25 
Carle BroMenn Medical Center,8720309,"PROSTHETIC TRAINING 15"" GP",,97761,420,$125.00 ,$125.00 ,$37.50 ,$113.75 ,$87.50 ,$37.50 ,$81.25 ,$90.00 ,$113.75 ,$93.75 
Carle BroMenn Medical Center,8720319,THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES GP,,97129,420,$185.00 ,$185.00 ,$55.50 ,$168.35 ,$129.50 ,$55.50 ,$120.25 ,$133.20 ,$168.35 ,$138.75 
Carle BroMenn Medical Center,8720322,THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES GP,,97130,420,$185.00 ,$185.00 ,$55.50 ,$168.35 ,$129.50 ,$55.50 ,$120.25 ,$133.20 ,$168.35 ,$138.75 
Carle BroMenn Medical Center,8720400,15' IFSP DEVELOPMENT-ONSITE GP,,99499,420,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8720401,15' IFSP DEVELOPMENT-OFFSITE GP,,99499,420,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8720410,ELECTRICAL STIM FOR ULCERS GP,,G0281,420,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8720412,ELECTRICAL STIM FOR WOUNDS GP,,G0282,420,$74.00 ,$74.00 ,$22.20 ,$67.34 ,$51.80 ,$22.20 ,$48.10 ,$53.28 ,$67.34 ,$55.50 
Carle BroMenn Medical Center,8720414,ELECTRICAL STIMULATION GP,,G0283,420,$79.00 ,$79.00 ,$23.70 ,$71.89 ,$55.30 ,$23.70 ,$51.35 ,$56.88 ,$71.89 ,$59.25 
Carle BroMenn Medical Center,8721581,APPLY MULTI-LAY CMPRSSN; LEG (BELOW KNEE) INCL ANKLE/FT,,29581,420,$415.00 ,$415.00 ,$124.50 ,$377.65 ,$290.50 ,$124.50 ,$269.75 ,$298.80 ,$377.65 ,$311.25 
Carle BroMenn Medical Center,8721584,APPLY MULTI-LAY CMPRSSN; UPPER ARM THRU HAND/FINGERS,,29584,420,$420.00 ,$420.00 ,$126.00 ,$382.20 ,$294.00 ,$126.00 ,$273.00 ,$302.40 ,$382.20 ,$315.00 
Carle BroMenn Medical Center,8730151,CANCELLATION-24 HOURS OR LESS,,,420,$334.00 ,$334.00 ,$100.20 ,$303.94 ,$233.80 ,$100.20 ,$217.10 ,$240.48 ,$303.94 ,$250.50 
Carle BroMenn Medical Center,8730152,CANCELLATION-25 TO 48 HOURS,,,420,$176.00 ,$176.00 ,$52.80 ,$160.16 ,$123.20 ,$52.80 ,$114.40 ,$126.72 ,$160.16 ,$132.00 
Carle BroMenn Medical Center,8730153,15' FUNCTIONAL MAINTENANCE,,,420,$20.00 ,$20.00 ,$6.00 ,$18.20 ,$14.00 ,$6.00 ,$13.00 ,$14.40 ,$18.20 ,$15.00 
Carle BroMenn Medical Center,8730154,DRIVERS EVALUATION,,,420,$360.00 ,$360.00 ,$108.00 ,$327.60 ,$252.00 ,$108.00 ,$234.00 ,$259.20 ,$327.60 ,$270.00 
Carle BroMenn Medical Center,8799201,ATC EVALUATION GP,,G0463,420,$125.00 ,$125.00 ,$37.50 ,$113.75 ,$87.50 ,$37.50 ,$81.25 ,$90.00 ,$113.75 ,$93.75 
Carle BroMenn Medical Center,8971368,"PT CHG TEAM CONF W/O PT/FAMILY PRSNT, EA 30 MIN",,99368,420,$195.00 ,$195.00 ,$58.50 ,$177.45 ,$136.50 ,$58.50 ,$126.75 ,$140.40 ,$177.45 ,$146.25 
Carle BroMenn Medical Center,8610027,PT EVAL LOW COMPLEXITY,,97161,424,$315.00 ,$315.00 ,$94.50 ,$286.65 ,$220.50 ,$94.50 ,$204.75 ,$226.80 ,$286.65 ,$236.25 
Carle BroMenn Medical Center,8611001,15' EVALUATION-ONSITE,,97161,424,$315.00 ,$315.00 ,$94.50 ,$286.65 ,$220.50 ,$94.50 ,$204.75 ,$226.80 ,$286.65 ,$236.25 
Carle BroMenn Medical Center,8615000,PT EVAL MODERATE COMPLEXITY (31-60 MINUTES),,97162,424,$265.00 ,$265.00 ,$79.50 ,$241.15 ,$185.50 ,$79.50 ,$172.25 ,$190.80 ,$241.15 ,$198.75 
Carle BroMenn Medical Center,8615001,PT EVAL MODERATE COMPLEXITY (61-90 MINUTES),,97162,424,$265.00 ,$265.00 ,$79.50 ,$241.15 ,$185.50 ,$79.50 ,$172.25 ,$190.80 ,$241.15 ,$198.75 
Carle BroMenn Medical Center,8615002,PT EVAL HIGH COMPLEXITY (31-60 MINUTES),,97163,424,$305.00 ,$305.00 ,$91.50 ,$277.55 ,$213.50 ,$91.50 ,$198.25 ,$219.60 ,$277.55 ,$228.75 
Carle BroMenn Medical Center,8615003,PT EVAL HIGH COMPLEXITY 61-90 MINUTES),,97163,424,$295.00 ,$295.00 ,$88.50 ,$268.45 ,$206.50 ,$88.50 ,$191.75 ,$212.40 ,$268.45 ,$221.25 
Carle BroMenn Medical Center,8617001,15' EVALUATION-OFFSITE,,97161,424,$315.00 ,$315.00 ,$94.50 ,$286.65 ,$220.50 ,$94.50 ,$204.75 ,$226.80 ,$286.65 ,$236.25 
Carle BroMenn Medical Center,8697161,PT EVAL LOW COMPLEXITY,,97161,424,$315.00 ,$315.00 ,$94.50 ,$286.65 ,$220.50 ,$94.50 ,$204.75 ,$226.80 ,$286.65 ,$236.25 
Carle BroMenn Medical Center,8697162,PT EVAL MODERATE COMPLEXITY (0-30 MINUTES),,97162,424,$265.00 ,$265.00 ,$79.50 ,$241.15 ,$185.50 ,$79.50 ,$172.25 ,$190.80 ,$241.15 ,$198.75 
Carle BroMenn Medical Center,8697163,PT EVAL HIGH COMPLEXITY (0-30 MINUTES),,97163,424,$265.00 ,$265.00 ,$79.50 ,$241.15 ,$185.50 ,$79.50 ,$172.25 ,$190.80 ,$241.15 ,$198.75 
Carle BroMenn Medical Center,8697164,PT RE-EVALUATION,,97164,424,$260.00 ,$260.00 ,$78.00 ,$236.60 ,$182.00 ,$78.00 ,$169.00 ,$187.20 ,$236.60 ,$195.00 
Carle BroMenn Medical Center,8720160,15' PT EVALUATION-ONSITE,,97161,424,$315.00 ,$315.00 ,$94.50 ,$286.65 ,$220.50 ,$94.50 ,$204.75 ,$226.80 ,$286.65 ,$236.25 
Carle BroMenn Medical Center,8720161,15' PT EVALUATION-OFFSITE,,97161,424,$315.00 ,$315.00 ,$94.50 ,$286.65 ,$220.50 ,$94.50 ,$204.75 ,$226.80 ,$286.65 ,$236.25 
Carle BroMenn Medical Center,8725000,PT EVAL MODERATE COMPLEXITY (31-60 MINUTES),,97162,424,$265.00 ,$265.00 ,$79.50 ,$241.15 ,$185.50 ,$79.50 ,$172.25 ,$190.80 ,$241.15 ,$198.75 
Carle BroMenn Medical Center,8725001,PT EVAL MODERATE COMPLEXITY (61-90 MINUTES),,97162,424,$265.00 ,$265.00 ,$79.50 ,$241.15 ,$185.50 ,$79.50 ,$172.25 ,$190.80 ,$241.15 ,$198.75 
Carle BroMenn Medical Center,8725002,PT EVAL HIGH COMPLEXITY (31-60 MINUTES),,97163,424,$315.00 ,$315.00 ,$94.50 ,$286.65 ,$220.50 ,$94.50 ,$204.75 ,$226.80 ,$286.65 ,$236.25 
Carle BroMenn Medical Center,8725003,PT EVAL HIGH COMPLEXITY (61-90 MINUTES),,97163,424,$375.00 ,$375.00 ,$112.50 ,$341.25 ,$262.50 ,$112.50 ,$243.75 ,$270.00 ,$341.25 ,$281.25 
Carle BroMenn Medical Center,8797161,PT EVAL LOW COMPLEXITY,,97161,424,$315.00 ,$315.00 ,$94.50 ,$286.65 ,$220.50 ,$94.50 ,$204.75 ,$226.80 ,$286.65 ,$236.25 
Carle BroMenn Medical Center,8797162,PT EVAL MODERATE COMPLEXITY (0-30 MINUTES),,97162,424,$240.00 ,$240.00 ,$72.00 ,$218.40 ,$168.00 ,$72.00 ,$156.00 ,$172.80 ,$218.40 ,$180.00 
Carle BroMenn Medical Center,8797163,PT EVAL HIGH COMPLEXITY (0-30 MINUTES),,97163,424,$315.00 ,$315.00 ,$94.50 ,$286.65 ,$220.50 ,$94.50 ,$204.75 ,$226.80 ,$286.65 ,$236.25 
Carle BroMenn Medical Center,8797164,PT RE-EVAL,,97164,424,$260.00 ,$260.00 ,$78.00 ,$236.60 ,$182.00 ,$78.00 ,$169.00 ,$187.20 ,$236.60 ,$195.00 
Carle BroMenn Medical Center,8297760,"ORTHOTIC MGMT AND TRAINING, EACH 15 MIN",,97760,429,$175.00 ,$175.00 ,$52.50 ,$159.25 ,$122.50 ,$52.50 ,$113.75 ,$126.00 ,$159.25 ,$131.25 
Carle BroMenn Medical Center,8607016,COMPRESSION PUMP,,97016,430,$71.00 ,$71.00 ,$21.30 ,$64.61 ,$49.70 ,$21.30 ,$46.15 ,$51.12 ,$64.61 ,$53.25 
Carle BroMenn Medical Center,8620004,CANCELLATION-24 HOURS OR LESS,,,430,$285.00 ,$285.00 ,$85.50 ,$259.35 ,$199.50 ,$85.50 ,$185.25 ,$205.20 ,$259.35 ,$213.75 
Carle BroMenn Medical Center,8620006,CANCELLATION-25 TO 48 HOURS,,,430,$143.00 ,$143.00 ,$42.90 ,$130.13 ,$100.10 ,$42.90 ,$92.95 ,$102.96 ,$130.13 ,$107.25 
Carle BroMenn Medical Center,8620008,DRIVERS EVALUATION,,,430,$364.00 ,$364.00 ,$109.20 ,$331.24 ,$254.80 ,$109.20 ,$236.60 ,$262.08 ,$331.24 ,$273.00 
Carle BroMenn Medical Center,8620009,"GROUP OT 61""-120""",,,430,$236.00 ,$236.00 ,$70.80 ,$214.76 ,$165.20 ,$70.80 ,$153.40 ,$169.92 ,$214.76 ,$177.00 
Carle BroMenn Medical Center,8620012,OSM SENIOR CLASS 1 HOUR,,,430,$2.00 ,$2.00 ,$0.60 ,$1.82 ,$1.40 ,$0.60 ,$1.30 ,$1.44 ,$1.82 ,$1.50 
Carle BroMenn Medical Center,8620013,OSM ACC 1 HOUR,,,430,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8620014,OSM ACC 1 HOUR (DISCOUNT),,,430,$14.00 ,$14.00 ,$4.20 ,$12.74 ,$9.80 ,$4.20 ,$9.10 ,$10.08 ,$12.74 ,$10.50 
Carle BroMenn Medical Center,8620015,OSM ACC 1 HOUR (TEAM),,,430,$11.00 ,$11.00 ,$3.30 ,$10.01 ,$7.70 ,$3.30 ,$7.15 ,$7.92 ,$10.01 ,$8.25 
Carle BroMenn Medical Center,8620016,OSM PEAK 1 HOUR,,,430,$30.00 ,$30.00 ,$9.00 ,$27.30 ,$21.00 ,$9.00 ,$19.50 ,$21.60 ,$27.30 ,$22.50 
Carle BroMenn Medical Center,8620017,OSM PEAK 1 HOUR (DISCOUNT),,,430,$27.00 ,$27.00 ,$8.10 ,$24.57 ,$18.90 ,$8.10 ,$17.55 ,$19.44 ,$24.57 ,$20.25 
Carle BroMenn Medical Center,8620018,OSM SPORT SPECIFIC 1 HOUR,,,430,$19.00 ,$19.00 ,$5.70 ,$17.29 ,$13.30 ,$5.70 ,$12.35 ,$13.68 ,$17.29 ,$14.25 
Carle BroMenn Medical Center,8620019,OSM SPORT SPECIFIC 1 HOUR (DISCOUNT),,,430,$17.00 ,$17.00 ,$5.10 ,$15.47 ,$11.90 ,$5.10 ,$11.05 ,$12.24 ,$15.47 ,$12.75 
Carle BroMenn Medical Center,8620020,OSM GRASTON 30 MINS,,,430,$38.00 ,$38.00 ,$11.40 ,$34.58 ,$26.60 ,$11.40 ,$24.70 ,$27.36 ,$34.58 ,$28.50 
Carle BroMenn Medical Center,8620021,OSM 30 MIN,,,430,$8.00 ,$8.00 ,$2.40 ,$7.28 ,$5.60 ,$2.40 ,$5.20 ,$5.76 ,$7.28 ,$6.00 
Carle BroMenn Medical Center,8620022,OSM ACC 30 MIN (DISCOUNT),,,430,$7.00 ,$7.00 ,$2.10 ,$6.37 ,$4.90 ,$2.10 ,$4.55 ,$5.04 ,$6.37 ,$5.25 
Carle BroMenn Medical Center,8620023,OSM PEAK 30 MIN,,,430,$15.00 ,$15.00 ,$4.50 ,$13.65 ,$10.50 ,$4.50 ,$9.75 ,$10.80 ,$13.65 ,$11.25 
Carle BroMenn Medical Center,8620024,OSM PEAK 30 MIN (DISCOUNT),,,430,$14.00 ,$14.00 ,$4.20 ,$12.74 ,$9.80 ,$4.20 ,$9.10 ,$10.08 ,$12.74 ,$10.50 
Carle BroMenn Medical Center,8620025,OSM SPORT SPECIFIC 30 MIN,,,430,$9.00 ,$9.00 ,$2.70 ,$8.19 ,$6.30 ,$2.70 ,$5.85 ,$6.48 ,$8.19 ,$6.75 
Carle BroMenn Medical Center,8620026,OSM SPORT SPECIFIC 30 MIN (DISCOUNT),,,430,$8.00 ,$8.00 ,$2.40 ,$7.28 ,$5.60 ,$2.40 ,$5.20 ,$5.76 ,$7.28 ,$6.00 
Carle BroMenn Medical Center,8620027,OSM ACC 90 MIN,,,430,$23.00 ,$23.00 ,$6.90 ,$20.93 ,$16.10 ,$6.90 ,$14.95 ,$16.56 ,$20.93 ,$17.25 
Carle BroMenn Medical Center,8620028,OSM ACC 90 MIN (DISCOUNT),,,430,$20.00 ,$20.00 ,$6.00 ,$18.20 ,$14.00 ,$6.00 ,$13.00 ,$14.40 ,$18.20 ,$15.00 
Carle BroMenn Medical Center,8620029,OSM PEAK 90 MIN,,,430,$45.00 ,$45.00 ,$13.50 ,$40.95 ,$31.50 ,$13.50 ,$29.25 ,$32.40 ,$40.95 ,$33.75 
Carle BroMenn Medical Center,8620030,OSM PEAK 90 MIN (DISCOUNT),,,430,$41.00 ,$41.00 ,$12.30 ,$37.31 ,$28.70 ,$12.30 ,$26.65 ,$29.52 ,$37.31 ,$30.75 
Carle BroMenn Medical Center,8620031,OSM SPORT SPECIFIC 90 MIN,,,430,$28.00 ,$28.00 ,$8.40 ,$25.48 ,$19.60 ,$8.40 ,$18.20 ,$20.16 ,$25.48 ,$21.00 
Carle BroMenn Medical Center,8620032,OSM SPORT SPECIFIC 90 MIN (DISCOUNT),,,430,$25.00 ,$25.00 ,$7.50 ,$22.75 ,$17.50 ,$7.50 ,$16.25 ,$18.00 ,$22.75 ,$18.75 
Carle BroMenn Medical Center,8620033,OT EVAL/ASSESSMENT ON/LOC CODE 11,,96112,430,$18.13 ,$18.13 ,$5.44 ,$16.50 ,$12.69 ,$5.44 ,$11.78 ,$13.05 ,$16.50 ,$13.60 
Carle BroMenn Medical Center,8620034,OT EVAL/ASSESSMENT OFF/LOC CODE 12,,96112,430,$18.13 ,$18.13 ,$5.44 ,$16.50 ,$12.69 ,$5.44 ,$11.78 ,$13.05 ,$16.50 ,$13.60 
Carle BroMenn Medical Center,8620035,OT EVAL/ASSESSMENT OFF/LOC CODE 99,,96112,430,$18.13 ,$18.13 ,$5.44 ,$16.50 ,$12.69 ,$5.44 ,$11.78 ,$13.05 ,$16.50 ,$13.60 
Carle BroMenn Medical Center,8620036,OT SERVICES ON/LOC CODE 11,,97530,430,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8620037,OT SERVICES OFF/LOC CODE 12,,97530,430,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8620038,OT SERVICES OFF/LOC CODE 99,,97530,430,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8620039,OT IFSP MTG/DEV ON/LOC CODE 11,,99499,430,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8620040,OT IFSP MTG/DEV OFF/LOC CODE 12,,99499,430,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8620041,OT IFSP MTG/DEV OFF/LOC CODE 99,,99499,430,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8620042,OSM ADULT FITNESS,,,430,$8.00 ,$8.00 ,$2.40 ,$7.28 ,$5.60 ,$2.40 ,$5.20 ,$5.76 ,$7.28 ,$6.00 
Carle BroMenn Medical Center,8620043,OSM PEAK BRIDGE VISIT,,,430,$38.00 ,$38.00 ,$11.40 ,$34.58 ,$26.60 ,$11.40 ,$24.70 ,$27.36 ,$34.58 ,$28.50 
Carle BroMenn Medical Center,8620046,OT EVAL - MOD COMPLEXITY,,97166,430,$360.00 ,$360.00 ,$108.00 ,$327.60 ,$252.00 ,$108.00 ,$234.00 ,$259.20 ,$327.60 ,$270.00 
Carle BroMenn Medical Center,8620047,OT EVAL - HIGH COMPLEXITY,,97167,430,$360.00 ,$360.00 ,$108.00 ,$327.60 ,$252.00 ,$108.00 ,$234.00 ,$259.20 ,$327.60 ,$270.00 
Carle BroMenn Medical Center,8620281,ELECTRICAL STIM FOR ULCERS,,G0281,430,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8620282,ELECTRICAL STIM FOR WOUNDS,,G0282,430,$74.00 ,$74.00 ,$22.20 ,$67.34 ,$51.80 ,$22.20 ,$48.10 ,$53.28 ,$67.34 ,$55.50 
Carle BroMenn Medical Center,8620283,ELECTRICAL STIMULATION,,G0283,430,$79.00 ,$79.00 ,$23.70 ,$71.89 ,$55.30 ,$23.70 ,$51.35 ,$56.88 ,$71.89 ,$59.25 
Carle BroMenn Medical Center,8620901,BIOFEEDBACK-SPEC MUSCLE GRPS,,90901,430,$158.00 ,$158.00 ,$47.40 ,$143.78 ,$110.60 ,$47.40 ,$102.70 ,$113.76 ,$143.78 ,$118.50 
Carle BroMenn Medical Center,8620911,BIOFEEDBACK-PERINEAL MUSCLES,,90911,430,$266.00 ,$266.00 ,$79.80 ,$242.06 ,$186.20 ,$79.80 ,$172.90 ,$191.52 ,$242.06 ,$199.50 
Carle BroMenn Medical Center,8621022,LIQUID WHIRLPOOL,,97022,430,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8621105,SPLINT APP LNG ARM STAT 31-60',,29105,430,$355.00 ,$355.00 ,$106.50 ,$323.05 ,$248.50 ,$106.50 ,$230.75 ,$255.60 ,$323.05 ,$266.25 
Carle BroMenn Medical Center,8621125,SPLINT APP SHT ARM STAT 16-30',,29125,430,$315.00 ,$315.00 ,$94.50 ,$286.65 ,$220.50 ,$94.50 ,$204.75 ,$226.80 ,$286.65 ,$236.25 
Carle BroMenn Medical Center,8621130,SPLINT APP FINGER STAT 16-30',,29130,430,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8621131,SPLINT APP FINGER DYN 31-60',,29131,430,$310.00 ,$310.00 ,$93.00 ,$282.10 ,$217.00 ,$93.00 ,$201.50 ,$223.20 ,$282.10 ,$232.50 
Carle BroMenn Medical Center,8621150,GROUP OT 8'-30',,97150,430,$90.00 ,$90.00 ,$27.00 ,$81.90 ,$63.00 ,$27.00 ,$58.50 ,$64.80 ,$81.90 ,$67.50 
Carle BroMenn Medical Center,8621201,ATC EVALUATION,,G0463,430,$185.00 ,$185.00 ,$55.50 ,$168.35 ,$129.50 ,$55.50 ,$120.25 ,$133.20 ,$168.35 ,$138.75 
Carle BroMenn Medical Center,8621260,"16-30"" STRAPPING ELBOW/WRIST",,29260,430,$230.00 ,$230.00 ,$69.00 ,$209.30 ,$161.00 ,$69.00 ,$149.50 ,$165.60 ,$209.30 ,$172.50 
Carle BroMenn Medical Center,8621280,"16-30"" STRAPPING HAND/FINGER",,29280,430,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8621499,15' IFSP DEVELOPMENT-OFFSITE,,99499,430,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8621505,SPLINT APP LONG LEG 31'-60',,29505,430,$345.00 ,$345.00 ,$103.50 ,$313.95 ,$241.50 ,$103.50 ,$224.25 ,$248.40 ,$313.95 ,$258.75 
Carle BroMenn Medical Center,8621515,SPLINT APP SHORT LEG 31'-60',,29515,430,$325.00 ,$325.00 ,$97.50 ,$295.75 ,$227.50 ,$97.50 ,$211.25 ,$234.00 ,$295.75 ,$243.75 
Carle BroMenn Medical Center,8621530,15' INDIVIDUAL THERAPY-ONSITE,,97530,430,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8621540,16'-30' ORTH CUST FT/ANKL STRP,,29540,430,$250.00 ,$250.00 ,$75.00 ,$227.50 ,$175.00 ,$75.00 ,$162.50 ,$180.00 ,$227.50 ,$187.50 
Carle BroMenn Medical Center,8621602,"31-60"" NONSELECTIVE DEBRIDEMNT",,97602,430,$710.00 ,$710.00 ,$213.00 ,$646.10 ,$497.00 ,$213.00 ,$461.50 ,$511.20 ,$646.10 ,$532.50 
Carle BroMenn Medical Center,8621750,FUNCTIONAL TESTS & MEASURES,,97750,430,$140.00 ,$140.00 ,$42.00 ,$127.40 ,$98.00 ,$42.00 ,$91.00 ,$100.80 ,$127.40 ,$105.00 
Carle BroMenn Medical Center,8621803,15' NUTRITION SERVICES-OFFSITE,,97803,430,$93.00 ,$93.00 ,$27.90 ,$84.63 ,$65.10 ,$27.90 ,$60.45 ,$66.96 ,$84.63 ,$69.75 
Carle BroMenn Medical Center,8621822,15' NUTRITION SVCS - OFFSITE,,97802,430,$93.00 ,$93.00 ,$27.90 ,$84.63 ,$65.10 ,$27.90 ,$60.45 ,$66.96 ,$84.63 ,$69.75 
Carle BroMenn Medical Center,8622110,15' THERAPEUTIC EXERCISE,,97110,430,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8622125,SPLINT APP SHT ARM STAT 31-45',,29125,430,$400.00 ,$400.00 ,$120.00 ,$364.00 ,$280.00 ,$120.00 ,$260.00 ,$288.00 ,$364.00 ,$300.00 
Carle BroMenn Medical Center,8622150,GROUP OT 31'-45',,97150,430,$115.00 ,$115.00 ,$34.50 ,$104.65 ,$80.50 ,$34.50 ,$74.75 ,$82.80 ,$104.65 ,$86.25 
Carle BroMenn Medical Center,8622260,"31-45"" STRAPPING ELBOW/WRIST",,29260,430,$310.00 ,$310.00 ,$93.00 ,$282.10 ,$217.00 ,$93.00 ,$201.50 ,$223.20 ,$282.10 ,$232.50 
Carle BroMenn Medical Center,8622280,"31-45"" STRAPPING HAND/FINGER",,29280,430,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8622499,15' IFSP DEVELOPMENT - ONSITE,,99499,430,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8622505,SPLINT APP LONG LEG 61'-75',,29505,430,$520.00 ,$520.00 ,$156.00 ,$473.20 ,$364.00 ,$156.00 ,$338.00 ,$374.40 ,$473.20 ,$390.00 
Carle BroMenn Medical Center,8622515,SPLINT APP SHORT LEG 61'-75',,29515,430,$520.00 ,$520.00 ,$156.00 ,$473.20 ,$364.00 ,$156.00 ,$338.00 ,$374.40 ,$473.20 ,$390.00 
Carle BroMenn Medical Center,8622530,15' INDIVIDUAL THERAPY-OFFSITE,,97530,430,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8622540,31'-60' ORTH CUST FT/ANKL STRP,,29540,430,$375.00 ,$375.00 ,$112.50 ,$341.25 ,$262.50 ,$112.50 ,$243.75 ,$270.00 ,$341.25 ,$281.25 
Carle BroMenn Medical Center,8623125,SPLINT APP SHT ARM STAT 46-60',,29125,430,$355.00 ,$355.00 ,$106.50 ,$323.05 ,$248.50 ,$106.50 ,$230.75 ,$255.60 ,$323.05 ,$266.25 
Carle BroMenn Medical Center,8623150,GROUP OT 46'-60',,97150,430,$175.00 ,$175.00 ,$52.50 ,$159.25 ,$122.50 ,$52.50 ,$113.75 ,$126.00 ,$159.25 ,$131.25 
Carle BroMenn Medical Center,8623260,"46-60"" STRAPPING ELBOW/WRIST",,29260,430,$365.00 ,$365.00 ,$109.50 ,$332.15 ,$255.50 ,$109.50 ,$237.25 ,$262.80 ,$332.15 ,$273.75 
Carle BroMenn Medical Center,8623280,"46-60"" STRAPPING HAND/FINGER",,29280,430,$345.00 ,$345.00 ,$103.50 ,$313.95 ,$241.50 ,$103.50 ,$224.25 ,$248.40 ,$313.95 ,$258.75 
Carle BroMenn Medical Center,8623499,15' IFSP DEVELOPMENT - OFFSITE,,99499,430,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8624150,GROUP OT 61'-120',,97150,430,$265.00 ,$265.00 ,$79.50 ,$241.15 ,$185.50 ,$79.50 ,$172.25 ,$190.80 ,$241.15 ,$198.75 
Carle BroMenn Medical Center,8624499,15' IFSP DEVELOPMENT-OFFSITE,,99499,430,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8625000,15' IFSP DEVELOPMENT-OFFSITE,,99499,430,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8625001,15' IFSP DEVELOPMENT-ONSITE,,99499,430,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8625499,15' IFSP DEVELOPMENT-ONSITE,,99499,430,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8625992,"CANALITH REPOSITIONING PROCEDURE, PER DAY",,95992,430,$120.00 ,$120.00 ,$36.00 ,$109.20 ,$84.00 ,$36.00 ,$78.00 ,$86.40 ,$109.20 ,$90.00 
Carle BroMenn Medical Center,8626020,DRSG/DEBRID SMALL AREA,,16020,430,$580.00 ,$580.00 ,$174.00 ,$527.80 ,$406.00 ,$174.00 ,$377.00 ,$417.60 ,$527.80 ,$435.00 
Carle BroMenn Medical Center,8626025,DRSG/DEBRID MEDIUM SIZE AREA,,16025,430,$620.00 ,$620.00 ,$186.00 ,$564.20 ,$434.00 ,$186.00 ,$403.00 ,$446.40 ,$564.20 ,$465.00 
Carle BroMenn Medical Center,8626030,DRSG/DEBRID LARGE AREA,,16030,430,$790.00 ,$790.00 ,$237.00 ,$718.90 ,$553.00 ,$237.00 ,$513.50 ,$568.80 ,$718.90 ,$592.50 
Carle BroMenn Medical Center,8626499,15' IFSP DEVELOPMENT-OFFSITE,,99499,430,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8627010,HOT/COLD PACKS,,97010,430,$36.00 ,$36.00 ,$10.80 ,$32.76 ,$25.20 ,$10.80 ,$23.40 ,$25.92 ,$32.76 ,$27.00 
Carle BroMenn Medical Center,8627012,PELVIC & CERVICAL TRACTION,,97012,430,$76.00 ,$76.00 ,$22.80 ,$69.16 ,$53.20 ,$22.80 ,$49.40 ,$54.72 ,$69.16 ,$57.00 
Carle BroMenn Medical Center,8627014,ELECTRIC STIMULATION THERAPY,,97014,430,$75.00 ,$75.00 ,$22.50 ,$68.25 ,$52.50 ,$22.50 ,$48.75 ,$54.00 ,$68.25 ,$56.25 
Carle BroMenn Medical Center,8627018,PARAFFIN,,97018,430,$74.00 ,$74.00 ,$22.20 ,$67.34 ,$51.80 ,$22.20 ,$48.10 ,$53.28 ,$67.34 ,$55.50 
Carle BroMenn Medical Center,8627022,DRY WHIRLPOOL,,97022,430,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8627026,"INFRARED 15""",,97026,430,$57.00 ,$57.00 ,$17.10 ,$51.87 ,$39.90 ,$17.10 ,$37.05 ,$41.04 ,$51.87 ,$42.75 
Carle BroMenn Medical Center,8627032,15' EMS 1:1,,97032,430,$89.00 ,$89.00 ,$26.70 ,$80.99 ,$62.30 ,$26.70 ,$57.85 ,$64.08 ,$80.99 ,$66.75 
Carle BroMenn Medical Center,8627033,15' IONTO 1:1,,97033,430,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8627034,15' CONTRAST BATH 1:1,,97034,430,$73.00 ,$73.00 ,$21.90 ,$66.43 ,$51.10 ,$21.90 ,$47.45 ,$52.56 ,$66.43 ,$54.75 
Carle BroMenn Medical Center,8627035,15' ULTRASOUND 1:1,,97035,430,$72.00 ,$72.00 ,$21.60 ,$65.52 ,$50.40 ,$21.60 ,$46.80 ,$51.84 ,$65.52 ,$54.00 
Carle BroMenn Medical Center,8627110,15' THERAPEUTIC EXERCISE,,97110,430,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8627112,15' NEUROMUSCULAR RE-EDUCATION,,97112,430,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8627113,15' AQUATIC THERAPY,,97113,430,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8627116,15' GAIT TRAINING,,97116,430,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8627129,THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES,,97129,430,$185.00 ,$185.00 ,$55.50 ,$168.35 ,$129.50 ,$55.50 ,$120.25 ,$133.20 ,$168.35 ,$138.75 
Carle BroMenn Medical Center,8627130,THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES,,97130,430,$185.00 ,$185.00 ,$55.50 ,$168.35 ,$129.50 ,$55.50 ,$120.25 ,$133.20 ,$168.35 ,$138.75 
Carle BroMenn Medical Center,8627139,THERAPEUTIC PROCEDURE,,97139,430,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8627140,15' MANUAL THERAPY,,97140,430,$125.00 ,$125.00 ,$37.50 ,$113.75 ,$87.50 ,$37.50 ,$81.25 ,$90.00 ,$113.75 ,$93.75 
Carle BroMenn Medical Center,8627150,15' GROUP THERAPY,,97150,430,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8627499,15' IFSP DEVELPMENT-ONSITE,,99499,430,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8627530,15' FUNCT THERAPY ACTIVITY,,97530,430,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8627533,15' SENSORY INTEGRATION,,97533,430,$154.00 ,$154.00 ,$46.20 ,$140.14 ,$107.80 ,$46.20 ,$100.10 ,$110.88 ,$140.14 ,$115.50 
Carle BroMenn Medical Center,8627535,15' ADL TRAINING,,97535,430,$135.00 ,$135.00 ,$40.50 ,$122.85 ,$94.50 ,$40.50 ,$87.75 ,$97.20 ,$122.85 ,$101.25 
Carle BroMenn Medical Center,8627537,15'  WORK & COMMUNITY RE-ENTRY,,97537,430,$109.00 ,$109.00 ,$32.70 ,$99.19 ,$76.30 ,$32.70 ,$70.85 ,$78.48 ,$99.19 ,$81.75 
Carle BroMenn Medical Center,8627542,15'  WHEELCHAIR MGMT TRAINING,,97542,430,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8627545,WORK CONDITIONING INITIAL 2 HR,,97545,430,$4.10 ,$4.10 ,$1.23 ,$3.73 ,$2.87 ,$1.23 ,$2.67 ,$2.95 ,$3.73 ,$3.08 
Carle BroMenn Medical Center,8627546,WORK CONDITIONING ADDTL HR,,97546,430,$4.10 ,$4.10 ,$1.23 ,$3.73 ,$2.87 ,$1.23 ,$2.67 ,$2.95 ,$3.73 ,$3.08 
Carle BroMenn Medical Center,8627597,SELECTIVE DEBRIDEMNT < 20SQ CM,,97597,430,$415.00 ,$415.00 ,$124.50 ,$377.65 ,$290.50 ,$124.50 ,$269.75 ,$298.80 ,$377.65 ,$311.25 
Carle BroMenn Medical Center,8627598,SELECTIVE DEBRIDEMNT > 20SQ CM,,97598,430,$280.00 ,$280.00 ,$84.00 ,$254.80 ,$196.00 ,$84.00 ,$182.00 ,$201.60 ,$254.80 ,$210.00 
Carle BroMenn Medical Center,8627602,"8-30"" NONSELECTIVE DEBRIDEMENT",,97602,430,$190.00 ,$190.00 ,$57.00 ,$172.90 ,$133.00 ,$57.00 ,$123.50 ,$136.80 ,$172.90 ,$142.50 
Carle BroMenn Medical Center,8627750,FUNCTIONAL CAPACITY EVALUATION,,97750,430,$140.00 ,$140.00 ,$42.00 ,$127.40 ,$98.00 ,$42.00 ,$91.00 ,$100.80 ,$127.40 ,$105.00 
Carle BroMenn Medical Center,8627760,"ORTHOTIC MGMNT & TRAINING 15""",,97760,430,$175.00 ,$175.00 ,$52.50 ,$159.25 ,$122.50 ,$52.50 ,$113.75 ,$126.00 ,$159.25 ,$131.25 
Carle BroMenn Medical Center,8627761,"PROSTHETIC TRAINING 15""",,97761,430,$125.00 ,$125.00 ,$37.50 ,$113.75 ,$87.50 ,$37.50 ,$81.25 ,$90.00 ,$113.75 ,$93.75 
Carle BroMenn Medical Center,8627763,ORTHOTICS/PROSTH MGMT &/TRAINJ SBSQ ENCTR 15 MIN,,97763,430,$125.00 ,$125.00 ,$37.50 ,$113.75 ,$87.50 ,$37.50 ,$81.25 ,$90.00 ,$113.75 ,$93.75 
Carle BroMenn Medical Center,8627802,15' NUTRITION SVCS - ONSITE,,97802,430,$93.00 ,$93.00 ,$27.90 ,$84.63 ,$65.10 ,$27.90 ,$60.45 ,$66.96 ,$84.63 ,$69.75 
Carle BroMenn Medical Center,8627803,15' NUTRITION SVCS-ONSITE,,97803,430,$93.00 ,$93.00 ,$27.90 ,$84.63 ,$65.10 ,$27.90 ,$60.45 ,$66.96 ,$84.63 ,$69.75 
Carle BroMenn Medical Center,8627804,15' GROUP NUTRITION SVCS,,97804,430,$79.00 ,$79.00 ,$23.70 ,$71.89 ,$55.30 ,$23.70 ,$51.35 ,$56.88 ,$71.89 ,$59.25 
Carle BroMenn Medical Center,8628499,15' IFSP DEVELOPMENT - OFFSITE,,99499,430,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8629010,15' GROUP TREATMENT,,H0004,430,$51.00 ,$51.00 ,$15.30 ,$46.41 ,$35.70 ,$15.30 ,$33.15 ,$36.72 ,$46.41 ,$38.25 
Carle BroMenn Medical Center,8629011,15' INDIVIDUAL TREATMNT-OFFSIT,,H0004,430,$51.00 ,$51.00 ,$15.30 ,$46.41 ,$35.70 ,$15.30 ,$33.15 ,$36.72 ,$46.41 ,$38.25 
Carle BroMenn Medical Center,8629012,15' INDVDUAL TREATMNT-ONSITE,,H0004,430,$51.00 ,$51.00 ,$15.30 ,$46.41 ,$35.70 ,$15.30 ,$33.15 ,$36.72 ,$46.41 ,$38.25 
Carle BroMenn Medical Center,8629013,15' EVALUATION - ONSITE,,T1001,430,$101.00 ,$101.00 ,$30.30 ,$91.91 ,$70.70 ,$30.30 ,$65.65 ,$72.72 ,$91.91 ,$75.75 
Carle BroMenn Medical Center,8629014,15' EVALUATION - OFFSITE,,T1001,430,$101.00 ,$101.00 ,$30.30 ,$91.91 ,$70.70 ,$30.30 ,$65.65 ,$72.72 ,$91.91 ,$75.75 
Carle BroMenn Medical Center,8629015,15' GROUP NURSING SERVICES,,T1002,430,$51.00 ,$51.00 ,$15.30 ,$46.41 ,$35.70 ,$15.30 ,$33.15 ,$36.72 ,$46.41 ,$38.25 
Carle BroMenn Medical Center,8629016,15' NURSING SERVICES - ONSITE,,T1002,430,$51.00 ,$51.00 ,$15.30 ,$46.41 ,$35.70 ,$15.30 ,$33.15 ,$36.72 ,$46.41 ,$38.25 
Carle BroMenn Medical Center,8629017,15' NURSING SERVICES - OFFSITE,,T1002,430,$51.00 ,$51.00 ,$15.30 ,$46.41 ,$35.70 ,$15.30 ,$33.15 ,$36.72 ,$46.41 ,$38.25 
Carle BroMenn Medical Center,8629018,15' INDIVIDUAL SERVICE COORDIN,,T1017,430,$40.00 ,$40.00 ,$12.00 ,$36.40 ,$28.00 ,$12.00 ,$26.00 ,$28.80 ,$36.40 ,$30.00 
Carle BroMenn Medical Center,8629019,15' GROUP FAMILY TRAIN/SUPPORT,,T1027,430,$51.00 ,$51.00 ,$15.30 ,$46.41 ,$35.70 ,$15.30 ,$33.15 ,$36.72 ,$46.41 ,$38.25 
Carle BroMenn Medical Center,8629020,15' FAMILY TRAIN/SUPPORT-ONSIT,,T1027,430,$51.00 ,$51.00 ,$15.30 ,$46.41 ,$35.70 ,$15.30 ,$33.15 ,$36.72 ,$46.41 ,$38.25 
Carle BroMenn Medical Center,8629021,15' INDIVIDUAL DT-ONSITE,,T1027,430,$51.00 ,$51.00 ,$15.30 ,$46.41 ,$35.70 ,$15.30 ,$33.15 ,$36.72 ,$46.41 ,$38.25 
Carle BroMenn Medical Center,8629022,15' FAMILY TRAIN/SUPORT-OFFSIT,,T1027,430,$51.00 ,$51.00 ,$15.30 ,$46.41 ,$35.70 ,$15.30 ,$33.15 ,$36.72 ,$46.41 ,$38.25 
Carle BroMenn Medical Center,8629023,15' INDIVIDUAL DT-OFFSITE,,T1027,430,$51.00 ,$51.00 ,$15.30 ,$46.41 ,$35.70 ,$15.30 ,$33.15 ,$36.72 ,$46.41 ,$38.25 
Carle BroMenn Medical Center,8629024,15' ASSESSMENT-ONSITE,,W8730,430,$40.00 ,$40.00 ,$12.00 ,$36.40 ,$28.00 ,$12.00 ,$26.00 ,$28.80 ,$36.40 ,$30.00 
Carle BroMenn Medical Center,8629025,15' ASSESSMENT-OFFSITE,,W8731,430,$40.00 ,$40.00 ,$12.00 ,$36.40 ,$28.00 ,$12.00 ,$26.00 ,$28.80 ,$36.40 ,$30.00 
Carle BroMenn Medical Center,8629026,15' ASSESSMENT-ONSITE,,W8739,430,$40.00 ,$40.00 ,$12.00 ,$36.40 ,$28.00 ,$12.00 ,$26.00 ,$28.80 ,$36.40 ,$30.00 
Carle BroMenn Medical Center,8629027,15' ASSESSMENT-OFFISTE,,W8740,430,$38.00 ,$38.00 ,$11.40 ,$34.58 ,$26.60 ,$11.40 ,$24.70 ,$27.36 ,$34.58 ,$28.50 
Carle BroMenn Medical Center,8629028,15' ASSESSMENT-ONSITE,,W8764,430,$40.00 ,$40.00 ,$12.00 ,$36.40 ,$28.00 ,$12.00 ,$26.00 ,$28.80 ,$36.40 ,$30.00 
Carle BroMenn Medical Center,8629029,15' ASSESSMENT-OFFSITE,,W8765,430,$40.00 ,$40.00 ,$12.00 ,$36.40 ,$28.00 ,$12.00 ,$26.00 ,$28.80 ,$36.40 ,$30.00 
Carle BroMenn Medical Center,8629030,15' ASSESSMENT - ONSITE,,W8768,430,$38.00 ,$38.00 ,$11.40 ,$34.58 ,$26.60 ,$11.40 ,$24.70 ,$27.36 ,$34.58 ,$28.50 
Carle BroMenn Medical Center,8629031,15' ASSESSMENT - OFFSITE,,W8769,430,$38.00 ,$38.00 ,$11.40 ,$34.58 ,$26.60 ,$11.40 ,$24.70 ,$27.36 ,$34.58 ,$28.50 
Carle BroMenn Medical Center,8629105,SPLINT APP LNG ARM STAT 8-30',,29105,430,$290.00 ,$290.00 ,$87.00 ,$263.90 ,$203.00 ,$87.00 ,$188.50 ,$208.80 ,$263.90 ,$217.50 
Carle BroMenn Medical Center,8629125,SPLINT APP SHT ARM STAT 8-15',,29125,430,$255.00 ,$255.00 ,$76.50 ,$232.05 ,$178.50 ,$76.50 ,$165.75 ,$183.60 ,$232.05 ,$191.25 
Carle BroMenn Medical Center,8629130,SPLINT APP FINGER STAT 8-15',,29130,430,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8629131,SPLINT APP FINGER DYN 8-30',,29131,430,$275.00 ,$275.00 ,$82.50 ,$250.25 ,$192.50 ,$82.50 ,$178.75 ,$198.00 ,$250.25 ,$206.25 
Carle BroMenn Medical Center,8629201,ATC EVALUATION,,G0463,430,$170.00 ,$170.00 ,$51.00 ,$154.70 ,$119.00 ,$51.00 ,$110.50 ,$122.40 ,$154.70 ,$127.50 
Carle BroMenn Medical Center,8629240,STRAPPING SHOULDER,,29240,430,$170.00 ,$170.00 ,$51.00 ,$154.70 ,$119.00 ,$51.00 ,$110.50 ,$122.40 ,$154.70 ,$127.50 
Carle BroMenn Medical Center,8629260,"8-15"" STRAPPING ELBOW/WRIST",,29260,430,$160.00 ,$160.00 ,$48.00 ,$145.60 ,$112.00 ,$48.00 ,$104.00 ,$115.20 ,$145.60 ,$120.00 
Carle BroMenn Medical Center,8629280,"8-15"" STRAPPING HAND/FINGER",,29280,430,$190.00 ,$190.00 ,$57.00 ,$172.90 ,$133.00 ,$57.00 ,$123.50 ,$136.80 ,$172.90 ,$142.50 
Carle BroMenn Medical Center,8629368,"OT CHG TEAM CONF W/O PT/FAMILY PRSNT, EA 30 MIN",,99368,430,$195.00 ,$195.00 ,$58.50 ,$177.45 ,$136.50 ,$58.50 ,$126.75 ,$140.40 ,$177.45 ,$146.25 
Carle BroMenn Medical Center,8629499,15' IFSP DEVELOPMENT-ONSITE,,99499,430,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8629505,SPLINT APP LONG LEG 8'-30',,29505,430,$295.00 ,$295.00 ,$88.50 ,$268.45 ,$206.50 ,$88.50 ,$191.75 ,$212.40 ,$268.45 ,$221.25 
Carle BroMenn Medical Center,8629515,SPLINT APP SHORT LEG 8'-30',,29515,430,$230.00 ,$230.00 ,$69.00 ,$209.30 ,$161.00 ,$69.00 ,$149.50 ,$165.60 ,$209.30 ,$172.50 
Carle BroMenn Medical Center,8629520,STRAPPING HIP,,29520,430,$169.00 ,$169.00 ,$50.70 ,$153.79 ,$118.30 ,$50.70 ,$109.85 ,$121.68 ,$153.79 ,$126.75 
Carle BroMenn Medical Center,8629530,STRAPPING KNEE,,29530,430,$185.00 ,$185.00 ,$55.50 ,$168.35 ,$129.50 ,$55.50 ,$120.25 ,$133.20 ,$168.35 ,$138.75 
Carle BroMenn Medical Center,8629540,8'-15' ORTH CUST FT/ANKL STRP,,29540,430,$125.00 ,$125.00 ,$37.50 ,$113.75 ,$87.50 ,$37.50 ,$81.25 ,$90.00 ,$113.75 ,$93.75 
Carle BroMenn Medical Center,8629550,STRAPPING TOE,,29550,430,$180.00 ,$180.00 ,$54.00 ,$163.80 ,$126.00 ,$54.00 ,$117.00 ,$129.60 ,$163.80 ,$135.00 
Carle BroMenn Medical Center,8629581,APPLY MULTI-LAY CMPRSSN; LEG (BELOW KNEE) INCL ANKLE/FT,,29581,430,$415.00 ,$415.00 ,$124.50 ,$377.65 ,$290.50 ,$124.50 ,$269.75 ,$298.80 ,$377.65 ,$311.25 
Carle BroMenn Medical Center,8629584,APPLY MULTI-LAY CMPRSSN; UPPER ARM THRU HAND/FINGERS,,29584,430,$420.00 ,$420.00 ,$126.00 ,$382.20 ,$294.00 ,$126.00 ,$273.00 ,$302.40 ,$382.20 ,$315.00 
Carle BroMenn Medical Center,8629599,15' IFSP DEVELOPMENT - ONSITE,,99499,430,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8690600,DEV THERAPY EVAL/ASSESS ON/LOC CODE 11,,96112,430,$18.13 ,$18.13 ,$5.44 ,$16.50 ,$12.69 ,$5.44 ,$11.78 ,$13.05 ,$16.50 ,$13.60 
Carle BroMenn Medical Center,8690601,DEV THERAPY EVAL/ASSESS ON/LOC CODE 12,,96112,430,$18.13 ,$18.13 ,$5.44 ,$16.50 ,$12.69 ,$5.44 ,$11.78 ,$13.05 ,$16.50 ,$13.60 
Carle BroMenn Medical Center,8690602,DEV THERAPY EVAL/ASSESS ON/LOC CODE 99,,96112,430,$18.13 ,$18.13 ,$5.44 ,$16.50 ,$12.69 ,$5.44 ,$11.78 ,$13.05 ,$16.50 ,$13.60 
Carle BroMenn Medical Center,8690603,DEV THERAPY SERVICES ON/LOC CODE 11,,T1027,430,$51.00 ,$51.00 ,$15.30 ,$46.41 ,$35.70 ,$15.30 ,$33.15 ,$36.72 ,$46.41 ,$38.25 
Carle BroMenn Medical Center,8690604,DEV THERAPY SERVICES ON/LOC CODE 12,,T1027,430,$51.00 ,$51.00 ,$15.30 ,$46.41 ,$35.70 ,$15.30 ,$33.15 ,$36.72 ,$46.41 ,$38.25 
Carle BroMenn Medical Center,8690605,DEV THERAPY SERVICES ON/LOC CODE 99,,T1027,430,$51.00 ,$51.00 ,$15.30 ,$46.41 ,$35.70 ,$15.30 ,$33.15 ,$36.72 ,$46.41 ,$38.25 
Carle BroMenn Medical Center,8690606,DEV THERAPY MEG/DEV ON/LOC CODE 11,,99499,430,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8690607,DEV THERAPY MEG/DEV ON/LOC CODE 12,,99499,430,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8690608,DEV THERAPY MEG/DEV ON/LOC CODE 99,,99499,430,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8690609,DEV THERAPY GROUP,,T1027,430,$51.00 ,$51.00 ,$15.30 ,$46.41 ,$35.70 ,$15.30 ,$33.15 ,$36.72 ,$46.41 ,$38.25 
Carle BroMenn Medical Center,8720002,DRSG/DEBRID SMALL AREA  GO,,16020,430,$580.00 ,$580.00 ,$174.00 ,$527.80 ,$406.00 ,$174.00 ,$377.00 ,$417.60 ,$527.80 ,$435.00 
Carle BroMenn Medical Center,8720004,DRSG/DEBRID MEDIUM SIZE AREA  GO,,16025,430,$620.00 ,$620.00 ,$186.00 ,$564.20 ,$434.00 ,$186.00 ,$403.00 ,$446.40 ,$564.20 ,$465.00 
Carle BroMenn Medical Center,8720006,DRSG/DEBRID LARGE AREA GO,,16030,430,$790.00 ,$790.00 ,$237.00 ,$718.90 ,$553.00 ,$237.00 ,$513.50 ,$568.80 ,$718.90 ,$592.50 
Carle BroMenn Medical Center,8720009,SPLINT APP LNG ARM STAT 31-60' GO,,29105,430,$480.00 ,$480.00 ,$144.00 ,$436.80 ,$336.00 ,$144.00 ,$312.00 ,$345.60 ,$436.80 ,$360.00 
Carle BroMenn Medical Center,8720010,SPLINT APP LNG ARM STAT 8-30' GO,,29105,430,$480.00 ,$480.00 ,$144.00 ,$436.80 ,$336.00 ,$144.00 ,$312.00 ,$345.60 ,$436.80 ,$360.00 
Carle BroMenn Medical Center,8720015,SPLINT APP SHT ARM STAT 16-30' GO,,29125,430,$265.00 ,$265.00 ,$79.50 ,$241.15 ,$185.50 ,$79.50 ,$172.25 ,$190.80 ,$241.15 ,$198.75 
Carle BroMenn Medical Center,8720016,SPLINT APP SHT ARM STAT 8-15' GO,,29125,430,$265.00 ,$265.00 ,$79.50 ,$241.15 ,$185.50 ,$79.50 ,$172.25 ,$190.80 ,$241.15 ,$198.75 
Carle BroMenn Medical Center,8720017,SPLINT APP SHT ARM STAT 31-45' GO,,29125,430,$400.00 ,$400.00 ,$120.00 ,$364.00 ,$280.00 ,$120.00 ,$260.00 ,$288.00 ,$364.00 ,$300.00 
Carle BroMenn Medical Center,8720018,SPLINT APP SHT ARM STAT 46-60' GO,,29125,430,$370.00 ,$370.00 ,$111.00 ,$336.70 ,$259.00 ,$111.00 ,$240.50 ,$266.40 ,$336.70 ,$277.50 
Carle BroMenn Medical Center,8720025,SPLINT APP FINGER STAT 8-15' GO,,29130,430,$155.00 ,$155.00 ,$46.50 ,$141.05 ,$108.50 ,$46.50 ,$100.75 ,$111.60 ,$141.05 ,$116.25 
Carle BroMenn Medical Center,8720026,SPLINT APP FINGER STAT 16-30' GO,,29130,430,$235.00 ,$235.00 ,$70.50 ,$213.85 ,$164.50 ,$70.50 ,$152.75 ,$169.20 ,$213.85 ,$176.25 
Carle BroMenn Medical Center,8720029,SPLINT APP FINGER DYN 31-60' GO,,29131,430,$325.00 ,$325.00 ,$97.50 ,$295.75 ,$227.50 ,$97.50 ,$211.25 ,$234.00 ,$295.75 ,$243.75 
Carle BroMenn Medical Center,8720030,SPLINT APP FINGER DYN 8-30' GO,,29131,430,$285.00 ,$285.00 ,$85.50 ,$259.35 ,$199.50 ,$85.50 ,$185.25 ,$205.20 ,$259.35 ,$213.75 
Carle BroMenn Medical Center,8720034,STRAPPING SHOULDER GO,,29240,430,$170.00 ,$170.00 ,$51.00 ,$154.70 ,$119.00 ,$51.00 ,$110.50 ,$122.40 ,$154.70 ,$127.50 
Carle BroMenn Medical Center,8720039,"8-15"" STRAPPING ELBOW/WRIST GO",,29260,430,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8720040,"16-30"" STRAPPING ELBOW/WRIST GO",,29260,430,$235.00 ,$235.00 ,$70.50 ,$213.85 ,$164.50 ,$70.50 ,$152.75 ,$169.20 ,$213.85 ,$176.25 
Carle BroMenn Medical Center,8720041,"31-45"" STRAPPING ELBOW/WRIST GO",,29260,430,$325.00 ,$325.00 ,$97.50 ,$295.75 ,$227.50 ,$97.50 ,$211.25 ,$234.00 ,$295.75 ,$243.75 
Carle BroMenn Medical Center,8720042,"46-60"" STRAPPING ELBOW/WRIST GO",,29260,430,$385.00 ,$385.00 ,$115.50 ,$350.35 ,$269.50 ,$115.50 ,$250.25 ,$277.20 ,$350.35 ,$288.75 
Carle BroMenn Medical Center,8720047,"8-15"" STRAPPING HAND/FINGER GO",,29280,430,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8720048,"16-30"" STRAPPING HAND/FINGER GO",,29280,430,$235.00 ,$235.00 ,$70.50 ,$213.85 ,$164.50 ,$70.50 ,$152.75 ,$169.20 ,$213.85 ,$176.25 
Carle BroMenn Medical Center,8720049,"31-45"" STRAPPING HAND/FINGER GO",,29280,430,$280.00 ,$280.00 ,$84.00 ,$254.80 ,$196.00 ,$84.00 ,$182.00 ,$201.60 ,$254.80 ,$210.00 
Carle BroMenn Medical Center,8720050,"46-60"" STRAPPING HAND/FINGER GO",,29280,430,$360.00 ,$360.00 ,$108.00 ,$327.60 ,$252.00 ,$108.00 ,$234.00 ,$259.20 ,$327.60 ,$270.00 
Carle BroMenn Medical Center,8720054,SPLINT APP LONG LEG 61'-75' GO,,29505,430,$530.00 ,$530.00 ,$159.00 ,$482.30 ,$371.00 ,$159.00 ,$344.50 ,$381.60 ,$482.30 ,$397.50 
Carle BroMenn Medical Center,8720055,SPLINT APP LONG LEG 31'-60' GO,,29505,430,$360.00 ,$360.00 ,$108.00 ,$327.60 ,$252.00 ,$108.00 ,$234.00 ,$259.20 ,$327.60 ,$270.00 
Carle BroMenn Medical Center,8720056,SPLINT APP LONG LEG 8'-30' GO,,29505,430,$305.00 ,$305.00 ,$91.50 ,$277.55 ,$213.50 ,$91.50 ,$198.25 ,$219.60 ,$277.55 ,$228.75 
Carle BroMenn Medical Center,8720060,SPLINT APP SHORT LEG 61'-75' GO,,29515,430,$530.00 ,$530.00 ,$159.00 ,$482.30 ,$371.00 ,$159.00 ,$344.50 ,$381.60 ,$482.30 ,$397.50 
Carle BroMenn Medical Center,8720061,SPLINT APP SHORT LEG 8'-30' GO,,29515,430,$235.00 ,$235.00 ,$70.50 ,$213.85 ,$164.50 ,$70.50 ,$152.75 ,$169.20 ,$213.85 ,$176.25 
Carle BroMenn Medical Center,8720062,SPLINT APP SHORT LEG 31'-60' GO,,29515,430,$345.00 ,$345.00 ,$103.50 ,$313.95 ,$241.50 ,$103.50 ,$224.25 ,$248.40 ,$313.95 ,$258.75 
Carle BroMenn Medical Center,8720064,STRAPPING HIP GO,,29520,430,$169.00 ,$169.00 ,$50.70 ,$153.79 ,$118.30 ,$50.70 ,$109.85 ,$121.68 ,$153.79 ,$126.75 
Carle BroMenn Medical Center,8720066,STRAPPING KNEE GO,,29530,430,$185.00 ,$185.00 ,$55.50 ,$168.35 ,$129.50 ,$55.50 ,$120.25 ,$133.20 ,$168.35 ,$138.75 
Carle BroMenn Medical Center,8720070,8'-15' ORTH CUST FT/ANKL STRP GO,,29540,430,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8720071,16'-30' ORTH CUST FT/ANKL STRP GO,,29540,430,$255.00 ,$255.00 ,$76.50 ,$232.05 ,$178.50 ,$76.50 ,$165.75 ,$183.60 ,$232.05 ,$191.25 
Carle BroMenn Medical Center,8720072,31'-60' ORTH CUST FT/ANKL STRP GO,,29540,430,$400.00 ,$400.00 ,$120.00 ,$364.00 ,$280.00 ,$120.00 ,$260.00 ,$288.00 ,$364.00 ,$300.00 
Carle BroMenn Medical Center,8720074,STRAPPING TOE GO,,29550,430,$180.00 ,$180.00 ,$54.00 ,$163.80 ,$126.00 ,$54.00 ,$117.00 ,$129.60 ,$163.80 ,$135.00 
Carle BroMenn Medical Center,8720086,BIOFEEDBACK-SPEC MUSCLE GRPS GO,,90901,430,$158.00 ,$158.00 ,$47.40 ,$143.78 ,$110.60 ,$47.40 ,$102.70 ,$113.76 ,$143.78 ,$118.50 
Carle BroMenn Medical Center,8720088,BIOFEEDBACK-PERINEAL MUSCLES GO,,90911,430,$266.00 ,$266.00 ,$79.80 ,$242.06 ,$186.20 ,$79.80 ,$172.90 ,$191.52 ,$242.06 ,$199.50 
Carle BroMenn Medical Center,8720181,ELECTRIC STIMULATION THERAPY,,97014,430,$75.00 ,$75.00 ,$22.50 ,$68.25 ,$52.50 ,$22.50 ,$48.75 ,$54.00 ,$68.25 ,$56.25 
Carle BroMenn Medical Center,8720191,PELVIC & CERVICAL TRACTION GO,,97012,430,$76.00 ,$76.00 ,$22.80 ,$69.16 ,$53.20 ,$22.80 ,$49.40 ,$54.72 ,$69.16 ,$57.00 
Carle BroMenn Medical Center,8720193,COMPRESSION PUMP (VASOPNEUMATIC DVCS) GO,,97016,430,$71.00 ,$71.00 ,$21.30 ,$64.61 ,$49.70 ,$21.30 ,$46.15 ,$51.12 ,$64.61 ,$53.25 
Carle BroMenn Medical Center,8720195,PARAFFIN BATH GO,,97018,430,$74.00 ,$74.00 ,$22.20 ,$67.34 ,$51.80 ,$22.20 ,$48.10 ,$53.28 ,$67.34 ,$55.50 
Carle BroMenn Medical Center,8720197,DRY WHIRLPOOL GO,,97022,430,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8720200,LIQUID WHIRLPOOL GO,,97022,430,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8720202,"INFRARED 15"" GO",,97026,430,$57.00 ,$57.00 ,$17.10 ,$51.87 ,$39.90 ,$17.10 ,$37.05 ,$41.04 ,$51.87 ,$42.75 
Carle BroMenn Medical Center,8720205,15' EMS 1:1 GO,,97032,430,$89.00 ,$89.00 ,$26.70 ,$80.99 ,$62.30 ,$26.70 ,$57.85 ,$64.08 ,$80.99 ,$66.75 
Carle BroMenn Medical Center,8720208,15' IONTO 1:1 GO,,97033,430,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8720210,15' CONTRAST BATH 1:1 GO,,97034,430,$73.00 ,$73.00 ,$21.90 ,$66.43 ,$51.10 ,$21.90 ,$47.45 ,$52.56 ,$66.43 ,$54.75 
Carle BroMenn Medical Center,8720212,15' ULTRASOUND 1:1 GO,,97035,430,$72.00 ,$72.00 ,$21.60 ,$65.52 ,$50.40 ,$21.60 ,$46.80 ,$51.84 ,$65.52 ,$54.00 
Carle BroMenn Medical Center,8720221,15' THERAPEUTIC EXERCISE GO,,97110,430,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8720226,15' NEUROMUSCULAR RE-EDUCATION GO,,97112,430,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8720229,15' AQUATIC THERAPY GO,,97113,430,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8720231,15' GAIT TRAINING GO,,97116,430,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8720233,THERAPEUTIC PROCEDURE GO,,97139,430,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8720236,15' MANUAL THERAPY GO,,97140,430,$125.00 ,$125.00 ,$37.50 ,$113.75 ,$87.50 ,$37.50 ,$81.25 ,$90.00 ,$113.75 ,$93.75 
Carle BroMenn Medical Center,8720241,15' GROUP THERAPY,,97150,430,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8720243,GROUP OT 8'-30' GO,,97150,430,$83.00 ,$83.00 ,$24.90 ,$75.53 ,$58.10 ,$24.90 ,$53.95 ,$59.76 ,$75.53 ,$62.25 
Carle BroMenn Medical Center,8720245,GROUP OT 31'-45' GO,,97150,430,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8720247,GROUP OT 46'-60' GO,,97150,430,$160.00 ,$160.00 ,$48.00 ,$145.60 ,$112.00 ,$48.00 ,$104.00 ,$115.20 ,$145.60 ,$120.00 
Carle BroMenn Medical Center,8720249,GROUP OT 61'-120' GO,,97150,430,$235.00 ,$235.00 ,$70.50 ,$213.85 ,$164.50 ,$70.50 ,$152.75 ,$169.20 ,$213.85 ,$176.25 
Carle BroMenn Medical Center,8720250,15' INDIVIDUAL FUNCT THERAPY-ONSITE,,97530,430,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8720251,15' INDIVIDUAL FUNCT THERAPY-OFFSITE,,97530,430,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8720253,15' FUNCT THERAPY ACTIVITY GO,,97530,430,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8720259,15' SENSORY INTEGRATION GO,,97533,430,$154.00 ,$154.00 ,$46.20 ,$140.14 ,$107.80 ,$46.20 ,$100.10 ,$110.88 ,$140.14 ,$115.50 
Carle BroMenn Medical Center,8720262,15' ADL TRAINING GO,,97535,430,$135.00 ,$135.00 ,$40.50 ,$122.85 ,$94.50 ,$40.50 ,$87.75 ,$97.20 ,$122.85 ,$101.25 
Carle BroMenn Medical Center,8720265,15'  WORK & COMMUNITY RE-ENTRY GO,,97537,430,$109.00 ,$109.00 ,$32.70 ,$99.19 ,$76.30 ,$32.70 ,$70.85 ,$78.48 ,$99.19 ,$81.75 
Carle BroMenn Medical Center,8720271,15'  WHEELCHAIR MGMT TRAINING GO,,97542,430,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8720273,WORK CONDITIONING INITIAL 2 HR GO,,97545,430,$4.10 ,$4.10 ,$1.23 ,$3.73 ,$2.87 ,$1.23 ,$2.67 ,$2.95 ,$3.73 ,$3.08 
Carle BroMenn Medical Center,8720275,WORK CONDITIONING ADDTL HR GO,,97546,430,$4.10 ,$4.10 ,$1.23 ,$3.73 ,$2.87 ,$1.23 ,$2.67 ,$2.95 ,$3.73 ,$3.08 
Carle BroMenn Medical Center,8720277,ORTHOTICS/PROSTH MGMT &/TRAINJ SBSQ ENCTR 15 MIN GO,,97763,430,$125.00 ,$125.00 ,$37.50 ,$113.75 ,$87.50 ,$37.50 ,$81.25 ,$90.00 ,$113.75 ,$93.75 
Carle BroMenn Medical Center,8720281,SELECTIVE DEBRIDEMNT < 20SQ CM GO,,97597,430,$415.00 ,$415.00 ,$124.50 ,$377.65 ,$290.50 ,$124.50 ,$269.75 ,$298.80 ,$377.65 ,$311.25 
Carle BroMenn Medical Center,8720283,SELECTIVE DEBRIDEMNT > 20SQ CM GO,,97598,430,$280.00 ,$280.00 ,$84.00 ,$254.80 ,$196.00 ,$84.00 ,$182.00 ,$201.60 ,$254.80 ,$210.00 
Carle BroMenn Medical Center,8720285,"8-30"" NONSELECTIVE DEBRIDEMENT GO",,97602,430,$205.00 ,$205.00 ,$61.50 ,$186.55 ,$143.50 ,$61.50 ,$133.25 ,$147.60 ,$186.55 ,$153.75 
Carle BroMenn Medical Center,8720287,"31-60"" NONSELECTIVE DEBRIDEMNT GO",,97602,430,$740.00 ,$740.00 ,$222.00 ,$673.40 ,$518.00 ,$222.00 ,$481.00 ,$532.80 ,$673.40 ,$555.00 
Carle BroMenn Medical Center,8720301,FUNCTIONAL CAPACITY EVALUATION GO,,97750,430,$140.00 ,$140.00 ,$42.00 ,$127.40 ,$98.00 ,$42.00 ,$91.00 ,$100.80 ,$127.40 ,$105.00 
Carle BroMenn Medical Center,8720303,FUNCTIONAL TESTS & MEASURES GO,,97750,430,$140.00 ,$140.00 ,$42.00 ,$127.40 ,$98.00 ,$42.00 ,$91.00 ,$100.80 ,$127.40 ,$105.00 
Carle BroMenn Medical Center,8720307,"ORTHOTIC MGMNT & TRAINING 15"" GO",,97760,430,$175.00 ,$175.00 ,$52.50 ,$159.25 ,$122.50 ,$52.50 ,$113.75 ,$126.00 ,$159.25 ,$131.25 
Carle BroMenn Medical Center,8720310,"PROSTHETIC TRAINING 15"" GO",,97761,430,$125.00 ,$125.00 ,$37.50 ,$113.75 ,$87.50 ,$37.50 ,$81.25 ,$90.00 ,$113.75 ,$93.75 
Carle BroMenn Medical Center,8720320,THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES GO,,97129,430,$185.00 ,$185.00 ,$55.50 ,$168.35 ,$129.50 ,$55.50 ,$120.25 ,$133.20 ,$168.35 ,$138.75 
Carle BroMenn Medical Center,8720323,THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES GO,,97130,430,$185.00 ,$185.00 ,$55.50 ,$168.35 ,$129.50 ,$55.50 ,$120.25 ,$133.20 ,$168.35 ,$138.75 
Carle BroMenn Medical Center,8720403,15' IFSP DEVELOPMENT-OFFSITE GO,,99499,430,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8720411,ELECTRICAL STIM FOR ULCERS GO,,G0281,430,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8720413,ELECTRICAL STIM FOR WOUNDS GO,,G0282,430,$74.00 ,$74.00 ,$22.20 ,$67.34 ,$51.80 ,$22.20 ,$48.10 ,$53.28 ,$67.34 ,$55.50 
Carle BroMenn Medical Center,8720415,ELECTRICAL STIMULATION GO,,G0283,430,$79.00 ,$79.00 ,$23.70 ,$71.89 ,$55.30 ,$23.70 ,$51.35 ,$56.88 ,$71.89 ,$59.25 
Carle BroMenn Medical Center,8721401,15' IFSP DEVELOPMENT-ONSITE GO,,99499,430,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8729368,"OT CHG TEAM CONF W/O PT/FAMILY PRSNT, EA 30 MIN",,99368,430,$195.00 ,$195.00 ,$58.50 ,$177.45 ,$136.50 ,$58.50 ,$126.75 ,$140.40 ,$177.45 ,$146.25 
Carle BroMenn Medical Center,8729581,APPLY MULTI-LAY CMPRSSN; LEG (BELOW KNEE) INCL ANKLE/FT,,29581,430,$415.00 ,$415.00 ,$124.50 ,$377.65 ,$290.50 ,$124.50 ,$269.75 ,$298.80 ,$377.65 ,$311.25 
Carle BroMenn Medical Center,8729584,APPLY MULTI-LAY CMPRSSN; UPPER ARM THRU HAND/FINGERS,,29584,430,$420.00 ,$420.00 ,$126.00 ,$382.20 ,$294.00 ,$126.00 ,$273.00 ,$302.40 ,$382.20 ,$315.00 
Carle BroMenn Medical Center,8730156,CANCELLATION-24 HOURS OR LESS,,,430,$334.00 ,$334.00 ,$100.20 ,$303.94 ,$233.80 ,$100.20 ,$217.10 ,$240.48 ,$303.94 ,$250.50 
Carle BroMenn Medical Center,8730157,CANCELLATION-25 TO 48 HOURS,,,430,$176.00 ,$176.00 ,$52.80 ,$160.16 ,$123.20 ,$52.80 ,$114.40 ,$126.72 ,$160.16 ,$132.00 
Carle BroMenn Medical Center,8730158,15' FUNCTIONAL MAINTENANCE,,,430,$20.00 ,$20.00 ,$6.00 ,$18.20 ,$14.00 ,$6.00 ,$13.00 ,$14.40 ,$18.20 ,$15.00 
Carle BroMenn Medical Center,8730159,DRIVERS EVALUATION,,,430,$360.00 ,$360.00 ,$108.00 ,$327.60 ,$252.00 ,$108.00 ,$234.00 ,$259.20 ,$327.60 ,$270.00 
Carle BroMenn Medical Center,8792201,ATC EVALUATION GO,,G0463,430,$125.00 ,$125.00 ,$37.50 ,$113.75 ,$87.50 ,$37.50 ,$81.25 ,$90.00 ,$113.75 ,$93.75 
Carle BroMenn Medical Center,8972368,"OT CHG TEAM CONF W/O PT/FAMILY PRSNT, EA 30 MIN",,99368,430,$195.00 ,$195.00 ,$58.50 ,$177.45 ,$136.50 ,$58.50 ,$126.75 ,$140.40 ,$177.45 ,$146.25 
Carle BroMenn Medical Center,8621003,15' EVALUATION-OFFSITE,,97165,434,$360.00 ,$360.00 ,$108.00 ,$327.60 ,$252.00 ,$108.00 ,$234.00 ,$259.20 ,$327.60 ,$270.00 
Carle BroMenn Medical Center,8625002,OT EVAL HIGH COMPLEXITY (31-60 MINUTES),,97167,434,$275.00 ,$275.00 ,$82.50 ,$250.25 ,$192.50 ,$82.50 ,$178.75 ,$198.00 ,$250.25 ,$206.25 
Carle BroMenn Medical Center,8625003,OT EVAL HIGH COMPLEXITY (61-90 MINUTES),,97167,434,$295.00 ,$295.00 ,$88.50 ,$268.45 ,$206.50 ,$88.50 ,$191.75 ,$212.40 ,$268.45 ,$221.25 
Carle BroMenn Medical Center,8625008,OT EVAL MODERATE COMPLEXITY (31-60 MINUTES),,97166,434,$275.00 ,$275.00 ,$82.50 ,$250.25 ,$192.50 ,$82.50 ,$178.75 ,$198.00 ,$250.25 ,$206.25 
Carle BroMenn Medical Center,8625009,OT EVAL MODERATE COMPLEXITY (61-90 MINUTES),,97166,434,$275.00 ,$275.00 ,$82.50 ,$250.25 ,$192.50 ,$82.50 ,$178.75 ,$198.00 ,$250.25 ,$206.25 
Carle BroMenn Medical Center,8627003,15' EVALUATION-ONSITE,,97165,434,$360.00 ,$360.00 ,$108.00 ,$327.60 ,$252.00 ,$108.00 ,$234.00 ,$259.20 ,$327.60 ,$270.00 
Carle BroMenn Medical Center,8679166,OT EVAL MODERATE COMPLEXITY (0-30 MINUTES),,97166,434,$275.00 ,$275.00 ,$82.50 ,$250.25 ,$192.50 ,$82.50 ,$178.75 ,$198.00 ,$250.25 ,$206.25 
Carle BroMenn Medical Center,8697165,OT EVAL LOW COMPLEXITY,,97165,434,$360.00 ,$360.00 ,$108.00 ,$327.60 ,$252.00 ,$108.00 ,$234.00 ,$259.20 ,$327.60 ,$270.00 
Carle BroMenn Medical Center,8697167,OT EVAL HIGH COMPLEXITY (0-30 MINUTES),,97167,434,$275.00 ,$275.00 ,$82.50 ,$250.25 ,$192.50 ,$82.50 ,$178.75 ,$198.00 ,$250.25 ,$206.25 
Carle BroMenn Medical Center,8697168,OT RE-EVAL,,97168,434,$290.00 ,$290.00 ,$87.00 ,$263.90 ,$203.00 ,$87.00 ,$188.50 ,$208.80 ,$263.90 ,$217.50 
Carle BroMenn Medical Center,8720166,15' OT EVALUATION-ONSITE,,97165,434,$360.00 ,$360.00 ,$108.00 ,$327.60 ,$252.00 ,$108.00 ,$234.00 ,$259.20 ,$327.60 ,$270.00 
Carle BroMenn Medical Center,8720167,15' OT EVALUATION-OFFSITE,,97165,434,$360.00 ,$360.00 ,$108.00 ,$327.60 ,$252.00 ,$108.00 ,$234.00 ,$259.20 ,$327.60 ,$270.00 
Carle BroMenn Medical Center,8725004,OT EVAL MODERATE COMPLEXITY (31-60 MINUTES),,97166,434,$275.00 ,$275.00 ,$82.50 ,$250.25 ,$192.50 ,$82.50 ,$178.75 ,$198.00 ,$250.25 ,$206.25 
Carle BroMenn Medical Center,8725005,OT EVAL MODERATE COMPLEXITY (61-90 MINUTES),,97166,434,$275.00 ,$275.00 ,$82.50 ,$250.25 ,$192.50 ,$82.50 ,$178.75 ,$198.00 ,$250.25 ,$206.25 
Carle BroMenn Medical Center,8725006,OT EVAL HIGH COMPLEXITY (31-60 MINUTES),,97167,434,$285.00 ,$285.00 ,$85.50 ,$259.35 ,$199.50 ,$85.50 ,$185.25 ,$205.20 ,$259.35 ,$213.75 
Carle BroMenn Medical Center,8725007,OT EVAL HIGH COMPLEXITY (61-90 MINUTES),,97167,434,$310.00 ,$310.00 ,$93.00 ,$282.10 ,$217.00 ,$93.00 ,$201.50 ,$223.20 ,$282.10 ,$232.50 
Carle BroMenn Medical Center,8797165,OT EVAL LOW COMPLEXITY,,97165,434,$360.00 ,$360.00 ,$108.00 ,$327.60 ,$252.00 ,$108.00 ,$234.00 ,$259.20 ,$327.60 ,$270.00 
Carle BroMenn Medical Center,8797166,OT EVAL MODERATE COMPLEXITY (0-30 MINUTES),,97166,434,$230.00 ,$230.00 ,$69.00 ,$209.30 ,$161.00 ,$69.00 ,$149.50 ,$165.60 ,$209.30 ,$172.50 
Carle BroMenn Medical Center,8797167,OT EVAL HIGH COMPLEXITY (0-30 MINUTES),,97167,434,$310.00 ,$310.00 ,$93.00 ,$282.10 ,$217.00 ,$93.00 ,$201.50 ,$223.20 ,$282.10 ,$232.50 
Carle BroMenn Medical Center,8797168,OT RE-EVAL,,97168,434,$290.00 ,$290.00 ,$87.00 ,$263.90 ,$203.00 ,$87.00 ,$188.50 ,$208.80 ,$263.90 ,$217.50 
Carle BroMenn Medical Center,8292521,EVAL SPEECH FLUENCY,,92521,440,$135.00 ,$135.00 ,$40.50 ,$122.85 ,$94.50 ,$40.50 ,$87.75 ,$97.20 ,$122.85 ,$101.25 
Carle BroMenn Medical Center,8292522,EVAL SPEECH SOUND PRODUCTION,,92522,440,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8292523,EVAL SPEECH SOUND PROD W/ EVAL LANG COMP/EXPRSN,,92523,440,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8292524,BEHAVRL/QUAL ANALYSIS VOICE/RESONANCE,,92524,440,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8616105,APHASIA TEST,,96105,440,$385.00 ,$385.00 ,$115.50 ,$350.35 ,$269.50 ,$115.50 ,$250.25 ,$277.20 ,$350.35 ,$288.75 
Carle BroMenn Medical Center,8626105,APHASIA TEST,,96105,440,$385.00 ,$385.00 ,$115.50 ,$350.35 ,$269.50 ,$115.50 ,$250.25 ,$277.20 ,$350.35 ,$288.75 
Carle BroMenn Medical Center,8630000,SPEECH EVAL/ASSESSMENT SPEECH FLUENCY ON/LOC CODE 11,,92521,440,$135.00 ,$135.00 ,$40.50 ,$122.85 ,$94.50 ,$40.50 ,$87.75 ,$97.20 ,$122.85 ,$101.25 
Carle BroMenn Medical Center,8630001,SPEECH EVAL/ASSESSMENT SPEECH FLUENCY OFF/LOC CODE 12,,92521,440,$135.00 ,$135.00 ,$40.50 ,$122.85 ,$94.50 ,$40.50 ,$87.75 ,$97.20 ,$122.85 ,$101.25 
Carle BroMenn Medical Center,8630002,SPEECH EVAL/ASSESSMENT SPEECH FLUENCY OFF/LOC CODE 99,,92521,440,$135.00 ,$135.00 ,$40.50 ,$122.85 ,$94.50 ,$40.50 ,$87.75 ,$97.20 ,$122.85 ,$101.25 
Carle BroMenn Medical Center,8630003,SPEECH THERAPY SERVICES ON/LOC CODE 11,,92507,440,$265.00 ,$265.00 ,$79.50 ,$241.15 ,$185.50 ,$79.50 ,$172.25 ,$190.80 ,$241.15 ,$198.75 
Carle BroMenn Medical Center,8630004,SPEECH THERAPY SERVICES OFF/LOC CODE 12,,92507,440,$265.00 ,$265.00 ,$79.50 ,$241.15 ,$185.50 ,$79.50 ,$172.25 ,$190.80 ,$241.15 ,$198.75 
Carle BroMenn Medical Center,8630005,SPEECH THERAPY SERVICES OFF/LOC CODE 99,,92507,440,$265.00 ,$265.00 ,$79.50 ,$241.15 ,$185.50 ,$79.50 ,$172.25 ,$190.80 ,$241.15 ,$198.75 
Carle BroMenn Medical Center,8630006,SPEECH IFSP MTG/DEV ON/LOC CODE 11,,99499,440,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8630007,SPEECH IFSP MTG/DEV OFF/LOC CODE 12,,99499,440,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8630008,SPEECH IFSP MTG/DEV OFF/LOC CODE 99,,99499,440,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8630009,SPEECH EVAL/ASSESSMENT SOUND PRODUCTION ON/LOC CODE 11,,92522,440,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8630010,SPEECH EVAL/ASSESSMENT SOUND PRODUCTION OFF/LOC CODE 12,,92522,440,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8630011,SPEECH EVAL/ASSESSMENT SOUND PRODUCTION OFF/LOC CODE 99,,92522,440,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8630012,SP EVAL/ASSESS SOUND PROD W/ LANG COMP AND EXPRESS ON/LOC CODE 11,,92523,440,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8630013,SP EVAL/ASSESS SOUND PROD W/ LANG COMP AND EXPRESS OFF/LOC CODE 12,,92523,440,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8630014,SP EVAL/ASSESS SOUND PROD W/ LANG COMP AND EXPRESS OFF/LOC CODE 99,,92523,440,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8630015,SPEECH EVAL/ASSESSMENT BEHAVIORAL/VOICE RESONANCE ON/LOC CODE 11,,92524,440,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8630016,SPEECH EVAL/ASSESSMENT BEHAVIORAL/VOICE RESONANCE OFF/LOC CODE 12,,92524,440,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8630017,SPEECH EVAL/ASSESSMENT BEHAVIORAL/VOICE RESONANCE OFF/LOC CODE 99,,92524,440,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8630018,SPEECH EVAL/ASSESSMENT SWALLOW ON/LOC CODE 11,,92610,440,$330.00 ,$330.00 ,$99.00 ,$300.30 ,$231.00 ,$99.00 ,$214.50 ,$237.60 ,$300.30 ,$247.50 
Carle BroMenn Medical Center,8630019,SPEECH EVAL/ASSESSMENT SWALLOW OFF/LOC CODE 12,,92610,440,$330.00 ,$330.00 ,$99.00 ,$300.30 ,$231.00 ,$99.00 ,$214.50 ,$237.60 ,$300.30 ,$247.50 
Carle BroMenn Medical Center,8630020,SPEECH EVAL/ASSESSMENT SWALLOW OFF/LOC CODE 99,,92610,440,$330.00 ,$330.00 ,$99.00 ,$300.30 ,$231.00 ,$99.00 ,$214.50 ,$237.60 ,$300.30 ,$247.50 
Carle BroMenn Medical Center,8630022,DSCC SPEECH THERAPY TREATMENT - 15 MIN,,92507,440,$265.00 ,$265.00 ,$79.50 ,$241.15 ,$185.50 ,$79.50 ,$172.25 ,$190.80 ,$241.15 ,$198.75 
Carle BroMenn Medical Center,8630023,EVAL OF SPEECH FLUENCY 15 MIN,,92521,440,$135.00 ,$135.00 ,$40.50 ,$122.85 ,$94.50 ,$40.50 ,$87.75 ,$97.20 ,$122.85 ,$101.25 
Carle BroMenn Medical Center,8630024,EVAL OF SPEECH SOUND PRODUCTION 15 MIN,,92522,440,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8630025,EVAL SPEECH PROD W LANGUAGE COMP 15MIN,,92523,440,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8630027,EVALUATE SWALLOWING FUNCTION,,92610,440,$330.00 ,$330.00 ,$99.00 ,$300.30 ,$231.00 ,$99.00 ,$214.50 ,$237.60 ,$300.30 ,$247.50 
Carle BroMenn Medical Center,8630028,MOTION FLUDROSCOPY/SWALLOW,,92611,440,$410.00 ,$410.00 ,$123.00 ,$373.10 ,$287.00 ,$123.00 ,$266.50 ,$295.20 ,$373.10 ,$307.50 
Carle BroMenn Medical Center,8630029,BEHAV & QUAL ANALYSIS OF VOICE 15 MIN,,92524,440,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8630030,E-I EVAL/ASSESS - ONSITE 15 MIN (SS W/L),,92522,440,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8630507,8'-30' SPEECH TREATMENT,,92507,440,$245.00 ,$245.00 ,$73.50 ,$222.95 ,$171.50 ,$73.50 ,$159.25 ,$176.40 ,$222.95 ,$183.75 
Carle BroMenn Medical Center,8630523,15' EVALUATION-ONSITE,,92523,440,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8631507,16-30' SPEECH TREATMENT,,92507,440,$205.00 ,$205.00 ,$61.50 ,$186.55 ,$143.50 ,$61.50 ,$133.25 ,$147.60 ,$186.55 ,$153.75 
Carle BroMenn Medical Center,8631508,GROUP SPEECH 8-15',,92508,440,$62.00 ,$62.00 ,$18.60 ,$56.42 ,$43.40 ,$18.60 ,$40.30 ,$44.64 ,$56.42 ,$46.50 
Carle BroMenn Medical Center,8631520,31'-60' LARYNGEAL FUNCTN STUDY,,92520,440,$405.00 ,$405.00 ,$121.50 ,$368.55 ,$283.50 ,$121.50 ,$263.25 ,$291.60 ,$368.55 ,$303.75 
Carle BroMenn Medical Center,8631526,31'-60' TREATMENT FOR FEEDING,,92526,440,$365.00 ,$365.00 ,$109.50 ,$332.15 ,$255.50 ,$109.50 ,$237.25 ,$262.80 ,$332.15 ,$273.75 
Carle BroMenn Medical Center,8631557,"45-59"" SPEECH/AUDIO TREATMENT",,92507,440,$335.00 ,$335.00 ,$100.50 ,$304.85 ,$234.50 ,$100.50 ,$217.75 ,$241.20 ,$304.85 ,$251.25 
Carle BroMenn Medical Center,8631558,"45""-60"" GROUP SPEECH",,92508,440,$160.00 ,$160.00 ,$48.00 ,$145.60 ,$112.00 ,$48.00 ,$104.00 ,$115.20 ,$145.60 ,$120.00 
Carle BroMenn Medical Center,8631610,31'-45' SWALLOW/ORAL FUNC EVAL,,92610,440,$295.00 ,$295.00 ,$88.50 ,$268.45 ,$206.50 ,$88.50 ,$191.75 ,$212.40 ,$268.45 ,$221.25 
Carle BroMenn Medical Center,8631657,31'-60' SPEECH TREATMENT,,92507,440,$405.00 ,$405.00 ,$121.50 ,$368.55 ,$283.50 ,$121.50 ,$263.25 ,$291.60 ,$368.55 ,$303.75 
Carle BroMenn Medical Center,8631658,"31-45"" GROUP SPEECH",,92508,440,$250.00 ,$250.00 ,$75.00 ,$227.50 ,$175.00 ,$75.00 ,$162.50 ,$180.00 ,$227.50 ,$187.50 
Carle BroMenn Medical Center,8631660,"61 - 90"" AUD REHAB PRE-LING",,92630,440,$560.00 ,$560.00 ,$168.00 ,$509.60 ,$392.00 ,$168.00 ,$364.00 ,$403.20 ,$509.60 ,$420.00 
Carle BroMenn Medical Center,8631757,61-75' SPEECH TREATMENT,,92507,440,$415.00 ,$415.00 ,$124.50 ,$377.65 ,$290.50 ,$124.50 ,$269.75 ,$298.80 ,$377.65 ,$311.25 
Carle BroMenn Medical Center,8631758,"30-44"" GROUP SPEECH",,92508,440,$265.00 ,$265.00 ,$79.50 ,$241.15 ,$185.50 ,$79.50 ,$172.25 ,$190.80 ,$241.15 ,$198.75 
Carle BroMenn Medical Center,8631760,"90"" AUD REHAB PRE-LING",,92630,440,$750.00 ,$750.00 ,$225.00 ,$682.50 ,$525.00 ,$225.00 ,$487.50 ,$540.00 ,$682.50 ,$562.50 
Carle BroMenn Medical Center,8631857,"60-74"" SPEECH/AUDIO TREATMENT",,92507,440,$460.00 ,$460.00 ,$138.00 ,$418.60 ,$322.00 ,$138.00 ,$299.00 ,$331.20 ,$418.60 ,$345.00 
Carle BroMenn Medical Center,8631858,61'-120' GROUP SPEECH,,92508,440,$305.00 ,$305.00 ,$91.50 ,$277.55 ,$213.50 ,$91.50 ,$198.25 ,$219.60 ,$277.55 ,$228.75 
Carle BroMenn Medical Center,8631860,"8 - 30"" AUD REHAB POST-LING",,92633,440,$195.00 ,$195.00 ,$58.50 ,$177.45 ,$136.50 ,$58.50 ,$126.75 ,$140.40 ,$177.45 ,$146.25 
Carle BroMenn Medical Center,8631957,SP 31'-60' TREATMENT FOR FEEDING,,92507,440,$430.00 ,$430.00 ,$129.00 ,$391.30 ,$301.00 ,$129.00 ,$279.50 ,$309.60 ,$391.30 ,$322.50 
Carle BroMenn Medical Center,8631958,"60""-120"" GROUP SPEECH",,92508,440,$340.00 ,$340.00 ,$102.00 ,$309.40 ,$238.00 ,$102.00 ,$221.00 ,$244.80 ,$309.40 ,$255.00 
Carle BroMenn Medical Center,8631960,"31 - 60"" AUD REHAB POST-LING",,92633,440,$375.00 ,$375.00 ,$112.50 ,$341.25 ,$262.50 ,$112.50 ,$243.75 ,$270.00 ,$341.25 ,$281.25 
Carle BroMenn Medical Center,8632107,76-90' SPEECH TREATMENT,,92507,440,$520.00 ,$520.00 ,$156.00 ,$473.20 ,$364.00 ,$156.00 ,$338.00 ,$374.40 ,$473.20 ,$390.00 
Carle BroMenn Medical Center,8632158,"46-60"" GROUP SPEECH",,92508,440,$370.00 ,$370.00 ,$111.00 ,$336.70 ,$259.00 ,$111.00 ,$240.50 ,$266.40 ,$336.70 ,$277.50 
Carle BroMenn Medical Center,8632160,"61 - 90"" AUD REHAB POST-LING",,92633,440,$560.00 ,$560.00 ,$168.00 ,$509.60 ,$392.00 ,$168.00 ,$364.00 ,$403.20 ,$509.60 ,$420.00 
Carle BroMenn Medical Center,8632207,"75-89"" SPEECH/AUDIO TREATMENT",,92507,440,$570.00 ,$570.00 ,$171.00 ,$518.70 ,$399.00 ,$171.00 ,$370.50 ,$410.40 ,$518.70 ,$427.50 
Carle BroMenn Medical Center,8632258,46-60' GROUP SPEECH,,92508,440,$370.00 ,$370.00 ,$111.00 ,$336.70 ,$259.00 ,$111.00 ,$240.50 ,$266.40 ,$336.70 ,$277.50 
Carle BroMenn Medical Center,8632307,"61-90"" SPEECH/AUDIO TREATMENT",,92507,440,$600.00 ,$600.00 ,$180.00 ,$546.00 ,$420.00 ,$180.00 ,$390.00 ,$432.00 ,$546.00 ,$450.00 
Carle BroMenn Medical Center,8632358,"45-59"" GROUP SPEECH",,92508,440,$400.00 ,$400.00 ,$120.00 ,$364.00 ,$280.00 ,$120.00 ,$260.00 ,$288.00 ,$364.00 ,$300.00 
Carle BroMenn Medical Center,8632407,"SPEECH TREATMENT > 90""",,92507,440,$750.00 ,$750.00 ,$225.00 ,$682.50 ,$525.00 ,$225.00 ,$487.50 ,$540.00 ,$682.50 ,$562.50 
Carle BroMenn Medical Center,8632458,"61-75"" GROUP SPEECH",,92508,440,$500.00 ,$500.00 ,$150.00 ,$455.00 ,$350.00 ,$150.00 ,$325.00 ,$360.00 ,$455.00 ,$375.00 
Carle BroMenn Medical Center,8632507,8-15' SPEECH TREATMENT,,92507,440,$115.00 ,$115.00 ,$34.50 ,$104.65 ,$80.50 ,$34.50 ,$74.75 ,$82.80 ,$104.65 ,$86.25 
Carle BroMenn Medical Center,8632508,15' GROUP THPY SPEECH/LANGUAGE,,92508,440,$87.00 ,$87.00 ,$26.10 ,$79.17 ,$60.90 ,$26.10 ,$56.55 ,$62.64 ,$79.17 ,$65.25 
Carle BroMenn Medical Center,8632517,"SPEECH TREATMENT > 90""",,92507,440,$640.00 ,$640.00 ,$192.00 ,$582.40 ,$448.00 ,$192.00 ,$416.00 ,$460.80 ,$582.40 ,$480.00 
Carle BroMenn Medical Center,8632520,8'-30' LARYNGEAL FUNCTN STUDY,,92520,440,$400.00 ,$400.00 ,$120.00 ,$364.00 ,$280.00 ,$120.00 ,$260.00 ,$288.00 ,$364.00 ,$300.00 
Carle BroMenn Medical Center,8632521,SPEECH FLUENCY 8-60,,92521,440,$135.00 ,$135.00 ,$40.50 ,$122.85 ,$94.50 ,$40.50 ,$87.75 ,$97.20 ,$122.85 ,$101.25 
Carle BroMenn Medical Center,8632522,SOUND PRODUCTION 8-60,,92522,440,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8632523,LANGUAGE COMP 8-60,,92523,440,$590.00 ,$590.00 ,$177.00 ,$536.90 ,$413.00 ,$177.00 ,$383.50 ,$424.80 ,$536.90 ,$442.50 
Carle BroMenn Medical Center,8632524,Voice/Resonance,,92524,440,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8632525,LANGUAGE COMP 60-120,,92523,440,$590.00 ,$590.00 ,$177.00 ,$536.90 ,$413.00 ,$177.00 ,$383.50 ,$424.80 ,$536.90 ,$442.50 
Carle BroMenn Medical Center,8632526,16'-30' TREATMENT FOR FEEDING,,92526,440,$265.00 ,$265.00 ,$79.50 ,$241.15 ,$185.50 ,$79.50 ,$172.25 ,$190.80 ,$241.15 ,$198.75 
Carle BroMenn Medical Center,8632558,"60-74"" GROUP SPEECH",,92508,440,$530.00 ,$530.00 ,$159.00 ,$482.30 ,$371.00 ,$159.00 ,$344.50 ,$381.60 ,$482.30 ,$397.50 
Carle BroMenn Medical Center,8632605,EVAL RX N-SP-GEN AUGMT ALT COMMUN DEV F2F 1ST HR,,92605,440,$184.00 ,$184.00 ,$55.20 ,$167.44 ,$128.80 ,$55.20 ,$119.60 ,$132.48 ,$167.44 ,$138.00 
Carle BroMenn Medical Center,8632606,"THER SRVC(S),NON-SPEECH GEN DEV, W/PROG",,92606,440,$139.00 ,$139.00 ,$41.70 ,$126.49 ,$97.30 ,$41.70 ,$90.35 ,$100.08 ,$126.49 ,$104.25 
Carle BroMenn Medical Center,8632607,8'-30' AUGMENTATIVE COMM EVAL,,92607,440,$420.00 ,$420.00 ,$126.00 ,$382.20 ,$294.00 ,$126.00 ,$273.00 ,$302.40 ,$382.20 ,$315.00 
Carle BroMenn Medical Center,8632608,"ADL 30"" EVAL SPEECH GN AC DVC",,92608,440,$176.00 ,$176.00 ,$52.80 ,$160.16 ,$123.20 ,$52.80 ,$114.40 ,$126.72 ,$160.16 ,$132.00 
Carle BroMenn Medical Center,8632609,TX SVCS SPEECH GN DVC PROG&MOD,,92609,440,$199.00 ,$199.00 ,$59.70 ,$181.09 ,$139.30 ,$59.70 ,$129.35 ,$143.28 ,$181.09 ,$149.25 
Carle BroMenn Medical Center,8632610,16'-30' SWALLOW/ORAL FUNC EVAL,,92610,440,$265.00 ,$265.00 ,$79.50 ,$241.15 ,$185.50 ,$79.50 ,$172.25 ,$190.80 ,$241.15 ,$198.75 
Carle BroMenn Medical Center,8632611,31'-45' RADIO-OPAQUE SWAL EVAL,,92611,440,$295.00 ,$295.00 ,$88.50 ,$268.45 ,$206.50 ,$88.50 ,$191.75 ,$212.40 ,$268.45 ,$221.25 
Carle BroMenn Medical Center,8632612,8'-30' FIBEROPTIC SWALLOW EVAL,,92612,440,$465.00 ,$465.00 ,$139.50 ,$423.15 ,$325.50 ,$139.50 ,$302.25 ,$334.80 ,$423.15 ,$348.75 
Carle BroMenn Medical Center,8632618,EVAL RX N-SP-GEN AUGMT ALT COMMUN DEV ADD 30 MIN,,92618,440,$94.00 ,$94.00 ,$28.20 ,$85.54 ,$65.80 ,$28.20 ,$61.10 ,$67.68 ,$85.54 ,$70.50 
Carle BroMenn Medical Center,8632630,"8-15"" AUD REHAB PRE-LING",,92630,440,$115.00 ,$115.00 ,$34.50 ,$104.65 ,$80.50 ,$34.50 ,$74.75 ,$82.80 ,$104.65 ,$86.25 
Carle BroMenn Medical Center,8632658,"76-90"" GROUP SPEECH",,92508,440,$620.00 ,$620.00 ,$186.00 ,$564.20 ,$434.00 ,$186.00 ,$403.00 ,$446.40 ,$564.20 ,$465.00 
Carle BroMenn Medical Center,8632758,"75-89"" GROUP SPEECH",,92508,440,$650.00 ,$650.00 ,$195.00 ,$591.50 ,$455.00 ,$195.00 ,$422.50 ,$468.00 ,$591.50 ,$487.50 
Carle BroMenn Medical Center,8632858,"91-105"" GROUP SPEECH",,92508,440,$710.00 ,$710.00 ,$213.00 ,$646.10 ,$497.00 ,$213.00 ,$461.50 ,$511.20 ,$646.10 ,$532.50 
Carle BroMenn Medical Center,8632907,"91-120"" SPEECH TREATMENT",,92507,440,$670.00 ,$670.00 ,$201.00 ,$609.70 ,$469.00 ,$201.00 ,$435.50 ,$482.40 ,$609.70 ,$502.50 
Carle BroMenn Medical Center,8632958,"90-104"" GROUP SPEECH",,92508,440,$780.00 ,$780.00 ,$234.00 ,$709.80 ,$546.00 ,$234.00 ,$507.00 ,$561.60 ,$709.80 ,$585.00 
Carle BroMenn Medical Center,8633058,"106-120""GROUP SPEECH",,92508,440,$870.00 ,$870.00 ,$261.00 ,$791.70 ,$609.00 ,$261.00 ,$565.50 ,$626.40 ,$791.70 ,$652.50 
Carle BroMenn Medical Center,8633158,"105-119"" GROUP SPEECH",,92508,440,$920.00 ,$920.00 ,$276.00 ,$837.20 ,$644.00 ,$276.00 ,$598.00 ,$662.40 ,$837.20 ,$690.00 
Carle BroMenn Medical Center,8633258,"105-119"" GROUP SPEECH",,92508,440,$920.00 ,$920.00 ,$276.00 ,$837.20 ,$644.00 ,$276.00 ,$598.00 ,$662.40 ,$837.20 ,$690.00 
Carle BroMenn Medical Center,8633358,"GROUP SPEECH 120""",,92508,440,"$1,040.00 ","$1,040.00 ",$312.00 ,$946.40 ,$728.00 ,$312.00 ,$676.00 ,$748.80 ,$946.40 ,$780.00 
Carle BroMenn Medical Center,8633458,"GROUP SPEECH > 120""",,92508,440,$980.00 ,$980.00 ,$294.00 ,$891.80 ,$686.00 ,$294.00 ,$637.00 ,$705.60 ,$891.80 ,$735.00 
Carle BroMenn Medical Center,8633507,"SPEECH/AUDIO TREATMENT 16-29""",,92507,440,$195.00 ,$195.00 ,$58.50 ,$177.45 ,$136.50 ,$58.50 ,$126.75 ,$140.40 ,$177.45 ,$146.25 
Carle BroMenn Medical Center,8633508,8'-30' GROUP SPEECH,,92508,440,$83.00 ,$83.00 ,$24.90 ,$75.53 ,$58.10 ,$24.90 ,$53.95 ,$59.76 ,$75.53 ,$62.25 
Carle BroMenn Medical Center,8633526,61'-120' TREATMENT FOR FEEDING,,92526,440,$700.00 ,$700.00 ,$210.00 ,$637.00 ,$490.00 ,$210.00 ,$455.00 ,$504.00 ,$637.00 ,$525.00 
Carle BroMenn Medical Center,8633607,1ST HR EVAL SPEECH GN AC DVC,,92607,440,$420.00 ,$420.00 ,$126.00 ,$382.20 ,$294.00 ,$126.00 ,$273.00 ,$302.40 ,$382.20 ,$315.00 
Carle BroMenn Medical Center,8633610,"0-15""' SWALLOW/ORAL FUNC EVAL",,92610,440,$155.00 ,$155.00 ,$46.50 ,$141.05 ,$108.50 ,$46.50 ,$100.75 ,$111.60 ,$141.05 ,$116.25 
Carle BroMenn Medical Center,8633611,46'-60' RADIO-OPAQUE SWAL EVAL,,92611,440,$400.00 ,$400.00 ,$120.00 ,$364.00 ,$280.00 ,$120.00 ,$260.00 ,$288.00 ,$364.00 ,$300.00 
Carle BroMenn Medical Center,8633612,31'-60'FIBEROPTIC SWALLOW EVAL,,92612,440,$590.00 ,$590.00 ,$177.00 ,$536.90 ,$413.00 ,$177.00 ,$383.50 ,$424.80 ,$536.90 ,$442.50 
Carle BroMenn Medical Center,8633630,"16-29"" AUD REHAB PRE-LING",,92630,440,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8634507,15' SLP A/R SERVICES-ONSITE,,92507,440,$265.00 ,$265.00 ,$79.50 ,$241.15 ,$185.50 ,$79.50 ,$172.25 ,$190.80 ,$241.15 ,$198.75 
Carle BroMenn Medical Center,8634508,31'-45' GROUP SPEECH,,92508,440,$90.00 ,$90.00 ,$27.00 ,$81.90 ,$63.00 ,$27.00 ,$58.50 ,$64.80 ,$81.90 ,$67.50 
Carle BroMenn Medical Center,8634526,"0-15"" TREATMENT FOR FEEDING",,92526,440,$120.00 ,$120.00 ,$36.00 ,$109.20 ,$84.00 ,$36.00 ,$78.00 ,$86.40 ,$109.20 ,$90.00 
Carle BroMenn Medical Center,8634610,"46""-60' SWALLOW/ORAL FUNC EVAL",,92610,440,$445.00 ,$445.00 ,$133.50 ,$404.95 ,$311.50 ,$133.50 ,$289.25 ,$320.40 ,$404.95 ,$333.75 
Carle BroMenn Medical Center,8634630,"8 - 30"" AUD REHAB PRE-LING",,92630,440,$195.00 ,$195.00 ,$58.50 ,$177.45 ,$136.50 ,$58.50 ,$126.75 ,$140.40 ,$177.45 ,$146.25 
Carle BroMenn Medical Center,8635507,15' INDIVIDUAL THERAPY-ONSITE,,92507,440,$265.00 ,$265.00 ,$79.50 ,$241.15 ,$185.50 ,$79.50 ,$172.25 ,$190.80 ,$241.15 ,$198.75 
Carle BroMenn Medical Center,8635508,15' GROUP A/R SERVICES,,92508,440,$87.00 ,$87.00 ,$26.10 ,$79.17 ,$60.90 ,$26.10 ,$56.55 ,$62.64 ,$79.17 ,$65.25 
Carle BroMenn Medical Center,8635630,"30-44"" AUD REHAB PRE-LING",,92630,440,$295.00 ,$295.00 ,$88.50 ,$268.45 ,$206.50 ,$88.50 ,$191.75 ,$212.40 ,$268.45 ,$221.25 
Carle BroMenn Medical Center,8636105,15'-30' APHASIA TEST,,96105,440,$315.00 ,$315.00 ,$94.50 ,$286.65 ,$220.50 ,$94.50 ,$204.75 ,$226.80 ,$286.65 ,$236.25 
Carle BroMenn Medical Center,8636125,"60"" COGNITIVE PERFORMANCE TEST",,96125,440,$345.00 ,$345.00 ,$103.50 ,$313.95 ,$241.50 ,$103.50 ,$224.25 ,$248.40 ,$313.95 ,$258.75 
Carle BroMenn Medical Center,8636205,31'-60' APHASIA TEST,,96105,440,$315.00 ,$315.00 ,$94.50 ,$286.65 ,$220.50 ,$94.50 ,$204.75 ,$226.80 ,$286.65 ,$236.25 
Carle BroMenn Medical Center,8636507,15' SLP A/R SERVICES-OFFSITE,,92507,440,$265.00 ,$265.00 ,$79.50 ,$241.15 ,$185.50 ,$79.50 ,$172.25 ,$190.80 ,$241.15 ,$198.75 
Carle BroMenn Medical Center,8636508,15' GROUP SLP A/R SERVICES,,92508,440,$87.00 ,$87.00 ,$26.10 ,$79.17 ,$60.90 ,$26.10 ,$56.55 ,$62.64 ,$79.17 ,$65.25 
Carle BroMenn Medical Center,8636630,"45-59"" AUD REHAB PRE-LING",,92630,440,$435.00 ,$435.00 ,$130.50 ,$395.85 ,$304.50 ,$130.50 ,$282.75 ,$313.20 ,$395.85 ,$326.25 
Carle BroMenn Medical Center,8637000,15' IFSP DEVELOPMENT-ONSITE,,99499,440,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8637001,"IFSP DEVELOPMENT-ONSITE 15""",,99499,440,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8637002,15' IFSP DEVELOPMEMT-OFFSITE,,99499,440,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8637003,15' IFSP DEVELOPMENT-OFFSITE,,99499,440,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8637004,15' SLPA/R IFSP DVLPMNT-ONSITE,,99499,440,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8637005,15' A/R IFSP DVLPMNT-ONSITE,,99499,440,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8637006,15' SLPA/R IFSP DVLPMT-OFFSITE,,99499,440,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8637007,15' A/R IFSP DVLPMNT-OFFSITE,,99499,440,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8637008,15' IFSP DEVELOPMENT-ONSITE,,99499,440,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8637030,15' INDIVIDUAL SVC COORDINATIN,,T1017,440,$40.00 ,$40.00 ,$12.00 ,$36.40 ,$28.00 ,$12.00 ,$26.00 ,$28.80 ,$36.40 ,$30.00 
Carle BroMenn Medical Center,8637031,15' IFSP DEVELOPMENT-ONSITE,,T1024,440,$116.00 ,$116.00 ,$34.80 ,$105.56 ,$81.20 ,$34.80 ,$75.40 ,$83.52 ,$105.56 ,$87.00 
Carle BroMenn Medical Center,8637032,"15"" SP EMS 1:1",,97032,440,$89.00 ,$89.00 ,$26.70 ,$80.99 ,$62.30 ,$26.70 ,$57.85 ,$64.08 ,$80.99 ,$66.75 
Carle BroMenn Medical Center,8637034,15' GRP FAM TRAINING & SUPPORT,,T1027,440,$51.00 ,$51.00 ,$15.30 ,$46.41 ,$35.70 ,$15.30 ,$33.15 ,$36.72 ,$46.41 ,$38.25 
Carle BroMenn Medical Center,8637035,15' GROUP DT,,T1027,440,$51.00 ,$51.00 ,$15.30 ,$46.41 ,$35.70 ,$15.30 ,$33.15 ,$36.72 ,$46.41 ,$38.25 
Carle BroMenn Medical Center,8637036,15' FAM TRAIN/SUPPORT-ONSITE,,T1027,440,$51.00 ,$51.00 ,$15.30 ,$46.41 ,$35.70 ,$15.30 ,$33.15 ,$36.72 ,$46.41 ,$38.25 
Carle BroMenn Medical Center,8637037,15' FAM TRAIN/SUPPORT-OFFSITE,,T1027,440,$51.00 ,$51.00 ,$15.30 ,$46.41 ,$35.70 ,$15.30 ,$33.15 ,$36.72 ,$46.41 ,$38.25 
Carle BroMenn Medical Center,8637038,15' INDIVIDUAL DT-ONSITE,,T1027,440,$51.00 ,$51.00 ,$15.30 ,$46.41 ,$35.70 ,$15.30 ,$33.15 ,$36.72 ,$46.41 ,$38.25 
Carle BroMenn Medical Center,8637039,15' INDIVIDUAL DT-OFFSITE,,T1027,440,$51.00 ,$51.00 ,$15.30 ,$46.41 ,$35.70 ,$15.30 ,$33.15 ,$36.72 ,$46.41 ,$38.25 
Carle BroMenn Medical Center,8637041,HEARING AID ASSESSMENT,,V5010,440,$176.00 ,$176.00 ,$52.80 ,$160.16 ,$123.20 ,$52.80 ,$114.40 ,$126.72 ,$160.16 ,$132.00 
Carle BroMenn Medical Center,8637042,"15"" SPEECH THERAPY/HLTHY KIDS",,W7088,440,$101.00 ,$101.00 ,$30.30 ,$91.91 ,$70.70 ,$30.30 ,$65.65 ,$72.72 ,$91.91 ,$75.75 
Carle BroMenn Medical Center,8637043,"15"" SPEECH EVAL/HEALTHY KIDS",,W7968,440,$101.00 ,$101.00 ,$30.30 ,$91.91 ,$70.70 ,$30.30 ,$65.65 ,$72.72 ,$91.91 ,$75.75 
Carle BroMenn Medical Center,8637050,15' ASSESSMENT-ONSITE,,W8730,440,$40.00 ,$40.00 ,$12.00 ,$36.40 ,$28.00 ,$12.00 ,$26.00 ,$28.80 ,$36.40 ,$30.00 
Carle BroMenn Medical Center,8637051,15' ASSESSMENT-OFFSITE,,W8731,440,$40.00 ,$40.00 ,$12.00 ,$36.40 ,$28.00 ,$12.00 ,$26.00 ,$28.80 ,$36.40 ,$30.00 
Carle BroMenn Medical Center,8637052,15' ASSESSMENT-ONSITE,,W8758,440,$46.00 ,$46.00 ,$13.80 ,$41.86 ,$32.20 ,$13.80 ,$29.90 ,$33.12 ,$41.86 ,$34.50 
Carle BroMenn Medical Center,8637053,15' ASSESSMENT-OFFSITE,,W8759,440,$46.00 ,$46.00 ,$13.80 ,$41.86 ,$32.20 ,$13.80 ,$29.90 ,$33.12 ,$41.86 ,$34.50 
Carle BroMenn Medical Center,8637110,SP TX EXERCISE - ORAL MOTOR ACT,,97110,440,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8637112,SP NEUROMUSCULAR RE-EDUCATION,,97112,440,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8637129,THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES,,97129,440,$185.00 ,$185.00 ,$55.50 ,$168.35 ,$129.50 ,$55.50 ,$120.25 ,$133.20 ,$168.35 ,$138.75 
Carle BroMenn Medical Center,8637130,THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES,,97130,440,$185.00 ,$185.00 ,$55.50 ,$168.35 ,$129.50 ,$55.50 ,$120.25 ,$133.20 ,$168.35 ,$138.75 
Carle BroMenn Medical Center,8637132,15' IFSP DEVELOPMENT-OFFSITE,,T1024,440,$116.00 ,$116.00 ,$34.80 ,$105.56 ,$81.20 ,$34.80 ,$75.40 ,$83.52 ,$105.56 ,$87.00 
Carle BroMenn Medical Center,8637139,THERAPEUTIC PROCEDURE,,97139,440,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8637507,15' INDIVIDUAL THERAPY-OFFSITE,,92507,440,$265.00 ,$265.00 ,$79.50 ,$241.15 ,$185.50 ,$79.50 ,$172.25 ,$190.80 ,$241.15 ,$198.75 
Carle BroMenn Medical Center,8637508,GROUP SPEECH,,92508,440,$87.00 ,$87.00 ,$26.10 ,$79.17 ,$60.90 ,$26.10 ,$56.55 ,$62.64 ,$79.17 ,$65.25 
Carle BroMenn Medical Center,8637530,SP INSTRUCT COMP SWALLOWING TECHN,,97530,440,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8637533,SP SENSORY INTEGRATION TECHNIQUES,,97533,440,$154.00 ,$154.00 ,$46.20 ,$140.14 ,$107.80 ,$46.20 ,$100.10 ,$110.88 ,$140.14 ,$115.50 
Carle BroMenn Medical Center,8637535,SP 15' ADL TRAINING,,97535,440,$135.00 ,$135.00 ,$40.50 ,$122.85 ,$94.50 ,$40.50 ,$87.75 ,$97.20 ,$122.85 ,$101.25 
Carle BroMenn Medical Center,8637537,SP 15' WORK & COMMUNITY RE-ENTRY,,97537,440,$109.00 ,$109.00 ,$32.70 ,$99.19 ,$76.30 ,$32.70 ,$70.85 ,$78.48 ,$99.19 ,$81.75 
Carle BroMenn Medical Center,8637630,"31 - 60"" AUD REHAB PRE-LING",,92630,440,$375.00 ,$375.00 ,$112.50 ,$341.25 ,$262.50 ,$112.50 ,$243.75 ,$270.00 ,$341.25 ,$281.25 
Carle BroMenn Medical Center,8637750,"SP 15"" PHYSICAL PERF TEST/MEAS.",,97750,440,$140.00 ,$140.00 ,$42.00 ,$127.40 ,$98.00 ,$42.00 ,$91.00 ,$100.80 ,$127.40 ,$105.00 
Carle BroMenn Medical Center,8637755,"SP 15"" ASSISTIVE TECH ASSESSMENT",,97755,440,$116.00 ,$116.00 ,$34.80 ,$105.56 ,$81.20 ,$34.80 ,$75.40 ,$83.52 ,$105.56 ,$87.00 
Carle BroMenn Medical Center,8638507,31-45' SPEECH TREATMENT,,92507,440,$245.00 ,$245.00 ,$73.50 ,$222.95 ,$171.50 ,$73.50 ,$159.25 ,$176.40 ,$222.95 ,$183.75 
Carle BroMenn Medical Center,8638508,15' GROUP SLP A/R SERVICES,,92508,440,$87.00 ,$87.00 ,$26.10 ,$79.17 ,$60.90 ,$26.10 ,$56.55 ,$62.64 ,$79.17 ,$65.25 
Carle BroMenn Medical Center,8638630,"60-74"" AUD REHAB PRE-LING",,92630,440,$510.00 ,$510.00 ,$153.00 ,$464.10 ,$357.00 ,$153.00 ,$331.50 ,$367.20 ,$464.10 ,$382.50 
Carle BroMenn Medical Center,8639368,"SLP CHG TEAM CONF W/O PT/FAMILY PRSNT, EA 30 MIN",,99368,440,$195.00 ,$195.00 ,$58.50 ,$177.45 ,$136.50 ,$58.50 ,$126.75 ,$140.40 ,$177.45 ,$146.25 
Carle BroMenn Medical Center,8639507,46-60' SPEECH TREATMENT,,92507,440,$305.00 ,$305.00 ,$91.50 ,$277.55 ,$213.50 ,$91.50 ,$198.25 ,$219.60 ,$277.55 ,$228.75 
Carle BroMenn Medical Center,8639508,46'-60' GROUP SPEECH,,92508,440,$140.00 ,$140.00 ,$42.00 ,$127.40 ,$98.00 ,$42.00 ,$91.00 ,$100.80 ,$127.40 ,$105.00 
Carle BroMenn Medical Center,8639630,"75-89"" AUD REHAB PRE-LING",,92630,440,$620.00 ,$620.00 ,$186.00 ,$564.20 ,$434.00 ,$186.00 ,$403.00 ,$446.40 ,$564.20 ,$465.00 
Carle BroMenn Medical Center,8640506,5'-6' SPEECH/AUDIO EVALUATION,,92523,440,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8642506,15' EVALUATION-ONSITE,,92523,440,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8642521,SPEECH FLUENCY,,92521,440,$135.00 ,$135.00 ,$40.50 ,$122.85 ,$94.50 ,$40.50 ,$87.75 ,$97.20 ,$122.85 ,$101.25 
Carle BroMenn Medical Center,8642522,SOUND PRODUCTION,,92522,440,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8642524,BEHAVIORAL,,92524,440,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8643506,15' EVALUATION-OFFSITE,,92523,440,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8645506,8'-59' SPEECH/AUDIO EVALUATION,,92523,440,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8646506,1'-2' SPEECH/AUDIO EVALUATION,,92523,440,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8647506,2'-3' SPEECH/AUDIO EVALUATION,,92523,440,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8648506,3'-4' SPEECH/AUDIO EVALUATION,,92523,440,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8649506,4'-5' SPEECH/AUDIO EVALUATION,,92523,440,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8720100,"SPEECH TREATMENT 8-15"" GN",,92507,440,$65.00 ,$65.00 ,$19.50 ,$59.15 ,$45.50 ,$19.50 ,$42.25 ,$46.80 ,$59.15 ,$48.75 
Carle BroMenn Medical Center,8720101,"SPEECH TREATMENT 16-30"" GN",,92507,440,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8720102,SPEECH TREATMENT 8'-30'  GN,,92507,440,$245.00 ,$245.00 ,$73.50 ,$222.95 ,$171.50 ,$73.50 ,$159.25 ,$176.40 ,$222.95 ,$183.75 
Carle BroMenn Medical Center,8720103,"SPEECH TREATMENT 31-45"" GN",,92507,440,$240.00 ,$240.00 ,$72.00 ,$218.40 ,$168.00 ,$72.00 ,$156.00 ,$172.80 ,$218.40 ,$180.00 
Carle BroMenn Medical Center,8720104,"SPEECH TREATMENT 46-60"" GN",,92507,440,$355.00 ,$355.00 ,$106.50 ,$323.05 ,$248.50 ,$106.50 ,$230.75 ,$255.60 ,$323.05 ,$266.25 
Carle BroMenn Medical Center,8720105,SPEECH TREATMENT 31'-60' GN,,92507,440,$435.00 ,$435.00 ,$130.50 ,$395.85 ,$304.50 ,$130.50 ,$282.75 ,$313.20 ,$395.85 ,$326.25 
Carle BroMenn Medical Center,8720106,"SPEECH TREATMENT 61-75"" GN",,92507,440,$475.00 ,$475.00 ,$142.50 ,$432.25 ,$332.50 ,$142.50 ,$308.75 ,$342.00 ,$432.25 ,$356.25 
Carle BroMenn Medical Center,8720107,"SPEECH TREATMENT 76-90"" GN",,92507,440,$590.00 ,$590.00 ,$177.00 ,$536.90 ,$413.00 ,$177.00 ,$383.50 ,$424.80 ,$536.90 ,$442.50 
Carle BroMenn Medical Center,8720108,"SPEECH TREATMENT > 90"" GN",,92507,440,$800.00 ,$800.00 ,$240.00 ,$728.00 ,$560.00 ,$240.00 ,$520.00 ,$576.00 ,$728.00 ,$600.00 
Carle BroMenn Medical Center,8720110,"GROUP SPEECH 8-15"" GN",,92508,440,$72.00 ,$72.00 ,$21.60 ,$65.52 ,$50.40 ,$21.60 ,$46.80 ,$51.84 ,$65.52 ,$54.00 
Carle BroMenn Medical Center,8720111,GROUP SPEECH 8'-30'  GN,,92508,440,$83.00 ,$83.00 ,$24.90 ,$75.53 ,$58.10 ,$24.90 ,$53.95 ,$59.76 ,$75.53 ,$62.25 
Carle BroMenn Medical Center,8720112,GROUP SPEECH 31'-45'  GN,,92508,440,$90.00 ,$90.00 ,$27.00 ,$81.90 ,$63.00 ,$27.00 ,$58.50 ,$64.80 ,$81.90 ,$67.50 
Carle BroMenn Medical Center,8720113,"GROUP SPEECH 16-30"" GN",,92508,440,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8720114,GROUP SPEECH 46'-60'  GN,,92508,440,$135.00 ,$135.00 ,$40.50 ,$122.85 ,$94.50 ,$40.50 ,$87.75 ,$97.20 ,$122.85 ,$101.25 
Carle BroMenn Medical Center,8720115,"GROUP SPEECH 31-45"" GN",,92508,440,$285.00 ,$285.00 ,$85.50 ,$259.35 ,$199.50 ,$85.50 ,$185.25 ,$205.20 ,$259.35 ,$213.75 
Carle BroMenn Medical Center,8720116,GROUP SPEECH 61'-120'  GN,,92508,440,$290.00 ,$290.00 ,$87.00 ,$263.90 ,$203.00 ,$87.00 ,$188.50 ,$208.80 ,$263.90 ,$217.50 
Carle BroMenn Medical Center,8720117,"GROUP SPEECH 46-60"" GN",,92508,440,$435.00 ,$435.00 ,$130.50 ,$395.85 ,$304.50 ,$130.50 ,$282.75 ,$313.20 ,$395.85 ,$326.25 
Carle BroMenn Medical Center,8720118,"GROUP SPEECH 61-75"" GN",,92508,440,$570.00 ,$570.00 ,$171.00 ,$518.70 ,$399.00 ,$171.00 ,$370.50 ,$410.40 ,$518.70 ,$427.50 
Carle BroMenn Medical Center,8720119,"GROUP SPEECH 76-90"" GN",,92508,440,$720.00 ,$720.00 ,$216.00 ,$655.20 ,$504.00 ,$216.00 ,$468.00 ,$518.40 ,$655.20 ,$540.00 
Carle BroMenn Medical Center,8720120,"GROUP SPEECH 91-105"" GN",,92508,440,$840.00 ,$840.00 ,$252.00 ,$764.40 ,$588.00 ,$252.00 ,$546.00 ,$604.80 ,$764.40 ,$630.00 
Carle BroMenn Medical Center,8720121,"GROUP SPEECH 106-120"" GN",,92508,440,$980.00 ,$980.00 ,$294.00 ,$891.80 ,$686.00 ,$294.00 ,$637.00 ,$705.60 ,$891.80 ,$735.00 
Carle BroMenn Medical Center,8720122,"GROUP SPEECH > 120"" GN",,92508,440,"$1,120.00 ","$1,120.00 ",$336.00 ,"$1,019.20 ",$784.00 ,$336.00 ,$728.00 ,$806.40 ,"$1,019.20 ",$840.00 
Carle BroMenn Medical Center,8720130,8'-30' LARYNGEAL FUNCTN STUDY GN,,92520,440,$315.00 ,$315.00 ,$94.50 ,$286.65 ,$220.50 ,$94.50 ,$204.75 ,$226.80 ,$286.65 ,$236.25 
Carle BroMenn Medical Center,8720131,31'-60' LARYNGEAL FUNCTN STUDY GN,,92520,440,$465.00 ,$465.00 ,$139.50 ,$423.15 ,$325.50 ,$139.50 ,$302.25 ,$334.80 ,$423.15 ,$348.75 
Carle BroMenn Medical Center,8720132,8'-30' TREATMENT FOR FEEDING GN,,92526,440,$265.00 ,$265.00 ,$79.50 ,$241.15 ,$185.50 ,$79.50 ,$172.25 ,$190.80 ,$241.15 ,$198.75 
Carle BroMenn Medical Center,8720133,31'-60' TREATMENT FOR FEEDING GN,,92526,440,$400.00 ,$400.00 ,$120.00 ,$364.00 ,$280.00 ,$120.00 ,$260.00 ,$288.00 ,$364.00 ,$300.00 
Carle BroMenn Medical Center,8720134,61'-120' TREATMENT FOR FEEDING GN,,92526,440,$760.00 ,$760.00 ,$228.00 ,$691.60 ,$532.00 ,$228.00 ,$494.00 ,$547.20 ,$691.60 ,$570.00 
Carle BroMenn Medical Center,8720140,1ST HR EVAL SPEECH GN AC DVC GN,,92607,440,$420.00 ,$420.00 ,$126.00 ,$382.20 ,$294.00 ,$126.00 ,$273.00 ,$302.40 ,$382.20 ,$315.00 
Carle BroMenn Medical Center,8720141,"ADL 30"" EVAL SPEECH GN AC DVC GN",,92608,440,$176.00 ,$176.00 ,$52.80 ,$160.16 ,$123.20 ,$52.80 ,$114.40 ,$126.72 ,$160.16 ,$132.00 
Carle BroMenn Medical Center,8720142,TX SVCS SPEECH GN DVC PROG&MOD GN,,92609,440,$199.00 ,$199.00 ,$59.70 ,$181.09 ,$139.30 ,$59.70 ,$129.35 ,$143.28 ,$181.09 ,$149.25 
Carle BroMenn Medical Center,8720143,8'-30' SWALLOW/ORAL FUNC EVAL GN,,92610,440,$265.00 ,$265.00 ,$79.50 ,$241.15 ,$185.50 ,$79.50 ,$172.25 ,$190.80 ,$241.15 ,$198.75 
Carle BroMenn Medical Center,8720144,31'-45' SWALLOW/ORAL FUNC EVAL GN,,92610,440,$320.00 ,$320.00 ,$96.00 ,$291.20 ,$224.00 ,$96.00 ,$208.00 ,$230.40 ,$291.20 ,$240.00 
Carle BroMenn Medical Center,8720145,31'-45' RADIO-OPAQUE SWAL EVAL GN,,92611,440,$310.00 ,$310.00 ,$93.00 ,$282.10 ,$217.00 ,$93.00 ,$201.50 ,$223.20 ,$282.10 ,$232.50 
Carle BroMenn Medical Center,8720146,46'-60' RADIO-OPAQUE SWAL EVAL GN,,92611,440,$430.00 ,$430.00 ,$129.00 ,$391.30 ,$301.00 ,$129.00 ,$279.50 ,$309.60 ,$391.30 ,$322.50 
Carle BroMenn Medical Center,8720147,8'-30' FIBEROPTIC SWALLOW EVAL GN,,92612,440,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8720148,31'-60' FIBEROPTIC SWALLOW EVAL GN,,92612,440,$390.00 ,$390.00 ,$117.00 ,$354.90 ,$273.00 ,$117.00 ,$253.50 ,$280.80 ,$354.90 ,$292.50 
Carle BroMenn Medical Center,8720149,15'-30' APHASIA TEST GN,,96105,440,$315.00 ,$315.00 ,$94.50 ,$286.65 ,$220.50 ,$94.50 ,$204.75 ,$226.80 ,$286.65 ,$236.25 
Carle BroMenn Medical Center,8720150,31'-60' APHASIA TEST GN,,96105,440,$325.00 ,$325.00 ,$97.50 ,$295.75 ,$227.50 ,$97.50 ,$211.25 ,$234.00 ,$295.75 ,$243.75 
Carle BroMenn Medical Center,8720203,"INFRARED 15"" GN",,97026,440,$57.00 ,$57.00 ,$17.10 ,$51.87 ,$39.90 ,$17.10 ,$37.05 ,$41.04 ,$51.87 ,$42.75 
Carle BroMenn Medical Center,8720206,"15"" EMS 1:1 GN",,97032,440,$89.00 ,$89.00 ,$26.70 ,$80.99 ,$62.30 ,$26.70 ,$57.85 ,$64.08 ,$80.99 ,$66.75 
Carle BroMenn Medical Center,8720222,TX EXERCISE - ORAL MOTOR ACT GN,,97110,440,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8720227,NEUROMUSCULAR RE-EDUCATION GN,,97112,440,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8720234,THERAPEUTIC PROCEDURE GN,,97139,440,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8720254,INSTRUCT COMP SWALLOWING TECHN GN,,97530,440,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8720260,SENSORY INTEGRATION TECHNIQUES GN,,97533,440,$154.00 ,$154.00 ,$46.20 ,$140.14 ,$107.80 ,$46.20 ,$100.10 ,$110.88 ,$140.14 ,$115.50 
Carle BroMenn Medical Center,8720263,15' ADL TRAINING GN,,97535,440,$135.00 ,$135.00 ,$40.50 ,$122.85 ,$94.50 ,$40.50 ,$87.75 ,$97.20 ,$122.85 ,$101.25 
Carle BroMenn Medical Center,8720266,15' WORK & COMMUNITY RE-ENTRY GN,,97537,440,$109.00 ,$109.00 ,$32.70 ,$99.19 ,$76.30 ,$32.70 ,$70.85 ,$78.48 ,$99.19 ,$81.75 
Carle BroMenn Medical Center,8720304,"15"" PHYSICAL PERF TEST/MEAS. GN",,97750,440,$140.00 ,$140.00 ,$42.00 ,$127.40 ,$98.00 ,$42.00 ,$91.00 ,$100.80 ,$127.40 ,$105.00 
Carle BroMenn Medical Center,8720305,"15"" ASSISTIVE TECH ASSESSMENT GN",,97755,440,$116.00 ,$116.00 ,$34.80 ,$105.56 ,$81.20 ,$34.80 ,$75.40 ,$83.52 ,$105.56 ,$87.00 
Carle BroMenn Medical Center,8720308,"ORTHOTIC MGMNT & TRAINING 15"" GN",,97760,440,$175.00 ,$175.00 ,$52.50 ,$159.25 ,$122.50 ,$52.50 ,$113.75 ,$126.00 ,$159.25 ,$131.25 
Carle BroMenn Medical Center,8720311,"PROSTHETIC TRAINING 15"" GN",,97761,440,$125.00 ,$125.00 ,$37.50 ,$113.75 ,$87.50 ,$37.50 ,$81.25 ,$90.00 ,$113.75 ,$93.75 
Carle BroMenn Medical Center,8720321,THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES GN,,97129,440,$185.00 ,$185.00 ,$55.50 ,$168.35 ,$129.50 ,$55.50 ,$120.25 ,$133.20 ,$168.35 ,$138.75 
Carle BroMenn Medical Center,8720324,THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES GN,,97130,440,$185.00 ,$185.00 ,$55.50 ,$168.35 ,$129.50 ,$55.50 ,$120.25 ,$133.20 ,$168.35 ,$138.75 
Carle BroMenn Medical Center,8722521,SPEECH FLUENCY 8-60,,92521,440,$135.00 ,$135.00 ,$40.50 ,$122.85 ,$94.50 ,$40.50 ,$87.75 ,$97.20 ,$122.85 ,$101.25 
Carle BroMenn Medical Center,8722522,SOUND PRODUCTION 8-60 GN,,92522,440,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8722523,LANGUAGE COMP 8-60 GN,,92523,440,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8722524,BEHAVIORAL 8-60 GN,,92524,440,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8722525,LANGUAGE COMP 60-120 GN,,92523,440,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8726125,COGNITIVE EVAL,,96125,440,$345.00 ,$345.00 ,$103.50 ,$313.95 ,$241.50 ,$103.50 ,$224.25 ,$248.40 ,$313.95 ,$258.75 
Carle BroMenn Medical Center,8739368,"SLP CHG TEAM CONF W/O PT/FAMILY PRSNT, EA 30 MIN",,99368,440,$195.00 ,$195.00 ,$58.50 ,$177.45 ,$136.50 ,$58.50 ,$126.75 ,$140.40 ,$177.45 ,$146.25 
Carle BroMenn Medical Center,8630021,TREATMENT OF SPEECH & LANGUAGE 15MIN,,92507,441,$265.00 ,$265.00 ,$79.50 ,$241.15 ,$185.50 ,$79.50 ,$172.25 ,$190.80 ,$241.15 ,$198.75 
Carle BroMenn Medical Center,8099281,OB EMERGENCY ROOM LEVEL 1,,99281,450,$237.00 ,$237.00 ,$71.10 ,$215.67 ,$165.90 ,$71.10 ,$154.05 ,$170.64 ,$215.67 ,$177.75 
Carle BroMenn Medical Center,8099282,OB EMERGENCY ROOM LEVEL 2,,99282,450,$396.00 ,$396.00 ,$118.80 ,$360.36 ,$277.20 ,$118.80 ,$257.40 ,$285.12 ,$360.36 ,$297.00 
Carle BroMenn Medical Center,8099283,OB EMERGENCY ROOM LEVEL 3,,99283,450,$664.00 ,$664.00 ,$199.20 ,$604.24 ,$464.80 ,$199.20 ,$431.60 ,$478.08 ,$604.24 ,$498.00 
Carle BroMenn Medical Center,8099284,OB EMERGENCY ROOM LEVEL 4,,99284,450,"$1,062.00 ","$1,062.00 ",$318.60 ,$966.42 ,$743.40 ,$318.60 ,$690.30 ,$764.64 ,$966.42 ,$796.50 
Carle BroMenn Medical Center,8099285,OB EMERGENCY ROOM LEVEL 5,,99285,450,"$1,593.00 ","$1,593.00 ",$477.90 ,"$1,449.63 ","$1,115.10 ",$477.90 ,"$1,035.45 ","$1,146.96 ","$1,449.63 ","$1,194.75 "
Carle BroMenn Medical Center,8099291,OB EMERGENCY ROOM LEVEL 6,,99291,450,"$1,620.00 ","$1,620.00 ",$486.00 ,"$1,474.20 ","$1,134.00 ",$486.00 ,"$1,053.00 ","$1,166.40 ","$1,474.20 ","$1,215.00 "
Carle BroMenn Medical Center,8800200,FOLEY INSERTION,,51702,450,$18.00 ,$18.00 ,$5.40 ,$16.38 ,$12.60 ,$5.40 ,$11.70 ,$12.96 ,$16.38 ,$13.50 
Carle BroMenn Medical Center,8800201,PHLEBOTOMY,,,450,$24.00 ,$24.00 ,$7.20 ,$21.84 ,$16.80 ,$7.20 ,$15.60 ,$17.28 ,$21.84 ,$18.00 
Carle BroMenn Medical Center,8800202,"EXAM - POSSIBLE TRAUMA, CHILD",,,450,$41.00 ,$41.00 ,$12.30 ,$37.31 ,$28.70 ,$12.30 ,$26.65 ,$29.52 ,$37.31 ,$30.75 
Carle BroMenn Medical Center,8800203,GAIT TRAINING,,,450,$67.00 ,$67.00 ,$20.10 ,$60.97 ,$46.90 ,$20.10 ,$43.55 ,$48.24 ,$60.97 ,$50.25 
Carle BroMenn Medical Center,8800204,STRAIGHT CATH INSERTION,,51701,450,$185.00 ,$185.00 ,$55.50 ,$168.35 ,$129.50 ,$55.50 ,$120.25 ,$133.20 ,$168.35 ,$138.75 
Carle BroMenn Medical Center,8800205,URINARY CATHETER INSERTION,,51702,450,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8800206,APPLICATION -KNEE IMMOBILIZER,,,450,$169.00 ,$169.00 ,$50.70 ,$153.79 ,$118.30 ,$50.70 ,$109.85 ,$121.68 ,$153.79 ,$126.75 
Carle BroMenn Medical Center,8800207,WOUND CLOSURES W/ DERMABOND,,,450,$203.00 ,$203.00 ,$60.90 ,$184.73 ,$142.10 ,$60.90 ,$131.95 ,$146.16 ,$184.73 ,$152.25 
Carle BroMenn Medical Center,8800208,APP-SHORT OR LONG LEG SPLINTS,,,450,$176.00 ,$176.00 ,$52.80 ,$160.16 ,$123.20 ,$52.80 ,$114.40 ,$126.72 ,$160.16 ,$132.00 
Carle BroMenn Medical Center,8800209,"APP-KNEE,ANKLE,TOE IMMOBILIZER",,,450,$176.00 ,$176.00 ,$52.80 ,$160.16 ,$123.20 ,$52.80 ,$114.40 ,$126.72 ,$160.16 ,$132.00 
Carle BroMenn Medical Center,8800210,APP OF VELCRO WRIST SPLINT,,,450,$176.00 ,$176.00 ,$52.80 ,$160.16 ,$123.20 ,$52.80 ,$114.40 ,$126.72 ,$160.16 ,$132.00 
Carle BroMenn Medical Center,8800211,APPLICATION -ANKLE IMMOBILIZER,,,450,$176.00 ,$176.00 ,$52.80 ,$160.16 ,$123.20 ,$52.80 ,$114.40 ,$126.72 ,$160.16 ,$132.00 
Carle BroMenn Medical Center,8800212,APPLICATION OF TOE IMMOBILIZER,,,450,$176.00 ,$176.00 ,$52.80 ,$160.16 ,$123.20 ,$52.80 ,$114.40 ,$126.72 ,$160.16 ,$132.00 
Carle BroMenn Medical Center,8800213,APPLICATION OF ACE/SLING,,,450,$176.00 ,$176.00 ,$52.80 ,$160.16 ,$123.20 ,$52.80 ,$114.40 ,$126.72 ,$160.16 ,$132.00 
Carle BroMenn Medical Center,8800214,EARWAX OR FOREIGN BODY REMOVAL,,,450,$236.00 ,$236.00 ,$70.80 ,$214.76 ,$165.20 ,$70.80 ,$153.40 ,$169.92 ,$214.76 ,$177.00 
Carle BroMenn Medical Center,8800215,JOINT OR BONE REDUCTIONS,,,450,$326.00 ,$326.00 ,$97.80 ,$296.66 ,$228.20 ,$97.80 ,$211.90 ,$234.72 ,$296.66 ,$244.50 
Carle BroMenn Medical Center,8800216,APP OF SHOULDER IMMOBILIZER,,,450,$233.00 ,$233.00 ,$69.90 ,$212.03 ,$163.10 ,$69.90 ,$151.45 ,$167.76 ,$212.03 ,$174.75 
Carle BroMenn Medical Center,8800217,APP OF SPLINTS AND CASTS,,,450,$281.00 ,$281.00 ,$84.30 ,$255.71 ,$196.70 ,$84.30 ,$182.65 ,$202.32 ,$255.71 ,$210.75 
Carle BroMenn Medical Center,8800218,NAIL PROCEDURES,,,450,$326.00 ,$326.00 ,$97.80 ,$296.66 ,$228.20 ,$97.80 ,$211.90 ,$234.72 ,$296.66 ,$244.50 
Carle BroMenn Medical Center,8800219,ARTERIAL CATHETERIZATION,,,450,$236.00 ,$236.00 ,$70.80 ,$214.76 ,$165.20 ,$70.80 ,$153.40 ,$169.92 ,$214.76 ,$177.00 
Carle BroMenn Medical Center,8800220,NASOPHARYNGOSCOPY,,,450,$248.00 ,$248.00 ,$74.40 ,$225.68 ,$173.60 ,$74.40 ,$161.20 ,$178.56 ,$225.68 ,$186.00 
Carle BroMenn Medical Center,8800221,LACERATION RPR W SUTURE/STAPLE,,,450,$383.00 ,$383.00 ,$114.90 ,$348.53 ,$268.10 ,$114.90 ,$248.95 ,$275.76 ,$348.53 ,$287.25 
Carle BroMenn Medical Center,8800222,APP OF BURN DRESSINGS,,,450,$334.00 ,$334.00 ,$100.20 ,$303.94 ,$233.80 ,$100.20 ,$217.10 ,$240.48 ,$303.94 ,$250.50 
Carle BroMenn Medical Center,8800223,CONTROL OF NOSEBLEED,,,450,$338.00 ,$338.00 ,$101.40 ,$307.58 ,$236.60 ,$101.40 ,$219.70 ,$243.36 ,$307.58 ,$253.50 
Carle BroMenn Medical Center,8800224,BLADDER IRRIGATION,,51700,450,$398.00 ,$398.00 ,$119.40 ,$362.18 ,$278.60 ,$119.40 ,$258.70 ,$286.56 ,$362.18 ,$298.50 
Carle BroMenn Medical Center,8800225,INCISION AND DRAINAGE,,,450,$428.00 ,$428.00 ,$128.40 ,$389.48 ,$299.60 ,$128.40 ,$278.20 ,$308.16 ,$389.48 ,$321.00 
Carle BroMenn Medical Center,8800226,WOUND DEBRIDEMENT,,,450,$398.00 ,$398.00 ,$119.40 ,$362.18 ,$278.60 ,$119.40 ,$258.70 ,$286.56 ,$362.18 ,$298.50 
Carle BroMenn Medical Center,8800227,NEEDLE ASPIRATION - JOINT,,,450,$518.00 ,$518.00 ,$155.40 ,$471.38 ,$362.60 ,$155.40 ,$336.70 ,$372.96 ,$471.38 ,$388.50 
Carle BroMenn Medical Center,8800228,GASTRIC LAVAGE,,,450,$518.00 ,$518.00 ,$155.40 ,$471.38 ,$362.60 ,$155.40 ,$336.70 ,$372.96 ,$471.38 ,$388.50 
Carle BroMenn Medical Center,8800229,INJECTION FOR CYSTOGRAPHY,,,450,$495.00 ,$495.00 ,$148.50 ,$450.45 ,$346.50 ,$148.50 ,$321.75 ,$356.40 ,$450.45 ,$371.25 
Carle BroMenn Medical Center,8800230,INTUBATION -ENDOTRACHEAL EMERG,,,450,$728.00 ,$728.00 ,$218.40 ,$662.48 ,$509.60 ,$218.40 ,$473.20 ,$524.16 ,$662.48 ,$546.00 
Carle BroMenn Medical Center,8800231,SPINAL PUNCTURE,,,450,$773.00 ,$773.00 ,$231.90 ,$703.43 ,$541.10 ,$231.90 ,$502.45 ,$556.56 ,$703.43 ,$579.75 
Carle BroMenn Medical Center,8800232,CHANGE/FIX G / J TUBE,,,450,$803.00 ,$803.00 ,$240.90 ,$730.73 ,$562.10 ,$240.90 ,$521.95 ,$578.16 ,$730.73 ,$602.25 
Carle BroMenn Medical Center,8800233,PERITONEAL LAVAGE,,,450,$840.00 ,$840.00 ,$252.00 ,$764.40 ,$588.00 ,$252.00 ,$546.00 ,$604.80 ,$764.40 ,$630.00 
Carle BroMenn Medical Center,8800234,EXPLORATION PENETRTING WOUND,,,450,"$2,768.00 ","$2,768.00 ",$830.40 ,"$2,518.88 ","$1,937.60 ",$830.40 ,"$1,799.20 ","$1,992.96 ","$2,518.88 ","$2,076.00 "
Carle BroMenn Medical Center,8800235,RMVL FOREIGN BODY FINGER,,,450,$555.00 ,$555.00 ,$166.50 ,$505.05 ,$388.50 ,$166.50 ,$360.75 ,$399.60 ,$505.05 ,$416.25 
Carle BroMenn Medical Center,8800236,REMOVAL CONTRACEPTIVE DEVICE/IMPLANT,,,450,$435.00 ,$435.00 ,$130.50 ,$395.85 ,$304.50 ,$130.50 ,$282.75 ,$313.20 ,$395.85 ,$326.25 
Carle BroMenn Medical Center,8800237,"INCISION & RMVL FOREIGN BODY, SIMPLE",,,450,$585.00 ,$585.00 ,$175.50 ,$532.35 ,$409.50 ,$175.50 ,$380.25 ,$421.20 ,$532.35 ,$438.75 
Carle BroMenn Medical Center,8800238,"INCISION & RMVL FOREIGN BODY, COMPLICATED",,,450,"$2,318.00 ","$2,318.00 ",$695.40 ,"$2,109.38 ","$1,622.60 ",$695.40 ,"$1,506.70 ","$1,668.96 ","$2,109.38 ","$1,738.50 "
Carle BroMenn Medical Center,8800239,THORACENTESIS/PARACENTESIS,,,450,"$1,005.00 ","$1,005.00 ",$301.50 ,$914.55 ,$703.50 ,$301.50 ,$653.25 ,$723.60 ,$914.55 ,$753.75 
Carle BroMenn Medical Center,8800240,CHEST TUBE INSERTION,,,450,$968.00 ,$968.00 ,$290.40 ,$880.88 ,$677.60 ,$290.40 ,$629.20 ,$696.96 ,$880.88 ,$726.00 
Carle BroMenn Medical Center,8800241,NG TUBE REPLACEMENT,,,450,"$1,028.00 ","$1,028.00 ",$308.40 ,$935.48 ,$719.60 ,$308.40 ,$668.20 ,$740.16 ,$935.48 ,$771.00 
Carle BroMenn Medical Center,8800242,CARDIOVERSION,,,450,"$1,448.00 ","$1,448.00 ",$434.40 ,"$1,317.68 ","$1,013.60 ",$434.40 ,$941.20 ,"$1,042.56 ","$1,317.68 ","$1,086.00 "
Carle BroMenn Medical Center,8800243,LARYNGOSCOPY,,,450,"$1,568.00 ","$1,568.00 ",$470.40 ,"$1,426.88 ","$1,097.60 ",$470.40 ,"$1,019.20 ","$1,128.96 ","$1,426.88 ","$1,176.00 "
Carle BroMenn Medical Center,8800244,CENTRAL LINE INSERTION,,,450,"$1,388.00 ","$1,388.00 ",$416.40 ,"$1,263.08 ",$971.60 ,$416.40 ,$902.20 ,$999.36 ,"$1,263.08 ","$1,041.00 "
Carle BroMenn Medical Center,8800245,PLACEMENT CENTRAL VENOUS CATH,,,450,"$1,403.00 ","$1,403.00 ",$420.90 ,"$1,276.73 ",$982.10 ,$420.90 ,$911.95 ,"$1,010.16 ","$1,276.73 ","$1,052.25 "
Carle BroMenn Medical Center,8800250,ORAL STABILIZATION PROCEDURES,,,450,$600.00 ,$600.00 ,$180.00 ,$546.00 ,$420.00 ,$180.00 ,$390.00 ,$432.00 ,$546.00 ,$450.00 
Carle BroMenn Medical Center,8800251,RECTAL PROCEDURES,,,450,$203.00 ,$203.00 ,$60.90 ,$184.73 ,$142.10 ,$60.90 ,$131.95 ,$146.16 ,$184.73 ,$152.25 
Carle BroMenn Medical Center,8800252,CHANGE CYSTOSTOMY TUBE,,,450,$555.00 ,$555.00 ,$166.50 ,$505.05 ,$388.50 ,$166.50 ,$360.75 ,$399.60 ,$505.05 ,$416.25 
Carle BroMenn Medical Center,8800253,JOINT/TENDON PROC,,,450,"$2,895.00 ","$2,895.00 ",$868.50 ,"$2,634.45 ","$2,026.50 ",$868.50 ,"$1,881.75 ","$2,084.40 ","$2,634.45 ","$2,171.25 "
Carle BroMenn Medical Center,8800255,DILATION URINARY SYSTEM,,,450,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8800256,TXMNT WOUND DEHISCENCE,,,450,"$1,080.00 ","$1,080.00 ",$324.00 ,$982.80 ,$756.00 ,$324.00 ,$702.00 ,$777.60 ,$982.80 ,$810.00 
Carle BroMenn Medical Center,8800257,REPAIR BLOOD VESSEL DIRECT UPPER,,,450,"$4,703.00 ","$4,703.00 ","$1,410.90 ","$4,279.73 ","$3,292.10 ","$1,410.90 ","$3,056.95 ","$3,386.16 ","$4,279.73 ","$3,527.25 "
Carle BroMenn Medical Center,8800258,WOUND EXPLORATION EXTREMITY,,,450,"$1,988.00 ","$1,988.00 ",$596.40 ,"$1,809.08 ","$1,391.60 ",$596.40 ,"$1,292.20 ","$1,431.36 ","$1,809.08 ","$1,491.00 "
Carle BroMenn Medical Center,8800260,INJ ANES AGENT NRV,,,450,"$1,613.00 ","$1,613.00 ",$483.90 ,"$1,467.83 ","$1,129.10 ",$483.90 ,"$1,048.45 ","$1,161.36 ","$1,467.83 ","$1,209.75 "
Carle BroMenn Medical Center,8800261,VENOUS CATH REPAIR,,,450,$960.00 ,$960.00 ,$288.00 ,$873.60 ,$672.00 ,$288.00 ,$624.00 ,$691.20 ,$873.60 ,$720.00 
Carle BroMenn Medical Center,8800262,JOINT INJECTION,,,450,$563.00 ,$563.00 ,$168.90 ,$512.33 ,$394.10 ,$168.90 ,$365.95 ,$405.36 ,$512.33 ,$422.25 
Carle BroMenn Medical Center,8800263,PERICARDIOCENTESIS,,,450,$840.00 ,$840.00 ,$252.00 ,$764.40 ,$588.00 ,$252.00 ,$546.00 ,$604.80 ,$764.40 ,$630.00 
Carle BroMenn Medical Center,8800264,URINARY SYSTEM PROC,,,450,$281.00 ,$281.00 ,$84.30 ,$255.71 ,$196.70 ,$84.30 ,$182.65 ,$202.32 ,$255.71 ,$210.75 
Carle BroMenn Medical Center,8800265,INJ TENDON/MUSCLE,,,450,$585.00 ,$585.00 ,$175.50 ,$532.35 ,$409.50 ,$175.50 ,$380.25 ,$421.20 ,$532.35 ,$438.75 
Carle BroMenn Medical Center,8800267,CONTROL OF BLEED ARTERY,,,450,$206.00 ,$206.00 ,$61.80 ,$187.46 ,$144.20 ,$61.80 ,$133.90 ,$148.32 ,$187.46 ,$154.50 
Carle BroMenn Medical Center,8800268,REMOVAL FOREIGN BODY EYE,,,450,$420.00 ,$420.00 ,$126.00 ,$382.20 ,$294.00 ,$126.00 ,$273.00 ,$302.40 ,$382.20 ,$315.00 
Carle BroMenn Medical Center,8800269,BIOPSY OF SKIN LESION,,,450,$259.00 ,$259.00 ,$77.70 ,$235.69 ,$181.30 ,$77.70 ,$168.35 ,$186.48 ,$235.69 ,$194.25 
Carle BroMenn Medical Center,8800270,CYSTOURETHROSCOPY W/CALBRTN DILTN STRCTR STNS,,,450,"$1,350.00 ","$1,350.00 ",$405.00 ,"$1,228.50 ",$945.00 ,$405.00 ,$877.50 ,$972.00 ,"$1,228.50 ","$1,012.50 "
Carle BroMenn Medical Center,8800271,CYSTOURETHROSCOPY W/CALBRTN DILTN STRCTR STNS,,,450,"$2,070.00 ","$2,070.00 ",$621.00 ,"$1,883.70 ","$1,449.00 ",$621.00 ,"$1,345.50 ","$1,490.40 ","$1,883.70 ","$1,552.50 "
Carle BroMenn Medical Center,8800272,REAO/GRT VESSEL,,,450,"$7,680.00 ","$7,680.00 ","$2,304.00 ","$6,988.80 ","$5,376.00 ","$2,304.00 ","$4,992.00 ","$5,529.60 ","$6,988.80 ","$5,760.00 "
Carle BroMenn Medical Center,8800273,REPAIR HEART WOUND,,,450,"$19,200.00 ","$19,200.00 ","$5,760.00 ","$17,472.00 ","$13,440.00 ","$5,760.00 ","$12,480.00 ","$13,824.00 ","$17,472.00 ","$14,400.00 "
Carle BroMenn Medical Center,8800274,CONTROL BLEED VENOUS,,,450,"$1,110.00 ","$1,110.00 ",$333.00 ,"$1,010.10 ",$777.00 ,$333.00 ,$721.50 ,$799.20 ,"$1,010.10 ",$832.50 
Carle BroMenn Medical Center,8800275,BIOPSY/EXCISION LYMPH NODE(S),,,450,"$3,938.00 ","$3,938.00 ","$1,181.40 ","$3,583.58 ","$2,756.60 ","$1,181.40 ","$2,559.70 ","$2,835.36 ","$3,583.58 ","$2,953.50 "
Carle BroMenn Medical Center,8800276,RPR RETINAL DTCHMNT,,,450,"$4,950.00 ","$4,950.00 ","$1,485.00 ","$4,504.50 ","$3,465.00 ","$1,485.00 ","$3,217.50 ","$3,564.00 ","$4,504.50 ","$3,712.50 "
Carle BroMenn Medical Center,8800278,THORACOTOMY W/CNTRL TRAUMATIC HEMMORRHAGE,,,450,"$7,500.00 ","$7,500.00 ","$2,250.00 ","$6,825.00 ","$5,250.00 ","$2,250.00 ","$4,875.00 ","$5,400.00 ","$6,825.00 ","$5,625.00 "
Carle BroMenn Medical Center,8800288,SKIN TISSUE PROC NOS,,,450,$510.00 ,$510.00 ,$153.00 ,$464.10 ,$357.00 ,$153.00 ,$331.50 ,$367.20 ,$464.10 ,$382.50 
Carle BroMenn Medical Center,8800330,FNA,,,450,$413.00 ,$413.00 ,$123.90 ,$375.83 ,$289.10 ,$123.90 ,$268.45 ,$297.36 ,$375.83 ,$309.75 
Carle BroMenn Medical Center,8800331,DRAINAGE SCROTAL WALL ABSCESS,,,450,"$1,920.00 ","$1,920.00 ",$576.00 ,"$1,747.20 ","$1,344.00 ",$576.00 ,"$1,248.00 ","$1,382.40 ","$1,747.20 ","$1,440.00 "
Carle BroMenn Medical Center,8800332,FORESKIN PROCEDURE,,,450,$593.00 ,$593.00 ,$177.90 ,$539.63 ,$415.10 ,$177.90 ,$385.45 ,$426.96 ,$539.63 ,$444.75 
Carle BroMenn Medical Center,8800334,VENTRICULOSTOMY,,,450,$945.00 ,$945.00 ,$283.50 ,$859.95 ,$661.50 ,$283.50 ,$614.25 ,$680.40 ,$859.95 ,$708.75 
Carle BroMenn Medical Center,8800341,CANTHOTOMY,,,450,"$1,538.00 ","$1,538.00 ",$461.40 ,"$1,399.58 ","$1,076.60 ",$461.40 ,$999.70 ,"$1,107.36 ","$1,399.58 ","$1,153.50 "
Carle BroMenn Medical Center,8802083,ADJ GASTIRC BAND,,,450,$206.00 ,$206.00 ,$61.80 ,$187.46 ,$144.20 ,$61.80 ,$133.90 ,$148.32 ,$187.46 ,$154.50 
Carle BroMenn Medical Center,8809803,HC HOSPITAL OUTPT CLINIC VISIT SPECIMEN COLLECTION,,C9803,450,$45.00 ,$45.00 ,$13.50 ,$40.95 ,$31.50 ,$13.50 ,$29.25 ,$32.40 ,$40.95 ,$33.75 
Carle BroMenn Medical Center,8811281,EMERGENCY ROOM LEVEL 1 NP/PA,,99281,450,$237.00 ,$237.00 ,$71.10 ,$215.67 ,$165.90 ,$71.10 ,$154.05 ,$170.64 ,$215.67 ,$177.75 
Carle BroMenn Medical Center,8812001,SIMPLE SKIN REPAIR,,,450,$180.00 ,$180.00 ,$54.00 ,$163.80 ,$126.00 ,$54.00 ,$117.00 ,$129.60 ,$163.80 ,$135.00 
Carle BroMenn Medical Center,8817110,DESTRUCTION BENIGN LESIONS UP TO 14,,,450,$308.00 ,$308.00 ,$92.40 ,$280.28 ,$215.60 ,$92.40 ,$200.20 ,$221.76 ,$280.28 ,$231.00 
Carle BroMenn Medical Center,8817250,CHEM CAUTRZTN GRNLTN TISSUE,,,450,$233.00 ,$233.00 ,$69.90 ,$212.03 ,$163.10 ,$69.90 ,$151.45 ,$167.76 ,$212.03 ,$174.75 
Carle BroMenn Medical Center,8819282,EMERGENCY ROOM LEVEL 2 NP/PA,,99282,450,$396.00 ,$396.00 ,$118.80 ,$360.36 ,$277.20 ,$118.80 ,$257.40 ,$285.12 ,$360.36 ,$297.00 
Carle BroMenn Medical Center,8819283,EMERGENCY ROOM LEVEL 3 NP/PA,,99283,450,$664.00 ,$664.00 ,$199.20 ,$604.24 ,$464.80 ,$199.20 ,$431.60 ,$478.08 ,$604.24 ,$498.00 
Carle BroMenn Medical Center,8819284,EMERGENCY ROOM LEVEL 4 NP/PA,,,450,$705.00 ,$705.00 ,$211.50 ,$641.55 ,$493.50 ,$211.50 ,$458.25 ,$507.60 ,$641.55 ,$528.75 
Carle BroMenn Medical Center,8820950,MONITOR INTRA MUSCU PRESSURE,,,450,$325.00 ,$325.00 ,$97.50 ,$295.75 ,$227.50 ,$97.50 ,$211.25 ,$234.00 ,$295.75 ,$243.75 
Carle BroMenn Medical Center,8831502,TRACH TUBE CHANGE,,,450,$443.00 ,$443.00 ,$132.90 ,$403.13 ,$310.10 ,$132.90 ,$287.95 ,$318.96 ,$403.13 ,$332.25 
Carle BroMenn Medical Center,8832160,THORACOTOMY W/CARDIAC MASSAGE,,,450,"$6,713.00 ","$6,713.00 ","$2,013.90 ","$6,108.83 ","$4,699.10 ","$2,013.90 ","$4,363.45 ","$4,833.36 ","$6,108.83 ","$5,034.75 "
Carle BroMenn Medical Center,8836400,VENI NECESSITATING SKILL OF PHYS OR QUAL PROF,,,450,$158.00 ,$158.00 ,$47.40 ,$143.78 ,$110.60 ,$47.40 ,$102.70 ,$113.76 ,$143.78 ,$118.50 
Carle BroMenn Medical Center,8836410,"VENI AGE 3 OR >, REQ PHYS SKILL",,,450,$120.00 ,$120.00 ,$36.00 ,$109.20 ,$84.00 ,$36.00 ,$78.00 ,$86.40 ,$109.20 ,$90.00 
Carle BroMenn Medical Center,8836572,INSERTION PICC W/RS&I < 5 YR,,36572,450,$893.00 ,$893.00 ,$267.90 ,$812.63 ,$625.10 ,$267.90 ,$580.45 ,$642.96 ,$812.63 ,$669.75 
Carle BroMenn Medical Center,8836573,INSERTION PICC W/RS&I 5 YR/>,,36573,450,"$2,242.00 ","$2,242.00 ",$672.60 ,"$2,040.22 ","$1,569.40 ",$672.60 ,"$1,457.30 ","$1,614.24 ","$2,040.22 ","$1,681.50 "
Carle BroMenn Medical Center,8836591,COLLECTN BLOOD SPCMN FROM VAD,,,450,$128.00 ,$128.00 ,$38.40 ,$116.48 ,$89.60 ,$38.40 ,$83.20 ,$92.16 ,$116.48 ,$96.00 
Carle BroMenn Medical Center,8836593,INJ THROMBLYTC AGENT,,,450,$570.00 ,$570.00 ,$171.00 ,$518.70 ,$399.00 ,$171.00 ,$370.50 ,$410.40 ,$518.70 ,$427.50 
Carle BroMenn Medical Center,8836680,PLCMNT IO ACCESS,,,450,$341.00 ,$341.00 ,$102.30 ,$310.31 ,$238.70 ,$102.30 ,$221.65 ,$245.52 ,$310.31 ,$255.75 
Carle BroMenn Medical Center,8836860,CATH DECLOT,,,450,$518.00 ,$518.00 ,$155.40 ,$471.38 ,$362.60 ,$155.40 ,$336.70 ,$372.96 ,$471.38 ,$388.50 
Carle BroMenn Medical Center,8843753,LAVAGE GASTRIC,,43753,450,$695.00 ,$695.00 ,$208.50 ,$632.45 ,$486.50 ,$208.50 ,$451.75 ,$500.40 ,$632.45 ,$521.25 
Carle BroMenn Medical Center,8851798,US BLADDER CAPACITY,,51798,450,$240.00 ,$240.00 ,$72.00 ,$218.40 ,$168.00 ,$72.00 ,$156.00 ,$172.80 ,$218.40 ,$180.00 
Carle BroMenn Medical Center,8854220,IRRIGATION FOR PRIAPISM,,,450,$578.00 ,$578.00 ,$173.40 ,$525.98 ,$404.60 ,$173.40 ,$375.70 ,$416.16 ,$525.98 ,$433.50 
Carle BroMenn Medical Center,8854600,PROC TESTIS,,,450,"$3,983.00 ","$3,983.00 ","$1,194.90 ","$3,624.53 ","$2,788.10 ","$1,194.90 ","$2,588.95 ","$2,867.76 ","$3,624.53 ","$2,987.25 "
Carle BroMenn Medical Center,8856420,I&D BARTHOLINS GLAND ABSCS,,,450,$360.00 ,$360.00 ,$108.00 ,$327.60 ,$252.00 ,$108.00 ,$234.00 ,$259.20 ,$327.60 ,$270.00 
Carle BroMenn Medical Center,8857180,INTRODCTN HEMOSTATIC AGENT/PACK VAG HEM,,,450,$450.00 ,$450.00 ,$135.00 ,$409.50 ,$315.00 ,$135.00 ,$292.50 ,$324.00 ,$409.50 ,$337.50 
Carle BroMenn Medical Center,8858100,ENDOMTRL BX,,,450,$308.00 ,$308.00 ,$92.40 ,$280.28 ,$215.60 ,$92.40 ,$200.20 ,$221.76 ,$280.28 ,$231.00 
Carle BroMenn Medical Center,8858301,IUD INSRTN/REMOVAL,,,450,$383.00 ,$383.00 ,$114.90 ,$348.53 ,$268.10 ,$114.90 ,$248.95 ,$275.76 ,$348.53 ,$287.25 
Carle BroMenn Medical Center,8859414,DELV PLACENTA,,,450,"$3,578.00 ","$3,578.00 ","$1,073.40 ","$3,255.98 ","$2,504.60 ","$1,073.40 ","$2,325.70 ","$2,576.16 ","$3,255.98 ","$2,683.50 "
Carle BroMenn Medical Center,8862273,INJ EPIDRL BLD OR CLT PATCH,,,450,"$1,620.00 ","$1,620.00 ",$486.00 ,"$1,474.20 ","$1,134.00 ",$486.00 ,"$1,053.00 ","$1,166.40 ","$1,474.20 ","$1,215.00 "
Carle BroMenn Medical Center,8862328,DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT,,,450,"$1,748.00 ","$1,748.00 ",$524.40 ,"$1,590.68 ","$1,223.60 ",$524.40 ,"$1,136.20 ","$1,258.56 ","$1,590.68 ","$1,311.00 "
Carle BroMenn Medical Center,8862329,THERAPEUTIC SPINAL PNXR DRAINAGE CSF W/FLUOR/CT,,,450,"$2,183.00 ","$2,183.00 ",$654.90 ,"$1,986.53 ","$1,528.10 ",$654.90 ,"$1,418.95 ","$1,571.76 ","$1,986.53 ","$1,637.25 "
Carle BroMenn Medical Center,8864402,INJ ANES AGENT FACIAL NRV,,,450,"$1,613.00 ","$1,613.00 ",$483.90 ,"$1,467.83 ","$1,129.10 ",$483.90 ,"$1,048.45 ","$1,161.36 ","$1,467.83 ","$1,209.75 "
Carle BroMenn Medical Center,8892950,RESUSCITATION TEAM,,92950,450,"$1,445.00 ","$1,445.00 ",$433.50 ,"$1,314.95 ","$1,011.50 ",$433.50 ,$939.25 ,"$1,040.40 ","$1,314.95 ","$1,083.75 "
Carle BroMenn Medical Center,8892953,TRANSCUTANEOUS PACING TEMPORARY,,92953,450,$980.00 ,$980.00 ,$294.00 ,$891.80 ,$686.00 ,$294.00 ,$637.00 ,$705.60 ,$891.80 ,$735.00 
Carle BroMenn Medical Center,8896360,HYDRATION IV INFUSN UP TO 1HR,,96360,450,$430.00 ,$430.00 ,$129.00 ,$391.30 ,$301.00 ,$129.00 ,$279.50 ,$309.60 ,$391.30 ,$322.50 
Carle BroMenn Medical Center,8896361,HYDRATION IV INFUSN EA ADNL HR,,96361,450,$138.00 ,$138.00 ,$41.40 ,$125.58 ,$96.60 ,$41.40 ,$89.70 ,$99.36 ,$125.58 ,$103.50 
Carle BroMenn Medical Center,8896365,IV INFUSION -UP TO 1HR,,96365,450,$635.00 ,$635.00 ,$190.50 ,$577.85 ,$444.50 ,$190.50 ,$412.75 ,$457.20 ,$577.85 ,$476.25 
Carle BroMenn Medical Center,8896366,IV INFUSION -EA ADNL HR,,96366,450,$170.00 ,$170.00 ,$51.00 ,$154.70 ,$119.00 ,$51.00 ,$110.50 ,$122.40 ,$154.70 ,$127.50 
Carle BroMenn Medical Center,8896367,IV INFUSION SEQ -UP TO 1HR,,96367,450,$191.00 ,$191.00 ,$57.30 ,$173.81 ,$133.70 ,$57.30 ,$124.15 ,$137.52 ,$173.81 ,$143.25 
Carle BroMenn Medical Center,8896368,IV INFUSION CONCURRENT,,96368,450,$385.00 ,$385.00 ,$115.50 ,$350.35 ,$269.50 ,$115.50 ,$250.25 ,$277.20 ,$350.35 ,$288.75 
Carle BroMenn Medical Center,8896372,INJECTION -SUBCUTAN/INTRAMUSC,,96372,450,$155.00 ,$155.00 ,$46.50 ,$141.05 ,$108.50 ,$46.50 ,$100.75 ,$111.60 ,$141.05 ,$116.25 
Carle BroMenn Medical Center,8896374,IV PUSH -SINGLE/INITIAL,,96374,450,$380.00 ,$380.00 ,$114.00 ,$345.80 ,$266.00 ,$114.00 ,$247.00 ,$273.60 ,$345.80 ,$285.00 
Carle BroMenn Medical Center,8896375,IV PUSH -EA ADNL NEW DRUG,,96375,450,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8896376,IV PUSH -EA ADNL SAME DRUG,,96376,450,$153.00 ,$153.00 ,$45.90 ,$139.23 ,$107.10 ,$45.90 ,$99.45 ,$110.16 ,$139.23 ,$114.75 
Carle BroMenn Medical Center,8896379,INIT PROLONG INFUSN REQ PUMP,,96379,450,$368.00 ,$368.00 ,$110.40 ,$334.88 ,$257.60 ,$110.40 ,$239.20 ,$264.96 ,$334.88 ,$276.00 
Carle BroMenn Medical Center,8896521,REFILLING/MAINTENANCE PORTABLE PUMP,,,450,$413.00 ,$413.00 ,$123.90 ,$375.83 ,$289.10 ,$123.90 ,$268.45 ,$297.36 ,$375.83 ,$309.75 
Carle BroMenn Medical Center,8896523,IRRIGATN IMPLNTD VEN ACC DVC,,96523,450,$190.00 ,$190.00 ,$57.00 ,$172.90 ,$133.00 ,$57.00 ,$123.50 ,$136.80 ,$172.90 ,$142.50 
Carle BroMenn Medical Center,8897605,WOUND TREATMENT VAC,,,450,$428.00 ,$428.00 ,$128.40 ,$389.48 ,$299.60 ,$128.40 ,$278.20 ,$308.16 ,$389.48 ,$321.00 
Carle BroMenn Medical Center,8899281,EMERGENCY ROOM LEVEL 1,,99281,450,$237.00 ,$237.00 ,$71.10 ,$215.67 ,$165.90 ,$71.10 ,$154.05 ,$170.64 ,$215.67 ,$177.75 
Carle BroMenn Medical Center,8899282,EMERGENCY ROOM LEVEL 2,,99282,450,$396.00 ,$396.00 ,$118.80 ,$360.36 ,$277.20 ,$118.80 ,$257.40 ,$285.12 ,$360.36 ,$297.00 
Carle BroMenn Medical Center,8899283,EMERGENCY ROOM LEVEL 3,,99283,450,$664.00 ,$664.00 ,$199.20 ,$604.24 ,$464.80 ,$199.20 ,$431.60 ,$478.08 ,$604.24 ,$498.00 
Carle BroMenn Medical Center,8899284,EMERGENCY ROOM LEVEL 4,,99284,450,"$1,062.00 ","$1,062.00 ",$318.60 ,$966.42 ,$743.40 ,$318.60 ,$690.30 ,$764.64 ,$966.42 ,$796.50 
Carle BroMenn Medical Center,8899285,EMERGENCY ROOM LEVEL 5,,99285,450,"$1,593.00 ","$1,593.00 ",$477.90 ,"$1,449.63 ","$1,115.10 ",$477.90 ,"$1,035.45 ","$1,146.96 ","$1,449.63 ","$1,194.75 "
Carle BroMenn Medical Center,8899291,EMERGENCY ROOM LEVEL 6,,99291,450,"$1,620.00 ","$1,620.00 ",$486.00 ,"$1,474.20 ","$1,134.00 ",$486.00 ,"$1,053.00 ","$1,166.40 ","$1,474.20 ","$1,215.00 "
Carle BroMenn Medical Center,8899292,CRITICAL CARE EACH ADD 30 MINUTES,,99292,450,"$1,320.00 ","$1,320.00 ",$396.00 ,"$1,201.20 ",$924.00 ,$396.00 ,$858.00 ,$950.40 ,"$1,201.20 ",$990.00 
Carle BroMenn Medical Center,8020001,CRYOSURF ADMINISTRATION,,94610,460,$555.00 ,$555.00 ,$166.50 ,$505.05 ,$388.50 ,$166.50 ,$360.75 ,$399.60 ,$505.05 ,$416.25 
Carle BroMenn Medical Center,8020004,CAR SEAT/BED TESTING; 1RST 60 MIN,,94780,460,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8020005,CAR SEAT/BED TESTING; EACH ADTNL 30 MIN,,94781,460,$50.00 ,$50.00 ,$15.00 ,$45.50 ,$35.00 ,$15.00 ,$32.50 ,$36.00 ,$45.50 ,$37.50 
Carle BroMenn Medical Center,8294010,BREATHING CAPACITY TEST,,94010,460,$165.00 ,$165.00 ,$49.50 ,$150.15 ,$115.50 ,$49.50 ,$107.25 ,$118.80 ,$150.15 ,$123.75 
Carle BroMenn Medical Center,8294060,EVAL OF BRONCHOSPASM,,94060,460,$475.00 ,$475.00 ,$142.50 ,$432.25 ,$332.50 ,$142.50 ,$308.75 ,$342.00 ,$432.25 ,$356.25 
Carle BroMenn Medical Center,8294070,"EVAL OF BRONCHOSPASM,PROLONGED",,94070,460,$900.00 ,$900.00 ,$270.00 ,$819.00 ,$630.00 ,$270.00 ,$585.00 ,$648.00 ,$819.00 ,$675.00 
Carle BroMenn Medical Center,8294617,EXERCISE TEST FOR BRONCHOSPASM,,94617,460,$370.00 ,$370.00 ,$111.00 ,$336.70 ,$259.00 ,$111.00 ,$240.50 ,$266.40 ,$336.70 ,$277.50 
Carle BroMenn Medical Center,8294618,PULMONARY STRESS TESTING,,94618,460,$480.00 ,$480.00 ,$144.00 ,$436.80 ,$336.00 ,$144.00 ,$312.00 ,$345.60 ,$436.80 ,$360.00 
Carle BroMenn Medical Center,8294621,"PULMONARY STRESS TESTING,COMPLEX [EAP 94621]",,94621,460,"$1,015.00 ","$1,015.00 ",$304.50 ,$923.65 ,$710.50 ,$304.50 ,$659.75 ,$730.80 ,$923.65 ,$761.25 
Carle BroMenn Medical Center,8294726,PLETHYSMOGRAPHY LUNG VOLUMES W/WO AIRWAY RESIST,,94726,460,$535.00 ,$535.00 ,$160.50 ,$486.85 ,$374.50 ,$160.50 ,$347.75 ,$385.20 ,$486.85 ,$401.25 
Carle BroMenn Medical Center,8294729,DIFFUSING CAPACITY,,94729,460,$260.00 ,$260.00 ,$78.00 ,$236.60 ,$182.00 ,$78.00 ,$169.00 ,$187.20 ,$236.60 ,$195.00 
Carle BroMenn Medical Center,8294750,PULM COMPLIANCE STUDY,,94750,460,$245.00 ,$245.00 ,$73.50 ,$222.95 ,$171.50 ,$73.50 ,$159.25 ,$176.40 ,$222.95 ,$183.75 
Carle BroMenn Medical Center,8294760,MEASURE BLOOD OXYGEN LEVEL,,94760,460,$48.00 ,$48.00 ,$14.40 ,$43.68 ,$33.60 ,$14.40 ,$31.20 ,$34.56 ,$43.68 ,$36.00 
Carle BroMenn Medical Center,8294761,"NONINVASV OXYGEN SATUR,MULTIPLE",,94761,460,$74.00 ,$74.00 ,$22.20 ,$67.34 ,$51.80 ,$22.20 ,$48.10 ,$53.28 ,$67.34 ,$55.50 
Carle BroMenn Medical Center,8294799,PULMONARY SERVICE/PROCEDURE,,94799,460,$14.86 ,$14.86 ,$4.46 ,$13.52 ,$10.40 ,$4.46 ,$9.66 ,$10.70 ,$13.52 ,$11.15 
Carle BroMenn Medical Center,8295012,FENO TESTING,,95012,460,$125.00 ,$125.00 ,$37.50 ,$113.75 ,$87.50 ,$37.50 ,$81.25 ,$90.00 ,$113.75 ,$93.75 
Carle BroMenn Medical Center,8650023,END TIDAL CO2 MONITORING/DAILY,,94799,460,$14.86 ,$14.86 ,$4.46 ,$13.52 ,$10.40 ,$4.46 ,$9.66 ,$10.70 ,$13.52 ,$11.15 
Carle BroMenn Medical Center,8650052,OXYGEN PER DAY,,94799,460,$194.00 ,$194.00 ,$58.20 ,$176.54 ,$135.80 ,$58.20 ,$126.10 ,$139.68 ,$176.54 ,$145.50 
Carle BroMenn Medical Center,8650072,VENT TRANSP-IN 30M,,,460,$14.86 ,$14.86 ,$4.46 ,$13.52 ,$10.40 ,$4.46 ,$9.66 ,$10.70 ,$13.52 ,$11.15 
Carle BroMenn Medical Center,8650074,MAINTENANCE PULMONARY EXERCISE,,94799,460,$14.86 ,$14.86 ,$4.46 ,$13.52 ,$10.40 ,$4.46 ,$9.66 ,$10.70 ,$13.52 ,$11.15 
Carle BroMenn Medical Center,8650078,EMPLOYER REQUIRED PULMONARY FUNCTION,,94010,460,$165.00 ,$165.00 ,$49.50 ,$150.15 ,$115.50 ,$49.50 ,$107.25 ,$118.80 ,$150.15 ,$123.75 
Carle BroMenn Medical Center,8651760,EAROX- TCM CHECK,,94760,460,$48.00 ,$48.00 ,$14.40 ,$43.68 ,$33.60 ,$14.40 ,$31.20 ,$34.56 ,$43.68 ,$36.00 
Carle BroMenn Medical Center,8654010,F.V.C. WITHOUT DILATOR,,94010,460,$165.00 ,$165.00 ,$49.50 ,$150.15 ,$115.50 ,$49.50 ,$107.25 ,$118.80 ,$150.15 ,$123.75 
Carle BroMenn Medical Center,8654060,F.V.C. PRE AND POST DILATOR,,94060,460,$475.00 ,$475.00 ,$142.50 ,$432.25 ,$332.50 ,$142.50 ,$308.75 ,$342.00 ,$432.25 ,$356.25 
Carle BroMenn Medical Center,8654618,PULMONARY STRESS TESTING,,94618,460,$480.00 ,$480.00 ,$144.00 ,$436.80 ,$336.00 ,$144.00 ,$312.00 ,$345.60 ,$436.80 ,$360.00 
Carle BroMenn Medical Center,8654664,AEROSOL INHALATION DEMO OR EVA,,94664,460,$110.00 ,$110.00 ,$33.00 ,$100.10 ,$77.00 ,$33.00 ,$71.50 ,$79.20 ,$100.10 ,$82.50 
Carle BroMenn Medical Center,8654667,CHEST PT-DEMONSTRATION OR EVAL,,94667,460,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8654726,PLETHYSMOGRAPHY,,94726,460,$535.00 ,$535.00 ,$160.50 ,$486.85 ,$374.50 ,$160.50 ,$347.75 ,$385.20 ,$486.85 ,$401.25 
Carle BroMenn Medical Center,8654729,CO DIFF CAPACITY,,94729,460,$260.00 ,$260.00 ,$78.00 ,$236.60 ,$182.00 ,$78.00 ,$169.00 ,$187.20 ,$236.60 ,$195.00 
Carle BroMenn Medical Center,8654760,"PULSE OXIMETRY, SINGLE DETERM",,94760,460,$48.00 ,$48.00 ,$14.40 ,$43.68 ,$33.60 ,$14.40 ,$31.20 ,$34.56 ,$43.68 ,$36.00 
Carle BroMenn Medical Center,8654761,"NONINVASV OXYGEN SATUR,MULTIPLE",,94761,460,$74.00 ,$74.00 ,$22.20 ,$67.34 ,$51.80 ,$22.20 ,$48.10 ,$53.28 ,$67.34 ,$55.50 
Carle BroMenn Medical Center,8664618,6 MINUTE WALK TEST,,94618,460,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8800248,"PULSE OXIMETRY, SINGLE DETERM",,,460,$98.00 ,$98.00 ,$29.40 ,$89.18 ,$68.60 ,$29.40 ,$63.70 ,$70.56 ,$89.18 ,$73.50 
Carle BroMenn Medical Center,8800249,"PULSE OXIMETRY, MULT DETERM",,,460,$120.00 ,$120.00 ,$36.00 ,$109.20 ,$84.00 ,$36.00 ,$78.00 ,$86.40 ,$109.20 ,$90.00 
Carle BroMenn Medical Center,8934762,ALL NIGHT OXIMETRY,,,460,$455.00 ,$455.00 ,$136.50 ,$414.05 ,$318.50 ,$136.50 ,$295.75 ,$327.60 ,$414.05 ,$341.25 
Carle BroMenn Medical Center,8294762,"NONINVASV OXYGEN SATUT,CONTINUOUS",,94762,469,$455.00 ,$455.00 ,$136.50 ,$414.05 ,$318.50 ,$136.50 ,$295.75 ,$327.60 ,$414.05 ,$341.25 
Carle BroMenn Medical Center,8642507,15' SLP A/R SERVICES-ONSITE,,92507,470,$265.00 ,$265.00 ,$79.50 ,$241.15 ,$185.50 ,$79.50 ,$172.25 ,$190.80 ,$241.15 ,$198.75 
Carle BroMenn Medical Center,8642508,15' GROUP THPY SPEECH/LANGUAGE,,92508,470,$87.00 ,$87.00 ,$26.10 ,$79.17 ,$60.90 ,$26.10 ,$56.55 ,$62.64 ,$79.17 ,$65.25 
Carle BroMenn Medical Center,8642570,ACOUSTIC IMMITTANCE TESTING,,92570,470,$315.00 ,$315.00 ,$94.50 ,$286.65 ,$220.50 ,$94.50 ,$204.75 ,$226.80 ,$286.65 ,$236.25 
Carle BroMenn Medical Center,8643507,15' SLP A/R SERVICES-OFFSITE,,92507,470,$265.00 ,$265.00 ,$79.50 ,$241.15 ,$185.50 ,$79.50 ,$172.25 ,$190.80 ,$241.15 ,$198.75 
Carle BroMenn Medical Center,8644506,15' A/R ASSESSMENT-OFFSITE,,92523,470,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8644508,15' GROUP A/R SERVICES,,92508,470,$87.00 ,$87.00 ,$26.10 ,$79.17 ,$60.90 ,$26.10 ,$56.55 ,$62.64 ,$79.17 ,$65.25 
Carle BroMenn Medical Center,8646112,DEVELOPMENTAL TST ADMIN PHYS/QHP 1ST HOUR,,96112,470,$18.13 ,$18.13 ,$5.44 ,$16.50 ,$12.69 ,$5.44 ,$11.78 ,$13.05 ,$16.50 ,$13.60 
Carle BroMenn Medical Center,8646507,15' INDIVIDUAL THERAPY-ONSITE,,92507,470,$265.00 ,$265.00 ,$79.50 ,$241.15 ,$185.50 ,$79.50 ,$172.25 ,$190.80 ,$241.15 ,$198.75 
Carle BroMenn Medical Center,8646630,"45-59"" AUD REHAB PRE-LING",,92630,470,$540.00 ,$540.00 ,$162.00 ,$491.40 ,$378.00 ,$162.00 ,$351.00 ,$388.80 ,$491.40 ,$405.00 
Carle BroMenn Medical Center,8647507,15' INDIVIDUAL THERAPY-OFFSITE,,92507,470,$265.00 ,$265.00 ,$79.50 ,$241.15 ,$185.50 ,$79.50 ,$172.25 ,$190.80 ,$241.15 ,$198.75 
Carle BroMenn Medical Center,8647508,15' GROUP SLP A/R SERVICES,,92508,470,$87.00 ,$87.00 ,$26.10 ,$79.17 ,$60.90 ,$26.10 ,$56.55 ,$62.64 ,$79.17 ,$65.25 
Carle BroMenn Medical Center,8649000,15' IFSP DEVELOPMENT-ONSITE,,99499,470,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8649001,15' IFSP DEVELOPMENT-OFFSITE,,99499,470,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8649002,15' IFSP DEVELOPMENT-ONSITE,,99499,470,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8649003,15' IFSP DEVELOPMENT-OFFSITE,,99499,470,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8649004,15' A/R IFSP DEVELOPMENT-ONSIT,,99499,470,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8649005,"A/R IFSP DEVELPMNT HS-ONST 15""",,99499,470,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8649006,15' A/R IFSP DEVELOPMNT-OFFSIT,,99499,470,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8649007,15' IFSP DEVELOPMENT-ONSITE,,99499,470,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8649008,15' IFSP DEVELOPMENT-OFFSITE,,99499,470,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8649009,15' INDIVIDUAL SVC COORDINATIN,,T1017,470,$40.00 ,$40.00 ,$12.00 ,$36.40 ,$28.00 ,$12.00 ,$26.00 ,$28.80 ,$36.40 ,$30.00 
Carle BroMenn Medical Center,8649010,15' GRP FAM TRAINING & SUPPORT,,T1027,470,$51.00 ,$51.00 ,$15.30 ,$46.41 ,$35.70 ,$15.30 ,$33.15 ,$36.72 ,$46.41 ,$38.25 
Carle BroMenn Medical Center,8649011,15' FAM TRAIN/SUPPORT-ONSITE,,T1027,470,$51.00 ,$51.00 ,$15.30 ,$46.41 ,$35.70 ,$15.30 ,$33.15 ,$36.72 ,$46.41 ,$38.25 
Carle BroMenn Medical Center,8649012,15' FAM TRAIN/SUPPORT-OFFSITE,,T1027,470,$51.00 ,$51.00 ,$15.30 ,$46.41 ,$35.70 ,$15.30 ,$33.15 ,$36.72 ,$46.41 ,$38.25 
Carle BroMenn Medical Center,8649013,15' INDIVIDUAL DT-ONSITE,,T1027,470,$51.00 ,$51.00 ,$15.30 ,$46.41 ,$35.70 ,$15.30 ,$33.15 ,$36.72 ,$46.41 ,$38.25 
Carle BroMenn Medical Center,8649014,15' INDIVIDUAL DT-OFFSITE,,T1027,470,$51.00 ,$51.00 ,$15.30 ,$46.41 ,$35.70 ,$15.30 ,$33.15 ,$36.72 ,$46.41 ,$38.25 
Carle BroMenn Medical Center,8649015,HEARING SCREENING,,V5008,470,$165.00 ,$165.00 ,$49.50 ,$150.15 ,$115.50 ,$49.50 ,$107.25 ,$118.80 ,$150.15 ,$123.75 
Carle BroMenn Medical Center,8649016,HEARING AID ASSESSMENT,,V5010,470,$176.00 ,$176.00 ,$52.80 ,$160.16 ,$123.20 ,$52.80 ,$114.40 ,$126.72 ,$160.16 ,$132.00 
Carle BroMenn Medical Center,8649022,15' ASSESSMENT-ONSITE,,W8730,470,$40.00 ,$40.00 ,$12.00 ,$36.40 ,$28.00 ,$12.00 ,$26.00 ,$28.80 ,$36.40 ,$30.00 
Carle BroMenn Medical Center,8649023,15' ASSESSMENT-OFFSITE,,W8731,470,$40.00 ,$40.00 ,$12.00 ,$36.40 ,$28.00 ,$12.00 ,$26.00 ,$28.80 ,$36.40 ,$30.00 
Carle BroMenn Medical Center,8649222,15' ASSESSMENT-ONSITE,,W8730,470,$40.00 ,$40.00 ,$12.00 ,$36.40 ,$28.00 ,$12.00 ,$26.00 ,$28.80 ,$36.40 ,$30.00 
Carle BroMenn Medical Center,8200225,60' COMPREHENSIVE AUDIOMETRY (INPT),,92557,471,$420.00 ,$420.00 ,$126.00 ,$382.20 ,$294.00 ,$126.00 ,$273.00 ,$302.40 ,$382.20 ,$315.00 
Carle BroMenn Medical Center,8200226,TYMPANOMETRY  -IMPEDANCE (INPT),,92567,471,$94.00 ,$94.00 ,$28.20 ,$85.54 ,$65.80 ,$28.20 ,$61.10 ,$67.68 ,$85.54 ,$70.50 
Carle BroMenn Medical Center,8200227,AUDITORY EVOKD RESPNSE: COMPLT (INPT),,92585,471,$850.00 ,$850.00 ,$255.00 ,$773.50 ,$595.00 ,$255.00 ,$552.50 ,$612.00 ,$773.50 ,$637.50 
Carle BroMenn Medical Center,8200228,OTOACOUSTIC EMISSION TEST (INPT),,92587,471,$203.00 ,$203.00 ,$60.90 ,$184.73 ,$142.10 ,$60.90 ,$131.95 ,$146.16 ,$184.73 ,$152.25 
Carle BroMenn Medical Center,8200229,OTOACOUSTIC EMISSION COMPRHNSV (INPT),,92588,471,$251.00 ,$251.00 ,$75.30 ,$228.41 ,$175.70 ,$75.30 ,$163.15 ,$180.72 ,$228.41 ,$188.25 
Carle BroMenn Medical Center,8200230,EVOKED OTOACOUSTIC EMISSIONS SCRN AUTO ANALYSIS (INPT),,92558,471,$128.00 ,$128.00 ,$38.40 ,$116.48 ,$89.60 ,$38.40 ,$83.20 ,$92.16 ,$116.48 ,$96.00 
Carle BroMenn Medical Center,8200231,ELECTROCOCHLEOGRAPHY (INPT),,92584,471,$360.00 ,$360.00 ,$108.00 ,$327.60 ,$252.00 ,$108.00 ,$234.00 ,$259.20 ,$327.60 ,$270.00 
Carle BroMenn Medical Center,8200233,PURE TONE AUDIOMETRY AIR ONLY (INPT),,92552,471,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8200234,PURE TONE AUDIOMETRY AIR&BONE (INPT),,92553,471,$191.00 ,$191.00 ,$57.30 ,$173.81 ,$133.70 ,$57.30 ,$124.15 ,$137.52 ,$173.81 ,$143.25 
Carle BroMenn Medical Center,8200241,AEP THRESHOLD ESTIMATION MLT FREQUENCIES I&R (INPT),,92652,471,$850.00 ,$850.00 ,$255.00 ,$773.50 ,$595.00 ,$255.00 ,$552.50 ,$612.00 ,$773.50 ,$637.50 
Carle BroMenn Medical Center,8202120,"COMPREHENSIVE AUDIOMETRY THRESHOLD AND SPEECH RECOGNITION, AUTOMATED",,0212T,471,$190.00 ,$190.00 ,$57.00 ,$172.90 ,$133.00 ,$57.00 ,$123.50 ,$136.80 ,$172.90 ,$142.50 
Carle BroMenn Medical Center,8205299,DOCS PROPLUGS,,V5299,471,$27.00 ,$27.00 ,$8.10 ,$24.57 ,$18.90 ,$8.10 ,$17.55 ,$19.44 ,$24.57 ,$20.25 
Carle BroMenn Medical Center,8212700,BAHA FITTING PER HR,,92700,471,$59.00 ,$59.00 ,$17.70 ,$53.69 ,$41.30 ,$17.70 ,$38.35 ,$42.48 ,$53.69 ,$44.25 
Carle BroMenn Medical Center,8212701,"Hearing Aid Programming, Ea 15 Min",,92700,471,$30.00 ,$30.00 ,$9.00 ,$27.30 ,$21.00 ,$9.00 ,$19.50 ,$21.60 ,$27.30 ,$22.50 
Carle BroMenn Medical Center,8212702,VEMP,,92700,471,$165.00 ,$165.00 ,$49.50 ,$150.15 ,$115.50 ,$49.50 ,$107.25 ,$118.80 ,$150.15 ,$123.75 
Carle BroMenn Medical Center,8292537,CALORIC VESTIBULAR TEST W/REC BI BITHERMAL,,92537,471,$345.00 ,$345.00 ,$103.50 ,$313.95 ,$241.50 ,$103.50 ,$224.25 ,$248.40 ,$313.95 ,$258.75 
Carle BroMenn Medical Center,8292538,CALORIC VESTIBULAR TEST W/REC BI MONOTHERMAL,,92538,471,$305.00 ,$305.00 ,$91.50 ,$277.55 ,$213.50 ,$91.50 ,$198.25 ,$219.60 ,$277.55 ,$228.75 
Carle BroMenn Medical Center,8292540,VESTIBULAR EVAL NYSTAG FOVL&PERPH STIM OSCIL TRACKING,,92540,471,$345.00 ,$345.00 ,$103.50 ,$313.95 ,$241.50 ,$103.50 ,$224.25 ,$248.40 ,$313.95 ,$258.75 
Carle BroMenn Medical Center,8292549,CDP-SOT 6 CONDITIONS W/I&R W/MCT & ADT,,92549,471,$185.00 ,$185.00 ,$55.50 ,$168.35 ,$129.50 ,$55.50 ,$120.25 ,$133.20 ,$168.35 ,$138.75 
Carle BroMenn Medical Center,8292550,TYMPANOMETRY AND REFLEX THRESHOLD MEASUREMENTS,,92550,471,$305.00 ,$305.00 ,$91.50 ,$277.55 ,$213.50 ,$91.50 ,$198.25 ,$219.60 ,$277.55 ,$228.75 
Carle BroMenn Medical Center,8292551,"PURE TONE HEARING TEST, AIR",,92551,471,$23.00 ,$23.00 ,$6.90 ,$20.93 ,$16.10 ,$6.90 ,$14.95 ,$16.56 ,$20.93 ,$17.25 
Carle BroMenn Medical Center,8292552,"PURE TONE AUDIOMETRY, AIR",,92552,471,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8292553,"AUDIOMETRY, AIR & BONE",,92553,471,$191.00 ,$191.00 ,$57.30 ,$173.81 ,$133.70 ,$57.30 ,$124.15 ,$137.52 ,$173.81 ,$143.25 
Carle BroMenn Medical Center,8292555,SPEECH THRESHOLD AUDIOMETRY,,92555,471,$88.00 ,$88.00 ,$26.40 ,$80.08 ,$61.60 ,$26.40 ,$57.20 ,$63.36 ,$80.08 ,$66.00 
Carle BroMenn Medical Center,8292556,"SPEECH AUDIOMETRY, COMPLETE",,92556,471,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8292557,COMPREHENSIVE HEARING TEST,,92557,471,$420.00 ,$420.00 ,$126.00 ,$382.20 ,$294.00 ,$126.00 ,$273.00 ,$302.40 ,$382.20 ,$315.00 
Carle BroMenn Medical Center,8292559,GROUP AUDIOMETRIC TESTING,,92559,471,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8292565,"STENGER TEST, PURE TONE",,92565,471,$84.00 ,$84.00 ,$25.20 ,$76.44 ,$58.80 ,$25.20 ,$54.60 ,$60.48 ,$76.44 ,$63.00 
Carle BroMenn Medical Center,8292567,TYMPANOMETRY,,92567,471,$94.00 ,$94.00 ,$28.20 ,$85.54 ,$65.80 ,$28.20 ,$61.10 ,$67.68 ,$85.54 ,$70.50 
Carle BroMenn Medical Center,8292579,VISUAL AUDIOMETRY (VRA),,92579,471,$345.00 ,$345.00 ,$103.50 ,$313.95 ,$241.50 ,$103.50 ,$224.25 ,$248.40 ,$313.95 ,$258.75 
Carle BroMenn Medical Center,8292582,CONDITIONING PLAY AUDIOMETRY,,92582,471,$266.00 ,$266.00 ,$79.80 ,$242.06 ,$186.20 ,$79.80 ,$172.90 ,$191.52 ,$242.06 ,$199.50 
Carle BroMenn Medical Center,8292584,ELECTROCOCHLEOGRAPHY,,92584,471,$360.00 ,$360.00 ,$108.00 ,$327.60 ,$252.00 ,$108.00 ,$234.00 ,$259.20 ,$327.60 ,$270.00 
Carle BroMenn Medical Center,8292585,AUDITORY EVOKED POTENTIAL,,92585,471,$750.00 ,$750.00 ,$225.00 ,$682.50 ,$525.00 ,$225.00 ,$487.50 ,$540.00 ,$682.50 ,$562.50 
Carle BroMenn Medical Center,8292586,"AUDITORY EVOKED POTENTIAL, LIMITED",,92586,471,$320.00 ,$320.00 ,$96.00 ,$291.20 ,$224.00 ,$96.00 ,$208.00 ,$230.40 ,$291.20 ,$240.00 
Carle BroMenn Medical Center,8292587,DISTORT PRODUCT EVOKED OTOACOUSTIC EMISNS LIMITD,,92587,471,$203.00 ,$203.00 ,$60.90 ,$184.73 ,$142.10 ,$60.90 ,$131.95 ,$146.16 ,$184.73 ,$152.25 
Carle BroMenn Medical Center,8292588,DISTRT PROD EVOKD OTOACOUSTIC EMSNS COMP/DX EVAL,,92588,471,$251.00 ,$251.00 ,$75.30 ,$228.41 ,$175.70 ,$75.30 ,$163.15 ,$180.72 ,$228.41 ,$188.25 
Carle BroMenn Medical Center,8292590,"HEARING AID EXAM, ONE EAR",,92590,471,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8292591,"HEARING AID EXAM, BOTH EARS",,92591,471,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8292593,"HEARING AID CHECK, BOTH EARS",,92593,471,$125.00 ,$125.00 ,$37.50 ,$113.75 ,$87.50 ,$37.50 ,$81.25 ,$90.00 ,$113.75 ,$93.75 
Carle BroMenn Medical Center,8292594,"ELECTRO HEARING AID TEST, ONE",,92594,471,$81.00 ,$81.00 ,$24.30 ,$73.71 ,$56.70 ,$24.30 ,$52.65 ,$58.32 ,$73.71 ,$60.75 
Carle BroMenn Medical Center,8292595,"ELECTRO HEARINGAID TEST, BOTH",,92595,471,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8292596,EAR PROTECTOR EVALUATION,,92596,471,$91.00 ,$91.00 ,$27.30 ,$82.81 ,$63.70 ,$27.30 ,$59.15 ,$65.52 ,$82.81 ,$68.25 
Carle BroMenn Medical Center,8292603,DX ANALYSIS COCHLEAR IMPLNT PT >7YR W/PRG 1HR,,92603,471,$345.00 ,$345.00 ,$103.50 ,$313.95 ,$241.50 ,$103.50 ,$224.25 ,$248.40 ,$313.95 ,$258.75 
Carle BroMenn Medical Center,8292604,DX ANALYSIS COCHLEAR IMPLNT >7YR REPROG 1HR,,92604,471,$300.00 ,$300.00 ,$90.00 ,$273.00 ,$210.00 ,$90.00 ,$195.00 ,$216.00 ,$273.00 ,$225.00 
Carle BroMenn Medical Center,8292620,"AUDITORY FUNCTION, 60 MIN",,92620,471,$240.00 ,$240.00 ,$72.00 ,$218.40 ,$168.00 ,$72.00 ,$156.00 ,$172.80 ,$218.40 ,$180.00 
Carle BroMenn Medical Center,8292621,EVAL CENTRAL AUDITORY FUNCJ W/REPRT EA 15 MIN,,92621,471,$39.00 ,$39.00 ,$11.70 ,$35.49 ,$27.30 ,$11.70 ,$25.35 ,$28.08 ,$35.49 ,$29.25 
Carle BroMenn Medical Center,8292625,TINNITUS ASSESSMENT,,92625,471,$210.00 ,$210.00 ,$63.00 ,$191.10 ,$147.00 ,$63.00 ,$136.50 ,$151.20 ,$191.10 ,$157.50 
Carle BroMenn Medical Center,8292626,"BAHA EVAL, FIRST HR",,92626,471,$300.00 ,$300.00 ,$90.00 ,$273.00 ,$210.00 ,$90.00 ,$195.00 ,$216.00 ,$273.00 ,$225.00 
Carle BroMenn Medical Center,8292627,"BAHA EVAL, EA ADD 15MIN",,92627,471,$57.00 ,$57.00 ,$17.10 ,$51.87 ,$39.90 ,$17.10 ,$37.05 ,$41.04 ,$51.87 ,$42.75 
Carle BroMenn Medical Center,8492584,ELECTROCOCHLEOGRAPHY,,92584,471,$360.00 ,$360.00 ,$108.00 ,$327.60 ,$252.00 ,$108.00 ,$234.00 ,$259.20 ,$327.60 ,$270.00 
Carle BroMenn Medical Center,8640673,60' COMPREHENSIVE AUDIOMETRY (INPT),,92557,471,$420.00 ,$420.00 ,$126.00 ,$382.20 ,$294.00 ,$126.00 ,$273.00 ,$302.40 ,$382.20 ,$315.00 
Carle BroMenn Medical Center,8640674,TYMPANOMETRY  -IMPEDANCE (INPT),,92567,471,$94.00 ,$94.00 ,$28.20 ,$85.54 ,$65.80 ,$28.20 ,$61.10 ,$67.68 ,$85.54 ,$70.50 
Carle BroMenn Medical Center,8640676,OTOACOUSTIC EMISSION TEST (INPT),,92587,471,$203.00 ,$203.00 ,$60.90 ,$184.73 ,$142.10 ,$60.90 ,$131.95 ,$146.16 ,$184.73 ,$152.25 
Carle BroMenn Medical Center,8640677,OTOACOUSTIC EMISSION COMPRHNSV (INPT),,92588,471,$251.00 ,$251.00 ,$75.30 ,$228.41 ,$175.70 ,$75.30 ,$163.15 ,$180.72 ,$228.41 ,$188.25 
Carle BroMenn Medical Center,8640678,EVOKED OTOACOUSTIC EMISSIONS SCRN AUTO ANALYSIS (INPT),,92558,471,$128.00 ,$128.00 ,$38.40 ,$116.48 ,$89.60 ,$38.40 ,$83.20 ,$92.16 ,$116.48 ,$96.00 
Carle BroMenn Medical Center,8640679,ELECTROCOCHLEOGRAPHY,,92584,471,$360.00 ,$360.00 ,$108.00 ,$327.60 ,$252.00 ,$108.00 ,$234.00 ,$259.20 ,$327.60 ,$270.00 
Carle BroMenn Medical Center,8640681,PURE TONE AUDIOMETRY AIR ONLY (INPT),,92552,471,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8640682,PURE TONE AUDIOMETRY AIR&BONE (INPT),,92553,471,$191.00 ,$191.00 ,$57.30 ,$173.81 ,$133.70 ,$57.30 ,$124.15 ,$137.52 ,$173.81 ,$143.25 
Carle BroMenn Medical Center,8641557,90' COMPREHENSIVE AUDIOMETRY,,92557,471,$420.00 ,$420.00 ,$126.00 ,$382.20 ,$294.00 ,$126.00 ,$273.00 ,$302.40 ,$382.20 ,$315.00 
Carle BroMenn Medical Center,8641567,TYMPANOMETRY  -IMPEDANCE,,92567,471,$94.00 ,$94.00 ,$28.20 ,$85.54 ,$65.80 ,$28.20 ,$61.10 ,$67.68 ,$85.54 ,$70.50 
Carle BroMenn Medical Center,8642000,"8-59"" ANALYSIS CI <7YRS W/PROG",,92601,471,$360.00 ,$360.00 ,$108.00 ,$327.60 ,$252.00 ,$108.00 ,$234.00 ,$259.20 ,$327.60 ,$270.00 
Carle BroMenn Medical Center,8642001,1-2' ANALYSIS CI <7YRS W/PROG,,92601,471,$360.00 ,$360.00 ,$108.00 ,$327.60 ,$252.00 ,$108.00 ,$234.00 ,$259.20 ,$327.60 ,$270.00 
Carle BroMenn Medical Center,8642002,2-3' ANALYSIS CI <7YRS W/PROG,,92601,471,$360.00 ,$360.00 ,$108.00 ,$327.60 ,$252.00 ,$108.00 ,$234.00 ,$259.20 ,$327.60 ,$270.00 
Carle BroMenn Medical Center,8642003,3-4' ANALYSIS CI <7YRS W/PROG,,92601,471,$360.00 ,$360.00 ,$108.00 ,$327.60 ,$252.00 ,$108.00 ,$234.00 ,$259.20 ,$327.60 ,$270.00 
Carle BroMenn Medical Center,8642004,4-5' ANALYSIS CI <7YRS W/PROG,,92601,471,$360.00 ,$360.00 ,$108.00 ,$327.60 ,$252.00 ,$108.00 ,$234.00 ,$259.20 ,$327.60 ,$270.00 
Carle BroMenn Medical Center,8642005,5-6' ANALYSIS CI <7YRS W/PROG,,92601,471,$360.00 ,$360.00 ,$108.00 ,$327.60 ,$252.00 ,$108.00 ,$234.00 ,$259.20 ,$327.60 ,$270.00 
Carle BroMenn Medical Center,8642006,6-7' ANALYSIS CI <7YRS W/PROG,,92601,471,$360.00 ,$360.00 ,$108.00 ,$327.60 ,$252.00 ,$108.00 ,$234.00 ,$259.20 ,$327.60 ,$270.00 
Carle BroMenn Medical Center,8642020,"8-59"" SUBSEQUENT CI PROG <7YRS",,92602,471,$360.00 ,$360.00 ,$108.00 ,$327.60 ,$252.00 ,$108.00 ,$234.00 ,$259.20 ,$327.60 ,$270.00 
Carle BroMenn Medical Center,8642021,1-2' SUBSEQUENT CI PROG <7YRS,,92602,471,$360.00 ,$360.00 ,$108.00 ,$327.60 ,$252.00 ,$108.00 ,$234.00 ,$259.20 ,$327.60 ,$270.00 
Carle BroMenn Medical Center,8642022,2-3' SUBSEQUENT CI PROG <7YRS,,92602,471,$360.00 ,$360.00 ,$108.00 ,$327.60 ,$252.00 ,$108.00 ,$234.00 ,$259.20 ,$327.60 ,$270.00 
Carle BroMenn Medical Center,8642023,3-4' SUBSEQUENT CI PROG <7YRS,,92602,471,$360.00 ,$360.00 ,$108.00 ,$327.60 ,$252.00 ,$108.00 ,$234.00 ,$259.20 ,$327.60 ,$270.00 
Carle BroMenn Medical Center,8642024,4-5' SUBSEQUENT CI PROG <7YRS,,92602,471,$360.00 ,$360.00 ,$108.00 ,$327.60 ,$252.00 ,$108.00 ,$234.00 ,$259.20 ,$327.60 ,$270.00 
Carle BroMenn Medical Center,8642025,5-6' SUBSEQUENT CI PROG <7YRS,,92602,471,$360.00 ,$360.00 ,$108.00 ,$327.60 ,$252.00 ,$108.00 ,$234.00 ,$259.20 ,$327.60 ,$270.00 
Carle BroMenn Medical Center,8642026,6-7' SUBSEQUENT CI PROG <7YRS,,92602,471,$360.00 ,$360.00 ,$108.00 ,$327.60 ,$252.00 ,$108.00 ,$234.00 ,$259.20 ,$327.60 ,$270.00 
Carle BroMenn Medical Center,8642551,"PURE TONE HEARING TEST, AIR",,92551,471,$23.00 ,$23.00 ,$6.90 ,$20.93 ,$16.10 ,$6.90 ,$14.95 ,$16.56 ,$20.93 ,$17.25 
Carle BroMenn Medical Center,8642552,PURE TONE AUDIOMETRY AIR ONLY,,92552,471,$124.00 ,$124.00 ,$37.20 ,$112.84 ,$86.80 ,$37.20 ,$80.60 ,$89.28 ,$112.84 ,$93.00 
Carle BroMenn Medical Center,8642553,PURE TONE AUDIOMETRY AIR&BONE,,92553,471,$191.00 ,$191.00 ,$57.30 ,$173.81 ,$133.70 ,$57.30 ,$124.15 ,$137.52 ,$173.81 ,$143.25 
Carle BroMenn Medical Center,8642557,60' COMPREHENSIVE AUDIOMETRY,,92557,471,$420.00 ,$420.00 ,$126.00 ,$382.20 ,$294.00 ,$126.00 ,$273.00 ,$302.40 ,$382.20 ,$315.00 
Carle BroMenn Medical Center,8642558,EVOKED OTOACOUSTIC EMISSIONS SCREEN AUTO ANALYSIS,,92558,471,$128.00 ,$128.00 ,$38.40 ,$116.48 ,$89.60 ,$38.40 ,$83.20 ,$92.16 ,$116.48 ,$96.00 
Carle BroMenn Medical Center,8642568,ACOUSTIC REFLEX TEST,,92568,471,$86.00 ,$86.00 ,$25.80 ,$78.26 ,$60.20 ,$25.80 ,$55.90 ,$61.92 ,$78.26 ,$64.50 
Carle BroMenn Medical Center,8642582,CONDITIONING PLAY AUDIOMETRY,,92582,471,$266.00 ,$266.00 ,$79.80 ,$242.06 ,$186.20 ,$79.80 ,$172.90 ,$191.52 ,$242.06 ,$199.50 
Carle BroMenn Medical Center,8642583,SELECT PICTURE AUDIOMETRY,,92583,471,$71.00 ,$71.00 ,$21.30 ,$64.61 ,$49.70 ,$21.30 ,$46.15 ,$51.12 ,$64.61 ,$53.25 
Carle BroMenn Medical Center,8642584,ELECTROCOCHLEOGRAPHY,,92584,471,$360.00 ,$360.00 ,$108.00 ,$327.60 ,$252.00 ,$108.00 ,$234.00 ,$259.20 ,$327.60 ,$270.00 
Carle BroMenn Medical Center,8642587,OTOACOUSTIC EMISSION TEST,,92587,471,$203.00 ,$203.00 ,$60.90 ,$184.73 ,$142.10 ,$60.90 ,$131.95 ,$146.16 ,$184.73 ,$152.25 
Carle BroMenn Medical Center,8642588,OTOACOUSTIC EMISSION COMPRHNSV,,92588,471,$251.00 ,$251.00 ,$75.30 ,$228.41 ,$175.70 ,$75.30 ,$163.15 ,$180.72 ,$228.41 ,$188.25 
Carle BroMenn Medical Center,8642590,HEARING AID EVAL/SELECT-MONO,,92590,471,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8642591,HEARING AID EVAL/SELECT-BIN,,92591,471,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8642592,HEARING AID TEST-MONAURAL,,92592,471,$74.00 ,$74.00 ,$22.20 ,$67.34 ,$51.80 ,$22.20 ,$48.10 ,$53.28 ,$67.34 ,$55.50 
Carle BroMenn Medical Center,8643557,TYMPANOMETRY  -IMPEDANCE,,92567,471,$94.00 ,$94.00 ,$28.20 ,$85.54 ,$65.80 ,$28.20 ,$61.10 ,$67.68 ,$85.54 ,$70.50 
Carle BroMenn Medical Center,8645557,60' COMPREHENSIVE AUDIOMETRY,,92557,471,$420.00 ,$420.00 ,$126.00 ,$382.20 ,$294.00 ,$126.00 ,$273.00 ,$302.40 ,$382.20 ,$315.00 
Carle BroMenn Medical Center,8645940,IONM IN OPERATNG ROOM 15 MIN,,95940,471,$184.00 ,$184.00 ,$55.20 ,$167.44 ,$128.80 ,$55.20 ,$119.60 ,$132.48 ,$167.44 ,$138.00 
Carle BroMenn Medical Center,8645941,IONM REMOTE/>1 PT OR PER HR,,95941,471,$413.00 ,$413.00 ,$123.90 ,$375.83 ,$289.10 ,$123.90 ,$268.45 ,$297.36 ,$375.83 ,$309.75 
Carle BroMenn Medical Center,8649960,"AUDIOLOGY STANDBY SVC, EA 30 MIN",,99360,471,$278.00 ,$278.00 ,$83.40 ,$252.98 ,$194.60 ,$83.40 ,$180.70 ,$200.16 ,$252.98 ,$208.50 
Carle BroMenn Medical Center,8652582,CONDITIONING PLAY AUDIOMETRY,,92582,471,$266.00 ,$266.00 ,$79.80 ,$242.06 ,$186.20 ,$79.80 ,$172.90 ,$191.52 ,$242.06 ,$199.50 
Carle BroMenn Medical Center,8652583,SELECT PICTURE AUDIOMETRY,,92583,471,$71.00 ,$71.00 ,$21.30 ,$64.61 ,$49.70 ,$21.30 ,$46.15 ,$51.12 ,$64.61 ,$53.25 
Carle BroMenn Medical Center,8652584,ELECTROCOCHLEOGRAPHY,,92584,471,$360.00 ,$360.00 ,$108.00 ,$327.60 ,$252.00 ,$108.00 ,$234.00 ,$259.20 ,$327.60 ,$270.00 
Carle BroMenn Medical Center,8201260,POCKETTALK EARBUD PAD PK,,V5299,472,$4.00 ,$4.00 ,$1.20 ,$3.64 ,$2.80 ,$1.20 ,$2.60 ,$2.88 ,$3.64 ,$3.00 
Carle BroMenn Medical Center,8201261,POCKETTALK PAD HEADPHONE,,V5299,472,$6.00 ,$6.00 ,$1.80 ,$5.46 ,$4.20 ,$1.80 ,$3.90 ,$4.32 ,$5.46 ,$4.50 
Carle BroMenn Medical Center,8201262,POCKETTALK MIC WINDSCREEN,,V5299,472,$17.00 ,$17.00 ,$5.10 ,$15.47 ,$11.90 ,$5.10 ,$11.05 ,$12.24 ,$15.47 ,$12.75 
Carle BroMenn Medical Center,8201263,DOCS PROPLUGS,,V5299,472,$28.00 ,$28.00 ,$8.40 ,$25.48 ,$19.60 ,$8.40 ,$18.20 ,$20.16 ,$25.48 ,$21.00 
Carle BroMenn Medical Center,8201279,POCKETTALK DLX HEADSET,,V5299,472,$62.00 ,$62.00 ,$18.60 ,$56.42 ,$43.40 ,$18.60 ,$40.30 ,$44.64 ,$56.42 ,$46.50 
Carle BroMenn Medical Center,8201280,POCKETTALKER  DUAL EARBUD,,V5299,472,$88.00 ,$88.00 ,$26.40 ,$80.08 ,$61.60 ,$26.40 ,$57.20 ,$63.36 ,$80.08 ,$66.00 
Carle BroMenn Medical Center,8637040,HEARING SCREENING,,V5008,472,$165.00 ,$165.00 ,$49.50 ,$150.15 ,$115.50 ,$49.50 ,$107.25 ,$118.80 ,$150.15 ,$123.75 
Carle BroMenn Medical Center,8640630,"8-15"" AUD REHAB PRE-LING",,92630,472,$540.00 ,$540.00 ,$162.00 ,$491.40 ,$378.00 ,$162.00 ,$351.00 ,$388.80 ,$491.40 ,$405.00 
Carle BroMenn Medical Center,8641230,"61 - 90"" AUD REHAB PRE-LING",,92630,472,$540.00 ,$540.00 ,$162.00 ,$491.40 ,$378.00 ,$162.00 ,$351.00 ,$388.80 ,$491.40 ,$405.00 
Carle BroMenn Medical Center,8641508,"8""-30"" GROUP SPEECH",,92508,472,$87.00 ,$87.00 ,$26.10 ,$79.17 ,$60.90 ,$26.10 ,$56.55 ,$62.64 ,$79.17 ,$65.25 
Carle BroMenn Medical Center,8642208,"60-120"" GROUP SPEECH",,92508,472,$87.00 ,$87.00 ,$26.10 ,$79.17 ,$60.90 ,$26.10 ,$56.55 ,$62.64 ,$79.17 ,$65.25 
Carle BroMenn Medical Center,8642230,"AUD REHAB PRE-LING 90""",,92630,472,$540.00 ,$540.00 ,$162.00 ,$491.40 ,$378.00 ,$162.00 ,$351.00 ,$388.80 ,$491.40 ,$405.00 
Carle BroMenn Medical Center,8642308,"45-59"" GROUP SPEECH",,92508,472,$87.00 ,$87.00 ,$26.10 ,$79.17 ,$60.90 ,$26.10 ,$56.55 ,$62.64 ,$79.17 ,$65.25 
Carle BroMenn Medical Center,8642408,"60-74"" GROUP SPEECH",,92508,472,$87.00 ,$87.00 ,$26.10 ,$79.17 ,$60.90 ,$26.10 ,$56.55 ,$62.64 ,$79.17 ,$65.25 
Carle BroMenn Medical Center,8642500,"SPEECH/AUDIO TREATMENT 90""",,92507,472,$265.00 ,$265.00 ,$79.50 ,$241.15 ,$185.50 ,$79.50 ,$172.25 ,$190.80 ,$241.15 ,$198.75 
Carle BroMenn Medical Center,8642518,"75-89"" GROUP SPEECH",,92508,472,$87.00 ,$87.00 ,$26.10 ,$79.17 ,$60.90 ,$26.10 ,$56.55 ,$62.64 ,$79.17 ,$65.25 
Carle BroMenn Medical Center,8642608,"90-104"" GROUP SPEECH",,92508,472,$87.00 ,$87.00 ,$26.10 ,$79.17 ,$60.90 ,$26.10 ,$56.55 ,$62.64 ,$79.17 ,$65.25 
Carle BroMenn Medical Center,8642630,"8-15"" AUD REHAB PRE-LING",,92630,472,$540.00 ,$540.00 ,$162.00 ,$491.40 ,$378.00 ,$162.00 ,$351.00 ,$388.80 ,$491.40 ,$405.00 
Carle BroMenn Medical Center,8642633,"8 - 30"" AUD REHAB POST-LING",,92633,472,$188.00 ,$188.00 ,$56.40 ,$171.08 ,$131.60 ,$56.40 ,$122.20 ,$135.36 ,$171.08 ,$141.00 
Carle BroMenn Medical Center,8642657,31'-60' SPEECH/AUDIO TREATMENT,,92507,472,$265.00 ,$265.00 ,$79.50 ,$241.15 ,$185.50 ,$79.50 ,$172.25 ,$190.80 ,$241.15 ,$198.75 
Carle BroMenn Medical Center,8642708,"105-119"" GROUP SPEECH",,92508,472,$87.00 ,$87.00 ,$26.10 ,$79.17 ,$60.90 ,$26.10 ,$56.55 ,$62.64 ,$79.17 ,$65.25 
Carle BroMenn Medical Center,8642757,"60-74"" SPEECH/AUDIO TREATMENT",,92507,472,$265.00 ,$265.00 ,$79.50 ,$241.15 ,$185.50 ,$79.50 ,$172.25 ,$190.80 ,$241.15 ,$198.75 
Carle BroMenn Medical Center,8642808,"120"" GROUP SPEECH",,92508,472,$87.00 ,$87.00 ,$26.10 ,$79.17 ,$60.90 ,$26.10 ,$56.55 ,$62.64 ,$79.17 ,$65.25 
Carle BroMenn Medical Center,8642857,"75-89"" SPEECH/AUDIO TREATMENT",,92507,472,$265.00 ,$265.00 ,$79.50 ,$241.15 ,$185.50 ,$79.50 ,$172.25 ,$190.80 ,$241.15 ,$198.75 
Carle BroMenn Medical Center,8642957,"61-90"" SPEECH/AUDIO TREATMENT",,92507,472,$265.00 ,$265.00 ,$79.50 ,$241.15 ,$185.50 ,$79.50 ,$172.25 ,$190.80 ,$241.15 ,$198.75 
Carle BroMenn Medical Center,8643508,"30-45"" GROUP SPEECH",,92508,472,$87.00 ,$87.00 ,$26.10 ,$79.17 ,$60.90 ,$26.10 ,$56.55 ,$62.64 ,$79.17 ,$65.25 
Carle BroMenn Medical Center,8643630,"16-29"" AUD REHAB PRE-LING",,92630,472,$540.00 ,$540.00 ,$162.00 ,$491.40 ,$378.00 ,$162.00 ,$351.00 ,$388.80 ,$491.40 ,$405.00 
Carle BroMenn Medical Center,8643633,"31 - 60"" AUD REHAB POST-LING",,92633,472,$188.00 ,$188.00 ,$56.40 ,$171.08 ,$131.60 ,$56.40 ,$122.20 ,$135.36 ,$171.08 ,$141.00 
Carle BroMenn Medical Center,8644507,"8-15"" SPEECH/AUDIO TREATMENT",,92507,472,$265.00 ,$265.00 ,$79.50 ,$241.15 ,$185.50 ,$79.50 ,$172.25 ,$190.80 ,$241.15 ,$198.75 
Carle BroMenn Medical Center,8644557,"45-59"" SPEECH/AUDIO TREATMENT",,92507,472,$265.00 ,$265.00 ,$79.50 ,$241.15 ,$185.50 ,$79.50 ,$172.25 ,$190.80 ,$241.15 ,$198.75 
Carle BroMenn Medical Center,8644630,"8 - 30"" AUD REHAB PRE-LING",,92630,472,$540.00 ,$540.00 ,$162.00 ,$491.40 ,$378.00 ,$162.00 ,$351.00 ,$388.80 ,$491.40 ,$405.00 
Carle BroMenn Medical Center,8644633,"61 - 90"" AUD REHAB POST-LING",,92633,472,$188.00 ,$188.00 ,$56.40 ,$171.08 ,$131.60 ,$56.40 ,$122.20 ,$135.36 ,$171.08 ,$141.00 
Carle BroMenn Medical Center,8645507,"16-29"" SPEECH/AUDIO TREATMENT",,92507,472,$265.00 ,$265.00 ,$79.50 ,$241.15 ,$185.50 ,$79.50 ,$172.25 ,$190.80 ,$241.15 ,$198.75 
Carle BroMenn Medical Center,8645508,"8-15"" GROUP SPEECH",,92508,472,$87.00 ,$87.00 ,$26.10 ,$79.17 ,$60.90 ,$26.10 ,$56.55 ,$62.64 ,$79.17 ,$65.25 
Carle BroMenn Medical Center,8645630,"30-44"" AUD REHAB PRE-LING",,92630,472,$540.00 ,$540.00 ,$162.00 ,$491.40 ,$378.00 ,$162.00 ,$351.00 ,$388.80 ,$491.40 ,$405.00 
Carle BroMenn Medical Center,8646508,"16-29"" GROUP SPEECH",,92508,472,$87.00 ,$87.00 ,$26.10 ,$79.17 ,$60.90 ,$26.10 ,$56.55 ,$62.64 ,$79.17 ,$65.25 
Carle BroMenn Medical Center,8647630,"31 - 60"" AUD REHAB PRE-LING",,92630,472,$540.00 ,$540.00 ,$162.00 ,$491.40 ,$378.00 ,$162.00 ,$351.00 ,$388.80 ,$491.40 ,$405.00 
Carle BroMenn Medical Center,8648507,8'-30' SPEECH/AUDIO TREATMENT,,92507,472,$265.00 ,$265.00 ,$79.50 ,$241.15 ,$185.50 ,$79.50 ,$172.25 ,$190.80 ,$241.15 ,$198.75 
Carle BroMenn Medical Center,8648508,"45-60"" GROUP SPEECH",,92508,472,$87.00 ,$87.00 ,$26.10 ,$79.17 ,$60.90 ,$26.10 ,$56.55 ,$62.64 ,$79.17 ,$65.25 
Carle BroMenn Medical Center,8648630,"60-74"" AUD REHAB PRE-LING",,92630,472,$540.00 ,$540.00 ,$162.00 ,$491.40 ,$378.00 ,$162.00 ,$351.00 ,$388.80 ,$491.40 ,$405.00 
Carle BroMenn Medical Center,8649507,"30-44"" SPEECH/AUDIO TREATMENT",,92507,472,$265.00 ,$265.00 ,$79.50 ,$241.15 ,$185.50 ,$79.50 ,$172.25 ,$190.80 ,$241.15 ,$198.75 
Carle BroMenn Medical Center,8649508,"30-44"" GROUP SPEECH",,92508,472,$87.00 ,$87.00 ,$26.10 ,$79.17 ,$60.90 ,$26.10 ,$56.55 ,$62.64 ,$79.17 ,$65.25 
Carle BroMenn Medical Center,8649630,"75-89"" AUD REHAB PRE-LING",,92630,472,$540.00 ,$540.00 ,$162.00 ,$491.40 ,$378.00 ,$162.00 ,$351.00 ,$388.80 ,$491.40 ,$405.00 
Carle BroMenn Medical Center,8022960,CARDIOVERSION,,92960,480,"$1,590.00 ","$1,590.00 ",$477.00 ,"$1,446.90 ","$1,113.00 ",$477.00 ,"$1,033.50 ","$1,144.80 ","$1,446.90 ","$1,192.50 "
Carle BroMenn Medical Center,8023009,CARDIOVERSION,,,480,"$1,035.00 ","$1,035.00 ",$310.50 ,$941.85 ,$724.50 ,$310.50 ,$672.75 ,$745.20 ,$941.85 ,$776.25 
Carle BroMenn Medical Center,8220660,Inter devc remote 30d,,G2066,480,$37.00 ,$37.00 ,$11.10 ,$33.67 ,$25.90 ,$11.10 ,$24.05 ,$26.64 ,$33.67 ,$27.75 
Carle BroMenn Medical Center,8293260,PRGRMG DEV EVAL IMPLANTABLE SUBQ LEAD DFB SYSTEM,,93260,480,$125.00 ,$125.00 ,$37.50 ,$113.75 ,$87.50 ,$37.50 ,$81.25 ,$90.00 ,$113.75 ,$93.75 
Carle BroMenn Medical Center,8293261,INTERROGATION EVAL F2F IMPLANT SUBQ LEAD DEFIB,,93261,480,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8293264,REMOTE MNTR WIRELESS P-ART PRS SNR UP TO 30 D,,93264,480,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8293279,PROGRAM EVAL IMPLANTABLE IN PRSN 1 LD PACEMAKER,,93279,480,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8293280,PROGRAM EVAL IMPLANTABLE IN PERSN DUAL LD PACER,,93280,480,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8293281,PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER,,93281,480,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8293282,PROGRAM EVAL IMPLANTABLE IN PERSN 1 LD CARD/DFB,,93282,480,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8293283,PROGRM EVAL IMPLANTABLE IN PRSN DUAL L CARD/DFB,,93283,480,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8293284,PROGRM EVAL IMPLANTABLE IN PRSN MLT LD CARD/DFB,,93284,480,$125.00 ,$125.00 ,$37.50 ,$113.75 ,$87.50 ,$37.50 ,$81.25 ,$90.00 ,$113.75 ,$93.75 
Carle BroMenn Medical Center,8293285,PROGRAM EVAL IMPLANTABLE DEV IN PRSN ILR SYSTEM,,93285,480,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8293288,INTERROGATION EVAL IN PERSON 1/DUAL/MLT LEAD PM,,93288,480,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8293289,INTERROGATION EVAL F2F 1/DUAL/MLT LEADS CVDFB,,93289,480,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8293290,INTERROGATION EVAL F2F IMPLANTABLE CV MNTR SYS,,93290,480,$46.00 ,$46.00 ,$13.80 ,$41.86 ,$32.20 ,$13.80 ,$29.90 ,$33.12 ,$41.86 ,$34.50 
Carle BroMenn Medical Center,8293291,INTERROGATION EVALUATION IN PERSON ILR SYSTEM,,93291,480,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8293296,"INTERROG EVAL, REMOTE, UP TO 90 DAYS, PACER/DEFIB,TECH REVIEW",,93296,480,$175.00 ,$175.00 ,$52.50 ,$159.25 ,$122.50 ,$52.50 ,$113.75 ,$126.00 ,$159.25 ,$131.25 
Carle BroMenn Medical Center,8293299,"INTERROG EVAL, REMOTE, UP TO 90 DAYS, CV MON/LOOP REC,TECH REVIEW",,93299,480,$115.00 ,$115.00 ,$34.50 ,$104.65 ,$80.50 ,$34.50 ,$74.75 ,$82.80 ,$104.65 ,$86.25 
Carle BroMenn Medical Center,8293660,TILT TABLE EVALUATION,,93660,480,"$1,370.00 ","$1,370.00 ",$411.00 ,"$1,246.70 ",$959.00 ,$411.00 ,$890.50 ,$986.40 ,"$1,246.70 ","$1,027.50 "
Carle BroMenn Medical Center,8293750,INTRRGTN VAD IN PRSON W/PHYS/QHP ANALYSIS,,93750,480,$330.00 ,$330.00 ,$99.00 ,$300.30 ,$231.00 ,$99.00 ,$214.50 ,$237.60 ,$300.30 ,$247.50 
Carle BroMenn Medical Center,8293786,AMBULATORY BP MONTR; RECORDING,,93786,480,$995.00 ,$995.00 ,$298.50 ,$905.45 ,$696.50 ,$298.50 ,$646.75 ,$716.40 ,$905.45 ,$746.25 
Carle BroMenn Medical Center,8293788,AMBULATORY BP MONTR; SCANNING,,93788,480,$320.00 ,$320.00 ,$96.00 ,$291.20 ,$224.00 ,$96.00 ,$208.00 ,$230.40 ,$291.20 ,$240.00 
Carle BroMenn Medical Center,8400006,ECHO TTE CONG CARD ANOMALIES W/ CONTRAST,,C8921,480,"$1,005.00 ","$1,005.00 ",$301.50 ,$914.55 ,$703.50 ,$301.50 ,$653.25 ,$723.60 ,$914.55 ,$753.75 
Carle BroMenn Medical Center,8400007,ECHO TTE CONG ANOMALIES LMTD W/ CONTRAST,,C8922,480,$578.00 ,$578.00 ,$173.40 ,$525.98 ,$404.60 ,$173.40 ,$375.70 ,$416.16 ,$525.98 ,$433.50 
Carle BroMenn Medical Center,8400008,ECHO REAL TIME TRANSESOPH W/ CONTRAST,,C8925,480,"$2,355.00 ","$2,355.00 ",$706.50 ,"$2,143.05 ","$1,648.50 ",$706.50 ,"$1,530.75 ","$1,695.60 ","$2,143.05 ","$1,766.25 "
Carle BroMenn Medical Center,8400009,"TTE W/DOPPLER, COMPLETE W/ CONTRAST",,C8929,480,"$2,170.00 ","$2,170.00 ",$651.00 ,"$1,974.70 ","$1,519.00 ",$651.00 ,"$1,410.50 ","$1,562.40 ","$1,974.70 ","$1,627.50 "
Carle BroMenn Medical Center,8400010,ECHO STRESS TST W/CMPLT CV STRS TST W/ CONTRAST,,C8930,480,"$2,355.00 ","$2,355.00 ",$706.50 ,"$2,143.05 ","$1,648.50 ",$706.50 ,"$1,530.75 ","$1,695.60 ","$2,143.05 ","$1,766.25 "
Carle BroMenn Medical Center,8400011,"ECHO REAL-TIME, LIMITED W/ CONTRAST",,93308,480,$610.00 ,$610.00 ,$183.00 ,$555.10 ,$427.00 ,$183.00 ,$396.50 ,$439.20 ,$555.10 ,$457.50 
Carle BroMenn Medical Center,8400502,COR FFR DERIVED CTA DATA PREP & TRANSMIS,,0502T,480,"$1,120.00 ","$1,120.00 ",$336.00 ,"$1,019.20 ",$784.00 ,$336.00 ,$728.00 ,$806.40 ,"$1,019.20 ",$840.00 
Carle BroMenn Medical Center,8400503,COR FFR CTA DATA ALYS & GNRJ ESTIMATED FFR MODEL,,0503T,480,"$4,450.00 ","$4,450.00 ","$1,335.00 ","$4,049.50 ","$3,115.00 ","$1,335.00 ","$2,892.50 ","$3,204.00 ","$4,049.50 ","$3,337.50 "
Carle BroMenn Medical Center,8413325,DOPPLER VELOCITY MAPPING,,93325,480,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8492960,ELECTIVE CARDIO VERSION,,92960,480,"$1,590.00 ","$1,590.00 ",$477.00 ,"$1,446.90 ","$1,113.00 ",$477.00 ,"$1,033.50 ","$1,144.80 ","$1,446.90 ","$1,192.50 "
Carle BroMenn Medical Center,8493303,ECHO TTE CONG CARD ANOMALIES W/O CONTRAST,,93303,480,"$1,350.00 ","$1,350.00 ",$405.00 ,"$1,228.50 ",$945.00 ,$405.00 ,$877.50 ,$972.00 ,"$1,228.50 ","$1,012.50 "
Carle BroMenn Medical Center,8493304,ECHO TTE CONG ANOMALIES LMTD W/O CONTRAST,,93304,480,$970.00 ,$970.00 ,$291.00 ,$882.70 ,$679.00 ,$291.00 ,$630.50 ,$698.40 ,$882.70 ,$727.50 
Carle BroMenn Medical Center,8493306,"TTE W/DOPPLER, COMPLETE W/O CONTRAST",,93306,480,"$1,365.00 ","$1,365.00 ",$409.50 ,"$1,242.15 ",$955.50 ,$409.50 ,$887.25 ,$982.80 ,"$1,242.15 ","$1,023.75 "
Carle BroMenn Medical Center,8493307,ECHO REAL-TIME COMPLETE,,93307,480,"$1,200.00 ","$1,200.00 ",$360.00 ,"$1,092.00 ",$840.00 ,$360.00 ,$780.00 ,$864.00 ,"$1,092.00 ",$900.00 
Carle BroMenn Medical Center,8493308,"ECHO REAL-TIME, LIMITED W/O CONTRAST",,93308,480,$610.00 ,$610.00 ,$183.00 ,$555.10 ,$427.00 ,$183.00 ,$396.50 ,$439.20 ,$555.10 ,$457.50 
Carle BroMenn Medical Center,8493312,ECHO REAL TIME TRANSESOPH W/O CONTRAST,,93312,480,"$1,595.00 ","$1,595.00 ",$478.50 ,"$1,451.45 ","$1,116.50 ",$478.50 ,"$1,036.75 ","$1,148.40 ","$1,451.45 ","$1,196.25 "
Carle BroMenn Medical Center,8493313,ECHO TEE PROBE PLACEMENT,,93313,480,$990.00 ,$990.00 ,$297.00 ,$900.90 ,$693.00 ,$297.00 ,$643.50 ,$712.80 ,$900.90 ,$742.50 
Carle BroMenn Medical Center,8493314,TEE IMAGE ACQUISITION INTRP/RPRT,,93314,480,"$1,208.00 ","$1,208.00 ",$362.40 ,"$1,099.28 ",$845.60 ,$362.40 ,$785.20 ,$869.76 ,"$1,099.28 ",$906.00 
Carle BroMenn Medical Center,8493315,ECHO TEE CONG CARDIAC ANOMALY,,93315,480,"$1,433.00 ","$1,433.00 ",$429.90 ,"$1,304.03 ","$1,003.10 ",$429.90 ,$931.45 ,"$1,031.76 ","$1,304.03 ","$1,074.75 "
Carle BroMenn Medical Center,8493316,TEE PROBE PLC CONG CARDIAC ANOMALIES,,93316,480,$480.00 ,$480.00 ,$144.00 ,$436.80 ,$336.00 ,$144.00 ,$312.00 ,$345.60 ,$436.80 ,$360.00 
Carle BroMenn Medical Center,8493318,TEE-INTRAOP W/2D+CONT ASSMENT,,93318,480,"$1,230.00 ","$1,230.00 ",$369.00 ,"$1,119.30 ",$861.00 ,$369.00 ,$799.50 ,$885.60 ,"$1,119.30 ",$922.50 
Carle BroMenn Medical Center,8493320,DOPPLER ECHOCARDIO GRAPHY,,93320,480,$385.00 ,$385.00 ,$115.50 ,$350.35 ,$269.50 ,$115.50 ,$250.25 ,$277.20 ,$350.35 ,$288.75 
Carle BroMenn Medical Center,8493321,"DOPPLER ECHO, LIMITED",,93321,480,$165.00 ,$165.00 ,$49.50 ,$150.15 ,$115.50 ,$49.50 ,$107.25 ,$118.80 ,$150.15 ,$123.75 
Carle BroMenn Medical Center,8493325,DOPPLER VELOCITY MAPPING,,93325,480,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8493350,ECHO STRESS TEST,,93350,480,"$1,485.00 ","$1,485.00 ",$445.50 ,"$1,351.35 ","$1,039.50 ",$445.50 ,$965.25 ,"$1,069.20 ","$1,351.35 ","$1,113.75 "
Carle BroMenn Medical Center,8493351,ECHO STRESS TST W/CMPLT CV STRS TST W/O CONTRAST,,93351,480,"$2,250.00 ","$2,250.00 ",$675.00 ,"$2,047.50 ","$1,575.00 ",$675.00 ,"$1,462.50 ","$1,620.00 ","$2,047.50 ","$1,687.50 "
Carle BroMenn Medical Center,8493352,CONTRAST ADMIN,,93352,480,$473.00 ,$473.00 ,$141.90 ,$430.43 ,$331.10 ,$141.90 ,$307.45 ,$340.56 ,$430.43 ,$354.75 
Carle BroMenn Medical Center,8493660,TILT TABLE TESTING,,93660,480,"$1,370.00 ","$1,370.00 ",$411.00 ,"$1,246.70 ",$959.00 ,$411.00 ,$890.50 ,$986.40 ,"$1,246.70 ","$1,027.50 "
Carle BroMenn Medical Center,8730161,CARDIOVERSION,,,480,$810.00 ,$810.00 ,$243.00 ,$737.10 ,$567.00 ,$243.00 ,$526.50 ,$583.20 ,$737.10 ,$607.50 
Carle BroMenn Medical Center,8893308,"ECHO REAL-TIME, LIMITED",,93308,480,$610.00 ,$610.00 ,$183.00 ,$555.10 ,$427.00 ,$183.00 ,$396.50 ,$439.20 ,$555.10 ,$457.50 
Carle BroMenn Medical Center,8970950,CARDIOPULMONARY RESUSCITATION,,92950,480,"$1,445.00 ","$1,445.00 ",$433.50 ,"$1,314.95 ","$1,011.50 ",$433.50 ,$939.25 ,"$1,040.40 ","$1,314.95 ","$1,083.75 "
Carle BroMenn Medical Center,8970960,CARDIOVERSION,,92960,480,"$1,590.00 ","$1,590.00 ",$477.00 ,"$1,446.90 ","$1,113.00 ",$477.00 ,"$1,033.50 ","$1,144.80 ","$1,446.90 ","$1,192.50 "
Carle BroMenn Medical Center,8971282,IMPLANT CARDIAC EVENT RECORDER,,33282,480,"$5,288.00 ","$5,288.00 ","$1,586.40 ","$4,812.08 ","$3,701.60 ","$1,586.40 ","$3,437.20 ","$3,807.36 ","$4,812.08 ","$3,966.00 "
Carle BroMenn Medical Center,8971950,CARDIOPULMONARY RESUSCITATION,,92950,480,"$1,445.00 ","$1,445.00 ",$433.50 ,"$1,314.95 ","$1,011.50 ",$433.50 ,$939.25 ,"$1,040.40 ","$1,314.95 ","$1,083.75 "
Carle BroMenn Medical Center,8972950,CARDIOPULMONARY RESUSCITATION,,92950,480,"$1,445.00 ","$1,445.00 ",$433.50 ,"$1,314.95 ","$1,011.50 ",$433.50 ,$939.25 ,"$1,040.40 ","$1,314.95 ","$1,083.75 "
Carle BroMenn Medical Center,8972960,CARDIOVERSION,,92960,480,"$1,590.00 ","$1,590.00 ",$477.00 ,"$1,446.90 ","$1,113.00 ",$477.00 ,"$1,033.50 ","$1,144.80 ","$1,446.90 ","$1,192.50 "
Carle BroMenn Medical Center,8972961,"CARDIOVERSION, INTERNAL",,92961,480,"$1,735.00 ","$1,735.00 ",$520.50 ,"$1,578.85 ","$1,214.50 ",$520.50 ,"$1,127.75 ","$1,249.20 ","$1,578.85 ","$1,301.25 "
Carle BroMenn Medical Center,8972975,THROMBOLYSIS INTRAC INFUS,,92975,480,"$1,965.00 ","$1,965.00 ",$589.50 ,"$1,788.15 ","$1,375.50 ",$589.50 ,"$1,277.25 ","$1,414.80 ","$1,788.15 ","$1,473.75 "
Carle BroMenn Medical Center,8972977,THROMBOLYSIS-CORONARY-IV INFUS,,92977,480,$945.00 ,$945.00 ,$283.50 ,$859.95 ,$661.50 ,$283.50 ,$614.25 ,$680.40 ,$859.95 ,$708.75 
Carle BroMenn Medical Center,8972978,INTRAVAS ULTRASND-CORN-INITIAL,,92978,480,"$3,030.00 ","$3,030.00 ",$909.00 ,"$2,757.30 ","$2,121.00 ",$909.00 ,"$1,969.50 ","$2,181.60 ","$2,757.30 ","$2,272.50 "
Carle BroMenn Medical Center,8972979,INTRAVAS ULTRASND-CORONARY-ADD,,92979,480,"$1,740.00 ","$1,740.00 ",$522.00 ,"$1,583.40 ","$1,218.00 ",$522.00 ,"$1,131.00 ","$1,252.80 ","$1,583.40 ","$1,305.00 "
Carle BroMenn Medical Center,8972986,BALLOON VALVULOPLSTY -AORTIC,,92986,480,"$14,865.00 ","$14,865.00 ","$4,459.50 ","$13,527.15 ","$10,405.50 ","$4,459.50 ","$9,662.25 ","$10,702.80 ","$13,527.15 ","$11,148.75 "
Carle BroMenn Medical Center,8972987,BALLOON VALVULOPLSTY -MITRAL,,92987,480,"$12,893.00 ","$12,893.00 ","$3,867.90 ","$11,732.63 ","$9,025.10 ","$3,867.90 ","$8,380.45 ","$9,282.96 ","$11,732.63 ","$9,669.75 "
Carle BroMenn Medical Center,8972990,BALLOON VALVULOPLSTY -PULMNRY,,92990,480,"$10,140.00 ","$10,140.00 ","$3,042.00 ","$9,227.40 ","$7,098.00 ","$3,042.00 ","$6,591.00 ","$7,300.80 ","$9,227.40 ","$7,605.00 "
Carle BroMenn Medical Center,8972992,"ATRIAL SEPTECTOMY/OSTOMY, TRNSVNS, BALLOON",,92992,480,"$11,850.00 ","$11,850.00 ","$3,555.00 ","$10,783.50 ","$8,295.00 ","$3,555.00 ","$7,702.50 ","$8,532.00 ","$10,783.50 ","$8,887.50 "
Carle BroMenn Medical Center,8972993,"ATRIAL SEPTECTOMY/OSTOMY, BLADE METHOD",,92993,480,"$10,673.00 ","$10,673.00 ","$3,201.90 ","$9,712.43 ","$7,471.10 ","$3,201.90 ","$6,937.45 ","$7,684.56 ","$9,712.43 ","$8,004.75 "
Carle BroMenn Medical Center,8972997,PULM ART ANGIOPLASTY SNGL VSL,,92997,480,"$10,080.00 ","$10,080.00 ","$3,024.00 ","$9,172.80 ","$7,056.00 ","$3,024.00 ","$6,552.00 ","$7,257.60 ","$9,172.80 ","$7,560.00 "
Carle BroMenn Medical Center,8972998,PULM ART ANGIOPLASTY ADNL VSL,,92998,480,"$5,655.00 ","$5,655.00 ","$1,696.50 ","$5,146.05 ","$3,958.50 ","$1,696.50 ","$3,675.75 ","$4,071.60 ","$5,146.05 ","$4,241.25 "
Carle BroMenn Medical Center,8973271,INSJ OF SUBQ IMPLANTABLE DEFIBRILLATOR ELECTRODE,,33271,480,"$21,893.00 ","$21,893.00 ","$6,567.90 ","$19,922.63 ","$15,325.10 ","$6,567.90 ","$14,230.45 ","$15,762.96 ","$19,922.63 ","$16,419.75 "
Carle BroMenn Medical Center,8973272,REMOVAL OF SUBQ IMPLANTABLE DEFIBRILLATOR ELECTRODE,,33272,480,"$6,218.00 ","$6,218.00 ","$1,865.40 ","$5,658.38 ","$4,352.60 ","$1,865.40 ","$4,041.70 ","$4,476.96 ","$5,658.38 ","$4,663.50 "
Carle BroMenn Medical Center,8973282,IMPLANT CARDIAC EVENT RECORDER,,33282,480,"$5,288.00 ","$5,288.00 ","$1,586.40 ","$4,812.08 ","$3,701.60 ","$1,586.40 ","$3,437.20 ","$3,807.36 ","$4,812.08 ","$3,966.00 "
Carle BroMenn Medical Center,8973284,CARDIAC EVENT RECORDR REMOVAL,,33284,480,"$2,235.00 ","$2,235.00 ",$670.50 ,"$2,033.85 ","$1,564.50 ",$670.50 ,"$1,452.75 ","$1,609.20 ","$2,033.85 ","$1,676.25 "
Carle BroMenn Medical Center,8973285,INSERTION SUBQ CARDIAC RHYTHM MONITOR W/PRGRMG,,33285,480,"$15,186.00 ","$15,186.00 ","$4,555.80 ","$13,819.26 ","$10,630.20 ","$4,555.80 ","$9,870.90 ","$10,933.92 ","$13,819.26 ","$11,389.50 "
Carle BroMenn Medical Center,8973286,PERI-PROC PACEMAKER EVAL,,93286,480,$98.00 ,$98.00 ,$29.40 ,$89.18 ,$68.60 ,$29.40 ,$63.70 ,$70.56 ,$89.18 ,$73.50 
Carle BroMenn Medical Center,8973287,PERI-PROC ICD EVAL,,93287,480,$109.00 ,$109.00 ,$32.70 ,$99.19 ,$76.30 ,$32.70 ,$70.85 ,$78.48 ,$99.19 ,$81.75 
Carle BroMenn Medical Center,8973308,"ECHO REAL-TIME, LIMITED",,93308,480,$610.00 ,$610.00 ,$183.00 ,$555.10 ,$427.00 ,$183.00 ,$396.50 ,$439.20 ,$555.10 ,$457.50 
Carle BroMenn Medical Center,8973318,TEE-INTRAOP W/2D+CONT ASSMENT,,93318,480,"$1,230.00 ","$1,230.00 ",$369.00 ,"$1,119.30 ",$861.00 ,$369.00 ,$799.50 ,$885.60 ,"$1,119.30 ",$922.50 
Carle BroMenn Medical Center,8973327,INSRTN SUBQ IMPLNT DEFIB SYSTM,,33270,480,"$48,045.00 ","$48,045.00 ","$14,413.50 ","$43,720.95 ","$33,631.50 ","$14,413.50 ","$31,229.25 ","$34,592.40 ","$43,720.95 ","$36,033.75 "
Carle BroMenn Medical Center,8973328,REMOVAL SUBCUTANEOUS CARDIAC RHYTHM MONITOR,,33286,480,"$1,455.00 ","$1,455.00 ",$436.50 ,"$1,324.05 ","$1,018.50 ",$436.50 ,$945.75 ,"$1,047.60 ","$1,324.05 ","$1,091.25 "
Carle BroMenn Medical Center,8973571,INTRAVASC DOPPLER INIT VESSEL,,93571,480,"$3,173.00 ","$3,173.00 ",$951.90 ,"$2,887.43 ","$2,221.10 ",$951.90 ,"$2,062.45 ","$2,284.56 ","$2,887.43 ","$2,379.75 "
Carle BroMenn Medical Center,8973572,INTRAVASC DOPPLER ADNL VESSEL,,93572,480,"$1,830.00 ","$1,830.00 ",$549.00 ,"$1,665.30 ","$1,281.00 ",$549.00 ,"$1,189.50 ","$1,317.60 ","$1,665.30 ","$1,372.50 "
Carle BroMenn Medical Center,8973602,INTRA-ARTERIAL RECORDING,,93602,480,"$4,110.00 ","$4,110.00 ","$1,233.00 ","$3,740.10 ","$2,877.00 ","$1,233.00 ","$2,671.50 ","$2,959.20 ","$3,740.10 ","$3,082.50 "
Carle BroMenn Medical Center,8973603,RT VENTRICULAR RECORDING,,93603,480,"$3,540.00 ","$3,540.00 ","$1,062.00 ","$3,221.40 ","$2,478.00 ","$1,062.00 ","$2,301.00 ","$2,548.80 ","$3,221.40 ","$2,655.00 "
Carle BroMenn Medical Center,8973609,MAPPING OF TACHY/MULTI,,93609,480,"$5,550.00 ","$5,550.00 ","$1,665.00 ","$5,050.50 ","$3,885.00 ","$1,665.00 ","$3,607.50 ","$3,996.00 ","$5,050.50 ","$4,162.50 "
Carle BroMenn Medical Center,8973610,INTRA-ARTERIAL PACING,,93610,480,"$4,110.00 ","$4,110.00 ","$1,233.00 ","$3,740.10 ","$2,877.00 ","$1,233.00 ","$2,671.50 ","$2,959.20 ","$3,740.10 ","$3,082.50 "
Carle BroMenn Medical Center,8973612,INTRAVENTRICULAR PACING,,93612,480,"$4,110.00 ","$4,110.00 ","$1,233.00 ","$3,740.10 ","$2,877.00 ","$1,233.00 ","$2,671.50 ","$2,959.20 ","$3,740.10 ","$3,082.50 "
Carle BroMenn Medical Center,8973613,INTRACARDIAC EP 3D MAPPING,,93613,480,"$7,215.00 ","$7,215.00 ","$2,164.50 ","$6,565.65 ","$5,050.50 ","$2,164.50 ","$4,689.75 ","$5,194.80 ","$6,565.65 ","$5,411.25 "
Carle BroMenn Medical Center,8973615,ESOPHAGEAL ATRIAL ECG,,93615,480,"$2,483.00 ","$2,483.00 ",$744.90 ,"$2,259.53 ","$1,738.10 ",$744.90 ,"$1,613.95 ","$1,787.76 ","$2,259.53 ","$1,862.25 "
Carle BroMenn Medical Center,8973616,ESOPH ATRIAL ECG W/PACING,,93616,480,"$3,315.00 ","$3,315.00 ",$994.50 ,"$3,016.65 ","$2,320.50 ",$994.50 ,"$2,154.75 ","$2,386.80 ","$3,016.65 ","$2,486.25 "
Carle BroMenn Medical Center,8973618,INDUCT ARRYTH ELEC PACING,,93618,480,"$3,413.00 ","$3,413.00 ","$1,023.90 ","$3,105.83 ","$2,389.10 ","$1,023.90 ","$2,218.45 ","$2,457.36 ","$3,105.83 ","$2,559.75 "
Carle BroMenn Medical Center,8973619,COMPREHENSIVE EP EVAL,,93619,480,"$11,858.00 ","$11,858.00 ","$3,557.40 ","$10,790.78 ","$8,300.60 ","$3,557.40 ","$7,707.70 ","$8,537.76 ","$10,790.78 ","$8,893.50 "
Carle BroMenn Medical Center,8973620,INTRACARDIAC EP EVAL,,93620,480,"$13,155.00 ","$13,155.00 ","$3,946.50 ","$11,971.05 ","$9,208.50 ","$3,946.50 ","$8,550.75 ","$9,471.60 ","$11,971.05 ","$9,866.25 "
Carle BroMenn Medical Center,8973621,COMP INTRACARDIAC EP EVAL,,93621,480,"$7,103.00 ","$7,103.00 ","$2,130.90 ","$6,463.73 ","$4,972.10 ","$2,130.90 ","$4,616.95 ","$5,114.16 ","$6,463.73 ","$5,327.25 "
Carle BroMenn Medical Center,8973622,LEFT VENTRICULAR PACE & RECORD,,93622,480,"$6,900.00 ","$6,900.00 ","$2,070.00 ","$6,279.00 ","$4,830.00 ","$2,070.00 ","$4,485.00 ","$4,968.00 ","$6,279.00 ","$5,175.00 "
Carle BroMenn Medical Center,8973623,POST INFUS STIMU/PACING,,93623,480,"$3,938.00 ","$3,938.00 ","$1,181.40 ","$3,583.58 ","$2,756.60 ","$1,181.40 ","$2,559.70 ","$2,835.36 ","$3,583.58 ","$2,953.50 "
Carle BroMenn Medical Center,8973624,EP F/U STUDY W/PAC & REC,,93624,480,"$4,343.00 ","$4,343.00 ","$1,302.90 ","$3,952.13 ","$3,040.10 ","$1,302.90 ","$2,822.95 ","$3,126.96 ","$3,952.13 ","$3,257.25 "
Carle BroMenn Medical Center,8973640,EP EVAL PCG ICD LDS & GENERATR,,93640,480,"$2,565.00 ","$2,565.00 ",$769.50 ,"$2,334.15 ","$1,795.50 ",$769.50 ,"$1,667.25 ","$1,846.80 ","$2,334.15 ","$1,923.75 "
Carle BroMenn Medical Center,8973641,EP EVAL PCG ICD LEADS&GENERATR,,93641,480,"$2,280.00 ","$2,280.00 ",$684.00 ,"$2,074.80 ","$1,596.00 ",$684.00 ,"$1,482.00 ","$1,641.60 ","$2,074.80 ","$1,710.00 "
Carle BroMenn Medical Center,8973642,EP EVAL CARDIOVRT/DEFIB,,93642,480,"$1,800.00 ","$1,800.00 ",$540.00 ,"$1,638.00 ","$1,260.00 ",$540.00 ,"$1,170.00 ","$1,296.00 ","$1,638.00 ","$1,350.00 "
Carle BroMenn Medical Center,8973650,INTRACARDIAC CATH ABLATN,,93650,480,"$12,090.00 ","$12,090.00 ","$3,627.00 ","$11,001.90 ","$8,463.00 ","$3,627.00 ","$7,858.50 ","$8,704.80 ","$11,001.90 ","$9,067.50 "
Carle BroMenn Medical Center,8973653,COMP EP EVAL W/ABLATION FOR SVT,,93653,480,"$21,008.00 ","$21,008.00 ","$6,302.40 ","$19,117.28 ","$14,705.60 ","$6,302.40 ","$13,655.20 ","$15,125.76 ","$19,117.28 ","$15,756.00 "
Carle BroMenn Medical Center,8973654,COMP EP EVAL W/ABLATION FOR V-TACH,,93654,480,"$35,903.00 ","$35,903.00 ","$10,770.90 ","$32,671.73 ","$25,132.10 ","$10,770.90 ","$23,336.95 ","$25,850.16 ","$32,671.73 ","$26,927.25 "
Carle BroMenn Medical Center,8973655,ABLATION OF ADDITIONAL ARRHYTHMIA,,93655,480,"$8,625.00 ","$8,625.00 ","$2,587.50 ","$7,848.75 ","$6,037.50 ","$2,587.50 ","$5,606.25 ","$6,210.00 ","$7,848.75 ","$6,468.75 "
Carle BroMenn Medical Center,8973656,COMP EP EVAL W/ABLATION FOR A-FIB,,93656,480,"$25,905.00 ","$25,905.00 ","$7,771.50 ","$23,573.55 ","$18,133.50 ","$7,771.50 ","$16,838.25 ","$18,651.60 ","$23,573.55 ","$19,428.75 "
Carle BroMenn Medical Center,8973657,ADDITIONAL ABLATION FOR A-FIB,,93657,480,"$5,790.00 ","$5,790.00 ","$1,737.00 ","$5,268.90 ","$4,053.00 ","$1,737.00 ","$3,763.50 ","$4,168.80 ","$5,268.90 ","$4,342.50 "
Carle BroMenn Medical Center,8973662,INTRACARDIAC ECHOCARDIOGRAPHY,,93662,480,"$3,098.00 ","$3,098.00 ",$929.40 ,"$2,819.18 ","$2,168.60 ",$929.40 ,"$2,013.70 ","$2,230.56 ","$2,819.18 ","$2,323.50 "
Carle BroMenn Medical Center,8973960,CARDIOVERSION,,92960,480,"$1,590.00 ","$1,590.00 ",$477.00 ,"$1,446.90 ","$1,113.00 ",$477.00 ,"$1,033.50 ","$1,144.80 ","$1,446.90 ","$1,192.50 "
Carle BroMenn Medical Center,8979600,BUNDLE OF HIS RECORDING,,93600,480,"$4,118.00 ","$4,118.00 ","$1,235.40 ","$3,747.38 ","$2,882.60 ","$1,235.40 ","$2,676.70 ","$2,964.96 ","$3,747.38 ","$3,088.50 "
Carle BroMenn Medical Center,8970128,DE CORONARY STENT PLACEMENT - 1 VSL,,C9600,481,"$10,763.00 ","$10,763.00 ","$3,228.90 ","$9,794.33 ","$7,534.10 ","$3,228.90 ","$6,995.95 ","$7,749.36 ","$9,794.33 ","$8,072.25 "
Carle BroMenn Medical Center,8970129,DE CORONARY STENT PLACEMNT - EA ADNL VSL,,C9601,481,"$6,315.00 ","$6,315.00 ","$1,894.50 ","$5,746.65 ","$4,420.50 ","$1,894.50 ","$4,104.75 ","$4,546.80 ","$5,746.65 ","$4,736.25 "
Carle BroMenn Medical Center,8970133,DE COR ATHERECTMY W/STENT - 1 VSL,,C9602,481,"$20,385.00 ","$20,385.00 ","$6,115.50 ","$18,550.35 ","$14,269.50 ","$6,115.50 ","$13,250.25 ","$14,677.20 ","$18,550.35 ","$15,288.75 "
Carle BroMenn Medical Center,8970134,DE COR ATHERECTMY W/STENT - EA ADNL VSL,,C9603,481,"$11,400.00 ","$11,400.00 ","$3,420.00 ","$10,374.00 ","$7,980.00 ","$3,420.00 ","$7,410.00 ","$8,208.00 ","$10,374.00 ","$8,550.00 "
Carle BroMenn Medical Center,8970137,DE COR GRAFT ATHRCTMY W/STENT - 1 VSL,,C9604,481,"$29,730.00 ","$29,730.00 ","$8,919.00 ","$27,054.30 ","$20,811.00 ","$8,919.00 ","$19,324.50 ","$21,405.60 ","$27,054.30 ","$22,297.50 "
Carle BroMenn Medical Center,8970138,DE COR GRAFT ATHRCTMY W/STENT - EA ADNL VSL,,C9605,481,"$11,775.00 ","$11,775.00 ","$3,532.50 ","$10,715.25 ","$8,242.50 ","$3,532.50 ","$7,653.75 ","$8,478.00 ","$10,715.25 ","$8,831.25 "
Carle BroMenn Medical Center,8970141,DE REVASC ACUTE OCCLUSN DURING ACUTE MI,,C9606,481,"$22,913.00 ","$22,913.00 ","$6,873.90 ","$20,850.83 ","$16,039.10 ","$6,873.90 ","$14,893.45 ","$16,497.36 ","$20,850.83 ","$17,184.75 "
Carle BroMenn Medical Center,8970143,DE REVASC CHRONIC TOTAL OCCLUSN - 1 VSL,,C9607,481,"$23,048.00 ","$23,048.00 ","$6,914.40 ","$20,973.68 ","$16,133.60 ","$6,914.40 ","$14,981.20 ","$16,594.56 ","$20,973.68 ","$17,286.00 "
Carle BroMenn Medical Center,8970144,DE REVASC CHRON TOT OCCLUSN - EA ADNL VSL,,C9608,481,"$11,775.00 ","$11,775.00 ","$3,532.50 ","$10,715.25 ","$8,242.50 ","$3,532.50 ","$7,653.75 ","$8,478.00 ","$10,715.25 ","$8,831.25 "
Carle BroMenn Medical Center,8970145,IMPL PRESSURE SENSOR W/ANGIO,,C9741,481,"$53,588.00 ","$53,588.00 ","$16,076.40 ","$48,765.08 ","$37,511.60 ","$16,076.40 ","$34,832.20 ","$38,583.36 ","$48,765.08 ","$40,191.00 "
Carle BroMenn Medical Center,8972920,CORONARY ANGIOPLASTY - 1 VSL,,92920,481,"$14,535.00 ","$14,535.00 ","$4,360.50 ","$13,226.85 ","$10,174.50 ","$4,360.50 ","$9,447.75 ","$10,465.20 ","$13,226.85 ","$10,901.25 "
Carle BroMenn Medical Center,8972921,CORONARY ANGIOPLASTY - EA ADNL VSL,,92921,481,"$5,070.00 ","$5,070.00 ","$1,521.00 ","$4,613.70 ","$3,549.00 ","$1,521.00 ","$3,295.50 ","$3,650.40 ","$4,613.70 ","$3,802.50 "
Carle BroMenn Medical Center,8972924,CORONARY ATHERECTOMY - 1 VSL,,92924,481,"$9,975.00 ","$9,975.00 ","$2,992.50 ","$9,077.25 ","$6,982.50 ","$2,992.50 ","$6,483.75 ","$7,182.00 ","$9,077.25 ","$7,481.25 "
Carle BroMenn Medical Center,8972925,CORONARY ATHERECTOMY - EA ADNL VSL,,92925,481,"$6,345.00 ","$6,345.00 ","$1,903.50 ","$5,773.95 ","$4,441.50 ","$1,903.50 ","$4,124.25 ","$4,568.40 ","$5,773.95 ","$4,758.75 "
Carle BroMenn Medical Center,8972928,CORONARY STENT PLACEMENT - 1 VSL,,92928,481,"$10,763.00 ","$10,763.00 ","$3,228.90 ","$9,794.33 ","$7,534.10 ","$3,228.90 ","$6,995.95 ","$7,749.36 ","$9,794.33 ","$8,072.25 "
Carle BroMenn Medical Center,8972929,CORONARY STENT PLACEMNT - EA ADNL VSL,,92929,481,"$5,280.00 ","$5,280.00 ","$1,584.00 ","$4,804.80 ","$3,696.00 ","$1,584.00 ","$3,432.00 ","$3,801.60 ","$4,804.80 ","$3,960.00 "
Carle BroMenn Medical Center,8972933,COR ATHERECTMY W/STENT - 1 VSL,,92933,481,"$21,450.00 ","$21,450.00 ","$6,435.00 ","$19,519.50 ","$15,015.00 ","$6,435.00 ","$13,942.50 ","$15,444.00 ","$19,519.50 ","$16,087.50 "
Carle BroMenn Medical Center,8972934,COR ATHERECTMY W/STENT - EA ADNL VSL,,92934,481,"$11,400.00 ","$11,400.00 ","$3,420.00 ","$10,374.00 ","$7,980.00 ","$3,420.00 ","$7,410.00 ","$8,208.00 ","$10,374.00 ","$8,550.00 "
Carle BroMenn Medical Center,8972937,COR GRAFT ATHRCTMY W/STENT - 1 VSL,,92937,481,"$29,730.00 ","$29,730.00 ","$8,919.00 ","$27,054.30 ","$20,811.00 ","$8,919.00 ","$19,324.50 ","$21,405.60 ","$27,054.30 ","$22,297.50 "
Carle BroMenn Medical Center,8972938,COR GRAFT ATHRCTMY W/STENT - EA ADNL VSL,,92938,481,"$11,400.00 ","$11,400.00 ","$3,420.00 ","$10,374.00 ","$7,980.00 ","$3,420.00 ","$7,410.00 ","$8,208.00 ","$10,374.00 ","$8,550.00 "
Carle BroMenn Medical Center,8972941,REVASC ACUTE OCCLUSN DURING ACUTE MI,,92941,481,"$23,048.00 ","$23,048.00 ","$6,914.40 ","$20,973.68 ","$16,133.60 ","$6,914.40 ","$14,981.20 ","$16,594.56 ","$20,973.68 ","$17,286.00 "
Carle BroMenn Medical Center,8972943,REVASC CHRONIC TOTAL OCCLUSN - 1 VSL,,92943,481,"$29,730.00 ","$29,730.00 ","$8,919.00 ","$27,054.30 ","$20,811.00 ","$8,919.00 ","$19,324.50 ","$21,405.60 ","$27,054.30 ","$22,297.50 "
Carle BroMenn Medical Center,8972944,REVASC CHRON TOT OCCLUSN - EA ADNL VSL,,92944,481,"$11,400.00 ","$11,400.00 ","$3,420.00 ","$10,374.00 ","$7,980.00 ","$3,420.00 ","$7,410.00 ","$8,208.00 ","$10,374.00 ","$8,550.00 "
Carle BroMenn Medical Center,8972973,PERC TRNSLUMNL CORNRY THRMBECT,,92973,481,"$2,558.00 ","$2,558.00 ",$767.40 ,"$2,327.78 ","$1,790.60 ",$767.40 ,"$1,662.70 ","$1,841.76 ","$2,327.78 ","$1,918.50 "
Carle BroMenn Medical Center,8972974,CATH PLC COR INTRVASC BRACHYTX,,92974,481,"$6,128.00 ","$6,128.00 ","$1,838.40 ","$5,576.48 ","$4,289.60 ","$1,838.40 ","$3,983.20 ","$4,412.16 ","$5,576.48 ","$4,596.00 "
Carle BroMenn Medical Center,8973361,TRNSCATH AORTIC VALVE RPLCMNT -PERC,,33361,481,"$10,328.00 ","$10,328.00 ","$3,098.40 ","$9,398.48 ","$7,229.60 ","$3,098.40 ","$6,713.20 ","$7,436.16 ","$9,398.48 ","$7,746.00 "
Carle BroMenn Medical Center,8973451,RIGHT HEART CATHETERIZATION,,93451,481,"$8,430.00 ","$8,430.00 ","$2,529.00 ","$7,671.30 ","$5,901.00 ","$2,529.00 ","$5,479.50 ","$6,069.60 ","$7,671.30 ","$6,322.50 "
Carle BroMenn Medical Center,8973452,LEFT HEART CATHETERIZATION,,93452,481,"$9,075.00 ","$9,075.00 ","$2,722.50 ","$8,258.25 ","$6,352.50 ","$2,722.50 ","$5,898.75 ","$6,534.00 ","$8,258.25 ","$6,806.25 "
Carle BroMenn Medical Center,8973453,COMBINED RT & LT HEART CATH,,93453,481,"$9,848.00 ","$9,848.00 ","$2,954.40 ","$8,961.68 ","$6,893.60 ","$2,954.40 ","$6,401.20 ","$7,090.56 ","$8,961.68 ","$7,386.00 "
Carle BroMenn Medical Center,8973454,CORONARY ANGIOGRAPHY,,93454,481,"$8,550.00 ","$8,550.00 ","$2,565.00 ","$7,780.50 ","$5,985.00 ","$2,565.00 ","$5,557.50 ","$6,156.00 ","$7,780.50 ","$6,412.50 "
Carle BroMenn Medical Center,8973455,CORONARY & GRAFT(S) ANGIOGRPHY,,93455,481,"$8,768.00 ","$8,768.00 ","$2,630.40 ","$7,978.88 ","$6,137.60 ","$2,630.40 ","$5,699.20 ","$6,312.96 ","$7,978.88 ","$6,576.00 "
Carle BroMenn Medical Center,8973456,RT HEART CATH W/COR ANGIOGRPHY,,93456,481,"$8,550.00 ","$8,550.00 ","$2,565.00 ","$7,780.50 ","$5,985.00 ","$2,565.00 ","$5,557.50 ","$6,156.00 ","$7,780.50 ","$6,412.50 "
Carle BroMenn Medical Center,8973457,RT HEART W/COR&GRFT ANGIOGRPHY,,93457,481,"$10,118.00 ","$10,118.00 ","$3,035.40 ","$9,207.38 ","$7,082.60 ","$3,035.40 ","$6,576.70 ","$7,284.96 ","$9,207.38 ","$7,588.50 "
Carle BroMenn Medical Center,8973458,LT HEART CATH W/COR ANGIOGRPHY,,93458,481,"$11,678.00 ","$11,678.00 ","$3,503.40 ","$10,626.98 ","$8,174.60 ","$3,503.40 ","$7,590.70 ","$8,408.16 ","$10,626.98 ","$8,758.50 "
Carle BroMenn Medical Center,8973459,LT HEART W/COR&GRFT ANGIOGRPHY,,93459,481,"$13,508.00 ","$13,508.00 ","$4,052.40 ","$12,292.28 ","$9,455.60 ","$4,052.40 ","$8,780.20 ","$9,725.76 ","$12,292.28 ","$10,131.00 "
Carle BroMenn Medical Center,8973460,RT/LT HEART W/COR ANGIOGRPHY,,93460,481,"$12,893.00 ","$12,893.00 ","$3,867.90 ","$11,732.63 ","$9,025.10 ","$3,867.90 ","$8,380.45 ","$9,282.96 ","$11,732.63 ","$9,669.75 "
Carle BroMenn Medical Center,8973461,RT/LT HRT W/COR&GRFT ANGIOGRPH,,93461,481,"$14,723.00 ","$14,723.00 ","$4,416.90 ","$13,397.93 ","$10,306.10 ","$4,416.90 ","$9,569.95 ","$10,600.56 ","$13,397.93 ","$11,042.25 "
Carle BroMenn Medical Center,8973462,TRANSSEPTAL/APICAL PUNCTURE,,93462,481,"$2,430.00 ","$2,430.00 ",$729.00 ,"$2,211.30 ","$1,701.00 ",$729.00 ,"$1,579.50 ","$1,749.60 ","$2,211.30 ","$1,822.50 "
Carle BroMenn Medical Center,8973463,PHARM ADMIN FOR HEMODYNAMICS,,93463,481,"$1,470.00 ","$1,470.00 ",$441.00 ,"$1,337.70 ","$1,029.00 ",$441.00 ,$955.50 ,"$1,058.40 ","$1,337.70 ","$1,102.50 "
Carle BroMenn Medical Center,8973503,INSERT FLOW-DIRECTED CATH,,93503,481,"$2,348.00 ","$2,348.00 ",$704.40 ,"$2,136.68 ","$1,643.60 ",$704.40 ,"$1,526.20 ","$1,690.56 ","$2,136.68 ","$1,761.00 "
Carle BroMenn Medical Center,8973505,ENDOMYOCARDIAL BX,,93505,481,"$2,235.00 ","$2,235.00 ",$670.50 ,"$2,033.85 ","$1,564.50 ",$670.50 ,"$1,452.75 ","$1,609.20 ","$2,033.85 ","$1,676.25 "
Carle BroMenn Medical Center,8973530,RT HEART CATH-CONGENITAL ANOMA,,93530,481,"$4,388.00 ","$4,388.00 ","$1,316.40 ","$3,993.08 ","$3,071.60 ","$1,316.40 ","$2,852.20 ","$3,159.36 ","$3,993.08 ","$3,291.00 "
Carle BroMenn Medical Center,8973531,LT/RT HEART CATH-CONGENITAL AN,,93531,481,"$8,108.00 ","$8,108.00 ","$2,432.40 ","$7,378.28 ","$5,675.60 ","$2,432.40 ","$5,270.20 ","$5,837.76 ","$7,378.28 ","$6,081.00 "
Carle BroMenn Medical Center,8973532,COMB RT/LT TRSP LT CATH-CONG A,,93532,481,"$7,853.00 ","$7,853.00 ","$2,355.90 ","$7,146.23 ","$5,497.10 ","$2,355.90 ","$5,104.45 ","$5,654.16 ","$7,146.23 ","$5,889.75 "
Carle BroMenn Medical Center,8973533,COMB RT/LT EXIST SPTL CATH-CON,,93533,481,"$6,990.00 ","$6,990.00 ","$2,097.00 ","$6,360.90 ","$4,893.00 ","$2,097.00 ","$4,543.50 ","$5,032.80 ","$6,360.90 ","$5,242.50 "
Carle BroMenn Medical Center,8973563,CORONARY ANGIOGRAPHY,,93563,481,"$3,060.00 ","$3,060.00 ",$918.00 ,"$2,784.60 ","$2,142.00 ",$918.00 ,"$1,989.00 ","$2,203.20 ","$2,784.60 ","$2,295.00 "
Carle BroMenn Medical Center,8973564,COR BYPASS GRFT(S) ANGIOGRPHY,,93564,481,"$3,488.00 ","$3,488.00 ","$1,046.40 ","$3,174.08 ","$2,441.60 ","$1,046.40 ","$2,267.20 ","$2,511.36 ","$3,174.08 ","$2,616.00 "
Carle BroMenn Medical Center,8973565,LT ATRIAL/VENTRICLE ANGIOGRPHY,,93565,481,"$2,115.00 ","$2,115.00 ",$634.50 ,"$1,924.65 ","$1,480.50 ",$634.50 ,"$1,374.75 ","$1,522.80 ","$1,924.65 ","$1,586.25 "
Carle BroMenn Medical Center,8973566,RT ATRIAL/VENTRICLE ANGIOGRPHY,,93566,481,"$1,845.00 ","$1,845.00 ",$553.50 ,"$1,678.95 ","$1,291.50 ",$553.50 ,"$1,199.25 ","$1,328.40 ","$1,678.95 ","$1,383.75 "
Carle BroMenn Medical Center,8973567,SUPRAVALVULAR AORTOGRAPHY,,93567,481,"$2,273.00 ","$2,273.00 ",$681.90 ,"$2,068.43 ","$1,591.10 ",$681.90 ,"$1,477.45 ","$1,636.56 ","$2,068.43 ","$1,704.75 "
Carle BroMenn Medical Center,8973568,PULOMONARY ANGIOGRAPHY,,93568,481,"$2,415.00 ","$2,415.00 ",$724.50 ,"$2,197.65 ","$1,690.50 ",$724.50 ,"$1,569.75 ","$1,738.80 ","$2,197.65 ","$1,811.25 "
Carle BroMenn Medical Center,8973580,TRANSCATHETER CLOSURE OF ASD,,93580,481,"$13,478.00 ","$13,478.00 ","$4,043.40 ","$12,264.98 ","$9,434.60 ","$4,043.40 ","$8,760.70 ","$9,704.16 ","$12,264.98 ","$10,108.50 "
Carle BroMenn Medical Center,8973581,TRANSCATHETER CLOSURE OF VSD,,93581,481,"$12,000.00 ","$12,000.00 ","$3,600.00 ","$10,920.00 ","$8,400.00 ","$3,600.00 ","$7,800.00 ","$8,640.00 ","$10,920.00 ","$9,000.00 "
Carle BroMenn Medical Center,8973582,PERQ TRANSCATH CLOSURE PDA,,93582,481,"$30,263.00 ","$30,263.00 ","$9,078.90 ","$27,539.33 ","$21,184.10 ","$9,078.90 ","$19,670.95 ","$21,789.36 ","$27,539.33 ","$22,697.25 "
Carle BroMenn Medical Center,8973583,PERQ TRANSCATH SEPTAL REDUCTN TX,,93583,481,"$33,668.00 ","$33,668.00 ","$10,100.40 ","$30,637.88 ","$23,567.60 ","$10,100.40 ","$21,884.20 ","$24,240.96 ","$30,637.88 ","$25,251.00 "
Carle BroMenn Medical Center,8973591,PERQ TRANSCATH CLS PARAVALVR LEAK 1 AORTIC VALVE,,93591,481,"$44,895.00 ","$44,895.00 ","$13,468.50 ","$40,854.45 ","$31,426.50 ","$13,468.50 ","$29,181.75 ","$32,324.40 ","$40,854.45 ","$33,671.25 "
Carle BroMenn Medical Center,8973967,PERCUT INSERTION IABC,,33967,481,"$2,160.00 ","$2,160.00 ",$648.00 ,"$1,965.60 ","$1,512.00 ",$648.00 ,"$1,404.00 ","$1,555.20 ","$1,965.60 ","$1,620.00 "
Carle BroMenn Medical Center,8973968,PERCUTANEOUS REMOVAL IABP,,33968,481,$668.00 ,$668.00 ,$200.40 ,$607.88 ,$467.60 ,$200.40 ,$434.20 ,$480.96 ,$607.88 ,$501.00 
Carle BroMenn Medical Center,8973990,PERC INSRTN VENT ASSIST DVC -ART ONLY,,33990,481,"$13,253.00 ","$13,253.00 ","$3,975.90 ","$12,060.23 ","$9,277.10 ","$3,975.90 ","$8,614.45 ","$9,542.16 ","$12,060.23 ","$9,939.75 "
Carle BroMenn Medical Center,8973991,PERC INSRTN VENT ASSIST DVC -ART & VEN,,33991,481,"$17,438.00 ","$17,438.00 ","$5,231.40 ","$15,868.58 ","$12,206.60 ","$5,231.40 ","$11,334.70 ","$12,555.36 ","$15,868.58 ","$13,078.50 "
Carle BroMenn Medical Center,8973992,REMOVAL PERC VENT ASSIST DVC,,33992,481,"$3,195.00 ","$3,195.00 ",$958.50 ,"$2,907.45 ","$2,236.50 ",$958.50 ,"$2,076.75 ","$2,300.40 ","$2,907.45 ","$2,396.25 "
Carle BroMenn Medical Center,8973993,REPOSITION PER VENT ASSIST DVC,,33993,481,"$2,805.00 ","$2,805.00 ",$841.50 ,"$2,552.55 ","$1,963.50 ",$841.50 ,"$1,823.25 ","$2,019.60 ","$2,552.55 ","$2,103.75 "
Carle BroMenn Medical Center,8979525,OCCLSV DEVICE PLCMNT POST-PROC,,G0269,481,$540.00 ,$540.00 ,$162.00 ,$491.40 ,$378.00 ,$162.00 ,$351.00 ,$388.80 ,$491.40 ,$405.00 
Carle BroMenn Medical Center,8979529,ILIAC ANGIOGRPHY W/CARDIAC CTH,,G0278,481,"$2,393.00 ","$2,393.00 ",$717.90 ,"$2,177.63 ","$1,675.10 ",$717.90 ,"$1,555.45 ","$1,722.96 ","$2,177.63 ","$1,794.75 "
Carle BroMenn Medical Center,8293017,"CARDIAC STRESS TST,TRACING ONLY",,93017,482,$765.00 ,$765.00 ,$229.50 ,$696.15 ,$535.50 ,$229.50 ,$497.25 ,$550.80 ,$696.15 ,$573.75 
Carle BroMenn Medical Center,8293050,ART PRESS WAVEFORM ANALYSIS CENTRL ART PRESSURE,,93050,482,$88.00 ,$88.00 ,$26.40 ,$80.08 ,$61.60 ,$26.40 ,$57.20 ,$63.36 ,$80.08 ,$66.00 
Carle BroMenn Medical Center,8493017,CV STRESS TEST TRACING ONLY,,93017,482,$765.00 ,$765.00 ,$229.50 ,$696.15 ,$535.50 ,$229.50 ,$497.25 ,$550.80 ,$696.15 ,$573.75 
Carle BroMenn Medical Center,8293303,"ECHO XTHORACIC,CONG ANOM,COMPLETE",,93303,483,"$1,350.00 ","$1,350.00 ",$405.00 ,"$1,228.50 ",$945.00 ,$405.00 ,$877.50 ,$972.00 ,"$1,228.50 ","$1,012.50 "
Carle BroMenn Medical Center,8293304,"ECHO XTHORACIC,CONG ANOM,LIMITED",,93304,483,$970.00 ,$970.00 ,$291.00 ,$882.70 ,$679.00 ,$291.00 ,$630.50 ,$698.40 ,$882.70 ,$727.50 
Carle BroMenn Medical Center,8293306,"ECHO HEART XTHORACIC,COMPLETE W DOPPLER",,93306,483,"$1,365.00 ","$1,365.00 ",$409.50 ,"$1,242.15 ",$955.50 ,$409.50 ,$887.25 ,$982.80 ,"$1,242.15 ","$1,023.75 "
Carle BroMenn Medical Center,8293308,"ECHO HEART XTHORACIC,LIMITED",,93308,483,$610.00 ,$610.00 ,$183.00 ,$555.10 ,$427.00 ,$183.00 ,$396.50 ,$439.20 ,$555.10 ,$457.50 
Carle BroMenn Medical Center,8293312,"ECHO HEART,TRANSESOPHAGEAL,COMPLETE",,93312,483,"$1,595.00 ","$1,595.00 ",$478.50 ,"$1,451.45 ","$1,116.50 ",$478.50 ,"$1,036.75 ","$1,148.40 ","$1,451.45 ","$1,196.25 "
Carle BroMenn Medical Center,8293320,"DOPPLER ECHO HEART,COMPLETE",,93320,483,$385.00 ,$385.00 ,$115.50 ,$350.35 ,$269.50 ,$115.50 ,$250.25 ,$277.20 ,$350.35 ,$288.75 
Carle BroMenn Medical Center,8293321,"DOPPLER ECHO HEART,LIMITED,F/U",,93321,483,$165.00 ,$165.00 ,$49.50 ,$150.15 ,$115.50 ,$49.50 ,$107.25 ,$118.80 ,$150.15 ,$123.75 
Carle BroMenn Medical Center,8293325,DOPPLER COLOR FLOW VELOCITY MAP,,93325,483,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8293350,"ECHO HEART XTHORACIC, STRESS/REST",,93350,483,"$1,485.00 ","$1,485.00 ",$445.50 ,"$1,351.35 ","$1,039.50 ",$445.50 ,$965.25 ,"$1,069.20 ","$1,351.35 ","$1,113.75 "
Carle BroMenn Medical Center,8293351,ECHO TTHRC R-T 2D W/WO M-MODE REST&STRS CONT ECG,,93351,483,"$2,250.00 ","$2,250.00 ",$675.00 ,"$2,047.50 ","$1,575.00 ",$675.00 ,"$1,462.50 ","$1,620.00 ","$2,047.50 ","$1,687.50 "
Carle BroMenn Medical Center,8470399,MYOCARDIAL STRAIN IMAGING QUAN ASSMT,,0399T,483,$390.00 ,$390.00 ,$117.00 ,$354.90 ,$273.00 ,$117.00 ,$253.50 ,$280.80 ,$354.90 ,$292.50 
Carle BroMenn Medical Center,8493355,ECHO TEE GUIDE TCAT ICAR/VESSL STRUCTRAL INTRVNTN,,93355,483,"$4,275.00 ","$4,275.00 ","$1,282.50 ","$3,890.25 ","$2,992.50 ","$1,282.50 ","$2,778.75 ","$3,078.00 ","$3,890.25 ","$3,206.25 "
Carle BroMenn Medical Center,8493356,MYOCRD STRAIN IMG SPECKLE TRCK ASSMT MYOCRD MECH,,93356,483,$400.00 ,$400.00 ,$120.00 ,$364.00 ,$280.00 ,$120.00 ,$260.00 ,$288.00 ,$364.00 ,$300.00 
Carle BroMenn Medical Center,8100005,SLT LASER PROCEDURE,,,490,$184.00 ,$184.00 ,$55.20 ,$167.44 ,$128.80 ,$55.20 ,$119.60 ,$132.48 ,$167.44 ,$138.00 
Carle BroMenn Medical Center,8100013,PHACO MACHINE,,,490,$900.00 ,$900.00 ,$270.00 ,$819.00 ,$630.00 ,$270.00 ,$585.00 ,$648.00 ,$819.00 ,$675.00 
Carle BroMenn Medical Center,8100014,ZEISS MICROSCOPE,,,490,$17.00 ,$17.00 ,$5.10 ,$15.47 ,$11.90 ,$5.10 ,$11.05 ,$12.24 ,$15.47 ,$12.75 
Carle BroMenn Medical Center,8100015,ECP LASER,,,490,$184.00 ,$184.00 ,$55.20 ,$167.44 ,$128.80 ,$55.20 ,$119.60 ,$132.48 ,$167.44 ,$138.00 
Carle BroMenn Medical Center,8100016,YAG LASER,,,490,$184.00 ,$184.00 ,$55.20 ,$167.44 ,$128.80 ,$55.20 ,$119.60 ,$132.48 ,$167.44 ,$138.00 
Carle BroMenn Medical Center,8100063,DASC L1 BASE OPERATING ROOM CHARGE,,,490,$848.00 ,$848.00 ,$254.40 ,$771.68 ,$593.60 ,$254.40 ,$551.20 ,$610.56 ,$771.68 ,$636.00 
Carle BroMenn Medical Center,8102063,DASC L2 BASE OPERATING ROOM CHARGE,,,490,$870.00 ,$870.00 ,$261.00 ,$791.70 ,$609.00 ,$261.00 ,$565.50 ,$626.40 ,$791.70 ,$652.50 
Carle BroMenn Medical Center,8103063,DASC L3 BASE OPERATING ROOM CHARGE,,,490,$743.00 ,$743.00 ,$222.90 ,$676.13 ,$520.10 ,$222.90 ,$482.95 ,$534.96 ,$676.13 ,$557.25 
Carle BroMenn Medical Center,8104063,DASC L4 BASE OPERATING ROOM CHARGE,,,490,$630.00 ,$630.00 ,$189.00 ,$573.30 ,$441.00 ,$189.00 ,$409.50 ,$453.60 ,$573.30 ,$472.50 
Carle BroMenn Medical Center,8105063,DASC L1 PER MIN OPERATING ROOM CHARGE,,,490,$79.00 ,$79.00 ,$23.70 ,$71.89 ,$55.30 ,$23.70 ,$51.35 ,$56.88 ,$71.89 ,$59.25 
Carle BroMenn Medical Center,8106063,DASC L2 PER MIN OPERATING ROOM CHARGE,,,490,$74.00 ,$74.00 ,$22.20 ,$67.34 ,$51.80 ,$22.20 ,$48.10 ,$53.28 ,$67.34 ,$55.50 
Carle BroMenn Medical Center,8107063,DASC L3 PER MIN OPERATING ROOM CHARGE,,,490,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8108063,DASC L4 PER MIN OPERATING ROOM CHARGE,,,490,$46.00 ,$46.00 ,$13.80 ,$41.86 ,$32.20 ,$13.80 ,$29.90 ,$33.12 ,$41.86 ,$34.50 
Carle BroMenn Medical Center,8108064,DASC L5 BASE OPERATING ROOM CHARGE,,,490,$450.00 ,$450.00 ,$135.00 ,$409.50 ,$315.00 ,$135.00 ,$292.50 ,$324.00 ,$409.50 ,$337.50 
Carle BroMenn Medical Center,8108065,DASC L5 PER MIN OPERATING ROOM CHARGE,,,490,$26.00 ,$26.00 ,$7.80 ,$23.66 ,$18.20 ,$7.80 ,$16.90 ,$18.72 ,$23.66 ,$19.50 
Carle BroMenn Medical Center,8200104,CA SCREEN;FLEXI SIGMOIDSCOPE,,G0104,510,$810.00 ,$810.00 ,$243.00 ,$737.10 ,$567.00 ,$243.00 ,$526.50 ,$583.20 ,$737.10 ,$607.50 
Carle BroMenn Medical Center,8200105,COLORECTAL SCRN; HI RISK IND,,G0105,510,"$1,920.00 ","$1,920.00 ",$576.00 ,"$1,747.20 ","$1,344.00 ",$576.00 ,"$1,248.00 ","$1,382.40 ","$1,747.20 ","$1,440.00 "
Carle BroMenn Medical Center,8200117,GLAUCOMA SCREEN EXAM MEDC,,G0117,510,$98.00 ,$98.00 ,$29.40 ,$89.18 ,$68.60 ,$29.40 ,$63.70 ,$70.56 ,$89.18 ,$73.50 
Carle BroMenn Medical Center,8200121,COLON CA SCRN NOT HI RSK IND,,G0121,510,"$1,920.00 ","$1,920.00 ",$576.00 ,"$1,747.20 ","$1,344.00 ",$576.00 ,"$1,248.00 ","$1,382.40 ","$1,747.20 ","$1,440.00 "
Carle BroMenn Medical Center,8200127,TRIM NAIL(S),,G0127,510,$88.00 ,$88.00 ,$26.40 ,$80.08 ,$61.60 ,$26.40 ,$57.20 ,$63.36 ,$80.08 ,$66.00 
Carle BroMenn Medical Center,8200168,WOUND CLOSURE UTLIZING TISSUE ADHESIVES ONLY,,G0168,510,$240.00 ,$240.00 ,$72.00 ,$218.40 ,$168.00 ,$72.00 ,$156.00 ,$172.80 ,$218.40 ,$180.00 
Carle BroMenn Medical Center,8200183,ABUTMENT REPLACEMENT PROCEDURE,,69399,510,$500.00 ,$500.00 ,$150.00 ,$455.00 ,$350.00 ,$150.00 ,$325.00 ,$360.00 ,$455.00 ,$375.00 
Carle BroMenn Medical Center,8200236,IPA MONAURAL DISPENSING FEE V5241,,V5241,510,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8200237,IPA BINAURAL DISPENSING FEE V5160,,V5160,510,$240.00 ,$240.00 ,$72.00 ,$218.40 ,$168.00 ,$72.00 ,$156.00 ,$172.80 ,$218.40 ,$180.00 
Carle BroMenn Medical Center,8200238,DRS MONAURAL DISPENSING FEE V5241,,V5241,510,$370.00 ,$370.00 ,$111.00 ,$336.70 ,$259.00 ,$111.00 ,$240.50 ,$266.40 ,$336.70 ,$277.50 
Carle BroMenn Medical Center,8200239,DRS BINAURAL DISPENSING FEE V5160,,V5160,510,$520.00 ,$520.00 ,$156.00 ,$473.20 ,$364.00 ,$156.00 ,$338.00 ,$374.40 ,$473.20 ,$390.00 
Carle BroMenn Medical Center,8200272,CDC CLINIC,,99214,510,$275.00 ,$275.00 ,$82.50 ,$250.25 ,$192.50 ,$82.50 ,$178.75 ,$198.00 ,$250.25 ,$206.25 
Carle BroMenn Medical Center,8200296,VISIT TO DETERMINE LDCT ELLIGIBILITY,,G0296,510,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8200333,PILOCARPINE DROP TEST,,92499,510,$36.00 ,$36.00 ,$10.80 ,$32.76 ,$25.20 ,$10.80 ,$23.40 ,$25.92 ,$32.76 ,$27.00 
Carle BroMenn Medical Center,8200334,APRACLONIDINE DROP TEST,,92499,510,$57.00 ,$57.00 ,$17.10 ,$51.87 ,$39.90 ,$17.10 ,$37.05 ,$41.04 ,$51.87 ,$42.75 
Carle BroMenn Medical Center,8200338,BLEPHEX,,92499,510,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8200339,ILUX,,92499,510,$255.00 ,$255.00 ,$76.50 ,$232.05 ,$178.50 ,$76.50 ,$165.75 ,$183.60 ,$232.05 ,$191.25 
Carle BroMenn Medical Center,8200340,LASIK NON-CARLE EMPLOYEE,,65760,510,"$2,870.00 ","$2,870.00 ",$861.00 ,"$2,611.70 ","$2,009.00 ",$861.00 ,"$1,865.50 ","$2,066.40 ","$2,611.70 ","$2,152.50 "
Carle BroMenn Medical Center,8200341,LASIK CARLE EMPLOYEE,,65760,510,"$2,310.00 ","$2,310.00 ",$693.00 ,"$2,102.10 ","$1,617.00 ",$693.00 ,"$1,501.50 ","$1,663.20 ","$2,102.10 ","$1,732.50 "
Carle BroMenn Medical Center,8200342,LASIK CONSULT,,,510,$26.00 ,$26.00 ,$7.80 ,$23.66 ,$18.20 ,$7.80 ,$16.90 ,$18.72 ,$23.66 ,$19.50 
Carle BroMenn Medical Center,8200355,GI TRACT IMAGING INTRALUMINAL COLON WITH I&R,,0355T,510,"$3,090.00 ","$3,090.00 ",$927.00 ,"$2,811.90 ","$2,163.00 ",$927.00 ,"$2,008.50 ","$2,224.80 ","$2,811.90 ","$2,317.50 "
Carle BroMenn Medical Center,8200377,ANOSCOPY W/BULKING AGENT INJ FOR FECAL INCONT,,0377T,510,"$4,380.00 ","$4,380.00 ","$1,314.00 ","$3,985.80 ","$3,066.00 ","$1,314.00 ","$2,847.00 ","$3,153.60 ","$3,985.80 ","$3,285.00 "
Carle BroMenn Medical Center,8200396,INTRAOP KINETIC BALANCE SENSR KNEE RPLCMT ARTHRP,,0396T,510,$300.00 ,$300.00 ,$90.00 ,$273.00 ,$210.00 ,$90.00 ,$195.00 ,$216.00 ,$273.00 ,$225.00 
Carle BroMenn Medical Center,8200442,ANNUAL ALCOHOL SCREEN 15 MIN,,G0442,510,$95.00 ,$95.00 ,$28.50 ,$86.45 ,$66.50 ,$28.50 ,$61.75 ,$68.40 ,$86.45 ,$71.25 
Carle BroMenn Medical Center,8200443,BRIEF ALCOHOL MISUSE COUNSEL,,G0443,510,$160.00 ,$160.00 ,$48.00 ,$145.60 ,$112.00 ,$48.00 ,$104.00 ,$115.20 ,$145.60 ,$120.00 
Carle BroMenn Medical Center,8200444,DEPRESSION SCREEN ANNUAL,,G0444,510,$98.00 ,$98.00 ,$29.40 ,$89.18 ,$68.60 ,$29.40 ,$63.70 ,$70.56 ,$89.18 ,$73.50 
Carle BroMenn Medical Center,8200446,INTENS BEHAVE THER CARDIO DX,,G0446,510,$95.00 ,$95.00 ,$28.50 ,$86.45 ,$66.50 ,$28.50 ,$61.75 ,$68.40 ,$86.45 ,$71.25 
Carle BroMenn Medical Center,8200447,BEHAVIOR COUNSEL OBESITY 15M,,G0447,510,$180.00 ,$180.00 ,$54.00 ,$163.80 ,$126.00 ,$54.00 ,$117.00 ,$129.60 ,$163.80 ,$135.00 
Carle BroMenn Medical Center,8200485,OCT MIDDLE EAR WITH I&R UNILATERAL,,0485T,510,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01 
Carle BroMenn Medical Center,8200486,OCT MIDDLE EAR WITH I&R BILATERAL,,0486T,510,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01 
Carle BroMenn Medical Center,8200591,LABIAPLASTY OFFICE,,56620,510,"$1,720.00 ","$1,720.00 ",$516.00 ,"$1,565.20 ","$1,204.00 ",$516.00 ,"$1,118.00 ","$1,238.40 ","$1,565.20 ","$1,290.00 "
Carle BroMenn Medical Center,8200592,COMPLEX SUTURE/INCISION OFFICE,,13011,510,$660.00 ,$660.00 ,$198.00 ,$600.60 ,$462.00 ,$198.00 ,$429.00 ,$475.20 ,$600.60 ,$495.00 
Carle BroMenn Medical Center,8200593,EYELID/NOSE/EAR/LIP LACERATION REPAIR 1.1 - 2.5 CM,,13151,510,"$1,400.00 ","$1,400.00 ",$420.00 ,"$1,274.00 ",$980.00 ,$420.00 ,$910.00 ,"$1,008.00 ","$1,274.00 ","$1,050.00 "
Carle BroMenn Medical Center,8200627,SPERM STORAGE - YEARLY,,89343,510,$385.00 ,$385.00 ,$115.50 ,$350.35 ,$269.50 ,$115.50 ,$250.25 ,$277.20 ,$350.35 ,$288.75 
Carle BroMenn Medical Center,8200628,SPERM STORAGE - MONTHLY,,99199,510,$20.00 ,$20.00 ,$6.00 ,$18.20 ,$14.00 ,$6.00 ,$13.00 ,$14.40 ,$18.20 ,$15.00 
Carle BroMenn Medical Center,8200676,MILIA EXTRACTION UP TO 5 (15 MIN),,,510,$53.00 ,$53.00 ,$15.90 ,$48.23 ,$37.10 ,$15.90 ,$34.45 ,$38.16 ,$48.23 ,$39.75 
Carle BroMenn Medical Center,8200677,MILIA EXTRACTION UP TO 15 (30 MIN),,,510,$140.00 ,$140.00 ,$42.00 ,$127.40 ,$98.00 ,$42.00 ,$91.00 ,$100.80 ,$127.40 ,$105.00 
Carle BroMenn Medical Center,8200678,MILIA EXTRACTION UP TO 15 (45 MIN),,,510,$245.00 ,$245.00 ,$73.50 ,$222.95 ,$171.50 ,$73.50 ,$159.25 ,$176.40 ,$222.95 ,$183.75 
Carle BroMenn Medical Center,8202083,ADJUSTMENT GASTRIC BAND,,S2083,510,$265.00 ,$265.00 ,$79.50 ,$241.15 ,$185.50 ,$79.50 ,$172.25 ,$190.80 ,$241.15 ,$198.75 
Carle BroMenn Medical Center,8202320,PRP INJECT HARVEST/PREP,,0232T,510,$400.00 ,$400.00 ,$120.00 ,$364.00 ,$280.00 ,$120.00 ,$260.00 ,$288.00 ,$364.00 ,$300.00 
Carle BroMenn Medical Center,8202960,EXT ECG > 48HR TO 21 DAY RCRD W/CONECT INTL RCRD,,0296T,510,$475.00 ,$475.00 ,$142.50 ,$432.25 ,$332.50 ,$142.50 ,$308.75 ,$342.00 ,$432.25 ,$356.25 
Carle BroMenn Medical Center,8209803,HOSPITAL OUTPT CLINIC VISIT SPECIMEN COLLECTION,,C9803,510,$45.00 ,$45.00 ,$13.50 ,$40.95 ,$31.50 ,$13.50 ,$29.25 ,$32.40 ,$40.95 ,$33.75 
Carle BroMenn Medical Center,8210004,FINE NEEDLE ASPIRATION BX W/O IMG GDN EA ADDL,,10004,510,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8210005,FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION,,10005,510,"$1,200.00 ","$1,200.00 ",$360.00 ,"$1,092.00 ",$840.00 ,$360.00 ,$780.00 ,$864.00 ,"$1,092.00 ",$900.00 
Carle BroMenn Medical Center,8210006,FINE NEEDLE ASPIRATION BX W/US GDN EA ADDL,,10006,510,$560.00 ,$560.00 ,$168.00 ,$509.60 ,$392.00 ,$168.00 ,$364.00 ,$403.20 ,$509.60 ,$420.00 
Carle BroMenn Medical Center,8210007,FINE NEEDLE ASPIRATION BX W/FLUOR GDN 1ST LESION,,10007,510,$405.00 ,$405.00 ,$121.50 ,$368.55 ,$283.50 ,$121.50 ,$263.25 ,$291.60 ,$368.55 ,$303.75 
Carle BroMenn Medical Center,8210010,FINE NEEDLE ASPIRATION BX W/CT GDN EA ADDL,,10010,510,$728.00 ,$728.00 ,$218.40 ,$662.48 ,$509.60 ,$218.40 ,$473.20 ,$524.16 ,$662.48 ,$546.00 
Carle BroMenn Medical Center,8210011,FINE NEEDLE ASPIRATION BX W/MR GDN 1ST LESION,,10011,510,$405.00 ,$405.00 ,$121.50 ,$368.55 ,$283.50 ,$121.50 ,$263.25 ,$291.60 ,$368.55 ,$303.75 
Carle BroMenn Medical Center,8210012,FINE NEEDLE ASPIRATION BX W/MR GDN EA ADDL,,10012,510,$250.00 ,$250.00 ,$75.00 ,$227.50 ,$175.00 ,$75.00 ,$162.50 ,$180.00 ,$227.50 ,$187.50 
Carle BroMenn Medical Center,8210021,FINE NEEDLE ASP;W/O IMAGING GUIDANCE,,10021,510,$530.00 ,$530.00 ,$159.00 ,$482.30 ,$371.00 ,$159.00 ,$344.50 ,$381.60 ,$482.30 ,$397.50 
Carle BroMenn Medical Center,8210022,FINE NEEDLE ASP W/IMAGING GUIDANCE,,10022,510,$420.00 ,$420.00 ,$126.00 ,$382.20 ,$294.00 ,$126.00 ,$273.00 ,$302.40 ,$382.20 ,$315.00 
Carle BroMenn Medical Center,8210030,IMAGE-GUIDED CATHETER FLUID COLLECTION DRAINAGE,,10030,510,"$1,891.50 ","$1,891.50 ",$567.45 ,"$1,721.27 ","$1,324.05 ",$567.45 ,"$1,229.48 ","$1,361.88 ","$1,721.27 ","$1,418.63 "
Carle BroMenn Medical Center,8210035,PERQ SFT TISS LOC DEVICE PLMT 1ST LES W/GDNCE,,10035,510,"$1,455.00 ","$1,455.00 ",$436.50 ,"$1,324.05 ","$1,018.50 ",$436.50 ,$945.75 ,"$1,047.60 ","$1,324.05 ","$1,091.25 "
Carle BroMenn Medical Center,8210036,PERQ SFT TISS LOC DEVICE PLMT ADD LES W/GDNCE,,10036,510,"$1,390.00 ","$1,390.00 ",$417.00 ,"$1,264.90 ",$973.00 ,$417.00 ,$903.50 ,"$1,000.80 ","$1,264.90 ","$1,042.50 "
Carle BroMenn Medical Center,8210040,ACNE SURGERY OF SKIN ABSCESS,,10040,510,$225.00 ,$225.00 ,$67.50 ,$204.75 ,$157.50 ,$67.50 ,$146.25 ,$162.00 ,$204.75 ,$168.75 
Carle BroMenn Medical Center,8210060,DRAIN SKIN ABSCESS SIMPLE,,10060,510,$675.00 ,$675.00 ,$202.50 ,$614.25 ,$472.50 ,$202.50 ,$438.75 ,$486.00 ,$614.25 ,$506.25 
Carle BroMenn Medical Center,8210061,DRAIN SKIN ABSCESS COMPLIC,,10061,510,"$1,155.00 ","$1,155.00 ",$346.50 ,"$1,051.05 ",$808.50 ,$346.50 ,$750.75 ,$831.60 ,"$1,051.05 ",$866.25 
Carle BroMenn Medical Center,8210080,DRAIN PILONIDAL CYST SIMPL,,10080,510,$830.00 ,$830.00 ,$249.00 ,$755.30 ,$581.00 ,$249.00 ,$539.50 ,$597.60 ,$755.30 ,$622.50 
Carle BroMenn Medical Center,8210081,DRAIN PILONIDAL CYST COMPLIC,,10081,510,"$1,660.00 ","$1,660.00 ",$498.00 ,"$1,510.60 ","$1,162.00 ",$498.00 ,"$1,079.00 ","$1,195.20 ","$1,510.60 ","$1,245.00 "
Carle BroMenn Medical Center,8210120,REMOVE FOREIGN BODY SIMPLE,,10120,510,$780.00 ,$780.00 ,$234.00 ,$709.80 ,$546.00 ,$234.00 ,$507.00 ,$561.60 ,$709.80 ,$585.00 
Carle BroMenn Medical Center,8210121,REMOVE FOREIGN BODY COMPLIC,,10121,510,"$4,085.00 ","$4,085.00 ","$1,225.50 ","$3,717.35 ","$2,859.50 ","$1,225.50 ","$2,655.25 ","$2,941.20 ","$3,717.35 ","$3,063.75 "
Carle BroMenn Medical Center,8210140,DRAINAGE OF HEMATOMA/FLUID,,10140,510,"$3,160.00 ","$3,160.00 ",$948.00 ,"$2,875.60 ","$2,212.00 ",$948.00 ,"$2,054.00 ","$2,275.20 ","$2,875.60 ","$2,370.00 "
Carle BroMenn Medical Center,8210160,PUNCTURE DRAINAGE OF LESION,,10160,510,$605.00 ,$605.00 ,$181.50 ,$550.55 ,$423.50 ,$181.50 ,$393.25 ,$435.60 ,$550.55 ,$453.75 
Carle BroMenn Medical Center,8210180,"COMPLEX DRAINAGE, WOUND [EAP 10180]",,10180,510,"$4,505.00 ","$4,505.00 ","$1,351.50 ","$4,099.55 ","$3,153.50 ","$1,351.50 ","$2,928.25 ","$3,243.60 ","$4,099.55 ","$3,378.75 "
Carle BroMenn Medical Center,8210500,INITIAL PRENATAL CARE VISIT,,G0463,510,$225.00 ,$225.00 ,$67.50 ,$204.75 ,$157.50 ,$67.50 ,$146.25 ,$162.00 ,$204.75 ,$168.75 
Carle BroMenn Medical Center,8210502,SUBSEQUENT PRENATAL CARE,,G0463,510,$225.00 ,$225.00 ,$67.50 ,$204.75 ,$157.50 ,$67.50 ,$146.25 ,$162.00 ,$204.75 ,$168.75 
Carle BroMenn Medical Center,8210503,POSTPARTUM CARE VISIT,,G0463,510,$225.00 ,$225.00 ,$67.50 ,$204.75 ,$157.50 ,$67.50 ,$146.25 ,$162.00 ,$204.75 ,$168.75 
Carle BroMenn Medical Center,8211000,DEBRIDEMENT INFECTED SKIN UP TO 10% BSA,,11000,510,$460.00 ,$460.00 ,$138.00 ,$418.60 ,$322.00 ,$138.00 ,$299.00 ,$331.20 ,$418.60 ,$345.00 
Carle BroMenn Medical Center,8211042,"DEBRIDEMENT, SKIN, SUB-Q TISSUE",,11042,510,$965.00 ,$965.00 ,$289.50 ,$878.15 ,$675.50 ,$289.50 ,$627.25 ,$694.80 ,$878.15 ,$723.75 
Carle BroMenn Medical Center,8211043,"DEBRIDEMENT, SKIN, SUB-Q TISSUE,MUSCLE",,11043,510,"$1,495.00 ","$1,495.00 ",$448.50 ,"$1,360.45 ","$1,046.50 ",$448.50 ,$971.75 ,"$1,076.40 ","$1,360.45 ","$1,121.25 "
Carle BroMenn Medical Center,8211044,"DEBRIDEMENT, SKIN, SUB-Q TISSUE,MUSCLE,BONE,=<20 SQ CM",,11044,510,"$4,080.00 ","$4,080.00 ","$1,224.00 ","$3,712.80 ","$2,856.00 ","$1,224.00 ","$2,652.00 ","$2,937.60 ","$3,712.80 ","$3,060.00 "
Carle BroMenn Medical Center,8211045,"DEBRIDEMENT, SKIN, SUB-Q TISSUE,EACH ADD 20 SQ CM",,11045,510,$410.00 ,$410.00 ,$123.00 ,$373.10 ,$287.00 ,$123.00 ,$266.50 ,$295.20 ,$373.10 ,$307.50 
Carle BroMenn Medical Center,8211046,"DEBRIDEMENT, SKIN, SUB-Q TISSUE,MUSCLE,EACH ADD 20 SQ CM",,11046,510,$410.00 ,$410.00 ,$123.00 ,$373.10 ,$287.00 ,$123.00 ,$266.50 ,$295.20 ,$373.10 ,$307.50 
Carle BroMenn Medical Center,8211047,"DEBRIDEMENT, SKIN, SUB-Q TISSUE,MUSCLE,BONE,EACH ADD 20 SQ CM",,11047,510,"$1,410.00 ","$1,410.00 ",$423.00 ,"$1,283.10 ",$987.00 ,$423.00 ,$916.50 ,"$1,015.20 ","$1,283.10 ","$1,057.50 "
Carle BroMenn Medical Center,8211055,"TRIM HYPERKERATOTIC SKIN LESION, ONE",,11055,510,$325.00 ,$325.00 ,$97.50 ,$295.75 ,$227.50 ,$97.50 ,$211.25 ,$234.00 ,$295.75 ,$243.75 
Carle BroMenn Medical Center,8211056,"TRIM BENIGN HYPERKERATOTIC SKIN LESION,2-4",,11056,510,$315.00 ,$315.00 ,$94.50 ,$286.65 ,$220.50 ,$94.50 ,$204.75 ,$226.80 ,$286.65 ,$236.25 
Carle BroMenn Medical Center,8211057,"TRIM BENIGN HYPERKERATOTIC SKIN LESION,>4",,11057,510,$460.00 ,$460.00 ,$138.00 ,$418.60 ,$322.00 ,$138.00 ,$299.00 ,$331.20 ,$418.60 ,$345.00 
Carle BroMenn Medical Center,8211100,BIOPSY OF SKIN LESION,,11100,510,$280.00 ,$280.00 ,$84.00 ,$254.80 ,$196.00 ,$84.00 ,$182.00 ,$201.60 ,$254.80 ,$210.00 
Carle BroMenn Medical Center,8211101,"BIOPSY, EACH ADDED LESION",,11101,510,$280.00 ,$280.00 ,$84.00 ,$254.80 ,$196.00 ,$84.00 ,$182.00 ,$201.60 ,$254.80 ,$210.00 
Carle BroMenn Medical Center,8211102,TANGENTIAL BIOPSY SKIN SINGLE LESION,,11102,510,$560.00 ,$560.00 ,$168.00 ,$509.60 ,$392.00 ,$168.00 ,$364.00 ,$403.20 ,$509.60 ,$420.00 
Carle BroMenn Medical Center,8211103,TANGENTIAL BIOPSY SKIN EA SEP/ADDITIONAL LESION,,11103,510,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8211104,PUNCH BIOPSY SKIN SINGLE LESION,,11104,510,$560.00 ,$560.00 ,$168.00 ,$509.60 ,$392.00 ,$168.00 ,$364.00 ,$403.20 ,$509.60 ,$420.00 
Carle BroMenn Medical Center,8211105,PUNCH BIOPSY SKIN EA SEP/ADDITIONAL LESION,,11105,510,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8211106,INCISIONAL BIOPSY SKIN SINGLE LESION,,11106,510,$644.00 ,$644.00 ,$193.20 ,$586.04 ,$450.80 ,$193.20 ,$418.60 ,$463.68 ,$586.04 ,$483.00 
Carle BroMenn Medical Center,8211107,INCISIONAL BIOPSY SKIN EA SEP/ADDITIONAL LESION,,11107,510,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8211200,"REMOVAL OF SKIN TAGS, UP TO 15",,11200,510,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8211201,"REMOVAL OF SKIN TAGS, EACH ADD 10",,11201,510,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8211300,"SHAV SKIN LES < 0.5 CM TRUNK,ARM,LEG [EAP 11300]",,11300,510,$325.00 ,$325.00 ,$97.50 ,$295.75 ,$227.50 ,$97.50 ,$211.25 ,$234.00 ,$295.75 ,$243.75 
Carle BroMenn Medical Center,8211301,"SHAV SKIN LES 0.6-1.0 CM TRUNK,ARM,LEG [EAP 11301]",,11301,510,$175.00 ,$175.00 ,$52.50 ,$159.25 ,$122.50 ,$52.50 ,$113.75 ,$126.00 ,$159.25 ,$131.25 
Carle BroMenn Medical Center,8211302,"SHAV SKIN LES 1.1-2.0 CM TRUNK,ARM,LEG [EAP 11302]",,11302,510,$450.00 ,$450.00 ,$135.00 ,$409.50 ,$315.00 ,$135.00 ,$292.50 ,$324.00 ,$409.50 ,$337.50 
Carle BroMenn Medical Center,8211303,"SHAV SKIN LES >2.1 CM TRUNK,ARM,LEG [EAP 11303]",,11303,510,$520.00 ,$520.00 ,$156.00 ,$473.20 ,$364.00 ,$156.00 ,$338.00 ,$374.40 ,$473.20 ,$390.00 
Carle BroMenn Medical Center,8211305,SHAV SKIN LES <0.5 CM REMAINDER BODY [EAP 11305],,11305,510,$335.00 ,$335.00 ,$100.50 ,$304.85 ,$234.50 ,$100.50 ,$217.75 ,$241.20 ,$304.85 ,$251.25 
Carle BroMenn Medical Center,8211306,SHAV SKIN LES 0.6-1.0 CM REMAINDER BODY [EAP 11306],,11306,510,$450.00 ,$450.00 ,$135.00 ,$409.50 ,$315.00 ,$135.00 ,$292.50 ,$324.00 ,$409.50 ,$337.50 
Carle BroMenn Medical Center,8211307,SHAV SKIN LES 1.1-2.0 CM REMAINDER BODY [EAP 11307],,11307,510,$450.00 ,$450.00 ,$135.00 ,$409.50 ,$315.00 ,$135.00 ,$292.50 ,$324.00 ,$409.50 ,$337.50 
Carle BroMenn Medical Center,8211308,SHAV SKIN LES >2.1 CM REMAINDER BODY [EAP 11308],,11308,510,$320.00 ,$320.00 ,$96.00 ,$291.20 ,$224.00 ,$96.00 ,$208.00 ,$230.40 ,$291.20 ,$240.00 
Carle BroMenn Medical Center,8211310,"SHAV SKIN LES <0.5 CM FACE,FACIAL [EAP 11310]",,11310,510,$390.00 ,$390.00 ,$117.00 ,$354.90 ,$273.00 ,$117.00 ,$253.50 ,$280.80 ,$354.90 ,$292.50 
Carle BroMenn Medical Center,8211311,"SHAV SKIN LES 0.6-1.0 CM FACE,FACIAL",,11311,510,$455.00 ,$455.00 ,$136.50 ,$414.05 ,$318.50 ,$136.50 ,$295.75 ,$327.60 ,$414.05 ,$341.25 
Carle BroMenn Medical Center,8211312,"SHAV SKIN LES 1.1-2.0 CM FACE,FACIAL",,11312,510,$560.00 ,$560.00 ,$168.00 ,$509.60 ,$392.00 ,$168.00 ,$364.00 ,$403.20 ,$509.60 ,$420.00 
Carle BroMenn Medical Center,8211313,"SHAV SKIN LES >2.1 CM FACE,FACIAL",,11313,510,$650.00 ,$650.00 ,$195.00 ,$591.50 ,$455.00 ,$195.00 ,$422.50 ,$468.00 ,$591.50 ,$487.50 
Carle BroMenn Medical Center,8211400,"EXC SKIN BENIG <0.5 CM TRUNK,ARM,LEG",,11400,510,$710.00 ,$710.00 ,$213.00 ,$646.10 ,$497.00 ,$213.00 ,$461.50 ,$511.20 ,$646.10 ,$532.50 
Carle BroMenn Medical Center,8211401,"EXC SKIN BENIG 0.6-1 CM TRUNK,ARM,LEG",,11401,510,$795.00 ,$795.00 ,$238.50 ,$723.45 ,$556.50 ,$238.50 ,$516.75 ,$572.40 ,$723.45 ,$596.25 
Carle BroMenn Medical Center,8211402,"EXC SKIN BENIG 1.1-2 CM TRUNK,ARM,LEG",,11402,510,"$1,010.00 ","$1,010.00 ",$303.00 ,$919.10 ,$707.00 ,$303.00 ,$656.50 ,$727.20 ,$919.10 ,$757.50 
Carle BroMenn Medical Center,8211403,"EXC SKIN BENIG 2.1-3 CM TRUNK,ARM,LEG",,11403,510,"$1,760.00 ","$1,760.00 ",$528.00 ,"$1,601.60 ","$1,232.00 ",$528.00 ,"$1,144.00 ","$1,267.20 ","$1,601.60 ","$1,320.00 "
Carle BroMenn Medical Center,8211404,"EXC SKIN BENIG 3.1-4 CM TRUNK,ARM,LEG",,11404,510,"$3,560.00 ","$3,560.00 ","$1,068.00 ","$3,239.60 ","$2,492.00 ","$1,068.00 ","$2,314.00 ","$2,563.20 ","$3,239.60 ","$2,670.00 "
Carle BroMenn Medical Center,8211406,"EXC SKIN BENIG >4 CM TRUNK,ARM,LEG",,11406,510,"$3,960.00 ","$3,960.00 ","$1,188.00 ","$3,603.60 ","$2,772.00 ","$1,188.00 ","$2,574.00 ","$2,851.20 ","$3,603.60 ","$2,970.00 "
Carle BroMenn Medical Center,8211420,EXC SKIN BENIG <0.5 CM REMAINDER BODY,,11420,510,"$1,860.00 ","$1,860.00 ",$558.00 ,"$1,692.60 ","$1,302.00 ",$558.00 ,"$1,209.00 ","$1,339.20 ","$1,692.60 ","$1,395.00 "
Carle BroMenn Medical Center,8211421,EXC SKIN BENIG 0.6-1 CM REMAINDR BODY,,11421,510,"$1,615.00 ","$1,615.00 ",$484.50 ,"$1,469.65 ","$1,130.50 ",$484.50 ,"$1,049.75 ","$1,162.80 ","$1,469.65 ","$1,211.25 "
Carle BroMenn Medical Center,8211422,EXC SKIN BENIG 1.1-2 CM REMAINDR BODY,,11422,510,"$2,780.00 ","$2,780.00 ",$834.00 ,"$2,529.80 ","$1,946.00 ",$834.00 ,"$1,807.00 ","$2,001.60 ","$2,529.80 ","$2,085.00 "
Carle BroMenn Medical Center,8211423,EXC SKIN BENIG 2.1-3 CM REMAINDR BODY,,11423,510,"$2,960.00 ","$2,960.00 ",$888.00 ,"$2,693.60 ","$2,072.00 ",$888.00 ,"$1,924.00 ","$2,131.20 ","$2,693.60 ","$2,220.00 "
Carle BroMenn Medical Center,8211424,EXC SKIN BENIG 3.1-4 CM REMAINDR BODY,,11424,510,"$3,450.00 ","$3,450.00 ","$1,035.00 ","$3,139.50 ","$2,415.00 ","$1,035.00 ","$2,242.50 ","$2,484.00 ","$3,139.50 ","$2,587.50 "
Carle BroMenn Medical Center,8211426,EXC SKIN BENIG >4 CM REMAINDR BODY,,11426,510,"$4,310.00 ","$4,310.00 ","$1,293.00 ","$3,922.10 ","$3,017.00 ","$1,293.00 ","$2,801.50 ","$3,103.20 ","$3,922.10 ","$3,232.50 "
Carle BroMenn Medical Center,8211440,"EXC SKIN BENIG <0.5 CM FACE,FACIAL",,11440,510,"$1,120.00 ","$1,120.00 ",$336.00 ,"$1,019.20 ",$784.00 ,$336.00 ,$728.00 ,$806.40 ,"$1,019.20 ",$840.00 
Carle BroMenn Medical Center,8211441,"EXC SKIN BENIG 0.6-1 CM FACE,FACIAL",,11441,510,"$1,370.00 ","$1,370.00 ",$411.00 ,"$1,246.70 ",$959.00 ,$411.00 ,$890.50 ,$986.40 ,"$1,246.70 ","$1,027.50 "
Carle BroMenn Medical Center,8211442,"EXC SKIN BENIG 1.1-2 CM FACE,FACIAL",,11442,510,"$1,760.00 ","$1,760.00 ",$528.00 ,"$1,601.60 ","$1,232.00 ",$528.00 ,"$1,144.00 ","$1,267.20 ","$1,601.60 ","$1,320.00 "
Carle BroMenn Medical Center,8211443,"EXC SKIN BENIG 2.1-3 CM FACE,FACIAL",,11443,510,"$2,310.00 ","$2,310.00 ",$693.00 ,"$2,102.10 ","$1,617.00 ",$693.00 ,"$1,501.50 ","$1,663.20 ","$2,102.10 ","$1,732.50 "
Carle BroMenn Medical Center,8211444,"EXC SKIN BENIG 3.1- 4 CM FACE,FACIAL",,11444,510,"$2,700.00 ","$2,700.00 ",$810.00 ,"$2,457.00 ","$1,890.00 ",$810.00 ,"$1,755.00 ","$1,944.00 ","$2,457.00 ","$2,025.00 "
Carle BroMenn Medical Center,8211446,"EXC SKIN BENIG >4 CM FACE,FACIAL",,11446,510,"$4,540.00 ","$4,540.00 ","$1,362.00 ","$4,131.40 ","$3,178.00 ","$1,362.00 ","$2,951.00 ","$3,268.80 ","$4,131.40 ","$3,405.00 "
Carle BroMenn Medical Center,8211450,EXC SWEAT GLAND LESN AXILL SIMPL,,11450,510,"$2,880.00 ","$2,880.00 ",$864.00 ,"$2,620.80 ","$2,016.00 ",$864.00 ,"$1,872.00 ","$2,073.60 ","$2,620.80 ","$2,160.00 "
Carle BroMenn Medical Center,8211600,"EXC SKIN MALIG <0.5 CM TRUNK,ARM,LEG",,11600,510,"$1,550.00 ","$1,550.00 ",$465.00 ,"$1,410.50 ","$1,085.00 ",$465.00 ,"$1,007.50 ","$1,116.00 ","$1,410.50 ","$1,162.50 "
Carle BroMenn Medical Center,8211601,"EXC SKIN MALIG 0.6-1 CM TRUNK,ARM,LEG",,11601,510,"$1,385.00 ","$1,385.00 ",$415.50 ,"$1,260.35 ",$969.50 ,$415.50 ,$900.25 ,$997.20 ,"$1,260.35 ","$1,038.75 "
Carle BroMenn Medical Center,8211602,"EXC SKIN MALIG 1.1-2 CM TRUNK,ARM,LEG",,11602,510,"$1,010.00 ","$1,010.00 ",$303.00 ,$919.10 ,$707.00 ,$303.00 ,$656.50 ,$727.20 ,$919.10 ,$757.50 
Carle BroMenn Medical Center,8211603,"EXC SKIN MALIG 2.1-3 CM TRUNK,ARM,LEG",,11603,510,"$1,530.00 ","$1,530.00 ",$459.00 ,"$1,392.30 ","$1,071.00 ",$459.00 ,$994.50 ,"$1,101.60 ","$1,392.30 ","$1,147.50 "
Carle BroMenn Medical Center,8211604,"EXC SKIN MALIG 3.1-4 CM TRUNK,ARM,LEG",,11604,510,"$1,760.00 ","$1,760.00 ",$528.00 ,"$1,601.60 ","$1,232.00 ",$528.00 ,"$1,144.00 ","$1,267.20 ","$1,601.60 ","$1,320.00 "
Carle BroMenn Medical Center,8211606,"EXC SKIN MALIG >4 CM TRUNK,ARM,LEG [EAP 11606]",,11606,510,"$3,700.00 ","$3,700.00 ","$1,110.00 ","$3,367.00 ","$2,590.00 ","$1,110.00 ","$2,405.00 ","$2,664.00 ","$3,367.00 ","$2,775.00 "
Carle BroMenn Medical Center,8211620,EXC SKIN MALIG <0.5 CM REMAINDER BODY,,11620,510,"$1,580.00 ","$1,580.00 ",$474.00 ,"$1,437.80 ","$1,106.00 ",$474.00 ,"$1,027.00 ","$1,137.60 ","$1,437.80 ","$1,185.00 "
Carle BroMenn Medical Center,8211621,EXC SKIN MALIG 0.6-1 CM REMAINDR BODY,,11621,510,"$1,530.00 ","$1,530.00 ",$459.00 ,"$1,392.30 ","$1,071.00 ",$459.00 ,$994.50 ,"$1,101.60 ","$1,392.30 ","$1,147.50 "
Carle BroMenn Medical Center,8211622,EXC SKIN MALIG 1.1-2 CM REMAINDR BODY,,11622,510,"$1,530.00 ","$1,530.00 ",$459.00 ,"$1,392.30 ","$1,071.00 ",$459.00 ,$994.50 ,"$1,101.60 ","$1,392.30 ","$1,147.50 "
Carle BroMenn Medical Center,8211623,EXC SKIN MALIG 2.1-3 CM REMAINDR BODY,,11623,510,"$3,710.00 ","$3,710.00 ","$1,113.00 ","$3,376.10 ","$2,597.00 ","$1,113.00 ","$2,411.50 ","$2,671.20 ","$3,376.10 ","$2,782.50 "
Carle BroMenn Medical Center,8211624,EXC SKIN MALIG 3.1-4 CM REMAINDR BODY,,11624,510,"$2,330.00 ","$2,330.00 ",$699.00 ,"$2,120.30 ","$1,631.00 ",$699.00 ,"$1,514.50 ","$1,677.60 ","$2,120.30 ","$1,747.50 "
Carle BroMenn Medical Center,8211626,EXC SKIN MALIG >4 CM REMAINDR BODY,,11626,510,"$5,840.00 ","$5,840.00 ","$1,752.00 ","$5,314.40 ","$4,088.00 ","$1,752.00 ","$3,796.00 ","$4,204.80 ","$5,314.40 ","$4,380.00 "
Carle BroMenn Medical Center,8211640,"EXC SKIN MALIG <0.5 CM FACE,FACIAL",,11640,510,"$1,090.00 ","$1,090.00 ",$327.00 ,$991.90 ,$763.00 ,$327.00 ,$708.50 ,$784.80 ,$991.90 ,$817.50 
Carle BroMenn Medical Center,8211641,"EXC SKIN MALIG 0.6-1CM FACE,FACIAL",,11641,510,"$1,130.00 ","$1,130.00 ",$339.00 ,"$1,028.30 ",$791.00 ,$339.00 ,$734.50 ,$813.60 ,"$1,028.30 ",$847.50 
Carle BroMenn Medical Center,8211642,"EXC SKIN MALIG 1.1-2 CM FACE,FACIAL",,11642,510,"$1,360.00 ","$1,360.00 ",$408.00 ,"$1,237.60 ",$952.00 ,$408.00 ,$884.00 ,$979.20 ,"$1,237.60 ","$1,020.00 "
Carle BroMenn Medical Center,8211643,"EXC SKIN MALIG 2.1-3 CM FACE,FACIAL",,11643,510,"$1,920.00 ","$1,920.00 ",$576.00 ,"$1,747.20 ","$1,344.00 ",$576.00 ,"$1,248.00 ","$1,382.40 ","$1,747.20 ","$1,440.00 "
Carle BroMenn Medical Center,8211644,"EXC SKIN MALIG 3.1-4 CM FACE,FACIAL",,11644,510,"$3,450.00 ","$3,450.00 ","$1,035.00 ","$3,139.50 ","$2,415.00 ","$1,035.00 ","$2,242.50 ","$2,484.00 ","$3,139.50 ","$2,587.50 "
Carle BroMenn Medical Center,8211646,"EXC SKIN MALIG >4 CM FACE,FACIAL",,11646,510,"$3,430.00 ","$3,430.00 ","$1,029.00 ","$3,121.30 ","$2,401.00 ","$1,029.00 ","$2,229.50 ","$2,469.60 ","$3,121.30 ","$2,572.50 "
Carle BroMenn Medical Center,8211719,TRIM NAIL(S),,11719,510,$215.00 ,$215.00 ,$64.50 ,$195.65 ,$150.50 ,$64.50 ,$139.75 ,$154.80 ,$195.65 ,$161.25 
Carle BroMenn Medical Center,8211720,"DEBRIDEMENT OF NAIL(S), 1-5",,11720,510,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8211721,"DEBRIDEMENT OF NAILS, 6 OR MORE",,11721,510,$165.00 ,$165.00 ,$49.50 ,$150.15 ,$115.50 ,$49.50 ,$107.25 ,$118.80 ,$150.15 ,$123.75 
Carle BroMenn Medical Center,8211730,REMOVAL OF NAIL PLATE,,11730,510,$375.00 ,$375.00 ,$112.50 ,$341.25 ,$262.50 ,$112.50 ,$243.75 ,$270.00 ,$341.25 ,$281.25 
Carle BroMenn Medical Center,8211732,REMOVE ADDITIONAL NAIL PLATE,,11732,510,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8211740,DRAIN BLOOD FROM UNDER NAIL [EAP 11740],,11740,510,$240.00 ,$240.00 ,$72.00 ,$218.40 ,$168.00 ,$72.00 ,$156.00 ,$172.80 ,$218.40 ,$180.00 
Carle BroMenn Medical Center,8211750,REMOVAL OF NAIL BED,,11750,510,"$1,170.00 ","$1,170.00 ",$351.00 ,"$1,064.70 ",$819.00 ,$351.00 ,$760.50 ,$842.40 ,"$1,064.70 ",$877.50 
Carle BroMenn Medical Center,8211755,BIOPSY NAIL UNIT,,11755,510,$540.00 ,$540.00 ,$162.00 ,$491.40 ,$378.00 ,$162.00 ,$351.00 ,$388.80 ,$491.40 ,$405.00 
Carle BroMenn Medical Center,8211765,"EXCISION OF NAIL FOLD, TOE",,11765,510,$760.00 ,$760.00 ,$228.00 ,$691.60 ,$532.00 ,$228.00 ,$494.00 ,$547.20 ,$691.60 ,$570.00 
Carle BroMenn Medical Center,8211900,"INJECTION INTO SKIN LESIONS, UP TO 7",,11900,510,$355.00 ,$355.00 ,$106.50 ,$323.05 ,$248.50 ,$106.50 ,$230.75 ,$255.60 ,$323.05 ,$266.25 
Carle BroMenn Medical Center,8211901,"INJECTION INTO SKIN LESIONS, 8 OR MORE",,11901,510,$365.00 ,$365.00 ,$109.50 ,$332.15 ,$255.50 ,$109.50 ,$237.25 ,$262.80 ,$332.15 ,$273.75 
Carle BroMenn Medical Center,8211920,CORRECT SKIN COLR DEFCT <6 SQCM,,11920,510,"$1,130.00 ","$1,130.00 ",$339.00 ,"$1,028.30 ",$791.00 ,$339.00 ,$734.50 ,$813.60 ,"$1,028.30 ",$847.50 
Carle BroMenn Medical Center,8211921,CORRECT SKIN COLR DEFCT 6.1-20 SQCM,,11921,510,"$2,030.00 ","$2,030.00 ",$609.00 ,"$1,847.30 ","$1,421.00 ",$609.00 ,"$1,319.50 ","$1,461.60 ","$1,847.30 ","$1,522.50 "
Carle BroMenn Medical Center,8211922,CORRECT SKIN COLR DEFCT ADDN 20 SQCM,,11922,510,"$1,900.00 ","$1,900.00 ",$570.00 ,"$1,729.00 ","$1,330.00 ",$570.00 ,"$1,235.00 ","$1,368.00 ","$1,729.00 ","$1,425.00 "
Carle BroMenn Medical Center,8211950,FILL CONTOUR DEFCT <1CC,,11950,510,$400.00 ,$400.00 ,$120.00 ,$364.00 ,$280.00 ,$120.00 ,$260.00 ,$288.00 ,$364.00 ,$300.00 
Carle BroMenn Medical Center,8211951,Hcfill Contour Defct 1.1-5cc,,11951,510,$510.00 ,$510.00 ,$153.00 ,$464.10 ,$357.00 ,$153.00 ,$331.50 ,$367.20 ,$464.10 ,$382.50 
Carle BroMenn Medical Center,8211976,REMOVAL OF CONTRACEPTIVE CAPSUL,,11976,510,$815.00 ,$815.00 ,$244.50 ,$741.65 ,$570.50 ,$244.50 ,$529.75 ,$586.80 ,$741.65 ,$611.25 
Carle BroMenn Medical Center,8211980,"IMPLANT, HOROMONE, SUBCUTANEOUS",,11980,510,$520.00 ,$520.00 ,$156.00 ,$473.20 ,$364.00 ,$156.00 ,$338.00 ,$374.40 ,$473.20 ,$390.00 
Carle BroMenn Medical Center,8211981,INSERTION DRUG IMPLANT DEVICE,,11981,510,$320.00 ,$320.00 ,$96.00 ,$291.20 ,$224.00 ,$96.00 ,$208.00 ,$230.40 ,$291.20 ,$240.00 
Carle BroMenn Medical Center,8211982,REMVOAL DRUG IMPLANT DEVICE,,11982,510,$165.00 ,$165.00 ,$49.50 ,$150.15 ,$115.50 ,$49.50 ,$107.25 ,$118.80 ,$150.15 ,$123.75 
Carle BroMenn Medical Center,8211983,REMOVAL W/ REINSERT DRUG IMPLANT DEVICE,,11983,510,"$1,060.00 ","$1,060.00 ",$318.00 ,$964.60 ,$742.00 ,$318.00 ,$689.00 ,$763.20 ,$964.60 ,$795.00 
Carle BroMenn Medical Center,8212001,RESUPERF WND BODY <2.5CM,,12001,510,$500.00 ,$500.00 ,$150.00 ,$455.00 ,$350.00 ,$150.00 ,$325.00 ,$360.00 ,$455.00 ,$375.00 
Carle BroMenn Medical Center,8212002,RESUP NPTERF WND BODY 2.6-7.5 CM [EAP 12002],,12002,510,$310.00 ,$310.00 ,$93.00 ,$282.10 ,$217.00 ,$93.00 ,$201.50 ,$223.20 ,$282.10 ,$232.50 
Carle BroMenn Medical Center,8212004,RESUPERF WND BODY 7.6-12.5 CM,,12004,510,$675.00 ,$675.00 ,$202.50 ,$614.25 ,$472.50 ,$202.50 ,$438.75 ,$486.00 ,$614.25 ,$506.25 
Carle BroMenn Medical Center,8212005,RESUPERF WND BODY 12.6-20 CM [EAP 12005],,12005,510,$850.00 ,$850.00 ,$255.00 ,$773.50 ,$595.00 ,$255.00 ,$552.50 ,$612.00 ,$773.50 ,$637.50 
Carle BroMenn Medical Center,8212006,RESUPERF WND BODY 20.1-30 CM [EAP 12006],,12006,510,"$1,055.00 ","$1,055.00 ",$316.50 ,$960.05 ,$738.50 ,$316.50 ,$685.75 ,$759.60 ,$960.05 ,$791.25 
Carle BroMenn Medical Center,8212007,RESUPERF WND BODY >30 CM [EAP 12007],,12007,510,"$1,405.00 ","$1,405.00 ",$421.50 ,"$1,278.55 ",$983.50 ,$421.50 ,$913.25 ,"$1,011.60 ","$1,278.55 ","$1,053.75 "
Carle BroMenn Medical Center,8212011,RESUPERF WND FACE <2.5 CM,,12011,510,$515.00 ,$515.00 ,$154.50 ,$468.65 ,$360.50 ,$154.50 ,$334.75 ,$370.80 ,$468.65 ,$386.25 
Carle BroMenn Medical Center,8212013,RESUPERF WND FACE 2.6-5 CM [EAP 12013],,12013,510,$675.00 ,$675.00 ,$202.50 ,$614.25 ,$472.50 ,$202.50 ,$438.75 ,$486.00 ,$614.25 ,$506.25 
Carle BroMenn Medical Center,8212014,RESUPERF WND FACE 5.1-7.5 CM [EAP 12014],,12014,510,$800.00 ,$800.00 ,$240.00 ,$728.00 ,$560.00 ,$240.00 ,$520.00 ,$576.00 ,$728.00 ,$600.00 
Carle BroMenn Medical Center,8212015,RESUPERF WND FACE 7.6-12.5 CM [EAP 12015],,12015,510,$875.00 ,$875.00 ,$262.50 ,$796.25 ,$612.50 ,$262.50 ,$568.75 ,$630.00 ,$796.25 ,$656.25 
Carle BroMenn Medical Center,8212016,RESUPERF WND FACE 12.6-20 CM [EAP 12016],,12016,510,$610.00 ,$610.00 ,$183.00 ,$555.10 ,$427.00 ,$183.00 ,$396.50 ,$439.20 ,$555.10 ,$457.50 
Carle BroMenn Medical Center,8212017,RESUPERF WND FACE 20.1-30 CM [EAP 12017],,12017,510,"$1,260.00 ","$1,260.00 ",$378.00 ,"$1,146.60 ",$882.00 ,$378.00 ,$819.00 ,$907.20 ,"$1,146.60 ",$945.00 
Carle BroMenn Medical Center,8212018,RESUPERF WND FACE >30 CM [EAP 12018],,12018,510,$695.00 ,$695.00 ,$208.50 ,$632.45 ,$486.50 ,$208.50 ,$451.75 ,$500.40 ,$632.45 ,$521.25 
Carle BroMenn Medical Center,8212020,TREATMENT SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE,,12020,510,"$1,630.00 ","$1,630.00 ",$489.00 ,"$1,483.30 ","$1,141.00 ",$489.00 ,"$1,059.50 ","$1,173.60 ","$1,483.30 ","$1,222.50 "
Carle BroMenn Medical Center,8212021,TREATMENT SUPERFICIAL WOUND DEHISCENCE W/PACKING,,12021,510,"$1,055.00 ","$1,055.00 ",$316.50 ,$960.05 ,$738.50 ,$316.50 ,$685.75 ,$759.60 ,$960.05 ,$791.25 
Carle BroMenn Medical Center,8212031,"LAYR CLOS WND TRUNK,ARM,LEG <2.5 CM",,12031,510,"$1,110.00 ","$1,110.00 ",$333.00 ,"$1,010.10 ",$777.00 ,$333.00 ,$721.50 ,$799.20 ,"$1,010.10 ",$832.50 
Carle BroMenn Medical Center,8212032,"LAYR CLOS WND TRUNK,ARM,LEG 2.6-7.5 CM [EAP 12032]",,12032,510,"$1,290.00 ","$1,290.00 ",$387.00 ,"$1,173.90 ",$903.00 ,$387.00 ,$838.50 ,$928.80 ,"$1,173.90 ",$967.50 
Carle BroMenn Medical Center,8212034,"LAYR CLOS WND TRUNK,ARM,LEG 7.6-12.5 CM [EAP 12034]",,12034,510,"$1,350.00 ","$1,350.00 ",$405.00 ,"$1,228.50 ",$945.00 ,$405.00 ,$877.50 ,$972.00 ,"$1,228.50 ","$1,012.50 "
Carle BroMenn Medical Center,8212035,"LAYR CLOS WND TRUNK,ARM,LEG 12.6-20 CM [EAP 12035]",,12035,510,"$1,170.00 ","$1,170.00 ",$351.00 ,"$1,064.70 ",$819.00 ,$351.00 ,$760.50 ,$842.40 ,"$1,064.70 ",$877.50 
Carle BroMenn Medical Center,8212036,"LAYR CLOS WND TRUNK,ARM,LEG 20.1-30 CM [EAP 12036]",,12036,510,"$1,770.00 ","$1,770.00 ",$531.00 ,"$1,610.70 ","$1,239.00 ",$531.00 ,"$1,150.50 ","$1,274.40 ","$1,610.70 ","$1,327.50 "
Carle BroMenn Medical Center,8212037,"LAYR CLOS WND TRUNK,ARM,LEG >30 CM [EAP 12037]",,12037,510,"$1,873.00 ","$1,873.00 ",$561.90 ,"$1,704.43 ","$1,311.10 ",$561.90 ,"$1,217.45 ","$1,348.56 ","$1,704.43 ","$1,404.75 "
Carle BroMenn Medical Center,8212041,LAYR CLOS WND REST BODY <2.5 CM,,12041,510,$980.00 ,$980.00 ,$294.00 ,$891.80 ,$686.00 ,$294.00 ,$637.00 ,$705.60 ,$891.80 ,$735.00 
Carle BroMenn Medical Center,8212042,LAYR CLOS WND REST BODY 2.6-7.5 CM,,12042,510,"$1,190.00 ","$1,190.00 ",$357.00 ,"$1,082.90 ",$833.00 ,$357.00 ,$773.50 ,$856.80 ,"$1,082.90 ",$892.50 
Carle BroMenn Medical Center,8212044,LAYR CLOS WND REST BODY 7.6-12.5 CM,,12044,510,"$1,235.00 ","$1,235.00 ",$370.50 ,"$1,123.85 ",$864.50 ,$370.50 ,$802.75 ,$889.20 ,"$1,123.85 ",$926.25 
Carle BroMenn Medical Center,8212045,LAYR CLOS WND REST BODY 12.6-20 CM,,12045,510,"$1,080.00 ","$1,080.00 ",$324.00 ,$982.80 ,$756.00 ,$324.00 ,$702.00 ,$777.60 ,$982.80 ,$810.00 
Carle BroMenn Medical Center,8212046,LAYR CLOS WND REST BODY 20.1-30 CM,,12046,510,"$1,400.00 ","$1,400.00 ",$420.00 ,"$1,274.00 ",$980.00 ,$420.00 ,$910.00 ,"$1,008.00 ","$1,274.00 ","$1,050.00 "
Carle BroMenn Medical Center,8212047,LAYR CLOS WND REST BODY >30 CM,,12047,510,"$1,450.00 ","$1,450.00 ",$435.00 ,"$1,319.50 ","$1,015.00 ",$435.00 ,$942.50 ,"$1,044.00 ","$1,319.50 ","$1,087.50 "
Carle BroMenn Medical Center,8212051,"LAYR CLOS WND FACE,FACIAL <2.5 CM",,12051,510,$675.00 ,$675.00 ,$202.50 ,$614.25 ,$472.50 ,$202.50 ,$438.75 ,$486.00 ,$614.25 ,$506.25 
Carle BroMenn Medical Center,8212052,"LAYR CLOS WND FACE,FACIAL 2.5-5 CM",,12052,510,"$1,215.00 ","$1,215.00 ",$364.50 ,"$1,105.65 ",$850.50 ,$364.50 ,$789.75 ,$874.80 ,"$1,105.65 ",$911.25 
Carle BroMenn Medical Center,8212053,"LAYR CLOS WND FACE,FACIAL 5.1-7.5 CM",,12053,510,"$1,260.00 ","$1,260.00 ",$378.00 ,"$1,146.60 ",$882.00 ,$378.00 ,$819.00 ,$907.20 ,"$1,146.60 ",$945.00 
Carle BroMenn Medical Center,8212054,"LAYR CLOS WND FACE,FACIAL 7.6-12.5 CM",,12054,510,"$1,170.00 ","$1,170.00 ",$351.00 ,"$1,064.70 ",$819.00 ,$351.00 ,$760.50 ,$842.40 ,"$1,064.70 ",$877.50 
Carle BroMenn Medical Center,8212055,"LAYR CLOS WND FACE,FACIAL 12.6-20 CM",,12055,510,"$1,480.00 ","$1,480.00 ",$444.00 ,"$1,346.80 ","$1,036.00 ",$444.00 ,$962.00 ,"$1,065.60 ","$1,346.80 ","$1,110.00 "
Carle BroMenn Medical Center,8212056,"LAYR CLOS WND FACE,FACIAL 20.1-30 CM",,12056,510,"$1,170.00 ","$1,170.00 ",$351.00 ,"$1,064.70 ",$819.00 ,$351.00 ,$760.50 ,$842.40 ,"$1,064.70 ",$877.50 
Carle BroMenn Medical Center,8212057,"LAYR CLOS WND FACE,FACIAL >30 CM",,12057,510,"$1,930.00 ","$1,930.00 ",$579.00 ,"$1,756.30 ","$1,351.00 ",$579.00 ,"$1,254.50 ","$1,389.60 ","$1,756.30 ","$1,447.50 "
Carle BroMenn Medical Center,8213100,EXC TRNK 1.1CM TO 2.5CM,,13100,510,"$1,120.00 ","$1,120.00 ",$336.00 ,"$1,019.20 ",$784.00 ,$336.00 ,$728.00 ,$806.40 ,"$1,019.20 ",$840.00 
Carle BroMenn Medical Center,8213101,TRNK 2.5CM TO 7.5CM,,13101,510,"$1,175.00 ","$1,175.00 ",$352.50 ,"$1,069.25 ",$822.50 ,$352.50 ,$763.75 ,$846.00 ,"$1,069.25 ",$881.25 
Carle BroMenn Medical Center,8213102,TRNK EA ADD 5CM OR LESS,,13102,510,$565.00 ,$565.00 ,$169.50 ,$514.15 ,$395.50 ,$169.50 ,$367.25 ,$406.80 ,$514.15 ,$423.75 
Carle BroMenn Medical Center,8213120,SCLP/ARMS/LGS 1.1CM TO 2.5CM,,13120,510,$945.00 ,$945.00 ,$283.50 ,$859.95 ,$661.50 ,$283.50 ,$614.25 ,$680.40 ,$859.95 ,$708.75 
Carle BroMenn Medical Center,8213121,SCLP/ARMS/LGS 2.6CM TO 7.5CM,,13121,510,"$1,315.00 ","$1,315.00 ",$394.50 ,"$1,196.65 ",$920.50 ,$394.50 ,$854.75 ,$946.80 ,"$1,196.65 ",$986.25 
Carle BroMenn Medical Center,8213122,SCLP/ARMS/LGS EA ADD 5CM OR LESS,,13122,510,$530.00 ,$530.00 ,$159.00 ,$482.30 ,$371.00 ,$159.00 ,$344.50 ,$381.60 ,$482.30 ,$397.50 
Carle BroMenn Medical Center,8213131,"RECMPL WND HEAD,FAC,HAND 1.1-2.5 CM",,13131,510,"$1,170.00 ","$1,170.00 ",$351.00 ,"$1,064.70 ",$819.00 ,$351.00 ,$760.50 ,$842.40 ,"$1,064.70 ",$877.50 
Carle BroMenn Medical Center,8213132,"RECMPL WND HEAD,FAC,HAND 2.6-7.5 CM",,13132,510,"$1,705.00 ","$1,705.00 ",$511.50 ,"$1,551.55 ","$1,193.50 ",$511.50 ,"$1,108.25 ","$1,227.60 ","$1,551.55 ","$1,278.75 "
Carle BroMenn Medical Center,8213133,"REPR,FACE,GENITAL,HAND,FT+5 CMCM/<",,13133,510,$605.00 ,$605.00 ,$181.50 ,$550.55 ,$423.50 ,$181.50 ,$393.25 ,$435.60 ,$550.55 ,$453.75 
Carle BroMenn Medical Center,8213151,"RECMPL WND LID,NOS,EAR 1.1-2.5 CM",,13151,510,"$1,400.00 ","$1,400.00 ",$420.00 ,"$1,274.00 ",$980.00 ,$420.00 ,$910.00 ,"$1,008.00 ","$1,274.00 ","$1,050.00 "
Carle BroMenn Medical Center,8213152,"RECMPL WND LID,NOS,EAR 2.5-7.5 CM",,13152,510,"$1,630.00 ","$1,630.00 ",$489.00 ,"$1,483.30 ","$1,141.00 ",$489.00 ,"$1,059.50 ","$1,173.60 ","$1,483.30 ","$1,222.50 "
Carle BroMenn Medical Center,8213153,"REPR,EYELID,NOSE,EAR,LIP+5 CM",,13153,510,$760.00 ,$760.00 ,$228.00 ,$691.60 ,$532.00 ,$228.00 ,$494.00 ,$547.20 ,$691.60 ,$570.00 
Carle BroMenn Medical Center,8214000,ADJ TISS XFER TRUNK <10 SQCM,,14000,510,"$2,830.00 ","$2,830.00 ",$849.00 ,"$2,575.30 ","$1,981.00 ",$849.00 ,"$1,839.50 ","$2,037.60 ","$2,575.30 ","$2,122.50 "
Carle BroMenn Medical Center,8214001,ADJ TISS XFER TRUNK DEFECT 10.1SQCM TO 30SQCM,,14001,510,"$3,040.00 ","$3,040.00 ",$912.00 ,"$2,766.40 ","$2,128.00 ",$912.00 ,"$1,976.00 ","$2,188.80 ","$2,766.40 ","$2,280.00 "
Carle BroMenn Medical Center,8214020,"ADJ TISS XFER SCALP,EXTREM <10 SQCM",,14020,510,"$2,020.00 ","$2,020.00 ",$606.00 ,"$1,838.20 ","$1,414.00 ",$606.00 ,"$1,313.00 ","$1,454.40 ","$1,838.20 ","$1,515.00 "
Carle BroMenn Medical Center,8214021,"ADJ TISS XFER SCALP,EXTREM 10.1-30 SQCM",,14021,510,"$4,070.00 ","$4,070.00 ","$1,221.00 ","$3,703.70 ","$2,849.00 ","$1,221.00 ","$2,645.50 ","$2,930.40 ","$3,703.70 ","$3,052.50 "
Carle BroMenn Medical Center,8214040,ADJ TISS XFER TRUNK <10 SQCM,,14040,510,"$4,010.00 ","$4,010.00 ","$1,203.00 ","$3,649.10 ","$2,807.00 ","$1,203.00 ","$2,606.50 ","$2,887.20 ","$3,649.10 ","$3,007.50 "
Carle BroMenn Medical Center,8214041,ADJ TISS XFER TRUNK <10 SQCM,,14041,510,"$4,070.00 ","$4,070.00 ","$1,221.00 ","$3,703.70 ","$2,849.00 ","$1,221.00 ","$2,645.50 ","$2,930.40 ","$3,703.70 ","$3,052.50 "
Carle BroMenn Medical Center,8214060,ADJ TISS XFER TRUNK <10 SQCM,,14060,510,"$4,070.00 ","$4,070.00 ","$1,221.00 ","$3,703.70 ","$2,849.00 ","$1,221.00 ","$2,645.50 ","$2,930.40 ","$3,703.70 ","$3,052.50 "
Carle BroMenn Medical Center,8214061,ADJ TISS XFER TRUNK <10 SQCM,,14061,510,"$4,070.00 ","$4,070.00 ","$1,221.00 ","$3,703.70 ","$2,849.00 ","$1,221.00 ","$2,645.50 ","$2,930.40 ","$3,703.70 ","$3,052.50 "
Carle BroMenn Medical Center,8214301,"ADJ TISS XFER ANY AREA,30.1-60 SQCM",,14301,510,"$5,980.00 ","$5,980.00 ","$1,794.00 ","$5,441.80 ","$4,186.00 ","$1,794.00 ","$3,887.00 ","$4,305.60 ","$5,441.80 ","$4,485.00 "
Carle BroMenn Medical Center,8214302,"ADJ TISS XFER ANY AREA,EA ADD 30.0 SQCM",,14302,510,"$2,740.00 ","$2,740.00 ",$822.00 ,"$2,493.40 ","$1,918.00 ",$822.00 ,"$1,781.00 ","$1,972.80 ","$2,493.40 ","$2,055.00 "
Carle BroMenn Medical Center,8215002,"WOUND PREP, PED, TRK/ARM/LG 1ST 100 CM",,15002,510,"$1,300.00 ","$1,300.00 ",$390.00 ,"$1,183.00 ",$910.00 ,$390.00 ,$845.00 ,$936.00 ,"$1,183.00 ",$975.00 
Carle BroMenn Medical Center,8215220,"FULL THICK GRFT SCALP,ARM,LEG <20SQC",,15220,510,"$4,680.00 ","$4,680.00 ","$1,404.00 ","$4,258.80 ","$3,276.00 ","$1,404.00 ","$3,042.00 ","$3,369.60 ","$4,258.80 ","$3,510.00 "
Carle BroMenn Medical Center,8215221,"FULL THICK GRFT SCALP,ARM ADD 20 SQCM",,15221,510,$970.00 ,$970.00 ,$291.00 ,$882.70 ,$679.00 ,$291.00 ,$630.50 ,$698.40 ,$882.70 ,$727.50 
Carle BroMenn Medical Center,8215240,"FULL THICK GRFT HEAD,FAC,HAND <20SQC",,15240,510,"$4,070.00 ","$4,070.00 ","$1,221.00 ","$3,703.70 ","$2,849.00 ","$1,221.00 ","$2,645.50 ","$2,930.40 ","$3,703.70 ","$3,052.50 "
Carle BroMenn Medical Center,8215241,"FULL TICK GRFT HEAD,FAC,HAND EA ADD 20SQC",,15241,510,$620.00 ,$620.00 ,$186.00 ,$564.20 ,$434.00 ,$186.00 ,$403.00 ,$446.40 ,$564.20 ,$465.00 
Carle BroMenn Medical Center,8215260,"FULL THICK GRFT NOS,EAR,LID <20 SQCM",,15260,510,"$4,070.00 ","$4,070.00 ","$1,221.00 ","$3,703.70 ","$2,849.00 ","$1,221.00 ","$2,645.50 ","$2,930.40 ","$3,703.70 ","$3,052.50 "
Carle BroMenn Medical Center,8215261,"FULL THICK GRFT NOS,EAR,LID ADD 20SQ",,15261,510,"$1,210.00 ","$1,210.00 ",$363.00 ,"$1,101.10 ",$847.00 ,$363.00 ,$786.50 ,$871.20 ,"$1,101.10 ",$907.50 
Carle BroMenn Medical Center,8215271,APP SKN SUB GRFT T/A/L AREA/<100SCM /<1ST 25 SCM,,15271,510,"$2,975.00 ","$2,975.00 ",$892.50 ,"$2,707.25 ","$2,082.50 ",$892.50 ,"$1,933.75 ","$2,142.00 ","$2,707.25 ","$2,231.25 "
Carle BroMenn Medical Center,8215272,APP SKN SUB GRFT T/A/L AREA/<100SCM EA ADL 25SCM,,15272,510,$630.00 ,$630.00 ,$189.00 ,$573.30 ,$441.00 ,$189.00 ,$409.50 ,$453.60 ,$573.30 ,$472.50 
Carle BroMenn Medical Center,8215275,SUB GRFT F/S/N/H/F/G/M/D /<100SCM /<1ST 25 SCM,,15275,510,"$2,975.00 ","$2,975.00 ",$892.50 ,"$2,707.25 ","$2,082.50 ",$892.50 ,"$1,933.75 ","$2,142.00 ","$2,707.25 ","$2,231.25 "
Carle BroMenn Medical Center,8215277,SUB GRFT F/S/N/H/F/G/M/D />100SCM 1ST 100SCM,,15277,510,"$3,850.00 ","$3,850.00 ","$1,155.00 ","$3,503.50 ","$2,695.00 ","$1,155.00 ","$2,502.50 ","$2,772.00 ","$3,503.50 ","$2,887.50 "
Carle BroMenn Medical Center,8215576,PEDICLE FLAP REPAIR EYELD/NOSE/EAR/LIP/INTRAORAL,,15576,510,"$4,420.00 ","$4,420.00 ","$1,326.00 ","$4,022.20 ","$3,094.00 ","$1,326.00 ","$2,873.00 ","$3,182.40 ","$4,022.20 ","$3,315.00 "
Carle BroMenn Medical Center,8215730,MIDFACE FLAP W/PRESERVATION OF VASCULAR PEDICLES,,15730,510,"$4,140.00 ","$4,140.00 ","$1,242.00 ","$3,767.40 ","$2,898.00 ","$1,242.00 ","$2,691.00 ","$2,980.80 ","$3,767.40 ","$3,105.00 "
Carle BroMenn Medical Center,8215733,MUSC MYOQ/FSCQ FLAP HEAD&NECK W/NAMED VASC PEDCL,,15733,510,"$4,260.00 ","$4,260.00 ","$1,278.00 ","$3,876.60 ","$2,982.00 ","$1,278.00 ","$2,769.00 ","$3,067.20 ","$3,876.60 ","$3,195.00 "
Carle BroMenn Medical Center,8215769,GRAFTING OF AUTOLOGOUS SOFT TISS BY DIRECT EXC,,15769,510,"$5,960.00 ","$5,960.00 ","$1,788.00 ","$5,423.60 ","$4,172.00 ","$1,788.00 ","$3,874.00 ","$4,291.20 ","$5,423.60 ","$4,470.00 "
Carle BroMenn Medical Center,8215771,GRAFTING OF AUTOLOGOUS FAT BY LIPO 50 CC OR LESS,,15771,510,"$5,960.00 ","$5,960.00 ","$1,788.00 ","$5,423.60 ","$4,172.00 ","$1,788.00 ","$3,874.00 ","$4,291.20 ","$5,423.60 ","$4,470.00 "
Carle BroMenn Medical Center,8215772,GRAFTING OF AUTOLOGOUS FAT BY LIPO EA ADDL 50 CC,,15772,510,"$3,580.00 ","$3,580.00 ","$1,074.00 ","$3,257.80 ","$2,506.00 ","$1,074.00 ","$2,327.00 ","$2,577.60 ","$3,257.80 ","$2,685.00 "
Carle BroMenn Medical Center,8215773,GRAFTING OF AUTOLOGOUS FAT BY LIPO 25 CC OR LESS,,15773,510,"$3,260.00 ","$3,260.00 ",$978.00 ,"$2,966.60 ","$2,282.00 ",$978.00 ,"$2,119.00 ","$2,347.20 ","$2,966.60 ","$2,445.00 "
Carle BroMenn Medical Center,8215774,GRAFTING OF AUTOLOGOUS FAT BY LIPO EA ADDL 25 CC,,15774,510,"$1,950.00 ","$1,950.00 ",$585.00 ,"$1,774.50 ","$1,365.00 ",$585.00 ,"$1,267.50 ","$1,404.00 ","$1,774.50 ","$1,462.50 "
Carle BroMenn Medical Center,8215788,"CHEM PEEL, FACE, EPIDERM",,15788,510,"$1,250.00 ","$1,250.00 ",$375.00 ,"$1,137.50 ",$875.00 ,$375.00 ,$812.50 ,$900.00 ,"$1,137.50 ",$937.50 
Carle BroMenn Medical Center,8215823,BLEPHAROPLASTY,,15823,510,"$2,790.00 ","$2,790.00 ",$837.00 ,"$2,538.90 ","$1,953.00 ",$837.00 ,"$1,813.50 ","$2,008.80 ","$2,538.90 ","$2,092.50 "
Carle BroMenn Medical Center,8215839,"EXCISE EXCESS SKIN TISSUE,OTHER",,15839,510,"$5,080.00 ","$5,080.00 ","$1,524.00 ","$4,622.80 ","$3,556.00 ","$1,524.00 ","$3,302.00 ","$3,657.60 ","$4,622.80 ","$3,810.00 "
Carle BroMenn Medical Center,8215850,REM SUTURES W ANESTH SAME SURGEON,,15850,510,$365.00 ,$365.00 ,$109.50 ,$332.15 ,$255.50 ,$109.50 ,$237.25 ,$262.80 ,$332.15 ,$273.75 
Carle BroMenn Medical Center,8215851,REM SUTURES W ANESTH OTHR SURGEON,,15851,510,"$1,120.00 ","$1,120.00 ",$336.00 ,"$1,019.20 ",$784.00 ,$336.00 ,$728.00 ,$806.40 ,"$1,019.20 ",$840.00 
Carle BroMenn Medical Center,8215852,"DRESSING CHANGE,NOT FOR BURN",,15852,510,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8216000,INITIAL RX BURN(S) 1ST DEGREE [EAP 16000],,16000,510,$420.00 ,$420.00 ,$126.00 ,$382.20 ,$294.00 ,$126.00 ,$273.00 ,$302.40 ,$382.20 ,$315.00 
Carle BroMenn Medical Center,8216020,DRESS/DEBRID SMALL BURN NO ANES,,16020,510,$580.00 ,$580.00 ,$174.00 ,$527.80 ,$406.00 ,$174.00 ,$377.00 ,$417.60 ,$527.80 ,$435.00 
Carle BroMenn Medical Center,8216025,DRESS/DEBRID MED BURN NO ANESTH,,16025,510,$620.00 ,$620.00 ,$186.00 ,$564.20 ,$434.00 ,$186.00 ,$403.00 ,$446.40 ,$564.20 ,$465.00 
Carle BroMenn Medical Center,8216030,DRESS/DEBRID LARGE BURN NO ANESTH,,16030,510,$790.00 ,$790.00 ,$237.00 ,$718.90 ,$553.00 ,$237.00 ,$513.50 ,$568.80 ,$718.90 ,$592.50 
Carle BroMenn Medical Center,8217000,DESTRUCTION PREMALIGNANT LSN FIRST,,17000,510,$385.00 ,$385.00 ,$115.50 ,$350.35 ,$269.50 ,$115.50 ,$250.25 ,$277.20 ,$350.35 ,$288.75 
Carle BroMenn Medical Center,8217003,DESTRUCTION PREMALIGNANT LSN 2ND-14 EACH,,17003,510,$50.00 ,$50.00 ,$15.00 ,$45.50 ,$35.00 ,$15.00 ,$32.50 ,$36.00 ,$45.50 ,$37.50 
Carle BroMenn Medical Center,8217004,DSTRCTN PREMALG 15+ LSNS,,17004,510,$810.00 ,$810.00 ,$243.00 ,$737.10 ,$567.00 ,$243.00 ,$526.50 ,$583.20 ,$737.10 ,$607.50 
Carle BroMenn Medical Center,8217106,DESTRCT CUTNS VASC LSNS > 20 SQ CM,,17106,510,$920.00 ,$920.00 ,$276.00 ,$837.20 ,$644.00 ,$276.00 ,$598.00 ,$662.40 ,$837.20 ,$690.00 
Carle BroMenn Medical Center,8217107,DESTRCT CUTNS VASC LSNS 10.1 TO 50.0 SQ CM,,17107,510,"$1,510.00 ","$1,510.00 ",$453.00 ,"$1,374.10 ","$1,057.00 ",$453.00 ,$981.50 ,"$1,087.20 ","$1,374.10 ","$1,132.50 "
Carle BroMenn Medical Center,8217108,DESTRCT CUTNS VASC LNS OVER 50.0 SQ CM,,17108,510,"$3,820.00 ","$3,820.00 ","$1,146.00 ","$3,476.20 ","$2,674.00 ","$1,146.00 ","$2,483.00 ","$2,750.40 ","$3,476.20 ","$2,865.00 "
Carle BroMenn Medical Center,8217110,DESTRUCTION BENIGN LESIONS UP TO 14,,17110,510,$475.00 ,$475.00 ,$142.50 ,$432.25 ,$332.50 ,$142.50 ,$308.75 ,$342.00 ,$432.25 ,$356.25 
Carle BroMenn Medical Center,8217111,DESTRUCTION BENIGN LESIONS 15 OR MORE,,17111,510,$450.00 ,$450.00 ,$135.00 ,$409.50 ,$315.00 ,$135.00 ,$292.50 ,$324.00 ,$409.50 ,$337.50 
Carle BroMenn Medical Center,8217250,CHEM CAUTERY GRANULATN TISSUE,,17250,510,$415.00 ,$415.00 ,$124.50 ,$377.65 ,$290.50 ,$124.50 ,$269.75 ,$298.80 ,$377.65 ,$311.25 
Carle BroMenn Medical Center,8217260,"DESTR MALIG TRUNK,EXTREM <0.6 CM",,17260,510,$370.00 ,$370.00 ,$111.00 ,$336.70 ,$259.00 ,$111.00 ,$240.50 ,$266.40 ,$336.70 ,$277.50 
Carle BroMenn Medical Center,8217261,"DESTR MALIG TRUNK,EXTREM 0.6-1 CM",,17261,510,$450.00 ,$450.00 ,$135.00 ,$409.50 ,$315.00 ,$135.00 ,$292.50 ,$324.00 ,$409.50 ,$337.50 
Carle BroMenn Medical Center,8217262,"DESTR MALIG TRUNK,EXTREM 1.1-2 CM",,17262,510,$450.00 ,$450.00 ,$135.00 ,$409.50 ,$315.00 ,$135.00 ,$292.50 ,$324.00 ,$409.50 ,$337.50 
Carle BroMenn Medical Center,8217263,"DESTR MALIG TRUNK,EXTREM 2.1-3 CM",,17263,510,$510.00 ,$510.00 ,$153.00 ,$464.10 ,$357.00 ,$153.00 ,$331.50 ,$367.20 ,$464.10 ,$382.50 
Carle BroMenn Medical Center,8217264,"DESTR MALIG TRUNK,EXTREM 3.1-4 CM",,17264,510,$810.00 ,$810.00 ,$243.00 ,$737.10 ,$567.00 ,$243.00 ,$526.50 ,$583.20 ,$737.10 ,$607.50 
Carle BroMenn Medical Center,8217266,"DESTR MALIG TRUNK,EXTREM >4.0 CM",,17266,510,$810.00 ,$810.00 ,$243.00 ,$737.10 ,$567.00 ,$243.00 ,$526.50 ,$583.20 ,$737.10 ,$607.50 
Carle BroMenn Medical Center,8217270,"DESTR MALIG SCAL,NCK,HAND <0.6 CM",,17270,510,$450.00 ,$450.00 ,$135.00 ,$409.50 ,$315.00 ,$135.00 ,$292.50 ,$324.00 ,$409.50 ,$337.50 
Carle BroMenn Medical Center,8217271,"DESTR MALIG SCAL,NCK,HAND 0.6-1 CM",,17271,510,$450.00 ,$450.00 ,$135.00 ,$409.50 ,$315.00 ,$135.00 ,$292.50 ,$324.00 ,$409.50 ,$337.50 
Carle BroMenn Medical Center,8217272,"DESTR MALIG SCAL,NCK,HAND 1.1-2 CM",,17272,510,$485.00 ,$485.00 ,$145.50 ,$441.35 ,$339.50 ,$145.50 ,$315.25 ,$349.20 ,$441.35 ,$363.75 
Carle BroMenn Medical Center,8217273,"DESTR MALIG SCAL,NCK,HAND 2.1-3 CM",,17273,510,$580.00 ,$580.00 ,$174.00 ,$527.80 ,$406.00 ,$174.00 ,$377.00 ,$417.60 ,$527.80 ,$435.00 
Carle BroMenn Medical Center,8217274,"DESTR MALIG SCAL,NCK,HAND 3.1-4 CM",,17274,510,$680.00 ,$680.00 ,$204.00 ,$618.80 ,$476.00 ,$204.00 ,$442.00 ,$489.60 ,$618.80 ,$510.00 
Carle BroMenn Medical Center,8217276,"DESTR MALIG SCAL,NCK,HAND >4 CM",,17276,510,$810.00 ,$810.00 ,$243.00 ,$737.10 ,$567.00 ,$243.00 ,$526.50 ,$583.20 ,$737.10 ,$607.50 
Carle BroMenn Medical Center,8217280,"DESTR MALIG FACE,NOSE,LIP <0.6 CM",,17280,510,$450.00 ,$450.00 ,$135.00 ,$409.50 ,$315.00 ,$135.00 ,$292.50 ,$324.00 ,$409.50 ,$337.50 
Carle BroMenn Medical Center,8217281,"DESTR MALIG FACE,NOSE,LIP 0.6-1 CM",,17281,510,$780.00 ,$780.00 ,$234.00 ,$709.80 ,$546.00 ,$234.00 ,$507.00 ,$561.60 ,$709.80 ,$585.00 
Carle BroMenn Medical Center,8217282,"DESTR MALIG FACE,NOSE,LIP 1.1-2 CM",,17282,510,$810.00 ,$810.00 ,$243.00 ,$737.10 ,$567.00 ,$243.00 ,$526.50 ,$583.20 ,$737.10 ,$607.50 
Carle BroMenn Medical Center,8217283,"DESTR MALIG FACE,NOSE,LIP 2.1-3 CM",,17283,510,$710.00 ,$710.00 ,$213.00 ,$646.10 ,$497.00 ,$213.00 ,$461.50 ,$511.20 ,$646.10 ,$532.50 
Carle BroMenn Medical Center,8217284,"DESTR MALIG FACE,NOSE,LIP 3.1-4 CM",,17284,510,$770.00 ,$770.00 ,$231.00 ,$700.70 ,$539.00 ,$231.00 ,$500.50 ,$554.40 ,$700.70 ,$577.50 
Carle BroMenn Medical Center,8217286,"DESTR MALIG FACE,NOSE,LIP >4 CM",,17286,510,$880.00 ,$880.00 ,$264.00 ,$800.80 ,$616.00 ,$264.00 ,$572.00 ,$633.60 ,$800.80 ,$660.00 
Carle BroMenn Medical Center,8217310,"Mohs, 1 Stage, Head/neck/hand/feet/gential",,17311,510,"$1,250.00 ","$1,250.00 ",$375.00 ,"$1,137.50 ",$875.00 ,$375.00 ,$812.50 ,$900.00 ,"$1,137.50 ",$937.50 
Carle BroMenn Medical Center,8217312,"Mohs, Addl Stage, Head/neck/hand/feet/gential",,17312,510,$970.00 ,$970.00 ,$291.00 ,$882.70 ,$679.00 ,$291.00 ,$630.50 ,$698.40 ,$882.70 ,$727.50 
Carle BroMenn Medical Center,8217313,"Mohs, 1 Stage, Trunk/arm/leg",,17313,510,"$1,250.00 ","$1,250.00 ",$375.00 ,"$1,137.50 ",$875.00 ,$375.00 ,$812.50 ,$900.00 ,"$1,137.50 ",$937.50 
Carle BroMenn Medical Center,8217314,"Mohs, Addl Stage, Trunk/arm/leg",,17314,510,$920.00 ,$920.00 ,$276.00 ,$837.20 ,$644.00 ,$276.00 ,$598.00 ,$662.40 ,$837.20 ,$690.00 
Carle BroMenn Medical Center,8217315,"Mohs Surg, Addl Block",,17315,510,$225.00 ,$225.00 ,$67.50 ,$204.75 ,$157.50 ,$67.50 ,$146.25 ,$162.00 ,$204.75 ,$168.75 
Carle BroMenn Medical Center,8217340,CRYOTHERAPY ACNE,,17340,510,$165.00 ,$165.00 ,$49.50 ,$150.15 ,$115.50 ,$49.50 ,$107.25 ,$118.80 ,$150.15 ,$123.75 
Carle BroMenn Medical Center,8217360,SKIN PEEL THERAPY ACNE,,17360,510,$335.00 ,$335.00 ,$100.50 ,$304.85 ,$234.50 ,$100.50 ,$217.75 ,$241.20 ,$304.85 ,$251.25 
Carle BroMenn Medical Center,8217999,SKIN TISSUE PROCEDURE UNLISTED,,17999,510,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8219000,PUNCTURE ASPRTN CYST OF BREAST,,19000,510,"$1,530.00 ","$1,530.00 ",$459.00 ,"$1,392.30 ","$1,071.00 ",$459.00 ,$994.50 ,"$1,101.60 ","$1,392.30 ","$1,147.50 "
Carle BroMenn Medical Center,8219020,EXPLOR/DRAIN BREAST ABSCESS,,19020,510,"$3,700.00 ","$3,700.00 ","$1,110.00 ","$3,367.00 ","$2,590.00 ","$1,110.00 ","$2,405.00 ","$2,664.00 ","$3,367.00 ","$2,775.00 "
Carle BroMenn Medical Center,8219100,"BIOPSY OF BREAST, NEEDLE CORE",,19100,510,"$1,560.00 ","$1,560.00 ",$468.00 ,"$1,419.60 ","$1,092.00 ",$468.00 ,"$1,014.00 ","$1,123.20 ","$1,419.60 ","$1,170.00 "
Carle BroMenn Medical Center,8219294,PREP TUMOR CAVITY IORT W/PARTIAL MASTECTOMY,,19294,510,$760.00 ,$760.00 ,$228.00 ,$691.60 ,$532.00 ,$228.00 ,$494.00 ,$547.20 ,$691.60 ,$570.00 
Carle BroMenn Medical Center,8219318,REDUCTION OF LARGE BREAST,,19318,510,"$6,430.00 ","$6,430.00 ","$1,929.00 ","$5,851.30 ","$4,501.00 ","$1,929.00 ","$4,179.50 ","$4,629.60 ","$5,851.30 ","$4,822.50 "
Carle BroMenn Medical Center,8220200,MUSCLE BIOPSY,,20200,510,"$2,530.00 ","$2,530.00 ",$759.00 ,"$2,302.30 ","$1,771.00 ",$759.00 ,"$1,644.50 ","$1,821.60 ","$2,302.30 ","$1,897.50 "
Carle BroMenn Medical Center,8220205,DEEP MUSCLE BIOPSY,,20205,510,"$3,140.00 ","$3,140.00 ",$942.00 ,"$2,857.40 ","$2,198.00 ",$942.00 ,"$2,041.00 ","$2,260.80 ","$2,857.40 ","$2,355.00 "
Carle BroMenn Medical Center,8220206,"NEEDLE BIOPSY,MUSCLE",,20206,510,"$2,574.00 ","$2,574.00 ",$772.20 ,"$2,342.34 ","$1,801.80 ",$772.20 ,"$1,673.10 ","$1,853.28 ","$2,342.34 ","$1,930.50 "
Carle BroMenn Medical Center,8220240,"BONE BIOPSY,EXCISIONAL SUPERF",,20240,510,"$6,445.00 ","$6,445.00 ","$1,933.50 ","$5,864.95 ","$4,511.50 ","$1,933.50 ","$4,189.25 ","$4,640.40 ","$5,864.95 ","$4,833.75 "
Carle BroMenn Medical Center,8220520,REMOVAL OF FOREIGN BODY,,20520,510,"$1,155.00 ","$1,155.00 ",$346.50 ,"$1,051.05 ",$808.50 ,$346.50 ,$750.75 ,$831.60 ,"$1,051.05 ",$866.25 
Carle BroMenn Medical Center,8220526,INJECT CARPAL TUNNEL,,20526,510,$520.00 ,$520.00 ,$156.00 ,$473.20 ,$364.00 ,$156.00 ,$338.00 ,$374.40 ,$473.20 ,$390.00 
Carle BroMenn Medical Center,8220550,INJECT TENDON SHEATH/LIGAMENT,,20550,510,$655.00 ,$655.00 ,$196.50 ,$596.05 ,$458.50 ,$196.50 ,$425.75 ,$471.60 ,$596.05 ,$491.25 
Carle BroMenn Medical Center,8220551,INJ SINGLE TENDON ORIGIN/INSRTN,,20551,510,$420.00 ,$420.00 ,$126.00 ,$382.20 ,$294.00 ,$126.00 ,$273.00 ,$302.40 ,$382.20 ,$315.00 
Carle BroMenn Medical Center,8220552,"INJECT TRIGGER POINT, 1 OR 2",,20552,510,$760.00 ,$760.00 ,$228.00 ,$691.60 ,$532.00 ,$228.00 ,$494.00 ,$547.20 ,$691.60 ,$570.00 
Carle BroMenn Medical Center,8220553,"INJECT TRIGGER POINTS, > 3",,20553,510,$760.00 ,$760.00 ,$228.00 ,$691.60 ,$532.00 ,$228.00 ,$494.00 ,$547.20 ,$691.60 ,$570.00 
Carle BroMenn Medical Center,8220560,Hc Needle Insertion W/o Injection 1 Or 2 Muscles,,20560,510,$215.00 ,$215.00 ,$64.50 ,$195.65 ,$150.50 ,$64.50 ,$139.75 ,$154.80 ,$195.65 ,$161.25 
Carle BroMenn Medical Center,8220561,NEEDLE INSERTION W/O INJECTION 3 OR MORE MUSCLES,,20561,510,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8220580,Ccm add 20min,,G2058,510,$115.00 ,$115.00 ,$34.50 ,$104.65 ,$80.50 ,$34.50 ,$74.75 ,$82.80 ,$104.65 ,$86.25 
Carle BroMenn Medical Center,8220600,DRAIN/INJECT SMALL JOINT/BURSA,,20600,510,$500.00 ,$500.00 ,$150.00 ,$455.00 ,$350.00 ,$150.00 ,$325.00 ,$360.00 ,$455.00 ,$375.00 
Carle BroMenn Medical Center,8220604,ARTHROCNT ASPIR&/INJ SMALL JT/BURSAW/US REC RPRT,,20604,510,$640.00 ,$640.00 ,$192.00 ,$582.40 ,$448.00 ,$192.00 ,$416.00 ,$460.80 ,$582.40 ,$480.00 
Carle BroMenn Medical Center,8220605,DRAIN/INJECT INTERMEDIATE JOINT/BURSA,,20605,510,$830.00 ,$830.00 ,$249.00 ,$755.30 ,$581.00 ,$249.00 ,$539.50 ,$597.60 ,$755.30 ,$622.50 
Carle BroMenn Medical Center,8220606,ARTHROCENTESIS ASPIR&/INJ INTERM JT/BURS W/US,,20606,510,"$1,041.00 ","$1,041.00 ",$312.30 ,$947.31 ,$728.70 ,$312.30 ,$676.65 ,$749.52 ,$947.31 ,$780.75 
Carle BroMenn Medical Center,8220610,DRAIN/INJECT LARGE JOINT/BURSA,,20610,510,$630.00 ,$630.00 ,$189.00 ,$573.30 ,$441.00 ,$189.00 ,$409.50 ,$453.60 ,$573.30 ,$472.50 
Carle BroMenn Medical Center,8220611,ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US,,20611,510,$760.00 ,$760.00 ,$228.00 ,$691.60 ,$532.00 ,$228.00 ,$494.00 ,$547.20 ,$691.60 ,$570.00 
Carle BroMenn Medical Center,8220612,ASPIRAT/INJECTION GANGLION CYST(S),,20612,510,$825.00 ,$825.00 ,$247.50 ,$750.75 ,$577.50 ,$247.50 ,$536.25 ,$594.00 ,$750.75 ,$618.75 
Carle BroMenn Medical Center,8220650,INSERT AND REMOVE BONE PIN,,20650,510,"$1,910.00 ","$1,910.00 ",$573.00 ,"$1,738.10 ","$1,337.00 ",$573.00 ,"$1,241.50 ","$1,375.20 ","$1,738.10 ","$1,432.50 "
Carle BroMenn Medical Center,8220661,APPLY/REMOVE HALO CRANIAL,,20661,510,"$1,900.00 ","$1,900.00 ",$570.00 ,"$1,729.00 ","$1,330.00 ",$570.00 ,"$1,235.00 ","$1,368.00 ","$1,729.00 ","$1,425.00 "
Carle BroMenn Medical Center,8220665,REMOVAL FIXATION DEVICE,,20665,510,$413.00 ,$413.00 ,$123.90 ,$375.83 ,$289.10 ,$123.90 ,$268.45 ,$297.36 ,$375.83 ,$309.75 
Carle BroMenn Medical Center,8220670,REMOVAL SUPERFICIAL IMPLANT,,20670,510,"$1,140.00 ","$1,140.00 ",$342.00 ,"$1,037.40 ",$798.00 ,$342.00 ,$741.00 ,$820.80 ,"$1,037.40 ",$855.00 
Carle BroMenn Medical Center,8220680,REMOVAL DEEP IMPLANT,,20680,510,"$3,290.00 ","$3,290.00 ",$987.00 ,"$2,993.90 ","$2,303.00 ",$987.00 ,"$2,138.50 ","$2,368.80 ","$2,993.90 ","$2,467.50 "
Carle BroMenn Medical Center,8220700,MANUAL PREP AND INSERTION DEEP DRUG DELIVERY DEV,,20700,510,$470.00 ,$470.00 ,$141.00 ,$427.70 ,$329.00 ,$141.00 ,$305.50 ,$338.40 ,$427.70 ,$352.50 
Carle BroMenn Medical Center,8220701,REMOVAL DEEP DRUG DELIVERY DEVICE,,20701,510,$305.00 ,$305.00 ,$91.50 ,$277.55 ,$213.50 ,$91.50 ,$198.25 ,$219.60 ,$277.55 ,$228.75 
Carle BroMenn Medical Center,8220702,MANUAL PREP&INSJ INTRAMEDULLARY DRUG DLVR DEVICE,,20702,510,$590.00 ,$590.00 ,$177.00 ,$536.90 ,$413.00 ,$177.00 ,$383.50 ,$424.80 ,$536.90 ,$442.50 
Carle BroMenn Medical Center,8220703,REMOVAL INTRAMEDULLARY DRUG DELIVERY DEVICE,,20703,510,$385.00 ,$385.00 ,$115.50 ,$350.35 ,$269.50 ,$115.50 ,$250.25 ,$277.20 ,$350.35 ,$288.75 
Carle BroMenn Medical Center,8220704,MANUAL PREP&INSJ I-ARTIC DRUG DELIVERY DEVICE,,20704,510,$740.00 ,$740.00 ,$222.00 ,$673.40 ,$518.00 ,$222.00 ,$481.00 ,$532.80 ,$673.40 ,$555.00 
Carle BroMenn Medical Center,8220705,REMOVAL INTRA-ARTICULAR DRUG DELIVERY DEVICE,,20705,510,$485.00 ,$485.00 ,$145.50 ,$441.35 ,$339.50 ,$145.50 ,$315.25 ,$349.20 ,$441.35 ,$363.75 
Carle BroMenn Medical Center,8220820,Visit esketamine 56m or less,,G2082,510,$880.00 ,$880.00 ,$264.00 ,$800.80 ,$616.00 ,$264.00 ,$572.00 ,$633.60 ,$800.80 ,$660.00 
Carle BroMenn Medical Center,8220830,"Visit esketamine, > 56m",,G2083,510,"$1,270.00 ","$1,270.00 ",$381.00 ,"$1,155.70 ",$889.00 ,$381.00 ,$825.50 ,$914.40 ,"$1,155.70 ",$952.50 
Carle BroMenn Medical Center,8220860,Off base opioid tx 70min,,G2086,510,$180.00 ,$180.00 ,$54.00 ,$163.80 ,$126.00 ,$54.00 ,$117.00 ,$129.60 ,$163.80 ,$135.00 
Carle BroMenn Medical Center,8220870,"Off base opioid tx, 60 m",,G2087,510,$135.00 ,$135.00 ,$40.50 ,$122.85 ,$94.50 ,$40.50 ,$87.75 ,$97.20 ,$122.85 ,$101.25 
Carle BroMenn Medical Center,8220880,"Off base opioid tx, add30",,G2088,510,$110.00 ,$110.00 ,$33.00 ,$100.10 ,$77.00 ,$33.00 ,$71.50 ,$79.20 ,$100.10 ,$82.50 
Carle BroMenn Medical Center,8220900,REMV BONE FOR GRAFT MINOR,,20900,510,"$4,750.00 ","$4,750.00 ","$1,425.00 ","$4,322.50 ","$3,325.00 ","$1,425.00 ","$3,087.50 ","$3,420.00 ","$4,322.50 ","$3,562.50 "
Carle BroMenn Medical Center,8220926,REMV TISSUE FOR GRAFT OTHR,,20926,510,"$1,960.00 ","$1,960.00 ",$588.00 ,"$1,783.60 ","$1,372.00 ",$588.00 ,"$1,274.00 ","$1,411.20 ","$1,783.60 ","$1,470.00 "
Carle BroMenn Medical Center,8220939,BONE MARROW ASPIRATION BONE GRFG SPI SURG ONLY,,20939,510,$990.00 ,$990.00 ,$297.00 ,$900.90 ,$693.00 ,$297.00 ,$643.50 ,$712.80 ,$900.90 ,$742.50 
Carle BroMenn Medical Center,8220950,MONTR INTRSTAL FLUID PRESSURE,,20950,510,$325.00 ,$325.00 ,$97.50 ,$295.75 ,$227.50 ,$97.50 ,$211.25 ,$234.00 ,$295.75 ,$243.75 
Carle BroMenn Medical Center,8220962,"MICROVASCULAR BONE GRAFT,OTHER",,20962,510,"$6,060.00 ","$6,060.00 ","$1,818.00 ","$5,514.60 ","$4,242.00 ","$1,818.00 ","$3,939.00 ","$4,363.20 ","$5,514.60 ","$4,545.00 "
Carle BroMenn Medical Center,8220983,ABLATJ BONE TUMOR CRYO PERQ W/IMG GDN WHEN PRFMD,,20983,510,"$9,010.00 ","$9,010.00 ","$2,703.00 ","$8,199.10 ","$6,307.00 ","$2,703.00 ","$5,856.50 ","$6,487.20 ","$8,199.10 ","$6,757.50 "
Carle BroMenn Medical Center,8221008,FINE NEEDLE ASPIRATION BX W/FLUOR GDN EA ADDL,,10008,510,$190.00 ,$190.00 ,$57.00 ,$172.90 ,$133.00 ,$57.00 ,$123.50 ,$136.80 ,$172.90 ,$142.50 
Carle BroMenn Medical Center,8221009,FINE NEEDLE ASPIRATION BX W/CT GDN 1ST LESION,,10009,510,"$1,560.00 ","$1,560.00 ",$468.00 ,"$1,419.60 ","$1,092.00 ",$468.00 ,"$1,014.00 ","$1,123.20 ","$1,419.60 ","$1,170.00 "
Carle BroMenn Medical Center,8221011,EXCISION TUMOR SOFT TISS FACE/SCALP SUBQ < 2CM,,21011,510,"$2,350.00 ","$2,350.00 ",$705.00 ,"$2,138.50 ","$1,645.00 ",$705.00 ,"$1,527.50 ","$1,692.00 ","$2,138.50 ","$1,762.50 "
Carle BroMenn Medical Center,8221012,EXCISION TUMOR SOFT TISS FACE/SCALP SUBQ 2+CM,,21012,510,"$3,070.00 ","$3,070.00 ",$921.00 ,"$2,793.70 ","$2,149.00 ",$921.00 ,"$1,995.50 ","$2,210.40 ","$2,793.70 ","$2,302.50 "
Carle BroMenn Medical Center,8221013,EXC TUMOR SOFT TISS FACE/SCALP SUBFASCIAL < 2CM,,21013,510,"$2,280.00 ","$2,280.00 ",$684.00 ,"$2,074.80 ","$1,596.00 ",$684.00 ,"$1,482.00 ","$1,641.60 ","$2,074.80 ","$1,710.00 "
Carle BroMenn Medical Center,8221015,RAD RESCT TUMOR SOFT TISS FACE/SCALP < 2CM,,21015,510,"$2,830.00 ","$2,830.00 ",$849.00 ,"$2,575.30 ","$1,981.00 ",$849.00 ,"$1,839.50 ","$2,037.60 ","$2,575.30 ","$2,122.50 "
Carle BroMenn Medical Center,8221030,"EXCISION,BENIGN TUMOR,MAXILLA/ZYGOMA",,21030,510,"$3,320.00 ","$3,320.00 ",$996.00 ,"$3,021.20 ","$2,324.00 ",$996.00 ,"$2,158.00 ","$2,390.40 ","$3,021.20 ","$2,490.00 "
Carle BroMenn Medical Center,8221031,"EXCISION,TORUS MANDIBULARIS",,21031,510,"$1,790.00 ","$1,790.00 ",$537.00 ,"$1,628.90 ","$1,253.00 ",$537.00 ,"$1,163.50 ","$1,288.80 ","$1,628.90 ","$1,342.50 "
Carle BroMenn Medical Center,8221032,"EXCISION,MAXILLARY TORUS PALATINUS",,21032,510,"$1,790.00 ","$1,790.00 ",$537.00 ,"$1,628.90 ","$1,253.00 ",$537.00 ,"$1,163.50 ","$1,288.80 ","$1,628.90 ","$1,342.50 "
Carle BroMenn Medical Center,8221040,"EXCISION,BENIGN TUMOR,MANDIBLE",,21040,510,"$2,360.00 ","$2,360.00 ",$708.00 ,"$2,147.60 ","$1,652.00 ",$708.00 ,"$1,534.00 ","$1,699.20 ","$2,147.60 ","$1,770.00 "
Carle BroMenn Medical Center,8221210,"NASAL,MAXILLA,MALAR BONE GRAFT",,21210,510,"$5,990.00 ","$5,990.00 ","$1,797.00 ","$5,450.90 ","$4,193.00 ","$1,797.00 ","$3,893.50 ","$4,312.80 ","$5,450.90 ","$4,492.50 "
Carle BroMenn Medical Center,8221215,MANDIBLE GRAFT,,21215,510,"$6,690.00 ","$6,690.00 ","$2,007.00 ","$6,087.90 ","$4,683.00 ","$2,007.00 ","$4,348.50 ","$4,816.80 ","$6,087.90 ","$5,017.50 "
Carle BroMenn Medical Center,8221320,CLOSED RX NOSE FX W STABILIZATN,,21320,510,"$1,790.00 ","$1,790.00 ",$537.00 ,"$1,628.90 ","$1,253.00 ",$537.00 ,"$1,163.50 ","$1,288.80 ","$1,628.90 ","$1,342.50 "
Carle BroMenn Medical Center,8221440,CLOSED RX DENTAL RIDGE FX,,21440,510,"$2,040.00 ","$2,040.00 ",$612.00 ,"$1,856.40 ","$1,428.00 ",$612.00 ,"$1,326.00 ","$1,468.80 ","$1,856.40 ","$1,530.00 "
Carle BroMenn Medical Center,8221450,CLOSED RX MANDIBLE FX,,21450,510,"$2,070.00 ","$2,070.00 ",$621.00 ,"$1,883.70 ","$1,449.00 ",$621.00 ,"$1,345.50 ","$1,490.40 ","$1,883.70 ","$1,552.50 "
Carle BroMenn Medical Center,8221501,I&D DEEP ABSC/HEMATOMA NECK/CHEST,,21501,510,"$1,680.00 ","$1,680.00 ",$504.00 ,"$1,528.80 ","$1,176.00 ",$504.00 ,"$1,092.00 ","$1,209.60 ","$1,528.80 ","$1,260.00 "
Carle BroMenn Medical Center,8221550,BIOPSY SOFT TISSUE NECK/CHEST,,21550,510,"$1,110.00 ","$1,110.00 ",$333.00 ,"$1,010.10 ",$777.00 ,$333.00 ,$721.50 ,$799.20 ,"$1,010.10 ",$832.50 
Carle BroMenn Medical Center,8221552,EXC TUMOR SOFT TISSUE NECK/ANT THORAX SUBQ 3+CM,,21552,510,"$3,210.00 ","$3,210.00 ",$963.00 ,"$2,921.10 ","$2,247.00 ",$963.00 ,"$2,086.50 ","$2,311.20 ","$2,921.10 ","$2,407.50 "
Carle BroMenn Medical Center,8221555,EXC TUMOR SOFT TISSUE NECK/ANT THORAX SUBQ <3CM,,21555,510,"$2,880.00 ","$2,880.00 ",$864.00 ,"$2,620.80 ","$2,016.00 ",$864.00 ,"$1,872.00 ","$2,073.60 ","$2,620.80 ","$2,160.00 "
Carle BroMenn Medical Center,8221556,EXC TUMOR SOFT TISSUE NECK/ANT THORAX SUBFASCIAL <5CM,,21556,510,"$1,920.00 ","$1,920.00 ",$576.00 ,"$1,747.20 ","$1,344.00 ",$576.00 ,"$1,248.00 ","$1,382.40 ","$1,747.20 ","$1,440.00 "
Carle BroMenn Medical Center,8221557,RAD RESCT TUMOR SOFT TISS NECK/ANT THORAX <5CM,,21557,510,"$3,790.00 ","$3,790.00 ","$1,137.00 ","$3,448.90 ","$2,653.00 ","$1,137.00 ","$2,463.50 ","$2,728.80 ","$3,448.90 ","$2,842.50 "
Carle BroMenn Medical Center,8221601,EXCISION CHEST WALL TUMOR INCLUDING RIBS,,21601,510,"$3,870.00 ","$3,870.00 ","$1,161.00 ","$3,521.70 ","$2,709.00 ","$1,161.00 ","$2,515.50 ","$2,786.40 ","$3,521.70 ","$2,902.50 "
Carle BroMenn Medical Center,8221811,OPEN TX RIB FX W/FIXJ THORACOSCOPIC VIS 1-3 RIBS,,21811,510,"$4,910.00 ","$4,910.00 ","$1,473.00 ","$4,468.10 ","$3,437.00 ","$1,473.00 ","$3,191.50 ","$3,535.20 ","$4,468.10 ","$3,682.50 "
Carle BroMenn Medical Center,8221812,OPEN TX RIB FX W/FIXJ THORACOSCOPIC VIS 4-6 RIBS,,21812,510,"$5,820.00 ","$5,820.00 ","$1,746.00 ","$5,296.20 ","$4,074.00 ","$1,746.00 ","$3,783.00 ","$4,190.40 ","$5,296.20 ","$4,365.00 "
Carle BroMenn Medical Center,8221813,OPEN TX RIB FX W/FIXJ THORACOSCOPIC VIS 7+ RIBS,,21813,510,"$7,830.00 ","$7,830.00 ","$2,349.00 ","$7,125.30 ","$5,481.00 ","$2,349.00 ","$5,089.50 ","$5,637.60 ","$7,125.30 ","$5,872.50 "
Carle BroMenn Medical Center,8221930,EXCISION TUMOR SOFT TISSUE BACK/FLANK SUBQ <3CM,,21930,510,"$3,450.00 ","$3,450.00 ","$1,035.00 ","$3,139.50 ","$2,415.00 ","$1,035.00 ","$2,242.50 ","$2,484.00 ","$3,139.50 ","$2,587.50 "
Carle BroMenn Medical Center,8221931,EXCISION TUMOR SOFT TISSUE BACK/FLANK SUBQ 3+CM,,21931,510,"$3,960.00 ","$3,960.00 ","$1,188.00 ","$3,603.60 ","$2,772.00 ","$1,188.00 ","$2,574.00 ","$2,851.20 ","$3,603.60 ","$2,970.00 "
Carle BroMenn Medical Center,8221932,EXC TUMOR SOFT TISS BACK/FLANK SUBFASCIAL <5CM,,21932,510,"$5,130.00 ","$5,130.00 ","$1,539.00 ","$4,668.30 ","$3,591.00 ","$1,539.00 ","$3,334.50 ","$3,693.60 ","$4,668.30 ","$3,847.50 "
Carle BroMenn Medical Center,8221933,EXC TUMOR SOFT TISS BACK/FLANK SUBFASCIAL 5+CM,,21933,510,"$3,720.00 ","$3,720.00 ","$1,116.00 ","$3,385.20 ","$2,604.00 ","$1,116.00 ","$2,418.00 ","$2,678.40 ","$3,385.20 ","$2,790.00 "
Carle BroMenn Medical Center,8221935,RAD RESECTION TUMOR SOFT TISSUE BACK/FLANK <5CM,,21935,510,"$5,240.00 ","$5,240.00 ","$1,572.00 ","$4,768.40 ","$3,668.00 ","$1,572.00 ","$3,406.00 ","$3,772.80 ","$4,768.40 ","$3,930.00 "
Carle BroMenn Medical Center,8222120,PROLONG OUTPT/OFFICE VIS,,G2212,510,$125.00 ,$125.00 ,$37.50 ,$113.75 ,$87.50 ,$37.50 ,$81.25 ,$90.00 ,$113.75 ,$93.75 
Carle BroMenn Medical Center,8222510,PERQ VERTEBROPLASTY UNI/BI INJX CERVICOTHORACIC,,22510,510,"$5,850.00 ","$5,850.00 ","$1,755.00 ","$5,323.50 ","$4,095.00 ","$1,755.00 ","$3,802.50 ","$4,212.00 ","$5,323.50 ","$4,387.50 "
Carle BroMenn Medical Center,8222511,PERQ VERTEBROPLASTY UNI/BI INJECTION LUMBOSACRAL,,22511,510,"$5,220.00 ","$5,220.00 ","$1,566.00 ","$4,750.20 ","$3,654.00 ","$1,566.00 ","$3,393.00 ","$3,758.40 ","$4,750.20 ","$3,915.00 "
Carle BroMenn Medical Center,8222512,VERTEBROPLASTY EACH ADDL CERVICOTHOR/LUMBOSACRAL,,22512,510,"$2,560.00 ","$2,560.00 ",$768.00 ,"$2,329.60 ","$1,792.00 ",$768.00 ,"$1,664.00 ","$1,843.20 ","$2,329.60 ","$1,920.00 "
Carle BroMenn Medical Center,8222513,PERQ VERT AGMNTJ CAVITY CRTJ UNI/BI CANNULATION,,22513,510,"$9,790.00 ","$9,790.00 ","$2,937.00 ","$8,908.90 ","$6,853.00 ","$2,937.00 ","$6,363.50 ","$7,048.80 ","$8,908.90 ","$7,342.50 "
Carle BroMenn Medical Center,8222514,PERQ VERT AGMNTJ CAVITY CRTJ UNI/BI CANNULJ LMBR,,22514,510,"$13,050.00 ","$13,050.00 ","$3,915.00 ","$11,875.50 ","$9,135.00 ","$3,915.00 ","$8,482.50 ","$9,396.00 ","$11,875.50 ","$9,787.50 "
Carle BroMenn Medical Center,8222515,PERQ VERT AGMNTJ CAVITY CRTJ UNI/BI CANNULJ EACH,,22515,510,"$5,880.00 ","$5,880.00 ","$1,764.00 ","$5,350.80 ","$4,116.00 ","$1,764.00 ","$3,822.00 ","$4,233.60 ","$5,350.80 ","$4,410.00 "
Carle BroMenn Medical Center,8222900,EXC TUMOR SOFT TISSUE ABDL WALL SUBFASCIAL <5CM,,22900,510,"$1,900.00 ","$1,900.00 ",$570.00 ,"$1,729.00 ","$1,330.00 ",$570.00 ,"$1,235.00 ","$1,368.00 ","$1,729.00 ","$1,425.00 "
Carle BroMenn Medical Center,8222902,EXC TUMOR SOFT TISSUE ABDOMINAL WALL SUBQ <3CM,,22902,510,"$2,540.00 ","$2,540.00 ",$762.00 ,"$2,311.40 ","$1,778.00 ",$762.00 ,"$1,651.00 ","$1,828.80 ","$2,311.40 ","$1,905.00 "
Carle BroMenn Medical Center,8222903,EXC TUMOR SOFT TISSUE ABDOMINAL WALL SUBQ 3+CM,,22903,510,"$2,690.00 ","$2,690.00 ",$807.00 ,"$2,447.90 ","$1,883.00 ",$807.00 ,"$1,748.50 ","$1,936.80 ","$2,447.90 ","$2,017.50 "
Carle BroMenn Medical Center,8222904,RAD RESECTION TUMOR SOFT TISSUE ABDL WALL <5CM,,22904,510,"$3,950.00 ","$3,950.00 ","$1,185.00 ","$3,594.50 ","$2,765.00 ","$1,185.00 ","$2,567.50 ","$2,844.00 ","$3,594.50 ","$2,962.50 "
Carle BroMenn Medical Center,8223071,EXCISION TUMOR SOFT TISSUE SHOULDER SUBQ 3+CM,,23071,510,"$3,500.00 ","$3,500.00 ","$1,050.00 ","$3,185.00 ","$2,450.00 ","$1,050.00 ","$2,275.00 ","$2,520.00 ","$3,185.00 ","$2,625.00 "
Carle BroMenn Medical Center,8223075,EXCISION TUMOR SOFT TISSUE SHOULDER SUBQ <3CM,,23075,510,"$2,320.00 ","$2,320.00 ",$696.00 ,"$2,111.20 ","$1,624.00 ",$696.00 ,"$1,508.00 ","$1,670.40 ","$2,111.20 ","$1,740.00 "
Carle BroMenn Medical Center,8223076,EXC TUMOR SOFT TISS SHOULDER SUBFASC <5CM,,23076,510,"$2,180.00 ","$2,180.00 ",$654.00 ,"$1,983.80 ","$1,526.00 ",$654.00 ,"$1,417.00 ","$1,569.60 ","$1,983.80 ","$1,635.00 "
Carle BroMenn Medical Center,8223077,RAD RESECTION TUMOR SOFT TISSUE SHOULDER <5CM,,23077,510,"$5,980.00 ","$5,980.00 ","$1,794.00 ","$5,441.80 ","$4,186.00 ","$1,794.00 ","$3,887.00 ","$4,305.60 ","$5,441.80 ","$4,485.00 "
Carle BroMenn Medical Center,8223333,REMOVAL SHOULDER FOREIGN BODY DEEP SUBFASCIAL/IM,,23333,510,"$1,550.00 ","$1,550.00 ",$465.00 ,"$1,410.50 ","$1,085.00 ",$465.00 ,"$1,007.50 ","$1,116.00 ","$1,410.50 ","$1,162.50 "
Carle BroMenn Medical Center,8223405,TENOTOMY  SHOULDER AREA,,23405,510,"$4,320.00 ","$4,320.00 ","$1,296.00 ","$3,931.20 ","$3,024.00 ","$1,296.00 ","$2,808.00 ","$3,110.40 ","$3,931.20 ","$3,240.00 "
Carle BroMenn Medical Center,8223500,CLOSED RX CLAVICLE FRACTURE,,23500,510,$640.00 ,$640.00 ,$192.00 ,$582.40 ,$448.00 ,$192.00 ,$416.00 ,$460.80 ,$582.40 ,$480.00 
Carle BroMenn Medical Center,8223600,CLOSED RX PROX HUMERUS FRACTURE,,23600,510,"$1,040.00 ","$1,040.00 ",$312.00 ,$946.40 ,$728.00 ,$312.00 ,$676.00 ,$748.80 ,$946.40 ,$780.00 
Carle BroMenn Medical Center,8223650,CLSD TX SHOULDER DISLC W/MANIP W/O ANES,,23650,510,$880.00 ,$880.00 ,$264.00 ,$800.80 ,$616.00 ,$264.00 ,$572.00 ,$633.60 ,$800.80 ,$660.00 
Carle BroMenn Medical Center,8223665,"CLOSED RX SHLDR DISLOC,GR TUB FX",,23665,510,"$1,445.00 ","$1,445.00 ",$433.50 ,"$1,314.95 ","$1,011.50 ",$433.50 ,$939.25 ,"$1,040.40 ","$1,314.95 ","$1,083.75 "
Carle BroMenn Medical Center,8224071,EXC TUMOR SOFT TISSUE UPPER ARM/ELBOW SUBQ 3+CM,,24071,510,"$3,360.00 ","$3,360.00 ","$1,008.00 ","$3,057.60 ","$2,352.00 ","$1,008.00 ","$2,184.00 ","$2,419.20 ","$3,057.60 ","$2,520.00 "
Carle BroMenn Medical Center,8224073,EXC TUMOR SOFT TISS UPPER ARM/ELBW SUBFASC 5+CM,,24073,510,"$4,810.00 ","$4,810.00 ","$1,443.00 ","$4,377.10 ","$3,367.00 ","$1,443.00 ","$3,126.50 ","$3,463.20 ","$4,377.10 ","$3,607.50 "
Carle BroMenn Medical Center,8224075,EXC TUMOR SOFT TISS UPPER ARM/ELBOW SUBQ <3CM,,24075,510,"$3,450.00 ","$3,450.00 ","$1,035.00 ","$3,139.50 ","$2,415.00 ","$1,035.00 ","$2,242.50 ","$2,484.00 ","$3,139.50 ","$2,587.50 "
Carle BroMenn Medical Center,8224076,EXC TUMOR SOFT TISS UPR ARM/ELBOW SUBFASC <5CM,,24076,510,"$2,490.00 ","$2,490.00 ",$747.00 ,"$2,265.90 ","$1,743.00 ",$747.00 ,"$1,618.50 ","$1,792.80 ","$2,265.90 ","$1,867.50 "
Carle BroMenn Medical Center,8224077,RAD RESECT TUMOR SOFT TISS UPPER ARM/ELBOW <5CM,,24077,510,"$4,060.00 ","$4,060.00 ","$1,218.00 ","$3,694.60 ","$2,842.00 ","$1,218.00 ","$2,639.00 ","$2,923.20 ","$3,694.60 ","$3,045.00 "
Carle BroMenn Medical Center,8224357,"TENOTOMY PERCTANEOUS, ELBOW LATERAL OR MEDIAL",,24357,510,"$7,330.00 ","$7,330.00 ","$2,199.00 ","$6,670.30 ","$5,131.00 ","$2,199.00 ","$4,764.50 ","$5,277.60 ","$6,670.30 ","$5,497.50 "
Carle BroMenn Medical Center,8224530,CLSD RX HUMERAL SUPRACONDYLAR FX,,24530,510,"$1,040.00 ","$1,040.00 ",$312.00 ,$946.40 ,$728.00 ,$312.00 ,$676.00 ,$748.80 ,$946.40 ,$780.00 
Carle BroMenn Medical Center,8224640,"CLOSED RX RADIAL HEAD DISLOC,CHILD",,24640,510,$770.00 ,$770.00 ,$231.00 ,$700.70 ,$539.00 ,$231.00 ,$500.50 ,$554.40 ,$700.70 ,$577.50 
Carle BroMenn Medical Center,8224650,CLOSED RX RADIAL HEAD/NEC FX,,24650,510,$720.00 ,$720.00 ,$216.00 ,$655.20 ,$504.00 ,$216.00 ,$468.00 ,$518.40 ,$655.20 ,$540.00 
Carle BroMenn Medical Center,8225000,INCISION - TENDON SHEATH,,25000,510,"$3,630.00 ","$3,630.00 ","$1,089.00 ","$3,303.30 ","$2,541.00 ","$1,089.00 ","$2,359.50 ","$2,613.60 ","$3,303.30 ","$2,722.50 "
Carle BroMenn Medical Center,8225071,EXC TUMOR SOFT TISS FOREARM AND/WRIST SUBQ 3+CM,,25071,510,"$2,160.00 ","$2,160.00 ",$648.00 ,"$1,965.60 ","$1,512.00 ",$648.00 ,"$1,404.00 ","$1,555.20 ","$1,965.60 ","$1,620.00 "
Carle BroMenn Medical Center,8225073,"EXC TUMOR SFT TISSUE FOREARM/WRIST, SUBFASCIAL; 3CM OR >",,25073,510,"$2,720.00 ","$2,720.00 ",$816.00 ,"$2,475.20 ","$1,904.00 ",$816.00 ,"$1,768.00 ","$1,958.40 ","$2,475.20 ","$2,040.00 "
Carle BroMenn Medical Center,8225075,EXC TUMOR SOFT TISSUE FOREARM &/WRIST SUBQ <3CM,,25075,510,"$3,170.00 ","$3,170.00 ",$951.00 ,"$2,884.70 ","$2,219.00 ",$951.00 ,"$2,060.50 ","$2,282.40 ","$2,884.70 ","$2,377.50 "
Carle BroMenn Medical Center,8225077,RAD RESECT TUMOR SOFT TISS FOREARM&/WRIST <3CM,,25077,510,"$5,010.00 ","$5,010.00 ","$1,503.00 ","$4,559.10 ","$3,507.00 ","$1,503.00 ","$3,256.50 ","$3,607.20 ","$4,559.10 ","$3,757.50 "
Carle BroMenn Medical Center,8225500,CLOSED RX RADIAL SHAFT FX,,25500,510,$770.00 ,$770.00 ,$231.00 ,$700.70 ,$539.00 ,$231.00 ,$500.50 ,$554.40 ,$700.70 ,$577.50 
Carle BroMenn Medical Center,8225530,CLOSED RX ULNA SHAFT FX,,25530,510,$800.00 ,$800.00 ,$240.00 ,$728.00 ,$560.00 ,$240.00 ,$520.00 ,$576.00 ,$728.00 ,$600.00 
Carle BroMenn Medical Center,8225600,CLOSED RX DIST RAD/ULNA FX,,25600,510,$800.00 ,$800.00 ,$240.00 ,$728.00 ,$560.00 ,$240.00 ,$520.00 ,$576.00 ,$728.00 ,$600.00 
Carle BroMenn Medical Center,8225622,CLOSED RX NAVICULAR FX,,25622,510,"$1,110.00 ","$1,110.00 ",$333.00 ,"$1,010.10 ",$777.00 ,$333.00 ,$721.50 ,$799.20 ,"$1,010.10 ",$832.50 
Carle BroMenn Medical Center,8226010,DRAIN FINGER ABSCESS SIMPLE,,26010,510,$610.00 ,$610.00 ,$183.00 ,$555.10 ,$427.00 ,$183.00 ,$396.50 ,$439.20 ,$555.10 ,$457.50 
Carle BroMenn Medical Center,8226011,"DRAIN FINGER ABSCESS,COMPLICATED",,26011,510,"$1,670.00 ","$1,670.00 ",$501.00 ,"$1,519.70 ","$1,169.00 ",$501.00 ,"$1,085.50 ","$1,202.40 ","$1,519.70 ","$1,252.50 "
Carle BroMenn Medical Center,8226040,RELEASE PALM CONTRACT PERCUT,,26040,510,"$2,630.00 ","$2,630.00 ",$789.00 ,"$2,393.30 ","$1,841.00 ",$789.00 ,"$1,709.50 ","$1,893.60 ","$2,393.30 ","$1,972.50 "
Carle BroMenn Medical Center,8226055,INCISE FINGER TENDON SHEATH,,26055,510,"$2,720.00 ","$2,720.00 ",$816.00 ,"$2,475.20 ","$1,904.00 ",$816.00 ,"$1,768.00 ","$1,958.40 ","$2,475.20 ","$2,040.00 "
Carle BroMenn Medical Center,8226115,EXC TUM/VASC MAL SFT TISS HAND/FNGR SUBQ <1.5CM,,26115,510,"$2,100.00 ","$2,100.00 ",$630.00 ,"$1,911.00 ","$1,470.00 ",$630.00 ,"$1,365.00 ","$1,512.00 ","$1,911.00 ","$1,575.00 "
Carle BroMenn Medical Center,8226116,EXC TUM/VAS MAL SFT TIS HAND/FNGR SUBFASC<1.5CM,,26116,510,"$2,320.00 ","$2,320.00 ",$696.00 ,"$2,111.20 ","$1,624.00 ",$696.00 ,"$1,508.00 ","$1,670.40 ","$2,111.20 ","$1,740.00 "
Carle BroMenn Medical Center,8226117,RAD RESECT TUMOR SOFT TISSUE HAND/FINGER <3CM,,26117,510,"$4,450.00 ","$4,450.00 ","$1,335.00 ","$4,049.50 ","$3,115.00 ","$1,335.00 ","$2,892.50 ","$3,204.00 ","$4,049.50 ","$3,337.50 "
Carle BroMenn Medical Center,8226600,CLOSED RX METACARPAL FX,,26600,510,$620.00 ,$620.00 ,$186.00 ,$564.20 ,$434.00 ,$186.00 ,$403.00 ,$446.40 ,$564.20 ,$465.00 
Carle BroMenn Medical Center,8226605,CLOSED TX METACARPAL FX W/MANIP,,26605,510,"$1,155.00 ","$1,155.00 ",$346.50 ,"$1,051.05 ",$808.50 ,$346.50 ,$750.75 ,$831.60 ,"$1,051.05 ",$866.25 
Carle BroMenn Medical Center,8226670,"CLOSED RX, CARPOMETACAR DISLOC,NON-THUMB",,26670,510,$800.00 ,$800.00 ,$240.00 ,$728.00 ,$560.00 ,$240.00 ,$520.00 ,$576.00 ,$728.00 ,$600.00 
Carle BroMenn Medical Center,8226700,CLOSED RX MC-P DISLOC,,26700,510,$770.00 ,$770.00 ,$231.00 ,$700.70 ,$539.00 ,$231.00 ,$500.50 ,$554.40 ,$700.70 ,$577.50 
Carle BroMenn Medical Center,8226720,CLOSE RX PROX/MID FING SHFT FX,,26720,510,$475.00 ,$475.00 ,$142.50 ,$432.25 ,$332.50 ,$142.50 ,$308.75 ,$342.00 ,$432.25 ,$356.25 
Carle BroMenn Medical Center,8226725,"CLOSE RX PROX/MID FING SHFT FX,MANIP",,26725,510,$880.00 ,$880.00 ,$264.00 ,$800.80 ,$616.00 ,$264.00 ,$572.00 ,$633.60 ,$800.80 ,$660.00 
Carle BroMenn Medical Center,8226740,CLOSE RX FINGR ARTICULAR FX,,26740,510,$710.00 ,$710.00 ,$213.00 ,$646.10 ,$497.00 ,$213.00 ,$461.50 ,$511.20 ,$646.10 ,$532.50 
Carle BroMenn Medical Center,8226742,CLOSED TX ARTICULAR FX W/MANIP,,26742,510,"$1,140.00 ","$1,140.00 ",$342.00 ,"$1,037.40 ",$798.00 ,$342.00 ,$741.00 ,$820.80 ,"$1,037.40 ",$855.00 
Carle BroMenn Medical Center,8226750,CLSD TX DISTL PHAL FX FINGER/THUMB W/O MAINP,,26750,510,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8226755,"CLOSE RX DIST FINGR FX, MANIP",,26755,510,$720.00 ,$720.00 ,$216.00 ,$655.20 ,$504.00 ,$216.00 ,$468.00 ,$518.40 ,$655.20 ,$540.00 
Carle BroMenn Medical Center,8226770,CLSD RX IP JT DISLOCATION,,26770,510,$760.00 ,$760.00 ,$228.00 ,$691.60 ,$532.00 ,$228.00 ,$494.00 ,$547.20 ,$691.60 ,$570.00 
Carle BroMenn Medical Center,8226775,CLSD RX ID JT DISLOCATION ANESTHESIA,,26775,510,"$1,061.00 ","$1,061.00 ",$318.30 ,$965.51 ,$742.70 ,$318.30 ,$689.65 ,$763.92 ,$965.51 ,$795.75 
Carle BroMenn Medical Center,8227000,"TENOTOMY  PERCUTANEOUS, ABDUCTOR OF HIP",,27000,510,"$2,760.00 ","$2,760.00 ",$828.00 ,"$2,511.60 ","$1,932.00 ",$828.00 ,"$1,794.00 ","$1,987.20 ","$2,511.60 ","$2,070.00 "
Carle BroMenn Medical Center,8227047,EXC TUMOR SOFT TISSUE PELVIS & HIP SUBQ <3CM,,27047,510,"$3,340.00 ","$3,340.00 ","$1,002.00 ","$3,039.40 ","$2,338.00 ","$1,002.00 ","$2,171.00 ","$2,404.80 ","$3,039.40 ","$2,505.00 "
Carle BroMenn Medical Center,8227048,EXC TUMOR SOFT TISSUE PELVIS & HIP SUBFASC <5CM,,27048,510,"$3,050.00 ","$3,050.00 ",$915.00 ,"$2,775.50 ","$2,135.00 ",$915.00 ,"$1,982.50 ","$2,196.00 ","$2,775.50 ","$2,287.50 "
Carle BroMenn Medical Center,8227049,RAD RESECT TUMOR SOFT TISSUE PELVIS & HIP <5CM,,27049,510,"$2,750.00 ","$2,750.00 ",$825.00 ,"$2,502.50 ","$1,925.00 ",$825.00 ,"$1,787.50 ","$1,980.00 ","$2,502.50 ","$2,062.50 "
Carle BroMenn Medical Center,8227096,"INJECTION,SACROILIAC JOINT",,G0260,510,"$1,580.00 ","$1,580.00 ",$474.00 ,"$1,437.80 ","$1,106.00 ",$474.00 ,"$1,027.00 ","$1,137.60 ","$1,437.80 ","$1,185.00 "
Carle BroMenn Medical Center,8227197,CLSD TX PELVIC RING FX W/O MANIP,,27197,510,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8227220,CLOSED RX ACETABULAR FX,,27220,510,"$1,910.00 ","$1,910.00 ",$573.00 ,"$1,738.10 ","$1,337.00 ",$573.00 ,"$1,241.50 ","$1,375.20 ","$1,738.10 ","$1,432.50 "
Carle BroMenn Medical Center,8227279,ARTHRODESIS SACROILIAC JOINT PERCUTANEOUS,,27279,510,"$24,480.00 ","$24,480.00 ","$7,344.00 ","$22,276.80 ","$17,136.00 ","$7,344.00 ","$15,912.00 ","$17,625.60 ","$22,276.80 ","$18,360.00 "
Carle BroMenn Medical Center,8227306,"TENOTOMY  PERCUTANEOUS, ABDUCTOR OR HAMSTRING, SINGLE TENDON",,27306,510,"$4,670.00 ","$4,670.00 ","$1,401.00 ","$4,249.70 ","$3,269.00 ","$1,401.00 ","$3,035.50 ","$3,362.40 ","$4,249.70 ","$3,502.50 "
Carle BroMenn Medical Center,8227307,"TENOTOMY  PERCUTANEOUS, ABDUCTOR OR HAMSTRING, MULTIPLE TENDON",,27307,510,"$4,320.00 ","$4,320.00 ","$1,296.00 ","$3,931.20 ","$3,024.00 ","$1,296.00 ","$2,808.00 ","$3,110.40 ","$3,931.20 ","$3,240.00 "
Carle BroMenn Medical Center,8227327,EXCISION TUMOR SOFT TISSUE THIGH/KNEE SUBQ <3CM,,27327,510,"$2,230.00 ","$2,230.00 ",$669.00 ,"$2,029.30 ","$1,561.00 ",$669.00 ,"$1,449.50 ","$1,605.60 ","$2,029.30 ","$1,672.50 "
Carle BroMenn Medical Center,8227328,EXC TUMOR SOFT TISSUE THIGH/KNEE SUBFASC <5CM,,27328,510,"$1,780.00 ","$1,780.00 ",$534.00 ,"$1,619.80 ","$1,246.00 ",$534.00 ,"$1,157.00 ","$1,281.60 ","$1,619.80 ","$1,335.00 "
Carle BroMenn Medical Center,8227337,EXCISON TUMOR SOFT TISSUE THIGH/KNEE SUBQ 3+CM,,27337,510,"$4,050.00 ","$4,050.00 ","$1,215.00 ","$3,685.50 ","$2,835.00 ","$1,215.00 ","$2,632.50 ","$2,916.00 ","$3,685.50 ","$3,037.50 "
Carle BroMenn Medical Center,8227369,NJX PX CNTRST KNE ARTHG CNTRST ENHNCD CT/MRI KNE,,27369,510,$490.00 ,$490.00 ,$147.00 ,$445.90 ,$343.00 ,$147.00 ,$318.50 ,$352.80 ,$445.90 ,$367.50 
Carle BroMenn Medical Center,8227502,CLOSED RX FEMUR SHAFT FX+MANIP,,27502,510,$585.00 ,$585.00 ,$175.50 ,$532.35 ,$409.50 ,$175.50 ,$380.25 ,$421.20 ,$532.35 ,$438.75 
Carle BroMenn Medical Center,8227530,CLOSED RX TIBIAL PLATEAU FX,,27530,510,"$1,210.00 ","$1,210.00 ",$363.00 ,"$1,101.10 ",$847.00 ,$363.00 ,$786.50 ,$871.20 ,"$1,101.10 ",$907.50 
Carle BroMenn Medical Center,8227599,FEMUR/KNEE SURG UNLISTED,,27599,510,$405.00 ,$405.00 ,$121.50 ,$368.55 ,$283.50 ,$121.50 ,$263.25 ,$291.60 ,$368.55 ,$303.75 
Carle BroMenn Medical Center,8227605,"TENOTOMY  PERCUTANEOUS, ACHILLES TENDON; LOCAL ANES",,27605,510,"$3,910.00 ","$3,910.00 ","$1,173.00 ","$3,558.10 ","$2,737.00 ","$1,173.00 ","$2,541.50 ","$2,815.20 ","$3,558.10 ","$2,932.50 "
Carle BroMenn Medical Center,8227606,"TENOTOMY  PERCUTANEOUS, ACHILLES TENDON; GENERAL ANES",,27606,510,"$2,760.00 ","$2,760.00 ",$828.00 ,"$2,511.60 ","$1,932.00 ",$828.00 ,"$1,794.00 ","$1,987.20 ","$2,511.60 ","$2,070.00 "
Carle BroMenn Medical Center,8227615,RAD RESECTION TUMOR SOFT TISSUE LEG/ANKLE <5CM,,27615,510,"$5,680.00 ","$5,680.00 ","$1,704.00 ","$5,168.80 ","$3,976.00 ","$1,704.00 ","$3,692.00 ","$4,089.60 ","$5,168.80 ","$4,260.00 "
Carle BroMenn Medical Center,8227618,EXC TUMOR SOFT TISSUE LEG/ANKLE SUBQ <3CM,,27618,510,"$2,610.00 ","$2,610.00 ",$783.00 ,"$2,375.10 ","$1,827.00 ",$783.00 ,"$1,696.50 ","$1,879.20 ","$2,375.10 ","$1,957.50 "
Carle BroMenn Medical Center,8227619,EXC TUMOR SOFT TISSUE LEG/ANKLE SUBFASCIAL <3CM,,27619,510,"$2,250.00 ","$2,250.00 ",$675.00 ,"$2,047.50 ","$1,575.00 ",$675.00 ,"$1,462.50 ","$1,620.00 ","$2,047.50 ","$1,687.50 "
Carle BroMenn Medical Center,8227750,CLOSED RX TIBIA SHAFT FX,,27750,510,"$1,060.00 ","$1,060.00 ",$318.00 ,$964.60 ,$742.00 ,$318.00 ,$689.00 ,$763.20 ,$964.60 ,$795.00 
Carle BroMenn Medical Center,8227759,"TREAT TIBIAL SHAFT FX, INTRAMED IMPLANT",,27759,510,"$8,030.00 ","$8,030.00 ","$2,409.00 ","$7,307.30 ","$5,621.00 ","$2,409.00 ","$5,219.50 ","$5,781.60 ","$7,307.30 ","$6,022.50 "
Carle BroMenn Medical Center,8227767,CLOSED TREATMENT PST MALLEOLUS FRACTURE W/O MANIP,,27767,510,"$1,750.00 ","$1,750.00 ",$525.00 ,"$1,592.50 ","$1,225.00 ",$525.00 ,"$1,137.50 ","$1,260.00 ","$1,592.50 ","$1,312.50 "
Carle BroMenn Medical Center,8227786,CLOSED RX DIST FIBULA FX,,27786,510,$860.00 ,$860.00 ,$258.00 ,$782.60 ,$602.00 ,$258.00 ,$559.00 ,$619.20 ,$782.60 ,$645.00 
Carle BroMenn Medical Center,8227808,CLOSED TX BIMALLEOLAR ANKLE FRACTURE W/O MANIP,,27808,510,$720.00 ,$720.00 ,$216.00 ,$655.20 ,$504.00 ,$216.00 ,$468.00 ,$518.40 ,$655.20 ,$540.00 
Carle BroMenn Medical Center,8228008,"FASCIOTOMY, FOOT AND/OR TOE",,28008,510,"$2,880.00 ","$2,880.00 ",$864.00 ,"$2,620.80 ","$2,016.00 ",$864.00 ,"$1,872.00 ","$2,073.60 ","$2,620.80 ","$2,160.00 "
Carle BroMenn Medical Center,8228043,EXCISION TUMOR SOFT TISSUE FOOT/TOE SUBQ <1.5CM,,28043,510,"$1,980.00 ","$1,980.00 ",$594.00 ,"$1,801.80 ","$1,386.00 ",$594.00 ,"$1,287.00 ","$1,425.60 ","$1,801.80 ","$1,485.00 "
Carle BroMenn Medical Center,8228045,EXC TUMOR SOFT TISSUE FOOT/TOE SUBFASC <1.5CM,,28045,510,"$1,680.00 ","$1,680.00 ",$504.00 ,"$1,528.80 ","$1,176.00 ",$504.00 ,"$1,092.00 ","$1,209.60 ","$1,528.80 ","$1,260.00 "
Carle BroMenn Medical Center,8228046,RAD RESECTION TUMOR SOFT TISSUE FOOT/TOE <3CM,,28046,510,"$5,020.00 ","$5,020.00 ","$1,506.00 ","$4,568.20 ","$3,514.00 ","$1,506.00 ","$3,263.00 ","$3,614.40 ","$4,568.20 ","$3,765.00 "
Carle BroMenn Medical Center,8228060,"FASCIOTOMY, PLANTAR FASCIA; PARTIAL",,28060,510,"$4,730.00 ","$4,730.00 ","$1,419.00 ","$4,304.30 ","$3,311.00 ","$1,419.00 ","$3,074.50 ","$3,405.60 ","$4,304.30 ","$3,547.50 "
Carle BroMenn Medical Center,8228124,PART REMV PHALANX OF TOE,,28124,510,"$1,950.00 ","$1,950.00 ",$585.00 ,"$1,774.50 ","$1,365.00 ",$585.00 ,"$1,267.50 ","$1,404.00 ","$1,774.50 ","$1,462.50 "
Carle BroMenn Medical Center,8228190,RMV FB FOOT SUBQ,,28190,510,"$1,620.00 ","$1,620.00 ",$486.00 ,"$1,474.20 ","$1,134.00 ",$486.00 ,"$1,053.00 ","$1,166.40 ","$1,474.20 ","$1,215.00 "
Carle BroMenn Medical Center,8228285,"REPAIR OF HAMMERTOE,ONE",,28285,510,"$1,910.00 ","$1,910.00 ",$573.00 ,"$1,738.10 ","$1,337.00 ",$573.00 ,"$1,241.50 ","$1,375.20 ","$1,738.10 ","$1,432.50 "
Carle BroMenn Medical Center,8228308,OSTEOTOMY METATARSAL (NOT 1ST),,28308,510,"$1,910.00 ","$1,910.00 ",$573.00 ,"$1,738.10 ","$1,337.00 ",$573.00 ,"$1,241.50 ","$1,375.20 ","$1,738.10 ","$1,432.50 "
Carle BroMenn Medical Center,8228400,CLOSED RX HEEL FX,,28400,510,$870.00 ,$870.00 ,$261.00 ,$791.70 ,$609.00 ,$261.00 ,$565.50 ,$626.40 ,$791.70 ,$652.50 
Carle BroMenn Medical Center,8228450,"CLOSED RX TARSAL FX,EACH",,28450,510,$770.00 ,$770.00 ,$231.00 ,$700.70 ,$539.00 ,$231.00 ,$500.50 ,$554.40 ,$700.70 ,$577.50 
Carle BroMenn Medical Center,8228470,CLOSED RX METATARSAL FX,,28470,510,$820.00 ,$820.00 ,$246.00 ,$746.20 ,$574.00 ,$246.00 ,$533.00 ,$590.40 ,$746.20 ,$615.00 
Carle BroMenn Medical Center,8228490,CLOSED RX BIG TOE FRACTURE,,28490,510,$460.00 ,$460.00 ,$138.00 ,$418.60 ,$322.00 ,$138.00 ,$299.00 ,$331.20 ,$418.60 ,$345.00 
Carle BroMenn Medical Center,8228505,OPEN TX FRACTURE GREAT TOE/PHALANX/PHALANGES,,28505,510,"$1,910.00 ","$1,910.00 ",$573.00 ,"$1,738.10 ","$1,337.00 ",$573.00 ,"$1,241.50 ","$1,375.20 ","$1,738.10 ","$1,432.50 "
Carle BroMenn Medical Center,8228510,CLOSED RX TOE FX,,28510,510,$620.00 ,$620.00 ,$186.00 ,$564.20 ,$434.00 ,$186.00 ,$403.00 ,$446.40 ,$564.20 ,$465.00 
Carle BroMenn Medical Center,8228515,"CLOSED RX TOE FX,MANIPULATN",,28515,510,$640.00 ,$640.00 ,$192.00 ,$582.40 ,$448.00 ,$192.00 ,$416.00 ,$460.80 ,$582.40 ,$480.00 
Carle BroMenn Medical Center,8228530,CLOSED RX SESAMOID BONE FX,,28530,510,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8228665,CLSD RX I-P JT TOES DISLOC ANES,,28665,510,$840.00 ,$840.00 ,$252.00 ,$764.40 ,$588.00 ,$252.00 ,$546.00 ,$604.80 ,$764.40 ,$630.00 
Carle BroMenn Medical Center,8228750,"FUSION BIG TOE,MT-P JT",,28750,510,"$4,090.00 ","$4,090.00 ","$1,227.00 ","$3,721.90 ","$2,863.00 ","$1,227.00 ","$2,658.50 ","$2,944.80 ","$3,721.90 ","$3,067.50 "
Carle BroMenn Medical Center,8228805,"AMPUTATION FOOT,TRANSMETATARSAL",,28805,510,"$2,960.00 ","$2,960.00 ",$888.00 ,"$2,693.60 ","$2,072.00 ",$888.00 ,"$1,924.00 ","$2,131.20 ","$2,693.60 ","$2,220.00 "
Carle BroMenn Medical Center,8229065,APPLY LONG ARM CAST,,29065,510,$510.00 ,$510.00 ,$153.00 ,$464.10 ,$357.00 ,$153.00 ,$331.50 ,$367.20 ,$464.10 ,$382.50 
Carle BroMenn Medical Center,8229075,APPLY FOREARM CAST,,29075,510,$655.00 ,$655.00 ,$196.50 ,$596.05 ,$458.50 ,$196.50 ,$425.75 ,$471.60 ,$596.05 ,$491.25 
Carle BroMenn Medical Center,8229085,APPLY HAND/WRIST CAST,,29085,510,$420.00 ,$420.00 ,$126.00 ,$382.20 ,$294.00 ,$126.00 ,$273.00 ,$302.40 ,$382.20 ,$315.00 
Carle BroMenn Medical Center,8229105,APPLY LONG ARM SPLINT,,29105,510,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8229125,"APPLY FOREARM SPLINT,STATIC",,29125,510,$440.00 ,$440.00 ,$132.00 ,$400.40 ,$308.00 ,$132.00 ,$286.00 ,$316.80 ,$400.40 ,$330.00 
Carle BroMenn Medical Center,8229126,"APPLY FOREARM SPLINT,DYNAMIC",,29126,510,$275.00 ,$275.00 ,$82.50 ,$250.25 ,$192.50 ,$82.50 ,$178.75 ,$198.00 ,$250.25 ,$206.25 
Carle BroMenn Medical Center,8229130,"APPLY FINGER SPLINT, STATIC",,29130,510,$240.00 ,$240.00 ,$72.00 ,$218.40 ,$168.00 ,$72.00 ,$156.00 ,$172.80 ,$218.40 ,$180.00 
Carle BroMenn Medical Center,8229345,APPLY LONG LEG CAST,,29345,510,$675.00 ,$675.00 ,$202.50 ,$614.25 ,$472.50 ,$202.50 ,$438.75 ,$486.00 ,$614.25 ,$506.25 
Carle BroMenn Medical Center,8229355,"APPLY LONG LEG CAST,WALKER",,29355,510,$485.00 ,$485.00 ,$145.50 ,$441.35 ,$339.50 ,$145.50 ,$315.25 ,$349.20 ,$441.35 ,$363.75 
Carle BroMenn Medical Center,8229405,APPLY SHORT LEG CAST,,29405,510,$670.00 ,$670.00 ,$201.00 ,$609.70 ,$469.00 ,$201.00 ,$435.50 ,$482.40 ,$609.70 ,$502.50 
Carle BroMenn Medical Center,8229425,"APPLY SHORT LEG CAST,WALKER",,29425,510,$670.00 ,$670.00 ,$201.00 ,$609.70 ,$469.00 ,$201.00 ,$435.50 ,$482.40 ,$609.70 ,$502.50 
Carle BroMenn Medical Center,8229450,APPLY OF CLUBFOOT CAST,,29450,510,$340.00 ,$340.00 ,$102.00 ,$309.40 ,$238.00 ,$102.00 ,$221.00 ,$244.80 ,$309.40 ,$255.00 
Carle BroMenn Medical Center,8229505,APPLY LONG LEG SPLINT,,29505,510,$495.00 ,$495.00 ,$148.50 ,$450.45 ,$346.50 ,$148.50 ,$321.75 ,$356.40 ,$450.45 ,$371.25 
Carle BroMenn Medical Center,8229515,APPLY LOWER LEG SPLINT,,29515,510,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8229540,STRAPPING ANKLE &/OR FOOT,,29540,510,$290.00 ,$290.00 ,$87.00 ,$263.90 ,$203.00 ,$87.00 ,$188.50 ,$208.80 ,$263.90 ,$217.50 
Carle BroMenn Medical Center,8229550,STRAPPING OF TOES,,29550,510,$180.00 ,$180.00 ,$54.00 ,$163.80 ,$126.00 ,$54.00 ,$117.00 ,$129.60 ,$163.80 ,$135.00 
Carle BroMenn Medical Center,8229580,STRAPPING UNNA BOOT,,29580,510,$340.00 ,$340.00 ,$102.00 ,$309.40 ,$238.00 ,$102.00 ,$221.00 ,$244.80 ,$309.40 ,$255.00 
Carle BroMenn Medical Center,8230000,"DRAIN ABSCESS/HEMATOMA, NASAL, INTERNAL APPRCH",,30000,510,$325.00 ,$325.00 ,$97.50 ,$295.75 ,$227.50 ,$97.50 ,$211.25 ,$234.00 ,$295.75 ,$243.75 
Carle BroMenn Medical Center,8230020,"DRAIN ABSCESS/HEMATOMA, NASAL SEPTUM",,30020,510,"$1,110.00 ","$1,110.00 ",$333.00 ,"$1,010.10 ",$777.00 ,$333.00 ,$721.50 ,$799.20 ,"$1,010.10 ",$832.50 
Carle BroMenn Medical Center,8230100,INTRANASAL BIOPSY,,30100,510,"$1,320.00 ","$1,320.00 ",$396.00 ,"$1,201.20 ",$924.00 ,$396.00 ,$858.00 ,$950.40 ,"$1,201.20 ",$990.00 
Carle BroMenn Medical Center,8230110,"EXCISION NASAL POLYP(S), SIMPLE",,30110,510,"$1,390.00 ","$1,390.00 ",$417.00 ,"$1,264.90 ",$973.00 ,$417.00 ,$903.50 ,"$1,000.80 ","$1,264.90 ","$1,042.50 "
Carle BroMenn Medical Center,8230115,"EXCISION NASAL POLYP(S), EXTENSIVE",,30115,510,"$3,230.00 ","$3,230.00 ",$969.00 ,"$2,939.30 ","$2,261.00 ",$969.00 ,"$2,099.50 ","$2,325.60 ","$2,939.30 ","$2,422.50 "
Carle BroMenn Medical Center,8230300,REMOVE NASAL FOREIGN BODY,,30300,510,$360.00 ,$360.00 ,$108.00 ,$327.60 ,$252.00 ,$108.00 ,$234.00 ,$259.20 ,$327.60 ,$270.00 
Carle BroMenn Medical Center,8230468,RPR NSL VLV COLLAPSE SUBQ/SBMCSL LAT WALL IMPLT,,30468,510,"$4,810.00 ","$4,810.00 ","$1,443.00 ","$4,377.10 ","$3,367.00 ","$1,443.00 ","$3,126.50 ","$3,463.20 ","$4,377.10 ","$3,607.50 "
Carle BroMenn Medical Center,8230802,"CAUTER TURBINATE MUCOSA,INTRAMURAL",,30802,510,"$1,110.00 ","$1,110.00 ",$333.00 ,"$1,010.10 ",$777.00 ,$333.00 ,$721.50 ,$799.20 ,"$1,010.10 ",$832.50 
Carle BroMenn Medical Center,8230901,"CTRL NOSEBLEED,ANTER,SIMPLE",,30901,510,$360.00 ,$360.00 ,$108.00 ,$327.60 ,$252.00 ,$108.00 ,$234.00 ,$259.20 ,$327.60 ,$270.00 
Carle BroMenn Medical Center,8230903,"CTRL NOSEBLEED,ANTER,COMPLEX",,30903,510,$440.00 ,$440.00 ,$132.00 ,$400.40 ,$308.00 ,$132.00 ,$286.00 ,$316.80 ,$400.40 ,$330.00 
Carle BroMenn Medical Center,8230905,"CTRL NOSEBLEED,POST,W/PACKS &/OR CAUT",,30905,510,$400.00 ,$400.00 ,$120.00 ,$364.00 ,$280.00 ,$120.00 ,$260.00 ,$288.00 ,$364.00 ,$300.00 
Carle BroMenn Medical Center,8230906,REPEAT CONTROL OF NOSEBLEED,,30906,510,$880.00 ,$880.00 ,$264.00 ,$800.80 ,$616.00 ,$264.00 ,$572.00 ,$633.60 ,$800.80 ,$660.00 
Carle BroMenn Medical Center,8231000,IRRIG MAXILLARY SINUS,,31000,510,$385.00 ,$385.00 ,$115.50 ,$350.35 ,$269.50 ,$115.50 ,$250.25 ,$277.20 ,$350.35 ,$288.75 
Carle BroMenn Medical Center,8231231,"NASAL ENDOSCOPY,DX",,31231,510,$850.00 ,$850.00 ,$255.00 ,$773.50 ,$595.00 ,$255.00 ,$552.50 ,$612.00 ,$773.50 ,$637.50 
Carle BroMenn Medical Center,8231237,"NASAL SCOPE,BX/RMV POLYP/DEBRID",,31237,510,"$3,811.00 ","$3,811.00 ","$1,143.30 ","$3,468.01 ","$2,667.70 ","$1,143.30 ","$2,477.15 ","$2,743.92 ","$3,468.01 ","$2,858.25 "
Carle BroMenn Medical Center,8231238,"NASAL/SINUS SCOPY,W/CONTROL NASAL HEM",,31238,510,"$2,460.00 ","$2,460.00 ",$738.00 ,"$2,238.60 ","$1,722.00 ",$738.00 ,"$1,599.00 ","$1,771.20 ","$2,238.60 ","$1,845.00 "
Carle BroMenn Medical Center,8231253,NASAL/SINUS NDSC TOT W/FRNT SINS EXPL TISS RMVL,,31253,510,"$3,800.00 ","$3,800.00 ","$1,140.00 ","$3,458.00 ","$2,660.00 ","$1,140.00 ","$2,470.00 ","$2,736.00 ","$3,458.00 ","$2,850.00 "
Carle BroMenn Medical Center,8231257,NASAL/SINUS NDSC TOTAL WITH SPHENOIDOTOMY,,31257,510,"$3,800.00 ","$3,800.00 ","$1,140.00 ","$3,458.00 ","$2,660.00 ","$1,140.00 ","$2,470.00 ","$2,736.00 ","$3,458.00 ","$2,850.00 "
Carle BroMenn Medical Center,8231259,NASAL/SINUS NDSC TOT W/SPHENDT W/SPHEN TISS RMVL,,31259,510,"$3,800.00 ","$3,800.00 ","$1,140.00 ","$3,458.00 ","$2,660.00 ","$1,140.00 ","$2,470.00 ","$2,736.00 ","$3,458.00 ","$2,850.00 "
Carle BroMenn Medical Center,8231298,NASAL/SINUS NDSC W/FRONTAL & SPHEN SINS DILATION,,31298,510,"$3,800.00 ","$3,800.00 ","$1,140.00 ","$3,458.00 ","$2,660.00 ","$1,140.00 ","$2,470.00 ","$2,736.00 ","$3,458.00 ","$2,850.00 "
Carle BroMenn Medical Center,8231502,TRACH TUBE CHANGE,,31502,510,$640.00 ,$640.00 ,$192.00 ,$582.40 ,$448.00 ,$192.00 ,$416.00 ,$460.80 ,$582.40 ,$480.00 
Carle BroMenn Medical Center,8231572,LARYNGOSCOPE FLEX ABLAT DEST LESN(S) UNI,,31572,510,"$5,660.00 ","$5,660.00 ","$1,698.00 ","$5,150.60 ","$3,962.00 ","$1,698.00 ","$3,679.00 ","$4,075.20 ","$5,150.60 ","$4,245.00 "
Carle BroMenn Medical Center,8231573,LARYNGOSCOPE FLEX THERAPEUTIC INJ UNI,,31573,510,"$2,950.00 ","$2,950.00 ",$885.00 ,"$2,684.50 ","$2,065.00 ",$885.00 ,"$1,917.50 ","$2,124.00 ","$2,684.50 ","$2,212.50 "
Carle BroMenn Medical Center,8231574,LARYNGOSCOPY FLEX W/INJ FOR AUGMENTATION,,31574,510,"$2,950.00 ","$2,950.00 ",$885.00 ,"$2,684.50 ","$2,065.00 ",$885.00 ,"$1,917.50 ","$2,124.00 ","$2,684.50 ","$2,212.50 "
Carle BroMenn Medical Center,8231575,"LARYNGOSCOPY,FLEX FIBER,DIAGNOSTIC",,31575,510,$585.00 ,$585.00 ,$175.50 ,$532.35 ,$409.50 ,$175.50 ,$380.25 ,$421.20 ,$532.35 ,$438.75 
Carle BroMenn Medical Center,8231576,"LARYNGOSCOPY,FLEX SCOPE,BIOPSY",,31576,510,"$1,280.00 ","$1,280.00 ",$384.00 ,"$1,164.80 ",$896.00 ,$384.00 ,$832.00 ,$921.60 ,"$1,164.80 ",$960.00 
Carle BroMenn Medical Center,8231577,"LARYNGOSCOPY,FLEX SCOPE,REMV F.B.",,31577,510,"$1,400.00 ","$1,400.00 ",$420.00 ,"$1,274.00 ",$980.00 ,$420.00 ,$910.00 ,"$1,008.00 ","$1,274.00 ","$1,050.00 "
Carle BroMenn Medical Center,8231579,"LARYNGOSCOPY,FLEX/RIGID+STROBOSCOPY",,31579,510,$860.00 ,$860.00 ,$258.00 ,$782.60 ,$602.00 ,$258.00 ,$559.00 ,$619.20 ,$782.60 ,$645.00 
Carle BroMenn Medical Center,8231615,TRACHEOBRONCH THRU EST TACH INCISION,,31615,510,"$1,180.00 ","$1,180.00 ",$354.00 ,"$1,073.80 ",$826.00 ,$354.00 ,$767.00 ,$849.60 ,"$1,073.80 ",$885.00 
Carle BroMenn Medical Center,8231652,BRNCHSC EBUS GUIDED SAMPL 1/2 NODE STATION/STRUX,,31652,510,"$2,690.00 ","$2,690.00 ",$807.00 ,"$2,447.90 ","$1,883.00 ",$807.00 ,"$1,748.50 ","$1,936.80 ","$2,447.90 ","$2,017.50 "
Carle BroMenn Medical Center,8231653,BRNCHSC EBUS GUIDED SAMPL 3/> NODE STATION/STRUX,,31653,510,"$2,690.00 ","$2,690.00 ",$807.00 ,"$2,447.90 ","$1,883.00 ",$807.00 ,"$1,748.50 ","$1,936.80 ","$2,447.90 ","$2,017.50 "
Carle BroMenn Medical Center,8231654,BRNSCHSC TNDSC EBUS DX/TX INTERVENTION PERPH LES,,31654,510,"$2,690.00 ","$2,690.00 ",$807.00 ,"$2,447.90 ","$1,883.00 ",$807.00 ,"$1,748.50 ","$1,936.80 ","$2,447.90 ","$2,017.50 "
Carle BroMenn Medical Center,8232408,CORE NEEDLE BX LUNG/MEDIASTINUM PERQ W/IMG,,32408,510,"$2,240.00 ","$2,240.00 ",$672.00 ,"$2,038.40 ","$1,568.00 ",$672.00 ,"$1,456.00 ","$1,612.80 ","$2,038.40 ","$1,680.00 "
Carle BroMenn Medical Center,8232551,TUBE THORACOSTOMY,,32551,510,"$1,400.00 ","$1,400.00 ",$420.00 ,"$1,274.00 ",$980.00 ,$420.00 ,$910.00 ,"$1,008.00 ","$1,274.00 ","$1,050.00 "
Carle BroMenn Medical Center,8232554,THORACENTESIS NEEDLE/CATH PLEURA W/O IMAGING,,32554,510,"$1,795.00 ","$1,795.00 ",$538.50 ,"$1,633.45 ","$1,256.50 ",$538.50 ,"$1,166.75 ","$1,292.40 ","$1,633.45 ","$1,346.25 "
Carle BroMenn Medical Center,8232555,THORACENTESIS NEEDLE/CATH PLEURA W/IMAGING,,32555,510,"$2,105.00 ","$2,105.00 ",$631.50 ,"$1,915.55 ","$1,473.50 ",$631.50 ,"$1,368.25 ","$1,515.60 ","$1,915.55 ","$1,578.75 "
Carle BroMenn Medical Center,8232556,PERC PLEURAL DRAINAGE W/O IMAGING,,32556,510,"$1,830.00 ","$1,830.00 ",$549.00 ,"$1,665.30 ","$1,281.00 ",$549.00 ,"$1,189.50 ","$1,317.60 ","$1,665.30 ","$1,372.50 "
Carle BroMenn Medical Center,8232561,"INSTILL VIA CHEST TUBE AGENT FOR FIBRINOLYSIS, 1ST DAY",,32561,510,"$1,345.50 ","$1,345.50 ",$403.65 ,"$1,224.41 ",$941.85 ,$403.65 ,$874.58 ,$968.76 ,"$1,224.41 ","$1,009.13 "
Carle BroMenn Medical Center,8232562,"INSTILL VIA CHEST TUBE AGENT FOR FIBRINOLYSIS, SUBSEQUENT",,32562,510,"$1,261.00 ","$1,261.00 ",$378.30 ,"$1,147.51 ",$882.70 ,$378.30 ,$819.65 ,$907.92 ,"$1,147.51 ",$945.75 
Carle BroMenn Medical Center,8232994,ABLATION THER 1+ PULM TUMORS PERQ CRYOABLATION,,32994,510,"$9,020.00 ","$9,020.00 ","$2,706.00 ","$8,208.20 ","$6,314.00 ","$2,706.00 ","$5,863.00 ","$6,494.40 ","$8,208.20 ","$6,765.00 "
Carle BroMenn Medical Center,8233016,PERICARDIOCENTESIS W/IMG GUIDANCE WHEN PERFORMED,,33016,510,"$1,545.00 ","$1,545.00 ",$463.50 ,"$1,405.95 ","$1,081.50 ",$463.50 ,"$1,004.25 ","$1,112.40 ","$1,405.95 ","$1,158.75 "
Carle BroMenn Medical Center,8233274,TCAT INSJ/RPL PERM LEADLESS PACEMAKER RV W/IMG,,33274,510,"$13,520.00 ","$13,520.00 ","$4,056.00 ","$12,303.20 ","$9,464.00 ","$4,056.00 ","$8,788.00 ","$9,734.40 ","$12,303.20 ","$10,140.00 "
Carle BroMenn Medical Center,8233275,TCAT REMOVAL PERM LEADLESS PACEMAKER R VENTR,,33275,510,"$2,330.00 ","$2,330.00 ",$699.00 ,"$2,120.30 ","$1,631.00 ",$699.00 ,"$1,514.50 ","$1,677.60 ","$2,120.30 ","$1,747.50 "
Carle BroMenn Medical Center,8233285,INSERTION SUBQ CARDIAC RHYTHM MONITOR W/PRGRMG,,33285,510,"$6,520.00 ","$6,520.00 ","$1,956.00 ","$5,933.20 ","$4,564.00 ","$1,956.00 ","$4,238.00 ","$4,694.40 ","$5,933.20 ","$4,890.00 "
Carle BroMenn Medical Center,8233286,REMOVAL SUBCUTANEOUS CARDIAC RHYTHM MONITOR,,33286,510,$520.00 ,$520.00 ,$156.00 ,$473.20 ,$364.00 ,$156.00 ,$338.00 ,$374.40 ,$473.20 ,$390.00 
Carle BroMenn Medical Center,8233289,TCAT IMPL WRLS P-ART PRS SNR L-T HEMODYN MNTR,,33289,510,"$25,820.00 ","$25,820.00 ","$7,746.00 ","$23,496.20 ","$18,074.00 ","$7,746.00 ","$16,783.00 ","$18,590.40 ","$23,496.20 ","$19,365.00 "
Carle BroMenn Medical Center,8233741,TAS CONGENITAL CARDIAC ANOMALIES ANY METHOD,,33741,510,"$5,600.00 ","$5,600.00 ","$1,680.00 ","$5,096.00 ","$3,920.00 ","$1,680.00 ","$3,640.00 ","$4,032.00 ","$5,096.00 ","$4,200.00 "
Carle BroMenn Medical Center,8233745,TIS CRTJ ST CONGENITAL CARDIAC ANOMAL 1ST SHUNT,,33745,510,"$4,900.00 ","$4,900.00 ","$1,470.00 ","$4,459.00 ","$3,430.00 ","$1,470.00 ","$3,185.00 ","$3,528.00 ","$4,459.00 ","$3,675.00 "
Carle BroMenn Medical Center,8233746,TIS CRTJ ST CONGENITAL CARDIAC ANOMAL EA ADDL,,33746,510,"$2,450.00 ","$2,450.00 ",$735.00 ,"$2,229.50 ","$1,715.00 ",$735.00 ,"$1,592.50 ","$1,764.00 ","$2,229.50 ","$1,837.50 "
Carle BroMenn Medical Center,8233995,INSJ PERQ VAD W/RS&I R HEART VENOUS ACCESS ONLY,,33995,510,"$2,800.00 ","$2,800.00 ",$840.00 ,"$2,548.00 ","$1,960.00 ",$840.00 ,"$1,820.00 ","$2,016.00 ","$2,548.00 ","$2,100.00 "
Carle BroMenn Medical Center,8233997,REMOVAL PERQ R HEART VAD VENOUS CANNULA SEP INSJ,,33997,510,"$1,750.00 ","$1,750.00 ",$525.00 ,"$1,592.50 ","$1,225.00 ",$525.00 ,"$1,137.50 ","$1,260.00 ","$1,592.50 ","$1,312.50 "
Carle BroMenn Medical Center,8234713,PERQ ACCESS & CLOSURE FEM ART FOR DELIVERY NDGFT,,34713,510,"$11,280.00 ","$11,280.00 ","$3,384.00 ","$10,264.80 ","$7,896.00 ","$3,384.00 ","$7,332.00 ","$8,121.60 ","$10,264.80 ","$8,460.00 "
Carle BroMenn Medical Center,8234714,OPN FEM ART EXPOS W/CNDT CRTJ DLVR EVASC PROSTH,,34714,510,"$11,280.00 ","$11,280.00 ","$3,384.00 ","$10,264.80 ","$7,896.00 ","$3,384.00 ","$7,332.00 ","$8,121.60 ","$10,264.80 ","$8,460.00 "
Carle BroMenn Medical Center,8234715,OPN AX/SUBCLA ART EXPOS DLVR EVASC PROSTH UNI,,34715,510,"$11,280.00 ","$11,280.00 ","$3,384.00 ","$10,264.80 ","$7,896.00 ","$3,384.00 ","$7,332.00 ","$8,121.60 ","$10,264.80 ","$8,460.00 "
Carle BroMenn Medical Center,8234716,OPN AXILLARY/SUBCLAVIAN ART EXPOS W/CNDT CRTJ,,34716,510,"$11,280.00 ","$11,280.00 ","$3,384.00 ","$10,264.80 ","$7,896.00 ","$3,384.00 ","$7,332.00 ","$8,121.60 ","$10,264.80 ","$8,460.00 "
Carle BroMenn Medical Center,8234839,PLNNING PT SPEC FENEST VISCERAL AORTIC GRAFT,,34839,510,$195.00 ,$195.00 ,$58.50 ,$177.45 ,$136.50 ,$58.50 ,$126.75 ,$140.40 ,$177.45 ,$146.25 
Carle BroMenn Medical Center,8236465,NJX NONCMPND SCLEROSANT SINGLE INCMPTNT VEIN,,36465,510,"$1,133.00 ","$1,133.00 ",$339.90 ,"$1,031.03 ",$793.10 ,$339.90 ,$736.45 ,$815.76 ,"$1,031.03 ",$849.75 
Carle BroMenn Medical Center,8236466,NJX NONCMPND SCLEROSANT MULTIPLE INCMPTNT VEINS,,36466,510,"$1,133.00 ","$1,133.00 ",$339.90 ,"$1,031.03 ",$793.10 ,$339.90 ,$736.45 ,$815.76 ,"$1,031.03 ",$849.75 
Carle BroMenn Medical Center,8236468,"INJECTION; SPIDER VEINS,LIMB/TRUNK",,36468,510,$560.00 ,$560.00 ,$168.00 ,$509.60 ,$392.00 ,$168.00 ,$364.00 ,$403.20 ,$509.60 ,$420.00 
Carle BroMenn Medical Center,8236470,"INJECTION THERAPY VEIN,ONE VEIN",,36470,510,$660.00 ,$660.00 ,$198.00 ,$600.60 ,$462.00 ,$198.00 ,$429.00 ,$475.20 ,$600.60 ,$495.00 
Carle BroMenn Medical Center,8236471,"INJECTION THERAPY VEIN,MULT VEINS",,36471,510,$930.00 ,$930.00 ,$279.00 ,$846.30 ,$651.00 ,$279.00 ,$604.50 ,$669.60 ,$846.30 ,$697.50 
Carle BroMenn Medical Center,8236475,"ENDOVENOUS RF, 1ST VEIN",,36475,510,"$9,090.00 ","$9,090.00 ","$2,727.00 ","$8,271.90 ","$6,363.00 ","$2,727.00 ","$5,908.50 ","$6,544.80 ","$8,271.90 ","$6,817.50 "
Carle BroMenn Medical Center,8236476,"ENDOVENOUS RF, VEIN ADD-ON",,36476,510,"$1,760.00 ","$1,760.00 ",$528.00 ,"$1,601.60 ","$1,232.00 ",$528.00 ,"$1,144.00 ","$1,267.20 ","$1,601.60 ","$1,320.00 "
Carle BroMenn Medical Center,8236478,"ENDOVENOUS LASER, 1ST VEIN",,36478,510,"$5,450.00 ","$5,450.00 ","$1,635.00 ","$4,959.50 ","$3,815.00 ","$1,635.00 ","$3,542.50 ","$3,924.00 ","$4,959.50 ","$4,087.50 "
Carle BroMenn Medical Center,8236479,ENDOVENOUS LASER VEIN ADDON,,36479,510,"$2,710.00 ","$2,710.00 ",$813.00 ,"$2,466.10 ","$1,897.00 ",$813.00 ,"$1,761.50 ","$1,951.20 ","$2,466.10 ","$2,032.50 "
Carle BroMenn Medical Center,8236482,ENDOVEN ABLTI THER CHEM ADHESIVE 1ST VEIN,,36482,510,"$3,218.00 ","$3,218.00 ",$965.40 ,"$2,928.38 ","$2,252.60 ",$965.40 ,"$2,091.70 ","$2,316.96 ","$2,928.38 ","$2,413.50 "
Carle BroMenn Medical Center,8236483,ENDOVEN ABLTI THER CHEM ADHESIVE SBSQ VEIN,,36483,510,$240.00 ,$240.00 ,$72.00 ,$218.40 ,$168.00 ,$72.00 ,$156.00 ,$172.80 ,$218.40 ,$180.00 
Carle BroMenn Medical Center,8236572,INSERTION PICC W/RS&I < 5 YR,,36572,510,$893.00 ,$893.00 ,$267.90 ,$812.63 ,$625.10 ,$267.90 ,$580.45 ,$642.96 ,$812.63 ,$669.75 
Carle BroMenn Medical Center,8236573,INSERTION PICC W/RS&I 5 YR/>,,36573,510,"$2,242.00 ","$2,242.00 ",$672.60 ,"$2,040.22 ","$1,569.40 ",$672.60 ,"$1,457.30 ","$1,614.24 ","$2,040.22 ","$1,681.50 "
Carle BroMenn Medical Center,8236575,REPAIR CV CATH W/O SUBQ PORT OR PUMP,,36575,510,"$1,845.00 ","$1,845.00 ",$553.50 ,"$1,678.95 ","$1,291.50 ",$553.50 ,"$1,199.25 ","$1,328.40 ","$1,678.95 ","$1,383.75 "
Carle BroMenn Medical Center,8236578,"REPLACE CV CATH, CATHETER",,36578,510,"$1,870.00 ","$1,870.00 ",$561.00 ,"$1,701.70 ","$1,309.00 ",$561.00 ,"$1,215.50 ","$1,346.40 ","$1,701.70 ","$1,402.50 "
Carle BroMenn Medical Center,8236589,REMOVAL TUNNELED CV CATH W/O SUBQ PORT OR PUMP,,36589,510,"$1,845.00 ","$1,845.00 ",$553.50 ,"$1,678.95 ","$1,291.50 ",$553.50 ,"$1,199.25 ","$1,328.40 ","$1,678.95 ","$1,383.75 "
Carle BroMenn Medical Center,8236590,REMOVAL TUNNELED CV CATH W SUBQ PORT OR PUMP,,36590,510,"$2,760.00 ","$2,760.00 ",$828.00 ,"$2,511.60 ","$1,932.00 ",$828.00 ,"$1,794.00 ","$1,987.20 ","$2,511.60 ","$2,070.00 "
Carle BroMenn Medical Center,8236591,COLLCTN BLD SPCMN FROM VAD,,36591,510,$230.00 ,$230.00 ,$69.00 ,$209.30 ,$161.00 ,$69.00 ,$149.50 ,$165.60 ,$209.30 ,$172.50 
Carle BroMenn Medical Center,8236592,COLLCTN BLD SPCMN FROM PICC,,36592,510,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8236593,DECLOT VASCULAR DEVICE,,36593,510,$760.00 ,$760.00 ,$228.00 ,$691.60 ,$532.00 ,$228.00 ,$494.00 ,$547.20 ,$691.60 ,$570.00 
Carle BroMenn Medical Center,8236597,REPOSITION VENOUS CATHETER,,36597,510,"$1,000.00 ","$1,000.00 ",$300.00 ,$910.00 ,$700.00 ,$300.00 ,$650.00 ,$720.00 ,$910.00 ,$750.00 
Carle BroMenn Medical Center,8236600,WITHDRAWAL OF ARTERIAL BLOOD,,36600,510,$44.00 ,$44.00 ,$13.20 ,$40.04 ,$30.80 ,$13.20 ,$28.60 ,$31.68 ,$40.04 ,$33.00 
Carle BroMenn Medical Center,8237609,TEMPORAL ARTERY LIGATN OR BX,,37609,510,"$3,465.00 ","$3,465.00 ","$1,039.50 ","$3,153.15 ","$2,425.50 ","$1,039.50 ","$2,252.25 ","$2,494.80 ","$3,153.15 ","$2,598.75 "
Carle BroMenn Medical Center,8237765,PHLEB VEINS - EXTREM - TO 20,,37765,510,"$5,150.00 ","$5,150.00 ","$1,545.00 ","$4,686.50 ","$3,605.00 ","$1,545.00 ","$3,347.50 ","$3,708.00 ","$4,686.50 ","$3,862.50 "
Carle BroMenn Medical Center,8237766,PHLEB VEINS - EXTREM 20+,,37766,510,"$4,740.00 ","$4,740.00 ","$1,422.00 ","$4,313.40 ","$3,318.00 ","$1,422.00 ","$3,081.00 ","$3,412.80 ","$4,313.40 ","$3,555.00 "
Carle BroMenn Medical Center,8238220,BONE MARROW ASPIRATION,,38220,510,$910.00 ,$910.00 ,$273.00 ,$828.10 ,$637.00 ,$273.00 ,$591.50 ,$655.20 ,$828.10 ,$682.50 
Carle BroMenn Medical Center,8238221,BONE MARROW BIOPSY,,38221,510,"$1,228.50 ","$1,228.50 ",$368.55 ,"$1,117.94 ",$859.95 ,$368.55 ,$798.53 ,$884.52 ,"$1,117.94 ",$921.38 
Carle BroMenn Medical Center,8238222,DIAGNOSTIC BONE MARROW BIOPSIES & ASPIRATIONS,,38222,510,"$1,620.00 ","$1,620.00 ",$486.00 ,"$1,474.20 ","$1,134.00 ",$486.00 ,"$1,053.00 ","$1,166.40 ","$1,474.20 ","$1,215.00 "
Carle BroMenn Medical Center,8238500,"BIOPSY/EXCISION, LYMPH NODE(S)",,38500,510,"$6,020.00 ","$6,020.00 ","$1,806.00 ","$5,478.20 ","$4,214.00 ","$1,806.00 ","$3,913.00 ","$4,334.40 ","$5,478.20 ","$4,515.00 "
Carle BroMenn Medical Center,8238531,OPEN BIOPSY/EXCISION INGUINOFEMORAL NODES,,38531,510,"$3,820.00 ","$3,820.00 ","$1,146.00 ","$3,476.20 ","$2,674.00 ","$1,146.00 ","$2,483.00 ","$2,750.40 ","$3,476.20 ","$2,865.00 "
Carle BroMenn Medical Center,8240490,BIOPSY OF LIP,,40490,510,$520.00 ,$520.00 ,$156.00 ,$473.20 ,$364.00 ,$156.00 ,$338.00 ,$374.40 ,$473.20 ,$390.00 
Carle BroMenn Medical Center,8240800,"DRAIN MOUTH ABSC/CYST/HEMATOMA,SIMPL",,40800,510,$340.00 ,$340.00 ,$102.00 ,$309.40 ,$238.00 ,$102.00 ,$221.00 ,$244.80 ,$309.40 ,$255.00 
Carle BroMenn Medical Center,8240806,INCISION OF LIP FOLD,,40806,510,$600.00 ,$600.00 ,$180.00 ,$546.00 ,$420.00 ,$180.00 ,$390.00 ,$432.00 ,$546.00 ,$450.00 
Carle BroMenn Medical Center,8240808,BIOPSY OF MOUTH LESION,,40808,510,$780.00 ,$780.00 ,$234.00 ,$709.80 ,$546.00 ,$234.00 ,$507.00 ,$561.60 ,$709.80 ,$585.00 
Carle BroMenn Medical Center,8240810,"EXCIS MOUTH MUCOSA/SUB,NO REPAIR",,40810,510,"$1,790.00 ","$1,790.00 ",$537.00 ,"$1,628.90 ","$1,253.00 ",$537.00 ,"$1,163.50 ","$1,288.80 ","$1,628.90 ","$1,342.50 "
Carle BroMenn Medical Center,8240812,"EXCIS MOUTH MUCOSA/SUB,SIMPL REPAIR",,40812,510,"$1,700.00 ","$1,700.00 ",$510.00 ,"$1,547.00 ","$1,190.00 ",$510.00 ,"$1,105.00 ","$1,224.00 ","$1,547.00 ","$1,275.00 "
Carle BroMenn Medical Center,8240819,EXCISE LIP OR CHEEK FOLD,,40819,510,"$1,700.00 ","$1,700.00 ",$510.00 ,"$1,547.00 ","$1,190.00 ",$510.00 ,"$1,105.00 ","$1,224.00 ","$1,547.00 ","$1,275.00 "
Carle BroMenn Medical Center,8240820,DESTRUC MOUTH LESION/SCAR,,40820,510,"$1,790.00 ","$1,790.00 ",$537.00 ,"$1,628.90 ","$1,253.00 ",$537.00 ,"$1,163.50 ","$1,288.80 ","$1,628.90 ","$1,342.50 "
Carle BroMenn Medical Center,8241100,"BIOPSY TONGUE,ANTER 2/3",,41100,510,"$1,010.00 ","$1,010.00 ",$303.00 ,$919.10 ,$707.00 ,$303.00 ,$656.50 ,$727.20 ,$919.10 ,$757.50 
Carle BroMenn Medical Center,8241105,"BIOPSY TONGUE,POSTER 1/3",,41105,510,"$2,720.00 ","$2,720.00 ",$816.00 ,"$2,475.20 ","$1,904.00 ",$816.00 ,"$1,768.00 ","$1,958.40 ","$2,475.20 ","$2,040.00 "
Carle BroMenn Medical Center,8241108,BIOPSY OF FLOOR OF MOUTH,,41108,510,"$1,560.00 ","$1,560.00 ",$468.00 ,"$1,419.60 ","$1,092.00 ",$468.00 ,"$1,014.00 ","$1,123.20 ","$1,419.60 ","$1,170.00 "
Carle BroMenn Medical Center,8241110,EXCIS TONGUE LESN,,41110,510,"$1,790.00 ","$1,790.00 ",$537.00 ,"$1,628.90 ","$1,253.00 ",$537.00 ,"$1,163.50 ","$1,288.80 ","$1,628.90 ","$1,342.50 "
Carle BroMenn Medical Center,8241112,"EXCIS TONGUE LESN,ANT 2/3+CLOS",,41112,510,"$2,720.00 ","$2,720.00 ",$816.00 ,"$2,475.20 ","$1,904.00 ",$816.00 ,"$1,768.00 ","$1,958.40 ","$2,475.20 ","$2,040.00 "
Carle BroMenn Medical Center,8241115,EXCIS TONGUE FOLD,,41115,510,$970.00 ,$970.00 ,$291.00 ,$882.70 ,$679.00 ,$291.00 ,$630.50 ,$698.40 ,$882.70 ,$727.50 
Carle BroMenn Medical Center,8241800,DRAINAGE OF GUM LESION,,41800,510,$440.00 ,$440.00 ,$132.00 ,$400.40 ,$308.00 ,$132.00 ,$286.00 ,$316.80 ,$400.40 ,$330.00 
Carle BroMenn Medical Center,8241822,"EXCIS FIBROUS TUBER,DENTOALV",,41822,510,$930.00 ,$930.00 ,$279.00 ,$846.30 ,$651.00 ,$279.00 ,$604.50 ,$669.60 ,$846.30 ,$697.50 
Carle BroMenn Medical Center,8241823,"EXCIS OSSEOUS TUBER,DENTOALV",,41823,510,"$3,320.00 ","$3,320.00 ",$996.00 ,"$3,021.20 ","$2,324.00 ",$996.00 ,"$2,158.00 ","$2,390.40 ","$3,021.20 ","$2,490.00 "
Carle BroMenn Medical Center,8241825,EXCIS DENTOALVEOLAR LESION,,41825,510,"$1,790.00 ","$1,790.00 ",$537.00 ,"$1,628.90 ","$1,253.00 ",$537.00 ,"$1,163.50 ","$1,288.80 ","$1,628.90 ","$1,342.50 "
Carle BroMenn Medical Center,8241826,"EXCIS DENTOALV LESN,SIMPL REPR",,41826,510,"$3,420.00 ","$3,420.00 ","$1,026.00 ","$3,112.20 ","$2,394.00 ","$1,026.00 ","$2,223.00 ","$2,462.40 ","$3,112.20 ","$2,565.00 "
Carle BroMenn Medical Center,8241874,REPAIR TOOTH SOCKET,,41874,510,"$1,790.00 ","$1,790.00 ",$537.00 ,"$1,628.90 ","$1,253.00 ",$537.00 ,"$1,163.50 ","$1,288.80 ","$1,628.90 ","$1,342.50 "
Carle BroMenn Medical Center,8241899,DENTAL SURGERY PROCEDURE,,41899,510,$640.00 ,$640.00 ,$192.00 ,$582.40 ,$448.00 ,$192.00 ,$416.00 ,$460.80 ,$582.40 ,$480.00 
Carle BroMenn Medical Center,8242000,DRAINAGE ABSCESS PALATE/UVULA,,42000,510,$455.00 ,$455.00 ,$136.50 ,$414.05 ,$318.50 ,$136.50 ,$295.75 ,$327.60 ,$414.05 ,$341.25 
Carle BroMenn Medical Center,8242100,BIOPSY PALATE/UVULA,,42100,510,"$1,320.00 ","$1,320.00 ",$396.00 ,"$1,201.20 ",$924.00 ,$396.00 ,$858.00 ,$950.40 ,"$1,201.20 ",$990.00 
Carle BroMenn Medical Center,8242104,"EXCIS LESN,PALATE/UVULA",,42104,510,"$2,720.00 ","$2,720.00 ",$816.00 ,"$2,475.20 ","$1,904.00 ",$816.00 ,"$1,768.00 ","$1,958.40 ","$2,475.20 ","$2,040.00 "
Carle BroMenn Medical Center,8242106,"EXCIS LESN,PALATE/UVULA-SIMPL CLOS",,42106,510,"$1,790.00 ","$1,790.00 ",$537.00 ,"$1,628.90 ","$1,253.00 ",$537.00 ,"$1,163.50 ","$1,288.80 ","$1,628.90 ","$1,342.50 "
Carle BroMenn Medical Center,8242330,"REMOVAL SALIVARY STONE,UNCOMPLIC",,42330,510,"$1,790.00 ","$1,790.00 ",$537.00 ,"$1,628.90 ","$1,253.00 ",$537.00 ,"$1,163.50 ","$1,288.80 ","$1,628.90 ","$1,342.50 "
Carle BroMenn Medical Center,8242405,"BIOPSY SALIVARY GLAND,INCISIONAL",,42405,510,"$2,720.00 ","$2,720.00 ",$816.00 ,"$2,475.20 ","$1,904.00 ",$816.00 ,"$1,768.00 ","$1,958.40 ","$2,475.20 ","$2,040.00 "
Carle BroMenn Medical Center,8242650,DILATION OF SALIVARY DUCT,,42650,510,$970.00 ,$970.00 ,$291.00 ,$882.70 ,$679.00 ,$291.00 ,$630.50 ,$698.40 ,$882.70 ,$727.50 
Carle BroMenn Medical Center,8242700,INC/DRAIN PERITONSIL ABSCESS,,42700,510,$780.00 ,$780.00 ,$234.00 ,$709.80 ,$546.00 ,$234.00 ,$507.00 ,$561.60 ,$709.80 ,$585.00 
Carle BroMenn Medical Center,8242800,BIOPSY OROPHARYNX,,42800,510,"$2,720.00 ","$2,720.00 ",$816.00 ,"$2,475.20 ","$1,904.00 ",$816.00 ,"$1,768.00 ","$1,958.40 ","$2,475.20 ","$2,040.00 "
Carle BroMenn Medical Center,8243180,ESOPHAGOSCP RIG TRANSORAL HYPOPHARYNX CRV ESOPH,,43180,510,"$4,680.00 ","$4,680.00 ","$1,404.00 ","$4,258.80 ","$3,276.00 ","$1,404.00 ","$3,042.00 ","$3,369.60 ","$4,258.80 ","$3,510.00 "
Carle BroMenn Medical Center,8243210,EGD PARTIAL/COMPL ESOPHAGOGASTRIC FUNDOPLASTY,,43210,510,"$5,810.00 ","$5,810.00 ","$1,743.00 ","$5,287.10 ","$4,067.00 ","$1,743.00 ","$3,776.50 ","$4,183.20 ","$5,287.10 ","$4,357.50 "
Carle BroMenn Medical Center,8243235,"UPPER GI ENDOSCOPY,DIAGNOSIS",,43235,510,"$1,180.00 ","$1,180.00 ",$354.00 ,"$1,073.80 ",$826.00 ,$354.00 ,$767.00 ,$849.60 ,"$1,073.80 ",$885.00 
Carle BroMenn Medical Center,8243239,"UPPER GI ENDOSCOPY,BIOPSY",,43239,510,"$1,730.00 ","$1,730.00 ",$519.00 ,"$1,574.30 ","$1,211.00 ",$519.00 ,"$1,124.50 ","$1,245.60 ","$1,574.30 ","$1,297.50 "
Carle BroMenn Medical Center,8243247,"UPPER GI ENDOSCOPY,REMOV F.B.",,43247,510,"$1,260.00 ","$1,260.00 ",$378.00 ,"$1,146.60 ",$882.00 ,$378.00 ,$819.00 ,$907.20 ,"$1,146.60 ",$945.00 
Carle BroMenn Medical Center,8243760,CHANGE GASTROSTOMY TUBE PERCUTANEOUS W/O GUIDE,,43760,510,$660.00 ,$660.00 ,$198.00 ,$600.60 ,$462.00 ,$198.00 ,$429.00 ,$475.20 ,$600.60 ,$495.00 
Carle BroMenn Medical Center,8243762,PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC,,43762,510,$500.00 ,$500.00 ,$150.00 ,$455.00 ,$350.00 ,$150.00 ,$325.00 ,$360.00 ,$455.00 ,$375.00 
Carle BroMenn Medical Center,8243763,PERQ REPLACEMENT GTUBE REQ REVJ GSTRST TRC,,43763,510,$730.00 ,$730.00 ,$219.00 ,$664.30 ,$511.00 ,$219.00 ,$474.50 ,$525.60 ,$664.30 ,$547.50 
Carle BroMenn Medical Center,8244381,ILEOSCOPY STOMA W/BALLOON DILATION,,44381,510,"$1,920.00 ","$1,920.00 ",$576.00 ,"$1,747.20 ","$1,344.00 ",$576.00 ,"$1,248.00 ","$1,382.40 ","$1,747.20 ","$1,440.00 "
Carle BroMenn Medical Center,8244384,ILEOSCOPY STOMA W/PLMT OF ENDOSCOPIC STENT,,44384,510,"$2,090.00 ","$2,090.00 ",$627.00 ,"$1,901.90 ","$1,463.00 ",$627.00 ,"$1,358.50 ","$1,504.80 ","$1,901.90 ","$1,567.50 "
Carle BroMenn Medical Center,8244385,NDSC EVAL INTSTINAL POUCH DX W/COLLJ SPEC SPX,,44385,510,$830.00 ,$830.00 ,$249.00 ,$755.30 ,$581.00 ,$249.00 ,$539.50 ,$597.60 ,$755.30 ,$622.50 
Carle BroMenn Medical Center,8244401,COLONOSCOPY STOMA ABLATION LESION,,44401,510,"$2,560.00 ","$2,560.00 ",$768.00 ,"$2,329.60 ","$1,792.00 ",$768.00 ,"$1,664.00 ","$1,843.20 ","$2,329.60 ","$1,920.00 "
Carle BroMenn Medical Center,8244402,COLONOSCOPY STOMA W/ENDOSCOPIC STENT PLCMT,,44402,510,"$3,280.00 ","$3,280.00 ",$984.00 ,"$2,984.80 ","$2,296.00 ",$984.00 ,"$2,132.00 ","$2,361.60 ","$2,984.80 ","$2,460.00 "
Carle BroMenn Medical Center,8244403,COLONOSCOPY STOMA W/ENDOSCOPIC MUCOSAL RESCJ,,44403,510,"$2,780.00 ","$2,780.00 ",$834.00 ,"$2,529.80 ","$1,946.00 ",$834.00 ,"$1,807.00 ","$2,001.60 ","$2,529.80 ","$2,085.00 "
Carle BroMenn Medical Center,8244404,COLONOSCOPY STOMA W/SUBMUCOSAL INJECTION,,44404,510,"$2,010.00 ","$2,010.00 ",$603.00 ,"$1,829.10 ","$1,407.00 ",$603.00 ,"$1,306.50 ","$1,447.20 ","$1,829.10 ","$1,507.50 "
Carle BroMenn Medical Center,8244405,COLONOSCOPY STOMA W/BALLOON DILATION,,44405,510,"$2,090.00 ","$2,090.00 ",$627.00 ,"$1,901.90 ","$1,463.00 ",$627.00 ,"$1,358.50 ","$1,504.80 ","$1,901.90 ","$1,567.50 "
Carle BroMenn Medical Center,8244406,COLONOSCOPY STOMA W/ENDOSCOPIC ULTRASOUND EXAM,,44406,510,"$2,560.00 ","$2,560.00 ",$768.00 ,"$2,329.60 ","$1,792.00 ",$768.00 ,"$1,664.00 ","$1,843.20 ","$2,329.60 ","$1,920.00 "
Carle BroMenn Medical Center,8244407,COLONOSCOPY STOMA W/US GID NDL ASPIR/BX,,44407,510,"$2,560.00 ","$2,560.00 ",$768.00 ,"$2,329.60 ","$1,792.00 ",$768.00 ,"$1,664.00 ","$1,843.20 ","$2,329.60 ","$1,920.00 "
Carle BroMenn Medical Center,8244408,COLONOSCOPY THROUGH STOMA WITH DECOMPRESSION,,44408,510,"$2,090.00 ","$2,090.00 ",$627.00 ,"$1,901.90 ","$1,463.00 ",$627.00 ,"$1,358.50 ","$1,504.80 ","$1,901.90 ","$1,567.50 "
Carle BroMenn Medical Center,8245300,"PROCTOSIGMOIDOSCOPY,RIGID,DIAGNOS",,45300,510,$850.00 ,$850.00 ,$255.00 ,$773.50 ,$595.00 ,$255.00 ,$552.50 ,$612.00 ,$773.50 ,$637.50 
Carle BroMenn Medical Center,8245305,"PROCTOSIGMOIDOSCOPY,BIOPSY",,45305,510,"$1,200.00 ","$1,200.00 ",$360.00 ,"$1,092.00 ",$840.00 ,$360.00 ,$780.00 ,$864.00 ,"$1,092.00 ",$900.00 
Carle BroMenn Medical Center,8245330,"SIGMOIDOSCOPY,DIAGNOSTIC",,45330,510,"$1,300.00 ","$1,300.00 ",$390.00 ,"$1,183.00 ",$910.00 ,$390.00 ,$845.00 ,$936.00 ,"$1,183.00 ",$975.00 
Carle BroMenn Medical Center,8245331,"SIGMOIDOSCOPY,BIOPSY",,45331,510,"$1,550.00 ","$1,550.00 ",$465.00 ,"$1,410.50 ","$1,085.00 ",$465.00 ,"$1,007.50 ","$1,116.00 ","$1,410.50 ","$1,162.50 "
Carle BroMenn Medical Center,8245333,"SIGMOIDOSCOPY,REMV LESN,FORCEP/CAUT",,45333,510,"$1,320.00 ","$1,320.00 ",$396.00 ,"$1,201.20 ",$924.00 ,$396.00 ,$858.00 ,$950.40 ,"$1,201.20 ",$990.00 
Carle BroMenn Medical Center,8245346,SIGMOIDOSCOPY FLX ABLATION TUMOR POLYP/OTH LES,,45346,510,"$1,950.00 ","$1,950.00 ",$585.00 ,"$1,774.50 ","$1,365.00 ",$585.00 ,"$1,267.50 ","$1,404.00 ","$1,774.50 ","$1,462.50 "
Carle BroMenn Medical Center,8245347,SIGMOIDOSCOPY FLX PLACEMENT OF ENDOSCOPIC STENT,,45347,510,"$3,280.00 ","$3,280.00 ",$984.00 ,"$2,984.80 ","$2,296.00 ",$984.00 ,"$2,132.00 ","$2,361.60 ","$2,984.80 ","$2,460.00 "
Carle BroMenn Medical Center,8245349,SGMDSC FLX WITH ENDOSCOPIC MUCOSAL RESECTION,,45349,510,"$2,010.00 ","$2,010.00 ",$603.00 ,"$1,829.10 ","$1,407.00 ",$603.00 ,"$1,306.50 ","$1,447.20 ","$1,829.10 ","$1,507.50 "
Carle BroMenn Medical Center,8245350,SIGMOIDOSCOPY FLX WITH WITH BAND LIGATION(S),,45350,510,"$1,990.00 ","$1,990.00 ",$597.00 ,"$1,810.90 ","$1,393.00 ",$597.00 ,"$1,293.50 ","$1,432.80 ","$1,810.90 ","$1,492.50 "
Carle BroMenn Medical Center,8245378,"COLONOSCOPY,DIAGNOSTIC",,45378,510,"$1,920.00 ","$1,920.00 ",$576.00 ,"$1,747.20 ","$1,344.00 ",$576.00 ,"$1,248.00 ","$1,382.40 ","$1,747.20 ","$1,440.00 "
Carle BroMenn Medical Center,8245380,"COLONOSCOPY,BIOPSY",,45380,510,"$2,530.00 ","$2,530.00 ",$759.00 ,"$2,302.30 ","$1,771.00 ",$759.00 ,"$1,644.50 ","$1,821.60 ","$2,302.30 ","$1,897.50 "
Carle BroMenn Medical Center,8245385,"COLONOSCOPY,REMV LESN,SNARE",,45385,510,"$2,580.00 ","$2,580.00 ",$774.00 ,"$2,347.80 ","$1,806.00 ",$774.00 ,"$1,677.00 ","$1,857.60 ","$2,347.80 ","$1,935.00 "
Carle BroMenn Medical Center,8245388,COLONOSCOPY FLX ABLATION TUMOR POLYP/OTHER LES,,45388,510,"$2,780.00 ","$2,780.00 ",$834.00 ,"$2,529.80 ","$1,946.00 ",$834.00 ,"$1,807.00 ","$2,001.60 ","$2,529.80 ","$2,085.00 "
Carle BroMenn Medical Center,8245389,COLONOSCOPY FLX WITH ENDOSCOPIC STENT PLACEMENT,,45389,510,"$3,280.00 ","$3,280.00 ",$984.00 ,"$2,984.80 ","$2,296.00 ",$984.00 ,"$2,132.00 ","$2,361.60 ","$2,984.80 ","$2,460.00 "
Carle BroMenn Medical Center,8245390,COLONOSCOPY FLX W/ENDOSCOPIC MUCOSAL RESECTION,,45390,510,"$4,160.00 ","$4,160.00 ","$1,248.00 ","$3,785.60 ","$2,912.00 ","$1,248.00 ","$2,704.00 ","$2,995.20 ","$3,785.60 ","$3,120.00 "
Carle BroMenn Medical Center,8245393,COLONOSCOPY FLEXIBLE WITH DECOMPRESSION,,45393,510,"$3,280.00 ","$3,280.00 ",$984.00 ,"$2,984.80 ","$2,296.00 ",$984.00 ,"$2,132.00 ","$2,361.60 ","$2,984.80 ","$2,460.00 "
Carle BroMenn Medical Center,8245398,COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S),,45398,510,"$4,090.00 ","$4,090.00 ","$1,227.00 ","$3,721.90 ","$2,863.00 ","$1,227.00 ","$2,658.50 ","$2,944.80 ","$3,721.90 ","$3,067.50 "
Carle BroMenn Medical Center,8246040,I&D PERIRECTAL ABSCESS,,46040,510,"$3,860.00 ","$3,860.00 ","$1,158.00 ","$3,512.60 ","$2,702.00 ","$1,158.00 ","$2,509.00 ","$2,779.20 ","$3,512.60 ","$2,895.00 "
Carle BroMenn Medical Center,8246050,"I&D PERIANAL ABSCESS, SUPERFICIAL",,46050,510,"$1,800.00 ","$1,800.00 ",$540.00 ,"$1,638.00 ","$1,260.00 ",$540.00 ,"$1,170.00 ","$1,296.00 ","$1,638.00 ","$1,350.00 "
Carle BroMenn Medical Center,8246083,INCISE EXTERNAL HEMORRHOID,,46083,510,$735.00 ,$735.00 ,$220.50 ,$668.85 ,$514.50 ,$220.50 ,$477.75 ,$529.20 ,$668.85 ,$551.25 
Carle BroMenn Medical Center,8246220,EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,,46220,510,"$1,030.00 ","$1,030.00 ",$309.00 ,$937.30 ,$721.00 ,$309.00 ,$669.50 ,$741.60 ,$937.30 ,$772.50 
Carle BroMenn Medical Center,8246221,HEMORRHOIDECTOMY INTERNAL RUBBER BAND LIGATIONS,,46221,510,"$1,280.00 ","$1,280.00 ",$384.00 ,"$1,164.80 ",$896.00 ,$384.00 ,$832.00 ,$921.60 ,"$1,164.80 ",$960.00 
Carle BroMenn Medical Center,8246230,EXCISION MULTIPLE EXTERNAL PAPILLAE/TAGS ANUS,,46230,510,"$2,710.00 ","$2,710.00 ",$813.00 ,"$2,466.10 ","$1,897.00 ",$813.00 ,"$1,761.50 ","$1,951.20 ","$2,466.10 ","$2,032.50 "
Carle BroMenn Medical Center,8246320,"EXCISION THROMBOSED HEMORRHOID, EXTERNAL",,46320,510,"$3,510.00 ","$3,510.00 ","$1,053.00 ","$3,194.10 ","$2,457.00 ","$1,053.00 ","$2,281.50 ","$2,527.20 ","$3,194.10 ","$2,632.50 "
Carle BroMenn Medical Center,8246600,DIAGNOSTIC ANOSCOPY,,46600,510,$235.00 ,$235.00 ,$70.50 ,$213.85 ,$164.50 ,$70.50 ,$152.75 ,$169.20 ,$213.85 ,$176.25 
Carle BroMenn Medical Center,8246601,ANOSCOPY DX W/HRA &CHEM AGNTS ENHANCEMENT,,46601,510,"$1,230.00 ","$1,230.00 ",$369.00 ,"$1,119.30 ",$861.00 ,$369.00 ,$799.50 ,$885.60 ,"$1,119.30 ",$922.50 
Carle BroMenn Medical Center,8246606,ANOSCOPY AND BIOPSY,,46606,510,"$1,470.00 ","$1,470.00 ",$441.00 ,"$1,337.70 ","$1,029.00 ",$441.00 ,$955.50 ,"$1,058.40 ","$1,337.70 ","$1,102.50 "
Carle BroMenn Medical Center,8246607,ANOSCOPY DX W/HRA &CHEM AGNTS ENHANCEMENT W/BX,,46607,510,"$2,530.00 ","$2,530.00 ",$759.00 ,"$2,302.30 ","$1,771.00 ",$759.00 ,"$1,644.50 ","$1,821.60 ","$2,302.30 ","$1,897.50 "
Carle BroMenn Medical Center,8246900,"DESTRUCT,ANAL LESN(S),SIMPLE,CHEM",,46900,510,$520.00 ,$520.00 ,$156.00 ,$473.20 ,$364.00 ,$156.00 ,$338.00 ,$374.40 ,$473.20 ,$390.00 
Carle BroMenn Medical Center,8246922,SURG EXCISION OF ANAL LESION(S),,46922,510,"$2,710.00 ","$2,710.00 ",$813.00 ,"$2,466.10 ","$1,897.00 ",$813.00 ,"$1,761.50 ","$1,951.20 ","$2,466.10 ","$2,032.50 "
Carle BroMenn Medical Center,8246930,"DESTRUCT INTERNAL HEMORRHOID, THERMAL",,46930,510,$680.00 ,$680.00 ,$204.00 ,$618.80 ,$476.00 ,$204.00 ,$442.00 ,$489.60 ,$618.80 ,$510.00 
Carle BroMenn Medical Center,8246945,"HEMORRHOIDECTOMY, INT, LIGATION NOT RUBBER BAND, SINGLE",,46945,510,"$1,690.00 ","$1,690.00 ",$507.00 ,"$1,537.90 ","$1,183.00 ",$507.00 ,"$1,098.50 ","$1,216.80 ","$1,537.90 ","$1,267.50 "
Carle BroMenn Medical Center,8246946,"HEMORRHOIDECTOMY, INT, LIGATION NOT RUBBER BAND, 2+",,46946,510,"$1,690.00 ","$1,690.00 ",$507.00 ,"$1,537.90 ","$1,183.00 ",$507.00 ,"$1,098.50 ","$1,216.80 ","$1,537.90 ","$1,267.50 "
Carle BroMenn Medical Center,8246948,INT HRHC TRANSANAL HROID DARTLZJ 2+ W/US GDN,,46948,510,"$2,350.00 ","$2,350.00 ",$705.00 ,"$2,138.50 ","$1,645.00 ",$705.00 ,"$1,527.50 ","$1,692.00 ","$2,138.50 ","$1,762.50 "
Carle BroMenn Medical Center,8249082,ABD PARACENTESIS,,49082,510,$965.00 ,$965.00 ,$289.50 ,$878.15 ,$675.50 ,$289.50 ,$627.25 ,$694.80 ,$878.15 ,$723.75 
Carle BroMenn Medical Center,8249083,ABD PARACENTESIS W/IMAGING,,49083,510,"$3,003.00 ","$3,003.00 ",$900.90 ,"$2,732.73 ","$2,102.10 ",$900.90 ,"$1,951.95 ","$2,162.16 ","$2,732.73 ","$2,252.25 "
Carle BroMenn Medical Center,8249084,PERITONEAL LAVAGE W/WO IMAGING GUIDANCE,,49084,510,"$2,730.00 ","$2,730.00 ",$819.00 ,"$2,484.30 ","$1,911.00 ",$819.00 ,"$1,774.50 ","$1,965.60 ","$2,484.30 ","$2,047.50 "
Carle BroMenn Medical Center,8249185,SCLEROTHERAPY FLUID COLLECITON PRQ W/IMG GID,,49185,510,"$5,260.00 ","$5,260.00 ","$1,578.00 ","$4,786.60 ","$3,682.00 ","$1,578.00 ","$3,419.00 ","$3,787.20 ","$4,786.60 ","$3,945.00 "
Carle BroMenn Medical Center,8249411,"PLACE INTERST RAD THER GUIDE, PERC,INTRAABD/INTRAPELV/RETROPER,1+",,49411,510,"$2,370.00 ","$2,370.00 ",$711.00 ,"$2,156.70 ","$1,659.00 ",$711.00 ,"$1,540.50 ","$1,706.40 ","$2,156.70 ","$1,777.50 "
Carle BroMenn Medical Center,8249422,REMOVE PERM CANNULA/CATHETER,,49422,510,"$2,890.00 ","$2,890.00 ",$867.00 ,"$2,629.90 ","$2,023.00 ",$867.00 ,"$1,878.50 ","$2,080.80 ","$2,629.90 ","$2,167.50 "
Carle BroMenn Medical Center,8249440,INSERT GASTROSTOMY TUBE PERCUTANEOUS,,49440,510,"$2,762.50 ","$2,762.50 ",$828.75 ,"$2,513.88 ","$1,933.75 ",$828.75 ,"$1,795.63 ","$1,989.00 ","$2,513.88 ","$2,071.88 "
Carle BroMenn Medical Center,8249450,REPLACE GASTROSTOMY/CECOSTOMY TUBE PERCUTANEOUS,,49450,510,"$2,100.00 ","$2,100.00 ",$630.00 ,"$1,911.00 ","$1,470.00 ",$630.00 ,"$1,365.00 ","$1,512.00 ","$1,911.00 ","$1,575.00 "
Carle BroMenn Medical Center,8250436,PERQ DILATION XST TRC ENDOUROLOGIC PX W/IMG,,50436,510,"$3,350.00 ","$3,350.00 ","$1,005.00 ","$3,048.50 ","$2,345.00 ","$1,005.00 ","$2,177.50 ","$2,412.00 ","$3,048.50 ","$2,512.50 "
Carle BroMenn Medical Center,8250437,PERQ DILATION XST TRC NEW ACCESS RENAL COLTJ SYS,,50437,510,"$5,640.00 ","$5,640.00 ","$1,692.00 ","$5,132.40 ","$3,948.00 ","$1,692.00 ","$3,666.00 ","$4,060.80 ","$5,132.40 ","$4,230.00 "
Carle BroMenn Medical Center,8251700,IRRIGATION OF BLADDER,,51700,510,$780.00 ,$780.00 ,$234.00 ,$709.80 ,$546.00 ,$234.00 ,$507.00 ,$561.60 ,$709.80 ,$585.00 
Carle BroMenn Medical Center,8251701,"INSERT,NON-INDWELLING BLADDER CATHETER",,51701,510,$185.00 ,$185.00 ,$55.50 ,$168.35 ,$129.50 ,$55.50 ,$120.25 ,$133.20 ,$168.35 ,$138.75 
Carle BroMenn Medical Center,8251702,URINARY CATHETER INSERTION,,51702,510,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8251703,"INSERT,TEMP INDWELLING BLAD CATH,COMP",,51703,510,$460.00 ,$460.00 ,$138.00 ,$418.60 ,$322.00 ,$138.00 ,$299.00 ,$331.20 ,$418.60 ,$345.00 
Carle BroMenn Medical Center,8251705,"CHANGE OF BLADDER TUBE,SIMPLE",,51705,510,$780.00 ,$780.00 ,$234.00 ,$709.80 ,$546.00 ,$234.00 ,$507.00 ,$561.60 ,$709.80 ,$585.00 
Carle BroMenn Medical Center,8251720,BLADDER INSTILLATION,,51720,510,$600.00 ,$600.00 ,$180.00 ,$546.00 ,$420.00 ,$180.00 ,$390.00 ,$432.00 ,$546.00 ,$450.00 
Carle BroMenn Medical Center,8251725,SIMPLE CYSTOMETROGRAM,,51725,510,$600.00 ,$600.00 ,$180.00 ,$546.00 ,$420.00 ,$180.00 ,$390.00 ,$432.00 ,$546.00 ,$450.00 
Carle BroMenn Medical Center,8251726,COMPLEX CYSTOMETROGRAM,,51726,510,$690.00 ,$690.00 ,$207.00 ,$627.90 ,$483.00 ,$207.00 ,$448.50 ,$496.80 ,$627.90 ,$517.50 
Carle BroMenn Medical Center,8251727,COMPLEX CYSTOMETROGRAM URETHRAL PRESS PROFILE,,51727,510,"$1,140.00 ","$1,140.00 ",$342.00 ,"$1,037.40 ",$798.00 ,$342.00 ,$741.00 ,$820.80 ,"$1,037.40 ",$855.00 
Carle BroMenn Medical Center,8251728,COMPLEX CYSTOMETROGRAM VOIDING PRESSURE STUDIES,,51728,510,$950.00 ,$950.00 ,$285.00 ,$864.50 ,$665.00 ,$285.00 ,$617.50 ,$684.00 ,$864.50 ,$712.50 
Carle BroMenn Medical Center,8251729,COMPLEX CYSTOMETROGRAM  W/VOID PRESS&URETHRAL PROFILE,,51729,510,$920.00 ,$920.00 ,$276.00 ,$837.20 ,$644.00 ,$276.00 ,$598.00 ,$662.40 ,$837.20 ,$690.00 
Carle BroMenn Medical Center,8251784,ANAL/URINARY MUSCLE STUDY,,51784,510,$259.00 ,$259.00 ,$77.70 ,$235.69 ,$181.30 ,$77.70 ,$168.35 ,$186.48 ,$235.69 ,$194.25 
Carle BroMenn Medical Center,8251785,"ANAL/URINARY MUSCLE STUDY,NEEDLE",,51785,510,$623.00 ,$623.00 ,$186.90 ,$566.93 ,$436.10 ,$186.90 ,$404.95 ,$448.56 ,$566.93 ,$467.25 
Carle BroMenn Medical Center,8251798,"MEAS,POST-VOID RES,US,NON-IMAGING",,51798,510,$240.00 ,$240.00 ,$72.00 ,$218.40 ,$168.00 ,$72.00 ,$156.00 ,$172.80 ,$218.40 ,$180.00 
Carle BroMenn Medical Center,8252000,CYSTOURETHROSCOPY,,52000,510,"$1,010.00 ","$1,010.00 ",$303.00 ,$919.10 ,$707.00 ,$303.00 ,$656.50 ,$727.20 ,$919.10 ,$757.50 
Carle BroMenn Medical Center,8252001,CYSTOURETHROSCOPY W/IRRIG & EVAC CLOTS,,52001,510,"$4,490.00 ","$4,490.00 ","$1,347.00 ","$4,085.90 ","$3,143.00 ","$1,347.00 ","$2,918.50 ","$3,232.80 ","$4,085.90 ","$3,367.50 "
Carle BroMenn Medical Center,8252005,"CYSTOURETHROSCOPY, URETER CATH",,52005,510,"$2,440.00 ","$2,440.00 ",$732.00 ,"$2,220.40 ","$1,708.00 ",$732.00 ,"$1,586.00 ","$1,756.80 ","$2,220.40 ","$1,830.00 "
Carle BroMenn Medical Center,8252204,"CYSTOURETHROSCOPY,BIOPSY",,52204,510,"$1,520.00 ","$1,520.00 ",$456.00 ,"$1,383.20 ","$1,064.00 ",$456.00 ,$988.00 ,"$1,094.40 ","$1,383.20 ","$1,140.00 "
Carle BroMenn Medical Center,8252214,"CYSTOURETHROSCOPY,FULGURATN",,52214,510,"$3,480.00 ","$3,480.00 ","$1,044.00 ","$3,166.80 ","$2,436.00 ","$1,044.00 ","$2,262.00 ","$2,505.60 ","$3,166.80 ","$2,610.00 "
Carle BroMenn Medical Center,8252224,"CYSTOURETHROSCOPY,FULGUR <0.5 CM LESN",,52224,510,"$3,700.00 ","$3,700.00 ","$1,110.00 ","$3,367.00 ","$2,590.00 ","$1,110.00 ","$2,405.00 ","$2,664.00 ","$3,367.00 ","$2,775.00 "
Carle BroMenn Medical Center,8252234,"CYSTOURETHROSCOPY,FULGUR 0.5-2 CM LESN",,52234,510,"$2,020.00 ","$2,020.00 ",$606.00 ,"$1,838.20 ","$1,414.00 ",$606.00 ,"$1,313.00 ","$1,454.40 ","$1,838.20 ","$1,515.00 "
Carle BroMenn Medical Center,8252235,"CYSTOURETHROSCOPY,FULGUR 2-5 CM LESN",,52235,510,"$2,250.00 ","$2,250.00 ",$675.00 ,"$2,047.50 ","$1,575.00 ",$675.00 ,"$1,462.50 ","$1,620.00 ","$2,047.50 ","$1,687.50 "
Carle BroMenn Medical Center,8252275,"CYSTOSCOPY,INTERN URETHROTOMY,MALE",,52275,510,"$1,830.00 ","$1,830.00 ",$549.00 ,"$1,665.30 ","$1,281.00 ",$549.00 ,"$1,189.50 ","$1,317.60 ","$1,665.30 ","$1,372.50 "
Carle BroMenn Medical Center,8252281,"CYSTOSCOPY,DIL URETHRAL STRICTURE",,52281,510,"$2,070.00 ","$2,070.00 ",$621.00 ,"$1,883.70 ","$1,449.00 ",$621.00 ,"$1,345.50 ","$1,490.40 ","$1,883.70 ","$1,552.50 "
Carle BroMenn Medical Center,8252310,"CYSTOSCOPY,REMV CALCULUS,SIMPLE",,52310,510,"$2,370.00 ","$2,370.00 ",$711.00 ,"$2,156.70 ","$1,659.00 ",$711.00 ,"$1,540.50 ","$1,706.40 ","$2,156.70 ","$1,777.50 "
Carle BroMenn Medical Center,8252354,"CYSTO/URETERO/PYELOSC,BX &/OR FULG LESN",,52354,510,"$3,200.00 ","$3,200.00 ",$960.00 ,"$2,912.00 ","$2,240.00 ",$960.00 ,"$2,080.00 ","$2,304.00 ","$2,912.00 ","$2,400.00 "
Carle BroMenn Medical Center,8252441,CYSTO INSERTION TRANSPROSTATIC IMPLANT 1-3,,C9739,510,"$5,450.00 ","$5,450.00 ","$1,635.00 ","$4,959.50 ","$3,815.00 ","$1,635.00 ","$3,542.50 ","$3,924.00 ","$4,959.50 ","$4,087.50 "
Carle BroMenn Medical Center,8252442,CYSTO INSERTION TRANSPROSTATIC IMPLANT 4 or >,,C9740,510,"$10,360.00 ","$10,360.00 ","$3,108.00 ","$9,427.60 ","$7,252.00 ","$3,108.00 ","$6,734.00 ","$7,459.20 ","$9,427.60 ","$7,770.00 "
Carle BroMenn Medical Center,8253060,DRAINAGE SKENES GLAND ABSCESS,,53060,510,"$2,000.00 ","$2,000.00 ",$600.00 ,"$1,820.00 ","$1,400.00 ",$600.00 ,"$1,300.00 ","$1,440.00 ","$1,820.00 ","$1,500.00 "
Carle BroMenn Medical Center,8253600,"DIL URETHRA STRIC,MALE,INITIAL",,53600,510,$520.00 ,$520.00 ,$156.00 ,$473.20 ,$364.00 ,$156.00 ,$338.00 ,$374.40 ,$473.20 ,$390.00 
Carle BroMenn Medical Center,8253601,"DIL URETHRA STRIC,MALE,SUBSEQ",,53601,510,$300.00 ,$300.00 ,$90.00 ,$273.00 ,$210.00 ,$90.00 ,$195.00 ,$216.00 ,$273.00 ,$225.00 
Carle BroMenn Medical Center,8253661,"DIL URETHRA,FEMALE,SUBSEQUENT",,53661,510,$320.00 ,$320.00 ,$96.00 ,$291.20 ,$224.00 ,$96.00 ,$208.00 ,$230.40 ,$291.20 ,$240.00 
Carle BroMenn Medical Center,8253854,TRURL DSTRJ PRST8 TISS RF WV THERMOTHERAPY,,53854,510,"$2,560.00 ","$2,560.00 ",$768.00 ,"$2,329.60 ","$1,792.00 ",$768.00 ,"$1,664.00 ","$1,843.20 ","$2,329.60 ","$1,920.00 "
Carle BroMenn Medical Center,8254050,DESTR LESN PENIS SIMPLE,,54050,510,$810.00 ,$810.00 ,$243.00 ,$737.10 ,$567.00 ,$243.00 ,$526.50 ,$583.20 ,$737.10 ,$607.50 
Carle BroMenn Medical Center,8254056,"DESTR PENIS LESN,SIMPL,CRYOSURG",,54056,510,$530.00 ,$530.00 ,$159.00 ,$482.30 ,$371.00 ,$159.00 ,$344.50 ,$381.60 ,$482.30 ,$397.50 
Carle BroMenn Medical Center,8254065,"DESTRUCTION LESION(S) PENIS, EXTENSIVE",,54065,510,"$1,700.00 ","$1,700.00 ",$510.00 ,"$1,547.00 ","$1,190.00 ",$510.00 ,"$1,105.00 ","$1,224.00 ","$1,547.00 ","$1,275.00 "
Carle BroMenn Medical Center,8254100,BIOPSY PENIS,,54100,510,"$2,330.00 ","$2,330.00 ",$699.00 ,"$2,120.30 ","$1,631.00 ",$699.00 ,"$1,514.50 ","$1,677.60 ","$2,120.30 ","$1,747.50 "
Carle BroMenn Medical Center,8254150,"CIRCUMCISION,CLAMP,NEWBORN",,54150,510,"$2,610.00 ","$2,610.00 ",$783.00 ,"$2,375.10 ","$1,827.00 ",$783.00 ,"$1,696.50 ","$1,879.20 ","$2,375.10 ","$1,957.50 "
Carle BroMenn Medical Center,8254160,"CIRCUMCISION,OTHR,NEWBORN",,54160,510,"$1,620.00 ","$1,620.00 ",$486.00 ,"$1,474.20 ","$1,134.00 ",$486.00 ,"$1,053.00 ","$1,166.40 ","$1,474.20 ","$1,215.00 "
Carle BroMenn Medical Center,8254162,"LYSIS/EXCIS,PENILE POSTCIRCUM ADHESIONS",,54162,510,"$1,370.00 ","$1,370.00 ",$411.00 ,"$1,246.70 ",$959.00 ,$411.00 ,$890.50 ,$986.40 ,"$1,246.70 ","$1,027.50 "
Carle BroMenn Medical Center,8254163,REPAIR INCOMPLETE CIRCUMCISION,,54163,510,"$1,480.00 ","$1,480.00 ",$444.00 ,"$1,346.80 ","$1,036.00 ",$444.00 ,$962.00 ,"$1,065.60 ","$1,346.80 ","$1,110.00 "
Carle BroMenn Medical Center,8254200,INJECT PROC PENILE PLAQUE,,54200,510,$600.00 ,$600.00 ,$180.00 ,$546.00 ,$420.00 ,$180.00 ,$390.00 ,$432.00 ,$546.00 ,$450.00 
Carle BroMenn Medical Center,8254220,"IRRIGAT CORPUS CAVERN,PRIAPISM",,54220,510,$630.00 ,$630.00 ,$189.00 ,$573.30 ,$441.00 ,$189.00 ,$409.50 ,$453.60 ,$573.30 ,$472.50 
Carle BroMenn Medical Center,8254235,"INJECT CORPORA CAVERN,PHARM AGNT",,54235,510,$720.00 ,$720.00 ,$216.00 ,$655.20 ,$504.00 ,$216.00 ,$468.00 ,$518.40 ,$655.20 ,$540.00 
Carle BroMenn Medical Center,8254450,PRIAPISM OPERATION,,54450,510,$400.00 ,$400.00 ,$120.00 ,$364.00 ,$280.00 ,$120.00 ,$260.00 ,$288.00 ,$364.00 ,$300.00 
Carle BroMenn Medical Center,8254700,"INCIS/DRAIN SCROTUM/TESTIS,EPIDIDYM",,54700,510,"$4,450.00 ","$4,450.00 ","$1,335.00 ","$4,049.50 ","$3,115.00 ","$1,335.00 ","$2,892.50 ","$3,204.00 ","$4,049.50 ","$3,337.50 "
Carle BroMenn Medical Center,8255100,DRAINAGE SCROTAL WALL ABSCESS,,55100,510,"$3,115.00 ","$3,115.00 ",$934.50 ,"$2,834.65 ","$2,180.50 ",$934.50 ,"$2,024.75 ","$2,242.80 ","$2,834.65 ","$2,336.25 "
Carle BroMenn Medical Center,8255250,REMOVAL OF SPERM DUCT(S),,55250,510,"$2,610.00 ","$2,610.00 ",$783.00 ,"$2,375.10 ","$1,827.00 ",$783.00 ,"$1,696.50 ","$1,879.20 ","$2,375.10 ","$1,957.50 "
Carle BroMenn Medical Center,8255700,"BIOPSY OF PROSTATE,NEEDLE/PUNCH",,55700,510,"$2,684.50 ","$2,684.50 ",$805.35 ,"$2,442.90 ","$1,879.15 ",$805.35 ,"$1,744.93 ","$1,932.84 ","$2,442.90 ","$2,013.38 "
Carle BroMenn Medical Center,8255874,TRANSPERINEAL PLMT BIODEGRADABLE MATRL 1/MLT NJX,,55874,510,"$2,880.00 ","$2,880.00 ",$864.00 ,"$2,620.80 ","$2,016.00 ",$864.00 ,"$1,872.00 ","$2,073.60 ","$2,620.80 ","$2,160.00 "
Carle BroMenn Medical Center,8255876,"PLACE RADIOTHER DEVICE/MARKER, PROSTATE",,55876,510,"$2,300.00 ","$2,300.00 ",$690.00 ,"$2,093.00 ","$1,610.00 ",$690.00 ,"$1,495.00 ","$1,656.00 ","$2,093.00 ","$1,725.00 "
Carle BroMenn Medical Center,8255880,TRANSRECTAL ABLTJ MAL PRST8 TISSUE HIFU W/US,,55880,510,"$3,600.00 ","$3,600.00 ","$1,080.00 ","$3,276.00 ","$2,520.00 ","$1,080.00 ","$2,340.00 ","$2,592.00 ","$3,276.00 ","$2,700.00 "
Carle BroMenn Medical Center,8256405,I&D VULVA/PERINEAL ABSCESS,,56405,510,"$1,215.00 ","$1,215.00 ",$364.50 ,"$1,105.65 ",$850.50 ,$364.50 ,$789.75 ,$874.80 ,"$1,105.65 ",$911.25 
Carle BroMenn Medical Center,8256420,I&D BARTHOLIN GLAND ABSCESS,,56420,510,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8256441,LYSIS OF LABIAL LESION(S),,56441,510,"$4,450.00 ","$4,450.00 ","$1,335.00 ","$4,049.50 ","$3,115.00 ","$1,335.00 ","$2,892.50 ","$3,204.00 ","$4,049.50 ","$3,337.50 "
Carle BroMenn Medical Center,8256501,"DESTRUCTION,LESION(S),VULVA,SIMPLE",,56501,510,"$4,680.00 ","$4,680.00 ","$1,404.00 ","$4,258.80 ","$3,276.00 ","$1,404.00 ","$3,042.00 ","$3,369.60 ","$4,258.80 ","$3,510.00 "
Carle BroMenn Medical Center,8256515,"DESTRUCTION,LESION(S),VULVA;EXTENSIVE",,56515,510,"$4,680.00 ","$4,680.00 ","$1,404.00 ","$4,258.80 ","$3,276.00 ","$1,404.00 ","$3,042.00 ","$3,369.60 ","$4,258.80 ","$3,510.00 "
Carle BroMenn Medical Center,8256605,"BIOPSY VULVA/PERINEUM,ONE LESN",,56605,510,"$1,140.00 ","$1,140.00 ",$342.00 ,"$1,037.40 ",$798.00 ,$342.00 ,$741.00 ,$820.80 ,"$1,037.40 ",$855.00 
Carle BroMenn Medical Center,8256606,"BX,VULVA/PERINEUM,ADDL LESION",,56606,510,$260.00 ,$260.00 ,$78.00 ,$236.60 ,$182.00 ,$78.00 ,$169.00 ,$187.20 ,$236.60 ,$195.00 
Carle BroMenn Medical Center,8256820,"COLPOSCOPY,VULVA",,56820,510,$425.00 ,$425.00 ,$127.50 ,$386.75 ,$297.50 ,$127.50 ,$276.25 ,$306.00 ,$386.75 ,$318.75 
Carle BroMenn Medical Center,8256821,"COLPOSCOPY,VULVA,W/BIOPSY(S)",,56821,510,$570.00 ,$570.00 ,$171.00 ,$518.70 ,$399.00 ,$171.00 ,$370.50 ,$410.40 ,$518.70 ,$427.50 
Carle BroMenn Medical Center,8257022,"I&D VAGINAL HEMATOMA,OBSTET/POSTPART",,57022,510,"$2,870.00 ","$2,870.00 ",$861.00 ,"$2,611.70 ","$2,009.00 ",$861.00 ,"$1,865.50 ","$2,066.40 ","$2,611.70 ","$2,152.50 "
Carle BroMenn Medical Center,8257061,DESTR VAG LSN SIMPLE,,57061,510,"$2,690.00 ","$2,690.00 ",$807.00 ,"$2,447.90 ","$1,883.00 ",$807.00 ,"$1,748.50 ","$1,936.80 ","$2,447.90 ","$2,017.50 "
Carle BroMenn Medical Center,8257100,"BIOPSY OF VAGINA,SIMPLE",,57100,510,"$1,610.00 ","$1,610.00 ",$483.00 ,"$1,465.10 ","$1,127.00 ",$483.00 ,"$1,046.50 ","$1,159.20 ","$1,465.10 ","$1,207.50 "
Carle BroMenn Medical Center,8257105,"BIOPSY OF VAGINA,EXTENSIVE",,57105,510,"$5,780.00 ","$5,780.00 ","$1,734.00 ","$5,259.80 ","$4,046.00 ","$1,734.00 ","$3,757.00 ","$4,161.60 ","$5,259.80 ","$4,335.00 "
Carle BroMenn Medical Center,8257135,EXCISION VAG CYST/TUMOR,,57135,510,"$5,920.00 ","$5,920.00 ","$1,776.00 ","$5,387.20 ","$4,144.00 ","$1,776.00 ","$3,848.00 ","$4,262.40 ","$5,387.20 ","$4,440.00 "
Carle BroMenn Medical Center,8257155,"INSERT, UTERINE TANDEMS &/OR VAG OVOIDS",,57155,510,"$4,670.00 ","$4,670.00 ","$1,401.00 ","$4,249.70 ","$3,269.00 ","$1,401.00 ","$3,035.50 ","$3,362.40 ","$4,249.70 ","$3,502.50 "
Carle BroMenn Medical Center,8257156,INSERT VAGINAL RADIATION DEVICE,,57156,510,$670.00 ,$670.00 ,$201.00 ,$609.70 ,$469.00 ,$201.00 ,$435.50 ,$482.40 ,$609.70 ,$502.50 
Carle BroMenn Medical Center,8257160,FIT/INSERT INTRAVAG SUPPORT DEVICE,,57160,510,$425.00 ,$425.00 ,$127.50 ,$386.75 ,$297.50 ,$127.50 ,$276.25 ,$306.00 ,$386.75 ,$318.75 
Carle BroMenn Medical Center,8257170,FITTING OF DIAPHRAGM/CAP,,57170,510,$125.00 ,$125.00 ,$37.50 ,$113.75 ,$87.50 ,$37.50 ,$81.25 ,$90.00 ,$113.75 ,$93.75 
Carle BroMenn Medical Center,8257420,"COLPOSCOPY,ENTIRE VAGINA",,57420,510,$780.00 ,$780.00 ,$234.00 ,$709.80 ,$546.00 ,$234.00 ,$507.00 ,$561.60 ,$709.80 ,$585.00 
Carle BroMenn Medical Center,8257421,"COLPOSCOPY,ENTIRE VAGINA,W/BIOPSY(S)",,57421,510,"$1,140.00 ","$1,140.00 ",$342.00 ,"$1,037.40 ",$798.00 ,$342.00 ,$741.00 ,$820.80 ,"$1,037.40 ",$855.00 
Carle BroMenn Medical Center,8257452,"COLPOSCOPY,CERVIX W/ADJ VAGINA",,57452,510,$485.00 ,$485.00 ,$145.50 ,$441.35 ,$339.50 ,$145.50 ,$315.25 ,$349.20 ,$441.35 ,$363.75 
Carle BroMenn Medical Center,8257454,"COLPOSC,CERVIX W/ADJ VAG,W/BX & CURRETAG",,57454,510,$780.00 ,$780.00 ,$234.00 ,$709.80 ,$546.00 ,$234.00 ,$507.00 ,$561.60 ,$709.80 ,$585.00 
Carle BroMenn Medical Center,8257455,"COLPOSCOPY,CERVIX W/ADJ VAGINA,W/BX",,57455,510,$780.00 ,$780.00 ,$234.00 ,$709.80 ,$546.00 ,$234.00 ,$507.00 ,$561.60 ,$709.80 ,$585.00 
Carle BroMenn Medical Center,8257456,"COLPOSCOPY,CERVIX W/ADJ VAGINA, CURETTAG",,57456,510,$780.00 ,$780.00 ,$234.00 ,$709.80 ,$546.00 ,$234.00 ,$507.00 ,$561.60 ,$709.80 ,$585.00 
Carle BroMenn Medical Center,8257460,"COLPOSCOPY,CERVIX W/ADJ VAG,W/LOOP BX",,57460,510,"$5,750.00 ","$5,750.00 ","$1,725.00 ","$5,232.50 ","$4,025.00 ","$1,725.00 ","$3,737.50 ","$4,140.00 ","$5,232.50 ","$4,312.50 "
Carle BroMenn Medical Center,8257461,"COLPOSCOPY,CERVIX W/ADJ VAG,W/LOOP CONIZ",,57461,510,"$6,870.00 ","$6,870.00 ","$2,061.00 ","$6,251.70 ","$4,809.00 ","$2,061.00 ","$4,465.50 ","$4,946.40 ","$6,251.70 ","$5,152.50 "
Carle BroMenn Medical Center,8257465,COMPUTER-AIDED MAPG CERVIX UTERI DRG COLPOSCOPY,,57465,510,"$1,050.00 ","$1,050.00 ",$315.00 ,$955.50 ,$735.00 ,$315.00 ,$682.50 ,$756.00 ,$955.50 ,$787.50 
Carle BroMenn Medical Center,8257500,"BIOPSY CERVIX, 1 OR MORE, OR EXCISION OF LESION",,57500,510,"$1,840.00 ","$1,840.00 ",$552.00 ,"$1,674.40 ","$1,288.00 ",$552.00 ,"$1,196.00 ","$1,324.80 ","$1,674.40 ","$1,380.00 "
Carle BroMenn Medical Center,8257505,ENDOCERVICAL CURETTAGE,,57505,510,"$1,840.00 ","$1,840.00 ",$552.00 ,"$1,674.40 ","$1,288.00 ",$552.00 ,"$1,196.00 ","$1,324.80 ","$1,674.40 ","$1,380.00 "
Carle BroMenn Medical Center,8257511,CRYOCAUTERY OF CERVIX,,57511,510,$590.00 ,$590.00 ,$177.00 ,$536.90 ,$413.00 ,$177.00 ,$383.50 ,$424.80 ,$536.90 ,$442.50 
Carle BroMenn Medical Center,8257520,"CONIZATION CERVIX,KNIFE/LASER",,57520,510,"$4,160.00 ","$4,160.00 ","$1,248.00 ","$3,785.60 ","$2,912.00 ","$1,248.00 ","$2,704.00 ","$2,995.20 ","$3,785.60 ","$3,120.00 "
Carle BroMenn Medical Center,8257522,"CONIZATION CERVIX,LOOP ELECTRD",,57522,510,"$6,870.00 ","$6,870.00 ","$2,061.00 ","$6,251.70 ","$4,809.00 ","$2,061.00 ","$4,465.50 ","$4,946.40 ","$6,251.70 ","$5,152.50 "
Carle BroMenn Medical Center,8257800,DILATION OF CERVICAL CANAL,,57800,510,"$4,210.00 ","$4,210.00 ","$1,263.00 ","$3,831.10 ","$2,947.00 ","$1,263.00 ","$2,736.50 ","$3,031.20 ","$3,831.10 ","$3,157.50 "
Carle BroMenn Medical Center,8258100,BIOPSY OF UTERUS LINING,,58100,510,$485.00 ,$485.00 ,$145.50 ,$441.35 ,$339.50 ,$145.50 ,$315.25 ,$349.20 ,$441.35 ,$363.75 
Carle BroMenn Medical Center,8258110,ENDOMET BIOPSY DONE W/COLPOSCOPY,,58110,510,$435.00 ,$435.00 ,$130.50 ,$395.85 ,$304.50 ,$130.50 ,$282.75 ,$313.20 ,$395.85 ,$326.25 
Carle BroMenn Medical Center,8258300,INSERT INTRAUTERINE DEVICE,,58300,510,$485.00 ,$485.00 ,$145.50 ,$441.35 ,$339.50 ,$145.50 ,$315.25 ,$349.20 ,$441.35 ,$363.75 
Carle BroMenn Medical Center,8258301,REMOVE INTRAUTERINE DEVICE,,58301,510,$385.00 ,$385.00 ,$115.50 ,$350.35 ,$269.50 ,$115.50 ,$250.25 ,$277.20 ,$350.35 ,$288.75 
Carle BroMenn Medical Center,8258322,"ARTIF INSEMINATION,INTRA-UTERINE",,58322,510,$610.00 ,$610.00 ,$183.00 ,$555.10 ,$427.00 ,$183.00 ,$396.50 ,$439.20 ,$555.10 ,$457.50 
Carle BroMenn Medical Center,8258340,CATH/INJECT HYSTEROSALPINGOGRAM,,58340,510,$425.00 ,$425.00 ,$127.50 ,$386.75 ,$297.50 ,$127.50 ,$276.25 ,$306.00 ,$386.75 ,$318.75 
Carle BroMenn Medical Center,8258555,"HYSTEROSCOPY,DX,SEP PROC",,58555,510,"$7,210.00 ","$7,210.00 ","$2,163.00 ","$6,561.10 ","$5,047.00 ","$2,163.00 ","$4,686.50 ","$5,191.20 ","$6,561.10 ","$5,407.50 "
Carle BroMenn Medical Center,8258558,"HYSTEROSCOPY,W/ENDO BX",,58558,510,"$7,210.00 ","$7,210.00 ","$2,163.00 ","$6,561.10 ","$5,047.00 ","$2,163.00 ","$4,686.50 ","$5,191.20 ","$6,561.10 ","$5,407.50 "
Carle BroMenn Medical Center,8258563,"HYSTEROSCOPY,W/ENDOMETRIAL ABLATION",,58563,510,"$6,580.00 ","$6,580.00 ","$1,974.00 ","$5,987.80 ","$4,606.00 ","$1,974.00 ","$4,277.00 ","$4,737.60 ","$5,987.80 ","$4,935.00 "
Carle BroMenn Medical Center,8258565,"HYSTEROSCOPY, STERILIZE W IMPLANTS",,58565,510,"$7,660.00 ","$7,660.00 ","$2,298.00 ","$6,970.60 ","$5,362.00 ","$2,298.00 ","$4,979.00 ","$5,515.20 ","$6,970.60 ","$5,745.00 "
Carle BroMenn Medical Center,8258800,DRAIN OVARIAN CYST VAG APPROACH,,58800,510,"$2,230.00 ","$2,230.00 ",$669.00 ,"$2,029.30 ","$1,561.00 ",$669.00 ,"$1,449.50 ","$1,605.60 ","$2,029.30 ","$1,672.50 "
Carle BroMenn Medical Center,8258974,"TRANSFER EMBRYO, INTRAUTERINE",,58974,510,$210.00 ,$210.00 ,$63.00 ,$191.10 ,$147.00 ,$63.00 ,$136.50 ,$151.20 ,$191.10 ,$157.50 
Carle BroMenn Medical Center,8259000,"AMNIOCENTESIS,DIAGNOSTIC",,59000,510,$615.00 ,$615.00 ,$184.50 ,$559.65 ,$430.50 ,$184.50 ,$399.75 ,$442.80 ,$559.65 ,$461.25 
Carle BroMenn Medical Center,8259015,"CHORIONIC VILLUS SAMPLING, ANY METHOD",,59015,510,"$2,100.00 ","$2,100.00 ",$630.00 ,"$1,911.00 ","$1,470.00 ",$630.00 ,"$1,365.00 ","$1,512.00 ","$1,911.00 ","$1,575.00 "
Carle BroMenn Medical Center,8259070,TRANSABDOM AMNIOINFUS W/ US,,59070,510,$290.00 ,$290.00 ,$87.00 ,$263.90 ,$203.00 ,$87.00 ,$188.50 ,$208.80 ,$263.90 ,$217.50 
Carle BroMenn Medical Center,8259160,D&C POSTPARTUM,,59160,510,"$5,500.00 ","$5,500.00 ","$1,650.00 ","$5,005.00 ","$3,850.00 ","$1,650.00 ","$3,575.00 ","$3,960.00 ","$5,005.00 ","$4,125.00 "
Carle BroMenn Medical Center,8259200,INSRTN CERVICAL DILATOR,,59200,510,$355.00 ,$355.00 ,$106.50 ,$323.05 ,$248.50 ,$106.50 ,$230.75 ,$255.60 ,$323.05 ,$266.25 
Carle BroMenn Medical Center,8259430,CARE AFTER DELIVERY ONLY,,59430,510,$570.00 ,$570.00 ,$171.00 ,$518.70 ,$399.00 ,$171.00 ,$370.50 ,$410.40 ,$518.70 ,$427.50 
Carle BroMenn Medical Center,8259871,REMOVE CERCLAGE SUTURE,,59871,510,"$5,260.00 ","$5,260.00 ","$1,578.00 ","$4,786.60 ","$3,682.00 ","$1,578.00 ","$3,419.00 ","$3,787.20 ","$4,786.60 ","$3,945.00 "
Carle BroMenn Medical Center,8261026,"VENTRICULAR PUNCTURE,PREV BURR HOLE",,61026,510,$900.00 ,$900.00 ,$270.00 ,$819.00 ,$630.00 ,$270.00 ,$585.00 ,$648.00 ,$819.00 ,$675.00 
Carle BroMenn Medical Center,8261070,BRAIN SHUNT TUBE/RESERV INJECTN,,61070,510,$900.00 ,$900.00 ,$270.00 ,$819.00 ,$630.00 ,$270.00 ,$585.00 ,$648.00 ,$819.00 ,$675.00 
Carle BroMenn Medical Center,8262252,"REPROGRAMMING,PROGRAMMABLE CSF SHUNT",,62252,510,$590.00 ,$590.00 ,$177.00 ,$536.90 ,$413.00 ,$177.00 ,$383.50 ,$424.80 ,$536.90 ,$442.50 
Carle BroMenn Medical Center,8262270,SPINAL FLUID TAP DIAGNOSTIC,,62270,510,"$1,035.00 ","$1,035.00 ",$310.50 ,$941.85 ,$724.50 ,$310.50 ,$672.75 ,$745.20 ,$941.85 ,$776.25 
Carle BroMenn Medical Center,8262273,"INJ,LUMB EPIDUR,BLOOD/CLOT PATCH",,62273,510,"$2,020.00 ","$2,020.00 ",$606.00 ,"$1,838.20 ","$1,414.00 ",$606.00 ,"$1,313.00 ","$1,454.40 ","$1,838.20 ","$1,515.00 "
Carle BroMenn Medical Center,8262282,"INJ,NEUROLYTIC,EPID/LUMB/CAUDAL",,62282,510,"$1,380.00 ","$1,380.00 ",$414.00 ,"$1,255.80 ",$966.00 ,$414.00 ,$897.00 ,$993.60 ,"$1,255.80 ","$1,035.00 "
Carle BroMenn Medical Center,8262290,"INJECT DISKOGRAM,LUMBAR,EA LEVEL",,62290,510,"$1,385.00 ","$1,385.00 ",$415.50 ,"$1,260.35 ",$969.50 ,$415.50 ,$900.25 ,$997.20 ,"$1,260.35 ","$1,038.75 "
Carle BroMenn Medical Center,8262291,"INJ,CERV/THORAC,FOR DISKOGRAPHY",,62291,510,"$1,385.00 ","$1,385.00 ",$415.50 ,"$1,260.35 ",$969.50 ,$415.50 ,$900.25 ,$997.20 ,"$1,260.35 ","$1,038.75 "
Carle BroMenn Medical Center,8262302,MYELOGRAPHY VIA LUMBAR INJECTION RS&I CERVICAL,,62302,510,"$1,775.00 ","$1,775.00 ",$532.50 ,"$1,615.25 ","$1,242.50 ",$532.50 ,"$1,153.75 ","$1,278.00 ","$1,615.25 ","$1,331.25 "
Carle BroMenn Medical Center,8262303,MYELOGRAPHY VIA LUMBAR INJECTION RS&I THORACIC,,62303,510,"$1,655.00 ","$1,655.00 ",$496.50 ,"$1,506.05 ","$1,158.50 ",$496.50 ,"$1,075.75 ","$1,191.60 ","$1,506.05 ","$1,241.25 "
Carle BroMenn Medical Center,8262304,MYELOGRAPHY VIA LUMBAR INJECT RS&I LUMBOSACRAL,,62304,510,"$1,215.00 ","$1,215.00 ",$364.50 ,"$1,105.65 ",$850.50 ,$364.50 ,$789.75 ,$874.80 ,"$1,105.65 ",$911.25 
Carle BroMenn Medical Center,8262305,MYELOGRAPHY VIA LUMBAR INJECTION RS&I 2+ REGIONS,,62305,510,"$1,590.00 ","$1,590.00 ",$477.00 ,"$1,446.90 ","$1,113.00 ",$477.00 ,"$1,033.50 ","$1,144.80 ","$1,446.90 ","$1,192.50 "
Carle BroMenn Medical Center,8262320,INJ DX/THER SBST INTRLMNR CRV/THRC W/O IMG GDN,,62320,510,"$1,810.00 ","$1,810.00 ",$543.00 ,"$1,647.10 ","$1,267.00 ",$543.00 ,"$1,176.50 ","$1,303.20 ","$1,647.10 ","$1,357.50 "
Carle BroMenn Medical Center,8262321,INJ DX/THER SBST INTRLMNR CRV/THRC W/ IMG GDN,,62321,510,"$1,990.00 ","$1,990.00 ",$597.00 ,"$1,810.90 ","$1,393.00 ",$597.00 ,"$1,293.50 ","$1,432.80 ","$1,810.90 ","$1,492.50 "
Carle BroMenn Medical Center,8262322,INJ DX/THER SBST INTRLMNR LMBR/SAC W/O IMG GDN,,62322,510,"$1,160.00 ","$1,160.00 ",$348.00 ,"$1,055.60 ",$812.00 ,$348.00 ,$754.00 ,$835.20 ,"$1,055.60 ",$870.00 
Carle BroMenn Medical Center,8262323,INJ DX/THER SBST INTRLMNR LMBR/SAC W/ IMG GDN,,62323,510,"$1,375.00 ","$1,375.00 ",$412.50 ,"$1,251.25 ",$962.50 ,$412.50 ,$893.75 ,$990.00 ,"$1,251.25 ","$1,031.25 "
Carle BroMenn Medical Center,8262324,"INJ DX/THER SBST, W/INDWLLNG CATH PLC, INTRLMNR CRV/THRC W/O IMG GDN",,62324,510,"$1,490.00 ","$1,490.00 ",$447.00 ,"$1,355.90 ","$1,043.00 ",$447.00 ,$968.50 ,"$1,072.80 ","$1,355.90 ","$1,117.50 "
Carle BroMenn Medical Center,8262325,"INJ DX/THER SBST, W/INDWLLNG CATH PLC, INTRLMNR CRV/THRC W/ IMG GDN",,62325,510,"$2,440.00 ","$2,440.00 ",$732.00 ,"$2,220.40 ","$1,708.00 ",$732.00 ,"$1,586.00 ","$1,756.80 ","$2,220.40 ","$1,830.00 "
Carle BroMenn Medical Center,8262326,"INJ DX/THER SBST, W/INDWLLNG CATH PLC, INTRLMNR LMBR/SAC W/O IMG GDN",,62326,510,"$1,320.00 ","$1,320.00 ",$396.00 ,"$1,201.20 ",$924.00 ,$396.00 ,$858.00 ,$950.40 ,"$1,201.20 ",$990.00 
Carle BroMenn Medical Center,8262327,"INJ DX/THER SBST, W/INDWLLNG CATH PLC, INTRLMNR LMBR/SAC W/ IMG GDN",,62327,510,"$2,250.00 ","$2,250.00 ",$675.00 ,"$2,047.50 ","$1,575.00 ",$675.00 ,"$1,462.50 ","$1,620.00 ","$2,047.50 ","$1,687.50 "
Carle BroMenn Medical Center,8262328,DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT,,62328,510,"$1,585.00 ","$1,585.00 ",$475.50 ,"$1,442.35 ","$1,109.50 ",$475.50 ,"$1,030.25 ","$1,141.20 ","$1,442.35 ","$1,188.75 "
Carle BroMenn Medical Center,8262329,THERAPEUTIC SPINAL PNXR DRAINAGE CSF W/FLUOR/CT,,62329,510,"$1,575.00 ","$1,575.00 ",$472.50 ,"$1,433.25 ","$1,102.50 ",$472.50 ,"$1,023.75 ","$1,134.00 ","$1,433.25 ","$1,181.25 "
Carle BroMenn Medical Center,8262368,ANALYZE INFUSN PUMP REPROGRAM,,62368,510,$690.00 ,$690.00 ,$207.00 ,$627.90 ,$483.00 ,$207.00 ,$448.50 ,$496.80 ,$627.90 ,$517.50 
Carle BroMenn Medical Center,8262370,ELECTRONIC ANALYZ IMPLNTD PUMP INTRTHCL/EPIDURAL DRUG INF,,62370,510,$780.00 ,$780.00 ,$234.00 ,$709.80 ,$546.00 ,$234.00 ,$507.00 ,$561.60 ,$709.80 ,$585.00 
Carle BroMenn Medical Center,8263650,"PERCUT IMPLNT NEUROELECT,EPIDURAL",,63650,510,"$10,410.00 ","$10,410.00 ","$3,123.00 ","$9,473.10 ","$7,287.00 ","$3,123.00 ","$6,766.50 ","$7,495.20 ","$9,473.10 ","$7,807.50 "
Carle BroMenn Medical Center,8263661,"REMOVE SPINAL NEUROSTIM ELECTRODE PERC ARRAY, INCL FLUORO",,63661,510,"$4,190.00 ","$4,190.00 ","$1,257.00 ","$3,812.90 ","$2,933.00 ","$1,257.00 ","$2,723.50 ","$3,016.80 ","$3,812.90 ","$3,142.50 "
Carle BroMenn Medical Center,8263663,"REVISION SPINAL NEUROSTIM ELECTRODE PERC ARRAY, INCL FLUORO",,63663,510,"$6,170.00 ","$6,170.00 ","$1,851.00 ","$5,614.70 ","$4,319.00 ","$1,851.00 ","$4,010.50 ","$4,442.40 ","$5,614.70 ","$4,627.50 "
Carle BroMenn Medical Center,8263685,IMPLANT SPINAL NEUROSTIM/RECEIVER,,63685,510,"$20,940.00 ","$20,940.00 ","$6,282.00 ","$19,055.40 ","$14,658.00 ","$6,282.00 ","$13,611.00 ","$15,076.80 ","$19,055.40 ","$15,705.00 "
Carle BroMenn Medical Center,8263688,REVISE/REMOVE SPINAL NEUROSTIM/RECEIVER,,63688,510,"$2,980.00 ","$2,980.00 ",$894.00 ,"$2,711.80 ","$2,086.00 ",$894.00 ,"$1,937.00 ","$2,145.60 ","$2,711.80 ","$2,235.00 "
Carle BroMenn Medical Center,8264400,"INJECT NERV BLCK, TRIGEMINAL",,64400,510,$830.00 ,$830.00 ,$249.00 ,$755.30 ,$581.00 ,$249.00 ,$539.50 ,$597.60 ,$755.30 ,$622.50 
Carle BroMenn Medical Center,8264402,"INJECT NERV BLCK,FACIAL NERV",,64402,510,"$1,780.00 ","$1,780.00 ",$534.00 ,"$1,619.80 ","$1,246.00 ",$534.00 ,"$1,157.00 ","$1,281.60 ","$1,619.80 ","$1,335.00 "
Carle BroMenn Medical Center,8264405,"INJECT NERV BLCK,GREAT OCCIPTL",,64405,510,$900.00 ,$900.00 ,$270.00 ,$819.00 ,$630.00 ,$270.00 ,$585.00 ,$648.00 ,$819.00 ,$675.00 
Carle BroMenn Medical Center,8264420,"INJECT NERV BLCK,INTERCOSTAL,ONE",,64420,510,"$1,070.00 ","$1,070.00 ",$321.00 ,$973.70 ,$749.00 ,$321.00 ,$695.50 ,$770.40 ,$973.70 ,$802.50 
Carle BroMenn Medical Center,8264421,"INJECT NERV BLCK,INTERCOST,MULTPL",,64421,510,"$2,350.00 ","$2,350.00 ",$705.00 ,"$2,138.50 ","$1,645.00 ",$705.00 ,"$1,527.50 ","$1,692.00 ","$2,138.50 ","$1,762.50 "
Carle BroMenn Medical Center,8264425,"INJECT NERV BLCK,ILIOINGU/ILIOHYP",,64425,510,"$1,320.00 ","$1,320.00 ",$396.00 ,"$1,201.20 ",$924.00 ,$396.00 ,$858.00 ,$950.40 ,"$1,201.20 ",$990.00 
Carle BroMenn Medical Center,8264435,"INJECT NERV BLCK,PARACERVICAL",,64435,510,"$1,180.00 ","$1,180.00 ",$354.00 ,"$1,073.80 ",$826.00 ,$354.00 ,$767.00 ,$849.60 ,"$1,073.80 ",$885.00 
Carle BroMenn Medical Center,8264445,"INJ,ANES AGENT,SCIATIC NERVE,SINGLE",,64445,510,"$1,410.00 ","$1,410.00 ",$423.00 ,"$1,283.10 ",$987.00 ,$423.00 ,$916.50 ,"$1,015.20 ","$1,283.10 ","$1,057.50 "
Carle BroMenn Medical Center,8264447,"INJ,ANES AGENT,FEMORAL NERVE,SINGLE",,64447,510,$930.00 ,$930.00 ,$279.00 ,$846.30 ,$651.00 ,$279.00 ,$604.50 ,$669.60 ,$846.30 ,$697.50 
Carle BroMenn Medical Center,8264448,"INJ,ANES AGENT,FEMORAL NERVE,CONT INF",,64448,510,$860.00 ,$860.00 ,$258.00 ,$782.60 ,$602.00 ,$258.00 ,$559.00 ,$619.20 ,$782.60 ,$645.00 
Carle BroMenn Medical Center,8264450,"INJECT NERV BLCK,OTHR PERIPH NERV",,64450,510,"$1,085.00 ","$1,085.00 ",$325.50 ,$987.35 ,$759.50 ,$325.50 ,$705.25 ,$781.20 ,$987.35 ,$813.75 
Carle BroMenn Medical Center,8264451,INJECTION AA&/STRD NERVES NRVTG SI JOINT W/IMG,,64451,510,"$2,300.00 ","$2,300.00 ",$690.00 ,"$2,093.00 ","$1,610.00 ",$690.00 ,"$1,495.00 ","$1,656.00 ","$2,093.00 ","$1,725.00 "
Carle BroMenn Medical Center,8264454,INJECTION AA&/STRD GENICULAR NRV BRANCHES W/IMG,,64454,510,"$2,370.00 ","$2,370.00 ",$711.00 ,"$2,156.70 ","$1,659.00 ",$711.00 ,"$1,540.50 ","$1,706.40 ","$2,156.70 ","$1,777.50 "
Carle BroMenn Medical Center,8264455,INJECT PLANTAR COMMON DIGITAL NERVE,,64455,510,$460.00 ,$460.00 ,$138.00 ,$418.60 ,$322.00 ,$138.00 ,$299.00 ,$331.20 ,$418.60 ,$345.00 
Carle BroMenn Medical Center,8264461,PVB THORACIC SINGLE INJECTION SITE W/IMG GID,,64461,510,"$1,120.00 ","$1,120.00 ",$336.00 ,"$1,019.20 ",$784.00 ,$336.00 ,$728.00 ,$806.40 ,"$1,019.20 ",$840.00 
Carle BroMenn Medical Center,8264462,PVB THORACIC SECOND & ADDL INJ SITE W/IMG GID,,64462,510,"$1,120.00 ","$1,120.00 ",$336.00 ,"$1,019.20 ",$784.00 ,$336.00 ,$728.00 ,$806.40 ,"$1,019.20 ",$840.00 
Carle BroMenn Medical Center,8264463,PVB THORACIC CONT CATHETER INFUSION W/IMG GID,,64463,510,$860.00 ,$860.00 ,$258.00 ,$782.60 ,$602.00 ,$258.00 ,$559.00 ,$619.20 ,$782.60 ,$645.00 
Carle BroMenn Medical Center,8264479,"INJ,FORAMEN C/T,1 LEVEL",,64479,510,"$2,350.00 ","$2,350.00 ",$705.00 ,"$2,138.50 ","$1,645.00 ",$705.00 ,"$1,527.50 ","$1,692.00 ","$2,138.50 ","$1,762.50 "
Carle BroMenn Medical Center,8264483,"INJ,FORAMEN,L/S,1 LEVEL",,64483,510,"$2,040.00 ","$2,040.00 ",$612.00 ,"$1,856.40 ","$1,428.00 ",$612.00 ,"$1,326.00 ","$1,468.80 ","$1,856.40 ","$1,530.00 "
Carle BroMenn Medical Center,8264484,"INJ,FORAMEN,L/S,ADDL LEVELS",,64484,510,$710.00 ,$710.00 ,$213.00 ,$646.10 ,$497.00 ,$213.00 ,$461.50 ,$511.20 ,$646.10 ,$532.50 
Carle BroMenn Medical Center,8264486,TAP BLOCK UNILATERAL BY INJECTION(S),,64486,510,$640.00 ,$640.00 ,$192.00 ,$582.40 ,$448.00 ,$192.00 ,$416.00 ,$460.80 ,$582.40 ,$480.00 
Carle BroMenn Medical Center,8264487,TAP BLOCK UNILATERAL BY CONTINUOUS INFUSION(S),,64487,510,$850.00 ,$850.00 ,$255.00 ,$773.50 ,$595.00 ,$255.00 ,$552.50 ,$612.00 ,$773.50 ,$637.50 
Carle BroMenn Medical Center,8264488,TAP BLOCK BILATERAL BY INJECTION(S),,64488,510,$930.00 ,$930.00 ,$279.00 ,$846.30 ,$651.00 ,$279.00 ,$604.50 ,$669.60 ,$846.30 ,$697.50 
Carle BroMenn Medical Center,8264489,TAP BLOCK BILATERAL BY CONTINUOUS INFUSION(S),,64489,510,"$1,040.00 ","$1,040.00 ",$312.00 ,$946.40 ,$728.00 ,$312.00 ,$676.00 ,$748.80 ,$946.40 ,$780.00 
Carle BroMenn Medical Center,8264490,"INJ DX/THER AGNT PARAVERT FACET JOINT, CERV/THORAC, 1ST LEVEL",,64490,510,"$1,440.00 ","$1,440.00 ",$432.00 ,"$1,310.40 ","$1,008.00 ",$432.00 ,$936.00 ,"$1,036.80 ","$1,310.40 ","$1,080.00 "
Carle BroMenn Medical Center,8264491,"INJ DX/THER AGNT PARAVERT FACET JOINT, CERV/THORAC, 2ND LEVEL",,64491,510,$390.00 ,$390.00 ,$117.00 ,$354.90 ,$273.00 ,$117.00 ,$253.50 ,$280.80 ,$354.90 ,$292.50 
Carle BroMenn Medical Center,8264492,"INJ DX/THER AGNT PARAVERT FACET JOINT, CERV/THORAC, ADD LEVEL",,64492,510,$400.00 ,$400.00 ,$120.00 ,$364.00 ,$280.00 ,$120.00 ,$260.00 ,$288.00 ,$364.00 ,$300.00 
Carle BroMenn Medical Center,8264493,"INJ DX/THER AGNT PARAVERT FACET JOINT, LUMBAR/SAC, 1ST LEVEL",,64493,510,"$1,750.00 ","$1,750.00 ",$525.00 ,"$1,592.50 ","$1,225.00 ",$525.00 ,"$1,137.50 ","$1,260.00 ","$1,592.50 ","$1,312.50 "
Carle BroMenn Medical Center,8264494,"INJ DX/THER AGNT PARAVERT FACET JOINT, LUMBAR/SAC, 2ND LEVEL",,64494,510,$485.00 ,$485.00 ,$145.50 ,$441.35 ,$339.50 ,$145.50 ,$315.25 ,$349.20 ,$441.35 ,$363.75 
Carle BroMenn Medical Center,8264495,"INJ DX/THER AGNT PARAVERT FACET JOINT, LUMBAR/SAC, ADD LEVEL",,64495,510,$490.00 ,$490.00 ,$147.00 ,$445.90 ,$343.00 ,$147.00 ,$318.50 ,$352.80 ,$445.90 ,$367.50 
Carle BroMenn Medical Center,8264510,"INJECT NERV BLCK,STELLATE GANGLION",,64510,510,"$2,350.00 ","$2,350.00 ",$705.00 ,"$2,138.50 ","$1,645.00 ",$705.00 ,"$1,527.50 ","$1,692.00 ","$2,138.50 ","$1,762.50 "
Carle BroMenn Medical Center,8264520,"INJECT NERV BLCK,PARAVERT SYMPATH",,64520,510,"$2,350.00 ","$2,350.00 ",$705.00 ,"$2,138.50 ","$1,645.00 ",$705.00 ,"$1,527.50 ","$1,692.00 ","$2,138.50 ","$1,762.50 "
Carle BroMenn Medical Center,8264550,APPLY SURFACE NEUROSTIMULATOR,,64550,510,$110.00 ,$110.00 ,$33.00 ,$100.10 ,$77.00 ,$33.00 ,$71.50 ,$79.20 ,$100.10 ,$82.50 
Carle BroMenn Medical Center,8264561,PRQ IMPLTJ NEUROSTIMULATOR ELTRD SACRAL NERVE,,64561,510,"$7,140.00 ","$7,140.00 ","$2,142.00 ","$6,497.40 ","$4,998.00 ","$2,142.00 ","$4,641.00 ","$5,140.80 ","$6,497.40 ","$5,355.00 "
Carle BroMenn Medical Center,8264566,"POST TIBIAL NEUROSTIMULATION,PERC NEEDLE ELECTRODE",,64566,510,$670.00 ,$670.00 ,$201.00 ,$609.70 ,$469.00 ,$201.00 ,$435.50 ,$482.40 ,$609.70 ,$502.50 
Carle BroMenn Medical Center,8264581,INC IMPLTJ NEUROSTIMULATOR ELTRD SACRAL NERVE,,64581,510,"$9,810.00 ","$9,810.00 ","$2,943.00 ","$8,927.10 ","$6,867.00 ","$2,943.00 ","$6,376.50 ","$7,063.20 ","$8,927.10 ","$7,357.50 "
Carle BroMenn Medical Center,8264610,"INJECT 5TH N.-2,3 DIV,F.OVALE,XRAY",,64610,510,"$2,790.00 ","$2,790.00 ",$837.00 ,"$2,538.90 ","$1,953.00 ",$837.00 ,"$1,813.50 ","$2,008.80 ","$2,538.90 ","$2,092.50 "
Carle BroMenn Medical Center,8264611,"CHEMODENERVATION PAROTID/SUBMANDIBULAR SALIVARY GLANDS, BILATERAL",,64611,510,$530.00 ,$530.00 ,$159.00 ,$482.30 ,$371.00 ,$159.00 ,$344.50 ,$381.60 ,$482.30 ,$397.50 
Carle BroMenn Medical Center,8264612,CHEMODNRVTJ MUSC MUSC INNERVATED FACIAL NRV UNIL,,64612,510,$990.00 ,$990.00 ,$297.00 ,$900.90 ,$693.00 ,$297.00 ,$643.50 ,$712.80 ,$900.90 ,$742.50 
Carle BroMenn Medical Center,8264615,CHEMODERVATE FACIAL/TRIGEM/CERV MUSC MIGRAINE,,64615,510,$760.00 ,$760.00 ,$228.00 ,$691.60 ,$532.00 ,$228.00 ,$494.00 ,$547.20 ,$691.60 ,$570.00 
Carle BroMenn Medical Center,8264616,CHEMODENERVATION MUSCLE NECK UNILAT FOR DYSTONIA,,64616,510,$760.00 ,$760.00 ,$228.00 ,$691.60 ,$532.00 ,$228.00 ,$494.00 ,$547.20 ,$691.60 ,$570.00 
Carle BroMenn Medical Center,8264617,CHEMODENERVATION MUSCLE LARYNX UNILAT W/EMG,,64617,510,$870.00 ,$870.00 ,$261.00 ,$791.70 ,$609.00 ,$261.00 ,$565.50 ,$626.40 ,$791.70 ,$652.50 
Carle BroMenn Medical Center,8264624,DESTRUCTION NEUROLYTIC AGT GENICULAR NERVE W/IMG,,64624,510,"$3,450.00 ","$3,450.00 ","$1,035.00 ","$3,139.50 ","$2,415.00 ","$1,035.00 ","$2,242.50 ","$2,484.00 ","$3,139.50 ","$2,587.50 "
Carle BroMenn Medical Center,8264625,RADIOFREQUENCY ABLTJ NRV NRVTG SI JT W/IMG GDN,,64625,510,"$4,480.00 ","$4,480.00 ","$1,344.00 ","$4,076.80 ","$3,136.00 ","$1,344.00 ","$2,912.00 ","$3,225.60 ","$4,076.80 ","$3,360.00 "
Carle BroMenn Medical Center,8264632,DESTRUCT BY NEURO AGENT; PLANTAR DIGITAL NERVE,,64632,510,$670.00 ,$670.00 ,$201.00 ,$609.70 ,$469.00 ,$201.00 ,$435.50 ,$482.40 ,$609.70 ,$502.50 
Carle BroMenn Medical Center,8264633,DSTR NROLYTC AGNT PARVERTEB FCT SNGL CRVCL/THORA,,64633,510,"$4,960.00 ","$4,960.00 ","$1,488.00 ","$4,513.60 ","$3,472.00 ","$1,488.00 ","$3,224.00 ","$3,571.20 ","$4,513.60 ","$3,720.00 "
Carle BroMenn Medical Center,8264634,DSTR NROLYTC AGNT PARVERTEB FCT ADDL CRVCL/THORA,,64634,510,"$1,340.00 ","$1,340.00 ",$402.00 ,"$1,219.40 ",$938.00 ,$402.00 ,$871.00 ,$964.80 ,"$1,219.40 ","$1,005.00 "
Carle BroMenn Medical Center,8264635,DSTR NROLYTC AGNT PARVERTEB FCT SNGL LMBR/SACRAL,,64635,510,"$4,960.00 ","$4,960.00 ","$1,488.00 ","$4,513.60 ","$3,472.00 ","$1,488.00 ","$3,224.00 ","$3,571.20 ","$4,513.60 ","$3,720.00 "
Carle BroMenn Medical Center,8264636,DSTR NROLYTC AGNT PARVERTEB FCT ADDL LMBR/SACRAL,,64636,510,"$1,210.00 ","$1,210.00 ",$363.00 ,"$1,101.10 ",$847.00 ,$363.00 ,$786.50 ,$871.20 ,"$1,101.10 ",$907.50 
Carle BroMenn Medical Center,8264640,"DESTRUCTION BY NEUROLYTIC AGENT, OTHR PERIPH NRV/BRNCH",,64640,510,"$2,040.00 ","$2,040.00 ",$612.00 ,"$1,856.40 ","$1,428.00 ",$612.00 ,"$1,326.00 ","$1,468.80 ","$1,856.40 ","$1,530.00 "
Carle BroMenn Medical Center,8264642,CHEMODENERVATION ONE EXTREMITY 1-4 MUSCLE,,64642,510,"$1,440.00 ","$1,440.00 ",$432.00 ,"$1,310.40 ","$1,008.00 ",$432.00 ,$936.00 ,"$1,036.80 ","$1,310.40 ","$1,080.00 "
Carle BroMenn Medical Center,8264643,CHEMODENERVATION 1 EXTREMITY EA ADDL 1-4 MUSCLE,,64643,510,$620.00 ,$620.00 ,$186.00 ,$564.20 ,$434.00 ,$186.00 ,$403.00 ,$446.40 ,$564.20 ,$465.00 
Carle BroMenn Medical Center,8264644,CHEMODENERVATION 1 EXTREMITY 5 OR MORE MUSCLES,,64644,510,"$1,440.00 ","$1,440.00 ",$432.00 ,"$1,310.40 ","$1,008.00 ",$432.00 ,$936.00 ,"$1,036.80 ","$1,310.40 ","$1,080.00 "
Carle BroMenn Medical Center,8264645,CHEMODENERVATION 1 EXTREMITY EA ADDL 5/< MUSCLES,,64645,510,$620.00 ,$620.00 ,$186.00 ,$564.20 ,$434.00 ,$186.00 ,$403.00 ,$446.40 ,$564.20 ,$465.00 
Carle BroMenn Medical Center,8264646,CHEMODENERVATION OF TRUNK MUSCLE 1-5 MUSCLES,,64646,510,$870.00 ,$870.00 ,$261.00 ,$791.70 ,$609.00 ,$261.00 ,$565.50 ,$626.40 ,$791.70 ,$652.50 
Carle BroMenn Medical Center,8264647,CHEMODENERVATION OF TRUNK 6 OR MORE MUSCLES,,64647,510,$870.00 ,$870.00 ,$261.00 ,$791.70 ,$609.00 ,$261.00 ,$565.50 ,$626.40 ,$791.70 ,$652.50 
Carle BroMenn Medical Center,8264650,CHEMODENERV ECCRINE GLANDS BOTH AXILLAE,,64650,510,$530.00 ,$530.00 ,$159.00 ,$482.30 ,$371.00 ,$159.00 ,$344.50 ,$381.60 ,$482.30 ,$397.50 
Carle BroMenn Medical Center,8264653,"CHEMODENERV ECCRINE GLANDS, NON-AXILLARY",,64653,510,$415.00 ,$415.00 ,$124.50 ,$377.65 ,$290.50 ,$124.50 ,$269.75 ,$298.80 ,$377.65 ,$311.25 
Carle BroMenn Medical Center,8264818,"SYMPATHECTOMY,LUMBAR",,64818,510,"$5,240.00 ","$5,240.00 ","$1,572.00 ","$4,768.40 ","$3,668.00 ","$1,572.00 ","$3,406.00 ","$3,772.80 ","$4,768.40 ","$3,930.00 "
Carle BroMenn Medical Center,8264999,NERVOUS SYSTEM SURGERY UNLISTED,,64999,510,$578.50 ,$578.50 ,$173.55 ,$526.44 ,$404.95 ,$173.55 ,$376.03 ,$416.52 ,$526.44 ,$433.88 
Carle BroMenn Medical Center,8265205,REMOVAL FB EXT EYE CONJUNCTIVAL SUPERFICIAL,,65205,510,$440.00 ,$440.00 ,$132.00 ,$400.40 ,$308.00 ,$132.00 ,$286.00 ,$316.80 ,$400.40 ,$330.00 
Carle BroMenn Medical Center,8265210,RMVL FB EXT EYE CNJNCTVL EMBEDDED SUBCNJ OR SCLRL NONPF,,65210,510,$714.00 ,$714.00 ,$214.20 ,$649.74 ,$499.80 ,$214.20 ,$464.10 ,$514.08 ,$649.74 ,$535.50 
Carle BroMenn Medical Center,8265220,REMOVE FB EYE CORNEA NO SLIT,,65220,510,$595.00 ,$595.00 ,$178.50 ,$541.45 ,$416.50 ,$178.50 ,$386.75 ,$428.40 ,$541.45 ,$446.25 
Carle BroMenn Medical Center,8265222,REMOVAL FB EXT EYE CORNEAL W/SLIT LAMP,,65222,510,$415.00 ,$415.00 ,$124.50 ,$377.65 ,$290.50 ,$124.50 ,$269.75 ,$298.80 ,$377.65 ,$311.25 
Carle BroMenn Medical Center,8265270,REPAIR CONJUNC LACERTATION,,65270,510,"$3,870.00 ","$3,870.00 ","$1,161.00 ","$3,521.70 ","$2,709.00 ","$1,161.00 ","$2,515.50 ","$2,786.40 ","$3,521.70 ","$2,902.50 "
Carle BroMenn Medical Center,8265286,"REPAIR CORNEA LAC, APPLY GLUE",,65286,510,"$3,510.00 ","$3,510.00 ","$1,053.00 ","$3,194.10 ","$2,457.00 ","$1,053.00 ","$2,281.50 ","$2,527.20 ","$3,194.10 ","$2,632.50 "
Carle BroMenn Medical Center,8265400,EXCISION LESION CORNEA (KERATECTOMY LAMELLAR PARTIAL) EXCEPT PTERYGIUM,,65400,510,"$2,030.00 ","$2,030.00 ",$609.00 ,"$1,847.30 ","$1,421.00 ",$609.00 ,"$1,319.50 ","$1,461.60 ","$1,847.30 ","$1,522.50 "
Carle BroMenn Medical Center,8265420,PTERYGIUM EXCIS  W/O GRAFT,,65420,510,"$1,600.00 ","$1,600.00 ",$480.00 ,"$1,456.00 ","$1,120.00 ",$480.00 ,"$1,040.00 ","$1,152.00 ","$1,456.00 ","$1,200.00 "
Carle BroMenn Medical Center,8265430,SCRAPING CORNEA DX SMEAR &/OR CULTURE,,65430,510,$640.00 ,$640.00 ,$192.00 ,$582.40 ,$448.00 ,$192.00 ,$416.00 ,$460.80 ,$582.40 ,$480.00 
Carle BroMenn Medical Center,8265435,"REMOVAL CORNEAL EPITHELIUM W/WO CHEMOCAUTERIZATION (ABRASION, CURETTAGE)",,65435,510,"$1,010.00 ","$1,010.00 ",$303.00 ,$919.10 ,$707.00 ,$303.00 ,$656.50 ,$727.20 ,$919.10 ,$757.50 
Carle BroMenn Medical Center,8265436,REMOVAL CORNEAL EPITHELIUM W/APPLICATION CHELATING AGENT,,65436,510,"$1,340.00 ","$1,340.00 ",$402.00 ,"$1,219.40 ",$938.00 ,$402.00 ,$871.00 ,$964.80 ,"$1,219.40 ","$1,005.00 "
Carle BroMenn Medical Center,8265450,"DESTR CORNEAL LESN, CRYO, PHOTO, THERM",,65450,510,"$2,750.00 ","$2,750.00 ",$825.00 ,"$2,502.50 ","$1,925.00 ",$825.00 ,"$1,787.50 ","$1,980.00 ","$2,502.50 ","$2,062.50 "
Carle BroMenn Medical Center,8265600,MULTIPLE PUNCTURES ANTERIOR CORNEA,,65600,510,"$2,150.00 ","$2,150.00 ",$645.00 ,"$1,956.50 ","$1,505.00 ",$645.00 ,"$1,397.50 ","$1,548.00 ","$1,956.50 ","$1,612.50 "
Carle BroMenn Medical Center,8265778,PLACE AMNIOTIC MEMBRANE OCULAR SURFACE W/O SUTURES,,65778,510,"$1,790.00 ","$1,790.00 ",$537.00 ,"$1,628.90 ","$1,253.00 ",$537.00 ,"$1,163.50 ","$1,288.80 ","$1,628.90 ","$1,342.50 "
Carle BroMenn Medical Center,8265785,IMPLNT INTRSTML CORNEAL RING SGMNTS,,65785,510,"$4,330.00 ","$4,330.00 ","$1,299.00 ","$3,940.30 ","$3,031.00 ","$1,299.00 ","$2,814.50 ","$3,117.60 ","$3,940.30 ","$3,247.50 "
Carle BroMenn Medical Center,8265800,PARACENTESIS ANT CHAMB EYE ASPIR AQUEOUS SPX,,65800,510,"$2,290.00 ","$2,290.00 ",$687.00 ,"$2,083.90 ","$1,603.00 ",$687.00 ,"$1,488.50 ","$1,648.80 ","$2,083.90 ","$1,717.50 "
Carle BroMenn Medical Center,8265855,TRABECULOPLASTY LASER SURGERY 1+ SESSIONS (DEFINED TREATMENT SERIES),,65855,510,"$2,200.00 ","$2,200.00 ",$660.00 ,"$2,002.00 ","$1,540.00 ",$660.00 ,"$1,430.00 ","$1,584.00 ","$2,002.00 ","$1,650.00 "
Carle BroMenn Medical Center,8265920,REMOVAL IMPLANTED MATERIAL ANTERIOR SEGMENT EYE,,65920,510,"$3,260.00 ","$3,260.00 ",$978.00 ,"$2,966.60 ","$2,282.00 ",$978.00 ,"$2,119.00 ","$2,347.20 ","$2,966.60 ","$2,445.00 "
Carle BroMenn Medical Center,8266020,"INJECTION,ANT CHAMBER,EYE,AIR/LIQUID",,66020,510,"$2,290.00 ","$2,290.00 ",$687.00 ,"$2,083.90 ","$1,603.00 ",$687.00 ,"$1,488.50 ","$1,648.80 ","$2,083.90 ","$1,717.50 "
Carle BroMenn Medical Center,8266030,INJECTION ANTERIOR CHAMBER EYE (SEP PROC) MEDICATION,,66030,510,"$2,290.00 ","$2,290.00 ",$687.00 ,"$2,083.90 ","$1,603.00 ",$687.00 ,"$1,488.50 ","$1,648.80 ","$2,083.90 ","$1,717.50 "
Carle BroMenn Medical Center,8266179,AQUEOUS SHUNT EXTRAOCULAR RESERVOIR W/O GRAFT,,66179,510,"$5,310.00 ","$5,310.00 ","$1,593.00 ","$4,832.10 ","$3,717.00 ","$1,593.00 ","$3,451.50 ","$3,823.20 ","$4,832.10 ","$3,982.50 "
Carle BroMenn Medical Center,8266183,INSERT ANTER DRAINAGE DEV W/O EXTRAOC RESERVOIR,,66183,510,"$2,660.00 ","$2,660.00 ",$798.00 ,"$2,420.60 ","$1,862.00 ",$798.00 ,"$1,729.00 ","$1,915.20 ","$2,420.60 ","$1,995.00 "
Carle BroMenn Medical Center,8266184,REVJ SHUNT EXTRAOCULAR RESERVOIR W/O GRAFT,,66184,510,"$3,870.00 ","$3,870.00 ","$1,161.00 ","$3,521.70 ","$2,709.00 ","$1,161.00 ","$2,515.50 ","$2,786.40 ","$3,521.70 ","$2,902.50 "
Carle BroMenn Medical Center,8266250,REVIS/REPAIR OP WOUND ANTER SGMT,,66250,510,"$4,820.00 ","$4,820.00 ","$1,446.00 ","$4,386.20 ","$3,374.00 ","$1,446.00 ","$3,133.00 ","$3,470.40 ","$4,386.20 ","$3,615.00 "
Carle BroMenn Medical Center,8266625,IRIDECTOMY W/CORNEOSCLERAL/CORNEAL SECTION PERIPHERAL GLAUCOMA (SEP PROC),,66625,510,"$2,160.00 ","$2,160.00 ",$648.00 ,"$1,965.60 ","$1,512.00 ",$648.00 ,"$1,404.00 ","$1,555.20 ","$1,965.60 ","$1,620.00 "
Carle BroMenn Medical Center,8266710,CILIARY TRANSSLERAL THERAPY,,66710,510,"$3,970.00 ","$3,970.00 ","$1,191.00 ","$3,612.70 ","$2,779.00 ","$1,191.00 ","$2,580.50 ","$2,858.40 ","$3,612.70 ","$2,977.50 "
Carle BroMenn Medical Center,8266720,CYCLOCRYOTHERAPY INT,,66720,510,"$2,660.00 ","$2,660.00 ",$798.00 ,"$2,420.60 ","$1,862.00 ",$798.00 ,"$1,729.00 ","$1,915.20 ","$2,420.60 ","$1,995.00 "
Carle BroMenn Medical Center,8266761,IRIDOTOMY/IRIDECTOMY LASER SURGERY (1+ SESSIONS),,66761,510,"$2,040.00 ","$2,040.00 ",$612.00 ,"$1,856.40 ","$1,428.00 ",$612.00 ,"$1,326.00 ","$1,468.80 ","$1,856.40 ","$1,530.00 "
Carle BroMenn Medical Center,8266762,LASER IRIDOPLASTY,,66762,510,"$4,190.00 ","$4,190.00 ","$1,257.00 ","$3,812.90 ","$2,933.00 ","$1,257.00 ","$2,723.50 ","$3,016.80 ","$3,812.90 ","$3,142.50 "
Carle BroMenn Medical Center,8266821,DISCISSION SECONDARY MEMBRANOUS CATARACT; LASER (1+ STAGES),,66821,510,"$1,510.00 ","$1,510.00 ",$453.00 ,"$1,374.10 ","$1,057.00 ",$453.00 ,$981.50 ,"$1,087.20 ","$1,374.10 ","$1,132.50 "
Carle BroMenn Medical Center,8266825,REPOSITION INTRAOCULAR LENS W INCIS,,66825,510,"$4,040.00 ","$4,040.00 ","$1,212.00 ","$3,676.40 ","$2,828.00 ","$1,212.00 ","$2,626.00 ","$2,908.80 ","$3,676.40 ","$3,030.00 "
Carle BroMenn Medical Center,8266987,XCAPSL CTRC RMVL INSJ IO LENS PROSTH CPLX W/ECP,,66987,510,"$5,100.00 ","$5,100.00 ","$1,530.00 ","$4,641.00 ","$3,570.00 ","$1,530.00 ","$3,315.00 ","$3,672.00 ","$4,641.00 ","$3,825.00 "
Carle BroMenn Medical Center,8266988,XCAPSL CTRC RMVL INSJ IO LENS PROSTH W/ECP,,66988,510,"$4,460.00 ","$4,460.00 ","$1,338.00 ","$4,058.60 ","$3,122.00 ","$1,338.00 ","$2,899.00 ","$3,211.20 ","$4,058.60 ","$3,345.00 "
Carle BroMenn Medical Center,8267015,ASPIRATION/RELEASE VITREOUS/SUBRETINAL/CHOROIDAL FLUID PARS PLANA APPROACH,,67015,510,"$4,330.00 ","$4,330.00 ","$1,299.00 ","$3,940.30 ","$3,031.00 ","$1,299.00 ","$2,814.50 ","$3,117.60 ","$3,940.30 ","$3,247.50 "
Carle BroMenn Medical Center,8267025,INJECTION VITREOUS SUBSTITUTE PARS PLANA/LIMBAL APPROACH W/WO ASPIRATION (SEP PROC),,67025,510,"$2,910.00 ","$2,910.00 ",$873.00 ,"$2,648.10 ","$2,037.00 ",$873.00 ,"$1,891.50 ","$2,095.20 ","$2,648.10 ","$2,182.50 "
Carle BroMenn Medical Center,8267028,INTRAVITREAL INJECTION A PHARMACOLOGIC AGENT (SEP PROC),,67028,510,$970.00 ,$970.00 ,$291.00 ,$882.70 ,$679.00 ,$291.00 ,$630.50 ,$698.40 ,$882.70 ,$727.50 
Carle BroMenn Medical Center,8267031,LASER SURGERY SEVER VITREOUS STRANDS,,67031,510,"$2,300.00 ","$2,300.00 ",$690.00 ,"$2,093.00 ","$1,610.00 ",$690.00 ,"$1,495.00 ","$1,656.00 ","$2,093.00 ","$1,725.00 "
Carle BroMenn Medical Center,8267105,"REPAIR RETINAL DETACHMENT, LASER PHOTOCOAGULATION",,67105,510,"$4,020.00 ","$4,020.00 ","$1,206.00 ","$3,658.20 ","$2,814.00 ","$1,206.00 ","$2,613.00 ","$2,894.40 ","$3,658.20 ","$3,015.00 "
Carle BroMenn Medical Center,8267110,"PNEUMATIC, REPAIR RETINAL DETACHMENT INJECTION AIR/OTHER GAS",,67110,510,"$5,830.00 ","$5,830.00 ","$1,749.00 ","$5,305.30 ","$4,081.00 ","$1,749.00 ","$3,789.50 ","$4,197.60 ","$5,305.30 ","$4,372.50 "
Carle BroMenn Medical Center,8267115,"RELEASE ENCIRCL MATERIAL,POST SGMT",,67115,510,"$2,660.00 ","$2,660.00 ",$798.00 ,"$2,420.60 ","$1,862.00 ",$798.00 ,"$1,729.00 ","$1,915.20 ","$2,420.60 ","$1,995.00 "
Carle BroMenn Medical Center,8267120,REMV POST EYE IMPLNT MATER EXTRAOCUL,,67120,510,"$2,810.00 ","$2,810.00 ",$843.00 ,"$2,557.10 ","$1,967.00 ",$843.00 ,"$1,826.50 ","$2,023.20 ","$2,557.10 ","$2,107.50 "
Carle BroMenn Medical Center,8267141,"PROPHYLAXIS (CRYO), RETINAL DETACHMENT 1+ SESSIONS CRYOTHERAPY, DIATHERMY",,67141,510,"$2,200.00 ","$2,200.00 ",$660.00 ,"$2,002.00 ","$1,540.00 ",$660.00 ,"$1,430.00 ","$1,584.00 ","$2,002.00 ","$1,650.00 "
Carle BroMenn Medical Center,8267145,"PROPHYLAXIS, RETINAL DETACHMENT 1+ SESSIONS PHOTOCOAGULATION",,67145,510,"$2,700.00 ","$2,700.00 ",$810.00 ,"$2,457.00 ","$1,890.00 ",$810.00 ,"$1,755.00 ","$1,944.00 ","$2,457.00 ","$2,025.00 "
Carle BroMenn Medical Center,8267208,DESTRUCTION LOCALIZED RETINAL LESION 1+ SESSIONS CRYOTHERAPY DIATHERMY,,67208,510,"$3,470.00 ","$3,470.00 ","$1,041.00 ","$3,157.70 ","$2,429.00 ","$1,041.00 ","$2,255.50 ","$2,498.40 ","$3,157.70 ","$2,602.50 "
Carle BroMenn Medical Center,8267210,DESTRUCTION LOCALIZED RETINAL LESION 1+ SESSIONS PHOTOCOAGULATION,,67210,510,"$3,140.00 ","$3,140.00 ",$942.00 ,"$2,857.40 ","$2,198.00 ",$942.00 ,"$2,041.00 ","$2,260.80 ","$2,857.40 ","$2,355.00 "
Carle BroMenn Medical Center,8267220,DESTRUCTION LOCALIZED LESION CHOROID PHOTOCOAGULATION 1+ SESSIONS,,67220,510,"$2,890.00 ","$2,890.00 ",$867.00 ,"$2,629.90 ","$2,023.00 ",$867.00 ,"$1,878.50 ","$2,080.80 ","$2,629.90 ","$2,167.50 "
Carle BroMenn Medical Center,8267221,DESTRUCTION LOCALIZED LESION CHOROID PHOTODYNAMIC THERAPY (W/IV INFUSION),,67221,510,"$1,730.00 ","$1,730.00 ",$519.00 ,"$1,574.30 ","$1,211.00 ",$519.00 ,"$1,124.50 ","$1,245.60 ","$1,574.30 ","$1,297.50 "
Carle BroMenn Medical Center,8267225,"DESTRCT LOCALIZED LSN CHOROID PHOTOCOAG, 2ND EYE, SINGLE SESSION",,67225,510,$205.00 ,$205.00 ,$61.50 ,$186.55 ,$143.50 ,$61.50 ,$133.25 ,$147.60 ,$186.55 ,$153.75 
Carle BroMenn Medical Center,8267227,"TREATMENT OF RETNIOPATHY, CRYO",,67227,510,"$2,500.00 ","$2,500.00 ",$750.00 ,"$2,275.00 ","$1,750.00 ",$750.00 ,"$1,625.00 ","$1,800.00 ","$2,275.00 ","$1,875.00 "
Carle BroMenn Medical Center,8267228,TREATMENT OF RETNIOPATHY PHOTOCOAGULATION 1 OR MORE SESSIONS,,67228,510,"$3,740.00 ","$3,740.00 ","$1,122.00 ","$3,403.40 ","$2,618.00 ","$1,122.00 ","$2,431.00 ","$2,692.80 ","$3,403.40 ","$2,805.00 "
Carle BroMenn Medical Center,8267345,CHEMODENERVATION EXTRAOCCULAR MUSCLE,,67345,510,$780.00 ,$780.00 ,$234.00 ,$709.80 ,$546.00 ,$234.00 ,$507.00 ,$561.60 ,$709.80 ,$585.00 
Carle BroMenn Medical Center,8267500,"RETROBULBAR INJECTION MEDICATION (SEP PROC, MEDICATION NOT INCLUDED)",,67500,510,$690.00 ,$690.00 ,$207.00 ,$627.90 ,$483.00 ,$207.00 ,$448.50 ,$496.80 ,$627.90 ,$517.50 
Carle BroMenn Medical Center,8267505,RETROBULBAR INJECTION ALCOHOL,,67505,510,$690.00 ,$690.00 ,$207.00 ,$627.90 ,$483.00 ,$207.00 ,$448.50 ,$496.80 ,$627.90 ,$517.50 
Carle BroMenn Medical Center,8267515,INJECTION THERAPEUTIC AGENT INTO TENON`S CAPSULE,,67515,510,$670.00 ,$670.00 ,$201.00 ,$609.70 ,$469.00 ,$201.00 ,$435.50 ,$482.40 ,$609.70 ,$502.50 
Carle BroMenn Medical Center,8267700,BLEPHAROTOMY DRAINAGE ABSCESS EYELID,,67700,510,"$1,075.00 ","$1,075.00 ",$322.50 ,$978.25 ,$752.50 ,$322.50 ,$698.75 ,$774.00 ,$978.25 ,$806.25 
Carle BroMenn Medical Center,8267710,SEVERING TARSORRHAPHY,,67710,510,$620.00 ,$620.00 ,$186.00 ,$564.20 ,$434.00 ,$186.00 ,$403.00 ,$446.40 ,$564.20 ,$465.00 
Carle BroMenn Medical Center,8267715,CANTHOTOMY (SEP PROC),,67715,510,"$1,340.00 ","$1,340.00 ",$402.00 ,"$1,219.40 ",$938.00 ,$402.00 ,$871.00 ,$964.80 ,"$1,219.40 ","$1,005.00 "
Carle BroMenn Medical Center,8267800,EXCISION CHALAZION; SINGLE,,67800,510,$780.00 ,$780.00 ,$234.00 ,$709.80 ,$546.00 ,$234.00 ,$507.00 ,$561.60 ,$709.80 ,$585.00 
Carle BroMenn Medical Center,8267801,EXCISION CHALAZION MULTIPLE SAME LID,,67801,510,"$1,200.00 ","$1,200.00 ",$360.00 ,"$1,092.00 ",$840.00 ,$360.00 ,$780.00 ,$864.00 ,"$1,092.00 ",$900.00 
Carle BroMenn Medical Center,8267805,"EXCISION CHALAZION MULTIPLE, DIFFERENT LIDS",,67805,510,$780.00 ,$780.00 ,$234.00 ,$709.80 ,$546.00 ,$234.00 ,$507.00 ,$561.60 ,$709.80 ,$585.00 
Carle BroMenn Medical Center,8267810,INCISIONAL BIOPSY EYELID SKIN & LID MARGIN,,67810,510,$690.00 ,$690.00 ,$207.00 ,$627.90 ,$483.00 ,$207.00 ,$448.50 ,$496.80 ,$627.90 ,$517.50 
Carle BroMenn Medical Center,8267820,CORRECTION TRICHIASIS EPILATION FORCEPS ONLY,,67820,510,$275.00 ,$275.00 ,$82.50 ,$250.25 ,$192.50 ,$82.50 ,$178.75 ,$198.00 ,$250.25 ,$206.25 
Carle BroMenn Medical Center,8267825,CORRECTION TRICHIASIS EPILATION NON-FORCEPS,,67825,510,$780.00 ,$780.00 ,$234.00 ,$709.80 ,$546.00 ,$234.00 ,$507.00 ,$561.60 ,$709.80 ,$585.00 
Carle BroMenn Medical Center,8267840,EXCISION LESION EYELID (EXCEPT CHALAZION) W/O CLOSURE OR W/SIMPLE DIRECT CLOSURE,,67840,510,"$1,470.00 ","$1,470.00 ",$441.00 ,"$1,337.70 ","$1,029.00 ",$441.00 ,$955.50 ,"$1,058.40 ","$1,337.70 ","$1,102.50 "
Carle BroMenn Medical Center,8267850,DESTRUCTION LESION LID MARGIN (UP TO 1 CM),,67850,510,$670.00 ,$670.00 ,$201.00 ,$609.70 ,$469.00 ,$201.00 ,$435.50 ,$482.40 ,$609.70 ,$502.50 
Carle BroMenn Medical Center,8267875,TEMP CLOSURE EYELID BY SUTURE,,67875,510,"$2,030.00 ","$2,030.00 ",$609.00 ,"$1,847.30 ","$1,421.00 ",$609.00 ,"$1,319.50 ","$1,461.60 ","$1,847.30 ","$1,522.50 "
Carle BroMenn Medical Center,8267880,CONSTRUCTION INTERMARGINAL ADHESIONS MEDIAN TARSORRHAPHY/CANTHORRHAPHY,,67880,510,"$3,210.00 ","$3,210.00 ",$963.00 ,"$2,921.10 ","$2,247.00 ",$963.00 ,"$2,086.50 ","$2,311.20 ","$2,921.10 ","$2,407.50 "
Carle BroMenn Medical Center,8267882,CONSTRUCTION INTERMARGINAL ADHESIONS/MEDIAN TARSORRHAPHY/CANTHORRHAPHY W/TRANSPOSE TARSAL PLATE,,67882,510,"$2,300.00 ","$2,300.00 ",$690.00 ,"$2,093.00 ","$1,610.00 ",$690.00 ,"$1,495.00 ","$1,656.00 ","$2,093.00 ","$1,725.00 "
Carle BroMenn Medical Center,8267911,CORRECTION OF LID RETRACTION,,67911,510,"$5,580.00 ","$5,580.00 ","$1,674.00 ","$5,077.80 ","$3,906.00 ","$1,674.00 ","$3,627.00 ","$4,017.60 ","$5,077.80 ","$4,185.00 "
Carle BroMenn Medical Center,8267914,"FIX EXTROPION, SUTURE",,67914,510,"$5,570.00 ","$5,570.00 ","$1,671.00 ","$5,068.70 ","$3,899.00 ","$1,671.00 ","$3,620.50 ","$4,010.40 ","$5,068.70 ","$4,177.50 "
Carle BroMenn Medical Center,8267921,REPAIR ENTROPION SUTURE,,67921,510,"$4,190.00 ","$4,190.00 ","$1,257.00 ","$3,812.90 ","$2,933.00 ","$1,257.00 ","$2,723.50 ","$3,016.80 ","$3,812.90 ","$3,142.50 "
Carle BroMenn Medical Center,8267930,SUTURE RECENT WOUND EYELID PARTIAL THICKNESS,,67930,510,"$1,340.00 ","$1,340.00 ",$402.00 ,"$1,219.40 ",$938.00 ,$402.00 ,$871.00 ,$964.80 ,"$1,219.40 ","$1,005.00 "
Carle BroMenn Medical Center,8267935,SUTURE RECENT WOUND EYELID FULL THICKNESS,,67935,510,"$2,010.00 ","$2,010.00 ",$603.00 ,"$1,829.10 ","$1,407.00 ",$603.00 ,"$1,306.50 ","$1,447.20 ","$1,829.10 ","$1,507.50 "
Carle BroMenn Medical Center,8267938,REMOVAL EMBEDDED FB EYELID,,67938,510,$600.00 ,$600.00 ,$180.00 ,$546.00 ,$420.00 ,$180.00 ,$390.00 ,$432.00 ,$546.00 ,$450.00 
Carle BroMenn Medical Center,8267950,CANTHOPLASTY (RECONSTRUCTION CANTHUS),,67950,510,"$5,580.00 ","$5,580.00 ","$1,674.00 ","$5,077.80 ","$3,906.00 ","$1,674.00 ","$3,627.00 ","$4,017.60 ","$5,077.80 ","$4,185.00 "
Carle BroMenn Medical Center,8267961,"EXCISION/REPAIR EYELID UP T0 ONE QUARTER, LID MARGIN",,67961,510,"$3,910.00 ","$3,910.00 ","$1,173.00 ","$3,558.10 ","$2,737.00 ","$1,173.00 ","$2,541.50 ","$2,815.20 ","$3,558.10 ","$2,932.50 "
Carle BroMenn Medical Center,8267966,EXCISION/REPAIR EYELID > ONE QUARTER LID MARGIN,,67966,510,"$4,900.00 ","$4,900.00 ","$1,470.00 ","$4,459.00 ","$3,430.00 ","$1,470.00 ","$3,185.00 ","$3,528.00 ","$4,459.00 ","$3,675.00 "
Carle BroMenn Medical Center,8268020,INCISION CONJUNCTIVA DRAINAGE CYST,,68020,510,"$1,010.00 ","$1,010.00 ",$303.00 ,$919.10 ,$707.00 ,$303.00 ,$656.50 ,$727.20 ,$919.10 ,$757.50 
Carle BroMenn Medical Center,8268100,BX CONJUNCTIVA,,68100,510,"$2,150.00 ","$2,150.00 ",$645.00 ,"$1,956.50 ","$1,505.00 ",$645.00 ,"$1,397.50 ","$1,548.00 ","$1,956.50 ","$1,612.50 "
Carle BroMenn Medical Center,8268110,EXCISION LESION CONJUNCTIVA UP TO 1 CM,,68110,510,"$2,150.00 ","$2,150.00 ",$645.00 ,"$1,956.50 ","$1,505.00 ",$645.00 ,"$1,397.50 ","$1,548.00 ","$1,956.50 ","$1,612.50 "
Carle BroMenn Medical Center,8268115,EXCISION LESION CONJUNCTIVA > 1 CM,,68115,510,"$1,340.00 ","$1,340.00 ",$402.00 ,"$1,219.40 ",$938.00 ,$402.00 ,$871.00 ,$964.80 ,"$1,219.40 ","$1,005.00 "
Carle BroMenn Medical Center,8268135,DESTRUCTION LESION CONJUNCTIVA,,68135,510,"$1,340.00 ","$1,340.00 ",$402.00 ,"$1,219.40 ",$938.00 ,$402.00 ,$871.00 ,$964.80 ,"$1,219.40 ","$1,005.00 "
Carle BroMenn Medical Center,8268200,SUBCONJUNCTIVAL INJECTION,,68200,510,$320.00 ,$320.00 ,$96.00 ,$291.20 ,$224.00 ,$96.00 ,$208.00 ,$230.40 ,$291.20 ,$240.00 
Carle BroMenn Medical Center,8268320,CONJUNCTIVOPLASTY W/CONJUNCTIVAL GRAFT/EXTENSIVE REARRANGEMENT,,68320,510,"$4,430.00 ","$4,430.00 ","$1,329.00 ","$4,031.30 ","$3,101.00 ","$1,329.00 ","$2,879.50 ","$3,189.60 ","$4,031.30 ","$3,322.50 "
Carle BroMenn Medical Center,8268340,REPAIR SYMBLEPHARON DIVISION SYMBLEPHARON,,68340,510,"$3,190.00 ","$3,190.00 ",$957.00 ,"$2,902.90 ","$2,233.00 ",$957.00 ,"$2,073.50 ","$2,296.80 ","$2,902.90 ","$2,392.50 "
Carle BroMenn Medical Center,8268400,INCISION DRAINAGE LACRIMAL GLAND,,68400,510,$840.00 ,$840.00 ,$252.00 ,$764.40 ,$588.00 ,$252.00 ,$546.00 ,$604.80 ,$764.40 ,$630.00 
Carle BroMenn Medical Center,8268420,INCISION DRAINAGE LACRIMAL SAC (DACRYOCYSTOTOMY/DACRYOCYSTOSTOMY),,68420,510,"$1,340.00 ","$1,340.00 ",$402.00 ,"$1,219.40 ",$938.00 ,$402.00 ,$871.00 ,$964.80 ,"$1,219.40 ","$1,005.00 "
Carle BroMenn Medical Center,8268440,SNIP INCISION LACRIMAL PUNCTUM,,68440,510,$690.00 ,$690.00 ,$207.00 ,$627.90 ,$483.00 ,$207.00 ,$448.50 ,$496.80 ,$627.90 ,$517.50 
Carle BroMenn Medical Center,8268520,EXCISION LACRIMAL SAC (DACRYOCYSTECTOMY),,68520,510,"$3,350.00 ","$3,350.00 ","$1,005.00 ","$3,048.50 ","$2,345.00 ","$1,005.00 ","$2,177.50 ","$2,412.00 ","$3,048.50 ","$2,512.50 "
Carle BroMenn Medical Center,8268530,REMOVAL FB/DACRYOLITH LACRIMAL PASSAGES,,68530,510,"$2,250.00 ","$2,250.00 ",$675.00 ,"$2,047.50 ","$1,575.00 ",$675.00 ,"$1,462.50 ","$1,620.00 ","$2,047.50 ","$1,687.50 "
Carle BroMenn Medical Center,8268760,CLOSURE LACRIMAL PUNCTUM THERMOCAUTERIZATION,,68760,510,$780.00 ,$780.00 ,$234.00 ,$709.80 ,$546.00 ,$234.00 ,$507.00 ,$561.60 ,$709.80 ,$585.00 
Carle BroMenn Medical Center,8268761,CLOSURE LACRIMAL PUNCTUM PLUG EACH,,68761,510,$690.00 ,$690.00 ,$207.00 ,$627.90 ,$483.00 ,$207.00 ,$448.50 ,$496.80 ,$627.90 ,$517.50 
Carle BroMenn Medical Center,8268770,CLOSURE LACRIMAL FISTULA (SEP PROC),,68770,510,"$1,850.00 ","$1,850.00 ",$555.00 ,"$1,683.50 ","$1,295.00 ",$555.00 ,"$1,202.50 ","$1,332.00 ","$1,683.50 ","$1,387.50 "
Carle BroMenn Medical Center,8268801,DILATION LACRIMAL PUNCTUM W/WO IRRIGATION,,68801,510,$540.00 ,$540.00 ,$162.00 ,$491.40 ,$378.00 ,$162.00 ,$351.00 ,$388.80 ,$491.40 ,$405.00 
Carle BroMenn Medical Center,8268810,PROBING NASOLACRIMAL DUCT W/WO IRRIGATION,,68810,510,$740.00 ,$740.00 ,$222.00 ,$673.40 ,$518.00 ,$222.00 ,$481.00 ,$532.80 ,$673.40 ,$555.00 
Carle BroMenn Medical Center,8268840,PROBING LACRIMAL CANALICULI W/WO IRRIGATION,,68840,510,$475.00 ,$475.00 ,$142.50 ,$432.25 ,$332.50 ,$142.50 ,$308.75 ,$342.00 ,$432.25 ,$356.25 
Carle BroMenn Medical Center,8269000,"DRAIN EXT EAR ABSC/BLOOD,SIMPLE",,69000,510,"$1,190.00 ","$1,190.00 ",$357.00 ,"$1,082.90 ",$833.00 ,$357.00 ,$773.50 ,$856.80 ,"$1,082.90 ",$892.50 
Carle BroMenn Medical Center,8269020,DRAIN EXT AUD CANAL ABSCESS,,69020,510,$335.00 ,$335.00 ,$100.50 ,$304.85 ,$234.50 ,$100.50 ,$217.75 ,$241.20 ,$304.85 ,$251.25 
Carle BroMenn Medical Center,8269100,BIOPSY OF EXTERNAL EAR,,69100,510,$520.00 ,$520.00 ,$156.00 ,$473.20 ,$364.00 ,$156.00 ,$338.00 ,$374.40 ,$473.20 ,$390.00 
Carle BroMenn Medical Center,8269105,BIOPSY OF EXT AUDITORY CANAL,,69105,510,"$1,550.00 ","$1,550.00 ",$465.00 ,"$1,410.50 ","$1,085.00 ",$465.00 ,"$1,007.50 ","$1,116.00 ","$1,410.50 ","$1,162.50 "
Carle BroMenn Medical Center,8269140,REMV EXT CANAL EXOSTOSIS,,69140,510,"$6,020.00 ","$6,020.00 ","$1,806.00 ","$5,478.20 ","$4,214.00 ","$1,806.00 ","$3,913.00 ","$4,334.40 ","$5,478.20 ","$4,515.00 "
Carle BroMenn Medical Center,8269200,REMV EXT CANAL FOREIGN BODY,,69200,510,$360.00 ,$360.00 ,$108.00 ,$327.60 ,$252.00 ,$108.00 ,$234.00 ,$259.20 ,$327.60 ,$270.00 
Carle BroMenn Medical Center,8269209,REMOVAL IMPACTED CERUMEN IRRIGATION/LVG UNILAT,,69209,510,$205.00 ,$205.00 ,$61.50 ,$186.55 ,$143.50 ,$61.50 ,$133.25 ,$147.60 ,$186.55 ,$153.75 
Carle BroMenn Medical Center,8269210,REMOVAL IMPACTED CERUMEN,,69210,510,$195.00 ,$195.00 ,$58.50 ,$177.45 ,$136.50 ,$58.50 ,$126.75 ,$140.40 ,$177.45 ,$146.25 
Carle BroMenn Medical Center,8269220,"DEBRIDE MASTOID CAVITY,SIMPLE",,69220,510,$450.00 ,$450.00 ,$135.00 ,$409.50 ,$315.00 ,$135.00 ,$292.50 ,$324.00 ,$409.50 ,$337.50 
Carle BroMenn Medical Center,8269222,"DEBRIDE MASTOID CAVITY,COMPLEX",,69222,510,"$1,110.00 ","$1,110.00 ",$333.00 ,"$1,010.10 ",$777.00 ,$333.00 ,$721.50 ,$799.20 ,"$1,010.10 ",$832.50 
Carle BroMenn Medical Center,8269310,"RECONSTRUCTION,EXT AUDITORY CANAL",,69310,510,"$5,100.00 ","$5,100.00 ","$1,530.00 ","$4,641.00 ","$3,570.00 ","$1,530.00 ","$3,315.00 ","$3,672.00 ","$4,641.00 ","$3,825.00 "
Carle BroMenn Medical Center,8269399,OUTER EAR SURGERY PROC UNLISTED,,69399,510,$500.00 ,$500.00 ,$150.00 ,$455.00 ,$350.00 ,$150.00 ,$325.00 ,$360.00 ,$455.00 ,$375.00 
Carle BroMenn Medical Center,8269420,"INCISION EARDRUM,ASPIR",,69420,510,$690.00 ,$690.00 ,$207.00 ,$627.90 ,$483.00 ,$207.00 ,$448.50 ,$496.80 ,$627.90 ,$517.50 
Carle BroMenn Medical Center,8269433,"CREATE EARDRUM OPENING,LOCAL ANESTH",,69433,510,"$1,280.00 ","$1,280.00 ",$384.00 ,"$1,164.80 ",$896.00 ,$384.00 ,$832.00 ,$921.60 ,"$1,164.80 ",$960.00 
Carle BroMenn Medical Center,8269610,REPAIR TYMPANIC MEMBRANE,,69610,510,"$2,730.00 ","$2,730.00 ",$819.00 ,"$2,484.30 ","$1,911.00 ",$819.00 ,"$1,774.50 ","$1,965.60 ","$2,484.30 ","$2,047.50 "
Carle BroMenn Medical Center,8269620,MYRINGOPLASTY,,69620,510,"$6,570.00 ","$6,570.00 ","$1,971.00 ","$5,978.70 ","$4,599.00 ","$1,971.00 ","$4,270.50 ","$4,730.40 ","$5,978.70 ","$4,927.50 "
Carle BroMenn Medical Center,8269705,SURG NASOPHARYNGOSCOPY DILAT EUSTACHIAN TUBE UNI,,69705,510,"$4,810.00 ","$4,810.00 ","$1,443.00 ","$4,377.10 ","$3,367.00 ","$1,443.00 ","$3,126.50 ","$3,463.20 ","$4,377.10 ","$3,607.50 "
Carle BroMenn Medical Center,8269706,SURG NASOPHARYNGOSCOPY DILAT EUSTACHIAN TUBE BI,,69706,510,"$4,810.00 ","$4,810.00 ","$1,443.00 ","$4,377.10 ","$3,367.00 ","$1,443.00 ","$3,126.50 ","$3,463.20 ","$4,377.10 ","$3,607.50 "
Carle BroMenn Medical Center,8269710,IMPLT/RPLC BONE CNDTCTN DVC,,69710,510,"$4,100.00 ","$4,100.00 ","$1,230.00 ","$3,731.00 ","$2,870.00 ","$1,230.00 ","$2,665.00 ","$2,952.00 ","$3,731.00 ","$3,075.00 "
Carle BroMenn Medical Center,8269711,RMVL /RPR BONE CNDCTN DVC,,69711,510,"$5,470.00 ","$5,470.00 ","$1,641.00 ","$4,977.70 ","$3,829.00 ","$1,641.00 ","$3,555.50 ","$3,938.40 ","$4,977.70 ","$4,102.50 "
Carle BroMenn Medical Center,8269801,"LABYRINTHOTOMY W PERFUSION VESTIBULOACTIVE DRUGS,TRANSCRANIAL",,69801,510,"$1,890.00 ","$1,890.00 ",$567.00 ,"$1,719.90 ","$1,323.00 ",$567.00 ,"$1,228.50 ","$1,360.80 ","$1,719.90 ","$1,417.50 "
Carle BroMenn Medical Center,8276145,MEDICAL PHYSICS DOSE EVAL RADIATION EXPOS W/RPRT,,76145,510,$580.00 ,$580.00 ,$174.00 ,$527.80 ,$406.00 ,$174.00 ,$377.00 ,$417.60 ,$527.80 ,$435.00 
Carle BroMenn Medical Center,8291035,GERD TST W/ MUCOS PH ELECTROD,,91035,510,$880.00 ,$880.00 ,$264.00 ,$800.80 ,$616.00 ,$264.00 ,$572.00 ,$633.60 ,$800.80 ,$660.00 
Carle BroMenn Medical Center,8292002,OPTH SVCS INTERMEDIATE NEW PT,,92002,510,$170.00 ,$170.00 ,$51.00 ,$154.70 ,$119.00 ,$51.00 ,$110.50 ,$122.40 ,$154.70 ,$127.50 
Carle BroMenn Medical Center,8292004,OPTH SVCS COMPREHENSIVE NEW PT,,92004,510,$340.00 ,$340.00 ,$102.00 ,$309.40 ,$238.00 ,$102.00 ,$221.00 ,$244.80 ,$309.40 ,$255.00 
Carle BroMenn Medical Center,8292012,OPTH SVCS INTERMEDIATE EST PT,,92012,510,$205.00 ,$205.00 ,$61.50 ,$186.55 ,$143.50 ,$61.50 ,$133.25 ,$147.60 ,$186.55 ,$153.75 
Carle BroMenn Medical Center,8292014,OPTH SVCS COMPREHENSIVE EST PT,,92014,510,$275.00 ,$275.00 ,$82.50 ,$250.25 ,$192.50 ,$82.50 ,$178.75 ,$198.00 ,$250.25 ,$206.25 
Carle BroMenn Medical Center,8292065,ORTHOPTIC/PLEOPTIC TRAINING,,92065,510,$165.00 ,$165.00 ,$49.50 ,$150.15 ,$115.50 ,$49.50 ,$107.25 ,$118.80 ,$150.15 ,$123.75 
Carle BroMenn Medical Center,8292145,CORNEA HYSTERESIS DETERMIN IMPULSE STIMJ UNI/BI,,92145,510,$125.00 ,$125.00 ,$37.50 ,$113.75 ,$87.50 ,$37.50 ,$81.25 ,$90.00 ,$113.75 ,$93.75 
Carle BroMenn Medical Center,8292229,IMG RETINA DETCJ/MNTR DS POC AUTO A/R UNI/BI,,92229,510,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8292504,EAR MICROSCOPY EXAMINATION,,92504,510,$98.00 ,$98.00 ,$29.40 ,$89.18 ,$68.60 ,$29.40 ,$63.70 ,$70.56 ,$89.18 ,$73.50 
Carle BroMenn Medical Center,8292511,NASOPHARYNGOSCOPY,,92511,510,$315.00 ,$315.00 ,$94.50 ,$286.65 ,$220.50 ,$94.50 ,$204.75 ,$226.80 ,$286.65 ,$236.25 
Carle BroMenn Medical Center,8292517,CERVICAL VEMP TESTING W/I&R,,92517,510,$365.00 ,$365.00 ,$109.50 ,$332.15 ,$255.50 ,$109.50 ,$237.25 ,$262.80 ,$332.15 ,$273.75 
Carle BroMenn Medical Center,8292518,OCULAR VEMP TESTING W/I&R,,92518,510,$365.00 ,$365.00 ,$109.50 ,$332.15 ,$255.50 ,$109.50 ,$237.25 ,$262.80 ,$332.15 ,$273.75 
Carle BroMenn Medical Center,8292519,CERVICAL & OCULAR VEMP TESTING W/I&R,,92519,510,$690.00 ,$690.00 ,$207.00 ,$627.90 ,$483.00 ,$207.00 ,$448.50 ,$496.80 ,$627.90 ,$517.50 
Carle BroMenn Medical Center,8292650,AEP SCR AUDITORY POTENTIAL W/STIMULI AUTO ALYS,,92650,510,$140.00 ,$140.00 ,$42.00 ,$127.40 ,$98.00 ,$42.00 ,$91.00 ,$100.80 ,$127.40 ,$105.00 
Carle BroMenn Medical Center,8292651,AEP HEARING STATUS DETER BROADBAND STIMULI I&R,,92651,510,$81.00 ,$81.00 ,$24.30 ,$73.71 ,$56.70 ,$24.30 ,$52.65 ,$58.32 ,$73.71 ,$60.75 
Carle BroMenn Medical Center,8292652,AEP THRESHOLD ESTIMATION MLT FREQUENCIES I&R,,92652,510,$850.00 ,$850.00 ,$255.00 ,$773.50 ,$595.00 ,$255.00 ,$552.50 ,$612.00 ,$773.50 ,$637.50 
Carle BroMenn Medical Center,8292653,AEP NEURODIAGNOSTIC INTERPRETATION AND REPORT,,92653,510,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8292960,"CARDIOVERSION, ELECTIVE;EXTERN",,92960,510,"$1,590.00 ","$1,590.00 ",$477.00 ,"$1,446.90 ","$1,113.00 ",$477.00 ,"$1,033.50 ","$1,144.80 ","$1,446.90 ","$1,192.50 "
Carle BroMenn Medical Center,8293242,EXTERNAL ECG REC>48HR<7D RECORDING,,93242,510,$160.00 ,$160.00 ,$48.00 ,$145.60 ,$112.00 ,$48.00 ,$104.00 ,$115.20 ,$145.60 ,$120.00 
Carle BroMenn Medical Center,8293243,EXTERNAL ECG REC>48HR<7D SCANNING ALYS W/REPORT,,93243,510,$255.00 ,$255.00 ,$76.50 ,$232.05 ,$178.50 ,$76.50 ,$165.75 ,$183.60 ,$232.05 ,$191.25 
Carle BroMenn Medical Center,8293246,EXTERNAL ECG REC>7D<15D RECORDING,,93246,510,$255.00 ,$255.00 ,$76.50 ,$232.05 ,$178.50 ,$76.50 ,$165.75 ,$183.60 ,$232.05 ,$191.25 
Carle BroMenn Medical Center,8293247,EXTERNAL ECG REC>7D<15D SCANNING ALYS W/REPORT,,93247,510,$510.00 ,$510.00 ,$153.00 ,$464.10 ,$357.00 ,$153.00 ,$331.50 ,$367.20 ,$464.10 ,$382.50 
Carle BroMenn Medical Center,8293668,"PERIPHERAL ART DISEASE REHAB, EA",,93668,510,$83.00 ,$83.00 ,$24.90 ,$75.53 ,$58.10 ,$24.90 ,$53.95 ,$59.76 ,$75.53 ,$62.25 
Carle BroMenn Medical Center,8293702,BIS EXTRACELLULAR FLUID ALYS LYMPHEDEMA ASSMNT,,93702,510,$530.00 ,$530.00 ,$159.00 ,$482.30 ,$371.00 ,$159.00 ,$344.50 ,$381.60 ,$482.30 ,$397.50 
Carle BroMenn Medical Center,8293792,PT/CAREGIVER TRAINJ FOR INITIATION HOME INR MNTR,,93792,510,$57.00 ,$57.00 ,$17.10 ,$51.87 ,$39.90 ,$17.10 ,$37.05 ,$41.04 ,$51.87 ,$42.75 
Carle BroMenn Medical Center,8294619,XERS TST BRNCSPSM PRE&POST SPMTRY&PLS OX WO /ECG,,94619,510,$32.00 ,$32.00 ,$9.60 ,$29.12 ,$22.40 ,$9.60 ,$20.80 ,$23.04 ,$29.12 ,$24.00 
Carle BroMenn Medical Center,8295115,"IMMUNOTHERAPY, ONE INJECTION",,95115,510,$48.00 ,$48.00 ,$14.40 ,$43.68 ,$33.60 ,$14.40 ,$31.20 ,$34.56 ,$43.68 ,$36.00 
Carle BroMenn Medical Center,8295117,"IMMUNOTHERAPY, 2+ INJECTIONS",,95117,510,$69.00 ,$69.00 ,$20.70 ,$62.79 ,$48.30 ,$20.70 ,$44.85 ,$49.68 ,$62.79 ,$51.75 
Carle BroMenn Medical Center,8295976,ELEC ALYS IMPLT SMPL CN NPGT PRGRMG,,95976,510,$98.00 ,$98.00 ,$29.40 ,$89.18 ,$68.60 ,$29.40 ,$63.70 ,$70.56 ,$89.18 ,$73.50 
Carle BroMenn Medical Center,8296040,"GENETIC COUNSELING, EACH 30 MIN",,96040,510,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8296160,ADMIN PT FCSD RISK ASSESS INSTRUMENT,,96160,510,$59.00 ,$59.00 ,$17.70 ,$53.69 ,$41.30 ,$17.70 ,$38.35 ,$42.48 ,$53.69 ,$44.25 
Carle BroMenn Medical Center,8296161,ADMIN CAREGIVER FCSD RISK ASSESS INSTRUMENT,,96161,510,$59.00 ,$59.00 ,$17.70 ,$53.69 ,$41.30 ,$17.70 ,$38.35 ,$42.48 ,$53.69 ,$44.25 
Carle BroMenn Medical Center,8296360,HYDRATION IV INFUSION INIT,,96360,510,$430.00 ,$430.00 ,$129.00 ,$391.30 ,$301.00 ,$129.00 ,$279.50 ,$309.60 ,$391.30 ,$322.50 
Carle BroMenn Medical Center,8296361,HYDRATE IV INFUSION ADD-ON,,96361,510,$138.00 ,$138.00 ,$41.40 ,$125.58 ,$96.60 ,$41.40 ,$89.70 ,$99.36 ,$125.58 ,$103.50 
Carle BroMenn Medical Center,8296365,THER/PROPH/DIAG IV INF INIT,,96365,510,$635.00 ,$635.00 ,$190.50 ,$577.85 ,$444.50 ,$190.50 ,$412.75 ,$457.20 ,$577.85 ,$476.25 
Carle BroMenn Medical Center,8296366,THER/PROPH/DIAG IV INF EA ADD HR,,96366,510,$170.00 ,$170.00 ,$51.00 ,$154.70 ,$119.00 ,$51.00 ,$110.50 ,$122.40 ,$154.70 ,$127.50 
Carle BroMenn Medical Center,8296367,TX/PROPH/DG ADDL SEQ IV INF,,96367,510,$191.00 ,$191.00 ,$57.30 ,$173.81 ,$133.70 ,$57.30 ,$124.15 ,$137.52 ,$173.81 ,$143.25 
Carle BroMenn Medical Center,8296368,IV INFUSION CONCURRENT,,96368,510,$385.00 ,$385.00 ,$115.50 ,$350.35 ,$269.50 ,$115.50 ,$250.25 ,$277.20 ,$350.35 ,$288.75 
Carle BroMenn Medical Center,8296369,"SUBCUT INFUSION, THERAP/PROPH/DIAGNOST,INITIAL,1ST HOUR",,96369,510,$353.00 ,$353.00 ,$105.90 ,$321.23 ,$247.10 ,$105.90 ,$229.45 ,$254.16 ,$321.23 ,$264.75 
Carle BroMenn Medical Center,8296370,"SUBCUT INFUSION, THERAP/PROPH/DIAGNOST,EA ADD HOUR",,96370,510,$98.00 ,$98.00 ,$29.40 ,$89.18 ,$68.60 ,$29.40 ,$63.70 ,$70.56 ,$89.18 ,$73.50 
Carle BroMenn Medical Center,8296371,"SUBCUT INFUSION, THERAP/PROPH/DIAGNOST,ADD PUMP SET",,96371,510,$113.00 ,$113.00 ,$33.90 ,$102.83 ,$79.10 ,$33.90 ,$73.45 ,$81.36 ,$102.83 ,$84.75 
Carle BroMenn Medical Center,8296372,THER/PROPH/DIAG INJ SC/IM,,96372,510,$155.00 ,$155.00 ,$46.50 ,$141.05 ,$108.50 ,$46.50 ,$100.75 ,$111.60 ,$141.05 ,$116.25 
Carle BroMenn Medical Center,8296373,"INJECTION,THERAP/PROPH/DIAGNOST, INTRA-ARTERIAL",,96373,510,$230.00 ,$230.00 ,$69.00 ,$209.30 ,$161.00 ,$69.00 ,$149.50 ,$165.60 ,$209.30 ,$172.50 
Carle BroMenn Medical Center,8296374,THER/PROPH/DIAG INJ IV PUSH,,96374,510,$380.00 ,$380.00 ,$114.00 ,$345.80 ,$266.00 ,$114.00 ,$247.00 ,$273.60 ,$345.80 ,$285.00 
Carle BroMenn Medical Center,8296375,TX/PRO/DX INJ NEW DRUG ADDON,,96375,510,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8296376,IV PUSH EA ADD SAME DRUG,,96376,510,$153.00 ,$153.00 ,$45.90 ,$139.23 ,$107.10 ,$45.90 ,$99.45 ,$110.16 ,$139.23 ,$114.75 
Carle BroMenn Medical Center,8296377,APPL ON-BODY INJECTOR FOR TIMED SUBQ INJ,,96377,510,$190.00 ,$190.00 ,$57.00 ,$172.90 ,$133.00 ,$57.00 ,$123.50 ,$136.80 ,$172.90 ,$142.50 
Carle BroMenn Medical Center,8296379,INIT PROLONG INFUSN REQ PUMP,,96379,510,$368.00 ,$368.00 ,$110.40 ,$334.88 ,$257.60 ,$110.40 ,$239.20 ,$264.96 ,$334.88 ,$276.00 
Carle BroMenn Medical Center,8296405,"INTRALESIONAL CHEMO ADMIN,<8 LESN",,96405,510,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8296406,"INTRALESIONAL CHEMO ADMIN,8+ LESN",,96406,510,$311.00 ,$311.00 ,$93.30 ,$283.01 ,$217.70 ,$93.30 ,$202.15 ,$223.92 ,$283.01 ,$233.25 
Carle BroMenn Medical Center,8296521,REFILL/MAINT PORTABLE PUMP,,96521,510,$750.00 ,$750.00 ,$225.00 ,$682.50 ,$525.00 ,$225.00 ,$487.50 ,$540.00 ,$682.50 ,$562.50 
Carle BroMenn Medical Center,8296522,REFILL & MAINT IMPLNTD PUMP,,96522,510,$638.00 ,$638.00 ,$191.40 ,$580.58 ,$446.60 ,$191.40 ,$414.70 ,$459.36 ,$580.58 ,$478.50 
Carle BroMenn Medical Center,8296523,IRRIG DRUG DELIVERY DEVICE,,96523,510,$190.00 ,$190.00 ,$57.00 ,$172.90 ,$133.00 ,$57.00 ,$123.50 ,$136.80 ,$172.90 ,$142.50 
Carle BroMenn Medical Center,8296567,EXT PHOTODYNAMIC THERAPY,,96567,510,$820.00 ,$820.00 ,$246.00 ,$746.20 ,$574.00 ,$246.00 ,$533.00 ,$590.40 ,$746.20 ,$615.00 
Carle BroMenn Medical Center,8296573,PDT DSTR PRMLG LES SKN ILLUM/ACTIVJ BY PHYS/QHP,,96573,510,$960.00 ,$960.00 ,$288.00 ,$873.60 ,$672.00 ,$288.00 ,$624.00 ,$691.20 ,$873.60 ,$720.00 
Carle BroMenn Medical Center,8296574,DEBRIDEMENT PRMLG HYPERKERATOTIC LES W/PDT,,96574,510,$960.00 ,$960.00 ,$288.00 ,$873.60 ,$672.00 ,$288.00 ,$624.00 ,$691.20 ,$873.60 ,$720.00 
Carle BroMenn Medical Center,8296910,PHOTOCHEMOTHERAPY WITH UV-B,,96910,510,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8297003,OCCUPATIONAL THERAPY EVAL,,97161,510,$315.00 ,$315.00 ,$94.50 ,$286.65 ,$220.50 ,$94.50 ,$204.75 ,$226.80 ,$286.65 ,$236.25 
Carle BroMenn Medical Center,8297127,THERAPEUTIC IVNTJ W/FOCUS ON COGNITIVE FUNCTION,,97127,510,$91.00 ,$91.00 ,$27.30 ,$82.81 ,$63.70 ,$27.30 ,$59.15 ,$65.52 ,$82.81 ,$68.25 
Carle BroMenn Medical Center,8297129,THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES,,97129,510,$185.00 ,$185.00 ,$55.50 ,$168.35 ,$129.50 ,$55.50 ,$120.25 ,$133.20 ,$168.35 ,$138.75 
Carle BroMenn Medical Center,8297130,THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES,,97130,510,$185.00 ,$185.00 ,$55.50 ,$168.35 ,$129.50 ,$55.50 ,$120.25 ,$133.20 ,$168.35 ,$138.75 
Carle BroMenn Medical Center,8297597,SELECTIVE DEBRIDEMNT < 20SQ CM,,97597,510,$415.00 ,$415.00 ,$124.50 ,$377.65 ,$290.50 ,$124.50 ,$269.75 ,$298.80 ,$377.65 ,$311.25 
Carle BroMenn Medical Center,8297598,SELECTIVE DEBRIDEMNT > 20SQ CM,,97598,510,$280.00 ,$280.00 ,$84.00 ,$254.80 ,$196.00 ,$84.00 ,$182.00 ,$201.60 ,$254.80 ,$210.00 
Carle BroMenn Medical Center,8297602,"WOUND DEBRIDEMENT, NON-SELECTIVE, EA",,97602,510,$415.00 ,$415.00 ,$124.50 ,$377.65 ,$290.50 ,$124.50 ,$269.75 ,$298.80 ,$377.65 ,$311.25 
Carle BroMenn Medical Center,8297605,WOUND TREATMENT (VAC) W/DME </=50SQ CM,,97605,510,$340.00 ,$340.00 ,$102.00 ,$309.40 ,$238.00 ,$102.00 ,$221.00 ,$244.80 ,$309.40 ,$255.00 
Carle BroMenn Medical Center,8297606,WOUND TREATMENT (VAC) W/DME > 50SQCM W/DME,,97606,510,$790.00 ,$790.00 ,$237.00 ,$718.90 ,$553.00 ,$237.00 ,$513.50 ,$568.80 ,$718.90 ,$592.50 
Carle BroMenn Medical Center,8297607,NEG PRESSURE WOUND THERAPY NON DME </= 50 SQ CM,,97607,510,$415.00 ,$415.00 ,$124.50 ,$377.65 ,$290.50 ,$124.50 ,$269.75 ,$298.80 ,$377.65 ,$311.25 
Carle BroMenn Medical Center,8297608,NEG PRESSURE WOUND THERAPY NON DME >50 SQ CM,,97608,510,$760.00 ,$760.00 ,$228.00 ,$691.60 ,$532.00 ,$228.00 ,$494.00 ,$547.20 ,$691.60 ,$570.00 
Carle BroMenn Medical Center,8299188,APPL TOPICAL FLUORIDE VARNISH BY PHYS/QHP,,99188,510,$20.00 ,$20.00 ,$6.00 ,$18.20 ,$14.00 ,$6.00 ,$13.00 ,$14.40 ,$18.20 ,$15.00 
Carle BroMenn Medical Center,8299201,"OFFICE/OP VISIT, NEW, BRIEF",,G0463,510,$125.00 ,$125.00 ,$37.50 ,$113.75 ,$87.50 ,$37.50 ,$81.25 ,$90.00 ,$113.75 ,$93.75 
Carle BroMenn Medical Center,8299202,"OFFICE/OP VISIT, NEW, LIMITED",,G0463,510,$175.00 ,$175.00 ,$52.50 ,$159.25 ,$122.50 ,$52.50 ,$113.75 ,$126.00 ,$159.25 ,$131.25 
Carle BroMenn Medical Center,8299203,"OFFICE/OP VISIT, NEW, INTERMED",,G0463,510,$225.00 ,$225.00 ,$67.50 ,$204.75 ,$157.50 ,$67.50 ,$146.25 ,$162.00 ,$204.75 ,$168.75 
Carle BroMenn Medical Center,8299204,"OFFICE/OP VISIT, NEW, EXTENDED",,G0463,510,$250.00 ,$250.00 ,$75.00 ,$227.50 ,$175.00 ,$75.00 ,$162.50 ,$180.00 ,$227.50 ,$187.50 
Carle BroMenn Medical Center,8299205,"OFFICE/OP VISIT, NEW, COMPLEX",,G0463,510,$315.00 ,$315.00 ,$94.50 ,$286.65 ,$220.50 ,$94.50 ,$204.75 ,$226.80 ,$286.65 ,$236.25 
Carle BroMenn Medical Center,8299211,"OFFICE/OP VISIT, EST, BRIEF",,G0463,510,$125.00 ,$125.00 ,$37.50 ,$113.75 ,$87.50 ,$37.50 ,$81.25 ,$90.00 ,$113.75 ,$93.75 
Carle BroMenn Medical Center,8299212,"OFFICE/OP VISIT, EST, LIMITED",,G0463,510,$175.00 ,$175.00 ,$52.50 ,$159.25 ,$122.50 ,$52.50 ,$113.75 ,$126.00 ,$159.25 ,$131.25 
Carle BroMenn Medical Center,8299213,"OFFICE/OP VISIT, EST, INTERMED",,G0463,510,$225.00 ,$225.00 ,$67.50 ,$204.75 ,$157.50 ,$67.50 ,$146.25 ,$162.00 ,$204.75 ,$168.75 
Carle BroMenn Medical Center,8299214,"OFFICE/OP VISIT, EST, EXTENDED",,G0463,510,$250.00 ,$250.00 ,$75.00 ,$227.50 ,$175.00 ,$75.00 ,$162.50 ,$180.00 ,$227.50 ,$187.50 
Carle BroMenn Medical Center,8299215,"OFFICE/OP VISIT, EST, COMPLEX",,G0463,510,$315.00 ,$315.00 ,$94.50 ,$286.65 ,$220.50 ,$94.50 ,$204.75 ,$226.80 ,$286.65 ,$236.25 
Carle BroMenn Medical Center,8299354,"PROLONGED SERV,OFFICE,1ST HR",,99354,510,$320.00 ,$320.00 ,$96.00 ,$291.20 ,$224.00 ,$96.00 ,$208.00 ,$230.40 ,$291.20 ,$240.00 
Carle BroMenn Medical Center,8299355,"PROLONGED SERV,OFFICE,EA ADD 30 MIN",,99355,510,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8299358,PROLNG E/M SVC BEFORE&/AFTER DIR PT CARE 1ST HR,,99358,510,$170.00 ,$170.00 ,$51.00 ,$154.70 ,$119.00 ,$51.00 ,$110.50 ,$122.40 ,$154.70 ,$127.50 
Carle BroMenn Medical Center,8299366,"MED TEAM CONF W/PATIENT PRESENT, 30 MIN OR >",,99366,510,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8299400,FEE FOR SERVICE NAIL CARE,,,510,$36.00 ,$36.00 ,$10.80 ,$32.76 ,$25.20 ,$10.80 ,$23.40 ,$25.92 ,$32.76 ,$27.00 
Carle BroMenn Medical Center,8299401,"PREVENT COUNSEL,INDIV,15 MIN",,99401,510,$115.00 ,$115.00 ,$34.50 ,$104.65 ,$80.50 ,$34.50 ,$74.75 ,$82.80 ,$104.65 ,$86.25 
Carle BroMenn Medical Center,8299402,"PREVENT COUNSEL,INDIV,30 MIN",,99402,510,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8299403,"PREVENT COUNSEL,INDIV,45 MIN",,99403,510,$195.00 ,$195.00 ,$58.50 ,$177.45 ,$136.50 ,$58.50 ,$126.75 ,$140.40 ,$177.45 ,$146.25 
Carle BroMenn Medical Center,8299404,"PREVENT COUNSEL,INDIV,60 MIN",,99404,510,$265.00 ,$265.00 ,$79.50 ,$241.15 ,$185.50 ,$79.50 ,$172.25 ,$190.80 ,$241.15 ,$198.75 
Carle BroMenn Medical Center,8299408,ALCOHOL AND/OR NON-TOBACCO SUBST ABUSE SCREEN/INTRVN 15-30 MIN,,G0396,510,$115.00 ,$115.00 ,$34.50 ,$104.65 ,$80.50 ,$34.50 ,$74.75 ,$82.80 ,$104.65 ,$86.25 
Carle BroMenn Medical Center,8299409,ALCOHOL AND/OR NON-TOBACCO SUBST ABUSE SCREEN/INTRVN >30 MIN,,G0397,510,$115.00 ,$115.00 ,$34.50 ,$104.65 ,$80.50 ,$34.50 ,$74.75 ,$82.80 ,$104.65 ,$86.25 
Carle BroMenn Medical Center,8299411,"PREVENT COUNSEL, GROUP, 30 MIN",,99411,510,$81.00 ,$81.00 ,$24.30 ,$73.71 ,$56.70 ,$24.30 ,$52.65 ,$58.32 ,$73.71 ,$60.75 
Carle BroMenn Medical Center,8299412,"PREVENT COUNSEL,GROUP,60 MIN",,99412,510,$110.00 ,$110.00 ,$33.00 ,$100.10 ,$77.00 ,$33.00 ,$71.50 ,$79.20 ,$100.10 ,$82.50 
Carle BroMenn Medical Center,8299417,PROLONGED OFFICE/OUTPATIENT E/M SVC EA 15 MIN,,99417,510,$125.00 ,$125.00 ,$37.50 ,$113.75 ,$87.50 ,$37.50 ,$81.25 ,$90.00 ,$113.75 ,$93.75 
Carle BroMenn Medical Center,8299439,CHRONIC CARE MANAGEMENT SERVICES EA ADDL 20 MIN,,99439,510,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8299451,NTRPROF PHONE/NTRNET/EHR ASSMT&MGMT 5/> MIN,,99451,510,$52.00 ,$52.00 ,$15.60 ,$47.32 ,$36.40 ,$15.60 ,$33.80 ,$37.44 ,$47.32 ,$39.00 
Carle BroMenn Medical Center,8299452,NTRPROF PHONE/NTRNET/EHR REFERRAL SVC 30 MIN,,99452,510,$52.00 ,$52.00 ,$15.60 ,$47.32 ,$36.40 ,$15.60 ,$33.80 ,$37.44 ,$47.32 ,$39.00 
Carle BroMenn Medical Center,8299457,REMOTE PHYSIOLOGIC MONITORING 20 MIN+ PER MONTH,,99457,510,$110.00 ,$110.00 ,$33.00 ,$100.10 ,$77.00 ,$33.00 ,$71.50 ,$79.20 ,$100.10 ,$82.50 
Carle BroMenn Medical Center,8299458,REMOTE PHYSIOLOGIC MONITORING EA ADDL 20 MIN MO,,99458,510,$110.00 ,$110.00 ,$33.00 ,$100.10 ,$77.00 ,$33.00 ,$71.50 ,$79.20 ,$100.10 ,$82.50 
Carle BroMenn Medical Center,8299483,ASSMT & CARE PLANNING PT W/COGNITIVE IMPAIRMENT,,99483,510,$115.00 ,$115.00 ,$34.50 ,$104.65 ,$80.50 ,$34.50 ,$74.75 ,$82.80 ,$104.65 ,$86.25 
Carle BroMenn Medical Center,8299484,CARE MGMT SERVICES BEHAVIORAL HLTH COND 20 MINS,,99484,510,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8299487,CMPLX CHRON CARE MGMT W/O PT VST 1ST HR PER MO,,99487,510,$260.00 ,$260.00 ,$78.00 ,$236.60 ,$182.00 ,$78.00 ,$169.00 ,$187.20 ,$236.60 ,$195.00 
Carle BroMenn Medical Center,8299489,CMPLX CHRON CARE MGMT EA ADDL 30 MIN PER MONTH,,99489,510,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8299490,CHRON CARE MANAGEMENT SRVC 20 MIN PER MONTH,,99490,510,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8299491,CHRONIC CARE MGMT SVC AT LEAST 30 MIN PER MONTH,,99491,510,$140.00 ,$140.00 ,$42.00 ,$127.40 ,$98.00 ,$42.00 ,$91.00 ,$100.80 ,$127.40 ,$105.00 
Carle BroMenn Medical Center,8299492,1ST PSYCHIATRIC COLLAB CARE MGMT 1ST 70 MINS,,99492,510,$265.00 ,$265.00 ,$79.50 ,$241.15 ,$185.50 ,$79.50 ,$172.25 ,$190.80 ,$241.15 ,$198.75 
Carle BroMenn Medical Center,8299493,SBSQ PSYCHIATRIC COLLAB CARE MGMT 1ST 60 MINS,,99493,510,$250.00 ,$250.00 ,$75.00 ,$227.50 ,$175.00 ,$75.00 ,$162.50 ,$180.00 ,$227.50 ,$187.50 
Carle BroMenn Medical Center,8299494,1ST/SBSQ PSYCH COLLAB CARE MGMT EA ADDL 30 MINS,,99494,510,$135.00 ,$135.00 ,$40.50 ,$122.85 ,$94.50 ,$40.50 ,$87.75 ,$97.20 ,$122.85 ,$101.25 
Carle BroMenn Medical Center,8299495,TRANSITIONAL CARE MANAGE SERVICE 14 DAY DISCHRGE,,99495,510,$295.00 ,$295.00 ,$88.50 ,$268.45 ,$206.50 ,$88.50 ,$191.75 ,$212.40 ,$268.45 ,$221.25 
Carle BroMenn Medical Center,8299496,TRANSITIONAL CARE MANAGE SERVICE 7 DAY DISCHARGE,,99496,510,$295.00 ,$295.00 ,$88.50 ,$268.45 ,$206.50 ,$88.50 ,$191.75 ,$212.40 ,$268.45 ,$221.25 
Carle BroMenn Medical Center,8299497,ADVANCE CARE PLANNING FIRST 30 MINS,,99497,510,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8299498,ADVANCE CARE PLANNING EA ADDL 30 MINS,,99498,510,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8299626,MULTIPLE DISCIPLINE VISIT,,G0463,510,$275.00 ,$275.00 ,$82.50 ,$250.25 ,$192.50 ,$82.50 ,$178.75 ,$198.00 ,$250.25 ,$206.25 
Carle BroMenn Medical Center,8299647,OCT TEST,,,510,$88.00 ,$88.00 ,$26.40 ,$80.08 ,$61.60 ,$26.40 ,$57.20 ,$63.36 ,$80.08 ,$66.00 
Carle BroMenn Medical Center,8299648,TOPOGRAPHY TEST,,,510,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8299779,EXOFIN,,G0168,510,$34.00 ,$34.00 ,$10.20 ,$30.94 ,$23.80 ,$10.20 ,$22.10 ,$24.48 ,$30.94 ,$25.50 
Carle BroMenn Medical Center,8610011,PT CHRONIC WOUND CLINIC,,,510,$53.00 ,$53.00 ,$15.90 ,$48.23 ,$37.10 ,$15.90 ,$34.45 ,$38.16 ,$48.23 ,$39.75 
Carle BroMenn Medical Center,8629211,"OFFICE/OP VISIT, EST, BRIEF",,G0463,510,$125.00 ,$125.00 ,$37.50 ,$113.75 ,$87.50 ,$37.50 ,$81.25 ,$90.00 ,$113.75 ,$93.75 
Carle BroMenn Medical Center,8629212,"OFFICE/OP VISIT, EST, LIMITED",,G0463,510,$175.00 ,$175.00 ,$52.50 ,$159.25 ,$122.50 ,$52.50 ,$113.75 ,$126.00 ,$159.25 ,$131.25 
Carle BroMenn Medical Center,8629213,"OFFICE/OP VISIT, EST, INTERMED",,G0463,510,$225.00 ,$225.00 ,$67.50 ,$204.75 ,$157.50 ,$67.50 ,$146.25 ,$162.00 ,$204.75 ,$168.75 
Carle BroMenn Medical Center,8800300,APP OF BURN DRESSINGS,,,510,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8816360,HYDRATION IV INFUSN UP TO 1HR,,96360,510,$430.00 ,$430.00 ,$129.00 ,$391.30 ,$301.00 ,$129.00 ,$279.50 ,$309.60 ,$391.30 ,$322.50 
Carle BroMenn Medical Center,8816361,HYDRATION IV INFUSN EA ADNL HR,,96361,510,$138.00 ,$138.00 ,$41.40 ,$125.58 ,$96.60 ,$41.40 ,$89.70 ,$99.36 ,$125.58 ,$103.50 
Carle BroMenn Medical Center,8816365,IV INFUSION -UP TO 1HR,,96365,510,$635.00 ,$635.00 ,$190.50 ,$577.85 ,$444.50 ,$190.50 ,$412.75 ,$457.20 ,$577.85 ,$476.25 
Carle BroMenn Medical Center,8816366,IV INFUSION -EA ADNL HR,,96366,510,$170.00 ,$170.00 ,$51.00 ,$154.70 ,$119.00 ,$51.00 ,$110.50 ,$122.40 ,$154.70 ,$127.50 
Carle BroMenn Medical Center,8816367,IV INFUSION SEQ -UP TO 1HR,,96367,510,$191.00 ,$191.00 ,$57.30 ,$173.81 ,$133.70 ,$57.30 ,$124.15 ,$137.52 ,$173.81 ,$143.25 
Carle BroMenn Medical Center,8816372,INJECTION -SUBCUTAN/INTRAMUSC,,96372,510,$155.00 ,$155.00 ,$46.50 ,$141.05 ,$108.50 ,$46.50 ,$100.75 ,$111.60 ,$141.05 ,$116.25 
Carle BroMenn Medical Center,8816374,IV PUSH -SINGLE/INITIAL,,96374,510,$380.00 ,$380.00 ,$114.00 ,$345.80 ,$266.00 ,$114.00 ,$247.00 ,$273.60 ,$345.80 ,$285.00 
Carle BroMenn Medical Center,8816375,IV PUSH -EA ADNL NEW DRUG,,96375,510,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8816379,INIT PROLONG INFUSN REQ PUMP,,96379,510,$368.00 ,$368.00 ,$110.40 ,$334.88 ,$257.60 ,$110.40 ,$239.20 ,$264.96 ,$334.88 ,$276.00 
Carle BroMenn Medical Center,8819211,EUREKA COLLEGE BASIC SERVICE,,99211,510,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8859020,FETAL CONTRACT STRESS TEST,,59020,510,$760.00 ,$760.00 ,$228.00 ,$691.60 ,$532.00 ,$228.00 ,$494.00 ,$547.20 ,$691.60 ,$570.00 
Carle BroMenn Medical Center,8859025,FETAL NON-STRESS TEST,,59025,510,$675.00 ,$675.00 ,$202.50 ,$614.25 ,$472.50 ,$202.50 ,$438.75 ,$486.00 ,$614.25 ,$506.25 
Carle BroMenn Medical Center,8890376,IV PUSH -EA ADNL SAME DRUG,,96376,510,$153.00 ,$153.00 ,$45.90 ,$139.23 ,$107.10 ,$45.90 ,$99.45 ,$110.16 ,$139.23 ,$114.75 
Carle BroMenn Medical Center,8899195,PHLEBTOMY,,99195,510,$250.00 ,$250.00 ,$75.00 ,$227.50 ,$175.00 ,$75.00 ,$162.50 ,$180.00 ,$227.50 ,$187.50 
Carle BroMenn Medical Center,8899201,NON-EMERGENT CARE LVL 1 NEW PT,,99201,510,$175.00 ,$175.00 ,$52.50 ,$159.25 ,$122.50 ,$52.50 ,$113.75 ,$126.00 ,$159.25 ,$131.25 
Carle BroMenn Medical Center,8899202,NON-EMERGENT CARE LVL 2 NEW PT,,99202,510,$250.00 ,$250.00 ,$75.00 ,$227.50 ,$175.00 ,$75.00 ,$162.50 ,$180.00 ,$227.50 ,$187.50 
Carle BroMenn Medical Center,8899203,NON-EMERGENT CARE LVL 3 NEW PT,,99203,510,$325.00 ,$325.00 ,$97.50 ,$295.75 ,$227.50 ,$97.50 ,$211.25 ,$234.00 ,$295.75 ,$243.75 
Carle BroMenn Medical Center,8899204,NON-EMERGENT CARE LVL 4 NEW PT,,99204,510,$425.00 ,$425.00 ,$127.50 ,$386.75 ,$297.50 ,$127.50 ,$276.25 ,$306.00 ,$386.75 ,$318.75 
Carle BroMenn Medical Center,8899205,NON-EMERGENT CARE LVL 5 NEW PT,,99205,510,$525.00 ,$525.00 ,$157.50 ,$477.75 ,$367.50 ,$157.50 ,$341.25 ,$378.00 ,$477.75 ,$393.75 
Carle BroMenn Medical Center,8899210,OB TRIAGE SERVICES,,99211,510,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8899211,NON-EMERGENT CARE LVL 1 EST PT,,99211,510,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8899212,NON-EMERGENT CARE LVL 2 EST PT,,99212,510,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8899213,NON-EMERGENT CARE LVL 3 EST PT,,99213,510,$240.00 ,$240.00 ,$72.00 ,$218.40 ,$168.00 ,$72.00 ,$156.00 ,$172.80 ,$218.40 ,$180.00 
Carle BroMenn Medical Center,8899214,NON-EMERGENT CARE LVL 4 EST PT,,99214,510,$275.00 ,$275.00 ,$82.50 ,$250.25 ,$192.50 ,$82.50 ,$178.75 ,$198.00 ,$250.25 ,$206.25 
Carle BroMenn Medical Center,8899215,NON-EMERGENT CARE LVL 5 EST PT,,99215,510,$315.00 ,$315.00 ,$94.50 ,$286.65 ,$220.50 ,$94.50 ,$204.75 ,$226.80 ,$286.65 ,$236.25 
Carle BroMenn Medical Center,8899395,EUREKA COLLEGE SPORTS SERVICE,,99395,510,$65.00 ,$65.00 ,$19.50 ,$59.15 ,$45.50 ,$19.50 ,$42.25 ,$46.80 ,$59.15 ,$48.75 
Carle BroMenn Medical Center,8910060,I&D ABSCESS-SIMPLE/SINGLE,,10060,510,$675.00 ,$675.00 ,$202.50 ,$614.25 ,$472.50 ,$202.50 ,$438.75 ,$486.00 ,$614.25 ,$506.25 
Carle BroMenn Medical Center,8910061,I & D ABSC COMPLICATED /MULTI,,10061,510,"$1,155.00 ","$1,155.00 ",$346.50 ,"$1,051.05 ",$808.50 ,$346.50 ,$750.75 ,$831.60 ,"$1,051.05 ",$866.25 
Carle BroMenn Medical Center,8910140,"I&D HEMATOMA, SEROMA, FLUID",,10140,510,"$3,160.00 ","$3,160.00 ",$948.00 ,"$2,875.60 ","$2,212.00 ",$948.00 ,"$2,054.00 ","$2,275.20 ","$2,875.60 ","$2,370.00 "
Carle BroMenn Medical Center,8910160,PUNCTURE DRAINAGE OF LESION,,10160,510,$605.00 ,$605.00 ,$181.50 ,$550.55 ,$423.50 ,$181.50 ,$393.25 ,$435.60 ,$550.55 ,$453.75 
Carle BroMenn Medical Center,8910220,BIOPSY-BONE SUPERFICIAL,,20220,510,"$1,715.00 ","$1,715.00 ",$514.50 ,"$1,560.65 ","$1,200.50 ",$514.50 ,"$1,114.75 ","$1,234.80 ","$1,560.65 ","$1,286.25 "
Carle BroMenn Medical Center,8910225,BIOPSY-BONE DEEP,,20225,510,"$2,307.50 ","$2,307.50 ",$692.25 ,"$2,099.83 ","$1,615.25 ",$692.25 ,"$1,499.88 ","$1,661.40 ","$2,099.83 ","$1,730.63 "
Carle BroMenn Medical Center,8911042,DEBRID SKN & SUBQ <OR=20SQCM,,11042,510,$965.00 ,$965.00 ,$289.50 ,$878.15 ,$675.50 ,$289.50 ,$627.25 ,$694.80 ,$878.15 ,$723.75 
Carle BroMenn Medical Center,8911043,DEBRID SKN THRU MUSCL<OR=20SQ,,11043,510,"$1,495.00 ","$1,495.00 ",$448.50 ,"$1,360.45 ","$1,046.50 ",$448.50 ,$971.75 ,"$1,076.40 ","$1,360.45 ","$1,121.25 "
Carle BroMenn Medical Center,8911044,DEBRID SKN THRU BONE<OR=20SQ,,11044,510,"$4,080.00 ","$4,080.00 ","$1,224.00 ","$3,712.80 ","$2,856.00 ","$1,224.00 ","$2,652.00 ","$2,937.60 ","$3,712.80 ","$3,060.00 "
Carle BroMenn Medical Center,8911045,DEBRID SKIN/SUBQ EA ADD20SQ,,11045,510,$410.00 ,$410.00 ,$123.00 ,$373.10 ,$287.00 ,$123.00 ,$266.50 ,$295.20 ,$373.10 ,$307.50 
Carle BroMenn Medical Center,8911046,DEBRIDE SKIN/MCSL EA ADD20SQ,,11046,510,$410.00 ,$410.00 ,$123.00 ,$373.10 ,$287.00 ,$123.00 ,$266.50 ,$295.20 ,$373.10 ,$307.50 
Carle BroMenn Medical Center,8911047,DEBRIDE SKIN/BONE EA ADD20SQCM,,11047,510,"$1,410.00 ","$1,410.00 ",$423.00 ,"$1,283.10 ",$987.00 ,$423.00 ,$916.50 ,"$1,015.20 ","$1,283.10 ","$1,057.50 "
Carle BroMenn Medical Center,8911055,PARING OF CALLUS; SINLE LESION,,11055,510,$325.00 ,$325.00 ,$97.50 ,$295.75 ,$227.50 ,$97.50 ,$211.25 ,$234.00 ,$295.75 ,$243.75 
Carle BroMenn Medical Center,8911056,PARING OF CALLUS; 2-4 LESIONS,,11056,510,$315.00 ,$315.00 ,$94.50 ,$286.65 ,$220.50 ,$94.50 ,$204.75 ,$226.80 ,$286.65 ,$236.25 
Carle BroMenn Medical Center,8911057,PARING OF CALLUS;OVER 4 LESION,,11057,510,$460.00 ,$460.00 ,$138.00 ,$418.60 ,$322.00 ,$138.00 ,$299.00 ,$331.20 ,$418.60 ,$345.00 
Carle BroMenn Medical Center,8911102,TANGENTIAL BIOPSY SKIN SINGLE LESION,,11102,510,$560.00 ,$560.00 ,$168.00 ,$509.60 ,$392.00 ,$168.00 ,$364.00 ,$403.20 ,$509.60 ,$420.00 
Carle BroMenn Medical Center,8911103,TANGENTIAL BIOPSY SKIN EA SEP/ADDITIONAL LESION,,11103,510,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8911104,PUNCH BIOPSY SKIN SINGLE LESION,,11104,510,$560.00 ,$560.00 ,$168.00 ,$509.60 ,$392.00 ,$168.00 ,$364.00 ,$403.20 ,$509.60 ,$420.00 
Carle BroMenn Medical Center,8911105,PUNCH BIOPSY SKIN EA SEP/ADDITIONAL LESION,,11105,510,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8911106,INCISIONAL BIOPSY SKIN SINGLE LESION,,11106,510,$644.00 ,$644.00 ,$193.20 ,$586.04 ,$450.80 ,$193.20 ,$418.60 ,$463.68 ,$586.04 ,$483.00 
Carle BroMenn Medical Center,8911107,INCISIONAL BIOPSY SKIN EA SEP/ADDITIONAL LESION,,11107,510,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8911719,TRIM NAIL(S),,11719,510,$215.00 ,$215.00 ,$64.50 ,$195.65 ,$150.50 ,$64.50 ,$139.75 ,$154.80 ,$195.65 ,$161.25 
Carle BroMenn Medical Center,8911720,"DEBRIDEMENT NAILS, 1-5",,11720,510,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8911721,"DEBRIDEMENT NAILS, >5",,11721,510,$165.00 ,$165.00 ,$49.50 ,$150.15 ,$115.50 ,$49.50 ,$107.25 ,$118.80 ,$150.15 ,$123.75 
Carle BroMenn Medical Center,8911730,AVULSION OF NAIL PLATE; SINGLE,,11730,510,$375.00 ,$375.00 ,$112.50 ,$341.25 ,$262.50 ,$112.50 ,$243.75 ,$270.00 ,$341.25 ,$281.25 
Carle BroMenn Medical Center,8911732,AVULSION NAIL PLATE;EA ADDTL,,11732,510,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8911750,EXCISION OF NAIL; PART OR COMP,,11750,510,"$1,170.00 ","$1,170.00 ",$351.00 ,"$1,064.70 ",$819.00 ,$351.00 ,$760.50 ,$842.40 ,"$1,064.70 ",$877.50 
Carle BroMenn Medical Center,8912001,WOUND REPAIR SIMPLE,,,510,$500.00 ,$500.00 ,$150.00 ,$455.00 ,$350.00 ,$150.00 ,$325.00 ,$360.00 ,$455.00 ,$375.00 
Carle BroMenn Medical Center,8912002,SMPL RPR SCALP/NECK/AXILLAE/EXT GENTL/TRNK/EXT 2.6-7.5CM,,12002,510,$310.00 ,$310.00 ,$93.00 ,$282.10 ,$217.00 ,$93.00 ,$201.50 ,$223.20 ,$282.10 ,$232.50 
Carle BroMenn Medical Center,8912004,SMPL RPR SCALP/NECK/AXILLAE/EXT GENTL/TRNK/EXT 7.6-12.5CM,,12004,510,$675.00 ,$675.00 ,$202.50 ,$614.25 ,$472.50 ,$202.50 ,$438.75 ,$486.00 ,$614.25 ,$506.25 
Carle BroMenn Medical Center,8912005,SMPL RPR SCALP/NECK/AXILLAE/EXT GENTL/TRNK/EXT 12.6-20.0CM,,12005,510,$850.00 ,$850.00 ,$255.00 ,$773.50 ,$595.00 ,$255.00 ,$552.50 ,$612.00 ,$773.50 ,$637.50 
Carle BroMenn Medical Center,8912006,SMPL RPR SCALP/NECK/AXILLAE/EXT GENTL/TRNK/EXT 20.1-30.0CM,,12006,510,"$1,055.00 ","$1,055.00 ",$316.50 ,$960.05 ,$738.50 ,$316.50 ,$685.75 ,$759.60 ,$960.05 ,$791.25 
Carle BroMenn Medical Center,8912007,SMPL RPR SCALP/NECK/AXILLAE/EXT GENTL/TRNK/EXT >30CM,,12007,510,"$1,405.00 ","$1,405.00 ",$421.50 ,"$1,278.55 ",$983.50 ,$421.50 ,$913.25 ,"$1,011.60 ","$1,278.55 ","$1,053.75 "
Carle BroMenn Medical Center,8912011,SMPL RPR FACE/EARS/EYELIDS/NOSE/LIPS/MCS MBRN 2.5CM OR <,,12011,510,$515.00 ,$515.00 ,$154.50 ,$468.65 ,$360.50 ,$154.50 ,$334.75 ,$370.80 ,$468.65 ,$386.25 
Carle BroMenn Medical Center,8912013,SMPL RPR FACE/EARS/EYELIDS/NOSE/LIPS/MCS MBRN 2.6-5.0CM,,12013,510,$675.00 ,$675.00 ,$202.50 ,$614.25 ,$472.50 ,$202.50 ,$438.75 ,$486.00 ,$614.25 ,$506.25 
Carle BroMenn Medical Center,8912014,SMPL RPR FACE/EARS/EYELIDS/NOSE/LIPS/MCS MBRN 5.1-7.5CM,,12014,510,$800.00 ,$800.00 ,$240.00 ,$728.00 ,$560.00 ,$240.00 ,$520.00 ,$576.00 ,$728.00 ,$600.00 
Carle BroMenn Medical Center,8912015,SMPL RPR FACE/EARS/EYELIDS/NOSE/LIPS/MCS MBRN 7.6-12.5CM,,12015,510,$875.00 ,$875.00 ,$262.50 ,$796.25 ,$612.50 ,$262.50 ,$568.75 ,$630.00 ,$796.25 ,$656.25 
Carle BroMenn Medical Center,8912016,SMPL RPR FACE/EARS/EYELIDS/NOSE/LIPS/MCS MBRN 12.6-20.0CM,,12016,510,$610.00 ,$610.00 ,$183.00 ,$555.10 ,$427.00 ,$183.00 ,$396.50 ,$439.20 ,$555.10 ,$457.50 
Carle BroMenn Medical Center,8912018,SMPL RPR FACE/EARS/EYELIDS/NOSE/LIPS/MCS MBRN >30CM,,12018,510,$695.00 ,$695.00 ,$208.50 ,$632.45 ,$486.50 ,$208.50 ,$451.75 ,$500.40 ,$632.45 ,$521.25 
Carle BroMenn Medical Center,8912020,TREATMENT WOUND DEHISCENCE SIMPLE,,12020,510,"$1,630.00 ","$1,630.00 ",$489.00 ,"$1,483.30 ","$1,141.00 ",$489.00 ,"$1,059.50 ","$1,173.60 ","$1,483.30 ","$1,222.50 "
Carle BroMenn Medical Center,8912021,TREATMENT WOUND DEHISCENCE W/PACKING,,12021,510,"$1,055.00 ","$1,055.00 ",$316.50 ,$960.05 ,$738.50 ,$316.50 ,$685.75 ,$759.60 ,$960.05 ,$791.25 
Carle BroMenn Medical Center,8912201,"OFFICE/OP VISIT, NEW, BRIEF",,G0463,510,$125.00 ,$125.00 ,$37.50 ,$113.75 ,$87.50 ,$37.50 ,$81.25 ,$90.00 ,$113.75 ,$93.75 
Carle BroMenn Medical Center,8912202,"OFFICE/OP VISIT, NEW, LIMITED",,G0463,510,$175.00 ,$175.00 ,$52.50 ,$159.25 ,$122.50 ,$52.50 ,$113.75 ,$126.00 ,$159.25 ,$131.25 
Carle BroMenn Medical Center,8912203,"OFFICE/OP VISIT, NEW, INTERMED",,G0463,510,$225.00 ,$225.00 ,$67.50 ,$204.75 ,$157.50 ,$67.50 ,$146.25 ,$162.00 ,$204.75 ,$168.75 
Carle BroMenn Medical Center,8912204,"OFFICE/OP VISIT, NEW, EXTENDED",,G0463,510,$250.00 ,$250.00 ,$75.00 ,$227.50 ,$175.00 ,$75.00 ,$162.50 ,$180.00 ,$227.50 ,$187.50 
Carle BroMenn Medical Center,8912205,"OFFICE/OP VISIT, NEW, COMPLEX",,G0463,510,$315.00 ,$315.00 ,$94.50 ,$286.65 ,$220.50 ,$94.50 ,$204.75 ,$226.80 ,$286.65 ,$236.25 
Carle BroMenn Medical Center,8912211,"OFFICE/OP VISIT, EST, BRIEF",,G0463,510,$125.00 ,$125.00 ,$37.50 ,$113.75 ,$87.50 ,$37.50 ,$81.25 ,$90.00 ,$113.75 ,$93.75 
Carle BroMenn Medical Center,8912212,"OFFICE/OP VISIT, EST, LIMITED",,G0463,510,$175.00 ,$175.00 ,$52.50 ,$159.25 ,$122.50 ,$52.50 ,$113.75 ,$126.00 ,$159.25 ,$131.25 
Carle BroMenn Medical Center,8912213,"OFFICE/OP VISIT, EST, INTERMED",,G0463,510,$225.00 ,$225.00 ,$67.50 ,$204.75 ,$157.50 ,$67.50 ,$146.25 ,$162.00 ,$204.75 ,$168.75 
Carle BroMenn Medical Center,8912214,"OFFICE/OP VISIT, EST, EXTENDED",,G0463,510,$250.00 ,$250.00 ,$75.00 ,$227.50 ,$175.00 ,$75.00 ,$162.50 ,$180.00 ,$227.50 ,$187.50 
Carle BroMenn Medical Center,8912215,"OFFICE/OP VISIT, EST, COMPLEX",,G0463,510,$315.00 ,$315.00 ,$94.50 ,$286.65 ,$220.50 ,$94.50 ,$204.75 ,$226.80 ,$286.65 ,$236.25 
Carle BroMenn Medical Center,8915271,"SKIN SUB APPLCTN TRUNK, ARMS, LEGS OR ANKLES-TOTAL <M",,15271,510,"$2,975.00 ","$2,975.00 ",$892.50 ,"$2,707.25 ","$2,082.50 ",$892.50 ,"$1,933.75 ","$2,142.00 ","$2,707.25 ","$2,231.25 "
Carle BroMenn Medical Center,8915272,"SKIN SUB APPLCTN TRUNK, ARMS, LEGS OR ANKLES-EA ADD'M",,15272,510,$630.00 ,$630.00 ,$189.00 ,$573.30 ,$441.00 ,$189.00 ,$409.50 ,$453.60 ,$573.30 ,$472.50 
Carle BroMenn Medical Center,8915273,"SKIN SUB APPLCTN TRUNK, ARMS, LEGS OR ANKLES-TOTAL >M",,15273,510,"$6,355.00 ","$6,355.00 ","$1,906.50 ","$5,783.05 ","$4,448.50 ","$1,906.50 ","$4,130.75 ","$4,575.60 ","$5,783.05 ","$4,766.25 "
Carle BroMenn Medical Center,8915274,"SKIN SUB APPLCTN TRUNK, ARMS, LEGS OR ANKES-EA ADD'LM",,15274,510,$745.00 ,$745.00 ,$223.50 ,$677.95 ,$521.50 ,$223.50 ,$484.25 ,$536.40 ,$677.95 ,$558.75 
Carle BroMenn Medical Center,8915275,"SKIN SUB APPLCTN FEET, HANDS, FACE, SCALP-TOTAL <100M",,15275,510,"$2,975.00 ","$2,975.00 ",$892.50 ,"$2,707.25 ","$2,082.50 ",$892.50 ,"$1,933.75 ","$2,142.00 ","$2,707.25 ","$2,231.25 "
Carle BroMenn Medical Center,8915276,"SKIN SUB APPLCTN FEET, HANDS, FACE, SCALP-EA ADD'L 2M",,15276,510,$630.00 ,$630.00 ,$189.00 ,$573.30 ,$441.00 ,$189.00 ,$409.50 ,$453.60 ,$573.30 ,$472.50 
Carle BroMenn Medical Center,8915277,"SKIN SUB APPLCTN FEET, HANDS, FACE, SCALP-TOTAL >100M",,15277,510,"$3,850.00 ","$3,850.00 ","$1,155.00 ","$3,503.50 ","$2,695.00 ","$1,155.00 ","$2,502.50 ","$2,772.00 ","$3,503.50 ","$2,887.50 "
Carle BroMenn Medical Center,8915278,"SKIN SUB APPLCTN FEET, HANDS, FACE, SCALP-EA ADD'L 1M",,15278,510,"$1,000.00 ","$1,000.00 ",$300.00 ,$910.00 ,$700.00 ,$300.00 ,$650.00 ,$720.00 ,$910.00 ,$750.00 
Carle BroMenn Medical Center,8916020,BURN DRESS/DEBRD SMALL,,16020,510,$580.00 ,$580.00 ,$174.00 ,$527.80 ,$406.00 ,$174.00 ,$377.00 ,$417.60 ,$527.80 ,$435.00 
Carle BroMenn Medical Center,8916025,BURN DRESS/DEBRD MEDIUM,,16025,510,$620.00 ,$620.00 ,$186.00 ,$564.20 ,$434.00 ,$186.00 ,$403.00 ,$446.40 ,$564.20 ,$465.00 
Carle BroMenn Medical Center,8916030,BURN DRESS/DEBRD LARGE,,16030,510,$790.00 ,$790.00 ,$237.00 ,$718.90 ,$553.00 ,$237.00 ,$513.50 ,$568.80 ,$718.90 ,$592.50 
Carle BroMenn Medical Center,8917250,CHEMICAL CAUTERIZATION GRNLTN TISSUE,,17250,510,$415.00 ,$415.00 ,$124.50 ,$377.65 ,$290.50 ,$124.50 ,$269.75 ,$298.80 ,$377.65 ,$311.25 
Carle BroMenn Medical Center,8917597,SELECTIVE DEBRIDEMNT < 20SQ CM,,97597,510,$415.00 ,$415.00 ,$124.50 ,$377.65 ,$290.50 ,$124.50 ,$269.75 ,$298.80 ,$377.65 ,$311.25 
Carle BroMenn Medical Center,8917598,SELECTIVE DEBRIDEMNT > 20SQ CM,,97598,510,$280.00 ,$280.00 ,$84.00 ,$254.80 ,$196.00 ,$84.00 ,$182.00 ,$201.60 ,$254.80 ,$210.00 
Carle BroMenn Medical Center,8917602,NONSELECTIVE DEBRIDEMENT,,97602,510,$415.00 ,$415.00 ,$124.50 ,$377.65 ,$290.50 ,$124.50 ,$269.75 ,$298.80 ,$377.65 ,$311.25 
Carle BroMenn Medical Center,8917605,WOUND TREATMENT (VAC) </=50SQ CM,,97605,510,$340.00 ,$340.00 ,$102.00 ,$309.40 ,$238.00 ,$102.00 ,$221.00 ,$244.80 ,$309.40 ,$255.00 
Carle BroMenn Medical Center,8917606,WOUND TREATMENT (VAC) > 50SQCM,,97606,510,$790.00 ,$790.00 ,$237.00 ,$718.90 ,$553.00 ,$237.00 ,$513.50 ,$568.80 ,$718.90 ,$592.50 
Carle BroMenn Medical Center,8919201,"OFFICE/OP VISIT, NEW, BRIEF",,G0463,510,$125.00 ,$125.00 ,$37.50 ,$113.75 ,$87.50 ,$37.50 ,$81.25 ,$90.00 ,$113.75 ,$93.75 
Carle BroMenn Medical Center,8919202,"OFFICE/OP VISIT, NEW, LIMITED",,G0463,510,$175.00 ,$175.00 ,$52.50 ,$159.25 ,$122.50 ,$52.50 ,$113.75 ,$126.00 ,$159.25 ,$131.25 
Carle BroMenn Medical Center,8919203,"OFFICE/OP VISIT, NEW, INTERMED",,G0463,510,$225.00 ,$225.00 ,$67.50 ,$204.75 ,$157.50 ,$67.50 ,$146.25 ,$162.00 ,$204.75 ,$168.75 
Carle BroMenn Medical Center,8919204,"OFFICE/OP VISIT, NEW, EXTENDED",,G0463,510,$250.00 ,$250.00 ,$75.00 ,$227.50 ,$175.00 ,$75.00 ,$162.50 ,$180.00 ,$227.50 ,$187.50 
Carle BroMenn Medical Center,8919205,"OFFICE/OP VISIT, NEW, COMPLEX",,G0463,510,$315.00 ,$315.00 ,$94.50 ,$286.65 ,$220.50 ,$94.50 ,$204.75 ,$226.80 ,$286.65 ,$236.25 
Carle BroMenn Medical Center,8919211,"OFFICE/OP VISIT, EST, BRIEF",,G0463,510,$125.00 ,$125.00 ,$37.50 ,$113.75 ,$87.50 ,$37.50 ,$81.25 ,$90.00 ,$113.75 ,$93.75 
Carle BroMenn Medical Center,8919212,"OFFICE/OP VISIT, EST, LIMITED",,G0463,510,$175.00 ,$175.00 ,$52.50 ,$159.25 ,$122.50 ,$52.50 ,$113.75 ,$126.00 ,$159.25 ,$131.25 
Carle BroMenn Medical Center,8919213,"OFFICE/OP VISIT, EST, INTERMED",,G0463,510,$225.00 ,$225.00 ,$67.50 ,$204.75 ,$157.50 ,$67.50 ,$146.25 ,$162.00 ,$204.75 ,$168.75 
Carle BroMenn Medical Center,8919214,"OFFICE/OP VISIT, EST, EXTENDED",,G0463,510,$250.00 ,$250.00 ,$75.00 ,$227.50 ,$175.00 ,$75.00 ,$162.50 ,$180.00 ,$227.50 ,$187.50 
Carle BroMenn Medical Center,8919215,"OFFICE/OP VISIT, EST, COMPLEX",,G0463,510,$315.00 ,$315.00 ,$94.50 ,$286.65 ,$220.50 ,$94.50 ,$204.75 ,$226.80 ,$286.65 ,$236.25 
Carle BroMenn Medical Center,8919445,TOTAL CONTACT CASTING,,29445,510,$730.00 ,$730.00 ,$219.00 ,$664.30 ,$511.00 ,$219.00 ,$474.50 ,$525.60 ,$664.30 ,$547.50 
Carle BroMenn Medical Center,8919581,APPLI MULTILAY COMP WOUND LEG,,29581,510,$415.00 ,$415.00 ,$124.50 ,$377.65 ,$290.50 ,$124.50 ,$269.75 ,$298.80 ,$377.65 ,$311.25 
Carle BroMenn Medical Center,8969211,WOUND/OSTOMY THERAPY LEVEL 1,,G0463,510,$125.00 ,$125.00 ,$37.50 ,$113.75 ,$87.50 ,$37.50 ,$81.25 ,$90.00 ,$113.75 ,$93.75 
Carle BroMenn Medical Center,8969212,WOUND/OSTOMY THERAPY LEVEL 2,,G0463,510,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8969213,WOUND/OSTOMY THERAPY LEVEL 3,,G0463,510,$250.00 ,$250.00 ,$75.00 ,$227.50 ,$175.00 ,$75.00 ,$162.50 ,$180.00 ,$227.50 ,$187.50 
Carle BroMenn Medical Center,8969214,WOUND/OSTOMY THERAPY LEVEL 4,,G0463,510,$350.00 ,$350.00 ,$105.00 ,$318.50 ,$245.00 ,$105.00 ,$227.50 ,$252.00 ,$318.50 ,$262.50 
Carle BroMenn Medical Center,8969215,WOUND/OSTOMY THERAPY LEVEL 5,,G0463,510,$425.00 ,$425.00 ,$127.50 ,$386.75 ,$297.50 ,$127.50 ,$276.25 ,$306.00 ,$386.75 ,$318.75 
Carle BroMenn Medical Center,8290867,REPET TMS TX INITIAL W/MAP/MOTR THRESHLD/DEL&MNG,,90867,513,$250.00 ,$250.00 ,$75.00 ,$227.50 ,$175.00 ,$75.00 ,$162.50 ,$180.00 ,$227.50 ,$187.50 
Carle BroMenn Medical Center,8290868,THERAP REPETITIVE TMS TX SUBSEQ DELIVERY & MNGT,,90868,513,$250.00 ,$250.00 ,$75.00 ,$227.50 ,$175.00 ,$75.00 ,$162.50 ,$180.00 ,$227.50 ,$187.50 
Carle BroMenn Medical Center,8298925,"OSTEOPATHIC MANIP,1-2 BODY REGN",,98925,530,$160.00 ,$160.00 ,$48.00 ,$145.60 ,$112.00 ,$48.00 ,$104.00 ,$115.20 ,$145.60 ,$120.00 
Carle BroMenn Medical Center,8298926,"OSTEOPATHIC MANIP,3-4 BODY REGN",,98926,530,$160.00 ,$160.00 ,$48.00 ,$145.60 ,$112.00 ,$48.00 ,$104.00 ,$115.20 ,$145.60 ,$120.00 
Carle BroMenn Medical Center,8298927,"OSTEOPATHIC MANIP,5-6 BODY REGN",,98927,530,$155.00 ,$155.00 ,$46.50 ,$141.05 ,$108.50 ,$46.50 ,$100.75 ,$111.60 ,$141.05 ,$116.25 
Carle BroMenn Medical Center,8298928,"OSTEOPATHIC MANIP,7-8 BODY REGN",,98928,530,$160.00 ,$160.00 ,$48.00 ,$145.60 ,$112.00 ,$48.00 ,$104.00 ,$115.20 ,$145.60 ,$120.00 
Carle BroMenn Medical Center,8298929,"OSTEOPATHIC MANIP, 9-10 BODY REGN",,98929,530,$190.00 ,$190.00 ,$57.00 ,$172.90 ,$133.00 ,$57.00 ,$123.50 ,$136.80 ,$172.90 ,$142.50 
Carle BroMenn Medical Center,8401590,MRI BREAST COMPUTER AIDED DETECTION,,0159T,610,$360.00 ,$360.00 ,$108.00 ,$327.60 ,$252.00 ,$108.00 ,$234.00 ,$259.20 ,$327.60 ,$270.00 
Carle BroMenn Medical Center,8408900,MRA ABDOMEN W CONTRAST,,C8900,610,"$3,120.00 ","$3,120.00 ",$936.00 ,"$2,839.20 ","$2,184.00 ",$936.00 ,"$2,028.00 ","$2,246.40 ","$2,839.20 ","$2,340.00 "
Carle BroMenn Medical Center,8408901,MRA ABDOMEN W/O CONTRAST,,C8901,610,"$2,740.00 ","$2,740.00 ",$822.00 ,"$2,493.40 ","$1,918.00 ",$822.00 ,"$1,781.00 ","$1,972.80 ","$2,493.40 ","$2,055.00 "
Carle BroMenn Medical Center,8408902,MRA - ABDOMEN W/O & W/CONTRAST,,C8902,610,"$5,420.00 ","$5,420.00 ","$1,626.00 ","$4,932.20 ","$3,794.00 ","$1,626.00 ","$3,523.00 ","$3,902.40 ","$4,932.20 ","$4,065.00 "
Carle BroMenn Medical Center,8408903,"MRI W/CONT, BREAST,  UNI",,C8903,610,"$1,190.00 ","$1,190.00 ",$357.00 ,"$1,082.90 ",$833.00 ,$357.00 ,$773.50 ,$856.80 ,"$1,082.90 ",$892.50 
Carle BroMenn Medical Center,8408906,MRI BREAST W/CONTRAST,,C8906,610,"$2,230.00 ","$2,230.00 ",$669.00 ,"$2,029.30 ","$1,561.00 ",$669.00 ,"$1,449.50 ","$1,605.60 ","$2,029.30 ","$1,672.50 "
Carle BroMenn Medical Center,8408907,MRI BREAST W/O CONTRAST,,C8907,610,"$1,870.00 ","$1,870.00 ",$561.00 ,"$1,701.70 ","$1,309.00 ",$561.00 ,"$1,215.50 ","$1,346.40 ","$1,701.70 ","$1,402.50 "
Carle BroMenn Medical Center,8408908,MRI BREAST BILAT WO&W/CNTRST,,C8908,610,"$5,380.00 ","$5,380.00 ","$1,614.00 ","$4,895.80 ","$3,766.00 ","$1,614.00 ","$3,497.00 ","$3,873.60 ","$4,895.80 ","$4,035.00 "
Carle BroMenn Medical Center,8408912,MRA W/CONTRAST  -LWR EXTREMITY,,C8912,610,"$2,860.00 ","$2,860.00 ",$858.00 ,"$2,602.60 ","$2,002.00 ",$858.00 ,"$1,859.00 ","$2,059.20 ","$2,602.60 ","$2,145.00 "
Carle BroMenn Medical Center,8408913,MRA-LOWER EXTREMITY W/O CNTRST,,C8913,610,"$3,860.00 ","$3,860.00 ","$1,158.00 ","$3,512.60 ","$2,702.00 ","$1,158.00 ","$2,509.00 ","$2,779.20 ","$3,512.60 ","$2,895.00 "
Carle BroMenn Medical Center,8408914,MRA W/O & W/CONTRAST  -LWR EXTREMITY,,C8914,610,"$5,490.00 ","$5,490.00 ","$1,647.00 ","$4,995.90 ","$3,843.00 ","$1,647.00 ","$3,568.50 ","$3,952.80 ","$4,995.90 ","$4,117.50 "
Carle BroMenn Medical Center,8408918,MRA PELVIS W/CONTRAST,,C8918,610,"$2,680.00 ","$2,680.00 ",$804.00 ,"$2,438.80 ","$1,876.00 ",$804.00 ,"$1,742.00 ","$1,929.60 ","$2,438.80 ","$2,010.00 "
Carle BroMenn Medical Center,8408919,MRA PELVIS W/O CONTRAST,,C8919,610,"$2,340.00 ","$2,340.00 ",$702.00 ,"$2,129.40 ","$1,638.00 ",$702.00 ,"$1,521.00 ","$1,684.80 ","$2,129.40 ","$1,755.00 "
Carle BroMenn Medical Center,8408920,MRA PELVIS W/O & W/CONTRAST,,C8920,610,"$6,310.00 ","$6,310.00 ","$1,893.00 ","$5,742.10 ","$4,417.00 ","$1,893.00 ","$4,101.50 ","$4,543.20 ","$5,742.10 ","$4,732.50 "
Carle BroMenn Medical Center,8408937,Cad breast mri,,C8937,610,"$2,150.00 ","$2,150.00 ",$645.00 ,"$1,956.50 ","$1,505.00 ",$645.00 ,"$1,397.50 ","$1,548.00 ","$1,956.50 ","$1,612.50 "
Carle BroMenn Medical Center,8470336,MRI TMJ,,70336,610,"$4,540.00 ","$4,540.00 ","$1,362.00 ","$4,131.40 ","$3,178.00 ","$1,362.00 ","$2,951.00 ","$3,268.80 ","$4,131.40 ","$3,405.00 "
Carle BroMenn Medical Center,8470540,MRI ORBIT/FACE/NECK W/O CNTRST,,70540,610,"$3,350.00 ","$3,350.00 ","$1,005.00 ","$3,048.50 ","$2,345.00 ","$1,005.00 ","$2,177.50 ","$2,412.00 ","$3,048.50 ","$2,512.50 "
Carle BroMenn Medical Center,8470542,MRI ORBIT/FACE/NECK W/CONTRAST,,70542,610,"$3,850.00 ","$3,850.00 ","$1,155.00 ","$3,503.50 ","$2,695.00 ","$1,155.00 ","$2,502.50 ","$2,772.00 ","$3,503.50 ","$2,887.50 "
Carle BroMenn Medical Center,8470543,MRI ORB/FACE/NECK W&W/O CNTRST,,70543,610,"$6,310.00 ","$6,310.00 ","$1,893.00 ","$5,742.10 ","$4,417.00 ","$1,893.00 ","$4,101.50 ","$4,543.20 ","$5,742.10 ","$4,732.50 "
Carle BroMenn Medical Center,8470544,MRA HEAD W/O CONTRAST,,70544,610,"$3,350.00 ","$3,350.00 ","$1,005.00 ","$3,048.50 ","$2,345.00 ","$1,005.00 ","$2,177.50 ","$2,412.00 ","$3,048.50 ","$2,512.50 "
Carle BroMenn Medical Center,8470545,MRA HEAD W/CONTRAST,,70545,610,"$6,310.00 ","$6,310.00 ","$1,893.00 ","$5,742.10 ","$4,417.00 ","$1,893.00 ","$4,101.50 ","$4,543.20 ","$5,742.10 ","$4,732.50 "
Carle BroMenn Medical Center,8470546,MRA HEAD W/O & W/CONTRAST,,70546,610,"$5,490.00 ","$5,490.00 ","$1,647.00 ","$4,995.90 ","$3,843.00 ","$1,647.00 ","$3,568.50 ","$3,952.80 ","$4,995.90 ","$4,117.50 "
Carle BroMenn Medical Center,8470547,MRA NECK W/O CONTRAST,,70547,610,"$3,350.00 ","$3,350.00 ","$1,005.00 ","$3,048.50 ","$2,345.00 ","$1,005.00 ","$2,177.50 ","$2,412.00 ","$3,048.50 ","$2,512.50 "
Carle BroMenn Medical Center,8470548,MRA NECK W/CONTRAST,,70548,610,"$5,780.00 ","$5,780.00 ","$1,734.00 ","$5,259.80 ","$4,046.00 ","$1,734.00 ","$3,757.00 ","$4,161.60 ","$5,259.80 ","$4,335.00 "
Carle BroMenn Medical Center,8470549,MRA NECK W/O & W/CONTRAST,,70549,610,"$5,490.00 ","$5,490.00 ","$1,647.00 ","$4,995.90 ","$3,843.00 ","$1,647.00 ","$3,568.50 ","$3,952.80 ","$4,995.90 ","$4,117.50 "
Carle BroMenn Medical Center,8470551,MRI BRAIN W/O CONTRAST,,70551,610,"$3,350.00 ","$3,350.00 ","$1,005.00 ","$3,048.50 ","$2,345.00 ","$1,005.00 ","$2,177.50 ","$2,412.00 ","$3,048.50 ","$2,512.50 "
Carle BroMenn Medical Center,8470552,MRI BRAIN W/CONTRAST,,70552,610,"$6,310.00 ","$6,310.00 ","$1,893.00 ","$5,742.10 ","$4,417.00 ","$1,893.00 ","$4,101.50 ","$4,543.20 ","$5,742.10 ","$4,732.50 "
Carle BroMenn Medical Center,8470553,MRI BRAIN W/O & W/CONTRAST,,70553,610,"$5,490.00 ","$5,490.00 ","$1,647.00 ","$4,995.90 ","$3,843.00 ","$1,647.00 ","$3,568.50 ","$3,952.80 ","$4,995.90 ","$4,117.50 "
Carle BroMenn Medical Center,8471550,MRI CHEST W/O CONTRAST,,71550,610,"$3,860.00 ","$3,860.00 ","$1,158.00 ","$3,512.60 ","$2,702.00 ","$1,158.00 ","$2,509.00 ","$2,779.20 ","$3,512.60 ","$2,895.00 "
Carle BroMenn Medical Center,8471551,MRI CHEST W/CONTRAST,,71551,610,"$4,450.00 ","$4,450.00 ","$1,335.00 ","$4,049.50 ","$3,115.00 ","$1,335.00 ","$2,892.50 ","$3,204.00 ","$4,049.50 ","$3,337.50 "
Carle BroMenn Medical Center,8471552,MRI CHEST WO & W CONTRAST,,71552,610,"$6,310.00 ","$6,310.00 ","$1,893.00 ","$5,742.10 ","$4,417.00 ","$1,893.00 ","$4,101.50 ","$4,543.20 ","$5,742.10 ","$4,732.50 "
Carle BroMenn Medical Center,8472142,MRI C SPINE W/CONTRAST,,72142,610,"$6,310.00 ","$6,310.00 ","$1,893.00 ","$5,742.10 ","$4,417.00 ","$1,893.00 ","$4,101.50 ","$4,543.20 ","$5,742.10 ","$4,732.50 "
Carle BroMenn Medical Center,8472147,MRI T SPINE W/CONTRAST,,72147,610,"$4,620.00 ","$4,620.00 ","$1,386.00 ","$4,204.20 ","$3,234.00 ","$1,386.00 ","$3,003.00 ","$3,326.40 ","$4,204.20 ","$3,465.00 "
Carle BroMenn Medical Center,8472148,MRI L SPINE W/O CONTRAST,,72148,610,"$3,660.00 ","$3,660.00 ","$1,098.00 ","$3,330.60 ","$2,562.00 ","$1,098.00 ","$2,379.00 ","$2,635.20 ","$3,330.60 ","$2,745.00 "
Carle BroMenn Medical Center,8472149,MRI L SPINE W/CONTRAST,,72149,610,"$6,310.00 ","$6,310.00 ","$1,893.00 ","$5,742.10 ","$4,417.00 ","$1,893.00 ","$4,101.50 ","$4,543.20 ","$5,742.10 ","$4,732.50 "
Carle BroMenn Medical Center,8472156,MRI C SPINE W/O & W/CONTRAST,,72156,610,"$5,490.00 ","$5,490.00 ","$1,647.00 ","$4,995.90 ","$3,843.00 ","$1,647.00 ","$3,568.50 ","$3,952.80 ","$4,995.90 ","$4,117.50 "
Carle BroMenn Medical Center,8472157,MRI T SPINE W/O & W/CONTRAST,,72157,610,"$5,490.00 ","$5,490.00 ","$1,647.00 ","$4,995.90 ","$3,843.00 ","$1,647.00 ","$3,568.50 ","$3,952.80 ","$4,995.90 ","$4,117.50 "
Carle BroMenn Medical Center,8472158,MRI L SPINE W/O & W/CONTRAST,,72158,610,"$5,490.00 ","$5,490.00 ","$1,647.00 ","$4,995.90 ","$3,843.00 ","$1,647.00 ","$3,568.50 ","$3,952.80 ","$4,995.90 ","$4,117.50 "
Carle BroMenn Medical Center,8472195,MRI PELVIS W/O CONTRAST,,72195,610,"$3,860.00 ","$3,860.00 ","$1,158.00 ","$3,512.60 ","$2,702.00 ","$1,158.00 ","$2,509.00 ","$2,779.20 ","$3,512.60 ","$2,895.00 "
Carle BroMenn Medical Center,8472196,MRI PELVIS W/CONTRAST,,72196,610,"$6,310.00 ","$6,310.00 ","$1,893.00 ","$5,742.10 ","$4,417.00 ","$1,893.00 ","$4,101.50 ","$4,543.20 ","$5,742.10 ","$4,732.50 "
Carle BroMenn Medical Center,8472197,MRI PELVIS W/O & W/CONTRAST,,72197,610,"$6,310.00 ","$6,310.00 ","$1,893.00 ","$5,742.10 ","$4,417.00 ","$1,893.00 ","$4,101.50 ","$4,543.20 ","$5,742.10 ","$4,732.50 "
Carle BroMenn Medical Center,8473218,MRI UPPER EXTREMITY W/O CNTRST,,73218,610,"$3,860.00 ","$3,860.00 ","$1,158.00 ","$3,512.60 ","$2,702.00 ","$1,158.00 ","$2,509.00 ","$2,779.20 ","$3,512.60 ","$2,895.00 "
Carle BroMenn Medical Center,8473219,MRI UPPER EXTREMITY W/CNTRST,,73219,610,"$4,470.00 ","$4,470.00 ","$1,341.00 ","$4,067.70 ","$3,129.00 ","$1,341.00 ","$2,905.50 ","$3,218.40 ","$4,067.70 ","$3,352.50 "
Carle BroMenn Medical Center,8473220,MRI UPPER EXTREMITY WO&W/CONTR,,73220,610,"$6,310.00 ","$6,310.00 ","$1,893.00 ","$5,742.10 ","$4,417.00 ","$1,893.00 ","$4,101.50 ","$4,543.20 ","$5,742.10 ","$4,732.50 "
Carle BroMenn Medical Center,8473221,MRI UPPR EXT JOINT W/O CONTRAST,,73221,610,"$3,860.00 ","$3,860.00 ","$1,158.00 ","$3,512.60 ","$2,702.00 ","$1,158.00 ","$2,509.00 ","$2,779.20 ","$3,512.60 ","$2,895.00 "
Carle BroMenn Medical Center,8473222,MRI UPPR EXT JOINT W/ CONTRAST,,73222,610,"$5,930.00 ","$5,930.00 ","$1,779.00 ","$5,396.30 ","$4,151.00 ","$1,779.00 ","$3,854.50 ","$4,269.60 ","$5,396.30 ","$4,447.50 "
Carle BroMenn Medical Center,8473223,MRI UPPR EXT JOINT W & W/O CONTRAST,,73223,610,"$5,490.00 ","$5,490.00 ","$1,647.00 ","$4,995.90 ","$3,843.00 ","$1,647.00 ","$3,568.50 ","$3,952.80 ","$4,995.90 ","$4,117.50 "
Carle BroMenn Medical Center,8473225,MRA UPPER EXTREMITY,,73225,610,"$5,170.00 ","$5,170.00 ","$1,551.00 ","$4,704.70 ","$3,619.00 ","$1,551.00 ","$3,360.50 ","$3,722.40 ","$4,704.70 ","$3,877.50 "
Carle BroMenn Medical Center,8473718,MRI LOWER EXTREMITY W/O CNTRST,,73718,610,"$3,860.00 ","$3,860.00 ","$1,158.00 ","$3,512.60 ","$2,702.00 ","$1,158.00 ","$2,509.00 ","$2,779.20 ","$3,512.60 ","$2,895.00 "
Carle BroMenn Medical Center,8473719,MRI LOWER EXTREMITY W/CONTRAST,,73719,610,"$6,310.00 ","$6,310.00 ","$1,893.00 ","$5,742.10 ","$4,417.00 ","$1,893.00 ","$4,101.50 ","$4,543.20 ","$5,742.10 ","$4,732.50 "
Carle BroMenn Medical Center,8473720,MRI LOWER EXTREMITY WO&W/CONTR,,73720,610,"$5,490.00 ","$5,490.00 ","$1,647.00 ","$4,995.90 ","$3,843.00 ","$1,647.00 ","$3,568.50 ","$3,952.80 ","$4,995.90 ","$4,117.50 "
Carle BroMenn Medical Center,8473721,MRI LWR EXT JOINT W/O CONTRAST,,73721,610,"$3,860.00 ","$3,860.00 ","$1,158.00 ","$3,512.60 ","$2,702.00 ","$1,158.00 ","$2,509.00 ","$2,779.20 ","$3,512.60 ","$2,895.00 "
Carle BroMenn Medical Center,8473722,MRI LWR EXT JOINT W/ONTRAST,,73722,610,"$6,820.00 ","$6,820.00 ","$2,046.00 ","$6,206.20 ","$4,774.00 ","$2,046.00 ","$4,433.00 ","$4,910.40 ","$6,206.20 ","$5,115.00 "
Carle BroMenn Medical Center,8473723,MRI LWR EXT JOINT W & W/O CONTRAST,,73723,610,"$5,490.00 ","$5,490.00 ","$1,647.00 ","$4,995.90 ","$3,843.00 ","$1,647.00 ","$3,568.50 ","$3,952.80 ","$4,995.90 ","$4,117.50 "
Carle BroMenn Medical Center,8474181,MRI ABDOMEN W/O CONTRAST,,74181,610,"$3,560.00 ","$3,560.00 ","$1,068.00 ","$3,239.60 ","$2,492.00 ","$1,068.00 ","$2,314.00 ","$2,563.20 ","$3,239.60 ","$2,670.00 "
Carle BroMenn Medical Center,8474182,MRI ABDOMEN W/CONTRAST,,74182,610,"$5,490.00 ","$5,490.00 ","$1,647.00 ","$4,995.90 ","$3,843.00 ","$1,647.00 ","$3,568.50 ","$3,952.80 ","$4,995.90 ","$4,117.50 "
Carle BroMenn Medical Center,8474183,MRI ABDOMEN W/O & W/CONTRAST,,74183,610,"$5,490.00 ","$5,490.00 ","$1,647.00 ","$4,995.90 ","$3,843.00 ","$1,647.00 ","$3,568.50 ","$3,952.80 ","$4,995.90 ","$4,117.50 "
Carle BroMenn Medical Center,8474185,MRI MRCP,,74185,610,"$5,260.00 ","$5,260.00 ","$1,578.00 ","$4,786.60 ","$3,682.00 ","$1,578.00 ","$3,419.00 ","$3,787.20 ","$4,786.60 ","$3,945.00 "
Carle BroMenn Medical Center,8474712,CHG FETAL MRI W/PLACNTL MATRNL PLVC IMG SING/1ST GES,,74712,610,"$4,080.00 ","$4,080.00 ","$1,224.00 ","$3,712.80 ","$2,856.00 ","$1,224.00 ","$2,652.00 ","$2,937.60 ","$3,712.80 ","$3,060.00 "
Carle BroMenn Medical Center,8474713,CHG FETAL MRI W/PLACNTL MATRNL PLVC IMG EA ADDL GES,,74713,610,"$1,950.00 ","$1,950.00 ",$585.00 ,"$1,774.50 ","$1,365.00 ",$585.00 ,"$1,267.50 ","$1,404.00 ","$1,774.50 ","$1,462.50 "
Carle BroMenn Medical Center,8475557,MRI CARDIAC MORPH W/O CONTRST,,75557,610,"$1,330.00 ","$1,330.00 ",$399.00 ,"$1,210.30 ",$931.00 ,$399.00 ,$864.50 ,$957.60 ,"$1,210.30 ",$997.50 
Carle BroMenn Medical Center,8475559,MRI CARDIAC W/STRESS IMG,,75559,610,"$1,550.00 ","$1,550.00 ",$465.00 ,"$1,410.50 ","$1,085.00 ",$465.00 ,"$1,007.50 ","$1,116.00 ","$1,410.50 ","$1,162.50 "
Carle BroMenn Medical Center,8475561,MRI CARDIAC MORPHOLOGY W/O & W/CONTRAST,,75561,610,"$1,840.00 ","$1,840.00 ",$552.00 ,"$1,674.40 ","$1,288.00 ",$552.00 ,"$1,196.00 ","$1,324.80 ","$1,674.40 ","$1,380.00 "
Carle BroMenn Medical Center,8475563,MRI CARDIAC W/STRESS IMG & DYE,,75563,610,"$1,880.00 ","$1,880.00 ",$564.00 ,"$1,710.80 ","$1,316.00 ",$564.00 ,"$1,222.00 ","$1,353.60 ","$1,710.80 ","$1,410.00 "
Carle BroMenn Medical Center,8475565,CARD MRI VEL FLW MAP ADD-ON,,75565,610,"$1,130.00 ","$1,130.00 ",$339.00 ,"$1,028.30 ",$791.00 ,$339.00 ,$734.50 ,$813.60 ,"$1,028.30 ",$847.50 
Carle BroMenn Medical Center,8476390,MR SPECTROSCOPY,,76390,610,"$3,520.00 ","$3,520.00 ","$1,056.00 ","$3,203.20 ","$2,464.00 ","$1,056.00 ","$2,288.00 ","$2,534.40 ","$3,203.20 ","$2,640.00 "
Carle BroMenn Medical Center,8476391,MAGNETIC RESONANCE ELASTOGRAPHY,,76391,610,"$3,610.00 ","$3,610.00 ","$1,083.00 ","$3,285.10 ","$2,527.00 ","$1,083.00 ","$2,346.50 ","$2,599.20 ","$3,285.10 ","$2,707.50 "
Carle BroMenn Medical Center,8476498,UNLISTED MR PROCEDURE,,76498,610,$940.00 ,$940.00 ,$282.00 ,$855.40 ,$658.00 ,$282.00 ,$611.00 ,$676.80 ,$855.40 ,$705.00 
Carle BroMenn Medical Center,8477021,MRI GUIDED NEEDLE/WIRE PLACMNT,,77021,610,"$2,120.00 ","$2,120.00 ",$636.00 ,"$1,929.20 ","$1,484.00 ",$636.00 ,"$1,378.00 ","$1,526.40 ","$1,929.20 ","$1,590.00 "
Carle BroMenn Medical Center,8477046,MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERAL,,77046,610,"$1,700.00 ","$1,700.00 ",$510.00 ,"$1,547.00 ","$1,190.00 ",$510.00 ,"$1,105.00 ","$1,224.00 ","$1,547.00 ","$1,275.00 "
Carle BroMenn Medical Center,8477047,MRI BREAST WITHOUT CONTRAST MATERIAL BILATERAL,,77047,610,"$1,700.00 ","$1,700.00 ",$510.00 ,"$1,547.00 ","$1,190.00 ",$510.00 ,"$1,105.00 ","$1,224.00 ","$1,547.00 ","$1,275.00 "
Carle BroMenn Medical Center,8477048,MRI BREAST W/OUT&WITH CONTRAST W/CAD UNILATERAL,,C8905,610,"$1,940.00 ","$1,940.00 ",$582.00 ,"$1,765.40 ","$1,358.00 ",$582.00 ,"$1,261.00 ","$1,396.80 ","$1,765.40 ","$1,455.00 "
Carle BroMenn Medical Center,8477049,MRI BREAST WITHOUT&WITH CONTRAST W/CAD BILATERAL,,C8908,610,"$3,790.00 ","$3,790.00 ","$1,137.00 ","$3,448.90 ","$2,653.00 ","$1,137.00 ","$2,463.50 ","$2,728.80 ","$3,448.90 ","$2,842.50 "
Carle BroMenn Medical Center,8477058,MRI BREAST UNILAT W/ AND/OR W/O CNTRST,,77058,610,"$1,999.00 ","$1,999.00 ",$599.70 ,"$1,819.09 ","$1,399.30 ",$599.70 ,"$1,299.35 ","$1,439.28 ","$1,819.09 ","$1,499.25 "
Carle BroMenn Medical Center,8477059,MRI BREAST BILAT W/ AND/OR W/O CNTRST,,77059,610,"$1,999.00 ","$1,999.00 ",$599.70 ,"$1,819.09 ","$1,399.30 ",$599.70 ,"$1,299.35 ","$1,439.28 ","$1,819.09 ","$1,499.25 "
Carle BroMenn Medical Center,8976391,MAGNETIC RESONANCE ELASTOGRAPHY,,76391,610,"$4,245.00 ","$4,245.00 ","$1,273.50 ","$3,862.95 ","$2,971.50 ","$1,273.50 ","$2,759.25 ","$3,056.40 ","$3,862.95 ","$3,183.75 "
Carle BroMenn Medical Center,8472141,MRI C SPINE W/O CONTRAST,,72141,612,"$3,730.00 ","$3,730.00 ","$1,119.00 ","$3,394.30 ","$2,611.00 ","$1,119.00 ","$2,424.50 ","$2,685.60 ","$3,394.30 ","$2,797.50 "
Carle BroMenn Medical Center,8472146,MRI T SPINE W/O CONTRAST,,72146,612,"$3,510.00 ","$3,510.00 ","$1,053.00 ","$3,194.10 ","$2,457.00 ","$1,053.00 ","$2,281.50 ","$2,527.20 ","$3,194.10 ","$2,632.50 "
Carle BroMenn Medical Center,8408909,MRA CHEST W/CONTRAST,,C8909,618,"$4,050.00 ","$4,050.00 ","$1,215.00 ","$3,685.50 ","$2,835.00 ","$1,215.00 ","$2,632.50 ","$2,916.00 ","$3,685.50 ","$3,037.50 "
Carle BroMenn Medical Center,8408910,MRA CHEST W/O CONTRAST,,C8910,618,"$3,350.00 ","$3,350.00 ","$1,005.00 ","$3,048.50 ","$2,345.00 ","$1,005.00 ","$2,177.50 ","$2,412.00 ","$3,048.50 ","$2,512.50 "
Carle BroMenn Medical Center,8408911,MRA CHEST WO&W/CONTRAST,,C8911,618,"$5,490.00 ","$5,490.00 ","$1,647.00 ","$4,995.90 ","$3,843.00 ","$1,647.00 ","$3,568.50 ","$3,952.80 ","$4,995.90 ","$4,117.50 "
Carle BroMenn Medical Center,8408931,MRA W/CONTRAST - SPINAL CANAL & CONTENTS,,C8931,618,"$1,920.00 ","$1,920.00 ",$576.00 ,"$1,747.20 ","$1,344.00 ",$576.00 ,"$1,248.00 ","$1,382.40 ","$1,747.20 ","$1,440.00 "
Carle BroMenn Medical Center,8408932,MRA W/O CONTRAST - SPINAL CANAL & CONTENTS,,C8932,618,$840.00 ,$840.00 ,$252.00 ,$764.40 ,$588.00 ,$252.00 ,$546.00 ,$604.80 ,$764.40 ,$630.00 
Carle BroMenn Medical Center,8408933,MRA W/O & W/CONTRAST - SPINAL CANAL & CONTENTS,,C8933,618,"$2,260.00 ","$2,260.00 ",$678.00 ,"$2,056.60 ","$1,582.00 ",$678.00 ,"$1,469.00 ","$1,627.20 ","$2,056.60 ","$1,695.00 "
Carle BroMenn Medical Center,8902478,T/R TUBE TRACH SHILEY 4CFS,,A7520,623,$530.00 ,$530.00 ,$159.00 ,$482.30 ,$371.00 ,$159.00 ,$344.50 ,$381.60 ,$482.30 ,$397.50 
Carle BroMenn Medical Center,8902479,SHI60XLTUD T/R TRACH UNCUFFED PROXIMAL EA,,A7520,623,$530.00 ,$530.00 ,$159.00 ,$482.30 ,$371.00 ,$159.00 ,$344.50 ,$381.60 ,$482.30 ,$397.50 
Carle BroMenn Medical Center,8902480,SHI60XLTCP T/R PROXIMAL EXT CUFFED BX,,A7520,623,$530.00 ,$530.00 ,$159.00 ,$482.30 ,$371.00 ,$159.00 ,$344.50 ,$381.60 ,$482.30 ,$397.50 
Carle BroMenn Medical Center,8902481,SHI6DCT T/R 6DCT MALLINCKRODT EA,,A7521,623,$627.00 ,$627.00 ,$188.10 ,$570.57 ,$438.90 ,$188.10 ,$407.55 ,$451.44 ,$570.57 ,$470.25 
Carle BroMenn Medical Center,8902514,"*SPECIAL ORDER ITEM, WOUND CARE",,A9999,623,$314.00 ,$314.00 ,$94.20 ,$285.74 ,$219.80 ,$94.20 ,$204.10 ,$226.08 ,$285.74 ,$235.50 
Carle BroMenn Medical Center,8902515,*WOUND CARE SUPPLIES,,A9999,623,$314.00 ,$314.00 ,$94.20 ,$285.74 ,$219.80 ,$94.20 ,$204.10 ,$226.08 ,$285.74 ,$235.50 
Carle BroMenn Medical Center,8902520,PMV2001 T/R PASSY-MUIR VALVE KIT,,L8501,623,$501.00 ,$501.00 ,$150.30 ,$455.91 ,$350.70 ,$150.30 ,$325.65 ,$360.72 ,$455.91 ,$375.75 
Carle BroMenn Medical Center,8902585,TRACH SPEAK VALVUE PM2000 PASSY,,L8501,623,$501.00 ,$501.00 ,$150.30 ,$455.91 ,$350.70 ,$150.30 ,$325.65 ,$360.72 ,$455.91 ,$375.75 
Carle BroMenn Medical Center,8980635,"epoetin alfa-epbx 10,000 unit/mL injection solution",69130801,,635,$585.40 ,$585.40 ,$175.62 ,$532.71 ,$409.78 ,$175.62 ,$380.51 ,$421.49 ,$532.71 ,$439.05 
Carle BroMenn Medical Center,8980635,"epoetin alfa-epbx 10,000 unit/mL injection solution",69130810,,635,$585.40 ,$585.40 ,$175.62 ,$532.71 ,$409.78 ,$175.62 ,$380.51 ,$421.49 ,$532.71 ,$439.05 
Carle BroMenn Medical Center,8980635,"epoetin alfa-epbx 40,000 unit/mL injection solution",69130901,,635,"$1,975.18 ","$1,975.18 ",$592.55 ,"$1,797.41 ","$1,382.63 ",$592.55 ,"$1,283.87 ","$1,422.13 ","$1,797.41 ","$1,481.39 "
Carle BroMenn Medical Center,8980635,"epoetin alfa-epbx 40,000 unit/mL injection solution",69130904,,635,"$1,975.18 ","$1,975.18 ",$592.55 ,"$1,797.41 ","$1,382.63 ",$592.55 ,"$1,283.87 ","$1,422.13 ","$1,797.41 ","$1,481.39 "
Carle BroMenn Medical Center,8200500,BOTOX COSMETIC,,64612,636,$96.00 ,$96.00 ,$28.80 ,$87.36 ,$67.20 ,$28.80 ,$62.40 ,$69.12 ,$87.36 ,$72.00 
Carle BroMenn Medical Center,8201253,APLIGRAF SKIN SUBSTITUTE,,Q4101,636,"$3,290.00 ","$3,290.00 ",$987.00 ,"$2,993.90 ","$2,303.00 ",$987.00 ,"$2,138.50 ","$2,368.80 ","$2,993.90 ","$2,467.50 "
Carle BroMenn Medical Center,8209956,OPTISON PERFLUTREN MCR 3ML,,Q9956,636,"$1,520.00 ","$1,520.00 ",$456.00 ,"$1,383.20 ","$1,064.00 ",$456.00 ,$988.00 ,"$1,094.40 ","$1,383.20 ","$1,140.00 "
Carle BroMenn Medical Center,8209957,DEFINITY 1ML,,Q9957,636,$312.00 ,$312.00 ,$93.60 ,$283.92 ,$218.40 ,$93.60 ,$202.80 ,$224.64 ,$283.92 ,$234.00 
Carle BroMenn Medical Center,8209965,"LOCM 100-199MG/ML IODINE,1ML",,Q9965,636,$5.00 ,$5.00 ,$1.50 ,$4.55 ,$3.50 ,$1.50 ,$3.25 ,$3.60 ,$4.55 ,$3.75 
Carle BroMenn Medical Center,8209966,"LOCM 200-299MG/ML IODINE,1ML",,Q9966,636,$5.00 ,$5.00 ,$1.50 ,$4.55 ,$3.50 ,$1.50 ,$3.25 ,$3.60 ,$4.55 ,$3.75 
Carle BroMenn Medical Center,8209967,"LOCM 300-399MG/ML IODINE,1ML",,Q9967,636,$4.15 ,$4.15 ,$1.25 ,$3.78 ,$2.91 ,$1.25 ,$2.70 ,$2.99 ,$3.78 ,$3.11 
Carle BroMenn Medical Center,8299668,EPIFIX ES-3300,,Q4186,636,$629.00 ,$629.00 ,$188.70 ,$572.39 ,$440.30 ,$188.70 ,$408.85 ,$452.88 ,$572.39 ,$471.75 
Carle BroMenn Medical Center,8299669,EPIFIX ES-4400,,Q4186,636,$629.00 ,$629.00 ,$188.70 ,$572.39 ,$440.30 ,$188.70 ,$408.85 ,$452.88 ,$572.39 ,$471.75 
Carle BroMenn Medical Center,8299684,TISSUE EPIFIX GS-5180 PER SQ CM,,Q4186,636,$629.00 ,$629.00 ,$188.70 ,$572.39 ,$440.30 ,$188.70 ,$408.85 ,$452.88 ,$572.39 ,$471.75 
Carle BroMenn Medical Center,8299698,EZ DERM NONPERF DRESSING PER SQ CM,,Q4136,636,$4.00 ,$4.00 ,$1.20 ,$3.64 ,$2.80 ,$1.20 ,$2.60 ,$2.88 ,$3.64 ,$3.00 
Carle BroMenn Medical Center,8378999,I-131 SODIUM IODIDE CAP PR MCI,,A9517,636,$17.00 ,$17.00 ,$5.10 ,$15.47 ,$11.90 ,$5.10 ,$11.05 ,$12.24 ,$15.47 ,$12.75 
Carle BroMenn Medical Center,8386997,RHIG (300 MICROGRAMS),,J2790,636,$347.00 ,$347.00 ,$104.10 ,$315.77 ,$242.90 ,$104.10 ,$225.55 ,$249.84 ,$315.77 ,$260.25 
Carle BroMenn Medical Center,8386998,RHO D IMMUNE GLOBULIN - 50 MCG,,J2788,636,$410.00 ,$410.00 ,$123.00 ,$373.10 ,$287.00 ,$123.00 ,$266.50 ,$295.20 ,$373.10 ,$307.50 
Carle BroMenn Medical Center,8400002,INJ ATROPINE SULFATE 0.3MG,,J0461,636,$173.00 ,$173.00 ,$51.90 ,$157.43 ,$121.10 ,$51.90 ,$112.45 ,$124.56 ,$157.43 ,$129.75 
Carle BroMenn Medical Center,8400003,ISURPEL HYDROCHLORIDE 1MG/5ML AMPULE,,J7659,636,$86.00 ,$86.00 ,$25.80 ,$78.26 ,$60.20 ,$25.80 ,$55.90 ,$61.92 ,$78.26 ,$64.50 
Carle BroMenn Medical Center,8400004,ATROPOINE SULFATE 1MG/10ML,,J0461,636,$173.00 ,$173.00 ,$51.90 ,$157.43 ,$121.10 ,$51.90 ,$112.45 ,$124.56 ,$157.43 ,$129.75 
Carle BroMenn Medical Center,8401250,DOBUTAMINE HCL 250MG INJECTION,,J1250,636,$20.00 ,$20.00 ,$6.00 ,$18.20 ,$14.00 ,$6.00 ,$13.00 ,$14.40 ,$18.20 ,$15.00 
Carle BroMenn Medical Center,8402250,MIDAZOLAM HCL 1MG INJECTION,,J2250,636,$14.00 ,$14.00 ,$4.20 ,$12.74 ,$9.80 ,$4.20 ,$9.10 ,$10.08 ,$12.74 ,$10.50 
Carle BroMenn Medical Center,8402785,INJ LAXISCAN .1MG /ML,,J2785,636,$210.00 ,$210.00 ,$63.00 ,$191.10 ,$147.00 ,$63.00 ,$136.50 ,$151.20 ,$191.10 ,$157.50 
Carle BroMenn Medical Center,8402805,INJ KINEVAC(SINCALIDE)5MCG,,J2805,636,$675.00 ,$675.00 ,$202.50 ,$614.25 ,$472.50 ,$202.50 ,$438.75 ,$486.00 ,$614.25 ,$506.25 
Carle BroMenn Medical Center,8403785,INJ LAXISCAN .1MG /ML,,J2785,636,$210.00 ,$210.00 ,$63.00 ,$191.10 ,$147.00 ,$63.00 ,$136.50 ,$151.20 ,$191.10 ,$157.50 
Carle BroMenn Medical Center,8409399,"XOFIGO (RADIUM 223), PER mMCI",,A9606,636,$455.00 ,$455.00 ,$136.50 ,$414.05 ,$318.50 ,$136.50 ,$295.75 ,$327.60 ,$414.05 ,$341.25 
Carle BroMenn Medical Center,8409517,I-131 SODIUM IODIDE CAP PR MCI,,A9517,636,$758.00 ,$758.00 ,$227.40 ,$689.78 ,$530.60 ,$227.40 ,$492.70 ,$545.76 ,$689.78 ,$568.50 
Carle BroMenn Medical Center,8409699,"THER RADIOPHARM IMAGING AGENT, NOC",,A9699,636,"$2,130.00 ","$2,130.00 ",$639.00 ,"$1,938.30 ","$1,491.00 ",$639.00 ,"$1,384.50 ","$1,533.60 ","$1,938.30 ","$1,597.50 "
Carle BroMenn Medical Center,8409957,DEFINITY (PERFLUTREN) 1ML INJ,,Q9957,636,$312.00 ,$312.00 ,$93.60 ,$283.92 ,$218.40 ,$93.60 ,$202.80 ,$224.64 ,$283.92 ,$234.00 
Carle BroMenn Medical Center,8409965,CONTRAST MATERIAL PER ML,,Q9965,636,$5.00 ,$5.00 ,$1.50 ,$4.55 ,$3.50 ,$1.50 ,$3.25 ,$3.60 ,$4.55 ,$3.75 
Carle BroMenn Medical Center,8409966,CONTRAST MATERIAL PER ML,,Q9966,636,$6.00 ,$6.00 ,$1.80 ,$5.46 ,$4.20 ,$1.80 ,$3.90 ,$4.32 ,$5.46 ,$4.50 
Carle BroMenn Medical Center,8409967,CONTRAST MATERIAL PER ML,,Q9967,636,$6.00 ,$6.00 ,$1.80 ,$5.46 ,$4.20 ,$1.80 ,$3.90 ,$4.32 ,$5.46 ,$4.50 
Carle BroMenn Medical Center,8419517,I-131 SODIUM IODIDE CAP PR MCI,,A9517,636,$758.00 ,$758.00 ,$227.40 ,$689.78 ,$530.60 ,$227.40 ,$492.70 ,$545.76 ,$689.78 ,$568.50 
Carle BroMenn Medical Center,8419699,"123 IOBENGUANE SULFATE, PER DOSE",,A9699,636,"$2,130.00 ","$2,130.00 ",$639.00 ,"$1,938.30 ","$1,491.00 ",$639.00 ,"$1,384.50 ","$1,533.60 ","$1,938.30 ","$1,597.50 "
Carle BroMenn Medical Center,8429517,I-131 SODIUM IODIDE CAP PR MCI,,A9517,636,$758.00 ,$758.00 ,$227.40 ,$689.78 ,$530.60 ,$227.40 ,$492.70 ,$545.76 ,$689.78 ,$568.50 
Carle BroMenn Medical Center,8910010,"HC NUSHIELD, PER SQ CM",,Q4160,636,$305.00 ,$305.00 ,$91.50 ,$277.55 ,$213.50 ,$91.50 ,$198.25 ,$219.60 ,$277.55 ,$228.75 
Carle BroMenn Medical Center,8910012,GRAFIX PRIME PER SQ CM,,Q4133,636,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8910014,GRAFIX CORE PER SQ CM,,Q4132,636,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8914101,APLIGRAF PER SQUARE CENTIMETER,,Q4101,636,$88.00 ,$88.00 ,$26.40 ,$80.08 ,$61.60 ,$26.40 ,$57.20 ,$63.36 ,$80.08 ,$66.00 
Carle BroMenn Medical Center,8914110,PRIMATRIX SKIN SUB PER SQ CM,,Q4110,636,$119.00 ,$119.00 ,$35.70 ,$108.29 ,$83.30 ,$35.70 ,$77.35 ,$85.68 ,$108.29 ,$89.25 
Carle BroMenn Medical Center,8914131,"EPIFIX, PER SQ CM",,Q4186,636,$629.00 ,$629.00 ,$188.70 ,$572.39 ,$440.30 ,$188.70 ,$408.85 ,$452.88 ,$572.39 ,$471.75 
Carle BroMenn Medical Center,8914187,EPICORD PER SQ CM,,Q4187,636,$564.00 ,$564.00 ,$169.20 ,$513.24 ,$394.80 ,$169.20 ,$366.60 ,$406.08 ,$513.24 ,$423.00 
Carle BroMenn Medical Center,8914196,PURAPLY AM PER SQ CM,,Q4196,636,$500.00 ,$500.00 ,$150.00 ,$455.00 ,$350.00 ,$150.00 ,$325.00 ,$360.00 ,$455.00 ,$375.00 
Carle BroMenn Medical Center,8980636,abatacept (with maltose) 250 mg intravenous solution,3218713,J0129,636,"$13,803.24 ","$13,803.24 ","$4,140.97 ","$12,560.95 ","$9,662.27 ","$4,140.97 ","$8,972.11 ","$9,938.33 ","$12,560.95 ","$10,352.43 "
Carle BroMenn Medical Center,8980636,"acetaminophen 1,000 mg/100 mL (10 mg/mL) intravenous solution",781315606,J0131,636,$88.67 ,$88.67 ,$26.60 ,$80.69 ,$62.07 ,$26.60 ,$57.64 ,$63.84 ,$80.69 ,$66.50 
Carle BroMenn Medical Center,8980636,"acetaminophen 1,000 mg/100 mL (10 mg/mL) intravenous solution",781315695,J0131,636,$88.67 ,$88.67 ,$26.60 ,$80.69 ,$62.07 ,$26.60 ,$57.64 ,$63.84 ,$80.69 ,$66.50 
Carle BroMenn Medical Center,8980636,acetaZOLAMIDE 500 mg solution for injection,143950301,J1120,636,$283.15 ,$283.15 ,$84.95 ,$257.67 ,$198.21 ,$84.95 ,$184.05 ,$203.87 ,$257.67 ,$212.36 
Carle BroMenn Medical Center,8980636,acetaZOLAMIDE 500 mg solution for injection,39822019001,J1120,636,$220.84 ,$220.84 ,$66.25 ,$200.96 ,$154.59 ,$66.25 ,$143.55 ,$159.00 ,$200.96 ,$165.63 
Carle BroMenn Medical Center,8980636,acetaZOLAMIDE 500 mg solution for injection,67457085350,J1120,636,$261.01 ,$261.01 ,$78.30 ,$237.52 ,$182.71 ,$78.30 ,$169.66 ,$187.93 ,$237.52 ,$195.76 
Carle BroMenn Medical Center,8980636,acetylcysteine 200 mg/mL (20 %) intravenous solution,574080530,J0132,636,$37.18 ,$37.18 ,$11.15 ,$33.83 ,$26.03 ,$11.15 ,$24.17 ,$26.77 ,$33.83 ,$27.89 
Carle BroMenn Medical Center,8980636,acetylcysteine 200 mg/mL (20 %) intravenous solution,63323096321,J0132,636,$37.18 ,$37.18 ,$11.15 ,$33.83 ,$26.03 ,$11.15 ,$24.17 ,$26.77 ,$33.83 ,$27.89 
Carle BroMenn Medical Center,8980636,acetylcysteine 200 mg/mL (20 %) intravenous solution,63323096330,J0132,636,$37.18 ,$37.18 ,$11.15 ,$33.83 ,$26.03 ,$11.15 ,$24.17 ,$26.77 ,$33.83 ,$27.89 
Carle BroMenn Medical Center,8980636,acetylcysteine 200 mg/mL (20 %) solution,409330803,J7608,636,$12.35 ,$12.35 ,$3.71 ,$11.24 ,$8.65 ,$3.71 ,$8.03 ,$8.89 ,$11.24 ,$9.26 
Carle BroMenn Medical Center,8980636,acetylcysteine 200 mg/mL (20 %) solution,517760425,J7608,636,$72.06 ,$72.06 ,$21.62 ,$65.57 ,$50.44 ,$21.62 ,$46.84 ,$51.88 ,$65.57 ,$54.05 
Carle BroMenn Medical Center,8980636,acetylcysteine 200 mg/mL (20 %) solution,63323069030,J7608,636,$118.92 ,$118.92 ,$35.68 ,$108.22 ,$83.24 ,$35.68 ,$77.30 ,$85.62 ,$108.22 ,$89.19 
Carle BroMenn Medical Center,8980636,acetylcysteine 200 mg/mL (20 %) solution,63323069404,J7608,636,$73.85 ,$73.85 ,$22.16 ,$67.20 ,$51.70 ,$22.16 ,$48.00 ,$53.17 ,$67.20 ,$55.39 
Carle BroMenn Medical Center,8980636,acyclovir sodium 50 mg/mL intravenous solution,55150015410,J0133,636,$128.07 ,$128.07 ,$38.42 ,$116.54 ,$89.65 ,$38.42 ,$83.25 ,$92.21 ,$116.54 ,$96.05 
Carle BroMenn Medical Center,8980636,acyclovir sodium 50 mg/mL intravenous solution,63323032503,J0133,636,$166.25 ,$166.25 ,$49.88 ,$151.29 ,$116.38 ,$49.88 ,$108.06 ,$119.70 ,$151.29 ,$124.69 
Carle BroMenn Medical Center,8980636,acyclovir sodium 50 mg/mL intravenous solution,63323032510,J0133,636,$166.25 ,$166.25 ,$49.88 ,$151.29 ,$116.38 ,$49.88 ,$108.06 ,$119.70 ,$151.29 ,$124.69 
Carle BroMenn Medical Center,8980636,acyclovir sodium 50 mg/mL intravenous solution,63323032514,J0133,636,$64.98 ,$64.98 ,$19.49 ,$59.13 ,$45.49 ,$19.49 ,$42.24 ,$46.79 ,$59.13 ,$48.74 
Carle BroMenn Medical Center,8980636,acyclovir sodium 50 mg/mL intravenous solution,63323032520,J0133,636,$157.17 ,$157.17 ,$47.15 ,$143.02 ,$110.02 ,$47.15 ,$102.16 ,$113.16 ,$143.02 ,$117.88 
Carle BroMenn Medical Center,8980636,acyclovir sodium 50 mg/mL intravenous solution,63323032524,J0133,636,$47.51 ,$47.51 ,$14.25 ,$43.23 ,$33.26 ,$14.25 ,$30.88 ,$34.21 ,$43.23 ,$35.63 
Carle BroMenn Medical Center,8980636,adenosine (diagnostic) 3 mg/mL intravenous solution,409193202,,636,$756.51 ,$756.51 ,$226.95 ,$688.42 ,$529.56 ,$226.95 ,$491.73 ,$544.69 ,$688.42 ,$567.38 
Carle BroMenn Medical Center,8980636,adenosine (diagnostic) 3 mg/mL intravenous solution,17478054430,,636,$778.16 ,$778.16 ,$233.45 ,$708.13 ,$544.71 ,$233.45 ,$505.80 ,$560.28 ,$708.13 ,$583.62 
Carle BroMenn Medical Center,8980636,adenosine (diagnostic) 3 mg/mL intravenous solution,55150019330,,636,$835.66 ,$835.66 ,$250.70 ,$760.45 ,$584.96 ,$250.70 ,$543.18 ,$601.68 ,$760.45 ,$626.75 
Carle BroMenn Medical Center,8980636,adenosine (diagnostic) 3 mg/mL intravenous solution,55150019330,,636,"$1,251.79 ","$1,251.79 ",$375.54 ,"$1,139.13 ",$876.25 ,$375.54 ,$813.66 ,$901.29 ,"$1,139.13 ",$938.84 
Carle BroMenn Medical Center,8980636,adenosine (diagnostic) 3 mg/mL intravenous solution,67457085730,,636,$915.98 ,$915.98 ,$274.79 ,$833.54 ,$641.19 ,$274.79 ,$595.39 ,$659.51 ,$833.54 ,$686.99 
Carle BroMenn Medical Center,8980636,adenosine 3 mg/mL intravenous solution,67457085500,,636,$47.05 ,$47.05 ,$14.12 ,$42.82 ,$32.94 ,$14.12 ,$30.58 ,$33.88 ,$42.82 ,$35.29 
Carle BroMenn Medical Center,8980636,adenosine 3 mg/mL intravenous solution,67457085502,,636,$47.05 ,$47.05 ,$14.12 ,$42.82 ,$32.94 ,$14.12 ,$30.58 ,$33.88 ,$42.82 ,$35.29 
Carle BroMenn Medical Center,8980636,"albumin, human 25 % intravenous solution",44206025105,P9047,636,$631.96 ,$631.96 ,$189.59 ,$575.08 ,$442.37 ,$189.59 ,$410.77 ,$455.01 ,$575.08 ,$473.97 
Carle BroMenn Medical Center,8980636,"albumin, human 25 % intravenous solution",44206025110,P9047,636,$631.96 ,$631.96 ,$189.59 ,$575.08 ,$442.37 ,$189.59 ,$410.77 ,$455.01 ,$575.08 ,$473.97 
Carle BroMenn Medical Center,8980636,"albumin, human 25 % intravenous solution",68516521601,P9047,636,$324.66 ,$324.66 ,$97.40 ,$295.44 ,$227.26 ,$97.40 ,$211.03 ,$233.76 ,$295.44 ,$243.50 
Carle BroMenn Medical Center,8980636,"albumin, human 25 % intravenous solution",68516521602,P9047,636,$324.66 ,$324.66 ,$97.40 ,$295.44 ,$227.26 ,$97.40 ,$211.03 ,$233.76 ,$295.44 ,$243.50 
Carle BroMenn Medical Center,8980636,"albumin, human 25 % intravenous solution",68516521603,P9047,636,$324.66 ,$324.66 ,$97.40 ,$295.44 ,$227.26 ,$97.40 ,$211.03 ,$233.76 ,$295.44 ,$243.50 
Carle BroMenn Medical Center,8980636,"albumin, human 25 % intravenous solution",68516521604,P9047,636,$324.66 ,$324.66 ,$97.40 ,$295.44 ,$227.26 ,$97.40 ,$211.03 ,$233.76 ,$295.44 ,$243.50 
Carle BroMenn Medical Center,8980636,"albumin, human 25 % intravenous solution",68516521605,P9046,636,$195.46 ,$195.46 ,$58.64 ,$177.87 ,$136.82 ,$58.64 ,$127.05 ,$140.73 ,$177.87 ,$146.60 
Carle BroMenn Medical Center,8980636,"albumin, human 5 % intravenous solution",44206031025,P9045,636,$658.15 ,$658.15 ,$197.45 ,$598.92 ,$460.71 ,$197.45 ,$427.80 ,$473.87 ,$598.92 ,$493.61 
Carle BroMenn Medical Center,8980636,"albumin, human 5 % intravenous solution",44206031050,P9045,636,$631.96 ,$631.96 ,$189.59 ,$575.08 ,$442.37 ,$189.59 ,$410.77 ,$455.01 ,$575.08 ,$473.97 
Carle BroMenn Medical Center,8980636,"albumin, human 5 % intravenous solution",68516521401,P9045,636,$338.05 ,$338.05 ,$101.42 ,$307.63 ,$236.64 ,$101.42 ,$219.73 ,$243.40 ,$307.63 ,$253.54 
Carle BroMenn Medical Center,8980636,"albumin, human 5 % intravenous solution",68516521402,P9045,636,$324.96 ,$324.96 ,$97.49 ,$295.71 ,$227.47 ,$97.49 ,$211.22 ,$233.97 ,$295.71 ,$243.72 
Carle BroMenn Medical Center,8980636,"albumin, human 5 % intravenous solution",68516521405,P9041,636,"$1,141.21 ","$1,141.21 ",$342.36 ,"$1,038.50 ",$798.85 ,$342.36 ,$741.79 ,$821.67 ,"$1,038.50 ",$855.91 
Carle BroMenn Medical Center,8980636,"Albumin, Human 5 % IV",44206031050,P9045,636,"$5,031.88 ","$5,031.88 ","$1,509.56 ","$4,579.01 ","$3,522.32 ","$1,509.56 ","$3,270.72 ","$3,622.95 ","$4,579.01 ","$3,773.91 "
Carle BroMenn Medical Center,8980636,"Albumin, Human 5 % IV",68516521402,P9045,636,"$2,575.84 ","$2,575.84 ",$772.75 ,"$2,344.01 ","$1,803.09 ",$772.75 ,"$1,674.30 ","$1,854.60 ","$2,344.01 ","$1,931.88 "
Carle BroMenn Medical Center,8980636,"albumin, human-kjda 25 % intravenous solution",64208251203,P9046,636,$198.95 ,$198.95 ,$59.69 ,$181.04 ,$139.27 ,$59.69 ,$129.32 ,$143.24 ,$181.04 ,$149.21 
Carle BroMenn Medical Center,8980636,"albumin, human-kjda 25 % intravenous solution",64208251207,P9046,636,$198.95 ,$198.95 ,$59.69 ,$181.04 ,$139.27 ,$59.69 ,$129.32 ,$143.24 ,$181.04 ,$149.21 
Carle BroMenn Medical Center,8980636,"albumin, human-kjda 5 % intravenous solution",64208251001,P9041,636,$492.28 ,$492.28 ,$147.68 ,$447.97 ,$344.60 ,$147.68 ,$319.98 ,$354.44 ,$447.97 ,$369.21 
Carle BroMenn Medical Center,8980636,"albumin, human-kjda 5 % intravenous solution",64208251005,P9041,636,$492.28 ,$492.28 ,$147.68 ,$447.97 ,$344.60 ,$147.68 ,$319.98 ,$354.44 ,$447.97 ,$369.21 
Carle BroMenn Medical Center,8980636,albuterol sulfate 1.25 mg/3 mL solution for nebulization,378699252,J7613,636,$10.06 ,$10.06 ,$3.02 ,$9.15 ,$7.04 ,$3.02 ,$6.54 ,$7.24 ,$9.15 ,$7.55 
Carle BroMenn Medical Center,8980636,albuterol sulfate 1.25 mg/3 mL solution for nebulization,378699298,J7613,636,$10.06 ,$10.06 ,$3.02 ,$9.15 ,$7.04 ,$3.02 ,$6.54 ,$7.24 ,$9.15 ,$7.55 
Carle BroMenn Medical Center,8980636,albuterol sulfate 1.25 mg/3 mL solution for nebulization,487990401,J7613,636,$9.75 ,$9.75 ,$2.93 ,$8.87 ,$6.83 ,$2.93 ,$6.34 ,$7.02 ,$8.87 ,$7.31 
Carle BroMenn Medical Center,8980636,albuterol sulfate 1.25 mg/3 mL solution for nebulization,487990425,J7613,636,$9.75 ,$9.75 ,$2.93 ,$8.87 ,$6.83 ,$2.93 ,$6.34 ,$7.02 ,$8.87 ,$7.31 
Carle BroMenn Medical Center,8980636,albuterol sulfate 2.5 mg/3 mL (0.083 %) solution for nebulization,487950101,J7613,636,$2.89 ,$2.89 ,$0.87 ,$2.63 ,$2.02 ,$0.87 ,$1.88 ,$2.08 ,$2.63 ,$2.17 
Carle BroMenn Medical Center,8980636,albuterol sulfate 2.5 mg/3 mL (0.083 %) solution for nebulization,60687039579,J7613,636,$2.90 ,$2.90 ,$0.87 ,$2.64 ,$2.03 ,$0.87 ,$1.89 ,$2.09 ,$2.64 ,$2.18 
Carle BroMenn Medical Center,8980636,albuterol sulfate 2.5 mg/3 mL (0.083 %) solution for nebulization,60687039583,J7613,636,$2.90 ,$2.90 ,$0.87 ,$2.64 ,$2.03 ,$0.87 ,$1.89 ,$2.09 ,$2.64 ,$2.18 
Carle BroMenn Medical Center,8980636,albuterol sulfate concentrate 2.5 mg/0.5 mL solution for nebulization,487990130,J7613,636,$4.45 ,$4.45 ,$1.34 ,$4.05 ,$3.12 ,$1.34 ,$2.89 ,$3.20 ,$4.05 ,$3.34 
Carle BroMenn Medical Center,8980636,aldesleukin 22 million unit intravenous solution,76310002201,J9015,636,"$16,442.49 ","$16,442.49 ","$4,932.75 ","$14,962.67 ","$11,509.74 ","$4,932.75 ","$10,687.62 ","$11,838.59 ","$14,962.67 ","$12,331.87 "
Carle BroMenn Medical Center,8980636,alemtuzumab 12 mg/1.2 mL intravenous solution,58468020001,,636,"$72,539.89 ","$72,539.89 ","$21,761.97 ","$66,011.30 ","$50,777.92 ","$21,761.97 ","$47,150.93 ","$52,228.72 ","$66,011.30 ","$54,404.92 "
Carle BroMenn Medical Center,8980636,alprostadiL 500 mcg/mL injection solution,9316901,J0270,636,$793.09 ,$793.09 ,$237.93 ,$721.71 ,$555.16 ,$237.93 ,$515.51 ,$571.02 ,$721.71 ,$594.82 
Carle BroMenn Medical Center,8980636,alprostadiL 500 mcg/mL injection solution,9316906,J0270,636,$793.09 ,$793.09 ,$237.93 ,$721.71 ,$555.16 ,$237.93 ,$515.51 ,$571.02 ,$721.71 ,$594.82 
Carle BroMenn Medical Center,8980636,alteplase 100 mg intravenous solution,50242008525,J2997,636,$666.86 ,$666.86 ,$200.06 ,$606.84 ,$466.80 ,$200.06 ,$433.46 ,$480.14 ,$606.84 ,$500.15 
Carle BroMenn Medical Center,8980636,alteplase 100 mg intravenous solution,50242008527,J2997,636,$666.86 ,$666.86 ,$200.06 ,$606.84 ,$466.80 ,$200.06 ,$433.46 ,$480.14 ,$606.84 ,$500.15 
Carle BroMenn Medical Center,8980636,Alteplase 100 mg IV Solution,50242008527,J2997,636,"$24,780.54 ","$24,780.54 ","$7,434.16 ","$22,550.29 ","$17,346.38 ","$7,434.16 ","$16,107.35 ","$17,841.99 ","$22,550.29 ","$18,585.41 "
Carle BroMenn Medical Center,8980636,alteplase 2 mg intra-catheter solution,50242004164,J2997,636,$764.99 ,$764.99 ,$229.50 ,$696.14 ,$535.49 ,$229.50 ,$497.24 ,$550.79 ,$696.14 ,$573.74 
Carle BroMenn Medical Center,8980636,alteplase 50 mg intravenous solution,50242004406,J2997,636,"$15,452.80 ","$15,452.80 ","$4,635.84 ","$14,062.05 ","$10,816.96 ","$4,635.84 ","$10,044.32 ","$11,126.02 ","$14,062.05 ","$11,589.60 "
Carle BroMenn Medical Center,8980636,alteplase 50 mg intravenous solution,50242004413,J2997,636,"$15,452.80 ","$15,452.80 ","$4,635.84 ","$14,062.05 ","$10,816.96 ","$4,635.84 ","$10,044.32 ","$11,126.02 ","$14,062.05 ","$11,589.60 "
Carle BroMenn Medical Center,8980636,amikacin 500 mg/2 mL injection solution,23155029031,J0278,636,$120.54 ,$120.54 ,$36.16 ,$109.69 ,$84.38 ,$36.16 ,$78.35 ,$86.79 ,$109.69 ,$90.41 
Carle BroMenn Medical Center,8980636,amikacin 500 mg/2 mL injection solution,23155029041,J0278,636,$120.54 ,$120.54 ,$36.16 ,$109.69 ,$84.38 ,$36.16 ,$78.35 ,$86.79 ,$109.69 ,$90.41 
Carle BroMenn Medical Center,8980636,amino acid 4.25 % in 10 % dextrose intravenous solution,338109104,B4189,636,$523.83 ,$523.83 ,$157.15 ,$476.69 ,$366.68 ,$157.15 ,$340.49 ,$377.16 ,$476.69 ,$392.87 
Carle BroMenn Medical Center,8980636,amino acid 4.25 % in 10 % dextrose intravenous solution,338113403,B4189,636,$535.47 ,$535.47 ,$160.64 ,$487.28 ,$374.83 ,$160.64 ,$348.06 ,$385.54 ,$487.28 ,$401.60 
Carle BroMenn Medical Center,8980636,amino acid 4.25 % in dextrose 5 % intravenous solution,338108904,B4189,636,$523.83 ,$523.83 ,$157.15 ,$476.69 ,$366.68 ,$157.15 ,$340.49 ,$377.16 ,$476.69 ,$392.87 
Carle BroMenn Medical Center,8980636,amino acid 4.25 % in dextrose 5 % intravenous solution,338113303,B4189,636,$523.83 ,$523.83 ,$157.15 ,$476.69 ,$366.68 ,$157.15 ,$340.49 ,$377.16 ,$476.69 ,$392.87 
Carle BroMenn Medical Center,8980636,amino acid 5 % in 15 % dextrose intravenous solution,338109904,B4189,636,$558.75 ,$558.75 ,$167.63 ,$508.46 ,$391.13 ,$167.63 ,$363.19 ,$402.30 ,$508.46 ,$419.06 
Carle BroMenn Medical Center,8980636,amino acid 5 % in 15 % dextrose intravenous solution,338113703,B4189,636,$605.31 ,$605.31 ,$181.59 ,$550.83 ,$423.72 ,$181.59 ,$393.45 ,$435.82 ,$550.83 ,$453.98 
Carle BroMenn Medical Center,8980636,aminophylline 250 mg/10 mL intravenous solution,409592101,J0280,636,$122.25 ,$122.25 ,$36.68 ,$111.25 ,$85.58 ,$36.68 ,$79.46 ,$88.02 ,$111.25 ,$91.69 
Carle BroMenn Medical Center,8980636,aminophylline 250 mg/10 mL intravenous solution,409592116,J0280,636,$122.25 ,$122.25 ,$36.68 ,$111.25 ,$85.58 ,$36.68 ,$79.46 ,$88.02 ,$111.25 ,$91.69 
Carle BroMenn Medical Center,8980636,"amiodarone 150 mg/100 mL (1.5 mg/mL) in dextrose, iso-osmotic IV",43066015010,J0282,636,$245.51 ,$245.51 ,$73.65 ,$223.41 ,$171.86 ,$73.65 ,$159.58 ,$176.77 ,$223.41 ,$184.13 
Carle BroMenn Medical Center,8980636,"amiodarone 360 mg/200 mL (1.8 mg/mL) in dextrose, iso-osmotic IV",43066036020,J0282,636,$357.38 ,$357.38 ,$107.21 ,$325.22 ,$250.17 ,$107.21 ,$232.30 ,$257.31 ,$325.22 ,$268.04 
Carle BroMenn Medical Center,8980636,amiodarone 50 mg/mL intravenous solution,143987501,J0282,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,amiodarone 50 mg/mL intravenous solution,143987525,J0282,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,amiodarone 50 mg/mL intravenous solution,63323061602,J0282,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,amiodarone 50 mg/mL intravenous solution,63323061603,J0282,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,amiodarone 50 mg/mL intravenous solution,63323061609,J0282,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,amiodarone 50 mg/mL intravenous solution,67457015318,J0282,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,amiodarone 50 mg/mL intravenous solution,67457015399,J0282,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,amphotericin B liposome 50 mg intravenous suspension,469305130,J0289,636,"$1,558.77 ","$1,558.77 ",$467.63 ,"$1,418.48 ","$1,091.14 ",$467.63 ,"$1,013.20 ","$1,122.31 ","$1,418.48 ","$1,169.08 "
Carle BroMenn Medical Center,8980636,ampicillin 1 gram solution for injection,409372601,J0290,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,ampicillin 1 gram solution for injection,409372610,J0290,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,ampicillin 1 gram solution for injection,781340485,J0290,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,ampicillin 1 gram solution for injection,781340495,J0290,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,ampicillin 1 gram solution for injection,781940485,J0290,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,ampicillin 2 gram solution for injection,409372001,J0290,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,ampicillin 2 gram solution for injection,409372010,J0290,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,ampicillin 2 gram solution for injection,781340880,J0290,636,$132.45 ,$132.45 ,$39.74 ,$120.53 ,$92.72 ,$39.74 ,$86.09 ,$95.36 ,$120.53 ,$99.34 
Carle BroMenn Medical Center,8980636,ampicillin 2 gram solution for injection,781340895,J0290,636,$132.45 ,$132.45 ,$39.74 ,$120.53 ,$92.72 ,$39.74 ,$86.09 ,$95.36 ,$120.53 ,$99.34 
Carle BroMenn Medical Center,8980636,ampicillin 2 gram solution for injection,781927380,J0290,636,$132.45 ,$132.45 ,$39.74 ,$120.53 ,$92.72 ,$39.74 ,$86.09 ,$95.36 ,$120.53 ,$99.34 
Carle BroMenn Medical Center,8980636,ampicillin 2 gram solution for injection,781927395,J0290,636,$132.45 ,$132.45 ,$39.74 ,$120.53 ,$92.72 ,$39.74 ,$86.09 ,$95.36 ,$120.53 ,$99.34 
Carle BroMenn Medical Center,8980636,ampicillin 2 gram solution for injection,67457035202,J0290,636,$127.60 ,$127.60 ,$38.28 ,$116.12 ,$89.32 ,$38.28 ,$82.94 ,$91.87 ,$116.12 ,$95.70 
Carle BroMenn Medical Center,8980636,ampicillin 2 gram solution for injection,67457035210,J0290,636,$127.60 ,$127.60 ,$38.28 ,$116.12 ,$89.32 ,$38.28 ,$82.94 ,$91.87 ,$116.12 ,$95.70 
Carle BroMenn Medical Center,8980636,ampicillin 2 gram solution for injection,67850002200,J0290,636,$126.91 ,$126.91 ,$38.07 ,$115.49 ,$88.84 ,$38.07 ,$82.49 ,$91.38 ,$115.49 ,$95.18 
Carle BroMenn Medical Center,8980636,ampicillin 2 gram solution for injection,67850002210,J0290,636,$126.91 ,$126.91 ,$38.07 ,$115.49 ,$88.84 ,$38.07 ,$82.49 ,$91.38 ,$115.49 ,$95.18 
Carle BroMenn Medical Center,8980636,ampicillin 250 mg solution for injection,781340278,J0290,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,ampicillin 250 mg solution for injection,781340295,J0290,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,ampicillin 500 mg solution for injection,781340795,J0290,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,ampicillin 500 mg solution for injection,44567010110,J0290,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,ampicillin-sulbactam 1.5 gram solution for injection,49001383,J0295,636,$88.28 ,$88.28 ,$26.48 ,$80.33 ,$61.80 ,$26.48 ,$57.38 ,$63.56 ,$80.33 ,$66.21 
Carle BroMenn Medical Center,8980636,ampicillin-sulbactam 1.5 gram solution for injection,641611601,J0295,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,ampicillin-sulbactam 1.5 gram solution for injection,641611610,J0295,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,ampicillin-sulbactam 1.5 gram solution for injection,25021014220,J0295,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,ampicillin-sulbactam 1.5 gram solution for injection,55150011620,J0295,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,ampicillin-sulbactam 15 gram solution for injection,67457064910,J0295,636,$422.19 ,$422.19 ,$126.66 ,$384.19 ,$295.53 ,$126.66 ,$274.42 ,$303.98 ,$384.19 ,$316.64 
Carle BroMenn Medical Center,8980636,ampicillin-sulbactam 3 gram solution for injection,49001481,J0295,636,$135.65 ,$135.65 ,$40.70 ,$123.44 ,$94.96 ,$40.70 ,$88.17 ,$97.67 ,$123.44 ,$101.74 
Carle BroMenn Medical Center,8980636,ampicillin-sulbactam 3 gram solution for injection,49001483,J0295,636,$135.65 ,$135.65 ,$40.70 ,$123.44 ,$94.96 ,$40.70 ,$88.17 ,$97.67 ,$123.44 ,$101.74 
Carle BroMenn Medical Center,8980636,ampicillin-sulbactam 3 gram solution for injection,55150011720,J0295,636,$119.92 ,$119.92 ,$35.98 ,$109.13 ,$83.94 ,$35.98 ,$77.95 ,$86.34 ,$109.13 ,$89.94 
Carle BroMenn Medical Center,8980636,ampicillin-sulbactam 3 gram solution for injection,67457034903,J0295,636,$124.40 ,$124.40 ,$37.32 ,$113.20 ,$87.08 ,$37.32 ,$80.86 ,$89.57 ,$113.20 ,$93.30 
Carle BroMenn Medical Center,8980636,ampicillin-sulbactam 3 gram solution for injection,67457034910,J0295,636,$124.40 ,$124.40 ,$37.32 ,$113.20 ,$87.08 ,$37.32 ,$80.86 ,$89.57 ,$113.20 ,$93.30 
Carle BroMenn Medical Center,8980636,ampicillin-sulbactam 3 gram solution for injection,71288000630,J0295,636,$92.01 ,$92.01 ,$27.60 ,$83.73 ,$64.41 ,$27.60 ,$59.81 ,$66.25 ,$83.73 ,$69.01 
Carle BroMenn Medical Center,8980636,anastrozole 1 mg tablet,16729003510,J8999,636,$54.71 ,$54.71 ,$16.41 ,$49.79 ,$38.30 ,$16.41 ,$35.56 ,$39.39 ,$49.79 ,$41.03 
Carle BroMenn Medical Center,8980636,anastrozole 1 mg tablet,60687011211,J8999,636,$11.99 ,$11.99 ,$3.60 ,$10.91 ,$8.39 ,$3.60 ,$7.79 ,$8.63 ,$10.91 ,$8.99 
Carle BroMenn Medical Center,8980636,anastrozole 1 mg tablet,60687011221,J8999,636,$11.99 ,$11.99 ,$3.60 ,$10.91 ,$8.39 ,$3.60 ,$7.79 ,$8.63 ,$10.91 ,$8.99 
Carle BroMenn Medical Center,8980636,"antihemophilic factor-vWF 1,000 unit-2,400 unit intravenous solution",63833061702,J7187,636,$34.95 ,$34.95 ,$10.49 ,$31.80 ,$24.47 ,$10.49 ,$22.72 ,$25.16 ,$31.80 ,$26.21 
Carle BroMenn Medical Center,8980636,antihemophilic factor-vWF 250 unit-600 unit intravenous solution,63833061502,J7187,636,$34.95 ,$34.95 ,$10.49 ,$31.80 ,$24.47 ,$10.49 ,$22.72 ,$25.16 ,$31.80 ,$26.21 
Carle BroMenn Medical Center,8980636,"antihemophilic factor-vWF 500 unit-1,200 unit intravenous solution",63833061602,J7187,636,$34.95 ,$34.95 ,$10.49 ,$31.80 ,$24.47 ,$10.49 ,$22.72 ,$25.16 ,$31.80 ,$26.21 
Carle BroMenn Medical Center,8980636,anti-inhibitor coagulant complex 350 unit-650 unit intravenous soln,64193042602,J7198,636,$34.95 ,$34.95 ,$10.49 ,$31.80 ,$24.47 ,$10.49 ,$22.72 ,$25.16 ,$31.80 ,$26.21 
Carle BroMenn Medical Center,8980636,"anti-inhibitor coagulant complex 700 unit-1,300 unit intravenous soln",64193042402,J7198,636,$34.95 ,$34.95 ,$10.49 ,$31.80 ,$24.47 ,$10.49 ,$22.72 ,$25.16 ,$31.80 ,$26.21 
Carle BroMenn Medical Center,8980636,"anti-inhibitor coagulant complx 1,750 unit-3,250 unit intravenous soln",64193042502,J7198,636,$34.95 ,$34.95 ,$10.49 ,$31.80 ,$24.47 ,$10.49 ,$22.72 ,$25.16 ,$31.80 ,$26.21 
Carle BroMenn Medical Center,8980636,argatroban 100 mg/mL intravenous solution,143967401,,636,"$2,860.07 ","$2,860.07 ",$858.02 ,"$2,602.66 ","$2,002.05 ",$858.02 ,"$1,859.05 ","$2,059.25 ","$2,602.66 ","$2,145.05 "
Carle BroMenn Medical Center,8980636,argatroban 1000 mcg/mL in 0.9 % sodium chloride,9999501812,,636,$710.36 ,$710.36 ,$213.11 ,$646.43 ,$497.25 ,$213.11 ,$461.73 ,$511.46 ,$646.43 ,$532.77 
Carle BroMenn Medical Center,8980636,atropine 0.1 mg/mL injection syringe,409491111,J0461,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,atropine 0.1 mg/mL injection syringe,409491134,J0461,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,atropine 0.1 mg/mL injection syringe,76329334001,J0461,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,atropine 0.4 mg/mL injection solution,517040125,J0461,636,$59.27 ,$59.27 ,$17.78 ,$53.94 ,$41.49 ,$17.78 ,$38.53 ,$42.67 ,$53.94 ,$44.45 
Carle BroMenn Medical Center,8980636,atropine 1 mg/mL injection solution,517101025,J0461,636,$91.12 ,$91.12 ,$27.34 ,$82.92 ,$63.78 ,$27.34 ,$59.23 ,$65.61 ,$82.92 ,$68.34 
Carle BroMenn Medical Center,8980636,azaTHIOprine 50 mg tablet,9999470205,J7500,636,$4.30 ,$4.30 ,$1.29 ,$3.91 ,$3.01 ,$1.29 ,$2.80 ,$3.10 ,$3.91 ,$3.23 
Carle BroMenn Medical Center,8980636,azaTHIOprine 50 mg tablet,68084022901,J7500,636,$6.27 ,$6.27 ,$1.88 ,$5.71 ,$4.39 ,$1.88 ,$4.08 ,$4.51 ,$5.71 ,$4.70 
Carle BroMenn Medical Center,8980636,azaTHIOprine 50 mg tablet,68084022911,J7500,636,$6.27 ,$6.27 ,$1.88 ,$5.71 ,$4.39 ,$1.88 ,$4.08 ,$4.51 ,$5.71 ,$4.70 
Carle BroMenn Medical Center,8980636,azithromycin 500 mg intravenous solution,63323039801,J0456,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,azithromycin 500 mg intravenous solution,63323039810,J0456,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,azithromycin 500 mg intravenous solution,70436001982,J0456,636,$135.64 ,$135.64 ,$40.69 ,$123.43 ,$94.95 ,$40.69 ,$88.17 ,$97.66 ,$123.43 ,$101.73 
Carle BroMenn Medical Center,8980636,belatacept 250 mg intravenous solution,3037113,J0485,636,"$4,148.85 ","$4,148.85 ","$1,244.66 ","$3,775.45 ","$2,904.20 ","$1,244.66 ","$2,696.75 ","$2,987.17 ","$3,775.45 ","$3,111.64 "
Carle BroMenn Medical Center,8980636,benztropine 1 mg/mL injection solution,63323097002,J0515,636,$191.11 ,$191.11 ,$57.33 ,$173.91 ,$133.78 ,$57.33 ,$124.22 ,$137.60 ,$173.91 ,$143.33 
Carle BroMenn Medical Center,8980636,benztropine 1 mg/mL injection solution,68382086010,J0515,636,$174.36 ,$174.36 ,$52.31 ,$158.67 ,$122.05 ,$52.31 ,$113.33 ,$125.54 ,$158.67 ,$130.77 
Carle BroMenn Medical Center,8980636,betamethasone acetate and sodium phos 6 mg/mL suspension for injection,517072001,J0702,636,$75.34 ,$75.34 ,$22.60 ,$68.56 ,$52.74 ,$22.60 ,$48.97 ,$54.24 ,$68.56 ,$56.51 
Carle BroMenn Medical Center,8980636,bicalutamide 50 mg tablet,904601946,J8999,636,$68.12 ,$68.12 ,$20.44 ,$61.99 ,$47.68 ,$20.44 ,$44.28 ,$49.05 ,$61.99 ,$51.09 
Carle BroMenn Medical Center,8980636,bicalutamide 50 mg tablet,16729002310,J8999,636,$74.73 ,$74.73 ,$22.42 ,$68.00 ,$52.31 ,$22.42 ,$48.57 ,$53.81 ,$68.00 ,$56.05 
Carle BroMenn Medical Center,8980636,bivalirudin 250 mg intravenous powder for solution,409830010,J0583,636,"$3,014.55 ","$3,014.55 ",$904.37 ,"$2,743.24 ","$2,110.19 ",$904.37 ,"$1,959.46 ","$2,170.48 ","$2,743.24 ","$2,260.91 "
Carle BroMenn Medical Center,8980636,bivalirudin 250 mg intravenous powder for solution,63323056210,J0583,636,"$2,904.81 ","$2,904.81 ",$871.44 ,"$2,643.38 ","$2,033.37 ",$871.44 ,"$1,888.13 ","$2,091.46 ","$2,643.38 ","$2,178.61 "
Carle BroMenn Medical Center,8980636,bivalirudin 250 mg intravenous powder for solution,67457025600,J0583,636,"$5,363.74 ","$5,363.74 ","$1,609.12 ","$4,881.00 ","$3,754.62 ","$1,609.12 ","$3,486.43 ","$3,861.89 ","$4,881.00 ","$4,022.81 "
Carle BroMenn Medical Center,8980636,bivalirudin 250 mg intravenous powder for solution,67457025610,J0583,636,"$5,363.74 ","$5,363.74 ","$1,609.12 ","$4,881.00 ","$3,754.62 ","$1,609.12 ","$3,486.43 ","$3,861.89 ","$4,881.00 ","$4,022.81 "
Carle BroMenn Medical Center,8980636,budesonide 0.25 mg/2 mL suspension for nebulization,487960101,,636,$46.54 ,$46.54 ,$13.96 ,$42.35 ,$32.58 ,$13.96 ,$30.25 ,$33.51 ,$42.35 ,$34.91 
Carle BroMenn Medical Center,8980636,budesonide 0.25 mg/2 mL suspension for nebulization,487960130,,636,$30.06 ,$30.06 ,$9.02 ,$27.35 ,$21.04 ,$9.02 ,$19.54 ,$21.64 ,$27.35 ,$22.55 
Carle BroMenn Medical Center,8980636,budesonide 0.5 mg/2 mL suspension for nebulization,487970101,,636,$47.23 ,$47.23 ,$14.17 ,$42.98 ,$33.06 ,$14.17 ,$30.70 ,$34.01 ,$42.98 ,$35.42 
Carle BroMenn Medical Center,8980636,budesonide 0.5 mg/2 mL suspension for nebulization,69097031932,,636,$47.23 ,$47.23 ,$14.17 ,$42.98 ,$33.06 ,$14.17 ,$30.70 ,$34.01 ,$42.98 ,$35.42 
Carle BroMenn Medical Center,8980636,budesonide 0.5 mg/2 mL suspension for nebulization,69097031953,,636,$47.23 ,$47.23 ,$14.17 ,$42.98 ,$33.06 ,$14.17 ,$30.70 ,$34.01 ,$42.98 ,$35.42 
Carle BroMenn Medical Center,8980636,budesonide 0.5 mg/2 mL suspension for nebulization,69097031986,,636,$46.93 ,$46.93 ,$14.08 ,$42.71 ,$32.85 ,$14.08 ,$30.50 ,$33.79 ,$42.71 ,$35.20 
Carle BroMenn Medical Center,8980636,buprenorphine HCL 2 mg sublingual tablet,42858050103,,636,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980636,buprenorphine HCL 2 mg sublingual tablet,50383092493,,636,$25.78 ,$25.78 ,$7.73 ,$23.46 ,$18.05 ,$7.73 ,$16.76 ,$18.56 ,$23.46 ,$19.34 
Carle BroMenn Medical Center,8980636,butorphanol 2 mg/mL injection solution,409162601,J0595,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,caffeine citrate 60 mg/3 mL (20 mg/mL) intravenous solution,63323040703,J0706,636,$201.97 ,$201.97 ,$60.59 ,$183.79 ,$141.38 ,$60.59 ,$131.28 ,$145.42 ,$183.79 ,$151.48 
Carle BroMenn Medical Center,8980636,caffeine citrate 60 mg/3 mL (20 mg/mL) intravenous solution,63323040704,J0706,636,$60.27 ,$60.27 ,$18.08 ,$54.85 ,$42.19 ,$18.08 ,$39.18 ,$43.39 ,$54.85 ,$45.20 
Carle BroMenn Medical Center,8980636,calcitonin (salmon) 200 unit/mL injection solution,24201040002,J0630,636,"$6,697.24 ","$6,697.24 ","$2,009.17 ","$6,094.49 ","$4,688.07 ","$2,009.17 ","$4,353.21 ","$4,822.01 ","$6,094.49 ","$5,022.93 "
Carle BroMenn Medical Center,8980636,calcitonin (salmon) 200 unit/mL injection solution,67457067502,J0630,636,"$6,699.55 ","$6,699.55 ","$2,009.87 ","$6,096.59 ","$4,689.69 ","$2,009.87 ","$4,354.71 ","$4,823.68 ","$6,096.59 ","$5,024.66 "
Carle BroMenn Medical Center,8980636,calcium gluconate 100 mg/mL (10 %) intravenous solution,63323036001,J0610,636,$104.91 ,$104.91 ,$31.47 ,$95.47 ,$73.44 ,$31.47 ,$68.19 ,$75.54 ,$95.47 ,$78.68 
Carle BroMenn Medical Center,8980636,calcium gluconate 100 mg/mL (10 %) intravenous solution,63323036019,J0610,636,$104.91 ,$104.91 ,$31.47 ,$95.47 ,$73.44 ,$31.47 ,$68.19 ,$75.54 ,$95.47 ,$78.68 
Carle BroMenn Medical Center,8980636,ceFAZolin 1 gram solution for injection,143926201,J0690,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,ceFAZolin 1 gram solution for injection,143992490,J0690,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,ceFAZolin 1 gram solution for injection,25021010110,J0690,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,ceFAZolin 1 gram solution for injection,44567070725,J0690,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,ceFAZolin 1 gram solution for injection,60505074905,J0690,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,ceFAZolin 1 gram solution for injection,60505614200,J0690,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,ceFAZolin 10 gram solution for injection,25021010299,J0690,636,$118.76 ,$118.76 ,$35.63 ,$108.07 ,$83.13 ,$35.63 ,$77.19 ,$85.51 ,$108.07 ,$89.07 
Carle BroMenn Medical Center,8980636,ceFAZolin 10 gram solution for injection,60505076900,J0690,636,$186.16 ,$186.16 ,$55.85 ,$169.41 ,$130.31 ,$55.85 ,$121.00 ,$134.04 ,$169.41 ,$139.62 
Carle BroMenn Medical Center,8980636,ceFAZolin 10 gram solution for injection,60505614300,J0690,636,$186.16 ,$186.16 ,$55.85 ,$169.41 ,$130.31 ,$55.85 ,$121.00 ,$134.04 ,$169.41 ,$139.62 
Carle BroMenn Medical Center,8980636,ceFAZolin 10 gram solution for injection,60505614304,J0690,636,$186.16 ,$186.16 ,$55.85 ,$169.41 ,$130.31 ,$55.85 ,$121.00 ,$134.04 ,$169.41 ,$139.62 
Carle BroMenn Medical Center,8980636,cefepime 1 gram solution for injection,25021012120,J0692,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,cefepime 1 gram solution for injection,25021012166,J0692,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,cefepime 1 gram solution for injection,60505614600,J0692,636,$153.27 ,$153.27 ,$45.98 ,$139.48 ,$107.29 ,$45.98 ,$99.63 ,$110.35 ,$139.48 ,$114.95 
Carle BroMenn Medical Center,8980636,cefepime 1 gram solution for injection,60505614604,J0692,636,$153.29 ,$153.29 ,$45.99 ,$139.49 ,$107.30 ,$45.99 ,$99.64 ,$110.37 ,$139.49 ,$114.97 
Carle BroMenn Medical Center,8980636,cefepime 2 gram solution for injection,25021012250,J0692,636,$104.79 ,$104.79 ,$31.44 ,$95.36 ,$73.35 ,$31.44 ,$68.11 ,$75.45 ,$95.36 ,$78.59 
Carle BroMenn Medical Center,8980636,cefepime 2 gram solution for injection,44567024110,J0692,636,$103.39 ,$103.39 ,$31.02 ,$94.08 ,$72.37 ,$31.02 ,$67.20 ,$74.44 ,$94.08 ,$77.54 
Carle BroMenn Medical Center,8980636,cefepime 2 gram solution for injection,60505068104,J0692,636,$252.13 ,$252.13 ,$75.64 ,$229.44 ,$176.49 ,$75.64 ,$163.88 ,$181.53 ,$229.44 ,$189.10 
Carle BroMenn Medical Center,8980636,ceftaroline fosamiL 600 mg intravenous solution,456060010,J0712,636,"$1,248.53 ","$1,248.53 ",$374.56 ,"$1,136.16 ",$873.97 ,$374.56 ,$811.54 ,$898.94 ,"$1,136.16 ",$936.40 
Carle BroMenn Medical Center,8980636,cefTAZidime 1 gram solution for injection,25021012720,J0713,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,cefTAZidime 2 gram solution for injection,25021012850,J0713,636,$111.77 ,$111.77 ,$33.53 ,$101.71 ,$78.24 ,$33.53 ,$72.65 ,$80.47 ,$101.71 ,$83.83 
Carle BroMenn Medical Center,8980636,cefTAZidime-avibactam 2.5 gram intravenous solution,456270001,,636,"$2,070.53 ","$2,070.53 ",$621.16 ,"$1,884.18 ","$1,449.37 ",$621.16 ,"$1,345.84 ","$1,490.78 ","$1,884.18 ","$1,552.90 "
Carle BroMenn Medical Center,8980636,cefTAZidime-avibactam 2.5 gram intravenous solution,456270010,,636,"$2,070.53 ","$2,070.53 ",$621.16 ,"$1,884.18 ","$1,449.37 ",$621.16 ,"$1,345.84 ","$1,490.78 ","$1,884.18 ","$1,552.90 "
Carle BroMenn Medical Center,8980636,cefTRIAXone 1 gram solution for injection,781320885,J0696,636,$278.43 ,$278.43 ,$83.53 ,$253.37 ,$194.90 ,$83.53 ,$180.98 ,$200.47 ,$253.37 ,$208.82 
Carle BroMenn Medical Center,8980636,cefTRIAXone 1 gram solution for injection,25021010610,J0696,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,cefTRIAXone 1 gram solution for injection,44567070125,J0696,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,cefTRIAXone 1 gram solution for injection,60505075204,J0696,636,$278.19 ,$278.19 ,$83.46 ,$253.15 ,$194.73 ,$83.46 ,$180.82 ,$200.30 ,$253.15 ,$208.64 
Carle BroMenn Medical Center,8980636,cefTRIAXone 1 gram solution for injection,60505614800,J0696,636,$251.45 ,$251.45 ,$75.44 ,$228.82 ,$176.02 ,$75.44 ,$163.44 ,$181.04 ,$228.82 ,$188.59 
Carle BroMenn Medical Center,8980636,cefTRIAXone 10 gram solution for injection,781321046,J0696,636,"$2,153.75 ","$2,153.75 ",$646.13 ,"$1,959.91 ","$1,507.63 ",$646.13 ,"$1,399.94 ","$1,550.70 ","$1,959.91 ","$1,615.31 "
Carle BroMenn Medical Center,8980636,cefTRIAXone 10 gram solution for injection,25021010899,J0696,636,$220.65 ,$220.65 ,$66.20 ,$200.79 ,$154.46 ,$66.20 ,$143.42 ,$158.87 ,$200.79 ,$165.49 
Carle BroMenn Medical Center,8980636,cefTRIAXone 2 gram solution for injection,781320990,J0696,636,$490.04 ,$490.04 ,$147.01 ,$445.94 ,$343.03 ,$147.01 ,$318.53 ,$352.83 ,$445.94 ,$367.53 
Carle BroMenn Medical Center,8980636,cefTRIAXone 2 gram solution for injection,781320995,J0696,636,$490.04 ,$490.04 ,$147.01 ,$445.94 ,$343.03 ,$147.01 ,$318.53 ,$352.83 ,$445.94 ,$367.53 
Carle BroMenn Medical Center,8980636,cefTRIAXone 2 gram solution for injection,25021010768,J0696,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,cefTRIAXone 2 gram solution for injection,44567070225,J0696,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,cefTRIAXone 2 gram solution for injection,60505075304,J0696,636,$489.56 ,$489.56 ,$146.87 ,$445.50 ,$342.69 ,$146.87 ,$318.21 ,$352.48 ,$445.50 ,$367.17 
Carle BroMenn Medical Center,8980636,cefTRIAXone 2 gram solution for injection,60505614900,J0696,636,$489.56 ,$489.56 ,$146.87 ,$445.50 ,$342.69 ,$146.87 ,$318.21 ,$352.48 ,$445.50 ,$367.17 
Carle BroMenn Medical Center,8980636,cefTRIAXone 2 gram solution for injection,60505614904,J0696,636,$489.56 ,$489.56 ,$146.87 ,$445.50 ,$342.69 ,$146.87 ,$318.21 ,$352.48 ,$445.50 ,$367.17 
Carle BroMenn Medical Center,8980636,cefTRIAXone 250 mg solution for injection,60505075004,J0696,636,$89.63 ,$89.63 ,$26.89 ,$81.56 ,$62.74 ,$26.89 ,$58.26 ,$64.53 ,$81.56 ,$67.22 
Carle BroMenn Medical Center,8980636,cefTRIAXone 250 mg solution for injection,60505615101,J0696,636,$121.18 ,$121.18 ,$36.35 ,$110.27 ,$84.83 ,$36.35 ,$78.77 ,$87.25 ,$110.27 ,$90.89 
Carle BroMenn Medical Center,8980636,cefTRIAXone 250 mg solution for injection,60505615104,J0696,636,$96.17 ,$96.17 ,$28.85 ,$87.51 ,$67.32 ,$28.85 ,$62.51 ,$69.24 ,$87.51 ,$72.13 
Carle BroMenn Medical Center,8980636,cefuroxime sodium 1.5 gram intravenous solution,25021011920,J0697,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,chloroprocaine (PF) 20 mg/mL (2 %) injection solution,143920901,J2400,636,$152.28 ,$152.28 ,$45.68 ,$138.57 ,$106.60 ,$45.68 ,$98.98 ,$109.64 ,$138.57 ,$114.21 
Carle BroMenn Medical Center,8980636,chloroprocaine (PF) 20 mg/mL (2 %) injection solution,143920910,J2400,636,$152.28 ,$152.28 ,$45.68 ,$138.57 ,$106.60 ,$45.68 ,$98.98 ,$109.64 ,$138.57 ,$114.21 
Carle BroMenn Medical Center,8980636,chloroprocaine (PF) 20 mg/mL (2 %) injection solution,63323047727,J2400,636,$152.28 ,$152.28 ,$45.68 ,$138.57 ,$106.60 ,$45.68 ,$98.98 ,$109.64 ,$138.57 ,$114.21 
Carle BroMenn Medical Center,8980636,chloroprocaine (PF) 30 mg/mL (3 %) injection solution,143921001,J2400,636,$159.73 ,$159.73 ,$47.92 ,$145.35 ,$111.81 ,$47.92 ,$103.82 ,$115.01 ,$145.35 ,$119.80 
Carle BroMenn Medical Center,8980636,chloroprocaine (PF) 30 mg/mL (3 %) injection solution,143921010,J2400,636,$159.73 ,$159.73 ,$47.92 ,$145.35 ,$111.81 ,$47.92 ,$103.82 ,$115.01 ,$145.35 ,$119.80 
Carle BroMenn Medical Center,8980636,chloroprocaine (PF) 30 mg/mL (3 %) injection solution,63323047827,J2400,636,$159.73 ,$159.73 ,$47.92 ,$145.35 ,$111.81 ,$47.92 ,$103.82 ,$115.01 ,$145.35 ,$119.80 
Carle BroMenn Medical Center,8980636,chlorothiazide sodium 500 mg intravenous solution,25021030520,J1205,636,$399.59 ,$399.59 ,$119.88 ,$363.63 ,$279.71 ,$119.88 ,$259.73 ,$287.70 ,$363.63 ,$299.69 
Carle BroMenn Medical Center,8980636,chlorothiazide sodium 500 mg intravenous solution,63323065820,J1205,636,$397.02 ,$397.02 ,$119.11 ,$361.29 ,$277.91 ,$119.11 ,$258.06 ,$285.85 ,$361.29 ,$297.77 
Carle BroMenn Medical Center,8980636,chlorothiazide sodium 500 mg intravenous solution,67457026330,J1205,636,"$1,728.81 ","$1,728.81 ",$518.64 ,"$1,573.22 ","$1,210.17 ",$518.64 ,"$1,123.73 ","$1,244.74 ","$1,573.22 ","$1,296.61 "
Carle BroMenn Medical Center,8980636,chlorproMAZINE 10 mg tablet,63304018501,Q0161,636,$22.37 ,$22.37 ,$6.71 ,$20.36 ,$15.66 ,$6.71 ,$14.54 ,$16.11 ,$20.36 ,$16.78 
Carle BroMenn Medical Center,8980636,chlorproMAZINE 25 mg tablet,60687043001,Q0161,636,$33.05 ,$33.05 ,$9.92 ,$30.08 ,$23.14 ,$9.92 ,$21.48 ,$23.80 ,$30.08 ,$24.79 
Carle BroMenn Medical Center,8980636,chlorproMAZINE 25 mg tablet,63304014301,Q0161,636,$34.89 ,$34.89 ,$10.47 ,$31.75 ,$24.42 ,$10.47 ,$22.68 ,$25.12 ,$31.75 ,$26.17 
Carle BroMenn Medical Center,8980636,chlorproMAZINE 25 mg/mL injection solution,641139835,J3230,636,$234.58 ,$234.58 ,$70.37 ,$213.47 ,$164.21 ,$70.37 ,$152.48 ,$168.90 ,$213.47 ,$175.94 
Carle BroMenn Medical Center,8980636,cholecalciferol (vitamin D3) 10 mcg/mL (400 unit/mL) oral drops,50383091750,A9152,636,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980636,cholecalciferol (vitamin D3) 10 mcg/mL (400 unit/mL) oral drops,69618001959,A9152,636,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980636,cinacalcet 30 mg tablet,16729044010,,636,$115.44 ,$115.44 ,$34.63 ,$105.05 ,$80.81 ,$34.63 ,$75.04 ,$83.12 ,$105.05 ,$86.58 
Carle BroMenn Medical Center,8980636,cinacalcet 30 mg tablet,16729044015,,636,$115.44 ,$115.44 ,$34.63 ,$105.05 ,$80.81 ,$34.63 ,$75.04 ,$83.12 ,$105.05 ,$86.58 
Carle BroMenn Medical Center,8980636,ciprofloxacin 200 mg/100 mL in 5 % dextrose intravenous piggyback,409477723,J0744,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,ciprofloxacin 400 mg/200 mL in 5 % dextrose intravenous piggyback,25021011487,J0744,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,ciprofloxacin 400 mg/200 mL in 5 % dextrose intravenous piggyback,36000000924,J0744,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,CISplatin 1 mg/mL intravenous solution,16729028811,J9060,636,$183.37 ,$183.37 ,$55.01 ,$166.87 ,$128.36 ,$55.01 ,$119.19 ,$132.03 ,$166.87 ,$137.53 
Carle BroMenn Medical Center,8980636,CISplatin 1 mg/mL intravenous solution,16729028838,J9060,636,$304.43 ,$304.43 ,$91.33 ,$277.03 ,$213.10 ,$91.33 ,$197.88 ,$219.19 ,$277.03 ,$228.32 
Carle BroMenn Medical Center,8980636,"cloNIDine (PF) 1,000 mcg/10 mL (100 mcg/mL) epidural solution",67457021810,J0735,636,$310.70 ,$310.70 ,$93.21 ,$282.74 ,$217.49 ,$93.21 ,$201.96 ,$223.70 ,$282.74 ,$233.03 
Carle BroMenn Medical Center,8980636,cocaine 4 % nasal solution,64950036204,,636,"$1,410.81 ","$1,410.81 ",$423.24 ,"$1,283.84 ",$987.57 ,$423.24 ,$917.03 ,"$1,015.78 ","$1,283.84 ","$1,058.11 "
Carle BroMenn Medical Center,8980636,colistin (colistimethate sodium) 150 mg solution for injection,63323039306,J0770,636,$193.86 ,$193.86 ,$58.16 ,$176.41 ,$135.70 ,$58.16 ,$126.01 ,$139.58 ,$176.41 ,$145.40 
Carle BroMenn Medical Center,8980636,conjugated estrogens 25 mg solution for injection,46074905,J1410,636,"$1,496.45 ","$1,496.45 ",$448.94 ,"$1,361.77 ","$1,047.52 ",$448.94 ,$972.69 ,"$1,077.44 ","$1,361.77 ","$1,122.34 "
Carle BroMenn Medical Center,8980636,cosyntropin 0.25 mg solution for injection,548590000,J0834,636,$660.07 ,$660.07 ,$198.02 ,$600.66 ,$462.05 ,$198.02 ,$429.05 ,$475.25 ,$600.66 ,$495.05 
Carle BroMenn Medical Center,8980636,cosyntropin 0.25 mg solution for injection,781344071,J0834,636,$512.55 ,$512.55 ,$153.77 ,$466.42 ,$358.79 ,$153.77 ,$333.16 ,$369.04 ,$466.42 ,$384.41 
Carle BroMenn Medical Center,8980636,cosyntropin 0.25 mg solution for injection,781344095,J0834,636,$512.55 ,$512.55 ,$153.77 ,$466.42 ,$358.79 ,$153.77 ,$333.16 ,$369.04 ,$466.42 ,$384.41 
Carle BroMenn Medical Center,8980636,crotalidae polyval immune fab solution for injection,50633011012,J0840,636,"$13,484.02 ","$13,484.02 ","$4,045.21 ","$12,270.46 ","$9,438.81 ","$4,045.21 ","$8,764.61 ","$9,708.49 ","$12,270.46 ","$10,113.02 "
Carle BroMenn Medical Center,8980636,"cyanocobalamin (vit B-12) 1,000 mcg/mL injection solution",143962125,J3420,636,$51.73 ,$51.73 ,$15.52 ,$47.07 ,$36.21 ,$15.52 ,$33.62 ,$37.25 ,$47.07 ,$38.80 
Carle BroMenn Medical Center,8980636,"cyanocobalamin (vit B-12) 1,000 mcg/mL injection solution",63323004401,J3420,636,$51.66 ,$51.66 ,$15.50 ,$47.01 ,$36.16 ,$15.50 ,$33.58 ,$37.20 ,$47.01 ,$38.75 
Carle BroMenn Medical Center,8980636,"cyanocobalamin (vit B-12) 1,000 mcg/mL injection solution",70069000501,J3420,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"cyanocobalamin (vit B-12) 1,000 mcg/mL injection solution",70069000510,J3420,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,cyclophosphamide 1 gram intravenous powder for solution,781324494,J9070,636,"$3,058.95 ","$3,058.95 ",$917.69 ,"$2,783.64 ","$2,141.27 ",$917.69 ,"$1,988.32 ","$2,202.44 ","$2,783.64 ","$2,294.21 "
Carle BroMenn Medical Center,8980636,cyclophosphamide 2 gram intravenous powder for solution,781325594,J9070,636,"$5,943.20 ","$5,943.20 ","$1,782.96 ","$5,408.31 ","$4,160.24 ","$1,782.96 ","$3,863.08 ","$4,279.10 ","$5,408.31 ","$4,457.40 "
Carle BroMenn Medical Center,8980636,cyclophosphamide 500 mg intravenous powder for solution,781323394,J9070,636,"$1,616.85 ","$1,616.85 ",$485.06 ,"$1,471.33 ","$1,131.80 ",$485.06 ,"$1,050.95 ","$1,164.13 ","$1,471.33 ","$1,212.64 "
Carle BroMenn Medical Center,8980636,cyclophosphamide 500 mg intravenous powder for solution,10019095501,J9070,636,"$1,712.99 ","$1,712.99 ",$513.90 ,"$1,558.82 ","$1,199.09 ",$513.90 ,"$1,113.44 ","$1,233.35 ","$1,558.82 ","$1,284.74 "
Carle BroMenn Medical Center,8980636,cycloSPORINE 25 mg capsule,60505013300,J7515,636,$18.64 ,$18.64 ,$5.59 ,$16.96 ,$13.05 ,$5.59 ,$12.12 ,$13.42 ,$16.96 ,$13.98 
Carle BroMenn Medical Center,8980636,cycloSPORINE 25 mg capsule,68084087995,J7515,636,$24.14 ,$24.14 ,$7.24 ,$21.97 ,$16.90 ,$7.24 ,$15.69 ,$17.38 ,$21.97 ,$18.11 
Carle BroMenn Medical Center,8980636,cycloSPORINE modified 25 mg capsule,60505463003,J7515,636,$8.74 ,$8.74 ,$2.62 ,$7.95 ,$6.12 ,$2.62 ,$5.68 ,$6.29 ,$7.95 ,$6.56 
Carle BroMenn Medical Center,8980636,DAPTOmycin 500 mg intravenous solution,16729043505,J0878,636,"$2,555.03 ","$2,555.03 ",$766.51 ,"$2,325.08 ","$1,788.52 ",$766.51 ,"$1,660.77 ","$1,839.62 ","$2,325.08 ","$1,916.27 "
Carle BroMenn Medical Center,8980636,DAPTOmycin 500 mg intravenous solution,67457081350,J0878,636,$763.12 ,$763.12 ,$228.94 ,$694.44 ,$534.18 ,$228.94 ,$496.03 ,$549.45 ,$694.44 ,$572.34 
Carle BroMenn Medical Center,8980636,DAPTOmycin 500 mg intravenous solution,70594003401,J0878,636,$399.59 ,$399.59 ,$119.88 ,$363.63 ,$279.71 ,$119.88 ,$259.73 ,$287.70 ,$363.63 ,$299.69 
Carle BroMenn Medical Center,8980636,DAPTOmycin 500 mg intravenous solution,71839010701,J0878,636,"$2,555.03 ","$2,555.03 ",$766.51 ,"$2,325.08 ","$1,788.52 ",$766.51 ,"$1,660.77 ","$1,839.62 ","$2,325.08 ","$1,916.27 "
Carle BroMenn Medical Center,8980636,deferoxamine 500 mg solution for injection,409233610,J0895,636,$101.01 ,$101.01 ,$30.30 ,$91.92 ,$70.71 ,$30.30 ,$65.66 ,$72.73 ,$91.92 ,$75.76 
Carle BroMenn Medical Center,8980636,deferoxamine 500 mg solution for injection,63323059710,J0895,636,$125.39 ,$125.39 ,$37.62 ,$114.10 ,$87.77 ,$37.62 ,$81.50 ,$90.28 ,$114.10 ,$94.04 
Carle BroMenn Medical Center,8980636,desmopressin 4 mcg/mL injection solution,69918089910,J2597,636,$228.46 ,$228.46 ,$68.54 ,$207.90 ,$159.92 ,$68.54 ,$148.50 ,$164.49 ,$207.90 ,$171.35 
Carle BroMenn Medical Center,8980636,desmopressin 4 mcg/mL injection solution,69918090110,J2597,636,$230.49 ,$230.49 ,$69.15 ,$209.75 ,$161.34 ,$69.15 ,$149.82 ,$165.95 ,$209.75 ,$172.87 
Carle BroMenn Medical Center,8980636,desmopressin 4 mcg/mL injection solution,70860045410,J2597,636,$210.86 ,$210.86 ,$63.26 ,$191.88 ,$147.60 ,$63.26 ,$137.06 ,$151.82 ,$191.88 ,$158.15 
Carle BroMenn Medical Center,8980636,dexAMETHasone 1 mg tablet,54817425,J8540,636,$2.76 ,$2.76 ,$0.83 ,$2.51 ,$1.93 ,$0.83 ,$1.79 ,$1.99 ,$2.51 ,$2.07 
Carle BroMenn Medical Center,8980636,dexAMETHasone 2 mg tablet,54817625,J8540,636,$2.76 ,$2.76 ,$0.83 ,$2.51 ,$1.93 ,$0.83 ,$1.79 ,$1.99 ,$2.51 ,$2.07 
Carle BroMenn Medical Center,8980636,dexAMETHasone 4 mg tablet,54418425,,636,$2.68 ,$2.68 ,$0.80 ,$2.44 ,$1.88 ,$0.80 ,$1.74 ,$1.93 ,$2.44 ,$2.01 
Carle BroMenn Medical Center,8980636,dexAMETHasone 4 mg tablet,54817525,,636,$2.68 ,$2.68 ,$0.80 ,$2.44 ,$1.88 ,$0.80 ,$1.74 ,$1.93 ,$2.44 ,$2.01 
Carle BroMenn Medical Center,8980636,dexAMETHasone sodium phosphate (PF) 10 mg/mL injection solution,63323050601,J1100,636,$47.12 ,$47.12 ,$14.14 ,$42.88 ,$32.98 ,$14.14 ,$30.63 ,$33.93 ,$42.88 ,$35.34 
Carle BroMenn Medical Center,8980636,dexAMETHasone sodium phosphate (PF) 10 mg/mL injection solution,70069002101,J1100,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,dexAMETHasone sodium phosphate 10 mg/mL injection solution,641036725,J1100,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,dexAMETHasone sodium phosphate 4 mg/mL injection solution,641614601,J1100,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,dexAMETHasone sodium phosphate 4 mg/mL injection solution,641614625,J1100,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,dexAMETHasone sodium phosphate 4 mg/mL injection solution,55150023805,J1100,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,dexAMETHasone sodium phosphate 4 mg/mL injection solution,55150023930,J1100,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,dexAMETHasone sodium phosphate 4 mg/mL injection solution,63323016501,J1100,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,dexAMETHasone sodium phosphate 4 mg/mL injection solution,63323016502,J1100,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,dexAMETHasone sodium phosphate 4 mg/mL injection solution,63323016503,J1100,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,dexAMETHasone sodium phosphate 4 mg/mL injection solution,63323016505,J1100,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,dexAMETHasone sodium phosphate 4 mg/mL injection solution,63323016516,J1100,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,dexAMETHasone sodium phosphate 4 mg/mL injection solution,63323016526,J1100,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,dexAMETHasone sodium phosphate 4 mg/mL injection solution,63323016530,J1100,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,dexAMETHasone sodium phosphate 4 mg/mL injection solution,67457042254,J1100,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,dexAMETHasone sodium phosphate 4 mg/mL injection solution,67457042312,J1100,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,dextran 40 10 % in 0.9 % sodium chloride intravenous solution,409741914,J7100,636,$203.71 ,$203.71 ,$61.11 ,$185.38 ,$142.60 ,$61.11 ,$132.41 ,$146.67 ,$185.38 ,$152.78 
Carle BroMenn Medical Center,8980636,dextrose 10 % and 0.45 % sodium chloride intravenous solution,264762200,J7042,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,dextrose 10 % in water (D10W) intravenous solution,264752000,J7060,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,dextrose 10 % in water (D10W) intravenous solution,990793003,J7060,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,dextrose 10 % in water (D10W) intravenous solution,990793009,J7060,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,dextrose 5 % and 0.2 % sodium chloride intravenous solution,264761600,J7042,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,dextrose 5 % and 0.2 % sodium chloride intravenous solution,264761610,J7042,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,dextrose 5 % and 0.2 % sodium chloride intravenous solution,990792403,J7042,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,dextrose 5 % and 0.2 % sodium chloride intravenous solution,990792409,J7042,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,dextrose 5 % and 0.45 % sodium chloride intravenous solution,264761200,J7042,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,dextrose 5 % and 0.45 % sodium chloride intravenous solution,990792609,J7042,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,dextrose 5 % and 0.9 % sodium chloride intravenous solution,264761000,J7042,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,dextrose 5 % and 0.9 % sodium chloride intravenous solution,990794109,J7042,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,dextrose 5 % and lactated ringers intravenous solution,264775100,J7120,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,dextrose 5 % and lactated ringers intravenous solution,990792909,J7120,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,dextrose 5 % in water (D5W) intravenous solution,264151031,J7060,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,dextrose 5 % in water (D5W) intravenous solution,264151032,J7060,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,dextrose 5 % in water (D5W) intravenous solution,264751000,J7070,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,dextrose 5 % in water (D5W) intravenous solution,264751010,J7060,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,dextrose 5 % in water (D5W) intravenous solution,264751020,J7060,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,dextrose 5 % in water (D5W) intravenous solution,990792202,J7060,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,dextrose 5 % in water (D5W) intravenous solution,990792203,J7060,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,dextrose 5 % in water (D5W) intravenous solution,990792209,J7070,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,dextrose 5 % in water (D5W) intravenous solution,990792313,J7060,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,dextrose 5 % in water (D5W) intravenous solution,990792323,J7060,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,dextrose 5 % in water (D5W) intravenous solution,990792337,J7060,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,dextrose 5 %-0.45 % sodium chloride IV,264761200,J7042,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,dextrose 5% in water (D5W) IV,990792203,J7060,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,dextrose 5% in water (D5W) IV,990792209,J7070,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,dextrose 50 % in water (D50W) intravenous solution,409664802,J7060,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,diazePAM 5 mg/mL injection syringe,409127332,J3360,636,$102.01 ,$102.01 ,$30.60 ,$92.83 ,$71.41 ,$30.60 ,$66.31 ,$73.45 ,$92.83 ,$76.51 
Carle BroMenn Medical Center,8980636,diazePAM 5 mg/mL injection syringe,69339013602,J3360,636,$91.78 ,$91.78 ,$27.53 ,$83.52 ,$64.25 ,$27.53 ,$59.66 ,$66.08 ,$83.52 ,$68.84 
Carle BroMenn Medical Center,8980636,diazePAM 5 mg/mL injection syringe,69339013603,J3360,636,$91.78 ,$91.78 ,$27.53 ,$83.52 ,$64.25 ,$27.53 ,$59.66 ,$66.08 ,$83.52 ,$68.84 
Carle BroMenn Medical Center,8980636,dicyclomine 10 mg/mL intramuscular solution,17478001502,J0500,636,$460.38 ,$460.38 ,$138.11 ,$418.95 ,$322.27 ,$138.11 ,$299.25 ,$331.47 ,$418.95 ,$345.29 
Carle BroMenn Medical Center,8980636,dicyclomine 10 mg/mL intramuscular solution,24201058510,J0500,636,$275.78 ,$275.78 ,$82.73 ,$250.96 ,$193.05 ,$82.73 ,$179.26 ,$198.56 ,$250.96 ,$206.84 
Carle BroMenn Medical Center,8980636,dicyclomine 10 mg/mL intramuscular solution,63323084221,J0500,636,$275.78 ,$275.78 ,$82.73 ,$250.96 ,$193.05 ,$82.73 ,$179.26 ,$198.56 ,$250.96 ,$206.84 
Carle BroMenn Medical Center,8980636,digoxin immune fab 40 mg intravenous solution,50633012011,J1162,636,"$17,409.49 ","$17,409.49 ","$5,222.85 ","$15,842.64 ","$12,186.64 ","$5,222.85 ","$11,316.17 ","$12,534.83 ","$15,842.64 ","$13,057.12 "
Carle BroMenn Medical Center,8980636,dihydroergotamine 1 mg/mL injection solution,574085010,J1110,636,$646.23 ,$646.23 ,$193.87 ,$588.07 ,$452.36 ,$193.87 ,$420.05 ,$465.29 ,$588.07 ,$484.67 
Carle BroMenn Medical Center,8980636,dihydroergotamine 1 mg/mL injection solution,61990041100,J1110,636,$819.81 ,$819.81 ,$245.94 ,$746.03 ,$573.87 ,$245.94 ,$532.88 ,$590.26 ,$746.03 ,$614.86 
Carle BroMenn Medical Center,8980636,dihydroergotamine 1 mg/mL injection solution,61990041101,J1110,636,$819.81 ,$819.81 ,$245.94 ,$746.03 ,$573.87 ,$245.94 ,$532.88 ,$590.26 ,$746.03 ,$614.86 
Carle BroMenn Medical Center,8980636,dihydroergotamine 1 mg/mL injection solution,61990041102,J1110,636,$750.04 ,$750.04 ,$225.01 ,$682.54 ,$525.03 ,$225.01 ,$487.53 ,$540.03 ,$682.54 ,$562.53 
Carle BroMenn Medical Center,8980636,dimercaproL 100 mg/mL intramuscular solution,17478052603,J0470,636,$336.39 ,$336.39 ,$100.92 ,$306.11 ,$235.47 ,$100.92 ,$218.65 ,$242.20 ,$306.11 ,$252.29 
Carle BroMenn Medical Center,8980636,"diph,pertus(acel),tet ped(PF) 25 Lf unit-58 mcg-10 Lf/0.5mL IM syringe",58160081043,90700,636,$57.70 ,$57.70 ,$17.31 ,$52.51 ,$40.39 ,$17.31 ,$37.51 ,$41.54 ,$52.51 ,$43.28 
Carle BroMenn Medical Center,8980636,"diph,pertus(acel),tet ped(PF) 25 Lf unit-58 mcg-10 Lf/0.5mL IM syringe",58160081052,90700,636,$57.70 ,$57.70 ,$17.31 ,$52.51 ,$40.39 ,$17.31 ,$37.51 ,$41.54 ,$52.51 ,$43.28 
Carle BroMenn Medical Center,8980636,diphenhydrAMINE 50 mg/mL injection solution,641037621,J1200,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,diphenhydrAMINE 50 mg/mL injection solution,641037625,J1200,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,diphenhydrAMINE 50 mg/mL injection solution,63323066400,J1200,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,diphenhydrAMINE 50 mg/mL injection solution,63323066401,J1200,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"diphth,pertussis(acel),tetanus 2.5 Lf unit-8 mcg-5 Lf/0.5mL IM syringe",58160084243,90715,636,$96.08 ,$96.08 ,$28.82 ,$87.43 ,$67.26 ,$28.82 ,$62.45 ,$69.18 ,$87.43 ,$72.06 
Carle BroMenn Medical Center,8980636,"diphth,pertussis(acel),tetanus 2.5 Lf unit-8 mcg-5 Lf/0.5mL IM syringe",58160084252,90715,636,$96.08 ,$96.08 ,$28.82 ,$87.43 ,$67.26 ,$28.82 ,$62.45 ,$69.18 ,$87.43 ,$72.06 
Carle BroMenn Medical Center,8980636,"DOBUTamine 1,000 mg/250 mL(4,000 mcg/mL) in 5 % dextrose IV",338107702,J1250,636,$206.62 ,$206.62 ,$61.99 ,$188.02 ,$144.63 ,$61.99 ,$134.30 ,$148.77 ,$188.02 ,$154.97 
Carle BroMenn Medical Center,8980636,"DOBUTamine 1,000 mg/250 mL(4,000 mcg/mL) in 5 % dextrose IV",409372432,J1250,636,$132.42 ,$132.42 ,$39.73 ,$120.50 ,$92.69 ,$39.73 ,$86.07 ,$95.34 ,$120.50 ,$99.32 
Carle BroMenn Medical Center,8980636,"DOBUTamine 500 mg/250 mL (2,000 mcg/mL) in 5 % dextrose IV",338107502,J1250,636,$283.74 ,$283.74 ,$85.12 ,$258.20 ,$198.62 ,$85.12 ,$184.43 ,$204.29 ,$258.20 ,$212.81 
Carle BroMenn Medical Center,8980636,"DOBUTamine 500 mg/250 mL (2,000 mcg/mL) in 5 % dextrose IV",409234732,J1250,636,$103.32 ,$103.32 ,$31.00 ,$94.02 ,$72.32 ,$31.00 ,$67.16 ,$74.39 ,$94.02 ,$77.49 
Carle BroMenn Medical Center,8980636,DOPamine 400 mg/10 mL (40 mg/mL) intravenous solution,409910420,J1265,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,"DOPamine 400 mg/250 mL (1,600 mcg/mL) in 5 % dextrose intravenous soln",338100702,J1265,636,$106.23 ,$106.23 ,$31.87 ,$96.67 ,$74.36 ,$31.87 ,$69.05 ,$76.49 ,$96.67 ,$79.67 
Carle BroMenn Medical Center,8980636,"DOPamine 400 mg/250 mL (1,600 mcg/mL) in 5 % dextrose intravenous soln",409780911,J1265,636,$106.23 ,$106.23 ,$31.87 ,$96.67 ,$74.36 ,$31.87 ,$69.05 ,$76.49 ,$96.67 ,$79.67 
Carle BroMenn Medical Center,8980636,"DOPamine 400 mg/250 mL (1,600 mcg/mL) in 5 % dextrose intravenous soln",409780922,J1265,636,$106.23 ,$106.23 ,$31.87 ,$96.67 ,$74.36 ,$31.87 ,$69.05 ,$76.49 ,$96.67 ,$79.67 
Carle BroMenn Medical Center,8980636,"DOPamine 800 mg/250 mL (3,200 mcg/mL) in 5 % dextrose intravenous soln",338100902,J1265,636,$144.06 ,$144.06 ,$43.22 ,$131.09 ,$100.84 ,$43.22 ,$93.64 ,$103.72 ,$131.09 ,$108.05 
Carle BroMenn Medical Center,8980636,"DOPamine 800 mg/250 mL (3,200 mcg/mL) in 5 % dextrose intravenous soln",409781011,J1265,636,$152.79 ,$152.79 ,$45.84 ,$139.04 ,$106.95 ,$45.84 ,$99.31 ,$110.01 ,$139.04 ,$114.59 
Carle BroMenn Medical Center,8980636,"DOPamine 800 mg/250 mL (3,200 mcg/mL) in 5 % dextrose intravenous soln",409781022,J1265,636,$152.79 ,$152.79 ,$45.84 ,$139.04 ,$106.95 ,$45.84 ,$99.31 ,$110.01 ,$139.04 ,$114.59 
Carle BroMenn Medical Center,8980636,dornase alfa 1 mg/mL solution for inhalation,50242010039,J7639,636,$490.81 ,$490.81 ,$147.24 ,$446.64 ,$343.57 ,$147.24 ,$319.03 ,$353.38 ,$446.64 ,$368.11 
Carle BroMenn Medical Center,8980636,dornase alfa 1 mg/mL solution for inhalation,50242010040,J7639,636,$490.81 ,$490.81 ,$147.24 ,$446.64 ,$343.57 ,$147.24 ,$319.03 ,$353.38 ,$446.64 ,$368.11 
Carle BroMenn Medical Center,8980636,DOXOrubicin 10 mg/5 mL intravenous solution,69400405,J9000,636,$145.61 ,$145.61 ,$43.68 ,$132.51 ,$101.93 ,$43.68 ,$94.65 ,$104.84 ,$132.51 ,$109.21 
Carle BroMenn Medical Center,8980636,DOXOrubicin 2 mg/mL intravenous solution,69303420,J9000,636,$504.63 ,$504.63 ,$151.39 ,$459.21 ,$353.24 ,$151.39 ,$328.01 ,$363.33 ,$459.21 ,$378.47 
Carle BroMenn Medical Center,8980636,DOXOrubicin 50 mg/25 mL intravenous solution,69402625,J9000,636,$298.17 ,$298.17 ,$89.45 ,$271.33 ,$208.72 ,$89.45 ,$193.81 ,$214.68 ,$271.33 ,$223.63 
Carle BroMenn Medical Center,8980636,dronabinoL 2.5 mg capsule,904674561,Q0167,636,$30.33 ,$30.33 ,$9.10 ,$27.60 ,$21.23 ,$9.10 ,$19.71 ,$21.84 ,$27.60 ,$22.75 
Carle BroMenn Medical Center,8980636,dronabinoL 2.5 mg capsule,42858086706,Q0167,636,$14.10 ,$14.10 ,$4.23 ,$12.83 ,$9.87 ,$4.23 ,$9.17 ,$10.15 ,$12.83 ,$10.58 
Carle BroMenn Medical Center,8980636,eculizumab 300 mg/30 mL intravenous solution,25682000101,J1300,636,"$36,540.69 ","$36,540.69 ","$10,962.21 ","$33,252.03 ","$25,578.48 ","$10,962.21 ","$23,751.45 ","$26,309.30 ","$33,252.03 ","$27,405.52 "
Carle BroMenn Medical Center,8980636,edetate calcium disodium 200 mg/mL injection solution,99207024005,J0600,636,"$22,741.10 ","$22,741.10 ","$6,822.33 ","$20,694.40 ","$15,918.77 ","$6,822.33 ","$14,781.72 ","$16,373.59 ","$20,694.40 ","$17,055.83 "
Carle BroMenn Medical Center,8980636,emtricitabine 200 mg-tenofovir disoproxil fumarate 300 mg tablet,93760756,J8499,636,$253.17 ,$253.17 ,$75.95 ,$230.38 ,$177.22 ,$75.95 ,$164.56 ,$182.28 ,$230.38 ,$189.88 
Carle BroMenn Medical Center,8980636,emtricitabine 200 mg-tenofovir disoproxil fumarate 300 mg tablet,93770456,J8499,636,$253.17 ,$253.17 ,$75.95 ,$230.38 ,$177.22 ,$75.95 ,$164.56 ,$182.28 ,$230.38 ,$189.88 
Carle BroMenn Medical Center,8980636,emtricitabine 200 mg-tenofovir disoproxil fumarate 300 mg tablet,378193093,J8499,636,$253.17 ,$253.17 ,$75.95 ,$230.38 ,$177.22 ,$75.95 ,$164.56 ,$182.28 ,$230.38 ,$189.88 
Carle BroMenn Medical Center,8980636,emtricitabine 200 mg-tenofovir disoproxil fumarate 300 mg tablet,61958070101,J8499,636,$266.07 ,$266.07 ,$79.82 ,$242.12 ,$186.25 ,$79.82 ,$172.95 ,$191.57 ,$242.12 ,$199.55 
Carle BroMenn Medical Center,8980636,enoxaparin 100 mg/mL subcutaneous syringe,781326805,J1650,636,$166.02 ,$166.02 ,$49.81 ,$151.08 ,$116.21 ,$49.81 ,$107.91 ,$119.53 ,$151.08 ,$124.52 
Carle BroMenn Medical Center,8980636,enoxaparin 100 mg/mL subcutaneous syringe,781326869,J1650,636,$166.02 ,$166.02 ,$49.81 ,$151.08 ,$116.21 ,$49.81 ,$107.91 ,$119.53 ,$151.08 ,$124.52 
Carle BroMenn Medical Center,8980636,enoxaparin 100 mg/mL subcutaneous syringe,955101001,J1650,636,$152.65 ,$152.65 ,$45.80 ,$138.91 ,$106.86 ,$45.80 ,$99.22 ,$109.91 ,$138.91 ,$114.49 
Carle BroMenn Medical Center,8980636,enoxaparin 100 mg/mL subcutaneous syringe,955101010,J1650,636,$152.65 ,$152.65 ,$45.80 ,$138.91 ,$106.86 ,$45.80 ,$99.22 ,$109.91 ,$138.91 ,$114.49 
Carle BroMenn Medical Center,8980636,enoxaparin 100 mg/mL subcutaneous syringe,71288041088,J1650,636,$108.16 ,$108.16 ,$32.45 ,$98.43 ,$75.71 ,$32.45 ,$70.30 ,$77.88 ,$98.43 ,$81.12 
Carle BroMenn Medical Center,8980636,enoxaparin 100 mg/mL subcutaneous syringe,71288041089,J1650,636,$108.16 ,$108.16 ,$32.45 ,$98.43 ,$75.71 ,$32.45 ,$70.30 ,$77.88 ,$98.43 ,$81.12 
Carle BroMenn Medical Center,8980636,enoxaparin 120 mg/0.8 mL subcutaneous syringe,75291200,J1650,636,$539.52 ,$539.52 ,$161.86 ,$490.96 ,$377.66 ,$161.86 ,$350.69 ,$388.45 ,$490.96 ,$404.64 
Carle BroMenn Medical Center,8980636,enoxaparin 120 mg/0.8 mL subcutaneous syringe,75291201,J1650,636,$539.52 ,$539.52 ,$161.86 ,$490.96 ,$377.66 ,$161.86 ,$350.69 ,$388.45 ,$490.96 ,$404.64 
Carle BroMenn Medical Center,8980636,enoxaparin 120 mg/0.8 mL subcutaneous syringe,703861021,J1650,636,$170.70 ,$170.70 ,$51.21 ,$155.34 ,$119.49 ,$51.21 ,$110.96 ,$122.90 ,$155.34 ,$128.03 
Carle BroMenn Medical Center,8980636,enoxaparin 120 mg/0.8 mL subcutaneous syringe,703861023,J1650,636,$170.70 ,$170.70 ,$51.21 ,$155.34 ,$119.49 ,$51.21 ,$110.96 ,$122.90 ,$155.34 ,$128.03 
Carle BroMenn Medical Center,8980636,enoxaparin 120 mg/0.8 mL subcutaneous syringe,63323065599,J1650,636,$170.70 ,$170.70 ,$51.21 ,$155.34 ,$119.49 ,$51.21 ,$110.96 ,$122.90 ,$155.34 ,$128.03 
Carle BroMenn Medical Center,8980636,enoxaparin 120 mg/0.8 mL subcutaneous syringe,71288041180,J1650,636,$129.11 ,$129.11 ,$38.73 ,$117.49 ,$90.38 ,$38.73 ,$83.92 ,$92.96 ,$117.49 ,$96.83 
Carle BroMenn Medical Center,8980636,enoxaparin 120 mg/0.8 mL subcutaneous syringe,71288041181,J1650,636,$129.11 ,$129.11 ,$38.73 ,$117.49 ,$90.38 ,$38.73 ,$83.92 ,$92.96 ,$117.49 ,$96.83 
Carle BroMenn Medical Center,8980636,enoxaparin 150 mg/mL subcutaneous syringe,75291500,J1650,636,$643.88 ,$643.88 ,$193.16 ,$585.93 ,$450.72 ,$193.16 ,$418.52 ,$463.59 ,$585.93 ,$482.91 
Carle BroMenn Medical Center,8980636,enoxaparin 150 mg/mL subcutaneous syringe,75291501,J1650,636,$643.88 ,$643.88 ,$193.16 ,$585.93 ,$450.72 ,$193.16 ,$418.52 ,$463.59 ,$585.93 ,$482.91 
Carle BroMenn Medical Center,8980636,enoxaparin 150 mg/mL subcutaneous syringe,71288041182,J1650,636,$160.54 ,$160.54 ,$48.16 ,$146.09 ,$112.38 ,$48.16 ,$104.35 ,$115.59 ,$146.09 ,$120.41 
Carle BroMenn Medical Center,8980636,enoxaparin 150 mg/mL subcutaneous syringe,71288041183,J1650,636,$160.54 ,$160.54 ,$48.16 ,$146.09 ,$112.38 ,$48.16 ,$104.35 ,$115.59 ,$146.09 ,$120.41 
Carle BroMenn Medical Center,8980636,enoxaparin 30 mg/0.3 mL subcutaneous syringe,548560100,J1650,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,enoxaparin 30 mg/0.3 mL subcutaneous syringe,955100301,J1650,636,$48.20 ,$48.20 ,$14.46 ,$43.86 ,$33.74 ,$14.46 ,$31.33 ,$34.70 ,$43.86 ,$36.15 
Carle BroMenn Medical Center,8980636,enoxaparin 30 mg/0.3 mL subcutaneous syringe,955100310,J1650,636,$48.20 ,$48.20 ,$14.46 ,$43.86 ,$33.74 ,$14.46 ,$31.33 ,$34.70 ,$43.86 ,$36.15 
Carle BroMenn Medical Center,8980636,enoxaparin 30 mg/0.3 mL subcutaneous syringe,60505079100,J1650,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,enoxaparin 30 mg/0.3 mL subcutaneous syringe,63323056883,J1650,636,$45.09 ,$45.09 ,$13.53 ,$41.03 ,$31.56 ,$13.53 ,$29.31 ,$32.46 ,$41.03 ,$33.82 
Carle BroMenn Medical Center,8980636,enoxaparin 30 mg/0.3 mL subcutaneous syringe,71288041080,J1650,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,enoxaparin 30 mg/0.3 mL subcutaneous syringe,71288041081,J1650,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,enoxaparin 40 mg/0.4 mL subcutaneous syringe,75062001,J1650,636,$261.06 ,$261.06 ,$78.32 ,$237.56 ,$182.74 ,$78.32 ,$169.69 ,$187.96 ,$237.56 ,$195.80 
Carle BroMenn Medical Center,8980636,enoxaparin 40 mg/0.4 mL subcutaneous syringe,75062040,J1650,636,$261.06 ,$261.06 ,$78.32 ,$237.56 ,$182.74 ,$78.32 ,$169.69 ,$187.96 ,$237.56 ,$195.80 
Carle BroMenn Medical Center,8980636,enoxaparin 40 mg/0.4 mL subcutaneous syringe,548560200,J1650,636,$45.30 ,$45.30 ,$13.59 ,$41.22 ,$31.71 ,$13.59 ,$29.45 ,$32.62 ,$41.22 ,$33.98 
Carle BroMenn Medical Center,8980636,enoxaparin 40 mg/0.4 mL subcutaneous syringe,955100401,J1650,636,$63.04 ,$63.04 ,$18.91 ,$57.37 ,$44.13 ,$18.91 ,$40.98 ,$45.39 ,$57.37 ,$47.28 
Carle BroMenn Medical Center,8980636,enoxaparin 40 mg/0.4 mL subcutaneous syringe,955100410,J1650,636,$63.04 ,$63.04 ,$18.91 ,$57.37 ,$44.13 ,$18.91 ,$40.98 ,$45.39 ,$57.37 ,$47.28 
Carle BroMenn Medical Center,8980636,enoxaparin 40 mg/0.4 mL subcutaneous syringe,63323056421,J1650,636,$58.85 ,$58.85 ,$17.66 ,$53.55 ,$41.20 ,$17.66 ,$38.25 ,$42.37 ,$53.55 ,$44.14 
Carle BroMenn Medical Center,8980636,enoxaparin 40 mg/0.4 mL subcutaneous syringe,71288041082,J1650,636,$45.30 ,$45.30 ,$13.59 ,$41.22 ,$31.71 ,$13.59 ,$29.45 ,$32.62 ,$41.22 ,$33.98 
Carle BroMenn Medical Center,8980636,enoxaparin 40 mg/0.4 mL subcutaneous syringe,71288041083,J1650,636,$45.30 ,$45.30 ,$13.59 ,$41.22 ,$31.71 ,$13.59 ,$29.45 ,$32.62 ,$41.22 ,$33.98 
Carle BroMenn Medical Center,8980636,enoxaparin 60 mg/0.6 mL subcutaneous syringe,548560300,J1650,636,$66.26 ,$66.26 ,$19.88 ,$60.30 ,$46.38 ,$19.88 ,$43.07 ,$47.71 ,$60.30 ,$49.70 
Carle BroMenn Medical Center,8980636,enoxaparin 60 mg/0.6 mL subcutaneous syringe,703856021,J1650,636,$86.72 ,$86.72 ,$26.02 ,$78.92 ,$60.70 ,$26.02 ,$56.37 ,$62.44 ,$78.92 ,$65.04 
Carle BroMenn Medical Center,8980636,enoxaparin 60 mg/0.6 mL subcutaneous syringe,781325603,J1650,636,$100.97 ,$100.97 ,$30.29 ,$91.88 ,$70.68 ,$30.29 ,$65.63 ,$72.70 ,$91.88 ,$75.73 
Carle BroMenn Medical Center,8980636,enoxaparin 60 mg/0.6 mL subcutaneous syringe,781325666,J1650,636,$100.97 ,$100.97 ,$30.29 ,$91.88 ,$70.68 ,$30.29 ,$65.63 ,$72.70 ,$91.88 ,$75.73 
Carle BroMenn Medical Center,8980636,enoxaparin 60 mg/0.6 mL subcutaneous syringe,955100601,J1650,636,$92.96 ,$92.96 ,$27.89 ,$84.59 ,$65.07 ,$27.89 ,$60.42 ,$66.93 ,$84.59 ,$69.72 
Carle BroMenn Medical Center,8980636,enoxaparin 60 mg/0.6 mL subcutaneous syringe,955100610,J1650,636,$92.96 ,$92.96 ,$27.89 ,$84.59 ,$65.07 ,$27.89 ,$60.42 ,$66.93 ,$84.59 ,$69.72 
Carle BroMenn Medical Center,8980636,enoxaparin 60 mg/0.6 mL subcutaneous syringe,71288041084,J1650,636,$66.26 ,$66.26 ,$19.88 ,$60.30 ,$46.38 ,$19.88 ,$43.07 ,$47.71 ,$60.30 ,$49.70 
Carle BroMenn Medical Center,8980636,enoxaparin 60 mg/0.6 mL subcutaneous syringe,71288041085,J1650,636,$66.26 ,$66.26 ,$19.88 ,$60.30 ,$46.38 ,$19.88 ,$43.07 ,$47.71 ,$60.30 ,$49.70 
Carle BroMenn Medical Center,8980636,enoxaparin 80 mg/0.8 mL subcutaneous syringe,75062201,J1650,636,$400.31 ,$400.31 ,$120.09 ,$364.28 ,$280.22 ,$120.09 ,$260.20 ,$288.22 ,$364.28 ,$300.23 
Carle BroMenn Medical Center,8980636,enoxaparin 80 mg/0.8 mL subcutaneous syringe,75062280,J1650,636,$400.31 ,$400.31 ,$120.09 ,$364.28 ,$280.22 ,$120.09 ,$260.20 ,$288.22 ,$364.28 ,$300.23 
Carle BroMenn Medical Center,8980636,enoxaparin 80 mg/0.8 mL subcutaneous syringe,781326204,J1650,636,$133.49 ,$133.49 ,$40.05 ,$121.48 ,$93.44 ,$40.05 ,$86.77 ,$96.11 ,$121.48 ,$100.12 
Carle BroMenn Medical Center,8980636,enoxaparin 80 mg/0.8 mL subcutaneous syringe,781326268,J1650,636,$133.49 ,$133.49 ,$40.05 ,$121.48 ,$93.44 ,$40.05 ,$86.77 ,$96.11 ,$121.48 ,$100.12 
Carle BroMenn Medical Center,8980636,enoxaparin 80 mg/0.8 mL subcutaneous syringe,955100801,J1650,636,$122.78 ,$122.78 ,$36.83 ,$111.73 ,$85.95 ,$36.83 ,$79.81 ,$88.40 ,$111.73 ,$92.09 
Carle BroMenn Medical Center,8980636,enoxaparin 80 mg/0.8 mL subcutaneous syringe,955100810,J1650,636,$122.78 ,$122.78 ,$36.83 ,$111.73 ,$85.95 ,$36.83 ,$79.81 ,$88.40 ,$111.73 ,$92.09 
Carle BroMenn Medical Center,8980636,enoxaparin 80 mg/0.8 mL subcutaneous syringe,71288041086,J1650,636,$87.21 ,$87.21 ,$26.16 ,$79.36 ,$61.05 ,$26.16 ,$56.69 ,$62.79 ,$79.36 ,$65.41 
Carle BroMenn Medical Center,8980636,enoxaparin 80 mg/0.8 mL subcutaneous syringe,71288041087,J1650,636,$87.21 ,$87.21 ,$26.16 ,$79.36 ,$61.05 ,$26.16 ,$56.69 ,$62.79 ,$79.36 ,$65.41 
Carle BroMenn Medical Center,8980636,ePHEDrine sulfate 50 mg/mL intravenous solution,42023021601,J3490,636,$199.72 ,$199.72 ,$59.92 ,$181.75 ,$139.80 ,$59.92 ,$129.82 ,$143.80 ,$181.75 ,$149.79 
Carle BroMenn Medical Center,8980636,ePHEDrine sulfate 50 mg/mL intravenous solution,42023021625,J3490,636,$199.72 ,$199.72 ,$59.92 ,$181.75 ,$139.80 ,$59.92 ,$129.82 ,$143.80 ,$181.75 ,$149.79 
Carle BroMenn Medical Center,8980636,ePHEDrine sulfate 50 mg/mL intravenous solution,42023021689,J3490,636,$132.46 ,$132.46 ,$39.74 ,$120.54 ,$92.72 ,$39.74 ,$86.10 ,$95.37 ,$120.54 ,$99.35 
Carle BroMenn Medical Center,8980636,ePHEDrine sulfate 50 mg/mL intravenous solution,51754420001,J3490,636,$110.95 ,$110.95 ,$33.29 ,$100.96 ,$77.67 ,$33.29 ,$72.12 ,$79.88 ,$100.96 ,$83.21 
Carle BroMenn Medical Center,8980636,ePHEDrine sulfate 50 mg/mL intravenous solution,51754420004,J3490,636,$110.95 ,$110.95 ,$33.29 ,$100.96 ,$77.67 ,$33.29 ,$72.12 ,$79.88 ,$100.96 ,$83.21 
Carle BroMenn Medical Center,8980636,EPINEPHrine 0.1 mg/mL injection syringe,409492134,J0171,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,EPINEPHrine 0.1 mg/mL injection syringe,409493311,J0171,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,EPINEPHrine 0.1 mg/mL injection syringe,76329331601,J0171,636,$64.51 ,$64.51 ,$19.35 ,$58.70 ,$45.16 ,$19.35 ,$41.93 ,$46.45 ,$58.70 ,$48.38 
Carle BroMenn Medical Center,8980636,EPINEPHrine 1 mg/mL (1 mL) injection solution,42023015901,J0171,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,EPINEPHrine 1 mg/mL injection solution,42023016801,J0171,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,EPINEPHrine 1 mg/mL injection solution,42023016889,J0171,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,EPINEPHrine 1 mg/mL injection solution,76329906000,J0171,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,EPINEPHrine HCl (PF) 1 mg/mL (1 mL) injection solution,54288010301,J0171,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,EPINEPHrine HCl (PF) 1 mg/mL (1 mL) injection solution,54288010310,J0171,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"epoetin alfa 10,000 unit/mL injection solution",59676031000,J0885,636,"$1,244.59 ","$1,244.59 ",$373.38 ,"$1,132.58 ",$871.21 ,$373.38 ,$808.98 ,$896.10 ,"$1,132.58 ",$933.44 
Carle BroMenn Medical Center,8980636,"epoetin alfa 10,000 unit/mL injection solution",59676031001,J0885,636,"$1,244.59 ","$1,244.59 ",$373.38 ,"$1,132.58 ",$871.21 ,$373.38 ,$808.98 ,$896.10 ,"$1,132.58 ",$933.44 
Carle BroMenn Medical Center,8980636,"epoetin alfa 2,000 unit/mL injection solution",59676030200,J0885,636,$336.28 ,$336.28 ,$100.88 ,$306.01 ,$235.40 ,$100.88 ,$218.58 ,$242.12 ,$306.01 ,$252.21 
Carle BroMenn Medical Center,8980636,"epoetin alfa 2,000 unit/mL injection solution",59676030201,J0885,636,$336.28 ,$336.28 ,$100.88 ,$306.01 ,$235.40 ,$100.88 ,$218.58 ,$242.12 ,$306.01 ,$252.21 
Carle BroMenn Medical Center,8980636,"epoetin alfa 20,000 unit/mL injection solution",59676032000,J0885,636,"$1,469.08 ","$1,469.08 ",$440.72 ,"$1,336.86 ","$1,028.36 ",$440.72 ,$954.90 ,"$1,057.74 ","$1,336.86 ","$1,101.81 "
Carle BroMenn Medical Center,8980636,"epoetin alfa 20,000 unit/mL injection solution",59676032004,J0885,636,"$1,469.08 ","$1,469.08 ",$440.72 ,"$1,336.86 ","$1,028.36 ",$440.72 ,$954.90 ,"$1,057.74 ","$1,336.86 ","$1,101.81 "
Carle BroMenn Medical Center,8980636,"epoetin alfa 3,000 unit/mL injection solution",55513026710,J0885,636,$315.48 ,$315.48 ,$94.64 ,$287.09 ,$220.84 ,$94.64 ,$205.06 ,$227.15 ,$287.09 ,$236.61 
Carle BroMenn Medical Center,8980636,eptifibatide 0.75 mg/mL intravenous solution,25021040851,J1327,636,"$1,749.40 ","$1,749.40 ",$524.82 ,"$1,591.95 ","$1,224.58 ",$524.82 ,"$1,137.11 ","$1,259.57 ","$1,591.95 ","$1,312.05 "
Carle BroMenn Medical Center,8980636,eptifibatide 0.75 mg/mL intravenous solution,70436002780,J1327,636,"$2,731.82 ","$2,731.82 ",$819.55 ,"$2,485.96 ","$1,912.27 ",$819.55 ,"$1,775.68 ","$1,966.91 ","$2,485.96 ","$2,048.87 "
Carle BroMenn Medical Center,8980636,eptifibatide 2 mg/mL intravenous solution,25021040910,J1327,636,$624.98 ,$624.98 ,$187.49 ,$568.73 ,$437.49 ,$187.49 ,$406.24 ,$449.99 ,$568.73 ,$468.74 
Carle BroMenn Medical Center,8980636,eptifibatide 2 mg/mL intravenous solution,55150021910,J1327,636,"$1,312.90 ","$1,312.90 ",$393.87 ,"$1,194.74 ",$919.03 ,$393.87 ,$853.39 ,$945.29 ,"$1,194.74 ",$984.68 
Carle BroMenn Medical Center,8980636,eptifibatide 2 mg/mL intravenous solution,70436002680,J1327,636,$889.44 ,$889.44 ,$266.83 ,$809.39 ,$622.61 ,$266.83 ,$578.14 ,$640.40 ,$809.39 ,$667.08 
Carle BroMenn Medical Center,8980636,eptinezumab-jjmr 100 mg/mL intravenous solution,67386013051,,636,"$8,633.16 ","$8,633.16 ","$2,589.95 ","$7,856.18 ","$6,043.21 ","$2,589.95 ","$5,611.55 ","$6,215.88 ","$7,856.18 ","$6,474.87 "
Carle BroMenn Medical Center,8980636,ertapenem 1 gram solution for injection,42023022101,J1335,636,$718.73 ,$718.73 ,$215.62 ,$654.04 ,$503.11 ,$215.62 ,$467.17 ,$517.49 ,$654.04 ,$539.05 
Carle BroMenn Medical Center,8980636,ertapenem 1 gram solution for injection,42023022110,J1335,636,$718.73 ,$718.73 ,$215.62 ,$654.04 ,$503.11 ,$215.62 ,$467.17 ,$517.49 ,$654.04 ,$539.05 
Carle BroMenn Medical Center,8980636,ertapenem 1 gram solution for injection,42023022185,J1335,636,$718.73 ,$718.73 ,$215.62 ,$654.04 ,$503.11 ,$215.62 ,$467.17 ,$517.49 ,$654.04 ,$539.05 
Carle BroMenn Medical Center,8980636,erythromycin lactobionate 500 mg intravenous solution,409648201,J1364,636,$521.52 ,$521.52 ,$156.46 ,$474.58 ,$365.06 ,$156.46 ,$338.99 ,$375.49 ,$474.58 ,$391.14 
Carle BroMenn Medical Center,8980636,erythromycin lactobionate 500 mg intravenous solution,409648211,J1364,636,$521.52 ,$521.52 ,$156.46 ,$474.58 ,$365.06 ,$156.46 ,$338.99 ,$375.49 ,$474.58 ,$391.14 
Carle BroMenn Medical Center,8980636,etoposide 20 mg/mL intravenous solution,68001026526,J9181,636,$486.74 ,$486.74 ,$146.02 ,$442.93 ,$340.72 ,$146.02 ,$316.38 ,$350.45 ,$442.93 ,$365.06 
Carle BroMenn Medical Center,8980636,fat emulsion 20 % intravenous,264446010,B4185,636,$180.57 ,$180.57 ,$54.17 ,$164.32 ,$126.40 ,$54.17 ,$117.37 ,$130.01 ,$164.32 ,$135.43 
Carle BroMenn Medical Center,8980636,fat emulsion 20 % intravenous,338051909,B4185,636,$285.42 ,$285.42 ,$85.63 ,$259.73 ,$199.79 ,$85.63 ,$185.52 ,$205.50 ,$259.73 ,$214.07 
Carle BroMenn Medical Center,8980636,fat emulsion 20 % intravenous,338051913,B4185,636,$245.81 ,$245.81 ,$73.74 ,$223.69 ,$172.07 ,$73.74 ,$159.78 ,$176.98 ,$223.69 ,$184.36 
Carle BroMenn Medical Center,8980636,fat emulsion 20 % intravenous,338051958,B4185,636,$189.89 ,$189.89 ,$56.97 ,$172.80 ,$132.92 ,$56.97 ,$123.43 ,$136.72 ,$172.80 ,$142.42 
Carle BroMenn Medical Center,8980636,fentaNYL (PF) 300 mcg/30 mL (10 mcg/mL) in 0.9 % NaCl PCA inj solution,9999401265,,636,$291.45 ,$291.45 ,$87.44 ,$265.22 ,$204.02 ,$87.44 ,$189.44 ,$209.84 ,$265.22 ,$218.59 
Carle BroMenn Medical Center,8980636,fentaNYL (PF) 50 mcg/mL injection solution,409909335,J3010,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,fentaNYL (PF) 50 mcg/mL injection solution,409909417,,636,$145.61 ,$145.61 ,$43.68 ,$132.51 ,$101.93 ,$43.68 ,$94.65 ,$104.84 ,$132.51 ,$109.21 
Carle BroMenn Medical Center,8980636,fentaNYL (PF) 50 mcg/mL injection solution,409909417,J3010,636,$145.61 ,$145.61 ,$43.68 ,$132.51 ,$101.93 ,$43.68 ,$94.65 ,$104.84 ,$132.51 ,$109.21 
Carle BroMenn Medical Center,8980636,fentaNYL (PF) 50 mcg/mL injection solution,409909422,J3010,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,fentaNYL (PF) 50 mcg/mL injection solution,409909425,J3010,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,fentaNYL (PF) 50 mcg/mL injection solution,409909428,J3010,636,$145.61 ,$145.61 ,$43.68 ,$132.51 ,$101.93 ,$43.68 ,$94.65 ,$104.84 ,$132.51 ,$109.21 
Carle BroMenn Medical Center,8980636,fentaNYL (PF) 50 mcg/mL injection solution,409909431,J3010,636,$145.61 ,$145.61 ,$43.68 ,$132.51 ,$101.93 ,$43.68 ,$94.65 ,$104.84 ,$132.51 ,$109.21 
Carle BroMenn Medical Center,8980636,fentaNYL (PF) 50 mcg/mL injection solution,409909461,J3010,636,$176.68 ,$176.68 ,$53.00 ,$160.78 ,$123.68 ,$53.00 ,$114.84 ,$127.21 ,$160.78 ,$132.51 
Carle BroMenn Medical Center,8980636,fentaNYL (PF) 50 mcg/mL injection solution,641602701,J3010,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,fentaNYL (PF) 50 mcg/mL injection solution,641602725,J3010,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,fentaNYL (PF) 50 mcg/mL injection solution,641602901,J3010,636,$145.61 ,$145.61 ,$43.68 ,$132.51 ,$101.93 ,$43.68 ,$94.65 ,$104.84 ,$132.51 ,$109.21 
Carle BroMenn Medical Center,8980636,fentaNYL (PF) 50 mcg/mL injection solution,641602925,J3010,636,$145.61 ,$145.61 ,$43.68 ,$132.51 ,$101.93 ,$43.68 ,$94.65 ,$104.84 ,$132.51 ,$109.21 
Carle BroMenn Medical Center,8980636,fentaNYL (PF) 50 mcg/mL injection solution,641603001,J3010,636,$145.61 ,$145.61 ,$43.68 ,$132.51 ,$101.93 ,$43.68 ,$94.65 ,$104.84 ,$132.51 ,$109.21 
Carle BroMenn Medical Center,8980636,fentaNYL (PF) 50 mcg/mL injection solution,9999470093,,636,$145.61 ,$145.61 ,$43.68 ,$132.51 ,$101.93 ,$43.68 ,$94.65 ,$104.84 ,$132.51 ,$109.21 
Carle BroMenn Medical Center,8980636,fentaNYL (PF) 50 mcg/mL injection solution,9999470093,J3010,636,$145.61 ,$145.61 ,$43.68 ,$132.51 ,$101.93 ,$43.68 ,$94.65 ,$104.84 ,$132.51 ,$109.21 
Carle BroMenn Medical Center,8980636,ferric carboxymaltose 50 mg iron/mL intravenous solution,517065001,J1439,636,"$6,825.29 ","$6,825.29 ","$2,047.59 ","$6,211.01 ","$4,777.70 ","$2,047.59 ","$4,436.44 ","$4,914.21 ","$6,211.01 ","$5,118.97 "
Carle BroMenn Medical Center,8980636,filgrastim 300 mcg/mL injection solution,55513053001,J1442,636,"$1,444.44 ","$1,444.44 ",$433.33 ,"$1,314.44 ","$1,011.11 ",$433.33 ,$938.89 ,"$1,040.00 ","$1,314.44 ","$1,083.33 "
Carle BroMenn Medical Center,8980636,filgrastim 300 mcg/mL injection solution,55513053010,J1442,636,"$1,444.44 ","$1,444.44 ",$433.33 ,"$1,314.44 ","$1,011.11 ",$433.33 ,$938.89 ,"$1,040.00 ","$1,314.44 ","$1,083.33 "
Carle BroMenn Medical Center,8980636,filgrastim 480 mcg/0.8 mL injection syringe,55513020901,J1442,636,"$1,954.81 ","$1,954.81 ",$586.44 ,"$1,778.88 ","$1,368.37 ",$586.44 ,"$1,270.63 ","$1,407.46 ","$1,778.88 ","$1,466.11 "
Carle BroMenn Medical Center,8980636,filgrastim 480 mcg/0.8 mL injection syringe,55513020991,J1442,636,"$2,354.16 ","$2,354.16 ",$706.25 ,"$2,142.29 ","$1,647.91 ",$706.25 ,"$1,530.20 ","$1,695.00 ","$2,142.29 ","$1,765.62 "
Carle BroMenn Medical Center,8980636,filgrastim 480 mcg/1.6 mL injection solution,55513054601,J1442,636,"$2,227.72 ","$2,227.72 ",$668.32 ,"$2,027.23 ","$1,559.40 ",$668.32 ,"$1,448.02 ","$1,603.96 ","$2,027.23 ","$1,670.79 "
Carle BroMenn Medical Center,8980636,filgrastim 480 mcg/1.6 mL injection solution,55513054610,J1442,636,"$2,227.72 ","$2,227.72 ",$668.32 ,"$2,027.23 ","$1,559.40 ",$668.32 ,"$1,448.02 ","$1,603.96 ","$2,027.23 ","$1,670.79 "
Carle BroMenn Medical Center,8980636,flu vaccine qs 2021-22(6mos up)(PF) 60 mcg(15 mcgx4)/0.5 mL IM syringe,19515081841,90686,636,$38.67 ,$38.67 ,$11.60 ,$35.19 ,$27.07 ,$11.60 ,$25.14 ,$27.84 ,$35.19 ,$29.00 
Carle BroMenn Medical Center,8980636,flu vaccine qs 2021-22(6mos up)(PF) 60 mcg(15 mcgx4)/0.5 mL IM syringe,19515081852,90686,636,$38.67 ,$38.67 ,$11.60 ,$35.19 ,$27.07 ,$11.60 ,$25.14 ,$27.84 ,$35.19 ,$29.00 
Carle BroMenn Medical Center,8980636,fluconazole 200 mg/100 mL in sod. chloride (iso) intravenous piggyback,338604648,J1450,636,$133.77 ,$133.77 ,$40.13 ,$121.73 ,$93.64 ,$40.13 ,$86.95 ,$96.31 ,$121.73 ,$100.33 
Carle BroMenn Medical Center,8980636,fluconazole 200 mg/100 mL in sod. chloride (iso) intravenous piggyback,69784000206,J1450,636,$45.30 ,$45.30 ,$13.59 ,$41.22 ,$31.71 ,$13.59 ,$29.45 ,$32.62 ,$41.22 ,$33.98 
Carle BroMenn Medical Center,8980636,fluconazole 400 mg/200 mL in sod. chloride(iso) intravenous piggyback,338604537,J1450,636,$148.90 ,$148.90 ,$44.67 ,$135.50 ,$104.23 ,$44.67 ,$96.79 ,$107.21 ,$135.50 ,$111.68 
Carle BroMenn Medical Center,8980636,fluconazole 400 mg/200 mL in sod. chloride(iso) intravenous piggyback,69784000306,J1450,636,$52.29 ,$52.29 ,$15.69 ,$47.58 ,$36.60 ,$15.69 ,$33.99 ,$37.65 ,$47.58 ,$39.22 
Carle BroMenn Medical Center,8980636,fluorouraciL 1 gram/20 mL intravenous solution,63323011720,,636,$145.61 ,$145.61 ,$43.68 ,$132.51 ,$101.93 ,$43.68 ,$94.65 ,$104.84 ,$132.51 ,$109.21 
Carle BroMenn Medical Center,8980636,fluPHENAZine 2.5 mg/mL injection solution,63323028110,J2680,636,$70.47 ,$70.47 ,$21.14 ,$64.13 ,$49.33 ,$21.14 ,$45.81 ,$50.74 ,$64.13 ,$52.85 
Carle BroMenn Medical Center,8980636,fluPHENAZine decanoate 25 mg/mL injection solution,42023012901,J2680,636,$112.35 ,$112.35 ,$33.71 ,$102.24 ,$78.65 ,$33.71 ,$73.03 ,$80.89 ,$102.24 ,$84.26 
Carle BroMenn Medical Center,8980636,fomepizole 1 gram/mL intravenous solution,70710147801,J1451,636,"$8,452.07 ","$8,452.07 ","$2,535.62 ","$7,691.38 ","$5,916.45 ","$2,535.62 ","$5,493.85 ","$6,085.49 ","$7,691.38 ","$6,339.05 "
Carle BroMenn Medical Center,8980636,fondaparinux 10 mg/0.8 mL subcutaneous solution syringe,781347612,J1652,636,$538.03 ,$538.03 ,$161.41 ,$489.61 ,$376.62 ,$161.41 ,$349.72 ,$387.38 ,$489.61 ,$403.52 
Carle BroMenn Medical Center,8980636,fondaparinux 10 mg/0.8 mL subcutaneous solution syringe,781347694,J1652,636,$538.03 ,$538.03 ,$161.41 ,$489.61 ,$376.62 ,$161.41 ,$349.72 ,$387.38 ,$489.61 ,$403.52 
Carle BroMenn Medical Center,8980636,fondaparinux 10 mg/0.8 mL subcutaneous solution syringe,55111068102,J1652,636,$597.44 ,$597.44 ,$179.23 ,$543.67 ,$418.21 ,$179.23 ,$388.34 ,$430.16 ,$543.67 ,$448.08 
Carle BroMenn Medical Center,8980636,fondaparinux 10 mg/0.8 mL subcutaneous solution syringe,55111068110,J1652,636,$572.28 ,$572.28 ,$171.68 ,$520.77 ,$400.60 ,$171.68 ,$371.98 ,$412.04 ,$520.77 ,$429.21 
Carle BroMenn Medical Center,8980636,fondaparinux 10 mg/0.8 mL subcutaneous solution syringe,55111068111,J1652,636,$597.44 ,$597.44 ,$179.23 ,$543.67 ,$418.21 ,$179.23 ,$388.34 ,$430.16 ,$543.67 ,$448.08 
Carle BroMenn Medical Center,8980636,fondaparinux 10 mg/0.8 mL subcutaneous solution syringe,70710151702,J1652,636,$572.28 ,$572.28 ,$171.68 ,$520.77 ,$400.60 ,$171.68 ,$371.98 ,$412.04 ,$520.77 ,$429.21 
Carle BroMenn Medical Center,8980636,fondaparinux 10 mg/0.8 mL subcutaneous solution syringe,70710151709,J1652,636,$597.44 ,$597.44 ,$179.23 ,$543.67 ,$418.21 ,$179.23 ,$388.34 ,$430.16 ,$543.67 ,$448.08 
Carle BroMenn Medical Center,8980636,fondaparinux 2.5 mg/0.5 mL subcutaneous solution syringe,781344394,J1652,636,$298.86 ,$298.86 ,$89.66 ,$271.96 ,$209.20 ,$89.66 ,$194.26 ,$215.18 ,$271.96 ,$224.15 
Carle BroMenn Medical Center,8980636,fondaparinux 2.5 mg/0.5 mL subcutaneous solution syringe,55111067811,J1652,636,$324.09 ,$324.09 ,$97.23 ,$294.92 ,$226.86 ,$97.23 ,$210.66 ,$233.34 ,$294.92 ,$243.07 
Carle BroMenn Medical Center,8980636,fondaparinux 7.5 mg/0.6 mL subcutaneous solution syringe,781346594,J1652,636,$538.03 ,$538.03 ,$161.41 ,$489.61 ,$376.62 ,$161.41 ,$349.72 ,$387.38 ,$489.61 ,$403.52 
Carle BroMenn Medical Center,8980636,fondaparinux 7.5 mg/0.6 mL subcutaneous solution syringe,781346595,J1652,636,$364.08 ,$364.08 ,$109.22 ,$331.31 ,$254.86 ,$109.22 ,$236.65 ,$262.14 ,$331.31 ,$273.06 
Carle BroMenn Medical Center,8980636,fondaparinux 7.5 mg/0.6 mL subcutaneous solution syringe,55111068011,J1652,636,$597.44 ,$597.44 ,$179.23 ,$543.67 ,$418.21 ,$179.23 ,$388.34 ,$430.16 ,$543.67 ,$448.08 
Carle BroMenn Medical Center,8980636,fondaparinux 7.5 mg/0.6 mL subcutaneous solution syringe,55150023200,J1652,636,$426.64 ,$426.64 ,$127.99 ,$388.24 ,$298.65 ,$127.99 ,$277.32 ,$307.18 ,$388.24 ,$319.98 
Carle BroMenn Medical Center,8980636,fondaparinux 7.5 mg/0.6 mL subcutaneous solution syringe,55150023210,J1652,636,$426.64 ,$426.64 ,$127.99 ,$388.24 ,$298.65 ,$127.99 ,$277.32 ,$307.18 ,$388.24 ,$319.98 
Carle BroMenn Medical Center,8980636,formoterol fumarate 20 mcg/2 mL solution for nebulization,49502060561,J7606,636,$86.21 ,$86.21 ,$25.86 ,$78.45 ,$60.35 ,$25.86 ,$56.04 ,$62.07 ,$78.45 ,$64.66 
Carle BroMenn Medical Center,8980636,formoterol fumarate 20 mcg/2 mL solution for nebulization,49502060595,J7606,636,$86.22 ,$86.22 ,$25.87 ,$78.46 ,$60.35 ,$25.87 ,$56.04 ,$62.08 ,$78.46 ,$64.67 
Carle BroMenn Medical Center,8980636,fosphenytoin 100 mg PE/2 mL injection solution,67457051625,Q2009,636,$139.71 ,$139.71 ,$41.91 ,$127.14 ,$97.80 ,$41.91 ,$90.81 ,$100.59 ,$127.14 ,$104.78 
Carle BroMenn Medical Center,8980636,fosphenytoin 500 mg PE/10 mL injection solution,69600110,Q2009,636,$733.47 ,$733.47 ,$220.04 ,$667.46 ,$513.43 ,$220.04 ,$476.76 ,$528.10 ,$667.46 ,$550.10 
Carle BroMenn Medical Center,8980636,fosphenytoin 500 mg PE/10 mL injection solution,69600121,Q2009,636,$733.47 ,$733.47 ,$220.04 ,$667.46 ,$513.43 ,$220.04 ,$476.76 ,$528.10 ,$667.46 ,$550.10 
Carle BroMenn Medical Center,8980636,fosphenytoin 500 mg PE/10 mL injection solution,67457051701,Q2009,636,$370.18 ,$370.18 ,$111.05 ,$336.86 ,$259.13 ,$111.05 ,$240.62 ,$266.53 ,$336.86 ,$277.64 
Carle BroMenn Medical Center,8980636,furosemide 10 mg/mL injection solution,25021031104,J1940,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,furosemide 10 mg/mL injection solution,25021031110,J1940,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,furosemide 10 mg/mL injection solution,36000028225,J1940,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,furosemide 10 mg/mL injection solution,36000028325,J1940,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,furosemide 10 mg/mL injection solution,36000028425,J1940,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,furosemide 10 mg/mL injection solution,55150032425,J1940,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,furosemide 10 mg/mL injection solution,63323028001,J1940,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,furosemide 10 mg/mL injection solution,63323028002,J1940,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,furosemide 10 mg/mL injection solution,63323028003,J1940,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,furosemide 10 mg/mL injection solution,63323028005,J1940,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,furosemide 10 mg/mL injection solution,63323028026,J1940,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,furosemide 10 mg/mL injection solution,64679075902,J1940,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,furosemide 10 mg/mL injection solution,64679075903,J1940,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,furosemide 10 mg/mL injection solution,64679075911,J1940,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,furosemide 10 mg/mL injection solution,64679075912,J1940,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,ganciclovir sodium 500 mg intravenous solution,63323031501,J1570,636,$608.00 ,$608.00 ,$182.40 ,$553.28 ,$425.60 ,$182.40 ,$395.20 ,$437.76 ,$553.28 ,$456.00 
Carle BroMenn Medical Center,8980636,ganciclovir sodium 500 mg intravenous solution,63323031510,J1570,636,$608.00 ,$608.00 ,$182.40 ,$553.28 ,$425.60 ,$182.40 ,$395.20 ,$437.76 ,$553.28 ,$456.00 
Carle BroMenn Medical Center,8980636,gentamicin 20 mg/2 mL injection solution,63323051302,J1580,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,gentamicin 40 mg/mL injection solution,63323001003,J1580,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,gentamicin 40 mg/mL injection solution,63323001020,J1580,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,gentamicin 80 mg/100 mL in sodium chloride(iso) intravenous piggyback,338050348,J1580,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,gentamicin sulfate (pediatric) (PF) 20 mg/2 mL injection solution,63323017302,J1580,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,gentamicin sulfate (pediatric) (PF) 20 mg/2 mL injection solution,63323017394,J1580,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,glatiramer 40 mg/mL subcutaneous syringe,378696112,J1595,636,"$1,957.18 ","$1,957.18 ",$587.15 ,"$1,781.03 ","$1,370.03 ",$587.15 ,"$1,272.17 ","$1,409.17 ","$1,781.03 ","$1,467.89 "
Carle BroMenn Medical Center,8980636,"glucagon (human recombinant) 1 mg/mL solution for injection,glucagon HCL 1 mg/mL solution for injection,glucagon HCL 1 mg solution for injection,glucagon 1 mg solution for injection",597005345,J1610,636,$842.86 ,$842.86 ,$252.86 ,$767.00 ,$590.00 ,$252.86 ,$547.86 ,$606.86 ,$767.00 ,$632.15 
Carle BroMenn Medical Center,8980636,"glucagon (human recombinant) 1 mg/mL solution for injection,glucagon HCL 1 mg/mL solution for injection,glucagon HCL 1 mg solution for injection,glucagon 1 mg solution for injection",597026010,J1610,636,$842.86 ,$842.86 ,$252.86 ,$767.00 ,$590.00 ,$252.86 ,$547.86 ,$606.86 ,$767.00 ,$632.15 
Carle BroMenn Medical Center,8980636,golimumab 12.5 mg/mL intravenous solution,57894035001,J1602,636,"$11,243.56 ","$11,243.56 ","$3,373.07 ","$10,231.64 ","$7,870.49 ","$3,373.07 ","$7,308.31 ","$8,095.36 ","$10,231.64 ","$8,432.67 "
Carle BroMenn Medical Center,8980636,granisetron HCL 1 mg/mL (1 mL) intravenous solution,143974401,J1626,636,$66.26 ,$66.26 ,$19.88 ,$60.30 ,$46.38 ,$19.88 ,$43.07 ,$47.71 ,$60.30 ,$49.70 
Carle BroMenn Medical Center,8980636,granisetron HCL 1 mg/mL (1 mL) intravenous solution,143974410,J1626,636,$66.26 ,$66.26 ,$19.88 ,$60.30 ,$46.38 ,$19.88 ,$43.07 ,$47.71 ,$60.30 ,$49.70 
Carle BroMenn Medical Center,8980636,haemoph b polysac conj-mening (PF) 7.5 mcg/0.5 mL intramuscular soln,6489700,90647,636,$62.12 ,$62.12 ,$18.64 ,$56.53 ,$43.48 ,$18.64 ,$40.38 ,$44.73 ,$56.53 ,$46.59 
Carle BroMenn Medical Center,8980636,haemoph b polysac conj-mening (PF) 7.5 mcg/0.5 mL intramuscular soln,6489701,90647,636,$62.12 ,$62.12 ,$18.64 ,$56.53 ,$43.48 ,$18.64 ,$40.38 ,$44.73 ,$56.53 ,$46.59 
Carle BroMenn Medical Center,8980636,haemophilus B polysaccharid conj-tetanus tox(PF) 10 mcg/0.5 mL IM soln,58160081605,90648,636,$25.46 ,$25.46 ,$7.64 ,$23.17 ,$17.82 ,$7.64 ,$16.55 ,$18.33 ,$23.17 ,$19.10 
Carle BroMenn Medical Center,8980636,haloperidol lactate 5 mg/mL injection solution,63323047400,J1630,636,$45.23 ,$45.23 ,$13.57 ,$41.16 ,$31.66 ,$13.57 ,$29.40 ,$32.57 ,$41.16 ,$33.92 
Carle BroMenn Medical Center,8980636,haloperidol lactate 5 mg/mL injection solution,63323047401,J1630,636,$45.23 ,$45.23 ,$13.57 ,$41.16 ,$31.66 ,$13.57 ,$29.40 ,$32.57 ,$41.16 ,$33.92 
Carle BroMenn Medical Center,8980636,haloperidol lactate 5 mg/mL injection solution,67457042600,J1630,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,haloperidol lactate 5 mg/mL injection solution,67457042612,J1630,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"heparin (porcine) (PF) 1,000 unit/500 mL in 0.9 % sodium chloride IV",264987210,J1644,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"heparin (porcine) (PF) 1,000 unit/500 mL in 0.9 % sodium chloride IV",338042418,J1644,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"heparin (porcine) (PF) 1,000 unit/500 mL in 0.9 % sodium chloride IV",63323051902,J1644,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"heparin (porcine) (PF) 1,000 unit/500 mL in 0.9 % sodium chloride IV",63323051977,J1644,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION",409272002,J1644,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION",409272031,J1644,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION",63323054005,J1644,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION",63323054033,J1644,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION",67457038599,J1644,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION",71288040231,J1644,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"heparin (porcine) 1,000 unit/mL injection solution",409272002,J1644,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"heparin (porcine) 1,000 unit/mL injection solution",409272031,J1644,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"heparin (porcine) 1,000 unit/mL injection solution",63323054005,J1644,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"heparin (porcine) 1,000 unit/mL injection solution",63323054033,J1644,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"heparin (porcine) 1,000 unit/mL injection solution",67457038599,J1644,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"heparin (porcine) 1,000 unit/mL injection solution",71288040231,J1644,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"heparin (porcine) 10,000 unit/mL injection solution",25021040304,J1644,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"heparin (porcine) 10,000 unit/mL injection solution",63323054207,J1644,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"heparin (porcine) 10,000 unit/mL injection solution",71288040404,J1644,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"heparin (porcine) 10,000 unit/mL injection solution",71288040405,J1644,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"heparin (porcine) 25,000 unit/250 mL (100 unit/mL) in dextrose 5 % IV",409779352,J1644,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,"heparin (porcine) 25,000 unit/250 mL (100 unit/mL) in dextrose 5 % IV",63323052301,J1644,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,"heparin (porcine) 25,000 unit/250 mL (100 unit/mL) in dextrose 5 % IV",63323052374,J1644,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,"heparin (porcine) 25,000 unit/250 mL in 0.45 % sodium chloride IV soln",63323051774,J1644,636,$64.51 ,$64.51 ,$19.35 ,$58.70 ,$45.16 ,$19.35 ,$41.93 ,$46.45 ,$58.70 ,$48.38 
Carle BroMenn Medical Center,8980636,"Heparin (Porcine) 5,000 unit/mL Injection",67457037499,J1644,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"Heparin (Porcine) 5,000 unit/mL Injection",71288040301,J1644,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"heparin (porcine) 5,000 unit/mL injection solution",63739095311,J1644,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"heparin (porcine) 5,000 unit/mL injection solution",63739095325,J1644,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"heparin (porcine) 5,000 unit/mL injection solution",67457037499,J1644,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"heparin (porcine) 5,000 unit/mL injection solution",71288040301,J1644,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"heparin (porcine) 5,000 unit/mL injection solution",71288040302,J1644,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"heparin, porcine (PF) 1,000 unit/mL injection solution",63323027602,J1644,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,"heparin, porcine (PF) 10 unit/mL intravenous syringe",8290306413,J1642,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"heparin, porcine (PF) 100 unit/mL intravenous syringe",63807060051,J1642,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"heparin, porcine (PF) 100 unit/mL intravenous syringe",64253033335,J1642,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"hepatitis B immune globulin > 1,560 unit/5 mL intramuscular solution",59730420301,90371,636,$315.71 ,$315.71 ,$94.71 ,$287.30 ,$221.00 ,$94.71 ,$205.21 ,$227.31 ,$287.30 ,$236.78 
Carle BroMenn Medical Center,8980636,hepatitis B immune globulin 110 unit/0.5 mL intramuscular syringe,13533063603,90371,636,$196.78 ,$196.78 ,$59.03 ,$179.07 ,$137.75 ,$59.03 ,$127.91 ,$141.68 ,$179.07 ,$147.59 
Carle BroMenn Medical Center,8980636,hepatitis B immune globulin 220 unit/mL (5 mL) intramuscular solution,13533063605,90371,636,$356.07 ,$356.07 ,$106.82 ,$324.02 ,$249.25 ,$106.82 ,$231.45 ,$256.37 ,$324.02 ,$267.05 
Carle BroMenn Medical Center,8980636,hepatitis B immune globulin 220 unit/mL intramuscular syringe,13533063602,90371,636,$371.08 ,$371.08 ,$111.32 ,$337.68 ,$259.76 ,$111.32 ,$241.20 ,$267.18 ,$337.68 ,$278.31 
Carle BroMenn Medical Center,8980636,hepatitis B virus vaccine recomb (PF) 10 mcg/0.5 mL IM syringe,58160082043,90744,636,$56.12 ,$56.12 ,$16.84 ,$51.07 ,$39.28 ,$16.84 ,$36.48 ,$40.41 ,$51.07 ,$42.09 
Carle BroMenn Medical Center,8980636,hepatitis B virus vaccine recomb (PF) 10 mcg/0.5 mL IM syringe,58160082052,90744,636,$56.12 ,$56.12 ,$16.84 ,$51.07 ,$39.28 ,$16.84 ,$36.48 ,$40.41 ,$51.07 ,$42.09 
Carle BroMenn Medical Center,8980636,hepatitis B virus vaccine recomb (PF) 20 mcg/mL intramuscular susp,58160082111,90746,636,$137.35 ,$137.35 ,$41.21 ,$124.99 ,$96.15 ,$41.21 ,$89.28 ,$98.89 ,$124.99 ,$103.01 
Carle BroMenn Medical Center,8980636,hum prothrombin cplx (PCC) 4factor 500 unit (400-620 unit) IV solution,63833038602,,636,$36.44 ,$36.44 ,$10.93 ,$33.16 ,$25.51 ,$10.93 ,$23.69 ,$26.24 ,$33.16 ,$27.33 
Carle BroMenn Medical Center,8980636,hum prothrombin cplx (PCC) 4factor 500 unit (400-620 unit) IV solution,63833039601,,636,$36.44 ,$36.44 ,$10.93 ,$33.16 ,$25.51 ,$10.93 ,$23.69 ,$26.24 ,$33.16 ,$27.33 
Carle BroMenn Medical Center,8980636,"hum prothrombin cplx(PCC)4fact 1,000 unit (800-1,240 unit) IV solution",63833038702,,636,$35.74 ,$35.74 ,$10.72 ,$32.52 ,$25.02 ,$10.72 ,$23.23 ,$25.73 ,$32.52 ,$26.81 
Carle BroMenn Medical Center,8980636,"hum prothrombin cplx(PCC)4fact 1,000 unit (800-1,240 unit) IV solution",63833039701,,636,$35.74 ,$35.74 ,$10.72 ,$32.52 ,$25.02 ,$10.72 ,$23.23 ,$25.73 ,$32.52 ,$26.81 
Carle BroMenn Medical Center,8980636,"human papillomavirus vaccine,9-valent(PF) 0.5 mL intramuscular syringe",6412101,90651,636,$563.93 ,$563.93 ,$169.18 ,$513.18 ,$394.75 ,$169.18 ,$366.55 ,$406.03 ,$513.18 ,$422.95 
Carle BroMenn Medical Center,8980636,"human papillomavirus vaccine,9-valent(PF) 0.5 mL intramuscular syringe",6412102,90651,636,$563.93 ,$563.93 ,$169.18 ,$513.18 ,$394.75 ,$169.18 ,$366.55 ,$406.03 ,$513.18 ,$422.95 
Carle BroMenn Medical Center,8980636,"hyaluronate sodium, stabilized 60 mg/3 mL intra-articular syringe",16986002080,,636,"$4,339.99 ","$4,339.99 ","$1,302.00 ","$3,949.39 ","$3,037.99 ","$1,302.00 ","$2,820.99 ","$3,124.79 ","$3,949.39 ","$3,254.99 "
Carle BroMenn Medical Center,8980636,"hyaluronate sodium, stabilized 60 mg/3 mL intra-articular syringe",89130202001,,636,"$4,339.99 ","$4,339.99 ","$1,302.00 ","$3,949.39 ","$3,037.99 ","$1,302.00 ","$2,820.99 ","$3,124.79 ","$3,949.39 ","$3,254.99 "
Carle BroMenn Medical Center,8980636,hyaluronidase 150 unit/mL injection solution,548909010,J3470,636,$349.36 ,$349.36 ,$104.81 ,$317.92 ,$244.55 ,$104.81 ,$227.08 ,$251.54 ,$317.92 ,$262.02 
Carle BroMenn Medical Center,8980636,hydrALAZINE 20 mg/mL injection solution,517090101,J0360,636,$108.16 ,$108.16 ,$32.45 ,$98.43 ,$75.71 ,$32.45 ,$70.30 ,$77.88 ,$98.43 ,$81.12 
Carle BroMenn Medical Center,8980636,hydrALAZINE 20 mg/mL injection solution,517090125,J0360,636,$108.16 ,$108.16 ,$32.45 ,$98.43 ,$75.71 ,$32.45 ,$70.30 ,$77.88 ,$98.43 ,$81.12 
Carle BroMenn Medical Center,8980636,hydrALAZINE 20 mg/mL injection solution,63323061400,J0360,636,$94.75 ,$94.75 ,$28.43 ,$86.22 ,$66.33 ,$28.43 ,$61.59 ,$68.22 ,$86.22 ,$71.06 
Carle BroMenn Medical Center,8980636,hydrALAZINE 20 mg/mL injection solution,63323061401,J0360,636,$94.75 ,$94.75 ,$28.43 ,$86.22 ,$66.33 ,$28.43 ,$61.59 ,$68.22 ,$86.22 ,$71.06 
Carle BroMenn Medical Center,8980636,hydrALAZINE 20 mg/mL injection solution,63323061416,J0360,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,hydrALAZINE 20 mg/mL injection solution,67457029100,J0360,636,$569.19 ,$569.19 ,$170.76 ,$517.96 ,$398.43 ,$170.76 ,$369.97 ,$409.82 ,$517.96 ,$426.89 
Carle BroMenn Medical Center,8980636,hydrALAZINE 20 mg/mL injection solution,67457029101,J0360,636,$569.19 ,$569.19 ,$170.76 ,$517.96 ,$398.43 ,$170.76 ,$369.97 ,$409.82 ,$517.96 ,$426.89 
Carle BroMenn Medical Center,8980636,hydrocortisone sod succinate (PF) 100 mg/2 mL solution for injection,9001103,J1720,636,$111.19 ,$111.19 ,$33.36 ,$101.18 ,$77.83 ,$33.36 ,$72.27 ,$80.06 ,$101.18 ,$83.39 
Carle BroMenn Medical Center,8980636,hydrocortisone sod succinate (PF) 100 mg/2 mL solution for injection,9001104,J1720,636,$111.13 ,$111.13 ,$33.34 ,$101.13 ,$77.79 ,$33.34 ,$72.23 ,$80.01 ,$101.13 ,$83.35 
Carle BroMenn Medical Center,8980636,hydrocortisone sod succinate (PF) 250 mg/2 mL solution for injection,9001305,J1720,636,$164.98 ,$164.98 ,$49.49 ,$150.13 ,$115.49 ,$49.49 ,$107.24 ,$118.79 ,$150.13 ,$123.74 
Carle BroMenn Medical Center,8980636,"HYDROmorphone (PF) 1 mg/mL injection syringe,HYDROmorphone 1 mg/mL injection syringe,HYDROmorphone 1 mg/mL injection solution,HYDROmorphone (PF) 1 mg/mL injection solution",409128331,J1170,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"HYDROmorphone (PF) 1 mg/mL injection syringe,HYDROmorphone 1 mg/mL injection syringe,HYDROmorphone 1 mg/mL injection solution,HYDROmorphone (PF) 1 mg/mL injection solution",76045000901,J1170,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"HYDROmorphone (PF) 1 mg/mL injection syringe,HYDROmorphone 1 mg/mL injection syringe,HYDROmorphone 1 mg/mL injection solution,HYDROmorphone (PF) 1 mg/mL injection solution",76045000911,J1170,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,HYDROmorphone (PF) 10 mg/mL injection solution,409263405,,636,$145.61 ,$145.61 ,$43.68 ,$132.51 ,$101.93 ,$43.68 ,$94.65 ,$104.84 ,$132.51 ,$109.21 
Carle BroMenn Medical Center,8980636,HYDROmorphone (PF) 10 mg/mL injection solution,409263425,,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"HYDROmorphone 0.5 mg/0.5 mL injection syringe,HYDROmorphone (PF) 0.5 mg/0.5 mL injection syringe",409128305,J1170,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"HYDROmorphone 0.5 mg/0.5 mL injection syringe,HYDROmorphone (PF) 0.5 mg/0.5 mL injection syringe",76045000906,J1170,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"HYDROmorphone 0.5 mg/0.5 mL injection syringe,HYDROmorphone (PF) 0.5 mg/0.5 mL injection syringe",76045000996,J1170,636,$145.61 ,$145.61 ,$43.68 ,$132.51 ,$101.93 ,$43.68 ,$94.65 ,$104.84 ,$132.51 ,$109.21 
Carle BroMenn Medical Center,8980636,hydroxyurea 500 mg capsule,68084028401,J8999,636,$9.80 ,$9.80 ,$2.94 ,$8.92 ,$6.86 ,$2.94 ,$6.37 ,$7.06 ,$8.92 ,$7.35 
Carle BroMenn Medical Center,8980636,hydroxyurea 500 mg capsule,68084028411,J8999,636,$9.80 ,$9.80 ,$2.94 ,$8.92 ,$6.86 ,$2.94 ,$6.37 ,$7.06 ,$8.92 ,$7.35 
Carle BroMenn Medical Center,8980636,hydrOXYzine HCL 50 mg/mL intramuscular solution,517560125,J3410,636,$85.29 ,$85.29 ,$25.59 ,$77.61 ,$59.70 ,$25.59 ,$55.44 ,$61.41 ,$77.61 ,$63.97 
Carle BroMenn Medical Center,8980636,hydrOXYzine pamoate 25 mg capsule,185067401,Q0177,636,$3.72 ,$3.72 ,$1.12 ,$3.39 ,$2.60 ,$1.12 ,$2.42 ,$2.68 ,$3.39 ,$2.79 
Carle BroMenn Medical Center,8980636,hydrOXYzine pamoate 25 mg capsule,68084084711,Q0177,636,$5.13 ,$5.13 ,$1.54 ,$4.67 ,$3.59 ,$1.54 ,$3.33 ,$3.69 ,$4.67 ,$3.85 
Carle BroMenn Medical Center,8980636,hydrOXYzine pamoate 50 mg capsule,185061501,Q0177,636,$3.83 ,$3.83 ,$1.15 ,$3.49 ,$2.68 ,$1.15 ,$2.49 ,$2.76 ,$3.49 ,$2.87 
Carle BroMenn Medical Center,8980636,hydrOXYzine pamoate 50 mg capsule,185067601,Q0177,636,$3.83 ,$3.83 ,$1.15 ,$3.49 ,$2.68 ,$1.15 ,$2.49 ,$2.76 ,$3.49 ,$2.87 
Carle BroMenn Medical Center,8980636,hylan g-f 20  48 mg/6 mL intra-articular syringe,58468009003,J7325,636,"$5,874.52 ","$5,874.52 ","$1,762.36 ","$5,345.81 ","$4,112.16 ","$1,762.36 ","$3,818.44 ","$4,229.65 ","$5,345.81 ","$4,405.89 "
Carle BroMenn Medical Center,8980636,hylan g-f 20 16 mg/2 mL intra-articular syringe,58468009001,J7325,636,"$2,039.60 ","$2,039.60 ",$611.88 ,"$1,856.04 ","$1,427.72 ",$611.88 ,"$1,325.74 ","$1,468.51 ","$1,856.04 ","$1,529.70 "
Carle BroMenn Medical Center,8980636,ibutilide fumarate 0.1 mg/mL intravenous solution,67457036610,J1742,636,"$1,801.69 ","$1,801.69 ",$540.51 ,"$1,639.54 ","$1,261.18 ",$540.51 ,"$1,171.10 ","$1,297.22 ","$1,639.54 ","$1,351.27 "
Carle BroMenn Medical Center,8980636,ifosfamide 3 gram intravenous solution,10019092602,J9208,636,$626.42 ,$626.42 ,$187.93 ,$570.04 ,$438.49 ,$187.93 ,$407.17 ,$451.02 ,$570.04 ,$469.82 
Carle BroMenn Medical Center,8980636,ifosfamide 3 gram intravenous solution,10019092616,J9208,636,$626.42 ,$626.42 ,$187.93 ,$570.04 ,$438.49 ,$187.93 ,$407.17 ,$451.02 ,$570.04 ,$469.82 
Carle BroMenn Medical Center,8980636,immune glob G 10 gram/100 mL(10%)-gly-IgA ave 46 mcg/mL injection soln,13533080071,J1561,636,"$9,090.75 ","$9,090.75 ","$2,727.23 ","$8,272.58 ","$6,363.53 ","$2,727.23 ","$5,908.99 ","$6,545.34 ","$8,272.58 ","$6,818.06 "
Carle BroMenn Medical Center,8980636,immune glob G 2.5 gram/25 mL(10%)-gly-IgA ave 46 mcg/mL injection soln,13533080015,J1561,636,"$2,275.24 ","$2,275.24 ",$682.57 ,"$2,070.47 ","$1,592.67 ",$682.57 ,"$1,478.91 ","$1,638.17 ","$2,070.47 ","$1,706.43 "
Carle BroMenn Medical Center,8980636,immune glob G 20 gram/200 mL(10%)-gly-IgA ave 46 mcg/mL injection soln,13533080024,J1561,636,"$18,178.10 ","$18,178.10 ","$5,453.43 ","$16,542.07 ","$12,724.67 ","$5,453.43 ","$11,815.77 ","$13,088.23 ","$16,542.07 ","$13,633.58 "
Carle BroMenn Medical Center,8980636,immune glob G 40 gram/400 mL(10%)-gly-IgA ave 46 mcg/mL injection soln,13533080040,J1561,636,"$36,352.79 ","$36,352.79 ","$10,905.84 ","$33,081.04 ","$25,446.95 ","$10,905.84 ","$23,629.31 ","$26,174.01 ","$33,081.04 ","$27,264.59 "
Carle BroMenn Medical Center,8980636,"immune glob,gamm(IgG) 10 %-pro-IgA 0 to 50 mcg/mL intravenous solution",44206043605,J1459,636,"$5,319.97 ","$5,319.97 ","$1,595.99 ","$4,841.17 ","$3,723.98 ","$1,595.99 ","$3,457.98 ","$3,830.38 ","$4,841.17 ","$3,989.98 "
Carle BroMenn Medical Center,8980636,"immune glob,gamm(IgG) 10 %-pro-IgA 0 to 50 mcg/mL intravenous solution",44206043710,J1459,636,"$10,636.54 ","$10,636.54 ","$3,190.96 ","$9,679.25 ","$7,445.58 ","$3,190.96 ","$6,913.75 ","$7,658.31 ","$9,679.25 ","$7,977.41 "
Carle BroMenn Medical Center,8980636,"immune glob,gamm(IgG) 10 %-pro-IgA 0 to 50 mcg/mL intravenous solution",44206043820,J1459,636,"$21,269.68 ","$21,269.68 ","$6,380.90 ","$19,355.41 ","$14,888.78 ","$6,380.90 ","$13,825.29 ","$15,314.17 ","$19,355.41 ","$15,952.26 "
Carle BroMenn Medical Center,8980636,"immune glob,gamm(IgG) 10 %-pro-IgA 0 to 50 mcg/mL intravenous solution",44206043940,J1459,636,"$42,535.96 ","$42,535.96 ","$12,760.79 ","$38,707.72 ","$29,775.17 ","$12,760.79 ","$27,648.37 ","$30,625.89 ","$38,707.72 ","$31,901.97 "
Carle BroMenn Medical Center,8980636,immune globu G 1 gram/10 mL(10 %)-gly-IgA ave 46 mcg/mL injection soln,13533080012,J1561,636,$912.13 ,$912.13 ,$273.64 ,$830.04 ,$638.49 ,$273.64 ,$592.88 ,$656.73 ,$830.04 ,$684.10 
Carle BroMenn Medical Center,8980636,immune globu G 5 gram/50 mL(10 %)-gly-IgA ave 46 mcg/mL injection soln,13533080020,J1561,636,"$4,547.07 ","$4,547.07 ","$1,364.12 ","$4,137.83 ","$3,182.95 ","$1,364.12 ","$2,955.60 ","$3,273.89 ","$4,137.83 ","$3,410.30 "
Carle BroMenn Medical Center,8980636,inFLIXimab 100 mg intravenous solution,57894003001,J1745,636,"$6,594.50 ","$6,594.50 ","$1,978.35 ","$6,001.00 ","$4,616.15 ","$1,978.35 ","$4,286.43 ","$4,748.04 ","$6,001.00 ","$4,945.88 "
Carle BroMenn Medical Center,8980636,inFLIXimab-dyyb 100 mg intravenous solution,69080901,,636,"$5,355.69 ","$5,355.69 ","$1,606.71 ","$4,873.68 ","$3,748.98 ","$1,606.71 ","$3,481.20 ","$3,856.10 ","$4,873.68 ","$4,016.77 "
Carle BroMenn Medical Center,8980636,insulin detemir (U-100) 100 unit/mL subcutaneous solution,169368712,J1815,636,"$1,760.46 ","$1,760.46 ",$528.14 ,"$1,602.02 ","$1,232.32 ",$528.14 ,"$1,144.30 ","$1,267.53 ","$1,602.02 ","$1,320.35 "
Carle BroMenn Medical Center,8980636,insulin glargine (U-100) 100 unit/mL (3 mL) subcutaneous pen,88221901,J1815,636,$496.64 ,$496.64 ,$148.99 ,$451.94 ,$347.65 ,$148.99 ,$322.82 ,$357.58 ,$451.94 ,$372.48 
Carle BroMenn Medical Center,8980636,insulin glargine (U-100) 100 unit/mL (3 mL) subcutaneous pen,88221905,J1815,636,$496.64 ,$496.64 ,$148.99 ,$451.94 ,$347.65 ,$148.99 ,$322.82 ,$357.58 ,$451.94 ,$372.48 
Carle BroMenn Medical Center,8980636,insulin glargine (U-100) 100 unit/mL subcutaneous solution,88222033,J1815,636,"$1,622.99 ","$1,622.99 ",$486.90 ,"$1,476.92 ","$1,136.09 ",$486.90 ,"$1,054.94 ","$1,168.55 ","$1,476.92 ","$1,217.24 "
Carle BroMenn Medical Center,8980636,insulin lispro (U-100) 100 unit/mL subcutaneous solution,2751001,J1815,636,$45.01 ,$45.01 ,$13.50 ,$40.96 ,$31.51 ,$13.50 ,$29.26 ,$32.41 ,$40.96 ,$33.76 
Carle BroMenn Medical Center,8980636,insulin lispro (U-100) 100 unit/mL subcutaneous solution,2751017,J1815,636,$45.01 ,$45.01 ,$13.50 ,$40.96 ,$31.51 ,$13.50 ,$29.26 ,$32.41 ,$40.96 ,$33.76 
Carle BroMenn Medical Center,8980636,insulin lispro protamine-lispro 100 unit/mL (75-25) subcutaneous susp,2751101,J1815,636,$45.29 ,$45.29 ,$13.59 ,$41.21 ,$31.70 ,$13.59 ,$29.44 ,$32.61 ,$41.21 ,$33.97 
Carle BroMenn Medical Center,8980636,insulin NPH isophane U-100 human 100 unit/mL subcutaneous suspension,2831517,J1815,636,$314.94 ,$314.94 ,$94.48 ,$286.60 ,$220.46 ,$94.48 ,$204.71 ,$226.76 ,$286.60 ,$236.21 
Carle BroMenn Medical Center,8980636,INSULIN REGULAR HUMAN 100 UNIT/ML INJECTION,2821517,J1815,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"insulin regular human U-500 ""concentrate"" 500 unit/mL(3 mL) subcut pen",2882401,J1815,636,"$1,626.43 ","$1,626.43 ",$487.93 ,"$1,480.05 ","$1,138.50 ",$487.93 ,"$1,057.18 ","$1,171.03 ","$1,480.05 ","$1,219.82 "
Carle BroMenn Medical Center,8980636,"insulin regular human U-500 ""concentrate"" 500 unit/mL(3 mL) subcut pen",2882427,J1815,636,"$1,626.43 ","$1,626.43 ",$487.93 ,"$1,480.05 ","$1,138.50 ",$487.93 ,"$1,057.18 ","$1,171.03 ","$1,480.05 ","$1,219.82 "
Carle BroMenn Medical Center,8980636,insulin U-100 regular human 100 unit/mL injection solution,2821517,J1815,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,iothalamate meglumine 17.2 % urethral solution,19086250,Q9958,636,$177.08 ,$177.08 ,$53.12 ,$161.14 ,$123.96 ,$53.12 ,$115.10 ,$127.50 ,$161.14 ,$132.81 
Carle BroMenn Medical Center,8980636,ipilimumab 50 mg/10 mL (5 mg/mL) intravenous solution,3232711,J9228,636,"$32,632.94 ","$32,632.94 ","$9,789.88 ","$29,695.98 ","$22,843.06 ","$9,789.88 ","$21,211.41 ","$23,495.72 ","$29,695.98 ","$24,474.71 "
Carle BroMenn Medical Center,8980636,ipratropium bromide 0.02 % solution for inhalation,487980101,J7644,636,$3.51 ,$3.51 ,$1.05 ,$3.19 ,$2.46 ,$1.05 ,$2.28 ,$2.53 ,$3.19 ,$2.63 
Carle BroMenn Medical Center,8980636,ipratropium bromide 0.02 % solution for inhalation,60687039479,J7644,636,$3.54 ,$3.54 ,$1.06 ,$3.22 ,$2.48 ,$1.06 ,$2.30 ,$2.55 ,$3.22 ,$2.66 
Carle BroMenn Medical Center,8980636,ipratropium bromide 0.02 % solution for inhalation,60687039483,J7644,636,$3.54 ,$3.54 ,$1.06 ,$3.22 ,$2.48 ,$1.06 ,$2.30 ,$2.55 ,$3.22 ,$2.66 
Carle BroMenn Medical Center,8980636,ipratropium bromide 0.02 % solution for inhalation,76204010060,J7644,636,$10.53 ,$10.53 ,$3.16 ,$9.58 ,$7.37 ,$3.16 ,$6.84 ,$7.58 ,$9.58 ,$7.90 
Carle BroMenn Medical Center,8980636,iron dextran 50 mg/mL injection solution,23608210,J1750,636,$142.06 ,$142.06 ,$42.62 ,$129.27 ,$99.44 ,$42.62 ,$92.34 ,$102.28 ,$129.27 ,$106.55 
Carle BroMenn Medical Center,8980636,iron sucrose 100 mg iron/5 mL intravenous solution,517234001,J1756,636,$227.01 ,$227.01 ,$68.10 ,$206.58 ,$158.91 ,$68.10 ,$147.56 ,$163.45 ,$206.58 ,$170.26 
Carle BroMenn Medical Center,8980636,iron sucrose 100 mg iron/5 mL intravenous solution,517234010,J1756,636,$227.01 ,$227.01 ,$68.10 ,$206.58 ,$158.91 ,$68.10 ,$147.56 ,$163.45 ,$206.58 ,$170.26 
Carle BroMenn Medical Center,8980636,iron sucrose 100 mg iron/5 mL intravenous solution,517234025,J1756,636,$227.01 ,$227.01 ,$68.10 ,$206.58 ,$158.91 ,$68.10 ,$147.56 ,$163.45 ,$206.58 ,$170.26 
Carle BroMenn Medical Center,8980636,isosulfan blue 1 % subcutaneous solution,67457022000,Q9968,636,"$4,577.89 ","$4,577.89 ","$1,373.37 ","$4,165.88 ","$3,204.52 ","$1,373.37 ","$2,975.63 ","$3,296.08 ","$4,165.88 ","$3,433.42 "
Carle BroMenn Medical Center,8980636,isosulfan blue 1 % subcutaneous solution,67457022005,Q9968,636,"$4,577.89 ","$4,577.89 ","$1,373.37 ","$4,165.88 ","$3,204.52 ","$1,373.37 ","$2,975.63 ","$3,296.08 ","$4,165.88 ","$3,433.42 "
Carle BroMenn Medical Center,8980636,ketorolac 30 mg/mL (1 mL) injection solution,338007225,J1885,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,ketorolac 30 mg/mL (1 mL) injection solution,409379501,J1885,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,ketorolac 30 mg/mL (1 mL) injection solution,409379519,J1885,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,ketorolac 30 mg/mL (1 mL) injection solution,63323016201,J1885,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,ketorolac 30 mg/mL (1 mL) injection solution,63323016216,J1885,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,ketorolac 30 mg/mL (1 mL) injection solution,72266011801,J1885,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,ketorolac 30 mg/mL (1 mL) injection solution,72266011825,J1885,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,ketorolac 30 mg/mL (1 mL) injection solution,72611072201,J1885,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,ketorolac 30 mg/mL (1 mL) injection solution,72611072225,J1885,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,lactated Ringers intravenous solution,264775000,J7120,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,lactated Ringers intravenous solution,264775010,J7120,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,lactated Ringers intravenous solution,990795303,J7120,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,lactated Ringers intravenous solution,990795309,J7120,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,lactated ringers IV,264775000,J7120,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,lactated ringers IV,264775010,J7120,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,lactated ringers IV,990795309,J7120,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,letrozole 2.5 mg tablet,16729003410,J8499,636,$71.33 ,$71.33 ,$21.40 ,$64.91 ,$49.93 ,$21.40 ,$46.36 ,$51.36 ,$64.91 ,$53.50 
Carle BroMenn Medical Center,8980636,letrozole 2.5 mg tablet,50268047611,J8499,636,$71.33 ,$71.33 ,$21.40 ,$64.91 ,$49.93 ,$21.40 ,$46.36 ,$51.36 ,$64.91 ,$53.50 
Carle BroMenn Medical Center,8980636,letrozole 2.5 mg tablet,50268047615,J8499,636,$71.33 ,$71.33 ,$21.40 ,$64.91 ,$49.93 ,$21.40 ,$46.36 ,$51.36 ,$64.91 ,$53.50 
Carle BroMenn Medical Center,8980636,leucovorin calcium 200 mg solution for injection,143955301,J0640,636,$198.28 ,$198.28 ,$59.48 ,$180.43 ,$138.80 ,$59.48 ,$128.88 ,$142.76 ,$180.43 ,$148.71 
Carle BroMenn Medical Center,8980636,leucovorin calcium 200 mg solution for injection,67457052920,J0640,636,$287.75 ,$287.75 ,$86.33 ,$261.85 ,$201.43 ,$86.33 ,$187.04 ,$207.18 ,$261.85 ,$215.81 
Carle BroMenn Medical Center,8980636,leuprolide 11.25 mg (3 month) intramuscular syringe kit,74366303,J1950,636,"$15,622.85 ","$15,622.85 ","$4,686.86 ","$14,216.79 ","$10,936.00 ","$4,686.86 ","$10,154.85 ","$11,248.45 ","$14,216.79 ","$11,717.14 "
Carle BroMenn Medical Center,8980636,leuprolide 3.75 mg intramuscular syringe kit,74364103,J1950,636,"$6,351.55 ","$6,351.55 ","$1,905.47 ","$5,779.91 ","$4,446.09 ","$1,905.47 ","$4,128.51 ","$4,573.12 ","$5,779.91 ","$4,763.66 "
Carle BroMenn Medical Center,8980636,leuprolide 7.5 mg intramuscular syringe kit,74364203,J9217,636,"$7,545.43 ","$7,545.43 ","$2,263.63 ","$6,866.34 ","$5,281.80 ","$2,263.63 ","$4,904.53 ","$5,432.71 ","$6,866.34 ","$5,659.07 "
Carle BroMenn Medical Center,8980636,levETIRAcetam 500 mg/5 mL intravenous solution,409188605,,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,levETIRAcetam 500 mg/5 mL intravenous solution,409188615,,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,levETIRAcetam 500 mg/5 mL intravenous solution,409188622,,636,$61.84 ,$61.84 ,$18.55 ,$56.27 ,$43.29 ,$18.55 ,$40.20 ,$44.52 ,$56.27 ,$46.38 
Carle BroMenn Medical Center,8980636,levETIRAcetam 500 mg/5 mL intravenous solution,39822400001,,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,levETIRAcetam 500 mg/5 mL intravenous solution,51224001301,,636,$76.07 ,$76.07 ,$22.82 ,$69.22 ,$53.25 ,$22.82 ,$49.45 ,$54.77 ,$69.22 ,$57.05 
Carle BroMenn Medical Center,8980636,levETIRAcetam 500 mg/5 mL intravenous solution,55150017705,,636,$122.25 ,$122.25 ,$36.68 ,$111.25 ,$85.58 ,$36.68 ,$79.46 ,$88.02 ,$111.25 ,$91.69 
Carle BroMenn Medical Center,8980636,levETIRAcetam 500 mg/5 mL intravenous solution,63323040005,,636,$90.07 ,$90.07 ,$27.02 ,$81.96 ,$63.05 ,$27.02 ,$58.55 ,$64.85 ,$81.96 ,$67.55 
Carle BroMenn Medical Center,8980636,levETIRAcetam 500 mg/5 mL intravenous solution,72485010601,,636,$73.36 ,$73.36 ,$22.01 ,$66.76 ,$51.35 ,$22.01 ,$47.68 ,$52.82 ,$66.76 ,$55.02 
Carle BroMenn Medical Center,8980636,levETIRAcetam 500 mg/5 mL intravenous solution,72485010610,,636,$73.36 ,$73.36 ,$22.01 ,$66.76 ,$51.35 ,$22.01 ,$47.68 ,$52.82 ,$66.76 ,$55.02 
Carle BroMenn Medical Center,8980636,levOCARNitine 200 mg/mL intravenous solution,54482014701,J1955,636,$266.27 ,$266.27 ,$79.88 ,$242.31 ,$186.39 ,$79.88 ,$173.08 ,$191.71 ,$242.31 ,$199.70 
Carle BroMenn Medical Center,8980636,levoFLOXacin 500 mg/100 mL in 5 % dextrose intravenous piggyback,143972101,J1956,636,$45.89 ,$45.89 ,$13.77 ,$41.76 ,$32.12 ,$13.77 ,$29.83 ,$33.04 ,$41.76 ,$34.42 
Carle BroMenn Medical Center,8980636,levoFLOXacin 750 mg/150 mL in 5 % dextrose intravenous piggyback,143931701,J1956,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,levoFLOXacin 750 mg/150 mL in 5 % dextrose intravenous piggyback,143972001,J1956,636,$49.47 ,$49.47 ,$14.84 ,$45.02 ,$34.63 ,$14.84 ,$32.16 ,$35.62 ,$45.02 ,$37.10 
Carle BroMenn Medical Center,8980636,levoFLOXacin 750 mg/150 mL in 5 % dextrose intravenous piggyback,143972024,J1956,636,$47.05 ,$47.05 ,$14.12 ,$42.82 ,$32.94 ,$14.12 ,$30.58 ,$33.88 ,$42.82 ,$35.29 
Carle BroMenn Medical Center,8980636,levoFLOXacin 750 mg/150 mL in 5 % dextrose intravenous piggyback,44567043724,J1956,636,$94.19 ,$94.19 ,$28.26 ,$85.71 ,$65.93 ,$28.26 ,$61.22 ,$67.82 ,$85.71 ,$70.64 
Carle BroMenn Medical Center,8980636,levonorgestreL 1.5 mg tablet,68180085211,,636,$51.18 ,$51.18 ,$15.35 ,$46.57 ,$35.83 ,$15.35 ,$33.27 ,$36.85 ,$46.57 ,$38.39 
Carle BroMenn Medical Center,8980636,levonorgestreL 17.5 mcg/24 hrs (5yrs) 19.5mg intrauterine device,50419042401,,636,"$4,205.14 ","$4,205.14 ","$1,261.54 ","$3,826.68 ","$2,943.60 ","$1,261.54 ","$2,733.34 ","$3,027.70 ","$3,826.68 ","$3,153.86 "
Carle BroMenn Medical Center,8980636,levonorgestreL 20 mcg/24 hours (7 yrs) 52 mg intrauterine device,50419042301,,636,"$4,205.14 ","$4,205.14 ","$1,261.54 ","$3,826.68 ","$2,943.60 ","$1,261.54 ","$2,733.34 ","$3,027.70 ","$3,826.68 ","$3,153.86 "
Carle BroMenn Medical Center,8980636,lidocaine (PF) 10 mg/mL (1 %) injection solution,143959501,J2001,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,lidocaine (PF) 10 mg/mL (1 %) injection solution,409427902,J2001,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,lidocaine (PF) 10 mg/mL (1 %) injection solution,409427916,J2001,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,lidocaine (PF) 10 mg/mL (1 %) injection solution,409471332,J2001,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,lidocaine (PF) 10 mg/mL (1 %) injection solution,409471342,J2001,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,lidocaine (PF) 10 mg/mL (1 %) injection solution,55150015872,J2001,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,lidocaine (PF) 10 mg/mL (1 %) injection solution,55150016205,J2001,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,lidocaine (PF) 10 mg/mL (1 %) injection solution,63323049207,J2001,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,lidocaine (PF) 10 mg/mL (1 %) injection solution,63323049226,J2001,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,lidocaine (PF) 10 mg/mL (1 %) injection solution,63323049237,J2001,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,lidocaine (PF) 10 mg/mL (1 %) injection solution,63323049243,J2001,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,lidocaine (PF) 10 mg/mL (1 %) injection solution,63323049245,J2001,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,lidocaine (PF) 10 mg/mL (1 %) injection solution,63323049257,J2001,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,lidocaine (PF) 100 mg/5 mL (2 %) intravenous syringe,409490311,J2001,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,lidocaine (PF) 100 mg/5 mL (2 %) intravenous syringe,409490334,J2001,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,lidocaine (PF) 100 mg/5 mL (2 %) intravenous syringe,76329339001,J2001,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,lidocaine (PF) 20 mg/mL (2 %) injection solution,55150016505,J2001,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,lidocaine (PF) 20 mg/mL (2 %) injection solution,63323049504,J2001,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,lidocaine (PF) 20 mg/mL (2 %) injection solution,63323049507,J2001,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,lidocaine (PF) 4 mg/mL (0.4 %) in 5 % dextrose intravenous solution,338040903,J2001,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,lidocaine (PF) 40 mg/mL (4 %) injection solution,409428301,J2001,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,lidocaine (PF) 40 mg/mL (4 %) injection solution,409428311,J2001,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,lidocaine (PF) 5 mg/mL (0.5 %) injection solution,63323049157,J2001,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,lidocaine (PF) 50 mg/5 mL (1 %) intravenous syringe,409490411,J2001,636,$74.32 ,$74.32 ,$22.30 ,$67.63 ,$52.02 ,$22.30 ,$48.31 ,$53.51 ,$67.63 ,$55.74 
Carle BroMenn Medical Center,8980636,lidocaine (PF) 50 mg/5 mL (1 %) intravenous syringe,409490434,J2001,636,$74.32 ,$74.32 ,$22.30 ,$67.63 ,$52.02 ,$22.30 ,$48.31 ,$53.51 ,$67.63 ,$55.74 
Carle BroMenn Medical Center,8980636,lidocaine HCL 10 mg/mL (1 %) injection solution,143957701,J2001,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,lidocaine HCL 10 mg/mL (1 %) injection solution,409427602,J2001,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,lidocaine HCL 10 mg/mL (1 %) injection solution,63323048501,J2001,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,lidocaine HCL 10 mg/mL (1 %) injection solution,63323048527,J2001,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,lidocaine HCL 10 mg/mL (1 %) injection solution,63323048557,J2001,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,lidocaine HCL 20 mg/mL (2 %) injection solution,143957501,J2001,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,lidocaine HCL 20 mg/mL (2 %) injection solution,143957510,J2001,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,lidocaine HCL 5 mg/mL (0.5 %) injection solution,63323048457,J2001,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,linezolid in 5% dextrose in water 600 mg/300 mL intravenous piggyback,9514001,J2020,636,$335.14 ,$335.14 ,$100.54 ,$304.98 ,$234.60 ,$100.54 ,$217.84 ,$241.30 ,$304.98 ,$251.36 
Carle BroMenn Medical Center,8980636,linezolid in 5% dextrose in water 600 mg/300 mL intravenous piggyback,9514004,J2020,636,$335.14 ,$335.14 ,$100.54 ,$304.98 ,$234.60 ,$100.54 ,$217.84 ,$241.30 ,$304.98 ,$251.36 
Carle BroMenn Medical Center,8980636,linezolid in 5% dextrose in water 600 mg/300 mL intravenous piggyback,63323071313,J2020,636,$282.76 ,$282.76 ,$84.83 ,$257.31 ,$197.93 ,$84.83 ,$183.79 ,$203.59 ,$257.31 ,$212.07 
Carle BroMenn Medical Center,8980636,"LORazepam 2 mg/mL injection solution,LORazepam 2 mg/mL injection syringe",641604401,J2060,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"LORazepam 2 mg/mL injection solution,LORazepam 2 mg/mL injection syringe",641604425,J2060,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"LORazepam 2 mg/mL injection solution,LORazepam 2 mg/mL injection syringe",641604601,J2060,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"LORazepam 2 mg/mL injection solution,LORazepam 2 mg/mL injection syringe",641604610,J2060,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"LORazepam 2 mg/mL injection solution,LORazepam 2 mg/mL injection syringe",641620701,J2060,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"LORazepam 2 mg/mL injection solution,LORazepam 2 mg/mL injection syringe",641620725,J2060,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"LORazepam 2 mg/mL injection solution,LORazepam 2 mg/mL injection syringe",76329826100,J2060,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"LORazepam 2 mg/mL injection solution,LORazepam 2 mg/mL injection syringe",76329826101,J2060,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,LORazepam 4 mg/mL injection solution,641604525,J2060,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,magnesium sulfate 1 gram/100 mL in dextrose 5 % intravenous piggyback,63323010800,J3475,636,$60.44 ,$60.44 ,$18.13 ,$55.00 ,$42.31 ,$18.13 ,$39.29 ,$43.52 ,$55.00 ,$45.33 
Carle BroMenn Medical Center,8980636,magnesium sulfate 1 gram/100 mL in dextrose 5 % intravenous piggyback,63323010801,J3475,636,$60.44 ,$60.44 ,$18.13 ,$55.00 ,$42.31 ,$18.13 ,$39.29 ,$43.52 ,$55.00 ,$45.33 
Carle BroMenn Medical Center,8980636,magnesium sulfate 1 gram/100 mL in dextrose 5 % intravenous piggyback,63323010802,J3475,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,magnesium sulfate 1 gram/100 mL in dextrose 5 % intravenous piggyback,63323010826,J3475,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,magnesium sulfate 1 gram/100 mL in dextrose 5 % intravenous piggyback,67457056700,J3475,636,$49.96 ,$49.96 ,$14.99 ,$45.46 ,$34.97 ,$14.99 ,$32.47 ,$35.97 ,$45.46 ,$37.47 
Carle BroMenn Medical Center,8980636,magnesium sulfate 2 gram/50 mL (4 %) in water intravenous piggyback,44567042000,J3475,636,$50.83 ,$50.83 ,$15.25 ,$46.26 ,$35.58 ,$15.25 ,$33.04 ,$36.60 ,$46.26 ,$38.12 
Carle BroMenn Medical Center,8980636,magnesium sulfate 2 gram/50 mL (4 %) in water intravenous piggyback,44567042024,J3475,636,$50.83 ,$50.83 ,$15.25 ,$46.26 ,$35.58 ,$15.25 ,$33.04 ,$36.60 ,$46.26 ,$38.12 
Carle BroMenn Medical Center,8980636,magnesium sulfate 2 gram/50 mL (4 %) in water intravenous piggyback,63323010602,J3475,636,$115.44 ,$115.44 ,$34.63 ,$105.05 ,$80.81 ,$34.63 ,$75.04 ,$83.12 ,$105.05 ,$86.58 
Carle BroMenn Medical Center,8980636,magnesium sulfate 2 gram/50 mL (4 %) in water intravenous piggyback,63323010605,J3475,636,$115.44 ,$115.44 ,$34.63 ,$105.05 ,$80.81 ,$34.63 ,$75.04 ,$83.12 ,$105.05 ,$86.58 
Carle BroMenn Medical Center,8980636,magnesium sulfate 2 gram/50 mL (4 %) in water intravenous piggyback,63323010626,J3475,636,$71.49 ,$71.49 ,$21.45 ,$65.06 ,$50.04 ,$21.45 ,$46.47 ,$51.47 ,$65.06 ,$53.62 
Carle BroMenn Medical Center,8980636,magnesium sulfate 2 gram/50 mL (4 %) in water intravenous piggyback,67457055300,J3475,636,$95.07 ,$95.07 ,$28.52 ,$86.51 ,$66.55 ,$28.52 ,$61.80 ,$68.45 ,$86.51 ,$71.30 
Carle BroMenn Medical Center,8980636,magnesium sulfate 20 gram/500 mL (4 %) in water intravenous solution,409672903,J3475,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,magnesium sulfate 20 gram/500 mL (4 %) in water intravenous solution,63323010615,J3475,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,magnesium sulfate 4 gram/50 mL (8 %) in water intravenous piggyback,409673013,J3475,636,$55.20 ,$55.20 ,$16.56 ,$50.23 ,$38.64 ,$16.56 ,$35.88 ,$39.74 ,$50.23 ,$41.40 
Carle BroMenn Medical Center,8980636,magnesium sulfate 4 gram/50 mL (8 %) in water intravenous piggyback,63323010701,J3475,636,$60.15 ,$60.15 ,$18.05 ,$54.74 ,$42.11 ,$18.05 ,$39.10 ,$43.31 ,$54.74 ,$45.11 
Carle BroMenn Medical Center,8980636,magnesium sulfate 4 gram/50 mL (8 %) in water intravenous piggyback,63323010705,J3475,636,$60.15 ,$60.15 ,$18.05 ,$54.74 ,$42.11 ,$18.05 ,$39.10 ,$43.31 ,$54.74 ,$45.11 
Carle BroMenn Medical Center,8980636,magnesium sulfate 4 mEq/mL (50 %) injection solution,63323006401,J3475,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,magnesium sulfate 4 mEq/mL (50 %) injection solution,63323006402,J3475,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,magnesium sulfate 4 mEq/mL (50 %) injection solution,63323006403,J3475,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,magnesium sulfate 4 mEq/mL (50 %) injection solution,63323006404,J3475,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,magnesium sulfate 4 mEq/mL (50 %) injection solution,63323006411,J3475,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,magnesium sulfate 4 mEq/mL (50 %) injection solution,63323006441,J3475,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,magnesium sulfate 4 mEq/mL (50 %) injection solution,63323006443,J3475,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,magnesium sulfate 4 mEq/mL (50 %) injection solution,63323064220,J3475,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,mannitoL 20 % intravenous solution,409771513,J2150,636,$14.55 ,$14.55 ,$4.37 ,$13.24 ,$10.19 ,$4.37 ,$9.46 ,$10.48 ,$13.24 ,$10.91 
Carle BroMenn Medical Center,8980636,mannitoL 20 % intravenous solution,990771503,J2150,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,mannitoL 20 % intravenous solution,990771513,J2150,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,mannitoL 25 % intravenous solution,409403101,J2150,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,mannitoL 25 % intravenous solution,409403116,J2150,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,"measles,mumps,rubella vaccine live(PF)1,000-12,500TCID50/0.5 mL subcut",6468100,90707,636,$193.42 ,$193.42 ,$58.03 ,$176.01 ,$135.39 ,$58.03 ,$125.72 ,$139.26 ,$176.01 ,$145.07 
Carle BroMenn Medical Center,8980636,"measles,mumps,rubella vaccine live(PF)1,000-12,500TCID50/0.5 mL subcut",6468101,90707,636,$193.42 ,$193.42 ,$58.03 ,$176.01 ,$135.39 ,$58.03 ,$125.72 ,$139.26 ,$176.01 ,$145.07 
Carle BroMenn Medical Center,8980636,medroxyPROGESTERone 150 mg/mL intramuscular suspension,548540000,J1050,636,$288.97 ,$288.97 ,$86.69 ,$262.96 ,$202.28 ,$86.69 ,$187.83 ,$208.06 ,$262.96 ,$216.73 
Carle BroMenn Medical Center,8980636,medroxyPROGESTERone 150 mg/mL intramuscular suspension,67457088799,J1050,636,$229.65 ,$229.65 ,$68.90 ,$208.98 ,$160.76 ,$68.90 ,$149.27 ,$165.35 ,$208.98 ,$172.24 
Carle BroMenn Medical Center,8980636,"meningoc vac A,C,Y,W-135 dip (PF) 4 mcg/0.5 mL intramuscular solution",49281058905,90734,636,$299.55 ,$299.55 ,$89.87 ,$272.59 ,$209.69 ,$89.87 ,$194.71 ,$215.68 ,$272.59 ,$224.66 
Carle BroMenn Medical Center,8980636,"meningoc vac A,C,Y,W-135 dip (PF) 4 mcg/0.5 mL intramuscular solution",49281058958,90734,636,$299.55 ,$299.55 ,$89.87 ,$272.59 ,$209.69 ,$89.87 ,$194.71 ,$215.68 ,$272.59 ,$224.66 
Carle BroMenn Medical Center,8980636,"meperidine (PF) 50 mg/mL injection solution,meperidine (PF) 50 mg/mL injection syringe",409117830,J2175,636,$48.99 ,$48.99 ,$14.70 ,$44.58 ,$34.29 ,$14.70 ,$31.84 ,$35.27 ,$44.58 ,$36.74 
Carle BroMenn Medical Center,8980636,"meperidine (PF) 50 mg/mL injection solution,meperidine (PF) 50 mg/mL injection syringe",641605301,J2175,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"meperidine (PF) 50 mg/mL injection solution,meperidine (PF) 50 mg/mL injection syringe",641605325,J2175,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,mepivacaine (PF) 10 mg/mL (1 %) injection solution,409103630,J0670,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,mepivacaine (PF) 10 mg/mL (1 %) injection solution,63323026001,J0670,636,$55.43 ,$55.43 ,$16.63 ,$50.44 ,$38.80 ,$16.63 ,$36.03 ,$39.91 ,$50.44 ,$41.57 
Carle BroMenn Medical Center,8980636,mepivacaine (PF) 10 mg/mL (1 %) injection solution,63323026037,J0670,636,$55.43 ,$55.43 ,$16.63 ,$50.44 ,$38.80 ,$16.63 ,$36.03 ,$39.91 ,$50.44 ,$41.57 
Carle BroMenn Medical Center,8980636,mepivacaine (PF) 20 mg/mL (2 %) injection solution,63323029401,J0670,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,mepivacaine (PF) 20 mg/mL (2 %) injection solution,63323029427,J0670,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,mercaptopurine 50 mg tablet,54458111,J8499,636,$145.61 ,$145.61 ,$43.68 ,$132.51 ,$101.93 ,$43.68 ,$94.65 ,$104.84 ,$132.51 ,$109.21 
Carle BroMenn Medical Center,8980636,mercaptopurine 50 mg tablet,378354752,J8499,636,$23.72 ,$23.72 ,$7.12 ,$21.59 ,$16.60 ,$7.12 ,$15.42 ,$17.08 ,$21.59 ,$17.79 
Carle BroMenn Medical Center,8980636,meropenem 1 gram intravenous solution,409139121,J2185,636,$227.84 ,$227.84 ,$68.35 ,$207.33 ,$159.49 ,$68.35 ,$148.10 ,$164.04 ,$207.33 ,$170.88 
Carle BroMenn Medical Center,8980636,meropenem 1 gram intravenous solution,781309894,J2185,636,$233.81 ,$233.81 ,$70.14 ,$212.77 ,$163.67 ,$70.14 ,$151.98 ,$168.34 ,$212.77 ,$175.36 
Carle BroMenn Medical Center,8980636,meropenem 1 gram intravenous solution,781309895,J2185,636,$233.81 ,$233.81 ,$70.14 ,$212.77 ,$163.67 ,$70.14 ,$151.98 ,$168.34 ,$212.77 ,$175.36 
Carle BroMenn Medical Center,8980636,meropenem 1 gram intravenous solution,63323050801,J2185,636,$174.63 ,$174.63 ,$52.39 ,$158.91 ,$122.24 ,$52.39 ,$113.51 ,$125.73 ,$158.91 ,$130.97 
Carle BroMenn Medical Center,8980636,meropenem 1 gram intravenous solution,63323050830,J2185,636,$174.63 ,$174.63 ,$52.39 ,$158.91 ,$122.24 ,$52.39 ,$113.51 ,$125.73 ,$158.91 ,$130.97 
Carle BroMenn Medical Center,8980636,meropenem 1 gram intravenous solution,63323050845,J2185,636,$111.77 ,$111.77 ,$33.53 ,$101.71 ,$78.24 ,$33.53 ,$72.65 ,$80.47 ,$101.71 ,$83.83 
Carle BroMenn Medical Center,8980636,meropenem 1 gram intravenous solution,70121145301,J2185,636,$111.77 ,$111.77 ,$33.53 ,$101.71 ,$78.24 ,$33.53 ,$72.65 ,$80.47 ,$101.71 ,$83.83 
Carle BroMenn Medical Center,8980636,meropenem 1 gram intravenous solution,70121145307,J2185,636,$111.77 ,$111.77 ,$33.53 ,$101.71 ,$78.24 ,$33.53 ,$72.65 ,$80.47 ,$101.71 ,$83.83 
Carle BroMenn Medical Center,8980636,meropenem 500 mg intravenous solution,781300094,J2185,636,$140.95 ,$140.95 ,$42.29 ,$128.26 ,$98.67 ,$42.29 ,$91.62 ,$101.48 ,$128.26 ,$105.71 
Carle BroMenn Medical Center,8980636,meropenem 500 mg intravenous solution,781300095,J2185,636,$140.95 ,$140.95 ,$42.29 ,$128.26 ,$98.67 ,$42.29 ,$91.62 ,$101.48 ,$128.26 ,$105.71 
Carle BroMenn Medical Center,8980636,meropenem 500 mg intravenous solution,63323050701,J2185,636,$104.79 ,$104.79 ,$31.44 ,$95.36 ,$73.35 ,$31.44 ,$68.11 ,$75.45 ,$95.36 ,$78.59 
Carle BroMenn Medical Center,8980636,meropenem 500 mg intravenous solution,63323050720,J2185,636,$104.79 ,$104.79 ,$31.44 ,$95.36 ,$73.35 ,$31.44 ,$68.11 ,$75.45 ,$95.36 ,$78.59 
Carle BroMenn Medical Center,8980636,meropenem-vaborbactam 2 gram intravenous solution,70842012001,,636,"$1,110.71 ","$1,110.71 ",$333.21 ,"$1,010.75 ",$777.50 ,$333.21 ,$721.96 ,$799.71 ,"$1,010.75 ",$833.03 
Carle BroMenn Medical Center,8980636,meropenem-vaborbactam 2 gram intravenous solution,70842012006,,636,"$1,110.71 ","$1,110.71 ",$333.21 ,"$1,010.75 ",$777.50 ,$333.21 ,$721.96 ,$799.71 ,"$1,010.75 ",$833.03 
Carle BroMenn Medical Center,8980636,mesna 100 mg/mL intravenous solution,25021020110,J9209,636,$174.63 ,$174.63 ,$52.39 ,$158.91 ,$122.24 ,$52.39 ,$113.51 ,$125.73 ,$158.91 ,$130.97 
Carle BroMenn Medical Center,8980636,mesna 100 mg/mL intravenous solution,25021020111,J9209,636,$174.63 ,$174.63 ,$52.39 ,$158.91 ,$122.24 ,$52.39 ,$113.51 ,$125.73 ,$158.91 ,$130.97 
Carle BroMenn Medical Center,8980636,methacholine chloride 0.1875 mg/3 mL (0.0625 mg/mL) nebulization soln,69374053703,J7999,636,$775.89 ,$775.89 ,$232.77 ,$706.06 ,$543.12 ,$232.77 ,$504.33 ,$558.64 ,$706.06 ,$581.92 
Carle BroMenn Medical Center,8980636,methotrexate sodium 2.5 mg tablet,54855025,J8610,636,$145.61 ,$145.61 ,$43.68 ,$132.51 ,$101.93 ,$43.68 ,$94.65 ,$104.84 ,$132.51 ,$109.21 
Carle BroMenn Medical Center,8980636,methotrexate sodium 2.5 mg tablet,47335023583,J8610,636,$21.27 ,$21.27 ,$6.38 ,$19.36 ,$14.89 ,$6.38 ,$13.83 ,$15.31 ,$19.36 ,$15.95 
Carle BroMenn Medical Center,8980636,methotrexate sodium 2.5 mg tablet,51079067001,J8610,636,$32.32 ,$32.32 ,$9.70 ,$29.41 ,$22.62 ,$9.70 ,$21.01 ,$23.27 ,$29.41 ,$24.24 
Carle BroMenn Medical Center,8980636,methotrexate sodium 2.5 mg tablet,51079067005,J8610,636,$32.32 ,$32.32 ,$9.70 ,$29.41 ,$22.62 ,$9.70 ,$21.01 ,$23.27 ,$29.41 ,$24.24 
Carle BroMenn Medical Center,8980636,methotrexate sodium 25 mg/mL injection solution,61703035037,J9250,636,$145.61 ,$145.61 ,$43.68 ,$132.51 ,$101.93 ,$43.68 ,$94.65 ,$104.84 ,$132.51 ,$109.21 
Carle BroMenn Medical Center,8980636,methotrexate sodium 25 mg/mL injection solution,61703035038,J9250,636,$145.61 ,$145.61 ,$43.68 ,$132.51 ,$101.93 ,$43.68 ,$94.65 ,$104.84 ,$132.51 ,$109.21 
Carle BroMenn Medical Center,8980636,methylene blue (antidote) 1 % (10 mg/mL) intravenous solution,17478050410,Q9968,636,"$1,175.32 ","$1,175.32 ",$352.60 ,"$1,069.54 ",$822.72 ,$352.60 ,$763.96 ,$846.23 ,"$1,069.54 ",$881.49 
Carle BroMenn Medical Center,8980636,methylene blue (antidote) 5 mg/mL (0.5 %) intravenous solution,517037401,Q9968,636,"$1,665.36 ","$1,665.36 ",$499.61 ,"$1,515.48 ","$1,165.75 ",$499.61 ,"$1,082.48 ","$1,199.06 ","$1,515.48 ","$1,249.02 "
Carle BroMenn Medical Center,8980636,methylene blue (antidote) 5 mg/mL (0.5 %) intravenous solution,517037405,Q9968,636,"$1,665.36 ","$1,665.36 ",$499.61 ,"$1,515.48 ","$1,165.75 ",$499.61 ,"$1,082.48 ","$1,199.06 ","$1,515.48 ","$1,249.02 "
Carle BroMenn Medical Center,8980636,methylergonovine 0.2 mg/mL (1 mL) injection solution,517074001,J2210,636,$195.02 ,$195.02 ,$58.51 ,$177.47 ,$136.51 ,$58.51 ,$126.76 ,$140.41 ,$177.47 ,$146.27 
Carle BroMenn Medical Center,8980636,methylergonovine 0.2 mg/mL (1 mL) injection solution,517074020,J2210,636,$195.02 ,$195.02 ,$58.51 ,$177.47 ,$136.51 ,$58.51 ,$126.76 ,$140.41 ,$177.47 ,$146.27 
Carle BroMenn Medical Center,8980636,methylnaltrexone 12 mg/0.6 mL subcutaneous solution,65649055102,J2212,636,$687.11 ,$687.11 ,$206.13 ,$625.27 ,$480.98 ,$206.13 ,$446.62 ,$494.72 ,$625.27 ,$515.33 
Carle BroMenn Medical Center,8980636,methylPREDNISolone 4 mg tablet,68382091601,J7509,636,$10.02 ,$10.02 ,$3.01 ,$9.12 ,$7.01 ,$3.01 ,$6.51 ,$7.21 ,$9.12 ,$7.52 
Carle BroMenn Medical Center,8980636,methylPREDNISolone acetate 40 mg/mL suspension for injection,9307301,J1030,636,$77.55 ,$77.55 ,$23.27 ,$70.57 ,$54.29 ,$23.27 ,$50.41 ,$55.84 ,$70.57 ,$58.16 
Carle BroMenn Medical Center,8980636,methylPREDNISolone acetate 40 mg/mL suspension for injection,703003101,J1030,636,$64.16 ,$64.16 ,$19.25 ,$58.39 ,$44.91 ,$19.25 ,$41.70 ,$46.20 ,$58.39 ,$48.12 
Carle BroMenn Medical Center,8980636,methylPREDNISolone acetate 40 mg/mL suspension for injection,703003104,J1030,636,$64.16 ,$64.16 ,$19.25 ,$58.39 ,$44.91 ,$19.25 ,$41.70 ,$46.20 ,$58.39 ,$48.12 
Carle BroMenn Medical Center,8980636,methylPREDNISolone acetate 80 mg/mL suspension for injection,9347501,J1040,636,$132.14 ,$132.14 ,$39.64 ,$120.25 ,$92.50 ,$39.64 ,$85.89 ,$95.14 ,$120.25 ,$99.11 
Carle BroMenn Medical Center,8980636,methylPREDNISolone acetate 80 mg/mL suspension for injection,703005101,J1040,636,$103.27 ,$103.27 ,$30.98 ,$93.98 ,$72.29 ,$30.98 ,$67.13 ,$74.35 ,$93.98 ,$77.45 
Carle BroMenn Medical Center,8980636,methylPREDNISolone acetate 80 mg/mL suspension for injection,703005104,J1040,636,$103.27 ,$103.27 ,$30.98 ,$93.98 ,$72.29 ,$30.98 ,$67.13 ,$74.35 ,$93.98 ,$77.45 
Carle BroMenn Medical Center,8980636,methylPREDNISolone acetate 80 mg/mL suspension for injection,70121157401,J1040,636,$117.36 ,$117.36 ,$35.21 ,$106.80 ,$82.15 ,$35.21 ,$76.28 ,$84.50 ,$106.80 ,$88.02 
Carle BroMenn Medical Center,8980636,methylPREDNISolone acetate 80 mg/mL suspension for injection,70121157405,J1040,636,$117.38 ,$117.38 ,$35.21 ,$106.82 ,$82.17 ,$35.21 ,$76.30 ,$84.51 ,$106.82 ,$88.04 
Carle BroMenn Medical Center,8980636,"methylPREDNISolone sod succ (PF) 1,000 mg/8 mL intravenous solution",9001820,J2930,636,$370.85 ,$370.85 ,$111.26 ,$337.47 ,$259.60 ,$111.26 ,$241.05 ,$267.01 ,$337.47 ,$278.14 
Carle BroMenn Medical Center,8980636,methylPREDNISolone sod succ (PF) 125 mg/2 mL solution for injection,9004704,J2930,636,$74.44 ,$74.44 ,$22.33 ,$67.74 ,$52.11 ,$22.33 ,$48.39 ,$53.60 ,$67.74 ,$55.83 
Carle BroMenn Medical Center,8980636,methylPREDNISolone sod succ (PF) 125 mg/2 mL solution for injection,9004722,J2930,636,$71.40 ,$71.40 ,$21.42 ,$64.97 ,$49.98 ,$21.42 ,$46.41 ,$51.41 ,$64.97 ,$53.55 
Carle BroMenn Medical Center,8980636,methylPREDNISolone sod succ (PF) 40 mg/mL solution for injection,9003906,J2920,636,$47.52 ,$47.52 ,$14.26 ,$43.24 ,$33.26 ,$14.26 ,$30.89 ,$34.21 ,$43.24 ,$35.64 
Carle BroMenn Medical Center,8980636,methylPREDNISolone sod succ (PF) 40 mg/mL solution for injection,9003928,J2920,636,$45.62 ,$45.62 ,$13.69 ,$41.51 ,$31.93 ,$13.69 ,$29.65 ,$32.85 ,$41.51 ,$34.22 
Carle BroMenn Medical Center,8980636,methylPREDNISolone sod succ (PF) 40 mg/mL solution for injection,9003930,J2920,636,$45.62 ,$45.62 ,$13.69 ,$41.51 ,$31.93 ,$13.69 ,$29.65 ,$32.85 ,$41.51 ,$34.22 
Carle BroMenn Medical Center,8980636,methylPREDNISolone sod succ (PF) 500 mg/4 mL intravenous solution,9000302,J2930,636,$266.60 ,$266.60 ,$79.98 ,$242.61 ,$186.62 ,$79.98 ,$173.29 ,$191.95 ,$242.61 ,$199.95 
Carle BroMenn Medical Center,8980636,"methylPREDNISolone sodium succinate 1,000 mg intravenous solution",9069801,J2930,636,$283.28 ,$283.28 ,$84.98 ,$257.78 ,$198.30 ,$84.98 ,$184.13 ,$203.96 ,$257.78 ,$212.46 
Carle BroMenn Medical Center,8980636,"methylPREDNISolone sodium succinate 1,000 mg intravenous solution",9069802,J2930,636,$310.02 ,$310.02 ,$93.01 ,$282.12 ,$217.01 ,$93.01 ,$201.51 ,$223.21 ,$282.12 ,$232.52 
Carle BroMenn Medical Center,8980636,"methylPREDNISolone sodium succinate 1,000 mg intravenous solution",143985101,J2930,636,$298.33 ,$298.33 ,$89.50 ,$271.48 ,$208.83 ,$89.50 ,$193.91 ,$214.80 ,$271.48 ,$223.75 
Carle BroMenn Medical Center,8980636,"methylPREDNISolone sodium succinate 1,000 mg intravenous solution",63323026530,J2930,636,$255.41 ,$255.41 ,$76.62 ,$232.42 ,$178.79 ,$76.62 ,$166.02 ,$183.90 ,$232.42 ,$191.56 
Carle BroMenn Medical Center,8980636,methylPREDNISolone sodium succinate 500 mg intravenous solution,9075801,J2930,636,$173.09 ,$173.09 ,$51.93 ,$157.51 ,$121.16 ,$51.93 ,$112.51 ,$124.62 ,$157.51 ,$129.82 
Carle BroMenn Medical Center,8980636,methylPREDNISolone sodium succinate 500 mg intravenous solution,143985001,J2930,636,$193.34 ,$193.34 ,$58.00 ,$175.94 ,$135.34 ,$58.00 ,$125.67 ,$139.20 ,$175.94 ,$145.01 
Carle BroMenn Medical Center,8980636,metoclopramide 5 mg/mL injection solution,409341401,J2765,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,metoclopramide 5 mg/mL injection solution,409341418,J2765,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,metoclopramide 5 mg/mL injection solution,23155024031,J2765,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,metoclopramide 5 mg/mL injection solution,23155024041,J2765,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,micafungin 100 mg intravenous solution,469321110,J2248,636,"$1,109.77 ","$1,109.77 ",$332.93 ,"$1,009.89 ",$776.84 ,$332.93 ,$721.35 ,$799.03 ,"$1,009.89 ",$832.33 
Carle BroMenn Medical Center,8980636,micafungin 100 mg intravenous solution,25021019110,J2248,636,"$1,109.77 ","$1,109.77 ",$332.93 ,"$1,009.89 ",$776.84 ,$332.93 ,$721.35 ,$799.03 ,"$1,009.89 ",$832.33 
Carle BroMenn Medical Center,8980636,micafungin 100 mg intravenous solution,63323072910,J2248,636,"$1,109.77 ","$1,109.77 ",$332.93 ,"$1,009.89 ",$776.84 ,$332.93 ,$721.35 ,$799.03 ,"$1,009.89 ",$832.33 
Carle BroMenn Medical Center,8980636,micafungin 50 mg intravenous solution,469325010,J2248,636,$587.16 ,$587.16 ,$176.15 ,$534.32 ,$411.01 ,$176.15 ,$381.65 ,$422.76 ,$534.32 ,$440.37 
Carle BroMenn Medical Center,8980636,micafungin 50 mg intravenous solution,63323072801,J2248,636,$586.92 ,$586.92 ,$176.08 ,$534.10 ,$410.84 ,$176.08 ,$381.50 ,$422.58 ,$534.10 ,$440.19 
Carle BroMenn Medical Center,8980636,micafungin 50 mg intravenous solution,63323072810,J2248,636,$586.92 ,$586.92 ,$176.08 ,$534.10 ,$410.84 ,$176.08 ,$381.50 ,$422.58 ,$534.10 ,$440.19 
Carle BroMenn Medical Center,8980636,midazolam (PF) 5 mg/ml injection solution,409230801,J2250,636,$145.61 ,$145.61 ,$43.68 ,$132.51 ,$101.93 ,$43.68 ,$94.65 ,$104.84 ,$132.51 ,$109.21 
Carle BroMenn Medical Center,8980636,midazolam 1 mg/mL injection solution,641605701,J2250,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,midazolam 1 mg/mL injection solution,641605725,J2250,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,midazolam 1 mg/mL injection solution,641605901,J2250,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,midazolam 1 mg/mL injection solution,641605910,J2250,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,midazolam 1 mg/mL injection solution,641620901,J2250,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,midazolam 1 mg/mL injection solution,641620925,J2250,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,midazolam 1 mg/mL injection solution,641621001,J2250,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,midazolam 1 mg/mL injection solution,641621010,J2250,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,midazolam 5 mg/mL injection solution,409259615,J2250,636,$145.61 ,$145.61 ,$43.68 ,$132.51 ,$101.93 ,$43.68 ,$94.65 ,$104.84 ,$132.51 ,$109.21 
Carle BroMenn Medical Center,8980636,midazolam 5 mg/mL injection solution,641606010,J2250,636,$145.61 ,$145.61 ,$43.68 ,$132.51 ,$101.93 ,$43.68 ,$94.65 ,$104.84 ,$132.51 ,$109.21 
Carle BroMenn Medical Center,8980636,midazolam 5 mg/mL injection solution,641606110,J2250,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,midazolam 5 mg/mL injection solution,641606125,J2250,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,midazolam 5 mg/mL injection solution,641621101,J2250,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,midazolam 5 mg/mL injection solution,72611074901,J2250,636,$145.61 ,$145.61 ,$43.68 ,$132.51 ,$101.93 ,$43.68 ,$94.65 ,$104.84 ,$132.51 ,$109.21 
Carle BroMenn Medical Center,8980636,midazolam 5 mg/mL injection solution,72611074910,J2250,636,$145.61 ,$145.61 ,$43.68 ,$132.51 ,$101.93 ,$43.68 ,$94.65 ,$104.84 ,$132.51 ,$109.21 
Carle BroMenn Medical Center,8980636,milrinone 1 mg/mL intravenous solution,143970910,J2260,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,milrinone 1 mg/mL intravenous solution,71288020020,J2260,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,milrinone 1 mg/mL intravenous solution,71288020021,J2260,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,milrinone 20 mg/100 mL(200 mcg/mL) in 5 % dextrose intravenous piggybk,143971910,J2260,636,$109.32 ,$109.32 ,$32.80 ,$99.48 ,$76.52 ,$32.80 ,$71.06 ,$78.71 ,$99.48 ,$81.99 
Carle BroMenn Medical Center,8980636,mitoMYcin 40 mg intravenous solution,67457052040,J9280,636,"$5,129.48 ","$5,129.48 ","$1,538.84 ","$4,667.83 ","$3,590.64 ","$1,538.84 ","$3,334.16 ","$3,693.23 ","$4,667.83 ","$3,847.11 "
Carle BroMenn Medical Center,8980636,morphine (PF) 1 mg/mL injection solution,409381511,,636,$57.73 ,$57.73 ,$17.32 ,$52.53 ,$40.41 ,$17.32 ,$37.52 ,$41.57 ,$52.53 ,$43.30 
Carle BroMenn Medical Center,8980636,morphine (PF) 1 mg/mL injection solution,409381512,,636,$57.73 ,$57.73 ,$17.32 ,$52.53 ,$40.41 ,$17.32 ,$37.52 ,$41.57 ,$52.53 ,$43.30 
Carle BroMenn Medical Center,8980636,morphine (PF) 1 mg/mL injection solution,641601910,,636,$208.07 ,$208.07 ,$62.42 ,$189.34 ,$145.65 ,$62.42 ,$135.25 ,$149.81 ,$189.34 ,$156.05 
Carle BroMenn Medical Center,8980636,morphine (PF) 10 mg/mL injection solution,641603901,,636,"$1,505.09 ","$1,505.09 ",$451.53 ,"$1,369.63 ","$1,053.56 ",$451.53 ,$978.31 ,"$1,083.66 ","$1,369.63 ","$1,128.82 "
Carle BroMenn Medical Center,8980636,"morphine 10 mg/mL intravenous syringe,morphine 10 mg/mL intravenous solution,morphine 10 mg/mL injection syringe",409189301,J2270,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"morphine 10 mg/mL intravenous syringe,morphine 10 mg/mL intravenous solution,morphine 10 mg/mL injection syringe",641612701,J2270,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,morphine 2 mg/mL intravenous syringe,409189001,J2270,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"morphine 2 mg/mL intravenous syringe,morphine 2 mg/mL injection syringe,morphine 2 mg/mL injection solution",409189001,J2270,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"morphine 2 mg/mL intravenous syringe,morphine 2 mg/mL injection syringe,morphine 2 mg/mL injection solution",76045000401,J2270,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"morphine 2 mg/mL intravenous syringe,morphine 2 mg/mL injection syringe,morphine 2 mg/mL injection solution",76045000411,J2270,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,morphine 30 mg/30 mL PCA intravenous solution,76329191101,J2270,636,$145.61 ,$145.61 ,$43.68 ,$132.51 ,$101.93 ,$43.68 ,$94.65 ,$104.84 ,$132.51 ,$109.21 
Carle BroMenn Medical Center,8980636,morphine 30 mg/30 mL PCA intravenous solution,76329191101,J2274,636,$145.61 ,$145.61 ,$43.68 ,$132.51 ,$101.93 ,$43.68 ,$94.65 ,$104.84 ,$132.51 ,$109.21 
Carle BroMenn Medical Center,8980636,"morphine 4 mg/mL injection solution,morphine 4 mg/mL injection syringe,morphine 4 mg/mL intravenous solution, morphine 4 mg/mL intravenous syringe",409189101,J2270,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"morphine 4 mg/mL injection solution,morphine 4 mg/mL injection syringe,morphine 4 mg/mL intravenous solution, morphine 4 mg/mL intravenous syringe",641612501,J2270,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"morphine 4 mg/mL injection solution,morphine 4 mg/mL injection syringe,morphine 4 mg/mL intravenous solution, morphine 4 mg/mL intravenous syringe",641612525,J2270,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"morphine 4 mg/mL injection solution,morphine 4 mg/mL injection syringe,morphine 4 mg/mL intravenous solution, morphine 4 mg/mL intravenous syringe",76045000501,J2270,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"morphine 4 mg/mL injection solution,morphine 4 mg/mL injection syringe,morphine 4 mg/mL intravenous solution, morphine 4 mg/mL intravenous syringe",76045000511,J2270,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,morphine 4 mg/mL intravenous syringe,409189101,J2270,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,morphine 5 mg/mL injection solution,63323045500,J2270,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,morphine 5 mg/mL injection solution,63323045501,J2270,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,morphine 50 mg/mL intravenous solution,409113403,J2270,636,$145.61 ,$145.61 ,$43.68 ,$132.51 ,$101.93 ,$43.68 ,$94.65 ,$104.84 ,$132.51 ,$109.21 
Carle BroMenn Medical Center,8980636,morphine 50 mg/mL intravenous solution,409113405,J2270,636,$145.61 ,$145.61 ,$43.68 ,$132.51 ,$101.93 ,$43.68 ,$94.65 ,$104.84 ,$132.51 ,$109.21 
Carle BroMenn Medical Center,8980636,"moxifloxacin 400 mg/250 mL-sodium acet,sul-water intravenous piggyback",63323085074,J2280,636,$338.05 ,$338.05 ,$101.42 ,$307.63 ,$236.64 ,$101.42 ,$219.73 ,$243.40 ,$307.63 ,$253.54 
Carle BroMenn Medical Center,8980636,moxifloxacin 400 mg/250 mL-sodium chloride(iso) intravenous piggyback,67457032325,J2280,636,$338.05 ,$338.05 ,$101.42 ,$307.63 ,$236.64 ,$101.42 ,$219.73 ,$243.40 ,$307.63 ,$253.54 
Carle BroMenn Medical Center,8980636,mycophenolate mofetil 250 mg capsule,60687049401,J7517,636,$5.83 ,$5.83 ,$1.75 ,$5.31 ,$4.08 ,$1.75 ,$3.79 ,$4.20 ,$5.31 ,$4.37 
Carle BroMenn Medical Center,8980636,nalbuphine 10 mg/mL injection solution,409146301,J2300,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,nalbuphine 10 mg/mL injection solution,409146371,J2300,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,naloxone 0.4 mg/mL injection solution,641613225,J2310,636,$73.24 ,$73.24 ,$21.97 ,$66.65 ,$51.27 ,$21.97 ,$47.61 ,$52.73 ,$66.65 ,$54.93 
Carle BroMenn Medical Center,8980636,naloxone 1 mg/mL injection syringe,43598075011,J2310,636,$112.87 ,$112.87 ,$33.86 ,$102.71 ,$79.01 ,$33.86 ,$73.37 ,$81.27 ,$102.71 ,$84.65 
Carle BroMenn Medical Center,8980636,naloxone 1 mg/mL injection syringe,43598075058,J2310,636,$112.87 ,$112.87 ,$33.86 ,$102.71 ,$79.01 ,$33.86 ,$73.37 ,$81.27 ,$102.71 ,$84.65 
Carle BroMenn Medical Center,8980636,naloxone 1 mg/mL injection syringe,76329336901,J2310,636,$118.64 ,$118.64 ,$35.59 ,$107.96 ,$83.05 ,$35.59 ,$77.12 ,$85.42 ,$107.96 ,$88.98 
Carle BroMenn Medical Center,8980636,natalizumab 300 mg/15 mL intravenous solution,64406000801,J2323,636,"$41,802.69 ","$41,802.69 ","$12,540.81 ","$38,040.45 ","$29,261.88 ","$12,540.81 ","$27,171.75 ","$30,097.94 ","$38,040.45 ","$31,352.02 "
Carle BroMenn Medical Center,8980636,neostigmine methylsulfate 1 mg/mL intravenous solution,641614901,J2710,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,neostigmine methylsulfate 1 mg/mL intravenous solution,641614910,J2710,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,neostigmine methylsulfate 1 mg/mL intravenous solution,42023018901,J2710,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,neostigmine methylsulfate 1 mg/mL intravenous solution,42023018910,J2710,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,neostigmine methylsulfate 1 mg/mL intravenous solution,63323041510,J2710,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,neostigmine methylsulfate 1 mg/mL intravenous solution,70700017222,J2710,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,neostigmine methylsulfate 1 mg/mL intravenous solution,71288050110,J2710,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,neostigmine methylsulfate 1 mg/mL intravenous solution,71288050111,J2710,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,neostigmine methylsulfate 1 mg/mL intravenous solution,76014000310,J2710,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,neostigmine methylsulfate 4 mg/4 mL (1 mg/mL) intravenous syringe,69374094204,J2710,636,$76.73 ,$76.73 ,$23.02 ,$69.82 ,$53.71 ,$23.02 ,$49.87 ,$55.25 ,$69.82 ,$57.55 
Carle BroMenn Medical Center,8980636,"obinutuzumab 1,000 mg/40 mL intravenous solution",50242007001,,636,"$28,939.56 ","$28,939.56 ","$8,681.87 ","$26,335.00 ","$20,257.69 ","$8,681.87 ","$18,810.71 ","$20,836.48 ","$26,335.00 ","$21,704.67 "
Carle BroMenn Medical Center,8980636,ocrelizumab 30 mg/mL intravenous solution,50242015001,,636,"$95,298.11 ","$95,298.11 ","$28,589.43 ","$86,721.28 ","$66,708.68 ","$28,589.43 ","$61,943.77 ","$68,614.64 ","$86,721.28 ","$71,473.58 "
Carle BroMenn Medical Center,8980636,octreotide acetate 100 mcg/mL injection solution,703331101,J2354,636,$24.45 ,$24.45 ,$7.34 ,$22.25 ,$17.12 ,$7.34 ,$15.89 ,$17.60 ,$22.25 ,$18.34 
Carle BroMenn Medical Center,8980636,octreotide acetate 100 mcg/mL injection solution,703331104,J2354,636,$24.45 ,$24.45 ,$7.34 ,$22.25 ,$17.12 ,$7.34 ,$15.89 ,$17.60 ,$22.25 ,$18.34 
Carle BroMenn Medical Center,8980636,octreotide acetate 100 mcg/mL injection solution,63323037601,J2354,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,octreotide acetate 100 mcg/mL injection solution,63323037604,J2354,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,octreotide acetate 500 mcg/mL injection solution,63323037701,J2354,636,$341.94 ,$341.94 ,$102.58 ,$311.17 ,$239.36 ,$102.58 ,$222.26 ,$246.20 ,$311.17 ,$256.46 
Carle BroMenn Medical Center,8980636,octreotide acetate 500 mcg/mL injection solution,63323037704,J2354,636,$107.46 ,$107.46 ,$32.24 ,$97.79 ,$75.22 ,$32.24 ,$69.85 ,$77.37 ,$97.79 ,$80.60 
Carle BroMenn Medical Center,8980636,OLANZapine 10 mg intramuscular solution,517095501,S0166,636,$90.01 ,$90.01 ,$27.00 ,$81.91 ,$63.01 ,$27.00 ,$58.51 ,$64.81 ,$81.91 ,$67.51 
Carle BroMenn Medical Center,8980636,OLANZapine 10 mg intramuscular solution,781910572,S0166,636,$85.68 ,$85.68 ,$25.70 ,$77.97 ,$59.98 ,$25.70 ,$55.69 ,$61.69 ,$77.97 ,$64.26 
Carle BroMenn Medical Center,8980636,onabotulinumtoxinA 100 unit solution for injection,23114501,J0585,636,"$2,734.54 ","$2,734.54 ",$820.36 ,"$2,488.43 ","$1,914.18 ",$820.36 ,"$1,777.45 ","$1,968.87 ","$2,488.43 ","$2,050.91 "
Carle BroMenn Medical Center,8980636,ondansetron 4 mg disintegrating tablet,65862039010,Q0162,636,$86.18 ,$86.18 ,$25.85 ,$78.42 ,$60.33 ,$25.85 ,$56.02 ,$62.05 ,$78.42 ,$64.64 
Carle BroMenn Medical Center,8980636,ondansetron 4 mg disintegrating tablet,68001024616,Q0162,636,$89.05 ,$89.05 ,$26.72 ,$81.04 ,$62.34 ,$26.72 ,$57.88 ,$64.12 ,$81.04 ,$66.79 
Carle BroMenn Medical Center,8980636,ondansetron 4 mg disintegrating tablet,68001024617,Q0162,636,$89.05 ,$89.05 ,$26.72 ,$81.04 ,$62.34 ,$26.72 ,$57.88 ,$64.12 ,$81.04 ,$66.79 
Carle BroMenn Medical Center,8980636,ondansetron 4 mg disintegrating tablet,68462015713,Q0162,636,$89.05 ,$89.05 ,$26.72 ,$81.04 ,$62.34 ,$26.72 ,$57.88 ,$64.12 ,$81.04 ,$66.79 
Carle BroMenn Medical Center,8980636,ondansetron 4 mg disintegrating tablet,68462015740,Q0162,636,$89.05 ,$89.05 ,$26.72 ,$81.04 ,$62.34 ,$26.72 ,$57.88 ,$64.12 ,$81.04 ,$66.79 
Carle BroMenn Medical Center,8980636,ondansetron HCl (PF) 4 mg/2 mL injection solution,641607825,J2405,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,ondansetron HCl (PF) 4 mg/2 mL injection solution,23155054731,J2405,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,ondansetron HCl (PF) 4 mg/2 mL injection solution,60505613000,J2405,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,ondansetron HCl (PF) 4 mg/2 mL injection solution,60505613005,J2405,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,ondansetron HCL 4 mg/5 mL oral solution,54006447,,636,$146.58 ,$146.58 ,$43.97 ,$133.39 ,$102.61 ,$43.97 ,$95.28 ,$105.54 ,$133.39 ,$109.94 
Carle BroMenn Medical Center,8980636,ondansetron HCL 4 mg/5 mL oral solution,9999038641,,636,$146.58 ,$146.58 ,$43.97 ,$133.39 ,$102.61 ,$43.97 ,$95.28 ,$105.54 ,$133.39 ,$109.94 
Carle BroMenn Medical Center,8980636,ondansetron HCL 4 mg/5 mL oral solution,54838055550,,636,$146.09 ,$146.09 ,$43.83 ,$132.94 ,$102.26 ,$43.83 ,$94.96 ,$105.18 ,$132.94 ,$109.57 
Carle BroMenn Medical Center,8980636,orphenadrine citrate 30 mg/mL injection solution,641618210,J2360,636,$112.35 ,$112.35 ,$33.71 ,$102.24 ,$78.65 ,$33.71 ,$73.03 ,$80.89 ,$102.24 ,$84.26 
Carle BroMenn Medical Center,8980636,orphenadrine citrate 30 mg/mL injection solution,17478053802,J2360,636,$132.63 ,$132.63 ,$39.79 ,$120.69 ,$92.84 ,$39.79 ,$86.21 ,$95.49 ,$120.69 ,$99.47 
Carle BroMenn Medical Center,8980636,oxacillin 1 gram solution for injection,55150012715,J2700,636,$119.34 ,$119.34 ,$35.80 ,$108.60 ,$83.54 ,$35.80 ,$77.57 ,$85.92 ,$108.60 ,$89.51 
Carle BroMenn Medical Center,8980636,oxacillin 1 gram solution for injection,63323081301,J2700,636,$116.52 ,$116.52 ,$34.96 ,$106.03 ,$81.56 ,$34.96 ,$75.74 ,$83.89 ,$106.03 ,$87.39 
Carle BroMenn Medical Center,8980636,oxacillin 1 gram solution for injection,64679069801,J2700,636,$119.34 ,$119.34 ,$35.80 ,$108.60 ,$83.54 ,$35.80 ,$77.57 ,$85.92 ,$108.60 ,$89.51 
Carle BroMenn Medical Center,8980636,oxacillin 1 gram solution for injection,64679069802,J2700,636,$119.34 ,$119.34 ,$35.80 ,$108.60 ,$83.54 ,$35.80 ,$77.57 ,$85.92 ,$108.60 ,$89.51 
Carle BroMenn Medical Center,8980636,oxacillin 10 gram solution for injection,25021016397,J2700,636,$679.19 ,$679.19 ,$203.76 ,$618.06 ,$475.43 ,$203.76 ,$441.47 ,$489.02 ,$618.06 ,$509.39 
Carle BroMenn Medical Center,8980636,oxacillin 10 gram solution for injection,25021016399,J2700,636,$679.19 ,$679.19 ,$203.76 ,$618.06 ,$475.43 ,$203.76 ,$441.47 ,$489.02 ,$618.06 ,$509.39 
Carle BroMenn Medical Center,8980636,oxacillin 2 gram intravenous solution,781309592,J2700,636,$238.12 ,$238.12 ,$71.44 ,$216.69 ,$166.68 ,$71.44 ,$154.78 ,$171.45 ,$216.69 ,$178.59 
Carle BroMenn Medical Center,8980636,oxacillin 2 gram solution for injection,55150012824,J2700,636,$195.83 ,$195.83 ,$58.75 ,$178.21 ,$137.08 ,$58.75 ,$127.29 ,$141.00 ,$178.21 ,$146.87 
Carle BroMenn Medical Center,8980636,oxacillin 2 gram solution for injection,64679069901,J2700,636,$199.21 ,$199.21 ,$59.76 ,$181.28 ,$139.45 ,$59.76 ,$129.49 ,$143.43 ,$181.28 ,$149.41 
Carle BroMenn Medical Center,8980636,oxacillin 2 gram solution for injection,64679069902,J2700,636,$199.21 ,$199.21 ,$59.76 ,$181.28 ,$139.45 ,$59.76 ,$129.49 ,$143.43 ,$181.28 ,$149.41 
Carle BroMenn Medical Center,8980636,oxytocin 10 unit/mL injection solution,42023011625,J2590,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,oxytocin 10 unit/mL injection solution,63323001203,J2590,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,oxytocin 10 unit/mL injection solution,63323001211,J2590,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,oxytocin 30 unit/500 mL in 0.9 % sodium chloride intravenous,72196604401,J2590,636,$61.60 ,$61.60 ,$18.48 ,$56.06 ,$43.12 ,$18.48 ,$40.04 ,$44.35 ,$56.06 ,$46.20 
Carle BroMenn Medical Center,8980636,oxytocin in lactated ringers 30 unit/500 mL intravenous solution,9999501525,J2590,636,$177.54 ,$177.54 ,$53.26 ,$161.56 ,$124.28 ,$53.26 ,$115.40 ,$127.83 ,$161.56 ,$133.16 
Carle BroMenn Medical Center,8980636,paliperidone palmitate 156 mg/mL intramuscular syringe,50458056301,J2426,636,"$8,354.35 ","$8,354.35 ","$2,506.31 ","$7,602.46 ","$5,848.05 ","$2,506.31 ","$5,430.33 ","$6,015.13 ","$7,602.46 ","$6,265.76 "
Carle BroMenn Medical Center,8980636,paliperidone palmitate 234 mg/1.5 mL intramuscular syringe,50458056401,J2426,636,"$12,470.18 ","$12,470.18 ","$3,741.05 ","$11,347.86 ","$8,729.13 ","$3,741.05 ","$8,105.62 ","$8,978.53 ","$11,347.86 ","$9,352.64 "
Carle BroMenn Medical Center,8980636,palonosetron 0.25 mg/5 mL intravenous solution,55111069407,J2469,636,$352.60 ,$352.60 ,$105.78 ,$320.87 ,$246.82 ,$105.78 ,$229.19 ,$253.87 ,$320.87 ,$264.45 
Carle BroMenn Medical Center,8980636,pamidronate 30 mg/10 mL (3 mg/mL) intravenous solution,67457043010,J2430,636,$223.52 ,$223.52 ,$67.06 ,$203.40 ,$156.46 ,$67.06 ,$145.29 ,$160.93 ,$203.40 ,$167.64 
Carle BroMenn Medical Center,8980636,pamidronate 90 mg/10 mL (9 mg/mL) intravenous solution,67457044610,J2430,636,$656.81 ,$656.81 ,$197.04 ,$597.70 ,$459.77 ,$197.04 ,$426.93 ,$472.90 ,$597.70 ,$492.61 
Carle BroMenn Medical Center,8980636,pantoprazole 40 mg intravenous solution,8092351,C9113,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,pantoprazole 40 mg intravenous solution,8092355,C9113,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,pantoprazole 40 mg intravenous solution,8400101,C9113,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,pantoprazole 40 mg intravenous solution,8400125,C9113,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,pantoprazole 40 mg intravenous solution,781323294,C9113,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,pantoprazole 40 mg intravenous solution,781323295,C9113,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,pantoprazole 40 mg intravenous solution,65219043301,C9113,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,pantoprazole 40 mg intravenous solution,65219043315,C9113,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,papaverine 30 mg/mL injection solution,517400225,J2440,636,$902.57 ,$902.57 ,$270.77 ,$821.34 ,$631.80 ,$270.77 ,$586.67 ,$649.85 ,$821.34 ,$676.93 
Carle BroMenn Medical Center,8980636,pegaspargase 750 unit/mL injection solution,944381001,J9266,636,"$71,498.03 ","$71,498.03 ","$21,449.41 ","$65,063.21 ","$50,048.62 ","$21,449.41 ","$46,473.72 ","$51,478.58 ","$65,063.21 ","$53,623.52 "
Carle BroMenn Medical Center,8980636,pegloticase 8 mg/mL intravenous solution,75987008010,J2507,636,"$60,417.96 ","$60,417.96 ","$18,125.39 ","$54,980.34 ","$42,292.57 ","$18,125.39 ","$39,271.67 ","$43,500.93 ","$54,980.34 ","$45,313.47 "
Carle BroMenn Medical Center,8980636,pembrolizumab 25 mg/mL intravenous solution,6302601,,636,"$21,739.05 ","$21,739.05 ","$6,521.72 ","$19,782.54 ","$15,217.34 ","$6,521.72 ","$14,130.38 ","$15,652.12 ","$19,782.54 ","$16,304.29 "
Carle BroMenn Medical Center,8980636,"penicillin G benzathine 1,200,000 unit/2 mL intramuscular syringe",60793070110,J0561,636,$302.91 ,$302.91 ,$90.87 ,$275.65 ,$212.04 ,$90.87 ,$196.89 ,$218.10 ,$275.65 ,$227.18 
Carle BroMenn Medical Center,8980636,"penicillin G benzathine 600,000 unit/mL intramuscular syringe",60793070010,J0561,636,$539.62 ,$539.62 ,$161.89 ,$491.05 ,$377.73 ,$161.89 ,$350.75 ,$388.53 ,$491.05 ,$404.72 
Carle BroMenn Medical Center,8980636,penicillin G potassium 5 million unit solution for injection,49042005,J2540,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,penicillin G potassium 5 million unit solution for injection,49052083,J2540,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,penicillin G potassium 5 million unit solution for injection,70860012620,J2540,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,PHENobarbital sodium 65 mg/mL injection solution,641047625,J2560,636,$173.30 ,$173.30 ,$51.99 ,$157.70 ,$121.31 ,$51.99 ,$112.65 ,$124.78 ,$157.70 ,$129.98 
Carle BroMenn Medical Center,8980636,PHENobarbital sodium 65 mg/mL injection solution,42494041501,J2560,636,$158.19 ,$158.19 ,$47.46 ,$143.95 ,$110.73 ,$47.46 ,$102.82 ,$113.90 ,$143.95 ,$118.64 
Carle BroMenn Medical Center,8980636,PHENobarbital sodium 65 mg/mL injection solution,42494041525,J2560,636,$158.21 ,$158.21 ,$47.46 ,$143.97 ,$110.75 ,$47.46 ,$102.84 ,$113.91 ,$143.97 ,$118.66 
Carle BroMenn Medical Center,8980636,phentolamine 5 mg injection solution,143956410,J2760,636,"$1,994.61 ","$1,994.61 ",$598.38 ,"$1,815.10 ","$1,396.23 ",$598.38 ,"$1,296.50 ","$1,436.12 ","$1,815.10 ","$1,495.96 "
Carle BroMenn Medical Center,8980636,phenylephrine 0.4 mg/10 mL (40 mcg/mL) in 0.9 %sod.chloride IV syringe,69374095510,J2370,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,phenylephrine 1 mg/10 mL (100 mcg/mL) in 0.9 % sod.chloride IV syringe,69374095710,J2370,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,phenylephrine 10 mg/mL injection solution,641614201,J2370,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,phenylephrine 10 mg/mL injection solution,641614225,J2370,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,phenylephrine 10 mg/mL injection solution,641618801,J2370,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,phenylephrine 10 mg/mL injection solution,641618810,J2370,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,phenylephrine 10 mg/mL injection solution,25021031501,J2370,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,phenylephrine 10 mg/mL injection solution,25021031599,J2370,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,phenylephrine 10 mg/mL injection solution,51754400001,J2370,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,phenylephrine 10 mg/mL injection solution,51754400003,J2370,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,phenylephrine 10 mg/mL injection solution,61990021100,J2370,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,phenylephrine 10 mg/mL injection solution,61990021103,J2370,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,phenylephrine 10 mg/mL injection solution,61990021200,J2370,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,phenylephrine 10 mg/mL injection solution,61990021202,J2370,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,phenylephrine 10 mg/mL injection solution,70121157801,J2370,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,phenylephrine 10 mg/mL injection solution,70121157807,J2370,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,phenylephrine 10 mg/mL injection solution,71288080702,J2370,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,phenylephrine 10 mg/mL injection solution,71288080875,J2370,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,phenylephrine 10 mg/mL injection solution,71288080877,J2370,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,phenylephrine 10 mg/mL injection solution,76014000410,J2370,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,phenylephrine 10 mg/mL injection solution,76014000432,J2370,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,phenytoin sodium 50 mg/mL intravenous solution,641049325,J1165,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,phenytoin sodium 50 mg/mL intravenous solution,641255545,J1165,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,phytonadione (vitamin K1) 1 mg/0.5 mL injection solution,409915731,,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,phytonadione (vitamin K1) 1 mg/0.5 mL injection solution,409915750,,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"phytonadione (vitamin K1) 1 mg/0.5 mL injection solution,phytonadione (vitamin K1) 1 mg/0.5 mL injection syringe",409915731,,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"phytonadione (vitamin K1) 1 mg/0.5 mL injection solution,phytonadione (vitamin K1) 1 mg/0.5 mL injection syringe",409915750,,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,"phytonadione (vitamin K1) 1 mg/0.5 mL injection solution,phytonadione (vitamin K1) 1 mg/0.5 mL injection syringe",76329124001,,636,$175.62 ,$175.62 ,$52.69 ,$159.81 ,$122.93 ,$52.69 ,$114.15 ,$126.45 ,$159.81 ,$131.72 
Carle BroMenn Medical Center,8980636,phytonadione (vitamin K1) 1 mg/0.5 mL injection syringe,76329124001,J3430,636,$175.62 ,$175.62 ,$52.69 ,$159.81 ,$122.93 ,$52.69 ,$114.15 ,$126.45 ,$159.81 ,$131.72 
Carle BroMenn Medical Center,8980636,phytonadione (vitamin K1) 10 mg/mL injection solution,409915801,J3430,636,$91.18 ,$91.18 ,$27.35 ,$82.97 ,$63.83 ,$27.35 ,$59.27 ,$65.65 ,$82.97 ,$68.39 
Carle BroMenn Medical Center,8980636,phytonadione (vitamin K1) 10 mg/mL injection solution,409915831,J3430,636,$91.18 ,$91.18 ,$27.35 ,$82.97 ,$63.83 ,$27.35 ,$59.27 ,$65.65 ,$82.97 ,$68.39 
Carle BroMenn Medical Center,8980636,phytonadione (vitamin K1) 10 mg/mL injection solution,43598040511,J3430,636,$87.99 ,$87.99 ,$26.40 ,$80.07 ,$61.59 ,$26.40 ,$57.19 ,$63.35 ,$80.07 ,$65.99 
Carle BroMenn Medical Center,8980636,phytonadione (vitamin K1) 10 mg/mL injection solution,43598040516,J3430,636,$87.99 ,$87.99 ,$26.40 ,$80.07 ,$61.59 ,$26.40 ,$57.19 ,$63.35 ,$80.07 ,$65.99 
Carle BroMenn Medical Center,8980636,piperacillin-tazobactam 2.25 gram intravenous solution,63323098121,J2543,636,$99.55 ,$99.55 ,$29.87 ,$90.59 ,$69.69 ,$29.87 ,$64.71 ,$71.68 ,$90.59 ,$74.66 
Carle BroMenn Medical Center,8980636,piperacillin-tazobactam 2.25 gram intravenous solution,63323098123,J2543,636,$99.55 ,$99.55 ,$29.87 ,$90.59 ,$69.69 ,$29.87 ,$64.71 ,$71.68 ,$90.59 ,$74.66 
Carle BroMenn Medical Center,8980636,piperacillin-tazobactam 3.375 gram intravenous solution,63323098321,J2543,636,$131.82 ,$131.82 ,$39.55 ,$119.96 ,$92.27 ,$39.55 ,$85.68 ,$94.91 ,$119.96 ,$98.87 
Carle BroMenn Medical Center,8980636,piperacillin-tazobactam 3.375 gram intravenous solution,63323098323,J2543,636,$131.82 ,$131.82 ,$39.55 ,$119.96 ,$92.27 ,$39.55 ,$85.68 ,$94.91 ,$119.96 ,$98.87 
Carle BroMenn Medical Center,8980636,piperacillin-tazobactam 3.375 gram intravenous solution,64679005601,J2543,636,$161.56 ,$161.56 ,$48.47 ,$147.02 ,$113.09 ,$48.47 ,$105.01 ,$116.32 ,$147.02 ,$121.17 
Carle BroMenn Medical Center,8980636,piperacillin-tazobactam 3.375 gram intravenous solution,64679005602,J2543,636,$161.56 ,$161.56 ,$48.47 ,$147.02 ,$113.09 ,$48.47 ,$105.01 ,$116.32 ,$147.02 ,$121.17 
Carle BroMenn Medical Center,8980636,piperacillin-tazobactam 4.5 gram intravenous solution,55150012150,J2543,636,$192.45 ,$192.45 ,$57.74 ,$175.13 ,$134.72 ,$57.74 ,$125.09 ,$138.56 ,$175.13 ,$144.34 
Carle BroMenn Medical Center,8980636,piperacillin-tazobactam 4.5 gram intravenous solution,64679001201,J2543,636,$192.45 ,$192.45 ,$57.74 ,$175.13 ,$134.72 ,$57.74 ,$125.09 ,$138.56 ,$175.13 ,$144.34 
Carle BroMenn Medical Center,8980636,piperacillin-tazobactam 4.5 gram intravenous solution,65219025905,J2543,636,$108.84 ,$108.84 ,$32.65 ,$99.04 ,$76.19 ,$32.65 ,$70.75 ,$78.36 ,$99.04 ,$81.63 
Carle BroMenn Medical Center,8980636,piperacillin-tazobactam 4.5 gram intravenous solution,65219025915,J2543,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,piperacillin-tazobactam 4.5 gram intravenous solution,65219025945,J2543,636,$108.84 ,$108.84 ,$32.65 ,$99.04 ,$76.19 ,$32.65 ,$70.75 ,$78.36 ,$99.04 ,$81.63 
Carle BroMenn Medical Center,8980636,piperacillin-tazobactam 4.5 gram intravenous solution,65219025955,J2543,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,PIPERACILLIN-TAZOBACTAM-DEXTROSE (ISO-OSM) 2.25 G,206886001,,636,$108.74 ,$108.74 ,$32.62 ,$98.95 ,$76.12 ,$32.62 ,$70.68 ,$78.29 ,$98.95 ,$81.56 
Carle BroMenn Medical Center,8980636,PIPERACILLIN-TAZOBACTAM-DEXTROSE (ISO-OSM) 2.25 G,206886001,J2543,636,$108.74 ,$108.74 ,$32.62 ,$98.95 ,$76.12 ,$32.62 ,$70.68 ,$78.29 ,$98.95 ,$81.56 
Carle BroMenn Medical Center,8980636,PIPERACILLIN-TAZOBACTAM-DEXTROSE (ISO-OSM) 2.25 G,206886002,,636,$108.74 ,$108.74 ,$32.62 ,$98.95 ,$76.12 ,$32.62 ,$70.68 ,$78.29 ,$98.95 ,$81.56 
Carle BroMenn Medical Center,8980636,PIPERACILLIN-TAZOBACTAM-DEXTROSE (ISO-OSM) 2.25 G,206886002,J2543,636,$108.74 ,$108.74 ,$32.62 ,$98.95 ,$76.12 ,$32.62 ,$70.68 ,$78.29 ,$98.95 ,$81.56 
Carle BroMenn Medical Center,8980636,pneumococcal 13-val conj vaccine-dip crm (PF) 0.5 mL IM syringe,5197102,90670,636,$471.08 ,$471.08 ,$141.32 ,$428.68 ,$329.76 ,$141.32 ,$306.20 ,$339.18 ,$428.68 ,$353.31 
Carle BroMenn Medical Center,8980636,pneumococcal 23 polyvalent vaccine 25 mcg/0.5 mL injection solution,6494300,90732,636,$260.48 ,$260.48 ,$78.14 ,$237.04 ,$182.34 ,$78.14 ,$169.31 ,$187.55 ,$237.04 ,$195.36 
Carle BroMenn Medical Center,8980636,potassium chloride 2 mEq/mL intravenous solution,409665305,J3480,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,potassium chloride 2 mEq/mL intravenous solution,409665318,J3480,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,potassium chloride 2 mEq/mL intravenous solution,63323096502,J3480,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,potassium chloride 2 mEq/mL intravenous solution,63323096510,J3480,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,potassium chloride 2 mEq/mL intravenous solution,63323096520,J3480,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,potassium chloride 20 mEq/100mL in sterile water intravenous piggyback,338070548,J3480,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,potassium chloride 20 mEq/100mL in sterile water intravenous piggyback,990707526,J3480,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,potassium chloride 20 mEq/L in 0.45 % sodium chloride intravenous soln,338070434,J3480,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,potassium chloride 20 mEq/L in 0.45 % sodium chloride intravenous soln,990925739,J3480,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,potassium chloride 20 mEq/L in 0.9 % sodium chloride intravenous,264786500,J3480,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,potassium chloride 20 mEq/L in 0.9 % sodium chloride intravenous,990711509,J3480,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,potassium chloride 40 mEq/L in 0.9 % sodium chloride intravenous,338069504,J3480,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,potassium chloride 40 mEq/L in 0.9 % sodium chloride intravenous,409711609,J3480,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,potassium chloride 40 mEq/L in 0.9 % sodium chloride intravenous,990711609,J3480,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,pralidoxime 1 gram solution for injection,60977014101,J2730,636,"$2,973.03 ","$2,973.03 ",$891.91 ,"$2,705.46 ","$2,081.12 ",$891.91 ,"$1,932.47 ","$2,140.58 ","$2,705.46 ","$2,229.77 "
Carle BroMenn Medical Center,8980636,"prednisoLONE 15 mg/5 mL oral solution,prednisoLONE sodium phosphate 15 mg/5 mL (3 mg/mL) oral solution",121075908,J7510,636,$431.83 ,$431.83 ,$129.55 ,$392.97 ,$302.28 ,$129.55 ,$280.69 ,$310.92 ,$392.97 ,$323.87 
Carle BroMenn Medical Center,8980636,"prednisoLONE 15 mg/5 mL oral solution,prednisoLONE sodium phosphate 15 mg/5 mL (3 mg/mL) oral solution",9999040078,J7510,636,$21.02 ,$21.02 ,$6.31 ,$19.13 ,$14.71 ,$6.31 ,$13.66 ,$15.13 ,$19.13 ,$15.77 
Carle BroMenn Medical Center,8980636,"prednisoLONE 15 mg/5 mL oral solution,prednisoLONE sodium phosphate 15 mg/5 mL (3 mg/mL) oral solution",50383004224,J7510,636,$680.25 ,$680.25 ,$204.08 ,$619.03 ,$476.18 ,$204.08 ,$442.16 ,$489.78 ,$619.03 ,$510.19 
Carle BroMenn Medical Center,8980636,"prednisoLONE 15 mg/5 mL oral solution,prednisoLONE sodium phosphate 15 mg/5 mL (3 mg/mL) oral solution",50383004248,J7510,636,"$1,082.53 ","$1,082.53 ",$324.76 ,$985.10 ,$757.77 ,$324.76 ,$703.64 ,$779.42 ,$985.10 ,$811.90 
Carle BroMenn Medical Center,8980636,"prednisoLONE 15 mg/5 mL oral solution,prednisoLONE sodium phosphate 15 mg/5 mL (3 mg/mL) oral solution",60432021208,J7510,636,$434.59 ,$434.59 ,$130.38 ,$395.48 ,$304.21 ,$130.38 ,$282.48 ,$312.90 ,$395.48 ,$325.94 
Carle BroMenn Medical Center,8980636,prednisoLONE sodium phosphate 15 mg/5 mL (3 mg/mL) oral solution,9999040078,,636,$12.60 ,$12.60 ,$3.78 ,$11.47 ,$8.82 ,$3.78 ,$8.19 ,$9.07 ,$11.47 ,$9.45 
Carle BroMenn Medical Center,8980636,predniSONE 1 mg tablet,54873925,,636,$3.63 ,$3.63 ,$1.09 ,$3.30 ,$2.54 ,$1.09 ,$2.36 ,$2.61 ,$3.30 ,$2.72 
Carle BroMenn Medical Center,8980636,predniSONE 10 mg tablet,54001720,,636,$3.57 ,$3.57 ,$1.07 ,$3.25 ,$2.50 ,$1.07 ,$2.32 ,$2.57 ,$3.25 ,$2.68 
Carle BroMenn Medical Center,8980636,predniSONE 10 mg tablet,60687013401,,636,$3.32 ,$3.32 ,$1.00 ,$3.02 ,$2.32 ,$1.00 ,$2.16 ,$2.39 ,$3.02 ,$2.49 
Carle BroMenn Medical Center,8980636,predniSONE 10 mg tablet,60687013411,,636,$3.32 ,$3.32 ,$1.00 ,$3.02 ,$2.32 ,$1.00 ,$2.16 ,$2.39 ,$3.02 ,$2.49 
Carle BroMenn Medical Center,8980636,predniSONE 2.5 mg tablet,54874025,,636,$3.17 ,$3.17 ,$0.95 ,$2.88 ,$2.22 ,$0.95 ,$2.06 ,$2.28 ,$2.88 ,$2.38 
Carle BroMenn Medical Center,8980636,predniSONE 20 mg tablet,54001820,,636,$3.66 ,$3.66 ,$1.10 ,$3.33 ,$2.56 ,$1.10 ,$2.38 ,$2.64 ,$3.33 ,$2.75 
Carle BroMenn Medical Center,8980636,predniSONE 20 mg tablet,60687014501,,636,$3.43 ,$3.43 ,$1.03 ,$3.12 ,$2.40 ,$1.03 ,$2.23 ,$2.47 ,$3.12 ,$2.57 
Carle BroMenn Medical Center,8980636,predniSONE 20 mg tablet,60687014511,,636,$3.43 ,$3.43 ,$1.03 ,$3.12 ,$2.40 ,$1.03 ,$2.23 ,$2.47 ,$3.12 ,$2.57 
Carle BroMenn Medical Center,8980636,predniSONE 5 mg tablet,54872425,,636,$3.49 ,$3.49 ,$1.05 ,$3.18 ,$2.44 ,$1.05 ,$2.27 ,$2.51 ,$3.18 ,$2.62 
Carle BroMenn Medical Center,8980636,predniSONE 5 mg tablet,60687012201,,636,$3.27 ,$3.27 ,$0.98 ,$2.98 ,$2.29 ,$0.98 ,$2.13 ,$2.35 ,$2.98 ,$2.45 
Carle BroMenn Medical Center,8980636,predniSONE 5 mg tablet,60687012211,,636,$3.27 ,$3.27 ,$0.98 ,$2.98 ,$2.29 ,$0.98 ,$2.13 ,$2.35 ,$2.98 ,$2.45 
Carle BroMenn Medical Center,8980636,procainamide 100 mg/mL injection solution,409190211,J2690,636,$641.28 ,$641.28 ,$192.38 ,$583.56 ,$448.90 ,$192.38 ,$416.83 ,$461.72 ,$583.56 ,$480.96 
Carle BroMenn Medical Center,8980636,procainamide 100 mg/mL injection solution,14789090107,J2690,636,"$1,392.41 ","$1,392.41 ",$417.72 ,"$1,267.09 ",$974.69 ,$417.72 ,$905.07 ,"$1,002.54 ","$1,267.09 ","$1,044.31 "
Carle BroMenn Medical Center,8980636,procainamide 100 mg/mL injection solution,14789090110,J2690,636,"$1,392.41 ","$1,392.41 ",$417.72 ,"$1,267.09 ",$974.69 ,$417.72 ,$905.07 ,"$1,002.54 ","$1,267.09 ","$1,044.31 "
Carle BroMenn Medical Center,8980636,prochlorperazine Edisylate 10 mg/2 mL (5 mg/mL) injection solution,23155029431,J0780,636,$132.60 ,$132.60 ,$39.78 ,$120.67 ,$92.82 ,$39.78 ,$86.19 ,$95.47 ,$120.67 ,$99.45 
Carle BroMenn Medical Center,8980636,prochlorperazine Edisylate 10 mg/2 mL (5 mg/mL) injection solution,23155029442,J0780,636,$132.60 ,$132.60 ,$39.78 ,$120.67 ,$92.82 ,$39.78 ,$86.19 ,$95.47 ,$120.67 ,$99.45 
Carle BroMenn Medical Center,8980636,prochlorperazine Edisylate 10 mg/2 mL (5 mg/mL) injection solution,67457064000,J0780,636,$132.60 ,$132.60 ,$39.78 ,$120.67 ,$92.82 ,$39.78 ,$86.19 ,$95.47 ,$120.67 ,$99.45 
Carle BroMenn Medical Center,8980636,prochlorperazine maleate 10 mg tablet,50268068511,Q0164,636,$10.60 ,$10.60 ,$3.18 ,$9.65 ,$7.42 ,$3.18 ,$6.89 ,$7.63 ,$9.65 ,$7.95 
Carle BroMenn Medical Center,8980636,prochlorperazine maleate 10 mg tablet,50268068515,Q0164,636,$10.60 ,$10.60 ,$3.18 ,$9.65 ,$7.42 ,$3.18 ,$6.89 ,$7.63 ,$9.65 ,$7.95 
Carle BroMenn Medical Center,8980636,prochlorperazine maleate 10 mg tablet,59746011506,Q0164,636,$6.49 ,$6.49 ,$1.95 ,$5.91 ,$4.54 ,$1.95 ,$4.22 ,$4.67 ,$5.91 ,$4.87 
Carle BroMenn Medical Center,8980636,prochlorperazine maleate 5 mg tablet,59746011306,Q0164,636,$5.10 ,$5.10 ,$1.53 ,$4.64 ,$3.57 ,$1.53 ,$3.32 ,$3.67 ,$4.64 ,$3.83 
Carle BroMenn Medical Center,8980636,progesterone 50 mg/mL intramuscular oil,63323026110,J2675,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,promethazine 25 mg/mL injection solution,641092825,J2550,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,promethazine 25 mg/mL injection solution,641094831,J2550,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,promethazine 25 mg/mL injection solution,641149531,J2550,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,promethazine 25 mg/mL injection solution,641608401,J2550,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,promethazine 25 mg/mL injection solution,641608425,J2550,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,promethazine 25 mg/mL injection solution,641620801,J2550,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,promethazine 25 mg/mL injection solution,39822552502,J2550,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,promethazine 25 mg/mL injection solution,39822552503,J2550,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,propofoL 10 mg/mL intravenous emulsion,69024801,,636,$152.97 ,$152.97 ,$45.89 ,$139.20 ,$107.08 ,$45.89 ,$99.43 ,$110.14 ,$139.20 ,$114.73 
Carle BroMenn Medical Center,8980636,propofoL 10 mg/mL intravenous emulsion,409469924,,636,$153.07 ,$153.07 ,$45.92 ,$139.29 ,$107.15 ,$45.92 ,$99.50 ,$110.21 ,$139.29 ,$114.80 
Carle BroMenn Medical Center,8980636,propofoL 10 mg/mL intravenous emulsion,409469954,,636,$152.97 ,$152.97 ,$45.89 ,$139.20 ,$107.08 ,$45.89 ,$99.43 ,$110.14 ,$139.20 ,$114.73 
Carle BroMenn Medical Center,8980636,propofoL 10 mg/mL intravenous emulsion,641619501,,636,$108.16 ,$108.16 ,$32.45 ,$98.43 ,$75.71 ,$32.45 ,$70.30 ,$77.88 ,$98.43 ,$81.12 
Carle BroMenn Medical Center,8980636,propofoL 10 mg/mL intravenous emulsion,25021060820,,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,propofoL 10 mg/mL intravenous emulsion,25021060851,,636,$207.68 ,$207.68 ,$62.30 ,$188.99 ,$145.38 ,$62.30 ,$134.99 ,$149.53 ,$188.99 ,$155.76 
Carle BroMenn Medical Center,8980636,propofoL 10 mg/mL intravenous emulsion,63323026950,,636,$108.16 ,$108.16 ,$32.45 ,$98.43 ,$75.71 ,$32.45 ,$70.30 ,$77.88 ,$98.43 ,$81.12 
Carle BroMenn Medical Center,8980636,propofoL 10 mg/mL intravenous emulsion,63323026959,,636,$45.30 ,$45.30 ,$13.59 ,$41.22 ,$31.71 ,$13.59 ,$29.45 ,$32.62 ,$41.22 ,$33.98 
Carle BroMenn Medical Center,8980636,propofoL 10 mg/mL intravenous emulsion,63323026965,,636,$212.92 ,$212.92 ,$63.88 ,$193.76 ,$149.04 ,$63.88 ,$138.40 ,$153.30 ,$193.76 ,$159.69 
Carle BroMenn Medical Center,8980636,propofoL 10 mg/mL intravenous emulsion,63323026969,,636,$87.31 ,$87.31 ,$26.19 ,$79.45 ,$61.12 ,$26.19 ,$56.75 ,$62.86 ,$79.45 ,$65.48 
Carle BroMenn Medical Center,8980636,Propofol 10 mg/mL IV,25021060820,,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,propranoloL 1 mg/mL intravenous solution,143987210,J1800,636,$59.27 ,$59.27 ,$17.78 ,$53.94 ,$41.49 ,$17.78 ,$38.53 ,$42.67 ,$53.94 ,$44.45 
Carle BroMenn Medical Center,8980636,propranoloL 1 mg/mL intravenous solution,63323060401,J1800,636,$73.73 ,$73.73 ,$22.12 ,$67.09 ,$51.61 ,$22.12 ,$47.92 ,$53.09 ,$67.09 ,$55.30 
Carle BroMenn Medical Center,8980636,protamine 10 mg/mL intravenous solution,63323022905,J2720,636,$89.25 ,$89.25 ,$26.78 ,$81.22 ,$62.48 ,$26.78 ,$58.01 ,$64.26 ,$81.22 ,$66.94 
Carle BroMenn Medical Center,8980636,protamine 10 mg/mL intravenous solution,63323022930,J2720,636,$54.88 ,$54.88 ,$16.46 ,$49.94 ,$38.42 ,$16.46 ,$35.67 ,$39.51 ,$49.94 ,$41.16 
Carle BroMenn Medical Center,8980636,protamine 10 mg/mL intravenous solution,63323022941,J2720,636,$71.79 ,$71.79 ,$21.54 ,$65.33 ,$50.25 ,$21.54 ,$46.66 ,$51.69 ,$65.33 ,$53.84 
Carle BroMenn Medical Center,8980636,protamine 10 mg/mL intravenous solution,63323022994,J2720,636,$71.79 ,$71.79 ,$21.54 ,$65.33 ,$50.25 ,$21.54 ,$46.66 ,$51.69 ,$65.33 ,$53.84 
Carle BroMenn Medical Center,8980636,protamine 10 mg/mL intravenous solution,63323022995,J2720,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,pyridoxine (vitamin B6) 100 mg/mL injection solution,63323018000,J3415,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,pyridoxine (vitamin B6) 100 mg/mL injection solution,63323018001,J3415,636,$119.12 ,$119.12 ,$35.74 ,$108.40 ,$83.38 ,$35.74 ,$77.43 ,$85.77 ,$108.40 ,$89.34 
Carle BroMenn Medical Center,8980636,rabies immune globulin (PF) 300 unit/mL intramuscular solution,13533031801,90375,636,"$1,491.60 ","$1,491.60 ",$447.48 ,"$1,357.36 ","$1,044.12 ",$447.48 ,$969.54 ,"$1,073.95 ","$1,357.36 ","$1,118.70 "
Carle BroMenn Medical Center,8980636,rabies immune globulin (PF) 300 unit/mL intramuscular solution,13533031805,90375,636,"$7,457.96 ","$7,457.96 ","$2,237.39 ","$6,786.74 ","$5,220.57 ","$2,237.39 ","$4,847.67 ","$5,369.73 ","$6,786.74 ","$5,593.47 "
Carle BroMenn Medical Center,8980636,"rabies vaccine, purified chicken embryo cell (PF) 2.5 unit IM susp",58160096412,90675,636,$803.13 ,$803.13 ,$240.94 ,$730.85 ,$562.19 ,$240.94 ,$522.03 ,$578.25 ,$730.85 ,$602.35 
Carle BroMenn Medical Center,8980636,"rabies vaccine,human diploid (PF) 2.5 unit intramuscular solution",49281025051,90675,636,$857.44 ,$857.44 ,$257.23 ,$780.27 ,$600.21 ,$257.23 ,$557.34 ,$617.36 ,$780.27 ,$643.08 
Carle BroMenn Medical Center,8980636,ramucirumab 10 mg/mL intravenous solution,2766901,,636,"$5,451.13 ","$5,451.13 ","$1,635.34 ","$4,960.53 ","$3,815.79 ","$1,635.34 ","$3,543.23 ","$3,924.81 ","$4,960.53 ","$4,088.35 "
Carle BroMenn Medical Center,8980636,rasburicase 7.5 mg intravenous solution,24515175,J2783,636,"$16,814.53 ","$16,814.53 ","$5,044.36 ","$15,301.22 ","$11,770.17 ","$5,044.36 ","$10,929.44 ","$12,106.46 ","$15,301.22 ","$12,610.90 "
Carle BroMenn Medical Center,8980636,regadenoson 0.4 mg/5 mL intravenous syringe,469650189,J2785,636,"$1,436.73 ","$1,436.73 ",$431.02 ,"$1,307.42 ","$1,005.71 ",$431.02 ,$933.87 ,"$1,034.45 ","$1,307.42 ","$1,077.55 "
Carle BroMenn Medical Center,8980636,"rho(D) immune globulin 1,500 unit (300 mcg) intramuscular syringe",562780505,J2790,636,$563.63 ,$563.63 ,$169.09 ,$512.90 ,$394.54 ,$169.09 ,$366.36 ,$405.81 ,$512.90 ,$422.72 
Carle BroMenn Medical Center,8980636,"rho(D) immune globulin 1,500 unit (300 mcg)/2 mL injection syringe",44206030001,J2791,636,$795.75 ,$795.75 ,$238.73 ,$724.13 ,$557.03 ,$238.73 ,$517.24 ,$572.94 ,$724.13 ,$596.81 
Carle BroMenn Medical Center,8980636,"rho(D) immune globulin 1,500 unit (300 mcg)/2 mL injection syringe",44206030010,J2791,636,$734.50 ,$734.50 ,$220.35 ,$668.40 ,$514.15 ,$220.35 ,$477.43 ,$528.84 ,$668.40 ,$550.88 
Carle BroMenn Medical Center,8980636,rho(D) immune globulin 250 unit (50 mcg) intramuscular syringe,562780600,J2788,636,$346.61 ,$346.61 ,$103.98 ,$315.42 ,$242.63 ,$103.98 ,$225.30 ,$249.56 ,$315.42 ,$259.96 
Carle BroMenn Medical Center,8980636,rho(D) immune globulin 250 unit (50 mcg) intramuscular syringe,562780601,J2788,636,$346.61 ,$346.61 ,$103.98 ,$315.42 ,$242.63 ,$103.98 ,$225.30 ,$249.56 ,$315.42 ,$259.96 
Carle BroMenn Medical Center,8980636,rho(D) immune globulin 250 unit (50 mcg) intramuscular syringe,562780625,J2788,636,$346.62 ,$346.62 ,$103.99 ,$315.42 ,$242.63 ,$103.99 ,$225.30 ,$249.57 ,$315.42 ,$259.97 
Carle BroMenn Medical Center,8980636,"risperiDONE microspheres ER 12.5 mg/2 mL intramuscular susp,ext releas",50458030911,J2794,636,"$1,241.30 ","$1,241.30 ",$372.39 ,"$1,129.58 ",$868.91 ,$372.39 ,$806.85 ,$893.74 ,"$1,129.58 ",$930.98 
Carle BroMenn Medical Center,8980636,"risperiDONE microspheres ER 25 mg/2 mL intramuscular susp,ext release",50458030611,J2794,636,"$2,360.36 ","$2,360.36 ",$708.11 ,"$2,147.93 ","$1,652.25 ",$708.11 ,"$1,534.23 ","$1,699.46 ","$2,147.93 ","$1,770.27 "
Carle BroMenn Medical Center,8980636,"risperiDONE microspheres ER 37.5 mg/2 mL intramuscular susp,ext releas",50458030711,J2794,636,"$3,479.62 ","$3,479.62 ","$1,043.89 ","$3,166.45 ","$2,435.73 ","$1,043.89 ","$2,261.75 ","$2,505.33 ","$3,166.45 ","$2,609.72 "
Carle BroMenn Medical Center,8980636,"riTUXimab 10 mg/mL concentrate,intravenous",50242005121,,636,"$4,120.71 ","$4,120.71 ","$1,236.21 ","$3,749.85 ","$2,884.50 ","$1,236.21 ","$2,678.46 ","$2,966.91 ","$3,749.85 ","$3,090.53 "
Carle BroMenn Medical Center,8980636,"riTUXimab 10 mg/mL concentrate,intravenous",50242005306,,636,"$19,904.59 ","$19,904.59 ","$5,971.38 ","$18,113.18 ","$13,933.21 ","$5,971.38 ","$12,937.98 ","$14,331.30 ","$18,113.18 ","$14,928.44 "
Carle BroMenn Medical Center,8980636,ropivacaine (PF) 10 mg/mL (1 %) injection solution,409930310,J2795,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,ropivacaine (PF) 10 mg/mL (1 %) injection solution,43066002701,J2795,636,$73.24 ,$73.24 ,$21.97 ,$66.65 ,$51.27 ,$21.97 ,$47.61 ,$52.73 ,$66.65 ,$54.93 
Carle BroMenn Medical Center,8980636,ropivacaine (PF) 10 mg/mL (1 %) injection solution,43066002710,J2795,636,$73.24 ,$73.24 ,$21.97 ,$66.65 ,$51.27 ,$21.97 ,$47.61 ,$52.73 ,$66.65 ,$54.93 
Carle BroMenn Medical Center,8980636,ropivacaine (PF) 10 mg/mL (1 %) injection solution,63323028807,J2795,636,$161.94 ,$161.94 ,$48.58 ,$147.37 ,$113.36 ,$48.58 ,$105.26 ,$116.60 ,$147.37 ,$121.46 
Carle BroMenn Medical Center,8980636,ropivacaine (PF) 10 mg/mL (1 %) injection solution,63323028811,J2795,636,$82.67 ,$82.67 ,$24.80 ,$75.23 ,$57.87 ,$24.80 ,$53.74 ,$59.52 ,$75.23 ,$62.00 
Carle BroMenn Medical Center,8980636,ropivacaine (PF) 10 mg/mL (1 %) injection solution,63323028821,J2795,636,$161.94 ,$161.94 ,$48.58 ,$147.37 ,$113.36 ,$48.58 ,$105.26 ,$116.60 ,$147.37 ,$121.46 
Carle BroMenn Medical Center,8980636,ropivacaine (PF) 2 mg/mL (0.2 %) Injection,25021067182,J2795,636,$273.45 ,$273.45 ,$82.04 ,$248.84 ,$191.42 ,$82.04 ,$177.74 ,$196.88 ,$248.84 ,$205.09 
Carle BroMenn Medical Center,8980636,ropivacaine (PF) 2 mg/mL (0.2 %) injection solution,143926301,J2795,636,$64.28 ,$64.28 ,$19.28 ,$58.49 ,$45.00 ,$19.28 ,$41.78 ,$46.28 ,$58.49 ,$48.21 
Carle BroMenn Medical Center,8980636,ropivacaine (PF) 2 mg/mL (0.2 %) injection solution,409930020,J2795,636,$27.94 ,$27.94 ,$8.38 ,$25.43 ,$19.56 ,$8.38 ,$18.16 ,$20.12 ,$25.43 ,$20.96 
Carle BroMenn Medical Center,8980636,ropivacaine (PF) 2 mg/mL (0.2 %) injection solution,409930021,J2795,636,$27.94 ,$27.94 ,$8.38 ,$25.43 ,$19.56 ,$8.38 ,$18.16 ,$20.12 ,$25.43 ,$20.96 
Carle BroMenn Medical Center,8980636,ropivacaine (PF) 2 mg/mL (0.2 %) injection solution,25021067182,J2795,636,$273.45 ,$273.45 ,$82.04 ,$248.84 ,$191.42 ,$82.04 ,$177.74 ,$196.88 ,$248.84 ,$205.09 
Carle BroMenn Medical Center,8980636,ropivacaine (PF) 2 mg/mL (0.2 %) injection solution,43066001501,J2795,636,$38.42 ,$38.42 ,$11.53 ,$34.96 ,$26.89 ,$11.53 ,$24.97 ,$27.66 ,$34.96 ,$28.82 
Carle BroMenn Medical Center,8980636,ropivacaine (PF) 2 mg/mL (0.2 %) injection solution,43066001510,J2795,636,$38.42 ,$38.42 ,$11.53 ,$34.96 ,$26.89 ,$11.53 ,$24.97 ,$27.66 ,$34.96 ,$28.82 
Carle BroMenn Medical Center,8980636,ropivacaine (PF) 2 mg/mL (0.2 %) injection solution,63323028502,J2795,636,$273.45 ,$273.45 ,$82.04 ,$248.84 ,$191.42 ,$82.04 ,$177.74 ,$196.88 ,$248.84 ,$205.09 
Carle BroMenn Medical Center,8980636,ropivacaine (PF) 2 mg/mL (0.2 %) injection solution,63323028523,J2795,636,$71.03 ,$71.03 ,$21.31 ,$64.64 ,$49.72 ,$21.31 ,$46.17 ,$51.14 ,$64.64 ,$53.27 
Carle BroMenn Medical Center,8980636,ropivacaine (PF) 2 mg/mL (0.2 %) injection solution,63323028557,J2795,636,$571.43 ,$571.43 ,$171.43 ,$520.00 ,$400.00 ,$171.43 ,$371.43 ,$411.43 ,$520.00 ,$428.57 
Carle BroMenn Medical Center,8980636,ropivacaine (PF) 2 mg/mL (0.2 %) injection solution,63323028564,J2795,636,$571.43 ,$571.43 ,$171.43 ,$520.00 ,$400.00 ,$171.43 ,$371.43 ,$411.43 ,$520.00 ,$428.57 
Carle BroMenn Medical Center,8980636,ropivacaine (PF) 5 mg/mL (0.5 %) injection solution,43066002301,J2795,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,ropivacaine (PF) 5 mg/mL (0.5 %) injection solution,43066002310,J2795,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,ropivacaine (PF) 5 mg/mL (0.5 %) injection solution,63323028623,J2795,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,ropivacaine (PF) 5 mg/mL (0.5 %) injection solution,63323028635,J2795,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,ropivacaine (PF) 5 mg/mL (0.5 %) injection solution,63323028638,J2795,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,ropivacaine (PF) 5 mg/mL (0.5 %) injection solution,63323028643,J2795,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,sargramostim 250 mcg solution for injection,71837584305,J2820,636,"$1,336.98 ","$1,336.98 ",$401.09 ,"$1,216.65 ",$935.89 ,$401.09 ,$869.04 ,$962.63 ,"$1,216.65 ","$1,002.74 "
Carle BroMenn Medical Center,8980636,sildenafiL (pulmonary hypertension) 20 mg tablet,93551798,J3490,636,$85.32 ,$85.32 ,$25.60 ,$77.64 ,$59.72 ,$25.60 ,$55.46 ,$61.43 ,$77.64 ,$63.99 
Carle BroMenn Medical Center,8980636,sildenafiL (pulmonary hypertension) 20 mg tablet,31722077690,J3490,636,$78.16 ,$78.16 ,$23.45 ,$71.13 ,$54.71 ,$23.45 ,$50.80 ,$56.28 ,$71.13 ,$58.62 
Carle BroMenn Medical Center,8980636,sildenafiL (pulmonary hypertension) 20 mg tablet,65862068890,J3490,636,$81.90 ,$81.90 ,$24.57 ,$74.53 ,$57.33 ,$24.57 ,$53.24 ,$58.97 ,$74.53 ,$61.43 
Carle BroMenn Medical Center,8980636,siltuximab 100 mg intravenous solution,57894042001,J2860,636,"$5,102.43 ","$5,102.43 ","$1,530.73 ","$4,643.21 ","$3,571.70 ","$1,530.73 ","$3,316.58 ","$3,673.75 ","$4,643.21 ","$3,826.82 "
Carle BroMenn Medical Center,8980636,sincalide 5 mcg solution for injection,270055615,J2805,636,$629.81 ,$629.81 ,$188.94 ,$573.13 ,$440.87 ,$188.94 ,$409.38 ,$453.46 ,$573.13 ,$472.36 
Carle BroMenn Medical Center,8980636,sodium chloride 0.45 % intravenous solution,264780200,J7040,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,sodium chloride 0.45 % intravenous solution,990798509,J7040,636,$453.97 ,$453.97 ,$136.19 ,$413.11 ,$317.78 ,$136.19 ,$295.08 ,$326.86 ,$413.11 ,$340.48 
Carle BroMenn Medical Center,8980636,sodium chloride 0.9 % injection solution,409488802,J7040,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,sodium chloride 0.9 % injection solution,409488803,J7040,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,sodium chloride 0.9 % injection solution,409488810,J7040,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,sodium chloride 0.9 % injection solution,409488820,J7040,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,sodium chloride 0.9 % injection solution,63323018601,J7040,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,sodium chloride 0.9 % injection solution,63323018604,J7040,636,$67.65 ,$67.65 ,$20.30 ,$61.56 ,$47.36 ,$20.30 ,$43.97 ,$48.71 ,$61.56 ,$50.74 
Carle BroMenn Medical Center,8980636,sodium chloride 0.9 % injection solution,63323018610,J7040,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,sodium chloride 0.9 % injection solution,63323018620,J7040,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,sodium chloride 0.9 % intravenous piggyback,338915930,J7050,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,sodium chloride 0.9 % intravenous solution,264180031,J7040,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,sodium chloride 0.9 % intravenous solution,264180032,J7030,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,sodium chloride 0.9 % intravenous solution,264780009,J7030,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,sodium chloride 0.9 % intravenous solution,264780010,J7040,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,sodium chloride 0.9 % intravenous solution,264780020,J7050,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,sodium chloride 0.9 % intravenous solution,338004902,J7050,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,sodium chloride 0.9 % intravenous solution,990798302,J7050,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,sodium chloride 0.9 % intravenous solution,990798303,J7040,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,sodium chloride 0.9 % intravenous solution,990798309,J7030,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,sodium chloride 0.9 % intravenous solution,990798413,J7040,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,sodium chloride 0.9 % intravenous solution,990798423,J7030,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,sodium chloride 0.9 % intravenous solution,990798437,J7030,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,sodium chloride 0.9 % intravenous solution,63323062374,J7050,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,sodium chloride 0.9 % IV,264180031,J7040,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,sodium chloride 0.9 % IV,264180032,J7030,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,sodium chloride 0.9 % IV,264780009,J7030,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,sodium chloride 0.9 % IV,264780010,J7040,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,sodium chloride 0.9 % IV,264780020,J7050,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,sodium chloride 0.9 % IV,990798309,J7030,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,sodium hyaluronate (viscosup) 10 mg/mL Intra-articul,89130444401,J7321,636,"$1,118.42 ","$1,118.42 ",$335.53 ,"$1,017.76 ",$782.89 ,$335.53 ,$726.97 ,$805.26 ,"$1,017.76 ",$838.82 
Carle BroMenn Medical Center,8980636,sodium hyaluronate 10 mg/mL intra-articular syringe,89122072420,J7321,636,$920.14 ,$920.14 ,$276.04 ,$837.33 ,$644.10 ,$276.04 ,$598.09 ,$662.50 ,$837.33 ,$690.11 
Carle BroMenn Medical Center,8980636,sodium hyaluronate 30 mg/2 mL intra-articular syringe,59676036001,J7324,636,"$2,129.74 ","$2,129.74 ",$638.92 ,"$1,938.06 ","$1,490.82 ",$638.92 ,"$1,384.33 ","$1,533.41 ","$1,938.06 ","$1,597.31 "
Carle BroMenn Medical Center,8980636,sodium thiosulfate 12.5 gram/50 mL (250 mg/mL) intravenous solution,60267070550,J3490,636,$626.14 ,$626.14 ,$187.84 ,$569.79 ,$438.30 ,$187.84 ,$406.99 ,$450.82 ,$569.79 ,$469.61 
Carle BroMenn Medical Center,8980636,succinylcholine chloride 20 mg/mL injection solution,69918070001,J0330,636,$76.03 ,$76.03 ,$22.81 ,$69.19 ,$53.22 ,$22.81 ,$49.42 ,$54.74 ,$69.19 ,$57.02 
Carle BroMenn Medical Center,8980636,succinylcholine chloride 20 mg/mL injection solution,69918070025,J0330,636,$76.03 ,$76.03 ,$22.81 ,$69.19 ,$53.22 ,$22.81 ,$49.42 ,$54.74 ,$69.19 ,$57.02 
Carle BroMenn Medical Center,8980636,SUMAtriptan 6 mg/0.5 mL subcutaneous solution,143963805,J3030,636,$171.54 ,$171.54 ,$51.46 ,$156.10 ,$120.08 ,$51.46 ,$111.50 ,$123.51 ,$156.10 ,$128.66 
Carle BroMenn Medical Center,8980636,SUMAtriptan 6 mg/0.5 mL subcutaneous solution,55150017301,J3030,636,$419.64 ,$419.64 ,$125.89 ,$381.87 ,$293.75 ,$125.89 ,$272.77 ,$302.14 ,$381.87 ,$314.73 
Carle BroMenn Medical Center,8980636,SUMAtriptan 6 mg/0.5 mL subcutaneous solution,63323027301,J3030,636,$336.52 ,$336.52 ,$100.96 ,$306.23 ,$235.56 ,$100.96 ,$218.74 ,$242.29 ,$306.23 ,$252.39 
Carle BroMenn Medical Center,8980636,SUMAtriptan 6 mg/0.5 mL subcutaneous solution,64679072801,J3030,636,$419.64 ,$419.64 ,$125.89 ,$381.87 ,$293.75 ,$125.89 ,$272.77 ,$302.14 ,$381.87 ,$314.73 
Carle BroMenn Medical Center,8980636,SUMAtriptan 6 mg/0.5 mL subcutaneous solution,64679072808,J3030,636,$419.64 ,$419.64 ,$125.89 ,$381.87 ,$293.75 ,$125.89 ,$272.77 ,$302.14 ,$381.87 ,$314.73 
Carle BroMenn Medical Center,8980636,"tacrolimus 0.5 mg capsule, immediate-release",68084044901,J7507,636,$12.72 ,$12.72 ,$3.82 ,$11.58 ,$8.90 ,$3.82 ,$8.27 ,$9.16 ,$11.58 ,$9.54 
Carle BroMenn Medical Center,8980636,"tacrolimus 0.5 mg capsule, immediate-release",68084044911,J7507,636,$12.72 ,$12.72 ,$3.82 ,$11.58 ,$8.90 ,$3.82 ,$8.27 ,$9.16 ,$11.58 ,$9.54 
Carle BroMenn Medical Center,8980636,"tacrolimus 1 mg capsule, immediate-release",51079081801,J7507,636,$23.11 ,$23.11 ,$6.93 ,$21.03 ,$16.18 ,$6.93 ,$15.02 ,$16.64 ,$21.03 ,$17.33 
Carle BroMenn Medical Center,8980636,"tacrolimus 1 mg capsule, immediate-release",51079081820,J7507,636,$23.11 ,$23.11 ,$6.93 ,$21.03 ,$16.18 ,$6.93 ,$15.02 ,$16.64 ,$21.03 ,$17.33 
Carle BroMenn Medical Center,8980636,"tacrolimus 1 mg capsule, immediate-release",68084045001,J7507,636,$23.11 ,$23.11 ,$6.93 ,$21.03 ,$16.18 ,$6.93 ,$15.02 ,$16.64 ,$21.03 ,$17.33 
Carle BroMenn Medical Center,8980636,"tacrolimus 1 mg capsule, immediate-release",68084045011,J7507,636,$23.11 ,$23.11 ,$6.93 ,$21.03 ,$16.18 ,$6.93 ,$15.02 ,$16.64 ,$21.03 ,$17.33 
Carle BroMenn Medical Center,8980636,tamoxifen 10 mg tablet,63739026910,J8999,636,$9.32 ,$9.32 ,$2.80 ,$8.48 ,$6.52 ,$2.80 ,$6.06 ,$6.71 ,$8.48 ,$6.99 
Carle BroMenn Medical Center,8980636,tenecteplase 50 mg intravenous solution,50242012047,J3101,636,"$13,703.45 ","$13,703.45 ","$4,111.04 ","$12,470.14 ","$9,592.42 ","$4,111.04 ","$8,907.24 ","$9,866.48 ","$12,470.14 ","$10,277.59 "
Carle BroMenn Medical Center,8980636,terbutaline 1 mg/mL subcutaneous solution,143974601,J3105,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,terbutaline 1 mg/mL subcutaneous solution,143974610,J3105,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,tetanus and diphtheria tox (PF) 5 Lf unit-2 Lf unit/0.5 mL IM syringe,49281021515,90714,636,$79.84 ,$79.84 ,$23.95 ,$72.65 ,$55.89 ,$23.95 ,$51.90 ,$57.48 ,$72.65 ,$59.88 
Carle BroMenn Medical Center,8980636,tetanus immune globulin (PF) 250 unit intramuscular syringe,13533063402,,636,"$1,299.77 ","$1,299.77 ",$389.93 ,"$1,182.79 ",$909.84 ,$389.93 ,$844.85 ,$935.83 ,"$1,182.79 ",$974.83 
Carle BroMenn Medical Center,8980636,thiamine HCl (vitamin B1) 100 mg/mL injection solution,641622801,J3411,636,$104.44 ,$104.44 ,$31.33 ,$95.04 ,$73.11 ,$31.33 ,$67.89 ,$75.20 ,$95.04 ,$78.33 
Carle BroMenn Medical Center,8980636,thiamine HCl (vitamin B1) 100 mg/mL injection solution,641622825,J3411,636,$104.44 ,$104.44 ,$31.33 ,$95.04 ,$73.11 ,$31.33 ,$67.89 ,$75.20 ,$95.04 ,$78.33 
Carle BroMenn Medical Center,8980636,thiamine HCl (vitamin B1) 100 mg/mL injection solution,25021050002,J3411,636,$104.44 ,$104.44 ,$31.33 ,$95.04 ,$73.11 ,$31.33 ,$67.89 ,$75.20 ,$95.04 ,$78.33 
Carle BroMenn Medical Center,8980636,thiamine HCl (vitamin B1) 100 mg/mL injection solution,63323001302,J3411,636,$104.44 ,$104.44 ,$31.33 ,$95.04 ,$73.11 ,$31.33 ,$67.89 ,$75.20 ,$95.04 ,$78.33 
Carle BroMenn Medical Center,8980636,thiamine HCl (vitamin B1) 100 mg/mL injection solution,67457019600,J3411,636,$97.04 ,$97.04 ,$29.11 ,$88.31 ,$67.93 ,$29.11 ,$63.08 ,$69.87 ,$88.31 ,$72.78 
Carle BroMenn Medical Center,8980636,thiamine HCl (vitamin B1) 100 mg/mL injection solution,67457019602,J3411,636,$97.04 ,$97.04 ,$29.11 ,$88.31 ,$67.93 ,$29.11 ,$63.08 ,$69.87 ,$88.31 ,$72.78 
Carle BroMenn Medical Center,8980636,tigecycline 50 mg intravenous solution,781348192,J3243,636,$793.36 ,$793.36 ,$238.01 ,$721.96 ,$555.35 ,$238.01 ,$515.68 ,$571.22 ,$721.96 ,$595.02 
Carle BroMenn Medical Center,8980636,tigecycline 50 mg intravenous solution,16729036403,J3243,636,$851.62 ,$851.62 ,$255.49 ,$774.97 ,$596.13 ,$255.49 ,$553.55 ,$613.17 ,$774.97 ,$638.72 
Carle BroMenn Medical Center,8980636,tigecycline 50 mg intravenous solution,16729036468,J3243,636,$851.62 ,$851.62 ,$255.49 ,$774.97 ,$596.13 ,$255.49 ,$553.55 ,$613.17 ,$774.97 ,$638.72 
Carle BroMenn Medical Center,8980636,tirofiban 12.5 mg/250 mL (50 mcg/mL)-0.9 % sodium chloride intravenous,25208000202,J3246,636,"$1,742.13 ","$1,742.13 ",$522.64 ,"$1,585.34 ","$1,219.49 ",$522.64 ,"$1,132.38 ","$1,254.33 ","$1,585.34 ","$1,306.60 "
Carle BroMenn Medical Center,8980636,tobramycin 1.2 gram solution for injection,39822041206,J3260,636,$500.95 ,$500.95 ,$150.29 ,$455.86 ,$350.67 ,$150.29 ,$325.62 ,$360.68 ,$455.86 ,$375.71 
Carle BroMenn Medical Center,8980636,tobramycin 300 mg/5 mL in 0.225 % sodium chloride for nebulization,68180096256,J7682,636,$156.57 ,$156.57 ,$46.97 ,$142.48 ,$109.60 ,$46.97 ,$101.77 ,$112.73 ,$142.48 ,$117.43 
Carle BroMenn Medical Center,8980636,tobramycin 40 mg/mL injection solution,36000024201,J3260,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,tobramycin 40 mg/mL injection solution,63323030630,J3260,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,tobramycin 40 mg/mL injection solution,67457047322,J3260,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,tocilizumab 200 mg/10 mL (20 mg/mL) intravenous solution,50242013601,J3262,636,"$6,511.09 ","$6,511.09 ","$1,953.33 ","$5,925.09 ","$4,557.76 ","$1,953.33 ","$4,232.21 ","$4,687.98 ","$5,925.09 ","$4,883.32 "
Carle BroMenn Medical Center,8980636,tocilizumab 400 mg/20 mL (20 mg/mL) intravenous solution,50242013701,J3262,636,"$12,958.10 ","$12,958.10 ","$3,887.43 ","$11,791.87 ","$9,070.67 ","$3,887.43 ","$8,422.77 ","$9,329.83 ","$11,791.87 ","$9,718.58 "
Carle BroMenn Medical Center,8980636,tolvaptan 15 mg tablet,59148002050,J8499,636,"$2,192.98 ","$2,192.98 ",$657.89 ,"$1,995.61 ","$1,535.09 ",$657.89 ,"$1,425.44 ","$1,578.95 ","$1,995.61 ","$1,644.74 "
Carle BroMenn Medical Center,8980636,tolvaptan 15 mg tablet,60505470400,J8499,636,"$1,984.90 ","$1,984.90 ",$595.47 ,"$1,806.26 ","$1,389.43 ",$595.47 ,"$1,290.19 ","$1,429.13 ","$1,806.26 ","$1,488.68 "
Carle BroMenn Medical Center,8980636,tolvaptan 15 mg tablet,60505470402,J8499,636,"$1,984.90 ","$1,984.90 ",$595.47 ,"$1,806.26 ","$1,389.43 ",$595.47 ,"$1,290.19 ","$1,429.13 ","$1,806.26 ","$1,488.68 "
Carle BroMenn Medical Center,8980636,tolvaptan 30 mg tablet,67877063602,J8499,636,"$1,919.33 ","$1,919.33 ",$575.80 ,"$1,746.59 ","$1,343.53 ",$575.80 ,"$1,247.56 ","$1,381.92 ","$1,746.59 ","$1,439.50 "
Carle BroMenn Medical Center,8980636,trastuzumab 150 mg intravenous solution,50242013201,J9355,636,"$6,720.09 ","$6,720.09 ","$2,016.03 ","$6,115.28 ","$4,704.06 ","$2,016.03 ","$4,368.06 ","$4,838.46 ","$6,115.28 ","$5,040.07 "
Carle BroMenn Medical Center,8980636,triamcinolone acetonide 10 mg/mL suspension for injection,3049420,J3301,636,$87.85 ,$87.85 ,$26.36 ,$79.94 ,$61.50 ,$26.36 ,$57.10 ,$63.25 ,$79.94 ,$65.89 
Carle BroMenn Medical Center,8980636,triamcinolone acetonide 40 mg/mL suspension for injection,70121104901,J3301,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,triamcinolone acetonide 40 mg/mL suspension for injection,70121104905,J3301,636,$44.27 ,$44.27 ,$13.28 ,$40.29 ,$30.99 ,$13.28 ,$28.78 ,$31.87 ,$40.29 ,$33.20 
Carle BroMenn Medical Center,8980636,trimethobenzamide 100 mg/mL intramuscular solution,42023011925,J3250,636,$314.05 ,$314.05 ,$94.22 ,$285.79 ,$219.84 ,$94.22 ,$204.13 ,$226.12 ,$285.79 ,$235.54 
Carle BroMenn Medical Center,8980636,tuberculin PPD 5 tub. unit/0.1 mL intradermal injection solution,42023010401,86580,636,$19.76 ,$19.76 ,$5.93 ,$17.98 ,$13.83 ,$5.93 ,$12.84 ,$14.23 ,$17.98 ,$14.82 
Carle BroMenn Medical Center,8980636,tuberculin PPD 5 tub. unit/0.1 mL intradermal injection solution,49281075221,86580,636,$19.96 ,$19.96 ,$5.99 ,$18.16 ,$13.97 ,$5.99 ,$12.97 ,$14.37 ,$18.16 ,$14.97 
Carle BroMenn Medical Center,8980636,ustekinumab 130 mg/26 mL intravenous solution,57894005427,,636,"$9,900.20 ","$9,900.20 ","$2,970.06 ","$9,009.18 ","$6,930.14 ","$2,970.06 ","$6,435.13 ","$7,128.14 ","$9,009.18 ","$7,425.15 "
Carle BroMenn Medical Center,8980636,"vancomycin 1,000 mg intravenous injection",63323028401,J3370,636,$146.00 ,$146.00 ,$43.80 ,$132.86 ,$102.20 ,$43.80 ,$94.90 ,$105.12 ,$132.86 ,$109.50 
Carle BroMenn Medical Center,8980636,"vancomycin 1,000 mg intravenous injection",63323028420,J3370,636,$146.00 ,$146.00 ,$43.80 ,$132.86 ,$102.20 ,$43.80 ,$94.90 ,$105.12 ,$132.86 ,$109.50 
Carle BroMenn Medical Center,8980636,"vancomycin 1,000 mg intravenous injection",67457034000,J3370,636,$146.97 ,$146.97 ,$44.09 ,$133.74 ,$102.88 ,$44.09 ,$95.53 ,$105.82 ,$133.74 ,$110.23 
Carle BroMenn Medical Center,8980636,"vancomycin 1,000 mg intravenous injection",67457034001,J3370,636,$146.97 ,$146.97 ,$44.09 ,$133.74 ,$102.88 ,$44.09 ,$95.53 ,$105.82 ,$133.74 ,$110.23 
Carle BroMenn Medical Center,8980636,"vancomycin 1,000 mg intravenous injection",72611076501,J3370,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,"vancomycin 1,000 mg intravenous injection",72611076510,J3370,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,vancomycin 10 gram intravenous solution,25021015899,J3370,636,$91.75 ,$91.75 ,$27.53 ,$83.49 ,$64.23 ,$27.53 ,$59.64 ,$66.06 ,$83.49 ,$68.81 
Carle BroMenn Medical Center,8980636,vancomycin 10 gram intravenous solution,63323031461,J3370,636,$123.49 ,$123.49 ,$37.05 ,$112.38 ,$86.44 ,$37.05 ,$80.27 ,$88.91 ,$112.38 ,$92.62 
Carle BroMenn Medical Center,8980636,vancomycin 10 gram intravenous solution,63323031466,J3370,636,$152.69 ,$152.69 ,$45.81 ,$138.95 ,$106.88 ,$45.81 ,$99.25 ,$109.94 ,$138.95 ,$114.52 
Carle BroMenn Medical Center,8980636,vancomycin 500 mg intravenous solution,63323022116,J3370,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,vancomycin 500 mg intravenous solution,63323022141,J3370,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,vancomycin 500 mg intravenous solution,63323022148,J3370,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,vancomycin 500 mg intravenous solution,72611076101,J3370,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,vancomycin 500 mg intravenous solution,72611076110,J3370,636,$87.36 ,$87.36 ,$26.21 ,$79.50 ,$61.15 ,$26.21 ,$56.78 ,$62.90 ,$79.50 ,$65.52 
Carle BroMenn Medical Center,8980636,vancomycin 750 mg intravenous solution,63323020301,J3370,636,$101.30 ,$101.30 ,$30.39 ,$92.18 ,$70.91 ,$30.39 ,$65.85 ,$72.94 ,$92.18 ,$75.98 
Carle BroMenn Medical Center,8980636,vancomycin 750 mg intravenous solution,63323020320,J3370,636,$101.30 ,$101.30 ,$30.39 ,$92.18 ,$70.91 ,$30.39 ,$65.85 ,$72.94 ,$92.18 ,$75.98 
Carle BroMenn Medical Center,8980636,vedolizumab 300 mg intravenous solution,64764030020,,636,"$25,497.36 ","$25,497.36 ","$7,649.21 ","$23,202.60 ","$17,848.15 ","$7,649.21 ","$16,573.28 ","$18,358.10 ","$23,202.60 ","$19,123.02 "
Carle BroMenn Medical Center,8980636,vinCRIStine 2 mg/2 mL intravenous solution,61703030916,J9370,636,$145.61 ,$145.61 ,$43.68 ,$132.51 ,$101.93 ,$43.68 ,$94.65 ,$104.84 ,$132.51 ,$109.21 
Carle BroMenn Medical Center,8980636,voriconazole 200 mg intravenous solution,49319028,J3465,636,$902.54 ,$902.54 ,$270.76 ,$821.31 ,$631.78 ,$270.76 ,$586.65 ,$649.83 ,$821.31 ,$676.91 
Carle BroMenn Medical Center,8980636,voriconazole 200 mg intravenous solution,39822107701,J3465,636,$297.07 ,$297.07 ,$89.12 ,$270.33 ,$207.95 ,$89.12 ,$193.10 ,$213.89 ,$270.33 ,$222.80 
Carle BroMenn Medical Center,8980636,voriconazole 200 mg intravenous solution,47781046671,J3465,636,$775.09 ,$775.09 ,$232.53 ,$705.33 ,$542.56 ,$232.53 ,$503.81 ,$558.06 ,$705.33 ,$581.32 
Carle BroMenn Medical Center,8980636,voriconazole 200 mg intravenous solution,65219019030,J3465,636,$399.59 ,$399.59 ,$119.88 ,$363.63 ,$279.71 ,$119.88 ,$259.73 ,$287.70 ,$363.63 ,$299.69 
Carle BroMenn Medical Center,8980636,zidovudine 10 mg/mL intravenous solution,49702021326,J3485,636,$238.77 ,$238.77 ,$71.63 ,$217.28 ,$167.14 ,$71.63 ,$155.20 ,$171.91 ,$217.28 ,$179.08 
Carle BroMenn Medical Center,8980636,ziprasidone 20 mg/mL (final concentration) intramuscular solution,49392083,J3486,636,$343.04 ,$343.04 ,$102.91 ,$312.17 ,$240.13 ,$102.91 ,$222.98 ,$246.99 ,$312.17 ,$257.28 
Carle BroMenn Medical Center,8980636,ziprasidone 20 mg/mL (final concentration) intramuscular solution,43598084811,J3486,636,$300.15 ,$300.15 ,$90.05 ,$273.14 ,$210.11 ,$90.05 ,$195.10 ,$216.11 ,$273.14 ,$225.11 
Carle BroMenn Medical Center,8980636,ziprasidone 20 mg/mL (final concentration) intramuscular solution,43598084858,J3486,636,$300.15 ,$300.15 ,$90.05 ,$273.14 ,$210.11 ,$90.05 ,$195.10 ,$216.11 ,$273.14 ,$225.11 
Carle BroMenn Medical Center,8980636,ziprasidone 20 mg/mL (final concentration) intramuscular solution,72266016001,J3486,636,$220.69 ,$220.69 ,$66.21 ,$200.83 ,$154.48 ,$66.21 ,$143.45 ,$158.90 ,$200.83 ,$165.52 
Carle BroMenn Medical Center,8980636,ziprasidone 20 mg/mL (final concentration) intramuscular solution,72266016010,J3486,636,$220.69 ,$220.69 ,$66.21 ,$200.83 ,$154.48 ,$66.21 ,$143.45 ,$158.90 ,$200.83 ,$165.52 
Carle BroMenn Medical Center,8980636,zoledronic acid 4 mg/5 mL intravenous solution,409421501,J3489,636,$343.76 ,$343.76 ,$103.13 ,$312.82 ,$240.63 ,$103.13 ,$223.44 ,$247.51 ,$312.82 ,$257.82 
Carle BroMenn Medical Center,8980636,zoledronic acid 4 mg/5 mL intravenous solution,54288010001,J3489,636,$296.85 ,$296.85 ,$89.06 ,$270.13 ,$207.80 ,$89.06 ,$192.95 ,$213.73 ,$270.13 ,$222.64 
Carle BroMenn Medical Center,8980636,zoledronic acid 5 mg/100 mL in mannitoL 5 %-water intravenous piggybck,409422801,J3489,636,"$1,582.95 ","$1,582.95 ",$474.89 ,"$1,440.48 ","$1,108.07 ",$474.89 ,"$1,028.92 ","$1,139.72 ","$1,440.48 ","$1,187.21 "
Carle BroMenn Medical Center,8980636,zoledronic acid 5 mg/100 mL in mannitoL 5 %-water intravenous piggybck,25021083082,J3489,636,"$2,447.80 ","$2,447.80 ",$734.34 ,"$2,227.50 ","$1,713.46 ",$734.34 ,"$1,591.07 ","$1,762.42 ","$2,227.50 ","$1,835.85 "
Carle BroMenn Medical Center,8980636,zoledronic acid 5 mg/100 mL in mannitoL 5 %-water intravenous piggybck,55111068852,J3489,636,"$2,098.60 ","$2,098.60 ",$629.58 ,"$1,909.73 ","$1,469.02 ",$629.58 ,"$1,364.09 ","$1,510.99 ","$1,909.73 ","$1,573.95 "
Carle BroMenn Medical Center,8980636,zoledronic acid 5 mg/100 mL in mannitoL 5 %-water intravenous piggybck,63323096600,J3489,636,"$2,098.60 ","$2,098.60 ",$629.58 ,"$1,909.73 ","$1,469.02 ",$629.58 ,"$1,364.09 ","$1,510.99 ","$1,909.73 ","$1,573.95 "
Carle BroMenn Medical Center,8980636,zoledronic acid 5 mg/100 mL in mannitoL 5 %-water intravenous piggybck,67457061910,J3489,636,"$1,644.64 ","$1,644.64 ",$493.39 ,"$1,496.62 ","$1,151.25 ",$493.39 ,"$1,069.02 ","$1,184.14 ","$1,496.62 ","$1,233.48 "
Carle BroMenn Medical Center,8980636,zoledronic acid 5 mg/100 mL in mannitoL 5 %-water intravenous piggybck,67457079410,J3489,636,$771.64 ,$771.64 ,$231.49 ,$702.19 ,$540.15 ,$231.49 ,$501.57 ,$555.58 ,$702.19 ,$578.73 
Carle BroMenn Medical Center,8980636,zoledronic acid 5 mg/100 mL in mannitoL 5 %-water intravenous piggybck,70860080282,J3489,636,$762.91 ,$762.91 ,$228.87 ,$694.25 ,$534.04 ,$228.87 ,$495.89 ,$549.30 ,$694.25 ,$572.18 
Carle BroMenn Medical Center,8980637,alvimopan 12 mg capsule,67919002010,,637,$771.88 ,$771.88 ,$231.56 ,$702.41 ,$540.32 ,$231.56 ,$501.72 ,$555.75 ,$702.41 ,$578.91 
Carle BroMenn Medical Center,8980637,apixaban 2.5 mg tablet,3089321,,637,$43.08 ,$43.08 ,$12.92 ,$39.20 ,$30.16 ,$12.92 ,$28.00 ,$31.02 ,$39.20 ,$32.31 
Carle BroMenn Medical Center,8980637,apixaban 2.5 mg tablet,3089331,,637,$43.09 ,$43.09 ,$12.93 ,$39.21 ,$30.16 ,$12.93 ,$28.01 ,$31.02 ,$39.21 ,$32.32 
Carle BroMenn Medical Center,8980637,apixaban 5 mg tablet,3089421,,637,$43.08 ,$43.08 ,$12.92 ,$39.20 ,$30.16 ,$12.92 ,$28.00 ,$31.02 ,$39.20 ,$32.31 
Carle BroMenn Medical Center,8980637,apixaban 5 mg tablet,3089431,,637,$43.09 ,$43.09 ,$12.93 ,$39.21 ,$30.16 ,$12.93 ,$28.01 ,$31.02 ,$39.21 ,$32.32 
Carle BroMenn Medical Center,8980637,atorvastatin 20 mg tablet,51079020901,,637,$4.78 ,$4.78 ,$1.43 ,$4.35 ,$3.35 ,$1.43 ,$3.11 ,$3.44 ,$4.35 ,$3.59 
Carle BroMenn Medical Center,8980637,atorvastatin 20 mg tablet,51079020920,,637,$4.78 ,$4.78 ,$1.43 ,$4.35 ,$3.35 ,$1.43 ,$3.11 ,$3.44 ,$4.35 ,$3.59 
Carle BroMenn Medical Center,8980637,atorvastatin 20 mg tablet,68084009801,,637,$6.32 ,$6.32 ,$1.90 ,$5.75 ,$4.42 ,$1.90 ,$4.11 ,$4.55 ,$5.75 ,$4.74 
Carle BroMenn Medical Center,8980637,atorvastatin 20 mg tablet,68084009811,,637,$6.32 ,$6.32 ,$1.90 ,$5.75 ,$4.42 ,$1.90 ,$4.11 ,$4.55 ,$5.75 ,$4.74 
Carle BroMenn Medical Center,8980637,caffeine citrate 60 mg/3 mL (20 mg/mL) oral solution,63323040601,J0706,637,$250.20 ,$250.20 ,$75.06 ,$227.68 ,$175.14 ,$75.06 ,$162.63 ,$180.14 ,$227.68 ,$187.65 
Carle BroMenn Medical Center,8980637,caffeine citrate 60 mg/3 mL (20 mg/mL) oral solution,63323040603,J0706,637,$250.20 ,$250.20 ,$75.06 ,$227.68 ,$175.14 ,$75.06 ,$162.63 ,$180.14 ,$227.68 ,$187.65 
Carle BroMenn Medical Center,8980637,dronedarone 400 mg tablet,24414210,,637,$54.24 ,$54.24 ,$16.27 ,$49.36 ,$37.97 ,$16.27 ,$35.26 ,$39.05 ,$49.36 ,$40.68 
Carle BroMenn Medical Center,8980637,dronedarone 400 mg tablet,24414260,,637,$56.54 ,$56.54 ,$16.96 ,$51.45 ,$39.58 ,$16.96 ,$36.75 ,$40.71 ,$51.45 ,$42.41 
Carle BroMenn Medical Center,8980637,escitalopram 20 mg tablet,904642761,,637,$23.63 ,$23.63 ,$7.09 ,$21.50 ,$16.54 ,$7.09 ,$15.36 ,$17.01 ,$21.50 ,$17.72 
Carle BroMenn Medical Center,8980637,escitalopram 20 mg tablet,68084061801,,637,$23.76 ,$23.76 ,$7.13 ,$21.62 ,$16.63 ,$7.13 ,$15.44 ,$17.11 ,$21.62 ,$17.82 
Carle BroMenn Medical Center,8980637,escitalopram 20 mg tablet,68084061811,,637,$23.76 ,$23.76 ,$7.13 ,$21.62 ,$16.63 ,$7.13 ,$15.44 ,$17.11 ,$21.62 ,$17.82 
Carle BroMenn Medical Center,8980637,fidaxomicin 200 mg tablet,52015008001,,637,$903.21 ,$903.21 ,$270.96 ,$821.92 ,$632.25 ,$270.96 ,$587.09 ,$650.31 ,$821.92 ,$677.41 
Carle BroMenn Medical Center,8980637,fingolimod 0.5 mg capsule,78060715,J8499,637,"$1,281.50 ","$1,281.50 ",$384.45 ,"$1,166.17 ",$897.05 ,$384.45 ,$832.98 ,$922.68 ,"$1,166.17 ",$961.13 
Carle BroMenn Medical Center,8980637,fingolimod 0.5 mg capsule,78060789,J8499,637,$824.52 ,$824.52 ,$247.36 ,$750.31 ,$577.16 ,$247.36 ,$535.94 ,$593.65 ,$750.31 ,$618.39 
Carle BroMenn Medical Center,8980637,fluorometholone 0.1 % eye ointment,23031604,,637,$768.42 ,$768.42 ,$230.53 ,$699.26 ,$537.89 ,$230.53 ,$499.47 ,$553.26 ,$699.26 ,$576.32 
Carle BroMenn Medical Center,8980637,fosfomycin tromethamine 3 gram oral packet,456430001,,637,$391.47 ,$391.47 ,$117.44 ,$356.24 ,$274.03 ,$117.44 ,$254.46 ,$281.86 ,$356.24 ,$293.60 
Carle BroMenn Medical Center,8980637,fosfomycin tromethamine 3 gram oral packet,70700026894,,637,$359.55 ,$359.55 ,$107.87 ,$327.19 ,$251.69 ,$107.87 ,$233.71 ,$258.88 ,$327.19 ,$269.66 
Carle BroMenn Medical Center,8980637,fosfomycin tromethamine 3 gram oral packet,70700026899,,637,$359.55 ,$359.55 ,$107.87 ,$327.19 ,$251.69 ,$107.87 ,$233.71 ,$258.88 ,$327.19 ,$269.66 
Carle BroMenn Medical Center,8980637,indomethacin 50 mg rectal suppository,69344010233,,637,"$1,457.15 ","$1,457.15 ",$437.15 ,"$1,326.01 ","$1,020.01 ",$437.15 ,$947.15 ,"$1,049.15 ","$1,326.01 ","$1,092.86 "
Carle BroMenn Medical Center,8980637,lacosamide 100 mg tablet,131247860,,637,$80.06 ,$80.06 ,$24.02 ,$72.85 ,$56.04 ,$24.02 ,$52.04 ,$57.64 ,$72.85 ,$60.05 
Carle BroMenn Medical Center,8980637,levETIRAcetam 250 mg tablet,68084085901,,637,$5.12 ,$5.12 ,$1.54 ,$4.66 ,$3.58 ,$1.54 ,$3.33 ,$3.69 ,$4.66 ,$3.84 
Carle BroMenn Medical Center,8980637,levETIRAcetam 250 mg tablet,68084085911,,637,$5.12 ,$5.12 ,$1.54 ,$4.66 ,$3.58 ,$1.54 ,$3.33 ,$3.69 ,$4.66 ,$3.84 
Carle BroMenn Medical Center,8980637,"lipase-protease-amylase 10,440-39,150-39,150 unit tablet",58914011210,,637,$20.33 ,$20.33 ,$6.10 ,$18.50 ,$14.23 ,$6.10 ,$13.21 ,$14.64 ,$18.50 ,$15.25 
Carle BroMenn Medical Center,8980637,"lipase-protease-amylase 36,000-114,000-180,000 unit capsule,delay rel",32301613,,637,$52.99 ,$52.99 ,$15.90 ,$48.22 ,$37.09 ,$15.90 ,$34.44 ,$38.15 ,$48.22 ,$39.74 
Carle BroMenn Medical Center,8980637,multivitamin with folic acid 400 mcg tablet,80681005000,,637,$0.59 ,$0.59 ,$0.18 ,$0.54 ,$0.41 ,$0.18 ,$0.38 ,$0.42 ,$0.54 ,$0.44 
Carle BroMenn Medical Center,8980637,oxybutynin chloride 5 mg/5 mL oral syrup,54838051080,,637,$10.13 ,$10.13 ,$3.04 ,$9.22 ,$7.09 ,$3.04 ,$6.58 ,$7.29 ,$9.22 ,$7.60 
Carle BroMenn Medical Center,8980637,QUEtiapine 100 mg tablet,904664061,,637,$4.96 ,$4.96 ,$1.49 ,$4.51 ,$3.47 ,$1.49 ,$3.22 ,$3.57 ,$4.51 ,$3.72 
Carle BroMenn Medical Center,8980637,QUEtiapine 100 mg tablet,68084053201,,637,$30.82 ,$30.82 ,$9.25 ,$28.05 ,$21.57 ,$9.25 ,$20.03 ,$22.19 ,$28.05 ,$23.12 
Carle BroMenn Medical Center,8980637,tiZANidine 2 mg tablet,29300016815,,637,$8.02 ,$8.02 ,$2.41 ,$7.30 ,$5.61 ,$2.41 ,$5.21 ,$5.77 ,$7.30 ,$6.02 
Carle BroMenn Medical Center,8980637,tiZANidine 2 mg tablet,55111017915,,637,$8.02 ,$8.02 ,$2.41 ,$7.30 ,$5.61 ,$2.41 ,$5.21 ,$5.77 ,$7.30 ,$6.02 
Carle BroMenn Medical Center,8980637,vilazodone 10 mg tablet,456111030,,637,$50.17 ,$50.17 ,$15.05 ,$45.65 ,$35.12 ,$15.05 ,$32.61 ,$36.12 ,$45.65 ,$37.63 
Carle BroMenn Medical Center,8980637,vilazodone 20 mg tablet,456112030,,637,$50.17 ,$50.17 ,$15.05 ,$45.65 ,$35.12 ,$15.05 ,$32.61 ,$36.12 ,$45.65 ,$37.63 
Carle BroMenn Medical Center,8980637,vilazodone 40 mg tablet,456114030,,637,$50.17 ,$50.17 ,$15.05 ,$45.65 ,$35.12 ,$15.05 ,$32.61 ,$36.12 ,$45.65 ,$37.63 
Carle BroMenn Medical Center,8819291,TRAUMA TEAM ACTIVATION CAT 1,,G0390,681,"$2,035.00 ","$2,035.00 ",$610.50 ,"$1,851.85 ","$1,424.50 ",$610.50 ,"$1,322.75 ","$1,465.20 ","$1,851.85 ","$1,526.25 "
Carle BroMenn Medical Center,8829291,TRAUMA TEAM ACTIVATION CAT 1 NO CRITICAL CARE,,,681,"$6,690.00 ","$6,690.00 ","$2,007.00 ","$6,087.90 ","$4,683.00 ","$2,007.00 ","$4,348.50 ","$4,816.80 ","$6,087.90 ","$5,017.50 "
Carle BroMenn Medical Center,8801231,TRAUMA TEAM ACTIVATION CAT 2 W/CRITICAL CARE,,G0390,682,"$2,035.00 ","$2,035.00 ",$610.50 ,"$1,851.85 ","$1,424.50 ",$610.50 ,"$1,322.75 ","$1,465.20 ","$1,851.85 ","$1,526.25 "
Carle BroMenn Medical Center,8801232,TRAUMA TEAM ACTIVATION CAT 2 W/O CRIT CARE,,,682,"$1,385.00 ","$1,385.00 ",$415.50 ,"$1,260.35 ",$969.50 ,$415.50 ,$900.25 ,$997.20 ,"$1,260.35 ","$1,038.75 "
Carle BroMenn Medical Center,8819285,TRAUMA TEAM ACTIVATION CAT 2,,,682,"$4,043.00 ","$4,043.00 ","$1,212.90 ","$3,679.13 ","$2,830.10 ","$1,212.90 ","$2,627.95 ","$2,910.96 ","$3,679.13 ","$3,032.25 "
Carle BroMenn Medical Center,8829284,TRAUMA TEAM ACTIVATION CAT 3,,,683,"$1,062.00 ","$1,062.00 ",$318.60 ,$966.42 ,$743.40 ,$318.60 ,$690.30 ,$764.64 ,$966.42 ,$796.50 
Carle BroMenn Medical Center,8015000,INTERMEDIATE CARE -PER HOUR,,,710,$19.00 ,$19.00 ,$5.70 ,$17.29 ,$13.30 ,$5.70 ,$12.35 ,$13.68 ,$17.29 ,$14.25 
Carle BroMenn Medical Center,8015007,INTERMEDIATE CARE HRLY -PAR,,,710,$20.00 ,$20.00 ,$6.00 ,$18.20 ,$14.00 ,$6.00 ,$13.00 ,$14.40 ,$18.20 ,$15.00 
Carle BroMenn Medical Center,8015008,RECOVERY FLOOR PATIENT CARE,,,710,$20.00 ,$20.00 ,$6.00 ,$18.20 ,$14.00 ,$6.00 ,$13.00 ,$14.40 ,$18.20 ,$15.00 
Carle BroMenn Medical Center,8015009,RECOVERY ICU SURCHARGE,,,710,$26.00 ,$26.00 ,$7.80 ,$23.66 ,$18.20 ,$7.80 ,$16.90 ,$18.72 ,$23.66 ,$19.50 
Carle BroMenn Medical Center,8015010,RECOVERY ICU II,,,710,$43.00 ,$43.00 ,$12.90 ,$39.13 ,$30.10 ,$12.90 ,$27.95 ,$30.96 ,$39.13 ,$32.25 
Carle BroMenn Medical Center,8015011,RECOVERY ICU III,,,710,$52.00 ,$52.00 ,$15.60 ,$47.32 ,$36.40 ,$15.60 ,$33.80 ,$37.44 ,$47.32 ,$39.00 
Carle BroMenn Medical Center,8027000,PREP/RECOVERY ROOM,,,710,$90.00 ,$90.00 ,$27.00 ,$81.90 ,$63.00 ,$27.00 ,$58.50 ,$64.80 ,$81.90 ,$67.50 
Carle BroMenn Medical Center,8027001,RECOVERY ROOM DELIVERY,,,710,$800.00 ,$800.00 ,$240.00 ,$728.00 ,$560.00 ,$240.00 ,$520.00 ,$576.00 ,$728.00 ,$600.00 
Carle BroMenn Medical Center,8027002,RECOVERY -POST OP,,,710,"$1,238.00 ","$1,238.00 ",$371.40 ,"$1,126.58 ",$866.60 ,$371.40 ,$804.70 ,$891.36 ,"$1,126.58 ",$928.50 
Carle BroMenn Medical Center,8100070,DASC BASE RECOVERY - PHASE 2,,,710,$563.00 ,$563.00 ,$168.90 ,$512.33 ,$394.10 ,$168.90 ,$365.95 ,$405.36 ,$512.33 ,$422.25 
Carle BroMenn Medical Center,8100071,DASC BASE RECOVERY ROOM - PHASE 1,,,710,"$1,155.00 ","$1,155.00 ",$346.50 ,"$1,051.05 ",$808.50 ,$346.50 ,$750.75 ,$831.60 ,"$1,051.05 ",$866.25 
Carle BroMenn Medical Center,8100170,DASC PER 15 MIN RECOVERY - PHASE 2,,,710,$79.00 ,$79.00 ,$23.70 ,$71.89 ,$55.30 ,$23.70 ,$51.35 ,$56.88 ,$71.89 ,$59.25 
Carle BroMenn Medical Center,8100171,DASC PER 15 MIN RECOVERY ROOM - PHASE 1,,,710,"$1,155.00 ","$1,155.00 ",$346.50 ,"$1,051.05 ",$808.50 ,$346.50 ,$750.75 ,$831.60 ,"$1,051.05 ",$866.25 
Carle BroMenn Medical Center,8120019,PHASE II EA ADD 30 MIN,,,710,$215.00 ,$215.00 ,$64.50 ,$195.65 ,$150.50 ,$64.50 ,$139.75 ,$154.80 ,$195.65 ,$161.25 
Carle BroMenn Medical Center,8120020,PHASE I RECOVERY FIRST 30 MIN,,,710,$515.00 ,$515.00 ,$154.50 ,$468.65 ,$360.50 ,$154.50 ,$334.75 ,$370.80 ,$468.65 ,$386.25 
Carle BroMenn Medical Center,8120021,PHASE I RECOVERY EA ADD 30 MIN,,,710,$235.00 ,$235.00 ,$70.50 ,$213.85 ,$164.50 ,$70.50 ,$152.75 ,$169.20 ,$213.85 ,$176.25 
Carle BroMenn Medical Center,8120022,PHASE II FIRST 30 MIN,,,710,$210.00 ,$210.00 ,$63.00 ,$191.10 ,$147.00 ,$63.00 ,$136.50 ,$151.20 ,$191.10 ,$157.50 
Carle BroMenn Medical Center,8120023,Phase I Recovery First 30 Min (8120023),,,710,$515.00 ,$515.00 ,$154.50 ,$468.65 ,$360.50 ,$154.50 ,$334.75 ,$370.80 ,$468.65 ,$386.25 
Carle BroMenn Medical Center,8120024,PHASE I RECOVERY EA ADD 30 MIN,,,710,$255.00 ,$255.00 ,$76.50 ,$232.05 ,$178.50 ,$76.50 ,$165.75 ,$183.60 ,$232.05 ,$191.25 
Carle BroMenn Medical Center,8120050,PACU BASE RECOVERY - PHASE 1,,,710,$425.00 ,$425.00 ,$127.50 ,$386.75 ,$297.50 ,$127.50 ,$276.25 ,$306.00 ,$386.75 ,$318.75 
Carle BroMenn Medical Center,8120053,DHC BASE RECOVERY - PHASE 1,,,710,$698.00 ,$698.00 ,$209.40 ,$635.18 ,$488.60 ,$209.40 ,$453.70 ,$502.56 ,$635.18 ,$523.50 
Carle BroMenn Medical Center,8120150,PACU PER 15 MIN RECOVERY - PHASE 1,,,710,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8120151,RECOVERY ODSC HOLD 15 MIN,,,710,$94.00 ,$94.00 ,$28.20 ,$85.54 ,$65.80 ,$28.20 ,$61.10 ,$67.68 ,$85.54 ,$70.50 
Carle BroMenn Medical Center,8120153,DHC PER 15 MIN RECOVER - PHASE 1,,,710,$180.00 ,$180.00 ,$54.00 ,$163.80 ,$126.00 ,$54.00 ,$117.00 ,$129.60 ,$163.80 ,$135.00 
Carle BroMenn Medical Center,8190050,DHC BASE RECOVERY - PHASE 2,,,710,$405.00 ,$405.00 ,$121.50 ,$368.55 ,$283.50 ,$121.50 ,$263.25 ,$291.60 ,$368.55 ,$303.75 
Carle BroMenn Medical Center,8190051,RECOVERY -EXTENDED,,,710,$8.00 ,$8.00 ,$2.40 ,$7.28 ,$5.60 ,$2.40 ,$5.20 ,$5.76 ,$7.28 ,$6.00 
Carle BroMenn Medical Center,8190052,ODSC BASE RECOVERY - PHASE 2,,,710,$653.00 ,$653.00 ,$195.90 ,$594.23 ,$457.10 ,$195.90 ,$424.45 ,$470.16 ,$594.23 ,$489.75 
Carle BroMenn Medical Center,8190055,PEDS BASE RECOVERY - PHASE 2,,,710,$653.00 ,$653.00 ,$195.90 ,$594.23 ,$457.10 ,$195.90 ,$424.45 ,$470.16 ,$594.23 ,$489.75 
Carle BroMenn Medical Center,8190150,DHC PER MIN RECOVERY - PHASE 2,,,710,$11.00 ,$11.00 ,$3.30 ,$10.01 ,$7.70 ,$3.30 ,$7.15 ,$7.92 ,$10.01 ,$8.25 
Carle BroMenn Medical Center,8190152,ODSC PER 15 MIN RECOVERY - PHASE 2,,,710,$94.00 ,$94.00 ,$28.20 ,$85.54 ,$65.80 ,$28.20 ,$61.10 ,$67.68 ,$85.54 ,$70.50 
Carle BroMenn Medical Center,8190155,PEDS PER 15 MIN RECOVERY - PHASE 2,,,710,$94.00 ,$94.00 ,$28.20 ,$85.54 ,$65.80 ,$28.20 ,$61.10 ,$67.68 ,$85.54 ,$70.50 
Carle BroMenn Medical Center,8190180,TREATMENT ROOM,,,710,$143.00 ,$143.00 ,$42.90 ,$130.13 ,$100.10 ,$42.90 ,$92.95 ,$102.96 ,$130.13 ,$107.25 
Carle BroMenn Medical Center,8029412,ANTEPARTUM MANIPULATION EXT. VERSION,,59412,720,"$2,120.00 ","$2,120.00 ",$636.00 ,"$1,929.20 ","$1,484.00 ",$636.00 ,"$1,378.00 ","$1,526.40 ","$1,929.20 ","$1,590.00 "
Carle BroMenn Medical Center,8027050,HIGH RISK,,,721,$460.00 ,$460.00 ,$138.00 ,$418.60 ,$322.00 ,$138.00 ,$299.00 ,$331.20 ,$418.60 ,$345.00 
Carle BroMenn Medical Center,8027051,INTERMEDIATE RISK,,,721,$248.00 ,$248.00 ,$74.40 ,$225.68 ,$173.60 ,$74.40 ,$161.20 ,$178.56 ,$225.68 ,$186.00 
Carle BroMenn Medical Center,8027052,LABOR ROOM,,G0463,721,$250.00 ,$250.00 ,$75.00 ,$227.50 ,$175.00 ,$75.00 ,$162.50 ,$180.00 ,$227.50 ,$187.50 
Carle BroMenn Medical Center,8027053,PV4 DELIVERY RM & ROUTINE SPLY,,,721,"$2,535.00 ","$2,535.00 ",$760.50 ,"$2,306.85 ","$1,774.50 ",$760.50 ,"$1,647.75 ","$1,825.20 ","$2,306.85 ","$1,901.25 "
Carle BroMenn Medical Center,8027054,PV4 HIGH RISK CARE,,,721,$326.00 ,$326.00 ,$97.80 ,$296.66 ,$228.20 ,$97.80 ,$211.90 ,$234.72 ,$296.66 ,$244.50 
Carle BroMenn Medical Center,8027056,LABOR ROOM 31-60 MINUTES,,G0463,721,$475.00 ,$475.00 ,$142.50 ,$432.25 ,$332.50 ,$142.50 ,$308.75 ,$342.00 ,$432.25 ,$356.25 
Carle BroMenn Medical Center,8027057,LABOR ROOM 1-2 HOURS,,G0463,721,$500.00 ,$500.00 ,$150.00 ,$455.00 ,$350.00 ,$150.00 ,$325.00 ,$360.00 ,$455.00 ,$375.00 
Carle BroMenn Medical Center,8027058,LABOR ROOM 2-4 HOURS,,G0463,721,$530.00 ,$530.00 ,$159.00 ,$482.30 ,$371.00 ,$159.00 ,$344.50 ,$381.60 ,$482.30 ,$397.50 
Carle BroMenn Medical Center,8027059,LABOR ROOM 4-6 HOURS,,G0463,721,$565.00 ,$565.00 ,$169.50 ,$514.15 ,$395.50 ,$169.50 ,$367.25 ,$406.80 ,$514.15 ,$423.75 
Carle BroMenn Medical Center,8027061,LABOR ROOM 6-8 HOURS,,G0463,721,$595.00 ,$595.00 ,$178.50 ,$541.45 ,$416.50 ,$178.50 ,$386.75 ,$428.40 ,$541.45 ,$446.25 
Carle BroMenn Medical Center,8027062,LABOR ROOM 8-10 HOURS,,G0463,721,$635.00 ,$635.00 ,$190.50 ,$577.85 ,$444.50 ,$190.50 ,$412.75 ,$457.20 ,$577.85 ,$476.25 
Carle BroMenn Medical Center,8027063,LABOR ROOM 10-14 HOURS,,G0463,721,$670.00 ,$670.00 ,$201.00 ,$609.70 ,$469.00 ,$201.00 ,$435.50 ,$482.40 ,$609.70 ,$502.50 
Carle BroMenn Medical Center,8027064,LABOR ROOM 14 + HOURS,,G0463,721,$750.00 ,$750.00 ,$225.00 ,$682.50 ,$525.00 ,$225.00 ,$487.50 ,$540.00 ,$682.50 ,$562.50 
Carle BroMenn Medical Center,8027060,CIRCUMCISION,,,723,$240.00 ,$240.00 ,$72.00 ,$218.40 ,$168.00 ,$72.00 ,$156.00 ,$172.80 ,$218.40 ,$180.00 
Carle BroMenn Medical Center,8027070,DELIVERY ROOM & ROUTINE SUPPL,,,724,"$1,500.00 ","$1,500.00 ",$450.00 ,"$1,365.00 ","$1,050.00 ",$450.00 ,$975.00 ,"$1,080.00 ","$1,365.00 ","$1,125.00 "
Carle BroMenn Medical Center,8293005,"ELECTROCARDIOGRAM, TRACING",,93005,730,$195.00 ,$195.00 ,$58.50 ,$177.45 ,$136.50 ,$58.50 ,$126.75 ,$140.40 ,$177.45 ,$146.25 
Carle BroMenn Medical Center,8293041,"RHYTHM ECG, TRACING",,93041,730,$235.00 ,$235.00 ,$70.50 ,$213.85 ,$164.50 ,$70.50 ,$152.75 ,$169.20 ,$213.85 ,$176.25 
Carle BroMenn Medical Center,8493005,ELECTROCARDIOGRAM TRACING ONLY,,93005,730,$195.00 ,$195.00 ,$58.50 ,$177.45 ,$136.50 ,$58.50 ,$126.75 ,$140.40 ,$177.45 ,$146.25 
Carle BroMenn Medical Center,8493041,RHYTHM ECG TRACING ONLY,,93041,730,$235.00 ,$235.00 ,$70.50 ,$213.85 ,$164.50 ,$70.50 ,$152.75 ,$169.20 ,$213.85 ,$176.25 
Carle BroMenn Medical Center,8493278,SIGNAL AVERAGED ECG,,93278,730,$505.00 ,$505.00 ,$151.50 ,$459.55 ,$353.50 ,$151.50 ,$328.25 ,$363.60 ,$459.55 ,$378.75 
Carle BroMenn Medical Center,8973024,ERGONOVINE PROVOCATION,,93024,730,$870.00 ,$870.00 ,$261.00 ,$791.70 ,$609.00 ,$261.00 ,$565.50 ,$626.40 ,$791.70 ,$652.50 
Carle BroMenn Medical Center,8293225,"EXT ECG RECORD CONTIN 48 HR, RECORD",,93225,731,$440.00 ,$440.00 ,$132.00 ,$400.40 ,$308.00 ,$132.00 ,$286.00 ,$316.80 ,$400.40 ,$330.00 
Carle BroMenn Medical Center,8293226,"EXT ECG RECORD CONTIN 48 HR, SCAN ANALYSIS W REPORT",,93226,731,$440.00 ,$440.00 ,$132.00 ,$400.40 ,$308.00 ,$132.00 ,$286.00 ,$316.80 ,$400.40 ,$330.00 
Carle BroMenn Medical Center,8293270,XTRNL PT ACTIV ECG TRANSMIS RECORDING </30 DAYS,,93270,731,$160.00 ,$160.00 ,$48.00 ,$145.60 ,$112.00 ,$48.00 ,$104.00 ,$115.20 ,$145.60 ,$120.00 
Carle BroMenn Medical Center,8293271,"EXT ECG,PT DEMAND EVENT, SYMPT MEMORY LOOP, TRANSMIT",,93271,731,"$1,630.00 ","$1,630.00 ",$489.00 ,"$1,483.30 ","$1,141.00 ",$489.00 ,"$1,059.50 ","$1,173.60 ","$1,483.30 ","$1,222.50 "
Carle BroMenn Medical Center,8493225,CARDIAC HOLTER 24 HR MNTR RCRDNG,,93225,731,$440.00 ,$440.00 ,$132.00 ,$400.40 ,$308.00 ,$132.00 ,$286.00 ,$316.80 ,$400.40 ,$330.00 
Carle BroMenn Medical Center,8493226,"EXT ECG RECORD CONTIN 48 HR, SCAN ANALYSIS W REPORT",,93226,731,$440.00 ,$440.00 ,$132.00 ,$400.40 ,$308.00 ,$132.00 ,$286.00 ,$316.80 ,$400.40 ,$330.00 
Carle BroMenn Medical Center,8493242,EXTERNAL ECG REC>48HR<7D RECORDING,,93242,731,$135.00 ,$135.00 ,$40.50 ,$122.85 ,$94.50 ,$40.50 ,$87.75 ,$97.20 ,$122.85 ,$101.25 
Carle BroMenn Medical Center,8493246,EXTERNAL ECG REC>7D<15D RECORDING,,93246,731,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8493270,CARDIO DIARY MEM TRC STRPS RCRDNG,,93270,731,$160.00 ,$160.00 ,$48.00 ,$145.60 ,$112.00 ,$48.00 ,$104.00 ,$115.20 ,$145.60 ,$120.00 
Carle BroMenn Medical Center,8293293,TRANSTELEPHONIC RHYTHM STRIP PACEMAKER EVAL,,93293,732,$175.00 ,$175.00 ,$52.50 ,$159.25 ,$122.50 ,$52.50 ,$113.75 ,$126.00 ,$159.25 ,$131.25 
Carle BroMenn Medical Center,8105938,SHORT-LATENCY SOMATOSENS EP STD UPR & LOW LIMBS,,95938,740,"$1,823.00 ","$1,823.00 ",$546.90 ,"$1,658.93 ","$1,276.10 ",$546.90 ,"$1,184.95 ","$1,312.56 ","$1,658.93 ","$1,367.25 "
Carle BroMenn Medical Center,8105939,CTR MOTR EP STD TRANSCRNL MOTR STIM UPR&LOW LIMB,,95939,740,"$3,158.00 ","$3,158.00 ",$947.40 ,"$2,873.78 ","$2,210.60 ",$947.40 ,"$2,052.70 ","$2,273.76 ","$2,873.78 ","$2,368.50 "
Carle BroMenn Medical Center,8105961,ELECTR STIMULATION BRAIN 1HR,,95961,740,"$3,300.00 ","$3,300.00 ",$990.00 ,"$3,003.00 ","$2,310.00 ",$990.00 ,"$2,145.00 ","$2,376.00 ","$3,003.00 ","$2,475.00 "
Carle BroMenn Medical Center,8105962,ELECT STIMU BRAIN EA ADD HR,,95962,740,$855.00 ,$855.00 ,$256.50 ,$778.05 ,$598.50 ,$256.50 ,$555.75 ,$615.60 ,$778.05 ,$641.25 
Carle BroMenn Medical Center,8105963,SURGERY ELECTROCORTICOGRAM,,95829,740,"$4,958.00 ","$4,958.00 ","$1,487.40 ","$4,511.78 ","$3,470.60 ","$1,487.40 ","$3,222.70 ","$3,569.76 ","$4,511.78 ","$3,718.50 "
Carle BroMenn Medical Center,8109012,EEG 41-60 MINUTES,,95812,740,"$1,166.00 ","$1,166.00 ",$349.80 ,"$1,061.06 ",$816.20 ,$349.80 ,$757.90 ,$839.52 ,"$1,061.06 ",$874.50 
Carle BroMenn Medical Center,8109013,EEG MORE THAN 1 HOUR,,95813,740,"$1,400.00 ","$1,400.00 ",$420.00 ,"$1,274.00 ",$980.00 ,$420.00 ,$910.00 ,"$1,008.00 ","$1,274.00 ","$1,050.00 "
Carle BroMenn Medical Center,8109014,EEG REC IN COMA/SLEEP,,95822,740,"$1,025.00 ","$1,025.00 ",$307.50 ,$932.75 ,$717.50 ,$307.50 ,$666.25 ,$738.00 ,$932.75 ,$768.75 
Carle BroMenn Medical Center,8109028,SSEP UPPER LIMBS,,95925,740,$735.00 ,$735.00 ,$220.50 ,$668.85 ,$514.50 ,$220.50 ,$477.75 ,$529.20 ,$668.85 ,$551.25 
Carle BroMenn Medical Center,8109029,SSEP LOWER LIMBS,,95926,740,$735.00 ,$735.00 ,$220.50 ,$668.85 ,$514.50 ,$220.50 ,$477.75 ,$529.20 ,$668.85 ,$551.25 
Carle BroMenn Medical Center,8109030,SSEP CORTICAL,,95927,740,$630.00 ,$630.00 ,$189.00 ,$573.30 ,$441.00 ,$189.00 ,$409.50 ,$453.60 ,$573.30 ,$472.50 
Carle BroMenn Medical Center,8109031,MEP UPPER LIMB,,95928,740,$720.00 ,$720.00 ,$216.00 ,$655.20 ,$504.00 ,$216.00 ,$468.00 ,$518.40 ,$655.20 ,$540.00 
Carle BroMenn Medical Center,8109032,MEP LOWER LIMBS,,95929,740,$720.00 ,$720.00 ,$216.00 ,$655.20 ,$504.00 ,$216.00 ,$468.00 ,$518.40 ,$655.20 ,$540.00 
Carle BroMenn Medical Center,8109033,VISUAL EVOKED POTENTIAL,,95930,740,$743.00 ,$743.00 ,$222.90 ,$676.13 ,$520.10 ,$222.90 ,$482.95 ,$534.96 ,$676.13 ,$557.25 
Carle BroMenn Medical Center,8109037,EEG NON CRANIAL SURGERY,,95955,740,$855.00 ,$855.00 ,$256.50 ,$778.05 ,$598.50 ,$256.50 ,$555.75 ,$615.60 ,$778.05 ,$641.25 
Carle BroMenn Medical Center,8109038,EEG DIGITAL QUANTI ANALYSIS,,95957,740,$518.00 ,$518.00 ,$155.40 ,$471.38 ,$362.60 ,$155.40 ,$336.70 ,$372.96 ,$471.38 ,$388.50 
Carle BroMenn Medical Center,8295819,"EEG,W/AWAKE & ASLEEP RECORD",,95819,740,"$1,096.00 ","$1,096.00 ",$328.80 ,$997.36 ,$767.20 ,$328.80 ,$712.40 ,$789.12 ,$997.36 ,$822.00 
Carle BroMenn Medical Center,8495700,EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS,,95700,740,$803.00 ,$803.00 ,$240.90 ,$730.73 ,$562.10 ,$240.90 ,$521.95 ,$578.16 ,$730.73 ,$602.25 
Carle BroMenn Medical Center,8495711,VEEG BY TECH 2-12 HOURS UNMONITORED,,95711,740,"$1,420.00 ","$1,420.00 ",$426.00 ,"$1,292.20 ",$994.00 ,$426.00 ,$923.00 ,"$1,022.40 ","$1,292.20 ","$1,065.00 "
Carle BroMenn Medical Center,8495712,VEEG BY TECH 2-12 HR INTERMITTENT MONITORING,,95712,740,"$1,800.00 ","$1,800.00 ",$540.00 ,"$1,638.00 ","$1,260.00 ",$540.00 ,"$1,170.00 ","$1,296.00 ","$1,638.00 ","$1,350.00 "
Carle BroMenn Medical Center,8495713,VEEG BY TECH 2-12 HR CONTINUOUS R-T MONITORING,,95713,740,"$1,598.00 ","$1,598.00 ",$479.40 ,"$1,454.18 ","$1,118.60 ",$479.40 ,"$1,038.70 ","$1,150.56 ","$1,454.18 ","$1,198.50 "
Carle BroMenn Medical Center,8495714,VEEG BY TECH EA INCR 12-26 HR UNMONITORED,,95714,740,"$2,720.00 ","$2,720.00 ",$816.00 ,"$2,475.20 ","$1,904.00 ",$816.00 ,"$1,768.00 ","$1,958.40 ","$2,475.20 ","$2,040.00 "
Carle BroMenn Medical Center,8495715,VEEG BY TECH EA INCR 12-26 HR INTERMITTENT MNTR,,95715,740,"$3,600.00 ","$3,600.00 ","$1,080.00 ","$3,276.00 ","$2,520.00 ","$1,080.00 ","$2,340.00 ","$2,592.00 ","$3,276.00 ","$2,700.00 "
Carle BroMenn Medical Center,8495716,VEEG BY TECH EA INCR 12-26 HR CONT R-T MNTR,,95716,740,"$3,810.00 ","$3,810.00 ","$1,143.00 ","$3,467.10 ","$2,667.00 ","$1,143.00 ","$2,476.50 ","$2,743.20 ","$3,467.10 ","$2,857.50 "
Carle BroMenn Medical Center,8495812,EEG EXTND MONITOR UP TO 1HR,,95812,740,"$1,166.00 ","$1,166.00 ",$349.80 ,"$1,061.06 ",$816.20 ,$349.80 ,$757.90 ,$839.52 ,"$1,061.06 ",$874.50 
Carle BroMenn Medical Center,8495813,EEG EXTND > THAN ONE HOUR,,95813,740,"$1,400.00 ","$1,400.00 ",$420.00 ,"$1,274.00 ",$980.00 ,$420.00 ,$910.00 ,"$1,008.00 ","$1,274.00 ","$1,050.00 "
Carle BroMenn Medical Center,8495816,EEG AWAKE & DROWSY,,95816,740,"$1,270.00 ","$1,270.00 ",$381.00 ,"$1,155.70 ",$889.00 ,$381.00 ,$825.50 ,$914.40 ,"$1,155.70 ",$952.50 
Carle BroMenn Medical Center,8495819,ELECTROENCEPHALOGRAM,,95819,740,"$1,096.00 ","$1,096.00 ",$328.80 ,$997.36 ,$767.20 ,$328.80 ,$712.40 ,$789.12 ,$997.36 ,$822.00 
Carle BroMenn Medical Center,8495822,EEG SLEEP ONLY,,95822,740,"$1,025.00 ","$1,025.00 ",$307.50 ,$932.75 ,$717.50 ,$307.50 ,$666.25 ,$738.00 ,$932.75 ,$768.75 
Carle BroMenn Medical Center,8495824,EEG CEREBRAL DEATH EVAL,,95824,740,"$1,785.00 ","$1,785.00 ",$535.50 ,"$1,624.35 ","$1,249.50 ",$535.50 ,"$1,160.25 ","$1,285.20 ","$1,624.35 ","$1,338.75 "
Carle BroMenn Medical Center,8495827,ALL NIGHT EEG,,95827,740,"$1,805.00 ","$1,805.00 ",$541.50 ,"$1,642.55 ","$1,263.50 ",$541.50 ,"$1,173.25 ","$1,299.60 ","$1,642.55 ","$1,353.75 "
Carle BroMenn Medical Center,8495950,EEG 24HR,,95950,740,$803.00 ,$803.00 ,$240.90 ,$730.73 ,$562.10 ,$240.90 ,$521.95 ,$578.16 ,$730.73 ,$602.25 
Carle BroMenn Medical Center,8495951,"EEG CMBND VIDEO/INTRP (EG PRESURG LCLZTN), EA 24 HRS",,95951,740,"$2,048.00 ","$2,048.00 ",$614.40 ,"$1,863.68 ","$1,433.60 ",$614.40 ,"$1,331.20 ","$1,474.56 ","$1,863.68 ","$1,536.00 "
Carle BroMenn Medical Center,8495953,EEG PORTABLE EACH 24 HR UNATTENDED,,95953,740,"$2,085.00 ","$2,085.00 ",$625.50 ,"$1,897.35 ","$1,459.50 ",$625.50 ,"$1,355.25 ","$1,501.20 ","$1,897.35 ","$1,563.75 "
Carle BroMenn Medical Center,8495955,EEG DURING NON-INTRACRANIAL SURG,,95955,740,$855.00 ,$855.00 ,$256.50 ,$778.05 ,$598.50 ,$256.50 ,$555.75 ,$615.60 ,$778.05 ,$641.25 
Carle BroMenn Medical Center,8495956,"EEG SEIZURE FOCUS RCRDNG/INTRP EA 24 HRS, ATTENDED",,95956,740,"$2,370.00 ","$2,370.00 ",$711.00 ,"$2,156.70 ","$1,659.00 ",$711.00 ,"$1,540.50 ","$1,706.40 ","$2,156.70 ","$1,777.50 "
Carle BroMenn Medical Center,8495957,DIGITAL ANALYSIS-EEG,,95957,740,$518.00 ,$518.00 ,$155.40 ,$471.38 ,$362.60 ,$155.40 ,$336.70 ,$372.96 ,$471.38 ,$388.50 
Carle BroMenn Medical Center,8495958,WADA ACTIVATION TEST,,95958,740,"$3,413.00 ","$3,413.00 ","$1,023.90 ","$3,105.83 ","$2,389.10 ","$1,023.90 ","$2,218.45 ","$2,457.36 ","$3,105.83 ","$2,559.75 "
Carle BroMenn Medical Center,8495961,ELECTR STIMULATION BRAIN 1HR,,95961,740,"$1,155.00 ","$1,155.00 ",$346.50 ,"$1,051.05 ",$808.50 ,$346.50 ,$750.75 ,$831.60 ,"$1,051.05 ",$866.25 
Carle BroMenn Medical Center,8495962,ELECT STIMU BRAIN EA ADD HR,,95962,740,$855.00 ,$855.00 ,$256.50 ,$778.05 ,$598.50 ,$256.50 ,$555.75 ,$615.60 ,$778.05 ,$641.25 
Carle BroMenn Medical Center,8935805,MULT SLEEP LAT/MAINT OF WAKE,,95805,740,"$2,100.00 ","$2,100.00 ",$630.00 ,"$1,911.00 ","$1,470.00 ",$630.00 ,"$1,365.00 ","$1,512.00 ","$1,911.00 ","$1,575.00 "
Carle BroMenn Medical Center,8935806,"SLEEP STUDY, UNATTENDED, SIMUL RECORD HR/O2 SAT/RESP FLOW/RESP EFF",,95806,740,"$5,705.00 ","$5,705.00 ","$1,711.50 ","$5,191.55 ","$3,993.50 ","$1,711.50 ","$3,708.25 ","$4,107.60 ","$5,191.55 ","$4,278.75 "
Carle BroMenn Medical Center,8935807,SLEEP STUDY ATTENDED,,95807,740,"$2,393.00 ","$2,393.00 ",$717.90 ,"$2,177.63 ","$1,675.10 ",$717.90 ,"$1,555.45 ","$1,722.96 ","$2,177.63 ","$1,794.75 "
Carle BroMenn Medical Center,8935810,ALL NIGHT POLYSOMNOGRAPHY,,95810,740,"$5,705.00 ","$5,705.00 ","$1,711.50 ","$5,191.55 ","$3,993.50 ","$1,711.50 ","$3,708.25 ","$4,107.60 ","$5,191.55 ","$4,278.75 "
Carle BroMenn Medical Center,8935811,ALL NIGHT POLYSOMNOGRAM W/CPAP,,95811,740,"$5,705.00 ","$5,705.00 ","$1,711.50 ","$5,191.55 ","$3,993.50 ","$1,711.50 ","$3,708.25 ","$4,107.60 ","$5,191.55 ","$4,278.75 "
Carle BroMenn Medical Center,8100020,DHC RESEARCH COLONOSCOPY-BASE ROOM CHARGE,,,750,$735.00 ,$735.00 ,$220.50 ,$668.85 ,$514.50 ,$220.50 ,$477.75 ,$529.20 ,$668.85 ,$551.25 
Carle BroMenn Medical Center,8100021,DHC RESEARCH COLONOSCOPY-PER MIN ROOM CHARGE,,,750,$101.00 ,$101.00 ,$30.30 ,$91.91 ,$70.70 ,$30.30 ,$65.65 ,$72.72 ,$91.91 ,$75.75 
Carle BroMenn Medical Center,8100072,L1 BASE OPERATING ROOM CHARGE,,,750,"$1,125.00 ","$1,125.00 ",$337.50 ,"$1,023.75 ",$787.50 ,$337.50 ,$731.25 ,$810.00 ,"$1,023.75 ",$843.75 
Carle BroMenn Medical Center,8102072,L2 BASE OPERATING ROOM CHARGE,,,750,$863.00 ,$863.00 ,$258.90 ,$785.33 ,$604.10 ,$258.90 ,$560.95 ,$621.36 ,$785.33 ,$647.25 
Carle BroMenn Medical Center,8103072,L3 BASE OPERATING ROOM CHARGE,,,750,$975.00 ,$975.00 ,$292.50 ,$887.25 ,$682.50 ,$292.50 ,$633.75 ,$702.00 ,$887.25 ,$731.25 
Carle BroMenn Medical Center,8104072,L4 BASE OPERATING ROOM CHARGE,,,750,$653.00 ,$653.00 ,$195.90 ,$594.23 ,$457.10 ,$195.90 ,$424.45 ,$470.16 ,$594.23 ,$489.75 
Carle BroMenn Medical Center,8105072,L1 PER MIN OPERATING ROOM CHARGE,,,750,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8106072,L2 PER MIN OPERATING ROOM CHARGE,,,750,$116.00 ,$116.00 ,$34.80 ,$105.56 ,$81.20 ,$34.80 ,$75.40 ,$83.52 ,$105.56 ,$87.00 
Carle BroMenn Medical Center,8107072,L3 PER MIN OPERATING ROOM CHARGE,,,750,$116.00 ,$116.00 ,$34.80 ,$105.56 ,$81.20 ,$34.80 ,$75.40 ,$83.52 ,$105.56 ,$87.00 
Carle BroMenn Medical Center,8108072,L4 PER MIN OPERATING ROOM CHARGE,,,750,$86.00 ,$86.00 ,$25.80 ,$78.26 ,$60.20 ,$25.80 ,$55.90 ,$61.92 ,$78.26 ,$64.50 
Carle BroMenn Medical Center,8191010,"ESOPHAGEAL MOTILITY STUDY, MANOMETRY",,91010,750,"$2,020.00 ","$2,020.00 ",$606.00 ,"$1,838.20 ","$1,414.00 ",$606.00 ,"$1,313.00 ","$1,454.40 ","$1,838.20 ","$1,515.00 "
Carle BroMenn Medical Center,8191038,"GERD TST W/ MUCOS IMPEDE ELECTROD,>1HR",,91038,750,"$2,020.00 ","$2,020.00 ",$606.00 ,"$1,838.20 ","$1,414.00 ",$606.00 ,"$1,313.00 ","$1,454.40 ","$1,838.20 ","$1,515.00 "
Carle BroMenn Medical Center,8201439,PR AGILE PATENCY CAPSULE,,91299,750,$300.00 ,$300.00 ,$90.00 ,$273.00 ,$210.00 ,$90.00 ,$195.00 ,$216.00 ,$273.00 ,$225.00 
Carle BroMenn Medical Center,8291010,"ESOPHAGEAL MOTILITY STUDY, MANOMETRY",,91010,750,"$2,020.00 ","$2,020.00 ",$606.00 ,"$1,838.20 ","$1,414.00 ",$606.00 ,"$1,313.00 ","$1,454.40 ","$1,838.20 ","$1,515.00 "
Carle BroMenn Medical Center,8291013,"ESOPHAGEAL MOTILITY STUDY, MANOMETRY W STIMULATION/PERFUSION",,91013,750,$245.00 ,$245.00 ,$73.50 ,$222.95 ,$171.50 ,$73.50 ,$159.25 ,$176.40 ,$222.95 ,$183.75 
Carle BroMenn Medical Center,8291038,"GERD TST W/ MUCOS IMPEDE ELECTROD,>1HR",,91038,750,"$2,020.00 ","$2,020.00 ",$606.00 ,"$1,838.20 ","$1,414.00 ",$606.00 ,"$1,313.00 ","$1,454.40 ","$1,838.20 ","$1,515.00 "
Carle BroMenn Medical Center,8291065,BREATH HYDROGEN TEST,,91065,750,$520.00 ,$520.00 ,$156.00 ,$473.20 ,$364.00 ,$156.00 ,$338.00 ,$374.40 ,$473.20 ,$390.00 
Carle BroMenn Medical Center,8291110,GI TRACT CAPSULE ENDOSCOPY,,91110,750,"$2,630.00 ","$2,630.00 ",$789.00 ,"$2,393.30 ","$1,841.00 ",$789.00 ,"$1,709.50 ","$1,893.60 ","$2,393.30 ","$1,972.50 "
Carle BroMenn Medical Center,8009803,HOSPITAL OUTPT CLINIC VISIT SPECIMEN COLLECTION,,C9803,761,$45.00 ,$45.00 ,$13.50 ,$40.95 ,$31.50 ,$13.50 ,$29.25 ,$32.40 ,$40.95 ,$33.75 
Carle BroMenn Medical Center,8020019,LARC INSERTION,,,761,$450.00 ,$450.00 ,$135.00 ,$409.50 ,$315.00 ,$135.00 ,$292.50 ,$324.00 ,$409.50 ,$337.50 
Carle BroMenn Medical Center,8020020,CERCLAGE,,,761,"$3,600.00 ","$3,600.00 ","$1,080.00 ","$3,276.00 ","$2,520.00 ","$1,080.00 ","$2,340.00 ","$2,592.00 ","$3,276.00 ","$2,700.00 "
Carle BroMenn Medical Center,8020036,NEEDLE ASPIRATION/INJ JOINT,,,761,$563.00 ,$563.00 ,$168.90 ,$512.33 ,$394.10 ,$168.90 ,$365.95 ,$405.36 ,$512.33 ,$422.25 
Carle BroMenn Medical Center,8021701,STRAIGHT CATH FOR PVR/DRAINAGE (NOT UA),,51701,761,$185.00 ,$185.00 ,$55.50 ,$168.35 ,$129.50 ,$55.50 ,$120.25 ,$133.20 ,$168.35 ,$138.75 
Carle BroMenn Medical Center,8021798,US PV RESIDUAL URINE,,51798,761,$240.00 ,$240.00 ,$72.00 ,$218.40 ,$168.00 ,$72.00 ,$156.00 ,$172.80 ,$218.40 ,$180.00 
Carle BroMenn Medical Center,8026360,HYDRATION IV INFUSN UP TO 1HR,,96360,761,$430.00 ,$430.00 ,$129.00 ,$391.30 ,$301.00 ,$129.00 ,$279.50 ,$309.60 ,$391.30 ,$322.50 
Carle BroMenn Medical Center,8026361,HYDRATION IV INFUSION EA ADD H,,96361,761,$138.00 ,$138.00 ,$41.40 ,$125.58 ,$96.60 ,$41.40 ,$89.70 ,$99.36 ,$125.58 ,$103.50 
Carle BroMenn Medical Center,8026365,IV INFUSION UP TO 1HR,,96365,761,$635.00 ,$635.00 ,$190.50 ,$577.85 ,$444.50 ,$190.50 ,$412.75 ,$457.20 ,$577.85 ,$476.25 
Carle BroMenn Medical Center,8026366,IV INFUSION EA ADD HR,,96366,761,$170.00 ,$170.00 ,$51.00 ,$154.70 ,$119.00 ,$51.00 ,$110.50 ,$122.40 ,$154.70 ,$127.50 
Carle BroMenn Medical Center,8026367,IV INFUSION SEQ -UP TO 1 HR,,96367,761,$191.00 ,$191.00 ,$57.30 ,$173.81 ,$133.70 ,$57.30 ,$124.15 ,$137.52 ,$173.81 ,$143.25 
Carle BroMenn Medical Center,8026368,IV INFUSION CONCURRENT,,96368,761,$385.00 ,$385.00 ,$115.50 ,$350.35 ,$269.50 ,$115.50 ,$250.25 ,$277.20 ,$350.35 ,$288.75 
Carle BroMenn Medical Center,8026374,IV PUSH THER/DIAG MED,,96374,761,$380.00 ,$380.00 ,$114.00 ,$345.80 ,$266.00 ,$114.00 ,$247.00 ,$273.60 ,$345.80 ,$285.00 
Carle BroMenn Medical Center,8026375,IV PUSH EA ADD NEW DRUG,,96375,761,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8026376,IV PUSH EA ADD SAME DRUG,,96376,761,$153.00 ,$153.00 ,$45.90 ,$139.23 ,$107.10 ,$45.90 ,$99.45 ,$110.16 ,$139.23 ,$114.75 
Carle BroMenn Medical Center,8026379,INIT PROLONG INFUSN REQ PUMP,,96379,761,$368.00 ,$368.00 ,$110.40 ,$334.88 ,$257.60 ,$110.40 ,$239.20 ,$264.96 ,$334.88 ,$276.00 
Carle BroMenn Medical Center,8026523,IRRIGATN IMPLNTD VEN ACC DVC,,96523,761,$190.00 ,$190.00 ,$57.00 ,$172.90 ,$133.00 ,$57.00 ,$123.50 ,$136.80 ,$172.90 ,$142.50 
Carle BroMenn Medical Center,8026589,RMVL TNNLD CVC W/O PORT/PUMP,,,761,"$1,845.00 ","$1,845.00 ",$553.50 ,"$1,678.95 ","$1,291.50 ",$553.50 ,"$1,199.25 ","$1,328.40 ","$1,678.95 ","$1,383.75 "
Carle BroMenn Medical Center,8026591,COLLCTN BLD SPCMN FROM VAD,,36591,761,$230.00 ,$230.00 ,$69.00 ,$209.30 ,$161.00 ,$69.00 ,$149.50 ,$165.60 ,$209.30 ,$172.50 
Carle BroMenn Medical Center,8026592,COLLCTN BLD SPCMN FROM PICC,,36592,761,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8026593,DECLOT VASCULAR ACCESS DVC/CTH,,36593,761,$760.00 ,$760.00 ,$228.00 ,$691.60 ,$532.00 ,$228.00 ,$494.00 ,$547.20 ,$691.60 ,$570.00 
Carle BroMenn Medical Center,8027600,BONE MARROW ASPIRATION/BIOPSY,,,761,$465.00 ,$465.00 ,$139.50 ,$423.15 ,$325.50 ,$139.50 ,$302.25 ,$334.80 ,$423.15 ,$348.75 
Carle BroMenn Medical Center,8027601,DEBRIDEMENT,,,761,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8027602,INSERTION -CERVICAL DILATOR,,,761,$540.00 ,$540.00 ,$162.00 ,$491.40 ,$378.00 ,$162.00 ,$351.00 ,$388.80 ,$491.40 ,$405.00 
Carle BroMenn Medical Center,8027603,SPINAL PUNCTURE,,,761,$773.00 ,$773.00 ,$231.90 ,$703.43 ,$541.10 ,$231.90 ,$502.45 ,$556.56 ,$703.43 ,$579.75 
Carle BroMenn Medical Center,8027605,TREATMENT ROOM,,,761,$188.00 ,$188.00 ,$56.40 ,$171.08 ,$131.60 ,$56.40 ,$122.20 ,$135.36 ,$171.08 ,$141.00 
Carle BroMenn Medical Center,8027610,URINARY CATHETER INSERTION,,51702,761,$154.00 ,$154.00 ,$46.20 ,$140.14 ,$107.80 ,$46.20 ,$100.10 ,$110.88 ,$140.14 ,$115.50 
Carle BroMenn Medical Center,8027611,WOUND TREATMENT (VAC),,,761,$413.00 ,$413.00 ,$123.90 ,$375.83 ,$289.10 ,$123.90 ,$268.45 ,$297.36 ,$375.83 ,$309.75 
Carle BroMenn Medical Center,8027612,WOUND TREATMENT (VAC),,,761,$810.00 ,$810.00 ,$243.00 ,$737.10 ,$567.00 ,$243.00 ,$526.50 ,$583.20 ,$737.10 ,$607.50 
Carle BroMenn Medical Center,8029201,"OFFICE/OP VISIT, NEW, BRIEF",,G0463,761,$125.00 ,$125.00 ,$37.50 ,$113.75 ,$87.50 ,$37.50 ,$81.25 ,$90.00 ,$113.75 ,$93.75 
Carle BroMenn Medical Center,8029202,"OFFICE/OP VISIT, NEW, LIMITED",,G0463,761,$175.00 ,$175.00 ,$52.50 ,$159.25 ,$122.50 ,$52.50 ,$113.75 ,$126.00 ,$159.25 ,$131.25 
Carle BroMenn Medical Center,8029203,"OFFICE/OP VISIT, NEW, INTERMED",,G0463,761,$250.00 ,$250.00 ,$75.00 ,$227.50 ,$175.00 ,$75.00 ,$162.50 ,$180.00 ,$227.50 ,$187.50 
Carle BroMenn Medical Center,8029204,"OFFICE/OP VISIT, NEW, EXTENDED",,G0463,761,$275.00 ,$275.00 ,$82.50 ,$250.25 ,$192.50 ,$82.50 ,$178.75 ,$198.00 ,$250.25 ,$206.25 
Carle BroMenn Medical Center,8029205,"OFFICE/OP VISIT, NEW, COMPLEX",,G0463,761,$315.00 ,$315.00 ,$94.50 ,$286.65 ,$220.50 ,$94.50 ,$204.75 ,$226.80 ,$286.65 ,$236.25 
Carle BroMenn Medical Center,8029211,PICC LINE DRESSING CHANGE,,G0463,761,$250.00 ,$250.00 ,$75.00 ,$227.50 ,$175.00 ,$75.00 ,$162.50 ,$180.00 ,$227.50 ,$187.50 
Carle BroMenn Medical Center,8029212,VISIT LEVEL 2,,G0463,761,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8029213,VISIT LEVEL 3,,G0463,761,$240.00 ,$240.00 ,$72.00 ,$218.40 ,$168.00 ,$72.00 ,$156.00 ,$172.80 ,$218.40 ,$180.00 
Carle BroMenn Medical Center,8029214,VISIT LEVEL 4,,G0463,761,$275.00 ,$275.00 ,$82.50 ,$250.25 ,$192.50 ,$82.50 ,$178.75 ,$198.00 ,$250.25 ,$206.25 
Carle BroMenn Medical Center,8029215,VISIT LEVEL 5,,G0463,761,$315.00 ,$315.00 ,$94.50 ,$286.65 ,$220.50 ,$94.50 ,$204.75 ,$226.80 ,$286.65 ,$236.25 
Carle BroMenn Medical Center,8029760,WOUND VAC DRESSING CHANGE,,97605,761,$340.00 ,$340.00 ,$102.00 ,$309.40 ,$238.00 ,$102.00 ,$221.00 ,$244.80 ,$309.40 ,$255.00 
Carle BroMenn Medical Center,8029921,VISIT LEVEL 1,,G0463,761,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8100761,TREATMENT ROOM,,,761,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8109040,HYDRATION IV INFUSN UP TO 1HR,,96360,761,$430.00 ,$430.00 ,$129.00 ,$391.30 ,$301.00 ,$129.00 ,$279.50 ,$309.60 ,$391.30 ,$322.50 
Carle BroMenn Medical Center,8109041,HYDRATION IV INFUSN EA ADNL HR,,96361,761,$138.00 ,$138.00 ,$41.40 ,$125.58 ,$96.60 ,$41.40 ,$89.70 ,$99.36 ,$125.58 ,$103.50 
Carle BroMenn Medical Center,8109042,IV INFUSION -UP TO 1HR,,96365,761,$635.00 ,$635.00 ,$190.50 ,$577.85 ,$444.50 ,$190.50 ,$412.75 ,$457.20 ,$577.85 ,$476.25 
Carle BroMenn Medical Center,8109043,IV INFUSION -EA ADNL HR,,96366,761,$170.00 ,$170.00 ,$51.00 ,$154.70 ,$119.00 ,$51.00 ,$110.50 ,$122.40 ,$154.70 ,$127.50 
Carle BroMenn Medical Center,8109044,IV INFUSION SEQ -UP TO 1HR,,96367,761,$191.00 ,$191.00 ,$57.30 ,$173.81 ,$133.70 ,$57.30 ,$124.15 ,$137.52 ,$173.81 ,$143.25 
Carle BroMenn Medical Center,8109045,IV INFUSION CONCURRENT,,96368,761,$385.00 ,$385.00 ,$115.50 ,$350.35 ,$269.50 ,$115.50 ,$250.25 ,$277.20 ,$350.35 ,$288.75 
Carle BroMenn Medical Center,8109047,IV PUSH -SINGLE/INITIAL,,96374,761,$380.00 ,$380.00 ,$114.00 ,$345.80 ,$266.00 ,$114.00 ,$247.00 ,$273.60 ,$345.80 ,$285.00 
Carle BroMenn Medical Center,8109048,IV PUSH -EA ADNL NEW DRUG,,96375,761,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8109049,IV PUSH -EA ADNL SAME DRUG,,96376,761,$153.00 ,$153.00 ,$45.90 ,$139.23 ,$107.10 ,$45.90 ,$99.45 ,$110.16 ,$139.23 ,$114.75 
Carle BroMenn Medical Center,8109910,INIT PROLONG INFUSN REQ PUMP,,96379,761,$368.00 ,$368.00 ,$110.40 ,$334.88 ,$257.60 ,$110.40 ,$239.20 ,$264.96 ,$334.88 ,$276.00 
Carle BroMenn Medical Center,8129910,INIT PROLONG INFUSN REQ PUMP,,96379,761,$368.00 ,$368.00 ,$110.40 ,$334.88 ,$257.60 ,$110.40 ,$239.20 ,$264.96 ,$334.88 ,$276.00 
Carle BroMenn Medical Center,8190053,TREATMENT ROOM,,,761,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8199040,HYDRATION IV INFUSN UP TO 1HR,,96360,761,$430.00 ,$430.00 ,$129.00 ,$391.30 ,$301.00 ,$129.00 ,$279.50 ,$309.60 ,$391.30 ,$322.50 
Carle BroMenn Medical Center,8199041,HYDRATION IV INFUSN EA ADNL HR,,96361,761,$138.00 ,$138.00 ,$41.40 ,$125.58 ,$96.60 ,$41.40 ,$89.70 ,$99.36 ,$125.58 ,$103.50 
Carle BroMenn Medical Center,8199042,IV INFUSION -UP TO 1HR,,96365,761,$635.00 ,$635.00 ,$190.50 ,$577.85 ,$444.50 ,$190.50 ,$412.75 ,$457.20 ,$577.85 ,$476.25 
Carle BroMenn Medical Center,8199043,IV INFUSION -EA ADNL HR,,96366,761,$170.00 ,$170.00 ,$51.00 ,$154.70 ,$119.00 ,$51.00 ,$110.50 ,$122.40 ,$154.70 ,$127.50 
Carle BroMenn Medical Center,8199044,IV INFUSION SEQ -UP TO 1HR,,96367,761,$191.00 ,$191.00 ,$57.30 ,$173.81 ,$133.70 ,$57.30 ,$124.15 ,$137.52 ,$173.81 ,$143.25 
Carle BroMenn Medical Center,8199045,IV INFUSION CONCURRENT,,96368,761,$385.00 ,$385.00 ,$115.50 ,$350.35 ,$269.50 ,$115.50 ,$250.25 ,$277.20 ,$350.35 ,$288.75 
Carle BroMenn Medical Center,8199047,IV PUSH -SINGLE/INITIAL,,96374,761,$380.00 ,$380.00 ,$114.00 ,$345.80 ,$266.00 ,$114.00 ,$247.00 ,$273.60 ,$345.80 ,$285.00 
Carle BroMenn Medical Center,8199048,IV PUSH -EA ADNL NEW DRUG,,96375,761,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8199049,IV PUSH -EA ADNL SAME DRUG,,96376,761,$153.00 ,$153.00 ,$45.90 ,$139.23 ,$107.10 ,$45.90 ,$99.45 ,$110.16 ,$139.23 ,$114.75 
Carle BroMenn Medical Center,8199211,"OFFICE/OP VISIT, EST, BRIEF",,G0463,761,$125.00 ,$125.00 ,$37.50 ,$113.75 ,$87.50 ,$37.50 ,$81.25 ,$90.00 ,$113.75 ,$93.75 
Carle BroMenn Medical Center,8199910,INIT PROLONG INFUSN REQ PUMP,,96379,761,$368.00 ,$368.00 ,$110.40 ,$334.88 ,$257.60 ,$110.40 ,$239.20 ,$264.96 ,$334.88 ,$276.00 
Carle BroMenn Medical Center,8199940,HYDRATION IV INFUSN UP TO 1HR,,96360,761,$430.00 ,$430.00 ,$129.00 ,$391.30 ,$301.00 ,$129.00 ,$279.50 ,$309.60 ,$391.30 ,$322.50 
Carle BroMenn Medical Center,8336520,THERAPEUTIC APHERESIS,,,761,"$2,230.00 ","$2,230.00 ",$669.00 ,"$2,029.30 ","$1,561.00 ",$669.00 ,"$1,449.50 ","$1,605.60 ","$2,029.30 ","$1,672.50 "
Carle BroMenn Medical Center,8400005,PLACEMENT GOLD SEED MARKER,,58999,761,"$2,085.00 ","$2,085.00 ",$625.50 ,"$1,897.35 ","$1,459.50 ",$625.50 ,"$1,355.25 ","$1,501.20 ","$1,897.35 ","$1,563.75 "
Carle BroMenn Medical Center,8401001,Cdsm evicore,,G1001,761,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01 
Carle BroMenn Medical Center,8401002,Cdsm medcurrent,,G1002,761,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01 
Carle BroMenn Medical Center,8401003,Cdsm medicalis,,G1003,761,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01 
Carle BroMenn Medical Center,8401004,Cdsm ndsc,,G1004,761,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01 
Carle BroMenn Medical Center,8401007,Cdsm aim,,G1007,761,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01 
Carle BroMenn Medical Center,8401008,Cdsm cranberry pk,,G1008,761,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01 
Carle BroMenn Medical Center,8401009,Cdsm sage health,,G1009,761,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01 
Carle BroMenn Medical Center,8401010,Cdsm stanson,,G1010,761,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01 
Carle BroMenn Medical Center,8401011,Cdsm qualified nos,,G1011,761,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01 
Carle BroMenn Medical Center,8401012,CDSM AGILEMD,,G1012,761,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01 
Carle BroMenn Medical Center,8401013,CDSM EVIDENCECARE IMAGING ADVISOR,,G1013,761,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01 
Carle BroMenn Medical Center,8401014,CDSM INVENIQA SEMANTIC ANSWERS IN MEDICINE,,G1014,761,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01 
Carle BroMenn Medical Center,8401015,CDSM RELIANT MEDICAL GROUP,,G1015,761,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01 
Carle BroMenn Medical Center,8401016,CDSM SPEED OF CARE,,G1016,761,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01 
Carle BroMenn Medical Center,8401017,CDSM HEALTHHELP,,G1017,761,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01 
Carle BroMenn Medical Center,8401018,CDSM INFINX,,G1018,761,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01 
Carle BroMenn Medical Center,8401019,CDSM LOGICNETS,,G1019,761,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01 
Carle BroMenn Medical Center,8410004,FINE NEEDLE ASPIRATION BX W/O IMG GDN EA ADDL,,10004,761,$160.00 ,$160.00 ,$48.00 ,$145.60 ,$112.00 ,$48.00 ,$104.00 ,$115.20 ,$145.60 ,$120.00 
Carle BroMenn Medical Center,8410005,FINE NEEDLE ASPIRATION BX W/US GDN 1ST LSN,,10005,761,"$1,200.00 ","$1,200.00 ",$360.00 ,"$1,092.00 ",$840.00 ,$360.00 ,$780.00 ,$864.00 ,"$1,092.00 ",$900.00 
Carle BroMenn Medical Center,8410006,FINE NEEDLE ASPIRATION BX W/US GDN EA ADDL,,10006,761,$560.00 ,$560.00 ,$168.00 ,$509.60 ,$392.00 ,$168.00 ,$364.00 ,$403.20 ,$509.60 ,$420.00 
Carle BroMenn Medical Center,8410007,FINE NEEDLE ASPIRATION BX W/FLUOR GDN 1ST LESION,,10007,761,$405.00 ,$405.00 ,$121.50 ,$368.55 ,$283.50 ,$121.50 ,$263.25 ,$291.60 ,$368.55 ,$303.75 
Carle BroMenn Medical Center,8410008,FINE NEEDLE ASPIRATION BX W/FLUOR GDN EA ADDL,,10008,761,$195.00 ,$195.00 ,$58.50 ,$177.45 ,$136.50 ,$58.50 ,$126.75 ,$140.40 ,$177.45 ,$146.25 
Carle BroMenn Medical Center,8410009,FINE NEEDLE ASPIRATION BX W/CT GDN 1ST LESION,,10009,761,"$1,560.00 ","$1,560.00 ",$468.00 ,"$1,419.60 ","$1,092.00 ",$468.00 ,"$1,014.00 ","$1,123.20 ","$1,419.60 ","$1,170.00 "
Carle BroMenn Medical Center,8410010,FINE NEEDLE ASPIRATION BX W/CT GDN EA ADDL,,10010,761,$728.00 ,$728.00 ,$218.40 ,$662.48 ,$509.60 ,$218.40 ,$473.20 ,$524.16 ,$662.48 ,$546.00 
Carle BroMenn Medical Center,8410011,FINE NEEDLE ASPIRATION BX W/MR GDN 1ST LESION,,10011,761,$405.00 ,$405.00 ,$121.50 ,$368.55 ,$283.50 ,$121.50 ,$263.25 ,$291.60 ,$368.55 ,$303.75 
Carle BroMenn Medical Center,8410012,FINE NEEDLE ASPIRATION BX W/MR GDN EA ADDL,,10012,761,$260.00 ,$260.00 ,$78.00 ,$236.60 ,$182.00 ,$78.00 ,$169.00 ,$187.20 ,$236.60 ,$195.00 
Carle BroMenn Medical Center,8410021,FINE NEEDLE ASP W/O IMAGING,,10021,761,$345.00 ,$345.00 ,$103.50 ,$313.95 ,$241.50 ,$103.50 ,$224.25 ,$248.40 ,$313.95 ,$258.75 
Carle BroMenn Medical Center,8410022,FINE NEEDLE ASPIRATN W/FLUORO,,10022,761,$495.00 ,$495.00 ,$148.50 ,$450.45 ,$346.50 ,$148.50 ,$321.75 ,$356.40 ,$450.45 ,$371.25 
Carle BroMenn Medical Center,8410030,"IMG GUIDE FLUID COLLECTION DRAIN BY CATH, PERCUT",,10030,761,"$1,891.50 ","$1,891.50 ",$567.45 ,"$1,721.27 ","$1,324.05 ",$567.45 ,"$1,229.48 ","$1,361.88 ","$1,721.27 ","$1,418.63 "
Carle BroMenn Medical Center,8410035,PERQ SFT TISS LOC DEVICE PLMT 1ST LES W/GDNCE,,10035,761,"$1,455.00 ","$1,455.00 ",$436.50 ,"$1,324.05 ","$1,018.50 ",$436.50 ,$945.75 ,"$1,047.60 ","$1,324.05 ","$1,091.25 "
Carle BroMenn Medical Center,8410060,DRAIN SKIN ABSCESS SIMPLE,,10060,761,$675.00 ,$675.00 ,$202.50 ,$614.25 ,$472.50 ,$202.50 ,$438.75 ,$486.00 ,$614.25 ,$506.25 
Carle BroMenn Medical Center,8410140,"I&D HEMATOMA, SEROMA, FLUID",,10140,761,"$3,160.00 ","$3,160.00 ",$948.00 ,"$2,875.60 ","$2,212.00 ",$948.00 ,"$2,054.00 ","$2,275.20 ","$2,875.60 ","$2,370.00 "
Carle BroMenn Medical Center,8410160,"PUNCTURE ASPRTN ABCSS, HMTMA, BULLA, CYST",,10160,761,$605.00 ,$605.00 ,$181.50 ,$550.55 ,$423.50 ,$181.50 ,$393.25 ,$435.60 ,$550.55 ,$453.75 
Carle BroMenn Medical Center,8411100,BIOPSY OF SKIN LESION,,11100,761,$250.00 ,$250.00 ,$75.00 ,$227.50 ,$175.00 ,$75.00 ,$162.50 ,$180.00 ,$227.50 ,$187.50 
Carle BroMenn Medical Center,8411104,PUNCH BIOPSY SKIN SINGLE LESION,,11104,761,$560.00 ,$560.00 ,$168.00 ,$509.60 ,$392.00 ,$168.00 ,$364.00 ,$403.20 ,$509.60 ,$420.00 
Carle BroMenn Medical Center,8417999,CT GUIDED CRYOBALATION SOFT TISSUE GROIN,,17999,761,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8419000,PUNCTURE ASPRTN CYST OF BREAST,,19000,761,$720.00 ,$720.00 ,$216.00 ,$655.20 ,$504.00 ,$216.00 ,$468.00 ,$518.40 ,$655.20 ,$540.00 
Carle BroMenn Medical Center,8419001,"PUNCTURE ASPRTN CYST OF BREAST, EA ADDTNL",,19001,761,$230.00 ,$230.00 ,$69.00 ,$209.30 ,$161.00 ,$69.00 ,$149.50 ,$165.60 ,$209.30 ,$172.50 
Carle BroMenn Medical Center,8419081,"BRST BX W/PLC LCL DVC STEREOTACTIC GUIDE, 1RST LSN",,19081,761,"$3,070.00 ","$3,070.00 ",$921.00 ,"$2,793.70 ","$2,149.00 ",$921.00 ,"$1,995.50 ","$2,210.40 ","$2,793.70 ","$2,302.50 "
Carle BroMenn Medical Center,8419082,"BRST BX W/PLX LCL DVC STEREOTACTIC GUIDE, EA ADD LSN",,19082,761,"$2,520.00 ","$2,520.00 ",$756.00 ,"$2,293.20 ","$1,764.00 ",$756.00 ,"$1,638.00 ","$1,814.40 ","$2,293.20 ","$1,890.00 "
Carle BroMenn Medical Center,8419083,"BRST BX W/PLC LCL DVC US GUIDE, 1RST LSN",,19083,761,"$4,080.00 ","$4,080.00 ","$1,224.00 ","$3,712.80 ","$2,856.00 ","$1,224.00 ","$2,652.00 ","$2,937.60 ","$3,712.80 ","$3,060.00 "
Carle BroMenn Medical Center,8419084,"BRST BX W/PLC LCL  DC US GUIDE, EA ADD LSN",,19084,761,"$1,925.00 ","$1,925.00 ",$577.50 ,"$1,751.75 ","$1,347.50 ",$577.50 ,"$1,251.25 ","$1,386.00 ","$1,751.75 ","$1,443.75 "
Carle BroMenn Medical Center,8419085,"BRST BX W/PLC LCL DVC MR GUIDE, 1RST LSN",,19085,761,"$2,820.00 ","$2,820.00 ",$846.00 ,"$2,566.20 ","$1,974.00 ",$846.00 ,"$1,833.00 ","$2,030.40 ","$2,566.20 ","$2,115.00 "
Carle BroMenn Medical Center,8419086,"BRST BX W/PLC LCL DVC MR GUIDE, EA ADD LSN",,19086,761,"$1,763.00 ","$1,763.00 ",$528.90 ,"$1,604.33 ","$1,234.10 ",$528.90 ,"$1,145.95 ","$1,269.36 ","$1,604.33 ","$1,322.25 "
Carle BroMenn Medical Center,8419281,PLC BRST LCLZTN DVC PERQ; 1RST LSN INCL MAMMO,,19281,761,"$1,780.00 ","$1,780.00 ",$534.00 ,"$1,619.80 ","$1,246.00 ",$534.00 ,"$1,157.00 ","$1,281.60 ","$1,619.80 ","$1,335.00 "
Carle BroMenn Medical Center,8419282,PLC BRST LCLZTN DVC PERQ; EA ADD LSN INCL MAMMO,,19282,761,$520.00 ,$520.00 ,$156.00 ,$473.20 ,$364.00 ,$156.00 ,$338.00 ,$374.40 ,$473.20 ,$390.00 
Carle BroMenn Medical Center,8419283,PLC BRST LCLZTN DVC PERQ; 1RST LSN INCL STEREO,,19283,761,$450.00 ,$450.00 ,$135.00 ,$409.50 ,$315.00 ,$135.00 ,$292.50 ,$324.00 ,$409.50 ,$337.50 
Carle BroMenn Medical Center,8419284,PLC BRST LCLZTN DVC PERQ; EA ADD LSN INCL STEREO,,19284,761,$184.00 ,$184.00 ,$55.20 ,$167.44 ,$128.80 ,$55.20 ,$119.60 ,$132.48 ,$167.44 ,$138.00 
Carle BroMenn Medical Center,8419285,PLC BRST LCLZTN DVC PERQ; 1RST LSN INCL US,,19285,761,"$1,455.00 ","$1,455.00 ",$436.50 ,"$1,324.05 ","$1,018.50 ",$436.50 ,$945.75 ,"$1,047.60 ","$1,324.05 ","$1,091.25 "
Carle BroMenn Medical Center,8419286,PLC BRST LCLZTN DVC PERQ; EA ADD LSN INLC US,,19286,761,"$1,210.00 ","$1,210.00 ",$363.00 ,"$1,101.10 ",$847.00 ,$363.00 ,$786.50 ,$871.20 ,"$1,101.10 ",$907.50 
Carle BroMenn Medical Center,8419287,PLC BRST LCLZTN DVC PERQ; 1RST LSN INCL MRI,,19287,761,$720.00 ,$720.00 ,$216.00 ,$655.20 ,$504.00 ,$216.00 ,$468.00 ,$518.40 ,$655.20 ,$540.00 
Carle BroMenn Medical Center,8419288,PLC BRST LCLZTN DVC PERQ; EA ADD LSN INCL MRI,,19288,761,$184.00 ,$184.00 ,$55.20 ,$167.44 ,$128.80 ,$55.20 ,$119.60 ,$132.48 ,$167.44 ,$138.00 
Carle BroMenn Medical Center,8419294,PREP TUMOR CAVITY IORT W/PARTIAL MASTECTOMY,,19294,761,$765.00 ,$765.00 ,$229.50 ,$696.15 ,$535.50 ,$229.50 ,$497.25 ,$550.80 ,$696.15 ,$573.75 
Carle BroMenn Medical Center,8420200,MUSCLE BIOPSY,,20200,761,"$2,535.00 ","$2,535.00 ",$760.50 ,"$2,306.85 ","$1,774.50 ",$760.50 ,"$1,647.75 ","$1,825.20 ","$2,306.85 ","$1,901.25 "
Carle BroMenn Medical Center,8420206,"BIOPSY, MUSCLE",,20206,761,"$2,574.00 ","$2,574.00 ",$772.20 ,"$2,342.34 ","$1,801.80 ",$772.20 ,"$1,673.10 ","$1,853.28 ","$2,342.34 ","$1,930.50 "
Carle BroMenn Medical Center,8420220,"BONE BIOPSY, SUPERFICIAL",,20220,761,"$1,460.00 ","$1,460.00 ",$438.00 ,"$1,328.60 ","$1,022.00 ",$438.00 ,$949.00 ,"$1,051.20 ","$1,328.60 ","$1,095.00 "
Carle BroMenn Medical Center,8420225,"BONE BIOPSY, DEEP",,20225,761,"$1,960.00 ","$1,960.00 ",$588.00 ,"$1,783.60 ","$1,372.00 ",$588.00 ,"$1,274.00 ","$1,411.20 ","$1,783.60 ","$1,470.00 "
Carle BroMenn Medical Center,8420501,INJECT SINUS TRACT FOR DX,,20501,761,$430.00 ,$430.00 ,$129.00 ,$391.30 ,$301.00 ,$129.00 ,$279.50 ,$309.60 ,$391.30 ,$322.50 
Carle BroMenn Medical Center,8420550,INJECT TENDON SHEATH/LIGAMENT,,20550,761,$655.00 ,$655.00 ,$196.50 ,$596.05 ,$458.50 ,$196.50 ,$425.75 ,$471.60 ,$596.05 ,$491.25 
Carle BroMenn Medical Center,8420551,INJ SINGLE TENDON ORIGIN/INSRTN,,20551,761,$420.00 ,$420.00 ,$126.00 ,$382.20 ,$294.00 ,$126.00 ,$273.00 ,$302.40 ,$382.20 ,$315.00 
Carle BroMenn Medical Center,8420552,"INJECT TRIGGER POINT, 1 OR 2",,20552,761,$760.00 ,$760.00 ,$228.00 ,$691.60 ,$532.00 ,$228.00 ,$494.00 ,$547.20 ,$691.60 ,$570.00 
Carle BroMenn Medical Center,8420600,ASP/INJ SMALL JOINT/BURSA W/O US GUIDANCE,,20600,761,$505.00 ,$505.00 ,$151.50 ,$459.55 ,$353.50 ,$151.50 ,$328.25 ,$363.60 ,$459.55 ,$378.75 
Carle BroMenn Medical Center,8420604,ASP/INJ SMALL JOINT/BURSA W/US GUIDANCE,,20604,761,$635.00 ,$635.00 ,$190.50 ,$577.85 ,$444.50 ,$190.50 ,$412.75 ,$457.20 ,$577.85 ,$476.25 
Carle BroMenn Medical Center,8420605,ASP/INJ INTERMED JOINT/BURSA  W/O US GUIDANCE,,20605,761,$830.00 ,$830.00 ,$249.00 ,$755.30 ,$581.00 ,$249.00 ,$539.50 ,$597.60 ,$755.30 ,$622.50 
Carle BroMenn Medical Center,8420606,ASP/INJ INTERMEDIATE JOINT/BURSA W/US GUIDANCE,,20606,761,"$1,041.00 ","$1,041.00 ",$312.30 ,$947.31 ,$728.70 ,$312.30 ,$676.65 ,$749.52 ,$947.31 ,$780.75 
Carle BroMenn Medical Center,8420610,ASP/INJ MAJOR JOINT/BURSA W/O US GUIDANCE,,20610,761,$630.00 ,$630.00 ,$189.00 ,$573.30 ,$441.00 ,$189.00 ,$409.50 ,$453.60 ,$573.30 ,$472.50 
Carle BroMenn Medical Center,8420611,ASP/INJ MAJOR JOINT/BURSA W/US GUIDANCE,,20611,761,$760.00 ,$760.00 ,$228.00 ,$691.60 ,$532.00 ,$228.00 ,$494.00 ,$547.20 ,$691.60 ,$570.00 
Carle BroMenn Medical Center,8420612,ASPRTN/INJ GANGLION CYST(S),,20612,761,$825.00 ,$825.00 ,$247.50 ,$750.75 ,$577.50 ,$247.50 ,$536.25 ,$594.00 ,$750.75 ,$618.75 
Carle BroMenn Medical Center,8420982,ABLTN BONE TUMOR INCL CT GUIDANCE,,20982,761,"$9,023.00 ","$9,023.00 ","$2,706.90 ","$8,210.93 ","$6,316.10 ","$2,706.90 ","$5,864.95 ","$6,496.56 ","$8,210.93 ","$6,767.25 "
Carle BroMenn Medical Center,8420983,ABLATJ BONE TUMOR CRYO PERQ W/IMG GDN WHEN PRFMD,,20983,761,"$9,010.00 ","$9,010.00 ","$2,703.00 ","$8,199.10 ","$6,307.00 ","$2,703.00 ","$5,856.50 ","$6,487.20 ","$8,199.10 ","$6,757.50 "
Carle BroMenn Medical Center,8421550,BIOPSY SOFT TISSUE NECK/CHEST,,21550,761,"$1,245.00 ","$1,245.00 ",$373.50 ,"$1,132.95 ",$871.50 ,$373.50 ,$809.25 ,$896.40 ,"$1,132.95 ",$933.75 
Carle BroMenn Medical Center,8421920,BIOPSY SOFT TISSUE BACK/FLANK; SUPERFICIAL,,21920,761,"$1,445.00 ","$1,445.00 ",$433.50 ,"$1,314.95 ","$1,011.50 ",$433.50 ,$939.25 ,"$1,040.40 ","$1,314.95 ","$1,083.75 "
Carle BroMenn Medical Center,8423350,INJ PROC SHOULDER ARTHROGRAPHY/CT/MRI,,23350,761,$460.00 ,$460.00 ,$138.00 ,$418.60 ,$322.00 ,$138.00 ,$299.00 ,$331.20 ,$418.60 ,$345.00 
Carle BroMenn Medical Center,8424220,INJ PROC ELBOW ARTHROGRAPHY,,24220,761,$280.00 ,$280.00 ,$84.00 ,$254.80 ,$196.00 ,$84.00 ,$182.00 ,$201.60 ,$254.80 ,$210.00 
Carle BroMenn Medical Center,8425246,INJ PROC WRIST ARTHROGRAPHY,,25246,761,$360.00 ,$360.00 ,$108.00 ,$327.60 ,$252.00 ,$108.00 ,$234.00 ,$259.20 ,$327.60 ,$270.00 
Carle BroMenn Medical Center,8427041,"BX SOFT TISSUES,PELV/HIP,DEEP",,27041,761,"$2,873.00 ","$2,873.00 ",$861.90 ,"$2,614.43 ","$2,011.10 ",$861.90 ,"$1,867.45 ","$2,068.56 ","$2,614.43 ","$2,154.75 "
Carle BroMenn Medical Center,8427093,INJ PROC HIP ARTHROGRAPHY W/O ANES,,27093,761,$480.00 ,$480.00 ,$144.00 ,$436.80 ,$336.00 ,$144.00 ,$312.00 ,$345.60 ,$436.80 ,$360.00 
Carle BroMenn Medical Center,8427369,NJX PX CNTRST KNE ARTHG CNTRST ENHNCD CT/MRI KNE,,27369,761,$490.00 ,$490.00 ,$147.00 ,$445.90 ,$343.00 ,$147.00 ,$318.50 ,$352.80 ,$445.90 ,$367.50 
Carle BroMenn Medical Center,8427370,INJ KNEE ARTHROGRAPHY,,27370,761,$383.00 ,$383.00 ,$114.90 ,$348.53 ,$268.10 ,$114.90 ,$248.95 ,$275.76 ,$348.53 ,$287.25 
Carle BroMenn Medical Center,8427648,INJ PROC FOR ANKLE ARTHROGRAPHY,,27648,761,$490.00 ,$490.00 ,$147.00 ,$445.90 ,$343.00 ,$147.00 ,$318.50 ,$352.80 ,$445.90 ,$367.50 
Carle BroMenn Medical Center,8431299,UNLISTED PROC ACCESSORY SINUSES,,31299,761,$308.00 ,$308.00 ,$92.40 ,$280.28 ,$215.60 ,$92.40 ,$200.20 ,$221.76 ,$280.28 ,$231.00 
Carle BroMenn Medical Center,8432400,"BIOPSY, PLEURA PERC NEEDLE",,32400,761,"$2,925.00 ","$2,925.00 ",$877.50 ,"$2,661.75 ","$2,047.50 ",$877.50 ,"$1,901.25 ","$2,106.00 ","$2,661.75 ","$2,193.75 "
Carle BroMenn Medical Center,8432405,"BIOPSY,LUNG/MEDIASTINUM,PERC",,32405,761,"$2,040.00 ","$2,040.00 ",$612.00 ,"$1,856.40 ","$1,428.00 ",$612.00 ,"$1,326.00 ","$1,468.80 ","$1,856.40 ","$1,530.00 "
Carle BroMenn Medical Center,8432408,CORE NEEDLE BX LUNG/MEDIASTINUM PERQ W/IMG,,32408,761,"$2,970.00 ","$2,970.00 ",$891.00 ,"$2,702.70 ","$2,079.00 ",$891.00 ,"$1,930.50 ","$2,138.40 ","$2,702.70 ","$2,227.50 "
Carle BroMenn Medical Center,8432551,TUBE THORACOSTOMY,,32551,761,"$1,400.00 ","$1,400.00 ",$420.00 ,"$1,274.00 ",$980.00 ,$420.00 ,$910.00 ,"$1,008.00 ","$1,274.00 ","$1,050.00 "
Carle BroMenn Medical Center,8432552,RMV TUNNLD PLEURAL CATH W/CUFF,,32552,761,$570.00 ,$570.00 ,$171.00 ,$518.70 ,$399.00 ,$171.00 ,$370.50 ,$410.40 ,$518.70 ,$427.50 
Carle BroMenn Medical Center,8432554,THORACENTESIS W/O IMAGING,,32554,761,"$1,795.00 ","$1,795.00 ",$538.50 ,"$1,633.45 ","$1,256.50 ",$538.50 ,"$1,166.75 ","$1,292.40 ","$1,633.45 ","$1,346.25 "
Carle BroMenn Medical Center,8432555,THORACENTESIS W/IMAGING,,32555,761,"$2,105.00 ","$2,105.00 ",$631.50 ,"$1,915.55 ","$1,473.50 ",$631.50 ,"$1,368.25 ","$1,515.60 ","$1,915.55 ","$1,578.75 "
Carle BroMenn Medical Center,8432557,PERC PLEURAL DRAINAGE W/IMAGING,,32557,761,"$1,845.00 ","$1,845.00 ",$553.50 ,"$1,678.95 ","$1,291.50 ",$553.50 ,"$1,199.25 ","$1,328.40 ","$1,678.95 ","$1,383.75 "
Carle BroMenn Medical Center,8432994,ABLATION THER 1+ PULM TUMORS PERQ CRYOABLATION,,32994,761,"$14,440.00 ","$14,440.00 ","$4,332.00 ","$13,140.40 ","$10,108.00 ","$4,332.00 ","$9,386.00 ","$10,396.80 ","$13,140.40 ","$10,830.00 "
Carle BroMenn Medical Center,8432998,ABLTN PULM TUMOR(S),,32998,761,"$11,115.00 ","$11,115.00 ","$3,334.50 ","$10,114.65 ","$7,780.50 ","$3,334.50 ","$7,224.75 ","$8,002.80 ","$10,114.65 ","$8,336.25 "
Carle BroMenn Medical Center,8432999,UNLISTED-LUNGS AND PLEURA,,32999,761,$760.00 ,$760.00 ,$228.00 ,$691.60 ,$532.00 ,$228.00 ,$494.00 ,$547.20 ,$691.60 ,$570.00 
Carle BroMenn Medical Center,8433016,PERICARDIOCENTESIS W/IMG GUIDANCE WHEN PERFORMED,,33016,761,"$1,545.00 ","$1,545.00 ",$463.50 ,"$1,405.95 ","$1,081.50 ",$463.50 ,"$1,004.25 ","$1,112.40 ","$1,405.95 ","$1,158.75 "
Carle BroMenn Medical Center,8433018,PERQ PRCRD DRG 0-5YR/ANY AGE W/CGEN CAR ANOMALY,,33018,761,"$5,040.00 ","$5,040.00 ","$1,512.00 ","$4,586.40 ","$3,528.00 ","$1,512.00 ","$3,276.00 ","$3,628.80 ","$4,586.40 ","$3,780.00 "
Carle BroMenn Medical Center,8433019,PERQ PERICARDIAL DRG W/INSJ NDWELLG CATH W/CT,,33019,761,"$4,035.00 ","$4,035.00 ","$1,210.50 ","$3,671.85 ","$2,824.50 ","$1,210.50 ","$2,622.75 ","$2,905.20 ","$3,671.85 ","$3,026.25 "
Carle BroMenn Medical Center,8436221,ANGIO CERVICOCEREBRAL (ARCH),,36221,761,"$4,290.00 ","$4,290.00 ","$1,287.00 ","$3,903.90 ","$3,003.00 ","$1,287.00 ","$2,788.50 ","$3,088.80 ","$3,903.90 ","$3,217.50 "
Carle BroMenn Medical Center,8436222,CERVICAL CAROTID ANGIO W/WO ARCH -UNI,,36222,761,"$7,635.00 ","$7,635.00 ","$2,290.50 ","$6,947.85 ","$5,344.50 ","$2,290.50 ","$4,962.75 ","$5,497.20 ","$6,947.85 ","$5,726.25 "
Carle BroMenn Medical Center,8436223,CEREBRL ANGIO W/WO EXT CAROTD/ARCH -UNI,,36223,761,"$10,530.00 ","$10,530.00 ","$3,159.00 ","$9,582.30 ","$7,371.00 ","$3,159.00 ","$6,844.50 ","$7,581.60 ","$9,582.30 ","$7,897.50 "
Carle BroMenn Medical Center,8436224,CEREBRL ANGIO W/WO EXT CAROTD/ARCH -UNI,,36224,761,"$12,458.00 ","$12,458.00 ","$3,737.40 ","$11,336.78 ","$8,720.60 ","$3,737.40 ","$8,097.70 ","$8,969.76 ","$11,336.78 ","$9,343.50 "
Carle BroMenn Medical Center,8436225,VERTEBRAL ANGIOGRPHY W/WO ARCH -UNI,,36225,761,"$7,073.00 ","$7,073.00 ","$2,121.90 ","$6,436.43 ","$4,951.10 ","$2,121.90 ","$4,597.45 ","$5,092.56 ","$6,436.43 ","$5,304.75 "
Carle BroMenn Medical Center,8436226,VERTEBRAL ANGIOGRPHY W/WO ARCH -UNI,,36226,761,"$8,460.00 ","$8,460.00 ","$2,538.00 ","$7,698.60 ","$5,922.00 ","$2,538.00 ","$5,499.00 ","$6,091.20 ","$7,698.60 ","$6,345.00 "
Carle BroMenn Medical Center,8436227,EXTERNAL CAROTID ANGIOGRPHY -UNI,,36227,761,"$5,933.00 ","$5,933.00 ","$1,779.90 ","$5,399.03 ","$4,153.10 ","$1,779.90 ","$3,856.45 ","$4,271.76 ","$5,399.03 ","$4,449.75 "
Carle BroMenn Medical Center,8436465,NJX NONCMPND SCLEROSANT SINGLE INCMPTNT VEIN,,36465,761,"$1,133.00 ","$1,133.00 ",$339.90 ,"$1,031.03 ",$793.10 ,$339.90 ,$736.45 ,$815.76 ,"$1,031.03 ",$849.75 
Carle BroMenn Medical Center,8436466,NJX NONCMPND SCLEROSANT MULTIPLE INCMPTNT VEINS,,36466,761,"$1,133.00 ","$1,133.00 ",$339.90 ,"$1,031.03 ",$793.10 ,$339.90 ,$736.45 ,$815.76 ,"$1,031.03 ",$849.75 
Carle BroMenn Medical Center,8436468,INJ SCLEROSING SLTN SPIDER VEINS LIMB/TRUNK,,36468,761,$755.00 ,$755.00 ,$226.50 ,$687.05 ,$528.50 ,$226.50 ,$490.75 ,$543.60 ,$687.05 ,$566.25 
Carle BroMenn Medical Center,8436470,INJ SCLEROSING SOLUTION SINGLE VEIN,,36470,761,"$1,050.00 ","$1,050.00 ",$315.00 ,$955.50 ,$735.00 ,$315.00 ,$682.50 ,$756.00 ,$955.50 ,$787.50 
Carle BroMenn Medical Center,8436471,INJ SCLEROSING SOLUTION MULT VEINS SAME LEG,,36471,761,"$1,490.00 ","$1,490.00 ",$447.00 ,"$1,355.90 ","$1,043.00 ",$447.00 ,$968.50 ,"$1,072.80 ","$1,355.90 ","$1,117.50 "
Carle BroMenn Medical Center,8436473,ENDOVEN ABLTJ INCMPTNT VEIN MCHNCHEM 1ST VEIN,,36473,761,"$5,753.00 ","$5,753.00 ","$1,725.90 ","$5,235.23 ","$4,027.10 ","$1,725.90 ","$3,739.45 ","$4,142.16 ","$5,235.23 ","$4,314.75 "
Carle BroMenn Medical Center,8436474,ENDOVEN ABLTJ INCMPTNT VEIN MCHNCHEM SBSQ VEINS,,36474,761,"$1,155.00 ","$1,155.00 ",$346.50 ,"$1,051.05 ",$808.50 ,$346.50 ,$750.75 ,$831.60 ,"$1,051.05 ",$866.25 
Carle BroMenn Medical Center,8436475,ENDOVENOUS ABLTN EXT VEIN PERCT 1RST VEIN,,36475,761,"$11,915.00 ","$11,915.00 ","$3,574.50 ","$10,842.65 ","$8,340.50 ","$3,574.50 ","$7,744.75 ","$8,578.80 ","$10,842.65 ","$8,936.25 "
Carle BroMenn Medical Center,8436476,ENDOVENOUS ABLTN EXT VEIN PERCT EA SPRT VEIN SITE,,36476,761,"$1,505.00 ","$1,505.00 ",$451.50 ,"$1,369.55 ","$1,053.50 ",$451.50 ,$978.25 ,"$1,083.60 ","$1,369.55 ","$1,128.75 "
Carle BroMenn Medical Center,8436478,"ENDOVENOUS ABLTN VEIN W/IMAGING, 1RST VEIN",,36478,761,"$8,710.00 ","$8,710.00 ","$2,613.00 ","$7,926.10 ","$6,097.00 ","$2,613.00 ","$5,661.50 ","$6,271.20 ","$7,926.10 ","$6,532.50 "
Carle BroMenn Medical Center,8436479,"ENDOVENOUS ABLTN VEIN W/IMGNG, 2ND AND > VEINS, EA",,36479,761,"$2,310.00 ","$2,310.00 ",$693.00 ,"$2,102.10 ","$1,617.00 ",$693.00 ,"$1,501.50 ","$1,663.20 ","$2,102.10 ","$1,732.50 "
Carle BroMenn Medical Center,8436482,ENDOVEN ABLTI THER CHEM ADHESIVE 1ST VEIN,,36482,761,"$3,218.00 ","$3,218.00 ",$965.40 ,"$2,928.38 ","$2,252.60 ",$965.40 ,"$2,091.70 ","$2,316.96 ","$2,928.38 ","$2,413.50 "
Carle BroMenn Medical Center,8436483,ENDOVEN ABLTI THER CHEM ADHESIVE SBSQ VEIN,,36483,761,$240.00 ,$240.00 ,$72.00 ,$218.40 ,$168.00 ,$72.00 ,$156.00 ,$172.80 ,$218.40 ,$180.00 
Carle BroMenn Medical Center,8436558,INSRTN TUNNLD CVC W/O PORT/PMP,,36558,761,"$2,220.00 ","$2,220.00 ",$666.00 ,"$2,020.20 ","$1,554.00 ",$666.00 ,"$1,443.00 ","$1,598.40 ","$2,020.20 ","$1,665.00 "
Carle BroMenn Medical Center,8436572,INSERTION PICC W/RS&I < 5 YR,,36572,761,$893.00 ,$893.00 ,$267.90 ,$812.63 ,$625.10 ,$267.90 ,$580.45 ,$642.96 ,$812.63 ,$669.75 
Carle BroMenn Medical Center,8436573,INSERTION PICC W/RS&I 5 YR/>,,36573,761,"$2,242.00 ","$2,242.00 ",$672.60 ,"$2,040.22 ","$1,569.40 ",$672.60 ,"$1,457.30 ","$1,614.24 ","$2,040.22 ","$1,681.50 "
Carle BroMenn Medical Center,8436589,RMVL TNNLD CVC W/O PORT/PUMP,,36589,761,"$1,845.00 ","$1,845.00 ",$553.50 ,"$1,678.95 ","$1,291.50 ",$553.50 ,"$1,199.25 ","$1,328.40 ","$1,678.95 ","$1,383.75 "
Carle BroMenn Medical Center,8436590,REMOVAL TUNNELED CV CATH W SUBQ PORT OR PUMP,,36590,761,"$2,760.00 ","$2,760.00 ",$828.00 ,"$2,511.60 ","$1,932.00 ",$828.00 ,"$1,794.00 ","$1,987.20 ","$2,511.60 ","$2,070.00 "
Carle BroMenn Medical Center,8436598,EVAL CV DVC W/INJECTN & FLUORO,,36598,761,$595.00 ,$595.00 ,$178.50 ,$541.45 ,$416.50 ,$178.50 ,$386.75 ,$428.40 ,$541.45 ,$446.25 
Carle BroMenn Medical Center,8437242,VASC EMBOLIZE/OCCLUDE ARTERY,,37242,761,"$21,623.00 ","$21,623.00 ","$6,486.90 ","$19,676.93 ","$15,136.10 ","$6,486.90 ","$14,054.95 ","$15,568.56 ","$19,676.93 ","$16,217.25 "
Carle BroMenn Medical Center,8437765,"STAB PLEBECTMY VARICOSE VEINS, 1 EXT, 10-20 STAB INC",,37765,761,"$8,245.00 ","$8,245.00 ","$2,473.50 ","$7,502.95 ","$5,771.50 ","$2,473.50 ","$5,359.25 ","$5,936.40 ","$7,502.95 ","$6,183.75 "
Carle BroMenn Medical Center,8438220,BONE MARROW ASPIRATION ONLY,,38220,761,$910.00 ,$910.00 ,$273.00 ,$828.10 ,$637.00 ,$273.00 ,$591.50 ,$655.20 ,$828.10 ,$682.50 
Carle BroMenn Medical Center,8438221,BONE MARROW BX ONLY,,38221,761,"$1,228.50 ","$1,228.50 ",$368.55 ,"$1,117.94 ",$859.95 ,$368.55 ,$798.53 ,$884.52 ,"$1,117.94 ",$921.38 
Carle BroMenn Medical Center,8438222,DIAGNOSTIC BONE MARROW BIOPSIES & ASPIRATIONS,,38222,761,"$1,620.00 ","$1,620.00 ",$486.00 ,"$1,474.20 ","$1,134.00 ",$486.00 ,"$1,053.00 ","$1,166.40 ","$1,474.20 ","$1,215.00 "
Carle BroMenn Medical Center,8438505,"NEEDLE BIOPSY, LYMPH NODES",,38505,761,"$2,340.00 ","$2,340.00 ",$702.00 ,"$2,129.40 ","$1,638.00 ",$702.00 ,"$1,521.00 ","$1,684.80 ","$2,129.40 ","$1,755.00 "
Carle BroMenn Medical Center,8438792,INJ PRC ID SENTINAL NODE,,38792,761,$990.00 ,$990.00 ,$297.00 ,$900.90 ,$693.00 ,$297.00 ,$643.50 ,$712.80 ,$900.90 ,$742.50 
Carle BroMenn Medical Center,8442400,BX SALIVARY GLAND; NEEDLE,,42400,761,"$1,455.00 ","$1,455.00 ",$436.50 ,"$1,324.05 ","$1,018.50 ",$436.50 ,$945.75 ,"$1,047.60 ","$1,324.05 ","$1,091.25 "
Carle BroMenn Medical Center,8443752,GASTRIC TUBE PLCMNT W/FLUORO,,43752,761,$510.00 ,$510.00 ,$153.00 ,$464.10 ,$357.00 ,$153.00 ,$331.50 ,$367.20 ,$464.10 ,$382.50 
Carle BroMenn Medical Center,8443762,PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC,,43762,761,$500.00 ,$500.00 ,$150.00 ,$455.00 ,$350.00 ,$150.00 ,$325.00 ,$360.00 ,$455.00 ,$375.00 
Carle BroMenn Medical Center,8443763,PERQ REPLACEMENT GTUBE REQ REVJ GSTRST TRC,,43763,761,$730.00 ,$730.00 ,$219.00 ,$664.30 ,$511.00 ,$219.00 ,$474.50 ,$525.60 ,$664.30 ,$547.50 
Carle BroMenn Medical Center,8447000,"BIOSPY OF LIVER, PERCUTANEOUS",,47000,761,"$2,210.00 ","$2,210.00 ",$663.00 ,"$2,011.10 ","$1,547.00 ",$663.00 ,"$1,436.50 ","$1,591.20 ","$2,011.10 ","$1,657.50 "
Carle BroMenn Medical Center,8447382,ABLTN LIVER TUMOR(S) PERCUT,,47382,761,"$9,997.00 ","$9,997.00 ","$2,999.10 ","$9,097.27 ","$6,997.90 ","$2,999.10 ","$6,498.05 ","$7,197.84 ","$9,097.27 ","$7,497.75 "
Carle BroMenn Medical Center,8447490,"CHOLECYSTOSTOMY, TUBE PLCMNT",,47490,761,"$5,928.00 ","$5,928.00 ","$1,778.40 ","$5,394.48 ","$4,149.60 ","$1,778.40 ","$3,853.20 ","$4,268.16 ","$5,394.48 ","$4,446.00 "
Carle BroMenn Medical Center,8447534,PRQ PLMT BILIARY DRG CATH W/IMG GID RS&I INT-EXT,,47534,761,"$4,665.00 ","$4,665.00 ","$1,399.50 ","$4,245.15 ","$3,265.50 ","$1,399.50 ","$3,032.25 ","$3,358.80 ","$4,245.15 ","$3,498.75 "
Carle BroMenn Medical Center,8447535,CONV EXT BIL DRG CATH TO INT-EXT BIL DRG CATH,,47535,761,"$5,483.00 ","$5,483.00 ","$1,644.90 ","$4,989.53 ","$3,838.10 ","$1,644.90 ","$3,563.95 ","$3,947.76 ","$4,989.53 ","$4,112.25 "
Carle BroMenn Medical Center,8448102,"BIOPSY, PANCREAS",,48102,761,"$2,265.90 ","$2,265.90 ",$679.77 ,"$2,061.97 ","$1,586.13 ",$679.77 ,"$1,472.84 ","$1,631.45 ","$2,061.97 ","$1,699.43 "
Carle BroMenn Medical Center,8449082,ABD PARACENTESIS W/O IMAGING GUIDANCE,,49082,761,$965.00 ,$965.00 ,$289.50 ,$878.15 ,$675.50 ,$289.50 ,$627.25 ,$694.80 ,$878.15 ,$723.75 
Carle BroMenn Medical Center,8449083,ABD PARACENTESIS W/ IMAGING GUIDANCE,,49083,761,"$3,003.00 ","$3,003.00 ",$900.90 ,"$2,732.73 ","$2,102.10 ",$900.90 ,"$1,951.95 ","$2,162.16 ","$2,732.73 ","$2,252.25 "
Carle BroMenn Medical Center,8449180,"BIOSPY,ABDOMINAL, PERC NEEDLE",,49180,761,"$2,340.00 ","$2,340.00 ",$702.00 ,"$2,129.40 ","$1,638.00 ",$702.00 ,"$1,521.00 ","$1,684.80 ","$2,129.40 ","$1,755.00 "
Carle BroMenn Medical Center,8449405,"IMG GUIDE CATH FLD CLCTN VISCERAL, PERQ",,49405,761,"$3,690.00 ","$3,690.00 ","$1,107.00 ","$3,357.90 ","$2,583.00 ","$1,107.00 ","$2,398.50 ","$2,656.80 ","$3,357.90 ","$2,767.50 "
Carle BroMenn Medical Center,8449406,"IMG GUIDE CATH FLD CLCTN PERI/RETRO, PERQ",,49406,761,"$1,900.00 ","$1,900.00 ",$570.00 ,"$1,729.00 ","$1,330.00 ",$570.00 ,"$1,235.00 ","$1,368.00 ","$1,729.00 ","$1,425.00 "
Carle BroMenn Medical Center,8449424,CNTRST INJ ABCSS/CYST VIA PRV PLCD CATH/TUBE,,49424,761,$515.00 ,$515.00 ,$154.50 ,$468.65 ,$360.50 ,$154.50 ,$334.75 ,$370.80 ,$468.65 ,$386.25 
Carle BroMenn Medical Center,8449451,REPLAC DUODEN/JEJUNOSTOMY TUBE,,49451,761,"$1,735.00 ","$1,735.00 ",$520.50 ,"$1,578.85 ","$1,214.50 ",$520.50 ,"$1,127.75 ","$1,249.20 ","$1,578.85 ","$1,301.25 "
Carle BroMenn Medical Center,8449465,EVALUATN GI-OSTOMY TUBE,,49465,761,$655.00 ,$655.00 ,$196.50 ,$596.05 ,$458.50 ,$196.50 ,$425.75 ,$471.60 ,$596.05 ,$491.25 
Carle BroMenn Medical Center,8449999,"UL PROC ABD, PERITONEUM, OMENTUN",,49999,761,"$1,550.00 ","$1,550.00 ",$465.00 ,"$1,410.50 ","$1,085.00 ",$465.00 ,"$1,007.50 ","$1,116.00 ","$1,410.50 ","$1,162.50 "
Carle BroMenn Medical Center,8450200,RENAL BIOPSY; PERCUTANEOUS,,50200,761,$990.00 ,$990.00 ,$297.00 ,$900.90 ,$693.00 ,$297.00 ,$643.50 ,$712.80 ,$900.90 ,$742.50 
Carle BroMenn Medical Center,8450390,"ASP/INJ RENAL CYST, PERCUT",,50390,761,"$1,355.00 ","$1,355.00 ",$406.50 ,"$1,233.05 ",$948.50 ,$406.50 ,$880.75 ,$975.60 ,"$1,233.05 ","$1,016.25 "
Carle BroMenn Medical Center,8450395,EST NEPHROSTOMY TRACT; PERCT,,50395,761,"$3,503.00 ","$3,503.00 ","$1,050.90 ","$3,187.73 ","$2,452.10 ","$1,050.90 ","$2,276.95 ","$2,522.16 ","$3,187.73 ","$2,627.25 "
Carle BroMenn Medical Center,8450431,NJX PX ANTEGRDE NFROSGRM &/URTRGRM EXSTNG ACESS,,50431,761,"$1,485.00 ","$1,485.00 ",$445.50 ,"$1,351.35 ","$1,039.50 ",$445.50 ,$965.25 ,"$1,069.20 ","$1,351.35 ","$1,113.75 "
Carle BroMenn Medical Center,8450432,PLMT NEPHROSTOMY CATH PRQ NEW ACCESS RS&I,,50432,761,"$3,615.00 ","$3,615.00 ","$1,084.50 ","$3,289.65 ","$2,530.50 ","$1,084.50 ","$2,349.75 ","$2,602.80 ","$3,289.65 ","$2,711.25 "
Carle BroMenn Medical Center,8450436,PERQ DILATION XST TRC ENDOUROLOGIC PX W/IMG,,50436,761,"$3,345.00 ","$3,345.00 ","$1,003.50 ","$3,043.95 ","$2,341.50 ","$1,003.50 ","$2,174.25 ","$2,408.40 ","$3,043.95 ","$2,508.75 "
Carle BroMenn Medical Center,8450437,PERQ DILATION XST TRC NEW ACCESS RENAL COLTJ SYS,,50437,761,"$5,640.00 ","$5,640.00 ","$1,692.00 ","$5,132.40 ","$3,948.00 ","$1,692.00 ","$3,666.00 ","$4,060.80 ","$5,132.40 ","$4,230.00 "
Carle BroMenn Medical Center,8450592,"ABLTN,RENAL TUMR,UNI,PERC,RADI",,50592,761,"$9,997.00 ","$9,997.00 ","$2,999.10 ","$9,097.27 ","$6,997.90 ","$2,999.10 ","$6,498.05 ","$7,197.84 ","$9,097.27 ","$7,497.75 "
Carle BroMenn Medical Center,8450593,"ABLTN,RENAL TUMR,UNI,PERC,CYRO",,50593,761,"$14,388.40 ","$14,388.40 ","$4,316.52 ","$13,093.44 ","$10,071.88 ","$4,316.52 ","$9,352.46 ","$10,359.65 ","$13,093.44 ","$10,791.30 "
Carle BroMenn Medical Center,8450690,INJ PROC VISUAL ILEAL CONDT/URETEROPYELOGRPHY,,50690,761,"$1,055.00 ","$1,055.00 ",$316.50 ,$960.05 ,$738.50 ,$316.50 ,$685.75 ,$759.60 ,$960.05 ,$791.25 
Carle BroMenn Medical Center,8451102,ASPRTN BLADDER,,51102,761,"$1,345.00 ","$1,345.00 ",$403.50 ,"$1,223.95 ",$941.50 ,$403.50 ,$874.25 ,$968.40 ,"$1,223.95 ","$1,008.75 "
Carle BroMenn Medical Center,8451600,INJ PRC CYSTGRPHY/URETHCYSTGRPHY,,51600,761,$645.00 ,$645.00 ,$193.50 ,$586.95 ,$451.50 ,$193.50 ,$419.25 ,$464.40 ,$586.95 ,$483.75 
Carle BroMenn Medical Center,8451610,INJ FOR RETROGRD URETHOCYSTGRPHY,,51610,761,$395.00 ,$395.00 ,$118.50 ,$359.45 ,$276.50 ,$118.50 ,$256.75 ,$284.40 ,$359.45 ,$296.25 
Carle BroMenn Medical Center,8453854,TRURL DSTRJ PRST8 TISS RF WV THERMOTHERAPY,,53854,761,"$2,560.00 ","$2,560.00 ",$768.00 ,"$2,329.60 ","$1,792.00 ",$768.00 ,"$1,664.00 ","$1,843.20 ","$2,329.60 ","$1,920.00 "
Carle BroMenn Medical Center,8455700,"BX PROSTATE NEEDLE OR PUNCH, SINGL OR MULT",,55700,761,"$2,684.50 ","$2,684.50 ",$805.35 ,"$2,442.90 ","$1,879.15 ",$805.35 ,"$1,744.93 ","$1,932.84 ","$2,442.90 ","$2,013.38 "
Carle BroMenn Medical Center,8455873,CRYOSURGICAL ABLATION PROSTATE,,55873,761,"$15,803.00 ","$15,803.00 ","$4,740.90 ","$14,380.73 ","$11,062.10 ","$4,740.90 ","$10,271.95 ","$11,378.16 ","$14,380.73 ","$11,852.25 "
Carle BroMenn Medical Center,8455874,TRANSPERINEAL PLMT BIODEGRADABLE MATRL 1/MLT NJX,,55874,761,"$2,875.00 ","$2,875.00 ",$862.50 ,"$2,616.25 ","$2,012.50 ",$862.50 ,"$1,868.75 ","$2,070.00 ","$2,616.25 ","$2,156.25 "
Carle BroMenn Medical Center,8455880,TRANSRECTAL ABLTJ MAL PRST8 TISSUE HIFU W/US,,55880,761,"$3,600.00 ","$3,600.00 ","$1,080.00 ","$3,276.00 ","$2,520.00 ","$1,080.00 ","$2,340.00 ","$2,592.00 ","$3,276.00 ","$2,700.00 "
Carle BroMenn Medical Center,8458300,INSERT INTRAUTERINE DEVICE,,58300,761,$420.00 ,$420.00 ,$126.00 ,$382.20 ,$294.00 ,$126.00 ,$273.00 ,$302.40 ,$382.20 ,$315.00 
Carle BroMenn Medical Center,8458340,CATH/INJECT HYSTEROSALPINGOGRAM,,58340,761,$425.00 ,$425.00 ,$127.50 ,$386.75 ,$297.50 ,$127.50 ,$276.25 ,$306.00 ,$386.75 ,$318.75 
Carle BroMenn Medical Center,8459000,AMNIOCENTESIS DIAGNOSTIC,,59000,761,$615.00 ,$615.00 ,$184.50 ,$559.65 ,$430.50 ,$184.50 ,$399.75 ,$442.80 ,$559.65 ,$461.25 
Carle BroMenn Medical Center,8459001,AMNIOCENTESIS THERAPEUTIC,,59001,761,$458.00 ,$458.00 ,$137.40 ,$416.78 ,$320.60 ,$137.40 ,$297.70 ,$329.76 ,$416.78 ,$343.50 
Carle BroMenn Medical Center,8459012,CORDOCENTESIS (INTRAUTERINE) ANY METHOD,,59012,761,$473.00 ,$473.00 ,$141.90 ,$430.43 ,$331.10 ,$141.90 ,$307.45 ,$340.56 ,$430.43 ,$354.75 
Carle BroMenn Medical Center,8460100,BX THYROID PERCUT CORE NEEDLE,,60100,761,"$1,183.00 ","$1,183.00 ",$354.90 ,"$1,076.53 ",$828.10 ,$354.90 ,$768.95 ,$851.76 ,"$1,076.53 ",$887.25 
Carle BroMenn Medical Center,8460699,UNLISTED PROC ENDOCRINE SYSTEM,,60699,761,"$6,402.50 ","$6,402.50 ","$1,920.75 ","$5,826.28 ","$4,481.75 ","$1,920.75 ","$4,161.63 ","$4,609.80 ","$5,826.28 ","$4,801.88 "
Carle BroMenn Medical Center,8461055,CISTERNAL/LAT CERV PUNCT; W/INJ,,61055,761,"$1,095.00 ","$1,095.00 ",$328.50 ,$996.45 ,$766.50 ,$328.50 ,$711.75 ,$788.40 ,$996.45 ,$821.25 
Carle BroMenn Medical Center,8462267,PERCUT ASPIRATION VERTEBRAL DISC,,62267,761,"$1,891.50 ","$1,891.50 ",$567.45 ,"$1,721.27 ","$1,324.05 ",$567.45 ,"$1,229.48 ","$1,361.88 ","$1,721.27 ","$1,418.63 "
Carle BroMenn Medical Center,8462270,LUMBAR PUNCTURE,,62270,761,"$1,035.00 ","$1,035.00 ",$310.50 ,$941.85 ,$724.50 ,$310.50 ,$672.75 ,$745.20 ,$941.85 ,$776.25 
Carle BroMenn Medical Center,8462272,"SPINAL PUNCTURE,THERAPEUTIC DRAINAGE",,62272,761,"$1,025.00 ","$1,025.00 ",$307.50 ,$932.75 ,$717.50 ,$307.50 ,$666.25 ,$738.00 ,$932.75 ,$768.75 
Carle BroMenn Medical Center,8462284,"INJ FOR MYELOGRAPHY,SPINAL",,62284,761,$580.00 ,$580.00 ,$174.00 ,$527.80 ,$406.00 ,$174.00 ,$377.00 ,$417.60 ,$527.80 ,$435.00 
Carle BroMenn Medical Center,8462302,MYELOGRAPHY VIA LUMBAR INJECTION RS&I CERVICAL,,62302,761,"$1,775.00 ","$1,775.00 ",$532.50 ,"$1,615.25 ","$1,242.50 ",$532.50 ,"$1,153.75 ","$1,278.00 ","$1,615.25 ","$1,331.25 "
Carle BroMenn Medical Center,8462303,MYELOGRAPHY VIA LUMBAR INJECTION RS&I THORACIC,,62303,761,"$1,655.00 ","$1,655.00 ",$496.50 ,"$1,506.05 ","$1,158.50 ",$496.50 ,"$1,075.75 ","$1,191.60 ","$1,506.05 ","$1,241.25 "
Carle BroMenn Medical Center,8462304,MYELOGRAPHY VIA LUMBAR INJECT RS&I LUMBOSACRAL,,62304,761,"$1,215.00 ","$1,215.00 ",$364.50 ,"$1,105.65 ",$850.50 ,$364.50 ,$789.75 ,$874.80 ,"$1,105.65 ",$911.25 
Carle BroMenn Medical Center,8462305,MYELOGRAPHY VIA LUMBAR INJECTION RS&I 2+ REGIONS,,62305,761,"$1,350.00 ","$1,350.00 ",$405.00 ,"$1,228.50 ",$945.00 ,$405.00 ,$877.50 ,$972.00 ,"$1,228.50 ","$1,012.50 "
Carle BroMenn Medical Center,8462328,DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT,,62328,761,"$1,350.00 ","$1,350.00 ",$405.00 ,"$1,228.50 ",$945.00 ,$405.00 ,$877.50 ,$972.00 ,"$1,228.50 ","$1,012.50 "
Carle BroMenn Medical Center,8462329,THERAPEUTIC SPINAL PNXR DRAINAGE CSF W/FLUOR/CT,,62329,761,"$1,340.00 ","$1,340.00 ",$402.00 ,"$1,219.40 ",$938.00 ,$402.00 ,$871.00 ,$964.80 ,"$1,219.40 ","$1,005.00 "
Carle BroMenn Medical Center,8464430,"INJECT NERV BLCK,PUDENDAL",,64430,761,"$1,178.00 ","$1,178.00 ",$353.40 ,"$1,071.98 ",$824.60 ,$353.40 ,$765.70 ,$848.16 ,"$1,071.98 ",$883.50 
Carle BroMenn Medical Center,8464450,"INJECT NERV BLCK,OTHR PERIPH NERV",,64450,761,"$1,085.00 ","$1,085.00 ",$325.50 ,$987.35 ,$759.50 ,$325.50 ,$705.25 ,$781.20 ,$987.35 ,$813.75 
Carle BroMenn Medical Center,8464451,INJECTION AA&/STRD NERVES NRVTG SI JOINT W/IMG,,64451,761,"$2,295.00 ","$2,295.00 ",$688.50 ,"$2,088.45 ","$1,606.50 ",$688.50 ,"$1,491.75 ","$1,652.40 ","$2,088.45 ","$1,721.25 "
Carle BroMenn Medical Center,8464454,INJECTION AA&/STRD GENICULAR NRV BRANCHES W/IMG,,64454,761,"$2,365.00 ","$2,365.00 ",$709.50 ,"$2,152.15 ","$1,655.50 ",$709.50 ,"$1,537.25 ","$1,702.80 ","$2,152.15 ","$1,773.75 "
Carle BroMenn Medical Center,8464455,INJECT PLANTAR COMMON DIGITAL NERVE,,64455,761,$460.00 ,$460.00 ,$138.00 ,$418.60 ,$322.00 ,$138.00 ,$299.00 ,$331.20 ,$418.60 ,$345.00 
Carle BroMenn Medical Center,8464461,PVB THORACIC SINGLE INJECTION SITE W/IMG GID,,64461,761,"$1,085.00 ","$1,085.00 ",$325.50 ,$987.35 ,$759.50 ,$325.50 ,$705.25 ,$781.20 ,$987.35 ,$813.75 
Carle BroMenn Medical Center,8464479,INJ ANES AGENT TRNSFRML EDIDRL C/T SNGL LVL,,64479,761,"$1,855.00 ","$1,855.00 ",$556.50 ,"$1,688.05 ","$1,298.50 ",$556.50 ,"$1,205.75 ","$1,335.60 ","$1,688.05 ","$1,391.25 "
Carle BroMenn Medical Center,8464483,"INJ,FORAMEN,L/S,1 LEVEL",,64483,761,"$1,580.00 ","$1,580.00 ",$474.00 ,"$1,437.80 ","$1,106.00 ",$474.00 ,"$1,027.00 ","$1,137.60 ","$1,437.80 ","$1,185.00 "
Carle BroMenn Medical Center,8464530,INJ ANES AGENT CELIAC PLEXUS,,64530,761,"$1,911.00 ","$1,911.00 ",$573.30 ,"$1,739.01 ","$1,337.70 ",$573.30 ,"$1,242.15 ","$1,375.92 ","$1,739.01 ","$1,433.25 "
Carle BroMenn Medical Center,8464624,DESTRUCTION NEUROLYTIC AGT GENICULAR NERVE W/IMG,,64624,761,"$3,450.00 ","$3,450.00 ","$1,035.00 ","$3,139.50 ","$2,415.00 ","$1,035.00 ","$2,242.50 ","$2,484.00 ","$3,139.50 ","$2,587.50 "
Carle BroMenn Medical Center,8464625,RADIOFREQUENCY ABLTJ NRV NRVTG SI JT W/IMG GDN,,64625,761,"$4,480.00 ","$4,480.00 ","$1,344.00 ","$4,076.80 ","$3,136.00 ","$1,344.00 ","$2,912.00 ","$3,225.60 ","$4,076.80 ","$3,360.00 "
Carle BroMenn Medical Center,8464680,"DESC W/NEURO AGENT,CELIAC PLXS",,64680,761,"$1,635.00 ","$1,635.00 ",$490.50 ,"$1,487.85 ","$1,144.50 ",$490.50 ,"$1,062.75 ","$1,177.20 ","$1,487.85 ","$1,226.25 "
Carle BroMenn Medical Center,8470554,FUNCTIONAL MRI BRAIN BY TECH,,70554,761,"$2,650.00 ","$2,650.00 ",$795.00 ,"$2,411.50 ","$1,855.00 ",$795.00 ,"$1,722.50 ","$1,908.00 ","$2,411.50 ","$1,987.50 "
Carle BroMenn Medical Center,8478607,BRAIN IMAGING TOMOGRAPHIC SPECT,,78607,761,"$3,480.00 ","$3,480.00 ","$1,044.00 ","$3,166.80 ","$2,436.00 ","$1,044.00 ","$2,262.00 ","$2,505.60 ","$3,166.80 ","$2,610.00 "
Carle BroMenn Medical Center,8650027,INTUBATION,,31500,761,$683.00 ,$683.00 ,$204.90 ,$621.53 ,$478.10 ,$204.90 ,$443.95 ,$491.76 ,$621.53 ,$512.25 
Carle BroMenn Medical Center,8730162,DEBRIDEMENT,,,761,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8730163,BONE MARROW ASPIRATION/BIOPSY,,,761,$450.00 ,$450.00 ,$135.00 ,$409.50 ,$315.00 ,$135.00 ,$292.50 ,$324.00 ,$409.50 ,$337.50 
Carle BroMenn Medical Center,8730164,URINARY CATHETER INSERTION,,51702,761,$135.00 ,$135.00 ,$40.50 ,$122.85 ,$94.50 ,$40.50 ,$87.75 ,$97.20 ,$122.85 ,$101.25 
Carle BroMenn Medical Center,8730165,SPINAL PUNCTURE,,,761,$608.00 ,$608.00 ,$182.40 ,$553.28 ,$425.60 ,$182.40 ,$395.20 ,$437.76 ,$553.28 ,$456.00 
Carle BroMenn Medical Center,8730166,WOUND TREATMENT (VAC),,,761,$398.00 ,$398.00 ,$119.40 ,$362.18 ,$278.60 ,$119.40 ,$258.70 ,$286.56 ,$362.18 ,$298.50 
Carle BroMenn Medical Center,8730167,WOUND TREATMENT (VAC),,,761,$773.00 ,$773.00 ,$231.90 ,$703.43 ,$541.10 ,$231.90 ,$502.45 ,$556.56 ,$703.43 ,$579.75 
Carle BroMenn Medical Center,8730168,TREATMENT ROOM,,,761,$143.00 ,$143.00 ,$42.90 ,$130.13 ,$100.10 ,$42.90 ,$92.95 ,$102.96 ,$130.13 ,$107.25 
Carle BroMenn Medical Center,8940016,MIDLINE INSERTION,,36410,761,"$1,980.00 ","$1,980.00 ",$594.00 ,"$1,801.80 ","$1,386.00 ",$594.00 ,"$1,287.00 ","$1,425.60 ","$1,801.80 ","$1,485.00 "
Carle BroMenn Medical Center,8956511,THERAPEUTIC APHERESIS; WHITE BLOOD CELLS,,36511,761,"$2,490.00 ","$2,490.00 ",$747.00 ,"$2,265.90 ","$1,743.00 ",$747.00 ,"$1,618.50 ","$1,792.80 ","$2,265.90 ","$1,867.50 "
Carle BroMenn Medical Center,8956512,THERAPEUTIC APHERESIS; RED BLOOD CELLS,,36512,761,"$4,140.00 ","$4,140.00 ","$1,242.00 ","$3,767.40 ","$2,898.00 ","$1,242.00 ","$2,691.00 ","$2,980.80 ","$3,767.40 ","$3,105.00 "
Carle BroMenn Medical Center,8956513,THERAPEUTIC APHERESIS; FOR PLATELETS,,36513,761,"$2,490.00 ","$2,490.00 ",$747.00 ,"$2,265.90 ","$1,743.00 ",$747.00 ,"$1,618.50 ","$1,792.80 ","$2,265.90 ","$1,867.50 "
Carle BroMenn Medical Center,8956514,THERAPEUTIC APHERESIS; FOR PLASMA PHERESIS,,36514,761,"$2,965.00 ","$2,965.00 ",$889.50 ,"$2,698.15 ","$2,075.50 ",$889.50 ,"$1,927.25 ","$2,134.80 ","$2,698.15 ","$2,223.75 "
Carle BroMenn Medical Center,8967605,WOUND TREATMENT (VAC),,97605,761,$340.00 ,$340.00 ,$102.00 ,$309.40 ,$238.00 ,$102.00 ,$221.00 ,$244.80 ,$309.40 ,$255.00 
Carle BroMenn Medical Center,8967606,WOUND TREATMENT (VAC),,97606,761,$790.00 ,$790.00 ,$237.00 ,$718.90 ,$553.00 ,$237.00 ,$513.50 ,$568.80 ,$718.90 ,$592.50 
Carle BroMenn Medical Center,8970211,EVALUATION AND MANAGEMENT,,G0463,761,$225.00 ,$225.00 ,$67.50 ,$204.75 ,$157.50 ,$67.50 ,$146.25 ,$162.00 ,$204.75 ,$168.75 
Carle BroMenn Medical Center,8972272,"SPINAL PUNCTURE,THERAPEUTIC DRAINAGE",,62272,761,"$1,025.00 ","$1,025.00 ",$307.50 ,$932.75 ,$717.50 ,$307.50 ,$666.25 ,$738.00 ,$932.75 ,$768.75 
Carle BroMenn Medical Center,8976360,HYDRATION IV INFUSN UP TO 1HR,,96360,761,$430.00 ,$430.00 ,$129.00 ,$391.30 ,$301.00 ,$129.00 ,$279.50 ,$309.60 ,$391.30 ,$322.50 
Carle BroMenn Medical Center,8976361,HYDRATION IV INFUSN EA ADNL HR,,96361,761,$138.00 ,$138.00 ,$41.40 ,$125.58 ,$96.60 ,$41.40 ,$89.70 ,$99.36 ,$125.58 ,$103.50 
Carle BroMenn Medical Center,8976365,IV INFUSION -UP TO 1HR,,96365,761,$635.00 ,$635.00 ,$190.50 ,$577.85 ,$444.50 ,$190.50 ,$412.75 ,$457.20 ,$577.85 ,$476.25 
Carle BroMenn Medical Center,8976366,IV INFUSION -EA ADNL HR,,96366,761,$170.00 ,$170.00 ,$51.00 ,$154.70 ,$119.00 ,$51.00 ,$110.50 ,$122.40 ,$154.70 ,$127.50 
Carle BroMenn Medical Center,8976367,IV INFUSION SEQ -UP TO 1HR,,96367,761,$191.00 ,$191.00 ,$57.30 ,$173.81 ,$133.70 ,$57.30 ,$124.15 ,$137.52 ,$173.81 ,$143.25 
Carle BroMenn Medical Center,8976368,IV INFUSION CONCURRENT,,96368,761,$385.00 ,$385.00 ,$115.50 ,$350.35 ,$269.50 ,$115.50 ,$250.25 ,$277.20 ,$350.35 ,$288.75 
Carle BroMenn Medical Center,8976374,IV PUSH -SINGLE/INITIAL,,96374,761,$380.00 ,$380.00 ,$114.00 ,$345.80 ,$266.00 ,$114.00 ,$247.00 ,$273.60 ,$345.80 ,$285.00 
Carle BroMenn Medical Center,8976375,IV PUSH -EA ADNL NEW DRUG,,96375,761,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8976376,IV PUSH -EA ADNL SAME DRUG,,96376,761,$153.00 ,$153.00 ,$45.90 ,$139.23 ,$107.10 ,$45.90 ,$99.45 ,$110.16 ,$139.23 ,$114.75 
Carle BroMenn Medical Center,8976523,IRRIGATN IMPLNTD VEN ACC DVC,,96523,761,$190.00 ,$190.00 ,$57.00 ,$172.90 ,$133.00 ,$57.00 ,$123.50 ,$136.80 ,$172.90 ,$142.50 
Carle BroMenn Medical Center,8979084,TREATMENT ROOM,,,761,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8013762,L1 OBSRVTN,,99218,762,$83.00 ,$83.00 ,$24.90 ,$75.53 ,$58.10 ,$24.90 ,$53.95 ,$59.76 ,$75.53 ,$62.25 
Carle BroMenn Medical Center,8200402,INITIAL PREVENTIVE EXAM,,G0402,770,$230.00 ,$230.00 ,$69.00 ,$209.30 ,$161.00 ,$69.00 ,$149.50 ,$165.60 ,$209.30 ,$172.50 
Carle BroMenn Medical Center,8200438,"PPPS, INITIAL VISIT",,G0438,770,$305.00 ,$305.00 ,$91.50 ,$277.55 ,$213.50 ,$91.50 ,$198.25 ,$219.60 ,$277.55 ,$228.75 
Carle BroMenn Medical Center,8200439,"PPPS, SUBSEQ VISIT",,G0439,770,$225.00 ,$225.00 ,$67.50 ,$204.75 ,$157.50 ,$67.50 ,$146.25 ,$162.00 ,$204.75 ,$168.75 
Carle BroMenn Medical Center,8210101,CA SCREEN;PELVIC/BREAST EXAM,,G0101,770,$170.00 ,$170.00 ,$51.00 ,$154.70 ,$119.00 ,$51.00 ,$110.50 ,$122.40 ,$154.70 ,$127.50 
Carle BroMenn Medical Center,8299381,"PREVENTIVE VISIT,NEW,INFANT < 1 YR",,99381,770,$230.00 ,$230.00 ,$69.00 ,$209.30 ,$161.00 ,$69.00 ,$149.50 ,$165.60 ,$209.30 ,$172.50 
Carle BroMenn Medical Center,8299382,"PREVENTIVE VISIT,NEW,AGE 1-4",,99382,770,$230.00 ,$230.00 ,$69.00 ,$209.30 ,$161.00 ,$69.00 ,$149.50 ,$165.60 ,$209.30 ,$172.50 
Carle BroMenn Medical Center,8299383,"PREVENTIVE VISIT,NEW,AGE5-11",,99383,770,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8299384,"PREVENTIVE VISIT,NEW,12-17",,99384,770,$230.00 ,$230.00 ,$69.00 ,$209.30 ,$161.00 ,$69.00 ,$149.50 ,$165.60 ,$209.30 ,$172.50 
Carle BroMenn Medical Center,8299385,"PREVENTIVE VISIT,NEW,18-39",,99385,770,$230.00 ,$230.00 ,$69.00 ,$209.30 ,$161.00 ,$69.00 ,$149.50 ,$165.60 ,$209.30 ,$172.50 
Carle BroMenn Medical Center,8299386,"PREVENTIVE VISIT,NEW,40-64",,99386,770,$230.00 ,$230.00 ,$69.00 ,$209.30 ,$161.00 ,$69.00 ,$149.50 ,$165.60 ,$209.30 ,$172.50 
Carle BroMenn Medical Center,8299387,"PREVENTIVE VISIT,NEW,65 & OVER",,99387,770,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8299391,"PREVENTIVE VISIT,EST, INFANT < 1 YR",,99391,770,$230.00 ,$230.00 ,$69.00 ,$209.30 ,$161.00 ,$69.00 ,$149.50 ,$165.60 ,$209.30 ,$172.50 
Carle BroMenn Medical Center,8299392,"PREVENTIVE VISIT,EST,AGE 1-4",,99392,770,$230.00 ,$230.00 ,$69.00 ,$209.30 ,$161.00 ,$69.00 ,$149.50 ,$165.60 ,$209.30 ,$172.50 
Carle BroMenn Medical Center,8299393,"PREVENTIVE VISIT,EST,AGE5-11",,99393,770,$230.00 ,$230.00 ,$69.00 ,$209.30 ,$161.00 ,$69.00 ,$149.50 ,$165.60 ,$209.30 ,$172.50 
Carle BroMenn Medical Center,8299394,"PREVENTIVE VISIT,EST,12-17",,99394,770,$230.00 ,$230.00 ,$69.00 ,$209.30 ,$161.00 ,$69.00 ,$149.50 ,$165.60 ,$209.30 ,$172.50 
Carle BroMenn Medical Center,8299395,"PREVENTIVE VISIT,EST,18-39",,99395,770,$65.00 ,$65.00 ,$19.50 ,$59.15 ,$45.50 ,$19.50 ,$42.25 ,$46.80 ,$59.15 ,$48.75 
Carle BroMenn Medical Center,8299396,"PREVENTIVE VISIT,EST,40-64",,99396,770,$230.00 ,$230.00 ,$69.00 ,$209.30 ,$161.00 ,$69.00 ,$149.50 ,$165.60 ,$209.30 ,$172.50 
Carle BroMenn Medical Center,8299397,"PREVENTIVE VISIT,EST,65 & OVER",,99397,770,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8000010,ADMIN HEPATITIS B VACCINE,,G0010,771,$90.00 ,$90.00 ,$27.00 ,$81.90 ,$63.00 ,$27.00 ,$58.50 ,$64.80 ,$81.90 ,$67.50 
Carle BroMenn Medical Center,8020008,ADMIN FLU VACCINE,,G0008,771,$94.00 ,$94.00 ,$28.20 ,$85.54 ,$65.80 ,$28.20 ,$61.10 ,$67.68 ,$85.54 ,$70.50 
Carle BroMenn Medical Center,8020009,ADMIN PNEUMONIA VACCINE,,G0009,771,$84.00 ,$84.00 ,$25.20 ,$76.44 ,$58.80 ,$25.20 ,$54.60 ,$60.48 ,$76.44 ,$63.00 
Carle BroMenn Medical Center,8020239,BAMLANIVIMAB-XXXX INFUSION,,M0239,771,$945.00 ,$945.00 ,$283.50 ,$859.95 ,$661.50 ,$283.50 ,$614.25 ,$680.40 ,$859.95 ,$708.75 
Carle BroMenn Medical Center,8020243,"INTRAVENOUS INFUSION, CASIRIVIMAB AND IMDEVIMAB",,M0243,771,$945.00 ,$945.00 ,$283.50 ,$859.95 ,$661.50 ,$283.50 ,$614.25 ,$680.40 ,$859.95 ,$708.75 
Carle BroMenn Medical Center,8020244,IV INF CASIRIVI AND IMDEVI,,M0244,771,"$1,870.00 ","$1,870.00 ",$561.00 ,"$1,701.70 ","$1,309.00 ",$561.00 ,"$1,215.50 ","$1,346.40 ","$1,701.70 ","$1,402.50 "
Carle BroMenn Medical Center,8020245,BAMLANIVIMAB AND ETESEVIMAB INFUSION,,M0245,771,$900.00 ,$900.00 ,$270.00 ,$819.00 ,$630.00 ,$270.00 ,$585.00 ,$648.00 ,$819.00 ,$675.00 
Carle BroMenn Medical Center,8020247,IV INF SOTORVIMAB,,M0247,771,"$1,350.00 ","$1,350.00 ",$405.00 ,"$1,228.50 ",$945.00 ,$405.00 ,$877.50 ,$972.00 ,"$1,228.50 ","$1,012.50 "
Carle BroMenn Medical Center,8020249,IV INF TOCILIZUMAB FIRST DOSE,,M0249,771,$945.00 ,$945.00 ,$283.50 ,$859.95 ,$661.50 ,$283.50 ,$614.25 ,$680.40 ,$859.95 ,$708.75 
Carle BroMenn Medical Center,8020250,IV INF TOCILIZUMAB SECOND DOSE,,M0250,771,$945.00 ,$945.00 ,$283.50 ,$859.95 ,$661.50 ,$283.50 ,$614.25 ,$680.40 ,$859.95 ,$708.75 
Carle BroMenn Medical Center,8020471,ADMIN VACCINE,,90471,771,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8020472,ADMIN ADDTNL VACCINE,,90472,771,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8021008,ADMIN FLU VACCINE,,G0008,771,$94.00 ,$94.00 ,$28.20 ,$85.54 ,$65.80 ,$28.20 ,$61.10 ,$67.68 ,$85.54 ,$70.50 
Carle BroMenn Medical Center,8021009,ADMIN PNEUMONIA VACCINE,,G0009,771,$84.00 ,$84.00 ,$25.20 ,$76.44 ,$58.80 ,$25.20 ,$54.60 ,$60.48 ,$76.44 ,$63.00 
Carle BroMenn Medical Center,8100010,ADMINISTER HEPATITS B VACCINE,,G0010,771,$90.00 ,$90.00 ,$27.00 ,$81.90 ,$63.00 ,$27.00 ,$58.50 ,$64.80 ,$81.90 ,$67.50 
Carle BroMenn Medical Center,8109901,ADMINISTER 1 VACCINE/TOXOID,,90471,771,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8109902,ADMINISTER ADNL VACCINE/TOXOID,,90472,771,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8109903,ADMINISTER -FLU VACCINE,,G0008,771,$94.00 ,$94.00 ,$28.20 ,$85.54 ,$65.80 ,$28.20 ,$61.10 ,$67.68 ,$85.54 ,$70.50 
Carle BroMenn Medical Center,8109904,ADMINISTER -PNEUMONIA VACCINE,,G0009,771,$84.00 ,$84.00 ,$25.20 ,$76.44 ,$58.80 ,$25.20 ,$54.60 ,$60.48 ,$76.44 ,$63.00 
Carle BroMenn Medical Center,8129903,ADMINISTER -FLU VACCINE,,G0008,771,$94.00 ,$94.00 ,$28.20 ,$85.54 ,$65.80 ,$28.20 ,$61.10 ,$67.68 ,$85.54 ,$70.50 
Carle BroMenn Medical Center,8129904,ADMINISTER -PNEUMONIA VACCINE,,G0009,771,$84.00 ,$84.00 ,$25.20 ,$76.44 ,$58.80 ,$25.20 ,$54.60 ,$60.48 ,$76.44 ,$63.00 
Carle BroMenn Medical Center,8199001,ADMINISTER 1 VACCINE/TOXOID,,90471,771,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8199002,ADMINISTER ADNL VACCINE/TOXOID,,90472,771,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8199003,ADMINISTER -FLU VACCINE,,G0008,771,$94.00 ,$94.00 ,$28.20 ,$85.54 ,$65.80 ,$28.20 ,$61.10 ,$67.68 ,$85.54 ,$70.50 
Carle BroMenn Medical Center,8199004,ADMINISTER -PNEUMONIA VACCINE,,G0009,771,$84.00 ,$84.00 ,$25.20 ,$76.44 ,$58.80 ,$25.20 ,$54.60 ,$60.48 ,$76.44 ,$63.00 
Carle BroMenn Medical Center,8199901,ADMINISTER 1 VACCINE/TOXOID,,90471,771,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8199902,ADMINISTER ADNL VACCINE/TOXOID,,90472,771,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8199903,ADMINISTER -FLU VACCINE,,G0008,771,$94.00 ,$94.00 ,$28.20 ,$85.54 ,$65.80 ,$28.20 ,$61.10 ,$67.68 ,$85.54 ,$70.50 
Carle BroMenn Medical Center,8199904,ADMINISTER -PNEUMONIA VACCINE,,G0009,771,$84.00 ,$84.00 ,$25.20 ,$76.44 ,$58.80 ,$25.20 ,$54.60 ,$60.48 ,$76.44 ,$63.00 
Carle BroMenn Medical Center,8200243,"INTRAVENOUS INFUSION, CASIRIVIMAB AND IMDEVIMAB",,M0243,771,$945.00 ,$945.00 ,$283.50 ,$859.95 ,$661.50 ,$283.50 ,$614.25 ,$680.40 ,$859.95 ,$708.75 
Carle BroMenn Medical Center,8200244,IV INF CASIRIVI AND IMDEVI,,M0244,771,"$1,870.00 ","$1,870.00 ",$561.00 ,"$1,701.70 ","$1,309.00 ",$561.00 ,"$1,215.50 ","$1,346.40 ","$1,701.70 ","$1,402.50 "
Carle BroMenn Medical Center,8200245,BAMLANIVIMAB AND ETESEVIMAB INFUSION,,M0245,771,$900.00 ,$900.00 ,$270.00 ,$819.00 ,$630.00 ,$270.00 ,$585.00 ,$648.00 ,$819.00 ,$675.00 
Carle BroMenn Medical Center,8200247,IV INF SOTORVIMAB,,M0247,771,"$1,350.00 ","$1,350.00 ",$405.00 ,"$1,228.50 ",$945.00 ,$405.00 ,$877.50 ,$972.00 ,"$1,228.50 ","$1,012.50 "
Carle BroMenn Medical Center,8210008,ADMIN INFLUENZA VIRUS VAC,,G0008,771,$94.00 ,$94.00 ,$28.20 ,$85.54 ,$65.80 ,$28.20 ,$61.10 ,$67.68 ,$85.54 ,$70.50 
Carle BroMenn Medical Center,8210009,ADMIN PNEUMOCOCCAL VACCINE,,G0009,771,$84.00 ,$84.00 ,$25.20 ,$76.44 ,$58.80 ,$25.20 ,$54.60 ,$60.48 ,$76.44 ,$63.00 
Carle BroMenn Medical Center,8220010,ADMIN HEPATITIS B VACCINE,,G0010,771,$90.00 ,$90.00 ,$27.00 ,$81.90 ,$63.00 ,$27.00 ,$58.50 ,$64.80 ,$81.90 ,$67.50 
Carle BroMenn Medical Center,8290007,ADMIN FLU MIST VACCINE,,G0008,771,$94.00 ,$94.00 ,$28.20 ,$85.54 ,$65.80 ,$28.20 ,$61.10 ,$67.68 ,$85.54 ,$70.50 
Carle BroMenn Medical Center,8290008,ADMIN FLU VACCINE,,G0008,771,$94.00 ,$94.00 ,$28.20 ,$85.54 ,$65.80 ,$28.20 ,$61.10 ,$67.68 ,$85.54 ,$70.50 
Carle BroMenn Medical Center,8290009,ADMIN PNEUMONIA VACCINE,,G0009,771,$84.00 ,$84.00 ,$25.20 ,$76.44 ,$58.80 ,$25.20 ,$54.60 ,$60.48 ,$76.44 ,$63.00 
Carle BroMenn Medical Center,8290010,HC ADM SARSCOV2 30MCG/0.3ML 1ST,,0001A,771,$55.00 ,$55.00 ,$16.50 ,$50.05 ,$38.50 ,$16.50 ,$35.75 ,$39.60 ,$50.05 ,$41.25 
Carle BroMenn Medical Center,8290011,ADM SARSCOV2 30MCG/0.3ML 2ND,,0002A,771,$95.00 ,$95.00 ,$28.50 ,$86.45 ,$66.50 ,$28.50 ,$61.75 ,$68.40 ,$86.45 ,$71.25 
Carle BroMenn Medical Center,8290012,ADM SARSCOV2 100MCG/0.5ML1ST,,0011A,771,$55.00 ,$55.00 ,$16.50 ,$50.05 ,$38.50 ,$16.50 ,$35.75 ,$39.60 ,$50.05 ,$41.25 
Carle BroMenn Medical Center,8290013,ADM SARSCOV2 100MCG/0.5ML2ND,,0012A,771,$95.00 ,$95.00 ,$28.50 ,$86.45 ,$66.50 ,$28.50 ,$61.75 ,$68.40 ,$86.45 ,$71.25 
Carle BroMenn Medical Center,8290014,ADM SARSCOV2 VAC 5X1010VP/.1ML 1ST,,0021A,771,$55.00 ,$55.00 ,$16.50 ,$50.05 ,$38.50 ,$16.50 ,$35.75 ,$39.60 ,$50.05 ,$41.25 
Carle BroMenn Medical Center,8290015,ADM SARSCOV2 VAC 5X1010VP/.1ML 2ND,,0022A,771,$95.00 ,$95.00 ,$28.50 ,$86.45 ,$66.50 ,$28.50 ,$61.75 ,$68.40 ,$86.45 ,$71.25 
Carle BroMenn Medical Center,8290016,ADM SARSCOV2 VAC AD26 .5ML,,0031A,771,$95.00 ,$95.00 ,$28.50 ,$86.45 ,$66.50 ,$28.50 ,$61.75 ,$68.40 ,$86.45 ,$71.25 
Carle BroMenn Medical Center,8290017,ADM SARSCOV2 30MCG/0.3ML 3RD,,0003A,771,$95.00 ,$95.00 ,$28.50 ,$86.45 ,$66.50 ,$28.50 ,$61.75 ,$68.40 ,$86.45 ,$71.25 
Carle BroMenn Medical Center,8290018,ADM SARSCOV2 100MCG/0.5ML 3RD,,0013A,771,$95.00 ,$95.00 ,$28.50 ,$86.45 ,$66.50 ,$28.50 ,$61.75 ,$68.40 ,$86.45 ,$71.25 
Carle BroMenn Medical Center,8290019,ADM SARSCOV2 30MCG/0.3ML BOOSTER,,0004A,771,$95.00 ,$95.00 ,$28.50 ,$86.45 ,$66.50 ,$28.50 ,$61.75 ,$68.40 ,$86.45 ,$71.25 
Carle BroMenn Medical Center,8290020,ADM SARSCOV2 100MCG/0.5ML BOOSTER,,0064A,771,$95.00 ,$95.00 ,$28.50 ,$86.45 ,$66.50 ,$28.50 ,$61.75 ,$68.40 ,$86.45 ,$71.25 
Carle BroMenn Medical Center,8290021,ADM SARSCV2 30MCG TRS-SUCR 1,,0051A,771,$55.00 ,$55.00 ,$16.50 ,$50.05 ,$38.50 ,$16.50 ,$35.75 ,$39.60 ,$50.05 ,$41.25 
Carle BroMenn Medical Center,8290022,ADM SARSCV2 30MCG TRS-SUCR 2,,0052A,771,$95.00 ,$95.00 ,$28.50 ,$86.45 ,$66.50 ,$28.50 ,$61.75 ,$68.40 ,$86.45 ,$71.25 
Carle BroMenn Medical Center,8290023,ADM SARSCV2 30MCG TRS-SUCR 3,,0053A,771,$95.00 ,$95.00 ,$28.50 ,$86.45 ,$66.50 ,$28.50 ,$61.75 ,$68.40 ,$86.45 ,$71.25 
Carle BroMenn Medical Center,8290024,ADM SARSCV2 30MCG TRS-SUCR B,,0054A,771,$95.00 ,$95.00 ,$28.50 ,$86.45 ,$66.50 ,$28.50 ,$61.75 ,$68.40 ,$86.45 ,$71.25 
Carle BroMenn Medical Center,8290025,ADM SARSCV2 10MCG TRS-SUCR 1,,0071A,771,$55.00 ,$55.00 ,$16.50 ,$50.05 ,$38.50 ,$16.50 ,$35.75 ,$39.60 ,$50.05 ,$41.25 
Carle BroMenn Medical Center,8290026,ADM SARSCV2 10MCG TRS-SUCR 2,,0072A,771,$95.00 ,$95.00 ,$28.50 ,$86.45 ,$66.50 ,$28.50 ,$61.75 ,$68.40 ,$86.45 ,$71.25 
Carle BroMenn Medical Center,8290027,ADM SARSCOV2 VAC AD26 .5ML B,,0034A,771,$95.00 ,$95.00 ,$28.50 ,$86.45 ,$66.50 ,$28.50 ,$61.75 ,$68.40 ,$86.45 ,$71.25 
Carle BroMenn Medical Center,8290460,"IMMUNIZ ADMIN, THRU AGE 18, ANY ROUTE,W COUNSEL, 1ST VACCINE/TOXOID",,90460,771,$77.00 ,$77.00 ,$23.10 ,$70.07 ,$53.90 ,$23.10 ,$50.05 ,$55.44 ,$70.07 ,$57.75 
Carle BroMenn Medical Center,8290461,"IMMUNIZ ADMIN, THRU AGE 18, ANY ROUTE,W COUNSEL, EA ADD VACCINE/TOXOID",,90461,771,$29.00 ,$29.00 ,$8.70 ,$26.39 ,$20.30 ,$8.70 ,$18.85 ,$20.88 ,$26.39 ,$21.75 
Carle BroMenn Medical Center,8290471,ADMIN VACCINE,,90471,771,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8290472,"IMMUNIZ,ADMIN,EACH ADDL",,90472,771,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8290473,"IMMUNIZ,ADMIN,INTRANASAL/ORAL,EACH ADDL",,90473,771,$88.00 ,$88.00 ,$26.40 ,$80.08 ,$61.60 ,$26.40 ,$57.20 ,$63.36 ,$80.08 ,$66.00 
Carle BroMenn Medical Center,8290474,"IMMUNIZ ADMIN,INTRANASAL/ORAL,EACH ADDL",,90474,771,$57.00 ,$57.00 ,$17.10 ,$51.87 ,$39.90 ,$17.10 ,$37.05 ,$41.04 ,$51.87 ,$42.75 
Carle BroMenn Medical Center,8659141,H1N1 VACCINE ADMINI,,90471,771,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8720080,ADMINISTER -FLU VACCINE,,G0008,771,$94.00 ,$94.00 ,$28.20 ,$85.54 ,$65.80 ,$28.20 ,$61.10 ,$67.68 ,$85.54 ,$70.50 
Carle BroMenn Medical Center,8720081,ADMINISTER -PNEUMONIA VACCINE,,G0009,771,$84.00 ,$84.00 ,$25.20 ,$76.44 ,$58.80 ,$25.20 ,$54.60 ,$60.48 ,$76.44 ,$63.00 
Carle BroMenn Medical Center,8720082,H1N1 VACCINE ADMIN,,90471,771,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8720083,ADMINISTER 1 VACCINE/TOXOID,,90471,771,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8720084,ADMINISTER ADNL VACCINE/TOXOID,,90472,771,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8800008,ADMINISTER -FLU VACCINE,,G0008,771,$94.00 ,$94.00 ,$28.20 ,$85.54 ,$65.80 ,$28.20 ,$61.10 ,$67.68 ,$85.54 ,$70.50 
Carle BroMenn Medical Center,8800009,ADMINISTER -PNEUMONIA VACCINE,,G0009,771,$84.00 ,$84.00 ,$25.20 ,$76.44 ,$58.80 ,$25.20 ,$54.60 ,$60.48 ,$76.44 ,$63.00 
Carle BroMenn Medical Center,8802390,BAMLANIVIMAB-XXXX INFUSION,,M0239,771,$945.00 ,$945.00 ,$283.50 ,$859.95 ,$661.50 ,$283.50 ,$614.25 ,$680.40 ,$859.95 ,$708.75 
Carle BroMenn Medical Center,8802430,"INTRAVENOUS INFUSION, CASIRIVIMAB AND IMDEVIMAB",,M0243,771,$945.00 ,$945.00 ,$283.50 ,$859.95 ,$661.50 ,$283.50 ,$614.25 ,$680.40 ,$859.95 ,$708.75 
Carle BroMenn Medical Center,8802450,BAMLANIVIMAB AND ETESEVIMAB INFUSION,,M0245,771,$900.00 ,$900.00 ,$270.00 ,$819.00 ,$630.00 ,$270.00 ,$585.00 ,$648.00 ,$819.00 ,$675.00 
Carle BroMenn Medical Center,8810008,ADMINISTER -FLU VACCINE,,G0008,771,$94.00 ,$94.00 ,$28.20 ,$85.54 ,$65.80 ,$28.20 ,$61.10 ,$67.68 ,$85.54 ,$70.50 
Carle BroMenn Medical Center,8810009,ADMINISTER -PNEUMONIA VACCINE,,G0009,771,$84.00 ,$84.00 ,$25.20 ,$76.44 ,$58.80 ,$25.20 ,$54.60 ,$60.48 ,$76.44 ,$63.00 
Carle BroMenn Medical Center,8810471,ADMINISTER 1 VACCINE/TOXOID,,90471,771,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8810472,ADMINISTER ADNL VACCINE/TOXOID,,90472,771,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8820244,IV INF CASIRIVI AND IMDEVI,,M0244,771,"$1,870.00 ","$1,870.00 ",$561.00 ,"$1,701.70 ","$1,309.00 ",$561.00 ,"$1,215.50 ","$1,346.40 ","$1,701.70 ","$1,402.50 "
Carle BroMenn Medical Center,8820247,IV INF SOTORVIMAB,,M0247,771,"$1,350.00 ","$1,350.00 ",$405.00 ,"$1,228.50 ",$945.00 ,$405.00 ,$877.50 ,$972.00 ,"$1,228.50 ","$1,012.50 "
Carle BroMenn Medical Center,8890471,ADMINISTER 1 VACCINE/TOXOID,,90471,771,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8890472,ADMINISTER ADNL VACCINE/TOXOID,,90472,771,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8900010,HH/HSPC ADMIN HEPATITIS B,,G0010,771,$90.00 ,$90.00 ,$27.00 ,$81.90 ,$63.00 ,$27.00 ,$58.50 ,$64.80 ,$81.90 ,$67.50 
Carle BroMenn Medical Center,8902003,HH/HSPC ADMIN FLU,,G0008,771,$94.00 ,$94.00 ,$28.20 ,$85.54 ,$65.80 ,$28.20 ,$61.10 ,$67.68 ,$85.54 ,$70.50 
Carle BroMenn Medical Center,8902004,HH/HSPC ADMIN PNEMONIA,,G0009,771,$84.00 ,$84.00 ,$25.20 ,$76.44 ,$58.80 ,$25.20 ,$54.60 ,$60.48 ,$76.44 ,$63.00 
Carle BroMenn Medical Center,8910471,H1N1 VACCINE ADMIN,,90471,771,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8970008,ADMINISTER -FLU VACCINE,,G0008,771,$94.00 ,$94.00 ,$28.20 ,$85.54 ,$65.80 ,$28.20 ,$61.10 ,$67.68 ,$85.54 ,$70.50 
Carle BroMenn Medical Center,8970009,ADMINISTER -PNEUMONIA VACCINE,,G0009,771,$84.00 ,$84.00 ,$25.20 ,$76.44 ,$58.80 ,$25.20 ,$54.60 ,$60.48 ,$76.44 ,$63.00 
Carle BroMenn Medical Center,8970471,ADMINISTER 1 VACCINE/TOXOID,,90471,771,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8970472,ADMINISTER ADNL VACCINE/TOXOID,,90472,771,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8979141,H1N1 VACCINE ADMINI,,90471,771,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8980004,SPECIAL VACCINE ADMIN,,90471,771,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8980008,Hc Special Vaccine Admin 90472,,90472,771,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8203014,TELEHEALTH FACILITY FEE,,Q3014,780,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8913014,TELEHEALTH FACILITY FEE,,Q3014,780,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8100073,LITHO UNILATERAL,,,790,"$11,708.00 ","$11,708.00 ","$3,512.40 ","$10,654.28 ","$8,195.60 ","$3,512.40 ","$7,610.20 ","$8,429.76 ","$10,654.28 ","$8,781.00 "
Carle BroMenn Medical Center,8100074,LITHO BILATERAL,,,790,"$14,393.00 ","$14,393.00 ","$4,317.90 ","$13,097.63 ","$10,075.10 ","$4,317.90 ","$9,355.45 ","$10,362.96 ","$13,097.63 ","$10,794.75 "
Carle BroMenn Medical Center,8020034,HEMODIALYSIS SERVICE IP,,90935,801,"$1,455.00 ","$1,455.00 ",$436.50 ,"$1,324.05 ","$1,018.50 ",$436.50 ,$945.75 ,"$1,047.60 ","$1,324.05 ","$1,091.25 "
Carle BroMenn Medical Center,8028000,ACUTE DIALYSIS,,,801,"$1,455.00 ","$1,455.00 ",$436.50 ,"$1,324.05 ","$1,018.50 ",$436.50 ,$945.75 ,"$1,047.60 ","$1,324.05 ","$1,091.25 "
Carle BroMenn Medical Center,8020035,CRRT-HEMO,,,804,"$1,550.00 ","$1,550.00 ",$465.00 ,"$1,410.50 ","$1,085.00 ",$465.00 ,"$1,007.50 ","$1,116.00 ","$1,410.50 ","$1,162.50 "
Carle BroMenn Medical Center,8020257,UNSCHED DIALYSIS ESRD PT HOS,,G0257,880,"$1,455.00 ","$1,455.00 ",$436.50 ,"$1,324.05 ","$1,018.50 ",$436.50 ,$945.75 ,"$1,047.60 ","$1,324.05 ","$1,091.25 "
Carle BroMenn Medical Center,8020935,HEMODIALYSIS PROCEDURE W/ PHYS/QHP EVALUATION,,90935,880,"$1,455.00 ","$1,455.00 ",$436.50 ,"$1,324.05 ","$1,018.50 ",$436.50 ,$945.75 ,"$1,047.60 ","$1,324.05 ","$1,091.25 "
Carle BroMenn Medical Center,8020945,DIALYSIS OTHER/THAN HEMODIALYSIS 1 PHYS/QHP EVAL,,90945,880,$655.00 ,$655.00 ,$196.50 ,$596.05 ,$458.50 ,$196.50 ,$425.75 ,$471.60 ,$596.05 ,$491.25 
Carle BroMenn Medical Center,8290791,PSYCHIATRIC DIAGNOSTIC EVALUATION,,90791,900,$330.00 ,$330.00 ,$99.00 ,$300.30 ,$231.00 ,$99.00 ,$214.50 ,$237.60 ,$300.30 ,$247.50 
Carle BroMenn Medical Center,8290792,PSYCHIATRIC DIAGNOSTIC EVAL W/MEDICAL SERVICES,,90792,900,$370.00 ,$370.00 ,$111.00 ,$336.70 ,$259.00 ,$111.00 ,$240.50 ,$266.40 ,$336.70 ,$277.50 
Carle BroMenn Medical Center,8290865,NARCOSYNTHESIS,,90865,900,$255.00 ,$255.00 ,$76.50 ,$232.05 ,$178.50 ,$76.50 ,$165.75 ,$183.60 ,$232.05 ,$191.25 
Carle BroMenn Medical Center,8290880,HYPNOTHERAPY,,90880,900,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8290882,ENVIRONMENTAL MANIPULATION,,90882,900,$205.00 ,$205.00 ,$61.50 ,$186.55 ,$143.50 ,$61.50 ,$133.25 ,$147.60 ,$186.55 ,$153.75 
Carle BroMenn Medical Center,8290885,PSYCHIATRIC EVALUATION OF RECORDS,,90885,900,$235.00 ,$235.00 ,$70.50 ,$213.85 ,$164.50 ,$70.50 ,$152.75 ,$169.20 ,$213.85 ,$176.25 
Carle BroMenn Medical Center,8290887,CONSULTATION WITH FAMILY,,90887,900,$195.00 ,$195.00 ,$58.50 ,$177.45 ,$136.50 ,$58.50 ,$126.75 ,$140.40 ,$177.45 ,$146.25 
Carle BroMenn Medical Center,8290889,PREP REPORT PT PSYCH STATUS AGENCY/PAYER,,90889,900,$185.00 ,$185.00 ,$55.50 ,$168.35 ,$129.50 ,$55.50 ,$120.25 ,$133.20 ,$168.35 ,$138.75 
Carle BroMenn Medical Center,8890839,PSYCHOTHERAPY FOR CRISIS INITIAL 60 MINUTES,,90839,900,$410.00 ,$410.00 ,$123.00 ,$373.10 ,$287.00 ,$123.00 ,$266.50 ,$295.20 ,$373.10 ,$307.50 
Carle BroMenn Medical Center,8890840,PSYCHOTHERAPY FOR CRISIS EACH ADDL 30 MINUTES,,90840,900,$205.00 ,$205.00 ,$61.50 ,$186.55 ,$143.50 ,$61.50 ,$133.25 ,$147.60 ,$186.55 ,$153.75 
Carle BroMenn Medical Center,8129010,MEDICAL SERVICE,,90870,901,$983.00 ,$983.00 ,$294.90 ,$894.53 ,$688.10 ,$294.90 ,$638.95 ,$707.76 ,$894.53 ,$737.25 
Carle BroMenn Medical Center,8290870,"ELECTROCONVULSIVE THERAPY,1 SEIZ",,90870,901,$983.00 ,$983.00 ,$294.90 ,$894.53 ,$688.10 ,$294.90 ,$638.95 ,$707.76 ,$894.53 ,$737.25 
Carle BroMenn Medical Center,8022853,IOP GROUP THERAPY COM PA,,90853,906,$600.00 ,$600.00 ,$180.00 ,$546.00 ,$420.00 ,$180.00 ,$390.00 ,$432.00 ,$546.00 ,$450.00 
Carle BroMenn Medical Center,8021853,PHP GROUP THERAPY COM PA,,90853,912,"$1,000.00 ","$1,000.00 ",$300.00 ,$910.00 ,$700.00 ,$300.00 ,$650.00 ,$720.00 ,$910.00 ,$750.00 
Carle BroMenn Medical Center,8290832,MEDICAL SERVICE,,90832,914,$165.00 ,$165.00 ,$49.50 ,$150.15 ,$115.50 ,$49.50 ,$107.25 ,$118.80 ,$150.15 ,$123.75 
Carle BroMenn Medical Center,8290833,PSYCHOTHERAPY PT&/FAMILY W/E&M SRVCS 30 MIN,,90833,914,$180.00 ,$180.00 ,$54.00 ,$163.80 ,$126.00 ,$54.00 ,$117.00 ,$129.60 ,$163.80 ,$135.00 
Carle BroMenn Medical Center,8290834,MEDICAL SERVICE,,90834,914,$235.00 ,$235.00 ,$70.50 ,$213.85 ,$164.50 ,$70.50 ,$152.75 ,$169.20 ,$213.85 ,$176.25 
Carle BroMenn Medical Center,8290836,PSYCHOTHERAPY PT&/FAMILY W/E&M SRVCS 45 MIN,,90836,914,$225.00 ,$225.00 ,$67.50 ,$204.75 ,$157.50 ,$67.50 ,$146.25 ,$162.00 ,$204.75 ,$168.75 
Carle BroMenn Medical Center,8290837,MEDICAL SERVICE,,90837,914,$275.00 ,$275.00 ,$82.50 ,$250.25 ,$192.50 ,$82.50 ,$178.75 ,$198.00 ,$250.25 ,$206.25 
Carle BroMenn Medical Center,8290838,PSYCHOTHERAPY PT&/FAMILY W/E&M SRVCS 60 MIN,,90838,914,$295.00 ,$295.00 ,$88.50 ,$268.45 ,$206.50 ,$88.50 ,$191.75 ,$212.40 ,$268.45 ,$221.25 
Carle BroMenn Medical Center,8290839,PSYCHOTHERAPY FOR CRISIS INITIAL 60 MINUTES,,90839,914,$410.00 ,$410.00 ,$123.00 ,$373.10 ,$287.00 ,$123.00 ,$266.50 ,$295.20 ,$373.10 ,$307.50 
Carle BroMenn Medical Center,8290840,PSYCHOTHERAPY FOR CRISIS EACH ADDL 30 MINUTES,,90840,914,$205.00 ,$205.00 ,$61.50 ,$186.55 ,$143.50 ,$61.50 ,$133.25 ,$147.60 ,$186.55 ,$153.75 
Carle BroMenn Medical Center,8020410,GROUP THERAPY MCR,,G0410,915,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8020853,GROUP THERAPY MCR,,90853,915,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8290853,GROUP PSYCHOTHERAPY,,90853,915,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8297154,GROUP ADAPTIVE BHV TX BY PROTOCOL TECH EA 15 MIN,,97154,915,$22.00 ,$22.00 ,$6.60 ,$20.02 ,$15.40 ,$6.60 ,$14.30 ,$15.84 ,$20.02 ,$16.50 
Carle BroMenn Medical Center,8297158,GRP ADAPT BHV PRTCL MODIFCAJ PHYS/QHP EA 15 MIN,,97158,915,$38.00 ,$38.00 ,$11.40 ,$34.58 ,$26.60 ,$11.40 ,$24.70 ,$27.36 ,$34.58 ,$28.50 
Carle BroMenn Medical Center,8020846,FAM THER WO PT 50 MIN MCR,,90846,916,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8020847,FAM THER W PT 50 MIN MCR,,90847,916,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8290846,FAMILY PSYTX W/O PATIENT,,90846,916,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8290847,FAMILY PSYTX W/PATIENT,,90847,916,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8290849,MULTIP FAMILY-GROUP PSYCHOTHERAPY,,90849,916,$120.00 ,$120.00 ,$36.00 ,$109.20 ,$84.00 ,$36.00 ,$78.00 ,$86.40 ,$109.20 ,$90.00 
Carle BroMenn Medical Center,8297156,FAMILY ADAPT BHV TX GDN PHYS/QHP EA 15 MIN,,97156,916,$38.00 ,$38.00 ,$11.40 ,$34.58 ,$26.60 ,$11.40 ,$24.70 ,$27.36 ,$34.58 ,$28.50 
Carle BroMenn Medical Center,8297157,MULTIPLE FAM GROUP BHV TX GDN PHYS/QHP EA 15 MIN,,97157,916,$29.00 ,$29.00 ,$8.70 ,$26.39 ,$20.30 ,$8.70 ,$18.85 ,$20.88 ,$26.39 ,$21.75 
Carle BroMenn Medical Center,8290875,INDIV PSYCHOPHYS BIOFEED TRAIN W/PSYTX 30 MIN,,90875,917,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8290876,INDIV PSYCHOPHYS BIOFEED TRAIN W/PSYTX 45 MIN,,90876,917,$240.00 ,$240.00 ,$72.00 ,$218.40 ,$168.00 ,$72.00 ,$156.00 ,$172.80 ,$218.40 ,$180.00 
Carle BroMenn Medical Center,8290912,BFB TRAING W/EMG &/MANOMETRY 1ST 15 MIN CNTCT,,90912,917,$170.00 ,$170.00 ,$51.00 ,$154.70 ,$119.00 ,$51.00 ,$110.50 ,$122.40 ,$154.70 ,$127.50 
Carle BroMenn Medical Center,8290913,BFB TRAING W/EMG&/MANOMETRY EA ADDL 15 MIN CNTCT,,90913,917,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8200028,NEUROPSYCH TESTING BY PSYCH/PHYS,,96118,918,$728.00 ,$728.00 ,$218.40 ,$662.48 ,$509.60 ,$218.40 ,$473.20 ,$524.16 ,$662.48 ,$546.00 
Carle BroMenn Medical Center,8200029,NEUROPSYCH TESTING BY TECHNICIAN,,96119,918,$364.00 ,$364.00 ,$109.20 ,$331.24 ,$254.80 ,$109.20 ,$236.60 ,$262.08 ,$331.24 ,$273.00 
Carle BroMenn Medical Center,8290785,PSYCHOTHERAPY COMPLEX INTERACTIVE,,90785,918,$28.00 ,$28.00 ,$8.40 ,$25.48 ,$19.60 ,$8.40 ,$18.20 ,$20.16 ,$25.48 ,$21.00 
Carle BroMenn Medical Center,8296101,PSYCHOLOGIC TESTING BY PSYCH/PHYS,,96101,918,$495.00 ,$495.00 ,$148.50 ,$450.45 ,$346.50 ,$148.50 ,$321.75 ,$356.40 ,$450.45 ,$371.25 
Carle BroMenn Medical Center,8296102,PSYCHOLOGIC TESTING BY TECHNICIAN,,96102,918,$330.00 ,$330.00 ,$99.00 ,$300.30 ,$231.00 ,$99.00 ,$214.50 ,$237.60 ,$300.30 ,$247.50 
Carle BroMenn Medical Center,8296103,PSYCHOLOGIC TESTING ADMIN BY COMPUTER,,96103,918,$215.00 ,$215.00 ,$64.50 ,$195.65 ,$150.50 ,$64.50 ,$139.75 ,$154.80 ,$195.65 ,$161.25 
Carle BroMenn Medical Center,8296105,ASSESSMENT OF APHASIA,,96105,918,$385.00 ,$385.00 ,$115.50 ,$350.35 ,$269.50 ,$115.50 ,$250.25 ,$277.20 ,$350.35 ,$288.75 
Carle BroMenn Medical Center,8296110,"DEVELOPMENTAL TEST, LIM",,96110,918,$120.00 ,$120.00 ,$36.00 ,$109.20 ,$84.00 ,$36.00 ,$78.00 ,$86.40 ,$109.20 ,$90.00 
Carle BroMenn Medical Center,8296111,DEVELOPMENTAL TESTING W/INTERP & REPORT,,96111,918,$290.00 ,$290.00 ,$87.00 ,$263.90 ,$203.00 ,$87.00 ,$188.50 ,$208.80 ,$263.90 ,$217.50 
Carle BroMenn Medical Center,8296112,DEVELOPMENTAL TST ADMIN PHYS/QHP 1ST HOUR,,96112,918,$18.13 ,$18.13 ,$5.44 ,$16.50 ,$12.69 ,$5.44 ,$11.78 ,$13.05 ,$16.50 ,$13.60 
Carle BroMenn Medical Center,8296113,DEVELOPMENTAL TST ADMIN PHYS/QHP EA ADDL 30 MIN,,96113,918,$155.00 ,$155.00 ,$46.50 ,$141.05 ,$108.50 ,$46.50 ,$100.75 ,$111.60 ,$141.05 ,$116.25 
Carle BroMenn Medical Center,8296116,NEUROBEHAVIORAL STATUS EXAM BY PSYCH/PHYS,,96116,918,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8296118,NEUROPSYCH TESTING BY PSYCH/PHYS,,96118,918,$728.00 ,$728.00 ,$218.40 ,$662.48 ,$509.60 ,$218.40 ,$473.20 ,$524.16 ,$662.48 ,$546.00 
Carle BroMenn Medical Center,8296119,NEUROPSYCH TESTING BY TECHNICIAN,,96119,918,$364.00 ,$364.00 ,$109.20 ,$331.24 ,$254.80 ,$109.20 ,$236.60 ,$262.08 ,$331.24 ,$273.00 
Carle BroMenn Medical Center,8296120,NEUROPSYCH TESTING BY COMPUTER,,96120,918,$300.00 ,$300.00 ,$90.00 ,$273.00 ,$210.00 ,$90.00 ,$195.00 ,$216.00 ,$273.00 ,$225.00 
Carle BroMenn Medical Center,8296121,NEUROBEHAVIORAL STATUS XM PHYS/QHP EA ADDL HOUR,,96121,918,$245.00 ,$245.00 ,$73.50 ,$222.95 ,$171.50 ,$73.50 ,$159.25 ,$176.40 ,$222.95 ,$183.75 
Carle BroMenn Medical Center,8296125,STANDARDIZED COGNITIVE PERFORMANCE TESTING,,96125,918,$370.00 ,$370.00 ,$111.00 ,$336.70 ,$259.00 ,$111.00 ,$240.50 ,$266.40 ,$336.70 ,$277.50 
Carle BroMenn Medical Center,8296127,BEHAV ASSMT W/SCORE & DOCD/STAND INSTRUMENT,,96127,918,$77.00 ,$77.00 ,$23.10 ,$70.07 ,$53.90 ,$23.10 ,$50.05 ,$55.44 ,$70.07 ,$57.75 
Carle BroMenn Medical Center,8296130,PSYCHOLOGICAL TST EVAL SVC PHYS/QHP FIRST HOUR,,96130,918,$345.00 ,$345.00 ,$103.50 ,$313.95 ,$241.50 ,$103.50 ,$224.25 ,$248.40 ,$313.95 ,$258.75 
Carle BroMenn Medical Center,8296131,PSYCHOLOGICAL TST EVAL SVC PHYS/QHP EA ADDL HOUR,,96131,918,$215.00 ,$215.00 ,$64.50 ,$195.65 ,$150.50 ,$64.50 ,$139.75 ,$154.80 ,$195.65 ,$161.25 
Carle BroMenn Medical Center,8296132,NEUROPSYCHOLOGICAL TST EVAL PHYS/QHP 1ST HOUR,,96132,918,$720.00 ,$720.00 ,$216.00 ,$655.20 ,$504.00 ,$216.00 ,$468.00 ,$518.40 ,$655.20 ,$540.00 
Carle BroMenn Medical Center,8296133,NEUROPSYCHOLOGICAL TST EVAL PHYS/QHP EA ADDL HR,,96133,918,$690.00 ,$690.00 ,$207.00 ,$627.90 ,$483.00 ,$207.00 ,$448.50 ,$496.80 ,$627.90 ,$517.50 
Carle BroMenn Medical Center,8296136,PSYL/NRPSYCL TST PHYS/QHP 2+ TST 1ST 30 MIN,,96136,918,$365.00 ,$365.00 ,$109.50 ,$332.15 ,$255.50 ,$109.50 ,$237.25 ,$262.80 ,$332.15 ,$273.75 
Carle BroMenn Medical Center,8296137,PSYCL/NRPSYCL TST PHYS/QHP 2+ TST EA ADDL 30 MIN,,96137,918,$325.00 ,$325.00 ,$97.50 ,$295.75 ,$227.50 ,$97.50 ,$211.25 ,$234.00 ,$295.75 ,$243.75 
Carle BroMenn Medical Center,8296138,PSYCL/NRPSYCL TST TECH 2+ TST 1ST 30 MIN,,96138,918,$180.00 ,$180.00 ,$54.00 ,$163.80 ,$126.00 ,$54.00 ,$117.00 ,$129.60 ,$163.80 ,$135.00 
Carle BroMenn Medical Center,8296139,PSYCL/NRPSYCL TST TECH 2+ TST EA ADDL 30 MIN,,96139,918,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8296146,PSYCL/NRPSYCL TST ELEC PLATFORM AUTO RESULT,,96146,918,$57.00 ,$57.00 ,$17.10 ,$51.87 ,$39.90 ,$17.10 ,$37.05 ,$41.04 ,$51.87 ,$42.75 
Carle BroMenn Medical Center,8296150,"HEAL & BEHAV ASSESS,EA 15 MIN,INIT",,96150,918,$91.00 ,$91.00 ,$27.30 ,$82.81 ,$63.70 ,$27.30 ,$59.15 ,$65.52 ,$82.81 ,$68.25 
Carle BroMenn Medical Center,8296152,"HEAL & BEHAV INTERVENT,EA 15 MIN,INDIV",,96152,918,$91.00 ,$91.00 ,$27.30 ,$82.81 ,$63.70 ,$27.30 ,$59.15 ,$65.52 ,$82.81 ,$68.25 
Carle BroMenn Medical Center,8296153,"HEAL & BEHAV INTERVENT,EA 15 MIN,GROUP",,96153,918,$22.00 ,$22.00 ,$6.60 ,$20.02 ,$15.40 ,$6.60 ,$14.30 ,$15.84 ,$20.02 ,$16.50 
Carle BroMenn Medical Center,8296154,"HEAL & BEHAV INTERV,EA 15 MIN,FAM W/PT",,96154,918,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8296155,"HEAL & BEHAV INTERV,EA 15 MIN,FAM W/O PT",,96155,918,$81.00 ,$81.00 ,$24.30 ,$73.71 ,$56.70 ,$24.30 ,$52.65 ,$58.32 ,$73.71 ,$60.75 
Carle BroMenn Medical Center,8296156,HEALTH BEHAVIOR ASSESSMENT/RE-ASSESSMENT,,96156,918,$540.00 ,$540.00 ,$162.00 ,$491.40 ,$378.00 ,$162.00 ,$351.00 ,$388.80 ,$491.40 ,$405.00 
Carle BroMenn Medical Center,8296158,HEALTH BEHAVIOR IVNTJ INDIV F2F 1ST 30 MIN,,96158,918,$135.00 ,$135.00 ,$40.50 ,$122.85 ,$94.50 ,$40.50 ,$87.75 ,$97.20 ,$122.85 ,$101.25 
Carle BroMenn Medical Center,8296159,HEALTH BEHAVIOR IVNTJ INDIV F2F EA ADDL 15 MIN,,96159,918,$135.00 ,$135.00 ,$40.50 ,$122.85 ,$94.50 ,$40.50 ,$87.75 ,$97.20 ,$122.85 ,$101.25 
Carle BroMenn Medical Center,8296164,HEALTH BEHAVIOR IVNTJ GROUP F2F 1ST 30 MIN,,96164,918,$56.00 ,$56.00 ,$16.80 ,$50.96 ,$39.20 ,$16.80 ,$36.40 ,$40.32 ,$50.96 ,$42.00 
Carle BroMenn Medical Center,8296165,HEALTH BEHAVIOR IVNTJ GROUP F2F EA ADDL 15 MIN,,96165,918,$28.00 ,$28.00 ,$8.40 ,$25.48 ,$19.60 ,$8.40 ,$18.20 ,$20.16 ,$25.48 ,$21.00 
Carle BroMenn Medical Center,8296167,HEALTH BEHAVIOR IVNTJ FAM W/PT F2F 1ST 30 MIN,,96167,918,$120.00 ,$120.00 ,$36.00 ,$109.20 ,$84.00 ,$36.00 ,$78.00 ,$86.40 ,$109.20 ,$90.00 
Carle BroMenn Medical Center,8296168,HEALTH BEHAVIOR IVNTJ FAM W/PT F2F EA ADD 15 MIN,,96168,918,$59.00 ,$59.00 ,$17.70 ,$53.69 ,$41.30 ,$17.70 ,$38.35 ,$42.48 ,$53.69 ,$44.25 
Carle BroMenn Medical Center,8296170,HEALTH BEHAVIOR IVNTJ FAM W/O PT F2F 1ST 30 MIN,,96170,918,$160.00 ,$160.00 ,$48.00 ,$145.60 ,$112.00 ,$48.00 ,$104.00 ,$115.20 ,$145.60 ,$120.00 
Carle BroMenn Medical Center,8296171,HEALTH BEHAVIOR IVNTJ FAM W/O PT F2F EA ADDL 15,,96171,918,$81.00 ,$81.00 ,$24.30 ,$73.71 ,$56.70 ,$24.30 ,$52.65 ,$58.32 ,$73.71 ,$60.75 
Carle BroMenn Medical Center,8297151,BEHAVIOR ID ASSESSMENT BY PHYS/QHP EA 15 MIN,,97151,918,$77.00 ,$77.00 ,$23.10 ,$70.07 ,$53.90 ,$23.10 ,$50.05 ,$55.44 ,$70.07 ,$57.75 
Carle BroMenn Medical Center,8297152,BEHAVIOR ID SUPPORT ASSMT BY 1 TECH EA 15 MIN,,97152,918,$59.00 ,$59.00 ,$17.70 ,$53.69 ,$41.30 ,$17.70 ,$38.35 ,$42.48 ,$53.69 ,$44.25 
Carle BroMenn Medical Center,8297153,ADAPTIVE BEHAVIOR TX BY PROTOCOL TECH EA 15 MIN,,97153,918,$49.00 ,$49.00 ,$14.70 ,$44.59 ,$34.30 ,$14.70 ,$31.85 ,$35.28 ,$44.59 ,$36.75 
Carle BroMenn Medical Center,8297155,ADAPT BHV TX PRTCL MODIFICAJ PHYS/QHP EA 15 MIN,,97155,918,$49.00 ,$49.00 ,$14.70 ,$44.59 ,$34.30 ,$14.70 ,$31.85 ,$35.28 ,$44.59 ,$36.75 
Carle BroMenn Medical Center,8020002,EYE EXAMS,,,920,$143.00 ,$143.00 ,$42.90 ,$130.13 ,$100.10 ,$42.90 ,$92.95 ,$102.96 ,$130.13 ,$107.25 
Carle BroMenn Medical Center,8022133,CMPTR OPHTH IMG OPTIC NERVE,,92133,920,$116.00 ,$116.00 ,$34.80 ,$105.56 ,$81.20 ,$34.80 ,$75.40 ,$83.52 ,$105.56 ,$87.00 
Carle BroMenn Medical Center,8022134,CPTR OPHTH DX IMG POST SEGMT,,92134,920,$116.00 ,$116.00 ,$34.80 ,$105.56 ,$81.20 ,$34.80 ,$75.40 ,$83.52 ,$105.56 ,$87.00 
Carle BroMenn Medical Center,8029025,FETAL NON-STRESS TEST,,59025,920,$675.00 ,$675.00 ,$202.50 ,$614.25 ,$472.50 ,$202.50 ,$438.75 ,$486.00 ,$614.25 ,$506.25 
Carle BroMenn Medical Center,8195940,INTRA OPERATIVE MONITORING/EA 15 MIN,,95940,920,$184.00 ,$184.00 ,$55.20 ,$167.44 ,$128.80 ,$55.20 ,$119.60 ,$132.48 ,$167.44 ,$138.00 
Carle BroMenn Medical Center,8200035,"CONTACT LENS FITTING, SPHERICAL",,92310,920,$44.00 ,$44.00 ,$13.20 ,$40.04 ,$30.80 ,$13.20 ,$28.60 ,$31.68 ,$40.04 ,$33.00 
Carle BroMenn Medical Center,8200036,"CONTACT LENS FITTING, TORIC",,92310,920,$57.00 ,$57.00 ,$17.10 ,$51.87 ,$39.90 ,$17.10 ,$37.05 ,$41.04 ,$51.87 ,$42.75 
Carle BroMenn Medical Center,8200037,"CONTACT LENS FITTING, BIFOCAL",,92310,920,$91.00 ,$91.00 ,$27.30 ,$82.81 ,$63.70 ,$27.30 ,$59.15 ,$65.52 ,$82.81 ,$68.25 
Carle BroMenn Medical Center,8251736,SIMPLE UROFLOWMETRY,,51736,920,$205.00 ,$205.00 ,$61.50 ,$186.55 ,$143.50 ,$61.50 ,$133.25 ,$147.60 ,$186.55 ,$153.75 
Carle BroMenn Medical Center,8251741,COMPLEX UROFLOWMETRY,,51741,920,$350.00 ,$350.00 ,$105.00 ,$318.50 ,$245.00 ,$105.00 ,$227.50 ,$252.00 ,$318.50 ,$262.50 
Carle BroMenn Medical Center,8251797,VOIDING PRESS STUDY INTRA-ABDOMINAL VOID,,51797,920,$400.00 ,$400.00 ,$120.00 ,$364.00 ,$280.00 ,$120.00 ,$260.00 ,$288.00 ,$364.00 ,$300.00 
Carle BroMenn Medical Center,8259025,FETAL NON-STRESS TEST,,59025,920,$675.00 ,$675.00 ,$202.50 ,$614.25 ,$472.50 ,$202.50 ,$438.75 ,$486.00 ,$614.25 ,$506.25 
Carle BroMenn Medical Center,8292015,REFRACTION,,92015,920,$77.00 ,$77.00 ,$23.10 ,$70.07 ,$53.90 ,$23.10 ,$50.05 ,$55.44 ,$70.07 ,$57.75 
Carle BroMenn Medical Center,8292020,GONIOSCOPY (SEP PROC),,92020,920,$205.00 ,$205.00 ,$61.50 ,$186.55 ,$143.50 ,$61.50 ,$133.25 ,$147.60 ,$186.55 ,$153.75 
Carle BroMenn Medical Center,8292025,CORNEAL TOPOGRAPHY,,92025,920,$88.00 ,$88.00 ,$26.40 ,$80.08 ,$61.60 ,$26.40 ,$57.20 ,$63.36 ,$80.08 ,$66.00 
Carle BroMenn Medical Center,8292060,SENSORIMOTOR EXAM W/MULTIPLE MEASUREMENTS OCULAR DEVIATION W/INTERPRETATION & REPORT,,92060,920,$135.00 ,$135.00 ,$40.50 ,$122.85 ,$94.50 ,$40.50 ,$87.75 ,$97.20 ,$122.85 ,$101.25 
Carle BroMenn Medical Center,8292071,FITTING OF CONTACT LENS FOR TREATMENT OF OCULAR SURFACE DISEASE,,92071,920,$155.00 ,$155.00 ,$46.50 ,$141.05 ,$108.50 ,$46.50 ,$100.75 ,$111.60 ,$141.05 ,$116.25 
Carle BroMenn Medical Center,8292072,"FITTING OF CONTACT LENS FOR MANAGEMENT OF KERATOCONUS, INITIAL FITTING",,92072,920,$370.00 ,$370.00 ,$111.00 ,$336.70 ,$259.00 ,$111.00 ,$240.50 ,$266.40 ,$336.70 ,$277.50 
Carle BroMenn Medical Center,8292081,VISUAL FIELD EXAM-LIMITED UNI/BILAT W/INTRP REPORT,,92081,920,$115.00 ,$115.00 ,$34.50 ,$104.65 ,$80.50 ,$34.50 ,$74.75 ,$82.80 ,$104.65 ,$86.25 
Carle BroMenn Medical Center,8292082,VISUAL FIELD EXAM-INTERMEDIATE UNI/BILAT W/ INTRP REPORT,,92082,920,$140.00 ,$140.00 ,$42.00 ,$127.40 ,$98.00 ,$42.00 ,$91.00 ,$100.80 ,$127.40 ,$105.00 
Carle BroMenn Medical Center,8292083,VISUAL FIELD EXAM-EXTENDED UNI/BILAT W/INTRP REPORT,,92083,920,$275.00 ,$275.00 ,$82.50 ,$250.25 ,$192.50 ,$82.50 ,$178.75 ,$198.00 ,$250.25 ,$206.25 
Carle BroMenn Medical Center,8292100,SERIAL TONOMETRY (SEP PROC) MULTIPLE MEASURE EXTENDED PERIOD TIME W/INTERPRET & REPORT SAME DAY,,92100,920,$180.00 ,$180.00 ,$54.00 ,$163.80 ,$126.00 ,$54.00 ,$117.00 ,$129.60 ,$163.80 ,$135.00 
Carle BroMenn Medical Center,8292132,CMPTR OPHTH DX IMG ANT SEGMT,,92132,920,$165.00 ,$165.00 ,$49.50 ,$150.15 ,$115.50 ,$49.50 ,$107.25 ,$118.80 ,$150.15 ,$123.75 
Carle BroMenn Medical Center,8292133,CMPTR OPHTH IMG OPTIC NERVE,,92133,920,$116.00 ,$116.00 ,$34.80 ,$105.56 ,$81.20 ,$34.80 ,$75.40 ,$83.52 ,$105.56 ,$87.00 
Carle BroMenn Medical Center,8292134,CPTR OPHTH DX IMG POST SEGMT,,92134,920,$116.00 ,$116.00 ,$34.80 ,$105.56 ,$81.20 ,$34.80 ,$75.40 ,$83.52 ,$105.56 ,$87.00 
Carle BroMenn Medical Center,8292136,OPHTHALMIC BIOMETRY BY PARTIAL COHERENCE INTERFEROMETRY W/INTRAOCULAR LENS POWER CALCULATION,,92136,920,$275.00 ,$275.00 ,$82.50 ,$250.25 ,$192.50 ,$82.50 ,$178.75 ,$198.00 ,$250.25 ,$206.25 
Carle BroMenn Medical Center,8292201,OPSCPY EXTND RTA DRAWING & SCL DEPRSN I&R UNI/BI,,92201,920,$170.00 ,$170.00 ,$51.00 ,$154.70 ,$119.00 ,$51.00 ,$110.50 ,$122.40 ,$154.70 ,$127.50 
Carle BroMenn Medical Center,8292202,OPSCPY EXTND OPTIC NRV/MACULA DRAWING I&R UNI/BI,,92202,920,$170.00 ,$170.00 ,$51.00 ,$154.70 ,$119.00 ,$51.00 ,$110.50 ,$122.40 ,$154.70 ,$127.50 
Carle BroMenn Medical Center,8292225,EXTENDED OPHTHALMOSCOPY W/RETINAL DRAWING W/INTERPRETATION & REPORT INITIAL,,92225,920,$170.00 ,$170.00 ,$51.00 ,$154.70 ,$119.00 ,$51.00 ,$110.50 ,$122.40 ,$154.70 ,$127.50 
Carle BroMenn Medical Center,8292226,EXTENDED OPHTHALMOSCOPY W/RETINAL DRAWING W/INTERPRETATION & REPORT SUBSEQUENT,,92226,920,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8292235,FLUORESCEIN ANGIOGRAPHY (W/MULTIFRAME IMAGING) W/INTERPRETATION & REPORT,,92235,920,$570.00 ,$570.00 ,$171.00 ,$518.70 ,$399.00 ,$171.00 ,$370.50 ,$410.40 ,$518.70 ,$427.50 
Carle BroMenn Medical Center,8292240,INDOCYANINE-GREEN ANGIOGRAPHY (W/MULTIFRAME IMAGING) W/INTERPRETATION & REPORT,,92240,920,$640.00 ,$640.00 ,$192.00 ,$582.40 ,$448.00 ,$192.00 ,$416.00 ,$460.80 ,$582.40 ,$480.00 
Carle BroMenn Medical Center,8292242,FLURORESCEIN ICG ANGRPH W/MULTIFRAME I&R UNI/BI,,92242,920,$740.00 ,$740.00 ,$222.00 ,$673.40 ,$518.00 ,$222.00 ,$481.00 ,$532.80 ,$673.40 ,$555.00 
Carle BroMenn Medical Center,8292250,FUNDUS PHOTOGRAPHY,,92250,920,$310.00 ,$310.00 ,$93.00 ,$282.10 ,$217.00 ,$93.00 ,$201.50 ,$223.20 ,$282.10 ,$232.50 
Carle BroMenn Medical Center,8292260,OPHTHALMODYNAMOMETRY,,92260,920,$120.00 ,$120.00 ,$36.00 ,$109.20 ,$84.00 ,$36.00 ,$78.00 ,$86.40 ,$109.20 ,$90.00 
Carle BroMenn Medical Center,8292273,FULL FIELD ELECTRORETINOGRAPHY W/I&R,,92273,920,$425.00 ,$425.00 ,$127.50 ,$386.75 ,$297.50 ,$127.50 ,$276.25 ,$306.00 ,$386.75 ,$318.75 
Carle BroMenn Medical Center,8292274,MULTIFOCAL ELECTRORETINOGRAPHY W/I&R,,92274,920,$230.00 ,$230.00 ,$69.00 ,$209.30 ,$161.00 ,$69.00 ,$149.50 ,$165.60 ,$209.30 ,$172.50 
Carle BroMenn Medical Center,8292283,COLOR VISION EXAMINATION,,92283,920,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8292285,"EXT OCULAR PHOTOGRAPHY W/INTERPRETATION & REPORT, MEDICAL PROGRESS",,92285,920,$135.00 ,$135.00 ,$40.50 ,$122.85 ,$94.50 ,$40.50 ,$87.75 ,$97.20 ,$122.85 ,$101.25 
Carle BroMenn Medical Center,8292286,ANT SGM IMAGING W/MICROSCOPY ENDOTHELIAL ANALY,,92286,920,$275.00 ,$275.00 ,$82.50 ,$250.25 ,$192.50 ,$82.50 ,$178.75 ,$198.00 ,$250.25 ,$206.25 
Carle BroMenn Medical Center,8292311,"CONTACT LENS FIT,APHAKIA UNILAT",,92311,920,$245.00 ,$245.00 ,$73.50 ,$222.95 ,$171.50 ,$73.50 ,$159.25 ,$176.40 ,$222.95 ,$183.75 
Carle BroMenn Medical Center,8292312,"CONTACT LENS FIT,APHAKIA BILAT",,92312,920,$125.00 ,$125.00 ,$37.50 ,$113.75 ,$87.50 ,$37.50 ,$81.25 ,$90.00 ,$113.75 ,$93.75 
Carle BroMenn Medical Center,8292325,MODIFICATION OF CONTACT LENS,,92325,920,$110.00 ,$110.00 ,$33.00 ,$100.10 ,$77.00 ,$33.00 ,$71.50 ,$79.20 ,$100.10 ,$82.50 
Carle BroMenn Medical Center,8292516,FACIAL NERVE FUNCTION TEST,,92516,920,$230.00 ,$230.00 ,$69.00 ,$209.30 ,$161.00 ,$69.00 ,$149.50 ,$165.60 ,$209.30 ,$172.50 
Carle BroMenn Medical Center,8292541,SPONTANEOUS NYSTAGMUS TEST,,92541,920,$225.00 ,$225.00 ,$67.50 ,$204.75 ,$157.50 ,$67.50 ,$146.25 ,$162.00 ,$204.75 ,$168.75 
Carle BroMenn Medical Center,8292542,POSITIONAL NYSTAGMUS TEST,,92542,920,$320.00 ,$320.00 ,$96.00 ,$291.20 ,$224.00 ,$96.00 ,$208.00 ,$230.40 ,$291.20 ,$240.00 
Carle BroMenn Medical Center,8292544,"OPTOKINETIC NYSTAGMUS TEST, BIDIREC, FOVEAL, PERIPH, W RECORD",,92544,920,$285.00 ,$285.00 ,$85.50 ,$259.35 ,$199.50 ,$85.50 ,$185.25 ,$205.20 ,$259.35 ,$213.75 
Carle BroMenn Medical Center,8292545,OSCILLATING TRACKING TEST,,92545,920,$175.00 ,$175.00 ,$52.50 ,$159.25 ,$122.50 ,$52.50 ,$113.75 ,$126.00 ,$159.25 ,$131.25 
Carle BroMenn Medical Center,8293895,CAROTID INTIMA MEDIA & CAROTID ATHEROMA EVAL BI,,93895,920,$620.00 ,$620.00 ,$186.00 ,$564.20 ,$434.00 ,$186.00 ,$403.00 ,$446.40 ,$564.20 ,$465.00 
Carle BroMenn Medical Center,8295249,CONT GLUC MONITORING PATIENT PROVIDED EQUIPTMENT,,95249,920,$390.00 ,$390.00 ,$117.00 ,$354.90 ,$273.00 ,$117.00 ,$253.50 ,$280.80 ,$354.90 ,$292.50 
Carle BroMenn Medical Center,8295250,GLUCOSE MONITORING 72 HRS SUBQ SENSOR,,95250,920,$670.00 ,$670.00 ,$201.00 ,$609.70 ,$469.00 ,$201.00 ,$435.50 ,$482.40 ,$609.70 ,$502.50 
Carle BroMenn Medical Center,8295857,TENSILON TEST,,95857,920,$235.00 ,$235.00 ,$70.50 ,$213.85 ,$164.50 ,$70.50 ,$152.75 ,$169.20 ,$213.85 ,$176.25 
Carle BroMenn Medical Center,8295930,VISUAL EVOKED POTENTIAL TEST,,95930,920,$743.00 ,$743.00 ,$222.90 ,$676.13 ,$520.10 ,$222.90 ,$482.95 ,$534.96 ,$676.13 ,$557.25 
Carle BroMenn Medical Center,8295970,ELEC ALYS NSTIM PLS GEN BRN/SC/PERPH W/O REPRGRM,,95970,920,$275.00 ,$275.00 ,$82.50 ,$250.25 ,$192.50 ,$82.50 ,$178.75 ,$198.00 ,$250.25 ,$206.25 
Carle BroMenn Medical Center,8295971,ELEC ANLYS NSTIM PULSE GEN SIMPLE SC/PERIPH W/PRGRMG,,95971,920,$560.00 ,$560.00 ,$168.00 ,$509.60 ,$392.00 ,$168.00 ,$364.00 ,$403.20 ,$509.60 ,$420.00 
Carle BroMenn Medical Center,8295972,ELEC ALYS NSTIM PLS GEN CPLX SC/PERPH 1ST HR,,95972,920,$670.00 ,$670.00 ,$201.00 ,$609.70 ,$469.00 ,$201.00 ,$435.50 ,$482.40 ,$609.70 ,$502.50 
Carle BroMenn Medical Center,8295974,"COMPLEX CRAINAIAL NEUROSTIM, 1RST HOUR",,95974,920,"$1,440.00 ","$1,440.00 ",$432.00 ,"$1,310.40 ","$1,008.00 ",$432.00 ,$936.00 ,"$1,036.80 ","$1,310.40 ","$1,080.00 "
Carle BroMenn Medical Center,8295975,"COMPLEX CRANIAL NEUROSTIM,EA 30 ADDN",,95975,920,$640.00 ,$640.00 ,$192.00 ,$582.40 ,$448.00 ,$192.00 ,$416.00 ,$460.80 ,$582.40 ,$480.00 
Carle BroMenn Medical Center,8299173,"VISUAL SCREENING TEST, BILAT",,99173,920,$42.00 ,$42.00 ,$12.60 ,$38.22 ,$29.40 ,$12.60 ,$27.30 ,$30.24 ,$38.22 ,$31.50 
Carle BroMenn Medical Center,8299177,INSTRUMENT BASED OCULAR SCR BI W/ONSITE ANALYSIS,,99177,920,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8299453,REM MNTR PHYSIOL PARAM 1ST SET UP PT EDUCAJ EQP,,99453,920,$225.00 ,$225.00 ,$67.50 ,$204.75 ,$157.50 ,$67.50 ,$146.25 ,$162.00 ,$204.75 ,$168.75 
Carle BroMenn Medical Center,8299454,REM MNTR PHYSIOL PARAM 1ST DEV SUPPLY EA 30 D,,99454,920,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8299473,SELF-MEAS BP PT EDUCAJ/TRAING & DEV CALIBRATION,,99473,920,$47.00 ,$47.00 ,$14.10 ,$42.77 ,$32.90 ,$14.10 ,$30.55 ,$33.84 ,$42.77 ,$35.25 
Carle BroMenn Medical Center,8495940,IONM IN OPERATNG ROOM 15 MIN,,95940,920,$184.00 ,$184.00 ,$55.20 ,$167.44 ,$128.80 ,$55.20 ,$119.60 ,$132.48 ,$167.44 ,$138.00 
Carle BroMenn Medical Center,8495941,IONM REMOTE/>1 PT OR PER HR,,95941,920,$413.00 ,$413.00 ,$123.90 ,$375.83 ,$289.10 ,$123.90 ,$268.45 ,$297.36 ,$375.83 ,$309.75 
Carle BroMenn Medical Center,8663668,"PERIPHERAL ART DISEASE REHAB, EA",,93668,920,$83.00 ,$83.00 ,$24.90 ,$75.53 ,$58.10 ,$24.90 ,$53.95 ,$59.76 ,$75.53 ,$62.25 
Carle BroMenn Medical Center,8930399,"Osct, Type Iii (4+ Channels)",,G0399,920,$475.00 ,$475.00 ,$142.50 ,$432.25 ,$332.50 ,$142.50 ,$308.75 ,$342.00 ,$432.25 ,$356.25 
Carle BroMenn Medical Center,8933811,POLYSOMNOGRAM W/CPAP (SPLIT),,95811,920,"$5,705.00 ","$5,705.00 ","$1,711.50 ","$5,191.55 ","$3,993.50 ","$1,711.50 ","$3,708.25 ","$4,107.60 ","$5,191.55 ","$4,278.75 "
Carle BroMenn Medical Center,8935782,POLYSOM < 6 YRS ATTENDED,,95782,920,"$5,415.00 ","$5,415.00 ","$1,624.50 ","$4,927.65 ","$3,790.50 ","$1,624.50 ","$3,519.75 ","$3,898.80 ","$4,927.65 ","$4,061.25 "
Carle BroMenn Medical Center,8935783,POLYSOM < 6 YRS W/PAP ATTENDED,,95783,920,"$4,598.00 ","$4,598.00 ","$1,379.40 ","$4,184.18 ","$3,218.60 ","$1,379.40 ","$2,988.70 ","$3,310.56 ","$4,184.18 ","$3,448.50 "
Carle BroMenn Medical Center,8935803,ACTIGRAPHY (3-14 DAYS),,95803,920,$840.00 ,$840.00 ,$252.00 ,$764.40 ,$588.00 ,$252.00 ,$546.00 ,$604.80 ,$764.40 ,$630.00 
Carle BroMenn Medical Center,8293880,"DUPLEX SCAN EXTRACRANIAL,BILAT",,93880,921,"$1,105.00 ","$1,105.00 ",$331.50 ,"$1,005.55 ",$773.50 ,$331.50 ,$718.25 ,$795.60 ,"$1,005.55 ",$828.75 
Carle BroMenn Medical Center,8293922,NON-INVAS PHYSIOLOGIC STD EXTREMITY ART 1-2 LEVEL,,93922,921,$445.00 ,$445.00 ,$133.50 ,$404.95 ,$311.50 ,$133.50 ,$289.25 ,$320.40 ,$404.95 ,$333.75 
Carle BroMenn Medical Center,8293923,NON-INVASIVE PHYSIOLOGIC STUDY EXTREMITY 3 LEVELS,,93923,921,$980.00 ,$980.00 ,$294.00 ,$891.80 ,$686.00 ,$294.00 ,$637.00 ,$705.60 ,$891.80 ,$735.00 
Carle BroMenn Medical Center,8293925,DUPLEX LO EXTREM ART BILAT,,93925,921,"$1,085.00 ","$1,085.00 ",$325.50 ,$987.35 ,$759.50 ,$325.50 ,$705.25 ,$781.20 ,$987.35 ,$813.75 
Carle BroMenn Medical Center,8293926,DUPLEX LO EXTREM ART UNILAT/LTD,,93926,921,$745.00 ,$745.00 ,$223.50 ,$677.95 ,$521.50 ,$223.50 ,$484.25 ,$536.40 ,$677.95 ,$558.75 
Carle BroMenn Medical Center,8293931,DUPLEX UP EXTREM ART UNILAT/LTD,,93931,921,$815.00 ,$815.00 ,$244.50 ,$741.65 ,$570.50 ,$244.50 ,$529.75 ,$586.80 ,$741.65 ,$611.25 
Carle BroMenn Medical Center,8293970,"DUPLEX EXTREM VENOUS,BILAT",,93970,921,"$1,645.00 ","$1,645.00 ",$493.50 ,"$1,496.95 ","$1,151.50 ",$493.50 ,"$1,069.25 ","$1,184.40 ","$1,496.95 ","$1,233.75 "
Carle BroMenn Medical Center,8293971,"DUPLEX EXTREM VENOUS,UNI OR LTD",,93971,921,$870.00 ,$870.00 ,$261.00 ,$791.70 ,$609.00 ,$261.00 ,$565.50 ,$626.40 ,$791.70 ,$652.50 
Carle BroMenn Medical Center,8293975,"DUPLEX ABD/PEL VASC STUDY,COMPLETE",,93975,921,"$1,740.00 ","$1,740.00 ",$522.00 ,"$1,583.40 ","$1,218.00 ",$522.00 ,"$1,131.00 ","$1,252.80 ","$1,583.40 ","$1,305.00 "
Carle BroMenn Medical Center,8293976,"DUPLEX ABD/PEL VASC STUDY,LIMITD",,93976,921,$870.00 ,$870.00 ,$261.00 ,$791.70 ,$609.00 ,$261.00 ,$565.50 ,$626.40 ,$791.70 ,$652.50 
Carle BroMenn Medical Center,8293978,"DUPLEX LARGE VESSEL(S),COMPLETE",,93978,921,"$1,130.00 ","$1,130.00 ",$339.00 ,"$1,028.30 ",$791.00 ,$339.00 ,$734.50 ,$813.60 ,"$1,028.30 ",$847.50 
Carle BroMenn Medical Center,8293990,DUPLEX HEMODIALYSIS ACCESS,,93990,921,$600.00 ,$600.00 ,$180.00 ,$546.00 ,$420.00 ,$180.00 ,$390.00 ,$432.00 ,$546.00 ,$450.00 
Carle BroMenn Medical Center,8493880,DUPLEX SCN EXTRCRN ART BILAT CMPLT,,93880,921,"$1,105.00 ","$1,105.00 ",$331.50 ,"$1,005.55 ",$773.50 ,$331.50 ,$718.25 ,$795.60 ,"$1,005.55 ",$828.75 
Carle BroMenn Medical Center,8493882,DUPLEX SCN EXTRCRN ART UNILAT/LMTD,,93882,921,$780.00 ,$780.00 ,$234.00 ,$709.80 ,$546.00 ,$234.00 ,$507.00 ,$561.60 ,$709.80 ,$585.00 
Carle BroMenn Medical Center,8493886,TRNSCRNL DOPPLER CMPLT,,93886,921,$815.00 ,$815.00 ,$244.50 ,$741.65 ,$570.50 ,$244.50 ,$529.75 ,$586.80 ,$741.65 ,$611.25 
Carle BroMenn Medical Center,8493888,TRNSCRNL DOPPLER LMTD,,93888,921,$713.00 ,$713.00 ,$213.90 ,$648.83 ,$499.10 ,$213.90 ,$463.45 ,$513.36 ,$648.83 ,$534.75 
Carle BroMenn Medical Center,8493922,ARTL EXTMTY DPPLR SNGL LVL BILAT,,93922,921,$445.00 ,$445.00 ,$133.50 ,$404.95 ,$311.50 ,$133.50 ,$289.25 ,$320.40 ,$404.95 ,$333.75 
Carle BroMenn Medical Center,8493923,ARTL EXTMTY DPPLR MULT LVLS BILAT,,93923,921,$980.00 ,$980.00 ,$294.00 ,$891.80 ,$686.00 ,$294.00 ,$637.00 ,$705.60 ,$891.80 ,$735.00 
Carle BroMenn Medical Center,8493925,DPLX SCN LWR EXT ART BILAT CMPLT,,93925,921,"$1,085.00 ","$1,085.00 ",$325.50 ,$987.35 ,$759.50 ,$325.50 ,$705.25 ,$781.20 ,$987.35 ,$813.75 
Carle BroMenn Medical Center,8493926,DPLX SCN LWR EXT ART UNILT/LMTD,,93926,921,$745.00 ,$745.00 ,$223.50 ,$677.95 ,$521.50 ,$223.50 ,$484.25 ,$536.40 ,$677.95 ,$558.75 
Carle BroMenn Medical Center,8493930,DPLX SCN UPPR EXT ART BILAT CMPLT,,93930,921,"$1,250.00 ","$1,250.00 ",$375.00 ,"$1,137.50 ",$875.00 ,$375.00 ,$812.50 ,$900.00 ,"$1,137.50 ",$937.50 
Carle BroMenn Medical Center,8493931,DPLX SCN UPPR EXT ART UNILT/LMTD,,93931,921,$815.00 ,$815.00 ,$244.50 ,$741.65 ,$570.50 ,$244.50 ,$529.75 ,$586.80 ,$741.65 ,$611.25 
Carle BroMenn Medical Center,8493970,BILATERAL VENOUS DUPLEX,,93970,921,"$1,645.00 ","$1,645.00 ",$493.50 ,"$1,496.95 ","$1,151.50 ",$493.50 ,"$1,069.25 ","$1,184.40 ","$1,496.95 ","$1,233.75 "
Carle BroMenn Medical Center,8493971,FOLLOW-UP LMTD VEN DUPLEX,,93971,921,$870.00 ,$870.00 ,$261.00 ,$791.70 ,$609.00 ,$261.00 ,$565.50 ,$626.40 ,$791.70 ,$652.50 
Carle BroMenn Medical Center,8493975,DPLX SCN ABD/PLVC/RTROPTNL CMPLT,,93975,921,"$1,740.00 ","$1,740.00 ",$522.00 ,"$1,583.40 ","$1,218.00 ",$522.00 ,"$1,131.00 ","$1,252.80 ","$1,583.40 ","$1,305.00 "
Carle BroMenn Medical Center,8493976,DPLX SCN ABD/PLVC/RTROPTNL LMTD,,93976,921,$870.00 ,$870.00 ,$261.00 ,$791.70 ,$609.00 ,$261.00 ,$565.50 ,$626.40 ,$791.70 ,$652.50 
Carle BroMenn Medical Center,8493978,DPLX SCN ARTA/IVC/ILAC CMPLT,,93978,921,"$1,130.00 ","$1,130.00 ",$339.00 ,"$1,028.30 ",$791.00 ,$339.00 ,$734.50 ,$813.60 ,"$1,028.30 ",$847.50 
Carle BroMenn Medical Center,8493979,DPLX SCN ARTA/IVC/ILAC LMTD,,93979,921,$710.00 ,$710.00 ,$213.00 ,$646.10 ,$497.00 ,$213.00 ,$461.50 ,$511.20 ,$646.10 ,$532.50 
Carle BroMenn Medical Center,8493980,DUPLX SCN PENILE VESSELS; COMPLETE,,93980,921,"$1,320.00 ","$1,320.00 ",$396.00 ,"$1,201.20 ",$924.00 ,$396.00 ,$858.00 ,$950.40 ,"$1,201.20 ",$990.00 
Carle BroMenn Medical Center,8493981,DUPLX SCN PENILE VESSELS; LIMITED OR F/U,,93981,921,$915.00 ,$915.00 ,$274.50 ,$832.65 ,$640.50 ,$274.50 ,$594.75 ,$658.80 ,$832.65 ,$686.25 
Carle BroMenn Medical Center,8493985,DUPLEX SCAN ARTL INFL&VEN O/F HEMO COMPL BI STD,,93985,921,"$1,553.00 ","$1,553.00 ",$465.90 ,"$1,413.23 ","$1,087.10 ",$465.90 ,"$1,009.45 ","$1,118.16 ","$1,413.23 ","$1,164.75 "
Carle BroMenn Medical Center,8493986,DUPLEX SCAN ARTL INFL&VEN O/F HEMO COMPL UNI STD,,93986,921,$750.00 ,$750.00 ,$225.00 ,$682.50 ,$525.00 ,$225.00 ,$487.50 ,$540.00 ,$682.50 ,$562.50 
Carle BroMenn Medical Center,8493990,DPLX SCN HEMODIALYSIS ACCESS,,93990,921,$510.00 ,$510.00 ,$153.00 ,$464.10 ,$357.00 ,$153.00 ,$331.50 ,$367.20 ,$464.10 ,$382.50 
Carle BroMenn Medical Center,8493998,UNLISTED NONINVASIVE VASCULAR DIAGNOSTIC STUDY,,93998,921,$125.00 ,$125.00 ,$37.50 ,$113.75 ,$87.50 ,$37.50 ,$81.25 ,$90.00 ,$113.75 ,$93.75 
Carle BroMenn Medical Center,8913323,BILAT MULT LVL DOPPLER W/TCOM,,93923,921,$980.00 ,$980.00 ,$294.00 ,$891.80 ,$686.00 ,$294.00 ,$637.00 ,$705.60 ,$891.80 ,$735.00 
Carle BroMenn Medical Center,8913920,TCOM DURING HBO -LOWER LEGIES,,93922,921,$445.00 ,$445.00 ,$133.50 ,$404.95 ,$311.50 ,$133.50 ,$289.25 ,$320.40 ,$404.95 ,$333.75 
Carle BroMenn Medical Center,8913922,SINGLE LEVEL ARTERIAL STUDIES,,93922,921,$445.00 ,$445.00 ,$133.50 ,$404.95 ,$311.50 ,$133.50 ,$289.25 ,$320.40 ,$404.95 ,$333.75 
Carle BroMenn Medical Center,8913923,BILAT MULT LVL DOPPLER W/TCOM,,93923,921,$980.00 ,$980.00 ,$294.00 ,$891.80 ,$686.00 ,$294.00 ,$637.00 ,$705.60 ,$891.80 ,$735.00 
Carle BroMenn Medical Center,8913926,UNILATERAL/LIMITED DOPPLER,,93926,921,$745.00 ,$745.00 ,$223.50 ,$677.95 ,$521.50 ,$223.50 ,$484.25 ,$536.40 ,$677.95 ,$558.75 
Carle BroMenn Medical Center,8973926,DPLX SCN LWR EXT ART UNILT/LMTD,,93926,921,$745.00 ,$745.00 ,$223.50 ,$677.95 ,$521.50 ,$223.50 ,$484.25 ,$536.40 ,$677.95 ,$558.75 
Carle BroMenn Medical Center,8101784,EMG ANAL/URETHRAL,,51784,922,$259.00 ,$259.00 ,$77.70 ,$235.69 ,$181.30 ,$77.70 ,$168.35 ,$186.48 ,$235.69 ,$194.25 
Carle BroMenn Medical Center,8105001,EMG ANAL SPHINCTER,,51785,922,$623.00 ,$623.00 ,$186.90 ,$566.93 ,$436.10 ,$186.90 ,$404.95 ,$448.56 ,$566.93 ,$467.25 
Carle BroMenn Medical Center,8105886,NEEDLE EMG EA EXTREMITY,,95886,922,$334.00 ,$334.00 ,$100.20 ,$303.94 ,$233.80 ,$100.20 ,$217.10 ,$240.48 ,$303.94 ,$250.50 
Carle BroMenn Medical Center,8105887,NEEDLE EMG NONEXTREMTY MSCLES W/NERVE CONDUCTION,,95887,922,$248.00 ,$248.00 ,$74.40 ,$225.68 ,$173.60 ,$74.40 ,$161.20 ,$178.56 ,$225.68 ,$186.00 
Carle BroMenn Medical Center,8109015,EMG 1 LIMB,,95860,922,$555.00 ,$555.00 ,$166.50 ,$505.05 ,$388.50 ,$166.50 ,$360.75 ,$399.60 ,$505.05 ,$416.25 
Carle BroMenn Medical Center,8109016,EMG 2 LIMBS,,95861,922,$600.00 ,$600.00 ,$180.00 ,$546.00 ,$420.00 ,$180.00 ,$390.00 ,$432.00 ,$546.00 ,$450.00 
Carle BroMenn Medical Center,8109017,EMG 3 LIMBS,,95863,922,$818.00 ,$818.00 ,$245.40 ,$744.38 ,$572.60 ,$245.40 ,$531.70 ,$588.96 ,$744.38 ,$613.50 
Carle BroMenn Medical Center,8109018,EMG 4 LIMBS,,95864,922,$855.00 ,$855.00 ,$256.50 ,$778.05 ,$598.50 ,$256.50 ,$555.75 ,$615.60 ,$778.05 ,$641.25 
Carle BroMenn Medical Center,8109019,EMG LARYNX/VOCALCORD/RECUNERVE,,95865,922,$330.00 ,$330.00 ,$99.00 ,$300.30 ,$231.00 ,$99.00 ,$214.50 ,$237.60 ,$300.30 ,$247.50 
Carle BroMenn Medical Center,8109020,EMG UNI LAT CRANIAL NERVES,,95867,922,$364.00 ,$364.00 ,$109.20 ,$331.24 ,$254.80 ,$109.20 ,$236.60 ,$262.08 ,$331.24 ,$273.00 
Carle BroMenn Medical Center,8109021,EMG BI LAT CRANIAL NERVES,,95868,922,$458.00 ,$458.00 ,$137.40 ,$416.78 ,$320.60 ,$137.40 ,$297.70 ,$329.76 ,$416.78 ,$343.50 
Carle BroMenn Medical Center,8109022,EMG THORACIC/PARASPINAL NERVES,,95869,922,$263.00 ,$263.00 ,$78.90 ,$239.33 ,$184.10 ,$78.90 ,$170.95 ,$189.36 ,$239.33 ,$197.25 
Carle BroMenn Medical Center,8109023,EMG AXIAL NERVES,,95870,922,$195.00 ,$195.00 ,$58.50 ,$177.45 ,$136.50 ,$58.50 ,$126.75 ,$140.40 ,$177.45 ,$146.25 
Carle BroMenn Medical Center,8109036,NEURO MUSCU JNC TEST EA NERVE,,95937,922,$364.00 ,$364.00 ,$109.20 ,$331.24 ,$254.80 ,$109.20 ,$236.60 ,$262.08 ,$331.24 ,$273.00 
Carle BroMenn Medical Center,8295860,"EMG, NEEDLE, ONE LIMB",,95860,922,$555.00 ,$555.00 ,$166.50 ,$505.05 ,$388.50 ,$166.50 ,$360.75 ,$399.60 ,$505.05 ,$416.25 
Carle BroMenn Medical Center,8295861,"EMG, NEEDLE, TWO LIMBS",,95861,922,$600.00 ,$600.00 ,$180.00 ,$546.00 ,$420.00 ,$180.00 ,$390.00 ,$432.00 ,$546.00 ,$450.00 
Carle BroMenn Medical Center,8295863,"EMG, NEEDLE, 3 LIMBS",,95863,922,$818.00 ,$818.00 ,$245.40 ,$744.38 ,$572.60 ,$245.40 ,$531.70 ,$588.96 ,$744.38 ,$613.50 
Carle BroMenn Medical Center,8295864,EMG -4 EXTREMITIES,,95864,922,$855.00 ,$855.00 ,$256.50 ,$778.05 ,$598.50 ,$256.50 ,$555.75 ,$615.60 ,$778.05 ,$641.25 
Carle BroMenn Medical Center,8295866,"EMG, NEEDLE, HEMIDIAPHRAGM",,95866,922,$220.00 ,$220.00 ,$66.00 ,$200.20 ,$154.00 ,$66.00 ,$143.00 ,$158.40 ,$200.20 ,$165.00 
Carle BroMenn Medical Center,8295867,EMG CRANIAL UNILATERAL,,95867,922,$364.00 ,$364.00 ,$109.20 ,$331.24 ,$254.80 ,$109.20 ,$236.60 ,$262.08 ,$331.24 ,$273.00 
Carle BroMenn Medical Center,8295869,"EMG,NEEDLE,THOR PARASPIN MUS,EXC T1/T12",,95869,922,$263.00 ,$263.00 ,$78.90 ,$239.33 ,$184.10 ,$78.90 ,$170.95 ,$189.36 ,$239.33 ,$197.25 
Carle BroMenn Medical Center,8295870,"EMG,1 EXTREM,NONPARASPINAL",,95870,922,$195.00 ,$195.00 ,$58.50 ,$177.45 ,$136.50 ,$58.50 ,$126.75 ,$140.40 ,$177.45 ,$146.25 
Carle BroMenn Medical Center,8295874,NEEDLE EMG GUIDANCE FOR CHEMODENERVATION,,95874,922,$220.00 ,$220.00 ,$66.00 ,$200.20 ,$154.00 ,$66.00 ,$143.00 ,$158.40 ,$200.20 ,$165.00 
Carle BroMenn Medical Center,8295885,NEEDLE EMG EA EXTREMITY W/PARASPINL AREA LIMITED,,95885,922,$210.00 ,$210.00 ,$63.00 ,$191.10 ,$147.00 ,$63.00 ,$136.50 ,$151.20 ,$191.10 ,$157.50 
Carle BroMenn Medical Center,8295886,NEEDLE EMG EA EXTREMTY W/PARASPINL AREA COMPLETE,,95886,922,$334.00 ,$334.00 ,$100.20 ,$303.94 ,$233.80 ,$100.20 ,$217.10 ,$240.48 ,$303.94 ,$250.50 
Carle BroMenn Medical Center,8295887,NEEDLE EMG NONEXTREMTY MSCLES W/NERVE CONDUCTION,,95887,922,$248.00 ,$248.00 ,$74.40 ,$225.68 ,$173.60 ,$74.40 ,$161.20 ,$178.56 ,$225.68 ,$186.00 
Carle BroMenn Medical Center,8295907,MOTOR &/SENS 1-2 NRV CNDJ PRECONF ELTRODE LIMB,,95907,922,$405.00 ,$405.00 ,$121.50 ,$368.55 ,$283.50 ,$121.50 ,$263.25 ,$291.60 ,$368.55 ,$303.75 
Carle BroMenn Medical Center,8295908,MOTOR &/SENS 3-4 NRV CNDJ PRECONF ELTRODE LIMB,,95908,922,$610.00 ,$610.00 ,$183.00 ,$555.10 ,$427.00 ,$183.00 ,$396.50 ,$439.20 ,$555.10 ,$457.50 
Carle BroMenn Medical Center,8295909,MOTOR &/SENS 5-6 NRV CNDJ PRECONF ELTRODE LIMB,,95909,922,$730.00 ,$730.00 ,$219.00 ,$664.30 ,$511.00 ,$219.00 ,$474.50 ,$525.60 ,$664.30 ,$547.50 
Carle BroMenn Medical Center,8295910,MOTOR &/SENS 7-8 NRV CNDJ PRECONF ELTRODE LIMB,,95910,922,$640.00 ,$640.00 ,$192.00 ,$582.40 ,$448.00 ,$192.00 ,$416.00 ,$460.80 ,$582.40 ,$480.00 
Carle BroMenn Medical Center,8295911,MOTOR &/SENS 9-10 NRV CNDJ PRECONF ELTRODE LIMB,,95911,922,$900.00 ,$900.00 ,$270.00 ,$819.00 ,$630.00 ,$270.00 ,$585.00 ,$648.00 ,$819.00 ,$675.00 
Carle BroMenn Medical Center,8295912,MOTOR &/SENS 11-12 NRV CNDJ PRECONF ELTRODE LIMB,,95912,922,"$1,030.00 ","$1,030.00 ",$309.00 ,$937.30 ,$721.00 ,$309.00 ,$669.50 ,$741.60 ,$937.30 ,$772.50 
Carle BroMenn Medical Center,8295913,MOTOR &/SENS 13/> NRV CNDJ PRECONF ELTRODE LIMB,,95913,922,"$1,090.00 ","$1,090.00 ",$327.00 ,$991.90 ,$763.00 ,$327.00 ,$708.50 ,$784.80 ,$991.90 ,$817.50 
Carle BroMenn Medical Center,8295926,BSER SOMATOSENSORY/LOWER,,95926,922,$735.00 ,$735.00 ,$220.50 ,$668.85 ,$514.50 ,$220.50 ,$477.75 ,$529.20 ,$668.85 ,$551.25 
Carle BroMenn Medical Center,8295937,NEUROMUSCULAR JUNCTION TEST,,95937,922,$364.00 ,$364.00 ,$109.20 ,$331.24 ,$254.80 ,$109.20 ,$236.60 ,$262.08 ,$331.24 ,$273.00 
Carle BroMenn Medical Center,8400263,VASCULAR SCREENING TESTING,,,922,$50.00 ,$50.00 ,$15.00 ,$45.50 ,$35.00 ,$15.00 ,$32.50 ,$36.00 ,$45.50 ,$37.50 
Carle BroMenn Medical Center,8495860,EMG 1 EXTREMITY,,95860,922,$555.00 ,$555.00 ,$166.50 ,$505.05 ,$388.50 ,$166.50 ,$360.75 ,$399.60 ,$505.05 ,$416.25 
Carle BroMenn Medical Center,8495861,EMG 2 EXTREMITIES & PSP,,95861,922,$600.00 ,$600.00 ,$180.00 ,$546.00 ,$420.00 ,$180.00 ,$390.00 ,$432.00 ,$546.00 ,$450.00 
Carle BroMenn Medical Center,8495864,EMG -4 EXTREMITIES,,95864,922,$855.00 ,$855.00 ,$256.50 ,$778.05 ,$598.50 ,$256.50 ,$555.75 ,$615.60 ,$778.05 ,$641.25 
Carle BroMenn Medical Center,8495867,EMG CRANIAL UNILATERAL,,95867,922,$364.00 ,$364.00 ,$109.20 ,$331.24 ,$254.80 ,$109.20 ,$236.60 ,$262.08 ,$331.24 ,$273.00 
Carle BroMenn Medical Center,8495870,EMG LMTD STUDY 1 EXTREMITY,,95870,922,$195.00 ,$195.00 ,$58.50 ,$177.45 ,$136.50 ,$58.50 ,$126.75 ,$140.40 ,$177.45 ,$146.25 
Carle BroMenn Medical Center,8495907,MOTOR/SENS NRVE CONDUCT TEST,,95907,922,$310.00 ,$310.00 ,$93.00 ,$282.10 ,$217.00 ,$93.00 ,$201.50 ,$223.20 ,$282.10 ,$232.50 
Carle BroMenn Medical Center,8495908,MOTOR&/SENS 3-4 NRV CNDJ TST,,95908,922,$385.00 ,$385.00 ,$115.50 ,$350.35 ,$269.50 ,$115.50 ,$250.25 ,$277.20 ,$350.35 ,$288.75 
Carle BroMenn Medical Center,8495909,MOTOR&/SENS 5-6 NRV CNDJ TST,,95909,922,$455.00 ,$455.00 ,$136.50 ,$414.05 ,$318.50 ,$136.50 ,$295.75 ,$327.60 ,$414.05 ,$341.25 
Carle BroMenn Medical Center,8495910,MOTOR&SENS 7-8 NRV CNDJ TEST,,95910,922,$580.00 ,$580.00 ,$174.00 ,$527.80 ,$406.00 ,$174.00 ,$377.00 ,$417.60 ,$527.80 ,$435.00 
Carle BroMenn Medical Center,8495911,MOTOR&SEN 9-10 NRV CNDJ TEST,,95911,922,$560.00 ,$560.00 ,$168.00 ,$509.60 ,$392.00 ,$168.00 ,$364.00 ,$403.20 ,$509.60 ,$420.00 
Carle BroMenn Medical Center,8495912,MOTOR&SEN 11-12 NRV CND TEST,,95912,922,$645.00 ,$645.00 ,$193.50 ,$586.95 ,$451.50 ,$193.50 ,$419.25 ,$464.40 ,$586.95 ,$483.75 
Carle BroMenn Medical Center,8495913,MOTOR&SENS 13/> NRV CND TEST,,95913,922,$680.00 ,$680.00 ,$204.00 ,$618.80 ,$476.00 ,$204.00 ,$442.00 ,$489.60 ,$618.80 ,$510.00 
Carle BroMenn Medical Center,8495926,BSER SOMATOSENSORY/LOWER,,95926,922,$735.00 ,$735.00 ,$220.50 ,$668.85 ,$514.50 ,$220.50 ,$477.75 ,$529.20 ,$668.85 ,$551.25 
Carle BroMenn Medical Center,8495930,VISUAL EVOKED POTENTIAL,,95930,922,$743.00 ,$743.00 ,$222.90 ,$676.13 ,$520.10 ,$222.90 ,$482.95 ,$534.96 ,$676.13 ,$557.25 
Carle BroMenn Medical Center,8495937,NEUROMUSCULAR JUNCT TSTNG,,95937,922,$364.00 ,$364.00 ,$109.20 ,$331.24 ,$254.80 ,$109.20 ,$236.60 ,$262.08 ,$331.24 ,$273.00 
Carle BroMenn Medical Center,8295004,PERCUT ALLERGY SKIN TESTS,,95004,924,$55.00 ,$55.00 ,$16.50 ,$50.05 ,$38.50 ,$16.50 ,$35.75 ,$39.60 ,$50.05 ,$41.25 
Carle BroMenn Medical Center,8295017,Allg Tstg Perq & Ic Venoms Immed React W/ I&r,,95017,924,$240.00 ,$240.00 ,$72.00 ,$218.40 ,$168.00 ,$72.00 ,$156.00 ,$172.80 ,$218.40 ,$180.00 
Carle BroMenn Medical Center,8295018,Allg Test Perq & Ic Drug/biol Immed React W/ I&r,,95018,924,$98.00 ,$98.00 ,$29.40 ,$89.18 ,$68.60 ,$29.40 ,$63.70 ,$70.56 ,$89.18 ,$73.50 
Carle BroMenn Medical Center,8295024,Icut Allergy Test Drug/bug,,95024,924,$91.00 ,$91.00 ,$27.30 ,$82.81 ,$63.70 ,$27.30 ,$59.15 ,$65.52 ,$82.81 ,$68.25 
Carle BroMenn Medical Center,8295044,PATCH/APPL TEST(S) (SPEC NUM OF TESTS),,95044,924,$34.00 ,$34.00 ,$10.20 ,$30.94 ,$23.80 ,$10.20 ,$22.10 ,$24.48 ,$30.94 ,$25.50 
Carle BroMenn Medical Center,8295070,"BRONCHIAL ALLERGY TESTS,DRUGS",,95070,924,$530.00 ,$530.00 ,$159.00 ,$482.30 ,$371.00 ,$159.00 ,$344.50 ,$381.60 ,$482.30 ,$397.50 
Carle BroMenn Medical Center,8295076,Ingestion Challenge Test Initial 120 Minutes,,95076,924,$610.00 ,$610.00 ,$183.00 ,$555.10 ,$427.00 ,$183.00 ,$396.50 ,$439.20 ,$555.10 ,$457.50 
Carle BroMenn Medical Center,8295079,Ingestion Challenge Test Each Addl 60 Minutes,,95079,924,$245.00 ,$245.00 ,$73.50 ,$222.95 ,$171.50 ,$73.50 ,$159.25 ,$176.40 ,$222.95 ,$183.75 
Carle BroMenn Medical Center,8026372,INJ THER/DIAG MED SUBQ/IM,,96372,940,$155.00 ,$155.00 ,$46.50 ,$141.05 ,$108.50 ,$46.50 ,$100.75 ,$111.60 ,$141.05 ,$116.25 
Carle BroMenn Medical Center,8029195,"PHLEBOTOMY, THERAPEUTIC",,99195,940,$250.00 ,$250.00 ,$75.00 ,$227.50 ,$175.00 ,$75.00 ,$162.50 ,$180.00 ,$227.50 ,$187.50 
Carle BroMenn Medical Center,8096369,SUBQ INF THERAPY UP TO 1 HR,,96369,940,$353.00 ,$353.00 ,$105.90 ,$321.23 ,$247.10 ,$105.90 ,$229.45 ,$254.16 ,$321.23 ,$264.75 
Carle BroMenn Medical Center,8096370,SUBQ INF THERAPY EA ADD HR,,96370,940,$98.00 ,$98.00 ,$29.40 ,$89.18 ,$68.60 ,$29.40 ,$63.70 ,$70.56 ,$89.18 ,$73.50 
Carle BroMenn Medical Center,8096371,SUBQ INF THERAPY ADDTNL PUMP SET UP,,96371,940,$113.00 ,$113.00 ,$33.90 ,$102.83 ,$79.10 ,$33.90 ,$73.45 ,$81.36 ,$102.83 ,$84.75 
Carle BroMenn Medical Center,8109046,INJECTION -SUBCUTAN/INTRAMUSC,,96372,940,$155.00 ,$155.00 ,$46.50 ,$141.05 ,$108.50 ,$46.50 ,$100.75 ,$111.60 ,$141.05 ,$116.25 
Carle BroMenn Medical Center,8199046,INJECTION -SUBCUTAN/INTRAMUSC,,96372,940,$155.00 ,$155.00 ,$46.50 ,$141.05 ,$108.50 ,$46.50 ,$100.75 ,$111.60 ,$141.05 ,$116.25 
Carle BroMenn Medical Center,8199195,"PHLEBOTOMY, THERAPEUTIC",,99195,940,$250.00 ,$250.00 ,$75.00 ,$227.50 ,$175.00 ,$75.00 ,$162.50 ,$180.00 ,$227.50 ,$187.50 
Carle BroMenn Medical Center,8295145,"PROF SVC, SPRVSN, PROVISION ANTIGENS, 1 INSECT VENOM",,95145,940,$81.00 ,$81.00 ,$24.30 ,$73.71 ,$56.70 ,$24.30 ,$52.65 ,$58.32 ,$73.71 ,$60.75 
Carle BroMenn Medical Center,8295146,"ANTIGEN RX SERV,INSECT,2 VENOMS",,95146,940,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8295147,"PROF SVC, SPRVSN, PROVISION ANTIGENS, 3 INSECT VENOMS",,95147,940,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8295148,"PROF SVC, SPRVSN, PROVISION ANTIGENS, 4 INSECT VENOMS",,95148,940,$91.00 ,$91.00 ,$27.30 ,$82.81 ,$63.70 ,$27.30 ,$59.15 ,$65.52 ,$82.81 ,$68.25 
Carle BroMenn Medical Center,8295149,"PROF SVC, SPRVSN, PROVISION ANTIGENS, 5 INSECT VENOMS",,95149,940,$91.00 ,$91.00 ,$27.30 ,$82.81 ,$63.70 ,$27.30 ,$59.15 ,$65.52 ,$82.81 ,$68.25 
Carle BroMenn Medical Center,8295165,"PROF SVC, SPRVSN PREP&PRVSN ANTIGENS, SINGLE/MULT ANTIGENS",,95165,940,$59.00 ,$59.00 ,$17.70 ,$53.69 ,$41.30 ,$17.70 ,$38.35 ,$42.48 ,$53.69 ,$44.25 
Carle BroMenn Medical Center,8295180,"RAPID DESENSITIZATION PROCEDURE, EACH HOUR",,95180,940,$450.00 ,$450.00 ,$135.00 ,$409.50 ,$315.00 ,$135.00 ,$292.50 ,$324.00 ,$409.50 ,$337.50 
Carle BroMenn Medical Center,8295990,"REFIL/MAINT,IMPLANT PUMP,DRUG DELIV,CNS",,95990,940,$265.00 ,$265.00 ,$79.50 ,$241.15 ,$185.50 ,$79.50 ,$172.25 ,$190.80 ,$241.15 ,$198.75 
Carle BroMenn Medical Center,8295991,RFL/MAIN IMPLT PMP/RSVR DLVR SPI/BRN PHY/QHP,,95991,940,$305.00 ,$305.00 ,$91.50 ,$277.55 ,$213.50 ,$91.50 ,$198.25 ,$219.60 ,$277.55 ,$228.75 
Carle BroMenn Medical Center,8295992,"CANALITH REPOSITIONING PROCEDURE, PER DAY",,95992,940,$120.00 ,$120.00 ,$36.00 ,$109.20 ,$84.00 ,$36.00 ,$78.00 ,$86.40 ,$109.20 ,$90.00 
Carle BroMenn Medical Center,8296920,"LASER TX,PSORIASIS,AREA <250 SQCM",,96920,940,$580.00 ,$580.00 ,$174.00 ,$527.80 ,$406.00 ,$174.00 ,$377.00 ,$417.60 ,$527.80 ,$435.00 
Carle BroMenn Medical Center,8296921,"LASER TX,PSORIASIS,AREA 250-500 SQCM",,96921,940,$485.00 ,$485.00 ,$145.50 ,$441.35 ,$339.50 ,$145.50 ,$315.25 ,$349.20 ,$441.35 ,$363.75 
Carle BroMenn Medical Center,8296922,"LASER TX,PSORIASIS,AREA >500 SQCM",,96922,940,$700.00 ,$700.00 ,$210.00 ,$637.00 ,$490.00 ,$210.00 ,$455.00 ,$504.00 ,$637.00 ,$525.00 
Carle BroMenn Medical Center,8297810,ACUPUNCT W/O ELEC STIMUL 15 MIN,,97810,940,$81.00 ,$81.00 ,$24.30 ,$73.71 ,$56.70 ,$24.30 ,$52.65 ,$58.32 ,$73.71 ,$60.75 
Carle BroMenn Medical Center,8297811,ACUPUNCT W/O ELEC STIMUL ADDL 15M,,97811,940,$68.00 ,$68.00 ,$20.40 ,$61.88 ,$47.60 ,$20.40 ,$44.20 ,$48.96 ,$61.88 ,$51.00 
Carle BroMenn Medical Center,8299195,PHLEBOTOMY,,99195,940,$250.00 ,$250.00 ,$75.00 ,$227.50 ,$175.00 ,$75.00 ,$162.50 ,$180.00 ,$227.50 ,$187.50 
Carle BroMenn Medical Center,8382381,THERAPUTIC PHLEBOTOMY,,99195,940,$250.00 ,$250.00 ,$75.00 ,$227.50 ,$175.00 ,$75.00 ,$162.50 ,$180.00 ,$227.50 ,$187.50 
Carle BroMenn Medical Center,8940010,PICC INSERTION,,,940,"$1,980.00 ","$1,980.00 ",$594.00 ,"$1,801.80 ","$1,386.00 ",$594.00 ,"$1,287.00 ","$1,425.60 ","$1,801.80 ","$1,485.00 "
Carle BroMenn Medical Center,8940011,PERIPHERAL IV START/RESTART,,,940,$180.00 ,$180.00 ,$54.00 ,$163.80 ,$126.00 ,$54.00 ,$117.00 ,$129.60 ,$163.80 ,$135.00 
Carle BroMenn Medical Center,8940012,CENTRAL LINE DRESSING CHANGE,,,940,$214.00 ,$214.00 ,$64.20 ,$194.74 ,$149.80 ,$64.20 ,$139.10 ,$154.08 ,$194.74 ,$160.50 
Carle BroMenn Medical Center,8940013,PERIPHERAL LINE DRESSING CHNGE,,,940,$83.00 ,$83.00 ,$24.90 ,$75.53 ,$58.10 ,$24.90 ,$53.95 ,$59.76 ,$75.53 ,$62.25 
Carle BroMenn Medical Center,8940014,DECLOTTING CENTRAL LINE,,,940,$510.00 ,$510.00 ,$153.00 ,$464.10 ,$357.00 ,$153.00 ,$331.50 ,$367.20 ,$464.10 ,$382.50 
Carle BroMenn Medical Center,8940015,ACCESSING IMPLANTED PORT,,,940,$218.00 ,$218.00 ,$65.40 ,$198.38 ,$152.60 ,$65.40 ,$141.70 ,$156.96 ,$198.38 ,$163.50 
Carle BroMenn Medical Center,8940017,CENTRAL LINE REPAIR,,,940,$750.00 ,$750.00 ,$225.00 ,$682.50 ,$525.00 ,$225.00 ,$487.50 ,$540.00 ,$682.50 ,$562.50 
Carle BroMenn Medical Center,8976372,INJECTION -SUBCUTAN/INTRAMUSC,,96372,940,$155.00 ,$155.00 ,$46.50 ,$141.05 ,$108.50 ,$46.50 ,$100.75 ,$111.60 ,$141.05 ,$116.25 
Carle BroMenn Medical Center,8020177,EDUCATION TRAINING MCR,,G0177,942,$200.00 ,$200.00 ,$60.00 ,$182.00 ,$140.00 ,$60.00 ,$130.00 ,$144.00 ,$182.00 ,$150.00 
Carle BroMenn Medical Center,8200109,DIAB MANAGE TRN IND/GROUP,,G0109,942,$53.00 ,$53.00 ,$15.90 ,$48.23 ,$37.10 ,$15.90 ,$34.45 ,$38.16 ,$48.23 ,$39.75 
Carle BroMenn Medical Center,8200271,GROUP MNT 2 OR MORE 30 MINS,,G0271,942,$41.00 ,$41.00 ,$12.30 ,$37.31 ,$28.70 ,$12.30 ,$26.65 ,$29.52 ,$37.31 ,$30.75 
Carle BroMenn Medical Center,8200420,ED SVC CKD IND PER SESSION,,G0420,942,$175.00 ,$175.00 ,$52.50 ,$159.25 ,$122.50 ,$52.50 ,$113.75 ,$126.00 ,$159.25 ,$131.25 
Carle BroMenn Medical Center,8200421,ED SVC CKD GRP PER SESSION,,G0421,942,$44.00 ,$44.00 ,$13.20 ,$40.04 ,$30.80 ,$13.20 ,$28.60 ,$31.68 ,$40.04 ,$33.00 
Carle BroMenn Medical Center,8201108,DIAB MANAGE TRN PER INDIV,,G0108,942,$190.00 ,$190.00 ,$57.00 ,$172.90 ,$133.00 ,$57.00 ,$123.50 ,$136.80 ,$172.90 ,$142.50 
Carle BroMenn Medical Center,8203108,HC DIAB ED IND 30 MIN TON PILO,,G0108,942,$40.00 ,$40.00 ,$12.00 ,$36.40 ,$28.00 ,$12.00 ,$26.00 ,$28.80 ,$36.40 ,$30.00 
Carle BroMenn Medical Center,8297802,"MED NUTR THER, 1ST, INDIV, EA 15 MIN",,97802,942,$93.00 ,$93.00 ,$27.90 ,$84.63 ,$65.10 ,$27.90 ,$60.45 ,$66.96 ,$84.63 ,$69.75 
Carle BroMenn Medical Center,8297803,"MED NUTR THER, SUBSQ, INDIV, EA 15 MIN",,97803,942,$93.00 ,$93.00 ,$27.90 ,$84.63 ,$65.10 ,$27.90 ,$60.45 ,$66.96 ,$84.63 ,$69.75 
Carle BroMenn Medical Center,8297804,"MED NUTR THER, GROUP, EA 30 MIN",,97804,942,$79.00 ,$79.00 ,$23.70 ,$71.89 ,$55.30 ,$23.70 ,$51.35 ,$56.88 ,$71.89 ,$59.25 
Carle BroMenn Medical Center,8298960,"SELF-MGMT EDUC & TRAIN, 1 PT, EA 30 MIN",,98960,942,$110.00 ,$110.00 ,$33.00 ,$100.10 ,$77.00 ,$33.00 ,$71.50 ,$79.20 ,$100.10 ,$82.50 
Carle BroMenn Medical Center,8299406,"SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT; INTERMEDIATE, >3 MINUTES",,99406,942,$65.00 ,$65.00 ,$19.50 ,$59.15 ,$45.50 ,$19.50 ,$42.25 ,$46.80 ,$59.15 ,$48.75 
Carle BroMenn Medical Center,8299407,"SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT; INTENSIVE, > THAN 10 MINUTES",,99407,942,$84.00 ,$84.00 ,$25.20 ,$76.44 ,$58.80 ,$25.20 ,$54.60 ,$60.48 ,$76.44 ,$63.00 
Carle BroMenn Medical Center,8299608,GROUP HEALTH EDUCATION,,99078,942,$330.00 ,$330.00 ,$99.00 ,$300.30 ,$231.00 ,$99.00 ,$214.50 ,$237.60 ,$300.30 ,$247.50 
Carle BroMenn Medical Center,8659406,"SMOKING/TOBACCO USE CESSATION COUNSELING; INTERMEDIATE, >3 MIN",,99406,942,$65.00 ,$65.00 ,$19.50 ,$59.15 ,$45.50 ,$19.50 ,$42.25 ,$46.80 ,$59.15 ,$48.75 
Carle BroMenn Medical Center,8659407,"SMOKING/TOBACCO USE CESSATION COUNSELING; INTENSIVE, > THAN 10 MIN",,99407,942,$95.00 ,$95.00 ,$28.50 ,$86.45 ,$66.50 ,$28.50 ,$61.75 ,$68.40 ,$86.45 ,$71.25 
Carle BroMenn Medical Center,8293797,OUTPATIENT CARDIAC REHAB W/O CONT ECG MONITOR,,93797,943,$14.86 ,$14.86 ,$4.46 ,$13.52 ,$10.40 ,$4.46 ,$9.66 ,$10.70 ,$13.52 ,$11.15 
Carle BroMenn Medical Center,8293798,CARDIAC REHAB/MONITOR,,93798,943,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8293799,CARDIAC REHAB PHASE III SESSION,,93799,943,$6.00 ,$6.00 ,$1.80 ,$5.46 ,$4.20 ,$1.80 ,$3.90 ,$4.32 ,$5.46 ,$4.50 
Carle BroMenn Medical Center,8653797,OUTPATIENT CARDIAC REHAB W/O CONT ECG MONITOR,,93797,943,$14.86 ,$14.86 ,$4.46 ,$13.52 ,$10.40 ,$4.46 ,$9.66 ,$10.70 ,$13.52 ,$11.15 
Carle BroMenn Medical Center,8653798,OUTPATIENT CARDIAC REHAB W/CONT ECG MONITORING,,93798,943,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8660943,CARDIAC REHAB PH 1 EXERCISE,,93799,943,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8663797,CARDIAC REHAB PH3 MONTHY,,93797,943,$57.86 ,$57.86 ,$17.36 ,$52.65 ,$40.50 ,$17.36 ,$37.61 ,$41.66 ,$52.65 ,$43.40 
Carle BroMenn Medical Center,8663798,CARDIAC REHAB-PHASE II,,93798,943,$145.00 ,$145.00 ,$43.50 ,$131.95 ,$101.50 ,$43.50 ,$94.25 ,$104.40 ,$131.95 ,$108.75 
Carle BroMenn Medical Center,8669797,CARDIAC REHAB PH3 WEEKLY,,93797,943,$14.86 ,$14.86 ,$4.46 ,$13.52 ,$10.40 ,$4.46 ,$9.66 ,$10.70 ,$13.52 ,$11.15 
Carle BroMenn Medical Center,8650075,PUL REHAB AEROBIC EXERCISE/HR,,G0424,948,$160.00 ,$160.00 ,$48.00 ,$145.60 ,$112.00 ,$48.00 ,$104.00 ,$115.20 ,$145.60 ,$120.00 
Carle BroMenn Medical Center,8611012,TRACTION,,97012,951,$76.00 ,$76.00 ,$22.80 ,$69.16 ,$53.20 ,$22.80 ,$49.40 ,$54.72 ,$69.16 ,$57.00 
Carle BroMenn Medical Center,8611032,15' EMS 1:1,,97032,951,$89.00 ,$89.00 ,$26.70 ,$80.99 ,$62.30 ,$26.70 ,$57.85 ,$64.08 ,$80.99 ,$66.75 
Carle BroMenn Medical Center,8611033,15' IONTO 1:1,,97033,951,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8611112,NEUROMUSCULAR RE-EDUCATION,,97112,951,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8611140,15' MANUAL THERAPY,,97140,951,$125.00 ,$125.00 ,$37.50 ,$113.75 ,$87.50 ,$37.50 ,$81.25 ,$90.00 ,$113.75 ,$93.75 
Carle BroMenn Medical Center,8611150,GROUP ATC 31'-45',,97150,951,$115.00 ,$115.00 ,$34.50 ,$104.65 ,$80.50 ,$34.50 ,$74.75 ,$82.80 ,$104.65 ,$86.25 
Carle BroMenn Medical Center,8611281,ELEC STIM UNATTEND FOR PRESS,,G0281,951,$61.00 ,$61.00 ,$18.30 ,$55.51 ,$42.70 ,$18.30 ,$39.65 ,$43.92 ,$55.51 ,$45.75 
Carle BroMenn Medical Center,8611282,ELECT STIM WOUND CARE NOT PD,,G0282,951,$74.00 ,$74.00 ,$22.20 ,$67.34 ,$51.80 ,$22.20 ,$48.10 ,$53.28 ,$67.34 ,$55.50 
Carle BroMenn Medical Center,8611283,ELECTRICAL STIMULATION,,G0283,951,$79.00 ,$79.00 ,$23.70 ,$71.89 ,$55.30 ,$23.70 ,$51.35 ,$56.88 ,$71.89 ,$59.25 
Carle BroMenn Medical Center,8611530,15' FUNCT THERAPY ACTIVITY,,97530,951,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8611760,"ORTHOTIC MGMNT & TRAINING 15""",,97760,951,$175.00 ,$175.00 ,$52.50 ,$159.25 ,$122.50 ,$52.50 ,$113.75 ,$126.00 ,$159.25 ,$131.25 
Carle BroMenn Medical Center,8611761,"PROSTHETIC TRAINING 15""",,97761,951,$125.00 ,$125.00 ,$37.50 ,$113.75 ,$87.50 ,$37.50 ,$81.25 ,$90.00 ,$113.75 ,$93.75 
Carle BroMenn Medical Center,8612112,NEUROMUSCULAR RE-EDUCATION,,97112,951,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8612150,GROUP ATC 46'-60',,97150,951,$175.00 ,$175.00 ,$52.50 ,$159.25 ,$122.50 ,$52.50 ,$113.75 ,$126.00 ,$159.25 ,$131.25 
Carle BroMenn Medical Center,8612750,FUNCTIONAL TESTS & MEASURES,,97750,951,$140.00 ,$140.00 ,$42.00 ,$127.40 ,$98.00 ,$42.00 ,$91.00 ,$100.80 ,$127.40 ,$105.00 
Carle BroMenn Medical Center,8613110,15' THERAPEUTIC EXERCISE,,97110,951,$150.00 ,$150.00 ,$45.00 ,$136.50 ,$105.00 ,$45.00 ,$97.50 ,$108.00 ,$136.50 ,$112.50 
Carle BroMenn Medical Center,8613150,GROUP ATC 61'-120',,97150,951,$265.00 ,$265.00 ,$79.50 ,$241.15 ,$185.50 ,$79.50 ,$172.25 ,$190.80 ,$241.15 ,$198.75 
Carle BroMenn Medical Center,8614150,GROUP ATC 8'-30',,97150,951,$90.00 ,$90.00 ,$27.00 ,$81.90 ,$63.00 ,$27.00 ,$58.50 ,$64.80 ,$81.90 ,$67.50 
Carle BroMenn Medical Center,8615250,GROUP ATC 8'-30',,97150,951,$90.00 ,$90.00 ,$27.00 ,$81.90 ,$63.00 ,$27.00 ,$58.50 ,$64.80 ,$81.90 ,$67.50 
Carle BroMenn Medical Center,8616350,GROUP ATC 61'-120',,97150,951,$265.00 ,$265.00 ,$79.50 ,$241.15 ,$185.50 ,$79.50 ,$172.25 ,$190.80 ,$241.15 ,$198.75 
Carle BroMenn Medical Center,8618250,"GROUP ATC 46-60""",,97150,951,$175.00 ,$175.00 ,$52.50 ,$159.25 ,$122.50 ,$52.50 ,$113.75 ,$126.00 ,$159.25 ,$131.25 
Carle BroMenn Medical Center,8619250,GROUP ATC 31'-45',,97150,951,$115.00 ,$115.00 ,$34.50 ,$104.65 ,$80.50 ,$34.50 ,$74.75 ,$82.80 ,$104.65 ,$86.25 
Carle BroMenn Medical Center,8697169,ATC EVAL LOW COMPLEXITY,,97169,951,$191.00 ,$191.00 ,$57.30 ,$173.81 ,$133.70 ,$57.30 ,$124.15 ,$137.52 ,$173.81 ,$143.25 
Carle BroMenn Medical Center,8697170,ATC EVAL MODERATE COMPLEXITY,,97170,951,$251.00 ,$251.00 ,$75.30 ,$228.41 ,$175.70 ,$75.30 ,$163.15 ,$180.72 ,$228.41 ,$188.25 
Carle BroMenn Medical Center,8697171,ATC EVAL HIGH COMPLEXITY,,97171,951,$315.00 ,$315.00 ,$94.50 ,$286.65 ,$220.50 ,$94.50 ,$204.75 ,$226.80 ,$286.65 ,$236.25 
Carle BroMenn Medical Center,8697172,ATC RE-EVAL,,97172,951,$180.00 ,$180.00 ,$54.00 ,$163.80 ,$126.00 ,$54.00 ,$117.00 ,$129.60 ,$163.80 ,$135.00 
Carle BroMenn Medical Center,8310051,PROF SVC ELECTROLYTE PANEL,,80051,971,$100.00 ,$100.00 ,$30.00 ,$91.00 ,$70.00 ,$30.00 ,$65.00 ,$72.00 ,$91.00 ,$75.00 
Carle BroMenn Medical Center,8311002,PROF SVC URINALYSIS,,81002,971,$37.00 ,$37.00 ,$11.10 ,$33.67 ,$25.90 ,$11.10 ,$24.05 ,$26.64 ,$33.67 ,$27.75 
Carle BroMenn Medical Center,8311003,PROF SVC URINALYSIS,,81003,971,$53.00 ,$53.00 ,$15.90 ,$48.23 ,$37.10 ,$15.90 ,$34.45 ,$38.16 ,$48.23 ,$39.75 
Carle BroMenn Medical Center,8311025,PROF SVC URINE PREGNANCY TEST,,81025,971,$90.00 ,$90.00 ,$27.00 ,$81.90 ,$63.00 ,$27.00 ,$58.50 ,$64.80 ,$81.90 ,$67.50 
Carle BroMenn Medical Center,8312270,PROF SVC OCCULT BLOOD,,82270,971,$42.00 ,$42.00 ,$12.60 ,$38.22 ,$29.40 ,$12.60 ,$27.30 ,$30.24 ,$38.22 ,$31.50 
Carle BroMenn Medical Center,8312272,PROF SVC OCCULT BLOOD -SINGLE SPECIMEN,,82272,971,$47.00 ,$47.00 ,$14.10 ,$42.77 ,$32.90 ,$14.10 ,$30.55 ,$33.84 ,$42.77 ,$35.25 
Carle BroMenn Medical Center,8312330,"PROF SVC CALCIUM, IONIZED",,82330,971,$130.00 ,$130.00 ,$39.00 ,$118.30 ,$91.00 ,$39.00 ,$84.50 ,$93.60 ,$118.30 ,$97.50 
Carle BroMenn Medical Center,8312374,PROF SVC CARBON DIOXIDE (BICARBONATE),,82374,971,$86.00 ,$86.00 ,$25.80 ,$78.26 ,$60.20 ,$25.80 ,$55.90 ,$61.92 ,$78.26 ,$64.50 
Carle BroMenn Medical Center,8312435,"PROF SVC CHLORIDE, BLOOD",,82435,971,$62.00 ,$62.00 ,$18.60 ,$56.42 ,$43.40 ,$18.60 ,$40.30 ,$44.64 ,$56.42 ,$46.50 
Carle BroMenn Medical Center,8312565,"PROF SVC CREATININE, BLOOD",,82565,971,$85.80 ,$85.80 ,$25.74 ,$78.08 ,$60.06 ,$25.74 ,$55.77 ,$61.78 ,$78.08 ,$64.35 
Carle BroMenn Medical Center,8312803,PROF SVC ABG,,82803,971,$190.00 ,$190.00 ,$57.00 ,$172.90 ,$133.00 ,$57.00 ,$123.50 ,$136.80 ,$172.90 ,$142.50 
Carle BroMenn Medical Center,8312947,"PROF SVC GLUCOSE, QUANTITATIVE",,82947,971,$46.00 ,$46.00 ,$13.80 ,$41.86 ,$32.20 ,$13.80 ,$29.90 ,$33.12 ,$41.86 ,$34.50 
Carle BroMenn Medical Center,8313880,PROF SVC B-NATRIURETIC PEPTIDE,,83880,971,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8313986,"PROF SVC PH, BODY FLUID, EXCEPT BLOOD",,83986,971,$76.00 ,$76.00 ,$22.80 ,$69.16 ,$53.20 ,$22.80 ,$49.40 ,$54.72 ,$69.16 ,$57.00 
Carle BroMenn Medical Center,8314112,PROF SVC AMNUSURE ROM,,84112,971,$158.00 ,$158.00 ,$47.40 ,$143.78 ,$110.60 ,$47.40 ,$102.70 ,$113.76 ,$143.78 ,$118.50 
Carle BroMenn Medical Center,8314132,"PROF SVC POTASSIUM, SERUM",,84132,971,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8314295,PROF SVC SODIUM SERUM PLASM/WHOLE BLOOD,,84295,971,$98.00 ,$98.00 ,$29.40 ,$89.18 ,$68.60 ,$29.40 ,$63.70 ,$70.56 ,$89.18 ,$73.50 
Carle BroMenn Medical Center,8314484,"PROF SVC TROPONIN, QUANTITATIVE",,84484,971,$180.00 ,$180.00 ,$54.00 ,$163.80 ,$126.00 ,$54.00 ,$117.00 ,$129.60 ,$163.80 ,$135.00 
Carle BroMenn Medical Center,8314520,"PROF SVC UREA NITROGEN, QUANTITATIVE",,84520,971,$87.10 ,$87.10 ,$26.13 ,$79.26 ,$60.97 ,$26.13 ,$56.62 ,$62.71 ,$79.26 ,$65.33 
Carle BroMenn Medical Center,8315014,PROF SVC HEMATOCRIT,,85014,971,$50.00 ,$50.00 ,$15.00 ,$45.50 ,$35.00 ,$15.00 ,$32.50 ,$36.00 ,$45.50 ,$37.50 
Carle BroMenn Medical Center,8315347,PATH MD PROF TEC COAG TIME; ACTIVATED,,85347,971,$60.00 ,$60.00 ,$18.00 ,$54.60 ,$42.00 ,$18.00 ,$39.00 ,$43.20 ,$54.60 ,$45.00 
Carle BroMenn Medical Center,8315610,PROF SVC PROTHROMBIN TIME,,85610,971,$94.00 ,$94.00 ,$28.20 ,$85.54 ,$65.80 ,$28.20 ,$61.10 ,$67.68 ,$85.54 ,$70.50 
Carle BroMenn Medical Center,8317081,PROF SVC BACT CULTURE SCREENING ONLY,,87081,971,$97.00 ,$97.00 ,$29.10 ,$88.27 ,$67.90 ,$29.10 ,$63.05 ,$69.84 ,$88.27 ,$72.75 
Carle BroMenn Medical Center,8293294,INTERROGATION EVAL REMOTE </90 D 1/2/MLT LEAD PM,,93294,985,$175.00 ,$175.00 ,$52.50 ,$159.25 ,$122.50 ,$52.50 ,$113.75 ,$126.00 ,$159.25 ,$131.25 
Carle BroMenn Medical Center,8200019,KIT ANTI AGING LEVEL II,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200040,SKINCARE OLLUMINATE EYE RPR,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200041,SKINCARE OLLUMINATE EYE RPR,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200174,SKINCARE ADV PIGMENT CORRECTOR,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200175,CREAM MY HERO MOIST RICH 1.7OZ,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200176,PROTECT & SERVE SPF 40,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200177,LHA SOLUTION,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200178,LHA SOLUTION,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200179,LHA CLARIFYING CLEANSER 400ML,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200180,LHA CLARIFYING CLEANSER,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200300,EYEBROW TINTING,,17999,990,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8200301,EYELASH TINTING,,17999,990,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8200302,PARAFFIN FOOT DIP,,17999,990,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8200303,PARAFFIN HAND DIP,,17999,990,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8200304,BACK FACIALS,,17999,990,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8200305,MEDICAL FACIALS,,17999,990,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8200306,EYELASH EXTENSIONS-FULL,,17999,990,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8200307,DERMAPLANE,,17999,990,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8200308,EYELASH EXTENSIONS-FILL,,17999,990,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8200309,WAXING,,17999,990,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8200310,SKIN EVAL/PEEL/PRODUCTS,,17999,990,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8200311,MICROPEEL RETURN VISIT,,17999,990,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8200312,CRYOTHERAPY DERM SVC,,17999,990,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8200313,NONCHEMICAL PEEL RETURN,,17999,990,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8200314,LASER HAIR CONSULTATION,,17999,990,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8200315,LASER HAIR RMVL LIP/CHIN,,17999,990,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8200316,LASER HAIR RMVL UNDER ARMS,,17999,990,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8200317,LASER HAIR RMVL BIKINI,,17999,990,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8200318,LASER HAIR RMVL FULL LEGS,,17999,990,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8200319,LASER HAIR RMVL LARGE BODY PART,,17999,990,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8200320,LASER HAIR RMVL SMALL BODY PART,,17999,990,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8200321,REJUVENATING PEEL SYSTEM,,17999,990,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8200322,MICRODERMABRASION,,17999,990,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8200323,MICRODERM WITH PEEL,,17999,990,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8200324,PLASTICS MICROPEEL RETURN VISIT,,17999,990,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8200325,EYEBROW TINTING PACKAGE OF 6,,17999,990,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8200326,EYELASH TINTING PACKAGE OF 6,,17999,990,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8200327,MEDICAL FACIALS PACKAGE OF 6,,17999,990,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8200328,DERMAPLANE PACKAGE OF 6,,17999,990,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8200329,WAXING PACKAGE OF 6,,17999,990,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8200331,MICROPEEL RETURN VISIT PACKAGE OF 6,,17999,990,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8200332,CRYOTHERAPY DERM SVC PACKAGE OF 6,,17999,990,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8200335,NONCHEMICAL PEEL RETURN PACKAGE OF 6,,17999,990,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8200336,MICRODERMABRASION PACKAGE OF 6,,17999,990,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8200337,MICRODERM WITH PEEL PACKAGE OF 6,,17999,990,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8200543,COSM IN OFFICE,,11200,990,$270.00 ,$270.00 ,$81.00 ,$245.70 ,$189.00 ,$81.00 ,$175.50 ,$194.40 ,$245.70 ,$202.50 
Carle BroMenn Medical Center,8200549,COSM IN OFFICE,,11401,990,$795.00 ,$795.00 ,$238.50 ,$723.45 ,$556.50 ,$238.50 ,$516.75 ,$572.40 ,$723.45 ,$596.25 
Carle BroMenn Medical Center,8200550,COSM IN OFFICE,,11402,990,"$1,010.00 ","$1,010.00 ",$303.00 ,$919.10 ,$707.00 ,$303.00 ,$656.50 ,$727.20 ,$919.10 ,$757.50 
Carle BroMenn Medical Center,8200554,COSM IN OFFICE,,11420,990,"$1,860.00 ","$1,860.00 ",$558.00 ,"$1,692.60 ","$1,302.00 ",$558.00 ,"$1,209.00 ","$1,339.20 ","$1,692.60 ","$1,395.00 "
Carle BroMenn Medical Center,8200555,COSM IN OFFICE,,11421,990,"$1,615.00 ","$1,615.00 ",$484.50 ,"$1,469.65 ","$1,130.50 ",$484.50 ,"$1,049.75 ","$1,162.80 ","$1,469.65 ","$1,211.25 "
Carle BroMenn Medical Center,8200572,COSM IN OFFICE,,12051,990,$675.00 ,$675.00 ,$202.50 ,$614.25 ,$472.50 ,$202.50 ,$438.75 ,$486.00 ,$614.25 ,$506.25 
Carle BroMenn Medical Center,8200576,MICRONEEDLING FULL FACE - PHYSICIAN,,17999,990,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8200577,MICRONEEDLING - AESTHETICIAN FULL FACE,,17999,990,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8200585,MICRONEEDLING PARTIAL FACE - PHYSICIAN,,17999,990,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8200587,MICRONEEDLING PARTIAL FACE - APP,,17999,990,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8200588,MICRONEEDLING FULL FACE - APP,,17999,990,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8200589,MICRONEEDLING - AESTHETICIAN PARTIAL FACE,,17999,990,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8200590,ZO 3 STEP PEEL - PKG OF 3,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200594,ZO STIMULATION FACIAL KIT PLUS SULFUR MASQUE,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200595,ZO STIMULATION FACIAL KIT PLUS HYDRA MASSAGE GEL,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200596,ZO STIMULATION FACIAL KIT PLUS BRIGHTENING MASQUE,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200597,ZO STIMULATION FACIAL KIT HAND REPAIR/RENEWAL,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200598,ZO 3 STEP PEEL,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200641,VITASCRUB,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200642,OILACLEANSE,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200643,TREATMENT MY HELPER ACNE SPOT,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200650,TCA/ZO DEEP PEEL FULL FACE,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200651,TCA/ZO DEEP PEEL PERIORAL AREA,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8200652,CO2 LASER RESURFACING FULL FACE,,17999,990,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8200653,CO2 LASER RESURFACING NECK,,17999,990,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8200654,CO2 LASER RESURFACING PERIORAL AREA,,17999,990,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8200655,CO2 LASER RESURFACING LOWER LIDS,,17999,990,$550.00 ,$550.00 ,$165.00 ,$500.50 ,$385.00 ,$165.00 ,$357.50 ,$396.00 ,$500.50 ,$412.50 
Carle BroMenn Medical Center,8202297,CEBATROL,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8202298,MELAMIX,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8202299,MELAMIN,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8202300,GLYCOGENT,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8202301,BALATONE,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8202302,FOAMACLEANSE,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8202303,NORMACLEANSE,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8202304,SKINCARE BIOCORNEUM 50G,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8202305,Skincare Biocorneum 20g,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8202307,HYDRAFIRM,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8202312,OCLIPSE SMART TONE ZO SKIN HEALTH,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8202313,OMMERSE OVERNIGHT RECOVERY CREAM ZO SKIN HLTH,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8202314,OMMERSE RENEWAL CREAM ZO SKIN HEALTH,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8202315,PHASE I DAILY SKIN CARE PROGRAM ZO SKIN HLTH,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8202316,PHASE II ANTIAGING PROGRAM ZO SKIN HLTH,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8202317,PHASE III AGGRESSIVE ANTIAGING PRGRM ZO SKIN HLTH,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8202321,SKINCARE OFFECTS EXFOL CLEANSR,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8202330,PHYSICAL MATTE UV DEFENSE,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8202589,SKINCARE OFFECTS TE-PADS,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8202590,SKINCARE OSSENTIAL 1.7 OZ DAILY POWER DEFENSE,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8202591,SKINCARE OSSENTIAL 1 OZ GROWTH FACTOR SERUM PLUS,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8202592,SKINCARE OSSENTIAL 2 OZ NIGHT ADV RADICAL REPAIR,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8202593,SKINCARE OCLIPSE,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8202594,BRIGHTENEX,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8202595,RETAMAX,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8202596,INVISAPEEL,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8202597,RESOTRACALM,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8202598,OFFECTS EXFOLIATING,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8202603,BRIGHTALIVE,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8202604,SKINCARE C-BRIGHT 1.7 FL OZ,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8220007,COSMETIC CONSULT,,99499,990,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8220008,COSMETIC RETURN EXAM,,99499,990,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8299399,SPORTS PHYSICAL AT CARE SPORTS MEDICINE,,99499,990,$14.53 ,$14.53 ,$4.36 ,$13.22 ,$10.17 ,$4.36 ,$9.44 ,$10.46 ,$13.22 ,$10.90 
Carle BroMenn Medical Center,8299616,MASQUE OSSENTIAL BRIGHTENING,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8299619,SYSTEM HYPERPIGMENTATION NON HYDROQUINONE,,99070,990,$168.00 ,$168.00 ,$50.40 ,$152.88 ,$117.60 ,$50.40 ,$109.20 ,$120.96 ,$152.88 ,$126.00 
Carle BroMenn Medical Center,8400016,CARDIAC CT SCORING,,,990,$125.00 ,$125.00 ,$37.50 ,$113.75 ,$87.50 ,$37.50 ,$81.25 ,$90.00 ,$113.75 ,$93.75 
Carle BroMenn Medical Center,8400039,LOW DOSE CT SCREEN,,,990,$105.00 ,$105.00 ,$31.50 ,$95.55 ,$73.50 ,$31.50 ,$68.25 ,$75.60 ,$95.55 ,$78.75 
Carle BroMenn Medical Center,8200012,RADIATION IMPLANT BRIEF X-LARGE,,A9999,,$314.00 ,$314.00 ,$94.20 ,$285.74 ,$219.80 ,$94.20 ,$204.10 ,$226.08 ,$285.74 ,$235.50 
Table 2: Payer Negotiated Rates,,,,,,,,,,,,,,,
ContractName,CodeType,Code,Description,Service Description,Base Rate Methodology,Negotiated Charge / Base Rate,ServiceCode,Deidentified Minimum,Deidentified Maximum,,,,,,
Aetna Commercial,DRG,MS-001,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W MCC,Surgical,Relative Weights,"$317,789.85 ",IP,"17,718.00","557,099.42",,,,,,
Aetna Commercial,DRG,MS-002,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W/O MCC,Surgical,Relative Weights,"$161,157.55 ",IP,"17,718.00","282,516.19",,,,,,
Aetna Commercial,DRG,MS-003,ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITH MAJOR O.R. PROCEDURES,Surgical,Relative Weights,"$217,969.85 ",IP,"111,577.60","382,110.62",,,,,,
Aetna Commercial,DRG,MS-004,TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES,Surgical,Relative Weights,"$132,753.70 ",IP,"69,628.33","232,723.01",,,,,,
Aetna Commercial,DRG,MS-005,LIVER TRANSPLANT W MCC OR INTESTINAL TRANSPLANT,Surgical,Relative Weights,"$118,596.05 ",IP,"59,773.19","207,904.03",,,,,,
Aetna Commercial,DRG,MS-006,LIVER TRANSPLANT W/O MCC,Surgical,Relative Weights,"$56,026.85 ",IP,"27,427.34","98,217.50",,,,,,
Aetna Commercial,DRG,MS-007,LUNG TRANSPLANT,Surgical,Relative Weights,"$124,042.45 ",IP,"67,628.10","217,451.81",,,,,,
Aetna Commercial,DRG,MS-008,SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,Surgical,Relative Weights,"$64,585.15 ",IP,"31,730.89","113,220.58",,,,,,
Aetna Commercial,DRG,MS-010,PANCREAS TRANSPLANT,Surgical,Relative Weights,"$45,725.15 ",IP,"2,420.00","80,158.18",,,,,,
Aetna Commercial,DRG,MS-011,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC,Surgical,Relative Weights,"$56,853.70 ",IP,"2,420.00","99,667.01",,,,,,
Aetna Commercial,DRG,MS-012,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC,Surgical,Relative Weights,"$43,401.00 ",IP,"2,420.00","76,083.84",,,,,,
Aetna Commercial,DRG,MS-013,TRACHEOSTOMY FOR FACE -  MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC,Surgical,Relative Weights,"$27,890.95 ",IP,"2,420.00","48,894.05",,,,,,
Aetna Commercial,DRG,MS-014,ALLOGENEIC BONE MARROW TRANSPLANT,Surgical,Relative Weights,"$146,680.20 ",IP,"2,420.00","257,136.77",,,,,,
Aetna Commercial,DRG,MS-016,AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,Surgical,Relative Weights,"$79,179.80 ",IP,"2,420.00","138,805.63",,,,,,
Aetna Commercial,DRG,MS-017,AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,Surgical,Relative Weights,"$51,145.10 ",IP,"2,420.00","89,659.58",,,,,,
Aetna Commercial,DRG,MS-020,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,Surgical,Relative Weights,"$124,441.50 ",IP,"2,420.00","218,151.36",,,,,,
Aetna Commercial,DRG,MS-021,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,Surgical,Relative Weights,"$95,147.55 ",IP,"2,420.00","166,797.79",,,,,,
Aetna Commercial,DRG,MS-022,INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W/O CC/MCC,Surgical,Relative Weights,"$56,715.70 ",IP,"2,420.00","99,425.09",,,,,,
Aetna Commercial,DRG,MS-023,CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX CNS PDX W MCC OR CHEMO IMPLANT,Surgical,Relative Weights,"$64,596.65 ",IP,"2,420.00","113,240.74",,,,,,
Aetna Commercial,DRG,MS-024,CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,Surgical,Relative Weights,"$46,189.75 ",IP,"2,420.00","80,972.64",,,,,,
Aetna Commercial,DRG,MS-025,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$50,536.75 ",IP,"2,420.00","88,593.12",,,,,,
Aetna Commercial,DRG,MS-026,CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC,Surgical,Relative Weights,"$35,026.70 ",IP,"2,420.00","61,403.33",,,,,,
Aetna Commercial,DRG,MS-027,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$27,562.05 ",IP,"2,420.00","48,317.47",,,,,,
Aetna Commercial,DRG,MS-028,SPINAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$64,289.60 ",IP,"2,420.00","112,702.46",,,,,,
Aetna Commercial,DRG,MS-029,SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,Surgical,Relative Weights,"$36,880.50 ",IP,"2,420.00","64,653.12",,,,,,
Aetna Commercial,DRG,MS-030,SPINAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$26,129.15 ",IP,"2,420.00","45,805.54",,,,,,
Aetna Commercial,DRG,MS-031,VENTRICULAR SHUNT PROCEDURES WITH MCC,Surgical,Relative Weights,"$50,306.75 ",IP,"2,420.00","88,189.92",,,,,,
Aetna Commercial,DRG,MS-032,VENTRICULAR SHUNT PROCEDURES WITH CC,Surgical,Relative Weights,"$25,209.15 ",IP,"2,420.00","44,192.74",,,,,,
Aetna Commercial,DRG,MS-033,VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$19,560.35 ",IP,"2,420.00","34,290.14",,,,,,
Aetna Commercial,DRG,MS-034,CAROTID ARTERY STENT PROCEDURE W MCC,Surgical,Relative Weights,"$43,167.55 ",IP,"2,420.00","75,674.59",,,,,,
Aetna Commercial,DRG,MS-035,CAROTID ARTERY STENT PROCEDURES WITH CC,Surgical,Relative Weights,"$26,475.30 ",IP,"2,420.00","46,412.35",,,,,,
Aetna Commercial,DRG,MS-036,CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$20,136.50 ",IP,"2,420.00","35,300.16",,,,,,
Aetna Commercial,DRG,MS-037,EXTRACRANIAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$37,297.95 ",IP,"2,420.00","65,384.93",,,,,,
Aetna Commercial,DRG,MS-038,EXTRACRANIAL PROCEDURES WITH CC,Surgical,Relative Weights,"$19,264.80 ",IP,"2,420.00","33,772.03",,,,,,
Aetna Commercial,DRG,MS-039,EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$13,009.95 ",IP,"2,420.00","22,807.01",,,,,,
Aetna Commercial,DRG,MS-040,PERIPHERAL- CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC,Surgical,Relative Weights,"$45,314.60 ",IP,"2,420.00","79,438.46",,,,,,
Aetna Commercial,DRG,MS-041,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W CC OR PERIPH NEUROSTIM,Surgical,Relative Weights,"$27,272.25 ",IP,"2,420.00","47,809.44",,,,,,
Aetna Commercial,DRG,MS-042,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W/O CC/MCC,Surgical,Relative Weights,"$21,255.45 ",IP,"2,420.00","37,261.73",,,,,,
Aetna Commercial,DRG,MS-052,SPINAL DISORDERS AND INJURIES WITH CC/MCC,Surgical,Relative Weights,"$18,732.35 ",IP,"2,420.00","32,838.62",,,,,,
Aetna Commercial,DRG,MS-053,SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,Surgical,Relative Weights,"$11,110.15 ",IP,"2,420.00","19,476.58",,,,,,
Aetna Commercial,DRG,MS-054,NERVOUS SYSTEM NEOPLASMS WITH MCC,Surgical,Relative Weights,"$15,411.15 ",IP,"2,420.00","27,016.42",,,,,,
Aetna Commercial,DRG,MS-055,NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,Surgical,Relative Weights,"$11,339.00 ",IP,"2,420.00","19,877.76",,,,,,
Aetna Commercial,DRG,MS-056,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,Surgical,Relative Weights,"$25,212.60 ",IP,"2,420.00","44,198.78",,,,,,
Aetna Commercial,DRG,MS-057,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,Surgical,Relative Weights,"$13,924.20 ",IP,"2,420.00","24,409.73",,,,,,
Aetna Commercial,DRG,MS-058,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,Surgical,Relative Weights,"$22,479.05 ",IP,"2,420.00","39,406.75",,,,,,
Aetna Commercial,DRG,MS-059,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,Surgical,Relative Weights,"$12,540.75 ",IP,"2,420.00","21,984.48",,,,,,
Aetna Commercial,DRG,MS-060,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,Surgical,Relative Weights,"$10,139.55 ",IP,"2,420.00","17,775.07",,,,,,
Aetna Commercial,DRG,MS-061,ISCHEMIC STROKE -  PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC,Surgical,Relative Weights,"$32,125.25 ",IP,"2,420.00","56,316.96",,,,,,
Aetna Commercial,DRG,MS-062,ISCHEMIC STROKE -  PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC,Surgical,Relative Weights,"$23,128.80 ",IP,"2,420.00","40,545.79",,,,,,
Aetna Commercial,DRG,MS-063,ISCHEMIC STROKE- PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC,Surgical,Relative Weights,"$19,329.20 ",IP,"2,420.00","33,884.93",,,,,,
Aetna Commercial,DRG,MS-064,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,Surgical,Relative Weights,"$21,560.20 ",IP,"2,420.00","37,795.97",,,,,,
Aetna Commercial,DRG,MS-065,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC,Surgical,Relative Weights,"$11,818.55 ",IP,"2,420.00","20,718.43",,,,,,
Aetna Commercial,DRG,MS-066,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,Surgical,Relative Weights,"$8,245.50 ",IP,"2,420.00","14,454.72",,,,,,
Aetna Commercial,DRG,MS-067,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,Surgical,Relative Weights,"$16,841.75 ",IP,"2,420.00","29,524.32",,,,,,
Aetna Commercial,DRG,MS-068,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,Surgical,Relative Weights,"$10,389.10 ",IP,"2,420.00","18,212.54",,,,,,
Aetna Commercial,DRG,MS-069,TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,Surgical,Relative Weights,"$8,973.45 ",IP,"2,420.00","15,730.85",,,,,,
Aetna Commercial,DRG,MS-070,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC,Surgical,Relative Weights,"$19,238.35 ",IP,"2,420.00","33,725.66",,,,,,
Aetna Commercial,DRG,MS-071,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC,Surgical,Relative Weights,"$11,439.05 ",IP,"2,420.00","20,053.15",,,,,,
Aetna Commercial,DRG,MS-072,NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$8,492.75 ",IP,"2,420.00","14,888.16",,,,,,
Aetna Commercial,DRG,MS-073,CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,Surgical,Relative Weights,"$16,279.40 ",IP,"2,420.00","28,538.50",,,,,,
Aetna Commercial,DRG,MS-074,CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,Surgical,Relative Weights,"$11,363.15 ",IP,"2,420.00","19,920.10",,,,,,
Aetna Commercial,DRG,MS-075,VIRAL MENINGITIS WITH CC/MCC,Surgical,Relative Weights,"$18,494.30 ",IP,"2,420.00","32,421.31",,,,,,
Aetna Commercial,DRG,MS-076,VIRAL MENINGITIS WITHOUT CC/MCC,Surgical,Relative Weights,"$10,378.75 ",IP,"2,420.00","18,194.40",,,,,,
Aetna Commercial,DRG,MS-077,HYPERTENSIVE ENCEPHALOPATHY WITH MCC,Surgical,Relative Weights,"$17,738.75 ",IP,"2,420.00","31,096.80",,,,,,
Aetna Commercial,DRG,MS-078,HYPERTENSIVE ENCEPHALOPATHY WITH CC,Surgical,Relative Weights,"$11,063.00 ",IP,"2,420.00","19,393.92",,,,,,
Aetna Commercial,DRG,MS-079,HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC,Surgical,Relative Weights,"$8,522.65 ",IP,"2,420.00","14,940.58",,,,,,
Aetna Commercial,DRG,MS-080,NONTRAUMATIC STUPOR & COMA W MCC,Surgical,Relative Weights,"$22,037.45 ",IP,"2,420.00","38,632.61",,,,,,
Aetna Commercial,DRG,MS-081,NONTRAUMATIC STUPOR & COMA W/O MCC,Surgical,Relative Weights,"$10,109.65 ",IP,"2,420.00","17,722.66",,,,,,
Aetna Commercial,DRG,MS-082,TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,Surgical,Relative Weights,"$25,895.70 ",IP,"2,420.00","45,396.29",,,,,,
Aetna Commercial,DRG,MS-083,TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,Surgical,Relative Weights,"$15,073.05 ",IP,"2,420.00","26,423.71",,,,,,
Aetna Commercial,DRG,MS-084,TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,Surgical,Relative Weights,"$10,318.95 ",IP,"2,420.00","18,089.57",,,,,,
Aetna Commercial,DRG,MS-085,TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,Surgical,Relative Weights,"$25,826.70 ",IP,"2,420.00","45,275.33",,,,,,
Aetna Commercial,DRG,MS-086,TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,Surgical,Relative Weights,"$14,234.70 ",IP,"2,420.00","24,954.05",,,,,,
Aetna Commercial,DRG,MS-087,TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,Surgical,Relative Weights,"$9,650.80 ",IP,"2,420.00","16,918.27",,,,,,
Aetna Commercial,DRG,MS-088,CONCUSSION WITH MCC,Surgical,Relative Weights,"$15,974.65 ",IP,"2,420.00","28,004.26",,,,,,
Aetna Commercial,DRG,MS-089,CONCUSSION WITH CC,Surgical,Relative Weights,"$11,342.45 ",IP,"2,420.00","19,883.81",,,,,,
Aetna Commercial,DRG,MS-090,CONCUSSION WITHOUT CC/MCC,Surgical,Relative Weights,"$9,755.45 ",IP,"2,420.00","17,101.73",,,,,,
Aetna Commercial,DRG,MS-091,OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,Surgical,Relative Weights,"$17,998.65 ",IP,"2,420.00","31,552.42",,,,,,
Aetna Commercial,DRG,MS-092,OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,Surgical,Relative Weights,"$11,110.15 ",IP,"2,420.00","19,476.58",,,,,,
Aetna Commercial,DRG,MS-093,OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,Surgical,Relative Weights,"$8,753.80 ",IP,"2,420.00","15,345.79",,,,,,
Aetna Commercial,DRG,MS-094,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,Surgical,Relative Weights,"$41,225.20 ",IP,"2,420.00","72,269.57",,,,,,
Aetna Commercial,DRG,MS-095,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,Surgical,Relative Weights,"$27,681.65 ",IP,"2,420.00","48,527.14",,,,,,
Aetna Commercial,DRG,MS-096,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,Surgical,Relative Weights,"$26,014.15 ",IP,"2,420.00","45,603.94",,,,,,
Aetna Commercial,DRG,MS-097,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,Surgical,Relative Weights,"$41,122.85 ",IP,"2,420.00","72,090.14",,,,,,
Aetna Commercial,DRG,MS-098,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,Surgical,Relative Weights,"$22,482.50 ",IP,"2,420.00","39,412.80",,,,,,
Aetna Commercial,DRG,MS-099,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,Surgical,Relative Weights,"$14,747.60 ",IP,"2,420.00","25,853.18",,,,,,
Aetna Commercial,DRG,MS-100,SEIZURES WITH MCC,Surgical,Relative Weights,"$20,932.30 ",IP,"2,420.00","36,695.23",,,,,,
Aetna Commercial,DRG,MS-101,SEIZURES WITHOUT MCC,Surgical,Relative Weights,"$10,153.35 ",IP,"2,420.00","17,799.26",,,,,,
Aetna Commercial,DRG,MS-102,HEADACHES WITH MCC,Surgical,Relative Weights,"$13,714.90 ",IP,"2,420.00","24,042.82",,,,,,
Aetna Commercial,DRG,MS-103,HEADACHES W/O MCC,Surgical,Relative Weights,"$9,194.25 ",IP,"2,420.00","16,117.92",,,,,,
Aetna Commercial,DRG,MS-113,ORBITAL PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$24,519.15 ",IP,"2,420.00","42,983.14",,,,,,
Aetna Commercial,DRG,MS-114,ORBITAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$13,694.20 ",IP,"2,420.00","24,006.53",,,,,,
Aetna Commercial,DRG,MS-115,EXTRAOCULAR PROCEDURES EXCEPT ORBIT,Surgical,Relative Weights,"$17,089.00 ",IP,"2,420.00","29,957.76",,,,,,
Aetna Commercial,DRG,MS-116,INTRAOCULAR PROCEDURES W CC/MCC,Surgical,Relative Weights,"$21,746.50 ",IP,"2,420.00","38,122.56",,,,,,
Aetna Commercial,DRG,MS-117,INTRAOCULAR PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$12,612.05 ",IP,"2,420.00","22,109.47",,,,,,
Aetna Commercial,DRG,MS-121,ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,Surgical,Relative Weights,"$14,579.70 ",IP,"2,420.00","25,558.85",,,,,,
Aetna Commercial,DRG,MS-122,ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,Surgical,Relative Weights,"$8,884.90 ",IP,"2,420.00","15,575.62",,,,,,
Aetna Commercial,DRG,MS-123,NEUROLOGICAL EYE DISORDERS,Surgical,Relative Weights,"$8,979.20 ",IP,"2,420.00","15,740.93",,,,,,
Aetna Commercial,DRG,MS-124,OTHER DISORDERS OF THE EYE WITH MCC,Surgical,Relative Weights,"$15,978.10 ",IP,"2,420.00","28,010.30",,,,,,
Aetna Commercial,DRG,MS-125,OTHER DISORDERS OF THE EYE WITHOUT MCC,Surgical,Relative Weights,"$9,078.10 ",IP,"2,420.00","15,914.30",,,,,,
Aetna Commercial,DRG,MS-129,MAJOR HEAD & NECK PROCEDURES W CC/MCC OR MAJOR DEVICE,Surgical,Relative Weights,"$26,326.95 ",IP,"21,710.46","46,152.29",,,,,,
Aetna Commercial,DRG,MS-130,MAJOR HEAD & NECK PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$16,624.40 ",IP,"13,709.28","29,143.30",,,,,,
Aetna Commercial,DRG,MS-131,CRANIAL/FACIAL PROCEDURES W CC/MCC,Surgical,Relative Weights,"$30,926.95 ",IP,"25,503.84","54,216.29",,,,,,
Aetna Commercial,DRG,MS-132,CRANIAL/FACIAL PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$18,279.25 ",IP,"15,073.94","32,044.32",,,,,,
Aetna Commercial,DRG,MS-133,OTHER EAR - NOSE - MOUTH & THROAT O.R. PROCEDURES W CC/MCC,Surgical,Relative Weights,"$24,689.35 ",IP,"20,360.02","43,281.50",,,,,,
Aetna Commercial,DRG,MS-134,OTHER EAR - NOSE - MOUTH & THROAT O.R. PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$13,904.65 ",IP,"11,466.44","24,375.46",,,,,,
Aetna Commercial,DRG,MS-135,SINUS AND MASTOID PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$26,272.90 ",IP,"2,420.00","46,057.54",,,,,,
Aetna Commercial,DRG,MS-136,SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$13,685.00 ",IP,"2,420.00","23,990.40",,,,,,
Aetna Commercial,DRG,MS-137,MOUTH PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$15,332.95 ",IP,"2,420.00","26,879.33",,,,,,
Aetna Commercial,DRG,MS-138,MOUTH PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$9,906.10 ",IP,"2,420.00","17,365.82",,,,,,
Aetna Commercial,DRG,MS-139,SALIVARY GLAND PROCEDURES,Surgical,Relative Weights,"$14,194.45 ",IP,"2,420.00","24,883.49",,,,,,
Aetna Commercial,DRG,MS-146,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH MCC,Surgical,Relative Weights,"$22,178.90 ",IP,"2,420.00","38,880.58",,,,,,
Aetna Commercial,DRG,MS-147,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH CC,Surgical,Relative Weights,"$14,270.35 ",IP,"2,420.00","25,016.54",,,,,,
Aetna Commercial,DRG,MS-148,EAR - NOSE - MOUTH & THROAT MALIGNANCY W/O CC/MCC,Surgical,Relative Weights,"$8,744.60 ",IP,"2,420.00","15,329.66",,,,,,
Aetna Commercial,DRG,MS-149,DYSEQUILIBRIUM,Surgical,Relative Weights,"$8,400.75 ",IP,"2,420.00","14,726.88",,,,,,
Aetna Commercial,DRG,MS-150,EPISTAXIS WITH MCC,Surgical,Relative Weights,"$14,852.25 ",IP,"2,420.00","26,036.64",,,,,,
Aetna Commercial,DRG,MS-151,EPISTAXIS WITHOUT MCC,Surgical,Relative Weights,"$8,039.65 ",IP,"2,420.00","14,093.86",,,,,,
Aetna Commercial,DRG,MS-152,OTITIS MEDIA AND URI WITH MCC,Surgical,Relative Weights,"$11,948.50 ",IP,"2,420.00","20,946.24",,,,,,
Aetna Commercial,DRG,MS-153,OTITIS MEDIA AND URI WITHOUT MCC,Surgical,Relative Weights,"$8,123.60 ",IP,"2,420.00","14,241.02",,,,,,
Aetna Commercial,DRG,MS-154,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH MCC,Surgical,Relative Weights,"$16,525.50 ",IP,"2,420.00","28,969.92",,,,,,
Aetna Commercial,DRG,MS-155,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH CC,Surgical,Relative Weights,"$10,362.65 ",IP,"2,420.00","18,166.18",,,,,,
Aetna Commercial,DRG,MS-156,OTHER EAR -  NOSE -  MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,526.75 ",IP,"2,420.00","13,194.72",,,,,,
Aetna Commercial,DRG,MS-157,DENTAL AND ORAL DISEASES WITH MCC,Surgical,Relative Weights,"$17,973.35 ",IP,"2,420.00","31,508.06",,,,,,
Aetna Commercial,DRG,MS-158,DENTAL AND ORAL DISEASES WITH CC,Surgical,Relative Weights,"$9,965.90 ",IP,"2,420.00","17,470.66",,,,,,
Aetna Commercial,DRG,MS-159,DENTAL AND ORAL DISEASES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,738.35 ",IP,"2,420.00","13,565.66",,,,,,
Aetna Commercial,DRG,MS-163,MAJOR CHEST PROCEDURES WITH MCC,Surgical,Relative Weights,"$56,047.55 ",IP,"2,420.00","98,253.79",,,,,,
Aetna Commercial,DRG,MS-164,MAJOR CHEST PROCEDURES WITH CC,Surgical,Relative Weights,"$29,113.40 ",IP,"2,420.00","51,037.06",,,,,,
Aetna Commercial,DRG,MS-165,MAJOR CHEST PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$21,265.80 ",IP,"2,420.00","37,279.87",,,,,,
Aetna Commercial,DRG,MS-166,OTHER RESP SYSTEM O.R. PROCEDURES W MCC,Surgical,Relative Weights,"$42,903.05 ",IP,"2,420.00","75,210.91",,,,,,
Aetna Commercial,DRG,MS-167,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$22,015.60 ",IP,"2,420.00","38,594.30",,,,,,
Aetna Commercial,DRG,MS-168,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$15,257.05 ",IP,"2,420.00","26,746.27",,,,,,
Aetna Commercial,DRG,MS-175,PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,Surgical,Relative Weights,"$16,610.60 ",IP,"2,420.00","29,119.10",,,,,,
Aetna Commercial,DRG,MS-176,PULMONARY EMBOLISM WITHOUT MCC,Surgical,Relative Weights,"$9,756.60 ",IP,"2,420.00","17,103.74",,,,,,
Aetna Commercial,DRG,MS-177,RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC,Surgical,Relative Weights,"$21,748.80 ",IP,"2,420.00","38,126.59",,,,,,
Aetna Commercial,DRG,MS-178,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,Surgical,Relative Weights,"$14,297.95 ",IP,"2,420.00","25,064.93",,,,,,
Aetna Commercial,DRG,MS-179,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,Surgical,Relative Weights,"$9,960.15 ",IP,"2,420.00","17,460.58",,,,,,
Aetna Commercial,DRG,MS-180,RESPIRATORY NEOPLASMS WITH MCC,Surgical,Relative Weights,"$19,836.35 ",IP,"2,420.00","34,773.98",,,,,,
Aetna Commercial,DRG,MS-181,RESPIRATORY NEOPLASMS WITH CC,Surgical,Relative Weights,"$13,248.00 ",IP,"2,420.00","23,224.32",,,,,,
Aetna Commercial,DRG,MS-182,RESPIRATORY NEOPLASMS WITHOUT CC/MCC,Surgical,Relative Weights,"$9,692.20 ",IP,"2,420.00","16,990.85",,,,,,
Aetna Commercial,DRG,MS-183,MAJOR CHEST TRAUMA WITH MCC,Surgical,Relative Weights,"$17,355.80 ",IP,"2,420.00","30,425.47",,,,,,
Aetna Commercial,DRG,MS-184,MAJOR CHEST TRAUMA WITH CC,Surgical,Relative Weights,"$11,709.30 ",IP,"2,420.00","20,526.91",,,,,,
Aetna Commercial,DRG,MS-185,MAJOR CHEST TRAUMA W/O CC/MCC,Surgical,Relative Weights,"$8,441.00 ",IP,"2,420.00","14,797.44",,,,,,
Aetna Commercial,DRG,MS-186,PLEURAL EFFUSION WITH MCC,Surgical,Relative Weights,"$17,743.35 ",IP,"2,420.00","31,104.86",,,,,,
Aetna Commercial,DRG,MS-187,PLEURAL EFFUSION WITH CC,Surgical,Relative Weights,"$11,820.85 ",IP,"2,420.00","20,722.46",,,,,,
Aetna Commercial,DRG,MS-188,PLEURAL EFFUSION WITHOUT CC/MCC,Surgical,Relative Weights,"$8,405.35 ",IP,"2,420.00","14,734.94",,,,,,
Aetna Commercial,DRG,MS-189,PULMONARY EDEMA AND RESPIRATORY FAILURE,Surgical,Relative Weights,"$13,980.55 ",IP,"2,420.00","24,508.51",,,,,,
Aetna Commercial,DRG,MS-190,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,Surgical,Relative Weights,"$13,156.00 ",IP,"2,420.00","23,063.04",,,,,,
Aetna Commercial,DRG,MS-191,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,Surgical,Relative Weights,"$10,267.20 ",IP,"2,420.00","17,998.85",,,,,,
Aetna Commercial,DRG,MS-192,CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC,Surgical,Relative Weights,"$8,155.80 ",IP,"2,420.00","14,297.47",,,,,,
Aetna Commercial,DRG,MS-193,SIMPLE PNEUMONIA & PLEURISY W MCC,Surgical,Relative Weights,"$15,335.25 ",IP,"2,420.00","26,883.36",,,,,,
Aetna Commercial,DRG,MS-194,SIMPLE PNEUMONIA AND PLEURISY WITH CC,Surgical,Relative Weights,"$10,218.90 ",IP,"2,420.00","17,914.18",,,,,,
Aetna Commercial,DRG,MS-195,SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,Surgical,Relative Weights,"$7,844.15 ",IP,"2,420.00","13,751.14",,,,,,
Aetna Commercial,DRG,MS-196,INTERSTITIAL LUNG DISEASE WITH MCC,Surgical,Relative Weights,"$19,267.10 ",IP,"2,420.00","33,776.06",,,,,,
Aetna Commercial,DRG,MS-197,INTERSTITIAL LUNG DISEASE WITH CC,Surgical,Relative Weights,"$11,747.25 ",IP,"2,420.00","20,593.44",,,,,,
Aetna Commercial,DRG,MS-198,INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,Surgical,Relative Weights,"$8,682.50 ",IP,"2,420.00","15,220.80",,,,,,
Aetna Commercial,DRG,MS-199,PNEUMOTHORAX WITH MCC,Surgical,Relative Weights,"$20,632.15 ",IP,"2,420.00","36,169.06",,,,,,
Aetna Commercial,DRG,MS-200,PNEUMOTHORAX WITH CC,Surgical,Relative Weights,"$12,444.15 ",IP,"2,420.00","21,815.14",,,,,,
Aetna Commercial,DRG,MS-201,PNEUMOTHORAX WITHOUT CC/MCC,Surgical,Relative Weights,"$8,257.00 ",IP,"2,420.00","14,474.88",,,,,,
Aetna Commercial,DRG,MS-202,BRONCHITIS AND ASTHMA WITH CC/MCC,Surgical,Relative Weights,"$10,902.00 ",IP,"2,420.00","19,111.68",,,,,,
Aetna Commercial,DRG,MS-203,BRONCHITIS AND ASTHMA WITHOUT CC/MCC,Surgical,Relative Weights,"$7,978.70 ",IP,"2,420.00","13,987.01",,,,,,
Aetna Commercial,DRG,MS-204,RESPIRATORY SIGNS AND SYMPTOMS,Surgical,Relative Weights,"$9,343.75 ",IP,"2,420.00","16,380.00",,,,,,
Aetna Commercial,DRG,MS-205,OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,Surgical,Relative Weights,"$18,793.30 ",IP,"2,420.00","32,945.47",,,,,,
Aetna Commercial,DRG,MS-206,OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,Surgical,Relative Weights,"$10,033.75 ",IP,"2,420.00","17,589.60",,,,,,
Aetna Commercial,DRG,MS-207,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS,Surgical,Relative Weights,"$65,959.40 ",IP,"2,420.00","115,629.70",,,,,,
Aetna Commercial,DRG,MS-208,RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,Surgical,Relative Weights,"$28,567.15 ",IP,"2,420.00","50,079.46",,,,,,
Aetna Commercial,DRG,MS-215,OTHER HEART ASSIST SYSTEM IMPLANT,Surgical,Relative Weights,"$148,190.15 ",IP,"61,661.88","259,783.78",,,,,,
Aetna Commercial,DRG,MS-216,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$115,487.60 ",IP,"58,630.29","202,454.78",,,,,,
Aetna Commercial,DRG,MS-217,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,Surgical,Relative Weights,"$76,493.40 ",IP,"37,864.14","134,096.26",,,,,,
Aetna Commercial,DRG,MS-218,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,Surgical,Relative Weights,"$62,116.10 ",IP,"35,678.79","108,892.22",,,,,,
Aetna Commercial,DRG,MS-219,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$90,161.15 ",IP,"47,057.01","158,056.42",,,,,,
Aetna Commercial,DRG,MS-220,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,Surgical,Relative Weights,"$61,017.85 ",IP,"31,567.37","106,966.94",,,,,,
Aetna Commercial,DRG,MS-221,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,Surgical,Relative Weights,"$52,856.30 ",IP,"26,746.97","92,659.39",,,,,,
Aetna Commercial,DRG,MS-222,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITH MCC,Surgical,Relative Weights,"$95,962.90 ",IP,"46,434.46","168,227.14",,,,,,
Aetna Commercial,DRG,MS-223,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITHOUT MCC,Surgical,Relative Weights,"$69,033.35 ",IP,"33,864.27","121,018.46",,,,,,
Aetna Commercial,DRG,MS-224,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITH MCC,Surgical,Relative Weights,"$85,056.30 ",IP,"43,912.13","149,107.39",,,,,,
Aetna Commercial,DRG,MS-225,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITHOUT MCC,Surgical,Relative Weights,"$64,961.20 ",IP,"32,808.39","113,879.81",,,,,,
Aetna Commercial,DRG,MS-226,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$76,908.55 ",IP,"25,420.00","134,824.03",,,,,,
Aetna Commercial,DRG,MS-227,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Surgical,Relative Weights,"$60,135.80 ",IP,"25,420.00","105,420.67",,,,,,
Aetna Commercial,DRG,MS-228,OTHER CARDIOTHORACIC PROCEDURES WITH MCC,Surgical,Relative Weights,"$72,292.45 ",IP,"31,129.37","126,731.81",,,,,,
Aetna Commercial,DRG,MS-229,OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$47,206.35 ",IP,"20,096.88","82,754.78",,,,,,
Aetna Commercial,DRG,MS-231,CORONARY BYPASS W PTCA W MCC,Surgical,Relative Weights,"$94,432.25 ",IP,"50,901.53","165,543.84",,,,,,
Aetna Commercial,DRG,MS-232,CORONARY BYPASS W PTCA W/O MCC,Surgical,Relative Weights,"$68,844.75 ",IP,"34,770.65","120,687.84",,,,,,
Aetna Commercial,DRG,MS-233,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,Surgical,Relative Weights,"$89,342.35 ",IP,"42,365.00","156,621.02",,,,,,
Aetna Commercial,DRG,MS-234,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,Surgical,Relative Weights,"$59,872.45 ",IP,"31,162.65","104,959.01",,,,,,
Aetna Commercial,DRG,MS-235,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$67,672.90 ",IP,"32,351.00","118,633.54",,,,,,
Aetna Commercial,DRG,MS-236,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Surgical,Relative Weights,"$46,334.65 ",IP,"23,926.80","81,226.66",,,,,,
Aetna Commercial,DRG,MS-239,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,Surgical,Relative Weights,"$53,701.55 ",IP,"2,420.00","94,141.15",,,,,,
Aetna Commercial,DRG,MS-240,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,Surgical,Relative Weights,"$31,740.00 ",IP,"2,420.00","55,641.60",,,,,,
Aetna Commercial,DRG,MS-241,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,Surgical,Relative Weights,"$17,437.45 ",IP,"2,420.00","30,568.61",,,,,,
Aetna Commercial,DRG,MS-242,PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,Surgical,Relative Weights,"$42,677.65 ",IP,"15,407.00","74,815.78",,,,,,
Aetna Commercial,DRG,MS-243,PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,Surgical,Relative Weights,"$29,088.10 ",IP,"14,708.24","50,992.70",,,,,,
Aetna Commercial,DRG,MS-244,PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,Surgical,Relative Weights,"$23,867.10 ",IP,"12,049.83","41,840.06",,,,,,
Aetna Commercial,DRG,MS-245,AICD GENERATOR PROCEDURES,Surgical,Relative Weights,"$59,889.70 ",IP,"15,407.00","104,989.25",,,,,,
Aetna Commercial,DRG,MS-246,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Surgical,Relative Weights,"$36,487.20 ",IP,"18,246.15","63,963.65",,,,,,
Aetna Commercial,DRG,MS-247,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITHOUT MCC,Surgical,Relative Weights,"$23,399.05 ",IP,"11,523.64","41,019.55",,,,,,
Aetna Commercial,DRG,MS-248,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Surgical,Relative Weights,"$35,609.75 ",IP,"18,467.49","62,425.44",,,,,,
Aetna Commercial,DRG,MS-249,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITHOUT MCC,Surgical,Relative Weights,"$22,040.90 ",IP,"10,942.55","38,638.66",,,,,,
Aetna Commercial,DRG,MS-250,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT CORONARY ARTERY STENT WITH MCC,Surgical,Relative Weights,"$29,326.15 ",IP,"14,727.51","51,410.02",,,,,,
Aetna Commercial,DRG,MS-251,PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W/O MCC,Surgical,Relative Weights,"$19,354.50 ",IP,"2,420.00","33,929.28",,,,,,
Aetna Commercial,DRG,MS-252,OTHER VASCULAR PROCEDURES W MCC,Surgical,Relative Weights,"$37,724.60 ",IP,"2,420.00","66,132.86",,,,,,
Aetna Commercial,DRG,MS-253,OTHER VASCULAR PROCEDURES WITH CC,Surgical,Relative Weights,"$29,975.90 ",IP,"2,420.00","52,549.06",,,,,,
Aetna Commercial,DRG,MS-254,OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$20,931.15 ",IP,"2,420.00","36,693.22",,,,,,
Aetna Commercial,DRG,MS-255,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,Surgical,Relative Weights,"$30,470.40 ",IP,"2,420.00","53,415.94",,,,,,
Aetna Commercial,DRG,MS-256,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,Surgical,Relative Weights,"$19,739.75 ",IP,"2,420.00","34,604.64",,,,,,
Aetna Commercial,DRG,MS-257,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$13,045.60 ",IP,"2,420.00","22,869.50",,,,,,
Aetna Commercial,DRG,MS-258,CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,Surgical,Relative Weights,"$35,175.05 ",IP,"11,861.00","61,663.39",,,,,,
Aetna Commercial,DRG,MS-259,CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,Surgical,Relative Weights,"$23,949.90 ",IP,"11,861.00","41,985.22",,,,,,
Aetna Commercial,DRG,MS-260,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,Surgical,Relative Weights,"$42,545.40 ",IP,"10,167.00","74,583.94",,,,,,
Aetna Commercial,DRG,MS-261,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,Surgical,Relative Weights,"$22,407.75 ",IP,"10,167.00","39,281.76",,,,,,
Aetna Commercial,DRG,MS-262,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,Surgical,Relative Weights,"$19,292.40 ",IP,"9,964.34","33,820.42",,,,,,
Aetna Commercial,DRG,MS-263,VEIN LIGATION AND STRIPPING,Surgical,Relative Weights,"$27,129.65 ",IP,"2,420.00","47,559.46",,,,,,
Aetna Commercial,DRG,MS-264,OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,Surgical,Relative Weights,"$37,237.00 ",IP,"2,420.00","65,278.08",,,,,,
Aetna Commercial,DRG,MS-265,AICD LEAD PROCEDURES,Surgical,Relative Weights,"$35,894.95 ",IP,"2,420.00","62,925.41",,,,,,
Aetna Commercial,DRG,MS-266,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,Surgical,Relative Weights,"$81,896.10 ",IP,"41,160.28","143,567.42",,,,,,
Aetna Commercial,DRG,MS-267,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$65,269.40 ",IP,"32,692.75","114,420.10",,,,,,
Aetna Commercial,DRG,MS-268,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,Surgical,Relative Weights,"$77,999.90 ",IP,"32,968.00","136,737.22",,,,,,
Aetna Commercial,DRG,MS-269,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,Surgical,Relative Weights,"$49,063.60 ",IP,"25,200.52","86,010.62",,,,,,
Aetna Commercial,DRG,MS-270,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,Surgical,Relative Weights,"$58,767.30 ",IP,"30,292.48","103,021.63",,,,,,
Aetna Commercial,DRG,MS-271,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,Surgical,Relative Weights,"$40,802.00 ",IP,"20,822.21","71,527.68",,,,,,
Aetna Commercial,DRG,MS-272,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$29,914.95 ",IP,"15,699.88","52,442.21",,,,,,
Aetna Commercial,DRG,MS-273,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,Surgical,Relative Weights,"$42,668.45 ",IP,"16,176.00","74,799.65",,,,,,
Aetna Commercial,DRG,MS-274,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$36,337.70 ",IP,"16,176.00","63,701.57",,,,,,
Aetna Commercial,DRG,MS-280,ACUTE MYOCARDIAL INFARCTION - DISCHARGED ALIVE W MCC,Surgical,Relative Weights,"$18,755.35 ",IP,"2,420.00","32,878.94",,,,,,
Aetna Commercial,DRG,MS-281,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITH CC,Surgical,Relative Weights,"$11,140.05 ",IP,"2,420.00","19,528.99",,,,,,
Aetna Commercial,DRG,MS-282,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITHOUT CC/MCC,Surgical,Relative Weights,"$8,485.85 ",IP,"2,420.00","14,876.06",,,,,,
Aetna Commercial,DRG,MS-283,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH MCC,Surgical,Relative Weights,"$20,696.55 ",IP,"2,420.00","36,281.95",,,,,,
Aetna Commercial,DRG,MS-284,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH CC,Surgical,Relative Weights,"$8,340.95 ",IP,"2,420.00","14,622.05",,,,,,
Aetna Commercial,DRG,MS-285,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITHOUT CC/MCC,Surgical,Relative Weights,"$5,954.70 ",IP,"2,420.00","10,438.85",,,,,,
Aetna Commercial,DRG,MS-286,CIRCULATORY DISORDERS EXCEPT AMI- WITH CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$25,270.10 ",IP,"2,420.00","44,299.58",,,,,,
Aetna Commercial,DRG,MS-287,CIRCULATORY DISORDERS EXCEPT AMI -  WITH CARDIAC CATHETERIZATION WITHOUT MCC,Surgical,Relative Weights,"$13,250.30 ",IP,"6,512.27","23,228.35",,,,,,
Aetna Commercial,DRG,MS-288,ACUTE & SUBACUTE ENDOCARDITIS W MCC,Surgical,Relative Weights,"$30,560.10 ",IP,"2,420.00","53,573.18",,,,,,
Aetna Commercial,DRG,MS-289,ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,Surgical,Relative Weights,"$19,133.70 ",IP,"9,181.00","33,542.21",,,,,,
Aetna Commercial,DRG,MS-290,ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,Surgical,Relative Weights,"$11,506.90 ",IP,"2,420.00","20,172.10",,,,,,
Aetna Commercial,DRG,MS-291,HEART FAILURE AND SHOCK WITH MCC,Surgical,Relative Weights,"$15,476.70 ",IP,"2,420.00","27,131.33",,,,,,
Aetna Commercial,DRG,MS-292,HEART FAILURE AND SHOCK WITH CC,Surgical,Relative Weights,"$10,413.25 ",IP,"2,420.00","18,254.88",,,,,,
Aetna Commercial,DRG,MS-293,HEART FAILURE AND SHOCK WITHOUT CC/MCC,Surgical,Relative Weights,"$7,535.95 ",IP,"2,420.00","13,210.85",,,,,,
Aetna Commercial,DRG,MS-294,DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC,Surgical,Relative Weights,"$14,626.85 ",IP,"2,420.00","25,641.50",,,,,,
Aetna Commercial,DRG,MS-295,DEEP VEIN THROMBOPHLEBITIS W/O CC/MCC,Surgical,Relative Weights,"$6,635.50 ",IP,"2,420.00","11,632.32",,,,,,
Aetna Commercial,DRG,MS-296,CARDIAC ARREST - UNEXPLAINED W MCC,Surgical,Relative Weights,"$18,059.60 ",IP,"2,420.00","31,659.26",,,,,,
Aetna Commercial,DRG,MS-297,CARDIAC ARREST- UNEXPLAINED WITH CC,Surgical,Relative Weights,"$8,314.50 ",IP,"2,420.00","14,575.68",,,,,,
Aetna Commercial,DRG,MS-298,CARDIAC ARREST- UNEXPLAINED WITHOUT CC/MCC,Surgical,Relative Weights,"$5,786.80 ",IP,"2,420.00","10,144.51",,,,,,
Aetna Commercial,DRG,MS-299,PERIPHERAL VASCULAR DISORDERS WITH MCC,Surgical,Relative Weights,"$16,671.55 ",IP,"2,420.00","29,225.95",,,,,,
Aetna Commercial,DRG,MS-300,PERIPHERAL VASCULAR DISORDERS WITH CC,Surgical,Relative Weights,"$11,817.40 ",IP,"2,420.00","20,716.42",,,,,,
Aetna Commercial,DRG,MS-301,PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$8,346.70 ",IP,"2,420.00","14,632.13",,,,,,
Aetna Commercial,DRG,MS-302,ATHEROSCLEROSIS WITH MCC,Surgical,Relative Weights,"$12,676.45 ",IP,"2,420.00","22,222.37",,,,,,
Aetna Commercial,DRG,MS-303,ATHEROSCLEROSIS WITHOUT MCC,Surgical,Relative Weights,"$7,770.55 ",IP,"2,420.00","13,622.11",,,,,,
Aetna Commercial,DRG,MS-304,HYPERTENSION WITH MCC,Surgical,Relative Weights,"$12,552.25 ",IP,"2,420.00","22,004.64",,,,,,
Aetna Commercial,DRG,MS-305,HYPERTENSION WITHOUT MCC,Surgical,Relative Weights,"$8,412.25 ",IP,"2,420.00","14,747.04",,,,,,
Aetna Commercial,DRG,MS-306,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,Surgical,Relative Weights,"$16,266.75 ",IP,"2,420.00","28,516.32",,,,,,
Aetna Commercial,DRG,MS-307,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,Surgical,Relative Weights,"$10,145.30 ",IP,"2,420.00","17,785.15",,,,,,
Aetna Commercial,DRG,MS-308,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,Surgical,Relative Weights,"$13,658.55 ",IP,"2,420.00","23,944.03",,,,,,
Aetna Commercial,DRG,MS-309,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,Surgical,Relative Weights,"$8,697.45 ",IP,"2,420.00","15,247.01",,,,,,
Aetna Commercial,DRG,MS-310,CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC,Surgical,Relative Weights,"$6,431.95 ",IP,"2,420.00","11,275.49",,,,,,
Aetna Commercial,DRG,MS-311,ANGINA PECTORIS,Surgical,Relative Weights,"$7,877.50 ",IP,"2,420.00","13,809.60",,,,,,
Aetna Commercial,DRG,MS-312,SYNCOPE AND COLLAPSE,Surgical,Relative Weights,"$9,390.90 ",IP,"2,420.00","16,462.66",,,,,,
Aetna Commercial,DRG,MS-313,CHEST PAIN,Surgical,Relative Weights,"$8,225.95 ",IP,"2,420.00","14,420.45",,,,,,
Aetna Commercial,DRG,MS-314,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,Surgical,Relative Weights,"$23,339.25 ",IP,"2,420.00","40,914.72",,,,,,
Aetna Commercial,DRG,MS-315,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,Surgical,Relative Weights,"$11,159.60 ",IP,"2,420.00","19,563.26",,,,,,
Aetna Commercial,DRG,MS-316,OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,535.30 ",IP,"2,420.00","14,962.75",,,,,,
Aetna Commercial,DRG,MS-319,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,Surgical,Relative Weights,"$47,158.05 ",IP,"2,420.00","82,670.11",,,,,,
Aetna Commercial,DRG,MS-320,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$26,998.55 ",IP,"2,420.00","47,329.63",,,,,,
Aetna Commercial,DRG,MS-326,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$60,610.75 ",IP,"2,420.00","106,253.28",,,,,,
Aetna Commercial,DRG,MS-327,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC,Surgical,Relative Weights,"$29,588.35 ",IP,"2,420.00","51,869.66",,,,,,
Aetna Commercial,DRG,MS-328,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$18,112.50 ",IP,"2,420.00","31,752.00",,,,,,
Aetna Commercial,DRG,MS-329,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Surgical,Relative Weights,"$56,432.80 ",IP,"2,420.00","98,929.15",,,,,,
Aetna Commercial,DRG,MS-330,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Surgical,Relative Weights,"$29,058.20 ",IP,"2,420.00","50,940.29",,,,,,
Aetna Commercial,DRG,MS-331,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$19,425.80 ",IP,"2,420.00","34,054.27",,,,,,
Aetna Commercial,DRG,MS-332,RECTAL RESECTION WITH MCC,Surgical,Relative Weights,"$40,156.85 ",IP,"2,420.00","70,396.70",,,,,,
Aetna Commercial,DRG,MS-333,RECTAL RESECTION WITH CC,Surgical,Relative Weights,"$26,026.80 ",IP,"2,420.00","45,626.11",,,,,,
Aetna Commercial,DRG,MS-334,RECTAL RESECTION WITHOUT CC/MCC,Surgical,Relative Weights,"$17,713.45 ",IP,"2,420.00","31,052.45",,,,,,
Aetna Commercial,DRG,MS-335,PERITONEAL ADHESIOLYSIS WITH MCC,Surgical,Relative Weights,"$46,518.65 ",IP,"2,420.00","81,549.22",,,,,,
Aetna Commercial,DRG,MS-336,PERITONEAL ADHESIOLYSIS WITH CC,Surgical,Relative Weights,"$26,061.30 ",IP,"2,420.00","45,686.59",,,,,,
Aetna Commercial,DRG,MS-337,PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$18,856.55 ",IP,"2,420.00","33,056.35",,,,,,
Aetna Commercial,DRG,MS-338,APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$33,466.15 ",IP,"2,420.00","58,667.62",,,,,,
Aetna Commercial,DRG,MS-339,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W CC,Surgical,Relative Weights,"$19,735.15 ",IP,"2,420.00","34,596.58",,,,,,
Aetna Commercial,DRG,MS-340,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC/MCC,Surgical,Relative Weights,"$14,231.25 ",IP,"2,420.00","24,948.00",,,,,,
Aetna Commercial,DRG,MS-341,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$29,418.15 ",IP,"2,420.00","51,571.30",,,,,,
Aetna Commercial,DRG,MS-342,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH CC,Surgical,Relative Weights,"$18,518.45 ",IP,"2,420.00","32,463.65",,,,,,
Aetna Commercial,DRG,MS-343,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$13,243.40 ",IP,"2,420.00","23,216.26",,,,,,
Aetna Commercial,DRG,MS-344,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Surgical,Relative Weights,"$34,443.65 ",IP,"2,420.00","60,381.22",,,,,,
Aetna Commercial,DRG,MS-345,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Surgical,Relative Weights,"$18,782.95 ",IP,"2,420.00","32,927.33",,,,,,
Aetna Commercial,DRG,MS-346,MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$14,751.05 ",IP,"2,420.00","25,859.23",,,,,,
Aetna Commercial,DRG,MS-347,ANAL AND STOMAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$30,318.60 ",IP,"2,420.00","53,149.82",,,,,,
Aetna Commercial,DRG,MS-348,ANAL AND STOMAL PROCEDURES WITH CC,Surgical,Relative Weights,"$16,206.95 ",IP,"2,420.00","28,411.49",,,,,,
Aetna Commercial,DRG,MS-349,ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$11,280.35 ",IP,"2,420.00","19,774.94",,,,,,
Aetna Commercial,DRG,MS-350,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,Surgical,Relative Weights,"$28,051.95 ",IP,"2,420.00","49,176.29",,,,,,
Aetna Commercial,DRG,MS-351,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,Surgical,Relative Weights,"$16,770.45 ",IP,"2,420.00","29,399.33",,,,,,
Aetna Commercial,DRG,MS-352,INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$12,383.20 ",IP,"2,420.00","21,708.29",,,,,,
Aetna Commercial,DRG,MS-353,HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,Surgical,Relative Weights,"$34,119.35 ",IP,"2,420.00","59,812.70",,,,,,
Aetna Commercial,DRG,MS-354,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W CC,Surgical,Relative Weights,"$19,804.15 ",IP,"2,420.00","34,717.54",,,,,,
Aetna Commercial,DRG,MS-355,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W/O CC/MCC,Surgical,Relative Weights,"$15,782.60 ",IP,"2,420.00","27,667.58",,,,,,
Aetna Commercial,DRG,MS-356,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$46,887.80 ",IP,"2,420.00","82,196.35",,,,,,
Aetna Commercial,DRG,MS-357,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$25,879.60 ",IP,"2,420.00","45,368.06",,,,,,
Aetna Commercial,DRG,MS-358,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$15,774.55 ",IP,"2,420.00","27,653.47",,,,,,
Aetna Commercial,DRG,MS-368,MAJOR ESOPHAGEAL DISORDERS WITH MCC,Surgical,Relative Weights,"$21,891.40 ",IP,"2,420.00","38,376.58",,,,,,
Aetna Commercial,DRG,MS-369,MAJOR ESOPHAGEAL DISORDERS WITH CC,Surgical,Relative Weights,"$12,225.65 ",IP,"2,420.00","21,432.10",,,,,,
Aetna Commercial,DRG,MS-370,MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$8,593.95 ",IP,"2,420.00","15,065.57",,,,,,
Aetna Commercial,DRG,MS-371,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,Surgical,Relative Weights,"$19,843.25 ",IP,"2,420.00","34,786.08",,,,,,
Aetna Commercial,DRG,MS-372,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,Surgical,Relative Weights,"$11,758.75 ",IP,"2,420.00","20,613.60",,,,,,
Aetna Commercial,DRG,MS-373,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,Surgical,Relative Weights,"$8,530.70 ",IP,"2,420.00","14,954.69",,,,,,
Aetna Commercial,DRG,MS-374,DIGESTIVE MALIGNANCY WITH MCC,Surgical,Relative Weights,"$22,971.25 ",IP,"2,420.00","40,269.60",,,,,,
Aetna Commercial,DRG,MS-375,DIGESTIVE MALIGNANCY WITH CC,Surgical,Relative Weights,"$13,883.95 ",IP,"2,420.00","24,339.17",,,,,,
Aetna Commercial,DRG,MS-376,DIGESTIVE MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$11,514.95 ",IP,"2,420.00","20,186.21",,,,,,
Aetna Commercial,DRG,MS-377,GASTROINTESTINAL HEMORRHAGE WITH MCC,Surgical,Relative Weights,"$20,353.85 ",IP,"2,420.00","35,681.18",,,,,,
Aetna Commercial,DRG,MS-378,GASTROINTESTINAL HEMORRHAGE WITH CC,Surgical,Relative Weights,"$11,363.15 ",IP,"2,420.00","19,920.10",,,,,,
Aetna Commercial,DRG,MS-379,GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,Surgical,Relative Weights,"$7,425.55 ",IP,"2,420.00","13,017.31",,,,,,
Aetna Commercial,DRG,MS-380,COMPLICATED PEPTIC ULCER WITH MCC,Surgical,Relative Weights,"$21,707.40 ",IP,"2,420.00","38,054.02",,,,,,
Aetna Commercial,DRG,MS-381,COMPLICATED PEPTIC ULCER WITH CC,Surgical,Relative Weights,"$12,382.05 ",IP,"2,420.00","21,706.27",,,,,,
Aetna Commercial,DRG,MS-382,COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,Surgical,Relative Weights,"$9,101.10 ",IP,"2,420.00","15,954.62",,,,,,
Aetna Commercial,DRG,MS-383,UNCOMPLICATED PEPTIC ULCER WITH MCC,Surgical,Relative Weights,"$15,252.45 ",IP,"2,420.00","26,738.21",,,,,,
Aetna Commercial,DRG,MS-384,UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,Surgical,Relative Weights,"$10,007.30 ",IP,"2,420.00","17,543.23",,,,,,
Aetna Commercial,DRG,MS-385,INFLAMMATORY BOWEL DISEASE WITH MCC,Surgical,Relative Weights,"$18,518.45 ",IP,"2,420.00","32,463.65",,,,,,
Aetna Commercial,DRG,MS-386,INFLAMMATORY BOWEL DISEASE W CC,Surgical,Relative Weights,"$11,329.80 ",IP,"2,420.00","19,861.63",,,,,,
Aetna Commercial,DRG,MS-387,INFLAMMATORY BOWEL DISEASE W/O CC/MCC,Surgical,Relative Weights,"$8,058.05 ",IP,"2,420.00","14,126.11",,,,,,
Aetna Commercial,DRG,MS-388,GASTROINTESTINAL OBSTRUCTION WITH MCC,Surgical,Relative Weights,"$17,538.65 ",IP,"2,420.00","30,746.02",,,,,,
Aetna Commercial,DRG,MS-389,GASTROINTESTINAL OBSTRUCTION WITH CC,Surgical,Relative Weights,"$9,656.55 ",IP,"2,420.00","16,928.35",,,,,,
Aetna Commercial,DRG,MS-390,GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,Surgical,Relative Weights,"$6,665.40 ",IP,"2,420.00","11,684.74",,,,,,
Aetna Commercial,DRG,MS-391,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC,Surgical,Relative Weights,"$14,202.50 ",IP,"2,420.00","24,897.60",,,,,,
Aetna Commercial,DRG,MS-392,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC,Surgical,Relative Weights,"$8,757.25 ",IP,"2,420.00","15,351.84",,,,,,
Aetna Commercial,DRG,MS-393,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,Surgical,Relative Weights,"$18,681.75 ",IP,"2,420.00","32,749.92",,,,,,
Aetna Commercial,DRG,MS-394,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,Surgical,Relative Weights,"$10,788.15 ",IP,"2,420.00","18,912.10",,,,,,
Aetna Commercial,DRG,MS-395,OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,525.60 ",IP,"2,420.00","13,192.70",,,,,,
Aetna Commercial,DRG,MS-405,PANCREAS- LIVER AND SHUNT PROCEDURES WITH MCC,Surgical,Relative Weights,"$62,412.80 ",IP,"2,420.00","109,412.35",,,,,,
Aetna Commercial,DRG,MS-406,PANCREAS -  LIVER AND SHUNT PROCEDURES WITH CC,Surgical,Relative Weights,"$32,095.35 ",IP,"2,420.00","56,264.54",,,,,,
Aetna Commercial,DRG,MS-407,PANCREAS -  LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$23,992.45 ",IP,"2,420.00","42,059.81",,,,,,
Aetna Commercial,DRG,MS-408,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,Surgical,Relative Weights,"$40,981.40 ",IP,"2,420.00","71,842.18",,,,,,
Aetna Commercial,DRG,MS-409,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,Surgical,Relative Weights,"$27,528.70 ",IP,"2,420.00","48,259.01",,,,,,
Aetna Commercial,DRG,MS-410,BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W/O CC/MCC,Surgical,Relative Weights,"$19,090.00 ",IP,"2,420.00","33,465.60",,,,,,
Aetna Commercial,DRG,MS-411,CHOLECYSTECTOMY W C.D.E. W MCC,Surgical,Relative Weights,"$44,049.60 ",IP,"2,420.00","77,220.86",,,,,,
Aetna Commercial,DRG,MS-412,CHOLECYSTECTOMY WITH C.D.E. WITH CC,Surgical,Relative Weights,"$27,335.50 ",IP,"2,420.00","47,920.32",,,,,,
Aetna Commercial,DRG,MS-413,CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,Surgical,Relative Weights,"$18,598.95 ",IP,"2,420.00","32,604.77",,,,,,
Aetna Commercial,DRG,MS-414,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,Surgical,Relative Weights,"$39,288.60 ",IP,"2,420.00","68,874.62",,,,,,
Aetna Commercial,DRG,MS-415,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,Surgical,Relative Weights,"$23,594.55 ",IP,"2,420.00","41,362.27",,,,,,
Aetna Commercial,DRG,MS-416,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,Surgical,Relative Weights,"$15,528.45 ",IP,"2,420.00","27,222.05",,,,,,
Aetna Commercial,DRG,MS-417,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,Surgical,Relative Weights,"$27,723.05 ",IP,"2,420.00","48,599.71",,,,,,
Aetna Commercial,DRG,MS-418,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,Surgical,Relative Weights,"$19,192.35 ",IP,"2,420.00","33,645.02",,,,,,
Aetna Commercial,DRG,MS-419,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,Surgical,Relative Weights,"$15,028.20 ",IP,"2,420.00","26,345.09",,,,,,
Aetna Commercial,DRG,MS-420,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,Surgical,Relative Weights,"$39,500.20 ",IP,"2,420.00","69,245.57",,,,,,
Aetna Commercial,DRG,MS-421,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,Surgical,Relative Weights,"$21,173.80 ",IP,"2,420.00","37,118.59",,,,,,
Aetna Commercial,DRG,MS-422,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$16,151.75 ",IP,"2,420.00","28,314.72",,,,,,
Aetna Commercial,DRG,MS-423,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$48,739.30 ",IP,"2,420.00","85,442.11",,,,,,
Aetna Commercial,DRG,MS-424,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$25,891.10 ",IP,"2,420.00","45,388.22",,,,,,
Aetna Commercial,DRG,MS-425,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$16,807.25 ",IP,"2,420.00","29,463.84",,,,,,
Aetna Commercial,DRG,MS-432,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,Surgical,Relative Weights,"$20,969.10 ",IP,"2,420.00","36,759.74",,,,,,
Aetna Commercial,DRG,MS-433,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,Surgical,Relative Weights,"$11,868.00 ",IP,"2,420.00","20,805.12",,,,,,
Aetna Commercial,DRG,MS-434,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Surgical,Relative Weights,"$7,358.85 ",IP,"2,420.00","12,900.38",,,,,,
Aetna Commercial,DRG,MS-435,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,Surgical,Relative Weights,"$19,516.65 ",IP,"2,420.00","34,213.54",,,,,,
Aetna Commercial,DRG,MS-436,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,Surgical,Relative Weights,"$12,945.55 ",IP,"2,420.00","22,694.11",,,,,,
Aetna Commercial,DRG,MS-437,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,Surgical,Relative Weights,"$10,095.85 ",IP,"2,420.00","17,698.46",,,,,,
Aetna Commercial,DRG,MS-438,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,Surgical,Relative Weights,"$18,840.45 ",IP,"2,420.00","33,028.13",,,,,,
Aetna Commercial,DRG,MS-439,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,Surgical,Relative Weights,"$9,742.80 ",IP,"2,420.00","17,079.55",,,,,,
Aetna Commercial,DRG,MS-440,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$7,079.40 ",IP,"2,420.00","12,410.50",,,,,,
Aetna Commercial,DRG,MS-441,DISORDERS OF LIVER EXCEPT MALIGNANCY- CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC,Surgical,Relative Weights,"$21,280.75 ",IP,"2,420.00","37,306.08",,,,,,
Aetna Commercial,DRG,MS-442,DISORDERS OF LIVER EXCEPT MALIGNANCY -  CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC,Surgical,Relative Weights,"$10,734.10 ",IP,"2,420.00","18,817.34",,,,,,
Aetna Commercial,DRG,MS-443,DISORDERS OF LIVER EXCEPT MALIGNANCY -  CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Surgical,Relative Weights,"$7,823.45 ",IP,"2,420.00","13,714.85",,,,,,
Aetna Commercial,DRG,MS-444,DISORDERS OF THE BILIARY TRACT WITH MCC,Surgical,Relative Weights,"$18,700.15 ",IP,"2,420.00","32,782.18",,,,,,
Aetna Commercial,DRG,MS-445,DISORDERS OF THE BILIARY TRACT WITH CC,Surgical,Relative Weights,"$12,356.75 ",IP,"2,420.00","21,661.92",,,,,,
Aetna Commercial,DRG,MS-446,DISORDERS OF THE BILIARY TRACT W/O CC/MCC,Surgical,Relative Weights,"$9,346.05 ",IP,"2,420.00","16,384.03",,,,,,
Aetna Commercial,DRG,MS-453,COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W MCC,Surgical,Relative Weights,"$108,180.50 ",IP,"2,420.00","189,645.12",,,,,,
Aetna Commercial,DRG,MS-454,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC,Surgical,Relative Weights,"$70,437.50 ",IP,"2,420.00","123,480.00",,,,,,
Aetna Commercial,DRG,MS-455,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CC/MCC,Surgical,Relative Weights,"$55,352.95 ",IP,"2,420.00","97,036.13",,,,,,
Aetna Commercial,DRG,MS-456,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH MCC,Surgical,Relative Weights,"$104,433.80 ",IP,"2,420.00","183,076.99",,,,,,
Aetna Commercial,DRG,MS-457,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH CC,Surgical,Relative Weights,"$74,902.95 ",IP,"2,420.00","131,308.13",,,,,,
Aetna Commercial,DRG,MS-458,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC,Surgical,Relative Weights,"$53,979.85 ",IP,"2,420.00","94,629.02",,,,,,
Aetna Commercial,DRG,MS-459,SPINAL FUSION EXCEPT CERVICAL WITH MCC,Surgical,Relative Weights,"$78,798.00 ",IP,"21,658.00","138,136.32",,,,,,
Aetna Commercial,DRG,MS-460,SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,Surgical,Relative Weights,"$45,544.60 ",IP,"21,658.00","79,841.66",,,,,,
Aetna Commercial,DRG,MS-461,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,Surgical,Relative Weights,"$61,856.20 ",IP,"2,420.00","108,436.61",,,,,,
Aetna Commercial,DRG,MS-462,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,Surgical,Relative Weights,"$36,068.60 ",IP,"2,420.00","63,229.82",,,,,,
Aetna Commercial,DRG,MS-463,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,Surgical,Relative Weights,"$60,119.70 ",IP,"2,420.00","105,392.45",,,,,,
Aetna Commercial,DRG,MS-464,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,Surgical,Relative Weights,"$33,956.05 ",IP,"2,420.00","59,526.43",,,,,,
Aetna Commercial,DRG,MS-465,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$22,024.80 ",IP,"2,420.00","38,610.43",,,,,,
Aetna Commercial,DRG,MS-466,REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,Surgical,Relative Weights,"$58,639.65 ",IP,"2,420.00","102,797.86",,,,,,
Aetna Commercial,DRG,MS-467,REVISION OF HIP OR KNEE REPLACEMENT W CC,Surgical,Relative Weights,"$40,389.15 ",IP,"2,420.00","70,803.94",,,,,,
Aetna Commercial,DRG,MS-468,REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,Surgical,Relative Weights,"$32,339.15 ",IP,"2,420.00","56,691.94",,,,,,
Aetna Commercial,DRG,MS-469,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,Surgical,Relative Weights,"$36,108.85 ",IP,"2,420.00","63,300.38",,,,,,
Aetna Commercial,DRG,MS-470,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,Surgical,Relative Weights,"$22,636.60 ",IP,"2,420.00","39,682.94",,,,,,
Aetna Commercial,DRG,MS-471,CERVICAL SPINAL FUSION WITH MCC,Surgical,Relative Weights,"$57,435.60 ",IP,"15,407.00","100,687.10",,,,,,
Aetna Commercial,DRG,MS-472,CERVICAL SPINAL FUSION WITH CC,Surgical,Relative Weights,"$34,977.25 ",IP,"15,407.00","61,316.64",,,,,,
Aetna Commercial,DRG,MS-473,CERVICAL SPINAL FUSION WITHOUT CC/MCC,Surgical,Relative Weights,"$28,892.60 ",IP,"14,827.96","50,649.98",,,,,,
Aetna Commercial,DRG,MS-474,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,Surgical,Relative Weights,"$44,561.35 ",IP,"2,420.00","78,117.98",,,,,,
Aetna Commercial,DRG,MS-475,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,Surgical,Relative Weights,"$24,161.50 ",IP,"2,420.00","42,356.16",,,,,,
Aetna Commercial,DRG,MS-476,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$13,394.05 ",IP,"2,420.00","23,480.35",,,,,,
Aetna Commercial,DRG,MS-477,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Surgical,Relative Weights,"$37,435.95 ",IP,"2,420.00","65,626.85",,,,,,
Aetna Commercial,DRG,MS-478,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Surgical,Relative Weights,"$26,646.65 ",IP,"2,420.00","46,712.74",,,,,,
Aetna Commercial,DRG,MS-479,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Surgical,Relative Weights,"$20,495.30 ",IP,"2,420.00","35,929.15",,,,,,
Aetna Commercial,DRG,MS-480,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,Surgical,Relative Weights,"$34,712.75 ",IP,"2,420.00","60,852.96",,,,,,
Aetna Commercial,DRG,MS-481,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,Surgical,Relative Weights,"$24,009.70 ",IP,"2,420.00","42,090.05",,,,,,
Aetna Commercial,DRG,MS-482,HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC,Surgical,Relative Weights,"$18,920.95 ",IP,"2,420.00","33,169.25",,,,,,
Aetna Commercial,DRG,MS-483,MAJOR JOINT & LIMB REATTACHMENT PROC OF UPPER EXTREMITY W CC/MCC,Surgical,Relative Weights,"$27,509.15 ",IP,"2,420.00","48,224.74",,,,,,
Aetna Commercial,DRG,MS-485,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,Surgical,Relative Weights,"$37,708.50 ",IP,"2,420.00","66,104.64",,,,,,
Aetna Commercial,DRG,MS-486,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,Surgical,Relative Weights,"$24,731.90 ",IP,"2,420.00","43,356.10",,,,,,
Aetna Commercial,DRG,MS-487,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Surgical,Relative Weights,"$18,482.80 ",IP,"2,420.00","32,401.15",,,,,,
Aetna Commercial,DRG,MS-488,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,Surgical,Relative Weights,"$22,645.80 ",IP,"2,420.00","39,699.07",,,,,,
Aetna Commercial,DRG,MS-489,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Surgical,Relative Weights,"$14,478.50 ",IP,"2,420.00","25,381.44",,,,,,
Aetna Commercial,DRG,MS-492,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH MCC,Surgical,Relative Weights,"$39,620.95 ",IP,"2,420.00","69,457.25",,,,,,
Aetna Commercial,DRG,MS-493,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH CC,Surgical,Relative Weights,"$26,473.00 ",IP,"2,420.00","46,408.32",,,,,,
Aetna Commercial,DRG,MS-494,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITHOUT CC/MCC,Surgical,Relative Weights,"$20,831.10 ",IP,"2,420.00","36,517.82",,,,,,
Aetna Commercial,DRG,MS-495,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,Surgical,Relative Weights,"$39,474.90 ",IP,"2,420.00","69,201.22",,,,,,
Aetna Commercial,DRG,MS-496,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,Surgical,Relative Weights,"$23,465.75 ",IP,"2,420.00","41,136.48",,,,,,
Aetna Commercial,DRG,MS-497,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,Surgical,Relative Weights,"$16,896.95 ",IP,"2,420.00","29,621.09",,,,,,
Aetna Commercial,DRG,MS-498,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,Surgical,Relative Weights,"$28,153.15 ",IP,"2,420.00","49,353.70",,,,,,
Aetna Commercial,DRG,MS-499,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,Surgical,Relative Weights,"$13,235.35 ",IP,"2,420.00","23,202.14",,,,,,
Aetna Commercial,DRG,MS-500,SOFT TISSUE PROCEDURES WITH MCC,Surgical,Relative Weights,"$34,674.80 ",IP,"2,420.00","60,786.43",,,,,,
Aetna Commercial,DRG,MS-501,SOFT TISSUE PROCEDURES WITH CC,Surgical,Relative Weights,"$19,297.00 ",IP,"2,420.00","33,828.48",,,,,,
Aetna Commercial,DRG,MS-502,SOFT TISSUE PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$15,188.05 ",IP,"2,420.00","26,625.31",,,,,,
Aetna Commercial,DRG,MS-503,FOOT PROCEDURES WITH MCC,Surgical,Relative Weights,"$31,240.90 ",IP,"2,420.00","54,766.66",,,,,,
Aetna Commercial,DRG,MS-504,FOOT PROCEDURES WITH CC,Surgical,Relative Weights,"$19,969.75 ",IP,"2,420.00","35,007.84",,,,,,
Aetna Commercial,DRG,MS-505,FOOT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$19,337.25 ",IP,"2,420.00","33,899.04",,,,,,
Aetna Commercial,DRG,MS-506,MAJOR THUMB OR JOINT PROCEDURES,Surgical,Relative Weights,"$15,393.90 ",IP,"2,420.00","26,986.18",,,,,,
Aetna Commercial,DRG,MS-507,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W CC/MCC,Surgical,Relative Weights,"$24,150.00 ",IP,"2,420.00","42,336.00",,,,,,
Aetna Commercial,DRG,MS-508,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$17,921.60 ",IP,"2,420.00","31,417.34",,,,,,
Aetna Commercial,DRG,MS-509,ARTHROSCOPY,Surgical,Relative Weights,"$16,004.55 ",IP,"2,420.00","28,056.67",,,,,,
Aetna Commercial,DRG,MS-510,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH MCC,Surgical,Relative Weights,"$32,062.00 ",IP,"2,420.00","56,206.08",,,,,,
Aetna Commercial,DRG,MS-511,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH CC,Surgical,Relative Weights,"$21,668.30 ",IP,"2,420.00","37,985.47",,,,,,
Aetna Commercial,DRG,MS-512,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$17,408.70 ",IP,"2,420.00","30,518.21",,,,,,
Aetna Commercial,DRG,MS-513,HAND OR WRIST PROCEDURES- EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$18,136.65 ",IP,"2,420.00","31,794.34",,,,,,
Aetna Commercial,DRG,MS-514,HAND OR WRIST PROCEDURES -  EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$12,268.20 ",IP,"2,420.00","21,506.69",,,,,,
Aetna Commercial,DRG,MS-515,OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W MCC,Surgical,Relative Weights,"$36,271.00 ",IP,"2,420.00","63,584.64",,,,,,
Aetna Commercial,DRG,MS-516,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$22,299.65 ",IP,"2,420.00","39,092.26",,,,,,
Aetna Commercial,DRG,MS-517,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$16,275.95 ",IP,"2,420.00","28,532.45",,,,,,
Aetna Commercial,DRG,MS-518,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,Surgical,Relative Weights,"$39,198.90 ",IP,"10,289.00","68,717.38",,,,,,
Aetna Commercial,DRG,MS-519,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,Surgical,Relative Weights,"$21,950.05 ",IP,"10,289.00","38,479.39",,,,,,
Aetna Commercial,DRG,MS-520,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,Surgical,Relative Weights,"$15,387.00 ",IP,"8,282.98","26,974.08",,,,,,
Aetna Commercial,DRG,MS-533,FRACTURES OF FEMUR WITH MCC,Surgical,Relative Weights,"$16,783.10 ",IP,"2,420.00","29,421.50",,,,,,
Aetna Commercial,DRG,MS-534,FRACTURES OF FEMUR WITHOUT MCC,Surgical,Relative Weights,"$8,944.70 ",IP,"2,420.00","15,680.45",,,,,,
Aetna Commercial,DRG,MS-535,FRACTURES OF HIP AND PELVIS WITH MCC,Surgical,Relative Weights,"$14,111.65 ",IP,"2,420.00","24,738.34",,,,,,
Aetna Commercial,DRG,MS-536,FRACTURES OF HIP AND PELVIS WITHOUT MCC,Surgical,Relative Weights,"$8,722.75 ",IP,"2,420.00","15,291.36",,,,,,
Aetna Commercial,DRG,MS-537,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITH CC/MCC,Surgical,Relative Weights,"$10,475.35 ",IP,"2,420.00","18,363.74",,,,,,
Aetna Commercial,DRG,MS-538,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITHOUT CC/MCC,Surgical,Relative Weights,"$8,291.50 ",IP,"2,420.00","14,535.36",,,,,,
Aetna Commercial,DRG,MS-539,OSTEOMYELITIS WITH MCC,Surgical,Relative Weights,"$21,679.80 ",IP,"2,420.00","38,005.63",,,,,,
Aetna Commercial,DRG,MS-540,OSTEOMYELITIS WITH CC,Surgical,Relative Weights,"$14,950.00 ",IP,"2,420.00","26,208.00",,,,,,
Aetna Commercial,DRG,MS-541,OSTEOMYELITIS WITHOUT CC/MCC,Surgical,Relative Weights,"$10,427.05 ",IP,"2,420.00","18,279.07",,,,,,
Aetna Commercial,DRG,MS-542,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,Surgical,Relative Weights,"$20,985.20 ",IP,"2,420.00","36,787.97",,,,,,
Aetna Commercial,DRG,MS-543,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,Surgical,Relative Weights,"$12,147.45 ",IP,"2,420.00","21,295.01",,,,,,
Aetna Commercial,DRG,MS-544,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$8,721.60 ",IP,"2,420.00","15,289.34",,,,,,
Aetna Commercial,DRG,MS-545,CONNECTIVE TISSUE DISORDERS WITH MCC,Surgical,Relative Weights,"$29,072.00 ",IP,"2,420.00","50,964.48",,,,,,
Aetna Commercial,DRG,MS-546,CONNECTIVE TISSUE DISORDERS WITH CC,Surgical,Relative Weights,"$13,839.10 ",IP,"2,420.00","24,260.54",,,,,,
Aetna Commercial,DRG,MS-547,CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$9,316.15 ",IP,"2,420.00","16,331.62",,,,,,
Aetna Commercial,DRG,MS-548,SEPTIC ARTHRITIS WITH MCC,Surgical,Relative Weights,"$22,807.95 ",IP,"2,420.00","39,983.33",,,,,,
Aetna Commercial,DRG,MS-549,SEPTIC ARTHRITIS W CC,Surgical,Relative Weights,"$13,720.65 ",IP,"2,420.00","24,052.90",,,,,,
Aetna Commercial,DRG,MS-550,SEPTIC ARTHRITIS W/O CC/MCC,Surgical,Relative Weights,"$9,936.00 ",IP,"2,420.00","17,418.24",,,,,,
Aetna Commercial,DRG,MS-551,MEDICAL BACK PROBLEMS WITH MCC,Surgical,Relative Weights,"$18,278.10 ",IP,"2,420.00","32,042.30",,,,,,
Aetna Commercial,DRG,MS-552,MEDICAL BACK PROBLEMS WITHOUT MCC,Surgical,Relative Weights,"$10,486.85 ",IP,"2,420.00","18,383.90",,,,,,
Aetna Commercial,DRG,MS-553,BONE DISEASES AND ARTHROPATHIES WITH MCC,Surgical,Relative Weights,"$14,783.25 ",IP,"2,420.00","25,915.68",,,,,,
Aetna Commercial,DRG,MS-554,BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,Surgical,Relative Weights,"$9,052.80 ",IP,"2,420.00","15,869.95",,,,,,
Aetna Commercial,DRG,MS-555,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Surgical,Relative Weights,"$15,125.95 ",IP,"2,420.00","26,516.45",,,,,,
Aetna Commercial,DRG,MS-556,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,Surgical,Relative Weights,"$9,105.70 ",IP,"2,420.00","15,962.69",,,,,,
Aetna Commercial,DRG,MS-557,TENDONITIS -  MYOSITIS AND BURSITIS WITH MCC,Surgical,Relative Weights,"$16,769.30 ",IP,"2,420.00","29,397.31",,,,,,
Aetna Commercial,DRG,MS-558,TENDONITIS- MYOSITIS AND BURSITIS WITHOUT MCC,Surgical,Relative Weights,"$9,906.10 ",IP,"2,420.00","17,365.82",,,,,,
Aetna Commercial,DRG,MS-559,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Surgical,Relative Weights,"$20,720.70 ",IP,"2,420.00","36,324.29",,,,,,
Aetna Commercial,DRG,MS-560,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Surgical,Relative Weights,"$12,000.25 ",IP,"2,420.00","21,036.96",,,,,,
Aetna Commercial,DRG,MS-561,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Surgical,Relative Weights,"$8,595.10 ",IP,"2,420.00","15,067.58",,,,,,
Aetna Commercial,DRG,MS-562,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITH MCC,Surgical,Relative Weights,"$15,491.65 ",IP,"2,420.00","27,157.54",,,,,,
Aetna Commercial,DRG,MS-563,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITHOUT MCC,Surgical,Relative Weights,"$9,821.00 ",IP,"2,420.00","17,216.64",,,,,,
Aetna Commercial,DRG,MS-564,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,Surgical,Relative Weights,"$17,388.00 ",IP,"2,420.00","30,481.92",,,,,,
Aetna Commercial,DRG,MS-565,OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W CC,Surgical,Relative Weights,"$11,275.75 ",IP,"2,420.00","19,766.88",,,,,,
Aetna Commercial,DRG,MS-566,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,713.55 ",IP,"2,420.00","15,275.23",,,,,,
Aetna Commercial,DRG,MS-570,SKIN DEBRIDEMENT WITH MCC,Surgical,Relative Weights,"$33,041.80 ",IP,"2,420.00","57,923.71",,,,,,
Aetna Commercial,DRG,MS-571,SKIN DEBRIDEMENT WITH CC,Surgical,Relative Weights,"$19,231.45 ",IP,"2,420.00","33,713.57",,,,,,
Aetna Commercial,DRG,MS-572,SKIN DEBRIDEMENT WITHOUT CC/MCC,Surgical,Relative Weights,"$12,899.55 ",IP,"2,420.00","22,613.47",,,,,,
Aetna Commercial,DRG,MS-573,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,Surgical,Relative Weights,"$61,125.95 ",IP,"2,420.00","107,156.45",,,,,,
Aetna Commercial,DRG,MS-574,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,Surgical,Relative Weights,"$35,900.70 ",IP,"2,420.00","62,935.49",,,,,,
Aetna Commercial,DRG,MS-575,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS W/O CC/MCC,Surgical,Relative Weights,"$20,205.50 ",IP,"2,420.00","35,421.12",,,,,,
Aetna Commercial,DRG,MS-576,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,Surgical,Relative Weights,"$55,765.80 ",IP,"2,420.00","97,759.87",,,,,,
Aetna Commercial,DRG,MS-577,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,Surgical,Relative Weights,"$27,779.40 ",IP,"2,420.00","48,698.50",,,,,,
Aetna Commercial,DRG,MS-578,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,Surgical,Relative Weights,"$18,715.10 ",IP,"2,420.00","32,808.38",,,,,,
Aetna Commercial,DRG,MS-579,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC,Surgical,Relative Weights,"$34,340.15 ",IP,"2,420.00","60,199.78",,,,,,
Aetna Commercial,DRG,MS-580,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC,Surgical,Relative Weights,"$18,500.05 ",IP,"2,420.00","32,431.39",,,,,,
Aetna Commercial,DRG,MS-581,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$14,430.20 ",IP,"2,420.00","25,296.77",,,,,,
Aetna Commercial,DRG,MS-582,MASTECTOMY FOR MALIGNANCY WITH CC/MCC,Surgical,Relative Weights,"$18,155.05 ",IP,"2,420.00","31,826.59",,,,,,
Aetna Commercial,DRG,MS-583,MASTECTOMY FOR MALIGNANCY W/O CC/MCC,Surgical,Relative Weights,"$16,806.10 ",IP,"2,420.00","29,461.82",,,,,,
Aetna Commercial,DRG,MS-584,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$21,026.60 ",IP,"2,420.00","36,860.54",,,,,,
Aetna Commercial,DRG,MS-585,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$19,518.95 ",IP,"2,420.00","34,217.57",,,,,,
Aetna Commercial,DRG,MS-592,SKIN ULCERS WITH MCC,Surgical,Relative Weights,"$20,519.45 ",IP,"2,420.00","35,971.49",,,,,,
Aetna Commercial,DRG,MS-593,SKIN ULCERS WITH CC,Surgical,Relative Weights,"$13,199.70 ",IP,"2,420.00","23,139.65",,,,,,
Aetna Commercial,DRG,MS-594,SKIN ULCERS WITHOUT CC/MCC,Surgical,Relative Weights,"$9,311.55 ",IP,"2,420.00","16,323.55",,,,,,
Aetna Commercial,DRG,MS-595,MAJOR SKIN DISORDERS WITH MCC,Surgical,Relative Weights,"$23,374.90 ",IP,"2,420.00","40,977.22",,,,,,
Aetna Commercial,DRG,MS-596,MAJOR SKIN DISORDERS W/O MCC,Surgical,Relative Weights,"$11,202.15 ",IP,"2,420.00","19,637.86",,,,,,
Aetna Commercial,DRG,MS-597,MALIGNANT BREAST DISORDERS W MCC,Surgical,Relative Weights,"$19,468.35 ",IP,"2,420.00","34,128.86",,,,,,
Aetna Commercial,DRG,MS-598,MALIGNANT BREAST DISORDERS WITH CC,Surgical,Relative Weights,"$12,518.90 ",IP,"2,420.00","21,946.18",,,,,,
Aetna Commercial,DRG,MS-599,MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$7,997.10 ",IP,"2,420.00","14,019.26",,,,,,
Aetna Commercial,DRG,MS-600,NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,Surgical,Relative Weights,"$11,030.80 ",IP,"2,420.00","19,337.47",,,,,,
Aetna Commercial,DRG,MS-601,NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$7,116.20 ",IP,"2,420.00","12,475.01",,,,,,
Aetna Commercial,DRG,MS-602,CELLULITIS WITH MCC,Surgical,Relative Weights,"$16,442.70 ",IP,"2,420.00","28,824.77",,,,,,
Aetna Commercial,DRG,MS-603,CELLULITIS WITHOUT MCC,Surgical,Relative Weights,"$9,700.25 ",IP,"2,420.00","17,004.96",,,,,,
Aetna Commercial,DRG,MS-604,TRAUMA TO THE SKIN -  SUBCUTANEOUS TISSUE AND BREAST WITH MCC,Surgical,Relative Weights,"$16,841.75 ",IP,"2,420.00","29,524.32",,,,,,
Aetna Commercial,DRG,MS-605,TRAUMA TO THE SKIN- SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC,Surgical,Relative Weights,"$10,070.55 ",IP,"2,420.00","17,654.11",,,,,,
Aetna Commercial,DRG,MS-606,MINOR SKIN DISORDERS WITH MCC,Surgical,Relative Weights,"$17,198.25 ",IP,"2,420.00","30,149.28",,,,,,
Aetna Commercial,DRG,MS-607,MINOR SKIN DISORDERS WITHOUT MCC,Surgical,Relative Weights,"$9,500.15 ",IP,"2,420.00","16,654.18",,,,,,
Aetna Commercial,DRG,MS-614,ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$27,982.95 ",IP,"2,420.00","49,055.33",,,,,,
Aetna Commercial,DRG,MS-615,ADRENAL & PITUITARY PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$17,067.15 ",IP,"2,420.00","29,919.46",,,,,,
Aetna Commercial,DRG,MS-616,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Surgical,Relative Weights,"$46,009.20 ",IP,"2,420.00","80,656.13",,,,,,
Aetna Commercial,DRG,MS-617,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Surgical,Relative Weights,"$23,589.95 ",IP,"2,420.00","41,354.21",,,,,,
Aetna Commercial,DRG,MS-618,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$14,426.75 ",IP,"2,420.00","25,290.72",,,,,,
Aetna Commercial,DRG,MS-619,O.R. PROCEDURES FOR OBESITY WITH MCC,Surgical,Relative Weights,"$35,402.75 ",IP,"2,420.00","62,062.56",,,,,,
Aetna Commercial,DRG,MS-620,O.R. PROCEDURES FOR OBESITY WITH CC,Surgical,Relative Weights,"$20,637.90 ",IP,"2,420.00","36,179.14",,,,,,
Aetna Commercial,DRG,MS-621,O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,Surgical,Relative Weights,"$18,078.00 ",IP,"2,420.00","31,691.52",,,,,,
Aetna Commercial,DRG,MS-622,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Surgical,Relative Weights,"$43,418.25 ",IP,"2,420.00","76,114.08",,,,,,
Aetna Commercial,DRG,MS-623,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE -  NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Surgical,Relative Weights,"$22,454.90 ",IP,"2,420.00","39,364.42",,,,,,
Aetna Commercial,DRG,MS-624,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$12,673.00 ",IP,"2,420.00","22,216.32",,,,,,
Aetna Commercial,DRG,MS-625,THYROID- PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$33,638.65 ",IP,"2,420.00","58,970.02",,,,,,
Aetna Commercial,DRG,MS-626,THYROID -  PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC,Surgical,Relative Weights,"$19,352.20 ",IP,"2,420.00","33,925.25",,,,,,
Aetna Commercial,DRG,MS-627,THYROID -  PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$13,129.55 ",IP,"2,420.00","23,016.67",,,,,,
Aetna Commercial,DRG,MS-628,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$42,426.95 ",IP,"2,420.00","74,376.29",,,,,,
Aetna Commercial,DRG,MS-629,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$26,712.20 ",IP,"2,420.00","46,827.65",,,,,,
Aetna Commercial,DRG,MS-630,OTHER ENDOCRINE - NUTRIT & METAB O.R. PROC W/O CC/MCC,Surgical,Relative Weights,"$16,661.20 ",IP,"2,420.00","29,207.81",,,,,,
Aetna Commercial,DRG,MS-637,DIABETES WITH MCC,Surgical,Relative Weights,"$15,935.55 ",IP,"2,420.00","27,935.71",,,,,,
Aetna Commercial,DRG,MS-638,DIABETES WITH CC,Surgical,Relative Weights,"$10,167.15 ",IP,"2,420.00","17,823.46",,,,,,
Aetna Commercial,DRG,MS-639,DIABETES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,051.80 ",IP,"2,420.00","12,362.11",,,,,,
Aetna Commercial,DRG,MS-640,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITH MCC,Surgical,Relative Weights,"$13,963.30 ",IP,"2,420.00","24,478.27",,,,,,
Aetna Commercial,DRG,MS-641,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITHOUT MCC,Surgical,Relative Weights,"$8,700.90 ",IP,"2,420.00","15,253.06",,,,,,
Aetna Commercial,DRG,MS-642,INBORN AND OTHER DISORDERS OF METABOLISM,Surgical,Relative Weights,"$13,981.70 ",IP,"2,420.00","24,510.53",,,,,,
Aetna Commercial,DRG,MS-643,ENDOCRINE DISORDERS WITH MCC,Surgical,Relative Weights,"$18,693.25 ",IP,"2,420.00","32,770.08",,,,,,
Aetna Commercial,DRG,MS-644,ENDOCRINE DISORDERS WITH CC,Surgical,Relative Weights,"$11,823.15 ",IP,"2,420.00","20,726.50",,,,,,
Aetna Commercial,DRG,MS-645,ENDOCRINE DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$8,799.80 ",IP,"2,420.00","15,426.43",,,,,,
Aetna Commercial,DRG,MS-652,KIDNEY TRANSPLANT,Surgical,Relative Weights,"$38,926.35 ",IP,"2,420.00","68,239.58",,,,,,
Aetna Commercial,DRG,MS-653,MAJOR BLADDER PROCEDURES WITH MCC,Surgical,Relative Weights,"$63,669.75 ",IP,"2,420.00","111,615.84",,,,,,
Aetna Commercial,DRG,MS-654,MAJOR BLADDER PROCEDURES WITH CC,Surgical,Relative Weights,"$32,340.30 ",IP,"2,420.00","56,693.95",,,,,,
Aetna Commercial,DRG,MS-655,MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$23,717.60 ",IP,"2,420.00","41,577.98",,,,,,
Aetna Commercial,DRG,MS-656,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,Surgical,Relative Weights,"$37,496.90 ",IP,"2,420.00","65,733.70",,,,,,
Aetna Commercial,DRG,MS-657,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,Surgical,Relative Weights,"$22,243.30 ",IP,"2,420.00","38,993.47",,,,,,
Aetna Commercial,DRG,MS-658,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,Surgical,Relative Weights,"$18,053.85 ",IP,"2,420.00","31,649.18",,,,,,
Aetna Commercial,DRG,MS-659,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,Surgical,Relative Weights,"$30,817.70 ",IP,"2,420.00","54,024.77",,,,,,
Aetna Commercial,DRG,MS-660,KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC,Surgical,Relative Weights,"$16,338.05 ",IP,"2,420.00","28,641.31",,,,,,
Aetna Commercial,DRG,MS-661,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,Surgical,Relative Weights,"$12,536.15 ",IP,"2,420.00","21,976.42",,,,,,
Aetna Commercial,DRG,MS-662,MINOR BLADDER PROCEDURES WITH MCC,Surgical,Relative Weights,"$36,394.05 ",IP,"2,420.00","63,800.35",,,,,,
Aetna Commercial,DRG,MS-663,MINOR BLADDER PROCEDURES WITH CC,Surgical,Relative Weights,"$17,519.10 ",IP,"2,420.00","30,711.74",,,,,,
Aetna Commercial,DRG,MS-664,MINOR BLADDER PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$12,725.90 ",IP,"2,420.00","22,309.06",,,,,,
Aetna Commercial,DRG,MS-665,PROSTATECTOMY WITH MCC,Surgical,Relative Weights,"$34,137.75 ",IP,"2,420.00","59,844.96",,,,,,
Aetna Commercial,DRG,MS-666,PROSTATECTOMY WITH CC,Surgical,Relative Weights,"$20,344.65 ",IP,"2,420.00","35,665.06",,,,,,
Aetna Commercial,DRG,MS-667,PROSTATECTOMY W/O CC/MCC,Surgical,Relative Weights,"$10,795.05 ",IP,"2,420.00","18,924.19",,,,,,
Aetna Commercial,DRG,MS-668,TRANSURETHRAL PROCEDURES W MCC,Surgical,Relative Weights,"$32,065.45 ",IP,"2,420.00","56,212.13",,,,,,
Aetna Commercial,DRG,MS-669,TRANSURETHRAL PROCEDURES WITH CC,Surgical,Relative Weights,"$17,775.55 ",IP,"2,420.00","31,161.31",,,,,,
Aetna Commercial,DRG,MS-670,TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$11,255.05 ",IP,"2,420.00","19,730.59",,,,,,
Aetna Commercial,DRG,MS-671,URETHRAL PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$21,017.40 ",IP,"2,420.00","36,844.42",,,,,,
Aetna Commercial,DRG,MS-672,URETHRAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$11,881.80 ",IP,"2,420.00","20,829.31",,,,,,
Aetna Commercial,DRG,MS-673,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,Surgical,Relative Weights,"$41,107.90 ",IP,"2,420.00","72,063.94",,,,,,
Aetna Commercial,DRG,MS-674,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,Surgical,Relative Weights,"$28,108.30 ",IP,"2,420.00","49,275.07",,,,,,
Aetna Commercial,DRG,MS-675,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$18,768.00 ",IP,"2,420.00","32,901.12",,,,,,
Aetna Commercial,DRG,MS-682,RENAL FAILURE WITH MCC,Surgical,Relative Weights,"$16,997.00 ",IP,"2,420.00","29,796.48",,,,,,
Aetna Commercial,DRG,MS-683,RENAL FAILURE WITH CC,Surgical,Relative Weights,"$10,318.95 ",IP,"2,420.00","18,089.57",,,,,,
Aetna Commercial,DRG,MS-684,RENAL FAILURE WITHOUT CC/MCC,Surgical,Relative Weights,"$7,075.95 ",IP,"2,420.00","12,404.45",,,,,,
Aetna Commercial,DRG,MS-686,KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,Surgical,Relative Weights,"$20,195.15 ",IP,"2,420.00","35,402.98",,,,,,
Aetna Commercial,DRG,MS-687,KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,Surgical,Relative Weights,"$12,104.90 ",IP,"2,420.00","21,220.42",,,,,,
Aetna Commercial,DRG,MS-688,KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,Surgical,Relative Weights,"$8,869.95 ",IP,"2,420.00","15,549.41",,,,,,
Aetna Commercial,DRG,MS-689,KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,Surgical,Relative Weights,"$12,863.90 ",IP,"2,420.00","22,550.98",,,,,,
Aetna Commercial,DRG,MS-690,KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,Surgical,Relative Weights,"$9,094.20 ",IP,"2,420.00","15,942.53",,,,,,
Aetna Commercial,DRG,MS-693,URINARY STONES WITH MCC,Surgical,Relative Weights,"$15,562.95 ",IP,"2,420.00","27,282.53",,,,,,
Aetna Commercial,DRG,MS-694,URINARY STONES WITHOUT MCC,Surgical,Relative Weights,"$8,514.60 ",IP,"2,420.00","14,926.46",,,,,,
Aetna Commercial,DRG,MS-695,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,Surgical,Relative Weights,"$13,481.45 ",IP,"2,420.00","23,633.57",,,,,,
Aetna Commercial,DRG,MS-696,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,Surgical,Relative Weights,"$7,813.10 ",IP,"2,420.00","13,696.70",,,,,,
Aetna Commercial,DRG,MS-697,URETHRAL STRICTURE,Surgical,Relative Weights,"$11,199.85 ",IP,"2,420.00","19,633.82",,,,,,
Aetna Commercial,DRG,MS-698,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,Surgical,Relative Weights,"$18,613.90 ",IP,"2,420.00","32,630.98",,,,,,
Aetna Commercial,DRG,MS-699,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,Surgical,Relative Weights,"$11,876.05 ",IP,"2,420.00","20,819.23",,,,,,
Aetna Commercial,DRG,MS-700,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,529.55 ",IP,"2,420.00","14,952.67",,,,,,
Aetna Commercial,DRG,MS-707,MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$21,503.85 ",IP,"2,420.00","37,697.18",,,,,,
Aetna Commercial,DRG,MS-708,MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$16,698.00 ",IP,"2,420.00","29,272.32",,,,,,
Aetna Commercial,DRG,MS-709,PENIS PROCEDURES W CC/MCC,Surgical,Relative Weights,"$27,664.40 ",IP,"2,420.00","48,496.90",,,,,,
Aetna Commercial,DRG,MS-710,PENIS PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$17,661.70 ",IP,"2,420.00","30,961.73",,,,,,
Aetna Commercial,DRG,MS-711,TESTES PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$24,646.80 ",IP,"2,420.00","43,206.91",,,,,,
Aetna Commercial,DRG,MS-712,TESTES PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$11,732.30 ",IP,"2,420.00","20,567.23",,,,,,
Aetna Commercial,DRG,MS-713,TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,Surgical,Relative Weights,"$16,813.00 ",IP,"2,420.00","29,473.92",,,,,,
Aetna Commercial,DRG,MS-714,TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,Surgical,Relative Weights,"$10,527.10 ",IP,"2,420.00","18,454.46",,,,,,
Aetna Commercial,DRG,MS-715,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,Surgical,Relative Weights,"$24,569.75 ",IP,"2,420.00","43,071.84",,,,,,
Aetna Commercial,DRG,MS-716,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$16,853.25 ",IP,"2,420.00","29,544.48",,,,,,
Aetna Commercial,DRG,MS-717,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,Surgical,Relative Weights,"$20,289.45 ",IP,"2,420.00","35,568.29",,,,,,
Aetna Commercial,DRG,MS-718,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$14,023.10 ",IP,"2,420.00","24,583.10",,,,,,
Aetna Commercial,DRG,MS-722,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH MCC,Surgical,Relative Weights,"$20,756.35 ",IP,"2,420.00","36,386.78",,,,,,
Aetna Commercial,DRG,MS-723,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH CC,Surgical,Relative Weights,"$12,735.10 ",IP,"2,420.00","22,325.18",,,,,,
Aetna Commercial,DRG,MS-724,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Surgical,Relative Weights,"$6,789.60 ",IP,"2,420.00","11,902.46",,,,,,
Aetna Commercial,DRG,MS-725,BENIGN PROSTATIC HYPERTROPHY WITH MCC,Surgical,Relative Weights,"$14,437.10 ",IP,"2,420.00","25,308.86",,,,,,
Aetna Commercial,DRG,MS-726,BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,Surgical,Relative Weights,"$8,794.05 ",IP,"2,420.00","15,416.35",,,,,,
Aetna Commercial,DRG,MS-727,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,Surgical,Relative Weights,"$16,413.95 ",IP,"2,420.00","28,774.37",,,,,,
Aetna Commercial,DRG,MS-728,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,Surgical,Relative Weights,"$9,228.75 ",IP,"2,420.00","16,178.40",,,,,,
Aetna Commercial,DRG,MS-729,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,Surgical,Relative Weights,"$12,349.85 ",IP,"2,420.00","21,649.82",,,,,,
Aetna Commercial,DRG,MS-730,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,263.40 ",IP,"2,420.00","12,733.06",,,,,,
Aetna Commercial,DRG,MS-734,PELVIC EVISCERATION -  RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC,Surgical,Relative Weights,"$25,206.85 ",IP,"2,420.00","44,188.70",,,,,,
Aetna Commercial,DRG,MS-735,PELVIC EVISCERATION -  RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC,Surgical,Relative Weights,"$15,803.30 ",IP,"2,420.00","27,703.87",,,,,,
Aetna Commercial,DRG,MS-736,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,Surgical,Relative Weights,"$49,690.35 ",IP,"2,420.00","87,109.34",,,,,,
Aetna Commercial,DRG,MS-737,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,Surgical,Relative Weights,"$22,851.65 ",IP,"2,420.00","40,059.94",,,,,,
Aetna Commercial,DRG,MS-738,UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY W/O CC/MCC,Surgical,Relative Weights,"$15,857.35 ",IP,"2,420.00","27,798.62",,,,,,
Aetna Commercial,DRG,MS-739,UTERINE -ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W MCC,Surgical,Relative Weights,"$43,061.75 ",IP,"2,420.00","75,489.12",,,,,,
Aetna Commercial,DRG,MS-740,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,Surgical,Relative Weights,"$20,526.35 ",IP,"2,420.00","35,983.58",,,,,,
Aetna Commercial,DRG,MS-741,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$15,289.25 ",IP,"2,420.00","26,802.72",,,,,,
Aetna Commercial,DRG,MS-742,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,Surgical,Relative Weights,"$19,429.25 ",IP,"2,420.00","34,060.32",,,,,,
Aetna Commercial,DRG,MS-743,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$13,207.75 ",IP,"2,420.00","23,153.76",,,,,,
Aetna Commercial,DRG,MS-744,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC,Surgical,Relative Weights,"$20,015.75 ",IP,"2,420.00","35,088.48",,,,,,
Aetna Commercial,DRG,MS-745,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC,Surgical,Relative Weights,"$12,250.95 ",IP,"2,420.00","21,476.45",,,,,,
Aetna Commercial,DRG,MS-746,VAGINA -  CERVIX AND VULVA PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$18,756.50 ",IP,"2,420.00","32,880.96",,,,,,
Aetna Commercial,DRG,MS-747,VAGINA- CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,720.30 ",IP,"2,420.00","18,793.15",,,,,,
Aetna Commercial,DRG,MS-748,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,Surgical,Relative Weights,"$15,199.55 ",IP,"2,420.00","26,645.47",,,,,,
Aetna Commercial,DRG,MS-749,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$29,810.30 ",IP,"2,420.00","52,258.75",,,,,,
Aetna Commercial,DRG,MS-750,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$15,308.80 ",IP,"2,420.00","26,836.99",,,,,,
Aetna Commercial,DRG,MS-754,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH MCC,Surgical,Relative Weights,"$20,261.85 ",IP,"2,420.00","35,519.90",,,,,,
Aetna Commercial,DRG,MS-755,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH CC,Surgical,Relative Weights,"$11,773.70 ",IP,"2,420.00","20,639.81",,,,,,
Aetna Commercial,DRG,MS-756,MALIGNANCY - FEMALE REPRODUCTIVE SYSTEM W/O CC/MCC,Surgical,Relative Weights,"$10,083.20 ",IP,"2,420.00","17,676.29",,,,,,
Aetna Commercial,DRG,MS-757,INFECTIONS - FEMALE REPRODUCTIVE SYSTEM W MCC,Surgical,Relative Weights,"$16,333.45 ",IP,"2,420.00","28,633.25",,,,,,
Aetna Commercial,DRG,MS-758,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITH CC,Surgical,Relative Weights,"$11,102.10 ",IP,"2,420.00","19,462.46",,,,,,
Aetna Commercial,DRG,MS-759,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Surgical,Relative Weights,"$7,593.45 ",IP,"2,420.00","13,311.65",,,,,,
Aetna Commercial,DRG,MS-760,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,Surgical,Relative Weights,"$10,378.75 ",IP,"2,420.00","18,194.40",,,,,,
Aetna Commercial,DRG,MS-761,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$6,502.10 ",IP,"2,420.00","11,398.46",,,,,,
Aetna Commercial,DRG,MS-768,VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C,Surgical,Relative Weights,"$11,586.25 ",IP,"2,420.00","20,311.20",,,,,,
Aetna Commercial,DRG,MS-769,POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,Surgical,Relative Weights,"$16,594.50 ",IP,"2,420.00","29,090.88",,,,,,
Aetna Commercial,DRG,MS-770,ABORTION WITH D&C- ASPIRATION CURETTAGE OR HYSTEROTOMY,Surgical,Relative Weights,"$9,042.45 ",IP,"2,420.00","15,851.81",,,,,,
Aetna Commercial,DRG,MS-776,POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,Surgical,Relative Weights,"$8,163.85 ",IP,"2,420.00","14,311.58",,,,,,
Aetna Commercial,DRG,MS-779,ABORTION WITHOUT D&C,Surgical,Relative Weights,"$13,130.70 ",IP,"2,420.00","23,018.69",,,,,,
Aetna Commercial,DRG,MS-783,CESAREAN SECTION WITH STERILIZATION WITH MCC,Surgical,Relative Weights,"$24,665.20 ",IP,"2,420.00","43,239.17",,,,,,
Aetna Commercial,DRG,MS-784,CESAREAN SECTION WITH STERILIZATION WITH CC,Surgical,Relative Weights,"$12,019.80 ",IP,"2,420.00","21,071.23",,,,,,
Aetna Commercial,DRG,MS-785,CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,Surgical,Relative Weights,"$9,871.60 ",IP,"2,420.00","17,305.34",,,,,,
Aetna Commercial,DRG,MS-786,CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,Surgical,Relative Weights,"$19,716.75 ",IP,"2,420.00","34,564.32",,,,,,
Aetna Commercial,DRG,MS-787,CESAREAN SECTION WITHOUT STERILIZATION WITH CC,Surgical,Relative Weights,"$12,023.25 ",IP,"2,420.00","21,077.28",,,,,,
Aetna Commercial,DRG,MS-788,CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,Surgical,Relative Weights,"$10,421.30 ",IP,"2,420.00","18,268.99",,,,,,
Aetna Commercial,DRG,MS-789,NEONATES- DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY,Surgical,Relative Weights,"$19,435.00 ",IP,"2,420.00","34,070.40",,,,,,
Aetna Commercial,DRG,MS-790,EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME- NEONATE,Surgical,Relative Weights,"$64,089.50 ",IP,"2,420.00","112,351.68",,,,,,
Aetna Commercial,DRG,MS-791,PREMATURITY W MAJOR PROBLEMS,Surgical,Relative Weights,"$43,771.30 ",IP,"2,420.00","76,732.99",,,,,,
Aetna Commercial,DRG,MS-792,PREMATURITY W/O MAJOR PROBLEMS,Surgical,Relative Weights,"$26,409.75 ",IP,"2,420.00","46,297.44",,,,,,
Aetna Commercial,DRG,MS-793,FULL TERM NEONATE WITH MAJOR PROBLEMS,Surgical,Relative Weights,"$44,961.55 ",IP,"2,420.00","78,819.55",,,,,,
Aetna Commercial,DRG,MS-794,NEONATE WITH OTHER SIGNIFICANT PROBLEMS,Surgical,Relative Weights,"$15,913.70 ",IP,"2,420.00","27,897.41",,,,,,
Aetna Commercial,DRG,MS-795,NORMAL NEWBORN,Surgical,Relative Weights,"$2,153.95 ",IP,"1,113.70","3,775.97",,,,,,
Aetna Commercial,DRG,MS-796,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,Surgical,Relative Weights,"$22,681.45 ",IP,"2,420.00","39,761.57",,,,,,
Aetna Commercial,DRG,MS-797,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,Surgical,Relative Weights,"$9,922.20 ",IP,"2,420.00","17,394.05",,,,,,
Aetna Commercial,DRG,MS-798,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,Surgical,Relative Weights,"$9,922.20 ",IP,"2,420.00","17,394.05",,,,,,
Aetna Commercial,DRG,MS-799,SPLENECTOMY WITH MCC,Surgical,Relative Weights,"$56,859.45 ",IP,"2,420.00","99,677.09",,,,,,
Aetna Commercial,DRG,MS-800,SPLENECTOMY WITH CC,Surgical,Relative Weights,"$32,683.00 ",IP,"2,420.00","57,294.72",,,,,,
Aetna Commercial,DRG,MS-801,SPLENECTOMY WITHOUT CC/MCC,Surgical,Relative Weights,"$21,541.80 ",IP,"2,420.00","37,763.71",,,,,,
Aetna Commercial,DRG,MS-802,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,Surgical,Relative Weights,"$36,252.60 ",IP,"2,420.00","63,552.38",,,,,,
Aetna Commercial,DRG,MS-803,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,Surgical,Relative Weights,"$20,488.40 ",IP,"2,420.00","35,917.06",,,,,,
Aetna Commercial,DRG,MS-804,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,Surgical,Relative Weights,"$15,669.90 ",IP,"2,420.00","27,470.02",,,,,,
Aetna Commercial,DRG,MS-805,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,Surgical,Relative Weights,"$11,968.05 ",IP,"2,420.00","20,980.51",,,,,,
Aetna Commercial,DRG,MS-806,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,Surgical,Relative Weights,"$8,155.80 ",IP,"2,420.00","14,297.47",,,,,,
Aetna Commercial,DRG,MS-807,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,Surgical,Relative Weights,"$7,208.20 ",IP,"2,420.00","12,636.29",,,,,,
Aetna Commercial,DRG,MS-808,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,Surgical,Relative Weights,"$24,490.40 ",IP,"2,420.00","42,932.74",,,,,,
Aetna Commercial,DRG,MS-809,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,Surgical,Relative Weights,"$13,982.85 ",IP,"2,420.00","24,512.54",,,,,,
Aetna Commercial,DRG,MS-810,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$10,757.10 ",IP,"2,420.00","18,857.66",,,,,,
Aetna Commercial,DRG,MS-811,RED BLOOD CELL DISORDERS WITH MCC,Surgical,Relative Weights,"$15,413.45 ",IP,"2,420.00","27,020.45",,,,,,
Aetna Commercial,DRG,MS-812,RED BLOOD CELL DISORDERS WITHOUT MCC,Surgical,Relative Weights,"$10,013.05 ",IP,"2,420.00","17,553.31",,,,,,
Aetna Commercial,DRG,MS-813,COAGULATION DISORDERS,Surgical,Relative Weights,"$18,229.80 ",IP,"2,420.00","31,957.63",,,,,,
Aetna Commercial,DRG,MS-814,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,Surgical,Relative Weights,"$20,114.65 ",IP,"2,420.00","35,261.86",,,,,,
Aetna Commercial,DRG,MS-815,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,Surgical,Relative Weights,"$11,647.20 ",IP,"2,420.00","20,418.05",,,,,,
Aetna Commercial,DRG,MS-816,RETICULOENDOTHELIAL & IMMUNITY DISORDERS W/O CC/MCC,Surgical,Relative Weights,"$8,232.85 ",IP,"2,420.00","14,432.54",,,,,,
Aetna Commercial,DRG,MS-817,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$28,936.30 ",IP,"2,420.00","50,726.59",,,,,,
Aetna Commercial,DRG,MS-818,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$14,649.85 ",IP,"2,420.00","25,681.82",,,,,,
Aetna Commercial,DRG,MS-819,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$9,175.85 ",IP,"2,420.00","16,085.66",,,,,,
Aetna Commercial,DRG,MS-820,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$65,742.05 ",IP,"2,420.00","115,248.67",,,,,,
Aetna Commercial,DRG,MS-821,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$25,671.45 ",IP,"2,420.00","45,003.17",,,,,,
Aetna Commercial,DRG,MS-822,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$14,540.60 ",IP,"2,420.00","25,490.30",,,,,,
Aetna Commercial,DRG,MS-823,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,Surgical,Relative Weights,"$48,647.30 ",IP,"2,420.00","85,280.83",,,,,,
Aetna Commercial,DRG,MS-824,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,Surgical,Relative Weights,"$26,738.65 ",IP,"2,420.00","46,874.02",,,,,,
Aetna Commercial,DRG,MS-825,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$15,576.75 ",IP,"2,420.00","27,306.72",,,,,,
Aetna Commercial,DRG,MS-826,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$57,672.50 ",IP,"2,420.00","101,102.40",,,,,,
Aetna Commercial,DRG,MS-827,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$26,636.30 ",IP,"2,420.00","46,694.59",,,,,,
Aetna Commercial,DRG,MS-828,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$18,988.80 ",IP,"2,420.00","33,288.19",,,,,,
Aetna Commercial,DRG,MS-829,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$36,108.85 ",IP,"2,420.00","63,300.38",,,,,,
Aetna Commercial,DRG,MS-830,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$15,856.20 ",IP,"2,420.00","27,796.61",,,,,,
Aetna Commercial,DRG,MS-831,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$12,402.75 ",IP,"2,420.00","21,742.56",,,,,,
Aetna Commercial,DRG,MS-832,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$8,228.25 ",IP,"2,420.00","14,424.48",,,,,,
Aetna Commercial,DRG,MS-833,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,119.15 ",IP,"2,420.00","10,727.14",,,,,,
Aetna Commercial,DRG,MS-834,ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W MCC,Surgical,Relative Weights,"$67,188.75 ",IP,"2,420.00","117,784.80",,,,,,
Aetna Commercial,DRG,MS-835,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$23,324.30 ",IP,"2,420.00","40,888.51",,,,,,
Aetna Commercial,DRG,MS-836,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$15,152.40 ",IP,"2,420.00","26,562.82",,,,,,
Aetna Commercial,DRG,MS-837,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,Surgical,Relative Weights,"$68,894.20 ",IP,"2,420.00","120,774.53",,,,,,
Aetna Commercial,DRG,MS-838,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,Surgical,Relative Weights,"$25,160.85 ",IP,"2,420.00","44,108.06",,,,,,
Aetna Commercial,DRG,MS-839,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$14,676.30 ",IP,"2,420.00","25,728.19",,,,,,
Aetna Commercial,DRG,MS-840,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,Surgical,Relative Weights,"$36,744.80 ",IP,"2,420.00","64,415.23",,,,,,
Aetna Commercial,DRG,MS-841,LYMPHOMA & NON-ACUTE LEUKEMIA W CC,Surgical,Relative Weights,"$18,534.55 ",IP,"2,420.00","32,491.87",,,,,,
Aetna Commercial,DRG,MS-842,LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,Surgical,Relative Weights,"$13,185.90 ",IP,"2,420.00","23,115.46",,,,,,
Aetna Commercial,DRG,MS-843,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,Surgical,Relative Weights,"$21,939.70 ",IP,"2,420.00","38,461.25",,,,,,
Aetna Commercial,DRG,MS-844,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,Surgical,Relative Weights,"$13,892.00 ",IP,"2,420.00","24,353.28",,,,,,
Aetna Commercial,DRG,MS-845,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,Surgical,Relative Weights,"$9,957.85 ",IP,"2,420.00","17,456.54",,,,,,
Aetna Commercial,DRG,MS-846,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$30,205.90 ",IP,"2,420.00","52,952.26",,,,,,
Aetna Commercial,DRG,MS-847,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,Surgical,Relative Weights,"$15,132.85 ",IP,"2,420.00","26,528.54",,,,,,
Aetna Commercial,DRG,MS-848,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$11,286.10 ",IP,"2,420.00","19,785.02",,,,,,
Aetna Commercial,DRG,MS-849,RADIOTHERAPY,Surgical,Relative Weights,"$24,446.70 ",IP,"2,420.00","42,856.13",,,,,,
Aetna Commercial,DRG,MS-853,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$58,633.90 ",IP,"2,420.00","102,787.78",,,,,,
Aetna Commercial,DRG,MS-854,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$24,853.80 ",IP,"2,420.00","43,569.79",,,,,,
Aetna Commercial,DRG,MS-855,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$18,437.95 ",IP,"2,420.00","32,322.53",,,,,,
Aetna Commercial,DRG,MS-856,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$50,895.55 ",IP,"2,420.00","89,222.11",,,,,,
Aetna Commercial,DRG,MS-857,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$23,382.95 ",IP,"2,420.00","40,991.33",,,,,,
Aetna Commercial,DRG,MS-858,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$15,828.60 ",IP,"2,420.00","27,748.22",,,,,,
Aetna Commercial,DRG,MS-862,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W MCC,Surgical,Relative Weights,"$21,281.90 ",IP,"2,420.00","37,308.10",,,,,,
Aetna Commercial,DRG,MS-863,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W/O MCC,Surgical,Relative Weights,"$11,362.00 ",IP,"2,420.00","19,918.08",,,,,,
Aetna Commercial,DRG,MS-864,FEVER AND INFLAMMATORY CONDITIONS,Surgical,Relative Weights,"$9,745.10 ",IP,"2,420.00","17,083.58",,,,,,
Aetna Commercial,DRG,MS-865,VIRAL ILLNESS WITH MCC,Surgical,Relative Weights,"$16,022.95 ",IP,"2,420.00","28,088.93",,,,,,
Aetna Commercial,DRG,MS-866,VIRAL ILLNESS WITHOUT MCC,Surgical,Relative Weights,"$9,415.05 ",IP,"2,420.00","16,504.99",,,,,,
Aetna Commercial,DRG,MS-867,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,Surgical,Relative Weights,"$25,129.80 ",IP,"2,420.00","44,053.63",,,,,,
Aetna Commercial,DRG,MS-868,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,Surgical,Relative Weights,"$12,615.50 ",IP,"2,420.00","22,115.52",,,,,,
Aetna Commercial,DRG,MS-869,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,538.75 ",IP,"2,420.00","14,968.80",,,,,,
Aetna Commercial,DRG,MS-870,SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,Surgical,Relative Weights,"$72,729.45 ",IP,"2,420.00","127,497.89",,,,,,
Aetna Commercial,DRG,MS-871,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,Surgical,Relative Weights,"$21,462.45 ",IP,"2,420.00","37,624.61",,,,,,
Aetna Commercial,DRG,MS-872,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,Surgical,Relative Weights,"$11,951.95 ",IP,"2,420.00","20,952.29",,,,,,
Aetna Commercial,DRG,MS-876,O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,Surgical,Relative Weights,"$41,860.00 ",IP,"2,420.00","73,382.40",,,,,,
Aetna Commercial,DRG,MS-880,ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,Surgical,Relative Weights,"$9,854.35 ",IP,886.74,"17,275.10",,,,,,
Aetna Commercial,DRG,MS-881,DEPRESSIVE NEUROSES,Surgical,Relative Weights,"$9,421.95 ",IP,886.74,"16,517.09",,,,,,
Aetna Commercial,DRG,MS-882,NEUROSES EXCEPT DEPRESSIVE,Surgical,Relative Weights,"$9,082.70 ",IP,886.74,"15,922.37",,,,,,
Aetna Commercial,DRG,MS-883,DISORDERS OF PERSONALITY & IMPULSE CONTROL,Surgical,Relative Weights,"$15,370.90 ",IP,886.74,"26,945.86",,,,,,
Aetna Commercial,DRG,MS-884,ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,Surgical,Relative Weights,"$16,537.00 ",IP,"2,420.00","28,990.08",,,,,,
Aetna Commercial,DRG,MS-885,PSYCHOSES,Surgical,Relative Weights,"$13,977.10 ",IP,886.74,"24,502.46",,,,,,
Aetna Commercial,DRG,MS-886,BEHAVIORAL AND DEVELOPMENTAL DISORDERS,Surgical,Relative Weights,"$15,474.40 ",IP,886.74,"27,127.30",,,,,,
Aetna Commercial,DRG,MS-887,OTHER MENTAL DISORDER DIAGNOSES,Surgical,Relative Weights,"$12,513.15 ",IP,886.74,"21,936.10",,,,,,
Aetna Commercial,DRG,MS-894,ALCOHOL- DRUG ABUSE OR DEPENDENCE- LEFT AMA,Surgical,Relative Weights,"$6,674.60 ",IP,696.72,"11,700.86",,,,,,
Aetna Commercial,DRG,MS-895,ALCOHOL- DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY,Surgical,Relative Weights,"$18,709.35 ",IP,696.72,"32,798.30",,,,,,
Aetna Commercial,DRG,MS-896,ALCOHOL -  DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC,Surgical,Relative Weights,"$19,776.55 ",IP,696.72,"34,669.15",,,,,,
Aetna Commercial,DRG,MS-897,ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC,Surgical,Relative Weights,"$9,450.70 ",IP,696.72,"16,567.49",,,,,,
Aetna Commercial,DRG,MS-901,WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,Surgical,Relative Weights,"$49,762.80 ",IP,"2,420.00","87,236.35",,,,,,
Aetna Commercial,DRG,MS-902,WOUND DEBRIDEMENTS FOR INJURIES WITH CC,Surgical,Relative Weights,"$22,619.35 ",IP,"2,420.00","39,652.70",,,,,,
Aetna Commercial,DRG,MS-903,WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,Surgical,Relative Weights,"$13,156.00 ",IP,"2,420.00","23,063.04",,,,,,
Aetna Commercial,DRG,MS-904,SKIN GRAFTS FOR INJURIES WITH CC/MCC,Surgical,Relative Weights,"$40,680.10 ",IP,"2,420.00","71,313.98",,,,,,
Aetna Commercial,DRG,MS-905,SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,Surgical,Relative Weights,"$19,140.60 ",IP,"2,420.00","33,554.30",,,,,,
Aetna Commercial,DRG,MS-906,HAND PROCEDURES FOR INJURIES,Surgical,Relative Weights,"$20,020.35 ",IP,"2,420.00","35,096.54",,,,,,
Aetna Commercial,DRG,MS-907,OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,Surgical,Relative Weights,"$45,880.40 ",IP,"2,420.00","80,430.34",,,,,,
Aetna Commercial,DRG,MS-908,OTHER O.R. PROCEDURES FOR INJURIES WITH CC,Surgical,Relative Weights,"$23,725.65 ",IP,"2,420.00","41,592.10",,,,,,
Aetna Commercial,DRG,MS-909,OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,Surgical,Relative Weights,"$15,165.05 ",IP,"2,420.00","26,584.99",,,,,,
Aetna Commercial,DRG,MS-913,TRAUMATIC INJURY WITH MCC,Surgical,Relative Weights,"$16,977.45 ",IP,"2,420.00","29,762.21",,,,,,
Aetna Commercial,DRG,MS-914,TRAUMATIC INJURY WITHOUT MCC,Surgical,Relative Weights,"$9,909.55 ",IP,"2,420.00","17,371.87",,,,,,
Aetna Commercial,DRG,MS-915,ALLERGIC REACTIONS WITH MCC,Surgical,Relative Weights,"$19,539.65 ",IP,"2,420.00","34,253.86",,,,,,
Aetna Commercial,DRG,MS-916,ALLERGIC REACTIONS WITHOUT MCC,Surgical,Relative Weights,"$7,281.80 ",IP,"2,420.00","12,765.31",,,,,,
Aetna Commercial,DRG,MS-917,POISONING & TOXIC EFFECTS OF DRUGS W MCC,Surgical,Relative Weights,"$16,826.80 ",IP,"2,420.00","29,498.11",,,,,,
Aetna Commercial,DRG,MS-918,POISONING & TOXIC EFFECTS OF DRUGS W/O MCC,Surgical,Relative Weights,"$9,016.00 ",IP,"2,420.00","15,805.44",,,,,,
Aetna Commercial,DRG,MS-919,COMPLICATIONS OF TREATMENT WITH MCC,Surgical,Relative Weights,"$20,990.95 ",IP,"2,420.00","36,798.05",,,,,,
Aetna Commercial,DRG,MS-920,COMPLICATIONS OF TREATMENT WITH CC,Surgical,Relative Weights,"$11,586.25 ",IP,"2,420.00","20,311.20",,,,,,
Aetna Commercial,DRG,MS-921,COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,Surgical,Relative Weights,"$7,941.90 ",IP,"2,420.00","13,922.50",,,,,,
Aetna Commercial,DRG,MS-922,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC,Surgical,Relative Weights,"$18,441.40 ",IP,"2,420.00","32,328.58",,,,,,
Aetna Commercial,DRG,MS-923,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC,Surgical,Relative Weights,"$9,953.25 ",IP,"2,420.00","17,448.48",,,,,,
Aetna Commercial,DRG,MS-927,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,Surgical,Relative Weights,"$229,350.25 ",IP,"2,420.00","402,060.96",,,,,,
Aetna Commercial,DRG,MS-928,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,Surgical,Relative Weights,"$71,241.35 ",IP,"2,420.00","124,889.18",,,,,,
Aetna Commercial,DRG,MS-929,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,Surgical,Relative Weights,"$33,827.25 ",IP,"2,420.00","59,300.64",,,,,,
Aetna Commercial,DRG,MS-933,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,Surgical,Relative Weights,"$36,112.30 ",IP,"2,420.00","63,306.43",,,,,,
Aetna Commercial,DRG,MS-934,FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,Surgical,Relative Weights,"$20,812.70 ",IP,"2,420.00","36,485.57",,,,,,
Aetna Commercial,DRG,MS-935,NON-EXTENSIVE BURNS,Surgical,Relative Weights,"$22,221.45 ",IP,"2,420.00","38,955.17",,,,,,
Aetna Commercial,DRG,MS-939,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,Surgical,Relative Weights,"$42,025.60 ",IP,"2,420.00","73,672.70",,,,,,
Aetna Commercial,DRG,MS-940,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,Surgical,Relative Weights,"$26,125.70 ",IP,"2,420.00","45,799.49",,,,,,
Aetna Commercial,DRG,MS-941,O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W/O CC/MCC,Surgical,Relative Weights,"$22,203.05 ",IP,"2,420.00","38,922.91",,,,,,
Aetna Commercial,DRG,MS-945,REHABILITATION WITH CC/MCC,Surgical,Relative Weights,"$16,735.95 ",IP,"2,420.00","29,338.85",,,,,,
Aetna Commercial,DRG,MS-946,REHABILITATION WITHOUT CC/MCC,Surgical,Relative Weights,"$12,500.50 ",IP,"2,420.00","21,913.92",,,,,,
Aetna Commercial,DRG,MS-947,SIGNS AND SYMPTOMS WITH MCC,Surgical,Relative Weights,"$13,768.95 ",IP,"2,420.00","24,137.57",,,,,,
Aetna Commercial,DRG,MS-948,SIGNS AND SYMPTOMS WITHOUT MCC,Surgical,Relative Weights,"$8,965.40 ",IP,"2,420.00","15,716.74",,,,,,
Aetna Commercial,DRG,MS-949,AFTERCARE WITH CC/MCC,Surgical,Relative Weights,"$12,522.35 ",IP,"2,420.00","21,952.22",,,,,,
Aetna Commercial,DRG,MS-950,AFTERCARE WITHOUT CC/MCC,Surgical,Relative Weights,"$8,520.35 ",IP,"2,420.00","14,936.54",,,,,,
Aetna Commercial,DRG,MS-951,OTHER FACTORS INFLUENCING HEALTH STATUS,Surgical,Relative Weights,"$6,744.75 ",IP,"2,420.00","11,823.84",,,,,,
Aetna Commercial,DRG,MS-955,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,Surgical,Relative Weights,"$69,925.75 ",IP,"2,420.00","122,582.88",,,,,,
Aetna Commercial,DRG,MS-956,LIMB REATTACHMENT- HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,Surgical,Relative Weights,"$45,117.95 ",IP,"2,420.00","79,093.73",,,,,,
Aetna Commercial,DRG,MS-957,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Surgical,Relative Weights,"$86,637.55 ",IP,"2,420.00","151,879.39",,,,,,
Aetna Commercial,DRG,MS-958,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,Surgical,Relative Weights,"$48,195.35 ",IP,"2,420.00","84,488.54",,,,,,
Aetna Commercial,DRG,MS-959,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,Surgical,Relative Weights,"$32,205.75 ",IP,"2,420.00","56,458.08",,,,,,
Aetna Commercial,DRG,MS-963,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Surgical,Relative Weights,"$31,338.65 ",IP,"2,420.00","54,938.02",,,,,,
Aetna Commercial,DRG,MS-964,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,Surgical,Relative Weights,"$17,175.25 ",IP,"2,420.00","30,108.96",,,,,,
Aetna Commercial,DRG,MS-965,OTHER MULTIPLE SIGNIFICANT TRAUMA W/O CC/MCC,Surgical,Relative Weights,"$10,546.65 ",IP,"2,420.00","18,488.74",,,,,,
Aetna Commercial,DRG,MS-969,HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$66,731.05 ",IP,"2,420.00","116,982.43",,,,,,
Aetna Commercial,DRG,MS-970,HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$33,545.50 ",IP,"2,420.00","58,806.72",,,,,,
Aetna Commercial,DRG,MS-974,HIV WITH MAJOR RELATED CONDITION WITH MCC,Surgical,Relative Weights,"$30,749.85 ",IP,"2,420.00","53,905.82",,,,,,
Aetna Commercial,DRG,MS-975,HIV WITH MAJOR RELATED CONDITION WITH CC,Surgical,Relative Weights,"$15,433.00 ",IP,"2,420.00","27,054.72",,,,,,
Aetna Commercial,DRG,MS-976,HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,Surgical,Relative Weights,"$10,513.30 ",IP,"2,420.00","18,430.27",,,,,,
Aetna Commercial,DRG,MS-977,HIV WITH OR WITHOUT OTHER RELATED CONDITION,Surgical,Relative Weights,"$14,955.75 ",IP,"2,420.00","26,218.08",,,,,,
Aetna Commercial,DRG,MS-981,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$51,643.05 ",IP,"2,420.00","90,532.51",,,,,,
Aetna Commercial,DRG,MS-982,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Surgical,Relative Weights,"$28,038.15 ",IP,"2,420.00","49,152.10",,,,,,
Aetna Commercial,DRG,MS-983,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$18,826.65 ",IP,"2,420.00","33,003.94",,,,,,
Aetna Commercial,DRG,MS-987,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$38,337.55 ",IP,"2,420.00","67,207.39",,,,,,
Aetna Commercial,DRG,MS-988,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Surgical,Relative Weights,"$19,760.45 ",IP,"2,420.00","34,640.93",,,,,,
Aetna Commercial,DRG,MS-989,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$13,252.60 ",IP,"2,420.00","23,232.38",,,,,,
Aetna Commercial,CPT,33017,Prcrd drg 6yr+ w/o cgen car,Cardiac Cath Procedures,Straight Discount,65.00%,OP,"4,314.00","11,815.21",,,,,,
Aetna Commercial,CPT,33018,Prcrd drg 0-5yr or w/anomly,Cardiac Cath Procedures,Straight Discount,65.00%,OP,"4,314.00","11,815.21",,,,,,
Aetna Commercial,CPT,33019,Perq prcrd drg insj cath ct,Cardiac Cath Procedures,Straight Discount,65.00%,OP,"4,314.00","11,815.21",,,,,,
Aetna Commercial,CPT,33289,Tcat impl wrls p-art prs snr,Cardiac Cath Procedures,Straight Discount,65.00%,OP,"4,314.00","29,487.35",,,,,,
Aetna Commercial,CPT,33477,Implant tcat pulm vlv perq,Cardiac Cath Procedures,Straight Discount,65.00%,OP,"4,314.00","11,815.21",,,,,,
Aetna Commercial,CPT,34717,Evasc rpr a-iliac ndgft,Cardiac Cath Procedures,Straight Discount,65.00%,OP,"4,314.00","11,815.21",,,,,,
Aetna Commercial,CPT,34718,Evasc rpr n/a a-iliac ndgft,Cardiac Cath Procedures,Straight Discount,65.00%,OP,"4,314.00","11,815.21",,,,,,
Aetna Commercial,CPT,51720,Treatment of bladder lesion,Chemotherapy,Straight Discount,65.00%,OP,259.67,"4,314.00",,,,,,
Aetna Commercial,CPT,70336,Magnetic image jaw joint,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,224.53,"1,507.00",,,,,,
Aetna Commercial,CPT,70450,Ct head/brain w/o dye,CAT Scan,Per Case,$927.00 ,OP,106.24,927,,,,,,
Aetna Commercial,CPT,70451,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,70452,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,70453,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,70454,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,70455,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,70456,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,70457,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,70458,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,70459,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,70460,Ct head/brain w/dye,CAT Scan,Per Case,$927.00 ,OP,174.31,965.53,,,,,,
Aetna Commercial,CPT,70461,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,70462,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,70463,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,70464,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,70465,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,70466,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,70467,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,70468,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,70469,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,70470,Ct head/brain w/o & w/dye,CAT Scan,Per Case,$927.00 ,OP,174.31,965.53,,,,,,
Aetna Commercial,CPT,70471,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,70472,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,70473,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,70474,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,70475,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,70476,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,70477,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,70478,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,70479,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,70480,Ct orbit/ear/fossa w/o dye,CAT Scan,Per Case,$927.00 ,OP,106.24,927,,,,,,
Aetna Commercial,CPT,70481,Ct orbit/ear/fossa w/dye,CAT Scan,Per Case,$927.00 ,OP,174.31,965.53,,,,,,
Aetna Commercial,CPT,70482,Ct orbit/ear/fossa w/o&w/dye,CAT Scan,Per Case,$927.00 ,OP,174.31,965.53,,,,,,
Aetna Commercial,CPT,70483,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,70484,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,70485,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,70486,Ct maxillofacial w/o dye,CAT Scan,Per Case,$927.00 ,OP,106.24,927,,,,,,
Aetna Commercial,CPT,70487,Ct maxillofacial w/dye,CAT Scan,Per Case,$927.00 ,OP,174.31,965.53,,,,,,
Aetna Commercial,CPT,70488,Ct maxillofacial w/o & w/dye,CAT Scan,Per Case,$927.00 ,OP,174.31,965.53,,,,,,
Aetna Commercial,CPT,70489,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,70490,Ct soft tissue neck w/o dye,CAT Scan,Per Case,$927.00 ,OP,106.24,927,,,,,,
Aetna Commercial,CPT,70491,Ct soft tissue neck w/dye,CAT Scan,Per Case,$927.00 ,OP,174.31,965.53,,,,,,
Aetna Commercial,CPT,70492,Ct sft tsue nck w/o & w/dye,CAT Scan,Per Case,$927.00 ,OP,174.31,965.53,,,,,,
Aetna Commercial,CPT,70493,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,70494,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,70495,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,70496,Ct angiography head,CAT Scan,Per Case,$927.00 ,OP,174.31,965.53,,,,,,
Aetna Commercial,CPT,70497,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,70498,Ct angiography neck,CAT Scan,Per Case,$927.00 ,OP,174.31,965.53,,,,,,
Aetna Commercial,CPT,70540,Mri orbit/face/neck w/o dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,224.53,"1,507.00",,,,,,
Aetna Commercial,CPT,70541,MAGNETIC IMAGE-HEAD (MRA),MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,"1,507.00","1,507.00",,,,,,
Aetna Commercial,CPT,70542,Mri orbit/face/neck w/dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,359.34,"1,609.22",,,,,,
Aetna Commercial,CPT,70543,Mri orbt/fac/nck w/o &w/dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,359.34,"1,609.22",,,,,,
Aetna Commercial,CPT,70544,Mr angiography head w/o dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,224.53,"1,507.00",,,,,,
Aetna Commercial,CPT,70545,Mr angiography head w/dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,359.34,"1,609.22",,,,,,
Aetna Commercial,CPT,70546,Mr angiograph head w/o&w/dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,359.34,"1,609.22",,,,,,
Aetna Commercial,CPT,70547,Mr angiography neck w/o dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,224.53,"1,507.00",,,,,,
Aetna Commercial,CPT,70548,Mr angiography neck w/dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,359.34,"1,609.22",,,,,,
Aetna Commercial,CPT,70549,Mr angiograph neck w/o&w/dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,359.34,"1,609.22",,,,,,
Aetna Commercial,CPT,70550,,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,"1,507.00","1,507.00",,,,,,
Aetna Commercial,CPT,70551,Mri brain stem w/o dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,224.53,"1,507.00",,,,,,
Aetna Commercial,CPT,70552,Mri brain stem w/dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,359.34,"1,609.22",,,,,,
Aetna Commercial,CPT,70553,Mri brain stem w/o & w/dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,359.34,"1,609.22",,,,,,
Aetna Commercial,CPT,70554,Fmri brain by tech,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,224.53,"1,507.00",,,,,,
Aetna Commercial,CPT,70555,Fmri brain by phys/psych,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,224.53,"1,507.00",,,,,,
Aetna Commercial,CPT,71250,Ct thorax dx c-,CAT Scan,Per Case,$927.00 ,OP,106.24,927,,,,,,
Aetna Commercial,CPT,71251,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,71252,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,71253,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,71254,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,71255,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,71256,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,71257,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,71258,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,71259,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,71260,Ct thorax dx c+,CAT Scan,Per Case,$927.00 ,OP,174.31,965.53,,,,,,
Aetna Commercial,CPT,71261,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,71262,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,71263,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,71264,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,71265,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,71266,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,71267,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,71268,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,71269,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,71270,Ct thorax dx c-/c+,CAT Scan,Per Case,$927.00 ,OP,174.31,965.53,,,,,,
Aetna Commercial,CPT,71271,Ct thorax lung cancer scr c-,CAT Scan,Per Case,$927.00 ,OP,82.79,927,,,,,,
Aetna Commercial,CPT,71272,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,71273,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,71274,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,71275,Ct angiography chest,CAT Scan,Per Case,$927.00 ,OP,174.31,965.53,,,,,,
Aetna Commercial,CPT,71550,Mri chest w/o dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,224.53,"1,507.00",,,,,,
Aetna Commercial,CPT,71551,Mri chest w/dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,698.14,"1,609.22",,,,,,
Aetna Commercial,CPT,71552,Mri chest w/o & w/dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,359.34,"1,609.22",,,,,,
Aetna Commercial,CPT,71553,,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,"1,507.00","1,507.00",,,,,,
Aetna Commercial,CPT,71554,,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,"1,507.00","1,507.00",,,,,,
Aetna Commercial,CPT,71555,Mri angio chest w or w/o dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,"1,507.00","1,609.22",,,,,,
Aetna Commercial,CPT,72125,Ct neck spine w/o dye,CAT Scan,Per Case,$927.00 ,OP,106.24,927,,,,,,
Aetna Commercial,CPT,72126,Ct neck spine w/dye,CAT Scan,Per Case,$927.00 ,OP,359.34,965.53,,,,,,
Aetna Commercial,CPT,72127,Ct neck spine w/o & w/dye,CAT Scan,Per Case,$927.00 ,OP,174.31,965.53,,,,,,
Aetna Commercial,CPT,72128,Ct chest spine w/o dye,CAT Scan,Per Case,$927.00 ,OP,106.24,927,,,,,,
Aetna Commercial,CPT,72129,Ct chest spine w/dye,CAT Scan,Per Case,$927.00 ,OP,174.31,965.53,,,,,,
Aetna Commercial,CPT,72130,Ct chest spine w/o & w/dye,CAT Scan,Per Case,$927.00 ,OP,174.31,965.53,,,,,,
Aetna Commercial,CPT,72131,Ct lumbar spine w/o dye,CAT Scan,Per Case,$927.00 ,OP,106.24,927,,,,,,
Aetna Commercial,CPT,72132,Ct lumbar spine w/dye,CAT Scan,Per Case,$927.00 ,OP,359.34,965.53,,,,,,
Aetna Commercial,CPT,72133,Ct lumbar spine w/o & w/dye,CAT Scan,Per Case,$927.00 ,OP,174.31,965.53,,,,,,
Aetna Commercial,CPT,72141,Mri neck spine w/o dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,224.53,"1,507.00",,,,,,
Aetna Commercial,CPT,72142,Mri neck spine w/dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,359.34,"1,609.22",,,,,,
Aetna Commercial,CPT,72143,,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,"1,507.00","1,507.00",,,,,,
Aetna Commercial,CPT,72144,,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,"1,507.00","1,507.00",,,,,,
Aetna Commercial,CPT,72145,,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,"1,507.00","1,507.00",,,,,,
Aetna Commercial,CPT,72146,Mri chest spine w/o dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,224.53,"1,507.00",,,,,,
Aetna Commercial,CPT,72147,Mri chest spine w/dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,359.34,"1,609.22",,,,,,
Aetna Commercial,CPT,72148,Mri lumbar spine w/o dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,224.53,"1,507.00",,,,,,
Aetna Commercial,CPT,72149,Mri lumbar spine w/dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,359.34,"1,609.22",,,,,,
Aetna Commercial,CPT,72150,,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,"1,507.00","1,507.00",,,,,,
Aetna Commercial,CPT,72151,,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,"1,507.00","1,507.00",,,,,,
Aetna Commercial,CPT,72152,,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,"1,507.00","1,507.00",,,,,,
Aetna Commercial,CPT,72153,,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,"1,507.00","1,507.00",,,,,,
Aetna Commercial,CPT,72154,,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,"1,507.00","1,507.00",,,,,,
Aetna Commercial,CPT,72155,,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,"1,507.00","1,507.00",,,,,,
Aetna Commercial,CPT,72156,Mri neck spine w/o & w/dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,359.34,"1,609.22",,,,,,
Aetna Commercial,CPT,72157,Mri chest spine w/o & w/dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,359.34,"1,609.22",,,,,,
Aetna Commercial,CPT,72158,Mri lumbar spine w/o & w/dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,359.34,"1,609.22",,,,,,
Aetna Commercial,CPT,72159,Mr angio spine w/o&w/dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,"1,507.00","1,609.22",,,,,,
Aetna Commercial,CPT,72191,Ct angiograph pelv w/o&w/dye,CAT Scan,Per Case,$927.00 ,OP,174.31,965.53,,,,,,
Aetna Commercial,CPT,72192,Ct pelvis w/o dye,CAT Scan,Per Case,$927.00 ,OP,106.24,927,,,,,,
Aetna Commercial,CPT,72193,Ct pelvis w/dye,CAT Scan,Per Case,$927.00 ,OP,174.31,965.53,,,,,,
Aetna Commercial,CPT,72194,Ct pelvis w/o & w/dye,CAT Scan,Per Case,$927.00 ,OP,174.31,965.53,,,,,,
Aetna Commercial,CPT,72195,Mri pelvis w/o dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,224.53,"1,507.00",,,,,,
Aetna Commercial,CPT,72196,Mri pelvis w/dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,359.34,"1,609.22",,,,,,
Aetna Commercial,CPT,72197,Mri pelvis w/o & w/dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,359.34,"1,609.22",,,,,,
Aetna Commercial,CPT,72198,Mr angio pelvis w/o & w/dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,"1,507.00","1,507.00",,,,,,
Aetna Commercial,CPT,73200,Ct upper extremity w/o dye,CAT Scan,Per Case,$927.00 ,OP,106.24,927,,,,,,
Aetna Commercial,CPT,73201,Ct upper extremity w/dye,CAT Scan,Per Case,$927.00 ,OP,359.34,965.53,,,,,,
Aetna Commercial,CPT,73202,Ct uppr extremity w/o&w/dye,CAT Scan,Per Case,$927.00 ,OP,174.31,965.53,,,,,,
Aetna Commercial,CPT,73203,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,73204,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,73205,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,73206,Ct angio upr extrm w/o&w/dye,CAT Scan,Per Case,$927.00 ,OP,174.31,965.53,,,,,,
Aetna Commercial,CPT,73218,Mri upper extremity w/o dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,224.53,"1,507.00",,,,,,
Aetna Commercial,CPT,73219,Mri upper extremity w/dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,359.34,"1,609.22",,,,,,
Aetna Commercial,CPT,73220,Mri uppr extremity w/o&w/dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,359.34,"1,609.22",,,,,,
Aetna Commercial,CPT,73221,Mri joint upr extrem w/o dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,224.53,"1,507.00",,,,,,
Aetna Commercial,CPT,73222,Mri joint upr extrem w/dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,698.14,"1,609.22",,,,,,
Aetna Commercial,CPT,73223,Mri joint upr extr w/o&w/dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,359.34,"1,609.22",,,,,,
Aetna Commercial,CPT,73224,,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,"1,507.00","1,507.00",,,,,,
Aetna Commercial,CPT,73225,Mr angio upr extr w/o&w/dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,"1,507.00","1,609.22",,,,,,
Aetna Commercial,CPT,73674,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,73675,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,73676,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,73677,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,73678,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,73679,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,73680,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,73700,Ct lower extremity w/o dye,CAT Scan,Per Case,$927.00 ,OP,106.24,927,,,,,,
Aetna Commercial,CPT,73701,Ct lower extremity w/dye,CAT Scan,Per Case,$927.00 ,OP,174.31,965.53,,,,,,
Aetna Commercial,CPT,73702,Ct lwr extremity w/o&w/dye,CAT Scan,Per Case,$927.00 ,OP,174.31,965.53,,,,,,
Aetna Commercial,CPT,73706,Ct angio lwr extr w/o&w/dye,CAT Scan,Per Case,$927.00 ,OP,174.31,965.53,,,,,,
Aetna Commercial,CPT,73718,Mri lower extremity w/o dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,224.53,"1,507.00",,,,,,
Aetna Commercial,CPT,73719,Mri lower extremity w/dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,359.34,"1,609.22",,,,,,
Aetna Commercial,CPT,73720,Mri lwr extremity w/o&w/dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,359.34,"1,609.22",,,,,,
Aetna Commercial,CPT,73721,Mri jnt of lwr extre w/o dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,224.53,"1,507.00",,,,,,
Aetna Commercial,CPT,73722,Mri joint of lwr extr w/dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,698.14,"1,609.22",,,,,,
Aetna Commercial,CPT,73723,Mri joint lwr extr w/o&w/dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,359.34,"1,609.22",,,,,,
Aetna Commercial,CPT,73724,,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,"1,507.00","1,507.00",,,,,,
Aetna Commercial,CPT,73725,Mr ang lwr ext w or w/o dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,"1,507.00","1,609.22",,,,,,
Aetna Commercial,CPT,74150,Ct abdomen w/o dye,CAT Scan,Per Case,$927.00 ,OP,106.24,927,,,,,,
Aetna Commercial,CPT,74151,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,74152,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,74153,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,74154,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,74155,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,74156,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,74157,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,74158,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,74159,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,74160,Ct abdomen w/dye,CAT Scan,Per Case,$927.00 ,OP,174.31,965.53,,,,,,
Aetna Commercial,CPT,74161,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,74162,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,74163,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,74164,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,74165,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,74166,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,74167,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,74168,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,74169,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,74170,Ct abdomen w/o & w/dye,CAT Scan,Per Case,$927.00 ,OP,174.31,965.53,,,,,,
Aetna Commercial,CPT,74171,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,74172,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,74173,Unknown,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,74174,Ct angio abd&pelv w/o&w/dye,CAT Scan,Per Case,$927.00 ,OP,359.34,965.53,,,,,,
Aetna Commercial,CPT,74175,Ct angio abdom w/o & w/dye,CAT Scan,Per Case,$927.00 ,OP,174.31,965.53,,,,,,
Aetna Commercial,CPT,74176,Ct abd & pelvis w/o contrast,CAT Scan,Per Case,$927.00 ,OP,224.53,927,,,,,,
Aetna Commercial,CPT,74177,Ct abd & pelv w/contrast,CAT Scan,Per Case,$927.00 ,OP,359.34,965.53,,,,,,
Aetna Commercial,CPT,74178,Ct abd & pelv 1/> regns,CAT Scan,Per Case,$927.00 ,OP,359.34,927,,,,,,
Aetna Commercial,CPT,74181,Mri abdomen w/o dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,224.53,"1,507.00",,,,,,
Aetna Commercial,CPT,74182,Mri abdomen w/dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,359.34,"1,609.22",,,,,,
Aetna Commercial,CPT,74183,Mri abdomen w/o & w/dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,359.34,"1,609.22",,,,,,
Aetna Commercial,CPT,74185,Mri angio abdom w orw/o dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,"1,507.00","1,609.22",,,,,,
Aetna Commercial,CPT,74261,Ct colonography dx,CAT Scan,Per Case,$927.00 ,OP,106.24,927,,,,,,
Aetna Commercial,CPT,74263,Ct colonography screening,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,74712,Mri fetal sngl/1st gestation,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,224.53,"1,507.00",,,,,,
Aetna Commercial,CPT,74713,Mri fetal ea addl gestation,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,"1,149.44","1,507.00",,,,,,
Aetna Commercial,CPT,75557,Cardiac mri for morph,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,224.53,"1,507.00",,,,,,
Aetna Commercial,CPT,75558,Cardiac mri flow/velocity,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,"1,507.00","1,507.00",,,,,,
Aetna Commercial,CPT,75559,Cardiac mri w/stress img,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,471.51,"1,507.00",,,,,,
Aetna Commercial,CPT,75560,Cardiac mri flow/vel/stress,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,"1,507.00","1,507.00",,,,,,
Aetna Commercial,CPT,75561,Cardiac mri for morph w/dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,359.34,"1,609.22",,,,,,
Aetna Commercial,CPT,75562,Card mri flow/vel w/dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,"1,507.00","4,266.40",,,,,,
Aetna Commercial,CPT,75563,Card mri w/stress img & dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,698.14,"1,609.22",,,,,,
Aetna Commercial,CPT,75564,Ht mri w/flo/vel/strs & dye,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,"1,507.00","5,017.50",,,,,,
Aetna Commercial,CPT,75565,Card mri veloc flow mapping,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,"1,507.00","1,507.00",,,,,,
Aetna Commercial,CPT,75571,Ct hrt w/o dye w/ca test,CAT Scan,Per Case,$927.00 ,OP,78.93,927,,,,,,
Aetna Commercial,CPT,75572,Ct hrt w/3d image,CAT Scan,Per Case,$927.00 ,OP,174.31,927,,,,,,
Aetna Commercial,CPT,75573,Ct hrt c+ strux cgen hrt ds,CAT Scan,Per Case,$927.00 ,OP,174.31,927,,,,,,
Aetna Commercial,CPT,75574,Ct angio hrt w/3d image,CAT Scan,Per Case,$927.00 ,OP,174.31,927,,,,,,
Aetna Commercial,CPT,75635,Ct angio abdominal arteries,CAT Scan,Per Case,$927.00 ,OP,174.31,965.53,,,,,,
Aetna Commercial,CPT,75989,Abscess drainage under x-ray,CAT Scan,Per Case,$927.00 ,OP,922.43,927,,,,,,
Aetna Commercial,CPT,76390,Mr spectroscopy,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,78.93,"1,507.00",,,,,,
Aetna Commercial,CPT,76391,Mr elastography,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,224.53,"1,507.00",,,,,,
Aetna Commercial,CPT,76497,Ct procedure,CAT Scan,Per Case,$927.00 ,OP,78.93,927,,,,,,
Aetna Commercial,CPT,76498,Mri procedure,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,78.93,"1,507.00",,,,,,
Aetna Commercial,CPT,77011,Ct scan for localization,CAT Scan,Per Case,$927.00 ,OP,927,"3,500.05",,,,,,
Aetna Commercial,CPT,77012,Ct scan for needle biopsy,CAT Scan,Per Case,$927.00 ,OP,689.66,927,,,,,,
Aetna Commercial,CPT,77013,Ct guide for tissue ablation,CAT Scan,Per Case,$927.00 ,OP,689.66,927,,,,,,
Aetna Commercial,CPT,77014,Ct scan for therapy guide,CAT Scan,Per Case,$927.00 ,OP,689.66,927,,,,,,
Aetna Commercial,CPT,77021,Mri guidance ndl plmt rs&i,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,"1,507.00","2,363.88",,,,,,
Aetna Commercial,CPT,77022,Mri gdn parnchyma tiss abltj,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,"1,507.00","3,637.31",,,,,,
Aetna Commercial,CPT,77046,Mri breast c- unilateral,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,224.53,"1,507.00",,,,,,
Aetna Commercial,CPT,77047,Mri breast c- bilateral,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,224.53,"1,507.00",,,,,,
Aetna Commercial,CPT,77048,Mri breast c-+ w/cad uni,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,"1,149.44","1,507.00",,,,,,
Aetna Commercial,CPT,77049,Mri breast c-+ w/cad bi,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,"1,149.44","1,507.00",,,,,,
Aetna Commercial,CPT,77078,Ct bone density axial,CAT Scan,Per Case,$927.00 ,OP,78.93,927,,,,,,
Aetna Commercial,CPT,77084,Magnetic image bone marrow,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,224.53,"1,507.00",,,,,,
Aetna Commercial,CPT,78830,Rp loclzj tum spect w/ct 1,CAT Scan,Per Case,$927.00 ,OP,927,"2,600.43",,,,,,
Aetna Commercial,CPT,78831,Rp loclzj tum spect 2 areas,CAT Scan,Per Case,$927.00 ,OP,927,"3,860.65",,,,,,
Aetna Commercial,CPT,78832,Rp loclzj tum spect w/ct 2,CAT Scan,Per Case,$927.00 ,OP,927,"5,097.10",,,,,,
Aetna Commercial,CPT,93000,Electrocardiogram complete,Cardiac Studies,Straight Discount,65.00%,OP,125.82,125.82,,,,,,
Aetna Commercial,CPT,93001,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93002,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93003,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93004,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93005,Electrocardiogram tracing,Cardiac Studies,Straight Discount,65.00%,OP,54.32,72.44,,,,,,
Aetna Commercial,CPT,93006,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93007,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93008,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93009,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93010,Electrocardiogram report,Cardiac Studies,Straight Discount,65.00%,OP,53.38,53.38,,,,,,
Aetna Commercial,CPT,93011,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93012,Transmission of ecg,Cardiac Studies,Straight Discount,65.00%,OP,"1,082.81","1,082.81",,,,,,
Aetna Commercial,CPT,93013,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93014,Report on transmitted ecg,Cardiac Studies,Straight Discount,65.00%,OP,160.13,160.13,,,,,,
Aetna Commercial,CPT,93015,Cardiovascular stress test,Cardiac Studies,Straight Discount,65.00%,OP,594.77,594.77,,,,,,
Aetna Commercial,CPT,93016,Cardiovascular stress test,Cardiac Studies,Straight Discount,65.00%,OP,141.07,141.07,,,,,,
Aetna Commercial,CPT,93017,Cardiovascular stress test,Cardiac Studies,Straight Discount,65.00%,OP,258.26,362.21,,,,,,
Aetna Commercial,CPT,93018,Cardiovascular stress test,Cardiac Studies,Straight Discount,65.00%,OP,91.51,91.51,,,,,,
Aetna Commercial,CPT,93019,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93020,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93021,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93022,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93023,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93024,Cardiac drug stress test,Cardiac Studies,Straight Discount,65.00%,OP,264.84,712.98,,,,,,
Aetna Commercial,CPT,93025,Microvolt t-wave assess,Cardiac Studies,Straight Discount,65.00%,OP,136.24,"1,246.76",,,,,,
Aetna Commercial,CPT,93026,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93027,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93028,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93029,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93030,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93031,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93032,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93033,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93034,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93035,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93036,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93037,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93038,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93039,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93040,Rhythm ecg with report,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93041,Rhythm ecg tracing,Cardiac Studies,Straight Discount,65.00%,OP,54.32,56.95,,,,,,
Aetna Commercial,CPT,93042,Rhythm ecg report,Cardiac Studies,Straight Discount,65.00%,OP,45.74,45.74,,,,,,
Aetna Commercial,CPT,93043,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93044,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93045,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93046,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93047,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93048,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93049,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93050,Art pressure waveform analys,Cardiac Studies,Straight Discount,65.00%,OP,24.1,25.25,,,,,,
Aetna Commercial,CPT,93051,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93052,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93053,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93054,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93055,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93056,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93057,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93058,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93059,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93060,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93061,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93062,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93063,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93064,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93065,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93066,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93067,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93068,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93069,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93070,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93071,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93072,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93073,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93074,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93075,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93076,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93077,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93078,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93079,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93080,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93081,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93082,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93083,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93084,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93085,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93086,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93087,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93088,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93089,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93090,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93091,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93092,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93093,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93094,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93095,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93096,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93097,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93098,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93099,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93100,ELECTROCARDIOGRAM-COMPLETE,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93101,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93102,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93103,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93104,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93105,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93106,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93107,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93108,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93109,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93110,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93111,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93112,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93113,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93114,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93115,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93116,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93117,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93118,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93119,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93120,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93121,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93122,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93123,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93124,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93125,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93126,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93127,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93128,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93129,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93130,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93131,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93132,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93133,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93134,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93135,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93136,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93137,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93138,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93139,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93140,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93141,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93142,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93143,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93144,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93145,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93146,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93147,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93148,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93149,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93150,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93151,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93152,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93153,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93154,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93155,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93156,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93157,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93158,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93159,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93160,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93161,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93162,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93163,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93164,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93165,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93166,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93167,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93168,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93169,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93170,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93171,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93172,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93173,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93174,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93175,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93176,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93177,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93178,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93179,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93180,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93181,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93182,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93183,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93184,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93185,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93186,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93187,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93188,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93189,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93190,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93191,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93192,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93193,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93194,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93195,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93196,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93197,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93198,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93199,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93200,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93201,Phonocardiogram w/or w/o ECG lead-w/supervision during recording w/interpretation & report (when equipment is supplied by the physician),Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93202,Phonocardiogram w/or w/o ECG lead-tracing only-w/o interpretation & report (eg-when equipment is supplied by the hospital-clinic),Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93203,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93204,Phonocardiogram w/or w/o ECG lead-interpretation & report,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93205,Phonocardiogram w/ECG lead-w/indirect carotid artery and/or jugular vein tracing-and/or apex cardiogram-w/interpretation & report,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93206,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93207,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93208,Phonocardiogram w/ECG lead-w/indirect carotid artery and/or jugular vein tracing-and/or apex cardiogram-tracing only-w/o interpretation & report,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93209,Phonocardiogram w/ECG lead-w/indirect carotid artery and/or jugular vein tracing-and/or apex cardiogram-interpretation & report only,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93210,Phonocardiogram-intracardiac,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93211,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93212,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93213,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93214,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93215,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93216,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93217,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93218,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93219,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93220,Vectorcardiogram (VCG)-w/or w/o ECG-w/interpretation & report,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93221,Vectorcardiogram (VCG)-w/or w/o ECG-tracing only-w/o interpretation & report,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93222,Vectorcardiogram (VCG)-w/or w/o ECG-interpretation & report only,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93223,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93224,Ecg monit/reprt up to 48 hrs,Cardiac Studies,Straight Discount,65.00%,OP,743.48,743.48,,,,,,
Aetna Commercial,CPT,93225,Ecg monit/reprt up to 48 hrs,Cardiac Studies,Straight Discount,65.00%,OP,110.04,224.95,,,,,,
Aetna Commercial,CPT,93226,Ecg monit/reprt up to 48 hrs,Cardiac Studies,Straight Discount,65.00%,OP,110.04,926.48,,,,,,
Aetna Commercial,CPT,93227,Ecg monit/reprt up to 48 hrs,Cardiac Studies,Straight Discount,65.00%,OP,163.95,163.95,,,,,,
Aetna Commercial,CPT,93228,Remote 30 day ecg rev/report,Cardiac Studies,Straight Discount,65.00%,OP,144.88,144.88,,,,,,
Aetna Commercial,CPT,93229,Remote 30 day ecg tech supp,Cardiac Studies,Straight Discount,65.00%,OP,136.24,142.8,,,,,,
Aetna Commercial,CPT,93230,ECG monitor/report - 24 hrs,Cardiac Studies,Straight Discount,65.00%,OP,743.48,743.48,,,,,,
Aetna Commercial,CPT,93231,Ecg monitor/record - 24 hrs,Cardiac Studies,Straight Discount,65.00%,OP,224.95,224.95,,,,,,
Aetna Commercial,CPT,93232,ECG monitor/report - 24 hrs,Cardiac Studies,Straight Discount,65.00%,OP,362.21,362.21,,,,,,
Aetna Commercial,CPT,93233,ECG monitor/review - 24 hrs,Cardiac Studies,Straight Discount,65.00%,OP,156.32,156.32,,,,,,
Aetna Commercial,CPT,93234,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93235,ECG monitor/report - 24 hrs,Cardiac Studies,Straight Discount,65.00%,OP,476.6,476.6,,,,,,
Aetna Commercial,CPT,93236,ECG monitor/report - 24 hrs,Cardiac Studies,Straight Discount,65.00%,OP,926.48,926.48,,,,,,
Aetna Commercial,CPT,93237,ECG monitor/review - 24 hrs,Cardiac Studies,Straight Discount,65.00%,OP,141.07,141.07,,,,,,
Aetna Commercial,CPT,93238,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93239,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93240,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93241,Ext ecg>48hr<7d rec scan a/r,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93242,Ext ecg>48hr<7d recording,Cardiac Studies,Straight Discount,65.00%,OP,34.63,54.32,,,,,,
Aetna Commercial,CPT,93243,Ext ecg>48hr<7d scan a/r,Cardiac Studies,Straight Discount,65.00%,OP,56.95,110.04,,,,,,
Aetna Commercial,CPT,93244,Ext ecg>48hr<7d rev&interpj,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93245,Ext ecg>7d<15d rec scan a/r,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93246,Ext ecg>7d<15d recording,Cardiac Studies,Straight Discount,65.00%,OP,54.32,56.95,,,,,,
Aetna Commercial,CPT,93247,Ext ecg>7d<15d scan a/r,Cardiac Studies,Straight Discount,65.00%,OP,110.04,114.56,,,,,,
Aetna Commercial,CPT,93248,Ext ecg>7d<15d rev&interpj,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93249,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93250,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93251,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93252,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93253,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93254,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93255,APEXCARDIOGRAPHY,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93256,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93257,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93258,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93259,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93260,Prgrmg dev eval impltbl sys,Cardiac Studies,Straight Discount,65.00%,OP,36.34,38.02,,,,,,
Aetna Commercial,CPT,93261,Interrogate subq defib,Cardiac Studies,Straight Discount,65.00%,OP,36.34,38.02,,,,,,
Aetna Commercial,CPT,93262,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93263,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93264,Rem mntr wrls p-art prs snr,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93265,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93266,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93267,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93268,Ecg record/review,Cardiac Studies,Straight Discount,65.00%,OP,"1,574.64","1,574.64",,,,,,
Aetna Commercial,CPT,93269,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93270,Remote 30 day ecg rev/report,Cardiac Studies,Straight Discount,65.00%,OP,36.34,137.25,,,,,,
Aetna Commercial,CPT,93271,Ecg/monitoring and analysis,Cardiac Studies,Straight Discount,65.00%,OP,97.96,"1,281.07",,,,,,
Aetna Commercial,CPT,93272,Ecg/review interpret only,Cardiac Studies,Straight Discount,65.00%,OP,156.32,156.32,,,,,,
Aetna Commercial,CPT,93273,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93274,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93275,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93276,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93277,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93278,Ecg/signal-averaged,Cardiac Studies,Straight Discount,65.00%,OP,54.32,251.64,,,,,,
Aetna Commercial,CPT,93279,Prgrmg dev eval pm/ldls pm,Cardiac Studies,Straight Discount,65.00%,OP,36.34,327.9,,,,,,
Aetna Commercial,CPT,93280,Pm device progr eval dual,Cardiac Studies,Straight Discount,65.00%,OP,36.34,381.27,,,,,,
Aetna Commercial,CPT,93281,Pm device progr eval multi,Cardiac Studies,Straight Discount,65.00%,OP,36.34,446.08,,,,,,
Aetna Commercial,CPT,93282,Prgrmg eval implantable dfb,Cardiac Studies,Straight Discount,65.00%,OP,36.34,415.59,,,,,,
Aetna Commercial,CPT,93283,Prgrmg eval implantable dfb,Cardiac Studies,Straight Discount,65.00%,OP,36.34,503.28,,,,,,
Aetna Commercial,CPT,93284,Prgrmg eval implantable dfb,Cardiac Studies,Straight Discount,65.00%,OP,36.34,587.16,,,,,,
Aetna Commercial,CPT,93285,Prgrmg dev eval scrms ip,Cardiac Studies,Straight Discount,65.00%,OP,36.34,282.14,,,,,,
Aetna Commercial,CPT,93286,Peri-px eval pm/ldls pm ip,Cardiac Studies,Straight Discount,65.00%,OP,160.13,160.13,,,,,,
Aetna Commercial,CPT,93287,Peri-px device eval & prgr,Cardiac Studies,Straight Discount,65.00%,OP,213.51,213.51,,,,,,
Aetna Commercial,CPT,93288,Interrog evl pm/ldls pm ip,Cardiac Studies,Straight Discount,65.00%,OP,36.34,255.45,,,,,,
Aetna Commercial,CPT,93289,Interrog device eval heart,Cardiac Studies,Straight Discount,65.00%,OP,36.34,385.09,,,,,,
Aetna Commercial,CPT,93290,Interrog dev eval icpms ip,Cardiac Studies,Straight Discount,65.00%,OP,36.34,190.64,,,,,,
Aetna Commercial,CPT,93291,Interrog dev eval scrms ip,Cardiac Studies,Straight Discount,65.00%,OP,24.1,244.01,,,,,,
Aetna Commercial,CPT,93292,Wcd device interrogate,Cardiac Studies,Straight Discount,65.00%,OP,36.34,38.02,,,,,,
Aetna Commercial,CPT,93293,Pm phone r-strip device eval,Cardiac Studies,Straight Discount,65.00%,OP,36.34,366.02,,,,,,
Aetna Commercial,CPT,93294,Rem interrog evl pm/ldls pm,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93295,Dev interrog remote 1/2/mlt,Cardiac Studies,Straight Discount,65.00%,OP,377.46,377.46,,,,,,
Aetna Commercial,CPT,93296,Rem interrog evl pm/ids,Cardiac Studies,Straight Discount,65.00%,OP,36.34,213.51,,,,,,
Aetna Commercial,CPT,93297,Rem interrog dev eval icpms,Cardiac Studies,Straight Discount,65.00%,OP,144.88,144.88,,,,,,
Aetna Commercial,CPT,93298,Rem interrog dev eval scrms,Cardiac Studies,Straight Discount,65.00%,OP,167.76,167.76,,,,,,
Aetna Commercial,CPT,93299,Icm/ilr remote tech serv,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93300,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93301,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93302,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93303,Echo transthoracic,Cardiac Studies,Straight Discount,65.00%,OP,471.51,"1,292.50",,,,,,
Aetna Commercial,CPT,93304,Echo transthoracic,Cardiac Studies,Straight Discount,65.00%,OP,471.51,796.85,,,,,,
Aetna Commercial,CPT,93305,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93306,Tte w/doppler complete,Cardiac Studies,Straight Discount,65.00%,OP,471.51,"1,593.72",,,,,,
Aetna Commercial,CPT,93307,Tte w/o doppler complete,Cardiac Studies,Straight Discount,65.00%,OP,224.53,"1,056.11",,,,,,
Aetna Commercial,CPT,93308,Tte f-up or lmtd,Cardiac Studies,Straight Discount,65.00%,OP,224.53,667.22,,,,,,
Aetna Commercial,CPT,93309,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93310,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93311,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93312,Echo transesophageal,Cardiac Studies,Straight Discount,65.00%,OP,471.51,"1,921.59",,,,,,
Aetna Commercial,CPT,93313,Echo transesophageal,Cardiac Studies,Straight Discount,65.00%,OP,471.51,494.15,,,,,,
Aetna Commercial,CPT,93314,Echo transesophageal,Cardiac Studies,Straight Discount,65.00%,OP,"1,662.33","1,662.33",,,,,,
Aetna Commercial,CPT,93315,Echo transesophageal,Cardiac Studies,Straight Discount,65.00%,OP,471.51,"1,738.59",,,,,,
Aetna Commercial,CPT,93316,Echo transesophageal,Cardiac Studies,Straight Discount,65.00%,OP,259.27,494.15,,,,,,
Aetna Commercial,CPT,93317,Echo transesophageal,Cardiac Studies,Straight Discount,65.00%,OP,"1,082.81","1,082.81",,,,,,
Aetna Commercial,CPT,93318,Echo transesophageal intraop,Cardiac Studies,Straight Discount,65.00%,OP,471.51,"1,330.63",,,,,,
Aetna Commercial,CPT,93319,3d echo img cgen car anomal,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93320,Doppler echo exam heart,Cardiac Studies,Straight Discount,65.00%,OP,468.96,468.96,,,,,,
Aetna Commercial,CPT,93321,Doppler echo exam heart,Cardiac Studies,Straight Discount,65.00%,OP,217.32,217.32,,,,,,
Aetna Commercial,CPT,93322,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93323,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93324,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93325,Doppler color flow add-on,Cardiac Studies,Straight Discount,65.00%,OP,346.96,346.96,,,,,,
Aetna Commercial,CPT,93326,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93327,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93328,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93329,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93330,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93331,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93332,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93333,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93334,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93335,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93336,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93337,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93338,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93339,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93340,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93341,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93342,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93343,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93344,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93345,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93346,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93347,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93348,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93349,Unknown,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93350,Stress tte only,Cardiac Studies,Straight Discount,65.00%,OP,471.51,"1,239.13",,,,,,
Aetna Commercial,CPT,93351,Stress tte complete,Cardiac Studies,Straight Discount,65.00%,OP,471.51,"1,635.64",,,,,,
Aetna Commercial,CPT,93352,Admin ecg contrast agent,Cardiac Studies,Straight Discount,65.00%,OP,228.77,228.77,,,,,,
Aetna Commercial,CPT,93451,Right heart cath,Cardiac Cath Procedures,Straight Discount,65.00%,OP,"2,829.67","9,201.00",,,,,,
Aetna Commercial,CPT,93452,Left hrt cath w/ventrclgrphy,Cardiac Cath Procedures,Straight Discount,65.00%,OP,"2,829.67","9,201.00",,,,,,
Aetna Commercial,CPT,93453,R&l hrt cath w/ventriclgrphy,Cardiac Cath Procedures,Straight Discount,65.00%,OP,"2,829.67","9,201.00",,,,,,
Aetna Commercial,CPT,93454,Coronary artery angio s&i,Cardiac Cath Procedures,Straight Discount,65.00%,OP,"2,829.67","2,966.62",,,,,,
Aetna Commercial,CPT,93455,Coronary art/grft angio s&i,Cardiac Cath Procedures,Straight Discount,65.00%,OP,"2,829.67","2,966.62",,,,,,
Aetna Commercial,CPT,93456,R hrt coronary artery angio,Cardiac Cath Procedures,Straight Discount,65.00%,OP,"2,829.67","9,201.00",,,,,,
Aetna Commercial,CPT,93457,R hrt art/grft angio,Cardiac Cath Procedures,Straight Discount,65.00%,OP,"2,829.67","9,201.00",,,,,,
Aetna Commercial,CPT,93458,L hrt artery/ventricle angio,Cardiac Cath Procedures,Straight Discount,65.00%,OP,"2,829.67","9,201.00",,,,,,
Aetna Commercial,CPT,93459,L hrt art/grft angio,Cardiac Cath Procedures,Straight Discount,65.00%,OP,"2,829.67","9,201.00",,,,,,
Aetna Commercial,CPT,93460,R&l hrt art/ventricle angio,Cardiac Cath Procedures,Straight Discount,65.00%,OP,"2,829.67","9,201.00",,,,,,
Aetna Commercial,CPT,93461,R&l hrt art/ventricle angio,Cardiac Cath Procedures,Straight Discount,65.00%,OP,"2,829.67","9,201.00",,,,,,
Aetna Commercial,CPT,93462,L hrt cath trnsptl puncture,Cardiac Cath Procedures,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93503,Insert/place heart catheter,Cardiac Cath Procedures,Straight Discount,65.00%,OP,651.97,"1,438.93",,,,,,
Aetna Commercial,CPT,93504,Unknown,Cardiac Cath Procedures,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93505,Biopsy of heart lining,Cardiac Cath Procedures,Straight Discount,65.00%,OP,"2,793.47","4,346.47",,,,,,
Aetna Commercial,CPT,93530,Rt heart cath congenital,Cardiac Cath Procedures,Straight Discount,65.00%,OP,"2,966.62","9,201.00",,,,,,
Aetna Commercial,CPT,93531,R & l heart cath congenital,Cardiac Cath Procedures,Straight Discount,65.00%,OP,"2,966.62","16,124.56",,,,,,
Aetna Commercial,CPT,93532,R & l heart cath congenital,Cardiac Cath Procedures,Straight Discount,65.00%,OP,"2,966.62","16,600.26",,,,,,
Aetna Commercial,CPT,93533,R & l heart cath congenital,Cardiac Cath Procedures,Straight Discount,65.00%,OP,"2,966.62","16,111.09",,,,,,
Aetna Commercial,CPT,93563,Inject congenital card cath,Cardiac Cath Injections,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93564,Inject hrt congntl art/grft,Cardiac Cath Injections,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93565,Inject l ventr/atrial angio,Cardiac Cath Injections,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93566,Inject r ventr/atrial angio,Cardiac Cath Injections,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93567,Inject suprvlv aortography,Cardiac Cath Injections,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93568,Inject pulm art hrt cath,Cardiac Cath Injections,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93880,Extracranial bilat study,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,224.53,"1,239.13",,,,,,
Aetna Commercial,CPT,93881,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93882,Extracranial uni/ltd study,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,106.24,815.92,,,,,,
Aetna Commercial,CPT,93883,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93884,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93885,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93886,Intracranial complete study,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,224.53,"1,483.14",,,,,,
Aetna Commercial,CPT,93887,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93888,Intracranial limited study,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,106.24,"1,010.37",,,,,,
Aetna Commercial,CPT,93889,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93890,Tcd vasoreactivity study,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,224.53,"1,307.75",,,,,,
Aetna Commercial,CPT,93891,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93892,Tcd emboli detect w/o inj,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,106.24,"1,425.95",,,,,,
Aetna Commercial,CPT,93893,Tcd emboli detect w/inj,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,106.24,"1,422.14",,,,,,
Aetna Commercial,CPT,93894,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93895,Carotid intima atheroma eval,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93896,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93897,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93898,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93899,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93900,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93901,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93902,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93903,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93904,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93905,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93906,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93907,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93908,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93909,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93910,LOWER LIMB ARTERY STUDY,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93911,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93912,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93913,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93914,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93915,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93916,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93917,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93918,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93919,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93920,UPPER EXTREMITY STUDY,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93921,LOWER EXTREMITY STUDY,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93922,Upr/l xtremity art 2 levels,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,110.04,594.77,,,,,,
Aetna Commercial,CPT,93923,Upr/lxtr art stdy 3+ lvls,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,136.24,922.67,,,,,,
Aetna Commercial,CPT,93924,Lwr xtr vasc stdy bilat,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,258.26,"1,136.19",,,,,,
Aetna Commercial,CPT,93925,Lower extremity study,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,224.53,"1,525.07",,,,,,
Aetna Commercial,CPT,93926,Lower extremity study,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,106.24,976.05,,,,,,
Aetna Commercial,CPT,93927,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93928,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93929,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93930,Upper extremity study,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,224.53,"1,223.88",,,,,,
Aetna Commercial,CPT,93931,Upper extremity study,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,106.24,815.92,,,,,,
Aetna Commercial,CPT,93932,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93933,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93934,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93935,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93936,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93937,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93938,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93939,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93940,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93941,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93942,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93943,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93944,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93945,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93946,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93947,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93948,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93949,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93950,LIMB VEIN STUDY,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93951,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93952,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93953,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93954,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93955,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93956,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93957,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93958,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93959,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93960,VENOUS FLOW STUDY-CALF,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93961,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93962,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93963,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93964,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93965,Extremity study,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,606.21,606.21,,,,,,
Aetna Commercial,CPT,93966,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93967,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93968,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93969,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93970,Extremity study,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,224.53,"1,273.44",,,,,,
Aetna Commercial,CPT,93971,Extremity study,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,106.24,842.61,,,,,,
Aetna Commercial,CPT,93972,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93973,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93974,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93975,Vascular study,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,224.53,367.82,,,,,,
Aetna Commercial,CPT,93976,Vascular study,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,106.24,"1,082.81",,,,,,
Aetna Commercial,CPT,93977,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93978,Vascular study,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,224.53,"1,197.20",,,,,,
Aetna Commercial,CPT,93979,Vascular study,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,106.24,823.54,,,,,,
Aetna Commercial,CPT,93980,Penile vascular study,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,106.24,934.12,,,,,,
Aetna Commercial,CPT,93981,Penile vascular study,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,106.24,667.22,,,,,,
Aetna Commercial,CPT,93982,Aneurysm pressure sens study,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,190.64,190.64,,,,,,
Aetna Commercial,CPT,93983,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93984,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93985,Dup-scan hemo compl bi std,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,224.53,"1,136.19",,,,,,
Aetna Commercial,CPT,93986,Dup-scan hemo compl uni std,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,106.24,646.72,,,,,,
Aetna Commercial,CPT,93987,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93988,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93989,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93990,Doppler flow testing,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,106.24,956.99,,,,,,
Aetna Commercial,CPT,93991,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93992,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93993,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93994,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93995,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93996,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93997,Unknown,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,93998,Noninvas vasc dx study proc,Vascular Diagnostic Studies,Straight Discount,65.00%,OP,24.1,25.25,,,,,,
Aetna Commercial,CPT,96401,Chemo anti-neopl sq/im,Chemotherapy,Straight Discount,65.00%,OP,60.5,377.46,,,,,,
Aetna Commercial,CPT,96402,Chemo hormon antineopl sq/im,Chemotherapy,Straight Discount,65.00%,OP,60.5,205.88,,,,,,
Aetna Commercial,CPT,96403,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96404,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96405,Chemo intralesional up to 7,Chemotherapy,Straight Discount,65.00%,OP,60.5,468.96,,,,,,
Aetna Commercial,CPT,96406,Chemo intralesional over 7,Chemotherapy,Straight Discount,65.00%,OP,199.63,648.16,,,,,,
Aetna Commercial,CPT,96407,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96408,CHEMOTHERAPY-PUSH TECHNIQUE,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96409,Chemo iv push sngl drug,Chemotherapy,Straight Discount,65.00%,OP,199.63,629.1,,,,,,
Aetna Commercial,CPT,96410,CHEMOTHERAPY-INFUSION METHOD,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96411,Chemo iv push addl drug,Chemotherapy,Straight Discount,65.00%,OP,60.5,362.21,,,,,,
Aetna Commercial,CPT,96412,CHEMOTX INFUSE METHOD ADD-ON,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96413,Chemo iv infusion 1 hr,Chemotherapy,Straight Discount,65.00%,OP,133.34,318,,,,,,
Aetna Commercial,CPT,96414,CHEMOTX INFUSE METHOD ADD-ON,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96415,Chemo iv infusion addl hr,Chemotherapy,Straight Discount,65.00%,OP,60.5,202.07,,,,,,
Aetna Commercial,CPT,96416,Chemo prolong infuse w/pump,Chemotherapy,Straight Discount,65.00%,OP,311.14,926.48,,,,,,
Aetna Commercial,CPT,96417,Chemo iv infus each addl seq,Chemotherapy,Straight Discount,65.00%,OP,60.5,427.03,,,,,,
Aetna Commercial,CPT,96418,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96419,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96420,Chemo ia push tecnique,Chemotherapy,Straight Discount,65.00%,OP,311.14,613.85,,,,,,
Aetna Commercial,CPT,96421,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96422,Chemo ia infusion up to 1 hr,Chemotherapy,Straight Discount,65.00%,OP,199.63,979.86,,,,,,
Aetna Commercial,CPT,96423,Chemo ia infuse each addl hr,Chemotherapy,Straight Discount,65.00%,OP,39.05,434.65,,,,,,
Aetna Commercial,CPT,96424,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96425,Chemotherapy infusion method,Chemotherapy,Straight Discount,65.00%,OP,311.14,968.43,,,,,,
Aetna Commercial,CPT,96426,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96427,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96428,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96429,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96430,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96431,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96432,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96433,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96434,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96435,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96436,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96437,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96438,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96439,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96440,Chemotherapy intracavitary,Chemotherapy,Straight Discount,65.00%,OP,311.14,"3,339.91",,,,,,
Aetna Commercial,CPT,96441,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96442,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96443,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96444,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96445,Chemotherapy - intracavitary,Chemotherapy,Straight Discount,65.00%,OP,"1,589.90","1,589.90",,,,,,
Aetna Commercial,CPT,96446,Chemotx admn prtl cavity,Chemotherapy,Straight Discount,65.00%,OP,311.14,318,,,,,,
Aetna Commercial,CPT,96447,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96448,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96449,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96450,Chemotherapy into cns,Chemotherapy,Straight Discount,65.00%,OP,311.14,"1,159.06",,,,,,
Aetna Commercial,CPT,96451,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96452,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96453,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96454,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96455,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96456,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96457,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96458,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96459,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96460,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96461,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96462,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96463,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96464,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96465,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96466,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96467,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96468,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96469,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96470,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96471,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96472,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96473,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96474,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96475,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96476,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96477,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96478,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96479,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96480,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96481,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96482,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96483,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96484,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96485,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96486,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96487,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96488,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96489,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96490,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96491,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96492,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96493,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96494,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96495,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96496,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96497,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96498,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96499,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96500,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96501,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96502,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96503,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96504,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96505,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96506,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96507,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96508,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96509,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96510,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96511,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96512,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96513,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96514,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96515,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96516,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96517,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96518,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96519,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96520,PUMP REFILLING-MAINTENANCE,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96521,Refill/maint portable pump,Chemotherapy,Straight Discount,65.00%,OP,199.63,716.79,,,,,,
Aetna Commercial,CPT,96522,Refill/maint pump/resvr syst,Chemotherapy,Straight Discount,65.00%,OP,199.63,610.03,,,,,,
Aetna Commercial,CPT,96523,Irrig drug delivery device,Chemotherapy,Straight Discount,65.00%,OP,54.32,141.07,,,,,,
Aetna Commercial,CPT,96524,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96525,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96526,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96527,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96528,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96529,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96530,PUMP REFILLING-MAINTENANCE,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96531,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96532,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96533,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96534,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96535,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96536,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96537,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96538,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96539,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96540,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96541,Unknown,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,96542,Chemotherapy injection,Chemotherapy,Straight Discount,65.00%,OP,199.63,751.1,,,,,,
Aetna Commercial,CPT,0042T,Ct perfusion w/contrast cbf,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,0408T,Insj/rplc cardiac modulj sys,Cardiac Cath Procedures,Straight Discount,65.00%,OP,"22,502.36","23,577.44",,,,,,
Aetna Commercial,CPT,0409T,Insj/rplc car modulj pls gn,Cardiac Cath Procedures,Straight Discount,65.00%,OP,"22,502.36","23,577.44",,,,,,
Aetna Commercial,CPT,0410T,Insj/rplc car modulj atr elt,Cardiac Cath Procedures,Straight Discount,65.00%,OP,"7,961.41","8,342.69",,,,,,
Aetna Commercial,CPT,0411T,Insj/rplc car modulj vnt elt,Cardiac Cath Procedures,Straight Discount,65.00%,OP,"7,961.41","8,342.69",,,,,,
Aetna Commercial,CPT,0412T,Rmvl cardiac modulj pls gen,Cardiac Cath Procedures,Straight Discount,65.00%,OP,"3,360.25","3,520.60",,,,,,
Aetna Commercial,CPT,0413T,Rmvl car modulj tranvns elt,Cardiac Cath Procedures,Straight Discount,65.00%,OP,"3,360.25","3,520.60",,,,,,
Aetna Commercial,CPT,0414T,Rmvl & rpl car modulj pls gn,Cardiac Cath Procedures,Straight Discount,65.00%,OP,"22,502.36","23,577.44",,,,,,
Aetna Commercial,CPT,0415T,Repos car modulj tranvns elt,Cardiac Cath Procedures,Straight Discount,65.00%,OP,527.46,554.25,,,,,,
Aetna Commercial,CPT,0541T,Myocardial imaging mcg,Cardiac Studies,Straight Discount,65.00%,OP,476.34,499.16,,,,,,
Aetna Commercial,CPT,0542T,Myocardial imaging mcg i&r,Cardiac Studies,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,0543T,Ta mv rpr w/artif chord tend,Cardiac Cath Procedures,Straight Discount,65.00%,OP,"8,948.83","11,815.21",,,,,,
Aetna Commercial,CPT,0544T,Tcat mv annulus rcnstj,Cardiac Cath Procedures,Straight Discount,65.00%,OP,"8,948.83","11,815.21",,,,,,
Aetna Commercial,CPT,0545T,Tcat tv annulus rcnstj,Cardiac Cath Procedures,Straight Discount,65.00%,OP,"8,948.83","11,815.21",,,,,,
Aetna Commercial,CPT,0558T,Ct scan f/biomchn ct alys,CAT Scan,Per Case,$927.00 ,OP,78.93,927,,,,,,
Aetna Commercial,CPT,0569T,Ttvr perq appr 1st prosth,Cardiac Cath Procedures,Straight Discount,65.00%,OP,"8,948.83","11,815.21",,,,,,
Aetna Commercial,CPT,0570T,Ttvr perq ea addl prosth,Cardiac Cath Procedures,Straight Discount,65.00%,OP,"8,948.83","11,815.21",,,,,,
Aetna Commercial,CPT,06010T,,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,"1,507.00","1,507.00",,,,,,
Aetna Commercial,CPT,0609T,Mrs disc pain acquisj data,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,224.53,"1,507.00",,,,,,
Aetna Commercial,CPT,0611T,Mrs disc pain alg alys data,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,224.53,"1,507.00",,,,,,
Aetna Commercial,CPT,0612T,Mrs discogenic pain i&r,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,"1,507.00","1,507.00",,,,,,
Aetna Commercial,CPT,A9513,Lutetium lu 177 dotatat ther,Chemotherapy Drugs,Straight Discount,65.00%,OP,274.33,274.33,,,,,,
Aetna Commercial,CPT,A9590,Iodine i-131 iobenguane 1mci,Chemotherapy Drugs,Straight Discount,65.00%,OP,320.12,320.12,,,,,,
Aetna Commercial,CPT,C8900,Mra w/cont- abd,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,359.34,"1,507.00",,,,,,
Aetna Commercial,CPT,C8901,Mra w/o cont- abd,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,224.53,"1,507.00",,,,,,
Aetna Commercial,CPT,C8902,Mra w/o fol w/cont- abd,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,359.34,"1,507.00",,,,,,
Aetna Commercial,CPT,C8903,Mri w/cont- breast-  uni,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,174.31,"1,507.00",,,,,,
Aetna Commercial,CPT,C8904,Mri w/o cont breast uni,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,"1,507.00","1,507.00",,,,,,
Aetna Commercial,CPT,C8905,Mri w/o fol w/cont- brst- un,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,359.34,"1,507.00",,,,,,
Aetna Commercial,CPT,C8906,Mri w/cont- breast-  bi,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,359.34,"1,507.00",,,,,,
Aetna Commercial,CPT,C8907,Mri w/o cont breast bi,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,"1,507.00","1,507.00",,,,,,
Aetna Commercial,CPT,C8908,Mri w/o fol w/cont- breast-,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,359.34,"1,507.00",,,,,,
Aetna Commercial,CPT,C8909,Mra w/cont- chest,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,359.34,"1,507.00",,,,,,
Aetna Commercial,CPT,C8910,Mra w/o cont- chest,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,224.53,"1,507.00",,,,,,
Aetna Commercial,CPT,C8911,Mra w/o fol w/cont- chest,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,359.34,"1,507.00",,,,,,
Aetna Commercial,CPT,C8912,Mra w/cont- lwr ext,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,359.34,"1,507.00",,,,,,
Aetna Commercial,CPT,C8913,Mra w/o cont- lwr ext,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,224.53,"1,507.00",,,,,,
Aetna Commercial,CPT,C8914,Mra w/o fol w/cont- lwr ext,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,359.34,"1,507.00",,,,,,
Aetna Commercial,CPT,C8918,Mra w/cont- pelvis,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,359.34,"1,507.00",,,,,,
Aetna Commercial,CPT,C8919,Mra w/o cont- pelvis,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,224.53,"1,507.00",,,,,,
Aetna Commercial,CPT,C8920,Mra w/o fol w/cont- pelvis,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,359.34,"1,507.00",,,,,,
Aetna Commercial,CPT,C8931,Mra- w/dye- spinal canal,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,359.34,"1,507.00",,,,,,
Aetna Commercial,CPT,C8932,Mra- w/o dye- spinal canal,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,224.53,"1,507.00",,,,,,
Aetna Commercial,CPT,C8933,Mra- w/o&w/dye- spinal canal,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,359.34,"1,507.00",,,,,,
Aetna Commercial,CPT,C8934,Mra- w/dye- upper extremity,MRI/MRA Scan,Per Unit,"$1,507.00 ",OP,359.34,"1,507.00",,,,,,
Aetna Commercial,CPT,C9758,Blind interatrial shunt ide,Cardiac Cath Procedures,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,G0297,Ldct for lung ca screen,CAT Scan,Per Case,$927.00 ,OP,927,927,,,,,,
Aetna Commercial,CPT,G0448,Place perm pacing cardiovert,Cardiac Cath Procedures,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,J0129,Abatacept injection,Chemotherapy Drugs,Straight Discount,65.00%,OP,44.52,73.44,,,,,,
Aetna Commercial,CPT,J0594,Busulfan injection,Chemotherapy Drugs,Straight Discount,65.00%,OP,1.45,61,,,,,,
Aetna Commercial,CPT,J0642,Injection- khapzory- 0.5 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,1.83,1.86,,,,,,
Aetna Commercial,CPT,J0881,Darbepoetin alfa- non-esrd,Chemotherapy Drugs,Straight Discount,65.00%,OP,3.09,15.26,,,,,,
Aetna Commercial,CPT,J0885,Epoetin alfa- non-esrd,Chemotherapy Drugs,Straight Discount,65.00%,OP,8.15,45.74,,,,,,
Aetna Commercial,CPT,J0894,Decitabine injection,Chemotherapy Drugs,Straight Discount,65.00%,OP,2.88,3.45,,,,,,
Aetna Commercial,CPT,J1147,Unknown,Chemotherapy Drugs,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,J1190,Dexrazoxane hcl injection,Chemotherapy Drugs,Straight Discount,65.00%,OP,189.84,"1,849.16",,,,,,
Aetna Commercial,CPT,J2430,Pamidronate disodium /30 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,J3316,Inj.- triptorelin xr 3.75 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,"3,067.25","3,120.11",,,,,,
Aetna Commercial,CPT,J7345,Aminolevulinic acid- 10% gel,Chemotherapy Drugs,Straight Discount,65.00%,OP,1.59,1.59,,,,,,
Aetna Commercial,CPT,J7521,Unknown,Chemotherapy Drugs,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,J7650,Isoetharine comp unit,Chemotherapy Drugs,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,J8530,Cyclophosphamide oral 25 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,3.82,3.82,,,,,,
Aetna Commercial,CPT,J8540,Oral dexamethasone,Chemotherapy Drugs,Straight Discount,65.00%,OP,1.9,1.9,,,,,,
Aetna Commercial,CPT,J8560,Etoposide oral 50 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,75.51,75.63,,,,,,
Aetna Commercial,CPT,J8565,Gefitinib oral,Chemotherapy Drugs,Straight Discount,65.00%,OP,228.45,228.45,,,,,,
Aetna Commercial,CPT,J8597,Antiemetic drug oral nos,Chemotherapy Drugs,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,J8600,Melphalan oral 2 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,22.88,22.88,,,,,,
Aetna Commercial,CPT,J8610,Methotrexate oral 2.5 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,1.9,1.9,,,,,,
Aetna Commercial,CPT,J8700,Temozolomide,Chemotherapy Drugs,Straight Discount,65.00%,OP,32.68,32.68,,,,,,
Aetna Commercial,CPT,J8999,Oral prescription drug chemo,Chemotherapy Drugs,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,J9000,Doxorubicin hcl injection,Chemotherapy Drugs,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,J9015,Aldesleukin injection,Chemotherapy Drugs,Straight Discount,65.00%,OP,"3,795.26","3,795.26",,,,,,
Aetna Commercial,CPT,J9017,Arsenic trioxide injection,Chemotherapy Drugs,Straight Discount,65.00%,OP,12.81,179.2,,,,,,
Aetna Commercial,CPT,J9019,Erwinaze injection,Chemotherapy Drugs,Straight Discount,65.00%,OP,427.27,427.27,,,,,,
Aetna Commercial,CPT,J9020,Asparaginase- nos,Chemotherapy Drugs,Straight Discount,65.00%,OP,282.14,282.14,,,,,,
Aetna Commercial,CPT,J9022,Inj- atezolizumab-10 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,79.58,79.75,,,,,,
Aetna Commercial,CPT,J9023,Injection- avelumab- 10 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,86.19,87.61,,,,,,
Aetna Commercial,CPT,J9025,Azacitidine injection,Chemotherapy Drugs,Straight Discount,65.00%,OP,0.89,22.88,,,,,,
Aetna Commercial,CPT,J9027,Clofarabine injection,Chemotherapy Drugs,Straight Discount,65.00%,OP,53.15,564.29,,,,,,
Aetna Commercial,CPT,J9030,Bcg live intravesical 1mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,11.51,11.51,,,,,,
Aetna Commercial,CPT,J9032,Injection- belinostat- 10mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,42.77,43.42,,,,,,
Aetna Commercial,CPT,J9034,Inj.- bendeka 1 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,19.08,19.65,,,,,,
Aetna Commercial,CPT,J9035,Bevacizumab injection,Chemotherapy Drugs,Straight Discount,65.00%,OP,67.86,278.32,,,,,,
Aetna Commercial,CPT,J9036,Inj. belrapzo/bendamustine,Chemotherapy Drugs,Straight Discount,65.00%,OP,21.47,22.88,,,,,,
Aetna Commercial,CPT,J9039,Injection- blinatumomab,Chemotherapy Drugs,Straight Discount,65.00%,OP,123.88,124.11,,,,,,
Aetna Commercial,CPT,J9040,Bleomycin sulfate injection,Chemotherapy Drugs,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,J9041,Inj.- velcade 0.1 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,44.79,175.39,,,,,,
Aetna Commercial,CPT,J9042,Brentuximab vedotin inj,Chemotherapy Drugs,Straight Discount,65.00%,OP,189.34,196.55,,,,,,
Aetna Commercial,CPT,J9044,Inj- bortezomib- nos- 0.1 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,16.77,18.31,,,,,,
Aetna Commercial,CPT,J9045,Carboplatin injection,Chemotherapy Drugs,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,J9047,Injection- carfilzomib- 1 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,41.1,41.11,,,,,,
Aetna Commercial,CPT,J9050,Carmustine injection,Chemotherapy Drugs,Straight Discount,65.00%,OP,"1,099.82","1,234.46",,,,,,
Aetna Commercial,CPT,J9055,Cetuximab injection,Chemotherapy Drugs,Straight Discount,65.00%,OP,66.71,240.2,,,,,,
Aetna Commercial,CPT,J9057,Inj.- copanlisib- 1 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,80.96,81.04,,,,,,
Aetna Commercial,CPT,J9060,Cisplatin 10 mg injection,Chemotherapy Drugs,Straight Discount,65.00%,OP,134.21,134.21,,,,,,
Aetna Commercial,CPT,J9065,Inj cladribine per 1 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,15.08,144.88,,,,,,
Aetna Commercial,CPT,J9070,Cyclophosphamide 100 mg inj,Chemotherapy Drugs,Straight Discount,65.00%,OP,19.07,29.15,,,,,,
Aetna Commercial,CPT,J9118,Inj. calaspargase pegol-mknl,Chemotherapy Drugs,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,J9119,Inj.- cemiplimab-rwlc- 1 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,27.54,27.67,,,,,,
Aetna Commercial,CPT,J9120,Dactinomycin injection,Chemotherapy Drugs,Straight Discount,65.00%,OP,838.88,"2,634.57",,,,,,
Aetna Commercial,CPT,J9130,Dacarbazine 100 mg inj,Chemotherapy Drugs,Straight Discount,65.00%,OP,19.07,19.07,,,,,,
Aetna Commercial,CPT,J9145,Injection- daratumumab 10 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,57.22,57.55,,,,,,
Aetna Commercial,CPT,J9150,Daunorubicin injection,Chemotherapy Drugs,Straight Discount,65.00%,OP,40.36,80.07,,,,,,
Aetna Commercial,CPT,J9151,Daunorubicin citrate inj,Chemotherapy Drugs,Straight Discount,65.00%,OP,270.71,270.71,,,,,,
Aetna Commercial,CPT,J9153,Inj daunorubicin- cytarabine,Chemotherapy Drugs,Straight Discount,65.00%,OP,202.6,207.63,,,,,,
Aetna Commercial,CPT,J9160,Denileukin diftitox inj,Chemotherapy Drugs,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,J9165,Diethylstilbestrol injection,Chemotherapy Drugs,Straight Discount,65.00%,OP,57.19,57.19,,,,,,
Aetna Commercial,CPT,J9173,Inj.- durvalumab- 10 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,76.86,76.86,,,,,,
Aetna Commercial,CPT,J9175,Elliotts b solution per ml,Chemotherapy Drugs,Straight Discount,65.00%,OP,19.07,19.07,,,,,,
Aetna Commercial,CPT,J9176,Injection- elotuzumab- 1mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,6.77,6.86,,,,,,
Aetna Commercial,CPT,J9177,Inj enfort vedo-ejfv 0.25mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,30.17,30.19,,,,,,
Aetna Commercial,CPT,J9178,Inj- epirubicin hcl- 2 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,98.98,98.98,,,,,,
Aetna Commercial,CPT,J9181,Etoposide injection,Chemotherapy Drugs,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,J9185,Fludarabine phosphate inj,Chemotherapy Drugs,Straight Discount,65.00%,OP,716.79,716.79,,,,,,
Aetna Commercial,CPT,J9190,Fluorouracil injection,Chemotherapy Drugs,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,J9198,Inj. infugem- 100 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,25.08,34,,,,,,
Aetna Commercial,CPT,J9200,Floxuridine injection,Chemotherapy Drugs,Straight Discount,65.00%,OP,282.14,282.14,,,,,,
Aetna Commercial,CPT,J9201,In gemcitabine hcl nos 200mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,548.88,548.88,,,,,,
Aetna Commercial,CPT,J9202,Goserelin acetate implant,Chemotherapy Drugs,Straight Discount,65.00%,OP,525.21,915.04,,,,,,
Aetna Commercial,CPT,J9203,Gemtuzumab ozogamicin 0.1 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,207.99,211.11,,,,,,
Aetna Commercial,CPT,J9204,Inj mogamulizumab-kpkc- 1 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,210.05,212.64,,,,,,
Aetna Commercial,CPT,J9205,Inj irinotecan liposome 1 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,57.2,57.37,,,,,,
Aetna Commercial,CPT,J9206,Irinotecan injection,Chemotherapy Drugs,Straight Discount,65.00%,OP,482.59,482.59,,,,,,
Aetna Commercial,CPT,J9208,Ifosfamide injection,Chemotherapy Drugs,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,J9209,Mesna injection,Chemotherapy Drugs,Straight Discount,65.00%,OP,80.07,80.07,,,,,,
Aetna Commercial,CPT,J9211,Idarubicin hcl injection,Chemotherapy Drugs,Straight Discount,65.00%,OP,629.1,629.1,,,,,,
Aetna Commercial,CPT,J9212,Interferon alfacon-1 inj,Chemotherapy Drugs,Straight Discount,65.00%,OP,27.26,27.26,,,,,,
Aetna Commercial,CPT,J9213,Interferon alfa-2a inj,Chemotherapy Drugs,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,J9214,Interferon alfa-2b inj,Chemotherapy Drugs,Straight Discount,65.00%,OP,32.74,72.44,,,,,,
Aetna Commercial,CPT,J9215,Interferon alfa-n3 inj,Chemotherapy Drugs,Straight Discount,65.00%,OP,41.94,41.94,,,,,,
Aetna Commercial,CPT,J9216,Interferon gamma 1-b inj,Chemotherapy Drugs,Straight Discount,65.00%,OP,"1,772.90","1,772.90",,,,,,
Aetna Commercial,CPT,J9217,Leuprolide acetate suspnsion,Chemotherapy Drugs,Straight Discount,65.00%,OP,139.09,987.49,,,,,,
Aetna Commercial,CPT,J9218,Leuprolide acetate injeciton,Chemotherapy Drugs,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,J9219,Leuprolide acetate implant,Chemotherapy Drugs,Straight Discount,65.00%,OP,"23,402.31","23,402.31",,,,,,
Aetna Commercial,CPT,J9225,Vantas implant,Chemotherapy Drugs,Straight Discount,65.00%,OP,"5,166.29","7,613.94",,,,,,
Aetna Commercial,CPT,J9229,Inj inotuzumab ozogam 0.1 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,"2,371.62","2,407.20",,,,,,
Aetna Commercial,CPT,J9230,Mechlorethamine hcl inj,Chemotherapy Drugs,Straight Discount,65.00%,OP,11.74,712.98,,,,,,
Aetna Commercial,CPT,J9245,Inj melpha hydroch nos 50 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,197.46,"7,888.46",,,,,,
Aetna Commercial,CPT,J9246,Inj.- evomela- 1 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,18.2,18.2,,,,,,
Aetna Commercial,CPT,J9250,Methotrexate sodium inj,Chemotherapy Drugs,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,J9260,Methotrexate sodium inj,Chemotherapy Drugs,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,J9261,Nelarabine injection,Chemotherapy Drugs,Straight Discount,65.00%,OP,155.9,488.04,,,,,,
Aetna Commercial,CPT,J9262,Inj- omacetaxine mep- 0.01mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,3.3,3.3,,,,,,
Aetna Commercial,CPT,J9263,Oxaliplatin,Chemotherapy Drugs,Straight Discount,65.00%,OP,45.74,45.74,,,,,,
Aetna Commercial,CPT,J9264,Paclitaxel protein bound,Chemotherapy Drugs,Straight Discount,65.00%,OP,14.04,45.74,,,,,,
Aetna Commercial,CPT,J9266,Pegaspargase injection,Chemotherapy Drugs,Straight Discount,65.00%,OP,"12,715.34","21,561.05",,,,,,
Aetna Commercial,CPT,J9267,Paclitaxel injection,Chemotherapy Drugs,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,J9268,Pentostatin injection,Chemotherapy Drugs,Straight Discount,65.00%,OP,"1,880.67","7,030.61",,,,,,
Aetna Commercial,CPT,J9269,Inj. tagraxofusp-erzs 10 mcg,Chemotherapy Drugs,Straight Discount,65.00%,OP,290.37,296.34,,,,,,
Aetna Commercial,CPT,J9270,Plicamycin (mithramycin) inj,Chemotherapy Drugs,Straight Discount,65.00%,OP,115.4,385.09,,,,,,
Aetna Commercial,CPT,J9271,Inj pembrolizumab,Chemotherapy Drugs,Straight Discount,65.00%,OP,52.3,52.75,,,,,,
Aetna Commercial,CPT,J9280,Mitomycin injection,Chemotherapy Drugs,Straight Discount,65.00%,OP,38.63,76.26,,,,,,
Aetna Commercial,CPT,J9285,Inj- olaratumab- 10 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,52.07,52.07,,,,,,
Aetna Commercial,CPT,J9293,Mitoxantrone hydrochl / 5 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,26.29,392.7,,,,,,
Aetna Commercial,CPT,J9295,Injection- necitumumab- 1 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,5.74,5.74,,,,,,
Aetna Commercial,CPT,J9299,Injection- nivolumab,Chemotherapy Drugs,Straight Discount,65.00%,OP,28.86,29.25,,,,,,
Aetna Commercial,CPT,J9301,Obinutuzumab inj,Chemotherapy Drugs,Straight Discount,65.00%,OP,64.11,64.54,,,,,,
Aetna Commercial,CPT,J9305,Inj. pemetrexed nos 10mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,74.93,232.58,,,,,,
Aetna Commercial,CPT,J9306,Injection- pertuzumab- 1 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,13.56,13.56,,,,,,
Aetna Commercial,CPT,J9308,Injection- ramucirumab,Chemotherapy Drugs,Straight Discount,65.00%,OP,62.69,63.56,,,,,,
Aetna Commercial,CPT,J9309,Inj- polatuzumab vedotin 1mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,113.57,113.57,,,,,,
Aetna Commercial,CPT,J9311,Inj rituximab- hyaluronidase,Chemotherapy Drugs,Straight Discount,65.00%,OP,37.94,38.21,,,,,,
Aetna Commercial,CPT,J9312,Inj.- rituximab- 10 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,85.63,86.94,,,,,,
Aetna Commercial,CPT,J9313,Inj.- lumoxiti- 0.01 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,23.39,23.39,,,,,,
Aetna Commercial,CPT,J9320,Streptozocin injection,Chemotherapy Drugs,Straight Discount,65.00%,OP,347.88,"1,372.57",,,,,,
Aetna Commercial,CPT,J9325,Inj talimogene laherparepvec,Chemotherapy Drugs,Straight Discount,65.00%,OP,57.22,57.26,,,,,,
Aetna Commercial,CPT,J9340,Thiotepa injection,Chemotherapy Drugs,Straight Discount,65.00%,OP,305.45,446.08,,,,,,
Aetna Commercial,CPT,J9351,Topotecan injection,Chemotherapy Drugs,Straight Discount,65.00%,OP,116.21,116.21,,,,,,
Aetna Commercial,CPT,J9353,Inj. margetuximab-cmkb- 5 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,42.99,43.76,,,,,,
Aetna Commercial,CPT,J9354,Inj- ado-trastuzumab emt 1mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,34.15,34.18,,,,,,
Aetna Commercial,CPT,J9355,Inj trastuzumab excl biosimi,Chemotherapy Drugs,Straight Discount,65.00%,OP,86.41,238.1,,,,,,
Aetna Commercial,CPT,J9356,Inj. herceptin hylecta- 10mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,71.49,71.85,,,,,,
Aetna Commercial,CPT,J9357,Valrubicin injection,Chemotherapy Drugs,Straight Discount,65.00%,OP,"1,425.37","1,795.78",,,,,,
Aetna Commercial,CPT,J9358,Inj fam-trastu deru-nxki 1mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,24.27,24.6,,,,,,
Aetna Commercial,CPT,J9360,Vinblastine sulfate inj,Chemotherapy Drugs,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,J9370,Vincristine sulfate 1 mg inj,Chemotherapy Drugs,Straight Discount,65.00%,OP,28.22,28.22,,,,,,
Aetna Commercial,CPT,J9371,Inj- vincristine sul lip 1mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,28.22,"3,420.78",,,,,,
Aetna Commercial,CPT,J9390,Vinorelbine tartrate inj,Chemotherapy Drugs,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,J9395,Injection- fulvestrant,Chemotherapy Drugs,Straight Discount,65.00%,OP,15.65,396.52,,,,,,
Aetna Commercial,CPT,J9400,Inj- ziv-aflibercept- 1mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,7.66,8.42,,,,,,
Aetna Commercial,CPT,J9600,Porfimer sodium injection,Chemotherapy Drugs,Straight Discount,65.00%,OP,"13,169.04","21,856.35",,,,,,
Aetna Commercial,CPT,J9999,Chemotherapy drug,Chemotherapy Drugs,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,JJ9100,Unknown,Chemotherapy Drugs,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,Q0083,Chemo by other than infusion,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,Q0084,Chemotherapy by infusion,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,Q0085,Chemo by both infusion and o,Chemotherapy,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,Q2017,Teniposide- 50 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,"1,582.28","2,645.71",,,,,,
Aetna Commercial,CPT,Q2041,Axicabtagene ciloleucel car+,Chemotherapy Drugs,Straight Discount,65.00%,OP,"395,380.00","411,916.00",,,,,,
Aetna Commercial,CPT,Q2042,Tisagenlecleucel car-pos t,Chemotherapy Drugs,Straight Discount,65.00%,OP,"429,374.63","434,337.60",,,,,,
Aetna Commercial,CPT,Q2050,Doxorubicin inj 10mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,200.52,"1,719.01",,,,,,
Aetna Commercial,CPT,Q5107,Inj mvasi 10 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,39.77,44.56,,,,,,
Aetna Commercial,CPT,Q5112,Inj ontruzant 10 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,61.11,66.55,,,,,,
Aetna Commercial,CPT,Q5113,Inj herzuma 10 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,48.5,57.3,,,,,,
Aetna Commercial,CPT,Q5114,Inj ogivri 10 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,55.72,59.91,,,,,,
Aetna Commercial,CPT,Q5115,Inj truxima 10 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,57.35,60.58,,,,,,
Aetna Commercial,CPT,Q5116,Inj.- trazimera- 10 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,55.79,59.93,,,,,,
Aetna Commercial,CPT,Q5117,Inj.- kanjinti- 10 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,47.41,53.18,,,,,,
Aetna Commercial,CPT,Q5118,Inj.- zirabev- 10 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,50.59,52.37,,,,,,
Aetna Commercial,CPT,Q5119,Inj ruxience- 10 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,56.37,58.8,,,,,,
Aetna Commercial,CPT,S0088,Imatinib 100 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,118.99,118.99,,,,,,
Aetna Commercial,CPT,S0108,Mercaptopurine 50 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,6.72,6.72,,,,,,
Aetna Commercial,CPT,S0117,Tretinoin topical 5 g,Chemotherapy Drugs,Straight Discount,65.00%,OP,49.56,49.56,,,,,,
Aetna Commercial,CPT,s0145,Peg interferon alfa-2a/180,Chemotherapy Drugs,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,S0148,Peg interferon alfa-2b/10,Chemotherapy Drugs,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,S0156,Exemestane 25 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,41.33,41.33,,,,,,
Aetna Commercial,CPT,S0170,Anastrozole 1 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,49.56,49.56,,,,,,
Aetna Commercial,CPT,S0172,Chlorambucil 2 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,15.26,15.26,,,,,,
Aetna Commercial,CPT,S0175,Flutamide 125 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,7.62,7.62,,,,,,
Aetna Commercial,CPT,S0176,Hydroxyurea 500 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,7.62,7.62,,,,,,
Aetna Commercial,CPT,S0178,Lomustine 10 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,41.94,41.94,,,,,,
Aetna Commercial,CPT,S0179,Megestrol 20 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,CPT,S0182,Procarbazine oral,Chemotherapy Drugs,Straight Discount,65.00%,OP,176.19,176.19,,,,,,
Aetna Commercial,CPT,S0183,Prochlorperazine 5 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,3.82,3.82,,,,,,
Aetna Commercial,CPT,S0187,Tamoxifen 10 mg,Chemotherapy Drugs,Straight Discount,65.00%,OP,7.62,7.62,,,,,,
Aetna Commercial,ExceptRevenueCode,274,Medical/Surgical Supplies: Prosthetic/Orthotic devices,Implants,Straight Discount,60.00%,OP,,,,,,,,
Aetna Commercial,ExceptRevenueCode,275,Medical/Surgical Supplies: Pacemaker,Implants,Straight Discount,60.00%,OP,,,,,,,,
Aetna Commercial,ExceptRevenueCode,278,Medical/Surgical Supplies: Other implants,Implants,Straight Discount,60.00%,OP,,,,,,,,
Aetna Commercial,ExceptRevenueCode,450,Emergency Room,ER,Straight Discount,60.00%,OP,"5,158.50","5,158.50",,,,,,
Aetna Commercial,ExceptRevenueCode,451,Emergency Room: EM/EMTALA,ER,Straight Discount,60.00%,OP,,,,,,,,
Aetna Commercial,ExceptRevenueCode,452,Emergency Room: ER/ Beyond EMTALA,ER,Straight Discount,60.00%,OP,,,,,,,,
Aetna Commercial,ExceptRevenueCode,459,Emergency Room: Other emergency room,ER,Straight Discount,60.00%,OP,,,,,,,,
Aetna Commercial,ExceptRevenueCode,760,Treatment/Observation Room,Observation,Straight Discount,60.00%,OP,"2,420.00","3,464.00",,,,,,
Aetna Commercial,ExceptRevenueCode,762,Treatment/Observation Room: Observation room,Observation,Straight Discount,60.00%,OP,"2,420.00","10,316.98",,,,,,
Aetna Commercial,ExceptRevenueCode,769,Treatment/Observation Room: Other treatment room,Observation,Straight Discount,60.00%,OP,"2,944.00","3,464.00",,,,,,
Aetna Commercial,ExceptRevenueCode,820,Hemo OPD/Home,Outpatient Dialysis,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,ExceptRevenueCode,821,Hemo OPD/Home: Hemodialysis comp or other rate,Outpatient Dialysis,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,ExceptRevenueCode,829,Hemo OPD/Home: Other HEMO outpatient,Outpatient Dialysis,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,ExceptRevenueCode,831,Peritoneal OPD/Home: Peritoneal comp or other rate,Outpatient Dialysis,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,ExceptRevenueCode,841,CAPD OPD/Home: CAPD comp or other rate,Outpatient Dialysis,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,ExceptRevenueCode,851,CCPD OPD/Home: CCPD comp or other rate,Outpatient Dialysis,Straight Discount,65.00%,OP,,,,,,,,
Aetna Commercial,,,,All Other,Straight Discount,65.00%,OP,,,,,,,,
Aetna MCR ADV,DRG,MS-001,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W MCC,Surgical,Relative Weights,"$168,855.33 ",IP,"17,718.00","557,099.42",,,,,,
Aetna MCR ADV,DRG,MS-002,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W/O MCC,Surgical,Relative Weights,"$87,426.55 ",IP,"17,718.00","282,516.19",,,,,,
Aetna MCR ADV,DRG,MS-003,ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITH MAJOR O.R. PROCEDURES,Surgical,Relative Weights,"$111,577.60 ",IP,"111,577.60","382,110.62",,,,,,
Aetna MCR ADV,DRG,MS-004,TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES,Surgical,Relative Weights,"$69,628.33 ",IP,"69,628.33","232,723.01",,,,,,
Aetna MCR ADV,DRG,MS-005,LIVER TRANSPLANT W MCC OR INTESTINAL TRANSPLANT,Surgical,Relative Weights,"$59,773.19 ",IP,"59,773.19","207,904.03",,,,,,
Aetna MCR ADV,DRG,MS-006,LIVER TRANSPLANT W/O MCC,Surgical,Relative Weights,"$27,427.34 ",IP,"27,427.34","98,217.50",,,,,,
Aetna MCR ADV,DRG,MS-007,LUNG TRANSPLANT,Surgical,Relative Weights,"$67,628.10 ",IP,"67,628.10","217,451.81",,,,,,
Aetna MCR ADV,DRG,MS-008,SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,Surgical,Relative Weights,"$31,730.89 ",IP,"31,730.89","113,220.58",,,,,,
Aetna MCR ADV,DRG,MS-010,PANCREAS TRANSPLANT,Surgical,Relative Weights,"$21,141.08 ",IP,"2,420.00","80,158.18",,,,,,
Aetna MCR ADV,DRG,MS-011,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC,Surgical,Relative Weights,"$29,325.37 ",IP,"2,420.00","99,667.01",,,,,,
Aetna MCR ADV,DRG,MS-012,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC,Surgical,Relative Weights,"$22,383.85 ",IP,"2,420.00","76,083.84",,,,,,
Aetna MCR ADV,DRG,MS-013,TRACHEOSTOMY FOR FACE -  MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC,Surgical,Relative Weights,"$15,907.20 ",IP,"2,420.00","48,894.05",,,,,,
Aetna MCR ADV,DRG,MS-014,ALLOGENEIC BONE MARROW TRANSPLANT,Surgical,Relative Weights,"$62,354.51 ",IP,"2,420.00","257,136.77",,,,,,
Aetna MCR ADV,DRG,MS-016,AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,Surgical,Relative Weights,"$39,340.51 ",IP,"2,420.00","138,805.63",,,,,,
Aetna MCR ADV,DRG,MS-017,AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,Surgical,Relative Weights,"$28,357.66 ",IP,"2,420.00","89,659.58",,,,,,
Aetna MCR ADV,DRG,MS-018,CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,Medical,Relative Weights,"$218,711.49 ",IP,"2,420.00","218,711.49",,,,,,
Aetna MCR ADV,DRG,MS-019,SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,Surgical,Relative Weights,"$39,009.97 ",IP,"2,420.00","39,009.97",,,,,,
Aetna MCR ADV,DRG,MS-020,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,Surgical,Relative Weights,"$60,368.88 ",IP,"2,420.00","218,151.36",,,,,,
Aetna MCR ADV,DRG,MS-021,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,Surgical,Relative Weights,"$44,054.63 ",IP,"2,420.00","166,797.79",,,,,,
Aetna MCR ADV,DRG,MS-022,INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W/O CC/MCC,Surgical,Relative Weights,"$28,282.33 ",IP,"2,420.00","99,425.09",,,,,,
Aetna MCR ADV,DRG,MS-023,CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX CNS PDX W MCC OR CHEMO IMPLANT,Surgical,Relative Weights,"$33,124.34 ",IP,"2,420.00","113,240.74",,,,,,
Aetna MCR ADV,DRG,MS-024,CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,Surgical,Relative Weights,"$23,004.07 ",IP,"2,420.00","80,972.64",,,,,,
Aetna MCR ADV,DRG,MS-025,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$26,265.17 ",IP,"2,420.00","88,593.12",,,,,,
Aetna MCR ADV,DRG,MS-026,CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC,Surgical,Relative Weights,"$17,882.32 ",IP,"2,420.00","61,403.33",,,,,,
Aetna MCR ADV,DRG,MS-027,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$14,683.71 ",IP,"2,420.00","48,317.47",,,,,,
Aetna MCR ADV,DRG,MS-028,SPINAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$34,007.36 ",IP,"2,420.00","112,702.46",,,,,,
Aetna MCR ADV,DRG,MS-029,SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,Surgical,Relative Weights,"$19,253.57 ",IP,"2,420.00","64,653.12",,,,,,
Aetna MCR ADV,DRG,MS-030,SPINAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$13,763.89 ",IP,"2,420.00","45,805.54",,,,,,
Aetna MCR ADV,DRG,MS-031,VENTRICULAR SHUNT PROCEDURES WITH MCC,Surgical,Relative Weights,"$25,531.07 ",IP,"2,420.00","88,189.92",,,,,,
Aetna MCR ADV,DRG,MS-032,VENTRICULAR SHUNT PROCEDURES WITH CC,Surgical,Relative Weights,"$12,944.53 ",IP,"2,420.00","44,192.74",,,,,,
Aetna MCR ADV,DRG,MS-033,VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,057.78 ",IP,"2,420.00","34,290.14",,,,,,
Aetna MCR ADV,DRG,MS-034,CAROTID ARTERY STENT PROCEDURE W MCC,Surgical,Relative Weights,"$23,232.41 ",IP,"2,420.00","75,674.59",,,,,,
Aetna MCR ADV,DRG,MS-035,CAROTID ARTERY STENT PROCEDURES WITH CC,Surgical,Relative Weights,"$13,664.03 ",IP,"2,420.00","46,412.35",,,,,,
Aetna MCR ADV,DRG,MS-036,CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,817.58 ",IP,"2,420.00","35,300.16",,,,,,
Aetna MCR ADV,DRG,MS-037,EXTRACRANIAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$19,141.44 ",IP,"2,420.00","65,384.93",,,,,,
Aetna MCR ADV,DRG,MS-038,EXTRACRANIAL PROCEDURES WITH CC,Surgical,Relative Weights,"$9,687.52 ",IP,"2,420.00","33,772.03",,,,,,
Aetna MCR ADV,DRG,MS-039,EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,652.43 ",IP,"2,420.00","22,807.01",,,,,,
Aetna MCR ADV,DRG,MS-040,PERIPHERAL- CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC,Surgical,Relative Weights,"$22,570.73 ",IP,"2,420.00","79,438.46",,,,,,
Aetna MCR ADV,DRG,MS-041,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W CC OR PERIPH NEUROSTIM,Surgical,Relative Weights,"$13,722.43 ",IP,"2,420.00","47,809.44",,,,,,
Aetna MCR ADV,DRG,MS-042,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W/O CC/MCC,Surgical,Relative Weights,"$11,103.16 ",IP,"2,420.00","37,261.73",,,,,,
Aetna MCR ADV,DRG,MS-052,SPINAL DISORDERS AND INJURIES WITH CC/MCC,Medical,Relative Weights,"$10,824.58 ",IP,"2,420.00","32,838.62",,,,,,
Aetna MCR ADV,DRG,MS-053,SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,Medical,Relative Weights,"$6,636.66 ",IP,"2,420.00","19,476.58",,,,,,
Aetna MCR ADV,DRG,MS-054,NERVOUS SYSTEM NEOPLASMS WITH MCC,Medical,Relative Weights,"$7,990.98 ",IP,"2,420.00","27,016.42",,,,,,
Aetna MCR ADV,DRG,MS-055,NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,Medical,Relative Weights,"$6,100.55 ",IP,"2,420.00","19,877.76",,,,,,
Aetna MCR ADV,DRG,MS-056,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,Medical,Relative Weights,"$12,820.72 ",IP,"2,420.00","44,198.78",,,,,,
Aetna MCR ADV,DRG,MS-057,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,Medical,Relative Weights,"$7,402.30 ",IP,"2,420.00","24,409.73",,,,,,
Aetna MCR ADV,DRG,MS-058,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,Medical,Relative Weights,"$10,148.89 ",IP,"2,420.00","39,406.75",,,,,,
Aetna MCR ADV,DRG,MS-059,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,Medical,Relative Weights,"$6,583.52 ",IP,"2,420.00","21,984.48",,,,,,
Aetna MCR ADV,DRG,MS-060,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,Medical,Relative Weights,"$5,359.44 ",IP,"2,420.00","17,775.07",,,,,,
Aetna MCR ADV,DRG,MS-061,ISCHEMIC STROKE -  PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC,Medical,Relative Weights,"$16,884.83 ",IP,"2,420.00","56,316.96",,,,,,
Aetna MCR ADV,DRG,MS-062,ISCHEMIC STROKE -  PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC,Medical,Relative Weights,"$11,611.83 ",IP,"2,420.00","40,545.79",,,,,,
Aetna MCR ADV,DRG,MS-063,ISCHEMIC STROKE- PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC,Medical,Relative Weights,"$9,984.78 ",IP,"2,420.00","33,884.93",,,,,,
Aetna MCR ADV,DRG,MS-064,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,Medical,Relative Weights,"$11,206.52 ",IP,"2,420.00","37,795.97",,,,,,
Aetna MCR ADV,DRG,MS-065,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC,Medical,Relative Weights,"$5,956.88 ",IP,"2,420.00","20,718.43",,,,,,
Aetna MCR ADV,DRG,MS-066,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,Medical,Relative Weights,"$4,155.80 ",IP,"2,420.00","14,454.72",,,,,,
Aetna MCR ADV,DRG,MS-067,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,Medical,Relative Weights,"$8,326.78 ",IP,"2,420.00","29,524.32",,,,,,
Aetna MCR ADV,DRG,MS-068,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,Medical,Relative Weights,"$5,191.24 ",IP,"2,420.00","18,212.54",,,,,,
Aetna MCR ADV,DRG,MS-069,TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,Medical,Relative Weights,"$4,596.73 ",IP,"2,420.00","15,730.85",,,,,,
Aetna MCR ADV,DRG,MS-070,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC,Medical,Relative Weights,"$9,808.99 ",IP,"2,420.00","33,725.66",,,,,,
Aetna MCR ADV,DRG,MS-071,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC,Medical,Relative Weights,"$5,908.99 ",IP,"2,420.00","20,053.15",,,,,,
Aetna MCR ADV,DRG,MS-072,NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$4,506.79 ",IP,"2,420.00","14,888.16",,,,,,
Aetna MCR ADV,DRG,MS-073,CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,Medical,Relative Weights,"$8,485.05 ",IP,"2,420.00","28,538.50",,,,,,
Aetna MCR ADV,DRG,MS-074,CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,Medical,Relative Weights,"$5,951.04 ",IP,"2,420.00","19,920.10",,,,,,
Aetna MCR ADV,DRG,MS-075,VIRAL MENINGITIS WITH CC/MCC,Medical,Relative Weights,"$9,501.81 ",IP,"2,420.00","32,421.31",,,,,,
Aetna MCR ADV,DRG,MS-076,VIRAL MENINGITIS WITHOUT CC/MCC,Medical,Relative Weights,"$5,751.89 ",IP,"2,420.00","18,194.40",,,,,,
Aetna MCR ADV,DRG,MS-077,HYPERTENSIVE ENCEPHALOPATHY WITH MCC,Medical,Relative Weights,"$8,952.25 ",IP,"2,420.00","31,096.80",,,,,,
Aetna MCR ADV,DRG,MS-078,HYPERTENSIVE ENCEPHALOPATHY WITH CC,Medical,Relative Weights,"$5,547.49 ",IP,"2,420.00","19,393.92",,,,,,
Aetna MCR ADV,DRG,MS-079,HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC,Medical,Relative Weights,"$4,256.25 ",IP,"2,420.00","14,940.58",,,,,,
Aetna MCR ADV,DRG,MS-080,NONTRAUMATIC STUPOR & COMA W MCC,Medical,Relative Weights,"$12,237.30 ",IP,"2,420.00","38,632.61",,,,,,
Aetna MCR ADV,DRG,MS-081,NONTRAUMATIC STUPOR & COMA W/O MCC,Medical,Relative Weights,"$4,515.55 ",IP,"2,420.00","17,722.66",,,,,,
Aetna MCR ADV,DRG,MS-082,TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,Medical,Relative Weights,"$13,221.35 ",IP,"2,420.00","45,396.29",,,,,,
Aetna MCR ADV,DRG,MS-083,TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,Medical,Relative Weights,"$7,849.06 ",IP,"2,420.00","26,423.71",,,,,,
Aetna MCR ADV,DRG,MS-084,TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,Medical,Relative Weights,"$5,288.77 ",IP,"2,420.00","18,089.57",,,,,,
Aetna MCR ADV,DRG,MS-085,TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,Medical,Relative Weights,"$13,500.51 ",IP,"2,420.00","45,275.33",,,,,,
Aetna MCR ADV,DRG,MS-086,TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,Medical,Relative Weights,"$7,443.18 ",IP,"2,420.00","24,954.05",,,,,,
Aetna MCR ADV,DRG,MS-087,TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,Medical,Relative Weights,"$5,043.49 ",IP,"2,420.00","16,918.27",,,,,,
Aetna MCR ADV,DRG,MS-088,CONCUSSION WITH MCC,Medical,Relative Weights,"$8,498.48 ",IP,"2,420.00","28,004.26",,,,,,
Aetna MCR ADV,DRG,MS-089,CONCUSSION WITH CC,Medical,Relative Weights,"$6,210.92 ",IP,"2,420.00","19,883.81",,,,,,
Aetna MCR ADV,DRG,MS-090,CONCUSSION WITHOUT CC/MCC,Medical,Relative Weights,"$4,990.93 ",IP,"2,420.00","17,101.73",,,,,,
Aetna MCR ADV,DRG,MS-091,OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,Medical,Relative Weights,"$9,640.80 ",IP,"2,420.00","31,552.42",,,,,,
Aetna MCR ADV,DRG,MS-092,OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,Medical,Relative Weights,"$5,775.25 ",IP,"2,420.00","19,476.58",,,,,,
Aetna MCR ADV,DRG,MS-093,OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,Medical,Relative Weights,"$4,568.11 ",IP,"2,420.00","15,345.79",,,,,,
Aetna MCR ADV,DRG,MS-094,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,Medical,Relative Weights,"$21,245.62 ",IP,"2,420.00","72,269.57",,,,,,
Aetna MCR ADV,DRG,MS-095,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,Medical,Relative Weights,"$14,642.83 ",IP,"2,420.00","48,527.14",,,,,,
Aetna MCR ADV,DRG,MS-096,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,Medical,Relative Weights,"$13,623.15 ",IP,"2,420.00","45,603.94",,,,,,
Aetna MCR ADV,DRG,MS-097,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,Medical,Relative Weights,"$21,961.03 ",IP,"2,420.00","72,090.14",,,,,,
Aetna MCR ADV,DRG,MS-098,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,Medical,Relative Weights,"$12,337.16 ",IP,"2,420.00","39,412.80",,,,,,
Aetna MCR ADV,DRG,MS-099,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,Medical,Relative Weights,"$8,187.20 ",IP,"2,420.00","25,853.18",,,,,,
Aetna MCR ADV,DRG,MS-100,SEIZURES WITH MCC,Medical,Relative Weights,"$10,958.32 ",IP,"2,420.00","36,695.23",,,,,,
Aetna MCR ADV,DRG,MS-101,SEIZURES WITHOUT MCC,Medical,Relative Weights,"$5,188.32 ",IP,"2,420.00","17,799.26",,,,,,
Aetna MCR ADV,DRG,MS-102,HEADACHES WITH MCC,Medical,Relative Weights,"$6,734.19 ",IP,"2,420.00","24,042.82",,,,,,
Aetna MCR ADV,DRG,MS-103,HEADACHES W/O MCC,Medical,Relative Weights,"$4,844.34 ",IP,"2,420.00","16,117.92",,,,,,
Aetna MCR ADV,DRG,MS-113,ORBITAL PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$12,815.47 ",IP,"2,420.00","42,983.14",,,,,,
Aetna MCR ADV,DRG,MS-114,ORBITAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,454.10 ",IP,"2,420.00","24,006.53",,,,,,
Aetna MCR ADV,DRG,MS-115,EXTRAOCULAR PROCEDURES EXCEPT ORBIT,Surgical,Relative Weights,"$8,506.66 ",IP,"2,420.00","29,957.76",,,,,,
Aetna MCR ADV,DRG,MS-116,INTRAOCULAR PROCEDURES W CC/MCC,Surgical,Relative Weights,"$10,995.11 ",IP,"2,420.00","38,122.56",,,,,,
Aetna MCR ADV,DRG,MS-117,INTRAOCULAR PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$6,080.69 ",IP,"2,420.00","22,109.47",,,,,,
Aetna MCR ADV,DRG,MS-121,ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,Medical,Relative Weights,"$6,953.20 ",IP,"2,420.00","25,558.85",,,,,,
Aetna MCR ADV,DRG,MS-122,ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,Medical,Relative Weights,"$3,769.77 ",IP,"2,420.00","15,575.62",,,,,,
Aetna MCR ADV,DRG,MS-123,NEUROLOGICAL EYE DISORDERS,Medical,Relative Weights,"$4,478.17 ",IP,"2,420.00","15,740.93",,,,,,
Aetna MCR ADV,DRG,MS-124,OTHER DISORDERS OF THE EYE WITH MCC,Medical,Relative Weights,"$8,187.79 ",IP,"2,420.00","28,010.30",,,,,,
Aetna MCR ADV,DRG,MS-125,OTHER DISORDERS OF THE EYE WITHOUT MCC,Medical,Relative Weights,"$4,888.14 ",IP,"2,420.00","15,914.30",,,,,,
Aetna MCR ADV,DRG,MS-135,SINUS AND MASTOID PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$12,518.21 ",IP,"2,420.00","46,057.54",,,,,,
Aetna MCR ADV,DRG,MS-136,SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,332.22 ",IP,"2,420.00","23,990.40",,,,,,
Aetna MCR ADV,DRG,MS-137,MOUTH PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$8,816.77 ",IP,"2,420.00","26,879.33",,,,,,
Aetna MCR ADV,DRG,MS-138,MOUTH PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$5,002.03 ",IP,"2,420.00","17,365.82",,,,,,
Aetna MCR ADV,DRG,MS-139,SALIVARY GLAND PROCEDURES,Surgical,Relative Weights,"$7,207.24 ",IP,"2,420.00","24,883.49",,,,,,
Aetna MCR ADV,DRG,MS-140,MAJOR HEAD AND NECK PROCEDURES WITH MCC,Medical,Relative Weights,"$23,231.24 ",IP,"2,420.00","23,231.24",,,,,,
Aetna MCR ADV,DRG,MS-141,MAJOR HEAD AND NECK PROCEDURES WITH CC,Medical,Relative Weights,"$12,883.80 ",IP,"2,420.00","12,883.80",,,,,,
Aetna MCR ADV,DRG,MS-142,MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,Medical,Relative Weights,"$9,373.91 ",IP,"2,420.00","9,373.91",,,,,,
Aetna MCR ADV,DRG,MS-143,OTHER EAR- NOSE- MOUTH AND THROAT O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$17,402.26 ",IP,"2,420.00","17,402.26",,,,,,
Aetna MCR ADV,DRG,MS-144,HERNIA PROCEDURES AGE 0-17,Surgical,Relative Weights,"$10,287.30 ",IP,"2,420.00","10,287.30",,,,,,
Aetna MCR ADV,DRG,MS-145,OTHER EAR -  NOSE -  MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC,Medical,Relative Weights,"$7,151.76 ",IP,"2,420.00","7,151.76",,,,,,
Aetna MCR ADV,DRG,MS-146,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH MCC,Medical,Relative Weights,"$11,920.18 ",IP,"2,420.00","38,880.58",,,,,,
Aetna MCR ADV,DRG,MS-147,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH CC,Medical,Relative Weights,"$7,598.52 ",IP,"2,420.00","25,016.54",,,,,,
Aetna MCR ADV,DRG,MS-148,EAR - NOSE - MOUTH & THROAT MALIGNANCY W/O CC/MCC,Medical,Relative Weights,"$4,596.14 ",IP,"2,420.00","15,329.66",,,,,,
Aetna MCR ADV,DRG,MS-149,DYSEQUILIBRIUM,Medical,Relative Weights,"$4,304.14 ",IP,"2,420.00","14,726.88",,,,,,
Aetna MCR ADV,DRG,MS-150,EPISTAXIS WITH MCC,Medical,Relative Weights,"$7,752.70 ",IP,"2,420.00","26,036.64",,,,,,
Aetna MCR ADV,DRG,MS-151,EPISTAXIS WITHOUT MCC,Medical,Relative Weights,"$4,312.31 ",IP,"2,420.00","14,093.86",,,,,,
Aetna MCR ADV,DRG,MS-152,OTITIS MEDIA AND URI WITH MCC,Medical,Relative Weights,"$6,310.20 ",IP,"2,420.00","20,946.24",,,,,,
Aetna MCR ADV,DRG,MS-153,OTITIS MEDIA AND URI WITHOUT MCC,Medical,Relative Weights,"$4,165.14 ",IP,"2,420.00","14,241.02",,,,,,
Aetna MCR ADV,DRG,MS-154,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH MCC,Medical,Relative Weights,"$9,033.43 ",IP,"2,420.00","28,969.92",,,,,,
Aetna MCR ADV,DRG,MS-155,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH CC,Medical,Relative Weights,"$5,311.55 ",IP,"2,420.00","18,166.18",,,,,,
Aetna MCR ADV,DRG,MS-156,OTHER EAR -  NOSE -  MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$3,845.11 ",IP,"2,420.00","13,194.72",,,,,,
Aetna MCR ADV,DRG,MS-157,DENTAL AND ORAL DISEASES WITH MCC,Medical,Relative Weights,"$9,205.13 ",IP,"2,420.00","31,508.06",,,,,,
Aetna MCR ADV,DRG,MS-158,DENTAL AND ORAL DISEASES WITH CC,Medical,Relative Weights,"$5,257.24 ",IP,"2,420.00","17,470.66",,,,,,
Aetna MCR ADV,DRG,MS-159,DENTAL AND ORAL DISEASES WITHOUT CC/MCC,Medical,Relative Weights,"$3,872.56 ",IP,"2,420.00","13,565.66",,,,,,
Aetna MCR ADV,DRG,MS-163,MAJOR CHEST PROCEDURES WITH MCC,Surgical,Relative Weights,"$29,240.10 ",IP,"2,420.00","98,253.79",,,,,,
Aetna MCR ADV,DRG,MS-164,MAJOR CHEST PROCEDURES WITH CC,Surgical,Relative Weights,"$15,508.91 ",IP,"2,420.00","51,037.06",,,,,,
Aetna MCR ADV,DRG,MS-165,MAJOR CHEST PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$11,193.09 ",IP,"2,420.00","37,279.87",,,,,,
Aetna MCR ADV,DRG,MS-166,OTHER RESP SYSTEM O.R. PROCEDURES W MCC,Surgical,Relative Weights,"$21,745.53 ",IP,"2,420.00","75,210.91",,,,,,
Aetna MCR ADV,DRG,MS-167,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$10,621.35 ",IP,"2,420.00","38,594.30",,,,,,
Aetna MCR ADV,DRG,MS-168,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,909.80 ",IP,"2,420.00","26,746.27",,,,,,
Aetna MCR ADV,DRG,MS-175,PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,Medical,Relative Weights,"$9,028.76 ",IP,"2,420.00","29,119.10",,,,,,
Aetna MCR ADV,DRG,MS-176,PULMONARY EMBOLISM WITHOUT MCC,Medical,Relative Weights,"$5,184.82 ",IP,"2,420.00","17,103.74",,,,,,
Aetna MCR ADV,DRG,MS-177,RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC,Medical,Relative Weights,"$10,798.89 ",IP,"2,420.00","38,126.59",,,,,,
Aetna MCR ADV,DRG,MS-178,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,Medical,Relative Weights,"$7,053.65 ",IP,"2,420.00","25,064.93",,,,,,
Aetna MCR ADV,DRG,MS-179,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,Medical,Relative Weights,"$5,096.64 ",IP,"2,420.00","17,460.58",,,,,,
Aetna MCR ADV,DRG,MS-180,RESPIRATORY NEOPLASMS WITH MCC,Medical,Relative Weights,"$10,161.15 ",IP,"2,420.00","34,773.98",,,,,,
Aetna MCR ADV,DRG,MS-181,RESPIRATORY NEOPLASMS WITH CC,Medical,Relative Weights,"$6,541.47 ",IP,"2,420.00","23,224.32",,,,,,
Aetna MCR ADV,DRG,MS-182,RESPIRATORY NEOPLASMS WITHOUT CC/MCC,Medical,Relative Weights,"$4,625.34 ",IP,"2,420.00","16,990.85",,,,,,
Aetna MCR ADV,DRG,MS-183,MAJOR CHEST TRAUMA WITH MCC,Medical,Relative Weights,"$9,104.10 ",IP,"2,420.00","30,425.47",,,,,,
Aetna MCR ADV,DRG,MS-184,MAJOR CHEST TRAUMA WITH CC,Medical,Relative Weights,"$6,078.94 ",IP,"2,420.00","20,526.91",,,,,,
Aetna MCR ADV,DRG,MS-185,MAJOR CHEST TRAUMA W/O CC/MCC,Medical,Relative Weights,"$4,525.48 ",IP,"2,420.00","14,797.44",,,,,,
Aetna MCR ADV,DRG,MS-186,PLEURAL EFFUSION WITH MCC,Medical,Relative Weights,"$9,015.91 ",IP,"2,420.00","31,104.86",,,,,,
Aetna MCR ADV,DRG,MS-187,PLEURAL EFFUSION WITH CC,Medical,Relative Weights,"$6,032.22 ",IP,"2,420.00","20,722.46",,,,,,
Aetna MCR ADV,DRG,MS-188,PLEURAL EFFUSION WITHOUT CC/MCC,Medical,Relative Weights,"$4,260.34 ",IP,"2,420.00","14,734.94",,,,,,
Aetna MCR ADV,DRG,MS-189,PULMONARY EDEMA AND RESPIRATORY FAILURE,Medical,Relative Weights,"$7,160.52 ",IP,"2,420.00","24,508.51",,,,,,
Aetna MCR ADV,DRG,MS-190,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,Medical,Relative Weights,"$6,570.67 ",IP,"2,420.00","23,063.04",,,,,,
Aetna MCR ADV,DRG,MS-191,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,Medical,Relative Weights,"$5,164.38 ",IP,"2,420.00","17,998.85",,,,,,
Aetna MCR ADV,DRG,MS-192,CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC,Medical,Relative Weights,"$4,062.36 ",IP,"2,420.00","14,297.47",,,,,,
Aetna MCR ADV,DRG,MS-193,SIMPLE PNEUMONIA & PLEURISY W MCC,Medical,Relative Weights,"$7,662.18 ",IP,"2,420.00","26,883.36",,,,,,
Aetna MCR ADV,DRG,MS-194,SIMPLE PNEUMONIA AND PLEURISY WITH CC,Medical,Relative Weights,"$5,045.24 ",IP,"2,420.00","17,914.18",,,,,,
Aetna MCR ADV,DRG,MS-195,SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,Medical,Relative Weights,"$3,888.32 ",IP,"2,420.00","13,751.14",,,,,,
Aetna MCR ADV,DRG,MS-196,INTERSTITIAL LUNG DISEASE WITH MCC,Medical,Relative Weights,"$10,153.56 ",IP,"2,420.00","33,776.06",,,,,,
Aetna MCR ADV,DRG,MS-197,INTERSTITIAL LUNG DISEASE WITH CC,Medical,Relative Weights,"$5,880.96 ",IP,"2,420.00","20,593.44",,,,,,
Aetna MCR ADV,DRG,MS-198,INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,Medical,Relative Weights,"$4,341.51 ",IP,"2,420.00","15,220.80",,,,,,
Aetna MCR ADV,DRG,MS-199,PNEUMOTHORAX WITH MCC,Medical,Relative Weights,"$10,453.74 ",IP,"2,420.00","36,169.06",,,,,,
Aetna MCR ADV,DRG,MS-200,PNEUMOTHORAX WITH CC,Medical,Relative Weights,"$6,286.84 ",IP,"2,420.00","21,815.14",,,,,,
Aetna MCR ADV,DRG,MS-201,PNEUMOTHORAX WITHOUT CC/MCC,Medical,Relative Weights,"$4,144.12 ",IP,"2,420.00","14,474.88",,,,,,
Aetna MCR ADV,DRG,MS-202,BRONCHITIS AND ASTHMA WITH CC/MCC,Medical,Relative Weights,"$5,647.36 ",IP,"2,420.00","19,111.68",,,,,,
Aetna MCR ADV,DRG,MS-203,BRONCHITIS AND ASTHMA WITHOUT CC/MCC,Medical,Relative Weights,"$4,128.93 ",IP,"2,420.00","13,987.01",,,,,,
Aetna MCR ADV,DRG,MS-204,RESPIRATORY SIGNS AND SYMPTOMS,Medical,Relative Weights,"$4,634.69 ",IP,"2,420.00","16,380.00",,,,,,
Aetna MCR ADV,DRG,MS-205,OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,Medical,Relative Weights,"$9,839.36 ",IP,"2,420.00","32,945.47",,,,,,
Aetna MCR ADV,DRG,MS-206,OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,Medical,Relative Weights,"$5,174.31 ",IP,"2,420.00","17,589.60",,,,,,
Aetna MCR ADV,DRG,MS-207,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS,Medical,Relative Weights,"$33,499.27 ",IP,"2,420.00","115,629.70",,,,,,
Aetna MCR ADV,DRG,MS-208,RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,Medical,Relative Weights,"$14,861.83 ",IP,"2,420.00","50,079.46",,,,,,
Aetna MCR ADV,DRG,MS-215,OTHER HEART ASSIST SYSTEM IMPLANT,Surgical,Relative Weights,"$61,661.88 ",IP,"61,661.88","259,783.78",,,,,,
Aetna MCR ADV,DRG,MS-216,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$58,630.29 ",IP,"58,630.29","202,454.78",,,,,,
Aetna MCR ADV,DRG,MS-217,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,Surgical,Relative Weights,"$37,864.14 ",IP,"37,864.14","134,096.26",,,,,,
Aetna MCR ADV,DRG,MS-218,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,Surgical,Relative Weights,"$35,678.79 ",IP,"35,678.79","108,892.22",,,,,,
Aetna MCR ADV,DRG,MS-219,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$47,057.01 ",IP,"47,057.01","158,056.42",,,,,,
Aetna MCR ADV,DRG,MS-220,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,Surgical,Relative Weights,"$31,567.37 ",IP,"31,567.37","106,966.94",,,,,,
Aetna MCR ADV,DRG,MS-221,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,Surgical,Relative Weights,"$26,746.97 ",IP,"26,746.97","92,659.39",,,,,,
Aetna MCR ADV,DRG,MS-222,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITH MCC,Surgical,Relative Weights,"$46,434.46 ",IP,"46,434.46","168,227.14",,,,,,
Aetna MCR ADV,DRG,MS-223,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITHOUT MCC,Surgical,Relative Weights,"$33,864.27 ",IP,"33,864.27","121,018.46",,,,,,
Aetna MCR ADV,DRG,MS-224,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITH MCC,Surgical,Relative Weights,"$43,912.13 ",IP,"43,912.13","149,107.39",,,,,,
Aetna MCR ADV,DRG,MS-225,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITHOUT MCC,Surgical,Relative Weights,"$32,808.39 ",IP,"32,808.39","113,879.81",,,,,,
Aetna MCR ADV,DRG,MS-226,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$38,340.11 ",IP,"25,420.00","134,824.03",,,,,,
Aetna MCR ADV,DRG,MS-227,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Surgical,Relative Weights,"$30,439.07 ",IP,"25,420.00","105,420.67",,,,,,
Aetna MCR ADV,DRG,MS-228,OTHER CARDIOTHORACIC PROCEDURES WITH MCC,Surgical,Relative Weights,"$31,129.37 ",IP,"31,129.37","126,731.81",,,,,,
Aetna MCR ADV,DRG,MS-229,OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$20,096.88 ",IP,"20,096.88","82,754.78",,,,,,
Aetna MCR ADV,DRG,MS-231,CORONARY BYPASS W PTCA W MCC,Surgical,Relative Weights,"$50,901.53 ",IP,"50,901.53","165,543.84",,,,,,
Aetna MCR ADV,DRG,MS-232,CORONARY BYPASS W PTCA W/O MCC,Surgical,Relative Weights,"$34,770.65 ",IP,"34,770.65","120,687.84",,,,,,
Aetna MCR ADV,DRG,MS-233,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,Surgical,Relative Weights,"$46,266.85 ",IP,"42,365.00","156,621.02",,,,,,
Aetna MCR ADV,DRG,MS-234,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,Surgical,Relative Weights,"$31,162.65 ",IP,"31,162.65","104,959.01",,,,,,
Aetna MCR ADV,DRG,MS-235,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$35,648.42 ",IP,"32,351.00","118,633.54",,,,,,
Aetna MCR ADV,DRG,MS-236,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Surgical,Relative Weights,"$23,926.80 ",IP,"23,926.80","81,226.66",,,,,,
Aetna MCR ADV,DRG,MS-239,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,Surgical,Relative Weights,"$28,125.81 ",IP,"2,420.00","94,141.15",,,,,,
Aetna MCR ADV,DRG,MS-240,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,Surgical,Relative Weights,"$16,286.81 ",IP,"2,420.00","55,641.60",,,,,,
Aetna MCR ADV,DRG,MS-241,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,Surgical,Relative Weights,"$9,299.74 ",IP,"2,420.00","30,568.61",,,,,,
Aetna MCR ADV,DRG,MS-242,PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,Surgical,Relative Weights,"$21,769.47 ",IP,"15,407.00","74,815.78",,,,,,
Aetna MCR ADV,DRG,MS-243,PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,Surgical,Relative Weights,"$14,708.24 ",IP,"14,708.24","50,992.70",,,,,,
Aetna MCR ADV,DRG,MS-244,PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,Surgical,Relative Weights,"$12,049.83 ",IP,"12,049.83","41,840.06",,,,,,
Aetna MCR ADV,DRG,MS-245,AICD GENERATOR PROCEDURES,Surgical,Relative Weights,"$31,640.37 ",IP,"15,407.00","104,989.25",,,,,,
Aetna MCR ADV,DRG,MS-246,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Surgical,Relative Weights,"$18,246.15 ",IP,"18,246.15","63,963.65",,,,,,
Aetna MCR ADV,DRG,MS-247,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITHOUT MCC,Surgical,Relative Weights,"$11,523.64 ",IP,"11,523.64","41,019.55",,,,,,
Aetna MCR ADV,DRG,MS-248,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Surgical,Relative Weights,"$18,467.49 ",IP,"18,467.49","62,425.44",,,,,,
Aetna MCR ADV,DRG,MS-249,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITHOUT MCC,Surgical,Relative Weights,"$10,942.55 ",IP,"10,942.55","38,638.66",,,,,,
Aetna MCR ADV,DRG,MS-250,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT CORONARY ARTERY STENT WITH MCC,Surgical,Relative Weights,"$14,727.51 ",IP,"14,727.51","51,410.02",,,,,,
Aetna MCR ADV,DRG,MS-251,PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W/O MCC,Surgical,Relative Weights,"$9,685.18 ",IP,"2,420.00","33,929.28",,,,,,
Aetna MCR ADV,DRG,MS-252,OTHER VASCULAR PROCEDURES W MCC,Surgical,Relative Weights,"$19,422.35 ",IP,"2,420.00","66,132.86",,,,,,
Aetna MCR ADV,DRG,MS-253,OTHER VASCULAR PROCEDURES WITH CC,Surgical,Relative Weights,"$15,497.23 ",IP,"2,420.00","52,549.06",,,,,,
Aetna MCR ADV,DRG,MS-254,OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,605.00 ",IP,"2,420.00","36,693.22",,,,,,
Aetna MCR ADV,DRG,MS-255,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,Surgical,Relative Weights,"$14,806.35 ",IP,"2,420.00","53,415.94",,,,,,
Aetna MCR ADV,DRG,MS-256,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,Surgical,Relative Weights,"$9,602.26 ",IP,"2,420.00","34,604.64",,,,,,
Aetna MCR ADV,DRG,MS-257,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$6,804.86 ",IP,"2,420.00","22,869.50",,,,,,
Aetna MCR ADV,DRG,MS-258,CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,Surgical,Relative Weights,"$18,501.95 ",IP,"11,861.00","61,663.39",,,,,,
Aetna MCR ADV,DRG,MS-259,CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,Surgical,Relative Weights,"$12,201.09 ",IP,"11,861.00","41,985.22",,,,,,
Aetna MCR ADV,DRG,MS-260,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,Surgical,Relative Weights,"$20,833.31 ",IP,"10,167.00","74,583.94",,,,,,
Aetna MCR ADV,DRG,MS-261,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,Surgical,Relative Weights,"$11,644.53 ",IP,"10,167.00","39,281.76",,,,,,
Aetna MCR ADV,DRG,MS-262,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,Surgical,Relative Weights,"$9,964.34 ",IP,"9,964.34","33,820.42",,,,,,
Aetna MCR ADV,DRG,MS-263,VEIN LIGATION AND STRIPPING,Surgical,Relative Weights,"$13,509.27 ",IP,"2,420.00","47,559.46",,,,,,
Aetna MCR ADV,DRG,MS-264,OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,Surgical,Relative Weights,"$19,001.28 ",IP,"2,420.00","65,278.08",,,,,,
Aetna MCR ADV,DRG,MS-265,AICD LEAD PROCEDURES,Surgical,Relative Weights,"$19,654.78 ",IP,"2,420.00","62,925.41",,,,,,
Aetna MCR ADV,DRG,MS-266,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,Surgical,Relative Weights,"$41,160.28 ",IP,"41,160.28","143,567.42",,,,,,
Aetna MCR ADV,DRG,MS-267,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$32,692.75 ",IP,"32,692.75","114,420.10",,,,,,
Aetna MCR ADV,DRG,MS-268,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,Surgical,Relative Weights,"$40,666.21 ",IP,"32,968.00","136,737.22",,,,,,
Aetna MCR ADV,DRG,MS-269,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,Surgical,Relative Weights,"$25,200.52 ",IP,"25,200.52","86,010.62",,,,,,
Aetna MCR ADV,DRG,MS-270,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,Surgical,Relative Weights,"$30,292.48 ",IP,"30,292.48","103,021.63",,,,,,
Aetna MCR ADV,DRG,MS-271,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,Surgical,Relative Weights,"$20,822.21 ",IP,"20,822.21","71,527.68",,,,,,
Aetna MCR ADV,DRG,MS-272,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$15,699.88 ",IP,"15,699.88","52,442.21",,,,,,
Aetna MCR ADV,DRG,MS-273,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,Surgical,Relative Weights,"$22,348.22 ",IP,"16,176.00","74,799.65",,,,,,
Aetna MCR ADV,DRG,MS-274,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$19,194.00 ",IP,"16,176.00","63,701.57",,,,,,
Aetna MCR ADV,DRG,MS-280,ACUTE MYOCARDIAL INFARCTION - DISCHARGED ALIVE W MCC,Medical,Relative Weights,"$9,384.42 ",IP,"2,420.00","32,878.94",,,,,,
Aetna MCR ADV,DRG,MS-281,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITH CC,Medical,Relative Weights,"$5,434.78 ",IP,"2,420.00","19,528.99",,,,,,
Aetna MCR ADV,DRG,MS-282,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITHOUT CC/MCC,Medical,Relative Weights,"$4,240.48 ",IP,"2,420.00","14,876.06",,,,,,
Aetna MCR ADV,DRG,MS-283,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH MCC,Medical,Relative Weights,"$10,889.99 ",IP,"2,420.00","36,281.95",,,,,,
Aetna MCR ADV,DRG,MS-284,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH CC,Medical,Relative Weights,"$4,224.71 ",IP,"2,420.00","14,622.05",,,,,,
Aetna MCR ADV,DRG,MS-285,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITHOUT CC/MCC,Medical,Relative Weights,"$2,889.09 ",IP,"2,420.00","10,438.85",,,,,,
Aetna MCR ADV,DRG,MS-286,CIRCULATORY DISORDERS EXCEPT AMI- WITH CARDIAC CATHETERIZATION WITH MCC,Medical,Relative Weights,"$12,476.16 ",IP,"2,420.00","44,299.58",,,,,,
Aetna MCR ADV,DRG,MS-287,CIRCULATORY DISORDERS EXCEPT AMI -  WITH CARDIAC CATHETERIZATION WITHOUT MCC,Medical,Relative Weights,"$6,512.27 ",IP,"6,512.27","23,228.35",,,,,,
Aetna MCR ADV,DRG,MS-288,ACUTE & SUBACUTE ENDOCARDITIS W MCC,Medical,Relative Weights,"$15,682.94 ",IP,"2,420.00","53,573.18",,,,,,
Aetna MCR ADV,DRG,MS-289,ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,Medical,Relative Weights,"$9,598.75 ",IP,"9,181.00","33,542.21",,,,,,
Aetna MCR ADV,DRG,MS-290,ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,Medical,Relative Weights,"$5,997.18 ",IP,"2,420.00","20,172.10",,,,,,
Aetna MCR ADV,DRG,MS-291,HEART FAILURE AND SHOCK WITH MCC,Medical,Relative Weights,"$7,406.97 ",IP,"2,420.00","27,131.33",,,,,,
Aetna MCR ADV,DRG,MS-292,HEART FAILURE AND SHOCK WITH CC,Medical,Relative Weights,"$5,042.91 ",IP,"2,420.00","18,254.88",,,,,,
Aetna MCR ADV,DRG,MS-293,HEART FAILURE AND SHOCK WITHOUT CC/MCC,Medical,Relative Weights,"$3,445.06 ",IP,"2,420.00","13,210.85",,,,,,
Aetna MCR ADV,DRG,MS-294,DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC,Medical,Relative Weights,"$7,491.65 ",IP,"2,420.00","25,641.50",,,,,,
Aetna MCR ADV,DRG,MS-295,DEEP VEIN THROMBOPHLEBITIS W/O CC/MCC,Medical,Relative Weights,"$5,747.22 ",IP,"2,420.00","11,632.32",,,,,,
Aetna MCR ADV,DRG,MS-296,CARDIAC ARREST - UNEXPLAINED W MCC,Medical,Relative Weights,"$9,316.09 ",IP,"2,420.00","31,659.26",,,,,,
Aetna MCR ADV,DRG,MS-297,CARDIAC ARREST- UNEXPLAINED WITH CC,Medical,Relative Weights,"$4,128.93 ",IP,"2,420.00","14,575.68",,,,,,
Aetna MCR ADV,DRG,MS-298,CARDIAC ARREST- UNEXPLAINED WITHOUT CC/MCC,Medical,Relative Weights,"$2,854.63 ",IP,"2,420.00","10,144.51",,,,,,
Aetna MCR ADV,DRG,MS-299,PERIPHERAL VASCULAR DISORDERS WITH MCC,Medical,Relative Weights,"$8,950.50 ",IP,"2,420.00","29,225.95",,,,,,
Aetna MCR ADV,DRG,MS-300,PERIPHERAL VASCULAR DISORDERS WITH CC,Medical,Relative Weights,"$6,095.87 ",IP,"2,420.00","20,716.42",,,,,,
Aetna MCR ADV,DRG,MS-301,PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$4,339.76 ",IP,"2,420.00","14,632.13",,,,,,
Aetna MCR ADV,DRG,MS-302,ATHEROSCLEROSIS WITH MCC,Medical,Relative Weights,"$6,393.72 ",IP,"2,420.00","22,222.37",,,,,,
Aetna MCR ADV,DRG,MS-303,ATHEROSCLEROSIS WITHOUT MCC,Medical,Relative Weights,"$3,957.24 ",IP,"2,420.00","13,622.11",,,,,,
Aetna MCR ADV,DRG,MS-304,HYPERTENSION WITH MCC,Medical,Relative Weights,"$6,406.57 ",IP,"2,420.00","22,004.64",,,,,,
Aetna MCR ADV,DRG,MS-305,HYPERTENSION WITHOUT MCC,Medical,Relative Weights,"$4,321.07 ",IP,"2,420.00","14,747.04",,,,,,
Aetna MCR ADV,DRG,MS-306,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,Medical,Relative Weights,"$8,803.33 ",IP,"2,420.00","28,516.32",,,,,,
Aetna MCR ADV,DRG,MS-307,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,Medical,Relative Weights,"$5,083.20 ",IP,"2,420.00","17,785.15",,,,,,
Aetna MCR ADV,DRG,MS-308,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,Medical,Relative Weights,"$7,013.35 ",IP,"2,420.00","23,944.03",,,,,,
Aetna MCR ADV,DRG,MS-309,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,Medical,Relative Weights,"$4,382.98 ",IP,"2,420.00","15,247.01",,,,,,
Aetna MCR ADV,DRG,MS-310,CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC,Medical,Relative Weights,"$3,265.77 ",IP,"2,420.00","11,275.49",,,,,,
Aetna MCR ADV,DRG,MS-311,ANGINA PECTORIS,Medical,Relative Weights,"$4,079.29 ",IP,"2,420.00","13,809.60",,,,,,
Aetna MCR ADV,DRG,MS-312,SYNCOPE AND COLLAPSE,Medical,Relative Weights,"$4,898.07 ",IP,"2,420.00","16,462.66",,,,,,
Aetna MCR ADV,DRG,MS-313,CHEST PAIN,Medical,Relative Weights,"$4,213.03 ",IP,"2,420.00","14,420.45",,,,,,
Aetna MCR ADV,DRG,MS-314,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,Medical,Relative Weights,"$12,174.81 ",IP,"2,420.00","40,914.72",,,,,,
Aetna MCR ADV,DRG,MS-315,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,Medical,Relative Weights,"$5,684.73 ",IP,"2,420.00","19,563.26",,,,,,
Aetna MCR ADV,DRG,MS-316,OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$4,224.71 ",IP,"2,420.00","14,962.75",,,,,,
Aetna MCR ADV,DRG,MS-319,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,Surgical,Relative Weights,"$25,216.87 ",IP,"2,420.00","82,670.11",,,,,,
Aetna MCR ADV,DRG,MS-320,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$14,048.89 ",IP,"2,420.00","47,329.63",,,,,,
Aetna MCR ADV,DRG,MS-326,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$31,047.60 ",IP,"2,420.00","106,253.28",,,,,,
Aetna MCR ADV,DRG,MS-327,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC,Surgical,Relative Weights,"$14,978.05 ",IP,"2,420.00","51,869.66",,,,,,
Aetna MCR ADV,DRG,MS-328,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$9,734.83 ",IP,"2,420.00","31,752.00",,,,,,
Aetna MCR ADV,DRG,MS-329,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Surgical,Relative Weights,"$28,535.79 ",IP,"2,420.00","98,929.15",,,,,,
Aetna MCR ADV,DRG,MS-330,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Surgical,Relative Weights,"$14,888.11 ",IP,"2,420.00","50,940.29",,,,,,
Aetna MCR ADV,DRG,MS-331,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$9,989.45 ",IP,"2,420.00","34,054.27",,,,,,
Aetna MCR ADV,DRG,MS-332,RECTAL RESECTION WITH MCC,Surgical,Relative Weights,"$24,303.48 ",IP,"2,420.00","70,396.70",,,,,,
Aetna MCR ADV,DRG,MS-333,RECTAL RESECTION WITH CC,Surgical,Relative Weights,"$12,505.36 ",IP,"2,420.00","45,626.11",,,,,,
Aetna MCR ADV,DRG,MS-334,RECTAL RESECTION WITHOUT CC/MCC,Surgical,Relative Weights,"$9,394.35 ",IP,"2,420.00","31,052.45",,,,,,
Aetna MCR ADV,DRG,MS-335,PERITONEAL ADHESIOLYSIS WITH MCC,Surgical,Relative Weights,"$22,855.14 ",IP,"2,420.00","81,549.22",,,,,,
Aetna MCR ADV,DRG,MS-336,PERITONEAL ADHESIOLYSIS WITH CC,Surgical,Relative Weights,"$13,381.37 ",IP,"2,420.00","45,686.59",,,,,,
Aetna MCR ADV,DRG,MS-337,PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$9,561.96 ",IP,"2,420.00","33,056.35",,,,,,
Aetna MCR ADV,DRG,MS-338,APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$16,336.45 ",IP,"2,420.00","58,667.62",,,,,,
Aetna MCR ADV,DRG,MS-339,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W CC,Surgical,Relative Weights,"$9,912.95 ",IP,"2,420.00","34,596.58",,,,,,
Aetna MCR ADV,DRG,MS-340,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC/MCC,Surgical,Relative Weights,"$7,173.37 ",IP,"2,420.00","24,948.00",,,,,,
Aetna MCR ADV,DRG,MS-341,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$13,563.00 ",IP,"2,420.00","51,571.30",,,,,,
Aetna MCR ADV,DRG,MS-342,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH CC,Surgical,Relative Weights,"$8,368.25 ",IP,"2,420.00","32,463.65",,,,,,
Aetna MCR ADV,DRG,MS-343,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$6,474.31 ",IP,"2,420.00","23,216.26",,,,,,
Aetna MCR ADV,DRG,MS-344,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Surgical,Relative Weights,"$16,459.67 ",IP,"2,420.00","60,381.22",,,,,,
Aetna MCR ADV,DRG,MS-345,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Surgical,Relative Weights,"$9,220.31 ",IP,"2,420.00","32,927.33",,,,,,
Aetna MCR ADV,DRG,MS-346,MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,448.43 ",IP,"2,420.00","25,859.23",,,,,,
Aetna MCR ADV,DRG,MS-347,ANAL AND STOMAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$14,394.04 ",IP,"2,420.00","53,149.82",,,,,,
Aetna MCR ADV,DRG,MS-348,ANAL AND STOMAL PROCEDURES WITH CC,Surgical,Relative Weights,"$7,873.01 ",IP,"2,420.00","28,411.49",,,,,,
Aetna MCR ADV,DRG,MS-349,ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$5,719.19 ",IP,"2,420.00","19,774.94",,,,,,
Aetna MCR ADV,DRG,MS-350,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,Surgical,Relative Weights,"$14,336.22 ",IP,"2,420.00","49,176.29",,,,,,
Aetna MCR ADV,DRG,MS-351,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,Surgical,Relative Weights,"$8,717.48 ",IP,"2,420.00","29,399.33",,,,,,
Aetna MCR ADV,DRG,MS-352,INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,449.78 ",IP,"2,420.00","21,708.29",,,,,,
Aetna MCR ADV,DRG,MS-353,HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,Surgical,Relative Weights,"$17,665.65 ",IP,"2,420.00","59,812.70",,,,,,
Aetna MCR ADV,DRG,MS-354,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W CC,Surgical,Relative Weights,"$10,423.37 ",IP,"2,420.00","34,717.54",,,,,,
Aetna MCR ADV,DRG,MS-355,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W/O CC/MCC,Surgical,Relative Weights,"$7,943.67 ",IP,"2,420.00","27,667.58",,,,,,
Aetna MCR ADV,DRG,MS-356,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$25,157.89 ",IP,"2,420.00","82,196.35",,,,,,
Aetna MCR ADV,DRG,MS-357,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$13,248.22 ",IP,"2,420.00","45,368.06",,,,,,
Aetna MCR ADV,DRG,MS-358,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,878.85 ",IP,"2,420.00","27,653.47",,,,,,
Aetna MCR ADV,DRG,MS-368,MAJOR ESOPHAGEAL DISORDERS WITH MCC,Medical,Relative Weights,"$11,382.90 ",IP,"2,420.00","38,376.58",,,,,,
Aetna MCR ADV,DRG,MS-369,MAJOR ESOPHAGEAL DISORDERS WITH CC,Medical,Relative Weights,"$6,290.93 ",IP,"2,420.00","21,432.10",,,,,,
Aetna MCR ADV,DRG,MS-370,MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$4,368.96 ",IP,"2,420.00","15,065.57",,,,,,
Aetna MCR ADV,DRG,MS-371,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,Medical,Relative Weights,"$10,110.34 ",IP,"2,420.00","34,786.08",,,,,,
Aetna MCR ADV,DRG,MS-372,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,Medical,Relative Weights,"$6,011.19 ",IP,"2,420.00","20,613.60",,,,,,
Aetna MCR ADV,DRG,MS-373,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,Medical,Relative Weights,"$4,348.52 ",IP,"2,420.00","14,954.69",,,,,,
Aetna MCR ADV,DRG,MS-374,DIGESTIVE MALIGNANCY WITH MCC,Medical,Relative Weights,"$12,110.57 ",IP,"2,420.00","40,269.60",,,,,,
Aetna MCR ADV,DRG,MS-375,DIGESTIVE MALIGNANCY WITH CC,Medical,Relative Weights,"$7,052.48 ",IP,"2,420.00","24,339.17",,,,,,
Aetna MCR ADV,DRG,MS-376,DIGESTIVE MALIGNANCY WITHOUT CC/MCC,Medical,Relative Weights,"$5,249.65 ",IP,"2,420.00","20,186.21",,,,,,
Aetna MCR ADV,DRG,MS-377,GASTROINTESTINAL HEMORRHAGE WITH MCC,Medical,Relative Weights,"$10,519.15 ",IP,"2,420.00","35,681.18",,,,,,
Aetna MCR ADV,DRG,MS-378,GASTROINTESTINAL HEMORRHAGE WITH CC,Medical,Relative Weights,"$5,802.12 ",IP,"2,420.00","19,920.10",,,,,,
Aetna MCR ADV,DRG,MS-379,GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,Medical,Relative Weights,"$3,721.30 ",IP,"2,420.00","13,017.31",,,,,,
Aetna MCR ADV,DRG,MS-380,COMPLICATED PEPTIC ULCER WITH MCC,Medical,Relative Weights,"$11,017.89 ",IP,"2,420.00","38,054.02",,,,,,
Aetna MCR ADV,DRG,MS-381,COMPLICATED PEPTIC ULCER WITH CC,Medical,Relative Weights,"$6,186.39 ",IP,"2,420.00","21,706.27",,,,,,
Aetna MCR ADV,DRG,MS-382,COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,Medical,Relative Weights,"$4,488.68 ",IP,"2,420.00","15,954.62",,,,,,
Aetna MCR ADV,DRG,MS-383,UNCOMPLICATED PEPTIC ULCER WITH MCC,Medical,Relative Weights,"$7,665.69 ",IP,"2,420.00","26,738.21",,,,,,
Aetna MCR ADV,DRG,MS-384,UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,Medical,Relative Weights,"$5,214.02 ",IP,"2,420.00","17,543.23",,,,,,
Aetna MCR ADV,DRG,MS-385,INFLAMMATORY BOWEL DISEASE WITH MCC,Medical,Relative Weights,"$9,474.36 ",IP,"2,420.00","32,463.65",,,,,,
Aetna MCR ADV,DRG,MS-386,INFLAMMATORY BOWEL DISEASE W CC,Medical,Relative Weights,"$5,811.46 ",IP,"2,420.00","19,861.63",,,,,,
Aetna MCR ADV,DRG,MS-387,INFLAMMATORY BOWEL DISEASE W/O CC/MCC,Medical,Relative Weights,"$4,173.90 ",IP,"2,420.00","14,126.11",,,,,,
Aetna MCR ADV,DRG,MS-388,GASTROINTESTINAL OBSTRUCTION WITH MCC,Medical,Relative Weights,"$8,845.38 ",IP,"2,420.00","30,746.02",,,,,,
Aetna MCR ADV,DRG,MS-389,GASTROINTESTINAL OBSTRUCTION WITH CC,Medical,Relative Weights,"$4,807.55 ",IP,"2,420.00","16,928.35",,,,,,
Aetna MCR ADV,DRG,MS-390,GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,Medical,Relative Weights,"$3,405.35 ",IP,"2,420.00","11,684.74",,,,,,
Aetna MCR ADV,DRG,MS-391,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC,Medical,Relative Weights,"$7,295.42 ",IP,"2,420.00","24,897.60",,,,,,
Aetna MCR ADV,DRG,MS-392,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC,Medical,Relative Weights,"$4,472.33 ",IP,"2,420.00","15,351.84",,,,,,
Aetna MCR ADV,DRG,MS-393,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,Medical,Relative Weights,"$9,701.54 ",IP,"2,420.00","32,749.92",,,,,,
Aetna MCR ADV,DRG,MS-394,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,Medical,Relative Weights,"$5,494.93 ",IP,"2,420.00","18,912.10",,,,,,
Aetna MCR ADV,DRG,MS-395,OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$3,804.81 ",IP,"2,420.00","13,192.70",,,,,,
Aetna MCR ADV,DRG,MS-405,PANCREAS- LIVER AND SHUNT PROCEDURES WITH MCC,Surgical,Relative Weights,"$33,508.03 ",IP,"2,420.00","109,412.35",,,,,,
Aetna MCR ADV,DRG,MS-406,PANCREAS -  LIVER AND SHUNT PROCEDURES WITH CC,Surgical,Relative Weights,"$16,824.68 ",IP,"2,420.00","56,264.54",,,,,,
Aetna MCR ADV,DRG,MS-407,PANCREAS -  LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$12,369.28 ",IP,"2,420.00","42,059.81",,,,,,
Aetna MCR ADV,DRG,MS-408,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,Surgical,Relative Weights,"$21,917.23 ",IP,"2,420.00","71,842.18",,,,,,
Aetna MCR ADV,DRG,MS-409,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,Surgical,Relative Weights,"$12,359.94 ",IP,"2,420.00","48,259.01",,,,,,
Aetna MCR ADV,DRG,MS-410,BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W/O CC/MCC,Surgical,Relative Weights,"$9,158.99 ",IP,"2,420.00","33,465.60",,,,,,
Aetna MCR ADV,DRG,MS-411,CHOLECYSTECTOMY W C.D.E. W MCC,Surgical,Relative Weights,"$21,920.73 ",IP,"2,420.00","77,220.86",,,,,,
Aetna MCR ADV,DRG,MS-412,CHOLECYSTECTOMY WITH C.D.E. WITH CC,Surgical,Relative Weights,"$13,300.78 ",IP,"2,420.00","47,920.32",,,,,,
Aetna MCR ADV,DRG,MS-413,CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,Surgical,Relative Weights,"$10,108.59 ",IP,"2,420.00","32,604.77",,,,,,
Aetna MCR ADV,DRG,MS-414,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,Surgical,Relative Weights,"$21,189.55 ",IP,"2,420.00","68,874.62",,,,,,
Aetna MCR ADV,DRG,MS-415,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,Surgical,Relative Weights,"$11,865.29 ",IP,"2,420.00","41,362.27",,,,,,
Aetna MCR ADV,DRG,MS-416,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,Surgical,Relative Weights,"$8,306.34 ",IP,"2,420.00","27,222.05",,,,,,
Aetna MCR ADV,DRG,MS-417,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,Surgical,Relative Weights,"$14,158.10 ",IP,"2,420.00","48,599.71",,,,,,
Aetna MCR ADV,DRG,MS-418,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,Surgical,Relative Weights,"$9,863.89 ",IP,"2,420.00","33,645.02",,,,,,
Aetna MCR ADV,DRG,MS-419,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,Surgical,Relative Weights,"$7,681.45 ",IP,"2,420.00","26,345.09",,,,,,
Aetna MCR ADV,DRG,MS-420,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,Surgical,Relative Weights,"$20,536.63 ",IP,"2,420.00","69,245.57",,,,,,
Aetna MCR ADV,DRG,MS-421,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,Surgical,Relative Weights,"$11,139.95 ",IP,"2,420.00","37,118.59",,,,,,
Aetna MCR ADV,DRG,MS-422,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,489.14 ",IP,"2,420.00","28,314.72",,,,,,
Aetna MCR ADV,DRG,MS-423,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$24,445.98 ",IP,"2,420.00","85,442.11",,,,,,
Aetna MCR ADV,DRG,MS-424,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$13,339.32 ",IP,"2,420.00","45,388.22",,,,,,
Aetna MCR ADV,DRG,MS-425,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$9,009.49 ",IP,"2,420.00","29,463.84",,,,,,
Aetna MCR ADV,DRG,MS-432,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,Medical,Relative Weights,"$10,984.02 ",IP,"2,420.00","36,759.74",,,,,,
Aetna MCR ADV,DRG,MS-433,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,Medical,Relative Weights,"$6,014.70 ",IP,"2,420.00","20,805.12",,,,,,
Aetna MCR ADV,DRG,MS-434,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Medical,Relative Weights,"$3,624.94 ",IP,"2,420.00","12,900.38",,,,,,
Aetna MCR ADV,DRG,MS-435,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,Medical,Relative Weights,"$10,239.99 ",IP,"2,420.00","34,213.54",,,,,,
Aetna MCR ADV,DRG,MS-436,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,Medical,Relative Weights,"$6,549.65 ",IP,"2,420.00","22,694.11",,,,,,
Aetna MCR ADV,DRG,MS-437,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,Medical,Relative Weights,"$5,232.13 ",IP,"2,420.00","17,698.46",,,,,,
Aetna MCR ADV,DRG,MS-438,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,Medical,Relative Weights,"$9,331.28 ",IP,"2,420.00","33,028.13",,,,,,
Aetna MCR ADV,DRG,MS-439,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,Medical,Relative Weights,"$4,936.03 ",IP,"2,420.00","17,079.55",,,,,,
Aetna MCR ADV,DRG,MS-440,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,Medical,Relative Weights,"$3,540.84 ",IP,"2,420.00","12,410.50",,,,,,
Aetna MCR ADV,DRG,MS-441,DISORDERS OF LIVER EXCEPT MALIGNANCY- CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC,Medical,Relative Weights,"$10,976.43 ",IP,"2,420.00","37,306.08",,,,,,
Aetna MCR ADV,DRG,MS-442,DISORDERS OF LIVER EXCEPT MALIGNANCY -  CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC,Medical,Relative Weights,"$5,431.27 ",IP,"2,420.00","18,817.34",,,,,,
Aetna MCR ADV,DRG,MS-443,DISORDERS OF LIVER EXCEPT MALIGNANCY -  CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Medical,Relative Weights,"$3,873.14 ",IP,"2,420.00","13,714.85",,,,,,
Aetna MCR ADV,DRG,MS-444,DISORDERS OF THE BILIARY TRACT WITH MCC,Medical,Relative Weights,"$9,762.27 ",IP,"2,420.00","32,782.18",,,,,,
Aetna MCR ADV,DRG,MS-445,DISORDERS OF THE BILIARY TRACT WITH CC,Medical,Relative Weights,"$6,292.68 ",IP,"2,420.00","21,661.92",,,,,,
Aetna MCR ADV,DRG,MS-446,DISORDERS OF THE BILIARY TRACT W/O CC/MCC,Medical,Relative Weights,"$4,769.01 ",IP,"2,420.00","16,384.03",,,,,,
Aetna MCR ADV,DRG,MS-453,COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W MCC,Surgical,Relative Weights,"$53,658.63 ",IP,"2,420.00","189,645.12",,,,,,
Aetna MCR ADV,DRG,MS-454,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC,Surgical,Relative Weights,"$35,584.18 ",IP,"2,420.00","123,480.00",,,,,,
Aetna MCR ADV,DRG,MS-455,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CC/MCC,Surgical,Relative Weights,"$27,923.16 ",IP,"2,420.00","97,036.13",,,,,,
Aetna MCR ADV,DRG,MS-456,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH MCC,Surgical,Relative Weights,"$50,224.67 ",IP,"2,420.00","183,076.99",,,,,,
Aetna MCR ADV,DRG,MS-457,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH CC,Surgical,Relative Weights,"$37,936.56 ",IP,"2,420.00","131,308.13",,,,,,
Aetna MCR ADV,DRG,MS-458,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC,Surgical,Relative Weights,"$29,244.77 ",IP,"2,420.00","94,629.02",,,,,,
Aetna MCR ADV,DRG,MS-459,SPINAL FUSION EXCEPT CERVICAL WITH MCC,Surgical,Relative Weights,"$39,324.16 ",IP,"21,658.00","138,136.32",,,,,,
Aetna MCR ADV,DRG,MS-460,SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,Surgical,Relative Weights,"$22,955.59 ",IP,"21,658.00","79,841.66",,,,,,
Aetna MCR ADV,DRG,MS-461,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,Surgical,Relative Weights,"$35,517.60 ",IP,"2,420.00","108,436.61",,,,,,
Aetna MCR ADV,DRG,MS-462,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,Surgical,Relative Weights,"$18,346.02 ",IP,"2,420.00","63,229.82",,,,,,
Aetna MCR ADV,DRG,MS-463,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,Surgical,Relative Weights,"$31,362.97 ",IP,"2,420.00","105,392.45",,,,,,
Aetna MCR ADV,DRG,MS-464,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,Surgical,Relative Weights,"$17,379.49 ",IP,"2,420.00","59,526.43",,,,,,
Aetna MCR ADV,DRG,MS-465,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$10,769.69 ",IP,"2,420.00","38,610.43",,,,,,
Aetna MCR ADV,DRG,MS-466,REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,Surgical,Relative Weights,"$31,219.30 ",IP,"2,420.00","102,797.86",,,,,,
Aetna MCR ADV,DRG,MS-467,REVISION OF HIP OR KNEE REPLACEMENT W CC,Surgical,Relative Weights,"$20,892.88 ",IP,"2,420.00","70,803.94",,,,,,
Aetna MCR ADV,DRG,MS-468,REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,Surgical,Relative Weights,"$16,366.23 ",IP,"2,420.00","56,691.94",,,,,,
Aetna MCR ADV,DRG,MS-469,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,Surgical,Relative Weights,"$18,021.90 ",IP,"2,420.00","63,300.38",,,,,,
Aetna MCR ADV,DRG,MS-470,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,Surgical,Relative Weights,"$11,097.90 ",IP,"2,420.00","39,682.94",,,,,,
Aetna MCR ADV,DRG,MS-471,CERVICAL SPINAL FUSION WITH MCC,Surgical,Relative Weights,"$29,315.44 ",IP,"15,407.00","100,687.10",,,,,,
Aetna MCR ADV,DRG,MS-472,CERVICAL SPINAL FUSION WITH CC,Surgical,Relative Weights,"$17,833.84 ",IP,"15,407.00","61,316.64",,,,,,
Aetna MCR ADV,DRG,MS-473,CERVICAL SPINAL FUSION WITHOUT CC/MCC,Surgical,Relative Weights,"$14,827.96 ",IP,"14,827.96","50,649.98",,,,,,
Aetna MCR ADV,DRG,MS-474,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,Surgical,Relative Weights,"$23,804.74 ",IP,"2,420.00","78,117.98",,,,,,
Aetna MCR ADV,DRG,MS-475,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,Surgical,Relative Weights,"$12,826.56 ",IP,"2,420.00","42,356.16",,,,,,
Aetna MCR ADV,DRG,MS-476,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$6,776.24 ",IP,"2,420.00","23,480.35",,,,,,
Aetna MCR ADV,DRG,MS-477,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Surgical,Relative Weights,"$19,616.24 ",IP,"2,420.00","65,626.85",,,,,,
Aetna MCR ADV,DRG,MS-478,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Surgical,Relative Weights,"$13,773.24 ",IP,"2,420.00","46,712.74",,,,,,
Aetna MCR ADV,DRG,MS-479,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Surgical,Relative Weights,"$10,567.62 ",IP,"2,420.00","35,929.15",,,,,,
Aetna MCR ADV,DRG,MS-480,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,Surgical,Relative Weights,"$17,670.91 ",IP,"2,420.00","60,852.96",,,,,,
Aetna MCR ADV,DRG,MS-481,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,Surgical,Relative Weights,"$12,241.39 ",IP,"2,420.00","42,090.05",,,,,,
Aetna MCR ADV,DRG,MS-482,HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC,Surgical,Relative Weights,"$9,611.60 ",IP,"2,420.00","33,169.25",,,,,,
Aetna MCR ADV,DRG,MS-483,MAJOR JOINT & LIMB REATTACHMENT PROC OF UPPER EXTREMITY W CC/MCC,Surgical,Relative Weights,"$13,932.67 ",IP,"2,420.00","48,224.74",,,,,,
Aetna MCR ADV,DRG,MS-485,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,Surgical,Relative Weights,"$19,912.33 ",IP,"2,420.00","66,104.64",,,,,,
Aetna MCR ADV,DRG,MS-486,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,Surgical,Relative Weights,"$12,552.66 ",IP,"2,420.00","43,356.10",,,,,,
Aetna MCR ADV,DRG,MS-487,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Surgical,Relative Weights,"$9,578.90 ",IP,"2,420.00","32,401.15",,,,,,
Aetna MCR ADV,DRG,MS-488,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,Surgical,Relative Weights,"$11,538.24 ",IP,"2,420.00","39,699.07",,,,,,
Aetna MCR ADV,DRG,MS-489,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Surgical,Relative Weights,"$7,581.59 ",IP,"2,420.00","25,381.44",,,,,,
Aetna MCR ADV,DRG,MS-492,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH MCC,Surgical,Relative Weights,"$20,265.07 ",IP,"2,420.00","69,457.25",,,,,,
Aetna MCR ADV,DRG,MS-493,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH CC,Surgical,Relative Weights,"$13,582.85 ",IP,"2,420.00","46,408.32",,,,,,
Aetna MCR ADV,DRG,MS-494,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITHOUT CC/MCC,Surgical,Relative Weights,"$10,814.07 ",IP,"2,420.00","36,517.82",,,,,,
Aetna MCR ADV,DRG,MS-495,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,Surgical,Relative Weights,"$21,268.98 ",IP,"2,420.00","69,201.22",,,,,,
Aetna MCR ADV,DRG,MS-496,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,Surgical,Relative Weights,"$11,600.73 ",IP,"2,420.00","41,136.48",,,,,,
Aetna MCR ADV,DRG,MS-497,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,Surgical,Relative Weights,"$8,476.87 ",IP,"2,420.00","29,621.09",,,,,,
Aetna MCR ADV,DRG,MS-498,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,Surgical,Relative Weights,"$15,089.01 ",IP,"2,420.00","49,353.70",,,,,,
Aetna MCR ADV,DRG,MS-499,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,Surgical,Relative Weights,"$7,002.25 ",IP,"2,420.00","23,202.14",,,,,,
Aetna MCR ADV,DRG,MS-500,SOFT TISSUE PROCEDURES WITH MCC,Surgical,Relative Weights,"$18,626.93 ",IP,"2,420.00","60,786.43",,,,,,
Aetna MCR ADV,DRG,MS-501,SOFT TISSUE PROCEDURES WITH CC,Surgical,Relative Weights,"$10,244.08 ",IP,"2,420.00","33,828.48",,,,,,
Aetna MCR ADV,DRG,MS-502,SOFT TISSUE PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,783.66 ",IP,"2,420.00","26,625.31",,,,,,
Aetna MCR ADV,DRG,MS-503,FOOT PROCEDURES WITH MCC,Surgical,Relative Weights,"$15,421.31 ",IP,"2,420.00","54,766.66",,,,,,
Aetna MCR ADV,DRG,MS-504,FOOT PROCEDURES WITH CC,Surgical,Relative Weights,"$10,366.14 ",IP,"2,420.00","35,007.84",,,,,,
Aetna MCR ADV,DRG,MS-505,FOOT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,366.14 ",IP,"2,420.00","33,899.04",,,,,,
Aetna MCR ADV,DRG,MS-506,MAJOR THUMB OR JOINT PROCEDURES,Surgical,Relative Weights,"$8,664.34 ",IP,"2,420.00","26,986.18",,,,,,
Aetna MCR ADV,DRG,MS-507,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W CC/MCC,Surgical,Relative Weights,"$12,035.82 ",IP,"2,420.00","42,336.00",,,,,,
Aetna MCR ADV,DRG,MS-508,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$8,232.76 ",IP,"2,420.00","31,417.34",,,,,,
Aetna MCR ADV,DRG,MS-509,ARTHROSCOPY,Surgical,Relative Weights,"$9,849.29 ",IP,"2,420.00","28,056.67",,,,,,
Aetna MCR ADV,DRG,MS-510,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH MCC,Surgical,Relative Weights,"$16,023.42 ",IP,"2,420.00","56,206.08",,,,,,
Aetna MCR ADV,DRG,MS-511,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH CC,Surgical,Relative Weights,"$11,489.77 ",IP,"2,420.00","37,985.47",,,,,,
Aetna MCR ADV,DRG,MS-512,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$9,078.40 ",IP,"2,420.00","30,518.21",,,,,,
Aetna MCR ADV,DRG,MS-513,HAND OR WRIST PROCEDURES- EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$9,180.60 ",IP,"2,420.00","31,794.34",,,,,,
Aetna MCR ADV,DRG,MS-514,HAND OR WRIST PROCEDURES -  EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$5,834.82 ",IP,"2,420.00","21,506.69",,,,,,
Aetna MCR ADV,DRG,MS-515,OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W MCC,Surgical,Relative Weights,"$18,341.35 ",IP,"2,420.00","63,584.64",,,,,,
Aetna MCR ADV,DRG,MS-516,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$11,462.90 ",IP,"2,420.00","39,092.26",,,,,,
Aetna MCR ADV,DRG,MS-517,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,165.60 ",IP,"2,420.00","28,532.45",,,,,,
Aetna MCR ADV,DRG,MS-518,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,Surgical,Relative Weights,"$20,947.77 ",IP,"10,289.00","68,717.38",,,,,,
Aetna MCR ADV,DRG,MS-519,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,Surgical,Relative Weights,"$11,446.55 ",IP,"10,289.00","38,479.39",,,,,,
Aetna MCR ADV,DRG,MS-520,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,Surgical,Relative Weights,"$8,282.98 ",IP,"8,282.98","26,974.08",,,,,,
Aetna MCR ADV,DRG,MS-521,HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,Surgical,Relative Weights,"$17,906.85 ",IP,"2,420.00","17,906.85",,,,,,
Aetna MCR ADV,DRG,MS-522,HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,Surgical,Relative Weights,"$12,786.27 ",IP,"2,420.00","12,786.27",,,,,,
Aetna MCR ADV,DRG,MS-533,FRACTURES OF FEMUR WITH MCC,Medical,Relative Weights,"$8,270.72 ",IP,"2,420.00","29,421.50",,,,,,
Aetna MCR ADV,DRG,MS-534,FRACTURES OF FEMUR WITHOUT MCC,Medical,Relative Weights,"$4,614.83 ",IP,"2,420.00","15,680.45",,,,,,
Aetna MCR ADV,DRG,MS-535,FRACTURES OF HIP AND PELVIS WITH MCC,Medical,Relative Weights,"$7,199.65 ",IP,"2,420.00","24,738.34",,,,,,
Aetna MCR ADV,DRG,MS-536,FRACTURES OF HIP AND PELVIS WITHOUT MCC,Medical,Relative Weights,"$4,506.79 ",IP,"2,420.00","15,291.36",,,,,,
Aetna MCR ADV,DRG,MS-537,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITH CC/MCC,Medical,Relative Weights,"$5,462.81 ",IP,"2,420.00","18,363.74",,,,,,
Aetna MCR ADV,DRG,MS-538,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITHOUT CC/MCC,Medical,Relative Weights,"$4,223.54 ",IP,"2,420.00","14,535.36",,,,,,
Aetna MCR ADV,DRG,MS-539,OSTEOMYELITIS WITH MCC,Medical,Relative Weights,"$11,374.72 ",IP,"2,420.00","38,005.63",,,,,,
Aetna MCR ADV,DRG,MS-540,OSTEOMYELITIS WITH CC,Medical,Relative Weights,"$7,601.45 ",IP,"2,420.00","26,208.00",,,,,,
Aetna MCR ADV,DRG,MS-541,OSTEOMYELITIS WITHOUT CC/MCC,Medical,Relative Weights,"$4,924.35 ",IP,"2,420.00","18,279.07",,,,,,
Aetna MCR ADV,DRG,MS-542,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,Medical,Relative Weights,"$10,565.87 ",IP,"2,420.00","36,787.97",,,,,,
Aetna MCR ADV,DRG,MS-543,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,Medical,Relative Weights,"$6,104.05 ",IP,"2,420.00","21,295.01",,,,,,
Aetna MCR ADV,DRG,MS-544,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,Medical,Relative Weights,"$4,541.83 ",IP,"2,420.00","15,289.34",,,,,,
Aetna MCR ADV,DRG,MS-545,CONNECTIVE TISSUE DISORDERS WITH MCC,Medical,Relative Weights,"$14,618.30 ",IP,"2,420.00","50,964.48",,,,,,
Aetna MCR ADV,DRG,MS-546,CONNECTIVE TISSUE DISORDERS WITH CC,Medical,Relative Weights,"$7,054.81 ",IP,"2,420.00","24,260.54",,,,,,
Aetna MCR ADV,DRG,MS-547,CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$4,868.29 ",IP,"2,420.00","16,331.62",,,,,,
Aetna MCR ADV,DRG,MS-548,SEPTIC ARTHRITIS WITH MCC,Medical,Relative Weights,"$11,976.83 ",IP,"2,420.00","39,983.33",,,,,,
Aetna MCR ADV,DRG,MS-549,SEPTIC ARTHRITIS W CC,Medical,Relative Weights,"$7,299.51 ",IP,"2,420.00","24,052.90",,,,,,
Aetna MCR ADV,DRG,MS-550,SEPTIC ARTHRITIS W/O CC/MCC,Medical,Relative Weights,"$5,132.84 ",IP,"2,420.00","17,418.24",,,,,,
Aetna MCR ADV,DRG,MS-551,MEDICAL BACK PROBLEMS WITH MCC,Medical,Relative Weights,"$9,504.14 ",IP,"2,420.00","32,042.30",,,,,,
Aetna MCR ADV,DRG,MS-552,MEDICAL BACK PROBLEMS WITHOUT MCC,Medical,Relative Weights,"$5,509.53 ",IP,"2,420.00","18,383.90",,,,,,
Aetna MCR ADV,DRG,MS-553,BONE DISEASES AND ARTHROPATHIES WITH MCC,Medical,Relative Weights,"$7,425.66 ",IP,"2,420.00","25,915.68",,,,,,
Aetna MCR ADV,DRG,MS-554,BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,Medical,Relative Weights,"$4,628.26 ",IP,"2,420.00","15,869.95",,,,,,
Aetna MCR ADV,DRG,MS-555,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Medical,Relative Weights,"$7,992.15 ",IP,"2,420.00","26,516.45",,,,,,
Aetna MCR ADV,DRG,MS-556,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,Medical,Relative Weights,"$4,722.87 ",IP,"2,420.00","15,962.69",,,,,,
Aetna MCR ADV,DRG,MS-557,TENDONITIS -  MYOSITIS AND BURSITIS WITH MCC,Medical,Relative Weights,"$8,170.85 ",IP,"2,420.00","29,397.31",,,,,,
Aetna MCR ADV,DRG,MS-558,TENDONITIS- MYOSITIS AND BURSITIS WITHOUT MCC,Medical,Relative Weights,"$5,030.64 ",IP,"2,420.00","17,365.82",,,,,,
Aetna MCR ADV,DRG,MS-559,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Medical,Relative Weights,"$10,893.50 ",IP,"2,420.00","36,324.29",,,,,,
Aetna MCR ADV,DRG,MS-560,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Medical,Relative Weights,"$6,283.92 ",IP,"2,420.00","21,036.96",,,,,,
Aetna MCR ADV,DRG,MS-561,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Medical,Relative Weights,"$4,627.68 ",IP,"2,420.00","15,067.58",,,,,,
Aetna MCR ADV,DRG,MS-562,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITH MCC,Medical,Relative Weights,"$8,245.02 ",IP,"2,420.00","27,157.54",,,,,,
Aetna MCR ADV,DRG,MS-563,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITHOUT MCC,Medical,Relative Weights,"$5,093.72 ",IP,"2,420.00","17,216.64",,,,,,
Aetna MCR ADV,DRG,MS-564,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,Medical,Relative Weights,"$8,897.94 ",IP,"2,420.00","30,481.92",,,,,,
Aetna MCR ADV,DRG,MS-565,OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W CC,Medical,Relative Weights,"$5,894.39 ",IP,"2,420.00","19,766.88",,,,,,
Aetna MCR ADV,DRG,MS-566,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$4,391.15 ",IP,"2,420.00","15,275.23",,,,,,
Aetna MCR ADV,DRG,MS-570,SKIN DEBRIDEMENT WITH MCC,Surgical,Relative Weights,"$16,595.75 ",IP,"2,420.00","57,923.71",,,,,,
Aetna MCR ADV,DRG,MS-571,SKIN DEBRIDEMENT WITH CC,Surgical,Relative Weights,"$9,550.86 ",IP,"2,420.00","33,713.57",,,,,,
Aetna MCR ADV,DRG,MS-572,SKIN DEBRIDEMENT WITHOUT CC/MCC,Surgical,Relative Weights,"$6,449.78 ",IP,"2,420.00","22,613.47",,,,,,
Aetna MCR ADV,DRG,MS-573,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,Surgical,Relative Weights,"$32,348.77 ",IP,"2,420.00","107,156.45",,,,,,
Aetna MCR ADV,DRG,MS-574,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,Surgical,Relative Weights,"$18,959.81 ",IP,"2,420.00","62,935.49",,,,,,
Aetna MCR ADV,DRG,MS-575,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS W/O CC/MCC,Surgical,Relative Weights,"$10,297.22 ",IP,"2,420.00","35,421.12",,,,,,
Aetna MCR ADV,DRG,MS-576,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,Surgical,Relative Weights,"$29,572.40 ",IP,"2,420.00","97,759.87",,,,,,
Aetna MCR ADV,DRG,MS-577,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,Surgical,Relative Weights,"$14,889.86 ",IP,"2,420.00","48,698.50",,,,,,
Aetna MCR ADV,DRG,MS-578,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,Surgical,Relative Weights,"$9,316.09 ",IP,"2,420.00","32,808.38",,,,,,
Aetna MCR ADV,DRG,MS-579,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC,Surgical,Relative Weights,"$18,366.46 ",IP,"2,420.00","60,199.78",,,,,,
Aetna MCR ADV,DRG,MS-580,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC,Surgical,Relative Weights,"$10,096.33 ",IP,"2,420.00","32,431.39",,,,,,
Aetna MCR ADV,DRG,MS-581,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,040.62 ",IP,"2,420.00","25,296.77",,,,,,
Aetna MCR ADV,DRG,MS-582,MASTECTOMY FOR MALIGNANCY WITH CC/MCC,Surgical,Relative Weights,"$9,595.83 ",IP,"2,420.00","31,826.59",,,,,,
Aetna MCR ADV,DRG,MS-583,MASTECTOMY FOR MALIGNANCY W/O CC/MCC,Surgical,Relative Weights,"$9,002.48 ",IP,"2,420.00","29,461.82",,,,,,
Aetna MCR ADV,DRG,MS-584,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$10,726.47 ",IP,"2,420.00","36,860.54",,,,,,
Aetna MCR ADV,DRG,MS-585,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,159.40 ",IP,"2,420.00","34,217.57",,,,,,
Aetna MCR ADV,DRG,MS-592,SKIN ULCERS WITH MCC,Medical,Relative Weights,"$9,894.84 ",IP,"2,420.00","35,971.49",,,,,,
Aetna MCR ADV,DRG,MS-593,SKIN ULCERS WITH CC,Medical,Relative Weights,"$6,661.19 ",IP,"2,420.00","23,139.65",,,,,,
Aetna MCR ADV,DRG,MS-594,SKIN ULCERS WITHOUT CC/MCC,Medical,Relative Weights,"$4,765.50 ",IP,"2,420.00","16,323.55",,,,,,
Aetna MCR ADV,DRG,MS-595,MAJOR SKIN DISORDERS WITH MCC,Medical,Relative Weights,"$11,776.52 ",IP,"2,420.00","40,977.22",,,,,,
Aetna MCR ADV,DRG,MS-596,MAJOR SKIN DISORDERS W/O MCC,Medical,Relative Weights,"$5,809.13 ",IP,"2,420.00","19,637.86",,,,,,
Aetna MCR ADV,DRG,MS-597,MALIGNANT BREAST DISORDERS W MCC,Medical,Relative Weights,"$9,601.09 ",IP,"2,420.00","34,128.86",,,,,,
Aetna MCR ADV,DRG,MS-598,MALIGNANT BREAST DISORDERS WITH CC,Medical,Relative Weights,"$6,499.42 ",IP,"2,420.00","21,946.18",,,,,,
Aetna MCR ADV,DRG,MS-599,MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$3,921.03 ",IP,"2,420.00","14,019.26",,,,,,
Aetna MCR ADV,DRG,MS-600,NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,Medical,Relative Weights,"$5,821.97 ",IP,"2,420.00","19,337.47",,,,,,
Aetna MCR ADV,DRG,MS-601,NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$4,010.97 ",IP,"2,420.00","12,475.01",,,,,,
Aetna MCR ADV,DRG,MS-602,CELLULITIS WITH MCC,Medical,Relative Weights,"$8,468.11 ",IP,"2,420.00","28,824.77",,,,,,
Aetna MCR ADV,DRG,MS-603,CELLULITIS WITHOUT MCC,Medical,Relative Weights,"$4,985.09 ",IP,"2,420.00","17,004.96",,,,,,
Aetna MCR ADV,DRG,MS-604,TRAUMA TO THE SKIN -  SUBCUTANEOUS TISSUE AND BREAST WITH MCC,Medical,Relative Weights,"$8,631.05 ",IP,"2,420.00","29,524.32",,,,,,
Aetna MCR ADV,DRG,MS-605,TRAUMA TO THE SKIN- SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC,Medical,Relative Weights,"$5,278.85 ",IP,"2,420.00","17,654.11",,,,,,
Aetna MCR ADV,DRG,MS-606,MINOR SKIN DISORDERS WITH MCC,Medical,Relative Weights,"$8,830.78 ",IP,"2,420.00","30,149.28",,,,,,
Aetna MCR ADV,DRG,MS-607,MINOR SKIN DISORDERS WITHOUT MCC,Medical,Relative Weights,"$4,836.75 ",IP,"2,420.00","16,654.18",,,,,,
Aetna MCR ADV,DRG,MS-614,ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$13,956.03 ",IP,"2,420.00","49,055.33",,,,,,
Aetna MCR ADV,DRG,MS-615,ADRENAL & PITUITARY PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$9,198.12 ",IP,"2,420.00","29,919.46",,,,,,
Aetna MCR ADV,DRG,MS-616,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Surgical,Relative Weights,"$23,162.92 ",IP,"2,420.00","80,656.13",,,,,,
Aetna MCR ADV,DRG,MS-617,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Surgical,Relative Weights,"$11,854.19 ",IP,"2,420.00","41,354.21",,,,,,
Aetna MCR ADV,DRG,MS-618,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$7,610.79 ",IP,"2,420.00","25,290.72",,,,,,
Aetna MCR ADV,DRG,MS-619,O.R. PROCEDURES FOR OBESITY WITH MCC,Surgical,Relative Weights,"$17,880.57 ",IP,"2,420.00","62,062.56",,,,,,
Aetna MCR ADV,DRG,MS-620,O.R. PROCEDURES FOR OBESITY WITH CC,Surgical,Relative Weights,"$10,294.30 ",IP,"2,420.00","36,179.14",,,,,,
Aetna MCR ADV,DRG,MS-621,O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,Surgical,Relative Weights,"$9,327.19 ",IP,"2,420.00","31,691.52",,,,,,
Aetna MCR ADV,DRG,MS-622,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Surgical,Relative Weights,"$21,111.30 ",IP,"2,420.00","76,114.08",,,,,,
Aetna MCR ADV,DRG,MS-623,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE -  NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Surgical,Relative Weights,"$10,929.71 ",IP,"2,420.00","39,364.42",,,,,,
Aetna MCR ADV,DRG,MS-624,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$6,417.66 ",IP,"2,420.00","22,216.32",,,,,,
Aetna MCR ADV,DRG,MS-625,THYROID- PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$16,586.99 ",IP,"2,420.00","58,970.02",,,,,,
Aetna MCR ADV,DRG,MS-626,THYROID -  PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC,Surgical,Relative Weights,"$9,653.06 ",IP,"2,420.00","33,925.25",,,,,,
Aetna MCR ADV,DRG,MS-627,THYROID -  PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,907.64 ",IP,"2,420.00","23,016.67",,,,,,
Aetna MCR ADV,DRG,MS-628,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$21,487.98 ",IP,"2,420.00","74,376.29",,,,,,
Aetna MCR ADV,DRG,MS-629,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$13,696.73 ",IP,"2,420.00","46,827.65",,,,,,
Aetna MCR ADV,DRG,MS-630,OTHER ENDOCRINE - NUTRIT & METAB O.R. PROC W/O CC/MCC,Surgical,Relative Weights,"$8,230.42 ",IP,"2,420.00","29,207.81",,,,,,
Aetna MCR ADV,DRG,MS-637,DIABETES WITH MCC,Medical,Relative Weights,"$8,039.45 ",IP,"2,420.00","27,935.71",,,,,,
Aetna MCR ADV,DRG,MS-638,DIABETES WITH CC,Medical,Relative Weights,"$5,135.76 ",IP,"2,420.00","17,823.46",,,,,,
Aetna MCR ADV,DRG,MS-639,DIABETES WITHOUT CC/MCC,Medical,Relative Weights,"$3,560.11 ",IP,"2,420.00","12,362.11",,,,,,
Aetna MCR ADV,DRG,MS-640,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITH MCC,Medical,Relative Weights,"$7,187.97 ",IP,"2,420.00","24,478.27",,,,,,
Aetna MCR ADV,DRG,MS-641,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITHOUT MCC,Medical,Relative Weights,"$4,404.59 ",IP,"2,420.00","15,253.06",,,,,,
Aetna MCR ADV,DRG,MS-642,INBORN AND OTHER DISORDERS OF METABOLISM,Medical,Relative Weights,"$7,532.53 ",IP,"2,420.00","24,510.53",,,,,,
Aetna MCR ADV,DRG,MS-643,ENDOCRINE DISORDERS WITH MCC,Medical,Relative Weights,"$9,739.50 ",IP,"2,420.00","32,770.08",,,,,,
Aetna MCR ADV,DRG,MS-644,ENDOCRINE DISORDERS WITH CC,Medical,Relative Weights,"$5,955.71 ",IP,"2,420.00","20,726.50",,,,,,
Aetna MCR ADV,DRG,MS-645,ENDOCRINE DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$4,488.68 ",IP,"2,420.00","15,426.43",,,,,,
Aetna MCR ADV,DRG,MS-650,KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,Neonate,Relative Weights,"$26,401.24 ",IP,"2,420.00","26,401.24",,,,,,
Aetna MCR ADV,DRG,MS-651,KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,Neonate,Relative Weights,"$21,598.94 ",IP,"2,420.00","21,598.94",,,,,,
Aetna MCR ADV,DRG,MS-652,KIDNEY TRANSPLANT,Surgical,Relative Weights,"$18,601.23 ",IP,"2,420.00","68,239.58",,,,,,
Aetna MCR ADV,DRG,MS-653,MAJOR BLADDER PROCEDURES WITH MCC,Surgical,Relative Weights,"$31,882.15 ",IP,"2,420.00","111,615.84",,,,,,
Aetna MCR ADV,DRG,MS-654,MAJOR BLADDER PROCEDURES WITH CC,Surgical,Relative Weights,"$16,952.58 ",IP,"2,420.00","56,693.95",,,,,,
Aetna MCR ADV,DRG,MS-655,MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$12,149.11 ",IP,"2,420.00","41,577.98",,,,,,
Aetna MCR ADV,DRG,MS-656,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,Surgical,Relative Weights,"$19,184.65 ",IP,"2,420.00","65,733.70",,,,,,
Aetna MCR ADV,DRG,MS-657,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,Surgical,Relative Weights,"$11,298.80 ",IP,"2,420.00","38,993.47",,,,,,
Aetna MCR ADV,DRG,MS-658,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,Surgical,Relative Weights,"$9,215.06 ",IP,"2,420.00","31,649.18",,,,,,
Aetna MCR ADV,DRG,MS-659,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,Surgical,Relative Weights,"$15,571.98 ",IP,"2,420.00","54,024.77",,,,,,
Aetna MCR ADV,DRG,MS-660,KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC,Surgical,Relative Weights,"$8,427.82 ",IP,"2,420.00","28,641.31",,,,,,
Aetna MCR ADV,DRG,MS-661,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,Surgical,Relative Weights,"$6,212.09 ",IP,"2,420.00","21,976.42",,,,,,
Aetna MCR ADV,DRG,MS-662,MINOR BLADDER PROCEDURES WITH MCC,Surgical,Relative Weights,"$17,154.06 ",IP,"2,420.00","63,800.35",,,,,,
Aetna MCR ADV,DRG,MS-663,MINOR BLADDER PROCEDURES WITH CC,Surgical,Relative Weights,"$9,341.20 ",IP,"2,420.00","30,711.74",,,,,,
Aetna MCR ADV,DRG,MS-664,MINOR BLADDER PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,913.48 ",IP,"2,420.00","22,309.06",,,,,,
Aetna MCR ADV,DRG,MS-665,PROSTATECTOMY WITH MCC,Surgical,Relative Weights,"$17,763.76 ",IP,"2,420.00","59,844.96",,,,,,
Aetna MCR ADV,DRG,MS-666,PROSTATECTOMY WITH CC,Surgical,Relative Weights,"$10,159.98 ",IP,"2,420.00","35,665.06",,,,,,
Aetna MCR ADV,DRG,MS-667,PROSTATECTOMY W/O CC/MCC,Surgical,Relative Weights,"$5,825.48 ",IP,"2,420.00","18,924.19",,,,,,
Aetna MCR ADV,DRG,MS-668,TRANSURETHRAL PROCEDURES W MCC,Surgical,Relative Weights,"$16,389.01 ",IP,"2,420.00","56,212.13",,,,,,
Aetna MCR ADV,DRG,MS-669,TRANSURETHRAL PROCEDURES WITH CC,Surgical,Relative Weights,"$9,130.96 ",IP,"2,420.00","31,161.31",,,,,,
Aetna MCR ADV,DRG,MS-670,TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$5,714.52 ",IP,"2,420.00","19,730.59",,,,,,
Aetna MCR ADV,DRG,MS-671,URETHRAL PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$10,402.93 ",IP,"2,420.00","36,844.42",,,,,,
Aetna MCR ADV,DRG,MS-672,URETHRAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,718.43 ",IP,"2,420.00","20,829.31",,,,,,
Aetna MCR ADV,DRG,MS-673,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,Surgical,Relative Weights,"$20,255.14 ",IP,"2,420.00","72,063.94",,,,,,
Aetna MCR ADV,DRG,MS-674,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,Surgical,Relative Weights,"$13,918.07 ",IP,"2,420.00","49,275.07",,,,,,
Aetna MCR ADV,DRG,MS-675,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,247.58 ",IP,"2,420.00","32,901.12",,,,,,
Aetna MCR ADV,DRG,MS-682,RENAL FAILURE WITH MCC,Medical,Relative Weights,"$8,600.68 ",IP,"2,420.00","29,796.48",,,,,,
Aetna MCR ADV,DRG,MS-683,RENAL FAILURE WITH CC,Medical,Relative Weights,"$5,135.18 ",IP,"2,420.00","18,089.57",,,,,,
Aetna MCR ADV,DRG,MS-684,RENAL FAILURE WITHOUT CC/MCC,Medical,Relative Weights,"$3,550.18 ",IP,"2,420.00","12,404.45",,,,,,
Aetna MCR ADV,DRG,MS-686,KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,Medical,Relative Weights,"$10,951.90 ",IP,"2,420.00","35,402.98",,,,,,
Aetna MCR ADV,DRG,MS-687,KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,Medical,Relative Weights,"$6,132.67 ",IP,"2,420.00","21,220.42",,,,,,
Aetna MCR ADV,DRG,MS-688,KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,Medical,Relative Weights,"$4,005.13 ",IP,"2,420.00","15,549.41",,,,,,
Aetna MCR ADV,DRG,MS-689,KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,Medical,Relative Weights,"$6,507.01 ",IP,"2,420.00","22,550.98",,,,,,
Aetna MCR ADV,DRG,MS-690,KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,Medical,Relative Weights,"$4,637.02 ",IP,"2,420.00","15,942.53",,,,,,
Aetna MCR ADV,DRG,MS-693,URINARY STONES WITH MCC,Medical,Relative Weights,"$7,799.42 ",IP,"2,420.00","27,282.53",,,,,,
Aetna MCR ADV,DRG,MS-694,URINARY STONES WITHOUT MCC,Medical,Relative Weights,"$4,503.87 ",IP,"2,420.00","14,926.46",,,,,,
Aetna MCR ADV,DRG,MS-695,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,Medical,Relative Weights,"$6,644.26 ",IP,"2,420.00","23,633.57",,,,,,
Aetna MCR ADV,DRG,MS-696,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,Medical,Relative Weights,"$4,040.75 ",IP,"2,420.00","13,696.70",,,,,,
Aetna MCR ADV,DRG,MS-697,URETHRAL STRICTURE,Medical,Relative Weights,"$5,835.99 ",IP,"2,420.00","19,633.82",,,,,,
Aetna MCR ADV,DRG,MS-698,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,Medical,Relative Weights,"$9,406.03 ",IP,"2,420.00","32,630.98",,,,,,
Aetna MCR ADV,DRG,MS-699,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,Medical,Relative Weights,"$5,997.76 ",IP,"2,420.00","20,819.23",,,,,,
Aetna MCR ADV,DRG,MS-700,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$4,359.62 ",IP,"2,420.00","14,952.67",,,,,,
Aetna MCR ADV,DRG,MS-707,MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$11,225.80 ",IP,"2,420.00","37,697.18",,,,,,
Aetna MCR ADV,DRG,MS-708,MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,708.72 ",IP,"2,420.00","29,272.32",,,,,,
Aetna MCR ADV,DRG,MS-709,PENIS PROCEDURES W CC/MCC,Surgical,Relative Weights,"$13,525.04 ",IP,"2,420.00","48,496.90",,,,,,
Aetna MCR ADV,DRG,MS-710,PENIS PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$9,353.47 ",IP,"2,420.00","30,961.73",,,,,,
Aetna MCR ADV,DRG,MS-711,TESTES PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$12,448.71 ",IP,"2,420.00","43,206.91",,,,,,
Aetna MCR ADV,DRG,MS-712,TESTES PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,190.48 ",IP,"2,420.00","20,567.23",,,,,,
Aetna MCR ADV,DRG,MS-713,TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,Surgical,Relative Weights,"$8,721.57 ",IP,"2,420.00","29,473.92",,,,,,
Aetna MCR ADV,DRG,MS-714,TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,Surgical,Relative Weights,"$5,424.26 ",IP,"2,420.00","18,454.46",,,,,,
Aetna MCR ADV,DRG,MS-715,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,Surgical,Relative Weights,"$11,806.30 ",IP,"2,420.00","43,071.84",,,,,,
Aetna MCR ADV,DRG,MS-716,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$7,450.77 ",IP,"2,420.00","29,544.48",,,,,,
Aetna MCR ADV,DRG,MS-717,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,Surgical,Relative Weights,"$10,515.64 ",IP,"2,420.00","35,568.29",,,,,,
Aetna MCR ADV,DRG,MS-718,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$7,210.16 ",IP,"2,420.00","24,583.10",,,,,,
Aetna MCR ADV,DRG,MS-722,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH MCC,Medical,Relative Weights,"$10,001.72 ",IP,"2,420.00","36,386.78",,,,,,
Aetna MCR ADV,DRG,MS-723,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH CC,Medical,Relative Weights,"$6,376.78 ",IP,"2,420.00","22,325.18",,,,,,
Aetna MCR ADV,DRG,MS-724,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Medical,Relative Weights,"$3,784.95 ",IP,"2,420.00","11,902.46",,,,,,
Aetna MCR ADV,DRG,MS-725,BENIGN PROSTATIC HYPERTROPHY WITH MCC,Medical,Relative Weights,"$7,507.42 ",IP,"2,420.00","25,308.86",,,,,,
Aetna MCR ADV,DRG,MS-726,BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,Medical,Relative Weights,"$4,349.11 ",IP,"2,420.00","15,416.35",,,,,,
Aetna MCR ADV,DRG,MS-727,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,Medical,Relative Weights,"$8,298.75 ",IP,"2,420.00","28,774.37",,,,,,
Aetna MCR ADV,DRG,MS-728,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,Medical,Relative Weights,"$4,705.35 ",IP,"2,420.00","16,178.40",,,,,,
Aetna MCR ADV,DRG,MS-729,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,Medical,Relative Weights,"$5,883.88 ",IP,"2,420.00","21,649.82",,,,,,
Aetna MCR ADV,DRG,MS-730,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$3,322.42 ",IP,"2,420.00","12,733.06",,,,,,
Aetna MCR ADV,DRG,MS-734,PELVIC EVISCERATION -  RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC,Surgical,Relative Weights,"$12,990.08 ",IP,"2,420.00","44,188.70",,,,,,
Aetna MCR ADV,DRG,MS-735,PELVIC EVISCERATION -  RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC,Surgical,Relative Weights,"$8,255.53 ",IP,"2,420.00","27,703.87",,,,,,
Aetna MCR ADV,DRG,MS-736,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,Surgical,Relative Weights,"$24,882.82 ",IP,"2,420.00","87,109.34",,,,,,
Aetna MCR ADV,DRG,MS-737,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,Surgical,Relative Weights,"$12,019.46 ",IP,"2,420.00","40,059.94",,,,,,
Aetna MCR ADV,DRG,MS-738,UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY W/O CC/MCC,Surgical,Relative Weights,"$8,619.37 ",IP,"2,420.00","27,798.62",,,,,,
Aetna MCR ADV,DRG,MS-739,UTERINE -ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W MCC,Surgical,Relative Weights,"$22,332.46 ",IP,"2,420.00","75,489.12",,,,,,
Aetna MCR ADV,DRG,MS-740,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,Surgical,Relative Weights,"$10,521.48 ",IP,"2,420.00","35,983.58",,,,,,
Aetna MCR ADV,DRG,MS-741,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$7,474.72 ",IP,"2,420.00","26,802.72",,,,,,
Aetna MCR ADV,DRG,MS-742,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,Surgical,Relative Weights,"$10,033.84 ",IP,"2,420.00","34,060.32",,,,,,
Aetna MCR ADV,DRG,MS-743,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$6,615.64 ",IP,"2,420.00","23,153.76",,,,,,
Aetna MCR ADV,DRG,MS-744,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC,Surgical,Relative Weights,"$10,485.28 ",IP,"2,420.00","35,088.48",,,,,,
Aetna MCR ADV,DRG,MS-745,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC,Surgical,Relative Weights,"$6,832.89 ",IP,"2,420.00","21,476.45",,,,,,
Aetna MCR ADV,DRG,MS-746,VAGINA -  CERVIX AND VULVA PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$9,411.29 ",IP,"2,420.00","32,880.96",,,,,,
Aetna MCR ADV,DRG,MS-747,VAGINA- CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$5,484.42 ",IP,"2,420.00","18,793.15",,,,,,
Aetna MCR ADV,DRG,MS-748,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,Surgical,Relative Weights,"$7,870.09 ",IP,"2,420.00","26,645.47",,,,,,
Aetna MCR ADV,DRG,MS-749,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$15,848.80 ",IP,"2,420.00","52,258.75",,,,,,
Aetna MCR ADV,DRG,MS-750,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,548.71 ",IP,"2,420.00","26,836.99",,,,,,
Aetna MCR ADV,DRG,MS-754,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH MCC,Medical,Relative Weights,"$10,665.15 ",IP,"2,420.00","35,519.90",,,,,,
Aetna MCR ADV,DRG,MS-755,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH CC,Medical,Relative Weights,"$6,595.20 ",IP,"2,420.00","20,639.81",,,,,,
Aetna MCR ADV,DRG,MS-756,MALIGNANCY - FEMALE REPRODUCTIVE SYSTEM W/O CC/MCC,Medical,Relative Weights,"$5,363.53 ",IP,"2,420.00","17,676.29",,,,,,
Aetna MCR ADV,DRG,MS-757,INFECTIONS - FEMALE REPRODUCTIVE SYSTEM W MCC,Medical,Relative Weights,"$8,904.37 ",IP,"2,420.00","28,633.25",,,,,,
Aetna MCR ADV,DRG,MS-758,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITH CC,Medical,Relative Weights,"$5,663.12 ",IP,"2,420.00","19,462.46",,,,,,
Aetna MCR ADV,DRG,MS-759,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Medical,Relative Weights,"$3,991.11 ",IP,"2,420.00","13,311.65",,,,,,
Aetna MCR ADV,DRG,MS-760,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,Medical,Relative Weights,"$5,373.46 ",IP,"2,420.00","18,194.40",,,,,,
Aetna MCR ADV,DRG,MS-761,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$3,450.32 ",IP,"2,420.00","11,398.46",,,,,,
Aetna MCR ADV,DRG,MS-768,VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C,Surgical,Relative Weights,"$6,830.55 ",IP,"2,420.00","20,311.20",,,,,,
Aetna MCR ADV,DRG,MS-769,POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,Surgical,Relative Weights,"$9,446.91 ",IP,"2,420.00","29,090.88",,,,,,
Aetna MCR ADV,DRG,MS-770,ABORTION WITH D&C- ASPIRATION CURETTAGE OR HYSTEROTOMY,Surgical,Relative Weights,"$5,196.50 ",IP,"2,420.00","15,851.81",,,,,,
Aetna MCR ADV,DRG,MS-776,POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,Medical,Relative Weights,"$4,523.14 ",IP,"2,420.00","14,311.58",,,,,,
Aetna MCR ADV,DRG,MS-779,ABORTION WITHOUT D&C,Medical,Relative Weights,"$6,184.64 ",IP,"2,420.00","23,018.69",,,,,,
Aetna MCR ADV,DRG,MS-783,CESAREAN SECTION WITH STERILIZATION WITH MCC,C-Section,Relative Weights,"$10,949.56 ",IP,"2,420.00","43,239.17",,,,,,
Aetna MCR ADV,DRG,MS-784,CESAREAN SECTION WITH STERILIZATION WITH CC,C-Section,Relative Weights,"$6,400.14 ",IP,"2,420.00","21,071.23",,,,,,
Aetna MCR ADV,DRG,MS-785,CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,C-Section,Relative Weights,"$5,354.18 ",IP,"2,420.00","17,305.34",,,,,,
Aetna MCR ADV,DRG,MS-786,CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,C-Section,Relative Weights,"$9,311.42 ",IP,"2,420.00","34,564.32",,,,,,
Aetna MCR ADV,DRG,MS-787,CESAREAN SECTION WITHOUT STERILIZATION WITH CC,C-Section,Relative Weights,"$6,216.18 ",IP,"2,420.00","21,077.28",,,,,,
Aetna MCR ADV,DRG,MS-788,CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,C-Section,Relative Weights,"$5,182.48 ",IP,"2,420.00","18,268.99",,,,,,
Aetna MCR ADV,DRG,MS-789,NEONATES- DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY,Medical,Relative Weights,"$10,044.93 ",IP,"2,420.00","34,070.40",,,,,,
Aetna MCR ADV,DRG,MS-790,EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME- NEONATE,Medical,Relative Weights,"$33,125.50 ",IP,"2,420.00","112,351.68",,,,,,
Aetna MCR ADV,DRG,MS-791,PREMATURITY W MAJOR PROBLEMS,Medical,Relative Weights,"$22,623.29 ",IP,"2,420.00","76,732.99",,,,,,
Aetna MCR ADV,DRG,MS-792,PREMATURITY W/O MAJOR PROBLEMS,Medical,Relative Weights,"$13,650.60 ",IP,"2,420.00","46,297.44",,,,,,
Aetna MCR ADV,DRG,MS-793,FULL TERM NEONATE WITH MAJOR PROBLEMS,Medical,Relative Weights,"$23,238.84 ",IP,"2,420.00","78,819.55",,,,,,
Aetna MCR ADV,DRG,MS-794,NEONATE WITH OTHER SIGNIFICANT PROBLEMS,Medical,Relative Weights,"$8,225.17 ",IP,"2,420.00","27,897.41",,,,,,
Aetna MCR ADV,DRG,MS-795,NORMAL NEWBORN,Medical,Relative Weights,"$1,113.70 ",IP,"1,113.70","3,775.97",,,,,,
Aetna MCR ADV,DRG,MS-796,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,Vaginal Delivery,Relative Weights,"$6,253.56 ",IP,"2,420.00","39,761.57",,,,,,
Aetna MCR ADV,DRG,MS-797,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,Vaginal Delivery,Relative Weights,"$5,369.37 ",IP,"2,420.00","17,394.05",,,,,,
Aetna MCR ADV,DRG,MS-798,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,Vaginal Delivery,Relative Weights,"$4,832.66 ",IP,"2,420.00","17,394.05",,,,,,
Aetna MCR ADV,DRG,MS-799,SPLENECTOMY WITH MCC,Surgical,Relative Weights,"$30,061.22 ",IP,"2,420.00","99,677.09",,,,,,
Aetna MCR ADV,DRG,MS-800,SPLENECTOMY WITH CC,Surgical,Relative Weights,"$17,251.01 ",IP,"2,420.00","57,294.72",,,,,,
Aetna MCR ADV,DRG,MS-801,SPLENECTOMY WITHOUT CC/MCC,Surgical,Relative Weights,"$9,834.69 ",IP,"2,420.00","37,763.71",,,,,,
Aetna MCR ADV,DRG,MS-802,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,Surgical,Relative Weights,"$21,676.62 ",IP,"2,420.00","63,552.38",,,,,,
Aetna MCR ADV,DRG,MS-803,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,Surgical,Relative Weights,"$11,017.31 ",IP,"2,420.00","35,917.06",,,,,,
Aetna MCR ADV,DRG,MS-804,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,Surgical,Relative Weights,"$7,976.96 ",IP,"2,420.00","27,470.02",,,,,,
Aetna MCR ADV,DRG,MS-805,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,Vaginal Delivery,Relative Weights,"$6,014.70 ",IP,"2,420.00","20,980.51",,,,,,
Aetna MCR ADV,DRG,MS-806,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,Vaginal Delivery,Relative Weights,"$4,290.12 ",IP,"2,420.00","14,297.47",,,,,,
Aetna MCR ADV,DRG,MS-807,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,Vaginal Delivery,Relative Weights,"$3,751.08 ",IP,"2,420.00","12,636.29",,,,,,
Aetna MCR ADV,DRG,MS-808,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,Medical,Relative Weights,"$12,765.24 ",IP,"2,420.00","42,932.74",,,,,,
Aetna MCR ADV,DRG,MS-809,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,Medical,Relative Weights,"$7,144.75 ",IP,"2,420.00","24,512.54",,,,,,
Aetna MCR ADV,DRG,MS-810,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$5,616.40 ",IP,"2,420.00","18,857.66",,,,,,
Aetna MCR ADV,DRG,MS-811,RED BLOOD CELL DISORDERS WITH MCC,Medical,Relative Weights,"$8,055.22 ",IP,"2,420.00","27,020.45",,,,,,
Aetna MCR ADV,DRG,MS-812,RED BLOOD CELL DISORDERS WITHOUT MCC,Medical,Relative Weights,"$5,141.02 ",IP,"2,420.00","17,553.31",,,,,,
Aetna MCR ADV,DRG,MS-813,COAGULATION DISORDERS,Medical,Relative Weights,"$9,023.50 ",IP,"2,420.00","31,957.63",,,,,,
Aetna MCR ADV,DRG,MS-814,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,Medical,Relative Weights,"$11,047.67 ",IP,"2,420.00","35,261.86",,,,,,
Aetna MCR ADV,DRG,MS-815,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,Medical,Relative Weights,"$5,801.53 ",IP,"2,420.00","20,418.05",,,,,,
Aetna MCR ADV,DRG,MS-816,RETICULOENDOTHELIAL & IMMUNITY DISORDERS W/O CC/MCC,Medical,Relative Weights,"$3,860.88 ",IP,"2,420.00","14,432.54",,,,,,
Aetna MCR ADV,DRG,MS-817,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$13,471.89 ",IP,"2,420.00","50,726.59",,,,,,
Aetna MCR ADV,DRG,MS-818,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$7,941.34 ",IP,"2,420.00","25,681.82",,,,,,
Aetna MCR ADV,DRG,MS-819,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$5,765.32 ",IP,"2,420.00","16,085.66",,,,,,
Aetna MCR ADV,DRG,MS-820,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$33,239.97 ",IP,"2,420.00","115,248.67",,,,,,
Aetna MCR ADV,DRG,MS-821,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$12,586.54 ",IP,"2,420.00","45,003.17",,,,,,
Aetna MCR ADV,DRG,MS-822,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,308.86 ",IP,"2,420.00","25,490.30",,,,,,
Aetna MCR ADV,DRG,MS-823,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,Surgical,Relative Weights,"$26,290.86 ",IP,"2,420.00","85,280.83",,,,,,
Aetna MCR ADV,DRG,MS-824,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,Surgical,Relative Weights,"$13,808.28 ",IP,"2,420.00","46,874.02",,,,,,
Aetna MCR ADV,DRG,MS-825,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,184.87 ",IP,"2,420.00","27,306.72",,,,,,
Aetna MCR ADV,DRG,MS-826,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$29,460.27 ",IP,"2,420.00","101,102.40",,,,,,
Aetna MCR ADV,DRG,MS-827,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$14,603.70 ",IP,"2,420.00","46,694.59",,,,,,
Aetna MCR ADV,DRG,MS-828,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$9,776.29 ",IP,"2,420.00","33,288.19",,,,,,
Aetna MCR ADV,DRG,MS-829,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$18,737.31 ",IP,"2,420.00","63,300.38",,,,,,
Aetna MCR ADV,DRG,MS-830,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,655.00 ",IP,"2,420.00","27,796.61",,,,,,
Aetna MCR ADV,DRG,MS-831,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,Medical,Relative Weights,"$6,551.40 ",IP,"2,420.00","21,742.56",,,,,,
Aetna MCR ADV,DRG,MS-832,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,Medical,Relative Weights,"$4,545.33 ",IP,"2,420.00","14,424.48",,,,,,
Aetna MCR ADV,DRG,MS-833,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,Medical,Relative Weights,"$3,136.12 ",IP,"2,420.00","10,727.14",,,,,,
Aetna MCR ADV,DRG,MS-834,ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W MCC,Medical,Relative Weights,"$35,345.32 ",IP,"2,420.00","117,784.80",,,,,,
Aetna MCR ADV,DRG,MS-835,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC,Medical,Relative Weights,"$12,344.17 ",IP,"2,420.00","40,888.51",,,,,,
Aetna MCR ADV,DRG,MS-836,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Medical,Relative Weights,"$6,853.33 ",IP,"2,420.00","26,562.82",,,,,,
Aetna MCR ADV,DRG,MS-837,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,Medical,Relative Weights,"$33,284.35 ",IP,"2,420.00","120,774.53",,,,,,
Aetna MCR ADV,DRG,MS-838,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,Medical,Relative Weights,"$13,199.74 ",IP,"2,420.00","44,108.06",,,,,,
Aetna MCR ADV,DRG,MS-839,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Medical,Relative Weights,"$8,685.36 ",IP,"2,420.00","25,728.19",,,,,,
Aetna MCR ADV,DRG,MS-840,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,Medical,Relative Weights,"$18,807.97 ",IP,"2,420.00","64,415.23",,,,,,
Aetna MCR ADV,DRG,MS-841,LYMPHOMA & NON-ACUTE LEUKEMIA W CC,Medical,Relative Weights,"$9,470.27 ",IP,"2,420.00","32,491.87",,,,,,
Aetna MCR ADV,DRG,MS-842,LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,Medical,Relative Weights,"$6,406.57 ",IP,"2,420.00","23,115.46",,,,,,
Aetna MCR ADV,DRG,MS-843,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,Medical,Relative Weights,"$11,140.53 ",IP,"2,420.00","38,461.25",,,,,,
Aetna MCR ADV,DRG,MS-844,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,Medical,Relative Weights,"$6,915.82 ",IP,"2,420.00","24,353.28",,,,,,
Aetna MCR ADV,DRG,MS-845,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$4,957.64 ",IP,"2,420.00","17,456.54",,,,,,
Aetna MCR ADV,DRG,MS-846,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,Medical,Relative Weights,"$15,609.94 ",IP,"2,420.00","52,952.26",,,,,,
Aetna MCR ADV,DRG,MS-847,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,Medical,Relative Weights,"$7,802.93 ",IP,"2,420.00","26,528.54",,,,,,
Aetna MCR ADV,DRG,MS-848,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Medical,Relative Weights,"$6,028.71 ",IP,"2,420.00","19,785.02",,,,,,
Aetna MCR ADV,DRG,MS-849,RADIOTHERAPY,Medical,Relative Weights,"$14,562.82 ",IP,"2,420.00","42,856.13",,,,,,
Aetna MCR ADV,DRG,MS-853,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$29,012.34 ",IP,"2,420.00","102,787.78",,,,,,
Aetna MCR ADV,DRG,MS-854,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$12,393.81 ",IP,"2,420.00","43,569.79",,,,,,
Aetna MCR ADV,DRG,MS-855,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,875.75 ",IP,"2,420.00","32,322.53",,,,,,
Aetna MCR ADV,DRG,MS-856,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$27,237.54 ",IP,"2,420.00","89,222.11",,,,,,
Aetna MCR ADV,DRG,MS-857,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$12,278.18 ",IP,"2,420.00","40,991.33",,,,,,
Aetna MCR ADV,DRG,MS-858,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,940.17 ",IP,"2,420.00","27,748.22",,,,,,
Aetna MCR ADV,DRG,MS-862,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W MCC,Medical,Relative Weights,"$11,076.88 ",IP,"2,420.00","37,308.10",,,,,,
Aetna MCR ADV,DRG,MS-863,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W/O MCC,Medical,Relative Weights,"$5,906.65 ",IP,"2,420.00","19,918.08",,,,,,
Aetna MCR ADV,DRG,MS-864,FEVER AND INFLAMMATORY CONDITIONS,Medical,Relative Weights,"$5,118.83 ",IP,"2,420.00","17,083.58",,,,,,
Aetna MCR ADV,DRG,MS-865,VIRAL ILLNESS WITH MCC,Medical,Relative Weights,"$8,630.47 ",IP,"2,420.00","28,088.93",,,,,,
Aetna MCR ADV,DRG,MS-866,VIRAL ILLNESS WITHOUT MCC,Medical,Relative Weights,"$4,899.83 ",IP,"2,420.00","16,504.99",,,,,,
Aetna MCR ADV,DRG,MS-867,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,Medical,Relative Weights,"$13,064.84 ",IP,"2,420.00","44,053.63",,,,,,
Aetna MCR ADV,DRG,MS-868,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,Medical,Relative Weights,"$6,225.52 ",IP,"2,420.00","22,115.52",,,,,,
Aetna MCR ADV,DRG,MS-869,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$4,254.50 ",IP,"2,420.00","14,968.80",,,,,,
Aetna MCR ADV,DRG,MS-870,SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,Medical,Relative Weights,"$37,604.26 ",IP,"2,420.00","127,497.89",,,,,,
Aetna MCR ADV,DRG,MS-871,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,Medical,Relative Weights,"$10,933.79 ",IP,"2,420.00","37,624.61",,,,,,
Aetna MCR ADV,DRG,MS-872,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,Medical,Relative Weights,"$5,993.67 ",IP,"2,420.00","20,952.29",,,,,,
Aetna MCR ADV,DRG,MS-876,O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,Surgical,Relative Weights,"$19,085.37 ",IP,"2,420.00","73,382.40",,,,,,
Aetna MCR ADV,DRG,MS-880,ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,Medical,Relative Weights,"$5,048.75 ",IP,"2,420.00","17,275.10",,,,,,
Aetna MCR ADV,DRG,MS-881,DEPRESSIVE NEUROSES,Medical,Relative Weights,"$4,683.74 ",IP,"2,420.00","16,517.09",,,,,,
Aetna MCR ADV,DRG,MS-882,NEUROSES EXCEPT DEPRESSIVE,Medical,Relative Weights,"$4,809.89 ",IP,"2,420.00","15,922.37",,,,,,
Aetna MCR ADV,DRG,MS-883,DISORDERS OF PERSONALITY & IMPULSE CONTROL,Medical,Relative Weights,"$9,237.83 ",IP,"2,420.00","26,945.86",,,,,,
Aetna MCR ADV,DRG,MS-884,ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,Medical,Relative Weights,"$8,452.34 ",IP,"2,420.00","28,990.08",,,,,,
Aetna MCR ADV,DRG,MS-885,PSYCHOSES,Medical,Relative Weights,"$7,238.19 ",IP,"2,420.00","24,502.46",,,,,,
Aetna MCR ADV,DRG,MS-886,BEHAVIORAL AND DEVELOPMENTAL DISORDERS,Medical,Relative Weights,"$7,146.50 ",IP,"2,420.00","27,127.30",,,,,,
Aetna MCR ADV,DRG,MS-887,OTHER MENTAL DISORDER DIAGNOSES,Medical,Relative Weights,"$6,306.12 ",IP,"2,420.00","21,936.10",,,,,,
Aetna MCR ADV,DRG,MS-894,ALCOHOL- DRUG ABUSE OR DEPENDENCE- LEFT AMA,Medical,Relative Weights,"$3,206.20 ",IP,"2,420.00","11,700.86",,,,,,
Aetna MCR ADV,DRG,MS-895,ALCOHOL- DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY,Medical,Relative Weights,"$9,339.45 ",IP,"2,420.00","32,798.30",,,,,,
Aetna MCR ADV,DRG,MS-896,ALCOHOL -  DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC,Medical,Relative Weights,"$10,397.09 ",IP,"2,420.00","34,669.15",,,,,,
Aetna MCR ADV,DRG,MS-897,ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC,Medical,Relative Weights,"$4,829.74 ",IP,"2,420.00","16,567.49",,,,,,
Aetna MCR ADV,DRG,MS-901,WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,Surgical,Relative Weights,"$24,929.54 ",IP,"2,420.00","87,236.35",,,,,,
Aetna MCR ADV,DRG,MS-902,WOUND DEBRIDEMENTS FOR INJURIES WITH CC,Surgical,Relative Weights,"$11,471.66 ",IP,"2,420.00","39,652.70",,,,,,
Aetna MCR ADV,DRG,MS-903,WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,630.24 ",IP,"2,420.00","23,063.04",,,,,,
Aetna MCR ADV,DRG,MS-904,SKIN GRAFTS FOR INJURIES WITH CC/MCC,Surgical,Relative Weights,"$21,765.97 ",IP,"2,420.00","71,313.98",,,,,,
Aetna MCR ADV,DRG,MS-905,SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,Surgical,Relative Weights,"$9,636.13 ",IP,"2,420.00","33,554.30",,,,,,
Aetna MCR ADV,DRG,MS-906,HAND PROCEDURES FOR INJURIES,Surgical,Relative Weights,"$10,534.33 ",IP,"2,420.00","35,096.54",,,,,,
Aetna MCR ADV,DRG,MS-907,OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,Surgical,Relative Weights,"$23,057.79 ",IP,"2,420.00","80,430.34",,,,,,
Aetna MCR ADV,DRG,MS-908,OTHER O.R. PROCEDURES FOR INJURIES WITH CC,Surgical,Relative Weights,"$11,974.50 ",IP,"2,420.00","41,592.10",,,,,,
Aetna MCR ADV,DRG,MS-909,OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,006.75 ",IP,"2,420.00","26,584.99",,,,,,
Aetna MCR ADV,DRG,MS-913,TRAUMATIC INJURY WITH MCC,Medical,Relative Weights,"$9,569.55 ",IP,"2,420.00","29,762.21",,,,,,
Aetna MCR ADV,DRG,MS-914,TRAUMATIC INJURY WITHOUT MCC,Medical,Relative Weights,"$5,179.56 ",IP,"2,420.00","17,371.87",,,,,,
Aetna MCR ADV,DRG,MS-915,ALLERGIC REACTIONS WITH MCC,Medical,Relative Weights,"$9,925.21 ",IP,"2,420.00","34,253.86",,,,,,
Aetna MCR ADV,DRG,MS-916,ALLERGIC REACTIONS WITHOUT MCC,Medical,Relative Weights,"$3,845.11 ",IP,"2,420.00","12,765.31",,,,,,
Aetna MCR ADV,DRG,MS-917,POISONING & TOXIC EFFECTS OF DRUGS W MCC,Medical,Relative Weights,"$8,634.55 ",IP,"2,420.00","29,498.11",,,,,,
Aetna MCR ADV,DRG,MS-918,POISONING & TOXIC EFFECTS OF DRUGS W/O MCC,Medical,Relative Weights,"$4,623.01 ",IP,"2,420.00","15,805.44",,,,,,
Aetna MCR ADV,DRG,MS-919,COMPLICATIONS OF TREATMENT WITH MCC,Medical,Relative Weights,"$10,769.69 ",IP,"2,420.00","36,798.05",,,,,,
Aetna MCR ADV,DRG,MS-920,COMPLICATIONS OF TREATMENT WITH CC,Medical,Relative Weights,"$5,983.74 ",IP,"2,420.00","20,311.20",,,,,,
Aetna MCR ADV,DRG,MS-921,COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,Medical,Relative Weights,"$4,075.79 ",IP,"2,420.00","13,922.50",,,,,,
Aetna MCR ADV,DRG,MS-922,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC,Medical,Relative Weights,"$9,275.21 ",IP,"2,420.00","32,328.58",,,,,,
Aetna MCR ADV,DRG,MS-923,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC,Medical,Relative Weights,"$5,488.50 ",IP,"2,420.00","17,448.48",,,,,,
Aetna MCR ADV,DRG,MS-927,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,Surgical,Relative Weights,"$123,174.83 ",IP,"2,420.00","402,060.96",,,,,,
Aetna MCR ADV,DRG,MS-928,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,Surgical,Relative Weights,"$38,145.05 ",IP,"2,420.00","124,889.18",,,,,,
Aetna MCR ADV,DRG,MS-929,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,Surgical,Relative Weights,"$17,601.41 ",IP,"2,420.00","59,300.64",,,,,,
Aetna MCR ADV,DRG,MS-933,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,Medical,Relative Weights,"$13,215.51 ",IP,"2,420.00","63,306.43",,,,,,
Aetna MCR ADV,DRG,MS-934,FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,Medical,Relative Weights,"$11,335.01 ",IP,"2,420.00","36,485.57",,,,,,
Aetna MCR ADV,DRG,MS-935,NON-EXTENSIVE BURNS,Medical,Relative Weights,"$11,288.29 ",IP,"2,420.00","38,955.17",,,,,,
Aetna MCR ADV,DRG,MS-939,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,Surgical,Relative Weights,"$19,707.93 ",IP,"2,420.00","73,672.70",,,,,,
Aetna MCR ADV,DRG,MS-940,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,Surgical,Relative Weights,"$12,970.23 ",IP,"2,420.00","45,799.49",,,,,,
Aetna MCR ADV,DRG,MS-941,O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W/O CC/MCC,Surgical,Relative Weights,"$11,231.05 ",IP,"2,420.00","38,922.91",,,,,,
Aetna MCR ADV,DRG,MS-945,REHABILITATION WITH CC/MCC,Medical,Relative Weights,"$8,654.41 ",IP,"2,420.00","29,338.85",,,,,,
Aetna MCR ADV,DRG,MS-946,REHABILITATION WITHOUT CC/MCC,Medical,Relative Weights,"$6,577.10 ",IP,"2,420.00","21,913.92",,,,,,
Aetna MCR ADV,DRG,MS-947,SIGNS AND SYMPTOMS WITH MCC,Medical,Relative Weights,"$6,973.05 ",IP,"2,420.00","24,137.57",,,,,,
Aetna MCR ADV,DRG,MS-948,SIGNS AND SYMPTOMS WITHOUT MCC,Medical,Relative Weights,"$4,596.73 ",IP,"2,420.00","15,716.74",,,,,,
Aetna MCR ADV,DRG,MS-949,AFTERCARE WITH CC/MCC,Medical,Relative Weights,"$6,481.90 ",IP,"2,420.00","21,952.22",,,,,,
Aetna MCR ADV,DRG,MS-950,AFTERCARE WITHOUT CC/MCC,Medical,Relative Weights,"$4,322.83 ",IP,"2,420.00","14,936.54",,,,,,
Aetna MCR ADV,DRG,MS-951,OTHER FACTORS INFLUENCING HEALTH STATUS,Medical,Relative Weights,"$3,268.11 ",IP,"2,420.00","11,823.84",,,,,,
Aetna MCR ADV,DRG,MS-955,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,Surgical,Relative Weights,"$36,730.00 ",IP,"2,420.00","122,582.88",,,,,,
Aetna MCR ADV,DRG,MS-956,LIMB REATTACHMENT- HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,Surgical,Relative Weights,"$22,484.30 ",IP,"2,420.00","79,093.73",,,,,,
Aetna MCR ADV,DRG,MS-957,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Surgical,Relative Weights,"$43,338.63 ",IP,"2,420.00","151,879.39",,,,,,
Aetna MCR ADV,DRG,MS-958,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,Surgical,Relative Weights,"$24,561.61 ",IP,"2,420.00","84,488.54",,,,,,
Aetna MCR ADV,DRG,MS-959,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,Surgical,Relative Weights,"$15,979.04 ",IP,"2,420.00","56,458.08",,,,,,
Aetna MCR ADV,DRG,MS-963,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Medical,Relative Weights,"$15,942.83 ",IP,"2,420.00","54,938.02",,,,,,
Aetna MCR ADV,DRG,MS-964,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,Medical,Relative Weights,"$8,712.23 ",IP,"2,420.00","30,108.96",,,,,,
Aetna MCR ADV,DRG,MS-965,OTHER MULTIPLE SIGNIFICANT TRAUMA W/O CC/MCC,Medical,Relative Weights,"$5,329.07 ",IP,"2,420.00","18,488.74",,,,,,
Aetna MCR ADV,DRG,MS-969,HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$34,175.55 ",IP,"2,420.00","116,982.43",,,,,,
Aetna MCR ADV,DRG,MS-970,HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$17,454.24 ",IP,"2,420.00","58,806.72",,,,,,
Aetna MCR ADV,DRG,MS-974,HIV WITH MAJOR RELATED CONDITION WITH MCC,Medical,Relative Weights,"$15,712.73 ",IP,"2,420.00","53,905.82",,,,,,
Aetna MCR ADV,DRG,MS-975,HIV WITH MAJOR RELATED CONDITION WITH CC,Medical,Relative Weights,"$7,487.56 ",IP,"2,420.00","27,054.72",,,,,,
Aetna MCR ADV,DRG,MS-976,HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,Medical,Relative Weights,"$5,545.74 ",IP,"2,420.00","18,430.27",,,,,,
Aetna MCR ADV,DRG,MS-977,HIV WITH OR WITHOUT OTHER RELATED CONDITION,Medical,Relative Weights,"$7,734.01 ",IP,"2,420.00","26,218.08",,,,,,
Aetna MCR ADV,DRG,MS-981,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$26,949.04 ",IP,"2,420.00","90,532.51",,,,,,
Aetna MCR ADV,DRG,MS-982,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Surgical,Relative Weights,"$14,813.94 ",IP,"2,420.00","49,152.10",,,,,,
Aetna MCR ADV,DRG,MS-983,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$9,649.56 ",IP,"2,420.00","33,003.94",,,,,,
Aetna MCR ADV,DRG,MS-987,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$19,131.51 ",IP,"2,420.00","67,207.39",,,,,,
Aetna MCR ADV,DRG,MS-988,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Surgical,Relative Weights,"$9,965.51 ",IP,"2,420.00","34,640.93",,,,,,
Aetna MCR ADV,DRG,MS-989,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$6,561.91 ",IP,"2,420.00","23,232.38",,,,,,
Aetna MCR ADV,CPT,176,Anesth pharyngeal surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,211,Anesth cran surg hemotoma,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,214,Anesth skull drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,215,Anesth skull repair/fract,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,524,Anesth chest drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,540,Anesth chest surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,542,Anesthesia removal pleura,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,546,Anesth lung chest wall surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,560,Anesth heart surg w/o pump,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,561,Anesth heart surg <1 yr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,562,Anesth hrt surg w/pmp age 1+,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,567,Anesth cabg w/pump,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,580,Anesth heart/lung transplnt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,632,Anesth removal of nerves,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,792,Anesth hemorr/excise liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,794,Anesth pancreas removal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,796,Anesth for liver transplant,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,844,Anesth pelvis surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,846,Anesth hysterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,848,Anesth pelvic organ surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,864,Anesth removal of bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,866,Anesth removal of adrenal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,868,Anesth kidney transplant,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,882,Anesth major vein ligation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,908,Anesth removal of prostate,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,932,Anesth amputation of penis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,934,Anesth penis nodes removal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,936,Anesth penis nodes removal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,1272,Anesth femoral artery surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,1442,Anesth knee artery surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,1444,Anesth knee artery repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,1502,Anesth lwr leg embolectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,1652,Anesth shoulder vessel surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,1654,Anesth shoulder vessel surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,1656,Anesth arm-leg vessel surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,1990,Support for organ donor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,10005,Fna bx w/us gdn 1st les,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,10007,Fna bx w/fluor gdn 1st les,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,10009,Fna bx w/ct gdn 1st les,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,10011,Fna bx w/mr gdn 1st les,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,10021,Fna bx w/o img gdn 1st les,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,10030,Guide cathet fluid drainage,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,10035,Perq dev soft tiss 1st imag,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,10040,Acne surgery,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,10060,Drainage of skin abscess,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,10061,Drainage of skin abscess,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,10080,Drainage of pilonidal cyst,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,10081,Drainage of pilonidal cyst,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,10120,Remove foreign body,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,10121,Remove foreign body,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,10140,Drainage of hematoma/fluid,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,10160,Puncture drainage of lesion,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,10180,Complex drainage wound,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,11000,Debride infected skin,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11004,Debride genitalia & perineum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,11005,Debride abdom wall,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,11006,Debride genit/per/abdom wall,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,11008,Remove mesh from abd wall,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,11010,Debride skin at fx site,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11011,Debride skin musc at fx site,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11012,Deb skin bone at fx site,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,11042,Deb subq tissue 20 sq cm/<,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11043,Deb musc/fascia 20 sq cm/<,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11044,Deb bone 20 sq cm/<,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,11055,Trim skin lesion,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11056,Trim skin lesions 2 to 4,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11057,Trim skin lesions over 4,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11102,Tangntl bx skin single les,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11104,Punch bx skin single lesion,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11106,Incal bx skn single les,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11200,Removal of skin tags <w/15,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11300,Shave skin lesion 0.5 cm/<,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11301,Shave skin lesion 0.6-1.0 cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11302,Shave skin lesion 1.1-2.0 cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11303,Shave skin lesion >2.0 cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11305,Shave skin lesion 0.5 cm/<,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11306,Shave skin lesion 0.6-1.0 cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11307,Shave skin lesion 1.1-2.0 cm,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11308,Shave skin lesion >2.0 cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11310,Shave skin lesion 0.5 cm/<,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11311,Shave skin lesion 0.6-1.0 cm,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11312,Shave skin lesion 1.1-2.0 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11313,Shave skin lesion >2.0 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11400,Exc tr-ext b9+marg 0.5 cm<,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11401,Exc tr-ext b9+marg 0.6-1 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11402,Exc tr-ext b9+marg 1.1-2 cm,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11403,Exc tr-ext b9+marg 2.1-3cm,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11404,Exc tr-ext b9+marg 3.1-4 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,11406,Exc tr-ext b9+marg >4.0 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,11420,Exc h-f-nk-sp b9+marg 0.5/<,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,11421,Exc h-f-nk-sp b9+marg 0.6-1,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11422,Exc h-f-nk-sp b9+marg 1.1-2,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,11423,Exc h-f-nk-sp b9+marg 2.1-3,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,11424,Exc h-f-nk-sp b9+marg 3.1-4,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,11426,Exc h-f-nk-sp b9+marg >4 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,11440,Exc face-mm b9+marg 0.5 cm/<,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11441,Exc face-mm b9+marg 0.6-1 cm,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11442,Exc face-mm b9+marg 1.1-2 cm,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11443,Exc face-mm b9+marg 2.1-3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,11444,Exc face-mm b9+marg 3.1-4 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,11446,Exc face-mm b9+marg >4 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,11450,Removal sweat gland lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,11451,Removal sweat gland lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,11462,Removal sweat gland lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,11463,Removal sweat gland lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,11470,Removal sweat gland lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,11471,Removal sweat gland lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,11600,Exc tr-ext mal+marg 0.5 cm/<,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11601,Exc tr-ext mal+marg 0.6-1 cm,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11602,Exc tr-ext mal+marg 1.1-2 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11603,Exc tr-ext mal+marg 2.1-3 cm,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11604,Exc tr-ext mal+marg 3.1-4 cm,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11606,Exc tr-ext mal+marg >4 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,11620,Exc h-f-nk-sp mal+marg 0.5/<,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,11621,Exc s/n/h/f/g mal+mrg 0.6-1,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11622,Exc s/n/h/f/g mal+mrg 1.1-2,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11623,Exc s/n/h/f/g mal+mrg 2.1-3,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,11624,Exc s/n/h/f/g mal+mrg 3.1-4,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,11626,Exc s/n/h/f/g mal+mrg >4 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,11640,Exc f/e/e/n/l mal+mrg 0.5cm<,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11641,Exc f/e/e/n/l mal+mrg 0.6-1,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11642,Exc f/e/e/n/l mal+mrg 1.1-2,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11643,Exc f/e/e/n/l mal+mrg 2.1-3,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,11644,Exc f/e/e/n/l mal+mrg 3.1-4,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,11646,Exc f/e/e/n/l mal+mrg >4 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,11719,Trim nail(s) any number,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11720,Debride nail 1-5,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11721,Debride nail 6 or more,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11730,Removal of nail plate,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11740,Drain blood from under nail,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11750,Removal of nail bed,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11755,Biopsy nail unit,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11760,Repair of nail bed,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11762,Reconstruction of nail bed,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,11765,Excision of nail fold toe,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11770,Remove pilonidal cyst simple,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,11771,Remove pilonidal cyst exten,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,11772,Remove pilonidal cyst compl,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,11900,Inject skin lesions </w 7,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11901,Inject skin lesions >7,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11920,Correct skin color 6.0 cm/<,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11921,Correct skn color 6.1-20.0cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11950,Tx contour defects 1 cc/<,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11951,Tx contour defects 1.1-5.0cc,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11952,Tx contour defects 5.1-10cc,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11954,Tx contour defects >10.0 cc,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11960,Insert tissue expander(s),APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,11970,Rplcmt tiss xpndr perm implt,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,11971,Rmvl tis xpndr wo insj implt,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,11976,Remove contraceptive capsule,APC 5071,RVU Per Case,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11980,Implant hormone pellet(s),APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11981,Insert drug implant device,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11982,Remove drug implant device,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Aetna MCR ADV,CPT,11983,Remove/insert drug implant,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Aetna MCR ADV,CPT,12001,Rpr s/n/ax/gen/trnk 2.5cm/<,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,12002,Rpr s/n/ax/gen/trnk2.6-7.5cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,12004,Rpr s/n/ax/gen/trk7.6-12.5cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,12005,Rpr s/n/a/gen/trk12.6-20.0cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,12006,Rpr s/n/a/gen/trk20.1-30.0cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,12007,Rpr s/n/ax/gen/trnk >30.0 cm,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,12011,Rpr f/e/e/n/l/m 2.5 cm/<,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,12013,Rpr f/e/e/n/l/m 2.6-5.0 cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,12014,Rpr f/e/e/n/l/m 5.1-7.5 cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,12015,Rpr f/e/e/n/l/m 7.6-12.5 cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,12016,Rpr fe/e/en/l/m 12.6-20.0 cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,12017,Rpr fe/e/en/l/m 20.1-30.0 cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,12018,Rpr f/e/e/n/l/m >30.0 cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,12020,Closure of split wound,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,12021,Closure of split wound,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,12031,Intmd rpr s/a/t/ext 2.5 cm/<,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,12032,Intmd rpr s/a/t/ext 2.6-7.5,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,12034,Intmd rpr s/tr/ext 7.6-12.5,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,12035,Intmd rpr s/a/t/ext 12.6-20,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,12036,Intmd rpr s/a/t/ext 20.1-30,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,12037,Intmd rpr s/tr/ext >30.0 cm,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,12041,Intmd rpr n-hf/genit 2.5cm/<,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,12042,Intmd rpr n-hf/genit2.6-7.5,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,12044,Intmd rpr n-hf/genit7.6-12.5,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,12045,Intmd rpr n-hf/genit12.6-20,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,12046,Intmd rpr n-hf/genit20.1-30,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,12047,Intmd rpr n-hf/genit >30.0cm,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,12051,Intmd rpr face/mm 2.5 cm/<,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,12052,Intmd rpr face/mm 2.6-5.0 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,12053,Intmd rpr face/mm 5.1-7.5 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,12054,Intmd rpr face/mm 7.6-12.5cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,12055,Intmd rpr face/mm 12.6-20 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,12056,Intmd rpr face/mm 20.1-30.0,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,12057,Intmd rpr face/mm >30.0 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,13100,Cmplx rpr trunk 1.1-2.5 cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,13101,Cmplx rpr trunk 2.6-7.5 cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,13120,Cmplx rpr s/a/l 1.1-2.5 cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,13121,Cmplx rpr s/a/l 2.6-7.5 cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,13131,Cmplx rpr f/c/c/m/n/ax/g/h/f,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,13132,Cmplx rpr f/c/c/m/n/ax/g/h/f,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,13151,Cmplx rpr e/n/e/l 1.1-2.5 cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,13152,Cmplx rpr e/n/e/l 2.6-7.5 cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,13160,Late closure of wound,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,14000,Tis trnfr trunk 10 sq cm/<,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,14001,Tis trnfr trunk 10.1-30sqcm,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,14020,Tis trnfr s/a/l 10 sq cm/<,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,14021,Tis trnfr s/a/l 10.1-30 sqcm,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,14040,Tis trnfr f/c/c/m/n/a/g/h/f,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,14041,Tis trnfr f/c/c/m/n/a/g/h/f,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,14060,Tis trnfr e/n/e/l 10 sq cm/<,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,14061,Tis trnfr e/n/e/l10.1-30sqcm,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,14301,Tis trnfr any 30.1-60 sq cm,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,14350,Filleted finger/toe flap,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,15002,Wound prep trk/arm/leg,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,15004,Wound prep f/n/hf/g,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,15040,Harvest cultured skin graft,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,15050,Skin pinch graft,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,15100,Skin splt grft trnk/arm/leg,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,15110,Epidrm autogrft trnk/arm/leg,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,15115,Epidrm a-grft face/nck/hf/g,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,15120,Skn splt a-grft fac/nck/hf/g,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,15130,Derm autograft trnk/arm/leg,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,15135,Derm autograft face/nck/hf/g,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,15150,Cult skin grft t/arm/leg,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,15155,Cult skin graft f/n/hf/g,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,15200,Skin full graft trunk,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,15220,Skin full graft sclp/arm/leg,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,15240,Skin full grft face/genit/hf,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,15260,Skin full graft een & lips,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,15271,Skin sub graft trnk/arm/leg,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,15273,Skin sub grft t/arm/lg child,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,15275,Skin sub graft face/nk/hf/g,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,15277,Skn sub grft f/n/hf/g child,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,15570,Skin pedicle flap trunk,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,15572,Skin pedicle flap arms/legs,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,15574,Pedcle fh/ch/ch/m/n/ax/g/h/f,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,15576,Pedicle e/n/e/l/ntroral,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,15600,Delay flap trunk,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,15610,Delay flap arms/legs,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,15620,Delay flap f/c/c/n/ax/g/h/f,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,15630,Delay flap eye/nos/ear/lip,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,15650,Transfer skin pedicle flap,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,15730,Mdfc flap w/prsrv vasc pedcl,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,15731,Forehead flap w/vasc pedicle,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,15733,Musc myoq/fscq flp h&n pedcl,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","9,201.00",,,,,,
Aetna MCR ADV,CPT,15734,Muscle-skin graft trunk,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,15736,Muscle-skin graft arm,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,15738,Muscle-skin graft leg,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,15740,Island pedicle flap graft,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,15750,Neurovascular pedicle flap,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,15756,Free myo/skin flap microvasc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,15757,Free skin flap microvasc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,15758,Free fascial flap microvasc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,15760,Composite skin graft,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,15769,Grfg autol soft tiss dir exc,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,15770,Derma-fat-fascia graft,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,15771,Grfg autol fat lipo 50 cc/<,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,15773,Grfg autol fat lipo 25 cc/<,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,15775,Hair trnspl 1-15 punch grfts,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,15776,Hair trnspl >15 punch grafts,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,15780,Dermabrasion total face,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,15781,Dermabrasion segmental face,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,15782,Dermabrasion other than face,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,15783,Dermabrasion suprfl any site,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,15786,Abrasion lesion single,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,15788,Chemical peel face epiderm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,15789,Chemical peel face dermal,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,15792,Chemical peel nonfacial,APC 5053,RVU Per Case,$536.39 ,OP,536.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,15793,Chemical peel nonfacial,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,15819,Plastic surgery neck,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,15820,Revision of lower eyelid,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,15821,Revision of lower eyelid,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,15822,Revision of upper eyelid,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,15823,Revision of upper eyelid,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,15824,Removal of forehead wrinkles,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,15825,Removal of neck wrinkles,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,15826,Removal of brow wrinkles,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,15828,Removal of face wrinkles,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,15829,Removal of skin wrinkles,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,15830,Exc skin abd,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,15832,Excise excessive skin thigh,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,15833,Excise excessive skin leg,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,15834,Excise excessive skin hip,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,15835,Excise excessive skin buttck,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,15836,Excise excessive skin arm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,15837,Excise excess skin arm/hand,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,15838,Excise excess skin fat pad,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,15839,Excise excess skin & tissue,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,15840,Nerve palsy fascial graft,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,15841,Nerve palsy muscle graft,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,15842,Nerve palsy microsurg graft,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,15845,Skin and muscle repair face,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,15850,Remove sutures same surgeon,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,15851,Remove sutures diff surgeon,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,15852,Dressing change not for burn,APC 5053,RVU Per Case,$536.39 ,OP,536.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,15860,Test for blood flow in graft,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Aetna MCR ADV,CPT,15876,Suction lipectomy head&neck,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,15877,Suction lipectomy trunk,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,15878,Suction lipectomy upr extrem,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,15879,Suction lipectomy lwr extrem,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,15920,Removal of tail bone ulcer,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,15922,Removal of tail bone ulcer,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,15931,Remove sacrum pressure sore,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,15933,Remove sacrum pressure sore,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,15934,Remove sacrum pressure sore,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,15935,Remove sacrum pressure sore,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,15936,Remove sacrum pressure sore,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,15937,Remove sacrum pressure sore,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,15940,Remove hip pressure sore,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,15941,Remove hip pressure sore,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,15944,Remove hip pressure sore,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,15945,Remove hip pressure sore,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,15946,Remove hip pressure sore,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,15950,Remove thigh pressure sore,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,15951,Remove thigh pressure sore,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,15952,Remove thigh pressure sore,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,15953,Remove thigh pressure sore,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,15956,Remove thigh pressure sore,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,15958,Remove thigh pressure sore,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,15999,Removal of pressure sore,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,16000,Initial treatment of burn(s),APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,16020,Dress/debrid p-thick burn s,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,16025,Dress/debrid p-thick burn m,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,16030,Dress/debrid p-thick burn l,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,16035,Incision of burn scab initi,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,16036,Escharotomy addl incision,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,17000,Destruct premalg lesion,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,17004,Destroy premal lesions 15/>,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,17106,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,17107,Destruction of skin lesions,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,17108,Destruction of skin lesions,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,17110,Destruct b9 lesion 1-14,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,17111,Destruct lesion 15 or more,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,17250,Chem caut of granltj tissue,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,17260,Destruction of skin lesions,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,17261,Destruction of skin lesions,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,17262,Destruction of skin lesions,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,17263,Destruction of skin lesions,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,17264,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,17266,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,17270,Destruction of skin lesions,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,17271,Destruction of skin lesions,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,17272,Destruction of skin lesions,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,17273,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,17274,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,17276,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,17280,Destruction of skin lesions,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,17281,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,17282,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,17283,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,17284,Destruction of skin lesions,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,17286,Destruction of skin lesions,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,17311,Mohs 1 stage h/n/hf/g,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,17313,Mohs 1 stage t/a/l,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,17340,Cryotherapy of skin,APC 5732,RVU Per Case,$34.63 ,OP,34.63,"4,314.00",,,,,,
Aetna MCR ADV,CPT,17360,Skin peel therapy,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,17380,Hair removal by electrolysis,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,17999,Skin tissue procedure,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,19000,Drainage of breast lesion,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,19020,Incision of breast lesion,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,19081,Bx breast 1st lesion strtctc,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,19083,Bx breast 1st lesion us imag,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,19085,Bx breast 1st lesion mr imag,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,19100,Bx breast percut w/o image,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,19101,Biopsy of breast open,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,19105,Cryosurg ablate fa each,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,19110,Nipple exploration,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,19112,Excise breast duct fistula,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,19120,Removal of breast lesion,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,19125,Excision breast lesion,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,19281,Perq device breast 1st imag,APC 5071,RVU Per Case,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,19283,Perq dev breast 1st strtctc,APC 5071,RVU Per Case,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,19285,Perq dev breast 1st us imag,APC 5071,RVU Per Case,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,19287,Perq dev breast 1st mr guide,APC 5071,RVU Per Case,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,19296,Place po breast cath for rad,APC 5093,RVU Per Case,"$9,128.05 ",OP,"4,314.00","9,128.05",,,,,,
Aetna MCR ADV,CPT,19298,Place breast rad tube/caths,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
Aetna MCR ADV,CPT,19300,Removal of breast tissue,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","9,201.00",,,,,,
Aetna MCR ADV,CPT,19301,Partial mastectomy,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,19302,P-mastectomy w/ln removal,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
Aetna MCR ADV,CPT,19303,Mast simple complete,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
Aetna MCR ADV,CPT,19305,Mast radical,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,19306,Mast rad urban type,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,19307,Mast mod rad,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,19316,Suspension of breast,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
Aetna MCR ADV,CPT,19318,Breast reduction,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,19325,Breast augmentation w/implt,APC 5093,RVU Per Case,"$9,128.05 ",OP,"4,314.00","9,128.05",,,,,,
Aetna MCR ADV,CPT,19328,Rmvl intact breast implant,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,19330,Rmvl ruptured breast implant,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,19340,Insj breast implt sm d mast,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,19342,Insj/rplcmt brst implt sep d,APC 5093,RVU Per Case,"$9,128.05 ",OP,"4,314.00","9,128.05",,,,,,
Aetna MCR ADV,CPT,19350,Breast reconstruction,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,19355,Correct inverted nipple(s),APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,19357,Tiss xpndr plmt brst rcnstj,APC 5094,RVU Per Case,"$15,276.83 ",OP,"4,140.35","15,276.83",,,,,,
Aetna MCR ADV,CPT,19361,Brst rcnstj latsms drsi flap,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,19364,Brst rcnstj free flap,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,19367,Brst rcnstj 1 pdcl tram flap,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,19368,Brst rcnstj 1pdcl tram anast,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,19369,Brst rcnstj 2 pdcl tram flap,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,19370,Revj peri-implt capsule brst,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,19371,Peri-implt capslc brst compl,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,19380,Revj reconstructed breast,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
Aetna MCR ADV,CPT,19396,Design custom breast implant,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,19499,Breast surgery procedure,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,20100,Explore wound neck,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,20101,Explore wound chest,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,20102,Explore wound abdomen,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,20103,Explore wound extremity,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,20150,Excise epiphyseal bar,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,20200,Muscle biopsy,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,20205,Deep muscle biopsy,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,20206,Needle biopsy muscle,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,20220,Bone biopsy trocar/needle,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,20225,Bone biopsy trocar/needle,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,20240,Bone biopsy open superficial,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,20245,Bone biopsy open deep,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,20250,Open bone biopsy,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,20251,Open bone biopsy,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,20500,Injection of sinus tract,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,20520,Removal of foreign body,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,20525,Removal of foreign body,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,20526,Ther injection carp tunnel,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Aetna MCR ADV,CPT,20527,Inj dupuytren cord w/enzyme,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Aetna MCR ADV,CPT,20550,Inj tendon sheath/ligament,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Aetna MCR ADV,CPT,20551,Inj tendon origin/insertion,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Aetna MCR ADV,CPT,20552,Inj trigger point 1/2 muscl,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Aetna MCR ADV,CPT,20553,Inject trigger points 3/>,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Aetna MCR ADV,CPT,20555,Place ndl musc/tis for rt,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,20560,Ndl insj w/o njx 1 or 2 musc,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,"4,314.00",,,,,,
Aetna MCR ADV,CPT,20561,Ndl insj w/o njx 3+ musc,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,"4,314.00",,,,,,
Aetna MCR ADV,CPT,20600,Drain/inj joint/bursa w/o us,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Aetna MCR ADV,CPT,20604,Drain/inj joint/bursa w/us,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Aetna MCR ADV,CPT,20605,Drain/inj joint/bursa w/o us,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Aetna MCR ADV,CPT,20606,Drain/inj joint/bursa w/us,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,20610,Drain/inj joint/bursa w/o us,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Aetna MCR ADV,CPT,20611,Drain/inj joint/bursa w/us,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Aetna MCR ADV,CPT,20612,Aspirate/inj ganglion cyst,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Aetna MCR ADV,CPT,20615,Treatment of bone cyst,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,20650,Insert and remove bone pin,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,20660,Apply rem fixation device,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,20661,Application of head brace,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,20662,Application of pelvis brace,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,20663,Application of thigh brace,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,20664,Application of halo,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,20665,Removal of fixation device,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Aetna MCR ADV,CPT,20670,Removal of support implant,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,20680,Removal of support implant,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,20690,Apply bone fixation device,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,20692,Apply bone fixation device,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,20693,Adjust bone fixation device,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,20694,Remove bone fixation device,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,20696,Comp multiplane ext fixation,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,20697,Comp ext fixate strut change,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,20802,Replantation arm complete,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,20805,Replant forearm complete,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,20808,Replantation hand complete,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,20816,Replantation digit complete,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,20822,Replantation digit complete,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,20824,Replantation thumb complete,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,20827,Replantation thumb complete,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,20838,Replantation foot complete,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,20900,Removal of bone for graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,20902,Removal of bone for graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,20910,Remove cartilage for graft,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,20912,Remove cartilage for graft,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,20920,Removal of fascia for graft,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,20922,Removal of fascia for graft,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,20924,Removal of tendon for graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,20950,Fluid pressure muscle,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,20955,Fibula bone graft microvasc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,20956,Iliac bone graft microvasc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,20957,Mt bone graft microvasc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,20962,Other bone graft microvasc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,20969,Bone/skin graft microvasc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,20970,Bone/skin graft iliac crest,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,20972,Bone/skin graft metatarsal,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,20973,Bone/skin graft great toe,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,20974,Electrical bone stimulation,Physician,Per Unit,$50.41 ,OP,50.41,"4,314.00",,,,,,
Aetna MCR ADV,CPT,20979,Us bone stimulation,APC 5731,RVU Per Case,$25.25 ,OP,25.25,"4,314.00",,,,,,
Aetna MCR ADV,CPT,20982,Ablate bone tumor(s) perq,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,20983,Ablate bone tumor(s) perq,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,20999,Musculoskeletal surgery,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,21010,Incision of jaw joint,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,21011,Exc face les sc <2 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,21012,Exc face les sbq 2 cm/>,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,21013,Exc face tum deep < 2 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,21014,Exc face tum deep 2 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,21015,Resect face/scalp tum < 2 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,21016,Resect face/scalp tum 2 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,21025,Excision of bone lower jaw,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21026,Excision of facial bone(s),APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21029,Contour of face bone lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,21030,Excise max/zygoma b9 tumor,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21031,Remove exostosis mandible,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,21032,Remove exostosis maxilla,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,21034,Excise max/zygoma mal tumor,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21040,Excise mandible lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,21044,Removal of jaw bone lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21045,Extensive jaw surgery,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21046,Remove mandible cyst complex,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21047,Excise lwr jaw cyst w/repair,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21048,Remove maxilla cyst complex,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21049,Excis uppr jaw cyst w/repair,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21050,Removal of jaw joint,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21060,Remove jaw joint cartilage,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21070,Remove coronoid process,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21073,Mnpj of tmj w/anesth,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,21076,Prepare face/oral prosthesis,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,21077,Prepare face/oral prosthesis,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21079,Prepare face/oral prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,21080,Prepare face/oral prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,21081,Prepare face/oral prosthesis,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21082,Prepare face/oral prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,21083,Prepare face/oral prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,21084,Prepare face/oral prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,21085,Prepare face/oral prosthesis,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Aetna MCR ADV,CPT,21086,Prepare face/oral prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,21087,Prepare face/oral prosthesis,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21088,Prepare face/oral prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,21089,Prepare face/oral prosthesis,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Aetna MCR ADV,CPT,21100,Maxillofacial fixation,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21110,Interdental fixation,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,21120,Reconstruction of chin,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21121,Reconstruction of chin,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,21122,Reconstruction of chin,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21123,Reconstruction of chin,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,21125,Augmentation lower jaw bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21127,Augmentation lower jaw bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21137,Reduction of forehead,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,21138,Reduction of forehead,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21139,Reduction of forehead,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21141,Lefort i-1 piece w/o graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21142,Lefort i-2 piece w/o graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21143,Lefort i-3/> piece w/o graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21145,Lefort i-1 piece w/ graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21146,Lefort i-2 piece w/ graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21147,Lefort i-3/> piece w/ graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21150,Lefort ii anterior intrusion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21151,Lefort ii w/bone grafts,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21154,Lefort iii w/o lefort i,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21155,Lefort iii w/ lefort i,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21159,Lefort iii w/fhdw/o lefort i,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21160,Lefort iii w/fhd w/ lefort i,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21172,Reconstruct orbit/forehead,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21175,Reconstruct orbit/forehead,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21179,Reconstruct entire forehead,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21180,Reconstruct entire forehead,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21181,Contour cranial bone lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21182,Reconstruct cranial bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21183,Reconstruct cranial bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21184,Reconstruct cranial bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21188,Reconstruction of midface,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21193,Reconst lwr jaw w/o graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,21194,Reconst lwr jaw w/graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21195,Reconst lwr jaw w/o fixation,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21196,Reconst lwr jaw w/fixation,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21198,Reconstr lwr jaw segment,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21199,Reconstr lwr jaw w/advance,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21206,Reconstruct upper jaw bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21208,Augmentation of facial bones,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21209,Reduction of facial bones,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21210,Face bone graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21215,Lower jaw bone graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21230,Rib cartilage graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21235,Ear cartilage graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21240,Reconstruction of jaw joint,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21242,Reconstruction of jaw joint,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21243,Reconstruction of jaw joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,21244,Reconstruction of lower jaw,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21245,Reconstruction of jaw,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21246,Reconstruction of jaw,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21247,Reconstruct lower jaw bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21248,Reconstruction of jaw,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21249,Reconstruction of jaw,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21255,Reconstruct lower jaw bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21256,Reconstruction of orbit,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21260,Revise eye sockets,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21261,Revise eye sockets,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21263,Revise eye sockets,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21267,Revise eye sockets,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21268,Revise eye sockets,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21270,Augmentation cheek bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21275,Revision orbitofacial bones,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21280,Revision of eyelid,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,21282,Revision of eyelid,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,21295,Revision of jaw muscle/bone,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,21296,Revision of jaw muscle/bone,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,21299,Cranio/maxillofacial surgery,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Aetna MCR ADV,CPT,21310,Closed tx nose fx w/o manj,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,21315,Closed tx nose fx w/o stablj,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,21320,Closed tx nose fx w/ stablj,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,21325,Open tx nose fx uncomplicatd,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,21330,Open tx nose fx w/skele fixj,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21335,Open tx nose & septal fx,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,21336,Open tx septal fx w/wo stabj,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,21337,Closed tx septal&nose fx,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,21338,Open nasoethmoid fx w/o fixj,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21339,Open nasoethmoid fx w/ fixj,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21340,Perq tx nasoethmoid fx,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,21343,Open tx dprsd front sinus fx,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21344,Open tx compl front sinus fx,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21345,Closed tx nose/jaw fx,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,21346,Opn tx nasomax fx w/fixj,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21347,Opn tx nasomax fx multple,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21348,Opn tx nasomax fx w/graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21355,Perq tx malar fracture,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,21356,Opn tx dprsd zygomatic arch,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21360,Opn tx dprsd malar fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21365,Opn tx complx malar fx,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21366,Opn tx complx malar w/grft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21385,Opn tx orbit fx transantral,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21386,Opn tx orbit fx periorbital,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21387,Opn tx orbit fx combined,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21390,Opn tx orbit periorbtl implt,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21395,Opn tx orbit periorbt w/grft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21400,Closed tx orbit w/o manipulj,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,21401,Closed tx orbit w/manipulj,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,21406,Opn tx orbit fx w/o implant,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21407,Opn tx orbit fx w/implant,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21408,Opn tx orbit fx w/bone grft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21421,Treat mouth roof fracture,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,21422,Treat mouth roof fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21423,Treat mouth roof fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21431,Treat craniofacial fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21432,Treat craniofacial fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21433,Treat craniofacial fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21435,Treat craniofacial fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21436,Treat craniofacial fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21440,Treat dental ridge fracture,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,21445,Treat dental ridge fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21450,Treat lower jaw fracture,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,21451,Treat lower jaw fracture,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,21452,Treat lower jaw fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21453,Treat lower jaw fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21454,Treat lower jaw fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21461,Treat lower jaw fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21462,Treat lower jaw fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,21465,Treat lower jaw fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21470,Treat lower jaw fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21480,Reset dislocated jaw,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,21485,Reset dislocated jaw,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,21490,Repair dislocated jaw,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,21497,Interdental wiring,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,21499,Head surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Aetna MCR ADV,CPT,21501,Drain neck/chest lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,21502,Drain chest lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,21510,Drainage of bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,21550,Biopsy of neck/chest,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,21552,Exc neck les sc 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,21554,Exc neck tum deep 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,21555,Exc neck les sc < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,21556,Exc neck tum deep < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,21557,Resect neck thorax tumor<5cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,21558,Resect neck tumor 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,21600,Partial removal of rib,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,21601,Exc chest wall tumor w/ribs,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,21602,Exc ch wal tum w/o lymphadec,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,21603,Exc ch wal tum w/lymphadec,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,21610,Partial removal of rib,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,21615,Removal of rib,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,21616,Removal of rib and nerves,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,21620,Partial removal of sternum,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,21627,Sternal debridement,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,21630,Extensive sternum surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,21632,Extensive sternum surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,21685,Hyoid myotomy & suspension,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,21700,Revision of neck muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,21705,Revision of neck muscle/rib,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,21720,Revision of neck muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,21725,Revision of neck muscle,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,21740,Reconstruction of sternum,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,21742,Repair stern/nuss w/o scope,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,21743,Repair sternum/nuss w/scope,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,21750,Repair of sternum separation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,21811,Optx of rib fx w/fixj scope,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,21812,Treatment of rib fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,21813,Treatment of rib fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,21820,Treat sternum fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,21825,Treat sternum fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,21899,Neck/chest surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Aetna MCR ADV,CPT,21920,Biopsy soft tissue of back,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,21925,Biopsy soft tissue of back,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,21930,Exc back les sc < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,21931,Exc back les sc 3 cm/>,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,21932,Exc back tum deep < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,21933,Exc back tum deep 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,21935,Resect back tum < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,21936,Resect back tum 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,22010,I&d p-spine c/t/cerv-thor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,22015,I&d abscess p-spine l/s/ls,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,22100,Remove part of neck vertebra,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,22101,Remove part thorax vertebra,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,22102,Remove part lumbar vertebra,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,22110,Remove part of neck vertebra,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,22112,Remove part thorax vertebra,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,22114,Remove part lumbar vertebra,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,22206,Incis spine 3 column thorac,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,22207,Incis spine 3 column lumbar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,22210,Incis 1 vertebral seg cerv,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,22212,Incis 1 vertebral seg thorac,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,22214,Incis 1 vertebral seg lumbar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,22220,Incis w/discectomy cervical,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,22222,Incis w/discectomy thoracic,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,22224,Incis w/discectomy lumbar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,22310,Closed tx vert fx w/o manj,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,22315,Closed tx vert fx w/manj,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,22318,Treat odontoid fx w/o graft,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,22319,Treat odontoid fx w/graft,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,22325,Treat spine fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,22326,Treat neck spine fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,22327,Treat thorax spine fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,22505,Manipulation of spine,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,22510,Perq cervicothoracic inject,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","15,496.26",,,,,,
Aetna MCR ADV,CPT,22511,Perq lumbosacral injection,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","9,201.00",,,,,,
Aetna MCR ADV,CPT,22513,Perq vertebral augmentation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,22514,Perq vertebral augmentation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,22532,Lat thorax spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,22533,Lat lumbar spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,22548,Neck spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,22551,Neck spine fuse&remov bel c2,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Aetna MCR ADV,CPT,22554,Neck spine fusion,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,22556,Thorax spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,22558,Lumbar spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,22586,Prescrl fuse w/ instr l5-s1,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,22590,Spine & skull spinal fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,22595,Neck spinal fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,22600,Neck spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,22610,Thorax spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,22612,Lumbar spine fusion,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,22630,Lumbar spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,22633,Lumbar spine fusion combined,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,22800,Post fusion </6 vert seg,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,22802,Post fusion 7-12 vert seg,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,22804,Post fusion 13/> vert seg,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,22808,Ant fusion 2-3 vert seg,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,22810,Ant fusion 4-7 vert seg,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,22812,Ant fusion 8/> vert seg,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,22818,Kyphectomy 1-2 segments,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,22819,Kyphectomy 3 or more,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,22830,Exploration of spinal fusion,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,22849,Reinsert spinal fixation,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,22850,Remove spine fixation device,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,22852,Remove spine fixation device,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,22855,Remove spine fixation device,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,22856,Cerv artific diskectomy,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,140.35","16,238.16",,,,,,
Aetna MCR ADV,CPT,22857,Lumbar artif diskectomy,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,22861,Revise cerv artific disc,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,22862,Revise lumbar artif disc,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,22864,Remove cerv artif disc,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,22865,Remove lumb artif disc,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,22867,Insj stablj dev w/dcmprn,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,22869,Insj stablj dev w/o dcmprn,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,22899,Spine surgery procedure,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,22900,Exc abdl tum deep < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,22901,Exc abdl tum deep 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,22902,Exc abd les sc < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,22903,Exc abd les sc 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,22904,Radical resect abd tumor<5cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,22905,Rad resect abd tumor 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,22999,Abdomen surgery procedure,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,23000,Removal of calcium deposits,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,23020,Release shoulder joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,23030,Drain shoulder lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,23031,Drain shoulder bursa,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,23035,Drain shoulder bone lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,23040,Exploratory shoulder surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,23044,Exploratory shoulder surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,23065,Biopsy shoulder tissues,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,23066,Biopsy shoulder tissues,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,23071,Exc shoulder les sc 3 cm/>,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,23073,Exc shoulder tum deep 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,23075,Exc shoulder les sc < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,23076,Exc shoulder tum deep < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,23077,Resect shoulder tumor < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,23078,Resect shoulder tumor 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,23100,Biopsy of shoulder joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,23101,Shoulder joint surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,23105,Remove shoulder joint lining,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,23106,Incision of collarbone joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,23107,Explore treat shoulder joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,23120,Partial removal collar bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,23125,Removal of collar bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,23130,Remove shoulder bone part,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,23140,Removal of bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,23145,Removal of bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,23146,Removal of bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,23150,Removal of humerus lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,23155,Removal of humerus lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,23156,Removal of humerus lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,23170,Remove collar bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,23172,Remove shoulder blade lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,23174,Remove humerus lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,23180,Remove collar bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,23182,Remove shoulder blade lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,23184,Remove humerus lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,23190,Partial removal of scapula,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,23195,Removal of head of humerus,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,23200,Resect clavicle tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,23210,Resect scapula tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,23220,Resect prox humerus tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,23330,Remove shoulder foreign body,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,23333,Remove shoulder fb deep,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,23334,Shoulder prosthesis removal,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,23335,Shoulder prosthesis removal,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,23395,Muscle transfer shoulder/arm,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,23397,Muscle transfers,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,23400,Fixation of shoulder blade,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,23405,Incision of tendon & muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,23406,Incise tendon(s) & muscle(s),APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,23410,Repair rotator cuff acute,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,23412,Repair rotator cuff chronic,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,23415,Release of shoulder ligament,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,23420,Repair of shoulder,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,23430,Repair biceps tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,23440,Remove/transplant tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,23450,Repair shoulder capsule,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,23455,Repair shoulder capsule,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,23460,Repair shoulder capsule,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,23462,Repair shoulder capsule,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,23465,Repair shoulder capsule,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,23466,Repair shoulder capsule,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,23470,Reconstruct shoulder joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,23472,Reconstruct shoulder joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,23473,Revis reconst shoulder joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,23474,Revis reconst shoulder joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,23480,Revision of collar bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,23485,Revision of collar bone,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,23490,Reinforce clavicle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,23491,Reinforce shoulder bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,23500,Treat clavicle fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,23505,Treat clavicle fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,23515,Treat clavicle fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,23520,Treat clavicle dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,23525,Treat clavicle dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,23530,Treat clavicle dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,23532,Treat clavicle dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,23540,Treat clavicle dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,23545,Treat clavicle dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,23550,Treat clavicle dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,23552,Treat clavicle dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,23570,Treat shoulder blade fx,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,23575,Treat shoulder blade fx,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,23585,Treat scapula fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,23600,Treat humerus fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,23605,Treat humerus fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,23615,Treat humerus fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Aetna MCR ADV,CPT,23616,Treat humerus fracture,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,23620,Treat humerus fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,23625,Treat humerus fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,23630,Treat humerus fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,23650,Treat shoulder dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,23655,Treat shoulder dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,23660,Treat shoulder dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,23665,Treat dislocation/fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,23670,Treat dislocation/fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,23675,Treat dislocation/fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,23680,Treat dislocation/fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,23700,Fixation of shoulder,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,23800,Fusion of shoulder joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,23802,Fusion of shoulder joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,23900,Amputation of arm & girdle,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,23920,Amputation at shoulder joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,23921,Amputation follow-up surgery,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,23929,Shoulder surgery procedure,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,23930,Drainage of arm lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,23931,Drainage of arm bursa,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,23935,Drain arm/elbow bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,24000,Exploratory elbow surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,24006,Release elbow joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,24065,Biopsy arm/elbow soft tissue,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,24066,Biopsy arm/elbow soft tissue,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,24071,Exc arm/elbow les sc 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,24073,Ex arm/elbow tum deep 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,24075,Exc arm/elbow les sc < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,24076,Ex arm/elbow tum deep < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,24077,Resect arm/elbow tum < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,24079,Resect arm/elbow tum 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,24100,Biopsy elbow joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,24101,Explore/treat elbow joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,24102,Remove elbow joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,24105,Removal of elbow bursa,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,24110,Remove humerus lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,24115,Remove/graft bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,24116,Remove/graft bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,24120,Remove elbow lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,24125,Remove/graft bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,24126,Remove/graft bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,24130,Removal of head of radius,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,24134,Removal of arm bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,24136,Remove radius bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,24138,Remove elbow bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,24140,Partial removal of arm bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,24145,Partial removal of radius,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,24147,Partial removal of elbow,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,24149,Radical resection of elbow,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,24150,Resect distal humerus tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,24152,Resect radius tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,24155,Removal of elbow joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,24160,Remove elbow joint implant,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,24164,Remove radius head implant,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,24200,Removal of arm foreign body,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,24201,Removal of arm foreign body,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,24300,Manipulate elbow w/anesth,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,24301,Muscle/tendon transfer,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,24305,Arm tendon lengthening,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,24310,Revision of arm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,24320,Repair of arm tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,24330,Revision of arm muscles,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,24331,Revision of arm muscles,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,24332,Tenolysis triceps,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,24340,Repair of biceps tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,24341,Repair arm tendon/muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,24342,Repair of ruptured tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,24343,Repr elbow lat ligmnt w/tiss,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,24344,Reconstruct elbow lat ligmnt,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,24345,Repr elbw med ligmnt w/tissu,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,24346,Reconstruct elbow med ligmnt,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,24357,Repair elbow perc,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,24358,Repair elbow w/deb open,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,24359,Repair elbow deb/attch open,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,24360,Reconstruct elbow joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,24361,Reconstruct elbow joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,24362,Reconstruct elbow joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,24363,Replace elbow joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,24365,Reconstruct head of radius,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,24366,Reconstruct head of radius,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,24370,Revise reconst elbow joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,24371,Revise reconst elbow joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,24400,Revision of humerus,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,24410,Revision of humerus,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,24420,Revision of humerus,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,24430,Repair of humerus,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,24435,Repair humerus with graft,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,24470,Revision of elbow joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,24495,Decompression of forearm,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,24498,Reinforce humerus,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,24500,Treat humerus fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,24505,Treat humerus fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,24515,Treat humerus fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Aetna MCR ADV,CPT,24516,Treat humerus fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,24530,Treat humerus fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,24535,Treat humerus fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,24538,Treat humerus fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,24545,Treat humerus fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Aetna MCR ADV,CPT,24546,Treat humerus fracture,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,24560,Treat humerus fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,24565,Treat humerus fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,24566,Treat humerus fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,24575,Treat humerus fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,24576,Treat humerus fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,24577,Treat humerus fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,24579,Treat humerus fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,24582,Treat humerus fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,24586,Treat elbow fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,24587,Treat elbow fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,24600,Treat elbow dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,24605,Treat elbow dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,24615,Treat elbow dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,24620,Treat elbow fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,24635,Treat elbow fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,24640,Treat elbow dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,24650,Treat radius fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,24655,Treat radius fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,24665,Treat radius fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,24666,Treat radius fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Aetna MCR ADV,CPT,24670,Treat ulnar fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,24675,Treat ulnar fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,24685,Treat ulnar fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,24800,Fusion of elbow joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,24802,Fusion/graft of elbow joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,24900,Amputation of upper arm,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,24920,Amputation of upper arm,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,24925,Amputation follow-up surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,24930,Amputation follow-up surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,24931,Amputate upper arm & implant,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,24935,Revision of amputation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,24940,Revision of upper arm,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,24999,Upper arm/elbow surgery,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,25000,Incision of tendon sheath,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,25001,Incise flexor carpi radialis,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25020,Decompress forearm 1 space,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,25023,Decompress forearm 1 space,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25024,Decompress forearm 2 spaces,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25025,Decompress forearm 2 spaces,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,25028,Drainage of forearm lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25031,Drainage of forearm bursa,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,25035,Treat forearm bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,25040,Explore/treat wrist joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25065,Biopsy forearm soft tissues,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,25066,Biopsy forearm soft tissues,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,25071,Exc forearm les sc 3 cm/>,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,25073,Exc forearm tum deep 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,25075,Exc forearm les sc < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,25076,Exc forearm tum deep < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,25077,Resect forearm/wrist tum<3cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,25078,Resect forarm/wrist tum 3cm>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,25085,Incision of wrist capsule,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25100,Biopsy of wrist joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25101,Explore/treat wrist joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25105,Remove wrist joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25107,Remove wrist joint cartilage,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25109,Excise tendon forearm/wrist,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25110,Remove wrist tendon lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,25111,Remove wrist tendon lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,25112,Reremove wrist tendon lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,25115,Remove wrist/forearm lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,25116,Remove wrist/forearm lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25118,Excise wrist tendon sheath,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,25119,Partial removal of ulna,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25120,Removal of forearm lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25125,Remove/graft forearm lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,25126,Remove/graft forearm lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25130,Removal of wrist lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25135,Remove & graft wrist lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,25136,Remove & graft wrist lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,25145,Remove forearm bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25150,Partial removal of ulna,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25151,Partial removal of radius,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","9,201.00",,,,,,
Aetna MCR ADV,CPT,25170,Resect radius/ulnar tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,25210,Removal of wrist bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25215,Removal of wrist bones,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25230,Partial removal of radius,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25240,Partial removal of ulna,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25248,Remove forearm foreign body,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,25250,Removal of wrist prosthesis,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,25251,Removal of wrist prosthesis,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25259,Manipulate wrist w/anesthes,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,25260,Repair forearm tendon/muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25263,Repair forearm tendon/muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,25265,Repair forearm tendon/muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25270,Repair forearm tendon/muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25272,Repair forearm tendon/muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25274,Repair forearm tendon/muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25275,Repair forearm tendon sheath,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25280,Revise wrist/forearm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25290,Incise wrist/forearm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25295,Release wrist/forearm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25300,Fusion of tendons at wrist,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25301,Fusion of tendons at wrist,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25310,Transplant forearm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25312,Transplant forearm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25315,Revise palsy hand tendon(s),APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,25316,Revise palsy hand tendon(s),APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,25320,Repair/revise wrist joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,25332,Revise wrist joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25335,Realignment of hand,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25337,Reconstruct ulna/radioulnar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,25350,Revision of radius,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,25355,Revision of radius,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25360,Revision of ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,25365,Revise radius & ulna,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,25370,Revise radius or ulna,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25375,Revise radius & ulna,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25390,Shorten radius or ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,25391,Lengthen radius or ulna,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,25392,Shorten radius & ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,25393,Lengthen radius & ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,25394,Repair carpal bone shorten,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25400,Repair radius or ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,25405,Repair/graft radius or ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,25415,Repair radius & ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,25420,Repair/graft radius & ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,25425,Repair/graft radius or ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,25426,Repair/graft radius & ulna,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25430,Vasc graft into carpal bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25431,Repair nonunion carpal bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,25440,Repair/graft wrist bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,25441,Reconstruct wrist joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,25442,Reconstruct wrist joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,25443,Reconstruct wrist joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,25444,Reconstruct wrist joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,25445,Reconstruct wrist joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,25446,Wrist replacement,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,25447,Repair wrist joints,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25449,Remove wrist joint implant,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,25450,Revision of wrist joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25455,Revision of wrist joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25490,Reinforce radius,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,25491,Reinforce ulna,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,25492,Reinforce radius and ulna,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25500,Treat fracture of radius,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,25505,Treat fracture of radius,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,25515,Treat fracture of radius,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,25520,Treat fracture of radius,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,25525,Treat fracture of radius,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,25526,Treat fracture of radius,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,25530,Treat fracture of ulna,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,25535,Treat fracture of ulna,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,25545,Treat fracture of ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,25560,Treat fracture radius & ulna,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,25565,Treat fracture radius & ulna,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,25574,Treat fracture radius & ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,25575,Treat fracture radius/ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,25600,Treat fracture radius/ulna,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,25605,Treat fracture radius/ulna,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,25606,Treat fx distal radial,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25607,Treat fx rad extra-articul,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,25608,Treat fx rad intra-articul,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,25609,Treat fx radial 3+ frag,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,25622,Treat wrist bone fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,25624,Treat wrist bone fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,25628,Treat wrist bone fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,25630,Treat wrist bone fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,25635,Treat wrist bone fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,25645,Treat wrist bone fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25650,Treat wrist bone fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,25651,Pin ulnar styloid fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25652,Treat fracture ulnar styloid,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,25660,Treat wrist dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,25670,Treat wrist dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,25671,Pin radioulnar dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25675,Treat wrist dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,25676,Treat wrist dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,25680,Treat wrist fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,25685,Treat wrist fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,25690,Treat wrist dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,25695,Treat wrist dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,25800,Fusion of wrist joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,25805,Fusion/graft of wrist joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,25810,Fusion/graft of wrist joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,25820,Fusion of hand bones,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,25825,Fuse hand bones with graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,25830,Fusion radioulnar jnt/ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,25900,Amputation of forearm,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,25905,Amputation of forearm,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,25907,Amputation follow-up surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25909,Amputation follow-up surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,25915,Amputation of forearm,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,25920,Amputate hand at wrist,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,25922,Amputate hand at wrist,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,25924,Amputation follow-up surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,25927,Amputation of hand,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25929,Amputation follow-up surgery,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,25931,Amputation follow-up surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,25999,Forearm or wrist surgery,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,26010,Drainage of finger abscess,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,26011,Drainage of finger abscess,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,26020,Drain hand tendon sheath,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26025,Drainage of palm bursa,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26030,Drainage of palm bursas,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26034,Treat hand bone lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,26035,Decompress fingers/hand,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26037,Decompress fingers/hand,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26040,Release palm contracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,26045,Release palm contracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26055,Incise finger tendon sheath,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,26060,Incision of finger tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,26070,Explore/treat hand joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,26075,Explore/treat finger joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26080,Explore/treat finger joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,26100,Biopsy hand joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26105,Biopsy finger joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26110,Biopsy finger joint lining,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,26111,Exc hand les sc 1.5 cm/>,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,26113,Exc hand tum deep 1.5 cm/>,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,26115,Exc hand les sc < 1.5 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,26116,Exc hand tum deep < 1.5 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,26117,Rad resect hand tumor < 3 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,26118,Rad resect hand tumor 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,26121,Release palm contracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26123,Release palm contracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26130,Remove wrist joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26135,Revise finger joint each,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26140,Revise finger joint each,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,26145,Tendon excision palm/finger,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,26160,Remove tendon sheath lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,26170,Removal of palm tendon each,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,26180,Removal of finger tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,26185,Remove finger bone,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,26200,Remove hand bone lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,26205,Remove/graft bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,26210,Removal of finger lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,26215,Remove/graft finger lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26230,Partial removal of hand bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26235,Partial removal finger bone,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,26236,Partial removal finger bone,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,26250,Extensive hand surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26260,Resect prox finger tumor,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26262,Resect distal finger tumor,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,26320,Removal of implant from hand,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,26340,Manipulate finger w/anesth,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,26341,Manipulat palm cord post inj,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,26350,Repair finger/hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26352,Repair/graft hand tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,26356,Repair finger/hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26357,Repair finger/hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26358,Repair/graft hand tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,26370,Repair finger/hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","9,201.00",,,,,,
Aetna MCR ADV,CPT,26372,Repair/graft hand tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,26373,Repair finger/hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26390,Revise hand/finger tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,26392,Repair/graft hand tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,26410,Repair hand tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,26412,Repair/graft hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26415,Excision hand/finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26416,Graft hand or finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26418,Repair finger tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,26420,Repair/graft finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26426,Repair finger/hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26428,Repair/graft finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26432,Repair finger tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,26433,Repair finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26434,Repair/graft finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26437,Realignment of tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26440,Release palm/finger tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,26442,Release palm & finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26445,Release hand/finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26449,Release forearm/hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26450,Incision of palm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26455,Incision of finger tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,26460,Incise hand/finger tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,26471,Fusion of finger tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26474,Fusion of finger tendons,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,26476,Tendon lengthening,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26477,Tendon shortening,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26478,Lengthening of hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26479,Shortening of hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26480,Transplant hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26483,Transplant/graft hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26485,Transplant palm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26489,Transplant/graft palm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26490,Revise thumb tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26492,Tendon transfer with graft,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26494,Hand tendon/muscle transfer,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26496,Revise thumb tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26497,Finger tendon transfer,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26498,Finger tendon transfer,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26499,Revision of finger,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26500,Hand tendon reconstruction,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,26502,Hand tendon reconstruction,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26508,Release thumb contracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26510,Thumb tendon transfer,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26516,Fusion of knuckle joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26517,Fusion of knuckle joints,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26518,Fusion of knuckle joints,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,26520,Release knuckle contracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26525,Release finger contracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,26530,Revise knuckle joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,26531,Revise knuckle with implant,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,26535,Revise finger joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26536,Revise/implant finger joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,26540,Repair hand joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26541,Repair hand joint with graft,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26542,Repair hand joint with graft,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26545,Reconstruct finger joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26546,Repair nonunion hand,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,26548,Reconstruct finger joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26550,Construct thumb replacement,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26551,Great toe-hand transfer,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,26553,Single transfer toe-hand,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,26554,Double transfer toe-hand,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,26555,Positional change of finger,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,26556,Toe joint transfer,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,26560,Repair of web finger,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,26561,Repair of web finger,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26562,Repair of web finger,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26565,Correct metacarpal flaw,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26567,Correct finger deformity,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26568,Lengthen metacarpal/finger,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,26580,Repair hand deformity,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26587,Reconstruct extra finger,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26590,Repair finger deformity,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,26591,Repair muscles of hand,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26593,Release muscles of hand,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26596,Excision constricting tissue,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26600,Treat metacarpal fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,26605,Treat metacarpal fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,26607,Treat metacarpal fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26608,Treat metacarpal fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26615,Treat metacarpal fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26641,Treat thumb dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,26645,Treat thumb fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,26650,Treat thumb fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26665,Treat thumb fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26670,Treat hand dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,26675,Treat hand dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,26676,Pin hand dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26685,Treat hand dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26686,Treat hand dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26700,Treat knuckle dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,26705,Treat knuckle dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,26706,Pin knuckle dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26715,Treat knuckle dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26720,Treat finger fracture each,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,26725,Treat finger fracture each,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,26727,Treat finger fracture each,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26735,Treat finger fracture each,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26740,Treat finger fracture each,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,26742,Treat finger fracture each,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,26746,Treat finger fracture each,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26750,Treat finger fracture each,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,26755,Treat finger fracture each,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,26756,Pin finger fracture each,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26765,Treat finger fracture each,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26770,Treat finger dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,26775,Treat finger dislocation,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Aetna MCR ADV,CPT,26776,Pin finger dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26785,Treat finger dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26820,Thumb fusion with graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,26841,Fusion of thumb,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,26842,Thumb fusion with graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,26843,Fusion of hand joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,26844,Fusion/graft of hand joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,26850,Fusion of knuckle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,26852,Fusion of knuckle with graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,26860,Fusion of finger joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26862,Fusion/graft of finger joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26910,Amputate metacarpal bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26951,Amputation of finger/thumb,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26952,Amputation of finger/thumb,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26989,Hand/finger surgery,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,26990,Drainage of pelvis lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,26991,Drainage of pelvis bursa,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,26992,Drainage of bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27000,Incision of hip tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,27001,Incision of hip tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27003,Incision of hip tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27005,Incision of hip tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27006,Incision of hip tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27025,Incision of hip/thigh fascia,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27027,Buttock fasciotomy,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27030,Drainage of hip joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27033,Exploration of hip joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27035,Denervation of hip joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27036,Excision of hip joint/muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27040,Biopsy of soft tissues,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,27041,Biopsy of soft tissues,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,27043,Exc hip pelvis les sc 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,27045,Exc hip/pelv tum deep 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,27047,Exc hip/pelvis les sc < 3 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,27048,Exc hip/pelv tum deep < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,27049,Resect hip/pelv tum < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,27050,Biopsy of sacroiliac joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,27052,Biopsy of hip joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,27054,Removal of hip joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27057,Buttock fasciotomy w/dbrdmt,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,27059,Resect hip/pelv tum 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,27060,Removal of ischial bursa,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27062,Remove femur lesion/bursa,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27065,Remove hip bone les super,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27066,Remove hip bone les deep,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27067,Remove/graft hip bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27070,Part remove hip bone super,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27071,Part removal hip bone deep,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27075,Resect hip tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27076,Resect hip tum incl acetabul,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27077,Resect hip tum w/innom bone,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,27078,Rsect hip tum incl femur,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,27080,Removal of tail bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27086,Remove hip foreign body,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,27087,Remove hip foreign body,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27090,Removal of hip prosthesis,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,27091,Removal of hip prosthesis,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,27097,Revision of hip tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27098,Transfer tendon to pelvis,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27100,Transfer of abdominal muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27105,Transfer of spinal muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27110,Transfer of iliopsoas muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27111,Transfer of iliopsoas muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27120,Reconstruction of hip socket,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,27122,Reconstruction of hip socket,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,27125,Partial hip replacement,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,27130,Total hip arthroplasty,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,27132,Total hip arthroplasty,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,27134,Revise hip joint replacement,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,27137,Revise hip joint replacement,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,27138,Revise hip joint replacement,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,27140,Transplant femur ridge,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,27146,Incision of hip bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27147,Revision of hip bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27151,Incision of hip bones,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27156,Revision of hip bones,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27158,Revision of pelvis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27161,Incision of neck of femur,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27165,Incision/fixation of femur,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27170,Repair/graft femur head/neck,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27175,Treat slipped epiphysis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27176,Treat slipped epiphysis,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,27177,Treat slipped epiphysis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27178,Treat slipped epiphysis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27179,Revise head/neck of femur,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27181,Treat slipped epiphysis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27185,Revision of femur epiphysis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27187,Reinforce hip bones,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27197,Clsd tx pelvic ring fx,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,27198,Clsd tx pelvic ring fx,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,27200,Treat tail bone fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,27202,Treat tail bone fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27220,Treat hip socket fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,27222,Treat hip socket fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,27226,Treat hip wall fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27227,Treat hip fracture(s),APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27228,Treat hip fracture(s),APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27230,Treat thigh fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,27232,Treat thigh fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,27235,Treat thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27236,Treat thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27238,Treat thigh fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,27240,Treat thigh fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,27244,Treat thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27245,Treat thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27246,Treat thigh fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,27248,Treat thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27250,Treat hip dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,27252,Treat hip dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,27253,Treat hip dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27254,Treat hip dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27256,Treat hip dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,27257,Treat hip dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,27258,Treat hip dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27259,Treat hip dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27265,Treat hip dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,27266,Treat hip dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,27267,Cltx thigh fx,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27268,Cltx thigh fx w/mnpj,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27269,Optx thigh fx,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,27275,Manipulation of hip joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,27279,Arthrodesis sacroiliac joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,27280,Fusion of sacroiliac joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,27282,Fusion of pubic bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,27284,Fusion of hip joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,27286,Fusion of hip joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,27290,Amputation of leg at hip,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,27295,Amputation of leg at hip,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,27299,Pelvis/hip joint surgery,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,27301,Drain thigh/knee lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,27303,Drainage of bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27305,Incise thigh tendon & fascia,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27306,Incision of thigh tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27307,Incision of thigh tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27310,Exploration of knee joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27323,Biopsy thigh soft tissues,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,27324,Biopsy thigh soft tissues,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,27325,Neurectomy hamstring,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,27326,Neurectomy popliteal,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,27327,Exc thigh/knee les sc < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,27328,Exc thigh/knee tum deep <5cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,27329,Resect thigh/knee tum < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,27330,Biopsy knee joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27331,Explore/treat knee joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27332,Removal of knee cartilage,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27333,Removal of knee cartilage,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27334,Remove knee joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27335,Remove knee joint lining,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27337,Exc thigh/knee les sc 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,27339,Exc thigh/knee tum dep 5cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,27340,Removal of kneecap bursa,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27345,Removal of knee cyst,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27347,Remove knee cyst,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27350,Removal of kneecap,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27355,Remove femur lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27356,Remove femur lesion/graft,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,27357,Remove femur lesion/graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27360,Partial removal leg bone(s),APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27364,Resect thigh/knee tum 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,27365,Resect femur/knee tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27372,Removal of foreign body,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,27380,Repair of kneecap tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27381,Repair/graft kneecap tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27385,Repair of thigh muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27386,Repair/graft of thigh muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27390,Incision of thigh tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27391,Incision of thigh tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27392,Incision of thigh tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27393,Lengthening of thigh tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27394,Lengthening of thigh tendons,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27395,Lengthening of thigh tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27396,Transplant of thigh tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27397,Transplants of thigh tendons,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27400,Revise thigh muscles/tendons,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27403,Repair of knee cartilage,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27405,Repair of knee ligament,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,27407,Repair of knee ligament,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,27409,Repair of knee ligaments,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,27412,Autochondrocyte implant knee,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27415,Osteochondral knee allograft,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,27416,Osteochondral knee autograft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27418,Repair degenerated kneecap,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27420,Revision of unstable kneecap,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27422,Revision of unstable kneecap,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27424,Revision/removal of kneecap,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27425,Lat retinacular release open,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27427,Reconstruction knee,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,27428,Reconstruction knee,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Aetna MCR ADV,CPT,27429,Reconstruction knee,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Aetna MCR ADV,CPT,27430,Revision of thigh muscles,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27435,Incision of knee joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27437,Revise kneecap,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27438,Revise kneecap with implant,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,27440,Revision of knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,27441,Revision of knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,27442,Revision of knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,27443,Revision of knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,27445,Revision of knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,27446,Revision of knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Aetna MCR ADV,CPT,27447,Total knee arthroplasty,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,27448,Incision of thigh,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27450,Incision of thigh,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27454,Realignment of thigh bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27455,Realignment of knee,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27457,Realignment of knee,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27465,Shortening of thigh bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27466,Lengthening of thigh bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27468,Shorten/lengthen thighs,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27470,Repair of thigh,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27472,Repair/graft of thigh,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27475,Surgery to stop leg growth,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27477,Surgery to stop leg growth,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27479,Surgery to stop leg growth,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27485,Surgery to stop leg growth,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27486,Revise/replace knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,27487,Revise/replace knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,27488,Removal of knee prosthesis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27495,Reinforce thigh,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27496,Decompression of thigh/knee,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27497,Decompression of thigh/knee,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27498,Decompression of thigh/knee,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,27499,Decompression of thigh/knee,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27500,Treatment of thigh fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,27501,Treatment of thigh fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,27502,Treatment of thigh fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,27503,Treatment of thigh fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,27506,Treatment of thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27507,Treatment of thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27508,Treatment of thigh fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,27509,Treatment of thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27510,Treatment of thigh fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,27511,Treatment of thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27513,Treatment of thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27514,Treatment of thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27516,Treat thigh fx growth plate,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,27517,Treat thigh fx growth plate,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,27519,Treat thigh fx growth plate,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27520,Treat kneecap fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,27524,Treat kneecap fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27530,Treat knee fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,27532,Treat knee fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27535,Treat knee fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27536,Treat knee fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27538,Treat knee fracture(s),APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,27540,Treat knee fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27550,Treat knee dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,27552,Treat knee dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,27556,Treat knee dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27557,Treat knee dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27558,Treat knee dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27560,Treat kneecap dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,27562,Treat kneecap dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,27566,Treat kneecap dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27570,Fixation of knee joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,27580,Fusion of knee,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,27590,Amputate leg at thigh,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,27591,Amputate leg at thigh,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,27592,Amputate leg at thigh,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,27594,Amputation follow-up surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27596,Amputation follow-up surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27598,Amputate lower leg at knee,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,27599,Leg surgery procedure,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,27600,Decompression of lower leg,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27601,Decompression of lower leg,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27602,Decompression of lower leg,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27603,Drain lower leg lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,27604,Drain lower leg bursa,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27605,Incision of achilles tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,27606,Incision of achilles tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27607,Treat lower leg bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27610,Explore/treat ankle joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27612,Exploration of ankle joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27613,Biopsy lower leg soft tissue,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,27614,Biopsy lower leg soft tissue,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,27615,Resect leg/ankle tum < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,27616,Resect leg/ankle tum 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,27618,Exc leg/ankle tum < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,27619,Exc leg/ankle tum deep <5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,27620,Explore/treat ankle joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27625,Remove ankle joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27626,Remove ankle joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27630,Removal of tendon lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27632,Exc leg/ankle les sc 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,27634,Exc leg/ankle tum dep 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,27635,Remove lower leg bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27637,Remove/graft leg bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27638,Remove/graft leg bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27640,Partial removal of tibia,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27641,Partial removal of fibula,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27645,Resect tibia tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27646,Resect fibula tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27647,Resect talus/calcaneus tum,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27650,Repair achilles tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27652,Repair/graft achilles tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,27654,Repair of achilles tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,27656,Repair leg fascia defect,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27658,Repair of leg tendon each,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27659,Repair of leg tendon each,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27664,Repair of leg tendon each,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27665,Repair of leg tendon each,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27675,Repair lower leg tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27676,Repair lower leg tendons,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27680,Release of lower leg tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27681,Release of lower leg tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27685,Revision of lower leg tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27686,Revise lower leg tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27687,Revision of calf tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27690,Revise lower leg tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27691,Revise lower leg tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,27695,Repair of ankle ligament,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27696,Repair of ankle ligaments,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27698,Repair of ankle ligament,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27700,Revision of ankle joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27702,Reconstruct ankle joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,27703,Reconstruction ankle joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,27704,Removal of ankle implant,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27705,Incision of tibia,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27707,Incision of fibula,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27709,Incision of tibia & fibula,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,27712,Realignment of lower leg,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,27715,Revision of lower leg,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,27720,Repair of tibia,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27722,Repair/graft of tibia,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27724,Repair/graft of tibia,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,27725,Repair of lower leg,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27726,Repair fibula nonunion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,27727,Repair of lower leg,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27730,Repair of tibia epiphysis,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27732,Repair of fibula epiphysis,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27734,Repair lower leg epiphyses,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27740,Repair of leg epiphyses,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27742,Repair of leg epiphyses,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27745,Reinforce tibia,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27750,Treatment of tibia fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,27752,Treatment of tibia fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,27756,Treatment of tibia fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27758,Treatment of tibia fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Aetna MCR ADV,CPT,27759,Treatment of tibia fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,27760,Cltx medial ankle fx,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,27762,Cltx med ankle fx w/mnpj,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,27766,Optx medial ankle fx,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27767,Cltx post ankle fx,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,27768,Cltx post ankle fx w/mnpj,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,27769,Optx post ankle fx,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27780,Treatment of fibula fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,27781,Treatment of fibula fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,27784,Treatment of fibula fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27786,Treatment of ankle fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,27788,Treatment of ankle fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,27792,Treatment of ankle fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27808,Treatment of ankle fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,27810,Treatment of ankle fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,27814,Treatment of ankle fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,27816,Treatment of ankle fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,27818,Treatment of ankle fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,27822,Treatment of ankle fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27823,Treatment of ankle fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27824,Treat lower leg fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,27825,Treat lower leg fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,27826,Treat lower leg fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27827,Treat lower leg fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,27828,Treat lower leg fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Aetna MCR ADV,CPT,27829,Treat lower leg joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27830,Treat lower leg dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,27831,Treat lower leg dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27832,Treat lower leg dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27840,Treat ankle dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,27842,Treat ankle dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,27846,Treat ankle dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27848,Treat ankle dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27860,Fixation of ankle joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27870,Fusion of ankle joint open,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Aetna MCR ADV,CPT,27871,Fusion of tibiofibular joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Aetna MCR ADV,CPT,27880,Amputation of lower leg,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,27881,Amputation of lower leg,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27882,Amputation of lower leg,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27884,Amputation follow-up surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27886,Amputation follow-up surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27888,Amputation of foot at ankle,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,27889,Amputation of foot at ankle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27892,Decompression of leg,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27893,Decompression of leg,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,27894,Decompression of leg,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,27899,Leg/ankle surgery procedure,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,28001,Drainage of bursa of foot,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,28002,Treatment of foot infection,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,28003,Treatment of foot infection,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28005,Treat foot bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28008,Incision of foot fascia,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28010,Incision of toe tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,28011,Incision of toe tendons,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,28020,Exploration of foot joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28022,Exploration of foot joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28024,Exploration of toe joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,28035,Decompression of tibia nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,28039,Exc foot/toe tum sc 1.5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,28041,Exc foot/toe tum dep 1.5cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,28043,Exc foot/toe tum sc < 1.5 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,28045,Exc foot/toe tum deep <1.5cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,28046,Resect foot/toe tumor < 3 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,28047,Resect foot/toe tumor 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,28050,Biopsy of foot joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28052,Biopsy of foot joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28054,Biopsy of toe joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28055,Neurectomy foot,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,28060,Partial removal foot fascia,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28062,Removal of foot fascia,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28070,Removal of foot joint lining,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,28072,Removal of foot joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28080,Removal of foot lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,28086,Excise foot tendon sheath,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28088,Excise foot tendon sheath,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28090,Removal of foot lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,28092,Removal of toe lesions,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,28100,Removal of ankle/heel lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28102,Remove/graft foot lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,28103,Remove/graft foot lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,28104,Removal of foot lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28106,Remove/graft foot lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,28107,Remove/graft foot lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,28108,Removal of toe lesions,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,28110,Part removal of metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28111,Part removal of metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28112,Part removal of metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28113,Part removal of metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28114,Removal of metatarsal heads,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28116,Revision of foot,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28118,Removal of heel bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28119,Removal of heel spur,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28120,Part removal of ankle/heel,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28122,Partial removal of foot bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28124,Partial removal of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28126,Partial removal of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28130,Removal of ankle bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,28140,Removal of metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28150,Removal of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28153,Partial removal of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28160,Partial removal of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28171,Resect tarsal tumor,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28173,Resect metatarsal tumor,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28175,Resect phalanx of toe tumor,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,28190,Removal of foot foreign body,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,28192,Removal of foot foreign body,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,28193,Removal of foot foreign body,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,28200,Repair of foot tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28202,Repair/graft of foot tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,28208,Repair of foot tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28210,Repair/graft of foot tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,28220,Release of foot tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,28222,Release of foot tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28225,Release of foot tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28226,Release of foot tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28230,Incision of foot tendon(s),APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,28232,Incision of toe tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,28234,Incision of foot tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,28238,Revision of foot tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,28240,Release of big toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28250,Revision of foot fascia,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28260,Release of midfoot joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28261,Revision of foot tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,28262,Revision of foot and ankle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,28264,Release of midfoot joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,28270,Release of foot contracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28272,Release of toe joint each,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,28280,Fusion of toes,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28285,Repair of hammertoe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28286,Repair of hammertoe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28288,Partial removal of foot bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28289,Corrj halux rigdus w/o implt,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28291,Corrj halux rigdus w/implt,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,28292,Correction hallux valgus,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28295,Correction hallux valgus,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28296,Correction hallux valgus,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28297,Correction hallux valgus,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,28298,Correction hallux valgus,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,28299,Correction hallux valgus,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,28300,Incision of heel bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,28302,Incision of ankle bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,28304,Incision of midfoot bones,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,28305,Incise/graft midfoot bones,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,28306,Incision of metatarsal,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,28307,Incision of metatarsal,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,28308,Incision of metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28309,Incision of metatarsals,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,28310,Revision of big toe,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,28312,Revision of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28313,Repair deformity of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28315,Removal of sesamoid bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28320,Repair of foot bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,28322,Repair of metatarsals,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,28340,Resect enlarged toe tissue,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28341,Resect enlarged toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28344,Repair extra toe(s),APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28345,Repair webbed toe(s),APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,28360,Reconstruct cleft foot,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,28400,Treatment of heel fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,28405,Treatment of heel fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,28406,Treatment of heel fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,28415,Treat heel fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,28420,Treat/graft heel fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,28430,Treatment of ankle fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,28435,Treatment of ankle fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,28436,Treatment of ankle fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,28445,Treat ankle fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,28446,Osteochondral talus autogrft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,28450,Treat midfoot fracture each,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,28455,Treat midfoot fracture each,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,28456,Treat midfoot fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,28465,Treat midfoot fracture each,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,28470,Treat metatarsal fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,28475,Treat metatarsal fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,28476,Treat metatarsal fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28485,Treat metatarsal fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,28490,Treat big toe fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,28495,Treat big toe fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,28496,Treat big toe fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28505,Treat big toe fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28510,Treatment of toe fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,28515,Treatment of toe fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,28525,Treat toe fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28530,Treat sesamoid bone fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,28531,Treat sesamoid bone fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,28540,Treat foot dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,28545,Treat foot dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28546,Treat foot dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,28555,Repair foot dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,28570,Treat foot dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,28575,Treat foot dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28576,Treat foot dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,28585,Repair foot dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,28600,Treat foot dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,28605,Treat foot dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,28606,Treat foot dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28615,Repair foot dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,28630,Treat toe dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,28635,Treat toe dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,28636,Treat toe dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28645,Repair toe dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28660,Treat toe dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,28665,Treat toe dislocation,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Aetna MCR ADV,CPT,28666,Treat toe dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28675,Repair of toe dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28705,Fusion of foot bones,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,28715,Fusion of foot bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Aetna MCR ADV,CPT,28725,Fusion of foot bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Aetna MCR ADV,CPT,28730,Fusion of foot bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Aetna MCR ADV,CPT,28735,Fusion of foot bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,28737,Revision of foot bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,28740,Fusion of foot bones,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,28750,Fusion of big toe joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,28755,Fusion of big toe joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,28760,Fusion of big toe joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,28800,Amputation of midfoot,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28805,Amputation thru metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28810,Amputation toe & metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28820,Amputation of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28825,Partial amputation of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,28890,Hi enrgy eswt plantar fascia,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,28899,Foot/toes surgery procedure,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29000,Application of body cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29010,Application of body cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29015,Application of body cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29035,Application of body cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29040,Application of body cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29044,Application of body cast,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29046,Application of body cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29049,Application of figure eight,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29055,Application of shoulder cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29058,Application of shoulder cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29065,Application of long arm cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29075,Application of forearm cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29085,Apply hand/wrist cast,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29086,Apply finger cast,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29105,Apply long arm splint,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29125,Apply forearm splint,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29126,Apply forearm splint,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29130,Application of finger splint,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29131,Application of finger splint,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29200,Strapping of chest,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29240,Strapping of shoulder,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29260,Strapping of elbow or wrist,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29280,Strapping of hand or finger,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29305,Application of hip cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29325,Application of hip casts,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29345,Application of long leg cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29355,Application of long leg cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29358,Apply long leg cast brace,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29365,Application of long leg cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29405,Apply short leg cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29425,Apply short leg cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29435,Apply short leg cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29440,Addition of walker to cast,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29445,Apply rigid leg cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29450,Application of leg cast,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29505,Application long leg splint,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29515,Application lower leg splint,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29520,Strapping of hip,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29530,Strapping of knee,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29540,Strapping of ankle and/or ft,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29550,Strapping of toes,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29580,Application of paste boot,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29581,Apply multlay comprs lwr leg,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29584,Appl multlay comprs arm/hand,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29700,Removal/revision of cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29705,Removal/revision of cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29710,Removal/revision of cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29720,Repair of body cast,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29730,Windowing of cast,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29740,Wedging of cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29750,Wedging of clubfoot cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29799,Casting/strapping procedure,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,29800,Jaw arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,29804,Jaw arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,29805,Sho arthrs dx +- synovial bx,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,29806,Sho arthrs srg capsulorpaphy,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,29807,Sho arthrs srg rpr slap les,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,29819,Sho arthrs srg rmvl loose/fb,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,29820,Sho arthrs srg prtl synvct,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,29821,Sho arthrs srg compl synvct,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,29822,Sho arthrs srg lmtd dbrdmt,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,29823,Sho arthrs srg xtnsv dbrdmt,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,29824,Sho arthrs srg dstl claviclc,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,29825,Sho arthrs srg lss&rescj ads,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,29827,Sho arthrs srg rt8tr cuf rpr,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,29828,Sho arthrs srg bicp tenodsis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,29830,Elbow arthroscopy,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,29834,Elbow arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,29835,Elbow arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,29836,Elbow arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,29837,Elbow arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,29838,Elbow arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,29840,Wrist arthroscopy,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,29843,Wrist arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,29844,Wrist arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,29845,Wrist arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,29846,Wrist arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,29847,Wrist arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,29848,Wrist endoscopy/surgery,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,29850,Knee arthroscopy/surgery,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,29851,Knee arthroscopy/surgery,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,29855,Tibial arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,29856,Tibial arthroscopy/surgery,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,29860,Hip arthroscopy dx,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,29861,Hip arthro w/fb removal,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,29862,Hip arthr0 w/debridement,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,29863,Hip arthr0 w/synovectomy,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,29866,Autgrft implnt knee w/scope,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,29867,Allgrft implnt knee w/scope,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,29868,Meniscal trnspl knee w/scpe,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,29870,Knee arthroscopy dx,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,29871,Knee arthroscopy/drainage,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,29873,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,29874,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,29875,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,29876,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,29877,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,29879,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,29880,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,29881,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,29882,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,29883,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,29884,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,29885,Knee arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,29886,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,29887,Knee arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,29888,Knee arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,29889,Knee arthroscopy/surgery,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Aetna MCR ADV,CPT,29891,Ankle arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,29892,Ankle arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,29893,Scope plantar fasciotomy,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,29894,Ankle arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,29895,Ankle arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,29897,Ankle arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,29898,Ankle arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,29899,Ankle arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,29900,Mcp joint arthroscopy dx,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,29901,Mcp joint arthroscopy surg,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,29902,Mcp joint arthroscopy surg,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Aetna MCR ADV,CPT,29904,Subtalar arthro w/fb rmvl,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,29905,Subtalar arthro w/exc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,29906,Subtalar arthro w/deb,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,29907,Subtalar arthro w/fusion,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,29914,Hip arthro w/femoroplasty,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,29915,Hip arthro acetabuloplasty,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,29916,Hip arthro w/labral repair,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,29999,Arthroscopy of joint,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Aetna MCR ADV,CPT,30000,Drainage of nose lesion,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Aetna MCR ADV,CPT,30020,Drainage of nose lesion,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,30100,Intranasal biopsy,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,30110,Removal of nose polyp(s),APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,30115,Removal of nose polyp(s),APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,30117,Removal of intranasal lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,30118,Removal of intranasal lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,30120,Revision of nose,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,30124,Removal of nose lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,30125,Removal of nose lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,30130,Excise inferior turbinate,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,30140,Resect inferior turbinate,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,30150,Partial removal of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,30160,Removal of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,30200,Injection treatment of nose,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,30210,Nasal sinus therapy,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,30220,Insert nasal septal button,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,30300,Remove nasal foreign body,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Aetna MCR ADV,CPT,30310,Remove nasal foreign body,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,30320,Remove nasal foreign body,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,30400,Reconstruction of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,30410,Reconstruction of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,30420,Reconstruction of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,30430,Revision of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,30435,Revision of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,30450,Revision of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,30460,Revision of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,30462,Revision of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,30465,Repair nasal stenosis,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,30468,Rpr nsl vlv collapse w/implt,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,30520,Repair of nasal septum,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,30540,Repair nasal defect,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,30545,Repair nasal defect,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,30560,Release of nasal adhesions,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,30580,Repair upper jaw fistula,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,30600,Repair mouth/nose fistula,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,30620,Intranasal reconstruction,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,30630,Repair nasal septum defect,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,30801,Ablate inf turbinate superf,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,30802,Ablate inf turbinate submuc,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,30901,Control of nosebleed,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Aetna MCR ADV,CPT,30903,Control of nosebleed,APC 5734,RVU Per Unit,$114.56 ,OP,114.56,"4,314.00",,,,,,
Aetna MCR ADV,CPT,30905,Control of nosebleed,APC 5734,RVU Per Unit,$114.56 ,OP,114.56,"4,314.00",,,,,,
Aetna MCR ADV,CPT,30906,Repeat control of nosebleed,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Aetna MCR ADV,CPT,30915,Ligation nasal sinus artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,30920,Ligation upper jaw artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,30930,Ther fx nasal inf turbinate,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,30999,Nasal surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Aetna MCR ADV,CPT,31000,Irrigation maxillary sinus,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Aetna MCR ADV,CPT,31002,Irrigation sphenoid sinus,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,31020,Exploration maxillary sinus,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,31030,Exploration maxillary sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,31032,Explore sinus remove polyps,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,31040,Exploration behind upper jaw,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,31050,Exploration sphenoid sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,31051,Sphenoid sinus surgery,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,31070,Exploration of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,31075,Exploration of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,31080,Removal of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,31081,Removal of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,31084,Removal of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,31085,Removal of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,31086,Removal of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,31087,Removal of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,31090,Exploration of sinuses,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,31200,Removal of ethmoid sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,31201,Removal of ethmoid sinus,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,31205,Removal of ethmoid sinus,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,31225,Removal of upper jaw,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,31230,Removal of upper jaw,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,31231,Nasal endoscopy dx,APC 5151,RVU Per Unit,$168.23 ,OP,168.23,"4,314.00",,,,,,
Aetna MCR ADV,CPT,31233,Nsl/sins ndsc dx max sinusc,APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
Aetna MCR ADV,CPT,31235,Nsl/sins ndsc dx sphn sinusc,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,31237,Nasal/sinus endoscopy surg,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,31238,Nasal/sinus endoscopy surg,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,31239,Nasal/sinus endoscopy surg,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Aetna MCR ADV,CPT,31240,Nasal/sinus endoscopy surg,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,31241,Nsl/sins ndsc w/artery lig,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,31253,Nsl/sins ndsc total,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,31254,Nsl/sins ndsc w/prtl ethmdct,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Aetna MCR ADV,CPT,31255,Nsl/sins ndsc w/tot ethmdct,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,31256,Exploration maxillary sinus,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Aetna MCR ADV,CPT,31257,Nsl/sins ndsc tot w/sphendt,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,31259,Nsl/sins ndsc sphn tiss rmvl,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,31267,Endoscopy maxillary sinus,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Aetna MCR ADV,CPT,31276,Nsl/sins ndsc frnt tiss rmvl,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,31287,Nasal/sinus endoscopy surg,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,31288,Nasal/sinus endoscopy surg,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,31290,Nasal/sinus endoscopy surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,31291,Nasal/sinus endoscopy surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,31292,Nsl/sins ndsc med/inf dcmprn,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Aetna MCR ADV,CPT,31293,Nsl/sins ndsc med&inf dcmprn,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Aetna MCR ADV,CPT,31294,Nsl/sins ndsc surg on dcmprn,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Aetna MCR ADV,CPT,31295,Nsl/sins ndsc surg max sins,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Aetna MCR ADV,CPT,31296,Nsl/sins ndsc surg frnt sins,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,31297,Nsl/sins ndsc surg sphn sins,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Aetna MCR ADV,CPT,31298,Nsl/sins ndsc surg frnt&sphn,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,31299,Sinus surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Aetna MCR ADV,CPT,31300,Removal of larynx lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,31360,Removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,31365,Removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,31367,Partial removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,31368,Partial removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,31370,Partial removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,31375,Partial removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,31380,Partial removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,31382,Partial removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,31390,Removal of larynx & pharynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,31395,Reconstruct larynx & pharynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,31400,Revision of larynx,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,31420,Removal of epiglottis,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,31500,Insert emergency airway,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Aetna MCR ADV,CPT,31502,Change of windpipe airway,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Aetna MCR ADV,CPT,31505,Diagnostic laryngoscopy,APC 5151,RVU Per Unit,$168.23 ,OP,168.23,"4,314.00",,,,,,
Aetna MCR ADV,CPT,31510,Laryngoscopy with biopsy,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Aetna MCR ADV,CPT,31511,Remove foreign body larynx,APC 5151,RVU Per Unit,$168.23 ,OP,168.23,"4,314.00",,,,,,
Aetna MCR ADV,CPT,31512,Removal of larynx lesion,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Aetna MCR ADV,CPT,31513,Injection into vocal cord,APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
Aetna MCR ADV,CPT,31515,Laryngoscopy for aspiration,APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
Aetna MCR ADV,CPT,31520,Dx laryngoscopy newborn,APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
Aetna MCR ADV,CPT,31525,Dx laryngoscopy excl nb,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,31526,Dx laryngoscopy w/oper scope,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,31527,Laryngoscopy for treatment,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Aetna MCR ADV,CPT,31528,Laryngoscopy and dilation,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Aetna MCR ADV,CPT,31529,Laryngoscopy and dilation,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Aetna MCR ADV,CPT,31530,Laryngoscopy w/fb removal,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,31531,Laryngoscopy w/fb & op scope,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Aetna MCR ADV,CPT,31535,Laryngoscopy w/biopsy,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Aetna MCR ADV,CPT,31536,Laryngoscopy w/bx & op scope,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Aetna MCR ADV,CPT,31540,Laryngoscopy w/exc of tumor,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Aetna MCR ADV,CPT,31541,Larynscop w/tumr exc + scope,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Aetna MCR ADV,CPT,31545,Remove vc lesion w/scope,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Aetna MCR ADV,CPT,31546,Remove vc lesion scope/graft,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Aetna MCR ADV,CPT,31551,Laryngoplasty laryngeal sten,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,31552,Laryngoplasty laryngeal sten,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,31553,Laryngoplasty laryngeal sten,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,31554,Laryngoplasty laryngeal sten,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,31560,Laryngoscop w/arytenoidectom,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Aetna MCR ADV,CPT,31561,Larynscop remve cart + scop,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Aetna MCR ADV,CPT,31570,Laryngoscope w/vc inj,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Aetna MCR ADV,CPT,31571,Laryngoscop w/vc inj + scope,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Aetna MCR ADV,CPT,31572,Largsc w/laser dstrj les,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Aetna MCR ADV,CPT,31573,Largsc w/ther injection,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,31574,Largsc w/njx augmentation,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,31575,Diagnostic laryngoscopy,APC 5151,RVU Per Unit,$168.23 ,OP,168.23,"4,314.00",,,,,,
Aetna MCR ADV,CPT,31576,Laryngoscopy with biopsy,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,31577,Largsc w/rmvl foreign bdy(s),APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
Aetna MCR ADV,CPT,31578,Largsc w/removal lesion,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Aetna MCR ADV,CPT,31579,Laryngoscopy telescopic,APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
Aetna MCR ADV,CPT,31580,Laryngoplasty laryngeal web,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,31584,Laryngoplasty fx rdctj fixj,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,31587,Laryngoplasty cricoid split,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,31590,Reinnervate larynx,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,31591,Laryngoplasty medialization,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,31592,Cricotracheal resection,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,31599,Larynx surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Aetna MCR ADV,CPT,31600,Incision of windpipe,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,31601,Incision of windpipe,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,31603,Incision of windpipe,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,31605,Incision of windpipe,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Aetna MCR ADV,CPT,31610,Incision of windpipe,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,31611,Surgery/speech prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,31612,Puncture/clear windpipe,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,31613,Repair windpipe opening,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,31614,Repair windpipe opening,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,31615,Visualization of windpipe,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,31622,Dx bronchoscope/wash,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,31623,Dx bronchoscope/brush,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,31624,Dx bronchoscope/lavage,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,31625,Bronchoscopy w/biopsy(s),APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,31626,Bronchoscopy w/markers,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Aetna MCR ADV,CPT,31628,Bronchoscopy/lung bx each,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Aetna MCR ADV,CPT,31629,Bronchoscopy/needle bx each,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Aetna MCR ADV,CPT,31630,Bronchoscopy dilate/fx repr,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Aetna MCR ADV,CPT,31631,Bronchoscopy dilate w/stent,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Aetna MCR ADV,CPT,31634,Bronch w/balloon occlusion,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Aetna MCR ADV,CPT,31635,Bronchoscopy w/fb removal,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,31636,Bronchoscopy bronch stents,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Aetna MCR ADV,CPT,31638,Bronchoscopy revise stent,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Aetna MCR ADV,CPT,31640,Bronchoscopy w/tumor excise,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Aetna MCR ADV,CPT,31641,Bronchoscopy treat blockage,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Aetna MCR ADV,CPT,31643,Diag bronchoscope/catheter,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,31645,Brnchsc w/ther aspir 1st,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,31646,Brnchsc w/ther aspir sbsq,APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
Aetna MCR ADV,CPT,31647,Bronchial valve init insert,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Aetna MCR ADV,CPT,31648,Bronchial valve remov init,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Aetna MCR ADV,CPT,31649,Bronchial valve remov addl,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,31652,Bronch ebus samplng 1/2 node,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Aetna MCR ADV,CPT,31653,Bronch ebus samplng 3/> node,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Aetna MCR ADV,CPT,31660,Bronch thermoplsty 1 lobe,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Aetna MCR ADV,CPT,31661,Bronch thermoplsty 2/> lobes,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Aetna MCR ADV,CPT,31717,Bronchial brush biopsy,APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
Aetna MCR ADV,CPT,31720,Clearance of airways,APC 5791,RVU Per Case,$192.26 ,OP,192.26,"4,314.00",,,,,,
Aetna MCR ADV,CPT,31725,Clearance of airways,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,31730,Intro windpipe wire/tube,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,31750,Repair of windpipe,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,31755,Repair of windpipe,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,31760,Repair of windpipe,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,31766,Reconstruction of windpipe,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,31770,Repair/graft of bronchus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,31775,Reconstruct bronchus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,31780,Reconstruct windpipe,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,31781,Reconstruct windpipe,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,31785,Remove windpipe lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,31786,Remove windpipe lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,31800,Repair of windpipe injury,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,31805,Repair of windpipe injury,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,31820,Closure of windpipe lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,31825,Repair of windpipe defect,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,31830,Revise windpipe scar,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,31899,Airways surgical procedure,APC 5151,RVU Per Unit,$168.23 ,OP,168.23,"4,314.00",,,,,,
Aetna MCR ADV,CPT,32035,Thoracostomy w/rib resection,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32036,Thoracostomy w/flap drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32096,Open wedge/bx lung infiltr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32097,Open wedge/bx lung nodule,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32098,Open biopsy of lung pleura,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32100,Exploration of chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32110,Explore/repair chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32120,Re-exploration of chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32124,Explore chest free adhesions,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32140,Removal of lung lesion(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32141,Remove/treat lung lesions,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32150,Removal of lung lesion(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32151,Remove lung foreign body,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32160,Open chest heart massage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32200,Drain open lung lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32215,Treat chest lining,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32220,Release of lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32225,Partial release of lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32310,Removal of chest lining,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32320,Free/remove chest lining,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32400,Needle biopsy chest lining,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,32408,Core ndl bx lng/med perq,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,32440,Remove lung pneumonectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32442,Sleeve pneumonectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32445,Removal of lung extrapleural,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32480,Partial removal of lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32482,Bilobectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32484,Segmentectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32486,Sleeve lobectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32488,Completion pneumonectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32491,Lung volume reduction,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32501,Repair bronchus add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32503,Resect apical lung tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32504,Resect apical lung tum/chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32505,Wedge resect of lung initial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32506,Wedge resect of lung add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32507,Wedge resect of lung diag,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32540,Removal of lung lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32550,Insert pleural cath,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Aetna MCR ADV,CPT,32551,Insertion of chest tube,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Aetna MCR ADV,CPT,32552,Remove lung catheter,APC 5181,RVU Per Case,$554.25 ,OP,554.25,"4,314.00",,,,,,
Aetna MCR ADV,CPT,32553,Ins mark thor for rt perq,APC 5613,RVU Per Unit,"$1,291.62 ",OP,"1,291.62","4,314.00",,,,,,
Aetna MCR ADV,CPT,32554,Aspirate pleura w/o imaging,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Aetna MCR ADV,CPT,32555,Aspirate pleura w/ imaging,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Aetna MCR ADV,CPT,32556,Insert cath pleura w/o image,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,32557,Insert cath pleura w/ image,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Aetna MCR ADV,CPT,32560,Treat pleurodesis w/agent,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Aetna MCR ADV,CPT,32561,Lyse chest fibrin init day,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Aetna MCR ADV,CPT,32562,Lyse chest fibrin subq day,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Aetna MCR ADV,CPT,32601,Thoracoscopy diagnostic,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,32604,Thoracoscopy wbx sac,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,32606,Thoracoscopy w/bx med space,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,32607,Thoracoscopy w/bx infiltrate,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,32608,Thoracoscopy w/bx nodule,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,32609,Thoracoscopy w/bx pleura,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,32650,Thoracoscopy w/pleurodesis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32651,Thoracoscopy remove cortex,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32652,Thoracoscopy rem totl cortex,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32653,Thoracoscopy remov fb/fibrin,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32654,Thoracoscopy contrl bleeding,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32655,Thoracoscopy resect bullae,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32656,Thoracoscopy w/pleurectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32658,Thoracoscopy w/sac fb remove,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32659,Thoracoscopy w/sac drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32661,Thoracoscopy w/pericard exc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32662,Thoracoscopy w/mediast exc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32663,Thoracoscopy w/lobectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32664,Thoracoscopy w/ th nrv exc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32665,Thoracoscop w/esoph musc exc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32666,Thoracoscopy w/wedge resect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32667,Thoracoscopy w/w resect addl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32668,Thoracoscopy w/w resect diag,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32669,Thoracoscopy remove segment,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32670,Thoracoscopy bilobectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32671,Thoracoscopy pneumonectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32672,Thoracoscopy for lvrs,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32673,Thoracoscopy w/thymus resect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32674,Thoracoscopy lymph node exc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32800,Repair lung hernia,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32810,Close chest after drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32815,Close bronchial fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32820,Reconstruct injured chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32850,Donor pneumonectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32851,Lung transplant single,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32852,Lung transplant with bypass,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32853,Lung transplant double,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32854,Lung transplant with bypass,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32855,Prepare donor lung single,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32856,Prepare donor lung double,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32900,Removal of rib(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32905,Revise & repair chest wall,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32906,Revise & repair chest wall,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32940,Revision of lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32960,Therapeutic pneumothorax,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Aetna MCR ADV,CPT,32994,Ablate pulm tumor perq crybl,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,32997,Total lung lavage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,32998,Ablate pulm tumor perq rf,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,32999,Chest surgery procedure,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Aetna MCR ADV,CPT,33016,Pericardiocentesis w/imaging,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Aetna MCR ADV,CPT,33017,Prcrd drg 6yr+ w/o cgen car,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33018,Prcrd drg 0-5yr or w/anomly,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33019,Perq prcrd drg insj cath ct,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33020,Incision of heart sac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33025,Incision of heart sac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33030,Partial removal of heart sac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33031,Partial removal of heart sac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33050,Resect heart sac lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33120,Removal of heart lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33130,Removal of heart lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33140,Heart revascularize (tmr),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33141,Heart tmr w/other procedure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33202,Insert epicard eltrd open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33203,Insert epicard eltrd endo,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33206,Insert heart pm atrial,APC 5223,RVU Per Case,"$10,642.67 ",OP,"4,314.00","10,642.67",,,,,,
Aetna MCR ADV,CPT,33207,Insert heart pm ventricular,APC 5223,RVU Per Case,"$10,642.67 ",OP,"4,314.00","10,642.67",,,,,,
Aetna MCR ADV,CPT,33208,Insrt heart pm atrial & vent,APC 5223,RVU Per Case,"$10,642.67 ",OP,"4,314.00","10,642.67",,,,,,
Aetna MCR ADV,CPT,33210,Insert electrd/pm cath sngl,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
Aetna MCR ADV,CPT,33211,Insert card electrodes dual,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
Aetna MCR ADV,CPT,33212,Insert pulse gen sngl lead,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
Aetna MCR ADV,CPT,33213,Insert pulse gen dual leads,APC 5223,RVU Per Case,"$10,642.67 ",OP,"4,314.00","10,642.67",,,,,,
Aetna MCR ADV,CPT,33214,Upgrade of pacemaker system,APC 5223,RVU Per Case,"$10,642.67 ",OP,"4,314.00","10,642.67",,,,,,
Aetna MCR ADV,CPT,33215,Reposition pacing-defib lead,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,33216,Insert 1 electrode pm-defib,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
Aetna MCR ADV,CPT,33217,Insert 2 electrode pm-defib,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
Aetna MCR ADV,CPT,33218,Repair lead pace-defib one,APC 5221,RVU Per Unit,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Aetna MCR ADV,CPT,33220,Repair lead pace-defib dual,APC 5221,RVU Per Unit,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Aetna MCR ADV,CPT,33221,Insert pulse gen mult leads,APC 5224,RVU Per Case,"$19,045.26 ",OP,"4,314.00","19,045.26",,,,,,
Aetna MCR ADV,CPT,33222,Relocation pocket pacemaker,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,33223,Relocate pocket for defib,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,33224,Insert pacing lead & connect,APC 5223,RVU Per Case,"$10,642.67 ",OP,"4,314.00","10,642.67",,,,,,
Aetna MCR ADV,CPT,33226,Reposition l ventric lead,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,33227,Remove&replace pm gen singl,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
Aetna MCR ADV,CPT,33228,Remv&replc pm gen dual lead,APC 5223,RVU Per Case,"$10,642.67 ",OP,"4,140.35","10,642.67",,,,,,
Aetna MCR ADV,CPT,33229,Remv&replc pm gen mult leads,APC 5224,RVU Per Case,"$19,045.26 ",OP,"4,314.00","19,045.26",,,,,,
Aetna MCR ADV,CPT,33230,Insrt pulse gen w/dual leads,APC 5231,RVU Per Case,"$23,577.44 ",OP,"4,314.00","23,577.44",,,,,,
Aetna MCR ADV,CPT,33231,Insrt pulse gen w/mult leads,APC 5232,RVU Per Case,"$33,604.66 ",OP,"4,314.00","33,604.66",,,,,,
Aetna MCR ADV,CPT,33233,Removal of pm generator,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
Aetna MCR ADV,CPT,33234,Removal of pacemaker system,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Aetna MCR ADV,CPT,33235,Removal pacemaker electrode,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Aetna MCR ADV,CPT,33236,Remove electrode/thoracotomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33237,Remove electrode/thoracotomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33238,Remove electrode/thoracotomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33240,Insrt pulse gen w/singl lead,APC 5231,RVU Per Case,"$23,577.44 ",OP,"4,140.35","23,577.44",,,,,,
Aetna MCR ADV,CPT,33241,Remove pulse generator,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Aetna MCR ADV,CPT,33243,Remove eltrd/thoracotomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33244,Remove elctrd transvenously,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Aetna MCR ADV,CPT,33249,Insj/rplcmt defib w/lead(s),APC 5232,RVU Per Case,"$33,604.66 ",OP,"4,140.35","33,604.66",,,,,,
Aetna MCR ADV,CPT,33250,Ablate heart dysrhythm focus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33251,Ablate heart dysrhythm focus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33254,Ablate atria lmtd,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33255,Ablate atria w/o bypass ext,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33256,Ablate atria w/bypass exten,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33257,Ablate atria lmtd add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33258,Ablate atria x10sv add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33259,Ablate atria w/bypass add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33261,Ablate heart dysrhythm focus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33262,Rmvl& replc pulse gen 1 lead,APC 5231,RVU Per Case,"$23,577.44 ",OP,"4,314.00","23,577.44",,,,,,
Aetna MCR ADV,CPT,33263,Rmvl & rplcmt dfb gen 2 lead,APC 5231,RVU Per Case,"$23,577.44 ",OP,"4,140.35","23,577.44",,,,,,
Aetna MCR ADV,CPT,33264,Rmvl & rplcmt dfb gen mlt ld,APC 5232,RVU Per Case,"$33,604.66 ",OP,"4,314.00","33,604.66",,,,,,
Aetna MCR ADV,CPT,33265,Ablate atria lmtd endo,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33266,Ablate atria x10sv endo,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33270,Ins/rep subq defibrillator,APC 5232,RVU Per Case,"$33,604.66 ",OP,"4,314.00","33,604.66",,,,,,
Aetna MCR ADV,CPT,33271,Insj subq impltbl dfb elctrd,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
Aetna MCR ADV,CPT,33272,Rmvl of subq defibrillator,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Aetna MCR ADV,CPT,33273,Repos prev impltbl subq dfb,APC 5221,RVU Per Unit,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Aetna MCR ADV,CPT,33274,Tcat insj/rpl perm ldls pm,APC 5194,RVU Per Case,"$16,438.60 ",OP,"4,314.00","16,438.60",,,,,,
Aetna MCR ADV,CPT,33275,Tcat rmvl perm ldls pm w/img,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,33285,Insj subq car rhythm mntr,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
Aetna MCR ADV,CPT,33286,Rmvl subq car rhythm mntr,APC 5071,RVU Per Case,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,33289,Tcat impl wrls p-art prs snr,APC 5200,RVU Per Case,"$29,487.35 ",OP,"4,314.00","29,487.35",,,,,,
Aetna MCR ADV,CPT,33300,Repair of heart wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33305,Repair of heart wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33310,Exploratory heart surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33315,Exploratory heart surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33320,Repair major blood vessel(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33321,Repair major vessel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33322,Repair major blood vessel(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33330,Insert major vessel graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33335,Insert major vessel graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33340,Perq clsr tcat l atr apndge,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33361,Replace aortic valve perq,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33362,Replace aortic valve open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33363,Replace aortic valve open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33364,Replace aortic valve open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33365,Replace aortic valve open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33366,Trcath replace aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33367,Replace aortic valve w/byp,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33368,Replace aortic valve w/byp,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33369,Replace aortic valve w/byp,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33390,Valvuloplasty aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33391,Valvuloplasty aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33404,Prepare heart-aorta conduit,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33405,Replacement aortic valve opn,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33406,Replacement aortic valve opn,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33410,Replacement aortic valve opn,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33411,Replacement of aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33412,Replacement of aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33413,Replacement of aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33414,Repair of aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33415,Revision subvalvular tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33416,Revise ventricle muscle,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33417,Repair of aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33418,Repair tcat mitral valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33420,Revision of mitral valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33422,Revision of mitral valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33425,Repair of mitral valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33426,Repair of mitral valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33427,Repair of mitral valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33430,Replacement of mitral valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33440,Rplcmt a-valve tlcj autol pv,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33460,Revision of tricuspid valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33463,Valvuloplasty tricuspid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33464,Valvuloplasty tricuspid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33465,Replace tricuspid valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33468,Revision of tricuspid valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33470,Revision of pulmonary valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33471,Valvotomy pulmonary valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33474,Revision of pulmonary valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33475,Replacement pulmonary valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33476,Revision of heart chamber,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33477,Implant tcat pulm vlv perq,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33478,Revision of heart chamber,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33496,Repair prosth valve clot,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33500,Repair heart vessel fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33501,Repair heart vessel fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33502,Coronary artery correction,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33503,Coronary artery graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33504,Coronary artery graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33505,Repair artery w/tunnel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33506,Repair artery translocation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33507,Repair art intramural,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33510,Cabg vein single,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33511,Cabg vein two,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33512,Cabg vein three,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33513,Cabg vein four,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33514,Cabg vein five,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33516,Cabg vein six or more,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33517,Cabg artery-vein single,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33518,Cabg artery-vein two,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33519,Cabg artery-vein three,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33521,Cabg artery-vein four,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33522,Cabg artery-vein five,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33523,Cabg art-vein six or more,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33530,Coronary artery bypass/reop,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33533,Cabg arterial single,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33534,Cabg arterial two,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33535,Cabg arterial three,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33536,Cabg arterial four or more,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33542,Removal of heart lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33545,Repair of heart damage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33548,Restore/remodel ventricle,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33572,Open coronary endarterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33600,Closure of valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33602,Closure of valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33606,Anastomosis/artery-aorta,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33608,Repair anomaly w/conduit,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33610,Repair by enlargement,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33611,Repair double ventricle,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33612,Repair double ventricle,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33615,Repair modified fontan,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33617,Repair single ventricle,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33619,Repair single ventricle,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33620,Apply r&l pulm art bands,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33621,Transthor cath for stent,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33622,Redo compl cardiac anomaly,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33641,Repair heart septum defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33645,Revision of heart veins,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33647,Repair heart septum defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33660,Repair of heart defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33665,Repair of heart defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33670,Repair of heart chambers,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33675,Close mult vsd,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33676,Close mult vsd w/resection,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33677,Cl mult vsd w/rem pul band,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33681,Repair heart septum defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33684,Repair heart septum defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33688,Repair heart septum defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33690,Reinforce pulmonary artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33692,Repair of heart defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33694,Repair of heart defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33697,Repair of heart defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33702,Repair of heart defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33710,Repair of heart defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33720,Repair of heart defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33722,Repair of heart defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33724,Repair venous anomaly,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33726,Repair pul venous stenosis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33730,Repair heart-vein defect(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33732,Repair heart-vein defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33735,Revision of heart chamber,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33736,Revision of heart chamber,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33737,Revision of heart chamber,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33741,Tas congenital car anomal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33745,Tis cgen car anomal 1st shnt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33746,Tis cgen car anomal ea addl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33750,Major vessel shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33755,Major vessel shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33762,Major vessel shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33764,Major vessel shunt & graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33766,Major vessel shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33767,Major vessel shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33768,Cavopulmonary shunting,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33770,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33771,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33774,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33775,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33776,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33777,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33778,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33779,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33780,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33781,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33782,Nikaidoh proc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33783,Nikaidoh proc w/ostia implt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33786,Repair arterial trunk,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33788,Revision of pulmonary artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33800,Aortic suspension,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33802,Repair vessel defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33803,Repair vessel defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33813,Repair septal defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33814,Repair septal defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33820,Revise major vessel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33822,Revise major vessel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33824,Revise major vessel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33840,Remove aorta constriction,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33845,Remove aorta constriction,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33851,Remove aorta constriction,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33852,Repair septal defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33853,Repair septal defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33858,As-aort grf f/aortic dsj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33859,As-aort grf f/ds oth/thn dsj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33863,Ascending aortic graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33864,Ascending aortic graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33871,Transvrs a-arch grf hypthrm,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33875,Thoracic aortic graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33877,Thoracoabdominal graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33880,Endovasc taa repr incl subcl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33881,Endovasc taa repr w/o subcl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33883,Insert endovasc prosth taa,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33884,Endovasc prosth taa add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33886,Endovasc prosth delayed,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33889,Artery transpose/endovas taa,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33891,Car-car bp grft/endovas taa,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33910,Remove lung artery emboli,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33915,Remove lung artery emboli,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33916,Surgery of great vessel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33917,Repair pulmonary artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33920,Repair pulmonary atresia,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33922,Transect pulmonary artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33924,Remove pulmonary shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33925,Rpr pul art unifocal w/o cpb,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33926,Repr pul art unifocal w/cpb,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33927,Impltj tot rplcmt hrt sys,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33928,Rmvl & rplcmt tot hrt sys,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33929,Rmvl rplcmt hrt sys f/trnspl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33930,Removal of donor heart/lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33933,Prepare donor heart/lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33935,Transplantation heart/lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33940,Removal of donor heart,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33944,Prepare donor heart,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33945,Transplantation of heart,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33946,Ecmo/ecls initiation venous,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33947,Ecmo/ecls initiation artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33948,Ecmo/ecls daily mgmt-venous,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33949,Ecmo/ecls daily mgmt artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33951,Ecmo/ecls insj prph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33952,Ecmo/ecls insj prph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33953,Ecmo/ecls insj prph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33954,Ecmo/ecls insj prph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33955,Ecmo/ecls insj ctr cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33956,Ecmo/ecls insj ctr cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33957,Ecmo/ecls repos perph cnula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33958,Ecmo/ecls repos perph cnula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33959,Ecmo/ecls repos perph cnula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33962,Ecmo/ecls repos perph cnula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33963,Ecmo/ecls repos perph cnula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33964,Ecmo/ecls repos perph cnula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33965,Ecmo/ecls rmvl perph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33966,Ecmo/ecls rmvl prph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33967,Insert i-aort percut device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33968,Remove aortic assist device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33969,Ecmo/ecls rmvl perph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33970,Aortic circulation assist,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33971,Aortic circulation assist,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33973,Insert balloon device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33974,Remove intra-aortic balloon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33975,Implant ventricular device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33976,Implant ventricular device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33977,Remove ventricular device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33978,Remove ventricular device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33979,Insert intracorporeal device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33980,Remove intracorporeal device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33981,Replace vad pump ext,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33982,Replace vad intra w/o bp,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33983,Replace vad intra w/bp,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33984,Ecmo/ecls rmvl prph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33985,Ecmo/ecls rmvl ctr cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33986,Ecmo/ecls rmvl ctr cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33987,Artery expos/graft artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33988,Insertion of left heart vent,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33989,Removal of left heart vent,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33990,Insj perq vad l hrt arterial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33991,Insj perq vad l hrt artl&ven,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33992,Rmvl perq left heart vad,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33993,Reposg perq r/l hrt vad,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33995,Insj perq vad r hrt venous,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33997,Rmvl perq right heart vad,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,33999,Cardiac surgery procedure,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Aetna MCR ADV,CPT,34001,Removal of artery clot,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,34051,Removal of artery clot,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,34101,Removal of artery clot,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,34111,Removal of arm artery clot,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,34151,Removal of artery clot,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,34201,Removal of artery clot,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,34203,Removal of leg artery clot,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,34401,Removal of vein clot,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,34421,Removal of vein clot,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,34451,Removal of vein clot,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,34471,Removal of vein clot,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Aetna MCR ADV,CPT,34490,Removal of vein clot,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,34501,Repair valve femoral vein,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,34502,Reconstruct vena cava,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,34510,Transposition of vein valve,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,34520,Cross-over vein graft,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,34530,Leg vein fusion,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,34701,Evasc rpr a-ao ndgft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,34702,Evasc rpr a-ao ndgft rpt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,34703,Evasc rpr a-unilac ndgft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,34704,Evasc rpr a-unilac ndgft rpt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,34705,Evac rpr a-biiliac ndgft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,34706,Evasc rpr a-biiliac rpt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,34707,Evasc rpr ilio-iliac ndgft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,34708,Evasc rpr ilio-iliac rpt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,34709,Plmt xtn prosth evasc rpr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,34710,Dlyd plmt xtn prosth 1st vsl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,34711,Dlyd plmt xtn prosth ea addl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,34712,Tcat dlvr enhncd fixj dev,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,34717,Evasc rpr a-iliac ndgft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,34718,Evasc rpr n/a a-iliac ndgft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,34808,Endovas iliac a device addon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,34812,Opn fem art expos,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,34813,Femoral endovas graft add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,34820,Opn iliac art expos,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,34830,Open aortic tube prosth repr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,34831,Open aortoiliac prosth repr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,34832,Open aortofemor prosth repr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,34833,Opn ilac art expos cndt crtj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,34834,Opn brach art expos,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,34841,Endovasc visc aorta 1 graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,34842,Endovasc visc aorta 2 graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,34843,Endovasc visc aorta 3 graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,34844,Endovasc visc aorta 4 graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,34845,Visc & infraren abd 1 prosth,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,34846,Visc & infraren abd 2 prosth,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,34847,Visc & infraren abd 3 prosth,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,34848,Visc & infraren abd 4+ prost,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35001,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35002,Repair artery rupture neck,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35005,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35011,Repair defect of artery,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,35013,Repair artery rupture arm,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35021,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35022,Repair artery rupture chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35045,Repair defect of arm artery,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,35081,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35082,Repair artery rupture aorta,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35091,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35092,Repair artery rupture aorta,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35102,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35103,Repair artery rupture aorta,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35111,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35112,Repair artery rupture spleen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35121,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35122,Repair artery rupture belly,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35131,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35132,Repair artery rupture groin,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35141,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35142,Repair artery rupture thigh,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35151,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35152,Repair ruptd popliteal art,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35180,Repair blood vessel lesion,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Aetna MCR ADV,CPT,35182,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35184,Repair blood vessel lesion,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,35188,Repair blood vessel lesion,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,35189,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35190,Repair blood vessel lesion,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,35201,Repair blood vessel lesion,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,35206,Repair blood vessel lesion,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,35207,Repair blood vessel lesion,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,35211,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35216,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35221,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35226,Repair blood vessel lesion,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,35231,Repair blood vessel lesion,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,35236,Repair blood vessel lesion,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,35241,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35246,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35251,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35256,Repair blood vessel lesion,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,35261,Repair blood vessel lesion,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,35266,Repair blood vessel lesion,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,35271,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35276,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35281,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35286,Repair blood vessel lesion,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,35301,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35302,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35303,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35304,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35305,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35306,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35311,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35321,Rechanneling of artery,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,35331,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35341,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35351,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35355,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35361,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35363,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35371,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35372,Rechanneling of artery,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,35390,Reoperation carotid add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35400,Angioscopy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35501,Art byp grft ipsilat carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35506,Art byp grft subclav-carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35508,Art byp grft carotid-vertbrl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35509,Art byp grft contral carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35510,Art byp grft carotid-brchial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35511,Art byp grft subclav-subclav,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35512,Art byp grft subclav-brchial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35515,Art byp grft subclav-vertbrl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35516,Art byp grft subclav-axilary,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35518,Art byp grft axillary-axilry,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35521,Art byp grft axill-femoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35522,Art byp grft axill-brachial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35523,Art byp grft brchl-ulnr-rdl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35525,Art byp grft brachial-brchl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35526,Art byp grft aor/carot/innom,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35531,Art byp grft aorcel/aormesen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35533,Art byp grft axill/fem/fem,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35535,Art byp grft hepatorenal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35536,Art byp grft splenorenal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35537,Art byp grft aortoiliac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35538,Art byp grft aortobi-iliac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35539,Art byp grft aortofemoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35540,Art byp grft aortbifemoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35556,Art byp grft fem-popliteal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35558,Art byp grft fem-femoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35560,Art byp grft aortorenal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35563,Art byp grft ilioiliac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35565,Art byp grft iliofemoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35566,Art byp fem-ant-post tib/prl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35570,Art byp tibial-tib/peroneal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35571,Art byp pop-tibl-prl-other,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35583,Vein byp grft fem-popliteal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35585,Vein byp fem-tibial peroneal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35587,Vein byp pop-tibl peroneal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35600,Harvest art for cabg add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35601,Art byp common ipsi carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35606,Art byp carotid-subclavian,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35612,Art byp subclav-subclavian,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35616,Art byp subclav-axillary,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35621,Art byp axillary-femoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35623,Art byp axillary-pop-tibial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35626,Art byp aorsubcl/carot/innom,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35631,Art byp aor-celiac-msn-renal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35632,Art byp ilio-celiac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35633,Art byp ilio-mesenteric,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35634,Art byp iliorenal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35636,Art byp spenorenal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35637,Art byp aortoiliac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35638,Art byp aortobi-iliac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35642,Art byp carotid-vertebral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35645,Art byp subclav-vertebrl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35646,Art byp aortobifemoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35647,Art byp aortofemoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35650,Art byp axillary-axillary,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35654,Art byp axill-fem-femoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35656,Art byp femoral-popliteal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35661,Art byp femoral-femoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35663,Art byp ilioiliac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35665,Art byp iliofemoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35666,Art byp fem-ant-post tib/prl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35671,Art byp pop-tibl-prl-other,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35681,Composite byp grft pros&vein,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35682,Composite byp grft 2 veins,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35683,Composite byp grft 3/> segmt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35691,Art trnsposj vertbrl carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35693,Art trnsposj subclavian,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35694,Art trnsposj subclav carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35695,Art trnsposj carotid subclav,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35697,Reimplant artery each,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35700,Reoperation bypass graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35701,Expl n/flwd surg neck art,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35702,Expl n/flwd surg uxtr art,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35703,Expl n/flwd surg lxtr art,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35800,Explore neck vessels,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,35820,Explore chest vessels,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35840,Explore abdominal vessels,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35860,Explore limb vessels,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,35870,Repair vessel graft defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35875,Removal of clot in graft,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,35876,Removal of clot in graft,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,35879,Revise graft w/vein,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,35881,Revise graft w/vein,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,35883,Revise graft w/nonauto graft,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,35884,Revise graft w/vein,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,35901,Excision graft neck,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35903,Excision graft extremity,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,35905,Excision graft thorax,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,35907,Excision graft abdomen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,36002,Pseudoaneurysm injection trt,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Aetna MCR ADV,CPT,36221,Place cath thoracic aorta,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,36222,Place cath carotid/inom art,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,36223,Place cath carotid/inom art,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,36224,Place cath carotd art,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,36225,Place cath subclavian art,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,36226,Place cath vertebral art,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,36251,Ins cath ren art 1st unilat,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,36252,Ins cath ren art 1st bilat,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,36253,Ins cath ren art 2nd+ unilat,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,36254,Ins cath ren art 2nd+ bilat,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,36260,Insertion of infusion pump,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,36261,Revision of infusion pump,APC 5221,RVU Per Unit,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Aetna MCR ADV,CPT,36262,Removal of infusion pump,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Aetna MCR ADV,CPT,36415,Routine venipuncture,Lab Services,Per Unit,$3.00 ,OP,3,"4,314.00",,,,,,
Aetna MCR ADV,CPT,36420,Vein access cutdown < 1 yr,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Aetna MCR ADV,CPT,36425,Vein access cutdown > 1 yr,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Aetna MCR ADV,CPT,36430,Blood transfusion service,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Aetna MCR ADV,CPT,36440,Bl push transfuse 2 yr/<,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Aetna MCR ADV,CPT,36450,Bl exchange/transfuse nb,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Aetna MCR ADV,CPT,36455,Bl exchange/transfuse non-nb,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Aetna MCR ADV,CPT,36456,Prtl exchange transfuse nb,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Aetna MCR ADV,CPT,36460,Transfusion service fetal,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Aetna MCR ADV,CPT,36465,Njx noncmpnd sclrsnt 1 vein,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,36466,Njx noncmpnd sclrsnt mlt vn,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,36468,Njx sclrsnt spider veins,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,36470,Njx sclrsnt 1 incmptnt vein,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,36471,Njx sclrsnt mlt incmptnt vn,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,36473,Endovenous mchnchem 1st vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,36475,Endovenous rf 1st vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,36478,Endovenous laser 1st vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,36482,Endoven ther chem adhes 1st,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,36511,Apheresis wbc,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
Aetna MCR ADV,CPT,36512,Apheresis rbc,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
Aetna MCR ADV,CPT,36513,Apheresis platelets,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Aetna MCR ADV,CPT,36514,Apheresis plasma,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
Aetna MCR ADV,CPT,36516,Apheresis immunoads slctv,APC 5243,RVU Per Unit,"$4,131.87 ",OP,"4,131.87","4,314.00",,,,,,
Aetna MCR ADV,CPT,36522,Photopheresis,APC 5243,RVU Per Unit,"$4,131.87 ",OP,"4,131.87","4,314.00",,,,,,
Aetna MCR ADV,CPT,36555,Insert non-tunnel cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,36556,Insert non-tunnel cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,36557,Insert tunneled cv cath,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,36558,Insert tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,36560,Insert tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,36561,Insert tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,36563,Insert tunneled cv cath,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,36565,Insert tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,36566,Insert tunneled cv cath,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,36568,Insj picc <5 yr w/o imaging,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Aetna MCR ADV,CPT,36569,Insj picc 5 yr+ w/o imaging,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Aetna MCR ADV,CPT,36570,Insert picvad cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,36571,Insert picvad cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,36572,Insj picc rs&i <5 yr,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Aetna MCR ADV,CPT,36573,Insj picc rs&i 5 yr+,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Aetna MCR ADV,CPT,36575,Repair tunneled cv cath,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Aetna MCR ADV,CPT,36576,Repair tunneled cv cath,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Aetna MCR ADV,CPT,36578,Replace tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,36580,Replace cvad cath,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Aetna MCR ADV,CPT,36581,Replace tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,36582,Replace tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,36583,Replace tunneled cv cath,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,36584,Compl rplcmt picc rs&i,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Aetna MCR ADV,CPT,36585,Replace picvad cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,36589,Removal tunneled cv cath,APC 5181,RVU Per Case,$554.25 ,OP,554.25,"4,314.00",,,,,,
Aetna MCR ADV,CPT,36590,Removal tunneled cv cath,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Aetna MCR ADV,CPT,36591,Draw blood off venous device,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Aetna MCR ADV,CPT,36592,Collect blood from picc,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Aetna MCR ADV,CPT,36593,Declot vascular device,APC 5694,RVU Per Unit,$318.00 ,OP,318,"4,314.00",,,,,,
Aetna MCR ADV,CPT,36595,Mech remov tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,36596,Mech remov tunneled cv cath,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Aetna MCR ADV,CPT,36597,Reposition venous catheter,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Aetna MCR ADV,CPT,36598,Inj w/fluor eval cv device,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,"4,314.00",,,,,,
Aetna MCR ADV,CPT,36600,Withdrawal of arterial blood,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Aetna MCR ADV,CPT,36640,Insertion catheter artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,36660,Insertion catheter artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,36680,Insert needle bone cavity,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Aetna MCR ADV,CPT,36800,Insertion of cannula,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,36810,Insertion of cannula,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,36815,Insertion of cannula,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,36818,Av fuse uppr arm cephalic,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,36819,Av fuse uppr arm basilic,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,36820,Av fusion/forearm vein,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,36821,Av fusion direct any site,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","9,201.00",,,,,,
Aetna MCR ADV,CPT,36823,Insertion of cannula(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,36825,Artery-vein autograft,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,36830,Artery-vein nonautograft,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,36831,Open thrombect av fistula,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,36832,Av fistula revision open,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,36833,Av fistula revision,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,36835,Artery to vein shunt,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,36838,Dist revas ligation hemo,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,36860,External cannula declotting,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Aetna MCR ADV,CPT,36861,Cannula declotting,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,36901,Intro cath dialysis circuit,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Aetna MCR ADV,CPT,36902,Intro cath dialysis circuit,APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,314.00","5,072.43",,,,,,
Aetna MCR ADV,CPT,36903,Intro cath dialysis circuit,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Aetna MCR ADV,CPT,36904,Thrmbc/nfs dialysis circuit,APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,314.00","5,072.43",,,,,,
Aetna MCR ADV,CPT,36905,Thrmbc/nfs dialysis circuit,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Aetna MCR ADV,CPT,36906,Thrmbc/nfs dialysis circuit,APC 5194,RVU Per Case,"$16,438.60 ",OP,"4,140.35","16,438.60",,,,,,
Aetna MCR ADV,CPT,37140,Revision of circulation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,37145,Revision of circulation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,37160,Revision of circulation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,37180,Revision of circulation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,37181,Splice spleen/kidney veins,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,37182,Insert hepatic shunt (tips),APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Aetna MCR ADV,CPT,37183,Remove hepatic shunt (tips),APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,314.00","5,072.43",,,,,,
Aetna MCR ADV,CPT,37184,Prim art m-thrmbc 1st vsl,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Aetna MCR ADV,CPT,37187,Venous mech thrombectomy,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
Aetna MCR ADV,CPT,37188,Ven mechnl thrmbc repeat tx,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,37191,Ins endovas vena cava filtr,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,37192,Redo endovas vena cava filtr,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,37193,Rem endovas vena cava filter,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,37195,Thrombolytic therapy stroke,APC 5694,RVU Per Unit,$318.00 ,OP,318,"4,314.00",,,,,,
Aetna MCR ADV,CPT,37197,Remove intrvas foreign body,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,37200,Transcatheter biopsy,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,37211,Thrombolytic art therapy,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,37212,Thrombolytic venous therapy,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,37213,Thromblytic art/ven therapy,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,37214,Cessj therapy cath removal,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,37215,Transcath stent cca w/eps,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,37217,Stent placemt retro carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,37218,Stent placemt ante carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,37220,Iliac revasc,APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,314.00","5,072.43",,,,,,
Aetna MCR ADV,CPT,37221,Iliac revasc w/stent,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
Aetna MCR ADV,CPT,37224,Fem/popl revas w/tla,APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,314.00","5,072.43",,,,,,
Aetna MCR ADV,CPT,37225,Fem/popl revas w/ather,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Aetna MCR ADV,CPT,37226,Fem/popl revasc w/stent,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
Aetna MCR ADV,CPT,37227,Fem/popl revasc stnt & ather,APC 5194,RVU Per Case,"$16,438.60 ",OP,"4,314.00","16,438.60",,,,,,
Aetna MCR ADV,CPT,37228,Tib/per revasc w/tla,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Aetna MCR ADV,CPT,37229,Tib/per revasc w/ather,APC 5194,RVU Per Case,"$16,438.60 ",OP,"4,314.00","16,438.60",,,,,,
Aetna MCR ADV,CPT,37230,Tib/per revasc w/stent,APC 5194,RVU Per Case,"$16,438.60 ",OP,"4,314.00","16,438.60",,,,,,
Aetna MCR ADV,CPT,37231,Tib/per revasc stent & ather,APC 5194,RVU Per Case,"$16,438.60 ",OP,"4,314.00","16,438.60",,,,,,
Aetna MCR ADV,CPT,37236,Open/perq place stent 1st,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Aetna MCR ADV,CPT,37238,Open/perq place stent same,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
Aetna MCR ADV,CPT,37241,Vasc embolize/occlude venous,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Aetna MCR ADV,CPT,37242,Vasc embolize/occlude artery,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
Aetna MCR ADV,CPT,37243,Vasc embolize/occlude organ,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Aetna MCR ADV,CPT,37244,Vasc embolize/occlude bleed,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
Aetna MCR ADV,CPT,37246,Trluml balo angiop 1st art,APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,314.00","5,072.43",,,,,,
Aetna MCR ADV,CPT,37248,Trluml balo angiop 1st vein,APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,314.00","5,072.43",,,,,,
Aetna MCR ADV,CPT,37500,Endoscopy ligate perf veins,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,37501,Vascular endoscopy procedure,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Aetna MCR ADV,CPT,37565,Ligation of neck vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,37600,Ligation of neck artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,37605,Ligation of neck artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,37606,Ligation of neck artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,37607,Ligation of a-v fistula,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,37609,Temporal artery procedure,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,37615,Ligation of neck artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,37616,Ligation of chest artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,37617,Ligation of abdomen artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,37618,Ligation of extremity artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,37619,Ligation of inf vena cava,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,37650,Revision of major vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,37660,Revision of major vein,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,37700,Revise leg vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,37718,Ligate/strip short leg vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,37722,Ligate/strip long leg vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,37735,Removal of leg veins/lesion,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,37760,Ligate leg veins radical,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,37761,Ligate leg veins open,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,37765,Stab phleb veins xtr 10-20,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,37766,Phleb veins - extrem 20+,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,37780,Revision of leg vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,37785,Ligate/divide/excise vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,37788,Revascularization penis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,37790,Penile venous occlusion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,37799,Vascular surgery procedure,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Aetna MCR ADV,CPT,38100,Removal of spleen total,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,38101,Removal of spleen partial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,38102,Removal of spleen total,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,38115,Repair of ruptured spleen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,38120,Laparoscopy splenectomy,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Aetna MCR ADV,CPT,38129,Laparoscope proc spleen,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,38206,Harvest auto stem cells,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
Aetna MCR ADV,CPT,38207,Cryopreserve stem cells,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Aetna MCR ADV,CPT,38208,Thaw preserved stem cells,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Aetna MCR ADV,CPT,38209,Wash harvest stem cells,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Aetna MCR ADV,CPT,38210,T-cell depletion of harvest,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Aetna MCR ADV,CPT,38211,Tumor cell deplete of harvst,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Aetna MCR ADV,CPT,38212,Rbc depletion of harvest,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Aetna MCR ADV,CPT,38213,Platelet deplete of harvest,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Aetna MCR ADV,CPT,38214,Volume deplete of harvest,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Aetna MCR ADV,CPT,38215,Harvest stem cell concentrte,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Aetna MCR ADV,CPT,38220,Dx bone marrow aspirations,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,38221,Dx bone marrow biopsies,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,38222,Dx bone marrow bx & aspir,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,38230,Bone marrow harvest allogen,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
Aetna MCR ADV,CPT,38232,Bone marrow harvest autolog,APC 5243,RVU Per Unit,"$4,131.87 ",OP,"4,131.87","4,314.00",,,,,,
Aetna MCR ADV,CPT,38240,Transplt allo hct/donor,APC 5244,RVU Per Case,"$32,580.57 ",OP,"4,314.00","32,580.57",,,,,,
Aetna MCR ADV,CPT,38241,Transplt autol hct/donor,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
Aetna MCR ADV,CPT,38242,Transplt allo lymphocytes,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
Aetna MCR ADV,CPT,38243,Transplj hematopoietic boost,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
Aetna MCR ADV,CPT,38300,Drainage lymph node lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,38305,Drainage lymph node lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,38308,Incision of lymph channels,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,38380,Thoracic duct procedure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,38381,Thoracic duct procedure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,38382,Thoracic duct procedure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,38500,Biopsy/removal lymph nodes,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,38505,Needle biopsy lymph nodes,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,38510,Biopsy/removal lymph nodes,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,38520,Biopsy/removal lymph nodes,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,38525,Biopsy/removal lymph nodes,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,38530,Biopsy/removal lymph nodes,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,38531,Open bx/exc inguinofem nodes,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,38542,Explore deep node(s) neck,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,38550,Removal neck/armpit lesion,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,38555,Removal neck/armpit lesion,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
Aetna MCR ADV,CPT,38562,Removal pelvic lymph nodes,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Aetna MCR ADV,CPT,38564,Removal abdomen lymph nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,38570,Laparoscopy lymph node biop,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,38571,Laparoscopy lymphadenectomy,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,38572,Laparoscopy lymphadenectomy,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,38573,Laps pelvic lymphadec,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,38589,Laparoscope proc lymphatic,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,38700,Removal of lymph nodes neck,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
Aetna MCR ADV,CPT,38720,Removal of lymph nodes neck,APC 5093,RVU Per Case,"$9,128.05 ",OP,"4,314.00","9,128.05",,,,,,
Aetna MCR ADV,CPT,38724,Removal of lymph nodes neck,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,38740,Remove armpit lymph nodes,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,38745,Remove armpit lymph nodes,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,38746,Remove thoracic lymph nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,38747,Remove abdominal lymph nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,38760,Remove groin lymph nodes,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
Aetna MCR ADV,CPT,38765,Remove groin lymph nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,38770,Remove pelvis lymph nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,38780,Remove abdomen lymph nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,38792,Ra tracer id of sentinl node,APC 5591,RVU Per Case,$385.91 ,OP,385.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,38999,Blood/lymph system procedure,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Aetna MCR ADV,CPT,39000,Exploration of chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,39010,Exploration of chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,39200,Resect mediastinal cyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,39220,Resect mediastinal tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,39401,Mediastinoscpy w/medstnl bx,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,39402,Mediastinoscpy w/lmph nod bx,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,39499,Chest procedure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,39501,Repair diaphragm laceration,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,39503,Repair of diaphragm hernia,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,39540,Repair of diaphragm hernia,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,39541,Repair of diaphragm hernia,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,39545,Revision of diaphragm,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,39560,Resect diaphragm simple,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,39561,Resect diaphragm complex,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,39599,Diaphragm surgery procedure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,40490,Biopsy of lip,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Aetna MCR ADV,CPT,40500,Partial excision of lip,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,40510,Partial excision of lip,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,40520,Partial excision of lip,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,40525,Reconstruct lip with flap,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,40527,Reconstruct lip with flap,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,40530,Partial removal of lip,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,40650,Repair lip,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,40652,Repair lip,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,40654,Repair lip,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,40700,Repair cleft lip/nasal,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,40701,Repair cleft lip/nasal,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,40702,Repair cleft lip/nasal,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,40720,Repair cleft lip/nasal,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,40761,Repair cleft lip/nasal,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,40799,Lip surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Aetna MCR ADV,CPT,40800,Drainage of mouth lesion,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,40801,Drainage of mouth lesion,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,40804,Removal foreign body mouth,APC 5301,RVU Per Case,$828.48 ,OP,828.48,"4,314.00",,,,,,
Aetna MCR ADV,CPT,40805,Removal foreign body mouth,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,40806,Incision of lip fold,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,40808,Biopsy of mouth lesion,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,40810,Excision of mouth lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,40812,Excise/repair mouth lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,40814,Excise/repair mouth lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,40816,Excision of mouth lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,40818,Excise oral mucosa for graft,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,40819,Excise lip or cheek fold,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,40820,Treatment of mouth lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,40830,Repair mouth laceration,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Aetna MCR ADV,CPT,40831,Repair mouth laceration,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,40840,Reconstruction of mouth,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,40842,Reconstruction of mouth,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,40843,Reconstruction of mouth,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,40844,Reconstruction of mouth,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,40845,Reconstruction of mouth,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,40899,Mouth surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Aetna MCR ADV,CPT,41000,Drainage of mouth lesion,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,41005,Drainage of mouth lesion,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Aetna MCR ADV,CPT,41006,Drainage of mouth lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,41007,Drainage of mouth lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,41008,Drainage of mouth lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,41009,Drainage of mouth lesion,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,41010,Incision of tongue fold,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,41015,Drainage of mouth lesion,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,41016,Drainage of mouth lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,41017,Drainage of mouth lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,41018,Drainage of mouth lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,41019,Place needles h&n for rt,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,41100,Biopsy of tongue,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,41105,Biopsy of tongue,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,41108,Biopsy of floor of mouth,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,41110,Excision of tongue lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,41112,Excision of tongue lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,41113,Excision of tongue lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,41114,Excision of tongue lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,41115,Excision of tongue fold,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,41116,Excision of mouth lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,41120,Partial removal of tongue,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,41130,Partial removal of tongue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,41135,Tongue and neck surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,41140,Removal of tongue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,41145,Tongue removal neck surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,41150,Tongue mouth jaw surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,41153,Tongue mouth neck surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,41155,Tongue jaw & neck surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,41250,Repair tongue laceration,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Aetna MCR ADV,CPT,41251,Repair tongue laceration,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Aetna MCR ADV,CPT,41252,Repair tongue laceration,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Aetna MCR ADV,CPT,41510,Tongue to lip surgery,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,41512,Tongue suspension,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,41520,Reconstruction tongue fold,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,41530,Tongue base vol reduction,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,41599,Tongue and mouth surgery,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Aetna MCR ADV,CPT,41800,Drainage of gum lesion,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Aetna MCR ADV,CPT,41805,Removal foreign body gum,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,41806,Removal foreign body jawbone,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,41820,Excision gum each quadrant,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,41821,Excision of gum flap,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,41822,Excision of gum lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,41823,Excision of gum lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,41825,Excision of gum lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,41826,Excision of gum lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,41827,Excision of gum lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,41828,Excision of gum lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,41830,Removal of gum tissue,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,41850,Treatment of gum lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,41870,Gum graft,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,41872,Repair gum,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,41874,Repair tooth socket,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,41899,Dental surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Aetna MCR ADV,CPT,42000,Drainage mouth roof lesion,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Aetna MCR ADV,CPT,42100,Biopsy roof of mouth,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,42104,Excision lesion mouth roof,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,42106,Excision lesion mouth roof,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,42107,Excision lesion mouth roof,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,42120,Remove palate/lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,42140,Excision of uvula,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,42145,Repair palate pharynx/uvula,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,42160,Treatment mouth roof lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,42180,Repair palate,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,42182,Repair palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,42200,Reconstruct cleft palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,42205,Reconstruct cleft palate,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,42210,Reconstruct cleft palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,42215,Reconstruct cleft palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,42220,Reconstruct cleft palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,42225,Reconstruct cleft palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,42226,Lengthening of palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,42227,Lengthening of palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,42235,Repair palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,42260,Repair nose to lip fistula,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,42280,Preparation palate mold,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,42281,Insertion palate prosthesis,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,42299,Palate/uvula surgery,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Aetna MCR ADV,CPT,42300,Drainage of salivary gland,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,42305,Drainage of salivary gland,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,42310,Drainage of salivary gland,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,42320,Drainage of salivary gland,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,42330,Removal of salivary stone,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,42335,Removal of salivary stone,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,42340,Removal of salivary stone,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,42400,Biopsy of salivary gland,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,42405,Biopsy of salivary gland,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,42408,Excision of salivary cyst,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,42409,Drainage of salivary cyst,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,42410,Excise parotid gland/lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,42415,Excise parotid gland/lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,42420,Excise parotid gland/lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,42425,Excise parotid gland/lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,42426,Excise parotid gland/lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,42440,Excise submaxillary gland,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,42450,Excise sublingual gland,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,42500,Repair salivary duct,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,42505,Repair salivary duct,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,42507,Parotid duct diversion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,42509,Parotid duct diversion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,42510,Parotid duct diversion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,42600,Closure of salivary fistula,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,42650,Dilation of salivary duct,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,42660,Dilation of salivary duct,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,42665,Ligation of salivary duct,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,42699,Salivary surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Aetna MCR ADV,CPT,42700,Drainage of tonsil abscess,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Aetna MCR ADV,CPT,42720,Drainage of throat abscess,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,42725,Drainage of throat abscess,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,42800,Biopsy of throat,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,42804,Biopsy of upper nose/throat,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,42806,Biopsy of upper nose/throat,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,42808,Excise pharynx lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,42809,Remove pharynx foreign body,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Aetna MCR ADV,CPT,42810,Excision of neck cyst,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,42815,Excision of neck cyst,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,42820,Remove tonsils and adenoids,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,42821,Remove tonsils and adenoids,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,42825,Removal of tonsils,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,42826,Removal of tonsils,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,42830,Removal of adenoids,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,42831,Removal of adenoids,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,42835,Removal of adenoids,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,42836,Removal of adenoids,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,42842,Extensive surgery of throat,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,42844,Extensive surgery of throat,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,42845,Extensive surgery of throat,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,42860,Excision of tonsil tags,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,42870,Excision of lingual tonsil,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,42890,Partial removal of pharynx,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,42892,Revision of pharyngeal walls,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,42894,Revision of pharyngeal walls,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,42900,Repair throat wound,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,42950,Reconstruction of throat,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,42953,Repair throat esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,42955,Surgical opening of throat,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,42960,Control throat bleeding,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,42961,Control throat bleeding,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,42962,Control throat bleeding,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,42970,Control nose/throat bleeding,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Aetna MCR ADV,CPT,42971,Control nose/throat bleeding,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,42972,Control nose/throat bleeding,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,42999,Throat surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Aetna MCR ADV,CPT,43020,Incision of esophagus,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,43030,Throat muscle surgery,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,43045,Incision of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43100,Excision of esophagus lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43101,Excision of esophagus lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43107,Removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43108,Removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43112,Esphg tot w/thrcm,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43113,Removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43116,Partial removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43117,Partial removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43118,Partial removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43121,Partial removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43122,Partial removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43123,Partial removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43124,Removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43130,Removal of esophagus pouch,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,43135,Removal of esophagus pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43180,Esophagoscopy rigid trnso,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,43191,Esophagoscopy rigid trnso dx,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,43192,Esophagoscp rig trnso inject,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,43193,Esophagoscp rig trnso biopsy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,43194,Esophagoscp rig trnso rem fb,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,43195,Esophagoscopy rigid balloon,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Aetna MCR ADV,CPT,43196,Esophagoscp guide wire dilat,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Aetna MCR ADV,CPT,43197,Esophagoscopy flex dx brush,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Aetna MCR ADV,CPT,43198,Esophagosc flex trnsn biopsy,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Aetna MCR ADV,CPT,43200,Esophagoscopy flexible brush,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Aetna MCR ADV,CPT,43201,Esoph scope w/submucous inj,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,43202,Esophagoscopy flex biopsy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,43204,Esoph scope w/sclerosis inj,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,43205,Esophagus endoscopy/ligation,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,43206,Esoph optical endomicroscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,43210,Egd esophagogastrc fndoplsty,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Aetna MCR ADV,CPT,43211,Esophagoscop mucosal resect,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,43212,Esophagoscop stent placement,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Aetna MCR ADV,CPT,43213,Esophagoscopy retro balloon,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,43214,Esophagosc dilate balloon 30,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,43215,Esophagoscopy flex remove fb,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,43216,Esophagoscopy lesion removal,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,43217,Esophagoscopy snare les remv,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,43220,Esophagoscopy balloon <30mm,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,43226,Esoph endoscopy dilation,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,43227,Esophagoscopy control bleed,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,43229,Esophagoscopy lesion ablate,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Aetna MCR ADV,CPT,43231,Esophagoscop ultrasound exam,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,43232,Esophagoscopy w/us needle bx,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,43233,Egd balloon dil esoph30 mm/>,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,43235,Egd diagnostic brush wash,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Aetna MCR ADV,CPT,43236,Uppr gi scope w/submuc inj,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Aetna MCR ADV,CPT,43237,Endoscopic us exam esoph,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,43238,Egd us fine needle bx/aspir,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,43239,Egd biopsy single/multiple,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Aetna MCR ADV,CPT,43240,Egd w/transmural drain cyst,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Aetna MCR ADV,CPT,43241,Egd tube/cath insertion,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,43242,Egd us fine needle bx/aspir,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,43243,Egd injection varices,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,43244,Egd varices ligation,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,43245,Egd dilate stricture,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,43246,Egd place gastrostomy tube,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,43247,Egd remove foreign body,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Aetna MCR ADV,CPT,43248,Egd guide wire insertion,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Aetna MCR ADV,CPT,43249,Esoph egd dilation <30 mm,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,43250,Egd cautery tumor polyp,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,43251,Egd remove lesion snare,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,43252,Egd optical endomicroscopy,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Aetna MCR ADV,CPT,43253,Egd us transmural injxn/mark,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,43254,Egd endo mucosal resection,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,43255,Egd control bleeding any,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,43257,Egd w/thrml txmnt gerd,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Aetna MCR ADV,CPT,43259,Egd us exam duodenum/jejunum,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,43260,Ercp w/specimen collection,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Aetna MCR ADV,CPT,43261,Endo cholangiopancreatograph,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Aetna MCR ADV,CPT,43262,Endo cholangiopancreatograph,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Aetna MCR ADV,CPT,43263,Ercp sphincter pressure meas,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Aetna MCR ADV,CPT,43264,Ercp remove duct calculi,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Aetna MCR ADV,CPT,43265,Ercp lithotripsy calculi,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Aetna MCR ADV,CPT,43266,Egd endoscopic stent place,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Aetna MCR ADV,CPT,43270,Egd lesion ablation,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,43274,Ercp duct stent placement,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Aetna MCR ADV,CPT,43275,Ercp remove forgn body duct,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Aetna MCR ADV,CPT,43276,Ercp stent exchange w/dilate,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Aetna MCR ADV,CPT,43277,Ercp ea duct/ampulla dilate,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Aetna MCR ADV,CPT,43278,Ercp lesion ablate w/dilate,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Aetna MCR ADV,CPT,43279,Lap myotomy heller,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43280,Laparoscopy fundoplasty,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Aetna MCR ADV,CPT,43281,Lap paraesophag hern repair,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Aetna MCR ADV,CPT,43282,Lap paraesoph her rpr w/mesh,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Aetna MCR ADV,CPT,43283,Lap esoph lengthening,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43284,Laps esophgl sphnctr agmntj,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Aetna MCR ADV,CPT,43285,Rmvl esophgl sphnctr dev,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,43286,Esphg tot w/laps moblj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43287,Esphg dstl 2/3 w/laps moblj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43288,Esphg thrsc moblj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43289,Laparoscope proc esoph,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,43300,Repair of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43305,Repair esophagus and fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43310,Repair of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43312,Repair esophagus and fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43313,Esophagoplasty congenital,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43314,Tracheo-esophagoplasty cong,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43320,Fuse esophagus & stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43325,Revise esophagus & stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43327,Esoph fundoplasty lap,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43328,Esoph fundoplasty thor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43330,Esophagomyotomy abdominal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43331,Esophagomyotomy thoracic,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43332,Transab esoph hiat hern rpr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43333,Transab esoph hiat hern rpr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43334,Transthor diaphrag hern rpr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43335,Transthor diaphrag hern rpr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43336,Thorabd diaphr hern repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43337,Thorabd diaphr hern repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43338,Esoph lengthening,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43340,Fuse esophagus & intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43341,Fuse esophagus & intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43351,Surgical opening esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43352,Surgical opening esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43360,Gastrointestinal repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43361,Gastrointestinal repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43400,Ligate esophagus veins,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43405,Ligate/staple esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43410,Repair esophagus wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43415,Repair esophagus wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43420,Repair esophagus opening,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,43425,Repair esophagus opening,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43450,Dilate esophagus 1/mult pass,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Aetna MCR ADV,CPT,43453,Dilate esophagus,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,43460,Pressure treatment esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43496,Free jejunum flap microvasc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43499,Esophagus surgery procedure,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Aetna MCR ADV,CPT,43500,Surgical opening of stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43501,Surgical repair of stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43502,Surgical repair of stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43510,Surgical opening of stomach,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Aetna MCR ADV,CPT,43520,Incision of pyloric muscle,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43605,Biopsy of stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43610,Excision of stomach lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43611,Excision of stomach lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43620,Removal of stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43621,Removal of stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43622,Removal of stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43631,Removal of stomach partial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43632,Removal of stomach partial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43633,Removal of stomach partial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43634,Removal of stomach partial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43635,Removal of stomach partial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43640,Vagotomy & pylorus repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43641,Vagotomy & pylorus repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43644,Lap gastric bypass/roux-en-y,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43645,Lap gastr bypass incl smll i,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43647,Lap impl electrode antrum,APC 5463,RVU Per Case,"$11,498.23 ",OP,"4,314.00","11,498.23",,,,,,
Aetna MCR ADV,CPT,43648,Lap revise/remv eltrd antrum,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,43651,Laparoscopy vagus nerve,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,43652,Laparoscopy vagus nerve,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,43653,Laparoscopy gastrostomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,43659,Laparoscope proc stom,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,43752,Nasal/orogastric w/tube plmt,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Aetna MCR ADV,CPT,43753,Tx gastro intub w/asp,APC 5722,RVU Per Case,$270.61 ,OP,270.61,"4,314.00",,,,,,
Aetna MCR ADV,CPT,43754,Dx gastr intub w/asp spec,APC 5722,RVU Per Case,$270.61 ,OP,270.61,"4,314.00",,,,,,
Aetna MCR ADV,CPT,43755,Dx gastr intub w/asp specs,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,"4,314.00",,,,,,
Aetna MCR ADV,CPT,43756,Dx duod intub w/asp spec,APC 5301,RVU Per Case,$828.48 ,OP,828.48,"4,314.00",,,,,,
Aetna MCR ADV,CPT,43757,Dx duod intub w/asp specs,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Aetna MCR ADV,CPT,43761,Reposition gastrostomy tube,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Aetna MCR ADV,CPT,43762,Rplc gtube no revj trc,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Aetna MCR ADV,CPT,43763,Rplc gtube revj gstrst trc,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Aetna MCR ADV,CPT,43770,Lap place gastr adj device,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,43771,Lap revise gastr adj device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43772,Lap rmvl gastr adj device,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Aetna MCR ADV,CPT,43773,Lap replace gastr adj device,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,43774,Lap rmvl gastr adj all parts,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Aetna MCR ADV,CPT,43775,Lap sleeve gastrectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43800,Reconstruction of pylorus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43810,Fusion of stomach and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43820,Fusion of stomach and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43825,Fusion of stomach and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43830,Place gastrostomy tube,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,43831,Place gastrostomy tube,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Aetna MCR ADV,CPT,43832,Place gastrostomy tube,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43840,Repair of stomach lesion,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Aetna MCR ADV,CPT,43843,Gastroplasty w/o v-band,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43845,Gastroplasty duodenal switch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43846,Gastric bypass for obesity,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43847,Gastric bypass incl small i,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43848,Revision gastroplasty,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43850,Revise stomach-bowel fusion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43855,Revise stomach-bowel fusion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43860,Revise stomach-bowel fusion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43865,Revise stomach-bowel fusion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43870,Repair stomach opening,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Aetna MCR ADV,CPT,43880,Repair stomach-bowel fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43881,Impl/redo electrd antrum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43882,Revise/remove electrd antrum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,43886,Revise gastric port open,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,43887,Remove gastric port open,APC 5054,RVU Per Case,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,43888,Change gastric port open,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,43999,Stomach surgery procedure,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Aetna MCR ADV,CPT,44005,Freeing of bowel adhesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44010,Incision of small bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44015,Insert needle cath bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44020,Explore small intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44021,Decompress small bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44025,Incision of large bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44050,Reduce bowel obstruction,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44055,Correct malrotation of bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44100,Biopsy of bowel,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Aetna MCR ADV,CPT,44110,Excise intestine lesion(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44111,Excision of bowel lesion(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44120,Removal of small intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44121,Removal of small intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44125,Removal of small intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44126,Enterectomy w/o taper cong,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44127,Enterectomy w/taper cong,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44128,Enterectomy cong add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44130,Bowel to bowel fusion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44132,Enterectomy cadaver donor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44133,Enterectomy live donor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44135,Intestine transplnt cadaver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44136,Intestine transplant live,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44137,Remove intestinal allograft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44139,Mobilization of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44140,Partial removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44141,Partial removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44143,Partial removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44144,Partial removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44145,Partial removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44146,Partial removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44147,Partial removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44150,Removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44151,Removal of colon/ileostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44155,Removal of colon/ileostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44156,Removal of colon/ileostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44157,Colectomy w/ileoanal anast,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44158,Colectomy w/neo-rectum pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44160,Removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44180,Lap enterolysis,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,44186,Lap jejunostomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,44187,Lap ileo/jejuno-stomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44188,Lap colostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44202,Lap enterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44203,Lap resect s/intestine addl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44204,Laparo partial colectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44205,Lap colectomy part w/ileum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44206,Lap part colectomy w/stoma,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44207,L colectomy/coloproctostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44208,L colectomy/coloproctostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44210,Laparo total proctocolectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44211,Lap colectomy w/proctectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44212,Laparo total proctocolectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44213,Lap mobil splenic fl add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44227,Lap close enterostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44238,Laparoscope proc intestine,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,44300,Open bowel to skin,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,44310,Ileostomy/jejunostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44312,Revision of ileostomy,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,44314,Revision of ileostomy,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,44316,Devise bowel pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44320,Colostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44322,Colostomy with biopsies,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44340,Revision of colostomy,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Aetna MCR ADV,CPT,44345,Revision of colostomy,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Aetna MCR ADV,CPT,44346,Revision of colostomy,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Aetna MCR ADV,CPT,44360,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,44361,Small bowel endoscopy/biopsy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,44363,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,44364,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,44365,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,44366,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,44369,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,44370,Small bowel endoscopy/stent,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Aetna MCR ADV,CPT,44372,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,44373,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,44376,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,44377,Small bowel endoscopy/biopsy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,44378,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,44379,S bowel endoscope w/stent,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Aetna MCR ADV,CPT,44380,Small bowel endoscopy br/wa,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Aetna MCR ADV,CPT,44381,Small bowel endoscopy br/wa,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,44382,Small bowel endoscopy,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Aetna MCR ADV,CPT,44384,Small bowel endoscopy,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Aetna MCR ADV,CPT,44385,Endoscopy of bowel pouch,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Aetna MCR ADV,CPT,44386,Endoscopy bowel pouch/biop,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Aetna MCR ADV,CPT,44388,Colonoscopy thru stoma spx,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Aetna MCR ADV,CPT,44389,Colonoscopy with biopsy,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,44390,Colonoscopy for foreign body,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Aetna MCR ADV,CPT,44391,Colonoscopy for bleeding,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,44392,Colonoscopy & polypectomy,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,44394,Colonoscopy w/snare,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,44401,Colonoscopy with ablation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,44402,Colonoscopy w/stent plcmt,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Aetna MCR ADV,CPT,44403,Colonoscopy w/resection,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,44404,Colonoscopy w/injection,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,44405,Colonoscopy w/dilation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,44406,Colonoscopy w/ultrasound,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,44407,Colonoscopy w/ndl aspir/bx,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,44408,Colonoscopy w/decompression,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Aetna MCR ADV,CPT,44500,Intro gastrointestinal tube,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Aetna MCR ADV,CPT,44602,Suture small intestine,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Aetna MCR ADV,CPT,44603,Suture small intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44604,Suture large intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44605,Repair of bowel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44615,Intestinal stricturoplasty,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44620,Repair bowel opening,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44625,Repair bowel opening,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44626,Repair bowel opening,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44640,Repair bowel-skin fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44650,Repair bowel fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44660,Repair bowel-bladder fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44661,Repair bowel-bladder fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44680,Surgical revision intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44700,Suspend bowel w/prosthesis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44715,Prepare donor intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44720,Prep donor intestine/venous,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44721,Prep donor intestine/artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44799,Unlisted px small intestine,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Aetna MCR ADV,CPT,44800,Excision of bowel pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44820,Excision of mesentery lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44850,Repair of mesentery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44899,Bowel surgery procedure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44900,Drain appendix abscess open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44950,Appendectomy,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Aetna MCR ADV,CPT,44960,Appendectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,44970,Laparoscopy appendectomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,44979,Laparoscope proc app,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,45000,Drainage of pelvic abscess,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,45005,Drainage of rectal abscess,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,45020,Drainage of rectal abscess,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,45100,Biopsy of rectum,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,45108,Removal of anorectal lesion,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,45110,Removal of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,45111,Partial removal of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,45112,Removal of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,45113,Partial proctectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,45114,Partial removal of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,45116,Partial removal of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,45119,Remove rectum w/reservoir,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,45120,Removal of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,45121,Removal of rectum and colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,45123,Partial proctectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,45126,Pelvic exenteration,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,45130,Excision of rectal prolapse,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,45135,Excision of rectal prolapse,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,45136,Excise ileoanal reservior,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,45150,Excision of rectal stricture,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,45160,Excision of rectal lesion,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,45171,Exc rect tum transanal part,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,45172,Exc rect tum transanal full,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,45190,Destruction rectal tumor,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,45300,Proctosigmoidoscopy dx,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Aetna MCR ADV,CPT,45303,Proctosigmoidoscopy dilate,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,45305,Proctosigmoidoscopy w/bx,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,45307,Proctosigmoidoscopy fb,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,45308,Proctosigmoidoscopy removal,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,45309,Proctosigmoidoscopy removal,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,45315,Proctosigmoidoscopy removal,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,45317,Proctosigmoidoscopy bleed,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,45320,Proctosigmoidoscopy ablate,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,45321,Proctosigmoidoscopy volvul,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,45327,Proctosigmoidoscopy w/stent,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Aetna MCR ADV,CPT,45330,Diagnostic sigmoidoscopy,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Aetna MCR ADV,CPT,45331,Sigmoidoscopy and biopsy,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Aetna MCR ADV,CPT,45332,Sigmoidoscopy w/fb removal,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,45333,Sigmoidoscopy & polypectomy,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Aetna MCR ADV,CPT,45334,Sigmoidoscopy for bleeding,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,45335,Sigmoidoscopy w/submuc inj,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Aetna MCR ADV,CPT,45337,Sigmoidoscopy & decompress,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Aetna MCR ADV,CPT,45338,Sigmoidoscopy w/tumr remove,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,45340,Sig w/tndsc balloon dilation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,45341,Sigmoidoscopy w/ultrasound,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Aetna MCR ADV,CPT,45342,Sigmoidoscopy w/us guide bx,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,45346,Sigmoidoscopy w/ablation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,45347,Sigmoidoscopy w/plcmt stent,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Aetna MCR ADV,CPT,45349,Sigmoidoscopy w/resection,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,45350,Sgmdsc w/band ligation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,45378,Diagnostic colonoscopy,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Aetna MCR ADV,CPT,45379,Colonoscopy w/fb removal,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,45380,Colonoscopy and biopsy,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,45381,Colonoscopy submucous njx,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,45382,Colonoscopy w/control bleed,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,45384,Colonoscopy w/lesion removal,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,45385,Colonoscopy w/lesion removal,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,45386,Colonoscopy w/balloon dilat,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,45388,Colonoscopy w/ablation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,45389,Colonoscopy w/stent plcmt,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Aetna MCR ADV,CPT,45390,Colonoscopy w/resection,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,45391,Colonoscopy w/endoscope us,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,45392,Colonoscopy w/endoscopic fnb,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,45393,Colonoscopy w/decompression,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,45395,Lap removal of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,45397,Lap remove rectum w/pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,45398,Colonoscopy w/band ligation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,45399,Unlisted procedure colon,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Aetna MCR ADV,CPT,45400,Laparoscopic proc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,45402,Lap proctopexy w/sig resect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,45499,Laparoscope proc rectum,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,45500,Repair of rectum,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,45505,Repair of rectum,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,45520,Treatment of rectal prolapse,APC 5311,RVU Per Case,$812.16 ,OP,812.16,"4,314.00",,,,,,
Aetna MCR ADV,CPT,45540,Correct rectal prolapse,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,45541,Correct rectal prolapse,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,45550,Repair rectum/remove sigmoid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,45560,Repair of rectocele,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,45562,Exploration/repair of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,45563,Exploration/repair of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,45800,Repair rect/bladder fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,45805,Repair fistula w/colostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,45820,Repair rectourethral fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,45825,Repair fistula w/colostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,45900,Reduction of rectal prolapse,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Aetna MCR ADV,CPT,45905,Dilation of anal sphincter,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,45910,Dilation of rectal narrowing,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,45915,Remove rectal obstruction,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,45990,Surg dx exam anorectal,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,45999,Rectum surgery procedure,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Aetna MCR ADV,CPT,46020,Placement of seton,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,46030,Removal of rectal marker,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,46040,Incision of rectal abscess,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,46045,Incision of rectal abscess,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,46050,Incision of anal abscess,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Aetna MCR ADV,CPT,46060,Incision of rectal abscess,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,46070,Incision of anal septum,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,46080,Incision of anal sphincter,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,46083,Incise external hemorrhoid,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Aetna MCR ADV,CPT,46200,Removal of anal fissure,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,46220,Excise anal ext tag/papilla,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,46221,Ligation of hemorrhoid(s),APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Aetna MCR ADV,CPT,46230,Removal of anal tags,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,46250,Remove ext hem groups 2+,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,46255,Remove int/ext hem 1 group,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,46257,Remove in/ex hem grp & fiss,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,46258,Remove in/ex hem grp w/fistu,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,46260,Remove in/ex hem groups 2+,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,46261,Remove in/ex hem grps & fiss,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,46262,Remove in/ex hem grps w/fist,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,46270,Remove anal fist subq,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,46275,Remove anal fist inter,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,46280,Remove anal fist complex,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,46285,Remove anal fist 2 stage,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,46288,Repair anal fistula,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,46320,Removal of hemorrhoid clot,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,46500,Injection into hemorrhoid(s),APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Aetna MCR ADV,CPT,46505,Chemodenervation anal musc,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,46600,Diagnostic anoscopy spx,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Aetna MCR ADV,CPT,46601,Diagnostic anoscopy,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Aetna MCR ADV,CPT,46604,Anoscopy and dilation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,46606,Anoscopy and biopsy,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,46607,Diagnostic anoscopy & biopsy,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,46608,Anoscopy remove for body,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Aetna MCR ADV,CPT,46610,Anoscopy remove lesion,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,46611,Anoscopy,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Aetna MCR ADV,CPT,46612,Anoscopy remove lesions,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,46614,Anoscopy control bleeding,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,46615,Anoscopy,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,46700,Repair of anal stricture,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,46705,Repair of anal stricture,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,46706,Repr of anal fistula w/glue,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,46707,Repair anorectal fist w/plug,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,46710,Repr per/vag pouch sngl proc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,46712,Repr per/vag pouch dbl proc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,46715,Rep perf anoper fistu,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,46716,Rep perf anoper/vestib fistu,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,46730,Construction of absent anus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,46735,Construction of absent anus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,46740,Construction of absent anus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,46742,Repair of imperforated anus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,46744,Repair of cloacal anomaly,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,46746,Repair of cloacal anomaly,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,46748,Repair of cloacal anomaly,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,46750,Repair of anal sphincter,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,46751,Repair of anal sphincter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,46753,Reconstruction of anus,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,46754,Removal of suture from anus,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,46760,Repair of anal sphincter,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,46761,Repair of anal sphincter,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,46900,Destruction anal lesion(s),APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,46910,Destruction anal lesion(s),APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,46916,Cryosurgery anal lesion(s),APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,46917,Laser surgery anal lesions,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,46922,Excision of anal lesion(s),APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,46924,Destruction anal lesion(s),APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,46930,Destroy internal hemorrhoids,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,46940,Treatment of anal fissure,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,46942,Treatment of anal fissure,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Aetna MCR ADV,CPT,46945,Int hrhc lig 1 hroid w/o img,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,46946,Int hrhc lig 2+hroid w/o img,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,46947,Hemorrhoidopexy by stapling,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,46948,Int hrhc tranal dartlzj 2+,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Aetna MCR ADV,CPT,46999,Anus surgery procedure,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Aetna MCR ADV,CPT,47000,Needle biopsy of liver,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,47010,Open drainage liver lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47015,Inject/aspirate liver cyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47100,Wedge biopsy of liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47120,Partial removal of liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47122,Extensive removal of liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47125,Partial removal of liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47130,Partial removal of liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47133,Removal of donor liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47135,Transplantation of liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47140,Partial removal donor liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47141,Partial removal donor liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47142,Partial removal donor liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47143,Prep donor liver whole,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47144,Prep donor liver 3-segment,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47145,Prep donor liver lobe split,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47146,Prep donor liver/venous,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47147,Prep donor liver/arterial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47300,Surgery for liver lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47350,Repair liver wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47360,Repair liver wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47361,Repair liver wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47362,Repair liver wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47370,Laparo ablate liver tumor rf,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Aetna MCR ADV,CPT,47371,Laparo ablate liver cryosurg,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Aetna MCR ADV,CPT,47379,Laparoscope procedure liver,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,47380,Open ablate liver tumor rf,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47381,Open ablate liver tumor cryo,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47382,Percut ablate liver rf,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,47383,Perq abltj lvr cryoablation,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,47399,Liver surgery procedure,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,47400,Incision of liver duct,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47420,Incision of bile duct,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47425,Incision of bile duct,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47460,Incise bile duct sphincter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47480,Incision of gallbladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47490,Incision of gallbladder,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Aetna MCR ADV,CPT,47531,Injection for cholangiogram,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Aetna MCR ADV,CPT,47532,Injection for cholangiogram,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Aetna MCR ADV,CPT,47533,Plmt biliary drainage cath,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Aetna MCR ADV,CPT,47534,Plmt biliary drainage cath,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Aetna MCR ADV,CPT,47535,Conversion ext bil drg cath,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Aetna MCR ADV,CPT,47536,Exchange biliary drg cath,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Aetna MCR ADV,CPT,47537,Removal biliary drg cath,APC 5301,RVU Per Case,$828.48 ,OP,828.48,"4,314.00",,,,,,
Aetna MCR ADV,CPT,47538,Perq plmt bile duct stent,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,47539,Perq plmt bile duct stent,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,47540,Perq plmt bile duct stent,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,47541,Plmt access bil tree sm bwl,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Aetna MCR ADV,CPT,47550,Bile duct endoscopy add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47552,Biliary endo perq dx w/speci,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Aetna MCR ADV,CPT,47553,Biliary endoscopy thru skin,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Aetna MCR ADV,CPT,47554,Biliary endoscopy thru skin,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,47555,Biliary endoscopy thru skin,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Aetna MCR ADV,CPT,47556,Biliary endoscopy thru skin,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,47562,Laparoscopic cholecystectomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,47563,Laparo cholecystectomy/graph,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,47564,Laparo cholecystectomy/explr,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,47570,Laparo cholecystoenterostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47579,Laparoscope proc biliary,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,47600,Removal of gallbladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,47605,Removal of gallbladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,47610,Removal of gallbladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,47612,Removal of gallbladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,47620,Removal of gallbladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,47700,Exploration of bile ducts,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47701,Bile duct revision,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47711,Excision of bile duct tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47712,Excision of bile duct tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47715,Excision of bile duct cyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47720,Fuse gallbladder & bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47721,Fuse upper gi structures,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47740,Fuse gallbladder & bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47741,Fuse gallbladder & bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47760,Fuse bile ducts and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47765,Fuse liver ducts & bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47780,Fuse bile ducts and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47785,Fuse bile ducts and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47800,Reconstruction of bile ducts,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47801,Placement bile duct support,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47802,Fuse liver duct & intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47900,Suture bile duct injury,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,47999,Bile tract surgery procedure,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Aetna MCR ADV,CPT,48000,Drainage of abdomen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,48001,Placement of drain pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,48020,Removal of pancreatic stone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,48100,Biopsy of pancreas open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,48102,Needle biopsy pancreas,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,48105,Resect/debride pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,48120,Removal of pancreas lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,48140,Partial removal of pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,48145,Partial removal of pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,48146,Pancreatectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,48148,Removal of pancreatic duct,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,48150,Partial removal of pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,48152,Pancreatectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,48153,Pancreatectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,48154,Pancreatectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,48155,Removal of pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,48400,Injection intraop add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,48500,Surgery of pancreatic cyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,48510,Drain pancreatic pseudocyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,48520,Fuse pancreas cyst and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,48540,Fuse pancreas cyst and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,48545,Pancreatorrhaphy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,48547,Duodenal exclusion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,48548,Fuse pancreas and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,48551,Prep donor pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,48552,Prep donor pancreas/venous,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,48554,Transpl allograft pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,48556,Removal allograft pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,48999,Pancreas surgery procedure,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,49000,Exploration of abdomen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,49002,Reopening of abdomen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,49010,Exploration behind abdomen,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Aetna MCR ADV,CPT,49013,Prpertl pel pack hemrrg trma,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,49014,Reexploration pelvic wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,49020,Drainage abdom abscess open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,49040,Drain open abdom abscess,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,49060,Drain open retroperi abscess,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,49062,Drain to peritoneal cavity,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,49082,Abd paracentesis,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Aetna MCR ADV,CPT,49083,Abd paracentesis w/imaging,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Aetna MCR ADV,CPT,49084,Peritoneal lavage,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Aetna MCR ADV,CPT,49180,Biopsy abdominal mass,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,49185,Sclerotx fluid collection,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,49203,Exc abd tum 5 cm or less,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,49204,Exc abd tum over 5 cm,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,49205,Exc abd tum over 10 cm,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,49215,Excise sacral spine tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,49250,Excision of umbilicus,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Aetna MCR ADV,CPT,49255,Removal of omentum,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Aetna MCR ADV,CPT,49320,Diag laparo separate proc,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,49321,Laparoscopy biopsy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,49322,Laparoscopy aspiration,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,49323,Laparo drain lymphocele,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,49324,Lap insert tunnel ip cath,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,49325,Lap revision perm ip cath,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,49329,Laparo proc abdm/per/oment,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,49402,Remove foreign body adbomen,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Aetna MCR ADV,CPT,49405,Image cath fluid colxn visc,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,49406,Image cath fluid peri/retro,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,49407,Image cath fluid trns/vgnl,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,49411,Ins mark abd/pel for rt perq,APC 5613,RVU Per Unit,"$1,291.62 ",OP,"1,291.62","4,314.00",,,,,,
Aetna MCR ADV,CPT,49412,Ins device for rt guide open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,49418,Insert tun ip cath perc,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Aetna MCR ADV,CPT,49419,Insert tun ip cath w/port,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Aetna MCR ADV,CPT,49421,Ins tun ip cath for dial opn,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Aetna MCR ADV,CPT,49422,Remove tunneled ip cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,49423,Exchange drainage catheter,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,49425,Insert abdomen-venous drain,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,49426,Revise abdomen-venous shunt,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Aetna MCR ADV,CPT,49428,Ligation of shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,49429,Removal of shunt,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Aetna MCR ADV,CPT,49436,Embedded ip cath exit-site,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,49440,Place gastrostomy tube perc,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,49441,Place duod/jej tube perc,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,49442,Place cecostomy tube perc,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Aetna MCR ADV,CPT,49446,Change g-tube to g-j perc,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Aetna MCR ADV,CPT,49450,Replace g/c tube perc,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Aetna MCR ADV,CPT,49451,Replace duod/jej tube perc,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Aetna MCR ADV,CPT,49452,Replace g-j tube perc,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Aetna MCR ADV,CPT,49460,Fix g/colon tube w/device,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Aetna MCR ADV,CPT,49465,Fluoro exam of g/colon tube,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"4,314.00",,,,,,
Aetna MCR ADV,CPT,49491,Rpr hern preemie reduc,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,49492,Rpr ing hern premie blocked,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Aetna MCR ADV,CPT,49495,Rpr ing hernia baby reduc,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Aetna MCR ADV,CPT,49496,Rpr ing hernia baby blocked,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Aetna MCR ADV,CPT,49500,Rpr ing hernia init reduce,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Aetna MCR ADV,CPT,49501,Rpr ing hernia init blocked,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Aetna MCR ADV,CPT,49505,Prp i/hern init reduc >5 yr,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Aetna MCR ADV,CPT,49507,Prp i/hern init block >5 yr,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Aetna MCR ADV,CPT,49520,Rerepair ing hernia reduce,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Aetna MCR ADV,CPT,49521,Rerepair ing hernia blocked,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Aetna MCR ADV,CPT,49525,Repair ing hernia sliding,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Aetna MCR ADV,CPT,49540,Repair lumbar hernia,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,49550,Rpr rem hernia init reduce,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Aetna MCR ADV,CPT,49553,Rpr fem hernia init blocked,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Aetna MCR ADV,CPT,49555,Rerepair fem hernia reduce,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Aetna MCR ADV,CPT,49557,Rerepair fem hernia blocked,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Aetna MCR ADV,CPT,49560,Rpr ventral hern init reduc,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Aetna MCR ADV,CPT,49561,Rpr ventral hern init block,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Aetna MCR ADV,CPT,49565,Rerepair ventrl hern reduce,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,49566,Rerepair ventrl hern block,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,49570,Rpr epigastric hern reduce,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Aetna MCR ADV,CPT,49572,Rpr epigastric hern blocked,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Aetna MCR ADV,CPT,49580,Rpr umbil hern reduc < 5 yr,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Aetna MCR ADV,CPT,49582,Rpr umbil hern block < 5 yr,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Aetna MCR ADV,CPT,49585,Rpr umbil hern reduc > 5 yr,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Aetna MCR ADV,CPT,49587,Rpr umbil hern block > 5 yr,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Aetna MCR ADV,CPT,49590,Repair spigelian hernia,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Aetna MCR ADV,CPT,49600,Repair umbilical lesion,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Aetna MCR ADV,CPT,49605,Repair umbilical lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,49606,Repair umbilical lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,49610,Repair umbilical lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,49611,Repair umbilical lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,49650,Lap ing hernia repair init,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,49651,Lap ing hernia repair recur,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,49652,Lap vent/abd hernia repair,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,49653,Lap vent/abd hern proc comp,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,49654,Lap inc hernia repair,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,49655,Lap inc hern repair comp,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Aetna MCR ADV,CPT,49656,Lap inc hernia repair recur,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Aetna MCR ADV,CPT,49657,Lap inc hern recur comp,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Aetna MCR ADV,CPT,49659,Laparo proc hernia repair,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,49900,Repair of abdominal wall,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,49904,Omental flap extra-abdom,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,49905,Omental flap intra-abdom,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,49906,Free omental flap microvasc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,49999,Abdomen surgery procedure,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Aetna MCR ADV,CPT,50010,Exploration of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50020,Renal abscess open drain,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,50040,Drainage of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50045,Exploration of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50060,Removal of kidney stone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50065,Incision of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50070,Incision of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50075,Removal of kidney stone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50080,Removal of kidney stone,APC 5376,RVU Per Case,"$8,450.70 ",OP,"4,314.00","8,450.70",,,,,,
Aetna MCR ADV,CPT,50081,Removal of kidney stone,APC 5376,RVU Per Case,"$8,450.70 ",OP,"4,314.00","8,450.70",,,,,,
Aetna MCR ADV,CPT,50100,Revise kidney blood vessels,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50120,Exploration of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50125,Explore and drain kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50130,Removal of kidney stone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50135,Exploration of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50200,Renal biopsy perq,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,50205,Renal biopsy open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50220,Remove kidney open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50225,Removal kidney open complex,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50230,Removal kidney open radical,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50234,Removal of kidney & ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50236,Removal of kidney & ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50240,Partial removal of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50250,Cryoablate renal mass open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50280,Removal of kidney lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50290,Removal of kidney lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50300,Remove cadaver donor kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50320,Remove kidney living donor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50323,Prep cadaver renal allograft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50325,Prep donor renal graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50327,Prep renal graft/venous,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50328,Prep renal graft/arterial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50329,Prep renal graft/ureteral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50340,Removal of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50360,Transplantation of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50365,Transplantation of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50370,Remove transplanted kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50380,Reimplantation of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50382,Change ureter stent percut,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,50384,Remove ureter stent percut,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,50385,Change stent via transureth,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,50386,Remove stent via transureth,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,50387,Change nephroureteral cath,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,50389,Remove renal tube w/fluoro,APC 5372,RVU Per Case,$588.17 ,OP,588.17,"4,314.00",,,,,,
Aetna MCR ADV,CPT,50390,Drainage of kidney lesion,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,50391,Instll rx agnt into rnal tub,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Aetna MCR ADV,CPT,50396,Measure kidney pressure,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Aetna MCR ADV,CPT,50400,Revision of kidney/ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50405,Revision of kidney/ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50430,Njx px nfrosgrm &/urtrgrm,APC 5372,RVU Per Case,$588.17 ,OP,588.17,"4,314.00",,,,,,
Aetna MCR ADV,CPT,50431,Njx px nfrosgrm &/urtrgrm,APC 5372,RVU Per Case,$588.17 ,OP,588.17,"4,314.00",,,,,,
Aetna MCR ADV,CPT,50432,Plmt nephrostomy catheter,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,50433,Plmt nephroureteral catheter,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,50434,Convert nephrostomy catheter,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,50435,Exchange nephrostomy cath,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,50436,Dilat xst trc ndurlgc px,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,50437,Dilat xst trc new access rcs,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,50500,Repair of kidney wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50520,Close kidney-skin fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50525,Close nephrovisceral fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50526,Close nephrovisceral fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50540,Revision of horseshoe kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50541,Laparo ablate renal cyst,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,50542,Laparo ablate renal mass,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Aetna MCR ADV,CPT,50543,Laparo partial nephrectomy,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Aetna MCR ADV,CPT,50544,Laparoscopy pyeloplasty,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,50545,Laparo radical nephrectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50546,Laparoscopic nephrectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50547,Laparo removal donor kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50548,Laparo remove w/ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50549,Laparoscope proc renal,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,50551,Kidney endoscopy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,50553,Kidney endoscopy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,50555,Kidney endoscopy & biopsy,APC 5376,RVU Per Case,"$8,450.70 ",OP,"4,314.00","8,450.70",,,,,,
Aetna MCR ADV,CPT,50557,Kidney endoscopy & treatment,APC 5376,RVU Per Case,"$8,450.70 ",OP,"4,314.00","8,450.70",,,,,,
Aetna MCR ADV,CPT,50561,Kidney endoscopy & treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,50562,Renal scope w/tumor resect,APC 5376,RVU Per Case,"$8,450.70 ",OP,"4,314.00","8,450.70",,,,,,
Aetna MCR ADV,CPT,50570,Kidney endoscopy,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,50572,Kidney endoscopy,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Aetna MCR ADV,CPT,50574,Kidney endoscopy & biopsy,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,50575,Kidney endoscopy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,50576,Kidney endoscopy & treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,50580,Kidney endoscopy & treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,50590,Fragmenting of kidney stone,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,50592,Perc rf ablate renal tumor,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,50593,Perc cryo ablate renal tum,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Aetna MCR ADV,CPT,50600,Exploration of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50605,Insert ureteral support,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50610,Removal of ureter stone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50620,Removal of ureter stone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50630,Removal of ureter stone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50650,Removal of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50660,Removal of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50686,Measure ureter pressure,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,"4,314.00",,,,,,
Aetna MCR ADV,CPT,50688,Change of ureter tube/stent,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,50693,Plmt ureteral stent prq,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,50694,Plmt ureteral stent prq,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,50695,Plmt ureteral stent prq,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,50700,Revision of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50715,Release of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50722,Release of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50725,Release/revise ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50727,Revise ureter,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,50728,Revise ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50740,Fusion of ureter & kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50750,Fusion of ureter & kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50760,Fusion of ureters,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50770,Splicing of ureters,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50780,Reimplant ureter in bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50782,Reimplant ureter in bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50783,Reimplant ureter in bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50785,Reimplant ureter in bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50800,Implant ureter in bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50810,Fusion of ureter & bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50815,Urine shunt to intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50820,Construct bowel bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50825,Construct bowel bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50830,Revise urine flow,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50840,Replace ureter by bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50845,Appendico-vesicostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50860,Transplant ureter to skin,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50900,Repair of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50920,Closure ureter/skin fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50930,Closure ureter/bowel fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50940,Release of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,50945,Laparoscopy ureterolithotomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,50947,Laparo new ureter/bladder,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,50948,Laparo new ureter/bladder,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Aetna MCR ADV,CPT,50949,Laparoscope proc ureter,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,50951,Endoscopy of ureter,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,50953,Endoscopy of ureter,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,50955,Ureter endoscopy & biopsy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,50957,Ureter endoscopy & treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,50961,Ureter endoscopy & treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,50970,Ureter endoscopy,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,50972,Ureter endoscopy & catheter,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,50974,Ureter endoscopy & biopsy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,50976,Ureter endoscopy & treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,50980,Ureter endoscopy & treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,51020,Incise & treat bladder,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,51030,Incise & treat bladder,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,51040,Incise & drain bladder,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,51045,Incise bladder/drain ureter,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,51050,Removal of bladder stone,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,51060,Removal of ureter stone,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,51065,Remove ureter calculus,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,51080,Drainage of bladder abscess,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,51100,Drain bladder by needle,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Aetna MCR ADV,CPT,51101,Drain bladder by trocar/cath,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"4,314.00",,,,,,
Aetna MCR ADV,CPT,51102,Drain bl w/cath insertion,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,51500,Removal of bladder cyst,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,51520,Removal of bladder lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,51525,Removal of bladder lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,51530,Removal of bladder lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,51535,Repair of ureter lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,51550,Partial removal of bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,51555,Partial removal of bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,51565,Revise bladder & ureter(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,51570,Removal of bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,51575,Removal of bladder & nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,51580,Remove bladder/revise tract,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,51585,Removal of bladder & nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,51590,Remove bladder/revise tract,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,51595,Remove bladder/revise tract,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,51596,Remove bladder/create pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,51597,Removal of pelvic structures,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,51700,Irrigation of bladder,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Aetna MCR ADV,CPT,51701,Insert bladder catheter,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Aetna MCR ADV,CPT,51702,Insert temp bladder cath,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Aetna MCR ADV,CPT,51703,Insert bladder cath complex,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,"4,314.00",,,,,,
Aetna MCR ADV,CPT,51705,Change of bladder tube,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Aetna MCR ADV,CPT,51710,Change of bladder tube,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Aetna MCR ADV,CPT,51715,Endoscopic injection/implant,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,51720,Treatment of bladder lesion,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Aetna MCR ADV,CPT,51725,Simple cystometrogram,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Aetna MCR ADV,CPT,51726,Complex cystometrogram,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Aetna MCR ADV,CPT,51727,Cystometrogram w/up,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Aetna MCR ADV,CPT,51728,Cystometrogram w/vp,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Aetna MCR ADV,CPT,51729,Cystometrogram w/vp&up,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Aetna MCR ADV,CPT,51736,Urine flow measurement,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Aetna MCR ADV,CPT,51741,Electro-uroflowmetry first,APC 5721,RVU Per Case,$142.80 ,OP,142.8,"4,314.00",,,,,,
Aetna MCR ADV,CPT,51784,Anal/urinary muscle study,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,"4,314.00",,,,,,
Aetna MCR ADV,CPT,51785,Anal/urinary muscle study,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Aetna MCR ADV,CPT,51792,Urinary reflex study,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Aetna MCR ADV,CPT,51798,Us urine capacity measure,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Aetna MCR ADV,CPT,51800,Revision of bladder/urethra,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,51820,Revision of urinary tract,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,51840,Attach bladder/urethra,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Aetna MCR ADV,CPT,51841,Attach bladder/urethra,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,51845,Repair bladder neck,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Aetna MCR ADV,CPT,51860,Repair of bladder wound,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,51865,Repair of bladder wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,51880,Repair of bladder opening,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,51900,Repair bladder/vagina lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,51920,Close bladder-uterus fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,51925,Hysterectomy/bladder repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,51940,Correction of bladder defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,51960,Revision of bladder & bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,51980,Construct bladder opening,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,51990,Laparo urethral suspension,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,51992,Laparo sling operation,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,51999,Laparoscope proc bla,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,52000,Cystoscopy,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Aetna MCR ADV,CPT,52001,Cystoscopy removal of clots,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,52005,Cystoscopy & ureter catheter,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,52007,Cystoscopy and biopsy,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,52010,Cystoscopy & duct catheter,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Aetna MCR ADV,CPT,52204,Cystoscopy w/biopsy(s),APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,52214,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,52224,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,52234,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,52235,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,52240,Cystoscopy and treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,52250,Cystoscopy and radiotracer,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,52260,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,52265,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,52270,Cystoscopy & revise urethra,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,52275,Cystoscopy & revise urethra,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,52276,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,52277,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,52281,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,52282,Cystoscopy implant stent,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,52283,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,52285,Cystoscopy and treatment,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Aetna MCR ADV,CPT,52287,Cystoscopy chemodenervation,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,52290,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,52300,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,52301,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,52305,Cystoscopy and treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,52310,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,52315,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,52317,Remove bladder stone,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,52318,Remove bladder stone,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,52320,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,52325,Cystoscopy stone removal,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,52327,Cystoscopy inject material,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,52330,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,52332,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,52334,Create passage to kidney,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,52341,Cysto w/ureter stricture tx,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,52342,Cysto w/up stricture tx,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,52343,Cysto w/renal stricture tx,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,52344,Cysto/uretero stricture tx,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,52345,Cysto/uretero w/up stricture,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,52346,Cystouretero w/renal strict,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,52351,Cystouretero & or pyeloscope,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,52352,Cystouretero w/stone remove,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,52353,Cystouretero w/lithotripsy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,52354,Cystouretero w/biopsy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,52355,Cystouretero w/excise tumor,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,52356,Cysto/uretero w/lithotripsy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,52400,Cystouretero w/congen repr,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,52402,Cystourethro cut ejacul duct,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,52450,Incision of prostate,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,52500,Revision of bladder neck,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,52601,Prostatectomy (turp),APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,52630,Remove prostate regrowth,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,52640,Relieve bladder contracture,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,52647,Laser surgery of prostate,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,52648,Laser surgery of prostate,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,52649,Prostate laser enucleation,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,52700,Drainage of prostate abscess,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,53000,Incision of urethra,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,53010,Incision of urethra,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,53020,Incision of urethra,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,53025,Incision of urethra,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,53040,Drainage of urethra abscess,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,53060,Drainage of urethra abscess,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,53080,Drainage of urinary leakage,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Aetna MCR ADV,CPT,53085,Drainage of urinary leakage,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,53200,Biopsy of urethra,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,53210,Removal of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,53215,Removal of urethra,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,53220,Treatment of urethra lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,53230,Removal of urethra lesion,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,53235,Removal of urethra lesion,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,53240,Surgery for urethra pouch,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,53250,Removal of urethra gland,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,53260,Treatment of urethra lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,53265,Treatment of urethra lesion,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,53270,Removal of urethra gland,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,53275,Repair of urethra defect,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,53400,Revise urethra stage 1,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,53405,Revise urethra stage 2,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,53410,Reconstruction of urethra,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,53415,Reconstruction of urethra,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,53420,Reconstruct urethra stage 1,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,53425,Reconstruct urethra stage 2,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,53430,Reconstruction of urethra,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,53431,Reconstruct urethra/bladder,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,53440,Male sling procedure,APC 5377,RVU Per Case,"$11,755.91 ",OP,"4,140.35","11,755.91",,,,,,
Aetna MCR ADV,CPT,53442,Remove/revise male sling,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,53444,Insert tandem cuff,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,314.00","18,684.12",,,,,,
Aetna MCR ADV,CPT,53445,Insert uro/ves nck sphincter,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,140.35","18,684.12",,,,,,
Aetna MCR ADV,CPT,53446,Remove uro sphincter,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,53447,Remove/replace ur sphincter,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,314.00","18,684.12",,,,,,
Aetna MCR ADV,CPT,53448,Remov/replc ur sphinctr comp,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,53449,Repair uro sphincter,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,53450,Revision of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,53460,Revision of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,53500,Urethrlys transvag w/ scope,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,53502,Repair of urethra injury,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,53505,Repair of urethra injury,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,53510,Repair of urethra injury,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,53515,Repair of urethra injury,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,53520,Repair of urethra defect,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,53600,Dilate urethra stricture,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Aetna MCR ADV,CPT,53601,Dilate urethra stricture,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Aetna MCR ADV,CPT,53605,Dilate urethra stricture,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,53620,Dilate urethra stricture,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Aetna MCR ADV,CPT,53621,Dilate urethra stricture,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Aetna MCR ADV,CPT,53660,Dilation of urethra,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,"4,314.00",,,,,,
Aetna MCR ADV,CPT,53661,Dilation of urethra,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Aetna MCR ADV,CPT,53665,Dilation of urethra,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,53850,Prostatic microwave thermotx,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,53852,Prostatic rf thermotx,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,53854,Trurl dstrj prst8 tiss rf wv,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,53855,Insert prost urethral stent,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,53860,Transurethral rf treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,53899,Urology surgery procedure,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Aetna MCR ADV,CPT,54000,Slitting of prepuce,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,54001,Slitting of prepuce,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,54015,Drain penis lesion,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,54050,Destruction penis lesion(s),APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,54055,Destruction penis lesion(s),APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,54056,Cryosurgery penis lesion(s),APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,54057,Laser surg penis lesion(s),APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,54060,Excision of penis lesion(s),APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,54065,Destruction penis lesion(s),APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,54100,Biopsy of penis,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,54105,Biopsy of penis,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,54110,Treatment of penis lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,54111,Treat penis lesion graft,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,54112,Treat penis lesion graft,APC 5376,RVU Per Case,"$8,450.70 ",OP,"4,314.00","8,450.70",,,,,,
Aetna MCR ADV,CPT,54115,Treatment of penis lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,54120,Partial removal of penis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,54125,Removal of penis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,54130,Remove penis & nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,54135,Remove penis & nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,54150,Circumcision w/regionl block,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,54160,Circumcision neonate,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Aetna MCR ADV,CPT,54161,Circum 28 days or older,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,54162,Lysis penil circumic lesion,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,54163,Repair of circumcision,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,54164,Frenulotomy of penis,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,54200,Treatment of penis lesion,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Aetna MCR ADV,CPT,54205,Treatment of penis lesion,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,54220,Treatment of penis lesion,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Aetna MCR ADV,CPT,54231,Dynamic cavernosometry,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Aetna MCR ADV,CPT,54235,Penile injection,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Aetna MCR ADV,CPT,54240,Penis study,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"4,314.00",,,,,,
Aetna MCR ADV,CPT,54250,Penis study,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Aetna MCR ADV,CPT,54300,Revision of penis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,54304,Revision of penis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,54308,Reconstruction of urethra,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,54312,Reconstruction of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,54316,Reconstruction of urethra,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,54318,Reconstruction of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,54322,Reconstruction of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,54324,Reconstruction of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,54326,Reconstruction of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,54328,Revise penis/urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,54332,Revise penis/urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,54336,Revise penis/urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,54340,Secondary urethral surgery,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,54344,Secondary urethral surgery,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,54348,Secondary urethral surgery,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,54352,Reconstruct urethra/penis,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,54360,Penis plastic surgery,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,54380,Repair penis,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,54385,Repair penis,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,54390,Repair penis and bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,54400,Insert semi-rigid prosthesis,APC 5377,RVU Per Case,"$11,755.91 ",OP,"4,314.00","11,755.91",,,,,,
Aetna MCR ADV,CPT,54401,Insert self-contd prosthesis,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,314.00","18,684.12",,,,,,
Aetna MCR ADV,CPT,54405,Insert multi-comp penis pros,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,140.35","18,684.12",,,,,,
Aetna MCR ADV,CPT,54406,Remove muti-comp penis pros,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,54408,Repair multi-comp penis pros,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,54410,Remove/replace penis prosth,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,140.35","18,684.12",,,,,,
Aetna MCR ADV,CPT,54411,Remov/replc penis pros comp,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,314.00","18,684.12",,,,,,
Aetna MCR ADV,CPT,54415,Remove self-contd penis pros,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,54416,Remv/repl penis contain pros,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,314.00","18,684.12",,,,,,
Aetna MCR ADV,CPT,54417,Remv/replc penis pros compl,APC 5377,RVU Per Case,"$11,755.91 ",OP,"4,314.00","11,755.91",,,,,,
Aetna MCR ADV,CPT,54420,Revision of penis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,54430,Revision of penis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,54435,Revision of penis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,54437,Repair corporeal tear,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,54438,Replantation of penis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,54440,Repair of penis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,54450,Preputial stretching,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Aetna MCR ADV,CPT,54500,Biopsy of testis,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,54505,Biopsy of testis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,54512,Excise lesion testis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,54520,Removal of testis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,54522,Orchiectomy partial,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,54530,Removal of testis,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Aetna MCR ADV,CPT,54535,Extensive testis surgery,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,54550,Exploration for testis,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Aetna MCR ADV,CPT,54560,Exploration for testis,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,54600,Reduce testis torsion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,54620,Suspension of testis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,54640,Orchiopexy ingun/scrot appr,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Aetna MCR ADV,CPT,54650,Orchiopexy (fowler-stephens),APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Aetna MCR ADV,CPT,54660,Revision of testis,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,54670,Repair testis injury,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,54680,Relocation of testis(es),APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,54690,Laparoscopy orchiectomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,54692,Laparoscopy orchiopexy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,54699,Laparoscope proc testis,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,54700,Drainage of scrotum,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,54800,Biopsy of epididymis,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,54830,Remove epididymis lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,54840,Remove epididymis lesion,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,54860,Removal of epididymis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,54861,Removal of epididymis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,54865,Explore epididymis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,54900,Fusion of spermatic ducts,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,54901,Fusion of spermatic ducts,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,55000,Drainage of hydrocele,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,55040,Removal of hydrocele,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Aetna MCR ADV,CPT,55041,Removal of hydroceles,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Aetna MCR ADV,CPT,55060,Repair of hydrocele,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,55100,Drainage of scrotum abscess,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,55110,Explore scrotum,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,55120,Removal of scrotum lesion,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,55150,Removal of scrotum,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,55175,Revision of scrotum,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,55180,Revision of scrotum,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,55200,Incision of sperm duct,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,55250,Removal of sperm duct(s),APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,55400,Repair of sperm duct,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,55500,Removal of hydrocele,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,55520,Removal of sperm cord lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,55530,Revise spermatic cord veins,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,55535,Revise spermatic cord veins,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Aetna MCR ADV,CPT,55540,Revise hernia & sperm veins,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Aetna MCR ADV,CPT,55550,Laparo ligate spermatic vein,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,55559,Laparo proc spermatic cord,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,55600,Incise sperm duct pouch,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,55605,Incise sperm duct pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,55650,Remove sperm duct pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,55680,Remove sperm pouch lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,55700,Biopsy of prostate,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Aetna MCR ADV,CPT,55705,Biopsy of prostate,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,55706,Prostate saturation sampling,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,55720,Drainage of prostate abscess,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,55725,Drainage of prostate abscess,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,55801,Removal of prostate,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,55810,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,55812,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,55815,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,55821,Removal of prostate,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,55831,Removal of prostate,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,55840,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,55842,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,55845,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,55860,Surgical exposure prostate,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,55862,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,55865,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,55866,Laparo radical prostatectomy,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Aetna MCR ADV,CPT,55870,Electroejaculation,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Aetna MCR ADV,CPT,55873,Cryoablate prostate,APC 5376,RVU Per Case,"$8,450.70 ",OP,"4,314.00","8,450.70",,,,,,
Aetna MCR ADV,CPT,55874,Tprnl plmt biodegrdabl matrl,APC 5375,RVU Per Unit,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,55875,Transperi needle place pros,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,55876,Place rt device/marker pros,APC 5613,RVU Per Unit,"$1,291.62 ",OP,"1,291.62","4,314.00",,,,,,
Aetna MCR ADV,CPT,55880,Abltj mal prst8 tiss hifu,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Aetna MCR ADV,CPT,55899,Genital surgery procedure,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Aetna MCR ADV,CPT,55920,Place needles pelvic for rt,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Aetna MCR ADV,CPT,55970,Sex transformation m to f,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Aetna MCR ADV,CPT,55980,Sex transformation f to m,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Aetna MCR ADV,CPT,56405,I & d of vulva/perineum,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Aetna MCR ADV,CPT,56420,Drainage of gland abscess,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Aetna MCR ADV,CPT,56440,Surgery for vulva lesion,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,56441,Lysis of labial lesion(s),APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,56442,Hymenotomy,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,56501,Destroy vulva lesions sim,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,56515,Destroy vulva lesion/s compl,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Aetna MCR ADV,CPT,56605,Biopsy of vulva/perineum,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Aetna MCR ADV,CPT,56620,Partial removal of vulva,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,56625,Complete removal of vulva,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,56630,Extensive vulva surgery,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Aetna MCR ADV,CPT,56631,Extensive vulva surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,56632,Extensive vulva surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,56633,Extensive vulva surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,56634,Extensive vulva surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,56637,Extensive vulva surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,56640,Extensive vulva surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,56700,Partial removal of hymen,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,56740,Remove vagina gland lesion,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,56800,Repair of vagina,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,56805,Repair clitoris,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,56810,Repair of perineum,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,56820,Exam of vulva w/scope,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Aetna MCR ADV,CPT,56821,Exam/biopsy of vulva w/scope,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Aetna MCR ADV,CPT,57000,Exploration of vagina,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,57010,Drainage of pelvic abscess,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,57020,Drainage of pelvic fluid,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Aetna MCR ADV,CPT,57022,I & d vaginal hematoma pp,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,57023,I & d vag hematoma non-ob,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,57061,Destroy vag lesions simple,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,57065,Destroy vag lesions complex,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,57100,Biopsy of vagina,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Aetna MCR ADV,CPT,57105,Biopsy of vagina,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,57106,Remove vagina wall partial,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,57107,Remove vagina tissue part,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,57109,Vaginectomy partial w/nodes,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,57110,Remove vagina wall complete,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,57111,Remove vagina tissue compl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,57120,Closure of vagina,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Aetna MCR ADV,CPT,57130,Remove vagina lesion,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,57135,Remove vagina lesion,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,57150,Treat vagina infection,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Aetna MCR ADV,CPT,57155,Insert uteri tandem/ovoids,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Aetna MCR ADV,CPT,57156,Ins vag brachytx device,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Aetna MCR ADV,CPT,57160,Insert pessary/other device,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Aetna MCR ADV,CPT,57170,Fitting of diaphragm/cap,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Aetna MCR ADV,CPT,57180,Treat vaginal bleeding,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Aetna MCR ADV,CPT,57200,Repair of vagina,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,57210,Repair vagina/perineum,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,57220,Revision of urethra,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Aetna MCR ADV,CPT,57230,Repair of urethral lesion,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,57240,Anterior colporrhaphy,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Aetna MCR ADV,CPT,57250,Repair rectum & vagina,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Aetna MCR ADV,CPT,57260,Cmbn ant pst colprhy,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Aetna MCR ADV,CPT,57265,Cmbn ap colprhy w/ntrcl rpr,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Aetna MCR ADV,CPT,57268,Repair of bowel bulge,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Aetna MCR ADV,CPT,57270,Repair of bowel pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,57280,Suspension of vagina,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,57282,Colpopexy extraperitoneal,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,57283,Colpopexy intraperitoneal,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,57284,Repair paravag defect open,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Aetna MCR ADV,CPT,57285,Repair paravag defect vag,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,57287,Revise/remove sling repair,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,57288,Repair bladder defect,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,57289,Repair bladder & vagina,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,314.00","6,952.74",,,,,,
Aetna MCR ADV,CPT,57291,Construction of vagina,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Aetna MCR ADV,CPT,57292,Construct vagina with graft,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Aetna MCR ADV,CPT,57295,Revise vag graft via vagina,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,57296,Revise vag graft open abd,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,57300,Repair rectum-vagina fistula,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,57305,Repair rectum-vagina fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,57307,Fistula repair & colostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,57308,Fistula repair transperine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,57310,Repair urethrovaginal lesion,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,314.00","6,952.74",,,,,,
Aetna MCR ADV,CPT,57311,Repair urethrovaginal lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,57320,Repair bladder-vagina lesion,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Aetna MCR ADV,CPT,57330,Repair bladder-vagina lesion,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,314.00","6,952.74",,,,,,
Aetna MCR ADV,CPT,57335,Repair vagina,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Aetna MCR ADV,CPT,57400,Dilation of vagina,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,57410,Pelvic examination,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,57415,Remove vaginal foreign body,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,57420,Exam of vagina w/scope,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Aetna MCR ADV,CPT,57421,Exam/biopsy of vag w/scope,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Aetna MCR ADV,CPT,57423,Repair paravag defect lap,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Aetna MCR ADV,CPT,57425,Laparoscopy surg colpopexy,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,57426,Revise prosth vag graft lap,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,314.00","6,952.74",,,,,,
Aetna MCR ADV,CPT,57452,Exam of cervix w/scope,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Aetna MCR ADV,CPT,57454,Bx/curett of cervix w/scope,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Aetna MCR ADV,CPT,57455,Biopsy of cervix w/scope,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Aetna MCR ADV,CPT,57456,Endocerv curettage w/scope,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Aetna MCR ADV,CPT,57460,Bx of cervix w/scope leep,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,57461,Conz of cervix w/scope leep,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,57500,Biopsy of cervix,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Aetna MCR ADV,CPT,57505,Endocervical curettage,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Aetna MCR ADV,CPT,57510,Cauterization of cervix,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,57511,Cryocautery of cervix,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Aetna MCR ADV,CPT,57513,Laser surgery of cervix,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,57520,Conization of cervix,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,57522,Conization of cervix,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,57530,Removal of cervix,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Aetna MCR ADV,CPT,57531,Removal of cervix radical,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,57540,Removal of residual cervix,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,57545,Remove cervix/repair pelvis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,57550,Removal of residual cervix,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Aetna MCR ADV,CPT,57555,Remove cervix/repair vagina,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Aetna MCR ADV,CPT,57556,Remove cervix repair bowel,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Aetna MCR ADV,CPT,57558,D&c of cervical stump,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,57700,Revision of cervix,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,57720,Revision of cervix,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,57800,Dilation of cervical canal,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,58100,Biopsy of uterus lining,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Aetna MCR ADV,CPT,58120,Dilation and curettage,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,58140,Myomectomy abdom method,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,58145,Myomectomy vag method,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","9,201.00",,,,,,
Aetna MCR ADV,CPT,58146,Myomectomy abdom complex,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,58150,Total hysterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,58152,Total hysterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,58180,Partial hysterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,58200,Extensive hysterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,58210,Extensive hysterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,58240,Removal of pelvis contents,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,58260,Vaginal hysterectomy,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Aetna MCR ADV,CPT,58262,Vag hyst including t/o,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Aetna MCR ADV,CPT,58263,Vag hyst w/t/o & vag repair,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Aetna MCR ADV,CPT,58267,Vag hyst w/urinary repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,58270,Vag hyst w/enterocele repair,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Aetna MCR ADV,CPT,58275,Hysterectomy/revise vagina,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,58280,Hysterectomy/revise vagina,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,58285,Extensive hysterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,58290,Vag hyst complex,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,314.00","6,952.74",,,,,,
Aetna MCR ADV,CPT,58291,Vag hyst incl t/o complex,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Aetna MCR ADV,CPT,58292,Vag hyst t/o & repair compl,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,314.00","6,952.74",,,,,,
Aetna MCR ADV,CPT,58294,Vag hyst w/enterocele compl,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Aetna MCR ADV,CPT,58301,Remove intrauterine device,APC 5412,RVU Per Case,$288.05 ,OP,288.05,"4,314.00",,,,,,
Aetna MCR ADV,CPT,58321,Artificial insemination,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Aetna MCR ADV,CPT,58322,Artificial insemination,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Aetna MCR ADV,CPT,58323,Sperm washing,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Aetna MCR ADV,CPT,58345,Reopen fallopian tube,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,58346,Insert heyman uteri capsule,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Aetna MCR ADV,CPT,58350,Reopen fallopian tube,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Aetna MCR ADV,CPT,58353,Endometr ablate thermal,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Aetna MCR ADV,CPT,58356,Endometrial cryoablation,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Aetna MCR ADV,CPT,58400,Suspension of uterus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,58410,Suspension of uterus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,58520,Repair of ruptured uterus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,58540,Revision of uterus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,58541,Lsh uterus 250 g or less,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,58542,Lsh w/t/o ut 250 g or less,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,58543,Lsh uterus above 250 g,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,58544,Lsh w/t/o uterus above 250 g,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,58545,Laparoscopic myomectomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,58546,Laparo-myomectomy complex,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,58548,Lap radical hyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,58550,Laparo-asst vag hysterectomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,58552,Laparo-vag hyst incl t/o,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,58553,Laparo-vag hyst complex,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,58554,Laparo-vag hyst w/t/o compl,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,58555,Hysteroscopy dx sep proc,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,58558,Hysteroscopy biopsy,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","9,201.00",,,,,,
Aetna MCR ADV,CPT,58559,Hysteroscopy lysis,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,58560,Hysteroscopy resect septum,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,58561,Hysteroscopy remove myoma,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,58562,Hysteroscopy remove fb,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,58563,Hysteroscopy ablation,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Aetna MCR ADV,CPT,58565,Hysteroscopy sterilization,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,58570,Tlh uterus 250 g or less,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,58571,Tlh w/t/o 250 g or less,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,58572,Tlh uterus over 250 g,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,58573,Tlh w/t/o uterus over 250 g,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,58575,Laps tot hyst resj mal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,58578,Laparo proc uterus,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,58579,Hysteroscope procedure,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Aetna MCR ADV,CPT,58600,Division of fallopian tube,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,58605,Division of fallopian tube,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,58611,Ligate oviduct(s) add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,58615,Occlude fallopian tube(s),APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,58660,Laparoscopy lysis,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,58661,Laparoscopy remove adnexa,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,58662,Laparoscopy excise lesions,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,58670,Laparoscopy tubal cautery,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,58671,Laparoscopy tubal block,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,58672,Laparoscopy fimbrioplasty,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,58673,Laparoscopy salpingostomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,58674,Laps abltj uterine fibroids,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,58679,Laparo proc oviduct-ovary,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,58700,Removal of fallopian tube,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,58720,Removal of ovary/tube(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,58740,Adhesiolysis tube ovary,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,58750,Repair oviduct,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,58752,Revise ovarian tube(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,58760,Fimbrioplasty,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,58770,Create new tubal opening,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,58800,Drainage of ovarian cyst(s),APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,58805,Drainage of ovarian cyst(s),APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,58820,Drain ovary abscess open,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,58822,Drain ovary abscess percut,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,58825,Transposition ovary(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,58900,Biopsy of ovary(s),APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,58920,Partial removal of ovary(s),APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,314.00","6,952.74",,,,,,
Aetna MCR ADV,CPT,58925,Removal of ovarian cyst(s),APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Aetna MCR ADV,CPT,58940,Removal of ovary(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,58943,Removal of ovary(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,58950,Resect ovarian malignancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,58951,Resect ovarian malignancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,58952,Resect ovarian malignancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,58953,Tah rad dissect for debulk,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,58954,Tah rad debulk/lymph remove,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,58956,Bso omentectomy w/tah,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,58957,Resect recurrent gyn mal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,58958,Resect recur gyn mal w/lym,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,58960,Exploration of abdomen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,58970,Retrieval of oocyte,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Aetna MCR ADV,CPT,58974,Transfer of embryo,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Aetna MCR ADV,CPT,58976,Transfer of embryo,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Aetna MCR ADV,CPT,58999,Genital surgery procedure,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Aetna MCR ADV,CPT,59000,Amniocentesis diagnostic,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Aetna MCR ADV,CPT,59001,Amniocentesis therapeutic,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Aetna MCR ADV,CPT,59012,Fetal cord puncture prenatal,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Aetna MCR ADV,CPT,59015,Chorion biopsy,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Aetna MCR ADV,CPT,59020,Fetal contract stress test,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Aetna MCR ADV,CPT,59025,Fetal non-stress test,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Aetna MCR ADV,CPT,59030,Fetal scalp blood sample,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Aetna MCR ADV,CPT,59070,Transabdom amnioinfus w/us,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Aetna MCR ADV,CPT,59072,Umbilical cord occlud w/us,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Aetna MCR ADV,CPT,59074,Fetal fluid drainage w/us,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Aetna MCR ADV,CPT,59076,Fetal shunt placement w/us,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Aetna MCR ADV,CPT,59100,Remove uterus lesion,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Aetna MCR ADV,CPT,59120,Treat ectopic pregnancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,59121,Treat ectopic pregnancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,59130,Treat ectopic pregnancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,59135,Treat ectopic pregnancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,59136,Treat ectopic pregnancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,59140,Treat ectopic pregnancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,59150,Treat ectopic pregnancy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,59151,Treat ectopic pregnancy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,59160,D & c after delivery,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,59200,Insert cervical dilator,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Aetna MCR ADV,CPT,59300,Episiotomy or vaginal repair,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,59320,Revision of cervix,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,59325,Revision of cervix,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,59350,Repair of uterus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,59409,Obstetrical care,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,59412,Antepartum manipulation,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,59414,Deliver placenta,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,59514,Cesarean delivery only,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,59525,Remove uterus after cesarean,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,59612,Vbac delivery only,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,59620,Attempted vbac delivery only,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,59812,Treatment of miscarriage,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,59820,Care of miscarriage,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,59821,Treatment of miscarriage,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,59830,Treat uterus infection,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,59840,Abortion,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,59841,Abortion,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,59850,Abortion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,59851,Abortion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,59852,Abortion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,59855,Abortion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,59856,Abortion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,59857,Abortion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,59866,Abortion (mpr),APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Aetna MCR ADV,CPT,59870,Evacuate mole of uterus,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,59871,Remove cerclage suture,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Aetna MCR ADV,CPT,59897,Fetal invas px w/us,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Aetna MCR ADV,CPT,59898,Laparo proc ob care/deliver,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,59899,Maternity care procedure,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Aetna MCR ADV,CPT,60000,Drain thyroid/tongue cyst,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,60100,Biopsy of thyroid,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,60200,Remove thyroid lesion,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,60210,Partial thyroid excision,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,60212,Partial thyroid excision,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,60220,Partial removal of thyroid,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,60225,Partial removal of thyroid,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,60240,Removal of thyroid,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,60252,Removal of thyroid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,60254,Extensive thyroid surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,60260,Repeat thyroid surgery,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,60270,Removal of thyroid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,60271,Removal of thyroid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,60280,Remove thyroid duct lesion,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,60281,Remove thyroid duct lesion,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,60300,Aspir/inj thyroid cyst,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,60500,Explore parathyroid glands,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,60502,Re-explore parathyroids,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,60505,Explore parathyroid glands,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,60520,Removal of thymus gland,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,60521,Removal of thymus gland,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,60522,Removal of thymus gland,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,60540,Explore adrenal gland,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,60545,Explore adrenal gland,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,60600,Remove carotid body lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,60605,Remove carotid body lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,60650,Laparoscopy adrenalectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,60659,Laparo proc endocrine,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,60699,Endocrine surgery procedure,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Aetna MCR ADV,CPT,61000,Remove cranial cavity fluid,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,61001,Remove cranial cavity fluid,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,61020,Remove brain cavity fluid,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Aetna MCR ADV,CPT,61026,Injection into brain canal,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,61050,Remove brain canal fluid,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Aetna MCR ADV,CPT,61055,Injection into brain canal,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Aetna MCR ADV,CPT,61070,Brain canal shunt procedure,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,61105,Twist drill hole,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61107,Drill skull for implantation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61108,Drill skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61120,Burr hole for puncture,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61140,Pierce skull for biopsy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61150,Pierce skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61151,Pierce skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61154,Pierce skull & remove clot,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61156,Pierce skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61210,Pierce skull implant device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61215,Insert brain-fluid device,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Aetna MCR ADV,CPT,61250,Pierce skull & explore,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61253,Pierce skull & explore,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61304,Open skull for exploration,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61305,Open skull for exploration,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61312,Open skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61313,Open skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61314,Open skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61315,Open skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61316,Implt cran bone flap to abdo,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61320,Open skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61321,Open skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61322,Decompressive craniotomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61323,Decompressive lobectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61330,Decompress eye socket,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,61333,Explore orbit/remove lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61340,Subtemporal decompression,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61343,Incise skull (press relief),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61345,Relieve cranial pressure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61450,Incise skull for surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61458,Incise skull for brain wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61460,Incise skull for surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61500,Removal of skull lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61501,Remove infected skull bone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61510,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61512,Remove brain lining lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61514,Removal of brain abscess,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61516,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61517,Implt brain chemotx add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61518,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61519,Remove brain lining lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61520,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61521,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61522,Removal of brain abscess,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61524,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61526,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61530,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61531,Implant brain electrodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61533,Implant brain electrodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61534,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61535,Remove brain electrodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61536,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61537,Removal of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61538,Removal of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61539,Removal of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61540,Removal of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61541,Incision of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61543,Removal of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61544,Remove & treat brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61545,Excision of brain tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61546,Removal of pituitary gland,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61548,Removal of pituitary gland,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61550,Release of skull seams,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61552,Release of skull seams,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61556,Incise skull/sutures,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61557,Incise skull/sutures,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61558,Excision of skull/sutures,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61559,Excision of skull/sutures,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61563,Excision of skull tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61564,Excision of skull tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61566,Removal of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61567,Incision of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61570,Remove foreign body brain,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61571,Incise skull for brain wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61575,Skull base/brainstem surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61576,Skull base/brainstem surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61580,Craniofacial approach skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61581,Craniofacial approach skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61582,Craniofacial approach skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61583,Craniofacial approach skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61584,Orbitocranial approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61585,Orbitocranial approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61586,Resect nasopharynx skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61590,Infratemporal approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61591,Infratemporal approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61592,Orbitocranial approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61595,Transtemporal approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61596,Transcochlear approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61597,Transcondylar approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61598,Transpetrosal approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61600,Resect/excise cranial lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61601,Resect/excise cranial lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61605,Resect/excise cranial lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61606,Resect/excise cranial lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61607,Resect/excise cranial lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61608,Resect/excise cranial lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61611,Transect artery sinus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61613,Remove aneurysm sinus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61615,Resect/excise lesion skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61616,Resect/excise lesion skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61618,Repair dura,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61619,Repair dura,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61623,Endovasc tempory vessel occl,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Aetna MCR ADV,CPT,61624,Transcath occlusion cns,APC 5194,RVU Per Case,"$16,438.60 ",OP,"4,314.00","16,438.60",,,,,,
Aetna MCR ADV,CPT,61626,Transcath occlusion non-cns,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Aetna MCR ADV,CPT,61630,Intracranial angioplasty,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61635,Intracran angioplsty w/stent,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61645,Perq art m-thrombect &/nfs,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61650,Evasc prlng admn rx agnt 1st,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61651,Evasc prlng admn rx agnt add,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61680,Intracranial vessel surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61682,Intracranial vessel surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61684,Intracranial vessel surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61686,Intracranial vessel surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61690,Intracranial vessel surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61692,Intracranial vessel surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61697,Brain aneurysm repr complx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61698,Brain aneurysm repr complx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61700,Brain aneurysm repr simple,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61702,Inner skull vessel surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61703,Clamp neck artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61705,Revise circulation to head,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61708,Revise circulation to head,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61710,Revise circulation to head,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61711,Fusion of skull arteries,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61720,Incise skull/brain surgery,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Aetna MCR ADV,CPT,61735,Incise skull/brain surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61750,Incise skull/brain biopsy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61751,Brain biopsy w/ct/mr guide,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61760,Implant brain electrodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61770,Incise skull for treatment,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Aetna MCR ADV,CPT,61790,Treat trigeminal nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,61791,Treat trigeminal tract,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,61850,Implant neuroelectrodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61860,Implant neuroelectrodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61863,Implant neuroelectrode,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61864,Implant neuroelectrde addl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61867,Implant neuroelectrode,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61868,Implant neuroelectrde addl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,61880,Revise/remove neuroelectrode,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","4,314.00",,,,,,
Aetna MCR ADV,CPT,61885,Insrt/redo neurostim 1 array,APC 5464,RVU Per Case,"$20,957.35 ",OP,"4,140.35","20,957.35",,,,,,
Aetna MCR ADV,CPT,61886,Implant neurostim arrays,APC 5465,RVU Per Case,"$30,131.14 ",OP,"4,314.00","30,131.14",,,,,,
Aetna MCR ADV,CPT,61888,Revise/remove neuroreceiver,APC 5463,RVU Per Case,"$11,498.23 ",OP,"4,314.00","11,498.23",,,,,,
Aetna MCR ADV,CPT,62000,Treat skull fracture,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,62005,Treat skull fracture,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,62010,Treatment of head injury,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,62100,Repair brain fluid leakage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,62115,Reduction of skull defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,62117,Reduction of skull defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,62120,Repair skull cavity lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,62121,Incise skull repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,62140,Repair of skull defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,62141,Repair of skull defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,62142,Remove skull plate/flap,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,62143,Replace skull plate/flap,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,62145,Repair of skull & brain,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,62146,Repair of skull with graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,62147,Repair of skull with graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,62148,Retr bone flap to fix skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,62161,Dissect brain w/scope,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,62162,Remove colloid cyst w/scope,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,62164,Remove brain tumor w/scope,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,62165,Remove pituit tumor w/scope,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,62180,Establish brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,62190,Establish brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,62192,Establish brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,62194,Replace/irrigate catheter,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,62200,Establish brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,62201,Brain cavity shunt w/scope,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,62220,Establish brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,62223,Establish brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,62225,Replace/irrigate catheter,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Aetna MCR ADV,CPT,62230,Replace/revise brain shunt,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Aetna MCR ADV,CPT,62252,Csf shunt reprogram,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,"4,314.00",,,,,,
Aetna MCR ADV,CPT,62256,Remove brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,62258,Replace brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,62263,Epidural lysis mult sessions,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Aetna MCR ADV,CPT,62264,Epidural lysis on single day,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Aetna MCR ADV,CPT,62267,Interdiscal perq aspir dx,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,62268,Drain spinal cord cyst,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Aetna MCR ADV,CPT,62269,Needle biopsy spinal cord,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,62270,Dx lmbr spi pnxr,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,62272,Ther spi pnxr drg csf,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,62273,Inject epidural patch,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,62280,Treat spinal cord lesion,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Aetna MCR ADV,CPT,62281,Treat spinal cord lesion,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Aetna MCR ADV,CPT,62282,Treat spinal canal lesion,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Aetna MCR ADV,CPT,62287,Percutaneous diskectomy,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,62292,Njx chemonucleolysis lmbr,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,62294,Injection into spinal artery,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Aetna MCR ADV,CPT,62302,Myelography lumbar injection,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"4,314.00",,,,,,
Aetna MCR ADV,CPT,62303,Myelography lumbar injection,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"4,314.00",,,,,,
Aetna MCR ADV,CPT,62304,Myelography lumbar injection,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"4,314.00",,,,,,
Aetna MCR ADV,CPT,62305,Myelography lumbar injection,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"4,314.00",,,,,,
Aetna MCR ADV,CPT,62320,Njx interlaminar crv/thrc,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,62321,Njx interlaminar crv/thrc,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,62322,Njx interlaminar lmbr/sac,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,62323,Njx interlaminar lmbr/sac,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,62324,Njx interlaminar crv/thrc,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Aetna MCR ADV,CPT,62325,Njx interlaminar crv/thrc,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Aetna MCR ADV,CPT,62326,Njx interlaminar lmbr/sac,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Aetna MCR ADV,CPT,62327,Njx interlaminar lmbr/sac,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Aetna MCR ADV,CPT,62328,Dx lmbr spi pnxr w/fluor/ct,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,62329,Ther spi pnxr csf fluor/ct,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,62350,Implant spinal canal cath,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Aetna MCR ADV,CPT,62351,Implant spinal canal cath,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,62355,Remove spinal canal catheter,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,62360,Insert spine infusion device,APC 5471,RVU Per Case,"$17,429.07 ",OP,"4,314.00","17,429.07",,,,,,
Aetna MCR ADV,CPT,62361,Implant spine infusion pump,APC 5471,RVU Per Case,"$17,429.07 ",OP,"4,314.00","17,429.07",,,,,,
Aetna MCR ADV,CPT,62362,Implant spine infusion pump,APC 5471,RVU Per Case,"$17,429.07 ",OP,"4,140.35","17,429.07",,,,,,
Aetna MCR ADV,CPT,62365,Remove spine infusion device,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Aetna MCR ADV,CPT,62367,Analyze spine infus pump,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,"4,314.00",,,,,,
Aetna MCR ADV,CPT,62368,Analyze sp inf pump w/reprog,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,"4,314.00",,,,,,
Aetna MCR ADV,CPT,62369,Anal sp inf pmp w/reprg&fill,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,"4,314.00",,,,,,
Aetna MCR ADV,CPT,62370,Anl sp inf pmp w/mdreprg&fil,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,"4,314.00",,,,,,
Aetna MCR ADV,CPT,62380,Ndsc dcmprn 1 ntrspc lumbar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,63001,Remove spine lamina 1/2 crvl,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,63003,Remove spine lamina 1/2 thrc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,63005,Remove spine lamina 1/2 lmbr,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,63011,Remove spine lamina 1/2 scrl,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,63012,Remove lamina/facets lumbar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,63015,Remove spine lamina >2 crvcl,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,63016,Remove spine lamina >2 thrc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,63017,Remove spine lamina >2 lmbr,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,63020,Neck spine disk surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,63030,Low back disk surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,63040,Laminotomy single cervical,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,63042,Laminotomy single lumbar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,63045,Remove spine lamina 1 crvl,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,63046,Remove spine lamina 1 thrc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,63047,Remove spine lamina 1 lmbr,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,63050,Cervical laminoplsty 2/> seg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63051,C-laminoplasty w/graft/plate,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63055,Decompress spinal cord thrc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,63056,Decompress spinal cord lmbr,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,63064,Decompress spinal cord thrc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,63075,Neck spine disk surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,63077,Spine disk surgery thorax,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63078,Spine disk surgery thorax,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63081,Remove vert body dcmprn crvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63082,Remove vertebral body add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63085,Remove vert body dcmprn thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63086,Remove vertebral body add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63087,Remov vertbr dcmprn thrclmbr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63088,Remove vertebral body add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63090,Remove vert body dcmprn lmbr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63091,Remove vertebral body add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63101,Remove vert body dcmprn thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63102,Remove vert body dcmprn lmbr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63103,Remove vertebral body add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63170,Incise spinal cord tract(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63172,Drainage of spinal cyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63173,Drainage of spinal cyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63185,Incise spine nrv half segmnt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63190,Incise spine nrv >2 segmnts,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63191,Incise spine accessory nerve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63194,Incise spine & cord cervical,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63195,Incise spine & cord thoracic,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63196,Incise spine&cord 2 trx crvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63197,Incise spine&cord 2 trx thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63198,Incise spin&cord 2 stgs crvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63199,Incise spin&cord 2 stgs thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63200,Release spinal cord lumbar,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63250,Revise spinal cord vsls crvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63251,Revise spinal cord vsls thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63252,Revise spine cord vsl thrlmb,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63265,Excise intraspinl lesion crv,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,63266,Excise intrspinl lesion thrc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,63267,Excise intrspinl lesion lmbr,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,63268,Excise intrspinl lesion scrl,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,63270,Excise intrspinl lesion crvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63271,Excise intrspinl lesion thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63272,Excise intrspinl lesion lmbr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63273,Excise intrspinl lesion scrl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63275,Bx/exc xdrl spine lesn crvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63276,Bx/exc xdrl spine lesn thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63277,Bx/exc xdrl spine lesn lmbr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63278,Bx/exc xdrl spine lesn scrl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63280,Bx/exc idrl spine lesn crvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63281,Bx/exc idrl spine lesn thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63282,Bx/exc idrl spine lesn lmbr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63283,Bx/exc idrl spine lesn scrl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63285,Bx/exc idrl imed lesn cervl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63286,Bx/exc idrl imed lesn thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63287,Bx/exc idrl imed lesn thrlmb,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63290,Bx/exc xdrl/idrl lsn any lvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63295,Repair laminectomy defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63300,Remove vert xdrl body crvcl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63301,Remove vert xdrl body thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63302,Remove vert xdrl body thrlmb,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63303,Remov vert xdrl bdy lmbr/sac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63304,Remove vert idrl body crvcl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63305,Remove vert idrl body thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63306,Remov vert idrl bdy thrclmbr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63307,Remov vert idrl bdy lmbr/sac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63308,Remove vertebral body add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63600,Remove spinal cord lesion,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,63610,Stimulation of spinal cord,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,63650,Implant neuroelectrodes,APC 5462,RVU Per Case,"$6,304.35 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,63655,Implant neuroelectrodes,APC 5464,RVU Per Case,"$20,957.35 ",OP,"4,140.35","20,957.35",,,,,,
Aetna MCR ADV,CPT,63661,Remove spine eltrd perq aray,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,63662,Remove spine eltrd plate,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","4,314.00",,,,,,
Aetna MCR ADV,CPT,63663,Revise spine eltrd perq aray,APC 5462,RVU Per Case,"$6,304.35 ",OP,"4,314.00","6,304.35",,,,,,
Aetna MCR ADV,CPT,63664,Revise spine eltrd plate,APC 5463,RVU Per Case,"$11,498.23 ",OP,"4,314.00","11,498.23",,,,,,
Aetna MCR ADV,CPT,63685,Insrt/redo spine n generator,APC 5465,RVU Per Case,"$30,131.14 ",OP,"4,140.35","30,131.14",,,,,,
Aetna MCR ADV,CPT,63688,Revise/remove neuroreceiver,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","4,314.00",,,,,,
Aetna MCR ADV,CPT,63700,Repair of spinal herniation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63702,Repair of spinal herniation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63704,Repair of spinal herniation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63706,Repair of spinal herniation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63707,Repair spinal fluid leakage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63709,Repair spinal fluid leakage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63710,Graft repair of spine defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63740,Install spinal shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,63741,Install spinal shunt,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Aetna MCR ADV,CPT,63744,Revision of spinal shunt,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Aetna MCR ADV,CPT,63746,Removal of spinal shunt,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,64400,Njx aa&/strd trigeminal nrv,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64405,Njx aa&/strd gr ocpl nrv,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64408,Njx aa&/strd vagus nrv,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64415,Njx aa&/strd brach plexus,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64416,Njx aa&/strd brach plex nfs,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64417,Njx aa&/strd axillary nrv,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64418,Njx aa&/strd sprscap nrv,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64420,Njx aa&/strd ntrcost nrv 1,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64421,Njx aa&/strd ntrcost nrv ea,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64425,Njx aa&/strd ii ih nerves,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64430,Njx aa&/strd pudendal nerve,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64435,Njx aa&/strd paracrv nrv,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64445,Njx aa&/strd sciatic nerve,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64446,Njx aa&/strd sciatic nrv nfs,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64447,Njx aa&/strd femoral nerve,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64448,Njx aa&/strd fem nerve nfs,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64449,Njx aa&/strd lmbr plex nfs,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64450,Njx aa&/strd other pn/branch,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64451,Njx aa&/strd nrv nrvtg si jt,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64454,Njx aa&/strd gnclr nrv brnch,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64455,Njx aa&/strd pltr com dg nrv,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64461,Pvb thoracic single inj site,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64463,Pvb thoracic cont infusion,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64479,Njx aa&/strd tfrm epi c/t 1,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64483,Njx aa&/strd tfrm epi l/s 1,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64490,Inj paravert f jnt c/t 1 lev,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64493,Inj paravert f jnt l/s 1 lev,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64505,N block spenopalatine gangl,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64510,N block stellate ganglion,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64517,N block inj hypogas plxs,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64520,N block lumbar/thoracic,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64530,N block inj celiac pelus,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64553,Implant neuroelectrodes,APC 5463,RVU Per Case,"$11,498.23 ",OP,"4,314.00","11,498.23",,,,,,
Aetna MCR ADV,CPT,64555,Implant neuroelectrodes,APC 5462,RVU Per Case,"$6,304.35 ",OP,"4,314.00","6,304.35",,,,,,
Aetna MCR ADV,CPT,64561,Implant neuroelectrodes,APC 5462,RVU Per Case,"$6,304.35 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,64566,Neuroeltrd stim post tibial,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64568,Inc for vagus n elect impl,APC 5465,RVU Per Case,"$30,131.14 ",OP,"4,140.35","30,131.14",,,,,,
Aetna MCR ADV,CPT,64569,Revise/repl vagus n eltrd,APC 5463,RVU Per Case,"$11,498.23 ",OP,"4,314.00","11,498.23",,,,,,
Aetna MCR ADV,CPT,64570,Remove vagus n eltrd,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Aetna MCR ADV,CPT,64575,Implant neuroelectrodes,APC 5463,RVU Per Case,"$11,498.23 ",OP,"4,314.00","11,498.23",,,,,,
Aetna MCR ADV,CPT,64580,Implant neuroelectrodes,APC 5464,RVU Per Case,"$20,957.35 ",OP,"4,314.00","20,957.35",,,,,,
Aetna MCR ADV,CPT,64581,Implant neuroelectrodes,APC 5462,RVU Per Case,"$6,304.35 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,64585,Revise/remove neuroelectrode,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","4,314.00",,,,,,
Aetna MCR ADV,CPT,64590,Insrt/redo pn/gastr stimul,APC 5464,RVU Per Case,"$20,957.35 ",OP,"4,140.35","20,957.35",,,,,,
Aetna MCR ADV,CPT,64595,Revise/rmv pn/gastr stimul,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","4,314.00",,,,,,
Aetna MCR ADV,CPT,64600,Injection treatment of nerve,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64605,Injection treatment of nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,64610,Injection treatment of nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,64611,Chemodenerv saliv glands,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64612,Destroy nerve face muscle,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64615,Chemodenerv musc migraine,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64616,Chemodenerv musc neck dyston,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64617,Chemodener muscle larynx emg,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64620,Injection treatment of nerve,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64624,Dstrj nulyt agt gnclr nrv,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,64625,Rf abltj nrv nrvtg si jt,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,64630,Injection treatment of nerve,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64632,N block inj common digit,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64633,Destroy cerv/thor facet jnt,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,64635,Destroy lumb/sac facet jnt,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,64640,Injection treatment of nerve,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64642,Chemodenerv 1 extremity 1-4,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64644,Chemodenerv 1 extrem 5/> mus,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64646,Chemodenerv trunk musc 1-5,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64647,Chemodenerv trunk musc 6/>,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64650,Chemodenerv eccrine glands,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64653,Chemodenerv eccrine glands,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64680,Injection treatment of nerve,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64681,Injection treatment of nerve,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Aetna MCR ADV,CPT,64702,Revise finger/toe nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,64704,Revise hand/foot nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,64708,Revise arm/leg nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,64712,Revision of sciatic nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,64713,Revision of arm nerve(s),APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,64714,Revise low back nerve(s),APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,64716,Revision of cranial nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,64718,Revise ulnar nerve at elbow,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,64719,Revise ulnar nerve at wrist,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,64721,Carpal tunnel surgery,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,64722,Relieve pressure on nerve(s),APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,64726,Release foot/toe nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,64732,Incision of brow nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,64734,Incision of cheek nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,64736,Incision of chin nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,64738,Incision of jaw nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,64740,Incision of tongue nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,64742,Incision of facial nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,64744,Incise nerve back of head,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,64746,Incise diaphragm nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,64755,Incision of stomach nerves,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,64760,Incision of vagus nerve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,64763,Incise hip/thigh nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,64766,Incise hip/thigh nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,64771,Sever cranial nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,64772,Incision of spinal nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,64774,Remove skin nerve lesion,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,64776,Remove digit nerve lesion,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,64782,Remove limb nerve lesion,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,64784,Remove nerve lesion,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,64786,Remove sciatic nerve lesion,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Aetna MCR ADV,CPT,64788,Remove skin nerve lesion,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,64790,Removal of nerve lesion,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,64792,Removal of nerve lesion,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Aetna MCR ADV,CPT,64795,Biopsy of nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,64802,Sympathectomy cervical,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,64804,Remove sympathetic nerves,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,64809,Remove sympathetic nerves,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,64818,Remove sympathetic nerves,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,64820,Sympathectomy digital artery,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,64821,Remove sympathetic nerves,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,64822,Remove sympathetic nerves,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,64823,Sympathectomy supfc palmar,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Aetna MCR ADV,CPT,64831,Repair of digit nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,64834,Repair of hand or foot nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Aetna MCR ADV,CPT,64835,Repair of hand or foot nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Aetna MCR ADV,CPT,64836,Repair of hand or foot nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Aetna MCR ADV,CPT,64840,Repair of leg nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Aetna MCR ADV,CPT,64856,Repair/transpose nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Aetna MCR ADV,CPT,64857,Repair arm/leg nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Aetna MCR ADV,CPT,64858,Repair sciatic nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,64861,Repair of arm nerves,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Aetna MCR ADV,CPT,64862,Repair of low back nerves,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Aetna MCR ADV,CPT,64864,Repair of facial nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Aetna MCR ADV,CPT,64865,Repair of facial nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Aetna MCR ADV,CPT,64866,Fusion of facial/other nerve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,64868,Fusion of facial/other nerve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,64885,Nerve graft head/neck </4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Aetna MCR ADV,CPT,64886,Nerve graft head/neck >4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Aetna MCR ADV,CPT,64890,Nerve graft hand/foot </4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Aetna MCR ADV,CPT,64891,Nerve graft hand/foot >4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Aetna MCR ADV,CPT,64892,Nerve graft arm/leg <4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Aetna MCR ADV,CPT,64893,Nerve graft arm/leg >4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Aetna MCR ADV,CPT,64895,Nerve graft hand/foot </4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Aetna MCR ADV,CPT,64896,Nerve graft hand/foot >4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Aetna MCR ADV,CPT,64897,Nerve graft arm/leg </4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Aetna MCR ADV,CPT,64898,Nerve graft arm/leg >4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Aetna MCR ADV,CPT,64905,Nerve pedicle transfer,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Aetna MCR ADV,CPT,64907,Nerve pedicle transfer,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Aetna MCR ADV,CPT,64910,Nerve repair w/allograft,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Aetna MCR ADV,CPT,64911,Neurorraphy w/vein autograft,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Aetna MCR ADV,CPT,64912,Nrv rpr w/nrv algrft 1st,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Aetna MCR ADV,CPT,64999,Nervous system surgery,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Aetna MCR ADV,CPT,65091,Revise eye,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,65093,Revise eye with implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,65101,Removal of eye,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,65103,Remove eye/insert implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,65105,Remove eye/attach implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,65110,Removal of eye,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,65112,Remove eye/revise socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,65114,Remove eye/revise socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,65125,Revise ocular implant,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,65130,Insert ocular implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,65135,Insert ocular implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,65140,Attach ocular implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,65150,Revise ocular implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,65155,Reinsert ocular implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,65175,Removal of ocular implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,65205,Remove foreign body from eye,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Aetna MCR ADV,CPT,65210,Remove foreign body from eye,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Aetna MCR ADV,CPT,65220,Remove foreign body from eye,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Aetna MCR ADV,CPT,65222,Remove foreign body from eye,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Aetna MCR ADV,CPT,65235,Remove foreign body from eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,65260,Remove foreign body from eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,65265,Remove foreign body from eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,65270,Repair of eye wound,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,65272,Repair of eye wound,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,65273,Repair of eye wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,65275,Repair of eye wound,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,65280,Repair of eye wound,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Aetna MCR ADV,CPT,65285,Repair of eye wound,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Aetna MCR ADV,CPT,65286,Repair of eye wound,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,65290,Repair of eye socket wound,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,65400,Removal of eye lesion,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Aetna MCR ADV,CPT,65410,Biopsy of cornea,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,65420,Removal of eye lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,65426,Removal of eye lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,65430,Corneal smear,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Aetna MCR ADV,CPT,65435,Curette/treat cornea,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Aetna MCR ADV,CPT,65436,Curette/treat cornea,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,65450,Treatment of corneal lesion,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Aetna MCR ADV,CPT,65600,Revision of cornea,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,65710,Corneal transplant,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Aetna MCR ADV,CPT,65730,Corneal transplant,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","9,201.00",,,,,,
Aetna MCR ADV,CPT,65750,Corneal transplant,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Aetna MCR ADV,CPT,65755,Corneal transplant,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Aetna MCR ADV,CPT,65756,Corneal trnspl endothelial,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","9,201.00",,,,,,
Aetna MCR ADV,CPT,65770,Revise cornea with implant,APC 5493,RVU Per Case,"$7,506.93 ",OP,"4,314.00","7,506.93",,,,,,
Aetna MCR ADV,CPT,65772,Correction of astigmatism,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Aetna MCR ADV,CPT,65775,Correction of astigmatism,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,65778,Cover eye w/membrane,APC 5502,RVU Per Case,$828.42 ,OP,828.42,"4,314.00",,,,,,
Aetna MCR ADV,CPT,65779,Cover eye w/membrane suture,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,65780,Ocular reconst transplant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,65781,Ocular reconst transplant,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Aetna MCR ADV,CPT,65782,Ocular reconst transplant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,65785,Impltj ntrstrml crnl rng seg,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Aetna MCR ADV,CPT,65800,Drainage of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,65810,Drainage of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,65815,Drainage of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,65820,Relieve inner eye pressure,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Aetna MCR ADV,CPT,65850,Incision of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,65855,Trabeculoplasty laser surg,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Aetna MCR ADV,CPT,65860,Incise inner eye adhesions,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Aetna MCR ADV,CPT,65865,Incise inner eye adhesions,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,65870,Incise inner eye adhesions,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,65875,Incise inner eye adhesions,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,65880,Incise inner eye adhesions,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Aetna MCR ADV,CPT,65900,Remove eye lesion,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,65920,Remove implant of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,65930,Remove blood clot from eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,66020,Injection treatment of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,66030,Injection treatment of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,66130,Remove eye lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,66150,Glaucoma surgery,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Aetna MCR ADV,CPT,66155,Glaucoma surgery,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Aetna MCR ADV,CPT,66160,Glaucoma surgery,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,66170,Glaucoma surgery,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,66172,Incision of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,66174,Translum dil eye canal,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Aetna MCR ADV,CPT,66175,Trnslum dil eye canal w/stnt,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Aetna MCR ADV,CPT,66179,Aqueous shunt eye w/o graft,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Aetna MCR ADV,CPT,66180,Aqueous shunt eye w/graft,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","9,201.00",,,,,,
Aetna MCR ADV,CPT,66183,Insert ant drainage device,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Aetna MCR ADV,CPT,66184,Revision of aqueous shunt,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,66185,Revise aqueous shunt eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,66225,Repair/graft eye lesion,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Aetna MCR ADV,CPT,66250,Follow-up surgery of eye,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,66500,Incision of iris,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,66505,Incision of iris,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,66600,Remove iris and lesion,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Aetna MCR ADV,CPT,66605,Removal of iris,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,66625,Removal of iris,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,66630,Removal of iris,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,66635,Removal of iris,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,66680,Repair iris & ciliary body,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,66682,Repair iris & ciliary body,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,66700,Destruction ciliary body,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,66710,Ciliary transsleral therapy,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,66711,Ecp ciliary body destruction,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,66720,Destruction ciliary body,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,66740,Destruction ciliary body,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,66761,Revision of iris,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Aetna MCR ADV,CPT,66762,Revision of iris,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Aetna MCR ADV,CPT,66770,Removal of inner eye lesion,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Aetna MCR ADV,CPT,66820,Incision secondary cataract,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,66821,After cataract laser surgery,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Aetna MCR ADV,CPT,66825,Reposition intraocular lens,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,66830,Removal of lens lesion,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,66840,Removal of lens material,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,66850,Removal of lens material,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,66852,Removal of lens material,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Aetna MCR ADV,CPT,66920,Extraction of lens,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,66930,Extraction of lens,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Aetna MCR ADV,CPT,66940,Extraction of lens,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,66982,Xcapsl ctrc rmvl cplx wo ecp,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,66983,Cataract surg w/iol 1 stage,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,66984,Xcapsl ctrc rmvl w/o ecp,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,66985,Insert lens prosthesis,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,66986,Exchange lens prosthesis,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,66987,Xcapsl ctrc rmvl cplx w/ecp,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Aetna MCR ADV,CPT,66988,Xcapsl ctrc rmvl w/ecp,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Aetna MCR ADV,CPT,66999,Eye surgery procedure,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,67005,Partial removal of eye fluid,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,67010,Partial removal of eye fluid,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,67015,Release of eye fluid,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,67025,Replace eye fluid,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,67027,Implant eye drug system,APC 5494,RVU Per Case,"$15,359.39 ",OP,"4,314.00","15,359.39",,,,,,
Aetna MCR ADV,CPT,67028,Injection eye drug,APC 5694,RVU Per Unit,$318.00 ,OP,318,"4,314.00",,,,,,
Aetna MCR ADV,CPT,67030,Incise inner eye strands,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,67031,Laser surgery eye strands,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Aetna MCR ADV,CPT,67036,Removal of inner eye fluid,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Aetna MCR ADV,CPT,67039,Laser treatment of retina,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Aetna MCR ADV,CPT,67040,Laser treatment of retina,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Aetna MCR ADV,CPT,67041,Vit for macular pucker,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Aetna MCR ADV,CPT,67042,Vit for macular hole,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Aetna MCR ADV,CPT,67043,Vit for membrane dissect,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Aetna MCR ADV,CPT,67101,Repair detached retina crtx,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,67105,Repair detached retina pc,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Aetna MCR ADV,CPT,67107,Repair detached retina,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Aetna MCR ADV,CPT,67108,Repair detached retina,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","9,201.00",,,,,,
Aetna MCR ADV,CPT,67110,Repair detached retina,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,67113,Repair retinal detach cplx,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","9,201.00",,,,,,
Aetna MCR ADV,CPT,67115,Release encircling material,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Aetna MCR ADV,CPT,67120,Remove eye implant material,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,67121,Remove eye implant material,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,67141,Treatment of retina,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Aetna MCR ADV,CPT,67145,Treatment of retina,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Aetna MCR ADV,CPT,67208,Treatment of retinal lesion,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Aetna MCR ADV,CPT,67210,Treatment of retinal lesion,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Aetna MCR ADV,CPT,67218,Treatment of retinal lesion,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,67220,Treatment of choroid lesion,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Aetna MCR ADV,CPT,67221,Ocular photodynamic ther,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Aetna MCR ADV,CPT,67227,Dstrj extensive retinopathy,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,67228,Treatment x10sv retinopathy,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Aetna MCR ADV,CPT,67229,Tr retinal les preterm inf,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Aetna MCR ADV,CPT,67250,Reinforce eye wall,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,67255,Reinforce/graft eye wall,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,67299,Eye surgery procedure,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,67311,Revise eye muscle,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,67312,Revise two eye muscles,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,67314,Revise eye muscle,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,67316,Revise two eye muscles,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,67318,Revise eye muscle(s),APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,67343,Release eye tissue,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,67345,Destroy nerve of eye muscle,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Aetna MCR ADV,CPT,67346,Biopsy eye muscle,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,67399,Unlisted px extraocular musc,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Aetna MCR ADV,CPT,67400,Explore/biopsy eye socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,67405,Explore/drain eye socket,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,67412,Explore/treat eye socket,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,67413,Explore/treat eye socket,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,67414,Explr/decompress eye socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,67415,Aspiration orbital contents,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,67420,Explore/treat eye socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,67430,Explore/treat eye socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,67440,Explore/drain eye socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,67445,Explr/decompress eye socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,67450,Explore/biopsy eye socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,67500,Inject/treat eye socket,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Aetna MCR ADV,CPT,67505,Inject/treat eye socket,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Aetna MCR ADV,CPT,67515,Inject/treat eye socket,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Aetna MCR ADV,CPT,67550,Insert eye socket implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,67560,Revise eye socket implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,67570,Decompress optic nerve,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,67599,Orbit surgery procedure,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Aetna MCR ADV,CPT,67700,Drainage of eyelid abscess,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Aetna MCR ADV,CPT,67710,Incision of eyelid,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Aetna MCR ADV,CPT,67715,Incision of eyelid fold,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,67800,Remove eyelid lesion,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Aetna MCR ADV,CPT,67801,Remove eyelid lesions,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Aetna MCR ADV,CPT,67805,Remove eyelid lesions,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Aetna MCR ADV,CPT,67808,Remove eyelid lesion(s),APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,67810,Biopsy eyelid & lid margin,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Aetna MCR ADV,CPT,67820,Revise eyelashes,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Aetna MCR ADV,CPT,67825,Revise eyelashes,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Aetna MCR ADV,CPT,67830,Revise eyelashes,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Aetna MCR ADV,CPT,67835,Revise eyelashes,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,67840,Remove eyelid lesion,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Aetna MCR ADV,CPT,67850,Treat eyelid lesion,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Aetna MCR ADV,CPT,67875,Closure of eyelid by suture,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Aetna MCR ADV,CPT,67880,Revision of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,67882,Revision of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,67900,Repair brow defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,67901,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,67902,Repair eyelid defect,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,67903,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,67904,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,67906,Repair eyelid defect,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,67908,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,67909,Revise eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,67911,Revise eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,67912,Correction eyelid w/implant,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,67914,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,67915,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,67916,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,67917,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,67921,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,67922,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,67923,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,67924,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,67930,Repair eyelid wound,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,67935,Repair eyelid wound,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,67938,Remove eyelid foreign body,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Aetna MCR ADV,CPT,67950,Revision of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,67961,Revision of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,67966,Revision of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,67971,Reconstruction of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,67973,Reconstruction of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,67974,Reconstruction of eyelid,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,67975,Reconstruction of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,67999,Revision of eyelid,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Aetna MCR ADV,CPT,68020,Incise/drain eyelid lining,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Aetna MCR ADV,CPT,68040,Treatment of eyelid lesions,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Aetna MCR ADV,CPT,68100,Biopsy of eyelid lining,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,68110,Remove eyelid lining lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,68115,Remove eyelid lining lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,68130,Remove eyelid lining lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,68135,Remove eyelid lining lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,68200,Treat eyelid by injection,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Aetna MCR ADV,CPT,68320,Revise/graft eyelid lining,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,68325,Revise/graft eyelid lining,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,68326,Revise/graft eyelid lining,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,68328,Revise/graft eyelid lining,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,68330,Revise eyelid lining,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Aetna MCR ADV,CPT,68335,Revise/graft eyelid lining,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,68340,Separate eyelid adhesions,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,68360,Revise eyelid lining,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,68362,Revise eyelid lining,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,68371,Harvest eye tissue alograft,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,68399,Eyelid lining surgery,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Aetna MCR ADV,CPT,68400,Incise/drain tear gland,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Aetna MCR ADV,CPT,68420,Incise/drain tear sac,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,68440,Incise tear duct opening,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Aetna MCR ADV,CPT,68500,Removal of tear gland,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,68505,Partial removal tear gland,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,68510,Biopsy of tear gland,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,68520,Removal of tear sac,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,68525,Biopsy of tear sac,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,68530,Clearance of tear duct,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Aetna MCR ADV,CPT,68540,Remove tear gland lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,68550,Remove tear gland lesion,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,68700,Repair tear ducts,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,68705,Revise tear duct opening,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Aetna MCR ADV,CPT,68720,Create tear sac drain,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,68745,Create tear duct drain,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,68750,Create tear duct drain,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Aetna MCR ADV,CPT,68760,Close tear duct opening,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Aetna MCR ADV,CPT,68761,Close tear duct opening,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Aetna MCR ADV,CPT,68770,Close tear system fistula,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,68801,Dilate tear duct opening,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Aetna MCR ADV,CPT,68810,Probe nasolacrimal duct,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Aetna MCR ADV,CPT,68811,Probe nasolacrimal duct,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,68815,Probe nasolacrimal duct,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,68816,Probe nl duct w/balloon,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Aetna MCR ADV,CPT,68840,Explore/irrigate tear ducts,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Aetna MCR ADV,CPT,68899,Tear duct system surgery,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Aetna MCR ADV,CPT,69000,Drain external ear lesion,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,69005,Drain external ear lesion,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,69020,Drain outer ear canal lesion,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Aetna MCR ADV,CPT,69100,Biopsy of external ear,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Aetna MCR ADV,CPT,69105,Biopsy of external ear canal,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,69110,Remove external ear partial,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,69120,Removal of external ear,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,69140,Remove ear canal lesion(s),APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,69145,Remove ear canal lesion(s),APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Aetna MCR ADV,CPT,69150,Extensive ear canal surgery,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,69155,Extensive ear/neck surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,69200,Clear outer ear canal,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Aetna MCR ADV,CPT,69205,Clear outer ear canal,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Aetna MCR ADV,CPT,69209,Remove impacted ear wax uni,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Aetna MCR ADV,CPT,69210,Remove impacted ear wax uni,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Aetna MCR ADV,CPT,69220,Clean out mastoid cavity,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Aetna MCR ADV,CPT,69222,Clean out mastoid cavity,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,69300,Revise external ear,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,69310,Rebuild outer ear canal,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,69320,Rebuild outer ear canal,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,69399,Outer ear surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Aetna MCR ADV,CPT,69420,Incision of eardrum,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Aetna MCR ADV,CPT,69421,Incision of eardrum,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,69424,Remove ventilating tube,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,69433,Create eardrum opening,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Aetna MCR ADV,CPT,69436,Create eardrum opening,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,69440,Exploration of middle ear,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,69450,Eardrum revision,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,69501,Mastoidectomy,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,69502,Mastoidectomy,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,69505,Remove mastoid structures,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,69511,Extensive mastoid surgery,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,69530,Extensive mastoid surgery,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,69535,Remove part of temporal bone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,69540,Remove ear lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,69550,Remove ear lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,69552,Remove ear lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,69554,Remove ear lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,69601,Mastoid surgery revision,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,69602,Mastoid surgery revision,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,69603,Mastoid surgery revision,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,69604,Mastoid surgery revision,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,69610,Repair of eardrum,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,69620,Repair of eardrum,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,69631,Repair eardrum structures,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,69632,Rebuild eardrum structures,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,69633,Rebuild eardrum structures,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,69635,Repair eardrum structures,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,69636,Rebuild eardrum structures,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,69637,Rebuild eardrum structures,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,69641,Revise middle ear & mastoid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,69642,Revise middle ear & mastoid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,69643,Revise middle ear & mastoid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,69644,Revise middle ear & mastoid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,69645,Revise middle ear & mastoid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,69646,Revise middle ear & mastoid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,69650,Release middle ear bone,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,69660,Revise middle ear bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,69661,Revise middle ear bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,69662,Revise middle ear bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,69666,Repair middle ear structures,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,69667,Repair middle ear structures,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,69670,Remove mastoid air cells,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,69676,Remove middle ear nerve,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,69700,Close mastoid fistula,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,69705,Nps surg dilat eust tube uni,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,69706,Nps surg dilat eust tube bi,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,69711,Remove/repair hearing aid,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,69714,Implant temple bone w/stimul,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,69715,Temple bne implnt w/stimulat,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Aetna MCR ADV,CPT,69717,Temple bone implant revision,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Aetna MCR ADV,CPT,69718,Revise temple bone implant,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Aetna MCR ADV,CPT,69720,Release facial nerve,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,69725,Release facial nerve,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,69740,Repair facial nerve,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,69745,Repair facial nerve,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,69799,Middle ear surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Aetna MCR ADV,CPT,69801,Incise inner ear,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Aetna MCR ADV,CPT,69805,Explore inner ear,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,69806,Explore inner ear,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,69905,Remove inner ear,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,69910,Remove inner ear & mastoid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,69915,Incise inner ear nerve,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Aetna MCR ADV,CPT,69930,Implant cochlear device,APC 5166,RVU Per Case,"$35,230.37 ",OP,"4,140.35","35,230.37",,,,,,
Aetna MCR ADV,CPT,69949,Inner ear surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Aetna MCR ADV,CPT,69950,Incise inner ear nerve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Aetna MCR ADV,CPT,69955,Release facial nerve,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,69960,Release inner ear canal,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,69970,Remove inner ear lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Aetna MCR ADV,CPT,69979,Temporal bone surgery,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Aetna MCR ADV,CPT,70010,Contrast x-ray of brain,APC 5572,RVU Per Case,$376.70 ,OP,376.7,899.79,,,,,,
Aetna MCR ADV,CPT,70015,Contrast x-ray of brain,APC 5573,RVU Per Case,$731.85 ,OP,731.85,735.85,,,,,,
Aetna MCR ADV,CPT,70030,X-ray eye for foreign body,APC 5521,RVU Per Case,$82.79 ,OP,82.79,144.88,,,,,,
Aetna MCR ADV,CPT,70100,X-ray exam of jaw <4views,APC 5521,RVU Per Case,$82.79 ,OP,82.79,156.32,,,,,,
Aetna MCR ADV,CPT,70110,X-ray exam of jaw 4/> views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,202.07,,,,,,
Aetna MCR ADV,CPT,70120,X-ray exam of mastoids,APC 5522,RVU Per Case,$111.51 ,OP,111.51,171.58,,,,,,
Aetna MCR ADV,CPT,70130,X-ray exam of mastoids,APC 5522,RVU Per Case,$111.51 ,OP,111.51,282.14,,,,,,
Aetna MCR ADV,CPT,70134,X-ray exam of middle ear,APC 5524,RVU Per Case,$494.15 ,OP,244.01,494.15,,,,,,
Aetna MCR ADV,CPT,70140,X-ray exam of facial bones,APC 5521,RVU Per Case,$82.79 ,OP,82.79,156.32,,,,,,
Aetna MCR ADV,CPT,70150,X-ray exam of facial bones,APC 5522,RVU Per Case,$111.51 ,OP,111.51,221.14,,,,,,
Aetna MCR ADV,CPT,70160,X-ray exam of nasal bones,APC 5521,RVU Per Case,$82.79 ,OP,82.79,163.95,,,,,,
Aetna MCR ADV,CPT,70170,X-ray exam of tear duct,APC 5523,RVU Per Case,$235.49 ,OP,235.49,274.51,,,,,,
Aetna MCR ADV,CPT,70190,X-ray exam of eye sockets,APC 5521,RVU Per Case,$82.79 ,OP,82.79,183.02,,,,,,
Aetna MCR ADV,CPT,70200,X-ray exam of eye sockets,APC 5522,RVU Per Case,$111.51 ,OP,111.51,228.77,,,,,,
Aetna MCR ADV,CPT,70210,X-ray exam of sinuses,APC 5521,RVU Per Case,$82.79 ,OP,82.79,156.32,,,,,,
Aetna MCR ADV,CPT,70220,X-ray exam of sinuses,APC 5521,RVU Per Case,$82.79 ,OP,82.79,202.07,,,,,,
Aetna MCR ADV,CPT,70240,X-ray exam pituitary saddle,APC 5521,RVU Per Case,$82.79 ,OP,82.79,148.69,,,,,,
Aetna MCR ADV,CPT,70250,X-ray exam of skull,APC 5522,RVU Per Case,$111.51 ,OP,111.51,186.82,,,,,,
Aetna MCR ADV,CPT,70260,X-ray exam of skull,APC 5522,RVU Per Case,$111.51 ,OP,111.51,251.64,,,,,,
Aetna MCR ADV,CPT,70300,X-ray exam of teeth,APC 5521,RVU Per Case,$82.79 ,OP,76.26,82.79,,,,,,
Aetna MCR ADV,CPT,70310,X-ray exam of teeth,APC 5523,RVU Per Case,$235.49 ,OP,235.49,235.49,,,,,,
Aetna MCR ADV,CPT,70320,Full mouth x-ray of teeth,APC 5523,RVU Per Case,$235.49 ,OP,235.49,247.83,,,,,,
Aetna MCR ADV,CPT,70328,X-ray exam of jaw joint,APC 5521,RVU Per Case,$82.79 ,OP,82.79,152.51,,,,,,
Aetna MCR ADV,CPT,70330,X-ray exam of jaw joints,APC 5521,RVU Per Case,$82.79 ,OP,82.79,244.01,,,,,,
Aetna MCR ADV,CPT,70332,X-ray exam of jaw joint,APC 5523,RVU Per Case,$235.49 ,OP,235.49,446.08,,,,,,
Aetna MCR ADV,CPT,70336,Magnetic image jaw joint,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Aetna MCR ADV,CPT,70350,X-ray head for orthodontia,APC 5521,RVU Per Case,$82.79 ,OP,82.79,106.76,,,,,,
Aetna MCR ADV,CPT,70355,Panoramic x-ray of jaws,APC 5521,RVU Per Case,$82.79 ,OP,82.79,122,,,,,,
Aetna MCR ADV,CPT,70360,X-ray exam of neck,APC 5521,RVU Per Case,$82.79 ,OP,82.79,137.25,,,,,,
Aetna MCR ADV,CPT,70370,Throat x-ray & fluoroscopy,APC 5521,RVU Per Case,$82.79 ,OP,82.79,381.27,,,,,,
Aetna MCR ADV,CPT,70371,Speech evaluation complex,APC 5523,RVU Per Case,$235.49 ,OP,235.49,510.9,,,,,,
Aetna MCR ADV,CPT,70380,X-ray exam of salivary gland,APC 5521,RVU Per Case,$82.79 ,OP,82.79,190.64,,,,,,
Aetna MCR ADV,CPT,70390,X-ray exam of salivary duct,APC 5523,RVU Per Case,$235.49 ,OP,235.49,235.49,,,,,,
Aetna MCR ADV,CPT,70450,Ct head/brain w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Aetna MCR ADV,CPT,70460,Ct head/brain w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Aetna MCR ADV,CPT,70470,Ct head/brain w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Aetna MCR ADV,CPT,70480,Ct orbit/ear/fossa w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Aetna MCR ADV,CPT,70481,Ct orbit/ear/fossa w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Aetna MCR ADV,CPT,70482,Ct orbit/ear/fossa w/o&w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Aetna MCR ADV,CPT,70486,Ct maxillofacial w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Aetna MCR ADV,CPT,70487,Ct maxillofacial w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Aetna MCR ADV,CPT,70488,Ct maxillofacial w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Aetna MCR ADV,CPT,70490,Ct soft tissue neck w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Aetna MCR ADV,CPT,70491,Ct soft tissue neck w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Aetna MCR ADV,CPT,70492,Ct sft tsue nck w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Aetna MCR ADV,CPT,70496,Ct angiography head,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Aetna MCR ADV,CPT,70498,Ct angiography neck,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Aetna MCR ADV,CPT,70540,Mri orbit/face/neck w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Aetna MCR ADV,CPT,70542,Mri orbit/face/neck w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Aetna MCR ADV,CPT,70543,Mri orbt/fac/nck w/o &w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Aetna MCR ADV,CPT,70544,Mr angiography head w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Aetna MCR ADV,CPT,70545,Mr angiography head w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Aetna MCR ADV,CPT,70546,Mr angiograph head w/o&w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Aetna MCR ADV,CPT,70547,Mr angiography neck w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Aetna MCR ADV,CPT,70548,Mr angiography neck w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Aetna MCR ADV,CPT,70549,Mr angiograph neck w/o&w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Aetna MCR ADV,CPT,70551,Mri brain stem w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Aetna MCR ADV,CPT,70552,Mri brain stem w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Aetna MCR ADV,CPT,70553,Mri brain stem w/o & w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Aetna MCR ADV,CPT,70554,Fmri brain by tech,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Aetna MCR ADV,CPT,70555,Fmri brain by phys/psych,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,507.00",,,,,,
Aetna MCR ADV,CPT,70557,Mri brain w/o dye,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,149.44",,,,,,
Aetna MCR ADV,CPT,70558,Mri brain w/dye,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,"1,609.22",,,,,,
Aetna MCR ADV,CPT,70559,Mri brain w/o & w/dye,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,"1,609.22",,,,,,
Aetna MCR ADV,CPT,71045,X-ray exam chest 1 view,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,152.51,,,,,,
Aetna MCR ADV,CPT,71046,X-ray exam chest 2 views,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,167.76,,,,,,
Aetna MCR ADV,CPT,71047,X-ray exam chest 3 views,APC 5521,RVU Per Case,$82.79 ,OP,82.79,240.2,,,,,,
Aetna MCR ADV,CPT,71048,X-ray exam chest 4+ views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,240.2,,,,,,
Aetna MCR ADV,CPT,71100,X-ray exam ribs uni 2 views,APC 5521,RVU Per Case,$82.79 ,OP,82.79,171.58,,,,,,
Aetna MCR ADV,CPT,71101,X-ray exam unilat ribs/chest,APC 5522,RVU Per Case,$111.51 ,OP,111.51,202.07,,,,,,
Aetna MCR ADV,CPT,71110,X-ray exam ribs bil 3 views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,213.51,,,,,,
Aetna MCR ADV,CPT,71111,X-ray exam ribs/chest4/> vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,270.71,,,,,,
Aetna MCR ADV,CPT,71120,X-ray exam breastbone 2/>vws,APC 5521,RVU Per Case,$82.79 ,OP,82.79,171.58,,,,,,
Aetna MCR ADV,CPT,71130,X-ray strenoclavic jt 3/>vws,APC 5521,RVU Per Case,$82.79 ,OP,82.79,194.45,,,,,,
Aetna MCR ADV,CPT,71250,Ct thorax dx c-,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Aetna MCR ADV,CPT,71260,Ct thorax dx c+,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Aetna MCR ADV,CPT,71270,Ct thorax dx c-/c+,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Aetna MCR ADV,CPT,71271,Ct thorax lung cancer scr c-,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,927,,,,,,
Aetna MCR ADV,CPT,71275,Ct angiography chest,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Aetna MCR ADV,CPT,71550,Mri chest w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Aetna MCR ADV,CPT,71551,Mri chest w/dye,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"1,609.22",,,,,,
Aetna MCR ADV,CPT,71552,Mri chest w/o & w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Aetna MCR ADV,CPT,72020,X-ray exam of spine 1 view,APC 5521,RVU Per Case,$82.79 ,OP,82.79,122,,,,,,
Aetna MCR ADV,CPT,72040,X-ray exam neck spine 2-3 vw,APC 5521,RVU Per Case,$82.79 ,OP,82.79,190.64,,,,,,
Aetna MCR ADV,CPT,72050,X-ray exam neck spine 4/5vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,293.57,,,,,,
Aetna MCR ADV,CPT,72052,X-ray exam neck spine 6/>vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,339.33,,,,,,
Aetna MCR ADV,CPT,72070,X-ray exam thorac spine 2vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,175.39,,,,,,
Aetna MCR ADV,CPT,72072,X-ray exam thorac spine 3vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,202.07,,,,,,
Aetna MCR ADV,CPT,72074,X-ray exam thorac spine4/>vw,APC 5522,RVU Per Case,$111.51 ,OP,111.51,236.38,,,,,,
Aetna MCR ADV,CPT,72080,X-ray exam thoracolmb 2/> vw,APC 5521,RVU Per Case,$82.79 ,OP,82.79,183.02,,,,,,
Aetna MCR ADV,CPT,72081,X-ray exam entire spi 1 vw,APC 5521,RVU Per Case,$82.79 ,OP,82.79,354.58,,,,,,
Aetna MCR ADV,CPT,72082,X-ray exam entire spi 2/3 vw,APC 5522,RVU Per Case,$111.51 ,OP,111.51,354.58,,,,,,
Aetna MCR ADV,CPT,72083,X-ray exam entire spi 4/5 vw,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,354.58,,,,,,
Aetna MCR ADV,CPT,72084,X-ray exam entire spi 6/> vw,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,354.58,,,,,,
Aetna MCR ADV,CPT,72100,X-ray exam l-s spine 2/3 vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,202.07,,,,,,
Aetna MCR ADV,CPT,72110,X-ray exam l-2 spine 4/>vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,301.2,,,,,,
Aetna MCR ADV,CPT,72114,X-ray exam l-s spine bending,APC 5522,RVU Per Case,$111.51 ,OP,111.51,362.21,,,,,,
Aetna MCR ADV,CPT,72120,X-ray bend only l-s spine,APC 5522,RVU Per Case,$111.51 ,OP,111.51,251.64,,,,,,
Aetna MCR ADV,CPT,72125,Ct neck spine w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Aetna MCR ADV,CPT,72126,Ct neck spine w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,965.53,,,,,,
Aetna MCR ADV,CPT,72127,Ct neck spine w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Aetna MCR ADV,CPT,72128,Ct chest spine w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Aetna MCR ADV,CPT,72129,Ct chest spine w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Aetna MCR ADV,CPT,72130,Ct chest spine w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Aetna MCR ADV,CPT,72131,Ct lumbar spine w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Aetna MCR ADV,CPT,72132,Ct lumbar spine w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,965.53,,,,,,
Aetna MCR ADV,CPT,72133,Ct lumbar spine w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Aetna MCR ADV,CPT,72141,Mri neck spine w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Aetna MCR ADV,CPT,72142,Mri neck spine w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Aetna MCR ADV,CPT,72146,Mri chest spine w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Aetna MCR ADV,CPT,72147,Mri chest spine w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Aetna MCR ADV,CPT,72148,Mri lumbar spine w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Aetna MCR ADV,CPT,72149,Mri lumbar spine w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Aetna MCR ADV,CPT,72156,Mri neck spine w/o & w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Aetna MCR ADV,CPT,72157,Mri chest spine w/o & w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Aetna MCR ADV,CPT,72158,Mri lumbar spine w/o & w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Aetna MCR ADV,CPT,72170,X-ray exam of pelvis,APC 5522,RVU Per Case,$111.51 ,OP,111.51,133.45,,,,,,
Aetna MCR ADV,CPT,72190,X-ray exam of pelvis,APC 5522,RVU Per Case,$111.51 ,OP,111.51,205.88,,,,,,
Aetna MCR ADV,CPT,72191,Ct angiograph pelv w/o&w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Aetna MCR ADV,CPT,72192,Ct pelvis w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Aetna MCR ADV,CPT,72193,Ct pelvis w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Aetna MCR ADV,CPT,72194,Ct pelvis w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Aetna MCR ADV,CPT,72195,Mri pelvis w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Aetna MCR ADV,CPT,72196,Mri pelvis w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Aetna MCR ADV,CPT,72197,Mri pelvis w/o & w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Aetna MCR ADV,CPT,72200,X-ray exam si joints,APC 5522,RVU Per Case,$111.51 ,OP,111.51,148.69,,,,,,
Aetna MCR ADV,CPT,72202,X-ray exam si joints 3/> vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,183.02,,,,,,
Aetna MCR ADV,CPT,72220,X-ray exam sacrum tailbone,APC 5521,RVU Per Case,$82.79 ,OP,82.79,156.32,,,,,,
Aetna MCR ADV,CPT,72240,Myelography neck spine,APC 5573,RVU Per Case,$731.85 ,OP,731.85,842.61,,,,,,
Aetna MCR ADV,CPT,72255,Myelography thoracic spine,APC 5573,RVU Per Case,$731.85 ,OP,731.85,766.35,,,,,,
Aetna MCR ADV,CPT,72265,Myelography l-s spine,APC 5573,RVU Per Case,$731.85 ,OP,731.85,781.61,,,,,,
Aetna MCR ADV,CPT,72270,Myelogphy 2/> spine regions,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"1,216.24",,,,,,
Aetna MCR ADV,CPT,72285,Discography cerv/thor spine,APC 5431,RVU Per Case,"$1,795.30 ",OP,976.05,"1,795.30",,,,,,
Aetna MCR ADV,CPT,72295,X-ray of lower spine disk,APC 5431,RVU Per Case,"$1,795.30 ",OP,873.11,"1,795.30",,,,,,
Aetna MCR ADV,CPT,73000,X-ray exam of collar bone,APC 5521,RVU Per Case,$82.79 ,OP,82.79,141.07,,,,,,
Aetna MCR ADV,CPT,73010,X-ray exam of shoulder blade,APC 5522,RVU Per Case,$111.51 ,OP,111.51,144.88,,,,,,
Aetna MCR ADV,CPT,73020,X-ray exam of shoulder,APC 5521,RVU Per Case,$82.79 ,OP,82.79,122,,,,,,
Aetna MCR ADV,CPT,73030,X-ray exam of shoulder,APC 5521,RVU Per Case,$82.79 ,OP,82.79,163.95,,,,,,
Aetna MCR ADV,CPT,73040,Contrast x-ray of shoulder,APC 5572,RVU Per Case,$376.70 ,OP,376.7,552.84,,,,,,
Aetna MCR ADV,CPT,73050,X-ray exam of shoulders,APC 5521,RVU Per Case,$82.79 ,OP,82.79,186.82,,,,,,
Aetna MCR ADV,CPT,73060,X-ray exam of humerus,APC 5521,RVU Per Case,$82.79 ,OP,82.79,152.51,,,,,,
Aetna MCR ADV,CPT,73070,X-ray exam of elbow,APC 5521,RVU Per Case,$82.79 ,OP,82.79,137.25,,,,,,
Aetna MCR ADV,CPT,73080,X-ray exam of elbow,APC 5521,RVU Per Case,$82.79 ,OP,82.79,179.2,,,,,,
Aetna MCR ADV,CPT,73085,Contrast x-ray of elbow,APC 5572,RVU Per Case,$376.70 ,OP,376.7,503.28,,,,,,
Aetna MCR ADV,CPT,73090,X-ray exam of forearm,APC 5521,RVU Per Case,$82.79 ,OP,82.79,137.25,,,,,,
Aetna MCR ADV,CPT,73092,X-ray exam of arm infant,APC 5522,RVU Per Case,$111.51 ,OP,111.51,141.07,,,,,,
Aetna MCR ADV,CPT,73100,X-ray exam of wrist,APC 5521,RVU Per Case,$82.79 ,OP,82.79,144.88,,,,,,
Aetna MCR ADV,CPT,73110,X-ray exam of wrist,APC 5521,RVU Per Case,$82.79 ,OP,82.79,171.58,,,,,,
Aetna MCR ADV,CPT,73115,Contrast x-ray of wrist,APC 5572,RVU Per Case,$376.70 ,OP,376.7,526.16,,,,,,
Aetna MCR ADV,CPT,73120,X-ray exam of hand,APC 5522,RVU Per Case,$111.51 ,OP,111.51,137.25,,,,,,
Aetna MCR ADV,CPT,73130,X-ray exam of hand,APC 5521,RVU Per Case,$82.79 ,OP,82.79,156.32,,,,,,
Aetna MCR ADV,CPT,73140,X-ray exam of finger(s),APC 5521,RVU Per Case,$82.79 ,OP,82.79,160.13,,,,,,
Aetna MCR ADV,CPT,73200,Ct upper extremity w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Aetna MCR ADV,CPT,73201,Ct upper extremity w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,965.53,,,,,,
Aetna MCR ADV,CPT,73202,Ct uppr extremity w/o&w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Aetna MCR ADV,CPT,73206,Ct angio upr extrm w/o&w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Aetna MCR ADV,CPT,73218,Mri upper extremity w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Aetna MCR ADV,CPT,73219,Mri upper extremity w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Aetna MCR ADV,CPT,73220,Mri uppr extremity w/o&w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Aetna MCR ADV,CPT,73221,Mri joint upr extrem w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Aetna MCR ADV,CPT,73222,Mri joint upr extrem w/dye,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"1,609.22",,,,,,
Aetna MCR ADV,CPT,73223,Mri joint upr extr w/o&w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Aetna MCR ADV,CPT,73501,X-ray exam hip uni 1 view,APC 5521,RVU Per Case,$82.79 ,OP,82.79,129.64,,,,,,
Aetna MCR ADV,CPT,73502,X-ray exam hip uni 2-3 views,APC 5521,RVU Per Case,$82.79 ,OP,82.79,198.25,,,,,,
Aetna MCR ADV,CPT,73503,X-ray exam hip uni 4/> views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,198.25,,,,,,
Aetna MCR ADV,CPT,73521,X-ray exam hips bi 2 views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,202.07,,,,,,
Aetna MCR ADV,CPT,73522,X-ray exam hips bi 3-4 views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,202.07,,,,,,
Aetna MCR ADV,CPT,73523,X-ray exam hips bi 5/> views,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,202.07,,,,,,
Aetna MCR ADV,CPT,73525,Contrast x-ray of hip,APC 5572,RVU Per Case,$376.70 ,OP,376.7,503.28,,,,,,
Aetna MCR ADV,CPT,73551,X-ray exam of femur 1,APC 5521,RVU Per Case,$82.79 ,OP,82.79,148.69,,,,,,
Aetna MCR ADV,CPT,73552,X-ray exam of femur 2/>,APC 5521,RVU Per Case,$82.79 ,OP,82.79,148.69,,,,,,
Aetna MCR ADV,CPT,73560,X-ray exam of knee 1 or 2,APC 5521,RVU Per Case,$82.79 ,OP,82.79,144.88,,,,,,
Aetna MCR ADV,CPT,73562,X-ray exam of knee 3,APC 5521,RVU Per Case,$82.79 ,OP,82.79,186.82,,,,,,
Aetna MCR ADV,CPT,73564,X-ray exam knee 4 or more,APC 5522,RVU Per Case,$111.51 ,OP,111.51,205.88,,,,,,
Aetna MCR ADV,CPT,73565,X-ray exam of knees,APC 5521,RVU Per Case,$82.79 ,OP,82.79,152.51,,,,,,
Aetna MCR ADV,CPT,73580,Contrast x-ray of knee joint,APC 5572,RVU Per Case,$376.70 ,OP,376.7,625.29,,,,,,
Aetna MCR ADV,CPT,73590,X-ray exam of lower leg,APC 5521,RVU Per Case,$82.79 ,OP,82.79,137.25,,,,,,
Aetna MCR ADV,CPT,73592,X-ray exam of leg infant,APC 5521,RVU Per Case,$82.79 ,OP,82.79,141.07,,,,,,
Aetna MCR ADV,CPT,73600,X-ray exam of ankle,APC 5521,RVU Per Case,$82.79 ,OP,82.79,137.25,,,,,,
Aetna MCR ADV,CPT,73610,X-ray exam of ankle,APC 5521,RVU Per Case,$82.79 ,OP,82.79,156.32,,,,,,
Aetna MCR ADV,CPT,73615,Contrast x-ray of ankle,APC 5572,RVU Per Case,$376.70 ,OP,376.7,376.7,,,,,,
Aetna MCR ADV,CPT,73620,X-ray exam of foot,APC 5521,RVU Per Case,$82.79 ,OP,82.79,133.45,,,,,,
Aetna MCR ADV,CPT,73630,X-ray exam of foot,APC 5521,RVU Per Case,$82.79 ,OP,82.79,156.32,,,,,,
Aetna MCR ADV,CPT,73650,X-ray exam of heel,APC 5521,RVU Per Case,$82.79 ,OP,82.79,137.25,,,,,,
Aetna MCR ADV,CPT,73660,X-ray exam of toe(s),APC 5521,RVU Per Case,$82.79 ,OP,82.79,141.07,,,,,,
Aetna MCR ADV,CPT,73700,Ct lower extremity w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Aetna MCR ADV,CPT,73701,Ct lower extremity w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Aetna MCR ADV,CPT,73702,Ct lwr extremity w/o&w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Aetna MCR ADV,CPT,73706,Ct angio lwr extr w/o&w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Aetna MCR ADV,CPT,73718,Mri lower extremity w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Aetna MCR ADV,CPT,73719,Mri lower extremity w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Aetna MCR ADV,CPT,73720,Mri lwr extremity w/o&w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Aetna MCR ADV,CPT,73721,Mri jnt of lwr extre w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Aetna MCR ADV,CPT,73722,Mri joint of lwr extr w/dye,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"1,609.22",,,,,,
Aetna MCR ADV,CPT,73723,Mri joint lwr extr w/o&w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Aetna MCR ADV,CPT,74018,X-ray exam abdomen 1 view,APC 5521,RVU Per Case,$82.79 ,OP,82.79,137.25,,,,,,
Aetna MCR ADV,CPT,74019,X-ray exam abdomen 2 views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,194.45,,,,,,
Aetna MCR ADV,CPT,74021,X-ray exam abdomen 3+ views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,205.88,,,,,,
Aetna MCR ADV,CPT,74022,X-ray exam complete abdomen,APC 5522,RVU Per Case,$111.51 ,OP,111.51,251.64,,,,,,
Aetna MCR ADV,CPT,74150,Ct abdomen w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Aetna MCR ADV,CPT,74160,Ct abdomen w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Aetna MCR ADV,CPT,74170,Ct abdomen w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Aetna MCR ADV,CPT,74174,Ct angio abd&pelv w/o&w/dye,APC 5572,RVU Per Unit,$376.70 ,OP,376.7,965.53,,,,,,
Aetna MCR ADV,CPT,74175,Ct angio abdom w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Aetna MCR ADV,CPT,74176,Ct abd & pelvis w/o contrast,APC 5523,RVU Per Case,$235.49 ,OP,235.49,927,,,,,,
Aetna MCR ADV,CPT,74177,Ct abd & pelv w/contrast,APC 5572,RVU Per Case,$376.70 ,OP,376.7,965.53,,,,,,
Aetna MCR ADV,CPT,74178,Ct abd & pelv 1/> regns,APC 5572,RVU Per Case,$376.70 ,OP,376.7,927,,,,,,
Aetna MCR ADV,CPT,74181,Mri abdomen w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Aetna MCR ADV,CPT,74182,Mri abdomen w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Aetna MCR ADV,CPT,74183,Mri abdomen w/o & w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Aetna MCR ADV,CPT,74190,X-ray exam of peritoneum,APC 5524,RVU Per Case,$494.15 ,OP,400.34,494.15,,,,,,
Aetna MCR ADV,CPT,74210,X-ray xm phrnx&/crv esoph c+,APC 5571,RVU Per Case,$182.72 ,OP,182.72,182.72,,,,,,
Aetna MCR ADV,CPT,74220,X-ray xm esophagus 1cntrst,APC 5571,RVU Per Case,$182.72 ,OP,182.72,446.08,,,,,,
Aetna MCR ADV,CPT,74221,X-ray xm esophagus 2cntrst,APC 5571,RVU Per Case,$182.72 ,OP,182.72,446.08,,,,,,
Aetna MCR ADV,CPT,74230,X-ray xm swlng funcj c+,APC 5571,RVU Per Case,$182.72 ,OP,182.72,457.52,,,,,,
Aetna MCR ADV,CPT,74240,X-ray xm upr gi trc 1cntrst,APC 5571,RVU Per Case,$182.72 ,OP,182.72,552.84,,,,,,
Aetna MCR ADV,CPT,74246,X-ray xm upr gi trc 2cntrst,APC 5571,RVU Per Case,$182.72 ,OP,182.72,632.91,,,,,,
Aetna MCR ADV,CPT,74250,X-ray xm sm int 1cntrst std,APC 5571,RVU Per Case,$182.72 ,OP,182.72,518.52,,,,,,
Aetna MCR ADV,CPT,74251,X-ray xm sm int 2cntrst std,APC 5571,RVU Per Case,$182.72 ,OP,182.72,"1,593.72",,,,,,
Aetna MCR ADV,CPT,74261,Ct colonography dx,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Aetna MCR ADV,CPT,74262,Ct colonography dx w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,182.72,,,,,,
Aetna MCR ADV,CPT,74270,X-ray xm colon 1cntrst std,APC 5571,RVU Per Case,$182.72 ,OP,182.72,747.28,,,,,,
Aetna MCR ADV,CPT,74280,X-ray xm colon 2cntrst std,APC 5571,RVU Per Case,$182.72 ,OP,182.72,"1,029.43",,,,,,
Aetna MCR ADV,CPT,74283,Ther nma rdctj intus/obstrcj,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,182.72,,,,,,
Aetna MCR ADV,CPT,74290,Contrast x-ray gallbladder,APC 5571,RVU Per Case,$182.72 ,OP,182.72,331.7,,,,,,
Aetna MCR ADV,CPT,74400,Urography iv +-kub tomog,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,568.09,,,,,,
Aetna MCR ADV,CPT,74410,Urography nfs drip&/bolus,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,598.59,,,,,,
Aetna MCR ADV,CPT,74415,Urography nfs drip&/bls w/nf,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,682.47,,,,,,
Aetna MCR ADV,CPT,74420,Urography rtrgr +-kub,APC 5572,RVU Per Unit,$376.70 ,OP,376.7,659.6,,,,,,
Aetna MCR ADV,CPT,74425,Urography antegrade rs&i,APC 5572,RVU Per Case,$376.70 ,OP,366.02,376.7,,,,,,
Aetna MCR ADV,CPT,74430,Contrast x-ray bladder,APC 5572,RVU Per Case,$376.70 ,OP,376.7,404.14,,,,,,
Aetna MCR ADV,CPT,74440,X-ray male genital tract,APC 5523,RVU Per Case,$235.49 ,OP,235.49,434.65,,,,,,
Aetna MCR ADV,CPT,74445,X-ray exam of penis,APC 5522,RVU Per Case,$111.51 ,OP,111.51,545.21,,,,,,
Aetna MCR ADV,CPT,74450,X-ray urethra/bladder,APC 5523,RVU Per Case,$235.49 ,OP,235.49,396.52,,,,,,
Aetna MCR ADV,CPT,74455,X-ray urethra/bladder,APC 5523,RVU Per Case,$235.49 ,OP,235.49,472.78,,,,,,
Aetna MCR ADV,CPT,74470,X-ray exam of kidney lesion,APC 5524,RVU Per Case,$494.15 ,OP,400.34,494.15,,,,,,
Aetna MCR ADV,CPT,74485,Dilation urtr/urt rs&i,APC 5373,RVU Per Case,"$1,834.80 ",OP,629.1,"1,834.80",,,,,,
Aetna MCR ADV,CPT,74710,X-ray measurement of pelvis,APC 5521,RVU Per Case,$82.79 ,OP,82.79,232.58,,,,,,
Aetna MCR ADV,CPT,74712,Mri fetal sngl/1st gestation,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,507.00",,,,,,
Aetna MCR ADV,CPT,74740,X-ray female genital tract,APC 5523,RVU Per Case,$235.49 ,OP,235.49,404.14,,,,,,
Aetna MCR ADV,CPT,74775,X-ray exam of perineum,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,457.52,,,,,,
Aetna MCR ADV,CPT,75557,Cardiac mri for morph,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Aetna MCR ADV,CPT,75559,Cardiac mri w/stress img,APC 5524,RVU Per Case,$494.15 ,OP,494.15,"1,507.00",,,,,,
Aetna MCR ADV,CPT,75561,Cardiac mri for morph w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Aetna MCR ADV,CPT,75563,Card mri w/stress img & dye,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"1,609.22",,,,,,
Aetna MCR ADV,CPT,75571,Ct hrt w/o dye w/ca test,APC 5521,RVU Per Case,$82.79 ,OP,82.79,927,,,,,,
Aetna MCR ADV,CPT,75572,Ct hrt w/3d image,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,927,,,,,,
Aetna MCR ADV,CPT,75573,Ct hrt w/3d image congen,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,927,,,,,,
Aetna MCR ADV,CPT,75574,Ct angio hrt w/3d image,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,927,,,,,,
Aetna MCR ADV,CPT,75600,Contrast exam thoracic aorta,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,742.41","2,928.39",,,,,,
Aetna MCR ADV,CPT,75605,Contrast exam thoracic aorta,APC 5184,RVU Per Case,"$4,881.61 ",OP,"1,506.03","4,881.61",,,,,,
Aetna MCR ADV,CPT,75625,Contrast exam abdominl aorta,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,486.95","2,928.39",,,,,,
Aetna MCR ADV,CPT,75630,X-ray aorta leg arteries,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","2,928.39",,,,,,
Aetna MCR ADV,CPT,75635,Ct angio abdominal arteries,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Aetna MCR ADV,CPT,75705,Artery x-rays spine,APC 5184,RVU Per Case,"$4,881.61 ",OP,"1,826.28","4,881.61",,,,,,
Aetna MCR ADV,CPT,75710,Artery x-rays arm/leg,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,567.02","2,928.39",,,,,,
Aetna MCR ADV,CPT,75716,Artery x-rays arms/legs,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,730.97","2,928.39",,,,,,
Aetna MCR ADV,CPT,75726,Artery x-rays abdomen,APC 5184,RVU Per Case,"$4,881.61 ",OP,"1,547.95","4,881.61",,,,,,
Aetna MCR ADV,CPT,75731,Artery x-rays adrenal gland,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,601.33","2,928.39",,,,,,
Aetna MCR ADV,CPT,75733,Artery x-rays adrenals,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,795.78","2,928.39",,,,,,
Aetna MCR ADV,CPT,75736,Artery x-rays pelvis,APC 5184,RVU Per Case,"$4,881.61 ",OP,"1,563.20","4,881.61",,,,,,
Aetna MCR ADV,CPT,75741,Artery x-rays lung,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,506.03","2,928.39",,,,,,
Aetna MCR ADV,CPT,75743,Artery x-rays lungs,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,635.64","2,928.39",,,,,,
Aetna MCR ADV,CPT,75746,Artery x-rays lung,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,517.46","2,928.39",,,,,,
Aetna MCR ADV,CPT,75756,Artery x-rays chest,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,601.33","2,928.39",,,,,,
Aetna MCR ADV,CPT,75801,Lymph vessel x-ray arm/leg,APC 5181,RVU Per Case,$554.25 ,OP,554.25,"1,281.07",,,,,,
Aetna MCR ADV,CPT,75803,Lymph vessel x-ray arms/legs,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,437.39","1,438.93",,,,,,
Aetna MCR ADV,CPT,75805,Lymph vessel x-ray trunk,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,483.14","2,928.39",,,,,,
Aetna MCR ADV,CPT,75807,Lymph vessel x-ray trunk,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,582.28","2,928.39",,,,,,
Aetna MCR ADV,CPT,75809,Nonvascular shunt x-ray,APC 5522,RVU Per Case,$111.51 ,OP,111.51,446.08,,,,,,
Aetna MCR ADV,CPT,75810,Vein x-ray spleen/liver,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,836.65","2,928.39",,,,,,
Aetna MCR ADV,CPT,75820,Vein x-ray arm/leg,APC 5182,RVU Per Case,"$1,438.93 ",OP,610.03,"1,438.93",,,,,,
Aetna MCR ADV,CPT,75822,Vein x-ray arms/legs,APC 5182,RVU Per Case,"$1,438.93 ",OP,747.28,"1,438.93",,,,,,
Aetna MCR ADV,CPT,75825,Vein x-ray trunk,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,441.20","2,928.39",,,,,,
Aetna MCR ADV,CPT,75827,Vein x-ray chest,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,433.58","1,438.93",,,,,,
Aetna MCR ADV,CPT,75831,Vein x-ray kidney,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,456.44","2,928.39",,,,,,
Aetna MCR ADV,CPT,75833,Vein x-ray kidneys,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,608.95","2,928.39",,,,,,
Aetna MCR ADV,CPT,75840,Vein x-ray adrenal gland,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,445.01","2,928.39",,,,,,
Aetna MCR ADV,CPT,75842,Vein x-ray adrenal glands,APC 5184,RVU Per Case,"$4,881.61 ",OP,"1,616.58","4,881.61",,,,,,
Aetna MCR ADV,CPT,75860,Vein x-ray neck,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,479.33","2,928.39",,,,,,
Aetna MCR ADV,CPT,75870,Vein x-ray skull,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,467.89","2,928.39",,,,,,
Aetna MCR ADV,CPT,75872,Vein x-ray skull epidural,APC 5181,RVU Per Case,$554.25 ,OP,554.25,"1,608.95",,,,,,
Aetna MCR ADV,CPT,75880,Vein x-ray eye socket,APC 5181,RVU Per Case,$554.25 ,OP,554.25,613.85,,,,,,
Aetna MCR ADV,CPT,75885,Vein x-ray liver w/hemodynam,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,536.51","2,928.39",,,,,,
Aetna MCR ADV,CPT,75887,Vein x-ray liver w/o hemodyn,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,547.95","2,928.39",,,,,,
Aetna MCR ADV,CPT,75889,Vein x-ray liver w/hemodynam,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,456.44","2,928.39",,,,,,
Aetna MCR ADV,CPT,75891,Vein x-ray liver,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,456.44","2,928.39",,,,,,
Aetna MCR ADV,CPT,75893,Venous sampling by catheter,APC 5184,RVU Per Case,"$4,881.61 ",OP,"1,296.32","4,881.61",,,,,,
Aetna MCR ADV,CPT,75898,Follow-up angiography,APC 5183,RVU Per Case,"$2,928.39 ",OP,655.78,"2,928.39",,,,,,
Aetna MCR ADV,CPT,75956,Xray endovasc thor ao repr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,75957,Xray endovasc thor ao repr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,597.52","8,948.83",,,,,,
Aetna MCR ADV,CPT,75958,Xray place prox ext thor ao,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,052.29","8,948.83",,,,,,
Aetna MCR ADV,CPT,75959,Xray place dist ext thor ao,APC 5881,RVU Per Case,"$8,948.83 ",OP,926.48,"8,948.83",,,,,,
Aetna MCR ADV,CPT,76000,Fluoroscopy <1 hr phys/qhp,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,495.65,,,,,,
Aetna MCR ADV,CPT,76010,X-ray nose to rectum,APC 5521,RVU Per Case,$82.79 ,OP,82.79,144.88,,,,,,
Aetna MCR ADV,CPT,76080,X-ray exam of fistula,APC 5524,RVU Per Case,$494.15 ,OP,331.7,494.15,,,,,,
Aetna MCR ADV,CPT,76098,X-ray exam surgical specimen,APC 5524,RVU Per Case,$494.15 ,OP,102.95,494.15,,,,,,
Aetna MCR ADV,CPT,76100,X-ray exam of body section,APC 5522,RVU Per Case,$111.51 ,OP,111.51,690.1,,,,,,
Aetna MCR ADV,CPT,76101,Complex body section x-ray,APC 5522,RVU Per Case,$111.51 ,OP,111.51,949.36,,,,,,
Aetna MCR ADV,CPT,76102,Complex body section x-rays,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,111.51,,,,,,
Aetna MCR ADV,CPT,76120,Cine/video x-rays,APC 5522,RVU Per Case,$111.51 ,OP,111.51,392.7,,,,,,
Aetna MCR ADV,CPT,76145,Med physic dos eval rad exps,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,129.83,,,,,,
Aetna MCR ADV,CPT,76380,Cat scan follow-up study,APC 5521,RVU Per Case,$82.79 ,OP,82.79,689.66,,,,,,
Aetna MCR ADV,CPT,76390,Mr spectroscopy,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,"1,507.00",,,,,,
Aetna MCR ADV,CPT,76391,Mr elastography,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Aetna MCR ADV,CPT,76496,Fluoroscopic procedure,APC 5521,RVU Per Case,$82.79 ,OP,82.79,82.79,,,,,,
Aetna MCR ADV,CPT,76497,Ct procedure,APC 5521,RVU Per Case,$82.79 ,OP,82.79,927,,,,,,
Aetna MCR ADV,CPT,76498,Mri procedure,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,"1,507.00",,,,,,
Aetna MCR ADV,CPT,76499,Radiographic procedure,APC 5521,RVU Per Case,$82.79 ,OP,82.79,82.79,,,,,,
Aetna MCR ADV,CPT,76506,Echo exam of head,APC 5522,RVU Per Case,$111.51 ,OP,111.51,602.41,,,,,,
Aetna MCR ADV,CPT,76510,Oph us dx b-scan&quan a-scan,APC 5734,RVU Per Case,$114.56 ,OP,114.56,751.1,,,,,,
Aetna MCR ADV,CPT,76511,Oph us dx quan a-scan only,APC 5522,RVU Per Case,$111.51 ,OP,111.51,495.65,,,,,,
Aetna MCR ADV,CPT,76512,Oph us dx b-scan,APC 5522,RVU Per Case,$111.51 ,OP,111.51,468.96,,,,,,
Aetna MCR ADV,CPT,76513,Oph us dx ant sgm us uni/bi,APC 5522,RVU Per Case,$111.51 ,OP,111.51,438.47,,,,,,
Aetna MCR ADV,CPT,76514,Echo exam of eye thickness,APC 5731,RVU Per Case,$25.25 ,OP,25.25,64.82,,,,,,
Aetna MCR ADV,CPT,76516,Echo exam of eye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,346.96,,,,,,
Aetna MCR ADV,CPT,76519,Echo exam of eye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,369.83,,,,,,
Aetna MCR ADV,CPT,76529,Echo exam of eye,APC 5521,RVU Per Case,$82.79 ,OP,82.79,354.58,,,,,,
Aetna MCR ADV,CPT,76536,Us exam of head and neck,APC 5522,RVU Per Case,$111.51 ,OP,111.51,594.77,,,,,,
Aetna MCR ADV,CPT,76604,Us exam chest,APC 5522,RVU Per Case,$111.51 ,OP,111.51,446.08,,,,,,
Aetna MCR ADV,CPT,76641,Ultrasound breast complete,APC 5522,RVU Per Case,$111.51 ,OP,111.51,174.71,,,,,,
Aetna MCR ADV,CPT,76642,Ultrasound breast limited,APC 5521,RVU Per Case,$82.79 ,OP,82.79,174.71,,,,,,
Aetna MCR ADV,CPT,76700,Us exam abdom complete,APC 5522,RVU Per Case,$111.51 ,OP,111.51,739.67,,,,,,
Aetna MCR ADV,CPT,76705,Echo exam of abdomen,APC 5522,RVU Per Case,$111.51 ,OP,111.51,537.6,,,,,,
Aetna MCR ADV,CPT,76706,Us abdl aorta screen aaa,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,575.73,,,,,,
Aetna MCR ADV,CPT,76770,Us exam abdo back wall comp,APC 5522,RVU Per Case,$111.51 ,OP,111.51,678.66,,,,,,
Aetna MCR ADV,CPT,76775,Us exam abdo back wall lim,APC 5522,RVU Per Case,$111.51 ,OP,111.51,602.41,,,,,,
Aetna MCR ADV,CPT,76776,Us exam k transpl w/doppler,APC 5522,RVU Per Case,$111.51 ,OP,111.51,751.1,,,,,,
Aetna MCR ADV,CPT,76800,Us exam spinal canal,APC 5522,RVU Per Case,$111.51 ,OP,111.51,632.91,,,,,,
Aetna MCR ADV,CPT,76801,Ob us < 14 wks single fetus,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,712.98,,,,,,
Aetna MCR ADV,CPT,76805,Ob us >= 14 wks sngl fetus,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,789.23,,,,,,
Aetna MCR ADV,CPT,76811,Ob us detailed sngl fetus,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,204.81",,,,,,
Aetna MCR ADV,CPT,76813,Ob us nuchal meas 1 gest,APC 5522,RVU Per Case,$111.51 ,OP,111.51,667.22,,,,,,
Aetna MCR ADV,CPT,76815,Ob us limited fetus(s),APC 5522,RVU Per Case,$111.51 ,OP,111.51,472.78,,,,,,
Aetna MCR ADV,CPT,76816,Ob us follow-up per fetus,APC 5522,RVU Per Case,$111.51 ,OP,111.51,571.91,,,,,,
Aetna MCR ADV,CPT,76817,Transvaginal us obstetric,APC 5522,RVU Per Case,$111.51 ,OP,111.51,560.47,,,,,,
Aetna MCR ADV,CPT,76818,Fetal biophys profile w/nst,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,625.29,,,,,,
Aetna MCR ADV,CPT,76819,Fetal biophys profil w/o nst,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,526.16,,,,,,
Aetna MCR ADV,CPT,76820,Umbilical artery echo,APC 5522,RVU Per Case,$111.51 ,OP,111.51,297.39,,,,,,
Aetna MCR ADV,CPT,76821,Middle cerebral artery echo,APC 5522,RVU Per Case,$111.51 ,OP,111.51,510.9,,,,,,
Aetna MCR ADV,CPT,76825,Echo exam of fetal heart,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,067.55",,,,,,
Aetna MCR ADV,CPT,76826,Echo exam of fetal heart,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,587.16,,,,,,
Aetna MCR ADV,CPT,76827,Echo exam of fetal heart,APC 5522,RVU Per Case,$111.51 ,OP,111.51,381.27,,,,,,
Aetna MCR ADV,CPT,76828,Echo exam of fetal heart,APC 5522,RVU Per Case,$111.51 ,OP,111.51,282.14,,,,,,
Aetna MCR ADV,CPT,76830,Transvaginal us non-ob,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,651.97,,,,,,
Aetna MCR ADV,CPT,76831,Echo exam uterus,APC 5523,RVU Per Case,$235.49 ,OP,235.49,621.47,,,,,,
Aetna MCR ADV,CPT,76856,Us exam pelvic complete,APC 5522,RVU Per Case,$111.51 ,OP,111.51,655.78,,,,,,
Aetna MCR ADV,CPT,76857,Us exam pelvic limited,APC 5522,RVU Per Case,$111.51 ,OP,111.51,518.52,,,,,,
Aetna MCR ADV,CPT,76870,Us exam scrotum,APC 5522,RVU Per Case,$111.51 ,OP,111.51,621.47,,,,,,
Aetna MCR ADV,CPT,76872,Us transrectal,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,735.85,,,,,,
Aetna MCR ADV,CPT,76873,Echograp trans r pros study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,934.12,,,,,,
Aetna MCR ADV,CPT,76881,Us compl joint r-t w/img,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,644.34,,,,,,
Aetna MCR ADV,CPT,76882,Us lmtd jt/nonvasc xtr strux,APC 5522,RVU Per Case,$111.51 ,OP,111.51,644.34,,,,,,
Aetna MCR ADV,CPT,76885,Us exam infant hips dynamic,APC 5521,RVU Per Case,$82.79 ,OP,82.79,701.54,,,,,,
Aetna MCR ADV,CPT,76886,Us exam infant hips static,APC 5521,RVU Per Case,$82.79 ,OP,82.79,518.52,,,,,,
Aetna MCR ADV,CPT,76936,Echo guide for artery repair,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,654.72",,,,,,
Aetna MCR ADV,CPT,76975,Gi endoscopic ultrasound,APC 5523,RVU Per Case,$235.49 ,OP,235.49,529.96,,,,,,
Aetna MCR ADV,CPT,76977,Us bone density measure,APC 5522,RVU Per Unit,$111.51 ,OP,80.07,111.51,,,,,,
Aetna MCR ADV,CPT,76978,Us trgt dyn mbubb 1st les,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,182.72,,,,,,
Aetna MCR ADV,CPT,76981,Use parenchyma,APC 5522,RVU Per Case,$111.51 ,OP,111.51,111.51,,,,,,
Aetna MCR ADV,CPT,76982,Use 1st target lesion,APC 5522,RVU Per Case,$111.51 ,OP,111.51,111.51,,,,,,
Aetna MCR ADV,CPT,76999,Echo examination procedure,APC 5521,RVU Per Case,$82.79 ,OP,82.79,82.79,,,,,,
Aetna MCR ADV,CPT,77046,Mri breast c- unilateral,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Aetna MCR ADV,CPT,77047,Mri breast c- bilateral,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Aetna MCR ADV,CPT,77053,X-ray of mammary duct,APC 5523,RVU Per Case,$235.49 ,OP,235.49,411.78,,,,,,
Aetna MCR ADV,CPT,77054,X-ray of mammary ducts,APC 5523,RVU Per Case,$235.49 ,OP,235.49,235.49,,,,,,
Aetna MCR ADV,CPT,77063,Breast tomosynthesis bi,Physician,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Aetna MCR ADV,CPT,77065,Dx mammo incl cad uni,Physician,Per Unit,$83.47 ,OP,83.47,275.87,,,,,,
Aetna MCR ADV,CPT,77066,Dx mammo incl cad bi,Physician,Per Unit,$106.70 ,OP,106.7,275.87,,,,,,
Aetna MCR ADV,CPT,77067,Scr mammo bi incl cad,Physician,Per Unit,$88.24 ,OP,88.24,275.87,,,,,,
Aetna MCR ADV,CPT,77071,X-ray stress view,APC 5521,RVU Per Case,$82.79 ,OP,82.79,205.88,,,,,,
Aetna MCR ADV,CPT,77072,X-rays for bone age,APC 5522,RVU Per Case,$111.51 ,OP,111.51,122,,,,,,
Aetna MCR ADV,CPT,77073,X-rays bone length studies,APC 5522,RVU Per Case,$111.51 ,OP,111.51,198.25,,,,,,
Aetna MCR ADV,CPT,77074,X-rays bone survey limited,APC 5522,RVU Per Case,$111.51 ,OP,111.51,358.39,,,,,,
Aetna MCR ADV,CPT,77075,X-rays bone survey complete,APC 5522,RVU Per Case,$111.51 ,OP,111.51,514.72,,,,,,
Aetna MCR ADV,CPT,77076,X-rays bone survey infant,APC 5522,RVU Per Case,$111.51 ,OP,111.51,476.6,,,,,,
Aetna MCR ADV,CPT,77077,Joint survey single view,APC 5522,RVU Per Case,$111.51 ,OP,111.51,224.95,,,,,,
Aetna MCR ADV,CPT,77078,Ct bone density axial,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,927,,,,,,
Aetna MCR ADV,CPT,77080,Dxa bone density axial,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,537.6,,,,,,
Aetna MCR ADV,CPT,77081,Dxa bone density/peripheral,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,167.76,,,,,,
Aetna MCR ADV,CPT,77084,Magnetic image bone marrow,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,507.00",,,,,,
Aetna MCR ADV,CPT,77085,Dxa bone density study,APC 5522,RVU Per Case,$111.51 ,OP,111.51,111.51,,,,,,
Aetna MCR ADV,CPT,77086,Fracture assessment via dxa,APC 5521,RVU Per Case,$82.79 ,OP,82.79,213.51,,,,,,
Aetna MCR ADV,CPT,77280,Set radiation therapy field,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,964.61,,,,,,
Aetna MCR ADV,CPT,77285,Set radiation therapy field,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,"1,662.33",,,,,,
Aetna MCR ADV,CPT,77290,Set radiation therapy field,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,"2,558.32",,,,,,
Aetna MCR ADV,CPT,77295,3-d radiotherapy plan,APC 5613,RVU Per Unit,"$1,291.62 ",OP,"1,291.62","3,736.44",,,,,,
Aetna MCR ADV,CPT,77299,Radiation therapy planning,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,129.83,,,,,,
Aetna MCR ADV,CPT,77300,Radiation therapy dose plan,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,388.89,,,,,,
Aetna MCR ADV,CPT,77301,Radiotherapy dose plan imrt,APC 5613,RVU Per Unit,"$1,291.62 ",OP,"1,291.62","11,205.50",,,,,,
Aetna MCR ADV,CPT,77306,Telethx isodose plan simple,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,392.7,,,,,,
Aetna MCR ADV,CPT,77307,Telethx isodose plan cplx,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,777.79,,,,,,
Aetna MCR ADV,CPT,77316,Brachytx isodose plan simple,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,747.28,,,,,,
Aetna MCR ADV,CPT,77317,Brachytx isodose intermed,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,"1,059.93",,,,,,
Aetna MCR ADV,CPT,77318,Brachytx isodose complex,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,"1,456.44",,,,,,
Aetna MCR ADV,CPT,77321,Special teletx port plan,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,659.6,,,,,,
Aetna MCR ADV,CPT,77331,Special radiation dosimetry,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,320.27,,,,,,
Aetna MCR ADV,CPT,77332,Radiation treatment aid(s),APC 5611,RVU Per Unit,$129.83 ,OP,129.83,407.96,,,,,,
Aetna MCR ADV,CPT,77333,Radiation treatment aid(s),APC 5611,RVU Per Unit,$129.83 ,OP,129.83,369.83,,,,,,
Aetna MCR ADV,CPT,77334,Radiation treatment aid(s),APC 5612,RVU Per Unit,$346.58 ,OP,346.58,869.3,,,,,,
Aetna MCR ADV,CPT,77336,Radiation physics consult,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,343.14,,,,,,
Aetna MCR ADV,CPT,77338,Design mlc device for imrt,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,346.58,,,,,,
Aetna MCR ADV,CPT,77370,Radiation physics consult,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,629.1,,,,,,
Aetna MCR ADV,CPT,77371,Srs multisource,APC 5627,RVU Per Case,"$7,954.01 ",OP,"6,969.60","7,954.01",,,,,,
Aetna MCR ADV,CPT,77372,Srs linear based,APC 5627,RVU Per Case,"$7,954.01 ",OP,"4,148.22","7,954.01",,,,,,
Aetna MCR ADV,CPT,77373,Sbrt delivery,APC 5626,RVU Per Unit,"$1,774.17 ",OP,"1,774.17","13,221.44",,,,,,
Aetna MCR ADV,CPT,77385,Ntsty modul rad tx dlvr smpl,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"1,379.33",,,,,,
Aetna MCR ADV,CPT,77386,Ntsty modul rad tx dlvr cplx,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"1,379.33",,,,,,
Aetna MCR ADV,CPT,77399,External radiation dosimetry,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,129.83,,,,,,
Aetna MCR ADV,CPT,77401,Radiation treatment delivery,APC 5621,RVU Per Unit,$123.36 ,OP,123.36,183.02,,,,,,
Aetna MCR ADV,CPT,77402,Radiation treatment delivery,APC 5621,RVU Per Unit,$123.36 ,OP,123.36,123.36,,,,,,
Aetna MCR ADV,CPT,77407,Radiation treatment delivery,APC 5622,RVU Per Unit,$247.32 ,OP,247.32,247.32,,,,,,
Aetna MCR ADV,CPT,77412,Radiation treatment delivery,APC 5622,RVU Per Unit,$247.32 ,OP,247.32,"1,067.55",,,,,,
Aetna MCR ADV,CPT,77423,Neutron beam tx complex,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"1,235.32",,,,,,
Aetna MCR ADV,CPT,77424,Io rad tx delivery by x-ray,APC 5627,RVU Per Case,"$7,954.01 ",OP,"7,954.01","7,954.01",,,,,,
Aetna MCR ADV,CPT,77425,Io rad tx deliver by elctrns,APC 5627,RVU Per Case,"$7,954.01 ",OP,"7,954.01","7,954.01",,,,,,
Aetna MCR ADV,CPT,77470,Special radiation treatment,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"1,509.83",,,,,,
Aetna MCR ADV,CPT,77520,Proton trmt simple w/o comp,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,555.2,,,,,,
Aetna MCR ADV,CPT,77522,Proton trmt simple w/comp,APC 5625,RVU Per Unit,"$1,328.18 ",OP,"1,328.18","1,328.18",,,,,,
Aetna MCR ADV,CPT,77523,Proton trmt intermediate,APC 5625,RVU Per Unit,"$1,328.18 ",OP,"1,328.18","1,328.18",,,,,,
Aetna MCR ADV,CPT,77525,Proton treatment complex,APC 5625,RVU Per Unit,"$1,328.18 ",OP,"1,328.18","1,328.18",,,,,,
Aetna MCR ADV,CPT,77600,Hyperthermia treatment,APC 5622,RVU Per Unit,$247.32 ,OP,247.32,"1,902.54",,,,,,
Aetna MCR ADV,CPT,77605,Hyperthermia treatment,APC 5624,RVU Per Unit,$724.98 ,OP,724.98,"3,397.11",,,,,,
Aetna MCR ADV,CPT,77610,Hyperthermia treatment,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"3,156.91",,,,,,
Aetna MCR ADV,CPT,77615,Hyperthermia treatment,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"4,464.67",,,,,,
Aetna MCR ADV,CPT,77620,Hyperthermia treatment,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"2,013.11",,,,,,
Aetna MCR ADV,CPT,77750,Infuse radioactive materials,APC 5622,RVU Per Unit,$247.32 ,OP,247.32,"1,730.97",,,,,,
Aetna MCR ADV,CPT,77761,Apply intrcav radiat simple,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"1,803.41",,,,,,
Aetna MCR ADV,CPT,77762,Apply intrcav radiat interm,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"2,463.00",,,,,,
Aetna MCR ADV,CPT,77763,Apply intrcav radiat compl,APC 5624,RVU Per Unit,$724.98 ,OP,724.98,724.98,,,,,,
Aetna MCR ADV,CPT,77767,Hdr rdncl skn surf brachytx,APC 5622,RVU Per Unit,$247.32 ,OP,247.32,247.32,,,,,,
Aetna MCR ADV,CPT,77768,Hdr rdncl skn surf brachytx,APC 5622,RVU Per Unit,$247.32 ,OP,247.32,247.32,,,,,,
Aetna MCR ADV,CPT,77770,Hdr rdncl ntrstl/icav brchtx,APC 5624,RVU Per Unit,$724.98 ,OP,724.98,964.61,,,,,,
Aetna MCR ADV,CPT,77771,Hdr rdncl ntrstl/icav brchtx,APC 5624,RVU Per Unit,$724.98 ,OP,724.98,"2,882.39",,,,,,
Aetna MCR ADV,CPT,77772,Hdr rdncl ntrstl/icav brchtx,APC 5624,RVU Per Unit,$724.98 ,OP,724.98,"4,285.47",,,,,,
Aetna MCR ADV,CPT,77778,Apply interstit radiat compl,APC 5624,RVU Per Unit,$724.98 ,OP,724.98,"4,209.21",,,,,,
Aetna MCR ADV,CPT,77789,Apply surf ldr radionuclide,APC 5621,RVU Per Unit,$123.36 ,OP,123.36,533.78,,,,,,
Aetna MCR ADV,CPT,77799,Radium/radioisotope therapy,APC 5621,RVU Per Unit,$123.36 ,OP,123.36,123.36,,,,,,
Aetna MCR ADV,CPT,78012,Thyroid uptake measurement,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,453.71,,,,,,
Aetna MCR ADV,CPT,78013,Thyroid imaging w/blood flow,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,884.55,,,,,,
Aetna MCR ADV,CPT,78014,Thyroid imaging w/blood flow,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,105.68",,,,,,
Aetna MCR ADV,CPT,78015,Thyroid met imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,044.69",,,,,,
Aetna MCR ADV,CPT,78016,Thyroid met imaging/studies,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,578.46",,,,,,
Aetna MCR ADV,CPT,78018,Thyroid met imaging body,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,616.58",,,,,,
Aetna MCR ADV,CPT,78070,Parathyroid planar imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,884.55,,,,,,
Aetna MCR ADV,CPT,78071,Parathyrd planar w/wo subtrj,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,884.55,,,,,,
Aetna MCR ADV,CPT,78072,Parathyrd planar w/spect&ct,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,884.55,,,,,,
Aetna MCR ADV,CPT,78075,Adrenal cortex & medulla img,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","2,085.54",,,,,,
Aetna MCR ADV,CPT,78099,Endocrine nuclear procedure,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Aetna MCR ADV,CPT,78102,Bone marrow imaging ltd,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Aetna MCR ADV,CPT,78103,Bone marrow imaging mult,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,109.50",,,,,,
Aetna MCR ADV,CPT,78104,Bone marrow imaging body,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,273.44",,,,,,
Aetna MCR ADV,CPT,78110,Plasma volume single,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,336.39",,,,,,
Aetna MCR ADV,CPT,78111,Plasma volume multiple,APC 5593,RVU Per Unit,"$1,336.39 ",OP,518.52,"1,336.39",,,,,,
Aetna MCR ADV,CPT,78120,Red cell mass single,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Aetna MCR ADV,CPT,78121,Red cell mass multiple,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,552.84,,,,,,
Aetna MCR ADV,CPT,78122,Blood volume,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,701.54,,,,,,
Aetna MCR ADV,CPT,78130,Red cell survival study,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,793.05,,,,,,
Aetna MCR ADV,CPT,78140,Red cell sequestration,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,781.61,,,,,,
Aetna MCR ADV,CPT,78185,Spleen imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Aetna MCR ADV,CPT,78191,Platelet survival,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,067.55",,,,,,
Aetna MCR ADV,CPT,78195,Lymph system imaging,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,704.28",,,,,,
Aetna MCR ADV,CPT,78199,Blood/lymph nuclear exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Aetna MCR ADV,CPT,78201,Liver imaging,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,884.55,,,,,,
Aetna MCR ADV,CPT,78202,Liver imaging with flow,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,014.17",,,,,,
Aetna MCR ADV,CPT,78215,Liver and spleen imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,941.74,,,,,,
Aetna MCR ADV,CPT,78216,Liver & spleen image/flow,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,728.23,,,,,,
Aetna MCR ADV,CPT,78226,Hepatobiliary system imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,570.83",,,,,,
Aetna MCR ADV,CPT,78227,Hepatobil syst image w/drug,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,570.83",,,,,,
Aetna MCR ADV,CPT,78230,Salivary gland imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,804.48,,,,,,
Aetna MCR ADV,CPT,78231,Serial salivary imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,697.72,,,,,,
Aetna MCR ADV,CPT,78232,Salivary gland function exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,712.98,,,,,,
Aetna MCR ADV,CPT,78258,Esophageal motility study,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,113.30",,,,,,
Aetna MCR ADV,CPT,78261,Gastric mucosa imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,242.94",,,,,,
Aetna MCR ADV,CPT,78262,Gastroesophageal reflux exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,227.68",,,,,,
Aetna MCR ADV,CPT,78264,Gastric emptying imag study,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,403.08",,,,,,
Aetna MCR ADV,CPT,78265,Gastric emptying imag study,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,403.08",,,,,,
Aetna MCR ADV,CPT,78266,Gastric emptying imag study,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,403.08",,,,,,
Aetna MCR ADV,CPT,78267,Breath tst attain/anal c-14,Lab Services,Per Unit,$11.06 ,OP,11.06,11.06,,,,,,
Aetna MCR ADV,CPT,78268,Breath test analysis c-14,Lab Services,Per Unit,$94.41 ,OP,94.41,301.2,,,,,,
Aetna MCR ADV,CPT,78278,Acute gi blood loss imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Aetna MCR ADV,CPT,78282,Gi protein loss exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,407.96,,,,,,
Aetna MCR ADV,CPT,78290,Meckels divert exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,498.39",,,,,,
Aetna MCR ADV,CPT,78291,Leveen/shunt patency exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,227.68",,,,,,
Aetna MCR ADV,CPT,78299,Gi nuclear procedure,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Aetna MCR ADV,CPT,78300,Bone imaging limited area,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,869.3,,,,,,
Aetna MCR ADV,CPT,78305,Bone imaging multiple areas,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,155.24",,,,,,
Aetna MCR ADV,CPT,78306,Bone imaging whole body,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,281.07",,,,,,
Aetna MCR ADV,CPT,78315,Bone imaging 3 phase,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,692.84",,,,,,
Aetna MCR ADV,CPT,78399,Musculoskeletal nuclear exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Aetna MCR ADV,CPT,78414,Non-imaging heart function,APC 5592,RVU Per Unit,$500.81 ,OP,377.46,500.81,,,,,,
Aetna MCR ADV,CPT,78428,Cardiac shunt imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,998.92,,,,,,
Aetna MCR ADV,CPT,78429,Myocrd img pet 1 std w/ct,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,240.30",,,,,,
Aetna MCR ADV,CPT,78430,Myocrd img pet rst/strs w/ct,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,217.42",,,,,,
Aetna MCR ADV,CPT,78431,Myocrd img pet rst&strs ct,APC 1522,RVU Per Unit,"$2,302.98 ",OP,"2,150.30","7,339.44",,,,,,
Aetna MCR ADV,CPT,78432,Myocrd img pet 2rtracer,APC 1523,RVU Per Unit,"$2,814.64 ",OP,"2,628.05","8,030.21",,,,,,
Aetna MCR ADV,CPT,78433,Myocrd img pet 2rtracer ct,APC 1523,RVU Per Unit,"$2,814.64 ",OP,"2,628.05","8,778.55",,,,,,
Aetna MCR ADV,CPT,78445,Vascular flow imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,838.79,,,,,,
Aetna MCR ADV,CPT,78451,Ht muscle image spect sing,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","2,116.06",,,,,,
Aetna MCR ADV,CPT,78452,Ht muscle image spect mult,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","3,343.73",,,,,,
Aetna MCR ADV,CPT,78453,Ht muscle image planar sing,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,631.84",,,,,,
Aetna MCR ADV,CPT,78454,Ht musc image planar mult,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,772.90",,,,,,
Aetna MCR ADV,CPT,78456,Acute venous thrombus image,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,784.34",,,,,,
Aetna MCR ADV,CPT,78457,Venous thrombosis imaging,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,964.61,,,,,,
Aetna MCR ADV,CPT,78458,Ven thrombosis images bilat,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,078.99",,,,,,
Aetna MCR ADV,CPT,78459,Myocrd img pet single study,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","7,240.30",,,,,,
Aetna MCR ADV,CPT,78466,Heart infarct image,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,922.67,,,,,,
Aetna MCR ADV,CPT,78468,Heart infarct image (ef),APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,166.68",,,,,,
Aetna MCR ADV,CPT,78469,Heart infarct image (3d),APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,338.26",,,,,,
Aetna MCR ADV,CPT,78472,Gated heart planar single,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,368.75",,,,,,
Aetna MCR ADV,CPT,78473,Gated heart multiple,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,872.03",,,,,,
Aetna MCR ADV,CPT,78481,Heart first pass single,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,201.00",,,,,,
Aetna MCR ADV,CPT,78483,Heart first pass multiple,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,700.46",,,,,,
Aetna MCR ADV,CPT,78491,Myocrd img pet 1std rst/strs,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,217.42",,,,,,
Aetna MCR ADV,CPT,78492,Myocrd img pet mlt rst&strs,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,339.44",,,,,,
Aetna MCR ADV,CPT,78494,Heart image spect,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,486.95",,,,,,
Aetna MCR ADV,CPT,78499,Cardiovascular nuclear exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Aetna MCR ADV,CPT,78579,Lung ventilation imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,155.24",,,,,,
Aetna MCR ADV,CPT,78580,Lung perfusion imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,071.37",,,,,,
Aetna MCR ADV,CPT,78582,Lung ventilat&perfus imaging,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,769.09",,,,,,
Aetna MCR ADV,CPT,78597,Lung perfusion differential,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,906.36",,,,,,
Aetna MCR ADV,CPT,78598,Lung perf&ventilat diferentl,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,906.36",,,,,,
Aetna MCR ADV,CPT,78599,Respiratory nuclear exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Aetna MCR ADV,CPT,78600,Brain image < 4 views,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,888.36,,,,,,
Aetna MCR ADV,CPT,78601,Brain image w/flow < 4 views,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,059.93",,,,,,
Aetna MCR ADV,CPT,78605,Brain image 4+ views,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,991.29,,,,,,
Aetna MCR ADV,CPT,78606,Brain image w/flow 4 + views,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,540.33",,,,,,
Aetna MCR ADV,CPT,78608,Brain imaging (pet),APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,209.80",,,,,,
Aetna MCR ADV,CPT,78610,Brain flow imaging only,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,888.36,,,,,,
Aetna MCR ADV,CPT,78630,Cerebrospinal fluid scan,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,647.08",,,,,,
Aetna MCR ADV,CPT,78635,Csf ventriculography,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,475.51",,,,,,
Aetna MCR ADV,CPT,78645,Csf shunt evaluation,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,502.21",,,,,,
Aetna MCR ADV,CPT,78650,Csf leakage imaging,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,601.33",,,,,,
Aetna MCR ADV,CPT,78660,Nuclear exam of tear flow,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,831.17,,,,,,
Aetna MCR ADV,CPT,78699,Nervous system nuclear exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Aetna MCR ADV,CPT,78700,Kidney imaging morphol,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,884.55,,,,,,
Aetna MCR ADV,CPT,78701,Kidney imaging with flow,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,056.11",,,,,,
Aetna MCR ADV,CPT,78707,K flow/funct image w/o drug,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,235.32",,,,,,
Aetna MCR ADV,CPT,78708,K flow/funct image w/drug,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,014.17",,,,,,
Aetna MCR ADV,CPT,78709,K flow/funct image multiple,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,795.78",,,,,,
Aetna MCR ADV,CPT,78725,Kidney function study,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,518.52,,,,,,
Aetna MCR ADV,CPT,78740,Ureteral reflux study,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,040.87",,,,,,
Aetna MCR ADV,CPT,78761,Testicular imaging w/flow,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,052.29",,,,,,
Aetna MCR ADV,CPT,78799,Genitourinary nuclear exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Aetna MCR ADV,CPT,78800,Rp loclzj tum 1 area 1 d img,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,949.36,,,,,,
Aetna MCR ADV,CPT,78801,Rp loclzj tum 2+area 1+d img,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,265.81",,,,,,
Aetna MCR ADV,CPT,78802,Rp loclzj tum whbdy 1 d img,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,654.72",,,,,,
Aetna MCR ADV,CPT,78803,Rp loclzj tum spect 1 area,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,826.28",,,,,,
Aetna MCR ADV,CPT,78804,Rp loclzj tum whbdy 2+d img,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","2,870.96",,,,,,
Aetna MCR ADV,CPT,78808,Iv inj ra drug dx study,APC 5591,RVU Per Case,$385.91 ,OP,385.91,385.91,,,,,,
Aetna MCR ADV,CPT,78811,Pet image ltd area,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,336.39",,,,,,
Aetna MCR ADV,CPT,78812,Pet image skull-thigh,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,347.07",,,,,,
Aetna MCR ADV,CPT,78813,Pet image full body,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,354.67",,,,,,
Aetna MCR ADV,CPT,78814,Pet image w/ct lmtd,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,404.24",,,,,,
Aetna MCR ADV,CPT,78815,Pet image w/ct skull-thigh,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,446.19",,,,,,
Aetna MCR ADV,CPT,78816,Pet image w/ct full body,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,461.44",,,,,,
Aetna MCR ADV,CPT,78830,Rp loclzj tum spect w/ct 1,APC 5593,RVU Per Unit,"$1,336.39 ",OP,927,"2,600.43",,,,,,
Aetna MCR ADV,CPT,78831,Rp loclzj tum spect 2 areas,APC 5593,RVU Per Unit,"$1,336.39 ",OP,927,"3,860.65",,,,,,
Aetna MCR ADV,CPT,78832,Rp loclzj tum spect w/ct 2,APC 5594,RVU Per Unit,"$1,514.86 ",OP,927,"5,097.10",,,,,,
Aetna MCR ADV,CPT,78999,Nuclear diagnostic exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Aetna MCR ADV,CPT,79005,Nuclear rx oral admin,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,800.67,,,,,,
Aetna MCR ADV,CPT,79101,Nuclear rx iv admin,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,896,,,,,,
Aetna MCR ADV,CPT,79200,Nuclear rx intracav admin,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,911.23,,,,,,
Aetna MCR ADV,CPT,79300,Nuclr rx interstit colloid,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,724.42,,,,,,
Aetna MCR ADV,CPT,79403,Hematopoietic nuclear tx,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,"1,132.37",,,,,,
Aetna MCR ADV,CPT,79440,Nuclear rx intra-articular,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,838.79,,,,,,
Aetna MCR ADV,CPT,79445,Nuclear rx intra-arterial,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,"1,162.87",,,,,,
Aetna MCR ADV,CPT,79999,Nuclear medicine therapy,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,255.45,,,,,,
Aetna MCR ADV,CPT,80047,Metabolic panel ionized ca,Lab Services,Per Unit,$13.73 ,OP,13.73,41.94,,,,,,
Aetna MCR ADV,CPT,80048,Metabolic panel total ca,Lab Services,Per Unit,$8.46 ,OP,8.46,132.19,,,,,,
Aetna MCR ADV,CPT,80051,Electrolyte panel,Lab Services,Per Unit,$7.01 ,OP,7.01,34.31,,,,,,
Aetna MCR ADV,CPT,80053,Comprehen metabolic panel,Lab Services,Per Unit,$10.56 ,OP,10.56,172.42,,,,,,
Aetna MCR ADV,CPT,80055,Obstetric panel,Lab Services,Per Unit,$47.81 ,OP,47.81,301.2,,,,,,
Aetna MCR ADV,CPT,80061,Lipid panel,Lab Services,Per Unit,$13.39 ,OP,13.39,68.63,,,,,,
Aetna MCR ADV,CPT,80069,Renal function panel,Lab Services,Per Unit,$8.68 ,OP,8.68,38.13,,,,,,
Aetna MCR ADV,CPT,80074,Acute hepatitis panel,Lab Services,Per Unit,$47.63 ,OP,47.63,213.51,,,,,,
Aetna MCR ADV,CPT,80076,Hepatic function panel,Lab Services,Per Unit,$8.17 ,OP,8.17,126.44,,,,,,
Aetna MCR ADV,CPT,80081,Obstetric panel,Lab Services,Per Unit,$74.86 ,OP,74.86,74.86,,,,,,
Aetna MCR ADV,CPT,80143,Drug assay acetaminophen,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,
Aetna MCR ADV,CPT,80145,Drug assay adalimumab,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,
Aetna MCR ADV,CPT,80150,Assay of amikacin,Lab Services,Per Unit,$15.08 ,OP,15.08,49.56,,,,,,
Aetna MCR ADV,CPT,80151,Drug assay amiodarone,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,
Aetna MCR ADV,CPT,80155,Drug assay caffeine,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,
Aetna MCR ADV,CPT,80156,Assay carbamazepine total,Lab Services,Per Unit,$14.57 ,OP,14.57,64.82,,,,,,
Aetna MCR ADV,CPT,80157,Assay carbamazepine free,Lab Services,Per Unit,$13.25 ,OP,13.25,57.19,,,,,,
Aetna MCR ADV,CPT,80158,Drug assay cyclosporine,Lab Services,Per Unit,$18.05 ,OP,18.05,80.07,,,,,,
Aetna MCR ADV,CPT,80159,Drug assay clozapine,Lab Services,Per Unit,$20.15 ,OP,20.15,20.15,,,,,,
Aetna MCR ADV,CPT,80161,Asy carbamazepin 10-11-epxid,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,
Aetna MCR ADV,CPT,80162,Assay of digoxin total,Lab Services,Per Unit,$13.28 ,OP,13.28,61,,,,,,
Aetna MCR ADV,CPT,80163,Assay of digoxin free,Lab Services,Per Unit,$13.28 ,OP,13.28,61,,,,,,
Aetna MCR ADV,CPT,80164,Assay dipropylacetic acd tot,Lab Services,Per Unit,$13.54 ,OP,13.54,61,,,,,,
Aetna MCR ADV,CPT,80165,Dipropylacetic acid free,Lab Services,Per Unit,$13.54 ,OP,13.54,61,,,,,,
Aetna MCR ADV,CPT,80167,Drug assay felbamate,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,
Aetna MCR ADV,CPT,80168,Assay of ethosuximide,Lab Services,Per Unit,$16.34 ,OP,16.34,72.44,,,,,,
Aetna MCR ADV,CPT,80169,Drug assay everolimus,Lab Services,Per Unit,$13.73 ,OP,13.73,13.73,,,,,,
Aetna MCR ADV,CPT,80170,Assay of gentamicin,Lab Services,Per Unit,$16.38 ,OP,16.38,72.44,,,,,,
Aetna MCR ADV,CPT,80171,Drug screen quant gabapentin,Lab Services,Per Unit,$21.67 ,OP,21.67,21.67,,,,,,
Aetna MCR ADV,CPT,80173,Assay of haloperidol,Lab Services,Per Unit,$15.78 ,OP,15.78,15.78,,,,,,
Aetna MCR ADV,CPT,80175,Drug screen quan lamotrigine,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,
Aetna MCR ADV,CPT,80176,Assay of lidocaine,Lab Services,Per Unit,$14.69 ,OP,14.69,64.82,,,,,,
Aetna MCR ADV,CPT,80177,Drug scrn quan levetiracetam,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,
Aetna MCR ADV,CPT,80178,Assay of lithium,Lab Services,Per Unit,$6.61 ,OP,6.61,30.51,,,,,,
Aetna MCR ADV,CPT,80179,Drug assay salicylate,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,
Aetna MCR ADV,CPT,80180,Drug scrn quan mycophenolate,Lab Services,Per Unit,$18.05 ,OP,18.05,18.05,,,,,,
Aetna MCR ADV,CPT,80181,Drug assay flecainide,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,
Aetna MCR ADV,CPT,80183,Drug scrn quant oxcarbazepin,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,
Aetna MCR ADV,CPT,80184,Assay of phenobarbital,Lab Services,Per Unit,$15.30 ,OP,15.3,49.56,,,,,,
Aetna MCR ADV,CPT,80185,Assay of phenytoin total,Lab Services,Per Unit,$13.25 ,OP,13.25,57.19,,,,,,
Aetna MCR ADV,CPT,80186,Assay of phenytoin free,Lab Services,Per Unit,$13.76 ,OP,13.76,61,,,,,,
Aetna MCR ADV,CPT,80187,Drug assay posaconazole,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,
Aetna MCR ADV,CPT,80188,Assay of primidone,Lab Services,Per Unit,$16.59 ,OP,16.59,72.44,,,,,,
Aetna MCR ADV,CPT,80189,Drug assay itraconzaole,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,
Aetna MCR ADV,CPT,80190,Assay of procainamide,Lab Services,Per Unit,$60.00 ,OP,60,76.26,,,,,,
Aetna MCR ADV,CPT,80192,Assay of procainamide,Lab Services,Per Unit,$16.75 ,OP,16.75,76.26,,,,,,
Aetna MCR ADV,CPT,80193,Drug assay leflunomide,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,
Aetna MCR ADV,CPT,80194,Assay of quinidine,Lab Services,Per Unit,$14.60 ,OP,14.6,64.82,,,,,,
Aetna MCR ADV,CPT,80195,Assay of sirolimus,Lab Services,Per Unit,$13.73 ,OP,13.73,61,,,,,,
Aetna MCR ADV,CPT,80197,Assay of tacrolimus,Lab Services,Per Unit,$13.73 ,OP,13.73,61,,,,,,
Aetna MCR ADV,CPT,80198,Assay of theophylline,Lab Services,Per Unit,$14.14 ,OP,14.14,64.82,,,,,,
Aetna MCR ADV,CPT,80199,Drug screen quant tiagabine,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,
Aetna MCR ADV,CPT,80200,Assay of tobramycin,Lab Services,Per Unit,$16.13 ,OP,16.13,49.56,,,,,,
Aetna MCR ADV,CPT,80201,Assay of topiramate,Lab Services,Per Unit,$11.92 ,OP,11.92,53.38,,,,,,
Aetna MCR ADV,CPT,80202,Assay of vancomycin,Lab Services,Per Unit,$13.54 ,OP,13.54,61,,,,,,
Aetna MCR ADV,CPT,80203,Drug screen quant zonisamide,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,
Aetna MCR ADV,CPT,80204,Drug assay methotrexate,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,
Aetna MCR ADV,CPT,80210,Drug assay rufinamide,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,
Aetna MCR ADV,CPT,80230,Drug assay infliximab,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,
Aetna MCR ADV,CPT,80235,Drug assay lacosamide,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,
Aetna MCR ADV,CPT,80280,Drug assay vedolizumab,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,
Aetna MCR ADV,CPT,80285,Drug assay voriconazole,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,
Aetna MCR ADV,CPT,80299,Quantitative assay drug,Lab Services,Per Unit,$18.64 ,OP,18.64,61,,,,,,
Aetna MCR ADV,CPT,80305,Drug test prsmv dir opt obs,Lab Services,Per Unit,$12.60 ,OP,12.6,64.82,,,,,,
Aetna MCR ADV,CPT,80306,Drug test prsmv instrmnt,Lab Services,Per Unit,$17.14 ,OP,17.14,64.82,,,,,,
Aetna MCR ADV,CPT,80307,Drug test prsmv chem anlyzr,Lab Services,Per Unit,$62.14 ,OP,62.14,62.14,,,,,,
Aetna MCR ADV,CPT,80400,Acth stimulation panel,Lab Services,Per Unit,$32.62 ,OP,32.62,144.88,,,,,,
Aetna MCR ADV,CPT,80402,Acth stimulation panel,Lab Services,Per Unit,$86.96 ,OP,86.96,388.89,,,,,,
Aetna MCR ADV,CPT,80406,Acth stimulation panel,Lab Services,Per Unit,$78.26 ,OP,78.26,346.96,,,,,,
Aetna MCR ADV,CPT,80408,Aldosterone suppression eval,Lab Services,Per Unit,$125.50 ,OP,125.5,560.47,,,,,,
Aetna MCR ADV,CPT,80410,Calcitonin stimul panel,Lab Services,Per Unit,$80.37 ,OP,80.37,358.39,,,,,,
Aetna MCR ADV,CPT,80412,Crh stimulation panel,Lab Services,Per Unit,$801.62 ,OP,801.62,"1,467.89",,,,,,
Aetna MCR ADV,CPT,80414,Testosterone response panel,Lab Services,Per Unit,$51.64 ,OP,51.64,228.77,,,,,,
Aetna MCR ADV,CPT,80415,Tot estradiol response panel,Lab Services,Per Unit,$55.89 ,OP,55.89,99.13,,,,,,
Aetna MCR ADV,CPT,80416,Renin stimulation panel,Lab Services,Per Unit,$209.32 ,OP,209.32,587.16,,,,,,
Aetna MCR ADV,CPT,80417,Renin stimulation panel,Lab Services,Per Unit,$43.99 ,OP,43.99,194.45,,,,,,
Aetna MCR ADV,CPT,80418,Pituitary evaluation panel,Lab Services,Per Unit,$579.48 ,OP,579.48,"2,573.58",,,,,,
Aetna MCR ADV,CPT,80420,Dexamethasone panel,Lab Services,Per Unit,$161.88 ,OP,161.88,320.27,,,,,,
Aetna MCR ADV,CPT,80422,Glucagon tolerance panel,Lab Services,Per Unit,$46.07 ,OP,46.07,205.88,,,,,,
Aetna MCR ADV,CPT,80424,Glucagon tolerance panel,Lab Services,Per Unit,$50.50 ,OP,50.5,224.95,,,,,,
Aetna MCR ADV,CPT,80426,Gonadotropin hormone panel,Lab Services,Per Unit,$148.41 ,OP,148.41,659.6,,,,,,
Aetna MCR ADV,CPT,80428,Growth hormone panel,Lab Services,Per Unit,$66.70 ,OP,66.7,289.76,,,,,,
Aetna MCR ADV,CPT,80430,Growth hormone panel,Lab Services,Per Unit,$129.33 ,OP,129.33,343.14,,,,,,
Aetna MCR ADV,CPT,80432,Insulin suppression panel,Lab Services,Per Unit,$165.61 ,OP,165.61,602.41,,,,,,
Aetna MCR ADV,CPT,80434,Insulin tolerance panel,Lab Services,Per Unit,$285.03 ,OP,285.03,449.9,,,,,,
Aetna MCR ADV,CPT,80435,Insulin tolerance panel,Lab Services,Per Unit,$103.00 ,OP,103,449.9,,,,,,
Aetna MCR ADV,CPT,80436,Metyrapone panel,Lab Services,Per Unit,$91.16 ,OP,91.16,301.2,,,,,,
Aetna MCR ADV,CPT,80438,Trh stimulation panel,Lab Services,Per Unit,$50.41 ,OP,50.41,224.95,,,,,,
Aetna MCR ADV,CPT,80439,Trh stimulation panel,Lab Services,Per Unit,$67.21 ,OP,67.21,297.39,,,,,,
Aetna MCR ADV,CPT,80500,Lab pathology consultation,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Aetna MCR ADV,CPT,80502,Lab pathology consultation,APC 5672,RVU Per Case,$152.64 ,OP,152.64,320.27,,,,,,
Aetna MCR ADV,CPT,81000,Urinalysis nonauto w/scope,Lab Services,Per Unit,$4.02 ,OP,4.02,15.26,,,,,,
Aetna MCR ADV,CPT,81001,Urinalysis auto w/scope,Lab Services,Per Unit,$3.17 ,OP,3.17,15.26,,,,,,
Aetna MCR ADV,CPT,81002,Urinalysis nonauto w/o scope,Lab Services,Per Unit,$3.48 ,OP,3.48,11.44,,,,,,
Aetna MCR ADV,CPT,81003,Urinalysis auto w/o scope,Lab Services,Per Unit,$2.25 ,OP,2.25,11.44,,,,,,
Aetna MCR ADV,CPT,81005,Urinalysis,Lab Services,Per Unit,$2.17 ,OP,2.17,11.44,,,,,,
Aetna MCR ADV,CPT,81007,Urine screen for bacteria,Lab Services,Per Unit,$29.98 ,OP,11.44,29.98,,,,,,
Aetna MCR ADV,CPT,81015,Microscopic exam of urine,Lab Services,Per Unit,$3.05 ,OP,3.05,15.26,,,,,,
Aetna MCR ADV,CPT,81020,Urinalysis glass test,Lab Services,Per Unit,$4.70 ,OP,4.7,15.26,,,,,,
Aetna MCR ADV,CPT,81025,Urine pregnancy test,Lab Services,Per Unit,$8.61 ,OP,8.61,30.51,,,,,,
Aetna MCR ADV,CPT,81050,Urinalysis volume measure,Lab Services,Per Unit,$3.64 ,OP,3.64,11.44,,,,,,
Aetna MCR ADV,CPT,81105,Hpa-1 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
Aetna MCR ADV,CPT,81106,Hpa-2 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
Aetna MCR ADV,CPT,81107,Hpa-3 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
Aetna MCR ADV,CPT,81108,Hpa-4 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
Aetna MCR ADV,CPT,81109,Hpa-5 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
Aetna MCR ADV,CPT,81110,Hpa-6 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
Aetna MCR ADV,CPT,81111,Hpa-9 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
Aetna MCR ADV,CPT,81112,Hpa-15 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
Aetna MCR ADV,CPT,81120,Idh1 common variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,
Aetna MCR ADV,CPT,81121,Idh2 common variants,Lab Services,Per Unit,$295.79 ,OP,295.79,295.79,,,,,,
Aetna MCR ADV,CPT,81161,Dmd dup/delet analysis,Lab Services,Per Unit,$279.00 ,OP,279,279,,,,,,
Aetna MCR ADV,CPT,81162,Brca1&2 gen full seq dup/del,Lab Services,Per Unit,"$1,824.88 ",OP,"1,824.88","1,824.88",,,,,,
Aetna MCR ADV,CPT,81163,Brca1&2 gene full seq alys,Lab Services,Per Unit,$468.00 ,OP,468,468,,,,,,
Aetna MCR ADV,CPT,81164,Brca1&2 gen ful dup/del alys,Lab Services,Per Unit,$584.23 ,OP,584.23,584.23,,,,,,
Aetna MCR ADV,CPT,81165,Brca1 gene full seq alys,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,
Aetna MCR ADV,CPT,81166,Brca1 gene full dup/del alys,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,
Aetna MCR ADV,CPT,81167,Brca2 gene full dup/del alys,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,
Aetna MCR ADV,CPT,81168,Ccnd1/igh translocation alys,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,
Aetna MCR ADV,CPT,81170,Abl1 gene,Lab Services,Per Unit,$300.00 ,OP,300,300,,,,,,
Aetna MCR ADV,CPT,81171,Aff2 gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Aetna MCR ADV,CPT,81172,Aff2 gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Aetna MCR ADV,CPT,81173,Ar gene full gene sequence,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,
Aetna MCR ADV,CPT,81174,Ar gene known famil variant,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Aetna MCR ADV,CPT,81175,Asxl1 full gene sequence,Lab Services,Per Unit,$676.50 ,OP,676.5,676.5,,,,,,
Aetna MCR ADV,CPT,81176,Asxl1 gene target seq alys,Lab Services,Per Unit,$241.90 ,OP,241.9,241.9,,,,,,
Aetna MCR ADV,CPT,81177,Atn1 gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Aetna MCR ADV,CPT,81178,Atxn1 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Aetna MCR ADV,CPT,81179,Atxn2 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Aetna MCR ADV,CPT,81180,Atxn3 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Aetna MCR ADV,CPT,81181,Atxn7 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Aetna MCR ADV,CPT,81182,Atxn8os gen detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Aetna MCR ADV,CPT,81183,Atxn10 gene detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Aetna MCR ADV,CPT,81184,Cacna1a gen detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Aetna MCR ADV,CPT,81185,Cacna1a gene full gene seq,Lab Services,Per Unit,$846.27 ,OP,846.27,846.27,,,,,,
Aetna MCR ADV,CPT,81186,Cacna1a gen known famil vrnt,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Aetna MCR ADV,CPT,81187,Cnbp gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Aetna MCR ADV,CPT,81188,Cstb gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Aetna MCR ADV,CPT,81189,Cstb gene full gene sequence,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Aetna MCR ADV,CPT,81190,Cstb gene known famil vrnt,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Aetna MCR ADV,CPT,81191,Ntrk1 translocation analysis,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,
Aetna MCR ADV,CPT,81192,Ntrk2 translocation analysis,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,
Aetna MCR ADV,CPT,81193,Ntrk3 translocation analysis,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,
Aetna MCR ADV,CPT,81194,Ntrk translocation analysis,Lab Services,Per Unit,$518.28 ,OP,518.28,518.28,,,,,,
Aetna MCR ADV,CPT,81200,Aspa gene,Lab Services,Per Unit,$47.25 ,OP,47.25,47.25,,,,,,
Aetna MCR ADV,CPT,81201,Apc gene full sequence,Lab Services,Per Unit,$780.00 ,OP,780,780,,,,,,
Aetna MCR ADV,CPT,81202,Apc gene known fam variants,Lab Services,Per Unit,$280.00 ,OP,280,280,,,,,,
Aetna MCR ADV,CPT,81203,Apc gene dup/delet variants,Lab Services,Per Unit,$200.00 ,OP,200,200,,,,,,
Aetna MCR ADV,CPT,81204,Ar gene charac alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Aetna MCR ADV,CPT,81205,Bckdhb gene,Lab Services,Per Unit,$94.99 ,OP,94.99,94.99,,,,,,
Aetna MCR ADV,CPT,81206,Bcr/abl1 gene major bp,Lab Services,Per Unit,$163.96 ,OP,163.96,163.96,,,,,,
Aetna MCR ADV,CPT,81207,Bcr/abl1 gene minor bp,Lab Services,Per Unit,$144.84 ,OP,144.84,144.84,,,,,,
Aetna MCR ADV,CPT,81208,Bcr/abl1 gene other bp,Lab Services,Per Unit,$214.62 ,OP,214.62,214.62,,,,,,
Aetna MCR ADV,CPT,81209,Blm gene,Lab Services,Per Unit,$39.31 ,OP,39.31,39.31,,,,,,
Aetna MCR ADV,CPT,81210,Braf gene,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,
Aetna MCR ADV,CPT,81212,Brca1&2 185&5385&6174 vrnt,Lab Services,Per Unit,$440.00 ,OP,440,440,,,,,,
Aetna MCR ADV,CPT,81215,Brca1 gene known famil vrnt,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,
Aetna MCR ADV,CPT,81216,Brca2 gene full seq alys,Lab Services,Per Unit,$185.12 ,OP,185.12,185.12,,,,,,
Aetna MCR ADV,CPT,81217,Brca2 gene known famil vrnt,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,
Aetna MCR ADV,CPT,81218,Cebpa gene full sequence,Lab Services,Per Unit,$241.90 ,OP,241.9,241.9,,,,,,
Aetna MCR ADV,CPT,81219,Calr gene com variants,Lab Services,Per Unit,$121.63 ,OP,121.63,121.63,,,,,,
Aetna MCR ADV,CPT,81220,Cftr gene com variants,Lab Services,Per Unit,$556.60 ,OP,556.6,556.6,,,,,,
Aetna MCR ADV,CPT,81221,Cftr gene known fam variants,Lab Services,Per Unit,$97.22 ,OP,97.22,97.22,,,,,,
Aetna MCR ADV,CPT,81222,Cftr gene dup/delet variants,Lab Services,Per Unit,$435.07 ,OP,435.07,435.07,,,,,,
Aetna MCR ADV,CPT,81223,Cftr gene full sequence,Lab Services,Per Unit,$499.00 ,OP,499,499,,,,,,
Aetna MCR ADV,CPT,81224,Cftr gene intron poly t,Lab Services,Per Unit,$168.75 ,OP,168.75,168.75,,,,,,
Aetna MCR ADV,CPT,81225,Cyp2c19 gene com variants,Lab Services,Per Unit,$291.36 ,OP,291.36,291.36,,,,,,
Aetna MCR ADV,CPT,81226,Cyp2d6 gene com variants,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,
Aetna MCR ADV,CPT,81227,Cyp2c9 gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Aetna MCR ADV,CPT,81228,Cytogen micrarray copy nmbr,Lab Services,Per Unit,$900.00 ,OP,900,900,,,,,,
Aetna MCR ADV,CPT,81229,Cytogen m array copy no&snp,Lab Services,Per Unit,"$1,160.00 ",OP,"1,160.00","1,160.00",,,,,,
Aetna MCR ADV,CPT,81230,Cyp3a4 gene common variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Aetna MCR ADV,CPT,81231,Cyp3a5 gene common variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Aetna MCR ADV,CPT,81232,Dpyd gene common variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Aetna MCR ADV,CPT,81233,Btk gene common variants,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,
Aetna MCR ADV,CPT,81234,Dmpk gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Aetna MCR ADV,CPT,81235,Egfr gene com variants,Lab Services,Per Unit,$324.58 ,OP,324.58,324.58,,,,,,
Aetna MCR ADV,CPT,81236,Ezh2 gene full gene sequence,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,
Aetna MCR ADV,CPT,81237,Ezh2 gene common variants,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,
Aetna MCR ADV,CPT,81238,F9 full gene sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,
Aetna MCR ADV,CPT,81239,Dmpk gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Aetna MCR ADV,CPT,81240,F2 gene,Lab Services,Per Unit,$65.69 ,OP,65.69,65.69,,,,,,
Aetna MCR ADV,CPT,81241,F5 gene,Lab Services,Per Unit,$73.37 ,OP,73.37,73.37,,,,,,
Aetna MCR ADV,CPT,81242,Fancc gene,Lab Services,Per Unit,$36.62 ,OP,36.62,36.62,,,,,,
Aetna MCR ADV,CPT,81243,Fmr1 gene detection,Lab Services,Per Unit,$57.04 ,OP,57.04,57.04,,,,,,
Aetna MCR ADV,CPT,81244,Fmr1 gene charac alleles,Lab Services,Per Unit,$44.89 ,OP,44.89,44.89,,,,,,
Aetna MCR ADV,CPT,81245,Flt3 gene,Lab Services,Per Unit,$165.51 ,OP,165.51,165.51,,,,,,
Aetna MCR ADV,CPT,81246,Flt3 gene analysis,Lab Services,Per Unit,$83.00 ,OP,83,83,,,,,,
Aetna MCR ADV,CPT,81247,G6pd gene alys cmn variant,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Aetna MCR ADV,CPT,81248,G6pd known familial variant,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,
Aetna MCR ADV,CPT,81249,G6pd full gene sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,
Aetna MCR ADV,CPT,81250,G6pc gene,Lab Services,Per Unit,$58.49 ,OP,58.49,58.49,,,,,,
Aetna MCR ADV,CPT,81251,Gba gene,Lab Services,Per Unit,$47.25 ,OP,47.25,47.25,,,,,,
Aetna MCR ADV,CPT,81252,Gjb2 gene full sequence,Lab Services,Per Unit,$101.12 ,OP,101.12,101.12,,,,,,
Aetna MCR ADV,CPT,81253,Gjb2 gene known fam variants,Lab Services,Per Unit,$61.52 ,OP,61.52,61.52,,,,,,
Aetna MCR ADV,CPT,81254,Gjb6 gene com variants,Lab Services,Per Unit,$35.00 ,OP,35,35,,,,,,
Aetna MCR ADV,CPT,81255,Hexa gene,Lab Services,Per Unit,$51.45 ,OP,51.45,51.45,,,,,,
Aetna MCR ADV,CPT,81256,Hfe gene,Lab Services,Per Unit,$65.36 ,OP,65.36,65.36,,,,,,
Aetna MCR ADV,CPT,81257,Hba1/hba2 gene,Lab Services,Per Unit,$102.26 ,OP,102.26,102.26,,,,,,
Aetna MCR ADV,CPT,81258,Hba1/hba2 gene fam vrnt,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,
Aetna MCR ADV,CPT,81259,Hba1/hba2 full gene sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,
Aetna MCR ADV,CPT,81260,Ikbkap gene,Lab Services,Per Unit,$39.31 ,OP,39.31,39.31,,,,,,
Aetna MCR ADV,CPT,81261,Igh gene rearrange amp meth,Lab Services,Per Unit,$197.99 ,OP,197.99,197.99,,,,,,
Aetna MCR ADV,CPT,81262,Igh gene rearrang dir probe,Lab Services,Per Unit,$68.55 ,OP,68.55,68.55,,,,,,
Aetna MCR ADV,CPT,81263,Igh vari regional mutation,Lab Services,Per Unit,$294.52 ,OP,294.52,294.52,,,,,,
Aetna MCR ADV,CPT,81264,Igk rearrangeabn clonal pop,Lab Services,Per Unit,$172.73 ,OP,172.73,172.73,,,,,,
Aetna MCR ADV,CPT,81265,Str markers specimen anal,Lab Services,Per Unit,$233.07 ,OP,233.07,233.07,,,,,,
Aetna MCR ADV,CPT,81266,Str markers spec anal addl,Lab Services,Per Unit,$304.81 ,OP,304.81,304.81,,,,,,
Aetna MCR ADV,CPT,81267,Chimerism anal no cell selec,Lab Services,Per Unit,$207.46 ,OP,207.46,207.46,,,,,,
Aetna MCR ADV,CPT,81268,Chimerism anal w/cell select,Lab Services,Per Unit,$260.79 ,OP,260.79,260.79,,,,,,
Aetna MCR ADV,CPT,81269,Hba1/hba2 gene dup/del vrnts,Lab Services,Per Unit,$202.40 ,OP,202.4,202.4,,,,,,
Aetna MCR ADV,CPT,81270,Jak2 gene,Lab Services,Per Unit,$91.66 ,OP,91.66,91.66,,,,,,
Aetna MCR ADV,CPT,81271,Htt gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Aetna MCR ADV,CPT,81272,Kit gene targeted seq analys,Lab Services,Per Unit,$329.51 ,OP,329.51,329.51,,,,,,
Aetna MCR ADV,CPT,81273,Kit gene analys d816 variant,Lab Services,Per Unit,$124.87 ,OP,124.87,124.87,,,,,,
Aetna MCR ADV,CPT,81274,Htt gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Aetna MCR ADV,CPT,81275,Kras gene variants exon 2,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,
Aetna MCR ADV,CPT,81276,Kras gene addl variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,
Aetna MCR ADV,CPT,81277,Cytogenomic neo microra alys,Lab Services,Per Unit,"$1,160.00 ",OP,"1,160.00","1,160.00",,,,,,
Aetna MCR ADV,CPT,81278,Igh@/bcl2 translocation alys,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,
Aetna MCR ADV,CPT,81279,Jak2 gene trgt sequence alys,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Aetna MCR ADV,CPT,81283,Ifnl3 gene,Lab Services,Per Unit,$73.37 ,OP,73.37,73.37,,,,,,
Aetna MCR ADV,CPT,81284,Fxn gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Aetna MCR ADV,CPT,81285,Fxn gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Aetna MCR ADV,CPT,81286,Fxn gene full gene sequence,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Aetna MCR ADV,CPT,81287,Mgmt gene prmtr mthyltn alys,Lab Services,Per Unit,$124.64 ,OP,124.64,124.64,,,,,,
Aetna MCR ADV,CPT,81288,Mlh1 gene,Lab Services,Per Unit,$192.32 ,OP,192.32,192.32,,,,,,
Aetna MCR ADV,CPT,81289,Fxn gene known famil variant,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Aetna MCR ADV,CPT,81290,Mcoln1 gene,Lab Services,Per Unit,$39.31 ,OP,39.31,39.31,,,,,,
Aetna MCR ADV,CPT,81291,Mthfr gene,Lab Services,Per Unit,$65.34 ,OP,65.34,65.34,,,,,,
Aetna MCR ADV,CPT,81292,Mlh1 gene full seq,Lab Services,Per Unit,$675.40 ,OP,675.4,675.4,,,,,,
Aetna MCR ADV,CPT,81293,Mlh1 gene known variants,Lab Services,Per Unit,$331.00 ,OP,331,331,,,,,,
Aetna MCR ADV,CPT,81294,Mlh1 gene dup/delete variant,Lab Services,Per Unit,$202.40 ,OP,202.4,202.4,,,,,,
Aetna MCR ADV,CPT,81295,Msh2 gene full seq,Lab Services,Per Unit,$381.70 ,OP,381.7,381.7,,,,,,
Aetna MCR ADV,CPT,81296,Msh2 gene known variants,Lab Services,Per Unit,$337.73 ,OP,337.73,337.73,,,,,,
Aetna MCR ADV,CPT,81297,Msh2 gene dup/delete variant,Lab Services,Per Unit,$213.30 ,OP,213.3,213.3,,,,,,
Aetna MCR ADV,CPT,81298,Msh6 gene full seq,Lab Services,Per Unit,$641.85 ,OP,641.85,641.85,,,,,,
Aetna MCR ADV,CPT,81299,Msh6 gene known variants,Lab Services,Per Unit,$308.00 ,OP,308,308,,,,,,
Aetna MCR ADV,CPT,81300,Msh6 gene dup/delete variant,Lab Services,Per Unit,$238.00 ,OP,238,238,,,,,,
Aetna MCR ADV,CPT,81301,Microsatellite instability,Lab Services,Per Unit,$348.56 ,OP,348.56,348.56,,,,,,
Aetna MCR ADV,CPT,81302,Mecp2 gene full seq,Lab Services,Per Unit,$527.87 ,OP,527.87,527.87,,,,,,
Aetna MCR ADV,CPT,81303,Mecp2 gene known variant,Lab Services,Per Unit,$120.00 ,OP,120,120,,,,,,
Aetna MCR ADV,CPT,81304,Mecp2 gene dup/delet variant,Lab Services,Per Unit,$150.00 ,OP,150,150,,,,,,
Aetna MCR ADV,CPT,81305,Myd88 gene p.leu265pro vrnt,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,
Aetna MCR ADV,CPT,81306,Nudt15 gene common variants,Lab Services,Per Unit,$291.36 ,OP,291.36,291.36,,,,,,
Aetna MCR ADV,CPT,81307,Palb2 gene full gene seq,Lab Services,Per Unit,$676.50 ,OP,676.5,676.5,,,,,,
Aetna MCR ADV,CPT,81308,Palb2 gene known famil vrnt,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,
Aetna MCR ADV,CPT,81309,Pik3ca gene trgt seq alys,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Aetna MCR ADV,CPT,81310,Npm1 gene,Lab Services,Per Unit,$246.52 ,OP,246.52,246.52,,,,,,
Aetna MCR ADV,CPT,81311,Nras gene variants exon 2&3,Lab Services,Per Unit,$295.79 ,OP,295.79,295.79,,,,,,
Aetna MCR ADV,CPT,81312,Pabpn1 gene detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Aetna MCR ADV,CPT,81313,Pca3/klk3 antigen,Lab Services,Per Unit,$255.05 ,OP,255.05,255.05,,,,,,
Aetna MCR ADV,CPT,81314,Pdgfra gene,Lab Services,Per Unit,$329.51 ,OP,329.51,329.51,,,,,,
Aetna MCR ADV,CPT,81315,Pml/raralpha com breakpoints,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,
Aetna MCR ADV,CPT,81316,Pml/raralpha 1 breakpoint,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,
Aetna MCR ADV,CPT,81317,Pms2 gene full seq analysis,Lab Services,Per Unit,$676.50 ,OP,676.5,676.5,,,,,,
Aetna MCR ADV,CPT,81318,Pms2 known familial variants,Lab Services,Per Unit,$331.00 ,OP,331,331,,,,,,
Aetna MCR ADV,CPT,81319,Pms2 gene dup/delet variants,Lab Services,Per Unit,$203.50 ,OP,203.5,203.5,,,,,,
Aetna MCR ADV,CPT,81320,Plcg2 gene common variants,Lab Services,Per Unit,$291.36 ,OP,291.36,291.36,,,,,,
Aetna MCR ADV,CPT,81321,Pten gene full sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,
Aetna MCR ADV,CPT,81322,Pten gene known fam variant,Lab Services,Per Unit,$46.60 ,OP,46.6,46.6,,,,,,
Aetna MCR ADV,CPT,81323,Pten gene dup/delet variant,Lab Services,Per Unit,$300.00 ,OP,300,300,,,,,,
Aetna MCR ADV,CPT,81324,Pmp22 gene dup/delet,Lab Services,Per Unit,$758.36 ,OP,758.36,758.36,,,,,,
Aetna MCR ADV,CPT,81325,Pmp22 gene full sequence,Lab Services,Per Unit,$769.58 ,OP,769.58,769.58,,,,,,
Aetna MCR ADV,CPT,81326,Pmp22 gene known fam variant,Lab Services,Per Unit,$46.60 ,OP,46.6,46.6,,,,,,
Aetna MCR ADV,CPT,81327,Sept9 gen prmtr mthyltn alys,Lab Services,Per Unit,$192.00 ,OP,192,192,,,,,,
Aetna MCR ADV,CPT,81328,Slco1b1 gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Aetna MCR ADV,CPT,81329,Smn1 gene dos/deletion alys,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Aetna MCR ADV,CPT,81330,Smpd1 gene common variants,Lab Services,Per Unit,$47.00 ,OP,47,47,,,,,,
Aetna MCR ADV,CPT,81331,Snrpn/ube3a gene,Lab Services,Per Unit,$51.07 ,OP,51.07,51.07,,,,,,
Aetna MCR ADV,CPT,81332,Serpina1 gene,Lab Services,Per Unit,$43.65 ,OP,43.65,43.65,,,,,,
Aetna MCR ADV,CPT,81333,Tgfbi gene common variants,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Aetna MCR ADV,CPT,81334,Runx1 gene targeted seq alys,Lab Services,Per Unit,$329.51 ,OP,329.51,329.51,,,,,,
Aetna MCR ADV,CPT,81335,Tpmt gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Aetna MCR ADV,CPT,81336,Smn1 gene full gene sequence,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,
Aetna MCR ADV,CPT,81337,Smn1 gen nown famil seq vrnt,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Aetna MCR ADV,CPT,81338,Mpl gene common variants,Lab Services,Per Unit,$150.33 ,OP,150.33,150.33,,,,,,
Aetna MCR ADV,CPT,81339,Mpl gene seq alys exon 10,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Aetna MCR ADV,CPT,81340,Trb@ gene rearrange amplify,Lab Services,Per Unit,$208.92 ,OP,208.92,208.92,,,,,,
Aetna MCR ADV,CPT,81341,Trb@ gene rearrange dirprobe,Lab Services,Per Unit,$49.59 ,OP,49.59,49.59,,,,,,
Aetna MCR ADV,CPT,81342,Trg gene rearrangement anal,Lab Services,Per Unit,$201.50 ,OP,201.5,201.5,,,,,,
Aetna MCR ADV,CPT,81343,Ppp2r2b gen detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Aetna MCR ADV,CPT,81344,Tbp gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Aetna MCR ADV,CPT,81345,Tert gene targeted seq alys,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Aetna MCR ADV,CPT,81346,Tyms gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Aetna MCR ADV,CPT,81347,Sf3b1 gene common variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,
Aetna MCR ADV,CPT,81348,Srsf2 gene common variants,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,
Aetna MCR ADV,CPT,81350,Ugt1a1 gene common variants,Lab Services,Per Unit,$234.00 ,OP,234,234,,,,,,
Aetna MCR ADV,CPT,81351,Tp53 gene full gene sequence,Lab Services,Per Unit,$641.85 ,OP,641.85,641.85,,,,,,
Aetna MCR ADV,CPT,81352,Tp53 gene trgt sequence alys,Lab Services,Per Unit,$329.51 ,OP,329.51,329.51,,,,,,
Aetna MCR ADV,CPT,81353,Tp53 gene known famil vrnt,Lab Services,Per Unit,$308.00 ,OP,308,308,,,,,,
Aetna MCR ADV,CPT,81355,Vkorc1 gene,Lab Services,Per Unit,$88.20 ,OP,88.2,88.2,,,,,,
Aetna MCR ADV,CPT,81357,U2af1 gene common variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,
Aetna MCR ADV,CPT,81360,Zrsr2 gene common variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,
Aetna MCR ADV,CPT,81361,Hbb gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Aetna MCR ADV,CPT,81362,Hbb gene known fam variant,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,
Aetna MCR ADV,CPT,81363,Hbb gene dup/del variants,Lab Services,Per Unit,$202.40 ,OP,202.4,202.4,,,,,,
Aetna MCR ADV,CPT,81364,Hbb full gene sequence,Lab Services,Per Unit,$324.58 ,OP,324.58,324.58,,,,,,
Aetna MCR ADV,CPT,81370,Hla i & ii typing lr,Lab Services,Per Unit,$402.12 ,OP,402.12,402.12,,,,,,
Aetna MCR ADV,CPT,81371,Hla i & ii type verify lr,Lab Services,Per Unit,$404.52 ,OP,404.52,404.52,,,,,,
Aetna MCR ADV,CPT,81372,Hla i typing complete lr,Lab Services,Per Unit,$403.59 ,OP,403.59,403.59,,,,,,
Aetna MCR ADV,CPT,81373,Hla i typing 1 locus lr,Lab Services,Per Unit,$127.43 ,OP,127.43,127.43,,,,,,
Aetna MCR ADV,CPT,81374,Hla i typing 1 antigen lr,Lab Services,Per Unit,$74.33 ,OP,74.33,74.33,,,,,,
Aetna MCR ADV,CPT,81375,Hla ii typing ag equiv lr,Lab Services,Per Unit,$220.74 ,OP,220.74,220.74,,,,,,
Aetna MCR ADV,CPT,81376,Hla ii typing 1 locus lr,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
Aetna MCR ADV,CPT,81377,Hla ii type 1 ag equiv lr,Lab Services,Per Unit,$94.74 ,OP,94.74,94.74,,,,,,
Aetna MCR ADV,CPT,81378,Hla i & ii typing hr,Lab Services,Per Unit,$345.57 ,OP,345.57,345.57,,,,,,
Aetna MCR ADV,CPT,81379,Hla i typing complete hr,Lab Services,Per Unit,$335.38 ,OP,335.38,335.38,,,,,,
Aetna MCR ADV,CPT,81380,Hla i typing 1 locus hr,Lab Services,Per Unit,$177.25 ,OP,177.25,177.25,,,,,,
Aetna MCR ADV,CPT,81381,Hla i typing 1 allele hr,Lab Services,Per Unit,$169.90 ,OP,169.9,169.9,,,,,,
Aetna MCR ADV,CPT,81382,Hla ii typing 1 loc hr,Lab Services,Per Unit,$123.68 ,OP,123.68,123.68,,,,,,
Aetna MCR ADV,CPT,81383,Hla ii typing 1 allele hr,Lab Services,Per Unit,$109.13 ,OP,109.13,109.13,,,,,,
Aetna MCR ADV,CPT,81400,Mopath procedure level 1,Lab Services,Per Unit,$63.96 ,OP,63.96,63.96,,,,,,
Aetna MCR ADV,CPT,81401,Mopath procedure level 2,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Aetna MCR ADV,CPT,81402,Mopath procedure level 3,Lab Services,Per Unit,$150.33 ,OP,150.33,150.33,,,,,,
Aetna MCR ADV,CPT,81403,Mopath procedure level 4,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Aetna MCR ADV,CPT,81404,Mopath procedure level 5,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Aetna MCR ADV,CPT,81405,Mopath procedure level 6,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,
Aetna MCR ADV,CPT,81406,Mopath procedure level 7,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,
Aetna MCR ADV,CPT,81407,Mopath procedure level 8,Lab Services,Per Unit,$846.27 ,OP,846.27,846.27,,,,,,
Aetna MCR ADV,CPT,81408,Mopath procedure level 9,Lab Services,Per Unit,"$2,000.00 ",OP,"2,000.00","2,000.00",,,,,,
Aetna MCR ADV,CPT,81410,Aortic dysfunction/dilation,Lab Services,Per Unit,$504.00 ,OP,504,504,,,,,,
Aetna MCR ADV,CPT,81411,Aortic dysfunction/dilation,Lab Services,Per Unit,"$1,350.19 ",OP,"1,350.19","1,350.19",,,,,,
Aetna MCR ADV,CPT,81412,Ashkenazi jewish assoc dis,Lab Services,Per Unit,"$2,448.56 ",OP,"2,448.56","2,448.56",,,,,,
Aetna MCR ADV,CPT,81413,Car ion chnnlpath inc 10 gns,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,
Aetna MCR ADV,CPT,81414,Car ion chnnlpath inc 2 gns,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,
Aetna MCR ADV,CPT,81415,Exome sequence analysis,Lab Services,Per Unit,"$4,780.00 ",OP,"4,780.00","4,780.00",,,,,,
Aetna MCR ADV,CPT,81416,Exome sequence analysis,Lab Services,Per Unit,"$12,000.00 ",OP,"12,000.00","12,000.00",,,,,,
Aetna MCR ADV,CPT,81417,Exome re-evaluation,Lab Services,Per Unit,$320.00 ,OP,320,320,,,,,,
Aetna MCR ADV,CPT,81419,Epilepsy gen seq alys panel,Lab Services,Per Unit,"$2,448.56 ",OP,"2,448.56","2,448.56",,,,,,
Aetna MCR ADV,CPT,81420,Fetal chrmoml aneuploidy,Lab Services,Per Unit,$759.05 ,OP,759.05,759.05,,,,,,
Aetna MCR ADV,CPT,81422,Fetal chrmoml microdeltj,Lab Services,Per Unit,$759.05 ,OP,759.05,759.05,,,,,,
Aetna MCR ADV,CPT,81425,Genome sequence analysis,Lab Services,Per Unit,"$5,031.20 ",OP,"5,031.20","5,031.20",,,,,,
Aetna MCR ADV,CPT,81426,Genome sequence analysis,Lab Services,Per Unit,"$2,709.95 ",OP,"2,709.95","2,709.95",,,,,,
Aetna MCR ADV,CPT,81427,Genome re-evaluation,Lab Services,Per Unit,"$2,337.65 ",OP,"2,337.65","2,337.65",,,,,,
Aetna MCR ADV,CPT,81430,Hearing loss sequence analys,Lab Services,Per Unit,"$1,625.00 ",OP,"1,625.00","1,625.00",,,,,,
Aetna MCR ADV,CPT,81431,Hearing loss dup/del analys,Lab Services,Per Unit,$679.57 ,OP,679.57,679.57,,,,,,
Aetna MCR ADV,CPT,81432,Hrdtry brst ca-rlatd dsordrs,Lab Services,Per Unit,$679.05 ,OP,679.05,679.05,,,,,,
Aetna MCR ADV,CPT,81433,Hrdtry brst ca-rlatd dsordrs,Lab Services,Per Unit,$438.93 ,OP,438.93,438.93,,,,,,
Aetna MCR ADV,CPT,81434,Hereditary retinal disorders,Lab Services,Per Unit,$597.91 ,OP,597.91,597.91,,,,,,
Aetna MCR ADV,CPT,81435,Hereditary colon ca dsordrs,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,
Aetna MCR ADV,CPT,81436,Hereditary colon ca dsordrs,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,
Aetna MCR ADV,CPT,81437,Heredtry nurondcrn tum dsrdr,Lab Services,Per Unit,$438.93 ,OP,438.93,438.93,,,,,,
Aetna MCR ADV,CPT,81438,Heredtry nurondcrn tum dsrdr,Lab Services,Per Unit,$438.93 ,OP,438.93,438.93,,,,,,
Aetna MCR ADV,CPT,81439,Hrdtry cardmypy gene panel,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,
Aetna MCR ADV,CPT,81440,Mitochondrial gene,Lab Services,Per Unit,"$3,324.00 ",OP,"3,324.00","3,324.00",,,,,,
Aetna MCR ADV,CPT,81442,Noonan spectrum disorders,Lab Services,Per Unit,"$2,143.60 ",OP,"2,143.60","2,143.60",,,,,,
Aetna MCR ADV,CPT,81443,Genetic tstg severe inh cond,Lab Services,Per Unit,"$2,448.56 ",OP,"2,448.56","2,448.56",,,,,,
Aetna MCR ADV,CPT,81445,Targeted genomic seq analys,Lab Services,Per Unit,$597.91 ,OP,597.91,597.91,,,,,,
Aetna MCR ADV,CPT,81448,Hrdtry perph neurphy panel,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,
Aetna MCR ADV,CPT,81450,Targeted genomic seq analys,Lab Services,Per Unit,$759.53 ,OP,759.53,759.53,,,,,,
Aetna MCR ADV,CPT,81455,Targeted genomic seq analys,Lab Services,Per Unit,"$2,919.60 ",OP,"2,919.60","2,919.60",,,,,,
Aetna MCR ADV,CPT,81460,Whole mitochondrial genome,Lab Services,Per Unit,"$1,287.00 ",OP,"1,287.00","1,287.00",,,,,,
Aetna MCR ADV,CPT,81465,Whole mitochondrial genome,Lab Services,Per Unit,$936.00 ,OP,936,936,,,,,,
Aetna MCR ADV,CPT,81470,X-linked intellectual dblt,Lab Services,Per Unit,$914.00 ,OP,914,914,,,,,,
Aetna MCR ADV,CPT,81471,X-linked intellectual dblt,Lab Services,Per Unit,$914.00 ,OP,914,914,,,,,,
Aetna MCR ADV,CPT,81490,Autoimmune rheumatoid arthr,Lab Services,Per Unit,$840.65 ,OP,840.65,840.65,,,,,,
Aetna MCR ADV,CPT,81493,Cor artery disease mrna,Lab Services,Per Unit,"$1,050.00 ",OP,"1,050.00","1,050.00",,,,,,
Aetna MCR ADV,CPT,81500,Onco (ovar) two proteins,Lab Services,Per Unit,$260.50 ,OP,91.51,260.5,,,,,,
Aetna MCR ADV,CPT,81503,Onco (ovar) five proteins,Lab Services,Per Unit,$897.00 ,OP,91.51,897,,,,,,
Aetna MCR ADV,CPT,81504,Oncology tissue of origin,Lab Services,Per Unit,$520.00 ,OP,520,520,,,,,,
Aetna MCR ADV,CPT,81506,Endo assay seven anal,Lab Services,Per Unit,$68.92 ,OP,57.19,68.92,,,,,,
Aetna MCR ADV,CPT,81507,Fetal aneuploidy trisom risk,Lab Services,Per Unit,$795.00 ,OP,795,795,,,,,,
Aetna MCR ADV,CPT,81508,Ftl cgen abnor two proteins,Lab Services,Per Unit,$54.30 ,OP,54.3,144.88,,,,,,
Aetna MCR ADV,CPT,81509,Ftl cgen abnor 3 proteins,Lab Services,Per Unit,"$1,487.37 ",OP,213.51,"1,487.37",,,,,,
Aetna MCR ADV,CPT,81510,Ftl cgen abnor three anal,Lab Services,Per Unit,$55.54 ,OP,55.54,202.07,,,,,,
Aetna MCR ADV,CPT,81511,Ftl cgen abnor four anal,Lab Services,Per Unit,$153.50 ,OP,153.5,270.71,,,,,,
Aetna MCR ADV,CPT,81512,Ftl cgen abnor five anal,Lab Services,Per Unit,$69.52 ,OP,69.52,270.71,,,,,,
Aetna MCR ADV,CPT,81513,Nfct ds bv rna vag flu alg,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
Aetna MCR ADV,CPT,81514,Nfct ds bv&vaginitis dna alg,Lab Services,Per Unit,$262.99 ,OP,262.99,262.99,,,,,,
Aetna MCR ADV,CPT,81518,Onc brst mrna 11 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
Aetna MCR ADV,CPT,81519,Oncology breast mrna,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
Aetna MCR ADV,CPT,81520,Onc breast mrna 58 genes,Lab Services,Per Unit,"$2,510.21 ",OP,"2,510.21","2,510.21",,,,,,
Aetna MCR ADV,CPT,81521,Onc breast mrna 70 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
Aetna MCR ADV,CPT,81522,Onc breast mrna 12 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
Aetna MCR ADV,CPT,81525,Oncology colon mrna,Lab Services,Per Unit,"$3,116.00 ",OP,"3,116.00","3,116.00",,,,,,
Aetna MCR ADV,CPT,81528,Oncology colorectal scr,Lab Services,Per Unit,$508.87 ,OP,508.87,508.87,,,,,,
Aetna MCR ADV,CPT,81529,Onc cutan mlnma mrna 31 gene,Lab Services,Per Unit,"$7,193.00 ",OP,"7,193.00","7,193.00",,,,,,
Aetna MCR ADV,CPT,81535,Oncology gynecologic,Lab Services,Per Unit,$579.46 ,OP,579.46,579.46,,,,,,
Aetna MCR ADV,CPT,81536,Oncology gynecologic,Lab Services,Per Unit,$177.56 ,OP,177.56,177.56,,,,,,
Aetna MCR ADV,CPT,81538,Oncology lung,Lab Services,Per Unit,"$2,871.00 ",OP,"2,871.00","2,871.00",,,,,,
Aetna MCR ADV,CPT,81539,Oncology prostate prob score,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
Aetna MCR ADV,CPT,81540,Oncology tum unknown origin,Lab Services,Per Unit,"$3,750.00 ",OP,"3,750.00","3,750.00",,,,,,
Aetna MCR ADV,CPT,81541,Onc prostate mrna 46 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
Aetna MCR ADV,CPT,81542,Onc prostate mrna 22 cnt gen,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
Aetna MCR ADV,CPT,81546,Onc thyr mrna 10-196 gen alg,Lab Services,Per Unit,"$3,600.00 ",OP,"3,600.00","3,600.00",,,,,,
Aetna MCR ADV,CPT,81551,Onc prostate 3 genes,Lab Services,Per Unit,"$2,030.00 ",OP,"2,030.00","2,030.00",,,,,,
Aetna MCR ADV,CPT,81552,Onc uveal mlnma mrna 15 gene,Lab Services,Per Unit,"$7,776.00 ",OP,"7,776.00","7,776.00",,,,,,
Aetna MCR ADV,CPT,81554,Pulm ds ipf mrna 190 gen alg,Lab Services,Per Unit,"$5,500.00 ",OP,"5,500.00","5,500.00",,,,,,
Aetna MCR ADV,CPT,81595,Cardiology hrt trnspl mrna,Lab Services,Per Unit,"$3,240.00 ",OP,"3,240.00","3,240.00",,,,,,
Aetna MCR ADV,CPT,81596,Nfct ds chrnc hcv 6 assays,Lab Services,Per Unit,$72.19 ,OP,72.19,72.19,,,,,,
Aetna MCR ADV,CPT,82009,Test for acetone/ketones,Lab Services,Per Unit,$4.52 ,OP,4.52,19.07,,,,,,
Aetna MCR ADV,CPT,82010,Acetone assay,Lab Services,Per Unit,$8.17 ,OP,8.17,41.94,,,,,,
Aetna MCR ADV,CPT,82013,Acetylcholinesterase assay,Lab Services,Per Unit,$12.29 ,OP,12.29,12.29,,,,,,
Aetna MCR ADV,CPT,82016,Acylcarnitines qual,Lab Services,Per Unit,$16.49 ,OP,16.49,61,,,,,,
Aetna MCR ADV,CPT,82017,Acylcarnitines quant,Lab Services,Per Unit,$16.87 ,OP,16.87,76.26,,,,,,
Aetna MCR ADV,CPT,82024,Assay of acth,Lab Services,Per Unit,$38.62 ,OP,38.62,171.58,,,,,,
Aetna MCR ADV,CPT,82030,Assay of adp & amp,Lab Services,Per Unit,$25.80 ,OP,25.8,99.13,,,,,,
Aetna MCR ADV,CPT,82040,Assay of serum albumin,Lab Services,Per Unit,$4.95 ,OP,4.95,22.88,,,,,,
Aetna MCR ADV,CPT,82042,Other source albumin quan ea,Lab Services,Per Unit,$7.78 ,OP,7.78,26.7,,,,,,
Aetna MCR ADV,CPT,82043,Ur albumin quantitative,Lab Services,Per Unit,$5.78 ,OP,5.78,26.7,,,,,,
Aetna MCR ADV,CPT,82044,Ur albumin semiquantitative,Lab Services,Per Unit,$6.23 ,OP,6.23,22.88,,,,,,
Aetna MCR ADV,CPT,82045,Albumin ischemia modified,Lab Services,Per Unit,$33.94 ,OP,33.94,125.82,,,,,,
Aetna MCR ADV,CPT,82075,Assay of breath ethanol,Lab Services,Per Unit,$30.00 ,OP,30,45.74,,,,,,
Aetna MCR ADV,CPT,82077,Assay spec xcp ur&breath ia,Lab Services,Per Unit,$17.27 ,OP,17.27,17.27,,,,,,
Aetna MCR ADV,CPT,82085,Assay of aldolase,Lab Services,Per Unit,$9.71 ,OP,9.71,41.94,,,,,,
Aetna MCR ADV,CPT,82088,Assay of aldosterone,Lab Services,Per Unit,$40.75 ,OP,40.75,183.02,,,,,,
Aetna MCR ADV,CPT,82103,Alpha-1-antitrypsin total,Lab Services,Per Unit,$13.44 ,OP,13.44,61,,,,,,
Aetna MCR ADV,CPT,82104,Alpha-1-antitrypsin pheno,Lab Services,Per Unit,$14.46 ,OP,14.46,64.82,,,,,,
Aetna MCR ADV,CPT,82105,Alpha-fetoprotein serum,Lab Services,Per Unit,$16.77 ,OP,16.77,76.26,,,,,,
Aetna MCR ADV,CPT,82106,Alpha-fetoprotein amniotic,Lab Services,Per Unit,$17.00 ,OP,17,76.26,,,,,,
Aetna MCR ADV,CPT,82107,Alpha-fetoprotein l3,Lab Services,Per Unit,$64.41 ,OP,64.41,209.7,,,,,,
Aetna MCR ADV,CPT,82108,Assay of aluminum,Lab Services,Per Unit,$25.48 ,OP,25.48,114.39,,,,,,
Aetna MCR ADV,CPT,82120,Amines vaginal fluid qual,Lab Services,Per Unit,$5.99 ,OP,5.99,19.07,,,,,,
Aetna MCR ADV,CPT,82127,Amino acid single qual,Lab Services,Per Unit,$14.18 ,OP,14.18,61,,,,,,
Aetna MCR ADV,CPT,82128,Amino acids mult qual,Lab Services,Per Unit,$13.87 ,OP,13.87,61,,,,,,
Aetna MCR ADV,CPT,82131,Amino acids single quant,Lab Services,Per Unit,$22.98 ,OP,22.98,76.26,,,,,,
Aetna MCR ADV,CPT,82135,Assay aminolevulinic acid,Lab Services,Per Unit,$16.45 ,OP,16.45,64.82,,,,,,
Aetna MCR ADV,CPT,82136,Amino acids quant 2-5,Lab Services,Per Unit,$19.61 ,OP,19.61,76.26,,,,,,
Aetna MCR ADV,CPT,82139,Amino acids quan 6 or more,Lab Services,Per Unit,$16.87 ,OP,16.87,16.87,,,,,,
Aetna MCR ADV,CPT,82140,Assay of ammonia,Lab Services,Per Unit,$14.57 ,OP,14.57,64.82,,,,,,
Aetna MCR ADV,CPT,82143,Amniotic fluid scan,Lab Services,Per Unit,$9.35 ,OP,9.35,30.51,,,,,,
Aetna MCR ADV,CPT,82150,Assay of amylase,Lab Services,Per Unit,$6.48 ,OP,6.48,34.31,,,,,,
Aetna MCR ADV,CPT,82154,Androstanediol glucuronide,Lab Services,Per Unit,$28.83 ,OP,28.83,28.83,,,,,,
Aetna MCR ADV,CPT,82157,Assay of androstenedione,Lab Services,Per Unit,$29.28 ,OP,29.28,129.64,,,,,,
Aetna MCR ADV,CPT,82160,Assay of androsterone,Lab Services,Per Unit,$25.55 ,OP,25.55,110.57,,,,,,
Aetna MCR ADV,CPT,82163,Assay of angiotensin ii,Lab Services,Per Unit,$20.52 ,OP,20.52,91.51,,,,,,
Aetna MCR ADV,CPT,82164,Angiotensin i enzyme test,Lab Services,Per Unit,$14.60 ,OP,14.6,64.82,,,,,,
Aetna MCR ADV,CPT,82172,Assay of apolipoprotein,Lab Services,Per Unit,$21.09 ,OP,21.09,68.63,,,,,,
Aetna MCR ADV,CPT,82175,Assay of arsenic,Lab Services,Per Unit,$18.97 ,OP,18.97,83.87,,,,,,
Aetna MCR ADV,CPT,82180,Assay of ascorbic acid,Lab Services,Per Unit,$9.89 ,OP,9.89,9.89,,,,,,
Aetna MCR ADV,CPT,82190,Atomic absorption,Lab Services,Per Unit,$15.90 ,OP,15.9,64.82,,,,,,
Aetna MCR ADV,CPT,82232,Assay of beta-2 protein,Lab Services,Per Unit,$16.18 ,OP,16.18,72.44,,,,,,
Aetna MCR ADV,CPT,82239,Bile acids total,Lab Services,Per Unit,$17.12 ,OP,17.12,76.26,,,,,,
Aetna MCR ADV,CPT,82240,Bile acids cholylglycine,Lab Services,Per Unit,$26.58 ,OP,26.58,64.82,,,,,,
Aetna MCR ADV,CPT,82247,Bilirubin total,Lab Services,Per Unit,$5.02 ,OP,5.02,26.7,,,,,,
Aetna MCR ADV,CPT,82248,Bilirubin direct,Lab Services,Per Unit,$5.02 ,OP,5.02,26.7,,,,,,
Aetna MCR ADV,CPT,82252,Fecal bilirubin test,Lab Services,Per Unit,$4.56 ,OP,4.56,19.07,,,,,,
Aetna MCR ADV,CPT,82261,Assay of biotinidase,Lab Services,Per Unit,$16.87 ,OP,16.87,76.26,,,,,,
Aetna MCR ADV,CPT,82270,Occult blood feces,Lab Services,Per Unit,$4.38 ,OP,4.38,15.26,,,,,,
Aetna MCR ADV,CPT,82271,Occult blood other sources,Lab Services,Per Unit,$5.32 ,OP,5.32,15.26,,,,,,
Aetna MCR ADV,CPT,82272,Occult bld feces 1-3 tests,Lab Services,Per Unit,$4.23 ,OP,4.23,15.26,,,,,,
Aetna MCR ADV,CPT,82274,Assay test for blood fecal,Lab Services,Per Unit,$15.92 ,OP,15.92,80.07,,,,,,
Aetna MCR ADV,CPT,82286,Assay of bradykinin,Lab Services,Per Unit,$5.16 ,OP,5.16,30.51,,,,,,
Aetna MCR ADV,CPT,82300,Assay of cadmium,Lab Services,Per Unit,$23.64 ,OP,23.64,102.95,,,,,,
Aetna MCR ADV,CPT,82306,Vitamin d 25 hydroxy,Lab Services,Per Unit,$29.60 ,OP,29.6,356.68,,,,,,
Aetna MCR ADV,CPT,82308,Assay of calcitonin,Lab Services,Per Unit,$26.79 ,OP,26.79,118.19,,,,,,
Aetna MCR ADV,CPT,82310,Assay of calcium,Lab Services,Per Unit,$5.16 ,OP,5.16,22.88,,,,,,
Aetna MCR ADV,CPT,82330,Assay of calcium,Lab Services,Per Unit,$13.68 ,OP,13.68,61,,,,,,
Aetna MCR ADV,CPT,82331,Calcium infusion test,Lab Services,Per Unit,$13.34 ,OP,13.34,22.88,,,,,,
Aetna MCR ADV,CPT,82340,Assay of calcium in urine,Lab Services,Per Unit,$6.03 ,OP,6.03,26.7,,,,,,
Aetna MCR ADV,CPT,82355,Calculus analysis qual,Lab Services,Per Unit,$11.58 ,OP,11.58,53.38,,,,,,
Aetna MCR ADV,CPT,82360,Calculus assay quant,Lab Services,Per Unit,$12.87 ,OP,12.87,45.74,,,,,,
Aetna MCR ADV,CPT,82365,Calculus spectroscopy,Lab Services,Per Unit,$12.90 ,OP,12.9,45.74,,,,,,
Aetna MCR ADV,CPT,82370,X-ray assay calculus,Lab Services,Per Unit,$12.52 ,OP,12.52,45.74,,,,,,
Aetna MCR ADV,CPT,82373,Assay c-d transfer measure,Lab Services,Per Unit,$18.06 ,OP,18.06,80.07,,,,,,
Aetna MCR ADV,CPT,82374,Assay blood carbon dioxide,Lab Services,Per Unit,$4.88 ,OP,4.88,22.88,,,,,,
Aetna MCR ADV,CPT,82375,Assay carboxyhb quant,Lab Services,Per Unit,$12.32 ,OP,12.32,26.7,,,,,,
Aetna MCR ADV,CPT,82376,Assay carboxyhb qual,Lab Services,Per Unit,$14.07 ,OP,14.07,26.7,,,,,,
Aetna MCR ADV,CPT,82378,Carcinoembryonic antigen,Lab Services,Per Unit,$18.96 ,OP,18.96,83.87,,,,,,
Aetna MCR ADV,CPT,82379,Assay of carnitine,Lab Services,Per Unit,$16.87 ,OP,16.87,76.26,,,,,,
Aetna MCR ADV,CPT,82380,Assay of carotene,Lab Services,Per Unit,$9.22 ,OP,9.22,41.94,,,,,,
Aetna MCR ADV,CPT,82382,Assay urine catecholamines,Lab Services,Per Unit,$27.30 ,OP,27.3,76.26,,,,,,
Aetna MCR ADV,CPT,82383,Assay blood catecholamines,Lab Services,Per Unit,$29.08 ,OP,29.08,110.57,,,,,,
Aetna MCR ADV,CPT,82384,Assay three catecholamines,Lab Services,Per Unit,$25.25 ,OP,25.25,110.57,,,,,,
Aetna MCR ADV,CPT,82387,Assay of cathepsin-d,Lab Services,Per Unit,$18.06 ,OP,18.06,91.51,,,,,,
Aetna MCR ADV,CPT,82390,Assay of ceruloplasmin,Lab Services,Per Unit,$10.74 ,OP,10.74,49.56,,,,,,
Aetna MCR ADV,CPT,82397,Chemiluminescent assay,Lab Services,Per Unit,$14.12 ,OP,14.12,64.82,,,,,,
Aetna MCR ADV,CPT,82415,Assay of chloramphenicol,Lab Services,Per Unit,$12.67 ,OP,12.67,57.19,,,,,,
Aetna MCR ADV,CPT,82435,Assay of blood chloride,Lab Services,Per Unit,$4.60 ,OP,4.6,19.07,,,,,,
Aetna MCR ADV,CPT,82436,Assay of urine chloride,Lab Services,Per Unit,$5.75 ,OP,5.75,22.88,,,,,,
Aetna MCR ADV,CPT,82438,Assay other fluid chlorides,Lab Services,Per Unit,$5.00 ,OP,5,5,,,,,,
Aetna MCR ADV,CPT,82441,Test for chlorohydrocarbons,Lab Services,Per Unit,$6.01 ,OP,6.01,26.7,,,,,,
Aetna MCR ADV,CPT,82465,Assay bld/serum cholesterol,Lab Services,Per Unit,$4.35 ,OP,4.35,22.88,,,,,,
Aetna MCR ADV,CPT,82480,Assay serum cholinesterase,Lab Services,Per Unit,$7.87 ,OP,7.87,34.31,,,,,,
Aetna MCR ADV,CPT,82482,Assay rbc cholinesterase,Lab Services,Per Unit,$9.81 ,OP,9.81,34.31,,,,,,
Aetna MCR ADV,CPT,82485,Assay chondroitin sulfate,Lab Services,Per Unit,$20.65 ,OP,20.65,91.51,,,,,,
Aetna MCR ADV,CPT,82495,Assay of chromium,Lab Services,Per Unit,$20.28 ,OP,20.28,91.51,,,,,,
Aetna MCR ADV,CPT,82507,Assay of citrate,Lab Services,Per Unit,$27.80 ,OP,27.8,57.19,,,,,,
Aetna MCR ADV,CPT,82523,Collagen crosslinks,Lab Services,Per Unit,$18.68 ,OP,18.68,95.32,,,,,,
Aetna MCR ADV,CPT,82525,Assay of copper,Lab Services,Per Unit,$12.41 ,OP,12.41,53.38,,,,,,
Aetna MCR ADV,CPT,82528,Assay of corticosterone,Lab Services,Per Unit,$22.52 ,OP,22.52,99.13,,,,,,
Aetna MCR ADV,CPT,82530,Cortisol free,Lab Services,Per Unit,$16.71 ,OP,16.71,76.26,,,,,,
Aetna MCR ADV,CPT,82533,Total cortisol,Lab Services,Per Unit,$16.30 ,OP,16.3,72.44,,,,,,
Aetna MCR ADV,CPT,82540,Assay of creatine,Lab Services,Per Unit,$4.64 ,OP,4.64,19.07,,,,,,
Aetna MCR ADV,CPT,82542,Col chromotography qual/quan,Lab Services,Per Unit,$24.09 ,OP,24.09,80.07,,,,,,
Aetna MCR ADV,CPT,82550,Assay of ck (cpk),Lab Services,Per Unit,$6.51 ,OP,6.51,30.51,,,,,,
Aetna MCR ADV,CPT,82552,Assay of cpk in blood,Lab Services,Per Unit,$13.39 ,OP,13.39,61,,,,,,
Aetna MCR ADV,CPT,82553,Creatine mb fraction,Lab Services,Per Unit,$11.55 ,OP,11.55,49.56,,,,,,
Aetna MCR ADV,CPT,82554,Creatine isoforms,Lab Services,Per Unit,$11.87 ,OP,11.87,53.38,,,,,,
Aetna MCR ADV,CPT,82565,Assay of creatinine,Lab Services,Per Unit,$5.12 ,OP,5.12,22.88,,,,,,
Aetna MCR ADV,CPT,82570,Assay of urine creatinine,Lab Services,Per Unit,$5.18 ,OP,5.18,26.7,,,,,,
Aetna MCR ADV,CPT,82575,Creatinine clearance test,Lab Services,Per Unit,$9.46 ,OP,9.46,41.94,,,,,,
Aetna MCR ADV,CPT,82585,Assay of cryofibrinogen,Lab Services,Per Unit,$14.14 ,OP,14.14,38.13,,,,,,
Aetna MCR ADV,CPT,82595,Assay of cryoglobulin,Lab Services,Per Unit,$6.47 ,OP,6.47,30.51,,,,,,
Aetna MCR ADV,CPT,82600,Assay of cyanide,Lab Services,Per Unit,$19.40 ,OP,19.4,19.4,,,,,,
Aetna MCR ADV,CPT,82607,Vitamin b-12,Lab Services,Per Unit,$15.08 ,OP,15.08,68.63,,,,,,
Aetna MCR ADV,CPT,82608,B-12 binding capacity,Lab Services,Per Unit,$14.32 ,OP,14.32,14.32,,,,,,
Aetna MCR ADV,CPT,82610,Cystatin c,Lab Services,Per Unit,$18.52 ,OP,18.52,61,,,,,,
Aetna MCR ADV,CPT,82615,Test for urine cystines,Lab Services,Per Unit,$9.55 ,OP,9.55,38.13,,,,,,
Aetna MCR ADV,CPT,82626,Dehydroepiandrosterone,Lab Services,Per Unit,$25.27 ,OP,25.27,114.39,,,,,,
Aetna MCR ADV,CPT,82627,Dehydroepiandrosterone,Lab Services,Per Unit,$22.23 ,OP,22.23,99.13,,,,,,
Aetna MCR ADV,CPT,82633,Desoxycorticosterone,Lab Services,Per Unit,$30.98 ,OP,30.98,122,,,,,,
Aetna MCR ADV,CPT,82634,Deoxycortisol,Lab Services,Per Unit,$29.28 ,OP,29.28,76.26,,,,,,
Aetna MCR ADV,CPT,82638,Assay of dibucaine number,Lab Services,Per Unit,$12.25 ,OP,12.25,53.38,,,,,,
Aetna MCR ADV,CPT,82642,Dihydrotestosterone,Lab Services,Per Unit,$29.28 ,OP,29.28,114.39,,,,,,
Aetna MCR ADV,CPT,82652,Vit d 1 25-dihydroxy,Lab Services,Per Unit,$38.50 ,OP,38.5,171.58,,,,,,
Aetna MCR ADV,CPT,82656,Pancreatic elastase fecal,Lab Services,Per Unit,$11.53 ,OP,11.53,11.53,,,,,,
Aetna MCR ADV,CPT,82657,Enzyme cell activity,Lab Services,Per Unit,$22.17 ,OP,22.17,80.07,,,,,,
Aetna MCR ADV,CPT,82658,Enzyme cell activity ra,Lab Services,Per Unit,$44.03 ,OP,44.03,44.03,,,,,,
Aetna MCR ADV,CPT,82664,Electrophoretic test,Lab Services,Per Unit,$61.50 ,OP,61.5,122,,,,,,
Aetna MCR ADV,CPT,82668,Assay of erythropoietin,Lab Services,Per Unit,$18.79 ,OP,18.79,83.87,,,,,,
Aetna MCR ADV,CPT,82670,Assay of total estradiol,Lab Services,Per Unit,$27.94 ,OP,27.94,49.56,,,,,,
Aetna MCR ADV,CPT,82671,Assay of estrogens,Lab Services,Per Unit,$32.30 ,OP,32.3,114.39,,,,,,
Aetna MCR ADV,CPT,82672,Assay of estrogen,Lab Services,Per Unit,$21.70 ,OP,21.7,95.32,,,,,,
Aetna MCR ADV,CPT,82677,Assay of estriol,Lab Services,Per Unit,$24.18 ,OP,24.18,49.56,,,,,,
Aetna MCR ADV,CPT,82679,Assay of estrone,Lab Services,Per Unit,$24.95 ,OP,24.95,57.19,,,,,,
Aetna MCR ADV,CPT,82681,Assay dir meas fr estradiol,Lab Services,Per Unit,$27.94 ,OP,27.94,27.94,,,,,,
Aetna MCR ADV,CPT,82693,Assay of ethylene glycol,Lab Services,Per Unit,$14.90 ,OP,14.9,64.82,,,,,,
Aetna MCR ADV,CPT,82696,Assay of etiocholanolone,Lab Services,Per Unit,$26.24 ,OP,26.24,64.82,,,,,,
Aetna MCR ADV,CPT,82705,Fats/lipids feces qual,Lab Services,Per Unit,$5.10 ,OP,5.1,5.1,,,,,,
Aetna MCR ADV,CPT,82710,Fats/lipids feces quant,Lab Services,Per Unit,$16.80 ,OP,16.8,16.8,,,,,,
Aetna MCR ADV,CPT,82715,Assay of fecal fat,Lab Services,Per Unit,$22.97 ,OP,15.26,22.97,,,,,,
Aetna MCR ADV,CPT,82725,Assay of blood fatty acids,Lab Services,Per Unit,$18.77 ,OP,18.77,18.77,,,,,,
Aetna MCR ADV,CPT,82726,Long chain fatty acids,Lab Services,Per Unit,$19.75 ,OP,19.75,80.07,,,,,,
Aetna MCR ADV,CPT,82728,Assay of ferritin,Lab Services,Per Unit,$13.63 ,OP,13.63,61,,,,,,
Aetna MCR ADV,CPT,82731,Assay of fetal fibronectin,Lab Services,Per Unit,$64.41 ,OP,64.41,236.38,,,,,,
Aetna MCR ADV,CPT,82735,Assay of fluoride,Lab Services,Per Unit,$18.54 ,OP,18.54,83.87,,,,,,
Aetna MCR ADV,CPT,82746,Assay of folic acid serum,Lab Services,Per Unit,$14.70 ,OP,14.7,64.82,,,,,,
Aetna MCR ADV,CPT,82747,Assay of folic acid rbc,Lab Services,Per Unit,$17.65 ,OP,17.65,76.26,,,,,,
Aetna MCR ADV,CPT,82757,Assay of semen fructose,Lab Services,Per Unit,$17.34 ,OP,17.34,76.26,,,,,,
Aetna MCR ADV,CPT,82759,Assay of rbc galactokinase,Lab Services,Per Unit,$21.48 ,OP,21.48,95.32,,,,,,
Aetna MCR ADV,CPT,82760,Assay of galactose,Lab Services,Per Unit,$11.20 ,OP,11.2,49.56,,,,,,
Aetna MCR ADV,CPT,82775,Assay galactose transferase,Lab Services,Per Unit,$21.07 ,OP,21.07,80.07,,,,,,
Aetna MCR ADV,CPT,82776,Galactose transferase test,Lab Services,Per Unit,$11.74 ,OP,11.74,26.7,,,,,,
Aetna MCR ADV,CPT,82777,Galectin-3,Lab Services,Per Unit,$44.25 ,OP,44.25,44.25,,,,,,
Aetna MCR ADV,CPT,82784,Assay iga/igd/igg/igm each,Lab Services,Per Unit,$9.30 ,OP,9.3,41.94,,,,,,
Aetna MCR ADV,CPT,82785,Assay of ige,Lab Services,Per Unit,$16.46 ,OP,16.46,72.44,,,,,,
Aetna MCR ADV,CPT,82787,Igg 1 2 3 or 4 each,Lab Services,Per Unit,$8.02 ,OP,8.02,34.31,,,,,,
Aetna MCR ADV,CPT,82800,Blood ph,Lab Services,Per Unit,$11.00 ,OP,11,30.51,,,,,,
Aetna MCR ADV,CPT,82803,Blood gases any combination,Lab Services,Per Unit,$26.07 ,OP,26.07,61,,,,,,
Aetna MCR ADV,CPT,82805,Blood gases w/o2 saturation,Lab Services,Per Unit,$78.77 ,OP,78.77,141.07,,,,,,
Aetna MCR ADV,CPT,82810,Blood gases o2 sat only,Lab Services,Per Unit,$9.77 ,OP,9.77,9.77,,,,,,
Aetna MCR ADV,CPT,82820,Hemoglobin-oxygen affinity,Lab Services,Per Unit,$13.34 ,OP,13.34,49.56,,,,,,
Aetna MCR ADV,CPT,82930,Gastric analy w/ph ea spec,Lab Services,Per Unit,$6.71 ,OP,6.71,6.71,,,,,,
Aetna MCR ADV,CPT,82938,Gastrin test,Lab Services,Per Unit,$17.69 ,OP,17.69,80.07,,,,,,
Aetna MCR ADV,CPT,82941,Assay of gastrin,Lab Services,Per Unit,$17.63 ,OP,17.63,80.07,,,,,,
Aetna MCR ADV,CPT,82943,Assay of glucagon,Lab Services,Per Unit,$14.29 ,OP,14.29,34.31,,,,,,
Aetna MCR ADV,CPT,82945,Glucose other fluid,Lab Services,Per Unit,$3.93 ,OP,3.93,19.07,,,,,,
Aetna MCR ADV,CPT,82946,Glucagon tolerance test,Lab Services,Per Unit,$17.77 ,OP,17.77,68.63,,,,,,
Aetna MCR ADV,CPT,82947,Assay glucose blood quant,Lab Services,Per Unit,$3.93 ,OP,3.93,19.07,,,,,,
Aetna MCR ADV,CPT,82948,Reagent strip/blood glucose,Lab Services,Per Unit,$5.04 ,OP,5.04,15.26,,,,,,
Aetna MCR ADV,CPT,82950,Glucose test,Lab Services,Per Unit,$4.75 ,OP,4.75,22.88,,,,,,
Aetna MCR ADV,CPT,82951,Glucose tolerance test (gtt),Lab Services,Per Unit,$12.87 ,OP,12.87,64.82,,,,,,
Aetna MCR ADV,CPT,82952,Gtt-added samples,Lab Services,Per Unit,$3.92 ,OP,3.92,19.07,,,,,,
Aetna MCR ADV,CPT,82955,Assay of g6pd enzyme,Lab Services,Per Unit,$9.70 ,OP,9.7,41.94,,,,,,
Aetna MCR ADV,CPT,82960,Test for g6pd enzyme,Lab Services,Per Unit,$6.05 ,OP,6.05,6.05,,,,,,
Aetna MCR ADV,CPT,82962,Glucose blood test,Lab Services,Per Unit,$3.28 ,OP,3.28,11.44,,,,,,
Aetna MCR ADV,CPT,82963,Assay of glucosidase,Lab Services,Per Unit,$21.48 ,OP,21.48,80.07,,,,,,
Aetna MCR ADV,CPT,82965,Assay of gdh enzyme,Lab Services,Per Unit,$13.15 ,OP,13.15,34.31,,,,,,
Aetna MCR ADV,CPT,82977,Assay of ggt,Lab Services,Per Unit,$7.20 ,OP,7.2,34.31,,,,,,
Aetna MCR ADV,CPT,82978,Assay of glutathione,Lab Services,Per Unit,$15.45 ,OP,15.45,64.82,,,,,,
Aetna MCR ADV,CPT,82979,Assay rbc glutathione,Lab Services,Per Unit,$9.44 ,OP,9.44,30.51,,,,,,
Aetna MCR ADV,CPT,82985,Assay of glycated protein,Lab Services,Per Unit,$16.76 ,OP,16.76,76.26,,,,,,
Aetna MCR ADV,CPT,83001,Assay of gonadotropin (fsh),Lab Services,Per Unit,$18.58 ,OP,18.58,91.51,,,,,,
Aetna MCR ADV,CPT,83002,Assay of gonadotropin (lh),Lab Services,Per Unit,$18.52 ,OP,18.52,91.51,,,,,,
Aetna MCR ADV,CPT,83003,Assay growth hormone (hgh),Lab Services,Per Unit,$16.67 ,OP,16.67,72.44,,,,,,
Aetna MCR ADV,CPT,83006,Growth stimulation gene 2,Lab Services,Per Unit,$75.60 ,OP,75.6,75.6,,,,,,
Aetna MCR ADV,CPT,83009,H pylori (c-13) blood,Lab Services,Per Unit,$67.36 ,OP,67.36,301.2,,,,,,
Aetna MCR ADV,CPT,83010,Assay of haptoglobin quant,Lab Services,Per Unit,$12.58 ,OP,12.58,57.19,,,,,,
Aetna MCR ADV,CPT,83012,Assay of haptoglobins,Lab Services,Per Unit,$26.89 ,OP,26.89,72.44,,,,,,
Aetna MCR ADV,CPT,83013,H pylori (c-13) breath,Lab Services,Per Unit,$67.36 ,OP,67.36,301.2,,,,,,
Aetna MCR ADV,CPT,83014,H pylori drug admin,Lab Services,Per Unit,$7.86 ,OP,7.86,34.31,,,,,,
Aetna MCR ADV,CPT,83015,Heavy metal qual any anal,Lab Services,Per Unit,$20.94 ,OP,20.94,83.87,,,,,,
Aetna MCR ADV,CPT,83018,Heavy metal quant each nes,Lab Services,Per Unit,$21.96 ,OP,21.96,99.13,,,,,,
Aetna MCR ADV,CPT,83020,Hemoglobin electrophoresis,Lab Services,Per Unit,$12.87 ,OP,12.87,45.74,,,,,,
Aetna MCR ADV,CPT,83021,Hemoglobin chromotography,Lab Services,Per Unit,$18.06 ,OP,18.06,80.07,,,,,,
Aetna MCR ADV,CPT,83026,Hemoglobin copper sulfate,Lab Services,Per Unit,$4.01 ,OP,4.01,4.01,,,,,,
Aetna MCR ADV,CPT,83030,Fetal hemoglobin chemical,Lab Services,Per Unit,$10.74 ,OP,10.74,10.74,,,,,,
Aetna MCR ADV,CPT,83033,Fetal hemoglobin assay qual,Lab Services,Per Unit,$8.00 ,OP,8,8,,,,,,
Aetna MCR ADV,CPT,83036,Glycosylated hemoglobin test,Lab Services,Per Unit,$9.71 ,OP,9.71,49.56,,,,,,
Aetna MCR ADV,CPT,83037,Glycosylated hb home device,Lab Services,Per Unit,$9.71 ,OP,9.71,41.94,,,,,,
Aetna MCR ADV,CPT,83045,Blood methemoglobin test,Lab Services,Per Unit,$6.49 ,OP,6.49,22.88,,,,,,
Aetna MCR ADV,CPT,83050,Blood methemoglobin assay,Lab Services,Per Unit,$8.20 ,OP,8.2,15.26,,,,,,
Aetna MCR ADV,CPT,83051,Assay of plasma hemoglobin,Lab Services,Per Unit,$7.31 ,OP,7.31,7.31,,,,,,
Aetna MCR ADV,CPT,83060,Blood sulfhemoglobin assay,Lab Services,Per Unit,$8.80 ,OP,8.8,15.26,,,,,,
Aetna MCR ADV,CPT,83065,Assay of hemoglobin heat,Lab Services,Per Unit,$9.00 ,OP,9,15.26,,,,,,
Aetna MCR ADV,CPT,83068,Hemoglobin stability screen,Lab Services,Per Unit,$9.47 ,OP,9.47,9.47,,,,,,
Aetna MCR ADV,CPT,83069,Assay of urine hemoglobin,Lab Services,Per Unit,$3.95 ,OP,3.95,7.62,,,,,,
Aetna MCR ADV,CPT,83070,Assay of hemosiderin qual,Lab Services,Per Unit,$4.75 ,OP,4.75,15.26,,,,,,
Aetna MCR ADV,CPT,83080,Assay of b hexosaminidase,Lab Services,Per Unit,$16.87 ,OP,16.87,76.26,,,,,,
Aetna MCR ADV,CPT,83088,Assay of histamine,Lab Services,Per Unit,$29.53 ,OP,29.53,129.64,,,,,,
Aetna MCR ADV,CPT,83090,Assay of homocystine,Lab Services,Per Unit,$17.92 ,OP,17.92,76.26,,,,,,
Aetna MCR ADV,CPT,83150,Assay of homovanillic acid,Lab Services,Per Unit,$22.41 ,OP,22.41,87.69,,,,,,
Aetna MCR ADV,CPT,83491,Assay of corticosteroids 17,Lab Services,Per Unit,$17.90 ,OP,17.9,76.26,,,,,,
Aetna MCR ADV,CPT,83497,Assay of 5-hiaa,Lab Services,Per Unit,$12.90 ,OP,12.9,57.19,,,,,,
Aetna MCR ADV,CPT,83498,Assay of progesterone 17-d,Lab Services,Per Unit,$27.17 ,OP,27.17,122,,,,,,
Aetna MCR ADV,CPT,83500,Assay free hydroxyproline,Lab Services,Per Unit,$22.65 ,OP,22.65,99.13,,,,,,
Aetna MCR ADV,CPT,83505,Assay total hydroxyproline,Lab Services,Per Unit,$24.30 ,OP,24.3,106.76,,,,,,
Aetna MCR ADV,CPT,83516,Immunoassay nonantibody,Lab Services,Per Unit,$11.53 ,OP,11.53,49.56,,,,,,
Aetna MCR ADV,CPT,83518,Immunoassay dipstick,Lab Services,Per Unit,$9.64 ,OP,9.64,9.64,,,,,,
Aetna MCR ADV,CPT,83519,Ria nonantibody,Lab Services,Per Unit,$18.40 ,OP,18.4,61,,,,,,
Aetna MCR ADV,CPT,83520,Immunoassay quant nos nonab,Lab Services,Per Unit,$17.27 ,OP,17.27,57.19,,,,,,
Aetna MCR ADV,CPT,83525,Assay of insulin,Lab Services,Per Unit,$11.43 ,OP,11.43,49.56,,,,,,
Aetna MCR ADV,CPT,83527,Assay of insulin,Lab Services,Per Unit,$12.95 ,OP,12.95,57.19,,,,,,
Aetna MCR ADV,CPT,83528,Assay of intrinsic factor,Lab Services,Per Unit,$19.82 ,OP,19.82,72.44,,,,,,
Aetna MCR ADV,CPT,83540,Assay of iron,Lab Services,Per Unit,$6.47 ,OP,6.47,30.51,,,,,,
Aetna MCR ADV,CPT,83550,Iron binding test,Lab Services,Per Unit,$8.74 ,OP,8.74,38.13,,,,,,
Aetna MCR ADV,CPT,83570,Assay of idh enzyme,Lab Services,Per Unit,$8.85 ,OP,8.85,38.13,,,,,,
Aetna MCR ADV,CPT,83582,Assay of ketogenic steroids,Lab Services,Per Unit,$15.47 ,OP,15.47,15.47,,,,,,
Aetna MCR ADV,CPT,83586,Assay 17- ketosteroids,Lab Services,Per Unit,$12.80 ,OP,12.8,57.19,,,,,,
Aetna MCR ADV,CPT,83593,Fractionation ketosteroids,Lab Services,Per Unit,$28.50 ,OP,28.5,118.19,,,,,,
Aetna MCR ADV,CPT,83605,Assay of lactic acid,Lab Services,Per Unit,$11.57 ,OP,11.57,53.38,,,,,,
Aetna MCR ADV,CPT,83615,Lactate (ld) (ldh) enzyme,Lab Services,Per Unit,$6.04 ,OP,6.04,26.7,,,,,,
Aetna MCR ADV,CPT,83625,Assay of ldh enzymes,Lab Services,Per Unit,$12.79 ,OP,12.79,49.56,,,,,,
Aetna MCR ADV,CPT,83630,Lactoferrin fecal (qual),Lab Services,Per Unit,$19.70 ,OP,19.7,87.69,,,,,,
Aetna MCR ADV,CPT,83631,Lactoferrin fecal (quant),Lab Services,Per Unit,$19.63 ,OP,19.63,87.69,,,,,,
Aetna MCR ADV,CPT,83632,Placental lactogen,Lab Services,Per Unit,$20.22 ,OP,20.22,91.51,,,,,,
Aetna MCR ADV,CPT,83633,Test urine for lactose,Lab Services,Per Unit,$11.25 ,OP,11.25,22.88,,,,,,
Aetna MCR ADV,CPT,83655,Assay of lead,Lab Services,Per Unit,$12.11 ,OP,12.11,53.38,,,,,,
Aetna MCR ADV,CPT,83661,L/s ratio fetal lung,Lab Services,Per Unit,$21.99 ,OP,21.99,99.13,,,,,,
Aetna MCR ADV,CPT,83662,Foam stability fetal lung,Lab Services,Per Unit,$18.91 ,OP,18.91,83.87,,,,,,
Aetna MCR ADV,CPT,83663,Fluoro polarize fetal lung,Lab Services,Per Unit,$18.91 ,OP,18.91,83.87,,,,,,
Aetna MCR ADV,CPT,83664,Lamellar bdy fetal lung,Lab Services,Per Unit,$19.32 ,OP,19.32,83.87,,,,,,
Aetna MCR ADV,CPT,83670,Assay of lap enzyme,Lab Services,Per Unit,$9.81 ,OP,9.81,41.94,,,,,,
Aetna MCR ADV,CPT,83690,Assay of lipase,Lab Services,Per Unit,$6.89 ,OP,6.89,61.5,,,,,,
Aetna MCR ADV,CPT,83695,Assay of lipoprotein(a),Lab Services,Per Unit,$14.32 ,OP,14.32,57.19,,,,,,
Aetna MCR ADV,CPT,83698,Assay lipoprotein pla2,Lab Services,Per Unit,$46.31 ,OP,46.31,125.82,,,,,,
Aetna MCR ADV,CPT,83700,Lipopro bld electrophoretic,Lab Services,Per Unit,$11.26 ,OP,11.26,49.56,,,,,,
Aetna MCR ADV,CPT,83701,Lipoprotein bld hr fraction,Lab Services,Per Unit,$33.86 ,OP,33.86,110.57,,,,,,
Aetna MCR ADV,CPT,83704,Lipoprotein bld quan part,Lab Services,Per Unit,$34.19 ,OP,34.19,141.07,,,,,,
Aetna MCR ADV,CPT,83718,Assay of lipoprotein,Lab Services,Per Unit,$8.19 ,OP,8.19,41.94,,,,,,
Aetna MCR ADV,CPT,83719,Assay of blood lipoprotein,Lab Services,Per Unit,$12.75 ,OP,12.75,53.38,,,,,,
Aetna MCR ADV,CPT,83721,Assay of blood lipoprotein,Lab Services,Per Unit,$10.50 ,OP,10.5,41.94,,,,,,
Aetna MCR ADV,CPT,83722,Lipoprtn dir meas sd ldl chl,Lab Services,Per Unit,$34.19 ,OP,34.19,141.07,,,,,,
Aetna MCR ADV,CPT,83727,Assay of lrh hormone,Lab Services,Per Unit,$17.19 ,OP,17.19,76.26,,,,,,
Aetna MCR ADV,CPT,83735,Assay of magnesium,Lab Services,Per Unit,$6.70 ,OP,6.7,34.31,,,,,,
Aetna MCR ADV,CPT,83775,Assay malate dehydrogenase,Lab Services,Per Unit,$7.37 ,OP,7.37,34.31,,,,,,
Aetna MCR ADV,CPT,83785,Assay of manganese,Lab Services,Per Unit,$26.65 ,OP,26.65,110.57,,,,,,
Aetna MCR ADV,CPT,83789,Mass spectrometry qual/quan,Lab Services,Per Unit,$24.11 ,OP,24.11,80.07,,,,,,
Aetna MCR ADV,CPT,83825,Assay of mercury,Lab Services,Per Unit,$16.26 ,OP,16.26,72.44,,,,,,
Aetna MCR ADV,CPT,83835,Assay of metanephrines,Lab Services,Per Unit,$16.94 ,OP,16.94,76.26,,,,,,
Aetna MCR ADV,CPT,83857,Assay of methemalbumin,Lab Services,Per Unit,$10.74 ,OP,10.74,49.56,,,,,,
Aetna MCR ADV,CPT,83861,Microfluid analy tears,Lab Services,Per Unit,$22.48 ,OP,22.48,22.48,,,,,,
Aetna MCR ADV,CPT,83864,Mucopolysaccharides,Lab Services,Per Unit,$28.50 ,OP,28.5,87.69,,,,,,
Aetna MCR ADV,CPT,83872,Assay synovial fluid mucin,Lab Services,Per Unit,$5.86 ,OP,5.86,26.7,,,,,,
Aetna MCR ADV,CPT,83873,Assay of csf protein,Lab Services,Per Unit,$17.20 ,OP,17.2,72.44,,,,,,
Aetna MCR ADV,CPT,83874,Assay of myoglobin,Lab Services,Per Unit,$12.92 ,OP,12.92,57.19,,,,,,
Aetna MCR ADV,CPT,83876,Assay myeloperoxidase,Lab Services,Per Unit,$50.86 ,OP,50.86,57.19,,,,,,
Aetna MCR ADV,CPT,83880,Assay of natriuretic peptide,Lab Services,Per Unit,$39.26 ,OP,39.26,245.98,,,,,,
Aetna MCR ADV,CPT,83883,Assay nephelometry not spec,Lab Services,Per Unit,$13.60 ,OP,13.6,61,,,,,,
Aetna MCR ADV,CPT,83885,Assay of nickel,Lab Services,Per Unit,$24.51 ,OP,24.51,45.74,,,,,,
Aetna MCR ADV,CPT,83915,Assay of nucleotidase,Lab Services,Per Unit,$11.15 ,OP,11.15,11.15,,,,,,
Aetna MCR ADV,CPT,83916,Oligoclonal bands,Lab Services,Per Unit,$27.39 ,OP,27.39,87.69,,,,,,
Aetna MCR ADV,CPT,83918,Organic acids total quant,Lab Services,Per Unit,$23.60 ,OP,23.6,72.44,,,,,,
Aetna MCR ADV,CPT,83919,Organic acids qual each,Lab Services,Per Unit,$16.45 ,OP,16.45,16.45,,,,,,
Aetna MCR ADV,CPT,83921,Organic acid single quant,Lab Services,Per Unit,$21.21 ,OP,21.21,72.44,,,,,,
Aetna MCR ADV,CPT,83930,Assay of blood osmolality,Lab Services,Per Unit,$6.61 ,OP,6.61,26.7,,,,,,
Aetna MCR ADV,CPT,83935,Assay of urine osmolality,Lab Services,Per Unit,$6.82 ,OP,6.82,30.51,,,,,,
Aetna MCR ADV,CPT,83937,Assay of osteocalcin,Lab Services,Per Unit,$29.85 ,OP,29.85,133.45,,,,,,
Aetna MCR ADV,CPT,83945,Assay of oxalate,Lab Services,Per Unit,$14.45 ,OP,14.45,57.19,,,,,,
Aetna MCR ADV,CPT,83950,Oncoprotein her-2/neu,Lab Services,Per Unit,$64.41 ,OP,64.41,209.7,,,,,,
Aetna MCR ADV,CPT,83951,Oncoprotein dcp,Lab Services,Per Unit,$64.41 ,OP,64.41,209.7,,,,,,
Aetna MCR ADV,CPT,83970,Assay of parathormone,Lab Services,Per Unit,$41.28 ,OP,41.28,183.02,,,,,,
Aetna MCR ADV,CPT,83986,Assay ph body fluid nos,Lab Services,Per Unit,$3.58 ,OP,3.58,19.07,,,,,,
Aetna MCR ADV,CPT,83987,Exhaled breath condensate,Lab Services,Per Unit,$3.58 ,OP,3.58,3.58,,,,,,
Aetna MCR ADV,CPT,83993,Assay for calprotectin fecal,Lab Services,Per Unit,$19.63 ,OP,19.63,87.69,,,,,,
Aetna MCR ADV,CPT,84030,Assay of blood pku,Lab Services,Per Unit,$5.50 ,OP,5.5,26.7,,,,,,
Aetna MCR ADV,CPT,84035,Assay of phenylketones,Lab Services,Per Unit,$3.98 ,OP,3.98,15.26,,,,,,
Aetna MCR ADV,CPT,84060,Assay acid phosphatase,Lab Services,Per Unit,$7.64 ,OP,7.64,34.31,,,,,,
Aetna MCR ADV,CPT,84066,Assay prostate phosphatase,Lab Services,Per Unit,$9.66 ,OP,9.66,41.94,,,,,,
Aetna MCR ADV,CPT,84075,Assay alkaline phosphatase,Lab Services,Per Unit,$5.18 ,OP,5.18,26.7,,,,,,
Aetna MCR ADV,CPT,84078,Assay alkaline phosphatase,Lab Services,Per Unit,$8.26 ,OP,8.26,34.31,,,,,,
Aetna MCR ADV,CPT,84080,Assay alkaline phosphatases,Lab Services,Per Unit,$14.78 ,OP,14.78,64.82,,,,,,
Aetna MCR ADV,CPT,84081,Assay phosphatidylglycerol,Lab Services,Per Unit,$16.52 ,OP,16.52,72.44,,,,,,
Aetna MCR ADV,CPT,84085,Assay of rbc pg6d enzyme,Lab Services,Per Unit,$9.44 ,OP,9.44,30.51,,,,,,
Aetna MCR ADV,CPT,84087,Assay phosphohexose enzymes,Lab Services,Per Unit,$10.73 ,OP,10.73,45.74,,,,,,
Aetna MCR ADV,CPT,84100,Assay of phosphorus,Lab Services,Per Unit,$4.74 ,OP,4.74,22.88,,,,,,
Aetna MCR ADV,CPT,84105,Assay of urine phosphorus,Lab Services,Per Unit,$5.78 ,OP,5.78,22.88,,,,,,
Aetna MCR ADV,CPT,84106,Test for porphobilinogen,Lab Services,Per Unit,$5.82 ,OP,5.82,19.07,,,,,,
Aetna MCR ADV,CPT,84110,Assay of porphobilinogen,Lab Services,Per Unit,$8.44 ,OP,8.44,38.13,,,,,,
Aetna MCR ADV,CPT,84112,Eval amniotic fluid protein,Lab Services,Per Unit,$98.11 ,OP,98.11,98.11,,,,,,
Aetna MCR ADV,CPT,84119,Test urine for porphyrins,Lab Services,Per Unit,$13.36 ,OP,13.36,13.36,,,,,,
Aetna MCR ADV,CPT,84120,Assay of urine porphyrins,Lab Services,Per Unit,$14.71 ,OP,14.71,64.82,,,,,,
Aetna MCR ADV,CPT,84126,Assay of feces porphyrins,Lab Services,Per Unit,$39.11 ,OP,39.11,114.39,,,,,,
Aetna MCR ADV,CPT,84132,Assay of serum potassium,Lab Services,Per Unit,$4.76 ,OP,4.76,22.88,,,,,,
Aetna MCR ADV,CPT,84133,Assay of urine potassium,Lab Services,Per Unit,$4.73 ,OP,4.73,19.07,,,,,,
Aetna MCR ADV,CPT,84134,Assay of prealbumin,Lab Services,Per Unit,$14.59 ,OP,14.59,64.82,,,,,,
Aetna MCR ADV,CPT,84135,Assay of pregnanediol,Lab Services,Per Unit,$21.27 ,OP,21.27,57.19,,,,,,
Aetna MCR ADV,CPT,84138,Assay of pregnanetriol,Lab Services,Per Unit,$21.05 ,OP,21.05,83.87,,,,,,
Aetna MCR ADV,CPT,84140,Assay of pregnenolone,Lab Services,Per Unit,$20.67 ,OP,20.67,91.51,,,,,,
Aetna MCR ADV,CPT,84143,Assay of 17-hydroxypregneno,Lab Services,Per Unit,$22.81 ,OP,22.81,102.95,,,,,,
Aetna MCR ADV,CPT,84144,Assay of progesterone,Lab Services,Per Unit,$20.86 ,OP,20.86,91.51,,,,,,
Aetna MCR ADV,CPT,84145,Procalcitonin (pct),Lab Services,Per Unit,$27.22 ,OP,27.22,27.22,,,,,,
Aetna MCR ADV,CPT,84146,Assay of prolactin,Lab Services,Per Unit,$19.38 ,OP,19.38,87.69,,,,,,
Aetna MCR ADV,CPT,84150,Assay of prostaglandin,Lab Services,Per Unit,$41.77 ,OP,41.77,41.77,,,,,,
Aetna MCR ADV,CPT,84152,Assay of psa complexed,Lab Services,Per Unit,$18.39 ,OP,18.39,80.07,,,,,,
Aetna MCR ADV,CPT,84153,Assay of psa total,Lab Services,Per Unit,$18.39 ,OP,18.39,80.07,,,,,,
Aetna MCR ADV,CPT,84154,Assay of psa free,Lab Services,Per Unit,$18.39 ,OP,18.39,80.07,,,,,,
Aetna MCR ADV,CPT,84155,Assay of protein serum,Lab Services,Per Unit,$3.67 ,OP,3.67,15.26,,,,,,
Aetna MCR ADV,CPT,84156,Assay of protein urine,Lab Services,Per Unit,$3.67 ,OP,3.67,15.26,,,,,,
Aetna MCR ADV,CPT,84157,Assay of protein other,Lab Services,Per Unit,$4.00 ,OP,4,19.07,,,,,,
Aetna MCR ADV,CPT,84160,Assay of protein any source,Lab Services,Per Unit,$5.61 ,OP,5.61,22.88,,,,,,
Aetna MCR ADV,CPT,84163,Pappa serum,Lab Services,Per Unit,$15.05 ,OP,15.05,68.63,,,,,,
Aetna MCR ADV,CPT,84165,Protein e-phoresis serum,Lab Services,Per Unit,$10.74 ,OP,10.74,49.56,,,,,,
Aetna MCR ADV,CPT,84166,Protein e-phoresis/urine/csf,Lab Services,Per Unit,$17.83 ,OP,17.83,80.07,,,,,,
Aetna MCR ADV,CPT,84181,Western blot test,Lab Services,Per Unit,$17.03 ,OP,17.03,118.19,,,,,,
Aetna MCR ADV,CPT,84182,Protein western blot test,Lab Services,Per Unit,$29.21 ,OP,29.21,129.64,,,,,,
Aetna MCR ADV,CPT,84202,Assay rbc protoporphyrin,Lab Services,Per Unit,$14.35 ,OP,14.35,64.82,,,,,,
Aetna MCR ADV,CPT,84203,Test rbc protoporphyrin,Lab Services,Per Unit,$9.74 ,OP,9.74,38.13,,,,,,
Aetna MCR ADV,CPT,84206,Assay of proinsulin,Lab Services,Per Unit,$26.69 ,OP,26.69,80.07,,,,,,
Aetna MCR ADV,CPT,84207,Assay of vitamin b-6,Lab Services,Per Unit,$28.10 ,OP,28.1,125.82,,,,,,
Aetna MCR ADV,CPT,84210,Assay of pyruvate,Lab Services,Per Unit,$14.48 ,OP,14.48,49.56,,,,,,
Aetna MCR ADV,CPT,84220,Assay of pyruvate kinase,Lab Services,Per Unit,$9.44 ,OP,9.44,41.94,,,,,,
Aetna MCR ADV,CPT,84228,Assay of quinine,Lab Services,Per Unit,$11.63 ,OP,11.63,53.38,,,,,,
Aetna MCR ADV,CPT,84233,Assay of estrogen,Lab Services,Per Unit,$87.88 ,OP,87.88,209.7,,,,,,
Aetna MCR ADV,CPT,84234,Assay of progesterone,Lab Services,Per Unit,$64.88 ,OP,64.88,183.02,,,,,,
Aetna MCR ADV,CPT,84235,Assay of endocrine hormone,Lab Services,Per Unit,$71.23 ,OP,71.23,163.95,,,,,,
Aetna MCR ADV,CPT,84238,Assay nonendocrine receptor,Lab Services,Per Unit,$36.57 ,OP,36.57,163.95,,,,,,
Aetna MCR ADV,CPT,84244,Assay of renin,Lab Services,Per Unit,$21.99 ,OP,21.99,99.13,,,,,,
Aetna MCR ADV,CPT,84252,Assay of vitamin b-2,Lab Services,Per Unit,$20.24 ,OP,20.24,20.24,,,,,,
Aetna MCR ADV,CPT,84255,Assay of selenium,Lab Services,Per Unit,$25.53 ,OP,25.53,114.39,,,,,,
Aetna MCR ADV,CPT,84260,Assay of serotonin,Lab Services,Per Unit,$30.98 ,OP,30.98,30.98,,,,,,
Aetna MCR ADV,CPT,84270,Assay of sex hormone globul,Lab Services,Per Unit,$21.73 ,OP,21.73,95.32,,,,,,
Aetna MCR ADV,CPT,84275,Assay of sialic acid,Lab Services,Per Unit,$13.44 ,OP,13.44,13.44,,,,,,
Aetna MCR ADV,CPT,84285,Assay of silica,Lab Services,Per Unit,$25.21 ,OP,25.21,38.13,,,,,,
Aetna MCR ADV,CPT,84295,Assay of serum sodium,Lab Services,Per Unit,$4.81 ,OP,4.81,22.88,,,,,,
Aetna MCR ADV,CPT,84300,Assay of urine sodium,Lab Services,Per Unit,$5.06 ,OP,5.06,22.88,,,,,,
Aetna MCR ADV,CPT,84302,Assay of sweat sodium,Lab Services,Per Unit,$4.86 ,OP,4.86,22.88,,,,,,
Aetna MCR ADV,CPT,84305,Assay of somatomedin,Lab Services,Per Unit,$21.26 ,OP,21.26,95.32,,,,,,
Aetna MCR ADV,CPT,84307,Assay of somatostatin,Lab Services,Per Unit,$18.28 ,OP,18.28,80.07,,,,,,
Aetna MCR ADV,CPT,84311,Spectrophotometry,Lab Services,Per Unit,$8.10 ,OP,8.1,30.51,,,,,,
Aetna MCR ADV,CPT,84315,Body fluid specific gravity,Lab Services,Per Unit,$3.28 ,OP,3.28,11.44,,,,,,
Aetna MCR ADV,CPT,84375,Chromatogram assay sugars,Lab Services,Per Unit,$39.00 ,OP,39,39,,,,,,
Aetna MCR ADV,CPT,84376,Sugars single qual,Lab Services,Per Unit,$5.50 ,OP,5.5,22.88,,,,,,
Aetna MCR ADV,CPT,84377,Sugars multiple qual,Lab Services,Per Unit,$5.50 ,OP,5.5,22.88,,,,,,
Aetna MCR ADV,CPT,84378,Sugars single quant,Lab Services,Per Unit,$11.53 ,OP,11.53,49.56,,,,,,
Aetna MCR ADV,CPT,84379,Sugars multiple quant,Lab Services,Per Unit,$11.53 ,OP,11.53,49.56,,,,,,
Aetna MCR ADV,CPT,84392,Assay of urine sulfate,Lab Services,Per Unit,$5.49 ,OP,5.49,22.88,,,,,,
Aetna MCR ADV,CPT,84402,Assay of free testosterone,Lab Services,Per Unit,$25.47 ,OP,25.47,114.39,,,,,,
Aetna MCR ADV,CPT,84403,Assay of total testosterone,Lab Services,Per Unit,$25.81 ,OP,25.81,114.39,,,,,,
Aetna MCR ADV,CPT,84410,Testosterone bioavailable,Lab Services,Per Unit,$51.28 ,OP,51.28,51.28,,,,,,
Aetna MCR ADV,CPT,84425,Assay of vitamin b-1,Lab Services,Per Unit,$21.23 ,OP,21.23,95.32,,,,,,
Aetna MCR ADV,CPT,84430,Assay of thiocyanate,Lab Services,Per Unit,$11.63 ,OP,11.63,53.38,,,,,,
Aetna MCR ADV,CPT,84431,Thromboxane urine,Lab Services,Per Unit,$35.11 ,OP,35.11,35.11,,,,,,
Aetna MCR ADV,CPT,84432,Assay of thyroglobulin,Lab Services,Per Unit,$16.06 ,OP,16.06,72.44,,,,,,
Aetna MCR ADV,CPT,84436,Assay of total thyroxine,Lab Services,Per Unit,$6.87 ,OP,6.87,30.51,,,,,,
Aetna MCR ADV,CPT,84437,Assay of neonatal thyroxine,Lab Services,Per Unit,$6.47 ,OP,6.47,30.51,,,,,,
Aetna MCR ADV,CPT,84439,Assay of free thyroxine,Lab Services,Per Unit,$9.02 ,OP,9.02,41.94,,,,,,
Aetna MCR ADV,CPT,84442,Assay of thyroid activity,Lab Services,Per Unit,$14.78 ,OP,14.78,64.82,,,,,,
Aetna MCR ADV,CPT,84443,Assay thyroid stim hormone,Lab Services,Per Unit,$16.80 ,OP,16.8,76.26,,,,,,
Aetna MCR ADV,CPT,84445,Assay of tsi globulin,Lab Services,Per Unit,$50.86 ,OP,50.86,224.95,,,,,,
Aetna MCR ADV,CPT,84446,Assay of vitamin e,Lab Services,Per Unit,$14.18 ,OP,14.18,64.82,,,,,,
Aetna MCR ADV,CPT,84449,Assay of transcortin,Lab Services,Per Unit,$18.00 ,OP,18,80.07,,,,,,
Aetna MCR ADV,CPT,84450,Transferase (ast) (sgot),Lab Services,Per Unit,$5.18 ,OP,5.18,22.88,,,,,,
Aetna MCR ADV,CPT,84460,Alanine amino (alt) (sgpt),Lab Services,Per Unit,$5.30 ,OP,5.3,26.7,,,,,,
Aetna MCR ADV,CPT,84466,Assay of transferrin,Lab Services,Per Unit,$12.76 ,OP,12.76,57.19,,,,,,
Aetna MCR ADV,CPT,84478,Assay of triglycerides,Lab Services,Per Unit,$5.74 ,OP,5.74,30.51,,,,,,
Aetna MCR ADV,CPT,84479,Assay of thyroid (t3 or t4),Lab Services,Per Unit,$6.47 ,OP,6.47,30.51,,,,,,
Aetna MCR ADV,CPT,84480,Assay triiodothyronine (t3),Lab Services,Per Unit,$14.18 ,OP,14.18,49.56,,,,,,
Aetna MCR ADV,CPT,84481,Free assay (ft-3),Lab Services,Per Unit,$16.94 ,OP,16.94,49.56,,,,,,
Aetna MCR ADV,CPT,84482,T3 reverse,Lab Services,Per Unit,$15.76 ,OP,15.76,68.63,,,,,,
Aetna MCR ADV,CPT,84484,Assay of troponin quant,Lab Services,Per Unit,$12.47 ,OP,12.47,92.24,,,,,,
Aetna MCR ADV,CPT,84485,Assay duodenal fluid trypsin,Lab Services,Per Unit,$7.20 ,OP,7.2,7.2,,,,,,
Aetna MCR ADV,CPT,84488,Test feces for trypsin,Lab Services,Per Unit,$7.30 ,OP,7.3,34.31,,,,,,
Aetna MCR ADV,CPT,84490,Assay of feces for trypsin,Lab Services,Per Unit,$9.93 ,OP,9.93,26.7,,,,,,
Aetna MCR ADV,CPT,84510,Assay of tyrosine,Lab Services,Per Unit,$10.63 ,OP,10.63,45.74,,,,,,
Aetna MCR ADV,CPT,84512,Assay of troponin qual,Lab Services,Per Unit,$10.09 ,OP,10.09,34.31,,,,,,
Aetna MCR ADV,CPT,84520,Assay of urea nitrogen,Lab Services,Per Unit,$3.95 ,OP,3.95,19.07,,,,,,
Aetna MCR ADV,CPT,84525,Urea nitrogen semi-quant,Lab Services,Per Unit,$5.13 ,OP,5.13,15.26,,,,,,
Aetna MCR ADV,CPT,84540,Assay of urine/urea-n,Lab Services,Per Unit,$5.56 ,OP,5.56,22.88,,,,,,
Aetna MCR ADV,CPT,84545,Urea-n clearance test,Lab Services,Per Unit,$7.20 ,OP,7.2,19.07,,,,,,
Aetna MCR ADV,CPT,84550,Assay of blood/uric acid,Lab Services,Per Unit,$4.52 ,OP,4.52,19.07,,,,,,
Aetna MCR ADV,CPT,84560,Assay of urine/uric acid,Lab Services,Per Unit,$5.08 ,OP,5.08,22.88,,,,,,
Aetna MCR ADV,CPT,84577,Assay of feces/urobilinogen,Lab Services,Per Unit,$16.80 ,OP,16.8,57.19,,,,,,
Aetna MCR ADV,CPT,84578,Test urine urobilinogen,Lab Services,Per Unit,$4.47 ,OP,4.47,15.26,,,,,,
Aetna MCR ADV,CPT,84580,Assay of urine urobilinogen,Lab Services,Per Unit,$9.55 ,OP,9.55,19.07,,,,,,
Aetna MCR ADV,CPT,84583,Assay of urine urobilinogen,Lab Services,Per Unit,$6.05 ,OP,6.05,22.88,,,,,,
Aetna MCR ADV,CPT,84585,Assay of urine vma,Lab Services,Per Unit,$15.50 ,OP,15.5,68.63,,,,,,
Aetna MCR ADV,CPT,84586,Assay of vip,Lab Services,Per Unit,$35.33 ,OP,35.33,156.32,,,,,,
Aetna MCR ADV,CPT,84588,Assay of vasopressin,Lab Services,Per Unit,$33.94 ,OP,33.94,125.82,,,,,,
Aetna MCR ADV,CPT,84590,Assay of vitamin a,Lab Services,Per Unit,$11.61 ,OP,11.61,53.38,,,,,,
Aetna MCR ADV,CPT,84591,Assay of nos vitamin,Lab Services,Per Unit,$17.06 ,OP,17.06,53.38,,,,,,
Aetna MCR ADV,CPT,84597,Assay of vitamin k,Lab Services,Per Unit,$13.72 ,OP,13.72,49.56,,,,,,
Aetna MCR ADV,CPT,84600,Assay of volatiles,Lab Services,Per Unit,$17.11 ,OP,17.11,72.44,,,,,,
Aetna MCR ADV,CPT,84620,Xylose tolerance test,Lab Services,Per Unit,$12.91 ,OP,12.91,38.13,,,,,,
Aetna MCR ADV,CPT,84630,Assay of zinc,Lab Services,Per Unit,$11.39 ,OP,11.39,49.56,,,,,,
Aetna MCR ADV,CPT,84681,Assay of c-peptide,Lab Services,Per Unit,$20.81 ,OP,20.81,91.51,,,,,,
Aetna MCR ADV,CPT,84702,Chorionic gonadotropin test,Lab Services,Per Unit,$15.05 ,OP,15.05,76.26,,,,,,
Aetna MCR ADV,CPT,84703,Chorionic gonadotropin assay,Lab Services,Per Unit,$7.52 ,OP,7.52,38.13,,,,,,
Aetna MCR ADV,CPT,84704,Hcg free betachain test,Lab Services,Per Unit,$15.29 ,OP,15.29,68.63,,,,,,
Aetna MCR ADV,CPT,84830,Ovulation tests,Lab Services,Per Unit,$12.70 ,OP,12.7,49.56,,,,,,
Aetna MCR ADV,CPT,85002,Bleeding time test,Lab Services,Per Unit,$4.82 ,OP,4.82,22.88,,,,,,
Aetna MCR ADV,CPT,85004,Automated diff wbc count,Lab Services,Per Unit,$6.47 ,OP,6.47,34.31,,,,,,
Aetna MCR ADV,CPT,85007,Bl smear w/diff wbc count,Lab Services,Per Unit,$3.80 ,OP,3.8,19.07,,,,,,
Aetna MCR ADV,CPT,85008,Bl smear w/o diff wbc count,Lab Services,Per Unit,$3.43 ,OP,3.43,19.07,,,,,,
Aetna MCR ADV,CPT,85009,Manual diff wbc count b-coat,Lab Services,Per Unit,$5.07 ,OP,5.07,19.07,,,,,,
Aetna MCR ADV,CPT,85013,Spun microhematocrit,Lab Services,Per Unit,$7.00 ,OP,7,7,,,,,,
Aetna MCR ADV,CPT,85014,Hematocrit,Lab Services,Per Unit,$2.37 ,OP,2.37,11.44,,,,,,
Aetna MCR ADV,CPT,85018,Hemoglobin,Lab Services,Per Unit,$2.37 ,OP,2.37,11.44,,,,,,
Aetna MCR ADV,CPT,85025,Complete cbc w/auto diff wbc,Lab Services,Per Unit,$7.77 ,OP,7.77,67.65,,,,,,
Aetna MCR ADV,CPT,85027,Complete cbc automated,Lab Services,Per Unit,$6.47 ,OP,6.47,34.31,,,,,,
Aetna MCR ADV,CPT,85032,Manual cell count each,Lab Services,Per Unit,$4.31 ,OP,4.31,22.88,,,,,,
Aetna MCR ADV,CPT,85041,Automated rbc count,Lab Services,Per Unit,$3.02 ,OP,3.02,11.44,,,,,,
Aetna MCR ADV,CPT,85044,Manual reticulocyte count,Lab Services,Per Unit,$4.31 ,OP,4.31,4.31,,,,,,
Aetna MCR ADV,CPT,85045,Automated reticulocyte count,Lab Services,Per Unit,$3.99 ,OP,3.99,19.07,,,,,,
Aetna MCR ADV,CPT,85046,Reticyte/hgb concentrate,Lab Services,Per Unit,$5.57 ,OP,5.57,26.7,,,,,,
Aetna MCR ADV,CPT,85048,Automated leukocyte count,Lab Services,Per Unit,$2.54 ,OP,2.54,11.44,,,,,,
Aetna MCR ADV,CPT,85049,Automated platelet count,Lab Services,Per Unit,$4.48 ,OP,4.48,22.88,,,,,,
Aetna MCR ADV,CPT,85055,Reticulated platelet assay,Lab Services,Per Unit,$35.74 ,OP,35.74,61,,,,,,
Aetna MCR ADV,CPT,85097,Bone marrow interpretation,APC 5674,RVU Per Case,$671.45 ,OP,438.47,671.45,,,,,,
Aetna MCR ADV,CPT,85130,Chromogenic substrate assay,Lab Services,Per Unit,$11.89 ,OP,11.89,53.38,,,,,,
Aetna MCR ADV,CPT,85170,Blood clot retraction,Lab Services,Per Unit,$16.30 ,OP,16.3,16.3,,,,,,
Aetna MCR ADV,CPT,85175,Blood clot lysis time,Lab Services,Per Unit,$20.37 ,OP,19.07,20.37,,,,,,
Aetna MCR ADV,CPT,85210,Clot factor ii prothrom spec,Lab Services,Per Unit,$12.98 ,OP,12.98,64.82,,,,,,
Aetna MCR ADV,CPT,85220,Blooc clot factor v test,Lab Services,Per Unit,$17.65 ,OP,17.65,80.07,,,,,,
Aetna MCR ADV,CPT,85230,Clot factor vii proconvertin,Lab Services,Per Unit,$17.90 ,OP,17.9,80.07,,,,,,
Aetna MCR ADV,CPT,85240,Clot factor viii ahg 1 stage,Lab Services,Per Unit,$17.90 ,OP,17.9,80.07,,,,,,
Aetna MCR ADV,CPT,85244,Clot factor viii reltd antgn,Lab Services,Per Unit,$20.42 ,OP,20.42,91.51,,,,,,
Aetna MCR ADV,CPT,85245,Clot factor viii vw ristoctn,Lab Services,Per Unit,$22.94 ,OP,22.94,64.82,,,,,,
Aetna MCR ADV,CPT,85246,Clot factor viii vw antigen,Lab Services,Per Unit,$22.94 ,OP,22.94,64.82,,,,,,
Aetna MCR ADV,CPT,85247,Clot factor viii multimetric,Lab Services,Per Unit,$22.94 ,OP,22.94,22.94,,,,,,
Aetna MCR ADV,CPT,85250,Clot factor ix ptc/chrstmas,Lab Services,Per Unit,$19.04 ,OP,19.04,83.87,,,,,,
Aetna MCR ADV,CPT,85260,Clot factor x stuart-power,Lab Services,Per Unit,$17.90 ,OP,17.9,80.07,,,,,,
Aetna MCR ADV,CPT,85270,Clot factor xi pta,Lab Services,Per Unit,$17.90 ,OP,17.9,80.07,,,,,,
Aetna MCR ADV,CPT,85280,Clot factor xii hageman,Lab Services,Per Unit,$19.35 ,OP,19.35,87.69,,,,,,
Aetna MCR ADV,CPT,85290,Clot factor xiii fibrin stab,Lab Services,Per Unit,$16.34 ,OP,16.34,72.44,,,,,,
Aetna MCR ADV,CPT,85291,Clot factor xiii fibrin scrn,Lab Services,Per Unit,$9.11 ,OP,9.11,38.13,,,,,,
Aetna MCR ADV,CPT,85292,Clot factor fletcher fact,Lab Services,Per Unit,$18.93 ,OP,18.93,83.87,,,,,,
Aetna MCR ADV,CPT,85293,Clot factor wght kininogen,Lab Services,Per Unit,$18.93 ,OP,18.93,83.87,,,,,,
Aetna MCR ADV,CPT,85300,Antithrombin iii activity,Lab Services,Per Unit,$11.85 ,OP,11.85,53.38,,,,,,
Aetna MCR ADV,CPT,85301,Antithrombin iii antigen,Lab Services,Per Unit,$10.81 ,OP,10.81,49.56,,,,,,
Aetna MCR ADV,CPT,85302,Clot inhibit prot c antigen,Lab Services,Per Unit,$12.01 ,OP,12.01,53.38,,,,,,
Aetna MCR ADV,CPT,85303,Clot inhibit prot c activity,Lab Services,Per Unit,$13.84 ,OP,13.84,61,,,,,,
Aetna MCR ADV,CPT,85305,Clot inhibit prot s total,Lab Services,Per Unit,$11.61 ,OP,11.61,53.38,,,,,,
Aetna MCR ADV,CPT,85306,Clot inhibit prot s free,Lab Services,Per Unit,$15.32 ,OP,15.32,68.63,,,,,,
Aetna MCR ADV,CPT,85307,Assay activated protein c,Lab Services,Per Unit,$15.32 ,OP,15.32,68.63,,,,,,
Aetna MCR ADV,CPT,85335,Factor inhibitor test,Lab Services,Per Unit,$12.87 ,OP,12.87,12.87,,,,,,
Aetna MCR ADV,CPT,85337,Thrombomodulin,Lab Services,Per Unit,$17.27 ,OP,17.27,45.74,,,,,,
Aetna MCR ADV,CPT,85345,Coagulation time lee & white,Lab Services,Per Unit,$4.69 ,OP,4.69,4.69,,,,,,
Aetna MCR ADV,CPT,85347,Coagulation time activated,Lab Services,Per Unit,$4.28 ,OP,4.28,15.26,,,,,,
Aetna MCR ADV,CPT,85348,Coagulation time otr method,Lab Services,Per Unit,$4.49 ,OP,4.49,15.26,,,,,,
Aetna MCR ADV,CPT,85360,Euglobulin lysis,Lab Services,Per Unit,$8.41 ,OP,8.41,38.13,,,,,,
Aetna MCR ADV,CPT,85362,Fibrin degradation products,Lab Services,Per Unit,$6.89 ,OP,6.89,30.51,,,,,,
Aetna MCR ADV,CPT,85366,Fibrinogen test,Lab Services,Per Unit,$80.46 ,OP,30.51,80.46,,,,,,
Aetna MCR ADV,CPT,85370,Fibrinogen test,Lab Services,Per Unit,$12.43 ,OP,12.43,49.56,,,,,,
Aetna MCR ADV,CPT,85378,Fibrin degrade semiquant,Lab Services,Per Unit,$9.72 ,OP,9.72,30.51,,,,,,
Aetna MCR ADV,CPT,85379,Fibrin degradation quant,Lab Services,Per Unit,$10.18 ,OP,10.18,135.29,,,,,,
Aetna MCR ADV,CPT,85380,Fibrin degradj d-dimer,Lab Services,Per Unit,$10.18 ,OP,10.18,45.74,,,,,,
Aetna MCR ADV,CPT,85384,Fibrinogen activity,Lab Services,Per Unit,$9.72 ,OP,9.72,38.13,,,,,,
Aetna MCR ADV,CPT,85385,Fibrinogen antigen,Lab Services,Per Unit,$14.46 ,OP,14.46,38.13,,,,,,
Aetna MCR ADV,CPT,85390,Fibrinolysins screen i&r,Lab Services,Per Unit,$15.48 ,OP,15.48,38.13,,,,,,
Aetna MCR ADV,CPT,85397,Clotting funct activity,Lab Services,Per Unit,$30.86 ,OP,30.86,30.86,,,,,,
Aetna MCR ADV,CPT,85400,Fibrinolytic plasmin,Lab Services,Per Unit,$7.71 ,OP,7.71,38.13,,,,,,
Aetna MCR ADV,CPT,85410,Fibrinolytic antiplasmin,Lab Services,Per Unit,$7.71 ,OP,7.71,34.31,,,,,,
Aetna MCR ADV,CPT,85415,Fibrinolytic plasminogen,Lab Services,Per Unit,$17.19 ,OP,17.19,76.26,,,,,,
Aetna MCR ADV,CPT,85420,Fibrinolytic plasminogen,Lab Services,Per Unit,$6.53 ,OP,6.53,6.53,,,,,,
Aetna MCR ADV,CPT,85421,Fibrinolytic plasminogen,Lab Services,Per Unit,$10.18 ,OP,10.18,45.74,,,,,,
Aetna MCR ADV,CPT,85441,Heinz bodies direct,Lab Services,Per Unit,$4.20 ,OP,4.2,19.07,,,,,,
Aetna MCR ADV,CPT,85445,Heinz bodies induced,Lab Services,Per Unit,$6.82 ,OP,6.82,30.51,,,,,,
Aetna MCR ADV,CPT,85460,Hemoglobin fetal,Lab Services,Per Unit,$7.73 ,OP,7.73,7.73,,,,,,
Aetna MCR ADV,CPT,85461,Hemoglobin fetal,Lab Services,Per Unit,$9.36 ,OP,9.36,30.51,,,,,,
Aetna MCR ADV,CPT,85475,Hemolysin acid,Lab Services,Per Unit,$8.87 ,OP,8.87,38.13,,,,,,
Aetna MCR ADV,CPT,85520,Heparin assay,Lab Services,Per Unit,$13.09 ,OP,13.09,57.19,,,,,,
Aetna MCR ADV,CPT,85525,Heparin neutralization,Lab Services,Per Unit,$11.84 ,OP,11.84,53.38,,,,,,
Aetna MCR ADV,CPT,85530,Heparin-protamine tolerance,Lab Services,Per Unit,$13.09 ,OP,13.09,48.46,,,,,,
Aetna MCR ADV,CPT,85536,Iron stain peripheral blood,Lab Services,Per Unit,$6.88 ,OP,6.88,30.51,,,,,,
Aetna MCR ADV,CPT,85540,Wbc alkaline phosphatase,Lab Services,Per Unit,$8.60 ,OP,8.6,38.13,,,,,,
Aetna MCR ADV,CPT,85547,Rbc mechanical fragility,Lab Services,Per Unit,$8.60 ,OP,8.6,11.44,,,,,,
Aetna MCR ADV,CPT,85549,Muramidase,Lab Services,Per Unit,$18.75 ,OP,18.75,83.87,,,,,,
Aetna MCR ADV,CPT,85555,Rbc osmotic fragility,Lab Services,Per Unit,$7.47 ,OP,7.47,30.51,,,,,,
Aetna MCR ADV,CPT,85557,Rbc osmotic fragility,Lab Services,Per Unit,$13.36 ,OP,13.36,13.36,,,,,,
Aetna MCR ADV,CPT,85576,Blood platelet aggregation,Lab Services,Per Unit,$24.91 ,OP,24.91,95.32,,,,,,
Aetna MCR ADV,CPT,85597,Phospholipid pltlt neutraliz,Lab Services,Per Unit,$17.98 ,OP,17.98,80.07,,,,,,
Aetna MCR ADV,CPT,85598,Hexagnal phosph pltlt neutrl,Lab Services,Per Unit,$17.98 ,OP,17.98,17.98,,,,,,
Aetna MCR ADV,CPT,85610,Prothrombin time,Lab Services,Per Unit,$4.29 ,OP,4.29,19.07,,,,,,
Aetna MCR ADV,CPT,85611,Prothrombin test,Lab Services,Per Unit,$3.94 ,OP,3.94,19.07,,,,,,
Aetna MCR ADV,CPT,85612,Viper venom prothrombin time,Lab Services,Per Unit,$17.49 ,OP,17.49,17.49,,,,,,
Aetna MCR ADV,CPT,85613,Russell viper venom diluted,Lab Services,Per Unit,$9.58 ,OP,9.58,41.94,,,,,,
Aetna MCR ADV,CPT,85635,Reptilase test,Lab Services,Per Unit,$9.85 ,OP,9.85,19.07,,,,,,
Aetna MCR ADV,CPT,85651,Rbc sed rate nonautomated,Lab Services,Per Unit,$4.27 ,OP,4.27,19.07,,,,,,
Aetna MCR ADV,CPT,85652,Rbc sed rate automated,Lab Services,Per Unit,$2.70 ,OP,2.7,15.26,,,,,,
Aetna MCR ADV,CPT,85660,Rbc sickle cell test,Lab Services,Per Unit,$5.51 ,OP,5.51,22.88,,,,,,
Aetna MCR ADV,CPT,85670,Thrombin time plasma,Lab Services,Per Unit,$5.77 ,OP,5.77,26.7,,,,,,
Aetna MCR ADV,CPT,85675,Thrombin time titer,Lab Services,Per Unit,$6.85 ,OP,6.85,30.51,,,,,,
Aetna MCR ADV,CPT,85705,Thromboplastin inhibition,Lab Services,Per Unit,$9.63 ,OP,9.63,41.94,,,,,,
Aetna MCR ADV,CPT,85730,Thromboplastin time partial,Lab Services,Per Unit,$6.01 ,OP,6.01,30.51,,,,,,
Aetna MCR ADV,CPT,85732,Thromboplastin time partial,Lab Services,Per Unit,$6.47 ,OP,6.47,30.51,,,,,,
Aetna MCR ADV,CPT,85810,Blood viscosity examination,Lab Services,Per Unit,$11.67 ,OP,11.67,53.38,,,,,,
Aetna MCR ADV,CPT,86000,Agglutinins febrile antigen,Lab Services,Per Unit,$6.98 ,OP,6.98,6.98,,,,,,
Aetna MCR ADV,CPT,86001,Allergen specific igg,Lab Services,Per Unit,$7.82 ,OP,7.82,22.88,,,,,,
Aetna MCR ADV,CPT,86003,Allg spec ige crude xtrc ea,Lab Services,Per Unit,$5.22 ,OP,5.22,22.88,,,,,,
Aetna MCR ADV,CPT,86005,Allg spec ige multiallg scr,Lab Services,Per Unit,$7.97 ,OP,7.97,7.97,,,,,,
Aetna MCR ADV,CPT,86008,Allg spec ige recomb ea,Lab Services,Per Unit,$17.93 ,OP,17.93,80.07,,,,,,
Aetna MCR ADV,CPT,86021,Wbc antibody identification,Lab Services,Per Unit,$15.05 ,OP,15.05,68.63,,,,,,
Aetna MCR ADV,CPT,86022,Platelet antibodies,Lab Services,Per Unit,$18.37 ,OP,18.37,64.82,,,,,,
Aetna MCR ADV,CPT,86023,Immunoglobulin assay,Lab Services,Per Unit,$12.46 ,OP,12.46,57.19,,,,,,
Aetna MCR ADV,CPT,86038,Antinuclear antibodies,Lab Services,Per Unit,$12.09 ,OP,12.09,53.38,,,,,,
Aetna MCR ADV,CPT,86039,Antinuclear antibodies (ana),Lab Services,Per Unit,$11.16 ,OP,11.16,49.56,,,,,,
Aetna MCR ADV,CPT,86060,Antistreptolysin o titer,Lab Services,Per Unit,$7.30 ,OP,7.3,34.31,,,,,,
Aetna MCR ADV,CPT,86063,Antistreptolysin o screen,Lab Services,Per Unit,$5.77 ,OP,5.77,26.7,,,,,,
Aetna MCR ADV,CPT,86077,Phys blood bank serv xmatch,APC 5731,RVU Per Case,$25.25 ,OP,25.25,244.01,,,,,,
Aetna MCR ADV,CPT,86078,Phys blood bank serv reactj,APC 5672,RVU Per Case,$152.64 ,OP,152.64,247.83,,,,,,
Aetna MCR ADV,CPT,86079,Phys blood bank serv authrj,APC 5671,RVU Per Case,$50.92 ,OP,50.92,251.64,,,,,,
Aetna MCR ADV,CPT,86140,C-reactive protein,Lab Services,Per Unit,$5.18 ,OP,5.18,22.88,,,,,,
Aetna MCR ADV,CPT,86141,C-reactive protein hs,Lab Services,Per Unit,$12.95 ,OP,12.95,57.19,,,,,,
Aetna MCR ADV,CPT,86146,Beta-2 glycoprotein antibody,Lab Services,Per Unit,$25.45 ,OP,25.45,114.39,,,,,,
Aetna MCR ADV,CPT,86147,Cardiolipin antibody ea ig,Lab Services,Per Unit,$25.45 ,OP,25.45,114.39,,,,,,
Aetna MCR ADV,CPT,86148,Anti-phospholipid antibody,Lab Services,Per Unit,$16.07 ,OP,16.07,72.44,,,,,,
Aetna MCR ADV,CPT,86152,Cell enumeration & id,Lab Services,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Aetna MCR ADV,CPT,86155,Chemotaxis assay,Lab Services,Per Unit,$15.99 ,OP,15.99,72.44,,,,,,
Aetna MCR ADV,CPT,86156,Cold agglutinin screen,Lab Services,Per Unit,$8.07 ,OP,8.07,30.51,,,,,,
Aetna MCR ADV,CPT,86157,Cold agglutinin titer,Lab Services,Per Unit,$8.06 ,OP,8.06,34.31,,,,,,
Aetna MCR ADV,CPT,86160,Complement antigen,Lab Services,Per Unit,$12.00 ,OP,12,53.38,,,,,,
Aetna MCR ADV,CPT,86161,Complement/function activity,Lab Services,Per Unit,$12.00 ,OP,12,53.38,,,,,,
Aetna MCR ADV,CPT,86162,Complement total (ch50),Lab Services,Per Unit,$20.32 ,OP,20.32,91.51,,,,,,
Aetna MCR ADV,CPT,86171,Complement fixation each,Lab Services,Per Unit,$10.01 ,OP,10.01,45.74,,,,,,
Aetna MCR ADV,CPT,86200,Ccp antibody,Lab Services,Per Unit,$12.95 ,OP,12.95,57.19,,,,,,
Aetna MCR ADV,CPT,86215,Deoxyribonuclease antibody,Lab Services,Per Unit,$13.25 ,OP,13.25,57.19,,,,,,
Aetna MCR ADV,CPT,86225,Dna antibody native,Lab Services,Per Unit,$13.74 ,OP,13.74,61,,,,,,
Aetna MCR ADV,CPT,86226,Dna antibody single strand,Lab Services,Per Unit,$12.11 ,OP,12.11,53.38,,,,,,
Aetna MCR ADV,CPT,86235,Nuclear antigen antibody,Lab Services,Per Unit,$17.93 ,OP,17.93,80.07,,,,,,
Aetna MCR ADV,CPT,86255,Fluorescent antibody screen,Lab Services,Per Unit,$12.05 ,OP,12.05,53.38,,,,,,
Aetna MCR ADV,CPT,86256,Fluorescent antibody titer,Lab Services,Per Unit,$12.05 ,OP,12.05,53.38,,,,,,
Aetna MCR ADV,CPT,86277,Growth hormone antibody,Lab Services,Per Unit,$15.74 ,OP,15.74,68.63,,,,,,
Aetna MCR ADV,CPT,86280,Hemagglutination inhibition,Lab Services,Per Unit,$8.19 ,OP,8.19,8.19,,,,,,
Aetna MCR ADV,CPT,86294,Immunoassay tumor qual,Lab Services,Per Unit,$25.57 ,OP,25.57,80.07,,,,,,
Aetna MCR ADV,CPT,86300,Immunoassay tumor ca 15-3,Lab Services,Per Unit,$20.81 ,OP,20.81,91.51,,,,,,
Aetna MCR ADV,CPT,86301,Immunoassay tumor ca 19-9,Lab Services,Per Unit,$20.81 ,OP,20.81,91.51,,,,,,
Aetna MCR ADV,CPT,86304,Immunoassay tumor ca 125,Lab Services,Per Unit,$20.81 ,OP,20.81,91.51,,,,,,
Aetna MCR ADV,CPT,86305,Human epididymis protein 4,Lab Services,Per Unit,$20.81 ,OP,20.81,20.81,,,,,,
Aetna MCR ADV,CPT,86308,Heterophile antibody screen,Lab Services,Per Unit,$5.18 ,OP,5.18,26.7,,,,,,
Aetna MCR ADV,CPT,86309,Heterophile antibody titer,Lab Services,Per Unit,$6.47 ,OP,6.47,30.51,,,,,,
Aetna MCR ADV,CPT,86310,Heterophile antibody absrbj,Lab Services,Per Unit,$7.37 ,OP,7.37,7.37,,,,,,
Aetna MCR ADV,CPT,86316,Immunoassay tumor other,Lab Services,Per Unit,$20.81 ,OP,20.81,91.51,,,,,,
Aetna MCR ADV,CPT,86317,Immunoassay infectious agent,Lab Services,Per Unit,$14.99 ,OP,14.99,68.63,,,,,,
Aetna MCR ADV,CPT,86318,Ia infectious agent antibody,Lab Services,Per Unit,$18.09 ,OP,18.09,64.82,,,,,,
Aetna MCR ADV,CPT,86320,Serum immunoelectrophoresis,Lab Services,Per Unit,$29.92 ,OP,29.92,99.13,,,,,,
Aetna MCR ADV,CPT,86325,Other immunoelectrophoresis,Lab Services,Per Unit,$23.13 ,OP,23.13,99.13,,,,,,
Aetna MCR ADV,CPT,86327,Immunoelectrophoresis assay,Lab Services,Per Unit,$29.92 ,OP,29.92,72.44,,,,,,
Aetna MCR ADV,CPT,86328,Ia nfct ab sarscov2 covid19,Lab Services,Per Unit,$45.23 ,OP,45.23,64.82,,,,,,
Aetna MCR ADV,CPT,86329,Immunodiffusion nes,Lab Services,Per Unit,$14.05 ,OP,14.05,14.05,,,,,,
Aetna MCR ADV,CPT,86331,Immunodiffusion ouchterlony,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Aetna MCR ADV,CPT,86332,Immune complex assay,Lab Services,Per Unit,$24.37 ,OP,24.37,106.76,,,,,,
Aetna MCR ADV,CPT,86334,Immunofix e-phoresis serum,Lab Services,Per Unit,$22.34 ,OP,22.34,99.13,,,,,,
Aetna MCR ADV,CPT,86335,Immunfix e-phorsis/urine/csf,Lab Services,Per Unit,$29.35 ,OP,29.35,129.64,,,,,,
Aetna MCR ADV,CPT,86336,Inhibin a,Lab Services,Per Unit,$15.59 ,OP,15.59,68.63,,,,,,
Aetna MCR ADV,CPT,86337,Insulin antibodies,Lab Services,Per Unit,$21.41 ,OP,21.41,95.32,,,,,,
Aetna MCR ADV,CPT,86340,Intrinsic factor antibody,Lab Services,Per Unit,$15.08 ,OP,15.08,68.63,,,,,,
Aetna MCR ADV,CPT,86341,Islet cell antibody,Lab Services,Per Unit,$23.57 ,OP,23.57,87.69,,,,,,
Aetna MCR ADV,CPT,86343,Leukocyte histamine release,Lab Services,Per Unit,$12.46 ,OP,12.46,57.19,,,,,,
Aetna MCR ADV,CPT,86344,Leukocyte phagocytosis,Lab Services,Per Unit,$10.39 ,OP,10.39,34.31,,,,,,
Aetna MCR ADV,CPT,86352,Cell function assay w/stim,Lab Services,Per Unit,$135.86 ,OP,135.86,135.86,,,,,,
Aetna MCR ADV,CPT,86353,Lymphocyte transformation,Lab Services,Per Unit,$49.03 ,OP,49.03,217.32,,,,,,
Aetna MCR ADV,CPT,86355,B cells total count,Lab Services,Per Unit,$37.73 ,OP,37.73,167.76,,,,,,
Aetna MCR ADV,CPT,86356,Mononuclear cell antigen,Lab Services,Per Unit,$26.78 ,OP,26.78,61,,,,,,
Aetna MCR ADV,CPT,86357,Nk cells total count,Lab Services,Per Unit,$37.73 ,OP,37.73,167.76,,,,,,
Aetna MCR ADV,CPT,86359,T cells total count,Lab Services,Per Unit,$37.73 ,OP,37.73,167.76,,,,,,
Aetna MCR ADV,CPT,86360,T cell absolute count/ratio,Lab Services,Per Unit,$46.98 ,OP,46.98,209.7,,,,,,
Aetna MCR ADV,CPT,86361,T cell absolute count,Lab Services,Per Unit,$26.78 ,OP,26.78,61,,,,,,
Aetna MCR ADV,CPT,86367,Stem cells total count,Lab Services,Per Unit,$77.78 ,OP,77.78,167.76,,,,,,
Aetna MCR ADV,CPT,86376,Microsomal antibody each,Lab Services,Per Unit,$14.55 ,OP,14.55,64.82,,,,,,
Aetna MCR ADV,CPT,86382,Neutralization test viral,Lab Services,Per Unit,$16.91 ,OP,16.91,76.26,,,,,,
Aetna MCR ADV,CPT,86384,Nitroblue tetrazolium dye,Lab Services,Per Unit,$13.61 ,OP,13.61,13.61,,,,,,
Aetna MCR ADV,CPT,86386,Nuclear matrix protein 22,Lab Services,Per Unit,$21.78 ,OP,21.78,21.78,,,,,,
Aetna MCR ADV,CPT,86403,Particle agglut antbdy scrn,Lab Services,Per Unit,$11.54 ,OP,11.54,26.7,,,,,,
Aetna MCR ADV,CPT,86406,Particle agglut antbdy titr,Lab Services,Per Unit,$10.64 ,OP,10.64,45.74,,,,,,
Aetna MCR ADV,CPT,86408,Neutrlzg antb sarscov2 scr,Lab Services,Per Unit,$42.13 ,OP,42.13,42.13,,,,,,
Aetna MCR ADV,CPT,86409,Neutrlzg antb sarscov2 titer,Lab Services,Per Unit,$105.33 ,OP,105.33,105.33,,,,,,
Aetna MCR ADV,CPT,86413,Sars-cov-2 antb quantitative,Lab Services,Per Unit,$51.43 ,OP,51.43,51.43,,,,,,
Aetna MCR ADV,CPT,86430,Rheumatoid factor test qual,Lab Services,Per Unit,$6.14 ,OP,6.14,26.7,,,,,,
Aetna MCR ADV,CPT,86431,Rheumatoid factor quant,Lab Services,Per Unit,$5.67 ,OP,5.67,26.7,,,,,,
Aetna MCR ADV,CPT,86480,Tb test cell immun measure,Lab Services,Per Unit,$61.98 ,OP,61.98,274.51,,,,,,
Aetna MCR ADV,CPT,86481,Tb ag response t-cell susp,Lab Services,Per Unit,$100.00 ,OP,100,100,,,,,,
Aetna MCR ADV,CPT,86485,Skin test candida,APC 5731,RVU Per Case,$25.25 ,OP,25.25,61,,,,,,
Aetna MCR ADV,CPT,86486,Skin test nos antigen,APC 5731,RVU Per Case,$25.25 ,OP,25.25,30.51,,,,,,
Aetna MCR ADV,CPT,86490,Coccidioidomycosis skin test,APC 5733,RVU Per Case,$56.95 ,OP,38.13,56.95,,,,,,
Aetna MCR ADV,CPT,86510,Histoplasmosis skin test,APC 5733,RVU Per Case,$56.95 ,OP,38.13,56.95,,,,,,
Aetna MCR ADV,CPT,86580,Tb intradermal test,APC 5731,RVU Per Case,$25.25 ,OP,25.25,38.13,,,,,,
Aetna MCR ADV,CPT,86590,Streptokinase antibody,Lab Services,Per Unit,$12.66 ,OP,12.66,49.56,,,,,,
Aetna MCR ADV,CPT,86592,Syphilis test non-trep qual,Lab Services,Per Unit,$4.27 ,OP,4.27,19.07,,,,,,
Aetna MCR ADV,CPT,86593,Syphilis test non-trep quant,Lab Services,Per Unit,$4.40 ,OP,4.4,19.07,,,,,,
Aetna MCR ADV,CPT,86602,Antinomyces antibody,Lab Services,Per Unit,$10.18 ,OP,10.18,45.74,,,,,,
Aetna MCR ADV,CPT,86603,Adenovirus antibody,Lab Services,Per Unit,$12.87 ,OP,12.87,12.87,,,,,,
Aetna MCR ADV,CPT,86606,Aspergillus antibody,Lab Services,Per Unit,$15.05 ,OP,15.05,68.63,,,,,,
Aetna MCR ADV,CPT,86609,Bacterium antibody,Lab Services,Per Unit,$12.88 ,OP,12.88,57.19,,,,,,
Aetna MCR ADV,CPT,86611,Bartonella antibody,Lab Services,Per Unit,$10.18 ,OP,10.18,45.74,,,,,,
Aetna MCR ADV,CPT,86612,Blastomyces antibody,Lab Services,Per Unit,$12.90 ,OP,12.9,57.19,,,,,,
Aetna MCR ADV,CPT,86615,Bordetella antibody,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
Aetna MCR ADV,CPT,86617,Lyme disease antibody,Lab Services,Per Unit,$15.49 ,OP,15.49,68.63,,,,,,
Aetna MCR ADV,CPT,86618,Lyme disease antibody,Lab Services,Per Unit,$17.03 ,OP,17.03,83.87,,,,,,
Aetna MCR ADV,CPT,86619,Borrelia antibody,Lab Services,Per Unit,$13.38 ,OP,13.38,61,,,,,,
Aetna MCR ADV,CPT,86622,Brucella antibody,Lab Services,Per Unit,$8.93 ,OP,8.93,38.13,,,,,,
Aetna MCR ADV,CPT,86625,Campylobacter antibody,Lab Services,Per Unit,$13.12 ,OP,13.12,57.19,,,,,,
Aetna MCR ADV,CPT,86628,Candida antibody,Lab Services,Per Unit,$12.01 ,OP,12.01,53.38,,,,,,
Aetna MCR ADV,CPT,86631,Chlamydia antibody,Lab Services,Per Unit,$11.82 ,OP,11.82,53.38,,,,,,
Aetna MCR ADV,CPT,86632,Chlamydia igm antibody,Lab Services,Per Unit,$12.68 ,OP,12.68,57.19,,,,,,
Aetna MCR ADV,CPT,86635,Coccidioides antibody,Lab Services,Per Unit,$11.47 ,OP,11.47,49.56,,,,,,
Aetna MCR ADV,CPT,86638,Q fever antibody,Lab Services,Per Unit,$12.12 ,OP,12.12,53.38,,,,,,
Aetna MCR ADV,CPT,86641,Cryptococcus antibody,Lab Services,Per Unit,$14.41 ,OP,14.41,64.82,,,,,,
Aetna MCR ADV,CPT,86644,Cmv antibody,Lab Services,Per Unit,$14.39 ,OP,14.39,64.82,,,,,,
Aetna MCR ADV,CPT,86645,Cmv antibody igm,Lab Services,Per Unit,$16.85 ,OP,16.85,76.26,,,,,,
Aetna MCR ADV,CPT,86648,Diphtheria antibody,Lab Services,Per Unit,$15.21 ,OP,15.21,68.63,,,,,,
Aetna MCR ADV,CPT,86651,Encephalitis californ antbdy,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
Aetna MCR ADV,CPT,86652,Encephaltis east eqne anbdy,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
Aetna MCR ADV,CPT,86653,Encephaltis st louis antbody,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
Aetna MCR ADV,CPT,86654,Encephaltis west eqne antbdy,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
Aetna MCR ADV,CPT,86658,Enterovirus antibody,Lab Services,Per Unit,$13.03 ,OP,13.03,57.19,,,,,,
Aetna MCR ADV,CPT,86663,Epstein-barr antibody,Lab Services,Per Unit,$13.12 ,OP,13.12,57.19,,,,,,
Aetna MCR ADV,CPT,86664,Epstein-barr nuclear antigen,Lab Services,Per Unit,$15.29 ,OP,15.29,68.63,,,,,,
Aetna MCR ADV,CPT,86665,Epstein-barr capsid vca,Lab Services,Per Unit,$18.14 ,OP,18.14,80.07,,,,,,
Aetna MCR ADV,CPT,86666,Ehrlichia antibody,Lab Services,Per Unit,$10.18 ,OP,10.18,45.74,,,,,,
Aetna MCR ADV,CPT,86668,Francisella tularensis,Lab Services,Per Unit,$14.16 ,OP,14.16,45.74,,,,,,
Aetna MCR ADV,CPT,86671,Fungus nes antibody,Lab Services,Per Unit,$12.25 ,OP,12.25,53.38,,,,,,
Aetna MCR ADV,CPT,86674,Giardia lamblia antibody,Lab Services,Per Unit,$14.72 ,OP,14.72,14.72,,,,,,
Aetna MCR ADV,CPT,86677,Helicobacter pylori antibody,Lab Services,Per Unit,$16.85 ,OP,16.85,64.82,,,,,,
Aetna MCR ADV,CPT,86682,Helminth antibody,Lab Services,Per Unit,$13.01 ,OP,13.01,57.19,,,,,,
Aetna MCR ADV,CPT,86684,Hemophilus influenza antibdy,Lab Services,Per Unit,$15.84 ,OP,15.84,72.44,,,,,,
Aetna MCR ADV,CPT,86687,Htlv-i antibody,Lab Services,Per Unit,$9.09 ,OP,9.09,38.13,,,,,,
Aetna MCR ADV,CPT,86688,Htlv-ii antibody,Lab Services,Per Unit,$14.00 ,OP,14,61,,,,,,
Aetna MCR ADV,CPT,86689,Htlv/hiv confirmj antibody,Lab Services,Per Unit,$19.35 ,OP,19.35,87.69,,,,,,
Aetna MCR ADV,CPT,86692,Hepatitis delta agent antbdy,Lab Services,Per Unit,$17.16 ,OP,17.16,76.26,,,,,,
Aetna MCR ADV,CPT,86694,Herpes simplex nes antbdy,Lab Services,Per Unit,$14.39 ,OP,14.39,64.82,,,,,,
Aetna MCR ADV,CPT,86695,Herpes simplex type 1 test,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
Aetna MCR ADV,CPT,86696,Herpes simplex type 2 test,Lab Services,Per Unit,$19.35 ,OP,19.35,87.69,,,,,,
Aetna MCR ADV,CPT,86698,Histoplasma antibody,Lab Services,Per Unit,$13.79 ,OP,13.79,57.19,,,,,,
Aetna MCR ADV,CPT,86701,Hiv-1antibody,Lab Services,Per Unit,$8.89 ,OP,8.89,38.13,,,,,,
Aetna MCR ADV,CPT,86702,Hiv-2 antibody,Lab Services,Per Unit,$13.52 ,OP,13.52,61,,,,,,
Aetna MCR ADV,CPT,86703,Hiv-1/hiv-2 1 result antbdy,Lab Services,Per Unit,$13.71 ,OP,13.71,61,,,,,,
Aetna MCR ADV,CPT,86704,Hep b core antibody total,Lab Services,Per Unit,$12.05 ,OP,12.05,53.38,,,,,,
Aetna MCR ADV,CPT,86705,Hep b core antibody igm,Lab Services,Per Unit,$11.77 ,OP,11.77,53.38,,,,,,
Aetna MCR ADV,CPT,86706,Hep b surface antibody,Lab Services,Per Unit,$10.74 ,OP,10.74,49.56,,,,,,
Aetna MCR ADV,CPT,86707,Hepatitis be antibody,Lab Services,Per Unit,$11.57 ,OP,11.57,53.38,,,,,,
Aetna MCR ADV,CPT,86708,Hepatitis a antibody,Lab Services,Per Unit,$12.39 ,OP,12.39,53.38,,,,,,
Aetna MCR ADV,CPT,86709,Hepatitis a igm antibody,Lab Services,Per Unit,$11.26 ,OP,11.26,49.56,,,,,,
Aetna MCR ADV,CPT,86710,Influenza virus antibody,Lab Services,Per Unit,$13.55 ,OP,13.55,68.63,,,,,,
Aetna MCR ADV,CPT,86711,John cunningham antibody,Lab Services,Per Unit,$16.89 ,OP,16.89,16.89,,,,,,
Aetna MCR ADV,CPT,86713,Legionella antibody,Lab Services,Per Unit,$15.30 ,OP,15.3,68.63,,,,,,
Aetna MCR ADV,CPT,86717,Leishmania antibody,Lab Services,Per Unit,$12.25 ,OP,12.25,53.38,,,,,,
Aetna MCR ADV,CPT,86720,Leptospira antibody,Lab Services,Per Unit,$16.20 ,OP,16.2,57.19,,,,,,
Aetna MCR ADV,CPT,86723,Listeria monocytogenes,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,
Aetna MCR ADV,CPT,86727,Lymph choriomeningitis ab,Lab Services,Per Unit,$12.87 ,OP,12.87,57.19,,,,,,
Aetna MCR ADV,CPT,86732,Mucormycosis antibody,Lab Services,Per Unit,$15.00 ,OP,15,57.19,,,,,,
Aetna MCR ADV,CPT,86735,Mumps antibody,Lab Services,Per Unit,$13.05 ,OP,13.05,57.19,,,,,,
Aetna MCR ADV,CPT,86738,Mycoplasma antibody,Lab Services,Per Unit,$13.24 ,OP,13.24,57.19,,,,,,
Aetna MCR ADV,CPT,86741,Neisseria meningitidis,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
Aetna MCR ADV,CPT,86744,Nocardia antibody,Lab Services,Per Unit,$15.99 ,OP,15.99,57.19,,,,,,
Aetna MCR ADV,CPT,86747,Parvovirus antibody,Lab Services,Per Unit,$15.03 ,OP,15.03,68.63,,,,,,
Aetna MCR ADV,CPT,86750,Malaria antibody,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
Aetna MCR ADV,CPT,86753,Protozoa antibody nos,Lab Services,Per Unit,$12.39 ,OP,12.39,53.38,,,,,,
Aetna MCR ADV,CPT,86756,Respiratory virus antibody,Lab Services,Per Unit,$15.89 ,OP,15.89,57.19,,,,,,
Aetna MCR ADV,CPT,86757,Rickettsia antibody,Lab Services,Per Unit,$19.35 ,OP,19.35,87.69,,,,,,
Aetna MCR ADV,CPT,86759,Rotavirus antibody,Lab Services,Per Unit,$18.23 ,OP,18.23,57.19,,,,,,
Aetna MCR ADV,CPT,86762,Rubella antibody,Lab Services,Per Unit,$14.39 ,OP,14.39,64.82,,,,,,
Aetna MCR ADV,CPT,86765,Rubeola antibody,Lab Services,Per Unit,$12.88 ,OP,12.88,57.19,,,,,,
Aetna MCR ADV,CPT,86768,Salmonella antibody,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,
Aetna MCR ADV,CPT,86769,Sars-cov-2 covid-19 antibody,Lab Services,Per Unit,$42.13 ,OP,42.13,57.19,,,,,,
Aetna MCR ADV,CPT,86771,Shigella antibody,Lab Services,Per Unit,$24.48 ,OP,24.48,57.19,,,,,,
Aetna MCR ADV,CPT,86774,Tetanus antibody,Lab Services,Per Unit,$14.80 ,OP,14.8,64.82,,,,,,
Aetna MCR ADV,CPT,86777,Toxoplasma antibody,Lab Services,Per Unit,$14.39 ,OP,14.39,64.82,,,,,,
Aetna MCR ADV,CPT,86778,Toxoplasma antibody igm,Lab Services,Per Unit,$14.41 ,OP,14.41,64.82,,,,,,
Aetna MCR ADV,CPT,86780,Treponema pallidum,Lab Services,Per Unit,$13.24 ,OP,13.24,13.24,,,,,,
Aetna MCR ADV,CPT,86784,Trichinella antibody,Lab Services,Per Unit,$12.56 ,OP,12.56,12.56,,,,,,
Aetna MCR ADV,CPT,86787,Varicella-zoster antibody,Lab Services,Per Unit,$12.88 ,OP,12.88,57.19,,,,,,
Aetna MCR ADV,CPT,86788,West nile virus ab igm,Lab Services,Per Unit,$16.85 ,OP,16.85,76.26,,,,,,
Aetna MCR ADV,CPT,86789,West nile virus antibody,Lab Services,Per Unit,$14.39 ,OP,14.39,64.82,,,,,,
Aetna MCR ADV,CPT,86790,Virus antibody nos,Lab Services,Per Unit,$12.88 ,OP,12.88,57.19,,,,,,
Aetna MCR ADV,CPT,86793,Yersinia antibody,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
Aetna MCR ADV,CPT,86794,Zika virus igm antibody,Lab Services,Per Unit,$16.85 ,OP,16.85,16.85,,,,,,
Aetna MCR ADV,CPT,86800,Thyroglobulin antibody,Lab Services,Per Unit,$15.91 ,OP,15.91,72.44,,,,,,
Aetna MCR ADV,CPT,86803,Hepatitis c ab test,Lab Services,Per Unit,$14.27 ,OP,14.27,64.82,,,,,,
Aetna MCR ADV,CPT,86804,Hep c ab test confirm,Lab Services,Per Unit,$15.49 ,OP,15.49,68.63,,,,,,
Aetna MCR ADV,CPT,86805,Lymphocytotoxicity assay,Lab Services,Per Unit,$189.51 ,OP,189.51,232.58,,,,,,
Aetna MCR ADV,CPT,86806,Lymphocytotoxicity assay,Lab Services,Per Unit,$47.59 ,OP,47.59,213.51,,,,,,
Aetna MCR ADV,CPT,86807,Cytotoxic antibody screening,Lab Services,Per Unit,$78.65 ,OP,78.65,175.39,,,,,,
Aetna MCR ADV,CPT,86808,Cytotoxic antibody screening,Lab Services,Per Unit,$29.68 ,OP,29.68,133.45,,,,,,
Aetna MCR ADV,CPT,86812,Hla typing a b or c,Lab Services,Per Unit,$25.81 ,OP,25.81,114.39,,,,,,
Aetna MCR ADV,CPT,86813,Hla typing a b or c,Lab Services,Per Unit,$58.00 ,OP,58,247.83,,,,,,
Aetna MCR ADV,CPT,86816,Hla typing dr/dq,Lab Services,Per Unit,$30.17 ,OP,30.17,102.95,,,,,,
Aetna MCR ADV,CPT,86817,Hla typing dr/dq,Lab Services,Per Unit,$106.14 ,OP,106.14,247.83,,,,,,
Aetna MCR ADV,CPT,86821,Lymphocyte culture mixed,Lab Services,Per Unit,$36.56 ,OP,36.56,251.64,,,,,,
Aetna MCR ADV,CPT,86825,Hla x-math non-cytotoxic,Lab Services,Per Unit,$109.49 ,OP,109.49,109.49,,,,,,
Aetna MCR ADV,CPT,86826,Hla x-match noncytotoxc addl,Lab Services,Per Unit,$36.53 ,OP,36.53,36.53,,,,,,
Aetna MCR ADV,CPT,86828,Hla class i&ii antibody qual,Lab Services,Per Unit,$64.19 ,OP,64.19,64.19,,,,,,
Aetna MCR ADV,CPT,86829,Hla class i/ii antibody qual,Lab Services,Per Unit,$64.19 ,OP,64.19,64.19,,,,,,
Aetna MCR ADV,CPT,86830,Hla class i phenotype qual,Lab Services,Per Unit,$95.52 ,OP,95.52,95.52,,,,,,
Aetna MCR ADV,CPT,86831,Hla class ii phenotype qual,Lab Services,Per Unit,$81.88 ,OP,81.88,81.88,,,,,,
Aetna MCR ADV,CPT,86832,Hla class i high defin qual,Lab Services,Per Unit,$323.75 ,OP,323.75,323.75,,,,,,
Aetna MCR ADV,CPT,86833,Hla class ii high defin qual,Lab Services,Per Unit,$325.80 ,OP,325.8,325.8,,,,,,
Aetna MCR ADV,CPT,86834,Hla class i semiquant panel,Lab Services,Per Unit,$357.56 ,OP,357.56,357.56,,,,,,
Aetna MCR ADV,CPT,86835,Hla class ii semiquant panel,Lab Services,Per Unit,$322.96 ,OP,322.96,322.96,,,,,,
Aetna MCR ADV,CPT,86850,Rbc antibody screen,APC 5671,RVU Per Case,$50.92 ,OP,50.92,76.26,,,,,,
Aetna MCR ADV,CPT,86860,Rbc antibody elution,APC 5672,RVU Per Case,$152.64 ,OP,91.51,152.64,,,,,,
Aetna MCR ADV,CPT,86870,Rbc antibody identification,APC 5673,RVU Per Case,$298.05 ,OP,141.07,298.05,,,,,,
Aetna MCR ADV,CPT,86880,Coombs test direct,APC 5733,RVU Per Case,$56.95 ,OP,22.88,56.95,,,,,,
Aetna MCR ADV,CPT,86885,Coombs test indirect qual,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Aetna MCR ADV,CPT,86886,Coombs test indirect titer,APC 5672,RVU Per Case,$152.64 ,OP,22.88,152.64,,,,,,
Aetna MCR ADV,CPT,86890,Autologous blood process,APC 5672,RVU Per Case,$152.64 ,OP,152.64,308.83,,,,,,
Aetna MCR ADV,CPT,86891,Autologous blood op salvage,APC 5674,RVU Per Case,$671.45 ,OP,480.4,671.45,,,,,,
Aetna MCR ADV,CPT,86900,Blood typing serologic abo,APC 5734,RVU Per Case,$114.56 ,OP,11.44,114.56,,,,,,
Aetna MCR ADV,CPT,86901,Blood typing serologic rh(d),APC 5732,RVU Per Case,$34.63 ,OP,22.88,34.63,,,,,,
Aetna MCR ADV,CPT,86902,Blood type antigen donor ea,APC 5673,RVU Per Case,$298.05 ,OP,41.94,298.05,,,,,,
Aetna MCR ADV,CPT,86904,Blood typing patient serum,APC 5732,RVU Per Case,$34.63 ,OP,34.63,41.94,,,,,,
Aetna MCR ADV,CPT,86905,Blood typing rbc antigens,APC 5673,RVU Per Case,$298.05 ,OP,15.26,298.05,,,,,,
Aetna MCR ADV,CPT,86906,Bld typing serologic rh phnt,APC 5732,RVU Per Case,$34.63 ,OP,34.31,34.63,,,,,,
Aetna MCR ADV,CPT,86920,Compatibility test spin,APC 5672,RVU Per Case,$152.64 ,OP,125.82,152.64,,,,,,
Aetna MCR ADV,CPT,86921,Compatibility test incubate,APC 5672,RVU Per Case,$152.64 ,OP,102.95,152.64,,,,,,
Aetna MCR ADV,CPT,86922,Compatibility test antiglob,APC 5672,RVU Per Case,$152.64 ,OP,118.19,152.64,,,,,,
Aetna MCR ADV,CPT,86923,Compatibility test electric,APC 5672,RVU Per Case,$152.64 ,OP,91.51,152.64,,,,,,
Aetna MCR ADV,CPT,86927,Plasma fresh frozen,APC 5672,RVU Per Unit,$152.64 ,OP,49.56,152.64,,,,,,
Aetna MCR ADV,CPT,86930,Frozen blood prep,APC 5673,RVU Per Case,$298.05 ,OP,298.05,385.09,,,,,,
Aetna MCR ADV,CPT,86931,Frozen blood thaw,APC 5673,RVU Per Case,$298.05 ,OP,289.76,298.05,,,,,,
Aetna MCR ADV,CPT,86932,Frozen blood freeze/thaw,APC 5732,RVU Per Case,$34.63 ,OP,34.63,385.09,,,,,,
Aetna MCR ADV,CPT,86940,Hemolysins/agglutinins auto,Lab Services,Per Unit,$8.77 ,OP,8.77,38.13,,,,,,
Aetna MCR ADV,CPT,86941,Hemolysins/agglutinins,Lab Services,Per Unit,$12.11 ,OP,12.11,53.38,,,,,,
Aetna MCR ADV,CPT,86945,Blood product/irradiation,APC 5732,RVU Per Case,$34.63 ,OP,34.63,110.57,,,,,,
Aetna MCR ADV,CPT,86950,Leukacyte transfusion,APC 5672,RVU Per Case,$152.64 ,OP,152.64,240.2,,,,,,
Aetna MCR ADV,CPT,86960,Vol reduction of blood/prod,APC 5672,RVU Per Case,$152.64 ,OP,110.57,152.64,,,,,,
Aetna MCR ADV,CPT,86965,Pooling blood platelets,APC 5672,RVU Per Case,$152.64 ,OP,95.32,152.64,,,,,,
Aetna MCR ADV,CPT,86970,Rbc pretx incubatj w/chemicl,APC 5732,RVU Per Case,$34.63 ,OP,34.63,76.26,,,,,,
Aetna MCR ADV,CPT,86971,Rbc pretx incubatj w/enzymes,APC 5673,RVU Per Case,$298.05 ,OP,298.05,298.05,,,,,,
Aetna MCR ADV,CPT,86972,Rbc pretx incubatj w/density,APC 5672,RVU Per Case,$152.64 ,OP,122,152.64,,,,,,
Aetna MCR ADV,CPT,86975,Rbc serum pretx incubj drugs,APC 5735,RVU Per Case,$276.53 ,OP,102.95,276.53,,,,,,
Aetna MCR ADV,CPT,86976,Rbc serum pretx id dilution,APC 5731,RVU Per Case,$25.25 ,OP,25.25,118.19,,,,,,
Aetna MCR ADV,CPT,86977,Rbc serum pretx incubj/inhib,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Aetna MCR ADV,CPT,86978,Rbc pretreatment serum,APC 5732,RVU Per Case,$34.63 ,OP,34.63,102.95,,,,,,
Aetna MCR ADV,CPT,86985,Split blood or products,APC 5672,RVU Per Case,$152.64 ,OP,76.26,152.64,,,,,,
Aetna MCR ADV,CPT,86999,Transfusion procedure,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Aetna MCR ADV,CPT,87003,Small animal inoculation,Lab Services,Per Unit,$16.84 ,OP,16.84,76.26,,,,,,
Aetna MCR ADV,CPT,87015,Specimen infect agnt concntj,Lab Services,Per Unit,$6.68 ,OP,6.68,30.51,,,,,,
Aetna MCR ADV,CPT,87040,Blood culture for bacteria,Lab Services,Per Unit,$10.32 ,OP,10.32,45.74,,,,,,
Aetna MCR ADV,CPT,87045,Feces culture aerobic bact,Lab Services,Per Unit,$9.44 ,OP,9.44,41.94,,,,,,
Aetna MCR ADV,CPT,87046,Stool cultr aerobic bact ea,Lab Services,Per Unit,$9.44 ,OP,9.44,41.94,,,,,,
Aetna MCR ADV,CPT,87070,Culture othr specimn aerobic,Lab Services,Per Unit,$8.62 ,OP,8.62,41.94,,,,,,
Aetna MCR ADV,CPT,87071,Culture aerobic quant other,Lab Services,Per Unit,$9.89 ,OP,9.89,41.94,,,,,,
Aetna MCR ADV,CPT,87073,Culture bacteria anaerobic,Lab Services,Per Unit,$9.66 ,OP,9.66,41.94,,,,,,
Aetna MCR ADV,CPT,87075,Cultr bacteria except blood,Lab Services,Per Unit,$9.47 ,OP,9.47,41.94,,,,,,
Aetna MCR ADV,CPT,87076,Culture anaerobe ident each,Lab Services,Per Unit,$8.08 ,OP,8.08,19.07,,,,,,
Aetna MCR ADV,CPT,87077,Culture aerobic identify,Lab Services,Per Unit,$8.08 ,OP,8.08,22.88,,,,,,
Aetna MCR ADV,CPT,87081,Culture screen only,Lab Services,Per Unit,$6.63 ,OP,6.63,34.31,,,,,,
Aetna MCR ADV,CPT,87084,Culture of specimen by kit,Lab Services,Per Unit,$27.07 ,OP,22.88,27.07,,,,,,
Aetna MCR ADV,CPT,87086,Urine culture/colony count,Lab Services,Per Unit,$8.07 ,OP,8.07,41.94,,,,,,
Aetna MCR ADV,CPT,87088,Urine bacteria culture,Lab Services,Per Unit,$8.09 ,OP,8.09,41.94,,,,,,
Aetna MCR ADV,CPT,87101,Skin fungi culture,Lab Services,Per Unit,$7.71 ,OP,7.71,34.31,,,,,,
Aetna MCR ADV,CPT,87102,Fungus isolation culture,Lab Services,Per Unit,$8.41 ,OP,8.41,38.13,,,,,,
Aetna MCR ADV,CPT,87103,Blood fungus culture,Lab Services,Per Unit,$20.46 ,OP,20.46,41.94,,,,,,
Aetna MCR ADV,CPT,87106,Fungi identification yeast,Lab Services,Per Unit,$10.32 ,OP,10.32,45.74,,,,,,
Aetna MCR ADV,CPT,87107,Fungi identification mold,Lab Services,Per Unit,$10.32 ,OP,10.32,45.74,,,,,,
Aetna MCR ADV,CPT,87109,Mycoplasma,Lab Services,Per Unit,$15.39 ,OP,15.39,68.63,,,,,,
Aetna MCR ADV,CPT,87110,Chlamydia culture,Lab Services,Per Unit,$19.60 ,OP,19.6,87.69,,,,,,
Aetna MCR ADV,CPT,87116,Mycobacteria culture,Lab Services,Per Unit,$10.80 ,OP,10.8,49.56,,,,,,
Aetna MCR ADV,CPT,87118,Mycobacteric identification,Lab Services,Per Unit,$14.61 ,OP,14.61,49.56,,,,,,
Aetna MCR ADV,CPT,87140,Culture type immunofluoresc,Lab Services,Per Unit,$5.57 ,OP,5.57,26.7,,,,,,
Aetna MCR ADV,CPT,87143,Culture typing glc/hplc,Lab Services,Per Unit,$12.52 ,OP,12.52,57.19,,,,,,
Aetna MCR ADV,CPT,87147,Culture type immunologic,Lab Services,Per Unit,$5.18 ,OP,5.18,22.88,,,,,,
Aetna MCR ADV,CPT,87149,Dna/rna direct probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
Aetna MCR ADV,CPT,87150,Dna/rna amplified probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,
Aetna MCR ADV,CPT,87152,Culture type pulse field gel,Lab Services,Per Unit,$7.74 ,OP,7.74,22.88,,,,,,
Aetna MCR ADV,CPT,87153,Dna/rna sequencing,Lab Services,Per Unit,$115.36 ,OP,115.36,115.36,,,,,,
Aetna MCR ADV,CPT,87158,Culture typing added method,Lab Services,Per Unit,$7.74 ,OP,7.74,7.74,,,,,,
Aetna MCR ADV,CPT,87164,Dark field examination,Lab Services,Per Unit,$10.74 ,OP,10.74,49.56,,,,,,
Aetna MCR ADV,CPT,87166,Dark field examination,Lab Services,Per Unit,$11.30 ,OP,11.3,49.56,,,,,,
Aetna MCR ADV,CPT,87168,Macroscopic exam arthropod,Lab Services,Per Unit,$4.27 ,OP,4.27,19.07,,,,,,
Aetna MCR ADV,CPT,87169,Macroscopic exam parasite,Lab Services,Per Unit,$4.31 ,OP,4.31,19.07,,,,,,
Aetna MCR ADV,CPT,87172,Pinworm exam,Lab Services,Per Unit,$4.27 ,OP,4.27,22.88,,,,,,
Aetna MCR ADV,CPT,87176,Tissue homogenization cultr,Lab Services,Per Unit,$5.88 ,OP,5.88,26.7,,,,,,
Aetna MCR ADV,CPT,87177,Ova and parasites smears,Lab Services,Per Unit,$8.90 ,OP,8.9,41.94,,,,,,
Aetna MCR ADV,CPT,87181,Microbe susceptible diffuse,Lab Services,Per Unit,$4.75 ,OP,4.75,22.88,,,,,,
Aetna MCR ADV,CPT,87184,Microbe susceptible disk,Lab Services,Per Unit,$7.48 ,OP,7.48,34.31,,,,,,
Aetna MCR ADV,CPT,87185,Microbe susceptible enzyme,Lab Services,Per Unit,$4.75 ,OP,4.75,22.88,,,,,,
Aetna MCR ADV,CPT,87186,Microbe susceptible mic,Lab Services,Per Unit,$8.65 ,OP,8.65,38.13,,,,,,
Aetna MCR ADV,CPT,87187,Microbe susceptible mlc,Lab Services,Per Unit,$40.17 ,OP,40.17,45.74,,,,,,
Aetna MCR ADV,CPT,87188,Microbe suscept macrobroth,Lab Services,Per Unit,$6.64 ,OP,6.64,30.51,,,,,,
Aetna MCR ADV,CPT,87190,Microbe suscept mycobacteri,Lab Services,Per Unit,$7.31 ,OP,7.31,26.7,,,,,,
Aetna MCR ADV,CPT,87197,Bactericidal level serum,Lab Services,Per Unit,$15.02 ,OP,15.02,68.63,,,,,,
Aetna MCR ADV,CPT,87205,Smear gram stain,Lab Services,Per Unit,$4.27 ,OP,4.27,22.88,,,,,,
Aetna MCR ADV,CPT,87206,Smear fluorescent/acid stai,Lab Services,Per Unit,$5.39 ,OP,5.39,26.7,,,,,,
Aetna MCR ADV,CPT,87207,Smear special stain,Lab Services,Per Unit,$5.99 ,OP,5.99,41.94,,,,,,
Aetna MCR ADV,CPT,87209,Smear complex stain,Lab Services,Per Unit,$17.98 ,OP,17.98,80.07,,,,,,
Aetna MCR ADV,CPT,87210,Smear wet mount saline/ink,Lab Services,Per Unit,$5.82 ,OP,5.82,22.88,,,,,,
Aetna MCR ADV,CPT,87220,Tissue exam for fungi,Lab Services,Per Unit,$4.27 ,OP,4.27,22.88,,,,,,
Aetna MCR ADV,CPT,87230,Assay toxin or antitoxin,Lab Services,Per Unit,$19.74 ,OP,19.74,87.69,,,,,,
Aetna MCR ADV,CPT,87250,Virus inoculate eggs/animal,Lab Services,Per Unit,$19.56 ,OP,19.56,87.69,,,,,,
Aetna MCR ADV,CPT,87252,Virus inoculation tissue,Lab Services,Per Unit,$26.07 ,OP,26.07,102.95,,,,,,
Aetna MCR ADV,CPT,87253,Virus inoculate tissue addl,Lab Services,Per Unit,$20.20 ,OP,20.2,91.51,,,,,,
Aetna MCR ADV,CPT,87254,Virus inoculation shell via,Lab Services,Per Unit,$19.56 ,OP,19.56,87.69,,,,,,
Aetna MCR ADV,CPT,87255,Genet virus isolate hsv,Lab Services,Per Unit,$33.86 ,OP,33.86,152.51,,,,,,
Aetna MCR ADV,CPT,87260,Adenovirus ag if,Lab Services,Per Unit,$14.43 ,OP,14.43,14.43,,,,,,
Aetna MCR ADV,CPT,87265,Pertussis ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Aetna MCR ADV,CPT,87267,Enterovirus antibody dfa,Lab Services,Per Unit,$13.42 ,OP,13.42,53.38,,,,,,
Aetna MCR ADV,CPT,87269,Giardia ag if,Lab Services,Per Unit,$13.61 ,OP,13.61,53.38,,,,,,
Aetna MCR ADV,CPT,87270,Chlamydia trachomatis ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Aetna MCR ADV,CPT,87271,Cytomegalovirus dfa,Lab Services,Per Unit,$13.42 ,OP,13.42,53.38,,,,,,
Aetna MCR ADV,CPT,87272,Cryptosporidium ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Aetna MCR ADV,CPT,87273,Herpes simplex 2 ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,
Aetna MCR ADV,CPT,87274,Herpes simplex 1 ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,
Aetna MCR ADV,CPT,87275,Influenza b ag if,Lab Services,Per Unit,$12.25 ,OP,12.25,53.38,,,,,,
Aetna MCR ADV,CPT,87276,Influenza a ag if,Lab Services,Per Unit,$16.07 ,OP,16.07,53.38,,,,,,
Aetna MCR ADV,CPT,87278,Legion pneumophilia ag if,Lab Services,Per Unit,$15.60 ,OP,15.6,53.38,,,,,,
Aetna MCR ADV,CPT,87279,Parainfluenza ag if,Lab Services,Per Unit,$16.43 ,OP,16.43,53.38,,,,,,
Aetna MCR ADV,CPT,87280,Respiratory syncytial ag if,Lab Services,Per Unit,$13.42 ,OP,13.42,53.38,,,,,,
Aetna MCR ADV,CPT,87281,Pneumocystis carinii ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Aetna MCR ADV,CPT,87283,Rubeola ag if,Lab Services,Per Unit,$60.80 ,OP,53.38,60.8,,,,,,
Aetna MCR ADV,CPT,87285,Treponema pallidum ag if,Lab Services,Per Unit,$12.18 ,OP,12.18,53.38,,,,,,
Aetna MCR ADV,CPT,87290,Varicella zoster ag if,Lab Services,Per Unit,$13.42 ,OP,13.42,53.38,,,,,,
Aetna MCR ADV,CPT,87299,Antibody detection nos if,Lab Services,Per Unit,$16.10 ,OP,16.1,53.38,,,,,,
Aetna MCR ADV,CPT,87300,Ag detection polyval if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,
Aetna MCR ADV,CPT,87301,Adenovirus ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Aetna MCR ADV,CPT,87305,Aspergillus ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Aetna MCR ADV,CPT,87320,Chylmd trach ag ia,Lab Services,Per Unit,$15.00 ,OP,15,53.38,,,,,,
Aetna MCR ADV,CPT,87324,Clostridium ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Aetna MCR ADV,CPT,87327,Cryptococcus neoform ag ia,Lab Services,Per Unit,$13.42 ,OP,13.42,53.38,,,,,,
Aetna MCR ADV,CPT,87328,Cryptosporidium ag ia,Lab Services,Per Unit,$13.82 ,OP,13.82,53.38,,,,,,
Aetna MCR ADV,CPT,87329,Giardia ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Aetna MCR ADV,CPT,87332,Cytomegalovirus ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Aetna MCR ADV,CPT,87335,E coli 0157 ag ia,Lab Services,Per Unit,$12.66 ,OP,12.66,53.38,,,,,,
Aetna MCR ADV,CPT,87336,Entamoeb hist dispr ag ia,Lab Services,Per Unit,$16.00 ,OP,16,53.38,,,,,,
Aetna MCR ADV,CPT,87337,Entamoeb hist group ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Aetna MCR ADV,CPT,87338,Hpylori stool ag ia,Lab Services,Per Unit,$14.38 ,OP,14.38,64.82,,,,,,
Aetna MCR ADV,CPT,87339,H pylori ag ia,Lab Services,Per Unit,$16.00 ,OP,16,53.38,,,,,,
Aetna MCR ADV,CPT,87340,Hepatitis b surface ag ia,Lab Services,Per Unit,$10.33 ,OP,10.33,45.74,,,,,,
Aetna MCR ADV,CPT,87341,Hepatitis b surface ag ia,Lab Services,Per Unit,$10.33 ,OP,10.33,45.74,,,,,,
Aetna MCR ADV,CPT,87350,Hepatitis be ag ia,Lab Services,Per Unit,$11.53 ,OP,11.53,49.56,,,,,,
Aetna MCR ADV,CPT,87380,Hepatitis delta agent ag ia,Lab Services,Per Unit,$18.36 ,OP,18.36,72.44,,,,,,
Aetna MCR ADV,CPT,87385,Histoplasma capsul ag ia,Lab Services,Per Unit,$13.25 ,OP,13.25,53.38,,,,,,
Aetna MCR ADV,CPT,87389,Hiv-1 ag w/hiv-1&2 ab ag ia,Lab Services,Per Unit,$24.08 ,OP,24.08,24.08,,,,,,
Aetna MCR ADV,CPT,87390,Hiv-1 ag ia,Lab Services,Per Unit,$24.06 ,OP,24.06,24.06,,,,,,
Aetna MCR ADV,CPT,87391,Hiv-2 ag ia,Lab Services,Per Unit,$21.90 ,OP,21.9,80.07,,,,,,
Aetna MCR ADV,CPT,87400,Influenza a/b each ag ia,Lab Services,Per Unit,$14.13 ,OP,14.13,61,,,,,,
Aetna MCR ADV,CPT,87420,Resp syncytial virus ag ia,Lab Services,Per Unit,$13.91 ,OP,13.91,53.38,,,,,,
Aetna MCR ADV,CPT,87425,Rotavirus ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Aetna MCR ADV,CPT,87426,Sarscov coronavirus ag ia,Lab Services,Per Unit,$35.33 ,OP,35.33,35.33,,,,,,
Aetna MCR ADV,CPT,87427,Shiga-like toxin ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Aetna MCR ADV,CPT,87428,Sarscov & inf vir a&b ag ia,Lab Services,Per Unit,$63.59 ,OP,63.59,63.59,,,,,,
Aetna MCR ADV,CPT,87430,Strep a ag ia,Lab Services,Per Unit,$16.81 ,OP,16.81,61,,,,,,
Aetna MCR ADV,CPT,87449,Nos each organism ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,61,,,,,,
Aetna MCR ADV,CPT,87451,Polyvalent mult org ea ag ia,Lab Services,Per Unit,$10.51 ,OP,10.51,41.94,,,,,,
Aetna MCR ADV,CPT,87471,Bartonella dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,
Aetna MCR ADV,CPT,87472,Bartonella dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Aetna MCR ADV,CPT,87475,Lyme dis dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
Aetna MCR ADV,CPT,87476,Lyme dis dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Aetna MCR ADV,CPT,87480,Candida dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,99.13,,,,,,
Aetna MCR ADV,CPT,87481,Candida dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Aetna MCR ADV,CPT,87482,Candida dna quant,Lab Services,Per Unit,$55.74 ,OP,55.74,186.82,,,,,,
Aetna MCR ADV,CPT,87483,Cns dna amp probe type 12-25,Lab Services,Per Unit,$416.78 ,OP,416.78,416.78,,,,,,
Aetna MCR ADV,CPT,87485,Chylmd pneum dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
Aetna MCR ADV,CPT,87486,Chylmd pneum dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Aetna MCR ADV,CPT,87487,Chylmd pneum dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Aetna MCR ADV,CPT,87490,Chylmd trach dna dir probe,Lab Services,Per Unit,$22.75 ,OP,22.75,99.13,,,,,,
Aetna MCR ADV,CPT,87491,Chylmd trach dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Aetna MCR ADV,CPT,87492,Chylmd trach dna quant,Lab Services,Per Unit,$53.47 ,OP,53.47,156.32,,,,,,
Aetna MCR ADV,CPT,87493,C diff amplified probe,Lab Services,Per Unit,$37.27 ,OP,37.27,37.27,,,,,,
Aetna MCR ADV,CPT,87495,Cytomeg dna dir probe,Lab Services,Per Unit,$30.03 ,OP,30.03,30.03,,,,,,
Aetna MCR ADV,CPT,87496,Cytomeg dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Aetna MCR ADV,CPT,87497,Cytomeg dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Aetna MCR ADV,CPT,87498,Enterovirus probe&revrs trns,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Aetna MCR ADV,CPT,87500,Vanomycin dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Aetna MCR ADV,CPT,87501,Influenza dna amp prob 1+,Lab Services,Per Unit,$51.31 ,OP,51.31,51.31,,,,,,
Aetna MCR ADV,CPT,87502,Influenza dna amp probe,Lab Services,Per Unit,$95.80 ,OP,95.8,95.8,,,,,,
Aetna MCR ADV,CPT,87503,Influenza dna amp prob addl,Lab Services,Per Unit,$29.22 ,OP,29.22,29.22,,,,,,
Aetna MCR ADV,CPT,87505,Nfct agent detection gi,Lab Services,Per Unit,$128.29 ,OP,128.29,128.29,,,,,,
Aetna MCR ADV,CPT,87506,Iadna-dna/rna probe tq 6-11,Lab Services,Per Unit,$262.99 ,OP,262.99,262.99,,,,,,
Aetna MCR ADV,CPT,87507,Iadna-dna/rna probe tq 12-25,Lab Services,Per Unit,$416.78 ,OP,416.78,416.78,,,,,,
Aetna MCR ADV,CPT,87510,Gardner vag dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,99.13,,,,,,
Aetna MCR ADV,CPT,87511,Gardner vag dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Aetna MCR ADV,CPT,87512,Gardner vag dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,186.82,,,,,,
Aetna MCR ADV,CPT,87516,Hepatitis b dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Aetna MCR ADV,CPT,87517,Hepatitis b dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Aetna MCR ADV,CPT,87520,Hepatitis c rna dir probe,Lab Services,Per Unit,$31.22 ,OP,31.22,87.69,,,,,,
Aetna MCR ADV,CPT,87521,Hepatitis c probe&rvrs trnsc,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Aetna MCR ADV,CPT,87522,Hepatitis c revrs trnscrpj,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Aetna MCR ADV,CPT,87525,Hepatitis g dna dir probe,Lab Services,Per Unit,$29.80 ,OP,29.8,87.69,,,,,,
Aetna MCR ADV,CPT,87526,Hepatitis g dna amp probe,Lab Services,Per Unit,$39.26 ,OP,39.26,156.32,,,,,,
Aetna MCR ADV,CPT,87527,Hepatitis g dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,186.82,,,,,,
Aetna MCR ADV,CPT,87528,Hsv dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
Aetna MCR ADV,CPT,87529,Hsv dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Aetna MCR ADV,CPT,87530,Hsv dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Aetna MCR ADV,CPT,87531,Hhv-6 dna dir probe,Lab Services,Per Unit,$58.00 ,OP,58,87.69,,,,,,
Aetna MCR ADV,CPT,87532,Hhv-6 dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,
Aetna MCR ADV,CPT,87533,Hhv-6 dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,186.82,,,,,,
Aetna MCR ADV,CPT,87534,Hiv-1 dna dir probe,Lab Services,Per Unit,$21.92 ,OP,21.92,87.69,,,,,,
Aetna MCR ADV,CPT,87535,Hiv-1 probe&reverse trnscrpj,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Aetna MCR ADV,CPT,87536,Hiv-1 quant&revrse trnscrpj,Lab Services,Per Unit,$85.10 ,OP,85.1,377.46,,,,,,
Aetna MCR ADV,CPT,87537,Hiv-2 dna dir probe,Lab Services,Per Unit,$21.92 ,OP,21.92,87.69,,,,,,
Aetna MCR ADV,CPT,87538,Hiv-2 probe&revrse trnscripj,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Aetna MCR ADV,CPT,87539,Hiv-2 quant&revrse trnscripj,Lab Services,Per Unit,$58.62 ,OP,58.62,190.64,,,,,,
Aetna MCR ADV,CPT,87540,Legion pneumo dna dir prob,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
Aetna MCR ADV,CPT,87541,Legion pneumo dna amp prob,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Aetna MCR ADV,CPT,87542,Legion pneumo dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,186.82,,,,,,
Aetna MCR ADV,CPT,87550,Mycobacteria dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
Aetna MCR ADV,CPT,87551,Mycobacteria dna amp probe,Lab Services,Per Unit,$48.24 ,OP,48.24,156.32,,,,,,
Aetna MCR ADV,CPT,87552,Mycobacteria dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Aetna MCR ADV,CPT,87555,M.tuberculo dna dir probe,Lab Services,Per Unit,$26.88 ,OP,26.88,87.69,,,,,,
Aetna MCR ADV,CPT,87556,M.tuberculo dna amp probe,Lab Services,Per Unit,$41.68 ,OP,41.68,156.32,,,,,,
Aetna MCR ADV,CPT,87557,M.tuberculo dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Aetna MCR ADV,CPT,87560,M.avium-intra dna dir prob,Lab Services,Per Unit,$27.29 ,OP,27.29,87.69,,,,,,
Aetna MCR ADV,CPT,87561,M.avium-intra dna amp prob,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Aetna MCR ADV,CPT,87562,M.avium-intra dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Aetna MCR ADV,CPT,87563,M. genitalium amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Aetna MCR ADV,CPT,87580,M.pneumon dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
Aetna MCR ADV,CPT,87581,M.pneumon dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Aetna MCR ADV,CPT,87582,M.pneumon dna quant,Lab Services,Per Unit,$302.62 ,OP,186.82,302.62,,,,,,
Aetna MCR ADV,CPT,87590,N.gonorrhoeae dna dir prob,Lab Services,Per Unit,$26.88 ,OP,26.88,99.13,,,,,,
Aetna MCR ADV,CPT,87591,N.gonorrhoeae dna amp prob,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Aetna MCR ADV,CPT,87592,N.gonorrhoeae dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,
Aetna MCR ADV,CPT,87623,Hpv low-risk types,Lab Services,Per Unit,$35.09 ,OP,35.09,93.87,,,,,,
Aetna MCR ADV,CPT,87624,Hpv high-risk types,Lab Services,Per Unit,$35.09 ,OP,35.09,93.87,,,,,,
Aetna MCR ADV,CPT,87625,Hpv types 16 & 18 only,Lab Services,Per Unit,$40.55 ,OP,40.55,93.87,,,,,,
Aetna MCR ADV,CPT,87631,Resp virus 3-5 targets,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
Aetna MCR ADV,CPT,87632,Resp virus 6-11 targets,Lab Services,Per Unit,$218.06 ,OP,218.06,218.06,,,,,,
Aetna MCR ADV,CPT,87633,Resp virus 12-25 targets,Lab Services,Per Unit,$416.78 ,OP,416.78,416.78,,,,,,
Aetna MCR ADV,CPT,87634,Rsv dna/rna amp probe,Lab Services,Per Unit,$70.20 ,OP,70.2,70.2,,,,,,
Aetna MCR ADV,CPT,87635,Sars-cov-2 covid-19 amp prb,Lab Services,Per Unit,$51.31 ,OP,51.31,51.31,,,,,,
Aetna MCR ADV,CPT,87636,Sarscov2 & inf a&b amp prb,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
Aetna MCR ADV,CPT,87637,Sarscov2&inf a&b&rsv amp prb,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
Aetna MCR ADV,CPT,87640,Staph a dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Aetna MCR ADV,CPT,87641,Mr-staph dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Aetna MCR ADV,CPT,87650,Strep a dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
Aetna MCR ADV,CPT,87651,Strep a dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Aetna MCR ADV,CPT,87652,Strep a dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,186.82,,,,,,
Aetna MCR ADV,CPT,87653,Strep b dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,
Aetna MCR ADV,CPT,87660,Trichomonas vagin dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
Aetna MCR ADV,CPT,87661,Trichomonas vaginalis amplif,Lab Services,Per Unit,$35.09 ,OP,35.09,87.69,,,,,,
Aetna MCR ADV,CPT,87662,Zika virus dna/rna amp probe,Lab Services,Per Unit,$51.31 ,OP,51.31,51.31,,,,,,
Aetna MCR ADV,CPT,87797,Detect agent nos dna dir,Lab Services,Per Unit,$30.03 ,OP,30.03,99.13,,,,,,
Aetna MCR ADV,CPT,87798,Detect agent nos dna amp,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Aetna MCR ADV,CPT,87799,Detect agent nos dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Aetna MCR ADV,CPT,87800,Detect agnt mult dna direc,Lab Services,Per Unit,$43.67 ,OP,43.67,179.2,,,,,,
Aetna MCR ADV,CPT,87801,Detect agnt mult dna ampli,Lab Services,Per Unit,$70.20 ,OP,70.2,312.64,,,,,,
Aetna MCR ADV,CPT,87802,Strep b assay w/optic,Lab Services,Per Unit,$12.73 ,OP,12.73,61,,,,,,
Aetna MCR ADV,CPT,87803,Clostridium toxin a w/optic,Lab Services,Per Unit,$16.00 ,OP,16,61,,,,,,
Aetna MCR ADV,CPT,87804,Influenza assay w/optic,Lab Services,Per Unit,$16.55 ,OP,16.55,61,,,,,,
Aetna MCR ADV,CPT,87806,Hiv w/hiv1&2 antb w/optic,Lab Services,Per Unit,$32.77 ,OP,32.77,61,,,,,,
Aetna MCR ADV,CPT,87807,Rsv assay w/optic,Lab Services,Per Unit,$13.10 ,OP,13.1,53.38,,,,,,
Aetna MCR ADV,CPT,87808,Trichomonas assay w/optic,Lab Services,Per Unit,$15.29 ,OP,15.29,61,,,,,,
Aetna MCR ADV,CPT,87809,Adenovirus assay w/optic,Lab Services,Per Unit,$21.76 ,OP,21.76,53.38,,,,,,
Aetna MCR ADV,CPT,87810,Chylmd trach assay w/optic,Lab Services,Per Unit,$35.29 ,OP,35.29,53.38,,,,,,
Aetna MCR ADV,CPT,87811,Sars-cov-2 covid19 w/optic,Lab Services,Per Unit,$41.38 ,OP,41.38,41.38,,,,,,
Aetna MCR ADV,CPT,87850,N. gonorrhoeae assay w/optic,Lab Services,Per Unit,$24.56 ,OP,24.56,53.38,,,,,,
Aetna MCR ADV,CPT,87880,Strep a assay w/optic,Lab Services,Per Unit,$16.53 ,OP,16.53,61,,,,,,
Aetna MCR ADV,CPT,87899,Agent nos assay w/optic,Lab Services,Per Unit,$16.07 ,OP,16.07,61,,,,,,
Aetna MCR ADV,CPT,87900,Phenotype infect agent drug,Lab Services,Per Unit,$130.35 ,OP,130.35,518.52,,,,,,
Aetna MCR ADV,CPT,87901,Genotype dna hiv reverse t,Lab Services,Per Unit,$257.45 ,OP,257.45,"1,147.62",,,,,,
Aetna MCR ADV,CPT,87902,Genotype dna/rna hep c,Lab Services,Per Unit,$257.45 ,OP,257.45,"1,147.62",,,,,,
Aetna MCR ADV,CPT,87903,Phenotype dna hiv w/culture,Lab Services,Per Unit,$488.66 ,OP,488.66,488.66,,,,,,
Aetna MCR ADV,CPT,87904,Phenotype dna hiv w/clt add,Lab Services,Per Unit,$26.07 ,OP,26.07,26.07,,,,,,
Aetna MCR ADV,CPT,87905,Sialidase enzyme assay,Lab Services,Per Unit,$12.22 ,OP,12.22,53.38,,,,,,
Aetna MCR ADV,CPT,87906,Genotype dna/rna hiv,Lab Services,Per Unit,$128.73 ,OP,128.73,128.73,,,,,,
Aetna MCR ADV,CPT,87910,Genotype cytomegalovirus,Lab Services,Per Unit,$257.45 ,OP,257.45,257.45,,,,,,
Aetna MCR ADV,CPT,87912,Genotype dna hepatitis b,Lab Services,Per Unit,$257.45 ,OP,257.45,257.45,,,,,,
Aetna MCR ADV,CPT,88104,Cytopath fl nongyn smears,APC 5732,RVU Per Case,$34.63 ,OP,34.63,175.39,,,,,,
Aetna MCR ADV,CPT,88106,Cytopath fl nongyn filter,APC 5731,RVU Per Case,$25.25 ,OP,25.25,247.83,,,,,,
Aetna MCR ADV,CPT,88108,Cytopath concentrate tech,APC 5732,RVU Per Case,$34.63 ,OP,34.63,228.77,,,,,,
Aetna MCR ADV,CPT,88112,Cytopath cell enhance tech,APC 5671,RVU Per Case,$50.92 ,OP,50.92,232.58,,,,,,
Aetna MCR ADV,CPT,88120,Cytp urne 3-5 probes ea spec,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Aetna MCR ADV,CPT,88121,Cytp urine 3-5 probes cmptr,APC 5673,RVU Per Case,$298.05 ,OP,298.05,298.05,,,,,,
Aetna MCR ADV,CPT,88125,Forensic cytopathology,APC 5671,RVU Per Case,$50.92 ,OP,45.74,50.92,,,,,,
Aetna MCR ADV,CPT,88130,Sex chromatin identification,Lab Services,Per Unit,$17.98 ,OP,17.98,68.63,,,,,,
Aetna MCR ADV,CPT,88140,Sex chromatin identification,Lab Services,Per Unit,$7.99 ,OP,7.99,34.31,,,,,,
Aetna MCR ADV,CPT,88142,Cytopath c/v thin layer,Lab Services,Per Unit,$20.26 ,OP,20.26,91.51,,,,,,
Aetna MCR ADV,CPT,88143,Cytopath c/v thin layer redo,Lab Services,Per Unit,$23.04 ,OP,23.04,91.51,,,,,,
Aetna MCR ADV,CPT,88147,Cytopath c/v automated,Lab Services,Per Unit,$50.56 ,OP,45.74,50.56,,,,,,
Aetna MCR ADV,CPT,88148,Cytopath c/v auto rescreen,Lab Services,Per Unit,$16.00 ,OP,16,45.74,,,,,,
Aetna MCR ADV,CPT,88150,Cytopath c/v manual,Lab Services,Per Unit,$15.15 ,OP,15.15,45.74,,,,,,
Aetna MCR ADV,CPT,88152,Cytopath c/v auto redo,Lab Services,Per Unit,$27.64 ,OP,27.64,45.74,,,,,,
Aetna MCR ADV,CPT,88153,Cytopath c/v redo,Lab Services,Per Unit,$24.03 ,OP,24.03,45.74,,,,,,
Aetna MCR ADV,CPT,88155,Cytopath c/v index add-on,Lab Services,Per Unit,$14.65 ,OP,14.65,26.7,,,,,,
Aetna MCR ADV,CPT,88160,Cytopath smear other source,APC 5731,RVU Per Case,$25.25 ,OP,25.25,141.07,,,,,,
Aetna MCR ADV,CPT,88161,Cytopath smear other source,APC 5731,RVU Per Case,$25.25 ,OP,25.25,152.51,,,,,,
Aetna MCR ADV,CPT,88162,Cytopath smear other source,APC 5671,RVU Per Case,$50.92 ,OP,50.92,205.88,,,,,,
Aetna MCR ADV,CPT,88164,Cytopath tbs c/v manual,Lab Services,Per Unit,$15.15 ,OP,15.15,45.74,,,,,,
Aetna MCR ADV,CPT,88165,Cytopath tbs c/v redo,Lab Services,Per Unit,$42.22 ,OP,42.22,45.74,,,,,,
Aetna MCR ADV,CPT,88166,Cytopath tbs c/v auto redo,Lab Services,Per Unit,$15.15 ,OP,15.15,45.74,,,,,,
Aetna MCR ADV,CPT,88167,Cytopath tbs c/v select,Lab Services,Per Unit,$15.15 ,OP,15.15,45.74,,,,,,
Aetna MCR ADV,CPT,88172,Cytp dx eval fna 1st ea site,APC 5672,RVU Per Case,$152.64 ,OP,118.19,152.64,,,,,,
Aetna MCR ADV,CPT,88173,Cytopath eval fna report,APC 5671,RVU Per Case,$50.92 ,OP,50.92,327.9,,,,,,
Aetna MCR ADV,CPT,88174,Cytopath c/v auto in fluid,Lab Services,Per Unit,$25.37 ,OP,25.37,95.32,,,,,,
Aetna MCR ADV,CPT,88175,Cytopath c/v auto fluid redo,Lab Services,Per Unit,$26.61 ,OP,26.61,118.19,,,,,,
Aetna MCR ADV,CPT,88182,Cell marker study,APC 5671,RVU Per Case,$50.92 ,OP,50.92,339.33,,,,,,
Aetna MCR ADV,CPT,88184,Flowcytometry/ tc 1 marker,APC 5673,RVU Per Case,$298.05 ,OP,298.05,404.14,,,,,,
Aetna MCR ADV,CPT,88199,Cytopathology procedure,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Aetna MCR ADV,CPT,88230,Tissue culture lymphocyte,Lab Services,Per Unit,$116.49 ,OP,116.49,518.52,,,,,,
Aetna MCR ADV,CPT,88233,Tissue culture skin/biopsy,Lab Services,Per Unit,$140.73 ,OP,140.73,625.29,,,,,,
Aetna MCR ADV,CPT,88235,Tissue culture placenta,Lab Services,Per Unit,$150.30 ,OP,150.3,655.78,,,,,,
Aetna MCR ADV,CPT,88237,Tissue culture bone marrow,Lab Services,Per Unit,$143.75 ,OP,143.75,564.29,,,,,,
Aetna MCR ADV,CPT,88239,Tissue culture tumor,Lab Services,Per Unit,$147.52 ,OP,147.52,655.78,,,,,,
Aetna MCR ADV,CPT,88240,Cell cryopreserve/storage,Lab Services,Per Unit,$13.07 ,OP,13.07,45.74,,,,,,
Aetna MCR ADV,CPT,88241,Frozen cell preparation,Lab Services,Per Unit,$12.09 ,OP,12.09,45.74,,,,,,
Aetna MCR ADV,CPT,88245,Chromosome analysis 20-25,Lab Services,Per Unit,$173.17 ,OP,173.17,648.16,,,,,,
Aetna MCR ADV,CPT,88248,Chromosome analysis 50-100,Lab Services,Per Unit,$173.17 ,OP,173.17,770.16,,,,,,
Aetna MCR ADV,CPT,88249,Chromosome analysis 100,Lab Services,Per Unit,$173.17 ,OP,173.17,770.16,,,,,,
Aetna MCR ADV,CPT,88261,Chromosome analysis 5,Lab Services,Per Unit,$264.34 ,OP,264.34,785.42,,,,,,
Aetna MCR ADV,CPT,88262,Chromosome analysis 15-20,Lab Services,Per Unit,$125.49 ,OP,125.49,556.65,,,,,,
Aetna MCR ADV,CPT,88263,Chromosome analysis 45,Lab Services,Per Unit,$150.29 ,OP,150.29,671.03,,,,,,
Aetna MCR ADV,CPT,88264,Chromosome analysis 20-25,Lab Services,Per Unit,$144.61 ,OP,144.61,556.65,,,,,,
Aetna MCR ADV,CPT,88267,Chromosome analys placenta,Lab Services,Per Unit,$188.57 ,OP,188.57,800.67,,,,,,
Aetna MCR ADV,CPT,88269,Chromosome analys amniotic,Lab Services,Per Unit,$173.66 ,OP,173.66,739.67,,,,,,
Aetna MCR ADV,CPT,88271,Cytogenetics dna probe,Lab Services,Per Unit,$21.42 ,OP,21.42,64.82,,,,,,
Aetna MCR ADV,CPT,88272,Cytogenetics 3-5,Lab Services,Per Unit,$40.70 ,OP,40.7,114.39,,,,,,
Aetna MCR ADV,CPT,88273,Cytogenetics 10-30,Lab Services,Per Unit,$34.81 ,OP,34.81,144.88,,,,,,
Aetna MCR ADV,CPT,88274,Cytogenetics 25-99,Lab Services,Per Unit,$42.38 ,OP,42.38,156.32,,,,,,
Aetna MCR ADV,CPT,88275,Cytogenetics 100-300,Lab Services,Per Unit,$51.19 ,OP,51.19,179.2,,,,,,
Aetna MCR ADV,CPT,88280,Chromosome karyotype study,Lab Services,Per Unit,$33.47 ,OP,33.47,110.57,,,,,,
Aetna MCR ADV,CPT,88283,Chromosome banding study,Lab Services,Per Unit,$68.60 ,OP,68.6,68.6,,,,,,
Aetna MCR ADV,CPT,88285,Chromosome count additional,Lab Services,Per Unit,$26.91 ,OP,26.91,83.87,,,,,,
Aetna MCR ADV,CPT,88289,Chromosome study additional,Lab Services,Per Unit,$34.43 ,OP,34.43,129.64,,,,,,
Aetna MCR ADV,CPT,88299,Cytogenetic study,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Aetna MCR ADV,CPT,88300,Surgical path gross,APC 5731,RVU Per Case,$25.25 ,OP,25.25,99.13,,,,,,
Aetna MCR ADV,CPT,88302,Tissue exam by pathologist,APC 5731,RVU Per Case,$25.25 ,OP,25.25,217.32,,,,,,
Aetna MCR ADV,CPT,88304,Tissue exam by pathologist,APC 5671,RVU Per Case,$50.92 ,OP,50.92,263.08,,,,,,
Aetna MCR ADV,CPT,88305,Tissue exam by pathologist,APC 5671,RVU Per Case,$50.92 ,OP,50.92,362.21,,,,,,
Aetna MCR ADV,CPT,88307,Tissue exam by pathologist,APC 5673,RVU Per Case,$298.05 ,OP,298.05,671.03,,,,,,
Aetna MCR ADV,CPT,88309,Tissue exam by pathologist,APC 5674,RVU Per Case,$671.45 ,OP,671.45,911.23,,,,,,
Aetna MCR ADV,CPT,88312,Special stains group 1,APC 5671,RVU Per Case,$50.92 ,OP,50.92,366.02,,,,,,
Aetna MCR ADV,CPT,88313,Special stains group 2,APC 5732,RVU Per Case,$34.63 ,OP,34.63,308.83,,,,,,
Aetna MCR ADV,CPT,88319,Enzyme histochemistry,APC 5674,RVU Per Case,$671.45 ,OP,568.09,671.45,,,,,,
Aetna MCR ADV,CPT,88321,Microslide consultation,APC 5732,RVU Per Case,$34.63 ,OP,34.63,438.47,,,,,,
Aetna MCR ADV,CPT,88323,Microslide consultation,APC 5671,RVU Per Case,$50.92 ,OP,50.92,289.76,,,,,,
Aetna MCR ADV,CPT,88325,Comprehensive review of data,APC 5672,RVU Per Case,$152.64 ,OP,152.64,949.36,,,,,,
Aetna MCR ADV,CPT,88329,Path consult introp,APC 5732,RVU Per Case,$34.63 ,OP,34.63,247.83,,,,,,
Aetna MCR ADV,CPT,88331,Path consult intraop 1 bloc,APC 5672,RVU Per Case,$152.64 ,OP,152.51,152.64,,,,,,
Aetna MCR ADV,CPT,88333,Intraop cyto path consult 1,APC 5674,RVU Per Case,$671.45 ,OP,163.95,671.45,,,,,,
Aetna MCR ADV,CPT,88342,Immunohisto antb 1st stain,APC 5672,RVU Per Case,$152.64 ,OP,152.64,297.39,,,,,,
Aetna MCR ADV,CPT,88344,Immunohisto antibody slide,APC 5673,RVU Per Case,$298.05 ,OP,297.39,298.05,,,,,,
Aetna MCR ADV,CPT,88346,Immunofluor antb 1st stain,APC 5673,RVU Per Case,$298.05 ,OP,293.57,298.05,,,,,,
Aetna MCR ADV,CPT,88348,Electron microscopy,APC 5674,RVU Per Case,$671.45 ,OP,671.45,"2,794.70",,,,,,
Aetna MCR ADV,CPT,88355,Analysis skeletal muscle,APC 5672,RVU Per Case,$152.64 ,OP,152.64,777.79,,,,,,
Aetna MCR ADV,CPT,88356,Analysis nerve,APC 5671,RVU Per Case,$50.92 ,OP,50.92,766.35,,,,,,
Aetna MCR ADV,CPT,88358,Analysis tumor,APC 5672,RVU Per Case,$152.64 ,OP,152.64,171.58,,,,,,
Aetna MCR ADV,CPT,88360,Tumor immunohistochem/manual,APC 5672,RVU Per Case,$152.64 ,OP,152.64,335.53,,,,,,
Aetna MCR ADV,CPT,88361,Tumor immunohistochem/comput,APC 5673,RVU Per Case,$298.05 ,OP,298.05,484.22,,,,,,
Aetna MCR ADV,CPT,88362,Nerve teasing preparations,APC 5674,RVU Per Case,$671.45 ,OP,671.45,793.05,,,,,,
Aetna MCR ADV,CPT,88363,Xm archive tissue molec anal,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Aetna MCR ADV,CPT,88365,Insitu hybridization (fish),APC 5672,RVU Per Case,$152.64 ,OP,152.64,499.47,,,,,,
Aetna MCR ADV,CPT,88366,Insitu hybridization (fish),APC 5673,RVU Per Case,$298.05 ,OP,298.05,499.47,,,,,,
Aetna MCR ADV,CPT,88367,Insitu hybridization auto,APC 5673,RVU Per Case,$298.05 ,OP,298.05,907.42,,,,,,
Aetna MCR ADV,CPT,88368,Insitu hybridization manual,APC 5673,RVU Per Case,$298.05 ,OP,298.05,747.28,,,,,,
Aetna MCR ADV,CPT,88374,M/phmtrc alys ishquant/semiq,APC 5672,RVU Per Case,$152.64 ,OP,152.64,907.42,,,,,,
Aetna MCR ADV,CPT,88377,M/phmtrc alys ishquant/semiq,APC 5672,RVU Per Case,$152.64 ,OP,152.64,747.28,,,,,,
Aetna MCR ADV,CPT,88399,Surgical pathology procedure,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Aetna MCR ADV,CPT,88720,Bilirubin total transcut,Lab Services,Per Unit,$5.02 ,OP,5.02,22.88,,,,,,
Aetna MCR ADV,CPT,88738,Hgb quant transcutaneous,Lab Services,Per Unit,$5.02 ,OP,5.02,5.02,,,,,,
Aetna MCR ADV,CPT,88740,Transcutaneous carboxyhb,Lab Services,Per Unit,$9.37 ,OP,9.37,22.88,,,,,,
Aetna MCR ADV,CPT,88741,Transcutaneous methb,Lab Services,Per Unit,$9.37 ,OP,9.37,22.88,,,,,,
Aetna MCR ADV,CPT,89049,Chct for mal hyperthermia,APC 5672,RVU Per Case,$152.64 ,OP,152.64,"1,201.00",,,,,,
Aetna MCR ADV,CPT,89050,Body fluid cell count,Lab Services,Per Unit,$4.72 ,OP,4.72,22.88,,,,,,
Aetna MCR ADV,CPT,89051,Body fluid cell count,Lab Services,Per Unit,$5.60 ,OP,5.6,26.7,,,,,,
Aetna MCR ADV,CPT,89055,Leukocyte assessment fecal,Lab Services,Per Unit,$4.27 ,OP,4.27,22.88,,,,,,
Aetna MCR ADV,CPT,89060,Exam synovial fluid crystals,Lab Services,Per Unit,$7.33 ,OP,7.33,30.51,,,,,,
Aetna MCR ADV,CPT,89125,Specimen fat stain,Lab Services,Per Unit,$5.88 ,OP,5.88,11.44,,,,,,
Aetna MCR ADV,CPT,89160,Exam feces for meat fibers,Lab Services,Per Unit,$4.85 ,OP,4.85,15.26,,,,,,
Aetna MCR ADV,CPT,89190,Nasal smear for eosinophils,Lab Services,Per Unit,$5.79 ,OP,5.79,22.88,,,,,,
Aetna MCR ADV,CPT,89220,Sputum specimen collection,APC 5672,RVU Per Case,$152.64 ,OP,80.07,152.64,,,,,,
Aetna MCR ADV,CPT,89230,Collect sweat for test,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Aetna MCR ADV,CPT,89240,Pathology lab procedure,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Aetna MCR ADV,CPT,89250,Cultr oocyte/embryo <4 days,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Aetna MCR ADV,CPT,89251,Cultr oocyte/embryo <4 days,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Aetna MCR ADV,CPT,89253,Embryo hatching,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Aetna MCR ADV,CPT,89254,Oocyte identification,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Aetna MCR ADV,CPT,89255,Prepare embryo for transfer,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Aetna MCR ADV,CPT,89257,Sperm identification,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Aetna MCR ADV,CPT,89258,Cryopreservation embryo(s),APC 5674,RVU Per Case,$671.45 ,OP,671.45,671.45,,,,,,
Aetna MCR ADV,CPT,89259,Cryopreservation sperm,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Aetna MCR ADV,CPT,89260,Sperm isolation simple,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Aetna MCR ADV,CPT,89261,Sperm isolation complex,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Aetna MCR ADV,CPT,89264,Identify sperm tissue,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Aetna MCR ADV,CPT,89268,Insemination of oocytes,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Aetna MCR ADV,CPT,89272,Extended culture of oocytes,APC 5674,RVU Per Case,$671.45 ,OP,671.45,671.45,,,,,,
Aetna MCR ADV,CPT,89280,Assist oocyte fertilization,APC 5674,RVU Per Case,$671.45 ,OP,671.45,671.45,,,,,,
Aetna MCR ADV,CPT,89281,Assist oocyte fertilization,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Aetna MCR ADV,CPT,89290,Biopsy oocyte polar body,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Aetna MCR ADV,CPT,89291,Biopsy oocyte polar body,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Aetna MCR ADV,CPT,89300,Semen analysis w/huhner,Lab Services,Per Unit,$9.84 ,OP,9.84,45.74,,,,,,
Aetna MCR ADV,CPT,89310,Semen analysis w/count,Lab Services,Per Unit,$8.61 ,OP,8.61,30.51,,,,,,
Aetna MCR ADV,CPT,89320,Semen anal vol/count/mot,Lab Services,Per Unit,$12.31 ,OP,12.31,49.56,,,,,,
Aetna MCR ADV,CPT,89321,Semen anal sperm detection,Lab Services,Per Unit,$12.05 ,OP,12.05,49.56,,,,,,
Aetna MCR ADV,CPT,89322,Semen anal strict criteria,Lab Services,Per Unit,$15.50 ,OP,15.5,61,,,,,,
Aetna MCR ADV,CPT,89325,Sperm antibody test,Lab Services,Per Unit,$10.67 ,OP,10.67,10.67,,,,,,
Aetna MCR ADV,CPT,89329,Sperm evaluation test,Lab Services,Per Unit,$19.59 ,OP,19.59,91.51,,,,,,
Aetna MCR ADV,CPT,89330,Evaluation cervical mucus,Lab Services,Per Unit,$10.38 ,OP,10.38,45.74,,,,,,
Aetna MCR ADV,CPT,89331,Retrograde ejaculation anal,Lab Services,Per Unit,$19.59 ,OP,19.59,83.87,,,,,,
Aetna MCR ADV,CPT,89335,Cryopreserve testicular tiss,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Aetna MCR ADV,CPT,89337,Cryopreservation oocyte(s),APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Aetna MCR ADV,CPT,89342,Storage/year embryo(s),APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Aetna MCR ADV,CPT,89343,Storage/year sperm/semen,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Aetna MCR ADV,CPT,89344,Storage/year reprod tissue,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Aetna MCR ADV,CPT,89346,Storage/year oocyte(s),APC 5673,RVU Per Case,$298.05 ,OP,298.05,298.05,,,,,,
Aetna MCR ADV,CPT,89352,Thawing cryopresrved embryo,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Aetna MCR ADV,CPT,89353,Thawing cryopresrved sperm,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Aetna MCR ADV,CPT,89354,Thaw cryoprsvrd reprod tiss,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Aetna MCR ADV,CPT,89356,Thawing cryopresrved oocyte,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Aetna MCR ADV,CPT,89398,Unlisted reprod med lab proc,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Aetna MCR ADV,CPT,90371,Hep b ig im,APC 1630,Per Unit,$130.31 ,OP,130.31,735.85,,,,,,
Aetna MCR ADV,CPT,90375,Rabies ig im/sc,APC 9133,Per Unit,$267.30 ,OP,267.3,617.65,,,,,,
Aetna MCR ADV,CPT,90376,Rabies ig heat treated,APC 9134,Per Unit,$287.38 ,OP,287.38,617.65,,,,,,
Aetna MCR ADV,CPT,90378,Rsv mab im 50mg,APC 9003,Per Unit,"$1,185.67 ",OP,"1,185.67","3,154.20",,,,,,
Aetna MCR ADV,CPT,90385,Rh ig minidose im,APC 9063,Per Unit,$151.41 ,OP,151.41,202.07,,,,,,
Aetna MCR ADV,CPT,90396,Varicella-zoster ig im,APC 9135,Per Unit,"$1,965.97 ",OP,495.65,"1,965.97",,,,,,
Aetna MCR ADV,CPT,90471,Immunization admin,APC 5692,RVU Per Case,$63.42 ,OP,57.19,63.42,,,,,,
Aetna MCR ADV,CPT,90473,Immune admin oral/nasal,APC 5692,RVU Per Case,$63.42 ,OP,57.19,63.42,,,,,,
Aetna MCR ADV,CPT,90630,Flu vacc iiv4 no preserv id,Other,Straight Discount,29.70%,OP,,,,,,,,
Aetna MCR ADV,CPT,90653,Iiv adjuvant vaccine im,Other,Straight Discount,29.70%,OP,,,,,,,,
Aetna MCR ADV,CPT,90654,Flu vacc iiv3 no preserv id,Other,Straight Discount,29.70%,OP,,,,,,,,
Aetna MCR ADV,CPT,90655,Iiv3 vacc no prsv 0.25 ml im,Other,Straight Discount,29.70%,OP,68.63,68.63,,,,,,
Aetna MCR ADV,CPT,90656,Iiv3 vacc no prsv 0.5 ml im,Other,Straight Discount,29.70%,OP,76.26,76.26,,,,,,
Aetna MCR ADV,CPT,90657,Iiv3 vaccine splt 0.25 ml im,Other,Straight Discount,29.70%,OP,110.57,110.57,,,,,,
Aetna MCR ADV,CPT,90660,Laiv3 vaccine intranasal,Other,Straight Discount,29.70%,OP,122,122,,,,,,
Aetna MCR ADV,CPT,90661,Cciiv3 vac no prsv 0.5 ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Aetna MCR ADV,CPT,90662,Iiv no prsv increased ag im,Other,Straight Discount,29.70%,OP,,,,,,,,
Aetna MCR ADV,CPT,90670,Pcv13 vaccine im,Other,Straight Discount,29.70%,OP,,,,,,,,
Aetna MCR ADV,CPT,90672,Laiv4 vaccine intranasal,Other,Straight Discount,29.70%,OP,,,,,,,,
Aetna MCR ADV,CPT,90673,Riv3 vaccine no preserv im,Other,Straight Discount,29.70%,OP,,,,,,,,
Aetna MCR ADV,CPT,90674,Cciiv4 vac no prsv 0.5 ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Aetna MCR ADV,CPT,90675,Rabies vaccine im,APC 9139,Per Unit,$327.53 ,OP,327.53,945.56,,,,,,
Aetna MCR ADV,CPT,90676,Rabies vaccine id,APC 9140,Per Unit,$189.63 ,OP,189.63,945.56,,,,,,
Aetna MCR ADV,CPT,90677,Pcv20 vaccine im,Other,Straight Discount,29.70%,OP,,,,,,,,
Aetna MCR ADV,CPT,90682,Riv4 vacc recombinant dna im,Other,Straight Discount,29.70%,OP,,,,,,,,
Aetna MCR ADV,CPT,90685,Iiv4 vacc no prsv 0.25 ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Aetna MCR ADV,CPT,90686,Iiv4 vacc no prsv 0.5 ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Aetna MCR ADV,CPT,90687,Iiv4 vaccine splt 0.25 ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Aetna MCR ADV,CPT,90688,Iiv4 vaccine splt 0.5 ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Aetna MCR ADV,CPT,90689,Vacc iiv4 no prsrv 0.25ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Aetna MCR ADV,CPT,90694,Vacc aiiv4 no prsrv 0.5ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Aetna MCR ADV,CPT,90732,Ppsv23 vacc 2 yrs+ subq/im,Other,Straight Discount,29.70%,OP,228.77,228.77,,,,,,
Aetna MCR ADV,CPT,90739,Hepb vacc 2 dose adult im,Other,Straight Discount,29.70%,OP,,,,,,,,
Aetna MCR ADV,CPT,90740,Hepb vacc 3 dose immunsup im,Other,Straight Discount,29.70%,OP,"1,029.43","1,029.43",,,,,,
Aetna MCR ADV,CPT,90743,Hepb vacc 2 dose adolesc im,Other,Straight Discount,29.70%,OP,141.07,141.07,,,,,,
Aetna MCR ADV,CPT,90744,Hepb vacc 3 dose ped/adol im,Other,Straight Discount,29.70%,OP,141.07,141.07,,,,,,
Aetna MCR ADV,CPT,90746,Hepb vaccine 3 dose adult im,Other,Straight Discount,29.70%,OP,369.83,369.83,,,,,,
Aetna MCR ADV,CPT,90747,Hepb vacc 4 dose immunsup im,Other,Straight Discount,29.70%,OP,"1,029.43","1,029.43",,,,,,
Aetna MCR ADV,CPT,90756,Cciiv4 vacc abx free im,Other,Straight Discount,29.70%,OP,,,,,,,,
Aetna MCR ADV,CPT,90791,Psych diagnostic evaluation,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,789.23,,,,,,
Aetna MCR ADV,CPT,90792,Psych diag eval w/med srvcs,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,789.23,,,,,,
Aetna MCR ADV,CPT,90832,Psytx w pt 30 minutes,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,331.7,,,,,,
Aetna MCR ADV,CPT,90834,Psytx w pt 45 minutes,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,480.4,,,,,,
Aetna MCR ADV,CPT,90837,Psytx w pt 60 minutes,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,705.35,,,,,,
Aetna MCR ADV,CPT,90839,Psytx crisis initial 60 min,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,136.74,,,,,,
Aetna MCR ADV,CPT,90845,Psychoanalysis,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,423.22,,,,,,
Aetna MCR ADV,CPT,90846,Family psytx w/o pt 50 min,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,449.9,,,,,,
Aetna MCR ADV,CPT,90847,Family psytx w/pt 50 min,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,583.35,,,,,,
Aetna MCR ADV,CPT,90849,Multiple family group psytx,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,171.58,,,,,,
Aetna MCR ADV,CPT,90853,Group psychotherapy,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,368.97,,,,,,
Aetna MCR ADV,CPT,90865,Narcosynthesis,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,808.29,,,,,,
Aetna MCR ADV,CPT,90867,Tcranial magn stim tx plan,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Aetna MCR ADV,CPT,90868,Tcranial magn stim tx deli,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Aetna MCR ADV,CPT,90869,Tcran magn stim redetemine,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Aetna MCR ADV,CPT,90870,Electroconvulsive therapy,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,709.16,,,,,,
Aetna MCR ADV,CPT,90880,Hypnotherapy,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,545.21,,,,,,
Aetna MCR ADV,CPT,90899,Psychiatric service/therapy,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Aetna MCR ADV,CPT,90901,Biofeedback train any meth,Physician,Per Unit,$19.59 ,OP,19.59,19.59,,,,,,
Aetna MCR ADV,CPT,90912,Bfb training 1st 15 min,Physician,Per Unit,$43.33 ,OP,43.33,476.6,,,,,,
Aetna MCR ADV,CPT,90913,Bfb training ea addl 15 min,Physician,Per Unit,$24.51 ,OP,24.51,264.78,,,,,,
Aetna MCR ADV,CPT,90935,Hemodialysis one evaluation,APC 5401,RVU Per Unit,$669.60 ,OP,373.65,669.6,,,,,,
Aetna MCR ADV,CPT,90945,Dialysis one evaluation,APC 5024,RVU Per Unit,$372.22 ,OP,372.22,388.89,,,,,,
Aetna MCR ADV,CPT,91010,Esophagus motility study,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Aetna MCR ADV,CPT,91020,Gastric motility studies,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,"1,265.81",,,,,,
Aetna MCR ADV,CPT,91022,Duodenal motility study,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,"1,044.69",,,,,,
Aetna MCR ADV,CPT,91030,Acid perfusion of esophagus,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,754.91,,,,,,
Aetna MCR ADV,CPT,91034,Gastroesophageal reflux test,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Aetna MCR ADV,CPT,91035,G-esoph reflx tst w/electrod,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Aetna MCR ADV,CPT,91037,Esoph imped function test,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Aetna MCR ADV,CPT,91038,Esoph imped funct test > 1hr,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Aetna MCR ADV,CPT,91040,Esoph balloon distension tst,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Aetna MCR ADV,CPT,91065,Breath hydrogen/methane test,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Aetna MCR ADV,CPT,91110,Gi tract capsule endoscopy,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,828.48,,,,,,
Aetna MCR ADV,CPT,91111,Esophageal capsule endoscopy,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,828.48,,,,,,
Aetna MCR ADV,CPT,91112,Gi wireless capsule measure,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,828.48,,,,,,
Aetna MCR ADV,CPT,91117,Colon motility 6 hr study,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,272.35,,,,,,
Aetna MCR ADV,CPT,91120,Rectal sensation test,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Aetna MCR ADV,CPT,91122,Anal pressure record,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,272.35,,,,,,
Aetna MCR ADV,CPT,91132,Electrogastrography,APC 5722,RVU Per Unit,$270.61 ,OP,244.01,270.61,,,,,,
Aetna MCR ADV,CPT,91133,Electrogastrography w/test,APC 5734,RVU Per Case,$114.56 ,OP,114.56,312.64,,,,,,
Aetna MCR ADV,CPT,91200,Liver elastography,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
Aetna MCR ADV,CPT,91299,Gastroenterology procedure,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Aetna MCR ADV,CPT,91300,Sarscov2 vac 30mcg/0.3ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Aetna MCR ADV,CPT,91301,Sarscov2 vac 100mcg/0.5ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Aetna MCR ADV,CPT,91303,Sarscov2 vac ad26 .5ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Aetna MCR ADV,CPT,92002,Eye exam new patient,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,354.58,,,,,,
Aetna MCR ADV,CPT,92004,Eye exam new patient,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,663.41,,,,,,
Aetna MCR ADV,CPT,92012,Eye exam establish patient,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,373.65,,,,,,
Aetna MCR ADV,CPT,92014,Eye exam&tx estab pt 1/>vst,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,545.21,,,,,,
Aetna MCR ADV,CPT,92018,New eye exam & treatment,APC 5503,RVU Per Case,"$2,049.05 ",OP,671.03,"2,049.05",,,,,,
Aetna MCR ADV,CPT,92019,Eye exam & treatment,APC 5503,RVU Per Case,"$2,049.05 ",OP,331.7,"2,049.05",,,,,,
Aetna MCR ADV,CPT,92020,Special eye evaluation,APC 5734,RVU Per Case,$114.56 ,OP,114.56,125.82,,,,,,
Aetna MCR ADV,CPT,92025,Corneal topography,APC 5733,RVU Per Case,$56.95 ,OP,56.95,167.76,,,,,,
Aetna MCR ADV,CPT,92060,Special eye evaluation,APC 5733,RVU Per Case,$56.95 ,OP,56.95,285.96,,,,,,
Aetna MCR ADV,CPT,92065,Orthoptic/pleoptic training,APC 5733,RVU Per Case,$56.95 ,OP,56.95,224.95,,,,,,
Aetna MCR ADV,CPT,92081,Visual field examination(s),APC 5733,RVU Per Case,$56.95 ,OP,56.95,255.45,,,,,,
Aetna MCR ADV,CPT,92082,Visual field examination(s),APC 5733,RVU Per Case,$56.95 ,OP,56.95,339.33,,,,,,
Aetna MCR ADV,CPT,92083,Visual field examination(s),APC 5734,RVU Per Case,$114.56 ,OP,114.56,385.09,,,,,,
Aetna MCR ADV,CPT,92132,Cmptr ophth dx img ant segmt,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Aetna MCR ADV,CPT,92133,Cmptr ophth img optic nerve,APC 5733,RVU Per Case,$56.95 ,OP,56.95,224.95,,,,,,
Aetna MCR ADV,CPT,92134,Cptr ophth dx img post segmt,APC 5733,RVU Per Case,$56.95 ,OP,56.95,224.95,,,,,,
Aetna MCR ADV,CPT,92136,Ophthalmic biometry,APC 5734,RVU Per Case,$114.56 ,OP,114.56,411.78,,,,,,
Aetna MCR ADV,CPT,92145,Corneal hysteresis deter,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Aetna MCR ADV,CPT,92201,Opscpy extnd rta draw uni/bi,APC 5733,RVU Per Case,$56.95 ,OP,56.95,118.19,,,,,,
Aetna MCR ADV,CPT,92202,Opscpy extnd on/mac draw,APC 5733,RVU Per Case,$56.95 ,OP,56.95,76.37,,,,,,
Aetna MCR ADV,CPT,92227,Img rta detcj/mntr ds staff,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Aetna MCR ADV,CPT,92228,Img rta detc/mntr ds phy/qhp,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Aetna MCR ADV,CPT,92229,Img rta detc/mntr ds poc aly,APC 5733,RVU Per Unit,$56.95 ,OP,56.95,56.95,,,,,,
Aetna MCR ADV,CPT,92230,Eye exam with photos,APC 5723,RVU Per Case,$499.16 ,OP,289.76,499.16,,,,,,
Aetna MCR ADV,CPT,92235,Fluorescein angrph uni/bi,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,629.1,,,,,,
Aetna MCR ADV,CPT,92240,Icg angiography uni/bi,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,162.87",,,,,,
Aetna MCR ADV,CPT,92242,Fluorescein icg angiography,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,791.98",,,,,,
Aetna MCR ADV,CPT,92250,Eye exam with photos,APC 5734,RVU Per Case,$114.56 ,OP,114.56,346.96,,,,,,
Aetna MCR ADV,CPT,92260,Ophthalmoscopy/dynamometry,APC 5732,RVU Per Case,$34.63 ,OP,34.63,87.69,,,,,,
Aetna MCR ADV,CPT,92265,Eye muscle evaluation,APC 5733,RVU Per Case,$56.95 ,OP,56.95,381.27,,,,,,
Aetna MCR ADV,CPT,92270,Electro-oculography,APC 5734,RVU Per Case,$114.56 ,OP,114.56,438.47,,,,,,
Aetna MCR ADV,CPT,92273,Full field erg w/i&r,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,648.16,,,,,,
Aetna MCR ADV,CPT,92274,Multifocal erg w/i&r,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,386.03,,,,,,
Aetna MCR ADV,CPT,92283,Color vision examination,APC 5733,RVU Per Case,$56.95 ,OP,56.95,224.95,,,,,,
Aetna MCR ADV,CPT,92284,Dark adaptation eye exam,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
Aetna MCR ADV,CPT,92285,Eye photography,APC 5733,RVU Per Case,$56.95 ,OP,56.95,205.88,,,,,,
Aetna MCR ADV,CPT,92286,Internal eye photography,APC 5734,RVU Per Case,$114.56 ,OP,114.56,583.35,,,,,,
Aetna MCR ADV,CPT,92287,Internal eye photography,APC 5734,RVU Per Case,$114.56 ,OP,114.56,549.03,,,,,,
Aetna MCR ADV,CPT,92311,Contact lens fitting,APC 5735,RVU Per Case,$276.53 ,OP,276.53,449.9,,,,,,
Aetna MCR ADV,CPT,92312,Contact lens fitting,APC 5734,RVU Per Case,$114.56 ,OP,114.56,510.9,,,,,,
Aetna MCR ADV,CPT,92313,Contact lens fitting,APC 5734,RVU Per Case,$114.56 ,OP,114.56,434.65,,,,,,
Aetna MCR ADV,CPT,92315,Rx cntact lens aphakia 1 eye,APC 5734,RVU Per Case,$114.56 ,OP,114.56,312.64,,,,,,
Aetna MCR ADV,CPT,92316,Rx cntact lens aphakia 2 eye,APC 5734,RVU Per Case,$114.56 ,OP,114.56,411.78,,,,,,
Aetna MCR ADV,CPT,92317,Rx corneoscleral cntact lens,APC 5732,RVU Per Case,$34.63 ,OP,34.63,324.09,,,,,,
Aetna MCR ADV,CPT,92325,Modification of contact lens,APC 5734,RVU Per Case,$114.56 ,OP,114.56,141.07,,,,,,
Aetna MCR ADV,CPT,92326,Replacement of contact lens,APC 5733,RVU Per Case,$56.95 ,OP,56.95,205.88,,,,,,
Aetna MCR ADV,CPT,92352,Fit aphakia spectcl monofocl,APC 5733,RVU Per Case,$56.95 ,OP,56.95,198.25,,,,,,
Aetna MCR ADV,CPT,92353,Fit aphakia spectcl multifoc,APC 5733,RVU Per Case,$56.95 ,OP,56.95,232.58,,,,,,
Aetna MCR ADV,CPT,92354,Fit spectacles single system,APC 5732,RVU Per Case,$34.63 ,OP,34.63,510.9,,,,,,
Aetna MCR ADV,CPT,92355,Fit spectacles compound lens,APC 5732,RVU Per Case,$34.63 ,OP,34.63,285.96,,,,,,
Aetna MCR ADV,CPT,92358,Aphakia prosth service temp,APC 5733,RVU Per Case,$56.95 ,OP,56.95,102.95,,,,,,
Aetna MCR ADV,CPT,92371,Repair & adjust spectacles,APC 5733,RVU Per Case,$56.95 ,OP,56.95,76.26,,,,,,
Aetna MCR ADV,CPT,92499,Eye service or procedure,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Aetna MCR ADV,CPT,92502,Ear and throat examination,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,526.16,,,,,,
Aetna MCR ADV,CPT,92507,Speech/hearing therapy,Physician,Per Unit,$75.75 ,OP,75.75,354.58,,,,,,
Aetna MCR ADV,CPT,92508,Speech/hearing therapy,Physician,Per Unit,$23.07 ,OP,23.07,171.58,,,,,,
Aetna MCR ADV,CPT,92511,Nasopharyngoscopy,APC 5151,RVU Per Unit,$168.23 ,OP,168.23,842.61,,,,,,
Aetna MCR ADV,CPT,92512,Nasal function studies,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,331.7,,,,,,
Aetna MCR ADV,CPT,92516,Facial nerve function test,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Aetna MCR ADV,CPT,92517,Vemp test i&r cervical,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Aetna MCR ADV,CPT,92518,Vemp test i&r ocular,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Aetna MCR ADV,CPT,92519,Vemp tst i&r cervical&ocular,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Aetna MCR ADV,CPT,92520,Laryngeal function studies,APC 5734,RVU Per Case,$114.56 ,OP,114.56,339.33,,,,,,
Aetna MCR ADV,CPT,92521,Evaluation of speech fluency,Physician,Per Unit,$132.47 ,OP,132.47,857.86,,,,,,
Aetna MCR ADV,CPT,92522,Evaluate speech production,Physician,Per Unit,$111.22 ,OP,111.22,857.86,,,,,,
Aetna MCR ADV,CPT,92523,Speech sound lang comprehen,Physician,Per Unit,$227.69 ,OP,227.69,857.86,,,,,,
Aetna MCR ADV,CPT,92524,Behavral qualit analys voice,Physician,Per Unit,$108.89 ,OP,108.89,857.86,,,,,,
Aetna MCR ADV,CPT,92526,Oral function therapy,Physician,Per Unit,$83.51 ,OP,83.51,453.71,,,,,,
Aetna MCR ADV,CPT,92537,Caloric vstblr test w/rec,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,163.95,,,,,,
Aetna MCR ADV,CPT,92538,Caloric vstblr test w/rec,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,163.95,,,,,,
Aetna MCR ADV,CPT,92540,Basic vestibular evaluation,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Aetna MCR ADV,CPT,92541,Spontaneous nystagmus test,APC 5734,RVU Per Case,$114.56 ,OP,114.56,335.53,,,,,,
Aetna MCR ADV,CPT,92542,Positional nystagmus test,APC 5734,RVU Per Case,$114.56 ,OP,114.56,346.96,,,,,,
Aetna MCR ADV,CPT,92544,Optokinetic nystagmus test,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,282.14,,,,,,
Aetna MCR ADV,CPT,92545,Oscillating tracking test,APC 5722,RVU Per Unit,$270.61 ,OP,263.08,270.61,,,,,,
Aetna MCR ADV,CPT,92546,Sinusoidal rotational test,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,468.96,,,,,,
Aetna MCR ADV,CPT,92548,Cdp-sot 6 cond w/i&r,APC 5734,RVU Per Case,$114.56 ,OP,114.56,556.65,,,,,,
Aetna MCR ADV,CPT,92549,Cdp-sot 6 cond w/i&r mct&adt,APC 5734,RVU Per Case,$114.56 ,OP,114.56,556.65,,,,,,
Aetna MCR ADV,CPT,92550,Tympanometry & reflex thresh,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
Aetna MCR ADV,CPT,92552,Pure tone audiometry air,APC 5734,RVU Per Case,$114.56 ,OP,114.56,129.64,,,,,,
Aetna MCR ADV,CPT,92553,Audiometry air & bone,APC 5721,RVU Per Case,$142.80 ,OP,142.8,175.39,,,,,,
Aetna MCR ADV,CPT,92555,Speech threshold audiometry,APC 5732,RVU Per Case,$34.63 ,OP,34.63,99.13,,,,,,
Aetna MCR ADV,CPT,92556,Speech audiometry complete,APC 5733,RVU Per Case,$56.95 ,OP,56.95,152.51,,,,,,
Aetna MCR ADV,CPT,92557,Comprehensive hearing test,APC 5721,RVU Per Case,$142.80 ,OP,142.8,278.32,,,,,,
Aetna MCR ADV,CPT,92561,Bekesy audiometry diagnosis,APC 5734,RVU Per Case,$114.56 ,OP,114.56,171.58,,,,,,
Aetna MCR ADV,CPT,92562,Loudness balance test,APC 5721,RVU Per Case,$142.80 ,OP,137.25,142.8,,,,,,
Aetna MCR ADV,CPT,92563,Tone decay hearing test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,125.82,,,,,,
Aetna MCR ADV,CPT,92564,Sisi hearing test,APC 5731,RVU Per Case,$25.25 ,OP,25.25,122,,,,,,
Aetna MCR ADV,CPT,92565,Stenger test pure tone,APC 5732,RVU Per Case,$34.63 ,OP,34.63,80.07,,,,,,
Aetna MCR ADV,CPT,92567,Tympanometry,APC 5732,RVU Per Case,$34.63 ,OP,34.63,110.57,,,,,,
Aetna MCR ADV,CPT,92568,Acoustic refl threshold tst,APC 5732,RVU Per Case,$34.63 ,OP,34.63,110.57,,,,,,
Aetna MCR ADV,CPT,92570,Acoustic immitance testing,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
Aetna MCR ADV,CPT,92571,Filtered speech hearing test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,102.95,,,,,,
Aetna MCR ADV,CPT,92572,Staggered spondaic word test,APC 5721,RVU Per Case,$142.80 ,OP,99.13,142.8,,,,,,
Aetna MCR ADV,CPT,92575,Sensorineural acuity test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,202.07,,,,,,
Aetna MCR ADV,CPT,92576,Synthetic sentence test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,129.64,,,,,,
Aetna MCR ADV,CPT,92577,Stenger test speech,APC 5723,RVU Per Case,$499.16 ,OP,114.39,499.16,,,,,,
Aetna MCR ADV,CPT,92579,Visual audiometry (vra),APC 5721,RVU Per Case,$142.80 ,OP,142.8,259.27,,,,,,
Aetna MCR ADV,CPT,92582,Conditioning play audiometry,APC 5721,RVU Per Case,$142.80 ,OP,142.8,247.83,,,,,,
Aetna MCR ADV,CPT,92583,Select picture audiometry,APC 5733,RVU Per Case,$56.95 ,OP,56.95,205.88,,,,,,
Aetna MCR ADV,CPT,92584,Electrocochleography,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,427.03,,,,,,
Aetna MCR ADV,CPT,92587,Evoked auditory test limited,APC 5722,RVU Per Unit,$270.61 ,OP,244.01,270.61,,,,,,
Aetna MCR ADV,CPT,92588,Evoked auditory tst complete,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,385.09,,,,,,
Aetna MCR ADV,CPT,92596,Ear protector evaluation,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Aetna MCR ADV,CPT,92597,Oral speech device eval,Physician,Per Unit,$70.53 ,OP,70.53,583.35,,,,,,
Aetna MCR ADV,CPT,92601,Cochlear implt f/up exam <7,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Aetna MCR ADV,CPT,92602,Reprogram cochlear implt <7,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Aetna MCR ADV,CPT,92603,Cochlear implt f/up exam 7/>,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Aetna MCR ADV,CPT,92604,Reprogram cochlear implt 7/>,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Aetna MCR ADV,CPT,92607,Ex for speech device rx 1hr,Physician,Per Unit,$122.72 ,OP,122.72,804.48,,,,,,
Aetna MCR ADV,CPT,92608,Ex for speech device rx addl,Physician,Per Unit,$49.31 ,OP,49.31,163.95,,,,,,
Aetna MCR ADV,CPT,92609,Use of speech device service,Physician,Per Unit,$102.45 ,OP,102.45,430.83,,,,,,
Aetna MCR ADV,CPT,92610,Evaluate swallowing function,Physician,Per Unit,$69.06 ,OP,69.06,423.22,,,,,,
Aetna MCR ADV,CPT,92611,Motion fluoroscopy/swallow,Physician,Per Unit,$90.57 ,OP,90.57,461.34,,,,,,
Aetna MCR ADV,CPT,92612,Endoscopy swallow (fees) vid,Physician,Per Unit,$65.56 ,OP,65.56,796.85,,,,,,
Aetna MCR ADV,CPT,92614,Laryngoscopic sensory vid,Physician,Per Unit,$64.93 ,OP,64.93,709.16,,,,,,
Aetna MCR ADV,CPT,92616,Fees w/laryngeal sense test,Physician,Per Unit,$97.82 ,OP,97.82,972.25,,,,,,
Aetna MCR ADV,CPT,92620,Auditory function 60 min,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
Aetna MCR ADV,CPT,92625,Tinnitus assessment,APC 5721,RVU Per Case,$142.80 ,OP,142.8,293.57,,,,,,
Aetna MCR ADV,CPT,92626,Eval aud funcj 1st hour,APC 5721,RVU Per Case,$142.80 ,OP,142.8,407.96,,,,,,
Aetna MCR ADV,CPT,92640,Aud brainstem implt programg,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,385.09,,,,,,
Aetna MCR ADV,CPT,92651,Aep hearing status deter i&r,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Aetna MCR ADV,CPT,92652,Aep thrshld est mlt freq i&r,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Aetna MCR ADV,CPT,92653,Aep neurodiagnostic i&r,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Aetna MCR ADV,CPT,92700,Ent procedure/service,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Aetna MCR ADV,CPT,92920,Prq cardiac angioplast 1 art,APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,92924,Prq card angio/athrect 1 art,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
Aetna MCR ADV,CPT,92928,Prq card stent w/angio 1 vsl,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Aetna MCR ADV,CPT,92933,Prq card stent/ath/angio,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Aetna MCR ADV,CPT,92937,Prq revasc byp graft 1 vsl,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Aetna MCR ADV,CPT,92941,Prq card revasc mi 1 vsl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,92943,Prq card revasc chronic 1vsl,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Aetna MCR ADV,CPT,92950,Heart/lung resuscitation cpr,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,567.02",,,,,,
Aetna MCR ADV,CPT,92953,Temporary external pacing,APC 5781,RVU Per Unit,$575.01 ,OP,575.01,575.01,,,,,,
Aetna MCR ADV,CPT,92960,Cardioversion electric ext,APC 5781,RVU Per Unit,$575.01 ,OP,575.01,"1,460.26",,,,,,
Aetna MCR ADV,CPT,92961,Cardioversion electric int,APC 5781,RVU Per Unit,$575.01 ,OP,575.01,"1,513.64",,,,,,
Aetna MCR ADV,CPT,92970,Cardioassist internal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,040.87","8,948.83",,,,,,
Aetna MCR ADV,CPT,92971,Cardioassist external,APC 5881,RVU Per Case,"$8,948.83 ",OP,590.97,"8,948.83",,,,,,
Aetna MCR ADV,CPT,92975,Dissolve clot heart vessel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"2,367.69","8,948.83",,,,,,
Aetna MCR ADV,CPT,92977,Dissolve clot heart vessel,APC 5694,RVU Per Unit,$318.00 ,OP,318,850.23,,,,,,
Aetna MCR ADV,CPT,92986,Revision of aortic valve,APC 5192,RVU Per Case,"$5,072.43 ",OP,"5,072.43","8,048.60",,,,,,
Aetna MCR ADV,CPT,92987,Revision of mitral valve,APC 5193,RVU Per Case,"$10,277.14 ",OP,"8,338.36","10,277.14",,,,,,
Aetna MCR ADV,CPT,92990,Revision of pulmonary valve,APC 5193,RVU Per Case,"$10,277.14 ",OP,"6,409.14","10,277.14",,,,,,
Aetna MCR ADV,CPT,92997,Pul art balloon repr percut,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
Aetna MCR ADV,CPT,93005,Electrocardiogram tracing,APC 5733,RVU Per Case,$56.95 ,OP,56.95,72.44,,,,,,
Aetna MCR ADV,CPT,93017,Cardiovascular stress test,APC 5722,RVU Per Case,$270.61 ,OP,270.61,362.21,,,,,,
Aetna MCR ADV,CPT,93024,Cardiac drug stress test,APC 5735,RVU Per Case,$276.53 ,OP,276.53,712.98,,,,,,
Aetna MCR ADV,CPT,93025,Microvolt t-wave assess,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,"1,246.76",,,,,,
Aetna MCR ADV,CPT,93041,Rhythm ecg tracing,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Aetna MCR ADV,CPT,93050,Art pressure waveform analys,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Aetna MCR ADV,CPT,93225,Ecg monit/reprt up to 48 hrs,APC 5734,RVU Per Case,$114.56 ,OP,114.56,224.95,,,,,,
Aetna MCR ADV,CPT,93226,Ecg monit/reprt up to 48 hrs,APC 5734,RVU Per Case,$114.56 ,OP,114.56,926.48,,,,,,
Aetna MCR ADV,CPT,93229,Remote 30 day ecg tech supp,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Aetna MCR ADV,CPT,93242,Ext ecg>48hr<7d recording,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Aetna MCR ADV,CPT,93243,Ext ecg>48hr<7d scan a/r,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Aetna MCR ADV,CPT,93246,Ext ecg>7d<15d recording,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Aetna MCR ADV,CPT,93247,Ext ecg>7d<15d scan a/r,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Aetna MCR ADV,CPT,93260,Prgrmg dev eval impltbl sys,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Aetna MCR ADV,CPT,93261,Interrogate subq defib,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Aetna MCR ADV,CPT,93270,Remote 30 day ecg rev/report,APC 5741,RVU Per Case,$38.02 ,OP,38.02,137.25,,,,,,
Aetna MCR ADV,CPT,93271,Ecg/monitoring and analysis,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,"1,281.07",,,,,,
Aetna MCR ADV,CPT,93278,Ecg/signal-averaged,APC 5733,RVU Per Case,$56.95 ,OP,56.95,251.64,,,,,,
Aetna MCR ADV,CPT,93279,Prgrmg dev eval pm/ldls pm,APC 5741,RVU Per Case,$38.02 ,OP,38.02,327.9,,,,,,
Aetna MCR ADV,CPT,93280,Pm device progr eval dual,APC 5741,RVU Per Case,$38.02 ,OP,38.02,381.27,,,,,,
Aetna MCR ADV,CPT,93281,Pm device progr eval multi,APC 5741,RVU Per Case,$38.02 ,OP,38.02,446.08,,,,,,
Aetna MCR ADV,CPT,93282,Prgrmg eval implantable dfb,APC 5741,RVU Per Case,$38.02 ,OP,38.02,415.59,,,,,,
Aetna MCR ADV,CPT,93283,Prgrmg eval implantable dfb,APC 5741,RVU Per Case,$38.02 ,OP,38.02,503.28,,,,,,
Aetna MCR ADV,CPT,93284,Prgrmg eval implantable dfb,APC 5741,RVU Per Case,$38.02 ,OP,38.02,587.16,,,,,,
Aetna MCR ADV,CPT,93285,Prgrmg dev eval scrms ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,282.14,,,,,,
Aetna MCR ADV,CPT,93288,Interrog evl pm/ldls pm ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,255.45,,,,,,
Aetna MCR ADV,CPT,93289,Interrog device eval heart,APC 5741,RVU Per Case,$38.02 ,OP,38.02,385.09,,,,,,
Aetna MCR ADV,CPT,93290,Interrog dev eval icpms ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,190.64,,,,,,
Aetna MCR ADV,CPT,93291,Interrog dev eval scrms ip,APC 5731,RVU Per Case,$25.25 ,OP,25.25,244.01,,,,,,
Aetna MCR ADV,CPT,93292,Wcd device interrogate,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Aetna MCR ADV,CPT,93293,Pm phone r-strip device eval,APC 5741,RVU Per Case,$38.02 ,OP,38.02,366.02,,,,,,
Aetna MCR ADV,CPT,93296,Rem interrog evl pm/ids,APC 5741,RVU Per Case,$38.02 ,OP,38.02,213.51,,,,,,
Aetna MCR ADV,CPT,93303,Echo transthoracic,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,292.50",,,,,,
Aetna MCR ADV,CPT,93304,Echo transthoracic,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,796.85,,,,,,
Aetna MCR ADV,CPT,93306,Tte w/doppler complete,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,593.72",,,,,,
Aetna MCR ADV,CPT,93307,Tte w/o doppler complete,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,056.11",,,,,,
Aetna MCR ADV,CPT,93308,Tte f-up or lmtd,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,667.22,,,,,,
Aetna MCR ADV,CPT,93312,Echo transesophageal,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,921.59",,,,,,
Aetna MCR ADV,CPT,93313,Echo transesophageal,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,494.15,,,,,,
Aetna MCR ADV,CPT,93315,Echo transesophageal,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,738.59",,,,,,
Aetna MCR ADV,CPT,93316,Echo transesophageal,APC 5524,RVU Per Unit,$494.15 ,OP,259.27,494.15,,,,,,
Aetna MCR ADV,CPT,93318,Echo transesophageal intraop,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,330.63",,,,,,
Aetna MCR ADV,CPT,93350,Stress tte only,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,239.13",,,,,,
Aetna MCR ADV,CPT,93351,Stress tte complete,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,635.64",,,,,,
Aetna MCR ADV,CPT,93451,Right heart cath,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Aetna MCR ADV,CPT,93452,Left hrt cath w/ventrclgrphy,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Aetna MCR ADV,CPT,93453,R&l hrt cath w/ventriclgrphy,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Aetna MCR ADV,CPT,93454,Coronary artery angio s&i,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","2,966.62",,,,,,
Aetna MCR ADV,CPT,93455,Coronary art/grft angio s&i,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","2,966.62",,,,,,
Aetna MCR ADV,CPT,93456,R hrt coronary artery angio,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Aetna MCR ADV,CPT,93457,R hrt art/grft angio,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Aetna MCR ADV,CPT,93458,L hrt artery/ventricle angio,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Aetna MCR ADV,CPT,93459,L hrt art/grft angio,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Aetna MCR ADV,CPT,93460,R&l hrt art/ventricle angio,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Aetna MCR ADV,CPT,93461,R&l hrt art/ventricle angio,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Aetna MCR ADV,CPT,93503,Insert/place heart catheter,APC 5182,RVU Per Case,"$1,438.93 ",OP,651.97,"1,438.93",,,,,,
Aetna MCR ADV,CPT,93505,Biopsy of heart lining,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,346.47",,,,,,
Aetna MCR ADV,CPT,93530,Rt heart cath congenital,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Aetna MCR ADV,CPT,93531,R & l heart cath congenital,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","16,124.56",,,,,,
Aetna MCR ADV,CPT,93532,R & l heart cath congenital,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","16,600.26",,,,,,
Aetna MCR ADV,CPT,93533,R & l heart cath congenital,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","16,111.09",,,,,,
Aetna MCR ADV,CPT,93580,Transcath closure of asd,APC 5194,RVU Per Case,"$16,438.60 ",OP,"5,905.86","16,438.60",,,,,,
Aetna MCR ADV,CPT,93581,Transcath closure of vsd,APC 5194,RVU Per Case,"$16,438.60 ",OP,"7,739.77","16,438.60",,,,,,
Aetna MCR ADV,CPT,93582,Perq transcath closure pda,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Aetna MCR ADV,CPT,93583,Perq transcath septal reduxn,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,93590,Perq transcath cls mitral,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Aetna MCR ADV,CPT,93591,Perq transcath cls aortic,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Aetna MCR ADV,CPT,93600,Bundle of his recording,APC 5212,RVU Per Case,"$6,220.22 ",OP,"6,220.22","6,220.22",,,,,,
Aetna MCR ADV,CPT,93602,Intra-atrial recording,APC 5212,RVU Per Case,"$6,220.22 ",OP,968.43,"6,220.22",,,,,,
Aetna MCR ADV,CPT,93603,Right ventricular recording,APC 5211,RVU Per Case,"$1,138.72 ",OP,"1,117.12","1,138.72",,,,,,
Aetna MCR ADV,CPT,93610,Intra-atrial pacing,APC 5212,RVU Per Case,"$6,220.22 ",OP,"1,323.01","6,220.22",,,,,,
Aetna MCR ADV,CPT,93612,Intraventricular pacing,APC 5212,RVU Per Case,"$6,220.22 ",OP,"1,376.38","6,220.22",,,,,,
Aetna MCR ADV,CPT,93615,Esophageal recording,APC 5211,RVU Per Case,"$1,138.72 ",OP,392.7,"1,138.72",,,,,,
Aetna MCR ADV,CPT,93616,Esophageal recording,APC 5211,RVU Per Case,"$1,138.72 ",OP,"1,138.72","1,138.72",,,,,,
Aetna MCR ADV,CPT,93618,Heart rhythm pacing,APC 5211,RVU Per Case,"$1,138.72 ",OP,"1,138.72","2,367.69",,,,,,
Aetna MCR ADV,CPT,93619,Electrophysiology evaluation,APC 5212,RVU Per Case,"$6,220.22 ",OP,"4,312.16","6,220.22",,,,,,
Aetna MCR ADV,CPT,93620,Electrophysiology evaluation,APC 5212,RVU Per Case,"$6,220.22 ",OP,"5,112.83","6,220.22",,,,,,
Aetna MCR ADV,CPT,93624,Electrophysiologic study,APC 5212,RVU Per Case,"$6,220.22 ",OP,"2,051.24","6,220.22",,,,,,
Aetna MCR ADV,CPT,93642,Electrophysiology evaluation,APC 5211,RVU Per Case,"$1,138.72 ",OP,"1,138.72","2,775.65",,,,,,
Aetna MCR ADV,CPT,93650,Ablate heart dysrhythm focus,APC 5212,RVU Per Case,"$6,220.22 ",OP,"3,488.62","6,220.22",,,,,,
Aetna MCR ADV,CPT,93653,Ep & ablate supravent arrhyt,APC 5213,RVU Per Case,"$21,964.94 ",OP,"10,420.09","21,964.94",,,,,,
Aetna MCR ADV,CPT,93654,Ep & ablate ventric tachy,APC 5213,RVU Per Case,"$21,964.94 ",OP,"10,889.05","21,964.94",,,,,,
Aetna MCR ADV,CPT,93656,Tx atrial fib pulm vein isol,APC 5213,RVU Per Case,"$21,964.94 ",OP,"10,420.09","21,964.94",,,,,,
Aetna MCR ADV,CPT,93660,Tilt table evaluation,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,983.68,,,,,,
Aetna MCR ADV,CPT,93668,Peripheral vascular rehab,APC 5733,RVU Per Unit,$56.95 ,OP,56.95,99.13,,,,,,
Aetna MCR ADV,CPT,93701,Bioimpedance cv analysis,APC 5734,RVU Per Case,$114.56 ,OP,114.56,198.25,,,,,,
Aetna MCR ADV,CPT,93702,Bis xtracell fluid analysis,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Aetna MCR ADV,CPT,93724,Analyze pacemaker system,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,"1,948.29",,,,,,
Aetna MCR ADV,CPT,93740,Temperature gradient studies,APC 5721,RVU Per Case,$142.80 ,OP,57.19,142.8,,,,,,
Aetna MCR ADV,CPT,93745,Set-up cardiovert-defibrill,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,278.82,,,,,,
Aetna MCR ADV,CPT,93750,Interrogation vad in person,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,102.65,,,,,,
Aetna MCR ADV,CPT,93786,Ambl bp mntr w/sw rec only,APC 5734,RVU Per Case,$114.56 ,OP,114.56,171.58,,,,,,
Aetna MCR ADV,CPT,93788,Ambl bp mntr w/sw a/r,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Aetna MCR ADV,CPT,93797,Cardiac rehab,APC 5771,RVU Per Unit,$118.77 ,OP,102.95,118.77,,,,,,
Aetna MCR ADV,CPT,93798,Cardiac rehab/monitor,APC 5771,RVU Per Unit,$118.77 ,OP,118.77,148.69,,,,,,
Aetna MCR ADV,CPT,93799,Cardiovascular procedure,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Aetna MCR ADV,CPT,93880,Extracranial bilat study,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,239.13",,,,,,
Aetna MCR ADV,CPT,93882,Extracranial uni/ltd study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,815.92,,,,,,
Aetna MCR ADV,CPT,93886,Intracranial complete study,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,483.14",,,,,,
Aetna MCR ADV,CPT,93888,Intracranial limited study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,"1,010.37",,,,,,
Aetna MCR ADV,CPT,93890,Tcd vasoreactivity study,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,307.75",,,,,,
Aetna MCR ADV,CPT,93892,Tcd emboli detect w/o inj,APC 5522,RVU Per Case,$111.51 ,OP,111.51,"1,425.95",,,,,,
Aetna MCR ADV,CPT,93893,Tcd emboli detect w/inj,APC 5522,RVU Per Case,$111.51 ,OP,111.51,"1,422.14",,,,,,
Aetna MCR ADV,CPT,93922,Upr/l xtremity art 2 levels,APC 5734,RVU Per Case,$114.56 ,OP,114.56,594.77,,,,,,
Aetna MCR ADV,CPT,93923,Upr/lxtr art stdy 3+ lvls,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,922.67,,,,,,
Aetna MCR ADV,CPT,93924,Lwr xtr vasc stdy bilat,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,136.19",,,,,,
Aetna MCR ADV,CPT,93925,Lower extremity study,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,525.07",,,,,,
Aetna MCR ADV,CPT,93926,Lower extremity study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,976.05,,,,,,
Aetna MCR ADV,CPT,93930,Upper extremity study,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,223.88",,,,,,
Aetna MCR ADV,CPT,93931,Upper extremity study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,815.92,,,,,,
Aetna MCR ADV,CPT,93970,Extremity study,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,273.44",,,,,,
Aetna MCR ADV,CPT,93971,Extremity study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,842.61,,,,,,
Aetna MCR ADV,CPT,93975,Vascular study,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,367.82,,,,,,
Aetna MCR ADV,CPT,93976,Vascular study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,"1,082.81",,,,,,
Aetna MCR ADV,CPT,93978,Vascular study,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,197.20",,,,,,
Aetna MCR ADV,CPT,93979,Vascular study,APC 5522,RVU Per Case,$111.51 ,OP,111.51,823.54,,,,,,
Aetna MCR ADV,CPT,93980,Penile vascular study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,934.12,,,,,,
Aetna MCR ADV,CPT,93981,Penile vascular study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,667.22,,,,,,
Aetna MCR ADV,CPT,93985,Dup-scan hemo compl bi std,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,136.19",,,,,,
Aetna MCR ADV,CPT,93986,Dup-scan hemo compl uni std,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,646.72,,,,,,
Aetna MCR ADV,CPT,93990,Doppler flow testing,APC 5522,RVU Per Case,$111.51 ,OP,111.51,956.99,,,,,,
Aetna MCR ADV,CPT,93998,Noninvas vasc dx study proc,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Aetna MCR ADV,CPT,94002,Vent mgmt inpat init day,APC 5801,RVU Per Unit,$496.58 ,OP,496.58,541.4,,,,,,
Aetna MCR ADV,CPT,94003,Vent mgmt inpat subq day,APC 5801,RVU Per Unit,$496.58 ,OP,496.58,496.58,,,,,,
Aetna MCR ADV,CPT,94010,Breathing capacity test,APC 5721,RVU Per Case,$142.80 ,OP,142.8,209.7,,,,,,
Aetna MCR ADV,CPT,94011,Spirometry up to 2 yrs old,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
Aetna MCR ADV,CPT,94012,Spirmtry w/brnchdil inf-2 yr,APC 5722,RVU Per Case,$270.61 ,OP,270.61,270.61,,,,,,
Aetna MCR ADV,CPT,94013,Meas lung vol thru 2 yrs,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Aetna MCR ADV,CPT,94014,Patient recorded spirometry,APC 5735,RVU Per Case,$276.53 ,OP,276.53,301.2,,,,,,
Aetna MCR ADV,CPT,94015,Patient recorded spirometry,APC 5722,RVU Per Case,$270.61 ,OP,148.69,270.61,,,,,,
Aetna MCR ADV,CPT,94016,Review patient spirometry,Physician,Per Unit,$24.70 ,OP,24.7,152.51,,,,,,
Aetna MCR ADV,CPT,94060,Evaluation of wheezing,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,369.83,,,,,,
Aetna MCR ADV,CPT,94070,Evaluation of wheezing,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,392.7,,,,,,
Aetna MCR ADV,CPT,94150,Vital capacity test,APC 5721,RVU Per Case,$142.80 ,OP,141.07,142.8,,,,,,
Aetna MCR ADV,CPT,94200,Lung function test (mbc/mvv),APC 5733,RVU Per Case,$56.95 ,OP,56.95,144.88,,,,,,
Aetna MCR ADV,CPT,94375,Respiratory flow volume loop,APC 5722,RVU Per Case,$270.61 ,OP,232.58,270.61,,,,,,
Aetna MCR ADV,CPT,94450,Hypoxia response curve,APC 5722,RVU Per Case,$270.61 ,OP,270.61,316.46,,,,,,
Aetna MCR ADV,CPT,94452,Hast w/report,APC 5734,RVU Per Case,$114.56 ,OP,114.56,346.96,,,,,,
Aetna MCR ADV,CPT,94453,Hast w/oxygen titrate,APC 5734,RVU Per Case,$114.56 ,OP,114.56,461.34,,,,,,
Aetna MCR ADV,CPT,94610,Surfactant admin thru tube,APC 5791,RVU Per Case,$192.26 ,OP,192.26,438.47,,,,,,
Aetna MCR ADV,CPT,94617,Exercise tst brncspsm w/ecg,APC 5734,RVU Per Case,$114.56 ,OP,114.56,465.15,,,,,,
Aetna MCR ADV,CPT,94618,Pulmonary stress testing,APC 5734,RVU Per Case,$114.56 ,OP,114.56,465.15,,,,,,
Aetna MCR ADV,CPT,94619,Exercise tst brncspsm wo ecg,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Aetna MCR ADV,CPT,94621,Cardiopulm exercise testing,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,017.99",,,,,,
Aetna MCR ADV,CPT,94640,Airway inhalation treatment,APC 5791,RVU Per Case,$192.26 ,OP,87.69,192.26,,,,,,
Aetna MCR ADV,CPT,94642,Aerosol inhalation treatment,APC 5791,RVU Per Case,$192.26 ,OP,192.26,255.45,,,,,,
Aetna MCR ADV,CPT,94644,Cbt 1st hour,APC 5734,RVU Per Case,$114.56 ,OP,114.56,217.32,,,,,,
Aetna MCR ADV,CPT,94660,Pos airway pressure cpap,APC 5791,RVU Per Case,$192.26 ,OP,192.26,346.96,,,,,,
Aetna MCR ADV,CPT,94662,Neg press ventilation cnp,APC 5801,RVU Per Unit,$496.58 ,OP,221.14,496.58,,,,,,
Aetna MCR ADV,CPT,94664,Evaluate pt use of inhaler,APC 5791,RVU Per Case,$192.26 ,OP,99.13,192.26,,,,,,
Aetna MCR ADV,CPT,94667,Chest wall manipulation,APC 5734,RVU Per Case,$114.56 ,OP,114.56,137.25,,,,,,
Aetna MCR ADV,CPT,94668,Chest wall manipulation,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Aetna MCR ADV,CPT,94669,Mechanical chest wall oscill,APC 5791,RVU Per Case,$192.26 ,OP,192.26,192.26,,,,,,
Aetna MCR ADV,CPT,94680,Exhaled air analysis o2,APC 5721,RVU Per Case,$142.80 ,OP,142.8,369.83,,,,,,
Aetna MCR ADV,CPT,94681,Exhaled air analysis o2/co2,APC 5722,RVU Per Case,$270.61 ,OP,270.61,270.61,,,,,,
Aetna MCR ADV,CPT,94690,Exhaled air analysis,APC 5733,RVU Per Case,$56.95 ,OP,56.95,320.27,,,,,,
Aetna MCR ADV,CPT,94726,Pulm funct tst plethysmograp,APC 5722,RVU Per Case,$270.61 ,OP,270.61,282.14,,,,,,
Aetna MCR ADV,CPT,94727,Pulm function test by gas,APC 5721,RVU Per Case,$142.80 ,OP,142.8,221.14,,,,,,
Aetna MCR ADV,CPT,94728,Airwy resist by oscillometry,APC 5722,RVU Per Case,$270.61 ,OP,270.61,282.14,,,,,,
Aetna MCR ADV,CPT,94762,Measure blood oxygen level,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,202.07,,,,,,
Aetna MCR ADV,CPT,94772,Breath recording infant,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Aetna MCR ADV,CPT,94775,Ped home apnea rec hk-up,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Aetna MCR ADV,CPT,94776,Ped home apnea rec downld,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Aetna MCR ADV,CPT,94780,Cars/bd tst inft-12mo 60 min,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Aetna MCR ADV,CPT,94799,Pulmonary service/procedure,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
Aetna MCR ADV,CPT,95004,Percut allergy skin tests,APC 5724,RVU Per Case,$941.27 ,OP,30.51,941.27,,,,,,
Aetna MCR ADV,CPT,95012,Exhaled nitric oxide meas,APC 5732,RVU Per Case,$34.63 ,OP,34.63,102.95,,,,,,
Aetna MCR ADV,CPT,95017,Perq & icut allg test venoms,APC 5731,RVU Per Case,$25.25 ,OP,25.25,87.69,,,,,,
Aetna MCR ADV,CPT,95018,Perq&ic allg test drugs/biol,APC 5732,RVU Per Case,$34.63 ,OP,34.63,87.69,,,,,,
Aetna MCR ADV,CPT,95024,Icut allergy test drug/bug,APC 5733,RVU Per Case,$56.95 ,OP,38.13,56.95,,,,,,
Aetna MCR ADV,CPT,95027,Icut allergy titrate-airborn,APC 5731,RVU Per Case,$25.25 ,OP,25.25,26.7,,,,,,
Aetna MCR ADV,CPT,95028,Icut allergy test-delayed,APC 5732,RVU Per Case,$34.63 ,OP,34.63,57.19,,,,,,
Aetna MCR ADV,CPT,95044,Allergy patch tests,APC 5724,RVU Per Case,$941.27 ,OP,34.31,941.27,,,,,,
Aetna MCR ADV,CPT,95052,Photo patch test,APC 5733,RVU Per Case,$56.95 ,OP,38.13,56.95,,,,,,
Aetna MCR ADV,CPT,95056,Photosensitivity tests,APC 5734,RVU Per Case,$114.56 ,OP,114.56,179.2,,,,,,
Aetna MCR ADV,CPT,95060,Eye allergy tests,APC 5734,RVU Per Case,$114.56 ,OP,114.56,122,,,,,,
Aetna MCR ADV,CPT,95065,Nose allergy test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,110.57,,,,,,
Aetna MCR ADV,CPT,95070,Bronchial allergy tests,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Aetna MCR ADV,CPT,95076,Ingest challenge ini 120 min,APC 5723,RVU Per Unit,$499.16 ,OP,320.27,499.16,,,,,,
Aetna MCR ADV,CPT,95115,Immunotherapy one injection,APC 5691,RVU Per Case,$40.93 ,OP,40.93,57.19,,,,,,
Aetna MCR ADV,CPT,95117,Immunotherapy injections,APC 5691,RVU Per Case,$40.93 ,OP,40.93,68.63,,,,,,
Aetna MCR ADV,CPT,95144,Antigen therapy services,APC 5691,RVU Per Case,$40.93 ,OP,40.93,61,,,,,,
Aetna MCR ADV,CPT,95145,Antigen therapy services,APC 5691,RVU Per Case,$40.93 ,OP,40.93,80.07,,,,,,
Aetna MCR ADV,CPT,95146,Antigen therapy services,APC 5691,RVU Per Case,$40.93 ,OP,40.93,129.64,,,,,,
Aetna MCR ADV,CPT,95147,Antigen therapy services,APC 5692,RVU Per Case,$63.42 ,OP,63.42,125.82,,,,,,
Aetna MCR ADV,CPT,95148,Antigen therapy services,APC 5692,RVU Per Case,$63.42 ,OP,63.42,179.2,,,,,,
Aetna MCR ADV,CPT,95149,Antigen therapy services,APC 5692,RVU Per Case,$63.42 ,OP,63.42,232.58,,,,,,
Aetna MCR ADV,CPT,95165,Antigen therapy services,APC 5691,RVU Per Case,$40.93 ,OP,40.93,61,,,,,,
Aetna MCR ADV,CPT,95170,Antigen therapy services,APC 5691,RVU Per Case,$40.93 ,OP,40.93,49.56,,,,,,
Aetna MCR ADV,CPT,95180,Rapid desensitization,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
Aetna MCR ADV,CPT,95199,Allergy immunology services,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Aetna MCR ADV,CPT,95249,Cont gluc mntr pt prov eqp,APC 5733,RVU Per Unit,$56.95 ,OP,56.95,686.28,,,,,,
Aetna MCR ADV,CPT,95250,Cont gluc mntr phys/qhp eqp,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,686.28,,,,,,
Aetna MCR ADV,CPT,95700,Eeg cont rec w/vid eeg tech,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Aetna MCR ADV,CPT,95705,Eeg w/o vid 2-12 hr unmntr,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Aetna MCR ADV,CPT,95706,Eeg wo vid 2-12hr intmt mntr,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Aetna MCR ADV,CPT,95707,Eeg w/o vid 2-12hr cont mntr,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Aetna MCR ADV,CPT,95708,Eeg wo vid ea 12-26hr unmntr,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Aetna MCR ADV,CPT,95709,Eeg w/o vid ea 12-26hr intmt,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Aetna MCR ADV,CPT,95710,Eeg w/o vid ea 12-26hr cont,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Aetna MCR ADV,CPT,95711,Veeg 2-12 hr unmonitored,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Aetna MCR ADV,CPT,95712,Veeg 2-12 hr intmt mntr,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Aetna MCR ADV,CPT,95713,Veeg 2-12 hr cont mntr,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Aetna MCR ADV,CPT,95714,Veeg ea 12-26 hr unmntr,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Aetna MCR ADV,CPT,95715,Veeg ea 12-26hr intmt mntr,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Aetna MCR ADV,CPT,95716,Veeg ea 12-26hr cont mntr,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,941.27,,,,,,
Aetna MCR ADV,CPT,95782,Polysom <6 yrs 4/> paramtrs,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"4,472.29",,,,,,
Aetna MCR ADV,CPT,95783,Polysom <6 yrs cpap/bilvl,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"4,472.29",,,,,,
Aetna MCR ADV,CPT,95800,Slp stdy unattended,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Aetna MCR ADV,CPT,95801,Slp stdy unatnd w/anal,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Aetna MCR ADV,CPT,95803,Actigraphy testing,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Aetna MCR ADV,CPT,95805,Multiple sleep latency test,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,"2,249.49",,,,,,
Aetna MCR ADV,CPT,95806,Sleep study unatt&resp efft,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,413.8,,,,,,
Aetna MCR ADV,CPT,95807,Sleep study attended,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,"2,638.38",,,,,,
Aetna MCR ADV,CPT,95808,Polysom any age 1-3> param,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,941.27,,,,,,
Aetna MCR ADV,CPT,95810,Polysom 6/> yrs 4/> param,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"1,103.46",,,,,,
Aetna MCR ADV,CPT,95811,Polysom 6/>yrs cpap 4/> parm,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"1,103.46",,,,,,
Aetna MCR ADV,CPT,95812,Eeg 41-60 minutes,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,242.94",,,,,,
Aetna MCR ADV,CPT,95813,Eeg extnd mntr 61-119 min,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,521.26",,,,,,
Aetna MCR ADV,CPT,95816,Eeg awake and drowsy,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,139.99",,,,,,
Aetna MCR ADV,CPT,95819,Eeg awake and asleep,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,223.88",,,,,,
Aetna MCR ADV,CPT,95822,Eeg coma or sleep only,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,223.88",,,,,,
Aetna MCR ADV,CPT,95824,Eeg cerebral death only,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,503.28,,,,,,
Aetna MCR ADV,CPT,95836,Ecog impltd brn npgt <30 d,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Aetna MCR ADV,CPT,95851,Range of motion measurements,Physician,Per Unit,$7.59 ,OP,7.59,83.87,,,,,,
Aetna MCR ADV,CPT,95852,Range of motion measurements,Physician,Per Unit,$5.52 ,OP,5.52,64.82,,,,,,
Aetna MCR ADV,CPT,95857,Cholinesterase challenge,APC 5722,RVU Per Unit,$270.61 ,OP,209.7,270.61,,,,,,
Aetna MCR ADV,CPT,95860,Muscle test one limb,APC 5734,RVU Per Case,$114.56 ,OP,114.56,423.22,,,,,,
Aetna MCR ADV,CPT,95861,Muscle test 2 limbs,APC 5734,RVU Per Case,$114.56 ,OP,114.56,613.85,,,,,,
Aetna MCR ADV,CPT,95863,Muscle test 3 limbs,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,732.04,,,,,,
Aetna MCR ADV,CPT,95864,Muscle test 4 limbs,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,850.23,,,,,,
Aetna MCR ADV,CPT,95865,Muscle test larynx,APC 5734,RVU Per Case,$114.56 ,OP,114.56,439,,,,,,
Aetna MCR ADV,CPT,95866,Muscle test hemidiaphragm,APC 5721,RVU Per Case,$142.80 ,OP,142.8,480.4,,,,,,
Aetna MCR ADV,CPT,95867,Muscle test cran nerv unilat,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,369.83,,,,,,
Aetna MCR ADV,CPT,95868,Muscle test cran nerve bilat,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,503.28,,,,,,
Aetna MCR ADV,CPT,95869,Muscle test thor paraspinal,APC 5721,RVU Per Case,$142.80 ,OP,142.8,236.38,,,,,,
Aetna MCR ADV,CPT,95870,Muscle test nonparaspinal,APC 5734,RVU Per Case,$114.56 ,OP,114.56,228.77,,,,,,
Aetna MCR ADV,CPT,95872,Muscle test one fiber,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,635.69,,,,,,
Aetna MCR ADV,CPT,95875,Limb exercise test,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,364.88,,,,,,
Aetna MCR ADV,CPT,95905,Motor &/ sens nrve cndj test,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
Aetna MCR ADV,CPT,95907,Nvr cndj tst 1-2 studies,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Aetna MCR ADV,CPT,95908,Nrv cndj tst 3-4 studies,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Aetna MCR ADV,CPT,95909,Nrv cndj tst 5-6 studies,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Aetna MCR ADV,CPT,95910,Nrv cndj test 7-8 studies,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Aetna MCR ADV,CPT,95911,Nrv cndj test 9-10 studies,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Aetna MCR ADV,CPT,95912,Nrv cndj test 11-12 studies,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Aetna MCR ADV,CPT,95913,Nrv cndj test 13/> studies,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Aetna MCR ADV,CPT,95921,Autonomic nrv parasym inervj,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,282.21,,,,,,
Aetna MCR ADV,CPT,95922,Autonomic nrv adrenrg inervj,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Aetna MCR ADV,CPT,95923,Autonomic nrv syst funj test,APC 5734,RVU Per Case,$114.56 ,OP,114.56,447.55,,,,,,
Aetna MCR ADV,CPT,95924,Ans parasymp & symp w/tilt,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Aetna MCR ADV,CPT,95925,Somatosensory testing,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,461.8,,,,,,
Aetna MCR ADV,CPT,95926,Somatosensory testing,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,602.41,,,,,,
Aetna MCR ADV,CPT,95927,Somatosensory testing,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,621.47,,,,,,
Aetna MCR ADV,CPT,95928,C motor evoked uppr limbs,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,964.61,,,,,,
Aetna MCR ADV,CPT,95929,C motor evoked lwr limbs,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,"1,017.99",,,,,,
Aetna MCR ADV,CPT,95930,Visual ep test cns w/i&r,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,537.6,,,,,,
Aetna MCR ADV,CPT,95933,Blink reflex test,APC 5733,RVU Per Case,$56.95 ,OP,56.95,339.33,,,,,,
Aetna MCR ADV,CPT,95937,Neuromuscular junction test,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,305.01,,,,,,
Aetna MCR ADV,CPT,95938,Somatosensory testing,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Aetna MCR ADV,CPT,95939,C motor evoked upr&lwr limbs,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,941.27,,,,,,
Aetna MCR ADV,CPT,95943,Parasymp&symp hrt rate test,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Aetna MCR ADV,CPT,95954,Eeg monitoring/giving drugs,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,"1,277.26",,,,,,
Aetna MCR ADV,CPT,95958,Eeg monitoring/function test,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"1,982.60",,,,,,
Aetna MCR ADV,CPT,95961,Electrode stimulation brain,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"1,265.81",,,,,,
Aetna MCR ADV,CPT,95965,Meg spontaneous,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"10,992.00",,,,,,
Aetna MCR ADV,CPT,95966,Meg evoked single,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"5,455.97",,,,,,
Aetna MCR ADV,CPT,95970,Alys npgt w/o prgrmg,APC 5734,RVU Per Case,$114.56 ,OP,114.56,255.45,,,,,,
Aetna MCR ADV,CPT,95971,Alys smpl sp/pn npgt w/prgrm,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,297.39,,,,,,
Aetna MCR ADV,CPT,95972,Alys cplx sp/pn npgt w/prgrm,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,533.78,,,,,,
Aetna MCR ADV,CPT,95976,Alys smpl cn npgt prgrmg,APC 5741,RVU Per Unit,$38.02 ,OP,38.02,657.7,,,,,,
Aetna MCR ADV,CPT,95977,Alys cplx cn npgt prgrmg,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,876.92,,,,,,
Aetna MCR ADV,CPT,95981,Io anal gast n-stim subsq,APC 5734,RVU Per Case,$114.56 ,OP,114.56,144.88,,,,,,
Aetna MCR ADV,CPT,95982,Io ga n-stim subsq w/reprog,APC 5741,RVU Per Case,$38.02 ,OP,38.02,224.95,,,,,,
Aetna MCR ADV,CPT,95983,Alys brn npgt prgrmg 15 min,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,260.22,,,,,,
Aetna MCR ADV,CPT,95990,Spin/brain pump refil & main,APC 5694,RVU Per Unit,$318.00 ,OP,312.64,318,,,,,,
Aetna MCR ADV,CPT,95991,Spin/brain pump refil & main,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,453.71,,,,,,
Aetna MCR ADV,CPT,95992,Canalith repositioning proc,Physician,Per Unit,$36.73 ,OP,36.73,36.73,,,,,,
Aetna MCR ADV,CPT,95999,Neurological procedure,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
Aetna MCR ADV,CPT,96000,Motion analysis video/3d,APC 5723,RVU Per Unit,$499.16 ,OP,449.9,499.16,,,,,,
Aetna MCR ADV,CPT,96001,Motion test w/ft press meas,APC 5724,RVU Per Unit,$941.27 ,OP,526.16,941.27,,,,,,
Aetna MCR ADV,CPT,96002,Dynamic surface emg,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Aetna MCR ADV,CPT,96003,Dynamic fine wire emg,APC 5722,RVU Per Case,$270.61 ,OP,91.51,270.61,,,,,,
Aetna MCR ADV,CPT,96105,Assessment of aphasia,Physician,Per Unit,$98.92 ,OP,98.92,419.4,,,,,,
Aetna MCR ADV,CPT,96112,Devel tst phys/qhp 1st hr,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,693.9,,,,,,
Aetna MCR ADV,CPT,96116,Nubhvl xm phys/qhp 1st hr,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,518.52,,,,,,
Aetna MCR ADV,CPT,96125,Cognitive test by hc pro,Physician,Per Unit,$103.76 ,OP,103.76,510.9,,,,,,
Aetna MCR ADV,CPT,96127,Brief emotional/behav assmt,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Aetna MCR ADV,CPT,96130,Psycl tst eval phys/qhp 1st,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,438.47,,,,,,
Aetna MCR ADV,CPT,96132,Nrpsyc tst eval phys/qhp 1st,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,583.35,,,,,,
Aetna MCR ADV,CPT,96136,Psycl/nrpsyc tst phy/qhp 1st,APC 5734,RVU Per Unit,$114.56 ,OP,114.56,219.24,,,,,,
Aetna MCR ADV,CPT,96138,Psycl/nrpsyc tech 1st,APC 5735,RVU Per Unit,$276.53 ,OP,133.45,276.53,,,,,,
Aetna MCR ADV,CPT,96146,Psycl/nrpsyc tst auto result,APC 5731,RVU Per Unit,$25.25 ,OP,18.8,25.25,,,,,,
Aetna MCR ADV,CPT,96156,Hlth bhv assmt/reassessment,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,526.34,,,,,,
Aetna MCR ADV,CPT,96158,Hlth bhv ivntj indiv 1st 30,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,236.39,,,,,,
Aetna MCR ADV,CPT,96160,Pt-focused hlth risk assmt,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Aetna MCR ADV,CPT,96161,Caregiver health risk assmt,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Aetna MCR ADV,CPT,96164,Hlth bhv ivntj grp 1st 30,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,61.03,,,,,,
Aetna MCR ADV,CPT,96167,Hlth bhv ivntj fam 1st 30,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,236.39,,,,,,
Aetna MCR ADV,CPT,96360,Hydration iv infusion init,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,293.57,,,,,,
Aetna MCR ADV,CPT,96361,Hydrate iv infusion add-on,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,122.99,,,,,,
Aetna MCR ADV,CPT,96365,Ther/proph/diag iv inf init,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,354.58,,,,,,
Aetna MCR ADV,CPT,96366,Ther/proph/diag iv inf addon,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,114.39,,,,,,
Aetna MCR ADV,CPT,96367,Tx/proph/dg addl seq iv inf,APC 5692,RVU Per Unit,$63.42 ,OP,63.42,179.2,,,,,,
Aetna MCR ADV,CPT,96369,Sc ther infusion up to 1 hr,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,758.72,,,,,,
Aetna MCR ADV,CPT,96370,Sc ther infusion addl hr,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,83.87,,,,,,
Aetna MCR ADV,CPT,96371,Sc ther infusion reset pump,APC 5692,RVU Per Case,$63.42 ,OP,63.42,366.02,,,,,,
Aetna MCR ADV,CPT,96372,Ther/proph/diag inj sc/im,APC 5692,RVU Per Case,$63.42 ,OP,63.42,106.76,,,,,,
Aetna MCR ADV,CPT,96373,Ther/proph/diag inj ia,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,208.24,,,,,,
Aetna MCR ADV,CPT,96374,Ther/proph/diag inj iv push,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,278.32,,,,,,
Aetna MCR ADV,CPT,96375,Tx/pro/dx inj new drug addon,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,202.94,,,,,,
Aetna MCR ADV,CPT,96377,Applicaton on-body injector,APC 5691,RVU Per Case,$40.93 ,OP,40.93,40.93,,,,,,
Aetna MCR ADV,CPT,96379,Ther/prop/diag inj/inf proc,APC 5691,RVU Per Case,$40.93 ,OP,40.93,40.93,,,,,,
Aetna MCR ADV,CPT,96401,Chemo anti-neopl sq/im,APC 5692,RVU Per Case,$63.42 ,OP,63.42,377.46,,,,,,
Aetna MCR ADV,CPT,96402,Chemo hormon antineopl sq/im,APC 5692,RVU Per Case,$63.42 ,OP,63.42,205.88,,,,,,
Aetna MCR ADV,CPT,96405,Chemo intralesional up to 7,APC 5692,RVU Per Case,$63.42 ,OP,63.42,468.96,,,,,,
Aetna MCR ADV,CPT,96406,Chemo intralesional over 7,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,648.16,,,,,,
Aetna MCR ADV,CPT,96409,Chemo iv push sngl drug,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,629.1,,,,,,
Aetna MCR ADV,CPT,96411,Chemo iv push addl drug,APC 5692,RVU Per Unit,$63.42 ,OP,63.42,362.21,,,,,,
Aetna MCR ADV,CPT,96413,Chemo iv infusion 1 hr,APC 5694,RVU Per Unit,$318.00 ,OP,133.34,318,,,,,,
Aetna MCR ADV,CPT,96415,Chemo iv infusion addl hr,APC 5692,RVU Per Unit,$63.42 ,OP,63.42,202.07,,,,,,
Aetna MCR ADV,CPT,96416,Chemo prolong infuse w/pump,APC 5694,RVU Per Unit,$318.00 ,OP,318,926.48,,,,,,
Aetna MCR ADV,CPT,96417,Chemo iv infus each addl seq,APC 5692,RVU Per Unit,$63.42 ,OP,63.42,427.03,,,,,,
Aetna MCR ADV,CPT,96420,Chemo ia push tecnique,APC 5694,RVU Per Unit,$318.00 ,OP,318,613.85,,,,,,
Aetna MCR ADV,CPT,96422,Chemo ia infusion up to 1 hr,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,979.86,,,,,,
Aetna MCR ADV,CPT,96423,Chemo ia infuse each addl hr,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,434.65,,,,,,
Aetna MCR ADV,CPT,96425,Chemotherapy infusion method,APC 5694,RVU Per Unit,$318.00 ,OP,318,968.43,,,,,,
Aetna MCR ADV,CPT,96440,Chemotherapy intracavitary,APC 5694,RVU Per Unit,$318.00 ,OP,318,"3,339.91",,,,,,
Aetna MCR ADV,CPT,96446,Chemotx admn prtl cavity,APC 5694,RVU Per Unit,$318.00 ,OP,318,318,,,,,,
Aetna MCR ADV,CPT,96450,Chemotherapy into cns,APC 5694,RVU Per Unit,$318.00 ,OP,318,"1,159.06",,,,,,
Aetna MCR ADV,CPT,96521,Refill/maint portable pump,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,716.79,,,,,,
Aetna MCR ADV,CPT,96522,Refill/maint pump/resvr syst,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,610.03,,,,,,
Aetna MCR ADV,CPT,96523,Irrig drug delivery device,APC 5733,RVU Per Case,$56.95 ,OP,56.95,141.07,,,,,,
Aetna MCR ADV,CPT,96542,Chemotherapy injection,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,751.1,,,,,,
Aetna MCR ADV,CPT,96549,Chemotherapy unspecified,APC 5691,RVU Per Case,$40.93 ,OP,40.93,40.93,,,,,,
Aetna MCR ADV,CPT,96567,Pdt dstr prmlg les skn,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
Aetna MCR ADV,CPT,96573,Pdt dstr prmlg les phys/qhp,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
Aetna MCR ADV,CPT,96574,Dbrdmt prmlg les w/pdt,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
Aetna MCR ADV,CPT,96900,Ultraviolet light therapy,APC 5732,RVU Per Case,$34.63 ,OP,34.63,114.39,,,,,,
Aetna MCR ADV,CPT,96910,Photochemotherapy with uv-b,APC 5733,RVU Per Case,$56.95 ,OP,56.95,335.53,,,,,,
Aetna MCR ADV,CPT,96912,Photochemotherapy with uv-a,APC 5733,RVU Per Case,$56.95 ,OP,56.95,430.83,,,,,,
Aetna MCR ADV,CPT,96913,Photochemotherapy uv-a or b,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,651.97,,,,,,
Aetna MCR ADV,CPT,96920,Laser tx skin < 250 sq cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
Aetna MCR ADV,CPT,96921,Laser tx skin 250-500 sq cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
Aetna MCR ADV,CPT,96922,Laser tx skin >500 sq cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"1,307.75",,,,,,
Aetna MCR ADV,CPT,96999,Dermatological procedure,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
Aetna MCR ADV,CPT,97012,Mechanical traction therapy,Physician,Per Unit,$14.55 ,OP,14.55,68.63,,,,,,
Aetna MCR ADV,CPT,97016,Vasopneumatic device therapy,Physician,Per Unit,$11.78 ,OP,11.78,72.44,,,,,,
Aetna MCR ADV,CPT,97018,Paraffin bath therapy,Physician,Per Unit,$5.69 ,OP,5.69,5.69,,,,,,
Aetna MCR ADV,CPT,97022,Whirlpool therapy,Physician,Per Unit,$17.16 ,OP,17.16,83.87,,,,,,
Aetna MCR ADV,CPT,97024,Diathermy eg microwave,Physician,Per Unit,$6.96 ,OP,6.96,26.7,,,,,,
Aetna MCR ADV,CPT,97026,Infrared therapy,Physician,Per Unit,$6.32 ,OP,6.32,26.7,,,,,,
Aetna MCR ADV,CPT,97028,Ultraviolet therapy,Physician,Per Unit,$7.98 ,OP,7.98,7.98,,,,,,
Aetna MCR ADV,CPT,97032,Electrical stimulation,Physician,Per Unit,$14.55 ,OP,14.55,76.26,,,,,,
Aetna MCR ADV,CPT,97033,Electric current therapy,Physician,Per Unit,$19.67 ,OP,19.67,114.39,,,,,,
Aetna MCR ADV,CPT,97034,Contrast bath therapy,Physician,Per Unit,$14.42 ,OP,14.42,68.63,,,,,,
Aetna MCR ADV,CPT,97035,Ultrasound therapy,Physician,Per Unit,$14.10 ,OP,14.1,53.38,,,,,,
Aetna MCR ADV,CPT,97036,Hydrotherapy,Physician,Per Unit,$33.09 ,OP,33.09,118.19,,,,,,
Aetna MCR ADV,CPT,97110,Therapeutic exercises,Physician,Per Unit,$29.26 ,OP,29.26,133.45,,,,,,
Aetna MCR ADV,CPT,97112,Neuromuscular reeducation,Physician,Per Unit,$33.86 ,OP,33.86,137.25,,,,,,
Aetna MCR ADV,CPT,97113,Aquatic therapy/exercises,Physician,Per Unit,$36.67 ,OP,36.67,160.13,,,,,,
Aetna MCR ADV,CPT,97116,Gait training therapy,Physician,Per Unit,$29.26 ,OP,29.26,114.39,,,,,,
Aetna MCR ADV,CPT,97124,Massage therapy,Physician,Per Unit,$28.22 ,OP,28.22,106.76,,,,,,
Aetna MCR ADV,CPT,97129,Ther ivntj 1st 15 min,Physician,Per Unit,$23.04 ,OP,23.04,114.39,,,,,,
Aetna MCR ADV,CPT,97130,Ther ivntj ea addl 15 min,Physician,Per Unit,$22.35 ,OP,22.35,110.97,,,,,,
Aetna MCR ADV,CPT,97140,Manual therapy 1/> regions,Physician,Per Unit,$26.97 ,OP,26.97,122,,,,,,
Aetna MCR ADV,CPT,97150,Group therapeutic procedures,Physician,Per Unit,$17.53 ,OP,17.53,83.87,,,,,,
Aetna MCR ADV,CPT,97151,Bhv id assmt by phys/qhp,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Aetna MCR ADV,CPT,97152,Bhv id suprt assmt by 1 tech,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Aetna MCR ADV,CPT,97153,Adaptive behavior tx by tech,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Aetna MCR ADV,CPT,97154,Grp adapt bhv tx by tech,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Aetna MCR ADV,CPT,97155,Adapt behavior tx phys/qhp,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Aetna MCR ADV,CPT,97156,Fam adapt bhv tx gdn phy/qhp,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Aetna MCR ADV,CPT,97157,Mult fam adapt bhv tx gdn,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Aetna MCR ADV,CPT,97158,Grp adapt bhv tx by phy/qhp,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Aetna MCR ADV,CPT,97161,Pt eval low complex 20 min,Physician,Per Unit,$98.12 ,OP,98.12,330.81,,,,,,
Aetna MCR ADV,CPT,97162,Pt eval mod complex 30 min,Physician,Per Unit,$98.12 ,OP,98.12,331.7,,,,,,
Aetna MCR ADV,CPT,97163,Pt eval high complex 45 min,Physician,Per Unit,$98.12 ,OP,98.12,331.7,,,,,,
Aetna MCR ADV,CPT,97164,Pt re-eval est plan care,Physician,Per Unit,$66.97 ,OP,66.97,175.39,,,,,,
Aetna MCR ADV,CPT,97165,Ot eval low complex 30 min,Physician,Per Unit,$95.26 ,OP,95.26,354.58,,,,,,
Aetna MCR ADV,CPT,97166,Ot eval mod complex 45 min,Physician,Per Unit,$95.26 ,OP,95.26,354.58,,,,,,
Aetna MCR ADV,CPT,97167,Ot eval high complex 60 min,Physician,Per Unit,$95.26 ,OP,95.26,354.58,,,,,,
Aetna MCR ADV,CPT,97168,Ot re-eval est plan care,Physician,Per Unit,$64.11 ,OP,64.11,202.07,,,,,,
Aetna MCR ADV,CPT,97530,Therapeutic activities,Physician,Per Unit,$37.50 ,OP,37.5,137.25,,,,,,
Aetna MCR ADV,CPT,97533,Sensory integration,Physician,Per Unit,$57.03 ,OP,57.03,122,,,,,,
Aetna MCR ADV,CPT,97535,Self care mngment training,Physician,Per Unit,$32.44 ,OP,32.44,137.25,,,,,,
Aetna MCR ADV,CPT,97537,Community/work reintegration,Physician,Per Unit,$31.26 ,OP,31.26,125.82,,,,,,
Aetna MCR ADV,CPT,97542,Wheelchair mngment training,Physician,Per Unit,$31.58 ,OP,31.58,125.82,,,,,,
Aetna MCR ADV,CPT,97597,Rmvl devital tis 20 cm/<,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,282.14,,,,,,
Aetna MCR ADV,CPT,97602,Wound(s) care non-selective,APC 5051,RVU Per Case,$183.73 ,OP,171.58,183.73,,,,,,
Aetna MCR ADV,CPT,97605,Neg press wound tx <=50 cm,APC 5051,RVU Per Case,$183.73 ,OP,163.95,183.73,,,,,,
Aetna MCR ADV,CPT,97606,Neg press wound tx >50 cm,APC 5052,RVU Per Case,$353.91 ,OP,175.39,353.91,,,,,,
Aetna MCR ADV,CPT,97607,Neg press wnd tx <=50 sq cm,APC 5052,RVU Per Unit,$353.91 ,OP,163.95,353.91,,,,,,
Aetna MCR ADV,CPT,97608,Neg press wound tx >50 cm,APC 5052,RVU Per Unit,$353.91 ,OP,175.39,353.91,,,,,,
Aetna MCR ADV,CPT,97610,Low frequency non-thermal us,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
Aetna MCR ADV,CPT,97750,Physical performance test,Physician,Per Unit,$33.07 ,OP,33.07,137.25,,,,,,
Aetna MCR ADV,CPT,97755,Assistive technology assess,Physician,Per Unit,$37.42 ,OP,37.42,156.32,,,,,,
Aetna MCR ADV,CPT,97760,Orthotic mgmt&traing 1st enc,Physician,Per Unit,$47.55 ,OP,47.55,152.51,,,,,,
Aetna MCR ADV,CPT,97761,Prosthetic traing 1st enc,Physician,Per Unit,$40.55 ,OP,40.55,133.45,,,,,,
Aetna MCR ADV,CPT,97763,Orthc/prostc mgmt sbsq enc,Physician,Per Unit,$51.94 ,OP,51.94,160.13,,,,,,
Aetna MCR ADV,CPT,97802,Medical nutrition indiv in,Physician,Per Unit,$30.75 ,OP,30.75,148.69,,,,,,
Aetna MCR ADV,CPT,97803,Med nutrition indiv subseq,Physician,Per Unit,$31.17 ,OP,31.17,129.64,,,,,,
Aetna MCR ADV,CPT,97804,Medical nutrition group,Physician,Per Unit,$16.45 ,OP,16.45,64.82,,,,,,
Aetna MCR ADV,CPT,97810,Acupunct w/o stimul 15 min,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,186.82,,,,,,
Aetna MCR ADV,CPT,97813,Acupunct w/stimul 15 min,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,198.25,,,,,,
Aetna MCR ADV,CPT,98925,Osteopath manj 1-2 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,141.07,,,,,,
Aetna MCR ADV,CPT,98926,Osteopath manj 3-4 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,27.17,,,,,,
Aetna MCR ADV,CPT,98927,Osteopath manj 5-6 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,251.64,,,,,,
Aetna MCR ADV,CPT,98928,Osteopath manj 7-8 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,297.39,,,,,,
Aetna MCR ADV,CPT,98929,Osteopath manj 9-10 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,343.14,,,,,,
Aetna MCR ADV,CPT,98940,Chiropract manj 1-2 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,125.82,,,,,,
Aetna MCR ADV,CPT,98941,Chiropract manj 3-4 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,171.58,,,,,,
Aetna MCR ADV,CPT,98942,Chiropractic manj 5 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,224.95,,,,,,
Aetna MCR ADV,CPT,98966,Hc pro phone call 5-10 min,Physician,Per Unit,$12.73 ,OP,12.73,61,,,,,,
Aetna MCR ADV,CPT,98967,Hc pro phone call 11-20 min,Physician,Per Unit,$25.14 ,OP,25.14,118.19,,,,,,
Aetna MCR ADV,CPT,98968,Hc pro phone call 21-30 min,Physician,Per Unit,$37.46 ,OP,37.46,171.58,,,,,,
Aetna MCR ADV,CPT,98970,Qnhp ol dig assmt&mgmt 5-10,Physician,Per Unit,$11.36 ,OP,11.36,11.36,,,,,,
Aetna MCR ADV,CPT,98971,Qnhp ol dig assmt&mgmt 11-20,Physician,Per Unit,$20.31 ,OP,20.31,20.31,,,,,,
Aetna MCR ADV,CPT,98972,Qnhp ol dig assmt&mgmt 21+,Physician,Per Unit,$32.41 ,OP,32.41,32.41,,,,,,
Aetna MCR ADV,CPT,99170,Anogenital exam child w imag,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,663.41,,,,,,
Aetna MCR ADV,CPT,99184,Hypothermia ill neonate,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,99190,Special pump services,APC 5881,RVU Per Case,"$8,948.83 ",OP,"2,299.05","8,948.83",,,,,,
Aetna MCR ADV,CPT,99191,Special pump services,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,612.76","8,948.83",,,,,,
Aetna MCR ADV,CPT,99192,Special pump services,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,151.42","8,948.83",,,,,,
Aetna MCR ADV,CPT,99195,Phlebotomy,APC 5734,RVU Per Case,$114.56 ,OP,114.56,331.7,,,,,,
Aetna MCR ADV,CPT,99281,Emergency dept visit,APC 5021,RVU Per Case,$74.29 ,OP,74.29,245.98,,,,,,
Aetna MCR ADV,CPT,99282,Emergency dept visit,APC 5022,RVU Per Case,$134.66 ,OP,134.66,368.97,,,,,,
Aetna MCR ADV,CPT,99283,Emergency dept visit,APC 5023,RVU Per Case,$237.00 ,OP,237,737.94,,,,,,
Aetna MCR ADV,CPT,99284,Emergency dept visit,APC 5024,RVU Per Case,$372.22 ,OP,372.22,"1,291.40",,,,,,
Aetna MCR ADV,CPT,99285,Emergency dept visit,APC 5025,RVU Per Case,$534.29 ,OP,534.29,"1,967.84",,,,,,
Aetna MCR ADV,CPT,99291,Critical care first hour,APC 5041,RVU Per Case,$708.83 ,OP,708.83,"1,197.20",,,,,,
Aetna MCR ADV,CPT,99356,Prolng svc i/p/obs 1st hour,APC 5881,RVU Per Case,"$8,948.83 ",OP,499.47,"8,948.83",,,,,,
Aetna MCR ADV,CPT,99357,Prolng svc i/p/obs ea addl,APC 5881,RVU Per Case,"$8,948.83 ",OP,507.08,"8,948.83",,,,,,
Aetna MCR ADV,CPT,99406,Behav chng smoking 3-10 min,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,64.82,,,,,,
Aetna MCR ADV,CPT,99407,Behav chng smoking > 10 min,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,125.82,,,,,,
Aetna MCR ADV,CPT,99453,Rem mntr physiol param setup,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,121.51,,,,,,
Aetna MCR ADV,CPT,99454,Rem mntr physiol param dev,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Aetna MCR ADV,CPT,99460,Init nb em per day hosp,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,305.01,,,,,,
Aetna MCR ADV,CPT,99462,Sbsq nb em per day hosp,APC 5881,RVU Per Case,"$8,948.83 ",OP,160.13,"8,948.83",,,,,,
Aetna MCR ADV,CPT,99463,Same day nb discharge,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,404.14,,,,,,
Aetna MCR ADV,CPT,99465,Nb resuscitation,APC 5781,RVU Per Unit,$575.01 ,OP,575.01,781.61,,,,,,
Aetna MCR ADV,CPT,99468,Neonate crit care initial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,510.41","8,948.83",,,,,,
Aetna MCR ADV,CPT,99469,Neonate crit care subsq,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,936.85","8,948.83",,,,,,
Aetna MCR ADV,CPT,99471,Ped critical care initial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,049.07","8,948.83",,,,,,
Aetna MCR ADV,CPT,99472,Ped critical care subsq,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,982.60","8,948.83",,,,,,
Aetna MCR ADV,CPT,99473,Self-meas bp pt educaj/train,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Aetna MCR ADV,CPT,99475,Ped crit care age 2-5 init,APC 5881,RVU Per Case,"$8,948.83 ",OP,"2,790.89","8,948.83",,,,,,
Aetna MCR ADV,CPT,99476,Ped crit care age 2-5 subsq,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,643.28","8,948.83",,,,,,
Aetna MCR ADV,CPT,99477,Init day hosp neonate care,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,734.78","8,948.83",,,,,,
Aetna MCR ADV,CPT,99478,Ic lbw inf < 1500 gm subsq,APC 5881,RVU Per Case,"$8,948.83 ",OP,716.79,"8,948.83",,,,,,
Aetna MCR ADV,CPT,99479,Ic lbw inf 1500-2500 g subsq,APC 5881,RVU Per Case,"$8,948.83 ",OP,629.1,"8,948.83",,,,,,
Aetna MCR ADV,CPT,99480,Ic inf pbw 2501-5000 g subsq,APC 5881,RVU Per Case,"$8,948.83 ",OP,606.21,"8,948.83",,,,,,
Aetna MCR ADV,CPT,99483,Assmt & care pln pt cog imp,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Aetna MCR ADV,CPT,99484,Care mgmt svc bhvl hlth cond,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Aetna MCR ADV,CPT,99487,Cplx chrnc care 1st 60 min,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,136.74,,,,,,
Aetna MCR ADV,CPT,99490,Chrnc care mgmt svc 1st 20,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Aetna MCR ADV,CPT,99492,1st psyc collab care mgmt,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Aetna MCR ADV,CPT,99493,Sbsq psyc collab care mgmt,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Aetna MCR ADV,CPT,99495,Trans care mgmt 14 day disch,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,121.51,,,,,,
Aetna MCR ADV,CPT,99496,Trans care mgmt 7 day disch,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,121.51,,,,,,
Aetna MCR ADV,CPT,99497,Advncd care plan 30 min,APC 5822,RVU Per Case,$76.62 ,OP,76.62,76.62,,,,,,
Aetna MCR ADV,CPT,0001A,Adm sarscov2 30mcg/0.3ml 1st,APC 9397,RVU Per Unit,$40.93 ,OP,40.93,40.93,,,,,,
Aetna MCR ADV,CPT,0001U,Rbc dna hea 35 ag 11 bld grp,Lab Services,Per Unit,$720.00 ,OP,720,720,,,,,,
Aetna MCR ADV,CPT,0002A,Adm sarscov2 30mcg/0.3ml 2nd,APC 9398,RVU Per Unit,$40.93 ,OP,40.93,40.93,,,,,,
Aetna MCR ADV,CPT,0002M,Liver dis 10 assays w/ash,Lab Services,Per Unit,$503.40 ,OP,503.4,503.4,,,,,,
Aetna MCR ADV,CPT,0002U,Onc clrct 3 ur metab alg plp,Lab Services,Per Unit,$25.00 ,OP,25,25,,,,,,
Aetna MCR ADV,CPT,0003A,Adm sarscov2 30mcg/0.3ml 3rd,APC 9398,RVU Per Unit,$40.93 ,OP,40.93,40.93,,,,,,
Aetna MCR ADV,CPT,0003M,Liver dis 10 assays w/nash,Lab Services,Per Unit,$503.40 ,OP,503.4,503.4,,,,,,
Aetna MCR ADV,CPT,0003U,Onc ovar 5 prtn ser alg scor,Lab Services,Per Unit,$950.00 ,OP,950,950,,,,,,
Aetna MCR ADV,CPT,0004M,Scoliosis dna alys,Lab Services,Per Unit,$79.00 ,OP,79,79,,,,,,
Aetna MCR ADV,CPT,0005U,Onco prst8 3 gene ur alg,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
Aetna MCR ADV,CPT,0006M,Onc hep gene risk classifier,Lab Services,Per Unit,$150.00 ,OP,150,150,,,,,,
Aetna MCR ADV,CPT,0007M,Onc gastro 51 gene nomogram,Lab Services,Per Unit,$375.00 ,OP,375,375,,,,,,
Aetna MCR ADV,CPT,0007U,Rx test prsmv ur w/def conf,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
Aetna MCR ADV,CPT,0008U,Hpylori detcj abx rstnc dna,Lab Services,Per Unit,$597.91 ,OP,597.91,597.91,,,,,,
Aetna MCR ADV,CPT,0009U,Onc brst ca erbb2 amp/nonamp,Lab Services,Per Unit,$107.00 ,OP,107,107,,,,,,
Aetna MCR ADV,CPT,0010U,Nfct ds strn typ whl gen seq,Lab Services,Per Unit,$427.26 ,OP,427.26,427.26,,,,,,
Aetna MCR ADV,CPT,0011A,Adm sarscov2 100mcg/0.5ml1st,APC 9397,RVU Per Unit,$40.93 ,OP,40.93,40.93,,,,,,
Aetna MCR ADV,CPT,0011M,Onc prst8 ca mrna 12 gen alg,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
Aetna MCR ADV,CPT,0011U,Rx mntr lc-ms/ms oral fluid,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
Aetna MCR ADV,CPT,0012A,Adm sarscov2 100mcg/0.5ml2nd,APC 9398,RVU Per Unit,$40.93 ,OP,40.93,40.93,,,,,,
Aetna MCR ADV,CPT,0012M,Onc mrna 5 gen rsk urthl ca,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
Aetna MCR ADV,CPT,0012U,Germln do gene reargmt detcj,Lab Services,Per Unit,"$2,515.60 ",OP,"2,515.60","2,515.60",,,,,,
Aetna MCR ADV,CPT,0013A,Adm sarscov2 100mcg/0.5ml3rd,APC 9398,RVU Per Unit,$40.93 ,OP,40.93,40.93,,,,,,
Aetna MCR ADV,CPT,0013M,Onc mrna 5 gen recr urthl ca,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
Aetna MCR ADV,CPT,0013U,Onc sld org neo gene reargmt,Lab Services,Per Unit,"$2,515.60 ",OP,"2,515.60","2,515.60",,,,,,
Aetna MCR ADV,CPT,0014M,Liver ds alys 3 bmrk srm alg,Lab Services,Per Unit,$176.19 ,OP,176.19,176.19,,,,,,
Aetna MCR ADV,CPT,0014U,Hem hmtlmf neo gene reargmt,Lab Services,Per Unit,"$2,515.60 ",OP,"2,515.60","2,515.60",,,,,,
Aetna MCR ADV,CPT,0016U,Onc hmtlmf neo rna bcr/abl1,Lab Services,Per Unit,$163.96 ,OP,163.96,163.96,,,,,,
Aetna MCR ADV,CPT,0017U,Onc hmtlmf neo jak2 mut dna,Lab Services,Per Unit,$91.66 ,OP,91.66,91.66,,,,,,
Aetna MCR ADV,CPT,0018U,Onc thyr 10 microrna seq alg,Lab Services,Per Unit,"$3,002.09 ",OP,"3,002.09","3,002.09",,,,,,
Aetna MCR ADV,CPT,0019U,Onc rna tiss predict alg,Lab Services,Per Unit,"$3,675.00 ",OP,"3,675.00","3,675.00",,,,,,
Aetna MCR ADV,CPT,0021U,Onc prst8 detcj 8 autoantb,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
Aetna MCR ADV,CPT,0022U,Trgt gen seq dna&rna 23 gene,Lab Services,Per Unit,"$1,950.00 ",OP,"1,950.00","1,950.00",,,,,,
Aetna MCR ADV,CPT,0023U,Onc aml dna detcj/nondetcj,Lab Services,Per Unit,$248.51 ,OP,248.51,248.51,,,,,,
Aetna MCR ADV,CPT,0024U,Glyca nuc mr spectrsc quan,Lab Services,Per Unit,$34.19 ,OP,34.19,34.19,,,,,,
Aetna MCR ADV,CPT,0025U,Tenofovir liq chrom ur quan,Lab Services,Per Unit,$85.77 ,OP,85.77,85.77,,,,,,
Aetna MCR ADV,CPT,0026U,Onc thyr dna&mrna 112 genes,Lab Services,Per Unit,"$3,600.00 ",OP,"3,600.00","3,600.00",,,,,,
Aetna MCR ADV,CPT,0027U,Jak2 gene trgt seq alys,Lab Services,Per Unit,$121.91 ,OP,121.91,121.91,,,,,,
Aetna MCR ADV,CPT,0029U,Rx metab advrs trgt seq alys,Lab Services,Per Unit,$742.27 ,OP,742.27,742.27,,,,,,
Aetna MCR ADV,CPT,0030U,Rx metab warf trgt seq alys,Lab Services,Per Unit,$134.13 ,OP,134.13,134.13,,,,,,
Aetna MCR ADV,CPT,0031A,Adm sarscov2 vac ad26 .5ml,APC 9398,RVU Per Unit,$40.93 ,OP,40.93,40.93,,,,,,
Aetna MCR ADV,CPT,0031U,Cyp1a2 gene,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Aetna MCR ADV,CPT,0032U,Comt gene,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Aetna MCR ADV,CPT,0033U,Htr2a htr2c genes,Lab Services,Per Unit,$349.62 ,OP,349.62,349.62,,,,,,
Aetna MCR ADV,CPT,0034U,Tpmt nudt15 genes,Lab Services,Per Unit,$466.17 ,OP,466.17,466.17,,,,,,
Aetna MCR ADV,CPT,0035U,Neuro csf prion prtn qual,Lab Services,Per Unit,$540.99 ,OP,540.99,540.99,,,,,,
Aetna MCR ADV,CPT,0036U,Xome tum & nml spec seq alys,Lab Services,Per Unit,"$4,780.00 ",OP,"4,780.00","4,780.00",,,,,,
Aetna MCR ADV,CPT,0037U,Trgt gen seq dna 324 genes,Lab Services,Per Unit,"$3,500.00 ",OP,"3,500.00","3,500.00",,,,,,
Aetna MCR ADV,CPT,0038U,Vitamin d srm microsamp quan,Lab Services,Per Unit,$29.60 ,OP,29.6,29.6,,,,,,
Aetna MCR ADV,CPT,0039U,Dna antb 2strand hi avidity,Lab Services,Per Unit,$13.74 ,OP,13.74,13.74,,,,,,
Aetna MCR ADV,CPT,0040U,Bcr/abl1 gene major bp quan,Lab Services,Per Unit,$409.90 ,OP,409.9,409.9,,,,,,
Aetna MCR ADV,CPT,0041U,B brgdrferi antb 5 prtn igm,Lab Services,Per Unit,$17.21 ,OP,17.21,17.21,,,,,,
Aetna MCR ADV,CPT,0042U,B brgdrferi antb 12 prtn igg,Lab Services,Per Unit,$17.21 ,OP,17.21,17.21,,,,,,
Aetna MCR ADV,CPT,0043U,Tbrf b grp antb 4 prtn igm,Lab Services,Per Unit,$14.86 ,OP,14.86,14.86,,,,,,
Aetna MCR ADV,CPT,0044U,Tbrf b grp antb 4 prtn igg,Lab Services,Per Unit,$14.86 ,OP,14.86,14.86,,,,,,
Aetna MCR ADV,CPT,0045U,Onc brst dux carc is 12 gene,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
Aetna MCR ADV,CPT,0046U,Flt3 gene itd variants quan,Lab Services,Per Unit,$407.43 ,OP,407.43,407.43,,,,,,
Aetna MCR ADV,CPT,0047U,Onc prst8 mrna 17 gene alg,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
Aetna MCR ADV,CPT,0048U,Onc sld org neo dna 468 gene,Lab Services,Per Unit,"$2,919.60 ",OP,"2,919.60","2,919.60",,,,,,
Aetna MCR ADV,CPT,0049U,Npm1 gene analysis quan,Lab Services,Per Unit,$407.43 ,OP,407.43,407.43,,,,,,
Aetna MCR ADV,CPT,0050U,Trgt gen seq dna 194 genes,Lab Services,Per Unit,"$2,916.60 ",OP,"2,916.60","2,916.60",,,,,,
Aetna MCR ADV,CPT,0051U,Rx mntr lc-ms/ms ur 31 pnl,Lab Services,Per Unit,$193.71 ,OP,193.71,193.71,,,,,,
Aetna MCR ADV,CPT,0052U,Lpoprtn bld w/5 maj classes,Lab Services,Per Unit,$33.86 ,OP,33.86,33.86,,,,,,
Aetna MCR ADV,CPT,0053U,Onc prst8 ca fish alys 4 gen,Lab Services,Per Unit,"$2,030.00 ",OP,"2,030.00","2,030.00",,,,,,
Aetna MCR ADV,CPT,0054U,Rx mntr 14+ drugs & sbsts,Lab Services,Per Unit,$148.96 ,OP,148.96,148.96,,,,,,
Aetna MCR ADV,CPT,0055U,Card hrt trnspl 96 dna seq,Lab Services,Per Unit,"$3,240.00 ",OP,"3,240.00","3,240.00",,,,,,
Aetna MCR ADV,CPT,0056U,Hem aml dna gene reargmt,Lab Services,Per Unit,"$2,515.60 ",OP,"2,515.60","2,515.60",,,,,,
Aetna MCR ADV,CPT,0058U,Onc merkel cll carc srm quan,Lab Services,Per Unit,$322.96 ,OP,322.96,322.96,,,,,,
Aetna MCR ADV,CPT,0059U,Onc merkel cll carc srm +/-,Lab Services,Per Unit,$322.96 ,OP,322.96,322.96,,,,,,
Aetna MCR ADV,CPT,0060U,Twn zyg gen seq alys chrms2,Lab Services,Per Unit,$759.05 ,OP,759.05,759.05,,,,,,
Aetna MCR ADV,CPT,0061U,Tc meas 5 bmrk sfdi m-s alys,Lab Services,Per Unit,$25.10 ,OP,25.1,25.1,,,,,,
Aetna MCR ADV,CPT,0062U,Ai sle igg&igm alys 80 bmrk,Lab Services,Per Unit,$380.72 ,OP,380.72,380.72,,,,,,
Aetna MCR ADV,CPT,0063U,Neuro autism 32 amines alg,Lab Services,Per Unit,$750.00 ,OP,750,750,,,,,,
Aetna MCR ADV,CPT,0064U,Antb tp total&rpr ia qual,Lab Services,Per Unit,$31.33 ,OP,31.33,31.33,,,,,,
Aetna MCR ADV,CPT,0065U,Syfls tst nontreponemal antb,Lab Services,Per Unit,$18.09 ,OP,18.09,18.09,,,,,,
Aetna MCR ADV,CPT,0066U,Pamg-1 ia cervico-vag fluid,Lab Services,Per Unit,$15.29 ,OP,15.29,15.29,,,,,,
Aetna MCR ADV,CPT,0067U,Onc brst imhchem prfl 4 bmrk,Lab Services,Per Unit,"$1,897.00 ",OP,"1,897.00","1,897.00",,,,,,
Aetna MCR ADV,CPT,0068U,Candida species pnl amp prb,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
Aetna MCR ADV,CPT,0069U,Onc clrct microrna mir-31-3p,Lab Services,Per Unit,$380.00 ,OP,380,380,,,,,,
Aetna MCR ADV,CPT,0070U,Cyp2d6 gen com&slct rar vrnt,Lab Services,Per Unit,$676.37 ,OP,676.37,676.37,,,,,,
Aetna MCR ADV,CPT,0071T,Us leiomyomata ablate <200,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","2,684.38",,,,,,
Aetna MCR ADV,CPT,0071U,Cyp2d6 full gene sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,
Aetna MCR ADV,CPT,0072T,Us leiomyomata ablate >200,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","2,684.38",,,,,,
Aetna MCR ADV,CPT,0072U,Cyp2d6 gen cyp2d6-2d7 hybrid,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,
Aetna MCR ADV,CPT,0073U,Cyp2d6 gen cyp2d7-2d6 hybrid,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,
Aetna MCR ADV,CPT,0074U,Cyp2d6 nonduplicated gene,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,
Aetna MCR ADV,CPT,0075T,Perq stent/chest vert art,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,0075U,Cyp2d6 5' gene dup/mlt,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,
Aetna MCR ADV,CPT,0076T,S&i stent/chest vert art,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,0076U,Cyp2d6 3' gene dup/mlt,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,
Aetna MCR ADV,CPT,0077U,Ig paraprotein qual bld/ur,Lab Services,Per Unit,$43.43 ,OP,43.43,43.43,,,,,,
Aetna MCR ADV,CPT,0078U,Pain mgt opi use gnotyp pnl,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,
Aetna MCR ADV,CPT,0080U,Onc lng 5 clin rsk factr alg,Lab Services,Per Unit,"$3,520.00 ",OP,"3,520.00","3,520.00",,,,,,
Aetna MCR ADV,CPT,0082U,Rx test def 90+ rx/sbsts ur,Lab Services,Per Unit,$246.92 ,OP,246.92,246.92,,,,,,
Aetna MCR ADV,CPT,0083U,Onc rspse chemo cntrst tomog,Lab Services,Per Unit,$167.35 ,OP,167.35,167.35,,,,,,
Aetna MCR ADV,CPT,0084U,Rbc dna gnotyp 10 bld groups,Lab Services,Per Unit,$720.00 ,OP,720,720,,,,,,
Aetna MCR ADV,CPT,0086U,Nfct ds bact&fng org id 6+,Lab Services,Per Unit,$200.00 ,OP,200,200,,,,,,
Aetna MCR ADV,CPT,0087U,Crd hrt trnspl mrna 1283 gen,Lab Services,Per Unit,"$3,159.42 ",OP,"3,159.42","3,159.42",,,,,,
Aetna MCR ADV,CPT,0088U,Trnsplj kdn algrft rej 1494,Lab Services,Per Unit,"$3,159.42 ",OP,"3,159.42","3,159.42",,,,,,
Aetna MCR ADV,CPT,0089U,Onc mlnma prame & linc00518,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
Aetna MCR ADV,CPT,0090U,Onc cutan mlnma mrna 23 gene,Lab Services,Per Unit,"$1,755.00 ",OP,"1,755.00","1,755.00",,,,,,
Aetna MCR ADV,CPT,0092U,Onc lng 3 prtn bmrk plsm alg,Lab Services,Per Unit,"$2,488.00 ",OP,"2,488.00","2,488.00",,,,,,
Aetna MCR ADV,CPT,0093U,Rx mntr 65 com drugs urine,Lab Services,Per Unit,$62.14 ,OP,62.14,62.14,,,,,,
Aetna MCR ADV,CPT,0094U,Genome rapid sequence alys,Lab Services,Per Unit,"$7,582.20 ",OP,"7,582.20","7,582.20",,,,,,
Aetna MCR ADV,CPT,0095U,Inflm ee elisa alys alg,Lab Services,Per Unit,$771.98 ,OP,771.98,771.98,,,,,,
Aetna MCR ADV,CPT,0096U,Hpv hi risk types male urine,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,
Aetna MCR ADV,CPT,0097U,Gi pathogen 22 targets,Lab Services,Per Unit,$363.04 ,OP,363.04,363.04,,,,,,
Aetna MCR ADV,CPT,0101T,Extracorp shockwv tx hi enrg,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","2,896.40",,,,,,
Aetna MCR ADV,CPT,0102T,Extracorp shockwv tx anesth,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","2,896.40",,,,,,
Aetna MCR ADV,CPT,0105U,Neph ckd mult eclia tum nec,Lab Services,Per Unit,$950.00 ,OP,950,950,,,,,,
Aetna MCR ADV,CPT,0106T,Touch quant sensory test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Aetna MCR ADV,CPT,0106U,Gstr emptg 7 timed brth spec,Lab Services,Per Unit,$874.49 ,OP,874.49,874.49,,,,,,
Aetna MCR ADV,CPT,0107T,Vibrate quant sensory test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Aetna MCR ADV,CPT,0107U,C diff tox ag detcj ia stool,Lab Services,Per Unit,$16.00 ,OP,16,16,,,,,,
Aetna MCR ADV,CPT,0108T,Cool quant sensory test,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Aetna MCR ADV,CPT,0108U,Gi barrett esoph 9 prtn bmrk,Lab Services,Per Unit,"$2,513.25 ",OP,"2,513.25","2,513.25",,,,,,
Aetna MCR ADV,CPT,0109T,Heat quant sensory test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Aetna MCR ADV,CPT,0109U,Id aspergillus dna 4 species,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
Aetna MCR ADV,CPT,0110T,Nos quant sensory test,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Aetna MCR ADV,CPT,0110U,Rx mntr 1+oral onc rx&sbsts,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,
Aetna MCR ADV,CPT,0111U,Onc colon ca kras&nras alys,Lab Services,Per Unit,$682.29 ,OP,682.29,682.29,,,,,,
Aetna MCR ADV,CPT,0112U,Iadi 16s&18s rrna genes,Lab Services,Per Unit,$356.13 ,OP,356.13,356.13,,,,,,
Aetna MCR ADV,CPT,0113U,Onc prst8 pca3&tmprss2-erg,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
Aetna MCR ADV,CPT,0114U,Gi barretts esoph vim&ccna1,Lab Services,Per Unit,"$1,938.01 ",OP,"1,938.01","1,938.01",,,,,,
Aetna MCR ADV,CPT,0115U,Respir iadna 18 viral&2 bact,Lab Services,Per Unit,$275.35 ,OP,275.35,275.35,,,,,,
Aetna MCR ADV,CPT,0116U,Rx mntr nzm ia 35+oral flu,Lab Services,Per Unit,$246.92 ,OP,246.92,246.92,,,,,,
Aetna MCR ADV,CPT,0117U,Pain mgmt 11 endogenous anal,Lab Services,Per Unit,$840.65 ,OP,840.65,840.65,,,,,,
Aetna MCR ADV,CPT,0118U,Trnsplj don-drv cll-fr dna,Lab Services,Per Unit,"$2,753.25 ",OP,"2,753.25","2,753.25",,,,,,
Aetna MCR ADV,CPT,0119U,Crd ceramides liq chrom plsm,Lab Services,Per Unit,$83.76 ,OP,83.76,83.76,,,,,,
Aetna MCR ADV,CPT,0120U,Onc b cll lymphm mrna 58 gen,Lab Services,Per Unit,"$2,510.21 ",OP,"2,510.21","2,510.21",,,,,,
Aetna MCR ADV,CPT,0121U,Sc dis vcam-1 whole blood,Lab Services,Per Unit,$509.20 ,OP,509.2,509.2,,,,,,
Aetna MCR ADV,CPT,0122U,Sc dis p-selectin whl blood,Lab Services,Per Unit,$526.23 ,OP,526.23,526.23,,,,,,
Aetna MCR ADV,CPT,0123U,Mchnl fragility rbc prflg,Lab Services,Per Unit,$357.63 ,OP,357.63,357.63,,,,,,
Aetna MCR ADV,CPT,0130U,Hered colon ca do mrna pnl,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,
Aetna MCR ADV,CPT,0131U,Hered brst ca rltd do pnl 13,Lab Services,Per Unit,$710.00 ,OP,710,710,,,,,,
Aetna MCR ADV,CPT,0132U,Hered ova ca rltd do pnl 17,Lab Services,Per Unit,$741.64 ,OP,741.64,741.64,,,,,,
Aetna MCR ADV,CPT,0133U,Hered prst8 ca rltd do 11,Lab Services,Per Unit,$690.29 ,OP,690.29,690.29,,,,,,
Aetna MCR ADV,CPT,0134U,Hered pan ca mrna pnl 18 gen,Lab Services,Per Unit,$748.39 ,OP,748.39,748.39,,,,,,
Aetna MCR ADV,CPT,0135U,Hered gyn ca mrna pnl 12 gen,Lab Services,Per Unit,$700.56 ,OP,700.56,700.56,,,,,,
Aetna MCR ADV,CPT,0136U,Atm mrna seq alys,Lab Services,Per Unit,$407.43 ,OP,407.43,407.43,,,,,,
Aetna MCR ADV,CPT,0137U,Palb2 mrna seq alys,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,
Aetna MCR ADV,CPT,0138U,Brca1 brca2 mrna seq alys,Lab Services,Per Unit,$468.33 ,OP,468.33,468.33,,,,,,
Aetna MCR ADV,CPT,0145U,Drug assay 65+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
Aetna MCR ADV,CPT,0146U,Drug assay 80+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
Aetna MCR ADV,CPT,0147U,Drug assay 85+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
Aetna MCR ADV,CPT,0148U,Drug assay 100+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
Aetna MCR ADV,CPT,0149U,Drug assay 60+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
Aetna MCR ADV,CPT,0150U,Drug assay 120+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
Aetna MCR ADV,CPT,0154U,Onc urthl ca rna fgfr3 gene,Lab Services,Per Unit,$482.14 ,OP,482.14,482.14,,,,,,
Aetna MCR ADV,CPT,0155U,Onc brst ca dna pik3ca gene,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Aetna MCR ADV,CPT,0166U,Liver ds 10 biochem asy srm,Lab Services,Per Unit,$503.40 ,OP,503.4,503.4,,,,,,
Aetna MCR ADV,CPT,0167U,Chornc gonadotropin hcg ia,Lab Services,Per Unit,$7.52 ,OP,7.52,7.52,,,,,,
Aetna MCR ADV,CPT,0169U,Nudt15&tpmt gene com vrnt,Lab Services,Per Unit,$466.17 ,OP,466.17,466.17,,,,,,
Aetna MCR ADV,CPT,0170U,Neuro asd rna next gen seq,Lab Services,Per Unit,"$1,755.00 ",OP,"1,755.00","1,755.00",,,,,,
Aetna MCR ADV,CPT,0172U,Onc sld tum alys brca1 brca2,Lab Services,Per Unit,"$3,030.00 ",OP,"3,030.00","3,030.00",,,,,,
Aetna MCR ADV,CPT,0176U,Cdtb&vinculin igg antb ia,Lab Services,Per Unit,$64.19 ,OP,64.19,64.19,,,,,,
Aetna MCR ADV,CPT,0177U,Onc brst ca dna pik3ca 11,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Aetna MCR ADV,CPT,0181U,Co gnotyp aqp1 exon 1,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Aetna MCR ADV,CPT,0182U,Crom gnotyp cd55 exons 1-10,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,
Aetna MCR ADV,CPT,0183U,Di gnotyp slc4a1 exon 19,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Aetna MCR ADV,CPT,0184T,Exc rectal tumor endoscopic,APC 5331,RVU Per Case,"$5,145.78 ",OP,"5,145.78","5,145.78",,,,,,
Aetna MCR ADV,CPT,0184U,Do gnotyp art4 exon 2,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Aetna MCR ADV,CPT,0185U,Fut1 gnotyp fut1 exon 4,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Aetna MCR ADV,CPT,0186U,Fut2 gnotyp fut2 exon 2,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Aetna MCR ADV,CPT,0187U,Fy gnotyp ackr1 exons 1-2,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Aetna MCR ADV,CPT,0188U,Ge gnotyp gypc exons 1-4,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Aetna MCR ADV,CPT,0189U,Gypa gnotyp ntrns 1 5 exon 2,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Aetna MCR ADV,CPT,0190U,Gypb gnotyp ntrns 1 5 seux 3,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Aetna MCR ADV,CPT,0191T,Insert ant segment drain int,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,009.10",,,,,,
Aetna MCR ADV,CPT,0191U,In gnotyp cd44 exons 2 3 6,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Aetna MCR ADV,CPT,0192U,Jk gnotyp slc14a1 exon 9,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Aetna MCR ADV,CPT,0193U,Jr gnotyp abcg2 exons 2-26,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,
Aetna MCR ADV,CPT,0194U,Kel gnotyp kel exon 8,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Aetna MCR ADV,CPT,0195U,Klf1 targeted sequencing,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,
Aetna MCR ADV,CPT,0196U,Lu gnotyp bcam exon 3,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Aetna MCR ADV,CPT,0197U,Lw gnotyp icam4 exon 1,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Aetna MCR ADV,CPT,0198T,Ocular blood flow measure,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Aetna MCR ADV,CPT,0198U,Rhd&rhce gntyp rhd1-10&rhce5,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,
Aetna MCR ADV,CPT,0199U,Sc gnotyp ermap exons 4 12,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Aetna MCR ADV,CPT,0200T,Perq sacral augmt unilat inj,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
Aetna MCR ADV,CPT,0200U,Xk gnotyp xk exons 1-3,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Aetna MCR ADV,CPT,0201T,Perq sacral augmt bilat inj,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
Aetna MCR ADV,CPT,0201U,Yt gnotyp ache exon 2,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Aetna MCR ADV,CPT,0202T,Post vert arthrplst 1 lumbar,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
Aetna MCR ADV,CPT,0202U,Nfct ds 22 trgt sars-cov-2,Lab Services,Per Unit,$416.78 ,OP,416.78,416.78,,,,,,
Aetna MCR ADV,CPT,0203U,Ai ibd mrna xprsn prfl 17,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
Aetna MCR ADV,CPT,0204U,Onc thyr mrna xprsn alys 593,Lab Services,Per Unit,"$2,919.60 ",OP,"2,919.60","2,919.60",,,,,,
Aetna MCR ADV,CPT,0205U,Oph amd alys 3 gene variants,Lab Services,Per Unit,$47.00 ,OP,47,47,,,,,,
Aetna MCR ADV,CPT,0207T,Clear eyelid gland w/heat,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Aetna MCR ADV,CPT,0208T,Audiometry air only,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Aetna MCR ADV,CPT,0209T,Audiometry air & bone,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Aetna MCR ADV,CPT,0210T,Speech audiometry threshold,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Aetna MCR ADV,CPT,0210U,Syphilis tst antb ia quan,Lab Services,Per Unit,$18.63 ,OP,18.63,18.63,,,,,,
Aetna MCR ADV,CPT,0211T,Speech audiom thresh & recog,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Aetna MCR ADV,CPT,0212T,Compre audiometry evaluation,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
Aetna MCR ADV,CPT,0213T,Njx paravert w/us cer/thor,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,841.63,,,,,,
Aetna MCR ADV,CPT,0216T,Njx paravert w/us lumb/sac,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,841.63,,,,,,
Aetna MCR ADV,CPT,0218U,Neuro musc dys dmd seq alys,Lab Services,Per Unit,"$2,279.00 ",OP,"2,279.00","2,279.00",,,,,,
Aetna MCR ADV,CPT,0219T,Plmt post facet implt cerv,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
Aetna MCR ADV,CPT,0220T,Plmt post facet implt thor,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
Aetna MCR ADV,CPT,0221T,Plmt post facet implt lumb,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
Aetna MCR ADV,CPT,0224U,Antibody sars-cov-2 titer(s),Lab Services,Per Unit,$42.13 ,OP,42.13,42.13,,,,,,
Aetna MCR ADV,CPT,0226U,Svnt sarscov2 elisa plsm srm,Lab Services,Per Unit,$42.28 ,OP,42.28,42.28,,,,,,
Aetna MCR ADV,CPT,0232T,Njx platelet plasma,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
Aetna MCR ADV,CPT,0234T,Trluml perip athrc renal art,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Aetna MCR ADV,CPT,0235T,Trluml perip athrc visceral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,0236T,Trluml perip athrc abd aorta,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Aetna MCR ADV,CPT,0237T,Trluml perip athrc brchiocph,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Aetna MCR ADV,CPT,0238T,Trluml perip athrc iliac art,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Aetna MCR ADV,CPT,0239U,Trgt gen seq alys pnl 311+,Lab Services,Per Unit,"$3,500.00 ",OP,"3,500.00","3,500.00",,,,,,
Aetna MCR ADV,CPT,0240U,Nfct ds vir resp rna 3 trgt,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
Aetna MCR ADV,CPT,0241U,Nfct ds vir resp rna 4 trgt,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
Aetna MCR ADV,CPT,0242U,Trgt gen seq alys pnl 55-74,Lab Services,Per Unit,"$5,000.00 ",OP,"5,000.00","5,000.00",,,,,,
Aetna MCR ADV,CPT,0253T,Insert aqueous drain device,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,009.10",,,,,,
Aetna MCR ADV,CPT,0263T,Im b1 mrw cel ther cmpl,APC 5243,RVU Per Unit,"$4,131.87 ",OP,"4,131.87","4,131.87",,,,,,
Aetna MCR ADV,CPT,0264T,Im b1 mrw cel ther xcl hrvst,APC 5243,RVU Per Unit,"$4,131.87 ",OP,"4,131.87","4,131.87",,,,,,
Aetna MCR ADV,CPT,0265T,Im b1 mrw cel ther hrvst onl,APC 5243,RVU Per Unit,"$4,131.87 ",OP,"4,131.87","4,131.87",,,,,,
Aetna MCR ADV,CPT,0266T,Implt/rpl crtd sns dev total,APC 5465,RVU Per Case,"$30,131.14 ",OP,"30,131.14","30,131.14",,,,,,
Aetna MCR ADV,CPT,0267T,Implt/rpl crtd sns dev lead,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Aetna MCR ADV,CPT,0268T,Implt/rpl crtd sns dev gen,APC 5465,RVU Per Case,"$30,131.14 ",OP,"30,131.14","30,131.14",,,,,,
Aetna MCR ADV,CPT,0269T,Rev/remvl crtd sns dev total,APC 5432,RVU Per Case,"$5,833.22 ",OP,"5,833.22","5,833.22",,,,,,
Aetna MCR ADV,CPT,0270T,Rev/remvl crtd sns dev lead,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Aetna MCR ADV,CPT,0271T,Rev/remvl crtd sns dev gen,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Aetna MCR ADV,CPT,0272T,Interrogate crtd sns dev,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Aetna MCR ADV,CPT,0273T,Interrogate crtd sns w/pgrmg,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Aetna MCR ADV,CPT,0274T,Perq lamot/lam crv/thrc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
Aetna MCR ADV,CPT,0275T,Perq lamot/lam lumbar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
Aetna MCR ADV,CPT,0278T,Tempr,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
Aetna MCR ADV,CPT,0308T,Insj ocular telescope prosth,APC 5495,RVU Per Case,"$21,250.81 ",OP,"21,250.81","21,250.81",,,,,,
Aetna MCR ADV,CPT,0312T,Laps impltj nstim vagus,APC 5465,RVU Per Case,"$30,131.14 ",OP,"30,131.14","30,131.14",,,,,,
Aetna MCR ADV,CPT,0313T,Laps rmvl nstim array vagus,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Aetna MCR ADV,CPT,0314T,Laps rmvl vgl arry&pls gen,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Aetna MCR ADV,CPT,0315T,Rmvl vagus nerve pls gen,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Aetna MCR ADV,CPT,0316T,Replc vagus nerve pls gen,APC 5465,RVU Per Case,"$30,131.14 ",OP,"30,131.14","30,131.14",,,,,,
Aetna MCR ADV,CPT,0317T,Elec alys vagus nrv pls gen,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Aetna MCR ADV,CPT,0330T,Tear film img uni/bi w/i&r,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Aetna MCR ADV,CPT,0331T,Heart symp image plnr,APC 5593,RVU Per Unit,"$1,336.39 ",OP,922.67,"1,336.39",,,,,,
Aetna MCR ADV,CPT,0332T,Heart symp image plnr spect,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,338.26",,,,,,
Aetna MCR ADV,CPT,0335T,Insj sinus tarsi implant,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
Aetna MCR ADV,CPT,0338T,Trnscth renal symp denrv unl,APC 5192,RVU Per Case,"$5,072.43 ",OP,"5,072.43","5,072.43",,,,,,
Aetna MCR ADV,CPT,0339T,Trnscth renal symp denrv bil,APC 5192,RVU Per Case,"$5,072.43 ",OP,"5,072.43","5,072.43",,,,,,
Aetna MCR ADV,CPT,0342T,Thxp apheresis w/hdl delip,APC 5243,RVU Per Unit,"$4,131.87 ",OP,"4,131.87","4,131.87",,,,,,
Aetna MCR ADV,CPT,0345T,Transcath mtral vlve repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,0347T,Ins bone device for rsa,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Aetna MCR ADV,CPT,0348T,Rsa spine exam,APC 5522,RVU Per Case,$111.51 ,OP,111.51,111.51,,,,,,
Aetna MCR ADV,CPT,0349T,Rsa upper extr exam,APC 5522,RVU Per Case,$111.51 ,OP,111.51,111.51,,,,,,
Aetna MCR ADV,CPT,0350T,Rsa lower extr exam,APC 5521,RVU Per Case,$82.79 ,OP,82.79,82.79,,,,,,
Aetna MCR ADV,CPT,0355T,Gi tract capsule endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","1,662.91",,,,,,
Aetna MCR ADV,CPT,0356T,Insrt drug device for iop,APC 5692,RVU Per Case,$63.42 ,OP,63.42,63.42,,,,,,
Aetna MCR ADV,CPT,0358T,Bia whole body,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Aetna MCR ADV,CPT,0362T,Bhv id suprt assmt ea 15 min,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Aetna MCR ADV,CPT,0373T,Adapt bhv tx ea 15 min,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Aetna MCR ADV,CPT,0379T,Vis field assmnt tech suppt,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Aetna MCR ADV,CPT,0394T,Hdr elctrnc skn surf brchytx,APC 5622,RVU Per Unit,$247.32 ,OP,247.32,247.32,,,,,,
Aetna MCR ADV,CPT,0395T,Hdr elctr ntrst/ntrcv brchtx,APC 5624,RVU Per Unit,$724.98 ,OP,724.98,724.98,,,,,,
Aetna MCR ADV,CPT,0398T,Mrgfus strtctc les abltj,APC 5463,RVU Per Case,"$11,498.23 ",OP,"11,498.23","11,498.23",,,,,,
Aetna MCR ADV,CPT,0402T,Colgn cross-link crn med sep,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","2,049.05",,,,,,
Aetna MCR ADV,CPT,0404T,Trnscrv uterin fibroid abltj,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,140.35","9,201.00",,,,,,
Aetna MCR ADV,CPT,0408T,Insj/rplc cardiac modulj sys,APC 5231,RVU Per Case,"$23,577.44 ",OP,"23,577.44","23,577.44",,,,,,
Aetna MCR ADV,CPT,0409T,Insj/rplc car modulj pls gn,APC 5231,RVU Per Case,"$23,577.44 ",OP,"23,577.44","23,577.44",,,,,,
Aetna MCR ADV,CPT,0410T,Insj/rplc car modulj atr elt,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
Aetna MCR ADV,CPT,0411T,Insj/rplc car modulj vnt elt,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
Aetna MCR ADV,CPT,0412T,Rmvl cardiac modulj pls gen,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Aetna MCR ADV,CPT,0413T,Rmvl car modulj tranvns elt,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Aetna MCR ADV,CPT,0414T,Rmvl & rpl car modulj pls gn,APC 5231,RVU Per Case,"$23,577.44 ",OP,"23,577.44","23,577.44",,,,,,
Aetna MCR ADV,CPT,0415T,Repos car modulj tranvns elt,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,554.25,,,,,,
Aetna MCR ADV,CPT,0416T,Reloc skin pocket pls gen,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","1,755.36",,,,,,
Aetna MCR ADV,CPT,0417T,Prgrmg eval cardiac modulj,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Aetna MCR ADV,CPT,0418T,Interro eval cardiac modulj,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Aetna MCR ADV,CPT,0419T,Dstrj neurofibroma xtnsv,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,536.39,,,,,,
Aetna MCR ADV,CPT,0420T,Dstrj neurofibroma xtnsv,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,536.39,,,,,,
Aetna MCR ADV,CPT,0421T,Waterjet prostate abltj cmpl,APC 5376,RVU Per Case,"$8,450.70 ",OP,"8,450.70","8,450.70",,,,,,
Aetna MCR ADV,CPT,0422T,Tactile breast img uni/bi,APC 5521,RVU Per Case,$82.79 ,OP,82.79,82.79,,,,,,
Aetna MCR ADV,CPT,0424T,Insj/rplc nstim apnea compl,APC 5465,RVU Per Case,"$30,131.14 ",OP,"30,131.14","30,131.14",,,,,,
Aetna MCR ADV,CPT,0425T,Insj/rplc nstim apnea sen ld,APC 5463,RVU Per Case,"$11,498.23 ",OP,"11,498.23","11,498.23",,,,,,
Aetna MCR ADV,CPT,0426T,Insj/rplc nstim apnea stm ld,APC 5463,RVU Per Case,"$11,498.23 ",OP,"11,498.23","11,498.23",,,,,,
Aetna MCR ADV,CPT,0427T,Insj/rplc nstim apnea pls gn,APC 5465,RVU Per Case,"$30,131.14 ",OP,"30,131.14","30,131.14",,,,,,
Aetna MCR ADV,CPT,0428T,Rmvl nstim apnea pls gen,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Aetna MCR ADV,CPT,0429T,Rmvl nstim apnea sen ld,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Aetna MCR ADV,CPT,0430T,Rmvl nstim apnea stimj ld,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Aetna MCR ADV,CPT,0431T,Rmvl/rplc nstim apnea pls gn,APC 5465,RVU Per Case,"$30,131.14 ",OP,"30,131.14","30,131.14",,,,,,
Aetna MCR ADV,CPT,0432T,Repos nstim apnea stimj ld,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Aetna MCR ADV,CPT,0433T,Repos nstim apnea sensing ld,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Aetna MCR ADV,CPT,0434T,Interro eval npgs apnea,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,102.65,,,,,,
Aetna MCR ADV,CPT,0435T,Prgrmg eval npgs apnea 1 ses,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,102.65,,,,,,
Aetna MCR ADV,CPT,0436T,Prgrmg eval npgs apnea study,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,941.27,,,,,,
Aetna MCR ADV,CPT,0440T,Abltj perc uxtr/perph nrv,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","1,795.30",,,,,,
Aetna MCR ADV,CPT,0441T,Abltj perc lxtr/perph nrv,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","1,795.30",,,,,,
Aetna MCR ADV,CPT,0442T,Abltj perc plex/trncl nrv,APC 5432,RVU Per Case,"$5,833.22 ",OP,"5,833.22","5,833.22",,,,,,
Aetna MCR ADV,CPT,0446T,Insj impltbl glucose sensor,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","1,755.36",,,,,,
Aetna MCR ADV,CPT,0447T,Rmvl impltbl glucose sensor,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
Aetna MCR ADV,CPT,0448T,Remvl insj impltbl gluc sens,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","1,755.36",,,,,,
Aetna MCR ADV,CPT,0449T,Insj aqueous drain dev 1st,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,009.10",,,,,,
Aetna MCR ADV,CPT,0451T,Insj/rplcmt aortic ventr sys,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,0452T,Insj/rplcmt dev vasc seal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,0453T,Insj/rplcmt mech-elec ntrfce,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
Aetna MCR ADV,CPT,0454T,Insj/rplcmt subq electrode,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
Aetna MCR ADV,CPT,0455T,Remvl aortic ventr cmpl sys,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,0456T,Remvl aortic dev vasc seal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,0457T,Remvl mech-elec skin ntrfce,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Aetna MCR ADV,CPT,0458T,Remvl subq electrode,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Aetna MCR ADV,CPT,0459T,Relocaj rplcmt aortic ventr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,0460T,Repos aortic ventr dev eltrd,APC 5221,RVU Per Unit,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Aetna MCR ADV,CPT,0461T,Repos aortic contrpulsj dev,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,0462T,Prgrmg eval aortic ventr sys,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,278.82,,,,,,
Aetna MCR ADV,CPT,0463T,Interrog aortic ventr sys,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,278.82,,,,,,
Aetna MCR ADV,CPT,0464T,Visual ep test for glaucoma,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Aetna MCR ADV,CPT,0465T,Supchrdl njx rx w/o supply,APC 5694,RVU Per Unit,$318.00 ,OP,318,318,,,,,,
Aetna MCR ADV,CPT,0467T,Revj/rplmnt ch respir eltrd,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Aetna MCR ADV,CPT,0468T,Rmvl ch wal respir eltrd/ra,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Aetna MCR ADV,CPT,0472T,Prgrmg io rta eltrd ra,APC 5743,RVU Per Case,$278.82 ,OP,278.82,278.82,,,,,,
Aetna MCR ADV,CPT,0473T,Reprgrmg io rta eltrd ra,APC 5742,RVU Per Case,$102.65 ,OP,102.65,102.65,,,,,,
Aetna MCR ADV,CPT,0476T,Rec ftl car sgl elec tr data,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Aetna MCR ADV,CPT,0477T,Rec ftl car sgl xrtj alys,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Aetna MCR ADV,CPT,0479T,Fxjl abl lsr 1st 100 sq cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,536.39,,,,,,
Aetna MCR ADV,CPT,0481T,Njx autol wbc concentrate,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
Aetna MCR ADV,CPT,0483T,Tmvi percutaneous approach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,0484T,Tmvi transthoracic exposure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,0485T,Oct mid ear i&r unilateral,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Aetna MCR ADV,CPT,0486T,Oct mid ear i&r bilateral,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Aetna MCR ADV,CPT,0487T,Trvg biomchn mapg w/reprt,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Aetna MCR ADV,CPT,0491T,Abl lsr opn wnd 1st 20 sqcm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,353.91,,,,,,
Aetna MCR ADV,CPT,0494T,Prep & cannulj cdvr don lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,0495T,Mntr cdvr don lng 1st 2 hrs,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,0496T,Mntr cdvr don lng ea addl hr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,0497T,Xtrnl pt act ecg in-off conn,APC 5741,RVU Per Case,$38.02 ,OP,38.02,"1,574.64",,,,,,
Aetna MCR ADV,CPT,0499T,Cysto f/urtl strix/stenosis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","3,148.08",,,,,,
Aetna MCR ADV,CPT,0503T,Cor ffr alys gnrj ffr mdl,APC 1511,RVU Per Unit,$972.67 ,OP,908.19,972.67,,,,,,
Aetna MCR ADV,CPT,0505T,Ev fempop artl revsc,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Aetna MCR ADV,CPT,0506T,Mac pgmt opt dns meas hfp,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Aetna MCR ADV,CPT,0507T,Near ifr 2img mibmn glnd i&r,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Aetna MCR ADV,CPT,0508T,Pls echo us b1 dns meas tib,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,111.51,,,,,,
Aetna MCR ADV,CPT,0509T,Pattern erg w/i&r,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,386.03,,,,,,
Aetna MCR ADV,CPT,0510T,Rmvl sinus tarsi implant,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","2,896.40",,,,,,
Aetna MCR ADV,CPT,0511T,Rmvl&rinsj sinus tarsi implt,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
Aetna MCR ADV,CPT,0512T,Esw integ wnd hlg 1st wnd,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,183.73,,,,,,
Aetna MCR ADV,CPT,0515T,Insj wcs lv compl sys,APC 5231,RVU Per Case,"$23,577.44 ",OP,"23,577.44","23,577.44",,,,,,
Aetna MCR ADV,CPT,0516T,Insj wcs lv eltrd only,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
Aetna MCR ADV,CPT,0517T,Insj wcs lv pg compnt,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
Aetna MCR ADV,CPT,0518T,Rmvl pg compnt wcs,APC 5221,RVU Per Unit,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Aetna MCR ADV,CPT,0519T,Rmvl & rplcmt pg compnt wcs,APC 5221,RVU Per Unit,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Aetna MCR ADV,CPT,0520T,Rmvl&rplcmt pg wcs new eltrd,APC 5231,RVU Per Case,"$23,577.44 ",OP,"23,577.44","23,577.44",,,,,,
Aetna MCR ADV,CPT,0521T,Interrog dev eval wcs ip,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Aetna MCR ADV,CPT,0522T,Prgrmg dev eval wcs ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Aetna MCR ADV,CPT,0524T,Ev cath dir chem abltj w/img,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","2,928.39",,,,,,
Aetna MCR ADV,CPT,0525T,Insj/rplcmt compl iims,APC 5223,RVU Per Case,"$10,642.67 ",OP,"10,642.67","10,642.67",,,,,,
Aetna MCR ADV,CPT,0526T,Insj/rplcmt iims eltrd only,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
Aetna MCR ADV,CPT,0527T,Insj/rplcmt iims implt mntr,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
Aetna MCR ADV,CPT,0528T,Prgrmg dev eval iims ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Aetna MCR ADV,CPT,0529T,Interrog dev eval iims ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Aetna MCR ADV,CPT,0530T,Removal complete iims,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Aetna MCR ADV,CPT,0531T,Removal iims electrode only,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Aetna MCR ADV,CPT,0532T,Removal iims implt mntr only,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Aetna MCR ADV,CPT,0534T,Cont rec mvmt do setup&train,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Aetna MCR ADV,CPT,0535T,Cont rec mvmt do reprt cnfig,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Aetna MCR ADV,CPT,0540T,Car-t cll admn autologous,APC 5694,RVU Per Unit,$318.00 ,OP,318,318,,,,,,
Aetna MCR ADV,CPT,0541T,Myocardial imaging mcg,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Aetna MCR ADV,CPT,0543T,Ta mv rpr w/artif chord tend,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,0544T,Tcat mv annulus rcnstj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,0545T,Tcat tv annulus rcnstj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,0548T,Tprnl balo cntnc dev bi,APC 5377,RVU Per Case,"$11,755.91 ",OP,"11,755.91","11,755.91",,,,,,
Aetna MCR ADV,CPT,0549T,Tprnl balo cntnc dev uni,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,516.83","4,516.83",,,,,,
Aetna MCR ADV,CPT,0550T,Tprnl balo cntnc dev rmvl ea,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","3,148.08",,,,,,
Aetna MCR ADV,CPT,0551T,Tprnl balo cntnc dev adjmt,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,272.35,,,,,,
Aetna MCR ADV,CPT,0555T,B1 str&fx rsk transmis data,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,25.25,,,,,,
Aetna MCR ADV,CPT,0556T,B1 str & fx rsk assessment,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,235.49,,,,,,
Aetna MCR ADV,CPT,0558T,Ct scan f/biomchn ct alys,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,927,,,,,,
Aetna MCR ADV,CPT,0559T,Antmc mdl 3d print 1st cmpnt,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Aetna MCR ADV,CPT,0561T,Antmc guide 3d print 1st gd,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Aetna MCR ADV,CPT,0563T,Evac meibomian glnd heat bi,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Aetna MCR ADV,CPT,0564T,Onc chemo rx cytotox csc 14,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Aetna MCR ADV,CPT,0565T,Autol cell implt adps hrvg,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Aetna MCR ADV,CPT,0566T,Autol cell implt adps njx,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,267.26,,,,,,
Aetna MCR ADV,CPT,0569T,Ttvr perq appr 1st prosth,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,0570T,Ttvr perq ea addl prosth,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,0571T,Insj/rplcmt icds ss eltrd,APC 5232,RVU Per Case,"$33,604.66 ",OP,"33,604.66","33,604.66",,,,,,
Aetna MCR ADV,CPT,0572T,Insertion ss dfb electrode,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
Aetna MCR ADV,CPT,0573T,Removal ss dfb electrode,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Aetna MCR ADV,CPT,0574T,Repos prev ss impl dfb eltrd,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Aetna MCR ADV,CPT,0575T,Prgrmg dev eval icds ss ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Aetna MCR ADV,CPT,0576T,Interrog dev eval icds ss ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Aetna MCR ADV,CPT,0577T,Ephys eval icds ss,APC 5211,RVU Per Case,"$1,138.72 ",OP,"1,138.72","2,775.65",,,,,,
Aetna MCR ADV,CPT,0579T,Rem interrog dev icds tech,APC 5741,RVU Per Case,$38.02 ,OP,38.02,213.51,,,,,,
Aetna MCR ADV,CPT,0580T,Rmvl ss impl dfb pg only,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Aetna MCR ADV,CPT,0583T,Tmpst auto tube dlvr sys,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","1,384.33",,,,,,
Aetna MCR ADV,CPT,0584T,Perq islet cell transplant,APC 5881,RVU Per Case,"$8,948.83 ",OP,"2,508.76","8,948.83",,,,,,
Aetna MCR ADV,CPT,0585T,Laps islet cell transplant,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,254.96","8,948.83",,,,,,
Aetna MCR ADV,CPT,0586T,Open islet cell transplant,APC 5881,RVU Per Case,"$8,948.83 ",OP,"6,965.79","8,948.83",,,,,,
Aetna MCR ADV,CPT,0587T,Perq impltj/rplcmt isdns ptn,APC 5462,RVU Per Case,"$6,304.35 ",OP,"6,304.35","6,304.35",,,,,,
Aetna MCR ADV,CPT,0588T,Revision/removal isdns ptn,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Aetna MCR ADV,CPT,0589T,Elec alys smpl prgrmg iins,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,255.45,,,,,,
Aetna MCR ADV,CPT,0590T,Elec alys cplx prgrmg iins,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,255.45,,,,,,
Aetna MCR ADV,CPT,0594T,Osteot hum xtrnl lngth dev,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
Aetna MCR ADV,CPT,0596T,Temp fml iu vlv-pmp 1st insj,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,588.17,,,,,,
Aetna MCR ADV,CPT,0597T,Temp fml iu valve-pmp rplcmt,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,588.17,,,,,,
Aetna MCR ADV,CPT,0598T,Ncntc r-t fluor wnd img 1st,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Aetna MCR ADV,CPT,0600T,Ire abltj 1+tum organ perq,APC 5362,RVU Per Case,"$9,115.38 ",OP,"9,115.38","9,115.38",,,,,,
Aetna MCR ADV,CPT,0601T,Ire abltj 1+tumors open,APC 5362,RVU Per Case,"$9,115.38 ",OP,"9,115.38","9,115.38",,,,,,
Aetna MCR ADV,CPT,0604T,Rem oct rta dev setup&educaj,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,121.51,,,,,,
Aetna MCR ADV,CPT,0605T,Rem oct rta techl sprt min 8,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Aetna MCR ADV,CPT,0607T,Rem mntr pulm flu mntr setup,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,121.51,,,,,,
Aetna MCR ADV,CPT,0608T,Rem mntr pulm flu mntr alys,APC 5741,RVU Per Unit,$38.02 ,OP,38.02,38.02,,,,,,
Aetna MCR ADV,CPT,0609T,Mrs disc pain acquisj data,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Aetna MCR ADV,CPT,0611T,Mrs disc pain alg alys data,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,507.00",,,,,,
Aetna MCR ADV,CPT,0614T,Rmvl&rplcmt ss impl dfb pg,APC 5231,RVU Per Case,"$23,577.44 ",OP,"23,577.44","23,577.44",,,,,,
Aetna MCR ADV,CPT,0615T,Eye mvmt alys w/o calbrj i&r,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Aetna MCR ADV,CPT,0616T,Insertion of iris prosthesis,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","2,127.64",,,,,,
Aetna MCR ADV,CPT,0617T,Insj iris prosth w/rmvl&insj,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,009.10",,,,,,
Aetna MCR ADV,CPT,0618T,Insj iris prosth sec io lens,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,009.10",,,,,,
Aetna MCR ADV,CPT,0619T,Cysto w/prst8 commissurotomy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,516.83","4,516.83",,,,,,
Aetna MCR ADV,CPT,0620T,Evasc ven artlz tibl/prnl vn,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Aetna MCR ADV,CPT,0627T,Perq njx algc fluor lmbr 1st,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
Aetna MCR ADV,CPT,0629T,Perq njx algc ct lmbr 1st,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
Aetna MCR ADV,CPT,0631T,Tc vis lit hyperspectral img,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Aetna MCR ADV,CPT,0632T,Perq tcat us abltj nrv p-art,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Aetna MCR ADV,CPT,0633T,Ct breast w/3d uni c-,APC 5522,RVU Per Case,$111.51 ,OP,111.51,111.51,,,,,,
Aetna MCR ADV,CPT,0634T,Ct breast w/3d uni c+,APC 5571,RVU Per Case,$182.72 ,OP,182.72,182.72,,,,,,
Aetna MCR ADV,CPT,0635T,Ct breast w/3d uni c-/c+,APC 5571,RVU Per Case,$182.72 ,OP,182.72,182.72,,,,,,
Aetna MCR ADV,CPT,0636T,Ct breast w/3d bi c-,APC 5523,RVU Per Case,$235.49 ,OP,235.49,235.49,,,,,,
Aetna MCR ADV,CPT,0637T,Ct breast w/3d bi c+,APC 5572,RVU Per Case,$376.70 ,OP,376.7,376.7,,,,,,
Aetna MCR ADV,CPT,0638T,Ct breast w/3d bi c-/c+,APC 5572,RVU Per Case,$376.70 ,OP,376.7,376.7,,,,,,
Aetna MCR ADV,CPT,0641T,Ncntc nr ifr spctrsc wnd img,APC 5732,RVU Per Unit,$34.63 ,OP,34.63,34.63,,,,,,
Aetna MCR ADV,CPT,0644T,Tcat rmvl/dblk icar mas perq,APC 5192,RVU Per Case,"$5,072.43 ",OP,"5,072.43","5,072.43",,,,,,
Aetna MCR ADV,CPT,0647T,Insj gtube perq mag gastrpxy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","1,662.91",,,,,,
Aetna MCR ADV,CPT,0648T,Quan mr alys tiss w/o mri,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,235.49,,,,,,
Aetna MCR ADV,CPT,0650T,Prgrmg dev eval scrms remote,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Aetna MCR ADV,CPT,0651T,Mag ctrld capsule endoscopy,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,828.48,,,,,,
Aetna MCR ADV,CPT,0652T,Egd flx transnasal dx br/wa,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,828.48,,,,,,
Aetna MCR ADV,CPT,0653T,Egd flx transnasal bx 1/ml,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,828.48,,,,,,
Aetna MCR ADV,CPT,0654T,Egd flx transnasal tube/cath,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","1,662.91",,,,,,
Aetna MCR ADV,CPT,0655T,Tprnl focal abltj mal prst8,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","3,148.08",,,,,,
Aetna MCR ADV,CPT,0656T,Vrt bdy tethering ant,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,0657T,Vrt bdy tethering ant 8+ seg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,0658T,Elec impd spectrsc 1+skn les,APC 5733,RVU Per Unit,$56.95 ,OP,56.95,56.95,,,,,,
Aetna MCR ADV,CPT,0659T,Tcat intra-c nfs supersat o2,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,0662T,Scalp cool 1st meas&calbrj,APC 5732,RVU Per Unit,$34.63 ,OP,34.63,34.63,,,,,,
Aetna MCR ADV,CPT,A0425,Ground mileage,Ambulance,Per Unit,$7.47 ,OP,7.47,7.47,,,,,,
Aetna MCR ADV,CPT,A0426,Als 1,Ambulance,Per Case,$231.98 ,OP,231.98,"2,249.49",,,,,,
Aetna MCR ADV,CPT,A0427,Als1-emergency,Ambulance,Per Case,$231.98 ,OP,231.98,"2,287.62",,,,,,
Aetna MCR ADV,CPT,A0428,Bls,Ambulance,Per Case,$231.98 ,OP,231.98,231.98,,,,,,
Aetna MCR ADV,CPT,A0429,Bls-emergency,Ambulance,Per Case,$231.98 ,OP,231.98,"1,883.47",,,,,,
Aetna MCR ADV,CPT,A0430,Fixed wing air transport,Ambulance,Per Case,"$3,147.91 ",OP,"3,147.91","3,147.91",,,,,,
Aetna MCR ADV,CPT,A0431,Rotary wing air transport,Ambulance,Per Case,"$3,659.92 ",OP,"3,659.92","3,659.92",,,,,,
Aetna MCR ADV,CPT,A0432,Pi volunteer ambulance co,Ambulance,Per Case,$231.98 ,OP,231.98,231.98,,,,,,
Aetna MCR ADV,CPT,A0433,Als 2,Ambulance,Per Case,$231.98 ,OP,231.98,"2,859.52",,,,,,
Aetna MCR ADV,CPT,A0434,Specialty care transport,Ambulance,Per Case,$231.98 ,OP,231.98,"6,100.31",,,,,,
Aetna MCR ADV,CPT,A0435,Fixed wing air mileage,Ambulance,Per Unit,$8.93 ,OP,8.93,8.93,,,,,,
Aetna MCR ADV,CPT,A0436,Rotary wing air mileage,Ambulance,Per Unit,$23.83 ,OP,23.83,23.83,,,,,,
Aetna MCR ADV,CPT,A4563,Vag inser rectal control sys,Durable Medical Equipment,Per Unit,"$1,372.71 ",OP,"1,372.71","1,372.71",,,,,,
Aetna MCR ADV,CPT,A9513,Lutetium lu 177 dotatat ther,APC 9067,Per Unit,$274.33 ,OP,274.33,274.33,,,,,,
Aetna MCR ADV,CPT,A9517,I131 iodide cap- rx,APC 1064,Per Unit,$20.12 ,OP,20.12,32.18,,,,,,
Aetna MCR ADV,CPT,A9527,Iodine i-125 sodium iodide,APC 2632,Per Unit,$30.66 ,OP,30.66,30.66,,,,,,
Aetna MCR ADV,CPT,A9530,I131 iodide sol- rx,APC 1150,Per Unit,$13.34 ,OP,13.34,13.34,,,,,,
Aetna MCR ADV,CPT,A9543,Y90 ibritumomab- rx,APC 1643,Per Unit,"$59,793.85 ",OP,"59,793.85","59,793.85",,,,,,
Aetna MCR ADV,CPT,A9563,P32 na phosphate,APC 1675,Per Unit,$458.34 ,OP,458.34,458.34,,,,,,
Aetna MCR ADV,CPT,A9590,Iodine i-131 iobenguane 1mci,APC 9339,Per Unit,$320.12 ,OP,320.12,320.12,,,,,,
Aetna MCR ADV,CPT,A9591,Fluoroestradiol f 18,APC 9370,Per Unit,$644.83 ,OP,644.83,644.83,,,,,,
Aetna MCR ADV,CPT,A9592,Copper cu 64 dotatate diag,APC 9383,Per Unit,$918.21 ,OP,918.21,918.21,,,,,,
Aetna MCR ADV,CPT,A9593,Gallium ga-68 psma-11 ucsf,APC 9409,Per Unit,$732.86 ,OP,732.86,732.86,,,,,,
Aetna MCR ADV,CPT,A9594,Gallium ga-68 psma-11- ucla,APC 9410,Per Unit,$717.55 ,OP,717.55,717.55,,,,,,
Aetna MCR ADV,CPT,A9600,Sr89 strontium,APC 0701,Per Unit,"$3,975.00 ",OP,"3,975.00","4,407.46",,,,,,
Aetna MCR ADV,CPT,A9604,Sm 153 lexidronam,APC 1295,Per Unit,"$17,259.85 ",OP,"17,259.85","17,259.85",,,,,,
Aetna MCR ADV,CPT,A9606,Radium ra223 dichloride ther,APC 1745,Per Unit,$145.65 ,OP,145.65,145.65,,,,,,
Aetna MCR ADV,CPT,C1052,Hemostatic agent- gi- topic,APC 2031,Straight Discount,29.70%,OP,,,,,,,,
Aetna MCR ADV,CPT,C1062,Intravertebral fx aug impl,APC 2032,Straight Discount,29.70%,OP,,,,,,,,
Aetna MCR ADV,CPT,C1716,Brachytx- non-str- gold-198,APC 2645,Per Unit,$330.76 ,OP,330.76,330.76,,,,,,
Aetna MCR ADV,CPT,C1717,Brachytx- non-str-hdr ir-192,APC 2646,Per Unit,$383.90 ,OP,383.9,383.9,,,,,,
Aetna MCR ADV,CPT,C1719,Brachytx- ns- non-hdrir-192,APC 2647,Per Unit,$323.97 ,OP,323.97,323.97,,,,,,
Aetna MCR ADV,CPT,C1734,Orth/devic/drug bn/bn-tis/bn,APC 2026,Straight Discount,29.70%,OP,,,,,,,,
Aetna MCR ADV,CPT,C1748,Endoscope- single- ugi,APC 2029,Straight Discount,29.70%,OP,,,,,,,,
Aetna MCR ADV,CPT,C1761,Cath- trans intra litho/coro,APC 2033,Straight Discount,29.70%,OP,,,,,,,,
Aetna MCR ADV,CPT,C1823,Gen- neuro- trans sen/stim,APC 2993,Straight Discount,29.70%,OP,,,,,,,,
Aetna MCR ADV,CPT,C1824,Generator- ccm- implant,APC 2024,Straight Discount,29.70%,OP,,,,,,,,
Aetna MCR ADV,CPT,C1825,Gen- neuro- carot sinus baro,APC 2030,Straight Discount,29.70%,OP,,,,,,,,
Aetna MCR ADV,CPT,C1831,Personalized interbody cage,APC 2034,Straight Discount,29.70%,OP,,,,,,,,
Aetna MCR ADV,CPT,C1839,Iris prosthesis,APC 2028,Straight Discount,29.70%,OP,,,,,,,,
Aetna MCR ADV,CPT,C1982,Cath- pressure-valve-occlu,APC 2025,Straight Discount,29.70%,OP,,,,,,,,
Aetna MCR ADV,CPT,C2596,Probe- robotic- water-jet,APC 2027,Straight Discount,29.70%,OP,,,,,,,,
Aetna MCR ADV,CPT,C2616,Brachytx- non-str-yttrium-90,APC 2616,Per Unit,"$19,955.81 ",OP,"19,955.81","19,955.81",,,,,,
Aetna MCR ADV,CPT,C2634,Brachytx- non-str- ha- i-125,APC 2634,Per Unit,$169.87 ,OP,169.87,169.87,,,,,,
Aetna MCR ADV,CPT,C2635,Brachytx- non-str- ha- p-103,APC 2635,Per Unit,$52.25 ,OP,52.25,52.25,,,,,,
Aetna MCR ADV,CPT,C2636,Brachy linear- non-str-p-103,APC 2636,Per Unit,$36.02 ,OP,36.02,36.02,,,,,,
Aetna MCR ADV,CPT,C2638,Brachytx- stranded- i-125,APC 2638,Per Unit,$42.90 ,OP,42.9,42.9,,,,,,
Aetna MCR ADV,CPT,C2639,Brachytx- non-stranded-i-125,APC 2639,Per Unit,$39.11 ,OP,39.11,39.11,,,,,,
Aetna MCR ADV,CPT,C2640,Brachytx- stranded- p-103,APC 2640,Per Unit,$100.65 ,OP,100.65,100.65,,,,,,
Aetna MCR ADV,CPT,C2641,Brachytx- non-stranded-p-103,APC 2641,Per Unit,$79.72 ,OP,79.72,79.72,,,,,,
Aetna MCR ADV,CPT,C2642,Brachytx- stranded- c-131,APC 2642,Per Unit,$82.43 ,OP,82.43,82.43,,,,,,
Aetna MCR ADV,CPT,C2643,Brachytx- non-stranded-c-131,APC 2643,Per Unit,$92.16 ,OP,92.16,92.16,,,,,,
Aetna MCR ADV,CPT,C2645,Brachytx planar- p-103,APC 2648,Per Unit,$5.38 ,OP,5.38,5.38,,,,,,
Aetna MCR ADV,CPT,C2698,Brachytx- stranded- nos,APC 2698,Per Unit,$42.90 ,OP,42.9,42.9,,,,,,
Aetna MCR ADV,CPT,C2699,Brachytx- non-stranded- nos,APC 2699,Per Unit,$36.02 ,OP,36.02,36.02,,,,,,
Aetna MCR ADV,CPT,C5271,Low cost skin substitute app,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,536.39,,,,,,
Aetna MCR ADV,CPT,C5273,Low cost skin substitute app,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","1,755.36",,,,,,
Aetna MCR ADV,CPT,C5275,Low cost skin substitute app,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,536.39,,,,,,
Aetna MCR ADV,CPT,C5277,Low cost skin substitute app,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,536.39,,,,,,
Aetna MCR ADV,CPT,C8900,Mra w/cont- abd,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Aetna MCR ADV,CPT,C8901,Mra w/o cont- abd,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Aetna MCR ADV,CPT,C8902,Mra w/o fol w/cont- abd,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Aetna MCR ADV,CPT,C8903,Mri w/cont- breast-  uni,APC 5571,RVU Per Case,$182.72 ,OP,182.72,"1,507.00",,,,,,
Aetna MCR ADV,CPT,C8905,Mri w/o fol w/cont- brst- un,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Aetna MCR ADV,CPT,C8906,Mri w/cont- breast-  bi,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Aetna MCR ADV,CPT,C8908,Mri w/o fol w/cont- breast-,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Aetna MCR ADV,CPT,C8909,Mra w/cont- chest,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Aetna MCR ADV,CPT,C8910,Mra w/o cont- chest,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Aetna MCR ADV,CPT,C8911,Mra w/o fol w/cont- chest,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Aetna MCR ADV,CPT,C8912,Mra w/cont- lwr ext,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Aetna MCR ADV,CPT,C8913,Mra w/o cont- lwr ext,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Aetna MCR ADV,CPT,C8914,Mra w/o fol w/cont- lwr ext,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Aetna MCR ADV,CPT,C8918,Mra w/cont- pelvis,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Aetna MCR ADV,CPT,C8919,Mra w/o cont- pelvis,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Aetna MCR ADV,CPT,C8920,Mra w/o fol w/cont- pelvis,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Aetna MCR ADV,CPT,C8921,Tte w or w/o fol w/cont- com,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
Aetna MCR ADV,CPT,C8922,Tte w or w/o fol w/cont- f/u,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
Aetna MCR ADV,CPT,C8923,2d tte w or w/o fol w/con-co,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
Aetna MCR ADV,CPT,C8924,2d tte w or w/o fol w/con-fu,APC 5572,RVU Per Unit,$376.70 ,OP,376.7,376.7,,,,,,
Aetna MCR ADV,CPT,C8925,2d tee w or w/o fol w/con-in,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
Aetna MCR ADV,CPT,C8926,Tee w or w/o fol w/cont-cong,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
Aetna MCR ADV,CPT,C8927,Tee w or w/o fol w/cont- mon,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
Aetna MCR ADV,CPT,C8928,Tte w or w/o fol w/con-stres,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
Aetna MCR ADV,CPT,C8929,Tte w or wo fol wcon-doppler,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
Aetna MCR ADV,CPT,C8930,Tte w or w/o contr- cont ecg,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
Aetna MCR ADV,CPT,C8931,Mra- w/dye- spinal canal,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Aetna MCR ADV,CPT,C8932,Mra- w/o dye- spinal canal,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Aetna MCR ADV,CPT,C8933,Mra- w/o&w/dye- spinal canal,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Aetna MCR ADV,CPT,C8934,Mra- w/dye- upper extremity,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Aetna MCR ADV,CPT,C8935,Mra- w/o dye- upper extr,APC 5523,RVU Per Case,$235.49 ,OP,235.49,235.49,,,,,,
Aetna MCR ADV,CPT,C8936,Mra- w/o&w/dye- upper extr,APC 5572,RVU Per Case,$376.70 ,OP,376.7,376.7,,,,,,
Aetna MCR ADV,CPT,C8957,Prolonged iv inf- req pump,APC 5694,RVU Per Unit,$318.00 ,OP,318,318,,,,,,
Aetna MCR ADV,CPT,C9046,Cocaine hcl nasal solution,APC 9307,Per Unit,$1.33 ,OP,1.33,1.33,,,,,,
Aetna MCR ADV,CPT,C9047,Injection- caplacizumab-yhdp,APC 9199,Per Unit,$691.29 ,OP,691.29,691.29,,,,,,
Aetna MCR ADV,CPT,C9067,Gallium ga-68 dotatoc,APC 9323,Per Unit,$8.64 ,OP,8.64,8.64,,,,,,
Aetna MCR ADV,CPT,C9081,Idecabtagene car pos t,APC 9422,Per Unit,"$432,085.00 ",OP,"432,085.00","432,085.00",,,,,,
Aetna MCR ADV,CPT,C9082,Inj dostarlimab-gxly- 100 mg,APC 9423,Per Unit,"$2,136.09 ",OP,"2,136.09","2,136.09",,,,,,
Aetna MCR ADV,CPT,C9083,Inj- amivantamab-vmjw- 10 mg,APC 9424,Per Unit,$87.89 ,OP,87.89,87.89,,,,,,
Aetna MCR ADV,CPT,C9084,loncastuximab-lpyl- 0.1 mg,APC 9425,Per Unit,$242.05 ,OP,242.05,242.05,,,,,,
Aetna MCR ADV,CPT,C9248,Inj- clevidipine butyrate,APC 9087,Per Unit,$2.91 ,OP,2.91,2.91,,,,,,
Aetna MCR ADV,CPT,C9250,Artiss fibrin sealant,APC 1848,Per Unit,$156.84 ,OP,156.84,156.84,,,,,,
Aetna MCR ADV,CPT,C9257,Bevacizumab injection,APC 1281,Per Unit,$1.76 ,OP,1.76,1.76,,,,,,
Aetna MCR ADV,CPT,C9460,Injection- cangrelor,APC 9460,Per Unit,$16.32 ,OP,16.32,16.32,,,,,,
Aetna MCR ADV,CPT,C9462,Injection- delafloxacin,APC 9462,Per Unit,$0.37 ,OP,0.37,0.37,,,,,,
Aetna MCR ADV,CPT,C9482,Sotalol hydrochloride iv,APC 9482,Per Unit,$17.58 ,OP,17.58,17.58,,,,,,
Aetna MCR ADV,CPT,C9488,Conivaptan hcl,APC 9488,Per Unit,$43.94 ,OP,43.94,43.94,,,,,,
Aetna MCR ADV,CPT,C9600,Perc drug-el cor stent sing,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Aetna MCR ADV,CPT,C9602,Perc d-e cor stent ather s,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Aetna MCR ADV,CPT,C9604,Perc d-e cor revasc t cabg s,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Aetna MCR ADV,CPT,C9606,Perc d-e cor revasc w ami s,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Aetna MCR ADV,CPT,C9607,Perc d-e cor revasc chro sin,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Aetna MCR ADV,CPT,C9725,Place endorectal app,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,812.16,,,,,,
Aetna MCR ADV,CPT,C9727,Insert palate implants,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","1,384.33",,,,,,
Aetna MCR ADV,CPT,C9728,Place device/marker- non pro,APC 5613,RVU Per Unit,"$1,291.62 ",OP,"1,291.62","1,291.62",,,,,,
Aetna MCR ADV,CPT,C9733,Non-ophthalmic fva,APC 5572,RVU Per Case,$376.70 ,OP,376.7,376.7,,,,,,
Aetna MCR ADV,CPT,C9734,U/s trtmt- not leiomyomata,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
Aetna MCR ADV,CPT,C9739,Cystoscopy prostatic imp 1-3,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,516.83","4,516.83",,,,,,
Aetna MCR ADV,CPT,C9740,Cysto impl 4 or more,APC 5376,RVU Per Case,"$8,450.70 ",OP,"8,450.70","8,450.70",,,,,,
Aetna MCR ADV,CPT,C9752,Intraosseous des lumb/sacrum,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
Aetna MCR ADV,CPT,C9757,Spine/lumbar disk surgery,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
Aetna MCR ADV,CPT,C9761,Cysto- litho- vacuum kidney,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,516.83","4,516.83",,,,,,
Aetna MCR ADV,CPT,C9762,Cardiac mri seg dys strain,APC 5524,RVU Per Case,$494.15 ,OP,494.15,494.15,,,,,,
Aetna MCR ADV,CPT,C9763,Cardiac mri seg dys stress,APC 5524,RVU Per Case,$494.15 ,OP,494.15,494.15,,,,,,
Aetna MCR ADV,CPT,C9764,Revasc intravasc lithotripsy,APC 5192,RVU Per Case,"$5,072.43 ",OP,"5,072.43","5,072.43",,,,,,
Aetna MCR ADV,CPT,C9765,Revasc intra lithotrip-stent,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Aetna MCR ADV,CPT,C9766,Revasc intra lithotrip-ather,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Aetna MCR ADV,CPT,C9767,Revasc lithotrip-stent-ather,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Aetna MCR ADV,CPT,C9769,Cysto w/temp pros implant,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,516.83","4,516.83",,,,,,
Aetna MCR ADV,CPT,C9771,Nsl/sins cryo post nasal tis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","2,800.20",,,,,,
Aetna MCR ADV,CPT,C9772,Revasc lithotrip tibi/perone,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Aetna MCR ADV,CPT,C9773,Revasc lithotr-stent tib/per,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Aetna MCR ADV,CPT,C9774,Revasc lithotr-ather tib/per,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Aetna MCR ADV,CPT,C9775,Revasc lith-sten-ath tib/per,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Aetna MCR ADV,CPT,C9778,Colpopexy- min/inv- ex-perit,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","2,684.38",,,,,,
Aetna MCR ADV,CPT,C9779,ESD endoscopy or colonoscopy,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","2,500.37",,,,,,
Aetna MCR ADV,CPT,C9780,Insert cv cath inf & sup app,APC 1534,RVU Per Unit,"$8,442.89 ",OP,"7,883.19","8,442.89",,,,,,
Aetna MCR ADV,CPT,C9803,Hopd covid-19 spec collect,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Aetna MCR ADV,CPT,D0150,Comprehensve oral evaluation,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D0240,Intraoral occlusal film,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D0250,Extraoral 2d project image,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D0251,Extraoral posterior image,APC 5521,RVU Per Case,$82.79 ,OP,82.79,82.79,,,,,,
Aetna MCR ADV,CPT,D0270,Dental bitewing single image,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D0272,Dental bitewings two images,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D0274,Bitewings four images,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D0277,Vert bitewings 7 to 8 images,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D0460,Pulp vitality test,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D0600,Non-ionizing diag proc,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D1510,Space maintainer fxd unilat,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D1516,Fixed bilat space maint- max,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D1517,Fixed bilat space maint- man,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D1520,Remove unilat space maintain,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D1526,Remove bilat space main- max,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D1527,Remove bilat space main- man,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D1551,Recement space maint - max,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D1552,Recement space maint - man,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D1553,Recement unilat space maint,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D1575,Dist space maint- fixed unil,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D2999,Dental unspec restorative pr,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D3460,Endodontic endosseous implan,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D3999,Endodontic procedure,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D4260,Osseous surgery 4 or more,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D4263,Bone replce graft first site,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D4264,Bone replce graft each add,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D4268,Surgical revision procedure,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D4270,Pedicle soft tissue graft pr,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D4273,Auto tissue graft 1st tooth,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D4355,Full mouth debridement,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D4381,Localized delivery antimicro,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D5911,Facial moulage sectional,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D5912,Facial moulage complete,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D5983,Radiation applicator,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D5984,Radiation shield,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D5985,Radiation cone locator,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D5987,Commissure splint,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D6920,Dental connector bar,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D7111,Extraction coronal remnants,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D7140,Extraction erupted tooth/exr,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D7210,Rem imp tooth w mucoper flp,APC 5871,RVU Per Unit,"$1,426.03 ",OP,953.17,"1,426.03",,,,,,
Aetna MCR ADV,CPT,D7220,Impact tooth remov soft tiss,APC 5871,RVU Per Unit,"$1,426.03 ",OP,953.17,"1,426.03",,,,,,
Aetna MCR ADV,CPT,D7230,Impact tooth remov part bony,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,391.64","1,426.03",,,,,,
Aetna MCR ADV,CPT,D7240,Impact tooth remov comp bony,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,715.71",,,,,,
Aetna MCR ADV,CPT,D7241,Impact tooth rem bony w/comp,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","2,001.67",,,,,,
Aetna MCR ADV,CPT,D7250,Tooth root removal,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D7260,Oral antral fistula closure,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D7261,Primary closure sinus perf,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D7291,Transseptal fiberotomy,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D7940,Reshaping bone orthognathic,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D9930,Treatment of complications,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D9944,Occ guard- hard- full arch,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D9945,Occ guard- soft- full arch,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D9946,Occ guard- hard- part arch,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D9950,Occlusion analysis,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D9951,Limited occlusal adjustment,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,D9952,Complete occlusal adjustment,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Aetna MCR ADV,CPT,G0008,Admin influenza virus vac,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,57.19,,,,,,
Aetna MCR ADV,CPT,G0009,Admin pneumococcal vaccine,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,57.19,,,,,,
Aetna MCR ADV,CPT,G0010,Admin hepatitis b vaccine,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,57.19,,,,,,
Aetna MCR ADV,CPT,G0027,Semen analysis,Lab Services,Per Unit,$6.50 ,OP,6.5,34.31,,,,,,
Aetna MCR ADV,CPT,G0101,Ca screen-pelvic/breast exam,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,186.82,,,,,,
Aetna MCR ADV,CPT,G0103,Psa screening,Lab Services,Per Unit,$19.31 ,OP,19.31,80.07,,,,,,
Aetna MCR ADV,CPT,G0104,Ca screen-flexi sigmoidscope,APC 5311,RVU Per Unit,$812.16 ,OP,678.66,812.16,,,,,,
Aetna MCR ADV,CPT,G0105,Colorectal scrn- hi risk ind,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,812.16,,,,,,
Aetna MCR ADV,CPT,G0106,Colon ca screen-barium enema,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,"1,090.43",,,,,,
Aetna MCR ADV,CPT,G0108,Diab manage trn  per indiv,Physician,Per Unit,$54.47 ,OP,54.47,125.82,,,,,,
Aetna MCR ADV,CPT,G0109,Diab manage trn ind/group,Physician,Per Unit,$15.18 ,OP,15.18,72.44,,,,,,
Aetna MCR ADV,CPT,G0117,Glaucoma scrn hgh risk direc,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,232.58,,,,,,
Aetna MCR ADV,CPT,G0118,Glaucoma scrn hgh risk direc,APC 5732,RVU Per Unit,$34.63 ,OP,34.63,160.13,,,,,,
Aetna MCR ADV,CPT,G0120,Colon ca scrn- barium enema,APC 5572,RVU Per Unit,$376.70 ,OP,376.7,"1,090.43",,,,,,
Aetna MCR ADV,CPT,G0121,Colon ca scrn not hi rsk ind,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,812.16,,,,,,
Aetna MCR ADV,CPT,G0123,Screen cerv/vag thin layer,Lab Services,Per Unit,$20.26 ,OP,20.26,91.51,,,,,,
Aetna MCR ADV,CPT,G0127,Trim nail(s),APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Aetna MCR ADV,CPT,G0129,Partial hosp prog service,APC 5853,RVU Per Case,$266.56 ,OP,266.56,266.56,,,,,,
Aetna MCR ADV,CPT,G0130,Single energy x-ray study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,171.58,,,,,,
Aetna MCR ADV,CPT,G0143,Scr c/v cyto-thinlayer-rescr,Lab Services,Per Unit,$27.05 ,OP,27.05,91.51,,,,,,
Aetna MCR ADV,CPT,G0144,Scr c/v cyto-thinlayer-rescr,Lab Services,Per Unit,$43.97 ,OP,43.97,95.32,,,,,,
Aetna MCR ADV,CPT,G0145,Scr c/v cyto-thinlayer-rescr,Lab Services,Per Unit,$26.49 ,OP,26.49,118.19,,,,,,
Aetna MCR ADV,CPT,G0147,Scr c/v cyto- automated sys,Lab Services,Per Unit,$15.15 ,OP,15.15,45.74,,,,,,
Aetna MCR ADV,CPT,G0148,Scr c/v cyto- autosys- rescr,Lab Services,Per Unit,$31.94 ,OP,31.94,45.74,,,,,,
Aetna MCR ADV,CPT,G0166,Extrnl counterpulse- per tx,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Aetna MCR ADV,CPT,G0175,Opps service-sched team conf,APC 5024,RVU Per Unit,$372.22 ,OP,372.22,392.7,,,,,,
Aetna MCR ADV,CPT,G0176,Opps/php-activity therapy,APC 5853,RVU Per Case,$266.56 ,OP,266.56,266.56,,,,,,
Aetna MCR ADV,CPT,G0186,Dstry eye lesn-fdr vssl tech,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,515.61,,,,,,
Aetna MCR ADV,CPT,G0235,Pet not otherwise specified,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"7,236.50",,,,,,
Aetna MCR ADV,CPT,G0237,Therapeutic procd strg endur,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,61,,,,,,
Aetna MCR ADV,CPT,G0238,Oth resp proc- indiv,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,64.82,,,,,,
Aetna MCR ADV,CPT,G0239,Oth resp proc- group,APC 5732,RVU Per Unit,$34.63 ,OP,34.63,64.82,,,,,,
Aetna MCR ADV,CPT,G0245,Initial foot exam pt lops,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,339.33,,,,,,
Aetna MCR ADV,CPT,G0246,Followup eval of foot pt lop,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,198.25,,,,,,
Aetna MCR ADV,CPT,G0247,Routine footcare pt w lops,APC 5051,RVU Per Case,$183.73 ,OP,183.73,232.58,,,,,,
Aetna MCR ADV,CPT,G0248,Demonstrate use home inr mon,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,804.48,,,,,,
Aetna MCR ADV,CPT,G0249,Provide inr test mater/equip,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,686.28,,,,,,
Aetna MCR ADV,CPT,G0257,Unsched dialysis esrd pt hos,APC 5401,RVU Per Unit,$669.60 ,OP,669.6,669.6,,,,,,
Aetna MCR ADV,CPT,G0260,Inj for sacroiliac jt anesth,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,649.39,,,,,,
Aetna MCR ADV,CPT,G0270,Mnt subs tx for change dx,Physician,Per Unit,$26.49 ,OP,26.49,122,,,,,,
Aetna MCR ADV,CPT,G0271,Group mnt 2 or more 30 mins,Physician,Per Unit,$13.98 ,OP,13.98,68.63,,,,,,
Aetna MCR ADV,CPT,G0276,Pild/placebo control clin tr,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
Aetna MCR ADV,CPT,G0277,Hbot- full body chamber- 30m,APC 5061,RVU Per Unit,$122.06 ,OP,122.06,122.06,,,,,,
Aetna MCR ADV,CPT,G0279,Tomosynthesis- mammo,Physician,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Aetna MCR ADV,CPT,G0281,Elec stim unattend for press,Physician,Per Unit,$12.74 ,OP,12.74,61,,,,,,
Aetna MCR ADV,CPT,G0283,Elec stim other than wound,Physician,Per Unit,$12.74 ,OP,12.74,61,,,,,,
Aetna MCR ADV,CPT,G0293,Non-cov surg proc-clin trial,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Aetna MCR ADV,CPT,G0294,Non-cov proc- clinical trial,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Aetna MCR ADV,CPT,G0296,Visit to determ ldct elig,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Aetna MCR ADV,CPT,G0302,Pre-op service lvrs complete,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Aetna MCR ADV,CPT,G0303,Pre-op service lvrs 10-15dos,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Aetna MCR ADV,CPT,G0304,Pre-op service lvrs 1-9 dos,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Aetna MCR ADV,CPT,G0305,Post op service lvrs min 6,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Aetna MCR ADV,CPT,G0306,Cbc/diffwbc w/o platelet,Lab Services,Per Unit,$7.77 ,OP,7.77,34.31,,,,,,
Aetna MCR ADV,CPT,G0307,Cbc without platelet,Lab Services,Per Unit,$6.47 ,OP,6.47,30.51,,,,,,
Aetna MCR ADV,CPT,G0328,Fecal blood scrn immunoassay,Lab Services,Per Unit,$18.05 ,OP,18.05,72.44,,,,,,
Aetna MCR ADV,CPT,G0329,Electromagntic tx for ulcers,Physician,Per Unit,$10.46 ,OP,10.46,45.74,,,,,,
Aetna MCR ADV,CPT,G0341,Percutaneous islet celltrans,APC 5881,RVU Per Case,"$8,948.83 ",OP,"2,508.76","8,948.83",,,,,,
Aetna MCR ADV,CPT,G0342,Laparoscopy islet cell trans,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,254.96","8,948.83",,,,,,
Aetna MCR ADV,CPT,G0343,Laparotomy islet cell transp,APC 5881,RVU Per Case,"$8,948.83 ",OP,"6,965.79","8,948.83",,,,,,
Aetna MCR ADV,CPT,G0379,Direct refer hospital observ,APC 5025,RVU Per Case,$534.29 ,OP,534.29,534.29,,,,,,
Aetna MCR ADV,CPT,G0380,Lev 1 hosp type b ed visit,APC 5031,RVU Per Case,$72.19 ,OP,72.19,72.19,,,,,,
Aetna MCR ADV,CPT,G0381,Lev 2 hosp type b ed visit,APC 5032,RVU Per Case,$97.63 ,OP,97.63,97.63,,,,,,
Aetna MCR ADV,CPT,G0382,Lev 3 hosp type b ed visit,APC 5033,RVU Per Case,$185.19 ,OP,185.19,185.19,,,,,,
Aetna MCR ADV,CPT,G0383,Lev 4 hosp type b ed visit,APC 5034,RVU Per Case,$233.92 ,OP,233.92,233.92,,,,,,
Aetna MCR ADV,CPT,G0384,Lev 5 hosp type b ed visit,APC 5035,RVU Per Case,$325.81 ,OP,325.81,325.81,,,,,,
Aetna MCR ADV,CPT,G0390,Trauma respons w/hosp criti,APC 5045,RVU Per Unit,$964.64 ,OP,964.64,964.64,,,,,,
Aetna MCR ADV,CPT,G0396,Alcohol/subs interv 15-30mn,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,163.95,,,,,,
Aetna MCR ADV,CPT,G0397,Alcohol/subs interv >30 min,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,136.74,,,,,,
Aetna MCR ADV,CPT,G0398,Home sleep test/type 2 porta,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,367.82,,,,,,
Aetna MCR ADV,CPT,G0399,Home sleep test/type 3 porta,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Aetna MCR ADV,CPT,G0400,Home sleep test/type 4 porta,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,367.82,,,,,,
Aetna MCR ADV,CPT,G0402,Initial preventive exam,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,491.83,,,,,,
Aetna MCR ADV,CPT,G0404,Ekg tracing for initial prev,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,25.25,,,,,,
Aetna MCR ADV,CPT,G0410,Grp psych partial hosp 45-50,APC 5853,RVU Per Case,$266.56 ,OP,266.56,266.56,,,,,,
Aetna MCR ADV,CPT,G0411,Inter active grp psych parti,APC 5853,RVU Per Case,$266.56 ,OP,266.56,266.56,,,,,,
Aetna MCR ADV,CPT,G0412,Open tx iliac spine uni/bil,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,510.41","6,411.04",,,,,,
Aetna MCR ADV,CPT,G0413,Pelvic ring fracture uni/bil,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,527.33",,,,,,
Aetna MCR ADV,CPT,G0414,Pelvic ring fx treat int fix,APC 5115,RVU Per Case,"$12,601.93 ",OP,"6,161.31","12,601.93",,,,,,
Aetna MCR ADV,CPT,G0415,Open tx post pelvic fxcture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"8,452.74","12,601.93",,,,,,
Aetna MCR ADV,CPT,G0416,Prostate biopsy- any mthd,APC 5673,RVU Per Case,$298.05 ,OP,298.05,"3,297.99",,,,,,
Aetna MCR ADV,CPT,G0420,Ed svc ckd ind per session,Physician,Per Unit,$111.79 ,OP,111.79,111.79,,,,,,
Aetna MCR ADV,CPT,G0421,Ed svc ckd grp per session,Physician,Per Unit,$26.73 ,OP,26.73,26.73,,,,,,
Aetna MCR ADV,CPT,G0422,Intens cardiac rehab w/exerc,APC 5771,RVU Per Unit,$118.77 ,OP,118.77,118.77,,,,,,
Aetna MCR ADV,CPT,G0423,Intens cardiac rehab no exer,APC 5771,RVU Per Unit,$118.77 ,OP,118.77,118.77,,,,,,
Aetna MCR ADV,CPT,G0424,Pulmonary rehab w exer,APC 5733,RVU Per Unit,$56.95 ,OP,56.95,56.95,,,,,,
Aetna MCR ADV,CPT,G0429,Dermal filler injection(s),APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","1,755.36",,,,,,
Aetna MCR ADV,CPT,G0432,Eia hiv-1/hiv-2 screen,Lab Services,Per Unit,$19.57 ,OP,19.57,19.57,,,,,,
Aetna MCR ADV,CPT,G0433,Elisa hiv-1/hiv-2 screen,Lab Services,Per Unit,$18.29 ,OP,18.29,18.29,,,,,,
Aetna MCR ADV,CPT,G0435,Oral hiv-1/hiv-2 screen,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,
Aetna MCR ADV,CPT,G0438,Ppps- initial visit,Physician,Per Unit,$163.74 ,OP,163.74,163.74,,,,,,
Aetna MCR ADV,CPT,G0439,Ppps- subseq visit,Physician,Per Unit,$129.00 ,OP,129,129,,,,,,
Aetna MCR ADV,CPT,G0442,Annual alcohol screen 15 min,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Aetna MCR ADV,CPT,G0443,Brief alcohol misuse counsel,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Aetna MCR ADV,CPT,G0444,Depression screen annual,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Aetna MCR ADV,CPT,G0445,High inten beh couns std 30m,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Aetna MCR ADV,CPT,G0446,Intens behave ther cardio dx,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Aetna MCR ADV,CPT,G0447,Behavior counsel obesity 15m,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Aetna MCR ADV,CPT,G0451,Devlopment test interpt&rep,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Aetna MCR ADV,CPT,G0455,Fecal microbiota prep instil,APC 5301,RVU Per Case,$828.48 ,OP,828.48,828.48,,,,,,
Aetna MCR ADV,CPT,G0460,Autologous prp for ulcers,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","1,755.36",,,,,,
Aetna MCR ADV,CPT,G0463,Hospital outpt clinic visit,APC 5012,RVU Per Case,$121.51 ,OP,95.32,121.51,,,,,,
Aetna MCR ADV,CPT,G0471,Ven blood coll snf/hha,Lab Services,Per Unit,$5.00 ,OP,5,5,,,,,,
Aetna MCR ADV,CPT,G0472,Hep c screen high risk/other,Lab Services,Per Unit,$46.35 ,OP,46.35,46.35,,,,,,
Aetna MCR ADV,CPT,G0473,Group behave couns 2-10,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Aetna MCR ADV,CPT,G0475,Hiv combination assay,Lab Services,Per Unit,$24.08 ,OP,24.08,24.08,,,,,,
Aetna MCR ADV,CPT,G0476,Hpv combo assay ca screen,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,
Aetna MCR ADV,CPT,G0480,Drug test def 1-7 classes,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
Aetna MCR ADV,CPT,G0481,Drug test def 8-14 classes,Lab Services,Per Unit,$156.59 ,OP,156.59,156.59,,,,,,
Aetna MCR ADV,CPT,G0482,Drug test def 15-21 classes,Lab Services,Per Unit,$198.74 ,OP,198.74,198.74,,,,,,
Aetna MCR ADV,CPT,G0483,Drug test def 22+ classes,Lab Services,Per Unit,$246.92 ,OP,246.92,246.92,,,,,,
Aetna MCR ADV,CPT,G0498,Chemo extend iv infus w/pump,APC 5694,RVU Per Unit,$318.00 ,OP,318,318,,,,,,
Aetna MCR ADV,CPT,G0499,Hepb screen high risk indiv,Lab Services,Per Unit,$28.27 ,OP,28.27,28.27,,,,,,
Aetna MCR ADV,CPT,G0516,Insert drug del implant- >=4,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
Aetna MCR ADV,CPT,G0517,Remove drug implant,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
Aetna MCR ADV,CPT,G0518,Remove w insert drug implant,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
Aetna MCR ADV,CPT,G0659,Drug test def simple all cl,Lab Services,Per Unit,$62.14 ,OP,62.14,62.14,,,,,,
Aetna MCR ADV,CPT,G2000,Blinded conv. tx mdd clin tr,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Aetna MCR ADV,CPT,G2011,Alcohol/sub misuse assess,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,25.25,,,,,,
Aetna MCR ADV,CPT,G2065,Clin mang h risk dx 30,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Aetna MCR ADV,CPT,G2066,Inter devc remote 30d,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Aetna MCR ADV,CPT,G2082,Visit esketamine 56m or less,APC 1508,RVU Per Unit,$665.67 ,OP,621.54,665.67,,,,,,
Aetna MCR ADV,CPT,G2083,Visit esketamine- > 56m,APC 1511,RVU Per Unit,$972.67 ,OP,972.67,972.67,,,,,,
Aetna MCR ADV,CPT,G2086,Off base opioid tx 70min,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,136.74,,,,,,
Aetna MCR ADV,CPT,G2087,Off base opioid tx- 60 m,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,136.74,,,,,,
Aetna MCR ADV,CPT,G2170,Avf by tissue w thermal e,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Aetna MCR ADV,CPT,G2171,Avf use magnetic/art/ven,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Aetna MCR ADV,CPT,G2214,Init/sub psych care m 1st 30,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Aetna MCR ADV,CPT,G2250,Remot img sub by pt- non e/m,Physician,Per Unit,$9.24 ,OP,9.24,9.24,,,,,,
Aetna MCR ADV,CPT,G2251,Brief chkin- 5-10- non-e/m,Physician,Per Unit,$13.05 ,OP,13.05,13.05,,,,,,
Aetna MCR ADV,CPT,G2252,Brief chkin by md/qhp- 11-20,Physician,Per Unit,$25.14 ,OP,25.14,25.14,,,,,,
Aetna MCR ADV,CPT,J0121,Inj.- omadacycline- 1 mg,APC 9311,Per Unit,$3.30 ,OP,3.3,3.3,,,,,,
Aetna MCR ADV,CPT,J0129,Abatacept injection,APC 9230,Per Unit,$45.27 ,OP,45.27,73.44,,,,,,
Aetna MCR ADV,CPT,J0135,Adalimumab injection,APC 1083,Per Unit,"$1,581.57 ",OP,"1,581.57","1,581.57",,,,,,
Aetna MCR ADV,CPT,J0178,Aflibercept injection,APC 1420,Per Unit,$917.94 ,OP,917.94,917.94,,,,,,
Aetna MCR ADV,CPT,J0179,Inj- brolucizumab-dbll- 1 mg,APC 9340,Per Unit,$312.01 ,OP,312.01,312.01,,,,,,
Aetna MCR ADV,CPT,J0180,Agalsidase beta injection,APC 9208,Per Unit,$198.14 ,OP,198.14,508.92,,,,,,
Aetna MCR ADV,CPT,J0185,Inj.- aprepitant- 1 mg,APC 9463,Per Unit,$1.69 ,OP,1.69,1.69,,,,,,
Aetna MCR ADV,CPT,J0202,Injection- alemtuzumab,APC 1809,Per Unit,"$2,086.32 ",OP,277.19,"2,086.32",,,,,,
Aetna MCR ADV,CPT,J0207,Amifostine,APC 7000,Per Unit,"$1,135.69 ",OP,"1,135.69","1,985.16",,,,,,
Aetna MCR ADV,CPT,J0220,Alglucosidase alfa injection,APC 9234,Per Unit,$117.07 ,OP,117.07,474.68,,,,,,
Aetna MCR ADV,CPT,J0221,Lumizyme injection,APC 1413,Per Unit,$180.35 ,OP,180.35,180.35,,,,,,
Aetna MCR ADV,CPT,J0222,Inj.- patisiran- 0.1 mg,APC 9180,Per Unit,$97.75 ,OP,97.75,97.75,,,,,,
Aetna MCR ADV,CPT,J0223,Inj givosiran 0.5 mg,APC 9343,Per Unit,$106.76 ,OP,106.76,106.76,,,,,,
Aetna MCR ADV,CPT,J0224,Inj. lumasiran- 0.5 mg,APC 9407,Per Unit,$302.30 ,OP,302.3,302.3,,,,,,
Aetna MCR ADV,CPT,J0256,Alpha 1 proteinase inhibitor,APC 0901,Per Unit,$4.54 ,OP,4.54,7.9,,,,,,
Aetna MCR ADV,CPT,J0257,Glassia injection,APC 1415,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,
Aetna MCR ADV,CPT,J0287,Amphotericin b lipid complex,APC 9024,Per Unit,$9.50 ,OP,9.5,49.56,,,,,,
Aetna MCR ADV,CPT,J0289,Amphotericin b liposome inj,APC 0736,Per Unit,$28.75 ,OP,28.75,118.19,,,,,,
Aetna MCR ADV,CPT,J0291,Inj.- plazomicin- 5 mg,APC 9183,Per Unit,$3.05 ,OP,3.05,3.05,,,,,,
Aetna MCR ADV,CPT,J0300,Amobarbital 125 mg inj,APC 1341,Per Unit,$125.22 ,OP,30.51,125.22,,,,,,
Aetna MCR ADV,CPT,J0390,Chloroquine injection,APC 9352,Per Unit,$165.22 ,OP,83.87,165.22,,,,,,
Aetna MCR ADV,CPT,J0401,Inj aripiprazole ext rel 1mg,APC 1468,Per Unit,$6.01 ,OP,6.01,7.62,,,,,,
Aetna MCR ADV,CPT,J0475,Baclofen 10 mg injection,APC 9032,Per Unit,$177.43 ,OP,177.43,826.29,,,,,,
Aetna MCR ADV,CPT,J0480,Basiliximab,APC 1683,Per Unit,"$4,013.08 ",OP,"4,013.08","7,724.52",,,,,,
Aetna MCR ADV,CPT,J0485,Belatacept injection,APC 9286,Per Unit,$3.80 ,OP,3.8,3.8,,,,,,
Aetna MCR ADV,CPT,J0490,Belimumab injection,APC 1353,Per Unit,$47.57 ,OP,47.57,47.57,,,,,,
Aetna MCR ADV,CPT,J0517,Inj.- benralizumab- 1 mg,APC 9466,Per Unit,$170.80 ,OP,170.8,170.8,,,,,,
Aetna MCR ADV,CPT,J0558,Peng benzathine/procaine inj,APC 9088,Per Unit,$11.79 ,OP,11.79,11.79,,,,,,
Aetna MCR ADV,CPT,J0561,Penicillin g benzathine inj,APC 1829,Per Unit,$14.95 ,OP,14.95,14.95,,,,,,
Aetna MCR ADV,CPT,J0565,Inj- bezlotoxumab- 10 mg,APC 9490,Per Unit,$39.77 ,OP,39.77,39.77,,,,,,
Aetna MCR ADV,CPT,J0570,Buprenorphine implant 74.2mg,APC 9058,Per Unit,"$1,311.75 ",OP,209.7,"1,311.75",,,,,,
Aetna MCR ADV,CPT,J0584,Injection- burosumab-twza 1m,APC 9187,Per Unit,$369.11 ,OP,369.11,369.11,,,,,,
Aetna MCR ADV,CPT,J0585,Injection-onabotulinumtoxina,APC 0902,Per Unit,$6.09 ,OP,6.09,6.09,,,,,,
Aetna MCR ADV,CPT,J0586,Abobotulinumtoxina,APC 1289,Per Unit,$8.41 ,OP,8.41,8.41,,,,,,
Aetna MCR ADV,CPT,J0587,Inj- rimabotulinumtoxinb,APC 9018,Per Unit,$12.05 ,OP,12.05,39.5,,,,,,
Aetna MCR ADV,CPT,J0588,Incobotulinumtoxin a,APC 9278,Per Unit,$5.05 ,OP,5.05,5.05,,,,,,
Aetna MCR ADV,CPT,J0594,Busulfan injection,APC 1178,Per Unit,$1.71 ,OP,1.71,61,,,,,,
Aetna MCR ADV,CPT,J0596,Injection- ruconest,APC 9445,Per Unit,$29.97 ,OP,29.97,29.97,,,,,,
Aetna MCR ADV,CPT,J0597,C-1 esterase- berinert,APC 9269,Per Unit,$57.39 ,OP,57.39,57.39,,,,,,
Aetna MCR ADV,CPT,J0598,C-1 esterase- cinryze,APC 9251,Per Unit,$58.93 ,OP,58.93,58.93,,,,,,
Aetna MCR ADV,CPT,J0599,Inj.- haegarda 10 units,APC 9015,Per Unit,$10.25 ,OP,10.25,10.25,,,,,,
Aetna MCR ADV,CPT,J0600,Edetate calcium disodium inj,APC 1274,Per Unit,"$5,708.59 ",OP,362.21,"5,708.59",,,,,,
Aetna MCR ADV,CPT,J0630,Calcitonin salmon injection,APC 1433,Per Unit,"$3,100.79 ",OP,191.13,"3,100.79",,,,,,
Aetna MCR ADV,CPT,J0638,Canakinumab injection,APC 1311,Per Unit,$115.61 ,OP,115.61,115.61,,,,,,
Aetna MCR ADV,CPT,J0641,Inj levoleucovorin nos 0.5mg,APC 1236,Per Unit,$0.09 ,OP,0.09,0.09,,,,,,
Aetna MCR ADV,CPT,J0642,Injection- khapzory- 0.5 mg,APC 9334,Per Unit,$1.86 ,OP,1.86,1.86,,,,,,
Aetna MCR ADV,CPT,J0691,Inj lefamulin 1 mg,APC 9332,Per Unit,$0.72 ,OP,0.72,0.72,,,,,,
Aetna MCR ADV,CPT,J0695,Inj ceftolozane tazobactam,APC 9452,Per Unit,$6.64 ,OP,6.64,6.64,,,,,,
Aetna MCR ADV,CPT,J0699,Inj- cefiderocol- 10 mg,APC 9426,Per Unit,$2.01 ,OP,2.01,2.01,,,,,,
Aetna MCR ADV,CPT,J0712,Ceftaroline fosamil inj,APC 1824,Per Unit,$3.51 ,OP,3.51,3.51,,,,,,
Aetna MCR ADV,CPT,J0714,Ceftazidime and avibactam,APC 1825,Per Unit,$92.39 ,OP,92.39,92.39,,,,,,
Aetna MCR ADV,CPT,J0716,Centruroides immune f(ab),APC 1431,Per Unit,"$5,190.15 ",OP,"5,190.15","5,190.15",,,,,,
Aetna MCR ADV,CPT,J0717,Certolizumab pegol inj 1mg,APC 1474,Per Unit,$6.27 ,OP,6.27,6.27,,,,,,
Aetna MCR ADV,CPT,J0740,Cidofovir injection,APC 9033,Per Unit,$563.76 ,OP,563.76,"3,694.50",,,,,,
Aetna MCR ADV,CPT,J0741,Inj- cabote rilpivir 2mg 3mg,APC 9414,Per Unit,$20.56 ,OP,20.56,20.56,,,,,,
Aetna MCR ADV,CPT,J0742,Inj imip 4 cilas 4 releb 2mg,APC 9362,Per Unit,$2.32 ,OP,2.32,2.32,,,,,,
Aetna MCR ADV,CPT,J0745,Inj codeine phosphate /30 mg,APC 9393,Per Unit,$135.64 ,OP,7.62,135.64,,,,,,
Aetna MCR ADV,CPT,J0775,Collagenase- clost hist inj,APC 1340,Per Unit,$56.66 ,OP,56.66,56.66,,,,,,
Aetna MCR ADV,CPT,J0791,Inj crizanlizumab-tmca 5mg,APC 9359,Per Unit,$123.29 ,OP,123.29,123.29,,,,,,
Aetna MCR ADV,CPT,J0795,Corticorelin ovine triflutal,APC 1684,Per Unit,$9.67 ,OP,9.67,22.88,,,,,,
Aetna MCR ADV,CPT,J0840,Crotalidae poly immune fab,APC 9274,Per Unit,"$2,743.36 ",OP,"2,743.36","2,743.36",,,,,,
Aetna MCR ADV,CPT,J0841,Inj crotalidae im f(ab)2 eq,APC 9188,Per Unit,"$1,189.81 ",OP,"1,189.81","1,189.81",,,,,,
Aetna MCR ADV,CPT,J0850,Cytomegalovirus imm iv /vial,APC 0903,Per Unit,"$1,538.70 ",OP,"1,538.70","4,266.40",,,,,,
Aetna MCR ADV,CPT,J0875,Injection- dalbavancin,APC 1823,Per Unit,$15.89 ,OP,15.89,15.89,,,,,,
Aetna MCR ADV,CPT,J0881,Darbepoetin alfa- non-esrd,APC 1685,Per Unit,$3.15 ,OP,3.15,15.26,,,,,,
Aetna MCR ADV,CPT,J0882,Darbepoetin alfa- esrd use,APC 1482,Per Unit,$3.15 ,OP,3.15,15.26,,,,,,
Aetna MCR ADV,CPT,J0883,Argatroban nonesrd use 1mg,APC 1859,Per Unit,$1.20 ,OP,1.2,1.2,,,,,,
Aetna MCR ADV,CPT,J0884,Argatroban esrd dialysis 1mg,APC 9065,Per Unit,$1.20 ,OP,1.2,1.2,,,,,,
Aetna MCR ADV,CPT,J0885,Epoetin alfa- non-esrd,APC 1686,Per Unit,$8.15 ,OP,8.15,45.74,,,,,,
Aetna MCR ADV,CPT,J0888,Epoetin beta non esrd,APC 9077,Per Unit,$1.51 ,OP,1.51,1.51,,,,,,
Aetna MCR ADV,CPT,J0894,Decitabine injection,APC 9231,Per Unit,$3.45 ,OP,3.45,3.45,,,,,,
Aetna MCR ADV,CPT,J0896,Inj luspatercept-aamt 0.25mg,APC 9347,Per Unit,$36.85 ,OP,36.85,36.85,,,,,,
Aetna MCR ADV,CPT,J0897,Denosumab injection,APC 9272,Per Unit,$21.19 ,OP,21.19,21.19,,,,,,
Aetna MCR ADV,CPT,J1095,Injection- dexamethasone 9%,APC 9172,Per Unit,$1.04 ,OP,1.04,1.04,,,,,,
Aetna MCR ADV,CPT,J1096,Dexametha opth insert 0.1 mg,APC 9308,Per Unit,$133.30 ,OP,133.3,133.3,,,,,,
Aetna MCR ADV,CPT,J1162,Digoxin immune fab (ovine),APC 1687,Per Unit,"$4,128.19 ",OP,"2,344.81","4,128.19",,,,,,
Aetna MCR ADV,CPT,J1190,Dexrazoxane hcl injection,APC 0726,Per Unit,$192.33 ,OP,192.33,"1,849.16",,,,,,
Aetna MCR ADV,CPT,J1201,Inj. cetirizine hcl 0.5mg,APC 9361,Per Unit,$15.38 ,OP,15.38,15.38,,,,,,
Aetna MCR ADV,CPT,J1212,Dimethyl sulfoxide 50% 50 ml,APC 1832,Per Unit,$637.11 ,OP,339.33,637.11,,,,,,
Aetna MCR ADV,CPT,J1290,Ecallantide injection,APC 9263,Per Unit,$503.88 ,OP,503.88,503.88,,,,,,
Aetna MCR ADV,CPT,J1300,Eculizumab injection,APC 9236,Per Unit,$229.23 ,OP,229.23,679.45,,,,,,
Aetna MCR ADV,CPT,J1301,Injection- edaravone- 1 mg,APC 9493,Per Unit,$20.51 ,OP,20.51,20.51,,,,,,
Aetna MCR ADV,CPT,J1303,Inj.- ravulizumab-cwvz 10 mg,APC 9312,Per Unit,$224.68 ,OP,224.68,224.68,,,,,,
Aetna MCR ADV,CPT,J1305,Inj- evinacumab-dgnb- 5mg,APC 9416,Per Unit,$165.63 ,OP,165.63,165.63,,,,,,
Aetna MCR ADV,CPT,J1322,Elosulfase alfa- injection,APC 1480,Per Unit,$250.33 ,OP,250.33,250.33,,,,,,
Aetna MCR ADV,CPT,J1364,Erythro lactobionate /500 mg,APC 1669,Per Unit,$77.75 ,OP,38.13,77.75,,,,,,
Aetna MCR ADV,CPT,J1410,Inj estrogen conjugate 25 mg,APC 9038,Per Unit,$341.46 ,OP,341.46,381.27,,,,,,
Aetna MCR ADV,CPT,J1426,Injection- casimersen- 10 mg,APC 9412,Per Unit,$166.47 ,OP,166.47,166.47,,,,,,
Aetna MCR ADV,CPT,J1427,Inj. viltolarsen,APC 9386,Per Unit,$59.05 ,OP,59.05,59.05,,,,,,
Aetna MCR ADV,CPT,J1429,Inj golodirsen 10 mg,APC 9356,Per Unit,$166.21 ,OP,166.21,166.21,,,,,,
Aetna MCR ADV,CPT,J1430,Ethanolamine oleate 100 mg,APC 1688,Per Unit,$444.10 ,OP,444.1,728.23,,,,,,
Aetna MCR ADV,CPT,J1437,Inj. fe derisomaltose 10 mg,APC 9388,Per Unit,$24.87 ,OP,24.87,24.87,,,,,,
Aetna MCR ADV,CPT,J1438,Etanercept injection,APC 1608,Per Unit,$790.78 ,OP,714.31,790.78,,,,,,
Aetna MCR ADV,CPT,J1439,Inj ferric carboxymaltos 1mg,APC 9441,Per Unit,$1.12 ,OP,1.12,1.12,,,,,,
Aetna MCR ADV,CPT,J1442,Inj filgrastim excl biosimil,APC 1469,Per Unit,$0.97 ,OP,0.97,3.09,,,,,,
Aetna MCR ADV,CPT,J1447,Inj tbo filgrastim 1 microg,APC 1748,Per Unit,$0.46 ,OP,0.46,3.1,,,,,,
Aetna MCR ADV,CPT,J1448,Injection- trilaciclib- 1mg,APC 9415,Per Unit,$4.97 ,OP,4.97,4.97,,,,,,
Aetna MCR ADV,CPT,J1451,Fomepizole- 15 mg,APC 1689,Per Unit,$5.98 ,OP,5.98,49.56,,,,,,
Aetna MCR ADV,CPT,J1453,Fosaprepitant injection,APC 9242,Per Unit,$0.24 ,OP,0.24,7.62,,,,,,
Aetna MCR ADV,CPT,J1454,Inj fosnetupitant- palonoset,APC 9099,Per Unit,$571.22 ,OP,571.22,571.22,,,,,,
Aetna MCR ADV,CPT,J1455,Foscarnet sodium injection,APC 1849,Per Unit,$72.86 ,OP,49.56,72.86,,,,,,
Aetna MCR ADV,CPT,J1458,Galsulfase injection,APC 9224,Per Unit,$411.92 ,OP,411.92,"1,289.57",,,,,,
Aetna MCR ADV,CPT,J1459,Inj ivig privigen 500 mg,APC 1214,Per Unit,$44.48 ,OP,44.48,143.18,,,,,,
Aetna MCR ADV,CPT,J1460,Gamma globulin 1 cc inj,APC 1850,Per Unit,$44.13 ,OP,44.13,61,,,,,,
Aetna MCR ADV,CPT,J1554,Inj. asceniv,APC 9392,Per Unit,$481.77 ,OP,481.77,481.77,,,,,,
Aetna MCR ADV,CPT,J1555,Inj cuvitru- 100 mg,APC 9034,Per Unit,$14.50 ,OP,14.5,14.5,,,,,,
Aetna MCR ADV,CPT,J1556,Inj- imm glob bivigam- 500mg,APC 9130,Per Unit,$70.49 ,OP,70.49,70.49,,,,,,
Aetna MCR ADV,CPT,J1557,Gammaplex injection,APC 9270,Per Unit,$48.53 ,OP,48.53,48.53,,,,,,
Aetna MCR ADV,CPT,J1558,Inj. xembify- 100 mg,APC 9372,Per Unit,$13.61 ,OP,13.61,13.61,,,,,,
Aetna MCR ADV,CPT,J1559,Hizentra injection,APC 1312,Per Unit,$11.58 ,OP,11.58,11.58,,,,,,
Aetna MCR ADV,CPT,J1560,Gamma globulin > 10 cc inj,APC 1851,Per Unit,$441.31 ,OP,441.31,621.47,,,,,,
Aetna MCR ADV,CPT,J1561,Gamunex-c/gammaked,APC 0948,Per Unit,$48.22 ,OP,48.22,158.91,,,,,,
Aetna MCR ADV,CPT,J1566,Immune globulin- powder,APC 2731,Per Unit,$65.49 ,OP,65.49,152.51,,,,,,
Aetna MCR ADV,CPT,J1568,Octagam injection,APC 0943,Per Unit,$41.63 ,OP,41.63,41.63,,,,,,
Aetna MCR ADV,CPT,J1569,Gammagard liquid injection,APC 0944,Per Unit,$44.49 ,OP,44.49,171.58,,,,,,
Aetna MCR ADV,CPT,J1571,Hepagam b im injection,APC 0946,Per Unit,$70.94 ,OP,70.94,213.51,,,,,,
Aetna MCR ADV,CPT,J1572,Flebogamma injection,APC 0947,Per Unit,$36.80 ,OP,36.8,171.58,,,,,,
Aetna MCR ADV,CPT,J1573,Hepagam b intravenous- inj,APC 1138,Per Unit,$71.24 ,OP,71.24,213.51,,,,,,
Aetna MCR ADV,CPT,J1575,Hyqvia 100mg immuneglobulin,APC 1826,Per Unit,$15.16 ,OP,15.16,15.16,,,,,,
Aetna MCR ADV,CPT,J1595,Injection glatiramer acetate,APC 1015,Per Unit,$141.29 ,OP,141.29,298.68,,,,,,
Aetna MCR ADV,CPT,J1602,Golimumab for iv use 1mg,APC 1475,Per Unit,$16.82 ,OP,16.82,16.82,,,,,,
Aetna MCR ADV,CPT,J1610,Glucagon hydrochloride/1 mg,APC 9042,Per Unit,$171.74 ,OP,171.74,343.14,,,,,,
Aetna MCR ADV,CPT,J1628,Inj.- guselkumab- 1 mg,APC 9029,Per Unit,$82.56 ,OP,82.56,82.56,,,,,,
Aetna MCR ADV,CPT,J1632,Inj.- brexanolone- 1 mg,APC 9333,Per Unit,$74.65 ,OP,74.65,74.65,,,,,,
Aetna MCR ADV,CPT,J1640,Hemin- 1 mg,APC 1690,Per Unit,$26.64 ,OP,26.64,38.13,,,,,,
Aetna MCR ADV,CPT,J1670,Tetanus immune globulin inj,APC 1670,Per Unit,$441.70 ,OP,441.7,"1,040.87",,,,,,
Aetna MCR ADV,CPT,J1726,Makena- 10 mg,APC 9074,Per Unit,$16.82 ,OP,16.82,16.82,,,,,,
Aetna MCR ADV,CPT,J1729,Inj hydroxyprogst capoat nos,APC 9318,Per Unit,$21.54 ,OP,21.54,21.54,,,,,,
Aetna MCR ADV,CPT,J1738,Inj. meloxicam 1 mg,APC 9371,Per Unit,$3.18 ,OP,3.18,3.18,,,,,,
Aetna MCR ADV,CPT,J1740,Ibandronate sodium injection,APC 9229,Per Unit,$37.09 ,OP,37.09,674.85,,,,,,
Aetna MCR ADV,CPT,J1742,Ibutilide fumarate injection,APC 9044,Per Unit,$205.06 ,OP,205.06,"1,898.73",,,,,,
Aetna MCR ADV,CPT,J1744,Icatibant injection,APC 1443,Per Unit,$204.96 ,OP,204.96,204.96,,,,,,
Aetna MCR ADV,CPT,J1745,Infliximab not biosimil 10mg,APC 7043,Per Unit,$39.53 ,OP,39.53,301.32,,,,,,
Aetna MCR ADV,CPT,J1746,Inj.- ibalizumab-uiyk- 10 mg,APC 9189,Per Unit,$66.39 ,OP,66.39,66.39,,,,,,
Aetna MCR ADV,CPT,J1750,Inj iron dextran,APC 1237,Per Unit,$15.84 ,OP,15.84,15.84,,,,,,
Aetna MCR ADV,CPT,J1786,Imuglucerase injection,APC 1327,Per Unit,$44.05 ,OP,44.05,44.05,,,,,,
Aetna MCR ADV,CPT,J1823,Inj. inebilizumab-cdon- 1 mg,APC 9394,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Aetna MCR ADV,CPT,J1826,Interferon beta-1a inj,APC 1852,Per Unit,"$2,293.85 ",OP,"2,293.85","2,293.85",,,,,,
Aetna MCR ADV,CPT,J1830,Interferon beta-1b / .25 mg,APC 0910,Per Unit,$406.24 ,OP,406.24,538.7,,,,,,
Aetna MCR ADV,CPT,J1833,Injection- isavuconazonium,APC 9456,Per Unit,$0.83 ,OP,0.83,0.83,,,,,,
Aetna MCR ADV,CPT,J1930,Lanreotide injection,APC 9237,Per Unit,$67.64 ,OP,67.64,129.64,,,,,,
Aetna MCR ADV,CPT,J1931,Laronidase injection,APC 9209,Per Unit,$34.75 ,OP,34.75,95.46,,,,,,
Aetna MCR ADV,CPT,J1943,Inj.- aristada initio- 1 mg,APC 9179,Per Unit,$3.05 ,OP,3.05,3.05,,,,,,
Aetna MCR ADV,CPT,J1944,Aripirazole lauroxil 1 mg,APC 9470,Per Unit,$2.99 ,OP,2.99,2.99,,,,,,
Aetna MCR ADV,CPT,J1950,Leuprolide acetate /3.75 mg,APC 0800,Per Unit,"$1,406.37 ",OP,"1,406.37","1,525.07",,,,,,
Aetna MCR ADV,CPT,J1951,Inj fensolvi 0.25 mg,APC 9419,Per Unit,$126.28 ,OP,126.28,126.28,,,,,,
Aetna MCR ADV,CPT,J2182,Injection- mepolizumab- 1mg,APC 9473,Per Unit,$28.29 ,OP,28.29,28.29,,,,,,
Aetna MCR ADV,CPT,J2186,Inj.- meropenem- vaborbactam,APC 9178,Per Unit,$1.76 ,OP,1.76,1.76,,,,,,
Aetna MCR ADV,CPT,J2248,Micafungin sodium injection,APC 9227,Per Unit,$0.97 ,OP,0.97,0.97,,,,,,
Aetna MCR ADV,CPT,J2265,Minocycline hydrochloride,APC 1853,Per Unit,$2.00 ,OP,2,2,,,,,,
Aetna MCR ADV,CPT,J2278,Ziconotide injection,APC 1694,Per Unit,$8.69 ,OP,8.69,30.51,,,,,,
Aetna MCR ADV,CPT,J2315,Naltrexone- depot form,APC 0759,Per Unit,$3.53 ,OP,3.53,3.53,,,,,,
Aetna MCR ADV,CPT,J2323,Natalizumab injection,APC 9126,Per Unit,$23.24 ,OP,23.24,103.45,,,,,,
Aetna MCR ADV,CPT,J2326,Inj- nusinersen- 0.1mg,APC 9489,Per Unit,"$1,122.13 ",OP,"1,122.13","1,122.13",,,,,,
Aetna MCR ADV,CPT,J2350,Injection- ocrelizumab- 1 mg,APC 9494,Per Unit,$58.29 ,OP,58.29,58.29,,,,,,
Aetna MCR ADV,CPT,J2353,Octreotide injection- depot,APC 1207,Per Unit,$205.37 ,OP,205.37,408.99,,,,,,
Aetna MCR ADV,CPT,J2357,Omalizumab injection,APC 9300,Per Unit,$37.67 ,OP,37.67,70.74,,,,,,
Aetna MCR ADV,CPT,J2358,Olanzapine long-acting inj,APC 1331,Per Unit,$2.91 ,OP,2.91,2.91,,,,,,
Aetna MCR ADV,CPT,J2406,Injection- oritavancin 10 mg,APC 9427,Per Unit,$41.92 ,OP,41.92,41.92,,,,,,
Aetna MCR ADV,CPT,J2407,Injection- oritavancin,APC 1660,Per Unit,$23.63 ,OP,23.63,23.63,,,,,,
Aetna MCR ADV,CPT,J2425,Palifermin injection,APC 1696,Per Unit,$23.93 ,OP,23.93,23.93,,,,,,
Aetna MCR ADV,CPT,J2426,Paliperidone palmitate inj,APC 9255,Per Unit,$12.66 ,OP,12.66,12.66,,,,,,
Aetna MCR ADV,CPT,J2502,Inj- pasireotide long acting,APC 9454,Per Unit,$359.03 ,OP,359.03,359.03,,,,,,
Aetna MCR ADV,CPT,J2504,Pegademase bovine- 25 iu,APC 1739,Per Unit,$4.06 ,OP,4.06,"1,098.07",,,,,,
Aetna MCR ADV,CPT,J2505,Injection- pegfilgrastim 6mg,APC 9119,Per Unit,"$2,221.63 ",OP,"2,221.63","10,481.09",,,,,,
Aetna MCR ADV,CPT,J2507,Pegloticase injection,APC 9281,Per Unit,"$2,960.91 ",OP,"2,960.91","2,960.91",,,,,,
Aetna MCR ADV,CPT,J2515,Pentobarbital sodium inj,APC 1854,Per Unit,$26.41 ,OP,26.41,26.41,,,,,,
Aetna MCR ADV,CPT,J2547,Injection- peramivir,APC 9451,Per Unit,$1.68 ,OP,1.68,1.68,,,,,,
Aetna MCR ADV,CPT,J2560,Phenobarbital sodium inj,APC 9069,Per Unit,$40.22 ,OP,40.22,40.22,,,,,,
Aetna MCR ADV,CPT,J2562,Plerixafor injection,APC 9252,Per Unit,$382.85 ,OP,382.85,382.85,,,,,,
Aetna MCR ADV,CPT,J2597,Inj desmopressin acetate,APC 1440,Per Unit,$9.40 ,OP,9.4,9.4,,,,,,
Aetna MCR ADV,CPT,J2724,Protein c concentrate,APC 1139,Per Unit,$15.13 ,OP,15.13,61,,,,,,
Aetna MCR ADV,CPT,J2760,Phentolaine mesylate inj,APC 1458,Per Unit,$416.00 ,OP,255.45,416,,,,,,
Aetna MCR ADV,CPT,J2770,Quinupristin/dalfopristin,APC 2770,Per Unit,$444.67 ,OP,444.67,712.98,,,,,,
Aetna MCR ADV,CPT,J2778,Ranibizumab injection,APC 9233,Per Unit,$318.47 ,OP,318.47,318.47,,,,,,
Aetna MCR ADV,CPT,J2783,Rasburicase,APC 0738,Per Unit,$315.06 ,OP,315.06,804.48,,,,,,
Aetna MCR ADV,CPT,J2786,Injection- reslizumab- 1mg,APC 9481,Per Unit,$10.11 ,OP,10.11,10.11,,,,,,
Aetna MCR ADV,CPT,J2792,Rho(d) immune globulin h- sd,APC 1609,Per Unit,$31.42 ,OP,31.42,80.07,,,,,,
Aetna MCR ADV,CPT,J2794,Inj risperdal consta- 0.5 mg,APC 9125,Per Unit,$11.04 ,OP,11.04,19.71,,,,,,
Aetna MCR ADV,CPT,J2796,Romiplostim injection,APC 9245,Per Unit,$83.47 ,OP,83.47,83.47,,,,,,
Aetna MCR ADV,CPT,J2798,Inj.- perseris- 0.5 mg,APC 9181,Per Unit,$10.69 ,OP,10.69,10.69,,,,,,
Aetna MCR ADV,CPT,J2820,Sargramostim injection,APC 0731,Per Unit,$51.55 ,OP,51.55,122,,,,,,
Aetna MCR ADV,CPT,J2840,Inj sebelipase alfa 1 mg,APC 9478,Per Unit,$539.91 ,OP,539.91,539.91,,,,,,
Aetna MCR ADV,CPT,J2850,Inj secretin synthetic human,APC 1700,Per Unit,$34.78 ,OP,34.78,129.64,,,,,,
Aetna MCR ADV,CPT,J2860,Injection- siltuximab,APC 9455,Per Unit,$124.09 ,OP,124.09,124.09,,,,,,
Aetna MCR ADV,CPT,J2941,Somatropin injection,APC 9319,Per Unit,$36.54 ,OP,36.54,226.93,,,,,,
Aetna MCR ADV,CPT,J2993,Reteplase injection,APC 9005,Per Unit,"$2,506.51 ",OP,"2,506.51","4,712.48",,,,,,
Aetna MCR ADV,CPT,J2997,Alteplase recombinant,APC 7048,Per Unit,$87.75 ,OP,87.75,163.95,,,,,,
Aetna MCR ADV,CPT,J3031,Inj.- fremanezumab-vfrm 1 mg,APC 9197,Per Unit,$2.34 ,OP,2.34,2.34,,,,,,
Aetna MCR ADV,CPT,J3032,Inj. eptinezumab-jjmr 1 mg,APC 9357,Per Unit,$15.64 ,OP,15.64,15.64,,,,,,
Aetna MCR ADV,CPT,J3060,Inj- taliglucerase alfa 10 u,APC 9294,Per Unit,$41.32 ,OP,41.32,41.32,,,,,,
Aetna MCR ADV,CPT,J3090,Inj tedizolid phosphate,APC 1662,Per Unit,$1.60 ,OP,1.6,1.6,,,,,,
Aetna MCR ADV,CPT,J3095,Telavancin injection,APC 9258,Per Unit,$6.16 ,OP,6.16,6.16,,,,,,
Aetna MCR ADV,CPT,J3101,Tenecteplase injection,APC 9002,Per Unit,$134.74 ,OP,134.74,202.07,,,,,,
Aetna MCR ADV,CPT,J3111,Inj. romosozumab-aqqg 1 mg,APC 9327,Per Unit,$9.34 ,OP,9.34,9.34,,,,,,
Aetna MCR ADV,CPT,J3145,Testosterone undecanoate 1mg,APC 9078,Per Unit,$1.63 ,OP,1.63,1.63,,,,,,
Aetna MCR ADV,CPT,J3240,Thyrotropin injection,APC 9108,Per Unit,"$1,837.25 ",OP,"1,837.25","3,617.49",,,,,,
Aetna MCR ADV,CPT,J3241,Inj. teprotumumab-trbw 10 mg,APC 9355,Per Unit,$315.88 ,OP,315.88,315.88,,,,,,
Aetna MCR ADV,CPT,J3243,Tigecycline injection,APC 9228,Per Unit,$1.12 ,OP,1.12,3.82,,,,,,
Aetna MCR ADV,CPT,J3245,Inj.- tildrakizumab- 1 mg,APC 9306,Per Unit,$134.08 ,OP,134.08,134.08,,,,,,
Aetna MCR ADV,CPT,J3246,Tirofiban hcl,APC 7041,Per Unit,$3.83 ,OP,3.83,3.83,,,,,,
Aetna MCR ADV,CPT,J3262,Tocilizumab injection,APC 9264,Per Unit,$5.55 ,OP,5.55,5.55,,,,,,
Aetna MCR ADV,CPT,J3285,Treprostinil injection,APC 1701,Per Unit,$59.68 ,OP,59.68,238.44,,,,,,
Aetna MCR ADV,CPT,J3304,Inj triamcinolone ace xr 1mg,APC 9469,Per Unit,$17.75 ,OP,17.75,17.75,,,,,,
Aetna MCR ADV,CPT,J3315,Triptorelin pamoate,APC 9122,Per Unit,$379.90 ,OP,379.9,379.9,,,,,,
Aetna MCR ADV,CPT,J3316,Inj.- triptorelin xr 3.75 mg,APC 9016,Per Unit,"$3,120.11 ",OP,"3,120.11","3,120.11",,,,,,
Aetna MCR ADV,CPT,J3357,Ustekinumab sub cu inj- 1 mg,APC 9261,Per Unit,$176.65 ,OP,176.65,176.65,,,,,,
Aetna MCR ADV,CPT,J3358,Ustekinumab- iv inject- 1 mg,APC 9487,Per Unit,$11.68 ,OP,11.68,11.68,,,,,,
Aetna MCR ADV,CPT,J3380,Injection- vedolizumab,APC 1489,Per Unit,$21.28 ,OP,21.28,21.28,,,,,,
Aetna MCR ADV,CPT,J3385,Velaglucerase alfa,APC 9271,Per Unit,$359.29 ,OP,359.29,359.29,,,,,,
Aetna MCR ADV,CPT,J3396,Verteporfin injection,APC 1203,Per Unit,$11.25 ,OP,11.25,37.64,,,,,,
Aetna MCR ADV,CPT,J3398,Inj luxturna 1 billion vec g,APC 9070,Per Unit,"$2,953.71 ",OP,"2,953.71","2,953.71",,,,,,
Aetna MCR ADV,CPT,J7168,Prothrombin complex kcentra,APC 9132,Per Unit,$1.99 ,OP,1.99,1.99,,,,,,
Aetna MCR ADV,CPT,J7169,Inj andexxa- 10 mg,APC 9198,Per Unit,$289.93 ,OP,289.93,289.93,,,,,,
Aetna MCR ADV,CPT,J7170,Inj.- emicizumab-kxwh 0.5 mg,APC 9257,Per Unit,$48.88 ,OP,48.88,48.88,,,,,,
Aetna MCR ADV,CPT,J7175,Inj- factor x- (human)- 1iu,APC 1857,Per Unit,$8.20 ,OP,8.2,8.2,,,,,,
Aetna MCR ADV,CPT,J7178,Inj human fibrinogen con nos,APC 1478,Per Unit,$1.30 ,OP,1.3,1.3,,,,,,
Aetna MCR ADV,CPT,J7179,Vonvendi inj 1 iu vwf:rco,APC 9059,Per Unit,$1.85 ,OP,1.85,1.85,,,,,,
Aetna MCR ADV,CPT,J7180,Factor xiii anti-hem factor,APC 1416,Per Unit,$9.14 ,OP,9.14,9.14,,,,,,
Aetna MCR ADV,CPT,J7181,Factor xiii recomb a-subunit,APC 1746,Per Unit,$15.87 ,OP,15.87,15.87,,,,,,
Aetna MCR ADV,CPT,J7182,Factor viii recomb novoeight,APC 1856,Per Unit,$1.51 ,OP,1.51,1.51,,,,,,
Aetna MCR ADV,CPT,J7183,Wilate injection,APC 1352,Per Unit,$1.16 ,OP,1.16,1.16,,,,,,
Aetna MCR ADV,CPT,J7185,Xyntha inj,APC 1268,Per Unit,$1.33 ,OP,1.33,1.33,,,,,,
Aetna MCR ADV,CPT,J7186,Antihemophilic viii/vwf comp,APC 1213,Per Unit,$1.14 ,OP,1.14,3.82,,,,,,
Aetna MCR ADV,CPT,J7187,Humate-p- inj,APC 1704,Per Unit,$1.26 ,OP,1.26,2.98,,,,,,
Aetna MCR ADV,CPT,J7188,Factor viii recomb obizur,APC 1827,Per Unit,$3.19 ,OP,3.19,3.19,,,,,,
Aetna MCR ADV,CPT,J7189,Factor viia recomb novoseven,APC 1705,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Aetna MCR ADV,CPT,J7190,Factor viii,APC 0925,Per Unit,$1.12 ,OP,1.12,3.02,,,,,,
Aetna MCR ADV,CPT,J7192,Factor viii recombinant nos,APC 0927,Per Unit,$1.43 ,OP,1.43,3.85,,,,,,
Aetna MCR ADV,CPT,J7193,Factor ix non-recombinant,APC 0931,Per Unit,$1.17 ,OP,1.17,3.36,,,,,,
Aetna MCR ADV,CPT,J7194,Factor ix complex,APC 0928,Per Unit,$1.54 ,OP,1.54,2.52,,,,,,
Aetna MCR ADV,CPT,J7195,Factor ix recombinant nos,APC 0932,Per Unit,$1.61 ,OP,1.61,3.57,,,,,,
Aetna MCR ADV,CPT,J7197,Antithrombin iii injection,APC 1263,Per Unit,$3.20 ,OP,3.2,10.61,,,,,,
Aetna MCR ADV,CPT,J7198,Anti-inhibitor,APC 0929,Per Unit,$2.21 ,OP,2.21,5.2,,,,,,
Aetna MCR ADV,CPT,J7200,Factor ix recombinan rixubis,APC 1467,Per Unit,$1.54 ,OP,1.54,1.54,,,,,,
Aetna MCR ADV,CPT,J7201,Factor ix alprolix recomb,APC 1486,Per Unit,$3.28 ,OP,3.28,3.28,,,,,,
Aetna MCR ADV,CPT,J7202,Factor ix idelvion inj,APC 9171,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Aetna MCR ADV,CPT,J7203,Factor ix recomb gly rebinyn,APC 9468,Per Unit,$4.23 ,OP,4.23,4.23,,,,,,
Aetna MCR ADV,CPT,J7204,Inj recombin esperoct per iu,APC 9354,Per Unit,$2.23 ,OP,2.23,2.23,,,,,,
Aetna MCR ADV,CPT,J7205,Factor viii fc fusion recomb,APC 1656,Per Unit,$2.15 ,OP,2.15,2.15,,,,,,
Aetna MCR ADV,CPT,J7207,Factor viii pegylated recomb,APC 1844,Per Unit,$1.92 ,OP,1.92,1.92,,,,,,
Aetna MCR ADV,CPT,J7208,Inj. jivi 1 iu,APC 9299,Per Unit,$2.10 ,OP,2.1,2.1,,,,,,
Aetna MCR ADV,CPT,J7209,Factor viii nuwiq recomb 1iu,APC 1846,Per Unit,$1.24 ,OP,1.24,1.24,,,,,,
Aetna MCR ADV,CPT,J7210,Inj- afstyla- 1 i.u.,APC 9043,Per Unit,$1.36 ,OP,1.36,1.36,,,,,,
Aetna MCR ADV,CPT,J7211,Inj- kovaltry- 1 i.u.,APC 9075,Per Unit,$1.24 ,OP,1.24,1.24,,,,,,
Aetna MCR ADV,CPT,J7212,Factor viia recomb sevenfact,APC 9395,Per Unit,$2.27 ,OP,2.27,2.27,,,,,,
Aetna MCR ADV,CPT,J7308,Aminolevulinic acid hcl top,APC 7308,Per Unit,$392.48 ,OP,392.48,392.48,,,,,,
Aetna MCR ADV,CPT,J7311,Inj.- retisert- 0.01 mg,APC 9225,Per Unit,$339.00 ,OP,339,"93,937.12",,,,,,
Aetna MCR ADV,CPT,J7312,Dexamethasone intra implant,APC 9256,Per Unit,$199.69 ,OP,199.69,199.69,,,,,,
Aetna MCR ADV,CPT,J7313,Inj.- iluvien- 0.01 mg,APC 9450,Per Unit,$490.95 ,OP,490.95,490.95,,,,,,
Aetna MCR ADV,CPT,J7314,Inj.- yutiq- 0.01 mg,APC 9328,Per Unit,$513.16 ,OP,513.16,513.16,,,,,,
Aetna MCR ADV,CPT,J7316,Inj- ocriplasmin- 0.125 mg,APC 9298,Per Unit,"$1,046.93 ",OP,"1,046.93","1,046.93",,,,,,
Aetna MCR ADV,CPT,J7318,Inj- durolane 1 mg,APC 9174,Per Unit,$17.23 ,OP,17.23,17.23,,,,,,
Aetna MCR ADV,CPT,J7320,Genvisc 850- inj- 1mg,APC 9079,Per Unit,$16.92 ,OP,16.92,16.92,,,,,,
Aetna MCR ADV,CPT,J7322,Hymovis injection 1 mg,APC 9471,Per Unit,$31.67 ,OP,31.67,903.6,,,,,,
Aetna MCR ADV,CPT,J7323,Euflexxa inj per dose,APC 0875,Per Unit,$138.82 ,OP,138.82,590.67,,,,,,
Aetna MCR ADV,CPT,J7324,Orthovisc inj per dose,APC 0877,Per Unit,$148.74 ,OP,148.74,880.74,,,,,,
Aetna MCR ADV,CPT,J7325,Synvisc or synvisc-one,APC 0874,Per Unit,$11.24 ,OP,11.24,11.24,,,,,,
Aetna MCR ADV,CPT,J7326,Gel-one,APC 1417,Per Unit,"$1,219.00 ",OP,"1,219.00","1,219.00",,,,,,
Aetna MCR ADV,CPT,J7327,Monovisc inj per dose,APC 1747,Per Unit,$762.80 ,OP,762.8,762.8,,,,,,
Aetna MCR ADV,CPT,J7328,Gelsyn-3 injection 0.1 mg,APC 1862,Per Unit,$2.18 ,OP,2.18,2.18,,,,,,
Aetna MCR ADV,CPT,J7329,Inj- trivisc 1 mg,APC 9196,Per Unit,$19.12 ,OP,19.12,19.12,,,,,,
Aetna MCR ADV,CPT,J7331,Synojoynt- inj.- 1 mg,APC 9337,Per Unit,$18.02 ,OP,18.02,18.02,,,,,,
Aetna MCR ADV,CPT,J7336,Capsaicin 8% patch,APC 9071,Per Unit,$3.23 ,OP,3.23,3.23,,,,,,
Aetna MCR ADV,CPT,J7340,Carbidopa levodopa ent 100ml,APC 9320,Per Unit,$211.70 ,OP,211.7,211.7,,,,,,
Aetna MCR ADV,CPT,J7342,Ciprofloxacin otic susp 6 mg,APC 9479,Per Unit,$29.98 ,OP,29.98,29.98,,,,,,
Aetna MCR ADV,CPT,J7345,Aminolevulinic acid- 10% gel,APC 9301,Per Unit,$1.59 ,OP,1.59,1.59,,,,,,
Aetna MCR ADV,CPT,J7351,Inj bimatoprost itc imp1mcg,APC 9351,Per Unit,$205.63 ,OP,205.63,205.63,,,,,,
Aetna MCR ADV,CPT,J7352,Afamelanotide implant- 1 mg,APC 9396,Per Unit,"$3,218.90 ",OP,"3,218.90","3,218.90",,,,,,
Aetna MCR ADV,CPT,J7402,Mometasone sinus sinuva,APC 9346,Per Unit,$10.56 ,OP,10.56,10.56,,,,,,
Aetna MCR ADV,CPT,J7501,Azathioprine parenteral,APC 0887,Per Unit,$245.02 ,OP,245.02,442.27,,,,,,
Aetna MCR ADV,CPT,J7504,Lymphocyte immune globulin,APC 0890,Per Unit,"$2,355.53 ",OP,"2,245.67","2,355.53",,,,,,
Aetna MCR ADV,CPT,J7511,Antithymocyte globuln rabbit,APC 9104,Per Unit,$837.42 ,OP,837.42,"1,807.23",,,,,,
Aetna MCR ADV,CPT,J7525,Tacrolimus injection,APC 9006,Per Unit,$219.33 ,OP,219.33,540.46,,,,,,
Aetna MCR ADV,CPT,J8560,Etoposide oral 50 mg,APC 0802,Per Unit,$75.63 ,OP,75.63,75.63,,,,,,
Aetna MCR ADV,CPT,J8655,Oral netupitant- palonosetro,APC 9448,Per Unit,$315.59 ,OP,315.59,315.59,,,,,,
Aetna MCR ADV,CPT,J8670,Rolapitant- oral- 1mg,APC 1761,Per Unit,$1.75 ,OP,1.75,1.75,,,,,,
Aetna MCR ADV,CPT,J9015,Aldesleukin injection,APC 0807,Per Unit,"$3,795.26 ",OP,"3,795.26","3,795.26",,,,,,
Aetna MCR ADV,CPT,J9017,Arsenic trioxide injection,APC 9012,Per Unit,$13.11 ,OP,13.11,179.2,,,,,,
Aetna MCR ADV,CPT,J9019,Erwinaze injection,APC 9289,Per Unit,$427.27 ,OP,427.27,427.27,,,,,,
Aetna MCR ADV,CPT,J9022,Inj- atezolizumab-10 mg,APC 9483,Per Unit,$79.75 ,OP,79.75,79.75,,,,,,
Aetna MCR ADV,CPT,J9023,Injection- avelumab- 10 mg,APC 9491,Per Unit,$86.19 ,OP,86.19,86.19,,,,,,
Aetna MCR ADV,CPT,J9025,Azacitidine injection,APC 1709,Per Unit,$0.93 ,OP,0.93,22.88,,,,,,
Aetna MCR ADV,CPT,J9027,Clofarabine injection,APC 1710,Per Unit,$53.15 ,OP,53.15,564.29,,,,,,
Aetna MCR ADV,CPT,J9032,Injection- belinostat- 10mg,APC 1658,Per Unit,$42.77 ,OP,42.77,42.77,,,,,,
Aetna MCR ADV,CPT,J9033,Inj.- treanda 1 mg,APC 9243,Per Unit,$22.01 ,OP,22.01,91.51,,,,,,
Aetna MCR ADV,CPT,J9034,Inj.- bendeka 1 mg,APC 1861,Per Unit,$19.65 ,OP,19.65,19.65,,,,,,
Aetna MCR ADV,CPT,J9035,Bevacizumab injection,APC 9214,Per Unit,$70.41 ,OP,70.41,278.32,,,,,,
Aetna MCR ADV,CPT,J9036,Inj. belrapzo/bendamustine,APC 9313,Per Unit,$21.47 ,OP,21.47,21.47,,,,,,
Aetna MCR ADV,CPT,J9037,Inj belantamab mafodont blmf,APC 9384,Per Unit,$42.78 ,OP,42.78,42.78,,,,,,
Aetna MCR ADV,CPT,J9039,Injection- blinatumomab,APC 9449,Per Unit,$123.88 ,OP,123.88,123.88,,,,,,
Aetna MCR ADV,CPT,J9041,Inj.- velcade 0.1 mg,APC 9207,Per Unit,$45.16 ,OP,45.16,175.39,,,,,,
Aetna MCR ADV,CPT,J9042,Brentuximab vedotin inj,APC 9287,Per Unit,$189.34 ,OP,189.34,189.34,,,,,,
Aetna MCR ADV,CPT,J9043,Cabazitaxel injection,APC 9276,Per Unit,$189.00 ,OP,189,189,,,,,,
Aetna MCR ADV,CPT,J9044,Inj- bortezomib- nos- 0.1 mg,APC 9192,Per Unit,$18.31 ,OP,18.31,18.31,,,,,,
Aetna MCR ADV,CPT,J9047,Injection- carfilzomib- 1 mg,APC 9295,Per Unit,$41.10 ,OP,41.1,41.1,,,,,,
Aetna MCR ADV,CPT,J9050,Carmustine injection,APC 0812,Per Unit,"$1,234.46 ",OP,"1,234.46","1,234.46",,,,,,
Aetna MCR ADV,CPT,J9055,Cetuximab injection,APC 9215,Per Unit,$66.71 ,OP,66.71,240.2,,,,,,
Aetna MCR ADV,CPT,J9057,Inj.- copanlisib- 1 mg,APC 9030,Per Unit,$80.96 ,OP,80.96,80.96,,,,,,
Aetna MCR ADV,CPT,J9065,Inj cladribine per 1 mg,APC 0858,Per Unit,$18.02 ,OP,18.02,144.88,,,,,,
Aetna MCR ADV,CPT,J9070,Cyclophosphamide 100 mg inj,APC 1408,Per Unit,$29.15 ,OP,19.07,29.15,,,,,,
Aetna MCR ADV,CPT,J9119,Inj.- cemiplimab-rwlc- 1 mg,APC 9304,Per Unit,$27.54 ,OP,27.54,27.54,,,,,,
Aetna MCR ADV,CPT,J9120,Dactinomycin injection,APC 0752,Per Unit,$890.64 ,OP,890.64,"2,634.57",,,,,,
Aetna MCR ADV,CPT,J9144,Daratumumab- hyaluronidase,APC 9378,Per Unit,$45.10 ,OP,45.1,45.1,,,,,,
Aetna MCR ADV,CPT,J9145,Injection- daratumumab 10 mg,APC 9476,Per Unit,$57.55 ,OP,57.55,57.55,,,,,,
Aetna MCR ADV,CPT,J9150,Daunorubicin injection,APC 0820,Per Unit,$40.36 ,OP,40.36,80.07,,,,,,
Aetna MCR ADV,CPT,J9153,Inj daunorubicin- cytarabine,APC 9302,Per Unit,$202.60 ,OP,202.6,202.6,,,,,,
Aetna MCR ADV,CPT,J9155,Degarelix injection,APC 1296,Per Unit,$4.12 ,OP,4.12,4.12,,,,,,
Aetna MCR ADV,CPT,J9173,Inj.- durvalumab- 10 mg,APC 9492,Per Unit,$76.86 ,OP,76.86,76.86,,,,,,
Aetna MCR ADV,CPT,J9176,Injection- elotuzumab- 1mg,APC 9477,Per Unit,$6.77 ,OP,6.77,6.77,,,,,,
Aetna MCR ADV,CPT,J9177,Inj enfort vedo-ejfv 0.25mg,APC 9364,Per Unit,$30.17 ,OP,30.17,30.17,,,,,,
Aetna MCR ADV,CPT,J9179,Eribulin mesylate injection,APC 1426,Per Unit,$123.93 ,OP,123.93,123.93,,,,,,
Aetna MCR ADV,CPT,J9198,Inj. infugem- 100 mg,APC 9387,Per Unit,$34.00 ,OP,34,34,,,,,,
Aetna MCR ADV,CPT,J9202,Goserelin acetate implant,APC 0810,Per Unit,$525.21 ,OP,525.21,915.04,,,,,,
Aetna MCR ADV,CPT,J9203,Gemtuzumab ozogamicin 0.1 mg,APC 9495,Per Unit,$207.99 ,OP,207.99,207.99,,,,,,
Aetna MCR ADV,CPT,J9204,Inj mogamulizumab-kpkc- 1 mg,APC 9182,Per Unit,$210.05 ,OP,210.05,210.05,,,,,,
Aetna MCR ADV,CPT,J9205,Inj irinotecan liposome 1 mg,APC 9474,Per Unit,$57.20 ,OP,57.2,57.2,,,,,,
Aetna MCR ADV,CPT,J9207,Ixabepilone injection,APC 9240,Per Unit,$112.12 ,OP,112.12,308.83,,,,,,
Aetna MCR ADV,CPT,J9210,Inj.- emapalumab-lzsg- 1 mg,APC 9310,Per Unit,$376.03 ,OP,376.03,376.03,,,,,,
Aetna MCR ADV,CPT,J9214,Interferon alfa-2b inj,APC 0836,Per Unit,$33.24 ,OP,33.24,72.44,,,,,,
Aetna MCR ADV,CPT,J9217,Leuprolide acetate suspnsion,APC 9217,Per Unit,$139.09 ,OP,139.09,987.49,,,,,,
Aetna MCR ADV,CPT,J9223,Inj. lurbinectedin- 0.1 mg,APC 9389,Per Unit,$174.03 ,OP,174.03,174.03,,,,,,
Aetna MCR ADV,CPT,J9225,Vantas implant,APC 1711,Per Unit,"$5,166.29 ",OP,"5,166.29","7,613.94",,,,,,
Aetna MCR ADV,CPT,J9226,Supprelin la implant,APC 1142,Per Unit,"$43,467.03 ",OP,"43,467.03","71,949.32",,,,,,
Aetna MCR ADV,CPT,J9227,Inj. isatuximab-irfc 10 mg,APC 9377,Per Unit,$67.60 ,OP,67.6,67.6,,,,,,
Aetna MCR ADV,CPT,J9228,Ipilimumab injection,APC 9284,Per Unit,$158.65 ,OP,158.65,158.65,,,,,,
Aetna MCR ADV,CPT,J9229,Inj inotuzumab ozogam 0.1 mg,APC 9028,Per Unit,"$2,371.62 ",OP,"2,371.62","2,371.62",,,,,,
Aetna MCR ADV,CPT,J9230,Mechlorethamine hcl inj,APC 0751,Per Unit,$11.74 ,OP,11.74,712.98,,,,,,
Aetna MCR ADV,CPT,J9245,Inj melpha hydroch nos 50 mg,APC 0840,Per Unit,$208.41 ,OP,208.41,"7,888.46",,,,,,
Aetna MCR ADV,CPT,J9246,Inj.- evomela- 1 mg,APC 9375,Per Unit,$18.20 ,OP,18.2,18.2,,,,,,
Aetna MCR ADV,CPT,J9247,Inj- melphalan flufenami 1mg,APC 9417,Per Unit,$499.86 ,OP,499.86,499.86,,,,,,
Aetna MCR ADV,CPT,J9261,Nelarabine injection,APC 0825,Per Unit,$155.90 ,OP,155.9,488.04,,,,,,
Aetna MCR ADV,CPT,J9262,Inj- omacetaxine mep- 0.01mg,APC 9297,Per Unit,$3.30 ,OP,3.3,3.3,,,,,,
Aetna MCR ADV,CPT,J9264,Paclitaxel protein bound,APC 1712,Per Unit,$14.08 ,OP,14.08,45.74,,,,,,
Aetna MCR ADV,CPT,J9266,Pegaspargase injection,APC 0843,Per Unit,"$21,561.05 ",OP,"12,715.34","21,561.05",,,,,,
Aetna MCR ADV,CPT,J9268,Pentostatin injection,APC 0844,Per Unit,"$1,880.67 ",OP,"1,880.67","7,030.61",,,,,,
Aetna MCR ADV,CPT,J9269,Inj. tagraxofusp-erzs 10 mcg,APC 9309,Per Unit,$290.37 ,OP,290.37,290.37,,,,,,
Aetna MCR ADV,CPT,J9270,Plicamycin (mithramycin) inj,APC 9093,Per Unit,$115.40 ,OP,115.4,385.09,,,,,,
Aetna MCR ADV,CPT,J9271,Inj pembrolizumab,APC 1490,Per Unit,$52.75 ,OP,52.75,52.75,,,,,,
Aetna MCR ADV,CPT,J9280,Mitomycin injection,APC 1232,Per Unit,$38.63 ,OP,38.63,76.26,,,,,,
Aetna MCR ADV,CPT,J9281,Mitomycin instillation,APC 9374,Per Unit,$281.88 ,OP,281.88,281.88,,,,,,
Aetna MCR ADV,CPT,J9285,Inj- olaratumab- 10 mg,APC 9485,Per Unit,$52.07 ,OP,52.07,52.07,,,,,,
Aetna MCR ADV,CPT,J9293,Mitoxantrone hydrochl / 5 mg,APC 0864,Per Unit,$26.29 ,OP,26.29,392.7,,,,,,
Aetna MCR ADV,CPT,J9295,Injection- necitumumab- 1 mg,APC 9475,Per Unit,$5.74 ,OP,5.74,5.74,,,,,,
Aetna MCR ADV,CPT,J9299,Injection- nivolumab,APC 9453,Per Unit,$28.86 ,OP,28.86,28.86,,,,,,
Aetna MCR ADV,CPT,J9301,Obinutuzumab inj,APC 1476,Per Unit,$64.54 ,OP,64.54,64.54,,,,,,
Aetna MCR ADV,CPT,J9302,Ofatumumab injection,APC 9260,Per Unit,$63.96 ,OP,63.96,63.96,,,,,,
Aetna MCR ADV,CPT,J9303,Panitumumab injection,APC 9235,Per Unit,$130.38 ,OP,130.38,130.38,,,,,,
Aetna MCR ADV,CPT,J9305,Inj. pemetrexed nos 10mg,APC 9213,Per Unit,$74.93 ,OP,74.93,232.58,,,,,,
Aetna MCR ADV,CPT,J9306,Injection- pertuzumab- 1 mg,APC 1471,Per Unit,$13.56 ,OP,13.56,13.56,,,,,,
Aetna MCR ADV,CPT,J9307,Pralatrexate injection,APC 9259,Per Unit,$314.84 ,OP,314.84,314.84,,,,,,
Aetna MCR ADV,CPT,J9308,Injection- ramucirumab,APC 1488,Per Unit,$62.69 ,OP,62.69,62.69,,,,,,
Aetna MCR ADV,CPT,J9309,Inj- polatuzumab vedotin 1mg,APC 9331,Per Unit,$113.57 ,OP,113.57,113.57,,,,,,
Aetna MCR ADV,CPT,J9311,Inj rituximab- hyaluronidase,APC 9467,Per Unit,$37.94 ,OP,37.94,37.94,,,,,,
Aetna MCR ADV,CPT,J9312,Inj.- rituximab- 10 mg,APC 9186,Per Unit,$86.94 ,OP,86.94,86.94,,,,,,
Aetna MCR ADV,CPT,J9313,Inj.- lumoxiti- 0.01 mg,APC 9305,Per Unit,$23.39 ,OP,23.39,23.39,,,,,,
Aetna MCR ADV,CPT,J9316,Pertuzu- trastuzu- 10 mg,APC 9390,Per Unit,$72.15 ,OP,72.15,72.15,,,,,,
Aetna MCR ADV,CPT,J9317,Sacituzumab govitecan-hziy,APC 9376,Per Unit,$30.35 ,OP,30.35,30.35,,,,,,
Aetna MCR ADV,CPT,J9318,Inj romidepsin non-lyo 0.1mg,APC 9428,Per Unit,$33.91 ,OP,33.91,33.91,,,,,,
Aetna MCR ADV,CPT,J9319,Inj romidepsin lyophil 0.1mg,APC 9429,Per Unit,$33.68 ,OP,33.68,33.68,,,,,,
Aetna MCR ADV,CPT,J9320,Streptozocin injection,APC 0850,Per Unit,$348.51 ,OP,348.51,"1,372.57",,,,,,
Aetna MCR ADV,CPT,J9325,Inj talimogene laherparepvec,APC 9472,Per Unit,$57.26 ,OP,57.26,57.26,,,,,,
Aetna MCR ADV,CPT,J9328,Temozolomide injection,APC 9253,Per Unit,$10.41 ,OP,10.41,10.41,,,,,,
Aetna MCR ADV,CPT,J9330,Temsirolimus injection,APC 1168,Per Unit,$38.25 ,OP,38.25,38.25,,,,,,
Aetna MCR ADV,CPT,J9340,Thiotepa injection,APC 0851,Per Unit,$305.84 ,OP,305.84,446.08,,,,,,
Aetna MCR ADV,CPT,J9348,Inj. naxitamab-gqgk- 1 mg,APC 9408,Per Unit,$539.07 ,OP,539.07,539.07,,,,,,
Aetna MCR ADV,CPT,J9349,Inj.- tafasitamab-cxix,APC 9385,Per Unit,$12.62 ,OP,12.62,12.62,,,,,,
Aetna MCR ADV,CPT,J9352,Injection trabectedin 0.1mg,APC 9480,Per Unit,$325.03 ,OP,325.03,325.03,,,,,,
Aetna MCR ADV,CPT,J9353,Inj. margetuximab-cmkb- 5 mg,APC 9418,Per Unit,$42.99 ,OP,42.99,42.99,,,,,,
Aetna MCR ADV,CPT,J9354,Inj- ado-trastuzumab emt 1mg,APC 9131,Per Unit,$34.18 ,OP,34.18,34.18,,,,,,
Aetna MCR ADV,CPT,J9355,Inj trastuzumab excl biosimi,APC 1613,Per Unit,$89.81 ,OP,89.81,238.1,,,,,,
Aetna MCR ADV,CPT,J9356,Inj. herceptin hylecta- 10mg,APC 9314,Per Unit,$71.85 ,OP,71.85,71.85,,,,,,
Aetna MCR ADV,CPT,J9357,Valrubicin injection,APC 1235,Per Unit,"$1,425.37 ",OP,"1,425.37","1,795.78",,,,,,
Aetna MCR ADV,CPT,J9358,Inj fam-trastu deru-nxki 1mg,APC 9353,Per Unit,$24.27 ,OP,24.27,24.27,,,,,,
Aetna MCR ADV,CPT,J9371,Inj- vincristine sul lip 1mg,APC 1466,Per Unit,"$3,370.23 ",OP,28.22,"3,370.23",,,,,,
Aetna MCR ADV,CPT,J9395,Injection- fulvestrant,APC 9120,Per Unit,$15.98 ,OP,15.98,396.52,,,,,,
Aetna MCR ADV,CPT,J9400,Inj- ziv-aflibercept- 1mg,APC 9296,Per Unit,$8.42 ,OP,8.42,8.42,,,,,,
Aetna MCR ADV,CPT,J9600,Porfimer sodium injection,APC 0856,Per Unit,"$21,856.35 ",OP,"13,169.04","21,856.35",,,,,,
Aetna MCR ADV,CPT,K0672,Removable soft interface le,Durable Medical Equipment,Per Unit,$85.14 ,OP,85.14,85.14,,,,,,
Aetna MCR ADV,CPT,L0112,Cranial cervical orthosis,Durable Medical Equipment,Per Unit,"$1,404.96 ",OP,"1,404.96","4,830.68",,,,,,
Aetna MCR ADV,CPT,L0113,Cranial cervical torticollis,Durable Medical Equipment,Per Unit,$286.27 ,OP,286.27,286.27,,,,,,
Aetna MCR ADV,CPT,L0120,Cerv flex n/adj foam pre ots,Durable Medical Equipment,Per Unit,$26.55 ,OP,26.55,91.51,,,,,,
Aetna MCR ADV,CPT,L0130,Flex thermoplastic collar mo,Durable Medical Equipment,Per Unit,$153.23 ,OP,153.23,526.16,,,,,,
Aetna MCR ADV,CPT,L0140,Cervical semi-rigid adjustab,Durable Medical Equipment,Per Unit,$60.09 ,OP,60.09,205.88,,,,,,
Aetna MCR ADV,CPT,L0150,Cerv semi-rig adj molded chn,Durable Medical Equipment,Per Unit,$107.45 ,OP,107.45,369.83,,,,,,
Aetna MCR ADV,CPT,L0160,Cerv sr wire occ/man pre ots,Durable Medical Equipment,Per Unit,$156.89 ,OP,156.89,541.4,,,,,,
Aetna MCR ADV,CPT,L0170,Cervical collar molded to pt,Durable Medical Equipment,Per Unit,$807.10 ,OP,807.1,"2,775.65",,,,,,
Aetna MCR ADV,CPT,L0172,Cerv col sr foam 2pc pre ots,Durable Medical Equipment,Per Unit,$142.17 ,OP,142.17,488.04,,,,,,
Aetna MCR ADV,CPT,L0174,Cerv sr 2pc thor ext pre ots,Durable Medical Equipment,Per Unit,$279.55 ,OP,279.55,960.8,,,,,,
Aetna MCR ADV,CPT,L0180,Cer post col occ/man sup adj,Durable Medical Equipment,Per Unit,$452.88 ,OP,452.88,"1,559.39",,,,,,
Aetna MCR ADV,CPT,L0190,Cerv collar supp adj cerv ba,Durable Medical Equipment,Per Unit,$534.12 ,OP,534.12,"1,837.71",,,,,,
Aetna MCR ADV,CPT,L0200,Cerv col supp adj bar & thor,Durable Medical Equipment,Per Unit,$619.54 ,OP,619.54,"2,131.30",,,,,,
Aetna MCR ADV,CPT,L0220,Thor rib belt custom fabrica,Durable Medical Equipment,Per Unit,$129.68 ,OP,129.68,446.08,,,,,,
Aetna MCR ADV,CPT,L0450,Tlso flex trunk/thor pre ots,Durable Medical Equipment,Per Unit,$128.11 ,OP,128.11,560.47,,,,,,
Aetna MCR ADV,CPT,L0454,Tlso trnk sj-t9 pre cst,Durable Medical Equipment,Per Unit,$348.14 ,OP,348.14,"1,197.20",,,,,,
Aetna MCR ADV,CPT,L0455,Tlso flex trnk sj-t9 pre ots,Durable Medical Equipment,Per Unit,$249.16 ,OP,249.16,249.16,,,,,,
Aetna MCR ADV,CPT,L0456,Tlso flex trnk sj-ss pre cst,Durable Medical Equipment,Per Unit,$998.38 ,OP,998.38,"3,435.25",,,,,,
Aetna MCR ADV,CPT,L0457,Tlso flex trnk sj-ss pre ots,Durable Medical Equipment,Per Unit,$714.52 ,OP,714.52,714.52,,,,,,
Aetna MCR ADV,CPT,L0458,Tlso 2mod symphis-xipho pre,Durable Medical Equipment,Per Unit,$895.27 ,OP,895.27,"3,080.66",,,,,,
Aetna MCR ADV,CPT,L0460,Tlso 2 shl symphys-stern cst,Durable Medical Equipment,Per Unit,"$1,007.68 ",OP,"1,007.68","3,465.73",,,,,,
Aetna MCR ADV,CPT,L0462,Tlso 3mod sacro-scap pre,Durable Medical Equipment,Per Unit,"$1,253.37 ",OP,"1,253.37","4,312.16",,,,,,
Aetna MCR ADV,CPT,L0464,Tlso 4mod sacro-scap pre,Durable Medical Equipment,Per Unit,"$1,492.13 ",OP,"1,492.13","5,131.88",,,,,,
Aetna MCR ADV,CPT,L0466,Tlso r fram soft ant pre cst,Durable Medical Equipment,Per Unit,$380.86 ,OP,380.86,"1,311.56",,,,,,
Aetna MCR ADV,CPT,L0467,Tlso r fram soft pre ots,Durable Medical Equipment,Per Unit,$277.04 ,OP,277.04,277.04,,,,,,
Aetna MCR ADV,CPT,L0468,Tlso rig fram pelvic pre cst,Durable Medical Equipment,Per Unit,$477.29 ,OP,477.29,"1,643.28",,,,,,
Aetna MCR ADV,CPT,L0469,Tlso rig fram pelvic pre ots,Durable Medical Equipment,Per Unit,$351.00 ,OP,351,351,,,,,,
Aetna MCR ADV,CPT,L0470,Tlso rigid frame pre subclav,Durable Medical Equipment,Per Unit,$660.47 ,OP,660.47,"2,272.36",,,,,,
Aetna MCR ADV,CPT,L0472,Tlso rigid frame hyperex pre,Durable Medical Equipment,Per Unit,$406.41 ,OP,406.41,"1,399.26",,,,,,
Aetna MCR ADV,CPT,L0480,Tlso rigid plastic custom fa,Durable Medical Equipment,Per Unit,"$1,516.23 ",OP,"1,516.23","5,215.77",,,,,,
Aetna MCR ADV,CPT,L0482,Tlso rigid lined custom fab,Durable Medical Equipment,Per Unit,"$1,693.64 ",OP,"1,693.64","5,825.80",,,,,,
Aetna MCR ADV,CPT,L0484,Tlso rigid plastic cust fab,Durable Medical Equipment,Per Unit,"$1,829.06 ",OP,"1,829.06","6,290.94",,,,,,
Aetna MCR ADV,CPT,L0486,Tlso rigidlined cust fab two,Durable Medical Equipment,Per Unit,"$2,054.11 ",OP,"2,054.11","7,064.92",,,,,,
Aetna MCR ADV,CPT,L0488,Tlso rigid lined pre one pie,Durable Medical Equipment,Per Unit,"$1,007.68 ",OP,"1,007.68","3,465.73",,,,,,
Aetna MCR ADV,CPT,L0490,Tlso rigid plastic pre one,Durable Medical Equipment,Per Unit,$283.96 ,OP,283.96,976.05,,,,,,
Aetna MCR ADV,CPT,L0491,Tlso 2 piece rigid shell,Durable Medical Equipment,Per Unit,$770.93 ,OP,770.93,"2,649.83",,,,,,
Aetna MCR ADV,CPT,L0492,Tlso 3 piece rigid shell,Durable Medical Equipment,Per Unit,$502.01 ,OP,502.01,"1,727.15",,,,,,
Aetna MCR ADV,CPT,L0621,Sio flex pelvic/sacr pre ots,Durable Medical Equipment,Per Unit,$67.68 ,OP,67.68,446.08,,,,,,
Aetna MCR ADV,CPT,L0622,Sio flex pelvisacral custom,Durable Medical Equipment,Per Unit,$268.31 ,OP,268.31,"1,384.01",,,,,,
Aetna MCR ADV,CPT,L0623,Sio rig pnl pelv/sac pre ots,Durable Medical Equipment,Per Unit,$126.95 ,OP,126.95,126.95,,,,,,
Aetna MCR ADV,CPT,L0625,Lo flex l1-below l5 pre ots,Durable Medical Equipment,Per Unit,$39.58 ,OP,39.58,285.96,,,,,,
Aetna MCR ADV,CPT,L0626,Lo sag rig pnl stays pre cst,Durable Medical Equipment,Per Unit,$78.25 ,OP,78.25,404.14,,,,,,
Aetna MCR ADV,CPT,L0627,Lo sag ri an/pos pnl pre cst,Durable Medical Equipment,Per Unit,$412.59 ,OP,412.59,"2,127.49",,,,,,
Aetna MCR ADV,CPT,L0628,Lso flex no ri stays pre ots,Durable Medical Equipment,Per Unit,$60.27 ,OP,60.27,434.65,,,,,,
Aetna MCR ADV,CPT,L0630,Lso r post pnl sj-t9 pre cst,Durable Medical Equipment,Per Unit,$162.59 ,OP,162.59,838.79,,,,,,
Aetna MCR ADV,CPT,L0631,Lso sag r an/pos pnl pre cst,Durable Medical Equipment,Per Unit,"$1,030.49 ",OP,"1,030.49","5,314.90",,,,,,
Aetna MCR ADV,CPT,L0633,Lso sc r pos/lat pnl pre cst,Durable Medical Equipment,Per Unit,$287.85 ,OP,287.85,"1,483.14",,,,,,
Aetna MCR ADV,CPT,L0635,Lso sagit rigid panel prefab,Durable Medical Equipment,Per Unit,"$1,003.05 ",OP,"1,003.05","5,173.83",,,,,,
Aetna MCR ADV,CPT,L0636,Lso sagittal rigid panel cus,Durable Medical Equipment,Per Unit,"$1,360.98 ",OP,"1,360.98","7,019.17",,,,,,
Aetna MCR ADV,CPT,L0637,Lso sc r ant/pos pnl pre cst,Durable Medical Equipment,Per Unit,"$1,300.47 ",OP,"1,300.47","6,710.34",,,,,,
Aetna MCR ADV,CPT,L0638,Lso sag-coronal panel custom,Durable Medical Equipment,Per Unit,"$1,323.97 ",OP,"1,323.97","6,828.54",,,,,,
Aetna MCR ADV,CPT,L0639,Lso s/c shell/panel prefab,Durable Medical Equipment,Per Unit,"$1,300.47 ",OP,"1,300.47","6,710.34",,,,,,
Aetna MCR ADV,CPT,L0640,Lso s/c shell/panel custom,Durable Medical Equipment,Per Unit,"$1,050.39 ",OP,"1,050.39","5,417.84",,,,,,
Aetna MCR ADV,CPT,L0641,Lo rig pos pnl l1-l5 pre ots,Durable Medical Equipment,Per Unit,$56.00 ,OP,56,56,,,,,,
Aetna MCR ADV,CPT,L0642,Lo sag ri an/pos pnl pre ots,Durable Medical Equipment,Per Unit,$295.35 ,OP,295.35,295.35,,,,,,
Aetna MCR ADV,CPT,L0643,Lso sag ctr rigi pos pre ots,Durable Medical Equipment,Per Unit,$116.37 ,OP,116.37,116.37,,,,,,
Aetna MCR ADV,CPT,L0648,Lso sag r an/pos pnl pre ots,Durable Medical Equipment,Per Unit,$737.61 ,OP,737.61,737.61,,,,,,
Aetna MCR ADV,CPT,L0649,Lso sc r pos/lat pnl pre ots,Durable Medical Equipment,Per Unit,$206.04 ,OP,206.04,206.04,,,,,,
Aetna MCR ADV,CPT,L0650,Lso sc r ant/pos pnl pre ots,Durable Medical Equipment,Per Unit,$880.49 ,OP,880.49,880.49,,,,,,
Aetna MCR ADV,CPT,L0651,Lso sag-co shell pnl pre ots,Durable Medical Equipment,Per Unit,$880.49 ,OP,880.49,880.49,,,,,,
Aetna MCR ADV,CPT,L0700,Ctlso a-p-l control molded,Durable Medical Equipment,Per Unit,"$1,998.37 ",OP,"1,998.37","6,874.29",,,,,,
Aetna MCR ADV,CPT,L0710,Ctlso a-p-l control w/ inter,Durable Medical Equipment,Per Unit,"$2,196.75 ",OP,"2,196.75","7,552.94",,,,,,
Aetna MCR ADV,CPT,L0810,Halo cervical into jckt vest,Durable Medical Equipment,Per Unit,"$2,683.14 ",OP,"2,683.14","9,226.72",,,,,,
Aetna MCR ADV,CPT,L0820,Halo cervical into body jack,Durable Medical Equipment,Per Unit,"$2,110.65 ",OP,"2,110.65","7,259.37",,,,,,
Aetna MCR ADV,CPT,L0830,Halo cerv into milwaukee typ,Durable Medical Equipment,Per Unit,"$3,229.60 ",OP,"3,229.60","11,106.37",,,,,,
Aetna MCR ADV,CPT,L0859,Mri compatible system,Durable Medical Equipment,Per Unit,"$1,143.45 ",OP,"1,143.45","3,930.89",,,,,,
Aetna MCR ADV,CPT,L0861,Halo repl liner/interface,Durable Medical Equipment,Per Unit,$216.37 ,OP,216.37,743.48,,,,,,
Aetna MCR ADV,CPT,L0970,Tlso corset front,Durable Medical Equipment,Per Unit,$107.27 ,OP,107.27,369.83,,,,,,
Aetna MCR ADV,CPT,L0972,Lso corset front,Durable Medical Equipment,Per Unit,$97.64 ,OP,97.64,335.53,,,,,,
Aetna MCR ADV,CPT,L0974,Tlso full corset,Durable Medical Equipment,Per Unit,$175.42 ,OP,175.42,602.41,,,,,,
Aetna MCR ADV,CPT,L0976,Lso full corset,Durable Medical Equipment,Per Unit,$150.09 ,OP,150.09,150.09,,,,,,
Aetna MCR ADV,CPT,L0978,Axillary crutch extension,Durable Medical Equipment,Per Unit,$188.90 ,OP,188.9,648.16,,,,,,
Aetna MCR ADV,CPT,L0980,Peroneal straps pair pre ots,Durable Medical Equipment,Per Unit,$17.15 ,OP,17.15,57.19,,,,,,
Aetna MCR ADV,CPT,L0982,Stocking sup grips 4 pre ots,Durable Medical Equipment,Per Unit,$15.70 ,OP,15.7,53.38,,,,,,
Aetna MCR ADV,CPT,L0984,Protect body sock ea pre ots,Durable Medical Equipment,Per Unit,$67.93 ,OP,67.93,232.58,,,,,,
Aetna MCR ADV,CPT,L1000,Ctlso milwauke initial model,Durable Medical Equipment,Per Unit,"$2,035.53 ",OP,"2,035.53","7,000.10",,,,,,
Aetna MCR ADV,CPT,L1005,Tension based scoliosis orth,Durable Medical Equipment,Per Unit,"$3,212.88 ",OP,"3,212.88","11,049.19",,,,,,
Aetna MCR ADV,CPT,L1010,Ctlso axilla sling,Durable Medical Equipment,Per Unit,$83.99 ,OP,83.99,289.76,,,,,,
Aetna MCR ADV,CPT,L1020,Kyphosis pad,Durable Medical Equipment,Per Unit,$108.17 ,OP,108.17,373.65,,,,,,
Aetna MCR ADV,CPT,L1025,Kyphosis pad floating,Durable Medical Equipment,Per Unit,$156.06 ,OP,156.06,537.6,,,,,,
Aetna MCR ADV,CPT,L1030,Lumbar bolster pad,Durable Medical Equipment,Per Unit,$78.60 ,OP,78.6,270.71,,,,,,
Aetna MCR ADV,CPT,L1040,Lumbar or lumbar rib pad,Durable Medical Equipment,Per Unit,$89.00 ,OP,89,305.01,,,,,,
Aetna MCR ADV,CPT,L1050,Sternal pad,Durable Medical Equipment,Per Unit,$100.72 ,OP,100.72,346.96,,,,,,
Aetna MCR ADV,CPT,L1060,Thoracic pad,Durable Medical Equipment,Per Unit,$108.72 ,OP,108.72,373.65,,,,,,
Aetna MCR ADV,CPT,L1070,Trapezius sling,Durable Medical Equipment,Per Unit,$112.62 ,OP,112.62,388.89,,,,,,
Aetna MCR ADV,CPT,L1080,Outrigger,Durable Medical Equipment,Per Unit,$52.52 ,OP,52.52,179.2,,,,,,
Aetna MCR ADV,CPT,L1085,Outrigger bil w/ vert extens,Durable Medical Equipment,Per Unit,$175.83 ,OP,175.83,606.21,,,,,,
Aetna MCR ADV,CPT,L1090,Lumbar sling,Durable Medical Equipment,Per Unit,$101.01 ,OP,101.01,346.96,,,,,,
Aetna MCR ADV,CPT,L1100,Ring flange plastic/leather,Durable Medical Equipment,Per Unit,$190.64 ,OP,190.64,655.78,,,,,,
Aetna MCR ADV,CPT,L1110,Ring flange plas/leather mol,Durable Medical Equipment,Per Unit,$319.63 ,OP,319.63,"1,098.07",,,,,,
Aetna MCR ADV,CPT,L1120,Covers for upright each,Durable Medical Equipment,Per Unit,$38.18 ,OP,38.18,129.64,,,,,,
Aetna MCR ADV,CPT,L1200,Furnsh initial orthosis only,Durable Medical Equipment,Per Unit,"$1,796.37 ",OP,"1,796.37","6,176.57",,,,,,
Aetna MCR ADV,CPT,L1210,Lateral thoracic extension,Durable Medical Equipment,Per Unit,$245.60 ,OP,245.6,846.41,,,,,,
Aetna MCR ADV,CPT,L1220,Anterior thoracic extension,Durable Medical Equipment,Per Unit,$239.05 ,OP,239.05,823.54,,,,,,
Aetna MCR ADV,CPT,L1230,Milwaukee type superstructur,Durable Medical Equipment,Per Unit,$669.67 ,OP,669.67,"2,302.87",,,,,,
Aetna MCR ADV,CPT,L1240,Lumbar derotation pad,Durable Medical Equipment,Per Unit,$91.29 ,OP,91.29,312.64,,,,,,
Aetna MCR ADV,CPT,L1250,Anterior asis pad,Durable Medical Equipment,Per Unit,$79.39 ,OP,79.39,274.51,,,,,,
Aetna MCR ADV,CPT,L1260,Anterior thoracic derotation,Durable Medical Equipment,Per Unit,$94.68 ,OP,94.68,324.09,,,,,,
Aetna MCR ADV,CPT,L1270,Abdominal pad,Durable Medical Equipment,Per Unit,$83.20 ,OP,83.2,285.96,,,,,,
Aetna MCR ADV,CPT,L1280,Rib gusset (elastic) each,Durable Medical Equipment,Per Unit,$87.71 ,OP,87.71,301.2,,,,,,
Aetna MCR ADV,CPT,L1290,Lateral trochanteric pad,Durable Medical Equipment,Per Unit,$78.00 ,OP,78,266.89,,,,,,
Aetna MCR ADV,CPT,L1300,Body jacket mold to patient,Durable Medical Equipment,Per Unit,"$1,730.06 ",OP,"1,730.06","5,951.62",,,,,,
Aetna MCR ADV,CPT,L1310,Post-operative body jacket,Durable Medical Equipment,Per Unit,"$1,802.00 ",OP,"1,802.00","6,195.63",,,,,,
Aetna MCR ADV,CPT,L1600,Ho flex frejka w/cov pre cst,Durable Medical Equipment,Per Unit,$129.35 ,OP,129.35,446.08,,,,,,
Aetna MCR ADV,CPT,L1610,Ho frejka cov only pre cst,Durable Medical Equipment,Per Unit,$54.94 ,OP,54.94,190.64,,,,,,
Aetna MCR ADV,CPT,L1620,Ho flex pavlik harns pre cst,Durable Medical Equipment,Per Unit,$157.73 ,OP,157.73,541.4,,,,,,
Aetna MCR ADV,CPT,L1630,Abduct control hip semi-flex,Durable Medical Equipment,Per Unit,$212.06 ,OP,212.06,728.23,,,,,,
Aetna MCR ADV,CPT,L1640,Pelv band/spread bar thigh c,Durable Medical Equipment,Per Unit,$475.20 ,OP,475.2,"1,635.64",,,,,,
Aetna MCR ADV,CPT,L1650,Ho abduction hip adjustable,Durable Medical Equipment,Per Unit,$247.55 ,OP,247.55,850.23,,,,,,
Aetna MCR ADV,CPT,L1652,Ho bi thighcuffs w sprdr bar,Durable Medical Equipment,Per Unit,$357.83 ,OP,357.83,"1,231.50",,,,,,
Aetna MCR ADV,CPT,L1660,Ho abduction static plastic,Durable Medical Equipment,Per Unit,$181.40 ,OP,181.4,625.29,,,,,,
Aetna MCR ADV,CPT,L1680,Pelvic & hip control thigh c,Durable Medical Equipment,Per Unit,"$1,143.62 ",OP,"1,143.62","3,934.69",,,,,,
Aetna MCR ADV,CPT,L1685,Post-op hip abduct custom fa,Durable Medical Equipment,Per Unit,"$1,116.47 ",OP,"1,116.47","3,839.39",,,,,,
Aetna MCR ADV,CPT,L1686,Ho post-op hip abduction,Durable Medical Equipment,Per Unit,$940.60 ,OP,940.6,"3,233.17",,,,,,
Aetna MCR ADV,CPT,L1690,Combination bilateral ho,Durable Medical Equipment,Per Unit,"$1,941.15 ",OP,"1,941.15","6,676.03",,,,,,
Aetna MCR ADV,CPT,L1700,Leg perthes orth toronto typ,Durable Medical Equipment,Per Unit,"$1,561.78 ",OP,"1,561.78","5,372.08",,,,,,
Aetna MCR ADV,CPT,L1710,Legg perthes orth newington,Durable Medical Equipment,Per Unit,"$1,988.75 ",OP,"1,988.75","6,839.98",,,,,,
Aetna MCR ADV,CPT,L1720,Legg perthes orthosis trilat,Durable Medical Equipment,Per Unit,"$1,480.82 ",OP,"1,480.82","5,093.76",,,,,,
Aetna MCR ADV,CPT,L1730,Legg perthes orth scottish r,Durable Medical Equipment,Per Unit,"$1,250.14 ",OP,"1,250.14","4,300.73",,,,,,
Aetna MCR ADV,CPT,L1755,Legg perthes patten bottom t,Durable Medical Equipment,Per Unit,"$1,797.35 ",OP,"1,797.35","6,180.39",,,,,,
Aetna MCR ADV,CPT,L1810,Ko elastic with joints,Durable Medical Equipment,Per Unit,$103.34 ,OP,103.34,103.34,,,,,,
Aetna MCR ADV,CPT,L1812,Ko elastic w/joints pre ots,Durable Medical Equipment,Per Unit,$81.50 ,OP,81.5,81.5,,,,,,
Aetna MCR ADV,CPT,L1820,Ko elas w/ condyle pads & jo,Durable Medical Equipment,Per Unit,$142.66 ,OP,142.66,142.66,,,,,,
Aetna MCR ADV,CPT,L1830,Ko immob canvas long pre ots,Durable Medical Equipment,Per Unit,$71.04 ,OP,71.04,285.96,,,,,,
Aetna MCR ADV,CPT,L1831,Knee orth pos locking joint,Durable Medical Equipment,Per Unit,$295.44 ,OP,295.44,"1,017.99",,,,,,
Aetna MCR ADV,CPT,L1832,Ko adj jnt pos r sup pre cst,Durable Medical Equipment,Per Unit,$691.44 ,OP,691.44,"2,379.12",,,,,,
Aetna MCR ADV,CPT,L1833,Ko adj jnt pos r sup pre ots,Durable Medical Equipment,Per Unit,$534.19 ,OP,534.19,534.19,,,,,,
Aetna MCR ADV,CPT,L1834,Ko w/0 joint rigid molded to,Durable Medical Equipment,Per Unit,$728.61 ,OP,728.61,"2,504.94",,,,,,
Aetna MCR ADV,CPT,L1836,Ko rigid w/o joints pre ots,Durable Medical Equipment,Per Unit,$104.41 ,OP,104.41,104.41,,,,,,
Aetna MCR ADV,CPT,L1840,Ko derot ant cruciate custom,Durable Medical Equipment,Per Unit,$944.00 ,OP,944,"3,248.41",,,,,,
Aetna MCR ADV,CPT,L1843,Ko single upright pre cst,Durable Medical Equipment,Per Unit,$900.70 ,OP,900.7,"3,095.90",,,,,,
Aetna MCR ADV,CPT,L1844,Ko w/adj jt rot cntrl molded,Durable Medical Equipment,Per Unit,"$1,528.66 ",OP,"1,528.66","5,257.70",,,,,,
Aetna MCR ADV,CPT,L1845,Ko double upright pre cst,Durable Medical Equipment,Per Unit,$840.88 ,OP,840.88,840.88,,,,,,
Aetna MCR ADV,CPT,L1846,Ko w adj flex/ext rotat mold,Durable Medical Equipment,Per Unit,"$1,174.51 ",OP,"1,174.51","1,174.51",,,,,,
Aetna MCR ADV,CPT,L1847,Ko dbl upright w/air pre cst,Durable Medical Equipment,Per Unit,$577.37 ,OP,577.37,"1,986.41",,,,,,
Aetna MCR ADV,CPT,L1848,Ko dbl upright w/air pre ots,Durable Medical Equipment,Per Unit,$577.37 ,OP,577.37,577.37,,,,,,
Aetna MCR ADV,CPT,L1850,Ko swedish type pre ots,Durable Medical Equipment,Per Unit,$234.85 ,OP,234.85,983.68,,,,,,
Aetna MCR ADV,CPT,L1851,Ko single upright prefab ots,Durable Medical Equipment,Per Unit,$702.11 ,OP,702.11,702.11,,,,,,
Aetna MCR ADV,CPT,L1852,Ko double upright prefab ots,Durable Medical Equipment,Per Unit,$665.20 ,OP,665.2,665.2,,,,,,
Aetna MCR ADV,CPT,L1860,Ko supracondylar socket mold,Durable Medical Equipment,Per Unit,"$1,251.75 ",OP,"1,251.75","4,304.53",,,,,,
Aetna MCR ADV,CPT,L1900,Afo sprng wir drsflx calf bd,Durable Medical Equipment,Per Unit,$286.39 ,OP,286.39,983.68,,,,,,
Aetna MCR ADV,CPT,L1902,Afo ankle gauntlet pre ots,Durable Medical Equipment,Per Unit,$74.93 ,OP,74.93,259.27,,,,,,
Aetna MCR ADV,CPT,L1904,Afo molded ankle gauntlet,Durable Medical Equipment,Per Unit,$453.09 ,OP,453.09,"1,559.39",,,,,,
Aetna MCR ADV,CPT,L1906,Afo multilig ank sup pre ots,Durable Medical Equipment,Per Unit,$112.88 ,OP,112.88,388.89,,,,,,
Aetna MCR ADV,CPT,L1907,Afo supramalleolar custom,Durable Medical Equipment,Per Unit,$564.86 ,OP,564.86,"1,944.48",,,,,,
Aetna MCR ADV,CPT,L1910,Afo sing bar clasp attach sh,Durable Medical Equipment,Per Unit,$281.51 ,OP,281.51,968.43,,,,,,
Aetna MCR ADV,CPT,L1920,Afo sing upright w/ adjust s,Durable Medical Equipment,Per Unit,$412.37 ,OP,412.37,"1,418.32",,,,,,
Aetna MCR ADV,CPT,L1930,Afo plastic,Durable Medical Equipment,Per Unit,$252.89 ,OP,252.89,869.3,,,,,,
Aetna MCR ADV,CPT,L1932,Afo rig ant tib prefab tcf/=,Durable Medical Equipment,Per Unit,$895.75 ,OP,895.75,"3,080.66",,,,,,
Aetna MCR ADV,CPT,L1940,Afo molded to patient plasti,Durable Medical Equipment,Per Unit,$488.84 ,OP,488.84,"1,681.40",,,,,,
Aetna MCR ADV,CPT,L1945,Afo molded plas rig ant tib,Durable Medical Equipment,Per Unit,"$1,126.77 ",OP,"1,126.77","3,873.69",,,,,,
Aetna MCR ADV,CPT,L1950,Afo spiral molded to pt plas,Durable Medical Equipment,Per Unit,$772.00 ,OP,772,"2,653.63",,,,,,
Aetna MCR ADV,CPT,L1951,Afo spiral prefabricated,Durable Medical Equipment,Per Unit,$843.02 ,OP,843.02,"2,897.65",,,,,,
Aetna MCR ADV,CPT,L1960,Afo pos solid ank plastic mo,Durable Medical Equipment,Per Unit,$622.25 ,OP,622.25,"2,138.93",,,,,,
Aetna MCR ADV,CPT,L1970,Afo plastic molded w/ankle j,Durable Medical Equipment,Per Unit,$694.78 ,OP,694.78,"2,390.56",,,,,,
Aetna MCR ADV,CPT,L1971,Afo w/ankle joint- prefab,Durable Medical Equipment,Per Unit,$470.55 ,OP,470.55,"1,616.58",,,,,,
Aetna MCR ADV,CPT,L1980,Afo sing solid stirrup calf,Durable Medical Equipment,Per Unit,$405.31 ,OP,405.31,"1,395.45",,,,,,
Aetna MCR ADV,CPT,L1990,Afo doub solid stirrup calf,Durable Medical Equipment,Per Unit,$469.10 ,OP,469.1,"1,612.76",,,,,,
Aetna MCR ADV,CPT,L2000,Kafo sing fre stirr thi/calf,Durable Medical Equipment,Per Unit,"$1,122.95 ",OP,"1,122.95","3,862.25",,,,,,
Aetna MCR ADV,CPT,L2005,Kafo sng/dbl mechanical act,Durable Medical Equipment,Per Unit,"$4,113.39 ",OP,"4,113.39","14,145.09",,,,,,
Aetna MCR ADV,CPT,L2010,Kafo sng solid stirrup w/o j,Durable Medical Equipment,Per Unit,$875.89 ,OP,875.89,"3,012.03",,,,,,
Aetna MCR ADV,CPT,L2020,Kafo dbl solid stirrup band/,Durable Medical Equipment,Per Unit,"$1,106.22 ",OP,"1,106.22","3,805.07",,,,,,
Aetna MCR ADV,CPT,L2030,Kafo dbl solid stirrup w/o j,Durable Medical Equipment,Per Unit,"$1,087.33 ",OP,"1,087.33","3,740.26",,,,,,
Aetna MCR ADV,CPT,L2034,Kafo pla sin up w/wo k/a cus,Durable Medical Equipment,Per Unit,"$2,039.24 ",OP,"2,039.24","7,011.54",,,,,,
Aetna MCR ADV,CPT,L2035,Kafo plastic pediatric size,Durable Medical Equipment,Per Unit,$173.91 ,OP,173.91,598.59,,,,,,
Aetna MCR ADV,CPT,L2036,Kafo plas doub free knee mol,Durable Medical Equipment,Per Unit,"$1,861.04 ",OP,"1,861.04","6,401.51",,,,,,
Aetna MCR ADV,CPT,L2037,Kafo plas sing free knee mol,Durable Medical Equipment,Per Unit,"$1,664.67 ",OP,"1,664.67","5,726.65",,,,,,
Aetna MCR ADV,CPT,L2038,Kafo w/o joint multi-axis an,Durable Medical Equipment,Per Unit,"$1,341.97 ",OP,"1,341.97","4,613.36",,,,,,
Aetna MCR ADV,CPT,L2040,Hkafo torsion bil rot straps,Durable Medical Equipment,Per Unit,$203.08 ,OP,203.08,697.72,,,,,,
Aetna MCR ADV,CPT,L2050,Hkafo torsion cable hip pelv,Durable Medical Equipment,Per Unit,$489.17 ,OP,489.17,"1,681.40",,,,,,
Aetna MCR ADV,CPT,L2060,Hkafo torsion ball bearing j,Durable Medical Equipment,Per Unit,$611.86 ,OP,611.86,"2,104.61",,,,,,
Aetna MCR ADV,CPT,L2070,Hkafo torsion unilat rot str,Durable Medical Equipment,Per Unit,$155.80 ,OP,155.8,537.6,,,,,,
Aetna MCR ADV,CPT,L2080,Hkafo unilat torsion cable,Durable Medical Equipment,Per Unit,$374.61 ,OP,374.61,"1,288.69",,,,,,
Aetna MCR ADV,CPT,L2090,Hkafo unilat torsion ball br,Durable Medical Equipment,Per Unit,$499.12 ,OP,499.12,"1,715.71",,,,,,
Aetna MCR ADV,CPT,L2106,Afo tib fx cast plaster mold,Durable Medical Equipment,Per Unit,$791.23 ,OP,791.23,"2,722.27",,,,,,
Aetna MCR ADV,CPT,L2108,Afo tib fx cast molded to pt,Durable Medical Equipment,Per Unit,"$1,154.03 ",OP,"1,154.03","3,969.02",,,,,,
Aetna MCR ADV,CPT,L2112,Afo tibial fracture soft,Durable Medical Equipment,Per Unit,$506.43 ,OP,506.43,"1,742.41",,,,,,
Aetna MCR ADV,CPT,L2114,Afo tib fx semi-rigid,Durable Medical Equipment,Per Unit,$634.33 ,OP,634.33,634.33,,,,,,
Aetna MCR ADV,CPT,L2116,Afo tibial fracture rigid,Durable Medical Equipment,Per Unit,$773.69 ,OP,773.69,773.69,,,,,,
Aetna MCR ADV,CPT,L2126,Kafo fem fx cast thermoplas,Durable Medical Equipment,Per Unit,"$1,281.77 ",OP,"1,281.77","4,407.46",,,,,,
Aetna MCR ADV,CPT,L2128,Kafo fem fx cast molded to p,Durable Medical Equipment,Per Unit,"$1,609.47 ",OP,"1,609.47","5,536.03",,,,,,
Aetna MCR ADV,CPT,L2132,Kafo femoral fx cast soft,Durable Medical Equipment,Per Unit,$976.92 ,OP,976.92,"3,358.99",,,,,,
Aetna MCR ADV,CPT,L2134,Kafo fem fx cast semi-rigid,Durable Medical Equipment,Per Unit,"$1,156.80 ",OP,"1,156.80","3,976.64",,,,,,
Aetna MCR ADV,CPT,L2136,Kafo femoral fx cast rigid,Durable Medical Equipment,Per Unit,"$1,265.95 ",OP,"1,265.95","4,354.09",,,,,,
Aetna MCR ADV,CPT,L2180,Plas shoe insert w ank joint,Durable Medical Equipment,Per Unit,$133.08 ,OP,133.08,457.52,,,,,,
Aetna MCR ADV,CPT,L2182,Drop lock knee,Durable Medical Equipment,Per Unit,$114.71 ,OP,114.71,392.7,,,,,,
Aetna MCR ADV,CPT,L2184,Limited motion knee joint,Durable Medical Equipment,Per Unit,$116.27 ,OP,116.27,400.34,,,,,,
Aetna MCR ADV,CPT,L2186,Adj motion knee jnt lerman t,Durable Medical Equipment,Per Unit,$154.63 ,OP,154.63,529.96,,,,,,
Aetna MCR ADV,CPT,L2188,Quadrilateral brim,Durable Medical Equipment,Per Unit,$281.10 ,OP,281.1,968.43,,,,,,
Aetna MCR ADV,CPT,L2190,Waist belt,Durable Medical Equipment,Per Unit,$85.62 ,OP,85.62,293.57,,,,,,
Aetna MCR ADV,CPT,L2192,Pelvic band & belt thigh fla,Durable Medical Equipment,Per Unit,$334.67 ,OP,334.67,"1,151.42",,,,,,
Aetna MCR ADV,CPT,L2200,Limited ankle motion ea jnt,Durable Medical Equipment,Per Unit,$50.44 ,OP,50.44,175.39,,,,,,
Aetna MCR ADV,CPT,L2210,Dorsiflexion assist each joi,Durable Medical Equipment,Per Unit,$63.09 ,OP,63.09,217.32,,,,,,
Aetna MCR ADV,CPT,L2220,Dorsi & plantar flex ass/res,Durable Medical Equipment,Per Unit,$81.22 ,OP,81.22,278.32,,,,,,
Aetna MCR ADV,CPT,L2230,Split flat caliper stirr & p,Durable Medical Equipment,Per Unit,$96.02 ,OP,96.02,331.7,,,,,,
Aetna MCR ADV,CPT,L2232,Rocker bottom- contact afo,Durable Medical Equipment,Per Unit,$97.51 ,OP,97.51,335.53,,,,,,
Aetna MCR ADV,CPT,L2240,Round caliper and plate atta,Durable Medical Equipment,Per Unit,$95.58 ,OP,95.58,327.9,,,,,,
Aetna MCR ADV,CPT,L2250,Foot plate molded stirrup at,Durable Medical Equipment,Per Unit,$335.30 ,OP,335.3,"1,151.42",,,,,,
Aetna MCR ADV,CPT,L2260,Reinforced solid stirrup,Durable Medical Equipment,Per Unit,$188.16 ,OP,188.16,648.16,,,,,,
Aetna MCR ADV,CPT,L2265,Long tongue stirrup,Durable Medical Equipment,Per Unit,$134.94 ,OP,134.94,465.15,,,,,,
Aetna MCR ADV,CPT,L2270,Varus/valgus strap padded/li,Durable Medical Equipment,Per Unit,$61.87 ,OP,61.87,213.51,,,,,,
Aetna MCR ADV,CPT,L2275,Plastic mod low ext pad/line,Durable Medical Equipment,Per Unit,$130.85 ,OP,130.85,449.9,,,,,,
Aetna MCR ADV,CPT,L2280,Molded inner boot,Durable Medical Equipment,Per Unit,$566.69 ,OP,566.69,"1,948.29",,,,,,
Aetna MCR ADV,CPT,L2300,Abduction bar jointed adjust,Durable Medical Equipment,Per Unit,$252.72 ,OP,252.72,869.3,,,,,,
Aetna MCR ADV,CPT,L2310,Abduction bar-straight,Durable Medical Equipment,Per Unit,$115.47 ,OP,115.47,396.52,,,,,,
Aetna MCR ADV,CPT,L2320,Non-molded lacer,Durable Medical Equipment,Per Unit,$193.64 ,OP,193.64,667.22,,,,,,
Aetna MCR ADV,CPT,L2330,Lacer molded to patient mode,Durable Medical Equipment,Per Unit,$368.55 ,OP,368.55,"1,265.81",,,,,,
Aetna MCR ADV,CPT,L2335,Anterior swing band,Durable Medical Equipment,Per Unit,$282.18 ,OP,282.18,972.25,,,,,,
Aetna MCR ADV,CPT,L2340,Pre-tibial shell molded to p,Durable Medical Equipment,Per Unit,$419.50 ,OP,419.5,"1,441.20",,,,,,
Aetna MCR ADV,CPT,L2350,Prosthetic type socket molde,Durable Medical Equipment,Per Unit,$836.35 ,OP,836.35,"2,874.78",,,,,,
Aetna MCR ADV,CPT,L2360,Extended steel shank,Durable Medical Equipment,Per Unit,$51.76 ,OP,51.76,179.2,,,,,,
Aetna MCR ADV,CPT,L2370,Patten bottom,Durable Medical Equipment,Per Unit,$321.26 ,OP,321.26,"1,105.68",,,,,,
Aetna MCR ADV,CPT,L2375,Torsion ank & half solid sti,Durable Medical Equipment,Per Unit,$123.52 ,OP,123.52,423.22,,,,,,
Aetna MCR ADV,CPT,L2380,Torsion straight knee joint,Durable Medical Equipment,Per Unit,$129.54 ,OP,129.54,446.08,,,,,,
Aetna MCR ADV,CPT,L2385,Straight knee joint heavy du,Durable Medical Equipment,Per Unit,$147.50 ,OP,147.5,507.08,,,,,,
Aetna MCR ADV,CPT,L2387,Add le poly knee custom kafo,Durable Medical Equipment,Per Unit,$191.63 ,OP,191.63,659.6,,,,,,
Aetna MCR ADV,CPT,L2390,Offset knee joint each,Durable Medical Equipment,Per Unit,$102.75 ,OP,102.75,354.58,,,,,,
Aetna MCR ADV,CPT,L2395,Offset knee joint heavy duty,Durable Medical Equipment,Per Unit,$146.86 ,OP,146.86,503.28,,,,,,
Aetna MCR ADV,CPT,L2397,Suspension sleeve lower ext,Durable Medical Equipment,Per Unit,$122.52 ,OP,122.52,423.22,,,,,,
Aetna MCR ADV,CPT,L2405,Knee joint drop lock ea jnt,Durable Medical Equipment,Per Unit,$87.52 ,OP,87.52,301.2,,,,,,
Aetna MCR ADV,CPT,L2415,Knee joint cam lock each joi,Durable Medical Equipment,Per Unit,$121.95 ,OP,121.95,419.4,,,,,,
Aetna MCR ADV,CPT,L2425,Knee disc/dial lock/adj flex,Durable Medical Equipment,Per Unit,$143.90 ,OP,143.9,495.65,,,,,,
Aetna MCR ADV,CPT,L2430,Knee jnt ratchet lock ea jnt,Durable Medical Equipment,Per Unit,$143.90 ,OP,143.9,495.65,,,,,,
Aetna MCR ADV,CPT,L2492,Knee lift loop drop lock rin,Durable Medical Equipment,Per Unit,$117.74 ,OP,117.74,404.14,,,,,,
Aetna MCR ADV,CPT,L2500,Thi/glut/ischia wgt bearing,Durable Medical Equipment,Per Unit,$314.13 ,OP,314.13,"1,078.99",,,,,,
Aetna MCR ADV,CPT,L2510,Th/wght bear quad-lat brim m,Durable Medical Equipment,Per Unit,$809.60 ,OP,809.6,"2,783.26",,,,,,
Aetna MCR ADV,CPT,L2520,Th/wght bear quad-lat brim c,Durable Medical Equipment,Per Unit,$539.56 ,OP,539.56,"1,856.79",,,,,,
Aetna MCR ADV,CPT,L2525,Th/wght bear nar m-l brim mo,Durable Medical Equipment,Per Unit,"$1,144.16 ",OP,"1,144.16","3,934.69",,,,,,
Aetna MCR ADV,CPT,L2526,Th/wght bear nar m-l brim cu,Durable Medical Equipment,Per Unit,$642.90 ,OP,642.9,"2,211.37",,,,,,
Aetna MCR ADV,CPT,L2530,Thigh/wght bear lacer non-mo,Durable Medical Equipment,Per Unit,$240.74 ,OP,240.74,827.35,,,,,,
Aetna MCR ADV,CPT,L2540,Thigh/wght bear lacer molded,Durable Medical Equipment,Per Unit,$455.54 ,OP,455.54,"1,567.02",,,,,,
Aetna MCR ADV,CPT,L2550,Thigh/wght bear high roll cu,Durable Medical Equipment,Per Unit,$341.55 ,OP,341.55,"1,174.31",,,,,,
Aetna MCR ADV,CPT,L2570,Hip clevis type 2 posit jnt,Durable Medical Equipment,Per Unit,$447.07 ,OP,447.07,"1,536.51",,,,,,
Aetna MCR ADV,CPT,L2580,Pelvic control pelvic sling,Durable Medical Equipment,Per Unit,$435.62 ,OP,435.62,"1,498.39",,,,,,
Aetna MCR ADV,CPT,L2600,Hip clevis/thrust bearing fr,Durable Medical Equipment,Per Unit,$214.10 ,OP,214.1,735.85,,,,,,
Aetna MCR ADV,CPT,L2610,Hip clevis/thrust bearing lo,Durable Medical Equipment,Per Unit,$236.58 ,OP,236.58,812.11,,,,,,
Aetna MCR ADV,CPT,L2620,Pelvic control hip heavy dut,Durable Medical Equipment,Per Unit,$250.96 ,OP,250.96,861.67,,,,,,
Aetna MCR ADV,CPT,L2622,Hip joint adjustable flexion,Durable Medical Equipment,Per Unit,$319.42 ,OP,319.42,"1,098.07",,,,,,
Aetna MCR ADV,CPT,L2624,Hip adj flex ext abduct cont,Durable Medical Equipment,Per Unit,$391.68 ,OP,391.68,"1,345.89",,,,,,
Aetna MCR ADV,CPT,L2627,Plastic mold recipro hip & c,Durable Medical Equipment,Per Unit,"$2,145.41 ",OP,"2,145.41","7,377.56",,,,,,
Aetna MCR ADV,CPT,L2628,Metal frame recipro hip & ca,Durable Medical Equipment,Per Unit,"$1,572.54 ",OP,"1,572.54","5,406.41",,,,,,
Aetna MCR ADV,CPT,L2630,Pelvic control band & belt u,Durable Medical Equipment,Per Unit,$232.43 ,OP,232.43,800.67,,,,,,
Aetna MCR ADV,CPT,L2640,Pelvic control band & belt b,Durable Medical Equipment,Per Unit,$315.42 ,OP,315.42,"1,086.62",,,,,,
Aetna MCR ADV,CPT,L2650,Pelv & thor control gluteal,Durable Medical Equipment,Per Unit,$138.91 ,OP,138.91,476.6,,,,,,
Aetna MCR ADV,CPT,L2660,Thoracic control thoracic ba,Durable Medical Equipment,Per Unit,$179.86 ,OP,179.86,617.65,,,,,,
Aetna MCR ADV,CPT,L2670,Thorac cont paraspinal uprig,Durable Medical Equipment,Per Unit,$160.11 ,OP,160.11,549.03,,,,,,
Aetna MCR ADV,CPT,L2680,Thorac cont lat support upri,Durable Medical Equipment,Per Unit,$146.88 ,OP,146.88,503.28,,,,,,
Aetna MCR ADV,CPT,L2750,Plating chrome/nickel pr bar,Durable Medical Equipment,Per Unit,$78.45 ,OP,78.45,270.71,,,,,,
Aetna MCR ADV,CPT,L2755,Carbon graphite lamination,Durable Medical Equipment,Per Unit,$131.16 ,OP,131.16,449.9,,,,,,
Aetna MCR ADV,CPT,L2760,Extension per extension per,Durable Medical Equipment,Per Unit,$57.03 ,OP,57.03,194.45,,,,,,
Aetna MCR ADV,CPT,L2768,Ortho sidebar disconnect,Durable Medical Equipment,Per Unit,$130.78 ,OP,130.78,449.9,,,,,,
Aetna MCR ADV,CPT,L2780,Non-corrosive finish,Durable Medical Equipment,Per Unit,$63.53 ,OP,63.53,217.32,,,,,,
Aetna MCR ADV,CPT,L2785,Drop lock retainer each,Durable Medical Equipment,Per Unit,$29.75 ,OP,29.75,102.95,,,,,,
Aetna MCR ADV,CPT,L2795,Knee control full kneecap,Durable Medical Equipment,Per Unit,$82.32 ,OP,82.32,282.14,,,,,,
Aetna MCR ADV,CPT,L2800,Knee cap medial or lateral p,Durable Medical Equipment,Per Unit,$101.09 ,OP,101.09,101.09,,,,,,
Aetna MCR ADV,CPT,L2810,Knee control condylar pad,Durable Medical Equipment,Per Unit,$81.98 ,OP,81.98,282.14,,,,,,
Aetna MCR ADV,CPT,L2820,Soft interface below knee se,Durable Medical Equipment,Per Unit,$81.51 ,OP,81.51,282.14,,,,,,
Aetna MCR ADV,CPT,L2830,Soft interface above knee se,Durable Medical Equipment,Per Unit,$88.18 ,OP,88.18,305.01,,,,,,
Aetna MCR ADV,CPT,L2840,Tibial length sock fx or equ,Durable Medical Equipment,Per Unit,$43.30 ,OP,43.3,148.69,,,,,,
Aetna MCR ADV,CPT,L2850,Femoral lgth sock fx or equa,Durable Medical Equipment,Per Unit,$60.72 ,OP,60.72,209.7,,,,,,
Aetna MCR ADV,CPT,L3000,Ft insert ucb berkeley shell,Durable Medical Equipment,Per Unit,$315.34 ,OP,315.34,"1,082.81",,,,,,
Aetna MCR ADV,CPT,L3001,Foot insert remov molded spe,Durable Medical Equipment,Per Unit,$132.78 ,OP,132.78,686.28,,,,,,
Aetna MCR ADV,CPT,L3002,Foot insert plastazote or eq,Durable Medical Equipment,Per Unit,$162.12 ,OP,162.12,834.98,,,,,,
Aetna MCR ADV,CPT,L3003,Foot insert silicone gel eac,Durable Medical Equipment,Per Unit,$174.89 ,OP,174.89,903.6,,,,,,
Aetna MCR ADV,CPT,L3010,Foot longitudinal arch suppo,Durable Medical Equipment,Per Unit,$174.89 ,OP,174.89,903.6,,,,,,
Aetna MCR ADV,CPT,L3020,Foot longitud/metatarsal sup,Durable Medical Equipment,Per Unit,$199.16 ,OP,199.16,"1,025.61",,,,,,
Aetna MCR ADV,CPT,L3030,Foot arch support remov prem,Durable Medical Equipment,Per Unit,$76.59 ,OP,76.59,"1,239.13",,,,,,
Aetna MCR ADV,CPT,L3031,Foot lamin/prepreg composite,Durable Medical Equipment,Per Unit,$122.94 ,OP,122.94,"1,334.45",,,,,,
Aetna MCR ADV,CPT,L3040,Ft arch suprt premold longit,Durable Medical Equipment,Per Unit,$47.25 ,OP,47.25,163.95,,,,,,
Aetna MCR ADV,CPT,L3050,Foot arch supp premold metat,Durable Medical Equipment,Per Unit,$47.25 ,OP,47.25,163.95,,,,,,
Aetna MCR ADV,CPT,L3060,Foot arch supp longitud/meta,Durable Medical Equipment,Per Unit,$74.04 ,OP,74.04,255.45,,,,,,
Aetna MCR ADV,CPT,L3070,Arch suprt att to sho longit,Durable Medical Equipment,Per Unit,$31.91 ,OP,31.91,110.57,,,,,,
Aetna MCR ADV,CPT,L3080,Arch supp att to shoe metata,Durable Medical Equipment,Per Unit,$31.91 ,OP,31.91,110.57,,,,,,
Aetna MCR ADV,CPT,L3090,Arch supp att to shoe long/m,Durable Medical Equipment,Per Unit,$40.86 ,OP,40.86,141.07,,,,,,
Aetna MCR ADV,CPT,L3100,Hallus-valgus nt dyn pre ots,Durable Medical Equipment,Per Unit,$43.43 ,OP,43.43,148.69,,,,,,
Aetna MCR ADV,CPT,L3140,Abduction rotation bar shoe,Durable Medical Equipment,Per Unit,$89.37 ,OP,89.37,308.83,,,,,,
Aetna MCR ADV,CPT,L3150,Abduct rotation bar w/o shoe,Durable Medical Equipment,Per Unit,$81.72 ,OP,81.72,282.14,,,,,,
Aetna MCR ADV,CPT,L3170,Foot plas heel stabi pre ots,Durable Medical Equipment,Per Unit,$51.06 ,OP,51.06,175.39,,,,,,
Aetna MCR ADV,CPT,L3224,Woman's shoe oxford brace,Durable Medical Equipment,Per Unit,$67.83 ,OP,67.83,232.58,,,,,,
Aetna MCR ADV,CPT,L3225,Man's shoe oxford brace,Durable Medical Equipment,Per Unit,$74.09 ,OP,74.09,255.45,,,,,,
Aetna MCR ADV,CPT,L3300,Sho lift taper to metatarsal,Durable Medical Equipment,Per Unit,$52.35 ,OP,52.35,179.2,,,,,,
Aetna MCR ADV,CPT,L3310,Shoe lift elev heel/sole neo,Durable Medical Equipment,Per Unit,$81.72 ,OP,81.72,282.14,,,,,,
Aetna MCR ADV,CPT,L3330,Lifts elevation metal extens,Durable Medical Equipment,Per Unit,$568.10 ,OP,568.1,"1,952.10",,,,,,
Aetna MCR ADV,CPT,L3332,Shoe lifts tapered to one-ha,Durable Medical Equipment,Per Unit,$74.04 ,OP,74.04,255.45,,,,,,
Aetna MCR ADV,CPT,L3334,Shoe lifts elevation heel /i,Durable Medical Equipment,Per Unit,$38.28 ,OP,38.28,133.45,,,,,,
Aetna MCR ADV,CPT,L3340,Shoe wedge sach,Durable Medical Equipment,Per Unit,$85.56 ,OP,85.56,293.57,,,,,,
Aetna MCR ADV,CPT,L3350,Shoe heel wedge,Durable Medical Equipment,Per Unit,$22.96 ,OP,22.96,80.07,,,,,,
Aetna MCR ADV,CPT,L3360,Shoe sole wedge outside sole,Durable Medical Equipment,Per Unit,$35.74 ,OP,35.74,122,,,,,,
Aetna MCR ADV,CPT,L3370,Shoe sole wedge between sole,Durable Medical Equipment,Per Unit,$49.79 ,OP,49.79,171.58,,,,,,
Aetna MCR ADV,CPT,L3380,Shoe clubfoot wedge,Durable Medical Equipment,Per Unit,$49.79 ,OP,49.79,171.58,,,,,,
Aetna MCR ADV,CPT,L3390,Shoe outflare wedge,Durable Medical Equipment,Per Unit,$49.79 ,OP,49.79,171.58,,,,,,
Aetna MCR ADV,CPT,L3400,Shoe metatarsal bar wedge ro,Durable Medical Equipment,Per Unit,$40.86 ,OP,40.86,141.07,,,,,,
Aetna MCR ADV,CPT,L3410,Shoe metatarsal bar between,Durable Medical Equipment,Per Unit,$93.19 ,OP,93.19,320.27,,,,,,
Aetna MCR ADV,CPT,L3420,Full sole/heel wedge btween,Durable Medical Equipment,Per Unit,$54.90 ,OP,54.9,190.64,,,,,,
Aetna MCR ADV,CPT,L3430,Sho heel count plast reinfor,Durable Medical Equipment,Per Unit,$160.86 ,OP,160.86,552.84,,,,,,
Aetna MCR ADV,CPT,L3440,Heel leather reinforced,Durable Medical Equipment,Per Unit,$76.59 ,OP,76.59,263.08,,,,,,
Aetna MCR ADV,CPT,L3450,Shoe heel sach cushion type,Durable Medical Equipment,Per Unit,$105.93 ,OP,105.93,105.93,,,,,,
Aetna MCR ADV,CPT,L3455,Shoe heel new leather standa,Durable Medical Equipment,Per Unit,$40.86 ,OP,40.86,141.07,,,,,,
Aetna MCR ADV,CPT,L3460,Shoe heel new rubber standar,Durable Medical Equipment,Per Unit,$34.49 ,OP,34.49,118.19,,,,,,
Aetna MCR ADV,CPT,L3465,Shoe heel thomas with wedge,Durable Medical Equipment,Per Unit,$58.76 ,OP,58.76,202.07,,,,,,
Aetna MCR ADV,CPT,L3470,Shoe heel thomas extend to b,Durable Medical Equipment,Per Unit,$62.54 ,OP,62.54,213.51,,,,,,
Aetna MCR ADV,CPT,L3480,Shoe heel pad & depress for,Durable Medical Equipment,Per Unit,$62.54 ,OP,62.54,213.51,,,,,,
Aetna MCR ADV,CPT,L3500,Ortho shoe add leather insol,Durable Medical Equipment,Per Unit,$29.35 ,OP,29.35,99.13,,,,,,
Aetna MCR ADV,CPT,L3510,Orthopedic shoe add rub insl,Durable Medical Equipment,Per Unit,$29.35 ,OP,29.35,99.13,,,,,,
Aetna MCR ADV,CPT,L3520,O shoe add felt w leath insl,Durable Medical Equipment,Per Unit,$31.91 ,OP,31.91,110.57,,,,,,
Aetna MCR ADV,CPT,L3530,Ortho shoe add half sole,Durable Medical Equipment,Per Unit,$31.91 ,OP,31.91,110.57,,,,,,
Aetna MCR ADV,CPT,L3540,Ortho shoe add full sole,Durable Medical Equipment,Per Unit,$51.06 ,OP,51.06,175.39,,,,,,
Aetna MCR ADV,CPT,L3550,O shoe add standard toe tap,Durable Medical Equipment,Per Unit,$8.97 ,OP,8.97,30.51,,,,,,
Aetna MCR ADV,CPT,L3560,O shoe add horseshoe toe tap,Durable Medical Equipment,Per Unit,$22.96 ,OP,22.96,80.07,,,,,,
Aetna MCR ADV,CPT,L3570,O shoe add instep extension,Durable Medical Equipment,Per Unit,$85.56 ,OP,85.56,293.57,,,,,,
Aetna MCR ADV,CPT,L3580,O shoe add instep velcro clo,Durable Medical Equipment,Per Unit,$65.11 ,OP,65.11,224.95,,,,,,
Aetna MCR ADV,CPT,L3590,O shoe convert to sof counte,Durable Medical Equipment,Per Unit,$53.63 ,OP,53.63,183.02,,,,,,
Aetna MCR ADV,CPT,L3595,Ortho shoe add march bar,Durable Medical Equipment,Per Unit,$42.10 ,OP,42.1,144.88,,,,,,
Aetna MCR ADV,CPT,L3600,Trans shoe calip plate exist,Durable Medical Equipment,Per Unit,$76.59 ,OP,76.59,263.08,,,,,,
Aetna MCR ADV,CPT,L3610,Trans shoe caliper plate new,Durable Medical Equipment,Per Unit,$100.86 ,OP,100.86,346.96,,,,,,
Aetna MCR ADV,CPT,L3620,Trans shoe solid stirrup exi,Durable Medical Equipment,Per Unit,$76.59 ,OP,76.59,263.08,,,,,,
Aetna MCR ADV,CPT,L3630,Trans shoe solid stirrup new,Durable Medical Equipment,Per Unit,$100.86 ,OP,100.86,346.96,,,,,,
Aetna MCR ADV,CPT,L3640,Shoe dennis browne splint bo,Durable Medical Equipment,Per Unit,$43.43 ,OP,43.43,148.69,,,,,,
Aetna MCR ADV,CPT,L3650,So 8 abd restraint pre ots,Durable Medical Equipment,Per Unit,$65.83 ,OP,65.83,224.95,,,,,,
Aetna MCR ADV,CPT,L3660,So 8 ab rstr can/web pre ots,Durable Medical Equipment,Per Unit,$94.40 ,OP,94.4,324.09,,,,,,
Aetna MCR ADV,CPT,L3670,So acro/clav can web pre ots,Durable Medical Equipment,Per Unit,$103.86 ,OP,103.86,358.39,,,,,,
Aetna MCR ADV,CPT,L3671,So cap design w/o jnts cf,Durable Medical Equipment,Per Unit,$823.17 ,OP,823.17,"2,832.83",,,,,,
Aetna MCR ADV,CPT,L3674,So airplane w/wo joint cf,Durable Medical Equipment,Per Unit,"$1,079.87 ",OP,"1,079.87","1,079.87",,,,,,
Aetna MCR ADV,CPT,L3675,So vest canvas/web pre ots,Durable Medical Equipment,Per Unit,$160.35 ,OP,160.35,552.84,,,,,,
Aetna MCR ADV,CPT,L3702,Eo w/o joints cf,Durable Medical Equipment,Per Unit,$263.81 ,OP,263.81,907.42,,,,,,
Aetna MCR ADV,CPT,L3710,Eo elas w/metal jnts pre ots,Durable Medical Equipment,Per Unit,$130.45 ,OP,130.45,449.9,,,,,,
Aetna MCR ADV,CPT,L3720,Forearm/arm cuffs free motio,Durable Medical Equipment,Per Unit,$624.22 ,OP,624.22,"2,146.54",,,,,,
Aetna MCR ADV,CPT,L3730,Forearm/arm cuffs ext/flex a,Durable Medical Equipment,Per Unit,$827.96 ,OP,827.96,"2,848.08",,,,,,
Aetna MCR ADV,CPT,L3740,Cuffs adj lock w/ active con,Durable Medical Equipment,Per Unit,$981.62 ,OP,981.62,"3,374.24",,,,,,
Aetna MCR ADV,CPT,L3760,Eo adj jt prefab custom fit,Durable Medical Equipment,Per Unit,$456.89 ,OP,456.89,"1,570.83",,,,,,
Aetna MCR ADV,CPT,L3761,Eo- adj lock joint prefab ot,Durable Medical Equipment,Per Unit,$456.89 ,OP,456.89,456.89,,,,,,
Aetna MCR ADV,CPT,L3762,Eo rigid w/o joints pre ots,Durable Medical Equipment,Per Unit,$98.22 ,OP,98.22,339.33,,,,,,
Aetna MCR ADV,CPT,L3763,Ewho rigid w/o jnts cf,Durable Medical Equipment,Per Unit,$683.66 ,OP,683.66,"2,352.44",,,,,,
Aetna MCR ADV,CPT,L3764,Ewho w/joint(s) cf,Durable Medical Equipment,Per Unit,$715.47 ,OP,715.47,"2,459.19",,,,,,
Aetna MCR ADV,CPT,L3765,Ewhfo rigid w/o jnts cf,Durable Medical Equipment,Per Unit,"$1,171.43 ",OP,"1,171.43","4,030.02",,,,,,
Aetna MCR ADV,CPT,L3766,Ewhfo w/joint(s) cf,Durable Medical Equipment,Per Unit,"$1,240.47 ",OP,"1,240.47","4,266.40",,,,,,
Aetna MCR ADV,CPT,L3806,Whfo w/joint(s) custom fab,Durable Medical Equipment,Per Unit,$414.97 ,OP,414.97,"1,425.95",,,,,,
Aetna MCR ADV,CPT,L3807,Whfo w/o joints pre cst,Durable Medical Equipment,Per Unit,$228.43 ,OP,228.43,785.42,,,,,,
Aetna MCR ADV,CPT,L3808,Whfo- rigid w/o joints,Durable Medical Equipment,Per Unit,$325.43 ,OP,325.43,"1,120.94",,,,,,
Aetna MCR ADV,CPT,L3809,Whfo w/o joints pre ots,Durable Medical Equipment,Per Unit,$228.43 ,OP,228.43,228.43,,,,,,
Aetna MCR ADV,CPT,L3900,Hinge extension/flex wrist/f,Durable Medical Equipment,Per Unit,"$1,479.93 ",OP,"1,479.93","5,089.95",,,,,,
Aetna MCR ADV,CPT,L3901,Hinge ext/flex wrist finger,Durable Medical Equipment,Per Unit,"$1,939.53 ",OP,"1,939.53","6,668.40",,,,,,
Aetna MCR ADV,CPT,L3904,Whfo electric custom fitted,Durable Medical Equipment,Per Unit,"$3,083.64 ",OP,"3,083.64","10,603.11",,,,,,
Aetna MCR ADV,CPT,L3905,Who w/nontorsion jnt(s) cf,Durable Medical Equipment,Per Unit,$905.97 ,OP,905.97,"3,114.97",,,,,,
Aetna MCR ADV,CPT,L3906,Who w/o joints cf,Durable Medical Equipment,Per Unit,$462.97 ,OP,462.97,"1,593.72",,,,,,
Aetna MCR ADV,CPT,L3908,Who cock-up nonmolde pre ots,Durable Medical Equipment,Per Unit,$66.98 ,OP,66.98,228.77,,,,,,
Aetna MCR ADV,CPT,L3912,Hfo flexion glove pre ots,Durable Medical Equipment,Per Unit,$96.25 ,OP,96.25,331.7,,,,,,
Aetna MCR ADV,CPT,L3913,Hfo w/o joints cf,Durable Medical Equipment,Per Unit,$247.41 ,OP,247.41,850.23,,,,,,
Aetna MCR ADV,CPT,L3915,Who nontorsion jnts pre cst,Durable Medical Equipment,Per Unit,$485.63 ,OP,485.63,"1,669.97",,,,,,
Aetna MCR ADV,CPT,L3916,Who nontorsion jnts pre ots,Durable Medical Equipment,Per Unit,$485.63 ,OP,485.63,485.63,,,,,,
Aetna MCR ADV,CPT,L3917,Metacarp fx orthosis pre cst,Durable Medical Equipment,Per Unit,$96.47 ,OP,96.47,331.7,,,,,,
Aetna MCR ADV,CPT,L3918,Metacarp fx orthosis pre ots,Durable Medical Equipment,Per Unit,$96.47 ,OP,96.47,96.47,,,,,,
Aetna MCR ADV,CPT,L3919,Ho w/o joints cf,Durable Medical Equipment,Per Unit,$247.41 ,OP,247.41,850.23,,,,,,
Aetna MCR ADV,CPT,L3921,Hfo w/joint(s) cf,Durable Medical Equipment,Per Unit,$293.46 ,OP,293.46,"1,010.37",,,,,,
Aetna MCR ADV,CPT,L3923,Hfo without joints pre cst,Durable Medical Equipment,Per Unit,$88.25 ,OP,88.25,305.01,,,,,,
Aetna MCR ADV,CPT,L3924,Hfo without joints pre ots,Durable Medical Equipment,Per Unit,$88.25 ,OP,88.25,88.25,,,,,,
Aetna MCR ADV,CPT,L3925,Fo pip dip jnt/sprng pre ots,Durable Medical Equipment,Per Unit,$60.01 ,OP,60.01,205.88,,,,,,
Aetna MCR ADV,CPT,L3927,Fo pip dip no jt spr pre ots,Durable Medical Equipment,Per Unit,$31.98 ,OP,31.98,110.57,,,,,,
Aetna MCR ADV,CPT,L3929,Hfo nontorsion jnts pre cst,Durable Medical Equipment,Per Unit,$83.44 ,OP,83.44,285.96,,,,,,
Aetna MCR ADV,CPT,L3930,Hfo nontorsion jnts pre ots,Durable Medical Equipment,Per Unit,$83.44 ,OP,83.44,83.44,,,,,,
Aetna MCR ADV,CPT,L3931,Whfo nontorsion joint prefab,Durable Medical Equipment,Per Unit,$190.48 ,OP,190.48,655.78,,,,,,
Aetna MCR ADV,CPT,L3933,Fo w/o joints cf,Durable Medical Equipment,Per Unit,$194.93 ,OP,194.93,671.03,,,,,,
Aetna MCR ADV,CPT,L3935,Fo nontorsion joint cf,Durable Medical Equipment,Per Unit,$201.82 ,OP,201.82,693.9,,,,,,
Aetna MCR ADV,CPT,L3960,Sewho airplan desig abdu pos,Durable Medical Equipment,Per Unit,$728.64 ,OP,728.64,"2,504.94",,,,,,
Aetna MCR ADV,CPT,L3961,Sewho cap design w/o jnts cf,Durable Medical Equipment,Per Unit,"$1,534.92 ",OP,"1,534.92","5,280.58",,,,,,
Aetna MCR ADV,CPT,L3962,Sewho erbs palsey design abd,Durable Medical Equipment,Per Unit,$659.00 ,OP,659,"2,264.75",,,,,,
Aetna MCR ADV,CPT,L3967,Sewho airplane w/o jnts cf,Durable Medical Equipment,Per Unit,"$1,812.20 ",OP,"1,812.20","6,233.76",,,,,,
Aetna MCR ADV,CPT,L3971,Sewho cap design w/jnt(s) cf,Durable Medical Equipment,Per Unit,"$1,720.20 ",OP,"1,720.20","5,917.29",,,,,,
Aetna MCR ADV,CPT,L3973,Sewho airplane w/jnt(s) cf,Durable Medical Equipment,Per Unit,"$1,812.20 ",OP,"1,812.20","6,233.76",,,,,,
Aetna MCR ADV,CPT,L3975,Sewhfo cap design w/o jnt cf,Durable Medical Equipment,Per Unit,"$1,534.92 ",OP,"1,534.92","5,280.58",,,,,,
Aetna MCR ADV,CPT,L3976,Sewhfo airplane w/o jnts cf,Durable Medical Equipment,Per Unit,"$1,534.92 ",OP,"1,534.92","5,280.58",,,,,,
Aetna MCR ADV,CPT,L3977,Sewhfo cap desgn w/jnt(s) cf,Durable Medical Equipment,Per Unit,"$1,720.20 ",OP,"1,720.20","5,917.29",,,,,,
Aetna MCR ADV,CPT,L3978,Sewhfo airplane w/jnt(s) cf,Durable Medical Equipment,Per Unit,"$1,812.20 ",OP,"1,812.20","6,233.76",,,,,,
Aetna MCR ADV,CPT,L3980,Up ext fx orthos humeral nos,Durable Medical Equipment,Per Unit,$353.43 ,OP,353.43,"1,216.24",,,,,,
Aetna MCR ADV,CPT,L3981,Ue fx orth shoul cap forearm,Durable Medical Equipment,Per Unit,$919.57 ,OP,919.57,919.57,,,,,,
Aetna MCR ADV,CPT,L3982,Upper ext fx orthosis rad/ul,Durable Medical Equipment,Per Unit,$358.87 ,OP,358.87,"1,235.32",,,,,,
Aetna MCR ADV,CPT,L3984,Upper ext fx orthosis wrist,Durable Medical Equipment,Per Unit,$316.13 ,OP,316.13,"1,086.62",,,,,,
Aetna MCR ADV,CPT,L3995,Sock fracture or equal each,Durable Medical Equipment,Per Unit,$37.51 ,OP,37.51,129.64,,,,,,
Aetna MCR ADV,CPT,L4000,Repl girdle milwaukee orth,Durable Medical Equipment,Per Unit,"$1,326.47 ",OP,"1,326.47","4,559.97",,,,,,
Aetna MCR ADV,CPT,L4010,Replace trilateral socket br,Durable Medical Equipment,Per Unit,$806.25 ,OP,806.25,"2,771.83",,,,,,
Aetna MCR ADV,CPT,L4020,Replace quadlat socket brim,Durable Medical Equipment,Per Unit,$968.52 ,OP,968.52,"3,332.30",,,,,,
Aetna MCR ADV,CPT,L4030,Replace socket brim cust fit,Durable Medical Equipment,Per Unit,$615.47 ,OP,615.47,"2,116.06",,,,,,
Aetna MCR ADV,CPT,L4040,Replace molded thigh lacer,Durable Medical Equipment,Per Unit,$416.80 ,OP,416.8,"1,433.58",,,,,,
Aetna MCR ADV,CPT,L4045,Replace non-molded thigh lac,Durable Medical Equipment,Per Unit,$307.89 ,OP,307.89,"1,059.93",,,,,,
Aetna MCR ADV,CPT,L4050,Replace molded calf lacer,Durable Medical Equipment,Per Unit,$412.80 ,OP,412.8,"1,418.32",,,,,,
Aetna MCR ADV,CPT,L4055,Replace non-molded calf lace,Durable Medical Equipment,Per Unit,$250.92 ,OP,250.92,861.67,,,,,,
Aetna MCR ADV,CPT,L4060,Replace high roll cuff,Durable Medical Equipment,Per Unit,$326.17 ,OP,326.17,"1,120.94",,,,,,
Aetna MCR ADV,CPT,L4070,Replace prox & dist upright,Durable Medical Equipment,Per Unit,$264.15 ,OP,264.15,907.42,,,,,,
Aetna MCR ADV,CPT,L4080,Repl met band kafo-afo prox,Durable Medical Equipment,Per Unit,$99.72 ,OP,99.72,343.14,,,,,,
Aetna MCR ADV,CPT,L4090,Repl met band kafo-afo calf/,Durable Medical Equipment,Per Unit,$84.84 ,OP,84.84,293.57,,,,,,
Aetna MCR ADV,CPT,L4100,Repl leath cuff kafo prox th,Durable Medical Equipment,Per Unit,$101.94 ,OP,101.94,350.76,,,,,,
Aetna MCR ADV,CPT,L4110,Repl leath cuff kafo-afo cal,Durable Medical Equipment,Per Unit,$79.60 ,OP,79.6,274.51,,,,,,
Aetna MCR ADV,CPT,L4130,Replace pretibial shell,Durable Medical Equipment,Per Unit,$481.14 ,OP,481.14,"1,654.72",,,,,,
Aetna MCR ADV,CPT,L4350,Ankle control ortho pre ots,Durable Medical Equipment,Per Unit,$97.13 ,OP,97.13,335.53,,,,,,
Aetna MCR ADV,CPT,L4360,Pneumat walking boot pre cst,Durable Medical Equipment,Per Unit,$259.89 ,OP,259.89,892.18,,,,,,
Aetna MCR ADV,CPT,L4361,Pneuma/vac walk boot pre ots,Durable Medical Equipment,Per Unit,$259.89 ,OP,259.89,259.89,,,,,,
Aetna MCR ADV,CPT,L4370,Pneum full leg splnt pre ots,Durable Medical Equipment,Per Unit,$236.26 ,OP,236.26,812.11,,,,,,
Aetna MCR ADV,CPT,L4386,Non-pneum walk boot pre cst,Durable Medical Equipment,Per Unit,$159.16 ,OP,159.16,549.03,,,,,,
Aetna MCR ADV,CPT,L4387,Non-pneum walk boot pre ots,Durable Medical Equipment,Per Unit,$159.16 ,OP,159.16,159.16,,,,,,
Aetna MCR ADV,CPT,L4392,Replace afo soft interface,Durable Medical Equipment,Per Unit,$23.62 ,OP,23.62,80.07,,,,,,
Aetna MCR ADV,CPT,L4394,Replace foot drop spint,Durable Medical Equipment,Per Unit,$17.23 ,OP,17.23,61,,,,,,
Aetna MCR ADV,CPT,L4396,Static or dynami afo pre cst,Durable Medical Equipment,Per Unit,$168.46 ,OP,168.46,579.53,,,,,,
Aetna MCR ADV,CPT,L4397,Static or dynami afo pre ots,Durable Medical Equipment,Per Unit,$168.46 ,OP,168.46,168.46,,,,,,
Aetna MCR ADV,CPT,L4398,Foot drop splint pre ots,Durable Medical Equipment,Per Unit,$77.54 ,OP,77.54,266.89,,,,,,
Aetna MCR ADV,CPT,L4631,Afo- walk boot type- cus fab,Durable Medical Equipment,Per Unit,"$1,479.79 ",OP,"1,479.79","1,479.79",,,,,,
Aetna MCR ADV,CPT,L5000,Sho insert w arch toe filler,Durable Medical Equipment,Per Unit,$576.42 ,OP,576.42,"1,982.60",,,,,,
Aetna MCR ADV,CPT,L5010,Mold socket ank hgt w/ toe f,Durable Medical Equipment,Per Unit,"$1,610.60 ",OP,"1,610.60","5,539.84",,,,,,
Aetna MCR ADV,CPT,L5020,Tibial tubercle hgt w/ toe f,Durable Medical Equipment,Per Unit,"$2,523.29 ",OP,"2,523.29","8,677.68",,,,,,
Aetna MCR ADV,CPT,L5050,Ank symes mold sckt sach ft,Durable Medical Equipment,Per Unit,"$2,755.91 ",OP,"2,755.91","9,478.35",,,,,,
Aetna MCR ADV,CPT,L5060,Symes met fr leath socket ar,Durable Medical Equipment,Per Unit,"$3,397.24 ",OP,"3,397.24","11,682.09",,,,,,
Aetna MCR ADV,CPT,L5100,Molded socket shin sach foot,Durable Medical Equipment,Per Unit,"$2,744.12 ",OP,"2,744.12","9,436.43",,,,,,
Aetna MCR ADV,CPT,L5105,Plast socket jts/thgh lacer,Durable Medical Equipment,Per Unit,"$3,872.55 ",OP,"3,872.55","13,317.74",,,,,,
Aetna MCR ADV,CPT,L5150,Mold sckt ext knee shin sach,Durable Medical Equipment,Per Unit,"$4,305.35 ",OP,"4,305.35","14,804.69",,,,,,
Aetna MCR ADV,CPT,L5160,Mold socket bent knee shin s,Durable Medical Equipment,Per Unit,"$4,727.07 ",OP,"4,727.07","16,257.32",,,,,,
Aetna MCR ADV,CPT,L5200,Kne sing axis fric shin sach,Durable Medical Equipment,Per Unit,"$3,656.04 ",OP,"3,656.04","12,574.26",,,,,,
Aetna MCR ADV,CPT,L5210,No knee/ankle joints w/ ft b,Durable Medical Equipment,Per Unit,"$2,902.89 ",OP,"2,902.89","9,981.64",,,,,,
Aetna MCR ADV,CPT,L5220,No knee joint with artic ali,Durable Medical Equipment,Per Unit,"$3,197.74 ",OP,"3,197.74","10,995.81",,,,,,
Aetna MCR ADV,CPT,L5230,Fem focal defic constant fri,Durable Medical Equipment,Per Unit,"$4,796.11 ",OP,"4,796.11","16,493.71",,,,,,
Aetna MCR ADV,CPT,L5250,Hip canad sing axi cons fric,Durable Medical Equipment,Per Unit,"$5,623.57 ",OP,"5,623.57","19,341.79",,,,,,
Aetna MCR ADV,CPT,L5270,Tilt table locking hip sing,Durable Medical Equipment,Per Unit,"$6,265.76 ",OP,"6,265.76","21,549.33",,,,,,
Aetna MCR ADV,CPT,L5280,Hemipelvect canad sing axis,Durable Medical Equipment,Per Unit,"$6,090.55 ",OP,"6,090.55","20,946.94",,,,,,
Aetna MCR ADV,CPT,L5301,Bk mold socket sach ft endo,Durable Medical Equipment,Per Unit,"$2,694.66 ",OP,"2,694.66","9,268.66",,,,,,
Aetna MCR ADV,CPT,L5312,Knee disart- sach ft- endo,Durable Medical Equipment,Per Unit,"$4,245.62 ",OP,"4,245.62","4,245.62",,,,,,
Aetna MCR ADV,CPT,L5321,Ak open end sach,Durable Medical Equipment,Per Unit,"$3,593.24 ",OP,"3,593.24","12,356.94",,,,,,
Aetna MCR ADV,CPT,L5331,Hip disart canadian sach ft,Durable Medical Equipment,Per Unit,"$5,262.80 ",OP,"5,262.80","18,098.85",,,,,,
Aetna MCR ADV,CPT,L5341,Hemipelvectomy canadian sach,Durable Medical Equipment,Per Unit,"$5,594.28 ",OP,"5,594.28","19,238.85",,,,,,
Aetna MCR ADV,CPT,L5400,Postop dress & 1 cast chg bk,Durable Medical Equipment,Per Unit,"$1,604.68 ",OP,"1,604.68","5,516.97",,,,,,
Aetna MCR ADV,CPT,L5410,Postop dsg bk ea add cast ch,Durable Medical Equipment,Per Unit,$443.32 ,OP,443.32,"1,525.07",,,,,,
Aetna MCR ADV,CPT,L5420,Postop dsg & 1 cast chg ak/d,Durable Medical Equipment,Per Unit,"$2,026.64 ",OP,"2,026.64","6,969.60",,,,,,
Aetna MCR ADV,CPT,L5430,Postop dsg ak ea add cast ch,Durable Medical Equipment,Per Unit,$550.12 ,OP,550.12,"1,891.10",,,,,,
Aetna MCR ADV,CPT,L5450,Postop app non-wgt bear dsg,Durable Medical Equipment,Per Unit,$475.67 ,OP,475.67,"1,635.64",,,,,,
Aetna MCR ADV,CPT,L5460,Postop app non-wgt bear dsg,Durable Medical Equipment,Per Unit,$623.89 ,OP,623.89,"2,146.54",,,,,,
Aetna MCR ADV,CPT,L5500,Init bk ptb plaster direct,Durable Medical Equipment,Per Unit,"$1,483.19 ",OP,"1,483.19","5,101.39",,,,,,
Aetna MCR ADV,CPT,L5505,Init ak ischal plstr direct,Durable Medical Equipment,Per Unit,"$2,086.44 ",OP,"2,086.44","7,175.49",,,,,,
Aetna MCR ADV,CPT,L5510,Prep bk ptb plaster molded,Durable Medical Equipment,Per Unit,"$1,771.18 ",OP,"1,771.18","6,092.69",,,,,,
Aetna MCR ADV,CPT,L5520,Perp bk ptb thermopls direct,Durable Medical Equipment,Per Unit,"$1,587.65 ",OP,"1,587.65","5,459.77",,,,,,
Aetna MCR ADV,CPT,L5530,Prep bk ptb thermopls molded,Durable Medical Equipment,Per Unit,"$2,087.07 ",OP,"2,087.07","7,179.30",,,,,,
Aetna MCR ADV,CPT,L5535,Prep bk ptb open end socket,Durable Medical Equipment,Per Unit,"$1,945.59 ",OP,"1,945.59","6,691.29",,,,,,
Aetna MCR ADV,CPT,L5540,Prep bk ptb laminated socket,Durable Medical Equipment,Per Unit,"$2,060.66 ",OP,"2,060.66","7,087.80",,,,,,
Aetna MCR ADV,CPT,L5560,Prep ak ischial plast molded,Durable Medical Equipment,Per Unit,"$2,348.01 ",OP,"2,348.01","8,075.28",,,,,,
Aetna MCR ADV,CPT,L5570,Prep ak ischial direct form,Durable Medical Equipment,Per Unit,"$2,278.83 ",OP,"2,278.83","7,838.89",,,,,,
Aetna MCR ADV,CPT,L5580,Prep ak ischial thermo mold,Durable Medical Equipment,Per Unit,"$2,828.36 ",OP,"2,828.36","9,726.18",,,,,,
Aetna MCR ADV,CPT,L5585,Prep ak ischial open end,Durable Medical Equipment,Per Unit,"$3,312.24 ",OP,"3,312.24","11,392.33",,,,,,
Aetna MCR ADV,CPT,L5590,Prep ak ischial laminated,Durable Medical Equipment,Per Unit,"$2,948.85 ",OP,"2,948.85","10,141.77",,,,,,
Aetna MCR ADV,CPT,L5595,Hip disartic sach thermopls,Durable Medical Equipment,Per Unit,"$4,608.29 ",OP,"4,608.29","15,849.36",,,,,,
Aetna MCR ADV,CPT,L5600,Hip disart sach laminat mold,Durable Medical Equipment,Per Unit,"$5,244.91 ",OP,"5,244.91","18,037.85",,,,,,
Aetna MCR ADV,CPT,L5610,Above knee hydracadence,Durable Medical Equipment,Per Unit,"$2,529.59 ",OP,"2,529.59","8,700.56",,,,,,
Aetna MCR ADV,CPT,L5611,Ak 4 bar link w/fric swing,Durable Medical Equipment,Per Unit,"$1,611.13 ",OP,"1,611.13","5,539.84",,,,,,
Aetna MCR ADV,CPT,L5613,Ak 4 bar ling w/hydraul swig,Durable Medical Equipment,Per Unit,"$2,450.64 ",OP,"2,450.64","8,429.87",,,,,,
Aetna MCR ADV,CPT,L5614,4-bar link above knee w/swng,Durable Medical Equipment,Per Unit,"$1,697.23 ",OP,"1,697.23","5,837.23",,,,,,
Aetna MCR ADV,CPT,L5616,Ak univ multiplex sys frict,Durable Medical Equipment,Per Unit,"$1,477.66 ",OP,"1,477.66","5,082.32",,,,,,
Aetna MCR ADV,CPT,L5617,Ak/bk self-aligning unit ea,Durable Medical Equipment,Per Unit,$562.74 ,OP,562.74,"1,936.85",,,,,,
Aetna MCR ADV,CPT,L5618,Test socket symes,Durable Medical Equipment,Per Unit,$336.06 ,OP,336.06,"1,155.24",,,,,,
Aetna MCR ADV,CPT,L5620,Test socket below knee,Durable Medical Equipment,Per Unit,$298.16 ,OP,298.16,"1,025.61",,,,,,
Aetna MCR ADV,CPT,L5622,Test socket knee disarticula,Durable Medical Equipment,Per Unit,$401.70 ,OP,401.7,"1,380.19",,,,,,
Aetna MCR ADV,CPT,L5624,Test socket above knee,Durable Medical Equipment,Per Unit,$401.54 ,OP,401.54,"1,380.19",,,,,,
Aetna MCR ADV,CPT,L5626,Test socket hip disarticulat,Durable Medical Equipment,Per Unit,$635.70 ,OP,635.7,"2,184.67",,,,,,
Aetna MCR ADV,CPT,L5628,Test socket hemipelvectomy,Durable Medical Equipment,Per Unit,$643.74 ,OP,643.74,"2,215.19",,,,,,
Aetna MCR ADV,CPT,L5629,Below knee acrylic socket,Durable Medical Equipment,Per Unit,$317.79 ,OP,317.79,"1,094.25",,,,,,
Aetna MCR ADV,CPT,L5630,Syme typ expandabl wall sckt,Durable Medical Equipment,Per Unit,$552.17 ,OP,552.17,"1,898.73",,,,,,
Aetna MCR ADV,CPT,L5631,Ak/knee disartic acrylic soc,Durable Medical Equipment,Per Unit,$439.37 ,OP,439.37,"1,509.83",,,,,,
Aetna MCR ADV,CPT,L5632,Symes type ptb brim design s,Durable Medical Equipment,Per Unit,$270.81 ,OP,270.81,930.3,,,,,,
Aetna MCR ADV,CPT,L5634,Symes type poster opening so,Durable Medical Equipment,Per Unit,$338.66 ,OP,338.66,"1,162.87",,,,,,
Aetna MCR ADV,CPT,L5636,Symes type medial opening so,Durable Medical Equipment,Per Unit,$258.86 ,OP,258.86,888.36,,,,,,
Aetna MCR ADV,CPT,L5637,Below knee total contact,Durable Medical Equipment,Per Unit,$385.17 ,OP,385.17,"1,323.01",,,,,,
Aetna MCR ADV,CPT,L5638,Below knee leather socket,Durable Medical Equipment,Per Unit,$648.87 ,OP,648.87,"2,230.43",,,,,,
Aetna MCR ADV,CPT,L5639,Below knee wood socket,Durable Medical Equipment,Per Unit,"$1,121.15 ",OP,"1,121.15","3,854.63",,,,,,
Aetna MCR ADV,CPT,L5640,Knee disarticulat leather so,Durable Medical Equipment,Per Unit,$736.94 ,OP,736.94,"2,535.44",,,,,,
Aetna MCR ADV,CPT,L5642,Above knee leather socket,Durable Medical Equipment,Per Unit,$683.11 ,OP,683.11,"2,348.62",,,,,,
Aetna MCR ADV,CPT,L5643,Hip flex inner socket ext fr,Durable Medical Equipment,Per Unit,"$2,014.84 ",OP,"2,014.84","6,927.67",,,,,,
Aetna MCR ADV,CPT,L5644,Above knee wood socket,Durable Medical Equipment,Per Unit,$590.63 ,OP,590.63,"2,032.17",,,,,,
Aetna MCR ADV,CPT,L5645,Bk flex inner socket ext fra,Durable Medical Equipment,Per Unit,$979.82 ,OP,979.82,"3,370.43",,,,,,
Aetna MCR ADV,CPT,L5646,Below knee cushion socket,Durable Medical Equipment,Per Unit,$620.93 ,OP,620.93,"2,135.11",,,,,,
Aetna MCR ADV,CPT,L5647,Below knee suction socket,Durable Medical Equipment,Per Unit,$795.44 ,OP,795.44,"2,733.70",,,,,,
Aetna MCR ADV,CPT,L5648,Above knee cushion socket,Durable Medical Equipment,Per Unit,$733.68 ,OP,733.68,"2,524.00",,,,,,
Aetna MCR ADV,CPT,L5649,Isch containmt/narrow m-l so,Durable Medical Equipment,Per Unit,"$2,465.24 ",OP,"2,465.24","8,479.43",,,,,,
Aetna MCR ADV,CPT,L5650,Tot contact ak/knee disart s,Durable Medical Equipment,Per Unit,$488.17 ,OP,488.17,"1,677.58",,,,,,
Aetna MCR ADV,CPT,L5651,Ak flex inner socket ext fra,Durable Medical Equipment,Per Unit,"$1,430.29 ",OP,"1,430.29","4,918.37",,,,,,
Aetna MCR ADV,CPT,L5652,Suction susp ak/knee disart,Durable Medical Equipment,Per Unit,$435.97 ,OP,435.97,"1,498.39",,,,,,
Aetna MCR ADV,CPT,L5653,Knee disart expand wall sock,Durable Medical Equipment,Per Unit,$680.24 ,OP,680.24,"2,341.00",,,,,,
Aetna MCR ADV,CPT,L5654,Socket insert symes,Durable Medical Equipment,Per Unit,$394.33 ,OP,394.33,"1,357.32",,,,,,
Aetna MCR ADV,CPT,L5655,Socket insert below knee,Durable Medical Equipment,Per Unit,$284.71 ,OP,284.71,979.86,,,,,,
Aetna MCR ADV,CPT,L5656,Socket insert knee articulat,Durable Medical Equipment,Per Unit,$432.53 ,OP,432.53,"1,486.95",,,,,,
Aetna MCR ADV,CPT,L5658,Socket insert above knee,Durable Medical Equipment,Per Unit,$456.55 ,OP,456.55,"1,570.83",,,,,,
Aetna MCR ADV,CPT,L5661,Multi-durometer symes,Durable Medical Equipment,Per Unit,$655.04 ,OP,655.04,"2,253.31",,,,,,
Aetna MCR ADV,CPT,L5665,Multi-durometer below knee,Durable Medical Equipment,Per Unit,$582.36 ,OP,582.36,"2,001.67",,,,,,
Aetna MCR ADV,CPT,L5666,Below knee cuff suspension,Durable Medical Equipment,Per Unit,$77.11 ,OP,77.11,266.89,,,,,,
Aetna MCR ADV,CPT,L5668,Bk molded distal cushion,Durable Medical Equipment,Per Unit,$114.86 ,OP,114.86,396.52,,,,,,
Aetna MCR ADV,CPT,L5670,Bk molded supracondylar susp,Durable Medical Equipment,Per Unit,$271.35 ,OP,271.35,934.12,,,,,,
Aetna MCR ADV,CPT,L5671,Bk/ak locking mechanism,Durable Medical Equipment,Per Unit,$497.40 ,OP,497.4,"1,711.89",,,,,,
Aetna MCR ADV,CPT,L5672,Bk removable medial brim sus,Durable Medical Equipment,Per Unit,$359.07 ,OP,359.07,"1,235.32",,,,,,
Aetna MCR ADV,CPT,L5673,Socket insert w lock mech,Durable Medical Equipment,Per Unit,$790.52 ,OP,790.52,"2,718.45",,,,,,
Aetna MCR ADV,CPT,L5676,Bk knee joints single axis p,Durable Medical Equipment,Per Unit,$362.36 ,OP,362.36,"1,246.76",,,,,,
Aetna MCR ADV,CPT,L5677,Bk knee joints polycentric p,Durable Medical Equipment,Per Unit,$554.97 ,OP,554.97,"1,910.16",,,,,,
Aetna MCR ADV,CPT,L5678,Bk joint covers pair,Durable Medical Equipment,Per Unit,$39.70 ,OP,39.7,137.25,,,,,,
Aetna MCR ADV,CPT,L5679,Socket insert w/o lock mech,Durable Medical Equipment,Per Unit,$658.75 ,OP,658.75,"2,264.75",,,,,,
Aetna MCR ADV,CPT,L5680,Bk thigh lacer non-molded,Durable Medical Equipment,Per Unit,$304.37 ,OP,304.37,"1,048.50",,,,,,
Aetna MCR ADV,CPT,L5681,Intl custm cong/latyp insert,Durable Medical Equipment,Per Unit,"$1,323.02 ",OP,"1,323.02","4,548.54",,,,,,
Aetna MCR ADV,CPT,L5682,Bk thigh lacer glut/ischia m,Durable Medical Equipment,Per Unit,$625.37 ,OP,625.37,"2,150.36",,,,,,
Aetna MCR ADV,CPT,L5683,Initial custom socket insert,Durable Medical Equipment,Per Unit,"$1,323.02 ",OP,"1,323.02","4,548.54",,,,,,
Aetna MCR ADV,CPT,L5684,Bk fork strap,Durable Medical Equipment,Per Unit,$48.13 ,OP,48.13,163.95,,,,,,
Aetna MCR ADV,CPT,L5685,Below knee sus/seal sleeve,Durable Medical Equipment,Per Unit,$128.85 ,OP,128.85,442.27,,,,,,
Aetna MCR ADV,CPT,L5686,Bk back check,Durable Medical Equipment,Per Unit,$57.89 ,OP,57.89,198.25,,,,,,
Aetna MCR ADV,CPT,L5688,Bk waist belt webbing,Durable Medical Equipment,Per Unit,$61.48 ,OP,61.48,209.7,,,,,,
Aetna MCR ADV,CPT,L5690,Bk waist belt padded and lin,Durable Medical Equipment,Per Unit,$125.50 ,OP,125.5,430.83,,,,,,
Aetna MCR ADV,CPT,L5692,Ak pelvic control belt light,Durable Medical Equipment,Per Unit,$132.88 ,OP,132.88,457.52,,,,,,
Aetna MCR ADV,CPT,L5694,Ak pelvic control belt pad/l,Durable Medical Equipment,Per Unit,$181.41 ,OP,181.41,625.29,,,,,,
Aetna MCR ADV,CPT,L5695,Ak sleeve susp neoprene/equa,Durable Medical Equipment,Per Unit,$163.08 ,OP,163.08,560.47,,,,,,
Aetna MCR ADV,CPT,L5696,Ak/knee disartic pelvic join,Durable Medical Equipment,Per Unit,$196.99 ,OP,196.99,678.66,,,,,,
Aetna MCR ADV,CPT,L5697,Ak/knee disartic pelvic band,Durable Medical Equipment,Per Unit,$93.55 ,OP,93.55,320.27,,,,,,
Aetna MCR ADV,CPT,L5698,Ak/knee disartic silesian ba,Durable Medical Equipment,Per Unit,$120.01 ,OP,120.01,411.78,,,,,,
Aetna MCR ADV,CPT,L5699,Shoulder harness,Durable Medical Equipment,Per Unit,$205.11 ,OP,205.11,705.35,,,,,,
Aetna MCR ADV,CPT,L5700,Replace socket below knee,Durable Medical Equipment,Per Unit,"$3,085.07 ",OP,"3,085.07","10,610.72",,,,,,
Aetna MCR ADV,CPT,L5701,Replace socket above knee,Durable Medical Equipment,Per Unit,"$3,827.32 ",OP,"3,827.32","13,161.41",,,,,,
Aetna MCR ADV,CPT,L5702,Replace socket hip,Durable Medical Equipment,Per Unit,"$4,823.75 ",OP,"4,823.75","16,589.03",,,,,,
Aetna MCR ADV,CPT,L5703,Symes ankle w/o (sach) foot,Durable Medical Equipment,Per Unit,"$2,537.43 ",OP,"2,537.43","8,727.25",,,,,,
Aetna MCR ADV,CPT,L5704,Custom shape cover bk,Durable Medical Equipment,Per Unit,$629.03 ,OP,629.03,"2,161.80",,,,,,
Aetna MCR ADV,CPT,L5705,Custom shape cover ak,Durable Medical Equipment,Per Unit,"$1,153.25 ",OP,"1,153.25","3,965.20",,,,,,
Aetna MCR ADV,CPT,L5706,Custom shape cvr knee disart,Durable Medical Equipment,Per Unit,"$1,124.85 ",OP,"1,124.85","3,869.89",,,,,,
Aetna MCR ADV,CPT,L5707,Custom shape cvr hip disart,Durable Medical Equipment,Per Unit,"$1,511.27 ",OP,"1,511.27","5,196.70",,,,,,
Aetna MCR ADV,CPT,L5710,Kne-shin exo sng axi mnl loc,Durable Medical Equipment,Per Unit,$359.65 ,OP,359.65,"1,235.32",,,,,,
Aetna MCR ADV,CPT,L5711,Knee-shin exo mnl lock ultra,Durable Medical Equipment,Per Unit,$603.60 ,OP,603.6,"2,074.10",,,,,,
Aetna MCR ADV,CPT,L5712,Knee-shin exo frict swg & st,Durable Medical Equipment,Per Unit,$430.88 ,OP,430.88,"1,483.14",,,,,,
Aetna MCR ADV,CPT,L5714,Knee-shin exo variable frict,Durable Medical Equipment,Per Unit,$438.43 ,OP,438.43,"1,506.03",,,,,,
Aetna MCR ADV,CPT,L5716,Knee-shin exo mech stance ph,Durable Medical Equipment,Per Unit,$866.93 ,OP,866.93,"2,981.52",,,,,,
Aetna MCR ADV,CPT,L5718,Knee-shin exo frct swg & sta,Durable Medical Equipment,Per Unit,$927.01 ,OP,927.01,"3,187.41",,,,,,
Aetna MCR ADV,CPT,L5722,Knee-shin pneum swg frct exo,Durable Medical Equipment,Per Unit,"$1,127.32 ",OP,"1,127.32","3,877.51",,,,,,
Aetna MCR ADV,CPT,L5724,Knee-shin exo fluid swing ph,Durable Medical Equipment,Per Unit,"$1,737.57 ",OP,"1,737.57","5,974.48",,,,,,
Aetna MCR ADV,CPT,L5726,Knee-shin ext jnts fld swg e,Durable Medical Equipment,Per Unit,"$2,068.65 ",OP,"2,068.65","7,114.49",,,,,,
Aetna MCR ADV,CPT,L5728,Knee-shin fluid swg & stance,Durable Medical Equipment,Per Unit,"$2,424.23 ",OP,"2,424.23","8,338.36",,,,,,
Aetna MCR ADV,CPT,L5780,Knee-shin pneum/hydra pneum,Durable Medical Equipment,Per Unit,"$1,334.72 ",OP,"1,334.72","4,590.49",,,,,,
Aetna MCR ADV,CPT,L5781,Lower limb pros vacuum pump,Durable Medical Equipment,Per Unit,"$4,024.33 ",OP,"4,024.33","13,840.07",,,,,,
Aetna MCR ADV,CPT,L5782,Hd low limb pros vacuum pump,Durable Medical Equipment,Per Unit,"$4,242.55 ",OP,"4,242.55","14,591.17",,,,,,
Aetna MCR ADV,CPT,L5785,Exoskeletal bk ultralt mater,Durable Medical Equipment,Per Unit,$519.54 ,OP,519.54,"1,788.15",,,,,,
Aetna MCR ADV,CPT,L5790,Exoskeletal ak ultra-light m,Durable Medical Equipment,Per Unit,$749.83 ,OP,749.83,"2,577.38",,,,,,
Aetna MCR ADV,CPT,L5795,Exoskel hip ultra-light mate,Durable Medical Equipment,Per Unit,"$1,073.66 ",OP,"1,073.66","3,690.70",,,,,,
Aetna MCR ADV,CPT,L5810,Endoskel knee-shin mnl lock,Durable Medical Equipment,Per Unit,$572.04 ,OP,572.04,"1,967.35",,,,,,
Aetna MCR ADV,CPT,L5811,Endo knee-shin mnl lck ultra,Durable Medical Equipment,Per Unit,$789.42 ,OP,789.42,"2,714.64",,,,,,
Aetna MCR ADV,CPT,L5812,Endo knee-shin frct swg & st,Durable Medical Equipment,Per Unit,$594.07 ,OP,594.07,"2,043.61",,,,,,
Aetna MCR ADV,CPT,L5814,Endo knee-shin hydral swg ph,Durable Medical Equipment,Per Unit,"$3,735.37 ",OP,"3,735.37","12,844.96",,,,,,
Aetna MCR ADV,CPT,L5816,Endo knee-shin polyc mch sta,Durable Medical Equipment,Per Unit,$850.43 ,OP,850.43,"2,924.33",,,,,,
Aetna MCR ADV,CPT,L5818,Endo knee-shin frct swg & st,Durable Medical Equipment,Per Unit,$960.30 ,OP,960.3,"3,301.79",,,,,,
Aetna MCR ADV,CPT,L5822,Endo knee-shin pneum swg frc,Durable Medical Equipment,Per Unit,"$1,761.65 ",OP,"1,761.65","6,058.37",,,,,,
Aetna MCR ADV,CPT,L5824,Endo knee-shin fluid swing p,Durable Medical Equipment,Per Unit,"$1,665.27 ",OP,"1,665.27","5,726.65",,,,,,
Aetna MCR ADV,CPT,L5826,Miniature knee joint,Durable Medical Equipment,Per Unit,"$3,140.97 ",OP,"3,140.97","10,801.35",,,,,,
Aetna MCR ADV,CPT,L5828,Endo knee-shin fluid swg/sta,Durable Medical Equipment,Per Unit,"$2,963.78 ",OP,"2,963.78","10,191.33",,,,,,
Aetna MCR ADV,CPT,L5830,Endo knee-shin pneum/swg pha,Durable Medical Equipment,Per Unit,"$1,998.37 ",OP,"1,998.37","6,874.29",,,,,,
Aetna MCR ADV,CPT,L5840,Multi-axial knee/shin system,Durable Medical Equipment,Per Unit,"$3,922.28 ",OP,"3,922.28","13,489.32",,,,,,
Aetna MCR ADV,CPT,L5845,Knee-shin sys stance flexion,Durable Medical Equipment,Per Unit,"$1,802.73 ",OP,"1,802.73","6,199.43",,,,,,
Aetna MCR ADV,CPT,L5848,Knee-shin sys hydraul stance,Durable Medical Equipment,Per Unit,"$1,081.55 ",OP,"1,081.55","3,721.19",,,,,,
Aetna MCR ADV,CPT,L5850,Endo ak/hip knee extens assi,Durable Medical Equipment,Per Unit,$127.92 ,OP,127.92,438.47,,,,,,
Aetna MCR ADV,CPT,L5855,Mech hip extension assist,Durable Medical Equipment,Per Unit,$308.82 ,OP,308.82,"1,063.73",,,,,,
Aetna MCR ADV,CPT,L5856,Elec knee-shin swing/stance,Durable Medical Equipment,Per Unit,"$24,144.68 ",OP,"24,144.68","83,036.63",,,,,,
Aetna MCR ADV,CPT,L5857,Elec knee-shin swing only,Durable Medical Equipment,Per Unit,"$8,567.44 ",OP,"8,567.44","29,464.49",,,,,,
Aetna MCR ADV,CPT,L5858,Stance phase only,Durable Medical Equipment,Per Unit,"$18,692.70 ",OP,"18,692.70","64,285.82",,,,,,
Aetna MCR ADV,CPT,L5859,Knee-shin pro flex/ext cont,Durable Medical Equipment,Per Unit,"$14,593.21 ",OP,"14,593.21","14,593.21",,,,,,
Aetna MCR ADV,CPT,L5910,Endo below knee alignable sy,Durable Medical Equipment,Per Unit,$362.17 ,OP,362.17,"1,246.76",,,,,,
Aetna MCR ADV,CPT,L5920,Endo ak/hip alignable system,Durable Medical Equipment,Per Unit,$530.58 ,OP,530.58,"1,826.28",,,,,,
Aetna MCR ADV,CPT,L5925,Above knee manual lock,Durable Medical Equipment,Per Unit,$336.00 ,OP,336,"1,155.24",,,,,,
Aetna MCR ADV,CPT,L5930,High activity knee frame,Durable Medical Equipment,Per Unit,"$3,385.39 ",OP,"3,385.39","11,643.96",,,,,,
Aetna MCR ADV,CPT,L5940,Endo bk ultra-light material,Durable Medical Equipment,Per Unit,$501.60 ,OP,501.6,"1,723.33",,,,,,
Aetna MCR ADV,CPT,L5950,Endo ak ultra-light material,Durable Medical Equipment,Per Unit,$777.99 ,OP,777.99,"2,676.51",,,,,,
Aetna MCR ADV,CPT,L5960,Endo hip ultra-light materia,Durable Medical Equipment,Per Unit,"$1,163.29 ",OP,"1,163.29","3,999.51",,,,,,
Aetna MCR ADV,CPT,L5961,Endo poly hip- pneu/hyd/rot,Durable Medical Equipment,Per Unit,"$4,800.88 ",OP,"4,800.88","4,800.88",,,,,,
Aetna MCR ADV,CPT,L5962,Below knee flex cover system,Durable Medical Equipment,Per Unit,$587.78 ,OP,587.78,"2,020.72",,,,,,
Aetna MCR ADV,CPT,L5964,Above knee flex cover system,Durable Medical Equipment,Per Unit,"$1,127.47 ",OP,"1,127.47","3,877.51",,,,,,
Aetna MCR ADV,CPT,L5966,Hip flexible cover system,Durable Medical Equipment,Per Unit,"$1,452.38 ",OP,"1,452.38","4,994.63",,,,,,
Aetna MCR ADV,CPT,L5968,Multiaxial ankle w dorsiflex,Durable Medical Equipment,Per Unit,"$3,654.91 ",OP,"3,654.91","12,570.45",,,,,,
Aetna MCR ADV,CPT,L5970,Foot external keel sach foot,Durable Medical Equipment,Per Unit,$218.47 ,OP,218.47,751.1,,,,,,
Aetna MCR ADV,CPT,L5971,Sach foot- replacement,Durable Medical Equipment,Per Unit,$218.47 ,OP,218.47,751.1,,,,,,
Aetna MCR ADV,CPT,L5972,Flexible keel foot,Durable Medical Equipment,Per Unit,$397.97 ,OP,397.97,"1,368.75",,,,,,
Aetna MCR ADV,CPT,L5973,Ank-foot sys dors-plant flex,Durable Medical Equipment,Per Unit,"$17,757.02 ",OP,"17,757.02","17,757.02",,,,,,
Aetna MCR ADV,CPT,L5974,Foot single axis ankle/foot,Durable Medical Equipment,Per Unit,$233.03 ,OP,233.03,800.67,,,,,,
Aetna MCR ADV,CPT,L5975,Combo ankle/foot prosthesis,Durable Medical Equipment,Per Unit,$466.28 ,OP,466.28,"1,605.15",,,,,,
Aetna MCR ADV,CPT,L5976,Energy storing foot,Durable Medical Equipment,Per Unit,$591.07 ,OP,591.07,"2,032.17",,,,,,
Aetna MCR ADV,CPT,L5978,Ft prosth multiaxial ankl/ft,Durable Medical Equipment,Per Unit,$313.20 ,OP,313.2,"1,078.99",,,,,,
Aetna MCR ADV,CPT,L5979,Multi-axial ankle/ft prosth,Durable Medical Equipment,Per Unit,"$2,507.69 ",OP,"2,507.69","8,624.30",,,,,,
Aetna MCR ADV,CPT,L5980,Flex foot system,Durable Medical Equipment,Per Unit,"$3,820.69 ",OP,"3,820.69","13,138.54",,,,,,
Aetna MCR ADV,CPT,L5981,Flex-walk sys low ext prosth,Durable Medical Equipment,Per Unit,"$3,431.91 ",OP,"3,431.91","11,804.09",,,,,,
Aetna MCR ADV,CPT,L5982,Exoskeletal axial rotation u,Durable Medical Equipment,Per Unit,$644.71 ,OP,644.71,"2,218.98",,,,,,
Aetna MCR ADV,CPT,L5984,Endoskeletal axial rotation,Durable Medical Equipment,Per Unit,$646.71 ,OP,646.71,"2,222.79",,,,,,
Aetna MCR ADV,CPT,L5985,Lwr ext dynamic prosth pylon,Durable Medical Equipment,Per Unit,$284.02 ,OP,284.02,976.05,,,,,,
Aetna MCR ADV,CPT,L5986,Multi-axial rotation unit,Durable Medical Equipment,Per Unit,$780.11 ,OP,780.11,"2,684.14",,,,,,
Aetna MCR ADV,CPT,L5987,Shank ft w vert load pylon,Durable Medical Equipment,Per Unit,"$7,235.38 ",OP,"7,235.38","24,881.63",,,,,,
Aetna MCR ADV,CPT,L5988,Vertical shock reducing pylo,Durable Medical Equipment,Per Unit,"$2,009.25 ",OP,"2,009.25","6,908.59",,,,,,
Aetna MCR ADV,CPT,L5990,User adjustable heel height,Durable Medical Equipment,Per Unit,"$1,824.64 ",OP,"1,824.64","6,275.69",,,,,,
Aetna MCR ADV,CPT,L6000,Part hand thumb rem,Durable Medical Equipment,Per Unit,"$1,771.55 ",OP,"1,771.55","6,092.69",,,,,,
Aetna MCR ADV,CPT,L6010,Part hand little/ring,Durable Medical Equipment,Per Unit,"$1,971.44 ",OP,"1,971.44","6,778.98",,,,,,
Aetna MCR ADV,CPT,L6020,Part hand no fingers,Durable Medical Equipment,Per Unit,"$1,838.05 ",OP,"1,838.05","6,321.45",,,,,,
Aetna MCR ADV,CPT,L6026,Part hand myo exclu term dev,Durable Medical Equipment,Per Unit,"$4,375.03 ",OP,"4,375.03","4,375.03",,,,,,
Aetna MCR ADV,CPT,L6050,Wrst mld sck flx hng tri pad,Durable Medical Equipment,Per Unit,"$2,500.12 ",OP,"2,500.12","8,597.63",,,,,,
Aetna MCR ADV,CPT,L6055,Wrst mold sock w/exp interfa,Durable Medical Equipment,Per Unit,"$3,189.04 ",OP,"3,189.04","10,969.11",,,,,,
Aetna MCR ADV,CPT,L6100,Elb mold sock flex hinge pad,Durable Medical Equipment,Per Unit,"$2,530.04 ",OP,"2,530.04","8,700.56",,,,,,
Aetna MCR ADV,CPT,L6110,Elbow mold sock suspension t,Durable Medical Equipment,Per Unit,"$2,676.61 ",OP,"2,676.61","9,203.84",,,,,,
Aetna MCR ADV,CPT,L6120,Elbow mold doub splt soc ste,Durable Medical Equipment,Per Unit,"$3,027.26 ",OP,"3,027.26","10,412.46",,,,,,
Aetna MCR ADV,CPT,L6130,Elbow stump activated lock h,Durable Medical Equipment,Per Unit,"$3,193.82 ",OP,"3,193.82","10,984.37",,,,,,
Aetna MCR ADV,CPT,L6200,Elbow mold outsid lock hinge,Durable Medical Equipment,Per Unit,"$3,290.01 ",OP,"3,290.01","11,316.08",,,,,,
Aetna MCR ADV,CPT,L6205,Elbow molded w/ expand inter,Durable Medical Equipment,Per Unit,"$4,538.50 ",OP,"4,538.50","15,609.16",,,,,,
Aetna MCR ADV,CPT,L6250,Elbow inter loc elbow forarm,Durable Medical Equipment,Per Unit,"$3,236.79 ",OP,"3,236.79","11,133.06",,,,,,
Aetna MCR ADV,CPT,L6300,Shlder disart int lock elbow,Durable Medical Equipment,Per Unit,"$4,464.43 ",OP,"4,464.43","15,353.72",,,,,,
Aetna MCR ADV,CPT,L6310,Shoulder passive restor comp,Durable Medical Equipment,Per Unit,"$4,046.04 ",OP,"4,046.04","13,916.32",,,,,,
Aetna MCR ADV,CPT,L6320,Shoulder passive restor cap,Durable Medical Equipment,Per Unit,"$2,108.67 ",OP,"2,108.67","7,251.74",,,,,,
Aetna MCR ADV,CPT,L6350,Thoracic intern lock elbow,Durable Medical Equipment,Per Unit,"$4,891.63 ",OP,"4,891.63","16,821.60",,,,,,
Aetna MCR ADV,CPT,L6360,Thoracic passive restor comp,Durable Medical Equipment,Per Unit,"$4,246.80 ",OP,"4,246.80","14,606.43",,,,,,
Aetna MCR ADV,CPT,L6370,Thoracic passive restor cap,Durable Medical Equipment,Per Unit,"$2,462.85 ",OP,"2,462.85","8,471.79",,,,,,
Aetna MCR ADV,CPT,L6380,Postop dsg cast chg wrst/elb,Durable Medical Equipment,Per Unit,"$1,424.44 ",OP,"1,424.44","4,899.32",,,,,,
Aetna MCR ADV,CPT,L6382,Postop dsg cast chg elb dis/,Durable Medical Equipment,Per Unit,"$1,695.74 ",OP,"1,695.74","5,833.42",,,,,,
Aetna MCR ADV,CPT,L6384,Postop dsg cast chg shlder/t,Durable Medical Equipment,Per Unit,"$2,145.20 ",OP,"2,145.20","7,377.56",,,,,,
Aetna MCR ADV,CPT,L6386,Postop ea cast chg & realign,Durable Medical Equipment,Per Unit,$470.24 ,OP,470.24,"1,616.58",,,,,,
Aetna MCR ADV,CPT,L6388,Postop applicat rigid dsg on,Durable Medical Equipment,Per Unit,$517.85 ,OP,517.85,"1,780.53",,,,,,
Aetna MCR ADV,CPT,L6400,Below elbow prosth tiss shap,Durable Medical Equipment,Per Unit,"$2,736.86 ",OP,"2,736.86","9,413.54",,,,,,
Aetna MCR ADV,CPT,L6450,Elb disart prosth tiss shap,Durable Medical Equipment,Per Unit,"$3,576.94 ",OP,"3,576.94","12,299.74",,,,,,
Aetna MCR ADV,CPT,L6500,Above elbow prosth tiss shap,Durable Medical Equipment,Per Unit,"$3,512.48 ",OP,"3,512.48","12,078.62",,,,,,
Aetna MCR ADV,CPT,L6550,Shldr disar prosth tiss shap,Durable Medical Equipment,Per Unit,"$4,549.39 ",OP,"4,549.39","15,647.29",,,,,,
Aetna MCR ADV,CPT,L6570,Scap thorac prosth tiss shap,Durable Medical Equipment,Per Unit,"$5,078.79 ",OP,"5,078.79","17,465.96",,,,,,
Aetna MCR ADV,CPT,L6580,Wrist/elbow bowden cable mol,Durable Medical Equipment,Per Unit,"$2,030.62 ",OP,"2,030.62","6,984.85",,,,,,
Aetna MCR ADV,CPT,L6582,Wrist/elbow bowden cbl dir f,Durable Medical Equipment,Per Unit,"$1,705.44 ",OP,"1,705.44","5,863.93",,,,,,
Aetna MCR ADV,CPT,L6584,Elbow fair lead cable molded,Durable Medical Equipment,Per Unit,"$2,525.30 ",OP,"2,525.30","8,685.31",,,,,,
Aetna MCR ADV,CPT,L6586,Elbow fair lead cable dir fo,Durable Medical Equipment,Per Unit,"$2,250.20 ",OP,"2,250.20","7,739.77",,,,,,
Aetna MCR ADV,CPT,L6588,Shdr fair lead cable molded,Durable Medical Equipment,Per Unit,"$3,583.73 ",OP,"3,583.73","12,326.44",,,,,,
Aetna MCR ADV,CPT,L6590,Shdr fair lead cable direct,Durable Medical Equipment,Per Unit,"$3,123.36 ",OP,"3,123.36","10,740.36",,,,,,
Aetna MCR ADV,CPT,L6600,Polycentric hinge pair,Durable Medical Equipment,Per Unit,$228.13 ,OP,228.13,785.42,,,,,,
Aetna MCR ADV,CPT,L6605,Single pivot hinge pair,Durable Medical Equipment,Per Unit,$234.81 ,OP,234.81,808.29,,,,,,
Aetna MCR ADV,CPT,L6610,Flexible metal hinge pair,Durable Medical Equipment,Per Unit,$221.98 ,OP,221.98,762.54,,,,,,
Aetna MCR ADV,CPT,L6611,Additional switch- ext power,Durable Medical Equipment,Per Unit,$414.10 ,OP,414.1,"1,425.95",,,,,,
Aetna MCR ADV,CPT,L6615,Disconnect locking wrist uni,Durable Medical Equipment,Per Unit,$215.48 ,OP,215.48,739.67,,,,,,
Aetna MCR ADV,CPT,L6616,Disconnect insert locking wr,Durable Medical Equipment,Per Unit,$64.86 ,OP,64.86,224.95,,,,,,
Aetna MCR ADV,CPT,L6620,Flexion/extension wrist unit,Durable Medical Equipment,Per Unit,$376.69 ,OP,376.69,"1,296.32",,,,,,
Aetna MCR ADV,CPT,L6621,Flex/ext wrist w/wo friction,Durable Medical Equipment,Per Unit,"$2,300.54 ",OP,"2,300.54","7,911.34",,,,,,
Aetna MCR ADV,CPT,L6623,Spring-ass rot wrst w/ latch,Durable Medical Equipment,Per Unit,$717.59 ,OP,717.59,"2,466.81",,,,,,
Aetna MCR ADV,CPT,L6624,Flex/ext/rotation wrist unit,Durable Medical Equipment,Per Unit,"$3,787.86 ",OP,"3,787.86","13,027.98",,,,,,
Aetna MCR ADV,CPT,L6625,Rotation wrst w/ cable lock,Durable Medical Equipment,Per Unit,$531.84 ,OP,531.84,"1,830.09",,,,,,
Aetna MCR ADV,CPT,L6628,Quick disconn hook adapter o,Durable Medical Equipment,Per Unit,$572.47 ,OP,572.47,"1,967.35",,,,,,
Aetna MCR ADV,CPT,L6629,Lamination collar w/ couplin,Durable Medical Equipment,Per Unit,$195.07 ,OP,195.07,671.03,,,,,,
Aetna MCR ADV,CPT,L6630,Stainless steel any wrist,Durable Medical Equipment,Per Unit,$287.35 ,OP,287.35,987.49,,,,,,
Aetna MCR ADV,CPT,L6632,Latex suspension sleeve each,Durable Medical Equipment,Per Unit,$64.97 ,OP,64.97,224.95,,,,,,
Aetna MCR ADV,CPT,L6635,Lift assist for elbow,Durable Medical Equipment,Per Unit,$207.68 ,OP,207.68,712.98,,,,,,
Aetna MCR ADV,CPT,L6637,Nudge control elbow lock,Durable Medical Equipment,Per Unit,$406.60 ,OP,406.6,"1,399.26",,,,,,
Aetna MCR ADV,CPT,L6638,Elec lock on manual pw elbow,Durable Medical Equipment,Per Unit,"$2,515.20 ",OP,"2,515.20","8,651.00",,,,,,
Aetna MCR ADV,CPT,L6640,Shoulder abduction joint pai,Durable Medical Equipment,Per Unit,$338.63 ,OP,338.63,"1,162.87",,,,,,
Aetna MCR ADV,CPT,L6641,Excursion amplifier pulley t,Durable Medical Equipment,Per Unit,$197.18 ,OP,197.18,678.66,,,,,,
Aetna MCR ADV,CPT,L6642,Excursion amplifier lever ty,Durable Medical Equipment,Per Unit,$289.92 ,OP,289.92,998.92,,,,,,
Aetna MCR ADV,CPT,L6645,Shoulder flexion-abduction j,Durable Medical Equipment,Per Unit,$366.21 ,OP,366.21,"1,258.19",,,,,,
Aetna MCR ADV,CPT,L6646,Multipo locking shoulder jnt,Durable Medical Equipment,Per Unit,"$3,172.24 ",OP,"3,172.24","10,908.12",,,,,,
Aetna MCR ADV,CPT,L6647,Shoulder lock actuator,Durable Medical Equipment,Per Unit,$522.26 ,OP,522.26,"1,795.78",,,,,,
Aetna MCR ADV,CPT,L6648,Ext pwrd shlder lock/unlock,Durable Medical Equipment,Per Unit,"$3,271.71 ",OP,"3,271.71","11,251.26",,,,,,
Aetna MCR ADV,CPT,L6650,Shoulder universal joint,Durable Medical Equipment,Per Unit,$397.20 ,OP,397.2,"1,364.94",,,,,,
Aetna MCR ADV,CPT,L6655,Standard control cable extra,Durable Medical Equipment,Per Unit,$77.05 ,OP,77.05,263.08,,,,,,
Aetna MCR ADV,CPT,L6660,Heavy duty control cable,Durable Medical Equipment,Per Unit,$103.11 ,OP,103.11,354.58,,,,,,
Aetna MCR ADV,CPT,L6665,Teflon or equal cable lining,Durable Medical Equipment,Per Unit,$46.05 ,OP,46.05,160.13,,,,,,
Aetna MCR ADV,CPT,L6670,Hook to hand cable adapter,Durable Medical Equipment,Per Unit,$47.96 ,OP,47.96,163.95,,,,,,
Aetna MCR ADV,CPT,L6672,Harness chest/shlder saddle,Durable Medical Equipment,Per Unit,$220.08 ,OP,220.08,758.72,,,,,,
Aetna MCR ADV,CPT,L6675,Harness figure of 8 sing con,Durable Medical Equipment,Per Unit,$120.09 ,OP,120.09,411.78,,,,,,
Aetna MCR ADV,CPT,L6676,Harness figure of 8 dual con,Durable Medical Equipment,Per Unit,$125.64 ,OP,125.64,430.83,,,,,,
Aetna MCR ADV,CPT,L6677,Ue triple control harness,Durable Medical Equipment,Per Unit,$298.35 ,OP,298.35,"1,025.61",,,,,,
Aetna MCR ADV,CPT,L6680,Test sock wrist disart/bel e,Durable Medical Equipment,Per Unit,$309.33 ,OP,309.33,"1,063.73",,,,,,
Aetna MCR ADV,CPT,L6682,Test sock elbw disart/above,Durable Medical Equipment,Per Unit,$342.01 ,OP,342.01,"1,178.12",,,,,,
Aetna MCR ADV,CPT,L6684,Test socket shldr disart/tho,Durable Medical Equipment,Per Unit,$464.75 ,OP,464.75,"1,597.52",,,,,,
Aetna MCR ADV,CPT,L6686,Suction socket,Durable Medical Equipment,Per Unit,$689.63 ,OP,689.63,"2,371.49",,,,,,
Aetna MCR ADV,CPT,L6687,Frame typ socket bel elbow/w,Durable Medical Equipment,Per Unit,$576.80 ,OP,576.8,"1,982.60",,,,,,
Aetna MCR ADV,CPT,L6688,Frame typ sock above elb/dis,Durable Medical Equipment,Per Unit,$638.36 ,OP,638.36,"2,196.11",,,,,,
Aetna MCR ADV,CPT,L6689,Frame typ socket shoulder di,Durable Medical Equipment,Per Unit,$760.81 ,OP,760.81,"2,615.51",,,,,,
Aetna MCR ADV,CPT,L6690,Frame typ sock interscap-tho,Durable Medical Equipment,Per Unit,$895.74 ,OP,895.74,"3,080.66",,,,,,
Aetna MCR ADV,CPT,L6691,Removable insert each,Durable Medical Equipment,Per Unit,$353.58 ,OP,353.58,"1,216.24",,,,,,
Aetna MCR ADV,CPT,L6692,Silicone gel insert or equal,Durable Medical Equipment,Per Unit,$643.25 ,OP,643.25,"2,211.37",,,,,,
Aetna MCR ADV,CPT,L6693,Lockingelbow forearm cntrbal,Durable Medical Equipment,Per Unit,"$2,855.43 ",OP,"2,855.43","9,821.50",,,,,,
Aetna MCR ADV,CPT,L6694,Elbow socket ins use w/lock,Durable Medical Equipment,Per Unit,$790.52 ,OP,790.52,"2,718.45",,,,,,
Aetna MCR ADV,CPT,L6695,Elbow socket ins use w/o lck,Durable Medical Equipment,Per Unit,$658.75 ,OP,658.75,"2,264.75",,,,,,
Aetna MCR ADV,CPT,L6696,Cus elbo skt in for con/atyp,Durable Medical Equipment,Per Unit,"$1,323.02 ",OP,"1,323.02","4,548.54",,,,,,
Aetna MCR ADV,CPT,L6697,Cus elbo skt in not con/atyp,Durable Medical Equipment,Per Unit,"$1,323.02 ",OP,"1,323.02","4,548.54",,,,,,
Aetna MCR ADV,CPT,L6698,Below/above elbow lock mech,Durable Medical Equipment,Per Unit,$497.40 ,OP,497.4,"1,711.89",,,,,,
Aetna MCR ADV,CPT,L6703,Term dev- passive hand mitt,Durable Medical Equipment,Per Unit,$351.79 ,OP,351.79,"1,208.62",,,,,,
Aetna MCR ADV,CPT,L6704,Term dev- sport/rec/work att,Durable Medical Equipment,Per Unit,$679.06 ,OP,679.06,"2,337.18",,,,,,
Aetna MCR ADV,CPT,L6706,Term dev mech hook vol open,Durable Medical Equipment,Per Unit,$421.40 ,OP,421.4,"1,448.82",,,,,,
Aetna MCR ADV,CPT,L6707,Term dev mech hook vol close,Durable Medical Equipment,Per Unit,"$1,490.70 ",OP,"1,490.70","5,128.07",,,,,,
Aetna MCR ADV,CPT,L6708,Term dev mech hand vol open,Durable Medical Equipment,Per Unit,$985.41 ,OP,985.41,"3,389.47",,,,,,
Aetna MCR ADV,CPT,L6709,Term dev mech hand vol close,Durable Medical Equipment,Per Unit,"$1,398.55 ",OP,"1,398.55","4,811.61",,,,,,
Aetna MCR ADV,CPT,L6711,Ped term dev- hook- vol open,Durable Medical Equipment,Per Unit,$676.19 ,OP,676.19,"2,325.74",,,,,,
Aetna MCR ADV,CPT,L6712,Ped term dev- hook- vol clos,Durable Medical Equipment,Per Unit,"$1,245.05 ",OP,"1,245.05","4,281.66",,,,,,
Aetna MCR ADV,CPT,L6713,Ped term dev- hand- vol open,Durable Medical Equipment,Per Unit,"$1,571.33 ",OP,"1,571.33","5,402.59",,,,,,
Aetna MCR ADV,CPT,L6714,Ped term dev- hand- vol clos,Durable Medical Equipment,Per Unit,"$1,330.91 ",OP,"1,330.91","4,579.05",,,,,,
Aetna MCR ADV,CPT,L6715,Term device- multi art digit,Durable Medical Equipment,Per Unit,"$3,175.42 ",OP,"3,175.42","3,175.42",,,,,,
Aetna MCR ADV,CPT,L6721,Hook/hand- hvy dty- vol open,Durable Medical Equipment,Per Unit,"$2,365.59 ",OP,"2,365.59","8,136.28",,,,,,
Aetna MCR ADV,CPT,L6722,Hook/hand- hvy dty- vol clos,Durable Medical Equipment,Per Unit,"$2,039.28 ",OP,"2,039.28","7,011.54",,,,,,
Aetna MCR ADV,CPT,L6805,Term dev modifier wrist unit,Durable Medical Equipment,Per Unit,$385.75 ,OP,385.75,"1,326.82",,,,,,
Aetna MCR ADV,CPT,L6810,Term dev precision pinch dev,Durable Medical Equipment,Per Unit,$205.07 ,OP,205.07,705.35,,,,,,
Aetna MCR ADV,CPT,L6880,Elec hand ind art digits,Durable Medical Equipment,Per Unit,"$24,030.68 ",OP,"24,030.68","24,030.68",,,,,,
Aetna MCR ADV,CPT,L6881,Term dev auto grasp feature,Durable Medical Equipment,Per Unit,"$4,111.91 ",OP,"4,111.91","14,141.27",,,,,,
Aetna MCR ADV,CPT,L6882,Microprocessor control uplmb,Durable Medical Equipment,Per Unit,"$3,119.08 ",OP,"3,119.08","10,725.10",,,,,,
Aetna MCR ADV,CPT,L6883,Replc sockt below e/w disa,Durable Medical Equipment,Per Unit,"$1,997.96 ",OP,"1,997.96","6,870.47",,,,,,
Aetna MCR ADV,CPT,L6884,Replc sockt above elbow disa,Durable Medical Equipment,Per Unit,"$2,733.67 ",OP,"2,733.67","9,402.10",,,,,,
Aetna MCR ADV,CPT,L6885,Replc sockt shldr dis/interc,Durable Medical Equipment,Per Unit,"$4,246.80 ",OP,"4,246.80","14,606.43",,,,,,
Aetna MCR ADV,CPT,L6890,Prefab glove for term device,Durable Medical Equipment,Per Unit,$200.88 ,OP,200.88,690.1,,,,,,
Aetna MCR ADV,CPT,L6895,Custom glove for term device,Durable Medical Equipment,Per Unit,$671.68 ,OP,671.68,"2,310.49",,,,,,
Aetna MCR ADV,CPT,L6900,Hand restorat thumb/1 finger,Durable Medical Equipment,Per Unit,"$1,950.52 ",OP,"1,950.52","6,706.52",,,,,,
Aetna MCR ADV,CPT,L6905,Hand restoration multiple fi,Durable Medical Equipment,Per Unit,"$1,930.47 ",OP,"1,930.47","6,637.91",,,,,,
Aetna MCR ADV,CPT,L6910,Hand restoration no fingers,Durable Medical Equipment,Per Unit,"$1,897.78 ",OP,"1,897.78","6,527.33",,,,,,
Aetna MCR ADV,CPT,L6915,Hand restoration replacmnt g,Durable Medical Equipment,Per Unit,$815.40 ,OP,815.4,"2,806.14",,,,,,
Aetna MCR ADV,CPT,L6920,Wrist disarticul switch ctrl,Durable Medical Equipment,Per Unit,"$8,425.39 ",OP,"8,425.39","28,976.47",,,,,,
Aetna MCR ADV,CPT,L6925,Wrist disart myoelectronic c,Durable Medical Equipment,Per Unit,"$9,001.12 ",OP,"9,001.12","30,955.25",,,,,,
Aetna MCR ADV,CPT,L6930,Below elbow switch control,Durable Medical Equipment,Per Unit,"$8,114.82 ",OP,"8,114.82","27,908.91",,,,,,
Aetna MCR ADV,CPT,L6935,Below elbow myoelectronic ct,Durable Medical Equipment,Per Unit,"$8,958.82 ",OP,"8,958.82","30,810.37",,,,,,
Aetna MCR ADV,CPT,L6940,Elbow disarticulation switch,Durable Medical Equipment,Per Unit,"$10,478.90 ",OP,"10,478.90","36,037.57",,,,,,
Aetna MCR ADV,CPT,L6945,Elbow disart myoelectronic c,Durable Medical Equipment,Per Unit,"$11,690.57 ",OP,"11,690.57","40,204.84",,,,,,
Aetna MCR ADV,CPT,L6950,Above elbow switch control,Durable Medical Equipment,Per Unit,"$10,459.47 ",OP,"10,459.47","35,972.77",,,,,,
Aetna MCR ADV,CPT,L6955,Above elbow myoelectronic ct,Durable Medical Equipment,Per Unit,"$12,129.70 ",OP,"12,129.70","41,714.68",,,,,,
Aetna MCR ADV,CPT,L6960,Shldr disartic switch contro,Durable Medical Equipment,Per Unit,"$12,759.97 ",OP,"12,759.97","43,884.09",,,,,,
Aetna MCR ADV,CPT,L6965,Shldr disartic myoelectronic,Durable Medical Equipment,Per Unit,"$15,116.16 ",OP,"15,116.16","51,986.07",,,,,,
Aetna MCR ADV,CPT,L6970,Interscapular-thor switch ct,Durable Medical Equipment,Per Unit,"$16,180.17 ",OP,"16,180.17","55,646.26",,,,,,
Aetna MCR ADV,CPT,L6975,Interscap-thor myoelectronic,Durable Medical Equipment,Per Unit,"$17,834.37 ",OP,"17,834.37","61,334.79",,,,,,
Aetna MCR ADV,CPT,L7007,Adult electric hand,Durable Medical Equipment,Per Unit,"$3,673.63 ",OP,"3,673.63","12,635.27",,,,,,
Aetna MCR ADV,CPT,L7008,Pediatric electric hand,Durable Medical Equipment,Per Unit,"$5,696.71 ",OP,"5,696.71","19,593.43",,,,,,
Aetna MCR ADV,CPT,L7009,Adult electric hook,Durable Medical Equipment,Per Unit,"$3,758.57 ",OP,"3,758.57","12,925.03",,,,,,
Aetna MCR ADV,CPT,L7040,Prehensile actuator,Durable Medical Equipment,Per Unit,"$3,059.23 ",OP,"3,059.23","10,519.22",,,,,,
Aetna MCR ADV,CPT,L7045,Pediatric electric hook,Durable Medical Equipment,Per Unit,"$1,616.29 ",OP,"1,616.29","5,558.92",,,,,,
Aetna MCR ADV,CPT,L7170,Electronic elbow hosmer swit,Durable Medical Equipment,Per Unit,"$6,050.00 ",OP,"6,050.00","20,805.87",,,,,,
Aetna MCR ADV,CPT,L7180,Electronic elbow sequential,Durable Medical Equipment,Per Unit,"$39,141.46 ",OP,"39,141.46","134,610.92",,,,,,
Aetna MCR ADV,CPT,L7181,Electronic elbo simultaneous,Durable Medical Equipment,Per Unit,"$40,299.84 ",OP,"40,299.84","138,595.19",,,,,,
Aetna MCR ADV,CPT,L7185,Electron elbow adolescent sw,Durable Medical Equipment,Per Unit,"$6,360.51 ",OP,"6,360.51","21,873.42",,,,,,
Aetna MCR ADV,CPT,L7186,Electron elbow child switch,Durable Medical Equipment,Per Unit,"$10,692.92 ",OP,"10,692.92","36,773.42",,,,,,
Aetna MCR ADV,CPT,L7190,Elbow adolescent myoelectron,Durable Medical Equipment,Per Unit,"$8,439.80 ",OP,"8,439.80","29,026.03",,,,,,
Aetna MCR ADV,CPT,L7191,Elbow child myoelectronic ct,Durable Medical Equipment,Per Unit,"$11,247.26 ",OP,"11,247.26","38,679.77",,,,,,
Aetna MCR ADV,CPT,L7259,Electronic wrist rotator any,Durable Medical Equipment,Per Unit,"$4,121.94 ",OP,"4,121.94","4,121.94",,,,,,
Aetna MCR ADV,CPT,L7360,Six volt bat otto bock/eq ea,Durable Medical Equipment,Per Unit,$266.08 ,OP,266.08,915.04,,,,,,
Aetna MCR ADV,CPT,L7362,Battery chrgr six volt otto,Durable Medical Equipment,Per Unit,$290.68 ,OP,290.68,998.92,,,,,,
Aetna MCR ADV,CPT,L7364,Twelve volt battery utah/equ,Durable Medical Equipment,Per Unit,$514.33 ,OP,514.33,"1,769.09",,,,,,
Aetna MCR ADV,CPT,L7366,Battery chrgr 12 volt utah/e,Durable Medical Equipment,Per Unit,$707.34 ,OP,707.34,"2,432.50",,,,,,
Aetna MCR ADV,CPT,L7367,Replacemnt lithium ionbatter,Durable Medical Equipment,Per Unit,$391.59 ,OP,391.59,"1,345.89",,,,,,
Aetna MCR ADV,CPT,L7368,Lithium ion battery charger,Durable Medical Equipment,Per Unit,$507.61 ,OP,507.61,"1,746.22",,,,,,
Aetna MCR ADV,CPT,L7400,Add ue prost be/wd- ultlite,Durable Medical Equipment,Per Unit,$308.25 ,OP,308.25,"1,059.93",,,,,,
Aetna MCR ADV,CPT,L7401,Add ue prost a/e ultlite mat,Durable Medical Equipment,Per Unit,$345.06 ,OP,345.06,"1,185.76",,,,,,
Aetna MCR ADV,CPT,L7402,Add ue prost s/d ultlite mat,Durable Medical Equipment,Per Unit,$372.68 ,OP,372.68,"1,281.07",,,,,,
Aetna MCR ADV,CPT,L7403,Add ue prost b/e acrylic,Durable Medical Equipment,Per Unit,$370.41 ,OP,370.41,"1,273.44",,,,,,
Aetna MCR ADV,CPT,L7404,Add ue prost a/e acrylic,Durable Medical Equipment,Per Unit,$559.06 ,OP,559.06,"1,921.59",,,,,,
Aetna MCR ADV,CPT,L7405,Add ue prost s/d acrylic,Durable Medical Equipment,Per Unit,$731.10 ,OP,731.1,"2,512.57",,,,,,
Aetna MCR ADV,CPT,L7700,Pros soc insert gasket/seal,Durable Medical Equipment,Per Unit,$150.48 ,OP,150.48,150.48,,,,,,
Aetna MCR ADV,CPT,L8000,Mastectomy bra,Durable Medical Equipment,Per Unit,$42.59 ,OP,42.59,144.88,,,,,,
Aetna MCR ADV,CPT,L8001,Breast prosthesis bra & form,Durable Medical Equipment,Per Unit,$126.18 ,OP,126.18,434.65,,,,,,
Aetna MCR ADV,CPT,L8002,Brst prsth bra & bilat form,Durable Medical Equipment,Per Unit,$165.94 ,OP,165.94,571.91,,,,,,
Aetna MCR ADV,CPT,L8015,Ext breastprosthesis garment,Durable Medical Equipment,Per Unit,$60.29 ,OP,60.29,205.88,,,,,,
Aetna MCR ADV,CPT,L8020,Mastectomy form,Durable Medical Equipment,Per Unit,$227.40 ,OP,227.4,781.61,,,,,,
Aetna MCR ADV,CPT,L8030,Breast prosthes w/o adhesive,Durable Medical Equipment,Per Unit,$351.55 ,OP,351.55,"1,208.62",,,,,,
Aetna MCR ADV,CPT,L8031,Breast prosthesis w adhesive,Durable Medical Equipment,Per Unit,$351.55 ,OP,351.55,351.55,,,,,,
Aetna MCR ADV,CPT,L8032,Reusable nipple prosthesis,Durable Medical Equipment,Per Unit,$39.39 ,OP,39.39,39.39,,,,,,
Aetna MCR ADV,CPT,L8035,Custom breast prosthesis,Durable Medical Equipment,Per Unit,"$3,684.79 ",OP,"3,684.79","12,673.39",,,,,,
Aetna MCR ADV,CPT,L8040,Nasal prosthesis,Durable Medical Equipment,Per Unit,"$2,493.50 ",OP,"2,493.50","8,574.74",,,,,,
Aetna MCR ADV,CPT,L8041,Midfacial prosthesis,Durable Medical Equipment,Per Unit,"$3,005.20 ",OP,"3,005.20","10,336.21",,,,,,
Aetna MCR ADV,CPT,L8042,Orbital prosthesis,Durable Medical Equipment,Per Unit,"$3,376.62 ",OP,"3,376.62","11,613.47",,,,,,
Aetna MCR ADV,CPT,L8043,Upper facial prosthesis,Durable Medical Equipment,Per Unit,"$3,781.84 ",OP,"3,781.84","13,005.10",,,,,,
Aetna MCR ADV,CPT,L8044,Hemi-facial prosthesis,Durable Medical Equipment,Per Unit,"$4,187.02 ",OP,"4,187.02","14,400.54",,,,,,
Aetna MCR ADV,CPT,L8045,Auricular prosthesis,Durable Medical Equipment,Per Unit,"$3,278.72 ",OP,"3,278.72","11,274.13",,,,,,
Aetna MCR ADV,CPT,L8046,Partial facial prosthesis,Durable Medical Equipment,Per Unit,"$2,701.33 ",OP,"2,701.33","9,291.53",,,,,,
Aetna MCR ADV,CPT,L8047,Nasal septal prosthesis,Durable Medical Equipment,Per Unit,"$1,384.42 ",OP,"1,384.42","4,762.05",,,,,,
Aetna MCR ADV,CPT,L8300,Truss single w/ standard pad,Durable Medical Equipment,Per Unit,$84.35 ,OP,84.35,289.76,,,,,,
Aetna MCR ADV,CPT,L8310,Truss double w/ standard pad,Durable Medical Equipment,Per Unit,$149.44 ,OP,149.44,514.72,,,,,,
Aetna MCR ADV,CPT,L8320,Truss addition to std pad wa,Durable Medical Equipment,Per Unit,$62.00 ,OP,62,213.51,,,,,,
Aetna MCR ADV,CPT,L8330,Truss add to std pad scrotal,Durable Medical Equipment,Per Unit,$49.37 ,OP,49.37,171.58,,,,,,
Aetna MCR ADV,CPT,L8400,Sheath below knee,Durable Medical Equipment,Per Unit,$15.74 ,OP,15.74,53.38,,,,,,
Aetna MCR ADV,CPT,L8410,Sheath above knee,Durable Medical Equipment,Per Unit,$20.72 ,OP,20.72,72.44,,,,,,
Aetna MCR ADV,CPT,L8415,Sheath upper limb,Durable Medical Equipment,Per Unit,$21.44 ,OP,21.44,72.44,,,,,,
Aetna MCR ADV,CPT,L8417,Pros sheath/sock w gel cushn,Durable Medical Equipment,Per Unit,$75.64 ,OP,75.64,259.27,,,,,,
Aetna MCR ADV,CPT,L8420,Prosthetic sock multi ply bk,Durable Medical Equipment,Per Unit,$20.98 ,OP,20.98,72.44,,,,,,
Aetna MCR ADV,CPT,L8430,Prosthetic sock multi ply ak,Durable Medical Equipment,Per Unit,$23.76 ,OP,23.76,80.07,,,,,,
Aetna MCR ADV,CPT,L8435,Pros sock multi ply upper lm,Durable Medical Equipment,Per Unit,$22.58 ,OP,22.58,76.26,,,,,,
Aetna MCR ADV,CPT,L8440,Shrinker below knee,Durable Medical Equipment,Per Unit,$46.88 ,OP,46.88,160.13,,,,,,
Aetna MCR ADV,CPT,L8460,Shrinker above knee,Durable Medical Equipment,Per Unit,$66.65 ,OP,66.65,228.77,,,,,,
Aetna MCR ADV,CPT,L8465,Shrinker upper limb,Durable Medical Equipment,Per Unit,$61.60 ,OP,61.6,213.51,,,,,,
Aetna MCR ADV,CPT,L8470,Pros sock single ply bk,Durable Medical Equipment,Per Unit,$6.67 ,OP,6.67,22.88,,,,,,
Aetna MCR ADV,CPT,L8480,Pros sock single ply ak,Durable Medical Equipment,Per Unit,$9.20 ,OP,9.2,30.51,,,,,,
Aetna MCR ADV,CPT,L8485,Pros sock single ply upper l,Durable Medical Equipment,Per Unit,$12.39 ,OP,12.39,41.94,,,,,,
Aetna MCR ADV,CPT,L8500,Artificial larynx,Durable Medical Equipment,Per Unit,$661.87 ,OP,661.87,"2,276.18",,,,,,
Aetna MCR ADV,CPT,L8501,Tracheostomy speaking valve,Durable Medical Equipment,Per Unit,$120.80 ,OP,120.8,415.59,,,,,,
Aetna MCR ADV,CPT,L8507,Trach-esoph voice pros pt in,Durable Medical Equipment,Per Unit,$42.11 ,OP,42.11,144.88,,,,,,
Aetna MCR ADV,CPT,L8509,Trach-esoph voice pros md in,Durable Medical Equipment,Per Unit,$109.85 ,OP,109.85,377.46,,,,,,
Aetna MCR ADV,CPT,L8510,Voice amplifier,Durable Medical Equipment,Per Unit,$254.17 ,OP,254.17,873.11,,,,,,
Aetna MCR ADV,CPT,L8511,Indwelling trach insert,Durable Medical Equipment,Per Unit,$73.14 ,OP,73.14,251.64,,,,,,
Aetna MCR ADV,CPT,L8512,Gel cap for trach voice pros,Durable Medical Equipment,Per Unit,$2.19 ,OP,2.19,7.62,,,,,,
Aetna MCR ADV,CPT,L8513,Trach pros cleaning device,Durable Medical Equipment,Per Unit,$5.22 ,OP,5.22,19.07,,,,,,
Aetna MCR ADV,CPT,L8514,Repl trach puncture dilator,Durable Medical Equipment,Per Unit,$94.85 ,OP,94.85,327.9,,,,,,
Aetna MCR ADV,CPT,L8515,Gel cap app device for trach,Durable Medical Equipment,Per Unit,$63.49 ,OP,63.49,217.32,,,,,,
Aetna MCR ADV,CPT,L8615,Coch implant headset replace,Durable Medical Equipment,Per Unit,$453.62 ,OP,453.62,"1,559.39",,,,,,
Aetna MCR ADV,CPT,L8616,Coch implant microphone repl,Durable Medical Equipment,Per Unit,$105.64 ,OP,105.64,362.21,,,,,,
Aetna MCR ADV,CPT,L8617,Coch implant trans coil repl,Durable Medical Equipment,Per Unit,$92.27 ,OP,92.27,92.27,,,,,,
Aetna MCR ADV,CPT,L8618,Coch implant tran cable repl,Durable Medical Equipment,Per Unit,$26.38 ,OP,26.38,91.51,,,,,,
Aetna MCR ADV,CPT,L8619,Coch imp ext proc/contr rplc,Durable Medical Equipment,Per Unit,"$8,454.02 ",OP,"8,454.02","29,075.59",,,,,,
Aetna MCR ADV,CPT,L8621,Repl zinc air battery,Durable Medical Equipment,Per Unit,$0.62 ,OP,0.62,3.82,,,,,,
Aetna MCR ADV,CPT,L8622,Repl alkaline battery,Durable Medical Equipment,Per Unit,$0.32 ,OP,0.32,1.9,,,,,,
Aetna MCR ADV,CPT,L8623,Lith ion batt cid-non-earlvl,Durable Medical Equipment,Per Unit,$65.06 ,OP,65.06,65.06,,,,,,
Aetna MCR ADV,CPT,L8624,Lith ion batt cid- ear level,Durable Medical Equipment,Per Unit,$162.20 ,OP,162.2,556.65,,,,,,
Aetna MCR ADV,CPT,L8625,Charger coch impl/aoi battry,Durable Medical Equipment,Per Unit,$189.97 ,OP,189.97,189.97,,,,,,
Aetna MCR ADV,CPT,L8627,Cid ext speech process repl,Durable Medical Equipment,Per Unit,"$7,175.59 ",OP,"7,175.59","7,175.59",,,,,,
Aetna MCR ADV,CPT,L8628,Cid ext controller repl,Durable Medical Equipment,Per Unit,"$1,278.42 ",OP,"1,278.42","1,278.42",,,,,,
Aetna MCR ADV,CPT,L8629,Cid transmit coil and cable,Durable Medical Equipment,Per Unit,$180.09 ,OP,180.09,180.09,,,,,,
Aetna MCR ADV,CPT,L8681,Pt prgrm for implt neurostim,Durable Medical Equipment,Per Unit,"$1,147.11 ",OP,"1,147.11","3,946.14",,,,,,
Aetna MCR ADV,CPT,L8683,Radiofq trsmtr for implt neu,Durable Medical Equipment,Per Unit,"$5,420.03 ",OP,"5,420.03","18,640.24",,,,,,
Aetna MCR ADV,CPT,L8684,Radiof trsmtr implt scrl neu,Durable Medical Equipment,Per Unit,$850.48 ,OP,850.48,"2,924.33",,,,,,
Aetna MCR ADV,CPT,L8689,External recharg sys intern,Durable Medical Equipment,Per Unit,"$1,734.92 ",OP,"1,734.92","5,966.87",,,,,,
Aetna MCR ADV,CPT,L8691,Aoi snd proc repl excl actua,Durable Medical Equipment,Per Unit,"$1,732.10 ",OP,"1,732.10","9,222.90",,,,,,
Aetna MCR ADV,CPT,L8693,Aud osseo dev- abutment,Durable Medical Equipment,Per Unit,"$1,525.09 ",OP,"1,525.09","1,525.09",,,,,,
Aetna MCR ADV,CPT,L8694,Aoi transducer/actuator repl,Durable Medical Equipment,Per Unit,$949.85 ,OP,949.85,949.85,,,,,,
Aetna MCR ADV,CPT,L8695,External recharg sys extern,Durable Medical Equipment,Per Unit,$16.77 ,OP,16.77,57.19,,,,,,
Aetna MCR ADV,CPT,L8696,Ext antenna phren nerve stim,Durable Medical Equipment,Per Unit,$217.98 ,OP,217.98,217.98,,,,,,
Aetna MCR ADV,CPT,M0201,Covid-19 vaccine home admin,APC 1494,RVU Per Unit,$36.33 ,OP,36.33,36.33,,,,,,
Aetna MCR ADV,CPT,M0240,Casiri and imdev repeat,APC 1506,RVU Per Unit,$461.00 ,OP,430.44,461,,,,,,
Aetna MCR ADV,CPT,M0241,Casiri and imdev repeat hm,APC 1509,RVU Per Unit,$768.00 ,OP,768,768,,,,,,
Aetna MCR ADV,CPT,M0243,Casirivi and imdevi inj,APC 1506,RVU Per Unit,$461.00 ,OP,461,461,,,,,,
Aetna MCR ADV,CPT,M0244,Casirivi and imdevi inj hm,APC 1509,RVU Per Unit,$768.00 ,OP,717.08,768,,,,,,
Aetna MCR ADV,CPT,M0245,Bamlan and etesev infusion,APC 1506,RVU Per Unit,$461.00 ,OP,430.44,461,,,,,,
Aetna MCR ADV,CPT,M0246,Bamlan and etesev infus home,APC 1509,RVU Per Unit,$768.00 ,OP,717.08,768,,,,,,
Aetna MCR ADV,CPT,M0247,Sotrovimab infusion,APC 1506,RVU Per Unit,$461.00 ,OP,430.44,461,,,,,,
Aetna MCR ADV,CPT,M0248,Sotrovimab inf- home admin,APC 1509,RVU Per Unit,$768.00 ,OP,717.08,768,,,,,,
Aetna MCR ADV,CPT,M0249,Adm tocilizu covid-19 1st,APC 1506,RVU Per Unit,$461.00 ,OP,430.44,461,,,,,,
Aetna MCR ADV,CPT,M0250,Adm tocilizu covid-19 2nd,APC 1506,RVU Per Unit,$461.00 ,OP,430.44,461,,,,,,
Aetna MCR ADV,CPT,P2028,Cephalin floculation test,Lab Services,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,
Aetna MCR ADV,CPT,P2029,Congo red blood test,Lab Services,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,
Aetna MCR ADV,CPT,P2033,Blood thymol turbidity,Lab Services,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,
Aetna MCR ADV,CPT,P2038,Blood mucoprotein,Lab Services,Per Unit,$4.95 ,OP,4.95,22.88,,,,,,
Aetna MCR ADV,CPT,P3000,Screen pap by tech w md supv,Lab Services,Per Unit,$15.15 ,OP,15.15,45.74,,,,,,
Aetna MCR ADV,CPT,P9010,Whole blood for transfusion,APC 9510,Per Unit,$172.22 ,OP,172.22,172.22,,,,,,
Aetna MCR ADV,CPT,P9011,Blood split unit,APC 9520,Per Unit,$169.28 ,OP,169.28,169.28,,,,,,
Aetna MCR ADV,CPT,P9012,Cryoprecipitate each unit,APC 9511,Per Unit,$91.59 ,OP,91.59,91.59,,,,,,
Aetna MCR ADV,CPT,P9016,Rbc leukocytes reduced,APC 9512,Per Unit,$216.23 ,OP,216.23,216.23,,,,,,
Aetna MCR ADV,CPT,P9017,Plasma 1 donor frz w/in 8 hr,APC 9508,Per Unit,$94.81 ,OP,94.81,94.81,,,,,,
Aetna MCR ADV,CPT,P9019,Platelets- each unit,APC 9515,Per Unit,$81.77 ,OP,81.77,81.77,,,,,,
Aetna MCR ADV,CPT,P9020,Plaelet rich plasma unit,APC 9516,Per Unit,$229.41 ,OP,229.41,229.41,,,,,,
Aetna MCR ADV,CPT,P9021,Red blood cells unit,APC 9517,Per Unit,$157.87 ,OP,157.87,157.87,,,,,,
Aetna MCR ADV,CPT,P9022,Washed red blood cells unit,APC 9518,Per Unit,$435.72 ,OP,435.72,435.72,,,,,,
Aetna MCR ADV,CPT,P9023,Frozen plasma- pooled- sd,APC 9509,Per Unit,$102.26 ,OP,102.26,102.26,,,,,,
Aetna MCR ADV,CPT,P9025,Plasma cryo redu path each,APC 9538,Per Unit,$75.36 ,OP,75.36,75.36,,,,,,
Aetna MCR ADV,CPT,P9026,Cryo fib comp path redu each,APC 9539,Per Unit,$91.59 ,OP,91.59,91.59,,,,,,
Aetna MCR ADV,CPT,P9031,Platelets leukocytes reduced,APC 9526,Per Unit,$171.96 ,OP,171.96,171.96,,,,,,
Aetna MCR ADV,CPT,P9032,Platelets- irradiated,APC 9500,Per Unit,$162.52 ,OP,162.52,162.52,,,,,,
Aetna MCR ADV,CPT,P9033,Platelets leukoreduced irrad,APC 9521,Per Unit,$244.54 ,OP,244.54,244.54,,,,,,
Aetna MCR ADV,CPT,P9034,Platelets- pheresis,APC 9507,Per Unit,$371.63 ,OP,371.63,371.63,,,,,,
Aetna MCR ADV,CPT,P9035,Platelet pheres leukoreduced,APC 9501,Per Unit,$558.38 ,OP,558.38,558.38,,,,,,
Aetna MCR ADV,CPT,P9036,Platelet pheresis irradiated,APC 9502,Per Unit,$693.83 ,OP,693.83,693.83,,,,,,
Aetna MCR ADV,CPT,P9037,Plate pheres leukoredu irrad,APC 9530,Per Unit,$708.10 ,OP,708.1,708.1,,,,,,
Aetna MCR ADV,CPT,P9038,Rbc irradiated,APC 9505,Per Unit,$194.21 ,OP,194.21,194.21,,,,,,
Aetna MCR ADV,CPT,P9039,Rbc deglycerolized,APC 9504,Per Unit,$500.86 ,OP,500.86,500.86,,,,,,
Aetna MCR ADV,CPT,P9040,Rbc leukoreduced irradiated,APC 9522,Per Unit,$298.86 ,OP,298.86,298.86,,,,,,
Aetna MCR ADV,CPT,P9041,Albumin (human)-5%- 50ml,APC 0961,Per Unit,$10.49 ,OP,10.49,10.49,,,,,,
Aetna MCR ADV,CPT,P9043,Plasma protein fract-5%-50ml,APC 9514,Per Unit,$9.16 ,OP,9.16,106.76,,,,,,
Aetna MCR ADV,CPT,P9044,Cryoprecipitatereducedplasma,APC 9523,Per Unit,$75.36 ,OP,75.36,75.36,,,,,,
Aetna MCR ADV,CPT,P9045,Albumin (human)- 5%- 250 ml,APC 0963,Per Unit,$52.45 ,OP,52.45,274.51,,,,,,
Aetna MCR ADV,CPT,P9046,Albumin (human)- 25%- 20 ml,APC 0964,Per Unit,$20.98 ,OP,20.98,129.64,,,,,,
Aetna MCR ADV,CPT,P9047,Albumin (human)- 25%- 50ml,APC 0965,Per Unit,$52.45 ,OP,52.45,255.45,,,,,,
Aetna MCR ADV,CPT,P9048,Plasmaprotein fract-5%-250ml,APC 9519,Per Unit,$183.92 ,OP,183.92,198.25,,,,,,
Aetna MCR ADV,CPT,P9051,Blood- l/r- cmv-neg,APC 9524,Per Unit,$243.44 ,OP,243.44,243.44,,,,,,
Aetna MCR ADV,CPT,P9052,Platelets- hla-m- l/r- unit,APC 9525,Per Unit,$923.57 ,OP,923.57,923.57,,,,,,
Aetna MCR ADV,CPT,P9053,Plt- pher- l/r cmv-neg- irr,APC 9531,Per Unit,$513.08 ,OP,513.08,513.08,,,,,,
Aetna MCR ADV,CPT,P9054,Blood- l/r- froz/degly/wash,APC 9527,Per Unit,$356.39 ,OP,356.39,356.39,,,,,,
Aetna MCR ADV,CPT,P9055,Plt- aph/pher- l/r- cmv-neg,APC 9528,Per Unit,$550.63 ,OP,550.63,550.63,,,,,,
Aetna MCR ADV,CPT,P9056,Blood- l/r- irradiated,APC 9529,Per Unit,$176.83 ,OP,176.83,176.83,,,,,,
Aetna MCR ADV,CPT,P9057,Rbc- frz/deg/wsh- l/r- irrad,APC 9532,Per Unit,$298.91 ,OP,298.91,298.91,,,,,,
Aetna MCR ADV,CPT,P9058,Rbc- l/r- cmv-neg- irrad,APC 9533,Per Unit,$279.73 ,OP,279.73,279.73,,,,,,
Aetna MCR ADV,CPT,P9059,Plasma- frz between 8-24hour,APC 9513,Per Unit,$81.61 ,OP,81.61,81.61,,,,,,
Aetna MCR ADV,CPT,P9060,Fr frz plasma donor retested,APC 9503,Per Unit,$74.65 ,OP,74.65,74.65,,,,,,
Aetna MCR ADV,CPT,P9070,Pathogen reduced plasma pool,APC 9534,Per Unit,$60.91 ,OP,60.91,60.91,,,,,,
Aetna MCR ADV,CPT,P9071,Pathogen reduced plasma sing,APC 9535,Per Unit,$140.88 ,OP,140.88,140.88,,,,,,
Aetna MCR ADV,CPT,P9073,Platelets pheresis path redu,APC 9536,Per Unit,$669.72 ,OP,669.72,669.72,,,,,,
Aetna MCR ADV,CPT,P9099,Blood component/product noc,APC 9537,Per Unit,$9.16 ,OP,9.16,9.16,,,,,,
Aetna MCR ADV,CPT,P9100,Pathogen test for platelets,APC 5732,RVU Per Unit,$34.63 ,OP,34.63,34.63,,,,,,
Aetna MCR ADV,CPT,P9612,Catheterize for urine spec,Lab Services,Per Unit,$3.00 ,OP,3,3,,,,,,
Aetna MCR ADV,CPT,Q0035,Cardiokymography,APC 5732,RVU Per Case,$34.63 ,OP,34.63,106.76,,,,,,
Aetna MCR ADV,CPT,Q0091,Obtaining screen pap smear,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,205.88,,,,,,
Aetna MCR ADV,CPT,Q0111,Wet mounts/ w preparations,Lab Services,Per Unit,$15.15 ,OP,15.15,15.15,,,,,,
Aetna MCR ADV,CPT,Q0112,Potassium hydroxide preps,Lab Services,Per Unit,$5.83 ,OP,5.83,22.88,,,,,,
Aetna MCR ADV,CPT,Q0113,Pinworm examinations,Lab Services,Per Unit,$4.27 ,OP,4.27,26.7,,,,,,
Aetna MCR ADV,CPT,Q0114,Fern test,Lab Services,Per Unit,$9.74 ,OP,9.74,34.31,,,,,,
Aetna MCR ADV,CPT,Q0115,Post-coital mucous exam,Lab Services,Per Unit,$25.00 ,OP,25,49.56,,,,,,
Aetna MCR ADV,CPT,Q0138,Ferumoxytol- non-esrd,APC 1297,Per Unit,$1.00 ,OP,1,1,,,,,,
Aetna MCR ADV,CPT,Q0139,Ferumoxytol- esrd use,APC 1485,Per Unit,$1.00 ,OP,1,1,,,,,,
Aetna MCR ADV,CPT,Q0240,Casirivi and imdevi 600 mg,Other,Straight Discount,29.70%,OP,,,,,,,,
Aetna MCR ADV,CPT,Q0243,Casirivimab and imdevimab,Other,Straight Discount,29.70%,OP,,,,,,,,
Aetna MCR ADV,CPT,Q0244,Casirivi and imdevi 1200 mg,Other,Straight Discount,29.70%,OP,,,,,,,,
Aetna MCR ADV,CPT,Q0245,Bamlanivimab and etesevima,Other,Straight Discount,29.70%,OP,,,,,,,,
Aetna MCR ADV,CPT,Q0247,Sotrovimab,Other,Straight Discount,29.70%,OP,,,,,,,,
Aetna MCR ADV,CPT,Q0249,Tocilizumab for covid-19,Other,Straight Discount,29.70%,OP,,,,,,,,
Aetna MCR ADV,CPT,Q0477,Pwr module pt cable lvad rpl,Durable Medical Equipment,Per Unit,$780.34 ,OP,780.34,780.34,,,,,,
Aetna MCR ADV,CPT,Q0478,Power adapter- combo vad,Durable Medical Equipment,Per Unit,$184.82 ,OP,184.82,184.82,,,,,,
Aetna MCR ADV,CPT,Q0479,Power module combo vad- rep,Durable Medical Equipment,Per Unit,"$12,073.17 ",OP,"12,073.17","12,073.17",,,,,,
Aetna MCR ADV,CPT,Q0480,Driver pneumatic vad- rep,Durable Medical Equipment,Per Unit,"$90,585.51 ",OP,"90,585.51","311,531.29",,,,,,
Aetna MCR ADV,CPT,Q0481,Microprcsr cu elec vad- rep,Durable Medical Equipment,Per Unit,"$14,614.95 ",OP,"14,614.95","50,262.72",,,,,,
Aetna MCR ADV,CPT,Q0482,Microprcsr cu combo vad- rep,Durable Medical Equipment,Per Unit,"$4,577.67 ",OP,"4,577.67","15,742.60",,,,,,
Aetna MCR ADV,CPT,Q0483,Monitor elec vad- rep,Durable Medical Equipment,Per Unit,"$18,857.93 ",OP,"18,857.93","64,853.90",,,,,,
Aetna MCR ADV,CPT,Q0484,Monitor elec or comb vad rep,Durable Medical Equipment,Per Unit,"$3,662.14 ",OP,"3,662.14","12,593.32",,,,,,
Aetna MCR ADV,CPT,Q0485,Monitor cable elec vad- rep,Durable Medical Equipment,Per Unit,$353.60 ,OP,353.6,"1,216.24",,,,,,
Aetna MCR ADV,CPT,Q0486,Mon cable elec/pneum vad rep,Durable Medical Equipment,Per Unit,$294.28 ,OP,294.28,"1,010.37",,,,,,
Aetna MCR ADV,CPT,Q0487,Leads any type vad- rep only,Durable Medical Equipment,Per Unit,$343.31 ,OP,343.31,"1,181.94",,,,,,
Aetna MCR ADV,CPT,Q0489,Pwr pck base combo vad- rep,Durable Medical Equipment,Per Unit,"$16,348.80 ",OP,"16,348.80","56,225.77",,,,,,
Aetna MCR ADV,CPT,Q0490,Emr pwr source elec vad- rep,Durable Medical Equipment,Per Unit,$707.17 ,OP,707.17,"2,432.50",,,,,,
Aetna MCR ADV,CPT,Q0491,Emr pwr source combo vad rep,Durable Medical Equipment,Per Unit,"$1,111.75 ",OP,"1,111.75","3,824.13",,,,,,
Aetna MCR ADV,CPT,Q0492,Emr pwr cbl elec vad- rep,Durable Medical Equipment,Per Unit,$89.58 ,OP,89.58,308.83,,,,,,
Aetna MCR ADV,CPT,Q0493,Emr pwr cbl combo vad- rep,Durable Medical Equipment,Per Unit,$255.02 ,OP,255.02,876.92,,,,,,
Aetna MCR ADV,CPT,Q0494,Emr hd pmp elec/combo- rep,Durable Medical Equipment,Per Unit,$215.79 ,OP,215.79,743.48,,,,,,
Aetna MCR ADV,CPT,Q0495,Charger elec/combo vad- rep,Durable Medical Equipment,Per Unit,"$4,201.23 ",OP,"4,201.23","14,450.10",,,,,,
Aetna MCR ADV,CPT,Q0496,Battery elec/combo vad- rep,Durable Medical Equipment,Per Unit,"$1,507.90 ",OP,"1,507.90","5,185.26",,,,,,
Aetna MCR ADV,CPT,Q0497,Bat clps elec/comb vad- rep,Durable Medical Equipment,Per Unit,$470.84 ,OP,470.84,"1,620.40",,,,,,
Aetna MCR ADV,CPT,Q0498,Holster elec/combo vad- rep,Durable Medical Equipment,Per Unit,$516.61 ,OP,516.61,"1,776.71",,,,,,
Aetna MCR ADV,CPT,Q0499,Belt/vest elec/combo vad rep,Durable Medical Equipment,Per Unit,$167.86 ,OP,167.86,575.73,,,,,,
Aetna MCR ADV,CPT,Q0500,Filters elec/combo vad- rep,Durable Medical Equipment,Per Unit,$30.69 ,OP,30.69,106.76,,,,,,
Aetna MCR ADV,CPT,Q0501,Shwr cov elec/combo vad- rep,Durable Medical Equipment,Per Unit,$513.63 ,OP,513.63,"1,765.27",,,,,,
Aetna MCR ADV,CPT,Q0502,Mobility cart pneum vad- rep,Durable Medical Equipment,Per Unit,$653.97 ,OP,653.97,"2,249.49",,,,,,
Aetna MCR ADV,CPT,Q0503,Battery pneum vad replacemnt,Durable Medical Equipment,Per Unit,"$1,307.87 ",OP,"1,307.87","4,498.98",,,,,,
Aetna MCR ADV,CPT,Q0504,Pwr adpt pneum vad- rep veh,Durable Medical Equipment,Per Unit,$690.16 ,OP,690.16,"2,375.30",,,,,,
Aetna MCR ADV,CPT,Q0506,Lith-ion batt elec/pneum vad,Durable Medical Equipment,Per Unit,$859.04 ,OP,859.04,859.04,,,,,,
Aetna MCR ADV,CPT,Q2017,Teniposide- 50 mg,APC 7035,Per Unit,"$2,645.71 ",OP,"1,582.28","2,645.71",,,,,,
Aetna MCR ADV,CPT,Q2026,Radiesse injection,APC 9094,Per Unit,$257.37 ,OP,257.37,257.37,,,,,,
Aetna MCR ADV,CPT,Q2028,Inj- sculptra- 0.5mg,APC 9095,Per Unit,$2.49 ,OP,2.49,2.49,,,,,,
Aetna MCR ADV,CPT,Q2034,Agriflu vaccine,Other,Straight Discount,29.70%,OP,,,,,,,,
Aetna MCR ADV,CPT,Q2035,Afluria vacc- 3 yrs & >- im,Other,Straight Discount,29.70%,OP,,,,,,,,
Aetna MCR ADV,CPT,Q2036,Flulaval vacc- 3 yrs & >- im,Other,Straight Discount,29.70%,OP,,,,,,,,
Aetna MCR ADV,CPT,Q2037,Fluvirin vacc- 3 yrs & >- im,Other,Straight Discount,29.70%,OP,,,,,,,,
Aetna MCR ADV,CPT,Q2038,Fluzone vacc- 3 yrs & >- im,Other,Straight Discount,29.70%,OP,,,,,,,,
Aetna MCR ADV,CPT,Q2039,Influenza virus vaccine- nos,Other,Straight Discount,29.70%,OP,,,,,,,,
Aetna MCR ADV,CPT,Q2041,Axicabtagene ciloleucel car+,APC 9035,Per Unit,"$395,380.00 ",OP,"395,380.00","395,380.00",,,,,,
Aetna MCR ADV,CPT,Q2042,Tisagenlecleucel car-pos t,APC 9194,Per Unit,"$434,337.60 ",OP,"434,337.60","434,337.60",,,,,,
Aetna MCR ADV,CPT,Q2043,Sipuleucel-t auto cd54+,APC 9273,Per Unit,"$53,017.58 ",OP,"53,017.58","53,017.58",,,,,,
Aetna MCR ADV,CPT,Q2049,Imported lipodox inj,APC 1421,Per Unit,$311.04 ,OP,311.04,311.04,,,,,,
Aetna MCR ADV,CPT,Q2050,Doxorubicin inj 10mg,APC 7046,Per Unit,$234.03 ,OP,234.03,"1,719.01",,,,,,
Aetna MCR ADV,CPT,Q2053,Brexucabtagene car pos t,APC 9391,Per Unit,"$395,380.00 ",OP,"395,380.00","395,380.00",,,,,,
Aetna MCR ADV,CPT,Q2054,Lisocabtagene mara car pos t,APC 9413,Per Unit,"$422,609.00 ",OP,"422,609.00","422,609.00",,,,,,
Aetna MCR ADV,CPT,Q3027,Inj beta interferon im 1 mcg,APC 1472,Per Unit,$55.29 ,OP,55.29,74.17,,,,,,
Aetna MCR ADV,CPT,Q5101,Injection- zarxio,APC 1822,Per Unit,$0.32 ,OP,0.32,0.32,,,,,,
Aetna MCR ADV,CPT,Q5103,Injection- inflectra,APC 1847,Per Unit,$41.19 ,OP,41.19,41.19,,,,,,
Aetna MCR ADV,CPT,Q5104,Injection- renflexis,APC 9036,Per Unit,$38.79 ,OP,38.79,38.79,,,,,,
Aetna MCR ADV,CPT,Q5106,Inj retacrit non-esrd use,APC 9097,Per Unit,$8.66 ,OP,8.66,8.66,,,,,,
Aetna MCR ADV,CPT,Q5107,Inj mvasi 10 mg,APC 9329,Per Unit,$44.56 ,OP,44.56,44.56,,,,,,
Aetna MCR ADV,CPT,Q5108,Injection- fulphila,APC 9173,Per Unit,$211.19 ,OP,211.19,211.19,,,,,,
Aetna MCR ADV,CPT,Q5110,Nivestym,APC 9193,Per Unit,$0.33 ,OP,0.33,0.33,,,,,,
Aetna MCR ADV,CPT,Q5111,Injection- udenyca 0.5 mg,APC 9195,Per Unit,$222.38 ,OP,222.38,222.38,,,,,,
Aetna MCR ADV,CPT,Q5112,Inj ontruzant 10 mg,APC 9382,Per Unit,$66.55 ,OP,66.55,66.55,,,,,,
Aetna MCR ADV,CPT,Q5113,Inj herzuma 10 mg,APC 9349,Per Unit,$57.30 ,OP,57.3,57.3,,,,,,
Aetna MCR ADV,CPT,Q5114,Inj ogivri 10 mg,APC 9341,Per Unit,$59.91 ,OP,59.91,59.91,,,,,,
Aetna MCR ADV,CPT,Q5115,Inj truxima 10 mg,APC 9336,Per Unit,$60.58 ,OP,60.58,60.58,,,,,,
Aetna MCR ADV,CPT,Q5116,Inj.- trazimera- 10 mg,APC 9350,Per Unit,$59.93 ,OP,59.93,59.93,,,,,,
Aetna MCR ADV,CPT,Q5117,Inj.- kanjinti- 10 mg,APC 9330,Per Unit,$53.18 ,OP,53.18,53.18,,,,,,
Aetna MCR ADV,CPT,Q5118,Inj.- zirabev- 10 mg,APC 9348,Per Unit,$52.37 ,OP,52.37,52.37,,,,,,
Aetna MCR ADV,CPT,Q5119,Inj ruxience- 10 mg,APC 9367,Per Unit,$58.80 ,OP,58.8,58.8,,,,,,
Aetna MCR ADV,CPT,Q5120,Inj pegfilgrastim-bmez 0.5mg,APC 9345,Per Unit,$245.43 ,OP,245.43,245.43,,,,,,
Aetna MCR ADV,CPT,Q5121,Inj. avsola- 10 mg,APC 9381,Per Unit,$47.12 ,OP,47.12,47.12,,,,,,
Aetna MCR ADV,CPT,Q5122,Inj- nyvepria,APC 9406,Per Unit,$284.69 ,OP,284.69,284.69,,,,,,
Aetna MCR ADV,CPT,Q5123,Inj. riabni- 10 mg,APC 9411,Per Unit,$72.23 ,OP,72.23,72.23,,,,,,
Aetna MCR ADV,CPT,Q9968,Visualization adjunct,APC 1446,Per Unit,$6.73 ,OP,6.73,6.73,,,,,,
Aetna MCR ADV,CPT,Q9969,Non-heu tc-99m add-on/dose,APC 1442,Per Unit,$10.00 ,OP,10,10,,,,,,
Aetna MCR ADV,CPT,Q9991,Buprenorph xr 100 mg or less,APC 9073,Per Unit,"$1,796.80 ",OP,"1,796.80","1,796.80",,,,,,
Aetna MCR ADV,CPT,Q9992,Buprenorphine xr over 100 mg,APC 9239,Per Unit,"$1,796.80 ",OP,"1,796.80","1,796.80",,,,,,
Aetna MCR ADV,CPT,U0001,2019-ncov diagnostic p,Lab Services,Per Unit,$35.91 ,OP,35.91,35.91,,,,,,
Aetna MCR ADV,CPT,U0002,Covid-19 lab test non-cdc,Lab Services,Per Unit,$51.31 ,OP,51.31,51.31,,,,,,
Aetna MCR ADV,CPT,U0003,Cov-19 amp prb hgh thruput,Lab Services,Per Unit,$75.00 ,OP,75,75,,,,,,
Aetna MCR ADV,CPT,U0004,Cov-19 test non-cdc hgh thru,Lab Services,Per Unit,$75.00 ,OP,75,75,,,,,,
Aetna MCR ADV,CPT,U0005,Infec agen detec ampli probe,Lab Services,Per Unit,$25.00 ,OP,25,25,,,,,,
Aetna MCR ADV,CPT,V2020,Vision svcs frames purchases,Durable Medical Equipment,Per Unit,$75.22 ,OP,75.22,388.89,,,,,,
Aetna MCR ADV,CPT,V2100,Lens spher single plano 4.00,Durable Medical Equipment,Per Unit,$46.49 ,OP,46.49,240.2,,,,,,
Aetna MCR ADV,CPT,V2101,Single visn sphere 4.12-7.00,Durable Medical Equipment,Per Unit,$44.67 ,OP,44.67,228.77,,,,,,
Aetna MCR ADV,CPT,V2102,Singl visn sphere 7.12-20.00,Durable Medical Equipment,Per Unit,$77.24 ,OP,77.24,400.34,,,,,,
Aetna MCR ADV,CPT,V2103,Spherocylindr 4.00d/12-2.00d,Durable Medical Equipment,Per Unit,$39.13 ,OP,39.13,202.07,,,,,,
Aetna MCR ADV,CPT,V2104,Spherocylindr 4.00d/2.12-4d,Durable Medical Equipment,Per Unit,$40.34 ,OP,40.34,209.7,,,,,,
Aetna MCR ADV,CPT,V2105,Spherocylinder 4.00d/4.25-6d,Durable Medical Equipment,Per Unit,$47.98 ,OP,47.98,247.83,,,,,,
Aetna MCR ADV,CPT,V2106,Spherocylinder 4.00d/>6.00d,Durable Medical Equipment,Per Unit,$53.15 ,OP,53.15,274.51,,,,,,
Aetna MCR ADV,CPT,V2107,Spherocylinder 4.25d/12-2d,Durable Medical Equipment,Per Unit,$47.33 ,OP,47.33,244.01,,,,,,
Aetna MCR ADV,CPT,V2108,Spherocylinder 4.25d/2.12-4d,Durable Medical Equipment,Per Unit,$47.46 ,OP,47.46,244.01,,,,,,
Aetna MCR ADV,CPT,V2109,Spherocylinder 4.25d/4.25-6d,Durable Medical Equipment,Per Unit,$66.10 ,OP,66.1,339.33,,,,,,
Aetna MCR ADV,CPT,V2110,Spherocylinder 4.25d/over 6d,Durable Medical Equipment,Per Unit,$53.39 ,OP,53.39,274.51,,,,,,
Aetna MCR ADV,CPT,V2111,Spherocylindr 7.25d/.25-2.25,Durable Medical Equipment,Per Unit,$64.70 ,OP,64.7,335.53,,,,,,
Aetna MCR ADV,CPT,V2112,Spherocylindr 7.25d/2.25-4d,Durable Medical Equipment,Per Unit,$73.09 ,OP,73.09,377.46,,,,,,
Aetna MCR ADV,CPT,V2113,Spherocylindr 7.25d/4.25-6d,Durable Medical Equipment,Per Unit,$73.91 ,OP,73.91,381.27,,,,,,
Aetna MCR ADV,CPT,V2114,Spherocylinder over 12.00d,Durable Medical Equipment,Per Unit,$87.57 ,OP,87.57,453.71,,,,,,
Aetna MCR ADV,CPT,V2115,Lens lenticular bifocal,Durable Medical Equipment,Per Unit,$88.27 ,OP,88.27,453.71,,,,,,
Aetna MCR ADV,CPT,V2118,Lens aniseikonic single,Durable Medical Equipment,Per Unit,$96.05 ,OP,96.05,495.65,,,,,,
Aetna MCR ADV,CPT,V2121,Lenticular lens- single,Durable Medical Equipment,Per Unit,$86.61 ,OP,86.61,446.08,,,,,,
Aetna MCR ADV,CPT,V2200,Lens spher bifoc plano 4.00d,Durable Medical Equipment,Per Unit,$52.35 ,OP,52.35,270.71,,,,,,
Aetna MCR ADV,CPT,V2201,Lens sphere bifocal 4.12-7.0,Durable Medical Equipment,Per Unit,$56.09 ,OP,56.09,289.76,,,,,,
Aetna MCR ADV,CPT,V2202,Lens sphere bifocal 7.12-20.,Durable Medical Equipment,Per Unit,$69.53 ,OP,69.53,358.39,,,,,,
Aetna MCR ADV,CPT,V2203,Lens sphcyl bifocal 4.00d/.1,Durable Medical Equipment,Per Unit,$53.92 ,OP,53.92,278.32,,,,,,
Aetna MCR ADV,CPT,V2204,Lens sphcy bifocal 4.00d/2.1,Durable Medical Equipment,Per Unit,$55.48 ,OP,55.48,285.96,,,,,,
Aetna MCR ADV,CPT,V2205,Lens sphcy bifocal 4.00d/4.2,Durable Medical Equipment,Per Unit,$61.51 ,OP,61.51,316.46,,,,,,
Aetna MCR ADV,CPT,V2206,Lens sphcy bifocal 4.00d/ove,Durable Medical Equipment,Per Unit,$72.21 ,OP,72.21,373.65,,,,,,
Aetna MCR ADV,CPT,V2207,Lens sphcy bifocal 4.25-7d/.,Durable Medical Equipment,Per Unit,$61.03 ,OP,61.03,316.46,,,,,,
Aetna MCR ADV,CPT,V2208,Lens sphcy bifocal 4.25-7/2.,Durable Medical Equipment,Per Unit,$59.97 ,OP,59.97,308.83,,,,,,
Aetna MCR ADV,CPT,V2209,Lens sphcy bifocal 4.25-7/4.,Durable Medical Equipment,Per Unit,$70.40 ,OP,70.4,362.21,,,,,,
Aetna MCR ADV,CPT,V2210,Lens sphcy bifocal 4.25-7/ov,Durable Medical Equipment,Per Unit,$75.86 ,OP,75.86,392.7,,,,,,
Aetna MCR ADV,CPT,V2211,Lens sphcy bifo 7.25-12/.25-,Durable Medical Equipment,Per Unit,$73.85 ,OP,73.85,381.27,,,,,,
Aetna MCR ADV,CPT,V2212,Lens sphcyl bifo 7.25-12/2.2,Durable Medical Equipment,Per Unit,$77.30 ,OP,77.3,400.34,,,,,,
Aetna MCR ADV,CPT,V2213,Lens sphcyl bifo 7.25-12/4.2,Durable Medical Equipment,Per Unit,$81.28 ,OP,81.28,419.4,,,,,,
Aetna MCR ADV,CPT,V2214,Lens sphcyl bifocal over 12.,Durable Medical Equipment,Per Unit,$84.95 ,OP,84.95,438.47,,,,,,
Aetna MCR ADV,CPT,V2215,Lens lenticular bifocal,Durable Medical Equipment,Per Unit,$106.06 ,OP,106.06,549.03,,,,,,
Aetna MCR ADV,CPT,V2218,Lens aniseikonic bifocal,Durable Medical Equipment,Per Unit,$108.09 ,OP,108.09,556.65,,,,,,
Aetna MCR ADV,CPT,V2219,Lens bifocal seg width over,Durable Medical Equipment,Per Unit,$49.86 ,OP,49.86,255.45,,,,,,
Aetna MCR ADV,CPT,V2220,Lens bifocal add over 3.25d,Durable Medical Equipment,Per Unit,$44.28 ,OP,44.28,228.77,,,,,,
Aetna MCR ADV,CPT,V2221,Lenticular lens- bifocal,Durable Medical Equipment,Per Unit,$88.33 ,OP,88.33,457.52,,,,,,
Aetna MCR ADV,CPT,V2300,Lens sphere trifocal 4.00d,Durable Medical Equipment,Per Unit,$71.57 ,OP,71.57,369.83,,,,,,
Aetna MCR ADV,CPT,V2301,Lens sphere trifocal 4.12-7.,Durable Medical Equipment,Per Unit,$87.77 ,OP,87.77,453.71,,,,,,
Aetna MCR ADV,CPT,V2302,Lens sphere trifocal 7.12-20,Durable Medical Equipment,Per Unit,$82.00 ,OP,82,423.22,,,,,,
Aetna MCR ADV,CPT,V2303,Lens sphcy trifocal 4.0/.12-,Durable Medical Equipment,Per Unit,$68.89 ,OP,68.89,354.58,,,,,,
Aetna MCR ADV,CPT,V2304,Lens sphcy trifocal 4.0/2.25,Durable Medical Equipment,Per Unit,$69.70 ,OP,69.7,358.39,,,,,,
Aetna MCR ADV,CPT,V2305,Lens sphcy trifocal 4.0/4.25,Durable Medical Equipment,Per Unit,$77.86 ,OP,77.86,400.34,,,,,,
Aetna MCR ADV,CPT,V2306,Lens sphcyl trifocal 4.00/>6,Durable Medical Equipment,Per Unit,$80.17 ,OP,80.17,411.78,,,,,,
Aetna MCR ADV,CPT,V2307,Lens sphcy trifocal 4.25-7/.,Durable Medical Equipment,Per Unit,$76.33 ,OP,76.33,392.7,,,,,,
Aetna MCR ADV,CPT,V2308,Lens sphc trifocal 4.25-7/2.,Durable Medical Equipment,Per Unit,$83.26 ,OP,83.26,430.83,,,,,,
Aetna MCR ADV,CPT,V2309,Lens sphc trifocal 4.25-7/4.,Durable Medical Equipment,Per Unit,$87.13 ,OP,87.13,449.9,,,,,,
Aetna MCR ADV,CPT,V2310,Lens sphc trifocal 4.25-7/>6,Durable Medical Equipment,Per Unit,$91.01 ,OP,91.01,468.96,,,,,,
Aetna MCR ADV,CPT,V2311,Lens sphc trifo 7.25-12/.25-,Durable Medical Equipment,Per Unit,$105.08 ,OP,105.08,541.4,,,,,,
Aetna MCR ADV,CPT,V2312,Lens sphc trifo 7.25-12/2.25,Durable Medical Equipment,Per Unit,$96.32 ,OP,96.32,495.65,,,,,,
Aetna MCR ADV,CPT,V2313,Lens sphc trifo 7.25-12/4.25,Durable Medical Equipment,Per Unit,$105.15 ,OP,105.15,541.4,,,,,,
Aetna MCR ADV,CPT,V2314,Lens sphcyl trifocal over 12,Durable Medical Equipment,Per Unit,$107.48 ,OP,107.48,552.84,,,,,,
Aetna MCR ADV,CPT,V2315,Lens lenticular trifocal,Durable Medical Equipment,Per Unit,$119.32 ,OP,119.32,613.85,,,,,,
Aetna MCR ADV,CPT,V2318,Lens aniseikonic trifocal,Durable Medical Equipment,Per Unit,$146.68 ,OP,146.68,754.91,,,,,,
Aetna MCR ADV,CPT,V2319,Lens trifocal seg width > 28,Durable Medical Equipment,Per Unit,$66.22 ,OP,66.22,343.14,,,,,,
Aetna MCR ADV,CPT,V2320,Lens trifocal add over 3.25d,Durable Medical Equipment,Per Unit,$69.85 ,OP,69.85,362.21,,,,,,
Aetna MCR ADV,CPT,V2321,Lenticular lens- trifocal,Durable Medical Equipment,Per Unit,$117.61 ,OP,117.61,606.21,,,,,,
Aetna MCR ADV,CPT,V2410,Lens variab asphericity sing,Durable Medical Equipment,Per Unit,$102.83 ,OP,102.83,529.96,,,,,,
Aetna MCR ADV,CPT,V2430,Lens variable asphericity bi,Durable Medical Equipment,Per Unit,$108.84 ,OP,108.84,560.47,,,,,,
Aetna MCR ADV,CPT,V2500,Contact lens pmma spherical,Durable Medical Equipment,Per Unit,$92.01 ,OP,92.01,92.01,,,,,,
Aetna MCR ADV,CPT,V2501,Cntct lens pmma-toric/prism,Durable Medical Equipment,Per Unit,$130.56 ,OP,130.56,674.85,,,,,,
Aetna MCR ADV,CPT,V2502,Contact lens pmma bifocal,Durable Medical Equipment,Per Unit,$176.91 ,OP,176.91,911.23,,,,,,
Aetna MCR ADV,CPT,V2503,Cntct lens pmma color vision,Durable Medical Equipment,Per Unit,$170.87 ,OP,170.87,880.74,,,,,,
Aetna MCR ADV,CPT,V2510,Cntct gas permeable sphericl,Durable Medical Equipment,Per Unit,$122.68 ,OP,122.68,632.91,,,,,,
Aetna MCR ADV,CPT,V2511,Cntct toric prism ballast,Durable Medical Equipment,Per Unit,$181.84 ,OP,181.84,937.93,,,,,,
Aetna MCR ADV,CPT,V2512,Cntct lens gas permbl bifocl,Durable Medical Equipment,Per Unit,$209.31 ,OP,209.31,"1,078.99",,,,,,
Aetna MCR ADV,CPT,V2513,Contact lens extended wear,Durable Medical Equipment,Per Unit,$210.87 ,OP,210.87,"1,086.62",,,,,,
Aetna MCR ADV,CPT,V2520,Contact lens hydrophilic,Durable Medical Equipment,Per Unit,$122.25 ,OP,122.25,629.1,,,,,,
Aetna MCR ADV,CPT,V2521,Cntct lens hydrophilic toric,Durable Medical Equipment,Per Unit,$242.09 ,OP,242.09,"1,250.57",,,,,,
Aetna MCR ADV,CPT,V2522,Cntct lens hydrophil bifocl,Durable Medical Equipment,Per Unit,$177.16 ,OP,177.16,915.04,,,,,,
Aetna MCR ADV,CPT,V2523,Cntct lens hydrophil extend,Durable Medical Equipment,Per Unit,$186.00 ,OP,186,960.8,,,,,,
Aetna MCR ADV,CPT,V2530,Contact lens gas impermeable,Durable Medical Equipment,Per Unit,$297.37 ,OP,297.37,"1,532.70",,,,,,
Aetna MCR ADV,CPT,V2531,Contact lens gas permeable,Durable Medical Equipment,Per Unit,$544.58 ,OP,544.58,"2,809.96",,,,,,
Aetna MCR ADV,CPT,V2623,Plastic eye prosth custom,Durable Medical Equipment,Per Unit,$942.94 ,OP,942.94,"4,864.99",,,,,,
Aetna MCR ADV,CPT,V2624,Polishing artifical eye,Durable Medical Equipment,Per Unit,$60.88 ,OP,60.88,312.64,,,,,,
Aetna MCR ADV,CPT,V2625,Enlargemnt of eye prosthesis,Durable Medical Equipment,Per Unit,$482.12 ,OP,482.12,"2,485.87",,,,,,
Aetna MCR ADV,CPT,V2626,Reduction of eye prosthesis,Durable Medical Equipment,Per Unit,$199.51 ,OP,199.51,"1,029.43",,,,,,
Aetna MCR ADV,CPT,V2627,Scleral cover shell,Durable Medical Equipment,Per Unit,"$1,430.28 ",OP,"1,430.28","7,377.56",,,,,,
Aetna MCR ADV,CPT,V2628,Fabrication & fitting,Durable Medical Equipment,Per Unit,$304.24 ,OP,304.24,"1,570.83",,,,,,
Aetna MCR ADV,CPT,V2700,Balance lens,Durable Medical Equipment,Per Unit,$44.84 ,OP,44.84,232.58,,,,,,
Aetna MCR ADV,CPT,V2710,Glass/plastic slab off prism,Durable Medical Equipment,Per Unit,$73.51 ,OP,73.51,377.46,,,,,,
Aetna MCR ADV,CPT,V2715,Prism lens/es,Durable Medical Equipment,Per Unit,$14.41 ,OP,14.41,72.44,,,,,,
Aetna MCR ADV,CPT,V2718,Fresnell prism press-on lens,Durable Medical Equipment,Per Unit,$31.12 ,OP,31.12,160.13,,,,,,
Aetna MCR ADV,CPT,V2730,Special base curve,Durable Medical Equipment,Per Unit,$26.06 ,OP,26.06,133.45,,,,,,
Aetna MCR ADV,CPT,V2744,Tint photochromatic lens/es,Durable Medical Equipment,Per Unit,$17.83 ,OP,17.83,91.51,,,,,,
Aetna MCR ADV,CPT,V2745,Tint- any color/solid/grad,Durable Medical Equipment,Per Unit,$10.27 ,OP,10.27,53.38,,,,,,
Aetna MCR ADV,CPT,V2750,Anti-reflective coating,Durable Medical Equipment,Per Unit,$20.02 ,OP,20.02,102.95,,,,,,
Aetna MCR ADV,CPT,V2755,Uv lens/es,Durable Medical Equipment,Per Unit,$16.76 ,OP,16.76,87.69,,,,,,
Aetna MCR ADV,CPT,V2770,Occluder lens/es,Durable Medical Equipment,Per Unit,$19.52 ,OP,19.52,99.13,,,,,,
Aetna MCR ADV,CPT,V2780,Oversize lens/es,Durable Medical Equipment,Per Unit,$12.53 ,OP,12.53,64.82,,,,,,
Aetna MCR ADV,CPT,V2782,Lens- 1.54-1.65 p/1.60-1.79g,Durable Medical Equipment,Per Unit,$64.75 ,OP,64.75,335.53,,,,,,
Aetna MCR ADV,CPT,V2783,Lens- >= 1.66 p/>=1.80 g,Durable Medical Equipment,Per Unit,$73.02 ,OP,73.02,377.46,,,,,,
Aetna MCR ADV,CPT,V2784,Lens polycarb or equal,Durable Medical Equipment,Per Unit,$47.48 ,OP,47.48,244.01,,,,,,
Aetna MCR ADV,CPT,V2785,Corneal tissue processing,Other,Straight Discount,29.70%,OP,,,,,,,,
BCBS Blue Choice,DRG,MS-001,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W MCC,Surgical,Relative Weights,"$262,064.71 ",IP,"17,718.00","557,099.42",,,,,,
BCBS Blue Choice,DRG,MS-002,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W/O MCC,Surgical,Relative Weights,"$132,898.22 ",IP,"17,718.00","282,516.19",,,,,,
BCBS Blue Choice,DRG,MS-003,ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITH MAJOR O.R. PROCEDURES,Surgical,Relative Weights,"$179,748.36 ",IP,"111,577.60","382,110.62",,,,,,
BCBS Blue Choice,DRG,MS-004,TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES,Surgical,Relative Weights,"$109,475.05 ",IP,"69,628.33","232,723.01",,,,,,
BCBS Blue Choice,DRG,MS-005,LIVER TRANSPLANT W MCC OR INTESTINAL TRANSPLANT,Surgical,Relative Weights,"$97,799.97 ",IP,"59,773.19","207,904.03",,,,,,
BCBS Blue Choice,DRG,MS-006,LIVER TRANSPLANT W/O MCC,Surgical,Relative Weights,"$46,202.42 ",IP,"27,427.34","98,217.50",,,,,,
BCBS Blue Choice,DRG,MS-007,LUNG TRANSPLANT,Surgical,Relative Weights,"$102,291.34 ",IP,"67,628.10","217,451.81",,,,,,
BCBS Blue Choice,DRG,MS-008,SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,Surgical,Relative Weights,"$53,260.00 ",IP,"31,730.89","113,220.58",,,,,,
BCBS Blue Choice,DRG,MS-010,PANCREAS TRANSPLANT,Surgical,Relative Weights,"$37,707.15 ",IP,"2,420.00","80,158.18",,,,,,
BCBS Blue Choice,DRG,MS-011,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC,Surgical,Relative Weights,"$46,884.28 ",IP,"2,420.00","99,667.01",,,,,,
BCBS Blue Choice,DRG,MS-012,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC,Surgical,Relative Weights,"$35,790.54 ",IP,"2,420.00","76,083.84",,,,,,
BCBS Blue Choice,DRG,MS-013,TRACHEOSTOMY FOR FACE -  MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC,Surgical,Relative Weights,"$23,000.21 ",IP,"2,420.00","48,894.05",,,,,,
BCBS Blue Choice,DRG,MS-014,ALLOGENEIC BONE MARROW TRANSPLANT,Surgical,Relative Weights,"$120,959.51 ",IP,"2,420.00","257,136.77",,,,,,
BCBS Blue Choice,DRG,MS-016,AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,Surgical,Relative Weights,"$65,295.45 ",IP,"2,420.00","138,805.63",,,,,,
BCBS Blue Choice,DRG,MS-017,AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,Surgical,Relative Weights,"$42,176.70 ",IP,"2,420.00","89,659.58",,,,,,
BCBS Blue Choice,DRG,MS-020,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,Surgical,Relative Weights,"$102,620.41 ",IP,"2,420.00","218,151.36",,,,,,
BCBS Blue Choice,DRG,MS-021,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,Surgical,Relative Weights,"$78,463.22 ",IP,"2,420.00","166,797.79",,,,,,
BCBS Blue Choice,DRG,MS-022,INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W/O CC/MCC,Surgical,Relative Weights,"$46,770.48 ",IP,"2,420.00","99,425.09",,,,,,
BCBS Blue Choice,DRG,MS-023,CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX CNS PDX W MCC OR CHEMO IMPLANT,Surgical,Relative Weights,"$53,269.49 ",IP,"2,420.00","113,240.74",,,,,,
BCBS Blue Choice,DRG,MS-024,CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,Surgical,Relative Weights,"$38,090.28 ",IP,"2,420.00","80,972.64",,,,,,
BCBS Blue Choice,DRG,MS-025,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$41,675.02 ",IP,"2,420.00","88,593.12",,,,,,
BCBS Blue Choice,DRG,MS-026,CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC,Surgical,Relative Weights,"$28,884.69 ",IP,"2,420.00","61,403.33",,,,,,
BCBS Blue Choice,DRG,MS-027,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$22,728.98 ",IP,"2,420.00","48,317.47",,,,,,
BCBS Blue Choice,DRG,MS-028,SPINAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$53,016.28 ",IP,"2,420.00","112,702.46",,,,,,
BCBS Blue Choice,DRG,MS-029,SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,Surgical,Relative Weights,"$30,413.42 ",IP,"2,420.00","64,653.12",,,,,,
BCBS Blue Choice,DRG,MS-030,SPINAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$21,547.35 ",IP,"2,420.00","45,805.54",,,,,,
BCBS Blue Choice,DRG,MS-031,VENTRICULAR SHUNT PROCEDURES WITH MCC,Surgical,Relative Weights,"$41,485.35 ",IP,"2,420.00","88,189.92",,,,,,
BCBS Blue Choice,DRG,MS-032,VENTRICULAR SHUNT PROCEDURES WITH CC,Surgical,Relative Weights,"$20,788.67 ",IP,"2,420.00","44,192.74",,,,,,
BCBS Blue Choice,DRG,MS-033,VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$16,130.40 ",IP,"2,420.00","34,290.14",,,,,,
BCBS Blue Choice,DRG,MS-034,CAROTID ARTERY STENT PROCEDURE W MCC,Surgical,Relative Weights,"$35,598.03 ",IP,"2,420.00","75,674.59",,,,,,
BCBS Blue Choice,DRG,MS-035,CAROTID ARTERY STENT PROCEDURES WITH CC,Surgical,Relative Weights,"$21,832.80 ",IP,"2,420.00","46,412.35",,,,,,
BCBS Blue Choice,DRG,MS-036,CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$16,605.52 ",IP,"2,420.00","35,300.16",,,,,,
BCBS Blue Choice,DRG,MS-037,EXTRACRANIAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$30,757.67 ",IP,"2,420.00","65,384.93",,,,,,
BCBS Blue Choice,DRG,MS-038,EXTRACRANIAL PROCEDURES WITH CC,Surgical,Relative Weights,"$15,886.68 ",IP,"2,420.00","33,772.03",,,,,,
BCBS Blue Choice,DRG,MS-039,EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,728.63 ",IP,"2,420.00","22,807.01",,,,,,
BCBS Blue Choice,DRG,MS-040,PERIPHERAL- CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC,Surgical,Relative Weights,"$37,368.59 ",IP,"2,420.00","79,438.46",,,,,,
BCBS Blue Choice,DRG,MS-041,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W CC OR PERIPH NEUROSTIM,Surgical,Relative Weights,"$22,490.00 ",IP,"2,420.00","47,809.44",,,,,,
BCBS Blue Choice,DRG,MS-042,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W/O CC/MCC,Surgical,Relative Weights,"$17,528.26 ",IP,"2,420.00","37,261.73",,,,,,
BCBS Blue Choice,DRG,MS-052,SPINAL DISORDERS AND INJURIES WITH CC/MCC,Surgical,Relative Weights,"$15,447.59 ",IP,"2,420.00","32,838.62",,,,,,
BCBS Blue Choice,DRG,MS-053,SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,Surgical,Relative Weights,"$9,161.96 ",IP,"2,420.00","19,476.58",,,,,,
BCBS Blue Choice,DRG,MS-054,NERVOUS SYSTEM NEOPLASMS WITH MCC,Surgical,Relative Weights,"$12,708.77 ",IP,"2,420.00","27,016.42",,,,,,
BCBS Blue Choice,DRG,MS-055,NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,Surgical,Relative Weights,"$9,350.68 ",IP,"2,420.00","19,877.76",,,,,,
BCBS Blue Choice,DRG,MS-056,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,Surgical,Relative Weights,"$20,791.52 ",IP,"2,420.00","44,198.78",,,,,,
BCBS Blue Choice,DRG,MS-057,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,Surgical,Relative Weights,"$11,482.56 ",IP,"2,420.00","24,409.73",,,,,,
BCBS Blue Choice,DRG,MS-058,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,Surgical,Relative Weights,"$18,537.30 ",IP,"2,420.00","39,406.75",,,,,,
BCBS Blue Choice,DRG,MS-059,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,Surgical,Relative Weights,"$10,341.70 ",IP,"2,420.00","21,984.48",,,,,,
BCBS Blue Choice,DRG,MS-060,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,Surgical,Relative Weights,"$8,361.56 ",IP,"2,420.00","17,775.07",,,,,,
BCBS Blue Choice,DRG,MS-061,ISCHEMIC STROKE -  PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC,Surgical,Relative Weights,"$26,492.02 ",IP,"2,420.00","56,316.96",,,,,,
BCBS Blue Choice,DRG,MS-062,ISCHEMIC STROKE -  PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC,Surgical,Relative Weights,"$19,073.11 ",IP,"2,420.00","40,545.79",,,,,,
BCBS Blue Choice,DRG,MS-063,ISCHEMIC STROKE- PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC,Surgical,Relative Weights,"$15,939.78 ",IP,"2,420.00","33,884.93",,,,,,
BCBS Blue Choice,DRG,MS-064,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,Surgical,Relative Weights,"$17,779.57 ",IP,"2,420.00","37,795.97",,,,,,
BCBS Blue Choice,DRG,MS-065,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC,Surgical,Relative Weights,"$9,746.14 ",IP,"2,420.00","20,718.43",,,,,,
BCBS Blue Choice,DRG,MS-066,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,Surgical,Relative Weights,"$6,799.63 ",IP,"2,420.00","14,454.72",,,,,,
BCBS Blue Choice,DRG,MS-067,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,Surgical,Relative Weights,"$13,888.51 ",IP,"2,420.00","29,524.32",,,,,,
BCBS Blue Choice,DRG,MS-068,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,Surgical,Relative Weights,"$8,567.35 ",IP,"2,420.00","18,212.54",,,,,,
BCBS Blue Choice,DRG,MS-069,TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,Surgical,Relative Weights,"$7,399.94 ",IP,"2,420.00","15,730.85",,,,,,
BCBS Blue Choice,DRG,MS-070,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC,Surgical,Relative Weights,"$15,864.86 ",IP,"2,420.00","33,725.66",,,,,,
BCBS Blue Choice,DRG,MS-071,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC,Surgical,Relative Weights,"$9,433.19 ",IP,"2,420.00","20,053.15",,,,,,
BCBS Blue Choice,DRG,MS-072,NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$7,003.53 ",IP,"2,420.00","14,888.16",,,,,,
BCBS Blue Choice,DRG,MS-073,CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,Surgical,Relative Weights,"$13,424.77 ",IP,"2,420.00","28,538.50",,,,,,
BCBS Blue Choice,DRG,MS-074,CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,Surgical,Relative Weights,"$9,370.60 ",IP,"2,420.00","19,920.10",,,,,,
BCBS Blue Choice,DRG,MS-075,VIRAL MENINGITIS WITH CC/MCC,Surgical,Relative Weights,"$15,251.28 ",IP,"2,420.00","32,421.31",,,,,,
BCBS Blue Choice,DRG,MS-076,VIRAL MENINGITIS WITHOUT CC/MCC,Surgical,Relative Weights,"$8,558.81 ",IP,"2,420.00","18,194.40",,,,,,
BCBS Blue Choice,DRG,MS-077,HYPERTENSIVE ENCEPHALOPATHY WITH MCC,Surgical,Relative Weights,"$14,628.22 ",IP,"2,420.00","31,096.80",,,,,,
BCBS Blue Choice,DRG,MS-078,HYPERTENSIVE ENCEPHALOPATHY WITH CC,Surgical,Relative Weights,"$9,123.08 ",IP,"2,420.00","19,393.92",,,,,,
BCBS Blue Choice,DRG,MS-079,HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC,Surgical,Relative Weights,"$7,028.18 ",IP,"2,420.00","14,940.58",,,,,,
BCBS Blue Choice,DRG,MS-080,NONTRAUMATIC STUPOR & COMA W MCC,Surgical,Relative Weights,"$18,173.14 ",IP,"2,420.00","38,632.61",,,,,,
BCBS Blue Choice,DRG,MS-081,NONTRAUMATIC STUPOR & COMA W/O MCC,Surgical,Relative Weights,"$8,336.90 ",IP,"2,420.00","17,722.66",,,,,,
BCBS Blue Choice,DRG,MS-082,TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,Surgical,Relative Weights,"$21,354.83 ",IP,"2,420.00","45,396.29",,,,,,
BCBS Blue Choice,DRG,MS-083,TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,Surgical,Relative Weights,"$12,429.96 ",IP,"2,420.00","26,423.71",,,,,,
BCBS Blue Choice,DRG,MS-084,TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,Surgical,Relative Weights,"$8,509.50 ",IP,"2,420.00","18,089.57",,,,,,
BCBS Blue Choice,DRG,MS-085,TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,Surgical,Relative Weights,"$21,297.93 ",IP,"2,420.00","45,275.33",,,,,,
BCBS Blue Choice,DRG,MS-086,TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,Surgical,Relative Weights,"$11,738.61 ",IP,"2,420.00","24,954.05",,,,,,
BCBS Blue Choice,DRG,MS-087,TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,Surgical,Relative Weights,"$7,958.51 ",IP,"2,420.00","16,918.27",,,,,,
BCBS Blue Choice,DRG,MS-088,CONCUSSION WITH MCC,Surgical,Relative Weights,"$13,173.46 ",IP,"2,420.00","28,004.26",,,,,,
BCBS Blue Choice,DRG,MS-089,CONCUSSION WITH CC,Surgical,Relative Weights,"$9,353.53 ",IP,"2,420.00","19,883.81",,,,,,
BCBS Blue Choice,DRG,MS-090,CONCUSSION WITHOUT CC/MCC,Surgical,Relative Weights,"$8,044.81 ",IP,"2,420.00","17,101.73",,,,,,
BCBS Blue Choice,DRG,MS-091,OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,Surgical,Relative Weights,"$14,842.55 ",IP,"2,420.00","31,552.42",,,,,,
BCBS Blue Choice,DRG,MS-092,OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,Surgical,Relative Weights,"$9,161.96 ",IP,"2,420.00","19,476.58",,,,,,
BCBS Blue Choice,DRG,MS-093,OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,Surgical,Relative Weights,"$7,218.80 ",IP,"2,420.00","15,345.79",,,,,,
BCBS Blue Choice,DRG,MS-094,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,Surgical,Relative Weights,"$33,996.27 ",IP,"2,420.00","72,269.57",,,,,,
BCBS Blue Choice,DRG,MS-095,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,Surgical,Relative Weights,"$22,827.61 ",IP,"2,420.00","48,527.14",,,,,,
BCBS Blue Choice,DRG,MS-096,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,Surgical,Relative Weights,"$21,452.51 ",IP,"2,420.00","45,603.94",,,,,,
BCBS Blue Choice,DRG,MS-097,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,Surgical,Relative Weights,"$33,911.87 ",IP,"2,420.00","72,090.14",,,,,,
BCBS Blue Choice,DRG,MS-098,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,Surgical,Relative Weights,"$18,540.14 ",IP,"2,420.00","39,412.80",,,,,,
BCBS Blue Choice,DRG,MS-099,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,Surgical,Relative Weights,"$12,161.58 ",IP,"2,420.00","25,853.18",,,,,,
BCBS Blue Choice,DRG,MS-100,SEIZURES WITH MCC,Surgical,Relative Weights,"$17,261.78 ",IP,"2,420.00","36,695.23",,,,,,
BCBS Blue Choice,DRG,MS-101,SEIZURES WITHOUT MCC,Surgical,Relative Weights,"$8,372.94 ",IP,"2,420.00","17,799.26",,,,,,
BCBS Blue Choice,DRG,MS-102,HEADACHES WITH MCC,Surgical,Relative Weights,"$11,309.96 ",IP,"2,420.00","24,042.82",,,,,,
BCBS Blue Choice,DRG,MS-103,HEADACHES W/O MCC,Surgical,Relative Weights,"$7,582.02 ",IP,"2,420.00","16,117.92",,,,,,
BCBS Blue Choice,DRG,MS-113,ORBITAL PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$20,219.66 ",IP,"2,420.00","42,983.14",,,,,,
BCBS Blue Choice,DRG,MS-114,ORBITAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$11,292.89 ",IP,"2,420.00","24,006.53",,,,,,
BCBS Blue Choice,DRG,MS-115,EXTRAOCULAR PROCEDURES EXCEPT ORBIT,Surgical,Relative Weights,"$14,092.41 ",IP,"2,420.00","29,957.76",,,,,,
BCBS Blue Choice,DRG,MS-116,INTRAOCULAR PROCEDURES W CC/MCC,Surgical,Relative Weights,"$17,933.20 ",IP,"2,420.00","38,122.56",,,,,,
BCBS Blue Choice,DRG,MS-117,INTRAOCULAR PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$10,400.50 ",IP,"2,420.00","22,109.47",,,,,,
BCBS Blue Choice,DRG,MS-121,ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,Surgical,Relative Weights,"$12,023.12 ",IP,"2,420.00","25,558.85",,,,,,
BCBS Blue Choice,DRG,MS-122,ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,Surgical,Relative Weights,"$7,326.91 ",IP,"2,420.00","15,575.62",,,,,,
BCBS Blue Choice,DRG,MS-123,NEUROLOGICAL EYE DISORDERS,Surgical,Relative Weights,"$7,404.68 ",IP,"2,420.00","15,740.93",,,,,,
BCBS Blue Choice,DRG,MS-124,OTHER DISORDERS OF THE EYE WITH MCC,Surgical,Relative Weights,"$13,176.31 ",IP,"2,420.00","28,010.30",,,,,,
BCBS Blue Choice,DRG,MS-125,OTHER DISORDERS OF THE EYE WITHOUT MCC,Surgical,Relative Weights,"$7,486.24 ",IP,"2,420.00","15,914.30",,,,,,
BCBS Blue Choice,DRG,MS-129,MAJOR HEAD & NECK PROCEDURES W CC/MCC OR MAJOR DEVICE,Surgical,Relative Weights,"$21,710.46 ",IP,"21,710.46","46,152.29",,,,,,
BCBS Blue Choice,DRG,MS-130,MAJOR HEAD & NECK PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$13,709.28 ",IP,"13,709.28","29,143.30",,,,,,
BCBS Blue Choice,DRG,MS-131,CRANIAL/FACIAL PROCEDURES W CC/MCC,Surgical,Relative Weights,"$25,503.84 ",IP,"25,503.84","54,216.29",,,,,,
BCBS Blue Choice,DRG,MS-132,CRANIAL/FACIAL PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$15,073.94 ",IP,"15,073.94","32,044.32",,,,,,
BCBS Blue Choice,DRG,MS-133,OTHER EAR - NOSE - MOUTH & THROAT O.R. PROCEDURES W CC/MCC,Surgical,Relative Weights,"$20,360.02 ",IP,"20,360.02","43,281.50",,,,,,
BCBS Blue Choice,DRG,MS-134,OTHER EAR - NOSE - MOUTH & THROAT O.R. PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$11,466.44 ",IP,"11,466.44","24,375.46",,,,,,
BCBS Blue Choice,DRG,MS-135,SINUS AND MASTOID PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$21,665.89 ",IP,"2,420.00","46,057.54",,,,,,
BCBS Blue Choice,DRG,MS-136,SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$11,285.31 ",IP,"2,420.00","23,990.40",,,,,,
BCBS Blue Choice,DRG,MS-137,MOUTH PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$12,644.28 ",IP,"2,420.00","26,879.33",,,,,,
BCBS Blue Choice,DRG,MS-138,MOUTH PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,169.04 ",IP,"2,420.00","17,365.82",,,,,,
BCBS Blue Choice,DRG,MS-139,SALIVARY GLAND PROCEDURES,Surgical,Relative Weights,"$11,705.42 ",IP,"2,420.00","24,883.49",,,,,,
BCBS Blue Choice,DRG,MS-146,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH MCC,Surgical,Relative Weights,"$18,289.78 ",IP,"2,420.00","38,880.58",,,,,,
BCBS Blue Choice,DRG,MS-147,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH CC,Surgical,Relative Weights,"$11,768.01 ",IP,"2,420.00","25,016.54",,,,,,
BCBS Blue Choice,DRG,MS-148,EAR - NOSE - MOUTH & THROAT MALIGNANCY W/O CC/MCC,Surgical,Relative Weights,"$7,211.22 ",IP,"2,420.00","15,329.66",,,,,,
BCBS Blue Choice,DRG,MS-149,DYSEQUILIBRIUM,Surgical,Relative Weights,"$6,927.66 ",IP,"2,420.00","14,726.88",,,,,,
BCBS Blue Choice,DRG,MS-150,EPISTAXIS WITH MCC,Surgical,Relative Weights,"$12,247.88 ",IP,"2,420.00","26,036.64",,,,,,
BCBS Blue Choice,DRG,MS-151,EPISTAXIS WITHOUT MCC,Surgical,Relative Weights,"$6,629.88 ",IP,"2,420.00","14,093.86",,,,,,
BCBS Blue Choice,DRG,MS-152,OTITIS MEDIA AND URI WITH MCC,Surgical,Relative Weights,"$9,853.30 ",IP,"2,420.00","20,946.24",,,,,,
BCBS Blue Choice,DRG,MS-153,OTITIS MEDIA AND URI WITHOUT MCC,Surgical,Relative Weights,"$6,699.11 ",IP,"2,420.00","14,241.02",,,,,,
BCBS Blue Choice,DRG,MS-154,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH MCC,Surgical,Relative Weights,"$13,627.72 ",IP,"2,420.00","28,969.92",,,,,,
BCBS Blue Choice,DRG,MS-155,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH CC,Surgical,Relative Weights,"$8,545.54 ",IP,"2,420.00","18,166.18",,,,,,
BCBS Blue Choice,DRG,MS-156,OTHER EAR -  NOSE -  MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,206.92 ",IP,"2,420.00","13,194.72",,,,,,
BCBS Blue Choice,DRG,MS-157,DENTAL AND ORAL DISEASES WITH MCC,Surgical,Relative Weights,"$14,821.68 ",IP,"2,420.00","31,508.06",,,,,,
BCBS Blue Choice,DRG,MS-158,DENTAL AND ORAL DISEASES WITH CC,Surgical,Relative Weights,"$8,218.36 ",IP,"2,420.00","17,470.66",,,,,,
BCBS Blue Choice,DRG,MS-159,DENTAL AND ORAL DISEASES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,381.41 ",IP,"2,420.00","13,565.66",,,,,,
BCBS Blue Choice,DRG,MS-163,MAJOR CHEST PROCEDURES WITH MCC,Surgical,Relative Weights,"$46,219.49 ",IP,"2,420.00","98,253.79",,,,,,
BCBS Blue Choice,DRG,MS-164,MAJOR CHEST PROCEDURES WITH CC,Surgical,Relative Weights,"$24,008.30 ",IP,"2,420.00","51,037.06",,,,,,
BCBS Blue Choice,DRG,MS-165,MAJOR CHEST PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$17,536.80 ",IP,"2,420.00","37,279.87",,,,,,
BCBS Blue Choice,DRG,MS-166,OTHER RESP SYSTEM O.R. PROCEDURES W MCC,Surgical,Relative Weights,"$35,379.91 ",IP,"2,420.00","75,210.91",,,,,,
BCBS Blue Choice,DRG,MS-167,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$18,155.12 ",IP,"2,420.00","38,594.30",,,,,,
BCBS Blue Choice,DRG,MS-168,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$12,581.69 ",IP,"2,420.00","26,746.27",,,,,,
BCBS Blue Choice,DRG,MS-175,PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,Surgical,Relative Weights,"$13,697.90 ",IP,"2,420.00","29,119.10",,,,,,
BCBS Blue Choice,DRG,MS-176,PULMONARY EMBOLISM WITHOUT MCC,Surgical,Relative Weights,"$8,045.76 ",IP,"2,420.00","17,103.74",,,,,,
BCBS Blue Choice,DRG,MS-177,RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC,Surgical,Relative Weights,"$17,935.10 ",IP,"2,420.00","38,126.59",,,,,,
BCBS Blue Choice,DRG,MS-178,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,Surgical,Relative Weights,"$11,790.77 ",IP,"2,420.00","25,064.93",,,,,,
BCBS Blue Choice,DRG,MS-179,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,Surgical,Relative Weights,"$8,213.62 ",IP,"2,420.00","17,460.58",,,,,,
BCBS Blue Choice,DRG,MS-180,RESPIRATORY NEOPLASMS WITH MCC,Surgical,Relative Weights,"$16,358.00 ",IP,"2,420.00","34,773.98",,,,,,
BCBS Blue Choice,DRG,MS-181,RESPIRATORY NEOPLASMS WITH CC,Surgical,Relative Weights,"$10,924.93 ",IP,"2,420.00","23,224.32",,,,,,
BCBS Blue Choice,DRG,MS-182,RESPIRATORY NEOPLASMS WITHOUT CC/MCC,Surgical,Relative Weights,"$7,992.65 ",IP,"2,420.00","16,990.85",,,,,,
BCBS Blue Choice,DRG,MS-183,MAJOR CHEST TRAUMA WITH MCC,Surgical,Relative Weights,"$14,312.42 ",IP,"2,420.00","30,425.47",,,,,,
BCBS Blue Choice,DRG,MS-184,MAJOR CHEST TRAUMA WITH CC,Surgical,Relative Weights,"$9,656.05 ",IP,"2,420.00","20,526.91",,,,,,
BCBS Blue Choice,DRG,MS-185,MAJOR CHEST TRAUMA W/O CC/MCC,Surgical,Relative Weights,"$6,960.85 ",IP,"2,420.00","14,797.44",,,,,,
BCBS Blue Choice,DRG,MS-186,PLEURAL EFFUSION WITH MCC,Surgical,Relative Weights,"$14,632.02 ",IP,"2,420.00","31,104.86",,,,,,
BCBS Blue Choice,DRG,MS-187,PLEURAL EFFUSION WITH CC,Surgical,Relative Weights,"$9,748.04 ",IP,"2,420.00","20,722.46",,,,,,
BCBS Blue Choice,DRG,MS-188,PLEURAL EFFUSION WITHOUT CC/MCC,Surgical,Relative Weights,"$6,931.45 ",IP,"2,420.00","14,734.94",,,,,,
BCBS Blue Choice,DRG,MS-189,PULMONARY EDEMA AND RESPIRATORY FAILURE,Surgical,Relative Weights,"$11,529.03 ",IP,"2,420.00","24,508.51",,,,,,
BCBS Blue Choice,DRG,MS-190,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,Surgical,Relative Weights,"$10,849.07 ",IP,"2,420.00","23,063.04",,,,,,
BCBS Blue Choice,DRG,MS-191,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,Surgical,Relative Weights,"$8,466.82 ",IP,"2,420.00","17,998.85",,,,,,
BCBS Blue Choice,DRG,MS-192,CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC,Surgical,Relative Weights,"$6,725.66 ",IP,"2,420.00","14,297.47",,,,,,
BCBS Blue Choice,DRG,MS-193,SIMPLE PNEUMONIA & PLEURISY W MCC,Surgical,Relative Weights,"$12,646.18 ",IP,"2,420.00","26,883.36",,,,,,
BCBS Blue Choice,DRG,MS-194,SIMPLE PNEUMONIA AND PLEURISY WITH CC,Surgical,Relative Weights,"$8,426.99 ",IP,"2,420.00","17,914.18",,,,,,
BCBS Blue Choice,DRG,MS-195,SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,Surgical,Relative Weights,"$6,468.66 ",IP,"2,420.00","13,751.14",,,,,,
BCBS Blue Choice,DRG,MS-196,INTERSTITIAL LUNG DISEASE WITH MCC,Surgical,Relative Weights,"$15,888.57 ",IP,"2,420.00","33,776.06",,,,,,
BCBS Blue Choice,DRG,MS-197,INTERSTITIAL LUNG DISEASE WITH CC,Surgical,Relative Weights,"$9,687.34 ",IP,"2,420.00","20,593.44",,,,,,
BCBS Blue Choice,DRG,MS-198,INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,Surgical,Relative Weights,"$7,160.00 ",IP,"2,420.00","15,220.80",,,,,,
BCBS Blue Choice,DRG,MS-199,PNEUMOTHORAX WITH MCC,Surgical,Relative Weights,"$17,014.26 ",IP,"2,420.00","36,169.06",,,,,,
BCBS Blue Choice,DRG,MS-200,PNEUMOTHORAX WITH CC,Surgical,Relative Weights,"$10,262.04 ",IP,"2,420.00","21,815.14",,,,,,
BCBS Blue Choice,DRG,MS-201,PNEUMOTHORAX WITHOUT CC/MCC,Surgical,Relative Weights,"$6,809.12 ",IP,"2,420.00","14,474.88",,,,,,
BCBS Blue Choice,DRG,MS-202,BRONCHITIS AND ASTHMA WITH CC/MCC,Surgical,Relative Weights,"$8,990.31 ",IP,"2,420.00","19,111.68",,,,,,
BCBS Blue Choice,DRG,MS-203,BRONCHITIS AND ASTHMA WITHOUT CC/MCC,Surgical,Relative Weights,"$6,579.62 ",IP,"2,420.00","13,987.01",,,,,,
BCBS Blue Choice,DRG,MS-204,RESPIRATORY SIGNS AND SYMPTOMS,Surgical,Relative Weights,"$7,705.30 ",IP,"2,420.00","16,380.00",,,,,,
BCBS Blue Choice,DRG,MS-205,OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,Surgical,Relative Weights,"$15,497.85 ",IP,"2,420.00","32,945.47",,,,,,
BCBS Blue Choice,DRG,MS-206,OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,Surgical,Relative Weights,"$8,274.31 ",IP,"2,420.00","17,589.60",,,,,,
BCBS Blue Choice,DRG,MS-207,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS,Surgical,Relative Weights,"$54,393.28 ",IP,"2,420.00","115,629.70",,,,,,
BCBS Blue Choice,DRG,MS-208,RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,Surgical,Relative Weights,"$23,557.84 ",IP,"2,420.00","50,079.46",,,,,,
BCBS Blue Choice,DRG,MS-215,OTHER HEART ASSIST SYSTEM IMPLANT,Surgical,Relative Weights,"$122,204.69 ",IP,"61,661.88","259,783.78",,,,,,
BCBS Blue Choice,DRG,MS-216,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$95,236.60 ",IP,"58,630.29","202,454.78",,,,,,
BCBS Blue Choice,DRG,MS-217,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,Surgical,Relative Weights,"$63,080.12 ",IP,"37,864.14","134,096.26",,,,,,
BCBS Blue Choice,DRG,MS-218,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,Surgical,Relative Weights,"$51,223.91 ",IP,"35,678.79","108,892.22",,,,,,
BCBS Blue Choice,DRG,MS-219,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$74,351.20 ",IP,"47,057.01","158,056.42",,,,,,
BCBS Blue Choice,DRG,MS-220,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,Surgical,Relative Weights,"$50,318.24 ",IP,"31,567.37","106,966.94",,,,,,
BCBS Blue Choice,DRG,MS-221,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,Surgical,Relative Weights,"$43,587.83 ",IP,"26,746.97","92,659.39",,,,,,
BCBS Blue Choice,DRG,MS-222,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITH MCC,Surgical,Relative Weights,"$79,135.60 ",IP,"46,434.46","168,227.14",,,,,,
BCBS Blue Choice,DRG,MS-223,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITHOUT MCC,Surgical,Relative Weights,"$56,928.20 ",IP,"33,864.27","121,018.46",,,,,,
BCBS Blue Choice,DRG,MS-224,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITH MCC,Surgical,Relative Weights,"$70,141.49 ",IP,"43,912.13","149,107.39",,,,,,
BCBS Blue Choice,DRG,MS-225,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITHOUT MCC,Surgical,Relative Weights,"$53,570.11 ",IP,"32,808.39","113,879.81",,,,,,
BCBS Blue Choice,DRG,MS-226,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$63,422.47 ",IP,"25,420.00","134,824.03",,,,,,
BCBS Blue Choice,DRG,MS-227,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Surgical,Relative Weights,"$49,590.86 ",IP,"25,420.00","105,420.67",,,,,,
BCBS Blue Choice,DRG,MS-228,OTHER CARDIOTHORACIC PROCEDURES WITH MCC,Surgical,Relative Weights,"$59,615.81 ",IP,"31,129.37","126,731.81",,,,,,
BCBS Blue Choice,DRG,MS-229,OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$38,928.61 ",IP,"20,096.88","82,754.78",,,,,,
BCBS Blue Choice,DRG,MS-231,CORONARY BYPASS W PTCA W MCC,Surgical,Relative Weights,"$77,873.35 ",IP,"50,901.53","165,543.84",,,,,,
BCBS Blue Choice,DRG,MS-232,CORONARY BYPASS W PTCA W/O MCC,Surgical,Relative Weights,"$56,772.67 ",IP,"34,770.65","120,687.84",,,,,,
BCBS Blue Choice,DRG,MS-233,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,Surgical,Relative Weights,"$73,675.97 ",IP,"42,365.00","156,621.02",,,,,,
BCBS Blue Choice,DRG,MS-234,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,Surgical,Relative Weights,"$49,373.69 ",IP,"31,162.65","104,959.01",,,,,,
BCBS Blue Choice,DRG,MS-235,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$55,806.31 ",IP,"32,351.00","118,633.54",,,,,,
BCBS Blue Choice,DRG,MS-236,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Surgical,Relative Weights,"$38,209.77 ",IP,"23,926.80","81,226.66",,,,,,
BCBS Blue Choice,DRG,MS-239,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,Surgical,Relative Weights,"$44,284.87 ",IP,"2,420.00","94,141.15",,,,,,
BCBS Blue Choice,DRG,MS-240,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,Surgical,Relative Weights,"$26,174.32 ",IP,"2,420.00","55,641.60",,,,,,
BCBS Blue Choice,DRG,MS-241,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,Surgical,Relative Weights,"$14,379.76 ",IP,"2,420.00","30,568.61",,,,,,
BCBS Blue Choice,DRG,MS-242,PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,Surgical,Relative Weights,"$35,194.03 ",IP,"15,407.00","74,815.78",,,,,,
BCBS Blue Choice,DRG,MS-243,PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,Surgical,Relative Weights,"$23,987.44 ",IP,"14,708.24","50,992.70",,,,,,
BCBS Blue Choice,DRG,MS-244,PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,Surgical,Relative Weights,"$19,681.95 ",IP,"12,049.83","41,840.06",,,,,,
BCBS Blue Choice,DRG,MS-245,AICD GENERATOR PROCEDURES,Surgical,Relative Weights,"$49,387.91 ",IP,"15,407.00","104,989.25",,,,,,
BCBS Blue Choice,DRG,MS-246,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Surgical,Relative Weights,"$30,089.09 ",IP,"18,246.15","63,963.65",,,,,,
BCBS Blue Choice,DRG,MS-247,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITHOUT MCC,Surgical,Relative Weights,"$19,295.98 ",IP,"11,523.64","41,019.55",,,,,,
BCBS Blue Choice,DRG,MS-248,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Surgical,Relative Weights,"$29,365.50 ",IP,"18,467.49","62,425.44",,,,,,
BCBS Blue Choice,DRG,MS-249,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITHOUT MCC,Surgical,Relative Weights,"$18,175.98 ",IP,"10,942.55","38,638.66",,,,,,
BCBS Blue Choice,DRG,MS-250,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT CORONARY ARTERY STENT WITH MCC,Surgical,Relative Weights,"$24,183.75 ",IP,"14,727.51","51,410.02",,,,,,
BCBS Blue Choice,DRG,MS-251,PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W/O MCC,Surgical,Relative Weights,"$15,960.65 ",IP,"2,420.00","33,929.28",,,,,,
BCBS Blue Choice,DRG,MS-252,OTHER VASCULAR PROCEDURES W MCC,Surgical,Relative Weights,"$31,109.51 ",IP,"2,420.00","66,132.86",,,,,,
BCBS Blue Choice,DRG,MS-253,OTHER VASCULAR PROCEDURES WITH CC,Surgical,Relative Weights,"$24,719.56 ",IP,"2,420.00","52,549.06",,,,,,
BCBS Blue Choice,DRG,MS-254,OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$17,260.83 ",IP,"2,420.00","36,693.22",,,,,,
BCBS Blue Choice,DRG,MS-255,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,Surgical,Relative Weights,"$25,127.35 ",IP,"2,420.00","53,415.94",,,,,,
BCBS Blue Choice,DRG,MS-256,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,Surgical,Relative Weights,"$16,278.34 ",IP,"2,420.00","34,604.64",,,,,,
BCBS Blue Choice,DRG,MS-257,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$10,758.03 ",IP,"2,420.00","22,869.50",,,,,,
BCBS Blue Choice,DRG,MS-258,CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,Surgical,Relative Weights,"$29,007.03 ",IP,"11,861.00","61,663.39",,,,,,
BCBS Blue Choice,DRG,MS-259,CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,Surgical,Relative Weights,"$19,750.23 ",IP,"11,861.00","41,985.22",,,,,,
BCBS Blue Choice,DRG,MS-260,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,Surgical,Relative Weights,"$35,084.97 ",IP,"10,167.00","74,583.94",,,,,,
BCBS Blue Choice,DRG,MS-261,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,Surgical,Relative Weights,"$18,478.50 ",IP,"10,167.00","39,281.76",,,,,,
BCBS Blue Choice,DRG,MS-262,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,Surgical,Relative Weights,"$15,909.44 ",IP,"9,964.34","33,820.42",,,,,,
BCBS Blue Choice,DRG,MS-263,VEIN LIGATION AND STRIPPING,Surgical,Relative Weights,"$22,372.41 ",IP,"2,420.00","47,559.46",,,,,,
BCBS Blue Choice,DRG,MS-264,OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,Surgical,Relative Weights,"$30,707.41 ",IP,"2,420.00","65,278.08",,,,,,
BCBS Blue Choice,DRG,MS-265,AICD LEAD PROCEDURES,Surgical,Relative Weights,"$29,600.69 ",IP,"2,420.00","62,925.41",,,,,,
BCBS Blue Choice,DRG,MS-266,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,Surgical,Relative Weights,"$67,535.44 ",IP,"41,160.28","143,567.42",,,,,,
BCBS Blue Choice,DRG,MS-267,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$53,824.27 ",IP,"32,692.75","114,420.10",,,,,,
BCBS Blue Choice,DRG,MS-268,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,Surgical,Relative Weights,"$64,322.45 ",IP,"32,968.00","136,737.22",,,,,,
BCBS Blue Choice,DRG,MS-269,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,Surgical,Relative Weights,"$40,460.19 ",IP,"25,200.52","86,010.62",,,,,,
BCBS Blue Choice,DRG,MS-270,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,Surgical,Relative Weights,"$48,462.33 ",IP,"30,292.48","103,021.63",,,,,,
BCBS Blue Choice,DRG,MS-271,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,Surgical,Relative Weights,"$33,647.28 ",IP,"20,822.21","71,527.68",,,,,,
BCBS Blue Choice,DRG,MS-272,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$24,669.30 ",IP,"15,699.88","52,442.21",,,,,,
BCBS Blue Choice,DRG,MS-273,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,Surgical,Relative Weights,"$35,186.44 ",IP,"16,176.00","74,799.65",,,,,,
BCBS Blue Choice,DRG,MS-274,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$29,965.81 ",IP,"16,176.00","63,701.57",,,,,,
BCBS Blue Choice,DRG,MS-280,ACUTE MYOCARDIAL INFARCTION - DISCHARGED ALIVE W MCC,Surgical,Relative Weights,"$15,466.56 ",IP,"2,420.00","32,878.94",,,,,,
BCBS Blue Choice,DRG,MS-281,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITH CC,Surgical,Relative Weights,"$9,186.62 ",IP,"2,420.00","19,528.99",,,,,,
BCBS Blue Choice,DRG,MS-282,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITHOUT CC/MCC,Surgical,Relative Weights,"$6,997.84 ",IP,"2,420.00","14,876.06",,,,,,
BCBS Blue Choice,DRG,MS-283,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH MCC,Surgical,Relative Weights,"$17,067.37 ",IP,"2,420.00","36,281.95",,,,,,
BCBS Blue Choice,DRG,MS-284,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH CC,Surgical,Relative Weights,"$6,878.35 ",IP,"2,420.00","14,622.05",,,,,,
BCBS Blue Choice,DRG,MS-285,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITHOUT CC/MCC,Surgical,Relative Weights,"$4,910.53 ",IP,"2,420.00","10,438.85",,,,,,
BCBS Blue Choice,DRG,MS-286,CIRCULATORY DISORDERS EXCEPT AMI- WITH CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$20,838.93 ",IP,"2,420.00","44,299.58",,,,,,
BCBS Blue Choice,DRG,MS-287,CIRCULATORY DISORDERS EXCEPT AMI -  WITH CARDIAC CATHETERIZATION WITHOUT MCC,Surgical,Relative Weights,"$10,926.83 ",IP,"6,512.27","23,228.35",,,,,,
BCBS Blue Choice,DRG,MS-288,ACUTE & SUBACUTE ENDOCARDITIS W MCC,Surgical,Relative Weights,"$25,201.32 ",IP,"2,420.00","53,573.18",,,,,,
BCBS Blue Choice,DRG,MS-289,ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,Surgical,Relative Weights,"$15,778.56 ",IP,"9,181.00","33,542.21",,,,,,
BCBS Blue Choice,DRG,MS-290,ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,Surgical,Relative Weights,"$9,489.14 ",IP,"2,420.00","20,172.10",,,,,,
BCBS Blue Choice,DRG,MS-291,HEART FAILURE AND SHOCK WITH MCC,Surgical,Relative Weights,"$12,762.83 ",IP,"2,420.00","27,131.33",,,,,,
BCBS Blue Choice,DRG,MS-292,HEART FAILURE AND SHOCK WITH CC,Surgical,Relative Weights,"$8,587.26 ",IP,"2,420.00","18,254.88",,,,,,
BCBS Blue Choice,DRG,MS-293,HEART FAILURE AND SHOCK WITHOUT CC/MCC,Surgical,Relative Weights,"$6,214.50 ",IP,"2,420.00","13,210.85",,,,,,
BCBS Blue Choice,DRG,MS-294,DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC,Surgical,Relative Weights,"$12,062.00 ",IP,"2,420.00","25,641.50",,,,,,
BCBS Blue Choice,DRG,MS-295,DEEP VEIN THROMBOPHLEBITIS W/O CC/MCC,Surgical,Relative Weights,"$5,471.95 ",IP,"2,420.00","11,632.32",,,,,,
BCBS Blue Choice,DRG,MS-296,CARDIAC ARREST - UNEXPLAINED W MCC,Surgical,Relative Weights,"$14,892.81 ",IP,"2,420.00","31,659.26",,,,,,
BCBS Blue Choice,DRG,MS-297,CARDIAC ARREST- UNEXPLAINED WITH CC,Surgical,Relative Weights,"$6,856.53 ",IP,"2,420.00","14,575.68",,,,,,
BCBS Blue Choice,DRG,MS-298,CARDIAC ARREST- UNEXPLAINED WITHOUT CC/MCC,Surgical,Relative Weights,"$4,772.07 ",IP,"2,420.00","10,144.51",,,,,,
BCBS Blue Choice,DRG,MS-299,PERIPHERAL VASCULAR DISORDERS WITH MCC,Surgical,Relative Weights,"$13,748.16 ",IP,"2,420.00","29,225.95",,,,,,
BCBS Blue Choice,DRG,MS-300,PERIPHERAL VASCULAR DISORDERS WITH CC,Surgical,Relative Weights,"$9,745.19 ",IP,"2,420.00","20,716.42",,,,,,
BCBS Blue Choice,DRG,MS-301,PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$6,883.09 ",IP,"2,420.00","14,632.13",,,,,,
BCBS Blue Choice,DRG,MS-302,ATHEROSCLEROSIS WITH MCC,Surgical,Relative Weights,"$10,453.61 ",IP,"2,420.00","22,222.37",,,,,,
BCBS Blue Choice,DRG,MS-303,ATHEROSCLEROSIS WITHOUT MCC,Surgical,Relative Weights,"$6,407.97 ",IP,"2,420.00","13,622.11",,,,,,
BCBS Blue Choice,DRG,MS-304,HYPERTENSION WITH MCC,Surgical,Relative Weights,"$10,351.19 ",IP,"2,420.00","22,004.64",,,,,,
BCBS Blue Choice,DRG,MS-305,HYPERTENSION WITHOUT MCC,Surgical,Relative Weights,"$6,937.14 ",IP,"2,420.00","14,747.04",,,,,,
BCBS Blue Choice,DRG,MS-306,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,Surgical,Relative Weights,"$13,414.34 ",IP,"2,420.00","28,516.32",,,,,,
BCBS Blue Choice,DRG,MS-307,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,Surgical,Relative Weights,"$8,366.30 ",IP,"2,420.00","17,785.15",,,,,,
BCBS Blue Choice,DRG,MS-308,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,Surgical,Relative Weights,"$11,263.49 ",IP,"2,420.00","23,944.03",,,,,,
BCBS Blue Choice,DRG,MS-309,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,Surgical,Relative Weights,"$7,172.33 ",IP,"2,420.00","15,247.01",,,,,,
BCBS Blue Choice,DRG,MS-310,CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC,Surgical,Relative Weights,"$5,304.09 ",IP,"2,420.00","11,275.49",,,,,,
BCBS Blue Choice,DRG,MS-311,ANGINA PECTORIS,Surgical,Relative Weights,"$6,496.16 ",IP,"2,420.00","13,809.60",,,,,,
BCBS Blue Choice,DRG,MS-312,SYNCOPE AND COLLAPSE,Surgical,Relative Weights,"$7,744.19 ",IP,"2,420.00","16,462.66",,,,,,
BCBS Blue Choice,DRG,MS-313,CHEST PAIN,Surgical,Relative Weights,"$6,783.51 ",IP,"2,420.00","14,420.45",,,,,,
BCBS Blue Choice,DRG,MS-314,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,Surgical,Relative Weights,"$19,246.66 ",IP,"2,420.00","40,914.72",,,,,,
BCBS Blue Choice,DRG,MS-315,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,Surgical,Relative Weights,"$9,202.74 ",IP,"2,420.00","19,563.26",,,,,,
BCBS Blue Choice,DRG,MS-316,OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,038.62 ",IP,"2,420.00","14,962.75",,,,,,
BCBS Blue Choice,DRG,MS-319,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,Surgical,Relative Weights,"$38,888.78 ",IP,"2,420.00","82,670.11",,,,,,
BCBS Blue Choice,DRG,MS-320,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$22,264.30 ",IP,"2,420.00","47,329.63",,,,,,
BCBS Blue Choice,DRG,MS-326,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$49,982.52 ",IP,"2,420.00","106,253.28",,,,,,
BCBS Blue Choice,DRG,MS-327,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC,Surgical,Relative Weights,"$24,399.97 ",IP,"2,420.00","51,869.66",,,,,,
BCBS Blue Choice,DRG,MS-328,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$14,936.43 ",IP,"2,420.00","31,752.00",,,,,,
BCBS Blue Choice,DRG,MS-329,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Surgical,Relative Weights,"$46,537.19 ",IP,"2,420.00","98,929.15",,,,,,
BCBS Blue Choice,DRG,MS-330,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Surgical,Relative Weights,"$23,962.78 ",IP,"2,420.00","50,940.29",,,,,,
BCBS Blue Choice,DRG,MS-331,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$16,019.44 ",IP,"2,420.00","34,054.27",,,,,,
BCBS Blue Choice,DRG,MS-332,RECTAL RESECTION WITH MCC,Surgical,Relative Weights,"$33,115.26 ",IP,"2,420.00","70,396.70",,,,,,
BCBS Blue Choice,DRG,MS-333,RECTAL RESECTION WITH CC,Surgical,Relative Weights,"$21,462.94 ",IP,"2,420.00","45,626.11",,,,,,
BCBS Blue Choice,DRG,MS-334,RECTAL RESECTION WITHOUT CC/MCC,Surgical,Relative Weights,"$14,607.36 ",IP,"2,420.00","31,052.45",,,,,,
BCBS Blue Choice,DRG,MS-335,PERITONEAL ADHESIOLYSIS WITH MCC,Surgical,Relative Weights,"$38,361.50 ",IP,"2,420.00","81,549.22",,,,,,
BCBS Blue Choice,DRG,MS-336,PERITONEAL ADHESIOLYSIS WITH CC,Surgical,Relative Weights,"$21,491.39 ",IP,"2,420.00","45,686.59",,,,,,
BCBS Blue Choice,DRG,MS-337,PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$15,550.01 ",IP,"2,420.00","33,056.35",,,,,,
BCBS Blue Choice,DRG,MS-338,APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$27,597.79 ",IP,"2,420.00","58,667.62",,,,,,
BCBS Blue Choice,DRG,MS-339,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W CC,Surgical,Relative Weights,"$16,274.55 ",IP,"2,420.00","34,596.58",,,,,,
BCBS Blue Choice,DRG,MS-340,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC/MCC,Surgical,Relative Weights,"$11,735.77 ",IP,"2,420.00","24,948.00",,,,,,
BCBS Blue Choice,DRG,MS-341,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$24,259.61 ",IP,"2,420.00","51,571.30",,,,,,
BCBS Blue Choice,DRG,MS-342,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH CC,Surgical,Relative Weights,"$15,271.20 ",IP,"2,420.00","32,463.65",,,,,,
BCBS Blue Choice,DRG,MS-343,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$10,921.14 ",IP,"2,420.00","23,216.26",,,,,,
BCBS Blue Choice,DRG,MS-344,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Surgical,Relative Weights,"$28,403.88 ",IP,"2,420.00","60,381.22",,,,,,
BCBS Blue Choice,DRG,MS-345,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Surgical,Relative Weights,"$15,489.32 ",IP,"2,420.00","32,927.33",,,,,,
BCBS Blue Choice,DRG,MS-346,MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$12,164.42 ",IP,"2,420.00","25,859.23",,,,,,
BCBS Blue Choice,DRG,MS-347,ANAL AND STOMAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$25,002.17 ",IP,"2,420.00","53,149.82",,,,,,
BCBS Blue Choice,DRG,MS-348,ANAL AND STOMAL PROCEDURES WITH CC,Surgical,Relative Weights,"$13,365.03 ",IP,"2,420.00","28,411.49",,,,,,
BCBS Blue Choice,DRG,MS-349,ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$9,302.32 ",IP,"2,420.00","19,774.94",,,,,,
BCBS Blue Choice,DRG,MS-350,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,Surgical,Relative Weights,"$23,132.98 ",IP,"2,420.00","49,176.29",,,,,,
BCBS Blue Choice,DRG,MS-351,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,Surgical,Relative Weights,"$13,829.72 ",IP,"2,420.00","29,399.33",,,,,,
BCBS Blue Choice,DRG,MS-352,INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,211.78 ",IP,"2,420.00","21,708.29",,,,,,
BCBS Blue Choice,DRG,MS-353,HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,Surgical,Relative Weights,"$28,136.45 ",IP,"2,420.00","59,812.70",,,,,,
BCBS Blue Choice,DRG,MS-354,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W CC,Surgical,Relative Weights,"$16,331.45 ",IP,"2,420.00","34,717.54",,,,,,
BCBS Blue Choice,DRG,MS-355,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W/O CC/MCC,Surgical,Relative Weights,"$13,015.09 ",IP,"2,420.00","27,667.58",,,,,,
BCBS Blue Choice,DRG,MS-356,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$38,665.92 ",IP,"2,420.00","82,196.35",,,,,,
BCBS Blue Choice,DRG,MS-357,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$21,341.56 ",IP,"2,420.00","45,368.06",,,,,,
BCBS Blue Choice,DRG,MS-358,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$13,008.45 ",IP,"2,420.00","27,653.47",,,,,,
BCBS Blue Choice,DRG,MS-368,MAJOR ESOPHAGEAL DISORDERS WITH MCC,Surgical,Relative Weights,"$18,052.70 ",IP,"2,420.00","38,376.58",,,,,,
BCBS Blue Choice,DRG,MS-369,MAJOR ESOPHAGEAL DISORDERS WITH CC,Surgical,Relative Weights,"$10,081.86 ",IP,"2,420.00","21,432.10",,,,,,
BCBS Blue Choice,DRG,MS-370,MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$7,086.98 ",IP,"2,420.00","15,065.57",,,,,,
BCBS Blue Choice,DRG,MS-371,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,Surgical,Relative Weights,"$16,363.69 ",IP,"2,420.00","34,786.08",,,,,,
BCBS Blue Choice,DRG,MS-372,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,Surgical,Relative Weights,"$9,696.83 ",IP,"2,420.00","20,613.60",,,,,,
BCBS Blue Choice,DRG,MS-373,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,Surgical,Relative Weights,"$7,034.82 ",IP,"2,420.00","14,954.69",,,,,,
BCBS Blue Choice,DRG,MS-374,DIGESTIVE MALIGNANCY WITH MCC,Surgical,Relative Weights,"$18,943.19 ",IP,"2,420.00","40,269.60",,,,,,
BCBS Blue Choice,DRG,MS-375,DIGESTIVE MALIGNANCY WITH CC,Surgical,Relative Weights,"$11,449.37 ",IP,"2,420.00","24,339.17",,,,,,
BCBS Blue Choice,DRG,MS-376,DIGESTIVE MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$9,495.78 ",IP,"2,420.00","20,186.21",,,,,,
BCBS Blue Choice,DRG,MS-377,GASTROINTESTINAL HEMORRHAGE WITH MCC,Surgical,Relative Weights,"$16,784.76 ",IP,"2,420.00","35,681.18",,,,,,
BCBS Blue Choice,DRG,MS-378,GASTROINTESTINAL HEMORRHAGE WITH CC,Surgical,Relative Weights,"$9,370.60 ",IP,"2,420.00","19,920.10",,,,,,
BCBS Blue Choice,DRG,MS-379,GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,Surgical,Relative Weights,"$6,123.46 ",IP,"2,420.00","13,017.31",,,,,,
BCBS Blue Choice,DRG,MS-380,COMPLICATED PEPTIC ULCER WITH MCC,Surgical,Relative Weights,"$17,900.96 ",IP,"2,420.00","38,054.02",,,,,,
BCBS Blue Choice,DRG,MS-381,COMPLICATED PEPTIC ULCER WITH CC,Surgical,Relative Weights,"$10,210.83 ",IP,"2,420.00","21,706.27",,,,,,
BCBS Blue Choice,DRG,MS-382,COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,Surgical,Relative Weights,"$7,505.20 ",IP,"2,420.00","15,954.62",,,,,,
BCBS Blue Choice,DRG,MS-383,UNCOMPLICATED PEPTIC ULCER WITH MCC,Surgical,Relative Weights,"$12,577.90 ",IP,"2,420.00","26,738.21",,,,,,
BCBS Blue Choice,DRG,MS-384,UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,Surgical,Relative Weights,"$8,252.50 ",IP,"2,420.00","17,543.23",,,,,,
BCBS Blue Choice,DRG,MS-385,INFLAMMATORY BOWEL DISEASE WITH MCC,Surgical,Relative Weights,"$15,271.20 ",IP,"2,420.00","32,463.65",,,,,,
BCBS Blue Choice,DRG,MS-386,INFLAMMATORY BOWEL DISEASE W CC,Surgical,Relative Weights,"$9,343.09 ",IP,"2,420.00","19,861.63",,,,,,
BCBS Blue Choice,DRG,MS-387,INFLAMMATORY BOWEL DISEASE W/O CC/MCC,Surgical,Relative Weights,"$6,645.05 ",IP,"2,420.00","14,126.11",,,,,,
BCBS Blue Choice,DRG,MS-388,GASTROINTESTINAL OBSTRUCTION WITH MCC,Surgical,Relative Weights,"$14,463.21 ",IP,"2,420.00","30,746.02",,,,,,
BCBS Blue Choice,DRG,MS-389,GASTROINTESTINAL OBSTRUCTION WITH CC,Surgical,Relative Weights,"$7,963.25 ",IP,"2,420.00","16,928.35",,,,,,
BCBS Blue Choice,DRG,MS-390,GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,Surgical,Relative Weights,"$5,496.61 ",IP,"2,420.00","11,684.74",,,,,,
BCBS Blue Choice,DRG,MS-391,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC,Surgical,Relative Weights,"$11,712.06 ",IP,"2,420.00","24,897.60",,,,,,
BCBS Blue Choice,DRG,MS-392,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC,Surgical,Relative Weights,"$7,221.65 ",IP,"2,420.00","15,351.84",,,,,,
BCBS Blue Choice,DRG,MS-393,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,Surgical,Relative Weights,"$15,405.86 ",IP,"2,420.00","32,749.92",,,,,,
BCBS Blue Choice,DRG,MS-394,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,Surgical,Relative Weights,"$8,896.42 ",IP,"2,420.00","18,912.10",,,,,,
BCBS Blue Choice,DRG,MS-395,OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,205.97 ",IP,"2,420.00","13,192.70",,,,,,
BCBS Blue Choice,DRG,MS-405,PANCREAS- LIVER AND SHUNT PROCEDURES WITH MCC,Surgical,Relative Weights,"$51,468.58 ",IP,"2,420.00","109,412.35",,,,,,
BCBS Blue Choice,DRG,MS-406,PANCREAS -  LIVER AND SHUNT PROCEDURES WITH CC,Surgical,Relative Weights,"$26,467.36 ",IP,"2,420.00","56,264.54",,,,,,
BCBS Blue Choice,DRG,MS-407,PANCREAS -  LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$19,785.32 ",IP,"2,420.00","42,059.81",,,,,,
BCBS Blue Choice,DRG,MS-408,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,Surgical,Relative Weights,"$33,795.22 ",IP,"2,420.00","71,842.18",,,,,,
BCBS Blue Choice,DRG,MS-409,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,Surgical,Relative Weights,"$22,701.48 ",IP,"2,420.00","48,259.01",,,,,,
BCBS Blue Choice,DRG,MS-410,BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W/O CC/MCC,Surgical,Relative Weights,"$15,742.53 ",IP,"2,420.00","33,465.60",,,,,,
BCBS Blue Choice,DRG,MS-411,CHOLECYSTECTOMY W C.D.E. W MCC,Surgical,Relative Weights,"$36,325.41 ",IP,"2,420.00","77,220.86",,,,,,
BCBS Blue Choice,DRG,MS-412,CHOLECYSTECTOMY WITH C.D.E. WITH CC,Surgical,Relative Weights,"$22,542.16 ",IP,"2,420.00","47,920.32",,,,,,
BCBS Blue Choice,DRG,MS-413,CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,Surgical,Relative Weights,"$15,337.58 ",IP,"2,420.00","32,604.77",,,,,,
BCBS Blue Choice,DRG,MS-414,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,Surgical,Relative Weights,"$32,399.26 ",IP,"2,420.00","68,874.62",,,,,,
BCBS Blue Choice,DRG,MS-415,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,Surgical,Relative Weights,"$19,457.19 ",IP,"2,420.00","41,362.27",,,,,,
BCBS Blue Choice,DRG,MS-416,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,Surgical,Relative Weights,"$12,805.50 ",IP,"2,420.00","27,222.05",,,,,,
BCBS Blue Choice,DRG,MS-417,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,Surgical,Relative Weights,"$22,861.75 ",IP,"2,420.00","48,599.71",,,,,,
BCBS Blue Choice,DRG,MS-418,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,Surgical,Relative Weights,"$15,826.93 ",IP,"2,420.00","33,645.02",,,,,,
BCBS Blue Choice,DRG,MS-419,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,Surgical,Relative Weights,"$12,392.97 ",IP,"2,420.00","26,345.09",,,,,,
BCBS Blue Choice,DRG,MS-420,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,Surgical,Relative Weights,"$32,573.75 ",IP,"2,420.00","69,245.57",,,,,,
BCBS Blue Choice,DRG,MS-421,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,Surgical,Relative Weights,"$17,460.93 ",IP,"2,420.00","37,118.59",,,,,,
BCBS Blue Choice,DRG,MS-422,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$13,319.51 ",IP,"2,420.00","28,314.72",,,,,,
BCBS Blue Choice,DRG,MS-423,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$40,192.76 ",IP,"2,420.00","85,442.11",,,,,,
BCBS Blue Choice,DRG,MS-424,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$21,351.04 ",IP,"2,420.00","45,388.22",,,,,,
BCBS Blue Choice,DRG,MS-425,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$13,860.06 ",IP,"2,420.00","29,463.84",,,,,,
BCBS Blue Choice,DRG,MS-432,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,Surgical,Relative Weights,"$17,292.12 ",IP,"2,420.00","36,759.74",,,,,,
BCBS Blue Choice,DRG,MS-433,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,Surgical,Relative Weights,"$9,786.92 ",IP,"2,420.00","20,805.12",,,,,,
BCBS Blue Choice,DRG,MS-434,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Surgical,Relative Weights,"$6,068.46 ",IP,"2,420.00","12,900.38",,,,,,
BCBS Blue Choice,DRG,MS-435,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,Surgical,Relative Weights,"$16,094.36 ",IP,"2,420.00","34,213.54",,,,,,
BCBS Blue Choice,DRG,MS-436,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,Surgical,Relative Weights,"$10,675.52 ",IP,"2,420.00","22,694.11",,,,,,
BCBS Blue Choice,DRG,MS-437,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,Surgical,Relative Weights,"$8,325.52 ",IP,"2,420.00","17,698.46",,,,,,
BCBS Blue Choice,DRG,MS-438,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,Surgical,Relative Weights,"$15,536.74 ",IP,"2,420.00","33,028.13",,,,,,
BCBS Blue Choice,DRG,MS-439,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,Surgical,Relative Weights,"$8,034.38 ",IP,"2,420.00","17,079.55",,,,,,
BCBS Blue Choice,DRG,MS-440,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$5,838.01 ",IP,"2,420.00","12,410.50",,,,,,
BCBS Blue Choice,DRG,MS-441,DISORDERS OF LIVER EXCEPT MALIGNANCY- CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC,Surgical,Relative Weights,"$17,549.12 ",IP,"2,420.00","37,306.08",,,,,,
BCBS Blue Choice,DRG,MS-442,DISORDERS OF LIVER EXCEPT MALIGNANCY -  CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC,Surgical,Relative Weights,"$8,851.85 ",IP,"2,420.00","18,817.34",,,,,,
BCBS Blue Choice,DRG,MS-443,DISORDERS OF LIVER EXCEPT MALIGNANCY -  CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Surgical,Relative Weights,"$6,451.59 ",IP,"2,420.00","13,714.85",,,,,,
BCBS Blue Choice,DRG,MS-444,DISORDERS OF THE BILIARY TRACT WITH MCC,Surgical,Relative Weights,"$15,421.04 ",IP,"2,420.00","32,782.18",,,,,,
BCBS Blue Choice,DRG,MS-445,DISORDERS OF THE BILIARY TRACT WITH CC,Surgical,Relative Weights,"$10,189.97 ",IP,"2,420.00","21,661.92",,,,,,
BCBS Blue Choice,DRG,MS-446,DISORDERS OF THE BILIARY TRACT W/O CC/MCC,Surgical,Relative Weights,"$7,707.20 ",IP,"2,420.00","16,384.03",,,,,,
BCBS Blue Choice,DRG,MS-453,COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W MCC,Surgical,Relative Weights,"$89,210.81 ",IP,"2,420.00","189,645.12",,,,,,
BCBS Blue Choice,DRG,MS-454,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC,Surgical,Relative Weights,"$58,086.13 ",IP,"2,420.00","123,480.00",,,,,,
BCBS Blue Choice,DRG,MS-455,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CC/MCC,Surgical,Relative Weights,"$45,646.69 ",IP,"2,420.00","97,036.13",,,,,,
BCBS Blue Choice,DRG,MS-456,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH MCC,Surgical,Relative Weights,"$86,121.11 ",IP,"2,420.00","183,076.99",,,,,,
BCBS Blue Choice,DRG,MS-457,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH CC,Surgical,Relative Weights,"$61,768.55 ",IP,"2,420.00","131,308.13",,,,,,
BCBS Blue Choice,DRG,MS-458,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC,Surgical,Relative Weights,"$44,514.37 ",IP,"2,420.00","94,629.02",,,,,,
BCBS Blue Choice,DRG,MS-459,SPINAL FUSION EXCEPT CERVICAL WITH MCC,Surgical,Relative Weights,"$64,980.60 ",IP,"21,658.00","138,136.32",,,,,,
BCBS Blue Choice,DRG,MS-460,SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,Surgical,Relative Weights,"$37,558.26 ",IP,"21,658.00","79,841.66",,,,,,
BCBS Blue Choice,DRG,MS-461,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,Surgical,Relative Weights,"$51,009.58 ",IP,"2,420.00","108,436.61",,,,,,
BCBS Blue Choice,DRG,MS-462,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,Surgical,Relative Weights,"$29,743.89 ",IP,"2,420.00","63,229.82",,,,,,
BCBS Blue Choice,DRG,MS-463,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,Surgical,Relative Weights,"$49,577.58 ",IP,"2,420.00","105,392.45",,,,,,
BCBS Blue Choice,DRG,MS-464,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,Surgical,Relative Weights,"$28,001.78 ",IP,"2,420.00","59,526.43",,,,,,
BCBS Blue Choice,DRG,MS-465,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$18,162.70 ",IP,"2,420.00","38,610.43",,,,,,
BCBS Blue Choice,DRG,MS-466,REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,Surgical,Relative Weights,"$48,357.06 ",IP,"2,420.00","102,797.86",,,,,,
BCBS Blue Choice,DRG,MS-467,REVISION OF HIP OR KNEE REPLACEMENT W CC,Surgical,Relative Weights,"$33,306.82 ",IP,"2,420.00","70,803.94",,,,,,
BCBS Blue Choice,DRG,MS-468,REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,Surgical,Relative Weights,"$26,668.41 ",IP,"2,420.00","56,691.94",,,,,,
BCBS Blue Choice,DRG,MS-469,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,Surgical,Relative Weights,"$29,777.08 ",IP,"2,420.00","63,300.38",,,,,,
BCBS Blue Choice,DRG,MS-470,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,Surgical,Relative Weights,"$18,667.22 ",IP,"2,420.00","39,682.94",,,,,,
BCBS Blue Choice,DRG,MS-471,CERVICAL SPINAL FUSION WITH MCC,Surgical,Relative Weights,"$47,364.14 ",IP,"15,407.00","100,687.10",,,,,,
BCBS Blue Choice,DRG,MS-472,CERVICAL SPINAL FUSION WITH CC,Surgical,Relative Weights,"$28,843.91 ",IP,"15,407.00","61,316.64",,,,,,
BCBS Blue Choice,DRG,MS-473,CERVICAL SPINAL FUSION WITHOUT CC/MCC,Surgical,Relative Weights,"$23,826.22 ",IP,"14,827.96","50,649.98",,,,,,
BCBS Blue Choice,DRG,MS-474,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,Surgical,Relative Weights,"$36,747.42 ",IP,"2,420.00","78,117.98",,,,,,
BCBS Blue Choice,DRG,MS-475,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,Surgical,Relative Weights,"$19,924.73 ",IP,"2,420.00","42,356.16",,,,,,
BCBS Blue Choice,DRG,MS-476,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$11,045.37 ",IP,"2,420.00","23,480.35",,,,,,
BCBS Blue Choice,DRG,MS-477,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Surgical,Relative Weights,"$30,871.47 ",IP,"2,420.00","65,626.85",,,,,,
BCBS Blue Choice,DRG,MS-478,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Surgical,Relative Weights,"$21,974.10 ",IP,"2,420.00","46,712.74",,,,,,
BCBS Blue Choice,DRG,MS-479,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Surgical,Relative Weights,"$16,901.40 ",IP,"2,420.00","35,929.15",,,,,,
BCBS Blue Choice,DRG,MS-480,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,Surgical,Relative Weights,"$28,625.79 ",IP,"2,420.00","60,852.96",,,,,,
BCBS Blue Choice,DRG,MS-481,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,Surgical,Relative Weights,"$19,799.55 ",IP,"2,420.00","42,090.05",,,,,,
BCBS Blue Choice,DRG,MS-482,HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC,Surgical,Relative Weights,"$15,603.12 ",IP,"2,420.00","33,169.25",,,,,,
BCBS Blue Choice,DRG,MS-483,MAJOR JOINT & LIMB REATTACHMENT PROC OF UPPER EXTREMITY W CC/MCC,Surgical,Relative Weights,"$22,685.36 ",IP,"2,420.00","48,224.74",,,,,,
BCBS Blue Choice,DRG,MS-485,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,Surgical,Relative Weights,"$31,096.23 ",IP,"2,420.00","66,104.64",,,,,,
BCBS Blue Choice,DRG,MS-486,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,Surgical,Relative Weights,"$20,395.11 ",IP,"2,420.00","43,356.10",,,,,,
BCBS Blue Choice,DRG,MS-487,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Surgical,Relative Weights,"$15,241.80 ",IP,"2,420.00","32,401.15",,,,,,
BCBS Blue Choice,DRG,MS-488,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,Surgical,Relative Weights,"$18,674.81 ",IP,"2,420.00","39,699.07",,,,,,
BCBS Blue Choice,DRG,MS-489,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Surgical,Relative Weights,"$11,939.66 ",IP,"2,420.00","25,381.44",,,,,,
BCBS Blue Choice,DRG,MS-492,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH MCC,Surgical,Relative Weights,"$32,673.33 ",IP,"2,420.00","69,457.25",,,,,,
BCBS Blue Choice,DRG,MS-493,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH CC,Surgical,Relative Weights,"$21,830.90 ",IP,"2,420.00","46,408.32",,,,,,
BCBS Blue Choice,DRG,MS-494,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITHOUT CC/MCC,Surgical,Relative Weights,"$17,178.32 ",IP,"2,420.00","36,517.82",,,,,,
BCBS Blue Choice,DRG,MS-495,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,Surgical,Relative Weights,"$32,552.89 ",IP,"2,420.00","69,201.22",,,,,,
BCBS Blue Choice,DRG,MS-496,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,Surgical,Relative Weights,"$19,350.98 ",IP,"2,420.00","41,136.48",,,,,,
BCBS Blue Choice,DRG,MS-497,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,Surgical,Relative Weights,"$13,934.03 ",IP,"2,420.00","29,621.09",,,,,,
BCBS Blue Choice,DRG,MS-498,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,Surgical,Relative Weights,"$23,216.43 ",IP,"2,420.00","49,353.70",,,,,,
BCBS Blue Choice,DRG,MS-499,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,Surgical,Relative Weights,"$10,914.50 ",IP,"2,420.00","23,202.14",,,,,,
BCBS Blue Choice,DRG,MS-500,SOFT TISSUE PROCEDURES WITH MCC,Surgical,Relative Weights,"$28,594.50 ",IP,"2,420.00","60,786.43",,,,,,
BCBS Blue Choice,DRG,MS-501,SOFT TISSUE PROCEDURES WITH CC,Surgical,Relative Weights,"$15,913.23 ",IP,"2,420.00","33,828.48",,,,,,
BCBS Blue Choice,DRG,MS-502,SOFT TISSUE PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$12,524.79 ",IP,"2,420.00","26,625.31",,,,,,
BCBS Blue Choice,DRG,MS-503,FOOT PROCEDURES WITH MCC,Surgical,Relative Weights,"$25,762.74 ",IP,"2,420.00","54,766.66",,,,,,
BCBS Blue Choice,DRG,MS-504,FOOT PROCEDURES WITH CC,Surgical,Relative Weights,"$16,468.01 ",IP,"2,420.00","35,007.84",,,,,,
BCBS Blue Choice,DRG,MS-505,FOOT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$15,946.42 ",IP,"2,420.00","33,899.04",,,,,,
BCBS Blue Choice,DRG,MS-506,MAJOR THUMB OR JOINT PROCEDURES,Surgical,Relative Weights,"$12,694.55 ",IP,"2,420.00","26,986.18",,,,,,
BCBS Blue Choice,DRG,MS-507,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W CC/MCC,Surgical,Relative Weights,"$19,915.25 ",IP,"2,420.00","42,336.00",,,,,,
BCBS Blue Choice,DRG,MS-508,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$14,779.01 ",IP,"2,420.00","31,417.34",,,,,,
BCBS Blue Choice,DRG,MS-509,ARTHROSCOPY,Surgical,Relative Weights,"$13,198.12 ",IP,"2,420.00","28,056.67",,,,,,
BCBS Blue Choice,DRG,MS-510,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH MCC,Surgical,Relative Weights,"$26,439.86 ",IP,"2,420.00","56,206.08",,,,,,
BCBS Blue Choice,DRG,MS-511,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH CC,Surgical,Relative Weights,"$17,868.72 ",IP,"2,420.00","37,985.47",,,,,,
BCBS Blue Choice,DRG,MS-512,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$14,356.05 ",IP,"2,420.00","30,518.21",,,,,,
BCBS Blue Choice,DRG,MS-513,HAND OR WRIST PROCEDURES- EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$14,956.35 ",IP,"2,420.00","31,794.34",,,,,,
BCBS Blue Choice,DRG,MS-514,HAND OR WRIST PROCEDURES -  EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,116.94 ",IP,"2,420.00","21,506.69",,,,,,
BCBS Blue Choice,DRG,MS-515,OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W MCC,Surgical,Relative Weights,"$29,910.80 ",IP,"2,420.00","63,584.64",,,,,,
BCBS Blue Choice,DRG,MS-516,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$18,389.36 ",IP,"2,420.00","39,092.26",,,,,,
BCBS Blue Choice,DRG,MS-517,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$13,421.93 ",IP,"2,420.00","28,532.45",,,,,,
BCBS Blue Choice,DRG,MS-518,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,Surgical,Relative Weights,"$32,325.29 ",IP,"10,289.00","68,717.38",,,,,,
BCBS Blue Choice,DRG,MS-519,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,Surgical,Relative Weights,"$18,101.06 ",IP,"10,289.00","38,479.39",,,,,,
BCBS Blue Choice,DRG,MS-520,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,Surgical,Relative Weights,"$12,688.86 ",IP,"8,282.98","26,974.08",,,,,,
BCBS Blue Choice,DRG,MS-533,FRACTURES OF FEMUR WITH MCC,Surgical,Relative Weights,"$13,840.15 ",IP,"2,420.00","29,421.50",,,,,,
BCBS Blue Choice,DRG,MS-534,FRACTURES OF FEMUR WITHOUT MCC,Surgical,Relative Weights,"$7,376.23 ",IP,"2,420.00","15,680.45",,,,,,
BCBS Blue Choice,DRG,MS-535,FRACTURES OF HIP AND PELVIS WITH MCC,Surgical,Relative Weights,"$11,637.14 ",IP,"2,420.00","24,738.34",,,,,,
BCBS Blue Choice,DRG,MS-536,FRACTURES OF HIP AND PELVIS WITHOUT MCC,Surgical,Relative Weights,"$7,193.20 ",IP,"2,420.00","15,291.36",,,,,,
BCBS Blue Choice,DRG,MS-537,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITH CC/MCC,Surgical,Relative Weights,"$8,638.47 ",IP,"2,420.00","18,363.74",,,,,,
BCBS Blue Choice,DRG,MS-538,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITHOUT CC/MCC,Surgical,Relative Weights,"$6,837.57 ",IP,"2,420.00","14,535.36",,,,,,
BCBS Blue Choice,DRG,MS-539,OSTEOMYELITIS WITH MCC,Surgical,Relative Weights,"$17,878.20 ",IP,"2,420.00","38,005.63",,,,,,
BCBS Blue Choice,DRG,MS-540,OSTEOMYELITIS WITH CC,Surgical,Relative Weights,"$12,328.49 ",IP,"2,420.00","26,208.00",,,,,,
BCBS Blue Choice,DRG,MS-541,OSTEOMYELITIS WITHOUT CC/MCC,Surgical,Relative Weights,"$8,598.64 ",IP,"2,420.00","18,279.07",,,,,,
BCBS Blue Choice,DRG,MS-542,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,Surgical,Relative Weights,"$17,305.40 ",IP,"2,420.00","36,787.97",,,,,,
BCBS Blue Choice,DRG,MS-543,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,Surgical,Relative Weights,"$10,017.37 ",IP,"2,420.00","21,295.01",,,,,,
BCBS Blue Choice,DRG,MS-544,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$7,192.25 ",IP,"2,420.00","15,289.34",,,,,,
BCBS Blue Choice,DRG,MS-545,CONNECTIVE TISSUE DISORDERS WITH MCC,Surgical,Relative Weights,"$23,974.16 ",IP,"2,420.00","50,964.48",,,,,,
BCBS Blue Choice,DRG,MS-546,CONNECTIVE TISSUE DISORDERS WITH CC,Surgical,Relative Weights,"$11,412.38 ",IP,"2,420.00","24,260.54",,,,,,
BCBS Blue Choice,DRG,MS-547,CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$7,682.54 ",IP,"2,420.00","16,331.62",,,,,,
BCBS Blue Choice,DRG,MS-548,SEPTIC ARTHRITIS WITH MCC,Surgical,Relative Weights,"$18,808.53 ",IP,"2,420.00","39,983.33",,,,,,
BCBS Blue Choice,DRG,MS-549,SEPTIC ARTHRITIS W CC,Surgical,Relative Weights,"$11,314.70 ",IP,"2,420.00","24,052.90",,,,,,
BCBS Blue Choice,DRG,MS-550,SEPTIC ARTHRITIS W/O CC/MCC,Surgical,Relative Weights,"$8,193.70 ",IP,"2,420.00","17,418.24",,,,,,
BCBS Blue Choice,DRG,MS-551,MEDICAL BACK PROBLEMS WITH MCC,Surgical,Relative Weights,"$15,073.00 ",IP,"2,420.00","32,042.30",,,,,,
BCBS Blue Choice,DRG,MS-552,MEDICAL BACK PROBLEMS WITHOUT MCC,Surgical,Relative Weights,"$8,647.96 ",IP,"2,420.00","18,383.90",,,,,,
BCBS Blue Choice,DRG,MS-553,BONE DISEASES AND ARTHROPATHIES WITH MCC,Surgical,Relative Weights,"$12,190.98 ",IP,"2,420.00","25,915.68",,,,,,
BCBS Blue Choice,DRG,MS-554,BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,Surgical,Relative Weights,"$7,465.37 ",IP,"2,420.00","15,869.95",,,,,,
BCBS Blue Choice,DRG,MS-555,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Surgical,Relative Weights,"$12,473.58 ",IP,"2,420.00","26,516.45",,,,,,
BCBS Blue Choice,DRG,MS-556,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,Surgical,Relative Weights,"$7,509.00 ",IP,"2,420.00","15,962.69",,,,,,
BCBS Blue Choice,DRG,MS-557,TENDONITIS -  MYOSITIS AND BURSITIS WITH MCC,Surgical,Relative Weights,"$13,828.77 ",IP,"2,420.00","29,397.31",,,,,,
BCBS Blue Choice,DRG,MS-558,TENDONITIS- MYOSITIS AND BURSITIS WITHOUT MCC,Surgical,Relative Weights,"$8,169.04 ",IP,"2,420.00","17,365.82",,,,,,
BCBS Blue Choice,DRG,MS-559,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Surgical,Relative Weights,"$17,087.28 ",IP,"2,420.00","36,324.29",,,,,,
BCBS Blue Choice,DRG,MS-560,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Surgical,Relative Weights,"$9,895.98 ",IP,"2,420.00","21,036.96",,,,,,
BCBS Blue Choice,DRG,MS-561,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Surgical,Relative Weights,"$7,087.93 ",IP,"2,420.00","15,067.58",,,,,,
BCBS Blue Choice,DRG,MS-562,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITH MCC,Surgical,Relative Weights,"$12,775.16 ",IP,"2,420.00","27,157.54",,,,,,
BCBS Blue Choice,DRG,MS-563,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITHOUT MCC,Surgical,Relative Weights,"$8,098.87 ",IP,"2,420.00","17,216.64",,,,,,
BCBS Blue Choice,DRG,MS-564,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,Surgical,Relative Weights,"$14,338.98 ",IP,"2,420.00","30,481.92",,,,,,
BCBS Blue Choice,DRG,MS-565,OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W CC,Surgical,Relative Weights,"$9,298.52 ",IP,"2,420.00","19,766.88",,,,,,
BCBS Blue Choice,DRG,MS-566,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,185.61 ",IP,"2,420.00","15,275.23",,,,,,
BCBS Blue Choice,DRG,MS-570,SKIN DEBRIDEMENT WITH MCC,Surgical,Relative Weights,"$27,247.85 ",IP,"2,420.00","57,923.71",,,,,,
BCBS Blue Choice,DRG,MS-571,SKIN DEBRIDEMENT WITH CC,Surgical,Relative Weights,"$15,859.17 ",IP,"2,420.00","33,713.57",,,,,,
BCBS Blue Choice,DRG,MS-572,SKIN DEBRIDEMENT WITHOUT CC/MCC,Surgical,Relative Weights,"$10,637.59 ",IP,"2,420.00","22,613.47",,,,,,
BCBS Blue Choice,DRG,MS-573,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,Surgical,Relative Weights,"$50,407.38 ",IP,"2,420.00","107,156.45",,,,,,
BCBS Blue Choice,DRG,MS-574,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,Surgical,Relative Weights,"$29,605.43 ",IP,"2,420.00","62,935.49",,,,,,
BCBS Blue Choice,DRG,MS-575,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS W/O CC/MCC,Surgical,Relative Weights,"$16,662.42 ",IP,"2,420.00","35,421.12",,,,,,
BCBS Blue Choice,DRG,MS-576,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,Surgical,Relative Weights,"$45,987.15 ",IP,"2,420.00","97,759.87",,,,,,
BCBS Blue Choice,DRG,MS-577,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,Surgical,Relative Weights,"$22,908.22 ",IP,"2,420.00","48,698.50",,,,,,
BCBS Blue Choice,DRG,MS-578,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,Surgical,Relative Weights,"$15,433.37 ",IP,"2,420.00","32,808.38",,,,,,
BCBS Blue Choice,DRG,MS-579,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC,Surgical,Relative Weights,"$28,318.53 ",IP,"2,420.00","60,199.78",,,,,,
BCBS Blue Choice,DRG,MS-580,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC,Surgical,Relative Weights,"$15,256.03 ",IP,"2,420.00","32,431.39",,,,,,
BCBS Blue Choice,DRG,MS-581,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$11,899.83 ",IP,"2,420.00","25,296.77",,,,,,
BCBS Blue Choice,DRG,MS-582,MASTECTOMY FOR MALIGNANCY WITH CC/MCC,Surgical,Relative Weights,"$14,971.52 ",IP,"2,420.00","31,826.59",,,,,,
BCBS Blue Choice,DRG,MS-583,MASTECTOMY FOR MALIGNANCY W/O CC/MCC,Surgical,Relative Weights,"$13,859.11 ",IP,"2,420.00","29,461.82",,,,,,
BCBS Blue Choice,DRG,MS-584,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$17,339.54 ",IP,"2,420.00","36,860.54",,,,,,
BCBS Blue Choice,DRG,MS-585,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$16,096.26 ",IP,"2,420.00","34,217.57",,,,,,
BCBS Blue Choice,DRG,MS-592,SKIN ULCERS WITH MCC,Surgical,Relative Weights,"$16,921.32 ",IP,"2,420.00","35,971.49",,,,,,
BCBS Blue Choice,DRG,MS-593,SKIN ULCERS WITH CC,Surgical,Relative Weights,"$10,885.10 ",IP,"2,420.00","23,139.65",,,,,,
BCBS Blue Choice,DRG,MS-594,SKIN ULCERS WITHOUT CC/MCC,Surgical,Relative Weights,"$7,678.75 ",IP,"2,420.00","16,323.55",,,,,,
BCBS Blue Choice,DRG,MS-595,MAJOR SKIN DISORDERS WITH MCC,Surgical,Relative Weights,"$19,276.06 ",IP,"2,420.00","40,977.22",,,,,,
BCBS Blue Choice,DRG,MS-596,MAJOR SKIN DISORDERS W/O MCC,Surgical,Relative Weights,"$9,237.83 ",IP,"2,420.00","19,637.86",,,,,,
BCBS Blue Choice,DRG,MS-597,MALIGNANT BREAST DISORDERS W MCC,Surgical,Relative Weights,"$16,054.53 ",IP,"2,420.00","34,128.86",,,,,,
BCBS Blue Choice,DRG,MS-598,MALIGNANT BREAST DISORDERS WITH CC,Surgical,Relative Weights,"$10,323.68 ",IP,"2,420.00","21,946.18",,,,,,
BCBS Blue Choice,DRG,MS-599,MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$6,594.79 ",IP,"2,420.00","14,019.26",,,,,,
BCBS Blue Choice,DRG,MS-600,NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,Surgical,Relative Weights,"$9,096.53 ",IP,"2,420.00","19,337.47",,,,,,
BCBS Blue Choice,DRG,MS-601,NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$5,868.36 ",IP,"2,420.00","12,475.01",,,,,,
BCBS Blue Choice,DRG,MS-602,CELLULITIS WITH MCC,Surgical,Relative Weights,"$13,559.44 ",IP,"2,420.00","28,824.77",,,,,,
BCBS Blue Choice,DRG,MS-603,CELLULITIS WITHOUT MCC,Surgical,Relative Weights,"$7,999.29 ",IP,"2,420.00","17,004.96",,,,,,
BCBS Blue Choice,DRG,MS-604,TRAUMA TO THE SKIN -  SUBCUTANEOUS TISSUE AND BREAST WITH MCC,Surgical,Relative Weights,"$13,888.51 ",IP,"2,420.00","29,524.32",,,,,,
BCBS Blue Choice,DRG,MS-605,TRAUMA TO THE SKIN- SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC,Surgical,Relative Weights,"$8,304.66 ",IP,"2,420.00","17,654.11",,,,,,
BCBS Blue Choice,DRG,MS-606,MINOR SKIN DISORDERS WITH MCC,Surgical,Relative Weights,"$14,182.50 ",IP,"2,420.00","30,149.28",,,,,,
BCBS Blue Choice,DRG,MS-607,MINOR SKIN DISORDERS WITHOUT MCC,Surgical,Relative Weights,"$7,834.28 ",IP,"2,420.00","16,654.18",,,,,,
BCBS Blue Choice,DRG,MS-614,ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$23,076.08 ",IP,"2,420.00","49,055.33",,,,,,
BCBS Blue Choice,DRG,MS-615,ADRENAL & PITUITARY PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$14,074.39 ",IP,"2,420.00","29,919.46",,,,,,
BCBS Blue Choice,DRG,MS-616,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Surgical,Relative Weights,"$37,941.39 ",IP,"2,420.00","80,656.13",,,,,,
BCBS Blue Choice,DRG,MS-617,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Surgical,Relative Weights,"$19,453.40 ",IP,"2,420.00","41,354.21",,,,,,
BCBS Blue Choice,DRG,MS-618,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$11,896.99 ",IP,"2,420.00","25,290.72",,,,,,
BCBS Blue Choice,DRG,MS-619,O.R. PROCEDURES FOR OBESITY WITH MCC,Surgical,Relative Weights,"$29,194.80 ",IP,"2,420.00","62,062.56",,,,,,
BCBS Blue Choice,DRG,MS-620,O.R. PROCEDURES FOR OBESITY WITH CC,Surgical,Relative Weights,"$17,019.00 ",IP,"2,420.00","36,179.14",,,,,,
BCBS Blue Choice,DRG,MS-621,O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,Surgical,Relative Weights,"$14,907.98 ",IP,"2,420.00","31,691.52",,,,,,
BCBS Blue Choice,DRG,MS-622,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Surgical,Relative Weights,"$35,804.77 ",IP,"2,420.00","76,114.08",,,,,,
BCBS Blue Choice,DRG,MS-623,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE -  NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Surgical,Relative Weights,"$18,517.38 ",IP,"2,420.00","39,364.42",,,,,,
BCBS Blue Choice,DRG,MS-624,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$10,450.76 ",IP,"2,420.00","22,216.32",,,,,,
BCBS Blue Choice,DRG,MS-625,THYROID- PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$27,740.04 ",IP,"2,420.00","58,970.02",,,,,,
BCBS Blue Choice,DRG,MS-626,THYROID -  PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC,Surgical,Relative Weights,"$15,958.75 ",IP,"2,420.00","33,925.25",,,,,,
BCBS Blue Choice,DRG,MS-627,THYROID -  PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,827.25 ",IP,"2,420.00","23,016.67",,,,,,
BCBS Blue Choice,DRG,MS-628,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$34,987.29 ",IP,"2,420.00","74,376.29",,,,,,
BCBS Blue Choice,DRG,MS-629,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$22,028.16 ",IP,"2,420.00","46,827.65",,,,,,
BCBS Blue Choice,DRG,MS-630,OTHER ENDOCRINE - NUTRIT & METAB O.R. PROC W/O CC/MCC,Surgical,Relative Weights,"$13,739.62 ",IP,"2,420.00","29,207.81",,,,,,
BCBS Blue Choice,DRG,MS-637,DIABETES WITH MCC,Surgical,Relative Weights,"$13,141.22 ",IP,"2,420.00","27,935.71",,,,,,
BCBS Blue Choice,DRG,MS-638,DIABETES WITH CC,Surgical,Relative Weights,"$8,384.32 ",IP,"2,420.00","17,823.46",,,,,,
BCBS Blue Choice,DRG,MS-639,DIABETES WITHOUT CC/MCC,Surgical,Relative Weights,"$5,815.25 ",IP,"2,420.00","12,362.11",,,,,,
BCBS Blue Choice,DRG,MS-640,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITH MCC,Surgical,Relative Weights,"$11,514.81 ",IP,"2,420.00","24,478.27",,,,,,
BCBS Blue Choice,DRG,MS-641,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITHOUT MCC,Surgical,Relative Weights,"$7,175.18 ",IP,"2,420.00","15,253.06",,,,,,
BCBS Blue Choice,DRG,MS-642,INBORN AND OTHER DISORDERS OF METABOLISM,Surgical,Relative Weights,"$11,529.98 ",IP,"2,420.00","24,510.53",,,,,,
BCBS Blue Choice,DRG,MS-643,ENDOCRINE DISORDERS WITH MCC,Surgical,Relative Weights,"$15,415.35 ",IP,"2,420.00","32,770.08",,,,,,
BCBS Blue Choice,DRG,MS-644,ENDOCRINE DISORDERS WITH CC,Surgical,Relative Weights,"$9,749.93 ",IP,"2,420.00","20,726.50",,,,,,
BCBS Blue Choice,DRG,MS-645,ENDOCRINE DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$7,256.74 ",IP,"2,420.00","15,426.43",,,,,,
BCBS Blue Choice,DRG,MS-652,KIDNEY TRANSPLANT,Surgical,Relative Weights,"$32,100.53 ",IP,"2,420.00","68,239.58",,,,,,
BCBS Blue Choice,DRG,MS-653,MAJOR BLADDER PROCEDURES WITH MCC,Surgical,Relative Weights,"$52,505.12 ",IP,"2,420.00","111,615.84",,,,,,
BCBS Blue Choice,DRG,MS-654,MAJOR BLADDER PROCEDURES WITH CC,Surgical,Relative Weights,"$26,669.36 ",IP,"2,420.00","56,693.95",,,,,,
BCBS Blue Choice,DRG,MS-655,MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$19,558.67 ",IP,"2,420.00","41,577.98",,,,,,
BCBS Blue Choice,DRG,MS-656,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,Surgical,Relative Weights,"$30,921.74 ",IP,"2,420.00","65,733.70",,,,,,
BCBS Blue Choice,DRG,MS-657,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,Surgical,Relative Weights,"$18,342.89 ",IP,"2,420.00","38,993.47",,,,,,
BCBS Blue Choice,DRG,MS-658,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,Surgical,Relative Weights,"$14,888.07 ",IP,"2,420.00","31,649.18",,,,,,
BCBS Blue Choice,DRG,MS-659,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,Surgical,Relative Weights,"$25,413.75 ",IP,"2,420.00","54,024.77",,,,,,
BCBS Blue Choice,DRG,MS-660,KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC,Surgical,Relative Weights,"$13,473.14 ",IP,"2,420.00","28,641.31",,,,,,
BCBS Blue Choice,DRG,MS-661,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,Surgical,Relative Weights,"$10,337.91 ",IP,"2,420.00","21,976.42",,,,,,
BCBS Blue Choice,DRG,MS-662,MINOR BLADDER PROCEDURES WITH MCC,Surgical,Relative Weights,"$30,012.27 ",IP,"2,420.00","63,800.35",,,,,,
BCBS Blue Choice,DRG,MS-663,MINOR BLADDER PROCEDURES WITH CC,Surgical,Relative Weights,"$14,447.09 ",IP,"2,420.00","30,711.74",,,,,,
BCBS Blue Choice,DRG,MS-664,MINOR BLADDER PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,494.39 ",IP,"2,420.00","22,309.06",,,,,,
BCBS Blue Choice,DRG,MS-665,PROSTATECTOMY WITH MCC,Surgical,Relative Weights,"$28,151.62 ",IP,"2,420.00","59,844.96",,,,,,
BCBS Blue Choice,DRG,MS-666,PROSTATECTOMY WITH CC,Surgical,Relative Weights,"$16,777.17 ",IP,"2,420.00","35,665.06",,,,,,
BCBS Blue Choice,DRG,MS-667,PROSTATECTOMY W/O CC/MCC,Surgical,Relative Weights,"$8,902.11 ",IP,"2,420.00","18,924.19",,,,,,
BCBS Blue Choice,DRG,MS-668,TRANSURETHRAL PROCEDURES W MCC,Surgical,Relative Weights,"$26,442.70 ",IP,"2,420.00","56,212.13",,,,,,
BCBS Blue Choice,DRG,MS-669,TRANSURETHRAL PROCEDURES WITH CC,Surgical,Relative Weights,"$14,658.57 ",IP,"2,420.00","31,161.31",,,,,,
BCBS Blue Choice,DRG,MS-670,TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$9,281.45 ",IP,"2,420.00","19,730.59",,,,,,
BCBS Blue Choice,DRG,MS-671,URETHRAL PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$17,331.95 ",IP,"2,420.00","36,844.42",,,,,,
BCBS Blue Choice,DRG,MS-672,URETHRAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$9,798.30 ",IP,"2,420.00","20,829.31",,,,,,
BCBS Blue Choice,DRG,MS-673,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,Surgical,Relative Weights,"$33,899.54 ",IP,"2,420.00","72,063.94",,,,,,
BCBS Blue Choice,DRG,MS-674,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,Surgical,Relative Weights,"$23,179.45 ",IP,"2,420.00","49,275.07",,,,,,
BCBS Blue Choice,DRG,MS-675,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$15,476.99 ",IP,"2,420.00","32,901.12",,,,,,
BCBS Blue Choice,DRG,MS-682,RENAL FAILURE WITH MCC,Surgical,Relative Weights,"$14,016.54 ",IP,"2,420.00","29,796.48",,,,,,
BCBS Blue Choice,DRG,MS-683,RENAL FAILURE WITH CC,Surgical,Relative Weights,"$8,509.50 ",IP,"2,420.00","18,089.57",,,,,,
BCBS Blue Choice,DRG,MS-684,RENAL FAILURE WITHOUT CC/MCC,Surgical,Relative Weights,"$5,835.17 ",IP,"2,420.00","12,404.45",,,,,,
BCBS Blue Choice,DRG,MS-686,KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,Surgical,Relative Weights,"$16,653.89 ",IP,"2,420.00","35,402.98",,,,,,
BCBS Blue Choice,DRG,MS-687,KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,Surgical,Relative Weights,"$9,982.28 ",IP,"2,420.00","21,220.42",,,,,,
BCBS Blue Choice,DRG,MS-688,KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,Surgical,Relative Weights,"$7,314.59 ",IP,"2,420.00","15,549.41",,,,,,
BCBS Blue Choice,DRG,MS-689,KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,Surgical,Relative Weights,"$10,608.19 ",IP,"2,420.00","22,550.98",,,,,,
BCBS Blue Choice,DRG,MS-690,KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,Surgical,Relative Weights,"$7,499.51 ",IP,"2,420.00","15,942.53",,,,,,
BCBS Blue Choice,DRG,MS-693,URINARY STONES WITH MCC,Surgical,Relative Weights,"$12,833.95 ",IP,"2,420.00","27,282.53",,,,,,
BCBS Blue Choice,DRG,MS-694,URINARY STONES WITHOUT MCC,Surgical,Relative Weights,"$7,021.55 ",IP,"2,420.00","14,926.46",,,,,,
BCBS Blue Choice,DRG,MS-695,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,Surgical,Relative Weights,"$11,117.45 ",IP,"2,420.00","23,633.57",,,,,,
BCBS Blue Choice,DRG,MS-696,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,Surgical,Relative Weights,"$6,443.06 ",IP,"2,420.00","13,696.70",,,,,,
BCBS Blue Choice,DRG,MS-697,URETHRAL STRICTURE,Surgical,Relative Weights,"$9,235.93 ",IP,"2,420.00","19,633.82",,,,,,
BCBS Blue Choice,DRG,MS-698,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,Surgical,Relative Weights,"$15,349.91 ",IP,"2,420.00","32,630.98",,,,,,
BCBS Blue Choice,DRG,MS-699,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,Surgical,Relative Weights,"$9,793.56 ",IP,"2,420.00","20,819.23",,,,,,
BCBS Blue Choice,DRG,MS-700,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,033.87 ",IP,"2,420.00","14,952.67",,,,,,
BCBS Blue Choice,DRG,MS-707,MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$17,733.10 ",IP,"2,420.00","37,697.18",,,,,,
BCBS Blue Choice,DRG,MS-708,MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$13,769.97 ",IP,"2,420.00","29,272.32",,,,,,
BCBS Blue Choice,DRG,MS-709,PENIS PROCEDURES W CC/MCC,Surgical,Relative Weights,"$22,813.39 ",IP,"2,420.00","48,496.90",,,,,,
BCBS Blue Choice,DRG,MS-710,PENIS PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$14,564.68 ",IP,"2,420.00","30,961.73",,,,,,
BCBS Blue Choice,DRG,MS-711,TESTES PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$20,324.93 ",IP,"2,420.00","43,206.91",,,,,,
BCBS Blue Choice,DRG,MS-712,TESTES PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$9,675.02 ",IP,"2,420.00","20,567.23",,,,,,
BCBS Blue Choice,DRG,MS-713,TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,Surgical,Relative Weights,"$13,864.80 ",IP,"2,420.00","29,473.92",,,,,,
BCBS Blue Choice,DRG,MS-714,TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,Surgical,Relative Weights,"$8,681.15 ",IP,"2,420.00","18,454.46",,,,,,
BCBS Blue Choice,DRG,MS-715,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,Surgical,Relative Weights,"$20,261.39 ",IP,"2,420.00","43,071.84",,,,,,
BCBS Blue Choice,DRG,MS-716,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$13,898.00 ",IP,"2,420.00","29,544.48",,,,,,
BCBS Blue Choice,DRG,MS-717,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,Surgical,Relative Weights,"$16,731.65 ",IP,"2,420.00","35,568.29",,,,,,
BCBS Blue Choice,DRG,MS-718,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$11,564.12 ",IP,"2,420.00","24,583.10",,,,,,
BCBS Blue Choice,DRG,MS-722,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH MCC,Surgical,Relative Weights,"$17,116.68 ",IP,"2,420.00","36,386.78",,,,,,
BCBS Blue Choice,DRG,MS-723,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH CC,Surgical,Relative Weights,"$10,501.97 ",IP,"2,420.00","22,325.18",,,,,,
BCBS Blue Choice,DRG,MS-724,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Surgical,Relative Weights,"$5,599.03 ",IP,"2,420.00","11,902.46",,,,,,
BCBS Blue Choice,DRG,MS-725,BENIGN PROSTATIC HYPERTROPHY WITH MCC,Surgical,Relative Weights,"$11,905.52 ",IP,"2,420.00","25,308.86",,,,,,
BCBS Blue Choice,DRG,MS-726,BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,Surgical,Relative Weights,"$7,251.99 ",IP,"2,420.00","15,416.35",,,,,,
BCBS Blue Choice,DRG,MS-727,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,Surgical,Relative Weights,"$13,535.73 ",IP,"2,420.00","28,774.37",,,,,,
BCBS Blue Choice,DRG,MS-728,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,Surgical,Relative Weights,"$7,610.47 ",IP,"2,420.00","16,178.40",,,,,,
BCBS Blue Choice,DRG,MS-729,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,Surgical,Relative Weights,"$10,184.28 ",IP,"2,420.00","21,649.82",,,,,,
BCBS Blue Choice,DRG,MS-730,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Surgical,Relative Weights,"$5,989.75 ",IP,"2,420.00","12,733.06",,,,,,
BCBS Blue Choice,DRG,MS-734,PELVIC EVISCERATION -  RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC,Surgical,Relative Weights,"$20,786.77 ",IP,"2,420.00","44,188.70",,,,,,
BCBS Blue Choice,DRG,MS-735,PELVIC EVISCERATION -  RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC,Surgical,Relative Weights,"$13,032.16 ",IP,"2,420.00","27,703.87",,,,,,
BCBS Blue Choice,DRG,MS-736,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,Surgical,Relative Weights,"$40,977.04 ",IP,"2,420.00","87,109.34",,,,,,
BCBS Blue Choice,DRG,MS-737,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,Surgical,Relative Weights,"$18,844.56 ",IP,"2,420.00","40,059.94",,,,,,
BCBS Blue Choice,DRG,MS-738,UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY W/O CC/MCC,Surgical,Relative Weights,"$13,076.73 ",IP,"2,420.00","27,798.62",,,,,,
BCBS Blue Choice,DRG,MS-739,UTERINE -ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W MCC,Surgical,Relative Weights,"$35,510.78 ",IP,"2,420.00","75,489.12",,,,,,
BCBS Blue Choice,DRG,MS-740,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,Surgical,Relative Weights,"$16,927.01 ",IP,"2,420.00","35,983.58",,,,,,
BCBS Blue Choice,DRG,MS-741,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$12,608.25 ",IP,"2,420.00","26,802.72",,,,,,
BCBS Blue Choice,DRG,MS-742,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,Surgical,Relative Weights,"$16,022.29 ",IP,"2,420.00","34,060.32",,,,,,
BCBS Blue Choice,DRG,MS-743,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$10,891.74 ",IP,"2,420.00","23,153.76",,,,,,
BCBS Blue Choice,DRG,MS-744,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC,Surgical,Relative Weights,"$16,505.94 ",IP,"2,420.00","35,088.48",,,,,,
BCBS Blue Choice,DRG,MS-745,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC,Surgical,Relative Weights,"$10,102.72 ",IP,"2,420.00","21,476.45",,,,,,
BCBS Blue Choice,DRG,MS-746,VAGINA -  CERVIX AND VULVA PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$15,467.51 ",IP,"2,420.00","32,880.96",,,,,,
BCBS Blue Choice,DRG,MS-747,VAGINA- CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,840.47 ",IP,"2,420.00","18,793.15",,,,,,
BCBS Blue Choice,DRG,MS-748,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,Surgical,Relative Weights,"$12,534.28 ",IP,"2,420.00","26,645.47",,,,,,
BCBS Blue Choice,DRG,MS-749,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$24,583.00 ",IP,"2,420.00","52,258.75",,,,,,
BCBS Blue Choice,DRG,MS-750,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$12,624.37 ",IP,"2,420.00","26,836.99",,,,,,
BCBS Blue Choice,DRG,MS-754,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH MCC,Surgical,Relative Weights,"$16,708.89 ",IP,"2,420.00","35,519.90",,,,,,
BCBS Blue Choice,DRG,MS-755,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH CC,Surgical,Relative Weights,"$9,709.16 ",IP,"2,420.00","20,639.81",,,,,,
BCBS Blue Choice,DRG,MS-756,MALIGNANCY - FEMALE REPRODUCTIVE SYSTEM W/O CC/MCC,Surgical,Relative Weights,"$8,315.09 ",IP,"2,420.00","17,676.29",,,,,,
BCBS Blue Choice,DRG,MS-757,INFECTIONS - FEMALE REPRODUCTIVE SYSTEM W MCC,Surgical,Relative Weights,"$13,469.34 ",IP,"2,420.00","28,633.25",,,,,,
BCBS Blue Choice,DRG,MS-758,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITH CC,Surgical,Relative Weights,"$9,155.32 ",IP,"2,420.00","19,462.46",,,,,,
BCBS Blue Choice,DRG,MS-759,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Surgical,Relative Weights,"$6,261.92 ",IP,"2,420.00","13,311.65",,,,,,
BCBS Blue Choice,DRG,MS-760,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,Surgical,Relative Weights,"$8,558.81 ",IP,"2,420.00","18,194.40",,,,,,
BCBS Blue Choice,DRG,MS-761,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$5,361.94 ",IP,"2,420.00","11,398.46",,,,,,
BCBS Blue Choice,DRG,MS-768,VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C,Surgical,Relative Weights,"$9,554.58 ",IP,"2,420.00","20,311.20",,,,,,
BCBS Blue Choice,DRG,MS-769,POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,Surgical,Relative Weights,"$13,684.62 ",IP,"2,420.00","29,090.88",,,,,,
BCBS Blue Choice,DRG,MS-770,ABORTION WITH D&C- ASPIRATION CURETTAGE OR HYSTEROTOMY,Surgical,Relative Weights,"$7,456.84 ",IP,"2,420.00","15,851.81",,,,,,
BCBS Blue Choice,DRG,MS-776,POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,Surgical,Relative Weights,"$6,732.30 ",IP,"2,420.00","14,311.58",,,,,,
BCBS Blue Choice,DRG,MS-779,ABORTION WITHOUT D&C,Surgical,Relative Weights,"$10,828.20 ",IP,"2,420.00","23,018.69",,,,,,
BCBS Blue Choice,DRG,MS-783,CESAREAN SECTION WITH STERILIZATION WITH MCC,Surgical,Relative Weights,"$20,340.10 ",IP,"2,420.00","43,239.17",,,,,,
BCBS Blue Choice,DRG,MS-784,CESAREAN SECTION WITH STERILIZATION WITH CC,Surgical,Relative Weights,"$9,912.10 ",IP,"2,420.00","21,071.23",,,,,,
BCBS Blue Choice,DRG,MS-785,CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,Surgical,Relative Weights,"$8,140.59 ",IP,"2,420.00","17,305.34",,,,,,
BCBS Blue Choice,DRG,MS-786,CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,Surgical,Relative Weights,"$16,259.38 ",IP,"2,420.00","34,564.32",,,,,,
BCBS Blue Choice,DRG,MS-787,CESAREAN SECTION WITHOUT STERILIZATION WITH CC,Surgical,Relative Weights,"$9,914.95 ",IP,"2,420.00","21,077.28",,,,,,
BCBS Blue Choice,DRG,MS-788,CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,Surgical,Relative Weights,"$8,593.90 ",IP,"2,420.00","18,268.99",,,,,,
BCBS Blue Choice,DRG,MS-789,NEONATES- DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY,Surgical,Relative Weights,"$16,027.03 ",IP,"2,420.00","34,070.40",,,,,,
BCBS Blue Choice,DRG,MS-790,EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME- NEONATE,Surgical,Relative Weights,"$52,851.27 ",IP,"2,420.00","112,351.68",,,,,,
BCBS Blue Choice,DRG,MS-791,PREMATURITY W MAJOR PROBLEMS,Surgical,Relative Weights,"$36,095.91 ",IP,"2,420.00","76,732.99",,,,,,
BCBS Blue Choice,DRG,MS-792,PREMATURITY W/O MAJOR PROBLEMS,Surgical,Relative Weights,"$21,778.74 ",IP,"2,420.00","46,297.44",,,,,,
BCBS Blue Choice,DRG,MS-793,FULL TERM NEONATE WITH MAJOR PROBLEMS,Surgical,Relative Weights,"$37,077.44 ",IP,"2,420.00","78,819.55",,,,,,
BCBS Blue Choice,DRG,MS-794,NEONATE WITH OTHER SIGNIFICANT PROBLEMS,Surgical,Relative Weights,"$13,123.20 ",IP,"2,420.00","27,897.41",,,,,,
BCBS Blue Choice,DRG,MS-795,NORMAL NEWBORN,Surgical,Relative Weights,"$1,776.25 ",IP,"1,113.70","3,775.97",,,,,,
BCBS Blue Choice,DRG,MS-796,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,Surgical,Relative Weights,"$18,704.21 ",IP,"2,420.00","39,761.57",,,,,,
BCBS Blue Choice,DRG,MS-797,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,Surgical,Relative Weights,"$8,182.32 ",IP,"2,420.00","17,394.05",,,,,,
BCBS Blue Choice,DRG,MS-798,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,Surgical,Relative Weights,"$8,182.32 ",IP,"2,420.00","17,394.05",,,,,,
BCBS Blue Choice,DRG,MS-799,SPLENECTOMY WITH MCC,Surgical,Relative Weights,"$46,889.02 ",IP,"2,420.00","99,677.09",,,,,,
BCBS Blue Choice,DRG,MS-800,SPLENECTOMY WITH CC,Surgical,Relative Weights,"$26,951.96 ",IP,"2,420.00","57,294.72",,,,,,
BCBS Blue Choice,DRG,MS-801,SPLENECTOMY WITHOUT CC/MCC,Surgical,Relative Weights,"$17,764.40 ",IP,"2,420.00","37,763.71",,,,,,
BCBS Blue Choice,DRG,MS-802,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,Surgical,Relative Weights,"$29,895.63 ",IP,"2,420.00","63,552.38",,,,,,
BCBS Blue Choice,DRG,MS-803,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,Surgical,Relative Weights,"$16,895.71 ",IP,"2,420.00","35,917.06",,,,,,
BCBS Blue Choice,DRG,MS-804,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,Surgical,Relative Weights,"$12,922.15 ",IP,"2,420.00","27,470.02",,,,,,
BCBS Blue Choice,DRG,MS-805,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,Surgical,Relative Weights,"$9,869.43 ",IP,"2,420.00","20,980.51",,,,,,
BCBS Blue Choice,DRG,MS-806,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,Surgical,Relative Weights,"$6,725.66 ",IP,"2,420.00","14,297.47",,,,,,
BCBS Blue Choice,DRG,MS-807,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,Surgical,Relative Weights,"$5,944.23 ",IP,"2,420.00","12,636.29",,,,,,
BCBS Blue Choice,DRG,MS-808,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,Surgical,Relative Weights,"$20,195.96 ",IP,"2,420.00","42,932.74",,,,,,
BCBS Blue Choice,DRG,MS-809,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,Surgical,Relative Weights,"$11,530.93 ",IP,"2,420.00","24,512.54",,,,,,
BCBS Blue Choice,DRG,MS-810,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$8,870.82 ",IP,"2,420.00","18,857.66",,,,,,
BCBS Blue Choice,DRG,MS-811,RED BLOOD CELL DISORDERS WITH MCC,Surgical,Relative Weights,"$12,710.67 ",IP,"2,420.00","27,020.45",,,,,,
BCBS Blue Choice,DRG,MS-812,RED BLOOD CELL DISORDERS WITHOUT MCC,Surgical,Relative Weights,"$8,257.24 ",IP,"2,420.00","17,553.31",,,,,,
BCBS Blue Choice,DRG,MS-813,COAGULATION DISORDERS,Surgical,Relative Weights,"$15,033.16 ",IP,"2,420.00","31,957.63",,,,,,
BCBS Blue Choice,DRG,MS-814,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,Surgical,Relative Weights,"$16,587.50 ",IP,"2,420.00","35,261.86",,,,,,
BCBS Blue Choice,DRG,MS-815,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,Surgical,Relative Weights,"$9,604.84 ",IP,"2,420.00","20,418.05",,,,,,
BCBS Blue Choice,DRG,MS-816,RETICULOENDOTHELIAL & IMMUNITY DISORDERS W/O CC/MCC,Surgical,Relative Weights,"$6,789.20 ",IP,"2,420.00","14,432.54",,,,,,
BCBS Blue Choice,DRG,MS-817,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$23,862.26 ",IP,"2,420.00","50,726.59",,,,,,
BCBS Blue Choice,DRG,MS-818,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$12,080.97 ",IP,"2,420.00","25,681.82",,,,,,
BCBS Blue Choice,DRG,MS-819,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,566.84 ",IP,"2,420.00","16,085.66",,,,,,
BCBS Blue Choice,DRG,MS-820,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$54,214.04 ",IP,"2,420.00","115,248.67",,,,,,
BCBS Blue Choice,DRG,MS-821,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$21,169.91 ",IP,"2,420.00","45,003.17",,,,,,
BCBS Blue Choice,DRG,MS-822,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$11,990.87 ",IP,"2,420.00","25,490.30",,,,,,
BCBS Blue Choice,DRG,MS-823,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,Surgical,Relative Weights,"$40,116.89 ",IP,"2,420.00","85,280.83",,,,,,
BCBS Blue Choice,DRG,MS-824,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,Surgical,Relative Weights,"$22,049.97 ",IP,"2,420.00","46,874.02",,,,,,
BCBS Blue Choice,DRG,MS-825,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$12,845.33 ",IP,"2,420.00","27,306.72",,,,,,
BCBS Blue Choice,DRG,MS-826,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$47,559.50 ",IP,"2,420.00","101,102.40",,,,,,
BCBS Blue Choice,DRG,MS-827,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$21,965.57 ",IP,"2,420.00","46,694.59",,,,,,
BCBS Blue Choice,DRG,MS-828,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$15,659.07 ",IP,"2,420.00","33,288.19",,,,,,
BCBS Blue Choice,DRG,MS-829,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$29,777.08 ",IP,"2,420.00","63,300.38",,,,,,
BCBS Blue Choice,DRG,MS-830,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$13,075.78 ",IP,"2,420.00","27,796.61",,,,,,
BCBS Blue Choice,DRG,MS-831,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$10,227.90 ",IP,"2,420.00","21,742.56",,,,,,
BCBS Blue Choice,DRG,MS-832,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$6,785.41 ",IP,"2,420.00","14,424.48",,,,,,
BCBS Blue Choice,DRG,MS-833,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$5,046.14 ",IP,"2,420.00","10,727.14",,,,,,
BCBS Blue Choice,DRG,MS-834,ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W MCC,Surgical,Relative Weights,"$55,407.06 ",IP,"2,420.00","117,784.80",,,,,,
BCBS Blue Choice,DRG,MS-835,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$19,234.33 ",IP,"2,420.00","40,888.51",,,,,,
BCBS Blue Choice,DRG,MS-836,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$12,495.39 ",IP,"2,420.00","26,562.82",,,,,,
BCBS Blue Choice,DRG,MS-837,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,Surgical,Relative Weights,"$56,813.45 ",IP,"2,420.00","120,774.53",,,,,,
BCBS Blue Choice,DRG,MS-838,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,Surgical,Relative Weights,"$20,748.84 ",IP,"2,420.00","44,108.06",,,,,,
BCBS Blue Choice,DRG,MS-839,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$12,102.78 ",IP,"2,420.00","25,728.19",,,,,,
BCBS Blue Choice,DRG,MS-840,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,Surgical,Relative Weights,"$30,301.52 ",IP,"2,420.00","64,415.23",,,,,,
BCBS Blue Choice,DRG,MS-841,LYMPHOMA & NON-ACUTE LEUKEMIA W CC,Surgical,Relative Weights,"$15,284.48 ",IP,"2,420.00","32,491.87",,,,,,
BCBS Blue Choice,DRG,MS-842,LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,Surgical,Relative Weights,"$10,873.72 ",IP,"2,420.00","23,115.46",,,,,,
BCBS Blue Choice,DRG,MS-843,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,Surgical,Relative Weights,"$18,092.53 ",IP,"2,420.00","38,461.25",,,,,,
BCBS Blue Choice,DRG,MS-844,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,Surgical,Relative Weights,"$11,456.01 ",IP,"2,420.00","24,353.28",,,,,,
BCBS Blue Choice,DRG,MS-845,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,211.72 ",IP,"2,420.00","17,456.54",,,,,,
BCBS Blue Choice,DRG,MS-846,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$24,909.23 ",IP,"2,420.00","52,952.26",,,,,,
BCBS Blue Choice,DRG,MS-847,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,Surgical,Relative Weights,"$12,479.27 ",IP,"2,420.00","26,528.54",,,,,,
BCBS Blue Choice,DRG,MS-848,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$9,307.06 ",IP,"2,420.00","19,785.02",,,,,,
BCBS Blue Choice,DRG,MS-849,RADIOTHERAPY,Surgical,Relative Weights,"$20,159.92 ",IP,"2,420.00","42,856.13",,,,,,
BCBS Blue Choice,DRG,MS-853,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$48,352.32 ",IP,"2,420.00","102,787.78",,,,,,
BCBS Blue Choice,DRG,MS-854,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$20,495.63 ",IP,"2,420.00","43,569.79",,,,,,
BCBS Blue Choice,DRG,MS-855,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$15,204.82 ",IP,"2,420.00","32,322.53",,,,,,
BCBS Blue Choice,DRG,MS-856,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$41,970.90 ",IP,"2,420.00","89,222.11",,,,,,
BCBS Blue Choice,DRG,MS-857,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$19,282.70 ",IP,"2,420.00","40,991.33",,,,,,
BCBS Blue Choice,DRG,MS-858,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$13,053.02 ",IP,"2,420.00","27,748.22",,,,,,
BCBS Blue Choice,DRG,MS-862,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W MCC,Surgical,Relative Weights,"$17,550.07 ",IP,"2,420.00","37,308.10",,,,,,
BCBS Blue Choice,DRG,MS-863,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W/O MCC,Surgical,Relative Weights,"$9,369.65 ",IP,"2,420.00","19,918.08",,,,,,
BCBS Blue Choice,DRG,MS-864,FEVER AND INFLAMMATORY CONDITIONS,Surgical,Relative Weights,"$8,036.28 ",IP,"2,420.00","17,083.58",,,,,,
BCBS Blue Choice,DRG,MS-865,VIRAL ILLNESS WITH MCC,Surgical,Relative Weights,"$13,213.29 ",IP,"2,420.00","28,088.93",,,,,,
BCBS Blue Choice,DRG,MS-866,VIRAL ILLNESS WITHOUT MCC,Surgical,Relative Weights,"$7,764.10 ",IP,"2,420.00","16,504.99",,,,,,
BCBS Blue Choice,DRG,MS-867,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,Surgical,Relative Weights,"$20,723.23 ",IP,"2,420.00","44,053.63",,,,,,
BCBS Blue Choice,DRG,MS-868,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,Surgical,Relative Weights,"$10,403.34 ",IP,"2,420.00","22,115.52",,,,,,
BCBS Blue Choice,DRG,MS-869,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,041.46 ",IP,"2,420.00","14,968.80",,,,,,
BCBS Blue Choice,DRG,MS-870,SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,Surgical,Relative Weights,"$59,976.18 ",IP,"2,420.00","127,497.89",,,,,,
BCBS Blue Choice,DRG,MS-871,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,Surgical,Relative Weights,"$17,698.96 ",IP,"2,420.00","37,624.61",,,,,,
BCBS Blue Choice,DRG,MS-872,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,Surgical,Relative Weights,"$9,856.15 ",IP,"2,420.00","20,952.29",,,,,,
BCBS Blue Choice,DRG,MS-876,O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,Surgical,Relative Weights,"$34,519.76 ",IP,"2,420.00","73,382.40",,,,,,
BCBS Blue Choice,DRG,MS-880,ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,Surgical,Relative Weights,"$8,126.37 ",IP,"2,420.00","17,275.10",,,,,,
BCBS Blue Choice,DRG,MS-881,DEPRESSIVE NEUROSES,Surgical,Relative Weights,"$7,769.79 ",IP,"2,420.00","16,517.09",,,,,,
BCBS Blue Choice,DRG,MS-882,NEUROSES EXCEPT DEPRESSIVE,Surgical,Relative Weights,"$7,490.03 ",IP,"2,420.00","15,922.37",,,,,,
BCBS Blue Choice,DRG,MS-883,DISORDERS OF PERSONALITY & IMPULSE CONTROL,Surgical,Relative Weights,"$12,675.58 ",IP,"2,420.00","26,945.86",,,,,,
BCBS Blue Choice,DRG,MS-884,ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,Surgical,Relative Weights,"$13,637.20 ",IP,"2,420.00","28,990.08",,,,,,
BCBS Blue Choice,DRG,MS-885,PSYCHOSES,Surgical,Relative Weights,"$11,526.19 ",IP,"2,420.00","24,502.46",,,,,,
BCBS Blue Choice,DRG,MS-886,BEHAVIORAL AND DEVELOPMENTAL DISORDERS,Surgical,Relative Weights,"$12,760.93 ",IP,"2,420.00","27,127.30",,,,,,
BCBS Blue Choice,DRG,MS-887,OTHER MENTAL DISORDER DIAGNOSES,Surgical,Relative Weights,"$10,318.94 ",IP,"2,420.00","21,936.10",,,,,,
BCBS Blue Choice,DRG,MS-894,ALCOHOL- DRUG ABUSE OR DEPENDENCE- LEFT AMA,Surgical,Relative Weights,"$5,504.19 ",IP,"2,420.00","11,700.86",,,,,,
BCBS Blue Choice,DRG,MS-895,ALCOHOL- DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY,Surgical,Relative Weights,"$15,428.62 ",IP,"2,420.00","32,798.30",,,,,,
BCBS Blue Choice,DRG,MS-896,ALCOHOL -  DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC,Surgical,Relative Weights,"$16,308.69 ",IP,"2,420.00","34,669.15",,,,,,
BCBS Blue Choice,DRG,MS-897,ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC,Surgical,Relative Weights,"$7,793.50 ",IP,"2,420.00","16,567.49",,,,,,
BCBS Blue Choice,DRG,MS-901,WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,Surgical,Relative Weights,"$41,036.78 ",IP,"2,420.00","87,236.35",,,,,,
BCBS Blue Choice,DRG,MS-902,WOUND DEBRIDEMENTS FOR INJURIES WITH CC,Surgical,Relative Weights,"$18,653.00 ",IP,"2,420.00","39,652.70",,,,,,
BCBS Blue Choice,DRG,MS-903,WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,849.07 ",IP,"2,420.00","23,063.04",,,,,,
BCBS Blue Choice,DRG,MS-904,SKIN GRAFTS FOR INJURIES WITH CC/MCC,Surgical,Relative Weights,"$33,546.76 ",IP,"2,420.00","71,313.98",,,,,,
BCBS Blue Choice,DRG,MS-905,SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,Surgical,Relative Weights,"$15,784.25 ",IP,"2,420.00","33,554.30",,,,,,
BCBS Blue Choice,DRG,MS-906,HAND PROCEDURES FOR INJURIES,Surgical,Relative Weights,"$16,509.74 ",IP,"2,420.00","35,096.54",,,,,,
BCBS Blue Choice,DRG,MS-907,OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,Surgical,Relative Weights,"$37,835.17 ",IP,"2,420.00","80,430.34",,,,,,
BCBS Blue Choice,DRG,MS-908,OTHER O.R. PROCEDURES FOR INJURIES WITH CC,Surgical,Relative Weights,"$19,565.31 ",IP,"2,420.00","41,592.10",,,,,,
BCBS Blue Choice,DRG,MS-909,OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,Surgical,Relative Weights,"$12,505.83 ",IP,"2,420.00","26,584.99",,,,,,
BCBS Blue Choice,DRG,MS-913,TRAUMATIC INJURY WITH MCC,Surgical,Relative Weights,"$14,000.42 ",IP,"2,420.00","29,762.21",,,,,,
BCBS Blue Choice,DRG,MS-914,TRAUMATIC INJURY WITHOUT MCC,Surgical,Relative Weights,"$8,171.89 ",IP,"2,420.00","17,371.87",,,,,,
BCBS Blue Choice,DRG,MS-915,ALLERGIC REACTIONS WITH MCC,Surgical,Relative Weights,"$16,113.33 ",IP,"2,420.00","34,253.86",,,,,,
BCBS Blue Choice,DRG,MS-916,ALLERGIC REACTIONS WITHOUT MCC,Surgical,Relative Weights,"$6,004.92 ",IP,"2,420.00","12,765.31",,,,,,
BCBS Blue Choice,DRG,MS-917,POISONING & TOXIC EFFECTS OF DRUGS W MCC,Surgical,Relative Weights,"$13,876.18 ",IP,"2,420.00","29,498.11",,,,,,
BCBS Blue Choice,DRG,MS-918,POISONING & TOXIC EFFECTS OF DRUGS W/O MCC,Surgical,Relative Weights,"$7,435.02 ",IP,"2,420.00","15,805.44",,,,,,
BCBS Blue Choice,DRG,MS-919,COMPLICATIONS OF TREATMENT WITH MCC,Surgical,Relative Weights,"$17,310.14 ",IP,"2,420.00","36,798.05",,,,,,
BCBS Blue Choice,DRG,MS-920,COMPLICATIONS OF TREATMENT WITH CC,Surgical,Relative Weights,"$9,554.58 ",IP,"2,420.00","20,311.20",,,,,,
BCBS Blue Choice,DRG,MS-921,COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,Surgical,Relative Weights,"$6,549.27 ",IP,"2,420.00","13,922.50",,,,,,
BCBS Blue Choice,DRG,MS-922,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC,Surgical,Relative Weights,"$15,207.66 ",IP,"2,420.00","32,328.58",,,,,,
BCBS Blue Choice,DRG,MS-923,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC,Surgical,Relative Weights,"$8,207.93 ",IP,"2,420.00","17,448.48",,,,,,
BCBS Blue Choice,DRG,MS-927,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,Surgical,Relative Weights,"$189,133.19 ",IP,"2,420.00","402,060.96",,,,,,
BCBS Blue Choice,DRG,MS-928,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,Surgical,Relative Weights,"$58,749.02 ",IP,"2,420.00","124,889.18",,,,,,
BCBS Blue Choice,DRG,MS-929,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,Surgical,Relative Weights,"$27,895.57 ",IP,"2,420.00","59,300.64",,,,,,
BCBS Blue Choice,DRG,MS-933,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,Surgical,Relative Weights,"$29,779.93 ",IP,"2,420.00","63,306.43",,,,,,
BCBS Blue Choice,DRG,MS-934,FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,Surgical,Relative Weights,"$17,163.15 ",IP,"2,420.00","36,485.57",,,,,,
BCBS Blue Choice,DRG,MS-935,NON-EXTENSIVE BURNS,Surgical,Relative Weights,"$18,324.87 ",IP,"2,420.00","38,955.17",,,,,,
BCBS Blue Choice,DRG,MS-939,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,Surgical,Relative Weights,"$34,656.32 ",IP,"2,420.00","73,672.70",,,,,,
BCBS Blue Choice,DRG,MS-940,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,Surgical,Relative Weights,"$21,544.50 ",IP,"2,420.00","45,799.49",,,,,,
BCBS Blue Choice,DRG,MS-941,O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W/O CC/MCC,Surgical,Relative Weights,"$18,309.70 ",IP,"2,420.00","38,922.91",,,,,,
BCBS Blue Choice,DRG,MS-945,REHABILITATION WITH CC/MCC,Surgical,Relative Weights,"$13,801.26 ",IP,"2,420.00","29,338.85",,,,,,
BCBS Blue Choice,DRG,MS-946,REHABILITATION WITHOUT CC/MCC,Surgical,Relative Weights,"$10,308.51 ",IP,"2,420.00","21,913.92",,,,,,
BCBS Blue Choice,DRG,MS-947,SIGNS AND SYMPTOMS WITH MCC,Surgical,Relative Weights,"$11,354.53 ",IP,"2,420.00","24,137.57",,,,,,
BCBS Blue Choice,DRG,MS-948,SIGNS AND SYMPTOMS WITHOUT MCC,Surgical,Relative Weights,"$7,393.30 ",IP,"2,420.00","15,716.74",,,,,,
BCBS Blue Choice,DRG,MS-949,AFTERCARE WITH CC/MCC,Surgical,Relative Weights,"$10,326.53 ",IP,"2,420.00","21,952.22",,,,,,
BCBS Blue Choice,DRG,MS-950,AFTERCARE WITHOUT CC/MCC,Surgical,Relative Weights,"$7,026.29 ",IP,"2,420.00","14,936.54",,,,,,
BCBS Blue Choice,DRG,MS-951,OTHER FACTORS INFLUENCING HEALTH STATUS,Surgical,Relative Weights,"$5,562.04 ",IP,"2,420.00","11,823.84",,,,,,
BCBS Blue Choice,DRG,MS-955,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,Surgical,Relative Weights,"$57,664.12 ",IP,"2,420.00","122,582.88",,,,,,
BCBS Blue Choice,DRG,MS-956,LIMB REATTACHMENT- HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,Surgical,Relative Weights,"$37,206.42 ",IP,"2,420.00","79,093.73",,,,,,
BCBS Blue Choice,DRG,MS-957,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Surgical,Relative Weights,"$71,445.47 ",IP,"2,420.00","151,879.39",,,,,,
BCBS Blue Choice,DRG,MS-958,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,Surgical,Relative Weights,"$39,744.19 ",IP,"2,420.00","84,488.54",,,,,,
BCBS Blue Choice,DRG,MS-959,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,Surgical,Relative Weights,"$26,558.40 ",IP,"2,420.00","56,458.08",,,,,,
BCBS Blue Choice,DRG,MS-963,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Surgical,Relative Weights,"$25,843.35 ",IP,"2,420.00","54,938.02",,,,,,
BCBS Blue Choice,DRG,MS-964,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,Surgical,Relative Weights,"$14,163.53 ",IP,"2,420.00","30,108.96",,,,,,
BCBS Blue Choice,DRG,MS-965,OTHER MULTIPLE SIGNIFICANT TRAUMA W/O CC/MCC,Surgical,Relative Weights,"$8,697.27 ",IP,"2,420.00","18,488.74",,,,,,
BCBS Blue Choice,DRG,MS-969,HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$55,029.62 ",IP,"2,420.00","116,982.43",,,,,,
BCBS Blue Choice,DRG,MS-970,HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$27,663.22 ",IP,"2,420.00","58,806.72",,,,,,
BCBS Blue Choice,DRG,MS-974,HIV WITH MAJOR RELATED CONDITION WITH MCC,Surgical,Relative Weights,"$25,357.80 ",IP,"2,420.00","53,905.82",,,,,,
BCBS Blue Choice,DRG,MS-975,HIV WITH MAJOR RELATED CONDITION WITH CC,Surgical,Relative Weights,"$12,726.79 ",IP,"2,420.00","27,054.72",,,,,,
BCBS Blue Choice,DRG,MS-976,HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,Surgical,Relative Weights,"$8,669.77 ",IP,"2,420.00","18,430.27",,,,,,
BCBS Blue Choice,DRG,MS-977,HIV WITH OR WITHOUT OTHER RELATED CONDITION,Surgical,Relative Weights,"$12,333.23 ",IP,"2,420.00","26,218.08",,,,,,
BCBS Blue Choice,DRG,MS-981,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$42,587.33 ",IP,"2,420.00","90,532.51",,,,,,
BCBS Blue Choice,DRG,MS-982,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Surgical,Relative Weights,"$23,121.60 ",IP,"2,420.00","49,152.10",,,,,,
BCBS Blue Choice,DRG,MS-983,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$15,525.36 ",IP,"2,420.00","33,003.94",,,,,,
BCBS Blue Choice,DRG,MS-987,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$31,614.98 ",IP,"2,420.00","67,207.39",,,,,,
BCBS Blue Choice,DRG,MS-988,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Surgical,Relative Weights,"$16,295.41 ",IP,"2,420.00","34,640.93",,,,,,
BCBS Blue Choice,DRG,MS-989,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$10,928.73 ",IP,"2,420.00","23,232.38",,,,,,
BCBS Blue Choice,CPT,11970,Rplcmt tiss xpndr perm implt,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,11970,Rplcmt tiss xpndr perm implt,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,15732,Muscle-skin graft head/neck,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,15732,Muscle-skin graft head/neck,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,15733,Musc myoq/fscq flp h&n pedcl,,Per Case,"$4,140.35 ",OP,"3,604.28","9,201.00",,,,,,
BCBS Blue Choice,CPT,15733,Musc myoq/fscq flp h&n pedcl,,Per Case,"$7,820.85 ",OP,"3,604.28","9,201.00",,,,,,
BCBS Blue Choice,CPT,15830,Exc skin abd,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,15830,Exc skin abd,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,19297,Place breast cath for rad,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,19297,Place breast cath for rad,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,19300,Removal of breast tissue,,Per Case,"$4,140.35 ",OP,"3,231.37","9,201.00",,,,,,
BCBS Blue Choice,CPT,19300,Removal of breast tissue,,Per Case,"$7,820.85 ",OP,"3,231.37","9,201.00",,,,,,
BCBS Blue Choice,CPT,19307,Mast mod rad,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,19307,Mast mod rad,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,19318,Breast reduction,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,19318,Breast reduction,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,19340,Insj breast implt sm d mast,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,19340,Insj breast implt sm d mast,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,19357,Tiss xpndr plmt brst rcnstj,,Per Case,"$4,140.35 ",OP,"4,140.35","15,276.83",,,,,,
BCBS Blue Choice,CPT,19357,Tiss xpndr plmt brst rcnstj,,Per Case,"$7,820.85 ",OP,"4,140.35","15,276.83",,,,,,
BCBS Blue Choice,CPT,21193,Reconst lwr jaw w/o graft,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,21193,Reconst lwr jaw w/o graft,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,21462,Treat lower jaw fracture,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,21462,Treat lower jaw fracture,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,22510,Perq cervicothoracic inject,,Per Case,"$7,820.85 ",OP,"2,896.40","15,496.26",,,,,,
BCBS Blue Choice,CPT,22510,Perq cervicothoracic inject,All Other,Per Case,"$4,140.35 ",OP,"2,896.40","15,496.26",,,,,,
BCBS Blue Choice,CPT,22511,Perq lumbosacral injection,,Per Case,"$4,140.35 ",OP,"2,896.40","9,201.00",,,,,,
BCBS Blue Choice,CPT,22511,Perq lumbosacral injection,,Per Case,"$7,820.85 ",OP,"2,896.40","9,201.00",,,,,,
BCBS Blue Choice,CPT,22512,Vertebroplasty addl inject,All Other,Per Unit,"$1,612.76 ",OP,"1,612.76","4,314.00",,,,,,
BCBS Blue Choice,CPT,22551,Neck spine fuse&remov bel c2,,Per Case,"$4,140.35 ",OP,"4,140.35","12,601.93",,,,,,
BCBS Blue Choice,CPT,22551,Neck spine fuse&remov bel c2,,Per Case,"$7,820.85 ",OP,"4,140.35","12,601.93",,,,,,
BCBS Blue Choice,CPT,22856,Cerv artific diskectomy,,Per Case,"$4,140.35 ",OP,"4,140.35","16,238.16",,,,,,
BCBS Blue Choice,CPT,22856,Cerv artific diskectomy,,Per Case,"$7,820.85 ",OP,"4,140.35","16,238.16",,,,,,
BCBS Blue Choice,CPT,23410,Repair rotator cuff acute,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,23410,Repair rotator cuff acute,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,23412,Repair rotator cuff chronic,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,23412,Repair rotator cuff chronic,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,23420,Repair of shoulder,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,23420,Repair of shoulder,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,23460,Repair shoulder capsule,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,23460,Repair shoulder capsule,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,23515,Treat clavicle fracture,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,23515,Treat clavicle fracture,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,23585,Treat scapula fracture,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,23585,Treat scapula fracture,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,23615,Treat humerus fracture,,Per Case,"$4,140.35 ",OP,"4,140.35","12,601.93",,,,,,
BCBS Blue Choice,CPT,23615,Treat humerus fracture,,Per Case,"$7,820.85 ",OP,"4,140.35","12,601.93",,,,,,
BCBS Blue Choice,CPT,24515,Treat humerus fracture,,Per Case,"$4,140.35 ",OP,"4,140.35","12,601.93",,,,,,
BCBS Blue Choice,CPT,24515,Treat humerus fracture,,Per Case,"$7,820.85 ",OP,"4,140.35","12,601.93",,,,,,
BCBS Blue Choice,CPT,24545,Treat humerus fracture,,Per Case,"$4,140.35 ",OP,"4,140.35","12,601.93",,,,,,
BCBS Blue Choice,CPT,24545,Treat humerus fracture,,Per Case,"$7,820.85 ",OP,"4,140.35","12,601.93",,,,,,
BCBS Blue Choice,CPT,24666,Treat radius fracture,,Per Case,"$4,140.35 ",OP,"4,140.35","12,601.93",,,,,,
BCBS Blue Choice,CPT,24666,Treat radius fracture,,Per Case,"$7,820.85 ",OP,"4,140.35","12,601.93",,,,,,
BCBS Blue Choice,CPT,25151,Partial removal of radius,,Per Case,"$4,140.35 ",OP,"2,896.40","9,201.00",,,,,,
BCBS Blue Choice,CPT,25151,Partial removal of radius,,Per Case,"$7,820.85 ",OP,"2,896.40","9,201.00",,,,,,
BCBS Blue Choice,CPT,25607,Treat fx rad extra-articul,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,25607,Treat fx rad extra-articul,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,25608,Treat fx rad intra-articul,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,25608,Treat fx rad intra-articul,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,25609,Treat fx radial 3+ frag,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,25609,Treat fx radial 3+ frag,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,26370,Repair finger/hand tendon,,Per Case,"$4,140.35 ",OP,"2,896.40","9,201.00",,,,,,
BCBS Blue Choice,CPT,26370,Repair finger/hand tendon,,Per Case,"$7,820.85 ",OP,"2,896.40","9,201.00",,,,,,
BCBS Blue Choice,CPT,27405,Repair of knee ligament,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,27405,Repair of knee ligament,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,27407,Repair of knee ligament,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,27407,Repair of knee ligament,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,27409,Repair of knee ligaments,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,27409,Repair of knee ligaments,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,27427,Reconstruction knee,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,27427,Reconstruction knee,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,27428,Reconstruction knee,,Per Case,"$4,140.35 ",OP,"4,140.35","12,601.93",,,,,,
BCBS Blue Choice,CPT,27428,Reconstruction knee,,Per Case,"$7,820.85 ",OP,"4,140.35","12,601.93",,,,,,
BCBS Blue Choice,CPT,27429,Reconstruction knee,,Per Case,"$4,140.35 ",OP,"4,140.35","12,601.93",,,,,,
BCBS Blue Choice,CPT,27429,Reconstruction knee,,Per Case,"$7,820.85 ",OP,"4,140.35","12,601.93",,,,,,
BCBS Blue Choice,CPT,27446,Revision of knee joint,,Per Case,"$4,140.35 ",OP,"4,140.35","12,601.93",,,,,,
BCBS Blue Choice,CPT,27446,Revision of knee joint,,Per Case,"$7,820.85 ",OP,"4,140.35","12,601.93",,,,,,
BCBS Blue Choice,CPT,27652,Repair/graft achilles tendon,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,27652,Repair/graft achilles tendon,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,27654,Repair of achilles tendon,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,27654,Repair of achilles tendon,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,27691,Revise lower leg tendon,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,27691,Revise lower leg tendon,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,27724,Repair/graft of tibia,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,27724,Repair/graft of tibia,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,27726,Repair fibula nonunion,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,27726,Repair fibula nonunion,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,27758,Treatment of tibia fracture,,Per Case,"$4,140.35 ",OP,"4,140.35","12,601.93",,,,,,
BCBS Blue Choice,CPT,27758,Treatment of tibia fracture,,Per Case,"$7,820.85 ",OP,"4,140.35","12,601.93",,,,,,
BCBS Blue Choice,CPT,27814,Treatment of ankle fracture,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,27814,Treatment of ankle fracture,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,27828,Treat lower leg fracture,,Per Case,"$4,140.35 ",OP,"4,140.35","12,601.93",,,,,,
BCBS Blue Choice,CPT,27828,Treat lower leg fracture,,Per Case,"$7,820.85 ",OP,"4,140.35","12,601.93",,,,,,
BCBS Blue Choice,CPT,27870,Fusion of ankle joint open,,Per Case,"$4,140.35 ",OP,"4,140.35","12,601.93",,,,,,
BCBS Blue Choice,CPT,27870,Fusion of ankle joint open,,Per Case,"$7,820.85 ",OP,"4,140.35","12,601.93",,,,,,
BCBS Blue Choice,CPT,27871,Fusion of tibiofibular joint,,Per Case,"$4,140.35 ",OP,"4,140.35","12,601.93",,,,,,
BCBS Blue Choice,CPT,27871,Fusion of tibiofibular joint,,Per Case,"$7,820.85 ",OP,"4,140.35","12,601.93",,,,,,
BCBS Blue Choice,CPT,28238,Revision of foot tendon,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,28238,Revision of foot tendon,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,28300,Incision of heel bone,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,28300,Incision of heel bone,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,28715,Fusion of foot bones,,Per Case,"$4,140.35 ",OP,"4,140.35","12,601.93",,,,,,
BCBS Blue Choice,CPT,28715,Fusion of foot bones,,Per Case,"$7,820.85 ",OP,"4,140.35","12,601.93",,,,,,
BCBS Blue Choice,CPT,28725,Fusion of foot bones,,Per Case,"$4,140.35 ",OP,"4,140.35","12,601.93",,,,,,
BCBS Blue Choice,CPT,28725,Fusion of foot bones,,Per Case,"$7,820.85 ",OP,"4,140.35","12,601.93",,,,,,
BCBS Blue Choice,CPT,28730,Fusion of foot bones,,Per Case,"$4,140.35 ",OP,"4,140.35","12,601.93",,,,,,
BCBS Blue Choice,CPT,28730,Fusion of foot bones,,Per Case,"$7,820.85 ",OP,"4,140.35","12,601.93",,,,,,
BCBS Blue Choice,CPT,28740,Fusion of foot bones,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,28740,Fusion of foot bones,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,28750,Fusion of big toe joint,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,28750,Fusion of big toe joint,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,29000,Application of body cast,All Other,Per Unit,"$1,532.70 ",OP,246.8,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29010,Application of body cast,All Other,Per Unit,"$1,414.51 ",OP,246.8,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29015,Application of body cast,All Other,Per Unit,"$1,330.63 ",OP,246.8,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29020,Application of body cast,All Other,Per Unit,"$1,277.26 ",OP,"1,277.26","4,314.00",,,,,,
BCBS Blue Choice,CPT,29025,Application of body cast,All Other,Per Unit,"$1,483.14 ",OP,"1,483.14","4,314.00",,,,,,
BCBS Blue Choice,CPT,29035,Application of body cast,All Other,Per Unit,"$1,342.07 ",OP,246.8,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29040,Application of body cast,All Other,Per Unit,"$1,315.38 ",OP,246.8,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29044,Application of body cast,All Other,Per Unit,"$1,467.89 ",OP,144.47,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29046,Application of body cast,All Other,Per Unit,"$1,608.95 ",OP,246.8,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29049,Application of figure eight,All Other,Per Unit,$488.04 ,OP,246.8,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29055,Application of shoulder cast,All Other,Per Unit,"$1,166.68 ",OP,246.8,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29058,Application of shoulder cast,All Other,Per Unit,$629.10 ,OP,246.8,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29065,Application of long arm cast,All Other,Per Unit,$533.78 ,OP,246.8,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29075,Application of forearm cast,All Other,Per Unit,$491.83 ,OP,246.8,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29085,Apply hand/wrist cast,All Other,Per Unit,$526.16 ,OP,144.47,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29086,Apply finger cast,All Other,Per Unit,$392.70 ,OP,144.47,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29105,Apply long arm splint,All Other,Per Unit,$484.22 ,OP,144.47,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29125,Apply forearm splint,All Other,Per Unit,$369.83 ,OP,114.56,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29126,Apply forearm splint,All Other,Per Unit,$423.22 ,OP,114.56,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29130,Application of finger splint,All Other,Per Unit,$228.77 ,OP,114.56,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29131,Application of finger splint,All Other,Per Unit,$270.71 ,OP,56.95,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29200,Strapping of chest,All Other,Per Unit,$293.57 ,OP,144.47,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29220,Strapping of low back,All Other,Per Unit,$301.20 ,OP,301.2,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29240,Strapping of shoulder,All Other,Per Unit,$331.70 ,OP,114.56,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29260,Strapping of elbow or wrist,All Other,Per Unit,$285.96 ,OP,56.95,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29280,Strapping of hand or finger,All Other,Per Unit,$270.71 ,OP,56.95,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29305,Application of hip cast,All Other,Per Unit,"$1,319.19 ",OP,246.8,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29325,Application of hip casts,All Other,Per Unit,"$1,471.70 ",OP,246.8,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29345,Application of long leg cast,All Other,Per Unit,$770.16 ,OP,246.8,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29355,Application of long leg cast,All Other,Per Unit,$800.67 ,OP,246.8,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29358,Apply long leg cast brace,All Other,Per Unit,$865.48 ,OP,246.8,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29365,Application of long leg cast,All Other,Per Unit,$690.10 ,OP,246.8,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29405,Apply short leg cast,All Other,Per Unit,$503.28 ,OP,246.8,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29425,Apply short leg cast,All Other,Per Unit,$545.21 ,OP,246.8,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29435,Apply short leg cast,All Other,Per Unit,$671.03 ,OP,246.8,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29440,Addition of walker to cast,All Other,Per Unit,$297.39 ,OP,144.47,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29445,Apply rigid leg cast,All Other,Per Unit,$846.41 ,OP,246.8,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29450,Application of leg cast,All Other,Per Unit,$888.36 ,OP,144.47,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29505,Application long leg splint,All Other,Per Unit,$419.40 ,OP,144.47,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29515,Application lower leg splint,All Other,Per Unit,$396.52 ,OP,144.47,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29530,Strapping of knee,All Other,Per Unit,$289.76 ,OP,114.56,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29540,Strapping of ankle and/or ft,All Other,Per Unit,$244.01 ,OP,144.47,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29550,Strapping of toes,All Other,Per Unit,$236.38 ,OP,56.95,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29580,Application of paste boot,All Other,Per Unit,$297.39 ,OP,144.47,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29590,Application of foot splint,All Other,Per Unit,$324.09 ,OP,324.09,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29700,Removal/revision of cast,All Other,Per Unit,$362.21 ,OP,246.8,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29705,Removal/revision of cast,All Other,Per Unit,$388.89 ,OP,246.8,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29710,Removal/revision of cast,All Other,Per Unit,$674.85 ,OP,246.8,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29715,Removal/revision of cast,All Other,Per Unit,$499.47 ,OP,499.47,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29720,Repair of body cast,All Other,Per Unit,$449.90 ,OP,144.47,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29730,Windowing of cast,All Other,Per Unit,$377.46 ,OP,144.47,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29740,Wedging of cast,All Other,Per Unit,$541.40 ,OP,246.8,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29750,Wedging of clubfoot cast,All Other,Per Unit,$594.77 ,OP,246.8,"4,314.00",,,,,,
BCBS Blue Choice,CPT,29806,Sho arthrs srg capsulorpaphy,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,29806,Sho arthrs srg capsulorpaphy,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,29807,Sho arthrs srg rpr slap les,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,29807,Sho arthrs srg rpr slap les,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,29827,Sho arthrs srg rt8tr cuf rpr,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,29827,Sho arthrs srg rt8tr cuf rpr,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,29861,Hip arthro w/fb removal,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,29861,Hip arthro w/fb removal,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,29888,Knee arthroscopy/surgery,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,29888,Knee arthroscopy/surgery,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,29889,Knee arthroscopy/surgery,,Per Case,"$4,140.35 ",OP,"4,140.35","12,601.93",,,,,,
BCBS Blue Choice,CPT,29889,Knee arthroscopy/surgery,,Per Case,"$7,820.85 ",OP,"4,140.35","12,601.93",,,,,,
BCBS Blue Choice,CPT,29914,Hip arthro w/femoroplasty,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,29914,Hip arthro w/femoroplasty,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,29915,Hip arthro acetabuloplasty,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,29915,Hip arthro acetabuloplasty,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,29916,Hip arthro w/labral repair,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,29916,Hip arthro w/labral repair,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,31253,Nsl/sins ndsc total,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,31253,Nsl/sins ndsc total,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,31255,Nsl/sins ndsc w/tot ethmdct,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,31255,Nsl/sins ndsc w/tot ethmdct,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,31257,Nsl/sins ndsc tot w/sphendt,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,31257,Nsl/sins ndsc tot w/sphendt,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,31259,Nsl/sins ndsc sphn tiss rmvl,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,31259,Nsl/sins ndsc sphn tiss rmvl,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,31276,Nsl/sins ndsc frnt tiss rmvl,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,31276,Nsl/sins ndsc frnt tiss rmvl,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,31287,Nasal/sinus endoscopy surg,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,31287,Nasal/sinus endoscopy surg,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,31288,Nasal/sinus endoscopy surg,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,31288,Nasal/sinus endoscopy surg,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,31296,Nsl/sins ndsc surg frnt sins,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,31296,Nsl/sins ndsc surg frnt sins,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,31298,Nsl/sins ndsc surg frnt&sphn,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,31298,Nsl/sins ndsc surg frnt&sphn,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,33228,Remv&replc pm gen dual lead,,Per Case,"$4,140.35 ",OP,"4,140.35","10,642.67",,,,,,
BCBS Blue Choice,CPT,33228,Remv&replc pm gen dual lead,,Per Case,"$7,820.85 ",OP,"4,140.35","10,642.67",,,,,,
BCBS Blue Choice,CPT,33240,Insrt pulse gen w/singl lead,,Per Case,"$4,140.35 ",OP,"4,140.35","23,577.44",,,,,,
BCBS Blue Choice,CPT,33240,Insrt pulse gen w/singl lead,,Per Case,"$7,820.85 ",OP,"4,140.35","23,577.44",,,,,,
BCBS Blue Choice,CPT,33249,Insj/rplcmt defib w/lead(s),,Per Case,"$4,140.35 ",OP,"4,140.35","33,604.66",,,,,,
BCBS Blue Choice,CPT,33249,Insj/rplcmt defib w/lead(s),,Per Case,"$7,820.85 ",OP,"4,140.35","33,604.66",,,,,,
BCBS Blue Choice,CPT,33263,Rmvl & rplcmt dfb gen 2 lead,,Per Case,"$4,140.35 ",OP,"4,140.35","23,577.44",,,,,,
BCBS Blue Choice,CPT,33263,Rmvl & rplcmt dfb gen 2 lead,,Per Case,"$7,820.85 ",OP,"4,140.35","23,577.44",,,,,,
BCBS Blue Choice,CPT,36013,Place catheter in artery,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,36013,Place catheter in artery,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,36821,Av fusion direct any site,,Per Case,"$4,140.35 ",OP,"2,928.39","9,201.00",,,,,,
BCBS Blue Choice,CPT,36821,Av fusion direct any site,,Per Case,"$7,820.85 ",OP,"2,928.39","9,201.00",,,,,,
BCBS Blue Choice,CPT,36906,Thrmbc/nfs dialysis circuit,,Per Case,"$4,140.35 ",OP,"4,140.35","16,438.60",,,,,,
BCBS Blue Choice,CPT,36906,Thrmbc/nfs dialysis circuit,,Per Case,"$7,820.85 ",OP,"4,140.35","16,438.60",,,,,,
BCBS Blue Choice,CPT,37187,Venous mech thrombectomy,,Per Case,"$4,140.35 ",OP,"4,140.35","10,277.14",,,,,,
BCBS Blue Choice,CPT,37187,Venous mech thrombectomy,,Per Case,"$7,820.85 ",OP,"4,140.35","10,277.14",,,,,,
BCBS Blue Choice,CPT,37221,Iliac revasc w/stent,,Per Case,"$4,140.35 ",OP,"4,140.35","10,277.14",,,,,,
BCBS Blue Choice,CPT,37221,Iliac revasc w/stent,,Per Case,"$7,820.85 ",OP,"4,140.35","10,277.14",,,,,,
BCBS Blue Choice,CPT,37226,Fem/popl revasc w/stent,,Per Case,"$4,140.35 ",OP,"4,140.35","10,277.14",,,,,,
BCBS Blue Choice,CPT,37226,Fem/popl revasc w/stent,,Per Case,"$7,820.85 ",OP,"4,140.35","10,277.14",,,,,,
BCBS Blue Choice,CPT,37238,Open/perq place stent same,,Per Case,"$4,140.35 ",OP,"4,140.35","10,277.14",,,,,,
BCBS Blue Choice,CPT,37238,Open/perq place stent same,,Per Case,"$7,820.85 ",OP,"4,140.35","10,277.14",,,,,,
BCBS Blue Choice,CPT,37239,Open/perq place stent ea add,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,37239,Open/perq place stent ea add,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,37242,Vasc embolize/occlude artery,,Per Case,"$4,140.35 ",OP,"4,140.35","10,277.14",,,,,,
BCBS Blue Choice,CPT,37242,Vasc embolize/occlude artery,,Per Case,"$7,820.85 ",OP,"4,140.35","10,277.14",,,,,,
BCBS Blue Choice,CPT,37244,Vasc embolize/occlude bleed,,Per Case,"$4,140.35 ",OP,"4,140.35","10,277.14",,,,,,
BCBS Blue Choice,CPT,37244,Vasc embolize/occlude bleed,,Per Case,"$7,820.85 ",OP,"4,140.35","10,277.14",,,,,,
BCBS Blue Choice,CPT,38571,Laparoscopy lymphadenectomy,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,38571,Laparoscopy lymphadenectomy,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,38572,Laparoscopy lymphadenectomy,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,38572,Laparoscopy lymphadenectomy,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,38573,Laps pelvic lymphadec,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,38573,Laps pelvic lymphadec,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,43770,Lap place gastr adj device,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,43770,Lap place gastr adj device,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,44238,Laparoscope proc intestine,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,44238,Laparoscope proc intestine,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,47379,Laparoscope procedure liver,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,47379,Laparoscope procedure liver,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,47562,Laparoscopic cholecystectomy,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,47562,Laparoscopic cholecystectomy,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,47563,Laparo cholecystectomy/graph,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,47563,Laparo cholecystectomy/graph,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,47564,Laparo cholecystectomy/explr,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,47564,Laparo cholecystectomy/explr,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,47600,Removal of gallbladder,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,47600,Removal of gallbladder,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,47605,Removal of gallbladder,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,47605,Removal of gallbladder,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,47610,Removal of gallbladder,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,47610,Removal of gallbladder,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,47612,Removal of gallbladder,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,47612,Removal of gallbladder,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,47620,Removal of gallbladder,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,47620,Removal of gallbladder,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,49329,Laparo proc abdm/per/oment,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,49329,Laparo proc abdm/per/oment,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,49491,Rpr hern preemie reduc,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,49491,Rpr hern preemie reduc,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,49492,Rpr ing hern premie blocked,,Per Case,"$4,140.35 ",OP,"3,257.65","9,201.00",,,,,,
BCBS Blue Choice,CPT,49492,Rpr ing hern premie blocked,,Per Case,"$7,820.85 ",OP,"3,257.65","9,201.00",,,,,,
BCBS Blue Choice,CPT,49495,Rpr ing hernia baby reduc,,Per Case,"$4,140.35 ",OP,"3,257.65","9,201.00",,,,,,
BCBS Blue Choice,CPT,49495,Rpr ing hernia baby reduc,,Per Case,"$7,820.85 ",OP,"3,257.65","9,201.00",,,,,,
BCBS Blue Choice,CPT,49496,Rpr ing hernia baby blocked,,Per Case,"$4,140.35 ",OP,"3,257.65","9,201.00",,,,,,
BCBS Blue Choice,CPT,49496,Rpr ing hernia baby blocked,,Per Case,"$7,820.85 ",OP,"3,257.65","9,201.00",,,,,,
BCBS Blue Choice,CPT,49500,Rpr ing hernia init reduce,,Per Case,"$4,140.35 ",OP,"3,257.65","9,201.00",,,,,,
BCBS Blue Choice,CPT,49500,Rpr ing hernia init reduce,,Per Case,"$7,820.85 ",OP,"3,257.65","9,201.00",,,,,,
BCBS Blue Choice,CPT,49501,Rpr ing hernia init blocked,,Per Case,"$4,140.35 ",OP,"3,257.65","9,201.00",,,,,,
BCBS Blue Choice,CPT,49501,Rpr ing hernia init blocked,,Per Case,"$7,820.85 ",OP,"3,257.65","9,201.00",,,,,,
BCBS Blue Choice,CPT,49505,Prp i/hern init reduc >5 yr,,Per Case,"$4,140.35 ",OP,"3,257.65","9,201.00",,,,,,
BCBS Blue Choice,CPT,49505,Prp i/hern init reduc >5 yr,,Per Case,"$7,820.85 ",OP,"3,257.65","9,201.00",,,,,,
BCBS Blue Choice,CPT,49507,Prp i/hern init block >5 yr,,Per Case,"$4,140.35 ",OP,"3,257.65","9,201.00",,,,,,
BCBS Blue Choice,CPT,49507,Prp i/hern init block >5 yr,,Per Case,"$7,820.85 ",OP,"3,257.65","9,201.00",,,,,,
BCBS Blue Choice,CPT,49520,Rerepair ing hernia reduce,,Per Case,"$4,140.35 ",OP,"3,257.65","9,201.00",,,,,,
BCBS Blue Choice,CPT,49520,Rerepair ing hernia reduce,,Per Case,"$7,820.85 ",OP,"3,257.65","9,201.00",,,,,,
BCBS Blue Choice,CPT,49521,Rerepair ing hernia blocked,,Per Case,"$4,140.35 ",OP,"3,257.65","9,201.00",,,,,,
BCBS Blue Choice,CPT,49521,Rerepair ing hernia blocked,,Per Case,"$7,820.85 ",OP,"3,257.65","9,201.00",,,,,,
BCBS Blue Choice,CPT,49525,Repair ing hernia sliding,,Per Case,"$4,140.35 ",OP,"3,257.65","9,201.00",,,,,,
BCBS Blue Choice,CPT,49525,Repair ing hernia sliding,,Per Case,"$7,820.85 ",OP,"3,257.65","9,201.00",,,,,,
BCBS Blue Choice,CPT,49560,Rpr ventral hern init reduc,,Per Case,"$4,140.35 ",OP,"3,257.65","9,201.00",,,,,,
BCBS Blue Choice,CPT,49560,Rpr ventral hern init reduc,,Per Case,"$7,820.85 ",OP,"3,257.65","9,201.00",,,,,,
BCBS Blue Choice,CPT,49561,Rpr ventral hern init block,,Per Case,"$4,140.35 ",OP,"3,257.65","9,201.00",,,,,,
BCBS Blue Choice,CPT,49561,Rpr ventral hern init block,,Per Case,"$7,820.85 ",OP,"3,257.65","9,201.00",,,,,,
BCBS Blue Choice,CPT,49565,Rerepair ventrl hern reduce,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,49565,Rerepair ventrl hern reduce,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,49566,Rerepair ventrl hern block,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,49566,Rerepair ventrl hern block,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,49568,Hernia repair w/mesh,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,49568,Hernia repair w/mesh,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,49650,Lap ing hernia repair init,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,49650,Lap ing hernia repair init,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,49651,Lap ing hernia repair recur,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,49651,Lap ing hernia repair recur,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,49652,Lap vent/abd hernia repair,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,49652,Lap vent/abd hernia repair,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,49654,Lap inc hernia repair,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,49654,Lap inc hernia repair,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,50544,Laparoscopy pyeloplasty,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,50544,Laparoscopy pyeloplasty,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,50949,Laparoscope proc ureter,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,50949,Laparoscope proc ureter,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,53440,Male sling procedure,,Per Case,"$4,140.35 ",OP,"4,140.35","11,755.91",,,,,,
BCBS Blue Choice,CPT,53440,Male sling procedure,,Per Case,"$7,820.85 ",OP,"4,140.35","11,755.91",,,,,,
BCBS Blue Choice,CPT,53445,Insert uro/ves nck sphincter,,Per Case,"$4,140.35 ",OP,"4,140.35","18,684.12",,,,,,
BCBS Blue Choice,CPT,53445,Insert uro/ves nck sphincter,,Per Case,"$7,820.85 ",OP,"4,140.35","18,684.12",,,,,,
BCBS Blue Choice,CPT,54405,Insert multi-comp penis pros,,Per Case,"$4,140.35 ",OP,"4,140.35","18,684.12",,,,,,
BCBS Blue Choice,CPT,54405,Insert multi-comp penis pros,,Per Case,"$7,820.85 ",OP,"4,140.35","18,684.12",,,,,,
BCBS Blue Choice,CPT,54410,Remove/replace penis prosth,,Per Case,"$4,140.35 ",OP,"4,140.35","18,684.12",,,,,,
BCBS Blue Choice,CPT,54410,Remove/replace penis prosth,,Per Case,"$7,820.85 ",OP,"4,140.35","18,684.12",,,,,,
BCBS Blue Choice,CPT,55540,Revise hernia & sperm veins,,Per Case,"$4,140.35 ",OP,"3,257.65","9,201.00",,,,,,
BCBS Blue Choice,CPT,55540,Revise hernia & sperm veins,,Per Case,"$7,820.85 ",OP,"3,257.65","9,201.00",,,,,,
BCBS Blue Choice,CPT,57282,Colpopexy extraperitoneal,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,57282,Colpopexy extraperitoneal,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,57283,Colpopexy intraperitoneal,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,57283,Colpopexy intraperitoneal,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,57285,Repair paravag defect vag,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,57285,Repair paravag defect vag,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,57288,Repair bladder defect,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,57288,Repair bladder defect,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,57425,Laparoscopy surg colpopexy,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,57425,Laparoscopy surg colpopexy,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58140,Myomectomy abdom method,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58140,Myomectomy abdom method,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58145,Myomectomy vag method,,Per Case,"$4,140.35 ",OP,"2,684.38","9,201.00",,,,,,
BCBS Blue Choice,CPT,58145,Myomectomy vag method,,Per Case,"$7,820.85 ",OP,"2,684.38","9,201.00",,,,,,
BCBS Blue Choice,CPT,58146,Myomectomy abdom complex,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58146,Myomectomy abdom complex,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58150,Total hysterectomy,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58150,Total hysterectomy,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58152,Total hysterectomy,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58152,Total hysterectomy,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58200,Extensive hysterectomy,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58200,Extensive hysterectomy,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58540,Revision of uterus,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58540,Revision of uterus,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58542,Lsh w/t/o ut 250 g or less,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58542,Lsh w/t/o ut 250 g or less,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58543,Lsh uterus above 250 g,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58543,Lsh uterus above 250 g,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58544,Lsh w/t/o uterus above 250 g,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58544,Lsh w/t/o uterus above 250 g,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58545,Laparoscopic myomectomy,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58545,Laparoscopic myomectomy,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58546,Laparo-myomectomy complex,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58546,Laparo-myomectomy complex,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58550,Laparo-asst vag hysterectomy,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58550,Laparo-asst vag hysterectomy,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58552,Laparo-vag hyst incl t/o,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58552,Laparo-vag hyst incl t/o,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58553,Laparo-vag hyst complex,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58553,Laparo-vag hyst complex,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58554,Laparo-vag hyst w/t/o compl,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58554,Laparo-vag hyst w/t/o compl,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58558,Hysteroscopy biopsy,,Per Case,"$4,140.35 ",OP,"2,684.38","9,201.00",,,,,,
BCBS Blue Choice,CPT,58558,Hysteroscopy biopsy,,Per Case,"$7,820.85 ",OP,"2,684.38","9,201.00",,,,,,
BCBS Blue Choice,CPT,58559,Hysteroscopy lysis,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58559,Hysteroscopy lysis,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58560,Hysteroscopy resect septum,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58560,Hysteroscopy resect septum,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58561,Hysteroscopy remove myoma,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58561,Hysteroscopy remove myoma,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58565,Hysteroscopy sterilization,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58565,Hysteroscopy sterilization,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58570,Tlh uterus 250 g or less,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58570,Tlh uterus 250 g or less,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58571,Tlh w/t/o 250 g or less,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58571,Tlh w/t/o 250 g or less,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58572,Tlh uterus over 250 g,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58572,Tlh uterus over 250 g,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58573,Tlh w/t/o uterus over 250 g,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58573,Tlh w/t/o uterus over 250 g,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58578,Laparo proc uterus,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58578,Laparo proc uterus,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58662,Laparoscopy excise lesions,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58662,Laparoscopy excise lesions,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58674,Laps abltj uterine fibroids,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58674,Laps abltj uterine fibroids,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58679,Laparo proc oviduct-ovary,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58679,Laparo proc oviduct-ovary,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58951,Resect ovarian malignancy,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58951,Resect ovarian malignancy,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58956,Bso omentectomy w/tah,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,58956,Bso omentectomy w/tah,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,59135,Treat ectopic pregnancy,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,59135,Treat ectopic pregnancy,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,59136,Treat ectopic pregnancy,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,59136,Treat ectopic pregnancy,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,59140,Treat ectopic pregnancy,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,59140,Treat ectopic pregnancy,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,59525,Remove uterus after cesarean,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,59525,Remove uterus after cesarean,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,60240,Removal of thyroid,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,60240,Removal of thyroid,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,60252,Removal of thyroid,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,60252,Removal of thyroid,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,61885,Insrt/redo neurostim 1 array,,Per Case,"$4,140.35 ",OP,"4,140.35","20,957.35",,,,,,
BCBS Blue Choice,CPT,61885,Insrt/redo neurostim 1 array,,Per Case,"$7,820.85 ",OP,"4,140.35","20,957.35",,,,,,
BCBS Blue Choice,CPT,62302,Myelography lumbar injection,All Other,Per Unit,$842.61 ,OP,731.85,"4,314.00",,,,,,
BCBS Blue Choice,CPT,62303,Myelography lumbar injection,All Other,Per Unit,$766.35 ,OP,731.85,"4,314.00",,,,,,
BCBS Blue Choice,CPT,62304,Myelography lumbar injection,All Other,Per Unit,$781.61 ,OP,731.85,"4,314.00",,,,,,
BCBS Blue Choice,CPT,62305,Myelography lumbar injection,All Other,Per Unit,"$1,216.24 ",OP,731.85,"4,314.00",,,,,,
BCBS Blue Choice,CPT,62362,Implant spine infusion pump,,Per Case,"$4,140.35 ",OP,"4,140.35","17,429.07",,,,,,
BCBS Blue Choice,CPT,62362,Implant spine infusion pump,,Per Case,"$7,820.85 ",OP,"4,140.35","17,429.07",,,,,,
BCBS Blue Choice,CPT,63042,Laminotomy single lumbar,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,63042,Laminotomy single lumbar,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,63047,Remove spine lamina 1 lmbr,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,63047,Remove spine lamina 1 lmbr,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,63650,Implant neuroelectrodes,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,63650,Implant neuroelectrodes,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,63655,Implant neuroelectrodes,,Per Case,"$4,140.35 ",OP,"4,140.35","20,957.35",,,,,,
BCBS Blue Choice,CPT,63655,Implant neuroelectrodes,,Per Case,"$7,820.85 ",OP,"4,140.35","20,957.35",,,,,,
BCBS Blue Choice,CPT,63685,Insrt/redo spine n generator,,Per Case,"$4,140.35 ",OP,"4,140.35","30,131.14",,,,,,
BCBS Blue Choice,CPT,63685,Insrt/redo spine n generator,,Per Case,"$7,820.85 ",OP,"4,140.35","30,131.14",,,,,,
BCBS Blue Choice,CPT,64561,Implant neuroelectrodes,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,64561,Implant neuroelectrodes,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,64568,Inc for vagus n elect impl,,Per Case,"$4,140.35 ",OP,"4,140.35","30,131.14",,,,,,
BCBS Blue Choice,CPT,64568,Inc for vagus n elect impl,,Per Case,"$7,820.85 ",OP,"4,140.35","30,131.14",,,,,,
BCBS Blue Choice,CPT,64581,Implant neuroelectrodes,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,64581,Implant neuroelectrodes,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,64590,Insrt/redo pn/gastr stimul,,Per Case,"$4,140.35 ",OP,"4,140.35","20,957.35",,,,,,
BCBS Blue Choice,CPT,64590,Insrt/redo pn/gastr stimul,,Per Case,"$7,820.85 ",OP,"4,140.35","20,957.35",,,,,,
BCBS Blue Choice,CPT,65730,Corneal transplant,,Per Case,"$4,140.35 ",OP,"4,009.10","9,201.00",,,,,,
BCBS Blue Choice,CPT,65730,Corneal transplant,,Per Case,"$7,820.85 ",OP,"4,009.10","9,201.00",,,,,,
BCBS Blue Choice,CPT,65756,Corneal trnspl endothelial,,Per Case,"$4,140.35 ",OP,"4,009.10","9,201.00",,,,,,
BCBS Blue Choice,CPT,65756,Corneal trnspl endothelial,,Per Case,"$7,820.85 ",OP,"4,009.10","9,201.00",,,,,,
BCBS Blue Choice,CPT,66180,Aqueous shunt eye w/graft,,Per Case,"$4,140.35 ",OP,"4,009.10","9,201.00",,,,,,
BCBS Blue Choice,CPT,66180,Aqueous shunt eye w/graft,,Per Case,"$7,820.85 ",OP,"4,009.10","9,201.00",,,,,,
BCBS Blue Choice,CPT,67108,Repair detached retina,,Per Case,"$4,140.35 ",OP,"4,009.10","9,201.00",,,,,,
BCBS Blue Choice,CPT,67108,Repair detached retina,,Per Case,"$7,820.85 ",OP,"4,009.10","9,201.00",,,,,,
BCBS Blue Choice,CPT,67113,Repair retinal detach cplx,,Per Case,"$4,140.35 ",OP,"4,009.10","9,201.00",,,,,,
BCBS Blue Choice,CPT,67113,Repair retinal detach cplx,,Per Case,"$7,820.85 ",OP,"4,009.10","9,201.00",,,,,,
BCBS Blue Choice,CPT,69930,Implant cochlear device,,Per Case,"$4,140.35 ",OP,"4,140.35","35,230.37",,,,,,
BCBS Blue Choice,CPT,69930,Implant cochlear device,,Per Case,"$7,820.85 ",OP,"4,140.35","35,230.37",,,,,,
BCBS Blue Choice,CPT,70010,Contrast x-ray of brain,All Other,Per Unit,$899.79 ,OP,376.7,899.79,,,,,,
BCBS Blue Choice,CPT,70015,Contrast x-ray of brain,All Other,Per Unit,$735.85 ,OP,731.85,735.85,,,,,,
BCBS Blue Choice,CPT,70030,X-ray eye for foreign body,All Other,Per Unit,$144.88 ,OP,82.79,144.88,,,,,,
BCBS Blue Choice,CPT,70100,X-ray exam of jaw <4views,All Other,Per Unit,$156.32 ,OP,82.79,156.32,,,,,,
BCBS Blue Choice,CPT,70110,X-ray exam of jaw 4/> views,All Other,Per Unit,$202.07 ,OP,111.51,202.07,,,,,,
BCBS Blue Choice,CPT,70120,X-ray exam of mastoids,All Other,Per Unit,$171.58 ,OP,111.51,171.58,,,,,,
BCBS Blue Choice,CPT,70130,X-ray exam of mastoids,All Other,Per Unit,$282.14 ,OP,111.51,282.14,,,,,,
BCBS Blue Choice,CPT,70134,X-ray exam of middle ear,All Other,Per Unit,$244.01 ,OP,244.01,494.15,,,,,,
BCBS Blue Choice,CPT,70140,X-ray exam of facial bones,All Other,Per Unit,$156.32 ,OP,82.79,156.32,,,,,,
BCBS Blue Choice,CPT,70150,X-ray exam of facial bones,All Other,Per Unit,$221.14 ,OP,111.51,221.14,,,,,,
BCBS Blue Choice,CPT,70160,X-ray exam of nasal bones,All Other,Per Unit,$163.95 ,OP,82.79,163.95,,,,,,
BCBS Blue Choice,CPT,70170,X-ray exam of tear duct,All Other,Per Unit,$274.51 ,OP,235.49,274.51,,,,,,
BCBS Blue Choice,CPT,70190,X-ray exam of eye sockets,All Other,Per Unit,$183.02 ,OP,82.79,183.02,,,,,,
BCBS Blue Choice,CPT,70200,X-ray exam of eye sockets,All Other,Per Unit,$228.77 ,OP,111.51,228.77,,,,,,
BCBS Blue Choice,CPT,70210,X-ray exam of sinuses,All Other,Per Unit,$156.32 ,OP,82.79,156.32,,,,,,
BCBS Blue Choice,CPT,70220,X-ray exam of sinuses,All Other,Per Unit,$202.07 ,OP,82.79,202.07,,,,,,
BCBS Blue Choice,CPT,70240,X-ray exam pituitary saddle,All Other,Per Unit,$148.69 ,OP,82.79,148.69,,,,,,
BCBS Blue Choice,CPT,70250,X-ray exam of skull,All Other,Per Unit,$186.82 ,OP,111.51,186.82,,,,,,
BCBS Blue Choice,CPT,70260,X-ray exam of skull,All Other,Per Unit,$251.64 ,OP,111.51,251.64,,,,,,
BCBS Blue Choice,CPT,70300,X-ray exam of teeth,All Other,Per Unit,$76.26 ,OP,76.26,82.79,,,,,,
BCBS Blue Choice,CPT,70320,Full mouth x-ray of teeth,All Other,Per Unit,$247.83 ,OP,235.49,247.83,,,,,,
BCBS Blue Choice,CPT,70328,X-ray exam of jaw joint,All Other,Per Unit,$152.51 ,OP,82.79,152.51,,,,,,
BCBS Blue Choice,CPT,70330,X-ray exam of jaw joints,All Other,Per Unit,$244.01 ,OP,82.79,244.01,,,,,,
BCBS Blue Choice,CPT,70332,X-ray exam of jaw joint,All Other,Per Unit,$446.08 ,OP,235.49,446.08,,,,,,
BCBS Blue Choice,CPT,70336,Magnetic image jaw joint,All Other,Per Unit,"$1,149.44 ",OP,235.49,"1,507.00",,,,,,
BCBS Blue Choice,CPT,70350,X-ray head for orthodontia,All Other,Per Unit,$106.76 ,OP,82.79,106.76,,,,,,
BCBS Blue Choice,CPT,70355,Panoramic x-ray of jaws,All Other,Per Unit,$122.00 ,OP,82.79,122,,,,,,
BCBS Blue Choice,CPT,70360,X-ray exam of neck,All Other,Per Unit,$137.25 ,OP,82.79,137.25,,,,,,
BCBS Blue Choice,CPT,70370,Throat x-ray & fluoroscopy,All Other,Per Unit,$381.27 ,OP,82.79,381.27,,,,,,
BCBS Blue Choice,CPT,70371,Speech evaluation complex,All Other,Per Unit,$510.90 ,OP,235.49,510.9,,,,,,
BCBS Blue Choice,CPT,70373,Contrast x-ray of larynx,All Other,Per Unit,$423.22 ,OP,423.22,423.22,,,,,,
BCBS Blue Choice,CPT,70380,X-ray exam of salivary gland,All Other,Per Unit,$190.64 ,OP,82.79,190.64,,,,,,
BCBS Blue Choice,CPT,70450,Ct head/brain w/o dye,All Other,Per Unit,$689.66 ,OP,111.51,927,,,,,,
BCBS Blue Choice,CPT,70460,Ct head/brain w/dye,All Other,Per Unit,$965.53 ,OP,182.72,965.53,,,,,,
BCBS Blue Choice,CPT,70470,Ct head/brain w/o & w/dye,All Other,Per Unit,$965.53 ,OP,182.72,965.53,,,,,,
BCBS Blue Choice,CPT,70480,Ct orbit/ear/fossa w/o dye,All Other,Per Unit,$689.66 ,OP,111.51,927,,,,,,
BCBS Blue Choice,CPT,70481,Ct orbit/ear/fossa w/dye,All Other,Per Unit,$965.53 ,OP,182.72,965.53,,,,,,
BCBS Blue Choice,CPT,70482,Ct orbit/ear/fossa w/o&w/dye,All Other,Per Unit,$965.53 ,OP,182.72,965.53,,,,,,
BCBS Blue Choice,CPT,70486,Ct maxillofacial w/o dye,All Other,Per Unit,$689.66 ,OP,111.51,927,,,,,,
BCBS Blue Choice,CPT,70487,Ct maxillofacial w/dye,All Other,Per Unit,$965.53 ,OP,182.72,965.53,,,,,,
BCBS Blue Choice,CPT,70488,Ct maxillofacial w/o & w/dye,All Other,Per Unit,$965.53 ,OP,182.72,965.53,,,,,,
BCBS Blue Choice,CPT,70490,Ct soft tissue neck w/o dye,All Other,Per Unit,$689.66 ,OP,111.51,927,,,,,,
BCBS Blue Choice,CPT,70491,Ct soft tissue neck w/dye,All Other,Per Unit,$965.53 ,OP,182.72,965.53,,,,,,
BCBS Blue Choice,CPT,70492,Ct sft tsue nck w/o & w/dye,All Other,Per Unit,$965.53 ,OP,182.72,965.53,,,,,,
BCBS Blue Choice,CPT,70496,Ct angiography head,All Other,Per Unit,$965.53 ,OP,182.72,965.53,,,,,,
BCBS Blue Choice,CPT,70498,Ct angiography neck,All Other,Per Unit,$965.53 ,OP,182.72,965.53,,,,,,
BCBS Blue Choice,CPT,70540,Mri orbit/face/neck w/o dye,All Other,Per Unit,"$1,149.44 ",OP,235.49,"1,507.00",,,,,,
BCBS Blue Choice,CPT,70542,Mri orbit/face/neck w/dye,All Other,Per Unit,"$1,609.22 ",OP,376.7,"1,609.22",,,,,,
BCBS Blue Choice,CPT,70543,Mri orbt/fac/nck w/o &w/dye,All Other,Per Unit,"$1,609.22 ",OP,376.7,"1,609.22",,,,,,
BCBS Blue Choice,CPT,70544,Mr angiography head w/o dye,All Other,Per Unit,"$1,149.44 ",OP,235.49,"1,507.00",,,,,,
BCBS Blue Choice,CPT,70545,Mr angiography head w/dye,All Other,Per Unit,"$1,609.22 ",OP,376.7,"1,609.22",,,,,,
BCBS Blue Choice,CPT,70546,Mr angiograph head w/o&w/dye,All Other,Per Unit,"$1,609.22 ",OP,376.7,"1,609.22",,,,,,
BCBS Blue Choice,CPT,70547,Mr angiography neck w/o dye,All Other,Per Unit,"$1,149.44 ",OP,235.49,"1,507.00",,,,,,
BCBS Blue Choice,CPT,70548,Mr angiography neck w/dye,All Other,Per Unit,"$1,609.22 ",OP,376.7,"1,609.22",,,,,,
BCBS Blue Choice,CPT,70549,Mr angiograph neck w/o&w/dye,All Other,Per Unit,"$1,609.22 ",OP,376.7,"1,609.22",,,,,,
BCBS Blue Choice,CPT,70551,Mri brain stem w/o dye,All Other,Per Unit,"$1,149.44 ",OP,235.49,"1,507.00",,,,,,
BCBS Blue Choice,CPT,70552,Mri brain stem w/dye,All Other,Per Unit,"$1,609.22 ",OP,376.7,"1,609.22",,,,,,
BCBS Blue Choice,CPT,70553,Mri brain stem w/o & w/dye,All Other,Per Unit,"$1,609.22 ",OP,376.7,"1,609.22",,,,,,
BCBS Blue Choice,CPT,70554,Fmri brain by tech,All Other,Per Unit,"$1,149.44 ",OP,235.49,"1,507.00",,,,,,
BCBS Blue Choice,CPT,70555,Fmri brain by phys/psych,All Other,Per Unit,"$1,149.44 ",OP,235.49,"1,507.00",,,,,,
BCBS Blue Choice,CPT,70557,Mri brain w/o dye,All Other,Per Unit,"$1,149.44 ",OP,494.15,"1,149.44",,,,,,
BCBS Blue Choice,CPT,70558,Mri brain w/dye,All Other,Per Unit,"$1,609.22 ",OP,182.72,"1,609.22",,,,,,
BCBS Blue Choice,CPT,70559,Mri brain w/o & w/dye,All Other,Per Unit,"$1,609.22 ",OP,182.72,"1,609.22",,,,,,
BCBS Blue Choice,CPT,71010,Chest x-ray,All Other,Per Unit,$129.64 ,OP,129.64,129.64,,,,,,
BCBS Blue Choice,CPT,71015,Chest x-ray,All Other,Per Unit,$152.51 ,OP,152.51,152.51,,,,,,
BCBS Blue Choice,CPT,71020,Chest x-ray,All Other,Per Unit,$167.76 ,OP,167.76,167.76,,,,,,
BCBS Blue Choice,CPT,71021,Chest x-ray,All Other,Per Unit,$202.07 ,OP,202.07,202.07,,,,,,
BCBS Blue Choice,CPT,71022,Chest x-ray,All Other,Per Unit,$240.20 ,OP,240.2,240.2,,,,,,
BCBS Blue Choice,CPT,71023,Chest x-ray and fluoroscopy,All Other,Per Unit,$343.14 ,OP,343.14,343.14,,,,,,
BCBS Blue Choice,CPT,71030,Chest x-ray,All Other,Per Unit,$240.20 ,OP,240.2,240.2,,,,,,
BCBS Blue Choice,CPT,71034,Chest x-ray and fluoroscopy,All Other,Per Unit,$472.78 ,OP,472.78,472.78,,,,,,
BCBS Blue Choice,CPT,71035,Chest x-ray,All Other,Per Unit,$175.39 ,OP,175.39,175.39,,,,,,
BCBS Blue Choice,CPT,71040,Contrast x-ray of bronchi,All Other,Per Unit,$495.65 ,OP,495.65,495.65,,,,,,
BCBS Blue Choice,CPT,71045,X-ray exam chest 1 view,All Other,Per Unit,$152.51 ,OP,82.79,152.51,,,,,,
BCBS Blue Choice,CPT,71046,X-ray exam chest 2 views,All Other,Per Unit,$167.76 ,OP,82.79,167.76,,,,,,
BCBS Blue Choice,CPT,71047,X-ray exam chest 3 views,All Other,Per Unit,$240.20 ,OP,82.79,240.2,,,,,,
BCBS Blue Choice,CPT,71048,X-ray exam chest 4+ views,All Other,Per Unit,$240.20 ,OP,111.51,240.2,,,,,,
BCBS Blue Choice,CPT,71060,Contrast x-ray of bronchi,All Other,Per Unit,$720.60 ,OP,720.6,720.6,,,,,,
BCBS Blue Choice,CPT,71090,X-ray & pacemaker insertion,All Other,Per Unit,$514.72 ,OP,514.72,514.72,,,,,,
BCBS Blue Choice,CPT,71100,X-ray exam ribs uni 2 views,All Other,Per Unit,$171.58 ,OP,82.79,171.58,,,,,,
BCBS Blue Choice,CPT,71101,X-ray exam unilat ribs/chest,All Other,Per Unit,$202.07 ,OP,111.51,202.07,,,,,,
BCBS Blue Choice,CPT,71110,X-ray exam ribs bil 3 views,All Other,Per Unit,$213.51 ,OP,111.51,213.51,,,,,,
BCBS Blue Choice,CPT,71111,X-ray exam ribs/chest4/> vws,All Other,Per Unit,$270.71 ,OP,111.51,270.71,,,,,,
BCBS Blue Choice,CPT,71120,X-ray exam breastbone 2/>vws,All Other,Per Unit,$171.58 ,OP,82.79,171.58,,,,,,
BCBS Blue Choice,CPT,71130,X-ray strenoclavic jt 3/>vws,All Other,Per Unit,$194.45 ,OP,82.79,194.45,,,,,,
BCBS Blue Choice,CPT,71250,Ct thorax dx c-,All Other,Per Unit,$689.66 ,OP,111.51,927,,,,,,
BCBS Blue Choice,CPT,71260,Ct thorax dx c+,All Other,Per Unit,$965.53 ,OP,182.72,965.53,,,,,,
BCBS Blue Choice,CPT,71270,Ct thorax dx c-/c+,All Other,Per Unit,$965.53 ,OP,182.72,965.53,,,,,,
BCBS Blue Choice,CPT,71275,Ct angiography chest,All Other,Per Unit,$965.53 ,OP,182.72,965.53,,,,,,
BCBS Blue Choice,CPT,71550,Mri chest w/o dye,All Other,Per Unit,"$1,149.44 ",OP,235.49,"1,507.00",,,,,,
BCBS Blue Choice,CPT,71551,Mri chest w/dye,All Other,Per Unit,"$1,609.22 ",OP,731.85,"1,609.22",,,,,,
BCBS Blue Choice,CPT,71552,Mri chest w/o & w/dye,All Other,Per Unit,"$1,609.22 ",OP,376.7,"1,609.22",,,,,,
BCBS Blue Choice,CPT,71555,Mri angio chest w or w/o dye,All Other,Per Unit,"$1,609.22 ",OP,"1,507.00","1,609.22",,,,,,
BCBS Blue Choice,CPT,72010,X-ray exam of spine,All Other,Per Unit,$354.58 ,OP,354.58,354.58,,,,,,
BCBS Blue Choice,CPT,72020,X-ray exam of spine 1 view,All Other,Per Unit,$122.00 ,OP,82.79,122,,,,,,
BCBS Blue Choice,CPT,72040,X-ray exam neck spine 2-3 vw,All Other,Per Unit,$190.64 ,OP,82.79,190.64,,,,,,
BCBS Blue Choice,CPT,72050,X-ray exam neck spine 4/5vws,All Other,Per Unit,$293.57 ,OP,111.51,293.57,,,,,,
BCBS Blue Choice,CPT,72052,X-ray exam neck spine 6/>vws,All Other,Per Unit,$339.33 ,OP,111.51,339.33,,,,,,
BCBS Blue Choice,CPT,72069,X-ray exam of trunk spine,All Other,Per Unit,$175.39 ,OP,175.39,175.39,,,,,,
BCBS Blue Choice,CPT,72070,X-ray exam thorac spine 2vws,All Other,Per Unit,$175.39 ,OP,111.51,175.39,,,,,,
BCBS Blue Choice,CPT,72072,X-ray exam thorac spine 3vws,All Other,Per Unit,$202.07 ,OP,111.51,202.07,,,,,,
BCBS Blue Choice,CPT,72074,X-ray exam thorac spine4/>vw,All Other,Per Unit,$236.38 ,OP,111.51,236.38,,,,,,
BCBS Blue Choice,CPT,72080,X-ray exam thoracolmb 2/> vw,All Other,Per Unit,$183.02 ,OP,82.79,183.02,,,,,,
BCBS Blue Choice,CPT,72081,X-ray exam entire spi 1 vw,All Other,Per Unit,$354.58 ,OP,82.79,354.58,,,,,,
BCBS Blue Choice,CPT,72082,X-ray exam entire spi 2/3 vw,All Other,Per Unit,$354.58 ,OP,111.51,354.58,,,,,,
BCBS Blue Choice,CPT,72083,X-ray exam entire spi 4/5 vw,All Other,Per Unit,$354.58 ,OP,111.51,354.58,,,,,,
BCBS Blue Choice,CPT,72084,X-ray exam entire spi 6/> vw,All Other,Per Unit,$354.58 ,OP,111.51,354.58,,,,,,
BCBS Blue Choice,CPT,72090,X-ray exam of trunk spine,All Other,Per Unit,$240.20 ,OP,240.2,240.2,,,,,,
BCBS Blue Choice,CPT,72100,X-ray exam l-s spine 2/3 vws,All Other,Per Unit,$202.07 ,OP,111.51,202.07,,,,,,
BCBS Blue Choice,CPT,72110,X-ray exam l-2 spine 4/>vws,All Other,Per Unit,$301.20 ,OP,111.51,301.2,,,,,,
BCBS Blue Choice,CPT,72114,X-ray exam l-s spine bending,All Other,Per Unit,$362.21 ,OP,111.51,362.21,,,,,,
BCBS Blue Choice,CPT,72120,X-ray bend only l-s spine,All Other,Per Unit,$251.64 ,OP,111.51,251.64,,,,,,
BCBS Blue Choice,CPT,72125,Ct neck spine w/o dye,All Other,Per Unit,$689.66 ,OP,111.51,927,,,,,,
BCBS Blue Choice,CPT,72126,Ct neck spine w/dye,All Other,Per Unit,$965.53 ,OP,376.7,965.53,,,,,,
BCBS Blue Choice,CPT,72127,Ct neck spine w/o & w/dye,All Other,Per Unit,$965.53 ,OP,182.72,965.53,,,,,,
BCBS Blue Choice,CPT,72128,Ct chest spine w/o dye,All Other,Per Unit,$689.66 ,OP,111.51,927,,,,,,
BCBS Blue Choice,CPT,72129,Ct chest spine w/dye,All Other,Per Unit,$965.53 ,OP,182.72,965.53,,,,,,
BCBS Blue Choice,CPT,72130,Ct chest spine w/o & w/dye,All Other,Per Unit,$965.53 ,OP,182.72,965.53,,,,,,
BCBS Blue Choice,CPT,72131,Ct lumbar spine w/o dye,All Other,Per Unit,$689.66 ,OP,111.51,927,,,,,,
BCBS Blue Choice,CPT,72132,Ct lumbar spine w/dye,All Other,Per Unit,$965.53 ,OP,376.7,965.53,,,,,,
BCBS Blue Choice,CPT,72133,Ct lumbar spine w/o & w/dye,All Other,Per Unit,$965.53 ,OP,182.72,965.53,,,,,,
BCBS Blue Choice,CPT,72141,Mri neck spine w/o dye,All Other,Per Unit,"$1,149.44 ",OP,235.49,"1,507.00",,,,,,
BCBS Blue Choice,CPT,72142,Mri neck spine w/dye,All Other,Per Unit,"$1,609.22 ",OP,376.7,"1,609.22",,,,,,
BCBS Blue Choice,CPT,72146,Mri chest spine w/o dye,All Other,Per Unit,"$1,149.44 ",OP,235.49,"1,507.00",,,,,,
BCBS Blue Choice,CPT,72147,Mri chest spine w/dye,All Other,Per Unit,"$1,609.22 ",OP,376.7,"1,609.22",,,,,,
BCBS Blue Choice,CPT,72148,Mri lumbar spine w/o dye,All Other,Per Unit,"$1,149.44 ",OP,235.49,"1,507.00",,,,,,
BCBS Blue Choice,CPT,72149,Mri lumbar spine w/dye,All Other,Per Unit,"$1,609.22 ",OP,376.7,"1,609.22",,,,,,
BCBS Blue Choice,CPT,72156,Mri neck spine w/o & w/dye,All Other,Per Unit,"$1,609.22 ",OP,376.7,"1,609.22",,,,,,
BCBS Blue Choice,CPT,72157,Mri chest spine w/o & w/dye,All Other,Per Unit,"$1,609.22 ",OP,376.7,"1,609.22",,,,,,
BCBS Blue Choice,CPT,72158,Mri lumbar spine w/o & w/dye,All Other,Per Unit,"$1,609.22 ",OP,376.7,"1,609.22",,,,,,
BCBS Blue Choice,CPT,72159,Mr angio spine w/o&w/dye,All Other,Per Unit,"$1,609.22 ",OP,"1,507.00","1,609.22",,,,,,
BCBS Blue Choice,CPT,72170,X-ray exam of pelvis,All Other,Per Unit,$133.45 ,OP,111.51,133.45,,,,,,
BCBS Blue Choice,CPT,72190,X-ray exam of pelvis,All Other,Per Unit,$205.88 ,OP,111.51,205.88,,,,,,
BCBS Blue Choice,CPT,72191,Ct angiograph pelv w/o&w/dye,All Other,Per Unit,$965.53 ,OP,182.72,965.53,,,,,,
BCBS Blue Choice,CPT,72192,Ct pelvis w/o dye,All Other,Per Unit,$689.66 ,OP,111.51,927,,,,,,
BCBS Blue Choice,CPT,72193,Ct pelvis w/dye,All Other,Per Unit,$965.53 ,OP,182.72,965.53,,,,,,
BCBS Blue Choice,CPT,72194,Ct pelvis w/o & w/dye,All Other,Per Unit,$965.53 ,OP,182.72,965.53,,,,,,
BCBS Blue Choice,CPT,72195,Mri pelvis w/o dye,All Other,Per Unit,"$1,149.44 ",OP,235.49,"1,507.00",,,,,,
BCBS Blue Choice,CPT,72196,Mri pelvis w/dye,All Other,Per Unit,"$1,609.22 ",OP,376.7,"1,609.22",,,,,,
BCBS Blue Choice,CPT,72197,Mri pelvis w/o & w/dye,All Other,Per Unit,"$1,609.22 ",OP,376.7,"1,609.22",,,,,,
BCBS Blue Choice,CPT,72200,X-ray exam si joints,All Other,Per Unit,$148.69 ,OP,111.51,148.69,,,,,,
BCBS Blue Choice,CPT,72202,X-ray exam si joints 3/> vws,All Other,Per Unit,$183.02 ,OP,111.51,183.02,,,,,,
BCBS Blue Choice,CPT,72220,X-ray exam sacrum tailbone,All Other,Per Unit,$156.32 ,OP,82.79,156.32,,,,,,
BCBS Blue Choice,CPT,72240,Myelography neck spine,All Other,Per Unit,$842.61 ,OP,731.85,842.61,,,,,,
BCBS Blue Choice,CPT,72255,Myelography thoracic spine,All Other,Per Unit,$766.35 ,OP,731.85,766.35,,,,,,
BCBS Blue Choice,CPT,72265,Myelography l-s spine,All Other,Per Unit,$781.61 ,OP,731.85,781.61,,,,,,
BCBS Blue Choice,CPT,72270,Myelogphy 2/> spine regions,All Other,Per Unit,"$1,216.24 ",OP,731.85,"1,216.24",,,,,,
BCBS Blue Choice,CPT,72285,Discography cerv/thor spine,All Other,Per Unit,$976.05 ,OP,976.05,"1,795.30",,,,,,
BCBS Blue Choice,CPT,72292,Perq verte/sacroplsty ct,All Other,Per Unit,"$1,635.64 ",OP,"1,635.64","1,635.64",,,,,,
BCBS Blue Choice,CPT,72295,X-ray of lower spine disk,All Other,Per Unit,$873.11 ,OP,873.11,"1,795.30",,,,,,
BCBS Blue Choice,CPT,73000,X-ray exam of collar bone,All Other,Per Unit,$141.07 ,OP,82.79,141.07,,,,,,
BCBS Blue Choice,CPT,73010,X-ray exam of shoulder blade,All Other,Per Unit,$144.88 ,OP,111.51,144.88,,,,,,
BCBS Blue Choice,CPT,73020,X-ray exam of shoulder,All Other,Per Unit,$122.00 ,OP,82.79,122,,,,,,
BCBS Blue Choice,CPT,73030,X-ray exam of shoulder,All Other,Per Unit,$163.95 ,OP,82.79,163.95,,,,,,
BCBS Blue Choice,CPT,73040,Contrast x-ray of shoulder,All Other,Per Unit,$552.84 ,OP,376.7,552.84,,,,,,
BCBS Blue Choice,CPT,73050,X-ray exam of shoulders,All Other,Per Unit,$186.82 ,OP,82.79,186.82,,,,,,
BCBS Blue Choice,CPT,73060,X-ray exam of humerus,All Other,Per Unit,$152.51 ,OP,82.79,152.51,,,,,,
BCBS Blue Choice,CPT,73070,X-ray exam of elbow,All Other,Per Unit,$137.25 ,OP,82.79,137.25,,,,,,
BCBS Blue Choice,CPT,73080,X-ray exam of elbow,All Other,Per Unit,$179.20 ,OP,82.79,179.2,,,,,,
BCBS Blue Choice,CPT,73085,Contrast x-ray of elbow,All Other,Per Unit,$503.28 ,OP,376.7,503.28,,,,,,
BCBS Blue Choice,CPT,73090,X-ray exam of forearm,All Other,Per Unit,$137.25 ,OP,82.79,137.25,,,,,,
BCBS Blue Choice,CPT,73092,X-ray exam of arm infant,All Other,Per Unit,$141.07 ,OP,111.51,141.07,,,,,,
BCBS Blue Choice,CPT,73100,X-ray exam of wrist,All Other,Per Unit,$144.88 ,OP,82.79,144.88,,,,,,
BCBS Blue Choice,CPT,73110,X-ray exam of wrist,All Other,Per Unit,$171.58 ,OP,82.79,171.58,,,,,,
BCBS Blue Choice,CPT,73115,Contrast x-ray of wrist,All Other,Per Unit,$526.16 ,OP,376.7,526.16,,,,,,
BCBS Blue Choice,CPT,73120,X-ray exam of hand,All Other,Per Unit,$137.25 ,OP,111.51,137.25,,,,,,
BCBS Blue Choice,CPT,73130,X-ray exam of hand,All Other,Per Unit,$156.32 ,OP,82.79,156.32,,,,,,
BCBS Blue Choice,CPT,73140,X-ray exam of finger(s),All Other,Per Unit,$160.13 ,OP,82.79,160.13,,,,,,
BCBS Blue Choice,CPT,73200,Ct upper extremity w/o dye,All Other,Per Unit,$689.66 ,OP,111.51,927,,,,,,
BCBS Blue Choice,CPT,73201,Ct upper extremity w/dye,All Other,Per Unit,$965.53 ,OP,376.7,965.53,,,,,,
BCBS Blue Choice,CPT,73202,Ct uppr extremity w/o&w/dye,All Other,Per Unit,$965.53 ,OP,182.72,965.53,,,,,,
BCBS Blue Choice,CPT,73206,Ct angio upr extrm w/o&w/dye,All Other,Per Unit,$965.53 ,OP,182.72,965.53,,,,,,
BCBS Blue Choice,CPT,73218,Mri upper extremity w/o dye,All Other,Per Unit,"$1,149.44 ",OP,235.49,"1,507.00",,,,,,
BCBS Blue Choice,CPT,73219,Mri upper extremity w/dye,All Other,Per Unit,"$1,609.22 ",OP,376.7,"1,609.22",,,,,,
BCBS Blue Choice,CPT,73220,Mri uppr extremity w/o&w/dye,All Other,Per Unit,"$1,609.22 ",OP,376.7,"1,609.22",,,,,,
BCBS Blue Choice,CPT,73221,Mri joint upr extrem w/o dye,All Other,Per Unit,"$1,149.44 ",OP,235.49,"1,507.00",,,,,,
BCBS Blue Choice,CPT,73222,Mri joint upr extrem w/dye,All Other,Per Unit,"$1,609.22 ",OP,731.85,"1,609.22",,,,,,
BCBS Blue Choice,CPT,73223,Mri joint upr extr w/o&w/dye,All Other,Per Unit,"$1,609.22 ",OP,376.7,"1,609.22",,,,,,
BCBS Blue Choice,CPT,73225,Mr angio upr extr w/o&w/dye,All Other,Per Unit,"$1,609.22 ",OP,"1,507.00","1,609.22",,,,,,
BCBS Blue Choice,CPT,73500,X-ray exam of hip,All Other,Per Unit,$129.64 ,OP,129.64,129.64,,,,,,
BCBS Blue Choice,CPT,73501,X-ray exam hip uni 1 view,All Other,Per Unit,$129.64 ,OP,82.79,129.64,,,,,,
BCBS Blue Choice,CPT,73502,X-ray exam hip uni 2-3 views,All Other,Per Unit,$198.25 ,OP,82.79,198.25,,,,,,
BCBS Blue Choice,CPT,73503,X-ray exam hip uni 4/> views,All Other,Per Unit,$198.25 ,OP,111.51,198.25,,,,,,
BCBS Blue Choice,CPT,73510,X-ray exam of hip,All Other,Per Unit,$198.25 ,OP,198.25,198.25,,,,,,
BCBS Blue Choice,CPT,73520,X-ray exam of hips,All Other,Per Unit,$202.07 ,OP,202.07,202.07,,,,,,
BCBS Blue Choice,CPT,73521,X-ray exam hips bi 2 views,All Other,Per Unit,$202.07 ,OP,111.51,202.07,,,,,,
BCBS Blue Choice,CPT,73522,X-ray exam hips bi 3-4 views,All Other,Per Unit,$202.07 ,OP,111.51,202.07,,,,,,
BCBS Blue Choice,CPT,73523,X-ray exam hips bi 5/> views,All Other,Per Unit,$202.07 ,OP,111.51,202.07,,,,,,
BCBS Blue Choice,CPT,73525,Contrast x-ray of hip,All Other,Per Unit,$503.28 ,OP,376.7,503.28,,,,,,
BCBS Blue Choice,CPT,73540,X-ray exam of pelvis & hips,All Other,Per Unit,$190.64 ,OP,190.64,190.64,,,,,,
BCBS Blue Choice,CPT,73542,X-ray exam sacroiliac joint,All Other,Per Unit,$419.40 ,OP,419.4,419.4,,,,,,
BCBS Blue Choice,CPT,73550,X-ray exam of thigh,All Other,Per Unit,$148.69 ,OP,148.69,148.69,,,,,,
BCBS Blue Choice,CPT,73551,X-ray exam of femur 1,All Other,Per Unit,$148.69 ,OP,82.79,148.69,,,,,,
BCBS Blue Choice,CPT,73552,X-ray exam of femur 2/>,All Other,Per Unit,$148.69 ,OP,82.79,148.69,,,,,,
BCBS Blue Choice,CPT,73560,X-ray exam of knee 1 or 2,All Other,Per Unit,$144.88 ,OP,82.79,144.88,,,,,,
BCBS Blue Choice,CPT,73562,X-ray exam of knee 3,All Other,Per Unit,$186.82 ,OP,82.79,186.82,,,,,,
BCBS Blue Choice,CPT,73564,X-ray exam knee 4 or more,All Other,Per Unit,$205.88 ,OP,111.51,205.88,,,,,,
BCBS Blue Choice,CPT,73565,X-ray exam of knees,All Other,Per Unit,$152.51 ,OP,82.79,152.51,,,,,,
BCBS Blue Choice,CPT,73580,Contrast x-ray of knee joint,All Other,Per Unit,$625.29 ,OP,376.7,625.29,,,,,,
BCBS Blue Choice,CPT,73590,X-ray exam of lower leg,All Other,Per Unit,$137.25 ,OP,82.79,137.25,,,,,,
BCBS Blue Choice,CPT,73592,X-ray exam of leg infant,All Other,Per Unit,$141.07 ,OP,82.79,141.07,,,,,,
BCBS Blue Choice,CPT,73600,X-ray exam of ankle,All Other,Per Unit,$137.25 ,OP,82.79,137.25,,,,,,
BCBS Blue Choice,CPT,73610,X-ray exam of ankle,All Other,Per Unit,$156.32 ,OP,82.79,156.32,,,,,,
BCBS Blue Choice,CPT,73620,X-ray exam of foot,All Other,Per Unit,$133.45 ,OP,82.79,133.45,,,,,,
BCBS Blue Choice,CPT,73630,X-ray exam of foot,All Other,Per Unit,$156.32 ,OP,82.79,156.32,,,,,,
BCBS Blue Choice,CPT,73650,X-ray exam of heel,All Other,Per Unit,$137.25 ,OP,82.79,137.25,,,,,,
BCBS Blue Choice,CPT,73660,X-ray exam of toe(s),All Other,Per Unit,$141.07 ,OP,82.79,141.07,,,,,,
BCBS Blue Choice,CPT,73700,Ct lower extremity w/o dye,All Other,Per Unit,$689.66 ,OP,111.51,927,,,,,,
BCBS Blue Choice,CPT,73701,Ct lower extremity w/dye,All Other,Per Unit,$965.53 ,OP,182.72,965.53,,,,,,
BCBS Blue Choice,CPT,73702,Ct lwr extremity w/o&w/dye,All Other,Per Unit,$965.53 ,OP,182.72,965.53,,,,,,
BCBS Blue Choice,CPT,73706,Ct angio lwr extr w/o&w/dye,All Other,Per Unit,$965.53 ,OP,182.72,965.53,,,,,,
BCBS Blue Choice,CPT,73718,Mri lower extremity w/o dye,All Other,Per Unit,"$1,149.44 ",OP,235.49,"1,507.00",,,,,,
BCBS Blue Choice,CPT,73719,Mri lower extremity w/dye,All Other,Per Unit,"$1,609.22 ",OP,376.7,"1,609.22",,,,,,
BCBS Blue Choice,CPT,73720,Mri lwr extremity w/o&w/dye,All Other,Per Unit,"$1,609.22 ",OP,376.7,"1,609.22",,,,,,
BCBS Blue Choice,CPT,73721,Mri jnt of lwr extre w/o dye,All Other,Per Unit,"$1,149.44 ",OP,235.49,"1,507.00",,,,,,
BCBS Blue Choice,CPT,73722,Mri joint of lwr extr w/dye,All Other,Per Unit,"$1,609.22 ",OP,731.85,"1,609.22",,,,,,
BCBS Blue Choice,CPT,73723,Mri joint lwr extr w/o&w/dye,All Other,Per Unit,"$1,609.22 ",OP,376.7,"1,609.22",,,,,,
BCBS Blue Choice,CPT,73725,Mr ang lwr ext w or w/o dye,All Other,Per Unit,"$1,609.22 ",OP,"1,507.00","1,609.22",,,,,,
BCBS Blue Choice,CPT,74000,X-ray exam of abdomen,All Other,Per Unit,$137.25 ,OP,137.25,137.25,,,,,,
BCBS Blue Choice,CPT,74010,X-ray exam of abdomen,All Other,Per Unit,$194.45 ,OP,194.45,194.45,,,,,,
BCBS Blue Choice,CPT,74018,X-ray exam abdomen 1 view,All Other,Per Unit,$137.25 ,OP,82.79,137.25,,,,,,
BCBS Blue Choice,CPT,74019,X-ray exam abdomen 2 views,All Other,Per Unit,$194.45 ,OP,111.51,194.45,,,,,,
BCBS Blue Choice,CPT,74020,X-ray exam of abdomen,All Other,Per Unit,$205.88 ,OP,205.88,205.88,,,,,,
BCBS Blue Choice,CPT,74021,X-ray exam abdomen 3+ views,All Other,Per Unit,$205.88 ,OP,111.51,205.88,,,,,,
BCBS Blue Choice,CPT,74022,X-ray exam complete abdomen,All Other,Per Unit,$251.64 ,OP,111.51,251.64,,,,,,
BCBS Blue Choice,CPT,74150,Ct abdomen w/o dye,All Other,Per Unit,$689.66 ,OP,111.51,927,,,,,,
BCBS Blue Choice,CPT,74160,Ct abdomen w/dye,All Other,Per Unit,$965.53 ,OP,182.72,965.53,,,,,,
BCBS Blue Choice,CPT,74170,Ct abdomen w/o & w/dye,All Other,Per Unit,$965.53 ,OP,182.72,965.53,,,,,,
BCBS Blue Choice,CPT,74174,Ct angio abd&pelv w/o&w/dye,All Other,Per Unit,$965.53 ,OP,376.7,965.53,,,,,,
BCBS Blue Choice,CPT,74175,Ct angio abdom w/o & w/dye,All Other,Per Unit,$965.53 ,OP,182.72,965.53,,,,,,
BCBS Blue Choice,CPT,74176,Ct abd & pelvis w/o contrast,All Other,Per Unit,$689.66 ,OP,235.49,927,,,,,,
BCBS Blue Choice,CPT,74177,Ct abd & pelv w/contrast,All Other,Per Unit,$965.53 ,OP,376.7,965.53,,,,,,
BCBS Blue Choice,CPT,74178,Ct abd & pelv 1/> regns,All Other,Per Unit,$689.66 ,OP,376.7,927,,,,,,
BCBS Blue Choice,CPT,74181,Mri abdomen w/o dye,All Other,Per Unit,"$1,149.44 ",OP,235.49,"1,507.00",,,,,,
BCBS Blue Choice,CPT,74182,Mri abdomen w/dye,All Other,Per Unit,"$1,609.22 ",OP,376.7,"1,609.22",,,,,,
BCBS Blue Choice,CPT,74183,Mri abdomen w/o & w/dye,All Other,Per Unit,"$1,609.22 ",OP,376.7,"1,609.22",,,,,,
BCBS Blue Choice,CPT,74185,Mri angio abdom w orw/o dye,All Other,Per Unit,"$1,609.22 ",OP,"1,507.00","1,609.22",,,,,,
BCBS Blue Choice,CPT,74190,X-ray exam of peritoneum,All Other,Per Unit,$400.34 ,OP,400.34,494.15,,,,,,
BCBS Blue Choice,CPT,74220,X-ray xm esophagus 1cntrst,All Other,Per Unit,$446.08 ,OP,182.72,446.08,,,,,,
BCBS Blue Choice,CPT,74221,X-ray xm esophagus 2cntrst,All Other,Per Unit,$446.08 ,OP,182.72,446.08,,,,,,
BCBS Blue Choice,CPT,74230,X-ray xm swlng funcj c+,All Other,Per Unit,$457.52 ,OP,182.72,457.52,,,,,,
BCBS Blue Choice,CPT,74235,Remove esophagus obstruction,All Other,Per Unit,$922.67 ,OP,922.67,922.67,,,,,,
BCBS Blue Choice,CPT,74240,X-ray xm upr gi trc 1cntrst,All Other,Per Unit,$552.84 ,OP,182.72,552.84,,,,,,
BCBS Blue Choice,CPT,74241,X-ray upper gi delay w/kub,All Other,Per Unit,$587.16 ,OP,587.16,587.16,,,,,,
BCBS Blue Choice,CPT,74245,X-ray upper gi&small intest,All Other,Per Unit,$884.55 ,OP,884.55,884.55,,,,,,
BCBS Blue Choice,CPT,74246,X-ray xm upr gi trc 2cntrst,All Other,Per Unit,$632.91 ,OP,182.72,632.91,,,,,,
BCBS Blue Choice,CPT,74247,Contrst x-ray uppr gi tract,All Other,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
BCBS Blue Choice,CPT,74248,X-ray sm int f-thru std,All Other,Per Unit,$321.29 ,OP,321.29,321.29,,,,,,
BCBS Blue Choice,CPT,74249,Contrst x-ray uppr gi tract,All Other,Per Unit,$945.56 ,OP,945.56,945.56,,,,,,
BCBS Blue Choice,CPT,74250,X-ray xm sm int 1cntrst std,All Other,Per Unit,$518.52 ,OP,182.72,518.52,,,,,,
BCBS Blue Choice,CPT,74251,X-ray xm sm int 2cntrst std,All Other,Per Unit,"$1,593.72 ",OP,182.72,"1,593.72",,,,,,
BCBS Blue Choice,CPT,74260,X-ray exam of small bowel,All Other,Per Unit,"$1,330.63 ",OP,"1,330.63","1,330.63",,,,,,
BCBS Blue Choice,CPT,74270,X-ray xm colon 1cntrst std,All Other,Per Unit,$747.28 ,OP,182.72,747.28,,,,,,
BCBS Blue Choice,CPT,74280,X-ray xm colon 2cntrst std,All Other,Per Unit,"$1,029.43 ",OP,182.72,"1,029.43",,,,,,
BCBS Blue Choice,CPT,74290,Contrast x-ray gallbladder,All Other,Per Unit,$331.70 ,OP,182.72,331.7,,,,,,
BCBS Blue Choice,CPT,74291,Contrast x-rays gallbladder,All Other,Per Unit,$282.14 ,OP,282.14,282.14,,,,,,
BCBS Blue Choice,CPT,74300,X-ray bile ducts/pancreas,All Other,Per Unit,$274.51 ,OP,274.51,274.51,,,,,,
BCBS Blue Choice,CPT,74301,X-rays at surgery add-on,All Other,Per Unit,$163.95 ,OP,163.95,163.95,,,,,,
BCBS Blue Choice,CPT,74305,X-ray bile ducts/pancreas,All Other,Per Unit,$274.51 ,OP,274.51,274.51,,,,,,
BCBS Blue Choice,CPT,74320,Contrast x-ray of bile ducts,All Other,Per Unit,$606.21 ,OP,606.21,606.21,,,,,,
BCBS Blue Choice,CPT,74327,X-ray bile stone removal,All Other,Per Unit,$671.03 ,OP,671.03,671.03,,,,,,
BCBS Blue Choice,CPT,74328,X-ray bile duct endoscopy,All Other,Per Unit,$861.67 ,OP,861.67,861.67,,,,,,
BCBS Blue Choice,CPT,74329,X-ray for pancreas endoscopy,All Other,Per Unit,$537.60 ,OP,537.6,537.6,,,,,,
BCBS Blue Choice,CPT,74330,X-ray bile/panc endoscopy,All Other,Per Unit,$896.00 ,OP,896,896,,,,,,
BCBS Blue Choice,CPT,74355,X-ray guide intestinal tube,All Other,Per Unit,$754.91 ,OP,754.91,754.91,,,,,,
BCBS Blue Choice,CPT,74360,X-ray guide gi dilation,All Other,Per Unit,$831.17 ,OP,831.17,831.17,,,,,,
BCBS Blue Choice,CPT,74363,X-ray bile duct dilation,All Other,Per Unit,$678.66 ,OP,678.66,678.66,,,,,,
BCBS Blue Choice,CPT,74400,Urography iv +-kub tomog,All Other,Per Unit,$568.09 ,OP,182.72,568.09,,,,,,
BCBS Blue Choice,CPT,74410,Urography nfs drip&/bolus,All Other,Per Unit,$598.59 ,OP,182.72,598.59,,,,,,
BCBS Blue Choice,CPT,74415,Urography nfs drip&/bls w/nf,All Other,Per Unit,$682.47 ,OP,182.72,682.47,,,,,,
BCBS Blue Choice,CPT,74420,Urography rtrgr +-kub,All Other,Per Unit,$659.60 ,OP,376.7,659.6,,,,,,
BCBS Blue Choice,CPT,74425,Urography antegrade rs&i,All Other,Per Unit,$366.02 ,OP,366.02,376.7,,,,,,
BCBS Blue Choice,CPT,74430,Contrast x-ray bladder,All Other,Per Unit,$404.14 ,OP,376.7,404.14,,,,,,
BCBS Blue Choice,CPT,74440,X-ray male genital tract,All Other,Per Unit,$434.65 ,OP,235.49,434.65,,,,,,
BCBS Blue Choice,CPT,74445,X-ray exam of penis,All Other,Per Unit,$545.21 ,OP,111.51,545.21,,,,,,
BCBS Blue Choice,CPT,74450,X-ray urethra/bladder,All Other,Per Unit,$396.52 ,OP,235.49,396.52,,,,,,
BCBS Blue Choice,CPT,74455,X-ray urethra/bladder,All Other,Per Unit,$472.78 ,OP,235.49,472.78,,,,,,
BCBS Blue Choice,CPT,74470,X-ray exam of kidney lesion,All Other,Per Unit,$400.34 ,OP,400.34,494.15,,,,,,
BCBS Blue Choice,CPT,74475,X-ray control cath insert,All Other,Per Unit,$663.41 ,OP,663.41,663.41,,,,,,
BCBS Blue Choice,CPT,74485,Dilation urtr/urt rs&i,All Other,Per Unit,$629.10 ,OP,629.1,"1,834.80",,,,,,
BCBS Blue Choice,CPT,74710,X-ray measurement of pelvis,All Other,Per Unit,$232.58 ,OP,82.79,232.58,,,,,,
BCBS Blue Choice,CPT,74712,Mri fetal sngl/1st gestation,All Other,Per Unit,"$1,149.44 ",OP,235.49,"1,507.00",,,,,,
BCBS Blue Choice,CPT,74713,Mri fetal ea addl gestation,All Other,Per Unit,"$1,149.44 ",OP,"1,149.44","1,507.00",,,,,,
BCBS Blue Choice,CPT,74740,X-ray female genital tract,All Other,Per Unit,$404.14 ,OP,235.49,404.14,,,,,,
BCBS Blue Choice,CPT,74742,X-ray fallopian tube,All Other,Per Unit,$461.34 ,OP,461.34,461.34,,,,,,
BCBS Blue Choice,CPT,74775,X-ray exam of perineum,All Other,Per Unit,$457.52 ,OP,235.49,457.52,,,,,,
BCBS Blue Choice,CPT,75557,Cardiac mri for morph,All Other,Per Unit,"$1,149.44 ",OP,235.49,"1,507.00",,,,,,
BCBS Blue Choice,CPT,75561,Cardiac mri for morph w/dye,All Other,Per Unit,"$1,609.22 ",OP,376.7,"1,609.22",,,,,,
BCBS Blue Choice,CPT,75562,Card mri flow/vel w/dye,All Other,Per Unit,"$4,266.40 ",OP,"1,507.00","4,266.40",,,,,,
BCBS Blue Choice,CPT,75563,Card mri w/stress img & dye,All Other,Per Unit,"$1,609.22 ",OP,731.85,"1,609.22",,,,,,
BCBS Blue Choice,CPT,75564,Ht mri w/flo/vel/strs & dye,All Other,Per Unit,"$5,017.50 ",OP,"1,507.00","5,017.50",,,,,,
BCBS Blue Choice,CPT,75600,Contrast exam thoracic aorta,All Other,Per Unit,"$1,742.41 ",OP,"1,742.41","2,928.39",,,,,,
BCBS Blue Choice,CPT,75605,Contrast exam thoracic aorta,All Other,Per Unit,"$1,506.03 ",OP,"1,506.03","4,881.61",,,,,,
BCBS Blue Choice,CPT,75625,Contrast exam abdominl aorta,All Other,Per Unit,"$1,486.95 ",OP,"1,486.95","2,928.39",,,,,,
BCBS Blue Choice,CPT,75635,Ct angio abdominal arteries,All Other,Per Unit,$965.53 ,OP,182.72,965.53,,,,,,
BCBS Blue Choice,CPT,75650,Artery x-rays head & neck,All Other,Per Unit,"$1,586.08 ",OP,"1,586.08","1,586.08",,,,,,
BCBS Blue Choice,CPT,75658,Artery x-rays arm,All Other,Per Unit,"$1,570.83 ",OP,"1,570.83","1,570.83",,,,,,
BCBS Blue Choice,CPT,75662,Artery x-rays head & neck,All Other,Per Unit,"$1,807.23 ",OP,"1,807.23","1,807.23",,,,,,
BCBS Blue Choice,CPT,75671,Artery x-rays head & neck,All Other,Per Unit,"$1,833.90 ",OP,"1,833.90","1,833.90",,,,,,
BCBS Blue Choice,CPT,75680,Artery x-rays neck,All Other,Per Unit,"$1,765.27 ",OP,"1,765.27","1,765.27",,,,,,
BCBS Blue Choice,CPT,75685,Artery x-rays spine,All Other,Per Unit,"$1,597.52 ",OP,"1,597.52","1,597.52",,,,,,
BCBS Blue Choice,CPT,75705,Artery x-rays spine,All Other,Per Unit,"$1,826.28 ",OP,"1,826.28","4,881.61",,,,,,
BCBS Blue Choice,CPT,75710,Artery x-rays arm/leg,All Other,Per Unit,"$1,567.02 ",OP,"1,567.02","2,928.39",,,,,,
BCBS Blue Choice,CPT,75716,Artery x-rays arms/legs,All Other,Per Unit,"$1,730.97 ",OP,"1,730.97","2,928.39",,,,,,
BCBS Blue Choice,CPT,75722,Artery x-rays kidney,All Other,Per Unit,"$1,547.95 ",OP,"1,547.95","1,547.95",,,,,,
BCBS Blue Choice,CPT,75724,Artery x-rays kidneys,All Other,Per Unit,"$1,776.71 ",OP,"1,776.71","1,776.71",,,,,,
BCBS Blue Choice,CPT,75726,Artery x-rays abdomen,All Other,Per Unit,"$1,547.95 ",OP,"1,547.95","4,881.61",,,,,,
BCBS Blue Choice,CPT,75731,Artery x-rays adrenal gland,All Other,Per Unit,"$1,601.33 ",OP,"1,601.33","2,928.39",,,,,,
BCBS Blue Choice,CPT,75733,Artery x-rays adrenals,All Other,Per Unit,"$1,795.78 ",OP,"1,795.78","2,928.39",,,,,,
BCBS Blue Choice,CPT,75736,Artery x-rays pelvis,All Other,Per Unit,"$1,563.20 ",OP,"1,563.20","4,881.61",,,,,,
BCBS Blue Choice,CPT,75741,Artery x-rays lung,All Other,Per Unit,"$1,506.03 ",OP,"1,506.03","2,928.39",,,,,,
BCBS Blue Choice,CPT,75743,Artery x-rays lungs,All Other,Per Unit,"$1,635.64 ",OP,"1,635.64","2,928.39",,,,,,
BCBS Blue Choice,CPT,75746,Artery x-rays lung,All Other,Per Unit,"$1,517.46 ",OP,"1,517.46","2,928.39",,,,,,
BCBS Blue Choice,CPT,75756,Artery x-rays chest,All Other,Per Unit,"$1,601.33 ",OP,"1,601.33","2,928.39",,,,,,
BCBS Blue Choice,CPT,75774,Artery x-ray each vessel,All Other,Per Unit,"$1,208.62 ",OP,"1,208.62","1,208.62",,,,,,
BCBS Blue Choice,CPT,75790,Visualize A-V shunt,All Other,Per Unit,$899.79 ,OP,899.79,899.79,,,,,,
BCBS Blue Choice,CPT,75791,Av dialysis shunt imaging,All Other,Per Unit,$899.79 ,OP,899.79,899.79,,,,,,
BCBS Blue Choice,CPT,75801,Lymph vessel x-ray arm/leg,All Other,Per Unit,"$1,281.07 ",OP,554.25,"1,281.07",,,,,,
BCBS Blue Choice,CPT,75803,Lymph vessel x-ray arms/legs,All Other,Per Unit,"$1,437.39 ",OP,"1,437.39","1,438.93",,,,,,
BCBS Blue Choice,CPT,75805,Lymph vessel x-ray trunk,All Other,Per Unit,"$1,483.14 ",OP,"1,483.14","2,928.39",,,,,,
BCBS Blue Choice,CPT,75807,Lymph vessel x-ray trunk,All Other,Per Unit,"$1,582.28 ",OP,"1,582.28","2,928.39",,,,,,
BCBS Blue Choice,CPT,75809,Nonvascular shunt x-ray,All Other,Per Unit,$446.08 ,OP,111.51,446.08,,,,,,
BCBS Blue Choice,CPT,75810,Vein x-ray spleen/liver,All Other,Per Unit,"$2,836.65 ",OP,"2,836.65","2,928.39",,,,,,
BCBS Blue Choice,CPT,75820,Vein x-ray arm/leg,All Other,Per Unit,$610.03 ,OP,610.03,"1,438.93",,,,,,
BCBS Blue Choice,CPT,75822,Vein x-ray arms/legs,All Other,Per Unit,$747.28 ,OP,747.28,"1,438.93",,,,,,
BCBS Blue Choice,CPT,75825,Vein x-ray trunk,All Other,Per Unit,"$1,441.20 ",OP,"1,441.20","2,928.39",,,,,,
BCBS Blue Choice,CPT,75827,Vein x-ray chest,All Other,Per Unit,"$1,433.58 ",OP,"1,433.58","1,438.93",,,,,,
BCBS Blue Choice,CPT,75831,Vein x-ray kidney,All Other,Per Unit,"$1,456.44 ",OP,"1,456.44","2,928.39",,,,,,
BCBS Blue Choice,CPT,75833,Vein x-ray kidneys,All Other,Per Unit,"$1,608.95 ",OP,"1,608.95","2,928.39",,,,,,
BCBS Blue Choice,CPT,75840,Vein x-ray adrenal gland,All Other,Per Unit,"$1,445.01 ",OP,"1,445.01","2,928.39",,,,,,
BCBS Blue Choice,CPT,75842,Vein x-ray adrenal glands,All Other,Per Unit,"$1,616.58 ",OP,"1,616.58","4,881.61",,,,,,
BCBS Blue Choice,CPT,75860,Vein x-ray neck,All Other,Per Unit,"$1,479.33 ",OP,"1,479.33","2,928.39",,,,,,
BCBS Blue Choice,CPT,75870,Vein x-ray skull,All Other,Per Unit,"$1,467.89 ",OP,"1,467.89","2,928.39",,,,,,
BCBS Blue Choice,CPT,75872,Vein x-ray skull epidural,All Other,Per Unit,"$1,608.95 ",OP,554.25,"1,608.95",,,,,,
BCBS Blue Choice,CPT,75880,Vein x-ray eye socket,All Other,Per Unit,$613.85 ,OP,554.25,613.85,,,,,,
BCBS Blue Choice,CPT,75885,Vein x-ray liver w/hemodynam,All Other,Per Unit,"$1,536.51 ",OP,"1,536.51","2,928.39",,,,,,
BCBS Blue Choice,CPT,75887,Vein x-ray liver w/o hemodyn,All Other,Per Unit,"$1,547.95 ",OP,"1,547.95","2,928.39",,,,,,
BCBS Blue Choice,CPT,75889,Vein x-ray liver w/hemodynam,All Other,Per Unit,"$1,456.44 ",OP,"1,456.44","2,928.39",,,,,,
BCBS Blue Choice,CPT,75891,Vein x-ray liver,All Other,Per Unit,"$1,456.44 ",OP,"1,456.44","2,928.39",,,,,,
BCBS Blue Choice,CPT,75893,Venous sampling by catheter,All Other,Per Unit,"$1,296.32 ",OP,"1,296.32","4,881.61",,,,,,
BCBS Blue Choice,CPT,75894,X-rays transcath therapy,All Other,Per Unit,"$5,124.26 ",OP,"5,124.26","5,124.26",,,,,,
BCBS Blue Choice,CPT,75896,X-rays transcath therapy,All Other,Per Unit,"$4,476.10 ",OP,"4,476.10","4,476.10",,,,,,
BCBS Blue Choice,CPT,75898,Follow-up angiography,All Other,Per Unit,$655.78 ,OP,655.78,"2,928.39",,,,,,
BCBS Blue Choice,CPT,75900,Intravascular cath exchange,All Other,Per Unit,$888.36 ,OP,888.36,888.36,,,,,,
BCBS Blue Choice,CPT,75901,Remove cva device obstruct,All Other,Per Unit,"$1,006.55 ",OP,"1,006.55","1,006.55",,,,,,
BCBS Blue Choice,CPT,75902,Remove cva lumen obstruct,All Other,Per Unit,$640.54 ,OP,640.54,640.54,,,,,,
BCBS Blue Choice,CPT,75940,X-ray placement vein filter,All Other,Per Unit,"$2,943.39 ",OP,"2,943.39","2,943.39",,,,,,
BCBS Blue Choice,CPT,75945,Intravascular us,All Other,Per Unit,"$1,021.81 ",OP,"1,021.81","1,021.81",,,,,,
BCBS Blue Choice,CPT,75946,Intravascular us add-on,All Other,Per Unit,"$1,006.55 ",OP,"1,006.55","1,006.55",,,,,,
BCBS Blue Choice,CPT,75952,Endovasc repair abdom aorta,All Other,Per Unit,"$1,185.76 ",OP,"1,185.76","1,185.76",,,,,,
BCBS Blue Choice,CPT,75953,Abdom aneurysm endovas rpr,All Other,Per Unit,$358.39 ,OP,358.39,358.39,,,,,,
BCBS Blue Choice,CPT,75954,Iliac aneurysm endovas rpr,All Other,Per Unit,$571.91 ,OP,571.91,571.91,,,,,,
BCBS Blue Choice,CPT,75957,Xray endovasc thor ao repr,All Other,Per Unit,"$1,597.52 ",OP,"1,597.52","8,948.83",,,,,,
BCBS Blue Choice,CPT,75958,Xray place prox ext thor ao,All Other,Per Unit,"$1,052.29 ",OP,"1,052.29","8,948.83",,,,,,
BCBS Blue Choice,CPT,75959,Xray place dist ext thor ao,All Other,Per Unit,$926.48 ,OP,926.48,"8,948.83",,,,,,
BCBS Blue Choice,CPT,75960,Transcath iv stent rs&i,All Other,Per Unit,"$1,479.33 ",OP,"1,479.33","1,479.33",,,,,,
BCBS Blue Choice,CPT,75961,Retrieval broken catheter,All Other,Per Unit,"$2,192.31 ",OP,"2,192.31","2,192.31",,,,,,
BCBS Blue Choice,CPT,75962,Repair arterial blockage,All Other,Per Unit,"$1,582.28 ",OP,"1,582.28","1,582.28",,,,,,
BCBS Blue Choice,CPT,75964,Repair artery blockage each,All Other,Per Unit,$922.67 ,OP,922.67,922.67,,,,,,
BCBS Blue Choice,CPT,75966,Repair arterial blockage,All Other,Per Unit,"$1,826.28 ",OP,"1,826.28","1,826.28",,,,,,
BCBS Blue Choice,CPT,75968,Repair artery blockage each,All Other,Per Unit,$922.67 ,OP,922.67,922.67,,,,,,
BCBS Blue Choice,CPT,75970,Vascular biopsy,All Other,Per Unit,"$2,520.20 ",OP,"2,520.20","2,520.20",,,,,,
BCBS Blue Choice,CPT,75980,Contrast xray exam bile duct,All Other,Per Unit,"$1,486.95 ",OP,"1,486.95","1,486.95",,,,,,
BCBS Blue Choice,CPT,75982,Contrast xray exam bile duct,All Other,Per Unit,"$1,685.20 ",OP,"1,685.20","1,685.20",,,,,,
BCBS Blue Choice,CPT,75984,Xray control catheter change,All Other,Per Unit,$594.77 ,OP,594.77,594.77,,,,,,
BCBS Blue Choice,CPT,75989,Abscess drainage under x-ray,All Other,Per Unit,$922.43 ,OP,922.43,927,,,,,,
BCBS Blue Choice,CPT,75992,Atherectomy - x-ray exam,All Other,Per Unit,"$3,774.56 ",OP,"3,774.56","3,774.56",,,,,,
BCBS Blue Choice,CPT,75993,Atherectomy - x-ray exam,All Other,Per Unit,"$2,482.06 ",OP,"2,482.06","2,482.06",,,,,,
BCBS Blue Choice,CPT,75994,Atherectomy - x-ray exam,All Other,Per Unit,"$3,313.22 ",OP,"3,313.22","3,313.22",,,,,,
BCBS Blue Choice,CPT,75995,Atherectomy - x-ray exam,All Other,Per Unit,"$3,503.86 ",OP,"3,503.86","3,503.86",,,,,,
BCBS Blue Choice,CPT,75996,Atherectomy - x-ray exam,All Other,Per Unit,$972.25 ,OP,972.25,972.25,,,,,,
BCBS Blue Choice,CPT,76000,Fluoroscopy <1 hr phys/qhp,All Other,Per Unit,$495.65 ,OP,235.49,495.65,,,,,,
BCBS Blue Choice,CPT,76001,Fluoroscope exam extensive,All Other,Per Unit,$735.85 ,OP,735.85,735.85,,,,,,
BCBS Blue Choice,CPT,76010,X-ray nose to rectum,All Other,Per Unit,$144.88 ,OP,82.79,144.88,,,,,,
BCBS Blue Choice,CPT,76080,X-ray exam of fistula,All Other,Per Unit,$331.70 ,OP,331.7,494.15,,,,,,
BCBS Blue Choice,CPT,76098,X-ray exam surgical specimen,All Other,Per Unit,$102.95 ,OP,102.95,494.15,,,,,,
BCBS Blue Choice,CPT,76100,X-ray exam of body section,All Other,Per Unit,$690.10 ,OP,111.51,690.1,,,,,,
BCBS Blue Choice,CPT,76101,Complex body section x-ray,All Other,Per Unit,$949.36 ,OP,111.51,949.36,,,,,,
BCBS Blue Choice,CPT,76120,Cine/video x-rays,All Other,Per Unit,$392.70 ,OP,111.51,392.7,,,,,,
BCBS Blue Choice,CPT,76125,Cine/video x-rays add-on,All Other,Per Unit,$244.01 ,OP,244.01,244.01,,,,,,
BCBS Blue Choice,CPT,76140,X-ray consultation,All Other,Per Unit,$83.87 ,OP,83.87,83.87,,,,,,
BCBS Blue Choice,CPT,76150,X-ray exam - dry process,All Other,Per Unit,$95.32 ,OP,95.32,95.32,,,,,,
BCBS Blue Choice,CPT,76350,Special x-ray contrast study,All Other,Per Unit,$213.51 ,OP,213.51,213.51,,,,,,
BCBS Blue Choice,CPT,76376,3d render w/intrp postproces,All Other,Per Unit,$922.43 ,OP,922.43,922.43,,,,,,
BCBS Blue Choice,CPT,76377,3d render w/intrp postproces,All Other,Per Unit,$922.43 ,OP,922.43,922.43,,,,,,
BCBS Blue Choice,CPT,76380,Cat scan follow-up study,All Other,Per Unit,$689.66 ,OP,82.79,689.66,,,,,,
BCBS Blue Choice,CPT,76390,Mr spectroscopy,All Other,Per Unit,"$1,149.44 ",OP,82.79,"1,507.00",,,,,,
BCBS Blue Choice,CPT,76506,Echo exam of head,All Other,Per Unit,$602.41 ,OP,111.51,602.41,,,,,,
BCBS Blue Choice,CPT,76510,Oph us dx b-scan&quan a-scan,All Other,Per Unit,$751.10 ,OP,114.56,751.1,,,,,,
BCBS Blue Choice,CPT,76511,Oph us dx quan a-scan only,All Other,Per Unit,$495.65 ,OP,111.51,495.65,,,,,,
BCBS Blue Choice,CPT,76512,Oph us dx b-scan,All Other,Per Unit,$468.96 ,OP,111.51,468.96,,,,,,
BCBS Blue Choice,CPT,76513,Oph us dx ant sgm us uni/bi,All Other,Per Unit,$438.47 ,OP,111.51,438.47,,,,,,
BCBS Blue Choice,CPT,76514,Echo exam of eye thickness,All Other,Per Unit,$64.82 ,OP,25.25,64.82,,,,,,
BCBS Blue Choice,CPT,76516,Echo exam of eye,All Other,Per Unit,$346.96 ,OP,111.51,346.96,,,,,,
BCBS Blue Choice,CPT,76519,Echo exam of eye,All Other,Per Unit,$369.83 ,OP,111.51,369.83,,,,,,
BCBS Blue Choice,CPT,76529,Echo exam of eye,All Other,Per Unit,$354.58 ,OP,82.79,354.58,,,,,,
BCBS Blue Choice,CPT,76536,Us exam of head and neck,All Other,Per Unit,$594.77 ,OP,111.51,594.77,,,,,,
BCBS Blue Choice,CPT,76604,Us exam chest,All Other,Per Unit,$446.08 ,OP,111.51,446.08,,,,,,
BCBS Blue Choice,CPT,76641,Ultrasound breast complete,All Other,Per Unit,$174.71 ,OP,111.51,174.71,,,,,,
BCBS Blue Choice,CPT,76642,Ultrasound breast limited,All Other,Per Unit,$174.71 ,OP,82.79,174.71,,,,,,
BCBS Blue Choice,CPT,76645,Us exam breast(s),All Other,Per Unit,$174.71 ,OP,174.71,174.71,,,,,,
BCBS Blue Choice,CPT,76700,Us exam abdom complete,All Other,Per Unit,$739.67 ,OP,111.51,739.67,,,,,,
BCBS Blue Choice,CPT,76705,Echo exam of abdomen,All Other,Per Unit,$537.60 ,OP,111.51,537.6,,,,,,
BCBS Blue Choice,CPT,76706,Us abdl aorta screen aaa,All Other,Per Unit,$575.73 ,OP,111.51,575.73,,,,,,
BCBS Blue Choice,CPT,76770,Us exam abdo back wall comp,All Other,Per Unit,$678.66 ,OP,111.51,678.66,,,,,,
BCBS Blue Choice,CPT,76775,Us exam abdo back wall lim,All Other,Per Unit,$602.41 ,OP,111.51,602.41,,,,,,
BCBS Blue Choice,CPT,76776,Us exam k transpl w/doppler,All Other,Per Unit,$751.10 ,OP,111.51,751.1,,,,,,
BCBS Blue Choice,CPT,76800,Us exam spinal canal,All Other,Per Unit,$632.91 ,OP,111.51,632.91,,,,,,
BCBS Blue Choice,CPT,76801,Ob us < 14 wks single fetus,All Other,Per Unit,$712.98 ,OP,111.51,712.98,,,,,,
BCBS Blue Choice,CPT,76802,Ob us < 14 wks addl fetus,All Other,Per Unit,$396.52 ,OP,396.52,396.52,,,,,,
BCBS Blue Choice,CPT,76805,Ob us >= 14 wks sngl fetus,All Other,Per Unit,$789.23 ,OP,111.51,789.23,,,,,,
BCBS Blue Choice,CPT,76810,Ob us >= 14 wks addl fetus,All Other,Per Unit,$549.03 ,OP,549.03,549.03,,,,,,
BCBS Blue Choice,CPT,76811,Ob us detailed sngl fetus,All Other,Per Unit,"$1,204.81 ",OP,235.49,"1,204.81",,,,,,
BCBS Blue Choice,CPT,76812,Ob us detailed addl fetus,All Other,Per Unit,"$1,090.43 ",OP,"1,090.43","1,090.43",,,,,,
BCBS Blue Choice,CPT,76813,Ob us nuchal meas 1 gest,All Other,Per Unit,$667.22 ,OP,111.51,667.22,,,,,,
BCBS Blue Choice,CPT,76814,Ob us nuchal meas add-on,All Other,Per Unit,$446.08 ,OP,446.08,446.08,,,,,,
BCBS Blue Choice,CPT,76815,Ob us limited fetus(s),All Other,Per Unit,$472.78 ,OP,111.51,472.78,,,,,,
BCBS Blue Choice,CPT,76816,Ob us follow-up per fetus,All Other,Per Unit,$571.91 ,OP,111.51,571.91,,,,,,
BCBS Blue Choice,CPT,76817,Transvaginal us obstetric,All Other,Per Unit,$560.47 ,OP,111.51,560.47,,,,,,
BCBS Blue Choice,CPT,76818,Fetal biophys profile w/nst,All Other,Per Unit,$625.29 ,OP,111.51,625.29,,,,,,
BCBS Blue Choice,CPT,76819,Fetal biophys profil w/o nst,All Other,Per Unit,$526.16 ,OP,111.51,526.16,,,,,,
BCBS Blue Choice,CPT,76820,Umbilical artery echo,All Other,Per Unit,$297.39 ,OP,111.51,297.39,,,,,,
BCBS Blue Choice,CPT,76821,Middle cerebral artery echo,All Other,Per Unit,$510.90 ,OP,111.51,510.9,,,,,,
BCBS Blue Choice,CPT,76825,Echo exam of fetal heart,All Other,Per Unit,"$1,067.55 ",OP,494.15,"1,067.55",,,,,,
BCBS Blue Choice,CPT,76826,Echo exam of fetal heart,All Other,Per Unit,$587.16 ,OP,235.49,587.16,,,,,,
BCBS Blue Choice,CPT,76827,Echo exam of fetal heart,All Other,Per Unit,$381.27 ,OP,111.51,381.27,,,,,,
BCBS Blue Choice,CPT,76828,Echo exam of fetal heart,All Other,Per Unit,$282.14 ,OP,111.51,282.14,,,,,,
BCBS Blue Choice,CPT,76830,Transvaginal us non-ob,All Other,Per Unit,$651.97 ,OP,111.51,651.97,,,,,,
BCBS Blue Choice,CPT,76831,Echo exam uterus,All Other,Per Unit,$621.47 ,OP,235.49,621.47,,,,,,
BCBS Blue Choice,CPT,76856,Us exam pelvic complete,All Other,Per Unit,$655.78 ,OP,111.51,655.78,,,,,,
BCBS Blue Choice,CPT,76857,Us exam pelvic limited,All Other,Per Unit,$518.52 ,OP,111.51,518.52,,,,,,
BCBS Blue Choice,CPT,76870,Us exam scrotum,All Other,Per Unit,$621.47 ,OP,111.51,621.47,,,,,,
BCBS Blue Choice,CPT,76872,Us transrectal,All Other,Per Unit,$735.85 ,OP,111.51,735.85,,,,,,
BCBS Blue Choice,CPT,76873,Echograp trans r pros study,All Other,Per Unit,$934.12 ,OP,111.51,934.12,,,,,,
BCBS Blue Choice,CPT,76880,Us exam - extremity,All Other,Per Unit,$644.34 ,OP,644.34,644.34,,,,,,
BCBS Blue Choice,CPT,76881,Us compl joint r-t w/img,All Other,Per Unit,$644.34 ,OP,111.51,644.34,,,,,,
BCBS Blue Choice,CPT,76882,Us lmtd jt/nonvasc xtr strux,All Other,Per Unit,$644.34 ,OP,111.51,644.34,,,,,,
BCBS Blue Choice,CPT,76885,Us exam infant hips dynamic,All Other,Per Unit,$701.54 ,OP,82.79,701.54,,,,,,
BCBS Blue Choice,CPT,76886,Us exam infant hips static,All Other,Per Unit,$518.52 ,OP,82.79,518.52,,,,,,
BCBS Blue Choice,CPT,76930,Echo guide cardiocentesis,All Other,Per Unit,$510.90 ,OP,510.9,510.9,,,,,,
BCBS Blue Choice,CPT,76932,Echo guide for heart biopsy,All Other,Per Unit,$510.90 ,OP,510.9,510.9,,,,,,
BCBS Blue Choice,CPT,76936,Echo guide for artery repair,All Other,Per Unit,"$1,654.72 ",OP,270.61,"1,654.72",,,,,,
BCBS Blue Choice,CPT,76937,Us guide vascular access,All Other,Per Unit,$202.07 ,OP,202.07,202.07,,,,,,
BCBS Blue Choice,CPT,76940,Us guide tissue ablation,All Other,Per Unit,$930.30 ,OP,930.3,930.3,,,,,,
BCBS Blue Choice,CPT,76941,Echo guide for transfusion,All Other,Per Unit,$640.54 ,OP,640.54,640.54,,,,,,
BCBS Blue Choice,CPT,76942,Echo guide for biopsy,All Other,Per Unit,$995.12 ,OP,995.12,995.12,,,,,,
BCBS Blue Choice,CPT,76945,Echo guide villus sampling,All Other,Per Unit,$480.40 ,OP,480.4,480.4,,,,,,
BCBS Blue Choice,CPT,76946,Echo guide for amniocentesis,All Other,Per Unit,$244.01 ,OP,244.01,244.01,,,,,,
BCBS Blue Choice,CPT,76950,Echo guidance radiotherapy,All Other,Per Unit,$369.83 ,OP,369.83,369.83,,,,,,
BCBS Blue Choice,CPT,76965,Echo guidance radiotherapy,All Other,Per Unit,$800.67 ,OP,800.67,800.67,,,,,,
BCBS Blue Choice,CPT,76970,Ultrasound exam follow-up,All Other,Per Unit,$430.83 ,OP,430.83,430.83,,,,,,
BCBS Blue Choice,CPT,76975,Gi endoscopic ultrasound,All Other,Per Unit,$529.96 ,OP,235.49,529.96,,,,,,
BCBS Blue Choice,CPT,76977,Us bone density measure,All Other,Per Unit,$80.07 ,OP,80.07,111.51,,,,,,
BCBS Blue Choice,CPT,76998,Us guide intraop,All Other,Per Unit,$324.09 ,OP,324.09,324.09,,,,,,
BCBS Blue Choice,CPT,77001,Fluoroguide for vein device,All Other,Per Unit,$541.40 ,OP,541.4,541.4,,,,,,
BCBS Blue Choice,CPT,77002,Needle localization by xray,All Other,Per Unit,$369.83 ,OP,369.83,369.83,,,,,,
BCBS Blue Choice,CPT,77003,Fluoroguide for spine inject,All Other,Per Unit,$312.64 ,OP,312.64,312.64,,,,,,
BCBS Blue Choice,CPT,77011,Ct scan for localization,All Other,Per Unit,"$3,500.05 ",OP,927,"3,500.05",,,,,,
BCBS Blue Choice,CPT,77012,Ct scan for needle biopsy,All Other,Per Unit,$689.66 ,OP,689.66,927,,,,,,
BCBS Blue Choice,CPT,77013,Ct guide for tissue ablation,All Other,Per Unit,$689.66 ,OP,689.66,927,,,,,,
BCBS Blue Choice,CPT,77014,Ct scan for therapy guide,All Other,Per Unit,$689.66 ,OP,689.66,927,,,,,,
BCBS Blue Choice,CPT,77021,Mri guidance ndl plmt rs&i,All Other,Per Unit,"$2,363.88 ",OP,"1,507.00","2,363.88",,,,,,
BCBS Blue Choice,CPT,77022,Mri gdn parnchyma tiss abltj,All Other,Per Unit,"$3,637.31 ",OP,"1,507.00","3,637.31",,,,,,
BCBS Blue Choice,CPT,77031,Stereotact guide for brst bx,All Other,Per Unit,"$1,044.69 ",OP,"1,044.69","1,044.69",,,,,,
BCBS Blue Choice,CPT,77032,Guidance for needle breast,All Other,Per Unit,$312.64 ,OP,312.64,312.64,,,,,,
BCBS Blue Choice,CPT,77046,Mri breast c- unilateral,All Other,Per Unit,$697.83 ,OP,235.49,"1,507.00",,,,,,
BCBS Blue Choice,CPT,77047,Mri breast c- bilateral,All Other,Per Unit,$697.02 ,OP,235.49,"1,507.00",,,,,,
BCBS Blue Choice,CPT,77048,Mri breast c-+ w/cad uni,All Other,Per Unit,"$1,149.44 ",OP,"1,149.44","1,507.00",,,,,,
BCBS Blue Choice,CPT,77049,Mri breast c-+ w/cad bi,All Other,Per Unit,"$1,149.44 ",OP,"1,149.44","1,507.00",,,,,,
BCBS Blue Choice,CPT,77051,Computer dx mammogram add-on,All Other,Per Unit,$45.98 ,OP,45.98,45.98,,,,,,
BCBS Blue Choice,CPT,77052,Comp screen mammogram add-on,All Other,Per Unit,$45.98 ,OP,45.98,45.98,,,,,,
BCBS Blue Choice,CPT,77053,X-ray of mammary duct,All Other,Per Unit,$411.78 ,OP,235.49,411.78,,,,,,
BCBS Blue Choice,CPT,77055,Mammogram one breast,All Other,Per Unit,$183.91 ,OP,183.91,183.91,,,,,,
BCBS Blue Choice,CPT,77056,Mammogram both breasts,All Other,Per Unit,$183.91 ,OP,183.91,183.91,,,,,,
BCBS Blue Choice,CPT,77057,Mammogram screening,All Other,Per Unit,$183.91 ,OP,183.91,183.91,,,,,,
BCBS Blue Choice,CPT,77058,Mri one breast,All Other,Per Unit,"$1,149.44 ",OP,"1,149.44","1,149.44",,,,,,
BCBS Blue Choice,CPT,77059,Mri both breasts,All Other,Per Unit,"$1,149.44 ",OP,"1,149.44","1,149.44",,,,,,
BCBS Blue Choice,CPT,77065,Dx mammo incl cad uni,All Other,Per Unit,$275.87 ,OP,83.47,275.87,,,,,,
BCBS Blue Choice,CPT,77066,Dx mammo incl cad bi,All Other,Per Unit,$275.87 ,OP,106.7,275.87,,,,,,
BCBS Blue Choice,CPT,77067,Scr mammo bi incl cad,All Other,Per Unit,$275.87 ,OP,88.24,275.87,,,,,,
BCBS Blue Choice,CPT,77071,X-ray stress view,All Other,Per Unit,$205.88 ,OP,82.79,205.88,,,,,,
BCBS Blue Choice,CPT,77072,X-rays for bone age,All Other,Per Unit,$122.00 ,OP,111.51,122,,,,,,
BCBS Blue Choice,CPT,77073,X-rays bone length studies,All Other,Per Unit,$198.25 ,OP,111.51,198.25,,,,,,
BCBS Blue Choice,CPT,77074,X-rays bone survey limited,All Other,Per Unit,$358.39 ,OP,111.51,358.39,,,,,,
BCBS Blue Choice,CPT,77075,X-rays bone survey complete,All Other,Per Unit,$514.72 ,OP,111.51,514.72,,,,,,
BCBS Blue Choice,CPT,77076,X-rays bone survey infant,All Other,Per Unit,$476.60 ,OP,111.51,476.6,,,,,,
BCBS Blue Choice,CPT,77077,Joint survey single view,All Other,Per Unit,$224.95 ,OP,111.51,224.95,,,,,,
BCBS Blue Choice,CPT,77078,Ct bone density axial,All Other,Per Unit,$892.18 ,OP,82.79,927,,,,,,
BCBS Blue Choice,CPT,77079,Ct bone density peripheral,All Other,Per Unit,$301.20 ,OP,301.2,301.2,,,,,,
BCBS Blue Choice,CPT,77080,Dxa bone density axial,All Other,Per Unit,$537.60 ,OP,111.51,537.6,,,,,,
BCBS Blue Choice,CPT,77081,Dxa bone density/peripheral,All Other,Per Unit,$167.76 ,OP,82.79,167.76,,,,,,
BCBS Blue Choice,CPT,77082,Dxa bone density vert fx,All Other,Per Unit,$213.51 ,OP,213.51,213.51,,,,,,
BCBS Blue Choice,CPT,77083,Radiographic absorptiometry,All Other,Per Unit,$144.88 ,OP,144.88,144.88,,,,,,
BCBS Blue Choice,CPT,77084,Magnetic image bone marrow,All Other,Per Unit,"$1,149.44 ",OP,235.49,"1,507.00",,,,,,
BCBS Blue Choice,CPT,77086,Fracture assessment via dxa,All Other,Per Unit,$213.51 ,OP,82.79,213.51,,,,,,
BCBS Blue Choice,CPT,77261,Radiation therapy planning,All Other,Per Unit,$358.39 ,OP,358.39,358.39,,,,,,
BCBS Blue Choice,CPT,77262,Radiation therapy planning,All Other,Per Unit,$541.40 ,OP,541.4,541.4,,,,,,
BCBS Blue Choice,CPT,77263,Radiation therapy planning,All Other,Per Unit,$800.67 ,OP,800.67,800.67,,,,,,
BCBS Blue Choice,CPT,77280,Set radiation therapy field,All Other,Per Unit,$964.61 ,OP,129.83,964.61,,,,,,
BCBS Blue Choice,CPT,77285,Set radiation therapy field,All Other,Per Unit,"$1,662.33 ",OP,346.58,"1,662.33",,,,,,
BCBS Blue Choice,CPT,77290,Set radiation therapy field,All Other,Per Unit,"$2,558.32 ",OP,346.58,"2,558.32",,,,,,
BCBS Blue Choice,CPT,77295,3-d radiotherapy plan,All Other,Per Unit,"$3,736.44 ",OP,"1,291.62","3,736.44",,,,,,
BCBS Blue Choice,CPT,77300,Radiation therapy dose plan,All Other,Per Unit,$388.89 ,OP,129.83,388.89,,,,,,
BCBS Blue Choice,CPT,77301,Radiotherapy dose plan imrt,All Other,Per Unit,"$11,205.50 ",OP,"1,291.62","11,205.50",,,,,,
BCBS Blue Choice,CPT,77305,Teletx isodose plan simple,All Other,Per Unit,$392.70 ,OP,392.7,392.7,,,,,,
BCBS Blue Choice,CPT,77306,Telethx isodose plan simple,All Other,Per Unit,$392.70 ,OP,346.58,392.7,,,,,,
BCBS Blue Choice,CPT,77307,Telethx isodose plan cplx,All Other,Per Unit,$777.79 ,OP,346.58,777.79,,,,,,
BCBS Blue Choice,CPT,77310,Teletx isodose plan intermed,All Other,Per Unit,$537.60 ,OP,537.6,537.6,,,,,,
BCBS Blue Choice,CPT,77315,Teletx isodose plan complex,All Other,Per Unit,$777.79 ,OP,777.79,777.79,,,,,,
BCBS Blue Choice,CPT,77316,Brachytx isodose plan simple,All Other,Per Unit,$747.28 ,OP,346.58,747.28,,,,,,
BCBS Blue Choice,CPT,77317,Brachytx isodose intermed,All Other,Per Unit,"$1,059.93 ",OP,346.58,"1,059.93",,,,,,
BCBS Blue Choice,CPT,77318,Brachytx isodose complex,All Other,Per Unit,"$1,456.44 ",OP,346.58,"1,456.44",,,,,,
BCBS Blue Choice,CPT,77321,Special teletx port plan,All Other,Per Unit,$659.60 ,OP,346.58,659.6,,,,,,
BCBS Blue Choice,CPT,77326,Brachytx isodose calc simp,All Other,Per Unit,$747.28 ,OP,747.28,747.28,,,,,,
BCBS Blue Choice,CPT,77327,Brachytx isodose calc interm,All Other,Per Unit,"$1,059.93 ",OP,"1,059.93","1,059.93",,,,,,
BCBS Blue Choice,CPT,77328,Brachytx isodose plan compl,All Other,Per Unit,"$1,456.44 ",OP,"1,456.44","1,456.44",,,,,,
BCBS Blue Choice,CPT,77331,Special radiation dosimetry,All Other,Per Unit,$320.27 ,OP,129.83,320.27,,,,,,
BCBS Blue Choice,CPT,77332,Radiation treatment aid(s),All Other,Per Unit,$407.96 ,OP,129.83,407.96,,,,,,
BCBS Blue Choice,CPT,77333,Radiation treatment aid(s),All Other,Per Unit,$369.83 ,OP,129.83,369.83,,,,,,
BCBS Blue Choice,CPT,77334,Radiation treatment aid(s),All Other,Per Unit,$869.30 ,OP,346.58,869.3,,,,,,
BCBS Blue Choice,CPT,77336,Radiation physics consult,All Other,Per Unit,$343.14 ,OP,129.83,343.14,,,,,,
BCBS Blue Choice,CPT,77370,Radiation physics consult,All Other,Per Unit,$629.10 ,OP,129.83,629.1,,,,,,
BCBS Blue Choice,CPT,77371,Srs multisource,All Other,Per Unit,"$6,969.60 ",OP,"6,969.60","7,954.01",,,,,,
BCBS Blue Choice,CPT,77372,Srs linear based,All Other,Per Unit,"$4,148.22 ",OP,"4,148.22","7,954.01",,,,,,
BCBS Blue Choice,CPT,77373,Sbrt delivery,All Other,Per Unit,"$13,221.44 ",OP,"1,774.17","13,221.44",,,,,,
BCBS Blue Choice,CPT,77385,Ntsty modul rad tx dlvr smpl,All Other,Per Unit,"$1,379.33 ",OP,555.2,"1,379.33",,,,,,
BCBS Blue Choice,CPT,77386,Ntsty modul rad tx dlvr cplx,All Other,Per Unit,"$1,379.33 ",OP,555.2,"1,379.33",,,,,,
BCBS Blue Choice,CPT,77387,Guidance for radj tx dlvr,All Other,Per Unit,$632.91 ,OP,632.91,632.91,,,,,,
BCBS Blue Choice,CPT,77401,Radiation treatment delivery,All Other,Per Unit,$183.02 ,OP,123.36,183.02,,,,,,
BCBS Blue Choice,CPT,77403,Radiation treatment delivery,All Other,Per Unit,$625.29 ,OP,625.29,625.29,,,,,,
BCBS Blue Choice,CPT,77404,Radiation treatment delivery,All Other,Per Unit,$686.28 ,OP,686.28,686.28,,,,,,
BCBS Blue Choice,CPT,77408,Radiation treatment delivery,All Other,Per Unit,$831.17 ,OP,831.17,831.17,,,,,,
BCBS Blue Choice,CPT,77409,Radiation treatment delivery,All Other,Per Unit,$915.04 ,OP,915.04,915.04,,,,,,
BCBS Blue Choice,CPT,77411,Radiation treatment delivery,All Other,Per Unit,$911.23 ,OP,911.23,911.23,,,,,,
BCBS Blue Choice,CPT,77412,Radiation treatment delivery,All Other,Per Unit,"$1,067.55 ",OP,247.32,"1,067.55",,,,,,
BCBS Blue Choice,CPT,77413,Radiation treatment delivery,All Other,Per Unit,$294.26 ,OP,294.26,294.26,,,,,,
BCBS Blue Choice,CPT,77414,Radiation treatment delivery,All Other,Per Unit,"$1,189.56 ",OP,"1,189.56","1,189.56",,,,,,
BCBS Blue Choice,CPT,77416,Radiation treatment delivery,All Other,Per Unit,"$1,197.20 ",OP,"1,197.20","1,197.20",,,,,,
BCBS Blue Choice,CPT,77417,Radiology port images(s),All Other,Per Unit,$95.32 ,OP,95.32,95.32,,,,,,
BCBS Blue Choice,CPT,77418,Radiation tx delivery imrt,All Other,Per Unit,"$1,379.33 ",OP,"1,379.33","1,379.33",,,,,,
BCBS Blue Choice,CPT,77421,Stereoscopic x-ray guidance,All Other,Per Unit,$632.91 ,OP,632.91,632.91,,,,,,
BCBS Blue Choice,CPT,77422,Neutron beam tx simple,All Other,Per Unit,"$1,078.99 ",OP,"1,078.99","1,078.99",,,,,,
BCBS Blue Choice,CPT,77423,Neutron beam tx complex,All Other,Per Unit,"$1,235.32 ",OP,555.2,"1,235.32",,,,,,
BCBS Blue Choice,CPT,77427,Radiation tx management x5,All Other,Per Unit,"$1,017.99 ",OP,"1,017.99","1,017.99",,,,,,
BCBS Blue Choice,CPT,77431,Radiation therapy management,All Other,Per Unit,$522.34 ,OP,522.34,522.34,,,,,,
BCBS Blue Choice,CPT,77432,Stereotactic radiation trmt,All Other,Per Unit,"$2,177.05 ",OP,"2,177.05","2,177.05",,,,,,
BCBS Blue Choice,CPT,77435,Sbrt management,All Other,Per Unit,"$3,610.62 ",OP,"3,610.62","3,610.62",,,,,,
BCBS Blue Choice,CPT,77470,Special radiation treatment,All Other,Per Unit,"$1,509.83 ",OP,555.2,"1,509.83",,,,,,
BCBS Blue Choice,CPT,77600,Hyperthermia treatment,All Other,Per Unit,"$1,902.54 ",OP,247.32,"1,902.54",,,,,,
BCBS Blue Choice,CPT,77605,Hyperthermia treatment,All Other,Per Unit,"$3,397.11 ",OP,724.98,"3,397.11",,,,,,
BCBS Blue Choice,CPT,77610,Hyperthermia treatment,All Other,Per Unit,"$3,156.91 ",OP,555.2,"3,156.91",,,,,,
BCBS Blue Choice,CPT,77615,Hyperthermia treatment,All Other,Per Unit,"$4,464.67 ",OP,555.2,"4,464.67",,,,,,
BCBS Blue Choice,CPT,77620,Hyperthermia treatment,All Other,Per Unit,"$2,013.11 ",OP,555.2,"2,013.11",,,,,,
BCBS Blue Choice,CPT,77750,Infuse radioactive materials,All Other,Per Unit,"$1,730.97 ",OP,247.32,"1,730.97",,,,,,
BCBS Blue Choice,CPT,77761,Apply intrcav radiat simple,All Other,Per Unit,"$1,803.41 ",OP,555.2,"1,803.41",,,,,,
BCBS Blue Choice,CPT,77762,Apply intrcav radiat interm,All Other,Per Unit,"$2,463.00 ",OP,555.2,"2,463.00",,,,,,
BCBS Blue Choice,CPT,77770,Hdr rdncl ntrstl/icav brchtx,All Other,Per Unit,$964.61 ,OP,724.98,964.61,,,,,,
BCBS Blue Choice,CPT,77771,Hdr rdncl ntrstl/icav brchtx,All Other,Per Unit,"$2,882.39 ",OP,724.98,"2,882.39",,,,,,
BCBS Blue Choice,CPT,77772,Hdr rdncl ntrstl/icav brchtx,All Other,Per Unit,"$4,285.47 ",OP,724.98,"4,285.47",,,,,,
BCBS Blue Choice,CPT,77776,Apply interstit radiat simpl,All Other,Per Unit,"$2,154.18 ",OP,"2,154.18","2,154.18",,,,,,
BCBS Blue Choice,CPT,77777,Apply interstit radiat inter,All Other,Per Unit,"$2,947.21 ",OP,"2,947.21","2,947.21",,,,,,
BCBS Blue Choice,CPT,77778,Apply interstit radiat compl,All Other,Per Unit,"$4,209.21 ",OP,724.98,"4,209.21",,,,,,
BCBS Blue Choice,CPT,77785,Hdr brachytx 1 channel,All Other,Per Unit,$964.61 ,OP,964.61,964.61,,,,,,
BCBS Blue Choice,CPT,77786,Hdr brachytx 2-12 channel,All Other,Per Unit,"$2,882.39 ",OP,"2,882.39","2,882.39",,,,,,
BCBS Blue Choice,CPT,77787,Hdr brachytx over 12 chan,All Other,Per Unit,"$4,285.47 ",OP,"4,285.47","4,285.47",,,,,,
BCBS Blue Choice,CPT,77789,Apply surf ldr radionuclide,All Other,Per Unit,$533.78 ,OP,123.36,533.78,,,,,,
BCBS Blue Choice,CPT,77790,Radiation handling,All Other,Per Unit,$446.08 ,OP,446.08,446.08,,,,,,
BCBS Blue Choice,CPT,78000,Thyroid single uptake,All Other,Per Unit,$358.39 ,OP,358.39,358.39,,,,,,
BCBS Blue Choice,CPT,78001,Thyroid multiple uptakes,All Other,Per Unit,$453.71 ,OP,453.71,453.71,,,,,,
BCBS Blue Choice,CPT,78003,Thyroid suppress/stimul,All Other,Per Unit,$392.70 ,OP,392.7,392.7,,,,,,
BCBS Blue Choice,CPT,78006,Thyroid imaging with uptake,All Other,Per Unit,"$1,105.68 ",OP,"1,105.68","1,105.68",,,,,,
BCBS Blue Choice,CPT,78007,Thyroid image mult uptakes,All Other,Per Unit,$686.28 ,OP,686.28,686.28,,,,,,
BCBS Blue Choice,CPT,78010,Thyroid imaging,All Other,Per Unit,$773.98 ,OP,773.98,773.98,,,,,,
BCBS Blue Choice,CPT,78011,Thyroid imaging with flow,All Other,Per Unit,$884.55 ,OP,884.55,884.55,,,,,,
BCBS Blue Choice,CPT,78012,Thyroid uptake measurement,All Other,Per Unit,$453.71 ,OP,385.91,453.71,,,,,,
BCBS Blue Choice,CPT,78013,Thyroid imaging w/blood flow,All Other,Per Unit,$884.55 ,OP,385.91,884.55,,,,,,
BCBS Blue Choice,CPT,78014,Thyroid imaging w/blood flow,All Other,Per Unit,"$1,105.68 ",OP,385.91,"1,105.68",,,,,,
BCBS Blue Choice,CPT,78015,Thyroid met imaging,All Other,Per Unit,"$1,044.69 ",OP,385.91,"1,044.69",,,,,,
BCBS Blue Choice,CPT,78016,Thyroid met imaging/studies,All Other,Per Unit,"$1,578.46 ",OP,385.91,"1,578.46",,,,,,
BCBS Blue Choice,CPT,78018,Thyroid met imaging body,All Other,Per Unit,"$1,616.58 ",OP,500.81,"1,616.58",,,,,,
BCBS Blue Choice,CPT,78020,Thyroid met uptake,All Other,Per Unit,$480.40 ,OP,480.4,480.4,,,,,,
BCBS Blue Choice,CPT,78070,Parathyroid planar imaging,All Other,Per Unit,$884.55 ,OP,385.91,884.55,,,,,,
BCBS Blue Choice,CPT,78071,Parathyrd planar w/wo subtrj,All Other,Per Unit,$884.55 ,OP,385.91,884.55,,,,,,
BCBS Blue Choice,CPT,78072,Parathyrd planar w/spect&ct,All Other,Per Unit,$884.55 ,OP,500.81,884.55,,,,,,
BCBS Blue Choice,CPT,78075,Adrenal cortex & medulla img,All Other,Per Unit,"$2,085.54 ",OP,"1,336.39","2,085.54",,,,,,
BCBS Blue Choice,CPT,78103,Bone marrow imaging mult,All Other,Per Unit,"$1,109.50 ",OP,385.91,"1,109.50",,,,,,
BCBS Blue Choice,CPT,78104,Bone marrow imaging body,All Other,Per Unit,"$1,273.44 ",OP,385.91,"1,273.44",,,,,,
BCBS Blue Choice,CPT,78111,Plasma volume multiple,All Other,Per Unit,$518.52 ,OP,518.52,"1,336.39",,,,,,
BCBS Blue Choice,CPT,78121,Red cell mass multiple,All Other,Per Unit,$552.84 ,OP,500.81,552.84,,,,,,
BCBS Blue Choice,CPT,78122,Blood volume,All Other,Per Unit,$701.54 ,OP,500.81,701.54,,,,,,
BCBS Blue Choice,CPT,78130,Red cell survival study,All Other,Per Unit,$793.05 ,OP,385.91,793.05,,,,,,
BCBS Blue Choice,CPT,78135,Red cell survival kinetics,All Other,Per Unit,"$1,643.28 ",OP,"1,643.28","1,643.28",,,,,,
BCBS Blue Choice,CPT,78140,Red cell sequestration,All Other,Per Unit,$781.61 ,OP,385.91,781.61,,,,,,
BCBS Blue Choice,CPT,78190,Platelet survival kinetics,All Other,Per Unit,"$1,891.10 ",OP,"1,891.10","1,891.10",,,,,,
BCBS Blue Choice,CPT,78191,Platelet survival,All Other,Per Unit,"$1,067.55 ",OP,385.91,"1,067.55",,,,,,
BCBS Blue Choice,CPT,78195,Lymph system imaging,All Other,Per Unit,"$1,704.28 ",OP,500.81,"1,704.28",,,,,,
BCBS Blue Choice,CPT,78201,Liver imaging,All Other,Per Unit,$884.55 ,OP,500.81,884.55,,,,,,
BCBS Blue Choice,CPT,78202,Liver imaging with flow,All Other,Per Unit,"$1,014.17 ",OP,500.81,"1,014.17",,,,,,
BCBS Blue Choice,CPT,78205,Liver imaging (3d),All Other,Per Unit,"$1,242.94 ",OP,"1,242.94","1,242.94",,,,,,
BCBS Blue Choice,CPT,78215,Liver and spleen imaging,All Other,Per Unit,$941.74 ,OP,385.91,941.74,,,,,,
BCBS Blue Choice,CPT,78216,Liver & spleen image/flow,All Other,Per Unit,$728.23 ,OP,385.91,728.23,,,,,,
BCBS Blue Choice,CPT,78220,Liver function study,All Other,Per Unit,$758.72 ,OP,758.72,758.72,,,,,,
BCBS Blue Choice,CPT,78223,Hepatobiliary imaging,All Other,Per Unit,"$1,570.83 ",OP,"1,570.83","1,570.83",,,,,,
BCBS Blue Choice,CPT,78226,Hepatobiliary system imaging,All Other,Per Unit,"$1,570.83 ",OP,385.91,"1,570.83",,,,,,
BCBS Blue Choice,CPT,78227,Hepatobil syst image w/drug,All Other,Per Unit,"$1,570.83 ",OP,500.81,"1,570.83",,,,,,
BCBS Blue Choice,CPT,78230,Salivary gland imaging,All Other,Per Unit,$804.48 ,OP,385.91,804.48,,,,,,
BCBS Blue Choice,CPT,78231,Serial salivary imaging,All Other,Per Unit,$697.72 ,OP,385.91,697.72,,,,,,
BCBS Blue Choice,CPT,78232,Salivary gland function exam,All Other,Per Unit,$712.98 ,OP,385.91,712.98,,,,,,
BCBS Blue Choice,CPT,78258,Esophageal motility study,All Other,Per Unit,"$1,113.30 ",OP,385.91,"1,113.30",,,,,,
BCBS Blue Choice,CPT,78261,Gastric mucosa imaging,All Other,Per Unit,"$1,242.94 ",OP,385.91,"1,242.94",,,,,,
BCBS Blue Choice,CPT,78262,Gastroesophageal reflux exam,All Other,Per Unit,"$1,227.68 ",OP,385.91,"1,227.68",,,,,,
BCBS Blue Choice,CPT,78264,Gastric emptying imag study,All Other,Per Unit,"$1,403.08 ",OP,385.91,"1,403.08",,,,,,
BCBS Blue Choice,CPT,78265,Gastric emptying imag study,All Other,Per Unit,"$1,403.08 ",OP,385.91,"1,403.08",,,,,,
BCBS Blue Choice,CPT,78266,Gastric emptying imag study,All Other,Per Unit,"$1,403.08 ",OP,500.81,"1,403.08",,,,,,
BCBS Blue Choice,CPT,78268,Breath test analysis c-14,All Other,Per Unit,$301.20 ,OP,94.41,301.2,,,,,,
BCBS Blue Choice,CPT,78270,Vit b-12 absorption exam,All Other,Per Unit,$415.59 ,OP,415.59,415.59,,,,,,
BCBS Blue Choice,CPT,78271,Vit b-12 absrp exam int fac,All Other,Per Unit,$419.40 ,OP,419.4,419.4,,,,,,
BCBS Blue Choice,CPT,78272,Vit b-12 absorp combined,All Other,Per Unit,$476.60 ,OP,476.6,476.6,,,,,,
BCBS Blue Choice,CPT,78282,Gi protein loss exam,All Other,Per Unit,$407.96 ,OP,385.91,407.96,,,,,,
BCBS Blue Choice,CPT,78290,Meckels divert exam,All Other,Per Unit,"$1,498.39 ",OP,385.91,"1,498.39",,,,,,
BCBS Blue Choice,CPT,78291,Leveen/shunt patency exam,All Other,Per Unit,"$1,227.68 ",OP,385.91,"1,227.68",,,,,,
BCBS Blue Choice,CPT,78300,Bone imaging limited area,All Other,Per Unit,$869.30 ,OP,385.91,869.3,,,,,,
BCBS Blue Choice,CPT,78305,Bone imaging multiple areas,All Other,Per Unit,"$1,155.24 ",OP,385.91,"1,155.24",,,,,,
BCBS Blue Choice,CPT,78306,Bone imaging whole body,All Other,Per Unit,"$1,281.07 ",OP,385.91,"1,281.07",,,,,,
BCBS Blue Choice,CPT,78315,Bone imaging 3 phase,All Other,Per Unit,"$1,692.84 ",OP,385.91,"1,692.84",,,,,,
BCBS Blue Choice,CPT,78320,Bone imaging (3d),All Other,Per Unit,"$1,326.82 ",OP,"1,326.82","1,326.82",,,,,,
BCBS Blue Choice,CPT,78350,Bone mineral single photon,All Other,Per Unit,$179.20 ,OP,179.2,179.2,,,,,,
BCBS Blue Choice,CPT,78351,Bone mineral dual photon,All Other,Per Unit,$76.26 ,OP,76.26,76.26,,,,,,
BCBS Blue Choice,CPT,78414,Non-imaging heart function,All Other,Per Unit,$377.46 ,OP,377.46,500.81,,,,,,
BCBS Blue Choice,CPT,78428,Cardiac shunt imaging,All Other,Per Unit,$998.92 ,OP,385.91,998.92,,,,,,
BCBS Blue Choice,CPT,78429,Myocrd img pet 1 std w/ct,All Other,Per Unit,"$7,240.30 ",OP,"1,514.86","7,240.30",,,,,,
BCBS Blue Choice,CPT,78430,Myocrd img pet rst/strs w/ct,All Other,Per Unit,"$7,217.42 ",OP,"1,514.86","7,217.42",,,,,,
BCBS Blue Choice,CPT,78431,Myocrd img pet rst&strs ct,All Other,Per Unit,"$7,339.44 ",OP,"2,150.30","7,339.44",,,,,,
BCBS Blue Choice,CPT,78432,Myocrd img pet 2rtracer,All Other,Per Unit,"$8,030.21 ",OP,"2,628.05","8,030.21",,,,,,
BCBS Blue Choice,CPT,78433,Myocrd img pet 2rtracer ct,All Other,Per Unit,"$8,778.55 ",OP,"2,628.05","8,778.55",,,,,,
BCBS Blue Choice,CPT,78445,Vascular flow imaging,All Other,Per Unit,$838.79 ,OP,385.91,838.79,,,,,,
BCBS Blue Choice,CPT,78451,Ht muscle image spect sing,All Other,Per Unit,"$2,116.06 ",OP,"1,336.39","2,116.06",,,,,,
BCBS Blue Choice,CPT,78452,Ht muscle image spect mult,All Other,Per Unit,"$3,343.73 ",OP,"1,336.39","3,343.73",,,,,,
BCBS Blue Choice,CPT,78453,Ht muscle image planar sing,All Other,Per Unit,"$1,631.84 ",OP,"1,336.39","1,631.84",,,,,,
BCBS Blue Choice,CPT,78454,Ht musc image planar mult,All Other,Per Unit,"$1,772.90 ",OP,"1,336.39","1,772.90",,,,,,
BCBS Blue Choice,CPT,78456,Acute venous thrombus image,All Other,Per Unit,"$1,784.34 ",OP,"1,336.39","1,784.34",,,,,,
BCBS Blue Choice,CPT,78457,Venous thrombosis imaging,All Other,Per Unit,$964.61 ,OP,500.81,964.61,,,,,,
BCBS Blue Choice,CPT,78458,Ven thrombosis images bilat,All Other,Per Unit,"$1,078.99 ",OP,385.91,"1,078.99",,,,,,
BCBS Blue Choice,CPT,78459,Myocrd img pet single study,All Other,Per Unit,"$7,240.30 ",OP,"1,336.39","7,240.30",,,,,,
BCBS Blue Choice,CPT,78460,Heart muscle blood - single,All Other,Per Unit,$964.61 ,OP,964.61,964.61,,,,,,
BCBS Blue Choice,CPT,78461,Heart muscle blood - multiple,All Other,Per Unit,"$1,105.68 ",OP,"1,105.68","1,105.68",,,,,,
BCBS Blue Choice,CPT,78464,Heart image (3d) - single,All Other,Per Unit,"$1,448.82 ",OP,"1,448.82","1,448.82",,,,,,
BCBS Blue Choice,CPT,78465,Heart image (3d) - multiple,All Other,Per Unit,"$2,676.51 ",OP,"2,676.51","2,676.51",,,,,,
BCBS Blue Choice,CPT,78466,Heart infarct image,All Other,Per Unit,$922.67 ,OP,385.91,922.67,,,,,,
BCBS Blue Choice,CPT,78468,Heart infarct image (ef),All Other,Per Unit,"$1,166.68 ",OP,500.81,"1,166.68",,,,,,
BCBS Blue Choice,CPT,78469,Heart infarct image (3d),All Other,Per Unit,"$1,338.26 ",OP,500.81,"1,338.26",,,,,,
BCBS Blue Choice,CPT,78472,Gated heart planar single,All Other,Per Unit,"$1,368.75 ",OP,385.91,"1,368.75",,,,,,
BCBS Blue Choice,CPT,78473,Gated heart multiple,All Other,Per Unit,"$1,872.03 ",OP,385.91,"1,872.03",,,,,,
BCBS Blue Choice,CPT,78481,Heart first pass single,All Other,Per Unit,"$1,201.00 ",OP,500.81,"1,201.00",,,,,,
BCBS Blue Choice,CPT,78483,Heart first pass multiple,All Other,Per Unit,"$1,700.46 ",OP,500.81,"1,700.46",,,,,,
BCBS Blue Choice,CPT,78491,Myocrd img pet 1std rst/strs,All Other,Per Unit,"$7,217.42 ",OP,"1,514.86","7,217.42",,,,,,
BCBS Blue Choice,CPT,78492,Myocrd img pet mlt rst&strs,All Other,Per Unit,"$7,339.44 ",OP,"1,514.86","7,339.44",,,,,,
BCBS Blue Choice,CPT,78494,Heart image spect,All Other,Per Unit,"$1,486.95 ",OP,385.91,"1,486.95",,,,,,
BCBS Blue Choice,CPT,78496,Heart first pass add-on,All Other,Per Unit,$648.16 ,OP,648.16,648.16,,,,,,
BCBS Blue Choice,CPT,78579,Lung ventilation imaging,All Other,Per Unit,"$1,155.24 ",OP,385.91,"1,155.24",,,,,,
BCBS Blue Choice,CPT,78580,Lung perfusion imaging,All Other,Per Unit,"$1,071.37 ",OP,385.91,"1,071.37",,,,,,
BCBS Blue Choice,CPT,78582,Lung ventilat&perfus imaging,All Other,Per Unit,"$1,769.09 ",OP,500.81,"1,769.09",,,,,,
BCBS Blue Choice,CPT,78584,Lung V/Q image single breath,All Other,Per Unit,$819.73 ,OP,819.73,819.73,,,,,,
BCBS Blue Choice,CPT,78585,Lung V/Q imaging,All Other,Per Unit,"$1,769.09 ",OP,"1,769.09","1,769.09",,,,,,
BCBS Blue Choice,CPT,78587,Aerosol lung image multiple,All Other,Per Unit,"$1,021.81 ",OP,"1,021.81","1,021.81",,,,,,
BCBS Blue Choice,CPT,78588,Perfusion lung image,All Other,Per Unit,"$1,620.40 ",OP,"1,620.40","1,620.40",,,,,,
BCBS Blue Choice,CPT,78591,Vent image 1 breath 1 proj,All Other,Per Unit,$831.17 ,OP,831.17,831.17,,,,,,
BCBS Blue Choice,CPT,78593,Vent image 1 proj gas,All Other,Per Unit,$979.86 ,OP,979.86,979.86,,,,,,
BCBS Blue Choice,CPT,78594,Vent image mult proj gas,All Other,Per Unit,"$1,155.24 ",OP,"1,155.24","1,155.24",,,,,,
BCBS Blue Choice,CPT,78596,Lung differential function,All Other,Per Unit,"$1,906.36 ",OP,"1,906.36","1,906.36",,,,,,
BCBS Blue Choice,CPT,78597,Lung perfusion differential,All Other,Per Unit,"$1,906.36 ",OP,385.91,"1,906.36",,,,,,
BCBS Blue Choice,CPT,78598,Lung perf&ventilat diferentl,All Other,Per Unit,"$1,906.36 ",OP,500.81,"1,906.36",,,,,,
BCBS Blue Choice,CPT,78600,Brain image < 4 views,All Other,Per Unit,$888.36 ,OP,385.91,888.36,,,,,,
BCBS Blue Choice,CPT,78601,Brain image w/flow < 4 views,All Other,Per Unit,"$1,059.93 ",OP,385.91,"1,059.93",,,,,,
BCBS Blue Choice,CPT,78605,Brain image 4+ views,All Other,Per Unit,$991.29 ,OP,500.81,991.29,,,,,,
BCBS Blue Choice,CPT,78606,Brain image w/flow 4 + views,All Other,Per Unit,"$1,540.33 ",OP,500.81,"1,540.33",,,,,,
BCBS Blue Choice,CPT,78607,Brain imaging (3d),All Other,Per Unit,"$1,868.22 ",OP,"1,868.22","1,868.22",,,,,,
BCBS Blue Choice,CPT,78608,Brain imaging (pet),All Other,Per Unit,"$7,209.80 ",OP,"1,514.86","7,209.80",,,,,,
BCBS Blue Choice,CPT,78609,Brain imaging (pet),All Other,Per Unit,"$7,194.56 ",OP,"7,194.56","7,194.56",,,,,,
BCBS Blue Choice,CPT,78610,Brain flow imaging only,All Other,Per Unit,$888.36 ,OP,500.81,888.36,,,,,,
BCBS Blue Choice,CPT,78630,Cerebrospinal fluid scan,All Other,Per Unit,"$1,647.08 ",OP,500.81,"1,647.08",,,,,,
BCBS Blue Choice,CPT,78635,Csf ventriculography,All Other,Per Unit,"$1,475.51 ",OP,500.81,"1,475.51",,,,,,
BCBS Blue Choice,CPT,78645,Csf shunt evaluation,All Other,Per Unit,"$1,502.21 ",OP,500.81,"1,502.21",,,,,,
BCBS Blue Choice,CPT,78647,Cerebrospinal fluid scan,All Other,Per Unit,"$1,742.41 ",OP,"1,742.41","1,742.41",,,,,,
BCBS Blue Choice,CPT,78650,Csf leakage imaging,All Other,Per Unit,"$1,601.33 ",OP,"1,336.39","1,601.33",,,,,,
BCBS Blue Choice,CPT,78660,Nuclear exam of tear flow,All Other,Per Unit,$831.17 ,OP,385.91,831.17,,,,,,
BCBS Blue Choice,CPT,78700,Kidney imaging morphol,All Other,Per Unit,$884.55 ,OP,385.91,884.55,,,,,,
BCBS Blue Choice,CPT,78701,Kidney imaging with flow,All Other,Per Unit,"$1,056.11 ",OP,385.91,"1,056.11",,,,,,
BCBS Blue Choice,CPT,78707,K flow/funct image w/o drug,All Other,Per Unit,"$1,235.32 ",OP,500.81,"1,235.32",,,,,,
BCBS Blue Choice,CPT,78708,K flow/funct image w/drug,All Other,Per Unit,"$1,014.17 ",OP,500.81,"1,014.17",,,,,,
BCBS Blue Choice,CPT,78709,K flow/funct image multiple,All Other,Per Unit,"$1,795.78 ",OP,500.81,"1,795.78",,,,,,
BCBS Blue Choice,CPT,78710,Kidney imaging (3d),All Other,Per Unit,"$1,235.32 ",OP,"1,235.32","1,235.32",,,,,,
BCBS Blue Choice,CPT,78725,Kidney function study,All Other,Per Unit,$518.52 ,OP,385.91,518.52,,,,,,
BCBS Blue Choice,CPT,78730,Urinary bladder retention,All Other,Per Unit,$400.34 ,OP,400.34,400.34,,,,,,
BCBS Blue Choice,CPT,78740,Ureteral reflux study,All Other,Per Unit,"$1,040.87 ",OP,385.91,"1,040.87",,,,,,
BCBS Blue Choice,CPT,78761,Testicular imaging w/flow,All Other,Per Unit,"$1,052.29 ",OP,385.91,"1,052.29",,,,,,
BCBS Blue Choice,CPT,78800,Rp loclzj tum 1 area 1 d img,All Other,Per Unit,$949.36 ,OP,385.91,949.36,,,,,,
BCBS Blue Choice,CPT,78801,Rp loclzj tum 2+area 1+d img,All Other,Per Unit,"$1,265.81 ",OP,385.91,"1,265.81",,,,,,
BCBS Blue Choice,CPT,78802,Rp loclzj tum whbdy 1 d img,All Other,Per Unit,"$1,654.72 ",OP,"1,336.39","1,654.72",,,,,,
BCBS Blue Choice,CPT,78803,Rp loclzj tum spect 1 area,All Other,Per Unit,"$1,826.28 ",OP,"1,336.39","1,826.28",,,,,,
BCBS Blue Choice,CPT,78804,Rp loclzj tum whbdy 2+d img,All Other,Per Unit,"$2,870.96 ",OP,"1,336.39","2,870.96",,,,,,
BCBS Blue Choice,CPT,78805,Abscess imaging ltd area,All Other,Per Unit,$949.36 ,OP,949.36,949.36,,,,,,
BCBS Blue Choice,CPT,78806,Abscess imaging whole body,All Other,Per Unit,"$1,738.59 ",OP,"1,738.59","1,738.59",,,,,,
BCBS Blue Choice,CPT,78807,Nuclear localization/abscess,All Other,Per Unit,"$1,830.09 ",OP,"1,830.09","1,830.09",,,,,,
BCBS Blue Choice,CPT,78812,Pet image skull-thigh,All Other,Per Unit,"$7,347.07 ",OP,"1,514.86","7,347.07",,,,,,
BCBS Blue Choice,CPT,78813,Pet image full body,All Other,Per Unit,"$7,354.67 ",OP,"1,514.86","7,354.67",,,,,,
BCBS Blue Choice,CPT,78814,Pet image w/ct lmtd,All Other,Per Unit,"$7,404.24 ",OP,"1,514.86","7,404.24",,,,,,
BCBS Blue Choice,CPT,78815,Pet image w/ct skull-thigh,All Other,Per Unit,"$7,446.19 ",OP,"1,514.86","7,446.19",,,,,,
BCBS Blue Choice,CPT,78816,Pet image w/ct full body,All Other,Per Unit,"$7,461.44 ",OP,"1,514.86","7,461.44",,,,,,
BCBS Blue Choice,CPT,78830,Rp loclzj tum spect w/ct 1,All Other,Per Unit,"$2,600.43 ",OP,927,"2,600.43",,,,,,
BCBS Blue Choice,CPT,78831,Rp loclzj tum spect 2 areas,All Other,Per Unit,"$3,860.65 ",OP,927,"3,860.65",,,,,,
BCBS Blue Choice,CPT,78832,Rp loclzj tum spect w/ct 2,All Other,Per Unit,"$5,097.10 ",OP,927,"5,097.10",,,,,,
BCBS Blue Choice,CPT,79005,Nuclear rx oral admin,All Other,Per Unit,$800.67 ,OP,255.45,800.67,,,,,,
BCBS Blue Choice,CPT,79101,Nuclear rx iv admin,All Other,Per Unit,$896.00 ,OP,255.45,896,,,,,,
BCBS Blue Choice,CPT,79200,Nuclear rx intracav admin,All Other,Per Unit,$911.23 ,OP,255.45,911.23,,,,,,
BCBS Blue Choice,CPT,79300,Nuclr rx interstit colloid,All Other,Per Unit,$724.42 ,OP,255.45,724.42,,,,,,
BCBS Blue Choice,CPT,79403,Hematopoietic nuclear tx,All Other,Per Unit,"$1,132.37 ",OP,255.45,"1,132.37",,,,,,
BCBS Blue Choice,CPT,79440,Nuclear rx intra-articular,All Other,Per Unit,$838.79 ,OP,255.45,838.79,,,,,,
BCBS Blue Choice,CPT,79445,Nuclear rx intra-arterial,All Other,Per Unit,"$1,162.87 ",OP,255.45,"1,162.87",,,,,,
BCBS Blue Choice,CPT,80047,Metabolic panel ionized ca,All Other,Per Unit,$41.94 ,OP,13.73,41.94,,,,,,
BCBS Blue Choice,CPT,80048,Metabolic panel total ca,All Other,Per Unit,$132.19 ,OP,8.46,132.19,,,,,,
BCBS Blue Choice,CPT,80050,General health panel,All Other,Per Unit,$266.89 ,OP,266.89,266.89,,,,,,
BCBS Blue Choice,CPT,80051,Electrolyte panel,All Other,Per Unit,$34.31 ,OP,7.01,34.31,,,,,,
BCBS Blue Choice,CPT,80053,Comprehen metabolic panel,All Other,Per Unit,$172.42 ,OP,10.56,172.42,,,,,,
BCBS Blue Choice,CPT,80055,Obstetric panel,All Other,Per Unit,$301.20 ,OP,47.81,301.2,,,,,,
BCBS Blue Choice,CPT,80061,Lipid panel,All Other,Per Unit,$68.63 ,OP,13.39,68.63,,,,,,
BCBS Blue Choice,CPT,80069,Renal function panel,All Other,Per Unit,$38.13 ,OP,8.68,38.13,,,,,,
BCBS Blue Choice,CPT,80074,Acute hepatitis panel,All Other,Per Unit,$213.51 ,OP,47.63,213.51,,,,,,
BCBS Blue Choice,CPT,80076,Hepatic function panel,All Other,Per Unit,$126.44 ,OP,8.17,126.44,,,,,,
BCBS Blue Choice,CPT,80100,Drug screen qualitate/multi,All Other,Per Unit,$64.82 ,OP,64.82,64.82,,,,,,
BCBS Blue Choice,CPT,80101,Drug screen single,All Other,Per Unit,$92.24 ,OP,92.24,92.24,,,,,,
BCBS Blue Choice,CPT,80102,Drug confirmation,All Other,Per Unit,$57.19 ,OP,57.19,57.19,,,,,,
BCBS Blue Choice,CPT,80103,Drug analysis tissue prep,All Other,Per Unit,$114.39 ,OP,114.39,114.39,,,,,,
BCBS Blue Choice,CPT,80150,Assay of amikacin,All Other,Per Unit,$49.56 ,OP,15.08,49.56,,,,,,
BCBS Blue Choice,CPT,80152,Assay of amitriptyline,All Other,Per Unit,$80.07 ,OP,80.07,80.07,,,,,,
BCBS Blue Choice,CPT,80154,Assay of benzodiazepines,All Other,Per Unit,$53.38 ,OP,53.38,53.38,,,,,,
BCBS Blue Choice,CPT,80156,Assay carbamazepine total,All Other,Per Unit,$64.82 ,OP,14.57,64.82,,,,,,
BCBS Blue Choice,CPT,80157,Assay carbamazepine free,All Other,Per Unit,$57.19 ,OP,13.25,57.19,,,,,,
BCBS Blue Choice,CPT,80158,Drug assay cyclosporine,All Other,Per Unit,$80.07 ,OP,18.05,80.07,,,,,,
BCBS Blue Choice,CPT,80160,Assay of desipramine,All Other,Per Unit,$76.26 ,OP,76.26,76.26,,,,,,
BCBS Blue Choice,CPT,80162,Assay of digoxin total,All Other,Per Unit,$61.00 ,OP,13.28,61,,,,,,
BCBS Blue Choice,CPT,80163,Assay of digoxin free,All Other,Per Unit,$61.00 ,OP,13.28,61,,,,,,
BCBS Blue Choice,CPT,80164,Assay dipropylacetic acd tot,All Other,Per Unit,$61.00 ,OP,13.54,61,,,,,,
BCBS Blue Choice,CPT,80165,Dipropylacetic acid free,All Other,Per Unit,$61.00 ,OP,13.54,61,,,,,,
BCBS Blue Choice,CPT,80166,Assay of doxepin,All Other,Per Unit,$68.63 ,OP,68.63,68.63,,,,,,
BCBS Blue Choice,CPT,80168,Assay of ethosuximide,All Other,Per Unit,$72.44 ,OP,16.34,72.44,,,,,,
BCBS Blue Choice,CPT,80170,Assay of gentamicin,All Other,Per Unit,$72.44 ,OP,16.38,72.44,,,,,,
BCBS Blue Choice,CPT,80172,Assay of gold,All Other,Per Unit,$72.44 ,OP,72.44,72.44,,,,,,
BCBS Blue Choice,CPT,80174,Assay of imipramine,All Other,Per Unit,$76.26 ,OP,76.26,76.26,,,,,,
BCBS Blue Choice,CPT,80176,Assay of lidocaine,All Other,Per Unit,$64.82 ,OP,14.69,64.82,,,,,,
BCBS Blue Choice,CPT,80178,Assay of lithium,All Other,Per Unit,$30.51 ,OP,6.61,30.51,,,,,,
BCBS Blue Choice,CPT,80182,Assay of nortriptyline,All Other,Per Unit,$61.00 ,OP,61,61,,,,,,
BCBS Blue Choice,CPT,80184,Assay of phenobarbital,All Other,Per Unit,$49.56 ,OP,15.3,49.56,,,,,,
BCBS Blue Choice,CPT,80185,Assay of phenytoin total,All Other,Per Unit,$57.19 ,OP,13.25,57.19,,,,,,
BCBS Blue Choice,CPT,80186,Assay of phenytoin free,All Other,Per Unit,$61.00 ,OP,13.76,61,,,,,,
BCBS Blue Choice,CPT,80188,Assay of primidone,All Other,Per Unit,$72.44 ,OP,16.59,72.44,,,,,,
BCBS Blue Choice,CPT,80190,Assay of procainamide,All Other,Per Unit,$76.26 ,OP,60,76.26,,,,,,
BCBS Blue Choice,CPT,80192,Assay of procainamide,All Other,Per Unit,$76.26 ,OP,16.75,76.26,,,,,,
BCBS Blue Choice,CPT,80194,Assay of quinidine,All Other,Per Unit,$64.82 ,OP,14.6,64.82,,,,,,
BCBS Blue Choice,CPT,80195,Assay of sirolimus,All Other,Per Unit,$61.00 ,OP,13.73,61,,,,,,
BCBS Blue Choice,CPT,80196,Assay of salicylate,All Other,Per Unit,$30.51 ,OP,30.51,30.51,,,,,,
BCBS Blue Choice,CPT,80197,Assay of tacrolimus,All Other,Per Unit,$61.00 ,OP,13.73,61,,,,,,
BCBS Blue Choice,CPT,80198,Assay of theophylline,All Other,Per Unit,$64.82 ,OP,14.14,64.82,,,,,,
BCBS Blue Choice,CPT,80200,Assay of tobramycin,All Other,Per Unit,$49.56 ,OP,16.13,49.56,,,,,,
BCBS Blue Choice,CPT,80201,Assay of topiramate,All Other,Per Unit,$53.38 ,OP,11.92,53.38,,,,,,
BCBS Blue Choice,CPT,80202,Assay of vancomycin,All Other,Per Unit,$61.00 ,OP,13.54,61,,,,,,
BCBS Blue Choice,CPT,80299,Quantitative assay drug,All Other,Per Unit,$61.00 ,OP,18.64,61,,,,,,
BCBS Blue Choice,CPT,80301,System Added,All Other,Per Unit,$92.24 ,OP,92.24,92.24,,,,,,
BCBS Blue Choice,CPT,80305,Drug test prsmv dir opt obs,All Other,Per Unit,$64.82 ,OP,12.6,64.82,,,,,,
BCBS Blue Choice,CPT,80306,Drug test prsmv instrmnt,All Other,Per Unit,$64.82 ,OP,17.14,64.82,,,,,,
BCBS Blue Choice,CPT,80320,Drug screen quantalcohols,All Other,Per Unit,$49.56 ,OP,49.56,49.56,,,,,,
BCBS Blue Choice,CPT,80323,Alkaloids nos,All Other,Per Unit,$99.13 ,OP,99.13,99.13,,,,,,
BCBS Blue Choice,CPT,80324,Drug screen amphetamines 1/2,All Other,Per Unit,$68.63 ,OP,68.63,68.63,,,,,,
BCBS Blue Choice,CPT,80325,Amphetamines 3or 4,All Other,Per Unit,$68.63 ,OP,68.63,68.63,,,,,,
BCBS Blue Choice,CPT,80326,Amphetamines 5 or more,All Other,Per Unit,$68.63 ,OP,68.63,68.63,,,,,,
BCBS Blue Choice,CPT,80327,Anabolic steroid 1 or 2,All Other,Per Unit,$114.39 ,OP,114.39,114.39,,,,,,
BCBS Blue Choice,CPT,80328,Anabolic steroid 3 or more,All Other,Per Unit,$114.39 ,OP,114.39,114.39,,,,,,
BCBS Blue Choice,CPT,80329,Analgesics non-opioid 1 or 2,All Other,Per Unit,$60.35 ,OP,60.35,60.35,,,,,,
BCBS Blue Choice,CPT,80335,Antidepressant tricyclic 1/2,All Other,Per Unit,$76.26 ,OP,76.26,76.26,,,,,,
BCBS Blue Choice,CPT,80336,Antidepressant tricyclic 3-5,All Other,Per Unit,$76.26 ,OP,76.26,76.26,,,,,,
BCBS Blue Choice,CPT,80337,Tricyclic & cyclicals 6/more,All Other,Per Unit,$76.26 ,OP,76.26,76.26,,,,,,
BCBS Blue Choice,CPT,80339,Antiepileptics nos 1-3,All Other,Per Unit,$64.82 ,OP,64.82,64.82,,,,,,
BCBS Blue Choice,CPT,80340,Antiepileptics nos 4-6,All Other,Per Unit,$64.82 ,OP,64.82,64.82,,,,,,
BCBS Blue Choice,CPT,80341,Antiepileptics nos 7/more,All Other,Per Unit,$64.82 ,OP,64.82,64.82,,,,,,
BCBS Blue Choice,CPT,80342,Antipsychotics nos 1-3,All Other,Per Unit,$68.63 ,OP,68.63,68.63,,,,,,
BCBS Blue Choice,CPT,80343,Antipsychotics nos 4-6,All Other,Per Unit,$68.63 ,OP,68.63,68.63,,,,,,
BCBS Blue Choice,CPT,80344,Antipsychotics nos 7/more,All Other,Per Unit,$68.63 ,OP,68.63,68.63,,,,,,
BCBS Blue Choice,CPT,80345,Drug screening barbiturates,All Other,Per Unit,$49.56 ,OP,49.56,49.56,,,,,,
BCBS Blue Choice,CPT,80346,Benzodiazepines1-12,All Other,Per Unit,$53.38 ,OP,53.38,53.38,,,,,,
BCBS Blue Choice,CPT,80347,Benzodiazepines 13 or more,All Other,Per Unit,$53.38 ,OP,53.38,53.38,,,,,,
BCBS Blue Choice,CPT,80353,Drug screening cocaine,All Other,Per Unit,$68.63 ,OP,68.63,68.63,,,,,,
BCBS Blue Choice,CPT,80358,Drug screening methadone,All Other,Per Unit,$72.44 ,OP,72.44,72.44,,,,,,
BCBS Blue Choice,CPT,80361,Opiates 1 or more,All Other,Per Unit,$91.51 ,OP,91.51,91.51,,,,,,
BCBS Blue Choice,CPT,80363,Opioids & opiate analogs 3/4,All Other,Per Unit,$91.51 ,OP,91.51,91.51,,,,,,
BCBS Blue Choice,CPT,80364,Opioid &opiate analog 5/more,All Other,Per Unit,$91.51 ,OP,91.51,91.51,,,,,,
BCBS Blue Choice,CPT,80400,Acth stimulation panel,All Other,Per Unit,$144.88 ,OP,32.62,144.88,,,,,,
BCBS Blue Choice,CPT,80402,Acth stimulation panel,All Other,Per Unit,$388.89 ,OP,86.96,388.89,,,,,,
BCBS Blue Choice,CPT,80406,Acth stimulation panel,All Other,Per Unit,$346.96 ,OP,78.26,346.96,,,,,,
BCBS Blue Choice,CPT,80408,Aldosterone suppression eval,All Other,Per Unit,$560.47 ,OP,125.5,560.47,,,,,,
BCBS Blue Choice,CPT,80410,Calcitonin stimul panel,All Other,Per Unit,$358.39 ,OP,80.37,358.39,,,,,,
BCBS Blue Choice,CPT,80412,Crh stimulation panel,All Other,Per Unit,"$1,467.89 ",OP,801.62,"1,467.89",,,,,,
BCBS Blue Choice,CPT,80414,Testosterone response panel,All Other,Per Unit,$228.77 ,OP,51.64,228.77,,,,,,
BCBS Blue Choice,CPT,80415,Tot estradiol response panel,All Other,Per Unit,$99.13 ,OP,55.89,99.13,,,,,,
BCBS Blue Choice,CPT,80416,Renin stimulation panel,All Other,Per Unit,$587.16 ,OP,209.32,587.16,,,,,,
BCBS Blue Choice,CPT,80417,Renin stimulation panel,All Other,Per Unit,$194.45 ,OP,43.99,194.45,,,,,,
BCBS Blue Choice,CPT,80418,Pituitary evaluation panel,All Other,Per Unit,"$2,573.58 ",OP,579.48,"2,573.58",,,,,,
BCBS Blue Choice,CPT,80420,Dexamethasone panel,All Other,Per Unit,$320.27 ,OP,161.88,320.27,,,,,,
BCBS Blue Choice,CPT,80422,Glucagon tolerance panel,All Other,Per Unit,$205.88 ,OP,46.07,205.88,,,,,,
BCBS Blue Choice,CPT,80424,Glucagon tolerance panel,All Other,Per Unit,$224.95 ,OP,50.5,224.95,,,,,,
BCBS Blue Choice,CPT,80426,Gonadotropin hormone panel,All Other,Per Unit,$659.60 ,OP,148.41,659.6,,,,,,
BCBS Blue Choice,CPT,80428,Growth hormone panel,All Other,Per Unit,$289.76 ,OP,66.7,289.76,,,,,,
BCBS Blue Choice,CPT,80430,Growth hormone panel,All Other,Per Unit,$343.14 ,OP,129.33,343.14,,,,,,
BCBS Blue Choice,CPT,80432,Insulin suppression panel,All Other,Per Unit,$602.41 ,OP,165.61,602.41,,,,,,
BCBS Blue Choice,CPT,80434,Insulin tolerance panel,All Other,Per Unit,$449.90 ,OP,285.03,449.9,,,,,,
BCBS Blue Choice,CPT,80435,Insulin tolerance panel,All Other,Per Unit,$449.90 ,OP,103,449.9,,,,,,
BCBS Blue Choice,CPT,80436,Metyrapone panel,All Other,Per Unit,$301.20 ,OP,91.16,301.2,,,,,,
BCBS Blue Choice,CPT,80438,Trh stimulation panel,All Other,Per Unit,$224.95 ,OP,50.41,224.95,,,,,,
BCBS Blue Choice,CPT,80439,Trh stimulation panel,All Other,Per Unit,$297.39 ,OP,67.21,297.39,,,,,,
BCBS Blue Choice,CPT,80440,TRH stimulation panel,All Other,Per Unit,$259.27 ,OP,259.27,259.27,,,,,,
BCBS Blue Choice,CPT,80502,Lab pathology consultation,All Other,Per Unit,$320.27 ,OP,152.64,320.27,,,,,,
BCBS Blue Choice,CPT,81000,Urinalysis nonauto w/scope,All Other,Per Unit,$15.26 ,OP,4.02,15.26,,,,,,
BCBS Blue Choice,CPT,81001,Urinalysis auto w/scope,All Other,Per Unit,$15.26 ,OP,3.17,15.26,,,,,,
BCBS Blue Choice,CPT,81002,Urinalysis nonauto w/o scope,All Other,Per Unit,$11.44 ,OP,3.48,11.44,,,,,,
BCBS Blue Choice,CPT,81003,Urinalysis auto w/o scope,All Other,Per Unit,$11.44 ,OP,2.25,11.44,,,,,,
BCBS Blue Choice,CPT,81005,Urinalysis,All Other,Per Unit,$11.44 ,OP,2.17,11.44,,,,,,
BCBS Blue Choice,CPT,81007,Urine screen for bacteria,All Other,Per Unit,$11.44 ,OP,11.44,29.98,,,,,,
BCBS Blue Choice,CPT,81015,Microscopic exam of urine,All Other,Per Unit,$15.26 ,OP,3.05,15.26,,,,,,
BCBS Blue Choice,CPT,81020,Urinalysis glass test,All Other,Per Unit,$15.26 ,OP,4.7,15.26,,,,,,
BCBS Blue Choice,CPT,81025,Urine pregnancy test,All Other,Per Unit,$30.51 ,OP,8.61,30.51,,,,,,
BCBS Blue Choice,CPT,81050,Urinalysis volume measure,All Other,Per Unit,$11.44 ,OP,3.64,11.44,,,,,,
BCBS Blue Choice,CPT,81500,Onco (ovar) two proteins,All Other,Per Unit,$91.51 ,OP,91.51,260.5,,,,,,
BCBS Blue Choice,CPT,81503,Onco (ovar) five proteins,All Other,Per Unit,$91.51 ,OP,91.51,897,,,,,,
BCBS Blue Choice,CPT,81506,Endo assay seven anal,All Other,Per Unit,$57.19 ,OP,57.19,68.92,,,,,,
BCBS Blue Choice,CPT,81508,Ftl cgen abnor two proteins,All Other,Per Unit,$144.88 ,OP,54.3,144.88,,,,,,
BCBS Blue Choice,CPT,81509,Ftl cgen abnor 3 proteins,All Other,Per Unit,$213.51 ,OP,213.51,"1,487.37",,,,,,
BCBS Blue Choice,CPT,81510,Ftl cgen abnor three anal,All Other,Per Unit,$202.07 ,OP,55.54,202.07,,,,,,
BCBS Blue Choice,CPT,81511,Ftl cgen abnor four anal,All Other,Per Unit,$270.71 ,OP,153.5,270.71,,,,,,
BCBS Blue Choice,CPT,81512,Ftl cgen abnor five anal,All Other,Per Unit,$270.71 ,OP,69.52,270.71,,,,,,
BCBS Blue Choice,CPT,82000,Assay of blood acetaldehyde,All Other,Per Unit,$45.74 ,OP,45.74,45.74,,,,,,
BCBS Blue Choice,CPT,82003,Assay of acetaminophen,All Other,Per Unit,$87.69 ,OP,87.69,87.69,,,,,,
BCBS Blue Choice,CPT,82009,Test for acetone/ketones,All Other,Per Unit,$19.07 ,OP,4.52,19.07,,,,,,
BCBS Blue Choice,CPT,82010,Acetone assay,All Other,Per Unit,$41.94 ,OP,8.17,41.94,,,,,,
BCBS Blue Choice,CPT,82016,Acylcarnitines qual,All Other,Per Unit,$61.00 ,OP,16.49,61,,,,,,
BCBS Blue Choice,CPT,82017,Acylcarnitines quant,All Other,Per Unit,$76.26 ,OP,16.87,76.26,,,,,,
BCBS Blue Choice,CPT,82024,Assay of acth,All Other,Per Unit,$171.58 ,OP,38.62,171.58,,,,,,
BCBS Blue Choice,CPT,82030,Assay of adp & amp,All Other,Per Unit,$99.13 ,OP,25.8,99.13,,,,,,
BCBS Blue Choice,CPT,82040,Assay of serum albumin,All Other,Per Unit,$22.88 ,OP,4.95,22.88,,,,,,
BCBS Blue Choice,CPT,82042,Other source albumin quan ea,All Other,Per Unit,$26.70 ,OP,7.78,26.7,,,,,,
BCBS Blue Choice,CPT,82043,Ur albumin quantitative,All Other,Per Unit,$26.70 ,OP,5.78,26.7,,,,,,
BCBS Blue Choice,CPT,82044,Ur albumin semiquantitative,All Other,Per Unit,$22.88 ,OP,6.23,22.88,,,,,,
BCBS Blue Choice,CPT,82045,Albumin ischemia modified,All Other,Per Unit,$125.82 ,OP,33.94,125.82,,,,,,
BCBS Blue Choice,CPT,82055,Assay of ethanol,All Other,Per Unit,$49.56 ,OP,49.56,49.56,,,,,,
BCBS Blue Choice,CPT,82075,Assay of breath ethanol,All Other,Per Unit,$45.74 ,OP,30,45.74,,,,,,
BCBS Blue Choice,CPT,82085,Assay of aldolase,All Other,Per Unit,$41.94 ,OP,9.71,41.94,,,,,,
BCBS Blue Choice,CPT,82088,Assay of aldosterone,All Other,Per Unit,$183.02 ,OP,40.75,183.02,,,,,,
BCBS Blue Choice,CPT,82101,Assay of urine alkaloids,All Other,Per Unit,$99.13 ,OP,99.13,99.13,,,,,,
BCBS Blue Choice,CPT,82103,Alpha-1-antitrypsin total,All Other,Per Unit,$61.00 ,OP,13.44,61,,,,,,
BCBS Blue Choice,CPT,82104,Alpha-1-antitrypsin pheno,All Other,Per Unit,$64.82 ,OP,14.46,64.82,,,,,,
BCBS Blue Choice,CPT,82105,Alpha-fetoprotein serum,All Other,Per Unit,$76.26 ,OP,16.77,76.26,,,,,,
BCBS Blue Choice,CPT,82106,Alpha-fetoprotein amniotic,All Other,Per Unit,$76.26 ,OP,17,76.26,,,,,,
BCBS Blue Choice,CPT,82107,Alpha-fetoprotein l3,All Other,Per Unit,$209.70 ,OP,64.41,209.7,,,,,,
BCBS Blue Choice,CPT,82108,Assay of aluminum,All Other,Per Unit,$114.39 ,OP,25.48,114.39,,,,,,
BCBS Blue Choice,CPT,82120,Amines vaginal fluid qual,All Other,Per Unit,$19.07 ,OP,5.99,19.07,,,,,,
BCBS Blue Choice,CPT,82127,Amino acid single qual,All Other,Per Unit,$61.00 ,OP,14.18,61,,,,,,
BCBS Blue Choice,CPT,82128,Amino acids mult qual,All Other,Per Unit,$61.00 ,OP,13.87,61,,,,,,
BCBS Blue Choice,CPT,82131,Amino acids single quant,All Other,Per Unit,$76.26 ,OP,22.98,76.26,,,,,,
BCBS Blue Choice,CPT,82135,Assay aminolevulinic acid,All Other,Per Unit,$64.82 ,OP,16.45,64.82,,,,,,
BCBS Blue Choice,CPT,82136,Amino acids quant 2-5,All Other,Per Unit,$76.26 ,OP,19.61,76.26,,,,,,
BCBS Blue Choice,CPT,82140,Assay of ammonia,All Other,Per Unit,$64.82 ,OP,14.57,64.82,,,,,,
BCBS Blue Choice,CPT,82143,Amniotic fluid scan,All Other,Per Unit,$30.51 ,OP,9.35,30.51,,,,,,
BCBS Blue Choice,CPT,82145,Assay of amphetamines,All Other,Per Unit,$68.63 ,OP,68.63,68.63,,,,,,
BCBS Blue Choice,CPT,82150,Assay of amylase,All Other,Per Unit,$34.31 ,OP,6.48,34.31,,,,,,
BCBS Blue Choice,CPT,82157,Assay of androstenedione,All Other,Per Unit,$129.64 ,OP,29.28,129.64,,,,,,
BCBS Blue Choice,CPT,82160,Assay of androsterone,All Other,Per Unit,$110.57 ,OP,25.55,110.57,,,,,,
BCBS Blue Choice,CPT,82163,Assay of angiotensin ii,All Other,Per Unit,$91.51 ,OP,20.52,91.51,,,,,,
BCBS Blue Choice,CPT,82164,Angiotensin i enzyme test,All Other,Per Unit,$64.82 ,OP,14.6,64.82,,,,,,
BCBS Blue Choice,CPT,82172,Assay of apolipoprotein,All Other,Per Unit,$68.63 ,OP,21.09,68.63,,,,,,
BCBS Blue Choice,CPT,82175,Assay of arsenic,All Other,Per Unit,$83.87 ,OP,18.97,83.87,,,,,,
BCBS Blue Choice,CPT,82190,Atomic absorption,All Other,Per Unit,$64.82 ,OP,15.9,64.82,,,,,,
BCBS Blue Choice,CPT,82205,Assay of barbiturates,All Other,Per Unit,$49.56 ,OP,49.56,49.56,,,,,,
BCBS Blue Choice,CPT,82232,Assay of beta-2 protein,All Other,Per Unit,$72.44 ,OP,16.18,72.44,,,,,,
BCBS Blue Choice,CPT,82239,Bile acids total,All Other,Per Unit,$76.26 ,OP,17.12,76.26,,,,,,
BCBS Blue Choice,CPT,82240,Bile acids cholylglycine,All Other,Per Unit,$64.82 ,OP,26.58,64.82,,,,,,
BCBS Blue Choice,CPT,82247,Bilirubin total,All Other,Per Unit,$26.70 ,OP,5.02,26.7,,,,,,
BCBS Blue Choice,CPT,82248,Bilirubin direct,All Other,Per Unit,$26.70 ,OP,5.02,26.7,,,,,,
BCBS Blue Choice,CPT,82252,Fecal bilirubin test,All Other,Per Unit,$19.07 ,OP,4.56,19.07,,,,,,
BCBS Blue Choice,CPT,82261,Assay of biotinidase,All Other,Per Unit,$76.26 ,OP,16.87,76.26,,,,,,
BCBS Blue Choice,CPT,82270,Occult blood feces,All Other,Per Unit,$15.26 ,OP,4.38,15.26,,,,,,
BCBS Blue Choice,CPT,82271,Occult blood other sources,All Other,Per Unit,$15.26 ,OP,5.32,15.26,,,,,,
BCBS Blue Choice,CPT,82272,Occult bld feces 1-3 tests,All Other,Per Unit,$15.26 ,OP,4.23,15.26,,,,,,
BCBS Blue Choice,CPT,82274,Assay test for blood fecal,All Other,Per Unit,$80.07 ,OP,15.92,80.07,,,,,,
BCBS Blue Choice,CPT,82286,Assay of bradykinin,All Other,Per Unit,$30.51 ,OP,5.16,30.51,,,,,,
BCBS Blue Choice,CPT,82300,Assay of cadmium,All Other,Per Unit,$102.95 ,OP,23.64,102.95,,,,,,
BCBS Blue Choice,CPT,82306,Vitamin d 25 hydroxy,All Other,Per Unit,$356.68 ,OP,29.6,356.68,,,,,,
BCBS Blue Choice,CPT,82307,Assay of vitamin D,All Other,Per Unit,$144.88 ,OP,144.88,144.88,,,,,,
BCBS Blue Choice,CPT,82308,Assay of calcitonin,All Other,Per Unit,$118.19 ,OP,26.79,118.19,,,,,,
BCBS Blue Choice,CPT,82310,Assay of calcium,All Other,Per Unit,$22.88 ,OP,5.16,22.88,,,,,,
BCBS Blue Choice,CPT,82330,Assay of calcium,All Other,Per Unit,$61.00 ,OP,13.68,61,,,,,,
BCBS Blue Choice,CPT,82331,Calcium infusion test,All Other,Per Unit,$22.88 ,OP,13.34,22.88,,,,,,
BCBS Blue Choice,CPT,82340,Assay of calcium in urine,All Other,Per Unit,$26.70 ,OP,6.03,26.7,,,,,,
BCBS Blue Choice,CPT,82355,Calculus analysis qual,All Other,Per Unit,$53.38 ,OP,11.58,53.38,,,,,,
BCBS Blue Choice,CPT,82360,Calculus assay quant,All Other,Per Unit,$45.74 ,OP,12.87,45.74,,,,,,
BCBS Blue Choice,CPT,82365,Calculus spectroscopy,All Other,Per Unit,$45.74 ,OP,12.9,45.74,,,,,,
BCBS Blue Choice,CPT,82370,X-ray assay calculus,All Other,Per Unit,$45.74 ,OP,12.52,45.74,,,,,,
BCBS Blue Choice,CPT,82373,Assay c-d transfer measure,All Other,Per Unit,$80.07 ,OP,18.06,80.07,,,,,,
BCBS Blue Choice,CPT,82374,Assay blood carbon dioxide,All Other,Per Unit,$22.88 ,OP,4.88,22.88,,,,,,
BCBS Blue Choice,CPT,82375,Assay carboxyhb quant,All Other,Per Unit,$26.70 ,OP,12.32,26.7,,,,,,
BCBS Blue Choice,CPT,82376,Assay carboxyhb qual,All Other,Per Unit,$26.70 ,OP,14.07,26.7,,,,,,
BCBS Blue Choice,CPT,82378,Carcinoembryonic antigen,All Other,Per Unit,$83.87 ,OP,18.96,83.87,,,,,,
BCBS Blue Choice,CPT,82379,Assay of carnitine,All Other,Per Unit,$76.26 ,OP,16.87,76.26,,,,,,
BCBS Blue Choice,CPT,82380,Assay of carotene,All Other,Per Unit,$41.94 ,OP,9.22,41.94,,,,,,
BCBS Blue Choice,CPT,82382,Assay urine catecholamines,All Other,Per Unit,$76.26 ,OP,27.3,76.26,,,,,,
BCBS Blue Choice,CPT,82383,Assay blood catecholamines,All Other,Per Unit,$110.57 ,OP,29.08,110.57,,,,,,
BCBS Blue Choice,CPT,82384,Assay three catecholamines,All Other,Per Unit,$110.57 ,OP,25.25,110.57,,,,,,
BCBS Blue Choice,CPT,82387,Assay of cathepsin-d,All Other,Per Unit,$91.51 ,OP,18.06,91.51,,,,,,
BCBS Blue Choice,CPT,82390,Assay of ceruloplasmin,All Other,Per Unit,$49.56 ,OP,10.74,49.56,,,,,,
BCBS Blue Choice,CPT,82397,Chemiluminescent assay,All Other,Per Unit,$64.82 ,OP,14.12,64.82,,,,,,
BCBS Blue Choice,CPT,82415,Assay of chloramphenicol,All Other,Per Unit,$57.19 ,OP,12.67,57.19,,,,,,
BCBS Blue Choice,CPT,82435,Assay of blood chloride,All Other,Per Unit,$19.07 ,OP,4.6,19.07,,,,,,
BCBS Blue Choice,CPT,82436,Assay of urine chloride,All Other,Per Unit,$22.88 ,OP,5.75,22.88,,,,,,
BCBS Blue Choice,CPT,82441,Test for chlorohydrocarbons,All Other,Per Unit,$26.70 ,OP,6.01,26.7,,,,,,
BCBS Blue Choice,CPT,82465,Assay bld/serum cholesterol,All Other,Per Unit,$22.88 ,OP,4.35,22.88,,,,,,
BCBS Blue Choice,CPT,82480,Assay serum cholinesterase,All Other,Per Unit,$34.31 ,OP,7.87,34.31,,,,,,
BCBS Blue Choice,CPT,82482,Assay rbc cholinesterase,All Other,Per Unit,$34.31 ,OP,9.81,34.31,,,,,,
BCBS Blue Choice,CPT,82485,Assay chondroitin sulfate,All Other,Per Unit,$91.51 ,OP,20.65,91.51,,,,,,
BCBS Blue Choice,CPT,82486,Gas/liquid chromatography,All Other,Per Unit,$80.07 ,OP,80.07,80.07,,,,,,
BCBS Blue Choice,CPT,82487,Paper chromatography,All Other,Per Unit,$72.44 ,OP,72.44,72.44,,,,,,
BCBS Blue Choice,CPT,82488,Paper chromatography,All Other,Per Unit,$95.32 ,OP,95.32,95.32,,,,,,
BCBS Blue Choice,CPT,82489,Thin layer chromatography,All Other,Per Unit,$83.87 ,OP,83.87,83.87,,,,,,
BCBS Blue Choice,CPT,82491,Chromotography quant sing,All Other,Per Unit,$80.07 ,OP,80.07,80.07,,,,,,
BCBS Blue Choice,CPT,82492,Chromotography quant mult,All Other,Per Unit,$80.07 ,OP,80.07,80.07,,,,,,
BCBS Blue Choice,CPT,82495,Assay of chromium,All Other,Per Unit,$91.51 ,OP,20.28,91.51,,,,,,
BCBS Blue Choice,CPT,82507,Assay of citrate,All Other,Per Unit,$57.19 ,OP,27.8,57.19,,,,,,
BCBS Blue Choice,CPT,82520,Assay of cocaine,All Other,Per Unit,$68.63 ,OP,68.63,68.63,,,,,,
BCBS Blue Choice,CPT,82523,Collagen crosslinks,All Other,Per Unit,$95.32 ,OP,18.68,95.32,,,,,,
BCBS Blue Choice,CPT,82525,Assay of copper,All Other,Per Unit,$53.38 ,OP,12.41,53.38,,,,,,
BCBS Blue Choice,CPT,82528,Assay of corticosterone,All Other,Per Unit,$99.13 ,OP,22.52,99.13,,,,,,
BCBS Blue Choice,CPT,82530,Cortisol free,All Other,Per Unit,$76.26 ,OP,16.71,76.26,,,,,,
BCBS Blue Choice,CPT,82533,Total cortisol,All Other,Per Unit,$72.44 ,OP,16.3,72.44,,,,,,
BCBS Blue Choice,CPT,82540,Assay of creatine,All Other,Per Unit,$19.07 ,OP,4.64,19.07,,,,,,
BCBS Blue Choice,CPT,82541,Column chromotography qual,All Other,Per Unit,$80.07 ,OP,80.07,80.07,,,,,,
BCBS Blue Choice,CPT,82542,Col chromotography qual/quan,All Other,Per Unit,$80.07 ,OP,24.09,80.07,,,,,,
BCBS Blue Choice,CPT,82543,Column chromotograph/isotope,All Other,Per Unit,$80.07 ,OP,80.07,80.07,,,,,,
BCBS Blue Choice,CPT,82544,Column chromotograph/isotope,All Other,Per Unit,$80.07 ,OP,80.07,80.07,,,,,,
BCBS Blue Choice,CPT,82550,Assay of ck (cpk),All Other,Per Unit,$30.51 ,OP,6.51,30.51,,,,,,
BCBS Blue Choice,CPT,82552,Assay of cpk in blood,All Other,Per Unit,$61.00 ,OP,13.39,61,,,,,,
BCBS Blue Choice,CPT,82553,Creatine mb fraction,All Other,Per Unit,$49.56 ,OP,11.55,49.56,,,,,,
BCBS Blue Choice,CPT,82554,Creatine isoforms,All Other,Per Unit,$53.38 ,OP,11.87,53.38,,,,,,
BCBS Blue Choice,CPT,82565,Assay of creatinine,All Other,Per Unit,$22.88 ,OP,5.12,22.88,,,,,,
BCBS Blue Choice,CPT,82570,Assay of urine creatinine,All Other,Per Unit,$26.70 ,OP,5.18,26.7,,,,,,
BCBS Blue Choice,CPT,82575,Creatinine clearance test,All Other,Per Unit,$41.94 ,OP,9.46,41.94,,,,,,
BCBS Blue Choice,CPT,82585,Assay of cryofibrinogen,All Other,Per Unit,$38.13 ,OP,14.14,38.13,,,,,,
BCBS Blue Choice,CPT,82595,Assay of cryoglobulin,All Other,Per Unit,$30.51 ,OP,6.47,30.51,,,,,,
BCBS Blue Choice,CPT,82607,Vitamin b-12,All Other,Per Unit,$68.63 ,OP,15.08,68.63,,,,,,
BCBS Blue Choice,CPT,82610,Cystatin c,All Other,Per Unit,$61.00 ,OP,18.52,61,,,,,,
BCBS Blue Choice,CPT,82615,Test for urine cystines,All Other,Per Unit,$38.13 ,OP,9.55,38.13,,,,,,
BCBS Blue Choice,CPT,82626,Dehydroepiandrosterone,All Other,Per Unit,$114.39 ,OP,25.27,114.39,,,,,,
BCBS Blue Choice,CPT,82627,Dehydroepiandrosterone,All Other,Per Unit,$99.13 ,OP,22.23,99.13,,,,,,
BCBS Blue Choice,CPT,82633,Desoxycorticosterone,All Other,Per Unit,$122.00 ,OP,30.98,122,,,,,,
BCBS Blue Choice,CPT,82634,Deoxycortisol,All Other,Per Unit,$76.26 ,OP,29.28,76.26,,,,,,
BCBS Blue Choice,CPT,82638,Assay of dibucaine number,All Other,Per Unit,$53.38 ,OP,12.25,53.38,,,,,,
BCBS Blue Choice,CPT,82642,Dihydrotestosterone,All Other,Per Unit,$114.39 ,OP,29.28,114.39,,,,,,
BCBS Blue Choice,CPT,82646,Assay of dihydrocodeinone,All Other,Per Unit,$91.51 ,OP,91.51,91.51,,,,,,
BCBS Blue Choice,CPT,82649,Assay of dihydromorphinone,All Other,Per Unit,$91.51 ,OP,91.51,91.51,,,,,,
BCBS Blue Choice,CPT,82651,Assay of dihydrotestosterone,All Other,Per Unit,$114.39 ,OP,114.39,114.39,,,,,,
BCBS Blue Choice,CPT,82652,Vit d 1 25-dihydroxy,All Other,Per Unit,$171.58 ,OP,38.5,171.58,,,,,,
BCBS Blue Choice,CPT,82654,Assay of dimethadione,All Other,Per Unit,$61.00 ,OP,61,61,,,,,,
BCBS Blue Choice,CPT,82657,Enzyme cell activity,All Other,Per Unit,$80.07 ,OP,22.17,80.07,,,,,,
BCBS Blue Choice,CPT,82664,Electrophoretic test,All Other,Per Unit,$122.00 ,OP,61.5,122,,,,,,
BCBS Blue Choice,CPT,82666,Assay of epiandrosterone,All Other,Per Unit,$83.87 ,OP,83.87,83.87,,,,,,
BCBS Blue Choice,CPT,82668,Assay of erythropoietin,All Other,Per Unit,$83.87 ,OP,18.79,83.87,,,,,,
BCBS Blue Choice,CPT,82670,Assay of total estradiol,All Other,Per Unit,$49.56 ,OP,27.94,49.56,,,,,,
BCBS Blue Choice,CPT,82671,Assay of estrogens,All Other,Per Unit,$114.39 ,OP,32.3,114.39,,,,,,
BCBS Blue Choice,CPT,82672,Assay of estrogen,All Other,Per Unit,$95.32 ,OP,21.7,95.32,,,,,,
BCBS Blue Choice,CPT,82677,Assay of estriol,All Other,Per Unit,$49.56 ,OP,24.18,49.56,,,,,,
BCBS Blue Choice,CPT,82679,Assay of estrone,All Other,Per Unit,$57.19 ,OP,24.95,57.19,,,,,,
BCBS Blue Choice,CPT,82690,Assay of ethchlorvynol,All Other,Per Unit,$76.26 ,OP,76.26,76.26,,,,,,
BCBS Blue Choice,CPT,82693,Assay of ethylene glycol,All Other,Per Unit,$64.82 ,OP,14.9,64.82,,,,,,
BCBS Blue Choice,CPT,82696,Assay of etiocholanolone,All Other,Per Unit,$64.82 ,OP,26.24,64.82,,,,,,
BCBS Blue Choice,CPT,82715,Assay of fecal fat,All Other,Per Unit,$15.26 ,OP,15.26,22.97,,,,,,
BCBS Blue Choice,CPT,82726,Long chain fatty acids,All Other,Per Unit,$80.07 ,OP,19.75,80.07,,,,,,
BCBS Blue Choice,CPT,82728,Assay of ferritin,All Other,Per Unit,$61.00 ,OP,13.63,61,,,,,,
BCBS Blue Choice,CPT,82731,Assay of fetal fibronectin,All Other,Per Unit,$236.38 ,OP,64.41,236.38,,,,,,
BCBS Blue Choice,CPT,82735,Assay of fluoride,All Other,Per Unit,$83.87 ,OP,18.54,83.87,,,,,,
BCBS Blue Choice,CPT,82742,Assay of flurazepam,All Other,Per Unit,$87.69 ,OP,87.69,87.69,,,,,,
BCBS Blue Choice,CPT,82746,Assay of folic acid serum,All Other,Per Unit,$64.82 ,OP,14.7,64.82,,,,,,
BCBS Blue Choice,CPT,82747,Assay of folic acid rbc,All Other,Per Unit,$76.26 ,OP,17.65,76.26,,,,,,
BCBS Blue Choice,CPT,82757,Assay of semen fructose,All Other,Per Unit,$76.26 ,OP,17.34,76.26,,,,,,
BCBS Blue Choice,CPT,82759,Assay of rbc galactokinase,All Other,Per Unit,$95.32 ,OP,21.48,95.32,,,,,,
BCBS Blue Choice,CPT,82760,Assay of galactose,All Other,Per Unit,$49.56 ,OP,11.2,49.56,,,,,,
BCBS Blue Choice,CPT,82775,Assay galactose transferase,All Other,Per Unit,$80.07 ,OP,21.07,80.07,,,,,,
BCBS Blue Choice,CPT,82776,Galactose transferase test,All Other,Per Unit,$26.70 ,OP,11.74,26.7,,,,,,
BCBS Blue Choice,CPT,82784,Assay iga/igd/igg/igm each,All Other,Per Unit,$41.94 ,OP,9.3,41.94,,,,,,
BCBS Blue Choice,CPT,82785,Assay of ige,All Other,Per Unit,$72.44 ,OP,16.46,72.44,,,,,,
BCBS Blue Choice,CPT,82787,Igg 1 2 3 or 4 each,All Other,Per Unit,$34.31 ,OP,8.02,34.31,,,,,,
BCBS Blue Choice,CPT,82800,Blood ph,All Other,Per Unit,$30.51 ,OP,11,30.51,,,,,,
BCBS Blue Choice,CPT,82803,Blood gases any combination,All Other,Per Unit,$61.00 ,OP,26.07,61,,,,,,
BCBS Blue Choice,CPT,82805,Blood gases w/o2 saturation,All Other,Per Unit,$141.07 ,OP,78.77,141.07,,,,,,
BCBS Blue Choice,CPT,82820,Hemoglobin-oxygen affinity,All Other,Per Unit,$49.56 ,OP,13.34,49.56,,,,,,
BCBS Blue Choice,CPT,82926,Assay of gastric acid,All Other,Per Unit,$22.88 ,OP,22.88,22.88,,,,,,
BCBS Blue Choice,CPT,82928,Assay of gastric acid,All Other,Per Unit,$30.51 ,OP,30.51,30.51,,,,,,
BCBS Blue Choice,CPT,82938,Gastrin test,All Other,Per Unit,$80.07 ,OP,17.69,80.07,,,,,,
BCBS Blue Choice,CPT,82941,Assay of gastrin,All Other,Per Unit,$80.07 ,OP,17.63,80.07,,,,,,
BCBS Blue Choice,CPT,82943,Assay of glucagon,All Other,Per Unit,$34.31 ,OP,14.29,34.31,,,,,,
BCBS Blue Choice,CPT,82945,Glucose other fluid,All Other,Per Unit,$19.07 ,OP,3.93,19.07,,,,,,
BCBS Blue Choice,CPT,82946,Glucagon tolerance test,All Other,Per Unit,$68.63 ,OP,17.77,68.63,,,,,,
BCBS Blue Choice,CPT,82947,Assay glucose blood quant,All Other,Per Unit,$19.07 ,OP,3.93,19.07,,,,,,
BCBS Blue Choice,CPT,82948,Reagent strip/blood glucose,All Other,Per Unit,$15.26 ,OP,5.04,15.26,,,,,,
BCBS Blue Choice,CPT,82950,Glucose test,All Other,Per Unit,$22.88 ,OP,4.75,22.88,,,,,,
BCBS Blue Choice,CPT,82951,Glucose tolerance test (gtt),All Other,Per Unit,$64.82 ,OP,12.87,64.82,,,,,,
BCBS Blue Choice,CPT,82952,Gtt-added samples,All Other,Per Unit,$19.07 ,OP,3.92,19.07,,,,,,
BCBS Blue Choice,CPT,82953,Glucose-tolbutamide test,All Other,Per Unit,$68.63 ,OP,68.63,68.63,,,,,,
BCBS Blue Choice,CPT,82955,Assay of g6pd enzyme,All Other,Per Unit,$41.94 ,OP,9.7,41.94,,,,,,
BCBS Blue Choice,CPT,82962,Glucose blood test,All Other,Per Unit,$11.44 ,OP,3.28,11.44,,,,,,
BCBS Blue Choice,CPT,82963,Assay of glucosidase,All Other,Per Unit,$80.07 ,OP,21.48,80.07,,,,,,
BCBS Blue Choice,CPT,82965,Assay of gdh enzyme,All Other,Per Unit,$34.31 ,OP,13.15,34.31,,,,,,
BCBS Blue Choice,CPT,82975,Assay of glutamine,All Other,Per Unit,$72.44 ,OP,72.44,72.44,,,,,,
BCBS Blue Choice,CPT,82977,Assay of ggt,All Other,Per Unit,$34.31 ,OP,7.2,34.31,,,,,,
BCBS Blue Choice,CPT,82978,Assay of glutathione,All Other,Per Unit,$64.82 ,OP,15.45,64.82,,,,,,
BCBS Blue Choice,CPT,82979,Assay rbc glutathione,All Other,Per Unit,$30.51 ,OP,9.44,30.51,,,,,,
BCBS Blue Choice,CPT,82980,Assay of glutethimide,All Other,Per Unit,$80.07 ,OP,80.07,80.07,,,,,,
BCBS Blue Choice,CPT,82985,Assay of glycated protein,All Other,Per Unit,$76.26 ,OP,16.76,76.26,,,,,,
BCBS Blue Choice,CPT,83001,Assay of gonadotropin (fsh),All Other,Per Unit,$91.51 ,OP,18.58,91.51,,,,,,
BCBS Blue Choice,CPT,83002,Assay of gonadotropin (lh),All Other,Per Unit,$91.51 ,OP,18.52,91.51,,,,,,
BCBS Blue Choice,CPT,83003,Assay growth hormone (hgh),All Other,Per Unit,$72.44 ,OP,16.67,72.44,,,,,,
BCBS Blue Choice,CPT,83008,Assay of guanosine,All Other,Per Unit,$76.26 ,OP,76.26,76.26,,,,,,
BCBS Blue Choice,CPT,83009,H pylori (c-13) blood,All Other,Per Unit,$301.20 ,OP,67.36,301.2,,,,,,
BCBS Blue Choice,CPT,83010,Assay of haptoglobin quant,All Other,Per Unit,$57.19 ,OP,12.58,57.19,,,,,,
BCBS Blue Choice,CPT,83012,Assay of haptoglobins,All Other,Per Unit,$72.44 ,OP,26.89,72.44,,,,,,
BCBS Blue Choice,CPT,83013,H pylori (c-13) breath,All Other,Per Unit,$301.20 ,OP,67.36,301.2,,,,,,
BCBS Blue Choice,CPT,83014,H pylori drug admin,All Other,Per Unit,$34.31 ,OP,7.86,34.31,,,,,,
BCBS Blue Choice,CPT,83015,Heavy metal qual any anal,All Other,Per Unit,$83.87 ,OP,20.94,83.87,,,,,,
BCBS Blue Choice,CPT,83018,Heavy metal quant each nes,All Other,Per Unit,$99.13 ,OP,21.96,99.13,,,,,,
BCBS Blue Choice,CPT,83020,Hemoglobin electrophoresis,All Other,Per Unit,$45.74 ,OP,12.87,45.74,,,,,,
BCBS Blue Choice,CPT,83021,Hemoglobin chromotography,All Other,Per Unit,$80.07 ,OP,18.06,80.07,,,,,,
BCBS Blue Choice,CPT,83036,Glycosylated hemoglobin test,All Other,Per Unit,$49.56 ,OP,9.71,49.56,,,,,,
BCBS Blue Choice,CPT,83037,Glycosylated hb home device,All Other,Per Unit,$41.94 ,OP,9.71,41.94,,,,,,
BCBS Blue Choice,CPT,83045,Blood methemoglobin test,All Other,Per Unit,$22.88 ,OP,6.49,22.88,,,,,,
BCBS Blue Choice,CPT,83050,Blood methemoglobin assay,All Other,Per Unit,$15.26 ,OP,8.2,15.26,,,,,,
BCBS Blue Choice,CPT,83055,Blood sulfhemoglobin test,All Other,Per Unit,$15.26 ,OP,15.26,15.26,,,,,,
BCBS Blue Choice,CPT,83060,Blood sulfhemoglobin assay,All Other,Per Unit,$15.26 ,OP,8.8,15.26,,,,,,
BCBS Blue Choice,CPT,83065,Assay of hemoglobin heat,All Other,Per Unit,$15.26 ,OP,9,15.26,,,,,,
BCBS Blue Choice,CPT,83069,Assay of urine hemoglobin,All Other,Per Unit,$7.62 ,OP,3.95,7.62,,,,,,
BCBS Blue Choice,CPT,83070,Assay of hemosiderin qual,All Other,Per Unit,$15.26 ,OP,4.75,15.26,,,,,,
BCBS Blue Choice,CPT,83071,Assay of hemosiderin quant,All Other,Per Unit,$15.26 ,OP,15.26,15.26,,,,,,
BCBS Blue Choice,CPT,83080,Assay of b hexosaminidase,All Other,Per Unit,$76.26 ,OP,16.87,76.26,,,,,,
BCBS Blue Choice,CPT,83088,Assay of histamine,All Other,Per Unit,$129.64 ,OP,29.53,129.64,,,,,,
BCBS Blue Choice,CPT,83090,Assay of homocystine,All Other,Per Unit,$76.26 ,OP,17.92,76.26,,,,,,
BCBS Blue Choice,CPT,83150,Assay of homovanillic acid,All Other,Per Unit,$87.69 ,OP,22.41,87.69,,,,,,
BCBS Blue Choice,CPT,83491,Assay of corticosteroids 17,All Other,Per Unit,$76.26 ,OP,17.9,76.26,,,,,,
BCBS Blue Choice,CPT,83497,Assay of 5-hiaa,All Other,Per Unit,$57.19 ,OP,12.9,57.19,,,,,,
BCBS Blue Choice,CPT,83498,Assay of progesterone 17-d,All Other,Per Unit,$122.00 ,OP,27.17,122,,,,,,
BCBS Blue Choice,CPT,83499,Assay of progesterone,All Other,Per Unit,$110.57 ,OP,110.57,110.57,,,,,,
BCBS Blue Choice,CPT,83500,Assay free hydroxyproline,All Other,Per Unit,$99.13 ,OP,22.65,99.13,,,,,,
BCBS Blue Choice,CPT,83505,Assay total hydroxyproline,All Other,Per Unit,$106.76 ,OP,24.3,106.76,,,,,,
BCBS Blue Choice,CPT,83516,Immunoassay nonantibody,All Other,Per Unit,$49.56 ,OP,11.53,49.56,,,,,,
BCBS Blue Choice,CPT,83519,Ria nonantibody,All Other,Per Unit,$61.00 ,OP,18.4,61,,,,,,
BCBS Blue Choice,CPT,83520,Immunoassay quant nos nonab,All Other,Per Unit,$57.19 ,OP,17.27,57.19,,,,,,
BCBS Blue Choice,CPT,83525,Assay of insulin,All Other,Per Unit,$49.56 ,OP,11.43,49.56,,,,,,
BCBS Blue Choice,CPT,83527,Assay of insulin,All Other,Per Unit,$57.19 ,OP,12.95,57.19,,,,,,
BCBS Blue Choice,CPT,83528,Assay of intrinsic factor,All Other,Per Unit,$72.44 ,OP,19.82,72.44,,,,,,
BCBS Blue Choice,CPT,83540,Assay of iron,All Other,Per Unit,$30.51 ,OP,6.47,30.51,,,,,,
BCBS Blue Choice,CPT,83550,Iron binding test,All Other,Per Unit,$38.13 ,OP,8.74,38.13,,,,,,
BCBS Blue Choice,CPT,83570,Assay of idh enzyme,All Other,Per Unit,$38.13 ,OP,8.85,38.13,,,,,,
BCBS Blue Choice,CPT,83586,Assay 17- ketosteroids,All Other,Per Unit,$57.19 ,OP,12.8,57.19,,,,,,
BCBS Blue Choice,CPT,83593,Fractionation ketosteroids,All Other,Per Unit,$118.19 ,OP,28.5,118.19,,,,,,
BCBS Blue Choice,CPT,83605,Assay of lactic acid,All Other,Per Unit,$53.38 ,OP,11.57,53.38,,,,,,
BCBS Blue Choice,CPT,83615,Lactate (ld) (ldh) enzyme,All Other,Per Unit,$26.70 ,OP,6.04,26.7,,,,,,
BCBS Blue Choice,CPT,83625,Assay of ldh enzymes,All Other,Per Unit,$49.56 ,OP,12.79,49.56,,,,,,
BCBS Blue Choice,CPT,83630,Lactoferrin fecal (qual),All Other,Per Unit,$87.69 ,OP,19.7,87.69,,,,,,
BCBS Blue Choice,CPT,83631,Lactoferrin fecal (quant),All Other,Per Unit,$87.69 ,OP,19.63,87.69,,,,,,
BCBS Blue Choice,CPT,83632,Placental lactogen,All Other,Per Unit,$91.51 ,OP,20.22,91.51,,,,,,
BCBS Blue Choice,CPT,83633,Test urine for lactose,All Other,Per Unit,$22.88 ,OP,11.25,22.88,,,,,,
BCBS Blue Choice,CPT,83634,Assay of urine for lactose,All Other,Per Unit,$49.56 ,OP,49.56,49.56,,,,,,
BCBS Blue Choice,CPT,83655,Assay of lead,All Other,Per Unit,$53.38 ,OP,12.11,53.38,,,,,,
BCBS Blue Choice,CPT,83661,L/s ratio fetal lung,All Other,Per Unit,$99.13 ,OP,21.99,99.13,,,,,,
BCBS Blue Choice,CPT,83662,Foam stability fetal lung,All Other,Per Unit,$83.87 ,OP,18.91,83.87,,,,,,
BCBS Blue Choice,CPT,83663,Fluoro polarize fetal lung,All Other,Per Unit,$83.87 ,OP,18.91,83.87,,,,,,
BCBS Blue Choice,CPT,83664,Lamellar bdy fetal lung,All Other,Per Unit,$83.87 ,OP,19.32,83.87,,,,,,
BCBS Blue Choice,CPT,83670,Assay of lap enzyme,All Other,Per Unit,$41.94 ,OP,9.81,41.94,,,,,,
BCBS Blue Choice,CPT,83690,Assay of lipase,All Other,Per Unit,$61.50 ,OP,6.89,61.5,,,,,,
BCBS Blue Choice,CPT,83695,Assay of lipoprotein(a),All Other,Per Unit,$57.19 ,OP,14.32,57.19,,,,,,
BCBS Blue Choice,CPT,83698,Assay lipoprotein pla2,All Other,Per Unit,$125.82 ,OP,46.31,125.82,,,,,,
BCBS Blue Choice,CPT,83700,Lipopro bld electrophoretic,All Other,Per Unit,$49.56 ,OP,11.26,49.56,,,,,,
BCBS Blue Choice,CPT,83701,Lipoprotein bld hr fraction,All Other,Per Unit,$110.57 ,OP,33.86,110.57,,,,,,
BCBS Blue Choice,CPT,83704,Lipoprotein bld quan part,All Other,Per Unit,$141.07 ,OP,34.19,141.07,,,,,,
BCBS Blue Choice,CPT,83718,Assay of lipoprotein,All Other,Per Unit,$41.94 ,OP,8.19,41.94,,,,,,
BCBS Blue Choice,CPT,83719,Assay of blood lipoprotein,All Other,Per Unit,$53.38 ,OP,12.75,53.38,,,,,,
BCBS Blue Choice,CPT,83721,Assay of blood lipoprotein,All Other,Per Unit,$41.94 ,OP,10.5,41.94,,,,,,
BCBS Blue Choice,CPT,83722,Lipoprtn dir meas sd ldl chl,All Other,Per Unit,$141.07 ,OP,34.19,141.07,,,,,,
BCBS Blue Choice,CPT,83727,Assay of lrh hormone,All Other,Per Unit,$76.26 ,OP,17.19,76.26,,,,,,
BCBS Blue Choice,CPT,83735,Assay of magnesium,All Other,Per Unit,$34.31 ,OP,6.7,34.31,,,,,,
BCBS Blue Choice,CPT,83775,Assay malate dehydrogenase,All Other,Per Unit,$34.31 ,OP,7.37,34.31,,,,,,
BCBS Blue Choice,CPT,83785,Assay of manganese,All Other,Per Unit,$110.57 ,OP,26.65,110.57,,,,,,
BCBS Blue Choice,CPT,83789,Mass spectrometry qual/quan,All Other,Per Unit,$80.07 ,OP,24.11,80.07,,,,,,
BCBS Blue Choice,CPT,83805,Assay of meprobamate,All Other,Per Unit,$80.07 ,OP,80.07,80.07,,,,,,
BCBS Blue Choice,CPT,83825,Assay of mercury,All Other,Per Unit,$72.44 ,OP,16.26,72.44,,,,,,
BCBS Blue Choice,CPT,83835,Assay of metanephrines,All Other,Per Unit,$76.26 ,OP,16.94,76.26,,,,,,
BCBS Blue Choice,CPT,83840,Assay of methadone,All Other,Per Unit,$72.44 ,OP,72.44,72.44,,,,,,
BCBS Blue Choice,CPT,83857,Assay of methemalbumin,All Other,Per Unit,$49.56 ,OP,10.74,49.56,,,,,,
BCBS Blue Choice,CPT,83858,Assay of methsuximide,All Other,Per Unit,$64.82 ,OP,64.82,64.82,,,,,,
BCBS Blue Choice,CPT,83864,Mucopolysaccharides,All Other,Per Unit,$87.69 ,OP,28.5,87.69,,,,,,
BCBS Blue Choice,CPT,83872,Assay synovial fluid mucin,All Other,Per Unit,$26.70 ,OP,5.86,26.7,,,,,,
BCBS Blue Choice,CPT,83873,Assay of csf protein,All Other,Per Unit,$72.44 ,OP,17.2,72.44,,,,,,
BCBS Blue Choice,CPT,83874,Assay of myoglobin,All Other,Per Unit,$57.19 ,OP,12.92,57.19,,,,,,
BCBS Blue Choice,CPT,83876,Assay myeloperoxidase,All Other,Per Unit,$57.19 ,OP,50.86,57.19,,,,,,
BCBS Blue Choice,CPT,83880,Assay of natriuretic peptide,All Other,Per Unit,$245.98 ,OP,39.26,245.98,,,,,,
BCBS Blue Choice,CPT,83883,Assay nephelometry not spec,All Other,Per Unit,$61.00 ,OP,13.6,61,,,,,,
BCBS Blue Choice,CPT,83885,Assay of nickel,All Other,Per Unit,$45.74 ,OP,24.51,45.74,,,,,,
BCBS Blue Choice,CPT,83887,Assay of nicotine,All Other,Per Unit,$91.51 ,OP,91.51,91.51,,,,,,
BCBS Blue Choice,CPT,83891,Molecule isolate nucleic,All Other,Per Unit,$19.07 ,OP,19.07,19.07,,,,,,
BCBS Blue Choice,CPT,83892,Molecular diagnostics,All Other,Per Unit,$19.07 ,OP,19.07,19.07,,,,,,
BCBS Blue Choice,CPT,83893,Molecule dot/slot/blot,All Other,Per Unit,$19.07 ,OP,19.07,19.07,,,,,,
BCBS Blue Choice,CPT,83894,Molecule gel electrophor,All Other,Per Unit,$19.07 ,OP,19.07,19.07,,,,,,
BCBS Blue Choice,CPT,83896,Molecular diagnostics,All Other,Per Unit,$19.07 ,OP,19.07,19.07,,,,,,
BCBS Blue Choice,CPT,83898,Molecule nucleic ampli each,All Other,Per Unit,$76.26 ,OP,76.26,76.26,,,,,,
BCBS Blue Choice,CPT,83900,Molecule nucleic ampli 2 seq,All Other,Per Unit,$148.69 ,OP,148.69,148.69,,,,,,
BCBS Blue Choice,CPT,83901,Molecule nucleic ampli addon,All Other,Per Unit,$76.26 ,OP,76.26,76.26,,,,,,
BCBS Blue Choice,CPT,83902,Molecular diagnostics,All Other,Per Unit,$64.82 ,OP,64.82,64.82,,,,,,
BCBS Blue Choice,CPT,83903,Molecule mutation scan,All Other,Per Unit,$76.26 ,OP,76.26,76.26,,,,,,
BCBS Blue Choice,CPT,83904,Molecule mutation identify,All Other,Per Unit,$76.26 ,OP,76.26,76.26,,,,,,
BCBS Blue Choice,CPT,83905,Molecule mutation identify,All Other,Per Unit,$76.26 ,OP,76.26,76.26,,,,,,
BCBS Blue Choice,CPT,83906,Molecule mutation identify,All Other,Per Unit,$76.26 ,OP,76.26,76.26,,,,,,
BCBS Blue Choice,CPT,83907,Lyse cells for nucleic ext,All Other,Per Unit,$61.00 ,OP,61,61,,,,,,
BCBS Blue Choice,CPT,83908,Nucleic acid signal ampli,All Other,Per Unit,$76.26 ,OP,76.26,76.26,,,,,,
BCBS Blue Choice,CPT,83909,Nucleic acid high resolute,All Other,Per Unit,$76.26 ,OP,76.26,76.26,,,,,,
BCBS Blue Choice,CPT,83912,Genetic examination,All Other,Per Unit,$30.51 ,OP,30.51,30.51,,,,,,
BCBS Blue Choice,CPT,83913,Molecular rna stabilization,All Other,Per Unit,$61.00 ,OP,61,61,,,,,,
BCBS Blue Choice,CPT,83914,Mutation ident ola/sbce/aspe,All Other,Per Unit,$76.26 ,OP,76.26,76.26,,,,,,
BCBS Blue Choice,CPT,83916,Oligoclonal bands,All Other,Per Unit,$87.69 ,OP,27.39,87.69,,,,,,
BCBS Blue Choice,CPT,83918,Organic acids total quant,All Other,Per Unit,$72.44 ,OP,23.6,72.44,,,,,,
BCBS Blue Choice,CPT,83921,Organic acid single quant,All Other,Per Unit,$72.44 ,OP,21.21,72.44,,,,,,
BCBS Blue Choice,CPT,83925,Assay of opiates,All Other,Per Unit,$87.69 ,OP,87.69,87.69,,,,,,
BCBS Blue Choice,CPT,83930,Assay of blood osmolality,All Other,Per Unit,$26.70 ,OP,6.61,26.7,,,,,,
BCBS Blue Choice,CPT,83935,Assay of urine osmolality,All Other,Per Unit,$30.51 ,OP,6.82,30.51,,,,,,
BCBS Blue Choice,CPT,83937,Assay of osteocalcin,All Other,Per Unit,$133.45 ,OP,29.85,133.45,,,,,,
BCBS Blue Choice,CPT,83945,Assay of oxalate,All Other,Per Unit,$57.19 ,OP,14.45,57.19,,,,,,
BCBS Blue Choice,CPT,83950,Oncoprotein her-2/neu,All Other,Per Unit,$209.70 ,OP,64.41,209.7,,,,,,
BCBS Blue Choice,CPT,83951,Oncoprotein dcp,All Other,Per Unit,$209.70 ,OP,64.41,209.7,,,,,,
BCBS Blue Choice,CPT,83970,Assay of parathormone,All Other,Per Unit,$183.02 ,OP,41.28,183.02,,,,,,
BCBS Blue Choice,CPT,83986,Assay ph body fluid nos,All Other,Per Unit,$19.07 ,OP,3.58,19.07,,,,,,
BCBS Blue Choice,CPT,83992,Assay for phencyclidine,All Other,Per Unit,$64.82 ,OP,64.82,64.82,,,,,,
BCBS Blue Choice,CPT,83993,Assay for calprotectin fecal,All Other,Per Unit,$87.69 ,OP,19.63,87.69,,,,,,
BCBS Blue Choice,CPT,84022,Assay of phenothiazine,All Other,Per Unit,$68.63 ,OP,68.63,68.63,,,,,,
BCBS Blue Choice,CPT,84030,Assay of blood pku,All Other,Per Unit,$26.70 ,OP,5.5,26.7,,,,,,
BCBS Blue Choice,CPT,84035,Assay of phenylketones,All Other,Per Unit,$15.26 ,OP,3.98,15.26,,,,,,
BCBS Blue Choice,CPT,84060,Assay acid phosphatase,All Other,Per Unit,$34.31 ,OP,7.64,34.31,,,,,,
BCBS Blue Choice,CPT,84061,Phosphatase forensic exam,All Other,Per Unit,$34.31 ,OP,34.31,34.31,,,,,,
BCBS Blue Choice,CPT,84066,Assay prostate phosphatase,All Other,Per Unit,$41.94 ,OP,9.66,41.94,,,,,,
BCBS Blue Choice,CPT,84075,Assay alkaline phosphatase,All Other,Per Unit,$26.70 ,OP,5.18,26.7,,,,,,
BCBS Blue Choice,CPT,84078,Assay alkaline phosphatase,All Other,Per Unit,$34.31 ,OP,8.26,34.31,,,,,,
BCBS Blue Choice,CPT,84080,Assay alkaline phosphatases,All Other,Per Unit,$64.82 ,OP,14.78,64.82,,,,,,
BCBS Blue Choice,CPT,84081,Assay phosphatidylglycerol,All Other,Per Unit,$72.44 ,OP,16.52,72.44,,,,,,
BCBS Blue Choice,CPT,84085,Assay of rbc pg6d enzyme,All Other,Per Unit,$30.51 ,OP,9.44,30.51,,,,,,
BCBS Blue Choice,CPT,84087,Assay phosphohexose enzymes,All Other,Per Unit,$45.74 ,OP,10.73,45.74,,,,,,
BCBS Blue Choice,CPT,84100,Assay of phosphorus,All Other,Per Unit,$22.88 ,OP,4.74,22.88,,,,,,
BCBS Blue Choice,CPT,84105,Assay of urine phosphorus,All Other,Per Unit,$22.88 ,OP,5.78,22.88,,,,,,
BCBS Blue Choice,CPT,84106,Test for porphobilinogen,All Other,Per Unit,$19.07 ,OP,5.82,19.07,,,,,,
BCBS Blue Choice,CPT,84110,Assay of porphobilinogen,All Other,Per Unit,$38.13 ,OP,8.44,38.13,,,,,,
BCBS Blue Choice,CPT,84120,Assay of urine porphyrins,All Other,Per Unit,$64.82 ,OP,14.71,64.82,,,,,,
BCBS Blue Choice,CPT,84126,Assay of feces porphyrins,All Other,Per Unit,$114.39 ,OP,39.11,114.39,,,,,,
BCBS Blue Choice,CPT,84127,Assay of feces porphyrins,All Other,Per Unit,$53.38 ,OP,53.38,53.38,,,,,,
BCBS Blue Choice,CPT,84132,Assay of serum potassium,All Other,Per Unit,$22.88 ,OP,4.76,22.88,,,,,,
BCBS Blue Choice,CPT,84133,Assay of urine potassium,All Other,Per Unit,$19.07 ,OP,4.73,19.07,,,,,,
BCBS Blue Choice,CPT,84134,Assay of prealbumin,All Other,Per Unit,$64.82 ,OP,14.59,64.82,,,,,,
BCBS Blue Choice,CPT,84135,Assay of pregnanediol,All Other,Per Unit,$57.19 ,OP,21.27,57.19,,,,,,
BCBS Blue Choice,CPT,84138,Assay of pregnanetriol,All Other,Per Unit,$83.87 ,OP,21.05,83.87,,,,,,
BCBS Blue Choice,CPT,84140,Assay of pregnenolone,All Other,Per Unit,$91.51 ,OP,20.67,91.51,,,,,,
BCBS Blue Choice,CPT,84143,Assay of 17-hydroxypregneno,All Other,Per Unit,$102.95 ,OP,22.81,102.95,,,,,,
BCBS Blue Choice,CPT,84144,Assay of progesterone,All Other,Per Unit,$91.51 ,OP,20.86,91.51,,,,,,
BCBS Blue Choice,CPT,84146,Assay of prolactin,All Other,Per Unit,$87.69 ,OP,19.38,87.69,,,,,,
BCBS Blue Choice,CPT,84152,Assay of psa complexed,All Other,Per Unit,$80.07 ,OP,18.39,80.07,,,,,,
BCBS Blue Choice,CPT,84153,Assay of psa total,All Other,Per Unit,$80.07 ,OP,18.39,80.07,,,,,,
BCBS Blue Choice,CPT,84154,Assay of psa free,All Other,Per Unit,$80.07 ,OP,18.39,80.07,,,,,,
BCBS Blue Choice,CPT,84155,Assay of protein serum,All Other,Per Unit,$15.26 ,OP,3.67,15.26,,,,,,
BCBS Blue Choice,CPT,84156,Assay of protein urine,All Other,Per Unit,$15.26 ,OP,3.67,15.26,,,,,,
BCBS Blue Choice,CPT,84157,Assay of protein other,All Other,Per Unit,$19.07 ,OP,4,19.07,,,,,,
BCBS Blue Choice,CPT,84160,Assay of protein any source,All Other,Per Unit,$22.88 ,OP,5.61,22.88,,,,,,
BCBS Blue Choice,CPT,84163,Pappa serum,All Other,Per Unit,$68.63 ,OP,15.05,68.63,,,,,,
BCBS Blue Choice,CPT,84165,Protein e-phoresis serum,All Other,Per Unit,$49.56 ,OP,10.74,49.56,,,,,,
BCBS Blue Choice,CPT,84166,Protein e-phoresis/urine/csf,All Other,Per Unit,$80.07 ,OP,17.83,80.07,,,,,,
BCBS Blue Choice,CPT,84181,Western blot test,All Other,Per Unit,$118.19 ,OP,17.03,118.19,,,,,,
BCBS Blue Choice,CPT,84182,Protein western blot test,All Other,Per Unit,$129.64 ,OP,29.21,129.64,,,,,,
BCBS Blue Choice,CPT,84202,Assay rbc protoporphyrin,All Other,Per Unit,$64.82 ,OP,14.35,64.82,,,,,,
BCBS Blue Choice,CPT,84203,Test rbc protoporphyrin,All Other,Per Unit,$38.13 ,OP,9.74,38.13,,,,,,
BCBS Blue Choice,CPT,84206,Assay of proinsulin,All Other,Per Unit,$80.07 ,OP,26.69,80.07,,,,,,
BCBS Blue Choice,CPT,84207,Assay of vitamin b-6,All Other,Per Unit,$125.82 ,OP,28.1,125.82,,,,,,
BCBS Blue Choice,CPT,84210,Assay of pyruvate,All Other,Per Unit,$49.56 ,OP,14.48,49.56,,,,,,
BCBS Blue Choice,CPT,84220,Assay of pyruvate kinase,All Other,Per Unit,$41.94 ,OP,9.44,41.94,,,,,,
BCBS Blue Choice,CPT,84228,Assay of quinine,All Other,Per Unit,$53.38 ,OP,11.63,53.38,,,,,,
BCBS Blue Choice,CPT,84233,Assay of estrogen,All Other,Per Unit,$209.70 ,OP,87.88,209.7,,,,,,
BCBS Blue Choice,CPT,84234,Assay of progesterone,All Other,Per Unit,$183.02 ,OP,64.88,183.02,,,,,,
BCBS Blue Choice,CPT,84235,Assay of endocrine hormone,All Other,Per Unit,$163.95 ,OP,71.23,163.95,,,,,,
BCBS Blue Choice,CPT,84238,Assay nonendocrine receptor,All Other,Per Unit,$163.95 ,OP,36.57,163.95,,,,,,
BCBS Blue Choice,CPT,84244,Assay of renin,All Other,Per Unit,$99.13 ,OP,21.99,99.13,,,,,,
BCBS Blue Choice,CPT,84255,Assay of selenium,All Other,Per Unit,$114.39 ,OP,25.53,114.39,,,,,,
BCBS Blue Choice,CPT,84270,Assay of sex hormone globul,All Other,Per Unit,$95.32 ,OP,21.73,95.32,,,,,,
BCBS Blue Choice,CPT,84285,Assay of silica,All Other,Per Unit,$38.13 ,OP,25.21,38.13,,,,,,
BCBS Blue Choice,CPT,84295,Assay of serum sodium,All Other,Per Unit,$22.88 ,OP,4.81,22.88,,,,,,
BCBS Blue Choice,CPT,84300,Assay of urine sodium,All Other,Per Unit,$22.88 ,OP,5.06,22.88,,,,,,
BCBS Blue Choice,CPT,84302,Assay of sweat sodium,All Other,Per Unit,$22.88 ,OP,4.86,22.88,,,,,,
BCBS Blue Choice,CPT,84305,Assay of somatomedin,All Other,Per Unit,$95.32 ,OP,21.26,95.32,,,,,,
BCBS Blue Choice,CPT,84307,Assay of somatostatin,All Other,Per Unit,$80.07 ,OP,18.28,80.07,,,,,,
BCBS Blue Choice,CPT,84311,Spectrophotometry,All Other,Per Unit,$30.51 ,OP,8.1,30.51,,,,,,
BCBS Blue Choice,CPT,84315,Body fluid specific gravity,All Other,Per Unit,$11.44 ,OP,3.28,11.44,,,,,,
BCBS Blue Choice,CPT,84376,Sugars single qual,All Other,Per Unit,$22.88 ,OP,5.5,22.88,,,,,,
BCBS Blue Choice,CPT,84377,Sugars multiple qual,All Other,Per Unit,$22.88 ,OP,5.5,22.88,,,,,,
BCBS Blue Choice,CPT,84378,Sugars single quant,All Other,Per Unit,$49.56 ,OP,11.53,49.56,,,,,,
BCBS Blue Choice,CPT,84379,Sugars multiple quant,All Other,Per Unit,$49.56 ,OP,11.53,49.56,,,,,,
BCBS Blue Choice,CPT,84392,Assay of urine sulfate,All Other,Per Unit,$22.88 ,OP,5.49,22.88,,,,,,
BCBS Blue Choice,CPT,84402,Assay of free testosterone,All Other,Per Unit,$114.39 ,OP,25.47,114.39,,,,,,
BCBS Blue Choice,CPT,84403,Assay of total testosterone,All Other,Per Unit,$114.39 ,OP,25.81,114.39,,,,,,
BCBS Blue Choice,CPT,84425,Assay of vitamin b-1,All Other,Per Unit,$95.32 ,OP,21.23,95.32,,,,,,
BCBS Blue Choice,CPT,84430,Assay of thiocyanate,All Other,Per Unit,$53.38 ,OP,11.63,53.38,,,,,,
BCBS Blue Choice,CPT,84432,Assay of thyroglobulin,All Other,Per Unit,$72.44 ,OP,16.06,72.44,,,,,,
BCBS Blue Choice,CPT,84436,Assay of total thyroxine,All Other,Per Unit,$30.51 ,OP,6.87,30.51,,,,,,
BCBS Blue Choice,CPT,84437,Assay of neonatal thyroxine,All Other,Per Unit,$30.51 ,OP,6.47,30.51,,,,,,
BCBS Blue Choice,CPT,84439,Assay of free thyroxine,All Other,Per Unit,$41.94 ,OP,9.02,41.94,,,,,,
BCBS Blue Choice,CPT,84442,Assay of thyroid activity,All Other,Per Unit,$64.82 ,OP,14.78,64.82,,,,,,
BCBS Blue Choice,CPT,84443,Assay thyroid stim hormone,All Other,Per Unit,$76.26 ,OP,16.8,76.26,,,,,,
BCBS Blue Choice,CPT,84445,Assay of tsi globulin,All Other,Per Unit,$224.95 ,OP,50.86,224.95,,,,,,
BCBS Blue Choice,CPT,84446,Assay of vitamin e,All Other,Per Unit,$64.82 ,OP,14.18,64.82,,,,,,
BCBS Blue Choice,CPT,84449,Assay of transcortin,All Other,Per Unit,$80.07 ,OP,18,80.07,,,,,,
BCBS Blue Choice,CPT,84450,Transferase (ast) (sgot),All Other,Per Unit,$22.88 ,OP,5.18,22.88,,,,,,
BCBS Blue Choice,CPT,84460,Alanine amino (alt) (sgpt),All Other,Per Unit,$26.70 ,OP,5.3,26.7,,,,,,
BCBS Blue Choice,CPT,84466,Assay of transferrin,All Other,Per Unit,$57.19 ,OP,12.76,57.19,,,,,,
BCBS Blue Choice,CPT,84478,Assay of triglycerides,All Other,Per Unit,$30.51 ,OP,5.74,30.51,,,,,,
BCBS Blue Choice,CPT,84479,Assay of thyroid (t3 or t4),All Other,Per Unit,$30.51 ,OP,6.47,30.51,,,,,,
BCBS Blue Choice,CPT,84480,Assay triiodothyronine (t3),All Other,Per Unit,$49.56 ,OP,14.18,49.56,,,,,,
BCBS Blue Choice,CPT,84481,Free assay (ft-3),All Other,Per Unit,$49.56 ,OP,16.94,49.56,,,,,,
BCBS Blue Choice,CPT,84482,T3 reverse,All Other,Per Unit,$68.63 ,OP,15.76,68.63,,,,,,
BCBS Blue Choice,CPT,84484,Assay of troponin quant,All Other,Per Unit,$92.24 ,OP,12.47,92.24,,,,,,
BCBS Blue Choice,CPT,84488,Test feces for trypsin,All Other,Per Unit,$34.31 ,OP,7.3,34.31,,,,,,
BCBS Blue Choice,CPT,84490,Assay of feces for trypsin,All Other,Per Unit,$26.70 ,OP,9.93,26.7,,,,,,
BCBS Blue Choice,CPT,84510,Assay of tyrosine,All Other,Per Unit,$45.74 ,OP,10.63,45.74,,,,,,
BCBS Blue Choice,CPT,84512,Assay of troponin qual,All Other,Per Unit,$34.31 ,OP,10.09,34.31,,,,,,
BCBS Blue Choice,CPT,84520,Assay of urea nitrogen,All Other,Per Unit,$19.07 ,OP,3.95,19.07,,,,,,
BCBS Blue Choice,CPT,84525,Urea nitrogen semi-quant,All Other,Per Unit,$15.26 ,OP,5.13,15.26,,,,,,
BCBS Blue Choice,CPT,84540,Assay of urine/urea-n,All Other,Per Unit,$22.88 ,OP,5.56,22.88,,,,,,
BCBS Blue Choice,CPT,84545,Urea-n clearance test,All Other,Per Unit,$19.07 ,OP,7.2,19.07,,,,,,
BCBS Blue Choice,CPT,84550,Assay of blood/uric acid,All Other,Per Unit,$19.07 ,OP,4.52,19.07,,,,,,
BCBS Blue Choice,CPT,84560,Assay of urine/uric acid,All Other,Per Unit,$22.88 ,OP,5.08,22.88,,,,,,
BCBS Blue Choice,CPT,84577,Assay of feces/urobilinogen,All Other,Per Unit,$57.19 ,OP,16.8,57.19,,,,,,
BCBS Blue Choice,CPT,84578,Test urine urobilinogen,All Other,Per Unit,$15.26 ,OP,4.47,15.26,,,,,,
BCBS Blue Choice,CPT,84580,Assay of urine urobilinogen,All Other,Per Unit,$19.07 ,OP,9.55,19.07,,,,,,
BCBS Blue Choice,CPT,84583,Assay of urine urobilinogen,All Other,Per Unit,$22.88 ,OP,6.05,22.88,,,,,,
BCBS Blue Choice,CPT,84585,Assay of urine vma,All Other,Per Unit,$68.63 ,OP,15.5,68.63,,,,,,
BCBS Blue Choice,CPT,84586,Assay of vip,All Other,Per Unit,$156.32 ,OP,35.33,156.32,,,,,,
BCBS Blue Choice,CPT,84588,Assay of vasopressin,All Other,Per Unit,$125.82 ,OP,33.94,125.82,,,,,,
BCBS Blue Choice,CPT,84590,Assay of vitamin a,All Other,Per Unit,$53.38 ,OP,11.61,53.38,,,,,,
BCBS Blue Choice,CPT,84591,Assay of nos vitamin,All Other,Per Unit,$53.38 ,OP,17.06,53.38,,,,,,
BCBS Blue Choice,CPT,84597,Assay of vitamin k,All Other,Per Unit,$49.56 ,OP,13.72,49.56,,,,,,
BCBS Blue Choice,CPT,84600,Assay of volatiles,All Other,Per Unit,$72.44 ,OP,17.11,72.44,,,,,,
BCBS Blue Choice,CPT,84620,Xylose tolerance test,All Other,Per Unit,$38.13 ,OP,12.91,38.13,,,,,,
BCBS Blue Choice,CPT,84630,Assay of zinc,All Other,Per Unit,$49.56 ,OP,11.39,49.56,,,,,,
BCBS Blue Choice,CPT,84681,Assay of c-peptide,All Other,Per Unit,$91.51 ,OP,20.81,91.51,,,,,,
BCBS Blue Choice,CPT,84702,Chorionic gonadotropin test,All Other,Per Unit,$76.26 ,OP,15.05,76.26,,,,,,
BCBS Blue Choice,CPT,84703,Chorionic gonadotropin assay,All Other,Per Unit,$38.13 ,OP,7.52,38.13,,,,,,
BCBS Blue Choice,CPT,84704,Hcg free betachain test,All Other,Per Unit,$68.63 ,OP,15.29,68.63,,,,,,
BCBS Blue Choice,CPT,84830,Ovulation tests,All Other,Per Unit,$49.56 ,OP,12.7,49.56,,,,,,
BCBS Blue Choice,CPT,85002,Bleeding time test,All Other,Per Unit,$22.88 ,OP,4.82,22.88,,,,,,
BCBS Blue Choice,CPT,85004,Automated diff wbc count,All Other,Per Unit,$34.31 ,OP,6.47,34.31,,,,,,
BCBS Blue Choice,CPT,85007,Bl smear w/diff wbc count,All Other,Per Unit,$19.07 ,OP,3.8,19.07,,,,,,
BCBS Blue Choice,CPT,85008,Bl smear w/o diff wbc count,All Other,Per Unit,$19.07 ,OP,3.43,19.07,,,,,,
BCBS Blue Choice,CPT,85009,Manual diff wbc count b-coat,All Other,Per Unit,$19.07 ,OP,5.07,19.07,,,,,,
BCBS Blue Choice,CPT,85014,Hematocrit,All Other,Per Unit,$11.44 ,OP,2.37,11.44,,,,,,
BCBS Blue Choice,CPT,85018,Hemoglobin,All Other,Per Unit,$11.44 ,OP,2.37,11.44,,,,,,
BCBS Blue Choice,CPT,85025,Complete cbc w/auto diff wbc,All Other,Per Unit,$67.65 ,OP,7.77,67.65,,,,,,
BCBS Blue Choice,CPT,85027,Complete cbc automated,All Other,Per Unit,$34.31 ,OP,6.47,34.31,,,,,,
BCBS Blue Choice,CPT,85032,Manual cell count each,All Other,Per Unit,$22.88 ,OP,4.31,22.88,,,,,,
BCBS Blue Choice,CPT,85041,Automated rbc count,All Other,Per Unit,$11.44 ,OP,3.02,11.44,,,,,,
BCBS Blue Choice,CPT,85045,Automated reticulocyte count,All Other,Per Unit,$19.07 ,OP,3.99,19.07,,,,,,
BCBS Blue Choice,CPT,85046,Reticyte/hgb concentrate,All Other,Per Unit,$26.70 ,OP,5.57,26.7,,,,,,
BCBS Blue Choice,CPT,85048,Automated leukocyte count,All Other,Per Unit,$11.44 ,OP,2.54,11.44,,,,,,
BCBS Blue Choice,CPT,85049,Automated platelet count,All Other,Per Unit,$22.88 ,OP,4.48,22.88,,,,,,
BCBS Blue Choice,CPT,85055,Reticulated platelet assay,All Other,Per Unit,$61.00 ,OP,35.74,61,,,,,,
BCBS Blue Choice,CPT,85060,Blood smear interpretation,All Other,Per Unit,$114.39 ,OP,114.39,114.39,,,,,,
BCBS Blue Choice,CPT,85097,Bone marrow interpretation,All Other,Per Unit,$438.47 ,OP,438.47,671.45,,,,,,
BCBS Blue Choice,CPT,85130,Chromogenic substrate assay,All Other,Per Unit,$53.38 ,OP,11.89,53.38,,,,,,
BCBS Blue Choice,CPT,85175,Blood clot lysis time,All Other,Per Unit,$19.07 ,OP,19.07,20.37,,,,,,
BCBS Blue Choice,CPT,85210,Clot factor ii prothrom spec,All Other,Per Unit,$64.82 ,OP,12.98,64.82,,,,,,
BCBS Blue Choice,CPT,85220,Blooc clot factor v test,All Other,Per Unit,$80.07 ,OP,17.65,80.07,,,,,,
BCBS Blue Choice,CPT,85230,Clot factor vii proconvertin,All Other,Per Unit,$80.07 ,OP,17.9,80.07,,,,,,
BCBS Blue Choice,CPT,85240,Clot factor viii ahg 1 stage,All Other,Per Unit,$80.07 ,OP,17.9,80.07,,,,,,
BCBS Blue Choice,CPT,85244,Clot factor viii reltd antgn,All Other,Per Unit,$91.51 ,OP,20.42,91.51,,,,,,
BCBS Blue Choice,CPT,85245,Clot factor viii vw ristoctn,All Other,Per Unit,$64.82 ,OP,22.94,64.82,,,,,,
BCBS Blue Choice,CPT,85246,Clot factor viii vw antigen,All Other,Per Unit,$64.82 ,OP,22.94,64.82,,,,,,
BCBS Blue Choice,CPT,85250,Clot factor ix ptc/chrstmas,All Other,Per Unit,$83.87 ,OP,19.04,83.87,,,,,,
BCBS Blue Choice,CPT,85260,Clot factor x stuart-power,All Other,Per Unit,$80.07 ,OP,17.9,80.07,,,,,,
BCBS Blue Choice,CPT,85270,Clot factor xi pta,All Other,Per Unit,$80.07 ,OP,17.9,80.07,,,,,,
BCBS Blue Choice,CPT,85280,Clot factor xii hageman,All Other,Per Unit,$87.69 ,OP,19.35,87.69,,,,,,
BCBS Blue Choice,CPT,85290,Clot factor xiii fibrin stab,All Other,Per Unit,$72.44 ,OP,16.34,72.44,,,,,,
BCBS Blue Choice,CPT,85291,Clot factor xiii fibrin scrn,All Other,Per Unit,$38.13 ,OP,9.11,38.13,,,,,,
BCBS Blue Choice,CPT,85292,Clot factor fletcher fact,All Other,Per Unit,$83.87 ,OP,18.93,83.87,,,,,,
BCBS Blue Choice,CPT,85293,Clot factor wght kininogen,All Other,Per Unit,$83.87 ,OP,18.93,83.87,,,,,,
BCBS Blue Choice,CPT,85300,Antithrombin iii activity,All Other,Per Unit,$53.38 ,OP,11.85,53.38,,,,,,
BCBS Blue Choice,CPT,85301,Antithrombin iii antigen,All Other,Per Unit,$49.56 ,OP,10.81,49.56,,,,,,
BCBS Blue Choice,CPT,85302,Clot inhibit prot c antigen,All Other,Per Unit,$53.38 ,OP,12.01,53.38,,,,,,
BCBS Blue Choice,CPT,85303,Clot inhibit prot c activity,All Other,Per Unit,$61.00 ,OP,13.84,61,,,,,,
BCBS Blue Choice,CPT,85305,Clot inhibit prot s total,All Other,Per Unit,$53.38 ,OP,11.61,53.38,,,,,,
BCBS Blue Choice,CPT,85306,Clot inhibit prot s free,All Other,Per Unit,$68.63 ,OP,15.32,68.63,,,,,,
BCBS Blue Choice,CPT,85307,Assay activated protein c,All Other,Per Unit,$68.63 ,OP,15.32,68.63,,,,,,
BCBS Blue Choice,CPT,85337,Thrombomodulin,All Other,Per Unit,$45.74 ,OP,17.27,45.74,,,,,,
BCBS Blue Choice,CPT,85347,Coagulation time activated,All Other,Per Unit,$15.26 ,OP,4.28,15.26,,,,,,
BCBS Blue Choice,CPT,85348,Coagulation time otr method,All Other,Per Unit,$15.26 ,OP,4.49,15.26,,,,,,
BCBS Blue Choice,CPT,85360,Euglobulin lysis,All Other,Per Unit,$38.13 ,OP,8.41,38.13,,,,,,
BCBS Blue Choice,CPT,85362,Fibrin degradation products,All Other,Per Unit,$30.51 ,OP,6.89,30.51,,,,,,
BCBS Blue Choice,CPT,85366,Fibrinogen test,All Other,Per Unit,$30.51 ,OP,30.51,80.46,,,,,,
BCBS Blue Choice,CPT,85370,Fibrinogen test,All Other,Per Unit,$49.56 ,OP,12.43,49.56,,,,,,
BCBS Blue Choice,CPT,85378,Fibrin degrade semiquant,All Other,Per Unit,$30.51 ,OP,9.72,30.51,,,,,,
BCBS Blue Choice,CPT,85379,Fibrin degradation quant,All Other,Per Unit,$135.29 ,OP,10.18,135.29,,,,,,
BCBS Blue Choice,CPT,85380,Fibrin degradj d-dimer,All Other,Per Unit,$45.74 ,OP,10.18,45.74,,,,,,
BCBS Blue Choice,CPT,85384,Fibrinogen activity,All Other,Per Unit,$38.13 ,OP,9.72,38.13,,,,,,
BCBS Blue Choice,CPT,85385,Fibrinogen antigen,All Other,Per Unit,$38.13 ,OP,14.46,38.13,,,,,,
BCBS Blue Choice,CPT,85390,Fibrinolysins screen i&r,All Other,Per Unit,$38.13 ,OP,15.48,38.13,,,,,,
BCBS Blue Choice,CPT,85396,Clotting assay whole blood,All Other,Per Unit,$99.13 ,OP,99.13,99.13,,,,,,
BCBS Blue Choice,CPT,85400,Fibrinolytic plasmin,All Other,Per Unit,$38.13 ,OP,7.71,38.13,,,,,,
BCBS Blue Choice,CPT,85410,Fibrinolytic antiplasmin,All Other,Per Unit,$34.31 ,OP,7.71,34.31,,,,,,
BCBS Blue Choice,CPT,85415,Fibrinolytic plasminogen,All Other,Per Unit,$76.26 ,OP,17.19,76.26,,,,,,
BCBS Blue Choice,CPT,85421,Fibrinolytic plasminogen,All Other,Per Unit,$45.74 ,OP,10.18,45.74,,,,,,
BCBS Blue Choice,CPT,85441,Heinz bodies direct,All Other,Per Unit,$19.07 ,OP,4.2,19.07,,,,,,
BCBS Blue Choice,CPT,85445,Heinz bodies induced,All Other,Per Unit,$30.51 ,OP,6.82,30.51,,,,,,
BCBS Blue Choice,CPT,85461,Hemoglobin fetal,All Other,Per Unit,$30.51 ,OP,9.36,30.51,,,,,,
BCBS Blue Choice,CPT,85475,Hemolysin acid,All Other,Per Unit,$38.13 ,OP,8.87,38.13,,,,,,
BCBS Blue Choice,CPT,85520,Heparin assay,All Other,Per Unit,$57.19 ,OP,13.09,57.19,,,,,,
BCBS Blue Choice,CPT,85525,Heparin neutralization,All Other,Per Unit,$53.38 ,OP,11.84,53.38,,,,,,
BCBS Blue Choice,CPT,85530,Heparin-protamine tolerance,All Other,Per Unit,$48.46 ,OP,13.09,48.46,,,,,,
BCBS Blue Choice,CPT,85536,Iron stain peripheral blood,All Other,Per Unit,$30.51 ,OP,6.88,30.51,,,,,,
BCBS Blue Choice,CPT,85540,Wbc alkaline phosphatase,All Other,Per Unit,$38.13 ,OP,8.6,38.13,,,,,,
BCBS Blue Choice,CPT,85547,Rbc mechanical fragility,All Other,Per Unit,$11.44 ,OP,8.6,11.44,,,,,,
BCBS Blue Choice,CPT,85549,Muramidase,All Other,Per Unit,$83.87 ,OP,18.75,83.87,,,,,,
BCBS Blue Choice,CPT,85555,Rbc osmotic fragility,All Other,Per Unit,$30.51 ,OP,7.47,30.51,,,,,,
BCBS Blue Choice,CPT,85576,Blood platelet aggregation,All Other,Per Unit,$95.32 ,OP,24.91,95.32,,,,,,
BCBS Blue Choice,CPT,85597,Phospholipid pltlt neutraliz,All Other,Per Unit,$80.07 ,OP,17.98,80.07,,,,,,
BCBS Blue Choice,CPT,85610,Prothrombin time,All Other,Per Unit,$19.07 ,OP,4.29,19.07,,,,,,
BCBS Blue Choice,CPT,85611,Prothrombin test,All Other,Per Unit,$19.07 ,OP,3.94,19.07,,,,,,
BCBS Blue Choice,CPT,85613,Russell viper venom diluted,All Other,Per Unit,$41.94 ,OP,9.58,41.94,,,,,,
BCBS Blue Choice,CPT,85635,Reptilase test,All Other,Per Unit,$19.07 ,OP,9.85,19.07,,,,,,
BCBS Blue Choice,CPT,85651,Rbc sed rate nonautomated,All Other,Per Unit,$19.07 ,OP,4.27,19.07,,,,,,
BCBS Blue Choice,CPT,85652,Rbc sed rate automated,All Other,Per Unit,$15.26 ,OP,2.7,15.26,,,,,,
BCBS Blue Choice,CPT,85660,Rbc sickle cell test,All Other,Per Unit,$22.88 ,OP,5.51,22.88,,,,,,
BCBS Blue Choice,CPT,85670,Thrombin time plasma,All Other,Per Unit,$26.70 ,OP,5.77,26.7,,,,,,
BCBS Blue Choice,CPT,85675,Thrombin time titer,All Other,Per Unit,$30.51 ,OP,6.85,30.51,,,,,,
BCBS Blue Choice,CPT,85705,Thromboplastin inhibition,All Other,Per Unit,$41.94 ,OP,9.63,41.94,,,,,,
BCBS Blue Choice,CPT,85730,Thromboplastin time partial,All Other,Per Unit,$30.51 ,OP,6.01,30.51,,,,,,
BCBS Blue Choice,CPT,85732,Thromboplastin time partial,All Other,Per Unit,$30.51 ,OP,6.47,30.51,,,,,,
BCBS Blue Choice,CPT,85810,Blood viscosity examination,All Other,Per Unit,$53.38 ,OP,11.67,53.38,,,,,,
BCBS Blue Choice,CPT,86001,Allergen specific igg,All Other,Per Unit,$22.88 ,OP,7.82,22.88,,,,,,
BCBS Blue Choice,CPT,86003,Allg spec ige crude xtrc ea,All Other,Per Unit,$22.88 ,OP,5.22,22.88,,,,,,
BCBS Blue Choice,CPT,86008,Allg spec ige recomb ea,All Other,Per Unit,$80.07 ,OP,17.93,80.07,,,,,,
BCBS Blue Choice,CPT,86021,Wbc antibody identification,All Other,Per Unit,$68.63 ,OP,15.05,68.63,,,,,,
BCBS Blue Choice,CPT,86022,Platelet antibodies,All Other,Per Unit,$64.82 ,OP,18.37,64.82,,,,,,
BCBS Blue Choice,CPT,86023,Immunoglobulin assay,All Other,Per Unit,$57.19 ,OP,12.46,57.19,,,,,,
BCBS Blue Choice,CPT,86038,Antinuclear antibodies,All Other,Per Unit,$53.38 ,OP,12.09,53.38,,,,,,
BCBS Blue Choice,CPT,86039,Antinuclear antibodies (ana),All Other,Per Unit,$49.56 ,OP,11.16,49.56,,,,,,
BCBS Blue Choice,CPT,86060,Antistreptolysin o titer,All Other,Per Unit,$34.31 ,OP,7.3,34.31,,,,,,
BCBS Blue Choice,CPT,86063,Antistreptolysin o screen,All Other,Per Unit,$26.70 ,OP,5.77,26.7,,,,,,
BCBS Blue Choice,CPT,86077,Phys blood bank serv xmatch,All Other,Per Unit,$244.01 ,OP,25.25,244.01,,,,,,
BCBS Blue Choice,CPT,86078,Phys blood bank serv reactj,All Other,Per Unit,$247.83 ,OP,152.64,247.83,,,,,,
BCBS Blue Choice,CPT,86079,Phys blood bank serv authrj,All Other,Per Unit,$251.64 ,OP,50.92,251.64,,,,,,
BCBS Blue Choice,CPT,86140,C-reactive protein,All Other,Per Unit,$22.88 ,OP,5.18,22.88,,,,,,
BCBS Blue Choice,CPT,86141,C-reactive protein hs,All Other,Per Unit,$57.19 ,OP,12.95,57.19,,,,,,
BCBS Blue Choice,CPT,86146,Beta-2 glycoprotein antibody,All Other,Per Unit,$114.39 ,OP,25.45,114.39,,,,,,
BCBS Blue Choice,CPT,86147,Cardiolipin antibody ea ig,All Other,Per Unit,$114.39 ,OP,25.45,114.39,,,,,,
BCBS Blue Choice,CPT,86148,Anti-phospholipid antibody,All Other,Per Unit,$72.44 ,OP,16.07,72.44,,,,,,
BCBS Blue Choice,CPT,86155,Chemotaxis assay,All Other,Per Unit,$72.44 ,OP,15.99,72.44,,,,,,
BCBS Blue Choice,CPT,86156,Cold agglutinin screen,All Other,Per Unit,$30.51 ,OP,8.07,30.51,,,,,,
BCBS Blue Choice,CPT,86157,Cold agglutinin titer,All Other,Per Unit,$34.31 ,OP,8.06,34.31,,,,,,
BCBS Blue Choice,CPT,86160,Complement antigen,All Other,Per Unit,$53.38 ,OP,12,53.38,,,,,,
BCBS Blue Choice,CPT,86161,Complement/function activity,All Other,Per Unit,$53.38 ,OP,12,53.38,,,,,,
BCBS Blue Choice,CPT,86162,Complement total (ch50),All Other,Per Unit,$91.51 ,OP,20.32,91.51,,,,,,
BCBS Blue Choice,CPT,86171,Complement fixation each,All Other,Per Unit,$45.74 ,OP,10.01,45.74,,,,,,
BCBS Blue Choice,CPT,86185,Counterimmunoelectrophoresis,All Other,Per Unit,$38.13 ,OP,38.13,38.13,,,,,,
BCBS Blue Choice,CPT,86200,Ccp antibody,All Other,Per Unit,$57.19 ,OP,12.95,57.19,,,,,,
BCBS Blue Choice,CPT,86215,Deoxyribonuclease antibody,All Other,Per Unit,$57.19 ,OP,13.25,57.19,,,,,,
BCBS Blue Choice,CPT,86225,Dna antibody native,All Other,Per Unit,$61.00 ,OP,13.74,61,,,,,,
BCBS Blue Choice,CPT,86226,Dna antibody single strand,All Other,Per Unit,$53.38 ,OP,12.11,53.38,,,,,,
BCBS Blue Choice,CPT,86235,Nuclear antigen antibody,All Other,Per Unit,$80.07 ,OP,17.93,80.07,,,,,,
BCBS Blue Choice,CPT,86243,Fc receptor,All Other,Per Unit,$91.51 ,OP,91.51,91.51,,,,,,
BCBS Blue Choice,CPT,86255,Fluorescent antibody screen,All Other,Per Unit,$53.38 ,OP,12.05,53.38,,,,,,
BCBS Blue Choice,CPT,86256,Fluorescent antibody titer,All Other,Per Unit,$53.38 ,OP,12.05,53.38,,,,,,
BCBS Blue Choice,CPT,86277,Growth hormone antibody,All Other,Per Unit,$68.63 ,OP,15.74,68.63,,,,,,
BCBS Blue Choice,CPT,86294,Immunoassay tumor qual,All Other,Per Unit,$80.07 ,OP,25.57,80.07,,,,,,
BCBS Blue Choice,CPT,86300,Immunoassay tumor ca 15-3,All Other,Per Unit,$91.51 ,OP,20.81,91.51,,,,,,
BCBS Blue Choice,CPT,86301,Immunoassay tumor ca 19-9,All Other,Per Unit,$91.51 ,OP,20.81,91.51,,,,,,
BCBS Blue Choice,CPT,86304,Immunoassay tumor ca 125,All Other,Per Unit,$91.51 ,OP,20.81,91.51,,,,,,
BCBS Blue Choice,CPT,86308,Heterophile antibody screen,All Other,Per Unit,$26.70 ,OP,5.18,26.7,,,,,,
BCBS Blue Choice,CPT,86309,Heterophile antibody titer,All Other,Per Unit,$30.51 ,OP,6.47,30.51,,,,,,
BCBS Blue Choice,CPT,86316,Immunoassay tumor other,All Other,Per Unit,$91.51 ,OP,20.81,91.51,,,,,,
BCBS Blue Choice,CPT,86317,Immunoassay infectious agent,All Other,Per Unit,$68.63 ,OP,14.99,68.63,,,,,,
BCBS Blue Choice,CPT,86318,Ia infectious agent antibody,All Other,Per Unit,$64.82 ,OP,18.09,64.82,,,,,,
BCBS Blue Choice,CPT,86320,Serum immunoelectrophoresis,All Other,Per Unit,$99.13 ,OP,29.92,99.13,,,,,,
BCBS Blue Choice,CPT,86325,Other immunoelectrophoresis,All Other,Per Unit,$99.13 ,OP,23.13,99.13,,,,,,
BCBS Blue Choice,CPT,86327,Immunoelectrophoresis assay,All Other,Per Unit,$72.44 ,OP,29.92,72.44,,,,,,
BCBS Blue Choice,CPT,86328,Ia nfct ab sarscov2 covid19,All Other,Per Unit,$64.82 ,OP,45.23,64.82,,,,,,
BCBS Blue Choice,CPT,86331,Immunodiffusion ouchterlony,All Other,Per Unit,$53.38 ,OP,11.98,53.38,,,,,,
BCBS Blue Choice,CPT,86332,Immune complex assay,All Other,Per Unit,$106.76 ,OP,24.37,106.76,,,,,,
BCBS Blue Choice,CPT,86334,Immunofix e-phoresis serum,All Other,Per Unit,$99.13 ,OP,22.34,99.13,,,,,,
BCBS Blue Choice,CPT,86335,Immunfix e-phorsis/urine/csf,All Other,Per Unit,$129.64 ,OP,29.35,129.64,,,,,,
BCBS Blue Choice,CPT,86336,Inhibin a,All Other,Per Unit,$68.63 ,OP,15.59,68.63,,,,,,
BCBS Blue Choice,CPT,86337,Insulin antibodies,All Other,Per Unit,$95.32 ,OP,21.41,95.32,,,,,,
BCBS Blue Choice,CPT,86340,Intrinsic factor antibody,All Other,Per Unit,$68.63 ,OP,15.08,68.63,,,,,,
BCBS Blue Choice,CPT,86341,Islet cell antibody,All Other,Per Unit,$87.69 ,OP,23.57,87.69,,,,,,
BCBS Blue Choice,CPT,86343,Leukocyte histamine release,All Other,Per Unit,$57.19 ,OP,12.46,57.19,,,,,,
BCBS Blue Choice,CPT,86344,Leukocyte phagocytosis,All Other,Per Unit,$34.31 ,OP,10.39,34.31,,,,,,
BCBS Blue Choice,CPT,86353,Lymphocyte transformation,All Other,Per Unit,$217.32 ,OP,49.03,217.32,,,,,,
BCBS Blue Choice,CPT,86355,B cells total count,All Other,Per Unit,$167.76 ,OP,37.73,167.76,,,,,,
BCBS Blue Choice,CPT,86356,Mononuclear cell antigen,All Other,Per Unit,$61.00 ,OP,26.78,61,,,,,,
BCBS Blue Choice,CPT,86357,Nk cells total count,All Other,Per Unit,$167.76 ,OP,37.73,167.76,,,,,,
BCBS Blue Choice,CPT,86359,T cells total count,All Other,Per Unit,$167.76 ,OP,37.73,167.76,,,,,,
BCBS Blue Choice,CPT,86360,T cell absolute count/ratio,All Other,Per Unit,$209.70 ,OP,46.98,209.7,,,,,,
BCBS Blue Choice,CPT,86361,T cell absolute count,All Other,Per Unit,$61.00 ,OP,26.78,61,,,,,,
BCBS Blue Choice,CPT,86367,Stem cells total count,All Other,Per Unit,$167.76 ,OP,77.78,167.76,,,,,,
BCBS Blue Choice,CPT,86376,Microsomal antibody each,All Other,Per Unit,$64.82 ,OP,14.55,64.82,,,,,,
BCBS Blue Choice,CPT,86382,Neutralization test viral,All Other,Per Unit,$76.26 ,OP,16.91,76.26,,,,,,
BCBS Blue Choice,CPT,86403,Particle agglut antbdy scrn,All Other,Per Unit,$26.70 ,OP,11.54,26.7,,,,,,
BCBS Blue Choice,CPT,86406,Particle agglut antbdy titr,All Other,Per Unit,$45.74 ,OP,10.64,45.74,,,,,,
BCBS Blue Choice,CPT,86430,Rheumatoid factor test qual,All Other,Per Unit,$26.70 ,OP,6.14,26.7,,,,,,
BCBS Blue Choice,CPT,86431,Rheumatoid factor quant,All Other,Per Unit,$26.70 ,OP,5.67,26.7,,,,,,
BCBS Blue Choice,CPT,86480,Tb test cell immun measure,All Other,Per Unit,$274.51 ,OP,61.98,274.51,,,,,,
BCBS Blue Choice,CPT,86485,Skin test candida,All Other,Per Unit,$61.00 ,OP,25.25,61,,,,,,
BCBS Blue Choice,CPT,86486,Skin test nos antigen,All Other,Per Unit,$30.51 ,OP,25.25,30.51,,,,,,
BCBS Blue Choice,CPT,86490,Coccidioidomycosis skin test,All Other,Per Unit,$38.13 ,OP,38.13,56.95,,,,,,
BCBS Blue Choice,CPT,86510,Histoplasmosis skin test,All Other,Per Unit,$38.13 ,OP,38.13,56.95,,,,,,
BCBS Blue Choice,CPT,86580,Tb intradermal test,All Other,Per Unit,$38.13 ,OP,25.25,38.13,,,,,,
BCBS Blue Choice,CPT,86590,Streptokinase antibody,All Other,Per Unit,$49.56 ,OP,12.66,49.56,,,,,,
BCBS Blue Choice,CPT,86592,Syphilis test non-trep qual,All Other,Per Unit,$19.07 ,OP,4.27,19.07,,,,,,
BCBS Blue Choice,CPT,86593,Syphilis test non-trep quant,All Other,Per Unit,$19.07 ,OP,4.4,19.07,,,,,,
BCBS Blue Choice,CPT,86602,Antinomyces antibody,All Other,Per Unit,$45.74 ,OP,10.18,45.74,,,,,,
BCBS Blue Choice,CPT,86606,Aspergillus antibody,All Other,Per Unit,$68.63 ,OP,15.05,68.63,,,,,,
BCBS Blue Choice,CPT,86609,Bacterium antibody,All Other,Per Unit,$57.19 ,OP,12.88,57.19,,,,,,
BCBS Blue Choice,CPT,86611,Bartonella antibody,All Other,Per Unit,$45.74 ,OP,10.18,45.74,,,,,,
BCBS Blue Choice,CPT,86612,Blastomyces antibody,All Other,Per Unit,$57.19 ,OP,12.9,57.19,,,,,,
BCBS Blue Choice,CPT,86615,Bordetella antibody,All Other,Per Unit,$57.19 ,OP,13.19,57.19,,,,,,
BCBS Blue Choice,CPT,86617,Lyme disease antibody,All Other,Per Unit,$68.63 ,OP,15.49,68.63,,,,,,
BCBS Blue Choice,CPT,86618,Lyme disease antibody,All Other,Per Unit,$83.87 ,OP,17.03,83.87,,,,,,
BCBS Blue Choice,CPT,86619,Borrelia antibody,All Other,Per Unit,$61.00 ,OP,13.38,61,,,,,,
BCBS Blue Choice,CPT,86622,Brucella antibody,All Other,Per Unit,$38.13 ,OP,8.93,38.13,,,,,,
BCBS Blue Choice,CPT,86625,Campylobacter antibody,All Other,Per Unit,$57.19 ,OP,13.12,57.19,,,,,,
BCBS Blue Choice,CPT,86628,Candida antibody,All Other,Per Unit,$53.38 ,OP,12.01,53.38,,,,,,
BCBS Blue Choice,CPT,86631,Chlamydia antibody,All Other,Per Unit,$53.38 ,OP,11.82,53.38,,,,,,
BCBS Blue Choice,CPT,86632,Chlamydia igm antibody,All Other,Per Unit,$57.19 ,OP,12.68,57.19,,,,,,
BCBS Blue Choice,CPT,86635,Coccidioides antibody,All Other,Per Unit,$49.56 ,OP,11.47,49.56,,,,,,
BCBS Blue Choice,CPT,86638,Q fever antibody,All Other,Per Unit,$53.38 ,OP,12.12,53.38,,,,,,
BCBS Blue Choice,CPT,86641,Cryptococcus antibody,All Other,Per Unit,$64.82 ,OP,14.41,64.82,,,,,,
BCBS Blue Choice,CPT,86644,Cmv antibody,All Other,Per Unit,$64.82 ,OP,14.39,64.82,,,,,,
BCBS Blue Choice,CPT,86645,Cmv antibody igm,All Other,Per Unit,$76.26 ,OP,16.85,76.26,,,,,,
BCBS Blue Choice,CPT,86648,Diphtheria antibody,All Other,Per Unit,$68.63 ,OP,15.21,68.63,,,,,,
BCBS Blue Choice,CPT,86651,Encephalitis californ antbdy,All Other,Per Unit,$57.19 ,OP,13.19,57.19,,,,,,
BCBS Blue Choice,CPT,86652,Encephaltis east eqne anbdy,All Other,Per Unit,$57.19 ,OP,13.19,57.19,,,,,,
BCBS Blue Choice,CPT,86653,Encephaltis st louis antbody,All Other,Per Unit,$57.19 ,OP,13.19,57.19,,,,,,
BCBS Blue Choice,CPT,86654,Encephaltis west eqne antbdy,All Other,Per Unit,$57.19 ,OP,13.19,57.19,,,,,,
BCBS Blue Choice,CPT,86658,Enterovirus antibody,All Other,Per Unit,$57.19 ,OP,13.03,57.19,,,,,,
BCBS Blue Choice,CPT,86663,Epstein-barr antibody,All Other,Per Unit,$57.19 ,OP,13.12,57.19,,,,,,
BCBS Blue Choice,CPT,86664,Epstein-barr nuclear antigen,All Other,Per Unit,$68.63 ,OP,15.29,68.63,,,,,,
BCBS Blue Choice,CPT,86665,Epstein-barr capsid vca,All Other,Per Unit,$80.07 ,OP,18.14,80.07,,,,,,
BCBS Blue Choice,CPT,86666,Ehrlichia antibody,All Other,Per Unit,$45.74 ,OP,10.18,45.74,,,,,,
BCBS Blue Choice,CPT,86668,Francisella tularensis,All Other,Per Unit,$45.74 ,OP,14.16,45.74,,,,,,
BCBS Blue Choice,CPT,86671,Fungus nes antibody,All Other,Per Unit,$53.38 ,OP,12.25,53.38,,,,,,
BCBS Blue Choice,CPT,86677,Helicobacter pylori antibody,All Other,Per Unit,$64.82 ,OP,16.85,64.82,,,,,,
BCBS Blue Choice,CPT,86682,Helminth antibody,All Other,Per Unit,$57.19 ,OP,13.01,57.19,,,,,,
BCBS Blue Choice,CPT,86684,Hemophilus influenza antibdy,All Other,Per Unit,$72.44 ,OP,15.84,72.44,,,,,,
BCBS Blue Choice,CPT,86687,Htlv-i antibody,All Other,Per Unit,$38.13 ,OP,9.09,38.13,,,,,,
BCBS Blue Choice,CPT,86688,Htlv-ii antibody,All Other,Per Unit,$61.00 ,OP,14,61,,,,,,
BCBS Blue Choice,CPT,86689,Htlv/hiv confirmj antibody,All Other,Per Unit,$87.69 ,OP,19.35,87.69,,,,,,
BCBS Blue Choice,CPT,86692,Hepatitis delta agent antbdy,All Other,Per Unit,$76.26 ,OP,17.16,76.26,,,,,,
BCBS Blue Choice,CPT,86694,Herpes simplex nes antbdy,All Other,Per Unit,$64.82 ,OP,14.39,64.82,,,,,,
BCBS Blue Choice,CPT,86695,Herpes simplex type 1 test,All Other,Per Unit,$57.19 ,OP,13.19,57.19,,,,,,
BCBS Blue Choice,CPT,86696,Herpes simplex type 2 test,All Other,Per Unit,$87.69 ,OP,19.35,87.69,,,,,,
BCBS Blue Choice,CPT,86698,Histoplasma antibody,All Other,Per Unit,$57.19 ,OP,13.79,57.19,,,,,,
BCBS Blue Choice,CPT,86701,Hiv-1antibody,All Other,Per Unit,$38.13 ,OP,8.89,38.13,,,,,,
BCBS Blue Choice,CPT,86702,Hiv-2 antibody,All Other,Per Unit,$61.00 ,OP,13.52,61,,,,,,
BCBS Blue Choice,CPT,86703,Hiv-1/hiv-2 1 result antbdy,All Other,Per Unit,$61.00 ,OP,13.71,61,,,,,,
BCBS Blue Choice,CPT,86704,Hep b core antibody total,All Other,Per Unit,$53.38 ,OP,12.05,53.38,,,,,,
BCBS Blue Choice,CPT,86705,Hep b core antibody igm,All Other,Per Unit,$53.38 ,OP,11.77,53.38,,,,,,
BCBS Blue Choice,CPT,86706,Hep b surface antibody,All Other,Per Unit,$49.56 ,OP,10.74,49.56,,,,,,
BCBS Blue Choice,CPT,86707,Hepatitis be antibody,All Other,Per Unit,$53.38 ,OP,11.57,53.38,,,,,,
BCBS Blue Choice,CPT,86708,Hepatitis a antibody,All Other,Per Unit,$53.38 ,OP,12.39,53.38,,,,,,
BCBS Blue Choice,CPT,86709,Hepatitis a igm antibody,All Other,Per Unit,$49.56 ,OP,11.26,49.56,,,,,,
BCBS Blue Choice,CPT,86710,Influenza virus antibody,All Other,Per Unit,$68.63 ,OP,13.55,68.63,,,,,,
BCBS Blue Choice,CPT,86713,Legionella antibody,All Other,Per Unit,$68.63 ,OP,15.3,68.63,,,,,,
BCBS Blue Choice,CPT,86717,Leishmania antibody,All Other,Per Unit,$53.38 ,OP,12.25,53.38,,,,,,
BCBS Blue Choice,CPT,86720,Leptospira antibody,All Other,Per Unit,$57.19 ,OP,16.2,57.19,,,,,,
BCBS Blue Choice,CPT,86727,Lymph choriomeningitis ab,All Other,Per Unit,$57.19 ,OP,12.87,57.19,,,,,,
BCBS Blue Choice,CPT,86729,Lympho venereum antibody,All Other,Per Unit,$53.38 ,OP,53.38,53.38,,,,,,
BCBS Blue Choice,CPT,86732,Mucormycosis antibody,All Other,Per Unit,$57.19 ,OP,15,57.19,,,,,,
BCBS Blue Choice,CPT,86735,Mumps antibody,All Other,Per Unit,$57.19 ,OP,13.05,57.19,,,,,,
BCBS Blue Choice,CPT,86738,Mycoplasma antibody,All Other,Per Unit,$57.19 ,OP,13.24,57.19,,,,,,
BCBS Blue Choice,CPT,86741,Neisseria meningitidis,All Other,Per Unit,$57.19 ,OP,13.19,57.19,,,,,,
BCBS Blue Choice,CPT,86744,Nocardia antibody,All Other,Per Unit,$57.19 ,OP,15.99,57.19,,,,,,
BCBS Blue Choice,CPT,86747,Parvovirus antibody,All Other,Per Unit,$68.63 ,OP,15.03,68.63,,,,,,
BCBS Blue Choice,CPT,86750,Malaria antibody,All Other,Per Unit,$57.19 ,OP,13.19,57.19,,,,,,
BCBS Blue Choice,CPT,86753,Protozoa antibody nos,All Other,Per Unit,$53.38 ,OP,12.39,53.38,,,,,,
BCBS Blue Choice,CPT,86756,Respiratory virus antibody,All Other,Per Unit,$57.19 ,OP,15.89,57.19,,,,,,
BCBS Blue Choice,CPT,86757,Rickettsia antibody,All Other,Per Unit,$87.69 ,OP,19.35,87.69,,,,,,
BCBS Blue Choice,CPT,86759,Rotavirus antibody,All Other,Per Unit,$57.19 ,OP,18.23,57.19,,,,,,
BCBS Blue Choice,CPT,86762,Rubella antibody,All Other,Per Unit,$64.82 ,OP,14.39,64.82,,,,,,
BCBS Blue Choice,CPT,86765,Rubeola antibody,All Other,Per Unit,$57.19 ,OP,12.88,57.19,,,,,,
BCBS Blue Choice,CPT,86769,Sars-cov-2 covid-19 antibody,All Other,Per Unit,$57.19 ,OP,42.13,57.19,,,,,,
BCBS Blue Choice,CPT,86771,Shigella antibody,All Other,Per Unit,$57.19 ,OP,24.48,57.19,,,,,,
BCBS Blue Choice,CPT,86774,Tetanus antibody,All Other,Per Unit,$64.82 ,OP,14.8,64.82,,,,,,
BCBS Blue Choice,CPT,86777,Toxoplasma antibody,All Other,Per Unit,$64.82 ,OP,14.39,64.82,,,,,,
BCBS Blue Choice,CPT,86778,Toxoplasma antibody igm,All Other,Per Unit,$64.82 ,OP,14.41,64.82,,,,,,
BCBS Blue Choice,CPT,86781,Treponema pallidum - confirm,All Other,Per Unit,$57.19 ,OP,57.19,57.19,,,,,,
BCBS Blue Choice,CPT,86787,Varicella-zoster antibody,All Other,Per Unit,$57.19 ,OP,12.88,57.19,,,,,,
BCBS Blue Choice,CPT,86788,West nile virus ab igm,All Other,Per Unit,$76.26 ,OP,16.85,76.26,,,,,,
BCBS Blue Choice,CPT,86789,West nile virus antibody,All Other,Per Unit,$64.82 ,OP,14.39,64.82,,,,,,
BCBS Blue Choice,CPT,86790,Virus antibody nos,All Other,Per Unit,$57.19 ,OP,12.88,57.19,,,,,,
BCBS Blue Choice,CPT,86793,Yersinia antibody,All Other,Per Unit,$57.19 ,OP,13.19,57.19,,,,,,
BCBS Blue Choice,CPT,86800,Thyroglobulin antibody,All Other,Per Unit,$72.44 ,OP,15.91,72.44,,,,,,
BCBS Blue Choice,CPT,86803,Hepatitis c ab test,All Other,Per Unit,$64.82 ,OP,14.27,64.82,,,,,,
BCBS Blue Choice,CPT,86804,Hep c ab test confirm,All Other,Per Unit,$68.63 ,OP,15.49,68.63,,,,,,
BCBS Blue Choice,CPT,86805,Lymphocytotoxicity assay,All Other,Per Unit,$232.58 ,OP,189.51,232.58,,,,,,
BCBS Blue Choice,CPT,86806,Lymphocytotoxicity assay,All Other,Per Unit,$213.51 ,OP,47.59,213.51,,,,,,
BCBS Blue Choice,CPT,86807,Cytotoxic antibody screening,All Other,Per Unit,$175.39 ,OP,78.65,175.39,,,,,,
BCBS Blue Choice,CPT,86808,Cytotoxic antibody screening,All Other,Per Unit,$133.45 ,OP,29.68,133.45,,,,,,
BCBS Blue Choice,CPT,86812,Hla typing a b or c,All Other,Per Unit,$114.39 ,OP,25.81,114.39,,,,,,
BCBS Blue Choice,CPT,86813,Hla typing a b or c,All Other,Per Unit,$247.83 ,OP,58,247.83,,,,,,
BCBS Blue Choice,CPT,86816,Hla typing dr/dq,All Other,Per Unit,$102.95 ,OP,30.17,102.95,,,,,,
BCBS Blue Choice,CPT,86817,Hla typing dr/dq,All Other,Per Unit,$247.83 ,OP,106.14,247.83,,,,,,
BCBS Blue Choice,CPT,86821,Lymphocyte culture mixed,All Other,Per Unit,$251.64 ,OP,36.56,251.64,,,,,,
BCBS Blue Choice,CPT,86822,Lymphocyte culture primed,All Other,Per Unit,$163.95 ,OP,163.95,163.95,,,,,,
BCBS Blue Choice,CPT,86850,Rbc antibody screen,All Other,Per Unit,$76.26 ,OP,50.92,76.26,,,,,,
BCBS Blue Choice,CPT,86860,Rbc antibody elution,All Other,Per Unit,$91.51 ,OP,91.51,152.64,,,,,,
BCBS Blue Choice,CPT,86870,Rbc antibody identification,All Other,Per Unit,$141.07 ,OP,141.07,298.05,,,,,,
BCBS Blue Choice,CPT,86880,Coombs test direct,All Other,Per Unit,$22.88 ,OP,22.88,56.95,,,,,,
BCBS Blue Choice,CPT,86886,Coombs test indirect titer,All Other,Per Unit,$22.88 ,OP,22.88,152.64,,,,,,
BCBS Blue Choice,CPT,86890,Autologous blood process,All Other,Per Unit,$308.83 ,OP,152.64,308.83,,,,,,
BCBS Blue Choice,CPT,86891,Autologous blood op salvage,All Other,Per Unit,$480.40 ,OP,480.4,671.45,,,,,,
BCBS Blue Choice,CPT,86900,Blood typing serologic abo,All Other,Per Unit,$11.44 ,OP,11.44,114.56,,,,,,
BCBS Blue Choice,CPT,86901,Blood typing serologic rh(d),All Other,Per Unit,$22.88 ,OP,22.88,34.63,,,,,,
BCBS Blue Choice,CPT,86902,Blood type antigen donor ea,All Other,Per Unit,$41.94 ,OP,41.94,298.05,,,,,,
BCBS Blue Choice,CPT,86903,Blood typing - antigen screen,All Other,Per Unit,$41.94 ,OP,41.94,41.94,,,,,,
BCBS Blue Choice,CPT,86904,Blood typing patient serum,All Other,Per Unit,$41.94 ,OP,34.63,41.94,,,,,,
BCBS Blue Choice,CPT,86905,Blood typing rbc antigens,All Other,Per Unit,$15.26 ,OP,15.26,298.05,,,,,,
BCBS Blue Choice,CPT,86906,Bld typing serologic rh phnt,All Other,Per Unit,$34.31 ,OP,34.31,34.63,,,,,,
BCBS Blue Choice,CPT,86910,Blood typing paternity test,All Other,Per Unit,$83.87 ,OP,83.87,83.87,,,,,,
BCBS Blue Choice,CPT,86911,Blood typing antigen system,All Other,Per Unit,$72.44 ,OP,72.44,72.44,,,,,,
BCBS Blue Choice,CPT,86920,Compatibility test spin,All Other,Per Unit,$125.82 ,OP,125.82,152.64,,,,,,
BCBS Blue Choice,CPT,86921,Compatibility test incubate,All Other,Per Unit,$102.95 ,OP,102.95,152.64,,,,,,
BCBS Blue Choice,CPT,86922,Compatibility test antiglob,All Other,Per Unit,$118.19 ,OP,118.19,152.64,,,,,,
BCBS Blue Choice,CPT,86923,Compatibility test electric,All Other,Per Unit,$91.51 ,OP,91.51,152.64,,,,,,
BCBS Blue Choice,CPT,86927,Plasma fresh frozen,All Other,Per Unit,$49.56 ,OP,49.56,152.64,,,,,,
BCBS Blue Choice,CPT,86930,Frozen blood prep,All Other,Per Unit,$385.09 ,OP,298.05,385.09,,,,,,
BCBS Blue Choice,CPT,86931,Frozen blood thaw,All Other,Per Unit,$289.76 ,OP,289.76,298.05,,,,,,
BCBS Blue Choice,CPT,86932,Frozen blood freeze/thaw,All Other,Per Unit,$385.09 ,OP,34.63,385.09,,,,,,
BCBS Blue Choice,CPT,86940,Hemolysins/agglutinins auto,All Other,Per Unit,$38.13 ,OP,8.77,38.13,,,,,,
BCBS Blue Choice,CPT,86941,Hemolysins/agglutinins,All Other,Per Unit,$53.38 ,OP,12.11,53.38,,,,,,
BCBS Blue Choice,CPT,86945,Blood product/irradiation,All Other,Per Unit,$110.57 ,OP,34.63,110.57,,,,,,
BCBS Blue Choice,CPT,86950,Leukacyte transfusion,All Other,Per Unit,$240.20 ,OP,152.64,240.2,,,,,,
BCBS Blue Choice,CPT,86960,Vol reduction of blood/prod,All Other,Per Unit,$110.57 ,OP,110.57,152.64,,,,,,
BCBS Blue Choice,CPT,86965,Pooling blood platelets,All Other,Per Unit,$95.32 ,OP,95.32,152.64,,,,,,
BCBS Blue Choice,CPT,86970,Rbc pretx incubatj w/chemicl,All Other,Per Unit,$76.26 ,OP,34.63,76.26,,,,,,
BCBS Blue Choice,CPT,86972,Rbc pretx incubatj w/density,All Other,Per Unit,$122.00 ,OP,122,152.64,,,,,,
BCBS Blue Choice,CPT,86975,Rbc serum pretx incubj drugs,All Other,Per Unit,$102.95 ,OP,102.95,276.53,,,,,,
BCBS Blue Choice,CPT,86976,Rbc serum pretx id dilution,All Other,Per Unit,$118.19 ,OP,25.25,118.19,,,,,,
BCBS Blue Choice,CPT,86978,Rbc pretreatment serum,All Other,Per Unit,$102.95 ,OP,34.63,102.95,,,,,,
BCBS Blue Choice,CPT,86985,Split blood or products,All Other,Per Unit,$76.26 ,OP,76.26,152.64,,,,,,
BCBS Blue Choice,CPT,87001,Small animal inoculation,All Other,Per Unit,$57.19 ,OP,57.19,57.19,,,,,,
BCBS Blue Choice,CPT,87003,Small animal inoculation,All Other,Per Unit,$76.26 ,OP,16.84,76.26,,,,,,
BCBS Blue Choice,CPT,87015,Specimen infect agnt concntj,All Other,Per Unit,$30.51 ,OP,6.68,30.51,,,,,,
BCBS Blue Choice,CPT,87040,Blood culture for bacteria,All Other,Per Unit,$45.74 ,OP,10.32,45.74,,,,,,
BCBS Blue Choice,CPT,87045,Feces culture aerobic bact,All Other,Per Unit,$41.94 ,OP,9.44,41.94,,,,,,
BCBS Blue Choice,CPT,87046,Stool cultr aerobic bact ea,All Other,Per Unit,$41.94 ,OP,9.44,41.94,,,,,,
BCBS Blue Choice,CPT,87070,Culture othr specimn aerobic,All Other,Per Unit,$41.94 ,OP,8.62,41.94,,,,,,
BCBS Blue Choice,CPT,87071,Culture aerobic quant other,All Other,Per Unit,$41.94 ,OP,9.89,41.94,,,,,,
BCBS Blue Choice,CPT,87073,Culture bacteria anaerobic,All Other,Per Unit,$41.94 ,OP,9.66,41.94,,,,,,
BCBS Blue Choice,CPT,87075,Cultr bacteria except blood,All Other,Per Unit,$41.94 ,OP,9.47,41.94,,,,,,
BCBS Blue Choice,CPT,87076,Culture anaerobe ident each,All Other,Per Unit,$19.07 ,OP,8.08,19.07,,,,,,
BCBS Blue Choice,CPT,87077,Culture aerobic identify,All Other,Per Unit,$22.88 ,OP,8.08,22.88,,,,,,
BCBS Blue Choice,CPT,87081,Culture screen only,All Other,Per Unit,$34.31 ,OP,6.63,34.31,,,,,,
BCBS Blue Choice,CPT,87084,Culture of specimen by kit,All Other,Per Unit,$22.88 ,OP,22.88,27.07,,,,,,
BCBS Blue Choice,CPT,87086,Urine culture/colony count,All Other,Per Unit,$41.94 ,OP,8.07,41.94,,,,,,
BCBS Blue Choice,CPT,87088,Urine bacteria culture,All Other,Per Unit,$41.94 ,OP,8.09,41.94,,,,,,
BCBS Blue Choice,CPT,87101,Skin fungi culture,All Other,Per Unit,$34.31 ,OP,7.71,34.31,,,,,,
BCBS Blue Choice,CPT,87102,Fungus isolation culture,All Other,Per Unit,$38.13 ,OP,8.41,38.13,,,,,,
BCBS Blue Choice,CPT,87103,Blood fungus culture,All Other,Per Unit,$41.94 ,OP,20.46,41.94,,,,,,
BCBS Blue Choice,CPT,87106,Fungi identification yeast,All Other,Per Unit,$45.74 ,OP,10.32,45.74,,,,,,
BCBS Blue Choice,CPT,87107,Fungi identification mold,All Other,Per Unit,$45.74 ,OP,10.32,45.74,,,,,,
BCBS Blue Choice,CPT,87109,Mycoplasma,All Other,Per Unit,$68.63 ,OP,15.39,68.63,,,,,,
BCBS Blue Choice,CPT,87110,Chlamydia culture,All Other,Per Unit,$87.69 ,OP,19.6,87.69,,,,,,
BCBS Blue Choice,CPT,87116,Mycobacteria culture,All Other,Per Unit,$49.56 ,OP,10.8,49.56,,,,,,
BCBS Blue Choice,CPT,87118,Mycobacteric identification,All Other,Per Unit,$49.56 ,OP,14.61,49.56,,,,,,
BCBS Blue Choice,CPT,87140,Culture type immunofluoresc,All Other,Per Unit,$26.70 ,OP,5.57,26.7,,,,,,
BCBS Blue Choice,CPT,87143,Culture typing glc/hplc,All Other,Per Unit,$57.19 ,OP,12.52,57.19,,,,,,
BCBS Blue Choice,CPT,87147,Culture type immunologic,All Other,Per Unit,$22.88 ,OP,5.18,22.88,,,,,,
BCBS Blue Choice,CPT,87149,Dna/rna direct probe,All Other,Per Unit,$87.69 ,OP,20.05,87.69,,,,,,
BCBS Blue Choice,CPT,87152,Culture type pulse field gel,All Other,Per Unit,$22.88 ,OP,7.74,22.88,,,,,,
BCBS Blue Choice,CPT,87164,Dark field examination,All Other,Per Unit,$49.56 ,OP,10.74,49.56,,,,,,
BCBS Blue Choice,CPT,87166,Dark field examination,All Other,Per Unit,$49.56 ,OP,11.3,49.56,,,,,,
BCBS Blue Choice,CPT,87168,Macroscopic exam arthropod,All Other,Per Unit,$19.07 ,OP,4.27,19.07,,,,,,
BCBS Blue Choice,CPT,87169,Macroscopic exam parasite,All Other,Per Unit,$19.07 ,OP,4.31,19.07,,,,,,
BCBS Blue Choice,CPT,87172,Pinworm exam,All Other,Per Unit,$22.88 ,OP,4.27,22.88,,,,,,
BCBS Blue Choice,CPT,87176,Tissue homogenization cultr,All Other,Per Unit,$26.70 ,OP,5.88,26.7,,,,,,
BCBS Blue Choice,CPT,87177,Ova and parasites smears,All Other,Per Unit,$41.94 ,OP,8.9,41.94,,,,,,
BCBS Blue Choice,CPT,87181,Microbe susceptible diffuse,All Other,Per Unit,$22.88 ,OP,4.75,22.88,,,,,,
BCBS Blue Choice,CPT,87184,Microbe susceptible disk,All Other,Per Unit,$34.31 ,OP,7.48,34.31,,,,,,
BCBS Blue Choice,CPT,87185,Microbe susceptible enzyme,All Other,Per Unit,$22.88 ,OP,4.75,22.88,,,,,,
BCBS Blue Choice,CPT,87186,Microbe susceptible mic,All Other,Per Unit,$38.13 ,OP,8.65,38.13,,,,,,
BCBS Blue Choice,CPT,87187,Microbe susceptible mlc,All Other,Per Unit,$45.74 ,OP,40.17,45.74,,,,,,
BCBS Blue Choice,CPT,87188,Microbe suscept macrobroth,All Other,Per Unit,$30.51 ,OP,6.64,30.51,,,,,,
BCBS Blue Choice,CPT,87190,Microbe suscept mycobacteri,All Other,Per Unit,$26.70 ,OP,7.31,26.7,,,,,,
BCBS Blue Choice,CPT,87197,Bactericidal level serum,All Other,Per Unit,$68.63 ,OP,15.02,68.63,,,,,,
BCBS Blue Choice,CPT,87205,Smear gram stain,All Other,Per Unit,$22.88 ,OP,4.27,22.88,,,,,,
BCBS Blue Choice,CPT,87206,Smear fluorescent/acid stai,All Other,Per Unit,$26.70 ,OP,5.39,26.7,,,,,,
BCBS Blue Choice,CPT,87207,Smear special stain,All Other,Per Unit,$41.94 ,OP,5.99,41.94,,,,,,
BCBS Blue Choice,CPT,87209,Smear complex stain,All Other,Per Unit,$80.07 ,OP,17.98,80.07,,,,,,
BCBS Blue Choice,CPT,87210,Smear wet mount saline/ink,All Other,Per Unit,$22.88 ,OP,5.82,22.88,,,,,,
BCBS Blue Choice,CPT,87220,Tissue exam for fungi,All Other,Per Unit,$22.88 ,OP,4.27,22.88,,,,,,
BCBS Blue Choice,CPT,87230,Assay toxin or antitoxin,All Other,Per Unit,$87.69 ,OP,19.74,87.69,,,,,,
BCBS Blue Choice,CPT,87250,Virus inoculate eggs/animal,All Other,Per Unit,$87.69 ,OP,19.56,87.69,,,,,,
BCBS Blue Choice,CPT,87252,Virus inoculation tissue,All Other,Per Unit,$102.95 ,OP,26.07,102.95,,,,,,
BCBS Blue Choice,CPT,87253,Virus inoculate tissue addl,All Other,Per Unit,$91.51 ,OP,20.2,91.51,,,,,,
BCBS Blue Choice,CPT,87254,Virus inoculation shell via,All Other,Per Unit,$87.69 ,OP,19.56,87.69,,,,,,
BCBS Blue Choice,CPT,87255,Genet virus isolate hsv,All Other,Per Unit,$152.51 ,OP,33.86,152.51,,,,,,
BCBS Blue Choice,CPT,87265,Pertussis ag if,All Other,Per Unit,$53.38 ,OP,11.98,53.38,,,,,,
BCBS Blue Choice,CPT,87267,Enterovirus antibody dfa,All Other,Per Unit,$53.38 ,OP,13.42,53.38,,,,,,
BCBS Blue Choice,CPT,87269,Giardia ag if,All Other,Per Unit,$53.38 ,OP,13.61,53.38,,,,,,
BCBS Blue Choice,CPT,87270,Chlamydia trachomatis ag if,All Other,Per Unit,$53.38 ,OP,11.98,53.38,,,,,,
BCBS Blue Choice,CPT,87271,Cytomegalovirus dfa,All Other,Per Unit,$53.38 ,OP,13.42,53.38,,,,,,
BCBS Blue Choice,CPT,87272,Cryptosporidium ag if,All Other,Per Unit,$53.38 ,OP,11.98,53.38,,,,,,
BCBS Blue Choice,CPT,87275,Influenza b ag if,All Other,Per Unit,$53.38 ,OP,12.25,53.38,,,,,,
BCBS Blue Choice,CPT,87276,Influenza a ag if,All Other,Per Unit,$53.38 ,OP,16.07,53.38,,,,,,
BCBS Blue Choice,CPT,87277,Legionella micdadei ag if,All Other,Per Unit,$53.38 ,OP,53.38,53.38,,,,,,
BCBS Blue Choice,CPT,87278,Legion pneumophilia ag if,All Other,Per Unit,$53.38 ,OP,15.6,53.38,,,,,,
BCBS Blue Choice,CPT,87279,Parainfluenza ag if,All Other,Per Unit,$53.38 ,OP,16.43,53.38,,,,,,
BCBS Blue Choice,CPT,87280,Respiratory syncytial ag if,All Other,Per Unit,$53.38 ,OP,13.42,53.38,,,,,,
BCBS Blue Choice,CPT,87281,Pneumocystis carinii ag if,All Other,Per Unit,$53.38 ,OP,11.98,53.38,,,,,,
BCBS Blue Choice,CPT,87283,Rubeola ag if,All Other,Per Unit,$53.38 ,OP,53.38,60.8,,,,,,
BCBS Blue Choice,CPT,87285,Treponema pallidum ag if,All Other,Per Unit,$53.38 ,OP,12.18,53.38,,,,,,
BCBS Blue Choice,CPT,87290,Varicella zoster ag if,All Other,Per Unit,$53.38 ,OP,13.42,53.38,,,,,,
BCBS Blue Choice,CPT,87299,Antibody detection nos if,All Other,Per Unit,$53.38 ,OP,16.1,53.38,,,,,,
BCBS Blue Choice,CPT,87301,Adenovirus ag ia,All Other,Per Unit,$53.38 ,OP,11.98,53.38,,,,,,
BCBS Blue Choice,CPT,87305,Aspergillus ag ia,All Other,Per Unit,$53.38 ,OP,11.98,53.38,,,,,,
BCBS Blue Choice,CPT,87320,Chylmd trach ag ia,All Other,Per Unit,$53.38 ,OP,15,53.38,,,,,,
BCBS Blue Choice,CPT,87324,Clostridium ag ia,All Other,Per Unit,$53.38 ,OP,11.98,53.38,,,,,,
BCBS Blue Choice,CPT,87327,Cryptococcus neoform ag ia,All Other,Per Unit,$53.38 ,OP,13.42,53.38,,,,,,
BCBS Blue Choice,CPT,87328,Cryptosporidium ag ia,All Other,Per Unit,$53.38 ,OP,13.82,53.38,,,,,,
BCBS Blue Choice,CPT,87329,Giardia ag ia,All Other,Per Unit,$53.38 ,OP,11.98,53.38,,,,,,
BCBS Blue Choice,CPT,87332,Cytomegalovirus ag ia,All Other,Per Unit,$53.38 ,OP,11.98,53.38,,,,,,
BCBS Blue Choice,CPT,87335,E coli 0157 ag ia,All Other,Per Unit,$53.38 ,OP,12.66,53.38,,,,,,
BCBS Blue Choice,CPT,87336,Entamoeb hist dispr ag ia,All Other,Per Unit,$53.38 ,OP,16,53.38,,,,,,
BCBS Blue Choice,CPT,87337,Entamoeb hist group ag ia,All Other,Per Unit,$53.38 ,OP,11.98,53.38,,,,,,
BCBS Blue Choice,CPT,87338,Hpylori stool ag ia,All Other,Per Unit,$64.82 ,OP,14.38,64.82,,,,,,
BCBS Blue Choice,CPT,87339,H pylori ag ia,All Other,Per Unit,$53.38 ,OP,16,53.38,,,,,,
BCBS Blue Choice,CPT,87340,Hepatitis b surface ag ia,All Other,Per Unit,$45.74 ,OP,10.33,45.74,,,,,,
BCBS Blue Choice,CPT,87341,Hepatitis b surface ag ia,All Other,Per Unit,$45.74 ,OP,10.33,45.74,,,,,,
BCBS Blue Choice,CPT,87350,Hepatitis be ag ia,All Other,Per Unit,$49.56 ,OP,11.53,49.56,,,,,,
BCBS Blue Choice,CPT,87380,Hepatitis delta agent ag ia,All Other,Per Unit,$72.44 ,OP,18.36,72.44,,,,,,
BCBS Blue Choice,CPT,87385,Histoplasma capsul ag ia,All Other,Per Unit,$53.38 ,OP,13.25,53.38,,,,,,
BCBS Blue Choice,CPT,87391,Hiv-2 ag ia,All Other,Per Unit,$80.07 ,OP,21.9,80.07,,,,,,
BCBS Blue Choice,CPT,87400,Influenza a/b each ag ia,All Other,Per Unit,$61.00 ,OP,14.13,61,,,,,,
BCBS Blue Choice,CPT,87420,Resp syncytial virus ag ia,All Other,Per Unit,$53.38 ,OP,13.91,53.38,,,,,,
BCBS Blue Choice,CPT,87425,Rotavirus ag ia,All Other,Per Unit,$53.38 ,OP,11.98,53.38,,,,,,
BCBS Blue Choice,CPT,87427,Shiga-like toxin ag ia,All Other,Per Unit,$53.38 ,OP,11.98,53.38,,,,,,
BCBS Blue Choice,CPT,87430,Strep a ag ia,All Other,Per Unit,$61.00 ,OP,16.81,61,,,,,,
BCBS Blue Choice,CPT,87449,Nos each organism ag ia,All Other,Per Unit,$61.00 ,OP,11.98,61,,,,,,
BCBS Blue Choice,CPT,87450,Ag detect nos ia single,All Other,Per Unit,$41.94 ,OP,41.94,41.94,,,,,,
BCBS Blue Choice,CPT,87451,Polyvalent mult org ea ag ia,All Other,Per Unit,$41.94 ,OP,10.51,41.94,,,,,,
BCBS Blue Choice,CPT,87470,Bartonella dna dir probe,All Other,Per Unit,$87.69 ,OP,87.69,87.69,,,,,,
BCBS Blue Choice,CPT,87472,Bartonella dna quant,All Other,Per Unit,$190.64 ,OP,42.84,190.64,,,,,,
BCBS Blue Choice,CPT,87475,Lyme dis dna dir probe,All Other,Per Unit,$87.69 ,OP,20.05,87.69,,,,,,
BCBS Blue Choice,CPT,87476,Lyme dis dna amp probe,All Other,Per Unit,$156.32 ,OP,35.09,156.32,,,,,,
BCBS Blue Choice,CPT,87477,Lyme dis dna quant,All Other,Per Unit,$190.64 ,OP,190.64,190.64,,,,,,
BCBS Blue Choice,CPT,87480,Candida dna dir probe,All Other,Per Unit,$99.13 ,OP,20.05,99.13,,,,,,
BCBS Blue Choice,CPT,87481,Candida dna amp probe,All Other,Per Unit,$156.32 ,OP,35.09,156.32,,,,,,
BCBS Blue Choice,CPT,87482,Candida dna quant,All Other,Per Unit,$186.82 ,OP,55.74,186.82,,,,,,
BCBS Blue Choice,CPT,87485,Chylmd pneum dna dir probe,All Other,Per Unit,$87.69 ,OP,20.05,87.69,,,,,,
BCBS Blue Choice,CPT,87486,Chylmd pneum dna amp probe,All Other,Per Unit,$156.32 ,OP,35.09,156.32,,,,,,
BCBS Blue Choice,CPT,87487,Chylmd pneum dna quant,All Other,Per Unit,$190.64 ,OP,42.84,190.64,,,,,,
BCBS Blue Choice,CPT,87490,Chylmd trach dna dir probe,All Other,Per Unit,$99.13 ,OP,22.75,99.13,,,,,,
BCBS Blue Choice,CPT,87491,Chylmd trach dna amp probe,All Other,Per Unit,$156.32 ,OP,35.09,156.32,,,,,,
BCBS Blue Choice,CPT,87492,Chylmd trach dna quant,All Other,Per Unit,$156.32 ,OP,53.47,156.32,,,,,,
BCBS Blue Choice,CPT,87496,Cytomeg dna amp probe,All Other,Per Unit,$156.32 ,OP,35.09,156.32,,,,,,
BCBS Blue Choice,CPT,87497,Cytomeg dna quant,All Other,Per Unit,$190.64 ,OP,42.84,190.64,,,,,,
BCBS Blue Choice,CPT,87498,Enterovirus probe&revrs trns,All Other,Per Unit,$156.32 ,OP,35.09,156.32,,,,,,
BCBS Blue Choice,CPT,87500,Vanomycin dna amp probe,All Other,Per Unit,$156.32 ,OP,35.09,156.32,,,,,,
BCBS Blue Choice,CPT,87510,Gardner vag dna dir probe,All Other,Per Unit,$99.13 ,OP,20.05,99.13,,,,,,
BCBS Blue Choice,CPT,87511,Gardner vag dna amp probe,All Other,Per Unit,$156.32 ,OP,35.09,156.32,,,,,,
BCBS Blue Choice,CPT,87512,Gardner vag dna quant,All Other,Per Unit,$186.82 ,OP,41.76,186.82,,,,,,
BCBS Blue Choice,CPT,87515,Hepatitis b dna dir probe,All Other,Per Unit,$87.69 ,OP,87.69,87.69,,,,,,
BCBS Blue Choice,CPT,87516,Hepatitis b dna amp probe,All Other,Per Unit,$156.32 ,OP,35.09,156.32,,,,,,
BCBS Blue Choice,CPT,87517,Hepatitis b dna quant,All Other,Per Unit,$190.64 ,OP,42.84,190.64,,,,,,
BCBS Blue Choice,CPT,87520,Hepatitis c rna dir probe,All Other,Per Unit,$87.69 ,OP,31.22,87.69,,,,,,
BCBS Blue Choice,CPT,87521,Hepatitis c probe&rvrs trnsc,All Other,Per Unit,$156.32 ,OP,35.09,156.32,,,,,,
BCBS Blue Choice,CPT,87522,Hepatitis c revrs trnscrpj,All Other,Per Unit,$190.64 ,OP,42.84,190.64,,,,,,
BCBS Blue Choice,CPT,87525,Hepatitis g dna dir probe,All Other,Per Unit,$87.69 ,OP,29.8,87.69,,,,,,
BCBS Blue Choice,CPT,87526,Hepatitis g dna amp probe,All Other,Per Unit,$156.32 ,OP,39.26,156.32,,,,,,
BCBS Blue Choice,CPT,87527,Hepatitis g dna quant,All Other,Per Unit,$186.82 ,OP,41.76,186.82,,,,,,
BCBS Blue Choice,CPT,87528,Hsv dna dir probe,All Other,Per Unit,$87.69 ,OP,20.05,87.69,,,,,,
BCBS Blue Choice,CPT,87529,Hsv dna amp probe,All Other,Per Unit,$156.32 ,OP,35.09,156.32,,,,,,
BCBS Blue Choice,CPT,87530,Hsv dna quant,All Other,Per Unit,$190.64 ,OP,42.84,190.64,,,,,,
BCBS Blue Choice,CPT,87531,Hhv-6 dna dir probe,All Other,Per Unit,$87.69 ,OP,58,87.69,,,,,,
BCBS Blue Choice,CPT,87533,Hhv-6 dna quant,All Other,Per Unit,$186.82 ,OP,41.76,186.82,,,,,,
BCBS Blue Choice,CPT,87534,Hiv-1 dna dir probe,All Other,Per Unit,$87.69 ,OP,21.92,87.69,,,,,,
BCBS Blue Choice,CPT,87535,Hiv-1 probe&reverse trnscrpj,All Other,Per Unit,$156.32 ,OP,35.09,156.32,,,,,,
BCBS Blue Choice,CPT,87536,Hiv-1 quant&revrse trnscrpj,All Other,Per Unit,$377.46 ,OP,85.1,377.46,,,,,,
BCBS Blue Choice,CPT,87537,Hiv-2 dna dir probe,All Other,Per Unit,$87.69 ,OP,21.92,87.69,,,,,,
BCBS Blue Choice,CPT,87538,Hiv-2 probe&revrse trnscripj,All Other,Per Unit,$156.32 ,OP,35.09,156.32,,,,,,
BCBS Blue Choice,CPT,87539,Hiv-2 quant&revrse trnscripj,All Other,Per Unit,$190.64 ,OP,58.62,190.64,,,,,,
BCBS Blue Choice,CPT,87540,Legion pneumo dna dir prob,All Other,Per Unit,$87.69 ,OP,20.05,87.69,,,,,,
BCBS Blue Choice,CPT,87541,Legion pneumo dna amp prob,All Other,Per Unit,$156.32 ,OP,35.09,156.32,,,,,,
BCBS Blue Choice,CPT,87542,Legion pneumo dna quant,All Other,Per Unit,$186.82 ,OP,41.76,186.82,,,,,,
BCBS Blue Choice,CPT,87550,Mycobacteria dna dir probe,All Other,Per Unit,$87.69 ,OP,20.05,87.69,,,,,,
BCBS Blue Choice,CPT,87551,Mycobacteria dna amp probe,All Other,Per Unit,$156.32 ,OP,48.24,156.32,,,,,,
BCBS Blue Choice,CPT,87552,Mycobacteria dna quant,All Other,Per Unit,$190.64 ,OP,42.84,190.64,,,,,,
BCBS Blue Choice,CPT,87555,M.tuberculo dna dir probe,All Other,Per Unit,$87.69 ,OP,26.88,87.69,,,,,,
BCBS Blue Choice,CPT,87556,M.tuberculo dna amp probe,All Other,Per Unit,$156.32 ,OP,41.68,156.32,,,,,,
BCBS Blue Choice,CPT,87557,M.tuberculo dna quant,All Other,Per Unit,$190.64 ,OP,42.84,190.64,,,,,,
BCBS Blue Choice,CPT,87560,M.avium-intra dna dir prob,All Other,Per Unit,$87.69 ,OP,27.29,87.69,,,,,,
BCBS Blue Choice,CPT,87561,M.avium-intra dna amp prob,All Other,Per Unit,$156.32 ,OP,35.09,156.32,,,,,,
BCBS Blue Choice,CPT,87562,M.avium-intra dna quant,All Other,Per Unit,$190.64 ,OP,42.84,190.64,,,,,,
BCBS Blue Choice,CPT,87563,M. genitalium amp probe,All Other,Per Unit,$156.32 ,OP,35.09,156.32,,,,,,
BCBS Blue Choice,CPT,87580,M.pneumon dna dir probe,All Other,Per Unit,$87.69 ,OP,20.05,87.69,,,,,,
BCBS Blue Choice,CPT,87581,M.pneumon dna amp probe,All Other,Per Unit,$156.32 ,OP,35.09,156.32,,,,,,
BCBS Blue Choice,CPT,87582,M.pneumon dna quant,All Other,Per Unit,$186.82 ,OP,186.82,302.62,,,,,,
BCBS Blue Choice,CPT,87590,N.gonorrhoeae dna dir prob,All Other,Per Unit,$99.13 ,OP,26.88,99.13,,,,,,
BCBS Blue Choice,CPT,87591,N.gonorrhoeae dna amp prob,All Other,Per Unit,$156.32 ,OP,35.09,156.32,,,,,,
BCBS Blue Choice,CPT,87620,Hpv dna dir probe,All Other,Per Unit,$87.69 ,OP,87.69,87.69,,,,,,
BCBS Blue Choice,CPT,87621,Hpv dna amp probe,All Other,Per Unit,$156.32 ,OP,156.32,156.32,,,,,,
BCBS Blue Choice,CPT,87622,Hpv dna quant,All Other,Per Unit,$186.82 ,OP,186.82,186.82,,,,,,
BCBS Blue Choice,CPT,87623,Hpv low-risk types,All Other,Per Unit,$93.87 ,OP,35.09,93.87,,,,,,
BCBS Blue Choice,CPT,87624,Hpv high-risk types,All Other,Per Unit,$93.87 ,OP,35.09,93.87,,,,,,
BCBS Blue Choice,CPT,87625,Hpv types 16 & 18 only,All Other,Per Unit,$93.87 ,OP,40.55,93.87,,,,,,
BCBS Blue Choice,CPT,87640,Staph a dna amp probe,All Other,Per Unit,$156.32 ,OP,35.09,156.32,,,,,,
BCBS Blue Choice,CPT,87641,Mr-staph dna amp probe,All Other,Per Unit,$156.32 ,OP,35.09,156.32,,,,,,
BCBS Blue Choice,CPT,87650,Strep a dna dir probe,All Other,Per Unit,$87.69 ,OP,20.05,87.69,,,,,,
BCBS Blue Choice,CPT,87651,Strep a dna amp probe,All Other,Per Unit,$156.32 ,OP,35.09,156.32,,,,,,
BCBS Blue Choice,CPT,87652,Strep a dna quant,All Other,Per Unit,$186.82 ,OP,41.76,186.82,,,,,,
BCBS Blue Choice,CPT,87660,Trichomonas vagin dir probe,All Other,Per Unit,$87.69 ,OP,20.05,87.69,,,,,,
BCBS Blue Choice,CPT,87661,Trichomonas vaginalis amplif,All Other,Per Unit,$87.69 ,OP,35.09,87.69,,,,,,
BCBS Blue Choice,CPT,87797,Detect agent nos dna dir,All Other,Per Unit,$99.13 ,OP,30.03,99.13,,,,,,
BCBS Blue Choice,CPT,87798,Detect agent nos dna amp,All Other,Per Unit,$156.32 ,OP,35.09,156.32,,,,,,
BCBS Blue Choice,CPT,87799,Detect agent nos dna quant,All Other,Per Unit,$190.64 ,OP,42.84,190.64,,,,,,
BCBS Blue Choice,CPT,87800,Detect agnt mult dna direc,All Other,Per Unit,$179.20 ,OP,43.67,179.2,,,,,,
BCBS Blue Choice,CPT,87801,Detect agnt mult dna ampli,All Other,Per Unit,$312.64 ,OP,70.2,312.64,,,,,,
BCBS Blue Choice,CPT,87802,Strep b assay w/optic,All Other,Per Unit,$61.00 ,OP,12.73,61,,,,,,
BCBS Blue Choice,CPT,87803,Clostridium toxin a w/optic,All Other,Per Unit,$61.00 ,OP,16,61,,,,,,
BCBS Blue Choice,CPT,87804,Influenza assay w/optic,All Other,Per Unit,$61.00 ,OP,16.55,61,,,,,,
BCBS Blue Choice,CPT,87806,Hiv w/hiv1&2 antb w/optic,All Other,Per Unit,$61.00 ,OP,32.77,61,,,,,,
BCBS Blue Choice,CPT,87807,Rsv assay w/optic,All Other,Per Unit,$53.38 ,OP,13.1,53.38,,,,,,
BCBS Blue Choice,CPT,87808,Trichomonas assay w/optic,All Other,Per Unit,$61.00 ,OP,15.29,61,,,,,,
BCBS Blue Choice,CPT,87809,Adenovirus assay w/optic,All Other,Per Unit,$53.38 ,OP,21.76,53.38,,,,,,
BCBS Blue Choice,CPT,87810,Chylmd trach assay w/optic,All Other,Per Unit,$53.38 ,OP,35.29,53.38,,,,,,
BCBS Blue Choice,CPT,87850,N. gonorrhoeae assay w/optic,All Other,Per Unit,$53.38 ,OP,24.56,53.38,,,,,,
BCBS Blue Choice,CPT,87880,Strep a assay w/optic,All Other,Per Unit,$61.00 ,OP,16.53,61,,,,,,
BCBS Blue Choice,CPT,87899,Agent nos assay w/optic,All Other,Per Unit,$61.00 ,OP,16.07,61,,,,,,
BCBS Blue Choice,CPT,87900,Phenotype infect agent drug,All Other,Per Unit,$518.52 ,OP,130.35,518.52,,,,,,
BCBS Blue Choice,CPT,87901,Genotype dna hiv reverse t,All Other,Per Unit,"$1,147.62 ",OP,257.45,"1,147.62",,,,,,
BCBS Blue Choice,CPT,87902,Genotype dna/rna hep c,All Other,Per Unit,"$1,147.62 ",OP,257.45,"1,147.62",,,,,,
BCBS Blue Choice,CPT,87905,Sialidase enzyme assay,All Other,Per Unit,$53.38 ,OP,12.22,53.38,,,,,,
BCBS Blue Choice,CPT,88104,Cytopath fl nongyn smears,All Other,Per Unit,$175.39 ,OP,34.63,175.39,,,,,,
BCBS Blue Choice,CPT,88106,Cytopath fl nongyn filter,All Other,Per Unit,$247.83 ,OP,25.25,247.83,,,,,,
BCBS Blue Choice,CPT,88107,Cytopath fl nongyn sm/fltr,All Other,Per Unit,$293.57 ,OP,293.57,293.57,,,,,,
BCBS Blue Choice,CPT,88108,Cytopath concentrate tech,All Other,Per Unit,$228.77 ,OP,34.63,228.77,,,,,,
BCBS Blue Choice,CPT,88112,Cytopath cell enhance tech,All Other,Per Unit,$232.58 ,OP,50.92,232.58,,,,,,
BCBS Blue Choice,CPT,88125,Forensic cytopathology,All Other,Per Unit,$45.74 ,OP,45.74,50.92,,,,,,
BCBS Blue Choice,CPT,88130,Sex chromatin identification,All Other,Per Unit,$68.63 ,OP,17.98,68.63,,,,,,
BCBS Blue Choice,CPT,88140,Sex chromatin identification,All Other,Per Unit,$34.31 ,OP,7.99,34.31,,,,,,
BCBS Blue Choice,CPT,88141,Cytopath c/v interpret,All Other,Per Unit,$137.25 ,OP,137.25,137.25,,,,,,
BCBS Blue Choice,CPT,88142,Cytopath c/v thin layer,All Other,Per Unit,$91.51 ,OP,20.26,91.51,,,,,,
BCBS Blue Choice,CPT,88143,Cytopath c/v thin layer redo,All Other,Per Unit,$91.51 ,OP,23.04,91.51,,,,,,
BCBS Blue Choice,CPT,88147,Cytopath c/v automated,All Other,Per Unit,$45.74 ,OP,45.74,50.56,,,,,,
BCBS Blue Choice,CPT,88148,Cytopath c/v auto rescreen,All Other,Per Unit,$45.74 ,OP,16,45.74,,,,,,
BCBS Blue Choice,CPT,88150,Cytopath c/v manual,All Other,Per Unit,$45.74 ,OP,15.15,45.74,,,,,,
BCBS Blue Choice,CPT,88152,Cytopath c/v auto redo,All Other,Per Unit,$45.74 ,OP,27.64,45.74,,,,,,
BCBS Blue Choice,CPT,88153,Cytopath c/v redo,All Other,Per Unit,$45.74 ,OP,24.03,45.74,,,,,,
BCBS Blue Choice,CPT,88154,Cytopath c/v select,All Other,Per Unit,$45.74 ,OP,45.74,45.74,,,,,,
BCBS Blue Choice,CPT,88155,Cytopath c/v index add-on,All Other,Per Unit,$26.70 ,OP,14.65,26.7,,,,,,
BCBS Blue Choice,CPT,88160,Cytopath smear other source,All Other,Per Unit,$141.07 ,OP,25.25,141.07,,,,,,
BCBS Blue Choice,CPT,88161,Cytopath smear other source,All Other,Per Unit,$152.51 ,OP,25.25,152.51,,,,,,
BCBS Blue Choice,CPT,88162,Cytopath smear other source,All Other,Per Unit,$205.88 ,OP,50.92,205.88,,,,,,
BCBS Blue Choice,CPT,88164,Cytopath tbs c/v manual,All Other,Per Unit,$45.74 ,OP,15.15,45.74,,,,,,
BCBS Blue Choice,CPT,88165,Cytopath tbs c/v redo,All Other,Per Unit,$45.74 ,OP,42.22,45.74,,,,,,
BCBS Blue Choice,CPT,88166,Cytopath tbs c/v auto redo,All Other,Per Unit,$45.74 ,OP,15.15,45.74,,,,,,
BCBS Blue Choice,CPT,88167,Cytopath tbs c/v select,All Other,Per Unit,$45.74 ,OP,15.15,45.74,,,,,,
BCBS Blue Choice,CPT,88172,Cytp dx eval fna 1st ea site,All Other,Per Unit,$118.19 ,OP,118.19,152.64,,,,,,
BCBS Blue Choice,CPT,88173,Cytopath eval fna report,All Other,Per Unit,$327.90 ,OP,50.92,327.9,,,,,,
BCBS Blue Choice,CPT,88174,Cytopath c/v auto in fluid,All Other,Per Unit,$95.32 ,OP,25.37,95.32,,,,,,
BCBS Blue Choice,CPT,88175,Cytopath c/v auto fluid redo,All Other,Per Unit,$118.19 ,OP,26.61,118.19,,,,,,
BCBS Blue Choice,CPT,88182,Cell marker study,All Other,Per Unit,$339.33 ,OP,50.92,339.33,,,,,,
BCBS Blue Choice,CPT,88184,Flowcytometry/ tc 1 marker,All Other,Per Unit,$404.14 ,OP,298.05,404.14,,,,,,
BCBS Blue Choice,CPT,88185,Flowcytometry/tc add-on,All Other,Per Unit,$240.20 ,OP,240.2,240.2,,,,,,
BCBS Blue Choice,CPT,88187,Flowcytometry/read 2-8,All Other,Per Unit,$316.46 ,OP,316.46,316.46,,,,,,
BCBS Blue Choice,CPT,88188,Flowcytometry/read 9-15,All Other,Per Unit,$388.89 ,OP,388.89,388.89,,,,,,
BCBS Blue Choice,CPT,88189,Flowcytometry/read 16 & >,All Other,Per Unit,$495.65 ,OP,495.65,495.65,,,,,,
BCBS Blue Choice,CPT,88230,Tissue culture lymphocyte,All Other,Per Unit,$518.52 ,OP,116.49,518.52,,,,,,
BCBS Blue Choice,CPT,88233,Tissue culture skin/biopsy,All Other,Per Unit,$625.29 ,OP,140.73,625.29,,,,,,
BCBS Blue Choice,CPT,88235,Tissue culture placenta,All Other,Per Unit,$655.78 ,OP,150.3,655.78,,,,,,
BCBS Blue Choice,CPT,88237,Tissue culture bone marrow,All Other,Per Unit,$564.29 ,OP,143.75,564.29,,,,,,
BCBS Blue Choice,CPT,88239,Tissue culture tumor,All Other,Per Unit,$655.78 ,OP,147.52,655.78,,,,,,
BCBS Blue Choice,CPT,88240,Cell cryopreserve/storage,All Other,Per Unit,$45.74 ,OP,13.07,45.74,,,,,,
BCBS Blue Choice,CPT,88241,Frozen cell preparation,All Other,Per Unit,$45.74 ,OP,12.09,45.74,,,,,,
BCBS Blue Choice,CPT,88245,Chromosome analysis 20-25,All Other,Per Unit,$648.16 ,OP,173.17,648.16,,,,,,
BCBS Blue Choice,CPT,88248,Chromosome analysis 50-100,All Other,Per Unit,$770.16 ,OP,173.17,770.16,,,,,,
BCBS Blue Choice,CPT,88249,Chromosome analysis 100,All Other,Per Unit,$770.16 ,OP,173.17,770.16,,,,,,
BCBS Blue Choice,CPT,88261,Chromosome analysis 5,All Other,Per Unit,$785.42 ,OP,264.34,785.42,,,,,,
BCBS Blue Choice,CPT,88262,Chromosome analysis 15-20,All Other,Per Unit,$556.65 ,OP,125.49,556.65,,,,,,
BCBS Blue Choice,CPT,88263,Chromosome analysis 45,All Other,Per Unit,$671.03 ,OP,150.29,671.03,,,,,,
BCBS Blue Choice,CPT,88264,Chromosome analysis 20-25,All Other,Per Unit,$556.65 ,OP,144.61,556.65,,,,,,
BCBS Blue Choice,CPT,88267,Chromosome analys placenta,All Other,Per Unit,$800.67 ,OP,188.57,800.67,,,,,,
BCBS Blue Choice,CPT,88269,Chromosome analys amniotic,All Other,Per Unit,$739.67 ,OP,173.66,739.67,,,,,,
BCBS Blue Choice,CPT,88271,Cytogenetics dna probe,All Other,Per Unit,$64.82 ,OP,21.42,64.82,,,,,,
BCBS Blue Choice,CPT,88272,Cytogenetics 3-5,All Other,Per Unit,$114.39 ,OP,40.7,114.39,,,,,,
BCBS Blue Choice,CPT,88273,Cytogenetics 10-30,All Other,Per Unit,$144.88 ,OP,34.81,144.88,,,,,,
BCBS Blue Choice,CPT,88274,Cytogenetics 25-99,All Other,Per Unit,$156.32 ,OP,42.38,156.32,,,,,,
BCBS Blue Choice,CPT,88275,Cytogenetics 100-300,All Other,Per Unit,$179.20 ,OP,51.19,179.2,,,,,,
BCBS Blue Choice,CPT,88280,Chromosome karyotype study,All Other,Per Unit,$110.57 ,OP,33.47,110.57,,,,,,
BCBS Blue Choice,CPT,88285,Chromosome count additional,All Other,Per Unit,$83.87 ,OP,26.91,83.87,,,,,,
BCBS Blue Choice,CPT,88289,Chromosome study additional,All Other,Per Unit,$129.64 ,OP,34.43,129.64,,,,,,
BCBS Blue Choice,CPT,88291,Cyto/molecular report,All Other,Per Unit,$144.88 ,OP,144.88,144.88,,,,,,
BCBS Blue Choice,CPT,88300,Surgical path gross,All Other,Per Unit,$99.13 ,OP,25.25,99.13,,,,,,
BCBS Blue Choice,CPT,88302,Tissue exam by pathologist,All Other,Per Unit,$217.32 ,OP,25.25,217.32,,,,,,
BCBS Blue Choice,CPT,88304,Tissue exam by pathologist,All Other,Per Unit,$263.08 ,OP,50.92,263.08,,,,,,
BCBS Blue Choice,CPT,88305,Tissue exam by pathologist,All Other,Per Unit,$362.21 ,OP,50.92,362.21,,,,,,
BCBS Blue Choice,CPT,88307,Tissue exam by pathologist,All Other,Per Unit,$671.03 ,OP,298.05,671.03,,,,,,
BCBS Blue Choice,CPT,88309,Tissue exam by pathologist,All Other,Per Unit,$911.23 ,OP,671.45,911.23,,,,,,
BCBS Blue Choice,CPT,88311,Decalcify tissue,All Other,Per Unit,$30.51 ,OP,30.51,30.51,,,,,,
BCBS Blue Choice,CPT,88312,Special stains group 1,All Other,Per Unit,$366.02 ,OP,50.92,366.02,,,,,,
BCBS Blue Choice,CPT,88313,Special stains group 2,All Other,Per Unit,$308.83 ,OP,34.63,308.83,,,,,,
BCBS Blue Choice,CPT,88314,Histochemical stains add-on,All Other,Per Unit,$335.53 ,OP,335.53,335.53,,,,,,
BCBS Blue Choice,CPT,88319,Enzyme histochemistry,All Other,Per Unit,$568.09 ,OP,568.09,671.45,,,,,,
BCBS Blue Choice,CPT,88321,Microslide consultation,All Other,Per Unit,$438.47 ,OP,34.63,438.47,,,,,,
BCBS Blue Choice,CPT,88323,Microslide consultation,All Other,Per Unit,$289.76 ,OP,50.92,289.76,,,,,,
BCBS Blue Choice,CPT,88325,Comprehensive review of data,All Other,Per Unit,$949.36 ,OP,152.64,949.36,,,,,,
BCBS Blue Choice,CPT,88329,Path consult introp,All Other,Per Unit,$247.83 ,OP,34.63,247.83,,,,,,
BCBS Blue Choice,CPT,88331,Path consult intraop 1 bloc,All Other,Per Unit,$152.51 ,OP,152.51,152.64,,,,,,
BCBS Blue Choice,CPT,88332,Path consult intraop addl,All Other,Per Unit,$53.38 ,OP,53.38,53.38,,,,,,
BCBS Blue Choice,CPT,88333,Intraop cyto path consult 1,All Other,Per Unit,$163.95 ,OP,163.95,671.45,,,,,,
BCBS Blue Choice,CPT,88334,Intraop cyto path consult 2,All Other,Per Unit,$99.13 ,OP,99.13,99.13,,,,,,
BCBS Blue Choice,CPT,88341,Immunohisto antb addl slide,All Other,Per Unit,$297.39 ,OP,297.39,297.39,,,,,,
BCBS Blue Choice,CPT,88342,Immunohisto antb 1st stain,All Other,Per Unit,$297.39 ,OP,152.64,297.39,,,,,,
BCBS Blue Choice,CPT,88344,Immunohisto antibody slide,All Other,Per Unit,$297.39 ,OP,297.39,298.05,,,,,,
BCBS Blue Choice,CPT,88346,Immunofluor antb 1st stain,All Other,Per Unit,$293.57 ,OP,293.57,298.05,,,,,,
BCBS Blue Choice,CPT,88347,Immunofluorescent study,All Other,Per Unit,$194.45 ,OP,194.45,194.45,,,,,,
BCBS Blue Choice,CPT,88348,Electron microscopy,All Other,Per Unit,"$2,794.70 ",OP,671.45,"2,794.70",,,,,,
BCBS Blue Choice,CPT,88349,Scanning electron microscopy,All Other,Per Unit,"$1,319.19 ",OP,"1,319.19","1,319.19",,,,,,
BCBS Blue Choice,CPT,88350,Immunofluor antb addl stain,All Other,Per Unit,$293.57 ,OP,293.57,293.57,,,,,,
BCBS Blue Choice,CPT,88355,Analysis skeletal muscle,All Other,Per Unit,$777.79 ,OP,152.64,777.79,,,,,,
BCBS Blue Choice,CPT,88356,Analysis nerve,All Other,Per Unit,$766.35 ,OP,50.92,766.35,,,,,,
BCBS Blue Choice,CPT,88358,Analysis tumor,All Other,Per Unit,$171.58 ,OP,152.64,171.58,,,,,,
BCBS Blue Choice,CPT,88360,Tumor immunohistochem/manual,All Other,Per Unit,$335.53 ,OP,152.64,335.53,,,,,,
BCBS Blue Choice,CPT,88361,Tumor immunohistochem/comput,All Other,Per Unit,$484.22 ,OP,298.05,484.22,,,,,,
BCBS Blue Choice,CPT,88362,Nerve teasing preparations,All Other,Per Unit,$793.05 ,OP,671.45,793.05,,,,,,
BCBS Blue Choice,CPT,88364,Insitu hybridization (fish),All Other,Per Unit,$499.47 ,OP,499.47,499.47,,,,,,
BCBS Blue Choice,CPT,88365,Insitu hybridization (fish),All Other,Per Unit,$499.47 ,OP,152.64,499.47,,,,,,
BCBS Blue Choice,CPT,88366,Insitu hybridization (fish),All Other,Per Unit,$499.47 ,OP,298.05,499.47,,,,,,
BCBS Blue Choice,CPT,88367,Insitu hybridization auto,All Other,Per Unit,$907.42 ,OP,298.05,907.42,,,,,,
BCBS Blue Choice,CPT,88368,Insitu hybridization manual,All Other,Per Unit,$747.28 ,OP,298.05,747.28,,,,,,
BCBS Blue Choice,CPT,88369,M/phmtrc alysishquant/semiq,All Other,Per Unit,$747.28 ,OP,747.28,747.28,,,,,,
BCBS Blue Choice,CPT,88371,Protein western blot tissue,All Other,Per Unit,$156.32 ,OP,156.32,156.32,,,,,,
BCBS Blue Choice,CPT,88372,Protein analysis w/probe,All Other,Per Unit,$160.13 ,OP,160.13,160.13,,,,,,
BCBS Blue Choice,CPT,88373,M/phmtrc alys ishquant/semiq,All Other,Per Unit,$907.42 ,OP,907.42,907.42,,,,,,
BCBS Blue Choice,CPT,88374,M/phmtrc alys ishquant/semiq,All Other,Per Unit,$907.42 ,OP,152.64,907.42,,,,,,
BCBS Blue Choice,CPT,88377,M/phmtrc alys ishquant/semiq,All Other,Per Unit,$747.28 ,OP,152.64,747.28,,,,,,
BCBS Blue Choice,CPT,88380,Microdissection laser,All Other,Per Unit,$613.85 ,OP,613.85,613.85,,,,,,
BCBS Blue Choice,CPT,88381,Microdissection manual,All Other,Per Unit,$789.23 ,OP,789.23,789.23,,,,,,
BCBS Blue Choice,CPT,88384,Eval molecular probes 11-50,All Other,Per Unit,"$1,875.84 ",OP,"1,875.84","1,875.84",,,,,,
BCBS Blue Choice,CPT,88385,Eval molecul probes 51-250,All Other,Per Unit,"$2,306.68 ",OP,"2,306.68","2,306.68",,,,,,
BCBS Blue Choice,CPT,88386,Eval molecul probes 251-500,All Other,Per Unit,"$2,912.91 ",OP,"2,912.91","2,912.91",,,,,,
BCBS Blue Choice,CPT,88720,Bilirubin total transcut,All Other,Per Unit,$22.88 ,OP,5.02,22.88,,,,,,
BCBS Blue Choice,CPT,88740,Transcutaneous carboxyhb,All Other,Per Unit,$22.88 ,OP,9.37,22.88,,,,,,
BCBS Blue Choice,CPT,88741,Transcutaneous methb,All Other,Per Unit,$22.88 ,OP,9.37,22.88,,,,,,
BCBS Blue Choice,CPT,89049,Chct for mal hyperthermia,All Other,Per Unit,"$1,201.00 ",OP,152.64,"1,201.00",,,,,,
BCBS Blue Choice,CPT,89050,Body fluid cell count,All Other,Per Unit,$22.88 ,OP,4.72,22.88,,,,,,
BCBS Blue Choice,CPT,89051,Body fluid cell count,All Other,Per Unit,$26.70 ,OP,5.6,26.7,,,,,,
BCBS Blue Choice,CPT,89055,Leukocyte assessment fecal,All Other,Per Unit,$22.88 ,OP,4.27,22.88,,,,,,
BCBS Blue Choice,CPT,89060,Exam synovial fluid crystals,All Other,Per Unit,$30.51 ,OP,7.33,30.51,,,,,,
BCBS Blue Choice,CPT,89100,Sample intestinal contents,All Other,Per Unit,"$1,220.06 ",OP,"1,220.06","1,220.06",,,,,,
BCBS Blue Choice,CPT,89105,Sample intestinal contents,All Other,Per Unit,"$1,254.37 ",OP,"1,254.37","1,254.37",,,,,,
BCBS Blue Choice,CPT,89125,Specimen fat stain,All Other,Per Unit,$11.44 ,OP,5.88,11.44,,,,,,
BCBS Blue Choice,CPT,89130,Sample stomach contents,All Other,Per Unit,"$1,063.73 ",OP,"1,063.73","1,063.73",,,,,,
BCBS Blue Choice,CPT,89132,Sample stomach contents,All Other,Per Unit,"$1,212.43 ",OP,"1,212.43","1,212.43",,,,,,
BCBS Blue Choice,CPT,89135,Sample stomach contents,All Other,Per Unit,"$1,445.01 ",OP,"1,445.01","1,445.01",,,,,,
BCBS Blue Choice,CPT,89136,Sample stomach contents,All Other,Per Unit,"$1,025.61 ",OP,"1,025.61","1,025.61",,,,,,
BCBS Blue Choice,CPT,89140,Sample stomach contents,All Other,Per Unit,"$1,201.00 ",OP,"1,201.00","1,201.00",,,,,,
BCBS Blue Choice,CPT,89141,Sample stomach contents,All Other,Per Unit,"$1,239.13 ",OP,"1,239.13","1,239.13",,,,,,
BCBS Blue Choice,CPT,89160,Exam feces for meat fibers,All Other,Per Unit,$15.26 ,OP,4.85,15.26,,,,,,
BCBS Blue Choice,CPT,89190,Nasal smear for eosinophils,All Other,Per Unit,$22.88 ,OP,5.79,22.88,,,,,,
BCBS Blue Choice,CPT,89220,Sputum specimen collection,All Other,Per Unit,$80.07 ,OP,80.07,152.64,,,,,,
BCBS Blue Choice,CPT,89225,Starch granules - feces,All Other,Per Unit,$15.26 ,OP,15.26,15.26,,,,,,
BCBS Blue Choice,CPT,89235,Water load test,All Other,Per Unit,$22.88 ,OP,22.88,22.88,,,,,,
BCBS Blue Choice,CPT,89300,Semen analysis w/huhner,All Other,Per Unit,$45.74 ,OP,9.84,45.74,,,,,,
BCBS Blue Choice,CPT,89310,Semen analysis w/count,All Other,Per Unit,$30.51 ,OP,8.61,30.51,,,,,,
BCBS Blue Choice,CPT,89320,Semen anal vol/count/mot,All Other,Per Unit,$49.56 ,OP,12.31,49.56,,,,,,
BCBS Blue Choice,CPT,89321,Semen anal sperm detection,All Other,Per Unit,$49.56 ,OP,12.05,49.56,,,,,,
BCBS Blue Choice,CPT,89322,Semen anal strict criteria,All Other,Per Unit,$61.00 ,OP,15.5,61,,,,,,
BCBS Blue Choice,CPT,89329,Sperm evaluation test,All Other,Per Unit,$91.51 ,OP,19.59,91.51,,,,,,
BCBS Blue Choice,CPT,89330,Evaluation cervical mucus,All Other,Per Unit,$45.74 ,OP,10.38,45.74,,,,,,
BCBS Blue Choice,CPT,89331,Retrograde ejaculation anal,All Other,Per Unit,$83.87 ,OP,19.59,83.87,,,,,,
BCBS Blue Choice,CPT,90281,Human ig im,All Other,Per Unit,$80.07 ,OP,80.07,80.07,,,,,,
BCBS Blue Choice,CPT,90283,Human ig iv,All Other,Per Unit,$72.44 ,OP,72.44,72.44,,,,,,
BCBS Blue Choice,CPT,90284,Human ig sc,All Other,Per Unit,$34.31 ,OP,34.31,34.31,,,,,,
BCBS Blue Choice,CPT,90287,Botulinum antitoxin,All Other,Per Unit,"$3,252.22 ",OP,"3,252.22","3,252.22",,,,,,
BCBS Blue Choice,CPT,90291,Cmv ig iv,All Other,Per Unit,$129.64 ,OP,129.64,129.64,,,,,,
BCBS Blue Choice,CPT,90296,Diphtheria antitoxin,All Other,Per Unit,"$1,692.84 ",OP,"1,692.84","1,692.84",,,,,,
BCBS Blue Choice,CPT,90371,Hep b ig im,All Other,Per Unit,$735.85 ,OP,130.31,735.85,,,,,,
BCBS Blue Choice,CPT,90375,Rabies ig im/sc,All Other,Per Unit,$617.65 ,OP,267.3,617.65,,,,,,
BCBS Blue Choice,CPT,90376,Rabies ig heat treated,All Other,Per Unit,$617.65 ,OP,287.38,617.65,,,,,,
BCBS Blue Choice,CPT,90378,Rsv mab im 50mg,All Other,Per Unit,"$3,154.20 ",OP,"1,185.67","3,154.20",,,,,,
BCBS Blue Choice,CPT,90379,Rsv ig - iv,All Other,Per Unit,$95.32 ,OP,95.32,95.32,,,,,,
BCBS Blue Choice,CPT,90384,Rh ig full-dose im,All Other,Per Unit,$13.79 ,OP,13.79,13.79,,,,,,
BCBS Blue Choice,CPT,90385,Rh ig minidose im,All Other,Per Unit,$202.07 ,OP,151.41,202.07,,,,,,
BCBS Blue Choice,CPT,90386,Rh ig iv,All Other,Per Unit,$758.72 ,OP,758.72,758.72,,,,,,
BCBS Blue Choice,CPT,90396,Varicella-zoster ig im,All Other,Per Unit,$495.65 ,OP,495.65,"1,965.97",,,,,,
BCBS Blue Choice,CPT,90465,Immune admin 1 inj - < 8 yrs,All Other,Per Unit,$99.13 ,OP,99.13,99.13,,,,,,
BCBS Blue Choice,CPT,90466,Immune admin addl inj - < 8 y,All Other,Per Unit,$49.56 ,OP,49.56,49.56,,,,,,
BCBS Blue Choice,CPT,90467,Immune admin o or n - < 8 yrs,All Other,Per Unit,$64.82 ,OP,64.82,64.82,,,,,,
BCBS Blue Choice,CPT,90468,Immune admin o/n - addl < 8 y,All Other,Per Unit,$49.56 ,OP,49.56,49.56,,,,,,
BCBS Blue Choice,CPT,90471,Immunization admin,All Other,Per Unit,$57.19 ,OP,57.19,63.42,,,,,,
BCBS Blue Choice,CPT,90472,Immunization admin each add,All Other,Per Unit,$30.51 ,OP,30.51,30.51,,,,,,
BCBS Blue Choice,CPT,90473,Immune admin oral/nasal,All Other,Per Unit,$57.19 ,OP,57.19,63.42,,,,,,
BCBS Blue Choice,CPT,90586,Bcg vaccine intravesical,All Other,Per Unit,$976.05 ,OP,976.05,976.05,,,,,,
BCBS Blue Choice,CPT,90619,Menacwy-tt vaccine im,All Other,Per Unit,$610.03 ,OP,610.03,610.03,,,,,,
BCBS Blue Choice,CPT,90632,Hepa vaccine adult im,All Other,Per Unit,$388.89 ,OP,388.89,388.89,,,,,,
BCBS Blue Choice,CPT,90633,Hepa vacc ped/adol 2 dose im,All Other,Per Unit,$194.45 ,OP,194.45,194.45,,,,,,
BCBS Blue Choice,CPT,90634,Hepa vacc ped/adol 3 dose,All Other,Per Unit,$175.39 ,OP,175.39,175.39,,,,,,
BCBS Blue Choice,CPT,90636,Hep a/hep b vacc adult im,All Other,Per Unit,$533.78 ,OP,533.78,533.78,,,,,,
BCBS Blue Choice,CPT,90645,Hib vaccine hboc im,All Other,Per Unit,$141.07 ,OP,141.07,141.07,,,,,,
BCBS Blue Choice,CPT,90646,Hib vaccine prp-d im,All Other,Per Unit,$141.07 ,OP,141.07,141.07,,,,,,
BCBS Blue Choice,CPT,90647,Hib prp-omp vacc 3 dose im,All Other,Per Unit,$141.07 ,OP,141.07,141.07,,,,,,
BCBS Blue Choice,CPT,90648,Hib prp-t vaccine 4 dose im,All Other,Per Unit,$141.07 ,OP,141.07,141.07,,,,,,
BCBS Blue Choice,CPT,90649,4vhpv vaccine 3 dose im,All Other,Per Unit,$598.59 ,OP,598.59,598.59,,,,,,
BCBS Blue Choice,CPT,90655,Iiv3 vacc no prsv 0.25 ml im,All Other,Per Unit,$68.63 ,OP,68.63,68.63,,,,,,
BCBS Blue Choice,CPT,90656,Iiv3 vacc no prsv 0.5 ml im,All Other,Per Unit,$76.26 ,OP,76.26,76.26,,,,,,
BCBS Blue Choice,CPT,90657,Iiv3 vaccine splt 0.25 ml im,All Other,Per Unit,$110.57 ,OP,110.57,110.57,,,,,,
BCBS Blue Choice,CPT,90658,Iiv3 vaccine splt 0.5 ml im,All Other,Per Unit,$110.57 ,OP,110.57,110.57,,,,,,
BCBS Blue Choice,CPT,90660,Laiv3 vaccine intranasal,All Other,Per Unit,$122.00 ,OP,122,122,,,,,,
BCBS Blue Choice,CPT,90665,Lyme disease vaccine im,All Other,Per Unit,$320.27 ,OP,320.27,320.27,,,,,,
BCBS Blue Choice,CPT,90669,Pneumococcal vacc 7 val im,All Other,Per Unit,$427.03 ,OP,427.03,427.03,,,,,,
BCBS Blue Choice,CPT,90675,Rabies vaccine im,All Other,Per Unit,$945.56 ,OP,327.53,945.56,,,,,,
BCBS Blue Choice,CPT,90676,Rabies vaccine id,All Other,Per Unit,$945.56 ,OP,189.63,945.56,,,,,,
BCBS Blue Choice,CPT,90680,Rv5 vacc 3 dose live oral,All Other,Per Unit,$438.47 ,OP,438.47,438.47,,,,,,
BCBS Blue Choice,CPT,90681,Rv1 vacc 2 dose live oral,All Other,Per Unit,$632.91 ,OP,632.91,632.91,,,,,,
BCBS Blue Choice,CPT,90690,Typhoid vaccine oral,All Other,Per Unit,$240.20 ,OP,240.2,240.2,,,,,,
BCBS Blue Choice,CPT,90691,Typhoid vaccine im,All Other,Per Unit,$289.76 ,OP,289.76,289.76,,,,,,
BCBS Blue Choice,CPT,90692,Typhoid vaccine h-p sc/id,All Other,Per Unit,$61.00 ,OP,61,61,,,,,,
BCBS Blue Choice,CPT,90696,Dtap-ipv vaccine 4-6 yrs im,All Other,Per Unit,$293.57 ,OP,293.57,293.57,,,,,,
BCBS Blue Choice,CPT,90698,Dtap-ipv/hib vaccine im,All Other,Per Unit,$446.08 ,OP,446.08,446.08,,,,,,
BCBS Blue Choice,CPT,90700,Dtap vaccine < 7 yrs im,All Other,Per Unit,$141.07 ,OP,141.07,141.07,,,,,,
BCBS Blue Choice,CPT,90701,Dtp vaccine im,All Other,Per Unit,$125.82 ,OP,125.82,125.82,,,,,,
BCBS Blue Choice,CPT,90703,Tetanus vaccine im,All Other,Per Unit,$133.45 ,OP,133.45,133.45,,,,,,
BCBS Blue Choice,CPT,90704,Mumps vaccine sc,All Other,Per Unit,$137.25 ,OP,137.25,137.25,,,,,,
BCBS Blue Choice,CPT,90705,Measles vaccine sc,All Other,Per Unit,$106.76 ,OP,106.76,106.76,,,,,,
BCBS Blue Choice,CPT,90706,Rubella vaccine sc,All Other,Per Unit,$118.19 ,OP,118.19,118.19,,,,,,
BCBS Blue Choice,CPT,90707,Mmr vaccine sc,All Other,Per Unit,$297.39 ,OP,297.39,297.39,,,,,,
BCBS Blue Choice,CPT,90708,Measles-rubella vaccine sc,All Other,Per Unit,$125.82 ,OP,125.82,125.82,,,,,,
BCBS Blue Choice,CPT,90710,Mmrv vaccine sc,All Other,Per Unit,$610.03 ,OP,610.03,610.03,,,,,,
BCBS Blue Choice,CPT,90712,Oral poliovirus vaccine,All Other,Per Unit,$102.95 ,OP,102.95,102.95,,,,,,
BCBS Blue Choice,CPT,90713,Poliovirus ipv sc/im,All Other,Per Unit,$171.58 ,OP,171.58,171.58,,,,,,
BCBS Blue Choice,CPT,90714,Td vacc no presv 7 yrs+ im,All Other,Per Unit,$118.19 ,OP,118.19,118.19,,,,,,
BCBS Blue Choice,CPT,90715,Tdap vaccine 7 yrs/> im,All Other,Per Unit,$228.77 ,OP,228.77,228.77,,,,,,
BCBS Blue Choice,CPT,90716,Var vaccine live subq,All Other,Per Unit,$522.34 ,OP,522.34,522.34,,,,,,
BCBS Blue Choice,CPT,90717,Yellow fever vaccine subq,All Other,Per Unit,$461.34 ,OP,461.34,461.34,,,,,,
BCBS Blue Choice,CPT,90718,Td vaccine > 7 im,All Other,Per Unit,$118.19 ,OP,118.19,118.19,,,,,,
BCBS Blue Choice,CPT,90719,Diphtheria vaccine im,All Other,Per Unit,$190.64 ,OP,190.64,190.64,,,,,,
BCBS Blue Choice,CPT,90720,Dtp/hib vaccine im,All Other,Per Unit,$152.51 ,OP,152.51,152.51,,,,,,
BCBS Blue Choice,CPT,90721,Dtap/hib vaccine im,All Other,Per Unit,$274.51 ,OP,274.51,274.51,,,,,,
BCBS Blue Choice,CPT,90723,Dtap-hep b-ipv vaccine im,All Other,Per Unit,$453.71 ,OP,453.71,453.71,,,,,,
BCBS Blue Choice,CPT,90725,Cholera vaccine injectable,All Other,Per Unit,$22.88 ,OP,22.88,22.88,,,,,,
BCBS Blue Choice,CPT,90727,Plague vaccine im,All Other,Per Unit,$38.13 ,OP,38.13,38.13,,,,,,
BCBS Blue Choice,CPT,90732,Ppsv23 vacc 2 yrs+ subq/im,All Other,Per Unit,$228.77 ,OP,228.77,228.77,,,,,,
BCBS Blue Choice,CPT,90733,Mpsv4 vaccine subq,All Other,Per Unit,$621.47 ,OP,621.47,621.47,,,,,,
BCBS Blue Choice,CPT,90734,Menacwyd/menacwycrm vacc im,All Other,Per Unit,$610.03 ,OP,610.03,610.03,,,,,,
BCBS Blue Choice,CPT,90735,Encephalitis vaccine sc,All Other,Per Unit,$594.77 ,OP,594.77,594.77,,,,,,
BCBS Blue Choice,CPT,90736,Hzv vaccine live subq,All Other,Per Unit,$770.16 ,OP,770.16,770.16,,,,,,
BCBS Blue Choice,CPT,90740,Hepb vacc 3 dose immunsup im,All Other,Per Unit,"$1,029.43 ",OP,"1,029.43","1,029.43",,,,,,
BCBS Blue Choice,CPT,90743,Hepb vacc 2 dose adolesc im,All Other,Per Unit,$141.07 ,OP,141.07,141.07,,,,,,
BCBS Blue Choice,CPT,90744,Hepb vacc 3 dose ped/adol im,All Other,Per Unit,$141.07 ,OP,141.07,141.07,,,,,,
BCBS Blue Choice,CPT,90746,Hepb vaccine 3 dose adult im,All Other,Per Unit,$369.83 ,OP,369.83,369.83,,,,,,
BCBS Blue Choice,CPT,90747,Hepb vacc 4 dose immunsup im,All Other,Per Unit,"$1,029.43 ",OP,"1,029.43","1,029.43",,,,,,
BCBS Blue Choice,CPT,90748,Hib-hepb vaccine im,All Other,Per Unit,$266.89 ,OP,266.89,266.89,,,,,,
BCBS Blue Choice,CPT,90785,Psytx complex interactive,All Other,Per Unit,$68.63 ,OP,68.63,68.63,,,,,,
BCBS Blue Choice,CPT,90791,Psych diagnostic evaluation,All Other,Per Unit,$789.23 ,OP,136.74,789.23,,,,,,
BCBS Blue Choice,CPT,90792,Psych diag eval w/med srvcs,All Other,Per Unit,$789.23 ,OP,136.74,789.23,,,,,,
BCBS Blue Choice,CPT,90801,Psy dx interview,All Other,Per Unit,$789.23 ,OP,789.23,789.23,,,,,,
BCBS Blue Choice,CPT,90802,Intac psy dx interview,All Other,Per Unit,$842.61 ,OP,842.61,842.61,,,,,,
BCBS Blue Choice,CPT,90804,Psytx office 20-30 min,All Other,Per Unit,$331.70 ,OP,331.7,331.7,,,,,,
BCBS Blue Choice,CPT,90805,Psytx off 20-30 min w/e&m,All Other,Per Unit,$366.02 ,OP,366.02,366.02,,,,,,
BCBS Blue Choice,CPT,90806,Psytx off 45-50 min,All Other,Per Unit,$480.40 ,OP,480.4,480.4,,,,,,
BCBS Blue Choice,CPT,90807,Psytx off 45-50 min w/e&m,All Other,Per Unit,$537.60 ,OP,537.6,537.6,,,,,,
BCBS Blue Choice,CPT,90808,Psytx office 75-80 min,All Other,Per Unit,$705.35 ,OP,705.35,705.35,,,,,,
BCBS Blue Choice,CPT,90809,Psytx off 75-80 w/e&m,All Other,Per Unit,$728.23 ,OP,728.23,728.23,,,,,,
BCBS Blue Choice,CPT,90810,Intac psytx off 20-30 min,All Other,Per Unit,$350.76 ,OP,350.76,350.76,,,,,,
BCBS Blue Choice,CPT,90811,Intac psytx 20-30 w/e&m,All Other,Per Unit,$407.96 ,OP,407.96,407.96,,,,,,
BCBS Blue Choice,CPT,90813,Intac psytx 45-50 min w/e&m,All Other,Per Unit,$556.65 ,OP,556.65,556.65,,,,,,
BCBS Blue Choice,CPT,90814,Intac psytx off 75-80 min,All Other,Per Unit,$724.42 ,OP,724.42,724.42,,,,,,
BCBS Blue Choice,CPT,90815,Intac psytx 75-80 w/e&m,All Other,Per Unit,$770.16 ,OP,770.16,770.16,,,,,,
BCBS Blue Choice,CPT,90816,Psytx hosp 20-30 min,All Other,Per Unit,$305.01 ,OP,305.01,305.01,,,,,,
BCBS Blue Choice,CPT,90817,Psytx hosp 20-30 min w/e&m,All Other,Per Unit,$339.33 ,OP,339.33,339.33,,,,,,
BCBS Blue Choice,CPT,90818,Psytx hosp 45-50 min,All Other,Per Unit,$453.71 ,OP,453.71,453.71,,,,,,
BCBS Blue Choice,CPT,90819,Psytx hosp 45-50 min w/e&m,All Other,Per Unit,$488.04 ,OP,488.04,488.04,,,,,,
BCBS Blue Choice,CPT,90821,Psytx hosp 75-80 min,All Other,Per Unit,$667.22 ,OP,667.22,667.22,,,,,,
BCBS Blue Choice,CPT,90822,Psytx hosp 75-80 min w/e&m,All Other,Per Unit,$705.35 ,OP,705.35,705.35,,,,,,
BCBS Blue Choice,CPT,90823,Intac psytx hosp 20-30 min,All Other,Per Unit,$327.90 ,OP,327.9,327.9,,,,,,
BCBS Blue Choice,CPT,90824,Intac psytx hsp 20-30 w/e&m,All Other,Per Unit,$366.02 ,OP,366.02,366.02,,,,,,
BCBS Blue Choice,CPT,90826,Intac psytx hosp 45-50 min,All Other,Per Unit,$480.40 ,OP,480.4,480.4,,,,,,
BCBS Blue Choice,CPT,90827,Intac psytx hsp 45-50 w/e&m,All Other,Per Unit,$510.90 ,OP,510.9,510.9,,,,,,
BCBS Blue Choice,CPT,90828,Intac psytx hosp 75-80 min,All Other,Per Unit,$693.90 ,OP,693.9,693.9,,,,,,
BCBS Blue Choice,CPT,90829,Intac psytx hsp 75-80 w/e&m,All Other,Per Unit,$724.42 ,OP,724.42,724.42,,,,,,
BCBS Blue Choice,CPT,90832,Psytx w pt 30 minutes,All Other,Per Unit,$331.70 ,OP,136.74,331.7,,,,,,
BCBS Blue Choice,CPT,90833,Psytx w pt w e/m 30 min,All Other,Per Unit,$366.02 ,OP,366.02,366.02,,,,,,
BCBS Blue Choice,CPT,90834,Psytx w pt 45 minutes,All Other,Per Unit,$480.40 ,OP,136.74,480.4,,,,,,
BCBS Blue Choice,CPT,90836,Psytx w pt w e/m 45 min,All Other,Per Unit,$537.60 ,OP,537.6,537.6,,,,,,
BCBS Blue Choice,CPT,90837,Psytx w pt 60 minutes,All Other,Per Unit,$705.35 ,OP,136.74,705.35,,,,,,
BCBS Blue Choice,CPT,90838,Psytx w pt w e/m 60 min,All Other,Per Unit,$728.23 ,OP,728.23,728.23,,,,,,
BCBS Blue Choice,CPT,90845,Psychoanalysis,All Other,Per Unit,$423.22 ,OP,136.74,423.22,,,,,,
BCBS Blue Choice,CPT,90846,Family psytx w/o pt 50 min,All Other,Per Unit,$449.90 ,OP,136.74,449.9,,,,,,
BCBS Blue Choice,CPT,90847,Family psytx w/pt 50 min,All Other,Per Unit,$583.35 ,OP,136.74,583.35,,,,,,
BCBS Blue Choice,CPT,90849,Multiple family group psytx,All Other,Per Unit,$171.58 ,OP,136.74,171.58,,,,,,
BCBS Blue Choice,CPT,90853,Group psychotherapy,All Other,Per Unit,$368.97 ,OP,76.62,368.97,,,,,,
BCBS Blue Choice,CPT,90857,Intac group psytx,All Other,Per Unit,$179.20 ,OP,179.2,179.2,,,,,,
BCBS Blue Choice,CPT,90862,Medication management,All Other,Per Unit,$285.96 ,OP,285.96,285.96,,,,,,
BCBS Blue Choice,CPT,90863,Pharmacologic mgmt w/psytx,All Other,Per Unit,$285.96 ,OP,285.96,285.96,,,,,,
BCBS Blue Choice,CPT,90865,Narcosynthesis,All Other,Per Unit,$808.29 ,OP,136.74,808.29,,,,,,
BCBS Blue Choice,CPT,90870,Electroconvulsive therapy,All Other,Per Unit,$709.16 ,OP,499.16,709.16,,,,,,
BCBS Blue Choice,CPT,90875,Psychophysiological therapy,All Other,Per Unit,$369.83 ,OP,369.83,369.83,,,,,,
BCBS Blue Choice,CPT,90876,Psychophysiological therapy,All Other,Per Unit,$545.21 ,OP,545.21,545.21,,,,,,
BCBS Blue Choice,CPT,90880,Hypnotherapy,All Other,Per Unit,$545.21 ,OP,76.62,545.21,,,,,,
BCBS Blue Choice,CPT,90882,Environmental manipulation,All Other,Per Unit,$457.52 ,OP,457.52,457.52,,,,,,
BCBS Blue Choice,CPT,90887,Consultation with family,All Other,Per Unit,$434.65 ,OP,434.65,434.65,,,,,,
BCBS Blue Choice,CPT,90911,Biofeedback peri/uro/rectal,All Other,Per Unit,$476.60 ,OP,476.6,476.6,,,,,,
BCBS Blue Choice,CPT,90912,Bfb training 1st 15 min,All Other,Per Unit,$476.60 ,OP,43.33,476.6,,,,,,
BCBS Blue Choice,CPT,90913,Bfb training ea addl 15 min,All Other,Per Unit,$264.78 ,OP,24.51,264.78,,,,,,
BCBS Blue Choice,CPT,90935,Hemodialysis one evaluation,All Other,Per Unit,$373.65 ,OP,373.65,669.6,,,,,,
BCBS Blue Choice,CPT,90937,Hemodialysis repeated eval,All Other,Per Unit,$613.85 ,OP,613.85,613.85,,,,,,
BCBS Blue Choice,CPT,90940,Hemodialysis access study,All Other,Per Unit,$327.90 ,OP,327.9,327.9,,,,,,
BCBS Blue Choice,CPT,90945,Dialysis one evaluation,All Other,Per Unit,$388.89 ,OP,372.22,388.89,,,,,,
BCBS Blue Choice,CPT,90947,Dialysis repeated eval,All Other,Per Unit,$629.10 ,OP,629.1,629.1,,,,,,
BCBS Blue Choice,CPT,90951,Esrd serv 4 visits p mo <2yr,All Other,Per Unit,"$5,429.27 ",OP,"5,429.27","5,429.27",,,,,,
BCBS Blue Choice,CPT,90952,Esrd serv 2-3 vsts p mo <2yr,All Other,Per Unit,"$4,117.71 ",OP,"4,117.71","4,117.71",,,,,,
BCBS Blue Choice,CPT,90953,Esrd serv 1 visit p mo <2yrs,All Other,Per Unit,"$2,745.14 ",OP,"2,745.14","2,745.14",,,,,,
BCBS Blue Choice,CPT,90954,Esrd serv 4 vsts p mo 2-11,All Other,Per Unit,"$4,449.42 ",OP,"4,449.42","4,449.42",,,,,,
BCBS Blue Choice,CPT,90955,Esrd srv 2-3 vsts p mo 2-11,All Other,Per Unit,"$2,524.00 ",OP,"2,524.00","2,524.00",,,,,,
BCBS Blue Choice,CPT,90956,Esrd srv 1 visit p mo 2-11,All Other,Per Unit,"$1,708.09 ",OP,"1,708.09","1,708.09",,,,,,
BCBS Blue Choice,CPT,90957,Esrd srv 4 vsts p mo 12-19,All Other,Per Unit,"$3,568.68 ",OP,"3,568.68","3,568.68",,,,,,
BCBS Blue Choice,CPT,90958,Esrd srv 2-3 vsts p mo 12-19,All Other,Per Unit,"$2,413.44 ",OP,"2,413.44","2,413.44",,,,,,
BCBS Blue Choice,CPT,90959,Esrd serv 1 vst p mo 12-19,All Other,Per Unit,"$1,578.46 ",OP,"1,578.46","1,578.46",,,,,,
BCBS Blue Choice,CPT,90960,Esrd srv 4 visits p mo 20+,All Other,Per Unit,"$1,589.90 ",OP,"1,589.90","1,589.90",,,,,,
BCBS Blue Choice,CPT,90961,Esrd srv 2-3 vsts p mo 20+,All Other,Per Unit,"$1,281.07 ",OP,"1,281.07","1,281.07",,,,,,
BCBS Blue Choice,CPT,90962,Esrd serv 1 visit p mo 20+,All Other,Per Unit,$926.48 ,OP,926.48,926.48,,,,,,
BCBS Blue Choice,CPT,90963,Esrd home pt serv p mo <2yrs,All Other,Per Unit,"$3,065.41 ",OP,"3,065.41","3,065.41",,,,,,
BCBS Blue Choice,CPT,90964,Esrd home pt serv p mo 2-11,All Other,Per Unit,"$2,558.32 ",OP,"2,558.32","2,558.32",,,,,,
BCBS Blue Choice,CPT,90965,Esrd home pt serv p mo 12-19,All Other,Per Unit,"$2,424.87 ",OP,"2,424.87","2,424.87",,,,,,
BCBS Blue Choice,CPT,90966,Esrd home pt serv p mo 20+,All Other,Per Unit,"$1,269.63 ",OP,"1,269.63","1,269.63",,,,,,
BCBS Blue Choice,CPT,90967,Esrd svc pr day pt <2,All Other,Per Unit,$110.57 ,OP,110.57,110.57,,,,,,
BCBS Blue Choice,CPT,90968,Esrd svc pr day pt 2-11,All Other,Per Unit,$83.87 ,OP,83.87,83.87,,,,,,
BCBS Blue Choice,CPT,90969,Esrd svc pr day pt 12-19,All Other,Per Unit,$83.87 ,OP,83.87,83.87,,,,,,
BCBS Blue Choice,CPT,90970,Esrd svc pr day pt 20+,All Other,Per Unit,$45.74 ,OP,45.74,45.74,,,,,,
BCBS Blue Choice,CPT,90989,Dialysis training complete,All Other,Per Unit,"$2,058.86 ",OP,"2,058.86","2,058.86",,,,,,
BCBS Blue Choice,CPT,90993,Dialysis training incompl,All Other,Per Unit,$446.08 ,OP,446.08,446.08,,,,,,
BCBS Blue Choice,CPT,90997,Hemoperfusion,All Other,Per Unit,$499.47 ,OP,499.47,499.47,,,,,,
BCBS Blue Choice,CPT,91000,Esophageal intubation,All Other,Per Unit,$488.04 ,OP,488.04,488.04,,,,,,
BCBS Blue Choice,CPT,91011,Esophagus motility study,All Other,Per Unit,"$1,391.64 ",OP,"1,391.64","1,391.64",,,,,,
BCBS Blue Choice,CPT,91012,Esophagus motility study,All Other,Per Unit,"$1,414.51 ",OP,"1,414.51","1,414.51",,,,,,
BCBS Blue Choice,CPT,91020,Gastric motility studies,All Other,Per Unit,"$1,265.81 ",OP,499.16,"1,265.81",,,,,,
BCBS Blue Choice,CPT,91022,Duodenal motility study,All Other,Per Unit,"$1,044.69 ",OP,499.16,"1,044.69",,,,,,
BCBS Blue Choice,CPT,91030,Acid perfusion of esophagus,All Other,Per Unit,$754.91 ,OP,499.16,754.91,,,,,,
BCBS Blue Choice,CPT,91052,Gastric analysis test,All Other,Per Unit,$671.03 ,OP,671.03,671.03,,,,,,
BCBS Blue Choice,CPT,91055,Gastric intubation for smear,All Other,Per Unit,$728.23 ,OP,728.23,728.23,,,,,,
BCBS Blue Choice,CPT,91105,Gastric intubation treatment,All Other,Per Unit,$434.65 ,OP,434.65,434.65,,,,,,
BCBS Blue Choice,CPT,91132,Electrogastrography,All Other,Per Unit,$244.01 ,OP,244.01,270.61,,,,,,
BCBS Blue Choice,CPT,91133,Electrogastrography w/test,All Other,Per Unit,$312.64 ,OP,114.56,312.64,,,,,,
BCBS Blue Choice,CPT,92002,Eye exam new patient,All Other,Per Unit,$354.58 ,OP,121.51,354.58,,,,,,
BCBS Blue Choice,CPT,92004,Eye exam new patient,All Other,Per Unit,$663.41 ,OP,121.51,663.41,,,,,,
BCBS Blue Choice,CPT,92012,Eye exam establish patient,All Other,Per Unit,$373.65 ,OP,121.51,373.65,,,,,,
BCBS Blue Choice,CPT,92014,Eye exam&tx estab pt 1/>vst,All Other,Per Unit,$545.21 ,OP,121.51,545.21,,,,,,
BCBS Blue Choice,CPT,92015,Determine refractive state,All Other,Per Unit,$167.76 ,OP,167.76,167.76,,,,,,
BCBS Blue Choice,CPT,92018,New eye exam & treatment,All Other,Per Unit,$671.03 ,OP,671.03,"2,049.05",,,,,,
BCBS Blue Choice,CPT,92019,Eye exam & treatment,All Other,Per Unit,$331.70 ,OP,331.7,"2,049.05",,,,,,
BCBS Blue Choice,CPT,92020,Special eye evaluation,All Other,Per Unit,$125.82 ,OP,114.56,125.82,,,,,,
BCBS Blue Choice,CPT,92025,Corneal topography,All Other,Per Unit,$167.76 ,OP,56.95,167.76,,,,,,
BCBS Blue Choice,CPT,92060,Special eye evaluation,All Other,Per Unit,$285.96 ,OP,56.95,285.96,,,,,,
BCBS Blue Choice,CPT,92065,Orthoptic/pleoptic training,All Other,Per Unit,$224.95 ,OP,56.95,224.95,,,,,,
BCBS Blue Choice,CPT,92070,Fitting of contact lens,All Other,Per Unit,$320.27 ,OP,320.27,320.27,,,,,,
BCBS Blue Choice,CPT,92071,Contact lens fitting for tx,All Other,Per Unit,$320.27 ,OP,320.27,320.27,,,,,,
BCBS Blue Choice,CPT,92072,Fit contac lens for managmnt,All Other,Per Unit,$320.27 ,OP,320.27,320.27,,,,,,
BCBS Blue Choice,CPT,92081,Visual field examination(s),All Other,Per Unit,$255.45 ,OP,56.95,255.45,,,,,,
BCBS Blue Choice,CPT,92082,Visual field examination(s),All Other,Per Unit,$339.33 ,OP,56.95,339.33,,,,,,
BCBS Blue Choice,CPT,92083,Visual field examination(s),All Other,Per Unit,$385.09 ,OP,114.56,385.09,,,,,,
BCBS Blue Choice,CPT,92100,Serial tonometry exam(s),All Other,Per Unit,$427.03 ,OP,427.03,427.03,,,,,,
BCBS Blue Choice,CPT,92120,Tonography & eye evaluation,All Other,Per Unit,$350.76 ,OP,350.76,350.76,,,,,,
BCBS Blue Choice,CPT,92130,Water provocation tonography,All Other,Per Unit,$388.89 ,OP,388.89,388.89,,,,,,
BCBS Blue Choice,CPT,92133,Cmptr ophth img optic nerve,All Other,Per Unit,$224.95 ,OP,56.95,224.95,,,,,,
BCBS Blue Choice,CPT,92134,Cptr ophth dx img post segmt,All Other,Per Unit,$224.95 ,OP,56.95,224.95,,,,,,
BCBS Blue Choice,CPT,92135,Ophth dx imaging post seg,All Other,Per Unit,$224.95 ,OP,224.95,224.95,,,,,,
BCBS Blue Choice,CPT,92136,Ophthalmic biometry,All Other,Per Unit,$411.78 ,OP,114.56,411.78,,,,,,
BCBS Blue Choice,CPT,92140,Glaucoma provocative tests,All Other,Per Unit,$274.51 ,OP,274.51,274.51,,,,,,
BCBS Blue Choice,CPT,92201,Opscpy extnd rta draw uni/bi,All Other,Per Unit,$118.19 ,OP,56.95,118.19,,,,,,
BCBS Blue Choice,CPT,92202,Opscpy extnd on/mac draw,All Other,Per Unit,$76.37 ,OP,56.95,76.37,,,,,,
BCBS Blue Choice,CPT,92225,Special eye exam initial,All Other,Per Unit,$118.19 ,OP,118.19,118.19,,,,,,
BCBS Blue Choice,CPT,92226,Special eye exam subsequent,All Other,Per Unit,$106.76 ,OP,106.76,106.76,,,,,,
BCBS Blue Choice,CPT,92230,Eye exam with photos,All Other,Per Unit,$289.76 ,OP,289.76,499.16,,,,,,
BCBS Blue Choice,CPT,92235,Fluorescein angrph uni/bi,All Other,Per Unit,$629.10 ,OP,270.61,629.1,,,,,,
BCBS Blue Choice,CPT,92240,Icg angiography uni/bi,All Other,Per Unit,"$1,162.87 ",OP,270.61,"1,162.87",,,,,,
BCBS Blue Choice,CPT,92242,Fluorescein icg angiography,All Other,Per Unit,"$1,791.98 ",OP,270.61,"1,791.98",,,,,,
BCBS Blue Choice,CPT,92250,Eye exam with photos,All Other,Per Unit,$346.96 ,OP,114.56,346.96,,,,,,
BCBS Blue Choice,CPT,92260,Ophthalmoscopy/dynamometry,All Other,Per Unit,$87.69 ,OP,34.63,87.69,,,,,,
BCBS Blue Choice,CPT,92265,Eye muscle evaluation,All Other,Per Unit,$381.27 ,OP,56.95,381.27,,,,,,
BCBS Blue Choice,CPT,92270,Electro-oculography,All Other,Per Unit,$438.47 ,OP,114.56,438.47,,,,,,
BCBS Blue Choice,CPT,92273,Full field erg w/i&r,All Other,Per Unit,$648.16 ,OP,270.61,648.16,,,,,,
BCBS Blue Choice,CPT,92274,Multifocal erg w/i&r,All Other,Per Unit,$386.03 ,OP,142.8,386.03,,,,,,
BCBS Blue Choice,CPT,92275,Electroretinography,All Other,Per Unit,$648.16 ,OP,648.16,648.16,,,,,,
BCBS Blue Choice,CPT,92283,Color vision examination,All Other,Per Unit,$224.95 ,OP,56.95,224.95,,,,,,
BCBS Blue Choice,CPT,92285,Eye photography,All Other,Per Unit,$205.88 ,OP,56.95,205.88,,,,,,
BCBS Blue Choice,CPT,92286,Internal eye photography,All Other,Per Unit,$583.35 ,OP,114.56,583.35,,,,,,
BCBS Blue Choice,CPT,92287,Internal eye photography,All Other,Per Unit,$549.03 ,OP,114.56,549.03,,,,,,
BCBS Blue Choice,CPT,92310,Contact lens fitting,All Other,Per Unit,$465.15 ,OP,465.15,465.15,,,,,,
BCBS Blue Choice,CPT,92311,Contact lens fitting,All Other,Per Unit,$449.90 ,OP,276.53,449.9,,,,,,
BCBS Blue Choice,CPT,92312,Contact lens fitting,All Other,Per Unit,$510.90 ,OP,114.56,510.9,,,,,,
BCBS Blue Choice,CPT,92313,Contact lens fitting,All Other,Per Unit,$434.65 ,OP,114.56,434.65,,,,,,
BCBS Blue Choice,CPT,92314,Prescription of contact lens,All Other,Per Unit,$366.02 ,OP,366.02,366.02,,,,,,
BCBS Blue Choice,CPT,92315,Rx cntact lens aphakia 1 eye,All Other,Per Unit,$312.64 ,OP,114.56,312.64,,,,,,
BCBS Blue Choice,CPT,92316,Rx cntact lens aphakia 2 eye,All Other,Per Unit,$411.78 ,OP,114.56,411.78,,,,,,
BCBS Blue Choice,CPT,92317,Rx corneoscleral cntact lens,All Other,Per Unit,$324.09 ,OP,34.63,324.09,,,,,,
BCBS Blue Choice,CPT,92325,Modification of contact lens,All Other,Per Unit,$141.07 ,OP,114.56,141.07,,,,,,
BCBS Blue Choice,CPT,92326,Replacement of contact lens,All Other,Per Unit,$205.88 ,OP,56.95,205.88,,,,,,
BCBS Blue Choice,CPT,92340,Fit spectacles monofocal,All Other,Per Unit,$179.20 ,OP,179.2,179.2,,,,,,
BCBS Blue Choice,CPT,92341,Fit spectacles bifocal,All Other,Per Unit,$205.88 ,OP,205.88,205.88,,,,,,
BCBS Blue Choice,CPT,92342,Fit spectacles multifocal,All Other,Per Unit,$221.14 ,OP,221.14,221.14,,,,,,
BCBS Blue Choice,CPT,92352,Fit aphakia spectcl monofocl,All Other,Per Unit,$198.25 ,OP,56.95,198.25,,,,,,
BCBS Blue Choice,CPT,92353,Fit aphakia spectcl multifoc,All Other,Per Unit,$232.58 ,OP,56.95,232.58,,,,,,
BCBS Blue Choice,CPT,92354,Fit spectacles single system,All Other,Per Unit,$510.90 ,OP,34.63,510.9,,,,,,
BCBS Blue Choice,CPT,92355,Fit spectacles compound lens,All Other,Per Unit,$285.96 ,OP,34.63,285.96,,,,,,
BCBS Blue Choice,CPT,92358,Aphakia prosth service temp,All Other,Per Unit,$102.95 ,OP,56.95,102.95,,,,,,
BCBS Blue Choice,CPT,92370,Repair & adjust spectacles,All Other,Per Unit,$160.13 ,OP,160.13,160.13,,,,,,
BCBS Blue Choice,CPT,92371,Repair & adjust spectacles,All Other,Per Unit,$76.26 ,OP,56.95,76.26,,,,,,
BCBS Blue Choice,CPT,92502,Ear and throat examination,All Other,Per Unit,$526.16 ,OP,462.91,526.16,,,,,,
BCBS Blue Choice,CPT,92504,Ear microscopy examination,All Other,Per Unit,$160.13 ,OP,160.13,160.13,,,,,,
BCBS Blue Choice,CPT,92506,Speech/hearing evaluation,All Other,Per Unit,$857.86 ,OP,857.86,857.86,,,,,,
BCBS Blue Choice,CPT,92507,Speech/hearing therapy,All Other,Per Unit,$354.58 ,OP,75.75,354.58,,,,,,
BCBS Blue Choice,CPT,92508,Speech/hearing therapy,All Other,Per Unit,$171.58 ,OP,23.07,171.58,,,,,,
BCBS Blue Choice,CPT,92511,Nasopharyngoscopy,All Other,Per Unit,$842.61 ,OP,168.23,842.61,,,,,,
BCBS Blue Choice,CPT,92512,Nasal function studies,All Other,Per Unit,$331.70 ,OP,270.61,331.7,,,,,,
BCBS Blue Choice,CPT,92520,Laryngeal function studies,All Other,Per Unit,$339.33 ,OP,114.56,339.33,,,,,,
BCBS Blue Choice,CPT,92521,Evaluation of speech fluency,All Other,Per Unit,$857.86 ,OP,132.47,857.86,,,,,,
BCBS Blue Choice,CPT,92522,Evaluate speech production,All Other,Per Unit,$857.86 ,OP,111.22,857.86,,,,,,
BCBS Blue Choice,CPT,92523,Speech sound lang comprehen,All Other,Per Unit,$857.86 ,OP,227.69,857.86,,,,,,
BCBS Blue Choice,CPT,92524,Behavral qualit analys voice,All Other,Per Unit,$857.86 ,OP,108.89,857.86,,,,,,
BCBS Blue Choice,CPT,92526,Oral function therapy,All Other,Per Unit,$453.71 ,OP,83.51,453.71,,,,,,
BCBS Blue Choice,CPT,92531,Spontaneous nystagmus study,All Other,Per Unit,$171.58 ,OP,171.58,171.58,,,,,,
BCBS Blue Choice,CPT,92532,Positional nystagmus test,All Other,Per Unit,$152.51 ,OP,152.51,152.51,,,,,,
BCBS Blue Choice,CPT,92533,Caloric vestibular test,All Other,Per Unit,$244.01 ,OP,244.01,244.01,,,,,,
BCBS Blue Choice,CPT,92534,Optokinetic nystagmus test,All Other,Per Unit,$125.82 ,OP,125.82,125.82,,,,,,
BCBS Blue Choice,CPT,92537,Caloric vstblr test w/rec,All Other,Per Unit,$163.95 ,OP,142.8,163.95,,,,,,
BCBS Blue Choice,CPT,92538,Caloric vstblr test w/rec,All Other,Per Unit,$163.95 ,OP,142.8,163.95,,,,,,
BCBS Blue Choice,CPT,92541,Spontaneous nystagmus test,All Other,Per Unit,$335.53 ,OP,114.56,335.53,,,,,,
BCBS Blue Choice,CPT,92542,Positional nystagmus test,All Other,Per Unit,$346.96 ,OP,114.56,346.96,,,,,,
BCBS Blue Choice,CPT,92543,Caloric vestibular test,All Other,Per Unit,$163.95 ,OP,163.95,163.95,,,,,,
BCBS Blue Choice,CPT,92544,Optokinetic nystagmus test,All Other,Per Unit,$282.14 ,OP,142.8,282.14,,,,,,
BCBS Blue Choice,CPT,92545,Oscillating tracking test,All Other,Per Unit,$263.08 ,OP,263.08,270.61,,,,,,
BCBS Blue Choice,CPT,92546,Sinusoidal rotational test,All Other,Per Unit,$468.96 ,OP,142.8,468.96,,,,,,
BCBS Blue Choice,CPT,92547,Supplemental electrical test,All Other,Per Unit,$41.94 ,OP,41.94,41.94,,,,,,
BCBS Blue Choice,CPT,92548,Cdp-sot 6 cond w/i&r,All Other,Per Unit,$556.65 ,OP,114.56,556.65,,,,,,
BCBS Blue Choice,CPT,92549,Cdp-sot 6 cond w/i&r mct&adt,All Other,Per Unit,$556.65 ,OP,114.56,556.65,,,,,,
BCBS Blue Choice,CPT,92552,Pure tone audiometry air,All Other,Per Unit,$129.64 ,OP,114.56,129.64,,,,,,
BCBS Blue Choice,CPT,92553,Audiometry air & bone,All Other,Per Unit,$175.39 ,OP,142.8,175.39,,,,,,
BCBS Blue Choice,CPT,92555,Speech threshold audiometry,All Other,Per Unit,$99.13 ,OP,34.63,99.13,,,,,,
BCBS Blue Choice,CPT,92556,Speech audiometry complete,All Other,Per Unit,$152.51 ,OP,56.95,152.51,,,,,,
BCBS Blue Choice,CPT,92557,Comprehensive hearing test,All Other,Per Unit,$278.32 ,OP,142.8,278.32,,,,,,
BCBS Blue Choice,CPT,92559,Group audiometric testing,All Other,Per Unit,$152.51 ,OP,152.51,152.51,,,,,,
BCBS Blue Choice,CPT,92560,Bekesy audiometry screen,All Other,Per Unit,$91.51 ,OP,91.51,91.51,,,,,,
BCBS Blue Choice,CPT,92561,Bekesy audiometry diagnosis,All Other,Per Unit,$171.58 ,OP,114.56,171.58,,,,,,
BCBS Blue Choice,CPT,92562,Loudness balance test,All Other,Per Unit,$137.25 ,OP,137.25,142.8,,,,,,
BCBS Blue Choice,CPT,92563,Tone decay hearing test,All Other,Per Unit,$125.82 ,OP,34.63,125.82,,,,,,
BCBS Blue Choice,CPT,92564,Sisi hearing test,All Other,Per Unit,$122.00 ,OP,25.25,122,,,,,,
BCBS Blue Choice,CPT,92565,Stenger test pure tone,All Other,Per Unit,$80.07 ,OP,34.63,80.07,,,,,,
BCBS Blue Choice,CPT,92567,Tympanometry,All Other,Per Unit,$110.57 ,OP,34.63,110.57,,,,,,
BCBS Blue Choice,CPT,92568,Acoustic refl threshold tst,All Other,Per Unit,$110.57 ,OP,34.63,110.57,,,,,,
BCBS Blue Choice,CPT,92569,Acoustic reflex decay test,All Other,Per Unit,$87.69 ,OP,87.69,87.69,,,,,,
BCBS Blue Choice,CPT,92571,Filtered speech hearing test,All Other,Per Unit,$102.95 ,OP,34.63,102.95,,,,,,
BCBS Blue Choice,CPT,92572,Staggered spondaic word test,All Other,Per Unit,$99.13 ,OP,99.13,142.8,,,,,,
BCBS Blue Choice,CPT,92575,Sensorineural acuity test,All Other,Per Unit,$202.07 ,OP,34.63,202.07,,,,,,
BCBS Blue Choice,CPT,92576,Synthetic sentence test,All Other,Per Unit,$129.64 ,OP,34.63,129.64,,,,,,
BCBS Blue Choice,CPT,92577,Stenger test speech,All Other,Per Unit,$114.39 ,OP,114.39,499.16,,,,,,
BCBS Blue Choice,CPT,92579,Visual audiometry (vra),All Other,Per Unit,$259.27 ,OP,142.8,259.27,,,,,,
BCBS Blue Choice,CPT,92582,Conditioning play audiometry,All Other,Per Unit,$247.83 ,OP,142.8,247.83,,,,,,
BCBS Blue Choice,CPT,92583,Select picture audiometry,All Other,Per Unit,$205.88 ,OP,56.95,205.88,,,,,,
BCBS Blue Choice,CPT,92584,Electrocochleography,All Other,Per Unit,$427.03 ,OP,142.8,427.03,,,,,,
BCBS Blue Choice,CPT,92585,Auditor evoke potent compre,All Other,Per Unit,$606.21 ,OP,606.21,606.21,,,,,,
BCBS Blue Choice,CPT,92586,Auditor evoke potent limit,All Other,Per Unit,$385.09 ,OP,385.09,385.09,,,,,,
BCBS Blue Choice,CPT,92587,Evoked auditory test limited,All Other,Per Unit,$244.01 ,OP,244.01,270.61,,,,,,
BCBS Blue Choice,CPT,92588,Evoked auditory tst complete,All Other,Per Unit,$385.09 ,OP,270.61,385.09,,,,,,
BCBS Blue Choice,CPT,92590,Hearing aid exam one ear,All Other,Per Unit,$289.76 ,OP,289.76,289.76,,,,,,
BCBS Blue Choice,CPT,92591,Hearing aid exam both ears,All Other,Per Unit,$289.76 ,OP,289.76,289.76,,,,,,
BCBS Blue Choice,CPT,92592,Hearing aid check one ear,All Other,Per Unit,$99.13 ,OP,99.13,99.13,,,,,,
BCBS Blue Choice,CPT,92593,Hearing aid check both ears,All Other,Per Unit,$99.13 ,OP,99.13,99.13,,,,,,
BCBS Blue Choice,CPT,92594,Electro hearng aid test one,All Other,Per Unit,$289.76 ,OP,289.76,289.76,,,,,,
BCBS Blue Choice,CPT,92597,Oral speech device eval,All Other,Per Unit,$583.35 ,OP,70.53,583.35,,,,,,
BCBS Blue Choice,CPT,92607,Ex for speech device rx 1hr,All Other,Per Unit,$804.48 ,OP,122.72,804.48,,,,,,
BCBS Blue Choice,CPT,92608,Ex for speech device rx addl,All Other,Per Unit,$163.95 ,OP,49.31,163.95,,,,,,
BCBS Blue Choice,CPT,92609,Use of speech device service,All Other,Per Unit,$430.83 ,OP,102.45,430.83,,,,,,
BCBS Blue Choice,CPT,92610,Evaluate swallowing function,All Other,Per Unit,$423.22 ,OP,69.06,423.22,,,,,,
BCBS Blue Choice,CPT,92611,Motion fluoroscopy/swallow,All Other,Per Unit,$461.34 ,OP,90.57,461.34,,,,,,
BCBS Blue Choice,CPT,92612,Endoscopy swallow (fees) vid,All Other,Per Unit,$796.85 ,OP,65.56,796.85,,,,,,
BCBS Blue Choice,CPT,92613,Endoscopy swallow (fees) i&r,All Other,Per Unit,$202.07 ,OP,202.07,202.07,,,,,,
BCBS Blue Choice,CPT,92614,Laryngoscopic sensory vid,All Other,Per Unit,$709.16 ,OP,64.93,709.16,,,,,,
BCBS Blue Choice,CPT,92615,Laryngoscopic sensory i&r,All Other,Per Unit,$183.02 ,OP,183.02,183.02,,,,,,
BCBS Blue Choice,CPT,92616,Fees w/laryngeal sense test,All Other,Per Unit,$972.25 ,OP,97.82,972.25,,,,,,
BCBS Blue Choice,CPT,92617,Fees w/laryngeal sense i&r,All Other,Per Unit,$221.14 ,OP,221.14,221.14,,,,,,
BCBS Blue Choice,CPT,92621,Auditory function + 15 min,All Other,Per Unit,$87.69 ,OP,87.69,87.69,,,,,,
BCBS Blue Choice,CPT,92625,Tinnitus assessment,All Other,Per Unit,$293.57 ,OP,142.8,293.57,,,,,,
BCBS Blue Choice,CPT,92626,Eval aud funcj 1st hour,All Other,Per Unit,$407.96 ,OP,142.8,407.96,,,,,,
BCBS Blue Choice,CPT,92627,Eval aud funcj ea addl 15,All Other,Per Unit,$99.13 ,OP,99.13,99.13,,,,,,
BCBS Blue Choice,CPT,92640,Aud brainstem implt programg,All Other,Per Unit,$385.09 ,OP,142.8,385.09,,,,,,
BCBS Blue Choice,CPT,92920,Prq cardiac angioplast 1 art,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,92920,Prq cardiac angioplast 1 art,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,92921,Prq cardiac angio addl art,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,92921,Prq cardiac angio addl art,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,92924,Prq card angio/athrect 1 art,,Per Case,"$4,140.35 ",OP,"4,140.35","10,277.14",,,,,,
BCBS Blue Choice,CPT,92924,Prq card angio/athrect 1 art,,Per Case,"$7,820.85 ",OP,"4,140.35","10,277.14",,,,,,
BCBS Blue Choice,CPT,92925,Prq card angio/athrect addl,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,92925,Prq card angio/athrect addl,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,92950,Heart/lung resuscitation cpr,All Other,Per Unit,"$1,567.02 ",OP,270.61,"1,567.02",,,,,,
BCBS Blue Choice,CPT,92960,Cardioversion electric ext,All Other,Per Unit,"$1,460.26 ",OP,575.01,"1,460.26",,,,,,
BCBS Blue Choice,CPT,92961,Cardioversion electric int,All Other,Per Unit,"$1,513.64 ",OP,575.01,"1,513.64",,,,,,
BCBS Blue Choice,CPT,92970,Cardioassist internal,All Other,Per Unit,"$1,040.87 ",OP,"1,040.87","8,948.83",,,,,,
BCBS Blue Choice,CPT,92971,Cardioassist external,All Other,Per Unit,$590.97 ,OP,590.97,"8,948.83",,,,,,
BCBS Blue Choice,CPT,92973,Prq coronary mech thrombect,All Other,Per Unit,"$1,078.99 ",OP,"1,078.99","1,078.99",,,,,,
BCBS Blue Choice,CPT,92974,Cath place cardio brachytx,All Other,Per Unit,$987.49 ,OP,987.49,987.49,,,,,,
BCBS Blue Choice,CPT,92975,Dissolve clot heart vessel,All Other,Per Unit,"$2,367.69 ",OP,"2,367.69","8,948.83",,,,,,
BCBS Blue Choice,CPT,92977,Dissolve clot heart vessel,All Other,Per Unit,$850.23 ,OP,318,850.23,,,,,,
BCBS Blue Choice,CPT,92978,Endoluminl ivus oct c 1st,All Other,Per Unit,"$1,677.58 ",OP,"1,677.58","1,677.58",,,,,,
BCBS Blue Choice,CPT,92979,Endoluminl ivus oct c ea,All Other,Per Unit,"$1,025.61 ",OP,"1,025.61","1,025.61",,,,,,
BCBS Blue Choice,CPT,92986,Revision of aortic valve,All Other,Per Unit,"$8,048.60 ",OP,"5,072.43","8,048.60",,,,,,
BCBS Blue Choice,CPT,92987,Revision of mitral valve,All Other,Per Unit,"$8,338.36 ",OP,"8,338.36","10,277.14",,,,,,
BCBS Blue Choice,CPT,92990,Revision of pulmonary valve,All Other,Per Unit,"$6,409.14 ",OP,"6,409.14","10,277.14",,,,,,
BCBS Blue Choice,CPT,92992,Revision of heart chamber,All Other,Per Unit,"$5,940.18 ",OP,"5,940.18","5,940.18",,,,,,
BCBS Blue Choice,CPT,92993,Revision of heart chamber,All Other,Per Unit,"$4,701.06 ",OP,"4,701.06","4,701.06",,,,,,
BCBS Blue Choice,CPT,92996,Coronary atherectomy add-on,All Other,Per Unit,"$1,025.61 ",OP,"1,025.61","1,025.61",,,,,,
BCBS Blue Choice,CPT,92997,Pul art balloon repr percut,,Per Case,"$7,820.85 ",OP,"4,140.35","10,277.14",,,,,,
BCBS Blue Choice,CPT,92997,Pul art balloon repr percut,All Other,Per Case,"$4,140.35 ",OP,"4,140.35","10,277.14",,,,,,
BCBS Blue Choice,CPT,92998,Pul art balloon repr percut,,Per Case,"$7,820.85 ",OP,"2,203.50","9,201.00",,,,,,
BCBS Blue Choice,CPT,92998,Pul art balloon repr percut,All Other,Per Case,"$4,140.35 ",OP,"2,203.50","9,201.00",,,,,,
BCBS Blue Choice,CPT,93000,Electrocardiogram complete,All Other,Per Unit,$125.82 ,OP,125.82,125.82,,,,,,
BCBS Blue Choice,CPT,93005,Electrocardiogram tracing,All Other,Per Unit,$72.44 ,OP,56.95,72.44,,,,,,
BCBS Blue Choice,CPT,93010,Electrocardiogram report,All Other,Per Unit,$53.38 ,OP,53.38,53.38,,,,,,
BCBS Blue Choice,CPT,93012,Transmission of ecg,All Other,Per Unit,"$1,082.81 ",OP,"1,082.81","1,082.81",,,,,,
BCBS Blue Choice,CPT,93014,Report on transmitted ecg,All Other,Per Unit,$160.13 ,OP,160.13,160.13,,,,,,
BCBS Blue Choice,CPT,93015,Cardiovascular stress test,All Other,Per Unit,$594.77 ,OP,594.77,594.77,,,,,,
BCBS Blue Choice,CPT,93016,Cardiovascular stress test,All Other,Per Unit,$141.07 ,OP,141.07,141.07,,,,,,
BCBS Blue Choice,CPT,93017,Cardiovascular stress test,All Other,Per Unit,$362.21 ,OP,270.61,362.21,,,,,,
BCBS Blue Choice,CPT,93018,Cardiovascular stress test,All Other,Per Unit,$91.51 ,OP,91.51,91.51,,,,,,
BCBS Blue Choice,CPT,93024,Cardiac drug stress test,All Other,Per Unit,$712.98 ,OP,276.53,712.98,,,,,,
BCBS Blue Choice,CPT,93025,Microvolt t-wave assess,All Other,Per Unit,"$1,246.76 ",OP,142.8,"1,246.76",,,,,,
BCBS Blue Choice,CPT,93042,Rhythm ecg report,All Other,Per Unit,$45.74 ,OP,45.74,45.74,,,,,,
BCBS Blue Choice,CPT,93224,Ecg monit/reprt up to 48 hrs,All Other,Per Unit,$743.48 ,OP,743.48,743.48,,,,,,
BCBS Blue Choice,CPT,93225,Ecg monit/reprt up to 48 hrs,All Other,Per Unit,$224.95 ,OP,114.56,224.95,,,,,,
BCBS Blue Choice,CPT,93226,Ecg monit/reprt up to 48 hrs,All Other,Per Unit,$926.48 ,OP,114.56,926.48,,,,,,
BCBS Blue Choice,CPT,93227,Ecg monit/reprt up to 48 hrs,All Other,Per Unit,$163.95 ,OP,163.95,163.95,,,,,,
BCBS Blue Choice,CPT,93228,Remote 30 day ecg rev/report,All Other,Per Unit,$144.88 ,OP,144.88,144.88,,,,,,
BCBS Blue Choice,CPT,93230,ECG monitor/report - 24 hrs,All Other,Per Unit,$743.48 ,OP,743.48,743.48,,,,,,
BCBS Blue Choice,CPT,93231,Ecg monitor/record - 24 hrs,All Other,Per Unit,$224.95 ,OP,224.95,224.95,,,,,,
BCBS Blue Choice,CPT,93232,ECG monitor/report - 24 hrs,All Other,Per Unit,$362.21 ,OP,362.21,362.21,,,,,,
BCBS Blue Choice,CPT,93233,ECG monitor/review - 24 hrs,All Other,Per Unit,$156.32 ,OP,156.32,156.32,,,,,,
BCBS Blue Choice,CPT,93235,ECG monitor/report - 24 hrs,All Other,Per Unit,$476.60 ,OP,476.6,476.6,,,,,,
BCBS Blue Choice,CPT,93236,ECG monitor/report - 24 hrs,All Other,Per Unit,$926.48 ,OP,926.48,926.48,,,,,,
BCBS Blue Choice,CPT,93237,ECG monitor/review - 24 hrs,All Other,Per Unit,$141.07 ,OP,141.07,141.07,,,,,,
BCBS Blue Choice,CPT,93268,Ecg record/review,All Other,Per Unit,"$1,574.64 ",OP,"1,574.64","1,574.64",,,,,,
BCBS Blue Choice,CPT,93270,Remote 30 day ecg rev/report,All Other,Per Unit,$137.25 ,OP,38.02,137.25,,,,,,
BCBS Blue Choice,CPT,93271,Ecg/monitoring and analysis,All Other,Per Unit,"$1,281.07 ",OP,102.65,"1,281.07",,,,,,
BCBS Blue Choice,CPT,93272,Ecg/review interpret only,All Other,Per Unit,$156.32 ,OP,156.32,156.32,,,,,,
BCBS Blue Choice,CPT,93278,Ecg/signal-averaged,All Other,Per Unit,$251.64 ,OP,56.95,251.64,,,,,,
BCBS Blue Choice,CPT,93279,Prgrmg dev eval pm/ldls pm,All Other,Per Unit,$327.90 ,OP,38.02,327.9,,,,,,
BCBS Blue Choice,CPT,93280,Pm device progr eval dual,All Other,Per Unit,$381.27 ,OP,38.02,381.27,,,,,,
BCBS Blue Choice,CPT,93281,Pm device progr eval multi,All Other,Per Unit,$446.08 ,OP,38.02,446.08,,,,,,
BCBS Blue Choice,CPT,93282,Prgrmg eval implantable dfb,All Other,Per Unit,$415.59 ,OP,38.02,415.59,,,,,,
BCBS Blue Choice,CPT,93283,Prgrmg eval implantable dfb,All Other,Per Unit,$503.28 ,OP,38.02,503.28,,,,,,
BCBS Blue Choice,CPT,93284,Prgrmg eval implantable dfb,All Other,Per Unit,$587.16 ,OP,38.02,587.16,,,,,,
BCBS Blue Choice,CPT,93285,Prgrmg dev eval scrms ip,All Other,Per Unit,$282.14 ,OP,38.02,282.14,,,,,,
BCBS Blue Choice,CPT,93286,Peri-px eval pm/ldls pm ip,All Other,Per Unit,$160.13 ,OP,160.13,160.13,,,,,,
BCBS Blue Choice,CPT,93287,Peri-px device eval & prgr,All Other,Per Unit,$213.51 ,OP,213.51,213.51,,,,,,
BCBS Blue Choice,CPT,93288,Interrog evl pm/ldls pm ip,All Other,Per Unit,$255.45 ,OP,38.02,255.45,,,,,,
BCBS Blue Choice,CPT,93289,Interrog device eval heart,All Other,Per Unit,$385.09 ,OP,38.02,385.09,,,,,,
BCBS Blue Choice,CPT,93290,Interrog dev eval icpms ip,All Other,Per Unit,$190.64 ,OP,38.02,190.64,,,,,,
BCBS Blue Choice,CPT,93291,Interrog dev eval scrms ip,All Other,Per Unit,$244.01 ,OP,25.25,244.01,,,,,,
BCBS Blue Choice,CPT,93293,Pm phone r-strip device eval,All Other,Per Unit,$366.02 ,OP,38.02,366.02,,,,,,
BCBS Blue Choice,CPT,93295,Dev interrog remote 1/2/mlt,All Other,Per Unit,$377.46 ,OP,377.46,377.46,,,,,,
BCBS Blue Choice,CPT,93296,Rem interrog evl pm/ids,All Other,Per Unit,$213.51 ,OP,38.02,213.51,,,,,,
BCBS Blue Choice,CPT,93297,Rem interrog dev eval icpms,All Other,Per Unit,$144.88 ,OP,144.88,144.88,,,,,,
BCBS Blue Choice,CPT,93298,Rem interrog dev eval scrms,All Other,Per Unit,$167.76 ,OP,167.76,167.76,,,,,,
BCBS Blue Choice,CPT,93303,Echo transthoracic,All Other,Per Unit,"$1,292.50 ",OP,494.15,"1,292.50",,,,,,
BCBS Blue Choice,CPT,93304,Echo transthoracic,All Other,Per Unit,$796.85 ,OP,494.15,796.85,,,,,,
BCBS Blue Choice,CPT,93306,Tte w/doppler complete,All Other,Per Unit,"$1,593.72 ",OP,494.15,"1,593.72",,,,,,
BCBS Blue Choice,CPT,93307,Tte w/o doppler complete,All Other,Per Unit,"$1,056.11 ",OP,235.49,"1,056.11",,,,,,
BCBS Blue Choice,CPT,93308,Tte f-up or lmtd,All Other,Per Unit,$667.22 ,OP,235.49,667.22,,,,,,
BCBS Blue Choice,CPT,93312,Echo transesophageal,All Other,Per Unit,"$1,921.59 ",OP,494.15,"1,921.59",,,,,,
BCBS Blue Choice,CPT,93314,Echo transesophageal,All Other,Per Unit,"$1,662.33 ",OP,"1,662.33","1,662.33",,,,,,
BCBS Blue Choice,CPT,93315,Echo transesophageal,All Other,Per Unit,"$1,738.59 ",OP,494.15,"1,738.59",,,,,,
BCBS Blue Choice,CPT,93316,Echo transesophageal,All Other,Per Unit,$259.27 ,OP,259.27,494.15,,,,,,
BCBS Blue Choice,CPT,93317,Echo transesophageal,All Other,Per Unit,"$1,082.81 ",OP,"1,082.81","1,082.81",,,,,,
BCBS Blue Choice,CPT,93318,Echo transesophageal intraop,All Other,Per Unit,"$1,330.63 ",OP,494.15,"1,330.63",,,,,,
BCBS Blue Choice,CPT,93320,Doppler echo exam heart,All Other,Per Unit,$468.96 ,OP,468.96,468.96,,,,,,
BCBS Blue Choice,CPT,93321,Doppler echo exam heart,All Other,Per Unit,$217.32 ,OP,217.32,217.32,,,,,,
BCBS Blue Choice,CPT,93325,Doppler color flow add-on,All Other,Per Unit,$346.96 ,OP,346.96,346.96,,,,,,
BCBS Blue Choice,CPT,93350,Stress tte only,All Other,Per Unit,"$1,239.13 ",OP,494.15,"1,239.13",,,,,,
BCBS Blue Choice,CPT,93351,Stress tte complete,All Other,Per Unit,"$1,635.64 ",OP,494.15,"1,635.64",,,,,,
BCBS Blue Choice,CPT,93352,Admin ecg contrast agent,All Other,Per Unit,$228.77 ,OP,228.77,228.77,,,,,,
BCBS Blue Choice,CPT,93451,Right heart cath,,Per Case,"$4,140.35 ",OP,"2,966.62","9,201.00",,,,,,
BCBS Blue Choice,CPT,93451,Right heart cath,,Per Case,"$7,820.85 ",OP,"2,966.62","9,201.00",,,,,,
BCBS Blue Choice,CPT,93452,Left hrt cath w/ventrclgrphy,,Per Case,"$4,140.35 ",OP,"2,966.62","9,201.00",,,,,,
BCBS Blue Choice,CPT,93452,Left hrt cath w/ventrclgrphy,,Per Case,"$7,820.85 ",OP,"2,966.62","9,201.00",,,,,,
BCBS Blue Choice,CPT,93453,R&l hrt cath w/ventriclgrphy,,Per Case,"$4,140.35 ",OP,"2,966.62","9,201.00",,,,,,
BCBS Blue Choice,CPT,93453,R&l hrt cath w/ventriclgrphy,,Per Case,"$7,820.85 ",OP,"2,966.62","9,201.00",,,,,,
BCBS Blue Choice,CPT,93456,R hrt coronary artery angio,,Per Case,"$4,140.35 ",OP,"2,966.62","9,201.00",,,,,,
BCBS Blue Choice,CPT,93456,R hrt coronary artery angio,,Per Case,"$7,820.85 ",OP,"2,966.62","9,201.00",,,,,,
BCBS Blue Choice,CPT,93457,R hrt art/grft angio,,Per Case,"$4,140.35 ",OP,"2,966.62","9,201.00",,,,,,
BCBS Blue Choice,CPT,93457,R hrt art/grft angio,,Per Case,"$7,820.85 ",OP,"2,966.62","9,201.00",,,,,,
BCBS Blue Choice,CPT,93458,L hrt artery/ventricle angio,,Per Case,"$4,140.35 ",OP,"2,966.62","9,201.00",,,,,,
BCBS Blue Choice,CPT,93458,L hrt artery/ventricle angio,,Per Case,"$7,820.85 ",OP,"2,966.62","9,201.00",,,,,,
BCBS Blue Choice,CPT,93459,L hrt art/grft angio,,Per Case,"$4,140.35 ",OP,"2,966.62","9,201.00",,,,,,
BCBS Blue Choice,CPT,93459,L hrt art/grft angio,,Per Case,"$7,820.85 ",OP,"2,966.62","9,201.00",,,,,,
BCBS Blue Choice,CPT,93460,R&l hrt art/ventricle angio,,Per Case,"$4,140.35 ",OP,"2,966.62","9,201.00",,,,,,
BCBS Blue Choice,CPT,93460,R&l hrt art/ventricle angio,,Per Case,"$7,820.85 ",OP,"2,966.62","9,201.00",,,,,,
BCBS Blue Choice,CPT,93461,R&l hrt art/ventricle angio,,Per Case,"$4,140.35 ",OP,"2,966.62","9,201.00",,,,,,
BCBS Blue Choice,CPT,93461,R&l hrt art/ventricle angio,,Per Case,"$7,820.85 ",OP,"2,966.62","9,201.00",,,,,,
BCBS Blue Choice,CPT,93503,Insert/place heart catheter,All Other,Per Unit,$651.97 ,OP,651.97,"1,438.93",,,,,,
BCBS Blue Choice,CPT,93505,Biopsy of heart lining,All Other,Per Unit,"$4,346.47 ",OP,"2,928.39","4,346.47",,,,,,
BCBS Blue Choice,CPT,93508,Cath placement - angiography,All Other,Per Unit,"$6,241.38 ",OP,"6,241.38","6,241.38",,,,,,
BCBS Blue Choice,CPT,93514,Left heart catheterization,All Other,Per Unit,"$10,763.23 ",OP,"10,763.23","10,763.23",,,,,,
BCBS Blue Choice,CPT,93524,Left heart catheterization,All Other,Per Unit,"$13,977.33 ",OP,"13,977.33","13,977.33",,,,,,
BCBS Blue Choice,CPT,93528,Rt & Lt heart catheters,All Other,Per Unit,"$14,011.66 ",OP,"14,011.66","14,011.66",,,,,,
BCBS Blue Choice,CPT,93529,Rt - lt heart catheterization,All Other,Per Unit,"$12,661.95 ",OP,"12,661.95","12,661.95",,,,,,
BCBS Blue Choice,CPT,93530,Rt heart cath congenital,,Per Case,"$7,820.85 ",OP,"2,966.62","9,201.00",,,,,,
BCBS Blue Choice,CPT,93530,Rt heart cath congenital,All Other,Per Case,"$4,140.35 ",OP,"2,966.62","9,201.00",,,,,,
BCBS Blue Choice,CPT,93531,R & l heart cath congenital,,Per Case,"$7,820.85 ",OP,"2,966.62","16,124.56",,,,,,
BCBS Blue Choice,CPT,93531,R & l heart cath congenital,All Other,Per Case,"$4,140.35 ",OP,"2,966.62","16,124.56",,,,,,
BCBS Blue Choice,CPT,93532,R & l heart cath congenital,,Per Case,"$7,820.85 ",OP,"2,966.62","16,600.26",,,,,,
BCBS Blue Choice,CPT,93532,R & l heart cath congenital,All Other,Per Case,"$4,140.35 ",OP,"2,966.62","16,600.26",,,,,,
BCBS Blue Choice,CPT,93533,R & l heart cath congenital,,Per Case,"$7,820.85 ",OP,"2,966.62","16,111.09",,,,,,
BCBS Blue Choice,CPT,93533,R & l heart cath congenital,All Other,Per Case,"$4,140.35 ",OP,"2,966.62","16,111.09",,,,,,
BCBS Blue Choice,CPT,93541,Injection for lung angiogram,All Other,Per Unit,$76.26 ,OP,76.26,76.26,,,,,,
BCBS Blue Choice,CPT,93542,Injection for heart x-rays,All Other,Per Unit,$709.16 ,OP,709.16,709.16,,,,,,
BCBS Blue Choice,CPT,93545,Inject for coronary x-rays,All Other,Per Unit,$815.92 ,OP,815.92,815.92,,,,,,
BCBS Blue Choice,CPT,93556,Imaging - cardiac cath,All Other,Per Unit,"$1,033.25 ",OP,"1,033.25","1,033.25",,,,,,
BCBS Blue Choice,CPT,93561,Cardiac output measurement,All Other,Per Unit,$255.45 ,OP,255.45,255.45,,,,,,
BCBS Blue Choice,CPT,93562,Card output measure subsq,All Other,Per Unit,$118.19 ,OP,118.19,118.19,,,,,,
BCBS Blue Choice,CPT,93571,Heart flow reserve measure,All Other,Per Unit,"$1,673.76 ",OP,"1,673.76","1,673.76",,,,,,
BCBS Blue Choice,CPT,93572,Heart flow reserve measure,All Other,Per Unit,$968.43 ,OP,968.43,968.43,,,,,,
BCBS Blue Choice,CPT,93580,Transcath closure of asd,All Other,Per Unit,"$5,905.86 ",OP,"5,905.86","16,438.60",,,,,,
BCBS Blue Choice,CPT,93581,Transcath closure of vsd,All Other,Per Unit,"$7,739.77 ",OP,"7,739.77","16,438.60",,,,,,
BCBS Blue Choice,CPT,93602,Intra-atrial recording,All Other,Per Unit,$968.43 ,OP,968.43,"6,220.22",,,,,,
BCBS Blue Choice,CPT,93603,Right ventricular recording,All Other,Per Unit,"$1,117.12 ",OP,"1,117.12","1,138.72",,,,,,
BCBS Blue Choice,CPT,93609,Map tachycardia add-on,All Other,Per Unit,"$2,287.62 ",OP,"2,287.62","2,287.62",,,,,,
BCBS Blue Choice,CPT,93610,Intra-atrial pacing,All Other,Per Unit,"$1,323.01 ",OP,"1,323.01","6,220.22",,,,,,
BCBS Blue Choice,CPT,93612,Intraventricular pacing,All Other,Per Unit,"$1,376.38 ",OP,"1,376.38","6,220.22",,,,,,
BCBS Blue Choice,CPT,93613,Electrophys map 3d add-on,All Other,Per Unit,"$2,291.44 ",OP,"2,291.44","2,291.44",,,,,,
BCBS Blue Choice,CPT,93615,Esophageal recording,All Other,Per Unit,$392.70 ,OP,392.7,"1,138.72",,,,,,
BCBS Blue Choice,CPT,93618,Heart rhythm pacing,All Other,Per Unit,"$2,367.69 ",OP,"1,138.72","2,367.69",,,,,,
BCBS Blue Choice,CPT,93619,Electrophysiology evaluation,All Other,Per Unit,"$4,312.16 ",OP,"4,312.16","6,220.22",,,,,,
BCBS Blue Choice,CPT,93620,Electrophysiology evaluation,All Other,Per Unit,"$5,112.83 ",OP,"5,112.83","6,220.22",,,,,,
BCBS Blue Choice,CPT,93621,Electrophysiology evaluation,All Other,Per Unit,$930.30 ,OP,930.3,930.3,,,,,,
BCBS Blue Choice,CPT,93622,Electrophysiology evaluation,All Other,Per Unit,"$1,353.52 ",OP,"1,353.52","1,353.52",,,,,,
BCBS Blue Choice,CPT,93623,Stimulation pacing heart,All Other,Per Unit,"$1,254.37 ",OP,"1,254.37","1,254.37",,,,,,
BCBS Blue Choice,CPT,93624,Electrophysiologic study,All Other,Per Unit,"$2,051.24 ",OP,"2,051.24","6,220.22",,,,,,
BCBS Blue Choice,CPT,93631,Heart pacing mapping,All Other,Per Unit,"$3,256.04 ",OP,"3,256.04","3,256.04",,,,,,
BCBS Blue Choice,CPT,93640,Evaluation heart device,All Other,Per Unit,"$2,920.52 ",OP,"2,920.52","2,920.52",,,,,,
BCBS Blue Choice,CPT,93641,Electrophysiology evaluation,All Other,Per Unit,"$3,713.56 ",OP,"3,713.56","3,713.56",,,,,,
BCBS Blue Choice,CPT,93642,Electrophysiology evaluation,All Other,Per Unit,"$2,775.65 ",OP,"1,138.72","2,775.65",,,,,,
BCBS Blue Choice,CPT,93650,Ablate heart dysrhythm focus,All Other,Per Unit,"$3,488.62 ",OP,"3,488.62","6,220.22",,,,,,
BCBS Blue Choice,CPT,93651,Ablate heart dysrhythm focus,All Other,Per Unit,"$5,307.27 ",OP,"5,307.27","5,307.27",,,,,,
BCBS Blue Choice,CPT,93652,Ablate heart dysrhythm focus,All Other,Per Unit,"$5,776.24 ",OP,"5,776.24","5,776.24",,,,,,
BCBS Blue Choice,CPT,93653,Ep & ablate supravent arrhyt,All Other,Per Unit,"$10,420.09 ",OP,"10,420.09","21,964.94",,,,,,
BCBS Blue Choice,CPT,93654,Ep & ablate ventric tachy,All Other,Per Unit,"$10,889.05 ",OP,"10,889.05","21,964.94",,,,,,
BCBS Blue Choice,CPT,93656,Tx atrial fib pulm vein isol,All Other,Per Unit,"$10,420.09 ",OP,"10,420.09","21,964.94",,,,,,
BCBS Blue Choice,CPT,93660,Tilt table evaluation,All Other,Per Unit,$983.68 ,OP,499.16,983.68,,,,,,
BCBS Blue Choice,CPT,93662,Intracardiac ecg (ice),All Other,Per Unit,"$1,181.94 ",OP,"1,181.94","1,181.94",,,,,,
BCBS Blue Choice,CPT,93668,Peripheral vascular rehab,All Other,Per Unit,$99.13 ,OP,56.95,99.13,,,,,,
BCBS Blue Choice,CPT,93701,Bioimpedance cv analysis,All Other,Per Unit,$198.25 ,OP,114.56,198.25,,,,,,
BCBS Blue Choice,CPT,93720,Total body plethysmography,All Other,Per Unit,$278.32 ,OP,278.32,278.32,,,,,,
BCBS Blue Choice,CPT,93721,Plethysmography tracing,All Other,Per Unit,$228.77 ,OP,228.77,228.77,,,,,,
BCBS Blue Choice,CPT,93722,Plethysmography report,All Other,Per Unit,$49.56 ,OP,49.56,49.56,,,,,,
BCBS Blue Choice,CPT,93724,Analyze pacemaker system,All Other,Per Unit,"$1,948.29 ",OP,278.82,"1,948.29",,,,,,
BCBS Blue Choice,CPT,93740,Temperature gradient studies,All Other,Per Unit,$57.19 ,OP,57.19,142.8,,,,,,
BCBS Blue Choice,CPT,93770,Measure venous pressure,All Other,Per Unit,$53.38 ,OP,53.38,53.38,,,,,,
BCBS Blue Choice,CPT,93784,Ambl bp mntr w/software,All Other,Per Unit,$377.46 ,OP,377.46,377.46,,,,,,
BCBS Blue Choice,CPT,93786,Ambl bp mntr w/sw rec only,All Other,Per Unit,$171.58 ,OP,114.56,171.58,,,,,,
BCBS Blue Choice,CPT,93790,Ambl bp mntr w/sw i&r,All Other,Per Unit,$106.76 ,OP,106.76,106.76,,,,,,
BCBS Blue Choice,CPT,93792,Pt/caregiver traing home inr,All Other,Per Unit,$644.34 ,OP,644.34,644.34,,,,,,
BCBS Blue Choice,CPT,93793,Anticoag mgmt pt warfarin,All Other,Per Unit,$224.95 ,OP,224.95,224.95,,,,,,
BCBS Blue Choice,CPT,93797,Cardiac rehab,All Other,Per Unit,$102.95 ,OP,102.95,118.77,,,,,,
BCBS Blue Choice,CPT,93798,Cardiac rehab/monitor,All Other,Per Unit,$148.69 ,OP,118.77,148.69,,,,,,
BCBS Blue Choice,CPT,93875,Extracranial study,All Other,Per Unit,$499.47 ,OP,499.47,499.47,,,,,,
BCBS Blue Choice,CPT,93880,Extracranial bilat study,All Other,Per Unit,"$1,239.13 ",OP,235.49,"1,239.13",,,,,,
BCBS Blue Choice,CPT,93882,Extracranial uni/ltd study,All Other,Per Unit,$815.92 ,OP,111.51,815.92,,,,,,
BCBS Blue Choice,CPT,93886,Intracranial complete study,All Other,Per Unit,"$1,483.14 ",OP,235.49,"1,483.14",,,,,,
BCBS Blue Choice,CPT,93888,Intracranial limited study,All Other,Per Unit,"$1,010.37 ",OP,111.51,"1,010.37",,,,,,
BCBS Blue Choice,CPT,93890,Tcd vasoreactivity study,All Other,Per Unit,"$1,307.75 ",OP,235.49,"1,307.75",,,,,,
BCBS Blue Choice,CPT,93892,Tcd emboli detect w/o inj,All Other,Per Unit,"$1,425.95 ",OP,111.51,"1,425.95",,,,,,
BCBS Blue Choice,CPT,93893,Tcd emboli detect w/inj,All Other,Per Unit,"$1,422.14 ",OP,111.51,"1,422.14",,,,,,
BCBS Blue Choice,CPT,93922,Upr/l xtremity art 2 levels,All Other,Per Unit,$594.77 ,OP,114.56,594.77,,,,,,
BCBS Blue Choice,CPT,93923,Upr/lxtr art stdy 3+ lvls,All Other,Per Unit,$922.67 ,OP,142.8,922.67,,,,,,
BCBS Blue Choice,CPT,93924,Lwr xtr vasc stdy bilat,All Other,Per Unit,"$1,136.19 ",OP,270.61,"1,136.19",,,,,,
BCBS Blue Choice,CPT,93925,Lower extremity study,All Other,Per Unit,"$1,525.07 ",OP,235.49,"1,525.07",,,,,,
BCBS Blue Choice,CPT,93926,Lower extremity study,All Other,Per Unit,$976.05 ,OP,111.51,976.05,,,,,,
BCBS Blue Choice,CPT,93930,Upper extremity study,All Other,Per Unit,"$1,223.88 ",OP,235.49,"1,223.88",,,,,,
BCBS Blue Choice,CPT,93931,Upper extremity study,All Other,Per Unit,$815.92 ,OP,111.51,815.92,,,,,,
BCBS Blue Choice,CPT,93965,Extremity study,All Other,Per Unit,$606.21 ,OP,606.21,606.21,,,,,,
BCBS Blue Choice,CPT,93970,Extremity study,All Other,Per Unit,"$1,273.44 ",OP,235.49,"1,273.44",,,,,,
BCBS Blue Choice,CPT,93971,Extremity study,All Other,Per Unit,$842.61 ,OP,111.51,842.61,,,,,,
BCBS Blue Choice,CPT,93975,Vascular study,All Other,Per Unit,$367.82 ,OP,235.49,367.82,,,,,,
BCBS Blue Choice,CPT,93976,Vascular study,All Other,Per Unit,"$1,082.81 ",OP,111.51,"1,082.81",,,,,,
BCBS Blue Choice,CPT,93978,Vascular study,All Other,Per Unit,"$1,197.20 ",OP,235.49,"1,197.20",,,,,,
BCBS Blue Choice,CPT,93979,Vascular study,All Other,Per Unit,$823.54 ,OP,111.51,823.54,,,,,,
BCBS Blue Choice,CPT,93980,Penile vascular study,All Other,Per Unit,$934.12 ,OP,111.51,934.12,,,,,,
BCBS Blue Choice,CPT,93981,Penile vascular study,All Other,Per Unit,$667.22 ,OP,111.51,667.22,,,,,,
BCBS Blue Choice,CPT,93982,Aneurysm pressure sens study,All Other,Per Unit,$190.64 ,OP,190.64,190.64,,,,,,
BCBS Blue Choice,CPT,93985,Dup-scan hemo compl bi std,All Other,Per Unit,"$1,136.19 ",OP,235.49,"1,136.19",,,,,,
BCBS Blue Choice,CPT,93986,Dup-scan hemo compl uni std,All Other,Per Unit,$646.72 ,OP,111.51,646.72,,,,,,
BCBS Blue Choice,CPT,93990,Doppler flow testing,All Other,Per Unit,$956.99 ,OP,111.51,956.99,,,,,,
BCBS Blue Choice,CPT,94002,Vent mgmt inpat init day,All Other,Per Unit,$541.40 ,OP,496.58,541.4,,,,,,
BCBS Blue Choice,CPT,94004,Vent mgmt nf per day,All Other,Per Unit,$285.96 ,OP,285.96,285.96,,,,,,
BCBS Blue Choice,CPT,94005,Home vent mgmt supervision,All Other,Per Unit,$545.21 ,OP,545.21,545.21,,,,,,
BCBS Blue Choice,CPT,94010,Breathing capacity test,All Other,Per Unit,$209.70 ,OP,142.8,209.7,,,,,,
BCBS Blue Choice,CPT,94014,Patient recorded spirometry,All Other,Per Unit,$301.20 ,OP,276.53,301.2,,,,,,
BCBS Blue Choice,CPT,94015,Patient recorded spirometry,All Other,Per Unit,$148.69 ,OP,148.69,270.61,,,,,,
BCBS Blue Choice,CPT,94016,Review patient spirometry,All Other,Per Unit,$152.51 ,OP,24.7,152.51,,,,,,
BCBS Blue Choice,CPT,94060,Evaluation of wheezing,All Other,Per Unit,$369.83 ,OP,270.61,369.83,,,,,,
BCBS Blue Choice,CPT,94070,Evaluation of wheezing,All Other,Per Unit,$392.70 ,OP,270.61,392.7,,,,,,
BCBS Blue Choice,CPT,94150,Vital capacity test,All Other,Per Unit,$141.07 ,OP,141.07,142.8,,,,,,
BCBS Blue Choice,CPT,94200,Lung function test (mbc/mvv),All Other,Per Unit,$144.88 ,OP,56.95,144.88,,,,,,
BCBS Blue Choice,CPT,94240,Residual lung capacity,All Other,Per Unit,$251.64 ,OP,251.64,251.64,,,,,,
BCBS Blue Choice,CPT,94250,Expired gas collection,All Other,Per Unit,$152.51 ,OP,152.51,152.51,,,,,,
BCBS Blue Choice,CPT,94260,Thoracic gas volume,All Other,Per Unit,$202.07 ,OP,202.07,202.07,,,,,,
BCBS Blue Choice,CPT,94350,Lung nitrogen washout curve,All Other,Per Unit,$221.14 ,OP,221.14,221.14,,,,,,
BCBS Blue Choice,CPT,94360,Measure airflow resistance,All Other,Per Unit,$282.14 ,OP,282.14,282.14,,,,,,
BCBS Blue Choice,CPT,94370,Breath airway closing volume,All Other,Per Unit,$209.70 ,OP,209.7,209.7,,,,,,
BCBS Blue Choice,CPT,94375,Respiratory flow volume loop,All Other,Per Unit,$232.58 ,OP,232.58,270.61,,,,,,
BCBS Blue Choice,CPT,94400,Co2 breathing response curve,All Other,Per Unit,$339.33 ,OP,339.33,339.33,,,,,,
BCBS Blue Choice,CPT,94450,Hypoxia response curve,All Other,Per Unit,$316.46 ,OP,270.61,316.46,,,,,,
BCBS Blue Choice,CPT,94452,Hast w/report,All Other,Per Unit,$346.96 ,OP,114.56,346.96,,,,,,
BCBS Blue Choice,CPT,94453,Hast w/oxygen titrate,All Other,Per Unit,$461.34 ,OP,114.56,461.34,,,,,,
BCBS Blue Choice,CPT,94610,Surfactant admin thru tube,All Other,Per Unit,$438.47 ,OP,192.26,438.47,,,,,,
BCBS Blue Choice,CPT,94617,Exercise tst brncspsm w/ecg,All Other,Per Unit,$465.15 ,OP,114.56,465.15,,,,,,
BCBS Blue Choice,CPT,94618,Pulmonary stress testing,All Other,Per Unit,$465.15 ,OP,114.56,465.15,,,,,,
BCBS Blue Choice,CPT,94620,Pulmonary stress test/simple,All Other,Per Unit,$465.15 ,OP,465.15,465.15,,,,,,
BCBS Blue Choice,CPT,94621,Cardiopulm exercise testing,All Other,Per Unit,"$1,017.99 ",OP,270.61,"1,017.99",,,,,,
BCBS Blue Choice,CPT,94640,Airway inhalation treatment,All Other,Per Unit,$87.69 ,OP,87.69,192.26,,,,,,
BCBS Blue Choice,CPT,94642,Aerosol inhalation treatment,All Other,Per Unit,$255.45 ,OP,192.26,255.45,,,,,,
BCBS Blue Choice,CPT,94644,Cbt 1st hour,All Other,Per Unit,$217.32 ,OP,114.56,217.32,,,,,,
BCBS Blue Choice,CPT,94645,Cbt each addl hour,All Other,Per Unit,$87.69 ,OP,87.69,87.69,,,,,,
BCBS Blue Choice,CPT,94660,Pos airway pressure cpap,All Other,Per Unit,$346.96 ,OP,192.26,346.96,,,,,,
BCBS Blue Choice,CPT,94662,Neg press ventilation cnp,All Other,Per Unit,$221.14 ,OP,221.14,496.58,,,,,,
BCBS Blue Choice,CPT,94664,Evaluate pt use of inhaler,All Other,Per Unit,$99.13 ,OP,99.13,192.26,,,,,,
BCBS Blue Choice,CPT,94667,Chest wall manipulation,All Other,Per Unit,$137.25 ,OP,114.56,137.25,,,,,,
BCBS Blue Choice,CPT,94680,Exhaled air analysis o2,All Other,Per Unit,$369.83 ,OP,142.8,369.83,,,,,,
BCBS Blue Choice,CPT,94690,Exhaled air analysis,All Other,Per Unit,$320.27 ,OP,56.95,320.27,,,,,,
BCBS Blue Choice,CPT,94720,Monoxide diffusing capacity,All Other,Per Unit,$331.70 ,OP,331.7,331.7,,,,,,
BCBS Blue Choice,CPT,94725,Membrane diffusion capacity,All Other,Per Unit,$438.47 ,OP,438.47,438.47,,,,,,
BCBS Blue Choice,CPT,94726,Pulm funct tst plethysmograp,All Other,Per Unit,$282.14 ,OP,270.61,282.14,,,,,,
BCBS Blue Choice,CPT,94727,Pulm function test by gas,All Other,Per Unit,$221.14 ,OP,142.8,221.14,,,,,,
BCBS Blue Choice,CPT,94728,Airwy resist by oscillometry,All Other,Per Unit,$282.14 ,OP,270.61,282.14,,,,,,
BCBS Blue Choice,CPT,94729,Co/membane diffuse capacity,All Other,Per Unit,$438.47 ,OP,438.47,438.47,,,,,,
BCBS Blue Choice,CPT,94750,Pulmonary compliance study,All Other,Per Unit,$446.08 ,OP,446.08,446.08,,,,,,
BCBS Blue Choice,CPT,94760,Measure blood oxygen level,All Other,Per Unit,$22.88 ,OP,22.88,22.88,,,,,,
BCBS Blue Choice,CPT,94761,Measure blood oxygen level,All Other,Per Unit,$45.74 ,OP,45.74,45.74,,,,,,
BCBS Blue Choice,CPT,94762,Measure blood oxygen level,All Other,Per Unit,$202.07 ,OP,142.8,202.07,,,,,,
BCBS Blue Choice,CPT,94770,Exhaled carbon dioxide test,All Other,Per Unit,$240.20 ,OP,240.2,240.2,,,,,,
BCBS Blue Choice,CPT,95004,Percut allergy skin tests,All Other,Per Unit,$30.51 ,OP,30.51,941.27,,,,,,
BCBS Blue Choice,CPT,95010,Percut allergy titrate test,All Other,Per Unit,$87.69 ,OP,87.69,87.69,,,,,,
BCBS Blue Choice,CPT,95012,Exhaled nitric oxide meas,All Other,Per Unit,$102.95 ,OP,34.63,102.95,,,,,,
BCBS Blue Choice,CPT,95015,Id allergy titrate-drug/bug,All Other,Per Unit,$64.82 ,OP,64.82,64.82,,,,,,
BCBS Blue Choice,CPT,95017,Perq & icut allg test venoms,All Other,Per Unit,$87.69 ,OP,25.25,87.69,,,,,,
BCBS Blue Choice,CPT,95018,Perq&ic allg test drugs/biol,All Other,Per Unit,$87.69 ,OP,34.63,87.69,,,,,,
BCBS Blue Choice,CPT,95024,Icut allergy test drug/bug,All Other,Per Unit,$38.13 ,OP,38.13,56.95,,,,,,
BCBS Blue Choice,CPT,95027,Icut allergy titrate-airborn,All Other,Per Unit,$26.70 ,OP,25.25,26.7,,,,,,
BCBS Blue Choice,CPT,95028,Icut allergy test-delayed,All Other,Per Unit,$57.19 ,OP,34.63,57.19,,,,,,
BCBS Blue Choice,CPT,95044,Allergy patch tests,All Other,Per Unit,$34.31 ,OP,34.31,941.27,,,,,,
BCBS Blue Choice,CPT,95052,Photo patch test,All Other,Per Unit,$38.13 ,OP,38.13,56.95,,,,,,
BCBS Blue Choice,CPT,95056,Photosensitivity tests,All Other,Per Unit,$179.20 ,OP,114.56,179.2,,,,,,
BCBS Blue Choice,CPT,95060,Eye allergy tests,All Other,Per Unit,$122.00 ,OP,114.56,122,,,,,,
BCBS Blue Choice,CPT,95065,Nose allergy test,All Other,Per Unit,$110.57 ,OP,34.63,110.57,,,,,,
BCBS Blue Choice,CPT,95071,Bronchial allergy tests,All Other,Per Unit,$278.32 ,OP,278.32,278.32,,,,,,
BCBS Blue Choice,CPT,95075,Ingestion challenge test,All Other,Per Unit,$320.27 ,OP,320.27,320.27,,,,,,
BCBS Blue Choice,CPT,95076,Ingest challenge ini 120 min,All Other,Per Unit,$320.27 ,OP,320.27,499.16,,,,,,
BCBS Blue Choice,CPT,95115,Immunotherapy one injection,All Other,Per Unit,$57.19 ,OP,40.93,57.19,,,,,,
BCBS Blue Choice,CPT,95117,Immunotherapy injections,All Other,Per Unit,$68.63 ,OP,40.93,68.63,,,,,,
BCBS Blue Choice,CPT,95125,Immunotherapy 2/> injections,All Other,Per Unit,$83.87 ,OP,83.87,83.87,,,,,,
BCBS Blue Choice,CPT,95130,Immntx 1 sting insect,All Other,Per Unit,$114.39 ,OP,114.39,114.39,,,,,,
BCBS Blue Choice,CPT,95133,Immntx 4 sting insects,All Other,Per Unit,$213.51 ,OP,213.51,213.51,,,,,,
BCBS Blue Choice,CPT,95134,Immntx 5 sting insects,All Other,Per Unit,$255.45 ,OP,255.45,255.45,,,,,,
BCBS Blue Choice,CPT,95144,Antigen therapy services,All Other,Per Unit,$61.00 ,OP,40.93,61,,,,,,
BCBS Blue Choice,CPT,95145,Antigen therapy services,All Other,Per Unit,$80.07 ,OP,40.93,80.07,,,,,,
BCBS Blue Choice,CPT,95146,Antigen therapy services,All Other,Per Unit,$129.64 ,OP,40.93,129.64,,,,,,
BCBS Blue Choice,CPT,95147,Antigen therapy services,All Other,Per Unit,$125.82 ,OP,63.42,125.82,,,,,,
BCBS Blue Choice,CPT,95148,Antigen therapy services,All Other,Per Unit,$179.20 ,OP,63.42,179.2,,,,,,
BCBS Blue Choice,CPT,95149,Antigen therapy services,All Other,Per Unit,$232.58 ,OP,63.42,232.58,,,,,,
BCBS Blue Choice,CPT,95165,Antigen therapy services,All Other,Per Unit,$61.00 ,OP,40.93,61,,,,,,
BCBS Blue Choice,CPT,95170,Antigen therapy services,All Other,Per Unit,$49.56 ,OP,40.93,49.56,,,,,,
BCBS Blue Choice,CPT,95249,Cont gluc mntr pt prov eqp,All Other,Per Unit,$686.28 ,OP,56.95,686.28,,,,,,
BCBS Blue Choice,CPT,95250,Cont gluc mntr phys/qhp eqp,All Other,Per Unit,$686.28 ,OP,121.51,686.28,,,,,,
BCBS Blue Choice,CPT,95251,Cont gluc mntr analysis i&r,All Other,Per Unit,$205.88 ,OP,205.88,205.88,,,,,,
BCBS Blue Choice,CPT,95782,Polysom <6 yrs 4/> paramtrs,All Other,Per Unit,"$4,472.29 ",OP,941.27,"4,472.29",,,,,,
BCBS Blue Choice,CPT,95783,Polysom <6 yrs cpap/bilvl,All Other,Per Unit,"$4,472.29 ",OP,941.27,"4,472.29",,,,,,
BCBS Blue Choice,CPT,95805,Multiple sleep latency test,All Other,Per Unit,"$2,249.49 ",OP,499.16,"2,249.49",,,,,,
BCBS Blue Choice,CPT,95806,Sleep study unatt&resp efft,All Other,Per Unit,$413.80 ,OP,142.8,413.8,,,,,,
BCBS Blue Choice,CPT,95807,Sleep study attended,All Other,Per Unit,"$2,638.38 ",OP,499.16,"2,638.38",,,,,,
BCBS Blue Choice,CPT,95810,Polysom 6/> yrs 4/> param,All Other,Per Unit,"$1,103.46 ",OP,941.27,"1,103.46",,,,,,
BCBS Blue Choice,CPT,95811,Polysom 6/>yrs cpap 4/> parm,All Other,Per Unit,"$1,103.46 ",OP,941.27,"1,103.46",,,,,,
BCBS Blue Choice,CPT,95812,Eeg 41-60 minutes,All Other,Per Unit,"$1,242.94 ",OP,270.61,"1,242.94",,,,,,
BCBS Blue Choice,CPT,95813,Eeg extnd mntr 61-119 min,All Other,Per Unit,"$1,521.26 ",OP,270.61,"1,521.26",,,,,,
BCBS Blue Choice,CPT,95816,Eeg awake and drowsy,All Other,Per Unit,"$1,139.99 ",OP,270.61,"1,139.99",,,,,,
BCBS Blue Choice,CPT,95819,Eeg awake and asleep,All Other,Per Unit,"$1,223.88 ",OP,270.61,"1,223.88",,,,,,
BCBS Blue Choice,CPT,95822,Eeg coma or sleep only,All Other,Per Unit,"$1,223.88 ",OP,270.61,"1,223.88",,,,,,
BCBS Blue Choice,CPT,95824,Eeg cerebral death only,All Other,Per Unit,$503.28 ,OP,499.16,503.28,,,,,,
BCBS Blue Choice,CPT,95827,Eeg all night recording,All Other,Per Unit,"$1,967.35 ",OP,"1,967.35","1,967.35",,,,,,
BCBS Blue Choice,CPT,95829,Surgery electrocorticogram,All Other,Per Unit,"$6,275.69 ",OP,"6,275.69","6,275.69",,,,,,
BCBS Blue Choice,CPT,95830,Insert electrodes for eeg,All Other,Per Unit,$911.23 ,OP,911.23,911.23,,,,,,
BCBS Blue Choice,CPT,95831,Limb muscle testing manual,All Other,Per Unit,$129.64 ,OP,129.64,129.64,,,,,,
BCBS Blue Choice,CPT,95833,Body muscle testing manual,All Other,Per Unit,$183.02 ,OP,183.02,183.02,,,,,,
BCBS Blue Choice,CPT,95834,Body muscle testing manual,All Other,Per Unit,$217.32 ,OP,217.32,217.32,,,,,,
BCBS Blue Choice,CPT,95851,Range of motion measurements,All Other,Per Unit,$83.87 ,OP,7.59,83.87,,,,,,
BCBS Blue Choice,CPT,95852,Range of motion measurements,All Other,Per Unit,$64.82 ,OP,5.52,64.82,,,,,,
BCBS Blue Choice,CPT,95857,Cholinesterase challenge,All Other,Per Unit,$209.70 ,OP,209.7,270.61,,,,,,
BCBS Blue Choice,CPT,95860,Muscle test one limb,All Other,Per Unit,$423.22 ,OP,114.56,423.22,,,,,,
BCBS Blue Choice,CPT,95861,Muscle test 2 limbs,All Other,Per Unit,$613.85 ,OP,114.56,613.85,,,,,,
BCBS Blue Choice,CPT,95863,Muscle test 3 limbs,All Other,Per Unit,$732.04 ,OP,142.8,732.04,,,,,,
BCBS Blue Choice,CPT,95864,Muscle test 4 limbs,All Other,Per Unit,$850.23 ,OP,142.8,850.23,,,,,,
BCBS Blue Choice,CPT,95865,Muscle test larynx,All Other,Per Unit,$439.00 ,OP,114.56,439,,,,,,
BCBS Blue Choice,CPT,95866,Muscle test hemidiaphragm,All Other,Per Unit,$480.40 ,OP,142.8,480.4,,,,,,
BCBS Blue Choice,CPT,95867,Muscle test cran nerv unilat,All Other,Per Unit,$369.83 ,OP,270.61,369.83,,,,,,
BCBS Blue Choice,CPT,95868,Muscle test cran nerve bilat,All Other,Per Unit,$503.28 ,OP,270.61,503.28,,,,,,
BCBS Blue Choice,CPT,95869,Muscle test thor paraspinal,All Other,Per Unit,$236.38 ,OP,142.8,236.38,,,,,,
BCBS Blue Choice,CPT,95870,Muscle test nonparaspinal,All Other,Per Unit,$228.77 ,OP,114.56,228.77,,,,,,
BCBS Blue Choice,CPT,95872,Muscle test one fiber,All Other,Per Unit,$635.69 ,OP,142.8,635.69,,,,,,
BCBS Blue Choice,CPT,95873,Guide nerv destr elec stim,All Other,Per Unit,$179.59 ,OP,179.59,179.59,,,,,,
BCBS Blue Choice,CPT,95874,Guide nerv destr needle emg,All Other,Per Unit,$168.19 ,OP,168.19,168.19,,,,,,
BCBS Blue Choice,CPT,95875,Limb exercise test,All Other,Per Unit,$364.88 ,OP,142.8,364.88,,,,,,
BCBS Blue Choice,CPT,95900,Motor nerve conduction test,All Other,Per Unit,$205.25 ,OP,205.25,205.25,,,,,,
BCBS Blue Choice,CPT,95903,Motor nerve conduction test,All Other,Per Unit,$324.09 ,OP,324.09,324.09,,,,,,
BCBS Blue Choice,CPT,95904,Sense nerve conduction test,All Other,Per Unit,$244.01 ,OP,244.01,244.01,,,,,,
BCBS Blue Choice,CPT,95920,Intraop nerve test add-on,All Other,Per Unit,$796.85 ,OP,796.85,796.85,,,,,,
BCBS Blue Choice,CPT,95921,Autonomic nrv parasym inervj,All Other,Per Unit,$282.21 ,OP,142.8,282.21,,,,,,
BCBS Blue Choice,CPT,95923,Autonomic nrv syst funj test,All Other,Per Unit,$447.55 ,OP,114.56,447.55,,,,,,
BCBS Blue Choice,CPT,95925,Somatosensory testing,All Other,Per Unit,$461.80 ,OP,270.61,461.8,,,,,,
BCBS Blue Choice,CPT,95926,Somatosensory testing,All Other,Per Unit,$602.41 ,OP,270.61,602.41,,,,,,
BCBS Blue Choice,CPT,95927,Somatosensory testing,All Other,Per Unit,$621.47 ,OP,270.61,621.47,,,,,,
BCBS Blue Choice,CPT,95928,C motor evoked uppr limbs,All Other,Per Unit,$964.61 ,OP,941.27,964.61,,,,,,
BCBS Blue Choice,CPT,95929,C motor evoked lwr limbs,All Other,Per Unit,"$1,017.99 ",OP,499.16,"1,017.99",,,,,,
BCBS Blue Choice,CPT,95930,Visual ep test cns w/i&r,All Other,Per Unit,$537.60 ,OP,270.61,537.6,,,,,,
BCBS Blue Choice,CPT,95933,Blink reflex test,All Other,Per Unit,$339.33 ,OP,56.95,339.33,,,,,,
BCBS Blue Choice,CPT,95934,H-reflex test,All Other,Per Unit,$247.83 ,OP,247.83,247.83,,,,,,
BCBS Blue Choice,CPT,95936,H-reflex test,All Other,Per Unit,$221.14 ,OP,221.14,221.14,,,,,,
BCBS Blue Choice,CPT,95937,Neuromuscular junction test,All Other,Per Unit,$305.01 ,OP,142.8,305.01,,,,,,
BCBS Blue Choice,CPT,95950,Ambulatory eeg monitoring,All Other,Per Unit,"$1,303.93 ",OP,"1,303.93","1,303.93",,,,,,
BCBS Blue Choice,CPT,95951,Eeg monitoring/videorecord,All Other,Per Unit,"$3,980.46 ",OP,"3,980.46","3,980.46",,,,,,
BCBS Blue Choice,CPT,95953,Eeg monitoring/computer,All Other,Per Unit,"$2,142.73 ",OP,"2,142.73","2,142.73",,,,,,
BCBS Blue Choice,CPT,95954,Eeg monitoring/giving drugs,All Other,Per Unit,"$1,277.26 ",OP,499.16,"1,277.26",,,,,,
BCBS Blue Choice,CPT,95955,Eeg during surgery,All Other,Per Unit,$739.67 ,OP,739.67,739.67,,,,,,
BCBS Blue Choice,CPT,95956,Eeg monitor technol attended,All Other,Per Unit,"$3,721.19 ",OP,"3,721.19","3,721.19",,,,,,
BCBS Blue Choice,CPT,95957,Eeg digital analysis,All Other,Per Unit,"$1,357.32 ",OP,"1,357.32","1,357.32",,,,,,
BCBS Blue Choice,CPT,95958,Eeg monitoring/function test,All Other,Per Unit,"$1,982.60 ",OP,941.27,"1,982.60",,,,,,
BCBS Blue Choice,CPT,95961,Electrode stimulation brain,All Other,Per Unit,"$1,265.81 ",OP,941.27,"1,265.81",,,,,,
BCBS Blue Choice,CPT,95962,Electrode stim brain add-on,All Other,Per Unit,"$1,136.19 ",OP,"1,136.19","1,136.19",,,,,,
BCBS Blue Choice,CPT,95965,Meg spontaneous,All Other,Per Unit,"$10,992.00 ",OP,941.27,"10,992.00",,,,,,
BCBS Blue Choice,CPT,95966,Meg evoked single,All Other,Per Unit,"$5,455.97 ",OP,941.27,"5,455.97",,,,,,
BCBS Blue Choice,CPT,95967,Meg evoked each addl,All Other,Per Unit,"$4,666.74 ",OP,"4,666.74","4,666.74",,,,,,
BCBS Blue Choice,CPT,95970,Alys npgt w/o prgrmg,All Other,Per Unit,$255.45 ,OP,114.56,255.45,,,,,,
BCBS Blue Choice,CPT,95971,Alys smpl sp/pn npgt w/prgrm,All Other,Per Unit,$297.39 ,OP,102.65,297.39,,,,,,
BCBS Blue Choice,CPT,95972,Alys cplx sp/pn npgt w/prgrm,All Other,Per Unit,$533.78 ,OP,102.65,533.78,,,,,,
BCBS Blue Choice,CPT,95973,Analyze neurostim complex,All Other,Per Unit,$289.76 ,OP,289.76,289.76,,,,,,
BCBS Blue Choice,CPT,95974,Cranial neurostim complex,All Other,Per Unit,$876.92 ,OP,876.92,876.92,,,,,,
BCBS Blue Choice,CPT,95975,Cranial neurostim complex,All Other,Per Unit,$491.83 ,OP,491.83,491.83,,,,,,
BCBS Blue Choice,CPT,95976,Alys smpl cn npgt prgrmg,All Other,Per Unit,$657.70 ,OP,38.02,657.7,,,,,,
BCBS Blue Choice,CPT,95977,Alys cplx cn npgt prgrmg,All Other,Per Unit,$876.92 ,OP,102.65,876.92,,,,,,
BCBS Blue Choice,CPT,95978,Analyze neurostim brain/1h,All Other,Per Unit,"$1,040.87 ",OP,"1,040.87","1,040.87",,,,,,
BCBS Blue Choice,CPT,95980,Io anal gast n-stim init,All Other,Per Unit,$213.51 ,OP,213.51,213.51,,,,,,
BCBS Blue Choice,CPT,95981,Io anal gast n-stim subsq,All Other,Per Unit,$144.88 ,OP,114.56,144.88,,,,,,
BCBS Blue Choice,CPT,95982,Io ga n-stim subsq w/reprog,All Other,Per Unit,$224.95 ,OP,38.02,224.95,,,,,,
BCBS Blue Choice,CPT,95983,Alys brn npgt prgrmg 15 min,All Other,Per Unit,$260.22 ,OP,102.65,260.22,,,,,,
BCBS Blue Choice,CPT,95984,Alys brn npgt prgrmg addl 15,All Other,Per Unit,$227.69 ,OP,227.69,227.69,,,,,,
BCBS Blue Choice,CPT,95990,Spin/brain pump refil & main,All Other,Per Unit,$312.64 ,OP,312.64,318,,,,,,
BCBS Blue Choice,CPT,95991,Spin/brain pump refil & main,All Other,Per Unit,$453.71 ,OP,267.26,453.71,,,,,,
BCBS Blue Choice,CPT,96000,Motion analysis video/3d,All Other,Per Unit,$449.90 ,OP,449.9,499.16,,,,,,
BCBS Blue Choice,CPT,96001,Motion test w/ft press meas,All Other,Per Unit,$526.16 ,OP,526.16,941.27,,,,,,
BCBS Blue Choice,CPT,96003,Dynamic fine wire emg,All Other,Per Unit,$91.51 ,OP,91.51,270.61,,,,,,
BCBS Blue Choice,CPT,96004,Phys review of motion tests,All Other,Per Unit,$568.09 ,OP,568.09,568.09,,,,,,
BCBS Blue Choice,CPT,96020,Functional brain mapping,All Other,Per Unit,$922.67 ,OP,922.67,922.67,,,,,,
BCBS Blue Choice,CPT,96040,Genetic counseling 30 min,All Other,Per Unit,$209.70 ,OP,209.7,209.7,,,,,,
BCBS Blue Choice,CPT,96101,Psycho testing by psych/phys,All Other,Per Unit,$438.47 ,OP,438.47,438.47,,,,,,
BCBS Blue Choice,CPT,96102,Psycho testing by technician,All Other,Per Unit,$266.89 ,OP,266.89,266.89,,,,,,
BCBS Blue Choice,CPT,96103,Psycho testing admin by comp,All Other,Per Unit,$244.01 ,OP,244.01,244.01,,,,,,
BCBS Blue Choice,CPT,96105,Assessment of aphasia,All Other,Per Unit,$419.40 ,OP,98.92,419.4,,,,,,
BCBS Blue Choice,CPT,96110,Developmental screen w/score,All Other,Per Unit,$95.32 ,OP,95.32,95.32,,,,,,
BCBS Blue Choice,CPT,96111,Developmental test extend,All Other,Per Unit,$693.90 ,OP,693.9,693.9,,,,,,
BCBS Blue Choice,CPT,96112,Devel tst phys/qhp 1st hr,All Other,Per Unit,$693.90 ,OP,270.61,693.9,,,,,,
BCBS Blue Choice,CPT,96113,Devel tst phys/qhp ea addl,All Other,Per Unit,$317.16 ,OP,317.16,317.16,,,,,,
BCBS Blue Choice,CPT,96116,Nubhvl xm phys/qhp 1st hr,All Other,Per Unit,$518.52 ,OP,270.61,518.52,,,,,,
BCBS Blue Choice,CPT,96118,Neuropsych tst by psych/phys,All Other,Per Unit,$583.35 ,OP,583.35,583.35,,,,,,
BCBS Blue Choice,CPT,96119,Neuropsych testing by tec,All Other,Per Unit,$415.59 ,OP,415.59,415.59,,,,,,
BCBS Blue Choice,CPT,96120,Neuropsych tst admin w/comp,All Other,Per Unit,$362.21 ,OP,362.21,362.21,,,,,,
BCBS Blue Choice,CPT,96121,Nubhvl xm phy/qhp ea addl hr,All Other,Per Unit,$475.49 ,OP,475.49,475.49,,,,,,
BCBS Blue Choice,CPT,96125,Cognitive test by hc pro,All Other,Per Unit,$510.90 ,OP,103.76,510.9,,,,,,
BCBS Blue Choice,CPT,96130,Psycl tst eval phys/qhp 1st,All Other,Per Unit,$438.47 ,OP,270.61,438.47,,,,,,
BCBS Blue Choice,CPT,96131,Psycl tst eval phys/qhp ea,All Other,Per Unit,$333.80 ,OP,333.8,333.8,,,,,,
BCBS Blue Choice,CPT,96132,Nrpsyc tst eval phys/qhp 1st,All Other,Per Unit,$583.35 ,OP,270.61,583.35,,,,,,
BCBS Blue Choice,CPT,96133,Nrpsyc tst eval phys/qhp ea,All Other,Per Unit,$447.11 ,OP,447.11,447.11,,,,,,
BCBS Blue Choice,CPT,96136,Psycl/nrpsyc tst phy/qhp 1st,All Other,Per Unit,$219.24 ,OP,114.56,219.24,,,,,,
BCBS Blue Choice,CPT,96137,Psycl/nrpsyc tst phy/qhp ea,All Other,Per Unit,$172.25 ,OP,172.25,172.25,,,,,,
BCBS Blue Choice,CPT,96138,Psycl/nrpsyc tech 1st,All Other,Per Unit,$133.45 ,OP,133.45,276.53,,,,,,
BCBS Blue Choice,CPT,96139,Psycl/nrpsyc tst tech ea,All Other,Per Unit,$133.45 ,OP,133.45,133.45,,,,,,
BCBS Blue Choice,CPT,96146,Psycl/nrpsyc tst auto result,All Other,Per Unit,$18.80 ,OP,18.8,25.25,,,,,,
BCBS Blue Choice,CPT,96150,Assess hlth/behave init,All Other,Per Unit,$129.64 ,OP,129.64,129.64,,,,,,
BCBS Blue Choice,CPT,96151,Assess hlth/behave subseq,All Other,Per Unit,$125.82 ,OP,125.82,125.82,,,,,,
BCBS Blue Choice,CPT,96152,Intervene hlth/behave indiv,All Other,Per Unit,$118.19 ,OP,118.19,118.19,,,,,,
BCBS Blue Choice,CPT,96153,Intervene hlth/behave group,All Other,Per Unit,$30.51 ,OP,30.51,30.51,,,,,,
BCBS Blue Choice,CPT,96154,Interv hlth/behav fam w/pt,All Other,Per Unit,$118.19 ,OP,118.19,118.19,,,,,,
BCBS Blue Choice,CPT,96156,Hlth bhv assmt/reassessment,All Other,Per Unit,$526.34 ,OP,76.62,526.34,,,,,,
BCBS Blue Choice,CPT,96158,Hlth bhv ivntj indiv 1st 30,All Other,Per Unit,$236.39 ,OP,76.62,236.39,,,,,,
BCBS Blue Choice,CPT,96159,Hlth bhv ivntj indiv ea addl,All Other,Per Unit,$81.57 ,OP,81.57,81.57,,,,,,
BCBS Blue Choice,CPT,96164,Hlth bhv ivntj grp 1st 30,All Other,Per Unit,$61.03 ,OP,26.84,61.03,,,,,,
BCBS Blue Choice,CPT,96165,Hlth bhv ivntj grp ea addl,All Other,Per Unit,$30.51 ,OP,30.51,30.51,,,,,,
BCBS Blue Choice,CPT,96167,Hlth bhv ivntj fam 1st 30,All Other,Per Unit,$236.39 ,OP,26.84,236.39,,,,,,
BCBS Blue Choice,CPT,96168,Hlth bhv ivntj fam ea addl,All Other,Per Unit,$118.19 ,OP,118.19,118.19,,,,,,
BCBS Blue Choice,CPT,96360,Hydration iv infusion init,All Other,Per Unit,$293.57 ,OP,208.24,293.57,,,,,,
BCBS Blue Choice,CPT,96361,Hydrate iv infusion add-on,All Other,Per Unit,$122.99 ,OP,40.93,122.99,,,,,,
BCBS Blue Choice,CPT,96365,Ther/proph/diag iv inf init,All Other,Per Unit,$354.58 ,OP,208.24,354.58,,,,,,
BCBS Blue Choice,CPT,96366,Ther/proph/diag iv inf addon,All Other,Per Unit,$114.39 ,OP,40.93,114.39,,,,,,
BCBS Blue Choice,CPT,96367,Tx/proph/dg addl seq iv inf,All Other,Per Unit,$179.20 ,OP,63.42,179.2,,,,,,
BCBS Blue Choice,CPT,96368,Ther/diag concurrent inf,All Other,Per Unit,$106.76 ,OP,106.76,106.76,,,,,,
BCBS Blue Choice,CPT,96369,Sc ther infusion up to 1 hr,All Other,Per Unit,$758.72 ,OP,208.24,758.72,,,,,,
BCBS Blue Choice,CPT,96370,Sc ther infusion addl hr,All Other,Per Unit,$83.87 ,OP,40.93,83.87,,,,,,
BCBS Blue Choice,CPT,96371,Sc ther infusion reset pump,All Other,Per Unit,$366.02 ,OP,63.42,366.02,,,,,,
BCBS Blue Choice,CPT,96372,Ther/proph/diag inj sc/im,All Other,Per Unit,$106.76 ,OP,63.42,106.76,,,,,,
BCBS Blue Choice,CPT,96374,Ther/proph/diag inj iv push,All Other,Per Unit,$278.32 ,OP,208.24,278.32,,,,,,
BCBS Blue Choice,CPT,96375,Tx/pro/dx inj new drug addon,All Other,Per Unit,$202.94 ,OP,40.93,202.94,,,,,,
BCBS Blue Choice,CPT,96376,Tx/pro/dx inj same drug adon,All Other,Per Unit,$184.49 ,OP,184.49,184.49,,,,,,
BCBS Blue Choice,CPT,96401,Chemo anti-neopl sq/im,All Other,Per Unit,$377.46 ,OP,63.42,377.46,,,,,,
BCBS Blue Choice,CPT,96402,Chemo hormon antineopl sq/im,All Other,Per Unit,$205.88 ,OP,63.42,205.88,,,,,,
BCBS Blue Choice,CPT,96405,Chemo intralesional up to 7,All Other,Per Unit,$468.96 ,OP,63.42,468.96,,,,,,
BCBS Blue Choice,CPT,96406,Chemo intralesional over 7,All Other,Per Unit,$648.16 ,OP,208.24,648.16,,,,,,
BCBS Blue Choice,CPT,96409,Chemo iv push sngl drug,All Other,Per Unit,$629.10 ,OP,208.24,629.1,,,,,,
BCBS Blue Choice,CPT,96411,Chemo iv push addl drug,All Other,Per Unit,$362.21 ,OP,63.42,362.21,,,,,,
BCBS Blue Choice,CPT,96413,Chemo iv infusion 1 hr,All Other,Per Unit,$133.34 ,OP,133.34,318,,,,,,
BCBS Blue Choice,CPT,96415,Chemo iv infusion addl hr,All Other,Per Unit,$202.07 ,OP,63.42,202.07,,,,,,
BCBS Blue Choice,CPT,96416,Chemo prolong infuse w/pump,All Other,Per Unit,$926.48 ,OP,318,926.48,,,,,,
BCBS Blue Choice,CPT,96417,Chemo iv infus each addl seq,All Other,Per Unit,$427.03 ,OP,63.42,427.03,,,,,,
BCBS Blue Choice,CPT,96420,Chemo ia push tecnique,All Other,Per Unit,$613.85 ,OP,318,613.85,,,,,,
BCBS Blue Choice,CPT,96422,Chemo ia infusion up to 1 hr,All Other,Per Unit,$979.86 ,OP,208.24,979.86,,,,,,
BCBS Blue Choice,CPT,96423,Chemo ia infuse each addl hr,All Other,Per Unit,$434.65 ,OP,40.93,434.65,,,,,,
BCBS Blue Choice,CPT,96425,Chemotherapy infusion method,All Other,Per Unit,$968.43 ,OP,318,968.43,,,,,,
BCBS Blue Choice,CPT,96440,Chemotherapy intracavitary,All Other,Per Unit,"$3,339.91 ",OP,318,"3,339.91",,,,,,
BCBS Blue Choice,CPT,96445,Chemotherapy - intracavitary,All Other,Per Unit,"$1,589.90 ",OP,"1,589.90","1,589.90",,,,,,
BCBS Blue Choice,CPT,96450,Chemotherapy into cns,All Other,Per Unit,"$1,159.06 ",OP,318,"1,159.06",,,,,,
BCBS Blue Choice,CPT,96521,Refill/maint portable pump,All Other,Per Unit,$716.79 ,OP,208.24,716.79,,,,,,
BCBS Blue Choice,CPT,96522,Refill/maint pump/resvr syst,All Other,Per Unit,$610.03 ,OP,208.24,610.03,,,,,,
BCBS Blue Choice,CPT,96523,Irrig drug delivery device,All Other,Per Unit,$141.07 ,OP,56.95,141.07,,,,,,
BCBS Blue Choice,CPT,96542,Chemotherapy injection,All Other,Per Unit,$751.10 ,OP,208.24,751.1,,,,,,
BCBS Blue Choice,CPT,96570,Photodynmc tx 30 min add-on,All Other,Per Unit,$331.70 ,OP,331.7,331.7,,,,,,
BCBS Blue Choice,CPT,96571,Photodynamic tx addl 15 min,All Other,Per Unit,$152.51 ,OP,152.51,152.51,,,,,,
BCBS Blue Choice,CPT,96900,Ultraviolet light therapy,All Other,Per Unit,$114.39 ,OP,34.63,114.39,,,,,,
BCBS Blue Choice,CPT,96902,Trichogram,All Other,Per Unit,$118.19 ,OP,118.19,118.19,,,,,,
BCBS Blue Choice,CPT,96904,Whole body photography,All Other,Per Unit,$366.02 ,OP,366.02,366.02,,,,,,
BCBS Blue Choice,CPT,96910,Photochemotherapy with uv-b,All Other,Per Unit,$335.53 ,OP,56.95,335.53,,,,,,
BCBS Blue Choice,CPT,96912,Photochemotherapy with uv-a,All Other,Per Unit,$430.83 ,OP,56.95,430.83,,,,,,
BCBS Blue Choice,CPT,96913,Photochemotherapy uv-a or b,All Other,Per Unit,$651.97 ,OP,353.91,651.97,,,,,,
BCBS Blue Choice,CPT,96922,Laser tx skin >500 sq cm,All Other,Per Unit,"$1,307.75 ",OP,353.91,"1,307.75",,,,,,
BCBS Blue Choice,CPT,97001,Pt evaluation,All Other,Per Unit,$331.70 ,OP,331.7,331.7,,,,,,
BCBS Blue Choice,CPT,97002,Pt re-evaluation,All Other,Per Unit,$175.39 ,OP,175.39,175.39,,,,,,
BCBS Blue Choice,CPT,97003,Ot evaluation,All Other,Per Unit,$354.58 ,OP,354.58,354.58,,,,,,
BCBS Blue Choice,CPT,97004,Ot re-evaluation,All Other,Per Unit,$202.07 ,OP,202.07,202.07,,,,,,
BCBS Blue Choice,CPT,97006,Athletic train reeval,All Other,Per Unit,$137.25 ,OP,137.25,137.25,,,,,,
BCBS Blue Choice,CPT,97010,Hot or cold packs therapy,All Other,Per Unit,$22.88 ,OP,22.88,22.88,,,,,,
BCBS Blue Choice,CPT,97012,Mechanical traction therapy,All Other,Per Unit,$68.63 ,OP,14.55,68.63,,,,,,
BCBS Blue Choice,CPT,97014,Electric stimulation therapy,All Other,Per Unit,$64.82 ,OP,64.82,64.82,,,,,,
BCBS Blue Choice,CPT,97016,Vasopneumatic device therapy,All Other,Per Unit,$72.44 ,OP,11.78,72.44,,,,,,
BCBS Blue Choice,CPT,97022,Whirlpool therapy,All Other,Per Unit,$83.87 ,OP,17.16,83.87,,,,,,
BCBS Blue Choice,CPT,97024,Diathermy eg microwave,All Other,Per Unit,$26.70 ,OP,6.96,26.7,,,,,,
BCBS Blue Choice,CPT,97026,Infrared therapy,All Other,Per Unit,$26.70 ,OP,6.32,26.7,,,,,,
BCBS Blue Choice,CPT,97032,Electrical stimulation,All Other,Per Unit,$76.26 ,OP,14.55,76.26,,,,,,
BCBS Blue Choice,CPT,97033,Electric current therapy,All Other,Per Unit,$114.39 ,OP,19.67,114.39,,,,,,
BCBS Blue Choice,CPT,97034,Contrast bath therapy,All Other,Per Unit,$68.63 ,OP,14.42,68.63,,,,,,
BCBS Blue Choice,CPT,97035,Ultrasound therapy,All Other,Per Unit,$53.38 ,OP,14.1,53.38,,,,,,
BCBS Blue Choice,CPT,97036,Hydrotherapy,All Other,Per Unit,$118.19 ,OP,33.09,118.19,,,,,,
BCBS Blue Choice,CPT,97110,Therapeutic exercises,All Other,Per Unit,$133.45 ,OP,29.26,133.45,,,,,,
BCBS Blue Choice,CPT,97112,Neuromuscular reeducation,All Other,Per Unit,$137.25 ,OP,33.86,137.25,,,,,,
BCBS Blue Choice,CPT,97113,Aquatic therapy/exercises,All Other,Per Unit,$160.13 ,OP,36.67,160.13,,,,,,
BCBS Blue Choice,CPT,97116,Gait training therapy,All Other,Per Unit,$114.39 ,OP,29.26,114.39,,,,,,
BCBS Blue Choice,CPT,97124,Massage therapy,All Other,Per Unit,$106.76 ,OP,28.22,106.76,,,,,,
BCBS Blue Choice,CPT,97127,Ther ivntj w/focus cog funcj,All Other,Per Unit,$114.39 ,OP,114.39,114.39,,,,,,
BCBS Blue Choice,CPT,97129,Ther ivntj 1st 15 min,All Other,Per Unit,$114.39 ,OP,23.04,114.39,,,,,,
BCBS Blue Choice,CPT,97130,Ther ivntj ea addl 15 min,All Other,Per Unit,$110.97 ,OP,22.35,110.97,,,,,,
BCBS Blue Choice,CPT,97140,Manual therapy 1/> regions,All Other,Per Unit,$122.00 ,OP,26.97,122,,,,,,
BCBS Blue Choice,CPT,97150,Group therapeutic procedures,All Other,Per Unit,$83.87 ,OP,17.53,83.87,,,,,,
BCBS Blue Choice,CPT,97161,Pt eval low complex 20 min,All Other,Per Unit,$330.81 ,OP,98.12,330.81,,,,,,
BCBS Blue Choice,CPT,97162,Pt eval mod complex 30 min,All Other,Per Unit,$331.70 ,OP,98.12,331.7,,,,,,
BCBS Blue Choice,CPT,97163,Pt eval high complex 45 min,All Other,Per Unit,$331.70 ,OP,98.12,331.7,,,,,,
BCBS Blue Choice,CPT,97164,Pt re-eval est plan care,All Other,Per Unit,$175.39 ,OP,66.97,175.39,,,,,,
BCBS Blue Choice,CPT,97165,Ot eval low complex 30 min,All Other,Per Unit,$354.58 ,OP,95.26,354.58,,,,,,
BCBS Blue Choice,CPT,97166,Ot eval mod complex 45 min,All Other,Per Unit,$354.58 ,OP,95.26,354.58,,,,,,
BCBS Blue Choice,CPT,97167,Ot eval high complex 60 min,All Other,Per Unit,$354.58 ,OP,95.26,354.58,,,,,,
BCBS Blue Choice,CPT,97168,Ot re-eval est plan care,All Other,Per Unit,$202.07 ,OP,64.11,202.07,,,,,,
BCBS Blue Choice,CPT,97172,Athletic trn re-eval plan cr,All Other,Per Unit,$137.25 ,OP,137.25,137.25,,,,,,
BCBS Blue Choice,CPT,97530,Therapeutic activities,All Other,Per Unit,$137.25 ,OP,37.5,137.25,,,,,,
BCBS Blue Choice,CPT,97532,Cognitive skills development,All Other,Per Unit,$114.39 ,OP,114.39,114.39,,,,,,
BCBS Blue Choice,CPT,97533,Sensory integration,All Other,Per Unit,$122.00 ,OP,57.03,122,,,,,,
BCBS Blue Choice,CPT,97535,Self care mngment training,All Other,Per Unit,$137.25 ,OP,32.44,137.25,,,,,,
BCBS Blue Choice,CPT,97537,Community/work reintegration,All Other,Per Unit,$125.82 ,OP,31.26,125.82,,,,,,
BCBS Blue Choice,CPT,97542,Wheelchair mngment training,All Other,Per Unit,$125.82 ,OP,31.58,125.82,,,,,,
BCBS Blue Choice,CPT,97545,Work hardening,All Other,Per Unit,$564.29 ,OP,564.29,564.29,,,,,,
BCBS Blue Choice,CPT,97546,Work hardening add-on,All Other,Per Unit,$224.95 ,OP,224.95,224.95,,,,,,
BCBS Blue Choice,CPT,97597,Rmvl devital tis 20 cm/<,All Other,Per Unit,$282.14 ,OP,183.73,282.14,,,,,,
BCBS Blue Choice,CPT,97598,Rmvl devital tis addl 20cm/<,All Other,Per Unit,$343.14 ,OP,343.14,343.14,,,,,,
BCBS Blue Choice,CPT,97602,Wound(s) care non-selective,All Other,Per Unit,$171.58 ,OP,171.58,183.73,,,,,,
BCBS Blue Choice,CPT,97605,Neg press wound tx <=50 cm,All Other,Per Unit,$163.95 ,OP,163.95,183.73,,,,,,
BCBS Blue Choice,CPT,97606,Neg press wound tx >50 cm,All Other,Per Unit,$175.39 ,OP,175.39,353.91,,,,,,
BCBS Blue Choice,CPT,97607,Neg press wnd tx <=50 sq cm,All Other,Per Unit,$163.95 ,OP,163.95,353.91,,,,,,
BCBS Blue Choice,CPT,97608,Neg press wound tx >50 cm,All Other,Per Unit,$175.39 ,OP,175.39,353.91,,,,,,
BCBS Blue Choice,CPT,97750,Physical performance test,All Other,Per Unit,$137.25 ,OP,33.07,137.25,,,,,,
BCBS Blue Choice,CPT,97755,Assistive technology assess,All Other,Per Unit,$156.32 ,OP,37.42,156.32,,,,,,
BCBS Blue Choice,CPT,97760,Orthotic mgmt&traing 1st enc,All Other,Per Unit,$152.51 ,OP,47.55,152.51,,,,,,
BCBS Blue Choice,CPT,97761,Prosthetic traing 1st enc,All Other,Per Unit,$133.45 ,OP,40.55,133.45,,,,,,
BCBS Blue Choice,CPT,97762,C/o for orthotic/prosth use,All Other,Per Unit,$160.13 ,OP,160.13,160.13,,,,,,
BCBS Blue Choice,CPT,97763,Orthc/prostc mgmt sbsq enc,All Other,Per Unit,$160.13 ,OP,51.94,160.13,,,,,,
BCBS Blue Choice,CPT,97802,Medical nutrition indiv in,All Other,Per Unit,$148.69 ,OP,30.75,148.69,,,,,,
BCBS Blue Choice,CPT,97803,Med nutrition indiv subseq,All Other,Per Unit,$129.64 ,OP,31.17,129.64,,,,,,
BCBS Blue Choice,CPT,97804,Medical nutrition group,All Other,Per Unit,$64.82 ,OP,16.45,64.82,,,,,,
BCBS Blue Choice,CPT,97810,Acupunct w/o stimul 15 min,All Other,Per Unit,$186.82 ,OP,25.25,186.82,,,,,,
BCBS Blue Choice,CPT,97813,Acupunct w/stimul 15 min,All Other,Per Unit,$198.25 ,OP,25.25,198.25,,,,,,
BCBS Blue Choice,CPT,97814,Acupunct w/stimul addl 15m,All Other,Per Unit,$160.13 ,OP,160.13,160.13,,,,,,
BCBS Blue Choice,CPT,98925,Osteopath manj 1-2 regions,All Other,Per Unit,$141.07 ,OP,27.17,141.07,,,,,,
BCBS Blue Choice,CPT,98927,Osteopath manj 5-6 regions,All Other,Per Unit,$251.64 ,OP,27.17,251.64,,,,,,
BCBS Blue Choice,CPT,98928,Osteopath manj 7-8 regions,All Other,Per Unit,$297.39 ,OP,27.17,297.39,,,,,,
BCBS Blue Choice,CPT,98929,Osteopath manj 9-10 regions,All Other,Per Unit,$343.14 ,OP,27.17,343.14,,,,,,
BCBS Blue Choice,CPT,98940,Chiropract manj 1-2 regions,All Other,Per Unit,$125.82 ,OP,27.17,125.82,,,,,,
BCBS Blue Choice,CPT,98941,Chiropract manj 3-4 regions,All Other,Per Unit,$171.58 ,OP,27.17,171.58,,,,,,
BCBS Blue Choice,CPT,98942,Chiropractic manj 5 regions,All Other,Per Unit,$224.95 ,OP,27.17,224.95,,,,,,
BCBS Blue Choice,CPT,98943,Chiropract manj xtrspinl 1/>,All Other,Per Unit,$118.19 ,OP,118.19,118.19,,,,,,
BCBS Blue Choice,CPT,98960,Self-mgmt educ & train 1 pt,All Other,Per Unit,$122.00 ,OP,122,122,,,,,,
BCBS Blue Choice,CPT,98962,Self-mgmt educ/train 5-8 pt,All Other,Per Unit,$45.74 ,OP,45.74,45.74,,,,,,
BCBS Blue Choice,CPT,98966,Hc pro phone call 5-10 min,All Other,Per Unit,$61.00 ,OP,12.73,61,,,,,,
BCBS Blue Choice,CPT,98967,Hc pro phone call 11-20 min,All Other,Per Unit,$118.19 ,OP,25.14,118.19,,,,,,
BCBS Blue Choice,CPT,98968,Hc pro phone call 21-30 min,All Other,Per Unit,$171.58 ,OP,37.46,171.58,,,,,,
BCBS Blue Choice,CPT,99000,Specimen handling office-lab,All Other,Per Unit,$26.70 ,OP,26.7,26.7,,,,,,
BCBS Blue Choice,CPT,99001,Specimen handling pt-lab,All Other,Per Unit,$34.31 ,OP,34.31,34.31,,,,,,
BCBS Blue Choice,CPT,99002,Device handling phys/qhp,All Other,Per Unit,$34.31 ,OP,34.31,34.31,,,,,,
BCBS Blue Choice,CPT,99050,Medical services after hrs,All Other,Per Unit,$91.51 ,OP,91.51,91.51,,,,,,
BCBS Blue Choice,CPT,99051,Med serv eve/wkend/holiday,All Other,Per Unit,$110.57 ,OP,110.57,110.57,,,,,,
BCBS Blue Choice,CPT,99053,Med serv 10pm-8am 24 hr fac,All Other,Per Unit,$190.64 ,OP,190.64,190.64,,,,,,
BCBS Blue Choice,CPT,99056,Med service out of office,All Other,Per Unit,$87.69 ,OP,87.69,87.69,,,,,,
BCBS Blue Choice,CPT,99060,Out of office emerg med serv,All Other,Per Unit,$122.00 ,OP,122,122,,,,,,
BCBS Blue Choice,CPT,99078,Group health education,All Other,Per Unit,$183.02 ,OP,183.02,183.02,,,,,,
BCBS Blue Choice,CPT,99090,Computer data analysis,All Other,Per Unit,$388.89 ,OP,388.89,388.89,,,,,,
BCBS Blue Choice,CPT,99091,Collj & interpj data ea 30 d,All Other,Per Unit,$240.20 ,OP,240.2,240.2,,,,,,
BCBS Blue Choice,CPT,99143,Mod cs by same phys < 5 yrs,All Other,Per Unit,$274.51 ,OP,274.51,274.51,,,,,,
BCBS Blue Choice,CPT,99144,Mod cs by same phys 5 yrs +,All Other,Per Unit,$228.77 ,OP,228.77,228.77,,,,,,
BCBS Blue Choice,CPT,99145,Mod cs by same phys add-on,All Other,Per Unit,$91.51 ,OP,91.51,91.51,,,,,,
BCBS Blue Choice,CPT,99148,Mod cs diff phys < 5 yrs,All Other,Per Unit,$247.83 ,OP,247.83,247.83,,,,,,
BCBS Blue Choice,CPT,99149,Mod cs diff phys 5 yrs +,All Other,Per Unit,$202.07 ,OP,202.07,202.07,,,,,,
BCBS Blue Choice,CPT,99150,Mod cs diff phys add-on,All Other,Per Unit,$91.51 ,OP,91.51,91.51,,,,,,
BCBS Blue Choice,CPT,99151,Mod sed same phys/qhp <5 yrs,All Other,Per Unit,$183.00 ,OP,183,183,,,,,,
BCBS Blue Choice,CPT,99152,Mod sed same phys/qhp 5/>yrs,All Other,Per Unit,$137.26 ,OP,137.26,137.26,,,,,,
BCBS Blue Choice,CPT,99153,Mod sed same phys/qhp ea,All Other,Per Unit,$91.51 ,OP,91.51,91.51,,,,,,
BCBS Blue Choice,CPT,99155,Mod sed oth phys/qhp <5 yrs,All Other,Per Unit,$156.32 ,OP,156.32,156.32,,,,,,
BCBS Blue Choice,CPT,99156,Mod sed oth phys/qhp 5/>yrs,All Other,Per Unit,$110.56 ,OP,110.56,110.56,,,,,,
BCBS Blue Choice,CPT,99157,Mod sed other phys/qhp ea,All Other,Per Unit,$91.51 ,OP,91.51,91.51,,,,,,
BCBS Blue Choice,CPT,99170,Anogenital exam child w imag,All Other,Per Unit,$663.41 ,OP,174.29,663.41,,,,,,
BCBS Blue Choice,CPT,99172,Ocular function screen,All Other,Per Unit,$91.51 ,OP,91.51,91.51,,,,,,
BCBS Blue Choice,CPT,99174,Ocular instrumnt screen bil,All Other,Per Unit,$118.19 ,OP,118.19,118.19,,,,,,
BCBS Blue Choice,CPT,99175,Induction of vomiting,All Other,Per Unit,$137.25 ,OP,137.25,137.25,,,,,,
BCBS Blue Choice,CPT,99177,Ocular instrumnt screen bil,All Other,Per Unit,$118.19 ,OP,118.19,118.19,,,,,,
BCBS Blue Choice,CPT,99183,Hyperbaric oxygen therapy,All Other,Per Unit,$892.18 ,OP,892.18,892.18,,,,,,
BCBS Blue Choice,CPT,99185,Regional hypothermia,All Other,Per Unit,$270.71 ,OP,270.71,270.71,,,,,,
BCBS Blue Choice,CPT,99190,Special pump services,All Other,Per Unit,"$2,299.05 ",OP,"2,299.05","8,948.83",,,,,,
BCBS Blue Choice,CPT,99191,Special pump services,All Other,Per Unit,"$1,612.76 ",OP,"1,612.76","8,948.83",,,,,,
BCBS Blue Choice,CPT,99192,Special pump services,All Other,Per Unit,"$1,151.42 ",OP,"1,151.42","8,948.83",,,,,,
BCBS Blue Choice,CPT,99195,Phlebotomy,All Other,Per Unit,$331.70 ,OP,114.56,331.7,,,,,,
BCBS Blue Choice,CPT,99201,Office/outpatient visit new,All Other,Per Unit,$81.84 ,OP,81.84,81.84,,,,,,
BCBS Blue Choice,CPT,99202,Office o/p new sf 15-29 min,All Other,Per Unit,$81.84 ,OP,81.84,81.84,,,,,,
BCBS Blue Choice,CPT,99203,Office o/p new low 30-44 min,All Other,Per Unit,$81.84 ,OP,81.84,81.84,,,,,,
BCBS Blue Choice,CPT,99204,Office o/p new mod 45-59 min,All Other,Per Unit,$81.84 ,OP,81.84,81.84,,,,,,
BCBS Blue Choice,CPT,99205,Office o/p new hi 60-74 min,All Other,Per Unit,$81.84 ,OP,81.84,81.84,,,,,,
BCBS Blue Choice,CPT,99211,Office o/p est minimal prob,All Other,Per Unit,$109.47 ,OP,109.47,109.47,,,,,,
BCBS Blue Choice,CPT,99212,Office o/p est sf 10-19 min,All Other,Per Unit,$81.84 ,OP,81.84,81.84,,,,,,
BCBS Blue Choice,CPT,99213,Office o/p est low 20-29 min,All Other,Per Unit,$81.84 ,OP,81.84,81.84,,,,,,
BCBS Blue Choice,CPT,99214,Office o/p est mod 30-39 min,All Other,Per Unit,$81.84 ,OP,81.84,81.84,,,,,,
BCBS Blue Choice,CPT,99215,Office o/p est hi 40-54 min,All Other,Per Unit,$81.84 ,OP,81.84,81.84,,,,,,
BCBS Blue Choice,CPT,99217,Observation care discharge,All Other,Per Unit,$335.53 ,OP,335.53,335.53,,,,,,
BCBS Blue Choice,CPT,99218,Initial observation care,All Other,Per Unit,$316.46 ,OP,316.46,316.46,,,,,,
BCBS Blue Choice,CPT,99219,Initial observation care,All Other,Per Unit,$522.34 ,OP,522.34,522.34,,,,,,
BCBS Blue Choice,CPT,99220,Initial observation care,All Other,Per Unit,$735.85 ,OP,735.85,735.85,,,,,,
BCBS Blue Choice,CPT,99221,Initial hospital care,All Other,Per Unit,$404.14 ,OP,404.14,404.14,,,,,,
BCBS Blue Choice,CPT,99222,Initial hospital care,All Other,Per Unit,$552.84 ,OP,552.84,552.84,,,,,,
BCBS Blue Choice,CPT,99223,Initial hospital care,All Other,Per Unit,$812.11 ,OP,812.11,812.11,,,,,,
BCBS Blue Choice,CPT,99232,Subsequent hospital care,All Other,Per Unit,$297.39 ,OP,297.39,297.39,,,,,,
BCBS Blue Choice,CPT,99233,Subsequent hospital care,All Other,Per Unit,$427.03 ,OP,427.03,427.03,,,,,,
BCBS Blue Choice,CPT,99234,Observ/hosp same date,All Other,Per Unit,$579.53 ,OP,579.53,579.53,,,,,,
BCBS Blue Choice,CPT,99235,Observ/hosp same date,All Other,Per Unit,$754.91 ,OP,754.91,754.91,,,,,,
BCBS Blue Choice,CPT,99236,Observ/hosp same date,All Other,Per Unit,$937.93 ,OP,937.93,937.93,,,,,,
BCBS Blue Choice,CPT,99238,Hospital discharge day,All Other,Per Unit,$301.20 ,OP,301.2,301.2,,,,,,
BCBS Blue Choice,CPT,99239,Hospital discharge day,All Other,Per Unit,$434.65 ,OP,434.65,434.65,,,,,,
BCBS Blue Choice,CPT,99241,Office consultation,All Other,Per Unit,$228.77 ,OP,228.77,228.77,,,,,,
BCBS Blue Choice,CPT,99242,Office consultation,All Other,Per Unit,$427.03 ,OP,427.03,427.03,,,,,,
BCBS Blue Choice,CPT,99243,Office consultation,All Other,Per Unit,$587.16 ,OP,587.16,587.16,,,,,,
BCBS Blue Choice,CPT,99244,Office consultation,All Other,Per Unit,$857.86 ,OP,857.86,857.86,,,,,,
BCBS Blue Choice,CPT,99245,Office consultation,All Other,Per Unit,"$1,056.11 ",OP,"1,056.11","1,056.11",,,,,,
BCBS Blue Choice,CPT,99251,Inpatient consultation,All Other,Per Unit,$224.95 ,OP,224.95,224.95,,,,,,
BCBS Blue Choice,CPT,99252,Inpatient consultation,All Other,Per Unit,$354.58 ,OP,354.58,354.58,,,,,,
BCBS Blue Choice,CPT,99253,Inpatient consultation,All Other,Per Unit,$533.78 ,OP,533.78,533.78,,,,,,
BCBS Blue Choice,CPT,99254,Inpatient consultation,All Other,Per Unit,$766.35 ,OP,766.35,766.35,,,,,,
BCBS Blue Choice,CPT,99255,Inpatient consultation,All Other,Per Unit,$934.12 ,OP,934.12,934.12,,,,,,
BCBS Blue Choice,CPT,99281,Emergency dept visit,All Other,Per Unit,$245.98 ,OP,74.29,245.98,,,,,,
BCBS Blue Choice,CPT,99282,Emergency dept visit,All Other,Per Unit,$368.97 ,OP,134.66,368.97,,,,,,
BCBS Blue Choice,CPT,99283,Emergency dept visit,All Other,Per Unit,$737.94 ,OP,237,737.94,,,,,,
BCBS Blue Choice,CPT,99284,Emergency dept visit,All Other,Per Unit,"$1,291.40 ",OP,372.22,"1,291.40",,,,,,
BCBS Blue Choice,CPT,99285,Emergency dept visit,All Other,Per Unit,"$1,967.84 ",OP,534.29,"1,967.84",,,,,,
BCBS Blue Choice,CPT,99288,Direct advanced life support,All Other,Per Unit,$812.11 ,OP,812.11,812.11,,,,,,
BCBS Blue Choice,CPT,99291,Critical care first hour,All Other,Per Unit,"$1,197.20 ",OP,708.83,"1,197.20",,,,,,
BCBS Blue Choice,CPT,99292,Critical care addl 30 min,All Other,Per Unit,$541.40 ,OP,541.4,541.4,,,,,,
BCBS Blue Choice,CPT,99304,Nursing facility care init,All Other,Per Unit,$430.83 ,OP,430.83,430.83,,,,,,
BCBS Blue Choice,CPT,99305,Nursing facility care init,All Other,Per Unit,$598.59 ,OP,598.59,598.59,,,,,,
BCBS Blue Choice,CPT,99307,Nursing fac care subseq,All Other,Per Unit,$213.51 ,OP,213.51,213.51,,,,,,
BCBS Blue Choice,CPT,99308,Nursing fac care subseq,All Other,Per Unit,$327.90 ,OP,327.9,327.9,,,,,,
BCBS Blue Choice,CPT,99309,Nursing fac care subseq,All Other,Per Unit,$434.65 ,OP,434.65,434.65,,,,,,
BCBS Blue Choice,CPT,99310,Nursing fac care subseq,All Other,Per Unit,$636.73 ,OP,636.73,636.73,,,,,,
BCBS Blue Choice,CPT,99315,Nursing fac discharge day,All Other,Per Unit,$312.64 ,OP,312.64,312.64,,,,,,
BCBS Blue Choice,CPT,99316,Nursing fac discharge day,All Other,Per Unit,$407.96 ,OP,407.96,407.96,,,,,,
BCBS Blue Choice,CPT,99318,Annual nursing fac assessmnt,All Other,Per Unit,$449.90 ,OP,449.9,449.9,,,,,,
BCBS Blue Choice,CPT,99324,Domicil/r-home visit new pat,All Other,Per Unit,$308.83 ,OP,308.83,308.83,,,,,,
BCBS Blue Choice,CPT,99325,Domicil/r-home visit new pat,All Other,Per Unit,$446.08 ,OP,446.08,446.08,,,,,,
BCBS Blue Choice,CPT,99326,Domicil/r-home visit new pat,All Other,Per Unit,$732.04 ,OP,732.04,732.04,,,,,,
BCBS Blue Choice,CPT,99327,Domicil/r-home visit new pat,All Other,Per Unit,$953.17 ,OP,953.17,953.17,,,,,,
BCBS Blue Choice,CPT,99328,Domicil/r-home visit new pat,All Other,Per Unit,"$1,120.94 ",OP,"1,120.94","1,120.94",,,,,,
BCBS Blue Choice,CPT,99334,Domicil/r-home visit est pat,All Other,Per Unit,$312.64 ,OP,312.64,312.64,,,,,,
BCBS Blue Choice,CPT,99335,Domicil/r-home visit est pat,All Other,Per Unit,$484.22 ,OP,484.22,484.22,,,,,,
BCBS Blue Choice,CPT,99336,Domicil/r-home visit est pat,All Other,Per Unit,$682.47 ,OP,682.47,682.47,,,,,,
BCBS Blue Choice,CPT,99337,Domicil/r-home visit est pat,All Other,Per Unit,$976.05 ,OP,976.05,976.05,,,,,,
BCBS Blue Choice,CPT,99339,Domicil/r-home care supervis,All Other,Per Unit,$419.40 ,OP,419.4,419.4,,,,,,
BCBS Blue Choice,CPT,99340,Domicil/r-home care supervis,All Other,Per Unit,$583.35 ,OP,583.35,583.35,,,,,,
BCBS Blue Choice,CPT,99341,Home visit new patient,All Other,Per Unit,$278.32 ,OP,278.32,278.32,,,,,,
BCBS Blue Choice,CPT,99342,Home visit new patient,All Other,Per Unit,$404.14 ,OP,404.14,404.14,,,,,,
BCBS Blue Choice,CPT,99343,Home visit new patient,All Other,Per Unit,$648.16 ,OP,648.16,648.16,,,,,,
BCBS Blue Choice,CPT,99344,Home visit new patient,All Other,Per Unit,$850.23 ,OP,850.23,850.23,,,,,,
BCBS Blue Choice,CPT,99345,Home visit new patient,All Other,Per Unit,"$1,021.81 ",OP,"1,021.81","1,021.81",,,,,,
BCBS Blue Choice,CPT,99347,Home visit est patient,All Other,Per Unit,$270.71 ,OP,270.71,270.71,,,,,,
BCBS Blue Choice,CPT,99348,Home visit est patient,All Other,Per Unit,$407.96 ,OP,407.96,407.96,,,,,,
BCBS Blue Choice,CPT,99349,Home visit est patient,All Other,Per Unit,$590.97 ,OP,590.97,590.97,,,,,,
BCBS Blue Choice,CPT,99350,Home visit est patient,All Other,Per Unit,$827.35 ,OP,827.35,827.35,,,,,,
BCBS Blue Choice,CPT,99354,Prolng svc o/p 1st hour,All Other,Per Unit,$549.03 ,OP,549.03,549.03,,,,,,
BCBS Blue Choice,CPT,99355,Prolng svc o/p ea addl 30,All Other,Per Unit,$541.40 ,OP,541.4,541.4,,,,,,
BCBS Blue Choice,CPT,99356,Prolng svc i/p/obs 1st hour,All Other,Per Unit,$499.47 ,OP,499.47,"8,948.83",,,,,,
BCBS Blue Choice,CPT,99357,Prolng svc i/p/obs ea addl,All Other,Per Unit,$507.08 ,OP,507.08,"8,948.83",,,,,,
BCBS Blue Choice,CPT,99358,Prolong service w/o contact,All Other,Per Unit,$903.60 ,OP,903.6,903.6,,,,,,
BCBS Blue Choice,CPT,99359,Prolong serv w/o contact add,All Other,Per Unit,$434.65 ,OP,434.65,434.65,,,,,,
BCBS Blue Choice,CPT,99360,Physician standby services,All Other,Per Unit,$354.58 ,OP,354.58,354.58,,,,,,
BCBS Blue Choice,CPT,99363,Anticoag mgmt init,All Other,Per Unit,$644.34 ,OP,644.34,644.34,,,,,,
BCBS Blue Choice,CPT,99364,Anticoag mgmt subseq,All Other,Per Unit,$224.95 ,OP,224.95,224.95,,,,,,
BCBS Blue Choice,CPT,99366,Team conf w/pat by hc prof,All Other,Per Unit,$232.58 ,OP,232.58,232.58,,,,,,
BCBS Blue Choice,CPT,99367,Team conf w/o pat by phys,All Other,Per Unit,$297.39 ,OP,297.39,297.39,,,,,,
BCBS Blue Choice,CPT,99368,Team conf w/o pat by hc pro,All Other,Per Unit,$194.45 ,OP,194.45,194.45,,,,,,
BCBS Blue Choice,CPT,99374,Home health care supervision,All Other,Per Unit,$407.96 ,OP,407.96,407.96,,,,,,
BCBS Blue Choice,CPT,99375,Home health care supervision,All Other,Per Unit,$644.34 ,OP,644.34,644.34,,,,,,
BCBS Blue Choice,CPT,99377,Hospice care supervision,All Other,Per Unit,$407.96 ,OP,407.96,407.96,,,,,,
BCBS Blue Choice,CPT,99378,Hospice care supervision,All Other,Per Unit,$667.22 ,OP,667.22,667.22,,,,,,
BCBS Blue Choice,CPT,99379,Nursing fac care supervision,All Other,Per Unit,$404.14 ,OP,404.14,404.14,,,,,,
BCBS Blue Choice,CPT,99380,Nursing fac care supervision,All Other,Per Unit,$610.03 ,OP,610.03,610.03,,,,,,
BCBS Blue Choice,CPT,99381,Init pm e/m new pat infant,All Other,Per Unit,$522.34 ,OP,522.34,522.34,,,,,,
BCBS Blue Choice,CPT,99382,Init pm e/m new pat 1-4 yrs,All Other,Per Unit,$564.29 ,OP,564.29,564.29,,,,,,
BCBS Blue Choice,CPT,99383,Prev visit new age 5-11,All Other,Per Unit,$560.47 ,OP,560.47,560.47,,,,,,
BCBS Blue Choice,CPT,99384,Prev visit new age 12-17,All Other,Per Unit,$610.03 ,OP,610.03,610.03,,,,,,
BCBS Blue Choice,CPT,99385,Prev visit new age 18-39,All Other,Per Unit,$610.03 ,OP,610.03,610.03,,,,,,
BCBS Blue Choice,CPT,99386,Prev visit new age 40-64,All Other,Per Unit,$712.98 ,OP,712.98,712.98,,,,,,
BCBS Blue Choice,CPT,99387,Init pm e/m new pat 65+ yrs,All Other,Per Unit,$781.61 ,OP,781.61,781.61,,,,,,
BCBS Blue Choice,CPT,99391,Per pm reeval est pat infant,All Other,Per Unit,$434.65 ,OP,434.65,434.65,,,,,,
BCBS Blue Choice,CPT,99392,Prev visit est age 1-4,All Other,Per Unit,$484.22 ,OP,484.22,484.22,,,,,,
BCBS Blue Choice,CPT,99393,Prev visit est age 5-11,All Other,Per Unit,$480.40 ,OP,480.4,480.4,,,,,,
BCBS Blue Choice,CPT,99394,Prev visit est age 12-17,All Other,Per Unit,$526.16 ,OP,526.16,526.16,,,,,,
BCBS Blue Choice,CPT,99395,Prev visit est age 18-39,All Other,Per Unit,$529.96 ,OP,529.96,529.96,,,,,,
BCBS Blue Choice,CPT,99396,Prev visit est age 40-64,All Other,Per Unit,$579.53 ,OP,579.53,579.53,,,,,,
BCBS Blue Choice,CPT,99397,Per pm reeval est pat 65+ yr,All Other,Per Unit,$648.16 ,OP,648.16,648.16,,,,,,
BCBS Blue Choice,CPT,99401,Preventive counseling indiv,All Other,Per Unit,$179.20 ,OP,179.2,179.2,,,,,,
BCBS Blue Choice,CPT,99402,Preventive counseling indiv,All Other,Per Unit,$305.01 ,OP,305.01,305.01,,,,,,
BCBS Blue Choice,CPT,99403,Preventive counseling indiv,All Other,Per Unit,$430.83 ,OP,430.83,430.83,,,,,,
BCBS Blue Choice,CPT,99404,Preventive counseling indiv,All Other,Per Unit,$552.84 ,OP,552.84,552.84,,,,,,
BCBS Blue Choice,CPT,99406,Behav chng smoking 3-10 min,All Other,Per Unit,$64.82 ,OP,26.84,64.82,,,,,,
BCBS Blue Choice,CPT,99407,Behav chng smoking > 10 min,All Other,Per Unit,$125.82 ,OP,26.84,125.82,,,,,,
BCBS Blue Choice,CPT,99408,Audit/dast 15-30 min,All Other,Per Unit,$167.76 ,OP,167.76,167.76,,,,,,
BCBS Blue Choice,CPT,99409,Audit/dast over 30 min,All Other,Per Unit,$327.90 ,OP,327.9,327.9,,,,,,
BCBS Blue Choice,CPT,99412,Preventive counseling group,All Other,Per Unit,$99.13 ,OP,99.13,99.13,,,,,,
BCBS Blue Choice,CPT,99441,Phone e/m phys/qhp 5-10 min,All Other,Per Unit,$76.26 ,OP,76.26,76.26,,,,,,
BCBS Blue Choice,CPT,99442,Phone e/m phys/qhp 11-20 min,All Other,Per Unit,$141.07 ,OP,141.07,141.07,,,,,,
BCBS Blue Choice,CPT,99443,Phone e/m phys/qhp 21-30 min,All Other,Per Unit,$205.88 ,OP,205.88,205.88,,,,,,
BCBS Blue Choice,CPT,99455,Work related disability exam,All Other,Per Unit,"$1,334.45 ",OP,"1,334.45","1,334.45",,,,,,
BCBS Blue Choice,CPT,99456,Disability examination,All Other,Per Unit,"$2,287.62 ",OP,"2,287.62","2,287.62",,,,,,
BCBS Blue Choice,CPT,99460,Init nb em per day hosp,All Other,Per Unit,$305.01 ,OP,121.51,305.01,,,,,,
BCBS Blue Choice,CPT,99461,Init nb em per day non-fac,All Other,Per Unit,$457.52 ,OP,457.52,457.52,,,,,,
BCBS Blue Choice,CPT,99462,Sbsq nb em per day hosp,All Other,Per Unit,$160.13 ,OP,160.13,"8,948.83",,,,,,
BCBS Blue Choice,CPT,99463,Same day nb discharge,All Other,Per Unit,$404.14 ,OP,121.51,404.14,,,,,,
BCBS Blue Choice,CPT,99464,Attendance at delivery,All Other,Per Unit,$476.60 ,OP,476.6,476.6,,,,,,
BCBS Blue Choice,CPT,99465,Nb resuscitation,All Other,Per Unit,$781.61 ,OP,575.01,781.61,,,,,,
BCBS Blue Choice,CPT,99466,Ped crit care transport,All Other,Per Unit,"$1,193.38 ",OP,"1,193.38","1,193.38",,,,,,
BCBS Blue Choice,CPT,99467,Ped crit care transport addl,All Other,Per Unit,$594.77 ,OP,594.77,594.77,,,,,,
BCBS Blue Choice,CPT,99468,Neonate crit care initial,All Other,Per Unit,"$4,510.41 ",OP,"4,510.41","8,948.83",,,,,,
BCBS Blue Choice,CPT,99469,Neonate crit care subsq,All Other,Per Unit,"$1,936.85 ",OP,"1,936.85","8,948.83",,,,,,
BCBS Blue Choice,CPT,99471,Ped critical care initial,All Other,Per Unit,"$4,049.07 ",OP,"4,049.07","8,948.83",,,,,,
BCBS Blue Choice,CPT,99472,Ped critical care subsq,All Other,Per Unit,"$1,982.60 ",OP,"1,982.60","8,948.83",,,,,,
BCBS Blue Choice,CPT,99475,Ped crit care age 2-5 init,All Other,Per Unit,"$2,790.89 ",OP,"2,790.89","8,948.83",,,,,,
BCBS Blue Choice,CPT,99476,Ped crit care age 2-5 subsq,All Other,Per Unit,"$1,643.28 ",OP,"1,643.28","8,948.83",,,,,,
BCBS Blue Choice,CPT,99477,Init day hosp neonate care,All Other,Per Unit,"$1,734.78 ",OP,"1,734.78","8,948.83",,,,,,
BCBS Blue Choice,CPT,99478,Ic lbw inf < 1500 gm subsq,All Other,Per Unit,$716.79 ,OP,716.79,"8,948.83",,,,,,
BCBS Blue Choice,CPT,99479,Ic lbw inf 1500-2500 g subsq,All Other,Per Unit,$629.10 ,OP,629.1,"8,948.83",,,,,,
BCBS Blue Choice,CPT,99480,Ic inf pbw 2501-5000 g subsq,All Other,Per Unit,$606.21 ,OP,606.21,"8,948.83",,,,,,
BCBS Blue Choice,CPT,99510,Home visit sing/m/fam couns,All Other,Per Unit,$133.45 ,OP,133.45,133.45,,,,,,
BCBS Blue Choice,CPT,99601,Home infusion/visit 2 hrs,All Other,Per Unit,$343.14 ,OP,343.14,343.14,,,,,,
BCBS Blue Choice,CPT,99602,Home infusion each addtl hr,All Other,Per Unit,$171.58 ,OP,171.58,171.58,,,,,,
BCBS Blue Choice,CPT,0144T,CT heart wo dye - qual calc,All Other,Per Unit,$705.35 ,OP,705.35,705.35,,,,,,
BCBS Blue Choice,CPT,0145T,CT heart w/wo dye funct,All Other,Per Unit,"$2,977.72 ",OP,"2,977.72","2,977.72",,,,,,
BCBS Blue Choice,CPT,0146T,CCTA w/wo dye,All Other,Per Unit,"$2,897.65 ",OP,"2,897.65","2,897.65",,,,,,
BCBS Blue Choice,CPT,0147T,CCTA w/wo - quan calcium,All Other,Per Unit,"$3,023.47 ",OP,"3,023.47","3,023.47",,,,,,
BCBS Blue Choice,CPT,0148T,CCTA w/wo - strxr,All Other,Per Unit,"$3,660.19 ",OP,"3,660.19","3,660.19",,,,,,
BCBS Blue Choice,CPT,0149T,CCTA w/wo - strxr quan calc,All Other,Per Unit,"$2,680.32 ",OP,"2,680.32","2,680.32",,,,,,
BCBS Blue Choice,CPT,0150T,CCTA w/wo - disease strxr,All Other,Per Unit,"$3,156.91 ",OP,"3,156.91","3,156.91",,,,,,
BCBS Blue Choice,CPT,0151T,CT heart funct add-on,All Other,Per Unit,"$1,178.12 ",OP,"1,178.12","1,178.12",,,,,,
BCBS Blue Choice,CPT,0331T,Heart symp image plnr,All Other,Per Unit,$922.67 ,OP,922.67,"1,336.39",,,,,,
BCBS Blue Choice,CPT,0332T,Heart symp image plnr spect,All Other,Per Unit,"$1,338.26 ",OP,"1,336.39","1,338.26",,,,,,
BCBS Blue Choice,CPT,0333T,Visual ep scr acuity auto,All Other,Per Unit,$537.60 ,OP,537.6,537.6,,,,,,
BCBS Blue Choice,CPT,0336T,,,Per Case,"$7,820.85 ",OP,"7,820.85","9,201.00",,,,,,
BCBS Blue Choice,CPT,0389T,Prog eval inper leadls pm,All Other,Per Unit,$378.39 ,OP,378.39,378.39,,,,,,
BCBS Blue Choice,CPT,0390T,Periproc eval inper ledls pm,All Other,Per Unit,$186.82 ,OP,186.82,186.82,,,,,,
BCBS Blue Choice,CPT,0391T,Intergt eval inper leadls pm,All Other,Per Unit,$385.09 ,OP,385.09,385.09,,,,,,
BCBS Blue Choice,CPT,0404T,Trnscrv uterin fibroid abltj,,Per Case,"$4,140.35 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,0404T,Trnscrv uterin fibroid abltj,,Per Case,"$7,820.85 ",OP,"4,140.35","9,201.00",,,,,,
BCBS Blue Choice,CPT,0497T,Xtrnl pt act ecg in-off conn,All Other,Per Unit,"$1,574.64 ",OP,38.02,"1,574.64",,,,,,
BCBS Blue Choice,CPT,0498T,Xtrnl pt act ecg r&i pr 30 d,All Other,Per Unit,"$1,574.64 ",OP,"1,574.64","1,574.64",,,,,,
BCBS Blue Choice,CPT,0500T,Hpv 5+ hi risk hpv types,All Other,Per Unit,$93.87 ,OP,93.87,93.87,,,,,,
BCBS Blue Choice,CPT,0509T,Pattern erg w/i&r,All Other,Per Unit,$386.03 ,OP,270.61,386.03,,,,,,
BCBS Blue Choice,CPT,0577T,Ephys eval icds ss,All Other,Per Unit,"$2,775.65 ",OP,"1,138.72","2,775.65",,,,,,
BCBS Blue Choice,CPT,0579T,Rem interrog dev icds tech,All Other,Per Unit,$213.51 ,OP,38.02,213.51,,,,,,
BCBS Blue Choice,CPT,0584T,Perq islet cell transplant,All Other,Per Unit,"$2,508.76 ",OP,"2,508.76","8,948.83",,,,,,
BCBS Blue Choice,CPT,0585T,Laps islet cell transplant,All Other,Per Unit,"$4,254.96 ",OP,"4,254.96","8,948.83",,,,,,
BCBS Blue Choice,CPT,0586T,Open islet cell transplant,All Other,Per Unit,"$6,965.79 ",OP,"6,965.79","8,948.83",,,,,,
BCBS Blue Choice,CPT,0589T,Elec alys smpl prgrmg iins,All Other,Per Unit,$255.45 ,OP,102.65,255.45,,,,,,
BCBS Blue Choice,CPT,0590T,Elec alys cplx prgrmg iins,All Other,Per Unit,$255.45 ,OP,102.65,255.45,,,,,,
BCBS Blue Choice,CPT,A0110,Nonemergency transport bus,All Other,Per Unit,$152.51 ,OP,152.51,152.51,,,,,,
BCBS Blue Choice,CPT,A0225,Neonatal emergency transport,All Other,Per Unit,"$2,001.67 ",OP,"2,001.67","2,001.67",,,,,,
BCBS Blue Choice,CPT,A0368,ADV ER NO SERV SEP MILE,All Other,Per Unit,"$1,467.89 ",OP,"1,467.89","1,467.89",,,,,,
BCBS Blue Choice,CPT,A0380,Basic life support mileage,All Other,Per Unit,$278.32 ,OP,278.32,278.32,,,,,,
BCBS Blue Choice,CPT,A0382,Basic support routine suppls,All Other,Per Unit,$114.39 ,OP,114.39,114.39,,,,,,
BCBS Blue Choice,CPT,A0384,Bls defibrillation supplies,All Other,Per Unit,$152.51 ,OP,152.51,152.51,,,,,,
BCBS Blue Choice,CPT,A0390,Advanced life support mileag,All Other,Per Unit,$324.09 ,OP,324.09,324.09,,,,,,
BCBS Blue Choice,CPT,A0392,Als defibrillation supplies,All Other,Per Unit,$343.14 ,OP,343.14,343.14,,,,,,
BCBS Blue Choice,CPT,A0394,Als iv drug therapy supplies,All Other,Per Unit,$190.64 ,OP,190.64,190.64,,,,,,
BCBS Blue Choice,CPT,A0396,Als esophageal intub suppls,All Other,Per Unit,$221.14 ,OP,221.14,221.14,,,,,,
BCBS Blue Choice,CPT,A0398,Als routine disposble suppls,All Other,Per Unit,$190.64 ,OP,190.64,190.64,,,,,,
BCBS Blue Choice,CPT,A0420,Ambulance waiting 1/2 hr,All Other,Per Unit,$945.56 ,OP,945.56,945.56,,,,,,
BCBS Blue Choice,CPT,A0422,Ambulance 02 life sustaining,All Other,Per Unit,$285.96 ,OP,285.96,285.96,,,,,,
BCBS Blue Choice,CPT,A0426,Als 1,All Other,Per Unit,"$2,249.49 ",OP,231.98,"2,249.49",,,,,,
BCBS Blue Choice,CPT,A0427,Als1-emergency,All Other,Per Unit,"$2,287.62 ",OP,231.98,"2,287.62",,,,,,
BCBS Blue Choice,CPT,A0429,Bls-emergency,All Other,Per Unit,"$1,883.47 ",OP,231.98,"1,883.47",,,,,,
BCBS Blue Choice,CPT,A0433,Als 2,All Other,Per Unit,"$2,859.52 ",OP,231.98,"2,859.52",,,,,,
BCBS Blue Choice,CPT,A0434,Specialty care transport,All Other,Per Unit,"$6,100.31 ",OP,231.98,"6,100.31",,,,,,
BCBS Blue Choice,CPT,A4206,1 cc sterile syringe&needle,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,A4207,2 cc sterile syringe&needle,All Other,Per Unit,$19.07 ,OP,19.07,19.07,,,,,,
BCBS Blue Choice,CPT,A4208,3 cc sterile syringe&needle,All Other,Per Unit,$26.70 ,OP,26.7,26.7,,,,,,
BCBS Blue Choice,CPT,A4209,5+ cc sterile syringe&needle,All Other,Per Unit,$15.26 ,OP,15.26,15.26,,,,,,
BCBS Blue Choice,CPT,A4210,Nonneedle injection device,All Other,Per Unit,$38.13 ,OP,38.13,38.13,,,,,,
BCBS Blue Choice,CPT,A4211,Supp for self-adm injections,All Other,Per Unit,$19.07 ,OP,19.07,19.07,,,,,,
BCBS Blue Choice,CPT,A4212,Non coring needle or stylet,All Other,Per Unit,$114.39 ,OP,114.39,114.39,,,,,,
BCBS Blue Choice,CPT,A4213,20+ cc syringe only,All Other,Per Unit,$34.31 ,OP,34.31,34.31,,,,,,
BCBS Blue Choice,CPT,A4217,Sterile water/saline- 500 ml,All Other,Per Unit,$11.44 ,OP,11.44,11.44,,,,,,
BCBS Blue Choice,CPT,A4218,Sterile saline or water,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,A4220,Infusion pump refill kit,All Other,Per Unit,$381.27 ,OP,381.27,381.27,,,,,,
BCBS Blue Choice,CPT,A4221,Supp non-insulin inf cath/wk,All Other,Per Unit,$91.51 ,OP,91.51,91.51,,,,,,
BCBS Blue Choice,CPT,A4222,Infusion supplies with pump,All Other,Per Unit,$179.20 ,OP,179.2,179.2,,,,,,
BCBS Blue Choice,CPT,A4230,Infus insulin pump non needl,All Other,Per Unit,$45.74 ,OP,45.74,45.74,,,,,,
BCBS Blue Choice,CPT,A4231,Infusion insulin pump needle,All Other,Per Unit,$26.70 ,OP,26.7,26.7,,,,,,
BCBS Blue Choice,CPT,A4232,Syringe w/needle insulin 3cc,All Other,Per Unit,$11.44 ,OP,11.44,11.44,,,,,,
BCBS Blue Choice,CPT,A4244,Alcohol or peroxide per pint,All Other,Per Unit,$19.07 ,OP,19.07,19.07,,,,,,
BCBS Blue Choice,CPT,A4246,Betadine/phisohex solution,All Other,Per Unit,$38.13 ,OP,38.13,38.13,,,,,,
BCBS Blue Choice,CPT,A4247,Betadine/iodine swabs/wipes,All Other,Per Unit,$34.31 ,OP,34.31,34.31,,,,,,
BCBS Blue Choice,CPT,A4248,Chlorhexidine antisept,All Other,Per Unit,$45.74 ,OP,45.74,45.74,,,,,,
BCBS Blue Choice,CPT,A4250,Urine reagent strips/tablets,All Other,Per Unit,$76.26 ,OP,76.26,76.26,,,,,,
BCBS Blue Choice,CPT,A4255,Glucose monitor platforms,All Other,Per Unit,$15.26 ,OP,15.26,15.26,,,,,,
BCBS Blue Choice,CPT,A4256,Calibrator solution/chips,All Other,Per Unit,$45.74 ,OP,45.74,45.74,,,,,,
BCBS Blue Choice,CPT,A4257,Replace lensshield cartridge,All Other,Per Unit,$49.56 ,OP,49.56,49.56,,,,,,
BCBS Blue Choice,CPT,A4258,Lancet device each,All Other,Per Unit,$72.44 ,OP,72.44,72.44,,,,,,
BCBS Blue Choice,CPT,A4259,Lancets per box,All Other,Per Unit,$49.56 ,OP,49.56,49.56,,,,,,
BCBS Blue Choice,CPT,A4262,Temporary tear duct plug,All Other,Per Unit,$571.91 ,OP,571.91,571.91,,,,,,
BCBS Blue Choice,CPT,A4263,Permanent tear duct plug,All Other,Per Unit,$571.91 ,OP,571.91,571.91,,,,,,
BCBS Blue Choice,CPT,A4265,Paraffin,All Other,Per Unit,$15.26 ,OP,15.26,15.26,,,,,,
BCBS Blue Choice,CPT,A4270,Disposable endoscope sheath,All Other,Per Unit,$133.45 ,OP,133.45,133.45,,,,,,
BCBS Blue Choice,CPT,A4280,Brst prsths adhsv attchmnt,All Other,Per Unit,$22.88 ,OP,22.88,22.88,,,,,,
BCBS Blue Choice,CPT,A4290,Sacral nerve stim test lead,All Other,Per Unit,$800.67 ,OP,800.67,800.67,,,,,,
BCBS Blue Choice,CPT,A4300,Cath impl vasc access portal,All Other,Per Unit,$571.91 ,OP,571.91,571.91,,,,,,
BCBS Blue Choice,CPT,A4305,Drug delivery system >=50 ml,All Other,Per Unit,$152.51 ,OP,152.51,152.51,,,,,,
BCBS Blue Choice,CPT,A4306,Drug delivery system <=50 ml,All Other,Per Unit,$301.20 ,OP,301.2,301.2,,,,,,
BCBS Blue Choice,CPT,A4310,Insert tray w/o bag/cath,All Other,Per Unit,$30.51 ,OP,30.51,30.51,,,,,,
BCBS Blue Choice,CPT,A4311,Catheter w/o bag 2-way latex,All Other,Per Unit,$61.00 ,OP,61,61,,,,,,
BCBS Blue Choice,CPT,A4312,Cath w/o bag 2-way silicone,All Other,Per Unit,$72.44 ,OP,72.44,72.44,,,,,,
BCBS Blue Choice,CPT,A4313,Catheter w/bag 3-way,All Other,Per Unit,$72.44 ,OP,72.44,72.44,,,,,,
BCBS Blue Choice,CPT,A4314,Cath w/drainage 2-way latex,All Other,Per Unit,$102.95 ,OP,102.95,102.95,,,,,,
BCBS Blue Choice,CPT,A4316,Cath w/drainage 3-way,All Other,Per Unit,$114.39 ,OP,114.39,114.39,,,,,,
BCBS Blue Choice,CPT,A4320,Irrigation tray,All Other,Per Unit,$19.07 ,OP,19.07,19.07,,,,,,
BCBS Blue Choice,CPT,A4326,Male external catheter,All Other,Per Unit,$41.94 ,OP,41.94,41.94,,,,,,
BCBS Blue Choice,CPT,A4327,Fem urinary collect dev cup,All Other,Per Unit,$179.20 ,OP,179.2,179.2,,,,,,
BCBS Blue Choice,CPT,A4328,Fem urinary collect pouch,All Other,Per Unit,$41.94 ,OP,41.94,41.94,,,,,,
BCBS Blue Choice,CPT,A4330,Stool collection pouch,All Other,Per Unit,$26.70 ,OP,26.7,26.7,,,,,,
BCBS Blue Choice,CPT,A4331,Extension drainage tubing,All Other,Per Unit,$11.44 ,OP,11.44,11.44,,,,,,
BCBS Blue Choice,CPT,A4332,Lube sterile packet,All Other,Per Unit,$1.90 ,OP,1.9,1.9,,,,,,
BCBS Blue Choice,CPT,A4333,Urinary cath anchor device,All Other,Per Unit,$7.62 ,OP,7.62,7.62,,,,,,
BCBS Blue Choice,CPT,A4334,Urinary cath leg strap,All Other,Per Unit,$19.07 ,OP,19.07,19.07,,,,,,
BCBS Blue Choice,CPT,A4335,Incontinence supply,All Other,Per Unit,$122.00 ,OP,122,122,,,,,,
BCBS Blue Choice,CPT,A4338,Indwelling catheter latex,All Other,Per Unit,$49.56 ,OP,49.56,49.56,,,,,,
BCBS Blue Choice,CPT,A4344,Cath indw foley 2 way silicn,All Other,Per Unit,$53.38 ,OP,53.38,53.38,,,,,,
BCBS Blue Choice,CPT,A4346,Cath indw foley 3 way,All Other,Per Unit,$80.07 ,OP,80.07,80.07,,,,,,
BCBS Blue Choice,CPT,A4349,Disposable male external cat,All Other,Per Unit,$7.62 ,OP,7.62,7.62,,,,,,
BCBS Blue Choice,CPT,A4352,Coude tip urinary catheter,All Other,Per Unit,$22.88 ,OP,22.88,22.88,,,,,,
BCBS Blue Choice,CPT,A4354,Cath insertion tray w/bag,All Other,Per Unit,$45.74 ,OP,45.74,45.74,,,,,,
BCBS Blue Choice,CPT,A4355,Bladder irrigation tubing,All Other,Per Unit,$34.31 ,OP,34.31,34.31,,,,,,
BCBS Blue Choice,CPT,A4356,Ext ureth clmp or compr dvc,All Other,Per Unit,$183.02 ,OP,183.02,183.02,,,,,,
BCBS Blue Choice,CPT,A4357,Bedside drainage bag,All Other,Per Unit,$38.13 ,OP,38.13,38.13,,,,,,
BCBS Blue Choice,CPT,A4358,Urinary leg or abdomen bag,All Other,Per Unit,$26.70 ,OP,26.7,26.7,,,,,,
BCBS Blue Choice,CPT,A4361,Ostomy face plate,All Other,Per Unit,$95.32 ,OP,95.32,95.32,,,,,,
BCBS Blue Choice,CPT,A4362,Solid skin barrier,All Other,Per Unit,$15.26 ,OP,15.26,15.26,,,,,,
BCBS Blue Choice,CPT,A4363,Ostomy clamp- replacement,All Other,Per Unit,$11.44 ,OP,11.44,11.44,,,,,,
BCBS Blue Choice,CPT,A4364,Adhesive- liquid or equal,All Other,Per Unit,$11.44 ,OP,11.44,11.44,,,,,,
BCBS Blue Choice,CPT,A4365,Adhesive remover wipes,All Other,Per Unit,$57.19 ,OP,57.19,57.19,,,,,,
BCBS Blue Choice,CPT,A4366,Ostomy vent,All Other,Per Unit,$7.62 ,OP,7.62,7.62,,,,,,
BCBS Blue Choice,CPT,A4367,Ostomy belt,All Other,Per Unit,$38.13 ,OP,38.13,38.13,,,,,,
BCBS Blue Choice,CPT,A4368,Ostomy filter,All Other,Per Unit,$1.90 ,OP,1.9,1.9,,,,,,
BCBS Blue Choice,CPT,A4369,Skin barrier liquid per oz,All Other,Per Unit,$11.44 ,OP,11.44,11.44,,,,,,
BCBS Blue Choice,CPT,A4371,Skin barrier powder per oz,All Other,Per Unit,$19.07 ,OP,19.07,19.07,,,,,,
BCBS Blue Choice,CPT,A4372,Skin barrier solid 4x4 equiv,All Other,Per Unit,$22.88 ,OP,22.88,22.88,,,,,,
BCBS Blue Choice,CPT,A4373,Skin barrier with flange,All Other,Per Unit,$34.31 ,OP,34.31,34.31,,,,,,
BCBS Blue Choice,CPT,A4375,Drainable plastic pch w fcpl,All Other,Per Unit,$87.69 ,OP,87.69,87.69,,,,,,
BCBS Blue Choice,CPT,A4376,Drainable rubber pch w fcplt,All Other,Per Unit,$247.83 ,OP,247.83,247.83,,,,,,
BCBS Blue Choice,CPT,A4377,Drainable plstic pch w/o fp,All Other,Per Unit,$22.88 ,OP,22.88,22.88,,,,,,
BCBS Blue Choice,CPT,A4378,Drainable rubber pch w/o fp,All Other,Per Unit,$160.13 ,OP,160.13,160.13,,,,,,
BCBS Blue Choice,CPT,A4379,Urinary plastic pouch w fcpl,All Other,Per Unit,$80.07 ,OP,80.07,80.07,,,,,,
BCBS Blue Choice,CPT,A4380,Urinary rubber pouch w fcplt,All Other,Per Unit,$194.45 ,OP,194.45,194.45,,,,,,
BCBS Blue Choice,CPT,A4381,Urinary plastic pouch w/o fp,All Other,Per Unit,$22.88 ,OP,22.88,22.88,,,,,,
BCBS Blue Choice,CPT,A4382,Urinary hvy plstc pch w/o fp,All Other,Per Unit,$129.64 ,OP,129.64,129.64,,,,,,
BCBS Blue Choice,CPT,A4383,Urinary rubber pouch w/o fp,All Other,Per Unit,$144.88 ,OP,144.88,144.88,,,,,,
BCBS Blue Choice,CPT,A4384,Ostomy faceplt/silicone ring,All Other,Per Unit,$49.56 ,OP,49.56,49.56,,,,,,
BCBS Blue Choice,CPT,A4385,Ost skn barrier sld ext wear,All Other,Per Unit,$26.70 ,OP,26.7,26.7,,,,,,
BCBS Blue Choice,CPT,A4387,Ost clsd pouch w att st barr,All Other,Per Unit,$19.07 ,OP,19.07,19.07,,,,,,
BCBS Blue Choice,CPT,A4388,Drainable pch w ex wear barr,All Other,Per Unit,$22.88 ,OP,22.88,22.88,,,,,,
BCBS Blue Choice,CPT,A4389,Drainable pch w st wear barr,All Other,Per Unit,$30.51 ,OP,30.51,30.51,,,,,,
BCBS Blue Choice,CPT,A4390,Drainable pch ex wear convex,All Other,Per Unit,$49.56 ,OP,49.56,49.56,,,,,,
BCBS Blue Choice,CPT,A4391,Urinary pouch w ex wear barr,All Other,Per Unit,$38.13 ,OP,38.13,38.13,,,,,,
BCBS Blue Choice,CPT,A4392,Urinary pouch w st wear barr,All Other,Per Unit,$41.94 ,OP,41.94,41.94,,,,,,
BCBS Blue Choice,CPT,A4393,Urine pch w ex wear bar conv,All Other,Per Unit,$45.74 ,OP,45.74,45.74,,,,,,
BCBS Blue Choice,CPT,A4394,Ostomy pouch liq deodorant,All Other,Per Unit,$15.26 ,OP,15.26,15.26,,,,,,
BCBS Blue Choice,CPT,A4395,Ostomy pouch solid deodorant,All Other,Per Unit,$1.90 ,OP,1.9,1.9,,,,,,
BCBS Blue Choice,CPT,A4396,Peristomal hernia supprt blt,All Other,Per Unit,$209.70 ,OP,209.7,209.7,,,,,,
BCBS Blue Choice,CPT,A4397,Irrigation supply sleeve,All Other,Per Unit,$26.70 ,OP,26.7,26.7,,,,,,
BCBS Blue Choice,CPT,A4398,Ostomy irrigation bag,All Other,Per Unit,$72.44 ,OP,72.44,72.44,,,,,,
BCBS Blue Choice,CPT,A4399,Ostomy irrig cone/cath w brs,All Other,Per Unit,$64.82 ,OP,64.82,64.82,,,,,,
BCBS Blue Choice,CPT,A4400,Ostomy irrigation set,All Other,Per Unit,$228.77 ,OP,228.77,228.77,,,,,,
BCBS Blue Choice,CPT,A4402,Lubricant per ounce,All Other,Per Unit,$7.62 ,OP,7.62,7.62,,,,,,
BCBS Blue Choice,CPT,A4404,Ostomy ring each,All Other,Per Unit,$7.62 ,OP,7.62,7.62,,,,,,
BCBS Blue Choice,CPT,A4405,Nonpectin based ostomy paste,All Other,Per Unit,$19.07 ,OP,19.07,19.07,,,,,,
BCBS Blue Choice,CPT,A4406,Pectin based ostomy paste,All Other,Per Unit,$30.51 ,OP,30.51,30.51,,,,,,
BCBS Blue Choice,CPT,A4407,Ext wear ost skn barr <=4sq,All Other,Per Unit,$45.74 ,OP,45.74,45.74,,,,,,
BCBS Blue Choice,CPT,A4408,Ext wear ost skn barr >4sq,All Other,Per Unit,$49.56 ,OP,49.56,49.56,,,,,,
BCBS Blue Choice,CPT,A4409,Ost skn barr convex <=4 sq i,All Other,Per Unit,$30.51 ,OP,30.51,30.51,,,,,,
BCBS Blue Choice,CPT,A4410,Ost skn barr extnd >4 sq,All Other,Per Unit,$45.74 ,OP,45.74,45.74,,,,,,
BCBS Blue Choice,CPT,A4411,Ost skn barr extnd =4sq,All Other,Per Unit,$26.70 ,OP,26.7,26.7,,,,,,
BCBS Blue Choice,CPT,A4412,Ost pouch drain high output,All Other,Per Unit,$15.26 ,OP,15.26,15.26,,,,,,
BCBS Blue Choice,CPT,A4413,2 pc drainable ost pouch,All Other,Per Unit,$30.51 ,OP,30.51,30.51,,,,,,
BCBS Blue Choice,CPT,A4414,Ost sknbar w/o conv<=4 sq in,All Other,Per Unit,$26.70 ,OP,26.7,26.7,,,,,,
BCBS Blue Choice,CPT,A4415,Ost skn barr w/o conv >4 sqi,All Other,Per Unit,$30.51 ,OP,30.51,30.51,,,,,,
BCBS Blue Choice,CPT,A4416,Ost pch clsd w barrier/filtr,All Other,Per Unit,$15.26 ,OP,15.26,15.26,,,,,,
BCBS Blue Choice,CPT,A4417,Ost pch w bar/bltinconv/fltr,All Other,Per Unit,$19.07 ,OP,19.07,19.07,,,,,,
BCBS Blue Choice,CPT,A4418,Ost pch clsd w/o bar w filtr,All Other,Per Unit,$7.62 ,OP,7.62,7.62,,,,,,
BCBS Blue Choice,CPT,A4419,Ost pch for bar w flange/flt,All Other,Per Unit,$7.62 ,OP,7.62,7.62,,,,,,
BCBS Blue Choice,CPT,A4422,Ost pouch absorbent material,All Other,Per Unit,$1.90 ,OP,1.9,1.9,,,,,,
BCBS Blue Choice,CPT,A4423,Ost pch for bar w lk fl/fltr,All Other,Per Unit,$11.44 ,OP,11.44,11.44,,,,,,
BCBS Blue Choice,CPT,A4424,Ost pch drain w bar & filter,All Other,Per Unit,$22.88 ,OP,22.88,22.88,,,,,,
BCBS Blue Choice,CPT,A4425,Ost pch drain for barrier fl,All Other,Per Unit,$19.07 ,OP,19.07,19.07,,,,,,
BCBS Blue Choice,CPT,A4426,Ost pch drain 2 piece system,All Other,Per Unit,$15.26 ,OP,15.26,15.26,,,,,,
BCBS Blue Choice,CPT,A4427,Ost pch drain/barr lk flng/f,All Other,Per Unit,$15.26 ,OP,15.26,15.26,,,,,,
BCBS Blue Choice,CPT,A4428,Urine ost pouch w faucet/tap,All Other,Per Unit,$34.31 ,OP,34.31,34.31,,,,,,
BCBS Blue Choice,CPT,A4429,Urine ost pouch w bltinconv,All Other,Per Unit,$41.94 ,OP,41.94,41.94,,,,,,
BCBS Blue Choice,CPT,A4430,Ost urine pch w b/bltin conv,All Other,Per Unit,$45.74 ,OP,45.74,45.74,,,,,,
BCBS Blue Choice,CPT,A4431,Ost pch urine w barrier/tapv,All Other,Per Unit,$30.51 ,OP,30.51,30.51,,,,,,
BCBS Blue Choice,CPT,A4432,Os pch urine w bar/fange/tap,All Other,Per Unit,$19.07 ,OP,19.07,19.07,,,,,,
BCBS Blue Choice,CPT,A4433,Urine ost pch bar w lock fln,All Other,Per Unit,$19.07 ,OP,19.07,19.07,,,,,,
BCBS Blue Choice,CPT,A4434,Ost pch urine w lock flng/ft,All Other,Per Unit,$19.07 ,OP,19.07,19.07,,,,,,
BCBS Blue Choice,CPT,A4450,Non-waterproof tape,All Other,Per Unit,$1.90 ,OP,1.9,1.9,,,,,,
BCBS Blue Choice,CPT,A4452,Waterproof tape,All Other,Per Unit,$1.90 ,OP,1.9,1.9,,,,,,
BCBS Blue Choice,CPT,A4455,Adhesive remover per ounce,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,A4461,Surgicl dress hold non-reuse,All Other,Per Unit,$11.44 ,OP,11.44,11.44,,,,,,
BCBS Blue Choice,CPT,A4463,Surgical dress holder reuse,All Other,Per Unit,$53.38 ,OP,53.38,53.38,,,,,,
BCBS Blue Choice,CPT,A4465,Non-elastic extremity binder,All Other,Per Unit,$114.39 ,OP,114.39,114.39,,,,,,
BCBS Blue Choice,CPT,A4480,Vabra aspirator,All Other,Per Unit,$64.82 ,OP,64.82,64.82,,,,,,
BCBS Blue Choice,CPT,A4481,Tracheostoma filter,All Other,Per Unit,$1.90 ,OP,1.9,1.9,,,,,,
BCBS Blue Choice,CPT,A4483,Moisture exchanger,All Other,Per Unit,$41.94 ,OP,41.94,41.94,,,,,,
BCBS Blue Choice,CPT,A4500,Below knee surgical stocking,All Other,Per Unit,$247.83 ,OP,247.83,247.83,,,,,,
BCBS Blue Choice,CPT,A4510,Full length surg stocking,All Other,Per Unit,$343.14 ,OP,343.14,343.14,,,,,,
BCBS Blue Choice,CPT,A4520,Incontinence garment anytype,All Other,Per Unit,$7.62 ,OP,7.62,7.62,,,,,,
BCBS Blue Choice,CPT,A4550,Surgical trays,All Other,Per Unit,$571.91 ,OP,571.91,571.91,,,,,,
BCBS Blue Choice,CPT,A4554,Disposable underpads,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,A4555,Ca tx e-stim electr/transduc,All Other,Per Unit,$41.94 ,OP,41.94,41.94,,,,,,
BCBS Blue Choice,CPT,A4556,Electrodes- pair,All Other,Per Unit,$41.94 ,OP,41.94,41.94,,,,,,
BCBS Blue Choice,CPT,A4557,Lead wires- pair,All Other,Per Unit,$72.44 ,OP,72.44,72.44,,,,,,
BCBS Blue Choice,CPT,A4558,Conductive gel or paste,All Other,Per Unit,$19.07 ,OP,19.07,19.07,,,,,,
BCBS Blue Choice,CPT,A4559,Coupling gel or paste,All Other,Per Unit,$1.90 ,OP,1.9,1.9,,,,,,
BCBS Blue Choice,CPT,A4561,Pessary rubber- any type,All Other,Per Unit,$83.87 ,OP,83.87,83.87,,,,,,
BCBS Blue Choice,CPT,A4562,Pessary- non rubber-any type,All Other,Per Unit,$202.07 ,OP,202.07,202.07,,,,,,
BCBS Blue Choice,CPT,A4565,Slings,All Other,Per Unit,$30.51 ,OP,30.51,30.51,,,,,,
BCBS Blue Choice,CPT,A4580,Cast supplies (plaster),All Other,Per Unit,$457.52 ,OP,457.52,457.52,,,,,,
BCBS Blue Choice,CPT,A4590,Special casting material,All Other,Per Unit,$358.39 ,OP,358.39,358.39,,,,,,
BCBS Blue Choice,CPT,A4595,Tens suppl 2 lead per month,All Other,Per Unit,$114.39 ,OP,114.39,114.39,,,,,,
BCBS Blue Choice,CPT,A4606,Oxygen probe used w oximeter,All Other,Per Unit,$266.89 ,OP,266.89,266.89,,,,,,
BCBS Blue Choice,CPT,A4608,Transtracheal oxygen cath,All Other,Per Unit,$202.07 ,OP,202.07,202.07,,,,,,
BCBS Blue Choice,CPT,A4614,Hand-held pefr meter,All Other,Per Unit,$95.32 ,OP,95.32,95.32,,,,,,
BCBS Blue Choice,CPT,A4616,Tubing (oxygen) per foot,All Other,Per Unit,$1.90 ,OP,1.9,1.9,,,,,,
BCBS Blue Choice,CPT,A4617,Mouth piece,All Other,Per Unit,$11.44 ,OP,11.44,11.44,,,,,,
BCBS Blue Choice,CPT,A4619,Face tent,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,A4620,Variable concentration mask,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,A4623,Tracheostomy inner cannula,All Other,Per Unit,$22.88 ,OP,22.88,22.88,,,,,,
BCBS Blue Choice,CPT,A4625,Trach care kit for new trach,All Other,Per Unit,$26.70 ,OP,26.7,26.7,,,,,,
BCBS Blue Choice,CPT,A4626,Tracheostomy cleaning brush,All Other,Per Unit,$11.44 ,OP,11.44,11.44,,,,,,
BCBS Blue Choice,CPT,A4627,Spacer bag/reservoir,All Other,Per Unit,$171.58 ,OP,171.58,171.58,,,,,,
BCBS Blue Choice,CPT,A4629,Tracheostomy care kit,All Other,Per Unit,$19.07 ,OP,19.07,19.07,,,,,,
BCBS Blue Choice,CPT,A4641,Radiopharm dx agent noc,All Other,Per Unit,$571.91 ,OP,571.91,571.91,,,,,,
BCBS Blue Choice,CPT,A4657,Syringe w/wo needle,All Other,Per Unit,$15.26 ,OP,15.26,15.26,,,,,,
BCBS Blue Choice,CPT,A4660,Sphyg/bp app w cuff and stet,All Other,Per Unit,$366.02 ,OP,366.02,366.02,,,,,,
BCBS Blue Choice,CPT,A4670,Automatic bp monitor- dial,All Other,Per Unit,$415.59 ,OP,415.59,415.59,,,,,,
BCBS Blue Choice,CPT,A4671,Disposable cycler set,All Other,Per Unit,$152.51 ,OP,152.51,152.51,,,,,,
BCBS Blue Choice,CPT,A4672,Drainage ext line- dialysis,All Other,Per Unit,$34.31 ,OP,34.31,34.31,,,,,,
BCBS Blue Choice,CPT,A4680,Activated carbon filter- ea,All Other,Per Unit,$68.63 ,OP,68.63,68.63,,,,,,
BCBS Blue Choice,CPT,A4690,Dialyzer- each,All Other,Per Unit,"$1,212.43 ",OP,"1,212.43","1,212.43",,,,,,
BCBS Blue Choice,CPT,A4737,Inj anesthetic per 10 ml,All Other,Per Unit,$30.51 ,OP,30.51,30.51,,,,,,
BCBS Blue Choice,CPT,A4750,Art or venous blood tubing,All Other,Per Unit,$57.19 ,OP,57.19,57.19,,,,,,
BCBS Blue Choice,CPT,A4770,Blood collection tube/vacuum,All Other,Per Unit,$19.07 ,OP,19.07,19.07,,,,,,
BCBS Blue Choice,CPT,A4772,Blood glucose test strips,All Other,Per Unit,$137.25 ,OP,137.25,137.25,,,,,,
BCBS Blue Choice,CPT,A4773,Occult blood test strips,All Other,Per Unit,$26.70 ,OP,26.7,26.7,,,,,,
BCBS Blue Choice,CPT,A4860,Disposable catheter tips,All Other,Per Unit,$19.07 ,OP,19.07,19.07,,,,,,
BCBS Blue Choice,CPT,A4913,Misc dialysis supplies noc,All Other,Per Unit,$38.13 ,OP,38.13,38.13,,,,,,
BCBS Blue Choice,CPT,A4927,Non-sterile gloves,All Other,Per Unit,$61.00 ,OP,61,61,,,,,,
BCBS Blue Choice,CPT,A4928,Surgical mask,All Other,Per Unit,$64.82 ,OP,64.82,64.82,,,,,,
BCBS Blue Choice,CPT,A4930,Sterile- gloves per pair,All Other,Per Unit,$57.19 ,OP,57.19,57.19,,,,,,
BCBS Blue Choice,CPT,A5051,Pouch clsd w barr attached,All Other,Per Unit,$7.62 ,OP,7.62,7.62,,,,,,
BCBS Blue Choice,CPT,A5052,Clsd ostomy pouch w/o barr,All Other,Per Unit,$7.62 ,OP,7.62,7.62,,,,,,
BCBS Blue Choice,CPT,A5053,Clsd ostomy pouch faceplate,All Other,Per Unit,$7.62 ,OP,7.62,7.62,,,,,,
BCBS Blue Choice,CPT,A5054,Clsd ostomy pouch w/flange,All Other,Per Unit,$7.62 ,OP,7.62,7.62,,,,,,
BCBS Blue Choice,CPT,A5055,Stoma cap,All Other,Per Unit,$7.62 ,OP,7.62,7.62,,,,,,
BCBS Blue Choice,CPT,A5061,Pouch drainable w barrier at,All Other,Per Unit,$15.26 ,OP,15.26,15.26,,,,,,
BCBS Blue Choice,CPT,A5062,Drnble ostomy pouch w/o barr,All Other,Per Unit,$7.62 ,OP,7.62,7.62,,,,,,
BCBS Blue Choice,CPT,A5063,Drain ostomy pouch w/flange,All Other,Per Unit,$11.44 ,OP,11.44,11.44,,,,,,
BCBS Blue Choice,CPT,A5071,Urinary pouch w/barrier,All Other,Per Unit,$22.88 ,OP,22.88,22.88,,,,,,
BCBS Blue Choice,CPT,A5072,Urinary pouch w/o barrier,All Other,Per Unit,$15.26 ,OP,15.26,15.26,,,,,,
BCBS Blue Choice,CPT,A5073,Urinary pouch on barr w/flng,All Other,Per Unit,$11.44 ,OP,11.44,11.44,,,,,,
BCBS Blue Choice,CPT,A5081,Stoma plug or seal- any type,All Other,Per Unit,$11.44 ,OP,11.44,11.44,,,,,,
BCBS Blue Choice,CPT,A5082,Continent stoma catheter,All Other,Per Unit,$45.74 ,OP,45.74,45.74,,,,,,
BCBS Blue Choice,CPT,A5083,Stoma absorptive cover,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,A5093,Ostomy accessory convex inse,All Other,Per Unit,$7.62 ,OP,7.62,7.62,,,,,,
BCBS Blue Choice,CPT,A5102,Bedside drain btl w/wo tube,All Other,Per Unit,$91.51 ,OP,91.51,91.51,,,,,,
BCBS Blue Choice,CPT,A5105,Urinary suspensory,All Other,Per Unit,$163.95 ,OP,163.95,163.95,,,,,,
BCBS Blue Choice,CPT,A5112,Urinary leg bag,All Other,Per Unit,$137.25 ,OP,137.25,137.25,,,,,,
BCBS Blue Choice,CPT,A5113,Latex leg strap,All Other,Per Unit,$19.07 ,OP,19.07,19.07,,,,,,
BCBS Blue Choice,CPT,A5114,Foam/fabric leg strap,All Other,Per Unit,$30.51 ,OP,30.51,30.51,,,,,,
BCBS Blue Choice,CPT,A5120,Skin barrier- wipe or swab,All Other,Per Unit,$1.90 ,OP,1.9,1.9,,,,,,
BCBS Blue Choice,CPT,A5121,Solid skin barrier 6x6,All Other,Per Unit,$30.51 ,OP,30.51,30.51,,,,,,
BCBS Blue Choice,CPT,A5122,Solid skin barrier 8x8,All Other,Per Unit,$49.56 ,OP,49.56,49.56,,,,,,
BCBS Blue Choice,CPT,A5126,Disk/foam pad +or- adhesive,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,A5131,Appliance cleaner,All Other,Per Unit,$57.19 ,OP,57.19,57.19,,,,,,
BCBS Blue Choice,CPT,A5200,Percutaneous catheter anchor,All Other,Per Unit,$45.74 ,OP,45.74,45.74,,,,,,
BCBS Blue Choice,CPT,A5500,Diab shoe for density insert,All Other,Per Unit,$255.45 ,OP,255.45,255.45,,,,,,
BCBS Blue Choice,CPT,A5501,Diabetic custom molded shoe,All Other,Per Unit,$762.54 ,OP,762.54,762.54,,,,,,
BCBS Blue Choice,CPT,A5503,Diabetic shoe w/roller/rockr,All Other,Per Unit,$114.39 ,OP,114.39,114.39,,,,,,
BCBS Blue Choice,CPT,A5504,Diabetic shoe with wedge,All Other,Per Unit,$114.39 ,OP,114.39,114.39,,,,,,
BCBS Blue Choice,CPT,A5505,Diab shoe w/metatarsal bar,All Other,Per Unit,$114.39 ,OP,114.39,114.39,,,,,,
BCBS Blue Choice,CPT,A5506,Diabetic shoe w/off set heel,All Other,Per Unit,$114.39 ,OP,114.39,114.39,,,,,,
BCBS Blue Choice,CPT,A5507,Modification diabetic shoe,All Other,Per Unit,$114.39 ,OP,114.39,114.39,,,,,,
BCBS Blue Choice,CPT,A5512,Multi den insert direct form,All Other,Per Unit,$102.95 ,OP,102.95,102.95,,,,,,
BCBS Blue Choice,CPT,A5513,Multi den insert custom mold,All Other,Per Unit,$156.32 ,OP,156.32,156.32,,,,,,
BCBS Blue Choice,CPT,A6010,Collagen based wound filler,All Other,Per Unit,$125.82 ,OP,125.82,125.82,,,,,,
BCBS Blue Choice,CPT,A6011,Collagen gel/paste wound fil,All Other,Per Unit,$7.62 ,OP,7.62,7.62,,,,,,
BCBS Blue Choice,CPT,A6021,Collagen dressing <=16 sq in,All Other,Per Unit,$83.87 ,OP,83.87,83.87,,,,,,
BCBS Blue Choice,CPT,A6022,Collagen drsg>16<=48 sq in,All Other,Per Unit,$83.87 ,OP,83.87,83.87,,,,,,
BCBS Blue Choice,CPT,A6023,Collagen dressing >48 sq in,All Other,Per Unit,$762.54 ,OP,762.54,762.54,,,,,,
BCBS Blue Choice,CPT,A6024,Collagen dsg wound filler,All Other,Per Unit,$26.70 ,OP,26.7,26.7,,,,,,
BCBS Blue Choice,CPT,A6025,Silicone gel sheet- each,All Other,Per Unit,$95.32 ,OP,95.32,95.32,,,,,,
BCBS Blue Choice,CPT,A6154,Wound pouch each,All Other,Per Unit,$57.19 ,OP,57.19,57.19,,,,,,
BCBS Blue Choice,CPT,A6196,Alginate dressing <=16 sq in,All Other,Per Unit,$30.51 ,OP,30.51,30.51,,,,,,
BCBS Blue Choice,CPT,A6197,Alginate drsg >16 <=48 sq in,All Other,Per Unit,$64.82 ,OP,64.82,64.82,,,,,,
BCBS Blue Choice,CPT,A6199,Alginate drsg wound filler,All Other,Per Unit,$22.88 ,OP,22.88,22.88,,,,,,
BCBS Blue Choice,CPT,A6200,Compos drsg <=16 no border,All Other,Per Unit,$38.13 ,OP,38.13,38.13,,,,,,
BCBS Blue Choice,CPT,A6201,Compos drsg >16<=48 no bdr,All Other,Per Unit,$80.07 ,OP,80.07,80.07,,,,,,
BCBS Blue Choice,CPT,A6202,Compos drsg >48 no border,All Other,Per Unit,$133.45 ,OP,133.45,133.45,,,,,,
BCBS Blue Choice,CPT,A6203,Composite drsg <= 16 sq in,All Other,Per Unit,$15.26 ,OP,15.26,15.26,,,,,,
BCBS Blue Choice,CPT,A6204,Composite drsg >16<=48 sq in,All Other,Per Unit,$26.70 ,OP,26.7,26.7,,,,,,
BCBS Blue Choice,CPT,A6209,Foam drsg <=16 sq in w/o bdr,All Other,Per Unit,$30.51 ,OP,30.51,30.51,,,,,,
BCBS Blue Choice,CPT,A6210,Foam drg >16<=48 sq in w/o b,All Other,Per Unit,$80.07 ,OP,80.07,80.07,,,,,,
BCBS Blue Choice,CPT,A6211,Foam drg > 48 sq in w/o brdr,All Other,Per Unit,$118.19 ,OP,118.19,118.19,,,,,,
BCBS Blue Choice,CPT,A6214,Foam drg > 48 sq in w/border,All Other,Per Unit,$41.94 ,OP,41.94,41.94,,,,,,
BCBS Blue Choice,CPT,A6218,Non-sterile gauze > 48 sq in,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,A6219,Gauze <= 16 sq in w/border,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,A6220,Gauze >16 <=48 sq in w/bordr,All Other,Per Unit,$11.44 ,OP,11.44,11.44,,,,,,
BCBS Blue Choice,CPT,A6221,Gauze > 48 sq in w/border,All Other,Per Unit,$152.51 ,OP,152.51,152.51,,,,,,
BCBS Blue Choice,CPT,A6222,Gauze <=16 in no w/sal w/o b,All Other,Per Unit,$7.62 ,OP,7.62,7.62,,,,,,
BCBS Blue Choice,CPT,A6223,Gauze >16<=48 no w/sal w/o b,All Other,Per Unit,$11.44 ,OP,11.44,11.44,,,,,,
BCBS Blue Choice,CPT,A6224,Gauze > 48 in no w/sal w/o b,All Other,Per Unit,$15.26 ,OP,15.26,15.26,,,,,,
BCBS Blue Choice,CPT,A6228,Gauze <= 16 sq in water/sal,All Other,Per Unit,"$2,745.14 ",OP,"2,745.14","2,745.14",,,,,,
BCBS Blue Choice,CPT,A6231,Hydrogel dsg<=16 sq in,All Other,Per Unit,$19.07 ,OP,19.07,19.07,,,,,,
BCBS Blue Choice,CPT,A6232,Hydrogel dsg>16<=48 sq in,All Other,Per Unit,$26.70 ,OP,26.7,26.7,,,,,,
BCBS Blue Choice,CPT,A6233,Hydrogel dressing >48 sq in,All Other,Per Unit,$76.26 ,OP,76.26,76.26,,,,,,
BCBS Blue Choice,CPT,A6234,Hydrocolld drg <=16 w/o bdr,All Other,Per Unit,$26.70 ,OP,26.7,26.7,,,,,,
BCBS Blue Choice,CPT,A6235,Hydrocolld drg >16<=48 w/o b,All Other,Per Unit,$68.63 ,OP,68.63,68.63,,,,,,
BCBS Blue Choice,CPT,A6236,Hydrocolld drg > 48 in w/o b,All Other,Per Unit,$110.57 ,OP,110.57,110.57,,,,,,
BCBS Blue Choice,CPT,A6237,Hydrocolld drg <=16 in w/bdr,All Other,Per Unit,$30.51 ,OP,30.51,30.51,,,,,,
BCBS Blue Choice,CPT,A6238,Hydrocolld drg >16<=48 w/bdr,All Other,Per Unit,$91.51 ,OP,91.51,91.51,,,,,,
BCBS Blue Choice,CPT,A6240,Hydrocolld drg filler paste,All Other,Per Unit,$49.56 ,OP,49.56,49.56,,,,,,
BCBS Blue Choice,CPT,A6241,Hydrocolloid drg filler dry,All Other,Per Unit,$11.44 ,OP,11.44,11.44,,,,,,
BCBS Blue Choice,CPT,A6242,Hydrogel drg <=16 in w/o bdr,All Other,Per Unit,$22.88 ,OP,22.88,22.88,,,,,,
BCBS Blue Choice,CPT,A6243,Hydrogel drg >16<=48 w/o bdr,All Other,Per Unit,$49.56 ,OP,49.56,49.56,,,,,,
BCBS Blue Choice,CPT,A6244,Hydrogel drg >48 in w/o bdr,All Other,Per Unit,$156.32 ,OP,156.32,156.32,,,,,,
BCBS Blue Choice,CPT,A6245,Hydrogel drg <= 16 in w/bdr,All Other,Per Unit,$30.51 ,OP,30.51,30.51,,,,,,
BCBS Blue Choice,CPT,A6246,Hydrogel drg >16<=48 in w/b,All Other,Per Unit,$38.13 ,OP,38.13,38.13,,,,,,
BCBS Blue Choice,CPT,A6247,Hydrogel drg > 48 sq in w/b,All Other,Per Unit,$95.32 ,OP,95.32,95.32,,,,,,
BCBS Blue Choice,CPT,A6248,Hydrogel drsg gel filler,All Other,Per Unit,$64.82 ,OP,64.82,64.82,,,,,,
BCBS Blue Choice,CPT,A6250,Skin seal protect moisturizr,All Other,Per Unit,$64.82 ,OP,64.82,64.82,,,,,,
BCBS Blue Choice,CPT,A6251,Absorpt drg <=16 sq in w/o b,All Other,Per Unit,$7.62 ,OP,7.62,7.62,,,,,,
BCBS Blue Choice,CPT,A6252,Absorpt drg >16 <=48 w/o bdr,All Other,Per Unit,$11.44 ,OP,11.44,11.44,,,,,,
BCBS Blue Choice,CPT,A6253,Absorpt drg > 48 sq in w/o b,All Other,Per Unit,$26.70 ,OP,26.7,26.7,,,,,,
BCBS Blue Choice,CPT,A6255,Absorpt drg >16<=48 in w/bdr,All Other,Per Unit,$11.44 ,OP,11.44,11.44,,,,,,
BCBS Blue Choice,CPT,A6258,Transparent film >16<=48 in,All Other,Per Unit,$19.07 ,OP,19.07,19.07,,,,,,
BCBS Blue Choice,CPT,A6259,Transparent film > 48 sq in,All Other,Per Unit,$41.94 ,OP,41.94,41.94,,,,,,
BCBS Blue Choice,CPT,A6260,Wound cleanser any type/size,All Other,Per Unit,$57.19 ,OP,57.19,57.19,,,,,,
BCBS Blue Choice,CPT,A6266,Impreg gauze no h20/sal/yard,All Other,Per Unit,$7.62 ,OP,7.62,7.62,,,,,,
BCBS Blue Choice,CPT,A6402,Sterile gauze <= 16 sq in,All Other,Per Unit,$1.90 ,OP,1.9,1.9,,,,,,
BCBS Blue Choice,CPT,A6403,Sterile gauze>16 <= 48 sq in,All Other,Per Unit,$1.90 ,OP,1.9,1.9,,,,,,
BCBS Blue Choice,CPT,A6404,Sterile gauze > 48 sq in,All Other,Per Unit,$152.51 ,OP,152.51,152.51,,,,,,
BCBS Blue Choice,CPT,A6407,Packing strips- non-impreg,All Other,Per Unit,$7.62 ,OP,7.62,7.62,,,,,,
BCBS Blue Choice,CPT,A6410,Sterile eye pad,All Other,Per Unit,$1.90 ,OP,1.9,1.9,,,,,,
BCBS Blue Choice,CPT,A6412,Occlusive eye patch,All Other,Per Unit,$72.44 ,OP,72.44,72.44,,,,,,
BCBS Blue Choice,CPT,A6441,Pad band w>=3,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,A6442,Conform band n/s w<3,All Other,Per Unit,$1.90 ,OP,1.9,1.9,,,,,,
BCBS Blue Choice,CPT,A6443,Conform band n/s w>=3,All Other,Per Unit,$1.90 ,OP,1.9,1.9,,,,,,
BCBS Blue Choice,CPT,A6444,Conform band n/s w>=5,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,A6445,Conform band s w <3,All Other,Per Unit,$1.90 ,OP,1.9,1.9,,,,,,
BCBS Blue Choice,CPT,A6446,Conform band s w>=3,All Other,Per Unit,$1.90 ,OP,1.9,1.9,,,,,,
BCBS Blue Choice,CPT,A6447,Conform band s w >=5,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,A6448,Lt compres band <3,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,A6450,Lt compres band >=5,All Other,Per Unit,$49.56 ,OP,49.56,49.56,,,,,,
BCBS Blue Choice,CPT,A6451,Mod compres band w>=3,All Other,Per Unit,$76.26 ,OP,76.26,76.26,,,,,,
BCBS Blue Choice,CPT,A6452,High compres band w>=3,All Other,Per Unit,$22.88 ,OP,22.88,22.88,,,,,,
BCBS Blue Choice,CPT,A6453,Self-adher band w <3,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,A6454,Self-adher band w>=3,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,A6455,Self-adher band >=5,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,A6456,Zinc paste band w >=3,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,A6457,Tubular dressing,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,A6530,Compression stocking bk18-30,All Other,Per Unit,$266.89 ,OP,266.89,266.89,,,,,,
BCBS Blue Choice,CPT,A6531,Compression stocking bk30-40,All Other,Per Unit,$266.89 ,OP,266.89,266.89,,,,,,
BCBS Blue Choice,CPT,A6532,Compression stocking bk40-50,All Other,Per Unit,$335.53 ,OP,335.53,335.53,,,,,,
BCBS Blue Choice,CPT,A6533,Gc stocking thighlngth 18-30,All Other,Per Unit,$366.02 ,OP,366.02,366.02,,,,,,
BCBS Blue Choice,CPT,A6534,Gc stocking thighlngth 30-40,All Other,Per Unit,$373.65 ,OP,373.65,373.65,,,,,,
BCBS Blue Choice,CPT,A6535,Gc stocking thighlngth 40-50,All Other,Per Unit,$377.46 ,OP,377.46,377.46,,,,,,
BCBS Blue Choice,CPT,A6536,Gc stocking full lngth 18-30,All Other,Per Unit,$285.96 ,OP,285.96,285.96,,,,,,
BCBS Blue Choice,CPT,A6537,Gc stocking full lngth 30-40,All Other,Per Unit,$285.96 ,OP,285.96,285.96,,,,,,
BCBS Blue Choice,CPT,A6539,Gc stocking waistlngth 18-30,All Other,Per Unit,$476.60 ,OP,476.6,476.6,,,,,,
BCBS Blue Choice,CPT,A6540,Gc stocking waistlngth 30-40,All Other,Per Unit,$468.96 ,OP,468.96,468.96,,,,,,
BCBS Blue Choice,CPT,A6541,Gc stocking waistlngth 40-50,All Other,Per Unit,$636.73 ,OP,636.73,636.73,,,,,,
BCBS Blue Choice,CPT,A6544,Gc stocking garter belt,All Other,Per Unit,$221.14 ,OP,221.14,221.14,,,,,,
BCBS Blue Choice,CPT,A6550,Neg pres wound ther drsg set,All Other,Per Unit,$137.25 ,OP,137.25,137.25,,,,,,
BCBS Blue Choice,CPT,A7018,Water distilled w/nebulizer,All Other,Per Unit,$1.90 ,OP,1.9,1.9,,,,,,
BCBS Blue Choice,CPT,A7040,One way chest drain valve,All Other,Per Unit,$160.13 ,OP,160.13,160.13,,,,,,
BCBS Blue Choice,CPT,A7041,Water seal drain container,All Other,Per Unit,$305.01 ,OP,305.01,305.01,,,,,,
BCBS Blue Choice,CPT,A7042,Implanted pleural catheter,All Other,Per Unit,$773.98 ,OP,773.98,773.98,,,,,,
BCBS Blue Choice,CPT,A7043,Vacuum drainagebottle/tubing,All Other,Per Unit,$114.39 ,OP,114.39,114.39,,,,,,
BCBS Blue Choice,CPT,A7501,Tracheostoma valve w diaphra,All Other,Per Unit,$419.40 ,OP,419.4,419.4,,,,,,
BCBS Blue Choice,CPT,A7502,Replacement diaphragm/fplate,All Other,Per Unit,$198.25 ,OP,198.25,198.25,,,,,,
BCBS Blue Choice,CPT,A7503,Hmes filter holder or cap,All Other,Per Unit,$45.74 ,OP,45.74,45.74,,,,,,
BCBS Blue Choice,CPT,A7504,Tracheostoma hmes filter,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,A7505,Hmes or trach valve housing,All Other,Per Unit,$19.07 ,OP,19.07,19.07,,,,,,
BCBS Blue Choice,CPT,A7506,Hmes/trachvalve adhesivedisk,All Other,Per Unit,$1.90 ,OP,1.9,1.9,,,,,,
BCBS Blue Choice,CPT,A7507,Integrated filter & holder,All Other,Per Unit,$11.44 ,OP,11.44,11.44,,,,,,
BCBS Blue Choice,CPT,A7508,Housing & integrated adhesiv,All Other,Per Unit,$11.44 ,OP,11.44,11.44,,,,,,
BCBS Blue Choice,CPT,A7509,Heat & moisture exchange sys,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,A7520,Trach/laryn tube non-cuffed,All Other,Per Unit,$190.64 ,OP,190.64,190.64,,,,,,
BCBS Blue Choice,CPT,A7521,Trach/laryn tube cuffed,All Other,Per Unit,$186.82 ,OP,186.82,186.82,,,,,,
BCBS Blue Choice,CPT,A7522,Trach/laryn tube stainless,All Other,Per Unit,$179.20 ,OP,179.2,179.2,,,,,,
BCBS Blue Choice,CPT,A7524,Tracheostoma stent/stud/bttn,All Other,Per Unit,$308.83 ,OP,308.83,308.83,,,,,,
BCBS Blue Choice,CPT,A7525,Tracheostomy mask,All Other,Per Unit,$7.62 ,OP,7.62,7.62,,,,,,
BCBS Blue Choice,CPT,A7526,Tracheostomy tube collar,All Other,Per Unit,$15.26 ,OP,15.26,15.26,,,,,,
BCBS Blue Choice,CPT,A7527,Trach/laryn tube plug/stop,All Other,Per Unit,$15.26 ,OP,15.26,15.26,,,,,,
BCBS Blue Choice,CPT,A9276,Disposable sensor- cgm sys,All Other,Per Unit,$41.94 ,OP,41.94,41.94,,,,,,
BCBS Blue Choice,CPT,A9277,External transmitter- cgm,All Other,Per Unit,"$2,276.18 ",OP,"2,276.18","2,276.18",,,,,,
BCBS Blue Choice,CPT,A9278,External receiver- cgm sys,All Other,Per Unit,"$1,929.22 ",OP,"1,929.22","1,929.22",,,,,,
BCBS Blue Choice,CPT,A9300,Exercise equipment,All Other,Per Unit,$57.19 ,OP,57.19,57.19,,,,,,
BCBS Blue Choice,CPT,A9500,Tc99m sestamibi,All Other,Per Unit,$275.87 ,OP,275.87,275.87,,,,,,
BCBS Blue Choice,CPT,A9502,Tc99m tetrofosmin,All Other,Per Unit,"$1,143.81 ",OP,"1,143.81","1,143.81",,,,,,
BCBS Blue Choice,CPT,A9503,Tc99m medronate,All Other,Per Unit,$217.32 ,OP,217.32,217.32,,,,,,
BCBS Blue Choice,CPT,A9504,Tc99m apcitide,All Other,Per Unit,"$2,173.23 ",OP,"2,173.23","2,173.23",,,,,,
BCBS Blue Choice,CPT,A9505,Tl201 thallium,All Other,Per Unit,$228.77 ,OP,228.77,228.77,,,,,,
BCBS Blue Choice,CPT,A9507,In111 capromab,All Other,Per Unit,"$10,031.20 ",OP,"10,031.20","10,031.20",,,,,,
BCBS Blue Choice,CPT,A9510,Tc99m disofenin,All Other,Per Unit,$259.27 ,OP,259.27,259.27,,,,,,
BCBS Blue Choice,CPT,A9516,Iodine i-123 sod iodide mic,All Other,Per Unit,$297.39 ,OP,297.39,297.39,,,,,,
BCBS Blue Choice,CPT,A9517,I131 iodide cap- rx,All Other,Per Unit,$32.18 ,OP,20.12,32.18,,,,,,
BCBS Blue Choice,CPT,A9520,Tc99 tilmanocept diag 0.5mci,All Other,Per Unit,$8.66 ,OP,8.66,8.66,,,,,,
BCBS Blue Choice,CPT,A9521,Tc99m exametazime,All Other,Per Unit,"$4,075.77 ",OP,"4,075.77","4,075.77",,,,,,
BCBS Blue Choice,CPT,A9524,I131 serum albumin- dx,All Other,Per Unit,$240.20 ,OP,240.2,240.2,,,,,,
BCBS Blue Choice,CPT,A9552,F18 fdg,All Other,Per Unit,"$1,525.07 ",OP,"1,525.07","1,525.07",,,,,,
BCBS Blue Choice,CPT,A9575,Inj gadoterate meglumi 0.1ml,All Other,Per Unit,$1.15 ,OP,1.15,1.15,,,,,,
BCBS Blue Choice,CPT,A9576,Inj prohance multipack,All Other,Per Unit,$11.44 ,OP,11.44,11.44,,,,,,
BCBS Blue Choice,CPT,A9577,Inj multihance,All Other,Per Unit,$11.44 ,OP,11.44,11.44,,,,,,
BCBS Blue Choice,CPT,A9578,Inj multihance multipack,All Other,Per Unit,$11.44 ,OP,11.44,11.44,,,,,,
BCBS Blue Choice,CPT,A9579,Gad-base mr contrast nos-1ml,All Other,Per Unit,$11.44 ,OP,11.44,11.44,,,,,,
BCBS Blue Choice,CPT,A9600,Sr89 strontium,All Other,Per Unit,"$4,407.46 ",OP,"3,975.00","4,407.46",,,,,,
BCBS Blue Choice,CPT,A9605,Sm 153 lexidronm,All Other,Per Unit,"$4,666.74 ",OP,"4,666.74","4,666.74",,,,,,
BCBS Blue Choice,CPT,A9700,Echocardiography contrast,All Other,Per Unit,$915.04 ,OP,915.04,915.04,,,,,,
BCBS Blue Choice,CPT,B4034,Enter feed supkit syr by day,All Other,Per Unit,$26.70 ,OP,26.7,26.7,,,,,,
BCBS Blue Choice,CPT,B4035,Enteral feed supp pump per d,All Other,Per Unit,$45.74 ,OP,45.74,45.74,,,,,,
BCBS Blue Choice,CPT,B4036,Enteral feed sup kit grav by,All Other,Per Unit,$34.31 ,OP,34.31,34.31,,,,,,
BCBS Blue Choice,CPT,B4081,Enteral ng tubing w/ stylet,All Other,Per Unit,$87.69 ,OP,87.69,87.69,,,,,,
BCBS Blue Choice,CPT,B4083,Enteral stomach tube levine,All Other,Per Unit,$11.44 ,OP,11.44,11.44,,,,,,
BCBS Blue Choice,CPT,B4087,Gastro/jejuno tube- std,All Other,Per Unit,$144.88 ,OP,144.88,144.88,,,,,,
BCBS Blue Choice,CPT,B4149,Ef blenderized foods,All Other,Per Unit,$7.62 ,OP,7.62,7.62,,,,,,
BCBS Blue Choice,CPT,B4150,Ef complet w/intact nutrient,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,B4152,Ef calorie dense>/=1.5kcal,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,B4153,Ef hydrolyzed/amino acids,All Other,Per Unit,$7.62 ,OP,7.62,7.62,,,,,,
BCBS Blue Choice,CPT,B4154,Ef spec metabolic noninherit,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,B4155,Ef incomplete/modular,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,B4157,Ef special metabolic inherit,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,B4158,Ef ped complete intact nut,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,B4159,Ef ped complete soy based,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,B4160,Ef ped caloric dense>/=0.7kc,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,B4161,Ef ped hydrolyzed/amino acid,All Other,Per Unit,$7.62 ,OP,7.62,7.62,,,,,,
BCBS Blue Choice,CPT,B4162,Ef ped specmetabolic inherit,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,B4164,Parenteral 50% dextrose solu,All Other,Per Unit,$68.63 ,OP,68.63,68.63,,,,,,
BCBS Blue Choice,CPT,B4168,Parenteral sol amino acid 3.,All Other,Per Unit,$99.13 ,OP,99.13,99.13,,,,,,
BCBS Blue Choice,CPT,B4176,Parenteral sol amino acid 7-,All Other,Per Unit,$190.64 ,OP,190.64,190.64,,,,,,
BCBS Blue Choice,CPT,B4178,Parenteral sol amino acid >,All Other,Per Unit,$228.77 ,OP,228.77,228.77,,,,,,
BCBS Blue Choice,CPT,B4180,Parenteral sol carb > 50%,All Other,Per Unit,$95.32 ,OP,95.32,95.32,,,,,,
BCBS Blue Choice,CPT,B4185,Pn soln nos 10 grams lipids,All Other,Per Unit,$45.74 ,OP,45.74,45.74,,,,,,
BCBS Blue Choice,CPT,B4189,Parenteral sol amino acid &,All Other,Per Unit,$705.35 ,OP,705.35,705.35,,,,,,
BCBS Blue Choice,CPT,B4193,Parenteral sol 52-73 gm prot,All Other,Per Unit,$911.23 ,OP,911.23,911.23,,,,,,
BCBS Blue Choice,CPT,B4197,Parenteral sol 74-100 gm pro,All Other,Per Unit,"$1,105.68 ",OP,"1,105.68","1,105.68",,,,,,
BCBS Blue Choice,CPT,B4199,Parenteral sol > 100gm prote,All Other,Per Unit,"$1,265.81 ",OP,"1,265.81","1,265.81",,,,,,
BCBS Blue Choice,CPT,B4216,Parenteral nutrition additiv,All Other,Per Unit,$30.51 ,OP,30.51,30.51,,,,,,
BCBS Blue Choice,CPT,B4220,Parenteral supply kit premix,All Other,Per Unit,$30.51 ,OP,30.51,30.51,,,,,,
BCBS Blue Choice,CPT,B4222,Parenteral supply kit homemi,All Other,Per Unit,$38.13 ,OP,38.13,38.13,,,,,,
BCBS Blue Choice,CPT,B4224,Parenteral administration ki,All Other,Per Unit,$99.13 ,OP,99.13,99.13,,,,,,
BCBS Blue Choice,CPT,B5000,Parenteral sol renal-amirosy,All Other,Per Unit,$45.74 ,OP,45.74,45.74,,,,,,
BCBS Blue Choice,CPT,B5100,Parenteral solution hepatic,All Other,Per Unit,$19.07 ,OP,19.07,19.07,,,,,,
BCBS Blue Choice,CPT,D7210,Rem imp tooth w mucoper flp,All Other,Per Unit,$953.17 ,OP,953.17,"1,426.03",,,,,,
BCBS Blue Choice,CPT,D7220,Impact tooth remov soft tiss,All Other,Per Unit,$953.17 ,OP,953.17,"1,426.03",,,,,,
BCBS Blue Choice,CPT,D7230,Impact tooth remov part bony,All Other,Per Unit,"$1,391.64 ",OP,"1,391.64","1,426.03",,,,,,
BCBS Blue Choice,CPT,D7240,Impact tooth remov comp bony,All Other,Per Unit,"$1,715.71 ",OP,"1,426.03","1,715.71",,,,,,
BCBS Blue Choice,CPT,D7241,Impact tooth rem bony w/comp,All Other,Per Unit,"$2,001.67 ",OP,"1,426.03","2,001.67",,,,,,
BCBS Blue Choice,CPT,D9430,Office visit during hours,All Other,Per Unit,$190.64 ,OP,190.64,190.64,,,,,,
BCBS Blue Choice,CPT,E0441,Stationary o2 contents- gas,All Other,Per Unit,$293.57 ,OP,293.57,293.57,,,,,,
BCBS Blue Choice,CPT,E0442,Stationary o2 contents- liq,All Other,Per Unit,$293.57 ,OP,293.57,293.57,,,,,,
BCBS Blue Choice,CPT,E0443,Portable 02 contents- gas,All Other,Per Unit,$293.57 ,OP,293.57,293.57,,,,,,
BCBS Blue Choice,CPT,E0444,Portable 02 contents- liquid,All Other,Per Unit,$293.57 ,OP,293.57,293.57,,,,,,
BCBS Blue Choice,CPT,E0785,Replacement impl pump cathet,All Other,Per Unit,"$1,891.10 ",OP,"1,891.10","1,891.10",,,,,,
BCBS Blue Choice,CPT,E1701,Repl cushions for jaw motion,All Other,Per Unit,$41.94 ,OP,41.94,41.94,,,,,,
BCBS Blue Choice,CPT,E1702,Repl measr scales jaw motion,All Other,Per Unit,$91.51 ,OP,91.51,91.51,,,,,,
BCBS Blue Choice,CPT,E1902,Aac non-electronic board,All Other,Per Unit,$186.82 ,OP,186.82,186.82,,,,,,
BCBS Blue Choice,CPT,G0008,Admin influenza virus vac,All Other,Per Unit,$57.19 ,OP,40.93,57.19,,,,,,
BCBS Blue Choice,CPT,G0009,Admin pneumococcal vaccine,All Other,Per Unit,$57.19 ,OP,40.93,57.19,,,,,,
BCBS Blue Choice,CPT,G0010,Admin hepatitis b vaccine,All Other,Per Unit,$57.19 ,OP,40.93,57.19,,,,,,
BCBS Blue Choice,CPT,G0027,Semen analysis,All Other,Per Unit,$34.31 ,OP,6.5,34.31,,,,,,
BCBS Blue Choice,CPT,G0101,Ca screen-pelvic/breast exam,All Other,Per Unit,$186.82 ,OP,76.62,186.82,,,,,,
BCBS Blue Choice,CPT,G0102,Prostate ca screening- dre,All Other,Per Unit,$102.95 ,OP,102.95,102.95,,,,,,
BCBS Blue Choice,CPT,G0103,Psa screening,All Other,Per Unit,$80.07 ,OP,19.31,80.07,,,,,,
BCBS Blue Choice,CPT,G0104,Ca screen-flexi sigmoidscope,All Other,Per Unit,$678.66 ,OP,678.66,812.16,,,,,,
BCBS Blue Choice,CPT,G0106,Colon ca screen-barium enema,All Other,Per Unit,"$1,090.43 ",OP,182.72,"1,090.43",,,,,,
BCBS Blue Choice,CPT,G0108,Diab manage trn  per indiv,All Other,Per Unit,$125.82 ,OP,54.47,125.82,,,,,,
BCBS Blue Choice,CPT,G0109,Diab manage trn ind/group,All Other,Per Unit,$72.44 ,OP,15.18,72.44,,,,,,
BCBS Blue Choice,CPT,G0117,Glaucoma scrn hgh risk direc,All Other,Per Unit,$232.58 ,OP,25.25,232.58,,,,,,
BCBS Blue Choice,CPT,G0118,Glaucoma scrn hgh risk direc,All Other,Per Unit,$160.13 ,OP,34.63,160.13,,,,,,
BCBS Blue Choice,CPT,G0120,Colon ca scrn- barium enema,All Other,Per Unit,"$1,090.43 ",OP,376.7,"1,090.43",,,,,,
BCBS Blue Choice,CPT,G0122,Colon ca scrn- barium enema,All Other,Per Unit,"$1,292.50 ",OP,"1,292.50","1,292.50",,,,,,
BCBS Blue Choice,CPT,G0123,Screen cerv/vag thin layer,All Other,Per Unit,$91.51 ,OP,20.26,91.51,,,,,,
BCBS Blue Choice,CPT,G0124,Screen c/v thin layer by md,All Other,Per Unit,$137.25 ,OP,137.25,137.25,,,,,,
BCBS Blue Choice,CPT,G0128,Corf skilled nursing service,All Other,Per Unit,$45.74 ,OP,45.74,45.74,,,,,,
BCBS Blue Choice,CPT,G0130,Single energy x-ray study,All Other,Per Unit,$171.58 ,OP,111.51,171.58,,,,,,
BCBS Blue Choice,CPT,G0141,Scr c/v cyto-autosys and md,All Other,Per Unit,$137.25 ,OP,137.25,137.25,,,,,,
BCBS Blue Choice,CPT,G0143,Scr c/v cyto-thinlayer-rescr,All Other,Per Unit,$91.51 ,OP,27.05,91.51,,,,,,
BCBS Blue Choice,CPT,G0144,Scr c/v cyto-thinlayer-rescr,All Other,Per Unit,$95.32 ,OP,43.97,95.32,,,,,,
BCBS Blue Choice,CPT,G0145,Scr c/v cyto-thinlayer-rescr,All Other,Per Unit,$118.19 ,OP,26.49,118.19,,,,,,
BCBS Blue Choice,CPT,G0147,Scr c/v cyto- automated sys,All Other,Per Unit,$45.74 ,OP,15.15,45.74,,,,,,
BCBS Blue Choice,CPT,G0148,Scr c/v cyto- autosys- rescr,All Other,Per Unit,$45.74 ,OP,31.94,45.74,,,,,,
BCBS Blue Choice,CPT,G0168,Wound closure by adhesive,All Other,Per Unit,$434.65 ,OP,434.65,434.65,,,,,,
BCBS Blue Choice,CPT,G0175,Opps service-sched team conf,All Other,Per Unit,$392.70 ,OP,372.22,392.7,,,,,,
BCBS Blue Choice,CPT,G0179,Md recertification hha pt,All Other,Per Unit,$209.70 ,OP,209.7,209.7,,,,,,
BCBS Blue Choice,CPT,G0180,Md certification hha patient,All Other,Per Unit,$278.32 ,OP,278.32,278.32,,,,,,
BCBS Blue Choice,CPT,G0181,Home health care supervision,All Other,Per Unit,$537.60 ,OP,537.6,537.6,,,,,,
BCBS Blue Choice,CPT,G0182,Hospice care supervision,All Other,Per Unit,$549.03 ,OP,549.03,549.03,,,,,,
BCBS Blue Choice,CPT,G0202,Screeningmammographydigital,All Other,Per Unit,$275.87 ,OP,275.87,275.87,,,,,,
BCBS Blue Choice,CPT,G0204,Diagnosticmammographydigital,All Other,Per Unit,$275.87 ,OP,275.87,275.87,,,,,,
BCBS Blue Choice,CPT,G0206,Diagnosticmammographydigital,All Other,Per Unit,$275.87 ,OP,275.87,275.87,,,,,,
BCBS Blue Choice,CPT,G0235,Pet not otherwise specified,All Other,Per Unit,"$7,236.50 ",OP,385.91,"7,236.50",,,,,,
BCBS Blue Choice,CPT,G0237,Therapeutic procd strg endur,All Other,Per Unit,$61.00 ,OP,25.25,61,,,,,,
BCBS Blue Choice,CPT,G0238,Oth resp proc- indiv,All Other,Per Unit,$64.82 ,OP,25.25,64.82,,,,,,
BCBS Blue Choice,CPT,G0239,Oth resp proc- group,All Other,Per Unit,$64.82 ,OP,34.63,64.82,,,,,,
BCBS Blue Choice,CPT,G0245,Initial foot exam pt lops,All Other,Per Unit,$339.33 ,OP,121.51,339.33,,,,,,
BCBS Blue Choice,CPT,G0246,Followup eval of foot pt lop,All Other,Per Unit,$198.25 ,OP,121.51,198.25,,,,,,
BCBS Blue Choice,CPT,G0247,Routine footcare pt w lops,All Other,Per Unit,$232.58 ,OP,183.73,232.58,,,,,,
BCBS Blue Choice,CPT,G0248,Demonstrate use home inr mon,All Other,Per Unit,$804.48 ,OP,121.51,804.48,,,,,,
BCBS Blue Choice,CPT,G0249,Provide inr test mater/equip,All Other,Per Unit,$686.28 ,OP,121.51,686.28,,,,,,
BCBS Blue Choice,CPT,G0250,Md inr test revie inter mgmt,All Other,Per Unit,$49.56 ,OP,49.56,49.56,,,,,,
BCBS Blue Choice,CPT,G0268,Removal of impacted wax md,All Other,Per Unit,$285.96 ,OP,285.96,285.96,,,,,,
BCBS Blue Choice,CPT,G0270,Mnt subs tx for change dx,All Other,Per Unit,$122.00 ,OP,26.49,122,,,,,,
BCBS Blue Choice,CPT,G0271,Group mnt 2 or more 30 mins,All Other,Per Unit,$68.63 ,OP,13.98,68.63,,,,,,
BCBS Blue Choice,CPT,G0275,Renal angio - cardiac cath,All Other,Per Unit,$76.26 ,OP,76.26,76.26,,,,,,
BCBS Blue Choice,CPT,G0278,Iliac art angio-cardiac cath,All Other,Per Unit,$76.26 ,OP,76.26,76.26,,,,,,
BCBS Blue Choice,CPT,G0281,Elec stim unattend for press,All Other,Per Unit,$61.00 ,OP,12.74,61,,,,,,
BCBS Blue Choice,CPT,G0283,Elec stim other than wound,All Other,Per Unit,$61.00 ,OP,12.74,61,,,,,,
BCBS Blue Choice,CPT,G0289,Arthro- loose body + chondro,All Other,Per Unit,$568.09 ,OP,568.09,568.09,,,,,,
BCBS Blue Choice,CPT,G0306,Cbc/diffwbc w/o platelet,All Other,Per Unit,$34.31 ,OP,7.77,34.31,,,,,,
BCBS Blue Choice,CPT,G0307,Cbc without platelet,All Other,Per Unit,$30.51 ,OP,6.47,30.51,,,,,,
BCBS Blue Choice,CPT,G0328,Fecal blood scrn immunoassay,All Other,Per Unit,$72.44 ,OP,18.05,72.44,,,,,,
BCBS Blue Choice,CPT,G0329,Electromagntic tx for ulcers,All Other,Per Unit,$45.74 ,OP,10.46,45.74,,,,,,
BCBS Blue Choice,CPT,G0333,Dispense fee initial 30 day,All Other,Per Unit,$217.32 ,OP,217.32,217.32,,,,,,
BCBS Blue Choice,CPT,G0337,Hospice evaluation preelecti,All Other,Per Unit,$369.83 ,OP,369.83,369.83,,,,,,
BCBS Blue Choice,CPT,G0341,Percutaneous islet celltrans,All Other,Per Unit,"$2,508.76 ",OP,"2,508.76","8,948.83",,,,,,
BCBS Blue Choice,CPT,G0342,Laparoscopy islet cell trans,All Other,Per Unit,"$4,254.96 ",OP,"4,254.96","8,948.83",,,,,,
BCBS Blue Choice,CPT,G0343,Laparotomy islet cell transp,All Other,Per Unit,"$6,965.79 ",OP,"6,965.79","8,948.83",,,,,,
BCBS Blue Choice,CPT,G0364,Bone marrow aspirate &biopsy,All Other,Per Unit,$80.07 ,OP,80.07,80.07,,,,,,
BCBS Blue Choice,CPT,G0365,Vessel mapping hemo access,All Other,Per Unit,"$1,136.19 ",OP,"1,136.19","1,136.19",,,,,,
BCBS Blue Choice,CPT,G0372,Md service required for pmd,All Other,Per Unit,$61.00 ,OP,61,61,,,,,,
BCBS Blue Choice,CPT,G0389,Ultrasound exam AAA screen,All Other,Per Unit,$575.73 ,OP,575.73,575.73,,,,,,
BCBS Blue Choice,CPT,G0392,AV fistula or graft arterial,All Other,Per Unit,"$12,292.12 ",OP,"12,292.12","12,292.12",,,,,,
BCBS Blue Choice,CPT,G0393,AV fistula or graft venous,All Other,Per Unit,"$9,268.66 ",OP,"9,268.66","9,268.66",,,,,,
BCBS Blue Choice,CPT,G0396,Alcohol/subs interv 15-30mn,All Other,Per Unit,$163.95 ,OP,26.84,163.95,,,,,,
BCBS Blue Choice,CPT,G0398,Home sleep test/type 2 porta,All Other,Per Unit,$367.82 ,OP,142.8,367.82,,,,,,
BCBS Blue Choice,CPT,G0400,Home sleep test/type 4 porta,All Other,Per Unit,$367.82 ,OP,270.61,367.82,,,,,,
BCBS Blue Choice,CPT,G0402,Initial preventive exam,All Other,Per Unit,$491.83 ,OP,121.51,491.83,,,,,,
BCBS Blue Choice,CPT,G0403,Ekg for initial prevent exam,All Other,Per Unit,$122.00 ,OP,122,122,,,,,,
BCBS Blue Choice,CPT,G0405,Ekg interpret & report preve,All Other,Per Unit,$45.74 ,OP,45.74,45.74,,,,,,
BCBS Blue Choice,CPT,G0406,Inpt/tele follow up 15,All Other,Per Unit,$194.45 ,OP,194.45,194.45,,,,,,
BCBS Blue Choice,CPT,G0407,Inpt/tele follow up 25,All Other,Per Unit,$346.96 ,OP,346.96,346.96,,,,,,
BCBS Blue Choice,CPT,G0408,Inpt/tele follow up 35,All Other,Per Unit,$495.65 ,OP,495.65,495.65,,,,,,
BCBS Blue Choice,CPT,G0409,Corf related serv 15 mins ea,All Other,Per Unit,$45.74 ,OP,45.74,45.74,,,,,,
BCBS Blue Choice,CPT,G0412,Open tx iliac spine uni/bil,All Other,Per Unit,"$4,510.41 ",OP,"4,510.41","6,411.04",,,,,,
BCBS Blue Choice,CPT,G0413,Pelvic ring fracture uni/bil,All Other,Per Unit,"$6,527.33 ",OP,"6,411.04","6,527.33",,,,,,
BCBS Blue Choice,CPT,G0414,Pelvic ring fx treat int fix,All Other,Per Unit,"$6,161.31 ",OP,"6,161.31","12,601.93",,,,,,
BCBS Blue Choice,CPT,G0415,Open tx post pelvic fxcture,All Other,Per Unit,"$8,452.74 ",OP,"8,452.74","12,601.93",,,,,,
BCBS Blue Choice,CPT,G0416,Prostate biopsy- any mthd,All Other,Per Unit,"$3,297.99 ",OP,298.05,"3,297.99",,,,,,
BCBS Blue Choice,CPT,G0417,Sat biopsy prostate 21-40,All Other,Per Unit,"$6,412.95 ",OP,"6,412.95","6,412.95",,,,,,
BCBS Blue Choice,CPT,G0418,Sat biopsy prostate 41-60,All Other,Per Unit,"$10,999.63 ",OP,"10,999.63","10,999.63",,,,,,
BCBS Blue Choice,CPT,G0419,Sat biopsy prostate: >60,All Other,Per Unit,"$13,066.10 ",OP,"13,066.10","13,066.10",,,,,,
BCBS Blue Choice,CPT,G0459,Telehealth inpt pharm mgmt,All Other,Per Unit,$285.96 ,OP,285.96,285.96,,,,,,
BCBS Blue Choice,CPT,G0463,Hospital outpt clinic visit,All Other,Per Unit,$95.32 ,OP,95.32,121.51,,,,,,
BCBS Blue Choice,CPT,G2023,Specimen collect covid-19,All Other,Per Unit,$80.07 ,OP,80.07,80.07,,,,,,
BCBS Blue Choice,CPT,G2024,Spec coll snf/lab covid-19,All Other,Per Unit,$80.07 ,OP,80.07,80.07,,,,,,
BCBS Blue Choice,CPT,G9041,Low vision rehab occupationa,All Other,Per Unit,$118.19 ,OP,118.19,118.19,,,,,,
BCBS Blue Choice,CPT,G9042,Low vision rehab orient/mobi,All Other,Per Unit,$41.94 ,OP,41.94,41.94,,,,,,
BCBS Blue Choice,CPT,G9043,Low vision lowvision therapi,All Other,Per Unit,$38.13 ,OP,38.13,38.13,,,,,,
BCBS Blue Choice,CPT,G9044,Low vision rehabilate teache,All Other,Per Unit,$38.13 ,OP,38.13,38.13,,,,,,
BCBS Blue Choice,CPT,J0128,Abarelix injection,All Other,Per Unit,$331.70 ,OP,331.7,331.7,,,,,,
BCBS Blue Choice,CPT,J0129,Abatacept injection,All Other,Per Unit,$73.44 ,OP,45.27,73.44,,,,,,
BCBS Blue Choice,CPT,J0132,Acetylcysteine injection,All Other,Per Unit,$11.44 ,OP,11.44,11.44,,,,,,
BCBS Blue Choice,CPT,J0133,Acyclovir injection,All Other,Per Unit,$1.90 ,OP,1.9,1.9,,,,,,
BCBS Blue Choice,CPT,J0150,Injection adenosine 6 MG,All Other,Per Unit,$49.56 ,OP,49.56,49.56,,,,,,
BCBS Blue Choice,CPT,J0151,INJ ADENOSINE 90 MG,All Other,Per Unit,$11.44 ,OP,11.44,11.44,,,,,,
BCBS Blue Choice,CPT,J0152,Adenosine injection,All Other,Per Unit,$343.14 ,OP,343.14,343.14,,,,,,
BCBS Blue Choice,CPT,J0153,Adenosine inj 1mg,All Other,Per Unit,$11.44 ,OP,11.44,11.44,,,,,,
BCBS Blue Choice,CPT,J0180,Agalsidase beta injection,All Other,Per Unit,$508.92 ,OP,198.14,508.92,,,,,,
BCBS Blue Choice,CPT,J0200,Alatrofloxacin mesylate,All Other,Per Unit,$83.87 ,OP,83.87,83.87,,,,,,
BCBS Blue Choice,CPT,J0202,Injection- alemtuzumab,All Other,Per Unit,$277.19 ,OP,277.19,"2,086.32",,,,,,
BCBS Blue Choice,CPT,J0205,Alglucerase injection,All Other,Per Unit,$202.07 ,OP,202.07,202.07,,,,,,
BCBS Blue Choice,CPT,J0207,Amifostine,All Other,Per Unit,"$1,985.16 ",OP,"1,135.69","1,985.16",,,,,,
BCBS Blue Choice,CPT,J0210,Methyldopate hcl injection,All Other,Per Unit,$133.45 ,OP,133.45,133.45,,,,,,
BCBS Blue Choice,CPT,J0215,Alefacept,All Other,Per Unit,$110.76 ,OP,110.76,110.76,,,,,,
BCBS Blue Choice,CPT,J0220,Alglucosidase alfa injection,All Other,Per Unit,$474.68 ,OP,117.07,474.68,,,,,,
BCBS Blue Choice,CPT,J0256,Alpha 1 proteinase inhibitor,All Other,Per Unit,$7.90 ,OP,4.54,7.9,,,,,,
BCBS Blue Choice,CPT,J0270,Alprostadil for injection,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,J0275,Alprostadil urethral suppos,All Other,Per Unit,$118.19 ,OP,118.19,118.19,,,,,,
BCBS Blue Choice,CPT,J0285,Amphotericin b,All Other,Per Unit,$64.82 ,OP,64.82,64.82,,,,,,
BCBS Blue Choice,CPT,J0287,Amphotericin b lipid complex,All Other,Per Unit,$49.56 ,OP,9.5,49.56,,,,,,
BCBS Blue Choice,CPT,J0288,Ampho b cholesteryl sulfate,All Other,Per Unit,$68.63 ,OP,68.63,68.63,,,,,,
BCBS Blue Choice,CPT,J0289,Amphotericin b liposome inj,All Other,Per Unit,$118.19 ,OP,28.75,118.19,,,,,,
BCBS Blue Choice,CPT,J0300,Amobarbital 125 mg inj,All Other,Per Unit,$30.51 ,OP,30.51,125.22,,,,,,
BCBS Blue Choice,CPT,J0330,Succinycholine chloride inj,All Other,Per Unit,$1.90 ,OP,1.9,1.9,,,,,,
BCBS Blue Choice,CPT,J0350,Injection anistreplase 30 u,All Other,Per Unit,"$11,014.86 ",OP,"11,014.86","11,014.86",,,,,,
BCBS Blue Choice,CPT,J0364,Apomorphine hydrochloride,All Other,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Blue Choice,CPT,J0365,Aprotonin- 10-000 kiu,All Other,Per Unit,$11.44 ,OP,11.44,11.44,,,,,,
BCBS Blue Choice,CPT,J0380,Inj metaraminol bitartrate,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,J0390,Chloroquine injection,All Other,Per Unit,$83.87 ,OP,83.87,165.22,,,,,,
BCBS Blue Choice,CPT,J0395,Arbutamine hcl injection,All Other,Per Unit,$777.79 ,OP,777.79,777.79,,,,,,
BCBS Blue Choice,CPT,J0400,Aripiprazole injection,All Other,Per Unit,$1.90 ,OP,1.9,1.9,,,,,,
BCBS Blue Choice,CPT,J0401,Inj aripiprazole ext rel 1mg,All Other,Per Unit,$7.62 ,OP,6.01,7.62,,,,,,
BCBS Blue Choice,CPT,J0470,Dimecaprol injection,All Other,Per Unit,$129.64 ,OP,129.64,129.64,,,,,,
BCBS Blue Choice,CPT,J0475,Baclofen 10 mg injection,All Other,Per Unit,$826.29 ,OP,177.43,826.29,,,,,,
BCBS Blue Choice,CPT,J0476,Baclofen intrathecal trial,All Other,Per Unit,$350.76 ,OP,350.76,350.76,,,,,,
BCBS Blue Choice,CPT,J0480,Basiliximab,All Other,Per Unit,"$7,724.52 ",OP,"4,013.08","7,724.52",,,,,,
BCBS Blue Choice,CPT,J0500,Dicyclomine injection,All Other,Per Unit,$87.69 ,OP,87.69,87.69,,,,,,
BCBS Blue Choice,CPT,J0515,Inj benztropine mesylate,All Other,Per Unit,$152.51 ,OP,152.51,152.51,,,,,,
BCBS Blue Choice,CPT,J0520,Bethanechol chloride inject,All Other,Per Unit,$72.44 ,OP,72.44,72.44,,,,,,
BCBS Blue Choice,CPT,J0530,Penicillin g benzathine inj,All Other,Per Unit,$72.44 ,OP,72.44,72.44,,,,,,
BCBS Blue Choice,CPT,J0540,Penicillin g benzathine inj,All Other,Per Unit,$167.76 ,OP,167.76,167.76,,,,,,
BCBS Blue Choice,CPT,J0560,Penicillin g benzathine inj,All Other,Per Unit,$122.00 ,OP,122,122,,,,,,
BCBS Blue Choice,CPT,J0570,Buprenorphine implant 74.2mg,All Other,Per Unit,$209.70 ,OP,209.7,"1,311.75",,,,,,
BCBS Blue Choice,CPT,J0580,Penicillin g benzathine inj,All Other,Per Unit,$240.20 ,OP,240.2,240.2,,,,,,
BCBS Blue Choice,CPT,J0583,Bivalirudin,All Other,Per Unit,$11.44 ,OP,11.44,11.44,,,,,,
BCBS Blue Choice,CPT,J0587,Inj- rimabotulinumtoxinb,All Other,Per Unit,$39.50 ,OP,12.05,39.5,,,,,,
BCBS Blue Choice,CPT,J0592,Buprenorphine hydrochloride,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,J0594,Busulfan injection,All Other,Per Unit,$61.00 ,OP,1.71,61,,,,,,
BCBS Blue Choice,CPT,J0600,Edetate calcium disodium inj,All Other,Per Unit,$362.21 ,OP,362.21,"5,708.59",,,,,,
BCBS Blue Choice,CPT,J0610,Calcium gluconate injection,All Other,Per Unit,$1.90 ,OP,1.9,1.9,,,,,,
BCBS Blue Choice,CPT,J0620,Calcium glycer & lact/10 ml,All Other,Per Unit,$41.94 ,OP,41.94,41.94,,,,,,
BCBS Blue Choice,CPT,J0630,Calcitonin salmon injection,All Other,Per Unit,$191.13 ,OP,191.13,"3,100.79",,,,,,
BCBS Blue Choice,CPT,J0636,Inj calcitriol per 0.1 mcg,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,J0637,Caspofungin acetate,All Other,Per Unit,$61.00 ,OP,61,61,,,,,,
BCBS Blue Choice,CPT,J0670,Inj mepivacaine hcl/10 ml,All Other,Per Unit,$7.62 ,OP,7.62,7.62,,,,,,
BCBS Blue Choice,CPT,J0694,Cefoxitin sodium injection,All Other,Per Unit,$45.74 ,OP,45.74,45.74,,,,,,
BCBS Blue Choice,CPT,J0698,Cefotaxime sodium injection,All Other,Per Unit,$19.07 ,OP,19.07,19.07,,,,,,
BCBS Blue Choice,CPT,J0702,Betamethasone acet&sod phosp,All Other,Per Unit,$30.51 ,OP,30.51,30.51,,,,,,
BCBS Blue Choice,CPT,J0715,Ceftizoxime sodium / 500 mg,All Other,Per Unit,$26.70 ,OP,26.7,26.7,,,,,,
BCBS Blue Choice,CPT,J0720,Chloramphenicol sodium injec,All Other,Per Unit,$83.87 ,OP,83.87,83.87,,,,,,
BCBS Blue Choice,CPT,J0735,Clonidine hydrochloride,All Other,Per Unit,$331.70 ,OP,331.7,331.7,,,,,,
BCBS Blue Choice,CPT,J0740,Cidofovir injection,All Other,Per Unit,"$3,694.50 ",OP,563.76,"3,694.50",,,,,,
BCBS Blue Choice,CPT,J0745,Inj codeine phosphate /30 mg,All Other,Per Unit,$7.62 ,OP,7.62,135.64,,,,,,
BCBS Blue Choice,CPT,J0760,Colchicine injection,All Other,Per Unit,$30.51 ,OP,30.51,30.51,,,,,,
BCBS Blue Choice,CPT,J0770,Colistimethate sodium inj,All Other,Per Unit,$87.69 ,OP,87.69,87.69,,,,,,
BCBS Blue Choice,CPT,J0795,Corticorelin ovine triflutal,All Other,Per Unit,$22.88 ,OP,9.67,22.88,,,,,,
BCBS Blue Choice,CPT,J0800,Corticotropin injection,All Other,Per Unit,"$9,315.32 ",OP,"9,315.32","9,315.32",,,,,,
BCBS Blue Choice,CPT,J0835,Inj cosyntropin per 0.25 MG,All Other,Per Unit,$461.34 ,OP,461.34,461.34,,,,,,
BCBS Blue Choice,CPT,J0850,Cytomegalovirus imm iv /vial,All Other,Per Unit,"$4,266.40 ",OP,"1,538.70","4,266.40",,,,,,
BCBS Blue Choice,CPT,J0878,Daptomycin injection,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,J0881,Darbepoetin alfa- non-esrd,All Other,Per Unit,$15.26 ,OP,3.15,15.26,,,,,,
BCBS Blue Choice,CPT,J0882,Darbepoetin alfa- esrd use,All Other,Per Unit,$15.26 ,OP,3.15,15.26,,,,,,
BCBS Blue Choice,CPT,J0885,Epoetin alfa- non-esrd,All Other,Per Unit,$45.74 ,OP,8.15,45.74,,,,,,
BCBS Blue Choice,CPT,J0900,Testosterone enanthate inj,All Other,Per Unit,$5.70 ,OP,5.7,5.7,,,,,,
BCBS Blue Choice,CPT,J0945,Brompheniramine maleate inj,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,J0970,Estradiol valerate injection,All Other,Per Unit,$171.58 ,OP,171.58,171.58,,,,,,
BCBS Blue Choice,CPT,J1000,Depo-estradiol cypionate inj,All Other,Per Unit,$30.51 ,OP,30.51,30.51,,,,,,
BCBS Blue Choice,CPT,J1030,Methylprednisolone 40 mg inj,All Other,Per Unit,$19.07 ,OP,19.07,19.07,,,,,,
BCBS Blue Choice,CPT,J1040,Methylprednisolone 80 mg inj,All Other,Per Unit,$38.13 ,OP,38.13,38.13,,,,,,
BCBS Blue Choice,CPT,J1050,Medroxyprogesterone acetate,All Other,Per Unit,$3.31 ,OP,3.31,3.31,,,,,,
BCBS Blue Choice,CPT,J1051,Medroxyprogesterone inj,All Other,Per Unit,$34.31 ,OP,34.31,34.31,,,,,,
BCBS Blue Choice,CPT,J1055,Medrxyprogester acetate inj,All Other,Per Unit,$305.01 ,OP,305.01,305.01,,,,,,
BCBS Blue Choice,CPT,J1056,MA/EC contraceptiveinjection,All Other,Per Unit,$110.57 ,OP,110.57,110.57,,,,,,
BCBS Blue Choice,CPT,J1070,Testosterone cypionat 100 MG,All Other,Per Unit,$25.59 ,OP,25.59,25.59,,,,,,
BCBS Blue Choice,CPT,J1080,Testosterone cypionat 200 MG,All Other,Per Unit,$95.55 ,OP,95.55,95.55,,,,,,
BCBS Blue Choice,CPT,J1094,Inj dexamethasone acetate,All Other,Per Unit,$1.90 ,OP,1.9,1.9,,,,,,
BCBS Blue Choice,CPT,J1120,Acetazolamid sodium injectio,All Other,Per Unit,$160.13 ,OP,160.13,160.13,,,,,,
BCBS Blue Choice,CPT,J1160,Digoxin injection,All Other,Per Unit,$7.62 ,OP,7.62,7.62,,,,,,
BCBS Blue Choice,CPT,J1162,Digoxin immune fab (ovine),All Other,Per Unit,"$2,344.81 ",OP,"2,344.81","4,128.19",,,,,,
BCBS Blue Choice,CPT,J1180,Dyphylline injection,All Other,Per Unit,$38.13 ,OP,38.13,38.13,,,,,,
BCBS Blue Choice,CPT,J1190,Dexrazoxane hcl injection,All Other,Per Unit,"$1,849.16 ",OP,192.33,"1,849.16",,,,,,
BCBS Blue Choice,CPT,J1212,Dimethyl sulfoxide 50% 50 ml,All Other,Per Unit,$339.33 ,OP,339.33,637.11,,,,,,
BCBS Blue Choice,CPT,J1260,Dolasetron mesylate,All Other,Per Unit,$15.71 ,OP,15.71,15.71,,,,,,
BCBS Blue Choice,CPT,J1270,Injection- doxercalciferol,All Other,Per Unit,$15.26 ,OP,15.26,15.26,,,,,,
BCBS Blue Choice,CPT,J1300,Eculizumab injection,All Other,Per Unit,$679.45 ,OP,229.23,679.45,,,,,,
BCBS Blue Choice,CPT,J1320,Amitriptyline injection,All Other,Per Unit,$11.44 ,OP,11.44,11.44,,,,,,
BCBS Blue Choice,CPT,J1324,Enfuvirtide injection,All Other,Per Unit,$129.64 ,OP,129.64,129.64,,,,,,
BCBS Blue Choice,CPT,J1325,Epoprostenol injection,All Other,Per Unit,$64.85 ,OP,64.85,64.85,,,,,,
BCBS Blue Choice,CPT,J1327,Eptifibatide injection,All Other,Per Unit,$87.69 ,OP,87.69,87.69,,,,,,
BCBS Blue Choice,CPT,J1335,Ertapenem injection,All Other,Per Unit,$125.82 ,OP,125.82,125.82,,,,,,
BCBS Blue Choice,CPT,J1364,Erythro lactobionate /500 mg,All Other,Per Unit,$38.13 ,OP,38.13,77.75,,,,,,
BCBS Blue Choice,CPT,J1380,Estradiol valerate 10 mg inj,All Other,Per Unit,$49.56 ,OP,49.56,49.56,,,,,,
BCBS Blue Choice,CPT,J1390,Estradiol valerate 20 MG inj,All Other,Per Unit,$95.32 ,OP,95.32,95.32,,,,,,
BCBS Blue Choice,CPT,J1410,Inj estrogen conjugate 25 mg,All Other,Per Unit,$381.27 ,OP,341.46,381.27,,,,,,
BCBS Blue Choice,CPT,J1430,Ethanolamine oleate 100 mg,All Other,Per Unit,$728.23 ,OP,444.1,728.23,,,,,,
BCBS Blue Choice,CPT,J1435,Injection estrone per 1 mg,All Other,Per Unit,$1.90 ,OP,1.9,1.9,,,,,,
BCBS Blue Choice,CPT,J1436,Etidronate disodium inj,All Other,Per Unit,$366.02 ,OP,366.02,366.02,,,,,,
BCBS Blue Choice,CPT,J1438,Etanercept injection,All Other,Per Unit,$714.31 ,OP,714.31,790.78,,,,,,
BCBS Blue Choice,CPT,J1440,Filgrastim 300 mcg injection,All Other,Per Unit,$927.93 ,OP,927.93,927.93,,,,,,
BCBS Blue Choice,CPT,J1441,Filgrastim 480 mcg injection,All Other,Per Unit,"$1,478.04 ",OP,"1,478.04","1,478.04",,,,,,
BCBS Blue Choice,CPT,J1442,Inj filgrastim excl biosimil,All Other,Per Unit,$3.09 ,OP,0.97,3.09,,,,,,
BCBS Blue Choice,CPT,J1447,Inj tbo filgrastim 1 microg,All Other,Per Unit,$3.10 ,OP,0.46,3.1,,,,,,
BCBS Blue Choice,CPT,J1451,Fomepizole- 15 mg,All Other,Per Unit,$49.56 ,OP,5.98,49.56,,,,,,
BCBS Blue Choice,CPT,J1452,Intraocular fomivirsen na,All Other,Per Unit,"$1,029.43 ",OP,"1,029.43","1,029.43",,,,,,
BCBS Blue Choice,CPT,J1453,Fosaprepitant injection,All Other,Per Unit,$7.62 ,OP,0.24,7.62,,,,,,
BCBS Blue Choice,CPT,J1455,Foscarnet sodium injection,All Other,Per Unit,$49.56 ,OP,49.56,72.86,,,,,,
BCBS Blue Choice,CPT,J1457,Gallium nitrate injection,All Other,Per Unit,$7.62 ,OP,7.62,7.62,,,,,,
BCBS Blue Choice,CPT,J1458,Galsulfase injection,All Other,Per Unit,"$1,289.57 ",OP,411.92,"1,289.57",,,,,,
BCBS Blue Choice,CPT,J1459,Inj ivig privigen 500 mg,All Other,Per Unit,$143.18 ,OP,44.48,143.18,,,,,,
BCBS Blue Choice,CPT,J1460,Gamma globulin 1 cc inj,All Other,Per Unit,$61.00 ,OP,44.13,61,,,,,,
BCBS Blue Choice,CPT,J1470,Gamma globulin 2 CC inj,All Other,Per Unit,$125.82 ,OP,125.82,125.82,,,,,,
BCBS Blue Choice,CPT,J1480,Gamma globulin 3 CC inj,All Other,Per Unit,$186.82 ,OP,186.82,186.82,,,,,,
BCBS Blue Choice,CPT,J1490,Gamma globulin 4 CC inj,All Other,Per Unit,$247.83 ,OP,247.83,247.83,,,,,,
BCBS Blue Choice,CPT,J1500,Gamma globulin 5 CC inj,All Other,Per Unit,$312.64 ,OP,312.64,312.64,,,,,,
BCBS Blue Choice,CPT,J1510,Gamma globulin 6 CC inj,All Other,Per Unit,$373.65 ,OP,373.65,373.65,,,,,,
BCBS Blue Choice,CPT,J1520,Gamma globulin 7 CC inj,All Other,Per Unit,$434.65 ,OP,434.65,434.65,,,,,,
BCBS Blue Choice,CPT,J1530,Gamma globulin 8 CC inj,All Other,Per Unit,$499.47 ,OP,499.47,499.47,,,,,,
BCBS Blue Choice,CPT,J1540,Gamma globulin 9 CC inj,All Other,Per Unit,$560.47 ,OP,560.47,560.47,,,,,,
BCBS Blue Choice,CPT,J1550,Gamma globulin 10 CC inj,All Other,Per Unit,$621.47 ,OP,621.47,621.47,,,,,,
BCBS Blue Choice,CPT,J1560,Gamma globulin > 10 cc inj,All Other,Per Unit,$621.47 ,OP,441.31,621.47,,,,,,
BCBS Blue Choice,CPT,J1561,Gamunex-c/gammaked,All Other,Per Unit,$158.91 ,OP,48.22,158.91,,,,,,
BCBS Blue Choice,CPT,J1562,Vivaglobin- inj,All Other,Per Unit,$34.31 ,OP,34.31,34.31,,,,,,
BCBS Blue Choice,CPT,J1565,RSV-ivig,All Other,Per Unit,$80.07 ,OP,80.07,80.07,,,,,,
BCBS Blue Choice,CPT,J1566,Immune globulin- powder,All Other,Per Unit,$152.51 ,OP,65.49,152.51,,,,,,
BCBS Blue Choice,CPT,J1569,Gammagard liquid injection,All Other,Per Unit,$171.58 ,OP,44.49,171.58,,,,,,
BCBS Blue Choice,CPT,J1570,Ganciclovir sodium injection,All Other,Per Unit,$217.32 ,OP,217.32,217.32,,,,,,
BCBS Blue Choice,CPT,J1571,Hepagam b im injection,All Other,Per Unit,$213.51 ,OP,70.94,213.51,,,,,,
BCBS Blue Choice,CPT,J1572,Flebogamma injection,All Other,Per Unit,$171.58 ,OP,36.8,171.58,,,,,,
BCBS Blue Choice,CPT,J1573,Hepagam b intravenous- inj,All Other,Per Unit,$213.51 ,OP,71.24,213.51,,,,,,
BCBS Blue Choice,CPT,J1590,Gatifloxacin injection,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,J1595,Injection glatiramer acetate,All Other,Per Unit,$298.68 ,OP,141.29,298.68,,,,,,
BCBS Blue Choice,CPT,J1600,Gold sodium thiomaleate inj,All Other,Per Unit,$38.13 ,OP,38.13,38.13,,,,,,
BCBS Blue Choice,CPT,J1610,Glucagon hydrochloride/1 mg,All Other,Per Unit,$343.14 ,OP,171.74,343.14,,,,,,
BCBS Blue Choice,CPT,J1620,Gonadorelin hydroch/ 100 mcg,All Other,Per Unit,$876.92 ,OP,876.92,876.92,,,,,,
BCBS Blue Choice,CPT,J1640,Hemin- 1 mg,All Other,Per Unit,$38.13 ,OP,26.64,38.13,,,,,,
BCBS Blue Choice,CPT,J1642,Inj heparin sodium per 10 u,All Other,Per Unit,$1.90 ,OP,1.9,1.9,,,,,,
BCBS Blue Choice,CPT,J1645,Dalteparin sodium,All Other,Per Unit,$53.38 ,OP,53.38,53.38,,,,,,
BCBS Blue Choice,CPT,J1650,Inj enoxaparin sodium,All Other,Per Unit,$28.36 ,OP,28.36,28.36,,,,,,
BCBS Blue Choice,CPT,J1652,Fondaparinux sodium,All Other,Per Unit,$28.48 ,OP,28.48,28.48,,,,,,
BCBS Blue Choice,CPT,J1655,Tinzaparin sodium injection,All Other,Per Unit,$11.44 ,OP,11.44,11.44,,,,,,
BCBS Blue Choice,CPT,J1670,Tetanus immune globulin inj,All Other,Per Unit,"$1,040.87 ",OP,441.7,"1,040.87",,,,,,
BCBS Blue Choice,CPT,J1700,Hydrocortisone acetate inj,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,J1710,Hydrocortisone sodium ph inj,All Other,Per Unit,$22.88 ,OP,22.88,22.88,,,,,,
BCBS Blue Choice,CPT,J1720,Hydrocortisone sodium succ i,All Other,Per Unit,$14.88 ,OP,14.88,14.88,,,,,,
BCBS Blue Choice,CPT,J1730,Diazoxide injection,All Other,Per Unit,$541.40 ,OP,541.4,541.4,,,,,,
BCBS Blue Choice,CPT,J1740,Ibandronate sodium injection,All Other,Per Unit,$674.85 ,OP,37.09,674.85,,,,,,
BCBS Blue Choice,CPT,J1742,Ibutilide fumarate injection,All Other,Per Unit,"$1,898.73 ",OP,205.06,"1,898.73",,,,,,
BCBS Blue Choice,CPT,J1743,Idursulfase injection,All Other,Per Unit,"$1,753.57 ",OP,"1,753.57","1,753.57",,,,,,
BCBS Blue Choice,CPT,J1745,Infliximab not biosimil 10mg,All Other,Per Unit,$301.32 ,OP,39.53,301.32,,,,,,
BCBS Blue Choice,CPT,J1756,Iron sucrose injection,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,J1785,Injection imiglucerase /unit,All Other,Per Unit,$15.71 ,OP,15.71,15.71,,,,,,
BCBS Blue Choice,CPT,J1800,Propranolol injection,All Other,Per Unit,$19.07 ,OP,19.07,19.07,,,,,,
BCBS Blue Choice,CPT,J1810,Droperidol/fentanyl inj,All Other,Per Unit,$30.51 ,OP,30.51,30.51,,,,,,
BCBS Blue Choice,CPT,J1817,Insulin for insulin pump use,All Other,Per Unit,$15.26 ,OP,15.26,15.26,,,,,,
BCBS Blue Choice,CPT,J1825,Interferon beta-1a,All Other,Per Unit,"$2,262.80 ",OP,"2,262.80","2,262.80",,,,,,
BCBS Blue Choice,CPT,J1830,Interferon beta-1b / .25 mg,All Other,Per Unit,$538.70 ,OP,406.24,538.7,,,,,,
BCBS Blue Choice,CPT,J1835,Itraconazole injection,All Other,Per Unit,$205.88 ,OP,205.88,205.88,,,,,,
BCBS Blue Choice,CPT,J1850,Kanamycin sulfate 75 mg inj,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,J1890,Cephalothin sodium injection,All Other,Per Unit,$41.94 ,OP,41.94,41.94,,,,,,
BCBS Blue Choice,CPT,J1930,Lanreotide injection,All Other,Per Unit,$129.64 ,OP,67.64,129.64,,,,,,
BCBS Blue Choice,CPT,J1931,Laronidase injection,All Other,Per Unit,$95.46 ,OP,34.75,95.46,,,,,,
BCBS Blue Choice,CPT,J1945,Lepirudin,All Other,Per Unit,$865.48 ,OP,865.48,865.48,,,,,,
BCBS Blue Choice,CPT,J1950,Leuprolide acetate /3.75 mg,All Other,Per Unit,"$1,525.07 ",OP,"1,406.37","1,525.07",,,,,,
BCBS Blue Choice,CPT,J1953,Levetiracetam injection,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,J1955,Inj levocarnitine per 1 gm,All Other,Per Unit,$30.51 ,OP,30.51,30.51,,,,,,
BCBS Blue Choice,CPT,J1960,Levorphanol tartrate inj,All Other,Per Unit,$15.26 ,OP,15.26,15.26,,,,,,
BCBS Blue Choice,CPT,J1980,Hyoscyamine sulfate inj,All Other,Per Unit,$49.56 ,OP,49.56,49.56,,,,,,
BCBS Blue Choice,CPT,J1990,Chlordiazepoxide injection,All Other,Per Unit,$102.95 ,OP,102.95,102.95,,,,,,
BCBS Blue Choice,CPT,J2001,Lidocaine injection,All Other,Per Unit,$1.90 ,OP,1.9,1.9,,,,,,
BCBS Blue Choice,CPT,J2010,Lincomycin injection,All Other,Per Unit,$22.88 ,OP,22.88,22.88,,,,,,
BCBS Blue Choice,CPT,J2020,Linezolid injection,All Other,Per Unit,$148.69 ,OP,148.69,148.69,,,,,,
BCBS Blue Choice,CPT,J2170,Mecasermin injection,All Other,Per Unit,$87.69 ,OP,87.69,87.69,,,,,,
BCBS Blue Choice,CPT,J2180,Meperidine/promethazine inj,All Other,Per Unit,$19.07 ,OP,19.07,19.07,,,,,,
BCBS Blue Choice,CPT,J2210,Methylergonovin maleate inj,All Other,Per Unit,$26.70 ,OP,26.7,26.7,,,,,,
BCBS Blue Choice,CPT,J2275,Morphine sulfate injection,All Other,Per Unit,$15.26 ,OP,15.26,15.26,,,,,,
BCBS Blue Choice,CPT,J2278,Ziconotide injection,All Other,Per Unit,$30.51 ,OP,8.69,30.51,,,,,,
BCBS Blue Choice,CPT,J2310,Inj naloxone hydrochloride,All Other,Per Unit,$22.88 ,OP,22.88,22.88,,,,,,
BCBS Blue Choice,CPT,J2320,Nandrolone decanoate 50 mg,All Other,Per Unit,$19.07 ,OP,19.07,19.07,,,,,,
BCBS Blue Choice,CPT,J2321,Nandrolone decanoate 100 MG,All Other,Per Unit,$34.31 ,OP,34.31,34.31,,,,,,
BCBS Blue Choice,CPT,J2322,Nandrolone decanoate 200 MG,All Other,Per Unit,$72.44 ,OP,72.44,72.44,,,,,,
BCBS Blue Choice,CPT,J2323,Natalizumab injection,All Other,Per Unit,$103.45 ,OP,23.24,103.45,,,,,,
BCBS Blue Choice,CPT,J2325,Nesiritide injection,All Other,Per Unit,$167.76 ,OP,167.76,167.76,,,,,,
BCBS Blue Choice,CPT,J2353,Octreotide injection- depot,All Other,Per Unit,$408.99 ,OP,205.37,408.99,,,,,,
BCBS Blue Choice,CPT,J2354,Octreotide inj- non-depot,All Other,Per Unit,$7.62 ,OP,7.62,7.62,,,,,,
BCBS Blue Choice,CPT,J2357,Omalizumab injection,All Other,Per Unit,$70.74 ,OP,37.67,70.74,,,,,,
BCBS Blue Choice,CPT,J2360,Orphenadrine injection,All Other,Per Unit,$38.13 ,OP,38.13,38.13,,,,,,
BCBS Blue Choice,CPT,J2410,Oxymorphone hcl injection,All Other,Per Unit,$11.44 ,OP,11.44,11.44,,,,,,
BCBS Blue Choice,CPT,J2460,Oxytetracycline injection,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,J2469,Palonosetron hcl,All Other,Per Unit,$83.87 ,OP,83.87,83.87,,,,,,
BCBS Blue Choice,CPT,J2501,Paricalcitol,All Other,Per Unit,$19.07 ,OP,19.07,19.07,,,,,,
BCBS Blue Choice,CPT,J2503,Pegaptanib sodium injection,All Other,Per Unit,"$3,983.27 ",OP,"3,983.27","3,983.27",,,,,,
BCBS Blue Choice,CPT,J2504,Pegademase bovine- 25 iu,All Other,Per Unit,"$1,098.07 ",OP,4.06,"1,098.07",,,,,,
BCBS Blue Choice,CPT,J2505,Injection- pegfilgrastim 6mg,All Other,Per Unit,"$10,481.09 ",OP,"2,221.63","10,481.09",,,,,,
BCBS Blue Choice,CPT,J2513,Pentastarch 10% solution,All Other,Per Unit,$61.00 ,OP,61,61,,,,,,
BCBS Blue Choice,CPT,J2543,Piperacillin/tazobactam,All Other,Per Unit,$26.70 ,OP,26.7,26.7,,,,,,
BCBS Blue Choice,CPT,J2545,Pentamidine non-comp unit,All Other,Per Unit,$205.88 ,OP,205.88,205.88,,,,,,
BCBS Blue Choice,CPT,J2650,Prednisolone acetate inj,All Other,Per Unit,$1.90 ,OP,1.9,1.9,,,,,,
BCBS Blue Choice,CPT,J2670,Totazoline hcl injection,All Other,Per Unit,$15.26 ,OP,15.26,15.26,,,,,,
BCBS Blue Choice,CPT,J2675,Inj progesterone per 50 mg,All Other,Per Unit,$7.62 ,OP,7.62,7.62,,,,,,
BCBS Blue Choice,CPT,J2680,Fluphenazine decanoate 25 mg,All Other,Per Unit,$26.70 ,OP,26.7,26.7,,,,,,
BCBS Blue Choice,CPT,J2710,Neostigmine methylslfte inj,All Other,Per Unit,$1.90 ,OP,1.9,1.9,,,,,,
BCBS Blue Choice,CPT,J2720,Inj protamine sulfate/10 mg,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,J2724,Protein c concentrate,All Other,Per Unit,$61.00 ,OP,15.13,61,,,,,,
BCBS Blue Choice,CPT,J2725,Inj protirelin per 250 mcg,All Other,Per Unit,$106.76 ,OP,106.76,106.76,,,,,,
BCBS Blue Choice,CPT,J2730,Pralidoxime chloride inj,All Other,Per Unit,$446.08 ,OP,446.08,446.08,,,,,,
BCBS Blue Choice,CPT,J2760,Phentolaine mesylate inj,All Other,Per Unit,$255.45 ,OP,255.45,416,,,,,,
BCBS Blue Choice,CPT,J2770,Quinupristin/dalfopristin,All Other,Per Unit,$712.98 ,OP,444.67,712.98,,,,,,
BCBS Blue Choice,CPT,J2780,Ranitidine hydrochloride inj,All Other,Per Unit,$7.62 ,OP,7.62,7.62,,,,,,
BCBS Blue Choice,CPT,J2783,Rasburicase,All Other,Per Unit,$804.48 ,OP,315.06,804.48,,,,,,
BCBS Blue Choice,CPT,J2785,Regadenoson injection,All Other,Per Unit,$244.01 ,OP,244.01,244.01,,,,,,
BCBS Blue Choice,CPT,J2788,Rho d immune globulin 50 mcg,All Other,Per Unit,$129.64 ,OP,129.64,129.64,,,,,,
BCBS Blue Choice,CPT,J2790,Rho d immune globulin inj,All Other,Per Unit,$424.36 ,OP,424.36,424.36,,,,,,
BCBS Blue Choice,CPT,J2791,Rhophylac injection,All Other,Per Unit,$26.70 ,OP,26.7,26.7,,,,,,
BCBS Blue Choice,CPT,J2792,Rho(d) immune globulin h- sd,All Other,Per Unit,$80.07 ,OP,31.42,80.07,,,,,,
BCBS Blue Choice,CPT,J2794,Inj risperdal consta- 0.5 mg,All Other,Per Unit,$19.71 ,OP,11.04,19.71,,,,,,
BCBS Blue Choice,CPT,J2795,Ropivacaine hcl injection,All Other,Per Unit,$1.90 ,OP,1.9,1.9,,,,,,
BCBS Blue Choice,CPT,J2800,Methocarbamol injection,All Other,Per Unit,$122.00 ,OP,122,122,,,,,,
BCBS Blue Choice,CPT,J2805,Sincalide injection,All Other,Per Unit,$297.39 ,OP,297.39,297.39,,,,,,
BCBS Blue Choice,CPT,J2810,Inj theophylline per 40 mg,All Other,Per Unit,$1.90 ,OP,1.9,1.9,,,,,,
BCBS Blue Choice,CPT,J2820,Sargramostim injection,All Other,Per Unit,$122.00 ,OP,51.55,122,,,,,,
BCBS Blue Choice,CPT,J2850,Inj secretin synthetic human,All Other,Per Unit,$129.64 ,OP,34.78,129.64,,,,,,
BCBS Blue Choice,CPT,J2910,Aurothioglucose injeciton,All Other,Per Unit,$118.19 ,OP,118.19,118.19,,,,,,
BCBS Blue Choice,CPT,J2916,Na ferric gluconate complex,All Other,Per Unit,$22.88 ,OP,22.88,22.88,,,,,,
BCBS Blue Choice,CPT,J2940,Somatrem injection,All Other,Per Unit,$205.88 ,OP,205.88,205.88,,,,,,
BCBS Blue Choice,CPT,J2941,Somatropin injection,All Other,Per Unit,$226.93 ,OP,36.54,226.93,,,,,,
BCBS Blue Choice,CPT,J2993,Reteplase injection,All Other,Per Unit,"$4,712.48 ",OP,"2,506.51","4,712.48",,,,,,
BCBS Blue Choice,CPT,J2995,Inj streptokinase /250000 iu,All Other,Per Unit,$385.09 ,OP,385.09,385.09,,,,,,
BCBS Blue Choice,CPT,J2997,Alteplase recombinant,All Other,Per Unit,$163.95 ,OP,87.75,163.95,,,,,,
BCBS Blue Choice,CPT,J3000,Streptomycin injection,All Other,Per Unit,$34.31 ,OP,34.31,34.31,,,,,,
BCBS Blue Choice,CPT,J3030,Sumatriptan succinate / 6 mg,All Other,Per Unit,$411.78 ,OP,411.78,411.78,,,,,,
BCBS Blue Choice,CPT,J3070,Pentazocine injection,All Other,Per Unit,$38.13 ,OP,38.13,38.13,,,,,,
BCBS Blue Choice,CPT,J3101,Tenecteplase injection,All Other,Per Unit,$202.07 ,OP,134.74,202.07,,,,,,
BCBS Blue Choice,CPT,J3110,Teriparatide injection,All Other,Per Unit,$39.16 ,OP,39.16,39.16,,,,,,
BCBS Blue Choice,CPT,J3130,Testosterone enanthate inj,All Other,Per Unit,$66.26 ,OP,66.26,66.26,,,,,,
BCBS Blue Choice,CPT,J3150,Testosteron propionate inj,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,J3230,Chlorpromazine hcl injection,All Other,Per Unit,$38.13 ,OP,38.13,38.13,,,,,,
BCBS Blue Choice,CPT,J3240,Thyrotropin injection,All Other,Per Unit,"$3,617.49 ",OP,"1,837.25","3,617.49",,,,,,
BCBS Blue Choice,CPT,J3243,Tigecycline injection,All Other,Per Unit,$3.82 ,OP,1.12,3.82,,,,,,
BCBS Blue Choice,CPT,J3250,Trimethobenzamide hcl inj,All Other,Per Unit,$22.88 ,OP,22.88,22.88,,,,,,
BCBS Blue Choice,CPT,J3265,Injection torsemide 10 mg/ml,All Other,Per Unit,$11.44 ,OP,11.44,11.44,,,,,,
BCBS Blue Choice,CPT,J3280,Thiethylperazine maleate inj,All Other,Per Unit,$22.88 ,OP,22.88,22.88,,,,,,
BCBS Blue Choice,CPT,J3285,Treprostinil injection,All Other,Per Unit,$238.44 ,OP,59.68,238.44,,,,,,
BCBS Blue Choice,CPT,J3301,Triamcinolone acet inj nos,All Other,Per Unit,$7.62 ,OP,7.62,7.62,,,,,,
BCBS Blue Choice,CPT,J3305,Inj trimetrexate glucoronate,All Other,Per Unit,$728.23 ,OP,728.23,728.23,,,,,,
BCBS Blue Choice,CPT,J3310,Perphenazine injeciton,All Other,Per Unit,$15.26 ,OP,15.26,15.26,,,,,,
BCBS Blue Choice,CPT,J3320,Spectinomycn di-hcl inj,All Other,Per Unit,$144.88 ,OP,144.88,144.88,,,,,,
BCBS Blue Choice,CPT,J3355,Urofollitropin- 75 iu,All Other,Per Unit,$265.10 ,OP,265.1,265.1,,,,,,
BCBS Blue Choice,CPT,J3365,Urokinase 250-000 iu inj,All Other,Per Unit,"$2,222.79 ",OP,"2,222.79","2,222.79",,,,,,
BCBS Blue Choice,CPT,J3396,Verteporfin injection,All Other,Per Unit,$37.64 ,OP,11.25,37.64,,,,,,
BCBS Blue Choice,CPT,J3400,Triflupromazine hcl inj,All Other,Per Unit,$57.19 ,OP,57.19,57.19,,,,,,
BCBS Blue Choice,CPT,J3430,Vitamin k phytonadione inj,All Other,Per Unit,$19.07 ,OP,19.07,19.07,,,,,,
BCBS Blue Choice,CPT,J3465,Injection- voriconazole,All Other,Per Unit,$26.70 ,OP,26.7,26.7,,,,,,
BCBS Blue Choice,CPT,J3472,Ovine- 1000 usp units,All Other,Per Unit,$621.47 ,OP,621.47,621.47,,,,,,
BCBS Blue Choice,CPT,J3473,Hyaluronidase recombinant,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,J3486,Ziprasidone mesylate,All Other,Per Unit,$26.70 ,OP,26.7,26.7,,,,,,
BCBS Blue Choice,CPT,J3487,Zoledronic acid,All Other,Per Unit,$851.58 ,OP,851.58,851.58,,,,,,
BCBS Blue Choice,CPT,J3488,Reclast injection,All Other,Per Unit,$840.55 ,OP,840.55,840.55,,,,,,
BCBS Blue Choice,CPT,J3489,Zoledronic acid 1mg,All Other,Per Unit,$851.58 ,OP,851.58,851.58,,,,,,
BCBS Blue Choice,CPT,J3520,Edetate disodium per 150 mg,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,J3535,Metered dose inhaler drug,All Other,Per Unit,$57.19 ,OP,57.19,57.19,,,,,,
BCBS Blue Choice,CPT,J7100,Dextran 40 infusion,All Other,Per Unit,$102.95 ,OP,102.95,102.95,,,,,,
BCBS Blue Choice,CPT,J7110,Dextran 75 infusion,All Other,Per Unit,$83.87 ,OP,83.87,83.87,,,,,,
BCBS Blue Choice,CPT,J7186,Antihemophilic viii/vwf comp,All Other,Per Unit,$3.82 ,OP,1.14,3.82,,,,,,
BCBS Blue Choice,CPT,J7187,Humate-p- inj,All Other,Per Unit,$2.98 ,OP,1.26,2.98,,,,,,
BCBS Blue Choice,CPT,J7190,Factor viii,All Other,Per Unit,$3.02 ,OP,1.12,3.02,,,,,,
BCBS Blue Choice,CPT,J7191,Factor viii (porcine),All Other,Per Unit,$7.62 ,OP,7.62,7.62,,,,,,
BCBS Blue Choice,CPT,J7192,Factor viii recombinant nos,All Other,Per Unit,$3.85 ,OP,1.43,3.85,,,,,,
BCBS Blue Choice,CPT,J7193,Factor ix non-recombinant,All Other,Per Unit,$3.36 ,OP,1.17,3.36,,,,,,
BCBS Blue Choice,CPT,J7194,Factor ix complex,All Other,Per Unit,$2.52 ,OP,1.54,2.52,,,,,,
BCBS Blue Choice,CPT,J7195,Factor ix recombinant nos,All Other,Per Unit,$3.57 ,OP,1.61,3.57,,,,,,
BCBS Blue Choice,CPT,J7197,Antithrombin iii injection,All Other,Per Unit,$10.61 ,OP,3.2,10.61,,,,,,
BCBS Blue Choice,CPT,J7198,Anti-inhibitor,All Other,Per Unit,$5.20 ,OP,2.21,5.2,,,,,,
BCBS Blue Choice,CPT,J7300,Intraut copper contraceptive,All Other,Per Unit,"$1,883.47 ",OP,"1,883.47","1,883.47",,,,,,
BCBS Blue Choice,CPT,J7303,Contraceptive vaginal ring,All Other,Per Unit,$122.00 ,OP,122,122,,,,,,
BCBS Blue Choice,CPT,J7304,Contraceptive hormone patch,All Other,Per Unit,$49.56 ,OP,49.56,49.56,,,,,,
BCBS Blue Choice,CPT,J7307,Etonogestrel implant system,All Other,Per Unit,"$2,836.65 ",OP,"2,836.65","2,836.65",,,,,,
BCBS Blue Choice,CPT,J7310,Ganciclovir long act implant,All Other,Per Unit,"$82,354.16 ",OP,"82,354.16","82,354.16",,,,,,
BCBS Blue Choice,CPT,J7311,Inj.- retisert- 0.01 mg,All Other,Per Unit,"$93,937.12 ",OP,339,"93,937.12",,,,,,
BCBS Blue Choice,CPT,J7321,Hyalgan supartz visco-3 dose,All Other,Per Unit,$480.55 ,OP,480.55,480.55,,,,,,
BCBS Blue Choice,CPT,J7322,Hymovis injection 1 mg,All Other,Per Unit,$903.60 ,OP,31.67,903.6,,,,,,
BCBS Blue Choice,CPT,J7323,Euflexxa inj per dose,All Other,Per Unit,$590.67 ,OP,138.82,590.67,,,,,,
BCBS Blue Choice,CPT,J7324,Orthovisc inj per dose,All Other,Per Unit,$880.74 ,OP,148.74,880.74,,,,,,
BCBS Blue Choice,CPT,J7330,Cultured chondrocytes implnt,All Other,Per Unit,"$117,621.56 ",OP,"117,621.56","117,621.56",,,,,,
BCBS Blue Choice,CPT,J7500,Azathioprine oral 50mg,All Other,Per Unit,$1.90 ,OP,1.9,1.9,,,,,,
BCBS Blue Choice,CPT,J7501,Azathioprine parenteral,All Other,Per Unit,$442.27 ,OP,245.02,442.27,,,,,,
BCBS Blue Choice,CPT,J7503,Tacrol envarsus ex rel oral,All Other,Per Unit,$3.91 ,OP,3.91,3.91,,,,,,
BCBS Blue Choice,CPT,J7504,Lymphocyte immune globulin,All Other,Per Unit,"$2,245.67 ",OP,"2,245.67","2,355.53",,,,,,
BCBS Blue Choice,CPT,J7505,Monoclonal antibodies,All Other,Per Unit,"$5,223.39 ",OP,"5,223.39","5,223.39",,,,,,
BCBS Blue Choice,CPT,J7506,Prednisone oral,All Other,Per Unit,$1.90 ,OP,1.9,1.9,,,,,,
BCBS Blue Choice,CPT,J7507,Tacrolimus imme rel oral 1mg,All Other,Per Unit,$15.71 ,OP,15.71,15.71,,,,,,
BCBS Blue Choice,CPT,J7508,Tacrol astagraf ex rel oral,All Other,Per Unit,$1.56 ,OP,1.56,1.56,,,,,,
BCBS Blue Choice,CPT,J7511,Antithymocyte globuln rabbit,All Other,Per Unit,"$1,807.23 ",OP,837.42,"1,807.23",,,,,,
BCBS Blue Choice,CPT,J7512,Prednisone ir or dr oral 1mg,All Other,Per Unit,$0.38 ,OP,0.38,0.38,,,,,,
BCBS Blue Choice,CPT,J7513,Daclizumab- parenteral,All Other,Per Unit,"$1,730.97 ",OP,"1,730.97","1,730.97",,,,,,
BCBS Blue Choice,CPT,J7516,Cyclosporin parenteral 250mg,All Other,Per Unit,$81.79 ,OP,81.79,81.79,,,,,,
BCBS Blue Choice,CPT,J7518,Mycophenolic acid,All Other,Per Unit,$11.82 ,OP,11.82,11.82,,,,,,
BCBS Blue Choice,CPT,J7520,Sirolimus- oral,All Other,Per Unit,$33.59 ,OP,33.59,33.59,,,,,,
BCBS Blue Choice,CPT,J7525,Tacrolimus injection,All Other,Per Unit,$540.46 ,OP,219.33,540.46,,,,,,
BCBS Blue Choice,CPT,J7605,Arformoterol non-comp unit,All Other,Per Unit,$22.88 ,OP,22.88,22.88,,,,,,
BCBS Blue Choice,CPT,J7606,Formoterol fumarate- inh,All Other,Per Unit,$22.88 ,OP,22.88,22.88,,,,,,
BCBS Blue Choice,CPT,J7608,Acetylcysteine non-comp unit,All Other,Per Unit,$7.62 ,OP,7.62,7.62,,,,,,
BCBS Blue Choice,CPT,J7611,Albuterol non-comp con,All Other,Per Unit,$1.90 ,OP,1.9,1.9,,,,,,
BCBS Blue Choice,CPT,J7626,Budesonide non-comp unit,All Other,Per Unit,$26.70 ,OP,26.7,26.7,,,,,,
BCBS Blue Choice,CPT,J7631,Cromolyn sodium noncomp unit,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,J7639,Dornase alfa non-comp unit,All Other,Per Unit,$91.86 ,OP,91.86,91.86,,,,,,
BCBS Blue Choice,CPT,J7669,Metaproterenol non-comp unit,All Other,Per Unit,$1.90 ,OP,1.9,1.9,,,,,,
BCBS Blue Choice,CPT,J7674,Methacholine chloride- neb,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,J7682,Tobramycin non-comp unit,All Other,Per Unit,$308.83 ,OP,308.83,308.83,,,,,,
BCBS Blue Choice,CPT,J8501,Oral aprepitant,All Other,Per Unit,$26.70 ,OP,26.7,26.7,,,,,,
BCBS Blue Choice,CPT,J8510,Oral busulfan,All Other,Per Unit,$15.26 ,OP,15.26,15.26,,,,,,
BCBS Blue Choice,CPT,J8515,Cabergoline- oral 0.25mg,All Other,Per Unit,$61.00 ,OP,61,61,,,,,,
BCBS Blue Choice,CPT,J8520,Capecitabine- oral- 150 mg,All Other,Per Unit,$23.40 ,OP,23.4,23.4,,,,,,
BCBS Blue Choice,CPT,J8521,Capecitabine- oral- 500 mg,All Other,Per Unit,$78.02 ,OP,78.02,78.02,,,,,,
BCBS Blue Choice,CPT,J8530,Cyclophosphamide oral 25 mg,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,J8540,Oral dexamethasone,All Other,Per Unit,$1.90 ,OP,1.9,1.9,,,,,,
BCBS Blue Choice,CPT,J8565,Gefitinib oral,All Other,Per Unit,$228.45 ,OP,228.45,228.45,,,,,,
BCBS Blue Choice,CPT,J8600,Melphalan oral 2 mg,All Other,Per Unit,$22.88 ,OP,22.88,22.88,,,,,,
BCBS Blue Choice,CPT,J8610,Methotrexate oral 2.5 mg,All Other,Per Unit,$1.90 ,OP,1.9,1.9,,,,,,
BCBS Blue Choice,CPT,J8650,Nabilone oral,All Other,Per Unit,$76.26 ,OP,76.26,76.26,,,,,,
BCBS Blue Choice,CPT,J8700,Temozolomide,All Other,Per Unit,$32.68 ,OP,32.68,32.68,,,,,,
BCBS Blue Choice,CPT,J8705,Topotecan oral,All Other,Per Unit,$331.70 ,OP,331.7,331.7,,,,,,
BCBS Blue Choice,CPT,J9001,Doxorubicin hcl liposome inj,All Other,Per Unit,"$1,719.01 ",OP,"1,719.01","1,719.01",,,,,,
BCBS Blue Choice,CPT,J9010,Alemtuzumab injection,All Other,Per Unit,"$2,771.83 ",OP,"2,771.83","2,771.83",,,,,,
BCBS Blue Choice,CPT,J9017,Arsenic trioxide injection,All Other,Per Unit,$179.20 ,OP,13.11,179.2,,,,,,
BCBS Blue Choice,CPT,J9020,Asparaginase- nos,All Other,Per Unit,$282.14 ,OP,282.14,282.14,,,,,,
BCBS Blue Choice,CPT,J9025,Azacitidine injection,All Other,Per Unit,$22.88 ,OP,0.93,22.88,,,,,,
BCBS Blue Choice,CPT,J9027,Clofarabine injection,All Other,Per Unit,$564.29 ,OP,53.15,564.29,,,,,,
BCBS Blue Choice,CPT,J9030,Bcg live intravesical 1mg,All Other,Per Unit,$11.51 ,OP,11.51,11.51,,,,,,
BCBS Blue Choice,CPT,J9031,Bcg live intravesical vac,All Other,Per Unit,$575.73 ,OP,575.73,575.73,,,,,,
BCBS Blue Choice,CPT,J9033,Inj.- treanda 1 mg,All Other,Per Unit,$91.51 ,OP,22.01,91.51,,,,,,
BCBS Blue Choice,CPT,J9035,Bevacizumab injection,All Other,Per Unit,$278.32 ,OP,70.41,278.32,,,,,,
BCBS Blue Choice,CPT,J9041,Inj.- velcade 0.1 mg,All Other,Per Unit,$175.39 ,OP,45.16,175.39,,,,,,
BCBS Blue Choice,CPT,J9055,Cetuximab injection,All Other,Per Unit,$240.20 ,OP,66.71,240.2,,,,,,
BCBS Blue Choice,CPT,J9060,Cisplatin 10 mg injection,All Other,Per Unit,$134.21 ,OP,134.21,134.21,,,,,,
BCBS Blue Choice,CPT,J9062,Cisplatin 50 MG injection,All Other,Per Unit,$61.00 ,OP,61,61,,,,,,
BCBS Blue Choice,CPT,J9065,Inj cladribine per 1 mg,All Other,Per Unit,$144.88 ,OP,18.02,144.88,,,,,,
BCBS Blue Choice,CPT,J9070,Cyclophosphamide 100 mg inj,All Other,Per Unit,$19.07 ,OP,19.07,29.15,,,,,,
BCBS Blue Choice,CPT,J9080,Cyclophosphamide 200 MG inj,All Other,Per Unit,$34.31 ,OP,34.31,34.31,,,,,,
BCBS Blue Choice,CPT,J9090,Cyclophosphamide 500 MG inj,All Other,Per Unit,$91.51 ,OP,91.51,91.51,,,,,,
BCBS Blue Choice,CPT,J9091,Cyclophosphamide 1.0 grm inj,All Other,Per Unit,$179.20 ,OP,179.2,179.2,,,,,,
BCBS Blue Choice,CPT,J9092,Cyclophosphamide 2.0 grm inj,All Other,Per Unit,$362.21 ,OP,362.21,362.21,,,,,,
BCBS Blue Choice,CPT,J9093,Cyclophosphamide lyophilized,All Other,Per Unit,$11.44 ,OP,11.44,11.44,,,,,,
BCBS Blue Choice,CPT,J9096,Cyclophosphamide lyophilized,All Other,Per Unit,$106.76 ,OP,106.76,106.76,,,,,,
BCBS Blue Choice,CPT,J9097,Cyclophosphamide lyophilized,All Other,Per Unit,$217.32 ,OP,217.32,217.32,,,,,,
BCBS Blue Choice,CPT,J9098,Cytarabine liposome inj,All Other,Per Unit,"$2,177.05 ",OP,"2,177.05","2,177.05",,,,,,
BCBS Blue Choice,CPT,J9120,Dactinomycin injection,All Other,Per Unit,"$2,634.57 ",OP,890.64,"2,634.57",,,,,,
BCBS Blue Choice,CPT,J9130,Dacarbazine 100 mg inj,All Other,Per Unit,$19.07 ,OP,19.07,19.07,,,,,,
BCBS Blue Choice,CPT,J9140,Dacarbazine 200 MG inj,All Other,Per Unit,$38.13 ,OP,38.13,38.13,,,,,,
BCBS Blue Choice,CPT,J9150,Daunorubicin injection,All Other,Per Unit,$80.07 ,OP,40.36,80.07,,,,,,
BCBS Blue Choice,CPT,J9151,Daunorubicin citrate inj,All Other,Per Unit,$270.71 ,OP,270.71,270.71,,,,,,
BCBS Blue Choice,CPT,J9165,Diethylstilbestrol injection,All Other,Per Unit,$57.19 ,OP,57.19,57.19,,,,,,
BCBS Blue Choice,CPT,J9170,Docetaxel,All Other,Per Unit,"$1,423.47 ",OP,"1,423.47","1,423.47",,,,,,
BCBS Blue Choice,CPT,J9175,Elliotts b solution per ml,All Other,Per Unit,$19.07 ,OP,19.07,19.07,,,,,,
BCBS Blue Choice,CPT,J9178,Inj- epirubicin hcl- 2 mg,All Other,Per Unit,$98.98 ,OP,98.98,98.98,,,,,,
BCBS Blue Choice,CPT,J9185,Fludarabine phosphate inj,All Other,Per Unit,$716.79 ,OP,716.79,716.79,,,,,,
BCBS Blue Choice,CPT,J9199,"Injection, infugem, 200 mg",All Other,Per Unit,$548.88 ,OP,548.88,548.88,,,,,,
BCBS Blue Choice,CPT,J9200,Floxuridine injection,All Other,Per Unit,$282.14 ,OP,282.14,282.14,,,,,,
BCBS Blue Choice,CPT,J9201,In gemcitabine hcl nos 200mg,All Other,Per Unit,$548.88 ,OP,548.88,548.88,,,,,,
BCBS Blue Choice,CPT,J9202,Goserelin acetate implant,All Other,Per Unit,$915.04 ,OP,525.21,915.04,,,,,,
BCBS Blue Choice,CPT,J9206,Irinotecan injection,All Other,Per Unit,$482.59 ,OP,482.59,482.59,,,,,,
BCBS Blue Choice,CPT,J9207,Ixabepilone injection,All Other,Per Unit,$308.83 ,OP,112.12,308.83,,,,,,
BCBS Blue Choice,CPT,J9209,Mesna injection,All Other,Per Unit,$80.07 ,OP,80.07,80.07,,,,,,
BCBS Blue Choice,CPT,J9211,Idarubicin hcl injection,All Other,Per Unit,$629.10 ,OP,629.1,629.1,,,,,,
BCBS Blue Choice,CPT,J9212,Interferon alfacon-1 inj,All Other,Per Unit,$27.26 ,OP,27.26,27.26,,,,,,
BCBS Blue Choice,CPT,J9214,Interferon alfa-2b inj,All Other,Per Unit,$72.44 ,OP,33.24,72.44,,,,,,
BCBS Blue Choice,CPT,J9215,Interferon alfa-n3 inj,All Other,Per Unit,$41.94 ,OP,41.94,41.94,,,,,,
BCBS Blue Choice,CPT,J9216,Interferon gamma 1-b inj,All Other,Per Unit,"$1,772.90 ",OP,"1,772.90","1,772.90",,,,,,
BCBS Blue Choice,CPT,J9217,Leuprolide acetate suspnsion,All Other,Per Unit,$987.49 ,OP,139.09,987.49,,,,,,
BCBS Blue Choice,CPT,J9219,Leuprolide acetate implant,All Other,Per Unit,"$23,402.31 ",OP,"23,402.31","23,402.31",,,,,,
BCBS Blue Choice,CPT,J9225,Vantas implant,All Other,Per Unit,"$7,613.94 ",OP,"5,166.29","7,613.94",,,,,,
BCBS Blue Choice,CPT,J9226,Supprelin la implant,All Other,Per Unit,"$71,949.32 ",OP,"43,467.03","71,949.32",,,,,,
BCBS Blue Choice,CPT,J9230,Mechlorethamine hcl inj,All Other,Per Unit,$712.98 ,OP,11.74,712.98,,,,,,
BCBS Blue Choice,CPT,J9245,Inj melpha hydroch nos 50 mg,All Other,Per Unit,"$7,888.46 ",OP,208.41,"7,888.46",,,,,,
BCBS Blue Choice,CPT,J9261,Nelarabine injection,All Other,Per Unit,$488.04 ,OP,155.9,488.04,,,,,,
BCBS Blue Choice,CPT,J9263,Oxaliplatin,All Other,Per Unit,$45.74 ,OP,45.74,45.74,,,,,,
BCBS Blue Choice,CPT,J9264,Paclitaxel protein bound,All Other,Per Unit,$45.74 ,OP,14.08,45.74,,,,,,
BCBS Blue Choice,CPT,J9266,Pegaspargase injection,All Other,Per Unit,"$12,715.34 ",OP,"12,715.34","21,561.05",,,,,,
BCBS Blue Choice,CPT,J9268,Pentostatin injection,All Other,Per Unit,"$7,030.61 ",OP,"1,880.67","7,030.61",,,,,,
BCBS Blue Choice,CPT,J9270,Plicamycin (mithramycin) inj,All Other,Per Unit,$385.09 ,OP,115.4,385.09,,,,,,
BCBS Blue Choice,CPT,J9280,Mitomycin injection,All Other,Per Unit,$76.26 ,OP,38.63,76.26,,,,,,
BCBS Blue Choice,CPT,J9290,Mitomycin 20 MG inj,All Other,Per Unit,$305.01 ,OP,305.01,305.01,,,,,,
BCBS Blue Choice,CPT,J9291,Mitomycin 40 MG inj,All Other,Per Unit,$610.03 ,OP,610.03,610.03,,,,,,
BCBS Blue Choice,CPT,J9293,Mitoxantrone hydrochl / 5 mg,All Other,Per Unit,$392.70 ,OP,26.29,392.7,,,,,,
BCBS Blue Choice,CPT,J9305,Inj. pemetrexed nos 10mg,All Other,Per Unit,$232.58 ,OP,74.93,232.58,,,,,,
BCBS Blue Choice,CPT,J9310,Rituximab injection,All Other,Per Unit,"$2,096.91 ",OP,"2,096.91","2,096.91",,,,,,
BCBS Blue Choice,CPT,J9320,Streptozocin injection,All Other,Per Unit,"$1,372.57 ",OP,348.51,"1,372.57",,,,,,
BCBS Blue Choice,CPT,J9340,Thiotepa injection,All Other,Per Unit,$446.08 ,OP,305.84,446.08,,,,,,
BCBS Blue Choice,CPT,J9350,Topotecan injection,All Other,Per Unit,"$4,647.67 ",OP,"4,647.67","4,647.67",,,,,,
BCBS Blue Choice,CPT,J9351,Topotecan injection,All Other,Per Unit,$116.21 ,OP,116.21,116.21,,,,,,
BCBS Blue Choice,CPT,J9355,Inj trastuzumab excl biosimi,All Other,Per Unit,$238.10 ,OP,89.81,238.1,,,,,,
BCBS Blue Choice,CPT,J9357,Valrubicin injection,All Other,Per Unit,"$1,795.78 ",OP,"1,425.37","1,795.78",,,,,,
BCBS Blue Choice,CPT,J9370,Vincristine sulfate 1 mg inj,All Other,Per Unit,$28.22 ,OP,28.22,28.22,,,,,,
BCBS Blue Choice,CPT,J9371,Inj- vincristine sul lip 1mg,All Other,Per Unit,$28.22 ,OP,28.22,"3,370.23",,,,,,
BCBS Blue Choice,CPT,J9380,Vincristine sulfate 5 MG inj,All Other,Per Unit,$141.07 ,OP,141.07,141.07,,,,,,
BCBS Blue Choice,CPT,J9395,Injection- fulvestrant,All Other,Per Unit,$396.52 ,OP,15.98,396.52,,,,,,
BCBS Blue Choice,CPT,J9600,Porfimer sodium injection,All Other,Per Unit,"$13,169.04 ",OP,"13,169.04","21,856.35",,,,,,
BCBS Blue Choice,CPT,K0552,Sup/ext non-ins inf pump syr,All Other,Per Unit,$11.44 ,OP,11.44,11.44,,,,,,
BCBS Blue Choice,CPT,K0609,Repl electrode for aed,All Other,Per Unit,"$3,225.54 ",OP,"3,225.54","3,225.54",,,,,,
BCBS Blue Choice,CPT,L0112,Cranial cervical orthosis,All Other,Per Unit,"$4,830.68 ",OP,"1,404.96","4,830.68",,,,,,
BCBS Blue Choice,CPT,L0120,Cerv flex n/adj foam pre ots,All Other,Per Unit,$91.51 ,OP,26.55,91.51,,,,,,
BCBS Blue Choice,CPT,L0130,Flex thermoplastic collar mo,All Other,Per Unit,$526.16 ,OP,153.23,526.16,,,,,,
BCBS Blue Choice,CPT,L0140,Cervical semi-rigid adjustab,All Other,Per Unit,$205.88 ,OP,60.09,205.88,,,,,,
BCBS Blue Choice,CPT,L0150,Cerv semi-rig adj molded chn,All Other,Per Unit,$369.83 ,OP,107.45,369.83,,,,,,
BCBS Blue Choice,CPT,L0160,Cerv sr wire occ/man pre ots,All Other,Per Unit,$541.40 ,OP,156.89,541.4,,,,,,
BCBS Blue Choice,CPT,L0170,Cervical collar molded to pt,All Other,Per Unit,"$2,775.65 ",OP,807.1,"2,775.65",,,,,,
BCBS Blue Choice,CPT,L0172,Cerv col sr foam 2pc pre ots,All Other,Per Unit,$488.04 ,OP,142.17,488.04,,,,,,
BCBS Blue Choice,CPT,L0174,Cerv sr 2pc thor ext pre ots,All Other,Per Unit,$960.80 ,OP,279.55,960.8,,,,,,
BCBS Blue Choice,CPT,L0180,Cer post col occ/man sup adj,All Other,Per Unit,"$1,559.39 ",OP,452.88,"1,559.39",,,,,,
BCBS Blue Choice,CPT,L0190,Cerv collar supp adj cerv ba,All Other,Per Unit,"$1,837.71 ",OP,534.12,"1,837.71",,,,,,
BCBS Blue Choice,CPT,L0200,Cerv col supp adj bar & thor,All Other,Per Unit,"$2,131.30 ",OP,619.54,"2,131.30",,,,,,
BCBS Blue Choice,CPT,L0220,Thor rib belt custom fabrica,All Other,Per Unit,$446.08 ,OP,129.68,446.08,,,,,,
BCBS Blue Choice,CPT,L0430,Dewall posture protector,All Other,Per Unit,"$5,261.52 ",OP,"5,261.52","5,261.52",,,,,,
BCBS Blue Choice,CPT,L0450,Tlso flex trunk/thor pre ots,All Other,Per Unit,$560.47 ,OP,128.11,560.47,,,,,,
BCBS Blue Choice,CPT,L0454,Tlso trnk sj-t9 pre cst,All Other,Per Unit,"$1,197.20 ",OP,348.14,"1,197.20",,,,,,
BCBS Blue Choice,CPT,L0456,Tlso flex trnk sj-ss pre cst,All Other,Per Unit,"$3,435.25 ",OP,998.38,"3,435.25",,,,,,
BCBS Blue Choice,CPT,L0458,Tlso 2mod symphis-xipho pre,All Other,Per Unit,"$3,080.66 ",OP,895.27,"3,080.66",,,,,,
BCBS Blue Choice,CPT,L0460,Tlso 2 shl symphys-stern cst,All Other,Per Unit,"$3,465.73 ",OP,"1,007.68","3,465.73",,,,,,
BCBS Blue Choice,CPT,L0462,Tlso 3mod sacro-scap pre,All Other,Per Unit,"$4,312.16 ",OP,"1,253.37","4,312.16",,,,,,
BCBS Blue Choice,CPT,L0464,Tlso 4mod sacro-scap pre,All Other,Per Unit,"$5,131.88 ",OP,"1,492.13","5,131.88",,,,,,
BCBS Blue Choice,CPT,L0466,Tlso r fram soft ant pre cst,All Other,Per Unit,"$1,311.56 ",OP,380.86,"1,311.56",,,,,,
BCBS Blue Choice,CPT,L0468,Tlso rig fram pelvic pre cst,All Other,Per Unit,"$1,643.28 ",OP,477.29,"1,643.28",,,,,,
BCBS Blue Choice,CPT,L0470,Tlso rigid frame pre subclav,All Other,Per Unit,"$2,272.36 ",OP,660.47,"2,272.36",,,,,,
BCBS Blue Choice,CPT,L0472,Tlso rigid frame hyperex pre,All Other,Per Unit,"$1,399.26 ",OP,406.41,"1,399.26",,,,,,
BCBS Blue Choice,CPT,L0480,Tlso rigid plastic custom fa,All Other,Per Unit,"$5,215.77 ",OP,"1,516.23","5,215.77",,,,,,
BCBS Blue Choice,CPT,L0482,Tlso rigid lined custom fab,All Other,Per Unit,"$5,825.80 ",OP,"1,693.64","5,825.80",,,,,,
BCBS Blue Choice,CPT,L0484,Tlso rigid plastic cust fab,All Other,Per Unit,"$6,290.94 ",OP,"1,829.06","6,290.94",,,,,,
BCBS Blue Choice,CPT,L0486,Tlso rigidlined cust fab two,All Other,Per Unit,"$7,064.92 ",OP,"2,054.11","7,064.92",,,,,,
BCBS Blue Choice,CPT,L0488,Tlso rigid lined pre one pie,All Other,Per Unit,"$3,465.73 ",OP,"1,007.68","3,465.73",,,,,,
BCBS Blue Choice,CPT,L0490,Tlso rigid plastic pre one,All Other,Per Unit,$976.05 ,OP,283.96,976.05,,,,,,
BCBS Blue Choice,CPT,L0491,Tlso 2 piece rigid shell,All Other,Per Unit,"$2,649.83 ",OP,770.93,"2,649.83",,,,,,
BCBS Blue Choice,CPT,L0492,Tlso 3 piece rigid shell,All Other,Per Unit,"$1,727.15 ",OP,502.01,"1,727.15",,,,,,
BCBS Blue Choice,CPT,L0621,Sio flex pelvic/sacr pre ots,All Other,Per Unit,$446.08 ,OP,67.68,446.08,,,,,,
BCBS Blue Choice,CPT,L0622,Sio flex pelvisacral custom,All Other,Per Unit,"$1,384.01 ",OP,268.31,"1,384.01",,,,,,
BCBS Blue Choice,CPT,L0625,Lo flex l1-below l5 pre ots,All Other,Per Unit,$285.96 ,OP,39.58,285.96,,,,,,
BCBS Blue Choice,CPT,L0626,Lo sag rig pnl stays pre cst,All Other,Per Unit,$404.14 ,OP,78.25,404.14,,,,,,
BCBS Blue Choice,CPT,L0627,Lo sag ri an/pos pnl pre cst,All Other,Per Unit,"$2,127.49 ",OP,412.59,"2,127.49",,,,,,
BCBS Blue Choice,CPT,L0628,Lso flex no ri stays pre ots,All Other,Per Unit,$434.65 ,OP,60.27,434.65,,,,,,
BCBS Blue Choice,CPT,L0630,Lso r post pnl sj-t9 pre cst,All Other,Per Unit,$838.79 ,OP,162.59,838.79,,,,,,
BCBS Blue Choice,CPT,L0631,Lso sag r an/pos pnl pre cst,All Other,Per Unit,"$5,314.90 ",OP,"1,030.49","5,314.90",,,,,,
BCBS Blue Choice,CPT,L0633,Lso sc r pos/lat pnl pre cst,All Other,Per Unit,"$1,483.14 ",OP,287.85,"1,483.14",,,,,,
BCBS Blue Choice,CPT,L0635,Lso sagit rigid panel prefab,All Other,Per Unit,"$5,173.83 ",OP,"1,003.05","5,173.83",,,,,,
BCBS Blue Choice,CPT,L0636,Lso sagittal rigid panel cus,All Other,Per Unit,"$7,019.17 ",OP,"1,360.98","7,019.17",,,,,,
BCBS Blue Choice,CPT,L0637,Lso sc r ant/pos pnl pre cst,All Other,Per Unit,"$6,710.34 ",OP,"1,300.47","6,710.34",,,,,,
BCBS Blue Choice,CPT,L0638,Lso sag-coronal panel custom,All Other,Per Unit,"$6,828.54 ",OP,"1,323.97","6,828.54",,,,,,
BCBS Blue Choice,CPT,L0639,Lso s/c shell/panel prefab,All Other,Per Unit,"$6,710.34 ",OP,"1,300.47","6,710.34",,,,,,
BCBS Blue Choice,CPT,L0640,Lso s/c shell/panel custom,All Other,Per Unit,"$5,417.84 ",OP,"1,050.39","5,417.84",,,,,,
BCBS Blue Choice,CPT,L0700,Ctlso a-p-l control molded,All Other,Per Unit,"$6,874.29 ",OP,"1,998.37","6,874.29",,,,,,
BCBS Blue Choice,CPT,L0710,Ctlso a-p-l control w/ inter,All Other,Per Unit,"$7,552.94 ",OP,"2,196.75","7,552.94",,,,,,
BCBS Blue Choice,CPT,L0810,Halo cervical into jckt vest,All Other,Per Unit,"$9,226.72 ",OP,"2,683.14","9,226.72",,,,,,
BCBS Blue Choice,CPT,L0820,Halo cervical into body jack,All Other,Per Unit,"$7,259.37 ",OP,"2,110.65","7,259.37",,,,,,
BCBS Blue Choice,CPT,L0830,Halo cerv into milwaukee typ,All Other,Per Unit,"$11,106.37 ",OP,"3,229.60","11,106.37",,,,,,
BCBS Blue Choice,CPT,L0859,Mri compatible system,All Other,Per Unit,"$3,930.89 ",OP,"1,143.45","3,930.89",,,,,,
BCBS Blue Choice,CPT,L0861,Halo repl liner/interface,All Other,Per Unit,$743.48 ,OP,216.37,743.48,,,,,,
BCBS Blue Choice,CPT,L0970,Tlso corset front,All Other,Per Unit,$369.83 ,OP,107.27,369.83,,,,,,
BCBS Blue Choice,CPT,L0972,Lso corset front,All Other,Per Unit,$335.53 ,OP,97.64,335.53,,,,,,
BCBS Blue Choice,CPT,L0974,Tlso full corset,All Other,Per Unit,$602.41 ,OP,175.42,602.41,,,,,,
BCBS Blue Choice,CPT,L0978,Axillary crutch extension,All Other,Per Unit,$648.16 ,OP,188.9,648.16,,,,,,
BCBS Blue Choice,CPT,L0980,Peroneal straps pair pre ots,All Other,Per Unit,$57.19 ,OP,17.15,57.19,,,,,,
BCBS Blue Choice,CPT,L0982,Stocking sup grips 4 pre ots,All Other,Per Unit,$53.38 ,OP,15.7,53.38,,,,,,
BCBS Blue Choice,CPT,L0984,Protect body sock ea pre ots,All Other,Per Unit,$232.58 ,OP,67.93,232.58,,,,,,
BCBS Blue Choice,CPT,L1000,Ctlso milwauke initial model,All Other,Per Unit,"$7,000.10 ",OP,"2,035.53","7,000.10",,,,,,
BCBS Blue Choice,CPT,L1005,Tension based scoliosis orth,All Other,Per Unit,"$11,049.19 ",OP,"3,212.88","11,049.19",,,,,,
BCBS Blue Choice,CPT,L1010,Ctlso axilla sling,All Other,Per Unit,$289.76 ,OP,83.99,289.76,,,,,,
BCBS Blue Choice,CPT,L1020,Kyphosis pad,All Other,Per Unit,$373.65 ,OP,108.17,373.65,,,,,,
BCBS Blue Choice,CPT,L1025,Kyphosis pad floating,All Other,Per Unit,$537.60 ,OP,156.06,537.6,,,,,,
BCBS Blue Choice,CPT,L1030,Lumbar bolster pad,All Other,Per Unit,$270.71 ,OP,78.6,270.71,,,,,,
BCBS Blue Choice,CPT,L1040,Lumbar or lumbar rib pad,All Other,Per Unit,$305.01 ,OP,89,305.01,,,,,,
BCBS Blue Choice,CPT,L1050,Sternal pad,All Other,Per Unit,$346.96 ,OP,100.72,346.96,,,,,,
BCBS Blue Choice,CPT,L1060,Thoracic pad,All Other,Per Unit,$373.65 ,OP,108.72,373.65,,,,,,
BCBS Blue Choice,CPT,L1070,Trapezius sling,All Other,Per Unit,$388.89 ,OP,112.62,388.89,,,,,,
BCBS Blue Choice,CPT,L1080,Outrigger,All Other,Per Unit,$179.20 ,OP,52.52,179.2,,,,,,
BCBS Blue Choice,CPT,L1085,Outrigger bil w/ vert extens,All Other,Per Unit,$606.21 ,OP,175.83,606.21,,,,,,
BCBS Blue Choice,CPT,L1090,Lumbar sling,All Other,Per Unit,$346.96 ,OP,101.01,346.96,,,,,,
BCBS Blue Choice,CPT,L1100,Ring flange plastic/leather,All Other,Per Unit,$655.78 ,OP,190.64,655.78,,,,,,
BCBS Blue Choice,CPT,L1110,Ring flange plas/leather mol,All Other,Per Unit,"$1,098.07 ",OP,319.63,"1,098.07",,,,,,
BCBS Blue Choice,CPT,L1120,Covers for upright each,All Other,Per Unit,$129.64 ,OP,38.18,129.64,,,,,,
BCBS Blue Choice,CPT,L1200,Furnsh initial orthosis only,All Other,Per Unit,"$6,176.57 ",OP,"1,796.37","6,176.57",,,,,,
BCBS Blue Choice,CPT,L1210,Lateral thoracic extension,All Other,Per Unit,$846.41 ,OP,245.6,846.41,,,,,,
BCBS Blue Choice,CPT,L1220,Anterior thoracic extension,All Other,Per Unit,$823.54 ,OP,239.05,823.54,,,,,,
BCBS Blue Choice,CPT,L1230,Milwaukee type superstructur,All Other,Per Unit,"$2,302.87 ",OP,669.67,"2,302.87",,,,,,
BCBS Blue Choice,CPT,L1240,Lumbar derotation pad,All Other,Per Unit,$312.64 ,OP,91.29,312.64,,,,,,
BCBS Blue Choice,CPT,L1250,Anterior asis pad,All Other,Per Unit,$274.51 ,OP,79.39,274.51,,,,,,
BCBS Blue Choice,CPT,L1260,Anterior thoracic derotation,All Other,Per Unit,$324.09 ,OP,94.68,324.09,,,,,,
BCBS Blue Choice,CPT,L1270,Abdominal pad,All Other,Per Unit,$285.96 ,OP,83.2,285.96,,,,,,
BCBS Blue Choice,CPT,L1280,Rib gusset (elastic) each,All Other,Per Unit,$301.20 ,OP,87.71,301.2,,,,,,
BCBS Blue Choice,CPT,L1290,Lateral trochanteric pad,All Other,Per Unit,$266.89 ,OP,78,266.89,,,,,,
BCBS Blue Choice,CPT,L1300,Body jacket mold to patient,All Other,Per Unit,"$5,951.62 ",OP,"1,730.06","5,951.62",,,,,,
BCBS Blue Choice,CPT,L1310,Post-operative body jacket,All Other,Per Unit,"$6,195.63 ",OP,"1,802.00","6,195.63",,,,,,
BCBS Blue Choice,CPT,L1500,Thkao mobility frame,All Other,Per Unit,"$6,664.59 ",OP,"6,664.59","6,664.59",,,,,,
BCBS Blue Choice,CPT,L1510,Thkao standing frame,All Other,Per Unit,"$4,106.27 ",OP,"4,106.27","4,106.27",,,,,,
BCBS Blue Choice,CPT,L1520,Thkao swivel walker,All Other,Per Unit,"$7,362.31 ",OP,"7,362.31","7,362.31",,,,,,
BCBS Blue Choice,CPT,L1600,Ho flex frejka w/cov pre cst,All Other,Per Unit,$446.08 ,OP,129.35,446.08,,,,,,
BCBS Blue Choice,CPT,L1610,Ho frejka cov only pre cst,All Other,Per Unit,$190.64 ,OP,54.94,190.64,,,,,,
BCBS Blue Choice,CPT,L1620,Ho flex pavlik harns pre cst,All Other,Per Unit,$541.40 ,OP,157.73,541.4,,,,,,
BCBS Blue Choice,CPT,L1630,Abduct control hip semi-flex,All Other,Per Unit,$728.23 ,OP,212.06,728.23,,,,,,
BCBS Blue Choice,CPT,L1640,Pelv band/spread bar thigh c,All Other,Per Unit,"$1,635.64 ",OP,475.2,"1,635.64",,,,,,
BCBS Blue Choice,CPT,L1650,Ho abduction hip adjustable,All Other,Per Unit,$850.23 ,OP,247.55,850.23,,,,,,
BCBS Blue Choice,CPT,L1652,Ho bi thighcuffs w sprdr bar,All Other,Per Unit,"$1,231.50 ",OP,357.83,"1,231.50",,,,,,
BCBS Blue Choice,CPT,L1660,Ho abduction static plastic,All Other,Per Unit,$625.29 ,OP,181.4,625.29,,,,,,
BCBS Blue Choice,CPT,L1680,Pelvic & hip control thigh c,All Other,Per Unit,"$3,934.69 ",OP,"1,143.62","3,934.69",,,,,,
BCBS Blue Choice,CPT,L1685,Post-op hip abduct custom fa,All Other,Per Unit,"$3,839.39 ",OP,"1,116.47","3,839.39",,,,,,
BCBS Blue Choice,CPT,L1686,Ho post-op hip abduction,All Other,Per Unit,"$3,233.17 ",OP,940.6,"3,233.17",,,,,,
BCBS Blue Choice,CPT,L1690,Combination bilateral ho,All Other,Per Unit,"$6,676.03 ",OP,"1,941.15","6,676.03",,,,,,
BCBS Blue Choice,CPT,L1700,Leg perthes orth toronto typ,All Other,Per Unit,"$5,372.08 ",OP,"1,561.78","5,372.08",,,,,,
BCBS Blue Choice,CPT,L1710,Legg perthes orth newington,All Other,Per Unit,"$6,839.98 ",OP,"1,988.75","6,839.98",,,,,,
BCBS Blue Choice,CPT,L1720,Legg perthes orthosis trilat,All Other,Per Unit,"$5,093.76 ",OP,"1,480.82","5,093.76",,,,,,
BCBS Blue Choice,CPT,L1730,Legg perthes orth scottish r,All Other,Per Unit,"$4,300.73 ",OP,"1,250.14","4,300.73",,,,,,
BCBS Blue Choice,CPT,L1755,Legg perthes patten bottom t,All Other,Per Unit,"$6,180.39 ",OP,"1,797.35","6,180.39",,,,,,
BCBS Blue Choice,CPT,L1800,Knee orthoses elas w stays,All Other,Per Unit,$217.32 ,OP,217.32,217.32,,,,,,
BCBS Blue Choice,CPT,L1825,Ko elastic knee cap,All Other,Per Unit,$205.88 ,OP,205.88,205.88,,,,,,
BCBS Blue Choice,CPT,L1830,Ko immob canvas long pre ots,All Other,Per Unit,$285.96 ,OP,71.04,285.96,,,,,,
BCBS Blue Choice,CPT,L1831,Knee orth pos locking joint,All Other,Per Unit,"$1,017.99 ",OP,295.44,"1,017.99",,,,,,
BCBS Blue Choice,CPT,L1832,Ko adj jnt pos r sup pre cst,All Other,Per Unit,"$2,379.12 ",OP,691.44,"2,379.12",,,,,,
BCBS Blue Choice,CPT,L1834,Ko w/0 joint rigid molded to,All Other,Per Unit,"$2,504.94 ",OP,728.61,"2,504.94",,,,,,
BCBS Blue Choice,CPT,L1840,Ko derot ant cruciate custom,All Other,Per Unit,"$3,248.41 ",OP,944,"3,248.41",,,,,,
BCBS Blue Choice,CPT,L1843,Ko single upright pre cst,All Other,Per Unit,"$3,095.90 ",OP,900.7,"3,095.90",,,,,,
BCBS Blue Choice,CPT,L1844,Ko w/adj jt rot cntrl molded,All Other,Per Unit,"$5,257.70 ",OP,"1,528.66","5,257.70",,,,,,
BCBS Blue Choice,CPT,L1847,Ko dbl upright w/air pre cst,All Other,Per Unit,"$1,986.41 ",OP,577.37,"1,986.41",,,,,,
BCBS Blue Choice,CPT,L1850,Ko swedish type pre ots,All Other,Per Unit,$983.68 ,OP,234.85,983.68,,,,,,
BCBS Blue Choice,CPT,L1860,Ko supracondylar socket mold,All Other,Per Unit,"$4,304.53 ",OP,"1,251.75","4,304.53",,,,,,
BCBS Blue Choice,CPT,L1900,Afo sprng wir drsflx calf bd,All Other,Per Unit,$983.68 ,OP,286.39,983.68,,,,,,
BCBS Blue Choice,CPT,L1901,Prefab ankle orthosis,All Other,Per Unit,$61.00 ,OP,61,61,,,,,,
BCBS Blue Choice,CPT,L1902,Afo ankle gauntlet pre ots,All Other,Per Unit,$259.27 ,OP,74.93,259.27,,,,,,
BCBS Blue Choice,CPT,L1904,Afo molded ankle gauntlet,All Other,Per Unit,"$1,559.39 ",OP,453.09,"1,559.39",,,,,,
BCBS Blue Choice,CPT,L1906,Afo multilig ank sup pre ots,All Other,Per Unit,$388.89 ,OP,112.88,388.89,,,,,,
BCBS Blue Choice,CPT,L1907,Afo supramalleolar custom,All Other,Per Unit,"$1,944.48 ",OP,564.86,"1,944.48",,,,,,
BCBS Blue Choice,CPT,L1910,Afo sing bar clasp attach sh,All Other,Per Unit,$968.43 ,OP,281.51,968.43,,,,,,
BCBS Blue Choice,CPT,L1920,Afo sing upright w/ adjust s,All Other,Per Unit,"$1,418.32 ",OP,412.37,"1,418.32",,,,,,
BCBS Blue Choice,CPT,L1930,Afo plastic,All Other,Per Unit,$869.30 ,OP,252.89,869.3,,,,,,
BCBS Blue Choice,CPT,L1932,Afo rig ant tib prefab tcf/=,All Other,Per Unit,"$3,080.66 ",OP,895.75,"3,080.66",,,,,,
BCBS Blue Choice,CPT,L1940,Afo molded to patient plasti,All Other,Per Unit,"$1,681.40 ",OP,488.84,"1,681.40",,,,,,
BCBS Blue Choice,CPT,L1945,Afo molded plas rig ant tib,All Other,Per Unit,"$3,873.69 ",OP,"1,126.77","3,873.69",,,,,,
BCBS Blue Choice,CPT,L1950,Afo spiral molded to pt plas,All Other,Per Unit,"$2,653.63 ",OP,772,"2,653.63",,,,,,
BCBS Blue Choice,CPT,L1951,Afo spiral prefabricated,All Other,Per Unit,"$2,897.65 ",OP,843.02,"2,897.65",,,,,,
BCBS Blue Choice,CPT,L1960,Afo pos solid ank plastic mo,All Other,Per Unit,"$2,138.93 ",OP,622.25,"2,138.93",,,,,,
BCBS Blue Choice,CPT,L1970,Afo plastic molded w/ankle j,All Other,Per Unit,"$2,390.56 ",OP,694.78,"2,390.56",,,,,,
BCBS Blue Choice,CPT,L1971,Afo w/ankle joint- prefab,All Other,Per Unit,"$1,616.58 ",OP,470.55,"1,616.58",,,,,,
BCBS Blue Choice,CPT,L1980,Afo sing solid stirrup calf,All Other,Per Unit,"$1,395.45 ",OP,405.31,"1,395.45",,,,,,
BCBS Blue Choice,CPT,L1990,Afo doub solid stirrup calf,All Other,Per Unit,"$1,612.76 ",OP,469.1,"1,612.76",,,,,,
BCBS Blue Choice,CPT,L2000,Kafo sing fre stirr thi/calf,All Other,Per Unit,"$3,862.25 ",OP,"1,122.95","3,862.25",,,,,,
BCBS Blue Choice,CPT,L2005,Kafo sng/dbl mechanical act,All Other,Per Unit,"$14,145.09 ",OP,"4,113.39","14,145.09",,,,,,
BCBS Blue Choice,CPT,L2006,Kaf sng/dbl swg/stn mcpr cus,All Other,Per Unit,"$14,145.09 ",OP,"14,145.09","14,145.09",,,,,,
BCBS Blue Choice,CPT,L2010,Kafo sng solid stirrup w/o j,All Other,Per Unit,"$3,012.03 ",OP,875.89,"3,012.03",,,,,,
BCBS Blue Choice,CPT,L2020,Kafo dbl solid stirrup band/,All Other,Per Unit,"$3,805.07 ",OP,"1,106.22","3,805.07",,,,,,
BCBS Blue Choice,CPT,L2030,Kafo dbl solid stirrup w/o j,All Other,Per Unit,"$3,740.26 ",OP,"1,087.33","3,740.26",,,,,,
BCBS Blue Choice,CPT,L2034,Kafo pla sin up w/wo k/a cus,All Other,Per Unit,"$7,011.54 ",OP,"2,039.24","7,011.54",,,,,,
BCBS Blue Choice,CPT,L2035,Kafo plastic pediatric size,All Other,Per Unit,$598.59 ,OP,173.91,598.59,,,,,,
BCBS Blue Choice,CPT,L2036,Kafo plas doub free knee mol,All Other,Per Unit,"$6,401.51 ",OP,"1,861.04","6,401.51",,,,,,
BCBS Blue Choice,CPT,L2037,Kafo plas sing free knee mol,All Other,Per Unit,"$5,726.65 ",OP,"1,664.67","5,726.65",,,,,,
BCBS Blue Choice,CPT,L2038,Kafo w/o joint multi-axis an,All Other,Per Unit,"$4,613.36 ",OP,"1,341.97","4,613.36",,,,,,
BCBS Blue Choice,CPT,L2040,Hkafo torsion bil rot straps,All Other,Per Unit,$697.72 ,OP,203.08,697.72,,,,,,
BCBS Blue Choice,CPT,L2050,Hkafo torsion cable hip pelv,All Other,Per Unit,"$1,681.40 ",OP,489.17,"1,681.40",,,,,,
BCBS Blue Choice,CPT,L2060,Hkafo torsion ball bearing j,All Other,Per Unit,"$2,104.61 ",OP,611.86,"2,104.61",,,,,,
BCBS Blue Choice,CPT,L2070,Hkafo torsion unilat rot str,All Other,Per Unit,$537.60 ,OP,155.8,537.6,,,,,,
BCBS Blue Choice,CPT,L2080,Hkafo unilat torsion cable,All Other,Per Unit,"$1,288.69 ",OP,374.61,"1,288.69",,,,,,
BCBS Blue Choice,CPT,L2090,Hkafo unilat torsion ball br,All Other,Per Unit,"$1,715.71 ",OP,499.12,"1,715.71",,,,,,
BCBS Blue Choice,CPT,L2106,Afo tib fx cast plaster mold,All Other,Per Unit,"$2,722.27 ",OP,791.23,"2,722.27",,,,,,
BCBS Blue Choice,CPT,L2108,Afo tib fx cast molded to pt,All Other,Per Unit,"$3,969.02 ",OP,"1,154.03","3,969.02",,,,,,
BCBS Blue Choice,CPT,L2112,Afo tibial fracture soft,All Other,Per Unit,"$1,742.41 ",OP,506.43,"1,742.41",,,,,,
BCBS Blue Choice,CPT,L2126,Kafo fem fx cast thermoplas,All Other,Per Unit,"$4,407.46 ",OP,"1,281.77","4,407.46",,,,,,
BCBS Blue Choice,CPT,L2128,Kafo fem fx cast molded to p,All Other,Per Unit,"$5,536.03 ",OP,"1,609.47","5,536.03",,,,,,
BCBS Blue Choice,CPT,L2132,Kafo femoral fx cast soft,All Other,Per Unit,"$3,358.99 ",OP,976.92,"3,358.99",,,,,,
BCBS Blue Choice,CPT,L2134,Kafo fem fx cast semi-rigid,All Other,Per Unit,"$3,976.64 ",OP,"1,156.80","3,976.64",,,,,,
BCBS Blue Choice,CPT,L2136,Kafo femoral fx cast rigid,All Other,Per Unit,"$4,354.09 ",OP,"1,265.95","4,354.09",,,,,,
BCBS Blue Choice,CPT,L2180,Plas shoe insert w ank joint,All Other,Per Unit,$457.52 ,OP,133.08,457.52,,,,,,
BCBS Blue Choice,CPT,L2182,Drop lock knee,All Other,Per Unit,$392.70 ,OP,114.71,392.7,,,,,,
BCBS Blue Choice,CPT,L2184,Limited motion knee joint,All Other,Per Unit,$400.34 ,OP,116.27,400.34,,,,,,
BCBS Blue Choice,CPT,L2186,Adj motion knee jnt lerman t,All Other,Per Unit,$529.96 ,OP,154.63,529.96,,,,,,
BCBS Blue Choice,CPT,L2188,Quadrilateral brim,All Other,Per Unit,$968.43 ,OP,281.1,968.43,,,,,,
BCBS Blue Choice,CPT,L2190,Waist belt,All Other,Per Unit,$293.57 ,OP,85.62,293.57,,,,,,
BCBS Blue Choice,CPT,L2192,Pelvic band & belt thigh fla,All Other,Per Unit,"$1,151.42 ",OP,334.67,"1,151.42",,,,,,
BCBS Blue Choice,CPT,L2200,Limited ankle motion ea jnt,All Other,Per Unit,$175.39 ,OP,50.44,175.39,,,,,,
BCBS Blue Choice,CPT,L2210,Dorsiflexion assist each joi,All Other,Per Unit,$217.32 ,OP,63.09,217.32,,,,,,
BCBS Blue Choice,CPT,L2220,Dorsi & plantar flex ass/res,All Other,Per Unit,$278.32 ,OP,81.22,278.32,,,,,,
BCBS Blue Choice,CPT,L2230,Split flat caliper stirr & p,All Other,Per Unit,$331.70 ,OP,96.02,331.7,,,,,,
BCBS Blue Choice,CPT,L2232,Rocker bottom- contact afo,All Other,Per Unit,$335.53 ,OP,97.51,335.53,,,,,,
BCBS Blue Choice,CPT,L2240,Round caliper and plate atta,All Other,Per Unit,$327.90 ,OP,95.58,327.9,,,,,,
BCBS Blue Choice,CPT,L2250,Foot plate molded stirrup at,All Other,Per Unit,"$1,151.42 ",OP,335.3,"1,151.42",,,,,,
BCBS Blue Choice,CPT,L2260,Reinforced solid stirrup,All Other,Per Unit,$648.16 ,OP,188.16,648.16,,,,,,
BCBS Blue Choice,CPT,L2265,Long tongue stirrup,All Other,Per Unit,$465.15 ,OP,134.94,465.15,,,,,,
BCBS Blue Choice,CPT,L2270,Varus/valgus strap padded/li,All Other,Per Unit,$213.51 ,OP,61.87,213.51,,,,,,
BCBS Blue Choice,CPT,L2275,Plastic mod low ext pad/line,All Other,Per Unit,$449.90 ,OP,130.85,449.9,,,,,,
BCBS Blue Choice,CPT,L2280,Molded inner boot,All Other,Per Unit,"$1,948.29 ",OP,566.69,"1,948.29",,,,,,
BCBS Blue Choice,CPT,L2300,Abduction bar jointed adjust,All Other,Per Unit,$869.30 ,OP,252.72,869.3,,,,,,
BCBS Blue Choice,CPT,L2310,Abduction bar-straight,All Other,Per Unit,$396.52 ,OP,115.47,396.52,,,,,,
BCBS Blue Choice,CPT,L2320,Non-molded lacer,All Other,Per Unit,$667.22 ,OP,193.64,667.22,,,,,,
BCBS Blue Choice,CPT,L2330,Lacer molded to patient mode,All Other,Per Unit,"$1,265.81 ",OP,368.55,"1,265.81",,,,,,
BCBS Blue Choice,CPT,L2335,Anterior swing band,All Other,Per Unit,$972.25 ,OP,282.18,972.25,,,,,,
BCBS Blue Choice,CPT,L2340,Pre-tibial shell molded to p,All Other,Per Unit,"$1,441.20 ",OP,419.5,"1,441.20",,,,,,
BCBS Blue Choice,CPT,L2350,Prosthetic type socket molde,All Other,Per Unit,"$2,874.78 ",OP,836.35,"2,874.78",,,,,,
BCBS Blue Choice,CPT,L2360,Extended steel shank,All Other,Per Unit,$179.20 ,OP,51.76,179.2,,,,,,
BCBS Blue Choice,CPT,L2370,Patten bottom,All Other,Per Unit,"$1,105.68 ",OP,321.26,"1,105.68",,,,,,
BCBS Blue Choice,CPT,L2375,Torsion ank & half solid sti,All Other,Per Unit,$423.22 ,OP,123.52,423.22,,,,,,
BCBS Blue Choice,CPT,L2380,Torsion straight knee joint,All Other,Per Unit,$446.08 ,OP,129.54,446.08,,,,,,
BCBS Blue Choice,CPT,L2385,Straight knee joint heavy du,All Other,Per Unit,$507.08 ,OP,147.5,507.08,,,,,,
BCBS Blue Choice,CPT,L2387,Add le poly knee custom kafo,All Other,Per Unit,$659.60 ,OP,191.63,659.6,,,,,,
BCBS Blue Choice,CPT,L2390,Offset knee joint each,All Other,Per Unit,$354.58 ,OP,102.75,354.58,,,,,,
BCBS Blue Choice,CPT,L2395,Offset knee joint heavy duty,All Other,Per Unit,$503.28 ,OP,146.86,503.28,,,,,,
BCBS Blue Choice,CPT,L2397,Suspension sleeve lower ext,All Other,Per Unit,$423.22 ,OP,122.52,423.22,,,,,,
BCBS Blue Choice,CPT,L2405,Knee joint drop lock ea jnt,All Other,Per Unit,$301.20 ,OP,87.52,301.2,,,,,,
BCBS Blue Choice,CPT,L2415,Knee joint cam lock each joi,All Other,Per Unit,$419.40 ,OP,121.95,419.4,,,,,,
BCBS Blue Choice,CPT,L2425,Knee disc/dial lock/adj flex,All Other,Per Unit,$495.65 ,OP,143.9,495.65,,,,,,
BCBS Blue Choice,CPT,L2430,Knee jnt ratchet lock ea jnt,All Other,Per Unit,$495.65 ,OP,143.9,495.65,,,,,,
BCBS Blue Choice,CPT,L2492,Knee lift loop drop lock rin,All Other,Per Unit,$404.14 ,OP,117.74,404.14,,,,,,
BCBS Blue Choice,CPT,L2500,Thi/glut/ischia wgt bearing,All Other,Per Unit,"$1,078.99 ",OP,314.13,"1,078.99",,,,,,
BCBS Blue Choice,CPT,L2510,Th/wght bear quad-lat brim m,All Other,Per Unit,"$2,783.26 ",OP,809.6,"2,783.26",,,,,,
BCBS Blue Choice,CPT,L2520,Th/wght bear quad-lat brim c,All Other,Per Unit,"$1,856.79 ",OP,539.56,"1,856.79",,,,,,
BCBS Blue Choice,CPT,L2525,Th/wght bear nar m-l brim mo,All Other,Per Unit,"$3,934.69 ",OP,"1,144.16","3,934.69",,,,,,
BCBS Blue Choice,CPT,L2526,Th/wght bear nar m-l brim cu,All Other,Per Unit,"$2,211.37 ",OP,642.9,"2,211.37",,,,,,
BCBS Blue Choice,CPT,L2530,Thigh/wght bear lacer non-mo,All Other,Per Unit,$827.35 ,OP,240.74,827.35,,,,,,
BCBS Blue Choice,CPT,L2540,Thigh/wght bear lacer molded,All Other,Per Unit,"$1,567.02 ",OP,455.54,"1,567.02",,,,,,
BCBS Blue Choice,CPT,L2550,Thigh/wght bear high roll cu,All Other,Per Unit,"$1,174.31 ",OP,341.55,"1,174.31",,,,,,
BCBS Blue Choice,CPT,L2570,Hip clevis type 2 posit jnt,All Other,Per Unit,"$1,536.51 ",OP,447.07,"1,536.51",,,,,,
BCBS Blue Choice,CPT,L2580,Pelvic control pelvic sling,All Other,Per Unit,"$1,498.39 ",OP,435.62,"1,498.39",,,,,,
BCBS Blue Choice,CPT,L2600,Hip clevis/thrust bearing fr,All Other,Per Unit,$735.85 ,OP,214.1,735.85,,,,,,
BCBS Blue Choice,CPT,L2610,Hip clevis/thrust bearing lo,All Other,Per Unit,$812.11 ,OP,236.58,812.11,,,,,,
BCBS Blue Choice,CPT,L2620,Pelvic control hip heavy dut,All Other,Per Unit,$861.67 ,OP,250.96,861.67,,,,,,
BCBS Blue Choice,CPT,L2622,Hip joint adjustable flexion,All Other,Per Unit,"$1,098.07 ",OP,319.42,"1,098.07",,,,,,
BCBS Blue Choice,CPT,L2624,Hip adj flex ext abduct cont,All Other,Per Unit,"$1,345.89 ",OP,391.68,"1,345.89",,,,,,
BCBS Blue Choice,CPT,L2627,Plastic mold recipro hip & c,All Other,Per Unit,"$7,377.56 ",OP,"2,145.41","7,377.56",,,,,,
BCBS Blue Choice,CPT,L2628,Metal frame recipro hip & ca,All Other,Per Unit,"$5,406.41 ",OP,"1,572.54","5,406.41",,,,,,
BCBS Blue Choice,CPT,L2630,Pelvic control band & belt u,All Other,Per Unit,$800.67 ,OP,232.43,800.67,,,,,,
BCBS Blue Choice,CPT,L2640,Pelvic control band & belt b,All Other,Per Unit,"$1,086.62 ",OP,315.42,"1,086.62",,,,,,
BCBS Blue Choice,CPT,L2650,Pelv & thor control gluteal,All Other,Per Unit,$476.60 ,OP,138.91,476.6,,,,,,
BCBS Blue Choice,CPT,L2660,Thoracic control thoracic ba,All Other,Per Unit,$617.65 ,OP,179.86,617.65,,,,,,
BCBS Blue Choice,CPT,L2670,Thorac cont paraspinal uprig,All Other,Per Unit,$549.03 ,OP,160.11,549.03,,,,,,
BCBS Blue Choice,CPT,L2680,Thorac cont lat support upri,All Other,Per Unit,$503.28 ,OP,146.88,503.28,,,,,,
BCBS Blue Choice,CPT,L2750,Plating chrome/nickel pr bar,All Other,Per Unit,$270.71 ,OP,78.45,270.71,,,,,,
BCBS Blue Choice,CPT,L2755,Carbon graphite lamination,All Other,Per Unit,$449.90 ,OP,131.16,449.9,,,,,,
BCBS Blue Choice,CPT,L2760,Extension per extension per,All Other,Per Unit,$194.45 ,OP,57.03,194.45,,,,,,
BCBS Blue Choice,CPT,L2768,Ortho sidebar disconnect,All Other,Per Unit,$449.90 ,OP,130.78,449.9,,,,,,
BCBS Blue Choice,CPT,L2770,Low ext orthosis per bar/jnt,All Other,Per Unit,$198.25 ,OP,198.25,198.25,,,,,,
BCBS Blue Choice,CPT,L2780,Non-corrosive finish,All Other,Per Unit,$217.32 ,OP,63.53,217.32,,,,,,
BCBS Blue Choice,CPT,L2785,Drop lock retainer each,All Other,Per Unit,$102.95 ,OP,29.75,102.95,,,,,,
BCBS Blue Choice,CPT,L2795,Knee control full kneecap,All Other,Per Unit,$282.14 ,OP,82.32,282.14,,,,,,
BCBS Blue Choice,CPT,L2810,Knee control condylar pad,All Other,Per Unit,$282.14 ,OP,81.98,282.14,,,,,,
BCBS Blue Choice,CPT,L2820,Soft interface below knee se,All Other,Per Unit,$282.14 ,OP,81.51,282.14,,,,,,
BCBS Blue Choice,CPT,L2830,Soft interface above knee se,All Other,Per Unit,$305.01 ,OP,88.18,305.01,,,,,,
BCBS Blue Choice,CPT,L2840,Tibial length sock fx or equ,All Other,Per Unit,$148.69 ,OP,43.3,148.69,,,,,,
BCBS Blue Choice,CPT,L2850,Femoral lgth sock fx or equa,All Other,Per Unit,$209.70 ,OP,60.72,209.7,,,,,,
BCBS Blue Choice,CPT,L3000,Ft insert ucb berkeley shell,All Other,Per Unit,"$1,082.81 ",OP,315.34,"1,082.81",,,,,,
BCBS Blue Choice,CPT,L3001,Foot insert remov molded spe,All Other,Per Unit,$686.28 ,OP,132.78,686.28,,,,,,
BCBS Blue Choice,CPT,L3002,Foot insert plastazote or eq,All Other,Per Unit,$834.98 ,OP,162.12,834.98,,,,,,
BCBS Blue Choice,CPT,L3003,Foot insert silicone gel eac,All Other,Per Unit,$903.60 ,OP,174.89,903.6,,,,,,
BCBS Blue Choice,CPT,L3010,Foot longitudinal arch suppo,All Other,Per Unit,$903.60 ,OP,174.89,903.6,,,,,,
BCBS Blue Choice,CPT,L3020,Foot longitud/metatarsal sup,All Other,Per Unit,"$1,025.61 ",OP,199.16,"1,025.61",,,,,,
BCBS Blue Choice,CPT,L3030,Foot arch support remov prem,All Other,Per Unit,"$1,239.13 ",OP,76.59,"1,239.13",,,,,,
BCBS Blue Choice,CPT,L3031,Foot lamin/prepreg composite,All Other,Per Unit,"$1,334.45 ",OP,122.94,"1,334.45",,,,,,
BCBS Blue Choice,CPT,L3040,Ft arch suprt premold longit,All Other,Per Unit,$163.95 ,OP,47.25,163.95,,,,,,
BCBS Blue Choice,CPT,L3050,Foot arch supp premold metat,All Other,Per Unit,$163.95 ,OP,47.25,163.95,,,,,,
BCBS Blue Choice,CPT,L3060,Foot arch supp longitud/meta,All Other,Per Unit,$255.45 ,OP,74.04,255.45,,,,,,
BCBS Blue Choice,CPT,L3070,Arch suprt att to sho longit,All Other,Per Unit,$110.57 ,OP,31.91,110.57,,,,,,
BCBS Blue Choice,CPT,L3080,Arch supp att to shoe metata,All Other,Per Unit,$110.57 ,OP,31.91,110.57,,,,,,
BCBS Blue Choice,CPT,L3090,Arch supp att to shoe long/m,All Other,Per Unit,$141.07 ,OP,40.86,141.07,,,,,,
BCBS Blue Choice,CPT,L3100,Hallus-valgus nt dyn pre ots,All Other,Per Unit,$148.69 ,OP,43.43,148.69,,,,,,
BCBS Blue Choice,CPT,L3140,Abduction rotation bar shoe,All Other,Per Unit,$308.83 ,OP,89.37,308.83,,,,,,
BCBS Blue Choice,CPT,L3150,Abduct rotation bar w/o shoe,All Other,Per Unit,$282.14 ,OP,81.72,282.14,,,,,,
BCBS Blue Choice,CPT,L3160,Shoe styled positioning dev,All Other,Per Unit,$541.40 ,OP,541.4,541.4,,,,,,
BCBS Blue Choice,CPT,L3170,Foot plas heel stabi pre ots,All Other,Per Unit,$175.39 ,OP,51.06,175.39,,,,,,
BCBS Blue Choice,CPT,L3201,Oxford w supinat/pronat inf,All Other,Per Unit,$266.89 ,OP,266.89,266.89,,,,,,
BCBS Blue Choice,CPT,L3202,Oxford w/ supinat/pronator c,All Other,Per Unit,$427.03 ,OP,427.03,427.03,,,,,,
BCBS Blue Choice,CPT,L3203,Oxford w/ supinator/pronator,All Other,Per Unit,$266.89 ,OP,266.89,266.89,,,,,,
BCBS Blue Choice,CPT,L3204,Hightop w/ supp/pronator inf,All Other,Per Unit,$495.65 ,OP,495.65,495.65,,,,,,
BCBS Blue Choice,CPT,L3206,Hightop w/ supp/pronator chi,All Other,Per Unit,$339.33 ,OP,339.33,339.33,,,,,,
BCBS Blue Choice,CPT,L3207,Hightop w/ supp/pronator jun,All Other,Per Unit,$343.14 ,OP,343.14,343.14,,,,,,
BCBS Blue Choice,CPT,L3208,Surgical boot each infant,All Other,Per Unit,$247.83 ,OP,247.83,247.83,,,,,,
BCBS Blue Choice,CPT,L3209,Surgical boot each child,All Other,Per Unit,$171.58 ,OP,171.58,171.58,,,,,,
BCBS Blue Choice,CPT,L3211,Surgical boot each junior,All Other,Per Unit,$156.32 ,OP,156.32,156.32,,,,,,
BCBS Blue Choice,CPT,L3212,Benesch boot pair infant,All Other,Per Unit,$247.83 ,OP,247.83,247.83,,,,,,
BCBS Blue Choice,CPT,L3213,Benesch boot pair child,All Other,Per Unit,$285.96 ,OP,285.96,285.96,,,,,,
BCBS Blue Choice,CPT,L3214,Benesch boot pair junior,All Other,Per Unit,$381.27 ,OP,381.27,381.27,,,,,,
BCBS Blue Choice,CPT,L3215,Orthopedic ftwear ladies oxf,All Other,Per Unit,$762.54 ,OP,762.54,762.54,,,,,,
BCBS Blue Choice,CPT,L3216,Orthoped ladies shoes dpth i,All Other,Per Unit,$430.83 ,OP,430.83,430.83,,,,,,
BCBS Blue Choice,CPT,L3217,Ladies shoes hightop depth i,All Other,Per Unit,$381.27 ,OP,381.27,381.27,,,,,,
BCBS Blue Choice,CPT,L3221,Orthopedic mens shoes dpth i,All Other,Per Unit,$953.17 ,OP,953.17,953.17,,,,,,
BCBS Blue Choice,CPT,L3224,Woman's shoe oxford brace,All Other,Per Unit,$232.58 ,OP,67.83,232.58,,,,,,
BCBS Blue Choice,CPT,L3225,Man's shoe oxford brace,All Other,Per Unit,$255.45 ,OP,74.09,255.45,,,,,,
BCBS Blue Choice,CPT,L3250,Custom mold shoe remov prost,All Other,Per Unit,"$1,906.36 ",OP,"1,906.36","1,906.36",,,,,,
BCBS Blue Choice,CPT,L3253,Shoe molded plastazote cust,All Other,Per Unit,$190.64 ,OP,190.64,190.64,,,,,,
BCBS Blue Choice,CPT,L3254,Orth foot non-stndard size/w,All Other,Per Unit,$133.45 ,OP,133.45,133.45,,,,,,
BCBS Blue Choice,CPT,L3255,Orth foot non-standard size/,All Other,Per Unit,$133.45 ,OP,133.45,133.45,,,,,,
BCBS Blue Choice,CPT,L3257,Orth foot add charge split s,All Other,Per Unit,$247.83 ,OP,247.83,247.83,,,,,,
BCBS Blue Choice,CPT,L3260,Ambulatory surgical boot eac,All Other,Per Unit,$190.64 ,OP,190.64,190.64,,,,,,
BCBS Blue Choice,CPT,L3265,Plastazote sandal each,All Other,Per Unit,$133.45 ,OP,133.45,133.45,,,,,,
BCBS Blue Choice,CPT,L3300,Sho lift taper to metatarsal,All Other,Per Unit,$179.20 ,OP,52.35,179.2,,,,,,
BCBS Blue Choice,CPT,L3310,Shoe lift elev heel/sole neo,All Other,Per Unit,$282.14 ,OP,81.72,282.14,,,,,,
BCBS Blue Choice,CPT,L3320,Shoe lift elev heel/sole cor,All Other,Per Unit,$45.74 ,OP,45.74,45.74,,,,,,
BCBS Blue Choice,CPT,L3330,Lifts elevation metal extens,All Other,Per Unit,"$1,952.10 ",OP,568.1,"1,952.10",,,,,,
BCBS Blue Choice,CPT,L3332,Shoe lifts tapered to one-ha,All Other,Per Unit,$255.45 ,OP,74.04,255.45,,,,,,
BCBS Blue Choice,CPT,L3334,Shoe lifts elevation heel /i,All Other,Per Unit,$133.45 ,OP,38.28,133.45,,,,,,
BCBS Blue Choice,CPT,L3340,Shoe wedge sach,All Other,Per Unit,$293.57 ,OP,85.56,293.57,,,,,,
BCBS Blue Choice,CPT,L3350,Shoe heel wedge,All Other,Per Unit,$80.07 ,OP,22.96,80.07,,,,,,
BCBS Blue Choice,CPT,L3360,Shoe sole wedge outside sole,All Other,Per Unit,$122.00 ,OP,35.74,122,,,,,,
BCBS Blue Choice,CPT,L3370,Shoe sole wedge between sole,All Other,Per Unit,$171.58 ,OP,49.79,171.58,,,,,,
BCBS Blue Choice,CPT,L3380,Shoe clubfoot wedge,All Other,Per Unit,$171.58 ,OP,49.79,171.58,,,,,,
BCBS Blue Choice,CPT,L3390,Shoe outflare wedge,All Other,Per Unit,$171.58 ,OP,49.79,171.58,,,,,,
BCBS Blue Choice,CPT,L3400,Shoe metatarsal bar wedge ro,All Other,Per Unit,$141.07 ,OP,40.86,141.07,,,,,,
BCBS Blue Choice,CPT,L3410,Shoe metatarsal bar between,All Other,Per Unit,$320.27 ,OP,93.19,320.27,,,,,,
BCBS Blue Choice,CPT,L3420,Full sole/heel wedge btween,All Other,Per Unit,$190.64 ,OP,54.9,190.64,,,,,,
BCBS Blue Choice,CPT,L3430,Sho heel count plast reinfor,All Other,Per Unit,$552.84 ,OP,160.86,552.84,,,,,,
BCBS Blue Choice,CPT,L3440,Heel leather reinforced,All Other,Per Unit,$263.08 ,OP,76.59,263.08,,,,,,
BCBS Blue Choice,CPT,L3455,Shoe heel new leather standa,All Other,Per Unit,$141.07 ,OP,40.86,141.07,,,,,,
BCBS Blue Choice,CPT,L3460,Shoe heel new rubber standar,All Other,Per Unit,$118.19 ,OP,34.49,118.19,,,,,,
BCBS Blue Choice,CPT,L3465,Shoe heel thomas with wedge,All Other,Per Unit,$202.07 ,OP,58.76,202.07,,,,,,
BCBS Blue Choice,CPT,L3470,Shoe heel thomas extend to b,All Other,Per Unit,$213.51 ,OP,62.54,213.51,,,,,,
BCBS Blue Choice,CPT,L3480,Shoe heel pad & depress for,All Other,Per Unit,$213.51 ,OP,62.54,213.51,,,,,,
BCBS Blue Choice,CPT,L3485,Shoe heel pad removable for,All Other,Per Unit,$190.64 ,OP,190.64,190.64,,,,,,
BCBS Blue Choice,CPT,L3500,Ortho shoe add leather insol,All Other,Per Unit,$99.13 ,OP,29.35,99.13,,,,,,
BCBS Blue Choice,CPT,L3510,Orthopedic shoe add rub insl,All Other,Per Unit,$99.13 ,OP,29.35,99.13,,,,,,
BCBS Blue Choice,CPT,L3520,O shoe add felt w leath insl,All Other,Per Unit,$110.57 ,OP,31.91,110.57,,,,,,
BCBS Blue Choice,CPT,L3530,Ortho shoe add half sole,All Other,Per Unit,$110.57 ,OP,31.91,110.57,,,,,,
BCBS Blue Choice,CPT,L3540,Ortho shoe add full sole,All Other,Per Unit,$175.39 ,OP,51.06,175.39,,,,,,
BCBS Blue Choice,CPT,L3550,O shoe add standard toe tap,All Other,Per Unit,$30.51 ,OP,8.97,30.51,,,,,,
BCBS Blue Choice,CPT,L3560,O shoe add horseshoe toe tap,All Other,Per Unit,$80.07 ,OP,22.96,80.07,,,,,,
BCBS Blue Choice,CPT,L3570,O shoe add instep extension,All Other,Per Unit,$293.57 ,OP,85.56,293.57,,,,,,
BCBS Blue Choice,CPT,L3580,O shoe add instep velcro clo,All Other,Per Unit,$224.95 ,OP,65.11,224.95,,,,,,
BCBS Blue Choice,CPT,L3590,O shoe convert to sof counte,All Other,Per Unit,$183.02 ,OP,53.63,183.02,,,,,,
BCBS Blue Choice,CPT,L3595,Ortho shoe add march bar,All Other,Per Unit,$144.88 ,OP,42.1,144.88,,,,,,
BCBS Blue Choice,CPT,L3600,Trans shoe calip plate exist,All Other,Per Unit,$263.08 ,OP,76.59,263.08,,,,,,
BCBS Blue Choice,CPT,L3610,Trans shoe caliper plate new,All Other,Per Unit,$346.96 ,OP,100.86,346.96,,,,,,
BCBS Blue Choice,CPT,L3620,Trans shoe solid stirrup exi,All Other,Per Unit,$263.08 ,OP,76.59,263.08,,,,,,
BCBS Blue Choice,CPT,L3630,Trans shoe solid stirrup new,All Other,Per Unit,$346.96 ,OP,100.86,346.96,,,,,,
BCBS Blue Choice,CPT,L3640,Shoe dennis browne splint bo,All Other,Per Unit,$148.69 ,OP,43.43,148.69,,,,,,
BCBS Blue Choice,CPT,L3650,So 8 abd restraint pre ots,All Other,Per Unit,$224.95 ,OP,65.83,224.95,,,,,,
BCBS Blue Choice,CPT,L3651,Prefab shoulder orthosis,All Other,Per Unit,$205.88 ,OP,205.88,205.88,,,,,,
BCBS Blue Choice,CPT,L3652,Prefab dbl shoulder orthosis,All Other,Per Unit,$625.29 ,OP,625.29,625.29,,,,,,
BCBS Blue Choice,CPT,L3660,So 8 ab rstr can/web pre ots,All Other,Per Unit,$324.09 ,OP,94.4,324.09,,,,,,
BCBS Blue Choice,CPT,L3670,So acro/clav can web pre ots,All Other,Per Unit,$358.39 ,OP,103.86,358.39,,,,,,
BCBS Blue Choice,CPT,L3671,So cap design w/o jnts cf,All Other,Per Unit,"$2,832.83 ",OP,823.17,"2,832.83",,,,,,
BCBS Blue Choice,CPT,L3672,SO airplane w/o jnts CF,All Other,Per Unit,"$3,519.12 ",OP,"3,519.12","3,519.12",,,,,,
BCBS Blue Choice,CPT,L3673,SO airplane w/joint CF,All Other,Per Unit,"$3,835.57 ",OP,"3,835.57","3,835.57",,,,,,
BCBS Blue Choice,CPT,L3675,So vest canvas/web pre ots,All Other,Per Unit,$552.84 ,OP,160.35,552.84,,,,,,
BCBS Blue Choice,CPT,L3700,Elbow orthoses elas w stays,All Other,Per Unit,$240.20 ,OP,240.2,240.2,,,,,,
BCBS Blue Choice,CPT,L3701,Prefab elbow orthosis,All Other,Per Unit,$64.82 ,OP,64.82,64.82,,,,,,
BCBS Blue Choice,CPT,L3702,Eo w/o joints cf,All Other,Per Unit,$907.42 ,OP,263.81,907.42,,,,,,
BCBS Blue Choice,CPT,L3710,Eo elas w/metal jnts pre ots,All Other,Per Unit,$449.90 ,OP,130.45,449.9,,,,,,
BCBS Blue Choice,CPT,L3720,Forearm/arm cuffs free motio,All Other,Per Unit,"$2,146.54 ",OP,624.22,"2,146.54",,,,,,
BCBS Blue Choice,CPT,L3730,Forearm/arm cuffs ext/flex a,All Other,Per Unit,"$2,848.08 ",OP,827.96,"2,848.08",,,,,,
BCBS Blue Choice,CPT,L3740,Cuffs adj lock w/ active con,All Other,Per Unit,"$3,374.24 ",OP,981.62,"3,374.24",,,,,,
BCBS Blue Choice,CPT,L3760,Eo adj jt prefab custom fit,All Other,Per Unit,"$1,570.83 ",OP,456.89,"1,570.83",,,,,,
BCBS Blue Choice,CPT,L3762,Eo rigid w/o joints pre ots,All Other,Per Unit,$339.33 ,OP,98.22,339.33,,,,,,
BCBS Blue Choice,CPT,L3763,Ewho rigid w/o jnts cf,All Other,Per Unit,"$2,352.44 ",OP,683.66,"2,352.44",,,,,,
BCBS Blue Choice,CPT,L3764,Ewho w/joint(s) cf,All Other,Per Unit,"$2,459.19 ",OP,715.47,"2,459.19",,,,,,
BCBS Blue Choice,CPT,L3765,Ewhfo rigid w/o jnts cf,All Other,Per Unit,"$4,030.02 ",OP,"1,171.43","4,030.02",,,,,,
BCBS Blue Choice,CPT,L3766,Ewhfo w/joint(s) cf,All Other,Per Unit,"$4,266.40 ",OP,"1,240.47","4,266.40",,,,,,
BCBS Blue Choice,CPT,L3806,Whfo w/joint(s) custom fab,All Other,Per Unit,"$1,425.95 ",OP,414.97,"1,425.95",,,,,,
BCBS Blue Choice,CPT,L3807,Whfo w/o joints pre cst,All Other,Per Unit,$785.42 ,OP,228.43,785.42,,,,,,
BCBS Blue Choice,CPT,L3808,Whfo- rigid w/o joints,All Other,Per Unit,"$1,120.94 ",OP,325.43,"1,120.94",,,,,,
BCBS Blue Choice,CPT,L3900,Hinge extension/flex wrist/f,All Other,Per Unit,"$5,089.95 ",OP,"1,479.93","5,089.95",,,,,,
BCBS Blue Choice,CPT,L3901,Hinge ext/flex wrist finger,All Other,Per Unit,"$6,668.40 ",OP,"1,939.53","6,668.40",,,,,,
BCBS Blue Choice,CPT,L3904,Whfo electric custom fitted,All Other,Per Unit,"$10,603.11 ",OP,"3,083.64","10,603.11",,,,,,
BCBS Blue Choice,CPT,L3905,Who w/nontorsion jnt(s) cf,All Other,Per Unit,"$3,114.97 ",OP,905.97,"3,114.97",,,,,,
BCBS Blue Choice,CPT,L3906,Who w/o joints cf,All Other,Per Unit,"$1,593.72 ",OP,462.97,"1,593.72",,,,,,
BCBS Blue Choice,CPT,L3908,Who cock-up nonmolde pre ots,All Other,Per Unit,$228.77 ,OP,66.98,228.77,,,,,,
BCBS Blue Choice,CPT,L3909,Prefab wrist orthosis,All Other,Per Unit,$45.74 ,OP,45.74,45.74,,,,,,
BCBS Blue Choice,CPT,L3911,Prefab hand finger orthosis,All Other,Per Unit,$76.26 ,OP,76.26,76.26,,,,,,
BCBS Blue Choice,CPT,L3912,Hfo flexion glove pre ots,All Other,Per Unit,$331.70 ,OP,96.25,331.7,,,,,,
BCBS Blue Choice,CPT,L3913,Hfo w/o joints cf,All Other,Per Unit,$850.23 ,OP,247.41,850.23,,,,,,
BCBS Blue Choice,CPT,L3915,Who nontorsion jnts pre cst,All Other,Per Unit,"$1,669.97 ",OP,485.63,"1,669.97",,,,,,
BCBS Blue Choice,CPT,L3917,Metacarp fx orthosis pre cst,All Other,Per Unit,$331.70 ,OP,96.47,331.7,,,,,,
BCBS Blue Choice,CPT,L3919,Ho w/o joints cf,All Other,Per Unit,$850.23 ,OP,247.41,850.23,,,,,,
BCBS Blue Choice,CPT,L3921,Hfo w/joint(s) cf,All Other,Per Unit,"$1,010.37 ",OP,293.46,"1,010.37",,,,,,
BCBS Blue Choice,CPT,L3923,Hfo without joints pre cst,All Other,Per Unit,$305.01 ,OP,88.25,305.01,,,,,,
BCBS Blue Choice,CPT,L3925,Fo pip dip jnt/sprng pre ots,All Other,Per Unit,$205.88 ,OP,60.01,205.88,,,,,,
BCBS Blue Choice,CPT,L3927,Fo pip dip no jt spr pre ots,All Other,Per Unit,$110.57 ,OP,31.98,110.57,,,,,,
BCBS Blue Choice,CPT,L3929,Hfo nontorsion jnts pre cst,All Other,Per Unit,$285.96 ,OP,83.44,285.96,,,,,,
BCBS Blue Choice,CPT,L3931,Whfo nontorsion joint prefab,All Other,Per Unit,$655.78 ,OP,190.48,655.78,,,,,,
BCBS Blue Choice,CPT,L3933,Fo w/o joints cf,All Other,Per Unit,$671.03 ,OP,194.93,671.03,,,,,,
BCBS Blue Choice,CPT,L3935,Fo nontorsion joint cf,All Other,Per Unit,$693.90 ,OP,201.82,693.9,,,,,,
BCBS Blue Choice,CPT,L3960,Sewho airplan desig abdu pos,All Other,Per Unit,"$2,504.94 ",OP,728.64,"2,504.94",,,,,,
BCBS Blue Choice,CPT,L3961,Sewho cap design w/o jnts cf,All Other,Per Unit,"$5,280.58 ",OP,"1,534.92","5,280.58",,,,,,
BCBS Blue Choice,CPT,L3962,Sewho erbs palsey design abd,All Other,Per Unit,"$2,264.75 ",OP,659,"2,264.75",,,,,,
BCBS Blue Choice,CPT,L3967,Sewho airplane w/o jnts cf,All Other,Per Unit,"$6,233.76 ",OP,"1,812.20","6,233.76",,,,,,
BCBS Blue Choice,CPT,L3971,Sewho cap design w/jnt(s) cf,All Other,Per Unit,"$5,917.29 ",OP,"1,720.20","5,917.29",,,,,,
BCBS Blue Choice,CPT,L3973,Sewho airplane w/jnt(s) cf,All Other,Per Unit,"$6,233.76 ",OP,"1,812.20","6,233.76",,,,,,
BCBS Blue Choice,CPT,L3975,Sewhfo cap design w/o jnt cf,All Other,Per Unit,"$5,280.58 ",OP,"1,534.92","5,280.58",,,,,,
BCBS Blue Choice,CPT,L3976,Sewhfo airplane w/o jnts cf,All Other,Per Unit,"$5,280.58 ",OP,"1,534.92","5,280.58",,,,,,
BCBS Blue Choice,CPT,L3977,Sewhfo cap desgn w/jnt(s) cf,All Other,Per Unit,"$5,917.29 ",OP,"1,720.20","5,917.29",,,,,,
BCBS Blue Choice,CPT,L3978,Sewhfo airplane w/jnt(s) cf,All Other,Per Unit,"$6,233.76 ",OP,"1,812.20","6,233.76",,,,,,
BCBS Blue Choice,CPT,L3980,Up ext fx orthos humeral nos,All Other,Per Unit,"$1,216.24 ",OP,353.43,"1,216.24",,,,,,
BCBS Blue Choice,CPT,L3982,Upper ext fx orthosis rad/ul,All Other,Per Unit,"$1,235.32 ",OP,358.87,"1,235.32",,,,,,
BCBS Blue Choice,CPT,L3984,Upper ext fx orthosis wrist,All Other,Per Unit,"$1,086.62 ",OP,316.13,"1,086.62",,,,,,
BCBS Blue Choice,CPT,L3995,Sock fracture or equal each,All Other,Per Unit,$129.64 ,OP,37.51,129.64,,,,,,
BCBS Blue Choice,CPT,L4000,Repl girdle milwaukee orth,All Other,Per Unit,"$4,559.97 ",OP,"1,326.47","4,559.97",,,,,,
BCBS Blue Choice,CPT,L4002,Replace strap- any orthosis,All Other,Per Unit,$114.39 ,OP,114.39,114.39,,,,,,
BCBS Blue Choice,CPT,L4010,Replace trilateral socket br,All Other,Per Unit,"$2,771.83 ",OP,806.25,"2,771.83",,,,,,
BCBS Blue Choice,CPT,L4020,Replace quadlat socket brim,All Other,Per Unit,"$3,332.30 ",OP,968.52,"3,332.30",,,,,,
BCBS Blue Choice,CPT,L4030,Replace socket brim cust fit,All Other,Per Unit,"$2,116.06 ",OP,615.47,"2,116.06",,,,,,
BCBS Blue Choice,CPT,L4040,Replace molded thigh lacer,All Other,Per Unit,"$1,433.58 ",OP,416.8,"1,433.58",,,,,,
BCBS Blue Choice,CPT,L4045,Replace non-molded thigh lac,All Other,Per Unit,"$1,059.93 ",OP,307.89,"1,059.93",,,,,,
BCBS Blue Choice,CPT,L4050,Replace molded calf lacer,All Other,Per Unit,"$1,418.32 ",OP,412.8,"1,418.32",,,,,,
BCBS Blue Choice,CPT,L4055,Replace non-molded calf lace,All Other,Per Unit,$861.67 ,OP,250.92,861.67,,,,,,
BCBS Blue Choice,CPT,L4060,Replace high roll cuff,All Other,Per Unit,"$1,120.94 ",OP,326.17,"1,120.94",,,,,,
BCBS Blue Choice,CPT,L4070,Replace prox & dist upright,All Other,Per Unit,$907.42 ,OP,264.15,907.42,,,,,,
BCBS Blue Choice,CPT,L4080,Repl met band kafo-afo prox,All Other,Per Unit,$343.14 ,OP,99.72,343.14,,,,,,
BCBS Blue Choice,CPT,L4090,Repl met band kafo-afo calf/,All Other,Per Unit,$293.57 ,OP,84.84,293.57,,,,,,
BCBS Blue Choice,CPT,L4100,Repl leath cuff kafo prox th,All Other,Per Unit,$350.76 ,OP,101.94,350.76,,,,,,
BCBS Blue Choice,CPT,L4110,Repl leath cuff kafo-afo cal,All Other,Per Unit,$274.51 ,OP,79.6,274.51,,,,,,
BCBS Blue Choice,CPT,L4130,Replace pretibial shell,All Other,Per Unit,"$1,654.72 ",OP,481.14,"1,654.72",,,,,,
BCBS Blue Choice,CPT,L4205,Ortho dvc repair per 15 min,All Other,Per Unit,$701.54 ,OP,701.54,701.54,,,,,,
BCBS Blue Choice,CPT,L4210,Orth dev repair/repl minor p,All Other,Per Unit,$362.21 ,OP,362.21,362.21,,,,,,
BCBS Blue Choice,CPT,L4350,Ankle control ortho pre ots,All Other,Per Unit,$335.53 ,OP,97.13,335.53,,,,,,
BCBS Blue Choice,CPT,L4360,Pneumat walking boot pre cst,All Other,Per Unit,$892.18 ,OP,259.89,892.18,,,,,,
BCBS Blue Choice,CPT,L4370,Pneum full leg splnt pre ots,All Other,Per Unit,$812.11 ,OP,236.26,812.11,,,,,,
BCBS Blue Choice,CPT,L4380,Pneumatic knee splint,All Other,Per Unit,$396.52 ,OP,396.52,396.52,,,,,,
BCBS Blue Choice,CPT,L4386,Non-pneum walk boot pre cst,All Other,Per Unit,$549.03 ,OP,159.16,549.03,,,,,,
BCBS Blue Choice,CPT,L4392,Replace afo soft interface,All Other,Per Unit,$80.07 ,OP,23.62,80.07,,,,,,
BCBS Blue Choice,CPT,L4394,Replace foot drop spint,All Other,Per Unit,$61.00 ,OP,17.23,61,,,,,,
BCBS Blue Choice,CPT,L4396,Static or dynami afo pre cst,All Other,Per Unit,$579.53 ,OP,168.46,579.53,,,,,,
BCBS Blue Choice,CPT,L4398,Foot drop splint pre ots,All Other,Per Unit,$266.89 ,OP,77.54,266.89,,,,,,
BCBS Blue Choice,CPT,L5000,Sho insert w arch toe filler,All Other,Per Unit,"$1,982.60 ",OP,576.42,"1,982.60",,,,,,
BCBS Blue Choice,CPT,L5010,Mold socket ank hgt w/ toe f,All Other,Per Unit,"$5,539.84 ",OP,"1,610.60","5,539.84",,,,,,
BCBS Blue Choice,CPT,L5020,Tibial tubercle hgt w/ toe f,All Other,Per Unit,"$8,677.68 ",OP,"2,523.29","8,677.68",,,,,,
BCBS Blue Choice,CPT,L5050,Ank symes mold sckt sach ft,All Other,Per Unit,"$9,478.35 ",OP,"2,755.91","9,478.35",,,,,,
BCBS Blue Choice,CPT,L5060,Symes met fr leath socket ar,All Other,Per Unit,"$11,682.09 ",OP,"3,397.24","11,682.09",,,,,,
BCBS Blue Choice,CPT,L5100,Molded socket shin sach foot,All Other,Per Unit,"$9,436.43 ",OP,"2,744.12","9,436.43",,,,,,
BCBS Blue Choice,CPT,L5105,Plast socket jts/thgh lacer,All Other,Per Unit,"$13,317.74 ",OP,"3,872.55","13,317.74",,,,,,
BCBS Blue Choice,CPT,L5150,Mold sckt ext knee shin sach,All Other,Per Unit,"$14,804.69 ",OP,"4,305.35","14,804.69",,,,,,
BCBS Blue Choice,CPT,L5160,Mold socket bent knee shin s,All Other,Per Unit,"$16,257.32 ",OP,"4,727.07","16,257.32",,,,,,
BCBS Blue Choice,CPT,L5200,Kne sing axis fric shin sach,All Other,Per Unit,"$12,574.26 ",OP,"3,656.04","12,574.26",,,,,,
BCBS Blue Choice,CPT,L5210,No knee/ankle joints w/ ft b,All Other,Per Unit,"$9,981.64 ",OP,"2,902.89","9,981.64",,,,,,
BCBS Blue Choice,CPT,L5220,No knee joint with artic ali,All Other,Per Unit,"$10,995.81 ",OP,"3,197.74","10,995.81",,,,,,
BCBS Blue Choice,CPT,L5230,Fem focal defic constant fri,All Other,Per Unit,"$16,493.71 ",OP,"4,796.11","16,493.71",,,,,,
BCBS Blue Choice,CPT,L5250,Hip canad sing axi cons fric,All Other,Per Unit,"$19,341.79 ",OP,"5,623.57","19,341.79",,,,,,
BCBS Blue Choice,CPT,L5270,Tilt table locking hip sing,All Other,Per Unit,"$21,549.33 ",OP,"6,265.76","21,549.33",,,,,,
BCBS Blue Choice,CPT,L5280,Hemipelvect canad sing axis,All Other,Per Unit,"$20,946.94 ",OP,"6,090.55","20,946.94",,,,,,
BCBS Blue Choice,CPT,L5301,Bk mold socket sach ft endo,All Other,Per Unit,"$9,268.66 ",OP,"2,694.66","9,268.66",,,,,,
BCBS Blue Choice,CPT,L5311,"Knee disart, SACH ft, endo",All Other,Per Unit,"$14,602.61 ",OP,"14,602.61","14,602.61",,,,,,
BCBS Blue Choice,CPT,L5321,Ak open end sach,All Other,Per Unit,"$12,356.94 ",OP,"3,593.24","12,356.94",,,,,,
BCBS Blue Choice,CPT,L5331,Hip disart canadian sach ft,All Other,Per Unit,"$18,098.85 ",OP,"5,262.80","18,098.85",,,,,,
BCBS Blue Choice,CPT,L5341,Hemipelvectomy canadian sach,All Other,Per Unit,"$19,238.85 ",OP,"5,594.28","19,238.85",,,,,,
BCBS Blue Choice,CPT,L5400,Postop dress & 1 cast chg bk,All Other,Per Unit,"$5,516.97 ",OP,"1,604.68","5,516.97",,,,,,
BCBS Blue Choice,CPT,L5410,Postop dsg bk ea add cast ch,All Other,Per Unit,"$1,525.07 ",OP,443.32,"1,525.07",,,,,,
BCBS Blue Choice,CPT,L5420,Postop dsg & 1 cast chg ak/d,All Other,Per Unit,"$6,969.60 ",OP,"2,026.64","6,969.60",,,,,,
BCBS Blue Choice,CPT,L5430,Postop dsg ak ea add cast ch,All Other,Per Unit,"$1,891.10 ",OP,550.12,"1,891.10",,,,,,
BCBS Blue Choice,CPT,L5450,Postop app non-wgt bear dsg,All Other,Per Unit,"$1,635.64 ",OP,475.67,"1,635.64",,,,,,
BCBS Blue Choice,CPT,L5460,Postop app non-wgt bear dsg,All Other,Per Unit,"$2,146.54 ",OP,623.89,"2,146.54",,,,,,
BCBS Blue Choice,CPT,L5500,Init bk ptb plaster direct,All Other,Per Unit,"$5,101.39 ",OP,"1,483.19","5,101.39",,,,,,
BCBS Blue Choice,CPT,L5505,Init ak ischal plstr direct,All Other,Per Unit,"$7,175.49 ",OP,"2,086.44","7,175.49",,,,,,
BCBS Blue Choice,CPT,L5510,Prep bk ptb plaster molded,All Other,Per Unit,"$6,092.69 ",OP,"1,771.18","6,092.69",,,,,,
BCBS Blue Choice,CPT,L5520,Perp bk ptb thermopls direct,All Other,Per Unit,"$5,459.77 ",OP,"1,587.65","5,459.77",,,,,,
BCBS Blue Choice,CPT,L5530,Prep bk ptb thermopls molded,All Other,Per Unit,"$7,179.30 ",OP,"2,087.07","7,179.30",,,,,,
BCBS Blue Choice,CPT,L5535,Prep bk ptb open end socket,All Other,Per Unit,"$6,691.29 ",OP,"1,945.59","6,691.29",,,,,,
BCBS Blue Choice,CPT,L5540,Prep bk ptb laminated socket,All Other,Per Unit,"$7,087.80 ",OP,"2,060.66","7,087.80",,,,,,
BCBS Blue Choice,CPT,L5560,Prep ak ischial plast molded,All Other,Per Unit,"$8,075.28 ",OP,"2,348.01","8,075.28",,,,,,
BCBS Blue Choice,CPT,L5570,Prep ak ischial direct form,All Other,Per Unit,"$7,838.89 ",OP,"2,278.83","7,838.89",,,,,,
BCBS Blue Choice,CPT,L5580,Prep ak ischial thermo mold,All Other,Per Unit,"$9,726.18 ",OP,"2,828.36","9,726.18",,,,,,
BCBS Blue Choice,CPT,L5585,Prep ak ischial open end,All Other,Per Unit,"$11,392.33 ",OP,"3,312.24","11,392.33",,,,,,
BCBS Blue Choice,CPT,L5590,Prep ak ischial laminated,All Other,Per Unit,"$10,141.77 ",OP,"2,948.85","10,141.77",,,,,,
BCBS Blue Choice,CPT,L5595,Hip disartic sach thermopls,All Other,Per Unit,"$15,849.36 ",OP,"4,608.29","15,849.36",,,,,,
BCBS Blue Choice,CPT,L5600,Hip disart sach laminat mold,All Other,Per Unit,"$18,037.85 ",OP,"5,244.91","18,037.85",,,,,,
BCBS Blue Choice,CPT,L5610,Above knee hydracadence,All Other,Per Unit,"$8,700.56 ",OP,"2,529.59","8,700.56",,,,,,
BCBS Blue Choice,CPT,L5611,Ak 4 bar link w/fric swing,All Other,Per Unit,"$5,539.84 ",OP,"1,611.13","5,539.84",,,,,,
BCBS Blue Choice,CPT,L5613,Ak 4 bar ling w/hydraul swig,All Other,Per Unit,"$8,429.87 ",OP,"2,450.64","8,429.87",,,,,,
BCBS Blue Choice,CPT,L5614,4-bar link above knee w/swng,All Other,Per Unit,"$5,837.23 ",OP,"1,697.23","5,837.23",,,,,,
BCBS Blue Choice,CPT,L5616,Ak univ multiplex sys frict,All Other,Per Unit,"$5,082.32 ",OP,"1,477.66","5,082.32",,,,,,
BCBS Blue Choice,CPT,L5617,Ak/bk self-aligning unit ea,All Other,Per Unit,"$1,936.85 ",OP,562.74,"1,936.85",,,,,,
BCBS Blue Choice,CPT,L5618,Test socket symes,All Other,Per Unit,"$1,155.24 ",OP,336.06,"1,155.24",,,,,,
BCBS Blue Choice,CPT,L5620,Test socket below knee,All Other,Per Unit,"$1,025.61 ",OP,298.16,"1,025.61",,,,,,
BCBS Blue Choice,CPT,L5622,Test socket knee disarticula,All Other,Per Unit,"$1,380.19 ",OP,401.7,"1,380.19",,,,,,
BCBS Blue Choice,CPT,L5624,Test socket above knee,All Other,Per Unit,"$1,380.19 ",OP,401.54,"1,380.19",,,,,,
BCBS Blue Choice,CPT,L5626,Test socket hip disarticulat,All Other,Per Unit,"$2,184.67 ",OP,635.7,"2,184.67",,,,,,
BCBS Blue Choice,CPT,L5628,Test socket hemipelvectomy,All Other,Per Unit,"$2,215.19 ",OP,643.74,"2,215.19",,,,,,
BCBS Blue Choice,CPT,L5629,Below knee acrylic socket,All Other,Per Unit,"$1,094.25 ",OP,317.79,"1,094.25",,,,,,
BCBS Blue Choice,CPT,L5630,Syme typ expandabl wall sckt,All Other,Per Unit,"$1,898.73 ",OP,552.17,"1,898.73",,,,,,
BCBS Blue Choice,CPT,L5631,Ak/knee disartic acrylic soc,All Other,Per Unit,"$1,509.83 ",OP,439.37,"1,509.83",,,,,,
BCBS Blue Choice,CPT,L5632,Symes type ptb brim design s,All Other,Per Unit,$930.30 ,OP,270.81,930.3,,,,,,
BCBS Blue Choice,CPT,L5634,Symes type poster opening so,All Other,Per Unit,"$1,162.87 ",OP,338.66,"1,162.87",,,,,,
BCBS Blue Choice,CPT,L5636,Symes type medial opening so,All Other,Per Unit,$888.36 ,OP,258.86,888.36,,,,,,
BCBS Blue Choice,CPT,L5637,Below knee total contact,All Other,Per Unit,"$1,323.01 ",OP,385.17,"1,323.01",,,,,,
BCBS Blue Choice,CPT,L5638,Below knee leather socket,All Other,Per Unit,"$2,230.43 ",OP,648.87,"2,230.43",,,,,,
BCBS Blue Choice,CPT,L5639,Below knee wood socket,All Other,Per Unit,"$3,854.63 ",OP,"1,121.15","3,854.63",,,,,,
BCBS Blue Choice,CPT,L5640,Knee disarticulat leather so,All Other,Per Unit,"$2,535.44 ",OP,736.94,"2,535.44",,,,,,
BCBS Blue Choice,CPT,L5642,Above knee leather socket,All Other,Per Unit,"$2,348.62 ",OP,683.11,"2,348.62",,,,,,
BCBS Blue Choice,CPT,L5643,Hip flex inner socket ext fr,All Other,Per Unit,"$6,927.67 ",OP,"2,014.84","6,927.67",,,,,,
BCBS Blue Choice,CPT,L5644,Above knee wood socket,All Other,Per Unit,"$2,032.17 ",OP,590.63,"2,032.17",,,,,,
BCBS Blue Choice,CPT,L5645,Bk flex inner socket ext fra,All Other,Per Unit,"$3,370.43 ",OP,979.82,"3,370.43",,,,,,
BCBS Blue Choice,CPT,L5646,Below knee cushion socket,All Other,Per Unit,"$2,135.11 ",OP,620.93,"2,135.11",,,,,,
BCBS Blue Choice,CPT,L5647,Below knee suction socket,All Other,Per Unit,"$2,733.70 ",OP,795.44,"2,733.70",,,,,,
BCBS Blue Choice,CPT,L5648,Above knee cushion socket,All Other,Per Unit,"$2,524.00 ",OP,733.68,"2,524.00",,,,,,
BCBS Blue Choice,CPT,L5649,Isch containmt/narrow m-l so,All Other,Per Unit,"$8,479.43 ",OP,"2,465.24","8,479.43",,,,,,
BCBS Blue Choice,CPT,L5650,Tot contact ak/knee disart s,All Other,Per Unit,"$1,677.58 ",OP,488.17,"1,677.58",,,,,,
BCBS Blue Choice,CPT,L5651,Ak flex inner socket ext fra,All Other,Per Unit,"$4,918.37 ",OP,"1,430.29","4,918.37",,,,,,
BCBS Blue Choice,CPT,L5652,Suction susp ak/knee disart,All Other,Per Unit,"$1,498.39 ",OP,435.97,"1,498.39",,,,,,
BCBS Blue Choice,CPT,L5653,Knee disart expand wall sock,All Other,Per Unit,"$2,341.00 ",OP,680.24,"2,341.00",,,,,,
BCBS Blue Choice,CPT,L5654,Socket insert symes,All Other,Per Unit,"$1,357.32 ",OP,394.33,"1,357.32",,,,,,
BCBS Blue Choice,CPT,L5655,Socket insert below knee,All Other,Per Unit,$979.86 ,OP,284.71,979.86,,,,,,
BCBS Blue Choice,CPT,L5656,Socket insert knee articulat,All Other,Per Unit,"$1,486.95 ",OP,432.53,"1,486.95",,,,,,
BCBS Blue Choice,CPT,L5658,Socket insert above knee,All Other,Per Unit,"$1,570.83 ",OP,456.55,"1,570.83",,,,,,
BCBS Blue Choice,CPT,L5661,Multi-durometer symes,All Other,Per Unit,"$2,253.31 ",OP,655.04,"2,253.31",,,,,,
BCBS Blue Choice,CPT,L5665,Multi-durometer below knee,All Other,Per Unit,"$2,001.67 ",OP,582.36,"2,001.67",,,,,,
BCBS Blue Choice,CPT,L5666,Below knee cuff suspension,All Other,Per Unit,$266.89 ,OP,77.11,266.89,,,,,,
BCBS Blue Choice,CPT,L5668,Bk molded distal cushion,All Other,Per Unit,$396.52 ,OP,114.86,396.52,,,,,,
BCBS Blue Choice,CPT,L5670,Bk molded supracondylar susp,All Other,Per Unit,$934.12 ,OP,271.35,934.12,,,,,,
BCBS Blue Choice,CPT,L5671,Bk/ak locking mechanism,All Other,Per Unit,"$1,711.89 ",OP,497.4,"1,711.89",,,,,,
BCBS Blue Choice,CPT,L5672,Bk removable medial brim sus,All Other,Per Unit,"$1,235.32 ",OP,359.07,"1,235.32",,,,,,
BCBS Blue Choice,CPT,L5673,Socket insert w lock mech,All Other,Per Unit,"$2,718.45 ",OP,790.52,"2,718.45",,,,,,
BCBS Blue Choice,CPT,L5676,Bk knee joints single axis p,All Other,Per Unit,"$1,246.76 ",OP,362.36,"1,246.76",,,,,,
BCBS Blue Choice,CPT,L5677,Bk knee joints polycentric p,All Other,Per Unit,"$1,910.16 ",OP,554.97,"1,910.16",,,,,,
BCBS Blue Choice,CPT,L5678,Bk joint covers pair,All Other,Per Unit,$137.25 ,OP,39.7,137.25,,,,,,
BCBS Blue Choice,CPT,L5679,Socket insert w/o lock mech,All Other,Per Unit,"$2,264.75 ",OP,658.75,"2,264.75",,,,,,
BCBS Blue Choice,CPT,L5680,Bk thigh lacer non-molded,All Other,Per Unit,"$1,048.50 ",OP,304.37,"1,048.50",,,,,,
BCBS Blue Choice,CPT,L5681,Intl custm cong/latyp insert,All Other,Per Unit,"$4,548.54 ",OP,"1,323.02","4,548.54",,,,,,
BCBS Blue Choice,CPT,L5682,Bk thigh lacer glut/ischia m,All Other,Per Unit,"$2,150.36 ",OP,625.37,"2,150.36",,,,,,
BCBS Blue Choice,CPT,L5683,Initial custom socket insert,All Other,Per Unit,"$4,548.54 ",OP,"1,323.02","4,548.54",,,,,,
BCBS Blue Choice,CPT,L5684,Bk fork strap,All Other,Per Unit,$163.95 ,OP,48.13,163.95,,,,,,
BCBS Blue Choice,CPT,L5685,Below knee sus/seal sleeve,All Other,Per Unit,$442.27 ,OP,128.85,442.27,,,,,,
BCBS Blue Choice,CPT,L5686,Bk back check,All Other,Per Unit,$198.25 ,OP,57.89,198.25,,,,,,
BCBS Blue Choice,CPT,L5688,Bk waist belt webbing,All Other,Per Unit,$209.70 ,OP,61.48,209.7,,,,,,
BCBS Blue Choice,CPT,L5690,Bk waist belt padded and lin,All Other,Per Unit,$430.83 ,OP,125.5,430.83,,,,,,
BCBS Blue Choice,CPT,L5692,Ak pelvic control belt light,All Other,Per Unit,$457.52 ,OP,132.88,457.52,,,,,,
BCBS Blue Choice,CPT,L5694,Ak pelvic control belt pad/l,All Other,Per Unit,$625.29 ,OP,181.41,625.29,,,,,,
BCBS Blue Choice,CPT,L5695,Ak sleeve susp neoprene/equa,All Other,Per Unit,$560.47 ,OP,163.08,560.47,,,,,,
BCBS Blue Choice,CPT,L5696,Ak/knee disartic pelvic join,All Other,Per Unit,$678.66 ,OP,196.99,678.66,,,,,,
BCBS Blue Choice,CPT,L5697,Ak/knee disartic pelvic band,All Other,Per Unit,$320.27 ,OP,93.55,320.27,,,,,,
BCBS Blue Choice,CPT,L5698,Ak/knee disartic silesian ba,All Other,Per Unit,$411.78 ,OP,120.01,411.78,,,,,,
BCBS Blue Choice,CPT,L5699,Shoulder harness,All Other,Per Unit,$705.35 ,OP,205.11,705.35,,,,,,
BCBS Blue Choice,CPT,L5700,Replace socket below knee,All Other,Per Unit,"$10,610.72 ",OP,"3,085.07","10,610.72",,,,,,
BCBS Blue Choice,CPT,L5701,Replace socket above knee,All Other,Per Unit,"$13,161.41 ",OP,"3,827.32","13,161.41",,,,,,
BCBS Blue Choice,CPT,L5702,Replace socket hip,All Other,Per Unit,"$16,589.03 ",OP,"4,823.75","16,589.03",,,,,,
BCBS Blue Choice,CPT,L5703,Symes ankle w/o (sach) foot,All Other,Per Unit,"$8,727.25 ",OP,"2,537.43","8,727.25",,,,,,
BCBS Blue Choice,CPT,L5704,Custom shape cover bk,All Other,Per Unit,"$2,161.80 ",OP,629.03,"2,161.80",,,,,,
BCBS Blue Choice,CPT,L5705,Custom shape cover ak,All Other,Per Unit,"$3,965.20 ",OP,"1,153.25","3,965.20",,,,,,
BCBS Blue Choice,CPT,L5706,Custom shape cvr knee disart,All Other,Per Unit,"$3,869.89 ",OP,"1,124.85","3,869.89",,,,,,
BCBS Blue Choice,CPT,L5707,Custom shape cvr hip disart,All Other,Per Unit,"$5,196.70 ",OP,"1,511.27","5,196.70",,,,,,
BCBS Blue Choice,CPT,L5710,Kne-shin exo sng axi mnl loc,All Other,Per Unit,"$1,235.32 ",OP,359.65,"1,235.32",,,,,,
BCBS Blue Choice,CPT,L5711,Knee-shin exo mnl lock ultra,All Other,Per Unit,"$2,074.10 ",OP,603.6,"2,074.10",,,,,,
BCBS Blue Choice,CPT,L5712,Knee-shin exo frict swg & st,All Other,Per Unit,"$1,483.14 ",OP,430.88,"1,483.14",,,,,,
BCBS Blue Choice,CPT,L5714,Knee-shin exo variable frict,All Other,Per Unit,"$1,506.03 ",OP,438.43,"1,506.03",,,,,,
BCBS Blue Choice,CPT,L5716,Knee-shin exo mech stance ph,All Other,Per Unit,"$2,981.52 ",OP,866.93,"2,981.52",,,,,,
BCBS Blue Choice,CPT,L5718,Knee-shin exo frct swg & sta,All Other,Per Unit,"$3,187.41 ",OP,927.01,"3,187.41",,,,,,
BCBS Blue Choice,CPT,L5722,Knee-shin pneum swg frct exo,All Other,Per Unit,"$3,877.51 ",OP,"1,127.32","3,877.51",,,,,,
BCBS Blue Choice,CPT,L5724,Knee-shin exo fluid swing ph,All Other,Per Unit,"$5,974.48 ",OP,"1,737.57","5,974.48",,,,,,
BCBS Blue Choice,CPT,L5726,Knee-shin ext jnts fld swg e,All Other,Per Unit,"$7,114.49 ",OP,"2,068.65","7,114.49",,,,,,
BCBS Blue Choice,CPT,L5728,Knee-shin fluid swg & stance,All Other,Per Unit,"$8,338.36 ",OP,"2,424.23","8,338.36",,,,,,
BCBS Blue Choice,CPT,L5780,Knee-shin pneum/hydra pneum,All Other,Per Unit,"$4,590.49 ",OP,"1,334.72","4,590.49",,,,,,
BCBS Blue Choice,CPT,L5781,Lower limb pros vacuum pump,All Other,Per Unit,"$13,840.07 ",OP,"4,024.33","13,840.07",,,,,,
BCBS Blue Choice,CPT,L5782,Hd low limb pros vacuum pump,All Other,Per Unit,"$14,591.17 ",OP,"4,242.55","14,591.17",,,,,,
BCBS Blue Choice,CPT,L5785,Exoskeletal bk ultralt mater,All Other,Per Unit,"$1,788.15 ",OP,519.54,"1,788.15",,,,,,
BCBS Blue Choice,CPT,L5790,Exoskeletal ak ultra-light m,All Other,Per Unit,"$2,577.38 ",OP,749.83,"2,577.38",,,,,,
BCBS Blue Choice,CPT,L5795,Exoskel hip ultra-light mate,All Other,Per Unit,"$3,690.70 ",OP,"1,073.66","3,690.70",,,,,,
BCBS Blue Choice,CPT,L5810,Endoskel knee-shin mnl lock,All Other,Per Unit,"$1,967.35 ",OP,572.04,"1,967.35",,,,,,
BCBS Blue Choice,CPT,L5811,Endo knee-shin mnl lck ultra,All Other,Per Unit,"$2,714.64 ",OP,789.42,"2,714.64",,,,,,
BCBS Blue Choice,CPT,L5812,Endo knee-shin frct swg & st,All Other,Per Unit,"$2,043.61 ",OP,594.07,"2,043.61",,,,,,
BCBS Blue Choice,CPT,L5814,Endo knee-shin hydral swg ph,All Other,Per Unit,"$12,844.96 ",OP,"3,735.37","12,844.96",,,,,,
BCBS Blue Choice,CPT,L5816,Endo knee-shin polyc mch sta,All Other,Per Unit,"$2,924.33 ",OP,850.43,"2,924.33",,,,,,
BCBS Blue Choice,CPT,L5818,Endo knee-shin frct swg & st,All Other,Per Unit,"$3,301.79 ",OP,960.3,"3,301.79",,,,,,
BCBS Blue Choice,CPT,L5822,Endo knee-shin pneum swg frc,All Other,Per Unit,"$6,058.37 ",OP,"1,761.65","6,058.37",,,,,,
BCBS Blue Choice,CPT,L5824,Endo knee-shin fluid swing p,All Other,Per Unit,"$5,726.65 ",OP,"1,665.27","5,726.65",,,,,,
BCBS Blue Choice,CPT,L5826,Miniature knee joint,All Other,Per Unit,"$10,801.35 ",OP,"3,140.97","10,801.35",,,,,,
BCBS Blue Choice,CPT,L5828,Endo knee-shin fluid swg/sta,All Other,Per Unit,"$10,191.33 ",OP,"2,963.78","10,191.33",,,,,,
BCBS Blue Choice,CPT,L5830,Endo knee-shin pneum/swg pha,All Other,Per Unit,"$6,874.29 ",OP,"1,998.37","6,874.29",,,,,,
BCBS Blue Choice,CPT,L5840,Multi-axial knee/shin system,All Other,Per Unit,"$13,489.32 ",OP,"3,922.28","13,489.32",,,,,,
BCBS Blue Choice,CPT,L5845,Knee-shin sys stance flexion,All Other,Per Unit,"$6,199.43 ",OP,"1,802.73","6,199.43",,,,,,
BCBS Blue Choice,CPT,L5848,Knee-shin sys hydraul stance,All Other,Per Unit,"$3,721.19 ",OP,"1,081.55","3,721.19",,,,,,
BCBS Blue Choice,CPT,L5850,Endo ak/hip knee extens assi,All Other,Per Unit,$438.47 ,OP,127.92,438.47,,,,,,
BCBS Blue Choice,CPT,L5855,Mech hip extension assist,All Other,Per Unit,"$1,063.73 ",OP,308.82,"1,063.73",,,,,,
BCBS Blue Choice,CPT,L5856,Elec knee-shin swing/stance,All Other,Per Unit,"$83,036.63 ",OP,"24,144.68","83,036.63",,,,,,
BCBS Blue Choice,CPT,L5857,Elec knee-shin swing only,All Other,Per Unit,"$29,464.49 ",OP,"8,567.44","29,464.49",,,,,,
BCBS Blue Choice,CPT,L5858,Stance phase only,All Other,Per Unit,"$64,285.82 ",OP,"18,692.70","64,285.82",,,,,,
BCBS Blue Choice,CPT,L5910,Endo below knee alignable sy,All Other,Per Unit,"$1,246.76 ",OP,362.17,"1,246.76",,,,,,
BCBS Blue Choice,CPT,L5920,Endo ak/hip alignable system,All Other,Per Unit,"$1,826.28 ",OP,530.58,"1,826.28",,,,,,
BCBS Blue Choice,CPT,L5925,Above knee manual lock,All Other,Per Unit,"$1,155.24 ",OP,336,"1,155.24",,,,,,
BCBS Blue Choice,CPT,L5930,High activity knee frame,All Other,Per Unit,"$11,643.96 ",OP,"3,385.39","11,643.96",,,,,,
BCBS Blue Choice,CPT,L5940,Endo bk ultra-light material,All Other,Per Unit,"$1,723.33 ",OP,501.6,"1,723.33",,,,,,
BCBS Blue Choice,CPT,L5950,Endo ak ultra-light material,All Other,Per Unit,"$2,676.51 ",OP,777.99,"2,676.51",,,,,,
BCBS Blue Choice,CPT,L5960,Endo hip ultra-light materia,All Other,Per Unit,"$3,999.51 ",OP,"1,163.29","3,999.51",,,,,,
BCBS Blue Choice,CPT,L5962,Below knee flex cover system,All Other,Per Unit,"$2,020.72 ",OP,587.78,"2,020.72",,,,,,
BCBS Blue Choice,CPT,L5964,Above knee flex cover system,All Other,Per Unit,"$3,877.51 ",OP,"1,127.47","3,877.51",,,,,,
BCBS Blue Choice,CPT,L5966,Hip flexible cover system,All Other,Per Unit,"$4,994.63 ",OP,"1,452.38","4,994.63",,,,,,
BCBS Blue Choice,CPT,L5968,Multiaxial ankle w dorsiflex,All Other,Per Unit,"$12,570.45 ",OP,"3,654.91","12,570.45",,,,,,
BCBS Blue Choice,CPT,L5970,Foot external keel sach foot,All Other,Per Unit,$751.10 ,OP,218.47,751.1,,,,,,
BCBS Blue Choice,CPT,L5971,Sach foot- replacement,All Other,Per Unit,$751.10 ,OP,218.47,751.1,,,,,,
BCBS Blue Choice,CPT,L5972,Flexible keel foot,All Other,Per Unit,"$1,368.75 ",OP,397.97,"1,368.75",,,,,,
BCBS Blue Choice,CPT,L5974,Foot single axis ankle/foot,All Other,Per Unit,$800.67 ,OP,233.03,800.67,,,,,,
BCBS Blue Choice,CPT,L5975,Combo ankle/foot prosthesis,All Other,Per Unit,"$1,605.15 ",OP,466.28,"1,605.15",,,,,,
BCBS Blue Choice,CPT,L5976,Energy storing foot,All Other,Per Unit,"$2,032.17 ",OP,591.07,"2,032.17",,,,,,
BCBS Blue Choice,CPT,L5978,Ft prosth multiaxial ankl/ft,All Other,Per Unit,"$1,078.99 ",OP,313.2,"1,078.99",,,,,,
BCBS Blue Choice,CPT,L5979,Multi-axial ankle/ft prosth,All Other,Per Unit,"$8,624.30 ",OP,"2,507.69","8,624.30",,,,,,
BCBS Blue Choice,CPT,L5980,Flex foot system,All Other,Per Unit,"$13,138.54 ",OP,"3,820.69","13,138.54",,,,,,
BCBS Blue Choice,CPT,L5981,Flex-walk sys low ext prosth,All Other,Per Unit,"$11,804.09 ",OP,"3,431.91","11,804.09",,,,,,
BCBS Blue Choice,CPT,L5982,Exoskeletal axial rotation u,All Other,Per Unit,"$2,218.98 ",OP,644.71,"2,218.98",,,,,,
BCBS Blue Choice,CPT,L5984,Endoskeletal axial rotation,All Other,Per Unit,"$2,222.79 ",OP,646.71,"2,222.79",,,,,,
BCBS Blue Choice,CPT,L5985,Lwr ext dynamic prosth pylon,All Other,Per Unit,$976.05 ,OP,284.02,976.05,,,,,,
BCBS Blue Choice,CPT,L5986,Multi-axial rotation unit,All Other,Per Unit,"$2,684.14 ",OP,780.11,"2,684.14",,,,,,
BCBS Blue Choice,CPT,L5987,Shank ft w vert load pylon,All Other,Per Unit,"$24,881.63 ",OP,"7,235.38","24,881.63",,,,,,
BCBS Blue Choice,CPT,L5988,Vertical shock reducing pylo,All Other,Per Unit,"$6,908.59 ",OP,"2,009.25","6,908.59",,,,,,
BCBS Blue Choice,CPT,L5990,User adjustable heel height,All Other,Per Unit,"$6,275.69 ",OP,"1,824.64","6,275.69",,,,,,
BCBS Blue Choice,CPT,L6000,Part hand thumb rem,All Other,Per Unit,"$6,092.69 ",OP,"1,771.55","6,092.69",,,,,,
BCBS Blue Choice,CPT,L6010,Part hand little/ring,All Other,Per Unit,"$6,778.98 ",OP,"1,971.44","6,778.98",,,,,,
BCBS Blue Choice,CPT,L6020,Part hand no fingers,All Other,Per Unit,"$6,321.45 ",OP,"1,838.05","6,321.45",,,,,,
BCBS Blue Choice,CPT,L6025,Part hand disart myoelectric,All Other,Per Unit,"$27,680.15 ",OP,"27,680.15","27,680.15",,,,,,
BCBS Blue Choice,CPT,L6050,Wrst mld sck flx hng tri pad,All Other,Per Unit,"$8,597.63 ",OP,"2,500.12","8,597.63",,,,,,
BCBS Blue Choice,CPT,L6055,Wrst mold sock w/exp interfa,All Other,Per Unit,"$10,969.11 ",OP,"3,189.04","10,969.11",,,,,,
BCBS Blue Choice,CPT,L6100,Elb mold sock flex hinge pad,All Other,Per Unit,"$8,700.56 ",OP,"2,530.04","8,700.56",,,,,,
BCBS Blue Choice,CPT,L6110,Elbow mold sock suspension t,All Other,Per Unit,"$9,203.84 ",OP,"2,676.61","9,203.84",,,,,,
BCBS Blue Choice,CPT,L6120,Elbow mold doub splt soc ste,All Other,Per Unit,"$10,412.46 ",OP,"3,027.26","10,412.46",,,,,,
BCBS Blue Choice,CPT,L6130,Elbow stump activated lock h,All Other,Per Unit,"$10,984.37 ",OP,"3,193.82","10,984.37",,,,,,
BCBS Blue Choice,CPT,L6200,Elbow mold outsid lock hinge,All Other,Per Unit,"$11,316.08 ",OP,"3,290.01","11,316.08",,,,,,
BCBS Blue Choice,CPT,L6205,Elbow molded w/ expand inter,All Other,Per Unit,"$15,609.16 ",OP,"4,538.50","15,609.16",,,,,,
BCBS Blue Choice,CPT,L6250,Elbow inter loc elbow forarm,All Other,Per Unit,"$11,133.06 ",OP,"3,236.79","11,133.06",,,,,,
BCBS Blue Choice,CPT,L6300,Shlder disart int lock elbow,All Other,Per Unit,"$15,353.72 ",OP,"4,464.43","15,353.72",,,,,,
BCBS Blue Choice,CPT,L6310,Shoulder passive restor comp,All Other,Per Unit,"$13,916.32 ",OP,"4,046.04","13,916.32",,,,,,
BCBS Blue Choice,CPT,L6320,Shoulder passive restor cap,All Other,Per Unit,"$7,251.74 ",OP,"2,108.67","7,251.74",,,,,,
BCBS Blue Choice,CPT,L6350,Thoracic intern lock elbow,All Other,Per Unit,"$16,821.60 ",OP,"4,891.63","16,821.60",,,,,,
BCBS Blue Choice,CPT,L6360,Thoracic passive restor comp,All Other,Per Unit,"$14,606.43 ",OP,"4,246.80","14,606.43",,,,,,
BCBS Blue Choice,CPT,L6370,Thoracic passive restor cap,All Other,Per Unit,"$8,471.79 ",OP,"2,462.85","8,471.79",,,,,,
BCBS Blue Choice,CPT,L6380,Postop dsg cast chg wrst/elb,All Other,Per Unit,"$4,899.32 ",OP,"1,424.44","4,899.32",,,,,,
BCBS Blue Choice,CPT,L6382,Postop dsg cast chg elb dis/,All Other,Per Unit,"$5,833.42 ",OP,"1,695.74","5,833.42",,,,,,
BCBS Blue Choice,CPT,L6384,Postop dsg cast chg shlder/t,All Other,Per Unit,"$7,377.56 ",OP,"2,145.20","7,377.56",,,,,,
BCBS Blue Choice,CPT,L6386,Postop ea cast chg & realign,All Other,Per Unit,"$1,616.58 ",OP,470.24,"1,616.58",,,,,,
BCBS Blue Choice,CPT,L6388,Postop applicat rigid dsg on,All Other,Per Unit,"$1,780.53 ",OP,517.85,"1,780.53",,,,,,
BCBS Blue Choice,CPT,L6400,Below elbow prosth tiss shap,All Other,Per Unit,"$9,413.54 ",OP,"2,736.86","9,413.54",,,,,,
BCBS Blue Choice,CPT,L6450,Elb disart prosth tiss shap,All Other,Per Unit,"$12,299.74 ",OP,"3,576.94","12,299.74",,,,,,
BCBS Blue Choice,CPT,L6500,Above elbow prosth tiss shap,All Other,Per Unit,"$12,078.62 ",OP,"3,512.48","12,078.62",,,,,,
BCBS Blue Choice,CPT,L6550,Shldr disar prosth tiss shap,All Other,Per Unit,"$15,647.29 ",OP,"4,549.39","15,647.29",,,,,,
BCBS Blue Choice,CPT,L6570,Scap thorac prosth tiss shap,All Other,Per Unit,"$17,465.96 ",OP,"5,078.79","17,465.96",,,,,,
BCBS Blue Choice,CPT,L6580,Wrist/elbow bowden cable mol,All Other,Per Unit,"$6,984.85 ",OP,"2,030.62","6,984.85",,,,,,
BCBS Blue Choice,CPT,L6582,Wrist/elbow bowden cbl dir f,All Other,Per Unit,"$5,863.93 ",OP,"1,705.44","5,863.93",,,,,,
BCBS Blue Choice,CPT,L6584,Elbow fair lead cable molded,All Other,Per Unit,"$8,685.31 ",OP,"2,525.30","8,685.31",,,,,,
BCBS Blue Choice,CPT,L6586,Elbow fair lead cable dir fo,All Other,Per Unit,"$7,739.77 ",OP,"2,250.20","7,739.77",,,,,,
BCBS Blue Choice,CPT,L6588,Shdr fair lead cable molded,All Other,Per Unit,"$12,326.44 ",OP,"3,583.73","12,326.44",,,,,,
BCBS Blue Choice,CPT,L6590,Shdr fair lead cable direct,All Other,Per Unit,"$10,740.36 ",OP,"3,123.36","10,740.36",,,,,,
BCBS Blue Choice,CPT,L6600,Polycentric hinge pair,All Other,Per Unit,$785.42 ,OP,228.13,785.42,,,,,,
BCBS Blue Choice,CPT,L6605,Single pivot hinge pair,All Other,Per Unit,$808.29 ,OP,234.81,808.29,,,,,,
BCBS Blue Choice,CPT,L6610,Flexible metal hinge pair,All Other,Per Unit,$762.54 ,OP,221.98,762.54,,,,,,
BCBS Blue Choice,CPT,L6611,Additional switch- ext power,All Other,Per Unit,"$1,425.95 ",OP,414.1,"1,425.95",,,,,,
BCBS Blue Choice,CPT,L6615,Disconnect locking wrist uni,All Other,Per Unit,$739.67 ,OP,215.48,739.67,,,,,,
BCBS Blue Choice,CPT,L6616,Disconnect insert locking wr,All Other,Per Unit,$224.95 ,OP,64.86,224.95,,,,,,
BCBS Blue Choice,CPT,L6620,Flexion/extension wrist unit,All Other,Per Unit,"$1,296.32 ",OP,376.69,"1,296.32",,,,,,
BCBS Blue Choice,CPT,L6621,Flex/ext wrist w/wo friction,All Other,Per Unit,"$7,911.34 ",OP,"2,300.54","7,911.34",,,,,,
BCBS Blue Choice,CPT,L6623,Spring-ass rot wrst w/ latch,All Other,Per Unit,"$2,466.81 ",OP,717.59,"2,466.81",,,,,,
BCBS Blue Choice,CPT,L6624,Flex/ext/rotation wrist unit,All Other,Per Unit,"$13,027.98 ",OP,"3,787.86","13,027.98",,,,,,
BCBS Blue Choice,CPT,L6625,Rotation wrst w/ cable lock,All Other,Per Unit,"$1,830.09 ",OP,531.84,"1,830.09",,,,,,
BCBS Blue Choice,CPT,L6628,Quick disconn hook adapter o,All Other,Per Unit,"$1,967.35 ",OP,572.47,"1,967.35",,,,,,
BCBS Blue Choice,CPT,L6629,Lamination collar w/ couplin,All Other,Per Unit,$671.03 ,OP,195.07,671.03,,,,,,
BCBS Blue Choice,CPT,L6630,Stainless steel any wrist,All Other,Per Unit,$987.49 ,OP,287.35,987.49,,,,,,
BCBS Blue Choice,CPT,L6632,Latex suspension sleeve each,All Other,Per Unit,$224.95 ,OP,64.97,224.95,,,,,,
BCBS Blue Choice,CPT,L6635,Lift assist for elbow,All Other,Per Unit,$712.98 ,OP,207.68,712.98,,,,,,
BCBS Blue Choice,CPT,L6637,Nudge control elbow lock,All Other,Per Unit,"$1,399.26 ",OP,406.6,"1,399.26",,,,,,
BCBS Blue Choice,CPT,L6638,Elec lock on manual pw elbow,All Other,Per Unit,"$8,651.00 ",OP,"2,515.20","8,651.00",,,,,,
BCBS Blue Choice,CPT,L6639,Heavy duty elbow feature,All Other,Per Unit,"$5,276.76 ",OP,"5,276.76","5,276.76",,,,,,
BCBS Blue Choice,CPT,L6640,Shoulder abduction joint pai,All Other,Per Unit,"$1,162.87 ",OP,338.63,"1,162.87",,,,,,
BCBS Blue Choice,CPT,L6641,Excursion amplifier pulley t,All Other,Per Unit,$678.66 ,OP,197.18,678.66,,,,,,
BCBS Blue Choice,CPT,L6642,Excursion amplifier lever ty,All Other,Per Unit,$998.92 ,OP,289.92,998.92,,,,,,
BCBS Blue Choice,CPT,L6645,Shoulder flexion-abduction j,All Other,Per Unit,"$1,258.19 ",OP,366.21,"1,258.19",,,,,,
BCBS Blue Choice,CPT,L6646,Multipo locking shoulder jnt,All Other,Per Unit,"$10,908.12 ",OP,"3,172.24","10,908.12",,,,,,
BCBS Blue Choice,CPT,L6647,Shoulder lock actuator,All Other,Per Unit,"$1,795.78 ",OP,522.26,"1,795.78",,,,,,
BCBS Blue Choice,CPT,L6648,Ext pwrd shlder lock/unlock,All Other,Per Unit,"$11,251.26 ",OP,"3,271.71","11,251.26",,,,,,
BCBS Blue Choice,CPT,L6650,Shoulder universal joint,All Other,Per Unit,"$1,364.94 ",OP,397.2,"1,364.94",,,,,,
BCBS Blue Choice,CPT,L6655,Standard control cable extra,All Other,Per Unit,$263.08 ,OP,77.05,263.08,,,,,,
BCBS Blue Choice,CPT,L6660,Heavy duty control cable,All Other,Per Unit,$354.58 ,OP,103.11,354.58,,,,,,
BCBS Blue Choice,CPT,L6665,Teflon or equal cable lining,All Other,Per Unit,$160.13 ,OP,46.05,160.13,,,,,,
BCBS Blue Choice,CPT,L6670,Hook to hand cable adapter,All Other,Per Unit,$163.95 ,OP,47.96,163.95,,,,,,
BCBS Blue Choice,CPT,L6672,Harness chest/shlder saddle,All Other,Per Unit,$758.72 ,OP,220.08,758.72,,,,,,
BCBS Blue Choice,CPT,L6675,Harness figure of 8 sing con,All Other,Per Unit,$411.78 ,OP,120.09,411.78,,,,,,
BCBS Blue Choice,CPT,L6676,Harness figure of 8 dual con,All Other,Per Unit,$430.83 ,OP,125.64,430.83,,,,,,
BCBS Blue Choice,CPT,L6677,Ue triple control harness,All Other,Per Unit,"$1,025.61 ",OP,298.35,"1,025.61",,,,,,
BCBS Blue Choice,CPT,L6680,Test sock wrist disart/bel e,All Other,Per Unit,"$1,063.73 ",OP,309.33,"1,063.73",,,,,,
BCBS Blue Choice,CPT,L6682,Test sock elbw disart/above,All Other,Per Unit,"$1,178.12 ",OP,342.01,"1,178.12",,,,,,
BCBS Blue Choice,CPT,L6684,Test socket shldr disart/tho,All Other,Per Unit,"$1,597.52 ",OP,464.75,"1,597.52",,,,,,
BCBS Blue Choice,CPT,L6686,Suction socket,All Other,Per Unit,"$2,371.49 ",OP,689.63,"2,371.49",,,,,,
BCBS Blue Choice,CPT,L6687,Frame typ socket bel elbow/w,All Other,Per Unit,"$1,982.60 ",OP,576.8,"1,982.60",,,,,,
BCBS Blue Choice,CPT,L6688,Frame typ sock above elb/dis,All Other,Per Unit,"$2,196.11 ",OP,638.36,"2,196.11",,,,,,
BCBS Blue Choice,CPT,L6689,Frame typ socket shoulder di,All Other,Per Unit,"$2,615.51 ",OP,760.81,"2,615.51",,,,,,
BCBS Blue Choice,CPT,L6690,Frame typ sock interscap-tho,All Other,Per Unit,"$3,080.66 ",OP,895.74,"3,080.66",,,,,,
BCBS Blue Choice,CPT,L6691,Removable insert each,All Other,Per Unit,"$1,216.24 ",OP,353.58,"1,216.24",,,,,,
BCBS Blue Choice,CPT,L6692,Silicone gel insert or equal,All Other,Per Unit,"$2,211.37 ",OP,643.25,"2,211.37",,,,,,
BCBS Blue Choice,CPT,L6693,Lockingelbow forearm cntrbal,All Other,Per Unit,"$9,821.50 ",OP,"2,855.43","9,821.50",,,,,,
BCBS Blue Choice,CPT,L6694,Elbow socket ins use w/lock,All Other,Per Unit,"$2,718.45 ",OP,790.52,"2,718.45",,,,,,
BCBS Blue Choice,CPT,L6695,Elbow socket ins use w/o lck,All Other,Per Unit,"$2,264.75 ",OP,658.75,"2,264.75",,,,,,
BCBS Blue Choice,CPT,L6696,Cus elbo skt in for con/atyp,All Other,Per Unit,"$4,548.54 ",OP,"1,323.02","4,548.54",,,,,,
BCBS Blue Choice,CPT,L6697,Cus elbo skt in not con/atyp,All Other,Per Unit,"$4,548.54 ",OP,"1,323.02","4,548.54",,,,,,
BCBS Blue Choice,CPT,L6698,Below/above elbow lock mech,All Other,Per Unit,"$1,711.89 ",OP,497.4,"1,711.89",,,,,,
BCBS Blue Choice,CPT,L6703,Term dev- passive hand mitt,All Other,Per Unit,"$1,208.62 ",OP,351.79,"1,208.62",,,,,,
BCBS Blue Choice,CPT,L6704,Term dev- sport/rec/work att,All Other,Per Unit,"$2,337.18 ",OP,679.06,"2,337.18",,,,,,
BCBS Blue Choice,CPT,L6706,Term dev mech hook vol open,All Other,Per Unit,"$1,448.82 ",OP,421.4,"1,448.82",,,,,,
BCBS Blue Choice,CPT,L6707,Term dev mech hook vol close,All Other,Per Unit,"$5,128.07 ",OP,"1,490.70","5,128.07",,,,,,
BCBS Blue Choice,CPT,L6708,Term dev mech hand vol open,All Other,Per Unit,"$3,389.47 ",OP,985.41,"3,389.47",,,,,,
BCBS Blue Choice,CPT,L6709,Term dev mech hand vol close,All Other,Per Unit,"$4,811.61 ",OP,"1,398.55","4,811.61",,,,,,
BCBS Blue Choice,CPT,L6711,Ped term dev- hook- vol open,All Other,Per Unit,"$2,325.74 ",OP,676.19,"2,325.74",,,,,,
BCBS Blue Choice,CPT,L6712,Ped term dev- hook- vol clos,All Other,Per Unit,"$4,281.66 ",OP,"1,245.05","4,281.66",,,,,,
BCBS Blue Choice,CPT,L6713,Ped term dev- hand- vol open,All Other,Per Unit,"$5,402.59 ",OP,"1,571.33","5,402.59",,,,,,
BCBS Blue Choice,CPT,L6714,Ped term dev- hand- vol clos,All Other,Per Unit,"$4,579.05 ",OP,"1,330.91","4,579.05",,,,,,
BCBS Blue Choice,CPT,L6721,Hook/hand- hvy dty- vol open,All Other,Per Unit,"$8,136.28 ",OP,"2,365.59","8,136.28",,,,,,
BCBS Blue Choice,CPT,L6722,Hook/hand- hvy dty- vol clos,All Other,Per Unit,"$7,011.54 ",OP,"2,039.28","7,011.54",,,,,,
BCBS Blue Choice,CPT,L6805,Term dev modifier wrist unit,All Other,Per Unit,"$1,326.82 ",OP,385.75,"1,326.82",,,,,,
BCBS Blue Choice,CPT,L6810,Term dev precision pinch dev,All Other,Per Unit,$705.35 ,OP,205.07,705.35,,,,,,
BCBS Blue Choice,CPT,L6881,Term dev auto grasp feature,All Other,Per Unit,"$14,141.27 ",OP,"4,111.91","14,141.27",,,,,,
BCBS Blue Choice,CPT,L6882,Microprocessor control uplmb,All Other,Per Unit,"$10,725.10 ",OP,"3,119.08","10,725.10",,,,,,
BCBS Blue Choice,CPT,L6883,Replc sockt below e/w disa,All Other,Per Unit,"$6,870.47 ",OP,"1,997.96","6,870.47",,,,,,
BCBS Blue Choice,CPT,L6884,Replc sockt above elbow disa,All Other,Per Unit,"$9,402.10 ",OP,"2,733.67","9,402.10",,,,,,
BCBS Blue Choice,CPT,L6885,Replc sockt shldr dis/interc,All Other,Per Unit,"$14,606.43 ",OP,"4,246.80","14,606.43",,,,,,
BCBS Blue Choice,CPT,L6890,Prefab glove for term device,All Other,Per Unit,$690.10 ,OP,200.88,690.1,,,,,,
BCBS Blue Choice,CPT,L6895,Custom glove for term device,All Other,Per Unit,"$2,310.49 ",OP,671.68,"2,310.49",,,,,,
BCBS Blue Choice,CPT,L6900,Hand restorat thumb/1 finger,All Other,Per Unit,"$6,706.52 ",OP,"1,950.52","6,706.52",,,,,,
BCBS Blue Choice,CPT,L6905,Hand restoration multiple fi,All Other,Per Unit,"$6,637.91 ",OP,"1,930.47","6,637.91",,,,,,
BCBS Blue Choice,CPT,L6910,Hand restoration no fingers,All Other,Per Unit,"$6,527.33 ",OP,"1,897.78","6,527.33",,,,,,
BCBS Blue Choice,CPT,L6915,Hand restoration replacmnt g,All Other,Per Unit,"$2,806.14 ",OP,815.4,"2,806.14",,,,,,
BCBS Blue Choice,CPT,L6920,Wrist disarticul switch ctrl,All Other,Per Unit,"$28,976.47 ",OP,"8,425.39","28,976.47",,,,,,
BCBS Blue Choice,CPT,L6925,Wrist disart myoelectronic c,All Other,Per Unit,"$30,955.25 ",OP,"9,001.12","30,955.25",,,,,,
BCBS Blue Choice,CPT,L6930,Below elbow switch control,All Other,Per Unit,"$27,908.91 ",OP,"8,114.82","27,908.91",,,,,,
BCBS Blue Choice,CPT,L6935,Below elbow myoelectronic ct,All Other,Per Unit,"$30,810.37 ",OP,"8,958.82","30,810.37",,,,,,
BCBS Blue Choice,CPT,L6940,Elbow disarticulation switch,All Other,Per Unit,"$36,037.57 ",OP,"10,478.90","36,037.57",,,,,,
BCBS Blue Choice,CPT,L6945,Elbow disart myoelectronic c,All Other,Per Unit,"$40,204.84 ",OP,"11,690.57","40,204.84",,,,,,
BCBS Blue Choice,CPT,L6950,Above elbow switch control,All Other,Per Unit,"$35,972.77 ",OP,"10,459.47","35,972.77",,,,,,
BCBS Blue Choice,CPT,L6955,Above elbow myoelectronic ct,All Other,Per Unit,"$41,714.68 ",OP,"12,129.70","41,714.68",,,,,,
BCBS Blue Choice,CPT,L6960,Shldr disartic switch contro,All Other,Per Unit,"$43,884.09 ",OP,"12,759.97","43,884.09",,,,,,
BCBS Blue Choice,CPT,L6965,Shldr disartic myoelectronic,All Other,Per Unit,"$51,986.07 ",OP,"15,116.16","51,986.07",,,,,,
BCBS Blue Choice,CPT,L6970,Interscapular-thor switch ct,All Other,Per Unit,"$55,646.26 ",OP,"16,180.17","55,646.26",,,,,,
BCBS Blue Choice,CPT,L6975,Interscap-thor myoelectronic,All Other,Per Unit,"$61,334.79 ",OP,"17,834.37","61,334.79",,,,,,
BCBS Blue Choice,CPT,L7007,Adult electric hand,All Other,Per Unit,"$12,635.27 ",OP,"3,673.63","12,635.27",,,,,,
BCBS Blue Choice,CPT,L7008,Pediatric electric hand,All Other,Per Unit,"$19,593.43 ",OP,"5,696.71","19,593.43",,,,,,
BCBS Blue Choice,CPT,L7009,Adult electric hook,All Other,Per Unit,"$12,925.03 ",OP,"3,758.57","12,925.03",,,,,,
BCBS Blue Choice,CPT,L7040,Prehensile actuator,All Other,Per Unit,"$10,519.22 ",OP,"3,059.23","10,519.22",,,,,,
BCBS Blue Choice,CPT,L7045,Pediatric electric hook,All Other,Per Unit,"$5,558.92 ",OP,"1,616.29","5,558.92",,,,,,
BCBS Blue Choice,CPT,L7170,Electronic elbow hosmer swit,All Other,Per Unit,"$20,805.87 ",OP,"6,050.00","20,805.87",,,,,,
BCBS Blue Choice,CPT,L7180,Electronic elbow sequential,All Other,Per Unit,"$134,610.92 ",OP,"39,141.46","134,610.92",,,,,,
BCBS Blue Choice,CPT,L7181,Electronic elbo simultaneous,All Other,Per Unit,"$138,595.19 ",OP,"40,299.84","138,595.19",,,,,,
BCBS Blue Choice,CPT,L7185,Electron elbow adolescent sw,All Other,Per Unit,"$21,873.42 ",OP,"6,360.51","21,873.42",,,,,,
BCBS Blue Choice,CPT,L7186,Electron elbow child switch,All Other,Per Unit,"$36,773.42 ",OP,"10,692.92","36,773.42",,,,,,
BCBS Blue Choice,CPT,L7190,Elbow adolescent myoelectron,All Other,Per Unit,"$29,026.03 ",OP,"8,439.80","29,026.03",,,,,,
BCBS Blue Choice,CPT,L7191,Elbow child myoelectronic ct,All Other,Per Unit,"$38,679.77 ",OP,"11,247.26","38,679.77",,,,,,
BCBS Blue Choice,CPT,L7260,Electron wrist rotator otto,All Other,Per Unit,"$7,552.94 ",OP,"7,552.94","7,552.94",,,,,,
BCBS Blue Choice,CPT,L7261,Electron wrist rotator utah,All Other,Per Unit,"$16,261.14 ",OP,"16,261.14","16,261.14",,,,,,
BCBS Blue Choice,CPT,L7266,Servo control steeper or equ,All Other,Per Unit,"$3,480.99 ",OP,"3,480.99","3,480.99",,,,,,
BCBS Blue Choice,CPT,L7272,Analogue control unb or equa,All Other,Per Unit,"$8,162.98 ",OP,"8,162.98","8,162.98",,,,,,
BCBS Blue Choice,CPT,L7274,Proportional ctl 12 volt uta,All Other,Per Unit,"$25,316.28 ",OP,"25,316.28","25,316.28",,,,,,
BCBS Blue Choice,CPT,L7360,Six volt bat otto bock/eq ea,All Other,Per Unit,$915.04 ,OP,266.08,915.04,,,,,,
BCBS Blue Choice,CPT,L7362,Battery chrgr six volt otto,All Other,Per Unit,$998.92 ,OP,290.68,998.92,,,,,,
BCBS Blue Choice,CPT,L7364,Twelve volt battery utah/equ,All Other,Per Unit,"$1,769.09 ",OP,514.33,"1,769.09",,,,,,
BCBS Blue Choice,CPT,L7366,Battery chrgr 12 volt utah/e,All Other,Per Unit,"$2,432.50 ",OP,707.34,"2,432.50",,,,,,
BCBS Blue Choice,CPT,L7367,Replacemnt lithium ionbatter,All Other,Per Unit,"$1,345.89 ",OP,391.59,"1,345.89",,,,,,
BCBS Blue Choice,CPT,L7368,Lithium ion battery charger,All Other,Per Unit,"$1,746.22 ",OP,507.61,"1,746.22",,,,,,
BCBS Blue Choice,CPT,L7400,Add ue prost be/wd- ultlite,All Other,Per Unit,"$1,059.93 ",OP,308.25,"1,059.93",,,,,,
BCBS Blue Choice,CPT,L7401,Add ue prost a/e ultlite mat,All Other,Per Unit,"$1,185.76 ",OP,345.06,"1,185.76",,,,,,
BCBS Blue Choice,CPT,L7402,Add ue prost s/d ultlite mat,All Other,Per Unit,"$1,281.07 ",OP,372.68,"1,281.07",,,,,,
BCBS Blue Choice,CPT,L7403,Add ue prost b/e acrylic,All Other,Per Unit,"$1,273.44 ",OP,370.41,"1,273.44",,,,,,
BCBS Blue Choice,CPT,L7404,Add ue prost a/e acrylic,All Other,Per Unit,"$1,921.59 ",OP,559.06,"1,921.59",,,,,,
BCBS Blue Choice,CPT,L7405,Add ue prost s/d acrylic,All Other,Per Unit,"$2,512.57 ",OP,731.1,"2,512.57",,,,,,
BCBS Blue Choice,CPT,L7520,Repair prosthesis per 15 min,All Other,Per Unit,$152.51 ,OP,152.51,152.51,,,,,,
BCBS Blue Choice,CPT,L7900,Male vacuum erection system,All Other,Per Unit,"$1,818.66 ",OP,"1,818.66","1,818.66",,,,,,
BCBS Blue Choice,CPT,L8000,Mastectomy bra,All Other,Per Unit,$144.88 ,OP,42.59,144.88,,,,,,
BCBS Blue Choice,CPT,L8001,Breast prosthesis bra & form,All Other,Per Unit,$434.65 ,OP,126.18,434.65,,,,,,
BCBS Blue Choice,CPT,L8002,Brst prsth bra & bilat form,All Other,Per Unit,$571.91 ,OP,165.94,571.91,,,,,,
BCBS Blue Choice,CPT,L8010,Mastectomy sleeve,All Other,Per Unit,$373.65 ,OP,373.65,373.65,,,,,,
BCBS Blue Choice,CPT,L8015,Ext breastprosthesis garment,All Other,Per Unit,$205.88 ,OP,60.29,205.88,,,,,,
BCBS Blue Choice,CPT,L8020,Mastectomy form,All Other,Per Unit,$781.61 ,OP,227.4,781.61,,,,,,
BCBS Blue Choice,CPT,L8030,Breast prosthes w/o adhesive,All Other,Per Unit,"$1,208.62 ",OP,351.55,"1,208.62",,,,,,
BCBS Blue Choice,CPT,L8035,Custom breast prosthesis,All Other,Per Unit,"$12,673.39 ",OP,"3,684.79","12,673.39",,,,,,
BCBS Blue Choice,CPT,L8040,Nasal prosthesis,All Other,Per Unit,"$8,574.74 ",OP,"2,493.50","8,574.74",,,,,,
BCBS Blue Choice,CPT,L8041,Midfacial prosthesis,All Other,Per Unit,"$10,336.21 ",OP,"3,005.20","10,336.21",,,,,,
BCBS Blue Choice,CPT,L8042,Orbital prosthesis,All Other,Per Unit,"$11,613.47 ",OP,"3,376.62","11,613.47",,,,,,
BCBS Blue Choice,CPT,L8043,Upper facial prosthesis,All Other,Per Unit,"$13,005.10 ",OP,"3,781.84","13,005.10",,,,,,
BCBS Blue Choice,CPT,L8044,Hemi-facial prosthesis,All Other,Per Unit,"$14,400.54 ",OP,"4,187.02","14,400.54",,,,,,
BCBS Blue Choice,CPT,L8045,Auricular prosthesis,All Other,Per Unit,"$11,274.13 ",OP,"3,278.72","11,274.13",,,,,,
BCBS Blue Choice,CPT,L8046,Partial facial prosthesis,All Other,Per Unit,"$9,291.53 ",OP,"2,701.33","9,291.53",,,,,,
BCBS Blue Choice,CPT,L8047,Nasal septal prosthesis,All Other,Per Unit,"$4,762.05 ",OP,"1,384.42","4,762.05",,,,,,
BCBS Blue Choice,CPT,L8049,Repair maxillofacial prosth,All Other,Per Unit,$61.00 ,OP,61,61,,,,,,
BCBS Blue Choice,CPT,L8300,Truss single w/ standard pad,All Other,Per Unit,$289.76 ,OP,84.35,289.76,,,,,,
BCBS Blue Choice,CPT,L8310,Truss double w/ standard pad,All Other,Per Unit,$514.72 ,OP,149.44,514.72,,,,,,
BCBS Blue Choice,CPT,L8320,Truss addition to std pad wa,All Other,Per Unit,$213.51 ,OP,62,213.51,,,,,,
BCBS Blue Choice,CPT,L8330,Truss add to std pad scrotal,All Other,Per Unit,$171.58 ,OP,49.37,171.58,,,,,,
BCBS Blue Choice,CPT,L8400,Sheath below knee,All Other,Per Unit,$53.38 ,OP,15.74,53.38,,,,,,
BCBS Blue Choice,CPT,L8410,Sheath above knee,All Other,Per Unit,$72.44 ,OP,20.72,72.44,,,,,,
BCBS Blue Choice,CPT,L8415,Sheath upper limb,All Other,Per Unit,$72.44 ,OP,21.44,72.44,,,,,,
BCBS Blue Choice,CPT,L8417,Pros sheath/sock w gel cushn,All Other,Per Unit,$259.27 ,OP,75.64,259.27,,,,,,
BCBS Blue Choice,CPT,L8420,Prosthetic sock multi ply bk,All Other,Per Unit,$72.44 ,OP,20.98,72.44,,,,,,
BCBS Blue Choice,CPT,L8430,Prosthetic sock multi ply ak,All Other,Per Unit,$80.07 ,OP,23.76,80.07,,,,,,
BCBS Blue Choice,CPT,L8435,Pros sock multi ply upper lm,All Other,Per Unit,$76.26 ,OP,22.58,76.26,,,,,,
BCBS Blue Choice,CPT,L8440,Shrinker below knee,All Other,Per Unit,$160.13 ,OP,46.88,160.13,,,,,,
BCBS Blue Choice,CPT,L8460,Shrinker above knee,All Other,Per Unit,$228.77 ,OP,66.65,228.77,,,,,,
BCBS Blue Choice,CPT,L8465,Shrinker upper limb,All Other,Per Unit,$213.51 ,OP,61.6,213.51,,,,,,
BCBS Blue Choice,CPT,L8470,Pros sock single ply bk,All Other,Per Unit,$22.88 ,OP,6.67,22.88,,,,,,
BCBS Blue Choice,CPT,L8480,Pros sock single ply ak,All Other,Per Unit,$30.51 ,OP,9.2,30.51,,,,,,
BCBS Blue Choice,CPT,L8485,Pros sock single ply upper l,All Other,Per Unit,$41.94 ,OP,12.39,41.94,,,,,,
BCBS Blue Choice,CPT,L8500,Artificial larynx,All Other,Per Unit,"$2,276.18 ",OP,661.87,"2,276.18",,,,,,
BCBS Blue Choice,CPT,L8501,Tracheostomy speaking valve,All Other,Per Unit,$415.59 ,OP,120.8,415.59,,,,,,
BCBS Blue Choice,CPT,L8507,Trach-esoph voice pros pt in,All Other,Per Unit,$144.88 ,OP,42.11,144.88,,,,,,
BCBS Blue Choice,CPT,L8509,Trach-esoph voice pros md in,All Other,Per Unit,$377.46 ,OP,109.85,377.46,,,,,,
BCBS Blue Choice,CPT,L8510,Voice amplifier,All Other,Per Unit,$873.11 ,OP,254.17,873.11,,,,,,
BCBS Blue Choice,CPT,L8511,Indwelling trach insert,All Other,Per Unit,$251.64 ,OP,73.14,251.64,,,,,,
BCBS Blue Choice,CPT,L8512,Gel cap for trach voice pros,All Other,Per Unit,$7.62 ,OP,2.19,7.62,,,,,,
BCBS Blue Choice,CPT,L8513,Trach pros cleaning device,All Other,Per Unit,$19.07 ,OP,5.22,19.07,,,,,,
BCBS Blue Choice,CPT,L8514,Repl trach puncture dilator,All Other,Per Unit,$327.90 ,OP,94.85,327.9,,,,,,
BCBS Blue Choice,CPT,L8515,Gel cap app device for trach,All Other,Per Unit,$217.32 ,OP,63.49,217.32,,,,,,
BCBS Blue Choice,CPT,L8606,Synthetic implnt urinary 1ml,All Other,Per Unit,$709.16 ,OP,709.16,709.16,,,,,,
BCBS Blue Choice,CPT,L8609,Artificial cornea,All Other,Per Unit,"$22,536.83 ",OP,"22,536.83","22,536.83",,,,,,
BCBS Blue Choice,CPT,L8610,Ocular implant,All Other,Per Unit,"$2,352.44 ",OP,"2,352.44","2,352.44",,,,,,
BCBS Blue Choice,CPT,L8612,Aqueous shunt prosthesis,All Other,Per Unit,"$2,737.52 ",OP,"2,737.52","2,737.52",,,,,,
BCBS Blue Choice,CPT,L8613,Ossicular implant,All Other,Per Unit,"$1,174.31 ",OP,"1,174.31","1,174.31",,,,,,
BCBS Blue Choice,CPT,L8614,Cochlear device,All Other,Per Unit,"$67,724.86 ",OP,"67,724.86","67,724.86",,,,,,
BCBS Blue Choice,CPT,L8615,Coch implant headset replace,All Other,Per Unit,"$1,559.39 ",OP,453.62,"1,559.39",,,,,,
BCBS Blue Choice,CPT,L8616,Coch implant microphone repl,All Other,Per Unit,$362.21 ,OP,105.64,362.21,,,,,,
BCBS Blue Choice,CPT,L8618,Coch implant tran cable repl,All Other,Per Unit,$91.51 ,OP,26.38,91.51,,,,,,
BCBS Blue Choice,CPT,L8619,Coch imp ext proc/contr rplc,All Other,Per Unit,"$29,075.59 ",OP,"8,454.02","29,075.59",,,,,,
BCBS Blue Choice,CPT,L8621,Repl zinc air battery,All Other,Per Unit,$3.82 ,OP,0.62,3.82,,,,,,
BCBS Blue Choice,CPT,L8622,Repl alkaline battery,All Other,Per Unit,$1.90 ,OP,0.32,1.9,,,,,,
BCBS Blue Choice,CPT,L8624,Lith ion batt cid- ear level,All Other,Per Unit,$556.65 ,OP,162.2,556.65,,,,,,
BCBS Blue Choice,CPT,L8630,Metacarpophalangeal implant,All Other,Per Unit,"$1,544.15 ",OP,"1,544.15","1,544.15",,,,,,
BCBS Blue Choice,CPT,L8631,Mcp joint repl 2 pc or more,All Other,Per Unit,"$7,610.13 ",OP,"7,610.13","7,610.13",,,,,,
BCBS Blue Choice,CPT,L8641,Metatarsal joint implant,All Other,Per Unit,"$1,204.81 ",OP,"1,204.81","1,204.81",,,,,,
BCBS Blue Choice,CPT,L8642,Hallux implant,All Other,Per Unit,"$1,075.18 ",OP,"1,075.18","1,075.18",,,,,,
BCBS Blue Choice,CPT,L8658,Interphalangeal joint spacer,All Other,Per Unit,"$1,048.50 ",OP,"1,048.50","1,048.50",,,,,,
BCBS Blue Choice,CPT,L8659,Interphalangeal joint repl,All Other,Per Unit,"$6,676.03 ",OP,"6,676.03","6,676.03",,,,,,
BCBS Blue Choice,CPT,L8670,Vascular graft- synthetic,All Other,Per Unit,"$1,913.96 ",OP,"1,913.96","1,913.96",,,,,,
BCBS Blue Choice,CPT,L8680,Implt neurostim elctr each,All Other,Per Unit,"$1,631.84 ",OP,"1,631.84","1,631.84",,,,,,
BCBS Blue Choice,CPT,L8681,Pt prgrm for implt neurostim,All Other,Per Unit,"$3,946.14 ",OP,"1,147.11","3,946.14",,,,,,
BCBS Blue Choice,CPT,L8682,Implt neurostim radiofq rec,All Other,Per Unit,"$21,175.69 ",OP,"21,175.69","21,175.69",,,,,,
BCBS Blue Choice,CPT,L8683,Radiofq trsmtr for implt neu,All Other,Per Unit,"$18,640.24 ",OP,"5,420.03","18,640.24",,,,,,
BCBS Blue Choice,CPT,L8684,Radiof trsmtr implt scrl neu,All Other,Per Unit,"$2,924.33 ",OP,850.48,"2,924.33",,,,,,
BCBS Blue Choice,CPT,L8685,Implt nrostm pls gen sng rec,All Other,Per Unit,"$46,450.03 ",OP,"46,450.03","46,450.03",,,,,,
BCBS Blue Choice,CPT,L8686,Implt nrostm pls gen sng non,All Other,Per Unit,"$29,639.87 ",OP,"29,639.87","29,639.87",,,,,,
BCBS Blue Choice,CPT,L8687,Implt nrostm pls gen dua rec,All Other,Per Unit,"$60,450.24 ",OP,"60,450.24","60,450.24",,,,,,
BCBS Blue Choice,CPT,L8688,Implt nrostm pls gen dua non,All Other,Per Unit,"$38,573.01 ",OP,"38,573.01","38,573.01",,,,,,
BCBS Blue Choice,CPT,L8689,External recharg sys intern,All Other,Per Unit,"$5,966.87 ",OP,"1,734.92","5,966.87",,,,,,
BCBS Blue Choice,CPT,L8690,Aud osseo dev- int/ext comp,All Other,Per Unit,"$16,455.58 ",OP,"16,455.58","16,455.58",,,,,,
BCBS Blue Choice,CPT,L8691,Aoi snd proc repl excl actua,All Other,Per Unit,"$9,222.90 ",OP,"1,732.10","9,222.90",,,,,,
BCBS Blue Choice,CPT,L8695,External recharg sys extern,All Other,Per Unit,$57.19 ,OP,16.77,57.19,,,,,,
BCBS Blue Choice,CPT,L9900,O&p supply/accessory/service,All Other,Per Unit,$144.88 ,OP,144.88,144.88,,,,,,
BCBS Blue Choice,CPT,M0064,Visit for drug monitoring,All Other,Per Unit,$217.32 ,OP,217.32,217.32,,,,,,
BCBS Blue Choice,CPT,M0076,Prolotherapy,All Other,Per Unit,$358.39 ,OP,358.39,358.39,,,,,,
BCBS Blue Choice,CPT,M0300,Iv chelationtherapy,All Other,Per Unit,$305.01 ,OP,305.01,305.01,,,,,,
BCBS Blue Choice,CPT,P2038,Blood mucoprotein,All Other,Per Unit,$22.88 ,OP,4.95,22.88,,,,,,
BCBS Blue Choice,CPT,P3000,Screen pap by tech w md supv,All Other,Per Unit,$45.74 ,OP,15.15,45.74,,,,,,
BCBS Blue Choice,CPT,P3001,Screening pap smear by phys,All Other,Per Unit,$137.25 ,OP,137.25,137.25,,,,,,
BCBS Blue Choice,CPT,P7001,Culture bacterial urine,All Other,Per Unit,$19.07 ,OP,19.07,19.07,,,,,,
BCBS Blue Choice,CPT,P9043,Plasma protein fract-5%-50ml,All Other,Per Unit,$106.76 ,OP,9.16,106.76,,,,,,
BCBS Blue Choice,CPT,P9045,Albumin (human)- 5%- 250 ml,All Other,Per Unit,$274.51 ,OP,52.45,274.51,,,,,,
BCBS Blue Choice,CPT,P9046,Albumin (human)- 25%- 20 ml,All Other,Per Unit,$129.64 ,OP,20.98,129.64,,,,,,
BCBS Blue Choice,CPT,P9047,Albumin (human)- 25%- 50ml,All Other,Per Unit,$255.45 ,OP,52.45,255.45,,,,,,
BCBS Blue Choice,CPT,P9048,Plasmaprotein fract-5%-250ml,All Other,Per Unit,$198.25 ,OP,183.92,198.25,,,,,,
BCBS Blue Choice,CPT,P9615,Urine specimen collect mult,All Other,Per Unit,$7.62 ,OP,7.62,7.62,,,,,,
BCBS Blue Choice,CPT,Q0035,Cardiokymography,All Other,Per Unit,$106.76 ,OP,34.63,106.76,,,,,,
BCBS Blue Choice,CPT,Q0091,Obtaining screen pap smear,All Other,Per Unit,$205.88 ,OP,25.25,205.88,,,,,,
BCBS Blue Choice,CPT,Q0092,Set up port xray equipment,All Other,Per Unit,$83.87 ,OP,83.87,83.87,,,,,,
BCBS Blue Choice,CPT,Q0112,Potassium hydroxide preps,All Other,Per Unit,$22.88 ,OP,5.83,22.88,,,,,,
BCBS Blue Choice,CPT,Q0113,Pinworm examinations,All Other,Per Unit,$26.70 ,OP,4.27,26.7,,,,,,
BCBS Blue Choice,CPT,Q0114,Fern test,All Other,Per Unit,$34.31 ,OP,9.74,34.31,,,,,,
BCBS Blue Choice,CPT,Q0115,Post-coital mucous exam,All Other,Per Unit,$49.56 ,OP,25,49.56,,,,,,
BCBS Blue Choice,CPT,Q0144,Azithromycin dihydrate- oral,All Other,Per Unit,$133.45 ,OP,133.45,133.45,,,,,,
BCBS Blue Choice,CPT,Q0161,Chlorpromazine hcl 5mg oral,All Other,Per Unit,$0.38 ,OP,0.38,0.38,,,,,,
BCBS Blue Choice,CPT,Q0167,Dronabinol 2.5mg oral,All Other,Per Unit,$26.70 ,OP,26.7,26.7,,,,,,
BCBS Blue Choice,CPT,Q0168,Dronabinol 5mg oral,All Other,Per Unit,$57.19 ,OP,57.19,57.19,,,,,,
BCBS Blue Choice,CPT,Q0169,Promethazine hcl 12.5mg oral,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,Q0170,Promethazine HCl 25 mg oral,All Other,Per Unit,$1.90 ,OP,1.9,1.9,,,,,,
BCBS Blue Choice,CPT,Q0172,Chlorpromazine HCl 25mg oral,All Other,Per Unit,$1.90 ,OP,1.9,1.9,,,,,,
BCBS Blue Choice,CPT,Q0173,Trimethobenzamide hcl 250mg,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,Q0174,Thiethylperazine maleate10mg,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,Q0175,Perphenazine 4mg oral,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,Q0176,Perphenazine 8mg oral,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,Q0177,Hydroxyzine pamoate 25mg,All Other,Per Unit,$1.90 ,OP,1.9,1.9,,,,,,
BCBS Blue Choice,CPT,Q0180,Dolasetron mesylate oral,All Other,Per Unit,$244.01 ,OP,244.01,244.01,,,,,,
BCBS Blue Choice,CPT,Q0480,Driver pneumatic vad- rep,All Other,Per Unit,"$311,531.29 ",OP,"90,585.51","311,531.29",,,,,,
BCBS Blue Choice,CPT,Q0481,Microprcsr cu elec vad- rep,All Other,Per Unit,"$50,262.72 ",OP,"14,614.95","50,262.72",,,,,,
BCBS Blue Choice,CPT,Q0482,Microprcsr cu combo vad- rep,All Other,Per Unit,"$15,742.60 ",OP,"4,577.67","15,742.60",,,,,,
BCBS Blue Choice,CPT,Q0483,Monitor elec vad- rep,All Other,Per Unit,"$64,853.90 ",OP,"18,857.93","64,853.90",,,,,,
BCBS Blue Choice,CPT,Q0484,Monitor elec or comb vad rep,All Other,Per Unit,"$12,593.32 ",OP,"3,662.14","12,593.32",,,,,,
BCBS Blue Choice,CPT,Q0485,Monitor cable elec vad- rep,All Other,Per Unit,"$1,216.24 ",OP,353.6,"1,216.24",,,,,,
BCBS Blue Choice,CPT,Q0486,Mon cable elec/pneum vad rep,All Other,Per Unit,"$1,010.37 ",OP,294.28,"1,010.37",,,,,,
BCBS Blue Choice,CPT,Q0487,Leads any type vad- rep only,All Other,Per Unit,"$1,181.94 ",OP,343.31,"1,181.94",,,,,,
BCBS Blue Choice,CPT,Q0489,Pwr pck base combo vad- rep,All Other,Per Unit,"$56,225.77 ",OP,"16,348.80","56,225.77",,,,,,
BCBS Blue Choice,CPT,Q0490,Emr pwr source elec vad- rep,All Other,Per Unit,"$2,432.50 ",OP,707.17,"2,432.50",,,,,,
BCBS Blue Choice,CPT,Q0491,Emr pwr source combo vad rep,All Other,Per Unit,"$3,824.13 ",OP,"1,111.75","3,824.13",,,,,,
BCBS Blue Choice,CPT,Q0492,Emr pwr cbl elec vad- rep,All Other,Per Unit,$308.83 ,OP,89.58,308.83,,,,,,
BCBS Blue Choice,CPT,Q0493,Emr pwr cbl combo vad- rep,All Other,Per Unit,$876.92 ,OP,255.02,876.92,,,,,,
BCBS Blue Choice,CPT,Q0494,Emr hd pmp elec/combo- rep,All Other,Per Unit,$743.48 ,OP,215.79,743.48,,,,,,
BCBS Blue Choice,CPT,Q0495,Charger elec/combo vad- rep,All Other,Per Unit,"$14,450.10 ",OP,"4,201.23","14,450.10",,,,,,
BCBS Blue Choice,CPT,Q0496,Battery elec/combo vad- rep,All Other,Per Unit,"$5,185.26 ",OP,"1,507.90","5,185.26",,,,,,
BCBS Blue Choice,CPT,Q0497,Bat clps elec/comb vad- rep,All Other,Per Unit,"$1,620.40 ",OP,470.84,"1,620.40",,,,,,
BCBS Blue Choice,CPT,Q0498,Holster elec/combo vad- rep,All Other,Per Unit,"$1,776.71 ",OP,516.61,"1,776.71",,,,,,
BCBS Blue Choice,CPT,Q0499,Belt/vest elec/combo vad rep,All Other,Per Unit,$575.73 ,OP,167.86,575.73,,,,,,
BCBS Blue Choice,CPT,Q0500,Filters elec/combo vad- rep,All Other,Per Unit,$106.76 ,OP,30.69,106.76,,,,,,
BCBS Blue Choice,CPT,Q0501,Shwr cov elec/combo vad- rep,All Other,Per Unit,"$1,765.27 ",OP,513.63,"1,765.27",,,,,,
BCBS Blue Choice,CPT,Q0502,Mobility cart pneum vad- rep,All Other,Per Unit,"$2,249.49 ",OP,653.97,"2,249.49",,,,,,
BCBS Blue Choice,CPT,Q0503,Battery pneum vad replacemnt,All Other,Per Unit,"$4,498.98 ",OP,"1,307.87","4,498.98",,,,,,
BCBS Blue Choice,CPT,Q0504,Pwr adpt pneum vad- rep veh,All Other,Per Unit,"$2,375.30 ",OP,690.16,"2,375.30",,,,,,
BCBS Blue Choice,CPT,Q0510,Dispens fee immunosupressive,All Other,Per Unit,$190.64 ,OP,190.64,190.64,,,,,,
BCBS Blue Choice,CPT,Q0511,Sup fee antiem-antica-immuno,All Other,Per Unit,$91.51 ,OP,91.51,91.51,,,,,,
BCBS Blue Choice,CPT,Q0512,Px sup fee anti-can sub pres,All Other,Per Unit,$61.00 ,OP,61,61,,,,,,
BCBS Blue Choice,CPT,Q0513,Disp fee inhal drugs/30 days,All Other,Per Unit,$125.82 ,OP,125.82,125.82,,,,,,
BCBS Blue Choice,CPT,Q0514,Disp fee inhal drugs/90 days,All Other,Per Unit,$251.64 ,OP,251.64,251.64,,,,,,
BCBS Blue Choice,CPT,Q0515,Sermorelin acetate injection,All Other,Per Unit,$7.62 ,OP,7.62,7.62,,,,,,
BCBS Blue Choice,CPT,Q2017,Teniposide- 50 mg,All Other,Per Unit,"$1,582.28 ",OP,"1,582.28","2,645.71",,,,,,
BCBS Blue Choice,CPT,Q2050,Doxorubicin inj 10mg,All Other,Per Unit,"$1,719.01 ",OP,234.03,"1,719.01",,,,,,
BCBS Blue Choice,CPT,Q3025,IM inj interferon beta 1-a,All Other,Per Unit,$815.92 ,OP,815.92,815.92,,,,,,
BCBS Blue Choice,CPT,Q3026,Subc inj interferon beta-1a,All Other,Per Unit,$178.51 ,OP,178.51,178.51,,,,,,
BCBS Blue Choice,CPT,Q3027,Inj beta interferon im 1 mcg,All Other,Per Unit,$74.17 ,OP,55.29,74.17,,,,,,
BCBS Blue Choice,CPT,Q3028,Inj beta interferon sq 1 mcg,All Other,Per Unit,$16.24 ,OP,16.24,16.24,,,,,,
BCBS Blue Choice,CPT,Q4001,Cast sup body cast plaster,All Other,Per Unit,$167.76 ,OP,167.76,167.76,,,,,,
BCBS Blue Choice,CPT,Q4002,Cast sup body cast fiberglas,All Other,Per Unit,$636.73 ,OP,636.73,636.73,,,,,,
BCBS Blue Choice,CPT,Q4003,Cast sup shoulder cast plstr,All Other,Per Unit,$122.00 ,OP,122,122,,,,,,
BCBS Blue Choice,CPT,Q4004,Cast sup shoulder cast fbrgl,All Other,Per Unit,$419.40 ,OP,419.4,419.4,,,,,,
BCBS Blue Choice,CPT,Q4005,Cast sup long arm adult plst,All Other,Per Unit,$45.74 ,OP,45.74,45.74,,,,,,
BCBS Blue Choice,CPT,Q4006,Cast sup long arm adult fbrg,All Other,Per Unit,$99.13 ,OP,99.13,99.13,,,,,,
BCBS Blue Choice,CPT,Q4007,Cast sup long arm ped plster,All Other,Per Unit,$22.88 ,OP,22.88,22.88,,,,,,
BCBS Blue Choice,CPT,Q4008,Cast sup long arm ped fbrgls,All Other,Per Unit,$49.56 ,OP,49.56,49.56,,,,,,
BCBS Blue Choice,CPT,Q4009,Cast sup sht arm adult plstr,All Other,Per Unit,$30.51 ,OP,30.51,30.51,,,,,,
BCBS Blue Choice,CPT,Q4010,Cast sup sht arm adult fbrgl,All Other,Per Unit,$68.63 ,OP,68.63,68.63,,,,,,
BCBS Blue Choice,CPT,Q4011,Cast sup sht arm ped plaster,All Other,Per Unit,$15.26 ,OP,15.26,15.26,,,,,,
BCBS Blue Choice,CPT,Q4012,Cast sup sht arm ped fbrglas,All Other,Per Unit,$34.31 ,OP,34.31,34.31,,,,,,
BCBS Blue Choice,CPT,Q4013,Cast sup gauntlet plaster,All Other,Per Unit,$53.38 ,OP,53.38,53.38,,,,,,
BCBS Blue Choice,CPT,Q4014,Cast sup gauntlet fiberglass,All Other,Per Unit,$91.51 ,OP,91.51,91.51,,,,,,
BCBS Blue Choice,CPT,Q4015,Cast sup gauntlet ped plster,All Other,Per Unit,$26.70 ,OP,26.7,26.7,,,,,,
BCBS Blue Choice,CPT,Q4016,Cast sup gauntlet ped fbrgls,All Other,Per Unit,$45.74 ,OP,45.74,45.74,,,,,,
BCBS Blue Choice,CPT,Q4017,Cast sup lng arm splint plst,All Other,Per Unit,$30.51 ,OP,30.51,30.51,,,,,,
BCBS Blue Choice,CPT,Q4018,Cast sup lng arm splint fbrg,All Other,Per Unit,$49.56 ,OP,49.56,49.56,,,,,,
BCBS Blue Choice,CPT,Q4019,Cast sup lng arm splnt ped p,All Other,Per Unit,$15.26 ,OP,15.26,15.26,,,,,,
BCBS Blue Choice,CPT,Q4020,Cast sup lng arm splnt ped f,All Other,Per Unit,$26.70 ,OP,26.7,26.7,,,,,,
BCBS Blue Choice,CPT,Q4021,Cast sup sht arm splint plst,All Other,Per Unit,$22.88 ,OP,22.88,22.88,,,,,,
BCBS Blue Choice,CPT,Q4022,Cast sup sht arm splint fbrg,All Other,Per Unit,$41.94 ,OP,41.94,41.94,,,,,,
BCBS Blue Choice,CPT,Q4023,Cast sup sht arm splnt ped p,All Other,Per Unit,$11.44 ,OP,11.44,11.44,,,,,,
BCBS Blue Choice,CPT,Q4024,Cast sup sht arm splnt ped f,All Other,Per Unit,$19.07 ,OP,19.07,19.07,,,,,,
BCBS Blue Choice,CPT,Q4025,Cast sup hip spica plaster,All Other,Per Unit,$129.64 ,OP,129.64,129.64,,,,,,
BCBS Blue Choice,CPT,Q4026,Cast sup hip spica fiberglas,All Other,Per Unit,$404.14 ,OP,404.14,404.14,,,,,,
BCBS Blue Choice,CPT,Q4027,Cast sup hip spica ped plstr,All Other,Per Unit,$64.82 ,OP,64.82,64.82,,,,,,
BCBS Blue Choice,CPT,Q4028,Cast sup hip spica ped fbrgl,All Other,Per Unit,$202.07 ,OP,202.07,202.07,,,,,,
BCBS Blue Choice,CPT,Q4029,Cast sup long leg plaster,All Other,Per Unit,$99.13 ,OP,99.13,99.13,,,,,,
BCBS Blue Choice,CPT,Q4030,Cast sup long leg fiberglass,All Other,Per Unit,$263.08 ,OP,263.08,263.08,,,,,,
BCBS Blue Choice,CPT,Q4031,Cast sup lng leg ped plaster,All Other,Per Unit,$49.56 ,OP,49.56,49.56,,,,,,
BCBS Blue Choice,CPT,Q4032,Cast sup lng leg ped fbrgls,All Other,Per Unit,$129.64 ,OP,129.64,129.64,,,,,,
BCBS Blue Choice,CPT,Q4033,Cast sup lng leg cylinder pl,All Other,Per Unit,$91.51 ,OP,91.51,91.51,,,,,,
BCBS Blue Choice,CPT,Q4034,Cast sup lng leg cylinder fb,All Other,Per Unit,$228.77 ,OP,228.77,228.77,,,,,,
BCBS Blue Choice,CPT,Q4035,Cast sup lngleg cylndr ped p,All Other,Per Unit,$45.74 ,OP,45.74,45.74,,,,,,
BCBS Blue Choice,CPT,Q4036,Cast sup lngleg cylndr ped f,All Other,Per Unit,$114.39 ,OP,114.39,114.39,,,,,,
BCBS Blue Choice,CPT,Q4037,Cast sup shrt leg plaster,All Other,Per Unit,$57.19 ,OP,57.19,57.19,,,,,,
BCBS Blue Choice,CPT,Q4038,Cast sup shrt leg fiberglass,All Other,Per Unit,$141.07 ,OP,141.07,141.07,,,,,,
BCBS Blue Choice,CPT,Q4039,Cast sup shrt leg ped plster,All Other,Per Unit,$26.70 ,OP,26.7,26.7,,,,,,
BCBS Blue Choice,CPT,Q4040,Cast sup shrt leg ped fbrgls,All Other,Per Unit,$72.44 ,OP,72.44,72.44,,,,,,
BCBS Blue Choice,CPT,Q4041,Cast sup lng leg splnt plstr,All Other,Per Unit,$68.63 ,OP,68.63,68.63,,,,,,
BCBS Blue Choice,CPT,Q4042,Cast sup lng leg splnt fbrgl,All Other,Per Unit,$118.19 ,OP,118.19,118.19,,,,,,
BCBS Blue Choice,CPT,Q4043,Cast sup lng leg splnt ped p,All Other,Per Unit,$34.31 ,OP,34.31,34.31,,,,,,
BCBS Blue Choice,CPT,Q4044,Cast sup lng leg splnt ped f,All Other,Per Unit,$57.19 ,OP,57.19,57.19,,,,,,
BCBS Blue Choice,CPT,Q4045,Cast sup sht leg splnt plstr,All Other,Per Unit,$38.13 ,OP,38.13,38.13,,,,,,
BCBS Blue Choice,CPT,Q4046,Cast sup sht leg splnt fbrgl,All Other,Per Unit,$64.82 ,OP,64.82,64.82,,,,,,
BCBS Blue Choice,CPT,Q4047,Cast sup sht leg splnt ped p,All Other,Per Unit,$19.07 ,OP,19.07,19.07,,,,,,
BCBS Blue Choice,CPT,Q4048,Cast sup sht leg splnt ped f,All Other,Per Unit,$30.51 ,OP,30.51,30.51,,,,,,
BCBS Blue Choice,CPT,Q4049,Finger splint- static,All Other,Per Unit,$7.62 ,OP,7.62,7.62,,,,,,
BCBS Blue Choice,CPT,Q4080,Iloprost non-comp unit dose,All Other,Per Unit,$236.38 ,OP,236.38,236.38,,,,,,
BCBS Blue Choice,CPT,Q4081,Epoetin alfa- 100 units esrd,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,Q4101,Apligraf,All Other,Per Unit,$152.51 ,OP,152.51,152.51,,,,,,
BCBS Blue Choice,CPT,Q4102,Oasis wound matrix,All Other,Per Unit,$19.07 ,OP,19.07,19.07,,,,,,
BCBS Blue Choice,CPT,Q4103,Oasis burn matrix,All Other,Per Unit,$19.07 ,OP,19.07,19.07,,,,,,
BCBS Blue Choice,CPT,Q4104,Integra bmwd,All Other,Per Unit,$57.19 ,OP,57.19,57.19,,,,,,
BCBS Blue Choice,CPT,Q4105,Integra drt or omnigraft,All Other,Per Unit,$57.19 ,OP,57.19,57.19,,,,,,
BCBS Blue Choice,CPT,Q4106,Dermagraft,All Other,Per Unit,$186.82 ,OP,186.82,186.82,,,,,,
BCBS Blue Choice,CPT,Q4108,Integra matrix,All Other,Per Unit,$91.51 ,OP,91.51,91.51,,,,,,
BCBS Blue Choice,CPT,Q4109,Tissuemend skin sub,All Other,Per Unit,$354.58 ,OP,354.58,354.58,,,,,,
BCBS Blue Choice,CPT,Q4110,Primatrix,All Other,Per Unit,$175.39 ,OP,175.39,175.39,,,,,,
BCBS Blue Choice,CPT,Q4111,Gammagraft,All Other,Per Unit,$34.31 ,OP,34.31,34.31,,,,,,
BCBS Blue Choice,CPT,Q4112,Cymetra injectable,All Other,Per Unit,"$1,502.21 ",OP,"1,502.21","1,502.21",,,,,,
BCBS Blue Choice,CPT,Q4113,Graftjacket xpress,All Other,Per Unit,"$1,502.21 ",OP,"1,502.21","1,502.21",,,,,,
BCBS Blue Choice,CPT,Q4114,Integra flowable wound matri,All Other,Per Unit,"$4,373.16 ",OP,"4,373.16","4,373.16",,,,,,
BCBS Blue Choice,CPT,Q9951,Locm >= 400 mg/ml iodine-1ml,All Other,Per Unit,$11.44 ,OP,11.44,11.44,,,,,,
BCBS Blue Choice,CPT,Q9953,Inj fe-based mr contrast-1ml,All Other,Per Unit,$148.69 ,OP,148.69,148.69,,,,,,
BCBS Blue Choice,CPT,Q9954,Oral mr contrast- 100 ml,All Other,Per Unit,$45.74 ,OP,45.74,45.74,,,,,,
BCBS Blue Choice,CPT,Q9955,Inj perflexane lip micros-ml,All Other,Per Unit,$64.82 ,OP,64.82,64.82,,,,,,
BCBS Blue Choice,CPT,Q9956,Inj octafluoropropane mic-ml,All Other,Per Unit,$202.07 ,OP,202.07,202.07,,,,,,
BCBS Blue Choice,CPT,Q9957,Inj perflutren lip micros-ml,All Other,Per Unit,$301.20 ,OP,301.2,301.2,,,,,,
BCBS Blue Choice,CPT,Q9958,Hocm <=149 mg/ml iodine- 1ml,All Other,Per Unit,$2.46 ,OP,2.46,2.46,,,,,,
BCBS Blue Choice,CPT,Q9960,Hocm 200-249mg/ml iodine-1ml,All Other,Per Unit,$2.46 ,OP,2.46,2.46,,,,,,
BCBS Blue Choice,CPT,Q9961,Hocm 250-299mg/ml iodine-1ml,All Other,Per Unit,$2.46 ,OP,2.46,2.46,,,,,,
BCBS Blue Choice,CPT,Q9963,Hocm 350-399mg/ml iodine-1ml,All Other,Per Unit,$2.46 ,OP,2.46,2.46,,,,,,
BCBS Blue Choice,CPT,Q9964,Hocm>= 400mg/ml iodine- 1ml,All Other,Per Unit,$2.46 ,OP,2.46,2.46,,,,,,
BCBS Blue Choice,CPT,Q9966,Locm 200-299mg/ml iodine-1ml,All Other,Per Unit,$2.46 ,OP,2.46,2.46,,,,,,
BCBS Blue Choice,CPT,Q9967,Locm 300-399mg/ml iodine-1ml,All Other,Per Unit,$2.46 ,OP,2.46,2.46,,,,,,
BCBS Blue Choice,CPT,R0070,Transport portable x-ray,All Other,Per Unit,$152.51 ,OP,152.51,152.51,,,,,,
BCBS Blue Choice,CPT,R0075,Transport port x-ray multipl,All Other,Per Unit,$137.25 ,OP,137.25,137.25,,,,,,
BCBS Blue Choice,CPT,R0076,Transport portable ekg,All Other,Per Unit,$137.25 ,OP,137.25,137.25,,,,,,
BCBS Blue Choice,CPT,S0012,Butorphanol tartrate nasal,All Other,Per Unit,$285.96 ,OP,285.96,285.96,,,,,,
BCBS Blue Choice,CPT,S0014,Tacrine hydrochloride 10 mg,All Other,Per Unit,$11.44 ,OP,11.44,11.44,,,,,,
BCBS Blue Choice,CPT,S0017,Injection aminocaproic acid,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,S0020,Injection bupivicaine hydro,All Other,Per Unit,$11.44 ,OP,11.44,11.44,,,,,,
BCBS Blue Choice,CPT,S0021,Injection cefoperazone sod,All Other,Per Unit,$68.63 ,OP,68.63,68.63,,,,,,
BCBS Blue Choice,CPT,S0023,Injection cimetidine hydroc,All Other,Per Unit,$11.44 ,OP,11.44,11.44,,,,,,
BCBS Blue Choice,CPT,S0028,Injection famotidine 20 mg,All Other,Per Unit,$19.07 ,OP,19.07,19.07,,,,,,
BCBS Blue Choice,CPT,S0030,Injection metronidazole,All Other,Per Unit,$19.07 ,OP,19.07,19.07,,,,,,
BCBS Blue Choice,CPT,S0034,Injection ofloxacin 400 mg,All Other,Per Unit,$11.44 ,OP,11.44,11.44,,,,,,
BCBS Blue Choice,CPT,S0039,Injection sulfamethoxazole,All Other,Per Unit,$22.88 ,OP,22.88,22.88,,,,,,
BCBS Blue Choice,CPT,S0040,Injection ticarcillin disod,All Other,Per Unit,$72.44 ,OP,72.44,72.44,,,,,,
BCBS Blue Choice,CPT,S0074,Injection cefotetan disodiu,All Other,Per Unit,$26.70 ,OP,26.7,26.7,,,,,,
BCBS Blue Choice,CPT,S0080,Injection pentamidine iseth,All Other,Per Unit,$205.88 ,OP,205.88,205.88,,,,,,
BCBS Blue Choice,CPT,S0081,Injection piperacillin sodi,All Other,Per Unit,$7.62 ,OP,7.62,7.62,,,,,,
BCBS Blue Choice,CPT,S0088,Imatinib 100 mg,All Other,Per Unit,$118.99 ,OP,118.99,118.99,,,,,,
BCBS Blue Choice,CPT,S0090,Sildenafil citrate 25 mg,All Other,Per Unit,$64.82 ,OP,64.82,64.82,,,,,,
BCBS Blue Choice,CPT,S0091,Granisetron 1mg,All Other,Per Unit,$45.74 ,OP,45.74,45.74,,,,,,
BCBS Blue Choice,CPT,S0092,Hydromorphone 250 mg,All Other,Per Unit,$457.52 ,OP,457.52,457.52,,,,,,
BCBS Blue Choice,CPT,S0093,Morphine 500 mg,All Other,Per Unit,$87.69 ,OP,87.69,87.69,,,,,,
BCBS Blue Choice,CPT,S0104,Zidovudine oral 100 mg,All Other,Per Unit,$61.00 ,OP,61,61,,,,,,
BCBS Blue Choice,CPT,S0106,Bupropion hcl sr 60 tablets,All Other,Per Unit,$491.83 ,OP,491.83,491.83,,,,,,
BCBS Blue Choice,CPT,S0108,Mercaptopurine 50 mg,All Other,Per Unit,$6.72 ,OP,6.72,6.72,,,,,,
BCBS Blue Choice,CPT,S0109,Methadone oral 5mg,All Other,Per Unit,$1.90 ,OP,1.9,1.9,,,,,,
BCBS Blue Choice,CPT,S0117,Tretinoin topical 5 g,All Other,Per Unit,$49.56 ,OP,49.56,49.56,,,,,,
BCBS Blue Choice,CPT,S0122,Inj menotropins 75 iu,All Other,Per Unit,$278.67 ,OP,278.67,278.67,,,,,,
BCBS Blue Choice,CPT,S0126,Inj follitropin alfa 75 iu,All Other,Per Unit,$339.52 ,OP,339.52,339.52,,,,,,
BCBS Blue Choice,CPT,S0128,Inj follitropin beta 75 iu,All Other,Per Unit,$331.25 ,OP,331.25,331.25,,,,,,
BCBS Blue Choice,CPT,S0132,Inj ganirelix acetat 250 mcg,All Other,Per Unit,$465.15 ,OP,465.15,465.15,,,,,,
BCBS Blue Choice,CPT,S0136,Clozapine 25 mg,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,S0137,Didanosine 25 mg,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,S0138,Finasteride 5 mg,All Other,Per Unit,$15.26 ,OP,15.26,15.26,,,,,,
BCBS Blue Choice,CPT,S0139,Minoxidil 10 mg,All Other,Per Unit,$7.62 ,OP,7.62,7.62,,,,,,
BCBS Blue Choice,CPT,S0140,Saquinavir 200 mg,All Other,Per Unit,$7.62 ,OP,7.62,7.62,,,,,,
BCBS Blue Choice,CPT,S0146,Peg interferon alfa-2b/10,All Other,Per Unit,$324.50 ,OP,324.5,324.5,,,,,,
BCBS Blue Choice,CPT,S0155,Epoprostenol dilutant,All Other,Per Unit,$61.00 ,OP,61,61,,,,,,
BCBS Blue Choice,CPT,S0156,Exemestane 25 mg,All Other,Per Unit,$41.33 ,OP,41.33,41.33,,,,,,
BCBS Blue Choice,CPT,S0157,Becaplermin gel 1% 0.5 gm,All Other,Per Unit,$80.07 ,OP,80.07,80.07,,,,,,
BCBS Blue Choice,CPT,S0160,Dextroamphetamine,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,S0161,Calcitrol,All Other,Per Unit,$7.62 ,OP,7.62,7.62,,,,,,
BCBS Blue Choice,CPT,S0162,Injection efalizumab,All Other,Per Unit,"$1,549.75 ",OP,"1,549.75","1,549.75",,,,,,
BCBS Blue Choice,CPT,S0164,Injection pantroprazole,All Other,Per Unit,$57.19 ,OP,57.19,57.19,,,,,,
BCBS Blue Choice,CPT,S0166,Inj olanzapine 2.5mg,All Other,Per Unit,$30.51 ,OP,30.51,30.51,,,,,,
BCBS Blue Choice,CPT,S0170,Anastrozole 1 mg,All Other,Per Unit,$49.56 ,OP,49.56,49.56,,,,,,
BCBS Blue Choice,CPT,S0171,Bumetanide 0.5 mg,All Other,Per Unit,$7.62 ,OP,7.62,7.62,,,,,,
BCBS Blue Choice,CPT,S0172,Chlorambucil 2 mg,All Other,Per Unit,$15.26 ,OP,15.26,15.26,,,,,,
BCBS Blue Choice,CPT,S0174,Dolasetron 50 mg,All Other,Per Unit,$228.77 ,OP,228.77,228.77,,,,,,
BCBS Blue Choice,CPT,S0175,Flutamide 125 mg,All Other,Per Unit,$7.62 ,OP,7.62,7.62,,,,,,
BCBS Blue Choice,CPT,S0176,Hydroxyurea 500 mg,All Other,Per Unit,$7.62 ,OP,7.62,7.62,,,,,,
BCBS Blue Choice,CPT,S0177,Levamisole 50 mg,All Other,Per Unit,$22.88 ,OP,22.88,22.88,,,,,,
BCBS Blue Choice,CPT,S0178,Lomustine 10 mg,All Other,Per Unit,$41.94 ,OP,41.94,41.94,,,,,,
BCBS Blue Choice,CPT,S0181,ONDANSETRON HYDROCHLORIDE ORAL 4 MG,All Other,Per Unit,$89.98 ,OP,89.98,89.98,,,,,,
BCBS Blue Choice,CPT,S0182,Procarbazine oral,All Other,Per Unit,$176.19 ,OP,176.19,176.19,,,,,,
BCBS Blue Choice,CPT,S0183,Prochlorperazine 5 mg,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,S0187,Tamoxifen 10 mg,All Other,Per Unit,$7.62 ,OP,7.62,7.62,,,,,,
BCBS Blue Choice,CPT,S0189,Testosterone pellet 75 mg,All Other,Per Unit,$285.96 ,OP,285.96,285.96,,,,,,
BCBS Blue Choice,CPT,S0190,Mifepristone oral 200 mg,All Other,Per Unit,$343.14 ,OP,343.14,343.14,,,,,,
BCBS Blue Choice,CPT,S0191,Misoprostol oral 200 mcg,All Other,Per Unit,$7.62 ,OP,7.62,7.62,,,,,,
BCBS Blue Choice,CPT,S0195,PNEUMCOCCL VAC IM 5-9 YR NOT PREV,All Other,Per Unit,$427.03 ,OP,427.03,427.03,,,,,,
BCBS Blue Choice,CPT,S0199,Med abortion inc all ex drug,All Other,Per Unit,"$2,600.26 ",OP,"2,600.26","2,600.26",,,,,,
BCBS Blue Choice,CPT,S0220,Medical conference by physic,All Other,Per Unit,$228.77 ,OP,228.77,228.77,,,,,,
BCBS Blue Choice,CPT,S0221,Medical conference 60 min,All Other,Per Unit,$293.57 ,OP,293.57,293.57,,,,,,
BCBS Blue Choice,CPT,S0345,Electrocardiographic monitoring utilizing a home computerized telemetry station,All Other,Per Unit,$19.07 ,OP,19.07,19.07,,,,,,
BCBS Blue Choice,CPT,S0395,Impression casting ft,All Other,Per Unit,$362.21 ,OP,362.21,362.21,,,,,,
BCBS Blue Choice,CPT,S0400,Global eswl kidney,All Other,Per Unit,"$7,007.73 ",OP,"7,007.73","7,007.73",,,,,,
BCBS Blue Choice,CPT,S0592,Comp cont lens eval,All Other,Per Unit,$449.90 ,OP,449.9,449.9,,,,,,
BCBS Blue Choice,CPT,S0601,Screening proctoscopy,All Other,Per Unit,$427.03 ,OP,427.03,427.03,,,,,,
BCBS Blue Choice,CPT,S0605,Digital rectal examination-,All Other,Per Unit,$102.95 ,OP,102.95,102.95,,,,,,
BCBS Blue Choice,CPT,S0610,Annual gynecological examina,All Other,Per Unit,$335.53 ,OP,335.53,335.53,,,,,,
BCBS Blue Choice,CPT,S0612,Annual gynecological examina,All Other,Per Unit,$198.25 ,OP,198.25,198.25,,,,,,
BCBS Blue Choice,CPT,S0613,Ann breast exam,All Other,Per Unit,$19.07 ,OP,19.07,19.07,,,,,,
BCBS Blue Choice,CPT,S0618,Audiometry for hearing aid,All Other,Per Unit,$571.91 ,OP,571.91,571.91,,,,,,
BCBS Blue Choice,CPT,S0620,Routine ophthalmological exa,All Other,Per Unit,$411.78 ,OP,411.78,411.78,,,,,,
BCBS Blue Choice,CPT,S0621,Routine ophthalmological exa,All Other,Per Unit,$434.65 ,OP,434.65,434.65,,,,,,
BCBS Blue Choice,CPT,S0625,Digital screening retina,All Other,Per Unit,$476.60 ,OP,476.6,476.6,,,,,,
BCBS Blue Choice,CPT,S0800,Laser in situ keratomileusis,All Other,Per Unit,"$7,625.38 ",OP,"7,625.38","7,625.38",,,,,,
BCBS Blue Choice,CPT,S0810,Photorefractive keratectomy,All Other,Per Unit,"$3,435.25 ",OP,"3,435.25","3,435.25",,,,,,
BCBS Blue Choice,CPT,S1015,Iv tubing extension set,All Other,Per Unit,$122.00 ,OP,122,122,,,,,,
BCBS Blue Choice,CPT,S1040,Cranial remolding orthosis,All Other,Per Unit,"$7,625.38 ",OP,"7,625.38","7,625.38",,,,,,
BCBS Blue Choice,CPT,S2060,Lobar lung transplantation,All Other,Per Unit,"$15,876.06 ",OP,"15,876.06","15,876.06",,,,,,
BCBS Blue Choice,CPT,S2112,Knee arthroscp harv,All Other,Per Unit,"$3,286.54 ",OP,"3,286.54","3,286.54",,,,,,
BCBS Blue Choice,CPT,S2120,Low density lipoprotein(ldl),All Other,Per Unit,"$11,903.22 ",OP,"11,903.22","11,903.22",,,,,,
BCBS Blue Choice,CPT,S2140,Cord blood harvesting,All Other,Per Unit,$953.17 ,OP,953.17,953.17,,,,,,
BCBS Blue Choice,CPT,S2202,Echosclerotherapy,All Other,Per Unit,"$1,567.02 ",OP,"1,567.02","1,567.02",,,,,,
BCBS Blue Choice,CPT,S2205,Minimally invasive direct co,All Other,Per Unit,"$11,175.00 ",OP,"11,175.00","11,175.00",,,,,,
BCBS Blue Choice,CPT,S2206,Minimally invasive direct co,All Other,Per Unit,"$12,841.16 ",OP,"12,841.16","12,841.16",,,,,,
BCBS Blue Choice,CPT,S2207,Minimally invasive direct co,All Other,Per Unit,"$11,403.76 ",OP,"11,403.76","11,403.76",,,,,,
BCBS Blue Choice,CPT,S2300,Arthroscopy shoulder surgi,All Other,Per Unit,"$3,515.30 ",OP,"3,515.30","3,515.30",,,,,,
BCBS Blue Choice,CPT,S2350,Diskectomy anterior with d,All Other,Per Unit,"$9,935.88 ",OP,"9,935.88","9,935.88",,,,,,
BCBS Blue Choice,CPT,S2351,Diskectomy anterior with d,All Other,Per Unit,"$1,780.53 ",OP,"1,780.53","1,780.53",,,,,,
BCBS Blue Choice,CPT,S2360,PERQ VERTPLSTY 1 VERT BDY UNILAT/BILAT INJ-CERV,All Other,Per Unit,"$13,165.23 ",OP,"13,165.23","13,165.23",,,,,,
BCBS Blue Choice,CPT,S2361,EACH ADDITIONAL CERVICAL VERTEBRAL BODY,All Other,Per Unit,"$1,612.76 ",OP,"1,612.76","1,612.76",,,,,,
BCBS Blue Choice,CPT,S2900,Robotic surgical system,All Other,Per Unit,"$9,531.74 ",OP,"9,531.74","9,531.74",,,,,,
BCBS Blue Choice,CPT,S3645,Hiv-1 antibody testing of or,All Other,Per Unit,$167.76 ,OP,167.76,167.76,,,,,,
BCBS Blue Choice,CPT,S3835,CMPL GENE SEQ ANALY CYSTIC FIBROSIS GENETIC TST,All Other,Per Unit,"$1,345.89 ",OP,"1,345.89","1,345.89",,,,,,
BCBS Blue Choice,CPT,S3902,Ballistocardiogram,All Other,Per Unit,$114.39 ,OP,114.39,114.39,,,,,,
BCBS Blue Choice,CPT,S3904,Masters two step,All Other,Per Unit,$114.39 ,OP,114.39,114.39,,,,,,
BCBS Blue Choice,CPT,S4981,Insert levonorgestrel ius,All Other,Per Unit,"$2,161.80 ",OP,"2,161.80","2,161.80",,,,,,
BCBS Blue Choice,CPT,S4989,Contracept iud,All Other,Per Unit,"$1,639.46 ",OP,"1,639.46","1,639.46",,,,,,
BCBS Blue Choice,CPT,S5498,Hit simple cath care,All Other,Per Unit,$30.51 ,OP,30.51,30.51,,,,,,
BCBS Blue Choice,CPT,S5501,Hit complex cath care,All Other,Per Unit,$57.19 ,OP,57.19,57.19,,,,,,
BCBS Blue Choice,CPT,S5502,Hit interim cath care,All Other,Per Unit,$57.19 ,OP,57.19,57.19,,,,,,
BCBS Blue Choice,CPT,S5517,Hit declotting kit,All Other,Per Unit,$76.26 ,OP,76.26,76.26,,,,,,
BCBS Blue Choice,CPT,S5520,Hit picc insert kit,All Other,Per Unit,$571.91 ,OP,571.91,571.91,,,,,,
BCBS Blue Choice,CPT,S5521,Hit midline cath insert kit,All Other,Per Unit,$495.65 ,OP,495.65,495.65,,,,,,
BCBS Blue Choice,CPT,S5522,Hit picc insert no supp,All Other,Per Unit,$495.65 ,OP,495.65,495.65,,,,,,
BCBS Blue Choice,CPT,S5523,Hip midline cath insert kit,All Other,Per Unit,$495.65 ,OP,495.65,495.65,,,,,,
BCBS Blue Choice,CPT,S8096,Portable peak flow meter,All Other,Per Unit,$91.51 ,OP,91.51,91.51,,,,,,
BCBS Blue Choice,CPT,S8101,Spacer with mask,All Other,Per Unit,$247.83 ,OP,247.83,247.83,,,,,,
BCBS Blue Choice,CPT,S8110,Peak expiratory flow rate (p,All Other,Per Unit,$122.00 ,OP,122,122,,,,,,
BCBS Blue Choice,CPT,S8421,Ready gradient sleev/glov,All Other,Per Unit,$392.70 ,OP,392.7,392.7,,,,,,
BCBS Blue Choice,CPT,S8424,Ready gradient sleeve,All Other,Per Unit,$453.71 ,OP,453.71,453.71,,,,,,
BCBS Blue Choice,CPT,S8427,Ready gradient glove,All Other,Per Unit,$629.10 ,OP,629.1,629.1,,,,,,
BCBS Blue Choice,CPT,S8428,Ready gradient gauntlet,All Other,Per Unit,$247.83 ,OP,247.83,247.83,,,,,,
BCBS Blue Choice,CPT,S8431,Compression bandage,All Other,Per Unit,$57.19 ,OP,57.19,57.19,,,,,,
BCBS Blue Choice,CPT,S8450,Splint digit,All Other,Per Unit,$110.57 ,OP,110.57,110.57,,,,,,
BCBS Blue Choice,CPT,S8451,Splint wrist or ankle,All Other,Per Unit,$183.02 ,OP,183.02,183.02,,,,,,
BCBS Blue Choice,CPT,S8452,Splint elbow,All Other,Per Unit,$133.45 ,OP,133.45,133.45,,,,,,
BCBS Blue Choice,CPT,S8948,Low-level laser trmt 15 min,All Other,Per Unit,$266.89 ,OP,266.89,266.89,,,,,,
BCBS Blue Choice,CPT,S8990,Pt or manip for maint,All Other,Per Unit,$133.45 ,OP,133.45,133.45,,,,,,
BCBS Blue Choice,CPT,S9015,Automated EEG monitoring,All Other,Per Unit,"$1,349.70 ",OP,"1,349.70","1,349.70",,,,,,
BCBS Blue Choice,CPT,S9025,Omnicardiogram/cardiointegra,All Other,Per Unit,$114.39 ,OP,114.39,114.39,,,,,,
BCBS Blue Choice,CPT,S9061,Medical supplies and equipme,All Other,Per Unit,$400.34 ,OP,400.34,400.34,,,,,,
BCBS Blue Choice,CPT,S9088,Services provided in urgent,All Other,Per Unit,$1.90 ,OP,1.9,1.9,,,,,,
BCBS Blue Choice,CPT,S9090,Vertebral axial decompressio,All Other,Per Unit,$762.54 ,OP,762.54,762.54,,,,,,
BCBS Blue Choice,CPT,S9122,Home health aide or certifie,All Other,Per Unit,$87.69 ,OP,87.69,87.69,,,,,,
BCBS Blue Choice,CPT,S9123,Nursing care in home rn,All Other,Per Unit,$209.70 ,OP,209.7,209.7,,,,,,
BCBS Blue Choice,CPT,S9124,Nursing care in the home; b,All Other,Per Unit,$183.02 ,OP,183.02,183.02,,,,,,
BCBS Blue Choice,CPT,S9128,Speech therapy in the home,All Other,Per Unit,$327.90 ,OP,327.9,327.9,,,,,,
BCBS Blue Choice,CPT,S9129,Occupational therapy in the,All Other,Per Unit,$400.34 ,OP,400.34,400.34,,,,,,
BCBS Blue Choice,CPT,S9131,Pt in the home per diem,All Other,Per Unit,$667.22 ,OP,667.22,667.22,,,,,,
BCBS Blue Choice,CPT,S9140,Diabetic management program,All Other,Per Unit,$125.82 ,OP,125.82,125.82,,,,,,
BCBS Blue Choice,CPT,S9141,Diabetic management program,All Other,Per Unit,$125.82 ,OP,125.82,125.82,,,,,,
BCBS Blue Choice,CPT,S9208,Home mgmt preterm labor,All Other,Per Unit,$388.89 ,OP,388.89,388.89,,,,,,
BCBS Blue Choice,CPT,S9209,Home mgmt pprom,All Other,Per Unit,$754.91 ,OP,754.91,754.91,,,,,,
BCBS Blue Choice,CPT,S9211,Home mgmt gest hypertension,All Other,Per Unit,$179.20 ,OP,179.2,179.2,,,,,,
BCBS Blue Choice,CPT,S9212,Hm postpar hyper per diem,All Other,Per Unit,$388.89 ,OP,388.89,388.89,,,,,,
BCBS Blue Choice,CPT,S9213,Hm preeclamp per diem,All Other,Per Unit,$388.89 ,OP,388.89,388.89,,,,,,
BCBS Blue Choice,CPT,S9214,Hm gest dm per diem,All Other,Per Unit,$571.91 ,OP,571.91,571.91,,,,,,
BCBS Blue Choice,CPT,S9325,Hit pain mgmt per diem,All Other,Per Unit,$228.77 ,OP,228.77,228.77,,,,,,
BCBS Blue Choice,CPT,S9326,Hit cont pain per diem,All Other,Per Unit,$285.96 ,OP,285.96,285.96,,,,,,
BCBS Blue Choice,CPT,S9327,Hit int pain per diem,All Other,Per Unit,$228.77 ,OP,228.77,228.77,,,,,,
BCBS Blue Choice,CPT,S9329,Hit chemo per diem,All Other,Per Unit,$305.01 ,OP,305.01,305.01,,,,,,
BCBS Blue Choice,CPT,S9330,Hit cont chem diem,All Other,Per Unit,$305.01 ,OP,305.01,305.01,,,,,,
BCBS Blue Choice,CPT,S9331,Hit intermit chemo diem,All Other,Per Unit,$305.01 ,OP,305.01,305.01,,,,,,
BCBS Blue Choice,CPT,S9336,Hit cont anticoag diem,All Other,Per Unit,$285.96 ,OP,285.96,285.96,,,,,,
BCBS Blue Choice,CPT,S9338,Hit immunotherapy diem,All Other,Per Unit,$381.27 ,OP,381.27,381.27,,,,,,
BCBS Blue Choice,CPT,S9340,Hit enteral per diem,All Other,Per Unit,$95.32 ,OP,95.32,95.32,,,,,,
BCBS Blue Choice,CPT,S9341,Hit enteral grav diem,All Other,Per Unit,$114.39 ,OP,114.39,114.39,,,,,,
BCBS Blue Choice,CPT,S9342,Hit enteral pump diem,All Other,Per Unit,$171.58 ,OP,171.58,171.58,,,,,,
BCBS Blue Choice,CPT,S9343,Hit enteral bolus nurs,All Other,Per Unit,$95.32 ,OP,95.32,95.32,,,,,,
BCBS Blue Choice,CPT,S9345,Hit anti-hemophil diem,All Other,Per Unit,$95.32 ,OP,95.32,95.32,,,,,,
BCBS Blue Choice,CPT,S9346,Hit alpha-1-proteinas diem,All Other,Per Unit,$266.89 ,OP,266.89,266.89,,,,,,
BCBS Blue Choice,CPT,S9347,Hit longterm infusion diem,All Other,Per Unit,$343.14 ,OP,343.14,343.14,,,,,,
BCBS Blue Choice,CPT,S9348,Hit sympathomim diem,All Other,Per Unit,$667.22 ,OP,667.22,667.22,,,,,,
BCBS Blue Choice,CPT,S9349,Hit tocolysis diem,All Other,Per Unit,$285.96 ,OP,285.96,285.96,,,,,,
BCBS Blue Choice,CPT,S9351,Hit cont antiemetic diem,All Other,Per Unit,$305.01 ,OP,305.01,305.01,,,,,,
BCBS Blue Choice,CPT,S9353,Hit cont insulin diem,All Other,Per Unit,$285.96 ,OP,285.96,285.96,,,,,,
BCBS Blue Choice,CPT,S9355,Hit chelation diem,All Other,Per Unit,$285.96 ,OP,285.96,285.96,,,,,,
BCBS Blue Choice,CPT,S9357,Hit enzyme replace diem,All Other,Per Unit,$285.96 ,OP,285.96,285.96,,,,,,
BCBS Blue Choice,CPT,S9359,Hit anti-tnf per diem,All Other,Per Unit,$305.01 ,OP,305.01,305.01,,,,,,
BCBS Blue Choice,CPT,S9361,Hit diuretic infus diem,All Other,Per Unit,$95.32 ,OP,95.32,95.32,,,,,,
BCBS Blue Choice,CPT,S9363,Hit anti-spasmotic diem,All Other,Per Unit,$95.32 ,OP,95.32,95.32,,,,,,
BCBS Blue Choice,CPT,S9364,Hit tpn total diem,All Other,Per Unit,$648.16 ,OP,648.16,648.16,,,,,,
BCBS Blue Choice,CPT,S9365,Hit tpn 1 liter diem,All Other,Per Unit,$648.16 ,OP,648.16,648.16,,,,,,
BCBS Blue Choice,CPT,S9366,Hit tpn 2 liter diem,All Other,Per Unit,$915.04 ,OP,915.04,915.04,,,,,,
BCBS Blue Choice,CPT,S9367,Hit tpn 3 liter diem,All Other,Per Unit,"$1,105.68 ",OP,"1,105.68","1,105.68",,,,,,
BCBS Blue Choice,CPT,S9368,Hit tpn over 3l diem,All Other,Per Unit,"$1,296.32 ",OP,"1,296.32","1,296.32",,,,,,
BCBS Blue Choice,CPT,S9370,Ht inj antiemetic diem,All Other,Per Unit,$266.89 ,OP,266.89,266.89,,,,,,
BCBS Blue Choice,CPT,S9372,Ht inj anticoag diem,All Other,Per Unit,$76.26 ,OP,76.26,76.26,,,,,,
BCBS Blue Choice,CPT,S9373,Hit hydra total diem,All Other,Per Unit,$152.51 ,OP,152.51,152.51,,,,,,
BCBS Blue Choice,CPT,S9374,Hit hydra 1 liter diem,All Other,Per Unit,$152.51 ,OP,152.51,152.51,,,,,,
BCBS Blue Choice,CPT,S9375,Hit hydra 2 liter diem,All Other,Per Unit,$190.64 ,OP,190.64,190.64,,,,,,
BCBS Blue Choice,CPT,S9376,Hit hydra 3 liter diem,All Other,Per Unit,$228.77 ,OP,228.77,228.77,,,,,,
BCBS Blue Choice,CPT,S9377,Hit hydra over 3l diem,All Other,Per Unit,$266.89 ,OP,266.89,266.89,,,,,,
BCBS Blue Choice,CPT,S9430,Pharmacy comp/disp serv,All Other,Per Unit,$3.82 ,OP,3.82,3.82,,,,,,
BCBS Blue Choice,CPT,S9455,Diabetic management program,All Other,Per Unit,$72.44 ,OP,72.44,72.44,,,,,,
BCBS Blue Choice,CPT,S9460,Diabetic management program,All Other,Per Unit,$125.82 ,OP,125.82,125.82,,,,,,
BCBS Blue Choice,CPT,S9465,Diabetic management program,All Other,Per Unit,$125.82 ,OP,125.82,125.82,,,,,,
BCBS Blue Choice,CPT,S9470,Nutritional counseling diet,All Other,Per Unit,$228.77 ,OP,228.77,228.77,,,,,,
BCBS Blue Choice,CPT,S9480,Intensive outpatient psychia,All Other,Per Unit,$468.96 ,OP,468.96,468.96,,,,,,
BCBS Blue Choice,CPT,S9490,Hit corticosteroid/diem,All Other,Per Unit,$228.77 ,OP,228.77,228.77,,,,,,
BCBS Blue Choice,CPT,S9494,Hit antibiotic total diem,All Other,Per Unit,$228.77 ,OP,228.77,228.77,,,,,,
BCBS Blue Choice,CPT,S9497,Hit antibiotic q3h diem,All Other,Per Unit,$324.09 ,OP,324.09,324.09,,,,,,
BCBS Blue Choice,CPT,S9500,Hit antibiotic q24h diem,All Other,Per Unit,$266.89 ,OP,266.89,266.89,,,,,,
BCBS Blue Choice,CPT,S9501,Hit antibiotic q12h diem,All Other,Per Unit,$266.89 ,OP,266.89,266.89,,,,,,
BCBS Blue Choice,CPT,S9502,Hit antibiotic q8h diem,All Other,Per Unit,$266.89 ,OP,266.89,266.89,,,,,,
BCBS Blue Choice,CPT,S9503,Hit antibiotic q6h diem,All Other,Per Unit,$305.01 ,OP,305.01,305.01,,,,,,
BCBS Blue Choice,CPT,S9504,Hit antibiotic q4h diem,All Other,Per Unit,$305.01 ,OP,305.01,305.01,,,,,,
BCBS Blue Choice,CPT,S9529,Venipuncture home/snf,All Other,Per Unit,$38.13 ,OP,38.13,38.13,,,,,,
BCBS Blue Choice,CPT,S9537,Ht hem horm inj diem,All Other,Per Unit,$76.26 ,OP,76.26,76.26,,,,,,
BCBS Blue Choice,CPT,S9538,Hit blood products diem,All Other,Per Unit,$305.01 ,OP,305.01,305.01,,,,,,
BCBS Blue Choice,CPT,S9542,Ht inj noc per diem,All Other,Per Unit,$76.26 ,OP,76.26,76.26,,,,,,
BCBS Blue Choice,CPT,S9558,Ht inj growth horm diem,All Other,Per Unit,$76.26 ,OP,76.26,76.26,,,,,,
BCBS Blue Choice,CPT,S9559,Hit inj interferon diem,All Other,Per Unit,$76.26 ,OP,76.26,76.26,,,,,,
BCBS Blue Choice,CPT,S9560,Ht inj hormone diem,All Other,Per Unit,$76.26 ,OP,76.26,76.26,,,,,,
BCBS Blue Choice,CPT,S9562,Ht inj palivizumab diem,All Other,Per Unit,$76.26 ,OP,76.26,76.26,,,,,,
BCBS Blue Choice,CPT,S9590,Ht irrigation diem,All Other,Per Unit,$76.26 ,OP,76.26,76.26,,,,,,
BCBS Blue Choice,CPT,V2020,Vision svcs frames purchases,All Other,Per Unit,$388.89 ,OP,75.22,388.89,,,,,,
BCBS Blue Choice,CPT,V2100,Lens spher single plano 4.00,All Other,Per Unit,$240.20 ,OP,46.49,240.2,,,,,,
BCBS Blue Choice,CPT,V2101,Single visn sphere 4.12-7.00,All Other,Per Unit,$228.77 ,OP,44.67,228.77,,,,,,
BCBS Blue Choice,CPT,V2102,Singl visn sphere 7.12-20.00,All Other,Per Unit,$400.34 ,OP,77.24,400.34,,,,,,
BCBS Blue Choice,CPT,V2103,Spherocylindr 4.00d/12-2.00d,All Other,Per Unit,$202.07 ,OP,39.13,202.07,,,,,,
BCBS Blue Choice,CPT,V2104,Spherocylindr 4.00d/2.12-4d,All Other,Per Unit,$209.70 ,OP,40.34,209.7,,,,,,
BCBS Blue Choice,CPT,V2105,Spherocylinder 4.00d/4.25-6d,All Other,Per Unit,$247.83 ,OP,47.98,247.83,,,,,,
BCBS Blue Choice,CPT,V2106,Spherocylinder 4.00d/>6.00d,All Other,Per Unit,$274.51 ,OP,53.15,274.51,,,,,,
BCBS Blue Choice,CPT,V2107,Spherocylinder 4.25d/12-2d,All Other,Per Unit,$244.01 ,OP,47.33,244.01,,,,,,
BCBS Blue Choice,CPT,V2108,Spherocylinder 4.25d/2.12-4d,All Other,Per Unit,$244.01 ,OP,47.46,244.01,,,,,,
BCBS Blue Choice,CPT,V2109,Spherocylinder 4.25d/4.25-6d,All Other,Per Unit,$339.33 ,OP,66.1,339.33,,,,,,
BCBS Blue Choice,CPT,V2110,Spherocylinder 4.25d/over 6d,All Other,Per Unit,$274.51 ,OP,53.39,274.51,,,,,,
BCBS Blue Choice,CPT,V2111,Spherocylindr 7.25d/.25-2.25,All Other,Per Unit,$335.53 ,OP,64.7,335.53,,,,,,
BCBS Blue Choice,CPT,V2112,Spherocylindr 7.25d/2.25-4d,All Other,Per Unit,$377.46 ,OP,73.09,377.46,,,,,,
BCBS Blue Choice,CPT,V2113,Spherocylindr 7.25d/4.25-6d,All Other,Per Unit,$381.27 ,OP,73.91,381.27,,,,,,
BCBS Blue Choice,CPT,V2114,Spherocylinder over 12.00d,All Other,Per Unit,$453.71 ,OP,87.57,453.71,,,,,,
BCBS Blue Choice,CPT,V2115,Lens lenticular bifocal,All Other,Per Unit,$453.71 ,OP,88.27,453.71,,,,,,
BCBS Blue Choice,CPT,V2118,Lens aniseikonic single,All Other,Per Unit,$495.65 ,OP,96.05,495.65,,,,,,
BCBS Blue Choice,CPT,V2121,Lenticular lens- single,All Other,Per Unit,$446.08 ,OP,86.61,446.08,,,,,,
BCBS Blue Choice,CPT,V2200,Lens spher bifoc plano 4.00d,All Other,Per Unit,$270.71 ,OP,52.35,270.71,,,,,,
BCBS Blue Choice,CPT,V2201,Lens sphere bifocal 4.12-7.0,All Other,Per Unit,$289.76 ,OP,56.09,289.76,,,,,,
BCBS Blue Choice,CPT,V2202,Lens sphere bifocal 7.12-20.,All Other,Per Unit,$358.39 ,OP,69.53,358.39,,,,,,
BCBS Blue Choice,CPT,V2203,Lens sphcyl bifocal 4.00d/.1,All Other,Per Unit,$278.32 ,OP,53.92,278.32,,,,,,
BCBS Blue Choice,CPT,V2204,Lens sphcy bifocal 4.00d/2.1,All Other,Per Unit,$285.96 ,OP,55.48,285.96,,,,,,
BCBS Blue Choice,CPT,V2205,Lens sphcy bifocal 4.00d/4.2,All Other,Per Unit,$316.46 ,OP,61.51,316.46,,,,,,
BCBS Blue Choice,CPT,V2206,Lens sphcy bifocal 4.00d/ove,All Other,Per Unit,$373.65 ,OP,72.21,373.65,,,,,,
BCBS Blue Choice,CPT,V2207,Lens sphcy bifocal 4.25-7d/.,All Other,Per Unit,$316.46 ,OP,61.03,316.46,,,,,,
BCBS Blue Choice,CPT,V2208,Lens sphcy bifocal 4.25-7/2.,All Other,Per Unit,$308.83 ,OP,59.97,308.83,,,,,,
BCBS Blue Choice,CPT,V2209,Lens sphcy bifocal 4.25-7/4.,All Other,Per Unit,$362.21 ,OP,70.4,362.21,,,,,,
BCBS Blue Choice,CPT,V2210,Lens sphcy bifocal 4.25-7/ov,All Other,Per Unit,$392.70 ,OP,75.86,392.7,,,,,,
BCBS Blue Choice,CPT,V2211,Lens sphcy bifo 7.25-12/.25-,All Other,Per Unit,$381.27 ,OP,73.85,381.27,,,,,,
BCBS Blue Choice,CPT,V2212,Lens sphcyl bifo 7.25-12/2.2,All Other,Per Unit,$400.34 ,OP,77.3,400.34,,,,,,
BCBS Blue Choice,CPT,V2213,Lens sphcyl bifo 7.25-12/4.2,All Other,Per Unit,$419.40 ,OP,81.28,419.4,,,,,,
BCBS Blue Choice,CPT,V2214,Lens sphcyl bifocal over 12.,All Other,Per Unit,$438.47 ,OP,84.95,438.47,,,,,,
BCBS Blue Choice,CPT,V2215,Lens lenticular bifocal,All Other,Per Unit,$549.03 ,OP,106.06,549.03,,,,,,
BCBS Blue Choice,CPT,V2218,Lens aniseikonic bifocal,All Other,Per Unit,$556.65 ,OP,108.09,556.65,,,,,,
BCBS Blue Choice,CPT,V2219,Lens bifocal seg width over,All Other,Per Unit,$255.45 ,OP,49.86,255.45,,,,,,
BCBS Blue Choice,CPT,V2220,Lens bifocal add over 3.25d,All Other,Per Unit,$228.77 ,OP,44.28,228.77,,,,,,
BCBS Blue Choice,CPT,V2221,Lenticular lens- bifocal,All Other,Per Unit,$457.52 ,OP,88.33,457.52,,,,,,
BCBS Blue Choice,CPT,V2300,Lens sphere trifocal 4.00d,All Other,Per Unit,$369.83 ,OP,71.57,369.83,,,,,,
BCBS Blue Choice,CPT,V2301,Lens sphere trifocal 4.12-7.,All Other,Per Unit,$453.71 ,OP,87.77,453.71,,,,,,
BCBS Blue Choice,CPT,V2302,Lens sphere trifocal 7.12-20,All Other,Per Unit,$423.22 ,OP,82,423.22,,,,,,
BCBS Blue Choice,CPT,V2303,Lens sphcy trifocal 4.0/.12-,All Other,Per Unit,$354.58 ,OP,68.89,354.58,,,,,,
BCBS Blue Choice,CPT,V2304,Lens sphcy trifocal 4.0/2.25,All Other,Per Unit,$358.39 ,OP,69.7,358.39,,,,,,
BCBS Blue Choice,CPT,V2305,Lens sphcy trifocal 4.0/4.25,All Other,Per Unit,$400.34 ,OP,77.86,400.34,,,,,,
BCBS Blue Choice,CPT,V2306,Lens sphcyl trifocal 4.00/>6,All Other,Per Unit,$411.78 ,OP,80.17,411.78,,,,,,
BCBS Blue Choice,CPT,V2307,Lens sphcy trifocal 4.25-7/.,All Other,Per Unit,$392.70 ,OP,76.33,392.7,,,,,,
BCBS Blue Choice,CPT,V2308,Lens sphc trifocal 4.25-7/2.,All Other,Per Unit,$430.83 ,OP,83.26,430.83,,,,,,
BCBS Blue Choice,CPT,V2309,Lens sphc trifocal 4.25-7/4.,All Other,Per Unit,$449.90 ,OP,87.13,449.9,,,,,,
BCBS Blue Choice,CPT,V2310,Lens sphc trifocal 4.25-7/>6,All Other,Per Unit,$468.96 ,OP,91.01,468.96,,,,,,
BCBS Blue Choice,CPT,V2311,Lens sphc trifo 7.25-12/.25-,All Other,Per Unit,$541.40 ,OP,105.08,541.4,,,,,,
BCBS Blue Choice,CPT,V2312,Lens sphc trifo 7.25-12/2.25,All Other,Per Unit,$495.65 ,OP,96.32,495.65,,,,,,
BCBS Blue Choice,CPT,V2313,Lens sphc trifo 7.25-12/4.25,All Other,Per Unit,$541.40 ,OP,105.15,541.4,,,,,,
BCBS Blue Choice,CPT,V2314,Lens sphcyl trifocal over 12,All Other,Per Unit,$552.84 ,OP,107.48,552.84,,,,,,
BCBS Blue Choice,CPT,V2315,Lens lenticular trifocal,All Other,Per Unit,$613.85 ,OP,119.32,613.85,,,,,,
BCBS Blue Choice,CPT,V2318,Lens aniseikonic trifocal,All Other,Per Unit,$754.91 ,OP,146.68,754.91,,,,,,
BCBS Blue Choice,CPT,V2319,Lens trifocal seg width > 28,All Other,Per Unit,$343.14 ,OP,66.22,343.14,,,,,,
BCBS Blue Choice,CPT,V2320,Lens trifocal add over 3.25d,All Other,Per Unit,$362.21 ,OP,69.85,362.21,,,,,,
BCBS Blue Choice,CPT,V2321,Lenticular lens- trifocal,All Other,Per Unit,$606.21 ,OP,117.61,606.21,,,,,,
BCBS Blue Choice,CPT,V2410,Lens variab asphericity sing,All Other,Per Unit,$529.96 ,OP,102.83,529.96,,,,,,
BCBS Blue Choice,CPT,V2430,Lens variable asphericity bi,All Other,Per Unit,$560.47 ,OP,108.84,560.47,,,,,,
BCBS Blue Choice,CPT,V2501,Cntct lens pmma-toric/prism,All Other,Per Unit,$674.85 ,OP,130.56,674.85,,,,,,
BCBS Blue Choice,CPT,V2502,Contact lens pmma bifocal,All Other,Per Unit,$911.23 ,OP,176.91,911.23,,,,,,
BCBS Blue Choice,CPT,V2503,Cntct lens pmma color vision,All Other,Per Unit,$880.74 ,OP,170.87,880.74,,,,,,
BCBS Blue Choice,CPT,V2510,Cntct gas permeable sphericl,All Other,Per Unit,$632.91 ,OP,122.68,632.91,,,,,,
BCBS Blue Choice,CPT,V2511,Cntct toric prism ballast,All Other,Per Unit,$937.93 ,OP,181.84,937.93,,,,,,
BCBS Blue Choice,CPT,V2512,Cntct lens gas permbl bifocl,All Other,Per Unit,"$1,078.99 ",OP,209.31,"1,078.99",,,,,,
BCBS Blue Choice,CPT,V2513,Contact lens extended wear,All Other,Per Unit,"$1,086.62 ",OP,210.87,"1,086.62",,,,,,
BCBS Blue Choice,CPT,V2520,Contact lens hydrophilic,All Other,Per Unit,$629.10 ,OP,122.25,629.1,,,,,,
BCBS Blue Choice,CPT,V2521,Cntct lens hydrophilic toric,All Other,Per Unit,"$1,250.57 ",OP,242.09,"1,250.57",,,,,,
BCBS Blue Choice,CPT,V2522,Cntct lens hydrophil bifocl,All Other,Per Unit,$915.04 ,OP,177.16,915.04,,,,,,
BCBS Blue Choice,CPT,V2523,Cntct lens hydrophil extend,All Other,Per Unit,$960.80 ,OP,186,960.8,,,,,,
BCBS Blue Choice,CPT,V2530,Contact lens gas impermeable,All Other,Per Unit,"$1,532.70 ",OP,297.37,"1,532.70",,,,,,
BCBS Blue Choice,CPT,V2531,Contact lens gas permeable,All Other,Per Unit,"$2,809.96 ",OP,544.58,"2,809.96",,,,,,
BCBS Blue Choice,CPT,V2623,Plastic eye prosth custom,All Other,Per Unit,"$4,864.99 ",OP,942.94,"4,864.99",,,,,,
BCBS Blue Choice,CPT,V2624,Polishing artifical eye,All Other,Per Unit,$312.64 ,OP,60.88,312.64,,,,,,
BCBS Blue Choice,CPT,V2625,Enlargemnt of eye prosthesis,All Other,Per Unit,"$2,485.87 ",OP,482.12,"2,485.87",,,,,,
BCBS Blue Choice,CPT,V2626,Reduction of eye prosthesis,All Other,Per Unit,"$1,029.43 ",OP,199.51,"1,029.43",,,,,,
BCBS Blue Choice,CPT,V2627,Scleral cover shell,All Other,Per Unit,"$7,377.56 ",OP,"1,430.28","7,377.56",,,,,,
BCBS Blue Choice,CPT,V2628,Fabrication & fitting,All Other,Per Unit,"$1,570.83 ",OP,304.24,"1,570.83",,,,,,
BCBS Blue Choice,CPT,V2630,Anter chamber intraocul lens,All Other,Per Unit,"$1,849.16 ",OP,"1,849.16","1,849.16",,,,,,
BCBS Blue Choice,CPT,V2631,Iris support intraoclr lens,All Other,Per Unit,"$1,849.16 ",OP,"1,849.16","1,849.16",,,,,,
BCBS Blue Choice,CPT,V2632,Post chmbr intraocular lens,All Other,Per Unit,"$1,849.16 ",OP,"1,849.16","1,849.16",,,,,,
BCBS Blue Choice,CPT,V2700,Balance lens,All Other,Per Unit,$232.58 ,OP,44.84,232.58,,,,,,
BCBS Blue Choice,CPT,V2710,Glass/plastic slab off prism,All Other,Per Unit,$377.46 ,OP,73.51,377.46,,,,,,
BCBS Blue Choice,CPT,V2715,Prism lens/es,All Other,Per Unit,$72.44 ,OP,14.41,72.44,,,,,,
BCBS Blue Choice,CPT,V2718,Fresnell prism press-on lens,All Other,Per Unit,$160.13 ,OP,31.12,160.13,,,,,,
BCBS Blue Choice,CPT,V2730,Special base curve,All Other,Per Unit,$133.45 ,OP,26.06,133.45,,,,,,
BCBS Blue Choice,CPT,V2744,Tint photochromatic lens/es,All Other,Per Unit,$91.51 ,OP,17.83,91.51,,,,,,
BCBS Blue Choice,CPT,V2745,Tint- any color/solid/grad,All Other,Per Unit,$53.38 ,OP,10.27,53.38,,,,,,
BCBS Blue Choice,CPT,V2750,Anti-reflective coating,All Other,Per Unit,$102.95 ,OP,20.02,102.95,,,,,,
BCBS Blue Choice,CPT,V2755,Uv lens/es,All Other,Per Unit,$87.69 ,OP,16.76,87.69,,,,,,
BCBS Blue Choice,CPT,V2760,Scratch resistant coating,All Other,Per Unit,$83.87 ,OP,83.87,83.87,,,,,,
BCBS Blue Choice,CPT,V2762,Polarization- any lens,All Other,Per Unit,$308.83 ,OP,308.83,308.83,,,,,,
BCBS Blue Choice,CPT,V2770,Occluder lens/es,All Other,Per Unit,$99.13 ,OP,19.52,99.13,,,,,,
BCBS Blue Choice,CPT,V2780,Oversize lens/es,All Other,Per Unit,$64.82 ,OP,12.53,64.82,,,,,,
BCBS Blue Choice,CPT,V2782,Lens- 1.54-1.65 p/1.60-1.79g,All Other,Per Unit,$335.53 ,OP,64.75,335.53,,,,,,
BCBS Blue Choice,CPT,V2783,Lens- >= 1.66 p/>=1.80 g,All Other,Per Unit,$377.46 ,OP,73.02,377.46,,,,,,
BCBS Blue Choice,CPT,V2784,Lens polycarb or equal,All Other,Per Unit,$244.01 ,OP,47.48,244.01,,,,,,
BCBS Blue Choice,CPT,V5008,Hearing screening,All Other,Per Unit,$354.58 ,OP,354.58,354.58,,,,,,
BCBS Blue Choice,CPT,V5010,Assessment for hearing aid,All Other,Per Unit,$648.16 ,OP,648.16,648.16,,,,,,
BCBS Blue Choice,CPT,V5014,Hearing aid repair/modifying,All Other,Per Unit,$953.17 ,OP,953.17,953.17,,,,,,
BCBS Blue Choice,CPT,V5020,Conformity evaluation,All Other,Per Unit,$190.64 ,OP,190.64,190.64,,,,,,
BCBS Blue Choice,ExceptRevenueCode,274,Medical/Surgical Supplies: Prosthetic/Orthotic devices,Implants,Straight Discount,28.31%,OP,,,,,,,,
BCBS Blue Choice,ExceptRevenueCode,275,Medical/Surgical Supplies: Pacemaker,Implants,Straight Discount,28.31%,OP,,,,,,,,
BCBS Blue Choice,ExceptRevenueCode,276,Medical/Surgical Supplies: Intraocular lens,Implants,Straight Discount,28.31%,OP,,,,,,,,
BCBS Blue Choice,ExceptRevenueCode,278,Medical/Surgical Supplies: Other implants,Implants,Straight Discount,28.31%,OP,,,,,,,,
BCBS Blue Choice,ExceptRevenueCode,760,Treatment/Observation Room,Observation,Per Case,"$2,944.00 ",OP,"2,420.00","3,464.00",,,,,,
BCBS Blue Choice,ExceptRevenueCode,762,Treatment/Observation Room: Observation room,Observation,Per Case,"$2,944.00 ",OP,"2,420.00","3,464.00",,,,,,
BCBS Blue Choice,ExceptRevenueCode,769,Treatment/Observation Room: Other treatment room,Observation,Per Case,"$2,944.00 ",OP,"2,944.00","3,464.00",,,,,,
BCBS Blue Choice,,,,All Other,Straight Discount,66.47%,OP,,,,,,,,
BCBS HMO,DRG,MS-001,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W MCC,Surgical,Per Case,"$17,718.00 ",IP,"17,718.00","557,099.42",,,,,,
BCBS HMO,DRG,MS-002,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W/O MCC,Surgical,Per Case,"$17,718.00 ",IP,"17,718.00","282,516.19",,,,,,
BCBS HMO,DRG,MS-010,PANCREAS TRANSPLANT,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","80,158.18",,,,,,
BCBS HMO,DRG,MS-011,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","99,667.01",,,,,,
BCBS HMO,DRG,MS-012,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","76,083.84",,,,,,
BCBS HMO,DRG,MS-013,TRACHEOSTOMY FOR FACE -  MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","48,894.05",,,,,,
BCBS HMO,DRG,MS-014,ALLOGENEIC BONE MARROW TRANSPLANT,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","257,136.77",,,,,,
BCBS HMO,DRG,MS-016,AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","138,805.63",,,,,,
BCBS HMO,DRG,MS-017,AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","89,659.58",,,,,,
BCBS HMO,DRG,MS-018,CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","218,711.49",,,,,,
BCBS HMO,DRG,MS-019,SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","39,009.97",,,,,,
BCBS HMO,DRG,MS-020,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","218,151.36",,,,,,
BCBS HMO,DRG,MS-021,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","166,797.79",,,,,,
BCBS HMO,DRG,MS-022,INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W/O CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","99,425.09",,,,,,
BCBS HMO,DRG,MS-023,CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX CNS PDX W MCC OR CHEMO IMPLANT,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","113,240.74",,,,,,
BCBS HMO,DRG,MS-024,CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","80,972.64",,,,,,
BCBS HMO,DRG,MS-025,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","88,593.12",,,,,,
BCBS HMO,DRG,MS-026,CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","61,403.33",,,,,,
BCBS HMO,DRG,MS-027,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","48,317.47",,,,,,
BCBS HMO,DRG,MS-028,SPINAL PROCEDURES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","112,702.46",,,,,,
BCBS HMO,DRG,MS-029,SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","64,653.12",,,,,,
BCBS HMO,DRG,MS-030,SPINAL PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","45,805.54",,,,,,
BCBS HMO,DRG,MS-031,VENTRICULAR SHUNT PROCEDURES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","88,189.92",,,,,,
BCBS HMO,DRG,MS-032,VENTRICULAR SHUNT PROCEDURES WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","44,192.74",,,,,,
BCBS HMO,DRG,MS-033,VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","34,290.14",,,,,,
BCBS HMO,DRG,MS-034,CAROTID ARTERY STENT PROCEDURE W MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","75,674.59",,,,,,
BCBS HMO,DRG,MS-035,CAROTID ARTERY STENT PROCEDURES WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","46,412.35",,,,,,
BCBS HMO,DRG,MS-036,CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","35,300.16",,,,,,
BCBS HMO,DRG,MS-037,EXTRACRANIAL PROCEDURES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","65,384.93",,,,,,
BCBS HMO,DRG,MS-038,EXTRACRANIAL PROCEDURES WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","33,772.03",,,,,,
BCBS HMO,DRG,MS-039,EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","22,807.01",,,,,,
BCBS HMO,DRG,MS-040,PERIPHERAL- CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","79,438.46",,,,,,
BCBS HMO,DRG,MS-041,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W CC OR PERIPH NEUROSTIM,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","47,809.44",,,,,,
BCBS HMO,DRG,MS-042,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W/O CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","37,261.73",,,,,,
BCBS HMO,DRG,MS-052,SPINAL DISORDERS AND INJURIES WITH CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","32,838.62",,,,,,
BCBS HMO,DRG,MS-053,SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","19,476.58",,,,,,
BCBS HMO,DRG,MS-054,NERVOUS SYSTEM NEOPLASMS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","27,016.42",,,,,,
BCBS HMO,DRG,MS-055,NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","19,877.76",,,,,,
BCBS HMO,DRG,MS-056,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","44,198.78",,,,,,
BCBS HMO,DRG,MS-057,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","24,409.73",,,,,,
BCBS HMO,DRG,MS-058,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","39,406.75",,,,,,
BCBS HMO,DRG,MS-059,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","21,984.48",,,,,,
BCBS HMO,DRG,MS-060,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","17,775.07",,,,,,
BCBS HMO,DRG,MS-061,ISCHEMIC STROKE -  PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","56,316.96",,,,,,
BCBS HMO,DRG,MS-062,ISCHEMIC STROKE -  PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","40,545.79",,,,,,
BCBS HMO,DRG,MS-063,ISCHEMIC STROKE- PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","33,884.93",,,,,,
BCBS HMO,DRG,MS-064,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","37,795.97",,,,,,
BCBS HMO,DRG,MS-065,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","20,718.43",,,,,,
BCBS HMO,DRG,MS-066,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","14,454.72",,,,,,
BCBS HMO,DRG,MS-067,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","29,524.32",,,,,,
BCBS HMO,DRG,MS-068,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","18,212.54",,,,,,
BCBS HMO,DRG,MS-069,TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","15,730.85",,,,,,
BCBS HMO,DRG,MS-070,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","33,725.66",,,,,,
BCBS HMO,DRG,MS-071,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","20,053.15",,,,,,
BCBS HMO,DRG,MS-072,NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","14,888.16",,,,,,
BCBS HMO,DRG,MS-073,CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","28,538.50",,,,,,
BCBS HMO,DRG,MS-074,CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","19,920.10",,,,,,
BCBS HMO,DRG,MS-075,VIRAL MENINGITIS WITH CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","32,421.31",,,,,,
BCBS HMO,DRG,MS-076,VIRAL MENINGITIS WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","18,194.40",,,,,,
BCBS HMO,DRG,MS-077,HYPERTENSIVE ENCEPHALOPATHY WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","31,096.80",,,,,,
BCBS HMO,DRG,MS-078,HYPERTENSIVE ENCEPHALOPATHY WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","19,393.92",,,,,,
BCBS HMO,DRG,MS-079,HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","14,940.58",,,,,,
BCBS HMO,DRG,MS-080,NONTRAUMATIC STUPOR & COMA W MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","38,632.61",,,,,,
BCBS HMO,DRG,MS-081,NONTRAUMATIC STUPOR & COMA W/O MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","17,722.66",,,,,,
BCBS HMO,DRG,MS-082,TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","45,396.29",,,,,,
BCBS HMO,DRG,MS-083,TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","26,423.71",,,,,,
BCBS HMO,DRG,MS-084,TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","18,089.57",,,,,,
BCBS HMO,DRG,MS-085,TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","45,275.33",,,,,,
BCBS HMO,DRG,MS-086,TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","24,954.05",,,,,,
BCBS HMO,DRG,MS-087,TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","16,918.27",,,,,,
BCBS HMO,DRG,MS-088,CONCUSSION WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","28,004.26",,,,,,
BCBS HMO,DRG,MS-089,CONCUSSION WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","19,883.81",,,,,,
BCBS HMO,DRG,MS-090,CONCUSSION WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","17,101.73",,,,,,
BCBS HMO,DRG,MS-091,OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","31,552.42",,,,,,
BCBS HMO,DRG,MS-092,OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","19,476.58",,,,,,
BCBS HMO,DRG,MS-093,OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","15,345.79",,,,,,
BCBS HMO,DRG,MS-094,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","72,269.57",,,,,,
BCBS HMO,DRG,MS-095,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","48,527.14",,,,,,
BCBS HMO,DRG,MS-096,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","45,603.94",,,,,,
BCBS HMO,DRG,MS-097,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","72,090.14",,,,,,
BCBS HMO,DRG,MS-098,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","39,412.80",,,,,,
BCBS HMO,DRG,MS-099,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","25,853.18",,,,,,
BCBS HMO,DRG,MS-100,SEIZURES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","36,695.23",,,,,,
BCBS HMO,DRG,MS-101,SEIZURES WITHOUT MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","17,799.26",,,,,,
BCBS HMO,DRG,MS-102,HEADACHES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","24,042.82",,,,,,
BCBS HMO,DRG,MS-103,HEADACHES W/O MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","16,117.92",,,,,,
BCBS HMO,DRG,MS-113,ORBITAL PROCEDURES WITH CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","42,983.14",,,,,,
BCBS HMO,DRG,MS-114,ORBITAL PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","24,006.53",,,,,,
BCBS HMO,DRG,MS-115,EXTRAOCULAR PROCEDURES EXCEPT ORBIT,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","29,957.76",,,,,,
BCBS HMO,DRG,MS-116,INTRAOCULAR PROCEDURES W CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","38,122.56",,,,,,
BCBS HMO,DRG,MS-117,INTRAOCULAR PROCEDURES W/O CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","22,109.47",,,,,,
BCBS HMO,DRG,MS-121,ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","25,558.85",,,,,,
BCBS HMO,DRG,MS-122,ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","15,575.62",,,,,,
BCBS HMO,DRG,MS-123,NEUROLOGICAL EYE DISORDERS,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","15,740.93",,,,,,
BCBS HMO,DRG,MS-124,OTHER DISORDERS OF THE EYE WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","28,010.30",,,,,,
BCBS HMO,DRG,MS-125,OTHER DISORDERS OF THE EYE WITHOUT MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","15,914.30",,,,,,
BCBS HMO,DRG,MS-135,SINUS AND MASTOID PROCEDURES WITH CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","46,057.54",,,,,,
BCBS HMO,DRG,MS-136,SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","23,990.40",,,,,,
BCBS HMO,DRG,MS-137,MOUTH PROCEDURES WITH CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","26,879.33",,,,,,
BCBS HMO,DRG,MS-138,MOUTH PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","17,365.82",,,,,,
BCBS HMO,DRG,MS-139,SALIVARY GLAND PROCEDURES,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","24,883.49",,,,,,
BCBS HMO,DRG,MS-140,MAJOR HEAD AND NECK PROCEDURES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","23,231.24",,,,,,
BCBS HMO,DRG,MS-141,MAJOR HEAD AND NECK PROCEDURES WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","12,883.80",,,,,,
BCBS HMO,DRG,MS-142,MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","9,373.91",,,,,,
BCBS HMO,DRG,MS-143,OTHER EAR- NOSE- MOUTH AND THROAT O.R. PROCEDURES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","17,402.26",,,,,,
BCBS HMO,DRG,MS-144,HERNIA PROCEDURES AGE 0-17,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","10,287.30",,,,,,
BCBS HMO,DRG,MS-145,OTHER EAR -  NOSE -  MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","7,151.76",,,,,,
BCBS HMO,DRG,MS-146,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","38,880.58",,,,,,
BCBS HMO,DRG,MS-147,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","25,016.54",,,,,,
BCBS HMO,DRG,MS-148,EAR - NOSE - MOUTH & THROAT MALIGNANCY W/O CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","15,329.66",,,,,,
BCBS HMO,DRG,MS-149,DYSEQUILIBRIUM,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","14,726.88",,,,,,
BCBS HMO,DRG,MS-150,EPISTAXIS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","26,036.64",,,,,,
BCBS HMO,DRG,MS-151,EPISTAXIS WITHOUT MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","14,093.86",,,,,,
BCBS HMO,DRG,MS-152,OTITIS MEDIA AND URI WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","20,946.24",,,,,,
BCBS HMO,DRG,MS-153,OTITIS MEDIA AND URI WITHOUT MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","14,241.02",,,,,,
BCBS HMO,DRG,MS-154,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","28,969.92",,,,,,
BCBS HMO,DRG,MS-155,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","18,166.18",,,,,,
BCBS HMO,DRG,MS-156,OTHER EAR -  NOSE -  MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","13,194.72",,,,,,
BCBS HMO,DRG,MS-157,DENTAL AND ORAL DISEASES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","31,508.06",,,,,,
BCBS HMO,DRG,MS-158,DENTAL AND ORAL DISEASES WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","17,470.66",,,,,,
BCBS HMO,DRG,MS-159,DENTAL AND ORAL DISEASES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","13,565.66",,,,,,
BCBS HMO,DRG,MS-163,MAJOR CHEST PROCEDURES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","98,253.79",,,,,,
BCBS HMO,DRG,MS-164,MAJOR CHEST PROCEDURES WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","51,037.06",,,,,,
BCBS HMO,DRG,MS-165,MAJOR CHEST PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","37,279.87",,,,,,
BCBS HMO,DRG,MS-166,OTHER RESP SYSTEM O.R. PROCEDURES W MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","75,210.91",,,,,,
BCBS HMO,DRG,MS-167,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","38,594.30",,,,,,
BCBS HMO,DRG,MS-168,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","26,746.27",,,,,,
BCBS HMO,DRG,MS-175,PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","29,119.10",,,,,,
BCBS HMO,DRG,MS-176,PULMONARY EMBOLISM WITHOUT MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","17,103.74",,,,,,
BCBS HMO,DRG,MS-177,RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","38,126.59",,,,,,
BCBS HMO,DRG,MS-178,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","25,064.93",,,,,,
BCBS HMO,DRG,MS-179,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","17,460.58",,,,,,
BCBS HMO,DRG,MS-180,RESPIRATORY NEOPLASMS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","34,773.98",,,,,,
BCBS HMO,DRG,MS-181,RESPIRATORY NEOPLASMS WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","23,224.32",,,,,,
BCBS HMO,DRG,MS-182,RESPIRATORY NEOPLASMS WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","16,990.85",,,,,,
BCBS HMO,DRG,MS-183,MAJOR CHEST TRAUMA WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","30,425.47",,,,,,
BCBS HMO,DRG,MS-184,MAJOR CHEST TRAUMA WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","20,526.91",,,,,,
BCBS HMO,DRG,MS-185,MAJOR CHEST TRAUMA W/O CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","14,797.44",,,,,,
BCBS HMO,DRG,MS-186,PLEURAL EFFUSION WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","31,104.86",,,,,,
BCBS HMO,DRG,MS-187,PLEURAL EFFUSION WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","20,722.46",,,,,,
BCBS HMO,DRG,MS-188,PLEURAL EFFUSION WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","14,734.94",,,,,,
BCBS HMO,DRG,MS-189,PULMONARY EDEMA AND RESPIRATORY FAILURE,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","24,508.51",,,,,,
BCBS HMO,DRG,MS-190,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","23,063.04",,,,,,
BCBS HMO,DRG,MS-191,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","17,998.85",,,,,,
BCBS HMO,DRG,MS-192,CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","14,297.47",,,,,,
BCBS HMO,DRG,MS-193,SIMPLE PNEUMONIA & PLEURISY W MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","26,883.36",,,,,,
BCBS HMO,DRG,MS-194,SIMPLE PNEUMONIA AND PLEURISY WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","17,914.18",,,,,,
BCBS HMO,DRG,MS-195,SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","13,751.14",,,,,,
BCBS HMO,DRG,MS-196,INTERSTITIAL LUNG DISEASE WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","33,776.06",,,,,,
BCBS HMO,DRG,MS-197,INTERSTITIAL LUNG DISEASE WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","20,593.44",,,,,,
BCBS HMO,DRG,MS-198,INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","15,220.80",,,,,,
BCBS HMO,DRG,MS-199,PNEUMOTHORAX WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","36,169.06",,,,,,
BCBS HMO,DRG,MS-200,PNEUMOTHORAX WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","21,815.14",,,,,,
BCBS HMO,DRG,MS-201,PNEUMOTHORAX WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","14,474.88",,,,,,
BCBS HMO,DRG,MS-202,BRONCHITIS AND ASTHMA WITH CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","19,111.68",,,,,,
BCBS HMO,DRG,MS-203,BRONCHITIS AND ASTHMA WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","13,987.01",,,,,,
BCBS HMO,DRG,MS-204,RESPIRATORY SIGNS AND SYMPTOMS,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","16,380.00",,,,,,
BCBS HMO,DRG,MS-205,OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","32,945.47",,,,,,
BCBS HMO,DRG,MS-206,OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","17,589.60",,,,,,
BCBS HMO,DRG,MS-207,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","115,629.70",,,,,,
BCBS HMO,DRG,MS-208,RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","50,079.46",,,,,,
BCBS HMO,DRG,MS-215,OTHER HEART ASSIST SYSTEM IMPLANT,Surgical,Per Case,"$81,651.00 ",IP,"61,661.88","259,783.78",,,,,,
BCBS HMO,DRG,MS-216,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,Surgical,Per Case,"$61,623.00 ",IP,"58,630.29","202,454.78",,,,,,
BCBS HMO,DRG,MS-217,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,Surgical,Per Case,"$61,623.00 ",IP,"37,864.14","134,096.26",,,,,,
BCBS HMO,DRG,MS-218,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,Surgical,Per Case,"$61,623.00 ",IP,"35,678.79","108,892.22",,,,,,
BCBS HMO,DRG,MS-219,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,Surgical,Per Case,"$58,543.00 ",IP,"47,057.01","158,056.42",,,,,,
BCBS HMO,DRG,MS-220,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,Surgical,Per Case,"$58,543.00 ",IP,"31,567.37","106,966.94",,,,,,
BCBS HMO,DRG,MS-221,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,Surgical,Per Case,"$58,543.00 ",IP,"26,746.97","92,659.39",,,,,,
BCBS HMO,DRG,MS-222,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITH MCC,Surgical,Per Case,"$58,543.00 ",IP,"46,434.46","168,227.14",,,,,,
BCBS HMO,DRG,MS-223,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITHOUT MCC,Surgical,Per Case,"$58,543.00 ",IP,"33,864.27","121,018.46",,,,,,
BCBS HMO,DRG,MS-224,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITH MCC,Surgical,Per Case,"$50,840.00 ",IP,"43,912.13","149,107.39",,,,,,
BCBS HMO,DRG,MS-225,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITHOUT MCC,Surgical,Per Case,"$50,840.00 ",IP,"32,808.39","113,879.81",,,,,,
BCBS HMO,DRG,MS-226,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITH MCC,Surgical,Per Case,"$25,420.00 ",IP,"25,420.00","134,824.03",,,,,,
BCBS HMO,DRG,MS-227,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Surgical,Per Case,"$25,420.00 ",IP,"25,420.00","105,420.67",,,,,,
BCBS HMO,DRG,MS-228,OTHER CARDIOTHORACIC PROCEDURES WITH MCC,Surgical,Per Case,"$46,217.00 ",IP,"31,129.37","126,731.81",,,,,,
BCBS HMO,DRG,MS-229,OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,Surgical,Per Case,"$46,217.00 ",IP,"20,096.88","82,754.78",,,,,,
BCBS HMO,DRG,MS-230,OTHER CARDIOTHORACIC PROCEDURES W/O CC/MCC,Surgical,Per Case,"$46,217.00 ",IP,"46,217.00","46,217.00",,,,,,
BCBS HMO,DRG,MS-231,CORONARY BYPASS W PTCA W MCC,Surgical,Per Case,"$53,920.00 ",IP,"50,901.53","165,543.84",,,,,,
BCBS HMO,DRG,MS-232,CORONARY BYPASS W PTCA W/O MCC,Surgical,Per Case,"$53,920.00 ",IP,"34,770.65","120,687.84",,,,,,
BCBS HMO,DRG,MS-233,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,Surgical,Per Case,"$42,365.00 ",IP,"42,365.00","156,621.02",,,,,,
BCBS HMO,DRG,MS-234,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,Surgical,Per Case,"$42,365.00 ",IP,"31,162.65","104,959.01",,,,,,
BCBS HMO,DRG,MS-235,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,Surgical,Per Case,"$32,351.00 ",IP,"32,351.00","118,633.54",,,,,,
BCBS HMO,DRG,MS-236,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Surgical,Per Case,"$32,351.00 ",IP,"23,926.80","81,226.66",,,,,,
BCBS HMO,DRG,MS-237,MAJOR CARDIOVASC PROCEDURES W MCC,Surgical,Per Case,"$32,968.00 ",IP,"32,968.00","32,968.00",,,,,,
BCBS HMO,DRG,MS-238,MAJOR CARDIOVASC PROCEDURES W/O MCC,Surgical,Per Case,"$32,968.00 ",IP,"32,968.00","32,968.00",,,,,,
BCBS HMO,DRG,MS-239,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","94,141.15",,,,,,
BCBS HMO,DRG,MS-240,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","55,641.60",,,,,,
BCBS HMO,DRG,MS-241,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","30,568.61",,,,,,
BCBS HMO,DRG,MS-242,PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,Surgical,Per Case,"$15,407.00 ",IP,"15,407.00","74,815.78",,,,,,
BCBS HMO,DRG,MS-243,PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,Surgical,Per Case,"$15,407.00 ",IP,"14,708.24","50,992.70",,,,,,
BCBS HMO,DRG,MS-244,PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,Surgical,Per Case,"$15,407.00 ",IP,"12,049.83","41,840.06",,,,,,
BCBS HMO,DRG,MS-245,AICD GENERATOR PROCEDURES,Surgical,Per Case,"$15,407.00 ",IP,"15,407.00","104,989.25",,,,,,
BCBS HMO,DRG,MS-246,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Surgical,Per Case,"$19,642.00 ",IP,"18,246.15","63,963.65",,,,,,
BCBS HMO,DRG,MS-247,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITHOUT MCC,Surgical,Per Case,"$19,642.00 ",IP,"11,523.64","41,019.55",,,,,,
BCBS HMO,DRG,MS-248,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Surgical,Per Case,"$19,533.00 ",IP,"18,467.49","62,425.44",,,,,,
BCBS HMO,DRG,MS-249,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITHOUT MCC,Surgical,Per Case,"$19,533.00 ",IP,"10,942.55","38,638.66",,,,,,
BCBS HMO,DRG,MS-250,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT CORONARY ARTERY STENT WITH MCC,Surgical,Per Case,"$16,176.00 ",IP,"14,727.51","51,410.02",,,,,,
BCBS HMO,DRG,MS-251,PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W/O MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","33,929.28",,,,,,
BCBS HMO,DRG,MS-252,OTHER VASCULAR PROCEDURES W MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","66,132.86",,,,,,
BCBS HMO,DRG,MS-253,OTHER VASCULAR PROCEDURES WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","52,549.06",,,,,,
BCBS HMO,DRG,MS-254,OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","36,693.22",,,,,,
BCBS HMO,DRG,MS-255,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","53,415.94",,,,,,
BCBS HMO,DRG,MS-256,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","34,604.64",,,,,,
BCBS HMO,DRG,MS-257,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","22,869.50",,,,,,
BCBS HMO,DRG,MS-258,CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,Surgical,Per Case,"$11,861.00 ",IP,"11,861.00","61,663.39",,,,,,
BCBS HMO,DRG,MS-259,CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,Surgical,Per Case,"$11,861.00 ",IP,"11,861.00","41,985.22",,,,,,
BCBS HMO,DRG,MS-260,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,Surgical,Per Case,"$10,167.00 ",IP,"10,167.00","74,583.94",,,,,,
BCBS HMO,DRG,MS-261,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,Surgical,Per Case,"$10,167.00 ",IP,"10,167.00","39,281.76",,,,,,
BCBS HMO,DRG,MS-262,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,Surgical,Per Case,"$10,167.00 ",IP,"9,964.34","33,820.42",,,,,,
BCBS HMO,DRG,MS-263,VEIN LIGATION AND STRIPPING,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","47,559.46",,,,,,
BCBS HMO,DRG,MS-264,OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","65,278.08",,,,,,
BCBS HMO,DRG,MS-265,AICD LEAD PROCEDURES,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","62,925.41",,,,,,
BCBS HMO,DRG,MS-266,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,Surgical,Per Case,"$61,623.00 ",IP,"41,160.28","143,567.42",,,,,,
BCBS HMO,DRG,MS-267,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,Surgical,Per Case,"$61,623.00 ",IP,"32,692.75","114,420.10",,,,,,
BCBS HMO,DRG,MS-268,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,Surgical,Per Case,"$32,968.00 ",IP,"32,968.00","136,737.22",,,,,,
BCBS HMO,DRG,MS-269,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,Surgical,Per Case,"$32,968.00 ",IP,"25,200.52","86,010.62",,,,,,
BCBS HMO,DRG,MS-270,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,Surgical,Per Case,"$32,968.00 ",IP,"30,292.48","103,021.63",,,,,,
BCBS HMO,DRG,MS-271,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,Surgical,Per Case,"$32,968.00 ",IP,"20,822.21","71,527.68",,,,,,
BCBS HMO,DRG,MS-272,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,Surgical,Per Case,"$32,968.00 ",IP,"15,699.88","52,442.21",,,,,,
BCBS HMO,DRG,MS-273,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,Surgical,Per Case,"$16,176.00 ",IP,"16,176.00","74,799.65",,,,,,
BCBS HMO,DRG,MS-274,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,Surgical,Per Case,"$16,176.00 ",IP,"16,176.00","63,701.57",,,,,,
BCBS HMO,DRG,MS-280,ACUTE MYOCARDIAL INFARCTION - DISCHARGED ALIVE W MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","32,878.94",,,,,,
BCBS HMO,DRG,MS-281,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","19,528.99",,,,,,
BCBS HMO,DRG,MS-282,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","14,876.06",,,,,,
BCBS HMO,DRG,MS-283,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","36,281.95",,,,,,
BCBS HMO,DRG,MS-284,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","14,622.05",,,,,,
BCBS HMO,DRG,MS-285,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","10,438.85",,,,,,
BCBS HMO,DRG,MS-286,CIRCULATORY DISORDERS EXCEPT AMI- WITH CARDIAC CATHETERIZATION WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","44,299.58",,,,,,
BCBS HMO,DRG,MS-287,CIRCULATORY DISORDERS EXCEPT AMI -  WITH CARDIAC CATHETERIZATION WITHOUT MCC,Surgical,Per Case,"$9,181.00 ",IP,"6,512.27","23,228.35",,,,,,
BCBS HMO,DRG,MS-288,ACUTE & SUBACUTE ENDOCARDITIS W MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","53,573.18",,,,,,
BCBS HMO,DRG,MS-289,ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,Surgical,Per Case,"$9,181.00 ",IP,"9,181.00","33,542.21",,,,,,
BCBS HMO,DRG,MS-290,ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","20,172.10",,,,,,
BCBS HMO,DRG,MS-291,HEART FAILURE AND SHOCK WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","27,131.33",,,,,,
BCBS HMO,DRG,MS-292,HEART FAILURE AND SHOCK WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","18,254.88",,,,,,
BCBS HMO,DRG,MS-293,HEART FAILURE AND SHOCK WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","13,210.85",,,,,,
BCBS HMO,DRG,MS-294,DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","25,641.50",,,,,,
BCBS HMO,DRG,MS-295,DEEP VEIN THROMBOPHLEBITIS W/O CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","11,632.32",,,,,,
BCBS HMO,DRG,MS-296,CARDIAC ARREST - UNEXPLAINED W MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","31,659.26",,,,,,
BCBS HMO,DRG,MS-297,CARDIAC ARREST- UNEXPLAINED WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","14,575.68",,,,,,
BCBS HMO,DRG,MS-298,CARDIAC ARREST- UNEXPLAINED WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","10,144.51",,,,,,
BCBS HMO,DRG,MS-299,PERIPHERAL VASCULAR DISORDERS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","29,225.95",,,,,,
BCBS HMO,DRG,MS-300,PERIPHERAL VASCULAR DISORDERS WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","20,716.42",,,,,,
BCBS HMO,DRG,MS-301,PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","14,632.13",,,,,,
BCBS HMO,DRG,MS-302,ATHEROSCLEROSIS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","22,222.37",,,,,,
BCBS HMO,DRG,MS-303,ATHEROSCLEROSIS WITHOUT MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","13,622.11",,,,,,
BCBS HMO,DRG,MS-304,HYPERTENSION WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","22,004.64",,,,,,
BCBS HMO,DRG,MS-305,HYPERTENSION WITHOUT MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","14,747.04",,,,,,
BCBS HMO,DRG,MS-306,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","28,516.32",,,,,,
BCBS HMO,DRG,MS-307,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","17,785.15",,,,,,
BCBS HMO,DRG,MS-308,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","23,944.03",,,,,,
BCBS HMO,DRG,MS-309,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","15,247.01",,,,,,
BCBS HMO,DRG,MS-310,CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","11,275.49",,,,,,
BCBS HMO,DRG,MS-311,ANGINA PECTORIS,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","13,809.60",,,,,,
BCBS HMO,DRG,MS-312,SYNCOPE AND COLLAPSE,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","16,462.66",,,,,,
BCBS HMO,DRG,MS-313,CHEST PAIN,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","14,420.45",,,,,,
BCBS HMO,DRG,MS-314,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","40,914.72",,,,,,
BCBS HMO,DRG,MS-315,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","19,563.26",,,,,,
BCBS HMO,DRG,MS-316,OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","14,962.75",,,,,,
BCBS HMO,DRG,MS-319,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","82,670.11",,,,,,
BCBS HMO,DRG,MS-320,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","47,329.63",,,,,,
BCBS HMO,DRG,MS-326,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","106,253.28",,,,,,
BCBS HMO,DRG,MS-327,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","51,869.66",,,,,,
BCBS HMO,DRG,MS-328,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","31,752.00",,,,,,
BCBS HMO,DRG,MS-329,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","98,929.15",,,,,,
BCBS HMO,DRG,MS-330,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","50,940.29",,,,,,
BCBS HMO,DRG,MS-331,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","34,054.27",,,,,,
BCBS HMO,DRG,MS-332,RECTAL RESECTION WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","70,396.70",,,,,,
BCBS HMO,DRG,MS-333,RECTAL RESECTION WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","45,626.11",,,,,,
BCBS HMO,DRG,MS-334,RECTAL RESECTION WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","31,052.45",,,,,,
BCBS HMO,DRG,MS-335,PERITONEAL ADHESIOLYSIS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","81,549.22",,,,,,
BCBS HMO,DRG,MS-336,PERITONEAL ADHESIOLYSIS WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","45,686.59",,,,,,
BCBS HMO,DRG,MS-337,PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","33,056.35",,,,,,
BCBS HMO,DRG,MS-338,APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","58,667.62",,,,,,
BCBS HMO,DRG,MS-339,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","34,596.58",,,,,,
BCBS HMO,DRG,MS-340,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","24,948.00",,,,,,
BCBS HMO,DRG,MS-341,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","51,571.30",,,,,,
BCBS HMO,DRG,MS-342,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","32,463.65",,,,,,
BCBS HMO,DRG,MS-343,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","23,216.26",,,,,,
BCBS HMO,DRG,MS-344,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","60,381.22",,,,,,
BCBS HMO,DRG,MS-345,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","32,927.33",,,,,,
BCBS HMO,DRG,MS-346,MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","25,859.23",,,,,,
BCBS HMO,DRG,MS-347,ANAL AND STOMAL PROCEDURES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","53,149.82",,,,,,
BCBS HMO,DRG,MS-348,ANAL AND STOMAL PROCEDURES WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","28,411.49",,,,,,
BCBS HMO,DRG,MS-349,ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","19,774.94",,,,,,
BCBS HMO,DRG,MS-350,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","49,176.29",,,,,,
BCBS HMO,DRG,MS-351,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","29,399.33",,,,,,
BCBS HMO,DRG,MS-352,INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","21,708.29",,,,,,
BCBS HMO,DRG,MS-353,HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","59,812.70",,,,,,
BCBS HMO,DRG,MS-354,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","34,717.54",,,,,,
BCBS HMO,DRG,MS-355,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W/O CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","27,667.58",,,,,,
BCBS HMO,DRG,MS-356,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","82,196.35",,,,,,
BCBS HMO,DRG,MS-357,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","45,368.06",,,,,,
BCBS HMO,DRG,MS-358,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","27,653.47",,,,,,
BCBS HMO,DRG,MS-368,MAJOR ESOPHAGEAL DISORDERS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","38,376.58",,,,,,
BCBS HMO,DRG,MS-369,MAJOR ESOPHAGEAL DISORDERS WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","21,432.10",,,,,,
BCBS HMO,DRG,MS-370,MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","15,065.57",,,,,,
BCBS HMO,DRG,MS-371,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","34,786.08",,,,,,
BCBS HMO,DRG,MS-372,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","20,613.60",,,,,,
BCBS HMO,DRG,MS-373,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","14,954.69",,,,,,
BCBS HMO,DRG,MS-374,DIGESTIVE MALIGNANCY WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","40,269.60",,,,,,
BCBS HMO,DRG,MS-375,DIGESTIVE MALIGNANCY WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","24,339.17",,,,,,
BCBS HMO,DRG,MS-376,DIGESTIVE MALIGNANCY WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","20,186.21",,,,,,
BCBS HMO,DRG,MS-377,GASTROINTESTINAL HEMORRHAGE WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","35,681.18",,,,,,
BCBS HMO,DRG,MS-378,GASTROINTESTINAL HEMORRHAGE WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","19,920.10",,,,,,
BCBS HMO,DRG,MS-379,GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","13,017.31",,,,,,
BCBS HMO,DRG,MS-380,COMPLICATED PEPTIC ULCER WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","38,054.02",,,,,,
BCBS HMO,DRG,MS-381,COMPLICATED PEPTIC ULCER WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","21,706.27",,,,,,
BCBS HMO,DRG,MS-382,COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","15,954.62",,,,,,
BCBS HMO,DRG,MS-383,UNCOMPLICATED PEPTIC ULCER WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","26,738.21",,,,,,
BCBS HMO,DRG,MS-384,UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","17,543.23",,,,,,
BCBS HMO,DRG,MS-385,INFLAMMATORY BOWEL DISEASE WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","32,463.65",,,,,,
BCBS HMO,DRG,MS-386,INFLAMMATORY BOWEL DISEASE W CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","19,861.63",,,,,,
BCBS HMO,DRG,MS-387,INFLAMMATORY BOWEL DISEASE W/O CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","14,126.11",,,,,,
BCBS HMO,DRG,MS-388,GASTROINTESTINAL OBSTRUCTION WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","30,746.02",,,,,,
BCBS HMO,DRG,MS-389,GASTROINTESTINAL OBSTRUCTION WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","16,928.35",,,,,,
BCBS HMO,DRG,MS-390,GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","11,684.74",,,,,,
BCBS HMO,DRG,MS-391,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","24,897.60",,,,,,
BCBS HMO,DRG,MS-392,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","15,351.84",,,,,,
BCBS HMO,DRG,MS-393,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","32,749.92",,,,,,
BCBS HMO,DRG,MS-394,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","18,912.10",,,,,,
BCBS HMO,DRG,MS-395,OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","13,192.70",,,,,,
BCBS HMO,DRG,MS-405,PANCREAS- LIVER AND SHUNT PROCEDURES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","109,412.35",,,,,,
BCBS HMO,DRG,MS-406,PANCREAS -  LIVER AND SHUNT PROCEDURES WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","56,264.54",,,,,,
BCBS HMO,DRG,MS-407,PANCREAS -  LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","42,059.81",,,,,,
BCBS HMO,DRG,MS-408,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","71,842.18",,,,,,
BCBS HMO,DRG,MS-409,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","48,259.01",,,,,,
BCBS HMO,DRG,MS-410,BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W/O CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","33,465.60",,,,,,
BCBS HMO,DRG,MS-411,CHOLECYSTECTOMY W C.D.E. W MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","77,220.86",,,,,,
BCBS HMO,DRG,MS-412,CHOLECYSTECTOMY WITH C.D.E. WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","47,920.32",,,,,,
BCBS HMO,DRG,MS-413,CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","32,604.77",,,,,,
BCBS HMO,DRG,MS-414,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","68,874.62",,,,,,
BCBS HMO,DRG,MS-415,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","41,362.27",,,,,,
BCBS HMO,DRG,MS-416,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","27,222.05",,,,,,
BCBS HMO,DRG,MS-417,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","48,599.71",,,,,,
BCBS HMO,DRG,MS-418,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","33,645.02",,,,,,
BCBS HMO,DRG,MS-419,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","26,345.09",,,,,,
BCBS HMO,DRG,MS-420,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","69,245.57",,,,,,
BCBS HMO,DRG,MS-421,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","37,118.59",,,,,,
BCBS HMO,DRG,MS-422,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","28,314.72",,,,,,
BCBS HMO,DRG,MS-423,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","85,442.11",,,,,,
BCBS HMO,DRG,MS-424,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","45,388.22",,,,,,
BCBS HMO,DRG,MS-425,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES W/O CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","29,463.84",,,,,,
BCBS HMO,DRG,MS-432,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","36,759.74",,,,,,
BCBS HMO,DRG,MS-433,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","20,805.12",,,,,,
BCBS HMO,DRG,MS-434,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","12,900.38",,,,,,
BCBS HMO,DRG,MS-435,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","34,213.54",,,,,,
BCBS HMO,DRG,MS-436,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","22,694.11",,,,,,
BCBS HMO,DRG,MS-437,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","17,698.46",,,,,,
BCBS HMO,DRG,MS-438,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","33,028.13",,,,,,
BCBS HMO,DRG,MS-439,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","17,079.55",,,,,,
BCBS HMO,DRG,MS-440,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","12,410.50",,,,,,
BCBS HMO,DRG,MS-441,DISORDERS OF LIVER EXCEPT MALIGNANCY- CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","37,306.08",,,,,,
BCBS HMO,DRG,MS-442,DISORDERS OF LIVER EXCEPT MALIGNANCY -  CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","18,817.34",,,,,,
BCBS HMO,DRG,MS-443,DISORDERS OF LIVER EXCEPT MALIGNANCY -  CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","13,714.85",,,,,,
BCBS HMO,DRG,MS-444,DISORDERS OF THE BILIARY TRACT WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","32,782.18",,,,,,
BCBS HMO,DRG,MS-445,DISORDERS OF THE BILIARY TRACT WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","21,661.92",,,,,,
BCBS HMO,DRG,MS-446,DISORDERS OF THE BILIARY TRACT W/O CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","16,384.03",,,,,,
BCBS HMO,DRG,MS-453,COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","189,645.12",,,,,,
BCBS HMO,DRG,MS-454,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","123,480.00",,,,,,
BCBS HMO,DRG,MS-455,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","97,036.13",,,,,,
BCBS HMO,DRG,MS-456,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","183,076.99",,,,,,
BCBS HMO,DRG,MS-457,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","131,308.13",,,,,,
BCBS HMO,DRG,MS-458,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","94,629.02",,,,,,
BCBS HMO,DRG,MS-459,SPINAL FUSION EXCEPT CERVICAL WITH MCC,Surgical,Per Case,"$21,658.00 ",IP,"21,658.00","138,136.32",,,,,,
BCBS HMO,DRG,MS-460,SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,Surgical,Per Case,"$21,658.00 ",IP,"21,658.00","79,841.66",,,,,,
BCBS HMO,DRG,MS-461,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","108,436.61",,,,,,
BCBS HMO,DRG,MS-462,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","63,229.82",,,,,,
BCBS HMO,DRG,MS-463,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","105,392.45",,,,,,
BCBS HMO,DRG,MS-464,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","59,526.43",,,,,,
BCBS HMO,DRG,MS-465,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","38,610.43",,,,,,
BCBS HMO,DRG,MS-466,REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","102,797.86",,,,,,
BCBS HMO,DRG,MS-467,REVISION OF HIP OR KNEE REPLACEMENT W CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","70,803.94",,,,,,
BCBS HMO,DRG,MS-468,REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","56,691.94",,,,,,
BCBS HMO,DRG,MS-469,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","63,300.38",,,,,,
BCBS HMO,DRG,MS-470,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","39,682.94",,,,,,
BCBS HMO,DRG,MS-471,CERVICAL SPINAL FUSION WITH MCC,Surgical,Per Case,"$15,407.00 ",IP,"15,407.00","100,687.10",,,,,,
BCBS HMO,DRG,MS-472,CERVICAL SPINAL FUSION WITH CC,Surgical,Per Case,"$15,407.00 ",IP,"15,407.00","61,316.64",,,,,,
BCBS HMO,DRG,MS-473,CERVICAL SPINAL FUSION WITHOUT CC/MCC,Surgical,Per Case,"$15,407.00 ",IP,"14,827.96","50,649.98",,,,,,
BCBS HMO,DRG,MS-474,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","78,117.98",,,,,,
BCBS HMO,DRG,MS-475,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","42,356.16",,,,,,
BCBS HMO,DRG,MS-476,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","23,480.35",,,,,,
BCBS HMO,DRG,MS-477,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","65,626.85",,,,,,
BCBS HMO,DRG,MS-478,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","46,712.74",,,,,,
BCBS HMO,DRG,MS-479,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","35,929.15",,,,,,
BCBS HMO,DRG,MS-480,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","60,852.96",,,,,,
BCBS HMO,DRG,MS-481,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","42,090.05",,,,,,
BCBS HMO,DRG,MS-482,HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","33,169.25",,,,,,
BCBS HMO,DRG,MS-483,MAJOR JOINT & LIMB REATTACHMENT PROC OF UPPER EXTREMITY W CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","48,224.74",,,,,,
BCBS HMO,DRG,MS-485,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","66,104.64",,,,,,
BCBS HMO,DRG,MS-486,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","43,356.10",,,,,,
BCBS HMO,DRG,MS-487,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","32,401.15",,,,,,
BCBS HMO,DRG,MS-488,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","39,699.07",,,,,,
BCBS HMO,DRG,MS-489,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","25,381.44",,,,,,
BCBS HMO,DRG,MS-492,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","69,457.25",,,,,,
BCBS HMO,DRG,MS-493,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","46,408.32",,,,,,
BCBS HMO,DRG,MS-494,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","36,517.82",,,,,,
BCBS HMO,DRG,MS-495,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","69,201.22",,,,,,
BCBS HMO,DRG,MS-496,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","41,136.48",,,,,,
BCBS HMO,DRG,MS-497,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","29,621.09",,,,,,
BCBS HMO,DRG,MS-498,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","49,353.70",,,,,,
BCBS HMO,DRG,MS-499,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","23,202.14",,,,,,
BCBS HMO,DRG,MS-500,SOFT TISSUE PROCEDURES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","60,786.43",,,,,,
BCBS HMO,DRG,MS-501,SOFT TISSUE PROCEDURES WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","33,828.48",,,,,,
BCBS HMO,DRG,MS-502,SOFT TISSUE PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","26,625.31",,,,,,
BCBS HMO,DRG,MS-503,FOOT PROCEDURES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","54,766.66",,,,,,
BCBS HMO,DRG,MS-504,FOOT PROCEDURES WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","35,007.84",,,,,,
BCBS HMO,DRG,MS-505,FOOT PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","33,899.04",,,,,,
BCBS HMO,DRG,MS-506,MAJOR THUMB OR JOINT PROCEDURES,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","26,986.18",,,,,,
BCBS HMO,DRG,MS-507,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","42,336.00",,,,,,
BCBS HMO,DRG,MS-508,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W/O CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","31,417.34",,,,,,
BCBS HMO,DRG,MS-509,ARTHROSCOPY,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","28,056.67",,,,,,
BCBS HMO,DRG,MS-510,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","56,206.08",,,,,,
BCBS HMO,DRG,MS-511,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","37,985.47",,,,,,
BCBS HMO,DRG,MS-512,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","30,518.21",,,,,,
BCBS HMO,DRG,MS-513,HAND OR WRIST PROCEDURES- EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","31,794.34",,,,,,
BCBS HMO,DRG,MS-514,HAND OR WRIST PROCEDURES -  EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","21,506.69",,,,,,
BCBS HMO,DRG,MS-515,OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","63,584.64",,,,,,
BCBS HMO,DRG,MS-516,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","39,092.26",,,,,,
BCBS HMO,DRG,MS-517,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","28,532.45",,,,,,
BCBS HMO,DRG,MS-518,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,Surgical,Per Case,"$10,289.00 ",IP,"10,289.00","68,717.38",,,,,,
BCBS HMO,DRG,MS-519,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,Surgical,Per Case,"$10,289.00 ",IP,"10,289.00","38,479.39",,,,,,
BCBS HMO,DRG,MS-520,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,Surgical,Per Case,"$10,289.00 ",IP,"8,282.98","26,974.08",,,,,,
BCBS HMO,DRG,MS-521,HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","17,906.85",,,,,,
BCBS HMO,DRG,MS-522,HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","12,786.27",,,,,,
BCBS HMO,DRG,MS-533,FRACTURES OF FEMUR WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","29,421.50",,,,,,
BCBS HMO,DRG,MS-534,FRACTURES OF FEMUR WITHOUT MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","15,680.45",,,,,,
BCBS HMO,DRG,MS-535,FRACTURES OF HIP AND PELVIS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","24,738.34",,,,,,
BCBS HMO,DRG,MS-536,FRACTURES OF HIP AND PELVIS WITHOUT MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","15,291.36",,,,,,
BCBS HMO,DRG,MS-537,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITH CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","18,363.74",,,,,,
BCBS HMO,DRG,MS-538,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","14,535.36",,,,,,
BCBS HMO,DRG,MS-539,OSTEOMYELITIS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","38,005.63",,,,,,
BCBS HMO,DRG,MS-540,OSTEOMYELITIS WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","26,208.00",,,,,,
BCBS HMO,DRG,MS-541,OSTEOMYELITIS WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","18,279.07",,,,,,
BCBS HMO,DRG,MS-542,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","36,787.97",,,,,,
BCBS HMO,DRG,MS-543,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","21,295.01",,,,,,
BCBS HMO,DRG,MS-544,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","15,289.34",,,,,,
BCBS HMO,DRG,MS-545,CONNECTIVE TISSUE DISORDERS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","50,964.48",,,,,,
BCBS HMO,DRG,MS-546,CONNECTIVE TISSUE DISORDERS WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","24,260.54",,,,,,
BCBS HMO,DRG,MS-547,CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","16,331.62",,,,,,
BCBS HMO,DRG,MS-548,SEPTIC ARTHRITIS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","39,983.33",,,,,,
BCBS HMO,DRG,MS-549,SEPTIC ARTHRITIS W CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","24,052.90",,,,,,
BCBS HMO,DRG,MS-550,SEPTIC ARTHRITIS W/O CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","17,418.24",,,,,,
BCBS HMO,DRG,MS-551,MEDICAL BACK PROBLEMS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","32,042.30",,,,,,
BCBS HMO,DRG,MS-552,MEDICAL BACK PROBLEMS WITHOUT MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","18,383.90",,,,,,
BCBS HMO,DRG,MS-553,BONE DISEASES AND ARTHROPATHIES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","25,915.68",,,,,,
BCBS HMO,DRG,MS-554,BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","15,869.95",,,,,,
BCBS HMO,DRG,MS-555,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","26,516.45",,,,,,
BCBS HMO,DRG,MS-556,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","15,962.69",,,,,,
BCBS HMO,DRG,MS-557,TENDONITIS -  MYOSITIS AND BURSITIS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","29,397.31",,,,,,
BCBS HMO,DRG,MS-558,TENDONITIS- MYOSITIS AND BURSITIS WITHOUT MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","17,365.82",,,,,,
BCBS HMO,DRG,MS-559,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","36,324.29",,,,,,
BCBS HMO,DRG,MS-560,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","21,036.96",,,,,,
BCBS HMO,DRG,MS-561,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","15,067.58",,,,,,
BCBS HMO,DRG,MS-562,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","27,157.54",,,,,,
BCBS HMO,DRG,MS-563,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITHOUT MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","17,216.64",,,,,,
BCBS HMO,DRG,MS-564,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","30,481.92",,,,,,
BCBS HMO,DRG,MS-565,OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","19,766.88",,,,,,
BCBS HMO,DRG,MS-566,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","15,275.23",,,,,,
BCBS HMO,DRG,MS-570,SKIN DEBRIDEMENT WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","57,923.71",,,,,,
BCBS HMO,DRG,MS-571,SKIN DEBRIDEMENT WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","33,713.57",,,,,,
BCBS HMO,DRG,MS-572,SKIN DEBRIDEMENT WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","22,613.47",,,,,,
BCBS HMO,DRG,MS-573,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","107,156.45",,,,,,
BCBS HMO,DRG,MS-574,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","62,935.49",,,,,,
BCBS HMO,DRG,MS-575,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS W/O CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","35,421.12",,,,,,
BCBS HMO,DRG,MS-576,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","97,759.87",,,,,,
BCBS HMO,DRG,MS-577,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","48,698.50",,,,,,
BCBS HMO,DRG,MS-578,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","32,808.38",,,,,,
BCBS HMO,DRG,MS-579,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","60,199.78",,,,,,
BCBS HMO,DRG,MS-580,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","32,431.39",,,,,,
BCBS HMO,DRG,MS-581,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","25,296.77",,,,,,
BCBS HMO,DRG,MS-582,MASTECTOMY FOR MALIGNANCY WITH CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","31,826.59",,,,,,
BCBS HMO,DRG,MS-583,MASTECTOMY FOR MALIGNANCY W/O CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","29,461.82",,,,,,
BCBS HMO,DRG,MS-584,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","36,860.54",,,,,,
BCBS HMO,DRG,MS-585,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","34,217.57",,,,,,
BCBS HMO,DRG,MS-592,SKIN ULCERS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","35,971.49",,,,,,
BCBS HMO,DRG,MS-593,SKIN ULCERS WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","23,139.65",,,,,,
BCBS HMO,DRG,MS-594,SKIN ULCERS WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","16,323.55",,,,,,
BCBS HMO,DRG,MS-595,MAJOR SKIN DISORDERS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","40,977.22",,,,,,
BCBS HMO,DRG,MS-596,MAJOR SKIN DISORDERS W/O MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","19,637.86",,,,,,
BCBS HMO,DRG,MS-597,MALIGNANT BREAST DISORDERS W MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","34,128.86",,,,,,
BCBS HMO,DRG,MS-598,MALIGNANT BREAST DISORDERS WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","21,946.18",,,,,,
BCBS HMO,DRG,MS-599,MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","14,019.26",,,,,,
BCBS HMO,DRG,MS-600,NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","19,337.47",,,,,,
BCBS HMO,DRG,MS-601,NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","12,475.01",,,,,,
BCBS HMO,DRG,MS-602,CELLULITIS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","28,824.77",,,,,,
BCBS HMO,DRG,MS-603,CELLULITIS WITHOUT MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","17,004.96",,,,,,
BCBS HMO,DRG,MS-604,TRAUMA TO THE SKIN -  SUBCUTANEOUS TISSUE AND BREAST WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","29,524.32",,,,,,
BCBS HMO,DRG,MS-605,TRAUMA TO THE SKIN- SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","17,654.11",,,,,,
BCBS HMO,DRG,MS-606,MINOR SKIN DISORDERS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","30,149.28",,,,,,
BCBS HMO,DRG,MS-607,MINOR SKIN DISORDERS WITHOUT MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","16,654.18",,,,,,
BCBS HMO,DRG,MS-614,ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","49,055.33",,,,,,
BCBS HMO,DRG,MS-615,ADRENAL & PITUITARY PROCEDURES W/O CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","29,919.46",,,,,,
BCBS HMO,DRG,MS-616,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","80,656.13",,,,,,
BCBS HMO,DRG,MS-617,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","41,354.21",,,,,,
BCBS HMO,DRG,MS-618,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","25,290.72",,,,,,
BCBS HMO,DRG,MS-619,O.R. PROCEDURES FOR OBESITY WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","62,062.56",,,,,,
BCBS HMO,DRG,MS-620,O.R. PROCEDURES FOR OBESITY WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","36,179.14",,,,,,
BCBS HMO,DRG,MS-621,O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","31,691.52",,,,,,
BCBS HMO,DRG,MS-622,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","76,114.08",,,,,,
BCBS HMO,DRG,MS-623,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE -  NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","39,364.42",,,,,,
BCBS HMO,DRG,MS-624,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","22,216.32",,,,,,
BCBS HMO,DRG,MS-625,THYROID- PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","58,970.02",,,,,,
BCBS HMO,DRG,MS-626,THYROID -  PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","33,925.25",,,,,,
BCBS HMO,DRG,MS-627,THYROID -  PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","23,016.67",,,,,,
BCBS HMO,DRG,MS-628,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","74,376.29",,,,,,
BCBS HMO,DRG,MS-629,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","46,827.65",,,,,,
BCBS HMO,DRG,MS-630,OTHER ENDOCRINE - NUTRIT & METAB O.R. PROC W/O CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","29,207.81",,,,,,
BCBS HMO,DRG,MS-637,DIABETES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","27,935.71",,,,,,
BCBS HMO,DRG,MS-638,DIABETES WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","17,823.46",,,,,,
BCBS HMO,DRG,MS-639,DIABETES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","12,362.11",,,,,,
BCBS HMO,DRG,MS-640,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","24,478.27",,,,,,
BCBS HMO,DRG,MS-641,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITHOUT MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","15,253.06",,,,,,
BCBS HMO,DRG,MS-642,INBORN AND OTHER DISORDERS OF METABOLISM,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","24,510.53",,,,,,
BCBS HMO,DRG,MS-643,ENDOCRINE DISORDERS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","32,770.08",,,,,,
BCBS HMO,DRG,MS-644,ENDOCRINE DISORDERS WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","20,726.50",,,,,,
BCBS HMO,DRG,MS-645,ENDOCRINE DISORDERS WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","15,426.43",,,,,,
BCBS HMO,DRG,MS-650,KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","26,401.24",,,,,,
BCBS HMO,DRG,MS-651,KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","21,598.94",,,,,,
BCBS HMO,DRG,MS-652,KIDNEY TRANSPLANT,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","68,239.58",,,,,,
BCBS HMO,DRG,MS-653,MAJOR BLADDER PROCEDURES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","111,615.84",,,,,,
BCBS HMO,DRG,MS-654,MAJOR BLADDER PROCEDURES WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","56,693.95",,,,,,
BCBS HMO,DRG,MS-655,MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","41,577.98",,,,,,
BCBS HMO,DRG,MS-656,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","65,733.70",,,,,,
BCBS HMO,DRG,MS-657,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","38,993.47",,,,,,
BCBS HMO,DRG,MS-658,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","31,649.18",,,,,,
BCBS HMO,DRG,MS-659,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","54,024.77",,,,,,
BCBS HMO,DRG,MS-660,KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","28,641.31",,,,,,
BCBS HMO,DRG,MS-661,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","21,976.42",,,,,,
BCBS HMO,DRG,MS-662,MINOR BLADDER PROCEDURES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","63,800.35",,,,,,
BCBS HMO,DRG,MS-663,MINOR BLADDER PROCEDURES WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","30,711.74",,,,,,
BCBS HMO,DRG,MS-664,MINOR BLADDER PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","22,309.06",,,,,,
BCBS HMO,DRG,MS-665,PROSTATECTOMY WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","59,844.96",,,,,,
BCBS HMO,DRG,MS-666,PROSTATECTOMY WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","35,665.06",,,,,,
BCBS HMO,DRG,MS-667,PROSTATECTOMY W/O CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","18,924.19",,,,,,
BCBS HMO,DRG,MS-668,TRANSURETHRAL PROCEDURES W MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","56,212.13",,,,,,
BCBS HMO,DRG,MS-669,TRANSURETHRAL PROCEDURES WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","31,161.31",,,,,,
BCBS HMO,DRG,MS-670,TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","19,730.59",,,,,,
BCBS HMO,DRG,MS-671,URETHRAL PROCEDURES WITH CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","36,844.42",,,,,,
BCBS HMO,DRG,MS-672,URETHRAL PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","20,829.31",,,,,,
BCBS HMO,DRG,MS-673,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","72,063.94",,,,,,
BCBS HMO,DRG,MS-674,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","49,275.07",,,,,,
BCBS HMO,DRG,MS-675,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","32,901.12",,,,,,
BCBS HMO,DRG,MS-682,RENAL FAILURE WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","29,796.48",,,,,,
BCBS HMO,DRG,MS-683,RENAL FAILURE WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","18,089.57",,,,,,
BCBS HMO,DRG,MS-684,RENAL FAILURE WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","12,404.45",,,,,,
BCBS HMO,DRG,MS-686,KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","35,402.98",,,,,,
BCBS HMO,DRG,MS-687,KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","21,220.42",,,,,,
BCBS HMO,DRG,MS-688,KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","15,549.41",,,,,,
BCBS HMO,DRG,MS-689,KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","22,550.98",,,,,,
BCBS HMO,DRG,MS-690,KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","15,942.53",,,,,,
BCBS HMO,DRG,MS-693,URINARY STONES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","27,282.53",,,,,,
BCBS HMO,DRG,MS-694,URINARY STONES WITHOUT MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","14,926.46",,,,,,
BCBS HMO,DRG,MS-695,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","23,633.57",,,,,,
BCBS HMO,DRG,MS-696,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","13,696.70",,,,,,
BCBS HMO,DRG,MS-697,URETHRAL STRICTURE,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","19,633.82",,,,,,
BCBS HMO,DRG,MS-698,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","32,630.98",,,,,,
BCBS HMO,DRG,MS-699,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","20,819.23",,,,,,
BCBS HMO,DRG,MS-700,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","14,952.67",,,,,,
BCBS HMO,DRG,MS-707,MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","37,697.18",,,,,,
BCBS HMO,DRG,MS-708,MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","29,272.32",,,,,,
BCBS HMO,DRG,MS-709,PENIS PROCEDURES W CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","48,496.90",,,,,,
BCBS HMO,DRG,MS-710,PENIS PROCEDURES W/O CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","30,961.73",,,,,,
BCBS HMO,DRG,MS-711,TESTES PROCEDURES WITH CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","43,206.91",,,,,,
BCBS HMO,DRG,MS-712,TESTES PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","20,567.23",,,,,,
BCBS HMO,DRG,MS-713,TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","29,473.92",,,,,,
BCBS HMO,DRG,MS-714,TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","18,454.46",,,,,,
BCBS HMO,DRG,MS-715,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","43,071.84",,,,,,
BCBS HMO,DRG,MS-716,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","29,544.48",,,,,,
BCBS HMO,DRG,MS-717,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","35,568.29",,,,,,
BCBS HMO,DRG,MS-718,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","24,583.10",,,,,,
BCBS HMO,DRG,MS-722,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","36,386.78",,,,,,
BCBS HMO,DRG,MS-723,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","22,325.18",,,,,,
BCBS HMO,DRG,MS-724,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","11,902.46",,,,,,
BCBS HMO,DRG,MS-725,BENIGN PROSTATIC HYPERTROPHY WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","25,308.86",,,,,,
BCBS HMO,DRG,MS-726,BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","15,416.35",,,,,,
BCBS HMO,DRG,MS-727,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","28,774.37",,,,,,
BCBS HMO,DRG,MS-728,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","16,178.40",,,,,,
BCBS HMO,DRG,MS-729,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","21,649.82",,,,,,
BCBS HMO,DRG,MS-730,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","12,733.06",,,,,,
BCBS HMO,DRG,MS-734,PELVIC EVISCERATION -  RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","44,188.70",,,,,,
BCBS HMO,DRG,MS-735,PELVIC EVISCERATION -  RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","27,703.87",,,,,,
BCBS HMO,DRG,MS-736,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","87,109.34",,,,,,
BCBS HMO,DRG,MS-737,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","40,059.94",,,,,,
BCBS HMO,DRG,MS-738,UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY W/O CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","27,798.62",,,,,,
BCBS HMO,DRG,MS-739,UTERINE -ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","75,489.12",,,,,,
BCBS HMO,DRG,MS-740,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","35,983.58",,,,,,
BCBS HMO,DRG,MS-741,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","26,802.72",,,,,,
BCBS HMO,DRG,MS-742,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","34,060.32",,,,,,
BCBS HMO,DRG,MS-743,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","23,153.76",,,,,,
BCBS HMO,DRG,MS-744,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","35,088.48",,,,,,
BCBS HMO,DRG,MS-745,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","21,476.45",,,,,,
BCBS HMO,DRG,MS-746,VAGINA -  CERVIX AND VULVA PROCEDURES WITH CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","32,880.96",,,,,,
BCBS HMO,DRG,MS-747,VAGINA- CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","18,793.15",,,,,,
BCBS HMO,DRG,MS-748,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","26,645.47",,,,,,
BCBS HMO,DRG,MS-749,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","52,258.75",,,,,,
BCBS HMO,DRG,MS-750,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","26,836.99",,,,,,
BCBS HMO,DRG,MS-754,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","35,519.90",,,,,,
BCBS HMO,DRG,MS-755,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","20,639.81",,,,,,
BCBS HMO,DRG,MS-756,MALIGNANCY - FEMALE REPRODUCTIVE SYSTEM W/O CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","17,676.29",,,,,,
BCBS HMO,DRG,MS-757,INFECTIONS - FEMALE REPRODUCTIVE SYSTEM W MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","28,633.25",,,,,,
BCBS HMO,DRG,MS-758,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","19,462.46",,,,,,
BCBS HMO,DRG,MS-759,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","13,311.65",,,,,,
BCBS HMO,DRG,MS-760,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","18,194.40",,,,,,
BCBS HMO,DRG,MS-761,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","11,398.46",,,,,,
BCBS HMO,DRG,MS-768,VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","20,311.20",,,,,,
BCBS HMO,DRG,MS-769,POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","29,090.88",,,,,,
BCBS HMO,DRG,MS-770,ABORTION WITH D&C- ASPIRATION CURETTAGE OR HYSTEROTOMY,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","15,851.81",,,,,,
BCBS HMO,DRG,MS-776,POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","14,311.58",,,,,,
BCBS HMO,DRG,MS-779,ABORTION WITHOUT D&C,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","23,018.69",,,,,,
BCBS HMO,DRG,MS-783,CESAREAN SECTION WITH STERILIZATION WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","43,239.17",,,,,,
BCBS HMO,DRG,MS-784,CESAREAN SECTION WITH STERILIZATION WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","21,071.23",,,,,,
BCBS HMO,DRG,MS-785,CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","17,305.34",,,,,,
BCBS HMO,DRG,MS-786,CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","34,564.32",,,,,,
BCBS HMO,DRG,MS-787,CESAREAN SECTION WITHOUT STERILIZATION WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","21,077.28",,,,,,
BCBS HMO,DRG,MS-788,CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","18,268.99",,,,,,
BCBS HMO,DRG,MS-789,NEONATES- DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","34,070.40",,,,,,
BCBS HMO,DRG,MS-790,EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME- NEONATE,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","112,351.68",,,,,,
BCBS HMO,DRG,MS-791,PREMATURITY W MAJOR PROBLEMS,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","76,732.99",,,,,,
BCBS HMO,DRG,MS-792,PREMATURITY W/O MAJOR PROBLEMS,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","46,297.44",,,,,,
BCBS HMO,DRG,MS-793,FULL TERM NEONATE WITH MAJOR PROBLEMS,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","78,819.55",,,,,,
BCBS HMO,DRG,MS-794,NEONATE WITH OTHER SIGNIFICANT PROBLEMS,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","27,897.41",,,,,,
BCBS HMO,DRG,MS-795,NORMAL NEWBORN,Surgical,Per Diem,"$2,420.00 ",IP,"1,113.70","3,775.97",,,,,,
BCBS HMO,DRG,MS-796,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","39,761.57",,,,,,
BCBS HMO,DRG,MS-797,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","17,394.05",,,,,,
BCBS HMO,DRG,MS-798,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","17,394.05",,,,,,
BCBS HMO,DRG,MS-799,SPLENECTOMY WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","99,677.09",,,,,,
BCBS HMO,DRG,MS-800,SPLENECTOMY WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","57,294.72",,,,,,
BCBS HMO,DRG,MS-801,SPLENECTOMY WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","37,763.71",,,,,,
BCBS HMO,DRG,MS-802,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","63,552.38",,,,,,
BCBS HMO,DRG,MS-803,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","35,917.06",,,,,,
BCBS HMO,DRG,MS-804,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","27,470.02",,,,,,
BCBS HMO,DRG,MS-805,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","20,980.51",,,,,,
BCBS HMO,DRG,MS-806,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","14,297.47",,,,,,
BCBS HMO,DRG,MS-807,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","12,636.29",,,,,,
BCBS HMO,DRG,MS-808,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","42,932.74",,,,,,
BCBS HMO,DRG,MS-809,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","24,512.54",,,,,,
BCBS HMO,DRG,MS-810,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","18,857.66",,,,,,
BCBS HMO,DRG,MS-811,RED BLOOD CELL DISORDERS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","27,020.45",,,,,,
BCBS HMO,DRG,MS-812,RED BLOOD CELL DISORDERS WITHOUT MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","17,553.31",,,,,,
BCBS HMO,DRG,MS-813,COAGULATION DISORDERS,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","31,957.63",,,,,,
BCBS HMO,DRG,MS-814,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","35,261.86",,,,,,
BCBS HMO,DRG,MS-815,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","20,418.05",,,,,,
BCBS HMO,DRG,MS-816,RETICULOENDOTHELIAL & IMMUNITY DISORDERS W/O CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","14,432.54",,,,,,
BCBS HMO,DRG,MS-817,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","50,726.59",,,,,,
BCBS HMO,DRG,MS-818,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","25,681.82",,,,,,
BCBS HMO,DRG,MS-819,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","16,085.66",,,,,,
BCBS HMO,DRG,MS-820,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","115,248.67",,,,,,
BCBS HMO,DRG,MS-821,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","45,003.17",,,,,,
BCBS HMO,DRG,MS-822,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","25,490.30",,,,,,
BCBS HMO,DRG,MS-823,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","85,280.83",,,,,,
BCBS HMO,DRG,MS-824,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","46,874.02",,,,,,
BCBS HMO,DRG,MS-825,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","27,306.72",,,,,,
BCBS HMO,DRG,MS-826,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","101,102.40",,,,,,
BCBS HMO,DRG,MS-827,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","46,694.59",,,,,,
BCBS HMO,DRG,MS-828,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","33,288.19",,,,,,
BCBS HMO,DRG,MS-829,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","63,300.38",,,,,,
BCBS HMO,DRG,MS-830,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","27,796.61",,,,,,
BCBS HMO,DRG,MS-831,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","21,742.56",,,,,,
BCBS HMO,DRG,MS-832,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","14,424.48",,,,,,
BCBS HMO,DRG,MS-833,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","10,727.14",,,,,,
BCBS HMO,DRG,MS-834,ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","117,784.80",,,,,,
BCBS HMO,DRG,MS-835,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","40,888.51",,,,,,
BCBS HMO,DRG,MS-836,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","26,562.82",,,,,,
BCBS HMO,DRG,MS-837,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","120,774.53",,,,,,
BCBS HMO,DRG,MS-838,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","44,108.06",,,,,,
BCBS HMO,DRG,MS-839,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","25,728.19",,,,,,
BCBS HMO,DRG,MS-840,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","64,415.23",,,,,,
BCBS HMO,DRG,MS-841,LYMPHOMA & NON-ACUTE LEUKEMIA W CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","32,491.87",,,,,,
BCBS HMO,DRG,MS-842,LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","23,115.46",,,,,,
BCBS HMO,DRG,MS-843,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","38,461.25",,,,,,
BCBS HMO,DRG,MS-844,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","24,353.28",,,,,,
BCBS HMO,DRG,MS-845,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","17,456.54",,,,,,
BCBS HMO,DRG,MS-846,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","52,952.26",,,,,,
BCBS HMO,DRG,MS-847,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","26,528.54",,,,,,
BCBS HMO,DRG,MS-848,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","19,785.02",,,,,,
BCBS HMO,DRG,MS-849,RADIOTHERAPY,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","42,856.13",,,,,,
BCBS HMO,DRG,MS-853,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","102,787.78",,,,,,
BCBS HMO,DRG,MS-854,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","43,569.79",,,,,,
BCBS HMO,DRG,MS-855,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","32,322.53",,,,,,
BCBS HMO,DRG,MS-856,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","89,222.11",,,,,,
BCBS HMO,DRG,MS-857,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","40,991.33",,,,,,
BCBS HMO,DRG,MS-858,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","27,748.22",,,,,,
BCBS HMO,DRG,MS-862,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","37,308.10",,,,,,
BCBS HMO,DRG,MS-863,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W/O MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","19,918.08",,,,,,
BCBS HMO,DRG,MS-864,FEVER AND INFLAMMATORY CONDITIONS,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","17,083.58",,,,,,
BCBS HMO,DRG,MS-865,VIRAL ILLNESS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","28,088.93",,,,,,
BCBS HMO,DRG,MS-866,VIRAL ILLNESS WITHOUT MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","16,504.99",,,,,,
BCBS HMO,DRG,MS-867,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","44,053.63",,,,,,
BCBS HMO,DRG,MS-868,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","22,115.52",,,,,,
BCBS HMO,DRG,MS-869,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","14,968.80",,,,,,
BCBS HMO,DRG,MS-870,SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","127,497.89",,,,,,
BCBS HMO,DRG,MS-871,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","37,624.61",,,,,,
BCBS HMO,DRG,MS-872,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","20,952.29",,,,,,
BCBS HMO,DRG,MS-876,O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","73,382.40",,,,,,
BCBS HMO,DRG,MS-880,ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","17,275.10",,,,,,
BCBS HMO,DRG,MS-881,DEPRESSIVE NEUROSES,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","16,517.09",,,,,,
BCBS HMO,DRG,MS-882,NEUROSES EXCEPT DEPRESSIVE,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","15,922.37",,,,,,
BCBS HMO,DRG,MS-883,DISORDERS OF PERSONALITY & IMPULSE CONTROL,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","26,945.86",,,,,,
BCBS HMO,DRG,MS-884,ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","28,990.08",,,,,,
BCBS HMO,DRG,MS-885,PSYCHOSES,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","24,502.46",,,,,,
BCBS HMO,DRG,MS-886,BEHAVIORAL AND DEVELOPMENTAL DISORDERS,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","27,127.30",,,,,,
BCBS HMO,DRG,MS-887,OTHER MENTAL DISORDER DIAGNOSES,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","21,936.10",,,,,,
BCBS HMO,DRG,MS-894,ALCOHOL- DRUG ABUSE OR DEPENDENCE- LEFT AMA,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","11,700.86",,,,,,
BCBS HMO,DRG,MS-895,ALCOHOL- DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","32,798.30",,,,,,
BCBS HMO,DRG,MS-896,ALCOHOL -  DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","34,669.15",,,,,,
BCBS HMO,DRG,MS-897,ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","16,567.49",,,,,,
BCBS HMO,DRG,MS-901,WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","87,236.35",,,,,,
BCBS HMO,DRG,MS-902,WOUND DEBRIDEMENTS FOR INJURIES WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","39,652.70",,,,,,
BCBS HMO,DRG,MS-903,WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","23,063.04",,,,,,
BCBS HMO,DRG,MS-904,SKIN GRAFTS FOR INJURIES WITH CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","71,313.98",,,,,,
BCBS HMO,DRG,MS-905,SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","33,554.30",,,,,,
BCBS HMO,DRG,MS-906,HAND PROCEDURES FOR INJURIES,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","35,096.54",,,,,,
BCBS HMO,DRG,MS-907,OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","80,430.34",,,,,,
BCBS HMO,DRG,MS-908,OTHER O.R. PROCEDURES FOR INJURIES WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","41,592.10",,,,,,
BCBS HMO,DRG,MS-909,OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","26,584.99",,,,,,
BCBS HMO,DRG,MS-913,TRAUMATIC INJURY WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","29,762.21",,,,,,
BCBS HMO,DRG,MS-914,TRAUMATIC INJURY WITHOUT MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","17,371.87",,,,,,
BCBS HMO,DRG,MS-915,ALLERGIC REACTIONS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","34,253.86",,,,,,
BCBS HMO,DRG,MS-916,ALLERGIC REACTIONS WITHOUT MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","12,765.31",,,,,,
BCBS HMO,DRG,MS-917,POISONING & TOXIC EFFECTS OF DRUGS W MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","29,498.11",,,,,,
BCBS HMO,DRG,MS-918,POISONING & TOXIC EFFECTS OF DRUGS W/O MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","15,805.44",,,,,,
BCBS HMO,DRG,MS-919,COMPLICATIONS OF TREATMENT WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","36,798.05",,,,,,
BCBS HMO,DRG,MS-920,COMPLICATIONS OF TREATMENT WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","20,311.20",,,,,,
BCBS HMO,DRG,MS-921,COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","13,922.50",,,,,,
BCBS HMO,DRG,MS-922,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","32,328.58",,,,,,
BCBS HMO,DRG,MS-923,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","17,448.48",,,,,,
BCBS HMO,DRG,MS-927,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","402,060.96",,,,,,
BCBS HMO,DRG,MS-928,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","124,889.18",,,,,,
BCBS HMO,DRG,MS-929,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","59,300.64",,,,,,
BCBS HMO,DRG,MS-933,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","63,306.43",,,,,,
BCBS HMO,DRG,MS-934,FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","36,485.57",,,,,,
BCBS HMO,DRG,MS-935,NON-EXTENSIVE BURNS,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","38,955.17",,,,,,
BCBS HMO,DRG,MS-939,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","73,672.70",,,,,,
BCBS HMO,DRG,MS-940,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","45,799.49",,,,,,
BCBS HMO,DRG,MS-941,O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W/O CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","38,922.91",,,,,,
BCBS HMO,DRG,MS-945,REHABILITATION WITH CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","29,338.85",,,,,,
BCBS HMO,DRG,MS-946,REHABILITATION WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","21,913.92",,,,,,
BCBS HMO,DRG,MS-947,SIGNS AND SYMPTOMS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","24,137.57",,,,,,
BCBS HMO,DRG,MS-948,SIGNS AND SYMPTOMS WITHOUT MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","15,716.74",,,,,,
BCBS HMO,DRG,MS-949,AFTERCARE WITH CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","21,952.22",,,,,,
BCBS HMO,DRG,MS-950,AFTERCARE WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","14,936.54",,,,,,
BCBS HMO,DRG,MS-951,OTHER FACTORS INFLUENCING HEALTH STATUS,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","11,823.84",,,,,,
BCBS HMO,DRG,MS-955,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","122,582.88",,,,,,
BCBS HMO,DRG,MS-956,LIMB REATTACHMENT- HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","79,093.73",,,,,,
BCBS HMO,DRG,MS-957,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","151,879.39",,,,,,
BCBS HMO,DRG,MS-958,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","84,488.54",,,,,,
BCBS HMO,DRG,MS-959,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","56,458.08",,,,,,
BCBS HMO,DRG,MS-963,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","54,938.02",,,,,,
BCBS HMO,DRG,MS-964,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","30,108.96",,,,,,
BCBS HMO,DRG,MS-965,OTHER MULTIPLE SIGNIFICANT TRAUMA W/O CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","18,488.74",,,,,,
BCBS HMO,DRG,MS-969,HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","116,982.43",,,,,,
BCBS HMO,DRG,MS-970,HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","58,806.72",,,,,,
BCBS HMO,DRG,MS-974,HIV WITH MAJOR RELATED CONDITION WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","53,905.82",,,,,,
BCBS HMO,DRG,MS-975,HIV WITH MAJOR RELATED CONDITION WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","27,054.72",,,,,,
BCBS HMO,DRG,MS-976,HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","18,430.27",,,,,,
BCBS HMO,DRG,MS-977,HIV WITH OR WITHOUT OTHER RELATED CONDITION,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","26,218.08",,,,,,
BCBS HMO,DRG,MS-981,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","90,532.51",,,,,,
BCBS HMO,DRG,MS-982,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","49,152.10",,,,,,
BCBS HMO,DRG,MS-983,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","33,003.94",,,,,,
BCBS HMO,DRG,MS-987,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","67,207.39",,,,,,
BCBS HMO,DRG,MS-988,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","34,640.93",,,,,,
BCBS HMO,DRG,MS-989,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","23,232.38",,,,,,
BCBS HMO,DRG,MS-998,PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","2,420.00",,,,,,
BCBS HMO,DRG,MS-999,UNGROUPABLE,Surgical,Per Diem,"$2,420.00 ",IP,"2,420.00","2,420.00",,,,,,
BCBS HMO,CPT,456,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,10000,Incision & drainage of sebaceous cyst-one,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,10001,Incision & drainage of sebaceous cyst-two,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,10002,Incision & drainage of sebaceous cyst-additonal,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,10003,Incision & drainage of sebaceous cyst w/sac,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,10004,Fna bx w/o img gdn ea addl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,10005,Fna bx w/us gdn 1st les,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,10006,Fna bx w/us gdn ea addl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,10007,Fna bx w/fluor gdn 1st les,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,10008,Fna bx w/fluor gdn ea addl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,10009,Fna bx w/ct gdn 1st les,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,10010,Fna bx w/ct gdn ea addl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,10011,Fna bx w/mr gdn 1st les,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,10012,Fna bx w/mr gdn ea addl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,10020,Incision & drainage of sebaceous cyst furuncle,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,10021,Fna bx w/o img gdn 1st les,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,10022,Fna w/image,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,10030,Guide cathet fluid drainage,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,10035,Perq dev soft tiss 1st imag,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,10036,Perq dev soft tiss add imag,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,10040,Acne surgery,Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,10060,Drainage of skin abscess,Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,10061,Drainage of skin abscess,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,10080,Drainage of pilonidal cyst,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,10081,Drainage of pilonidal cyst,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,10100,Drainage paronychia-one,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,10101,Drainage paronychia-mutliple,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,10120,Remove foreign body,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,10121,Remove foreign body,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,10140,Drainage of hematoma/fluid,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,10141,Drainage of hematoma,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,10160,Puncture drainage of lesion,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,10180,Complex drainage wound,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,11000,Debride infected skin,Surgical,Per Case,"$4,314.00 ",OP,536.39,"4,314.00",,,,,,
BCBS HMO,CPT,11001,Debride infected skin add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,11004,Debride genitalia & perineum,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,11005,Debride abdom wall,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,11006,Debride genit/per/abdom wall,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,11008,Remove mesh from abd wall,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,11010,Debride skin at fx site,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,11011,Debride skin musc at fx site,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,11012,Deb skin bone at fx site,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,11040,Debride skin - partial,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,11041,Debride skin - full,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,11042,Deb subq tissue 20 sq cm/<,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,11043,Deb musc/fascia 20 sq cm/<,Surgical,Per Case,"$4,314.00 ",OP,536.39,"4,314.00",,,,,,
BCBS HMO,CPT,11044,Deb bone 20 sq cm/<,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,11045,Deb subq tissue add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,11046,Deb musc/fascia add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,11047,Deb bone add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,11050,TRIM SKIN LESION,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,11051,TRIM 2 TO 4 SKIN LESIONS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,11052,TRIM OVER 4 SKIN LESIONS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,11055,Trim skin lesion,Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,11056,Trim skin lesions 2 to 4,Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,11057,Trim skin lesions over 4,Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,11060,SHAVE SKIN LESION,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,11061,SHAVE SKIN LESIONS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,11062,SHAVE SKIN LESIONS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,11100,Biopsy skin lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,11101,Biopsy skin add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,11102,Tangntl bx skin single les,Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,11103,Tangntl bx skin ea sep/addl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,11104,Punch bx skin single lesion,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,11105,Punch bx skin ea sep/addl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,11106,Incal bx skn single les,Surgical,Per Case,"$4,314.00 ",OP,536.39,"4,314.00",,,,,,
BCBS HMO,CPT,11107,Incal bx skn ea sep/addl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,11200,Removal of skin tags <w/15,Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,11201,Remove skin tags add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,11300,Shave skin lesion 0.5 cm/<,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,11301,Shave skin lesion 0.6-1.0 cm,Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,11302,Shave skin lesion 1.1-2.0 cm,Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,11303,Shave skin lesion >2.0 cm,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,11305,Shave skin lesion 0.5 cm/<,Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,11306,Shave skin lesion 0.6-1.0 cm,Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,11307,Shave skin lesion 1.1-2.0 cm,Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,11308,Shave skin lesion >2.0 cm,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,11310,Shave skin lesion 0.5 cm/<,Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,11311,Shave skin lesion 0.6-1.0 cm,Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,11312,Shave skin lesion 1.1-2.0 cm,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,11313,Shave skin lesion >2.0 cm,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,11400,Exc tr-ext b9+marg 0.5 cm<,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,11401,Exc tr-ext b9+marg 0.6-1 cm,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,11402,Exc tr-ext b9+marg 1.1-2 cm,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,11403,Exc tr-ext b9+marg 2.1-3cm,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,11404,Exc tr-ext b9+marg 3.1-4 cm,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,11406,Exc tr-ext b9+marg >4.0 cm,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,11420,Exc h-f-nk-sp b9+marg 0.5/<,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,11421,Exc h-f-nk-sp b9+marg 0.6-1,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,11422,Exc h-f-nk-sp b9+marg 1.1-2,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,11423,Exc h-f-nk-sp b9+marg 2.1-3,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,11424,Exc h-f-nk-sp b9+marg 3.1-4,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,11426,Exc h-f-nk-sp b9+marg >4 cm,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,11440,Exc face-mm b9+marg 0.5 cm/<,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,11441,Exc face-mm b9+marg 0.6-1 cm,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,11442,Exc face-mm b9+marg 1.1-2 cm,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,11443,Exc face-mm b9+marg 2.1-3 cm,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,11444,Exc face-mm b9+marg 3.1-4 cm,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,11446,Exc face-mm b9+marg >4 cm,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,11450,Removal sweat gland lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,11451,Removal sweat gland lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,11462,Removal sweat gland lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,11463,Removal sweat gland lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,11470,Removal sweat gland lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,11471,Removal sweat gland lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,11600,Exc tr-ext mal+marg 0.5 cm/<,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,11601,Exc tr-ext mal+marg 0.6-1 cm,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,11602,Exc tr-ext mal+marg 1.1-2 cm,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,11603,Exc tr-ext mal+marg 2.1-3 cm,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,11604,Exc tr-ext mal+marg 3.1-4 cm,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,11606,Exc tr-ext mal+marg >4 cm,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,11620,Exc h-f-nk-sp mal+marg 0.5/<,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,11621,Exc s/n/h/f/g mal+mrg 0.6-1,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,11622,Exc s/n/h/f/g mal+mrg 1.1-2,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,11623,Exc s/n/h/f/g mal+mrg 2.1-3,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,11624,Exc s/n/h/f/g mal+mrg 3.1-4,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,11626,Exc s/n/h/f/g mal+mrg >4 cm,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,11640,Exc f/e/e/n/l mal+mrg 0.5cm<,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,11641,Exc f/e/e/n/l mal+mrg 0.6-1,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,11642,Exc f/e/e/n/l mal+mrg 1.1-2,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,11643,Exc f/e/e/n/l mal+mrg 2.1-3,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,11644,Exc f/e/e/n/l mal+mrg 3.1-4,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,11646,Exc f/e/e/n/l mal+mrg >4 cm,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,11700,Debridement of nails-manual-five or less,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,11701,Debridement of nails-manual-each additional-five or less,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,11710,Debridement of nails-electric grinder-five or less,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,11711,Debridement of nails-electric grinder-each additional-five or less,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,11719,Trim nail(s) any number,Surgical,Per Case,"$4,314.00 ",OP,56.95,"4,314.00",,,,,,
BCBS HMO,CPT,11720,Debride nail 1-5,Surgical,Per Case,"$4,314.00 ",OP,56.95,"4,314.00",,,,,,
BCBS HMO,CPT,11721,Debride nail 6 or more,Surgical,Per Case,"$4,314.00 ",OP,56.95,"4,314.00",,,,,,
BCBS HMO,CPT,11730,Removal of nail plate,Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,11731,REMOVAL OF SECOND NAIL,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,11732,Remove nail plate add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,11740,Drain blood from under nail,Surgical,Per Case,"$4,314.00 ",OP,114.56,"4,314.00",,,,,,
BCBS HMO,CPT,11750,Removal of nail bed,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,11752,Remove nail bed/finger tip,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,11755,Biopsy nail unit,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,11760,Repair of nail bed,Surgical,Per Case,"$4,314.00 ",OP,536.39,"4,314.00",,,,,,
BCBS HMO,CPT,11762,Reconstruction of nail bed,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,11765,Excision of nail fold toe,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,11770,Remove pilonidal cyst simple,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,11771,Remove pilonidal cyst exten,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,11772,Remove pilonidal cyst compl,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,11900,Inject skin lesions </w 7,Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,11901,Inject skin lesions >7,Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,11920,Correct skin color 6.0 cm/<,Surgical,Per Case,"$4,314.00 ",OP,536.39,"4,314.00",,,,,,
BCBS HMO,CPT,11921,Correct skn color 6.1-20.0cm,Surgical,Per Case,"$4,314.00 ",OP,536.39,"4,314.00",,,,,,
BCBS HMO,CPT,11922,Correct skin color ea 20.0cm,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,11950,Tx contour defects 1 cc/<,Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,11951,Tx contour defects 1.1-5.0cc,Surgical,Per Case,"$4,314.00 ",OP,536.39,"4,314.00",,,,,,
BCBS HMO,CPT,11952,Tx contour defects 5.1-10cc,Surgical,Per Case,"$4,314.00 ",OP,536.39,"4,314.00",,,,,,
BCBS HMO,CPT,11954,Tx contour defects >10.0 cc,Surgical,Per Case,"$4,314.00 ",OP,536.39,"4,314.00",,,,,,
BCBS HMO,CPT,11960,Insert tissue expander(s),Surgical,Per Case,"$4,314.00 ",OP,"3,604.28","4,314.00",,,,,,
BCBS HMO,CPT,11970,Rplcmt tiss xpndr perm implt,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,11971,Rmvl tis xpndr wo insj implt,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,11975,Insert contraceptive cap,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,11976,Remove contraceptive capsule,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,11977,Removal/reinsert contra cap,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,11980,Implant hormone pellet(s),Surgical,Per Case,"$4,314.00 ",OP,276.53,"4,314.00",,,,,,
BCBS HMO,CPT,11981,Insert drug implant device,Surgical,Per Case,"$4,314.00 ",OP,114.56,"4,314.00",,,,,,
BCBS HMO,CPT,11982,Remove drug implant device,Surgical,Per Case,"$4,314.00 ",OP,276.53,"4,314.00",,,,,,
BCBS HMO,CPT,11983,Remove/insert drug implant,Surgical,Per Case,"$4,314.00 ",OP,276.53,"4,314.00",,,,,,
BCBS HMO,CPT,11999,MISCELLANEOUS SURGERY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,12001,Rpr s/n/ax/gen/trnk 2.5cm/<,Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,12002,Rpr s/n/ax/gen/trnk2.6-7.5cm,Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,12004,Rpr s/n/ax/gen/trk7.6-12.5cm,Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,12005,Rpr s/n/a/gen/trk12.6-20.0cm,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,12006,Rpr s/n/a/gen/trk20.1-30.0cm,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,12007,Rpr s/n/ax/gen/trnk >30.0 cm,Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,12011,Rpr f/e/e/n/l/m 2.5 cm/<,Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,12013,Rpr f/e/e/n/l/m 2.6-5.0 cm,Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,12014,Rpr f/e/e/n/l/m 5.1-7.5 cm,Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,12015,Rpr f/e/e/n/l/m 7.6-12.5 cm,Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,12016,Rpr fe/e/en/l/m 12.6-20.0 cm,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,12017,Rpr fe/e/en/l/m 20.1-30.0 cm,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,12018,Rpr f/e/e/n/l/m >30.0 cm,Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,12020,Closure of split wound,Surgical,Per Case,"$4,314.00 ",OP,536.39,"4,314.00",,,,,,
BCBS HMO,CPT,12021,Closure of split wound,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,12031,Intmd rpr s/a/t/ext 2.5 cm/<,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,12032,Intmd rpr s/a/t/ext 2.6-7.5,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,12034,Intmd rpr s/tr/ext 7.6-12.5,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,12035,Intmd rpr s/a/t/ext 12.6-20,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,12036,Intmd rpr s/a/t/ext 20.1-30,Surgical,Per Case,"$4,314.00 ",OP,536.39,"4,314.00",,,,,,
BCBS HMO,CPT,12037,Intmd rpr s/tr/ext >30.0 cm,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,12041,Intmd rpr n-hf/genit 2.5cm/<,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,12042,Intmd rpr n-hf/genit2.6-7.5,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,12044,Intmd rpr n-hf/genit7.6-12.5,Surgical,Per Case,"$4,314.00 ",OP,536.39,"4,314.00",,,,,,
BCBS HMO,CPT,12045,Intmd rpr n-hf/genit12.6-20,Surgical,Per Case,"$4,314.00 ",OP,536.39,"4,314.00",,,,,,
BCBS HMO,CPT,12046,Intmd rpr n-hf/genit20.1-30,Surgical,Per Case,"$4,314.00 ",OP,536.39,"4,314.00",,,,,,
BCBS HMO,CPT,12047,Intmd rpr n-hf/genit >30.0cm,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,12051,Intmd rpr face/mm 2.5 cm/<,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,12052,Intmd rpr face/mm 2.6-5.0 cm,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,12053,Intmd rpr face/mm 5.1-7.5 cm,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,12054,Intmd rpr face/mm 7.6-12.5cm,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,12055,Intmd rpr face/mm 12.6-20 cm,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,12056,Intmd rpr face/mm 20.1-30.0,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,12057,Intmd rpr face/mm >30.0 cm,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,13100,Cmplx rpr trunk 1.1-2.5 cm,Surgical,Per Case,"$4,314.00 ",OP,536.39,"4,314.00",,,,,,
BCBS HMO,CPT,13101,Cmplx rpr trunk 2.6-7.5 cm,Surgical,Per Case,"$4,314.00 ",OP,536.39,"4,314.00",,,,,,
BCBS HMO,CPT,13102,Cmplx rpr trunk addl 5cm/<,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,13120,Cmplx rpr s/a/l 1.1-2.5 cm,Surgical,Per Case,"$4,314.00 ",OP,536.39,"4,314.00",,,,,,
BCBS HMO,CPT,13121,Cmplx rpr s/a/l 2.6-7.5 cm,Surgical,Per Case,"$4,314.00 ",OP,536.39,"4,314.00",,,,,,
BCBS HMO,CPT,13122,Cmplx rpr s/a/l addl 5 cm/>,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,13131,Cmplx rpr f/c/c/m/n/ax/g/h/f,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,13132,Cmplx rpr f/c/c/m/n/ax/g/h/f,Surgical,Per Case,"$4,314.00 ",OP,536.39,"4,314.00",,,,,,
BCBS HMO,CPT,13133,Cmplx rpr f/c/c/m/n/ax/g/h/f,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,13150,Repair of wound or lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,13151,Cmplx rpr e/n/e/l 1.1-2.5 cm,Surgical,Per Case,"$4,314.00 ",OP,536.39,"4,314.00",,,,,,
BCBS HMO,CPT,13152,Cmplx rpr e/n/e/l 2.6-7.5 cm,Surgical,Per Case,"$4,314.00 ",OP,536.39,"4,314.00",,,,,,
BCBS HMO,CPT,13153,Cmplx rpr e/n/e/l addl 5cm/<,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,13160,Late closure of wound,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,13300,REPAIR OF WOUND OR LESION,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,14000,Tis trnfr trunk 10 sq cm/<,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,14001,Tis trnfr trunk 10.1-30sqcm,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,14020,Tis trnfr s/a/l 10 sq cm/<,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,14021,Tis trnfr s/a/l 10.1-30 sqcm,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,14040,Tis trnfr f/c/c/m/n/a/g/h/f,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,14041,Tis trnfr f/c/c/m/n/a/g/h/f,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,14060,Tis trnfr e/n/e/l 10 sq cm/<,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,14061,Tis trnfr e/n/e/l10.1-30sqcm,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,14300,Skin tissue rearrangement,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,14301,Tis trnfr any 30.1-60 sq cm,Surgical,Per Case,"$4,314.00 ",OP,"3,604.28","4,314.00",,,,,,
BCBS HMO,CPT,14302,Tis trnfr addl 30 sq cm,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,14350,Filleted finger/toe flap,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,15000,Wound prep-1st 100 sq cm,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15001,Wound prep-addl 100 sq cm,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15002,Wound prep trk/arm/leg,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,15003,Wound prep addl 100 cm,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15004,Wound prep f/n/hf/g,Surgical,Per Case,"$4,314.00 ",OP,536.39,"4,314.00",,,,,,
BCBS HMO,CPT,15005,Wnd prep f/n/hf/g addl cm,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15040,Harvest cultured skin graft,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,15050,Skin pinch graft,Surgical,Per Case,"$4,314.00 ",OP,536.39,"4,314.00",,,,,,
BCBS HMO,CPT,15100,Skin splt grft trnk/arm/leg,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,15101,Skin splt grft t/a/l add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15110,Epidrm autogrft trnk/arm/leg,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,15111,Epidrm autogrft t/a/l add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15115,Epidrm a-grft face/nck/hf/g,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,15116,Epidrm a-grft f/n/hf/g addl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15120,Skn splt a-grft fac/nck/hf/g,Surgical,Per Case,"$4,314.00 ",OP,"3,604.28","4,314.00",,,,,,
BCBS HMO,CPT,15121,Skn splt a-grft f/n/hf/g add,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15130,Derm autograft trnk/arm/leg,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,15131,Derm autograft t/a/l add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15135,Derm autograft face/nck/hf/g,Surgical,Per Case,"$4,314.00 ",OP,"3,604.28","4,314.00",,,,,,
BCBS HMO,CPT,15136,Derm autograft f/n/hf/g add,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15150,Cult skin grft t/arm/leg,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,15151,Cult skin grft t/a/l addl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15152,Cult skin graft t/a/l +%,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15155,Cult skin graft f/n/hf/g,Surgical,Per Case,"$4,314.00 ",OP,"3,604.28","4,314.00",,,,,,
BCBS HMO,CPT,15156,Cult skin grft f/n/hfg add,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15157,Cult epiderm grft f/n/hfg +%,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15170,Acell graft trunk/arms/legs,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15171,Acell graft t/arm/leg add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15175,Acellular graft f/n/hf/g,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15176,Acell graft f/n/hf/g add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15200,Skin full graft trunk,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,15201,Skin full graft trunk add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15220,Skin full graft sclp/arm/leg,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,15221,Skin full graft add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15240,Skin full grft face/genit/hf,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,15241,Skin full graft add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15260,Skin full graft een & lips,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,15261,Skin full graft add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15271,Skin sub graft trnk/arm/leg,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,15272,Skin sub graft t/a/l add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15273,Skin sub grft t/arm/lg child,Surgical,Per Case,"$4,314.00 ",OP,"3,604.28","4,314.00",,,,,,
BCBS HMO,CPT,15274,Skn sub grft t/a/l child add,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15275,Skin sub graft face/nk/hf/g,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,15276,Skin sub graft f/n/hf/g addl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15277,Skn sub grft f/n/hf/g child,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,15278,Skn sub grft f/n/hf/g ch add,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15300,Apply skinallogrft t/arm/lg,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15301,Apply sknallogrft t/a/l addl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15320,Apply skin allogrft f/n/hf/g,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15321,Aply sknallogrft f/n/hfg add,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15330,Aply acell alogrft t/arm/leg,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15331,Aply acell grft t/a/l add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15335,Apply acell graft f/n/hf/g,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15336,Aply acell grft f/n/hf/g add,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15340,Apply cult skin substitute,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15341,Apply cult skin sub add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15342,Cultured skin graft-25 cm,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15343,Culture skn graft addl 25 cm,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15350,SKIN HOMOGRAFT,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15351,SKIN HOMOGRAFT ADD-ON,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15360,Apply cult derm sub t/a/l,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15361,Aply cult derm sub t/a/l add,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15365,Apply cult derm sub f/n/hf/g,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15366,Apply cult derm f/hf/g add,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15400,Apply skin xenograft t/a/l,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15401,Apply skn xenogrft t/a/l add,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15410,Skin flap transplant,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15412,Skin flap transplant,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15414,Skin flap transplant,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15416,Skin flap transplant,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15420,Apply skin xgraft f/n/hf/g,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15421,Apply skn xgrft f/n/hf/g add,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15430,Apply acellular xenograft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15431,Apply acellular xgraft add,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15500,Form skin pedicle graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15505,Form skin pedicle graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15510,Form skin pedicle graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15515,Form skin pedicle graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15540,Attach skin pedicle graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15545,Attach skin pedicle graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15550,Attach skin pedicle graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15555,Attach skin pedicle graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15570,Skin pedicle flap trunk,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,15572,Skin pedicle flap arms/legs,Surgical,Per Case,"$4,314.00 ",OP,"3,604.28","4,314.00",,,,,,
BCBS HMO,CPT,15574,Pedcle fh/ch/ch/m/n/ax/g/h/f,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,15576,Pedicle e/n/e/l/ntroral,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,15580,ATTACH SKIN PEDICLE GRAFT,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15600,Delay flap trunk,Surgical,Per Case,"$4,314.00 ",OP,"3,604.28","4,314.00",,,,,,
BCBS HMO,CPT,15610,Delay flap arms/legs,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,15620,Delay flap f/c/c/n/ax/g/h/f,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,15625,SKIN GRAFT,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15630,Delay flap eye/nos/ear/lip,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,15650,Transfer skin pedicle flap,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,15700,Preparation for skin graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15710,Preparation for skin graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15720,Preparation for skin graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15730,Mdfc flap w/prsrv vasc pedcl,Surgical,Per Case,"$4,314.00 ",OP,"3,604.28","4,314.00",,,,,,
BCBS HMO,CPT,15731,Forehead flap w/vasc pedicle,Surgical,Per Case,"$4,314.00 ",OP,"3,604.28","4,314.00",,,,,,
BCBS HMO,CPT,15732,Muscle-skin graft head/neck,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,15733,Musc myoq/fscq flp h&n pedcl,Surgical,Per Case,"$4,314.00 ",OP,"3,604.28","9,201.00",,,,,,
BCBS HMO,CPT,15734,Muscle-skin graft trunk,Surgical,Per Case,"$4,314.00 ",OP,"3,604.28","4,314.00",,,,,,
BCBS HMO,CPT,15736,Muscle-skin graft arm,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,15738,Muscle-skin graft leg,Surgical,Per Case,"$4,314.00 ",OP,"3,604.28","4,314.00",,,,,,
BCBS HMO,CPT,15740,Island pedicle flap graft,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,15745,Myocutaneous flap graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15750,Neurovascular pedicle flap,Surgical,Per Case,"$4,314.00 ",OP,"3,604.28","4,314.00",,,,,,
BCBS HMO,CPT,15755,Free flap (microvascular transfer),Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15756,Free myo/skin flap microvasc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,15757,Free skin flap microvasc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,15758,Free fascial flap microvasc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,15760,Composite skin graft,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,15769,Grfg autol soft tiss dir exc,Surgical,Per Case,"$4,314.00 ",OP,"3,604.28","4,314.00",,,,,,
BCBS HMO,CPT,15770,Derma-fat-fascia graft,Surgical,Per Case,"$4,314.00 ",OP,"3,604.28","4,314.00",,,,,,
BCBS HMO,CPT,15771,Grfg autol fat lipo 50 cc/<,Surgical,Per Case,"$4,314.00 ",OP,"3,604.28","4,314.00",,,,,,
BCBS HMO,CPT,15772,Grfg autol fat lipo ea addl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15773,Grfg autol fat lipo 25 cc/<,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,15774,Gfrg autol fat lipo ea addl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15775,Hair trnspl 1-15 punch grfts,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,15776,Hair trnspl >15 punch grafts,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,15777,Acellular derm matrix implt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15780,Dermabrasion total face,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,15781,Dermabrasion segmental face,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,15782,Dermabrasion other than face,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,15783,Dermabrasion suprfl any site,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,15786,Abrasion lesion single,Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,15787,Abrasion lesions add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15788,Chemical peel face epiderm,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,15789,Chemical peel face dermal,Surgical,Per Case,"$4,314.00 ",OP,536.39,"4,314.00",,,,,,
BCBS HMO,CPT,15790,Chemical peel-face,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15791,Chemical peel-of skin,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15792,Chemical peel nonfacial,Surgical,Per Case,"$4,314.00 ",OP,536.39,"4,314.00",,,,,,
BCBS HMO,CPT,15793,Chemical peel nonfacial,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,15810,SALABRASION,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15811,SALABRASION,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15819,Plastic surgery neck,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,15820,Revision of lower eyelid,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,15821,Revision of lower eyelid,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,15822,Revision of upper eyelid,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,15823,Revision of upper eyelid,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,15824,Removal of forehead wrinkles,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,15825,Removal of neck wrinkles,Surgical,Per Case,"$4,314.00 ",OP,"3,604.28","4,314.00",,,,,,
BCBS HMO,CPT,15826,Removal of brow wrinkles,Surgical,Per Case,"$4,314.00 ",OP,"3,604.28","4,314.00",,,,,,
BCBS HMO,CPT,15828,Removal of face wrinkles,Surgical,Per Case,"$4,314.00 ",OP,"3,604.28","4,314.00",,,,,,
BCBS HMO,CPT,15829,Removal of skin wrinkles,Surgical,Per Case,"$4,314.00 ",OP,"3,604.28","4,314.00",,,,,,
BCBS HMO,CPT,15830,Exc skin abd,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,15831,Excise excessive skin tissue,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15832,Excise excessive skin thigh,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,15833,Excise excessive skin leg,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,15834,Excise excessive skin hip,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,15835,Excise excessive skin buttck,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,15836,Excise excessive skin arm,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,15837,Excise excess skin arm/hand,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,15838,Excise excess skin fat pad,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,15839,Excise excess skin & tissue,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,15840,Nerve palsy fascial graft,Surgical,Per Case,"$4,314.00 ",OP,"3,604.28","4,314.00",,,,,,
BCBS HMO,CPT,15841,Nerve palsy muscle graft,Surgical,Per Case,"$4,314.00 ",OP,"3,604.28","4,314.00",,,,,,
BCBS HMO,CPT,15842,Nerve palsy microsurg graft,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,15845,Skin and muscle repair face,Surgical,Per Case,"$4,314.00 ",OP,"3,604.28","4,314.00",,,,,,
BCBS HMO,CPT,15847,Exc skin abd add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15850,Remove sutures same surgeon,Surgical,Per Case,"$4,314.00 ",OP,536.39,"4,314.00",,,,,,
BCBS HMO,CPT,15851,Remove sutures diff surgeon,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,15852,Dressing change not for burn,Surgical,Per Case,"$4,314.00 ",OP,536.39,"4,314.00",,,,,,
BCBS HMO,CPT,15860,Test for blood flow in graft,Surgical,Per Case,"$4,314.00 ",OP,276.53,"4,314.00",,,,,,
BCBS HMO,CPT,15876,Suction lipectomy head&neck,Surgical,Per Case,"$4,314.00 ",OP,"3,604.28","4,314.00",,,,,,
BCBS HMO,CPT,15877,Suction lipectomy trunk,Surgical,Per Case,"$4,314.00 ",OP,"3,604.28","4,314.00",,,,,,
BCBS HMO,CPT,15878,Suction lipectomy upr extrem,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,15879,Suction lipectomy lwr extrem,Surgical,Per Case,"$4,314.00 ",OP,"3,604.28","4,314.00",,,,,,
BCBS HMO,CPT,15920,Removal of tail bone ulcer,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,15922,Removal of tail bone ulcer,Surgical,Per Case,"$4,314.00 ",OP,"3,604.28","4,314.00",,,,,,
BCBS HMO,CPT,15931,Remove sacrum pressure sore,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,15933,Remove sacrum pressure sore,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,15934,Remove sacrum pressure sore,Surgical,Per Case,"$4,314.00 ",OP,"3,604.28","4,314.00",,,,,,
BCBS HMO,CPT,15935,Remove sacrum pressure sore,Surgical,Per Case,"$4,314.00 ",OP,"3,604.28","4,314.00",,,,,,
BCBS HMO,CPT,15936,Remove sacrum pressure sore,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,15937,Remove sacrum pressure sore,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,15940,Remove hip pressure sore,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,15941,Remove hip pressure sore,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,15944,Remove hip pressure sore,Surgical,Per Case,"$4,314.00 ",OP,"3,604.28","4,314.00",,,,,,
BCBS HMO,CPT,15945,Remove hip pressure sore,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,15946,Remove hip pressure sore,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,15950,Remove thigh pressure sore,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,15951,Remove thigh pressure sore,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,15952,Remove thigh pressure sore,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,15953,Remove thigh pressure sore,Surgical,Per Case,"$4,314.00 ",OP,"3,604.28","4,314.00",,,,,,
BCBS HMO,CPT,15954,Remove thigh pressure sore,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15955,Remove thigh pressure sore,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15956,Remove thigh pressure sore,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,15958,Remove thigh pressure sore,Surgical,Per Case,"$4,314.00 ",OP,"3,604.28","4,314.00",,,,,,
BCBS HMO,CPT,15960,Remove heel pressure sore,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15961,Remove heel pressure sore,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15964,Remove heel pressure sore,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15965,Remove heel pressure sore,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15966,Remove heel pressure sore,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15967,Remove heel pressure sore,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15970,Remove leg pressure sore,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15971,Remove leg pressure sore,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15972,Remove leg pressure sore,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15973,Remove leg pressure sore,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15974,Remove leg pressure sore,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15975,Remove leg pressure sore,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15980,Remove knee pressure sore,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15981,Remove knee pressure sore,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15982,Remove knee pressure sore,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15983,Remove knee pressure sore,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,15999,Removal of pressure sore,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,16000,Initial treatment of burn(s),Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,16010,TREATMENT OF BURN(S),Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,16015,TREATMENT OF BURN(S),Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,16020,Dress/debrid p-thick burn s,Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,16025,Dress/debrid p-thick burn m,Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,16030,Dress/debrid p-thick burn l,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,16035,Incision of burn scab initi,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,16036,Escharotomy addl incision,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,16040,BURN WOUND EXCISION,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,16041,BURN WOUND EXCISION,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,16042,BURN WOUND EXCISION,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,17000,Destruct premalg lesion,Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,17001,DESTRUCTION OF ADDED,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,17002,DESTRUCTION OF ADDED,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,17003,Destruct premalg les 2-14,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,17004,Destroy premal lesions 15/>,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,17010,12 DESTRUCTION SKIN,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,17100,12 DESTRUCTION OF SKIN,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,17101,DESTRUCTION OF 2ND,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,17102,DESTRUCTION OF ADDED,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,17104,DESTRUCTION OF SKIN,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,17105,DESTRUCTION OF SKIN,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,17106,Destruction of skin lesions,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,17107,Destruction of skin lesions,Surgical,Per Case,"$4,314.00 ",OP,536.39,"4,314.00",,,,,,
BCBS HMO,CPT,17108,Destruction of skin lesions,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,17110,Destruct b9 lesion 1-14,Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,17111,Destruct lesion 15 or more,Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,17200,1 ELECTROCAUTERY OF SKIN,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,17201,ELECTROCAUTERY ADDED,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,17250,Chem caut of granltj tissue,Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,17260,Destruction of skin lesions,Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,17261,Destruction of skin lesions,Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,17262,Destruction of skin lesions,Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,17263,Destruction of skin lesions,Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,17264,Destruction of skin lesions,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,17266,Destruction of skin lesions,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,17270,Destruction of skin lesions,Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,17271,Destruction of skin lesions,Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,17272,Destruction of skin lesions,Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,17273,Destruction of skin lesions,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,17274,Destruction of skin lesions,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,17276,Destruction of skin lesions,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,17280,Destruction of skin lesions,Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,17281,Destruction of skin lesions,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,17282,Destruction of skin lesions,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,17283,Destruction of skin lesions,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,17284,Destruction of skin lesions,Surgical,Per Case,"$4,314.00 ",OP,536.39,"4,314.00",,,,,,
BCBS HMO,CPT,17286,Destruction of skin lesions,Surgical,Per Case,"$4,314.00 ",OP,536.39,"4,314.00",,,,,,
BCBS HMO,CPT,17303,CHEMOSURGERY OF SKIN LESION,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,17304,1 stage mohs-up to 5 spec,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,17305,2 stage mohs-up to 5 spec,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,17306,3 stage mohs-up to 5 spec,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,17307,Mohs addl stage up to 5 spec,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,17310,Mohs any stage > 5 spec each,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,17311,Mohs 1 stage h/n/hf/g,Surgical,Per Case,"$4,314.00 ",OP,536.39,"4,314.00",,,,,,
BCBS HMO,CPT,17312,Mohs addl stage,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,17313,Mohs 1 stage t/a/l,Surgical,Per Case,"$4,314.00 ",OP,536.39,"4,314.00",,,,,,
BCBS HMO,CPT,17314,Mohs addl stage t/a/l,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,17315,Mohs surg addl block,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,17340,Cryotherapy of skin,Surgical,Per Case,"$4,314.00 ",OP,34.63,"4,314.00",,,,,,
BCBS HMO,CPT,17360,Skin peel therapy,Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,17380,Hair removal by electrolysis,Surgical,Per Case,"$4,314.00 ",OP,536.39,"4,314.00",,,,,,
BCBS HMO,CPT,17999,Skin tissue procedure,Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,19000,Drainage of breast lesion,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,19001,Drain breast lesion add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,19020,Incision of breast lesion,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,19030,Injection for breast x-ray,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,19081,Bx breast 1st lesion strtctc,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,19082,Bx breast add lesion strtctc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,19083,Bx breast 1st lesion us imag,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,19084,Bx breast add lesion us imag,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,19085,Bx breast 1st lesion mr imag,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,19086,Bx breast add lesion mr imag,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,19100,Bx breast percut w/o image,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,19101,Biopsy of breast open,Surgical,Per Case,"$4,314.00 ",OP,"3,231.37","4,314.00",,,,,,
BCBS HMO,CPT,19102,Bx breast percut w/image,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,19103,Bx breast percut w/device,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,19105,Cryosurg ablate fa each,Surgical,Per Case,"$4,314.00 ",OP,"3,231.37","4,314.00",,,,,,
BCBS HMO,CPT,19110,Nipple exploration,Surgical,Per Case,"$4,314.00 ",OP,"3,231.37","4,314.00",,,,,,
BCBS HMO,CPT,19112,Excise breast duct fistula,Surgical,Per Case,"$4,314.00 ",OP,"3,231.37","4,314.00",,,,,,
BCBS HMO,CPT,19120,Removal of breast lesion,Surgical,Per Case,"$4,314.00 ",OP,"3,231.37","4,314.00",,,,,,
BCBS HMO,CPT,19125,Excision breast lesion,Surgical,Per Case,"$4,314.00 ",OP,"3,231.37","4,314.00",,,,,,
BCBS HMO,CPT,19126,Excision addl breast lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,19130,Stereotactic needle 1-5,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,19131,6-10 samples,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,19140,Removal of breast tissue,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,19160,Partial mastectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,19162,P-mastectomy w/ln removal,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,19180,Removal of breast,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,19182,Removal of breast,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,19200,Removal of breast,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,19220,Removal of breast,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,19240,Removal of breast,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,19260,Removal of chest wall lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,19271,Revision of chest wall,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,19272,Extensive chest wall surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,19281,Perq device breast 1st imag,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,19282,Perq device breast ea imag,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,19283,Perq dev breast 1st strtctc,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,19284,Perq dev breast add strtctc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,19285,Perq dev breast 1st us imag,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,19286,Perq dev breast add us imag,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,19287,Perq dev breast 1st mr guide,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,19288,Perq dev breast add mr guide,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,19290,Place needle wire breast,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,19291,Place needle wire breast,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,19294,Prep tum cav iort prtl mast,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,19295,Place breast clip percut,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,19296,Place po breast cath for rad,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","9,128.05",,,,,,
BCBS HMO,CPT,19297,Place breast cath for rad,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,19298,Place breast rad tube/caths,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,662.99",,,,,,
BCBS HMO,CPT,19300,Removal of breast tissue,Surgical,Per Case,"$4,314.00 ",OP,"3,231.37","9,201.00",,,,,,
BCBS HMO,CPT,19301,Partial mastectomy,Surgical,Per Case,"$4,314.00 ",OP,"3,231.37","4,314.00",,,,,,
BCBS HMO,CPT,19302,P-mastectomy w/ln removal,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,662.99",,,,,,
BCBS HMO,CPT,19303,Mast simple complete,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,662.99",,,,,,
BCBS HMO,CPT,19304,Mast subq,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,19305,Mast radical,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,19306,Mast rad urban type,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,19307,Mast mod rad,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,19316,Suspension of breast,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,662.99",,,,,,
BCBS HMO,CPT,19318,Breast reduction,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,19324,Enlarge breast,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,19325,Breast augmentation w/implt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","9,128.05",,,,,,
BCBS HMO,CPT,19328,Rmvl intact breast implant,Surgical,Per Case,"$4,314.00 ",OP,"3,231.37","4,314.00",,,,,,
BCBS HMO,CPT,19330,Rmvl ruptured breast implant,Surgical,Per Case,"$4,314.00 ",OP,"3,231.37","4,314.00",,,,,,
BCBS HMO,CPT,19340,Insj breast implt sm d mast,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,19342,Insj/rplcmt brst implt sep d,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","9,128.05",,,,,,
BCBS HMO,CPT,19350,Breast reconstruction,Surgical,Per Case,"$4,314.00 ",OP,"3,231.37","4,314.00",,,,,,
BCBS HMO,CPT,19355,Correct inverted nipple(s),Surgical,Per Case,"$4,314.00 ",OP,"3,231.37","4,314.00",,,,,,
BCBS HMO,CPT,19357,Tiss xpndr plmt brst rcnstj,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","15,276.83",,,,,,
BCBS HMO,CPT,19360,Breast reconstruction,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,19361,Brst rcnstj latsms drsi flap,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,19362,Breast reconstruction,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,19364,Brst rcnstj free flap,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,19366,Breast reconstruction,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,19367,Brst rcnstj 1 pdcl tram flap,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,19368,Brst rcnstj 1pdcl tram anast,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,19369,Brst rcnstj 2 pdcl tram flap,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,19370,Revj peri-implt capsule brst,Surgical,Per Case,"$4,314.00 ",OP,"3,231.37","4,314.00",,,,,,
BCBS HMO,CPT,19371,Peri-implt capslc brst compl,Surgical,Per Case,"$4,314.00 ",OP,"3,231.37","4,314.00",,,,,,
BCBS HMO,CPT,19380,Revj reconstructed breast,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,662.99",,,,,,
BCBS HMO,CPT,19396,Design custom breast implant,Surgical,Per Case,"$4,314.00 ",OP,"3,231.37","4,314.00",,,,,,
BCBS HMO,CPT,19499,Breast surgery procedure,Surgical,Per Case,"$4,314.00 ",OP,"3,231.37","4,314.00",,,,,,
BCBS HMO,CPT,20000,Incision of abscess,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,20005,I&d abscess subfascial,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,20100,Explore wound neck,Surgical,Per Case,"$4,314.00 ",OP,462.91,"4,314.00",,,,,,
BCBS HMO,CPT,20101,Explore wound chest,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,20102,Explore wound abdomen,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,20103,Explore wound extremity,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,20150,Excise epiphyseal bar,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,20200,Muscle biopsy,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,20205,Deep muscle biopsy,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,20206,Needle biopsy muscle,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,20220,Bone biopsy trocar/needle,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,20225,Bone biopsy trocar/needle,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,20240,Bone biopsy open superficial,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,20245,Bone biopsy open deep,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,20250,Open bone biopsy,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,20251,Open bone biopsy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,20500,Injection of sinus tract,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,20501,Inject sinus tract for x-ray,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,20520,Removal of foreign body,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,20525,Removal of foreign body,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,20526,Ther injection carp tunnel,Surgical,Per Case,"$4,314.00 ",OP,267.26,"4,314.00",,,,,,
BCBS HMO,CPT,20527,Inj dupuytren cord w/enzyme,Surgical,Per Case,"$4,314.00 ",OP,267.26,"4,314.00",,,,,,
BCBS HMO,CPT,20550,Inj tendon sheath/ligament,Surgical,Per Case,"$4,314.00 ",OP,267.26,"4,314.00",,,,,,
BCBS HMO,CPT,20551,Inj tendon origin/insertion,Surgical,Per Case,"$4,314.00 ",OP,267.26,"4,314.00",,,,,,
BCBS HMO,CPT,20552,Inj trigger point 1/2 muscl,Surgical,Per Case,"$4,314.00 ",OP,267.26,"4,314.00",,,,,,
BCBS HMO,CPT,20553,Inject trigger points 3/>,Surgical,Per Case,"$4,314.00 ",OP,267.26,"4,314.00",,,,,,
BCBS HMO,CPT,20555,Place ndl musc/tis for rt,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,20560,Ndl insj w/o njx 1 or 2 musc,Surgical,Per Case,"$4,314.00 ",OP,25.25,"4,314.00",,,,,,
BCBS HMO,CPT,20561,Ndl insj w/o njx 3+ musc,Surgical,Per Case,"$4,314.00 ",OP,25.25,"4,314.00",,,,,,
BCBS HMO,CPT,20600,Drain/inj joint/bursa w/o us,Surgical,Per Case,"$4,314.00 ",OP,267.26,"4,314.00",,,,,,
BCBS HMO,CPT,20604,Drain/inj joint/bursa w/us,Surgical,Per Case,"$4,314.00 ",OP,267.26,"4,314.00",,,,,,
BCBS HMO,CPT,20605,Drain/inj joint/bursa w/o us,Surgical,Per Case,"$4,314.00 ",OP,267.26,"4,314.00",,,,,,
BCBS HMO,CPT,20606,Drain/inj joint/bursa w/us,Surgical,Per Case,"$4,314.00 ",OP,649.39,"4,314.00",,,,,,
BCBS HMO,CPT,20610,Drain/inj joint/bursa w/o us,Surgical,Per Case,"$4,314.00 ",OP,267.26,"4,314.00",,,,,,
BCBS HMO,CPT,20611,Drain/inj joint/bursa w/us,Surgical,Per Case,"$4,314.00 ",OP,267.26,"4,314.00",,,,,,
BCBS HMO,CPT,20612,Aspirate/inj ganglion cyst,Surgical,Per Case,"$4,314.00 ",OP,267.26,"4,314.00",,,,,,
BCBS HMO,CPT,20615,Treatment of bone cyst,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,20650,Insert and remove bone pin,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,20660,Apply rem fixation device,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,20661,Application of head brace,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,20662,Application of pelvis brace,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,20663,Application of thigh brace,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,20664,Application of halo,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,20665,Removal of fixation device,Surgical,Per Case,"$4,314.00 ",OP,276.53,"4,314.00",,,,,,
BCBS HMO,CPT,20670,Removal of support implant,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,20680,Removal of support implant,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,20690,Apply bone fixation device,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,20692,Apply bone fixation device,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,20693,Adjust bone fixation device,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,20694,Remove bone fixation device,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,20696,Comp multiplane ext fixation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,20697,Comp ext fixate strut change,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,20700,Mnl prep&insj dp rx dlvr dev,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,20701,Rmvl deep rx delivery device,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,20702,Mnl prep&insj imed rx dev,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,20703,Rmvl imed rx delivery device,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,20704,Mnl prep&insj i-artic rx dev,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,20705,Rmvl i-artic rx delivery dev,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,20802,Replantation arm complete,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,20804,Replantation-arm-partial,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,20805,Replant forearm complete,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,20806,Replantation-forearm-partial,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,20808,Replantation hand complete,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,20812,Replantation-hand-partial,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,20816,Replantation digit complete,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,20820,Replantation-digit-partial,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,20822,Replantation digit complete,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,20823,Replantation-digit-partial,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,20824,Replantation thumb complete,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,20826,Replantation-thumb-partial,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,20827,Replantation thumb complete,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,20828,Replantation-thumb-partial,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,20832,Replantation-leg-complete,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,20834,Replantation-leg-partial,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,20838,Replantation foot complete,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,20840,Replantation-foot-partial,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,20900,Removal of bone for graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,20902,Removal of bone for graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,20910,Remove cartilage for graft,Surgical,Per Case,"$4,314.00 ",OP,536.39,"4,314.00",,,,,,
BCBS HMO,CPT,20912,Remove cartilage for graft,Surgical,Per Case,"$4,314.00 ",OP,"3,604.28","4,314.00",,,,,,
BCBS HMO,CPT,20920,Removal of fascia for graft,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,20922,Removal of fascia for graft,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,20924,Removal of tendon for graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,20926,Removal of tissue for graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,20930,Sp bone algrft morsel add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,20931,Sp bone algrft struct add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,20932,Osteoart algrft w/surf & b1,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,20933,Hemicrt intrclry algrft prtl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,20934,Intercalary algrft compl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,20936,Sp bone agrft local add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,20937,Sp bone agrft morsel add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,20938,Sp bone agrft struct add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,20939,Bone marrow aspir bone grfg,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,20950,Fluid pressure muscle,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,20955,Fibula bone graft microvasc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,20956,Iliac bone graft microvasc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,20957,Mt bone graft microvasc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,20960,Bone graft w/microvascular anastomosis-rib,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,20962,Other bone graft microvasc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,20969,Bone/skin graft microvasc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,20970,Bone/skin graft iliac crest,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,20971,Free osteocutaneous flap w/microvascular anastomosis-rib,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,20972,Bone/skin graft metatarsal,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,20973,Bone/skin graft great toe,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,20974,Electrical bone stimulation,Surgical,Per Case,"$4,314.00 ",OP,50.41,"4,314.00",,,,,,
BCBS HMO,CPT,20975,Electrical bone stimulation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,20976,Electrical bone stimulation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,20979,Us bone stimulation,Surgical,Per Case,"$4,314.00 ",OP,25.25,"4,314.00",,,,,,
BCBS HMO,CPT,20982,Ablate bone tumor(s) perq,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,20983,Ablate bone tumor(s) perq,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,20985,Cptr-asst dir ms px,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,20986,Cptr-asst dir ms px io img,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,20987,Cptr-asst dir ms px  pre img,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,20999,Musculoskeletal surgery,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,21010,Incision of jaw joint,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,21011,Exc face les sc <2 cm,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,21012,Exc face les sbq 2 cm/>,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,21013,Exc face tum deep < 2 cm,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,21014,Exc face tum deep 2 cm/>,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,21015,Resect face/scalp tum < 2 cm,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,21016,Resect face/scalp tum 2 cm/>,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,21025,Excision of bone lower jaw,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21026,Excision of facial bone(s),Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21029,Contour of face bone lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,21030,Excise max/zygoma b9 tumor,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21031,Remove exostosis mandible,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,21032,Remove exostosis maxilla,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,21034,Excise max/zygoma mal tumor,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21040,Excise mandible lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,21041,REMOVAL OF JAW BONE LESION,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,21044,Removal of jaw bone lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21045,Extensive jaw surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21046,Remove mandible cyst complex,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21047,Excise lwr jaw cyst w/repair,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21048,Remove maxilla cyst complex,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21049,Excis uppr jaw cyst w/repair,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21050,Removal of jaw joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21060,Remove jaw joint cartilage,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21070,Remove coronoid process,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21073,Mnpj of tmj w/anesth,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,21076,Prepare face/oral prosthesis,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,21077,Prepare face/oral prosthesis,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21079,Prepare face/oral prosthesis,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,21080,Prepare face/oral prosthesis,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,21081,Prepare face/oral prosthesis,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21082,Prepare face/oral prosthesis,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,21083,Prepare face/oral prosthesis,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,21084,Prepare face/oral prosthesis,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,21085,Prepare face/oral prosthesis,Surgical,Per Case,"$4,314.00 ",OP,216.54,"4,314.00",,,,,,
BCBS HMO,CPT,21086,Prepare face/oral prosthesis,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,21087,Prepare face/oral prosthesis,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21088,Prepare face/oral prosthesis,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,21089,Prepare face/oral prosthesis,Surgical,Per Case,"$4,314.00 ",OP,216.54,"4,314.00",,,,,,
BCBS HMO,CPT,21100,Maxillofacial fixation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21110,Interdental fixation,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,21116,Injection jaw joint x-ray,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,21120,Reconstruction of chin,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21121,Reconstruction of chin,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,21122,Reconstruction of chin,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21123,Reconstruction of chin,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,21125,Augmentation lower jaw bone,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21127,Augmentation lower jaw bone,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21137,Reduction of forehead,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,21138,Reduction of forehead,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21139,Reduction of forehead,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21141,Lefort i-1 piece w/o graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21142,Lefort i-2 piece w/o graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21143,Lefort i-3/> piece w/o graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21144,Reconstruction midface-LeFort I,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,21145,Lefort i-1 piece w/ graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21146,Lefort i-2 piece w/ graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21147,Lefort i-3/> piece w/ graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21150,Lefort ii anterior intrusion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21151,Lefort ii w/bone grafts,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21154,Lefort iii w/o lefort i,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21155,Lefort iii w/ lefort i,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21159,Lefort iii w/fhdw/o lefort i,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21160,Lefort iii w/fhd w/ lefort i,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21172,Reconstruct orbit/forehead,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21175,Reconstruct orbit/forehead,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21179,Reconstruct entire forehead,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21180,Reconstruct entire forehead,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21181,Contour cranial bone lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21182,Reconstruct cranial bone,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21183,Reconstruct cranial bone,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21184,Reconstruct cranial bone,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21188,Reconstruction of midface,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21193,Reconst lwr jaw w/o graft,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,21194,Reconst lwr jaw w/graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21195,Reconst lwr jaw w/o fixation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21196,Reconst lwr jaw w/fixation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21198,Reconstr lwr jaw segment,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21199,Reconstr lwr jaw w/advance,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21200,Osteotom-mandible,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,21202,Repair Segmental facial bone,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,21203,Osteotomy mandibular/ramus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,21204,Osteotomy maxilla-total,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,21206,Reconstruct upper jaw bone,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21208,Augmentation of facial bones,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21209,Reduction of facial bones,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21210,Face bone graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21215,Lower jaw bone graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21230,Rib cartilage graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21235,Ear cartilage graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21239,Arthroplasty-temporomandibular joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,21240,Reconstruction of jaw joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21242,Reconstruction of jaw joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21243,Reconstruction of jaw joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,21244,Reconstruction of lower jaw,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21245,Reconstruction of jaw,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21246,Reconstruction of jaw,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21247,Reconstruct lower jaw bone,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21248,Reconstruction of jaw,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21249,Reconstruction of jaw,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21250,Osteoplasty maxilla,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,21254,Osteoplasty maxilla w/graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,21255,Reconstruct lower jaw bone,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21256,Reconstruction of orbit,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21260,Revise eye sockets,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21261,Revise eye sockets,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21263,Revise eye sockets,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21267,Revise eye sockets,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21268,Revise eye sockets,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21270,Augmentation cheek bone,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21275,Revision orbitofacial bones,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21280,Revision of eyelid,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,21282,Revision of eyelid,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,21295,Revision of jaw muscle/bone,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,21296,Revision of jaw muscle/bone,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,21299,Cranio/maxillofacial surgery,Surgical,Per Case,"$4,314.00 ",OP,216.54,"4,314.00",,,,,,
BCBS HMO,CPT,21300,Treatment of skull fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,21310,Closed tx nose fx w/o manj,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,21315,Closed tx nose fx w/o stablj,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,21320,Closed tx nose fx w/ stablj,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,21325,Open tx nose fx uncomplicatd,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,21330,Open tx nose fx w/skele fixj,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21335,Open tx nose & septal fx,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,21336,Open tx septal fx w/wo stabj,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,21337,Closed tx septal&nose fx,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,21338,Open nasoethmoid fx w/o fixj,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21339,Open nasoethmoid fx w/ fixj,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21340,Perq tx nasoethmoid fx,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,21343,Open tx dprsd front sinus fx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21344,Open tx compl front sinus fx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21345,Closed tx nose/jaw fx,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,21346,Opn tx nasomax fx w/fixj,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21347,Opn tx nasomax fx multple,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21348,Opn tx nasomax fx w/graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21355,Perq tx malar fracture,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,21356,Opn tx dprsd zygomatic arch,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21360,Opn tx dprsd malar fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21365,Opn tx complx malar fx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21366,Opn tx complx malar w/grft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21385,Opn tx orbit fx transantral,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21386,Opn tx orbit fx periorbital,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21387,Opn tx orbit fx combined,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21390,Opn tx orbit periorbtl implt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21395,Opn tx orbit periorbt w/grft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21400,Closed tx orbit w/o manipulj,Surgical,Per Case,"$4,314.00 ",OP,462.91,"4,314.00",,,,,,
BCBS HMO,CPT,21401,Closed tx orbit w/manipulj,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,21406,Opn tx orbit fx w/o implant,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21407,Opn tx orbit fx w/implant,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21408,Opn tx orbit fx w/bone grft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21421,Treat mouth roof fracture,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,21422,Treat mouth roof fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21423,Treat mouth roof fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21431,Treat craniofacial fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21432,Treat craniofacial fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21433,Treat craniofacial fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21435,Treat craniofacial fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21436,Treat craniofacial fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21440,Treat dental ridge fracture,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,21445,Treat dental ridge fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21450,Treat lower jaw fracture,Surgical,Per Case,"$4,314.00 ",OP,462.91,"4,314.00",,,,,,
BCBS HMO,CPT,21451,Treat lower jaw fracture,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,21452,Treat lower jaw fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21453,Treat lower jaw fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21454,Treat lower jaw fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21455,Repari lower jaw fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,21461,Treat lower jaw fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21462,Treat lower jaw fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,21465,Treat lower jaw fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21470,Treat lower jaw fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21480,Reset dislocated jaw,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,21485,Reset dislocated jaw,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,21490,Repair dislocated jaw,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,21493,TREAT HYOID BONE FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,21494,REPAIR HYOID BONE FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,21495,Treat hyoid bone fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,21497,Interdental wiring,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,21499,Head surgery procedure,Surgical,Per Case,"$4,314.00 ",OP,216.54,"4,314.00",,,,,,
BCBS HMO,CPT,21501,Drain neck/chest lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,21502,Drain chest lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,21510,Drainage of bone lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,21550,Biopsy of neck/chest,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,21552,Exc neck les sc 3 cm/>,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,21554,Exc neck tum deep 5 cm/>,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,21555,Exc neck les sc < 3 cm,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,21556,Exc neck tum deep < 5 cm,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,21557,Resect neck thorax tumor<5cm,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,21558,Resect neck tumor 5 cm/>,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,21600,Partial removal of rib,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,21601,Exc chest wall tumor w/ribs,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,21602,Exc ch wal tum w/o lymphadec,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,21603,Exc ch wal tum w/lymphadec,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,21610,Partial removal of rib,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,21615,Removal of rib,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,21616,Removal of rib and nerves,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,21620,Partial removal of sternum,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,21627,Sternal debridement,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,21630,Extensive sternum surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,21632,Extensive sternum surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,21633,Extensive sternum surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,21685,Hyoid myotomy & suspension,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,21700,Revision of neck muscle,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,21705,Revision of neck muscle/rib,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,21720,Revision of neck muscle,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,21725,Revision of neck muscle,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,21740,Reconstruction of sternum,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,21742,Repair stern/nuss w/o scope,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,21743,Repair sternum/nuss w/scope,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,21750,Repair of sternum separation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,21800,Treatment of rib fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,21805,Treatment of rib fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,21810,Treatment of rib fracture(s),Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,21811,Optx of rib fx w/fixj scope,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,21812,Treatment of rib fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,21813,Treatment of rib fracture,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,21820,Treat sternum fracture,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,21825,Treat sternum fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,21899,Neck/chest surgery procedure,Surgical,Per Case,"$4,314.00 ",OP,216.54,"4,314.00",,,,,,
BCBS HMO,CPT,21920,Biopsy soft tissue of back,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,21925,Biopsy soft tissue of back,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,21930,Exc back les sc < 3 cm,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,21931,Exc back les sc 3 cm/>,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,21932,Exc back tum deep < 5 cm,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,21933,Exc back tum deep 5 cm/>,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,21935,Resect back tum < 5 cm,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,21936,Resect back tum 5 cm/>,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,22010,I&d p-spine c/t/cerv-thor,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,22015,I&d abscess p-spine l/s/ls,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,22100,Remove part of neck vertebra,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,22101,Remove part thorax vertebra,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,22102,Remove part lumbar vertebra,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,22103,Remove extra spine segment,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22105,Remove part of neck-vertebra,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22106,Remove part of thorax-vertebra,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22107,Remove part of lumbar-vertebra,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22110,Remove part of neck vertebra,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,22112,Remove part thorax vertebra,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,22114,Remove part lumbar vertebra,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,22116,Remove extra spine segment,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22140,Reconstruct neck spine,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22141,Reconstruct thorax spine,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22142,Reconstruct lumbar spine,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22145,Reconstruct vertebra,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22148,Harvesting bone graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22150,Reconstruct neck spine,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22151,Reconstruct thorax spine,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22152,Reconstruct lumbar spine,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22206,Incis spine 3 column thorac,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,22207,Incis spine 3 column lumbar,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,22208,Incis spine 3 column adl seg,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22210,Incis 1 vertebral seg cerv,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,22212,Incis 1 vertebral seg thorac,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,22214,Incis 1 vertebral seg lumbar,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,22216,Incis addl spine segment,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22220,Incis w/discectomy cervical,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,22222,Incis w/discectomy thoracic,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,22224,Incis w/discectomy lumbar,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,22226,Revise extra spine segment,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22230,Additional revision of spine,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22305,Treat spine process fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22310,Closed tx vert fx w/o manj,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,22315,Closed tx vert fx w/manj,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,22318,Treat odontoid fx w/o graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,22319,Treat odontoid fx w/graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,22325,Treat spine fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,22326,Treat neck spine fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,22327,Treat thorax spine fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,22328,Treat each add spine fx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22505,Manipulation of spine,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,22510,Perq cervicothoracic inject,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","15,496.26",,,,,,
BCBS HMO,CPT,22511,Perq lumbosacral injection,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","9,201.00",,,,,,
BCBS HMO,CPT,22512,Vertebroplasty addl inject,Surgical,Per Case,"$4,314.00 ",OP,"1,612.76","4,314.00",,,,,,
BCBS HMO,CPT,22513,Perq vertebral augmentation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,22514,Perq vertebral augmentation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,22515,Perq vertebral augmentation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22520,Percut vertebroplasty thor,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22521,Percut vertebroplasty lumb,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22522,Percut vertebroplasty addl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22523,Percut kyphoplasty thor,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22524,Percut kyphoplasty lumbar,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22525,Percut kyphoplasty add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22526,Idet single level,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22527,Idet 1 or more levels,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22532,Lat thorax spine fusion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,22533,Lat lumbar spine fusion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,22534,Lat thor/lumb addl seg,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22548,Neck spine fusion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,22551,Neck spine fuse&remov bel c2,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS HMO,CPT,22552,Addl neck spine fusion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22554,Neck spine fusion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,22556,Thorax spine fusion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,22558,Lumbar spine fusion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,22585,Additional spinal fusion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22586,Prescrl fuse w/ instr l5-s1,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,22590,Spine & skull spinal fusion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,22595,Neck spinal fusion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,22600,Neck spine fusion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,22610,Thorax spine fusion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,22612,Lumbar spine fusion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,22614,Spine fusion extra segment,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22625,Lumbar spine fusion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22630,Lumbar spine fusion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,22632,Spine fusion extra segment,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22633,Lumbar spine fusion combined,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,22634,Spine fusion extra segment,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22650,Additional spinal fusion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22800,Post fusion </6 vert seg,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,22802,Post fusion 7-12 vert seg,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,22804,Post fusion 13/> vert seg,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,22808,Ant fusion 2-3 vert seg,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,22810,Ant fusion 4-7 vert seg,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,22812,Ant fusion 8/> vert seg,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,22818,Kyphectomy 1-2 segments,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,22819,Kyphectomy 3 or more,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,22820,Harvesting of bone,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22830,Exploration of spinal fusion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,22840,Insert spine fixation device,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22841,Insert spine fixation device,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22842,Insert spine fixation device,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22843,Insert spine fixation device,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22844,Insert spine fixation device,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22845,Insert spine fixation device,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22846,Insert spine fixation device,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22847,Insert spine fixation device,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22848,Insert pelv fixation device,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22849,Reinsert spinal fixation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,22850,Remove spine fixation device,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,22851,Apply spine prosth device,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22852,Remove spine fixation device,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,22853,Insj biomechanical device,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22854,Insj biomechanical device,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22855,Remove spine fixation device,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,22856,Cerv artific diskectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","16,238.16",,,,,,
BCBS HMO,CPT,22857,Lumbar artif diskectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,22858,Second level cer diskectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22859,Insj biomechanical device,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22861,Revise cerv artific disc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,22862,Revise lumbar artif disc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,22864,Remove cerv artif disc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,22865,Remove lumb artif disc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,22867,Insj stablj dev w/dcmprn,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,22868,Insj stablj dev w/dcmprn,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22869,Insj stablj dev w/o dcmprn,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,22870,Insj stablj dev w/o dcmprn,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,22899,Spine surgery procedure,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,22900,Exc abdl tum deep < 5 cm,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,22901,Exc abdl tum deep 5 cm/>,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,22902,Exc abd les sc < 3 cm,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,22903,Exc abd les sc 3 cm/>,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,22904,Radical resect abd tumor<5cm,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,22905,Rad resect abd tumor 5 cm/>,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,22999,Abdomen surgery procedure,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,23000,Removal of calcium deposits,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,23020,Release shoulder joint,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,23030,Drain shoulder lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,23031,Drain shoulder bursa,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,23035,Drain shoulder bone lesion,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,23040,Exploratory shoulder surgery,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,23044,Exploratory shoulder surgery,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,23065,Biopsy shoulder tissues,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,23066,Biopsy shoulder tissues,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,23071,Exc shoulder les sc 3 cm/>,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,23073,Exc shoulder tum deep 5 cm/>,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,23075,Exc shoulder les sc < 3 cm,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,23076,Exc shoulder tum deep < 5 cm,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,23077,Resect shoulder tumor < 5 cm,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,23078,Resect shoulder tumor 5 cm/>,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,23100,Biopsy of shoulder joint,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,23101,Shoulder joint surgery,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,23105,Remove shoulder joint lining,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,23106,Incision of collarbone joint,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,23107,Explore treat shoulder joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,23120,Partial removal collar bone,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,23125,Removal of collar bone,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,23130,Remove shoulder bone part,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,23140,Removal of bone lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,23141,EXCISE/CURETTAGE BONE CYST,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,23145,Removal of bone lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,23146,Removal of bone lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,23150,Removal of humerus lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,23155,Removal of humerus lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,23156,Removal of humerus lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,23170,Remove collar bone lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,23172,Remove shoulder blade lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,23174,Remove humerus lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,23180,Remove collar bone lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,23182,Remove shoulder blade lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,23184,Remove humerus lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,23190,Partial removal of scapula,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,23195,Removal of head of humerus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,23200,Resect clavicle tumor,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,23210,Resect scapula tumor,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,23220,Resect prox humerus tumor,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,23221,Partial removal of humerus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,23222,Partial removal of humerus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,23330,Remove shoulder foreign body,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,23331,Remove shoulder foreign body,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,23332,Remove shoulder foreign body,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,23333,Remove shoulder fb deep,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,23334,Shoulder prosthesis removal,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,23335,Shoulder prosthesis removal,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,23350,Injection for shoulder x-ray,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,23395,Muscle transfer shoulder/arm,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,23397,Muscle transfers,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,23400,Fixation of shoulder blade,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,23405,Incision of tendon & muscle,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,23406,Incise tendon(s) & muscle(s),Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,23410,Repair rotator cuff acute,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,23412,Repair rotator cuff chronic,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,23415,Release of shoulder ligament,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,23420,Repair of shoulder,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,23430,Repair biceps tendon,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,23440,Remove/transplant tendon,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,23450,Repair shoulder capsule,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,23455,Repair shoulder capsule,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,23460,Repair shoulder capsule,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,23462,Repair shoulder capsule,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,23465,Repair shoulder capsule,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,23466,Repair shoulder capsule,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,23470,Reconstruct shoulder joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,23472,Reconstruct shoulder joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,23473,Revis reconst shoulder joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,23474,Revis reconst shoulder joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,23480,Revision of collar bone,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,23485,Revision of collar bone,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,23490,Reinforce clavicle,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,23491,Reinforce shoulder bones,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,23500,Treat clavicle fracture,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,23505,Treat clavicle fracture,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,23510,REPAIR CLAVICLE FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,23515,Treat clavicle fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,23520,Treat clavicle dislocation,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,23525,Treat clavicle dislocation,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,23530,Treat clavicle dislocation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,23532,Treat clavicle dislocation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,23540,Treat clavicle dislocation,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,23545,Treat clavicle dislocation,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,23550,Treat clavicle dislocation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,23552,Treat clavicle dislocation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,23570,Treat shoulder blade fx,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,23575,Treat shoulder blade fx,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,23580,REPAIR SCAPULA FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,23585,Treat scapula fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,23600,Treat humerus fracture,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,23605,Treat humerus fracture,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,23610,REPAIR HUMERUS FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,23615,Treat humerus fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS HMO,CPT,23616,Treat humerus fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,23620,Treat humerus fracture,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,23625,Treat humerus fracture,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,23630,Treat humerus fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,23650,Treat shoulder dislocation,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,23655,Treat shoulder dislocation,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,23658,REPAIR SHOULDER DISLOCATION,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,23660,Treat shoulder dislocation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,23665,Treat dislocation/fracture,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,23670,Treat dislocation/fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,23675,Treat dislocation/fracture,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,23680,Treat dislocation/fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,23700,Fixation of shoulder,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,23800,Fusion of shoulder joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,23802,Fusion of shoulder joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,23900,Amputation of arm & girdle,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,23920,Amputation at shoulder joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,23921,Amputation follow-up surgery,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,23929,Shoulder surgery procedure,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,23930,Drainage of arm lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,23931,Drainage of arm bursa,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,23935,Drain arm/elbow bone lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,24000,Exploratory elbow surgery,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,24006,Release elbow joint,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,24065,Biopsy arm/elbow soft tissue,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,24066,Biopsy arm/elbow soft tissue,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,24071,Exc arm/elbow les sc 3 cm/>,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,24073,Ex arm/elbow tum deep 5 cm/>,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,24075,Exc arm/elbow les sc < 3 cm,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,24076,Ex arm/elbow tum deep < 5 cm,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,24077,Resect arm/elbow tum < 5 cm,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,24079,Resect arm/elbow tum 5 cm/>,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,24100,Biopsy elbow joint lining,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,24101,Explore/treat elbow joint,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,24102,Remove elbow joint lining,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,24105,Removal of elbow bursa,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,24110,Remove humerus lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,24115,Remove/graft bone lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,24116,Remove/graft bone lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,24120,Remove elbow lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,24125,Remove/graft bone lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,24126,Remove/graft bone lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,24130,Removal of head of radius,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,24134,Removal of arm bone lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,24136,Remove radius bone lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,24138,Remove elbow bone lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,24140,Partial removal of arm bone,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,24145,Partial removal of radius,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,24147,Partial removal of elbow,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,24149,Radical resection of elbow,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,24150,Resect distal humerus tumor,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,24151,Extensive humerus surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,24152,Resect radius tumor,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,24153,Extensive radius surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,24155,Removal of elbow joint,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,24160,Remove elbow joint implant,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,24164,Remove radius head implant,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,24200,Removal of arm foreign body,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,24201,Removal of arm foreign body,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,24220,Injection for elbow x-ray,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,24300,Manipulate elbow w/anesth,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,24301,Muscle/tendon transfer,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,24305,Arm tendon lengthening,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,24310,Revision of arm tendon,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,24320,Repair of arm tendon,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,24330,Revision of arm muscles,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,24331,Revision of arm muscles,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,24332,Tenolysis triceps,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,24340,Repair of biceps tendon,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,24341,Repair arm tendon/muscle,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,24342,Repair of ruptured tendon,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,24343,Repr elbow lat ligmnt w/tiss,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,24344,Reconstruct elbow lat ligmnt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,24345,Repr elbw med ligmnt w/tissu,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,24346,Reconstruct elbow med ligmnt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,24350,Repair of tennis elbow,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,24351,Repair of tennis elbow,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,24352,Repair of tennis elbow,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,24354,Repair of tennis elbow,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,24356,Revision of tennis elbow,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,24357,Repair elbow perc,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,24358,Repair elbow w/deb open,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,24359,Repair elbow deb/attch open,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,24360,Reconstruct elbow joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,24361,Reconstruct elbow joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,24362,Reconstruct elbow joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,24363,Replace elbow joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,24365,Reconstruct head of radius,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,24366,Reconstruct head of radius,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,24370,Revise reconst elbow joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,24371,Revise reconst elbow joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,24400,Revision of humerus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,24410,Revision of humerus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,24420,Revision of humerus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,24430,Repair of humerus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,24435,Repair humerus with graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,24470,Revision of elbow joint,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,24495,Decompression of forearm,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,24498,Reinforce humerus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,24500,Treat humerus fracture,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,24505,Treat humerus fracture,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,24506,TREAT HUMERUS FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,24510,REPAIR HUMERUS FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,24515,Treat humerus fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS HMO,CPT,24516,Treat humerus fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,24530,Treat humerus fracture,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,24531,TREAT HUMERUS FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,24535,Treat humerus fracture,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,24536,TREAT HUMERUS FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,24538,Treat humerus fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,24540,TREAT HUMERUS FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,24542,TREAT HUMERUS FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,24545,Treat humerus fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS HMO,CPT,24546,Treat humerus fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,24560,Treat humerus fracture,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,24565,Treat humerus fracture,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,24566,Treat humerus fracture,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,24570,REPAIR HUMERUS FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,24575,Treat humerus fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,24576,Treat humerus fracture,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,24577,Treat humerus fracture,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,24578,REPAIR HUMERUS FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,24579,Treat humerus fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,24580,TREAT ELBOW FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,24581,TREAT ELBOW FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,24582,Treat humerus fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,24583,REPAIR ELBOW FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,24585,REPAIR ELBOW FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,24586,Treat elbow fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,24587,Treat elbow fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,24588,REPAIR ELBOW FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,24600,Treat elbow dislocation,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,24605,Treat elbow dislocation,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,24610,REPAIR ELBOW DISLOCATION,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,24615,Treat elbow dislocation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,24620,Treat elbow fracture,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,24625,REPAIR ELBOW FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,24635,Treat elbow fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,24640,Treat elbow dislocation,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,24650,Treat radius fracture,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,24655,Treat radius fracture,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,24660,REPAIR RADIUS FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,24665,Treat radius fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,24666,Treat radius fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS HMO,CPT,24670,Treat ulnar fracture,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,24675,Treat ulnar fracture,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,24680,REPAIR ULNA FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,24685,Treat ulnar fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,24800,Fusion of elbow joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,24802,Fusion/graft of elbow joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,24900,Amputation of upper arm,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,24920,Amputation of upper arm,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,24925,Amputation follow-up surgery,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,24930,Amputation follow-up surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,24931,Amputate upper arm & implant,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,24935,Revision of amputation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,24940,Revision of upper arm,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,24999,Upper arm/elbow surgery,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,25000,Incision of tendon sheath,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,25001,Incise flexor carpi radialis,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25005,INCISION OF TENDON SHEATH,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,25020,Decompress forearm 1 space,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,25023,Decompress forearm 1 space,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25024,Decompress forearm 2 spaces,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25025,Decompress forearm 2 spaces,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,25028,Drainage of forearm lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25031,Drainage of forearm bursa,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,25035,Treat forearm bone lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,25040,Explore/treat wrist joint,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25065,Biopsy forearm soft tissues,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,25066,Biopsy forearm soft tissues,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,25071,Exc forearm les sc 3 cm/>,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,25073,Exc forearm tum deep 3 cm/>,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,25075,Exc forearm les sc < 3 cm,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,25076,Exc forearm tum deep < 3 cm,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,25077,Resect forearm/wrist tum<3cm,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,25078,Resect forarm/wrist tum 3cm>,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,25085,Incision of wrist capsule,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25100,Biopsy of wrist joint,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25101,Explore/treat wrist joint,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25105,Remove wrist joint lining,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25107,Remove wrist joint cartilage,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25109,Excise tendon forearm/wrist,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25110,Remove wrist tendon lesion,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,25111,Remove wrist tendon lesion,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,25112,Reremove wrist tendon lesion,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,25115,Remove wrist/forearm lesion,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,25116,Remove wrist/forearm lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25118,Excise wrist tendon sheath,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,25119,Partial removal of ulna,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25120,Removal of forearm lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25125,Remove/graft forearm lesion,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,25126,Remove/graft forearm lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25130,Removal of wrist lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25135,Remove & graft wrist lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,25136,Remove & graft wrist lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,25145,Remove forearm bone lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25150,Partial removal of ulna,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25151,Partial removal of radius,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","9,201.00",,,,,,
BCBS HMO,CPT,25170,Resect radius/ulnar tumor,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,25210,Removal of wrist bone,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25215,Removal of wrist bones,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25230,Partial removal of radius,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25240,Partial removal of ulna,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25246,Injection for wrist x-ray,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,25248,Remove forearm foreign body,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,25250,Removal of wrist prosthesis,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,25251,Removal of wrist prosthesis,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25259,Manipulate wrist w/anesthes,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,25260,Repair forearm tendon/muscle,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25263,Repair forearm tendon/muscle,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,25265,Repair forearm tendon/muscle,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25270,Repair forearm tendon/muscle,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25272,Repair forearm tendon/muscle,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25274,Repair forearm tendon/muscle,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25275,Repair forearm tendon sheath,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25280,Revise wrist/forearm tendon,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25290,Incise wrist/forearm tendon,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25295,Release wrist/forearm tendon,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25300,Fusion of tendons at wrist,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25301,Fusion of tendons at wrist,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25310,Transplant forearm tendon,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25312,Transplant forearm tendon,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25315,Revise palsy hand tendon(s),Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,25316,Revise palsy hand tendon(s),Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,25317,REVISE hand CONTRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,25318,REVISE hand CONTRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,25320,Repair/revise wrist joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,25330,Arthroplasty-wrist,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,25331,Arthroplasty-wrist-w/implant,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,25332,Revise wrist joint,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25335,Realignment of hand,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25337,Reconstruct ulna/radioulnar,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,25350,Revision of radius,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,25355,Revision of radius,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25360,Revision of ulna,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,25365,Revise radius & ulna,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,25370,Revise radius or ulna,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25375,Revise radius & ulna,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25390,Shorten radius or ulna,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,25391,Lengthen radius or ulna,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,25392,Shorten radius & ulna,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,25393,Lengthen radius & ulna,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,25394,Repair carpal bone shorten,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25400,Repair radius or ulna,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,25405,Repair/graft radius or ulna,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,25415,Repair radius & ulna,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,25420,Repair/graft radius & ulna,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,25425,Repair/graft radius or ulna,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,25426,Repair/graft radius & ulna,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25430,Vasc graft into carpal bone,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25431,Repair nonunion carpal bone,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,25440,Repair/graft wrist bone,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,25441,Reconstruct wrist joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,25442,Reconstruct wrist joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,25443,Reconstruct wrist joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,25444,Reconstruct wrist joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,25445,Reconstruct wrist joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,25446,Wrist replacement,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,25447,Repair wrist joints,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25449,Remove wrist joint implant,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,25450,Revision of wrist joint,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25455,Revision of wrist joint,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25490,Reinforce radius,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,25491,Reinforce ulna,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,25492,Reinforce radius and ulna,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25500,Treat fracture of radius,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,25505,Treat fracture of radius,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,25510,REPAIR FRACTURE OF RADIUS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,25515,Treat fracture of radius,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,25520,Treat fracture of radius,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,25525,Treat fracture of radius,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,25526,Treat fracture of radius,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,25530,Treat fracture of ulna,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,25535,Treat fracture of ulna,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,25540,REPAIR FRACTURE OF ULNA,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,25545,Treat fracture of ulna,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,25560,Treat fracture radius & ulna,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,25565,Treat fracture radius & ulna,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,25570,REPAIR FRACTURE RADIUS/ULNA,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,25574,Treat fracture radius & ulna,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,25575,Treat fracture radius/ulna,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,25600,Treat fracture radius/ulna,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,25605,Treat fracture radius/ulna,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,25606,Treat fx distal radial,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25607,Treat fx rad extra-articul,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,25608,Treat fx rad intra-articul,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,25609,Treat fx radial 3+ frag,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,25610,REPAIR FRACTURE RADIUS/ULNA,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,25611,Treat fracture radius/ulna,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,25615,REPAIR FRACTURE RADIUS/ULNA,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,25620,Treat fracture radius/ulna,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,25622,Treat wrist bone fracture,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,25624,Treat wrist bone fracture,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,25626,REPAIR WRIST BONE FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,25628,Treat wrist bone fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,25630,Treat wrist bone fracture,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,25635,Treat wrist bone fracture,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,25640,REPAIR WRIST BONE FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,25645,Treat wrist bone fracture,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25650,Treat wrist bone fracture,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,25651,Pin ulnar styloid fracture,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25652,Treat fracture ulnar styloid,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,25660,Treat wrist dislocation,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,25665,REPAIR WRIST DISLOCATION,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,25670,Treat wrist dislocation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,25671,Pin radioulnar dislocation,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25675,Treat wrist dislocation,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,25676,Treat wrist dislocation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,25680,Treat wrist fracture,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,25685,Treat wrist fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,25690,Treat wrist dislocation,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,25695,Treat wrist dislocation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,25800,Fusion of wrist joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,25805,Fusion/graft of wrist joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,25810,Fusion/graft of wrist joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,25820,Fusion of hand bones,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,25825,Fuse hand bones with graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,25830,Fusion radioulnar jnt/ulna,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,25900,Amputation of forearm,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,25905,Amputation of forearm,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,25907,Amputation follow-up surgery,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25909,Amputation follow-up surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,25915,Amputation of forearm,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,25920,Amputate hand at wrist,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,25922,Amputate hand at wrist,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,25924,Amputation follow-up surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,25927,Amputation of hand,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25929,Amputation follow-up surgery,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,25931,Amputation follow-up surgery,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,25999,Forearm or wrist surgery,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,26010,Drainage of finger abscess,Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,26011,Drainage of finger abscess,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,26020,Drain hand tendon sheath,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26025,Drainage of palm bursa,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26030,Drainage of palm bursas,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26034,Treat hand bone lesion,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,26035,Decompress fingers/hand,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26037,Decompress fingers/hand,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26040,Release palm contracture,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,26045,Release palm contracture,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26055,Incise finger tendon sheath,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,26060,Incision of finger tendon,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,26070,Explore/treat hand joint,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,26075,Explore/treat finger joint,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26080,Explore/treat finger joint,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,26100,Biopsy hand joint lining,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26105,Biopsy finger joint lining,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26110,Biopsy finger joint lining,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,26111,Exc hand les sc 1.5 cm/>,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,26113,Exc hand tum deep 1.5 cm/>,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,26115,Exc hand les sc < 1.5 cm,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,26116,Exc hand tum deep < 1.5 cm,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,26117,Rad resect hand tumor < 3 cm,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,26118,Rad resect hand tumor 3 cm/>,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,26120,RELEASE OF PALM CONTRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,26121,Release palm contracture,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26122,REVISION OF PALM CONTRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,26123,Release palm contracture,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26124,REVISION/GRAFT hand & FINGER,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,26125,Release palm contracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,26126,EACH ADDITIONAL FINGER,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,26128,EACH ADDITIONAL JOINT,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,26130,Remove wrist joint lining,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26135,Revise finger joint each,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26140,Revise finger joint each,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,26145,Tendon excision palm/finger,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,26160,Remove tendon sheath lesion,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,26170,Removal of palm tendon each,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,26180,Removal of finger tendon,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,26185,Remove finger bone,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,26200,Remove hand bone lesion,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,26205,Remove/graft bone lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,26210,Removal of finger lesion,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,26215,Remove/graft finger lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26230,Partial removal of hand bone,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26235,Partial removal finger bone,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,26236,Partial removal finger bone,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,26250,Extensive hand surgery,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26255,Extensive hand surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,26260,Resect prox finger tumor,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26261,Extensive finger surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,26262,Resect distal finger tumor,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,26320,Removal of implant from hand,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,26340,Manipulate finger w/anesth,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,26341,Manipulat palm cord post inj,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,26350,Repair finger/hand tendon,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26352,Repair/graft hand tendon,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,26356,Repair finger/hand tendon,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26357,Repair finger/hand tendon,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26358,Repair/graft hand tendon,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,26370,Repair finger/hand tendon,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","9,201.00",,,,,,
BCBS HMO,CPT,26372,Repair/graft hand tendon,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,26373,Repair finger/hand tendon,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26390,Revise hand/finger tendon,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,26392,Repair/graft hand tendon,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,26410,Repair hand tendon,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,26412,Repair/graft hand tendon,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26415,Excision hand/finger tendon,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26416,Graft hand or finger tendon,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26418,Repair finger tendon,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,26420,Repair/graft finger tendon,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26426,Repair finger/hand tendon,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26428,Repair/graft finger tendon,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26432,Repair finger tendon,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,26433,Repair finger tendon,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26434,Repair/graft finger tendon,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26437,Realignment of tendons,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26440,Release palm/finger tendon,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,26442,Release palm & finger tendon,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26445,Release hand/finger tendon,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26449,Release forearm/hand tendon,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26450,Incision of palm tendon,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26455,Incision of finger tendon,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,26460,Incise hand/finger tendon,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,26471,Fusion of finger tendons,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26474,Fusion of finger tendons,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,26476,Tendon lengthening,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26477,Tendon shortening,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26478,Lengthening of hand tendon,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26479,Shortening of hand tendon,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26480,Transplant hand tendon,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26483,Transplant/graft hand tendon,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26485,Transplant palm tendon,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26489,Transplant/graft palm tendon,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26490,Revise thumb tendon,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26492,Tendon transfer with graft,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26494,Hand tendon/muscle transfer,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26496,Revise thumb tendon,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26497,Finger tendon transfer,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26498,Finger tendon transfer,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26499,Revision of finger,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26500,Hand tendon reconstruction,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,26502,Hand tendon reconstruction,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26504,Hand tendon reconstruction,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,26508,Release thumb contracture,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26510,Thumb tendon transfer,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26516,Fusion of knuckle joint,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26517,Fusion of knuckle joints,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26518,Fusion of knuckle joints,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,26520,Release knuckle contracture,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26525,Release finger contracture,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,26527,REVISE WRIST JOINT,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,26530,Revise knuckle joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,26531,Revise knuckle with implant,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,26535,Revise finger joint,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26536,Revise/implant finger joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,26540,Repair hand joint,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26541,Repair hand joint with graft,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26542,Repair hand joint with graft,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26545,Reconstruct finger joint,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26546,Repair nonunion hand,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,26548,Reconstruct finger joint,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26550,Construct thumb replacement,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26551,Great toe-hand transfer,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,26552,Reconstruction thumb w/toe,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,26553,Single transfer toe-hand,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,26554,Double transfer toe-hand,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,26555,Positional change of finger,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,26556,Toe joint transfer,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,26557,Toe to finger transfer-first stage,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,26558,Toe to finger transfer-each delay,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,26559,Toe to finger transfer-second stage,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,26560,Repair of web finger,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,26561,Repair of web finger,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26562,Repair of web finger,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26565,Correct metacarpal flaw,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26567,Correct finger deformity,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26568,Lengthen metacarpal/finger,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,26570,BONE GRAFT-METACARPAL,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,26574,BONE GRAFT-PHALANX,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,26580,Repair hand deformity,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26585,REPAIR FINGER DEFORMITY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,26587,Reconstruct extra finger,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26590,Repair finger deformity,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,26591,Repair muscles of hand,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26593,Release muscles of hand,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26596,Excision constricting tissue,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26597,RELEASE OF SCAR CONTRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,26600,Treat metacarpal fracture,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,26605,Treat metacarpal fracture,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,26607,Treat metacarpal fracture,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26608,Treat metacarpal fracture,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26610,REPAIR METACARPAL FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,26615,Treat metacarpal fracture,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26641,Treat thumb dislocation,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,26645,Treat thumb fracture,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,26650,Treat thumb fracture,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26655,REPAIR THUMB FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,26660,REPAIR THUMB FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,26665,Treat thumb fracture,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26670,Treat hand dislocation,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,26675,Treat hand dislocation,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,26676,Pin hand dislocation,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26680,REPAIR hand DISLOCATION,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,26685,Treat hand dislocation,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26686,Treat hand dislocation,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26700,Treat knuckle dislocation,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,26705,Treat knuckle dislocation,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,26706,Pin knuckle dislocation,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26710,REPAIR KNUCKLE DISLOCATION,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,26715,Treat knuckle dislocation,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26720,Treat finger fracture each,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,26725,Treat finger fracture each,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,26727,Treat finger fracture each,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26730,REPAIR FINGER FRACTURE-EACH,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,26735,Treat finger fracture each,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26740,Treat finger fracture each,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,26742,Treat finger fracture each,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,26744,REPAIR FINGER FRACTURE-EACH,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,26746,Treat finger fracture each,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26750,Treat finger fracture each,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,26755,Treat finger fracture each,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,26756,Pin finger fracture each,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26760,REPAIR FINGER FRACTURE-EACH,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,26765,Treat finger fracture each,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26770,Treat finger dislocation,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,26775,Treat finger dislocation,Surgical,Per Case,"$4,314.00 ",OP,246.8,"4,314.00",,,,,,
BCBS HMO,CPT,26776,Pin finger dislocation,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26780,REPAIR FINGER DISLOCATION,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,26785,Treat finger dislocation,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26820,Thumb fusion with graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,26841,Fusion of thumb,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,26842,Thumb fusion with graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,26843,Fusion of hand joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,26844,Fusion/graft of hand joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,26850,Fusion of knuckle,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,26852,Fusion of knuckle with graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,26860,Fusion of finger joint,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26861,Fusion of finger jnt add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,26862,Fusion/graft of finger joint,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26863,Fuse/graft added joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,26910,Amputate metacarpal bone,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26951,Amputation of finger/thumb,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26952,Amputation of finger/thumb,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26989,Hand/finger surgery,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,26990,Drainage of pelvis lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,26991,Drainage of pelvis bursa,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,26992,Drainage of bone lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27000,Incision of hip tendon,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,27001,Incision of hip tendon,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27002,INCISION OF HIP TENDONS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27003,Incision of hip tendon,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27004,INCISION OF HIP TENDONS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27005,Incision of hip tendon,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27006,Incision of hip tendons,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27010,FASCIOTOMY GLUTEAL-ILIOTIB,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27015,FASCIOTOMY ILIAC,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27025,Incision of hip/thigh fascia,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27027,Buttock fasciotomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27030,Drainage of hip joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27033,Exploration of hip joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27035,Denervation of hip joint,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27036,Excision of hip joint/muscle,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27040,Biopsy of soft tissues,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,27041,Biopsy of soft tissues,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,27043,Exc hip pelvis les sc 3 cm/>,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,27045,Exc hip/pelv tum deep 5 cm/>,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,27047,Exc hip/pelvis les sc < 3 cm,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,27048,Exc hip/pelv tum deep < 5 cm,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,27049,Resect hip/pelv tum < 5 cm,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,27050,Biopsy of sacroiliac joint,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,27052,Biopsy of hip joint,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,27054,Removal of hip joint lining,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27057,Buttock fasciotomy w/dbrdmt,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,27059,Resect hip/pelv tum 5 cm/>,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,27060,Removal of ischial bursa,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27062,Remove femur lesion/bursa,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27065,Remove hip bone les super,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27066,Remove hip bone les deep,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27067,Remove/graft hip bone lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27070,Part remove hip bone super,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27071,Part removal hip bone deep,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27075,Resect hip tumor,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27076,Resect hip tum incl acetabul,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27077,Resect hip tum w/innom bone,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,27078,Rsect hip tum incl femur,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,27079,Extensive hip surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27080,Removal of tail bone,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27086,Remove hip foreign body,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,27087,Remove hip foreign body,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27090,Removal of hip prosthesis,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,27091,Removal of hip prosthesis,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,27093,Injection for hip x-ray,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27095,Injection for hip x-ray,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27096,Inject sacroiliac joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27097,Revision of hip tendon,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27098,Transfer tendon to pelvis,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27100,Transfer of abdominal muscle,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27105,Transfer of spinal muscle,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27110,Transfer of iliopsoas muscle,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27111,Transfer of iliopsoas muscle,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27120,Reconstruction of hip socket,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,27122,Reconstruction of hip socket,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,27125,Partial hip replacement,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,27126,ARTHROPLASTY-CUP,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27127,ARTHROPLASTY-W/ACETABULOPLA,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27130,Total hip arthroplasty,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,27132,Total hip arthroplasty,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,27134,Revise hip joint replacement,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,27137,Revise hip joint replacement,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,27138,Revise hip joint replacement,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,27140,Transplant femur ridge,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,27146,Incision of hip bone,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27147,Revision of hip bone,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27151,Incision of hip bones,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27156,Revision of hip bones,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27157,ACETABULAR AUGMENTATION,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27158,Revision of pelvis,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27161,Incision of neck of femur,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27165,Incision/fixation of femur,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27170,Repair/graft femur head/neck,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27175,Treat slipped epiphysis,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27176,Treat slipped epiphysis,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,27177,Treat slipped epiphysis,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27178,Treat slipped epiphysis,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27179,Revise head/neck of femur,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27181,Treat slipped epiphysis,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27185,Revision of femur epiphysis,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27187,Reinforce hip bones,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27190,TREATMENT OF SACRUM FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27192,REPAIR OF SACRUM FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27193,Treat pelvic ring fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27194,Treat pelvic ring fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27195,TREAT PELVIS DISLOCATION,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27196,TREAT PELVIS DISLOCATION,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27197,Clsd tx pelvic ring fx,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,27198,Clsd tx pelvic ring fx,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,27200,Treat tail bone fracture,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,27201,REPAIR TAIL BONE FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27202,Treat tail bone fracture,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27210,TREAT PELVIS FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27212,REPAIR PELVIS FRACTURE(S),Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27214,REPAIR PELVIS FRACTURE(S),Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27215,Treat pelvic fracture(s),Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27216,Treat pelvic ring fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27217,Treat pelvic ring fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27218,Treat pelvic ring fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27220,Treat hip socket fracture,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,27222,Treat hip socket fracture,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,27224,REPAIR HIP SOCKET FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27225,REPAIR HIP SOCKET FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27226,Treat hip wall fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27227,Treat hip fracture(s),Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27228,Treat hip fracture(s),Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27230,Treat thigh fracture,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,27232,Treat thigh fracture,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,27234,REPAIR FRACTURE OF FEMUR,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27235,Treat thigh fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27236,Treat thigh fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27238,Treat thigh fracture,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,27240,Treat thigh fracture,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,27242,Repair Femur Fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27244,Treat thigh fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27245,Treat thigh fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27246,Treat thigh fracture,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,27248,Treat thigh fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27250,Treat hip dislocation,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,27252,Treat hip dislocation,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,27253,Treat hip dislocation,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27254,Treat hip dislocation,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27255,Repair Hip Dislocation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27256,Treat hip dislocation,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,27257,Treat hip dislocation,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,27258,Treat hip dislocation,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27259,Treat hip dislocation,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27265,Treat hip dislocation,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,27266,Treat hip dislocation,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,27267,Cltx thigh fx,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27268,Cltx thigh fx w/mnpj,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27269,Optx thigh fx,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,27275,Manipulation of hip joint,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,27279,Arthrodesis sacroiliac joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,27280,Fusion of sacroiliac joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,27282,Fusion of pubic bones,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,27284,Fusion of hip joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,27286,Fusion of hip joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,27290,Amputation of leg at hip,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,27295,Amputation of leg at hip,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,27299,Pelvis/hip joint surgery,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,27301,Drain thigh/knee lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,27303,Drainage of bone lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27305,Incise thigh tendon & fascia,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27306,Incision of thigh tendon,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27307,Incision of thigh tendons,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27310,Exploration of knee joint,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27315,Partial removal-thigh nerve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27320,Partial removal-thigh nerve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27323,Biopsy thigh soft tissues,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,27324,Biopsy thigh soft tissues,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,27325,Neurectomy hamstring,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,27326,Neurectomy popliteal,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,27327,Exc thigh/knee les sc < 3 cm,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,27328,Exc thigh/knee tum deep <5cm,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,27329,Resect thigh/knee tum < 5 cm,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,27330,Biopsy knee joint lining,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27331,Explore/treat knee joint,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27332,Removal of knee cartilage,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27333,Removal of knee cartilage,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27334,Remove knee joint lining,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27335,Remove knee joint lining,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27337,Exc thigh/knee les sc 3 cm/>,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,27339,Exc thigh/knee tum dep 5cm/>,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,27340,Removal of kneecap bursa,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27345,Removal of knee cyst,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27347,Remove knee cyst,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27350,Removal of kneecap,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27355,Remove femur lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27356,Remove femur lesion/graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,27357,Remove femur lesion/graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27358,Remove femur lesion/fixation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27360,Partial removal leg bone(s),Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27364,Resect thigh/knee tum 5 cm/>,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,27365,Resect femur/knee tumor,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27369,Njx cntrst kne arthg/ct/mri,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27370,Injection for knee x-ray,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27372,Removal of foreign body,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,27373,KNEE ARTHROSCOPY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27374,KNEE ARTHROSCOPY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27376,KNEE ARTHROSCOPY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27378,KNEE ARTHROSCOPY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27380,Repair of kneecap tendon,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27381,Repair/graft kneecap tendon,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27385,Repair of thigh muscle,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27386,Repair/graft of thigh muscle,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27390,Incision of thigh tendon,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27391,Incision of thigh tendons,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27392,Incision of thigh tendons,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27393,Lengthening of thigh tendon,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27394,Lengthening of thigh tendons,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27395,Lengthening of thigh tendons,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27396,Transplant of thigh tendon,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27397,Transplants of thigh tendons,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27400,Revise thigh muscles/tendons,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27403,Repair of knee cartilage,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27405,Repair of knee ligament,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,27407,Repair of knee ligament,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,27409,Repair of knee ligaments,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,27412,Autochondrocyte implant knee,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27415,Osteochondral knee allograft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,27416,Osteochondral knee autograft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27418,Repair degenerated kneecap,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27420,Revision of unstable kneecap,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27422,Revision of unstable kneecap,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27424,Revision/removal of kneecap,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27425,Lat retinacular release open,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27427,Reconstruction knee,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,27428,Reconstruction knee,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS HMO,CPT,27429,Reconstruction knee,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS HMO,CPT,27430,Revision of thigh muscles,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27435,Incision of knee joint,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27437,Revise kneecap,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27438,Revise kneecap with implant,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,27440,Revision of knee joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,27441,Revision of knee joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,27442,Revision of knee joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,27443,Revision of knee joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,27445,Revision of knee joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,27446,Revision of knee joint,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS HMO,CPT,27447,Total knee arthroplasty,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,27448,Incision of thigh,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27450,Incision of thigh,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27454,Realignment of thigh bone,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27455,Realignment of knee,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27457,Realignment of knee,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27465,Shortening of thigh bone,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27466,Lengthening of thigh bone,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27468,Shorten/lengthen thighs,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27470,Repair of thigh,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27472,Repair/graft of thigh,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27475,Surgery to stop leg growth,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27477,Surgery to stop leg growth,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27479,Surgery to stop leg growth,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27485,Surgery to stop leg growth,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27486,Revise/replace knee joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,27487,Revise/replace knee joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,27488,Removal of knee prosthesis,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27495,Reinforce thigh,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27496,Decompression of thigh/knee,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27497,Decompression of thigh/knee,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27498,Decompression of thigh/knee,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,27499,Decompression of thigh/knee,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27500,Treatment of thigh fracture,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,27501,Treatment of thigh fracture,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,27502,Treatment of thigh fracture,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,27503,Treatment of thigh fracture,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,27504,REPAIR OF FEMUR FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27506,Treatment of thigh fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27507,Treatment of thigh fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27508,Treatment of thigh fracture,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,27509,Treatment of thigh fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27510,Treatment of thigh fracture,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,27511,Treatment of thigh fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27512,REPAIR OF FEMUR FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27513,Treatment of thigh fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27514,Treatment of thigh fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27516,Treat thigh fx growth plate,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,27517,Treat thigh fx growth plate,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,27518,REPAIR OF FEMUR EPIPHYSIS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27519,Treat thigh fx growth plate,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27520,Treat kneecap fracture,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,27522,REPAIR OF KNEECAP FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27524,Treat kneecap fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27530,Treat knee fracture,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,27532,Treat knee fracture,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27534,REPAIR OF KNEE FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27535,Treat knee fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27536,Treat knee fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27537,REPAIR/GRAFT KNEE FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27538,Treat knee fracture(s),Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,27540,Treat knee fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27550,Treat knee dislocation,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,27552,Treat knee dislocation,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,27554,REPAIR OF KNEE DISLOCATION,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27556,Treat knee dislocation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27557,Treat knee dislocation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27558,Treat knee dislocation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27560,Treat kneecap dislocation,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,27562,Treat kneecap dislocation,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,27564,REPAIR KNEECAP DISLOCATION,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27566,Treat kneecap dislocation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27570,Fixation of knee joint,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,27580,Fusion of knee,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,27590,Amputate leg at thigh,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,27591,Amputate leg at thigh,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,27592,Amputate leg at thigh,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,27594,Amputation follow-up surgery,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27596,Amputation follow-up surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27598,Amputate lower leg at knee,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,27599,Leg surgery procedure,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,27600,Decompression of lower leg,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27601,Decompression of lower leg,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27602,Decompression of lower leg,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27603,Drain lower leg lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,27604,Drain lower leg bursa,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27605,Incision of achilles tendon,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,27606,Incision of achilles tendon,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27607,Treat lower leg bone lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27610,Explore/treat ankle joint,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27612,Exploration of ankle joint,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27613,Biopsy lower leg soft tissue,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,27614,Biopsy lower leg soft tissue,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,27615,Resect leg/ankle tum < 5 cm,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,27616,Resect leg/ankle tum 5 cm/>,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,27618,Exc leg/ankle tum < 3 cm,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,27619,Exc leg/ankle tum deep <5 cm,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,27620,Explore/treat ankle joint,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27625,Remove ankle joint lining,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27626,Remove ankle joint lining,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27630,Removal of tendon lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27632,Exc leg/ankle les sc 3 cm/>,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,27634,Exc leg/ankle tum dep 5 cm/>,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,27635,Remove lower leg bone lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27637,Remove/graft leg bone lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27638,Remove/graft leg bone lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27640,Partial removal of tibia,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27641,Partial removal of fibula,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27645,Resect tibia tumor,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27646,Resect fibula tumor,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27647,Resect talus/calcaneus tum,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27648,Injection for ankle x-ray,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27650,Repair achilles tendon,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27652,Repair/graft achilles tendon,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,27654,Repair of achilles tendon,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,27656,Repair leg fascia defect,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27658,Repair of leg tendon each,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27659,Repair of leg tendon each,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27664,Repair of leg tendon each,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27665,Repair of leg tendon each,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27675,Repair lower leg tendons,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27676,Repair lower leg tendons,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27680,Release of lower leg tendon,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27681,Release of lower leg tendons,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27685,Revision of lower leg tendon,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27686,Revise lower leg tendons,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27687,Revision of calf tendon,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27690,Revise lower leg tendon,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27691,Revise lower leg tendon,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,27692,Revise additional leg tendon,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27695,Repair of ankle ligament,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27696,Repair of ankle ligaments,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27698,Repair of ankle ligament,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27700,Revision of ankle joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27702,Reconstruct ankle joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,27703,Reconstruction ankle joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,27704,Removal of ankle implant,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27705,Incision of tibia,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27707,Incision of fibula,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27709,Incision of tibia & fibula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,27712,Realignment of lower leg,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,27715,Revision of lower leg,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,27720,Repair of tibia,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27722,Repair/graft of tibia,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27724,Repair/graft of tibia,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,27725,Repair of lower leg,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27726,Repair fibula nonunion,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,27727,Repair of lower leg,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27730,Repair of tibia epiphysis,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27732,Repair of fibula epiphysis,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27734,Repair lower leg epiphyses,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27740,Repair of leg epiphyses,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27742,Repair of leg epiphyses,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27745,Reinforce tibia,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27750,Treatment of tibia fracture,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,27752,Treatment of tibia fracture,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,27754,REPAIR OF TIBIA FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27756,Treatment of tibia fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27758,Treatment of tibia fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS HMO,CPT,27759,Treatment of tibia fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,27760,Cltx medial ankle fx,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,27762,Cltx med ankle fx w/mnpj,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,27764,REPAIR OF ANKLE FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27766,Optx medial ankle fx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27767,Cltx post ankle fx,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,27768,Cltx post ankle fx w/mnpj,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,27769,Optx post ankle fx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27780,Treatment of fibula fracture,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,27781,Treatment of fibula fracture,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,27782,REPAIR OF FIBULA FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27784,Treatment of fibula fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27786,Treatment of ankle fracture,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,27788,Treatment of ankle fracture,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,27790,REPAIR OF ANKLE FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27792,Treatment of ankle fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27800,TREAT LOWER LEG FRACTURES,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27802,TREAT LOWER LEG FRACTURES,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27804,REPAIR LOWER LEG FRACTURES,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27806,REPAIR LOWER LEG FRACTURES,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27808,Treatment of ankle fracture,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,27810,Treatment of ankle fracture,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,27812,REPAIR OF ANKLE FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27814,Treatment of ankle fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,27816,Treatment of ankle fracture,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,27818,Treatment of ankle fracture,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,27820,REPAIR OF ANKLE FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27822,Treatment of ankle fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27823,Treatment of ankle fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27824,Treat lower leg fracture,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,27825,Treat lower leg fracture,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,27826,Treat lower leg fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27827,Treat lower leg fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,27828,Treat lower leg fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS HMO,CPT,27829,Treat lower leg joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27830,Treat lower leg dislocation,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,27831,Treat lower leg dislocation,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27832,Treat lower leg dislocation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27840,Treat ankle dislocation,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,27842,Treat ankle dislocation,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,27844,REPAIR ANKLE DISLOCATION,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,27846,Treat ankle dislocation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27848,Treat ankle dislocation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27860,Fixation of ankle joint,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27870,Fusion of ankle joint open,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS HMO,CPT,27871,Fusion of tibiofibular joint,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS HMO,CPT,27880,Amputation of lower leg,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,27881,Amputation of lower leg,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27882,Amputation of lower leg,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27884,Amputation follow-up surgery,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27886,Amputation follow-up surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27888,Amputation of foot at ankle,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,27889,Amputation of foot at ankle,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27892,Decompression of leg,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27893,Decompression of leg,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,27894,Decompression of leg,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,27899,Leg/ankle surgery procedure,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,28001,Drainage of bursa of foot,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,28002,Treatment of foot infection,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,28003,Treatment of foot infection,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28005,Treat foot bone lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28008,Incision of foot fascia,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28010,Incision of toe tendon,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,28011,Incision of toe tendons,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,28020,Exploration of foot joint,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28022,Exploration of foot joint,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28024,Exploration of toe joint,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,28030,Removal of foot nerve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,28035,Decompression of tibia nerve,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,28039,Exc foot/toe tum sc 1.5 cm/>,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,28041,Exc foot/toe tum dep 1.5cm/>,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,28043,Exc foot/toe tum sc < 1.5 cm,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,28045,Exc foot/toe tum deep <1.5cm,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,28046,Resect foot/toe tumor < 3 cm,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,28047,Resect foot/toe tumor 3 cm/>,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,28050,Biopsy of foot joint lining,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28052,Biopsy of foot joint lining,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28054,Biopsy of toe joint lining,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28055,Neurectomy foot,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,28060,Partial removal foot fascia,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28062,Removal of foot fascia,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28070,Removal of foot joint lining,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,28072,Removal of foot joint lining,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28080,Removal of foot lesion,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,28086,Excise foot tendon sheath,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28088,Excise foot tendon sheath,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28090,Removal of foot lesion,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,28092,Removal of toe lesions,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,28100,Removal of ankle/heel lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28102,Remove/graft foot lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,28103,Remove/graft foot lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,28104,Removal of foot lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28106,Remove/graft foot lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,28107,Remove/graft foot lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,28108,Removal of toe lesions,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,28110,Part removal of metatarsal,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28111,Part removal of metatarsal,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28112,Part removal of metatarsal,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28113,Part removal of metatarsal,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28114,Removal of metatarsal heads,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28116,Revision of foot,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28118,Removal of heel bone,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28119,Removal of heel spur,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28120,Part removal of ankle/heel,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28122,Partial removal of foot bone,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28124,Partial removal of toe,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28126,Partial removal of toe,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28130,Removal of ankle bone,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,28135,CALCANECTOMY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,28140,Removal of metatarsal,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28150,Removal of toe,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28153,Partial removal of toe,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28160,Partial removal of toe,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28171,Resect tarsal tumor,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28173,Resect metatarsal tumor,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28175,Resect phalanx of toe tumor,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,28190,Removal of foot foreign body,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,28192,Removal of foot foreign body,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,28193,Removal of foot foreign body,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,28200,Repair of foot tendon,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28202,Repair/graft of foot tendon,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,28208,Repair of foot tendon,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28210,Repair/graft of foot tendon,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,28220,Release of foot tendon,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,28222,Release of foot tendons,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28225,Release of foot tendon,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28226,Release of foot tendons,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28230,Incision of foot tendon(s),Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,28232,Incision of toe tendon,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,28234,Incision of foot tendon,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,28236,TRANSFER OF FOOT TENDON,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,28238,Revision of foot tendon,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,28240,Release of big toe,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28250,Revision of foot fascia,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28260,Release of midfoot joint,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28261,Revision of foot tendon,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,28262,Revision of foot and ankle,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,28264,Release of midfoot joint,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,28270,Release of foot contracture,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28272,Release of toe joint each,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,28280,Fusion of toes,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28285,Repair of hammertoe,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28286,Repair of hammertoe,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28288,Partial removal of foot bone,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28289,Corrj halux rigdus w/o implt,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28290,Correction of bunion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,28291,Corrj halux rigdus w/implt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,28292,Correction hallux valgus,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28293,Correction of bunion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,28294,Correction of bunion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,28295,Correction hallux valgus,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28296,Correction hallux valgus,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28297,Correction hallux valgus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,28298,Correction hallux valgus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,28299,Correction hallux valgus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,28300,Incision of heel bone,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,28302,Incision of ankle bone,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,28304,Incision of midfoot bones,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,28305,Incise/graft midfoot bones,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,28306,Incision of metatarsal,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,28307,Incision of metatarsal,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,28308,Incision of metatarsal,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28309,Incision of metatarsals,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,28310,Revision of big toe,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,28312,Revision of toe,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28313,Repair deformity of toe,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28315,Removal of sesamoid bone,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28320,Repair of foot bones,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,28322,Repair of metatarsals,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,28340,Resect enlarged toe tissue,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28341,Resect enlarged toe,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28344,Repair extra toe(s),Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28345,Repair webbed toe(s),Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,28360,Reconstruct cleft foot,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,28400,Treatment of heel fracture,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,28405,Treatment of heel fracture,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,28406,Treatment of heel fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,28410,REPAIR OF HEEL FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,28415,Treat heel fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,28420,Treat/graft heel fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,28430,Treatment of ankle fracture,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,28435,Treatment of ankle fracture,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,28436,Treatment of ankle fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,28440,REPAIR OF ANKLE FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,28445,Treat ankle fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,28446,Osteochondral talus autogrft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,28450,Treat midfoot fracture each,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,28455,Treat midfoot fracture each,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,28456,Treat midfoot fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,28460,REPAIR MIDFOOT FRACTURE-EACH,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,28465,Treat midfoot fracture each,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,28470,Treat metatarsal fracture,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,28475,Treat metatarsal fracture,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,28476,Treat metatarsal fracture,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28480,REPAIR METATARSAL FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,28485,Treat metatarsal fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,28490,Treat big toe fracture,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,28495,Treat big toe fracture,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,28496,Treat big toe fracture,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28500,REPAIR BIG TOE FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,28505,Treat big toe fracture,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28510,Treatment of toe fracture,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,28515,Treatment of toe fracture,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,28520,REPAIR OF TOE FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,28525,Treat toe fracture,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28530,Treat sesamoid bone fracture,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,28531,Treat sesamoid bone fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,28540,Treat foot dislocation,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,28545,Treat foot dislocation,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28546,Treat foot dislocation,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,28550,REPAIR FOOT DISLOCATION,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,28555,Repair foot dislocation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,28570,Treat foot dislocation,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,28575,Treat foot dislocation,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28576,Treat foot dislocation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,28580,REPAIR FOOT DISLOCATION,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,28585,Repair foot dislocation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,28600,Treat foot dislocation,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,28605,Treat foot dislocation,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,28606,Treat foot dislocation,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28610,REPAIR FOOT DISLOCATION,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,28615,Repair foot dislocation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,28630,Treat toe dislocation,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,28635,Treat toe dislocation,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,28636,Treat toe dislocation,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28640,REPAIR TOE DISLOCATION,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,28645,Repair toe dislocation,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28660,Treat toe dislocation,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,28665,Treat toe dislocation,Surgical,Per Case,"$4,314.00 ",OP,246.8,"4,314.00",,,,,,
BCBS HMO,CPT,28666,Treat toe dislocation,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28670,REPAIR OF TOE DISLOCATION,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,28675,Repair of toe dislocation,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28705,Fusion of foot bones,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,28715,Fusion of foot bones,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS HMO,CPT,28725,Fusion of foot bones,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS HMO,CPT,28730,Fusion of foot bones,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS HMO,CPT,28735,Fusion of foot bones,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,28737,Revision of foot bones,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,28740,Fusion of foot bones,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,28750,Fusion of big toe joint,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,28755,Fusion of big toe joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,28760,Fusion of big toe joint,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,28800,Amputation of midfoot,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28805,Amputation thru metatarsal,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28810,Amputation toe & metatarsal,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28820,Amputation of toe,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28825,Partial amputation of toe,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,28890,Hi enrgy eswt plantar fascia,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,28899,Foot/toes surgery procedure,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,29000,Application of body cast,Surgical,Per Case,"$4,314.00 ",OP,246.8,"4,314.00",,,,,,
BCBS HMO,CPT,29010,Application of body cast,Surgical,Per Case,"$4,314.00 ",OP,246.8,"4,314.00",,,,,,
BCBS HMO,CPT,29015,Application of body cast,Surgical,Per Case,"$4,314.00 ",OP,246.8,"4,314.00",,,,,,
BCBS HMO,CPT,29020,Application of body cast,Surgical,Per Case,"$4,314.00 ",OP,"1,277.26","4,314.00",,,,,,
BCBS HMO,CPT,29025,Application of body cast,Surgical,Per Case,"$4,314.00 ",OP,"1,483.14","4,314.00",,,,,,
BCBS HMO,CPT,29035,Application of body cast,Surgical,Per Case,"$4,314.00 ",OP,246.8,"4,314.00",,,,,,
BCBS HMO,CPT,29040,Application of body cast,Surgical,Per Case,"$4,314.00 ",OP,246.8,"4,314.00",,,,,,
BCBS HMO,CPT,29044,Application of body cast,Surgical,Per Case,"$4,314.00 ",OP,144.47,"4,314.00",,,,,,
BCBS HMO,CPT,29046,Application of body cast,Surgical,Per Case,"$4,314.00 ",OP,246.8,"4,314.00",,,,,,
BCBS HMO,CPT,29049,Application of figure eight,Surgical,Per Case,"$4,314.00 ",OP,246.8,"4,314.00",,,,,,
BCBS HMO,CPT,29055,Application of shoulder cast,Surgical,Per Case,"$4,314.00 ",OP,246.8,"4,314.00",,,,,,
BCBS HMO,CPT,29058,Application of shoulder cast,Surgical,Per Case,"$4,314.00 ",OP,246.8,"4,314.00",,,,,,
BCBS HMO,CPT,29065,Application of long arm cast,Surgical,Per Case,"$4,314.00 ",OP,246.8,"4,314.00",,,,,,
BCBS HMO,CPT,29075,Application of forearm cast,Surgical,Per Case,"$4,314.00 ",OP,246.8,"4,314.00",,,,,,
BCBS HMO,CPT,29085,Apply hand/wrist cast,Surgical,Per Case,"$4,314.00 ",OP,144.47,"4,314.00",,,,,,
BCBS HMO,CPT,29086,Apply finger cast,Surgical,Per Case,"$4,314.00 ",OP,144.47,"4,314.00",,,,,,
BCBS HMO,CPT,29105,Apply long arm splint,Surgical,Per Case,"$4,314.00 ",OP,144.47,"4,314.00",,,,,,
BCBS HMO,CPT,29125,Apply forearm splint,Surgical,Per Case,"$4,314.00 ",OP,114.56,"4,314.00",,,,,,
BCBS HMO,CPT,29126,Apply forearm splint,Surgical,Per Case,"$4,314.00 ",OP,114.56,"4,314.00",,,,,,
BCBS HMO,CPT,29130,Application of finger splint,Surgical,Per Case,"$4,314.00 ",OP,114.56,"4,314.00",,,,,,
BCBS HMO,CPT,29131,Application of finger splint,Surgical,Per Case,"$4,314.00 ",OP,56.95,"4,314.00",,,,,,
BCBS HMO,CPT,29200,Strapping of chest,Surgical,Per Case,"$4,314.00 ",OP,144.47,"4,314.00",,,,,,
BCBS HMO,CPT,29220,Strapping of low back,Surgical,Per Case,"$4,314.00 ",OP,301.2,"4,314.00",,,,,,
BCBS HMO,CPT,29240,Strapping of shoulder,Surgical,Per Case,"$4,314.00 ",OP,114.56,"4,314.00",,,,,,
BCBS HMO,CPT,29260,Strapping of elbow or wrist,Surgical,Per Case,"$4,314.00 ",OP,56.95,"4,314.00",,,,,,
BCBS HMO,CPT,29280,Strapping of hand or finger,Surgical,Per Case,"$4,314.00 ",OP,56.95,"4,314.00",,,,,,
BCBS HMO,CPT,29305,Application of hip cast,Surgical,Per Case,"$4,314.00 ",OP,246.8,"4,314.00",,,,,,
BCBS HMO,CPT,29325,Application of hip casts,Surgical,Per Case,"$4,314.00 ",OP,246.8,"4,314.00",,,,,,
BCBS HMO,CPT,29345,Application of long leg cast,Surgical,Per Case,"$4,314.00 ",OP,246.8,"4,314.00",,,,,,
BCBS HMO,CPT,29355,Application of long leg cast,Surgical,Per Case,"$4,314.00 ",OP,246.8,"4,314.00",,,,,,
BCBS HMO,CPT,29358,Apply long leg cast brace,Surgical,Per Case,"$4,314.00 ",OP,246.8,"4,314.00",,,,,,
BCBS HMO,CPT,29359,LEG CAST NO PREMADE MATERIAL,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,29365,Application of long leg cast,Surgical,Per Case,"$4,314.00 ",OP,246.8,"4,314.00",,,,,,
BCBS HMO,CPT,29405,Apply short leg cast,Surgical,Per Case,"$4,314.00 ",OP,246.8,"4,314.00",,,,,,
BCBS HMO,CPT,29425,Apply short leg cast,Surgical,Per Case,"$4,314.00 ",OP,246.8,"4,314.00",,,,,,
BCBS HMO,CPT,29435,Apply short leg cast,Surgical,Per Case,"$4,314.00 ",OP,246.8,"4,314.00",,,,,,
BCBS HMO,CPT,29440,Addition of walker to cast,Surgical,Per Case,"$4,314.00 ",OP,144.47,"4,314.00",,,,,,
BCBS HMO,CPT,29445,Apply rigid leg cast,Surgical,Per Case,"$4,314.00 ",OP,246.8,"4,314.00",,,,,,
BCBS HMO,CPT,29450,Application of leg cast,Surgical,Per Case,"$4,314.00 ",OP,144.47,"4,314.00",,,,,,
BCBS HMO,CPT,29505,Application long leg splint,Surgical,Per Case,"$4,314.00 ",OP,144.47,"4,314.00",,,,,,
BCBS HMO,CPT,29515,Application lower leg splint,Surgical,Per Case,"$4,314.00 ",OP,144.47,"4,314.00",,,,,,
BCBS HMO,CPT,29520,Strapping of hip,Surgical,Per Case,"$4,314.00 ",OP,114.56,"4,314.00",,,,,,
BCBS HMO,CPT,29530,Strapping of knee,Surgical,Per Case,"$4,314.00 ",OP,114.56,"4,314.00",,,,,,
BCBS HMO,CPT,29540,Strapping of ankle and/or ft,Surgical,Per Case,"$4,314.00 ",OP,144.47,"4,314.00",,,,,,
BCBS HMO,CPT,29550,Strapping of toes,Surgical,Per Case,"$4,314.00 ",OP,56.95,"4,314.00",,,,,,
BCBS HMO,CPT,29580,Application of paste boot,Surgical,Per Case,"$4,314.00 ",OP,144.47,"4,314.00",,,,,,
BCBS HMO,CPT,29581,Apply multlay comprs lwr leg,Surgical,Per Case,"$4,314.00 ",OP,144.47,"4,314.00",,,,,,
BCBS HMO,CPT,29582,Apply multlay comprs upr leg,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,29583,Apply multlay comprs upr arm,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,29584,Appl multlay comprs arm/hand,Surgical,Per Case,"$4,314.00 ",OP,144.47,"4,314.00",,,,,,
BCBS HMO,CPT,29590,Application of foot splint,Surgical,Per Case,"$4,314.00 ",OP,324.09,"4,314.00",,,,,,
BCBS HMO,CPT,29700,Removal/revision of cast,Surgical,Per Case,"$4,314.00 ",OP,246.8,"4,314.00",,,,,,
BCBS HMO,CPT,29705,Removal/revision of cast,Surgical,Per Case,"$4,314.00 ",OP,246.8,"4,314.00",,,,,,
BCBS HMO,CPT,29710,Removal/revision of cast,Surgical,Per Case,"$4,314.00 ",OP,246.8,"4,314.00",,,,,,
BCBS HMO,CPT,29715,Removal/revision of cast,Surgical,Per Case,"$4,314.00 ",OP,499.47,"4,314.00",,,,,,
BCBS HMO,CPT,29720,Repair of body cast,Surgical,Per Case,"$4,314.00 ",OP,144.47,"4,314.00",,,,,,
BCBS HMO,CPT,29730,Windowing of cast,Surgical,Per Case,"$4,314.00 ",OP,144.47,"4,314.00",,,,,,
BCBS HMO,CPT,29740,Wedging of cast,Surgical,Per Case,"$4,314.00 ",OP,246.8,"4,314.00",,,,,,
BCBS HMO,CPT,29750,Wedging of clubfoot cast,Surgical,Per Case,"$4,314.00 ",OP,246.8,"4,314.00",,,,,,
BCBS HMO,CPT,29799,Casting/strapping procedure,Surgical,Per Case,"$4,314.00 ",OP,144.47,"4,314.00",,,,,,
BCBS HMO,CPT,29800,Jaw arthroscopy/surgery,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,29804,Jaw arthroscopy/surgery,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,29805,Sho arthrs dx +- synovial bx,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,29806,Sho arthrs srg capsulorpaphy,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,29807,Sho arthrs srg rpr slap les,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,29815,SHOULDER ARTHROSCOPY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,29819,Sho arthrs srg rmvl loose/fb,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,29820,Sho arthrs srg prtl synvct,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,29821,Sho arthrs srg compl synvct,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,29822,Sho arthrs srg lmtd dbrdmt,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,29823,Sho arthrs srg xtnsv dbrdmt,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,29824,Sho arthrs srg dstl claviclc,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,29825,Sho arthrs srg lss&rescj ads,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,29826,Sho arthrs srg decompression,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,29827,Sho arthrs srg rt8tr cuf rpr,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,29828,Sho arthrs srg bicp tenodsis,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,29830,Elbow arthroscopy,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,29834,Elbow arthroscopy/surgery,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,29835,Elbow arthroscopy/surgery,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,29836,Elbow arthroscopy/surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,29837,Elbow arthroscopy/surgery,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,29838,Elbow arthroscopy/surgery,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,29840,Wrist arthroscopy,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,29843,Wrist arthroscopy/surgery,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,29844,Wrist arthroscopy/surgery,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,29845,Wrist arthroscopy/surgery,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,29846,Wrist arthroscopy/surgery,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,29847,Wrist arthroscopy/surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,29848,Wrist endoscopy/surgery,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,29850,Knee arthroscopy/surgery,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,29851,Knee arthroscopy/surgery,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,29855,Tibial arthroscopy/surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,29856,Tibial arthroscopy/surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,29860,Hip arthroscopy dx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,29861,Hip arthro w/fb removal,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,29862,Hip arthr0 w/debridement,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,29863,Hip arthr0 w/synovectomy,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,29866,Autgrft implnt knee w/scope,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,29867,Allgrft implnt knee w/scope,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,29868,Meniscal trnspl knee w/scpe,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,29870,Knee arthroscopy dx,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,29871,Knee arthroscopy/drainage,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,29872,ARTHROSCOPY KNEE IRRIGATION,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,29873,Knee arthroscopy/surgery,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,29874,Knee arthroscopy/surgery,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,29875,Knee arthroscopy/surgery,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,29876,Knee arthroscopy/surgery,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,29877,Knee arthroscopy/surgery,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,29878,KNEE ARTHROSCOPY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,29879,Knee arthroscopy/surgery,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,29880,Knee arthroscopy/surgery,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,29881,Knee arthroscopy/surgery,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,29882,Knee arthroscopy/surgery,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,29883,Knee arthroscopy/surgery,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,29884,Knee arthroscopy/surgery,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,29885,Knee arthroscopy/surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,29886,Knee arthroscopy/surgery,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,29887,Knee arthroscopy/surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,29888,Knee arthroscopy/surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,29889,Knee arthroscopy/surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS HMO,CPT,29890,ARTHROSCOPY ANKLE DIAGNOSTIC,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,29891,Ankle arthroscopy/surgery,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,29892,Ankle arthroscopy/surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,29893,Scope plantar fasciotomy,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,29894,Ankle arthroscopy/surgery,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,29895,Ankle arthroscopy/surgery,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,29896,ARTHROSCOPY ANKLE SYN. COMP,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,29897,Ankle arthroscopy/surgery,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,29898,Ankle arthroscopy/surgery,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,29899,Ankle arthroscopy/surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,29900,Mcp joint arthroscopy dx,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,29901,Mcp joint arthroscopy surg,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,29902,Mcp joint arthroscopy surg,Surgical,Per Case,"$4,314.00 ",OP,"1,424.82","4,314.00",,,,,,
BCBS HMO,CPT,29904,Subtalar arthro w/fb rmvl,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,29905,Subtalar arthro w/exc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,29906,Subtalar arthro w/deb,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,29907,Subtalar arthro w/fusion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,29909,ARTHROSCOPY OF JOINT,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,29914,Hip arthro w/femoroplasty,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,29915,Hip arthro acetabuloplasty,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,29916,Hip arthro w/labral repair,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,29999,Arthroscopy of joint,Surgical,Per Case,"$4,314.00 ",OP,211,"4,314.00",,,,,,
BCBS HMO,CPT,30000,Drainage of nose lesion,Surgical,Per Case,"$4,314.00 ",OP,216.54,"4,314.00",,,,,,
BCBS HMO,CPT,30020,Drainage of nose lesion,Surgical,Per Case,"$4,314.00 ",OP,462.91,"4,314.00",,,,,,
BCBS HMO,CPT,30100,Intranasal biopsy,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,30110,Removal of nose polyp(s),Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,30115,Removal of nose polyp(s),Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,30116,REMOVAL OF NOSE POLYPS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,30117,Removal of intranasal lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,30118,Removal of intranasal lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,30120,Revision of nose,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,30124,Removal of nose lesion,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,30125,Removal of nose lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,30130,Excise inferior turbinate,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,30140,Resect inferior turbinate,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,30150,Partial removal of nose,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,30160,Removal of nose,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,30200,Injection treatment of nose,Surgical,Per Case,"$4,314.00 ",OP,462.91,"4,314.00",,,,,,
BCBS HMO,CPT,30210,Nasal sinus therapy,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,30220,Insert nasal septal button,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,30300,Remove nasal foreign body,Surgical,Per Case,"$4,314.00 ",OP,114.56,"4,314.00",,,,,,
BCBS HMO,CPT,30310,Remove nasal foreign body,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,30320,Remove nasal foreign body,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,30400,Reconstruction of nose,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,30410,Reconstruction of nose,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,30420,Reconstruction of nose,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,30430,Revision of nose,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,30435,Revision of nose,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,30450,Revision of nose,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,30460,Revision of nose,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,30462,Revision of nose,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,30465,Repair nasal stenosis,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,30468,Rpr nsl vlv collapse w/implt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,30500,REMOVAL OF NASAL SEPTUM,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,30520,Repair of nasal septum,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,30540,Repair nasal defect,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,30545,Repair nasal defect,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,30560,Release of nasal adhesions,Surgical,Per Case,"$4,314.00 ",OP,462.91,"4,314.00",,,,,,
BCBS HMO,CPT,30580,Repair upper jaw fistula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,30600,Repair mouth/nose fistula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,30620,Intranasal reconstruction,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,30630,Repair nasal septum defect,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,30800,CAUTERIZATION INNER NOSE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,30801,Ablate inf turbinate superf,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,30802,Ablate inf turbinate submuc,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,30805,CAUTERIZATION INNER NOSE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,30820,CAUTERIZATION INNER NOSE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,30901,Control of nosebleed,Surgical,Per Case,"$4,314.00 ",OP,114.56,"4,314.00",,,,,,
BCBS HMO,CPT,30903,Control of nosebleed,Surgical,Per Case,"$4,314.00 ",OP,114.56,"4,314.00",,,,,,
BCBS HMO,CPT,30905,Control of nosebleed,Surgical,Per Case,"$4,314.00 ",OP,114.56,"4,314.00",,,,,,
BCBS HMO,CPT,30906,Repeat control of nosebleed,Surgical,Per Case,"$4,314.00 ",OP,216.54,"4,314.00",,,,,,
BCBS HMO,CPT,30915,Ligation nasal sinus artery,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,30920,Ligation upper jaw artery,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,30930,Ther fx nasal inf turbinate,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,30999,Nasal surgery procedure,Surgical,Per Case,"$4,314.00 ",OP,216.54,"4,314.00",,,,,,
BCBS HMO,CPT,31000,Irrigation maxillary sinus,Surgical,Per Case,"$4,314.00 ",OP,216.54,"4,314.00",,,,,,
BCBS HMO,CPT,31002,Irrigation sphenoid sinus,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,31020,Exploration maxillary sinus,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,31021,EXPLORATION OF SINUSES,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31030,Exploration maxillary sinus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,31031,EXPLORATION OF SINUSES,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31032,Explore sinus remove polyps,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,31033,ENTER SINUSES-REMOVE POLYPS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31040,Exploration behind upper jaw,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,31050,Exploration sphenoid sinus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,31051,Sphenoid sinus surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,31070,Exploration of frontal sinus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,31071,EXPLORATION OF FRONTAL SINUS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31075,Exploration of frontal sinus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,31080,Removal of frontal sinus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,31081,Removal of frontal sinus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,31084,Removal of frontal sinus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,31085,Removal of frontal sinus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,31086,Removal of frontal sinus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,31087,Removal of frontal sinus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,31090,Exploration of sinuses,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,31200,Removal of ethmoid sinus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,31201,Removal of ethmoid sinus,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,31205,Removal of ethmoid sinus,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,31225,Removal of upper jaw,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,31230,Removal of upper jaw,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,31231,Nasal endoscopy dx,Surgical,Per Case,"$4,314.00 ",OP,168.23,"4,314.00",,,,,,
BCBS HMO,CPT,31233,Nsl/sins ndsc dx max sinusc,Surgical,Per Case,"$4,314.00 ",OP,385.29,"4,314.00",,,,,,
BCBS HMO,CPT,31235,Nsl/sins ndsc dx sphn sinusc,Surgical,Per Case,"$4,314.00 ",OP,"1,531.28","4,314.00",,,,,,
BCBS HMO,CPT,31237,Nasal/sinus endoscopy surg,Surgical,Per Case,"$4,314.00 ",OP,"1,531.28","4,314.00",,,,,,
BCBS HMO,CPT,31238,Nasal/sinus endoscopy surg,Surgical,Per Case,"$4,314.00 ",OP,"1,531.28","4,314.00",,,,,,
BCBS HMO,CPT,31239,Nasal/sinus endoscopy surg,Surgical,Per Case,"$4,314.00 ",OP,"3,170.26","4,314.00",,,,,,
BCBS HMO,CPT,31240,Nasal/sinus endoscopy surg,Surgical,Per Case,"$4,314.00 ",OP,"1,531.28","4,314.00",,,,,,
BCBS HMO,CPT,31241,Nsl/sins ndsc w/artery lig,Surgical,Per Case,"$4,314.00 ",OP,"1,531.28","4,314.00",,,,,,
BCBS HMO,CPT,31245,NASAL/SINUS ENDOSCOPY-SURG,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31246,NASAL/SINUS ENDOSCOPY-SURG,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31247,NASAL/SINUS ENDOSCOPY-SURG,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31248,NASAL/SINUS ENDOSCOPY-SURG,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31249,NASAL/SINUS ENDOSCOPY-SURG,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31250,NASAL ENDOSCOPY-DIAGNOSTIC,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31251,NASAL/SINUS ENDOSCOPY-SURG,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31252,NASAL ENDOSCOPY-POLYPECTOMY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31253,Nsl/sins ndsc total,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,31254,Nsl/sins ndsc w/prtl ethmdct,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,958.54",,,,,,
BCBS HMO,CPT,31255,Nsl/sins ndsc w/tot ethmdct,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,31256,Exploration maxillary sinus,Surgical,Per Case,"$4,314.00 ",OP,"3,170.26","4,314.00",,,,,,
BCBS HMO,CPT,31257,Nsl/sins ndsc tot w/sphendt,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,31258,NASAL ENDOSCOPY-SURGICAL,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31259,Nsl/sins ndsc sphn tiss rmvl,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,31260,ENDOSCOPY-MAXILLARY SINUS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31261,NASAL/SINUS ENDOSCOPY-SURG,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31262,NASAL/SINUS ENDOSCOPY-SURG,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31263,ENDOSCOPY-MAXILLARY SINUS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31264,NASAL/SINUS ENDOSCOPY-SURG,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31265,ENDOSCOPY-MAXILLARY SINUS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31266,NASAL/SINUS ENDOSCOPY-SURG,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31267,Endoscopy maxillary sinus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,958.54",,,,,,
BCBS HMO,CPT,31268,ENDOSCOPY-MAXILLARY SINUS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31269,NASAL/SINUS ENDOSCOPY-SURG,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31270,ENDOSCOPY-SPHENOID SINUS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31271,NASAL/SINUS ENDOSCOPY-SURG,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31275,SPHENOID ENDOSCOPY-SURGICAL,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31276,Nsl/sins ndsc frnt tiss rmvl,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,31277,SPHENOID ENDOSCOPY-SURGICAL,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31280,NASAL/SINUS ENDOSCOPY-SURG,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31281,NASAL/SINUS ENDOSCOPY-SURG,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31282,NASAL/SINUS ENDOSCOPY-SURG,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31283,NASAL/SINUS ENDOSCOPY-SURG,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31284,NASAL/SINUS ENDOSCOPY-SURG,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31285,ENDOSCOPY-COMBINED SINUSES,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31286,NASAL/SINUS ENDOSCOPY-SURG,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31287,Nasal/sinus endoscopy surg,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,31288,Nasal/sinus endoscopy surg,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,31290,Nasal/sinus endoscopy surg,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,31291,Nasal/sinus endoscopy surg,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,31292,Nsl/sins ndsc med/inf dcmprn,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,958.54",,,,,,
BCBS HMO,CPT,31293,Nsl/sins ndsc med&inf dcmprn,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,958.54",,,,,,
BCBS HMO,CPT,31294,Nsl/sins ndsc surg on dcmprn,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,958.54",,,,,,
BCBS HMO,CPT,31295,Nsl/sins ndsc surg max sins,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,958.54",,,,,,
BCBS HMO,CPT,31296,Nsl/sins ndsc surg frnt sins,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,31297,Nsl/sins ndsc surg sphn sins,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,958.54",,,,,,
BCBS HMO,CPT,31298,Nsl/sins ndsc surg frnt&sphn,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,31299,Sinus surgery procedure,Surgical,Per Case,"$4,314.00 ",OP,216.54,"4,314.00",,,,,,
BCBS HMO,CPT,31300,Removal of larynx lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,31320,Diagnostic incision larynx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31360,Removal of larynx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,31365,Removal of larynx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,31367,Partial removal of larynx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,31368,Partial removal of larynx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,31370,Partial removal of larynx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,31375,Partial removal of larynx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,31380,Partial removal of larynx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,31382,Partial removal of larynx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,31390,Removal of larynx & pharynx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,31395,Reconstruct larynx & pharynx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,31400,Revision of larynx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,31420,Removal of epiglottis,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,31500,Insert emergency airway,Surgical,Per Case,"$4,314.00 ",OP,216.54,"4,314.00",,,,,,
BCBS HMO,CPT,31502,Change of windpipe airway,Surgical,Per Case,"$4,314.00 ",OP,216.54,"4,314.00",,,,,,
BCBS HMO,CPT,31505,Diagnostic laryngoscopy,Surgical,Per Case,"$4,314.00 ",OP,168.23,"4,314.00",,,,,,
BCBS HMO,CPT,31510,Laryngoscopy with biopsy,Surgical,Per Case,"$4,314.00 ",OP,"3,170.26","4,314.00",,,,,,
BCBS HMO,CPT,31511,Remove foreign body larynx,Surgical,Per Case,"$4,314.00 ",OP,168.23,"4,314.00",,,,,,
BCBS HMO,CPT,31512,Removal of larynx lesion,Surgical,Per Case,"$4,314.00 ",OP,"3,170.26","4,314.00",,,,,,
BCBS HMO,CPT,31513,Injection into vocal cord,Surgical,Per Case,"$4,314.00 ",OP,385.29,"4,314.00",,,,,,
BCBS HMO,CPT,31515,Laryngoscopy for aspiration,Surgical,Per Case,"$4,314.00 ",OP,385.29,"4,314.00",,,,,,
BCBS HMO,CPT,31520,Dx laryngoscopy newborn,Surgical,Per Case,"$4,314.00 ",OP,385.29,"4,314.00",,,,,,
BCBS HMO,CPT,31525,Dx laryngoscopy excl nb,Surgical,Per Case,"$4,314.00 ",OP,"1,531.28","4,314.00",,,,,,
BCBS HMO,CPT,31526,Dx laryngoscopy w/oper scope,Surgical,Per Case,"$4,314.00 ",OP,"1,531.28","4,314.00",,,,,,
BCBS HMO,CPT,31527,Laryngoscopy for treatment,Surgical,Per Case,"$4,314.00 ",OP,"3,170.26","4,314.00",,,,,,
BCBS HMO,CPT,31528,Laryngoscopy and dilation,Surgical,Per Case,"$4,314.00 ",OP,"3,170.26","4,314.00",,,,,,
BCBS HMO,CPT,31529,Laryngoscopy and dilation,Surgical,Per Case,"$4,314.00 ",OP,"3,170.26","4,314.00",,,,,,
BCBS HMO,CPT,31530,Laryngoscopy w/fb removal,Surgical,Per Case,"$4,314.00 ",OP,"1,531.28","4,314.00",,,,,,
BCBS HMO,CPT,31531,Laryngoscopy w/fb & op scope,Surgical,Per Case,"$4,314.00 ",OP,"3,170.26","4,314.00",,,,,,
BCBS HMO,CPT,31535,Laryngoscopy w/biopsy,Surgical,Per Case,"$4,314.00 ",OP,"3,170.26","4,314.00",,,,,,
BCBS HMO,CPT,31536,Laryngoscopy w/bx & op scope,Surgical,Per Case,"$4,314.00 ",OP,"3,170.26","4,314.00",,,,,,
BCBS HMO,CPT,31540,Laryngoscopy w/exc of tumor,Surgical,Per Case,"$4,314.00 ",OP,"3,170.26","4,314.00",,,,,,
BCBS HMO,CPT,31541,Larynscop w/tumr exc + scope,Surgical,Per Case,"$4,314.00 ",OP,"3,170.26","4,314.00",,,,,,
BCBS HMO,CPT,31545,Remove vc lesion w/scope,Surgical,Per Case,"$4,314.00 ",OP,"3,170.26","4,314.00",,,,,,
BCBS HMO,CPT,31546,Remove vc lesion scope/graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,958.54",,,,,,
BCBS HMO,CPT,31551,Laryngoplasty laryngeal sten,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,31552,Laryngoplasty laryngeal sten,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,31553,Laryngoplasty laryngeal sten,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,31554,Laryngoplasty laryngeal sten,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,31560,Laryngoscop w/arytenoidectom,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,958.54",,,,,,
BCBS HMO,CPT,31561,Larynscop remve cart + scop,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,958.54",,,,,,
BCBS HMO,CPT,31570,Laryngoscope w/vc inj,Surgical,Per Case,"$4,314.00 ",OP,"3,170.26","4,314.00",,,,,,
BCBS HMO,CPT,31571,Laryngoscop w/vc inj + scope,Surgical,Per Case,"$4,314.00 ",OP,"3,170.26","4,314.00",,,,,,
BCBS HMO,CPT,31572,Largsc w/laser dstrj les,Surgical,Per Case,"$4,314.00 ",OP,"3,170.26","4,314.00",,,,,,
BCBS HMO,CPT,31573,Largsc w/ther injection,Surgical,Per Case,"$4,314.00 ",OP,"1,531.28","4,314.00",,,,,,
BCBS HMO,CPT,31574,Largsc w/njx augmentation,Surgical,Per Case,"$4,314.00 ",OP,"1,531.28","4,314.00",,,,,,
BCBS HMO,CPT,31575,Diagnostic laryngoscopy,Surgical,Per Case,"$4,314.00 ",OP,168.23,"4,314.00",,,,,,
BCBS HMO,CPT,31576,Laryngoscopy with biopsy,Surgical,Per Case,"$4,314.00 ",OP,"1,531.28","4,314.00",,,,,,
BCBS HMO,CPT,31577,Largsc w/rmvl foreign bdy(s),Surgical,Per Case,"$4,314.00 ",OP,385.29,"4,314.00",,,,,,
BCBS HMO,CPT,31578,Largsc w/removal lesion,Surgical,Per Case,"$4,314.00 ",OP,"3,170.26","4,314.00",,,,,,
BCBS HMO,CPT,31579,Laryngoscopy telescopic,Surgical,Per Case,"$4,314.00 ",OP,385.29,"4,314.00",,,,,,
BCBS HMO,CPT,31580,Laryngoplasty laryngeal web,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,31582,Revision of larynx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31584,Laryngoplasty fx rdctj fixj,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,31585,REPAIR OF LARYNX FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31586,REPAIR OF LARYNX FRACTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31587,Laryngoplasty cricoid split,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,31588,Revision of larynx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31590,Reinnervate larynx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,31591,Laryngoplasty medialization,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,31592,Cricotracheal resection,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,31595,Larynx nerve surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31599,Larynx surgery procedure,Surgical,Per Case,"$4,314.00 ",OP,216.54,"4,314.00",,,,,,
BCBS HMO,CPT,31600,Incision of windpipe,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,31601,Incision of windpipe,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,31603,Incision of windpipe,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,31605,Incision of windpipe,Surgical,Per Case,"$4,314.00 ",OP,216.54,"4,314.00",,,,,,
BCBS HMO,CPT,31610,Incision of windpipe,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,31611,Surgery/speech prosthesis,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,31612,Puncture/clear windpipe,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,31613,Repair windpipe opening,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,31614,Repair windpipe opening,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,31615,Visualization of windpipe,Surgical,Per Case,"$4,314.00 ",OP,462.91,"4,314.00",,,,,,
BCBS HMO,CPT,31620,Endobronchial us add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31621,DIAGNOSTIC BRONCHOSCOPY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31622,Dx bronchoscope/wash,Surgical,Per Case,"$4,314.00 ",OP,"1,531.28","4,314.00",,,,,,
BCBS HMO,CPT,31623,Dx bronchoscope/brush,Surgical,Per Case,"$4,314.00 ",OP,"1,531.28","4,314.00",,,,,,
BCBS HMO,CPT,31624,Dx bronchoscope/lavage,Surgical,Per Case,"$4,314.00 ",OP,"1,531.28","4,314.00",,,,,,
BCBS HMO,CPT,31625,Bronchoscopy w/biopsy(s),Surgical,Per Case,"$4,314.00 ",OP,"1,531.28","4,314.00",,,,,,
BCBS HMO,CPT,31626,Bronchoscopy w/markers,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,958.54",,,,,,
BCBS HMO,CPT,31627,Navigational bronchoscopy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31628,Bronchoscopy/lung bx each,Surgical,Per Case,"$4,314.00 ",OP,"3,170.26","4,314.00",,,,,,
BCBS HMO,CPT,31629,Bronchoscopy/needle bx each,Surgical,Per Case,"$4,314.00 ",OP,"3,170.26","4,314.00",,,,,,
BCBS HMO,CPT,31630,Bronchoscopy dilate/fx repr,Surgical,Per Case,"$4,314.00 ",OP,"3,170.26","4,314.00",,,,,,
BCBS HMO,CPT,31631,Bronchoscopy dilate w/stent,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,958.54",,,,,,
BCBS HMO,CPT,31632,Bronchoscopy/lung bx addl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31633,Bronchoscopy/needle bx addl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31634,Bronch w/balloon occlusion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,958.54",,,,,,
BCBS HMO,CPT,31635,Bronchoscopy w/fb removal,Surgical,Per Case,"$4,314.00 ",OP,"1,531.28","4,314.00",,,,,,
BCBS HMO,CPT,31636,Bronchoscopy bronch stents,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,958.54",,,,,,
BCBS HMO,CPT,31637,Bronchoscopy stent add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31638,Bronchoscopy revise stent,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,958.54",,,,,,
BCBS HMO,CPT,31640,Bronchoscopy w/tumor excise,Surgical,Per Case,"$4,314.00 ",OP,"3,170.26","4,314.00",,,,,,
BCBS HMO,CPT,31641,Bronchoscopy treat blockage,Surgical,Per Case,"$4,314.00 ",OP,"3,170.26","4,314.00",,,,,,
BCBS HMO,CPT,31643,Diag bronchoscope/catheter,Surgical,Per Case,"$4,314.00 ",OP,"1,531.28","4,314.00",,,,,,
BCBS HMO,CPT,31645,Brnchsc w/ther aspir 1st,Surgical,Per Case,"$4,314.00 ",OP,"1,531.28","4,314.00",,,,,,
BCBS HMO,CPT,31646,Brnchsc w/ther aspir sbsq,Surgical,Per Case,"$4,314.00 ",OP,385.29,"4,314.00",,,,,,
BCBS HMO,CPT,31647,Bronchial valve init insert,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,958.54",,,,,,
BCBS HMO,CPT,31648,Bronchial valve remov init,Surgical,Per Case,"$4,314.00 ",OP,"3,170.26","4,314.00",,,,,,
BCBS HMO,CPT,31649,Bronchial valve remov addl,Surgical,Per Case,"$4,314.00 ",OP,"1,531.28","4,314.00",,,,,,
BCBS HMO,CPT,31651,Bronchial valve addl insert,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31652,Bronch ebus samplng 1/2 node,Surgical,Per Case,"$4,314.00 ",OP,"3,170.26","4,314.00",,,,,,
BCBS HMO,CPT,31653,Bronch ebus samplng 3/> node,Surgical,Per Case,"$4,314.00 ",OP,"3,170.26","4,314.00",,,,,,
BCBS HMO,CPT,31654,Bronch ebus ivntj perph les,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31656,Bronchoscopy inj for x-ray,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31659,BRONCHOSCOPIC PROCEDURES,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31660,Bronch thermoplsty 1 lobe,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,958.54",,,,,,
BCBS HMO,CPT,31661,Bronch thermoplsty 2/> lobes,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,958.54",,,,,,
BCBS HMO,CPT,31700,Insertion of airway catheter,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31708,Instill airway contrast dye,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31710,Insertion of airway catheter,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31715,Injection for bronchus x-ray,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31717,Bronchial brush biopsy,Surgical,Per Case,"$4,314.00 ",OP,385.29,"4,314.00",,,,,,
BCBS HMO,CPT,31719,INSERT WINDPIPE TUBE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31720,Clearance of airways,Surgical,Per Case,"$4,314.00 ",OP,192.26,"4,314.00",,,,,,
BCBS HMO,CPT,31725,Clearance of airways,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,31730,Intro windpipe wire/tube,Surgical,Per Case,"$4,314.00 ",OP,"1,531.28","4,314.00",,,,,,
BCBS HMO,CPT,31731,INSERT WINDPIPE CATH FOR O2,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,31750,Repair of windpipe,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,31755,Repair of windpipe,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,31760,Repair of windpipe,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,31766,Reconstruction of windpipe,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,31770,Repair/graft of bronchus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,31775,Reconstruct bronchus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,31780,Reconstruct windpipe,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,31781,Reconstruct windpipe,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,31785,Remove windpipe lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,31786,Remove windpipe lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,31800,Repair of windpipe injury,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,31805,Repair of windpipe injury,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,31820,Closure of windpipe lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,31825,Repair of windpipe defect,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,31830,Revise windpipe scar,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,31899,Airways surgical procedure,Surgical,Per Case,"$4,314.00 ",OP,168.23,"4,314.00",,,,,,
BCBS HMO,CPT,32000,Drainage of chest,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,32001,TOTAL LUNG LAVAGE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,32002,Treatment of collapsed lung,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,32005,Treat lung lining chemically,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,32019,Insert pleural catheter,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,32020,Insertion of chest tube,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,32035,Thoracostomy w/rib resection,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32036,Thoracostomy w/flap drainage,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32050,INSERTION PLUERAL SHUNT,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,32095,Biopsy through chest wall,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,32096,Open wedge/bx lung infiltr,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32097,Open wedge/bx lung nodule,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32098,Open biopsy of lung pleura,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32100,Exploration of chest,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32110,Explore/repair chest,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32120,Re-exploration of chest,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32124,Explore chest free adhesions,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32140,Removal of lung lesion(s),Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32141,Remove/treat lung lesions,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32150,Removal of lung lesion(s),Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32151,Remove lung foreign body,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32160,Open chest heart massage,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32200,Drain open lung lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32201,Drain percut lung lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,32215,Treat chest lining,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32220,Release of lung,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32225,Partial release of lung,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32310,Removal of chest lining,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32315,PARTIAL REMOVAL CHEST LINING,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,32320,Free/remove chest lining,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32400,Needle biopsy chest lining,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,32402,Open biopsy chest lining,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,32405,Percut bx lung/mediastinum,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,32408,Core ndl bx lng/med perq,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,32420,Puncture/clear lung,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,32421,Thoracentesis for aspiration,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,32422,Thoracentesis w/tube insert,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,32440,Remove lung pneumonectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32441,DONOR PNEUMONECTOMY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,32442,Sleeve pneumonectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32445,Removal of lung extrapleural,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32450,REMOVAL OF LUNG,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,32480,Partial removal of lung,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32482,Bilobectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32484,Segmentectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32485,PARTIAL REMOVAL OF LUNG,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,32486,Sleeve lobectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32488,Completion pneumonectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32490,PARTIAL REMOVAL OF LUNG,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,32491,Lung volume reduction,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32500,Partial removal of lung,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,32501,Repair bronchus add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32503,Resect apical lung tumor,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32504,Resect apical lung tum/chest,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32505,Wedge resect of lung initial,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32506,Wedge resect of lung add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32507,Wedge resect of lung diag,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32520,REMOVE LUNG & REVISE CHEST,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,32522,REMOVE LUNG & REVISE CHEST,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,32525,REMOVE LUNG & REVISE CHEST,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,32540,Removal of lung lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32545,REMOVAL OF LUNG LOBE/LESION,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,32550,Insert pleural cath,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","4,314.00",,,,,,
BCBS HMO,CPT,32551,Insertion of chest tube,Surgical,Per Case,"$4,314.00 ",OP,"1,438.93","4,314.00",,,,,,
BCBS HMO,CPT,32552,Remove lung catheter,Surgical,Per Case,"$4,314.00 ",OP,554.25,"4,314.00",,,,,,
BCBS HMO,CPT,32553,Ins mark thor for rt perq,Surgical,Per Case,"$4,314.00 ",OP,"1,291.62","4,314.00",,,,,,
BCBS HMO,CPT,32554,Aspirate pleura w/o imaging,Surgical,Per Case,"$4,314.00 ",OP,554.25,"4,314.00",,,,,,
BCBS HMO,CPT,32555,Aspirate pleura w/ imaging,Surgical,Per Case,"$4,314.00 ",OP,554.25,"4,314.00",,,,,,
BCBS HMO,CPT,32556,Insert cath pleura w/o image,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,32557,Insert cath pleura w/ image,Surgical,Per Case,"$4,314.00 ",OP,"1,438.93","4,314.00",,,,,,
BCBS HMO,CPT,32560,Treat pleurodesis w/agent,Surgical,Per Case,"$4,314.00 ",OP,554.25,"4,314.00",,,,,,
BCBS HMO,CPT,32561,Lyse chest fibrin init day,Surgical,Per Case,"$4,314.00 ",OP,554.25,"4,314.00",,,,,,
BCBS HMO,CPT,32562,Lyse chest fibrin subq day,Surgical,Per Case,"$4,314.00 ",OP,554.25,"4,314.00",,,,,,
BCBS HMO,CPT,32601,Thoracoscopy diagnostic,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,32602,Thoracoscopy diagnostic,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,32603,Thoracoscopy diagnostic,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,32604,Thoracoscopy wbx sac,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,32605,Thoracoscopy diagnostic,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,32606,Thoracoscopy w/bx med space,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,32607,Thoracoscopy w/bx infiltrate,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,32608,Thoracoscopy w/bx nodule,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,32609,Thoracoscopy w/bx pleura,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,32650,Thoracoscopy w/pleurodesis,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32651,Thoracoscopy remove cortex,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32652,Thoracoscopy rem totl cortex,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32653,Thoracoscopy remov fb/fibrin,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32654,Thoracoscopy contrl bleeding,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32655,Thoracoscopy resect bullae,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32656,Thoracoscopy w/pleurectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32657,Thoracoscopy surgical,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,32658,Thoracoscopy w/sac fb remove,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32659,Thoracoscopy w/sac drainage,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32660,Thoracoscopy surgical,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,32661,Thoracoscopy w/pericard exc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32662,Thoracoscopy w/mediast exc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32663,Thoracoscopy w/lobectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32664,Thoracoscopy w/ th nrv exc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32665,Thoracoscop w/esoph musc exc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32666,Thoracoscopy w/wedge resect,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32667,Thoracoscopy w/w resect addl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32668,Thoracoscopy w/w resect diag,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32669,Thoracoscopy remove segment,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32670,Thoracoscopy bilobectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32671,Thoracoscopy pneumonectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32672,Thoracoscopy for lvrs,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32673,Thoracoscopy w/thymus resect,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32674,Thoracoscopy lymph node exc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32700,VISUALIZE CHEST CAVITY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,32701,Thorax stereo rad targetw/tx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,32705,INSPECT/BIOPSY CHEST CAVITY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,32800,Repair lung hernia,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32810,Close chest after drainage,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32815,Close bronchial fistula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32820,Reconstruct injured chest,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32850,Donor pneumonectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32851,Lung transplant single,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32852,Lung transplant with bypass,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32853,Lung transplant double,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32854,Lung transplant with bypass,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32855,Prepare donor lung single,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32856,Prepare donor lung double,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32900,Removal of rib(s),Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32905,Revise & repair chest wall,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32906,Revise & repair chest wall,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32940,Revision of lung,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32960,Therapeutic pneumothorax,Surgical,Per Case,"$4,314.00 ",OP,554.25,"4,314.00",,,,,,
BCBS HMO,CPT,32994,Ablate pulm tumor perq crybl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,32997,Total lung lavage,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,32998,Ablate pulm tumor perq rf,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,32999,Chest surgery procedure,Surgical,Per Case,"$4,314.00 ",OP,554.25,"4,314.00",,,,,,
BCBS HMO,CPT,33010,Drainage of heart sac,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33011,Repeat drainage of heart sac,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33015,Incision of heart sac,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33016,Pericardiocentesis w/imaging,Surgical,Per Case,"$4,314.00 ",OP,"1,438.93","4,314.00",,,,,,
BCBS HMO,CPT,33017,Prcrd drg 6yr+ w/o cgen car,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33018,Prcrd drg 0-5yr or w/anomly,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33019,Perq prcrd drg insj cath ct,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33020,Incision of heart sac,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33025,Incision of heart sac,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33030,Partial removal of heart sac,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33031,Partial removal of heart sac,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33035,VENTRICULAR DECORT. W/BYPASS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33050,Resect heart sac lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33100,REMOVAL OF HEART SAC,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33120,Removal of heart lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33130,Removal of heart lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33140,Heart revascularize (tmr),Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33141,Heart tmr w/other procedure,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33200,Insertion of heart pacemaker,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33201,Insertion of heart pacemaker,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33202,Insert epicard eltrd open,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33203,Insert epicard eltrd endo,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33206,Insert heart pm atrial,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","10,642.67",,,,,,
BCBS HMO,CPT,33207,Insert heart pm ventricular,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","10,642.67",,,,,,
BCBS HMO,CPT,33208,Insrt heart pm atrial & vent,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","10,642.67",,,,,,
BCBS HMO,CPT,33210,Insert electrd/pm cath sngl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,342.69",,,,,,
BCBS HMO,CPT,33211,Insert card electrodes dual,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,342.69",,,,,,
BCBS HMO,CPT,33212,Insert pulse gen sngl lead,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,342.69",,,,,,
BCBS HMO,CPT,33213,Insert pulse gen dual leads,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","10,642.67",,,,,,
BCBS HMO,CPT,33214,Upgrade of pacemaker system,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","10,642.67",,,,,,
BCBS HMO,CPT,33215,Reposition pacing-defib lead,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,33216,Insert 1 electrode pm-defib,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,342.69",,,,,,
BCBS HMO,CPT,33217,Insert 2 electrode pm-defib,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,342.69",,,,,,
BCBS HMO,CPT,33218,Repair lead pace-defib one,Surgical,Per Case,"$4,314.00 ",OP,"3,520.60","4,314.00",,,,,,
BCBS HMO,CPT,33219,REPAIR OF PACEMAKER,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33220,Repair lead pace-defib dual,Surgical,Per Case,"$4,314.00 ",OP,"3,520.60","4,314.00",,,,,,
BCBS HMO,CPT,33221,Insert pulse gen mult leads,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","19,045.26",,,,,,
BCBS HMO,CPT,33222,Relocation pocket pacemaker,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,33223,Relocate pocket for defib,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,33224,Insert pacing lead & connect,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","10,642.67",,,,,,
BCBS HMO,CPT,33225,L ventric pacing lead add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33226,Reposition l ventric lead,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,33227,Remove&replace pm gen singl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,342.69",,,,,,
BCBS HMO,CPT,33228,Remv&replc pm gen dual lead,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","10,642.67",,,,,,
BCBS HMO,CPT,33229,Remv&replc pm gen mult leads,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","19,045.26",,,,,,
BCBS HMO,CPT,33230,Insrt pulse gen w/dual leads,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","23,577.44",,,,,,
BCBS HMO,CPT,33231,Insrt pulse gen w/mult leads,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","33,604.66",,,,,,
BCBS HMO,CPT,33232,REMOVAL OF PACEMAKER,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33233,Removal of pm generator,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,342.69",,,,,,
BCBS HMO,CPT,33234,Removal of pacemaker system,Surgical,Per Case,"$4,314.00 ",OP,"3,520.60","4,314.00",,,,,,
BCBS HMO,CPT,33235,Removal pacemaker electrode,Surgical,Per Case,"$4,314.00 ",OP,"3,520.60","4,314.00",,,,,,
BCBS HMO,CPT,33236,Remove electrode/thoracotomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33237,Remove electrode/thoracotomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33238,Remove electrode/thoracotomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33240,Insrt pulse gen w/singl lead,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","23,577.44",,,,,,
BCBS HMO,CPT,33241,Remove pulse generator,Surgical,Per Case,"$4,314.00 ",OP,"3,520.60","4,314.00",,,,,,
BCBS HMO,CPT,33242,REPAIR PULSE GENERATOR/LEADS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33243,Remove eltrd/thoracotomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33244,Remove elctrd transvenously,Surgical,Per Case,"$4,314.00 ",OP,"3,520.60","4,314.00",,,,,,
BCBS HMO,CPT,33245,Insert epic eltrd pace-defib,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33246,Insert epic eltrd/generator,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33247,INSERT/REPLACE LEADS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33248,REVISE/REMOVE DEFIBRILLATOR,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33249,Insj/rplcmt defib w/lead(s),Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","33,604.66",,,,,,
BCBS HMO,CPT,33250,Ablate heart dysrhythm focus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33251,Ablate heart dysrhythm focus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33253,Reconstruct atria,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33254,Ablate atria lmtd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33255,Ablate atria w/o bypass ext,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33256,Ablate atria w/bypass exten,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33257,Ablate atria lmtd add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33258,Ablate atria x10sv add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33259,Ablate atria w/bypass add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33260,ABLATE HEART DYSRHYTHM FOCUS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33261,Ablate heart dysrhythm focus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33262,Rmvl& replc pulse gen 1 lead,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","23,577.44",,,,,,
BCBS HMO,CPT,33263,Rmvl & rplcmt dfb gen 2 lead,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","23,577.44",,,,,,
BCBS HMO,CPT,33264,Rmvl & rplcmt dfb gen mlt ld,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","33,604.66",,,,,,
BCBS HMO,CPT,33265,Ablate atria lmtd endo,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33266,Ablate atria x10sv endo,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33270,Ins/rep subq defibrillator,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","33,604.66",,,,,,
BCBS HMO,CPT,33271,Insj subq impltbl dfb elctrd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,342.69",,,,,,
BCBS HMO,CPT,33272,Rmvl of subq defibrillator,Surgical,Per Case,"$4,314.00 ",OP,"3,520.60","4,314.00",,,,,,
BCBS HMO,CPT,33273,Repos prev impltbl subq dfb,Surgical,Per Case,"$4,314.00 ",OP,"3,520.60","4,314.00",,,,,,
BCBS HMO,CPT,33274,Tcat insj/rpl perm ldls pm,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,438.60",,,,,,
BCBS HMO,CPT,33275,Tcat rmvl perm ldls pm w/img,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,33282,Implant pat-active ht record,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33284,Remove pat-active ht record,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33285,Insj subq car rhythm mntr,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,342.69",,,,,,
BCBS HMO,CPT,33286,Rmvl subq car rhythm mntr,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,33289,Tcat impl wrls p-art prs snr,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","29,487.35",,,,,,
BCBS HMO,CPT,33300,Repair of heart wound,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33305,Repair of heart wound,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33310,Exploratory heart surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33315,Exploratory heart surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33320,Repair major blood vessel(s),Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33321,Repair major vessel,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33322,Repair major blood vessel(s),Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33330,Insert major vessel graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33332,Insert major vessel graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33335,Insert major vessel graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33340,Perq clsr tcat l atr apndge,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33350,REPAIR MAJOR BLOOD VESSEL(S),Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33361,Replace aortic valve perq,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33362,Replace aortic valve open,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33363,Replace aortic valve open,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33364,Replace aortic valve open,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33365,Replace aortic valve open,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33366,Trcath replace aortic valve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33367,Replace aortic valve w/byp,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33368,Replace aortic valve w/byp,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33369,Replace aortic valve w/byp,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33390,Valvuloplasty aortic valve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33391,Valvuloplasty aortic valve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33400,Repair of aortic valve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33401,Valvuloplasty open,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33403,Valvuloplasty w/cp bypass,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33404,Prepare heart-aorta conduit,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33405,Replacement aortic valve opn,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33406,Replacement aortic valve opn,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33407,REVISION OF AORTIC VALVE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33408,REVISION OF AORTIC VALVE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33410,Replacement aortic valve opn,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33411,Replacement of aortic valve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33412,Replacement of aortic valve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33413,Replacement of aortic valve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33414,Repair of aortic valve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33415,Revision subvalvular tissue,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33416,Revise ventricle muscle,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33417,Repair of aortic valve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33418,Repair tcat mitral valve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33419,Repair tcat mitral valve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33420,Revision of mitral valve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33422,Revision of mitral valve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33425,Repair of mitral valve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33426,Repair of mitral valve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33427,Repair of mitral valve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33430,Replacement of mitral valve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33440,Rplcmt a-valve tlcj autol pv,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33450,COMMISSUROTOMY-CLOSED,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33452,REVISION OF TRICUSPID VALVE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33460,Revision of tricuspid valve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33463,Valvuloplasty tricuspid,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33464,Valvuloplasty tricuspid,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33465,Replace tricuspid valve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33468,Revision of tricuspid valve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33470,Revision of pulmonary valve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33471,Valvotomy pulmonary valve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33472,Revision of pulmonary valve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33474,Revision of pulmonary valve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33475,Replacement pulmonary valve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33476,Revision of heart chamber,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33477,Implant tcat pulm vlv perq,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33478,Revision of heart chamber,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33480,REVISION OF HEART VALVES,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33481,REVISION OF HEART VALVES,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33482,REVISION OF HEART VALVES,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33483,replace HEART VALVES,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33485,replace HEART VALVES,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33490,REVISION OF HEART VALVES,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33492,replace HEART VALVES,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33496,Repair prosth valve clot,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33500,Repair heart vessel fistula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33501,Repair heart vessel fistula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33502,Coronary artery correction,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33503,Coronary artery graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33504,Coronary artery graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33505,Repair artery w/tunnel,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33506,Repair artery translocation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33507,Repair art intramural,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33508,Endoscopic vein harvest,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33510,Cabg vein single,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33511,Cabg vein two,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33512,Cabg vein three,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33513,Cabg vein four,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33514,Cabg vein five,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33516,Cabg vein six or more,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33517,Cabg artery-vein single,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33518,Cabg artery-vein two,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33519,Cabg artery-vein three,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33520,CORONARY ARTERY-BYPASS/GRAFT,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33521,Cabg artery-vein four,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33522,Cabg artery-vein five,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33523,Cabg art-vein six or more,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33525,CORONARY ARTERY-BYPASS/GRAFT,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33528,CORONARY ARTERY-BYPASS/GRAFT,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33530,Coronary artery bypass/reop,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33533,Cabg arterial single,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33534,Cabg arterial two,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33535,Cabg arterial three,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33536,Cabg arterial four or more,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33542,Removal of heart lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33545,Repair of heart damage,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33548,Restore/remodel ventricle,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33570,REVISE CORONARY CIRCULATION,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33572,Open coronary endarterectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33575,REVISE CORONARY CIRCULATION,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33600,Closure of valve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33602,Closure of valve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33606,Anastomosis/artery-aorta,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33608,Repair anomaly w/conduit,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33610,Repair by enlargement,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33611,Repair double ventricle,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33612,Repair double ventricle,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33615,Repair modified fontan,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33617,Repair single ventricle,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33619,Repair single ventricle,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33620,Apply r&l pulm art bands,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33621,Transthor cath for stent,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33622,Redo compl cardiac anomaly,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33640,ATRIAL REPAIR WO/BYPASS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33641,Repair heart septum defect,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33643,ATRIAL REPAIR PATCH CLOSURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33645,Revision of heart veins,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33647,Repair heart septum defects,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33649,REPAIR TRICUSPID DEFECT,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33660,Repair of heart defects,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33665,Repair of heart defects,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33670,Repair of heart chambers,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33675,Close mult vsd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33676,Close mult vsd w/resection,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33677,Cl mult vsd w/rem pul band,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33681,Repair heart septum defect,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33682,VENTRICULR REP. PATCH CLOSE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33684,Repair heart septum defect,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33688,Repair heart septum defect,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33690,Reinforce pulmonary artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33692,Repair of heart defects,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33694,Repair of heart defects,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33696,REPAIR OF HEART DEFECTS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33697,Repair of heart defects,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33698,REPAIR OF HEART DEFECTS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33702,Repair of heart defects,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33710,Repair of heart defects,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33720,Repair of heart defect,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33722,Repair of heart defect,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33724,Repair venous anomaly,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33726,Repair pul venous stenosis,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33730,Repair heart-vein defect(s),Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33732,Repair heart-vein defect,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33735,Revision of heart chamber,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33736,Revision of heart chamber,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33737,Revision of heart chamber,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33738,REVISION OF HEART CHAMBER,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33739,REVISION OF HEART CHAMBER,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33741,Tas congenital car anomal,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33745,Tis cgen car anomal 1st shnt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33746,Tis cgen car anomal ea addl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33750,Major vessel shunt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33755,Major vessel shunt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33762,Major vessel shunt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33764,Major vessel shunt & graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33766,Major vessel shunt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33767,Major vessel shunt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33768,Cavopulmonary shunting,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33770,Repair great vessels defect,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33771,Repair great vessels defect,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33774,Repair great vessels defect,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33775,Repair great vessels defect,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33776,Repair great vessels defect,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33777,Repair great vessels defect,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33778,Repair great vessels defect,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33779,Repair great vessels defect,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33780,Repair great vessels defect,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33781,Repair great vessels defect,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33782,Nikaidoh proc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33783,Nikaidoh proc w/ostia implt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33786,Repair arterial trunk,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33788,Revision of pulmonary artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33800,Aortic suspension,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33802,Repair vessel defect,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33803,Repair vessel defect,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33810,AORTOPULMONARY WINDOW W/O BY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33812,AORTOPULMONARY WINDOW W BY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33813,Repair septal defect,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33814,Repair septal defect,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33820,Revise major vessel,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33822,Revise major vessel,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33824,Revise major vessel,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33826,DUCTUS 18+ w/BYPASS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33830,REVISE MAJOR VESSEL,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33840,Remove aorta constriction,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33845,Remove aorta constriction,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33851,Remove aorta constriction,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33852,Repair septal defect,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33853,Repair septal defect,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33855,REPAIR SEPTAL DEFECT,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33858,As-aort grf f/aortic dsj,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33859,As-aort grf f/ds oth/thn dsj,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33860,Ascending aortic graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33861,Ascending aortic graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33863,Ascending aortic graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33864,Ascending aortic graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33865,ASCENDING AORTA GRAFT,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33866,Aortic hemiarch graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33870,Transverse aortic arch graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33871,Transvrs a-arch grf hypthrm,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33875,Thoracic aortic graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33877,Thoracoabdominal graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33880,Endovasc taa repr incl subcl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33881,Endovasc taa repr w/o subcl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33883,Insert endovasc prosth taa,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33884,Endovasc prosth taa add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33886,Endovasc prosth delayed,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33889,Artery transpose/endovas taa,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33891,Car-car bp grft/endovas taa,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33910,Remove lung artery emboli,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33915,Remove lung artery emboli,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33916,Surgery of great vessel,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33917,Repair pulmonary artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33918,REPAIR PULMONARY ATRESIA,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33919,REPAIR PULMONARY ATRESIA,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33920,Repair pulmonary atresia,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33922,Transect pulmonary artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33924,Remove pulmonary shunt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33925,Rpr pul art unifocal w/o cpb,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33926,Repr pul art unifocal w/cpb,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33927,Impltj tot rplcmt hrt sys,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33928,Rmvl & rplcmt tot hrt sys,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33929,Rmvl rplcmt hrt sys f/trnspl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33930,Removal of donor heart/lung,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33933,Prepare donor heart/lung,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33935,Transplantation heart/lung,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33940,Removal of donor heart,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33944,Prepare donor heart,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33945,Transplantation of heart,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33946,Ecmo/ecls initiation venous,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33947,Ecmo/ecls initiation artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33948,Ecmo/ecls daily mgmt-venous,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33949,Ecmo/ecls daily mgmt artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33951,Ecmo/ecls insj prph cannula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33952,Ecmo/ecls insj prph cannula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33953,Ecmo/ecls insj prph cannula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33954,Ecmo/ecls insj prph cannula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33955,Ecmo/ecls insj ctr cannula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33956,Ecmo/ecls insj ctr cannula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33957,Ecmo/ecls repos perph cnula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33958,Ecmo/ecls repos perph cnula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33959,Ecmo/ecls repos perph cnula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33960,External circulation assist,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33961,External circulation assist,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33962,Ecmo/ecls repos perph cnula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33963,Ecmo/ecls repos perph cnula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33964,Ecmo/ecls repos perph cnula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33965,Ecmo/ecls rmvl perph cannula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33966,Ecmo/ecls rmvl prph cannula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33967,Insert i-aort percut device,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33968,Remove aortic assist device,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33969,Ecmo/ecls rmvl perph cannula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33970,Aortic circulation assist,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33971,Aortic circulation assist,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33972,AORTIC CIRCULATION ASSIST,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,33973,Insert balloon device,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33974,Remove intra-aortic balloon,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33975,Implant ventricular device,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33976,Implant ventricular device,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33977,Remove ventricular device,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33978,Remove ventricular device,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33979,Insert intracorporeal device,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33980,Remove intracorporeal device,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33981,Replace vad pump ext,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33982,Replace vad intra w/o bp,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33983,Replace vad intra w/bp,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33984,Ecmo/ecls rmvl prph cannula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33985,Ecmo/ecls rmvl ctr cannula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33986,Ecmo/ecls rmvl ctr cannula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33987,Artery expos/graft artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33988,Insertion of left heart vent,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33989,Removal of left heart vent,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33990,Insj perq vad l hrt arterial,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33991,Insj perq vad l hrt artl&ven,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33992,Rmvl perq left heart vad,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33993,Reposg perq r/l hrt vad,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33995,Insj perq vad r hrt venous,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33997,Rmvl perq right heart vad,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,33999,Cardiac surgery procedure,Surgical,Per Case,"$4,314.00 ",OP,554.25,"4,314.00",,,,,,
BCBS HMO,CPT,34001,Removal of artery clot,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,34051,Removal of artery clot,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,34101,Removal of artery clot,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,34111,Removal of arm artery clot,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,34151,Removal of artery clot,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,34201,Removal of artery clot,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,34203,Removal of leg artery clot,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,34401,Removal of vein clot,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,34421,Removal of vein clot,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,34451,Removal of vein clot,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,34471,Removal of vein clot,Surgical,Per Case,"$4,314.00 ",OP,554.25,"4,314.00",,,,,,
BCBS HMO,CPT,34490,Removal of vein clot,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,34501,Repair valve femoral vein,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,34502,Reconstruct vena cava,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,34510,Transposition of vein valve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,34520,Cross-over vein graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,34530,Leg vein fusion,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,34701,Evasc rpr a-ao ndgft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,34702,Evasc rpr a-ao ndgft rpt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,34703,Evasc rpr a-unilac ndgft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,34704,Evasc rpr a-unilac ndgft rpt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,34705,Evac rpr a-biiliac ndgft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,34706,Evasc rpr a-biiliac rpt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,34707,Evasc rpr ilio-iliac ndgft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,34708,Evasc rpr ilio-iliac rpt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,34709,Plmt xtn prosth evasc rpr,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,34710,Dlyd plmt xtn prosth 1st vsl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,34711,Dlyd plmt xtn prosth ea addl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,34712,Tcat dlvr enhncd fixj dev,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,34713,Perq access & clsr fem art,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,34714,Opn fem art expos cndt crtj,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,34715,Opn ax/subcla art expos,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,34716,Opn ax/subcla art expos cndt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,34717,Evasc rpr a-iliac ndgft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,34718,Evasc rpr n/a a-iliac ndgft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,34800,Endovas aaa repr w/sm tube,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,34802,Endovas aaa repr w/2-p part,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,34803,Endovas aaa repr w/3-p part,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,34804,Endovas aaa repr w/1-p part,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,34805,Endovas aaa repr w/long tube,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,34806,Aneurysm press sensor add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,34808,Endovas iliac a device addon,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,34812,Opn fem art expos,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,34813,Femoral endovas graft add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,34820,Opn iliac art expos,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,34825,Endovasc extend prosth init,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,34826,Endovasc exten prosth addl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,34830,Open aortic tube prosth repr,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,34831,Open aortoiliac prosth repr,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,34832,Open aortofemor prosth repr,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,34833,Opn ilac art expos cndt crtj,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,34834,Opn brach art expos,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,34839,Plnning pt spec fenest graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,34841,Endovasc visc aorta 1 graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,34842,Endovasc visc aorta 2 graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,34843,Endovasc visc aorta 3 graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,34844,Endovasc visc aorta 4 graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,34845,Visc & infraren abd 1 prosth,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,34846,Visc & infraren abd 2 prosth,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,34847,Visc & infraren abd 3 prosth,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,34848,Visc & infraren abd 4+ prost,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,34900,Endovasc iliac repr w/graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35001,Repair defect of artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35002,Repair artery rupture neck,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35005,Repair defect of artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35011,Repair defect of artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,35013,Repair artery rupture arm,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35021,Repair defect of artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35022,Repair artery rupture chest,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35045,Repair defect of arm artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,35081,Repair defect of artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35082,Repair artery rupture aorta,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35091,Repair defect of artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35092,Repair artery rupture aorta,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35102,Repair defect of artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35103,Repair artery rupture aorta,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35111,Repair defect of artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35112,Repair artery rupture spleen,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35121,Repair defect of artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35122,Repair artery rupture belly,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35131,Repair defect of artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35132,Repair artery rupture groin,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35141,Repair defect of artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35142,Repair artery rupture thigh,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35151,Repair defect of artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35152,Repair ruptd popliteal art,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35161,REPAIR DEFECT OF ARTERY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35162,REPAIR ARTERY RUPTURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35180,Repair blood vessel lesion,Surgical,Per Case,"$4,314.00 ",OP,"1,438.93","4,314.00",,,,,,
BCBS HMO,CPT,35182,Repair blood vessel lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35184,Repair blood vessel lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,35188,Repair blood vessel lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,35189,Repair blood vessel lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35190,Repair blood vessel lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,35201,Repair blood vessel lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,35206,Repair blood vessel lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,35207,Repair blood vessel lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,35211,Repair blood vessel lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35216,Repair blood vessel lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35221,Repair blood vessel lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35226,Repair blood vessel lesion,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,35231,Repair blood vessel lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,35236,Repair blood vessel lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,35241,Repair blood vessel lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35246,Repair blood vessel lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35251,Repair blood vessel lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35256,Repair blood vessel lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,35261,Repair blood vessel lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,35266,Repair blood vessel lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,35271,Repair blood vessel lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35275,Misc. blood vessel repair procedure,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35276,Repair blood vessel lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35281,Repair blood vessel lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35286,Repair blood vessel lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,35301,Rechanneling of artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35302,Rechanneling of artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35303,Rechanneling of artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35304,Rechanneling of artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35305,Rechanneling of artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35306,Rechanneling of artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35311,Rechanneling of artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35321,Rechanneling of artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,35331,Rechanneling of artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35341,Rechanneling of artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35351,Rechanneling of artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35355,Rechanneling of artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35361,Rechanneling of artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35363,Rechanneling of artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35371,Rechanneling of artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35372,Rechanneling of artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,35375,SUPERFICIAL FEMORAL THROM.,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35381,Rechanneling of artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35390,Reoperation carotid add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35400,Angioscopy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35450,Repair arterial blockage,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35452,Repair arterial blockage,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35454,Repair arterial blockage,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35456,Repair arterial blockage,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35458,Repair arterial blockage,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35459,Repair arterial blockage,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35460,Repair venous blockage,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35470,Repair arterial blockage,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35471,Repair arterial blockage,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35472,Repair arterial blockage,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35473,Repair arterial blockage,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35474,Repair arterial blockage,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35475,Repair arterial blockage,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35476,Repair venous blockage,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35480,Atherectomy - open,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35481,Atherectomy - open,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35482,Atherectomy - open,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35483,Atherectomy - open,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35484,Atherectomy - open,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35485,Atherectomy - open,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35490,Atherectomy - percutaneous,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35491,Atherectomy - percutaneous,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35492,Atherectomy - percutaneous,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35493,Atherectomy - percutaneous,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35494,Atherectomy - percutaneous,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35495,Atherectomy - percutaneous,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35500,Harvest vein for bypass,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35501,Art byp grft ipsilat carotid,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35506,Art byp grft subclav-carotid,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35507,Artery bypass graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35508,Art byp grft carotid-vertbrl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35509,Art byp grft contral carotid,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35510,Art byp grft carotid-brchial,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35511,Art byp grft subclav-subclav,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35512,Art byp grft subclav-brchial,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35515,Art byp grft subclav-vertbrl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35516,Art byp grft subclav-axilary,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35518,Art byp grft axillary-axilry,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35521,Art byp grft axill-femoral,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35522,Art byp grft axill-brachial,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35523,Art byp grft brchl-ulnr-rdl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35525,Art byp grft brachial-brchl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35526,Art byp grft aor/carot/innom,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35531,Art byp grft aorcel/aormesen,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35533,Art byp grft axill/fem/fem,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35535,Art byp grft hepatorenal,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35536,Art byp grft splenorenal,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35537,Art byp grft aortoiliac,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35538,Art byp grft aortobi-iliac,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35539,Art byp grft aortofemoral,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35540,Art byp grft aortbifemoral,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35541,Artery bypass graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35546,Artery bypass graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35548,Artery bypass graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35549,Artery bypass graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35551,Artery bypass graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35556,Art byp grft fem-popliteal,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35558,Art byp grft fem-femoral,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35560,Art byp grft aortorenal,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35563,Art byp grft ilioiliac,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35565,Art byp grft iliofemoral,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35566,Art byp fem-ant-post tib/prl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35570,Art byp tibial-tib/peroneal,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35571,Art byp pop-tibl-prl-other,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35572,Harvest femoropopliteal vein,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35582,VEIN BYPASS GRAFT,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35583,Vein byp grft fem-popliteal,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35585,Vein byp fem-tibial peroneal,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35587,Vein byp pop-tibl peroneal,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35600,Harvest art for cabg add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35601,Art byp common ipsi carotid,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35606,Art byp carotid-subclavian,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35612,Art byp subclav-subclavian,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35616,Art byp subclav-axillary,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35621,Art byp axillary-femoral,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35623,Art byp axillary-pop-tibial,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35626,Art byp aorsubcl/carot/innom,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35631,Art byp aor-celiac-msn-renal,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35632,Art byp ilio-celiac,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35633,Art byp ilio-mesenteric,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35634,Art byp iliorenal,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35636,Art byp spenorenal,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35637,Art byp aortoiliac,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35638,Art byp aortobi-iliac,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35641,Artery bypass graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35642,Art byp carotid-vertebral,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35645,Art byp subclav-vertebrl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35646,Art byp aortobifemoral,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35647,Art byp aortofemoral,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35650,Art byp axillary-axillary,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35651,Artery bypass graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35654,Art byp axill-fem-femoral,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35656,Art byp femoral-popliteal,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35661,Art byp femoral-femoral,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35663,Art byp ilioiliac,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35665,Art byp iliofemoral,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35666,Art byp fem-ant-post tib/prl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35671,Art byp pop-tibl-prl-other,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35681,Composite byp grft pros&vein,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35682,Composite byp grft 2 veins,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35683,Composite byp grft 3/> segmt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35685,Bypass graft patency/patch,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35686,Bypass graft/av fist patency,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35691,Art trnsposj vertbrl carotid,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35693,Art trnsposj subclavian,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35694,Art trnsposj subclav carotid,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35695,Art trnsposj carotid subclav,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35697,Reimplant artery each,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35700,Reoperation bypass graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35701,Expl n/flwd surg neck art,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35702,Expl n/flwd surg uxtr art,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35703,Expl n/flwd surg lxtr art,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35721,Exploration femoral artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35741,Exploration popliteal artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35761,Exploration of artery/vein,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35800,Explore neck vessels,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,35820,Explore chest vessels,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35840,Explore abdominal vessels,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35860,Explore limb vessels,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,35870,Repair vessel graft defect,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35875,Removal of clot in graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,35876,Removal of clot in graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,35879,Revise graft w/vein,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,35881,Revise graft w/vein,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,35883,Revise graft w/nonauto graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,35884,Revise graft w/vein,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,35900,REMOVE VESSEL GRAFT,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35901,Excision graft neck,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35902,INFECTED GRAFT EXTREMITY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,35903,Excision graft extremity,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,35905,Excision graft thorax,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35907,Excision graft abdomen,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,35910,REVISE CIRCULATION,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36000,Place needle in vein,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36002,Pseudoaneurysm injection trt,Surgical,Per Case,"$4,314.00 ",OP,554.25,"4,314.00",,,,,,
BCBS HMO,CPT,36005,Injection ext venography,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36010,Place catheter in vein,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36011,Place catheter in vein,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36012,Place catheter in vein,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36013,Place catheter in artery,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,36014,Place catheter in artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36015,Place catheter in artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36100,Establish access to artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36120,Establish access to artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36140,Intro ndl icath upr/lxtr art,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36145,Artery to vein shunt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36147,Access av dial grft for eval,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36148,Access av dial grft for proc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36160,Establish access to aorta,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36200,Place catheter in aorta,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36215,Place catheter in artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36216,Place catheter in artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36217,Place catheter in artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36218,Place catheter in artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36221,Place cath thoracic aorta,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,36222,Place cath carotid/inom art,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,36223,Place cath carotid/inom art,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,36224,Place cath carotd art,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,36225,Place cath subclavian art,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,36226,Place cath vertebral art,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,36227,Place cath xtrnl carotid,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36228,Place cath intracranial art,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36230,PLACE CATHETER IN ARTERY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36245,Ins cath abd/l-ext art 1st,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36246,Ins cath abd/l-ext art 2nd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36247,Ins cath abd/l-ext art 3rd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36248,Ins cath abd/l-ext art addl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36251,Ins cath ren art 1st unilat,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,36252,Ins cath ren art 1st bilat,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,36253,Ins cath ren art 2nd+ unilat,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,36254,Ins cath ren art 2nd+ bilat,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,36260,Insertion of infusion pump,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,36261,Revision of infusion pump,Surgical,Per Case,"$4,314.00 ",OP,"3,520.60","4,314.00",,,,,,
BCBS HMO,CPT,36262,Removal of infusion pump,Surgical,Per Case,"$4,314.00 ",OP,"3,520.60","4,314.00",,,,,,
BCBS HMO,CPT,36299,Vessel injection procedure,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36400,Bl draw < 3 yrs fem/jugular,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36405,Bl draw <3 yrs scalp vein,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36406,Bl draw <3 yrs other vein,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36410,Non-routine bl draw 3/> yrs,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36415,Routine venipuncture,Surgical,Per Case,"$4,314.00 ",OP,3,"4,314.00",,,,,,
BCBS HMO,CPT,36416,Capillary blood draw,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36417,PHLEBOTOMY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36420,Vein access cutdown < 1 yr,Surgical,Per Case,"$4,314.00 ",OP,114.56,"4,314.00",,,,,,
BCBS HMO,CPT,36425,Vein access cutdown > 1 yr,Surgical,Per Case,"$4,314.00 ",OP,276.53,"4,314.00",,,,,,
BCBS HMO,CPT,36430,Blood transfusion service,Surgical,Per Case,"$4,314.00 ",OP,406.32,"4,314.00",,,,,,
BCBS HMO,CPT,36440,Bl push transfuse 2 yr/<,Surgical,Per Case,"$4,314.00 ",OP,406.32,"4,314.00",,,,,,
BCBS HMO,CPT,36450,Bl exchange/transfuse nb,Surgical,Per Case,"$4,314.00 ",OP,406.32,"4,314.00",,,,,,
BCBS HMO,CPT,36455,Bl exchange/transfuse non-nb,Surgical,Per Case,"$4,314.00 ",OP,406.32,"4,314.00",,,,,,
BCBS HMO,CPT,36456,Prtl exchange transfuse nb,Surgical,Per Case,"$4,314.00 ",OP,406.32,"4,314.00",,,,,,
BCBS HMO,CPT,36460,Transfusion service fetal,Surgical,Per Case,"$4,314.00 ",OP,406.32,"4,314.00",,,,,,
BCBS HMO,CPT,36465,Njx noncmpnd sclrsnt 1 vein,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,36466,Njx noncmpnd sclrsnt mlt vn,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,36468,Njx sclrsnt spider veins,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,36469,Injection(s) spider veins,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36470,Njx sclrsnt 1 incmptnt vein,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,36471,Njx sclrsnt mlt incmptnt vn,Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,36473,Endovenous mchnchem 1st vein,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,36474,Endovenous mchnchem add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36475,Endovenous rf 1st vein,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,36476,Endovenous rf vein add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36478,Endovenous laser 1st vein,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,36479,Endovenous laser vein addon,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36481,Insertion of catheter vein,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36482,Endoven ther chem adhes 1st,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,36483,Endoven ther chem adhes sbsq,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36488,INSERTION OF CATHETER-VEIN,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36489,INSERTION OF CATHETER-VEIN,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36490,INSERTION OF CATHETER-VEIN,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36491,INSERTION OF CATHETER-VEIN,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36493,REPOSITIONING OF CVC,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36495,IMPLANT INFUSION PUMP,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36496,REVISE INFUSION PUMP,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36497,REMOVE INFUSION PUMP,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36500,Insertion of catheter vein,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36510,Insertion of catheter vein,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36511,Apheresis wbc,Surgical,Per Case,"$4,314.00 ",OP,"1,394.95","4,314.00",,,,,,
BCBS HMO,CPT,36512,Apheresis rbc,Surgical,Per Case,"$4,314.00 ",OP,"1,394.95","4,314.00",,,,,,
BCBS HMO,CPT,36513,Apheresis platelets,Surgical,Per Case,"$4,314.00 ",OP,406.32,"4,314.00",,,,,,
BCBS HMO,CPT,36514,Apheresis plasma,Surgical,Per Case,"$4,314.00 ",OP,"1,394.95","4,314.00",,,,,,
BCBS HMO,CPT,36515,Apheresis adsorp/reinfuse,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36516,Apheresis immunoads slctv,Surgical,Per Case,"$4,314.00 ",OP,"4,131.87","4,314.00",,,,,,
BCBS HMO,CPT,36520,PLASMA AND/OR CELL EXCHANGE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36521,APHERESIS W/ ADSORP/REINFUSE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36522,Photopheresis,Surgical,Per Case,"$4,314.00 ",OP,"4,131.87","4,314.00",,,,,,
BCBS HMO,CPT,36530,INSERTION OF INFUSION PUMP,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36531,REVISION OF INFUSION PUMP,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36532,REMOVAL OF INFUSION PUMP,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36533,INSERTION OF ACCESS PORT,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36534,REVISION OF ACCESS PORT,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36535,REMOVAL OF ACCESS PORT,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36536,REMOVE CVA DEVICE OBSTRUCT,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36537,REMOVE CVA LUMEN OBSTRUCT,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36540,Collect blood venous device,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36550,Declot vascular device,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36555,Insert non-tunnel cv cath,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,36556,Insert non-tunnel cv cath,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,36557,Insert tunneled cv cath,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,36558,Insert tunneled cv cath,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,36560,Insert tunneled cv cath,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,36561,Insert tunneled cv cath,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,36563,Insert tunneled cv cath,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,36565,Insert tunneled cv cath,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,36566,Insert tunneled cv cath,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,36568,Insj picc <5 yr w/o imaging,Surgical,Per Case,"$4,314.00 ",OP,"1,438.93","4,314.00",,,,,,
BCBS HMO,CPT,36569,Insj picc 5 yr+ w/o imaging,Surgical,Per Case,"$4,314.00 ",OP,"1,438.93","4,314.00",,,,,,
BCBS HMO,CPT,36570,Insert picvad cath,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,36571,Insert picvad cath,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,36572,Insj picc rs&i <5 yr,Surgical,Per Case,"$4,314.00 ",OP,554.25,"4,314.00",,,,,,
BCBS HMO,CPT,36573,Insj picc rs&i 5 yr+,Surgical,Per Case,"$4,314.00 ",OP,"1,438.93","4,314.00",,,,,,
BCBS HMO,CPT,36575,Repair tunneled cv cath,Surgical,Per Case,"$4,314.00 ",OP,554.25,"4,314.00",,,,,,
BCBS HMO,CPT,36576,Repair tunneled cv cath,Surgical,Per Case,"$4,314.00 ",OP,"1,438.93","4,314.00",,,,,,
BCBS HMO,CPT,36578,Replace tunneled cv cath,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,36580,Replace cvad cath,Surgical,Per Case,"$4,314.00 ",OP,"1,438.93","4,314.00",,,,,,
BCBS HMO,CPT,36581,Replace tunneled cv cath,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,36582,Replace tunneled cv cath,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,36583,Replace tunneled cv cath,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,36584,Compl rplcmt picc rs&i,Surgical,Per Case,"$4,314.00 ",OP,"1,438.93","4,314.00",,,,,,
BCBS HMO,CPT,36585,Replace picvad cath,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,36589,Removal tunneled cv cath,Surgical,Per Case,"$4,314.00 ",OP,554.25,"4,314.00",,,,,,
BCBS HMO,CPT,36590,Removal tunneled cv cath,Surgical,Per Case,"$4,314.00 ",OP,"1,438.93","4,314.00",,,,,,
BCBS HMO,CPT,36591,Draw blood off venous device,Surgical,Per Case,"$4,314.00 ",OP,114.56,"4,314.00",,,,,,
BCBS HMO,CPT,36592,Collect blood from picc,Surgical,Per Case,"$4,314.00 ",OP,114.56,"4,314.00",,,,,,
BCBS HMO,CPT,36593,Declot vascular device,Surgical,Per Case,"$4,314.00 ",OP,318,"4,314.00",,,,,,
BCBS HMO,CPT,36595,Mech remov tunneled cv cath,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,36596,Mech remov tunneled cv cath,Surgical,Per Case,"$4,314.00 ",OP,"1,438.93","4,314.00",,,,,,
BCBS HMO,CPT,36597,Reposition venous catheter,Surgical,Per Case,"$4,314.00 ",OP,"1,438.93","4,314.00",,,,,,
BCBS HMO,CPT,36598,Inj w/fluor eval cv device,Surgical,Per Case,"$4,314.00 ",OP,208.24,"4,314.00",,,,,,
BCBS HMO,CPT,36600,Withdrawal of arterial blood,Surgical,Per Case,"$4,314.00 ",OP,114.56,"4,314.00",,,,,,
BCBS HMO,CPT,36620,Insertion catheter artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36625,Insertion catheter artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36640,Insertion catheter artery,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,36660,Insertion catheter artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,36680,Insert needle bone cavity,Surgical,Per Case,"$4,314.00 ",OP,276.53,"4,314.00",,,,,,
BCBS HMO,CPT,36800,Insertion of cannula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,36810,Insertion of cannula,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,36815,Insertion of cannula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,36818,Av fuse uppr arm cephalic,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,36819,Av fuse uppr arm basilic,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,36820,Av fusion/forearm vein,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,36821,Av fusion direct any site,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","9,201.00",,,,,,
BCBS HMO,CPT,36822,Insertion of cannula(s),Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36823,Insertion of cannula(s),Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,36825,Artery-vein autograft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,36829,Misc. Intervascular cannulization or shunt procedures,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36830,Artery-vein nonautograft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,36831,Open thrombect av fistula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,36832,Av fistula revision open,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,36833,Av fistula revision,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,36834,Repair A-V aneurysm,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36835,Artery to vein shunt,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,36838,Dist revas ligation hemo,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,36840,INSERT M&RIL,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36845,FUSION w/M&RIL,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36860,External cannula declotting,Surgical,Per Case,"$4,314.00 ",OP,"1,438.93","4,314.00",,,,,,
BCBS HMO,CPT,36861,Cannula declotting,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,36870,Percut thrombect av fistula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36901,Intro cath dialysis circuit,Surgical,Per Case,"$4,314.00 ",OP,"1,438.93","4,314.00",,,,,,
BCBS HMO,CPT,36902,Intro cath dialysis circuit,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,072.43",,,,,,
BCBS HMO,CPT,36903,Intro cath dialysis circuit,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","10,277.14",,,,,,
BCBS HMO,CPT,36904,Thrmbc/nfs dialysis circuit,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,072.43",,,,,,
BCBS HMO,CPT,36905,Thrmbc/nfs dialysis circuit,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","10,277.14",,,,,,
BCBS HMO,CPT,36906,Thrmbc/nfs dialysis circuit,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","16,438.60",,,,,,
BCBS HMO,CPT,36907,Balo angiop ctr dialysis seg,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36908,Stent plmt ctr dialysis seg,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,36909,Dialysis circuit embolj,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,37140,Revision of circulation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,37145,Revision of circulation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,37160,Revision of circulation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,37180,Revision of circulation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,37181,Splice spleen/kidney veins,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,37182,Insert hepatic shunt (tips),Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","10,277.14",,,,,,
BCBS HMO,CPT,37183,Remove hepatic shunt (tips),Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,072.43",,,,,,
BCBS HMO,CPT,37184,Prim art m-thrmbc 1st vsl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","10,277.14",,,,,,
BCBS HMO,CPT,37185,Prim art m-thrmbc sbsq vsl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,37186,Sec art thrombectomy add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,37187,Venous mech thrombectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","10,277.14",,,,,,
BCBS HMO,CPT,37188,Ven mechnl thrmbc repeat tx,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,37190,REPAIR OF CIRCULATION DEFECT,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,37191,Ins endovas vena cava filtr,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,37192,Redo endovas vena cava filtr,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,37193,Rem endovas vena cava filter,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,37195,Thrombolytic therapy stroke,Surgical,Per Case,"$4,314.00 ",OP,318,"4,314.00",,,,,,
BCBS HMO,CPT,37197,Remove intrvas foreign body,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,37200,Transcatheter biopsy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,37201,Transcatheter therapy infuse,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,37202,Transcatheter therapy infuse,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,37203,Transcatheter retrieval,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,37204,Transcatheter occlusion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,37205,Transcath iv stent percut,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,37206,Transcath iv stent/perc addl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,37207,Transcath iv stent open,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,37208,Transcath iv stent/open addl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,37209,Change iv cath at thromb tx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,37210,Embolization uterine fibroid,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,37211,Thrombolytic art therapy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,37212,Thrombolytic venous therapy,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,37213,Thromblytic art/ven therapy,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,37214,Cessj therapy cath removal,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,37215,Transcath stent cca w/eps,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,37216,Transcath stent cca w/o eps,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,37217,Stent placemt retro carotid,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,37218,Stent placemt ante carotid,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,37220,Iliac revasc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,072.43",,,,,,
BCBS HMO,CPT,37221,Iliac revasc w/stent,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","10,277.14",,,,,,
BCBS HMO,CPT,37222,Iliac revasc add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,37223,Iliac revasc w/stent add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,37224,Fem/popl revas w/tla,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,072.43",,,,,,
BCBS HMO,CPT,37225,Fem/popl revas w/ather,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","10,277.14",,,,,,
BCBS HMO,CPT,37226,Fem/popl revasc w/stent,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","10,277.14",,,,,,
BCBS HMO,CPT,37227,Fem/popl revasc stnt & ather,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,438.60",,,,,,
BCBS HMO,CPT,37228,Tib/per revasc w/tla,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","10,277.14",,,,,,
BCBS HMO,CPT,37229,Tib/per revasc w/ather,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,438.60",,,,,,
BCBS HMO,CPT,37230,Tib/per revasc w/stent,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,438.60",,,,,,
BCBS HMO,CPT,37231,Tib/per revasc stent & ather,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,438.60",,,,,,
BCBS HMO,CPT,37232,Tib/per revasc add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,37233,Tibper revasc w/ather add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,37234,Revsc opn/prq tib/pero stent,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,37235,Tib/per revasc stnt & ather,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,37236,Open/perq place stent 1st,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","10,277.14",,,,,,
BCBS HMO,CPT,37237,Open/perq place stent ea add,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,37238,Open/perq place stent same,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","10,277.14",,,,,,
BCBS HMO,CPT,37239,Open/perq place stent ea add,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,37241,Vasc embolize/occlude venous,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","10,277.14",,,,,,
BCBS HMO,CPT,37242,Vasc embolize/occlude artery,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","10,277.14",,,,,,
BCBS HMO,CPT,37243,Vasc embolize/occlude organ,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","10,277.14",,,,,,
BCBS HMO,CPT,37244,Vasc embolize/occlude bleed,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","10,277.14",,,,,,
BCBS HMO,CPT,37246,Trluml balo angiop 1st art,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,072.43",,,,,,
BCBS HMO,CPT,37247,Trluml balo angiop addl art,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,37248,Trluml balo angiop 1st vein,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,072.43",,,,,,
BCBS HMO,CPT,37249,Trluml balo angiop addl vein,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,37250,Iv us first vessel add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,37251,Iv us each add vessel add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,37252,Intrvasc us noncoronary 1st,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,37253,Intrvasc us noncoronary addl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,37500,Endoscopy ligate perf veins,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,37501,Vascular endoscopy procedure,Surgical,Per Case,"$4,314.00 ",OP,554.25,"4,314.00",,,,,,
BCBS HMO,CPT,37560,REPAIR OF MAJOR VEIN,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,37565,Ligation of neck vein,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,37600,Ligation of neck artery,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,37605,Ligation of neck artery,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,37606,Ligation of neck artery,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,37607,Ligation of a-v fistula,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,37609,Temporal artery procedure,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,37615,Ligation of neck artery,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,37616,Ligation of chest artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,37617,Ligation of abdomen artery,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,37618,Ligation of extremity artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,37619,Ligation of inf vena cava,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,37620,Revision of major vein,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,37650,Revision of major vein,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,37660,Revision of major vein,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,37700,Revise leg vein,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,37701,REVISE LEG VEINS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,37718,Ligate/strip short leg vein,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,37720,REMOVAL OF LEG VEIN,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,37721,REMOVAL OF LEG VEINS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,37722,Ligate/strip long leg vein,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,37730,REMOVAL OF LEG VEINS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,37731,REMOVAL OF LEG VEINS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,37735,Removal of leg veins/lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,37737,REMOVAL OF LEG VEINS/LESION,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,37760,Ligate leg veins radical,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,37761,Ligate leg veins open,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,37765,Stab phleb veins xtr 10-20,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,37766,Phleb veins - extrem 20+,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,37780,Revision of leg vein,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,37781,REVISION OF LEG VEINS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,37785,Ligate/divide/excise vein,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,37787,REVISE SECONDARY VARICOSITY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,37788,Revascularization penis,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,37790,Penile venous occlusion,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,37799,Vascular surgery procedure,Surgical,Per Case,"$4,314.00 ",OP,554.25,"4,314.00",,,,,,
BCBS HMO,CPT,38100,Removal of spleen total,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,38101,Removal of spleen partial,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,38102,Removal of spleen total,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,38115,Repair of ruptured spleen,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,38120,Laparoscopy splenectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","9,115.38",,,,,,
BCBS HMO,CPT,38129,Laparoscope proc spleen,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,38200,Injection for spleen x-ray,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,38204,Bl donor search management,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,38205,Harvest allogeneic stem cell,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,38206,Harvest auto stem cells,Surgical,Per Case,"$4,314.00 ",OP,"1,394.95","4,314.00",,,,,,
BCBS HMO,CPT,38207,Cryopreserve stem cells,Surgical,Per Case,"$4,314.00 ",OP,406.32,"4,314.00",,,,,,
BCBS HMO,CPT,38208,Thaw preserved stem cells,Surgical,Per Case,"$4,314.00 ",OP,406.32,"4,314.00",,,,,,
BCBS HMO,CPT,38209,Wash harvest stem cells,Surgical,Per Case,"$4,314.00 ",OP,406.32,"4,314.00",,,,,,
BCBS HMO,CPT,38210,T-cell depletion of harvest,Surgical,Per Case,"$4,314.00 ",OP,406.32,"4,314.00",,,,,,
BCBS HMO,CPT,38211,Tumor cell deplete of harvst,Surgical,Per Case,"$4,314.00 ",OP,406.32,"4,314.00",,,,,,
BCBS HMO,CPT,38212,Rbc depletion of harvest,Surgical,Per Case,"$4,314.00 ",OP,406.32,"4,314.00",,,,,,
BCBS HMO,CPT,38213,Platelet deplete of harvest,Surgical,Per Case,"$4,314.00 ",OP,406.32,"4,314.00",,,,,,
BCBS HMO,CPT,38214,Volume deplete of harvest,Surgical,Per Case,"$4,314.00 ",OP,406.32,"4,314.00",,,,,,
BCBS HMO,CPT,38215,Harvest stem cell concentrte,Surgical,Per Case,"$4,314.00 ",OP,406.32,"4,314.00",,,,,,
BCBS HMO,CPT,38220,Dx bone marrow aspirations,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,38221,Dx bone marrow biopsies,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,38222,Dx bone marrow bx & aspir,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,38230,Bone marrow harvest allogen,Surgical,Per Case,"$4,314.00 ",OP,"1,394.95","4,314.00",,,,,,
BCBS HMO,CPT,38231,STEM CELL COLLECTION,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,38232,Bone marrow harvest autolog,Surgical,Per Case,"$4,314.00 ",OP,"4,131.87","4,314.00",,,,,,
BCBS HMO,CPT,38240,Transplt allo hct/donor,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","32,580.57",,,,,,
BCBS HMO,CPT,38241,Transplt autol hct/donor,Surgical,Per Case,"$4,314.00 ",OP,"1,394.95","4,314.00",,,,,,
BCBS HMO,CPT,38242,Transplt allo lymphocytes,Surgical,Per Case,"$4,314.00 ",OP,"1,394.95","4,314.00",,,,,,
BCBS HMO,CPT,38243,Transplj hematopoietic boost,Surgical,Per Case,"$4,314.00 ",OP,"1,394.95","4,314.00",,,,,,
BCBS HMO,CPT,38300,Drainage lymph node lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,38305,Drainage lymph node lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,38308,Incision of lymph channels,Surgical,Per Case,"$4,314.00 ",OP,"3,231.37","4,314.00",,,,,,
BCBS HMO,CPT,38380,Thoracic duct procedure,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,38381,Thoracic duct procedure,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,38382,Thoracic duct procedure,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,38500,Biopsy/removal lymph nodes,Surgical,Per Case,"$4,314.00 ",OP,"3,231.37","4,314.00",,,,,,
BCBS HMO,CPT,38505,Needle biopsy lymph nodes,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,38510,Biopsy/removal lymph nodes,Surgical,Per Case,"$4,314.00 ",OP,"3,231.37","4,314.00",,,,,,
BCBS HMO,CPT,38520,Biopsy/removal lymph nodes,Surgical,Per Case,"$4,314.00 ",OP,"3,231.37","4,314.00",,,,,,
BCBS HMO,CPT,38525,Biopsy/removal lymph nodes,Surgical,Per Case,"$4,314.00 ",OP,"3,231.37","4,314.00",,,,,,
BCBS HMO,CPT,38530,Biopsy/removal lymph nodes,Surgical,Per Case,"$4,314.00 ",OP,"3,231.37","4,314.00",,,,,,
BCBS HMO,CPT,38531,Open bx/exc inguinofem nodes,Surgical,Per Case,"$4,314.00 ",OP,"3,231.37","4,314.00",,,,,,
BCBS HMO,CPT,38542,Explore deep node(s) neck,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,38550,Removal neck/armpit lesion,Surgical,Per Case,"$4,314.00 ",OP,"3,231.37","4,314.00",,,,,,
BCBS HMO,CPT,38555,Removal neck/armpit lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,662.99",,,,,,
BCBS HMO,CPT,38562,Removal pelvic lymph nodes,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","9,115.38",,,,,,
BCBS HMO,CPT,38564,Removal abdomen lymph nodes,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,38570,Laparoscopy lymph node biop,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,38571,Laparoscopy lymphadenectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,38572,Laparoscopy lymphadenectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,38573,Laps pelvic lymphadec,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,38589,Laparoscope proc lymphatic,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,38700,Removal of lymph nodes neck,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,662.99",,,,,,
BCBS HMO,CPT,38701,REMOVAL OF LYMPH NODES-NECK,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,38720,Removal of lymph nodes neck,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","9,128.05",,,,,,
BCBS HMO,CPT,38724,Removal of lymph nodes neck,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,38740,Remove armpit lymph nodes,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,38745,Remove armpit lymph nodes,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,38746,Remove thoracic lymph nodes,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,38747,Remove abdominal lymph nodes,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,38760,Remove groin lymph nodes,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,662.99",,,,,,
BCBS HMO,CPT,38761,REMOVE GROINS LYMPH NODES,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,38765,Remove groin lymph nodes,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,38770,Remove pelvis lymph nodes,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,38780,Remove abdomen lymph nodes,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,38790,Inject for lymphatic x-ray,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,38791,INJECTION FOR LYMPHATIC XRAY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,38792,Ra tracer id of sentinl node,Surgical,Per Case,"$4,314.00 ",OP,385.91,"4,314.00",,,,,,
BCBS HMO,CPT,38794,Access thoracic lymph duct,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,38900,Io map of sent lymph node,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,38999,Blood/lymph system procedure,Surgical,Per Case,"$4,314.00 ",OP,406.32,"4,314.00",,,,,,
BCBS HMO,CPT,39000,Exploration of chest,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,39010,Exploration of chest,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,39020,EXPLORATION OF CHEST,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,39200,Resect mediastinal cyst,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,39220,Resect mediastinal tumor,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,39221,MEDIASTINAL MALIGNANT,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,39400,Mediastinoscopy incl biopsy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,39401,Mediastinoscpy w/medstnl bx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,39402,Mediastinoscpy w/lmph nod bx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,39499,Chest procedure,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,39501,Repair diaphragm laceration,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,39502,Repair paraesophageal hernia,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,39503,Repair of diaphragm hernia,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,39520,Repair of diaphragm hernia,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,39530,Repair of diaphragm hernia,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,39531,Repair of diaphragm hernia,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,39540,Repair of diaphragm hernia,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,39541,Repair of diaphragm hernia,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,39545,Revision of diaphragm,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,39547,REVISION OF DIAPHRAGM,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,39560,Resect diaphragm simple,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,39561,Resect diaphragm complex,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,39599,Diaphragm surgery procedure,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,40200,Unknown,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,40490,Biopsy of lip,Surgical,Per Case,"$4,314.00 ",OP,216.54,"4,314.00",,,,,,
BCBS HMO,CPT,40500,Partial excision of lip,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,40510,Partial excision of lip,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,40520,Partial excision of lip,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,40525,Reconstruct lip with flap,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,40527,Reconstruct lip with flap,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,40530,Partial removal of lip,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,40650,Repair lip,Surgical,Per Case,"$4,314.00 ",OP,462.91,"4,314.00",,,,,,
BCBS HMO,CPT,40652,Repair lip,Surgical,Per Case,"$4,314.00 ",OP,462.91,"4,314.00",,,,,,
BCBS HMO,CPT,40654,Repair lip,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,40700,Repair cleft lip/nasal,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,40701,Repair cleft lip/nasal,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,40702,Repair cleft lip/nasal,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,40720,Repair cleft lip/nasal,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,40761,Repair cleft lip/nasal,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,40799,Lip surgery procedure,Surgical,Per Case,"$4,314.00 ",OP,216.54,"4,314.00",,,,,,
BCBS HMO,CPT,40800,Drainage of mouth lesion,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,40801,Drainage of mouth lesion,Surgical,Per Case,"$4,314.00 ",OP,462.91,"4,314.00",,,,,,
BCBS HMO,CPT,40804,Removal foreign body mouth,Surgical,Per Case,"$4,314.00 ",OP,828.48,"4,314.00",,,,,,
BCBS HMO,CPT,40805,Removal foreign body mouth,Surgical,Per Case,"$4,314.00 ",OP,462.91,"4,314.00",,,,,,
BCBS HMO,CPT,40806,Incision of lip fold,Surgical,Per Case,"$4,314.00 ",OP,462.91,"4,314.00",,,,,,
BCBS HMO,CPT,40808,Biopsy of mouth lesion,Surgical,Per Case,"$4,314.00 ",OP,462.91,"4,314.00",,,,,,
BCBS HMO,CPT,40810,Excision of mouth lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,40812,Excise/repair mouth lesion,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,40814,Excise/repair mouth lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,40816,Excision of mouth lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,40818,Excise oral mucosa for graft,Surgical,Per Case,"$4,314.00 ",OP,462.91,"4,314.00",,,,,,
BCBS HMO,CPT,40819,Excise lip or cheek fold,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,40820,Treatment of mouth lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,40830,Repair mouth laceration,Surgical,Per Case,"$4,314.00 ",OP,216.54,"4,314.00",,,,,,
BCBS HMO,CPT,40831,Repair mouth laceration,Surgical,Per Case,"$4,314.00 ",OP,462.91,"4,314.00",,,,,,
BCBS HMO,CPT,40840,Reconstruction of mouth,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,40842,Reconstruction of mouth,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,40843,Reconstruction of mouth,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,40844,Reconstruction of mouth,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,40845,Reconstruction of mouth,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,40899,Mouth surgery procedure,Surgical,Per Case,"$4,314.00 ",OP,216.54,"4,314.00",,,,,,
BCBS HMO,CPT,41000,Drainage of mouth lesion,Surgical,Per Case,"$4,314.00 ",OP,462.91,"4,314.00",,,,,,
BCBS HMO,CPT,41005,Drainage of mouth lesion,Surgical,Per Case,"$4,314.00 ",OP,216.54,"4,314.00",,,,,,
BCBS HMO,CPT,41006,Drainage of mouth lesion,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,41007,Drainage of mouth lesion,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,41008,Drainage of mouth lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,41009,Drainage of mouth lesion,Surgical,Per Case,"$4,314.00 ",OP,462.91,"4,314.00",,,,,,
BCBS HMO,CPT,41010,Incision of tongue fold,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,41015,Drainage of mouth lesion,Surgical,Per Case,"$4,314.00 ",OP,462.91,"4,314.00",,,,,,
BCBS HMO,CPT,41016,Drainage of mouth lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,41017,Drainage of mouth lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,41018,Drainage of mouth lesion,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,41019,Place needles h&n for rt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,41100,Biopsy of tongue,Surgical,Per Case,"$4,314.00 ",OP,462.91,"4,314.00",,,,,,
BCBS HMO,CPT,41105,Biopsy of tongue,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,41108,Biopsy of floor of mouth,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,41110,Excision of tongue lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,41112,Excision of tongue lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,41113,Excision of tongue lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,41114,Excision of tongue lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,41115,Excision of tongue fold,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,41116,Excision of mouth lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,41120,Partial removal of tongue,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,41130,Partial removal of tongue,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,41135,Tongue and neck surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,41140,Removal of tongue,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,41145,Tongue removal neck surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,41150,Tongue mouth jaw surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,41153,Tongue mouth neck surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,41155,Tongue jaw & neck surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,41250,Repair tongue laceration,Surgical,Per Case,"$4,314.00 ",OP,276.53,"4,314.00",,,,,,
BCBS HMO,CPT,41251,Repair tongue laceration,Surgical,Per Case,"$4,314.00 ",OP,216.54,"4,314.00",,,,,,
BCBS HMO,CPT,41252,Repair tongue laceration,Surgical,Per Case,"$4,314.00 ",OP,216.54,"4,314.00",,,,,,
BCBS HMO,CPT,41500,Fixation of tongue,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,41510,Tongue to lip surgery,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,41512,Tongue suspension,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,41520,Reconstruction tongue fold,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,41530,Tongue base vol reduction,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,41599,Tongue and mouth surgery,Surgical,Per Case,"$4,314.00 ",OP,216.54,"4,314.00",,,,,,
BCBS HMO,CPT,41800,Drainage of gum lesion,Surgical,Per Case,"$4,314.00 ",OP,114.56,"4,314.00",,,,,,
BCBS HMO,CPT,41805,Removal foreign body gum,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,41806,Removal foreign body jawbone,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,41820,Excision gum each quadrant,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,41821,Excision of gum flap,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,41822,Excision of gum lesion,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,41823,Excision of gum lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,41825,Excision of gum lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,41826,Excision of gum lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,41827,Excision of gum lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,41828,Excision of gum lesion,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,41830,Removal of gum tissue,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,41850,Treatment of gum lesion,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,41870,Gum graft,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,41872,Repair gum,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,41874,Repair tooth socket,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,41899,Dental surgery procedure,Surgical,Per Case,"$4,314.00 ",OP,216.54,"4,314.00",,,,,,
BCBS HMO,CPT,42000,Drainage mouth roof lesion,Surgical,Per Case,"$4,314.00 ",OP,216.54,"4,314.00",,,,,,
BCBS HMO,CPT,42100,Biopsy roof of mouth,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,42104,Excision lesion mouth roof,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,42106,Excision lesion mouth roof,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,42107,Excision lesion mouth roof,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,42120,Remove palate/lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,42140,Excision of uvula,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,42145,Repair palate pharynx/uvula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,42150,EXOSTOSIS PALATE BONY PLATE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,42160,Treatment mouth roof lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,42180,Repair palate,Surgical,Per Case,"$4,314.00 ",OP,462.91,"4,314.00",,,,,,
BCBS HMO,CPT,42182,Repair palate,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,42200,Reconstruct cleft palate,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,42205,Reconstruct cleft palate,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,42210,Reconstruct cleft palate,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,42215,Reconstruct cleft palate,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,42220,Reconstruct cleft palate,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,42225,Reconstruct cleft palate,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,42226,Lengthening of palate,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,42227,Lengthening of palate,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,42235,Repair palate,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,42260,Repair nose to lip fistula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,42280,Preparation palate mold,Surgical,Per Case,"$4,314.00 ",OP,462.91,"4,314.00",,,,,,
BCBS HMO,CPT,42281,Insertion palate prosthesis,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,42299,Palate/uvula surgery,Surgical,Per Case,"$4,314.00 ",OP,216.54,"4,314.00",,,,,,
BCBS HMO,CPT,42300,Drainage of salivary gland,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,42305,Drainage of salivary gland,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,42310,Drainage of salivary gland,Surgical,Per Case,"$4,314.00 ",OP,462.91,"4,314.00",,,,,,
BCBS HMO,CPT,42320,Drainage of salivary gland,Surgical,Per Case,"$4,314.00 ",OP,462.91,"4,314.00",,,,,,
BCBS HMO,CPT,42325,CREATE SALIVARY CYST DRAIN,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,42326,CREATE SALIVARY CYST DRAIN,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,42330,Removal of salivary stone,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,42335,Removal of salivary stone,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,42340,Removal of salivary stone,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,42400,Biopsy of salivary gland,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,42405,Biopsy of salivary gland,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,42408,Excision of salivary cyst,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,42409,Drainage of salivary cyst,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,42410,Excise parotid gland/lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,42415,Excise parotid gland/lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,42420,Excise parotid gland/lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,42425,Excise parotid gland/lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,42426,Excise parotid gland/lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,42440,Excise submaxillary gland,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,42450,Excise sublingual gland,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,42500,Repair salivary duct,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,42505,Repair salivary duct,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,42507,Parotid duct diversion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,42508,Parotid duct diversion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,42509,Parotid duct diversion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,42510,Parotid duct diversion,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,42550,Injection for salivary x-ray,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,42600,Closure of salivary fistula,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,42650,Dilation of salivary duct,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,42660,Dilation of salivary duct,Surgical,Per Case,"$4,314.00 ",OP,462.91,"4,314.00",,,,,,
BCBS HMO,CPT,42665,Ligation of salivary duct,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,42699,Salivary surgery procedure,Surgical,Per Case,"$4,314.00 ",OP,216.54,"4,314.00",,,,,,
BCBS HMO,CPT,42700,Drainage of tonsil abscess,Surgical,Per Case,"$4,314.00 ",OP,216.54,"4,314.00",,,,,,
BCBS HMO,CPT,42720,Drainage of throat abscess,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,42725,Drainage of throat abscess,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,42800,Biopsy of throat,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,42802,Biopsy of throat,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,42804,Biopsy of upper nose/throat,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,42806,Biopsy of upper nose/throat,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,42808,Excise pharynx lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,42809,Remove pharynx foreign body,Surgical,Per Case,"$4,314.00 ",OP,276.53,"4,314.00",,,,,,
BCBS HMO,CPT,42810,Excision of neck cyst,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,42815,Excision of neck cyst,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,42820,Remove tonsils and adenoids,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,42821,Remove tonsils and adenoids,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,42825,Removal of tonsils,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,42826,Removal of tonsils,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,42830,Removal of adenoids,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,42831,Removal of adenoids,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,42832,ADENOIDECTOMY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,42833,ADENOIDECTOMY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,42834,ADENOIDECTOMY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,42835,Removal of adenoids,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,42836,Removal of adenoids,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,42840,Unknown,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,42842,Extensive surgery of throat,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,42844,Extensive surgery of throat,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,42845,Extensive surgery of throat,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,42860,Excision of tonsil tags,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,42870,Excision of lingual tonsil,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,42880,Excision nasopharyngeal lesion (eg-fibroma),Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,42890,Partial removal of pharynx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,42892,Revision of pharyngeal walls,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,42894,Revision of pharyngeal walls,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,42900,Repair throat wound,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,42950,Reconstruction of throat,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,42953,Repair throat esophagus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,42955,Surgical opening of throat,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,42960,Control throat bleeding,Surgical,Per Case,"$4,314.00 ",OP,462.91,"4,314.00",,,,,,
BCBS HMO,CPT,42961,Control throat bleeding,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,42962,Control throat bleeding,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,42970,Control nose/throat bleeding,Surgical,Per Case,"$4,314.00 ",OP,216.54,"4,314.00",,,,,,
BCBS HMO,CPT,42971,Control nose/throat bleeding,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,42972,Control nose/throat bleeding,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,42999,Throat surgery procedure,Surgical,Per Case,"$4,314.00 ",OP,216.54,"4,314.00",,,,,,
BCBS HMO,CPT,43000,INCISION OF ESOPHAGUS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,43020,Incision of esophagus,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,43030,Throat muscle surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,43040,INCISION OF ESOPHAGUS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,43045,Incision of esophagus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43100,Excision of esophagus lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43101,Excision of esophagus lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43105,REMOVAL OF UPPER ESOPHAGUS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,43106,REMOVAL OF UPPER ESOPHAGUS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,43107,Removal of esophagus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43108,Removal of esophagus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43110,PARTIAL REMOVAL OF ESOPHAGUS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,43111,PARTIAL REMOVAL OF ESOPHAGUS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,43112,Esphg tot w/thrcm,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43113,Removal of esophagus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43115,PARTIAL REMOVAL OF ESOPHAGUS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,43116,Partial removal of esophagus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43117,Partial removal of esophagus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43118,Partial removal of esophagus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43119,REMOVAL OF ESOPHAGUS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,43120,REMOVE ESOPHAGUS & STOMACH,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,43121,Partial removal of esophagus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43122,Partial removal of esophagus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43123,Partial removal of esophagus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43124,Removal of esophagus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43130,Removal of esophagus pouch,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,43135,Removal of esophagus pouch,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43136,FIXATION OF ESOPHAGUS POUCH,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,43180,Esophagoscopy rigid trnso,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,43191,Esophagoscopy rigid trnso dx,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,43192,Esophagoscp rig trnso inject,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,43193,Esophagoscp rig trnso biopsy,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,43194,Esophagoscp rig trnso rem fb,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,43195,Esophagoscopy rigid balloon,Surgical,Per Case,"$4,314.00 ",OP,"3,152.63","4,314.00",,,,,,
BCBS HMO,CPT,43196,Esophagoscp guide wire dilat,Surgical,Per Case,"$4,314.00 ",OP,"3,152.63","4,314.00",,,,,,
BCBS HMO,CPT,43197,Esophagoscopy flex dx brush,Surgical,Per Case,"$4,314.00 ",OP,828.48,"4,314.00",,,,,,
BCBS HMO,CPT,43198,Esophagosc flex trnsn biopsy,Surgical,Per Case,"$4,314.00 ",OP,828.48,"4,314.00",,,,,,
BCBS HMO,CPT,43200,Esophagoscopy flexible brush,Surgical,Per Case,"$4,314.00 ",OP,828.48,"4,314.00",,,,,,
BCBS HMO,CPT,43201,Esoph scope w/submucous inj,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,43202,Esophagoscopy flex biopsy,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,43204,Esoph scope w/sclerosis inj,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,43205,Esophagus endoscopy/ligation,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,43206,Esoph optical endomicroscopy,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,43210,Egd esophagogastrc fndoplsty,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","9,115.38",,,,,,
BCBS HMO,CPT,43211,Esophagoscop mucosal resect,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,43212,Esophagoscop stent placement,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,145.78",,,,,,
BCBS HMO,CPT,43213,Esophagoscopy retro balloon,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,43214,Esophagosc dilate balloon 30,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,43215,Esophagoscopy flex remove fb,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,43216,Esophagoscopy lesion removal,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,43217,Esophagoscopy snare les remv,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,43219,Esophagus endoscopy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,43220,Esophagoscopy balloon <30mm,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,43226,Esoph endoscopy dilation,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,43227,Esophagoscopy control bleed,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,43228,Esoph endoscopy ablation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,43229,Esophagoscopy lesion ablate,Surgical,Per Case,"$4,314.00 ",OP,"3,152.63","4,314.00",,,,,,
BCBS HMO,CPT,43231,Esophagoscop ultrasound exam,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,43232,Esophagoscopy w/us needle bx,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,43233,Egd balloon dil esoph30 mm/>,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,43234,Upper gi endoscopy exam,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,43235,Egd diagnostic brush wash,Surgical,Per Case,"$4,314.00 ",OP,828.48,"4,314.00",,,,,,
BCBS HMO,CPT,43236,Uppr gi scope w/submuc inj,Surgical,Per Case,"$4,314.00 ",OP,828.48,"4,314.00",,,,,,
BCBS HMO,CPT,43237,Endoscopic us exam esoph,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,43238,Egd us fine needle bx/aspir,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,43239,Egd biopsy single/multiple,Surgical,Per Case,"$4,314.00 ",OP,828.48,"4,314.00",,,,,,
BCBS HMO,CPT,43240,Egd w/transmural drain cyst,Surgical,Per Case,"$4,314.00 ",OP,"3,152.63","4,314.00",,,,,,
BCBS HMO,CPT,43241,Egd tube/cath insertion,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,43242,Egd us fine needle bx/aspir,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,43243,Egd injection varices,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,43244,Egd varices ligation,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,43245,Egd dilate stricture,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,43246,Egd place gastrostomy tube,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,43247,Egd remove foreign body,Surgical,Per Case,"$4,314.00 ",OP,828.48,"4,314.00",,,,,,
BCBS HMO,CPT,43248,Egd guide wire insertion,Surgical,Per Case,"$4,314.00 ",OP,828.48,"4,314.00",,,,,,
BCBS HMO,CPT,43249,Esoph egd dilation <30 mm,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,43250,Egd cautery tumor polyp,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,43251,Egd remove lesion snare,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,43252,Egd optical endomicroscopy,Surgical,Per Case,"$4,314.00 ",OP,"3,152.63","4,314.00",,,,,,
BCBS HMO,CPT,43253,Egd us transmural injxn/mark,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,43254,Egd endo mucosal resection,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,43255,Egd control bleeding any,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,43256,Uppr gi endoscopy w/stent,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,43257,Egd w/thrml txmnt gerd,Surgical,Per Case,"$4,314.00 ",OP,"3,152.63","4,314.00",,,,,,
BCBS HMO,CPT,43258,Operative upper GI endoscopy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,43259,Egd us exam duodenum/jejunum,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,43260,Ercp w/specimen collection,Surgical,Per Case,"$4,314.00 ",OP,"3,152.63","4,314.00",,,,,,
BCBS HMO,CPT,43261,Endo cholangiopancreatograph,Surgical,Per Case,"$4,314.00 ",OP,"3,152.63","4,314.00",,,,,,
BCBS HMO,CPT,43262,Endo cholangiopancreatograph,Surgical,Per Case,"$4,314.00 ",OP,"3,152.63","4,314.00",,,,,,
BCBS HMO,CPT,43263,Ercp sphincter pressure meas,Surgical,Per Case,"$4,314.00 ",OP,"3,152.63","4,314.00",,,,,,
BCBS HMO,CPT,43264,Ercp remove duct calculi,Surgical,Per Case,"$4,314.00 ",OP,"3,152.63","4,314.00",,,,,,
BCBS HMO,CPT,43265,Ercp lithotripsy calculi,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,145.78",,,,,,
BCBS HMO,CPT,43266,Egd endoscopic stent place,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,145.78",,,,,,
BCBS HMO,CPT,43267,Endo cholangiopancreatograph,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,43268,Endo cholangiopancreatograph,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,43269,Endo cholangiopancreatograph,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,43270,Egd lesion ablation,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,43271,Endo cholangiopancreatograph,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,43272,Endo cholangiopancreatograph,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,43273,Endoscopic pancreatoscopy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,43274,Ercp duct stent placement,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,145.78",,,,,,
BCBS HMO,CPT,43275,Ercp remove forgn body duct,Surgical,Per Case,"$4,314.00 ",OP,"3,152.63","4,314.00",,,,,,
BCBS HMO,CPT,43276,Ercp stent exchange w/dilate,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,145.78",,,,,,
BCBS HMO,CPT,43277,Ercp ea duct/ampulla dilate,Surgical,Per Case,"$4,314.00 ",OP,"3,152.63","4,314.00",,,,,,
BCBS HMO,CPT,43278,Ercp lesion ablate w/dilate,Surgical,Per Case,"$4,314.00 ",OP,"3,152.63","4,314.00",,,,,,
BCBS HMO,CPT,43279,Lap myotomy heller,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43280,Laparoscopy fundoplasty,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","9,115.38",,,,,,
BCBS HMO,CPT,43281,Lap paraesophag hern repair,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","9,115.38",,,,,,
BCBS HMO,CPT,43282,Lap paraesoph her rpr w/mesh,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","9,115.38",,,,,,
BCBS HMO,CPT,43283,Lap esoph lengthening,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43284,Laps esophgl sphnctr agmntj,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","9,115.38",,,,,,
BCBS HMO,CPT,43285,Rmvl esophgl sphnctr dev,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,43286,Esphg tot w/laps moblj,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43287,Esphg dstl 2/3 w/laps moblj,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43288,Esphg thrsc moblj,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43289,Laparoscope proc esoph,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,43300,Repair of esophagus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43305,Repair esophagus and fistula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43310,Repair of esophagus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43312,Repair esophagus and fistula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43313,Esophagoplasty congenital,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43314,Tracheo-esophagoplasty cong,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43320,Fuse esophagus & stomach,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43321,FUSE ESOPHAGUS & STOMACH,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,43324,Revise esophagus & stomach,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,43325,Revise esophagus & stomach,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43326,Revise esophagus & stomach,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,43327,Esoph fundoplasty lap,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43328,Esoph fundoplasty thor,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43330,Esophagomyotomy abdominal,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43331,Esophagomyotomy thoracic,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43332,Transab esoph hiat hern rpr,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43333,Transab esoph hiat hern rpr,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43334,Transthor diaphrag hern rpr,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43335,Transthor diaphrag hern rpr,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43336,Thorabd diaphr hern repair,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43337,Thorabd diaphr hern repair,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43338,Esoph lengthening,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43340,Fuse esophagus & intestine,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43341,Fuse esophagus & intestine,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43350,Surgical opening esophagus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,43351,Surgical opening esophagus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43352,Surgical opening esophagus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43360,Gastrointestinal repair,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43361,Gastrointestinal repair,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43400,Ligate esophagus veins,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43401,Esophagus surgery for veins,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,43405,Ligate/staple esophagus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43410,Repair esophagus wound,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43415,Repair esophagus wound,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43420,Repair esophagus opening,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,43425,Repair esophagus opening,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43450,Dilate esophagus 1/mult pass,Surgical,Per Case,"$4,314.00 ",OP,828.48,"4,314.00",,,,,,
BCBS HMO,CPT,43451,REDILATE ESOPHAGUS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,43453,Dilate esophagus,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,43455,DILATE ESOPHAGUS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,43456,Dilate esophagus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,43458,Dilate esophagus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,43460,Pressure treatment esophagus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43496,Free jejunum flap microvasc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43499,Esophagus surgery procedure,Surgical,Per Case,"$4,314.00 ",OP,828.48,"4,314.00",,,,,,
BCBS HMO,CPT,43500,Surgical opening of stomach,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43501,Surgical repair of stomach,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43502,Surgical repair of stomach,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43510,Surgical opening of stomach,Surgical,Per Case,"$4,314.00 ",OP,828.48,"4,314.00",,,,,,
BCBS HMO,CPT,43520,Incision of pyloric muscle,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43600,Biopsy of stomach,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,43605,Biopsy of stomach,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43610,Excision of stomach lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43611,Excision of stomach lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43620,Removal of stomach,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43621,Removal of stomach,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43622,Removal of stomach,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43625,REMOVAL OF STOMACH,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,43630,PARTIAL REMOVAL OF STOMACH,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,43631,Removal of stomach partial,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43632,Removal of stomach partial,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43633,Removal of stomach partial,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43634,Removal of stomach partial,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43635,Removal of stomach partial,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43638,PARTIAL REMOVAL OF STOMACH,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,43639,REMOVAL STOMACH-PARTIAL,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,43640,Vagotomy & pylorus repair,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43641,Vagotomy & pylorus repair,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43644,Lap gastric bypass/roux-en-y,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43645,Lap gastr bypass incl smll i,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43647,Lap impl electrode antrum,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","11,498.23",,,,,,
BCBS HMO,CPT,43648,Lap revise/remv eltrd antrum,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,43651,Laparoscopy vagus nerve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,43652,Laparoscopy vagus nerve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,43653,Laparoscopy gastrostomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,43659,Laparoscope proc stom,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,43750,Place gastrostomy tube,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,43752,Nasal/orogastric w/tube plmt,Surgical,Per Case,"$4,314.00 ",OP,276.53,"4,314.00",,,,,,
BCBS HMO,CPT,43753,Tx gastro intub w/asp,Surgical,Per Case,"$4,314.00 ",OP,270.61,"4,314.00",,,,,,
BCBS HMO,CPT,43754,Dx gastr intub w/asp spec,Surgical,Per Case,"$4,314.00 ",OP,270.61,"4,314.00",,,,,,
BCBS HMO,CPT,43755,Dx gastr intub w/asp specs,Surgical,Per Case,"$4,314.00 ",OP,142.8,"4,314.00",,,,,,
BCBS HMO,CPT,43756,Dx duod intub w/asp spec,Surgical,Per Case,"$4,314.00 ",OP,828.48,"4,314.00",,,,,,
BCBS HMO,CPT,43757,Dx duod intub w/asp specs,Surgical,Per Case,"$4,314.00 ",OP,828.48,"4,314.00",,,,,,
BCBS HMO,CPT,43760,Change gastrostomy tube,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,43761,Reposition gastrostomy tube,Surgical,Per Case,"$4,314.00 ",OP,272.35,"4,314.00",,,,,,
BCBS HMO,CPT,43762,Rplc gtube no revj trc,Surgical,Per Case,"$4,314.00 ",OP,272.35,"4,314.00",,,,,,
BCBS HMO,CPT,43763,Rplc gtube revj gstrst trc,Surgical,Per Case,"$4,314.00 ",OP,272.35,"4,314.00",,,,,,
BCBS HMO,CPT,43770,Lap place gastr adj device,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,43771,Lap revise gastr adj device,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43772,Lap rmvl gastr adj device,Surgical,Per Case,"$4,314.00 ",OP,"3,152.63","4,314.00",,,,,,
BCBS HMO,CPT,43773,Lap replace gastr adj device,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,43774,Lap rmvl gastr adj all parts,Surgical,Per Case,"$4,314.00 ",OP,"3,152.63","4,314.00",,,,,,
BCBS HMO,CPT,43775,Lap sleeve gastrectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43800,Reconstruction of pylorus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43810,Fusion of stomach and bowel,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43820,Fusion of stomach and bowel,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43825,Fusion of stomach and bowel,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43830,Place gastrostomy tube,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,43831,Place gastrostomy tube,Surgical,Per Case,"$4,314.00 ",OP,828.48,"4,314.00",,,,,,
BCBS HMO,CPT,43832,Place gastrostomy tube,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43840,Repair of stomach lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,145.78",,,,,,
BCBS HMO,CPT,43842,V-band gastroplasty,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,43843,Gastroplasty w/o v-band,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43844,GASTRIC BYPASS FOR OBESITY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,43845,Gastroplasty duodenal switch,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43846,Gastric bypass for obesity,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43847,Gastric bypass incl small i,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43848,Revision gastroplasty,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43850,Revise stomach-bowel fusion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43855,Revise stomach-bowel fusion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43860,Revise stomach-bowel fusion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43865,Revise stomach-bowel fusion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43870,Repair stomach opening,Surgical,Per Case,"$4,314.00 ",OP,"3,152.63","4,314.00",,,,,,
BCBS HMO,CPT,43880,Repair stomach-bowel fistula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43881,Impl/redo electrd antrum,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43882,Revise/remove electrd antrum,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,43885,REVISE STOMACH PLACEMENT,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,43886,Revise gastric port open,Surgical,Per Case,"$4,314.00 ",OP,"3,604.28","4,314.00",,,,,,
BCBS HMO,CPT,43887,Remove gastric port open,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,43888,Change gastric port open,Surgical,Per Case,"$4,314.00 ",OP,"3,604.28","4,314.00",,,,,,
BCBS HMO,CPT,43999,Stomach surgery procedure,Surgical,Per Case,"$4,314.00 ",OP,828.48,"4,314.00",,,,,,
BCBS HMO,CPT,44005,Freeing of bowel adhesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44010,Incision of small bowel,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44015,Insert needle cath bowel,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44020,Explore small intestine,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44021,Decompress small bowel,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44025,Incision of large bowel,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44040,EXTERIORIZATION OF BOWEL,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,44050,Reduce bowel obstruction,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44055,Correct malrotation of bowel,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44100,Biopsy of bowel,Surgical,Per Case,"$4,314.00 ",OP,828.48,"4,314.00",,,,,,
BCBS HMO,CPT,44110,Excise intestine lesion(s),Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44111,Excision of bowel lesion(s),Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44120,Removal of small intestine,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44121,Removal of small intestine,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44125,Removal of small intestine,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44126,Enterectomy w/o taper cong,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44127,Enterectomy w/taper cong,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44128,Enterectomy cong add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44130,Bowel to bowel fusion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44131,INTESTINAL BYPASS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,44132,Enterectomy cadaver donor,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44133,Enterectomy live donor,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44135,Intestine transplnt cadaver,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44136,Intestine transplant live,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44137,Remove intestinal allograft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44139,Mobilization of colon,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44140,Partial removal of colon,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44141,Partial removal of colon,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44143,Partial removal of colon,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44144,Partial removal of colon,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44145,Partial removal of colon,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44146,Partial removal of colon,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44147,Partial removal of colon,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44150,Removal of colon,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44151,Removal of colon/ileostomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44152,Removal of colon/ileostomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,44153,Removal of colon/ileostomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,44155,Removal of colon/ileostomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44156,Removal of colon/ileostomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44157,Colectomy w/ileoanal anast,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44158,Colectomy w/neo-rectum pouch,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44160,Removal of colon,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44180,Lap enterolysis,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,44186,Lap jejunostomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,44187,Lap ileo/jejuno-stomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44188,Lap colostomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44200,LAPAROSCOPY-ENTEROLYSIS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,44201,LAPAROSCOPY-JEJUNOSTOMY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,44202,Lap enterectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44203,Lap resect s/intestine addl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44204,Laparo partial colectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44205,Lap colectomy part w/ileum,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44206,Lap part colectomy w/stoma,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44207,L colectomy/coloproctostomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44208,L colectomy/coloproctostomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44209,LAPAROSCOPE PROC-INTESTINE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,44210,Laparo total proctocolectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44211,Lap colectomy w/proctectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44212,Laparo total proctocolectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44213,Lap mobil splenic fl add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44227,Lap close enterostomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44238,Laparoscope proc intestine,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,44239,LAPAROSCOPE PROC-RECTUM,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,44300,Open bowel to skin,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,44305,TUBE IN CONJUNCTION W/OTHER,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,44310,Ileostomy/jejunostomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44312,Revision of ileostomy,Surgical,Per Case,"$4,314.00 ",OP,"3,604.28","4,314.00",,,,,,
BCBS HMO,CPT,44314,Revision of ileostomy,Surgical,Per Case,"$4,314.00 ",OP,"3,604.28","4,314.00",,,,,,
BCBS HMO,CPT,44316,Devise bowel pouch,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44320,Colostomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44322,Colostomy with biopsies,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44332,Unknown,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,44340,Revision of colostomy,Surgical,Per Case,"$4,314.00 ",OP,"3,604.28","4,314.00",,,,,,
BCBS HMO,CPT,44345,Revision of colostomy,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","4,314.00",,,,,,
BCBS HMO,CPT,44346,Revision of colostomy,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","4,314.00",,,,,,
BCBS HMO,CPT,44360,Small bowel endoscopy,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,44361,Small bowel endoscopy/biopsy,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,44363,Small bowel endoscopy,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,44364,Small bowel endoscopy,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,44365,Small bowel endoscopy,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,44366,Small bowel endoscopy,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,44369,Small bowel endoscopy,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,44370,Small bowel endoscopy/stent,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,145.78",,,,,,
BCBS HMO,CPT,44372,Small bowel endoscopy,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,44373,Small bowel endoscopy,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,44376,Small bowel endoscopy,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,44377,Small bowel endoscopy/biopsy,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,44378,Small bowel endoscopy,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,44379,S bowel endoscope w/stent,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,145.78",,,,,,
BCBS HMO,CPT,44380,Small bowel endoscopy br/wa,Surgical,Per Case,"$4,314.00 ",OP,828.48,"4,314.00",,,,,,
BCBS HMO,CPT,44381,Small bowel endoscopy br/wa,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,44382,Small bowel endoscopy,Surgical,Per Case,"$4,314.00 ",OP,828.48,"4,314.00",,,,,,
BCBS HMO,CPT,44383,Ileoscopy w/stent,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,44384,Small bowel endoscopy,Surgical,Per Case,"$4,314.00 ",OP,"3,152.63","4,314.00",,,,,,
BCBS HMO,CPT,44385,Endoscopy of bowel pouch,Surgical,Per Case,"$4,314.00 ",OP,812.16,"4,314.00",,,,,,
BCBS HMO,CPT,44386,Endoscopy bowel pouch/biop,Surgical,Per Case,"$4,314.00 ",OP,812.16,"4,314.00",,,,,,
BCBS HMO,CPT,44388,Colonoscopy thru stoma spx,Surgical,Per Case,"$4,314.00 ",OP,812.16,"4,314.00",,,,,,
BCBS HMO,CPT,44389,Colonoscopy with biopsy,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,44390,Colonoscopy for foreign body,Surgical,Per Case,"$4,314.00 ",OP,812.16,"4,314.00",,,,,,
BCBS HMO,CPT,44391,Colonoscopy for bleeding,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,44392,Colonoscopy & polypectomy,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,44393,Colonoscopy lesion removal,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,44394,Colonoscopy w/snare,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,44397,Colonoscopy w/stent,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,44401,Colonoscopy with ablation,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,44402,Colonoscopy w/stent plcmt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,145.78",,,,,,
BCBS HMO,CPT,44403,Colonoscopy w/resection,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,44404,Colonoscopy w/injection,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,44405,Colonoscopy w/dilation,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,44406,Colonoscopy w/ultrasound,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,44407,Colonoscopy w/ndl aspir/bx,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,44408,Colonoscopy w/decompression,Surgical,Per Case,"$4,314.00 ",OP,812.16,"4,314.00",,,,,,
BCBS HMO,CPT,44500,Intro gastrointestinal tube,Surgical,Per Case,"$4,314.00 ",OP,828.48,"4,314.00",,,,,,
BCBS HMO,CPT,44600,REPAIR OF BOWEL LESION,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,44602,Suture small intestine,Surgical,Per Case,"$4,314.00 ",OP,"3,152.63","4,314.00",,,,,,
BCBS HMO,CPT,44603,Suture small intestine,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44604,Suture large intestine,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44605,Repair of bowel lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44610,REPAIR OF BOWEL LESIONS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,44615,Intestinal stricturoplasty,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44620,Repair bowel opening,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44625,Repair bowel opening,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44626,Repair bowel opening,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44640,Repair bowel-skin fistula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44650,Repair bowel fistula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44660,Repair bowel-bladder fistula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44661,Repair bowel-bladder fistula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44680,Surgical revision intestine,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44700,Suspend bowel w/prosthesis,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44701,Intraop colon lavage add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,44705,Prepare fecal microbiota,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,44715,Prepare donor intestine,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44720,Prep donor intestine/venous,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44721,Prep donor intestine/artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44799,Unlisted px small intestine,Surgical,Per Case,"$4,314.00 ",OP,828.48,"4,314.00",,,,,,
BCBS HMO,CPT,44800,Excision of bowel pouch,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44820,Excision of mesentery lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44850,Repair of mesentery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44899,Bowel surgery procedure,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44900,Drain appendix abscess open,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44901,Drain app abscess percut,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,44950,Appendectomy,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","4,314.00",,,,,,
BCBS HMO,CPT,44955,Appendectomy add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,44960,Appendectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,44970,Laparoscopy appendectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,44972,LAPAROSCOPIC APPENDECTOMY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,44979,Laparoscope proc app,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,45000,Drainage of pelvic abscess,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,45005,Drainage of rectal abscess,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,45020,Drainage of rectal abscess,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,45100,Biopsy of rectum,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,45108,Removal of anorectal lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,45110,Removal of rectum,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,45111,Partial removal of rectum,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,45112,Removal of rectum,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,45113,Partial proctectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,45114,Partial removal of rectum,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,45116,Partial removal of rectum,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,45119,Remove rectum w/reservoir,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,45120,Removal of rectum,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,45121,Removal of rectum and colon,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,45123,Partial proctectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,45126,Pelvic exenteration,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,45130,Excision of rectal prolapse,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,45135,Excision of rectal prolapse,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,45136,Excise ileoanal reservior,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,45150,Excision of rectal stricture,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,45160,Excision of rectal lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,45170,Excision of rectal lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,45171,Exc rect tum transanal part,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,45172,Exc rect tum transanal full,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,45180,REMOVAL OF RECTAL LESION,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,45190,Destruction rectal tumor,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,45300,Proctosigmoidoscopy dx,Surgical,Per Case,"$4,314.00 ",OP,812.16,"4,314.00",,,,,,
BCBS HMO,CPT,45302,PROCTOSIGMOIDOSCOPY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,45303,Proctosigmoidoscopy dilate,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,45305,Proctosigmoidoscopy w/bx,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,45307,Proctosigmoidoscopy fb,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,45308,Proctosigmoidoscopy removal,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,45309,Proctosigmoidoscopy removal,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,45310,PROCTOSIGMOIDOSCOPY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,45315,Proctosigmoidoscopy removal,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,45317,Proctosigmoidoscopy bleed,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,45320,Proctosigmoidoscopy ablate,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,45321,Proctosigmoidoscopy volvul,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,45327,Proctosigmoidoscopy w/stent,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,145.78",,,,,,
BCBS HMO,CPT,45330,Diagnostic sigmoidoscopy,Surgical,Per Case,"$4,314.00 ",OP,812.16,"4,314.00",,,,,,
BCBS HMO,CPT,45331,Sigmoidoscopy and biopsy,Surgical,Per Case,"$4,314.00 ",OP,812.16,"4,314.00",,,,,,
BCBS HMO,CPT,45332,Sigmoidoscopy w/fb removal,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,45333,Sigmoidoscopy & polypectomy,Surgical,Per Case,"$4,314.00 ",OP,812.16,"4,314.00",,,,,,
BCBS HMO,CPT,45334,Sigmoidoscopy for bleeding,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,45335,Sigmoidoscopy w/submuc inj,Surgical,Per Case,"$4,314.00 ",OP,812.16,"4,314.00",,,,,,
BCBS HMO,CPT,45336,SIGMOIDOSCOPY-LESION REMOVAL,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,45337,Sigmoidoscopy & decompress,Surgical,Per Case,"$4,314.00 ",OP,812.16,"4,314.00",,,,,,
BCBS HMO,CPT,45338,Sigmoidoscopy w/tumr remove,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,45339,Sigmoidoscopy w/ablate tumr,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,45340,Sig w/tndsc balloon dilation,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,45341,Sigmoidoscopy w/ultrasound,Surgical,Per Case,"$4,314.00 ",OP,812.16,"4,314.00",,,,,,
BCBS HMO,CPT,45342,Sigmoidoscopy w/us guide bx,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,45345,Sigmoidoscopy w/stent,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,45346,Sigmoidoscopy w/ablation,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,45347,Sigmoidoscopy w/plcmt stent,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,145.78",,,,,,
BCBS HMO,CPT,45349,Sigmoidoscopy w/resection,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,45350,Sgmdsc w/band ligation,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,45355,Surgical colonoscopy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,45360,DIAGNOSTIC COLONOSCOPY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,45365,COLONOSCOPY & BIOPSY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,45370,COLONOSCOPY-LESION REMOVAL,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,45378,Diagnostic colonoscopy,Surgical,Per Case,"$4,314.00 ",OP,812.16,"4,314.00",,,,,,
BCBS HMO,CPT,45379,Colonoscopy w/fb removal,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,45380,Colonoscopy and biopsy,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,45381,Colonoscopy submucous njx,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,45382,Colonoscopy w/control bleed,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,45383,Lesion removal colonoscopy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,45384,Colonoscopy w/lesion removal,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,45385,Colonoscopy w/lesion removal,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,45386,Colonoscopy w/balloon dilat,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,45387,Colonoscopy w/stent,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,45388,Colonoscopy w/ablation,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,45389,Colonoscopy w/stent plcmt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,145.78",,,,,,
BCBS HMO,CPT,45390,Colonoscopy w/resection,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,45391,Colonoscopy w/endoscope us,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,45392,Colonoscopy w/endoscopic fnb,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,45393,Colonoscopy w/decompression,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,45395,Lap removal of rectum,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,45397,Lap remove rectum w/pouch,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,45398,Colonoscopy w/band ligation,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,45399,Unlisted procedure colon,Surgical,Per Case,"$4,314.00 ",OP,812.16,"4,314.00",,,,,,
BCBS HMO,CPT,45400,Laparoscopic proc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,45402,Lap proctopexy w/sig resect,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,45499,Laparoscope proc rectum,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,45500,Repair of rectum,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,45505,Repair of rectum,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,45520,Treatment of rectal prolapse,Surgical,Per Case,"$4,314.00 ",OP,812.16,"4,314.00",,,,,,
BCBS HMO,CPT,45521,TREATMENT OF RECTAL PROLAPSE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,45540,Correct rectal prolapse,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,45541,Correct rectal prolapse,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,45550,Repair rectum/remove sigmoid,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,45560,Repair of rectocele,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,45562,Exploration/repair of rectum,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,45563,Exploration/repair of rectum,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,45800,Repair rect/bladder fistula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,45805,Repair fistula w/colostomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,45820,Repair rectourethral fistula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,45825,Repair fistula w/colostomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,45900,Reduction of rectal prolapse,Surgical,Per Case,"$4,314.00 ",OP,812.16,"4,314.00",,,,,,
BCBS HMO,CPT,45905,Dilation of anal sphincter,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,45910,Dilation of rectal narrowing,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,45915,Remove rectal obstruction,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,45990,Surg dx exam anorectal,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,45999,Rectum surgery procedure,Surgical,Per Case,"$4,314.00 ",OP,812.16,"4,314.00",,,,,,
BCBS HMO,CPT,46000,INCISION OF ANAL FISTULA,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,46020,Placement of seton,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,46030,Removal of rectal marker,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,46040,Incision of rectal abscess,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,46045,Incision of rectal abscess,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,46050,Incision of anal abscess,Surgical,Per Case,"$4,314.00 ",OP,812.16,"4,314.00",,,,,,
BCBS HMO,CPT,46060,Incision of rectal abscess,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,46070,Incision of anal septum,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,46080,Incision of anal sphincter,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,46083,Incise external hemorrhoid,Surgical,Per Case,"$4,314.00 ",OP,272.35,"4,314.00",,,,,,
BCBS HMO,CPT,46200,Removal of anal fissure,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,46210,Removal of anal crypt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,46211,Removal of anal crypts,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,46220,Excise anal ext tag/papilla,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,46221,Ligation of hemorrhoid(s),Surgical,Per Case,"$4,314.00 ",OP,812.16,"4,314.00",,,,,,
BCBS HMO,CPT,46230,Removal of anal tags,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,46250,Remove ext hem groups 2+,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,46255,Remove int/ext hem 1 group,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,46257,Remove in/ex hem grp & fiss,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,46258,Remove in/ex hem grp w/fistu,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,46260,Remove in/ex hem groups 2+,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,46261,Remove in/ex hem grps & fiss,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,46262,Remove in/ex hem grps w/fist,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,46270,Remove anal fist subq,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,46275,Remove anal fist inter,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,46280,Remove anal fist complex,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,46281,CLOSURE OF ANAL FISTULA,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,46285,Remove anal fist 2 stage,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,46288,Repair anal fistula,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,46320,Removal of hemorrhoid clot,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,46500,Injection into hemorrhoid(s),Surgical,Per Case,"$4,314.00 ",OP,812.16,"4,314.00",,,,,,
BCBS HMO,CPT,46505,Chemodenervation anal musc,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,46600,Diagnostic anoscopy spx,Surgical,Per Case,"$4,314.00 ",OP,114.56,"4,314.00",,,,,,
BCBS HMO,CPT,46601,Diagnostic anoscopy,Surgical,Per Case,"$4,314.00 ",OP,114.56,"4,314.00",,,,,,
BCBS HMO,CPT,46602,DIAGNOSTIC ANOSCOPY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,46604,Anoscopy and dilation,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,46606,Anoscopy and biopsy,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,46607,Diagnostic anoscopy & biopsy,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,46608,Anoscopy remove for body,Surgical,Per Case,"$4,314.00 ",OP,812.16,"4,314.00",,,,,,
BCBS HMO,CPT,46610,Anoscopy remove lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,46611,Anoscopy,Surgical,Per Case,"$4,314.00 ",OP,812.16,"4,314.00",,,,,,
BCBS HMO,CPT,46612,Anoscopy remove lesions,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,46614,Anoscopy control bleeding,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,46615,Anoscopy,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,46700,Repair of anal stricture,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,46705,Repair of anal stricture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,46706,Repr of anal fistula w/glue,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,46707,Repair anorectal fist w/plug,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,46710,Repr per/vag pouch sngl proc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,46712,Repr per/vag pouch dbl proc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,46715,Rep perf anoper fistu,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,46716,Rep perf anoper/vestib fistu,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,46730,Construction of absent anus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,46735,Construction of absent anus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,46740,Construction of absent anus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,46742,Repair of imperforated anus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,46744,Repair of cloacal anomaly,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,46746,Repair of cloacal anomaly,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,46748,Repair of cloacal anomaly,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,46750,Repair of anal sphincter,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,46751,Repair of anal sphincter,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,46753,Reconstruction of anus,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,46754,Removal of suture from anus,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,46760,Repair of anal sphincter,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,46761,Repair of anal sphincter,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,46762,Implant artificial sphincter,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,46900,Destruction anal lesion(s),Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,46910,Destruction anal lesion(s),Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,46916,Cryosurgery anal lesion(s),Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,46917,Laser surgery anal lesions,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,46922,Excision of anal lesion(s),Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,46924,Destruction anal lesion(s),Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,46930,Destroy internal hemorrhoids,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,46934,Destruction of hemorrhoids,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,46935,Destruction of hemorrhoids,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,46936,Destruction of hemorrhoids,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,46937,Cryotherapy of rectal lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,46938,Cryotherapy of rectal lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,46940,Treatment of anal fissure,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,46942,Treatment of anal fissure,Surgical,Per Case,"$4,314.00 ",OP,812.16,"4,314.00",,,,,,
BCBS HMO,CPT,46945,Int hrhc lig 1 hroid w/o img,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,46946,Int hrhc lig 2+hroid w/o img,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,46947,Hemorrhoidopexy by stapling,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,46948,Int hrhc tranal dartlzj 2+,Surgical,Per Case,"$4,314.00 ",OP,"2,500.37","4,314.00",,,,,,
BCBS HMO,CPT,46999,Anus surgery procedure,Surgical,Per Case,"$4,314.00 ",OP,812.16,"4,314.00",,,,,,
BCBS HMO,CPT,47000,Needle biopsy of liver,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,47001,Needle biopsy liver add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,47010,Open drainage liver lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47011,Percut drain liver lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,47015,Inject/aspirate liver cyst,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47100,Wedge biopsy of liver,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47120,Partial removal of liver,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47122,Extensive removal of liver,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47125,Partial removal of liver,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47130,Partial removal of liver,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47133,Removal of donor liver,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47134,PARTIAL REMOVAL-DONOR LIVER,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,47135,Transplantation of liver,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47136,Transplantation of liver,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,47137,TRANS-AORTO-HEPATIC ARTERIL,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,47138,TRANS-PORT-HEPATIC VENOUS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,47139,TRANS-CHOLEDOCHOJEJUNOSTOMY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,47140,Partial removal donor liver,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47141,Partial removal donor liver,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47142,Partial removal donor liver,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47143,Prep donor liver whole,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47144,Prep donor liver 3-segment,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47145,Prep donor liver lobe split,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47146,Prep donor liver/venous,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47147,Prep donor liver/arterial,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47300,Surgery for liver lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47350,Repair liver wound,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47355,REPAIR LIVER WOUND,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,47360,Repair liver wound,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47361,Repair liver wound,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47362,Repair liver wound,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47370,Laparo ablate liver tumor rf,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","9,115.38",,,,,,
BCBS HMO,CPT,47371,Laparo ablate liver cryosurg,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","9,115.38",,,,,,
BCBS HMO,CPT,47379,Laparoscope procedure liver,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,47380,Open ablate liver tumor rf,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47381,Open ablate liver tumor cryo,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47382,Percut ablate liver rf,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,47383,Perq abltj lvr cryoablation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,47399,Liver surgery procedure,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,47400,Incision of liver duct,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47420,Incision of bile duct,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47425,Incision of bile duct,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47440,INCISION OF BILE DUCT,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,47460,Incise bile duct sphincter,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47480,Incision of gallbladder,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47490,Incision of gallbladder,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","4,314.00",,,,,,
BCBS HMO,CPT,47500,Injection for liver x-rays,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,47505,Injection for liver x-rays,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,47510,Insert catheter bile duct,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,47511,Insert bile duct drain,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,47525,Change bile duct catheter,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,47530,Revise/reinsert bile tube,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,47531,Injection for cholangiogram,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","4,314.00",,,,,,
BCBS HMO,CPT,47532,Injection for cholangiogram,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","4,314.00",,,,,,
BCBS HMO,CPT,47533,Plmt biliary drainage cath,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","4,314.00",,,,,,
BCBS HMO,CPT,47534,Plmt biliary drainage cath,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","4,314.00",,,,,,
BCBS HMO,CPT,47535,Conversion ext bil drg cath,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","4,314.00",,,,,,
BCBS HMO,CPT,47536,Exchange biliary drg cath,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","4,314.00",,,,,,
BCBS HMO,CPT,47537,Removal biliary drg cath,Surgical,Per Case,"$4,314.00 ",OP,828.48,"4,314.00",,,,,,
BCBS HMO,CPT,47538,Perq plmt bile duct stent,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,47539,Perq plmt bile duct stent,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,47540,Perq plmt bile duct stent,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,47541,Plmt access bil tree sm bwl,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","4,314.00",,,,,,
BCBS HMO,CPT,47542,Dilate biliary duct/ampulla,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,47543,Endoluminal bx biliary tree,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,47544,Removal duct glbldr calculi,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,47550,Bile duct endoscopy add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47552,Biliary endo perq dx w/speci,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","4,314.00",,,,,,
BCBS HMO,CPT,47553,Biliary endoscopy thru skin,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","4,314.00",,,,,,
BCBS HMO,CPT,47554,Biliary endoscopy thru skin,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,47555,Biliary endoscopy thru skin,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","4,314.00",,,,,,
BCBS HMO,CPT,47556,Biliary endoscopy thru skin,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,47560,Laparoscopy w/cholangio,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,47561,Laparo w/cholangio/biopsy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,47562,Laparoscopic cholecystectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,47563,Laparo cholecystectomy/graph,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,47564,Laparo cholecystectomy/explr,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,47570,Laparo cholecystoenterostomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47579,Laparoscope proc biliary,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,47600,Removal of gallbladder,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,47605,Removal of gallbladder,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,47610,Removal of gallbladder,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,47612,Removal of gallbladder,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,47620,Removal of gallbladder,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,47630,Remove bile duct stone,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,47700,Exploration of bile ducts,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47701,Bile duct revision,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47710,EXCISION OF BILE DUCT TUMOR,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,47711,Excision of bile duct tumor,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47712,Excision of bile duct tumor,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47715,Excision of bile duct cyst,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47716,Fusion of bile duct cyst,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,47719,Fusion of bile duct cyst,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,47720,Fuse gallbladder & bowel,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47721,Fuse upper gi structures,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47740,Fuse gallbladder & bowel,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47741,Fuse gallbladder & bowel,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47760,Fuse bile ducts and bowel,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47765,Fuse liver ducts & bowel,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47780,Fuse bile ducts and bowel,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47785,Fuse bile ducts and bowel,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47800,Reconstruction of bile ducts,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47801,Placement bile duct support,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47802,Fuse liver duct & intestine,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47900,Suture bile duct injury,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,47999,Bile tract surgery procedure,Surgical,Per Case,"$4,314.00 ",OP,828.48,"4,314.00",,,,,,
BCBS HMO,CPT,48000,Drainage of abdomen,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,48001,Placement of drain pancreas,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,48005,Resect/debride pancreas,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,48020,Removal of pancreatic stone,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,48100,Biopsy of pancreas open,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,48102,Needle biopsy pancreas,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,48105,Resect/debride pancreas,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,48120,Removal of pancreas lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,48140,Partial removal of pancreas,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,48145,Partial removal of pancreas,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,48146,Pancreatectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,48148,Removal of pancreatic duct,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,48150,Partial removal of pancreas,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,48151,PARTIAL REMOVAL OF PANCREAS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,48152,Pancreatectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,48153,Pancreatectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,48154,Pancreatectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,48155,Removal of pancreas,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,48160,Pancreas removal/transplant,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,48180,Fuse pancreas and bowel,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,48400,Injection intraop add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,48500,Surgery of pancreatic cyst,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,48510,Drain pancreatic pseudocyst,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,48511,Drain pancreatic pseudocyst,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,48520,Fuse pancreas cyst and bowel,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,48540,Fuse pancreas cyst and bowel,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,48545,Pancreatorrhaphy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,48547,Duodenal exclusion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,48548,Fuse pancreas and bowel,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,48550,Donor pancreatectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,48551,Prep donor pancreas,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,48552,Prep donor pancreas/venous,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,48554,Transpl allograft pancreas,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,48556,Removal allograft pancreas,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,48999,Pancreas surgery procedure,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,49000,Exploration of abdomen,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,49002,Reopening of abdomen,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,49010,Exploration behind abdomen,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","4,314.00",,,,,,
BCBS HMO,CPT,49013,Prpertl pel pack hemrrg trma,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,49014,Reexploration pelvic wound,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,49020,Drainage abdom abscess open,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,49021,Drain abdominal abscess,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,49040,Drain open abdom abscess,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,49041,Drain percut abdom abscess,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,49060,Drain open retroperi abscess,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,49061,Drain percut retroper absc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,49062,Drain to peritoneal cavity,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,49080,Puncture peritoneal cavity,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,49081,Removal of abdominal fluid,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,49082,Abd paracentesis,Surgical,Per Case,"$4,314.00 ",OP,828.48,"4,314.00",,,,,,
BCBS HMO,CPT,49083,Abd paracentesis w/imaging,Surgical,Per Case,"$4,314.00 ",OP,828.48,"4,314.00",,,,,,
BCBS HMO,CPT,49084,Peritoneal lavage,Surgical,Per Case,"$4,314.00 ",OP,828.48,"4,314.00",,,,,,
BCBS HMO,CPT,49085,Remove abdomen foreign body,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,49180,Biopsy abdominal mass,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,49185,Sclerotx fluid collection,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,49200,Removal of abdominal lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,49201,Remove abdom lesion-complex,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,49203,Exc abd tum 5 cm or less,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,49204,Exc abd tum over 5 cm,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,49205,Exc abd tum over 10 cm,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,49215,Excise sacral spine tumor,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,49220,Multiple surgery abdomen,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,49250,Excision of umbilicus,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","4,314.00",,,,,,
BCBS HMO,CPT,49255,Removal of omentum,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","4,314.00",,,,,,
BCBS HMO,CPT,49300,PERITONEOSCOPY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,49301,PERITONEOSCOPY w/BIOPSY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,49302,PERITONEOSCOPY w/X-RAY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,49303,PERITONEOSCOPY-XRAY & BIOPSY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,49310,LAPAROSCOPIC CHOLECYSTECTOMY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,49311,LAPAROSCOPIC CHOLECYSTECTOMY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,49315,LAPAROSCOPIC APPENDECTOMY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,49320,Diag laparo separate proc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,49321,Laparoscopy biopsy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,49322,Laparoscopy aspiration,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,49323,Laparo drain lymphocele,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,49324,Lap insert tunnel ip cath,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,49325,Lap revision perm ip cath,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,49326,Lap w/omentopexy add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,49327,Lap ins device for rt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,49329,Laparo proc abdm/per/oment,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,49400,Air injection into abdomen,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,49401,AIR INJECTION INTO ABDOMEN,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,49402,Remove foreign body adbomen,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","4,314.00",,,,,,
BCBS HMO,CPT,49405,Image cath fluid colxn visc,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,49406,Image cath fluid peri/retro,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,49407,Image cath fluid trns/vgnl,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,49411,Ins mark abd/pel for rt perq,Surgical,Per Case,"$4,314.00 ",OP,"1,291.62","4,314.00",,,,,,
BCBS HMO,CPT,49412,Ins device for rt guide open,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,49418,Insert tun ip cath perc,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","4,314.00",,,,,,
BCBS HMO,CPT,49419,Insert tun ip cath w/port,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,881.61",,,,,,
BCBS HMO,CPT,49420,Insert abdom drain - temp,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,49421,Ins tun ip cath for dial opn,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","4,314.00",,,,,,
BCBS HMO,CPT,49422,Remove tunneled ip cath,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,49423,Exchange drainage catheter,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,49424,Assess cyst contrast inject,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,49425,Insert abdomen-venous drain,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,49426,Revise abdomen-venous shunt,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","4,314.00",,,,,,
BCBS HMO,CPT,49427,Injection abdominal shunt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,49428,Ligation of shunt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,49429,Removal of shunt,Surgical,Per Case,"$4,314.00 ",OP,"2,928.39","4,314.00",,,,,,
BCBS HMO,CPT,49435,Insert subq exten to ip cath,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,49436,Embedded ip cath exit-site,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,49440,Place gastrostomy tube perc,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,49441,Place duod/jej tube perc,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,49442,Place cecostomy tube perc,Surgical,Per Case,"$4,314.00 ",OP,"1,061.14","4,314.00",,,,,,
BCBS HMO,CPT,49446,Change g-tube to g-j perc,Surgical,Per Case,"$4,314.00 ",OP,"1,662.91","4,314.00",,,,,,
BCBS HMO,CPT,49450,Replace g/c tube perc,Surgical,Per Case,"$4,314.00 ",OP,828.48,"4,314.00",,,,,,
BCBS HMO,CPT,49451,Replace duod/jej tube perc,Surgical,Per Case,"$4,314.00 ",OP,828.48,"4,314.00",,,,,,
BCBS HMO,CPT,49452,Replace g-j tube perc,Surgical,Per Case,"$4,314.00 ",OP,828.48,"4,314.00",,,,,,
BCBS HMO,CPT,49460,Fix g/colon tube w/device,Surgical,Per Case,"$4,314.00 ",OP,828.48,"4,314.00",,,,,,
BCBS HMO,CPT,49465,Fluoro exam of g/colon tube,Surgical,Per Case,"$4,314.00 ",OP,235.49,"4,314.00",,,,,,
BCBS HMO,CPT,49491,Rpr hern preemie reduc,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,49492,Rpr ing hern premie blocked,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","9,201.00",,,,,,
BCBS HMO,CPT,49495,Rpr ing hernia baby reduc,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","9,201.00",,,,,,
BCBS HMO,CPT,49496,Rpr ing hernia baby blocked,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","9,201.00",,,,,,
BCBS HMO,CPT,49500,Rpr ing hernia init reduce,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","9,201.00",,,,,,
BCBS HMO,CPT,49501,Rpr ing hernia init blocked,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","9,201.00",,,,,,
BCBS HMO,CPT,49505,Prp i/hern init reduc >5 yr,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","9,201.00",,,,,,
BCBS HMO,CPT,49507,Prp i/hern init block >5 yr,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","9,201.00",,,,,,
BCBS HMO,CPT,49510,REPAIR HERNIA-REMOVE TESTIS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,49515,REPAIR INGUINAL HERNIA,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,49520,Rerepair ing hernia reduce,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","9,201.00",,,,,,
BCBS HMO,CPT,49521,Rerepair ing hernia blocked,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","9,201.00",,,,,,
BCBS HMO,CPT,49525,Repair ing hernia sliding,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","9,201.00",,,,,,
BCBS HMO,CPT,49530,REPAIR INCARCERATED HERNIA,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,49535,REPAIR STRANGULATED HERNIA,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,49540,Repair lumbar hernia,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,49550,Rpr rem hernia init reduce,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","4,314.00",,,,,,
BCBS HMO,CPT,49552,REPAIR FEMORAL HERNIA,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,49553,Rpr fem hernia init blocked,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","4,314.00",,,,,,
BCBS HMO,CPT,49555,Rerepair fem hernia reduce,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","4,314.00",,,,,,
BCBS HMO,CPT,49557,Rerepair fem hernia blocked,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","4,314.00",,,,,,
BCBS HMO,CPT,49560,Rpr ventral hern init reduc,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","9,201.00",,,,,,
BCBS HMO,CPT,49561,Rpr ventral hern init block,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","9,201.00",,,,,,
BCBS HMO,CPT,49565,Rerepair ventrl hern reduce,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,49566,Rerepair ventrl hern block,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,49568,Hernia repair w/mesh,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,49570,Rpr epigastric hern reduce,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","4,314.00",,,,,,
BCBS HMO,CPT,49572,Rpr epigastric hern blocked,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","4,314.00",,,,,,
BCBS HMO,CPT,49575,REPAIR EPIGASTRIC HERNIA,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,49580,Rpr umbil hern reduc < 5 yr,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","4,314.00",,,,,,
BCBS HMO,CPT,49581,REPAIR UMBILICAL HERNIA,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,49582,Rpr umbil hern block < 5 yr,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","4,314.00",,,,,,
BCBS HMO,CPT,49585,Rpr umbil hern reduc > 5 yr,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","4,314.00",,,,,,
BCBS HMO,CPT,49587,Rpr umbil hern block > 5 yr,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","4,314.00",,,,,,
BCBS HMO,CPT,49590,Repair spigelian hernia,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","4,314.00",,,,,,
BCBS HMO,CPT,49600,Repair umbilical lesion,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","4,314.00",,,,,,
BCBS HMO,CPT,49605,Repair umbilical lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,49606,Repair umbilical lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,49610,Repair umbilical lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,49611,Repair umbilical lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,49635,OMENTOPEXY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,49650,Lap ing hernia repair init,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,49651,Lap ing hernia repair recur,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,49652,Lap vent/abd hernia repair,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,49653,Lap vent/abd hern proc comp,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,49654,Lap inc hernia repair,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,49655,Lap inc hern repair comp,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","9,115.38",,,,,,
BCBS HMO,CPT,49656,Lap inc hernia repair recur,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","9,115.38",,,,,,
BCBS HMO,CPT,49657,Lap inc hern recur comp,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","9,115.38",,,,,,
BCBS HMO,CPT,49659,Laparo proc hernia repair,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,49900,Repair of abdominal wall,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,49904,Omental flap extra-abdom,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,49905,Omental flap intra-abdom,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,49906,Free omental flap microvasc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,49999,Abdomen surgery procedure,Surgical,Per Case,"$4,314.00 ",OP,828.48,"4,314.00",,,,,,
BCBS HMO,CPT,50010,Exploration of kidney,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50020,Renal abscess open drain,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,50021,Renal abscess percut drain,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,50040,Drainage of kidney,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50045,Exploration of kidney,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50060,Removal of kidney stone,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50065,Incision of kidney,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50070,Incision of kidney,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50075,Removal of kidney stone,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50080,Removal of kidney stone,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,450.70",,,,,,
BCBS HMO,CPT,50081,Removal of kidney stone,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,450.70",,,,,,
BCBS HMO,CPT,50082,REMOVAL OF KIDNEY STONE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,50100,Revise kidney blood vessels,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50120,Exploration of kidney,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50125,Explore and drain kidney,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50130,Removal of kidney stone,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50135,Exploration of kidney,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50200,Renal biopsy perq,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,50205,Renal biopsy open,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50220,Remove kidney open,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50225,Removal kidney open complex,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50230,Removal kidney open radical,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50234,Removal of kidney & ureter,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50236,Removal of kidney & ureter,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50240,Partial removal of kidney,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50250,Cryoablate renal mass open,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50280,Removal of kidney lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50290,Removal of kidney lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50300,Remove cadaver donor kidney,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50320,Remove kidney living donor,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50323,Prep cadaver renal allograft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50325,Prep donor renal graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50327,Prep renal graft/venous,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50328,Prep renal graft/arterial,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50329,Prep renal graft/ureteral,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50340,Removal of kidney,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50360,Transplantation of kidney,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50365,Transplantation of kidney,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50370,Remove transplanted kidney,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50380,Reimplantation of kidney,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50382,Change ureter stent percut,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,50384,Remove ureter stent percut,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,50385,Change stent via transureth,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,50386,Remove stent via transureth,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,50387,Change nephroureteral cath,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,50389,Remove renal tube w/fluoro,Surgical,Per Case,"$4,314.00 ",OP,588.17,"4,314.00",,,,,,
BCBS HMO,CPT,50390,Drainage of kidney lesion,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,50391,Instll rx agnt into rnal tub,Surgical,Per Case,"$4,314.00 ",OP,272.35,"4,314.00",,,,,,
BCBS HMO,CPT,50392,Insert kidney drain,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,50393,Insert ureteral tube,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,50394,Injection for kidney x-ray,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,50395,Create passage to kidney,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,50396,Measure kidney pressure,Surgical,Per Case,"$4,314.00 ",OP,588.17,"4,314.00",,,,,,
BCBS HMO,CPT,50398,Change kidney tube,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,50400,Revision of kidney/ureter,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50405,Revision of kidney/ureter,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50420,NEPHROPEXY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,50430,Njx px nfrosgrm &/urtrgrm,Surgical,Per Case,"$4,314.00 ",OP,588.17,"4,314.00",,,,,,
BCBS HMO,CPT,50431,Njx px nfrosgrm &/urtrgrm,Surgical,Per Case,"$4,314.00 ",OP,588.17,"4,314.00",,,,,,
BCBS HMO,CPT,50432,Plmt nephrostomy catheter,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,50433,Plmt nephroureteral catheter,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,50434,Convert nephrostomy catheter,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,50435,Exchange nephrostomy cath,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,50436,Dilat xst trc ndurlgc px,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,50437,Dilat xst trc new access rcs,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,50500,Repair of kidney wound,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50520,Close kidney-skin fistula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50525,Close nephrovisceral fistula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50526,Close nephrovisceral fistula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50540,Revision of horseshoe kidney,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50541,Laparo ablate renal cyst,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,50542,Laparo ablate renal mass,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","9,115.38",,,,,,
BCBS HMO,CPT,50543,Laparo partial nephrectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","9,115.38",,,,,,
BCBS HMO,CPT,50544,Laparoscopy pyeloplasty,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,50545,Laparo radical nephrectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50546,Laparoscopic nephrectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50547,Laparo removal donor kidney,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50548,Laparo remove w/ureter,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50549,Laparoscope proc renal,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,50551,Kidney endoscopy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,50553,Kidney endoscopy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,50554,KIDNEY ENDOSCOPY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,50555,Kidney endoscopy & biopsy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,450.70",,,,,,
BCBS HMO,CPT,50557,Kidney endoscopy & treatment,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,450.70",,,,,,
BCBS HMO,CPT,50559,RENAL ENDOSCOPY-RADIOTRACER,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,50561,Kidney endoscopy & treatment,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,50562,Renal scope w/tumor resect,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,450.70",,,,,,
BCBS HMO,CPT,50570,Kidney endoscopy,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,50572,Kidney endoscopy,Surgical,Per Case,"$4,314.00 ",OP,588.17,"4,314.00",,,,,,
BCBS HMO,CPT,50574,Kidney endoscopy & biopsy,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,50575,Kidney endoscopy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,50576,Kidney endoscopy & treatment,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,50578,RENAL ENDOSCOPY-RADIOTRACER,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,50580,Kidney endoscopy & treatment,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,50590,Fragmenting of kidney stone,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,50592,Perc rf ablate renal tumor,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,50593,Perc cryo ablate renal tum,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","9,115.38",,,,,,
BCBS HMO,CPT,50600,Exploration of ureter,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50605,Insert ureteral support,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50606,Endoluminal bx urtr rnl plvs,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,50610,Removal of ureter stone,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50620,Removal of ureter stone,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50630,Removal of ureter stone,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50650,Removal of ureter,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50660,Removal of ureter,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50684,Injection for ureter x-ray,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,50686,Measure ureter pressure,Surgical,Per Case,"$4,314.00 ",OP,142.8,"4,314.00",,,,,,
BCBS HMO,CPT,50688,Change of ureter tube/stent,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,50690,Injection for ureter x-ray,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,50693,Plmt ureteral stent prq,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,50694,Plmt ureteral stent prq,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,50695,Plmt ureteral stent prq,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,50700,Revision of ureter,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50705,Ureteral embolization/occl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,50706,Balloon dilate urtrl strix,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,50715,Release of ureter,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50722,Release of ureter,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50725,Release/revise ureter,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50727,Revise ureter,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,50728,Revise ureter,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50740,Fusion of ureter & kidney,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50750,Fusion of ureter & kidney,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50760,Fusion of ureters,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50770,Splicing of ureters,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50780,Reimplant ureter in bladder,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50782,Reimplant ureter in bladder,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50783,Reimplant ureter in bladder,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50785,Reimplant ureter in bladder,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50800,Implant ureter in bowel,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50810,Fusion of ureter & bowel,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50815,Urine shunt to intestine,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50820,Construct bowel bladder,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50825,Construct bowel bladder,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50830,Revise urine flow,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50840,Replace ureter by bowel,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50845,Appendico-vesicostomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50860,Transplant ureter to skin,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50900,Repair of ureter,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50920,Closure ureter/skin fistula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50930,Closure ureter/bowel fistula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50940,Release of ureter,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,50945,Laparoscopy ureterolithotomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,50947,Laparo new ureter/bladder,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,50948,Laparo new ureter/bladder,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","9,115.38",,,,,,
BCBS HMO,CPT,50949,Laparoscope proc ureter,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,50951,Endoscopy of ureter,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,50953,Endoscopy of ureter,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,50955,Ureter endoscopy & biopsy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,50957,Ureter endoscopy & treatment,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,50959,URETER ENDOSCOPY & TRACER,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,50961,Ureter endoscopy & treatment,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,50970,Ureter endoscopy,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,50972,Ureter endoscopy & catheter,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,50974,Ureter endoscopy & biopsy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,50976,Ureter endoscopy & treatment,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,50978,URETER ENDOSCOPY & TRACER,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,50980,Ureter endoscopy & treatment,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,51000,Drainage of bladder,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,51005,Drainage of bladder,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,51010,Drainage of bladder,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,51020,Incise & treat bladder,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,51030,Incise & treat bladder,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,51040,Incise & drain bladder,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,51041,CYSTOSTOMY-CLOSED,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,51045,Incise bladder/drain ureter,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,51050,Removal of bladder stone,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,51060,Removal of ureter stone,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,51065,Remove ureter calculus,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,51080,Drainage of bladder abscess,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,51100,Drain bladder by needle,Surgical,Per Case,"$4,314.00 ",OP,272.35,"4,314.00",,,,,,
BCBS HMO,CPT,51101,Drain bladder by trocar/cath,Surgical,Per Case,"$4,314.00 ",OP,941.27,"4,314.00",,,,,,
BCBS HMO,CPT,51102,Drain bl w/cath insertion,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,51500,Removal of bladder cyst,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,51520,Removal of bladder lesion,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,51525,Removal of bladder lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,51530,Removal of bladder lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,51535,Repair of ureter lesion,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,51536,CYSTOTOMY W/INSERT URETERAL CATH,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,51550,Partial removal of bladder,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,51555,Partial removal of bladder,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,51565,Revise bladder & ureter(s),Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,51570,Removal of bladder,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,51575,Removal of bladder & nodes,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,51580,Remove bladder/revise tract,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,51585,Removal of bladder & nodes,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,51590,Remove bladder/revise tract,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,51595,Remove bladder/revise tract,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,51596,Remove bladder/create pouch,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,51597,Removal of pelvic structures,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,51600,Injection for bladder x-ray,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,51605,Preparation for bladder xray,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,51610,Injection for bladder x-ray,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,51700,Irrigation of bladder,Surgical,Per Case,"$4,314.00 ",OP,272.35,"4,314.00",,,,,,
BCBS HMO,CPT,51701,Insert bladder catheter,Surgical,Per Case,"$4,314.00 ",OP,114.56,"4,314.00",,,,,,
BCBS HMO,CPT,51702,Insert temp bladder cath,Surgical,Per Case,"$4,314.00 ",OP,114.56,"4,314.00",,,,,,
BCBS HMO,CPT,51703,Insert bladder cath complex,Surgical,Per Case,"$4,314.00 ",OP,142.8,"4,314.00",,,,,,
BCBS HMO,CPT,51705,Change of bladder tube,Surgical,Per Case,"$4,314.00 ",OP,272.35,"4,314.00",,,,,,
BCBS HMO,CPT,51710,Change of bladder tube,Surgical,Per Case,"$4,314.00 ",OP,588.17,"4,314.00",,,,,,
BCBS HMO,CPT,51715,Endoscopic injection/implant,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,51720,Treatment of bladder lesion,Surgical,Per Case,"$4,314.00 ",OP,272.35,"4,314.00",,,,,,
BCBS HMO,CPT,51725,Simple cystometrogram,Surgical,Per Case,"$4,314.00 ",OP,272.35,"4,314.00",,,,,,
BCBS HMO,CPT,51726,Complex cystometrogram,Surgical,Per Case,"$4,314.00 ",OP,272.35,"4,314.00",,,,,,
BCBS HMO,CPT,51727,Cystometrogram w/up,Surgical,Per Case,"$4,314.00 ",OP,588.17,"4,314.00",,,,,,
BCBS HMO,CPT,51728,Cystometrogram w/vp,Surgical,Per Case,"$4,314.00 ",OP,588.17,"4,314.00",,,,,,
BCBS HMO,CPT,51729,Cystometrogram w/vp&up,Surgical,Per Case,"$4,314.00 ",OP,588.17,"4,314.00",,,,,,
BCBS HMO,CPT,51736,Urine flow measurement,Surgical,Per Case,"$4,314.00 ",OP,114.56,"4,314.00",,,,,,
BCBS HMO,CPT,51737,UROFLOWMETRY PHARMACOLOGICAL,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,51738,UROFLOWMETRY-NERVE BLOCK,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,51739,SOUND RECORD OF URINE STREAM,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,51741,Electro-uroflowmetry first,Surgical,Per Case,"$4,314.00 ",OP,142.8,"4,314.00",,,,,,
BCBS HMO,CPT,51742,COMPLEX UROFLOW ADDITIONAL,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,51743,COMPLEX UROFLOW PHARMACOLOGC,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,51744,COMPLEX UROFLOW NERVE BLOCK,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,51772,Urethra pressure profile,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,51773,UPP-ADDITIONAL,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,51776,UPP w/INTRA-ABDOMINAL,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,51777,UPP w/I-A ADDITIONAL,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,51778,UPP w/BLADDER & I-A,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,51779,UPP w/BLADDER & I-A-ADD.,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,51780,UPP PHARMACOLOGICAL 1-6,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,51781,UPP PHARMACOLOGICAL 6+,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,51782,UPP NERVE BLOCK 1-6,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,51783,UPP NERVE BLOCK 6+,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,51784,Anal/urinary muscle study,Surgical,Per Case,"$4,314.00 ",OP,142.8,"4,314.00",,,,,,
BCBS HMO,CPT,51785,Anal/urinary muscle study,Surgical,Per Case,"$4,314.00 ",OP,272.35,"4,314.00",,,,,,
BCBS HMO,CPT,51786,EMG w/CYSTOGRAM,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,51787,EMG w/UROFLOW,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,51788,EMG w/CGRAM & UROFLOW,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,51792,Urinary reflex study,Surgical,Per Case,"$4,314.00 ",OP,56.95,"4,314.00",,,,,,
BCBS HMO,CPT,51795,Urine voiding pressure study,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,51796,VP SUPRAPUBIC,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,51797,Intraabdominal pressure test,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,51798,Us urine capacity measure,Surgical,Per Case,"$4,314.00 ",OP,56.95,"4,314.00",,,,,,
BCBS HMO,CPT,51800,Revision of bladder/urethra,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,51820,Revision of urinary tract,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,51840,Attach bladder/urethra,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,512.36",,,,,,
BCBS HMO,CPT,51841,Attach bladder/urethra,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,51845,Repair bladder neck,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,512.36",,,,,,
BCBS HMO,CPT,51846,VAGINAL NECK W/O ENDOSCOPE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,51860,Repair of bladder wound,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,51865,Repair of bladder wound,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,51880,Repair of bladder opening,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,51900,Repair bladder/vagina lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,51920,Close bladder-uterus fistula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,51925,Hysterectomy/bladder repair,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,51940,Correction of bladder defect,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,51960,Revision of bladder & bowel,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,51980,Construct bladder opening,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,51990,Laparo urethral suspension,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,51992,Laparo sling operation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,51999,Laparoscope proc bla,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,52000,Cystoscopy,Surgical,Per Case,"$4,314.00 ",OP,588.17,"4,314.00",,,,,,
BCBS HMO,CPT,52001,Cystoscopy removal of clots,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,52005,Cystoscopy & ureter catheter,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,52007,Cystoscopy and biopsy,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,52010,Cystoscopy & duct catheter,Surgical,Per Case,"$4,314.00 ",OP,588.17,"4,314.00",,,,,,
BCBS HMO,CPT,52011,CYSTO INDWELLING  STENT,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,52100,CYSTOSCOPY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,52105,CYSTOSCOPY & URETER CATHETER,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,52202,CYSTOSCOPY & BIOPSY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,52204,Cystoscopy w/biopsy(s),Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,52214,Cystoscopy and treatment,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,52224,Cystoscopy and treatment,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,52234,Cystoscopy and treatment,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,52235,Cystoscopy and treatment,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,52236,CYSTOSCOPY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,52237,CYSTOSCOPY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,52238,CYSTOSCOPY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,52239,CYSTOSCOPY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,52240,Cystoscopy and treatment,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,52250,Cystoscopy and radiotracer,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,52260,Cystoscopy and treatment,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,52265,Cystoscopy and treatment,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,52270,Cystoscopy & revise urethra,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,52271,CYSTOSCOPY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,52272,CYSTOSCOPY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,52273,CYSTOSCOPY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,52274,CYSTOSCOPY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,52275,Cystoscopy & revise urethra,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,52276,Cystoscopy and treatment,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,52277,Cystoscopy and treatment,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,52280,CYSTOSCOPY & TREATMENT,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,52281,Cystoscopy and treatment,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,52282,Cystoscopy implant stent,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,52283,Cystoscopy and treatment,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,52285,Cystoscopy and treatment,Surgical,Per Case,"$4,314.00 ",OP,588.17,"4,314.00",,,,,,
BCBS HMO,CPT,52287,Cystoscopy chemodenervation,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,52290,Cystoscopy and treatment,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,52300,Cystoscopy and treatment,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,52301,Cystoscopy and treatment,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,52305,Cystoscopy and treatment,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,52310,Cystoscopy and treatment,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,52315,Cystoscopy and treatment,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,52317,Remove bladder stone,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,52318,Remove bladder stone,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,52320,Cystoscopy and treatment,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,52325,Cystoscopy stone removal,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,52327,Cystoscopy inject material,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,52330,Cystoscopy and treatment,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,52332,Cystoscopy and treatment,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,52333,CYSTO w/BALLOON OF UPJ,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,52334,Create passage to kidney,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,52335,ENDOSCOPY OF URINARY TRACT,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,52336,CYSTOSCOPY-STONE REMOVAL,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,52337,CYSTOSCOPY-STONE REMOVAL,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,52338,CYSTOSCOPY AND TREATMENT,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,52339,CYSTOSCOPY AND TREATMENT,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,52340,CYSTOSCOPY AND TREATMENT,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,52341,Cysto w/ureter stricture tx,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,52342,Cysto w/up stricture tx,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,52343,Cysto w/renal stricture tx,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,52344,Cysto/uretero stricture tx,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,52345,Cysto/uretero w/up stricture,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,52346,Cystouretero w/renal strict,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,52347,CYSTURETHRSCPY W/TU RES/INCI EJACULATORY DUCTS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,52351,Cystouretero & or pyeloscope,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,52352,Cystouretero w/stone remove,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,52353,Cystouretero w/lithotripsy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,52354,Cystouretero w/biopsy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,52355,Cystouretero w/excise tumor,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,52356,Cysto/uretero w/lithotripsy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,52400,Cystouretero w/congen repr,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,52402,Cystourethro cut ejacul duct,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,52441,Cystourethro w/implant,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,52442,Cystourethro w/addl implant,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,52450,Incision of prostate,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,52500,Revision of bladder neck,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,52510,Dilation prostatic urethra,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,52601,Prostatectomy (turp),Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,52606,Control postop bleeding,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,52612,Prostatectomy - first stage,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,52614,Prostatectomy - second stage,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,52620,Remove residual prostate,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,52630,Remove prostate regrowth,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,52640,Relieve bladder contracture,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,52647,Laser surgery of prostate,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,52648,Laser surgery of prostate,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,52649,Prostate laser enucleation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,52650,PROSTATECTOMY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,52680,MICROWAVE OF PROSTATE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,52700,Drainage of prostate abscess,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,53000,Incision of urethra,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,53010,Incision of urethra,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,53020,Incision of urethra,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,53025,Incision of urethra,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,53040,Drainage of urethra abscess,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,53060,Drainage of urethra abscess,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,53080,Drainage of urinary leakage,Surgical,Per Case,"$4,314.00 ",OP,588.17,"4,314.00",,,,,,
BCBS HMO,CPT,53085,Drainage of urinary leakage,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,53200,Biopsy of urethra,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,53210,Removal of urethra,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,53215,Removal of urethra,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,53220,Treatment of urethra lesion,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,53230,Removal of urethra lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,53235,Removal of urethra lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,53240,Surgery for urethra pouch,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,53250,Removal of urethra gland,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,53260,Treatment of urethra lesion,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,53265,Treatment of urethra lesion,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,53270,Removal of urethra gland,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,53275,Repair of urethra defect,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,53400,Revise urethra stage 1,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,53405,Revise urethra stage 2,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,53410,Reconstruction of urethra,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,53415,Reconstruction of urethra,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,53420,Reconstruct urethra stage 1,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,53425,Reconstruct urethra stage 2,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,53430,Reconstruction of urethra,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,53431,Reconstruct urethra/bladder,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,53440,Male sling procedure,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","11,755.91",,,,,,
BCBS HMO,CPT,53442,Remove/revise male sling,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,53443,RECONSTRUCTION OF URETHRA,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,53444,Insert tandem cuff,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","18,684.12",,,,,,
BCBS HMO,CPT,53445,Insert uro/ves nck sphincter,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","18,684.12",,,,,,
BCBS HMO,CPT,53446,Remove uro sphincter,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,53447,Remove/replace ur sphincter,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","18,684.12",,,,,,
BCBS HMO,CPT,53448,Remov/replc ur sphinctr comp,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,53449,Repair uro sphincter,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,53450,Revision of urethra,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,53460,Revision of urethra,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,53500,Urethrlys transvag w/ scope,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,53502,Repair of urethra injury,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,53505,Repair of urethra injury,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,53510,Repair of urethra injury,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,53515,Repair of urethra injury,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,53520,Repair of urethra defect,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,53600,Dilate urethra stricture,Surgical,Per Case,"$4,314.00 ",OP,272.35,"4,314.00",,,,,,
BCBS HMO,CPT,53601,Dilate urethra stricture,Surgical,Per Case,"$4,314.00 ",OP,114.56,"4,314.00",,,,,,
BCBS HMO,CPT,53605,Dilate urethra stricture,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,53620,Dilate urethra stricture,Surgical,Per Case,"$4,314.00 ",OP,588.17,"4,314.00",,,,,,
BCBS HMO,CPT,53621,Dilate urethra stricture,Surgical,Per Case,"$4,314.00 ",OP,272.35,"4,314.00",,,,,,
BCBS HMO,CPT,53640,Passage of filiform & follower for acute vesical retention-male,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,53660,Dilation of urethra,Surgical,Per Case,"$4,314.00 ",OP,142.8,"4,314.00",,,,,,
BCBS HMO,CPT,53661,Dilation of urethra,Surgical,Per Case,"$4,314.00 ",OP,114.56,"4,314.00",,,,,,
BCBS HMO,CPT,53665,Dilation of urethra,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,53670,INSERT URINARY CATHETER,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,53675,INSERT URINARY CATHETER,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,53800,URINALYSIS-GLASS TEST,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,53850,Prostatic microwave thermotx,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,53852,Prostatic rf thermotx,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,53853,Prostatic water thermother,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,53854,Trurl dstrj prst8 tiss rf wv,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,53855,Insert prost urethral stent,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,53860,Transurethral rf treatment,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,53899,Urology surgery procedure,Surgical,Per Case,"$4,314.00 ",OP,272.35,"4,314.00",,,,,,
BCBS HMO,CPT,54000,Slitting of prepuce,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,54001,Slitting of prepuce,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,54015,Drain penis lesion,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,54050,Destruction penis lesion(s),Surgical,Per Case,"$4,314.00 ",OP,353.91,"4,314.00",,,,,,
BCBS HMO,CPT,54055,Destruction penis lesion(s),Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,54056,Cryosurgery penis lesion(s),Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,54057,Laser surg penis lesion(s),Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,54060,Excision of penis lesion(s),Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,54065,Destruction penis lesion(s),Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,54100,Biopsy of penis,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,54105,Biopsy of penis,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,54110,Treatment of penis lesion,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,54111,Treat penis lesion graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,54112,Treat penis lesion graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,450.70",,,,,,
BCBS HMO,CPT,54115,Treatment of penis lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,54120,Partial removal of penis,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,54125,Removal of penis,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,54130,Remove penis & nodes,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,54135,Remove penis & nodes,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,54150,Circumcision w/regionl block,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,54152,Circumcision,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,54160,Circumcision neonate,Surgical,Per Case,"$4,314.00 ",OP,588.17,"4,314.00",,,,,,
BCBS HMO,CPT,54161,Circum 28 days or older,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,54162,Lysis penil circumic lesion,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,54163,Repair of circumcision,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,54164,Frenulotomy of penis,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,54200,Treatment of penis lesion,Surgical,Per Case,"$4,314.00 ",OP,272.35,"4,314.00",,,,,,
BCBS HMO,CPT,54205,Treatment of penis lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,54220,Treatment of penis lesion,Surgical,Per Case,"$4,314.00 ",OP,272.35,"4,314.00",,,,,,
BCBS HMO,CPT,54230,Prepare penis study,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,54231,Dynamic cavernosometry,Surgical,Per Case,"$4,314.00 ",OP,272.35,"4,314.00",,,,,,
BCBS HMO,CPT,54235,Penile injection,Surgical,Per Case,"$4,314.00 ",OP,272.35,"4,314.00",,,,,,
BCBS HMO,CPT,54240,Penis study,Surgical,Per Case,"$4,314.00 ",OP,270.61,"4,314.00",,,,,,
BCBS HMO,CPT,54250,Penis study,Surgical,Per Case,"$4,314.00 ",OP,272.35,"4,314.00",,,,,,
BCBS HMO,CPT,54251,PENILE TUMESCENCE OTHER,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,54300,Revision of penis,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,54304,Revision of penis,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,54308,Reconstruction of urethra,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,54312,Reconstruction of urethra,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,54316,Reconstruction of urethra,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,54318,Reconstruction of urethra,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,54322,Reconstruction of urethra,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,54324,Reconstruction of urethra,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,54326,Reconstruction of urethra,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,54328,Revise penis/urethra,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,54332,Revise penis/urethra,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,54336,Revise penis/urethra,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,54340,Secondary urethral surgery,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,54344,Secondary urethral surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,54348,Secondary urethral surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,54352,Reconstruct urethra/penis,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,54360,Penis plastic surgery,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,54380,Repair penis,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,54385,Repair penis,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,54390,Repair penis and bladder,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,54400,Insert semi-rigid prosthesis,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","11,755.91",,,,,,
BCBS HMO,CPT,54401,Insert self-contd prosthesis,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","18,684.12",,,,,,
BCBS HMO,CPT,54402,REMOVE PENIS PROSTHESIS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,54405,Insert multi-comp penis pros,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","18,684.12",,,,,,
BCBS HMO,CPT,54406,Remove muti-comp penis pros,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,54407,REMOVE MULTI-COMP PROSTHESIS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,54408,Repair multi-comp penis pros,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,54409,REVISE PENIS PROSTHESIS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,54410,Remove/replace penis prosth,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","18,684.12",,,,,,
BCBS HMO,CPT,54411,Remov/replc penis pros comp,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","18,684.12",,,,,,
BCBS HMO,CPT,54412,DORSAL VEIN LEGATION/PENIS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,54415,Remove self-contd penis pros,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,54416,Remv/repl penis contain pros,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","18,684.12",,,,,,
BCBS HMO,CPT,54417,Remv/replc penis pros compl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","11,755.91",,,,,,
BCBS HMO,CPT,54420,Revision of penis,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,54430,Revision of penis,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,54435,Revision of penis,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,54437,Repair corporeal tear,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,54438,Replantation of penis,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,54440,Repair of penis,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,54450,Preputial stretching,Surgical,Per Case,"$4,314.00 ",OP,272.35,"4,314.00",,,,,,
BCBS HMO,CPT,54500,Biopsy of testis,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,54505,Biopsy of testis,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,54506,BIOPSY OF TESTES,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,54510,REMOVAL OF TESTIS LESION,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,54512,Excise lesion testis,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,54520,Removal of testis,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,54521,REMOVAL OF TESTES,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,54522,Orchiectomy partial,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,54530,Removal of testis,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","4,314.00",,,,,,
BCBS HMO,CPT,54535,Extensive testis surgery,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,54550,Exploration for testis,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","4,314.00",,,,,,
BCBS HMO,CPT,54560,Exploration for testis,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,54600,Reduce testis torsion,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,54620,Suspension of testis,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,54640,Orchiopexy ingun/scrot appr,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","4,314.00",,,,,,
BCBS HMO,CPT,54645,SUSPENSION OF TESTIS-STAGE 2,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,54650,Orchiopexy (fowler-stephens),Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","4,314.00",,,,,,
BCBS HMO,CPT,54660,Revision of testis,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,54670,Repair testis injury,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,54680,Relocation of testis(es),Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,54690,Laparoscopy orchiectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,54692,Laparoscopy orchiopexy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,54699,Laparoscope proc testis,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,54700,Drainage of scrotum,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,54800,Biopsy of epididymis,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,54820,Exploration of epididymis,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,54830,Remove epididymis lesion,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,54840,Remove epididymis lesion,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,54860,Removal of epididymis,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,54861,Removal of epididymis,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,54865,Explore epididymis,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,54900,Fusion of spermatic ducts,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,54901,Fusion of spermatic ducts,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,55000,Drainage of hydrocele,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,55040,Removal of hydrocele,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","4,314.00",,,,,,
BCBS HMO,CPT,55041,Removal of hydroceles,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","4,314.00",,,,,,
BCBS HMO,CPT,55060,Repair of hydrocele,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,55100,Drainage of scrotum abscess,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,55110,Explore scrotum,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,55120,Removal of scrotum lesion,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,55150,Removal of scrotum,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,55175,Revision of scrotum,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,55180,Revision of scrotum,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,55200,Incision of sperm duct,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,55250,Removal of sperm duct(s),Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,55300,Prepare sperm duct x-ray,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,55400,Repair of sperm duct,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,55401,REPAIR OF SPERM DUCTS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,55450,Ligation of sperm duct,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,55500,Removal of hydrocele,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,55520,Removal of sperm cord lesion,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,55530,Revise spermatic cord veins,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,55535,Revise spermatic cord veins,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","4,314.00",,,,,,
BCBS HMO,CPT,55540,Revise hernia & sperm veins,Surgical,Per Case,"$4,314.00 ",OP,"3,257.65","9,201.00",,,,,,
BCBS HMO,CPT,55550,Laparo ligate spermatic vein,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,55559,Laparo proc spermatic cord,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,55600,Incise sperm duct pouch,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,55605,Incise sperm duct pouch,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,55650,Remove sperm duct pouch,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,55651,REMOVE SPERM DUCT POUCHES,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,55680,Remove sperm pouch lesion,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,55700,Biopsy of prostate,Surgical,Per Case,"$4,314.00 ",OP,"1,834.80","4,314.00",,,,,,
BCBS HMO,CPT,55705,Biopsy of prostate,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,55706,Prostate saturation sampling,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,55720,Drainage of prostate abscess,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,55725,Drainage of prostate abscess,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,55740,REMOVAL OF PROSTATE STONE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,55780,ULTRASOUND PROSTATE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,55782,ULTRASOUND BIOPSY PROSTATE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,55801,Removal of prostate,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,55810,Extensive prostate surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,55812,Extensive prostate surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,55815,Extensive prostate surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,55821,Removal of prostate,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,55831,Removal of prostate,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,55840,Extensive prostate surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,55842,Extensive prostate surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,55845,Extensive prostate surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,55859,Percut/needle insert-pros,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,55860,Surgical exposure prostate,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,55862,Extensive prostate surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,55865,Extensive prostate surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,55866,Laparo radical prostatectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","9,115.38",,,,,,
BCBS HMO,CPT,55870,Electroejaculation,Surgical,Per Case,"$4,314.00 ",OP,648.18,"4,314.00",,,,,,
BCBS HMO,CPT,55873,Cryoablate prostate,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,450.70",,,,,,
BCBS HMO,CPT,55874,Tprnl plmt biodegrdabl matrl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,55875,Transperi needle place pros,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,55876,Place rt device/marker pros,Surgical,Per Case,"$4,314.00 ",OP,"1,291.62","4,314.00",,,,,,
BCBS HMO,CPT,55880,Abltj mal prst8 tiss hifu,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,516.83",,,,,,
BCBS HMO,CPT,55899,Genital surgery procedure,Surgical,Per Case,"$4,314.00 ",OP,272.35,"4,314.00",,,,,,
BCBS HMO,CPT,55920,Place needles pelvic for rt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,512.36",,,,,,
BCBS HMO,CPT,55970,Sex transformation m to f,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,512.36",,,,,,
BCBS HMO,CPT,55980,Sex transformation f to m,Surgical,Per Case,"$4,314.00 ",OP,"3,148.08","4,314.00",,,,,,
BCBS HMO,CPT,56000,DRAINAGE OF PERINEAL ABSCESS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56100,BIOPSY OF PERINEUM,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56200,REPAIR OF PERINEUM,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56300,LAPAROSCOPY-DIAGNOSTIC,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56301,LAPAROSCOPY-TUBAL CAUTERY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56302,LAPAROSCOPY-TUBAL BLOCK,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56303,LAPAROSCOPY-EXCISE LESIONS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56304,LAPAROSCOPY-LYSIS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56305,LAPAROSCOPY-BIOPSY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56306,LAPAROSCOPY-ASPIRATION,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56307,LAPAROSCOPY-REMOVE ADNEXA,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56308,LAPAROSCOPY-HYSTERECTOMY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56309,LAPAROSCOPY-REMOVE MYOMA,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56310,LAPAROSCOPIC ENTEROLYSIS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56311,LAPAROSCOPIC LYMPH NODE BIOP,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56312,LAPAROSCOPIC LYMPHADENECTOMY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56313,LAPAROSCOPIC LYMPHADENECTOMY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56314,LAPAR-DRAIN LYMPHOCELE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56315,LAPAROSCOPIC APPENDECTOMY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56316,LAPAROSCOPIC HERNIA REPAIR,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56317,LAPAROSCOPIC HERNIA REPAIR,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56318,LAPAROSCOPIC ORCHIECTOMY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56320,LAPAROSCOPY-SPERMATIC VEINS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56321,LAPAROSCOPY-ADRENALECTOMY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56322,LAPAROSCOPY-VAGUS NERVES,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56323,LAPAROSCOPY-VAGUS NERVES,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56324,LAPAROSCOPY-CHOLECYSTOENTER,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56340,LAPAROSCOPIC CHOLECYSTECTOMY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56341,LAPAROSCOPIC CHOLECYSTECTOMY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56342,LAPAROSCOPIC CHOLECYSTECTOMY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56343,LAPAROSCOPIC SALPINGOSTOMY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56344,LAPAROSCOPIC FIMBRIOPLASTY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56345,LAPAROSCOPIC SPLENECTOMY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56346,LAPAROSCOPIC GASTROSTOMY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56347,LAPAROSCOPIC JEJUNOSTOMY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56348,LAPARO-RESECT INTESTINE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56349,LAPAROSCOPY-FUNDOPLASTY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56350,HYSTEROSCOPY-DIAGNOSTIC,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56351,HYSTEROSCOPY-BIOPSY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56352,HYSTEROSCOPY-LYSIS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56353,HYSTEROSCOPY-RESECT SEPTUM,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56354,HYSTEROSCOPY-REMOVE MYOMA,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56355,HYSTEROSCOPY-REMOVE IMPACT,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56356,HYSTEROSCOPY-ABLATION,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56360,Hysteroscopy-surgical-Peritoneoscopy-w/o biopsy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56361,Hysteroscopy-surgical-w/biopsy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56362,LAPAROSCOPY W/CHOLANGIO,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56363,LAPAROSCOPY W/BIOPSY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56399,LAPAROSCOPY PROCEDURE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56400,DRAINAGE OF VULVA,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56405,I & d of vulva/perineum,Surgical,Per Case,"$4,314.00 ",OP,288.05,"4,314.00",,,,,,
BCBS HMO,CPT,56420,Drainage of gland abscess,Surgical,Per Case,"$4,314.00 ",OP,174.29,"4,314.00",,,,,,
BCBS HMO,CPT,56440,Surgery for vulva lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,56441,Lysis of labial lesion(s),Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,56442,Hymenotomy,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,56501,Destroy vulva lesions sim,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,56507,LASER SURGERY-VULVA LESIONS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56515,Destroy vulva lesion/s compl,Surgical,Per Case,"$4,314.00 ",OP,"1,755.36","4,314.00",,,,,,
BCBS HMO,CPT,56600,BIOPSY OF VULVA,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56605,Biopsy of vulva/perineum,Surgical,Per Case,"$4,314.00 ",OP,648.18,"4,314.00",,,,,,
BCBS HMO,CPT,56606,Biopsy of vulva/perineum,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56620,Partial removal of vulva,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,56625,Complete removal of vulva,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,56630,Extensive vulva surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,512.36",,,,,,
BCBS HMO,CPT,56631,Extensive vulva surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,56632,Extensive vulva surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,56633,Extensive vulva surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,56634,Extensive vulva surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,56635,EXTENSIVE VULVA SURGERY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56637,Extensive vulva surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,56640,Extensive vulva surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,56680,REMOVAL OF CLITORIS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56685,EXTENSIVE CLITORIS SURGERY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56700,Partial removal of hymen,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,56710,HYMEN REVISION,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56720,Incision of hymen,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,56740,Remove vagina gland lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,56800,Repair of vagina,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,56805,Repair clitoris,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,56810,Repair of perineum,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,56820,Exam of vulva w/scope,Surgical,Per Case,"$4,314.00 ",OP,174.29,"4,314.00",,,,,,
BCBS HMO,CPT,56821,Exam/biopsy of vulva w/scope,Surgical,Per Case,"$4,314.00 ",OP,288.05,"4,314.00",,,,,,
BCBS HMO,CPT,57000,Exploration of vagina,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,57010,Drainage of pelvic abscess,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,57020,Drainage of pelvic fluid,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,512.36",,,,,,
BCBS HMO,CPT,57022,I & d vaginal hematoma pp,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,57023,I & d vag hematoma non-ob,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,57061,Destroy vag lesions simple,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,57065,Destroy vag lesions complex,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,57100,Biopsy of vagina,Surgical,Per Case,"$4,314.00 ",OP,648.18,"4,314.00",,,,,,
BCBS HMO,CPT,57105,Biopsy of vagina,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,57106,Remove vagina wall partial,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,57107,Remove vagina tissue part,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,57108,PARTIAL REMOVAL OF,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,57109,Vaginectomy partial w/nodes,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,57110,Remove vagina wall complete,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,57111,Remove vagina tissue compl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,57112,Vaginectomy w/nodes compl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,57120,Closure of vagina,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,512.36",,,,,,
BCBS HMO,CPT,57130,Remove vagina lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,57135,Remove vagina lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,57150,Treat vagina infection,Surgical,Per Case,"$4,314.00 ",OP,56.95,"4,314.00",,,,,,
BCBS HMO,CPT,57155,Insert uteri tandem/ovoids,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,512.36",,,,,,
BCBS HMO,CPT,57156,Ins vag brachytx device,Surgical,Per Case,"$4,314.00 ",OP,288.05,"4,314.00",,,,,,
BCBS HMO,CPT,57160,Insert pessary/other device,Surgical,Per Case,"$4,314.00 ",OP,174.29,"4,314.00",,,,,,
BCBS HMO,CPT,57170,Fitting of diaphragm/cap,Surgical,Per Case,"$4,314.00 ",OP,174.29,"4,314.00",,,,,,
BCBS HMO,CPT,57180,Treat vaginal bleeding,Surgical,Per Case,"$4,314.00 ",OP,174.29,"4,314.00",,,,,,
BCBS HMO,CPT,57200,Repair of vagina,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,57210,Repair vagina/perineum,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,57220,Revision of urethra,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,512.36",,,,,,
BCBS HMO,CPT,57230,Repair of urethral lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,57240,Anterior colporrhaphy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,512.36",,,,,,
BCBS HMO,CPT,57250,Repair rectum & vagina,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,512.36",,,,,,
BCBS HMO,CPT,57260,Cmbn ant pst colprhy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,512.36",,,,,,
BCBS HMO,CPT,57265,Cmbn ap colprhy w/ntrcl rpr,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,512.36",,,,,,
BCBS HMO,CPT,57267,Insert mesh/pelvic flr addon,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,57268,Repair of bowel bulge,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,512.36",,,,,,
BCBS HMO,CPT,57269,Unknown,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,57270,Repair of bowel pouch,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,57280,Suspension of vagina,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,57282,Colpopexy extraperitoneal,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,57283,Colpopexy intraperitoneal,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,57284,Repair paravag defect open,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,512.36",,,,,,
BCBS HMO,CPT,57285,Repair paravag defect vag,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,57287,Revise/remove sling repair,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,57288,Repair bladder defect,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,57289,Repair bladder & vagina,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,952.74",,,,,,
BCBS HMO,CPT,57291,Construction of vagina,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,512.36",,,,,,
BCBS HMO,CPT,57292,Construct vagina with graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,512.36",,,,,,
BCBS HMO,CPT,57295,Revise vag graft via vagina,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,57296,Revise vag graft open abd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,57300,Repair rectum-vagina fistula,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,57305,Repair rectum-vagina fistula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,57307,Fistula repair & colostomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,57308,Fistula repair transperine,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,57310,Repair urethrovaginal lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,952.74",,,,,,
BCBS HMO,CPT,57311,Repair urethrovaginal lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,57320,Repair bladder-vagina lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,512.36",,,,,,
BCBS HMO,CPT,57330,Repair bladder-vagina lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,952.74",,,,,,
BCBS HMO,CPT,57335,Repair vagina,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,512.36",,,,,,
BCBS HMO,CPT,57400,Dilation of vagina,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,57410,Pelvic examination,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,57415,Remove vaginal foreign body,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,57420,Exam of vagina w/scope,Surgical,Per Case,"$4,314.00 ",OP,288.05,"4,314.00",,,,,,
BCBS HMO,CPT,57421,Exam/biopsy of vag w/scope,Surgical,Per Case,"$4,314.00 ",OP,648.18,"4,314.00",,,,,,
BCBS HMO,CPT,57423,Repair paravag defect lap,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","9,115.38",,,,,,
BCBS HMO,CPT,57425,Laparoscopy surg colpopexy,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,57426,Revise prosth vag graft lap,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,952.74",,,,,,
BCBS HMO,CPT,57450,PELVIS ENDOSCOPY VIA VAGINA,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,57451,PELVIS ENDOSCOPY & BIOPSY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,57452,Exam of cervix w/scope,Surgical,Per Case,"$4,314.00 ",OP,174.29,"4,314.00",,,,,,
BCBS HMO,CPT,57454,Bx/curett of cervix w/scope,Surgical,Per Case,"$4,314.00 ",OP,288.05,"4,314.00",,,,,,
BCBS HMO,CPT,57455,Biopsy of cervix w/scope,Surgical,Per Case,"$4,314.00 ",OP,288.05,"4,314.00",,,,,,
BCBS HMO,CPT,57456,Endocerv curettage w/scope,Surgical,Per Case,"$4,314.00 ",OP,288.05,"4,314.00",,,,,,
BCBS HMO,CPT,57460,Bx of cervix w/scope leep,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,57461,Conz of cervix w/scope leep,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,57465,Cam cervix uteri drg colp,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,57500,Biopsy of cervix,Surgical,Per Case,"$4,314.00 ",OP,648.18,"4,314.00",,,,,,
BCBS HMO,CPT,57505,Endocervical curettage,Surgical,Per Case,"$4,314.00 ",OP,648.18,"4,314.00",,,,,,
BCBS HMO,CPT,57510,Cauterization of cervix,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,57511,Cryocautery of cervix,Surgical,Per Case,"$4,314.00 ",OP,288.05,"4,314.00",,,,,,
BCBS HMO,CPT,57513,Laser surgery of cervix,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,57520,Conization of cervix,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,57522,Conization of cervix,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,57530,Removal of cervix,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,512.36",,,,,,
BCBS HMO,CPT,57531,Removal of cervix radical,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,57540,Removal of residual cervix,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,57545,Remove cervix/repair pelvis,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,57550,Removal of residual cervix,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,512.36",,,,,,
BCBS HMO,CPT,57555,Remove cervix/repair vagina,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,512.36",,,,,,
BCBS HMO,CPT,57556,Remove cervix repair bowel,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,512.36",,,,,,
BCBS HMO,CPT,57558,D&c of cervical stump,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,57700,Revision of cervix,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,57720,Revision of cervix,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,57800,Dilation of cervical canal,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,57820,D & c of residual cervix,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,58100,Biopsy of uterus lining,Surgical,Per Case,"$4,314.00 ",OP,174.29,"4,314.00",,,,,,
BCBS HMO,CPT,58101,ENDOMETRIAL SAMPLING,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,58102,CURETTAGE OF UTERUS LINING,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,58110,Bx done w/colposcopy add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,58120,Dilation and curettage,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,58140,Myomectomy abdom method,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,58145,Myomectomy vag method,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","9,201.00",,,,,,
BCBS HMO,CPT,58146,Myomectomy abdom complex,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,58150,Total hysterectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,58152,Total hysterectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,58180,Partial hysterectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,58200,Extensive hysterectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,58210,Extensive hysterectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,58240,Removal of pelvis contents,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,58260,Vaginal hysterectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,512.36",,,,,,
BCBS HMO,CPT,58262,Vag hyst including t/o,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,512.36",,,,,,
BCBS HMO,CPT,58263,Vag hyst w/t/o & vag repair,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,512.36",,,,,,
BCBS HMO,CPT,58265,HYSTERECTOMY W VAGINOPLASTY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,58267,Vag hyst w/urinary repair,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,58270,Vag hyst w/enterocele repair,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,512.36",,,,,,
BCBS HMO,CPT,58275,Hysterectomy/revise vagina,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,58280,Hysterectomy/revise vagina,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,58285,Extensive hysterectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,58290,Vag hyst complex,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,952.74",,,,,,
BCBS HMO,CPT,58291,Vag hyst incl t/o complex,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,512.36",,,,,,
BCBS HMO,CPT,58292,Vag hyst t/o & repair compl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,952.74",,,,,,
BCBS HMO,CPT,58293,Vag hyst w/uro repair compl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,58294,Vag hyst w/enterocele compl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,512.36",,,,,,
BCBS HMO,CPT,58300,Insert intrauterine device,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,58301,Remove intrauterine device,Surgical,Per Case,"$4,314.00 ",OP,288.05,"4,314.00",,,,,,
BCBS HMO,CPT,58310,ARTIFICIAL INSEMINATION,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,58311,ARTIFICIAL INSEMINATION,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,58321,Artificial insemination,Surgical,Per Case,"$4,314.00 ",OP,288.05,"4,314.00",,,,,,
BCBS HMO,CPT,58322,Artificial insemination,Surgical,Per Case,"$4,314.00 ",OP,174.29,"4,314.00",,,,,,
BCBS HMO,CPT,58323,Sperm washing,Surgical,Per Case,"$4,314.00 ",OP,174.29,"4,314.00",,,,,,
BCBS HMO,CPT,58340,Catheter for hysterography,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,58345,Reopen fallopian tube,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,58346,Insert heyman uteri capsule,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,512.36",,,,,,
BCBS HMO,CPT,58350,Reopen fallopian tube,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,512.36",,,,,,
BCBS HMO,CPT,58353,Endometr ablate thermal,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,512.36",,,,,,
BCBS HMO,CPT,58356,Endometrial cryoablation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,512.36",,,,,,
BCBS HMO,CPT,58400,Suspension of uterus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,58410,Suspension of uterus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,58520,Repair of ruptured uterus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,58540,Revision of uterus,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,58541,Lsh uterus 250 g or less,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,58542,Lsh w/t/o ut 250 g or less,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,58543,Lsh uterus above 250 g,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,58544,Lsh w/t/o uterus above 250 g,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,58545,Laparoscopic myomectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,58546,Laparo-myomectomy complex,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,58548,Lap radical hyst,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,58550,Laparo-asst vag hysterectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,58551,LAPAROSCOPY-REMOVE MYOMA,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,58552,Laparo-vag hyst incl t/o,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,58553,Laparo-vag hyst complex,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,58554,Laparo-vag hyst w/t/o compl,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,58555,Hysteroscopy dx sep proc,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,58558,Hysteroscopy biopsy,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","9,201.00",,,,,,
BCBS HMO,CPT,58559,Hysteroscopy lysis,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,58560,Hysteroscopy resect septum,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,58561,Hysteroscopy remove myoma,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,58562,Hysteroscopy remove fb,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,58563,Hysteroscopy ablation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,512.36",,,,,,
BCBS HMO,CPT,58565,Hysteroscopy sterilization,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,58570,Tlh uterus 250 g or less,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,58571,Tlh w/t/o 250 g or less,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,58572,Tlh uterus over 250 g,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,58573,Tlh w/t/o uterus over 250 g,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,58575,Laps tot hyst resj mal,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,58578,Laparo proc uterus,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,58579,Hysteroscope procedure,Surgical,Per Case,"$4,314.00 ",OP,174.29,"4,314.00",,,,,,
BCBS HMO,CPT,58600,Division of fallopian tube,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,58605,Division of fallopian tube,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,58611,Ligate oviduct(s) add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,58615,Occlude fallopian tube(s),Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,58660,Laparoscopy lysis,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,58661,Laparoscopy remove adnexa,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,58662,Laparoscopy excise lesions,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,58670,Laparoscopy tubal cautery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,58671,Laparoscopy tubal block,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,58672,Laparoscopy fimbrioplasty,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,58673,Laparoscopy salpingostomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,58674,Laps abltj uterine fibroids,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,58679,Laparo proc oviduct-ovary,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,58700,Removal of fallopian tube,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,58720,Removal of ovary/tube(s),Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,58740,Adhesiolysis tube ovary,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,58750,Repair oviduct,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,58752,Revise ovarian tube(s),Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,58760,Fimbrioplasty,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,58770,Create new tubal opening,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,58800,Drainage of ovarian cyst(s),Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,58805,Drainage of ovarian cyst(s),Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,58820,Drain ovary abscess open,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,58822,Drain ovary abscess percut,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,58823,Drain pelvic abscess percut,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,58825,Transposition ovary(s),Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,58900,Biopsy of ovary(s),Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,58920,Partial removal of ovary(s),Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,952.74",,,,,,
BCBS HMO,CPT,58925,Removal of ovarian cyst(s),Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,512.36",,,,,,
BCBS HMO,CPT,58940,Removal of ovary(s),Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,58943,Removal of ovary(s),Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,58950,Resect ovarian malignancy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,58951,Resect ovarian malignancy,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,58952,Resect ovarian malignancy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,58953,Tah rad dissect for debulk,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,58954,Tah rad debulk/lymph remove,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,58956,Bso omentectomy w/tah,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,58957,Resect recurrent gyn mal,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,58958,Resect recur gyn mal w/lym,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,58960,Exploration of abdomen,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,58970,Retrieval of oocyte,Surgical,Per Case,"$4,314.00 ",OP,648.18,"4,314.00",,,,,,
BCBS HMO,CPT,58971,LAPAROSCOPY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,58972,FERTILIZATION OF OOCYTE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,58973,LAPAROSCOPY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,58974,Transfer of embryo,Surgical,Per Case,"$4,314.00 ",OP,648.18,"4,314.00",,,,,,
BCBS HMO,CPT,58975,LAPAROSCOPY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,58976,Transfer of embryo,Surgical,Per Case,"$4,314.00 ",OP,288.05,"4,314.00",,,,,,
BCBS HMO,CPT,58980,LAPAROSCOPY OF PELVIS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,58982,LAPAROSCOPY-TUBAL CAUTERY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,58983,LAPAROSCOPY-TUBAL BLOCK,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,58984,LAPAROSCOPY OF PELVIS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,58985,LAPAROSCOPY OF PELVIS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,58986,PELVIS LAPAROSCOPY & BIOPSY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,58987,LAPAROSCOPY OF PELVIS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,58988,LAPAROSCOPY-REMOVE ADNEXA,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,58989,UNLISTED PELVIC W/LAPROSCOPE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,58990,DIAGNOSTIC HYSTEROSCOPY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,58992,TREATMENT HYSTEROSCOPY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,58994,TREATMENT HYSTEROSCOPY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,58996,TREATMENT HYSTEROSCOPY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,58999,Genital surgery procedure,Surgical,Per Case,"$4,314.00 ",OP,174.29,"4,314.00",,,,,,
BCBS HMO,CPT,59000,Amniocentesis diagnostic,Surgical,Per Case,"$4,314.00 ",OP,648.18,"4,314.00",,,,,,
BCBS HMO,CPT,59001,Amniocentesis therapeutic,Surgical,Per Case,"$4,314.00 ",OP,288.05,"4,314.00",,,,,,
BCBS HMO,CPT,59012,Fetal cord puncture prenatal,Surgical,Per Case,"$4,314.00 ",OP,288.05,"4,314.00",,,,,,
BCBS HMO,CPT,59015,Chorion biopsy,Surgical,Per Case,"$4,314.00 ",OP,648.18,"4,314.00",,,,,,
BCBS HMO,CPT,59020,Fetal contract stress test,Surgical,Per Case,"$4,314.00 ",OP,174.29,"4,314.00",,,,,,
BCBS HMO,CPT,59025,Fetal non-stress test,Surgical,Per Case,"$4,314.00 ",OP,174.29,"4,314.00",,,,,,
BCBS HMO,CPT,59030,Fetal scalp blood sample,Surgical,Per Case,"$4,314.00 ",OP,288.05,"4,314.00",,,,,,
BCBS HMO,CPT,59050,Fetal monitor w/report,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,59051,Fetal monitor/interpret only,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,59070,Transabdom amnioinfus w/us,Surgical,Per Case,"$4,314.00 ",OP,288.05,"4,314.00",,,,,,
BCBS HMO,CPT,59072,Umbilical cord occlud w/us,Surgical,Per Case,"$4,314.00 ",OP,288.05,"4,314.00",,,,,,
BCBS HMO,CPT,59074,Fetal fluid drainage w/us,Surgical,Per Case,"$4,314.00 ",OP,288.05,"4,314.00",,,,,,
BCBS HMO,CPT,59076,Fetal shunt placement w/us,Surgical,Per Case,"$4,314.00 ",OP,288.05,"4,314.00",,,,,,
BCBS HMO,CPT,59100,Remove uterus lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,512.36",,,,,,
BCBS HMO,CPT,59101,HYSTEROTOMY W/ TUBAL,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,59105,HYSTEROTOMY ABORTION,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,59106,HYSTEROTOMY W/TUBAL,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,59120,Treat ectopic pregnancy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,59121,Treat ectopic pregnancy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,59130,Treat ectopic pregnancy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,59135,Treat ectopic pregnancy,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,59136,Treat ectopic pregnancy,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,59140,Treat ectopic pregnancy,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,59150,Treat ectopic pregnancy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,59151,Treat ectopic pregnancy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,59160,D & c after delivery,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,59200,Insert cervical dilator,Surgical,Per Case,"$4,314.00 ",OP,288.05,"4,314.00",,,,,,
BCBS HMO,CPT,59300,Episiotomy or vaginal repair,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,59305,EPISIORRHAPHY EXTENSIVE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,59314,Unknown,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,59320,Revision of cervix,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,59325,Revision of cervix,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,59350,Repair of uterus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,59400,Obstetrical care,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,59409,Obstetrical care,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,59410,Obstetrical care,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,59412,Antepartum manipulation,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,59414,Deliver placenta,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,59420,CARE BEFORE DELIVERY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,59425,Antepartum care only,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,59426,Antepartum care only,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,59430,Care after delivery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,59510,Cesarean delivery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,59514,Cesarean delivery only,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,59515,Cesarean delivery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,59525,Remove uterus after cesarean,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,59610,Vbac delivery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,59612,Vbac delivery only,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,59614,Vbac care after delivery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,59618,Attempted vbac delivery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,59620,Attempted vbac delivery only,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,59622,Attempted vbac after care,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,59801,CARE OF MISCARRIAGE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,59812,Treatment of miscarriage,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,59820,Care of miscarriage,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,59821,Treatment of miscarriage,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,59830,Treat uterus infection,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,59840,Abortion,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,59841,Abortion,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,59850,Abortion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,59851,Abortion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,59852,Abortion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,59855,Abortion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,59856,Abortion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,59857,Abortion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,59866,Abortion (mpr),Surgical,Per Case,"$4,314.00 ",OP,288.05,"4,314.00",,,,,,
BCBS HMO,CPT,59870,Evacuate mole of uterus,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,59871,Remove cerclage suture,Surgical,Per Case,"$4,314.00 ",OP,"2,684.38","4,314.00",,,,,,
BCBS HMO,CPT,59897,Fetal invas px w/us,Surgical,Per Case,"$4,314.00 ",OP,174.29,"4,314.00",,,,,,
BCBS HMO,CPT,59898,Laparo proc ob care/deliver,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,59899,Maternity care procedure,Surgical,Per Case,"$4,314.00 ",OP,174.29,"4,314.00",,,,,,
BCBS HMO,CPT,60000,Drain thyroid/tongue cyst,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,60001,Aspirate/inject thyriod cyst,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,60100,Biopsy of thyroid,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,60200,Remove thyroid lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,60210,Partial thyroid excision,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,60212,Partial thyroid excision,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,60220,Partial removal of thyroid,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,60225,Partial removal of thyroid,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,60240,Removal of thyroid,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,60242,THYROIDECTOMY NEAR TOTAL,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,60245,PARTIAL REMOVAL OF THYROID,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,60246,PARTIAL REMOVAL OF THYROID,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,60252,Removal of thyroid,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,60254,Extensive thyroid surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,60260,Repeat thyroid surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,60270,Removal of thyroid,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,60271,Removal of thyroid,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,60280,Remove thyroid duct lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,60281,Remove thyroid duct lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,60300,Aspir/inj thyroid cyst,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,60500,Explore parathyroid glands,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,60502,Re-explore parathyroids,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,60505,Explore parathyroid glands,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,60512,Autotransplant parathyroid,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,60520,Removal of thymus gland,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,60521,Removal of thymus gland,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,60522,Removal of thymus gland,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,60540,Explore adrenal gland,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,60545,Explore adrenal gland,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,60600,Remove carotid body lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,60605,Remove carotid body lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,60650,Laparoscopy adrenalectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,60659,Laparo proc endocrine,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,60699,Endocrine surgery procedure,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,178.44",,,,,,
BCBS HMO,CPT,61000,Remove cranial cavity fluid,Surgical,Per Case,"$4,314.00 ",OP,649.39,"4,314.00",,,,,,
BCBS HMO,CPT,61001,Remove cranial cavity fluid,Surgical,Per Case,"$4,314.00 ",OP,649.39,"4,314.00",,,,,,
BCBS HMO,CPT,61020,Remove brain cavity fluid,Surgical,Per Case,"$4,314.00 ",OP,841.63,"4,314.00",,,,,,
BCBS HMO,CPT,61026,Injection into brain canal,Surgical,Per Case,"$4,314.00 ",OP,649.39,"4,314.00",,,,,,
BCBS HMO,CPT,61050,Remove brain canal fluid,Surgical,Per Case,"$4,314.00 ",OP,267.26,"4,314.00",,,,,,
BCBS HMO,CPT,61055,Injection into brain canal,Surgical,Per Case,"$4,314.00 ",OP,267.26,"4,314.00",,,,,,
BCBS HMO,CPT,61070,Brain canal shunt procedure,Surgical,Per Case,"$4,314.00 ",OP,649.39,"4,314.00",,,,,,
BCBS HMO,CPT,61105,Twist drill hole,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61106,DRILL SKULL FOR EXAM/,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,61107,Drill skull for implantation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61108,Drill skull for drainage,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61120,Burr hole for puncture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61130,PIERCE SKULL-EXAM/,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,61140,Pierce skull for biopsy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61150,Pierce skull for drainage,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61151,Pierce skull for drainage,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61154,Pierce skull & remove clot,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61156,Pierce skull for drainage,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61210,Pierce skull implant device,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61215,Insert brain-fluid device,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,833.22",,,,,,
BCBS HMO,CPT,61250,Pierce skull & explore,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61253,Pierce skull & explore,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61304,Open skull for exploration,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61305,Open skull for exploration,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61312,Open skull for drainage,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61313,Open skull for drainage,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61314,Open skull for drainage,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61315,Open skull for drainage,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61316,Implt cran bone flap to abdo,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61320,Open skull for drainage,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61321,Open skull for drainage,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61322,Decompressive craniotomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61323,Decompressive lobectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61330,Decompress eye socket,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,61332,Explore/biopsy eye socket,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,61333,Explore orbit/remove lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61334,Explore orbit/remove object,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,61340,Subtemporal decompression,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61343,Incise skull (press relief),Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61345,Relieve cranial pressure,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61440,Incise skull for surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,61450,Incise skull for surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61458,Incise skull for brain wound,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61460,Incise skull for surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61470,Incise skull for surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,61480,Incise skull for surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,61490,Incise skull for surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,61500,Removal of skull lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61501,Remove infected skull bone,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61510,Removal of brain lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61512,Remove brain lining lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61514,Removal of brain abscess,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61516,Removal of brain lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61517,Implt brain chemotx add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61518,Removal of brain lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61519,Remove brain lining lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61520,Removal of brain lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61521,Removal of brain lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61522,Removal of brain abscess,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61524,Removal of brain lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61526,Removal of brain lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61530,Removal of brain lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61531,Implant brain electrodes,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61533,Implant brain electrodes,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61534,Removal of brain lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61535,Remove brain electrodes,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61536,Removal of brain lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61537,Removal of brain tissue,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61538,Removal of brain tissue,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61539,Removal of brain tissue,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61540,Removal of brain tissue,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61541,Incision of brain tissue,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61542,Removal of brain tissue,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,61543,Removal of brain tissue,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61544,Remove & treat brain lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61545,Excision of brain tumor,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61546,Removal of pituitary gland,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61548,Removal of pituitary gland,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61550,Release of skull seams,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61552,Release of skull seams,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61553,CRANIECTOMY MULTIPLE - EACH,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,61555,RECONSTRUCTION SKULL,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,61556,Incise skull/sutures,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61557,Incise skull/sutures,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61558,Excision of skull/sutures,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61559,Excision of skull/sutures,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61561,FRONTAL LOBE DECOMPRESSION,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,61563,Excision of skull tumor,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61564,Excision of skull tumor,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61566,Removal of brain tissue,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61567,Incision of brain tissue,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61570,Remove foreign body brain,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61571,Incise skull for brain wound,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61575,Skull base/brainstem surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61576,Skull base/brainstem surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61580,Craniofacial approach skull,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61581,Craniofacial approach skull,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61582,Craniofacial approach skull,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61583,Craniofacial approach skull,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61584,Orbitocranial approach/skull,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61585,Orbitocranial approach/skull,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61586,Resect nasopharynx skull,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61590,Infratemporal approach/skull,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61591,Infratemporal approach/skull,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61592,Orbitocranial approach/skull,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61595,Transtemporal approach/skull,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61596,Transcochlear approach/skull,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61597,Transcondylar approach/skull,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61598,Transpetrosal approach/skull,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61600,Resect/excise cranial lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61601,Resect/excise cranial lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61605,Resect/excise cranial lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61606,Resect/excise cranial lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61607,Resect/excise cranial lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61608,Resect/excise cranial lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61609,Transect artery sinus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,61610,Transect artery sinus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,61611,Transect artery sinus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61612,Transect artery sinus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,61613,Remove aneurysm sinus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61615,Resect/excise lesion skull,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61616,Resect/excise lesion skull,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61618,Repair dura,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61619,Repair dura,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61623,Endovasc tempory vessel occl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","10,277.14",,,,,,
BCBS HMO,CPT,61624,Transcath occlusion cns,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,438.60",,,,,,
BCBS HMO,CPT,61626,Transcath occlusion non-cns,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","10,277.14",,,,,,
BCBS HMO,CPT,61630,Intracranial angioplasty,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61635,Intracran angioplsty w/stent,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61640,Dilate ic vasospasm init,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,61641,Dilat ic vspsm ea vsl sm ter,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,61642,Dilat ic vspsm ea diff ter,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,61645,Perq art m-thrombect &/nfs,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61650,Evasc prlng admn rx agnt 1st,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61651,Evasc prlng admn rx agnt add,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61680,Intracranial vessel surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61682,Intracranial vessel surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61684,Intracranial vessel surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61686,Intracranial vessel surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61690,Intracranial vessel surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61692,Intracranial vessel surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61697,Brain aneurysm repr complx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61698,Brain aneurysm repr complx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61700,Brain aneurysm repr simple,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61702,Inner skull vessel surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61703,Clamp neck artery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61705,Revise circulation to head,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61708,Revise circulation to head,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61710,Revise circulation to head,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61711,Fusion of skull arteries,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61712,SKULL OR SPINE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,61715,HYPOPHYSECTOMY STEROTATIC,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,61720,Incise skull/brain surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,833.22",,,,,,
BCBS HMO,CPT,61735,Incise skull/brain surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61750,Incise skull/brain biopsy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61751,Brain biopsy w/ct/mr guide,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61760,Implant brain electrodes,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61770,Incise skull for treatment,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,833.22",,,,,,
BCBS HMO,CPT,61780,INCISE SKULL/BRAIN EXAM,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,61781,Scan proc cranial intra,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,61782,Scan proc cranial extra,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,61783,Scan proc spinal,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,61790,Treat trigeminal nerve,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,61791,Treat trigeminal tract,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,61793,Focus radiation beam,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,61795,Brain surgery using computer,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,61796,Srs cranial lesion simple,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,61797,Srs cran les simple addl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,61798,Srs cranial lesion complex,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,61799,Srs cran les complex addl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,61800,Apply srs headframe add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,61850,Implant neuroelectrodes,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61855,IMPLANT NEUROELECTRODES,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,61860,Implant neuroelectrodes,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61862,IMPLANT NEUROSTIMUL-SUBCORT,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,61863,Implant neuroelectrode,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61864,Implant neuroelectrde addl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61865,IMPLANT NEUROELECTRODES,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,61867,Implant neuroelectrode,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61868,Implant neuroelectrde addl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,61870,Implant neuroelectrodes,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,61875,Implant neuroelectrodes,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,61880,Revise/remove neuroelectrode,Surgical,Per Case,"$4,314.00 ",OP,"3,351.68","4,314.00",,,,,,
BCBS HMO,CPT,61885,Insrt/redo neurostim 1 array,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","20,957.35",,,,,,
BCBS HMO,CPT,61886,Implant neurostim arrays,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","30,131.14",,,,,,
BCBS HMO,CPT,61888,Revise/remove neuroreceiver,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","11,498.23",,,,,,
BCBS HMO,CPT,62000,Treat skull fracture,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,62005,Treat skull fracture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,62010,Treatment of head injury,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,62100,Repair brain fluid leakage,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,62115,Reduction of skull defect,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,62116,Reduction of skull defect,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,62117,Reduction of skull defect,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,62120,Repair skull cavity lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,62121,Incise skull repair,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,62140,Repair of skull defect,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,62141,Repair of skull defect,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,62142,Remove skull plate/flap,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,62143,Replace skull plate/flap,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,62145,Repair of skull & brain,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,62146,Repair of skull with graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,62147,Repair of skull with graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,62148,Retr bone flap to fix skull,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,62160,Neuroendoscopy add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,62161,Dissect brain w/scope,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,62162,Remove colloid cyst w/scope,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,62163,Zneuroendoscopy w/fb removal,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,62164,Remove brain tumor w/scope,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,62165,Remove pituit tumor w/scope,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,62180,Establish brain cavity shunt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,62190,Establish brain cavity shunt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,62192,Establish brain cavity shunt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,62194,Replace/irrigate catheter,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,62200,Establish brain cavity shunt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,62201,Brain cavity shunt w/scope,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,62220,Establish brain cavity shunt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,62223,Establish brain cavity shunt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,62225,Replace/irrigate catheter,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,833.22",,,,,,
BCBS HMO,CPT,62230,Replace/revise brain shunt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,833.22",,,,,,
BCBS HMO,CPT,62252,Csf shunt reprogram,Surgical,Per Case,"$4,314.00 ",OP,278.82,"4,314.00",,,,,,
BCBS HMO,CPT,62256,Remove brain cavity shunt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,62258,Replace brain cavity shunt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,62263,Epidural lysis mult sessions,Surgical,Per Case,"$4,314.00 ",OP,841.63,"4,314.00",,,,,,
BCBS HMO,CPT,62264,Epidural lysis on single day,Surgical,Per Case,"$4,314.00 ",OP,841.63,"4,314.00",,,,,,
BCBS HMO,CPT,62267,Interdiscal perq aspir dx,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,62268,Drain spinal cord cyst,Surgical,Per Case,"$4,314.00 ",OP,841.63,"4,314.00",,,,,,
BCBS HMO,CPT,62269,Needle biopsy spinal cord,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,62270,Dx lmbr spi pnxr,Surgical,Per Case,"$4,314.00 ",OP,649.39,"4,314.00",,,,,,
BCBS HMO,CPT,62272,Ther spi pnxr drg csf,Surgical,Per Case,"$4,314.00 ",OP,649.39,"4,314.00",,,,,,
BCBS HMO,CPT,62273,Inject epidural patch,Surgical,Per Case,"$4,314.00 ",OP,649.39,"4,314.00",,,,,,
BCBS HMO,CPT,62274,INJECT SPINAL ANESTHETIC,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,62275,INJECT SPINAL ANESTHETIC,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,62276,INJECT SPINAL ANESTHETIC,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,62277,INJECT SPINAL ANESTHETIC,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,62278,INJECT SPINAL ANESTHETIC,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,62279,INJECT SPINAL ANESTHETIC,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,62280,Treat spinal cord lesion,Surgical,Per Case,"$4,314.00 ",OP,841.63,"4,314.00",,,,,,
BCBS HMO,CPT,62281,Treat spinal cord lesion,Surgical,Per Case,"$4,314.00 ",OP,841.63,"4,314.00",,,,,,
BCBS HMO,CPT,62282,Treat spinal canal lesion,Surgical,Per Case,"$4,314.00 ",OP,841.63,"4,314.00",,,,,,
BCBS HMO,CPT,62284,Injection for myelogram,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,62287,Percutaneous diskectomy,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,62288,INJECTION INTO SPINAL CANAL,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,62289,INJECTION INTO SPINAL CANAL,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,62290,Njx px discography lumbar,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,62291,Njx px discography crv/thrc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,62292,Njx chemonucleolysis lmbr,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,62294,Injection into spinal artery,Surgical,Per Case,"$4,314.00 ",OP,841.63,"4,314.00",,,,,,
BCBS HMO,CPT,62298,INJECTION INTO SPINAL CANAL,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,62302,Myelography lumbar injection,Surgical,Per Case,"$4,314.00 ",OP,731.85,"4,314.00",,,,,,
BCBS HMO,CPT,62303,Myelography lumbar injection,Surgical,Per Case,"$4,314.00 ",OP,731.85,"4,314.00",,,,,,
BCBS HMO,CPT,62304,Myelography lumbar injection,Surgical,Per Case,"$4,314.00 ",OP,731.85,"4,314.00",,,,,,
BCBS HMO,CPT,62305,Myelography lumbar injection,Surgical,Per Case,"$4,314.00 ",OP,731.85,"4,314.00",,,,,,
BCBS HMO,CPT,62310,Inject spine c/t,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,62311,Inject spine l/s (cd),Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,62318,Inject spine w/cath c/t,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,62319,Inject spine w/cath l/s (cd),Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,62320,Njx interlaminar crv/thrc,Surgical,Per Case,"$4,314.00 ",OP,649.39,"4,314.00",,,,,,
BCBS HMO,CPT,62321,Njx interlaminar crv/thrc,Surgical,Per Case,"$4,314.00 ",OP,649.39,"4,314.00",,,,,,
BCBS HMO,CPT,62322,Njx interlaminar lmbr/sac,Surgical,Per Case,"$4,314.00 ",OP,649.39,"4,314.00",,,,,,
BCBS HMO,CPT,62323,Njx interlaminar lmbr/sac,Surgical,Per Case,"$4,314.00 ",OP,649.39,"4,314.00",,,,,,
BCBS HMO,CPT,62324,Njx interlaminar crv/thrc,Surgical,Per Case,"$4,314.00 ",OP,841.63,"4,314.00",,,,,,
BCBS HMO,CPT,62325,Njx interlaminar crv/thrc,Surgical,Per Case,"$4,314.00 ",OP,841.63,"4,314.00",,,,,,
BCBS HMO,CPT,62326,Njx interlaminar lmbr/sac,Surgical,Per Case,"$4,314.00 ",OP,841.63,"4,314.00",,,,,,
BCBS HMO,CPT,62327,Njx interlaminar lmbr/sac,Surgical,Per Case,"$4,314.00 ",OP,841.63,"4,314.00",,,,,,
BCBS HMO,CPT,62328,Dx lmbr spi pnxr w/fluor/ct,Surgical,Per Case,"$4,314.00 ",OP,649.39,"4,314.00",,,,,,
BCBS HMO,CPT,62329,Ther spi pnxr csf fluor/ct,Surgical,Per Case,"$4,314.00 ",OP,649.39,"4,314.00",,,,,,
BCBS HMO,CPT,62350,Implant spinal canal cath,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,833.22",,,,,,
BCBS HMO,CPT,62351,Implant spinal canal cath,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,62355,Remove spinal canal catheter,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,62360,Insert spine infusion device,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","17,429.07",,,,,,
BCBS HMO,CPT,62361,Implant spine infusion pump,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","17,429.07",,,,,,
BCBS HMO,CPT,62362,Implant spine infusion pump,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","17,429.07",,,,,,
BCBS HMO,CPT,62365,Remove spine infusion device,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,833.22",,,,,,
BCBS HMO,CPT,62367,Analyze spine infus pump,Surgical,Per Case,"$4,314.00 ",OP,278.82,"4,314.00",,,,,,
BCBS HMO,CPT,62368,Analyze sp inf pump w/reprog,Surgical,Per Case,"$4,314.00 ",OP,278.82,"4,314.00",,,,,,
BCBS HMO,CPT,62369,Anal sp inf pmp w/reprg&fill,Surgical,Per Case,"$4,314.00 ",OP,278.82,"4,314.00",,,,,,
BCBS HMO,CPT,62370,Anl sp inf pmp w/mdreprg&fil,Surgical,Per Case,"$4,314.00 ",OP,278.82,"4,314.00",,,,,,
BCBS HMO,CPT,62380,Ndsc dcmprn 1 ntrspc lumbar,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,62770,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,63001,Remove spine lamina 1/2 crvl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,63003,Remove spine lamina 1/2 thrc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,63005,Remove spine lamina 1/2 lmbr,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,63011,Remove spine lamina 1/2 scrl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,63012,Remove lamina/facets lumbar,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,63015,Remove spine lamina >2 crvcl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,63016,Remove spine lamina >2 thrc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,63017,Remove spine lamina >2 lmbr,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,63020,Neck spine disk surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,63030,Low back disk surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,63035,Spinal disk surgery add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,63040,Laminotomy single cervical,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,63041,LAMINOTOMY THORACIC,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,63042,Laminotomy single lumbar,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,63043,Laminotomy addl cervical,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,63044,Laminotomy addl lumbar,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,63045,Remove spine lamina 1 crvl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,63046,Remove spine lamina 1 thrc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,63047,Remove spine lamina 1 lmbr,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,63048,Remove spinal lamina add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,63050,Cervical laminoplsty 2/> seg,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63051,C-laminoplasty w/graft/plate,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63055,Decompress spinal cord thrc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,63056,Decompress spinal cord lmbr,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,63057,Decompress spine cord add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,63064,Decompress spinal cord thrc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,63066,Decompress spine cord add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,63075,Neck spine disk surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,63076,Neck spine disk surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,63077,Spine disk surgery thorax,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63078,Spine disk surgery thorax,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63081,Remove vert body dcmprn crvl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63082,Remove vertebral body add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63085,Remove vert body dcmprn thrc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63086,Remove vertebral body add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63087,Remov vertbr dcmprn thrclmbr,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63088,Remove vertebral body add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63090,Remove vert body dcmprn lmbr,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63091,Remove vertebral body add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63101,Remove vert body dcmprn thrc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63102,Remove vert body dcmprn lmbr,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63103,Remove vertebral body add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63170,Incise spinal cord tract(s),Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63172,Drainage of spinal cyst,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63173,Drainage of spinal cyst,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63180,Revise spinal cord ligaments,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,63182,Revise spinal cord ligaments,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,63185,Incise spine nrv half segmnt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63190,Incise spine nrv >2 segmnts,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63191,Incise spine accessory nerve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63194,Incise spine & cord cervical,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63195,Incise spine & cord thoracic,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63196,Incise spine&cord 2 trx crvl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63197,Incise spine&cord 2 trx thrc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63198,Incise spin&cord 2 stgs crvl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63199,Incise spin&cord 2 stgs thrc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63200,Release spinal cord lumbar,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63250,Revise spinal cord vsls crvl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63251,Revise spinal cord vsls thrc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63252,Revise spine cord vsl thrlmb,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63265,Excise intraspinl lesion crv,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,63266,Excise intrspinl lesion thrc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,63267,Excise intrspinl lesion lmbr,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,63268,Excise intrspinl lesion scrl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,63270,Excise intrspinl lesion crvl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63271,Excise intrspinl lesion thrc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63272,Excise intrspinl lesion lmbr,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63273,Excise intrspinl lesion scrl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63275,Bx/exc xdrl spine lesn crvl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63276,Bx/exc xdrl spine lesn thrc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63277,Bx/exc xdrl spine lesn lmbr,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63278,Bx/exc xdrl spine lesn scrl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63280,Bx/exc idrl spine lesn crvl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63281,Bx/exc idrl spine lesn thrc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63282,Bx/exc idrl spine lesn lmbr,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63283,Bx/exc idrl spine lesn scrl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63285,Bx/exc idrl imed lesn cervl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63286,Bx/exc idrl imed lesn thrc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63287,Bx/exc idrl imed lesn thrlmb,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63290,Bx/exc xdrl/idrl lsn any lvl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63295,Repair laminectomy defect,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63300,Remove vert xdrl body crvcl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63301,Remove vert xdrl body thrc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63302,Remove vert xdrl body thrlmb,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63303,Remov vert xdrl bdy lmbr/sac,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63304,Remove vert idrl body crvcl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63305,Remove vert idrl body thrc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63306,Remov vert idrl bdy thrclmbr,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63307,Remov vert idrl bdy lmbr/sac,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63308,Remove vertebral body add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63600,Remove spinal cord lesion,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,63610,Stimulation of spinal cord,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,63615,Remove lesion of spinal cord,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,63620,Srs spinal lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,63621,Srs spinal lesion addl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,63650,Implant neuroelectrodes,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,63655,Implant neuroelectrodes,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","20,957.35",,,,,,
BCBS HMO,CPT,63657,IMPLANT NEUROELECTRODES,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,63658,IMPLANT NEUROELECTRODES,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,63660,Revise/remove neuroelectrode,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,63661,Remove spine eltrd perq aray,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,63662,Remove spine eltrd plate,Surgical,Per Case,"$4,314.00 ",OP,"3,351.68","4,314.00",,,,,,
BCBS HMO,CPT,63663,Revise spine eltrd perq aray,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,304.35",,,,,,
BCBS HMO,CPT,63664,Revise spine eltrd plate,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","11,498.23",,,,,,
BCBS HMO,CPT,63685,Insrt/redo spine n generator,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","30,131.14",,,,,,
BCBS HMO,CPT,63688,Revise/remove neuroreceiver,Surgical,Per Case,"$4,314.00 ",OP,"3,351.68","4,314.00",,,,,,
BCBS HMO,CPT,63690,ANALYSIS OF,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,63691,ANALYSIS OF,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,63700,Repair of spinal herniation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63702,Repair of spinal herniation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63704,Repair of spinal herniation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63706,Repair of spinal herniation,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63707,Repair spinal fluid leakage,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63709,Repair spinal fluid leakage,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63710,Graft repair of spine defect,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63740,Install spinal shunt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,63741,Install spinal shunt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,833.22",,,,,,
BCBS HMO,CPT,63744,Revision of spinal shunt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,833.22",,,,,,
BCBS HMO,CPT,63746,Removal of spinal shunt,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,63750,INSERT SPINAL CANAL CATHETER,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,63780,INSERT SPINAL CANAL CATHETER,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64400,Njx aa&/strd trigeminal nrv,Surgical,Per Case,"$4,314.00 ",OP,267.26,"4,314.00",,,,,,
BCBS HMO,CPT,64402,N block inj facial,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64405,Njx aa&/strd gr ocpl nrv,Surgical,Per Case,"$4,314.00 ",OP,267.26,"4,314.00",,,,,,
BCBS HMO,CPT,64408,Njx aa&/strd vagus nrv,Surgical,Per Case,"$4,314.00 ",OP,267.26,"4,314.00",,,,,,
BCBS HMO,CPT,64410,N block inj phrenic,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64412,N block inj spinal accessor,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64413,N block inj cervical plexus,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64415,Njx aa&/strd brach plexus,Surgical,Per Case,"$4,314.00 ",OP,841.63,"4,314.00",,,,,,
BCBS HMO,CPT,64416,Njx aa&/strd brach plex nfs,Surgical,Per Case,"$4,314.00 ",OP,841.63,"4,314.00",,,,,,
BCBS HMO,CPT,64417,Njx aa&/strd axillary nrv,Surgical,Per Case,"$4,314.00 ",OP,841.63,"4,314.00",,,,,,
BCBS HMO,CPT,64418,Njx aa&/strd sprscap nrv,Surgical,Per Case,"$4,314.00 ",OP,649.39,"4,314.00",,,,,,
BCBS HMO,CPT,64420,Njx aa&/strd ntrcost nrv 1,Surgical,Per Case,"$4,314.00 ",OP,649.39,"4,314.00",,,,,,
BCBS HMO,CPT,64421,Njx aa&/strd ntrcost nrv ea,Surgical,Per Case,"$4,314.00 ",OP,841.63,"4,314.00",,,,,,
BCBS HMO,CPT,64425,Njx aa&/strd ii ih nerves,Surgical,Per Case,"$4,314.00 ",OP,649.39,"4,314.00",,,,,,
BCBS HMO,CPT,64430,Njx aa&/strd pudendal nerve,Surgical,Per Case,"$4,314.00 ",OP,841.63,"4,314.00",,,,,,
BCBS HMO,CPT,64435,Njx aa&/strd paracrv nrv,Surgical,Per Case,"$4,314.00 ",OP,649.39,"4,314.00",,,,,,
BCBS HMO,CPT,64440,INJECTION FOR NERVE BLOCK,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64441,INJECTION FOR NERVE BLOCK,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64442,INJECTION FOR NERVE BLOCK,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64443,INJECT-NERVE BLOCK ADD-ON,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64445,Njx aa&/strd sciatic nerve,Surgical,Per Case,"$4,314.00 ",OP,649.39,"4,314.00",,,,,,
BCBS HMO,CPT,64446,Njx aa&/strd sciatic nrv nfs,Surgical,Per Case,"$4,314.00 ",OP,841.63,"4,314.00",,,,,,
BCBS HMO,CPT,64447,Njx aa&/strd femoral nerve,Surgical,Per Case,"$4,314.00 ",OP,649.39,"4,314.00",,,,,,
BCBS HMO,CPT,64448,Njx aa&/strd fem nerve nfs,Surgical,Per Case,"$4,314.00 ",OP,841.63,"4,314.00",,,,,,
BCBS HMO,CPT,64449,Njx aa&/strd lmbr plex nfs,Surgical,Per Case,"$4,314.00 ",OP,841.63,"4,314.00",,,,,,
BCBS HMO,CPT,64450,Njx aa&/strd other pn/branch,Surgical,Per Case,"$4,314.00 ",OP,649.39,"4,314.00",,,,,,
BCBS HMO,CPT,64451,Njx aa&/strd nrv nrvtg si jt,Surgical,Per Case,"$4,314.00 ",OP,649.39,"4,314.00",,,,,,
BCBS HMO,CPT,64454,Njx aa&/strd gnclr nrv brnch,Surgical,Per Case,"$4,314.00 ",OP,649.39,"4,314.00",,,,,,
BCBS HMO,CPT,64455,Njx aa&/strd pltr com dg nrv,Surgical,Per Case,"$4,314.00 ",OP,267.26,"4,314.00",,,,,,
BCBS HMO,CPT,64461,Pvb thoracic single inj site,Surgical,Per Case,"$4,314.00 ",OP,649.39,"4,314.00",,,,,,
BCBS HMO,CPT,64462,Pvb thoracic 2nd+ inj site,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64463,Pvb thoracic cont infusion,Surgical,Per Case,"$4,314.00 ",OP,649.39,"4,314.00",,,,,,
BCBS HMO,CPT,64470,Inj paravertebral c/t,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64472,Inj paravertebral c/t add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64475,Inj paravertebral l/s,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64476,Inj paravertebral l/s add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64479,Njx aa&/strd tfrm epi c/t 1,Surgical,Per Case,"$4,314.00 ",OP,841.63,"4,314.00",,,,,,
BCBS HMO,CPT,64480,Njx aa&/strd tfrm epi c/t ea,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64483,Njx aa&/strd tfrm epi l/s 1,Surgical,Per Case,"$4,314.00 ",OP,841.63,"4,314.00",,,,,,
BCBS HMO,CPT,64484,Njx aa&/strd tfrm epi l/s ea,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64486,Tap block unil by injection,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64487,Tap block uni by infusion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64488,Tap block bi injection,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64489,Tap block bi by infusion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64490,Inj paravert f jnt c/t 1 lev,Surgical,Per Case,"$4,314.00 ",OP,841.63,"4,314.00",,,,,,
BCBS HMO,CPT,64491,Inj paravert f jnt c/t 2 lev,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64492,Inj paravert f jnt c/t 3 lev,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64493,Inj paravert f jnt l/s 1 lev,Surgical,Per Case,"$4,314.00 ",OP,841.63,"4,314.00",,,,,,
BCBS HMO,CPT,64494,Inj paravert f jnt l/s 2 lev,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64495,Inj paravert f jnt l/s 3 lev,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64505,N block spenopalatine gangl,Surgical,Per Case,"$4,314.00 ",OP,267.26,"4,314.00",,,,,,
BCBS HMO,CPT,64508,N block carotid sinus s/p,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64510,N block stellate ganglion,Surgical,Per Case,"$4,314.00 ",OP,841.63,"4,314.00",,,,,,
BCBS HMO,CPT,64517,N block inj hypogas plxs,Surgical,Per Case,"$4,314.00 ",OP,841.63,"4,314.00",,,,,,
BCBS HMO,CPT,64520,N block lumbar/thoracic,Surgical,Per Case,"$4,314.00 ",OP,841.63,"4,314.00",,,,,,
BCBS HMO,CPT,64530,N block inj celiac pelus,Surgical,Per Case,"$4,314.00 ",OP,841.63,"4,314.00",,,,,,
BCBS HMO,CPT,64550,Appl surface neurostimulator,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64553,Implant neuroelectrodes,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","11,498.23",,,,,,
BCBS HMO,CPT,64555,Implant neuroelectrodes,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,304.35",,,,,,
BCBS HMO,CPT,64560,Implant neuroelectrodes,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64561,Implant neuroelectrodes,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,64565,Implant neuroelectrodes,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64566,Neuroeltrd stim post tibial,Surgical,Per Case,"$4,314.00 ",OP,267.26,"4,314.00",,,,,,
BCBS HMO,CPT,64568,Inc for vagus n elect impl,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","30,131.14",,,,,,
BCBS HMO,CPT,64569,Revise/repl vagus n eltrd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","11,498.23",,,,,,
BCBS HMO,CPT,64570,Remove vagus n eltrd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,833.22",,,,,,
BCBS HMO,CPT,64573,Implant neuroelectrodes,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64575,Implant neuroelectrodes,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","11,498.23",,,,,,
BCBS HMO,CPT,64577,Implant neuroelectrodes,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64580,Implant neuroelectrodes,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","20,957.35",,,,,,
BCBS HMO,CPT,64581,Implant neuroelectrodes,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS HMO,CPT,64585,Revise/remove neuroelectrode,Surgical,Per Case,"$4,314.00 ",OP,"3,351.68","4,314.00",,,,,,
BCBS HMO,CPT,64590,Insrt/redo pn/gastr stimul,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","20,957.35",,,,,,
BCBS HMO,CPT,64595,Revise/rmv pn/gastr stimul,Surgical,Per Case,"$4,314.00 ",OP,"3,351.68","4,314.00",,,,,,
BCBS HMO,CPT,64600,Injection treatment of nerve,Surgical,Per Case,"$4,314.00 ",OP,841.63,"4,314.00",,,,,,
BCBS HMO,CPT,64605,Injection treatment of nerve,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,64610,Injection treatment of nerve,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,64611,Chemodenerv saliv glands,Surgical,Per Case,"$4,314.00 ",OP,267.26,"4,314.00",,,,,,
BCBS HMO,CPT,64612,Destroy nerve face muscle,Surgical,Per Case,"$4,314.00 ",OP,267.26,"4,314.00",,,,,,
BCBS HMO,CPT,64613,Destroy nerve neck muscle,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64614,Destroy nerve extrem musc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64615,Chemodenerv musc migraine,Surgical,Per Case,"$4,314.00 ",OP,267.26,"4,314.00",,,,,,
BCBS HMO,CPT,64616,Chemodenerv musc neck dyston,Surgical,Per Case,"$4,314.00 ",OP,267.26,"4,314.00",,,,,,
BCBS HMO,CPT,64617,Chemodener muscle larynx emg,Surgical,Per Case,"$4,314.00 ",OP,267.26,"4,314.00",,,,,,
BCBS HMO,CPT,64620,Injection treatment of nerve,Surgical,Per Case,"$4,314.00 ",OP,841.63,"4,314.00",,,,,,
BCBS HMO,CPT,64622,Destr paravertebrl nerve l/s,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64623,Destr paravertebral n add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64624,Dstrj nulyt agt gnclr nrv,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,64625,Rf abltj nrv nrvtg si jt,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,64626,Destr paravertebrl nerve c/t,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64627,Destr paravertebral n add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64630,Injection treatment of nerve,Surgical,Per Case,"$4,314.00 ",OP,841.63,"4,314.00",,,,,,
BCBS HMO,CPT,64632,N block inj common digit,Surgical,Per Case,"$4,314.00 ",OP,267.26,"4,314.00",,,,,,
BCBS HMO,CPT,64633,Destroy cerv/thor facet jnt,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,64634,Destroy c/th facet jnt addl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64635,Destroy lumb/sac facet jnt,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,64636,Destroy l/s facet jnt addl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64640,Injection treatment of nerve,Surgical,Per Case,"$4,314.00 ",OP,841.63,"4,314.00",,,,,,
BCBS HMO,CPT,64642,Chemodenerv 1 extremity 1-4,Surgical,Per Case,"$4,314.00 ",OP,649.39,"4,314.00",,,,,,
BCBS HMO,CPT,64643,Chemodenerv 1 extrem 1-4 ea,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64644,Chemodenerv 1 extrem 5/> mus,Surgical,Per Case,"$4,314.00 ",OP,649.39,"4,314.00",,,,,,
BCBS HMO,CPT,64645,Chemodenerv 1 extrem 5/> ea,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64646,Chemodenerv trunk musc 1-5,Surgical,Per Case,"$4,314.00 ",OP,649.39,"4,314.00",,,,,,
BCBS HMO,CPT,64647,Chemodenerv trunk musc 6/>,Surgical,Per Case,"$4,314.00 ",OP,649.39,"4,314.00",,,,,,
BCBS HMO,CPT,64650,Chemodenerv eccrine glands,Surgical,Per Case,"$4,314.00 ",OP,267.26,"4,314.00",,,,,,
BCBS HMO,CPT,64653,Chemodenerv eccrine glands,Surgical,Per Case,"$4,314.00 ",OP,267.26,"4,314.00",,,,,,
BCBS HMO,CPT,64680,Injection treatment of nerve,Surgical,Per Case,"$4,314.00 ",OP,841.63,"4,314.00",,,,,,
BCBS HMO,CPT,64681,Injection treatment of nerve,Surgical,Per Case,"$4,314.00 ",OP,841.63,"4,314.00",,,,,,
BCBS HMO,CPT,64702,Revise finger/toe nerve,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,64704,Revise hand/foot nerve,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,64708,Revise arm/leg nerve,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,64712,Revision of sciatic nerve,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,64713,Revision of arm nerve(s),Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,64714,Revise low back nerve(s),Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,64716,Revision of cranial nerve,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,64718,Revise ulnar nerve at elbow,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,64719,Revise ulnar nerve at wrist,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,64721,Carpal tunnel surgery,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,64722,Relieve pressure on nerve(s),Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,64726,Release foot/toe nerve,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,64727,Internal nerve revision,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64732,Incision of brow nerve,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,64734,Incision of cheek nerve,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,64736,Incision of chin nerve,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,64738,Incision of jaw nerve,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,64740,Incision of tongue nerve,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,64742,Incision of facial nerve,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,64744,Incise nerve back of head,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,64746,Incise diaphragm nerve,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,64752,Incision of vagus nerve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64755,Incision of stomach nerves,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,64760,Incision of vagus nerve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,64761,Incision of pelvis nerve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64763,Incise hip/thigh nerve,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,64766,Incise hip/thigh nerve,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,64771,Sever cranial nerve,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,64772,Incision of spinal nerve,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,64774,Remove skin nerve lesion,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,64776,Remove digit nerve lesion,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,64778,Digit nerve surgery add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64782,Remove limb nerve lesion,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,64783,Limb nerve surgery add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64784,Remove nerve lesion,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,64786,Remove sciatic nerve lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,833.22",,,,,,
BCBS HMO,CPT,64787,Implant nerve end,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64788,Remove skin nerve lesion,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,64790,Removal of nerve lesion,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,64792,Removal of nerve lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,833.22",,,,,,
BCBS HMO,CPT,64795,Biopsy of nerve,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,64802,Sympathectomy cervical,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,64803,REMOVE SYMPATHETIC NERVES,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64804,Remove sympathetic nerves,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,64809,Remove sympathetic nerves,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,64818,Remove sympathetic nerves,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,64820,Sympathectomy digital artery,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,64821,Remove sympathetic nerves,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,64822,Remove sympathetic nerves,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,64823,Sympathectomy supfc palmar,Surgical,Per Case,"$4,314.00 ",OP,"2,896.40","4,314.00",,,,,,
BCBS HMO,CPT,64830,MICROREPAIR OF NERVE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64831,Repair of digit nerve,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,64832,Repair nerve add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64834,Repair of hand or foot nerve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,833.22",,,,,,
BCBS HMO,CPT,64835,Repair of hand or foot nerve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,833.22",,,,,,
BCBS HMO,CPT,64836,Repair of hand or foot nerve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,833.22",,,,,,
BCBS HMO,CPT,64837,Repair nerve add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64840,Repair of leg nerve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,833.22",,,,,,
BCBS HMO,CPT,64856,Repair/transpose nerve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,833.22",,,,,,
BCBS HMO,CPT,64857,Repair arm/leg nerve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,833.22",,,,,,
BCBS HMO,CPT,64858,Repair sciatic nerve,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,64859,Nerve surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64861,Repair of arm nerves,Surgical,Per Case,"$4,314.00 ",OP,"1,795.30","4,314.00",,,,,,
BCBS HMO,CPT,64862,Repair of low back nerves,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,833.22",,,,,,
BCBS HMO,CPT,64864,Repair of facial nerve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,833.22",,,,,,
BCBS HMO,CPT,64865,Repair of facial nerve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,833.22",,,,,,
BCBS HMO,CPT,64866,Fusion of facial/other nerve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,64868,Fusion of facial/other nerve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,64870,Fusion of facial/other nerve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64872,Subsequent repair of nerve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64874,Repair & revise nerve add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64876,Repair nerve/shorten bone,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64885,Nerve graft head/neck </4 cm,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,833.22",,,,,,
BCBS HMO,CPT,64886,Nerve graft head/neck >4 cm,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,833.22",,,,,,
BCBS HMO,CPT,64890,Nerve graft hand/foot </4 cm,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,833.22",,,,,,
BCBS HMO,CPT,64891,Nerve graft hand/foot >4 cm,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,833.22",,,,,,
BCBS HMO,CPT,64892,Nerve graft arm/leg <4 cm,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,833.22",,,,,,
BCBS HMO,CPT,64893,Nerve graft arm/leg >4 cm,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,833.22",,,,,,
BCBS HMO,CPT,64895,Nerve graft hand/foot </4 cm,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,833.22",,,,,,
BCBS HMO,CPT,64896,Nerve graft hand/foot >4 cm,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,833.22",,,,,,
BCBS HMO,CPT,64897,Nerve graft arm/leg </4 cm,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,833.22",,,,,,
BCBS HMO,CPT,64898,Nerve graft arm/leg >4 cm,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,833.22",,,,,,
BCBS HMO,CPT,64901,Nerve graft add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64902,Nerve graft add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64905,Nerve pedicle transfer,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,833.22",,,,,,
BCBS HMO,CPT,64907,Nerve pedicle transfer,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,833.22",,,,,,
BCBS HMO,CPT,64910,Nerve repair w/allograft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,833.22",,,,,,
BCBS HMO,CPT,64911,Neurorraphy w/vein autograft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,833.22",,,,,,
BCBS HMO,CPT,64912,Nrv rpr w/nrv algrft 1st,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,833.22",,,,,,
BCBS HMO,CPT,64913,Nrv rpr w/nrv algrft ea addl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,64999,Nervous system surgery,Surgical,Per Case,"$4,314.00 ",OP,267.26,"4,314.00",,,,,,
BCBS HMO,CPT,65091,Revise eye,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,65093,Revise eye with implant,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,65101,Removal of eye,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,65103,Remove eye/insert implant,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,65105,Remove eye/attach implant,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,65110,Removal of eye,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,65112,Remove eye/revise socket,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,65114,Remove eye/revise socket,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,65125,Revise ocular implant,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,65130,Insert ocular implant,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,65135,Insert ocular implant,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,65140,Attach ocular implant,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,65150,Revise ocular implant,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,65155,Reinsert ocular implant,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,65175,Removal of ocular implant,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,65205,Remove foreign body from eye,Surgical,Per Case,"$4,314.00 ",OP,114.56,"4,314.00",,,,,,
BCBS HMO,CPT,65210,Remove foreign body from eye,Surgical,Per Case,"$4,314.00 ",OP,276.53,"4,314.00",,,,,,
BCBS HMO,CPT,65220,Remove foreign body from eye,Surgical,Per Case,"$4,314.00 ",OP,276.53,"4,314.00",,,,,,
BCBS HMO,CPT,65222,Remove foreign body from eye,Surgical,Per Case,"$4,314.00 ",OP,114.56,"4,314.00",,,,,,
BCBS HMO,CPT,65230,REMOVAL F.B. MAGNETIC ANT.,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,65235,Remove foreign body from eye,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,65240,REMOVAL F.B. LENS MAGNETIC,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,65245,REMOVAL F.B. LENS NONMAG.,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,65260,Remove foreign body from eye,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,65265,Remove foreign body from eye,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,65270,Repair of eye wound,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,65272,Repair of eye wound,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,65273,Repair of eye wound,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,65275,Repair of eye wound,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,65280,Repair of eye wound,Surgical,Per Case,"$4,314.00 ",OP,"4,009.10","4,314.00",,,,,,
BCBS HMO,CPT,65285,Repair of eye wound,Surgical,Per Case,"$4,314.00 ",OP,"4,009.10","4,314.00",,,,,,
BCBS HMO,CPT,65286,Repair of eye wound,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,65290,Repair of eye socket wound,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,65400,Removal of eye lesion,Surgical,Per Case,"$4,314.00 ",OP,828.42,"4,314.00",,,,,,
BCBS HMO,CPT,65410,Biopsy of cornea,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,65420,Removal of eye lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,65426,Removal of eye lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,65430,Corneal smear,Surgical,Per Case,"$4,314.00 ",OP,276.53,"4,314.00",,,,,,
BCBS HMO,CPT,65435,Curette/treat cornea,Surgical,Per Case,"$4,314.00 ",OP,828.42,"4,314.00",,,,,,
BCBS HMO,CPT,65436,Curette/treat cornea,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,65450,Treatment of corneal lesion,Surgical,Per Case,"$4,314.00 ",OP,267.38,"4,314.00",,,,,,
BCBS HMO,CPT,65600,Revision of cornea,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,65710,Corneal transplant,Surgical,Per Case,"$4,314.00 ",OP,"4,009.10","4,314.00",,,,,,
BCBS HMO,CPT,65720,KERATOPLASTY-HOMOGRAFT-FRESH,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,65725,KERATOPLASTY-HOMOGRAFT-FRESH,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,65730,Corneal transplant,Surgical,Per Case,"$4,314.00 ",OP,"4,009.10","9,201.00",,,,,,
BCBS HMO,CPT,65740,KERATOPLASTY-HOMOGRAFT-FRESH,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,65745,KERATOPLASTY-HOMOGRAFT-FRESH,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,65750,Corneal transplant,Surgical,Per Case,"$4,314.00 ",OP,"4,009.10","4,314.00",,,,,,
BCBS HMO,CPT,65755,Corneal transplant,Surgical,Per Case,"$4,314.00 ",OP,"4,009.10","4,314.00",,,,,,
BCBS HMO,CPT,65756,Corneal trnspl endothelial,Surgical,Per Case,"$4,314.00 ",OP,"4,009.10","9,201.00",,,,,,
BCBS HMO,CPT,65757,Prep corneal endo allograft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,65760,Revision of cornea,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,65765,Revision of cornea,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,65767,Corneal tissue transplant,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,65770,Revise cornea with implant,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","7,506.93",,,,,,
BCBS HMO,CPT,65771,Radial keratotomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,65772,Correction of astigmatism,Surgical,Per Case,"$4,314.00 ",OP,828.42,"4,314.00",,,,,,
BCBS HMO,CPT,65775,Correction of astigmatism,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,65778,Cover eye w/membrane,Surgical,Per Case,"$4,314.00 ",OP,828.42,"4,314.00",,,,,,
BCBS HMO,CPT,65779,Cover eye w/membrane suture,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,65780,Ocular reconst transplant,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,65781,Ocular reconst transplant,Surgical,Per Case,"$4,314.00 ",OP,"4,009.10","4,314.00",,,,,,
BCBS HMO,CPT,65782,Ocular reconst transplant,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,65785,Impltj ntrstrml crnl rng seg,Surgical,Per Case,"$4,314.00 ",OP,"4,009.10","4,314.00",,,,,,
BCBS HMO,CPT,65800,Drainage of eye,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,65805,Drainage of eye,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,65810,Drainage of eye,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,65815,Drainage of eye,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,65820,Relieve inner eye pressure,Surgical,Per Case,"$4,314.00 ",OP,"4,009.10","4,314.00",,,,,,
BCBS HMO,CPT,65850,Incision of eye,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,65855,Trabeculoplasty laser surg,Surgical,Per Case,"$4,314.00 ",OP,515.61,"4,314.00",,,,,,
BCBS HMO,CPT,65860,Incise inner eye adhesions,Surgical,Per Case,"$4,314.00 ",OP,515.61,"4,314.00",,,,,,
BCBS HMO,CPT,65865,Incise inner eye adhesions,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,65870,Incise inner eye adhesions,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,65875,Incise inner eye adhesions,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,65880,Incise inner eye adhesions,Surgical,Per Case,"$4,314.00 ",OP,"4,009.10","4,314.00",,,,,,
BCBS HMO,CPT,65900,Remove eye lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,65920,Remove implant of eye,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,65930,Remove blood clot from eye,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,66020,Injection treatment of eye,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,66030,Injection treatment of eye,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,66130,Remove eye lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,66150,Glaucoma surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,009.10","4,314.00",,,,,,
BCBS HMO,CPT,66155,Glaucoma surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,009.10","4,314.00",,,,,,
BCBS HMO,CPT,66160,Glaucoma surgery,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,66165,Glaucoma surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,66170,Glaucoma surgery,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,66172,Incision of eye,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,66174,Translum dil eye canal,Surgical,Per Case,"$4,314.00 ",OP,"4,009.10","4,314.00",,,,,,
BCBS HMO,CPT,66175,Trnslum dil eye canal w/stnt,Surgical,Per Case,"$4,314.00 ",OP,"4,009.10","4,314.00",,,,,,
BCBS HMO,CPT,66179,Aqueous shunt eye w/o graft,Surgical,Per Case,"$4,314.00 ",OP,"4,009.10","4,314.00",,,,,,
BCBS HMO,CPT,66180,Aqueous shunt eye w/graft,Surgical,Per Case,"$4,314.00 ",OP,"4,009.10","9,201.00",,,,,,
BCBS HMO,CPT,66183,Insert ant drainage device,Surgical,Per Case,"$4,314.00 ",OP,"4,009.10","4,314.00",,,,,,
BCBS HMO,CPT,66184,Revision of aqueous shunt,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,66185,Revise aqueous shunt eye,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,66220,Repair eye lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,66225,Repair/graft eye lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,009.10","4,314.00",,,,,,
BCBS HMO,CPT,66250,Follow-up surgery of eye,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,66500,Incision of iris,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,66505,Incision of iris,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,66600,Remove iris and lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,009.10","4,314.00",,,,,,
BCBS HMO,CPT,66605,Removal of iris,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,66625,Removal of iris,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,66630,Removal of iris,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,66635,Removal of iris,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,66680,Repair iris & ciliary body,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,66682,Repair iris & ciliary body,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,66700,Destruction ciliary body,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,66702,DESTRUCTION-CILIARY BODY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,66710,Ciliary transsleral therapy,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,66711,Ecp ciliary body destruction,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,66720,Destruction ciliary body,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,66740,Destruction ciliary body,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,66761,Revision of iris,Surgical,Per Case,"$4,314.00 ",OP,515.61,"4,314.00",,,,,,
BCBS HMO,CPT,66762,Revision of iris,Surgical,Per Case,"$4,314.00 ",OP,515.61,"4,314.00",,,,,,
BCBS HMO,CPT,66770,Removal of inner eye lesion,Surgical,Per Case,"$4,314.00 ",OP,515.61,"4,314.00",,,,,,
BCBS HMO,CPT,66820,Incision secondary cataract,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,66821,After cataract laser surgery,Surgical,Per Case,"$4,314.00 ",OP,515.61,"4,314.00",,,,,,
BCBS HMO,CPT,66825,Reposition intraocular lens,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,66830,Removal of lens lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,66840,Removal of lens material,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,66850,Removal of lens material,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,66852,Removal of lens material,Surgical,Per Case,"$4,314.00 ",OP,"4,009.10","4,314.00",,,,,,
BCBS HMO,CPT,66920,Extraction of lens,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,66930,Extraction of lens,Surgical,Per Case,"$4,314.00 ",OP,"4,009.10","4,314.00",,,,,,
BCBS HMO,CPT,66940,Extraction of lens,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,66980,INSERT LENS PROSTHESIS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,66982,Xcapsl ctrc rmvl cplx wo ecp,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,66983,Cataract surg w/iol 1 stage,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,66984,Xcapsl ctrc rmvl w/o ecp,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,66985,Insert lens prosthesis,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,66986,Exchange lens prosthesis,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,66987,Xcapsl ctrc rmvl cplx w/ecp,Surgical,Per Case,"$4,314.00 ",OP,"4,009.10","4,314.00",,,,,,
BCBS HMO,CPT,66988,Xcapsl ctrc rmvl w/ecp,Surgical,Per Case,"$4,314.00 ",OP,"4,009.10","4,314.00",,,,,,
BCBS HMO,CPT,66990,Ophthalmic endoscope add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,66999,Eye surgery procedure,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,67005,Partial removal of eye fluid,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,67010,Partial removal of eye fluid,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,67015,Release of eye fluid,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,67025,Replace eye fluid,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,67027,Implant eye drug system,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","15,359.39",,,,,,
BCBS HMO,CPT,67028,Injection eye drug,Surgical,Per Case,"$4,314.00 ",OP,318,"4,314.00",,,,,,
BCBS HMO,CPT,67030,Incise inner eye strands,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,67031,Laser surgery eye strands,Surgical,Per Case,"$4,314.00 ",OP,515.61,"4,314.00",,,,,,
BCBS HMO,CPT,67036,Removal of inner eye fluid,Surgical,Per Case,"$4,314.00 ",OP,"4,009.10","4,314.00",,,,,,
BCBS HMO,CPT,67038,Strip retinal membrane,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,67039,Laser treatment of retina,Surgical,Per Case,"$4,314.00 ",OP,"4,009.10","4,314.00",,,,,,
BCBS HMO,CPT,67040,Laser treatment of retina,Surgical,Per Case,"$4,314.00 ",OP,"4,009.10","4,314.00",,,,,,
BCBS HMO,CPT,67041,Vit for macular pucker,Surgical,Per Case,"$4,314.00 ",OP,"4,009.10","4,314.00",,,,,,
BCBS HMO,CPT,67042,Vit for macular hole,Surgical,Per Case,"$4,314.00 ",OP,"4,009.10","4,314.00",,,,,,
BCBS HMO,CPT,67043,Vit for membrane dissect,Surgical,Per Case,"$4,314.00 ",OP,"4,009.10","4,314.00",,,,,,
BCBS HMO,CPT,67101,Repair detached retina crtx,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,67105,Repair detached retina pc,Surgical,Per Case,"$4,314.00 ",OP,515.61,"4,314.00",,,,,,
BCBS HMO,CPT,67107,Repair detached retina,Surgical,Per Case,"$4,314.00 ",OP,"4,009.10","4,314.00",,,,,,
BCBS HMO,CPT,67108,Repair detached retina,Surgical,Per Case,"$4,314.00 ",OP,"4,009.10","9,201.00",,,,,,
BCBS HMO,CPT,67109,REPAIR DETACHED RETINA,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,67110,Repair detached retina,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,67112,Rerepair detached retina,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,67113,Repair retinal detach cplx,Surgical,Per Case,"$4,314.00 ",OP,"4,009.10","9,201.00",,,,,,
BCBS HMO,CPT,67115,Release encircling material,Surgical,Per Case,"$4,314.00 ",OP,"4,009.10","4,314.00",,,,,,
BCBS HMO,CPT,67120,Remove eye implant material,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,67121,Remove eye implant material,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,67141,Treatment of retina,Surgical,Per Case,"$4,314.00 ",OP,267.38,"4,314.00",,,,,,
BCBS HMO,CPT,67145,Treatment of retina,Surgical,Per Case,"$4,314.00 ",OP,515.61,"4,314.00",,,,,,
BCBS HMO,CPT,67208,Treatment of retinal lesion,Surgical,Per Case,"$4,314.00 ",OP,267.38,"4,314.00",,,,,,
BCBS HMO,CPT,67210,Treatment of retinal lesion,Surgical,Per Case,"$4,314.00 ",OP,515.61,"4,314.00",,,,,,
BCBS HMO,CPT,67218,Treatment of retinal lesion,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,67220,Treatment of choroid lesion,Surgical,Per Case,"$4,314.00 ",OP,515.61,"4,314.00",,,,,,
BCBS HMO,CPT,67221,Ocular photodynamic ther,Surgical,Per Case,"$4,314.00 ",OP,515.61,"4,314.00",,,,,,
BCBS HMO,CPT,67225,Eye photodynamic ther add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,67227,Dstrj extensive retinopathy,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,67228,Treatment x10sv retinopathy,Surgical,Per Case,"$4,314.00 ",OP,515.61,"4,314.00",,,,,,
BCBS HMO,CPT,67229,Tr retinal les preterm inf,Surgical,Per Case,"$4,314.00 ",OP,515.61,"4,314.00",,,,,,
BCBS HMO,CPT,67250,Reinforce eye wall,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,67255,Reinforce/graft eye wall,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,67299,Eye surgery procedure,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,67311,Revise eye muscle,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,67312,Revise two eye muscles,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,67313,STRABISMUS 3+ MUSCLES,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,67314,Revise eye muscle,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,67316,Revise two eye muscles,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,67318,Revise eye muscle(s),Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,67320,Revise eye muscle(s) add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,67331,Eye surgery follow-up add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,67332,Rerevise eye muscles add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,67334,Revise eye muscle w/suture,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,67335,Eye suture during surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,67340,Revise eye muscle add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,67343,Release eye tissue,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,67345,Destroy nerve of eye muscle,Surgical,Per Case,"$4,314.00 ",OP,267.38,"4,314.00",,,,,,
BCBS HMO,CPT,67346,Biopsy eye muscle,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,67350,Biopsy eye muscle,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,67399,Unlisted px extraocular musc,Surgical,Per Case,"$4,314.00 ",OP,267.38,"4,314.00",,,,,,
BCBS HMO,CPT,67400,Explore/biopsy eye socket,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,67405,Explore/drain eye socket,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,67412,Explore/treat eye socket,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,67413,Explore/treat eye socket,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,67414,Explr/decompress eye socket,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,67415,Aspiration orbital contents,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,67420,Explore/treat eye socket,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,67430,Explore/treat eye socket,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,67440,Explore/drain eye socket,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,67445,Explr/decompress eye socket,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,67450,Explore/biopsy eye socket,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,67500,Inject/treat eye socket,Surgical,Per Case,"$4,314.00 ",OP,267.38,"4,314.00",,,,,,
BCBS HMO,CPT,67505,Inject/treat eye socket,Surgical,Per Case,"$4,314.00 ",OP,267.38,"4,314.00",,,,,,
BCBS HMO,CPT,67515,Inject/treat eye socket,Surgical,Per Case,"$4,314.00 ",OP,267.38,"4,314.00",,,,,,
BCBS HMO,CPT,67550,Insert eye socket implant,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,67560,Revise eye socket implant,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,67570,Decompress optic nerve,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,67599,Orbit surgery procedure,Surgical,Per Case,"$4,314.00 ",OP,267.38,"4,314.00",,,,,,
BCBS HMO,CPT,67700,Drainage of eyelid abscess,Surgical,Per Case,"$4,314.00 ",OP,267.38,"4,314.00",,,,,,
BCBS HMO,CPT,67710,Incision of eyelid,Surgical,Per Case,"$4,314.00 ",OP,828.42,"4,314.00",,,,,,
BCBS HMO,CPT,67715,Incision of eyelid fold,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,67800,Remove eyelid lesion,Surgical,Per Case,"$4,314.00 ",OP,267.38,"4,314.00",,,,,,
BCBS HMO,CPT,67801,Remove eyelid lesions,Surgical,Per Case,"$4,314.00 ",OP,828.42,"4,314.00",,,,,,
BCBS HMO,CPT,67805,Remove eyelid lesions,Surgical,Per Case,"$4,314.00 ",OP,267.38,"4,314.00",,,,,,
BCBS HMO,CPT,67808,Remove eyelid lesion(s),Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,67810,Biopsy eyelid & lid margin,Surgical,Per Case,"$4,314.00 ",OP,267.38,"4,314.00",,,,,,
BCBS HMO,CPT,67820,Revise eyelashes,Surgical,Per Case,"$4,314.00 ",OP,114.56,"4,314.00",,,,,,
BCBS HMO,CPT,67825,Revise eyelashes,Surgical,Per Case,"$4,314.00 ",OP,267.38,"4,314.00",,,,,,
BCBS HMO,CPT,67830,Revise eyelashes,Surgical,Per Case,"$4,314.00 ",OP,828.42,"4,314.00",,,,,,
BCBS HMO,CPT,67835,Revise eyelashes,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,67840,Remove eyelid lesion,Surgical,Per Case,"$4,314.00 ",OP,828.42,"4,314.00",,,,,,
BCBS HMO,CPT,67850,Treat eyelid lesion,Surgical,Per Case,"$4,314.00 ",OP,828.42,"4,314.00",,,,,,
BCBS HMO,CPT,67875,Closure of eyelid by suture,Surgical,Per Case,"$4,314.00 ",OP,828.42,"4,314.00",,,,,,
BCBS HMO,CPT,67880,Revision of eyelid,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,67882,Revision of eyelid,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,67900,Repair brow defect,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,67901,Repair eyelid defect,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,67902,Repair eyelid defect,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,67903,Repair eyelid defect,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,67904,Repair eyelid defect,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,67906,Repair eyelid defect,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,67907,REPAIR EYELID DEFECT,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,67908,Repair eyelid defect,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,67909,Revise eyelid defect,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,67911,Revise eyelid defect,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,67912,Correction eyelid w/implant,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,67914,Repair eyelid defect,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,67915,Repair eyelid defect,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,67916,Repair eyelid defect,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,67917,Repair eyelid defect,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,67921,Repair eyelid defect,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,67922,Repair eyelid defect,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,67923,Repair eyelid defect,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,67924,Repair eyelid defect,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,67930,Repair eyelid wound,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,67935,Repair eyelid wound,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,67938,Remove eyelid foreign body,Surgical,Per Case,"$4,314.00 ",OP,267.38,"4,314.00",,,,,,
BCBS HMO,CPT,67950,Revision of eyelid,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,67961,Revision of eyelid,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,67966,Revision of eyelid,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,67971,Reconstruction of eyelid,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,67973,Reconstruction of eyelid,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,67974,Reconstruction of eyelid,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,67975,Reconstruction of eyelid,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,67999,Revision of eyelid,Surgical,Per Case,"$4,314.00 ",OP,267.38,"4,314.00",,,,,,
BCBS HMO,CPT,68020,Incise/drain eyelid lining,Surgical,Per Case,"$4,314.00 ",OP,828.42,"4,314.00",,,,,,
BCBS HMO,CPT,68040,Treatment of eyelid lesions,Surgical,Per Case,"$4,314.00 ",OP,267.38,"4,314.00",,,,,,
BCBS HMO,CPT,68100,Biopsy of eyelid lining,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,68110,Remove eyelid lining lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,68115,Remove eyelid lining lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,68130,Remove eyelid lining lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,68135,Remove eyelid lining lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,68200,Treat eyelid by injection,Surgical,Per Case,"$4,314.00 ",OP,276.53,"4,314.00",,,,,,
BCBS HMO,CPT,68320,Revise/graft eyelid lining,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,68325,Revise/graft eyelid lining,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,68326,Revise/graft eyelid lining,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,68328,Revise/graft eyelid lining,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,68330,Revise eyelid lining,Surgical,Per Case,"$4,314.00 ",OP,"2,127.64","4,314.00",,,,,,
BCBS HMO,CPT,68335,Revise/graft eyelid lining,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,68340,Separate eyelid adhesions,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,68360,Revise eyelid lining,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,68362,Revise eyelid lining,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,68371,Harvest eye tissue alograft,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,68399,Eyelid lining surgery,Surgical,Per Case,"$4,314.00 ",OP,267.38,"4,314.00",,,,,,
BCBS HMO,CPT,68400,Incise/drain tear gland,Surgical,Per Case,"$4,314.00 ",OP,828.42,"4,314.00",,,,,,
BCBS HMO,CPT,68420,Incise/drain tear sac,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,68440,Incise tear duct opening,Surgical,Per Case,"$4,314.00 ",OP,267.38,"4,314.00",,,,,,
BCBS HMO,CPT,68500,Removal of tear gland,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,68505,Partial removal tear gland,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,68510,Biopsy of tear gland,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,68520,Removal of tear sac,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,68525,Biopsy of tear sac,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,68530,Clearance of tear duct,Surgical,Per Case,"$4,314.00 ",OP,267.38,"4,314.00",,,,,,
BCBS HMO,CPT,68540,Remove tear gland lesion,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,68550,Remove tear gland lesion,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,68700,Repair tear ducts,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,68705,Revise tear duct opening,Surgical,Per Case,"$4,314.00 ",OP,267.38,"4,314.00",,,,,,
BCBS HMO,CPT,68720,Create tear sac drain,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,68745,Create tear duct drain,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,68750,Create tear duct drain,Surgical,Per Case,"$4,314.00 ",OP,"3,382.53","4,314.00",,,,,,
BCBS HMO,CPT,68760,Close tear duct opening,Surgical,Per Case,"$4,314.00 ",OP,267.38,"4,314.00",,,,,,
BCBS HMO,CPT,68761,Close tear duct opening,Surgical,Per Case,"$4,314.00 ",OP,267.38,"4,314.00",,,,,,
BCBS HMO,CPT,68770,Close tear system fistula,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,68800,Dilation of lacrimal punctum-w/or w/o irrigation-unilateral or bilateral,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,68801,Dilate tear duct opening,Surgical,Per Case,"$4,314.00 ",OP,276.53,"4,314.00",,,,,,
BCBS HMO,CPT,68810,Probe nasolacrimal duct,Surgical,Per Case,"$4,314.00 ",OP,267.38,"4,314.00",,,,,,
BCBS HMO,CPT,68811,Probe nasolacrimal duct,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,68815,Probe nasolacrimal duct,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,68816,Probe nl duct w/balloon,Surgical,Per Case,"$4,314.00 ",OP,"2,049.05","4,314.00",,,,,,
BCBS HMO,CPT,68820,Probing of nasolacrimal duct-w/or w/o irrigation-unilateral or bilateral-,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,68825,Probing of nasolacrimal duct-w/or w/o irrigation-unilateral or bilateral-requiring general anesthesia,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,68830,Probing of nasolacrimal duct-w/or w/o irrigation-unilateral or bilateral-w/insertion of tube or stent,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,68840,Explore/irrigate tear ducts,Surgical,Per Case,"$4,314.00 ",OP,267.38,"4,314.00",,,,,,
BCBS HMO,CPT,68850,Injection for tear sac x-ray,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,68899,Tear duct system surgery,Surgical,Per Case,"$4,314.00 ",OP,267.38,"4,314.00",,,,,,
BCBS HMO,CPT,69000,Drain external ear lesion,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,69005,Drain external ear lesion,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,69020,Drain outer ear canal lesion,Surgical,Per Case,"$4,314.00 ",OP,636.47,"4,314.00",,,,,,
BCBS HMO,CPT,69090,Pierce earlobes,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,69100,Biopsy of external ear,Surgical,Per Case,"$4,314.00 ",OP,216.54,"4,314.00",,,,,,
BCBS HMO,CPT,69105,Biopsy of external ear canal,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,69110,Remove external ear partial,Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,69120,Removal of external ear,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,69140,Remove ear canal lesion(s),Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,69145,Remove ear canal lesion(s),Surgical,Per Case,"$4,314.00 ",OP,"2,425.27","4,314.00",,,,,,
BCBS HMO,CPT,69150,Extensive ear canal surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,69155,Extensive ear/neck surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,69200,Clear outer ear canal,Surgical,Per Case,"$4,314.00 ",OP,114.56,"4,314.00",,,,,,
BCBS HMO,CPT,69205,Clear outer ear canal,Surgical,Per Case,"$4,314.00 ",OP,"1,439.81","4,314.00",,,,,,
BCBS HMO,CPT,69209,Remove impacted ear wax uni,Surgical,Per Case,"$4,314.00 ",OP,56.95,"4,314.00",,,,,,
BCBS HMO,CPT,69210,Remove impacted ear wax uni,Surgical,Per Case,"$4,314.00 ",OP,56.95,"4,314.00",,,,,,
BCBS HMO,CPT,69220,Clean out mastoid cavity,Surgical,Per Case,"$4,314.00 ",OP,183.73,"4,314.00",,,,,,
BCBS HMO,CPT,69222,Clean out mastoid cavity,Surgical,Per Case,"$4,314.00 ",OP,462.91,"4,314.00",,,,,,
BCBS HMO,CPT,69300,Revise external ear,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,69310,Rebuild outer ear canal,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,69320,Rebuild outer ear canal,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,69399,Outer ear surgery procedure,Surgical,Per Case,"$4,314.00 ",OP,216.54,"4,314.00",,,,,,
BCBS HMO,CPT,69400,Inflate middle ear canal,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,69401,Inflate middle ear canal,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,69405,Catheterize middle ear canal,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,69410,INSET MIDDLE EAR BAFFLE,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,69420,Incision of eardrum,Surgical,Per Case,"$4,314.00 ",OP,216.54,"4,314.00",,,,,,
BCBS HMO,CPT,69421,Incision of eardrum,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,69424,Remove ventilating tube,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,69433,Create eardrum opening,Surgical,Per Case,"$4,314.00 ",OP,462.91,"4,314.00",,,,,,
BCBS HMO,CPT,69435,Unknown,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,69436,Create eardrum opening,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,69437,CREATE EARDRUM OPENINGS,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,69440,Exploration of middle ear,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,69450,Eardrum revision,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,69501,Mastoidectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,69502,Mastoidectomy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,69505,Remove mastoid structures,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,69511,Extensive mastoid surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,69530,Extensive mastoid surgery,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,69535,Remove part of temporal bone,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,69540,Remove ear lesion,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,69550,Remove ear lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,69552,Remove ear lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,69554,Remove ear lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,69601,Mastoid surgery revision,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,69602,Mastoid surgery revision,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,69603,Mastoid surgery revision,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,69604,Mastoid surgery revision,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,69605,Mastoid surgery revision,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,69610,Repair of eardrum,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,69611,TYMPANIC REPAIR W/GRAFT,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,69620,Repair of eardrum,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,69631,Repair eardrum structures,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,69632,Rebuild eardrum structures,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,69633,Rebuild eardrum structures,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,69635,Repair eardrum structures,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,69636,Rebuild eardrum structures,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,69637,Rebuild eardrum structures,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,69641,Revise middle ear & mastoid,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,69642,Revise middle ear & mastoid,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,69643,Revise middle ear & mastoid,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,69644,Revise middle ear & mastoid,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,69645,Revise middle ear & mastoid,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,69646,Revise middle ear & mastoid,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,69650,Release middle ear bone,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,69660,Revise middle ear bone,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,69661,Revise middle ear bone,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,69662,Revise middle ear bone,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,69666,Repair middle ear structures,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,69667,Repair middle ear structures,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,69670,Remove mastoid air cells,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,69676,Remove middle ear nerve,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,69677,REMOVE MIDDLE EAR NERVES,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,69700,Close mastoid fistula,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,69705,Nps surg dilat eust tube uni,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,69706,Nps surg dilat eust tube bi,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,69710,Implant/replace hearing aid,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,69711,Remove/repair hearing aid,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,69714,Implant temple bone w/stimul,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,69715,Temple bne implnt w/stimulat,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","16,238.16",,,,,,
BCBS HMO,CPT,69717,Temple bone implant revision,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","6,411.04",,,,,,
BCBS HMO,CPT,69718,Revise temple bone implant,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","12,601.93",,,,,,
BCBS HMO,CPT,69720,Release facial nerve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,69725,Release facial nerve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,69740,Repair facial nerve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,69745,Repair facial nerve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,69799,Middle ear surgery procedure,Surgical,Per Case,"$4,314.00 ",OP,216.54,"4,314.00",,,,,,
BCBS HMO,CPT,69801,Incise inner ear,Surgical,Per Case,"$4,314.00 ",OP,"1,384.33","4,314.00",,,,,,
BCBS HMO,CPT,69802,Incise inner ear,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,69805,Explore inner ear,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,69806,Explore inner ear,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,69820,Establish inner ear window,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,69840,Revise inner ear window,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,69905,Remove inner ear,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,69910,Remove inner ear & mastoid,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,69915,Incise inner ear nerve,Surgical,Per Case,"$4,314.00 ",OP,"2,800.20","4,314.00",,,,,,
BCBS HMO,CPT,69930,Implant cochlear device,Surgical,Per Case,"$4,314.00 ",OP,"4,140.35","35,230.37",,,,,,
BCBS HMO,CPT,69949,Inner ear surgery procedure,Surgical,Per Case,"$4,314.00 ",OP,216.54,"4,314.00",,,,,,
BCBS HMO,CPT,69950,Incise inner ear nerve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","8,948.83",,,,,,
BCBS HMO,CPT,69955,Release facial nerve,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,69960,Release inner ear canal,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,69965,EUSTACHIAN TUBOPLASTY,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,69970,Remove inner ear lesion,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","5,204.66",,,,,,
BCBS HMO,CPT,69979,Temporal bone surgery,Surgical,Per Case,"$4,314.00 ",OP,216.54,"4,314.00",,,,,,
BCBS HMO,CPT,69990,Microsurgery add-on,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1000F,Tobacco use assessed,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1001F,TOBACCO USE-NON-SMOKING,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1002F,Assess anginal symptom/level,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1003F,Level of activity assess,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1004F,Clin symp vol ovrld assess,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1005F,Asthma symptoms evaluate,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1006F,Osteoarthritis assess,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1007F,Anti-inflm/anlgsc otc assess,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1008F,Gi/renal risk assess,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1010F,Severity angina by actvty,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1011F,Angina present,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1012F,Angina absent,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1015F,Copd symptoms assess,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1018F,Assess dyspnea not present,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1019F,Assess dyspnea present,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1022F,Pneumo imm status assess,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1026F,Co-morbid condition assess,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1030F,Influenza imm status assess,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1031F,Smoking & 2nd hand assessed,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1032F,Smoker/exposed 2nd hnd smoke,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1033F,Tobacco nonsmoker nor 2ndhnd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1034F,Current tobacco smoker,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1035F,Smokeless tobacco user,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1036F,Tobacco non-user,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1038F,Persistent asthma,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1039F,Intermittent asthma,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1040F,Dsm-5 info mdd docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1050F,History of mole changes,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1052F,Type location activityassess,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1055F,Visual funct status assess,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1060F,Doc perm/cont/parox atr fib,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1061F,Doc lack perm+cont+parox fib,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1065F,Ischm stroke symp lt3 hrsb/4,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1066F,Ischm stroke symp ge3 hrsb/4,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1070F,Alarm symp assessed-absent,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1071F,Alarm symp assessed-1+ prsnt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1080F,URROG DECSN MKR/ADV CARE PLAN DOC'D MED RECORD,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1090F,Pres/absn urine incon assess,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1091F,Urine incon characterized,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1100F,Ptfalls assess-docd ge2>/yr,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1101F,Pt falls assess-docd le1/yr,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1110F,Pt lft inpt fac w/in 60 days,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1111F,Dschrg med/current med merge,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1116F,Auric/peri pain assessed,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1118F,Gerd symps assessed 12 month,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1119F,Init eval for condition,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1121F,Subs eval for condition,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1123F,Acp discuss/dscn mkr docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1124F,Acp discuss-no dscnmkr docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1125F,Amnt pain noted pain prsnt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1126F,Amnt pain noted none prsnt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1127F,New episode for condition,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1128F,Subs episode for condition,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1130F,Bk pain & fxn assessed,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1134F,Epsd bk pain for 6 wks/<,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1135F,Epsd bk pain for >6 wks,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1136F,Epsd bk pain for 12 wks/<,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1137F,Epsd bk pain for >12 wks,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1150F,Doc pt rsk death w/in 1yr,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1151F,Doc no pt rsk death w/in 1yr,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1152F,Doc advncd dis comfort 1st,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1153F,Doc advncd dis cmfrt not 1st,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1157F,Advnc care plan in rcrd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1158F,Advnc care plan tlk docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1159F,Med list docd in rcrd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1160F,Rvw meds by rx/dr in rcrd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1170F,Fxnl status assessed,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1175F,Function stat assessed rvwd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1180F,Thromboemb risk assessed,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1181F,Neuropsychia sympts assessed,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1182F,Neuropsychi sympt 1+present,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1183F,Neuropsychiatric symp absent,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1200F,Seizure type& frequ docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1205F,Epi etiol synd rvwd and docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1220F,Pt screened for depression,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1400F,Prkns diag rviewed,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1450F,Symptoms improved/consist,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1451F,Sympt show clin import drop,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1460F,Qual card diag prior 12 mons,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1461F,No qual card diag prior12mon,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1490F,Dem severity classified mild,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1491F,Dem severity classified mod,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1493F,Dem severity class severe,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1494F,Cognit assessed and reviewed,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1500F,Symptom+sign symm polyneuro,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1501F,Not initial eval for cond,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1502F,Pt queried pain fxn w/ instr,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1503F,Pt queried symp resp insuff,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1504F,Pt has resp insufficiency,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1505F,Pt has no resp insufficiency,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1AA11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1AB11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1AB21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1AC11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1AC21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1AC31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1AFK1,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1AFKS,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1AGM1,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1AHK1,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1AHK2,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1AHK4,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1AHL1,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1AHLS,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1AHM1,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1AHMS,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1AHP1,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1AHP2,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1BA11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1BA21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1BB11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1BB21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1BB31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1BC11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1BC21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1BC31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1BGK1,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1BGK2,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1BGKS,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1BGKT,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1BGLS,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1BGM1,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1BHK1,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1BHK2,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1BHK3,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1BHK4,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1BHKS,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1BHKT,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1BHKV,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1BHL1,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1BHLS,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1BHM1,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1BHM2,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1BHMS,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1BHMT,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1BHP1,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1BHP2,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1BHP3,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1BHPS,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1BHPT,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1BHPU,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CA11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CA21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CA31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CB11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CB21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CB31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CC11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CC21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CC31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CGK1,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CGK2,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CGK4,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CGK5,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CGKS,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CGKT,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CGKV,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CGL1,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CGLS,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CGM1,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CGMS,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CHK1,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CHK2,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CHK3,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CHK4,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CHK5,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CHKS,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CHKT,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CHKU,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CHKV,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CHKW,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CHL1,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CHL2,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CHL3,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CHL5,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CHLS,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CHLT,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CHLW,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CHM1,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CHM2,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CHM3,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CHM4,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CHMS,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CHMT,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CHMU,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CHMV,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CHN1,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CHN2,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CHP1,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CHP2,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CHP3,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CHPS,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1CHPU,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1DA11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1DA21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1DA31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1DB11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1DB21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1DB31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1DC11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1DC21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1DC31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1EA11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1EA21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1EB11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1EB21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1EB31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1EC11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1EC21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1EC31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1FA11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1FB11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1FC11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1FC21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1GA11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1GA21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1GB11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1GB21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1HA21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1HB11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1HB21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1HB31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1HC11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1HC21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1HC31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1IA11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1IA31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1IB11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1IC11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1IC21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1JA11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1JA21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1JB11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1JB21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1JC11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1JC31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1KA21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1KB11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1KB21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1KC11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1KC21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1KC31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1LA11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1LA21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1LB11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1LB21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1LC11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1LC21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,1LC31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2000F,Blood pressure measure,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2001F,Weight record,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2002F,Clin sign vol ovrld assess,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2003F,AUSCULTATION HRT PFRMD,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2004F,Initial exam involved joints,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2010F,Vital signs recorded,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2014F,Mental status assess,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2015F,Asthma impairment assessed,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2016F,Asthma risk assessed,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2018F,Hydration status assess,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2019F,Dilated macul exam done,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2020F,Dilated fundus eval done,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2021F,Dilat macular exam done,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2022F,Dilat rta xm evc rtnopthy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2023F,Dilat rta xm w/o rtnopthy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2024F,7 fld rta photo evc rtnopthy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2025F,7 fld rta photo w/o rtnopthy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2026F,Eye img valid evc rtnopthy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2027F,Optic nerve head eval done,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2028F,Foot exam performed,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2029F,Complete phys skin exam done,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2030F,H2o stat docd normal,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2031F,H2o stat docd dehydrated,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2033F,Eye img valid w/o rtnopthy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2035F,Tymp memb motion examd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2040F,Bk pn xm on init visit date,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2044F,Doc mntl tst b/4 bk trxmnt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2050F,Wound char size etc docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2060F,Pt talk eval hlthwkr re mdd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2AA11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2AA21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2AA31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2AB11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2AB21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2AB31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2AC11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2AC21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2AC31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2AFK1,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2AFM1,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2AFMS,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2AHL1,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2BA11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2BA21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2BA31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2BB11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2BB21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2BB31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2BC11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2BC21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2BC31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2BFK1,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2BFKS,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2BFL1,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2BFM1,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2BFMT,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2BHK1,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2BHK2,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2BHKS,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2BHKT,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2CA11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2CA21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2CA31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2CB11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2CB21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2CB31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2CC11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2CC21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2CC31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2CFK1,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2CFK2,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2CFK3,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2CFKS,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2CFKU,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2CFL1,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2CFLS,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2CFM1,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2CFM5,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2CFMW,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2DA11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2DA21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2DB11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2DB21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2DB31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2DC11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2DC21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2DC31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2EA11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2EA21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2EA31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2EB11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2EB21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2EB31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2EC11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2EC21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2EC31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2FC11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2FC21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2GA11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2GA21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2GA31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2GB11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2GB21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2GB31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2GC11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2GC21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2GC31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2HA11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2HA21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2HA31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2HB11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2HB21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2HB31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2HC11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2HC21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2HC31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2IA11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2IB11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2IB21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2IB31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2IC11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2IC21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2IC31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2JA11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2JA21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2JA31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2JB11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2JB21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2JB31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2JC11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2JC21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2JC31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2KA11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2KA21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2KA31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2KB11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2KB21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2KB31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2KC11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2KC21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2KC31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2LA11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2LA21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2LA31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2LB11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2LB21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2LB31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2LC11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2LC21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,2LC31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3000F,BLD PRESS 140/90 MM HG,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3002F,BLD PRESS >140/90 MM HG,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3006F,Cxr doc rev,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3008F,Body mass index docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3011F,Lipid panel doc rev,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3014F,Screen mammo doc rev,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3015F,Cerv cancer screen docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3016F,Pt scrnd unhlthy oh use,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3017F,Colorectal ca screen doc rev,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3018F,Pre-prxd rsk et al docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3019F,Lvef assess planpost dschrge,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3020F,Lvf assess,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3021F,Lvef mod/sever deprs syst,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3022F,Lvef >/=40% systolic,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3023F,Spirom doc rev,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3025F,Spirom fev/fvc <70% w/copd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3027F,Spirom fev/fvc>/=70%/w/ocopd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3028F,O2 saturation doc rev,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3035F,O2 saturation</=88%/pao</=55,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3037F,O2 saturation >88%/pao>55 hg,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3038F,Pulm fx w/in 12 mon b/4 surg,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3040F,Fev <40% predicted value,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3042F,Fev >/=40% predicted value,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3044F,Hg a1c level lt 7.0%,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3045F,Hg a1c level 7.0-9.0%,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3046F,Hemoglobin a1c level >9.0%,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3047F,HEMOGLOBIN A1C LEVEL = 9.0%,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3048F,Ldl-c <100 mg/dl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3049F,Ldl-c 100-129 mg/dl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3050F,Ldl-c >/= 130 mg/dl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3051F,Hg a1c>equal 7.0%<8.0%,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3052F,Hg a1c>equal 8.0%<equal 9.0%,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3055F,Lvef less than/equal to 35%,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3056F,Lvef greater than 35%,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3060F,Pos microalbuminuria rev,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3061F,Neg microalbuminuria rev,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3062F,Pos macroalbuminuria rev,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3066F,Nephropathy doc tx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3072F,Low risk for retinopathy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3073F,Pre-surg eye measures docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3074F,Syst bp lt 130 mm hg,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3075F,Syst bp ge 130 - 139mm hg,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3076F,SYST BP < 140 MM HG,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3077F,Syst bp >/= 140 mm hg,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3078F,Diast bp <80 mm hg,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3079F,Diast bp 80-89 mm hg,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3080F,Diast bp >/= 90 mm hg,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3082F,Kt/v <1.2,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3083F,Kt/v =/> 1.2 & <1.7,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3084F,Kt/v >= 1.7,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3085F,Suicide risk assessed,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3088F,Mdd mild,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3089F,Mdd moderate,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3090F,Mdd severe w/o psych,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3091F,Mdd severe w/psych,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3092F,Mdd in remission,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3093F,Doc new diag 1st/addl mdd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3095F,Central dexa results docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3096F,Central dexa ordered,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3100F,Image test ref carot diam,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3101F,Intl carot blk 30v99% range,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3102F,Int carot blk < 30%,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3110F,Pres/absn hmrhg/lesion docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3111F,Ct/mri brain done w/in 24hrs,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3112F,Ct/mri brain done 24 hrs,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3115F,Quant results activity &symp,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3117F,Hf assessment tool completed,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3118F,Ny heart assoc class docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3119F,No eval activity clin symp,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3120F,12-lead ecg performed,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3125F,Esoph bx rprt w/dyspl info,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3126F,Esoph bx rprt w/dyspl info,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3130F,Upper gi endoscopy performed,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3132F,Doc ref upper gi endoscopy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3140F,Upper gi endo shows barrtts,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3141F,Upper gi endo not barrtts,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3142F,Barium swallow test ordered,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3143F,Doc order barium swallow tst,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3150F,Forceps esoph biopsy done,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3155F,Cytogen test marrow b/4 tx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3160F,Doc fe+ stores b/4 epo thx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3170F,Baselin flo cytometry b/4 tx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3200F,Barium swallow test not req,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3210F,Grp a strep test performed,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3215F,Pt immunity to hep a docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3216F,Pt immunity to hep b docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3218F,Rna tstng hep c docd done,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3220F,Hep c quant rna tstng docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3230F,Note hring tst w/in 6 mon,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3250F,Nonprim loc anat bx site tum,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3260F,Pt cat/pn cat/hist grd docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3265F,Rna tstng hepc vir ord/docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3266F,Hepc gn tstng docd b/4txmnt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3267F,Path rprt w/ pt pn cat et al,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3268F,Psa/t/glsc docd b/4 txmnt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3269F,Bone scn b/4 txmnt/aftr dx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3270F,No bone scn b/4 txmnt/aftrdx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3271F,Low risk prostate cancer,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3272F,Med risk prostate cancer,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3273F,High risk prostate cancer,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3274F,Prost cncr rsk not lw/md/hgh,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3278F,Serum lvls ca/ipth/lpd ord,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3279F,Hgb lvl >/= 13 g/dl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3280F,Hgb lvl 11-12.9 g/dl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3281F,Hgb lvl <11 g/dl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3284F,Iop down >15% of pre-svc lvl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3285F,Iop down <15% of pre-svc lvl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3288F,Fall risk assessment docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3290F,Pt=d(rh)- and unsensitized,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3291F,Pt=d(rh)+ or sensitized,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3292F,Hiv tstng asked/docd/revwd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3293F,Abo rh blood typing docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3294F,Grp b strep screening docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3300F,Ajcc stage docd b/4 thxpy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3301F,Cancer stage docd metast,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3302F,AJCC stage 0 doc'd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3303F,AJCC stage IA doc'd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3304F,AJCC stage IB doc'd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3305F,AJCC stage IC doc'd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3306F,AJCC stage IIA doc'd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3307F,AJCC stage IIB doc'd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3308F,AJCC stage IIC doc'd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3309F,AJCC stage IIIA doc'd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3310F,AJCC stage IIIB doc'd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3311F,AJCC stage IIIC doc'd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3312F,AJCC stage IVA doc'd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3313F,AJCC stage IVB doc'd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3314F,AJCC stage IVC doc'd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3315F,Er+ or pr+ breast cancer,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3316F,Er- or pr- breast cancer,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3317F,Path rpt malig cancer docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3318F,Path rpt malig cancer docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3319F,X-ray/ct/ultrsnd et al ord,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3320F,No xray/ct/ et al ordd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3321F,Ajcc cncr 0/ia melan docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3322F,Melanomaajcc stage 0 or ia,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3323F,Clin node stgng docdb/4 surg,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3324F,Mri ct scan ord rvwd rqstd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3325F,Preop asses 4 cataract surg,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3328F,Prfrmnc docd 2 wks b/4 surg,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3330F,Imaging study ordered (bkp),Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3331F,Bk imaging tst not ordered,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3340F,Mammo assess inc xray docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3341F,Mammo assess negative docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3342F,Mammo assess bengn docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3343F,Mammo probably bengn docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3344F,Mammo assess susp docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3345F,Mammo assess hghlymalig doc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3350F,Mammo bx proven malig docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3351F,Neg scrn dep symp by deptool,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3352F,No sig dep symp by dep tool,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3353F,Mild-mod dep symp by deptool,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3354F,Clin sig dep sym by dep tool,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3370F,Ajcc brst cncr stage 0 docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3372F,Ajcc brst cncr stage 1 docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3374F,Ajcc brst cncr stage 1 docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3376F,Ajcc brstcncr stage 2 docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3378F,Ajcc brstcncr stage 3 docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3380F,Ajcc brstcncr stage 4 docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3382F,Ajcc cln cncr stage 0 docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3384F,Ajcc cln cncr stage 1 docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3386F,Ajcc cln cncr stage 2 docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3388F,Ajcc cln cncr stage 3 docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3390F,Ajcc cln cncr stage 4 docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3394F,Quant her2 ihc eval brst cx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3395F,Quant nonher2 ihc brst cx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3450F,Dyspnea scrnd no-mild dysp,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3451F,Dyspnea scrnd mod-high dysp,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3452F,Dyspnea not screened,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3455F,Tb scrng done-interpd 6mon,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3470F,Ra disease activity low,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3471F,Ra disease activity mod,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3472F,Ra disease activity high,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3475F,Disease progn ra poor docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3476F,Disease progn ra good docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3490F,History aids-defining cond,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3491F,Hiv unsure baby of hiv+moms,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3492F,History cd4+ cell count <350,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3493F,No hist cd4+ cell count <350,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3494F,Cd4+cell count <200cells/mm3,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3495F,Cd4+cell cnt 200-499 cells,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3496F,Cd4+ cell count >= 500 cells,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3497F,Cd4+ cell percentage <15%,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3498F,Cd4+ cell =15% (hiv),Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3500F,Cd4+cell cnt/% docd as done,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3502F,Hiv rna vrl ld <lmts quantif,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3503F,Hiv rna vrl ldnot<lmts quntf,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3510F,Doc tb scrng-rslts interpd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3511F,Chlmyd/gonrh tsts docd done,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3512F,Syph scrng docd as done,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3513F,Hep b scrng docd as done,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3514F,Hep c scrng docd as done,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3515F,Pt has docd immun to hep c,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3517F,Hbv assess&results intrp 1yr,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3520F,Cdifficile testing performed,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3550F,Low rsk thromboembolism,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3551F,Intrmed rsk thromboembolism,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3552F,Hgh risk for thromboembolism,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3555F,Pt inr measurement performed,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3570F,Rprt bone scint xref w xray,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3572F,Pt consid poss risk fx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3573F,Pt not consid poss risk fx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3650F,Eeg ordered rvwd reqstd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3700F,Psych disorders assessed,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3720F,Cognit impairment assessed,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3725F,Screen depression performed,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3750F,Ptnotrcvngsteroid>/=10mg/day,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3751F,Electrodiag polyneuro 6 mn,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3752F,No electrodiag polyneuro 6mn,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3753F,Pt has symp&signs neuropathy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3754F,Screening tests dm done,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3755F,Cog&behav imprmnt scrng done,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3756F,Pt w/pseudobulb affect/als,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3757F,Pt w/o pseudobulbaffect/als,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3758F,Pt ref pulm fx test/peakflow,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3759F,Pt scrn dysphag/wt loss/nutr,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3760F,Pt w/ dysphag/wt loss/nutr,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3761F,Pt w/o dysphag/wt loss/nutr,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3762F,Patient is dysarthric,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3763F,Patient is not dysarthric,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3775F,Adenoma detected screening,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3776F,Adenoma not detect screening,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3AA11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3AA21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3AB11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3AB21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3AB31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3AC11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3AC21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3AC31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3AGK2,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3AGKT,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3AHK2,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3AHK4,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3AHKT,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3AHKU,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3AHKV,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3AHL1,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3BA11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3BA21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3BB11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3BB21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3BB31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3BC11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3BC21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3BC31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3BHKT,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3BHKU,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3BHKV,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3BHMT,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3CA11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3CA21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3CA31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3CB11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3CB21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3CB31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3CC11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3CC21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3CC31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3CGKW,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3CHK1,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3CHK2,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3CHK3,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3CHK4,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3CHK5,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3CHK6,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3CHKS,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3CHKT,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3CHKU,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3CHKV,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3CHKW,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3CHKX,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3CHMW,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3DA11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3DA21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3DA31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3DB11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3DB21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3DB31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3DC11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3DC21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3DC31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3EA11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3EA21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3EB11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3EB21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3EB31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3EC11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3EC21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3EC31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3GA11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3GA21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3GB11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3GB21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3GB31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3GC11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3GC21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3GC31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3HA11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3HA21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3HA31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3HB11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3HB21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3HB31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3HC11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3HC21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3HC31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3IA11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3IA21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3IA31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3IB11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3IB21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3IB31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3IC11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3IC21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3IC31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3JA11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3JA21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3JA31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3JB11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3JB21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3JB31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3JC11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3JC21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3JC31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3KA11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3KA21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3KA31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3KB11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3KB21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3KB31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3KC11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3KC21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3KC31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3LA11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3LA21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3LA31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3LB11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3LB21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3LB31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3LC11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3LC21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,3LC31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4000F,Tobacco use txmnt counseling,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4001F,Tobacco use txmnt pharmacol,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4002F,Statin therapy rx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4003F,Pt ed write/oral pts w/ hf,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4004F,Pt tobacco screen rcvd tlk,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4005F,Pharm thx for op rxd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4006F,Beta-blocker therapy rx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4007F,NTIOX SUPP/AREDS PRESCRIBED/RECOMMENDED,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4008F,Beta-blocker therapy rxd/tkn,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4009F,Ace/arb inhibitor therapy rx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4010F,Ace/arb therapy rxd/taken,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4011F,Oral antiplatelet therapy rx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4012F,Warfarin therapy rx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4013F,Statin therapy/currently tkn,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4014F,Written discharge instr prvd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4015F,Persist asthma medicine ctrl,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4016F,Anti-inflm/anlgsc agent rx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4017F,Gi prophylaxis for nsaid rx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4018F,Therapy exercise joint rx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4019F,Doc recpt counsl vit d/calc+,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4025F,Inhaled bronchodilator rx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4030F,Oxygen therapy rx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4033F,Pulmonary rehab rec,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4035F,Influenza imm rec,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4037F,Influenza imm order/admin,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4040F,Pneumoc vac/admin/rcvd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4041F,Doc order cefazolin/cefurox,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4042F,Doc antibio not given,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4043F,Doc order given stop antibio,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4044F,Doc order given vte prophylx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4045F,Empiric antibiotic rx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4046F,Doc antibio given b/4 surg,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4047F,Doc antibio given b/4 surg,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4048F,Doc antibio given b/4 surg,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4049F,Doc order given stop antibio,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4050F,Ht care plan doc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4051F,Referred for an av fistula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4052F,Hemodialysis via av fistula,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4053F,Hemodialysis via av graft,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4054F,Hemodialysis via catheter,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4055F,Pt rcvng periton dialysis,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4056F,Approp oral rehyd recommd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4058F,Ped gastro ed given caregvr,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4060F,Psych svcs provided,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4062F,Pt referral psych docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4063F,Antidepres rxthxpy not rxd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4064F,Antidepressant rx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4065F,Antipsychotic rx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4066F,Ect provided,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4067F,Pt referral for ect docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4069F,Vte prophylaxis rcvd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4070F,Dvt prophylx recvd day 2,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4073F,Oral antiplat thx rx dischrg,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4075F,Anticoag thx rx at dischrg,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4077F,Doc t-pa admin considered,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4079F,Doc rehab svcs considered,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4084F,Aspirin recvd w/in 24 hrs,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4086F,Aspirin/clopidogrel rxd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4090F,Pt rcvng epo thxpy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4095F,Pt not rcvng epo thxpy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4100F,Biphos thxpy vein ord/recvd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4110F,Int mam art used for cabg,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4115F,Beta blckr admin w/in 24 hrs,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4120F,Antibiot rxd/given,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4124F,Antibiot not rxd/given,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4130F,Topical prep rx aoe,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4131F,Syst antimicrobial thx rx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4132F,No syst antimicrobial thx rx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4133F,Antihist/decong rx/recom,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4134F,No antihist/decong rx/recom,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4135F,Systemic corticosteroids rx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4136F,Syst corticosteroids not rx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4140F,Inhaled corticosteroids rxd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4142F,Corticoster sparng thrpy rxd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4144F,Alt long-term cntrl med rxd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4145F,2+ anti-hyprtnsv agents tkn,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4148F,Hep a vac injxn admin/recvd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4149F,Hep b vac injxn admin/recvd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4150F,Pt recvng antivir txmnt hepc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4151F,Pt not recvng antiv hep c,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4152F,Doc'd pegintf/rib thxy consd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4153F,Combo pegintf/rib rx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4154F,Hep A vac series recommended,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4155F,Hep a vac series prev recvd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4156F,Hep B vac series recommended,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4157F,Hep b vac series prev recvd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4158F,Pt edu re alcoh drnkng done,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4159F,Contrcp talk b/4 antiv txmnt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4163F,Pt couns 4 txmnt opt prost,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4164F,Adjv hrmnl thxpy rxd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4165F,3d-crt/imrt received,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4167F,Hd bed tilted 1st day vent,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4168F,Pt care icu&vent w/in 24hrs,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4169F,No pt care icu/vent in 24hrs,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4171F,Pt rcvng esa thxpy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4172F,Pt not rcvng esa thxpy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4174F,Couns potent glauc impct,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4175F,Vis 20/40/> w/in 90 days,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4176F,Talk re uv light pt/crgvr,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4177F,Talk pt/crgvr re areds prev,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4178F,Antid glbln rcvd w/in 26wks,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4179F,Tamoxifen/ai prescribed,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4180F,Adjv thxpyrxd/rcvd colon ca,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4181F,Conformal radn thxpy rcvd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4182F,No conformal radn thxpy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4185F,Continuous ppi or h2ra rcvd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4186F,No cont ppi or h2ra rcvd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4187F,Anti rheum drugthxpyrxd/gvn,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4188F,Approp ace/arb tstng done,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4189F,Approp digoxin tstng done,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4190F,Approp diuretic tstng done,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4191F,Approp anticonvuls tstng,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4192F,Pt not rcvng glucoco thxpy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4193F,Pt rcvng<10mg daily predniso,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4194F,Pt rcvng10mg daily predniso,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4195F,Pt rcvng anti-rheum thxpy ra,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4196F,Ptnot rcvng anti-rhm thxpyra,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4200F,External beam to prost only,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4201F,Extrnl beam other than prost,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4210F,Ace/arb thxpy for mos/>,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4220F,Digoxin thxpy for 6 mos/>,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4221F,Diuretic thxpy for 6 mos/>,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4230F,Anticonv thxpy for 6 mos/>,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4240F,Instr xrcz back pain 12 wks,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4242F,Sprvsd xrcz back pn >12 wks,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4245F,Pt instr nrml lifest,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4248F,Pt instr no bd rest 4 days/>,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4250F,Wrmng 4 surg normothermia,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4255F,Anesth 60 min/> as docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4256F,Anesthe <60 min as docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4260F,Wound srfc culturetech used,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4261F,Tech other than surfc cultr,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4265F,Wet-dry dressings rx recmd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4266F,No wet-dry drssings rx recmd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4267F,Comprssion thxpy prescribed,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4268F,Pt ed re comp thxpy rcvd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4269F,Appropos mthd offloading rxd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4270F,Pt rcvng anti r-viral thxpy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4271F,Pt rcvng anti r-viral thxpy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4274F,Flu immuno admind rcvd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4275F,Hep b vac inj admin/ rcvd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4276F,Potent antivir thxpy rxd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4279F,Pcp prophylaxis rxd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4280F,Pcp prophylax rxd 3mon low %,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4290F,Pt scrned for inj drug use,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4293F,Pt scrnd hgh-risk sex behav,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4300F,Pt rcvng warf thxpy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4301F,Pt not rcvng warf thxpy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4305F,Pt ed re ft care inspct rcvd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4306F,Pt tlk psych & rx opd addic,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4320F,Pt talk psychsoc&rx oh dpnd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4322F,Crgvr prov w/ ed addl rsrcs,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4324F,Pt queried prkns complic,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4325F,Med txmnt options rvwd w/pt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4326F,Pt asked re symp auto dysfxn,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4328F,Pt asked re sleep disturb,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4330F,Cnslng epi spec sfty issues,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4340F,Cnslng chldbrng women epi,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4350F,Cnslng provided symp mngmnt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4400F,Rehab thxpy options w/pt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4450F,Self-care ed provided to pt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4470F,Icd counseling provided,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4480F,Pt rcvng ace/arb b-blockertx,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4481F,Pt rcvng ace/arb blker >3mos,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4500F,Ref to outpt card rehab prog,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4510F,Prev cardrehab qualcardevent,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4525F,Neuropsychia interven order,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4526F,Neuropsychia interven rcvd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4540F,Disease modif pharmacothxpy,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4541F,Pt offered tx for pseudobulb,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4550F,Noninvas resp support talk,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4551F,Nutritional support offered,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4552F,Pt ref for speech lang path,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4553F,Pt asst re end life issues,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4554F,Pt recvd inhal anesthetic,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4555F,Pt recvd no inhal anesthic,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4556F,Pt w/3+ post-op nausea&vom,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4557F,Pt w/o 3+ post-opnausea&vom,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4558F,Pt recvd 2 rx anti-emet agt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4559F,1 bodytemp >=35.5cw/in 30min,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4560F,Anesth w/o gen/neurax anesth,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4561F,Pt w/ coronary artery stent,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4562F,Pt w/o coronary artery stent,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4563F,Pt recvd aspirin w/in 24 hrs,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4AB21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4AC21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4BA11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4BA21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4BB11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4BB21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4BC11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4BC21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4BC31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4CA11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4CA21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4CB11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4CB21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4CB31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4CC11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4CC21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4CC31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4DB21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4DB31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4DC11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4DC21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4DC31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4EA11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4EA21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4EB11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4EB31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4EC11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4EC21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4EC31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4GA11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4GB11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4GB21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4GC11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4GC21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4GC31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4HA11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4HA21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4HB21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4HB31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4HC21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4HC31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4IB31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4IC11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4IC21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4JA11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4JA21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4JB11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4JB21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4JB31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4JC11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4JC21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4JC31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4KA11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4KA21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4KB11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4KB21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4KB31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4KC11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4KC21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4KC31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4LA11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4LB21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4LB31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4LC11,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4LC21,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,4LC31,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,5005F,Pt counsld on exam for moles,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,5010F,Macul result phy/qhp mng dm,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,5015F,Doc fx & test/txmnt for op,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,5020F,Txmnts 2 phys/qhp by 1 mon,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,5050F,Plan 2 main dr by 1 month,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,5060F,Fndngs mammo 2pt w/in 3 days,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,5062F,Mammo result com to pt 5 day,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,5100F,Rsk fx ref w/n 24 hrs xray,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,5200F,Eval appros surg thxpy epi,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,5250F,Asthma discharge plan presnt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,5AHK3,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,5BHK1,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,5BHKS,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,5CHK1,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,5CHK2,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,5CHK3,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,5CHKS,System Added,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,6005F,Care level rationale doc,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,6010F,Dysphag test done b/4 eating,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,6015F,Dysphag test done b/4 eating,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,6020F,Npo (nothing-mouth) ordered,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,6030F,Max sterile barriers follwd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,6040F,Appro rad ds dvcs techs docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,6045F,Radxps in end rprt4fluro pxd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,6070F,Pt asked/cnsld aed effects,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,6080F,Pt/caregiver queried falls,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,6090F,Pt/caregiver counsel safety,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,6100F,Verify pt site pxd docd,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,6101F,Safety counseling dementia,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,6102F,Safety counseling dem order,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,6110F,Counsel prov driving risks,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,CPT,6150F,Pt notrcvng1st antitnf txmnt,Surgical,Per Case,"$4,314.00 ",OP,"4,314.00","4,314.00",,,,,,
BCBS HMO,ExceptRevenueCode,480,Cardiology,Observation,Straight Discount,36.10%,OP,,,,,,,,
BCBS HMO,ExceptRevenueCode,481,Cardiology: Cardiac catheter lab,Observation,Per Case,"$2,420.00 ",OP,"2,420.00","2,420.00",,,,,,
BCBS HMO,ExceptRevenueCode,760,Treatment/Observation Room,Observation,Per Case,"$2,420.00 ",OP,"2,420.00","3,464.00",,,,,,
BCBS HMO,ExceptRevenueCode,762,Treatment/Observation Room: Observation room,Observation,Per Case,"$2,420.00 ",OP,"2,420.00","3,464.00",,,,,,
BCBS HMO,,,,All Other,Straight Discount,63.90%,OP,,,,,,,,
BCBS Medicaid,DRG,11,LIVER TRANSPLANT andOR INTESTINAL TRANSPLANT,,Relative Weights,"$38,043.18 ",IP,"38,043.18","38,043.18",,,,,,
BCBS Medicaid,DRG,12,LIVER TRANSPLANT andOR INTESTINAL TRANSPLANT,,Relative Weights,"$40,281.56 ",IP,"40,281.56","40,281.56",,,,,,
BCBS Medicaid,DRG,13,LIVER TRANSPLANT andOR INTESTINAL TRANSPLANT,,Relative Weights,"$42,053.29 ",IP,"42,053.29","42,053.29",,,,,,
BCBS Medicaid,DRG,14,LIVER TRANSPLANT andOR INTESTINAL TRANSPLANT,,Relative Weights,"$78,175.26 ",IP,"78,175.26","78,175.26",,,,,,
BCBS Medicaid,DRG,21,HEART andOR LUNG TRANSPLANT,,Relative Weights,"$45,599.51 ",IP,"45,599.51","45,599.51",,,,,,
BCBS Medicaid,DRG,22,HEART &/OR LUNG TRANSPLANT,,Relative Weights,"$58,026.75 ",IP,"58,026.75","58,026.75",,,,,,
BCBS Medicaid,DRG,23,HEART andOR LUNG TRANSPLANT,,Relative Weights,"$74,400.53 ",IP,"74,400.53","74,400.53",,,,,,
BCBS Medicaid,DRG,24,HEART andOR LUNG TRANSPLANT,,Relative Weights,"$107,953.54 ",IP,"107,953.54","107,953.54",,,,,,
BCBS Medicaid,DRG,41,TRACHEOSTOMY W MV 96+ HOURS W EXTENSIVE PROCEDURE,,Relative Weights,"$33,014.21 ",IP,"33,014.21","33,014.21",,,,,,
BCBS Medicaid,DRG,42,TRACHEOSTOMY W MV 96+ HOURS W EXTENSIVE PROCEDURE,,Relative Weights,"$37,820.51 ",IP,"37,820.51","37,820.51",,,,,,
BCBS Medicaid,DRG,43,TRACHEOSTOMY W MV 96 HOURS W EXTENSIVE PROCEDURE,,Relative Weights,"$49,052.96 ",IP,"49,052.96","49,052.96",,,,,,
BCBS Medicaid,DRG,44,TRACHEOSTOMY W MV 96 HOURS W EXTENSIVE PROCEDURE,,Relative Weights,"$72,921.22 ",IP,"72,921.22","72,921.22",,,,,,
BCBS Medicaid,DRG,51,TRACHEOSTOMY W MV 96 HOURS WO EXTENSIVE PROCEDURE,,Relative Weights,"$23,684.08 ",IP,"23,684.08","23,684.08",,,,,,
BCBS Medicaid,DRG,52,TRACHEOSTOMY W MV 96+ HOURS W/O EXTENSIVE PROCEDURE,,Relative Weights,"$26,315.91 ",IP,"26,315.91","26,315.91",,,,,,
BCBS Medicaid,DRG,53,TRACHEOSTOMY W MV 96 HOURS WO EXTENSIVE PROCEDURE,,Relative Weights,"$36,197.91 ",IP,"36,197.91","36,197.91",,,,,,
BCBS Medicaid,DRG,54,TRACHEOSTOMY W MV 96 HOURS WO EXTENSIVE PROCEDURE,,Relative Weights,"$48,934.75 ",IP,"48,934.75","48,934.75",,,,,,
BCBS Medicaid,DRG,61,PANCREAS TRANSPLANT,,Relative Weights,"$40,520.03 ",IP,"40,520.03","40,520.03",,,,,,
BCBS Medicaid,DRG,62,PANCREAS TRANSPLANT,,Relative Weights,"$45,022.22 ",IP,"45,022.22","45,022.22",,,,,,
BCBS Medicaid,DRG,63,PANCREAS TRANSPLANT,,Relative Weights,"$47,794.94 ",IP,"47,794.94","47,794.94",,,,,,
BCBS Medicaid,DRG,64,PANCREAS TRANSPLANT,,Relative Weights,"$66,459.33 ",IP,"66,459.33","66,459.33",,,,,,
BCBS Medicaid,DRG,71,ALLOGENEIC BONE MARROW TRANSPLANT,,Relative Weights,"$38,434.91 ",IP,"38,434.91","38,434.91",,,,,,
BCBS Medicaid,DRG,72,ALLOGENEIC BONE MARROW TRANSPLANT,,Relative Weights,"$48,059.19 ",IP,"48,059.19","48,059.19",,,,,,
BCBS Medicaid,DRG,73,ALLOGENEIC BONE MARROW TRANSPLANT,,Relative Weights,"$59,827.69 ",IP,"59,827.69","59,827.69",,,,,,
BCBS Medicaid,DRG,74,ALLOGENEIC BONE MARROW TRANSPLANT,,Relative Weights,"$99,672.84 ",IP,"99,672.84","99,672.84",,,,,,
BCBS Medicaid,DRG,81,AUTOLOGOUS BONE MARROW TRANSPLANT,,Relative Weights,"$22,091.37 ",IP,"22,091.37","22,091.37",,,,,,
BCBS Medicaid,DRG,82,AUTOLOGOUS BONE MARROW TRANSPLANT,,Relative Weights,"$27,118.96 ",IP,"27,118.96","27,118.96",,,,,,
BCBS Medicaid,DRG,83,AUTOLOGOUS BONE MARROW TRANSPLANT,,Relative Weights,"$32,175.76 ",IP,"32,175.76","32,175.76",,,,,,
BCBS Medicaid,DRG,84,AUTOLOGOUS BONE MARROW TRANSPLANT,,Relative Weights,"$51,576.54 ",IP,"51,576.54","51,576.54",,,,,,
BCBS Medicaid,DRG,91,EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO),,Relative Weights,"$27,699.69 ",IP,"27,699.69","27,699.69",,,,,,
BCBS Medicaid,DRG,92,EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO),,Relative Weights,"$30,776.86 ",IP,"30,776.86","30,776.86",,,,,,
BCBS Medicaid,DRG,93,EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO),,Relative Weights,"$36,358.72 ",IP,"36,358.72","36,358.72",,,,,,
BCBS Medicaid,DRG,94,EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO),,Relative Weights,"$79,300.63 ",IP,"79,300.63","79,300.63",,,,,,
BCBS Medicaid,DRG,101,HEAD TRAUMA WITH DEEP COMA,,Relative Weights,"$4,104.27 ",IP,"4,104.27","4,104.27",,,,,,
BCBS Medicaid,DRG,102,HEAD TRAUMA WITH DEEP COMA,,Relative Weights,"$7,527.81 ",IP,"7,527.81","7,527.81",,,,,,
BCBS Medicaid,DRG,103,HEAD TRAUMA WITH DEEP COMA,,Relative Weights,"$12,592.86 ",IP,"12,592.86","12,592.86",,,,,,
BCBS Medicaid,DRG,104,HEAD TRAUMA WITH DEEP COMA,,Relative Weights,"$37,584.09 ",IP,"37,584.09","37,584.09",,,,,,
BCBS Medicaid,DRG,201,CRANIOTOMY FOR TRAUMA,,Relative Weights,"$9,991.61 ",IP,"9,991.61","9,991.61",,,,,,
BCBS Medicaid,DRG,202,CRANIOTOMY FOR TRAUMA,,Relative Weights,"$11,868.15 ",IP,"11,868.15","11,868.15",,,,,,
BCBS Medicaid,DRG,203,CRANIOTOMY FOR TRAUMA,,Relative Weights,"$16,002.32 ",IP,"16,002.32","16,002.32",,,,,,
BCBS Medicaid,DRG,204,CRANIOTOMY FOR TRAUMA,,Relative Weights,"$28,673.87 ",IP,"28,673.87","28,673.87",,,,,,
BCBS Medicaid,DRG,211,CRANIOTOMY EXCEPT FOR TRAUMA,,Relative Weights,"$9,882.68 ",IP,"9,882.68","9,882.68",,,,,,
BCBS Medicaid,DRG,212,CRANIOTOMY EXCEPT FOR TRAUMA,,Relative Weights,"$13,243.69 ",IP,"13,243.69","13,243.69",,,,,,
BCBS Medicaid,DRG,213,CRANIOTOMY EXCEPT FOR TRAUMA,,Relative Weights,"$18,834.48 ",IP,"18,834.48","18,834.48",,,,,,
BCBS Medicaid,DRG,214,CRANIOTOMY EXCEPT FOR TRAUMA,,Relative Weights,"$27,671.86 ",IP,"27,671.86","27,671.86",,,,,,
BCBS Medicaid,DRG,221,VENTRICULAR SHUNT PROCEDURES,,Relative Weights,"$6,449.86 ",IP,"6,449.86","6,449.86",,,,,,
BCBS Medicaid,DRG,222,VENTRICULAR SHUNT PROCEDURES,,Relative Weights,"$7,492.76 ",IP,"7,492.76","7,492.76",,,,,,
BCBS Medicaid,DRG,223,VENTRICULAR SHUNT PROCEDURES,,Relative Weights,"$10,628.01 ",IP,"10,628.01","10,628.01",,,,,,
BCBS Medicaid,DRG,224,VENTRICULAR SHUNT PROCEDURES,,Relative Weights,"$25,450.32 ",IP,"25,450.32","25,450.32",,,,,,
BCBS Medicaid,DRG,231,SPINAL PROCEDURES,,Relative Weights,"$7,646.71 ",IP,"7,646.71","7,646.71",,,,,,
BCBS Medicaid,DRG,232,SPINAL PROCEDURES,,Relative Weights,"$9,630.12 ",IP,"9,630.12","9,630.12",,,,,,
BCBS Medicaid,DRG,233,SPINAL PROCEDURES,,Relative Weights,"$16,000.26 ",IP,"16,000.26","16,000.26",,,,,,
BCBS Medicaid,DRG,234,SPINAL PROCEDURES,,Relative Weights,"$29,075.91 ",IP,"29,075.91","29,075.91",,,,,,
BCBS Medicaid,DRG,241,EXTRACRANIAL VASCULAR PROCEDURES,,Relative Weights,"$5,741.65 ",IP,"5,741.65","5,741.65",,,,,,
BCBS Medicaid,DRG,242,EXTRACRANIAL VASCULAR PROCEDURES,,Relative Weights,"$6,726.14 ",IP,"6,726.14","6,726.14",,,,,,
BCBS Medicaid,DRG,243,EXTRACRANIAL VASCULAR PROCEDURES,,Relative Weights,"$13,747.79 ",IP,"13,747.79","13,747.79",,,,,,
BCBS Medicaid,DRG,244,EXTRACRANIAL VASCULAR PROCEDURES,,Relative Weights,"$24,782.31 ",IP,"24,782.31","24,782.31",,,,,,
BCBS Medicaid,DRG,261,OTHER NERVOUS SYSTEM and RELATED PROCEDURES,,Relative Weights,"$7,157.39 ",IP,"7,157.39","7,157.39",,,,,,
BCBS Medicaid,DRG,262,OTHER NERVOUS SYSTEM and RELATED PROCEDURES,,Relative Weights,"$8,935.31 ",IP,"8,935.31","8,935.31",,,,,,
BCBS Medicaid,DRG,263,OTHER NERVOUS SYSTEM and RELATED PROCEDURES,,Relative Weights,"$12,455.76 ",IP,"12,455.76","12,455.76",,,,,,
BCBS Medicaid,DRG,264,OTHER NERVOUS SYSTEM & RELATED PROCEDURES,,Relative Weights,"$22,781.03 ",IP,"22,781.03","22,781.03",,,,,,
BCBS Medicaid,DRG,401,SPINAL DISORDERS and INJURIES,,Relative Weights,"$5,482.55 ",IP,"5,482.55","5,482.55",,,,,,
BCBS Medicaid,DRG,402,SPINAL DISORDERS and INJURIES,,Relative Weights,"$5,877.72 ",IP,"5,877.72","5,877.72",,,,,,
BCBS Medicaid,DRG,403,SPINAL DISORDERS and INJURIES,,Relative Weights,"$8,545.98 ",IP,"8,545.98","8,545.98",,,,,,
BCBS Medicaid,DRG,404,SPINAL DISORDERS and INJURIES,,Relative Weights,"$17,945.87 ",IP,"17,945.87","17,945.87",,,,,,
BCBS Medicaid,DRG,411,NERVOUS SYSTEM MALIGNANCY,,Relative Weights,"$4,340.00 ",IP,"4,340.00","4,340.00",,,,,,
BCBS Medicaid,DRG,412,NERVOUS SYSTEM MALIGNANCY,,Relative Weights,"$4,441.02 ",IP,"4,441.02","4,441.02",,,,,,
BCBS Medicaid,DRG,413,NERVOUS SYSTEM MALIGNANCY,,Relative Weights,"$5,802.81 ",IP,"5,802.81","5,802.81",,,,,,
BCBS Medicaid,DRG,414,NERVOUS SYSTEM MALIGNANCY,,Relative Weights,"$8,029.51 ",IP,"8,029.51","8,029.51",,,,,,
BCBS Medicaid,DRG,421,DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS,,Relative Weights,"$3,328.02 ",IP,"3,328.02","3,328.02",,,,,,
BCBS Medicaid,DRG,422,DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS,,Relative Weights,"$3,814.25 ",IP,"3,814.25","3,814.25",,,,,,
BCBS Medicaid,DRG,423,DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS,,Relative Weights,"$5,381.53 ",IP,"5,381.53","5,381.53",,,,,,
BCBS Medicaid,DRG,424,DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS,,Relative Weights,"$12,544.07 ",IP,"12,544.07","12,544.07",,,,,,
BCBS Medicaid,DRG,431,MULTIPLE SCLEROSIS and OTHER DEMYELINATING DISEASES,,Relative Weights,"$4,040.70 ",IP,"4,040.70","4,040.70",,,,,,
BCBS Medicaid,DRG,432,MULTIPLE SCLEROSIS and OTHER DEMYELINATING DISEASES,,Relative Weights,"$5,014.88 ",IP,"5,014.88","5,014.88",,,,,,
BCBS Medicaid,DRG,433,MULTIPLE SCLEROSIS and OTHER DEMYELINATING DISEASES,,Relative Weights,"$7,268.72 ",IP,"7,268.72","7,268.72",,,,,,
BCBS Medicaid,DRG,434,MULTIPLE SCLEROSIS & OTHER DEMYELINATING DISEASES,,Relative Weights,"$15,032.61 ",IP,"15,032.61","15,032.61",,,,,,
BCBS Medicaid,DRG,441,INTRACRANIAL HEMORRHAGE,,Relative Weights,"$3,968.19 ",IP,"3,968.19","3,968.19",,,,,,
BCBS Medicaid,DRG,442,INTRACRANIAL HEMORRHAGE,,Relative Weights,"$4,927.25 ",IP,"4,927.25","4,927.25",,,,,,
BCBS Medicaid,DRG,443,INTRACRANIAL HEMORRHAGE,,Relative Weights,"$6,702.77 ",IP,"6,702.77","6,702.77",,,,,,
BCBS Medicaid,DRG,444,INTRACRANIAL HEMORRHAGE,,Relative Weights,"$9,326.01 ",IP,"9,326.01","9,326.01",,,,,,
BCBS Medicaid,DRG,451,CVA and PRECEREBRAL OCCLUSION W INFARCT,,Relative Weights,"$3,612.20 ",IP,"3,612.20","3,612.20",,,,,,
BCBS Medicaid,DRG,452,CVA and PRECEREBRAL OCCLUSION W INFARCT,,Relative Weights,"$4,429.34 ",IP,"4,429.34","4,429.34",,,,,,
BCBS Medicaid,DRG,453,CVA and PRECEREBRAL OCCLUSION W INFARCT,,Relative Weights,"$5,951.60 ",IP,"5,951.60","5,951.60",,,,,,
BCBS Medicaid,DRG,454,CVA and PRECEREBRAL OCCLUSION W INFARCT,,Relative Weights,"$10,976.10 ",IP,"10,976.10","10,976.10",,,,,,
BCBS Medicaid,DRG,461,NONSPECIFIC CVA and PRECEREBRAL OCCLUSION WO INFARCT,,Relative Weights,"$3,784.70 ",IP,"3,784.70","3,784.70",,,,,,
BCBS Medicaid,DRG,462,NONSPECIFIC CVA and PRECEREBRAL OCCLUSION WO INFARCT,,Relative Weights,"$4,264.40 ",IP,"4,264.40","4,264.40",,,,,,
BCBS Medicaid,DRG,463,NONSPECIFIC CVA and PRECEREBRAL OCCLUSION WO INFARCT,,Relative Weights,"$5,292.53 ",IP,"5,292.53","5,292.53",,,,,,
BCBS Medicaid,DRG,464,NONSPECIFIC CVA and PRECEREBRAL OCCLUSION WO INFARCT,,Relative Weights,"$10,621.82 ",IP,"10,621.82","10,621.82",,,,,,
BCBS Medicaid,DRG,471,TRANSIENT ISCHEMIA,,Relative Weights,"$3,321.15 ",IP,"3,321.15","3,321.15",,,,,,
BCBS Medicaid,DRG,472,TRANSIENT ISCHEMIA,,Relative Weights,"$3,597.42 ",IP,"3,597.42","3,597.42",,,,,,
BCBS Medicaid,DRG,473,TRANSIENT ISCHEMIA,,Relative Weights,"$4,242.41 ",IP,"4,242.41","4,242.41",,,,,,
BCBS Medicaid,DRG,474,TRANSIENT ISCHEMIA,,Relative Weights,"$7,719.21 ",IP,"7,719.21","7,719.21",,,,,,
BCBS Medicaid,DRG,481,PERIPHERAL CRANIAL and AUTONOMIC NERVE DISORDERS,,Relative Weights,"$3,400.87 ",IP,"3,400.87","3,400.87",,,,,,
BCBS Medicaid,DRG,482,PERIPHERAL CRANIAL and AUTONOMIC NERVE DISORDERS,,Relative Weights,"$3,627.32 ",IP,"3,627.32","3,627.32",,,,,,
BCBS Medicaid,DRG,483,PERIPHERAL CRANIAL and AUTONOMIC NERVE DISORDERS,,Relative Weights,"$4,545.48 ",IP,"4,545.48","4,545.48",,,,,,
BCBS Medicaid,DRG,484,"PERIPHERAL, CRANIAL & AUTONOMIC NERVE DISORDERS",,Relative Weights,"$10,429.39 ",IP,"10,429.39","10,429.39",,,,,,
BCBS Medicaid,DRG,491,BACTERIAL and TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,,Relative Weights,"$5,943.01 ",IP,"5,943.01","5,943.01",,,,,,
BCBS Medicaid,DRG,492,BACTERIAL and TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,,Relative Weights,"$9,716.03 ",IP,"9,716.03","9,716.03",,,,,,
BCBS Medicaid,DRG,493,BACTERIAL and TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,,Relative Weights,"$11,066.13 ",IP,"11,066.13","11,066.13",,,,,,
BCBS Medicaid,DRG,494,BACTERIAL and TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,,Relative Weights,"$20,732.33 ",IP,"20,732.33","20,732.33",,,,,,
BCBS Medicaid,DRG,501,NONBACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS,,Relative Weights,"$3,211.53 ",IP,"3,211.53","3,211.53",,,,,,
BCBS Medicaid,DRG,502,NONBACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS,,Relative Weights,"$6,688.34 ",IP,"6,688.34","6,688.34",,,,,,
BCBS Medicaid,DRG,503,NONBACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS,,Relative Weights,"$10,165.49 ",IP,"10,165.49","10,165.49",,,,,,
BCBS Medicaid,DRG,504,NONBACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS,,Relative Weights,"$22,308.54 ",IP,"22,308.54","22,308.54",,,,,,
BCBS Medicaid,DRG,511,VIRAL MENINGITIS,,Relative Weights,"$2,048.35 ",IP,"2,048.35","2,048.35",,,,,,
BCBS Medicaid,DRG,512,VIRAL MENINGITIS,,Relative Weights,"$3,205.00 ",IP,"3,205.00","3,205.00",,,,,,
BCBS Medicaid,DRG,513,VIRAL MENINGITIS,,Relative Weights,"$5,993.52 ",IP,"5,993.52","5,993.52",,,,,,
BCBS Medicaid,DRG,514,VIRAL MENINGITIS,,Relative Weights,"$12,441.32 ",IP,"12,441.32","12,441.32",,,,,,
BCBS Medicaid,DRG,521,ALTERATION IN CONSCIOUSNESS,,Relative Weights,"$3,101.91 ",IP,"3,101.91","3,101.91",,,,,,
BCBS Medicaid,DRG,522,ALTERATION IN CONSCIOUSNESS,,Relative Weights,"$3,492.61 ",IP,"3,492.61","3,492.61",,,,,,
BCBS Medicaid,DRG,523,ALTERATION IN CONSCIOUSNESS,,Relative Weights,"$4,423.15 ",IP,"4,423.15","4,423.15",,,,,,
BCBS Medicaid,DRG,524,ALTERATION IN CONSCIOUSNESS,,Relative Weights,"$9,303.33 ",IP,"9,303.33","9,303.33",,,,,,
BCBS Medicaid,DRG,531,SEIZURE,,Relative Weights,"$2,710.87 ",IP,"2,710.87","2,710.87",,,,,,
BCBS Medicaid,DRG,532,SEIZURE,,Relative Weights,"$3,311.87 ",IP,"3,311.87","3,311.87",,,,,,
BCBS Medicaid,DRG,533,SEIZURE,,Relative Weights,"$4,410.44 ",IP,"4,410.44","4,410.44",,,,,,
BCBS Medicaid,DRG,534,SEIZURE,,Relative Weights,"$10,918.03 ",IP,"10,918.03","10,918.03",,,,,,
BCBS Medicaid,DRG,541,MIGRAINE and OTHER HEADACHES,,Relative Weights,"$2,681.66 ",IP,"2,681.66","2,681.66",,,,,,
BCBS Medicaid,DRG,542,MIGRAINE and OTHER HEADACHES,,Relative Weights,"$3,180.26 ",IP,"3,180.26","3,180.26",,,,,,
BCBS Medicaid,DRG,543,MIGRAINE and OTHER HEADACHES,,Relative Weights,"$3,960.98 ",IP,"3,960.98","3,960.98",,,,,,
BCBS Medicaid,DRG,544,MIGRAINE and OTHER HEADACHES,,Relative Weights,"$6,681.46 ",IP,"6,681.46","6,681.46",,,,,,
BCBS Medicaid,DRG,551,HEAD TRAUMA W COMA 1 HR OR HEMORRHAGE,,Relative Weights,"$3,376.47 ",IP,"3,376.47","3,376.47",,,,,,
BCBS Medicaid,DRG,552,HEAD TRAUMA W COMA 1 HR OR HEMORRHAGE,,Relative Weights,"$4,570.57 ",IP,"4,570.57","4,570.57",,,,,,
BCBS Medicaid,DRG,553,HEAD TRAUMA W COMA 1 HR OR HEMORRHAGE,,Relative Weights,"$6,561.54 ",IP,"6,561.54","6,561.54",,,,,,
BCBS Medicaid,DRG,554,HEAD TRAUMA W COMA 1 HR OR HEMORRHAGE,,Relative Weights,"$13,008.65 ",IP,"13,008.65","13,008.65",,,,,,
BCBS Medicaid,DRG,561,BRAIN CONTUSIONLACERATION and COMPLICATED SKULL FX COMA  1 HR OR NO COMA,,Relative Weights,"$3,264.10 ",IP,"3,264.10","3,264.10",,,,,,
BCBS Medicaid,DRG,562,BRAIN CONTUSIONLACERATION and COMPLICATED SKULL FX COMA  1 HR OR NO COMA,,Relative Weights,"$4,370.58 ",IP,"4,370.58","4,370.58",,,,,,
BCBS Medicaid,DRG,563,BRAIN CONTUSIONLACERATION and COMPLICATED SKULL FX COMA  1 HR OR NO COMA,,Relative Weights,"$6,249.87 ",IP,"6,249.87","6,249.87",,,,,,
BCBS Medicaid,DRG,564,BRAIN CONTUSIONLACERATION and COMPLICATED SKULL FX COMA  1 HR OR NO COMA,,Relative Weights,"$13,974.93 ",IP,"13,974.93","13,974.93",,,,,,
BCBS Medicaid,DRG,571,CONCUSSION CLOSED SKULL FX NOSUNCOMPLICATED INTRACRANIAL INJURY COMA  1 HR OR NO COMA,,Relative Weights,"$2,653.48 ",IP,"2,653.48","2,653.48",,,,,,
BCBS Medicaid,DRG,572,CONCUSSION CLOSED SKULL FX NOSUNCOMPLICATED INTRACRANIAL INJURY COMA  1 HR OR NO COMA,,Relative Weights,"$3,996.71 ",IP,"3,996.71","3,996.71",,,,,,
BCBS Medicaid,DRG,573,CONCUSSION CLOSED SKULL FX NOSUNCOMPLICATED INTRACRANIAL INJURY COMA  1 HR OR NO COMA,,Relative Weights,"$5,550.25 ",IP,"5,550.25","5,550.25",,,,,,
BCBS Medicaid,DRG,574,CONCUSSION CLOSED SKULL FX NOSUNCOMPLICATED INTRACRANIAL INJURY COMA  1 HR OR NO COMA,,Relative Weights,"$10,437.98 ",IP,"10,437.98","10,437.98",,,,,,
BCBS Medicaid,DRG,581,OTHER DISORDERS OF NERVOUS SYSTEM,,Relative Weights,"$3,385.75 ",IP,"3,385.75","3,385.75",,,,,,
BCBS Medicaid,DRG,582,OTHER DISORDERS OF NERVOUS SYSTEM,,Relative Weights,"$4,062.35 ",IP,"4,062.35","4,062.35",,,,,,
BCBS Medicaid,DRG,583,OTHER DISORDERS OF NERVOUS SYSTEM,,Relative Weights,"$5,313.15 ",IP,"5,313.15","5,313.15",,,,,,
BCBS Medicaid,DRG,584,OTHER DISORDERS OF NERVOUS SYSTEM,,Relative Weights,"$10,386.78 ",IP,"10,386.78","10,386.78",,,,,,
BCBS Medicaid,DRG,591,ANOXIC and OTHER SEVERE BRAIN DAMAGE,,Relative Weights,"$3,746.90 ",IP,"3,746.90","3,746.90",,,,,,
BCBS Medicaid,DRG,592,ANOXIC and OTHER SEVERE BRAIN DAMAGE,,Relative Weights,"$4,463.01 ",IP,"4,463.01","4,463.01",,,,,,
BCBS Medicaid,DRG,593,ANOXIC and OTHER SEVERE BRAIN DAMAGE,,Relative Weights,"$6,809.98 ",IP,"6,809.98","6,809.98",,,,,,
BCBS Medicaid,DRG,594,ANOXIC & OTHER SEVERE BRAIN DAMAGE,,Relative Weights,"$11,699.43 ",IP,"11,699.43","11,699.43",,,,,,
BCBS Medicaid,DRG,731,ORBIT AND EYE PROCEDURES,,Relative Weights,"$5,014.53 ",IP,"5,014.53","5,014.53",,,,,,
BCBS Medicaid,DRG,732,ORBIT AND EYE PROCEDURES,,Relative Weights,"$6,421.34 ",IP,"6,421.34","6,421.34",,,,,,
BCBS Medicaid,DRG,733,ORBIT AND EYE PROCEDURES,,Relative Weights,"$9,718.43 ",IP,"9,718.43","9,718.43",,,,,,
BCBS Medicaid,DRG,734,ORBIT AND EYE PROCEDURES,,Relative Weights,"$22,403.73 ",IP,"22,403.73","22,403.73",,,,,,
BCBS Medicaid,DRG,821,EYE INFECTIONS AND OTHER EYE DISORDERS,,Relative Weights,"$2,633.21 ",IP,"2,633.21","2,633.21",,,,,,
BCBS Medicaid,DRG,822,EYE INFECTIONS AND OTHER EYE DISORDERS,,Relative Weights,"$3,410.83 ",IP,"3,410.83","3,410.83",,,,,,
BCBS Medicaid,DRG,823,EYE INFECTIONS AND OTHER EYE DISORDERS,,Relative Weights,"$4,809.73 ",IP,"4,809.73","4,809.73",,,,,,
BCBS Medicaid,DRG,824,EYE INFECTIONS AND OTHER EYE DISORDERS,,Relative Weights,"$13,027.89 ",IP,"13,027.89","13,027.89",,,,,,
BCBS Medicaid,DRG,891,MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$9,059.01 ",IP,"9,059.01","9,059.01",,,,,,
BCBS Medicaid,DRG,892,MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$11,457.52 ",IP,"11,457.52","11,457.52",,,,,,
BCBS Medicaid,DRG,893,MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$17,804.98 ",IP,"17,804.98","17,804.98",,,,,,
BCBS Medicaid,DRG,894,MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$32,041.75 ",IP,"32,041.75","32,041.75",,,,,,
BCBS Medicaid,DRG,911,OTHER MAJOR HEAD and NECK PROCEDURES,,Relative Weights,"$6,729.57 ",IP,"6,729.57","6,729.57",,,,,,
BCBS Medicaid,DRG,912,OTHER MAJOR HEAD and NECK PROCEDURES,,Relative Weights,"$9,964.47 ",IP,"9,964.47","9,964.47",,,,,,
BCBS Medicaid,DRG,913,OTHER MAJOR HEAD and NECK PROCEDURES,,Relative Weights,"$16,613.29 ",IP,"16,613.29","16,613.29",,,,,,
BCBS Medicaid,DRG,914,OTHER MAJOR HEAD and NECK PROCEDURES,,Relative Weights,"$32,825.56 ",IP,"32,825.56","32,825.56",,,,,,
BCBS Medicaid,DRG,921,FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$6,039.23 ",IP,"6,039.23","6,039.23",,,,,,
BCBS Medicaid,DRG,922,FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$8,191.36 ",IP,"8,191.36","8,191.36",,,,,,
BCBS Medicaid,DRG,923,FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$13,246.44 ",IP,"13,246.44","13,246.44",,,,,,
BCBS Medicaid,DRG,924,FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$30,839.40 ",IP,"30,839.40","30,839.40",,,,,,
BCBS Medicaid,DRG,951,CLEFT LIP and PALATE REPAIR,,Relative Weights,"$4,246.53 ",IP,"4,246.53","4,246.53",,,,,,
BCBS Medicaid,DRG,952,CLEFT LIP and PALATE REPAIR,,Relative Weights,"$4,867.46 ",IP,"4,867.46","4,867.46",,,,,,
BCBS Medicaid,DRG,953,CLEFT LIP & PALATE REPAIR,,Relative Weights,"$7,436.75 ",IP,"7,436.75","7,436.75",,,,,,
BCBS Medicaid,DRG,954,CLEFT LIP and PALATE REPAIR,,Relative Weights,"$14,987.25 ",IP,"14,987.25","14,987.25",,,,,,
BCBS Medicaid,DRG,971,TONSIL and ADENOID PROCEDURES,,Relative Weights,"$2,853.47 ",IP,"2,853.47","2,853.47",,,,,,
BCBS Medicaid,DRG,972,TONSIL & ADENOID PROCEDURES,,Relative Weights,"$3,981.59 ",IP,"3,981.59","3,981.59",,,,,,
BCBS Medicaid,DRG,973,TONSIL & ADENOID PROCEDURES,,Relative Weights,"$6,406.56 ",IP,"6,406.56","6,406.56",,,,,,
BCBS Medicaid,DRG,974,TONSIL and ADENOID PROCEDURES,,Relative Weights,"$15,100.30 ",IP,"15,100.30","15,100.30",,,,,,
BCBS Medicaid,DRG,981,OTHER EAR NOSE MOUTH and THROAT PROCEDURES,,Relative Weights,"$4,806.30 ",IP,"4,806.30","4,806.30",,,,,,
BCBS Medicaid,DRG,982,OTHER EAR NOSE MOUTH and THROAT PROCEDURES,,Relative Weights,"$6,289.73 ",IP,"6,289.73","6,289.73",,,,,,
BCBS Medicaid,DRG,983,"OTHER EAR, NOSE, MOUTH & THROAT PROCEDURES",,Relative Weights,"$10,153.46 ",IP,"10,153.46","10,153.46",,,,,,
BCBS Medicaid,DRG,984,OTHER EAR NOSE MOUTH and THROAT PROCEDURES,,Relative Weights,"$19,630.32 ",IP,"19,630.32","19,630.32",,,,,,
BCBS Medicaid,DRG,1101,EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES,,Relative Weights,"$4,539.30 ",IP,"4,539.30","4,539.30",,,,,,
BCBS Medicaid,DRG,1102,EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES,,Relative Weights,"$4,571.26 ",IP,"4,571.26","4,571.26",,,,,,
BCBS Medicaid,DRG,1103,EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES,,Relative Weights,"$6,424.43 ",IP,"6,424.43","6,424.43",,,,,,
BCBS Medicaid,DRG,1104,EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES,,Relative Weights,"$10,388.84 ",IP,"10,388.84","10,388.84",,,,,,
BCBS Medicaid,DRG,1111,VERTIGO and OTHER LABYRINTH DISORDERS,,Relative Weights,"$3,014.97 ",IP,"3,014.97","3,014.97",,,,,,
BCBS Medicaid,DRG,1112,VERTIGO and OTHER LABYRINTH DISORDERS,,Relative Weights,"$3,232.83 ",IP,"3,232.83","3,232.83",,,,,,
BCBS Medicaid,DRG,1113,VERTIGO and OTHER LABYRINTH DISORDERS,,Relative Weights,"$3,830.06 ",IP,"3,830.06","3,830.06",,,,,,
BCBS Medicaid,DRG,1114,VERTIGO and OTHER LABYRINTH DISORDERS,,Relative Weights,"$5,856.07 ",IP,"5,856.07","5,856.07",,,,,,
BCBS Medicaid,DRG,1131,INFECTIONS OF UPPER RESPIRATORY TRACT,,Relative Weights,"$1,710.57 ",IP,"1,710.57","1,710.57",,,,,,
BCBS Medicaid,DRG,1132,INFECTIONS OF UPPER RESPIRATORY TRACT,,Relative Weights,"$2,449.71 ",IP,"2,449.71","2,449.71",,,,,,
BCBS Medicaid,DRG,1133,INFECTIONS OF UPPER RESPIRATORY TRACT,,Relative Weights,"$3,709.10 ",IP,"3,709.10","3,709.10",,,,,,
BCBS Medicaid,DRG,1134,INFECTIONS OF UPPER RESPIRATORY TRACT,,Relative Weights,"$7,363.91 ",IP,"7,363.91","7,363.91",,,,,,
BCBS Medicaid,DRG,1141,DENTAL DISEASES AND DISORDERS,,Relative Weights,"$2,233.23 ",IP,"2,233.23","2,233.23",,,,,,
BCBS Medicaid,DRG,1142,DENTAL DISEASES AND DISORDERS,,Relative Weights,"$3,024.94 ",IP,"3,024.94","3,024.94",,,,,,
BCBS Medicaid,DRG,1143,DENTAL DISEASES AND DISORDERS,,Relative Weights,"$4,392.57 ",IP,"4,392.57","4,392.57",,,,,,
BCBS Medicaid,DRG,1144,DENTAL DISEASES AND DISORDERS,,Relative Weights,"$11,476.08 ",IP,"11,476.08","11,476.08",,,,,,
BCBS Medicaid,DRG,1151,OTHER EAR NOSE MOUTHTHROAT and CRANIALFACIAL DIAGNOSES,,Relative Weights,"$2,472.39 ",IP,"2,472.39","2,472.39",,,,,,
BCBS Medicaid,DRG,1152,OTHER EAR NOSE MOUTHTHROAT and CRANIALFACIAL DIAGNOSES,,Relative Weights,"$3,380.25 ",IP,"3,380.25","3,380.25",,,,,,
BCBS Medicaid,DRG,1153,"OTHER EAR, NOSE, MOUTH,THROAT & CRANIAL/FACIAL DIAGNOSES",,Relative Weights,"$4,829.66 ",IP,"4,829.66","4,829.66",,,,,,
BCBS Medicaid,DRG,1154,"OTHER EAR, NOSE, MOUTH,THROAT & CRANIAL/FACIAL DIAGNOSES",,Relative Weights,"$10,560.66 ",IP,"10,560.66","10,560.66",,,,,,
BCBS Medicaid,DRG,1201,MAJOR RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$8,978.60 ",IP,"8,978.60","8,978.60",,,,,,
BCBS Medicaid,DRG,1202,MAJOR RESPIRATORY & CHEST PROCEDURES,,Relative Weights,"$10,724.22 ",IP,"10,724.22","10,724.22",,,,,,
BCBS Medicaid,DRG,1203,MAJOR RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$15,096.86 ",IP,"15,096.86","15,096.86",,,,,,
BCBS Medicaid,DRG,1204,MAJOR RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$30,187.20 ",IP,"30,187.20","30,187.20",,,,,,
BCBS Medicaid,DRG,1211,OTHER RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$6,647.79 ",IP,"6,647.79","6,647.79",,,,,,
BCBS Medicaid,DRG,1212,OTHER RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$8,066.62 ",IP,"8,066.62","8,066.62",,,,,,
BCBS Medicaid,DRG,1213,OTHER RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$12,267.10 ",IP,"12,267.10","12,267.10",,,,,,
BCBS Medicaid,DRG,1214,OTHER RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$23,708.13 ",IP,"23,708.13","23,708.13",,,,,,
BCBS Medicaid,DRG,1301,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96 HOURS,,Relative Weights,"$15,152.88 ",IP,"15,152.88","15,152.88",,,,,,
BCBS Medicaid,DRG,1302,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS,,Relative Weights,"$17,209.82 ",IP,"17,209.82","17,209.82",,,,,,
BCBS Medicaid,DRG,1303,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96 HOURS,,Relative Weights,"$20,315.17 ",IP,"20,315.17","20,315.17",,,,,,
BCBS Medicaid,DRG,1304,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96 HOURS,,Relative Weights,"$28,326.47 ",IP,"28,326.47","28,326.47",,,,,,
BCBS Medicaid,DRG,1311,CYSTIC FIBROSIS  PULMONARY DISEASE,,Relative Weights,"$6,540.23 ",IP,"6,540.23","6,540.23",,,,,,
BCBS Medicaid,DRG,1312,CYSTIC FIBROSIS - PULMONARY DISEASE,,Relative Weights,"$9,797.46 ",IP,"9,797.46","9,797.46",,,,,,
BCBS Medicaid,DRG,1313,CYSTIC FIBROSIS - PULMONARY DISEASE,,Relative Weights,"$13,253.65 ",IP,"13,253.65","13,253.65",,,,,,
BCBS Medicaid,DRG,1314,CYSTIC FIBROSIS  PULMONARY DISEASE,,Relative Weights,"$17,241.78 ",IP,"17,241.78","17,241.78",,,,,,
BCBS Medicaid,DRG,1321,BPD and OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,,Relative Weights,"$2,377.20 ",IP,"2,377.20","2,377.20",,,,,,
BCBS Medicaid,DRG,1322,BPD and OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,,Relative Weights,"$3,157.24 ",IP,"3,157.24","3,157.24",,,,,,
BCBS Medicaid,DRG,1323,BPD & OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,,Relative Weights,"$5,204.90 ",IP,"5,204.90","5,204.90",,,,,,
BCBS Medicaid,DRG,1324,BPD and OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,,Relative Weights,"$9,706.75 ",IP,"9,706.75","9,706.75",,,,,,
BCBS Medicaid,DRG,1331,RESPIRATORY FAILURE,,Relative Weights,"$2,072.41 ",IP,"2,072.41","2,072.41",,,,,,
BCBS Medicaid,DRG,1332,RESPIRATORY FAILURE,,Relative Weights,"$3,703.26 ",IP,"3,703.26","3,703.26",,,,,,
BCBS Medicaid,DRG,1333,RESPIRATORY FAILURE,,Relative Weights,"$5,064.70 ",IP,"5,064.70","5,064.70",,,,,,
BCBS Medicaid,DRG,1334,RESPIRATORY FAILURE,,Relative Weights,"$9,349.38 ",IP,"9,349.38","9,349.38",,,,,,
BCBS Medicaid,DRG,1341,PULMONARY EMBOLISM,,Relative Weights,"$2,977.18 ",IP,"2,977.18","2,977.18",,,,,,
BCBS Medicaid,DRG,1342,PULMONARY EMBOLISM,,Relative Weights,"$3,832.12 ",IP,"3,832.12","3,832.12",,,,,,
BCBS Medicaid,DRG,1343,PULMONARY EMBOLISM,,Relative Weights,"$5,276.03 ",IP,"5,276.03","5,276.03",,,,,,
BCBS Medicaid,DRG,1344,PULMONARY EMBOLISM,,Relative Weights,"$8,166.27 ",IP,"8,166.27","8,166.27",,,,,,
BCBS Medicaid,DRG,1351,MAJOR CHEST and RESPIRAZORY TRAUMA,,Relative Weights,"$3,792.26 ",IP,"3,792.26","3,792.26",,,,,,
BCBS Medicaid,DRG,1352,MAJOR CHEST & RESPIRATORY TRAUMA,,Relative Weights,"$3,955.48 ",IP,"3,955.48","3,955.48",,,,,,
BCBS Medicaid,DRG,1353,MAJOR CHEST and RESPIRATORY TRAUMA,,Relative Weights,"$5,683.92 ",IP,"5,683.92","5,683.92",,,,,,
BCBS Medicaid,DRG,1354,MAJOR CHEST and RESPIRATORY TRAUMA,,Relative Weights,"$10,178.89 ",IP,"10,178.89","10,178.89",,,,,,
BCBS Medicaid,DRG,1361,RESPIRATORY MALIGNANCY,,Relative Weights,"$4,244.47 ",IP,"4,244.47","4,244.47",,,,,,
BCBS Medicaid,DRG,1362,RESPIRATORY MALIGNANCY,,Relative Weights,"$4,742.73 ",IP,"4,742.73","4,742.73",,,,,,
BCBS Medicaid,DRG,1363,RESPIRATORY MALIGNANCY,,Relative Weights,"$6,049.19 ",IP,"6,049.19","6,049.19",,,,,,
BCBS Medicaid,DRG,1364,RESPIRATORY MALIGNANCY,,Relative Weights,"$9,049.05 ",IP,"9,049.05","9,049.05",,,,,,
BCBS Medicaid,DRG,1371,MAJOR RESPIRATORY INFECTIONS and INFLAMMATIONS,,Relative Weights,"$3,151.74 ",IP,"3,151.74","3,151.74",,,,,,
BCBS Medicaid,DRG,1372,MAJOR RESPIRATORY INFECTIONS and INFLAMMATIONS,,Relative Weights,"$3,930.39 ",IP,"3,930.39","3,930.39",,,,,,
BCBS Medicaid,DRG,1373,MAJOR RESPIRATORY INFECTIONS & INFLAMMATIONS,,Relative Weights,"$5,471.90 ",IP,"5,471.90","5,471.90",,,,,,
BCBS Medicaid,DRG,1374,MAJOR RESPIRATORY INFECTIONS and INFLAMMATIONS,,Relative Weights,"$8,758.68 ",IP,"8,758.68","8,758.68",,,,,,
BCBS Medicaid,DRG,1381,BRONCHIOLITIS and RSV PNEUMONIA,,Relative Weights,"$1,796.82 ",IP,"1,796.82","1,796.82",,,,,,
BCBS Medicaid,DRG,1382,BRONCHIOLITIS and RSV PNEUMONIA,,Relative Weights,"$2,575.82 ",IP,"2,575.82","2,575.82",,,,,,
BCBS Medicaid,DRG,1383,BRONCHIOLITIS and RSV PNEUMONIA,,Relative Weights,"$4,712.83 ",IP,"4,712.83","4,712.83",,,,,,
BCBS Medicaid,DRG,1384,BRONCHIOLITIS and RSV PNEUMONIA,,Relative Weights,"$9,865.85 ",IP,"9,865.85","9,865.85",,,,,,
BCBS Medicaid,DRG,1391,OTHER PNEUMONIA,,Relative Weights,"$2,182.71 ",IP,"2,182.71","2,182.71",,,,,,
BCBS Medicaid,DRG,1392,OTHER PNEUMONIA,,Relative Weights,"$3,016.35 ",IP,"3,016.35","3,016.35",,,,,,
BCBS Medicaid,DRG,1393,OTHER PNEUMONIA,,Relative Weights,"$4,342.75 ",IP,"4,342.75","4,342.75",,,,,,
BCBS Medicaid,DRG,1394,OTHER PNEUMONIA,,Relative Weights,"$7,186.59 ",IP,"7,186.59","7,186.59",,,,,,
BCBS Medicaid,DRG,1401,CHRONIC OBSTRUCTIVE PULMONARY DISEASE,,Relative Weights,"$2,639.05 ",IP,"2,639.05","2,639.05",,,,,,
BCBS Medicaid,DRG,1402,CHRONIC OBSTRUCTIVE PULMONARY DISEASE,,Relative Weights,"$3,167.20 ",IP,"3,167.20","3,167.20",,,,,,
BCBS Medicaid,DRG,1403,CHRONIC OBSTRUCTIVE PULMONARY DISEASE,,Relative Weights,"$3,958.92 ",IP,"3,958.92","3,958.92",,,,,,
BCBS Medicaid,DRG,1404,CHRONIC OBSTRUCTIVE PULMONARY DISEASE,,Relative Weights,"$5,969.47 ",IP,"5,969.47","5,969.47",,,,,,
BCBS Medicaid,DRG,1411,ASTHMA,,Relative Weights,"$2,018.80 ",IP,"2,018.80","2,018.80",,,,,,
BCBS Medicaid,DRG,1412,ASTHMA,,Relative Weights,"$2,763.78 ",IP,"2,763.78","2,763.78",,,,,,
BCBS Medicaid,DRG,1413,ASTHMA,,Relative Weights,"$4,049.98 ",IP,"4,049.98","4,049.98",,,,,,
BCBS Medicaid,DRG,1414,ASTHMA,,Relative Weights,"$6,508.28 ",IP,"6,508.28","6,508.28",,,,,,
BCBS Medicaid,DRG,1421,INTERSTITIAL and ALVEOLAR LUNG DISEASES,,Relative Weights,"$3,358.26 ",IP,"3,358.26","3,358.26",,,,,,
BCBS Medicaid,DRG,1422,INTERSTITIAL and ALVEOLAR LUNG DISEASES,,Relative Weights,"$3,679.89 ",IP,"3,679.89","3,679.89",,,,,,
BCBS Medicaid,DRG,1423,INTERSTITIAL and ALVEOLAR LUNG DISEASES,,Relative Weights,"$4,888.08 ",IP,"4,888.08","4,888.08",,,,,,
BCBS Medicaid,DRG,1424,INTERSTITIAL and ALVEOLAR LUNG DISEASES,,Relative Weights,"$7,901.68 ",IP,"7,901.68","7,901.68",,,,,,
BCBS Medicaid,DRG,1431,OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$2,504.69 ",IP,"2,504.69","2,504.69",,,,,,
BCBS Medicaid,DRG,1432,OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$3,509.11 ",IP,"3,509.11","3,509.11",,,,,,
BCBS Medicaid,DRG,1433,OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$5,145.11 ",IP,"5,145.11","5,145.11",,,,,,
BCBS Medicaid,DRG,1434,OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$8,358.70 ",IP,"8,358.70","8,358.70",,,,,,
BCBS Medicaid,DRG,1441,"RESPIRATORY SIGNS, SYMPTOMS & MINOR DIAGNOSES",,Relative Weights,"$2,636.99 ",IP,"2,636.99","2,636.99",,,,,,
BCBS Medicaid,DRG,1442,RESPIRATORY SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$3,405.68 ",IP,"3,405.68","3,405.68",,,,,,
BCBS Medicaid,DRG,1443,RESPIRATORY SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$4,454.42 ",IP,"4,454.42","4,454.42",,,,,,
BCBS Medicaid,DRG,1444,RESPIRATORY SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$7,998.24 ",IP,"7,998.24","7,998.24",,,,,,
BCBS Medicaid,DRG,1451,ACUTE BRONCHITIS AND RELATED SYMPTOMS,,Relative Weights,"$2,478.23 ",IP,"2,478.23","2,478.23",,,,,,
BCBS Medicaid,DRG,1452,ACUTE BRONCHITIS AND RELATED SYMPTOMS,,Relative Weights,"$2,974.43 ",IP,"2,974.43","2,974.43",,,,,,
BCBS Medicaid,DRG,1453,ACUTE BRONCHITIS AND RELATED SYMPTOMS,,Relative Weights,"$3,820.09 ",IP,"3,820.09","3,820.09",,,,,,
BCBS Medicaid,DRG,1454,ACUTE BRONCHITIS AND RELATED SYMPTOMS,,Relative Weights,"$6,746.07 ",IP,"6,746.07","6,746.07",,,,,,
BCBS Medicaid,DRG,1601,MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,,Relative Weights,"$19,007.33 ",IP,"19,007.33","19,007.33",,,,,,
BCBS Medicaid,DRG,1602,MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,,Relative Weights,"$21,418.55 ",IP,"21,418.55","21,418.55",,,,,,
BCBS Medicaid,DRG,1603,MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,,Relative Weights,"$29,897.52 ",IP,"29,897.52","29,897.52",,,,,,
BCBS Medicaid,DRG,1604,MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,,Relative Weights,"$58,616.75 ",IP,"58,616.75","58,616.75",,,,,,
BCBS Medicaid,DRG,1611,CARDIAC DEFIBRILLATOR and HEART ASSIST IMPLANT,,Relative Weights,"$21,623.70 ",IP,"21,623.70","21,623.70",,,,,,
BCBS Medicaid,DRG,1612,CARDIAC DEFIBRILLATOR and HEART ASSIST IMPLANT,,Relative Weights,"$25,324.21 ",IP,"25,324.21","25,324.21",,,,,,
BCBS Medicaid,DRG,1613,CARDIAC DEFIBRILLATOR and HEART ASSIST IMPLANT,,Relative Weights,"$37,168.99 ",IP,"37,168.99","37,168.99",,,,,,
BCBS Medicaid,DRG,1614,CARDIAC DEFIBRILLATOR and HEART ASSIST IMPLANT,,Relative Weights,"$84,952.59 ",IP,"84,952.59","84,952.59",,,,,,
BCBS Medicaid,DRG,1621,CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX,,Relative Weights,"$21,734.00 ",IP,"21,734.00","21,734.00",,,,,,
BCBS Medicaid,DRG,1622,CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX,,Relative Weights,"$25,647.21 ",IP,"25,647.21","25,647.21",,,,,,
BCBS Medicaid,DRG,1623,CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX,,Relative Weights,"$32,557.19 ",IP,"32,557.19","32,557.19",,,,,,
BCBS Medicaid,DRG,1624,CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX,,Relative Weights,"$51,493.39 ",IP,"51,493.39","51,493.39",,,,,,
BCBS Medicaid,DRG,1631,CARDIAC VALVE PROCEDURES WO AMI OR COMPLEX PDX,,Relative Weights,"$18,870.57 ",IP,"18,870.57","18,870.57",,,,,,
BCBS Medicaid,DRG,1632,CARDIAC VALVE PROCEDURES WO AMI OR COMPLEX PDX,,Relative Weights,"$20,678.38 ",IP,"20,678.38","20,678.38",,,,,,
BCBS Medicaid,DRG,1633,CARDIAC VALVE PROCEDURES WO AMI OR COMPLEX PDX,,Relative Weights,"$25,441.73 ",IP,"25,441.73","25,441.73",,,,,,
BCBS Medicaid,DRG,1634,CARDIAC VALVE PROCEDURES WO AMI OR COMPLEX PDX,,Relative Weights,"$42,290.40 ",IP,"42,290.40","42,290.40",,,,,,
BCBS Medicaid,DRG,1651,CORONARY BYPASS W AMI OR COMPLEX PDX,,Relative Weights,"$17,424.93 ",IP,"17,424.93","17,424.93",,,,,,
BCBS Medicaid,DRG,1652,CORONARY BYPASS W AMI OR COMPLEX PDX,,Relative Weights,"$20,592.13 ",IP,"20,592.13","20,592.13",,,,,,
BCBS Medicaid,DRG,1653,CORONARY BYPASS W AMI OR COMPLEX PDX,,Relative Weights,"$24,876.46 ",IP,"24,876.46","24,876.46",,,,,,
BCBS Medicaid,DRG,1654,CORONARY BYPASS W AMI OR COMPLEX PDX,,Relative Weights,"$37,414.00 ",IP,"37,414.00","37,414.00",,,,,,
BCBS Medicaid,DRG,1661,CORONARY BYPASS W/O AMI OR COMPLEX PDX,,Relative Weights,"$16,087.19 ",IP,"16,087.19","16,087.19",,,,,,
BCBS Medicaid,DRG,1662,CORONARY BYPASS WO AMI OR COMPLEX PDX,,Relative Weights,"$17,173.40 ",IP,"17,173.40","17,173.40",,,,,,
BCBS Medicaid,DRG,1663,CORONARY BYPASS WO AMI OR COMPLEX PDX,,Relative Weights,"$20,743.67 ",IP,"20,743.67","20,743.67",,,,,,
BCBS Medicaid,DRG,1664,CORONARY BYPASS WO AMI OR COMPLEX PDX,,Relative Weights,"$33,503.88 ",IP,"33,503.88","33,503.88",,,,,,
BCBS Medicaid,DRG,1671,OTHER CARDIOTHORACIC and THORACIC VASCULAR PROCEDURES,,Relative Weights,"$15,753.88 ",IP,"15,753.88","15,753.88",,,,,,
BCBS Medicaid,DRG,1672,OTHER CARDIOTHORACIC & THORACIC VASCULAR PROCEDURES,,Relative Weights,"$16,654.52 ",IP,"16,654.52","16,654.52",,,,,,
BCBS Medicaid,DRG,1673,OTHER CARDIOTHORACIC & THORACIC VASCULAR PROCEDURES,,Relative Weights,"$20,943.66 ",IP,"20,943.66","20,943.66",,,,,,
BCBS Medicaid,DRG,1674,OTHER CARDIOTHORACIC and THORACIC VASCULAR PROCEDURES,,Relative Weights,"$39,564.41 ",IP,"39,564.41","39,564.41",,,,,,
BCBS Medicaid,DRG,1691,MAJOR ABDOMINAL VASCULAR PROCEDURES,,Relative Weights,"$9,314.67 ",IP,"9,314.67","9,314.67",,,,,,
BCBS Medicaid,DRG,1692,MAJOR ABDOMINAL VASCULAR PROCEDURES,,Relative Weights,"$12,244.08 ",IP,"12,244.08","12,244.08",,,,,,
BCBS Medicaid,DRG,1693,MAJOR ABDOMINAL VASCULAR PROCEDURES,,Relative Weights,"$19,456.45 ",IP,"19,456.45","19,456.45",,,,,,
BCBS Medicaid,DRG,1694,MAJOR ABDOMINAL VASCULAR PROCEDURES,,Relative Weights,"$33,906.95 ",IP,"33,906.95","33,906.95",,,,,,
BCBS Medicaid,DRG,1701,PERMANENT CARDIAC PACEMAKER IMPLANT W AMI HEART FAILURE OR SHOCK,,Relative Weights,"$10,265.14 ",IP,"10,265.14","10,265.14",,,,,,
BCBS Medicaid,DRG,1702,PERMANENT CARDIAC PACEMAKER IMPLANT W AMI HEART FAILURE OR SHOCK,,Relative Weights,"$10,949.99 ",IP,"10,949.99","10,949.99",,,,,,
BCBS Medicaid,DRG,1703,PERMANENT CARDIAC PACEMAKER IMPLANT W AMI HEART FAILURE OR SHOCK,,Relative Weights,"$13,975.61 ",IP,"13,975.61","13,975.61",,,,,,
BCBS Medicaid,DRG,1704,"PERMANENT CARDIAC PACEMAKER IMPLANT W AMI, HEART FAILURE OR SHOCK",,Relative Weights,"$19,895.26 ",IP,"19,895.26","19,895.26",,,,,,
BCBS Medicaid,DRG,1711,PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK,,Relative Weights,"$8,272.45 ",IP,"8,272.45","8,272.45",,,,,,
BCBS Medicaid,DRG,1712,PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK,,Relative Weights,"$9,180.66 ",IP,"9,180.66","9,180.66",,,,,,
BCBS Medicaid,DRG,1713,PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK,,Relative Weights,"$10,971.29 ",IP,"10,971.29","10,971.29",,,,,,
BCBS Medicaid,DRG,1714,PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK,,Relative Weights,"$17,965.80 ",IP,"17,965.80","17,965.80",,,,,,
BCBS Medicaid,DRG,1741,PERCUTANEOUS CORONARY INTERVENTION W AMI,,Relative Weights,"$9,597.47 ",IP,"9,597.47","9,597.47",,,,,,
BCBS Medicaid,DRG,1742,PERCUTANEOUS CORONARY INTERVENTION W AMI,,Relative Weights,"$10,364.10 ",IP,"10,364.10","10,364.10",,,,,,
BCBS Medicaid,DRG,1743,PERCUTANEOUS CORONARY INTERVENTION W AMI,,Relative Weights,"$12,874.29 ",IP,"12,874.29","12,874.29",,,,,,
BCBS Medicaid,DRG,1744,PERCUTANEOUS CORONARY INTERVENTION W AMI,,Relative Weights,"$19,364.01 ",IP,"19,364.01","19,364.01",,,,,,
BCBS Medicaid,DRG,1751,PERCUTANEOUS CORONARY INTERVENTION WO AMI,,Relative Weights,"$11,256.84 ",IP,"11,256.84","11,256.84",,,,,,
BCBS Medicaid,DRG,1752,PERCUTANEOUS CORONARY INTERVENTION WO AMI,,Relative Weights,"$12,009.39 ",IP,"12,009.39","12,009.39",,,,,,
BCBS Medicaid,DRG,1753,PERCUTANEOUS CORONARY INTERVENTION WO AMI,,Relative Weights,"$14,253.95 ",IP,"14,253.95","14,253.95",,,,,,
BCBS Medicaid,DRG,1754,PERCUTANEOUS CORONARY INTERVENTION WO AMI,,Relative Weights,"$25,147.58 ",IP,"25,147.58","25,147.58",,,,,,
BCBS Medicaid,DRG,1761,CARDIAC PACEMAKER and DEFIBRILLATOR DEVICE REPLACEMENT,,Relative Weights,"$9,268.97 ",IP,"9,268.97","9,268.97",,,,,,
BCBS Medicaid,DRG,1762,CARDIAC PACEMAKER and DEFIBRILLATOR DEVICE REPLACEMENT,,Relative Weights,"$10,537.63 ",IP,"10,537.63","10,537.63",,,,,,
BCBS Medicaid,DRG,1763,CARDIAC PACEMAKER & DEFIBRILLATOR DEVICE REPLACEMENT,,Relative Weights,"$15,961.08 ",IP,"15,961.08","15,961.08",,,,,,
BCBS Medicaid,DRG,1764,CARDIAC PACEMAKER and DEFIBRILLATOR DEVICE REPLACEMENT,,Relative Weights,"$25,961.29 ",IP,"25,961.29","25,961.29",,,,,,
BCBS Medicaid,DRG,1771,CARDIAC PACEMAKER and DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,,Relative Weights,"$6,530.96 ",IP,"6,530.96","6,530.96",,,,,,
BCBS Medicaid,DRG,1772,CARDIAC PACEMAKER and DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,,Relative Weights,"$9,029.80 ",IP,"9,029.80","9,029.80",,,,,,
BCBS Medicaid,DRG,1773,CARDIAC PACEMAKER & DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,,Relative Weights,"$11,280.21 ",IP,"11,280.21","11,280.21",,,,,,
BCBS Medicaid,DRG,1774,CARDIAC PACEMAKER & DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,,Relative Weights,"$17,033.20 ",IP,"17,033.20","17,033.20",,,,,,
BCBS Medicaid,DRG,1801,OTHER CIRCULATORY SYSTEM PROCEDURES,,Relative Weights,"$6,351.58 ",IP,"6,351.58","6,351.58",,,,,,
BCBS Medicaid,DRG,1802,OTHER CIRCULATORY SYSTEM PROCEDURES,,Relative Weights,"$7,715.78 ",IP,"7,715.78","7,715.78",,,,,,
BCBS Medicaid,DRG,1803,OTHER CIRCULATORY SYSTEM PROCEDURES,,Relative Weights,"$10,872.33 ",IP,"10,872.33","10,872.33",,,,,,
BCBS Medicaid,DRG,1804,OTHER CIRCULATORY SYSTEM PROCEDURES,,Relative Weights,"$20,062.95 ",IP,"20,062.95","20,062.95",,,,,,
BCBS Medicaid,DRG,1811,LOWER EXTREMITY ARTERIAL PROCEDURES,,Relative Weights,"$9,268.28 ",IP,"9,268.28","9,268.28",,,,,,
BCBS Medicaid,DRG,1812,LOWER EXTREMITY ARTERIAL PROCEDURES,,Relative Weights,"$11,438.97 ",IP,"11,438.97","11,438.97",,,,,,
BCBS Medicaid,DRG,1813,LOWER EXTREMITY ARTERIAL PROCEDURES,,Relative Weights,"$16,303.68 ",IP,"16,303.68","16,303.68",,,,,,
BCBS Medicaid,DRG,1814,LOWER EXTREMITY ARTERIAL PROCEDURES,,Relative Weights,"$27,105.22 ",IP,"27,105.22","27,105.22",,,,,,
BCBS Medicaid,DRG,1821,OTHER PERIPHERAL VASCULAR PROCEDURES,,Relative Weights,"$9,585.79 ",IP,"9,585.79","9,585.79",,,,,,
BCBS Medicaid,DRG,1822,OTHER PERIPHERAL VASCULAR PROCEDURES,,Relative Weights,"$11,451.68 ",IP,"11,451.68","11,451.68",,,,,,
BCBS Medicaid,DRG,1823,OTHER PERIPHERAL VASCULAR PROCEDURES,,Relative Weights,"$12,966.73 ",IP,"12,966.73","12,966.73",,,,,,
BCBS Medicaid,DRG,1824,OTHER PERIPHERAL VASCULAR PROCEDURES,,Relative Weights,"$25,526.94 ",IP,"25,526.94","25,526.94",,,,,,
BCBS Medicaid,DRG,1901,ACUTE MYOCARDIAL INFARCTION,,Relative Weights,"$3,454.82 ",IP,"3,454.82","3,454.82",,,,,,
BCBS Medicaid,DRG,1902,ACUTE MYOCARDIAL INFARCTION,,Relative Weights,"$4,023.17 ",IP,"4,023.17","4,023.17",,,,,,
BCBS Medicaid,DRG,1903,ACUTE MYOCARDIAL INFARCTION,,Relative Weights,"$5,278.78 ",IP,"5,278.78","5,278.78",,,,,,
BCBS Medicaid,DRG,1904,ACUTE MYOCARDIAL INFARCTION,,Relative Weights,"$8,568.66 ",IP,"8,568.66","8,568.66",,,,,,
BCBS Medicaid,DRG,1911,CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,,Relative Weights,"$4,795.99 ",IP,"4,795.99","4,795.99",,,,,,
BCBS Medicaid,DRG,1912,CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,,Relative Weights,"$5,349.23 ",IP,"5,349.23","5,349.23",,,,,,
BCBS Medicaid,DRG,1913,CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,,Relative Weights,"$6,652.26 ",IP,"6,652.26","6,652.26",,,,,,
BCBS Medicaid,DRG,1914,CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,,Relative Weights,"$10,568.22 ",IP,"10,568.22","10,568.22",,,,,,
BCBS Medicaid,DRG,1921,CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS,,Relative Weights,"$5,126.56 ",IP,"5,126.56","5,126.56",,,,,,
BCBS Medicaid,DRG,1922,CARDIAC CATHETERIZATION FOR OTHER NONCORONARY CONDITIONS,,Relative Weights,"$5,995.59 ",IP,"5,995.59","5,995.59",,,,,,
BCBS Medicaid,DRG,1923,CARDIAC CATHETERIZATION FOR OTHER NONCORONARY CONDITIONS,,Relative Weights,"$8,192.04 ",IP,"8,192.04","8,192.04",,,,,,
BCBS Medicaid,DRG,1924,CARDIAC CATHETERIZATION FOR OTHER NONCORONARY CONDITIONS,,Relative Weights,"$14,030.25 ",IP,"14,030.25","14,030.25",,,,,,
BCBS Medicaid,DRG,1931,ACUTE & SUBACUTE ENDOCARDITIS,,Relative Weights,"$4,156.16 ",IP,"4,156.16","4,156.16",,,,,,
BCBS Medicaid,DRG,1932,ACUTE & SUBACUTE ENDOCARDITIS,,Relative Weights,"$5,201.81 ",IP,"5,201.81","5,201.81",,,,,,
BCBS Medicaid,DRG,1933,ACUTE and SUBACUTE ENDOCARDITIS,,Relative Weights,"$7,472.15 ",IP,"7,472.15","7,472.15",,,,,,
BCBS Medicaid,DRG,1934,ACUTE and SUBACUTE ENDOCARDITIS,,Relative Weights,"$12,655.75 ",IP,"12,655.75","12,655.75",,,,,,
BCBS Medicaid,DRG,1941,HEART FAILURE,,Relative Weights,"$2,590.60 ",IP,"2,590.60","2,590.60",,,,,,
BCBS Medicaid,DRG,1942,HEART FAILURE,,Relative Weights,"$3,135.24 ",IP,"3,135.24","3,135.24",,,,,,
BCBS Medicaid,DRG,1943,HEART FAILURE,,Relative Weights,"$4,368.86 ",IP,"4,368.86","4,368.86",,,,,,
BCBS Medicaid,DRG,1944,HEART FAILURE,,Relative Weights,"$7,070.79 ",IP,"7,070.79","7,070.79",,,,,,
BCBS Medicaid,DRG,1961,CARDIAC ARREST and SHOCK,,Relative Weights,"$2,365.52 ",IP,"2,365.52","2,365.52",,,,,,
BCBS Medicaid,DRG,1962,CARDIAC ARREST and SHOCK,,Relative Weights,"$2,596.44 ",IP,"2,596.44","2,596.44",,,,,,
BCBS Medicaid,DRG,1963,CARDIAC ARREST & SHOCK,,Relative Weights,"$4,010.12 ",IP,"4,010.12","4,010.12",,,,,,
BCBS Medicaid,DRG,1964,CARDIAC ARREST & SHOCK,,Relative Weights,"$8,325.03 ",IP,"8,325.03","8,325.03",,,,,,
BCBS Medicaid,DRG,1971,PERIPHERAL and OTHER VASCULAR DISORDERS,,Relative Weights,"$2,758.63 ",IP,"2,758.63","2,758.63",,,,,,
BCBS Medicaid,DRG,1972,PERIPHERAL and OTHER VASCULAR DISORDERS,,Relative Weights,"$3,488.49 ",IP,"3,488.49","3,488.49",,,,,,
BCBS Medicaid,DRG,1973,PERIPHERAL and OTHER VASCULAR DISORDERS,,Relative Weights,"$4,794.61 ",IP,"4,794.61","4,794.61",,,,,,
BCBS Medicaid,DRG,1974,PERIPHERAL & OTHER VASCULAR DISORDERS,,Relative Weights,"$9,053.51 ",IP,"9,053.51","9,053.51",,,,,,
BCBS Medicaid,DRG,1981,ANGINA PECTORIS & CORONARY ATHEROSCLEROSIS,,Relative Weights,"$2,680.28 ",IP,"2,680.28","2,680.28",,,,,,
BCBS Medicaid,DRG,1982,ANGINA PECTORIS and CORONARY ATHEROSCLEROSIS,,Relative Weights,"$2,985.77 ",IP,"2,985.77","2,985.77",,,,,,
BCBS Medicaid,DRG,1983,ANGINA PECTORIS and CORONARY ATHEROSCLEROSIS,,Relative Weights,"$3,628.00 ",IP,"3,628.00","3,628.00",,,,,,
BCBS Medicaid,DRG,1984,ANGINA PECTORIS and CORONARY ATHEROSCLEROSIS,,Relative Weights,"$6,763.25 ",IP,"6,763.25","6,763.25",,,,,,
BCBS Medicaid,DRG,1991,HYPERTENSION,,Relative Weights,"$2,662.41 ",IP,"2,662.41","2,662.41",,,,,,
BCBS Medicaid,DRG,1992,HYPERTENSION,,Relative Weights,"$2,956.56 ",IP,"2,956.56","2,956.56",,,,,,
BCBS Medicaid,DRG,1993,HYPERTENSION,,Relative Weights,"$3,736.93 ",IP,"3,736.93","3,736.93",,,,,,
BCBS Medicaid,DRG,1994,HYPERTENSION,,Relative Weights,"$6,634.39 ",IP,"6,634.39","6,634.39",,,,,,
BCBS Medicaid,DRG,2001,CARDIAC STRUCTURAL and VALVULAR DISORDERS,,Relative Weights,"$2,919.45 ",IP,"2,919.45","2,919.45",,,,,,
BCBS Medicaid,DRG,2002,CARDIAC STRUCTURAL and VALVULAR DISORDERS,,Relative Weights,"$3,565.12 ",IP,"3,565.12","3,565.12",,,,,,
BCBS Medicaid,DRG,2003,CARDIAC STRUCTURAL & VALVULAR DISORDERS,,Relative Weights,"$4,853.03 ",IP,"4,853.03","4,853.03",,,,,,
BCBS Medicaid,DRG,2004,CARDIAC STRUCTURAL and VALVULAR DISORDERS,,Relative Weights,"$10,524.92 ",IP,"10,524.92","10,524.92",,,,,,
BCBS Medicaid,DRG,2011,CARDIAC ARRHYTHMIA and CONDUCTION DISORDERS,,Relative Weights,"$2,322.91 ",IP,"2,322.91","2,322.91",,,,,,
BCBS Medicaid,DRG,2012,CARDIAC ARRHYTHMIA and CONDUCTION DISORDERS,,Relative Weights,"$2,865.50 ",IP,"2,865.50","2,865.50",,,,,,
BCBS Medicaid,DRG,2013,CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS,,Relative Weights,"$3,988.81 ",IP,"3,988.81","3,988.81",,,,,,
BCBS Medicaid,DRG,2014,CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS,,Relative Weights,"$7,490.70 ",IP,"7,490.70","7,490.70",,,,,,
BCBS Medicaid,DRG,2031,CHEST PAIN,,Relative Weights,"$2,896.08 ",IP,"2,896.08","2,896.08",,,,,,
BCBS Medicaid,DRG,2032,CHEST PAIN,,Relative Weights,"$3,156.55 ",IP,"3,156.55","3,156.55",,,,,,
BCBS Medicaid,DRG,2033,CHEST PAIN,,Relative Weights,"$3,647.25 ",IP,"3,647.25","3,647.25",,,,,,
BCBS Medicaid,DRG,2034,CHEST PAIN,,Relative Weights,"$5,656.08 ",IP,"5,656.08","5,656.08",,,,,,
BCBS Medicaid,DRG,2041,SYNCOPE and COLLAPSE,,Relative Weights,"$3,210.15 ",IP,"3,210.15","3,210.15",,,,,,
BCBS Medicaid,DRG,2042,SYNCOPE and COLLAPSE,,Relative Weights,"$3,469.25 ",IP,"3,469.25","3,469.25",,,,,,
BCBS Medicaid,DRG,2043,SYNCOPE and COLLAPSE,,Relative Weights,"$3,913.56 ",IP,"3,913.56","3,913.56",,,,,,
BCBS Medicaid,DRG,2044,SYNCOPE and COLLAPSE,,Relative Weights,"$6,621.67 ",IP,"6,621.67","6,621.67",,,,,,
BCBS Medicaid,DRG,2051,CARDIOMYOPATHY,,Relative Weights,"$3,094.70 ",IP,"3,094.70","3,094.70",,,,,,
BCBS Medicaid,DRG,2052,CARDIOMYOPATHY,,Relative Weights,"$3,108.78 ",IP,"3,108.78","3,108.78",,,,,,
BCBS Medicaid,DRG,2053,CARDIOMYOPATHY,,Relative Weights,"$4,834.47 ",IP,"4,834.47","4,834.47",,,,,,
BCBS Medicaid,DRG,2054,CARDIOMYOPATHY,,Relative Weights,"$12,099.76 ",IP,"12,099.76","12,099.76",,,,,,
BCBS Medicaid,DRG,2061,MALFUNCTIONREACTIONCOMPLICATION OF CARDIACVASC DEVICE OR PROCEDURE,,Relative Weights,"$3,915.62 ",IP,"3,915.62","3,915.62",,,,,,
BCBS Medicaid,DRG,2062,MALFUNCTIONREACTIONCOMPLICATION OF CARDIACVASC DEVICE OR PROCEDURE,,Relative Weights,"$4,064.41 ",IP,"4,064.41","4,064.41",,,,,,
BCBS Medicaid,DRG,2063,"MALFUNCTION,REACTION,COMPLICATION OF CARDIAC/VASC DEVICE OR PROCEDURE",,Relative Weights,"$5,616.22 ",IP,"5,616.22","5,616.22",,,,,,
BCBS Medicaid,DRG,2064,MALFUNCTIONREACTIONCOMPLICATION OF CARDIACVASC DEVICE OR PROCEDURE,,Relative Weights,"$11,629.68 ",IP,"11,629.68","11,629.68",,,,,,
BCBS Medicaid,DRG,2071,OTHER CIRCULATORY SYSTEM DIAGNOSES,,Relative Weights,"$2,947.97 ",IP,"2,947.97","2,947.97",,,,,,
BCBS Medicaid,DRG,2072,OTHER CIRCULATORY SYSTEM DIAGNOSES,,Relative Weights,"$3,511.17 ",IP,"3,511.17","3,511.17",,,,,,
BCBS Medicaid,DRG,2073,OTHER CIRCULATORY SYSTEM DIAGNOSES,,Relative Weights,"$4,590.50 ",IP,"4,590.50","4,590.50",,,,,,
BCBS Medicaid,DRG,2074,OTHER CIRCULATORY SYSTEM DIAGNOSES,,Relative Weights,"$8,837.72 ",IP,"8,837.72","8,837.72",,,,,,
BCBS Medicaid,DRG,2201,MAJOR STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$7,004.47 ",IP,"7,004.47","7,004.47",,,,,,
BCBS Medicaid,DRG,2202,MAJOR STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$10,124.94 ",IP,"10,124.94","10,124.94",,,,,,
BCBS Medicaid,DRG,2203,MAJOR STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$15,446.33 ",IP,"15,446.33","15,446.33",,,,,,
BCBS Medicaid,DRG,2204,MAJOR STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$29,728.80 ",IP,"29,728.80","29,728.80",,,,,,
BCBS Medicaid,DRG,2221,OTHER STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$3,629.38 ",IP,"3,629.38","3,629.38",,,,,,
BCBS Medicaid,DRG,2222,OTHER STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$5,962.94 ",IP,"5,962.94","5,962.94",,,,,,
BCBS Medicaid,DRG,2223,OTHER STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$9,116.74 ",IP,"9,116.74","9,116.74",,,,,,
BCBS Medicaid,DRG,2224,"OTHER STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES",,Relative Weights,"$19,946.46 ",IP,"19,946.46","19,946.46",,,,,,
BCBS Medicaid,DRG,2231,OTHER SMALL & LARGE BOWEL PROCEDURES,,Relative Weights,"$5,180.51 ",IP,"5,180.51","5,180.51",,,,,,
BCBS Medicaid,DRG,2232,OTHER SMALL and LARGE BOWEL PROCEDURES,,Relative Weights,"$7,107.90 ",IP,"7,107.90","7,107.90",,,,,,
BCBS Medicaid,DRG,2233,OTHER SMALL and LARGE BOWEL PROCEDURES,,Relative Weights,"$10,759.27 ",IP,"10,759.27","10,759.27",,,,,,
BCBS Medicaid,DRG,2234,OTHER SMALL and LARGE BOWEL PROCEDURES,,Relative Weights,"$20,449.53 ",IP,"20,449.53","20,449.53",,,,,,
BCBS Medicaid,DRG,2241,PERITONEAL ADHESIOLYSIS,,Relative Weights,"$6,143.69 ",IP,"6,143.69","6,143.69",,,,,,
BCBS Medicaid,DRG,2242,PERITONEAL ADHESIOLYSIS,,Relative Weights,"$7,746.36 ",IP,"7,746.36","7,746.36",,,,,,
BCBS Medicaid,DRG,2243,PERITONEAL ADHESIOLYSIS,,Relative Weights,"$11,242.41 ",IP,"11,242.41","11,242.41",,,,,,
BCBS Medicaid,DRG,2244,PERITONEAL ADHESIOLYSIS,,Relative Weights,"$20,422.04 ",IP,"20,422.04","20,422.04",,,,,,
BCBS Medicaid,DRG,2261,ANAL PROCEDURES,,Relative Weights,"$4,263.71 ",IP,"4,263.71","4,263.71",,,,,,
BCBS Medicaid,DRG,2262,ANAL PROCEDURES,,Relative Weights,"$5,861.92 ",IP,"5,861.92","5,861.92",,,,,,
BCBS Medicaid,DRG,2263,ANAL PROCEDURES,,Relative Weights,"$7,950.47 ",IP,"7,950.47","7,950.47",,,,,,
BCBS Medicaid,DRG,2264,ANAL PROCEDURES,,Relative Weights,"$17,017.73 ",IP,"17,017.73","17,017.73",,,,,,
BCBS Medicaid,DRG,2271,HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL and UMBILICAL,,Relative Weights,"$5,689.07 ",IP,"5,689.07","5,689.07",,,,,,
BCBS Medicaid,DRG,2272,HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL and UMBILICAL,,Relative Weights,"$6,795.89 ",IP,"6,795.89","6,795.89",,,,,,
BCBS Medicaid,DRG,2273,"HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL & UMBILICAL",,Relative Weights,"$10,114.97 ",IP,"10,114.97","10,114.97",,,,,,
BCBS Medicaid,DRG,2274,"HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL & UMBILICAL",,Relative Weights,"$20,038.21 ",IP,"20,038.21","20,038.21",,,,,,
BCBS Medicaid,DRG,2281,INGUINAL FEMORAL and UMBILICAL HERNIA PROCEDURES,,Relative Weights,"$4,335.53 ",IP,"4,335.53","4,335.53",,,,,,
BCBS Medicaid,DRG,2282,INGUINAL FEMORAL and UMBILICAL HERNIA PROCEDURES,,Relative Weights,"$5,502.48 ",IP,"5,502.48","5,502.48",,,,,,
BCBS Medicaid,DRG,2283,INGUINAL FEMORAL and UMBILICAL HERNIA PROCEDURES,,Relative Weights,"$7,788.28 ",IP,"7,788.28","7,788.28",,,,,,
BCBS Medicaid,DRG,2284,"INGUINAL, FEMORAL & UMBILICAL HERNIA PROCEDURES",,Relative Weights,"$16,501.95 ",IP,"16,501.95","16,501.95",,,,,,
BCBS Medicaid,DRG,2291,OTHER DIGESTIVE SYSTEM & ABDOMINAL PROCEDURES,,Relative Weights,"$5,564.34 ",IP,"5,564.34","5,564.34",,,,,,
BCBS Medicaid,DRG,2292,OTHER DIGESTIVE SYSTEM and ABDOMINAL PROCEDURES,,Relative Weights,"$7,117.87 ",IP,"7,117.87","7,117.87",,,,,,
BCBS Medicaid,DRG,2293,OTHER DIGESTIVE SYSTEM and ABDOMINAL PROCEDURES,,Relative Weights,"$10,259.30 ",IP,"10,259.30","10,259.30",,,,,,
BCBS Medicaid,DRG,2294,OTHER DIGESTIVE SYSTEM and ABDOMINAL PROCEDURES,,Relative Weights,"$20,018.28 ",IP,"20,018.28","20,018.28",,,,,,
BCBS Medicaid,DRG,2301,MAJOR SMALL BOWEL PROCEDURES,,Relative Weights,"$6,770.12 ",IP,"6,770.12","6,770.12",,,,,,
BCBS Medicaid,DRG,2302,MAJOR SMALL BOWEL PROCEDURES,,Relative Weights,"$8,787.20 ",IP,"8,787.20","8,787.20",,,,,,
BCBS Medicaid,DRG,2303,MAJOR SMALL BOWEL PROCEDURES,,Relative Weights,"$13,506.56 ",IP,"13,506.56","13,506.56",,,,,,
BCBS Medicaid,DRG,2304,MAJOR SMALL BOWEL PROCEDURES,,Relative Weights,"$27,168.10 ",IP,"27,168.10","27,168.10",,,,,,
BCBS Medicaid,DRG,2311,MAJOR LARGE BOWEL PROCEDURES,,Relative Weights,"$6,900.01 ",IP,"6,900.01","6,900.01",,,,,,
BCBS Medicaid,DRG,2312,MAJOR LARGE BOWEL PROCEDURES,,Relative Weights,"$8,451.83 ",IP,"8,451.83","8,451.83",,,,,,
BCBS Medicaid,DRG,2313,MAJOR LARGE BOWEL PROCEDURES,,Relative Weights,"$12,656.43 ",IP,"12,656.43","12,656.43",,,,,,
BCBS Medicaid,DRG,2314,MAJOR LARGE BOWEL PROCEDURES,,Relative Weights,"$23,212.62 ",IP,"23,212.62","23,212.62",,,,,,
BCBS Medicaid,DRG,2321,GASTRIC FUNDOPLICATION,,Relative Weights,"$5,317.96 ",IP,"5,317.96","5,317.96",,,,,,
BCBS Medicaid,DRG,2322,GASTRIC FUNDOPLICATION,,Relative Weights,"$6,619.27 ",IP,"6,619.27","6,619.27",,,,,,
BCBS Medicaid,DRG,2323,GASTRIC FUNDOPLICATION,,Relative Weights,"$9,668.60 ",IP,"9,668.60","9,668.60",,,,,,
BCBS Medicaid,DRG,2324,GASTRIC FUNDOPLICATION,,Relative Weights,"$26,510.06 ",IP,"26,510.06","26,510.06",,,,,,
BCBS Medicaid,DRG,2331,APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$5,328.61 ",IP,"5,328.61","5,328.61",,,,,,
BCBS Medicaid,DRG,2332,APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$6,525.46 ",IP,"6,525.46","6,525.46",,,,,,
BCBS Medicaid,DRG,2333,APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$9,426.35 ",IP,"9,426.35","9,426.35",,,,,,
BCBS Medicaid,DRG,2334,APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$16,969.28 ",IP,"16,969.28","16,969.28",,,,,,
BCBS Medicaid,DRG,2341,APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$3,837.96 ",IP,"3,837.96","3,837.96",,,,,,
BCBS Medicaid,DRG,2342,APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$4,853.72 ",IP,"4,853.72","4,853.72",,,,,,
BCBS Medicaid,DRG,2343,APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$7,767.67 ",IP,"7,767.67","7,767.67",,,,,,
BCBS Medicaid,DRG,2344,APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$15,153.91 ",IP,"15,153.91","15,153.91",,,,,,
BCBS Medicaid,DRG,2401,DIGESTIVE MALIGNANCY,,Relative Weights,"$4,130.38 ",IP,"4,130.38","4,130.38",,,,,,
BCBS Medicaid,DRG,2402,DIGESTIVE MALIGNANCY,,Relative Weights,"$4,471.61 ",IP,"4,471.61","4,471.61",,,,,,
BCBS Medicaid,DRG,2403,DIGESTIVE MALIGNANCY,,Relative Weights,"$5,940.95 ",IP,"5,940.95","5,940.95",,,,,,
BCBS Medicaid,DRG,2404,DIGESTIVE MALIGNANCY,,Relative Weights,"$10,480.94 ",IP,"10,480.94","10,480.94",,,,,,
BCBS Medicaid,DRG,2411,PEPTIC ULCER & GASTRITIS,,Relative Weights,"$3,142.46 ",IP,"3,142.46","3,142.46",,,,,,
BCBS Medicaid,DRG,2412,PEPTIC ULCER and GASTRITIS,,Relative Weights,"$3,833.49 ",IP,"3,833.49","3,833.49",,,,,,
BCBS Medicaid,DRG,2413,PEPTIC ULCER and GASTRITIS,,Relative Weights,"$5,293.90 ",IP,"5,293.90","5,293.90",,,,,,
BCBS Medicaid,DRG,2414,PEPTIC ULCER and GASTRITIS,,Relative Weights,"$11,497.38 ",IP,"11,497.38","11,497.38",,,,,,
BCBS Medicaid,DRG,2421,MAJOR ESOPHAGEAL DISORDERS,,Relative Weights,"$2,834.23 ",IP,"2,834.23","2,834.23",,,,,,
BCBS Medicaid,DRG,2422,MAJOR ESOPHAGEAL DISORDERS,,Relative Weights,"$3,630.75 ",IP,"3,630.75","3,630.75",,,,,,
BCBS Medicaid,DRG,2423,MAJOR ESOPHAGEAL DISORDERS,,Relative Weights,"$5,095.29 ",IP,"5,095.29","5,095.29",,,,,,
BCBS Medicaid,DRG,2424,MAJOR ESOPHAGEAL DISORDERS,,Relative Weights,"$11,235.54 ",IP,"11,235.54","11,235.54",,,,,,
BCBS Medicaid,DRG,2431,OTHER ESOPHAGEAL DISORDERS,,Relative Weights,"$2,619.12 ",IP,"2,619.12","2,619.12",,,,,,
BCBS Medicaid,DRG,2432,OTHER ESOPHAGEAL DISORDERS,,Relative Weights,"$3,394.34 ",IP,"3,394.34","3,394.34",,,,,,
BCBS Medicaid,DRG,2433,OTHER ESOPHAGEAL DISORDERS,,Relative Weights,"$4,672.28 ",IP,"4,672.28","4,672.28",,,,,,
BCBS Medicaid,DRG,2434,OTHER ESOPHAGEAL DISORDERS,,Relative Weights,"$10,028.72 ",IP,"10,028.72","10,028.72",,,,,,
BCBS Medicaid,DRG,2441,DIVERTICULITIS and DIVERTICULOSIS,,Relative Weights,"$2,541.46 ",IP,"2,541.46","2,541.46",,,,,,
BCBS Medicaid,DRG,2442,DIVERTICULITIS and DIVERTICULOSIS,,Relative Weights,"$3,268.57 ",IP,"3,268.57","3,268.57",,,,,,
BCBS Medicaid,DRG,2443,DIVERTICULITIS & DIVERTICULOSIS,,Relative Weights,"$4,670.91 ",IP,"4,670.91","4,670.91",,,,,,
BCBS Medicaid,DRG,2444,DIVERTICULITIS & DIVERTICULOSIS,,Relative Weights,"$10,075.80 ",IP,"10,075.80","10,075.80",,,,,,
BCBS Medicaid,DRG,2451,INFLAMMATORY BOWEL DISEASE,,Relative Weights,"$3,109.82 ",IP,"3,109.82","3,109.82",,,,,,
BCBS Medicaid,DRG,2452,INFLAMMATORY BOWEL DISEASE,,Relative Weights,"$3,884.35 ",IP,"3,884.35","3,884.35",,,,,,
BCBS Medicaid,DRG,2453,INFLAMMATORY BOWEL DISEASE,,Relative Weights,"$5,370.53 ",IP,"5,370.53","5,370.53",,,,,,
BCBS Medicaid,DRG,2454,INFLAMMATORY BOWEL DISEASE,,Relative Weights,"$12,127.25 ",IP,"12,127.25","12,127.25",,,,,,
BCBS Medicaid,DRG,2461,GASTROINTESTINAL VASCULAR INSUFFICIENCY,,Relative Weights,"$3,009.82 ",IP,"3,009.82","3,009.82",,,,,,
BCBS Medicaid,DRG,2462,GASTROINTESTINAL VASCULAR INSUFFICIENCY,,Relative Weights,"$3,644.84 ",IP,"3,644.84","3,644.84",,,,,,
BCBS Medicaid,DRG,2463,GASTROINTESTINAL VASCULAR INSUFFICIENCY,,Relative Weights,"$5,068.14 ",IP,"5,068.14","5,068.14",,,,,,
BCBS Medicaid,DRG,2464,GASTROINTESTINAL VASCULAR INSUFFICIENCY,,Relative Weights,"$9,550.40 ",IP,"9,550.40","9,550.40",,,,,,
BCBS Medicaid,DRG,2471,INTESTINAL OBSTRUCTION,,Relative Weights,"$2,323.60 ",IP,"2,323.60","2,323.60",,,,,,
BCBS Medicaid,DRG,2472,INTESTINAL OBSTRUCTION,,Relative Weights,"$2,999.17 ",IP,"2,999.17","2,999.17",,,,,,
BCBS Medicaid,DRG,2473,INTESTINAL OBSTRUCTION,,Relative Weights,"$4,431.74 ",IP,"4,431.74","4,431.74",,,,,,
BCBS Medicaid,DRG,2474,INTESTINAL OBSTRUCTION,,Relative Weights,"$9,108.15 ",IP,"9,108.15","9,108.15",,,,,,
BCBS Medicaid,DRG,2481,MAJOR GASTROINTESTINAL and PERITONEAL INFECTIONS,,Relative Weights,"$2,573.42 ",IP,"2,573.42","2,573.42",,,,,,
BCBS Medicaid,DRG,2482,MAJOR GASTROINTESTINAL and PERITONEAL INFECTIONS,,Relative Weights,"$3,590.89 ",IP,"3,590.89","3,590.89",,,,,,
BCBS Medicaid,DRG,2483,MAJOR GASTROINTESTINAL & PERITONEAL INFECTIONS,,Relative Weights,"$4,839.63 ",IP,"4,839.63","4,839.63",,,,,,
BCBS Medicaid,DRG,2484,MAJOR GASTROINTESTINAL and PERITONEAL INFECTIONS,,Relative Weights,"$10,133.19 ",IP,"10,133.19","10,133.19",,,,,,
BCBS Medicaid,DRG,2491,OTHER GASTROENTERITIS NAUSEA and VOMITING,,Relative Weights,"$2,187.52 ",IP,"2,187.52","2,187.52",,,,,,
BCBS Medicaid,DRG,2492,OTHER GASTROENTERITIS NAUSEA and VOMITING,,Relative Weights,"$2,797.80 ",IP,"2,797.80","2,797.80",,,,,,
BCBS Medicaid,DRG,2493,"OTHER GASTROENTERITIS, NAUSEA & VOMITING",,Relative Weights,"$3,754.80 ",IP,"3,754.80","3,754.80",,,,,,
BCBS Medicaid,DRG,2494,"OTHER GASTROENTERITIS, NAUSEA & VOMITING",,Relative Weights,"$8,298.22 ",IP,"8,298.22","8,298.22",,,,,,
BCBS Medicaid,DRG,2511,ABDOMINAL PAIN,,Relative Weights,"$2,520.84 ",IP,"2,520.84","2,520.84",,,,,,
BCBS Medicaid,DRG,2512,ABDOMINAL PAIN,,Relative Weights,"$3,175.79 ",IP,"3,175.79","3,175.79",,,,,,
BCBS Medicaid,DRG,2513,ABDOMINAL PAIN,,Relative Weights,"$4,112.86 ",IP,"4,112.86","4,112.86",,,,,,
BCBS Medicaid,DRG,2514,ABDOMINAL PAIN,,Relative Weights,"$7,334.01 ",IP,"7,334.01","7,334.01",,,,,,
BCBS Medicaid,DRG,2521,MALFUNCTION REACTION and COMPLICATION OF GI DEVICE OR PROCEDURE,,Relative Weights,"$2,913.26 ",IP,"2,913.26","2,913.26",,,,,,
BCBS Medicaid,DRG,2522,MALFUNCTION REACTION and COMPLICATION OF GI DEVICE OR PROCEDURE,,Relative Weights,"$3,639.34 ",IP,"3,639.34","3,639.34",,,,,,
BCBS Medicaid,DRG,2523,MALFUNCTION REACTION and COMPLICATION OF GI DEVICE OR PROCEDURE,,Relative Weights,"$5,172.60 ",IP,"5,172.60","5,172.60",,,,,,
BCBS Medicaid,DRG,2524,MALFUNCTION REACTION and COMPLICATION OF GI DEVICE OR PROCEDURE,,Relative Weights,"$11,168.53 ",IP,"11,168.53","11,168.53",,,,,,
BCBS Medicaid,DRG,2531,OTHER and UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,,Relative Weights,"$2,890.24 ",IP,"2,890.24","2,890.24",,,,,,
BCBS Medicaid,DRG,2532,OTHER and UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,,Relative Weights,"$3,602.23 ",IP,"3,602.23","3,602.23",,,,,,
BCBS Medicaid,DRG,2533,OTHER and UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,,Relative Weights,"$5,054.39 ",IP,"5,054.39","5,054.39",,,,,,
BCBS Medicaid,DRG,2534,OTHER and UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,,Relative Weights,"$9,586.48 ",IP,"9,586.48","9,586.48",,,,,,
BCBS Medicaid,DRG,2541,OTHER DIGESTIVE SYSTEM DIAGNOSES,,Relative Weights,"$2,614.99 ",IP,"2,614.99","2,614.99",,,,,,
BCBS Medicaid,DRG,2542,OTHER DIGESTIVE SYSTEM DIAGNOSES,,Relative Weights,"$3,386.43 ",IP,"3,386.43","3,386.43",,,,,,
BCBS Medicaid,DRG,2543,OTHER DIGESTIVE SYSTEM DIAGNOSES,,Relative Weights,"$4,771.93 ",IP,"4,771.93","4,771.93",,,,,,
BCBS Medicaid,DRG,2544,OTHER DIGESTIVE SYSTEM DIAGNOSES,,Relative Weights,"$9,778.91 ",IP,"9,778.91","9,778.91",,,,,,
BCBS Medicaid,DRG,2601,MAJOR PANCREAS LIVER and SHUNT PROCEDURES,,Relative Weights,"$9,438.72 ",IP,"9,438.72","9,438.72",,,,,,
BCBS Medicaid,DRG,2602,MAJOR PANCREAS LIVER and SHUNT PROCEDURES,,Relative Weights,"$11,500.13 ",IP,"11,500.13","11,500.13",,,,,,
BCBS Medicaid,DRG,2603,MAJOR PANCREAS LIVER and SHUNT PROCEDURES,,Relative Weights,"$16,312.61 ",IP,"16,312.61","16,312.61",,,,,,
BCBS Medicaid,DRG,2604,MAJOR PANCREAS LIVER and SHUNT PROCEDURES,,Relative Weights,"$34,324.11 ",IP,"34,324.11","34,324.11",,,,,,
BCBS Medicaid,DRG,2611,MAJOR BILIARY TRACT PROCEDURES,,Relative Weights,"$6,801.05 ",IP,"6,801.05","6,801.05",,,,,,
BCBS Medicaid,DRG,2612,MAJOR BILIARY TRACT PROCEDURES,,Relative Weights,"$10,119.10 ",IP,"10,119.10","10,119.10",,,,,,
BCBS Medicaid,DRG,2613,MAJOR BILIARY TRACT PROCEDURES,,Relative Weights,"$14,491.05 ",IP,"14,491.05","14,491.05",,,,,,
BCBS Medicaid,DRG,2614,MAJOR BILIARY TRACT PROCEDURES,,Relative Weights,"$28,576.97 ",IP,"28,576.97","28,576.97",,,,,,
BCBS Medicaid,DRG,2631,CHOLECYSTECTOMY,,Relative Weights,"$5,153.36 ",IP,"5,153.36","5,153.36",,,,,,
BCBS Medicaid,DRG,2632,CHOLECYSTECTOMY,,Relative Weights,"$6,574.60 ",IP,"6,574.60","6,574.60",,,,,,
BCBS Medicaid,DRG,2633,CHOLECYSTECTOMY,,Relative Weights,"$8,823.28 ",IP,"8,823.28","8,823.28",,,,,,
BCBS Medicaid,DRG,2634,CHOLECYSTECTOMY,,Relative Weights,"$16,983.37 ",IP,"16,983.37","16,983.37",,,,,,
BCBS Medicaid,DRG,2641,OTHER HEPATOBILIARY PANCREAS and ABDOMINAL PROCEDURES,,Relative Weights,"$6,826.47 ",IP,"6,826.47","6,826.47",,,,,,
BCBS Medicaid,DRG,2642,OTHER HEPATOBILIARY PANCREAS and ABDOMINAL PROCEDURES,,Relative Weights,"$7,584.86 ",IP,"7,584.86","7,584.86",,,,,,
BCBS Medicaid,DRG,2643,"OTHER HEPATOBILIARY, PANCREAS & ABDOMINAL PROCEDURES",,Relative Weights,"$11,612.15 ",IP,"11,612.15","11,612.15",,,,,,
BCBS Medicaid,DRG,2644,OTHER HEPATOBILIARY PANCREAS and ABDOMINAL PROCEDURES,,Relative Weights,"$29,218.86 ",IP,"29,218.86","29,218.86",,,,,,
BCBS Medicaid,DRG,2791,HEPATIC COMA and OTHER MAJOR ACUTE LIVER DISORDERS,,Relative Weights,"$2,567.92 ",IP,"2,567.92","2,567.92",,,,,,
BCBS Medicaid,DRG,2792,HEPATIC COMA and OTHER MAJOR ACUTE LIVER DISORDERS,,Relative Weights,"$3,323.89 ",IP,"3,323.89","3,323.89",,,,,,
BCBS Medicaid,DRG,2793,HEPATIC COMA & OTHER MAJOR ACUTE LIVER DISORDERS,,Relative Weights,"$4,704.93 ",IP,"4,704.93","4,704.93",,,,,,
BCBS Medicaid,DRG,2794,HEPATIC COMA and OTHER MAJOR ACUTE LIVER DISORDERS,,Relative Weights,"$11,290.86 ",IP,"11,290.86","11,290.86",,,,,,
BCBS Medicaid,DRG,2801,ALCOHOLIC LIVER DISEASE,,Relative Weights,"$2,499.54 ",IP,"2,499.54","2,499.54",,,,,,
BCBS Medicaid,DRG,2802,ALCOHOLIC LIVER DISEASE,,Relative Weights,"$3,093.32 ",IP,"3,093.32","3,093.32",,,,,,
BCBS Medicaid,DRG,2803,ALCOHOLIC LIVER DISEASE,,Relative Weights,"$4,638.26 ",IP,"4,638.26","4,638.26",,,,,,
BCBS Medicaid,DRG,2804,ALCOHOLIC LIVER DISEASE,,Relative Weights,"$10,324.24 ",IP,"10,324.24","10,324.24",,,,,,
BCBS Medicaid,DRG,2811,MALIGNANCY OF HEPATOBILIARY SYSTEM & PANCREAS,,Relative Weights,"$3,619.41 ",IP,"3,619.41","3,619.41",,,,,,
BCBS Medicaid,DRG,2812,MALIGNANCY OF HEPATOBILIARY SYSTEM and PANCREAS,,Relative Weights,"$4,564.04 ",IP,"4,564.04","4,564.04",,,,,,
BCBS Medicaid,DRG,2813,MALIGNANCY OF HEPATOBILIARY SYSTEM and PANCREAS,,Relative Weights,"$5,844.73 ",IP,"5,844.73","5,844.73",,,,,,
BCBS Medicaid,DRG,2814,MALIGNANCY OF HEPATOBILIARY SYSTEM and PANCREAS,,Relative Weights,"$9,186.50 ",IP,"9,186.50","9,186.50",,,,,,
BCBS Medicaid,DRG,2821,DISORDERS OF PANCREAS EXCEPT MALIGNANCY,,Relative Weights,"$2,462.42 ",IP,"2,462.42","2,462.42",,,,,,
BCBS Medicaid,DRG,2822,DISORDERS OF PANCREAS EXCEPT MALIGNANCY,,Relative Weights,"$3,135.24 ",IP,"3,135.24","3,135.24",,,,,,
BCBS Medicaid,DRG,2823,DISORDERS OF PANCREAS EXCEPT MALIGNANCY,,Relative Weights,"$4,746.16 ",IP,"4,746.16","4,746.16",,,,,,
BCBS Medicaid,DRG,2824,DISORDERS OF PANCREAS EXCEPT MALIGNANCY,,Relative Weights,"$12,503.18 ",IP,"12,503.18","12,503.18",,,,,,
BCBS Medicaid,DRG,2831,OTHER DISORDERS OF THE LIVER,,Relative Weights,"$2,720.83 ",IP,"2,720.83","2,720.83",,,,,,
BCBS Medicaid,DRG,2832,OTHER DISORDERS OF THE LIVER,,Relative Weights,"$3,349.67 ",IP,"3,349.67","3,349.67",,,,,,
BCBS Medicaid,DRG,2833,OTHER DISORDERS OF THE LIVER,,Relative Weights,"$4,885.67 ",IP,"4,885.67","4,885.67",,,,,,
BCBS Medicaid,DRG,2834,OTHER DISORDERS OF THE LIVER,,Relative Weights,"$10,248.65 ",IP,"10,248.65","10,248.65",,,,,,
BCBS Medicaid,DRG,2841,DISORDERS OF GALLBLADDER and BILIARY TRACT,,Relative Weights,"$3,351.73 ",IP,"3,351.73","3,351.73",,,,,,
BCBS Medicaid,DRG,2842,DISORDERS OF GALLBLADDER and BILIARY TRACT,,Relative Weights,"$4,147.57 ",IP,"4,147.57","4,147.57",,,,,,
BCBS Medicaid,DRG,2843,DISORDERS OF GALLBLADDER and BILIARY TRACT,,Relative Weights,"$5,552.31 ",IP,"5,552.31","5,552.31",,,,,,
BCBS Medicaid,DRG,2844,DISORDERS OF GALLBLADDER and BILIARY TRACT,,Relative Weights,"$10,788.48 ",IP,"10,788.48","10,788.48",,,,,,
BCBS Medicaid,DRG,3011,HIP JOINT REPLACEMENT,,Relative Weights,"$7,771.10 ",IP,"7,771.10","7,771.10",,,,,,
BCBS Medicaid,DRG,3012,HIP JOINT REPLACEMENT,,Relative Weights,"$8,122.29 ",IP,"8,122.29","8,122.29",,,,,,
BCBS Medicaid,DRG,3013,HIP JOINT REPLACEMENT,,Relative Weights,"$10,480.59 ",IP,"10,480.59","10,480.59",,,,,,
BCBS Medicaid,DRG,3014,HIP JOINT REPLACEMENT,,Relative Weights,"$16,617.41 ",IP,"16,617.41","16,617.41",,,,,,
BCBS Medicaid,DRG,3021,KNEE JOINT REPLACEMENT,,Relative Weights,"$7,208.24 ",IP,"7,208.24","7,208.24",,,,,,
BCBS Medicaid,DRG,3022,KNEE JOINT REPLACEMENT,,Relative Weights,"$7,702.03 ",IP,"7,702.03","7,702.03",,,,,,
BCBS Medicaid,DRG,3023,KNEE JOINT REPLACEMENT,,Relative Weights,"$9,864.13 ",IP,"9,864.13","9,864.13",,,,,,
BCBS Medicaid,DRG,3024,KNEE JOINT REPLACEMENT,,Relative Weights,"$17,075.12 ",IP,"17,075.12","17,075.12",,,,,,
BCBS Medicaid,DRG,3031,DORSAL and LUMBAR FUSION PROC FOR CURVATURE OF BACK,,Relative Weights,"$22,622.27 ",IP,"22,622.27","22,622.27",,,,,,
BCBS Medicaid,DRG,3032,DORSAL and LUMBAR FUSION PROC FOR CURVATURE OF BACK,,Relative Weights,"$26,401.82 ",IP,"26,401.82","26,401.82",,,,,,
BCBS Medicaid,DRG,3033,DORSAL and LUMBAR FUSION PROC FOR CURVATURE OF BACK,,Relative Weights,"$36,462.15 ",IP,"36,462.15","36,462.15",,,,,,
BCBS Medicaid,DRG,3034,DORSAL and LUMBAR FUSION PROC FOR CURVATURE OF BACK,,Relative Weights,"$46,680.22 ",IP,"46,680.22","46,680.22",,,,,,
BCBS Medicaid,DRG,3041,DORSAL and LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK,,Relative Weights,"$13,662.91 ",IP,"13,662.91","13,662.91",,,,,,
BCBS Medicaid,DRG,3042,DORSAL and LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK,,Relative Weights,"$15,568.66 ",IP,"15,568.66","15,568.66",,,,,,
BCBS Medicaid,DRG,3043,DORSAL and LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK,,Relative Weights,"$23,409.86 ",IP,"23,409.86","23,409.86",,,,,,
BCBS Medicaid,DRG,3044,DORSAL and LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK,,Relative Weights,"$37,522.24 ",IP,"37,522.24","37,522.24",,,,,,
BCBS Medicaid,DRG,3051,AMPUTATION OF LOWER LIMB EXCEPT TOES,,Relative Weights,"$4,866.09 ",IP,"4,866.09","4,866.09",,,,,,
BCBS Medicaid,DRG,3052,AMPUTATION OF LOWER LIMB EXCEPT TOES,,Relative Weights,"$6,637.82 ",IP,"6,637.82","6,637.82",,,,,,
BCBS Medicaid,DRG,3053,AMPUTATION OF LOWER LIMB EXCEPT TOES,,Relative Weights,"$10,080.61 ",IP,"10,080.61","10,080.61",,,,,,
BCBS Medicaid,DRG,3054,AMPUTATION OF LOWER LIMB EXCEPT TOES,,Relative Weights,"$19,786.33 ",IP,"19,786.33","19,786.33",,,,,,
BCBS Medicaid,DRG,3081,HIP and FEMUR FRACTURE REPAIR,,Relative Weights,"$6,633.70 ",IP,"6,633.70","6,633.70",,,,,,
BCBS Medicaid,DRG,3082,HIP and FEMUR FRACTURE REPAIR,,Relative Weights,"$7,529.88 ",IP,"7,529.88","7,529.88",,,,,,
BCBS Medicaid,DRG,3083,HIP & FEMUR FRACTURE REPAIR,,Relative Weights,"$9,249.72 ",IP,"9,249.72","9,249.72",,,,,,
BCBS Medicaid,DRG,3084,HIP and FEMUR FRACTURE REPAIR,,Relative Weights,"$14,744.30 ",IP,"14,744.30","14,744.30",,,,,,
BCBS Medicaid,DRG,3091,OTHER SIGNIFICANT HIP and FEMUR SURGERY,,Relative Weights,"$7,238.83 ",IP,"7,238.83","7,238.83",,,,,,
BCBS Medicaid,DRG,3092,OTHER SIGNIFICANT HIP and FEMUR SURGERY,,Relative Weights,"$9,130.83 ",IP,"9,130.83","9,130.83",,,,,,
BCBS Medicaid,DRG,3093,OTHER SIGNIFICANT HIP & FEMUR SURGERY,,Relative Weights,"$12,063.33 ",IP,"12,063.33","12,063.33",,,,,,
BCBS Medicaid,DRG,3094,OTHER SIGNIFICANT HIP & FEMUR SURGERY,,Relative Weights,"$21,019.95 ",IP,"21,019.95","21,019.95",,,,,,
BCBS Medicaid,DRG,3101,INTERVERTEBRAL DISC EXCISION and DECOMPRESSION,,Relative Weights,"$5,634.78 ",IP,"5,634.78","5,634.78",,,,,,
BCBS Medicaid,DRG,3102,INTERVERTEBRAL DISC EXCISION and DECOMPRESSION,,Relative Weights,"$6,775.27 ",IP,"6,775.27","6,775.27",,,,,,
BCBS Medicaid,DRG,3103,INTERVERTEBRAL DISC EXCISION and DECOMPRESSION,,Relative Weights,"$9,328.07 ",IP,"9,328.07","9,328.07",,,,,,
BCBS Medicaid,DRG,3104,INTERVERTEBRAL DISC EXCISION & DECOMPRESSION,,Relative Weights,"$18,301.18 ",IP,"18,301.18","18,301.18",,,,,,
BCBS Medicaid,DRG,3121,SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$6,515.49 ",IP,"6,515.49","6,515.49",,,,,,
BCBS Medicaid,DRG,3122,SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$8,587.21 ",IP,"8,587.21","8,587.21",,,,,,
BCBS Medicaid,DRG,3123,SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$12,636.50 ",IP,"12,636.50","12,636.50",,,,,,
BCBS Medicaid,DRG,3124,SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$31,602.60 ",IP,"31,602.60","31,602.60",,,,,,
BCBS Medicaid,DRG,3131,KNEE & LOWER LEG PROCEDURES EXCEPT FOOT,,Relative Weights,"$5,906.59 ",IP,"5,906.59","5,906.59",,,,,,
BCBS Medicaid,DRG,3132,KNEE and LOWER LEG PROCEDURES EXCEPT FOOT,,Relative Weights,"$7,791.03 ",IP,"7,791.03","7,791.03",,,,,,
BCBS Medicaid,DRG,3133,KNEE and LOWER LEG PROCEDURES EXCEPT FOOT,,Relative Weights,"$10,674.40 ",IP,"10,674.40","10,674.40",,,,,,
BCBS Medicaid,DRG,3134,KNEE and LOWER LEG PROCEDURES EXCEPT FOOT,,Relative Weights,"$18,704.94 ",IP,"18,704.94","18,704.94",,,,,,
BCBS Medicaid,DRG,3141,FOOT & TOE PROCEDURES,,Relative Weights,"$5,184.29 ",IP,"5,184.29","5,184.29",,,,,,
BCBS Medicaid,DRG,3142,FOOT and TOE PROCEDURES,,Relative Weights,"$5,760.89 ",IP,"5,760.89","5,760.89",,,,,,
BCBS Medicaid,DRG,3143,FOOT and TOE PROCEDURES,,Relative Weights,"$7,587.61 ",IP,"7,587.61","7,587.61",,,,,,
BCBS Medicaid,DRG,3144,FOOT and TOE PROCEDURES,,Relative Weights,"$15,541.86 ",IP,"15,541.86","15,541.86",,,,,,
BCBS Medicaid,DRG,3151,SHOULDER UPPER ARM and FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT,,Relative Weights,"$4,407.35 ",IP,"4,407.35","4,407.35",,,,,,
BCBS Medicaid,DRG,3152,SHOULDER UPPER ARM and FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT,,Relative Weights,"$7,204.46 ",IP,"7,204.46","7,204.46",,,,,,
BCBS Medicaid,DRG,3153,SHOULDER UPPER ARM and FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT,,Relative Weights,"$9,814.99 ",IP,"9,814.99","9,814.99",,,,,,
BCBS Medicaid,DRG,3154,SHOULDER UPPER ARM and FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT,,Relative Weights,"$17,630.42 ",IP,"17,630.42","17,630.42",,,,,,
BCBS Medicaid,DRG,3161,HAND and WRIST PROCEDURES,,Relative Weights,"$4,228.66 ",IP,"4,228.66","4,228.66",,,,,,
BCBS Medicaid,DRG,3162,HAND and WRIST PROCEDURES,,Relative Weights,"$5,513.82 ",IP,"5,513.82","5,513.82",,,,,,
BCBS Medicaid,DRG,3163,HAND and WRIST PROCEDURES,,Relative Weights,"$8,327.78 ",IP,"8,327.78","8,327.78",,,,,,
BCBS Medicaid,DRG,3164,HAND and WRIST PROCEDURES,,Relative Weights,"$17,742.44 ",IP,"17,742.44","17,742.44",,,,,,
BCBS Medicaid,DRG,3171,TENDON MUSCLE and OTHER SOFT TISSUE PROCEDURES,,Relative Weights,"$4,914.20 ",IP,"4,914.20","4,914.20",,,,,,
BCBS Medicaid,DRG,3172,TENDON MUSCLE and OTHER SOFT TISSUE PROCEDURES,,Relative Weights,"$6,410.69 ",IP,"6,410.69","6,410.69",,,,,,
BCBS Medicaid,DRG,3173,TENDON MUSCLE and OTHER SOFT TISSUE PROCEDURES,,Relative Weights,"$9,611.56 ",IP,"9,611.56","9,611.56",,,,,,
BCBS Medicaid,DRG,3174,TENDON MUSCLE and OTHER SOFT TISSUE PROCEDURES,,Relative Weights,"$20,290.08 ",IP,"20,290.08","20,290.08",,,,,,
BCBS Medicaid,DRG,3201,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE PROCEDURES,,Relative Weights,"$5,415.55 ",IP,"5,415.55","5,415.55",,,,,,
BCBS Medicaid,DRG,3202,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE PROCEDURES,,Relative Weights,"$6,995.19 ",IP,"6,995.19","6,995.19",,,,,,
BCBS Medicaid,DRG,3203,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE PROCEDURES,,Relative Weights,"$10,390.22 ",IP,"10,390.22","10,390.22",,,,,,
BCBS Medicaid,DRG,3204,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE PROCEDURES,,Relative Weights,"$19,965.01 ",IP,"19,965.01","19,965.01",,,,,,
BCBS Medicaid,DRG,3211,CERVICAL SPINAL FUSION and OTHER BACKNECK PROC EXC DISC EXCISDECOMP,,Relative Weights,"$8,441.17 ",IP,"8,441.17","8,441.17",,,,,,
BCBS Medicaid,DRG,3212,CERVICAL SPINAL FUSION and OTHER BACKNECK PROC EXC DISC EXCISDECOMP,,Relative Weights,"$10,023.57 ",IP,"10,023.57","10,023.57",,,,,,
BCBS Medicaid,DRG,3213,CERVICAL SPINAL FUSION and OTHER BACKNECK PROC EXC DISC EXCISDECOMP,,Relative Weights,"$14,027.50 ",IP,"14,027.50","14,027.50",,,,,,
BCBS Medicaid,DRG,3214,CERVICAL SPINAL FUSION and OTHER BACKNECK PROC EXC DISC EXCISDECOMP,,Relative Weights,"$25,569.90 ",IP,"25,569.90","25,569.90",,,,,,
BCBS Medicaid,DRG,3221,SHOULDER and ELBOW JOINT REPLACEMENT,,Relative Weights,"$8,466.60 ",IP,"8,466.60","8,466.60",,,,,,
BCBS Medicaid,DRG,3222,SHOULDER and ELBOW JOINT REPLACEMENT,,Relative Weights,"$8,949.40 ",IP,"8,949.40","8,949.40",,,,,,
BCBS Medicaid,DRG,3223,SHOULDER and ELBOW JOINT REPLACEMENT,,Relative Weights,"$11,526.59 ",IP,"11,526.59","11,526.59",,,,,,
BCBS Medicaid,DRG,3224,SHOULDER and ELBOW JOINT REPLACEMENT,,Relative Weights,"$17,494.69 ",IP,"17,494.69","17,494.69",,,,,,
BCBS Medicaid,DRG,3401,FRACTURE OF FEMUR,,Relative Weights,"$2,284.43 ",IP,"2,284.43","2,284.43",,,,,,
BCBS Medicaid,DRG,3402,FRACTURE OF FEMUR,,Relative Weights,"$2,649.70 ",IP,"2,649.70","2,649.70",,,,,,
BCBS Medicaid,DRG,3403,FRACTURE OF FEMUR,,Relative Weights,"$3,664.08 ",IP,"3,664.08","3,664.08",,,,,,
BCBS Medicaid,DRG,3404,FRACTURE OF FEMUR,,Relative Weights,"$6,893.48 ",IP,"6,893.48","6,893.48",,,,,,
BCBS Medicaid,DRG,3411,FRACTURE OF PELVIS OR DISLOCATION OF HIP,,Relative Weights,"$2,584.41 ",IP,"2,584.41","2,584.41",,,,,,
BCBS Medicaid,DRG,3412,FRACTURE OF PELVIS OR DISLOCATION OF HIP,,Relative Weights,"$2,958.62 ",IP,"2,958.62","2,958.62",,,,,,
BCBS Medicaid,DRG,3413,FRACTURE OF PELVIS OR DISLOCATION OF HIP,,Relative Weights,"$3,751.71 ",IP,"3,751.71","3,751.71",,,,,,
BCBS Medicaid,DRG,3414,FRACTURE OF PELVIS OR DISLOCATION OF HIP,,Relative Weights,"$8,259.05 ",IP,"8,259.05","8,259.05",,,,,,
BCBS Medicaid,DRG,3421,FRACTURES and DISLOCATIONS EXCEPT FEMUR PELVIS and BACK,,Relative Weights,"$2,677.53 ",IP,"2,677.53","2,677.53",,,,,,
BCBS Medicaid,DRG,3422,"FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK",,Relative Weights,"$3,262.04 ",IP,"3,262.04","3,262.04",,,,,,
BCBS Medicaid,DRG,3423,"FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK",,Relative Weights,"$4,236.57 ",IP,"4,236.57","4,236.57",,,,,,
BCBS Medicaid,DRG,3424,FRACTURES and DISLOCATIONS EXCEPT FEMUR PELVIS and BACK,,Relative Weights,"$8,410.59 ",IP,"8,410.59","8,410.59",,,,,,
BCBS Medicaid,DRG,3431,MUSCULOSKELETAL MALIGNANCY and PATHOL FRACTURE DT MUSCSKEL MALIG,,Relative Weights,"$4,528.30 ",IP,"4,528.30","4,528.30",,,,,,
BCBS Medicaid,DRG,3432,MUSCULOSKELETAL MALIGNANCY and PATHOL FRACTURE DT MUSCSKEL MALIG,,Relative Weights,"$4,916.60 ",IP,"4,916.60","4,916.60",,,,,,
BCBS Medicaid,DRG,3433,MUSCULOSKELETAL MALIGNANCY & PATHOL FRACTURE D/T MUSCSKEL MALIG,,Relative Weights,"$6,907.57 ",IP,"6,907.57","6,907.57",,,,,,
BCBS Medicaid,DRG,3434,MUSCULOSKELETAL MALIGNANCY and PATHOL FRACTURE DT MUSCSKEL MALIG,,Relative Weights,"$11,710.09 ",IP,"11,710.09","11,710.09",,,,,,
BCBS Medicaid,DRG,3441,OSTEOMYELITIS SEPTIC ARTHRITIS and OTHER MUSCULOSKELETAL INFECTIONS,,Relative Weights,"$3,603.61 ",IP,"3,603.61","3,603.61",,,,,,
BCBS Medicaid,DRG,3442,OSTEOMYELITIS SEPTIC ARTHRITIS and OTHER MUSCULOSKELETAL INFECTIONS,,Relative Weights,"$4,272.99 ",IP,"4,272.99","4,272.99",,,,,,
BCBS Medicaid,DRG,3443,OSTEOMYELITIS SEPTIC ARTHRITIS and OTHER MUSCULOSKELETAL INFECTIONS,,Relative Weights,"$5,859.85 ",IP,"5,859.85","5,859.85",,,,,,
BCBS Medicaid,DRG,3444,OSTEOMYELITIS SEPTIC ARTHRITIS and OTHER MUSCULOSKELETAL INFECTIONS,,Relative Weights,"$10,885.73 ",IP,"10,885.73","10,885.73",,,,,,
BCBS Medicaid,DRG,3461,CONNECTIVE TISSUE DISORDERS,,Relative Weights,"$3,601.54 ",IP,"3,601.54","3,601.54",,,,,,
BCBS Medicaid,DRG,3462,CONNECTIVE TISSUE DISORDERS,,Relative Weights,"$4,539.99 ",IP,"4,539.99","4,539.99",,,,,,
BCBS Medicaid,DRG,3463,CONNECTIVE TISSUE DISORDERS,,Relative Weights,"$6,445.74 ",IP,"6,445.74","6,445.74",,,,,,
BCBS Medicaid,DRG,3464,CONNECTIVE TISSUE DISORDERS,,Relative Weights,"$15,116.11 ",IP,"15,116.11","15,116.11",,,,,,
BCBS Medicaid,DRG,3471,OTHER BACK and NECK DISORDERS FRACTURES and INJURIES,,Relative Weights,"$3,279.91 ",IP,"3,279.91","3,279.91",,,,,,
BCBS Medicaid,DRG,3472,"OTHER BACK & NECK DISORDERS, FRACTURES & INJURIES",,Relative Weights,"$3,772.33 ",IP,"3,772.33","3,772.33",,,,,,
BCBS Medicaid,DRG,3473,OTHER BACK and NECK DISORDERS FRACTURES and INJURIES,,Relative Weights,"$4,894.95 ",IP,"4,894.95","4,894.95",,,,,,
BCBS Medicaid,DRG,3474,OTHER BACK and NECK DISORDERS FRACTURES and INJURIES,,Relative Weights,"$9,864.13 ",IP,"9,864.13","9,864.13",,,,,,
BCBS Medicaid,DRG,3491,MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE,,Relative Weights,"$2,603.31 ",IP,"2,603.31","2,603.31",,,,,,
BCBS Medicaid,DRG,3492,MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE,,Relative Weights,"$3,535.91 ",IP,"3,535.91","3,535.91",,,,,,
BCBS Medicaid,DRG,3493,MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE,,Relative Weights,"$5,006.97 ",IP,"5,006.97","5,006.97",,,,,,
BCBS Medicaid,DRG,3494,MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE,,Relative Weights,"$9,666.89 ",IP,"9,666.89","9,666.89",,,,,,
BCBS Medicaid,DRG,3511,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$2,708.80 ",IP,"2,708.80","2,708.80",,,,,,
BCBS Medicaid,DRG,3512,OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$3,066.17 ",IP,"3,066.17","3,066.17",,,,,,
BCBS Medicaid,DRG,3513,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$4,449.61 ",IP,"4,449.61","4,449.61",,,,,,
BCBS Medicaid,DRG,3514,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$8,785.14 ",IP,"8,785.14","8,785.14",,,,,,
BCBS Medicaid,DRG,3611,SKIN GRAFT FOR SKIN and SUBCUTANEOUS TISSUE DIAGNOSES,,Relative Weights,"$5,861.92 ",IP,"5,861.92","5,861.92",,,,,,
BCBS Medicaid,DRG,3612,SKIN GRAFT FOR SKIN and SUBCUTANEOUS TISSUE DIAGNOSES,,Relative Weights,"$6,759.47 ",IP,"6,759.47","6,759.47",,,,,,
BCBS Medicaid,DRG,3613,SKIN GRAFT FOR SKIN and SUBCUTANEOUS TISSUE DIAGNOSES,,Relative Weights,"$10,411.18 ",IP,"10,411.18","10,411.18",,,,,,
BCBS Medicaid,DRG,3614,SKIN GRAFT FOR SKIN & SUBCUTANEOUS TISSUE DIAGNOSES,,Relative Weights,"$23,051.12 ",IP,"23,051.12","23,051.12",,,,,,
BCBS Medicaid,DRG,3621,MASTECTOMY PROCEDURES,,Relative Weights,"$5,733.06 ",IP,"5,733.06","5,733.06",,,,,,
BCBS Medicaid,DRG,3622,MASTECTOMY PROCEDURES,,Relative Weights,"$6,783.86 ",IP,"6,783.86","6,783.86",,,,,,
BCBS Medicaid,DRG,3623,MASTECTOMY PROCEDURES,,Relative Weights,"$8,730.85 ",IP,"8,730.85","8,730.85",,,,,,
BCBS Medicaid,DRG,3624,MASTECTOMY PROCEDURES,,Relative Weights,"$15,662.13 ",IP,"15,662.13","15,662.13",,,,,,
BCBS Medicaid,DRG,3631,BREAST PROCEDURES EXCEPT MASTECTOMY,,Relative Weights,"$5,772.23 ",IP,"5,772.23","5,772.23",,,,,,
BCBS Medicaid,DRG,3632,BREAST PROCEDURES EXCEPT MASTECTOMY,,Relative Weights,"$7,919.20 ",IP,"7,919.20","7,919.20",,,,,,
BCBS Medicaid,DRG,3633,BREAST PROCEDURES EXCEPT MASTECTOMY,,Relative Weights,"$10,641.07 ",IP,"10,641.07","10,641.07",,,,,,
BCBS Medicaid,DRG,3634,BREAST PROCEDURES EXCEPT MASTECTOMY,,Relative Weights,"$13,007.96 ",IP,"13,007.96","13,007.96",,,,,,
BCBS Medicaid,DRG,3641,OTHER SKIN SUBCUTANEOUS TISSUE and RELATED PROCEDURES,,Relative Weights,"$3,659.27 ",IP,"3,659.27","3,659.27",,,,,,
BCBS Medicaid,DRG,3642,"OTHER SKIN, SUBCUTANEOUS TISSUE & RELATED PROCEDURES",,Relative Weights,"$5,232.39 ",IP,"5,232.39","5,232.39",,,,,,
BCBS Medicaid,DRG,3643,OTHER SKIN SUBCUTANEOUS TISSUE and RELATED PROCEDURES,,Relative Weights,"$8,152.18 ",IP,"8,152.18","8,152.18",,,,,,
BCBS Medicaid,DRG,3644,OTHER SKIN SUBCUTANEOUS TISSUE and RELATED PROCEDURES,,Relative Weights,"$16,685.79 ",IP,"16,685.79","16,685.79",,,,,,
BCBS Medicaid,DRG,3801,SKIN ULCERS,,Relative Weights,"$2,950.72 ",IP,"2,950.72","2,950.72",,,,,,
BCBS Medicaid,DRG,3802,SKIN ULCERS,,Relative Weights,"$3,415.64 ",IP,"3,415.64","3,415.64",,,,,,
BCBS Medicaid,DRG,3803,SKIN ULCERS,,Relative Weights,"$4,667.13 ",IP,"4,667.13","4,667.13",,,,,,
BCBS Medicaid,DRG,3804,SKIN ULCERS,,Relative Weights,"$9,197.15 ",IP,"9,197.15","9,197.15",,,,,,
BCBS Medicaid,DRG,3811,MAJOR SKIN DISORDERS,,Relative Weights,"$2,135.64 ",IP,"2,135.64","2,135.64",,,,,,
BCBS Medicaid,DRG,3812,MAJOR SKIN DISORDERS,,Relative Weights,"$3,426.98 ",IP,"3,426.98","3,426.98",,,,,,
BCBS Medicaid,DRG,3813,MAJOR SKIN DISORDERS,,Relative Weights,"$6,058.47 ",IP,"6,058.47","6,058.47",,,,,,
BCBS Medicaid,DRG,3814,MAJOR SKIN DISORDERS,,Relative Weights,"$15,997.51 ",IP,"15,997.51","15,997.51",,,,,,
BCBS Medicaid,DRG,3821,MALIGNANT BREAST DISORDERS,,Relative Weights,"$3,708.41 ",IP,"3,708.41","3,708.41",,,,,,
BCBS Medicaid,DRG,3822,MALIGNANT BREAST DISORDERS,,Relative Weights,"$3,837.96 ",IP,"3,837.96","3,837.96",,,,,,
BCBS Medicaid,DRG,3823,MALIGNANT BREAST DISORDERS,,Relative Weights,"$5,221.05 ",IP,"5,221.05","5,221.05",,,,,,
BCBS Medicaid,DRG,3824,MALIGNANT BREAST DISORDERS,,Relative Weights,"$8,582.75 ",IP,"8,582.75","8,582.75",,,,,,
BCBS Medicaid,DRG,3831,CELLULITIS & OTHER SKIN INFECTIONS,,Relative Weights,"$2,128.08 ",IP,"2,128.08","2,128.08",,,,,,
BCBS Medicaid,DRG,3832,CELLULITIS and OTHER SKIN INFECTIONS,,Relative Weights,"$2,886.11 ",IP,"2,886.11","2,886.11",,,,,,
BCBS Medicaid,DRG,3833,CELLULITIS and OTHER SKIN INFECTIONS,,Relative Weights,"$4,151.00 ",IP,"4,151.00","4,151.00",,,,,,
BCBS Medicaid,DRG,3834,CELLULITIS and OTHER SKIN INFECTIONS,,Relative Weights,"$8,552.16 ",IP,"8,552.16","8,552.16",,,,,,
BCBS Medicaid,DRG,3841,CONTUSION OPEN WOUND and OTHER TRAUMA TO SKIN and SUBCUTANEOUS TISSUE,,Relative Weights,"$2,690.94 ",IP,"2,690.94","2,690.94",,,,,,
BCBS Medicaid,DRG,3842,CONTUSION OPEN WOUND and OTHER TRAUMA TO SKIN and SUBCUTANEOUS TISSUE,,Relative Weights,"$3,464.09 ",IP,"3,464.09","3,464.09",,,,,,
BCBS Medicaid,DRG,3843,CONTUSION OPEN WOUND and OTHER TRAUMA TO SKIN and SUBCUTANEOUS TISSUE,,Relative Weights,"$4,737.92 ",IP,"4,737.92","4,737.92",,,,,,
BCBS Medicaid,DRG,3844,CONTUSION OPEN WOUND and OTHER TRAUMA TO SKIN and SUBCUTANEOUS TISSUE,,Relative Weights,"$9,439.41 ",IP,"9,439.41","9,439.41",,,,,,
BCBS Medicaid,DRG,3851,OTHER SKIN SUBCUTANEOUS TISSUE and BREAST DISORDERS,,Relative Weights,"$2,189.24 ",IP,"2,189.24","2,189.24",,,,,,
BCBS Medicaid,DRG,3852,OTHER SKIN SUBCUTANEOUS TISSUE and BREAST DISORDERS,,Relative Weights,"$2,880.96 ",IP,"2,880.96","2,880.96",,,,,,
BCBS Medicaid,DRG,3853,"OTHER SKIN, SUBCUTANEOUS TISSUE & BREAST DISORDERS",,Relative Weights,"$4,186.05 ",IP,"4,186.05","4,186.05",,,,,,
BCBS Medicaid,DRG,3854,OTHER SKIN SUBCUTANEOUS TISSUE and BREAST DISORDERS,,Relative Weights,"$8,871.05 ",IP,"8,871.05","8,871.05",,,,,,
BCBS Medicaid,DRG,4011,ADRENAL PROCEDURES,,Relative Weights,"$6,855.68 ",IP,"6,855.68","6,855.68",,,,,,
BCBS Medicaid,DRG,4012,ADRENAL PROCEDURES,,Relative Weights,"$10,778.52 ",IP,"10,778.52","10,778.52",,,,,,
BCBS Medicaid,DRG,4013,ADRENAL PROCEDURES,,Relative Weights,"$13,300.04 ",IP,"13,300.04","13,300.04",,,,,,
BCBS Medicaid,DRG,4014,ADRENAL PROCEDURES,,Relative Weights,"$24,027.70 ",IP,"24,027.70","24,027.70",,,,,,
BCBS Medicaid,DRG,4031,PROCEDURES FOR OBESITY,,Relative Weights,"$5,110.06 ",IP,"5,110.06","5,110.06",,,,,,
BCBS Medicaid,DRG,4032,PROCEDURES FOR OBESITY,,Relative Weights,"$6,108.30 ",IP,"6,108.30","6,108.30",,,,,,
BCBS Medicaid,DRG,4033,PROCEDURES FOR OBESITY,,Relative Weights,"$9,074.13 ",IP,"9,074.13","9,074.13",,,,,,
BCBS Medicaid,DRG,4034,PROCEDURES FOR OBESITY,,Relative Weights,"$26,392.19 ",IP,"26,392.19","26,392.19",,,,,,
BCBS Medicaid,DRG,4041,"THYROID, PARATHYROID & THYROGLOSSAL PROCEDURES",,Relative Weights,"$4,728.64 ",IP,"4,728.64","4,728.64",,,,,,
BCBS Medicaid,DRG,4042,THYROID PARATHYROID and THYROGLOSSAL PROCEDURES,,Relative Weights,"$6,537.48 ",IP,"6,537.48","6,537.48",,,,,,
BCBS Medicaid,DRG,4043,THYROID PARATHYROID and THYROGLOSSAL PROCEDURES,,Relative Weights,"$10,989.85 ",IP,"10,989.85","10,989.85",,,,,,
BCBS Medicaid,DRG,4044,THYROID PARATHYROID and THYROGLOSSAL PROCEDURES,,Relative Weights,"$24,206.39 ",IP,"24,206.39","24,206.39",,,,,,
BCBS Medicaid,DRG,4051,OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL and METABOLIC DISORDERS,,Relative Weights,"$7,505.82 ",IP,"7,505.82","7,505.82",,,,,,
BCBS Medicaid,DRG,4052,OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL and METABOLIC DISORDERS,,Relative Weights,"$8,475.19 ",IP,"8,475.19","8,475.19",,,,,,
BCBS Medicaid,DRG,4053,OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL and METABOLIC DISORDERS,,Relative Weights,"$12,612.79 ",IP,"12,612.79","12,612.79",,,,,,
BCBS Medicaid,DRG,4054,OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL and METABOLIC DISORDERS,,Relative Weights,"$26,164.03 ",IP,"26,164.03","26,164.03",,,,,,
BCBS Medicaid,DRG,4201,DIABETES,,Relative Weights,"$2,259.68 ",IP,"2,259.68","2,259.68",,,,,,
BCBS Medicaid,DRG,4202,DIABETES,,Relative Weights,"$2,723.24 ",IP,"2,723.24","2,723.24",,,,,,
BCBS Medicaid,DRG,4203,DIABETES,,Relative Weights,"$3,776.79 ",IP,"3,776.79","3,776.79",,,,,,
BCBS Medicaid,DRG,4204,DIABETES,,Relative Weights,"$8,028.82 ",IP,"8,028.82","8,028.82",,,,,,
BCBS Medicaid,DRG,4211,MALNUTRITION FAILURE TO THRIVE and OTHER NUTRITIONAL DISORDERS,,Relative Weights,"$2,343.53 ",IP,"2,343.53","2,343.53",,,,,,
BCBS Medicaid,DRG,4212,MALNUTRITION FAILURE TO THRIVE and OTHER NUTRITIONAL DISORDERS,,Relative Weights,"$3,329.74 ",IP,"3,329.74","3,329.74",,,,,,
BCBS Medicaid,DRG,4213,"MALNUTRITION, FAILURE TO THRIVE & OTHER NUTRITIONAL DISORDERS",,Relative Weights,"$5,181.88 ",IP,"5,181.88","5,181.88",,,,,,
BCBS Medicaid,DRG,4214,MALNUTRITION FAILURE TO THRIVE and OTHER NUTRITIONAL DISORDERS,,Relative Weights,"$10,295.72 ",IP,"10,295.72","10,295.72",,,,,,
BCBS Medicaid,DRG,4221,HYPOVOLEMIA and RELATED ELECTROLYTE DISORDERS,,Relative Weights,"$1,870.01 ",IP,"1,870.01","1,870.01",,,,,,
BCBS Medicaid,DRG,4222,HYPOVOLEMIA and RELATED ELECTROLYTE DISORDERS,,Relative Weights,"$2,609.84 ",IP,"2,609.84","2,609.84",,,,,,
BCBS Medicaid,DRG,4223,HYPOVOLEMIA and RELATED ELECTROLYTE DISORDERS,,Relative Weights,"$3,459.28 ",IP,"3,459.28","3,459.28",,,,,,
BCBS Medicaid,DRG,4224,HYPOVOLEMIA and RELATED ELECTROLYTE DISORDERS,,Relative Weights,"$7,038.84 ",IP,"7,038.84","7,038.84",,,,,,
BCBS Medicaid,DRG,4231,INBORN ERRORS OF METABOLISM,,Relative Weights,"$5,529.29 ",IP,"5,529.29","5,529.29",,,,,,
BCBS Medicaid,DRG,4232,INBORN ERRORS OF METABOLISM,,Relative Weights,"$5,948.85 ",IP,"5,948.85","5,948.85",,,,,,
BCBS Medicaid,DRG,4233,INBORN ERRORS OF METABOLISM,,Relative Weights,"$8,447.01 ",IP,"8,447.01","8,447.01",,,,,,
BCBS Medicaid,DRG,4234,INBORN ERRORS OF METABOLISM,,Relative Weights,"$27,194.91 ",IP,"27,194.91","27,194.91",,,,,,
BCBS Medicaid,DRG,4241,OTHER ENDOCRINE DISORDERS,,Relative Weights,"$2,869.62 ",IP,"2,869.62","2,869.62",,,,,,
BCBS Medicaid,DRG,4242,OTHER ENDOCRINE DISORDERS,,Relative Weights,"$3,662.02 ",IP,"3,662.02","3,662.02",,,,,,
BCBS Medicaid,DRG,4243,OTHER ENDOCRINE DISORDERS,,Relative Weights,"$5,028.28 ",IP,"5,028.28","5,028.28",,,,,,
BCBS Medicaid,DRG,4244,OTHER ENDOCRINE DISORDERS,,Relative Weights,"$10,807.73 ",IP,"10,807.73","10,807.73",,,,,,
BCBS Medicaid,DRG,4251,OTHER NONHYPOVOLEMIC ELECTROLYTE DISORDERS,,Relative Weights,"$2,221.89 ",IP,"2,221.89","2,221.89",,,,,,
BCBS Medicaid,DRG,4252,OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS,,Relative Weights,"$2,908.79 ",IP,"2,908.79","2,908.79",,,,,,
BCBS Medicaid,DRG,4253,OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS,,Relative Weights,"$3,943.11 ",IP,"3,943.11","3,943.11",,,,,,
BCBS Medicaid,DRG,4254,OTHER NONHYPOVOLEMIC ELECTROLYTE DISORDERS,,Relative Weights,"$7,662.17 ",IP,"7,662.17","7,662.17",,,,,,
BCBS Medicaid,DRG,4261,NONHYPOVOLEMIC SODIUM DISORDERS,,Relative Weights,"$2,409.16 ",IP,"2,409.16","2,409.16",,,,,,
BCBS Medicaid,DRG,4262,NONHYPOVOLEMIC SODIUM DISORDERS,,Relative Weights,"$2,941.78 ",IP,"2,941.78","2,941.78",,,,,,
BCBS Medicaid,DRG,4263,NON-HYPOVOLEMIC SODIUM DISORDERS,,Relative Weights,"$4,191.21 ",IP,"4,191.21","4,191.21",,,,,,
BCBS Medicaid,DRG,4264,NONHYPOVOLEMIC SODIUM DISORDERS,,Relative Weights,"$8,224.69 ",IP,"8,224.69","8,224.69",,,,,,
BCBS Medicaid,DRG,4271,THYROID DISORDERS,,Relative Weights,"$2,411.91 ",IP,"2,411.91","2,411.91",,,,,,
BCBS Medicaid,DRG,4272,THYROID DISORDERS,,Relative Weights,"$3,208.44 ",IP,"3,208.44","3,208.44",,,,,,
BCBS Medicaid,DRG,4273,THYROID DISORDERS,,Relative Weights,"$4,621.77 ",IP,"4,621.77","4,621.77",,,,,,
BCBS Medicaid,DRG,4274,THYROID DISORDERS,,Relative Weights,"$9,834.92 ",IP,"9,834.92","9,834.92",,,,,,
BCBS Medicaid,DRG,4401,KIDNEY TRANSPLANT,,Relative Weights,"$26,376.39 ",IP,"26,376.39","26,376.39",,,,,,
BCBS Medicaid,DRG,4402,KIDNEY TRANSPLANT,,Relative Weights,"$28,441.58 ",IP,"28,441.58","28,441.58",,,,,,
BCBS Medicaid,DRG,4403,KIDNEY TRANSPLANT,,Relative Weights,"$31,863.75 ",IP,"31,863.75","31,863.75",,,,,,
BCBS Medicaid,DRG,4404,KIDNEY TRANSPLANT,,Relative Weights,"$48,433.40 ",IP,"48,433.40","48,433.40",,,,,,
BCBS Medicaid,DRG,4411,MAJOR BLADDER PROCEDURES,,Relative Weights,"$7,124.74 ",IP,"7,124.74","7,124.74",,,,,,
BCBS Medicaid,DRG,4412,MAJOR BLADDER PROCEDURES,,Relative Weights,"$11,337.94 ",IP,"11,337.94","11,337.94",,,,,,
BCBS Medicaid,DRG,4413,MAJOR BLADDER PROCEDURES,,Relative Weights,"$14,853.23 ",IP,"14,853.23","14,853.23",,,,,,
BCBS Medicaid,DRG,4414,MAJOR BLADDER PROCEDURES,,Relative Weights,"$32,299.47 ",IP,"32,299.47","32,299.47",,,,,,
BCBS Medicaid,DRG,4421,KIDNEY and URINARY TRACT PROCEDURES FOR MALIGNANCY,,Relative Weights,"$7,007.22 ",IP,"7,007.22","7,007.22",,,,,,
BCBS Medicaid,DRG,4422,KIDNEY and URINARY TRACT PROCEDURES FOR MALIGNANCY,,Relative Weights,"$7,784.16 ",IP,"7,784.16","7,784.16",,,,,,
BCBS Medicaid,DRG,4423,KIDNEY & URINARY TRACT PROCEDURES FOR MALIGNANCY,,Relative Weights,"$11,551.33 ",IP,"11,551.33","11,551.33",,,,,,
BCBS Medicaid,DRG,4424,KIDNEY and URINARY TRACT PROCEDURES FOR MALIGNANCY,,Relative Weights,"$20,973.56 ",IP,"20,973.56","20,973.56",,,,,,
BCBS Medicaid,DRG,4431,KIDNEY and URINARY TRACT PROCEDURES FOR NONMALIGNANCY,,Relative Weights,"$5,745.77 ",IP,"5,745.77","5,745.77",,,,,,
BCBS Medicaid,DRG,4432,KIDNEY and URINARY TRACT PROCEDURES FOR NONMALIGNANCY,,Relative Weights,"$6,928.19 ",IP,"6,928.19","6,928.19",,,,,,
BCBS Medicaid,DRG,4433,KIDNEY & URINARY TRACT PROCEDURES FOR NONMALIGNANCY,,Relative Weights,"$10,300.53 ",IP,"10,300.53","10,300.53",,,,,,
BCBS Medicaid,DRG,4434,KIDNEY & URINARY TRACT PROCEDURES FOR NONMALIGNANCY,,Relative Weights,"$21,259.80 ",IP,"21,259.80","21,259.80",,,,,,
BCBS Medicaid,DRG,4441,RENAL DIALYSIS ACCESS DEVICE AND VESSEL REPAIR,,Relative Weights,"$6,643.67 ",IP,"6,643.67","6,643.67",,,,,,
BCBS Medicaid,DRG,4442,RENAL DIALYSIS ACCESS DEVICE AND VESSEL REPAIR,,Relative Weights,"$8,351.49 ",IP,"8,351.49","8,351.49",,,,,,
BCBS Medicaid,DRG,4443,RENAL DIALYSIS ACCESS DEVICE AND VESSEL REPAIR,,Relative Weights,"$12,840.62 ",IP,"12,840.62","12,840.62",,,,,,
BCBS Medicaid,DRG,4444,RENAL DIALYSIS ACCESS DEVICE AND VESSEL REPAIR,,Relative Weights,"$25,251.70 ",IP,"25,251.70","25,251.70",,,,,,
BCBS Medicaid,DRG,4451,OTHER BLADDER PROCEDURES,,Relative Weights,"$4,867.46 ",IP,"4,867.46","4,867.46",,,,,,
BCBS Medicaid,DRG,4452,OTHER BLADDER PROCEDURES,,Relative Weights,"$6,607.93 ",IP,"6,607.93","6,607.93",,,,,,
BCBS Medicaid,DRG,4453,OTHER BLADDER PROCEDURES,,Relative Weights,"$8,634.63 ",IP,"8,634.63","8,634.63",,,,,,
BCBS Medicaid,DRG,4454,OTHER BLADDER PROCEDURES,,Relative Weights,"$17,913.22 ",IP,"17,913.22","17,913.22",,,,,,
BCBS Medicaid,DRG,4461,URETHRAL & TRANSURETHRAL PROCEDURES,,Relative Weights,"$4,096.37 ",IP,"4,096.37","4,096.37",,,,,,
BCBS Medicaid,DRG,4462,URETHRAL & TRANSURETHRAL PROCEDURES,,Relative Weights,"$5,093.91 ",IP,"5,093.91","5,093.91",,,,,,
BCBS Medicaid,DRG,4463,URETHRAL and TRANSURETHRAL PROCEDURES,,Relative Weights,"$7,454.97 ",IP,"7,454.97","7,454.97",,,,,,
BCBS Medicaid,DRG,4464,URETHRAL and TRANSURETHRAL PROCEDURES,,Relative Weights,"$15,279.67 ",IP,"15,279.67","15,279.67",,,,,,
BCBS Medicaid,DRG,4471,OTHER KIDNEY URINARY TRACT and RELATED PROCEDURES,,Relative Weights,"$6,383.54 ",IP,"6,383.54","6,383.54",,,,,,
BCBS Medicaid,DRG,4472,"OTHER KIDNEY, URINARY TRACT & RELATED PROCEDURES",,Relative Weights,"$7,988.27 ",IP,"7,988.27","7,988.27",,,,,,
BCBS Medicaid,DRG,4473,OTHER KIDNEY URINARY TRACT and RELATED PROCEDURES,,Relative Weights,"$11,578.48 ",IP,"11,578.48","11,578.48",,,,,,
BCBS Medicaid,DRG,4474,OTHER KIDNEY URINARY TRACT and RELATED PROCEDURES,,Relative Weights,"$26,335.15 ",IP,"26,335.15","26,335.15",,,,,,
BCBS Medicaid,DRG,4611,KIDNEY and URINARY TRACT MALIGNANCY,,Relative Weights,"$4,213.89 ",IP,"4,213.89","4,213.89",,,,,,
BCBS Medicaid,DRG,4612,KIDNEY and URINARY TRACT MALIGNANCY,,Relative Weights,"$4,354.09 ",IP,"4,354.09","4,354.09",,,,,,
BCBS Medicaid,DRG,4613,KIDNEY and URINARY TRACT MALIGNANCY,,Relative Weights,"$5,833.40 ",IP,"5,833.40","5,833.40",,,,,,
BCBS Medicaid,DRG,4614,KIDNEY & URINARY TRACT MALIGNANCY,,Relative Weights,"$10,495.71 ",IP,"10,495.71","10,495.71",,,,,,
BCBS Medicaid,DRG,4621,NEPHRITIS and NEPHROSIS,,Relative Weights,"$2,361.40 ",IP,"2,361.40","2,361.40",,,,,,
BCBS Medicaid,DRG,4622,NEPHRITIS and NEPHROSIS,,Relative Weights,"$3,007.07 ",IP,"3,007.07","3,007.07",,,,,,
BCBS Medicaid,DRG,4623,NEPHRITIS and NEPHROSIS,,Relative Weights,"$5,343.04 ",IP,"5,343.04","5,343.04",,,,,,
BCBS Medicaid,DRG,4624,NEPHRITIS and NEPHROSIS,,Relative Weights,"$14,645.34 ",IP,"14,645.34","14,645.34",,,,,,
BCBS Medicaid,DRG,4631,KIDNEY and URINARY TRACT INFECTIONS,,Relative Weights,"$2,386.48 ",IP,"2,386.48","2,386.48",,,,,,
BCBS Medicaid,DRG,4632,KIDNEY and URINARY TRACT INFECTIONS,,Relative Weights,"$2,925.29 ",IP,"2,925.29","2,925.29",,,,,,
BCBS Medicaid,DRG,4633,KIDNEY and URINARY TRACT INFECTIONS,,Relative Weights,"$3,755.49 ",IP,"3,755.49","3,755.49",,,,,,
BCBS Medicaid,DRG,4634,KIDNEY and URINARY TRACT INFECTIONS,,Relative Weights,"$6,746.75 ",IP,"6,746.75","6,746.75",,,,,,
BCBS Medicaid,DRG,4651,URINARY STONES & ACQUIRED UPPER URINARY TRACT OBSTRUCTION,,Relative Weights,"$2,676.16 ",IP,"2,676.16","2,676.16",,,,,,
BCBS Medicaid,DRG,4652,URINARY STONES and ACQUIRED UPPER URINARY TRACT OBSTRUCTION,,Relative Weights,"$3,212.22 ",IP,"3,212.22","3,212.22",,,,,,
BCBS Medicaid,DRG,4653,URINARY STONES and ACQUIRED UPPER URINARY TRACT OBSTRUCTION,,Relative Weights,"$4,385.36 ",IP,"4,385.36","4,385.36",,,,,,
BCBS Medicaid,DRG,4654,URINARY STONES and ACQUIRED UPPER URINARY TRACT OBSTRUCTION,,Relative Weights,"$8,949.40 ",IP,"8,949.40","8,949.40",,,,,,
BCBS Medicaid,DRG,4661,"MALFUNCTION, REACTION, COMPLIC OF GENITOURINARY DEVICE OR PROC",,Relative Weights,"$2,602.62 ",IP,"2,602.62","2,602.62",,,,,,
BCBS Medicaid,DRG,4662,"MALFUNCTION, REACTION, COMPLIC OF GENITOURINARY DEVICE OR PROC",,Relative Weights,"$3,336.61 ",IP,"3,336.61","3,336.61",,,,,,
BCBS Medicaid,DRG,4663,MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC,,Relative Weights,"$4,821.07 ",IP,"4,821.07","4,821.07",,,,,,
BCBS Medicaid,DRG,4664,MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC,,Relative Weights,"$8,281.73 ",IP,"8,281.73","8,281.73",,,,,,
BCBS Medicaid,DRG,4681,OTHER KIDNEY and URINARY TRACT DIAGNOSES SIGNS and SYMPTOMS,,Relative Weights,"$2,645.58 ",IP,"2,645.58","2,645.58",,,,,,
BCBS Medicaid,DRG,4682,OTHER KIDNEY and URINARY TRACT DIAGNOSES SIGNS and SYMPTOMS,,Relative Weights,"$3,341.08 ",IP,"3,341.08","3,341.08",,,,,,
BCBS Medicaid,DRG,4683,"OTHER KIDNEY & URINARY TRACT DIAGNOSES, SIGNS & SYMPTOMS",,Relative Weights,"$4,559.92 ",IP,"4,559.92","4,559.92",,,,,,
BCBS Medicaid,DRG,4684,OTHER KIDNEY and URINARY TRACT DIAGNOSES SIGNS and SYMPTOMS,,Relative Weights,"$9,588.20 ",IP,"9,588.20","9,588.20",,,,,,
BCBS Medicaid,DRG,4691,ACUTE KIDNEY INJURY,,Relative Weights,"$2,379.95 ",IP,"2,379.95","2,379.95",,,,,,
BCBS Medicaid,DRG,4692,ACUTE KIDNEY INJURY,,Relative Weights,"$3,050.71 ",IP,"3,050.71","3,050.71",,,,,,
BCBS Medicaid,DRG,4693,ACUTE KIDNEY INJURY,,Relative Weights,"$4,563.35 ",IP,"4,563.35","4,563.35",,,,,,
BCBS Medicaid,DRG,4694,ACUTE KIDNEY INJURY,,Relative Weights,"$9,568.95 ",IP,"9,568.95","9,568.95",,,,,,
BCBS Medicaid,DRG,4701,CHRONIC KIDNEY DISEASE,,Relative Weights,"$2,503.66 ",IP,"2,503.66","2,503.66",,,,,,
BCBS Medicaid,DRG,4702,CHRONIC KIDNEY DISEASE,,Relative Weights,"$3,283.35 ",IP,"3,283.35","3,283.35",,,,,,
BCBS Medicaid,DRG,4703,CHRONIC KIDNEY DISEASE,,Relative Weights,"$4,530.02 ",IP,"4,530.02","4,530.02",,,,,,
BCBS Medicaid,DRG,4704,CHRONIC KIDNEY DISEASE,,Relative Weights,"$8,193.42 ",IP,"8,193.42","8,193.42",,,,,,
BCBS Medicaid,DRG,4801,MAJOR MALE PELVIC PROCEDURES,,Relative Weights,"$6,131.66 ",IP,"6,131.66","6,131.66",,,,,,
BCBS Medicaid,DRG,4802,MAJOR MALE PELVIC PROCEDURES,,Relative Weights,"$6,485.60 ",IP,"6,485.60","6,485.60",,,,,,
BCBS Medicaid,DRG,4803,MAJOR MALE PELVIC PROCEDURES,,Relative Weights,"$10,188.85 ",IP,"10,188.85","10,188.85",,,,,,
BCBS Medicaid,DRG,4804,MAJOR MALE PELVIC PROCEDURES,,Relative Weights,"$21,900.66 ",IP,"21,900.66","21,900.66",,,,,,
BCBS Medicaid,DRG,4821,TRANSURETHRAL PROSTATECTOMY,,Relative Weights,"$4,027.30 ",IP,"4,027.30","4,027.30",,,,,,
BCBS Medicaid,DRG,4822,TRANSURETHRAL PROSTATECTOMY,,Relative Weights,"$4,459.58 ",IP,"4,459.58","4,459.58",,,,,,
BCBS Medicaid,DRG,4823,TRANSURETHRAL PROSTATECTOMY,,Relative Weights,"$7,759.08 ",IP,"7,759.08","7,759.08",,,,,,
BCBS Medicaid,DRG,4824,TRANSURETHRAL PROSTATECTOMY,,Relative Weights,"$15,069.03 ",IP,"15,069.03","15,069.03",,,,,,
BCBS Medicaid,DRG,4831,PENIS TESTES and SCROTAL PROCEDURES,,Relative Weights,"$5,523.10 ",IP,"5,523.10","5,523.10",,,,,,
BCBS Medicaid,DRG,4832,PENIS TESTES and SCROTAL PROCEDURES,,Relative Weights,"$6,593.84 ",IP,"6,593.84","6,593.84",,,,,,
BCBS Medicaid,DRG,4833,PENIS TESTES and SCROTAL PROCEDURES,,Relative Weights,"$8,503.71 ",IP,"8,503.71","8,503.71",,,,,,
BCBS Medicaid,DRG,4834,PENIS TESTES and SCROTAL PROCEDURES,,Relative Weights,"$16,764.14 ",IP,"16,764.14","16,764.14",,,,,,
BCBS Medicaid,DRG,4841,OTHER MALE REPRODUCTIVE SYSTEM and RELATED PROCEDURES,,Relative Weights,"$6,414.47 ",IP,"6,414.47","6,414.47",,,,,,
BCBS Medicaid,DRG,4842,OTHER MALE REPRODUCTIVE SYSTEM and RELATED PROCEDURES,,Relative Weights,"$6,893.48 ",IP,"6,893.48","6,893.48",,,,,,
BCBS Medicaid,DRG,4843,OTHER MALE REPRODUCTIVE SYSTEM and RELATED PROCEDURES,,Relative Weights,"$7,922.98 ",IP,"7,922.98","7,922.98",,,,,,
BCBS Medicaid,DRG,4844,OTHER MALE REPRODUCTIVE SYSTEM and RELATED PROCEDURES,,Relative Weights,"$22,148.41 ",IP,"22,148.41","22,148.41",,,,,,
BCBS Medicaid,DRG,5001,MALIGNANCY MALE REPRODUCTIVE SYSTEM,,Relative Weights,"$3,471.31 ",IP,"3,471.31","3,471.31",,,,,,
BCBS Medicaid,DRG,5002,MALIGNANCY MALE REPRODUCTIVE SYSTEM,,Relative Weights,"$3,960.98 ",IP,"3,960.98","3,960.98",,,,,,
BCBS Medicaid,DRG,5003,"MALIGNANCY, MALE REPRODUCTIVE SYSTEM",,Relative Weights,"$5,381.18 ",IP,"5,381.18","5,381.18",,,,,,
BCBS Medicaid,DRG,5004,MALIGNANCY MALE REPRODUCTIVE SYSTEM,,Relative Weights,"$8,653.88 ",IP,"8,653.88","8,653.88",,,,,,
BCBS Medicaid,DRG,5011,MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,,Relative Weights,"$2,269.65 ",IP,"2,269.65","2,269.65",,,,,,
BCBS Medicaid,DRG,5012,MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,,Relative Weights,"$2,988.52 ",IP,"2,988.52","2,988.52",,,,,,
BCBS Medicaid,DRG,5013,MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,,Relative Weights,"$4,126.95 ",IP,"4,126.95","4,126.95",,,,,,
BCBS Medicaid,DRG,5014,MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,,Relative Weights,"$8,519.52 ",IP,"8,519.52","8,519.52",,,,,,
BCBS Medicaid,DRG,5101,PELVIC EVISCERATION RADICAL HYSTERECTOMY and OTHER RADICAL GYN PROCS,,Relative Weights,"$6,667.03 ",IP,"6,667.03","6,667.03",,,,,,
BCBS Medicaid,DRG,5102,PELVIC EVISCERATION RADICAL HYSTERECTOMY and OTHER RADICAL GYN PROCS,,Relative Weights,"$7,636.06 ",IP,"7,636.06","7,636.06",,,,,,
BCBS Medicaid,DRG,5103,"PELVIC EVISCERATION, RADICAL HYSTERECTOMY & OTHER RADICAL GYN PROCS",,Relative Weights,"$12,159.55 ",IP,"12,159.55","12,159.55",,,,,,
BCBS Medicaid,DRG,5104,PELVIC EVISCERATION RADICAL HYSTERECTOMY and OTHER RADICAL GYN PROCS,,Relative Weights,"$22,308.54 ",IP,"22,308.54","22,308.54",,,,,,
BCBS Medicaid,DRG,5111,UTERINE and ADNEXA PROCEDURES FOR OVARIAN and ADNEXAL MALIGNANCY,,Relative Weights,"$6,477.69 ",IP,"6,477.69","6,477.69",,,,,,
BCBS Medicaid,DRG,5112,UTERINE and ADNEXA PROCEDURES FOR OVARIAN and ADNEXAL MALIGNANCY,,Relative Weights,"$7,830.89 ",IP,"7,830.89","7,830.89",,,,,,
BCBS Medicaid,DRG,5113,UTERINE & ADNEXA PROCEDURES FOR OVARIAN & ADNEXAL MALIGNANCY,,Relative Weights,"$10,746.90 ",IP,"10,746.90","10,746.90",,,,,,
BCBS Medicaid,DRG,5114,UTERINE & ADNEXA PROCEDURES FOR OVARIAN & ADNEXAL MALIGNANCY,,Relative Weights,"$23,120.88 ",IP,"23,120.88","23,120.88",,,,,,
BCBS Medicaid,DRG,5121,UTERINE and ADNEXA PROCEDURES FOR NONOVARIAN and NONADNEXAL MALIG,,Relative Weights,"$6,341.62 ",IP,"6,341.62","6,341.62",,,,,,
BCBS Medicaid,DRG,5122,UTERINE and ADNEXA PROCEDURES FOR NONOVARIAN and NONADNEXAL MALIG,,Relative Weights,"$7,038.84 ",IP,"7,038.84","7,038.84",,,,,,
BCBS Medicaid,DRG,5123,UTERINE and ADNEXA PROCEDURES FOR NONOVARIAN and NONADNEXAL MALIG,,Relative Weights,"$9,937.66 ",IP,"9,937.66","9,937.66",,,,,,
BCBS Medicaid,DRG,5124,UTERINE & ADNEXA PROCEDURES FOR NON-OVARIAN & NON-ADNEXAL MALIG,,Relative Weights,"$20,453.99 ",IP,"20,453.99","20,453.99",,,,,,
BCBS Medicaid,DRG,5131,UTERINE & ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA,,Relative Weights,"$4,384.67 ",IP,"4,384.67","4,384.67",,,,,,
BCBS Medicaid,DRG,5132,UTERINE and ADNEXA PROCEDURES FOR NONMALIGNANCY EXCEPT LEIOMYOMA,,Relative Weights,"$5,107.31 ",IP,"5,107.31","5,107.31",,,,,,
BCBS Medicaid,DRG,5133,UTERINE and ADNEXA PROCEDURES FOR NONMALIGNANCY EXCEPT LEIOMYOMA,,Relative Weights,"$8,107.86 ",IP,"8,107.86","8,107.86",,,,,,
BCBS Medicaid,DRG,5134,UTERINE and ADNEXA PROCEDURES FOR NONMALIGNANCY EXCEPT LEIOMYOMA,,Relative Weights,"$16,632.53 ",IP,"16,632.53","16,632.53",,,,,,
BCBS Medicaid,DRG,5141,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,,Relative Weights,"$3,945.51 ",IP,"3,945.51","3,945.51",,,,,,
BCBS Medicaid,DRG,5142,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,,Relative Weights,"$5,893.19 ",IP,"5,893.19","5,893.19",,,,,,
BCBS Medicaid,DRG,5143,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,,Relative Weights,"$10,581.96 ",IP,"10,581.96","10,581.96",,,,,,
BCBS Medicaid,DRG,5144,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,,Relative Weights,"$22,849.41 ",IP,"22,849.41","22,849.41",,,,,,
BCBS Medicaid,DRG,5171,DILATION and CURETTAGE FOR NONOBSTETRIC DIAGNOSES,,Relative Weights,"$3,258.61 ",IP,"3,258.61","3,258.61",,,,,,
BCBS Medicaid,DRG,5172,DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES,,Relative Weights,"$4,494.28 ",IP,"4,494.28","4,494.28",,,,,,
BCBS Medicaid,DRG,5173,DILATION and CURETTAGE FOR NONOBSTETRIC DIAGNOSES,,Relative Weights,"$6,942.62 ",IP,"6,942.62","6,942.62",,,,,,
BCBS Medicaid,DRG,5174,DILATION and CURETTAGE FOR NONOBSTETRIC DIAGNOSES,,Relative Weights,"$14,767.33 ",IP,"14,767.33","14,767.33",,,,,,
BCBS Medicaid,DRG,5181,OTHER FEMALE REPRODUCTIVE SYSTEM and RELATED PROCEDURES,,Relative Weights,"$4,123.51 ",IP,"4,123.51","4,123.51",,,,,,
BCBS Medicaid,DRG,5182,OTHER FEMALE REPRODUCTIVE SYSTEM & RELATED PROCEDURES,,Relative Weights,"$5,436.16 ",IP,"5,436.16","5,436.16",,,,,,
BCBS Medicaid,DRG,5183,OTHER FEMALE REPRODUCTIVE SYSTEM & RELATED PROCEDURES,,Relative Weights,"$9,420.16 ",IP,"9,420.16","9,420.16",,,,,,
BCBS Medicaid,DRG,5184,OTHER FEMALE REPRODUCTIVE SYSTEM and RELATED PROCEDURES,,Relative Weights,"$21,115.47 ",IP,"21,115.47","21,115.47",,,,,,
BCBS Medicaid,DRG,5191,UTERINE and ADNEXA PROCEDURES FOR LEIOMYOMA,,Relative Weights,"$3,160.33 ",IP,"3,160.33","3,160.33",,,,,,
BCBS Medicaid,DRG,5192,UTERINE and ADNEXA PROCEDURES FOR LEIOMYOMA,,Relative Weights,"$3,849.30 ",IP,"3,849.30","3,849.30",,,,,,
BCBS Medicaid,DRG,5193,UTERINE & ADNEXA PROCEDURES FOR LEIOMYOMA,,Relative Weights,"$7,527.81 ",IP,"7,527.81","7,527.81",,,,,,
BCBS Medicaid,DRG,5194,UTERINE and ADNEXA PROCEDURES FOR LEIOMYOMA,,Relative Weights,"$15,622.96 ",IP,"15,622.96","15,622.96",,,,,,
BCBS Medicaid,DRG,5301,FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,,Relative Weights,"$3,382.31 ",IP,"3,382.31","3,382.31",,,,,,
BCBS Medicaid,DRG,5302,FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,,Relative Weights,"$3,815.97 ",IP,"3,815.97","3,815.97",,,,,,
BCBS Medicaid,DRG,5303,FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,,Relative Weights,"$5,327.23 ",IP,"5,327.23","5,327.23",,,,,,
BCBS Medicaid,DRG,5304,FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,,Relative Weights,"$9,039.08 ",IP,"9,039.08","9,039.08",,,,,,
BCBS Medicaid,DRG,5311,FEMALE REPRODUCTIVE SYSTEM INFECTIONS,,Relative Weights,"$2,096.46 ",IP,"2,096.46","2,096.46",,,,,,
BCBS Medicaid,DRG,5312,FEMALE REPRODUCTIVE SYSTEM INFECTIONS,,Relative Weights,"$2,868.93 ",IP,"2,868.93","2,868.93",,,,,,
BCBS Medicaid,DRG,5313,FEMALE REPRODUCTIVE SYSTEM INFECTIONS,,Relative Weights,"$4,503.56 ",IP,"4,503.56","4,503.56",,,,,,
BCBS Medicaid,DRG,5314,FEMALE REPRODUCTIVE SYSTEM INFECTIONS,,Relative Weights,"$9,958.97 ",IP,"9,958.97","9,958.97",,,,,,
BCBS Medicaid,DRG,5321,MENSTRUAL and OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,,Relative Weights,"$2,302.29 ",IP,"2,302.29","2,302.29",,,,,,
BCBS Medicaid,DRG,5322,MENSTRUAL and OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,,Relative Weights,"$2,696.78 ",IP,"2,696.78","2,696.78",,,,,,
BCBS Medicaid,DRG,5323,MENSTRUAL and OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,,Relative Weights,"$4,143.44 ",IP,"4,143.44","4,143.44",,,,,,
BCBS Medicaid,DRG,5324,MENSTRUAL and OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,,Relative Weights,"$9,044.24 ",IP,"9,044.24","9,044.24",,,,,,
BCBS Medicaid,DRG,5401,CESAREAN DELIVERY,,Relative Weights,"$2,493.69 ",IP,"2,493.69","2,493.69",,,,,,
BCBS Medicaid,DRG,5402,CESAREAN DELIVERY,,Relative Weights,"$2,909.48 ",IP,"2,909.48","2,909.48",,,,,,
BCBS Medicaid,DRG,5403,CESAREAN DELIVERY,,Relative Weights,"$4,140.35 ",IP,"4,140.35","4,140.35",,,,,,
BCBS Medicaid,DRG,5404,CESAREAN DELIVERY,,Relative Weights,"$8,525.02 ",IP,"8,525.02","8,525.02",,,,,,
BCBS Medicaid,DRG,5411,VAGINAL DELIVERY W STERILIZATION &/OR D&C,,Relative Weights,"$2,683.03 ",IP,"2,683.03","2,683.03",,,,,,
BCBS Medicaid,DRG,5412,VAGINAL DELIVERY W STERILIZATION andOR DandC,,Relative Weights,"$2,694.03 ",IP,"2,694.03","2,694.03",,,,,,
BCBS Medicaid,DRG,5413,VAGINAL DELIVERY W STERILIZATION andOR DandC,,Relative Weights,"$3,800.85 ",IP,"3,800.85","3,800.85",,,,,,
BCBS Medicaid,DRG,5414,VAGINAL DELIVERY W STERILIZATION andOR DandC,,Relative Weights,"$9,356.59 ",IP,"9,356.59","9,356.59",,,,,,
BCBS Medicaid,DRG,5421,VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION &/OR D&C,,Relative Weights,"$1,729.81 ",IP,"1,729.81","1,729.81",,,,,,
BCBS Medicaid,DRG,5422,VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION andOR DandC,,Relative Weights,"$1,962.10 ",IP,"1,962.10","1,962.10",,,,,,
BCBS Medicaid,DRG,5423,VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION andOR DandC,,Relative Weights,"$2,979.24 ",IP,"2,979.24","2,979.24",,,,,,
BCBS Medicaid,DRG,5424,VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION andOR DandC,,Relative Weights,"$11,346.53 ",IP,"11,346.53","11,346.53",,,,,,
BCBS Medicaid,DRG,5441,DandC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES,,Relative Weights,"$1,946.30 ",IP,"1,946.30","1,946.30",,,,,,
BCBS Medicaid,DRG,5442,"D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES",,Relative Weights,"$2,595.06 ",IP,"2,595.06","2,595.06",,,,,,
BCBS Medicaid,DRG,5443,"D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES",,Relative Weights,"$3,856.51 ",IP,"3,856.51","3,856.51",,,,,,
BCBS Medicaid,DRG,5444,DandC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES,,Relative Weights,"$14,310.30 ",IP,"14,310.30","14,310.30",,,,,,
BCBS Medicaid,DRG,5451,ECTOPIC PREGNANCY PROCEDURE,,Relative Weights,"$2,785.09 ",IP,"2,785.09","2,785.09",,,,,,
BCBS Medicaid,DRG,5452,ECTOPIC PREGNANCY PROCEDURE,,Relative Weights,"$3,114.63 ",IP,"3,114.63","3,114.63",,,,,,
BCBS Medicaid,DRG,5453,ECTOPIC PREGNANCY PROCEDURE,,Relative Weights,"$3,214.96 ",IP,"3,214.96","3,214.96",,,,,,
BCBS Medicaid,DRG,5454,ECTOPIC PREGNANCY PROCEDURE,,Relative Weights,"$4,812.48 ",IP,"4,812.48","4,812.48",,,,,,
BCBS Medicaid,DRG,5461,OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES,,Relative Weights,"$2,385.45 ",IP,"2,385.45","2,385.45",,,,,,
BCBS Medicaid,DRG,5462,OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES,,Relative Weights,"$4,587.41 ",IP,"4,587.41","4,587.41",,,,,,
BCBS Medicaid,DRG,5463,OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES,,Relative Weights,"$5,857.79 ",IP,"5,857.79","5,857.79",,,,,,
BCBS Medicaid,DRG,5464,OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES,,Relative Weights,"$11,895.30 ",IP,"11,895.30","11,895.30",,,,,,
BCBS Medicaid,DRG,5601,VAGINAL DELIVERY,VAGINAL DELIVERY,Relative Weights,"$1,539.10 ",IP,"1,539.10","1,539.10",,,,,,
BCBS Medicaid,DRG,5602,VAGINAL DELIVERY,VAGINAL DELIVERY,Relative Weights,"$1,659.37 ",IP,"1,659.37","1,659.37",,,,,,
BCBS Medicaid,DRG,5603,VAGINAL DELIVERY,VAGINAL DELIVERY,Relative Weights,"$2,337.34 ",IP,"2,337.34","2,337.34",,,,,,
BCBS Medicaid,DRG,5604,VAGINAL DELIVERY,VAGINAL DELIVERY,Relative Weights,"$4,292.23 ",IP,"4,292.23","4,292.23",,,,,,
BCBS Medicaid,DRG,5611,POSTPARTUM and POST ABORTION DIAGNOSES WO PROCEDURE,,Relative Weights,"$1,236.71 ",IP,"1,236.71","1,236.71",,,,,,
BCBS Medicaid,DRG,5612,POSTPARTUM and POST ABORTION DIAGNOSES WO PROCEDURE,,Relative Weights,"$1,778.26 ",IP,"1,778.26","1,778.26",,,,,,
BCBS Medicaid,DRG,5613,POSTPARTUM and POST ABORTION DIAGNOSES WO PROCEDURE,,Relative Weights,"$2,747.29 ",IP,"2,747.29","2,747.29",,,,,,
BCBS Medicaid,DRG,5614,POSTPARTUM and POST ABORTION DIAGNOSES WO PROCEDURE,,Relative Weights,"$5,898.34 ",IP,"5,898.34","5,898.34",,,,,,
BCBS Medicaid,DRG,5631,PRETERM LABOR,,Relative Weights,"$1,387.56 ",IP,"1,387.56","1,387.56",,,,,,
BCBS Medicaid,DRG,5632,PRETERM LABOR,,Relative Weights,"$1,719.85 ",IP,"1,719.85","1,719.85",,,,,,
BCBS Medicaid,DRG,5633,PRETERM LABOR,,Relative Weights,"$2,634.92 ",IP,"2,634.92","2,634.92",,,,,,
BCBS Medicaid,DRG,5634,PRETERM LABOR,,Relative Weights,"$4,637.23 ",IP,"4,637.23","4,637.23",,,,,,
BCBS Medicaid,DRG,5641,ABORTION WO DandC ASPIRATION CURETTAGE OR HYSTEROTOMY,,Relative Weights,"$1,463.85 ",IP,"1,463.85","1,463.85",,,,,,
BCBS Medicaid,DRG,5642,"ABORTION W/O D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",,Relative Weights,"$1,520.55 ",IP,"1,520.55","1,520.55",,,,,,
BCBS Medicaid,DRG,5643,"ABORTION W/O D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",,Relative Weights,"$2,435.62 ",IP,"2,435.62","2,435.62",,,,,,
BCBS Medicaid,DRG,5644,ABORTION WO DandC ASPIRATION CURETTAGE OR HYSTEROTOMY,,Relative Weights,"$3,935.55 ",IP,"3,935.55","3,935.55",,,,,,
BCBS Medicaid,DRG,5651,FALSE LABOR,FALSE LABOR,Relative Weights,$992.39 ,IP,992.39,992.39,,,,,,
BCBS Medicaid,DRG,5652,FALSE LABOR,FALSE LABOR,Relative Weights,"$1,254.23 ",IP,"1,254.23","1,254.23",,,,,,
BCBS Medicaid,DRG,5653,FALSE LABOR,FALSE LABOR,Relative Weights,"$2,123.61 ",IP,"2,123.61","2,123.61",,,,,,
BCBS Medicaid,DRG,5654,FALSE LABOR,FALSE LABOR,Relative Weights,"$2,123.61 ",IP,"2,123.61","2,123.61",,,,,,
BCBS Medicaid,DRG,5661,OTHER ANTEPARTUM DIAGNOSES,,Relative Weights,"$1,462.82 ",IP,"1,462.82","1,462.82",,,,,,
BCBS Medicaid,DRG,5662,OTHER ANTEPARTUM DIAGNOSES,,Relative Weights,"$1,906.44 ",IP,"1,906.44","1,906.44",,,,,,
BCBS Medicaid,DRG,5663,OTHER ANTEPARTUM DIAGNOSES,,Relative Weights,"$2,718.08 ",IP,"2,718.08","2,718.08",,,,,,
BCBS Medicaid,DRG,5664,OTHER ANTEPARTUM DIAGNOSES,,Relative Weights,"$5,715.19 ",IP,"5,715.19","5,715.19",,,,,,
BCBS Medicaid,DRG,5801,NEONATE TRANSFERRED 5 DAYS OLD NOT BORN HERE,,Relative Weights,"$1,625.35 ",IP,"1,625.35","1,625.35",,,,,,
BCBS Medicaid,DRG,5802,NEONATE TRANSFERRED 5 DAYS OLD NOT BORN HERE,,Relative Weights,"$2,301.61 ",IP,"2,301.61","2,301.61",,,,,,
BCBS Medicaid,DRG,5803,NEONATE TRANSFERRED 5 DAYS OLD NOT BORN HERE,,Relative Weights,"$3,477.84 ",IP,"3,477.84","3,477.84",,,,,,
BCBS Medicaid,DRG,5804,NEONATE TRANSFERRED 5 DAYS OLD NOT BORN HERE,,Relative Weights,"$6,537.48 ",IP,"6,537.48","6,537.48",,,,,,
BCBS Medicaid,DRG,5811,NEONATE TRANSFERRED  5 DAYS OLD BORN HERE,,Relative Weights,$559.42 ,IP,559.42,559.42,,,,,,
BCBS Medicaid,DRG,5812,NEONATE TRANSFERRED  5 DAYS OLD BORN HERE,,Relative Weights,$716.80 ,IP,716.8,716.8,,,,,,
BCBS Medicaid,DRG,5813,NEONATE TRANSFERRED  5 DAYS OLD BORN HERE,,Relative Weights,"$1,204.41 ",IP,"1,204.41","1,204.41",,,,,,
BCBS Medicaid,DRG,5814,NEONATE TRANSFERRED  5 DAYS OLD BORN HERE,,Relative Weights,"$2,109.52 ",IP,"2,109.52","2,109.52",,,,,,
BCBS Medicaid,DRG,5831,NEONATE W ECMO,,Relative Weights,"$87,271.04 ",IP,"87,271.04","87,271.04",,,,,,
BCBS Medicaid,DRG,5832,NEONATE W ECMO,,Relative Weights,"$87,459.00 ",IP,"87,459.00","87,459.00",,,,,,
BCBS Medicaid,DRG,5833,NEONATE W ECMO,,Relative Weights,"$148,358.12 ",IP,"148,358.12","148,358.12",,,,,,
BCBS Medicaid,DRG,5834,NEONATE W ECMO,,Relative Weights,"$163,193.83 ",IP,"163,193.83","163,193.83",,,,,,
BCBS Medicaid,DRG,5881,NEONATE BWT <1500G W MAJOR PROCEDURE,,Relative Weights,"$67,852.39 ",IP,"67,852.39","67,852.39",,,,,,
BCBS Medicaid,DRG,5882,NEONATE BWT <1500G W MAJOR PROCEDURE,,Relative Weights,"$75,391.54 ",IP,"75,391.54","75,391.54",,,,,,
BCBS Medicaid,DRG,5883,NEONATE BWT 1500G W MAJOR PROCEDURE,,Relative Weights,"$83,636.16 ",IP,"83,636.16","83,636.16",,,,,,
BCBS Medicaid,DRG,5884,NEONATE BWT 1500G W MAJOR PROCEDURE,,Relative Weights,"$133,619.66 ",IP,"133,619.66","133,619.66",,,,,,
BCBS Medicaid,DRG,5891,NEONATE BWT 500G OR GA 24 WEEKS,,Relative Weights,"$98,896.59 ",IP,"98,896.59","98,896.59",,,,,,
BCBS Medicaid,DRG,5892,NEONATE BWT 500G OR GA 24 WEEKS,,Relative Weights,"$69,370.87 ",IP,"69,370.87","69,370.87",,,,,,
BCBS Medicaid,DRG,5893,NEONATE BWT 500G OR GA 24 WEEKS,,Relative Weights,"$63,064.65 ",IP,"63,064.65","63,064.65",,,,,,
BCBS Medicaid,DRG,5894,NEONATE BWT <500G OR GA <24 WEEKS,,Relative Weights,"$11,889.12 ",IP,"11,889.12","11,889.12",,,,,,
BCBS Medicaid,DRG,5911,NEONATE BIRTHWT 500749G WO MAJOR PROCEDURE,,Relative Weights,"$57,344.65 ",IP,"57,344.65","57,344.65",,,,,,
BCBS Medicaid,DRG,5912,NEONATE BIRTHWT 500749G WO MAJOR PROCEDURE,,Relative Weights,"$79,559.04 ",IP,"79,559.04","79,559.04",,,,,,
BCBS Medicaid,DRG,5913,NEONATE BIRTHWT 500749G WO MAJOR PROCEDURE,,Relative Weights,"$85,488.65 ",IP,"85,488.65","85,488.65",,,,,,
BCBS Medicaid,DRG,5914,NEONATE BIRTHWT 500-749G W/O MAJOR PROCEDURE,,Relative Weights,"$110,417.00 ",IP,"110,417.00","110,417.00",,,,,,
BCBS Medicaid,DRG,5931,NEONATE BIRTHWT 750-999G W/O MAJOR PROCEDURE,,Relative Weights,"$37,781.34 ",IP,"37,781.34","37,781.34",,,,,,
BCBS Medicaid,DRG,5932,NEONATE BIRTHWT 750999G WO MAJOR PROCEDURE,,Relative Weights,"$59,330.12 ",IP,"59,330.12","59,330.12",,,,,,
BCBS Medicaid,DRG,5933,NEONATE BIRTHWT 750999G WO MAJOR PROCEDURE,,Relative Weights,"$71,323.01 ",IP,"71,323.01","71,323.01",,,,,,
BCBS Medicaid,DRG,5934,NEONATE BIRTHWT 750999G WO MAJOR PROCEDURE,,Relative Weights,"$96,423.52 ",IP,"96,423.52","96,423.52",,,,,,
BCBS Medicaid,DRG,6021,NEONATE BWT 10001249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$36,367.31 ",IP,"36,367.31","36,367.31",,,,,,
BCBS Medicaid,DRG,6022,NEONATE BWT 10001249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$43,081.42 ",IP,"43,081.42","43,081.42",,,,,,
BCBS Medicaid,DRG,6023,NEONATE BWT 10001249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$56,708.94 ",IP,"56,708.94","56,708.94",,,,,,
BCBS Medicaid,DRG,6024,NEONATE BWT 10001249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$82,218.02 ",IP,"82,218.02","82,218.02",,,,,,
BCBS Medicaid,DRG,6031,NEONATE BIRTHWT 10001249G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$21,131.62 ",IP,"21,131.62","21,131.62",,,,,,
BCBS Medicaid,DRG,6032,NEONATE BIRTHWT 10001249G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$31,760.66 ",IP,"31,760.66","31,760.66",,,,,,
BCBS Medicaid,DRG,6033,NEONATE BIRTHWT 10001249G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$45,733.18 ",IP,"45,733.18","45,733.18",,,,,,
BCBS Medicaid,DRG,6034,NEONATE BIRTHWT 10001249G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$71,521.63 ",IP,"71,521.63","71,521.63",,,,,,
BCBS Medicaid,DRG,6071,NEONATE BWT 1250-1499G W RESP DIST SYND/OTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$24,973.02 ",IP,"24,973.02","24,973.02",,,,,,
BCBS Medicaid,DRG,6072,NEONATE BWT 12501499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$31,699.15 ",IP,"31,699.15","31,699.15",,,,,,
BCBS Medicaid,DRG,6073,NEONATE BWT 12501499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$41,632.01 ",IP,"41,632.01","41,632.01",,,,,,
BCBS Medicaid,DRG,6074,NEONATE BWT 12501499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$64,492.07 ",IP,"64,492.07","64,492.07",,,,,,
BCBS Medicaid,DRG,6081,NEONATE BWT 12501499G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$16,607.44 ",IP,"16,607.44","16,607.44",,,,,,
BCBS Medicaid,DRG,6082,NEONATE BWT 12501499G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$23,967.23 ",IP,"23,967.23","23,967.23",,,,,,
BCBS Medicaid,DRG,6083,NEONATE BWT 12501499G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$34,646.09 ",IP,"34,646.09","34,646.09",,,,,,
BCBS Medicaid,DRG,6084,NEONATE BWT 12501499G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$60,788.81 ",IP,"60,788.81","60,788.81",,,,,,
BCBS Medicaid,DRG,6091,NEONATE BWT 15002499G W MAJOR PROCEDURE,,Relative Weights,"$25,499.11 ",IP,"25,499.11","25,499.11",,,,,,
BCBS Medicaid,DRG,6092,NEONATE BWT 15002499G W MAJOR PROCEDURE,,Relative Weights,"$27,431.32 ",IP,"27,431.32","27,431.32",,,,,,
BCBS Medicaid,DRG,6093,NEONATE BWT 15002499G W MAJOR PROCEDURE,,Relative Weights,"$47,002.54 ",IP,"47,002.54","47,002.54",,,,,,
BCBS Medicaid,DRG,6094,NEONATE BWT 15002499G W MAJOR PROCEDURE,,Relative Weights,"$99,687.62 ",IP,"99,687.62","99,687.62",,,,,,
BCBS Medicaid,DRG,6111,NEONATE BIRTHWT 15001999G W MAJOR ANOMALY,,Relative Weights,"$12,585.30 ",IP,"12,585.30","12,585.30",,,,,,
BCBS Medicaid,DRG,6112,NEONATE BIRTHWT 15001999G W MAJOR ANOMALY,,Relative Weights,"$19,393.91 ",IP,"19,393.91","19,393.91",,,,,,
BCBS Medicaid,DRG,6113,NEONATE BIRTHWT 15001999G W MAJOR ANOMALY,,Relative Weights,"$32,347.92 ",IP,"32,347.92","32,347.92",,,,,,
BCBS Medicaid,DRG,6114,NEONATE BIRTHWT 15001999G W MAJOR ANOMALY,,Relative Weights,"$58,174.51 ",IP,"58,174.51","58,174.51",,,,,,
BCBS Medicaid,DRG,6121,NEONATE BWT 1500-1999G W RESP DIST SYND/OTH MAJ RESP COND,,Relative Weights,"$16,224.65 ",IP,"16,224.65","16,224.65",,,,,,
BCBS Medicaid,DRG,6122,NEONATE BWT 15001999G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$21,637.79 ",IP,"21,637.79","21,637.79",,,,,,
BCBS Medicaid,DRG,6123,NEONATE BWT 15001999G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$29,186.22 ",IP,"29,186.22","29,186.22",,,,,,
BCBS Medicaid,DRG,6124,NEONATE BWT 15001999G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$42,407.23 ",IP,"42,407.23","42,407.23",,,,,,
BCBS Medicaid,DRG,6131,NEONATE BIRTHWT 1500-1999G W CONGENITAL/PERINATAL INFECTION,,Relative Weights,"$13,196.61 ",IP,"13,196.61","13,196.61",,,,,,
BCBS Medicaid,DRG,6132,NEONATE BIRTHWT 15001999G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$21,189.35 ",IP,"21,189.35","21,189.35",,,,,,
BCBS Medicaid,DRG,6133,NEONATE BIRTHWT 15001999G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$27,656.40 ",IP,"27,656.40","27,656.40",,,,,,
BCBS Medicaid,DRG,6134,NEONATE BIRTHWT 15001999G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$47,731.03 ",IP,"47,731.03","47,731.03",,,,,,
BCBS Medicaid,DRG,6141,NEONATE BWT 15001999G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$8,925.34 ",IP,"8,925.34","8,925.34",,,,,,
BCBS Medicaid,DRG,6142,NEONATE BWT 1500-1999G W OR W/O OTHER SIGNIFICANT CONDITION,,Relative Weights,"$15,030.54 ",IP,"15,030.54","15,030.54",,,,,,
BCBS Medicaid,DRG,6143,NEONATE BWT 1500-1999G W OR W/O OTHER SIGNIFICANT CONDITION,,Relative Weights,"$25,580.55 ",IP,"25,580.55","25,580.55",,,,,,
BCBS Medicaid,DRG,6144,NEONATE BWT 15001999G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$45,341.79 ",IP,"45,341.79","45,341.79",,,,,,
BCBS Medicaid,DRG,6211,NEONATE BWT 20002499G W MAJOR ANOMALY,,Relative Weights,"$6,929.91 ",IP,"6,929.91","6,929.91",,,,,,
BCBS Medicaid,DRG,6212,NEONATE BWT 20002499G W MAJOR ANOMALY,,Relative Weights,"$14,367.69 ",IP,"14,367.69","14,367.69",,,,,,
BCBS Medicaid,DRG,6213,NEONATE BWT 20002499G W MAJOR ANOMALY,,Relative Weights,"$26,320.72 ",IP,"26,320.72","26,320.72",,,,,,
BCBS Medicaid,DRG,6214,NEONATE BWT 20002499G W MAJOR ANOMALY,,Relative Weights,"$49,514.79 ",IP,"49,514.79","49,514.79",,,,,,
BCBS Medicaid,DRG,6221,NEONATE BWT 20002499G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$10,129.06 ",IP,"10,129.06","10,129.06",,,,,,
BCBS Medicaid,DRG,6222,NEONATE BWT 20002499G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$13,681.47 ",IP,"13,681.47","13,681.47",,,,,,
BCBS Medicaid,DRG,6223,NEONATE BWT 20002499G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$17,417.03 ",IP,"17,417.03","17,417.03",,,,,,
BCBS Medicaid,DRG,6224,NEONATE BWT 20002499G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$32,501.52 ",IP,"32,501.52","32,501.52",,,,,,
BCBS Medicaid,DRG,6231,NEONATE BWT 20002499G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$7,947.73 ",IP,"7,947.73","7,947.73",,,,,,
BCBS Medicaid,DRG,6232,NEONATE BWT 20002499G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$11,704.59 ",IP,"11,704.59","11,704.59",,,,,,
BCBS Medicaid,DRG,6233,NEONATE BWT 20002499G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$18,604.26 ",IP,"18,604.26","18,604.26",,,,,,
BCBS Medicaid,DRG,6234,NEONATE BWT 2000-2499G W CONGENITAL/PERINATAL INFECTION,,Relative Weights,"$29,470.40 ",IP,"29,470.40","29,470.40",,,,,,
BCBS Medicaid,DRG,6251,NEONATE BWT 20002499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$8,481.72 ",IP,"8,481.72","8,481.72",,,,,,
BCBS Medicaid,DRG,6252,NEONATE BWT 20002499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$12,056.81 ",IP,"12,056.81","12,056.81",,,,,,
BCBS Medicaid,DRG,6253,NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$17,253.12 ",IP,"17,253.12","17,253.12",,,,,,
BCBS Medicaid,DRG,6254,NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$25,500.83 ",IP,"25,500.83","25,500.83",,,,,,
BCBS Medicaid,DRG,6261,NEONATE BWT 20002499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM,,Relative Weights,"$1,026.75 ",IP,"1,026.75","1,026.75",,,,,,
BCBS Medicaid,DRG,6262,NEONATE BWT 20002499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM,,Relative Weights,"$1,832.56 ",IP,"1,832.56","1,832.56",,,,,,
BCBS Medicaid,DRG,6263,NEONATE BWT 20002499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM,,Relative Weights,"$5,129.99 ",IP,"5,129.99","5,129.99",,,,,,
BCBS Medicaid,DRG,6264,"NEONATE BWT 2000-2499G, NORMAL NEWBORN OR NEONATE W OTHER PROBLEM",,Relative Weights,"$14,511.67 ",IP,"14,511.67","14,511.67",,,,,,
BCBS Medicaid,DRG,6301,NEONATE BIRTHWT 2499G W MAJOR CARDIOVASCULAR PROCEDURE,,Relative Weights,"$14,642.59 ",IP,"14,642.59","14,642.59",,,,,,
BCBS Medicaid,DRG,6302,NEONATE BIRTHWT 2499G W MAJOR CARDIOVASCULAR PROCEDURE,,Relative Weights,"$26,499.41 ",IP,"26,499.41","26,499.41",,,,,,
BCBS Medicaid,DRG,6303,NEONATE BIRTHWT 2499G W MAJOR CARDIOVASCULAR PROCEDURE,,Relative Weights,"$44,508.84 ",IP,"44,508.84","44,508.84",,,,,,
BCBS Medicaid,DRG,6304,NEONATE BIRTHWT >2499G W MAJOR CARDIOVASCULAR PROCEDURE,,Relative Weights,"$79,154.59 ",IP,"79,154.59","79,154.59",,,,,,
BCBS Medicaid,DRG,6311,NEONATE BIRTHWT 2499G W OTHER MAJOR PROCEDURE,,Relative Weights,"$11,884.65 ",IP,"11,884.65","11,884.65",,,,,,
BCBS Medicaid,DRG,6312,NEONATE BIRTHWT 2499G W OTHER MAJOR PROCEDURE,,Relative Weights,"$19,077.77 ",IP,"19,077.77","19,077.77",,,,,,
BCBS Medicaid,DRG,6313,NEONATE BIRTHWT 2499G W OTHER MAJOR PROCEDURE,,Relative Weights,"$33,764.00 ",IP,"33,764.00","33,764.00",,,,,,
BCBS Medicaid,DRG,6314,NEONATE BIRTHWT 2499G W OTHER MAJOR PROCEDURE,,Relative Weights,"$74,464.79 ",IP,"74,464.79","74,464.79",,,,,,
BCBS Medicaid,DRG,6331,NEONATE BIRTHWT 2499G W MAJOR ANOMALY,,Relative Weights,"$2,688.87 ",IP,"2,688.87","2,688.87",,,,,,
BCBS Medicaid,DRG,6332,NEONATE BIRTHWT 2499G W MAJOR ANOMALY,,Relative Weights,"$7,851.51 ",IP,"7,851.51","7,851.51",,,,,,
BCBS Medicaid,DRG,6333,NEONATE BIRTHWT 2499G W MAJOR ANOMALY,,Relative Weights,"$17,713.92 ",IP,"17,713.92","17,713.92",,,,,,
BCBS Medicaid,DRG,6334,NEONATE BIRTHWT 2499G W MAJOR ANOMALY,,Relative Weights,"$44,843.19 ",IP,"44,843.19","44,843.19",,,,,,
BCBS Medicaid,DRG,6341,"NEONATE, BIRTHWT >2499G W RESP DIST SYND/OTH MAJ RESP COND",,Relative Weights,"$4,461.64 ",IP,"4,461.64","4,461.64",,,,,,
BCBS Medicaid,DRG,6342,"NEONATE, BIRTHWT >2499G W RESP DIST SYND/OTH MAJ RESP COND",,Relative Weights,"$7,881.41 ",IP,"7,881.41","7,881.41",,,,,,
BCBS Medicaid,DRG,6343,NEONATE BIRTHWT 2499G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$11,444.81 ",IP,"11,444.81","11,444.81",,,,,,
BCBS Medicaid,DRG,6344,NEONATE BIRTHWT 2499G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$28,806.17 ",IP,"28,806.17","28,806.17",,,,,,
BCBS Medicaid,DRG,6361,NEONATE BIRTHWT 2499G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$4,375.39 ",IP,"4,375.39","4,375.39",,,,,,
BCBS Medicaid,DRG,6362,NEONATE BIRTHWT 2499G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$6,615.83 ",IP,"6,615.83","6,615.83",,,,,,
BCBS Medicaid,DRG,6363,NEONATE BIRTHWT >2499G W CONGENITAL/PERINATAL INFECTION,,Relative Weights,"$13,140.60 ",IP,"13,140.60","13,140.60",,,,,,
BCBS Medicaid,DRG,6364,NEONATE BIRTHWT 2499G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$22,289.30 ",IP,"22,289.30","22,289.30",,,,,,
BCBS Medicaid,DRG,6391,NEONATE BIRTHWT 2499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$4,122.14 ",IP,"4,122.14","4,122.14",,,,,,
BCBS Medicaid,DRG,6392,NEONATE BIRTHWT >2499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$7,440.19 ",IP,"7,440.19","7,440.19",,,,,,
BCBS Medicaid,DRG,6393,NEONATE BIRTHWT >2499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$11,681.22 ",IP,"11,681.22","11,681.22",,,,,,
BCBS Medicaid,DRG,6394,NEONATE BIRTHWT 2499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$20,735.08 ",IP,"20,735.08","20,735.08",,,,,,
BCBS Medicaid,DRG,6401,NEONATE BIRTHWT 2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM,,Relative Weights,$571.11 ,IP,571.11,571.11,,,,,,
BCBS Medicaid,DRG,6402,NEONATE BIRTHWT 2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM,,Relative Weights,$900.64 ,IP,900.64,900.64,,,,,,
BCBS Medicaid,DRG,6403,"NEONATE BIRTHWT >2499G, NORMAL NEWBORN OR NEONATE W OTHER PROBLEM",,Relative Weights,"$2,228.41 ",IP,"2,228.41","2,228.41",,,,,,
BCBS Medicaid,DRG,6404,NEONATE BIRTHWT 2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM,,Relative Weights,"$13,890.74 ",IP,"13,890.74","13,890.74",,,,,,
BCBS Medicaid,DRG,6501,SPLENECTOMY,,Relative Weights,"$6,304.16 ",IP,"6,304.16","6,304.16",,,,,,
BCBS Medicaid,DRG,6502,SPLENECTOMY,,Relative Weights,"$8,491.69 ",IP,"8,491.69","8,491.69",,,,,,
BCBS Medicaid,DRG,6503,SPLENECTOMY,,Relative Weights,"$13,332.00 ",IP,"13,332.00","13,332.00",,,,,,
BCBS Medicaid,DRG,6504,SPLENECTOMY,,Relative Weights,"$23,483.06 ",IP,"23,483.06","23,483.06",,,,,,
BCBS Medicaid,DRG,6511,OTHER PROCEDURES OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$5,293.90 ",IP,"5,293.90","5,293.90",,,,,,
BCBS Medicaid,DRG,6512,OTHER PROCEDURES OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$7,236.76 ",IP,"7,236.76","7,236.76",,,,,,
BCBS Medicaid,DRG,6513,OTHER PROCEDURES OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$10,916.31 ",IP,"10,916.31","10,916.31",,,,,,
BCBS Medicaid,DRG,6514,OTHER PROCEDURES OF BLOOD & BLOOD-FORMING ORGANS,,Relative Weights,"$33,538.24 ",IP,"33,538.24","33,538.24",,,,,,
BCBS Medicaid,DRG,6601,MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS and COAGUL,,Relative Weights,"$3,747.59 ",IP,"3,747.59","3,747.59",,,,,,
BCBS Medicaid,DRG,6602,MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS and COAGUL,,Relative Weights,"$4,287.77 ",IP,"4,287.77","4,287.77",,,,,,
BCBS Medicaid,DRG,6603,MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS and COAGUL,,Relative Weights,"$6,366.70 ",IP,"6,366.70","6,366.70",,,,,,
BCBS Medicaid,DRG,6604,MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS and COAGUL,,Relative Weights,"$16,194.41 ",IP,"16,194.41","16,194.41",,,,,,
BCBS Medicaid,DRG,6611,COAGULATION and PLATELET DISORDERS,,Relative Weights,"$3,902.56 ",IP,"3,902.56","3,902.56",,,,,,
BCBS Medicaid,DRG,6612,COAGULATION and PLATELET DISORDERS,,Relative Weights,"$5,668.11 ",IP,"5,668.11","5,668.11",,,,,,
BCBS Medicaid,DRG,6613,COAGULATION and PLATELET DISORDERS,,Relative Weights,"$9,739.74 ",IP,"9,739.74","9,739.74",,,,,,
BCBS Medicaid,DRG,6614,COAGULATION and PLATELET DISORDERS,,Relative Weights,"$15,545.30 ",IP,"15,545.30","15,545.30",,,,,,
BCBS Medicaid,DRG,6621,SICKLE CELL ANEMIA CRISIS,,Relative Weights,"$2,821.17 ",IP,"2,821.17","2,821.17",,,,,,
BCBS Medicaid,DRG,6622,SICKLE CELL ANEMIA CRISIS,,Relative Weights,"$3,681.27 ",IP,"3,681.27","3,681.27",,,,,,
BCBS Medicaid,DRG,6623,SICKLE CELL ANEMIA CRISIS,,Relative Weights,"$5,206.96 ",IP,"5,206.96","5,206.96",,,,,,
BCBS Medicaid,DRG,6624,SICKLE CELL ANEMIA CRISIS,,Relative Weights,"$10,694.33 ",IP,"10,694.33","10,694.33",,,,,,
BCBS Medicaid,DRG,6631,OTHER ANEMIA and DISORDERS OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$2,701.59 ",IP,"2,701.59","2,701.59",,,,,,
BCBS Medicaid,DRG,6632,OTHER ANEMIA and DISORDERS OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$3,327.33 ",IP,"3,327.33","3,327.33",,,,,,
BCBS Medicaid,DRG,6633,OTHER ANEMIA and DISORDERS OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$4,391.20 ",IP,"4,391.20","4,391.20",,,,,,
BCBS Medicaid,DRG,6634,OTHER ANEMIA and DISORDERS OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$8,007.52 ",IP,"8,007.52","8,007.52",,,,,,
BCBS Medicaid,DRG,6801,MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$7,740.52 ",IP,"7,740.52","7,740.52",,,,,,
BCBS Medicaid,DRG,6802,MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$10,236.62 ",IP,"10,236.62","10,236.62",,,,,,
BCBS Medicaid,DRG,6803,MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$16,199.56 ",IP,"16,199.56","16,199.56",,,,,,
BCBS Medicaid,DRG,6804,MAJOR O.R. PROCEDURES FOR LYMPHATIC/HEMATOPOIETIC/OTHER NEOPLASMS,,Relative Weights,"$34,974.94 ",IP,"34,974.94","34,974.94",,,,,,
BCBS Medicaid,DRG,6811,OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$6,220.66 ",IP,"6,220.66","6,220.66",,,,,,
BCBS Medicaid,DRG,6812,OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$7,805.46 ",IP,"7,805.46","7,805.46",,,,,,
BCBS Medicaid,DRG,6813,OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$13,731.30 ",IP,"13,731.30","13,731.30",,,,,,
BCBS Medicaid,DRG,6814,OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$32,311.50 ",IP,"32,311.50","32,311.50",,,,,,
BCBS Medicaid,DRG,6901,ACUTE LEUKEMIA,,Relative Weights,"$8,376.23 ",IP,"8,376.23","8,376.23",,,,,,
BCBS Medicaid,DRG,6902,ACUTE LEUKEMIA,,Relative Weights,"$11,965.06 ",IP,"11,965.06","11,965.06",,,,,,
BCBS Medicaid,DRG,6903,ACUTE LEUKEMIA,,Relative Weights,"$18,264.07 ",IP,"18,264.07","18,264.07",,,,,,
BCBS Medicaid,DRG,6904,ACUTE LEUKEMIA,,Relative Weights,"$33,495.63 ",IP,"33,495.63","33,495.63",,,,,,
BCBS Medicaid,DRG,6911,LYMPHOMA MYELOMA and NONACUTE LEUKEMIA,,Relative Weights,"$6,184.92 ",IP,"6,184.92","6,184.92",,,,,,
BCBS Medicaid,DRG,6912,"LYMPHOMA, MYELOMA & NON-ACUTE LEUKEMIA",,Relative Weights,"$6,251.93 ",IP,"6,251.93","6,251.93",,,,,,
BCBS Medicaid,DRG,6913,LYMPHOMA MYELOMA and NONACUTE LEUKEMIA,,Relative Weights,"$9,090.97 ",IP,"9,090.97","9,090.97",,,,,,
BCBS Medicaid,DRG,6914,LYMPHOMA MYELOMA and NONACUTE LEUKEMIA,,Relative Weights,"$18,806.65 ",IP,"18,806.65","18,806.65",,,,,,
BCBS Medicaid,DRG,6921,RADIOTHERAPY,,Relative Weights,"$5,028.28 ",IP,"5,028.28","5,028.28",,,,,,
BCBS Medicaid,DRG,6922,RADIOTHERAPY,,Relative Weights,"$8,603.36 ",IP,"8,603.36","8,603.36",,,,,,
BCBS Medicaid,DRG,6923,RADIOTHERAPY,,Relative Weights,"$11,232.45 ",IP,"11,232.45","11,232.45",,,,,,
BCBS Medicaid,DRG,6924,RADIOTHERAPY,,Relative Weights,"$22,232.95 ",IP,"22,232.95","22,232.95",,,,,,
BCBS Medicaid,DRG,6941,LYMPHATIC & OTHER MALIGNANCIES & NEOPLASMS OF UNCERTAIN BEHAVIOR,,Relative Weights,"$3,669.93 ",IP,"3,669.93","3,669.93",,,,,,
BCBS Medicaid,DRG,6942,LYMPHATIC and OTHER MALIGNANCIES and NEOPLASMS OF UNCERTAIN BEHAVIOR,,Relative Weights,"$4,230.04 ",IP,"4,230.04","4,230.04",,,,,,
BCBS Medicaid,DRG,6943,LYMPHATIC and OTHER MALIGNANCIES and NEOPLASMS OF UNCERTAIN BEHAVIOR,,Relative Weights,"$5,867.41 ",IP,"5,867.41","5,867.41",,,,,,
BCBS Medicaid,DRG,6944,LYMPHATIC and OTHER MALIGNANCIES and NEOPLASMS OF UNCERTAIN BEHAVIOR,,Relative Weights,"$11,092.25 ",IP,"11,092.25","11,092.25",,,,,,
BCBS Medicaid,DRG,6951,CHEMOTHERAPY FOR ACUTE LEUKEMIA,,Relative Weights,"$3,844.14 ",IP,"3,844.14","3,844.14",,,,,,
BCBS Medicaid,DRG,6952,CHEMOTHERAPY FOR ACUTE LEUKEMIA,,Relative Weights,"$4,908.70 ",IP,"4,908.70","4,908.70",,,,,,
BCBS Medicaid,DRG,6953,CHEMOTHERAPY FOR ACUTE LEUKEMIA,,Relative Weights,"$11,375.74 ",IP,"11,375.74","11,375.74",,,,,,
BCBS Medicaid,DRG,6954,CHEMOTHERAPY FOR ACUTE LEUKEMIA,,Relative Weights,"$32,868.17 ",IP,"32,868.17","32,868.17",,,,,,
BCBS Medicaid,DRG,6961,OTHER CHEMOTHERAPY,,Relative Weights,"$4,174.03 ",IP,"4,174.03","4,174.03",,,,,,
BCBS Medicaid,DRG,6962,OTHER CHEMOTHERAPY,,Relative Weights,"$5,397.68 ",IP,"5,397.68","5,397.68",,,,,,
BCBS Medicaid,DRG,6963,OTHER CHEMOTHERAPY,,Relative Weights,"$7,757.01 ",IP,"7,757.01","7,757.01",,,,,,
BCBS Medicaid,DRG,6964,OTHER CHEMOTHERAPY,,Relative Weights,"$17,845.53 ",IP,"17,845.53","17,845.53",,,,,,
BCBS Medicaid,DRG,7101,INFECTIOUS & PARASITIC DISEASES INCLUDING HIV W O.R. PROCEDURE,,Relative Weights,"$5,318.64 ",IP,"5,318.64","5,318.64",,,,,,
BCBS Medicaid,DRG,7102,INFECTIOUS and PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE,,Relative Weights,"$7,922.30 ",IP,"7,922.30","7,922.30",,,,,,
BCBS Medicaid,DRG,7103,INFECTIOUS and PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE,,Relative Weights,"$12,117.63 ",IP,"12,117.63","12,117.63",,,,,,
BCBS Medicaid,DRG,7104,INFECTIOUS and PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE,,Relative Weights,"$24,582.32 ",IP,"24,582.32","24,582.32",,,,,,
BCBS Medicaid,DRG,7111,POSTOP POSTTRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE,,Relative Weights,"$5,432.73 ",IP,"5,432.73","5,432.73",,,,,,
BCBS Medicaid,DRG,7112,POSTOP POSTTRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE,,Relative Weights,"$7,124.05 ",IP,"7,124.05","7,124.05",,,,,,
BCBS Medicaid,DRG,7113,POSTOP POSTTRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE,,Relative Weights,"$12,166.42 ",IP,"12,166.42","12,166.42",,,,,,
BCBS Medicaid,DRG,7114,POSTOP POSTTRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE,,Relative Weights,"$25,010.82 ",IP,"25,010.82","25,010.82",,,,,,
BCBS Medicaid,DRG,7201,SEPTICEMIA and DISSEMINATED INFECTIONS,,Relative Weights,"$2,801.24 ",IP,"2,801.24","2,801.24",,,,,,
BCBS Medicaid,DRG,7202,SEPTICEMIA and DISSEMINATED INFECTIONS,,Relative Weights,"$3,678.52 ",IP,"3,678.52","3,678.52",,,,,,
BCBS Medicaid,DRG,7203,SEPTICEMIA and DISSEMINATED INFECTIONS,,Relative Weights,"$5,399.74 ",IP,"5,399.74","5,399.74",,,,,,
BCBS Medicaid,DRG,7204,SEPTICEMIA and DISSEMINATED INFECTIONS,,Relative Weights,"$10,740.72 ",IP,"10,740.72","10,740.72",,,,,,
BCBS Medicaid,DRG,7211,"POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS",,Relative Weights,"$2,917.38 ",IP,"2,917.38","2,917.38",,,,,,
BCBS Medicaid,DRG,7212,POSTOPERATIVE POSTTRAUMATIC OTHER DEVICE INFECTIONS,,Relative Weights,"$3,837.27 ",IP,"3,837.27","3,837.27",,,,,,
BCBS Medicaid,DRG,7213,POSTOPERATIVE POSTTRAUMATIC OTHER DEVICE INFECTIONS,,Relative Weights,"$6,182.18 ",IP,"6,182.18","6,182.18",,,,,,
BCBS Medicaid,DRG,7214,POSTOPERATIVE POSTTRAUMATIC OTHER DEVICE INFECTIONS,,Relative Weights,"$12,158.86 ",IP,"12,158.86","12,158.86",,,,,,
BCBS Medicaid,DRG,7221,FEVER,,Relative Weights,"$1,952.14 ",IP,"1,952.14","1,952.14",,,,,,
BCBS Medicaid,DRG,7222,FEVER,,Relative Weights,"$2,920.13 ",IP,"2,920.13","2,920.13",,,,,,
BCBS Medicaid,DRG,7223,FEVER,,Relative Weights,"$3,952.39 ",IP,"3,952.39","3,952.39",,,,,,
BCBS Medicaid,DRG,7224,FEVER,,Relative Weights,"$6,941.25 ",IP,"6,941.25","6,941.25",,,,,,
BCBS Medicaid,DRG,7231,VIRAL ILLNESS,,Relative Weights,"$1,908.50 ",IP,"1,908.50","1,908.50",,,,,,
BCBS Medicaid,DRG,7232,VIRAL ILLNESS,,Relative Weights,"$2,685.44 ",IP,"2,685.44","2,685.44",,,,,,
BCBS Medicaid,DRG,7233,VIRAL ILLNESS,,Relative Weights,"$4,131.07 ",IP,"4,131.07","4,131.07",,,,,,
BCBS Medicaid,DRG,7234,VIRAL ILLNESS,,Relative Weights,"$10,429.39 ",IP,"10,429.39","10,429.39",,,,,,
BCBS Medicaid,DRG,7241,OTHER INFECTIOUS and PARASITIC DISEASES,,Relative Weights,"$3,048.31 ",IP,"3,048.31","3,048.31",,,,,,
BCBS Medicaid,DRG,7242,OTHER INFECTIOUS and PARASITIC DISEASES,,Relative Weights,"$3,655.49 ",IP,"3,655.49","3,655.49",,,,,,
BCBS Medicaid,DRG,7243,OTHER INFECTIOUS and PARASITIC DISEASES,,Relative Weights,"$5,820.68 ",IP,"5,820.68","5,820.68",,,,,,
BCBS Medicaid,DRG,7244,OTHER INFECTIOUS and PARASITIC DISEASES,,Relative Weights,"$13,099.02 ",IP,"13,099.02","13,099.02",,,,,,
BCBS Medicaid,DRG,7401,MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE,,Relative Weights,"$6,032.70 ",IP,"6,032.70","6,032.70",,,,,,
BCBS Medicaid,DRG,7402,MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE,,Relative Weights,"$6,703.46 ",IP,"6,703.46","6,703.46",,,,,,
BCBS Medicaid,DRG,7403,MENTAL ILLNESS DIAGNOSIS W O.R. PROCEDURE,,Relative Weights,"$13,324.79 ",IP,"13,324.79","13,324.79",,,,,,
BCBS Medicaid,DRG,7404,MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE,,Relative Weights,"$26,668.81 ",IP,"26,668.81","26,668.81",,,,,,
BCBS Medicaid,DRG,7501,SCHIZOPHRENIA,,Relative Weights,"$2,530.12 ",IP,"2,530.12","2,530.12",,,,,,
BCBS Medicaid,DRG,7502,SCHIZOPHRENIA,,Relative Weights,"$2,708.80 ",IP,"2,708.80","2,708.80",,,,,,
BCBS Medicaid,DRG,7503,SCHIZOPHRENIA,,Relative Weights,"$4,799.08 ",IP,"4,799.08","4,799.08",,,,,,
BCBS Medicaid,DRG,7504,SCHIZOPHRENIA,,Relative Weights,"$13,473.58 ",IP,"13,473.58","13,473.58",,,,,,
BCBS Medicaid,DRG,7511,MAJOR DEPRESSIVE DISORDERS and OTHERUNSPECIFIED PSYCHOSES,,Relative Weights,"$1,760.40 ",IP,"1,760.40","1,760.40",,,,,,
BCBS Medicaid,DRG,7512,MAJOR DEPRESSIVE DISORDERS & OTHER/UNSPECIFIED PSYCHOSES,,Relative Weights,"$2,237.01 ",IP,"2,237.01","2,237.01",,,,,,
BCBS Medicaid,DRG,7513,MAJOR DEPRESSIVE DISORDERS and OTHERUNSPECIFIED PSYCHOSES,,Relative Weights,"$3,773.70 ",IP,"3,773.70","3,773.70",,,,,,
BCBS Medicaid,DRG,7514,MAJOR DEPRESSIVE DISORDERS and OTHERUNSPECIFIED PSYCHOSES,,Relative Weights,"$8,518.14 ",IP,"8,518.14","8,518.14",,,,,,
BCBS Medicaid,DRG,7521,DISORDERS OF PERSONALITY and IMPULSE CONTROL,,Relative Weights,"$1,687.20 ",IP,"1,687.20","1,687.20",,,,,,
BCBS Medicaid,DRG,7522,DISORDERS OF PERSONALITY & IMPULSE CONTROL,,Relative Weights,"$2,102.30 ",IP,"2,102.30","2,102.30",,,,,,
BCBS Medicaid,DRG,7523,DISORDERS OF PERSONALITY & IMPULSE CONTROL,,Relative Weights,"$3,885.72 ",IP,"3,885.72","3,885.72",,,,,,
BCBS Medicaid,DRG,7524,DISORDERS OF PERSONALITY and IMPULSE CONTROL,,Relative Weights,"$13,737.14 ",IP,"13,737.14","13,737.14",,,,,,
BCBS Medicaid,DRG,7531,BIPOLAR DISORDERS,,Relative Weights,"$1,873.11 ",IP,"1,873.11","1,873.11",,,,,,
BCBS Medicaid,DRG,7532,BIPOLAR DISORDERS,,Relative Weights,"$2,183.40 ",IP,"2,183.40","2,183.40",,,,,,
BCBS Medicaid,DRG,7533,BIPOLAR DISORDERS,,Relative Weights,"$3,541.07 ",IP,"3,541.07","3,541.07",,,,,,
BCBS Medicaid,DRG,7534,BIPOLAR DISORDERS,,Relative Weights,"$10,043.84 ",IP,"10,043.84","10,043.84",,,,,,
BCBS Medicaid,DRG,7541,DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,,Relative Weights,"$1,523.64 ",IP,"1,523.64","1,523.64",,,,,,
BCBS Medicaid,DRG,7542,DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,,Relative Weights,"$2,007.46 ",IP,"2,007.46","2,007.46",,,,,,
BCBS Medicaid,DRG,7543,DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,,Relative Weights,"$3,012.23 ",IP,"3,012.23","3,012.23",,,,,,
BCBS Medicaid,DRG,7544,DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,,Relative Weights,"$7,979.68 ",IP,"7,979.68","7,979.68",,,,,,
BCBS Medicaid,DRG,7551,ADJUSTMENT DISORDERS and NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,,Relative Weights,"$1,532.57 ",IP,"1,532.57","1,532.57",,,,,,
BCBS Medicaid,DRG,7552,ADJUSTMENT DISORDERS and NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,,Relative Weights,"$2,506.06 ",IP,"2,506.06","2,506.06",,,,,,
BCBS Medicaid,DRG,7553,ADJUSTMENT DISORDERS and NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,,Relative Weights,"$3,538.32 ",IP,"3,538.32","3,538.32",,,,,,
BCBS Medicaid,DRG,7554,ADJUSTMENT DISORDERS and NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,,Relative Weights,"$6,118.26 ",IP,"6,118.26","6,118.26",,,,,,
BCBS Medicaid,DRG,7561,ACUTE ANXIETY and DELIRIUM STATES,,Relative Weights,"$2,496.79 ",IP,"2,496.79","2,496.79",,,,,,
BCBS Medicaid,DRG,7562,ACUTE ANXIETY & DELIRIUM STATES,,Relative Weights,"$3,057.58 ",IP,"3,057.58","3,057.58",,,,,,
BCBS Medicaid,DRG,7563,ACUTE ANXIETY and DELIRIUM STATES,,Relative Weights,"$3,397.43 ",IP,"3,397.43","3,397.43",,,,,,
BCBS Medicaid,DRG,7564,ACUTE ANXIETY and DELIRIUM STATES,,Relative Weights,"$7,384.52 ",IP,"7,384.52","7,384.52",,,,,,
BCBS Medicaid,DRG,7571,ORGANIC MENTAL HEALTH DISTURBANCES,,Relative Weights,"$2,504.35 ",IP,"2,504.35","2,504.35",,,,,,
BCBS Medicaid,DRG,7572,ORGANIC MENTAL HEALTH DISTURBANCES,,Relative Weights,"$3,161.02 ",IP,"3,161.02","3,161.02",,,,,,
BCBS Medicaid,DRG,7573,ORGANIC MENTAL HEALTH DISTURBANCES,,Relative Weights,"$5,750.24 ",IP,"5,750.24","5,750.24",,,,,,
BCBS Medicaid,DRG,7574,ORGANIC MENTAL HEALTH DISTURBANCES,,Relative Weights,"$15,933.94 ",IP,"15,933.94","15,933.94",,,,,,
BCBS Medicaid,DRG,7581,BEHAVIORAL DISORDERS,,Relative Weights,"$2,326.35 ",IP,"2,326.35","2,326.35",,,,,,
BCBS Medicaid,DRG,7582,BEHAVIORAL DISORDERS,,Relative Weights,"$2,881.65 ",IP,"2,881.65","2,881.65",,,,,,
BCBS Medicaid,DRG,7583,BEHAVIORAL DISORDERS,,Relative Weights,"$4,037.26 ",IP,"4,037.26","4,037.26",,,,,,
BCBS Medicaid,DRG,7584,BEHAVIORAL DISORDERS,,Relative Weights,"$5,464.00 ",IP,"5,464.00","5,464.00",,,,,,
BCBS Medicaid,DRG,7591,EATING DISORDERS,,Relative Weights,"$4,564.04 ",IP,"4,564.04","4,564.04",,,,,,
BCBS Medicaid,DRG,7592,EATING DISORDERS,,Relative Weights,"$5,955.04 ",IP,"5,955.04","5,955.04",,,,,,
BCBS Medicaid,DRG,7593,EATING DISORDERS,,Relative Weights,"$9,440.78 ",IP,"9,440.78","9,440.78",,,,,,
BCBS Medicaid,DRG,7594,EATING DISORDERS,,Relative Weights,"$12,954.01 ",IP,"12,954.01","12,954.01",,,,,,
BCBS Medicaid,DRG,7601,OTHER MENTAL HEALTH DISORDERS,,Relative Weights,"$2,553.48 ",IP,"2,553.48","2,553.48",,,,,,
BCBS Medicaid,DRG,7602,OTHER MENTAL HEALTH DISORDERS,,Relative Weights,"$3,467.19 ",IP,"3,467.19","3,467.19",,,,,,
BCBS Medicaid,DRG,7603,OTHER MENTAL HEALTH DISORDERS,,Relative Weights,"$6,902.07 ",IP,"6,902.07","6,902.07",,,,,,
BCBS Medicaid,DRG,7604,OTHER MENTAL HEALTH DISORDERS,,Relative Weights,"$12,546.82 ",IP,"12,546.82","12,546.82",,,,,,
BCBS Medicaid,DRG,7701,DRUG and ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE,,Relative Weights,"$1,041.53 ",IP,"1,041.53","1,041.53",,,,,,
BCBS Medicaid,DRG,7702,"DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE",,Relative Weights,"$1,522.95 ",IP,"1,522.95","1,522.95",,,,,,
BCBS Medicaid,DRG,7703,"DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE",,Relative Weights,"$2,633.89 ",IP,"2,633.89","2,633.89",,,,,,
BCBS Medicaid,DRG,7704,DRUG and ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE,,Relative Weights,"$6,153.65 ",IP,"6,153.65","6,153.65",,,,,,
BCBS Medicaid,DRG,7721,ALCOHOL and DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY,,Relative Weights,"$2,743.85 ",IP,"2,743.85","2,743.85",,,,,,
BCBS Medicaid,DRG,7722,ALCOHOL and DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY,,Relative Weights,"$3,502.58 ",IP,"3,502.58","3,502.58",,,,,,
BCBS Medicaid,DRG,7723,ALCOHOL and DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY,,Relative Weights,"$4,241.72 ",IP,"4,241.72","4,241.72",,,,,,
BCBS Medicaid,DRG,7724,ALCOHOL & DRUG DEPENDENCE W REHAB OR REHAB/DETOX THERAPY,,Relative Weights,"$9,550.40 ",IP,"9,550.40","9,550.40",,,,,,
BCBS Medicaid,DRG,7731,OPIOID ABUSE and DEPENDENCE,,Relative Weights,"$1,275.88 ",IP,"1,275.88","1,275.88",,,,,,
BCBS Medicaid,DRG,7732,OPIOID ABUSE and DEPENDENCE,,Relative Weights,"$1,881.01 ",IP,"1,881.01","1,881.01",,,,,,
BCBS Medicaid,DRG,7733,OPIOID ABUSE and DEPENDENCE,,Relative Weights,"$3,476.12 ",IP,"3,476.12","3,476.12",,,,,,
BCBS Medicaid,DRG,7734,OPIOID ABUSE & DEPENDENCE,,Relative Weights,"$9,565.86 ",IP,"9,565.86","9,565.86",,,,,,
BCBS Medicaid,DRG,7741,COCAINE ABUSE and DEPENDENCE,,Relative Weights,"$1,761.43 ",IP,"1,761.43","1,761.43",,,,,,
BCBS Medicaid,DRG,7742,COCAINE ABUSE and DEPENDENCE,,Relative Weights,"$1,956.95 ",IP,"1,956.95","1,956.95",,,,,,
BCBS Medicaid,DRG,7743,COCAINE ABUSE and DEPENDENCE,,Relative Weights,"$3,314.62 ",IP,"3,314.62","3,314.62",,,,,,
BCBS Medicaid,DRG,7744,COCAINE ABUSE and DEPENDENCE,,Relative Weights,"$9,105.40 ",IP,"9,105.40","9,105.40",,,,,,
BCBS Medicaid,DRG,7751,ALCOHOL ABUSE and DEPENDENCE,,Relative Weights,"$1,741.50 ",IP,"1,741.50","1,741.50",,,,,,
BCBS Medicaid,DRG,7752,ALCOHOL ABUSE & DEPENDENCE,,Relative Weights,"$2,441.81 ",IP,"2,441.81","2,441.81",,,,,,
BCBS Medicaid,DRG,7753,ALCOHOL ABUSE and DEPENDENCE,,Relative Weights,"$3,986.06 ",IP,"3,986.06","3,986.06",,,,,,
BCBS Medicaid,DRG,7754,ALCOHOL ABUSE and DEPENDENCE,,Relative Weights,"$10,751.37 ",IP,"10,751.37","10,751.37",,,,,,
BCBS Medicaid,DRG,7761,OTHER DRUG ABUSE and DEPENDENCE,,Relative Weights,"$2,414.66 ",IP,"2,414.66","2,414.66",,,,,,
BCBS Medicaid,DRG,7762,OTHER DRUG ABUSE & DEPENDENCE,,Relative Weights,"$2,653.48 ",IP,"2,653.48","2,653.48",,,,,,
BCBS Medicaid,DRG,7763,OTHER DRUG ABUSE & DEPENDENCE,,Relative Weights,"$4,175.40 ",IP,"4,175.40","4,175.40",,,,,,
BCBS Medicaid,DRG,7764,OTHER DRUG ABUSE and DEPENDENCE,,Relative Weights,"$7,699.28 ",IP,"7,699.28","7,699.28",,,,,,
BCBS Medicaid,DRG,7921,EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$7,773.51 ",IP,"7,773.51","7,773.51",,,,,,
BCBS Medicaid,DRG,7922,EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$8,931.53 ",IP,"8,931.53","8,931.53",,,,,,
BCBS Medicaid,DRG,7923,EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$13,005.21 ",IP,"13,005.21","13,005.21",,,,,,
BCBS Medicaid,DRG,7924,EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$27,591.45 ",IP,"27,591.45","27,591.45",,,,,,
BCBS Medicaid,DRG,7931,MODERATELY EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$4,608.37 ",IP,"4,608.37","4,608.37",,,,,,
BCBS Medicaid,DRG,7932,MODERATELY EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$6,350.90 ",IP,"6,350.90","6,350.90",,,,,,
BCBS Medicaid,DRG,7933,MODERATELY EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$9,808.12 ",IP,"9,808.12","9,808.12",,,,,,
BCBS Medicaid,DRG,7934,MODERATELY EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$20,177.03 ",IP,"20,177.03","20,177.03",,,,,,
BCBS Medicaid,DRG,7941,NONEXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$3,990.87 ",IP,"3,990.87","3,990.87",,,,,,
BCBS Medicaid,DRG,7942,NONEXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$5,327.92 ",IP,"5,327.92","5,327.92",,,,,,
BCBS Medicaid,DRG,7943,NONEXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$7,911.30 ",IP,"7,911.30","7,911.30",,,,,,
BCBS Medicaid,DRG,7944,NON-EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$16,457.28 ",IP,"16,457.28","16,457.28",,,,,,
BCBS Medicaid,DRG,8101,HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION,,Relative Weights,"$2,594.03 ",IP,"2,594.03","2,594.03",,,,,,
BCBS Medicaid,DRG,8102,HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION,,Relative Weights,"$3,420.11 ",IP,"3,420.11","3,420.11",,,,,,
BCBS Medicaid,DRG,8103,HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION,,Relative Weights,"$5,351.98 ",IP,"5,351.98","5,351.98",,,,,,
BCBS Medicaid,DRG,8104,HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION,,Relative Weights,"$10,772.68 ",IP,"10,772.68","10,772.68",,,,,,
BCBS Medicaid,DRG,8111,ALLERGIC REACTIONS,,Relative Weights,"$1,582.40 ",IP,"1,582.40","1,582.40",,,,,,
BCBS Medicaid,DRG,8112,ALLERGIC REACTIONS,,Relative Weights,"$2,325.66 ",IP,"2,325.66","2,325.66",,,,,,
BCBS Medicaid,DRG,8113,ALLERGIC REACTIONS,,Relative Weights,"$4,003.24 ",IP,"4,003.24","4,003.24",,,,,,
BCBS Medicaid,DRG,8114,ALLERGIC REACTIONS,,Relative Weights,"$9,358.65 ",IP,"9,358.65","9,358.65",,,,,,
BCBS Medicaid,DRG,8121,POISONING OF MEDICINAL AGENTS,,Relative Weights,"$1,778.95 ",IP,"1,778.95","1,778.95",,,,,,
BCBS Medicaid,DRG,8122,POISONING OF MEDICINAL AGENTS,,Relative Weights,"$2,471.70 ",IP,"2,471.70","2,471.70",,,,,,
BCBS Medicaid,DRG,8123,POISONING OF MEDICINAL AGENTS,,Relative Weights,"$3,713.91 ",IP,"3,713.91","3,713.91",,,,,,
BCBS Medicaid,DRG,8124,POISONING OF MEDICINAL AGENTS,,Relative Weights,"$7,487.95 ",IP,"7,487.95","7,487.95",,,,,,
BCBS Medicaid,DRG,8131,OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$2,963.09 ",IP,"2,963.09","2,963.09",,,,,,
BCBS Medicaid,DRG,8132,OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$3,546.91 ",IP,"3,546.91","3,546.91",,,,,,
BCBS Medicaid,DRG,8133,OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$5,048.90 ",IP,"5,048.90","5,048.90",,,,,,
BCBS Medicaid,DRG,8134,OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$10,108.45 ",IP,"10,108.45","10,108.45",,,,,,
BCBS Medicaid,DRG,8151,OTHER INJURY POISONING and TOXIC EFFECT DIAGNOSES,,Relative Weights,"$2,225.32 ",IP,"2,225.32","2,225.32",,,,,,
BCBS Medicaid,DRG,8152,"OTHER INJURY, POISONING & TOXIC EFFECT DIAGNOSES",,Relative Weights,"$3,062.74 ",IP,"3,062.74","3,062.74",,,,,,
BCBS Medicaid,DRG,8153,OTHER INJURY POISONING and TOXIC EFFECT DIAGNOSES,,Relative Weights,"$5,006.29 ",IP,"5,006.29","5,006.29",,,,,,
BCBS Medicaid,DRG,8154,OTHER INJURY POISONING and TOXIC EFFECT DIAGNOSES,,Relative Weights,"$14,243.99 ",IP,"14,243.99","14,243.99",,,,,,
BCBS Medicaid,DRG,8161,TOXIC EFFECTS OF NONMEDICINAL SUBSTANCES,,Relative Weights,"$2,832.85 ",IP,"2,832.85","2,832.85",,,,,,
BCBS Medicaid,DRG,8162,TOXIC EFFECTS OF NONMEDICINAL SUBSTANCES,,Relative Weights,"$3,147.27 ",IP,"3,147.27","3,147.27",,,,,,
BCBS Medicaid,DRG,8163,TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES,,Relative Weights,"$3,543.13 ",IP,"3,543.13","3,543.13",,,,,,
BCBS Medicaid,DRG,8164,TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES,,Relative Weights,"$7,485.21 ",IP,"7,485.21","7,485.21",,,,,,
BCBS Medicaid,DRG,8171,OVERDOSE,,Relative Weights,"$1,970.70 ",IP,"1,970.70","1,970.70",,,,,,
BCBS Medicaid,DRG,8172,OVERDOSE,,Relative Weights,"$2,320.16 ",IP,"2,320.16","2,320.16",,,,,,
BCBS Medicaid,DRG,8173,OVERDOSE,,Relative Weights,"$3,714.94 ",IP,"3,714.94","3,714.94",,,,,,
BCBS Medicaid,DRG,8174,OVERDOSE,,Relative Weights,"$7,902.37 ",IP,"7,902.37","7,902.37",,,,,,
BCBS Medicaid,DRG,8411,EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT,,Relative Weights,"$22,662.13 ",IP,"22,662.13","22,662.13",,,,,,
BCBS Medicaid,DRG,8412,EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT,,Relative Weights,"$23,053.18 ",IP,"23,053.18","23,053.18",,,,,,
BCBS Medicaid,DRG,8413,EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT,,Relative Weights,"$35,475.26 ",IP,"35,475.26","35,475.26",,,,,,
BCBS Medicaid,DRG,8414,EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT,,Relative Weights,"$76,935.80 ",IP,"76,935.80","76,935.80",,,,,,
BCBS Medicaid,DRG,8421,BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS,,Relative Weights,"$7,378.34 ",IP,"7,378.34","7,378.34",,,,,,
BCBS Medicaid,DRG,8422,BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS,,Relative Weights,"$11,298.08 ",IP,"11,298.08","11,298.08",,,,,,
BCBS Medicaid,DRG,8423,BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS,,Relative Weights,"$20,251.94 ",IP,"20,251.94","20,251.94",,,,,,
BCBS Medicaid,DRG,8424,BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS,,Relative Weights,"$47,998.02 ",IP,"47,998.02","47,998.02",,,,,,
BCBS Medicaid,DRG,8431,EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT,,Relative Weights,"$3,499.14 ",IP,"3,499.14","3,499.14",,,,,,
BCBS Medicaid,DRG,8432,EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT,,Relative Weights,"$3,888.47 ",IP,"3,888.47","3,888.47",,,,,,
BCBS Medicaid,DRG,8433,EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT,,Relative Weights,"$4,320.07 ",IP,"4,320.07","4,320.07",,,,,,
BCBS Medicaid,DRG,8434,EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS W/O SKIN GRAFT,,Relative Weights,"$12,575.34 ",IP,"12,575.34","12,575.34",,,,,,
BCBS Medicaid,DRG,8441,PARTIAL THICKNESS BURNS WO SKIN GRAFT,,Relative Weights,"$2,201.96 ",IP,"2,201.96","2,201.96",,,,,,
BCBS Medicaid,DRG,8442,PARTIAL THICKNESS BURNS WO SKIN GRAFT,,Relative Weights,"$3,652.06 ",IP,"3,652.06","3,652.06",,,,,,
BCBS Medicaid,DRG,8443,PARTIAL THICKNESS BURNS WO SKIN GRAFT,,Relative Weights,"$7,050.86 ",IP,"7,050.86","7,050.86",,,,,,
BCBS Medicaid,DRG,8444,PARTIAL THICKNESS BURNS W/O SKIN GRAFT,,Relative Weights,"$19,183.95 ",IP,"19,183.95","19,183.95",,,,,,
BCBS Medicaid,DRG,8501,PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE,,Relative Weights,"$9,879.93 ",IP,"9,879.93","9,879.93",,,,,,
BCBS Medicaid,DRG,8502,PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE,,Relative Weights,"$12,498.36 ",IP,"12,498.36","12,498.36",,,,,,
BCBS Medicaid,DRG,8503,PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE,,Relative Weights,"$15,265.59 ",IP,"15,265.59","15,265.59",,,,,,
BCBS Medicaid,DRG,8504,"PROCEDURE W DIAG OF REHAB, AFTERCARE OR OTH CONTACT W HEALTH SERVICE",,Relative Weights,"$33,306.29 ",IP,"33,306.29","33,306.29",,,,,,
BCBS Medicaid,DRG,8601,REHABILITATION,REHABILITATION,Relative Weights,"$2,725.99 ",IP,"2,725.99","2,725.99",,,,,,
BCBS Medicaid,DRG,8602,REHABILITATION,REHABILITATION,Relative Weights,"$2,784.40 ",IP,"2,784.40","2,784.40",,,,,,
BCBS Medicaid,DRG,8603,REHABILITATION,REHABILITATION,Relative Weights,"$4,569.88 ",IP,"4,569.88","4,569.88",,,,,,
BCBS Medicaid,DRG,8604,REHABILITATION,REHABILITATION,Relative Weights,"$7,353.25 ",IP,"7,353.25","7,353.25",,,,,,
BCBS Medicaid,DRG,8611,"SIGNS, SYMPTOMS & OTHER FACTORS INFLUENCING HEALTH STATUS",,Relative Weights,"$2,528.74 ",IP,"2,528.74","2,528.74",,,,,,
BCBS Medicaid,DRG,8612,SIGNS SYMPTOMS and OTHER FACTORS INFLUENCING HEALTH STATUS,,Relative Weights,"$3,061.36 ",IP,"3,061.36","3,061.36",,,,,,
BCBS Medicaid,DRG,8613,SIGNS SYMPTOMS and OTHER FACTORS INFLUENCING HEALTH STATUS,,Relative Weights,"$4,043.10 ",IP,"4,043.10","4,043.10",,,,,,
BCBS Medicaid,DRG,8614,SIGNS SYMPTOMS and OTHER FACTORS INFLUENCING HEALTH STATUS,,Relative Weights,"$7,783.47 ",IP,"7,783.47","7,783.47",,,,,,
BCBS Medicaid,DRG,8621,OTHER AFTERCARE and CONVALESCENCE,,Relative Weights,"$2,738.70 ",IP,"2,738.70","2,738.70",,,,,,
BCBS Medicaid,DRG,8622,OTHER AFTERCARE and CONVALESCENCE,,Relative Weights,"$3,392.96 ",IP,"3,392.96","3,392.96",,,,,,
BCBS Medicaid,DRG,8623,OTHER AFTERCARE and CONVALESCENCE,,Relative Weights,"$4,971.92 ",IP,"4,971.92","4,971.92",,,,,,
BCBS Medicaid,DRG,8624,OTHER AFTERCARE and CONVALESCENCE,,Relative Weights,"$9,845.92 ",IP,"9,845.92","9,845.92",,,,,,
BCBS Medicaid,DRG,8631,NEONATAL AFTERCARE,,Relative Weights,"$4,260.96 ",IP,"4,260.96","4,260.96",,,,,,
BCBS Medicaid,DRG,8632,NEONATAL AFTERCARE,,Relative Weights,"$10,340.39 ",IP,"10,340.39","10,340.39",,,,,,
BCBS Medicaid,DRG,8633,NEONATAL AFTERCARE,,Relative Weights,"$23,505.05 ",IP,"23,505.05","23,505.05",,,,,,
BCBS Medicaid,DRG,8634,NEONATAL AFTERCARE,,Relative Weights,"$48,982.51 ",IP,"48,982.51","48,982.51",,,,,,
BCBS Medicaid,DRG,8901,HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS,,Relative Weights,"$3,464.78 ",IP,"3,464.78","3,464.78",,,,,,
BCBS Medicaid,DRG,8902,HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS,,Relative Weights,"$4,475.73 ",IP,"4,475.73","4,475.73",,,,,,
BCBS Medicaid,DRG,8903,HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS,,Relative Weights,"$6,306.22 ",IP,"6,306.22","6,306.22",,,,,,
BCBS Medicaid,DRG,8904,HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS,,Relative Weights,"$13,523.40 ",IP,"13,523.40","13,523.40",,,,,,
BCBS Medicaid,DRG,8921,HIV W MAJOR HIV RELATED CONDITION,,Relative Weights,"$3,450.69 ",IP,"3,450.69","3,450.69",,,,,,
BCBS Medicaid,DRG,8922,HIV W MAJOR HIV RELATED CONDITION,,Relative Weights,"$4,178.15 ",IP,"4,178.15","4,178.15",,,,,,
BCBS Medicaid,DRG,8923,HIV W MAJOR HIV RELATED CONDITION,,Relative Weights,"$4,816.26 ",IP,"4,816.26","4,816.26",,,,,,
BCBS Medicaid,DRG,8924,HIV W MAJOR HIV RELATED CONDITION,,Relative Weights,"$8,453.20 ",IP,"8,453.20","8,453.20",,,,,,
BCBS Medicaid,DRG,8931,HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,,Relative Weights,"$2,817.73 ",IP,"2,817.73","2,817.73",,,,,,
BCBS Medicaid,DRG,8932,HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,,Relative Weights,"$4,010.80 ",IP,"4,010.80","4,010.80",,,,,,
BCBS Medicaid,DRG,8933,HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,,Relative Weights,"$5,201.12 ",IP,"5,201.12","5,201.12",,,,,,
BCBS Medicaid,DRG,8934,HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,,Relative Weights,"$9,134.61 ",IP,"9,134.61","9,134.61",,,,,,
BCBS Medicaid,DRG,8941,HIV W ONE SIGNIF HIV COND OR W/O SIGNIF RELATED COND,,Relative Weights,"$2,969.96 ",IP,"2,969.96","2,969.96",,,,,,
BCBS Medicaid,DRG,8942,HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND,,Relative Weights,"$3,496.05 ",IP,"3,496.05","3,496.05",,,,,,
BCBS Medicaid,DRG,8943,HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND,,Relative Weights,"$4,518.34 ",IP,"4,518.34","4,518.34",,,,,,
BCBS Medicaid,DRG,8944,HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND,,Relative Weights,"$6,751.91 ",IP,"6,751.91","6,751.91",,,,,,
BCBS Medicaid,DRG,9101,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$13,920.63 ",IP,"13,920.63","13,920.63",,,,,,
BCBS Medicaid,DRG,9102,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$15,317.47 ",IP,"15,317.47","15,317.47",,,,,,
BCBS Medicaid,DRG,9103,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$18,619.37 ",IP,"18,619.37","18,619.37",,,,,,
BCBS Medicaid,DRG,9104,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$36,457.00 ",IP,"36,457.00","36,457.00",,,,,,
BCBS Medicaid,DRG,9111,EXTENSIVE ABDOMINAL/THORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA,,Relative Weights,"$7,838.80 ",IP,"7,838.80","7,838.80",,,,,,
BCBS Medicaid,DRG,9112,EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA,,Relative Weights,"$10,303.63 ",IP,"10,303.63","10,303.63",,,,,,
BCBS Medicaid,DRG,9113,EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA,,Relative Weights,"$13,414.47 ",IP,"13,414.47","13,414.47",,,,,,
BCBS Medicaid,DRG,9114,EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA,,Relative Weights,"$32,085.73 ",IP,"32,085.73","32,085.73",,,,,,
BCBS Medicaid,DRG,9121,MUSCULOSKELETAL and OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$8,688.93 ",IP,"8,688.93","8,688.93",,,,,,
BCBS Medicaid,DRG,9122,MUSCULOSKELETAL and OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$9,567.24 ",IP,"9,567.24","9,567.24",,,,,,
BCBS Medicaid,DRG,9123,MUSCULOSKELETAL & OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$14,948.76 ",IP,"14,948.76","14,948.76",,,,,,
BCBS Medicaid,DRG,9124,MUSCULOSKELETAL & OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$30,211.60 ",IP,"30,211.60","30,211.60",,,,,,
BCBS Medicaid,DRG,9301,MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE,,Relative Weights,"$3,875.76 ",IP,"3,875.76","3,875.76",,,,,,
BCBS Medicaid,DRG,9302,MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE,,Relative Weights,"$4,609.06 ",IP,"4,609.06","4,609.06",,,,,,
BCBS Medicaid,DRG,9303,MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE,,Relative Weights,"$7,139.17 ",IP,"7,139.17","7,139.17",,,,,,
BCBS Medicaid,DRG,9304,MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE,,Relative Weights,"$15,709.89 ",IP,"15,709.89","15,709.89",,,,,,
BCBS Medicaid,DRG,9501,EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$7,265.63 ",IP,"7,265.63","7,265.63",,,,,,
BCBS Medicaid,DRG,9502,EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$9,410.20 ",IP,"9,410.20","9,410.20",,,,,,
BCBS Medicaid,DRG,9503,EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$12,679.80 ",IP,"12,679.80","12,679.80",,,,,,
BCBS Medicaid,DRG,9504,EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$27,388.02 ",IP,"27,388.02","27,388.02",,,,,,
BCBS Medicaid,DRG,9511,MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$5,641.31 ",IP,"5,641.31","5,641.31",,,,,,
BCBS Medicaid,DRG,9512,MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$7,394.49 ",IP,"7,394.49","7,394.49",,,,,,
BCBS Medicaid,DRG,9513,MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$11,184.68 ",IP,"11,184.68","11,184.68",,,,,,
BCBS Medicaid,DRG,9514,MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$22,584.13 ",IP,"22,584.13","22,584.13",,,,,,
BCBS Medicaid,DRG,9521,NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$4,663.69 ",IP,"4,663.69","4,663.69",,,,,,
BCBS Medicaid,DRG,9522,NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$6,212.76 ",IP,"6,212.76","6,212.76",,,,,,
BCBS Medicaid,DRG,9523,NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$9,852.10 ",IP,"9,852.10","9,852.10",,,,,,
BCBS Medicaid,DRG,9524,NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$20,519.28 ",IP,"20,519.28","20,519.28",,,,,,
BCBS Medicaid,CPT,100,Anesth salivary gland,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,102,Anesth repair of cleft lip,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,103,Anesth blepharoplasty,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,104,Anesth electroshock,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,120,Anesth ear surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,124,Anesth ear exam,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,126,Anesth tympanotomy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,140,Anesth procedures on eye,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,142,Anesth lens surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,144,Anesth corneal transplant,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,145,Anesth vitreoretinal surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,147,Anesth iridectomy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,148,Anesth eye exam,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,160,Anesth nose/sinus surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,162,Anesth nose/sinus surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,164,Anesth biopsy of nose,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,170,Anesth procedure on mouth,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,172,Anesth cleft palate repair,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,174,Anesth pharyngeal surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,176,Anesth pharyngeal surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,190,Anesth face/skull bone surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,192,Anesth facial bone surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,210,Anesth cranial surg nos,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,211,Anesth cran surg hemotoma,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,212,Anesth skull drainage,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,214,Anesth skull drainage,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,215,Anesth skull repair/fract,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,216,Anesth head vessel surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,218,Anesth special head surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,220,Anesth intrcrn nerve,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,222,Anesth head nerve surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,300,Anesth head/neck/ptrunk,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,320,Anesth neck organ 1yr/>,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,322,Anesth biopsy of thyroid,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,326,Anesth larynx/trach < 1 yr,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,350,Anesth neck vessel surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,352,Anesth neck vessel surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,400,Anesth skin ext/per/atrunk,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,402,Anesth surgery of breast,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,404,Anesth surgery of breast,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,406,Anesth surgery of breast,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,410,Anesth correct heart rhythm,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,450,Anesth surgery of shoulder,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,454,Anesth collar bone biopsy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,470,Anesth removal of rib,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,472,Anesth chest wall repair,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,474,Anesth surgery of rib,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,500,Anesth esophageal surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,520,Anesth chest procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,522,Anesth chest lining biopsy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,524,Anesth chest drainage,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,528,Anes mediascpy & dx thorscpy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,529,Anes medscpy&thorscpy 1 lung,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,530,Anesth pacemaker insertion,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,532,Anesth vascular access,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,534,Anesth cardioverter/defib,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,537,Anesth cardiac electrophys,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,539,Anesth trach-bronch reconst,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,540,Anesth chest surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,541,Anesth one lung ventilation,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,542,Anesthesia removal pleura,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,546,Anesth lung chest wall surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,548,Anesth trachea bronchi surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,550,Anesth sternal debridement,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,560,Anesth heart surg w/o pump,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,561,Anesth heart surg <1 yr,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,562,Anesth hrt surg w/pmp age 1+,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,563,Anesth heart surg w/arrest,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,566,Anesth cabg w/o pump,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,567,Anesth cabg w/pump,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,580,Anesth heart/lung transplnt,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,600,Anesth spine cord surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,604,Anesth sitting procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,620,Anesth spine cord surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,625,Anes spine tranthor w/o vent,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,626,Anes spine transthor w/vent,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,630,Anesth spine cord surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,632,Anesth removal of nerves,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,635,Anesth lumbar puncture,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,640,Anesth spine manipulation,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,670,Anesth spine cord surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,700,Anesth abdominal wall surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,702,Anesth for liver biopsy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,730,Anesth abdominal wall surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,731,Anes upr gi ndsc px nos,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,732,Anes upr gi ndsc px ercp,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,740,Anesth upper gi visualize,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,750,Anesth repair of hernia,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,752,Anesth repair of hernia,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,754,Anesth repair of hernia,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,756,Anesth repair of hernia,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,770,Anesth blood vessel repair,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,790,Anesth surg upper abdomen,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,792,Anesth hemorr/excise liver,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,794,Anesth pancreas removal,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,796,Anesth for liver transplant,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,797,Anesth surgery for obesity,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,800,Anesth abdominal wall surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,802,Anesth fat layer removal,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,810,Anesth low intestine scope,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,811,Anes lwr intst ndsc nos,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,812,Anes lwr intst scr colsc,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,813,Anes upr lwr gi ndsc px,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,820,Anesth abdominal wall surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,830,Anesth repair of hernia,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,832,Anesth repair of hernia,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,834,Anesth hernia repair < 1 yr,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,836,Anesth hernia repair preemie,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,840,Anesth surg lower abdomen,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,842,Anesth amniocentesis,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,844,Anesth pelvis surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,846,Anesth hysterectomy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,848,Anesth pelvic organ surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,851,Anesth tubal ligation,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,860,Anesth surgery of abdomen,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,862,Anesth kidney/ureter surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,864,Anesth removal of bladder,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,865,Anesth removal of prostate,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,866,Anesth removal of adrenal,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,868,Anesth kidney transplant,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,870,Anesth bladder stone surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,872,Anesth kidney stone destruct,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,873,Anesth kidney stone destruct,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,880,Anesth abdomen vessel surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,882,Anesth major vein ligation,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,902,Anesth anorectal surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,904,Anesth perineal surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,906,Anesth removal of vulva,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,908,Anesth removal of prostate,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,910,Anesth bladder surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,912,Anesth bladder tumor surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,914,Anesth removal of prostate,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,916,Anesth bleeding control,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,918,Anesth stone removal,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,920,Anesth genitalia surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,921,Anesth vasectomy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,922,Anesth sperm duct surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,924,Anesth testis exploration,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,926,Anesth removal of testis,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,928,Anesth removal of testis,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,930,Anesth testis suspension,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,932,Anesth amputation of penis,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,934,Anesth penis nodes removal,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,936,Anesth penis nodes removal,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,938,Anesth insert penis device,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,940,Anesth vaginal procedures,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,942,Anesth surg on vag/urethral,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,944,Anesth vaginal hysterectomy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,948,Anesth repair of cervix,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,950,Anesth vaginal endoscopy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,952,Anesth hysteroscope/graph,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1112,Anesth bone aspirate/bx,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1120,Anesth pelvis surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1130,Anesth body cast procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1140,Anesth amputation at pelvis,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1150,Anesth pelvic tumor surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1160,Anesth pelvis procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1170,Anesth pelvis surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1173,Anesth fx repair pelvis,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1180,Anesth pelvis nerve removal,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1190,Anesth pelvis nerve removal,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1200,Anesth hip joint procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1202,Anesth arthroscopy of hip,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1210,Anesth hip joint surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1212,Anesth hip disarticulation,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1214,Anesth hip arthroplasty,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1215,Anesth revise hip repair,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1220,Anesth procedure on femur,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1230,Anesth surgery of femur,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1232,Anesth amputation of femur,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1234,Anesth radical femur surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1250,Anesth upper leg surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1260,Anesth upper leg veins surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1270,Anesth thigh arteries surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1272,Anesth femoral artery surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1274,Anesth femoral embolectomy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1320,Anesth knee area surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1340,Anesth knee area procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1360,Anesth knee area surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1380,Anesth knee joint procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1382,Anesth dx knee arthroscopy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1390,Anesth knee area procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1392,Anesth knee area surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1400,Anesth knee joint surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1402,Anesth knee arthroplasty,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1404,Anesth amputation at knee,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1420,Anesth knee joint casting,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1430,Anesth knee veins surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1432,Anesth knee vessel surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1440,Anesth knee arteries surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1442,Anesth knee artery surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1444,Anesth knee artery repair,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1462,Anesth lower leg procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1464,Anesth ankle/ft arthroscopy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1470,Anesth lower leg surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1472,Anesth achilles tendon surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1474,Anesth lower leg surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1480,Anesth lower leg bone surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1482,Anesth radical leg surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1484,Anesth lower leg revision,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1486,Anesth ankle replacement,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1490,Anesth lower leg casting,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1500,Anesth leg arteries surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1502,Anesth lwr leg embolectomy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1520,Anesth lower leg vein surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1522,Anesth lower leg vein surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1610,Anesth surgery of shoulder,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1620,Anesth shoulder procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1622,Anes dx shoulder arthroscopy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1630,Anesth surgery of shoulder,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1634,Anesth shoulder joint amput,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1636,Anesth forequarter amput,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1638,Anesth shoulder replacement,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1650,Anesth shoulder artery surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1652,Anesth shoulder vessel surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1654,Anesth shoulder vessel surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1656,Anesth arm-leg vessel surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1670,Anesth shoulder vein surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1680,Anesth shoulder casting,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1682,Anesth airplane cast,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1710,Anesth elbow area surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1712,Anesth uppr arm tendon surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1714,Anesth uppr arm tendon surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1716,Anesth biceps tendon repair,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1730,Anesth uppr arm procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1732,Anesth dx elbow arthroscopy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1740,Anesth upper arm surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1742,Anesth humerus surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1744,Anesth humerus repair,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1756,Anesth radical humerus surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1758,Anesth humeral lesion surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1760,Anesth elbow replacement,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1770,Anesth uppr arm artery surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1772,Anesth uppr arm embolectomy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1780,Anesth upper arm vein surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1782,Anesth uppr arm vein repair,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1810,Anesth lower arm surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1820,Anesth lower arm procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1829,Anesth dx wrist arthroscopy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1830,Anesth lower arm surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1832,Anesth wrist replacement,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1840,Anesth lwr arm artery surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1842,Anesth lwr arm embolectomy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1844,Anesth vascular shunt surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1850,Anesth lower arm vein surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1852,Anesth lwr arm vein repair,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1860,Anesth lower arm casting,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1916,Anesth dx arteriography,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1920,Anesth catheterize heart,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1922,Anesth cat or mri scan,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1924,Anes ther interven rad artrl,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1925,Anes ther interven rad card,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1926,Anes tx interv rad hrt/cran,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1930,Anes ther interven rad vein,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1931,Anes ther interven rad tips,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1932,Anes tx interv rad th vein,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1933,Anes tx interv rad cran vein,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1935,Anesth perc img dx sp proc,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1936,Anesth perc img tx sp proc,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1951,Anesth burn less 4 percent,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1952,Anesth burn 4-9 percent,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1953,Anesth burn each 9 percent,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1958,Anesth antepartum manipul,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1960,Anesth vaginal delivery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1961,Anesth cs delivery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1962,Anesth emer hysterectomy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1963,Anesth cs hysterectomy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1965,Anesth inc/missed ab proc,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1966,Anesth induced ab procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1967,Anesth/analg vag delivery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1968,Anes/analg cs deliver add-on,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1969,Anesth/analg cs hyst add-on,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1991,Anesth nerve block/inj,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1992,Anesth n block/inj prone,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1996,Hosp manage cont drug admin,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,1999,Unlisted anesth procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,10004,Fna bx w/o img gdn ea addl,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
BCBS Medicaid,CPT,10005,Fna bx w/us gdn 1st les,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
BCBS Medicaid,CPT,10006,Fna bx w/us gdn ea addl,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
BCBS Medicaid,CPT,10007,Fna bx w/fluor gdn 1st les,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
BCBS Medicaid,CPT,10008,Fna bx w/fluor gdn ea addl,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
BCBS Medicaid,CPT,10009,Fna bx w/ct gdn 1st les,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
BCBS Medicaid,CPT,10010,Fna bx w/ct gdn ea addl,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
BCBS Medicaid,CPT,10011,Fna bx w/mr gdn 1st les,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
BCBS Medicaid,CPT,10012,Fna bx w/mr gdn ea addl,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
BCBS Medicaid,CPT,10021,Fna bx w/o img gdn 1st les,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
BCBS Medicaid,CPT,10022,Fna w/image,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
BCBS Medicaid,CPT,10030,Guide cathet fluid drainage,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
BCBS Medicaid,CPT,10040,Acne surgery,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,10060,Drainage of skin abscess,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,10061,Drainage of skin abscess,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,10080,Drainage of pilonidal cyst,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,10081,Drainage of pilonidal cyst,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
BCBS Medicaid,CPT,10120,Remove foreign body,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,10121,Remove foreign body,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
BCBS Medicaid,CPT,10140,Drainage of hematoma/fluid,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
BCBS Medicaid,CPT,10160,Puncture drainage of lesion,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,11055,Trim skin lesion,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,11056,Trim skin lesions 2 to 4,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,11057,Trim skin lesions over 4,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,11100,Biopsy skin lesion,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,11101,Biopsy skin add-on,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,11102,Tangntl bx skin single les,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,11103,Tangntl bx skin ea sep/addl,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,11104,Punch bx skin single lesion,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,11105,Punch bx skin ea sep/addl,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,11106,Incal bx skn single les,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,11107,Incal bx skn ea sep/addl,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,11200,Removal of skin tags <w/15,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,11201,Remove skin tags add-on,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,11300,Shave skin lesion 0.5 cm/<,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,11301,Shave skin lesion 0.6-1.0 cm,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,11302,Shave skin lesion 1.1-2.0 cm,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,11303,Shave skin lesion >2.0 cm,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,11305,Shave skin lesion 0.5 cm/<,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,11306,Shave skin lesion 0.6-1.0 cm,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,11307,Shave skin lesion 1.1-2.0 cm,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,11308,Shave skin lesion >2.0 cm,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,11310,Shave skin lesion 0.5 cm/<,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,11311,Shave skin lesion 0.6-1.0 cm,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,11312,Shave skin lesion 1.1-2.0 cm,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,11313,Shave skin lesion >2.0 cm,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,11400,Exc tr-ext b9+marg 0.5 cm<,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,11401,Exc tr-ext b9+marg 0.6-1 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,11402,Exc tr-ext b9+marg 1.1-2 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,11403,Exc tr-ext b9+marg 2.1-3cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,11404,Exc tr-ext b9+marg 3.1-4 cm,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
BCBS Medicaid,CPT,11406,Exc tr-ext b9+marg >4.0 cm,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
BCBS Medicaid,CPT,11420,Exc h-f-nk-sp b9+marg 0.5/<,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
BCBS Medicaid,CPT,11421,Exc h-f-nk-sp b9+marg 0.6-1,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,11422,Exc h-f-nk-sp b9+marg 1.1-2,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
BCBS Medicaid,CPT,11423,Exc h-f-nk-sp b9+marg 2.1-3,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
BCBS Medicaid,CPT,11424,Exc h-f-nk-sp b9+marg 3.1-4,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
BCBS Medicaid,CPT,11426,Exc h-f-nk-sp b9+marg >4 cm,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
BCBS Medicaid,CPT,11440,Exc face-mm b9+marg 0.5 cm/<,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,11441,Exc face-mm b9+marg 0.6-1 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,11442,Exc face-mm b9+marg 1.1-2 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,11443,Exc face-mm b9+marg 2.1-3 cm,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
BCBS Medicaid,CPT,11444,Exc face-mm b9+marg 3.1-4 cm,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
BCBS Medicaid,CPT,11446,Exc face-mm b9+marg >4 cm,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
BCBS Medicaid,CPT,11450,Removal sweat gland lesion,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
BCBS Medicaid,CPT,11451,Removal sweat gland lesion,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
BCBS Medicaid,CPT,11462,Removal sweat gland lesion,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
BCBS Medicaid,CPT,11463,Removal sweat gland lesion,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
BCBS Medicaid,CPT,11470,Removal sweat gland lesion,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
BCBS Medicaid,CPT,11471,Removal sweat gland lesion,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
BCBS Medicaid,CPT,11600,Exc tr-ext mal+marg 0.5 cm/<,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,11601,Exc tr-ext mal+marg 0.6-1 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,11602,Exc tr-ext mal+marg 1.1-2 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,11603,Exc tr-ext mal+marg 2.1-3 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,11604,Exc tr-ext mal+marg 3.1-4 cm,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
BCBS Medicaid,CPT,11606,Exc tr-ext mal+marg >4 cm,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
BCBS Medicaid,CPT,11620,Exc h-f-nk-sp mal+marg 0.5/<,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
BCBS Medicaid,CPT,11621,Exc s/n/h/f/g mal+mrg 0.6-1,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,11622,Exc s/n/h/f/g mal+mrg 1.1-2,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,11623,Exc s/n/h/f/g mal+mrg 2.1-3,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
BCBS Medicaid,CPT,11624,Exc s/n/h/f/g mal+mrg 3.1-4,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
BCBS Medicaid,CPT,11626,Exc s/n/h/f/g mal+mrg >4 cm,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
BCBS Medicaid,CPT,11640,Exc f/e/e/n/l mal+mrg 0.5cm<,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,11641,Exc f/e/e/n/l mal+mrg 0.6-1,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,11642,Exc f/e/e/n/l mal+mrg 1.1-2,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,11643,Exc f/e/e/n/l mal+mrg 2.1-3,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
BCBS Medicaid,CPT,11644,Exc f/e/e/n/l mal+mrg 3.1-4,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
BCBS Medicaid,CPT,11646,Exc f/e/e/n/l mal+mrg >4 cm,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
BCBS Medicaid,CPT,11719,Trim nail(s) any number,General Surgery,Per Unit,$46.77 ,OP,46.77,46.77,,,,,,
BCBS Medicaid,CPT,11720,Debride nail 1-5,General Surgery,Per Unit,$46.77 ,OP,46.77,46.77,,,,,,
BCBS Medicaid,CPT,11721,Debride nail 6 or more,General Surgery,Per Unit,$46.77 ,OP,46.77,46.77,,,,,,
BCBS Medicaid,CPT,11730,Removal of nail plate,General Surgery,Per Unit,$46.77 ,OP,46.77,46.77,,,,,,
BCBS Medicaid,CPT,11732,Remove nail plate add-on,General Surgery,Per Unit,$46.77 ,OP,46.77,46.77,,,,,,
BCBS Medicaid,CPT,11740,Drain blood from under nail,General Surgery,Per Unit,$46.77 ,OP,46.77,46.77,,,,,,
BCBS Medicaid,CPT,11750,Removal of nail bed,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,11752,Remove nail bed/tip,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
BCBS Medicaid,CPT,11755,Biopsy nail unit,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,11760,Repair of nail bed,General Surgery,Per Unit,$46.77 ,OP,46.77,46.77,,,,,,
BCBS Medicaid,CPT,11762,Reconstruction of nail bed,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
BCBS Medicaid,CPT,11765,Excision of nail fold toe,General Surgery,Per Unit,$46.77 ,OP,46.77,46.77,,,,,,
BCBS Medicaid,CPT,11770,Remove pilonidal cyst simple,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
BCBS Medicaid,CPT,11771,Remove pilonidal cyst exten,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
BCBS Medicaid,CPT,11772,Remove pilonidal cyst compl,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
BCBS Medicaid,CPT,11900,Inject skin lesions </w 7,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,11901,Inject skin lesions >7,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,11920,Correct skin color 6.0 cm/<,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,11921,Correct skn color 6.1-20.0cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,11922,Correct skin color ea 20.0cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,11950,Tx contour defects 1 cc/<,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,11951,Tx contour defects 1.1-5.0cc,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,11952,Tx contour defects 5.1-10cc,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,11954,Tx contour defects >10.0 cc,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
BCBS Medicaid,CPT,11960,Insert tissue expander(s),General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
BCBS Medicaid,CPT,11971,Rmvl tis xpndr wo insj implt,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
BCBS Medicaid,CPT,11976,Remove contraceptive capsule,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,11980,Implant hormone pellet(s),General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,11981,Insert drug implant device,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,11982,Remove drug implant device,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,11983,Remove/insert drug implant,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
BCBS Medicaid,CPT,13100,Cmplx rpr trunk 1.1-2.5 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,13101,Cmplx rpr trunk 2.6-7.5 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,13102,Cmplx rpr trunk addl 5cm/<,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,13120,Cmplx rpr s/a/l 1.1-2.5 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,13121,Cmplx rpr s/a/l 2.6-7.5 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,13122,Cmplx rpr s/a/l addl 5 cm/>,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,13131,Cmplx rpr f/c/c/m/n/ax/g/h/f,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,13132,Cmplx rpr f/c/c/m/n/ax/g/h/f,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,13133,Cmplx rpr f/c/c/m/n/ax/g/h/f,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,13151,Cmplx rpr e/n/e/l 1.1-2.5 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,13152,Cmplx rpr e/n/e/l 2.6-7.5 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,13153,Cmplx rpr e/n/e/l addl 5cm/<,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
BCBS Medicaid,CPT,15050,Skin pinch graft,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,15775,Hair trnspl 1-15 punch grfts,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,15776,Hair trnspl >15 punch grafts,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,15780,Dermabrasion total face,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
BCBS Medicaid,CPT,15781,Dermabrasion segmental face,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
BCBS Medicaid,CPT,15782,Dermabrasion other than face,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
BCBS Medicaid,CPT,15783,Dermabrasion suprfl any site,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
BCBS Medicaid,CPT,15786,Abrasion lesion single,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,15787,Abrasion lesions add-on,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,15788,Chemical peel face epiderm,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,15789,Chemical peel face dermal,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,15792,Chemical peel nonfacial,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,15793,Chemical peel nonfacial,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
BCBS Medicaid,CPT,15819,Plastic surgery neck,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
BCBS Medicaid,CPT,15820,Revision of lower eyelid,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
BCBS Medicaid,CPT,15821,Revision of lower eyelid,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
BCBS Medicaid,CPT,15822,Revision of upper eyelid,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
BCBS Medicaid,CPT,15823,Revision of upper eyelid,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
BCBS Medicaid,CPT,15824,Removal of forehead wrinkles,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
BCBS Medicaid,CPT,15825,Removal of neck wrinkles,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
BCBS Medicaid,CPT,15826,Removal of brow wrinkles,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
BCBS Medicaid,CPT,15828,Removal of face wrinkles,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
BCBS Medicaid,CPT,15829,Removal of skin wrinkles,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
BCBS Medicaid,CPT,15830,Exc skin abd,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
BCBS Medicaid,CPT,15832,Excise excessive skin thigh,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
BCBS Medicaid,CPT,15833,Excise excessive skin leg,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
BCBS Medicaid,CPT,15834,Excise excessive skin hip,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
BCBS Medicaid,CPT,15835,Excise excessive skin buttck,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
BCBS Medicaid,CPT,15836,Excise excessive skin arm,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
BCBS Medicaid,CPT,15837,Excise excess skin arm/hand,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
BCBS Medicaid,CPT,15838,Excise excess skin fat pad,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
BCBS Medicaid,CPT,15839,Excise excess skin & tissue,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
BCBS Medicaid,CPT,15847,Exc skin abd add-on,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
BCBS Medicaid,CPT,15850,Remove sutures same surgeon,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
BCBS Medicaid,CPT,15851,Remove sutures diff surgeon,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
BCBS Medicaid,CPT,15876,Suction lipectomy head&neck,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
BCBS Medicaid,CPT,15877,Suction lipectomy trunk,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
BCBS Medicaid,CPT,15878,Suction lipectomy upr extrem,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
BCBS Medicaid,CPT,15879,Suction lipectomy lwr extrem,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
BCBS Medicaid,CPT,17000,Destruct premalg lesion,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,17003,Destruct premalg les 2-14,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,17004,Destroy premal lesions 15/>,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,17106,Destruction of skin lesions,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
BCBS Medicaid,CPT,17107,Destruction of skin lesions,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
BCBS Medicaid,CPT,17108,Destruction of skin lesions,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
BCBS Medicaid,CPT,17110,Destruct b9 lesion 1-14,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,17111,Destruct lesion 15 or more,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,17250,Chem caut of granltj tissue,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,17260,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,17261,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,17262,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,17263,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,17264,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,17266,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,17270,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,17271,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,17272,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,17273,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,17274,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,17276,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,17280,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,17281,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,17282,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,17283,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,17284,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,17286,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,17340,Cryotherapy of skin,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,17360,Skin peel therapy,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,17380,Hair removal by electrolysis,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,17999,Skin tissue procedure,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,19000,Drainage of breast lesion,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
BCBS Medicaid,CPT,19001,Drain breast lesion add-on,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
BCBS Medicaid,CPT,19020,Incision of breast lesion,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
BCBS Medicaid,CPT,19081,Bx breast 1st lesion strtctc,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
BCBS Medicaid,CPT,19082,Bx breast add lesion strtctc,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
BCBS Medicaid,CPT,19083,Bx breast 1st lesion us imag,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
BCBS Medicaid,CPT,19084,Bx breast add lesion us imag,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
BCBS Medicaid,CPT,19085,Bx breast 1st lesion mr imag,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
BCBS Medicaid,CPT,19086,Bx breast add lesion mr imag,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
BCBS Medicaid,CPT,19100,Bx breast percut w/o image,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
BCBS Medicaid,CPT,19101,Biopsy of breast open,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
BCBS Medicaid,CPT,19105,Cryosurg ablate fa each,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
BCBS Medicaid,CPT,19110,Nipple exploration,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
BCBS Medicaid,CPT,19112,Excise breast duct fistula,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
BCBS Medicaid,CPT,19120,Removal of breast lesion,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
BCBS Medicaid,CPT,19125,Excision breast lesion,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
BCBS Medicaid,CPT,19126,Excision addl breast lesion,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
BCBS Medicaid,CPT,19294,Prep tum cav iort prtl mast,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
BCBS Medicaid,CPT,19297,Place breast cath for rad,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
BCBS Medicaid,CPT,19298,Place breast rad tube/caths,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
BCBS Medicaid,CPT,19300,Removal of breast tissue,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
BCBS Medicaid,CPT,19301,Partial mastectomy,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
BCBS Medicaid,CPT,19302,P-mastectomy w/ln removal,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
BCBS Medicaid,CPT,19303,Mast simple complete,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
BCBS Medicaid,CPT,19304,Mast subq,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
BCBS Medicaid,CPT,19305,Mast radical,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
BCBS Medicaid,CPT,19306,Mast rad urban type,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
BCBS Medicaid,CPT,19307,Mast mod rad,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
BCBS Medicaid,CPT,19316,Suspension of breast,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
BCBS Medicaid,CPT,19318,Breast reduction,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
BCBS Medicaid,CPT,19324,Enlarge breast,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
BCBS Medicaid,CPT,19325,Breast augmentation w/implt,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
BCBS Medicaid,CPT,19328,Rmvl intact breast implant,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
BCBS Medicaid,CPT,19330,Rmvl ruptured breast implant,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
BCBS Medicaid,CPT,19340,Insj breast implt sm d mast,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
BCBS Medicaid,CPT,19342,Insj/rplcmt brst implt sep d,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
BCBS Medicaid,CPT,19350,Breast reconstruction,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
BCBS Medicaid,CPT,19355,Correct inverted nipple(s),General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
BCBS Medicaid,CPT,19357,Tiss xpndr plmt brst rcnstj,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
BCBS Medicaid,CPT,19361,Brst rcnstj latsms drsi flap,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
BCBS Medicaid,CPT,19364,Brst rcnstj free flap,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
BCBS Medicaid,CPT,19366,Breast reconstruction,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
BCBS Medicaid,CPT,19367,Brst rcnstj 1 pdcl tram flap,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
BCBS Medicaid,CPT,19368,Brst rcnstj 1pdcl tram anast,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
BCBS Medicaid,CPT,19369,Brst rcnstj 2 pdcl tram flap,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
BCBS Medicaid,CPT,19370,Revj peri-implt capsule brst,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
BCBS Medicaid,CPT,19371,Peri-implt capslc brst compl,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
BCBS Medicaid,CPT,19380,Revj reconstructed breast,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
BCBS Medicaid,CPT,19396,Design custom breast implant,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
BCBS Medicaid,CPT,19499,Breast surgery procedure,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
BCBS Medicaid,CPT,20206,Needle biopsy muscle,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
BCBS Medicaid,CPT,20220,Bone biopsy trocar/needle,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
BCBS Medicaid,CPT,20500,Injection of sinus tract,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,20526,Ther injection carp tunnel,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
BCBS Medicaid,CPT,20527,Inj dupuytren cord w/enzyme,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
BCBS Medicaid,CPT,20550,Inj tendon sheath/ligament,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
BCBS Medicaid,CPT,20551,Inj tendon origin/insertion,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
BCBS Medicaid,CPT,20552,Inj trigger point 1/2 muscl,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
BCBS Medicaid,CPT,20553,Inject trigger points 3/>,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
BCBS Medicaid,CPT,20560,Ndl insj w/o njx 1 or 2 musc,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,20561,Ndl insj w/o njx 3+ musc,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,20600,Drain/inj joint/bursa w/o us,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
BCBS Medicaid,CPT,20605,Drain/inj joint/bursa w/o us,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
BCBS Medicaid,CPT,20610,Drain/inj joint/bursa w/o us,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
BCBS Medicaid,CPT,20612,Aspirate/inj ganglion cyst,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
BCBS Medicaid,CPT,20822,Replantation digit complete,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,20824,Replantation thumb complete,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,20827,Replantation thumb complete,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,20957,Mt bone graft microvasc,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,20972,Bone/skin graft metatarsal,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,20973,Bone/skin graft great toe,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,20999,Musculoskeletal surgery,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,21010,Incision of jaw joint,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,21025,Excision of bone lower jaw,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,21030,Excise max/zygoma b9 tumor,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
BCBS Medicaid,CPT,21031,Remove exostosis mandible,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
BCBS Medicaid,CPT,21032,Remove exostosis maxilla,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,21034,Excise max/zygoma mal tumor,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,21040,Excise mandible lesion,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,21044,Removal of jaw bone lesion,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,21045,Extensive jaw surgery,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,21046,Remove mandible cyst complex,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
BCBS Medicaid,CPT,21047,Excise lwr jaw cyst w/repair,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,21048,Remove maxilla cyst complex,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,21049,Excis uppr jaw cyst w/repair,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,21050,Removal of jaw joint,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,21060,Remove jaw joint cartilage,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,21070,Remove coronoid process,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,21073,Mnpj of tmj w/anesth,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,21076,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
BCBS Medicaid,CPT,21077,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
BCBS Medicaid,CPT,21079,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
BCBS Medicaid,CPT,21080,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
BCBS Medicaid,CPT,21081,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
BCBS Medicaid,CPT,21082,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
BCBS Medicaid,CPT,21083,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
BCBS Medicaid,CPT,21084,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
BCBS Medicaid,CPT,21085,Prepare face/oral prosthesis,Dental,Per Unit,$30.61 ,OP,30.61,30.61,,,,,,
BCBS Medicaid,CPT,21086,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
BCBS Medicaid,CPT,21087,Prepare face/oral prosthesis,Dental,Per Unit,$30.61 ,OP,30.61,30.61,,,,,,
BCBS Medicaid,CPT,21088,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
BCBS Medicaid,CPT,21089,Prepare face/oral prosthesis,Dental,Per Unit,$30.61 ,OP,30.61,30.61,,,,,,
BCBS Medicaid,CPT,21100,Maxillofacial fixation,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
BCBS Medicaid,CPT,21110,Interdental fixation,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,21120,Reconstruction of chin,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,21121,Reconstruction of chin,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,21122,Reconstruction of chin,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
BCBS Medicaid,CPT,21123,Reconstruction of chin,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,21125,Augmentation lower jaw bone,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,21127,Augmentation lower jaw bone,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,21138,Reduction of forehead,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,21172,Reconstruct orbit/forehead,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,21175,Reconstruct orbit/forehead,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,21193,Reconst lwr jaw w/o graft,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,21195,Reconst lwr jaw w/o fixation,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,21196,Reconst lwr jaw w/fixation,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,21198,Reconstr lwr jaw segment,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,21199,Reconstr lwr jaw w/advance,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,21206,Reconstruct upper jaw bone,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,21215,Lower jaw bone graft,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,21235,Ear cartilage graft,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,21240,Reconstruction of jaw joint,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,21242,Reconstruction of jaw joint,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,21243,Reconstruction of jaw joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
BCBS Medicaid,CPT,21244,Reconstruction of lower jaw,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,21245,Reconstruction of jaw,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,21246,Reconstruction of jaw,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,21248,Reconstruction of jaw,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,21249,Reconstruction of jaw,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,21270,Augmentation cheek bone,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,21280,Revision of eyelid,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,21282,Revision of eyelid,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,21295,Revision of jaw muscle/bone,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,21296,Revision of jaw muscle/bone,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,21315,Closed tx nose fx w/o stablj,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,21320,Closed tx nose fx w/ stablj,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,21336,Open tx septal fx w/wo stabj,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,21337,Closed tx septal&nose fx,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,21345,Closed tx nose/jaw fx,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,21346,Opn tx nasomax fx w/fixj,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,21400,Closed tx orbit w/o manipulj,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,21401,Closed tx orbit w/manipulj,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,21421,Treat mouth roof fracture,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
BCBS Medicaid,CPT,21422,Treat mouth roof fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,21440,Treat dental ridge fracture,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
BCBS Medicaid,CPT,21445,Treat dental ridge fracture,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
BCBS Medicaid,CPT,21450,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,21451,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,21452,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
BCBS Medicaid,CPT,21453,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,21454,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,21461,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,21462,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,21465,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,21470,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,21485,Reset dislocated jaw,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,21490,Repair dislocated jaw,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,21495,Treat hyoid bone fracture,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,21497,Interdental wiring,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,21685,Hyoid myotomy & suspension,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,21805,Treatment of rib fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,21811,Optx of rib fx w/fixj scope,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,21812,Treatment of rib fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,21813,Treatment of rib fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,21820,Treat sternum fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,21825,Treat sternum fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,22305,Closed tx spine process fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,22310,Closed tx vert fx w/o manj,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,22315,Closed tx vert fx w/manj,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,22505,Manipulation of spine,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
BCBS Medicaid,CPT,22515,Perq vertebral augmentation,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"7,098.75","7,098.75",,,,,,
BCBS Medicaid,CPT,22999,Abdomen surgery procedure,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,23470,Reconstruct shoulder joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
BCBS Medicaid,CPT,23472,Reconstruct shoulder joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
BCBS Medicaid,CPT,23473,Revis reconst shoulder joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
BCBS Medicaid,CPT,23474,Revis reconst shoulder joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
BCBS Medicaid,CPT,23500,Treat clavicle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,23505,Treat clavicle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,23515,Treat clavicle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,23520,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,23525,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,23530,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,23532,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,23540,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,23545,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,23550,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,23552,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,23570,Treat shoulder blade fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,23575,Treat shoulder blade fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,23585,Treat scapula fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,23600,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,23605,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,23615,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,23616,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,23620,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,23625,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,23630,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,23650,Treat shoulder dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,23655,Treat shoulder dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
BCBS Medicaid,CPT,23660,Treat shoulder dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,23665,Treat dislocation/fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,23670,Treat dislocation/fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,23675,Treat dislocation/fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,23680,Treat dislocation/fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,23700,Fixation of shoulder,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
BCBS Medicaid,CPT,23929,Shoulder surgery procedure,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,24300,Manipulate elbow w/anesth,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
BCBS Medicaid,CPT,24360,Reconstruct elbow joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
BCBS Medicaid,CPT,24361,Reconstruct elbow joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
BCBS Medicaid,CPT,24362,Reconstruct elbow joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
BCBS Medicaid,CPT,24363,Replace elbow joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
BCBS Medicaid,CPT,24365,Reconstruct head of radius,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
BCBS Medicaid,CPT,24366,Reconstruct head of radius,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
BCBS Medicaid,CPT,24370,Revise reconst elbow joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
BCBS Medicaid,CPT,24371,Revise reconst elbow joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
BCBS Medicaid,CPT,24500,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,24505,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,24515,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,24516,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,24530,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,24535,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,24538,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,24545,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,24546,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,24560,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,24565,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,24566,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,24575,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,24576,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,24577,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,24579,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,24582,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,24586,Treat elbow fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,24587,Treat elbow fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,24600,Treat elbow dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,24605,Treat elbow dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
BCBS Medicaid,CPT,24615,Treat elbow dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,24620,Treat elbow fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,24635,Treat elbow fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,24640,Treat elbow dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,24650,Treat radius fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,24655,Treat radius fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,24665,Treat radius fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,24666,Treat radius fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,24670,Treat ulnar fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,24675,Treat ulnar fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,24685,Treat ulnar fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,24999,Upper arm/elbow surgery,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,25001,Incise flexor carpi radialis,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,25111,Remove wrist tendon lesion,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,25112,Reremove wrist tendon lesion,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,25136,Remove & graft wrist lesion,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,25210,Removal of wrist bone,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,25215,Removal of wrist bones,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,25259,Manipulate wrist w/anesthes,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
BCBS Medicaid,CPT,25315,Revise palsy hand tendon(s),Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,25316,Revise palsy hand tendon(s),Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,25332,Revise wrist joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
BCBS Medicaid,CPT,25394,Repair carpal bone shorten,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,25430,Vasc graft into carpal bone,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,25431,Repair nonunion carpal bone,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,25441,Reconstruct wrist joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
BCBS Medicaid,CPT,25442,Reconstruct wrist joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
BCBS Medicaid,CPT,25443,Reconstruct wrist joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
BCBS Medicaid,CPT,25444,Reconstruct wrist joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
BCBS Medicaid,CPT,25445,Reconstruct wrist joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
BCBS Medicaid,CPT,25446,Wrist replacement,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
BCBS Medicaid,CPT,25447,Repair wrist joints,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
BCBS Medicaid,CPT,25449,Remove wrist joint implant,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
BCBS Medicaid,CPT,25500,Treat fracture of radius,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,25505,Treat fracture of radius,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,25515,Treat fracture of radius,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,25520,Treat fracture of radius,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,25525,Treat fracture of radius,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,25526,Treat fracture of radius,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,25530,Treat fracture of ulna,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,25535,Treat fracture of ulna,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,25545,Treat fracture of ulna,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,25560,Treat fracture radius & ulna,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,25565,Treat fracture radius & ulna,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,25574,Treat fracture radius & ulna,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,25575,Treat fracture radius/ulna,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,25600,Treat fracture radius/ulna,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,25605,Treat fracture radius/ulna,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,25606,Treat fx distal radial,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,25607,Treat fx rad extra-articul,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,25608,Treat fx rad intra-articul,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,25609,Treat fx radial 3+ frag,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,25622,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,25624,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,25628,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,25630,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,25635,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,25645,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,25650,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,25651,Pin ulnar styloid fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,25652,Treat fracture ulnar styloid,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,25660,Treat wrist dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,25670,Treat wrist dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,25671,Pin radioulnar dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,25675,Treat wrist dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,25676,Treat wrist dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,25680,Treat wrist fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,25685,Treat wrist fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,25690,Treat wrist dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,25695,Treat wrist dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,25820,Fusion of hand bones,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,25825,Fuse hand bones with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,25929,Amputation follow-up surgery,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,25999,Forearm or wrist surgery,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,26010,Drainage of finger abscess,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,26011,Drainage of finger abscess,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
BCBS Medicaid,CPT,26020,Drain hand tendon sheath,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26025,Drainage of palm bursa,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26030,Drainage of palm bursas,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26034,Treat hand bone lesion,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26035,Decompress fingers/hand,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26037,Decompress fingers/hand,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26040,Release palm contracture,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26045,Release palm contracture,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26055,Incise finger tendon sheath,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26060,Incision of finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26070,Explore/treat hand joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26075,Explore/treat finger joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26080,Explore/treat finger joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26100,Biopsy hand joint lining,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26105,Biopsy finger joint lining,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26110,Biopsy finger joint lining,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26111,Exc hand les sc 1.5 cm/>,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26113,Exc hand tum deep 1.5 cm/>,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26115,Exc hand les sc < 1.5 cm,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26116,Exc hand tum deep < 1.5 cm,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26117,Rad resect hand tumor < 3 cm,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26118,Rad resect hand tumor 3 cm/>,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26121,Release palm contracture,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26123,Release palm contracture,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26125,Release palm contracture,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26130,Remove wrist joint lining,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26135,Revise finger joint each,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26140,Revise finger joint each,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26145,Tendon excision palm/finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26160,Remove tendon sheath lesion,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26170,Removal of palm tendon each,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26180,Removal of finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26185,Remove finger bone,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26200,Remove hand bone lesion,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26205,Remove/graft bone lesion,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26210,Removal of finger lesion,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26215,Remove/graft finger lesion,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26230,Partial removal of hand bone,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26235,Partial removal finger bone,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26236,Partial removal finger bone,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26250,Extensive hand surgery,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26260,Resect prox finger tumor,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26262,Resect distal finger tumor,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26320,Removal of implant from hand,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26340,Manipulate finger w/anesth,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
BCBS Medicaid,CPT,26341,Manipulat palm cord post inj,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,26350,Repair finger/hand tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26352,Repair/graft hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26356,Repair finger/hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26357,Repair finger/hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26358,Repair/graft hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26370,Repair finger/hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26372,Repair/graft hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26373,Repair finger/hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26390,Revise hand/finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26392,Repair/graft hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26410,Repair hand tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26412,Repair/graft hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26415,Excision hand/finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26416,Graft hand or finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26418,Repair finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26420,Repair/graft finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26426,Repair finger/hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26428,Repair/graft finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26432,Repair finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26433,Repair finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26434,Repair/graft finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26437,Realignment of tendons,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26440,Release palm/finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26442,Release palm & finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26445,Release hand/finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26449,Release forearm/hand tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26450,Incision of palm tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26455,Incision of finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26460,Incise hand/finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26471,Fusion of finger tendons,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26474,Fusion of finger tendons,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26476,Tendon lengthening,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26477,Tendon shortening,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26478,Lengthening of hand tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26479,Shortening of hand tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26480,Transplant hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26483,Transplant/graft hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26485,Transplant palm tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26489,Transplant/graft palm tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26490,Revise thumb tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26492,Tendon transfer with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26494,Hand tendon/muscle transfer,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26496,Revise thumb tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26497,Finger tendon transfer,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26498,Finger tendon transfer,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26499,Revision of finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26500,Hand tendon reconstruction,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26502,Hand tendon reconstruction,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26508,Release thumb contracture,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26510,Thumb tendon transfer,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26516,Fusion of knuckle joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26517,Fusion of knuckle joints,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26518,Fusion of knuckle joints,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26520,Release knuckle contracture,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26525,Release finger contracture,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26530,Revise knuckle joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
BCBS Medicaid,CPT,26531,Revise knuckle with implant,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
BCBS Medicaid,CPT,26535,Revise finger joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
BCBS Medicaid,CPT,26536,Revise/implant finger joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
BCBS Medicaid,CPT,26540,Repair hand joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26541,Repair hand joint with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26542,Repair hand joint with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26545,Reconstruct finger joint,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26546,Repair nonunion hand,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26548,Reconstruct finger joint,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26550,Construct thumb replacement,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26555,Positional change of finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26560,Repair of web finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26561,Repair of web finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26562,Repair of web finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26565,Correct metacarpal flaw,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26567,Correct finger deformity,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26568,Lengthen metacarpal/finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26580,Repair hand deformity,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26587,Reconstruct extra finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26590,Repair finger deformity,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26591,Repair muscles of hand,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26593,Release muscles of hand,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26596,Excision constricting tissue,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26600,Treat metacarpal fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,26605,Treat metacarpal fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,26607,Treat metacarpal fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,26608,Treat metacarpal fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,26615,Treat metacarpal fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,26641,Treat thumb dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,26645,Treat thumb fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,26650,Treat thumb fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,26665,Treat thumb fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,26670,Treat hand dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,26675,Treat hand dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
BCBS Medicaid,CPT,26676,Pin hand dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,26685,Treat hand dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,26686,Treat hand dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,26700,Treat knuckle dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,26705,Treat knuckle dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
BCBS Medicaid,CPT,26706,Pin knuckle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,26715,Treat knuckle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,26720,Treat finger fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,26725,Treat finger fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,26727,Treat finger fracture each,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,26735,Treat finger fracture each,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,26740,Treat finger fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,26742,Treat finger fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,26746,Treat finger fracture each,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,26750,Treat finger fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,26755,Treat finger fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,26756,Pin finger fracture each,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,26765,Treat finger fracture each,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,26770,Treat finger dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,26775,Treat finger dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
BCBS Medicaid,CPT,26776,Pin finger dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,26785,Treat finger dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,26820,Thumb fusion with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26841,Fusion of thumb,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26842,Thumb fusion with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26843,Fusion of hand joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26844,Fusion/graft of hand joint,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26850,Fusion of knuckle,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26852,Fusion of knuckle with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26860,Fusion of finger joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26861,Fusion of finger jnt add-on,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26862,Fusion/graft of finger joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26863,Fuse/graft added joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26910,Amputate metacarpal bone,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26951,Amputation of finger/thumb,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
BCBS Medicaid,CPT,26952,Amputation of finger/thumb,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
BCBS Medicaid,CPT,26989,Hand/finger surgery,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27125,Partial hip replacement,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
BCBS Medicaid,CPT,27130,Total hip arthroplasty,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
BCBS Medicaid,CPT,27132,Total hip arthroplasty,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
BCBS Medicaid,CPT,27134,Revise hip joint replacement,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
BCBS Medicaid,CPT,27137,Revise hip joint replacement,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
BCBS Medicaid,CPT,27138,Revise hip joint replacement,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
BCBS Medicaid,CPT,27175,Treat slipped epiphysis,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,27178,Treat slipped epiphysis,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,27181,Treat slipped epiphysis,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,27193,Treat pelvic ring fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27194,Treat pelvic ring fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27197,Clsd tx pelvic ring fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27198,Clsd tx pelvic ring fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27200,Treat tail bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27202,Treat tail bone fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,27215,Treat pelvic fracture(s),Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,27216,Treat pelvic ring fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,27217,Treat pelvic ring fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,27218,Treat pelvic ring fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,27220,Treat hip socket fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27222,Treat hip socket fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27226,Treat hip wall fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,27227,Treat hip fracture(s),Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,27230,Treat thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27232,Treat thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27235,Treat thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,27236,Treat thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,27238,Treat thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27240,Treat thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27246,Treat thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27248,Treat thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,27250,Treat hip dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27252,Treat hip dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
BCBS Medicaid,CPT,27253,Treat hip dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,27256,Treat hip dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27257,Treat hip dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
BCBS Medicaid,CPT,27265,Treat hip dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27266,Treat hip dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
BCBS Medicaid,CPT,27267,Cltx thigh fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27268,Cltx thigh fx w/mnpj,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27269,Optx thigh fx,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,27275,Manipulation of hip joint,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
BCBS Medicaid,CPT,27299,Pelvis/hip joint surgery,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27412,Autochondrocyte implant knee,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
BCBS Medicaid,CPT,27415,Osteochondral knee allograft,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
BCBS Medicaid,CPT,27437,Revise kneecap,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
BCBS Medicaid,CPT,27438,Revise kneecap with implant,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
BCBS Medicaid,CPT,27440,Revision of knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
BCBS Medicaid,CPT,27441,Revision of knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
BCBS Medicaid,CPT,27442,Revision of knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
BCBS Medicaid,CPT,27443,Revision of knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
BCBS Medicaid,CPT,27445,Revision of knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
BCBS Medicaid,CPT,27446,Revision of knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
BCBS Medicaid,CPT,27447,Total knee arthroplasty,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
BCBS Medicaid,CPT,27486,Revise/replace knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
BCBS Medicaid,CPT,27487,Revise/replace knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
BCBS Medicaid,CPT,27500,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27501,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27502,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27503,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27507,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,27508,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27509,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,27510,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27511,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,27513,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,27514,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,27516,Treat thigh fx growth plate,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27517,Treat thigh fx growth plate,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27520,Treat kneecap fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27524,Treat kneecap fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,27530,Treat knee fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27532,Treat knee fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27535,Treat knee fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,27536,Treat knee fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,27538,Treat knee fracture(s),Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27540,Treat knee fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,27550,Treat knee dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27552,Treat knee dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
BCBS Medicaid,CPT,27560,Treat kneecap dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27562,Treat kneecap dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
BCBS Medicaid,CPT,27566,Treat kneecap dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,27570,Fixation of knee joint,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
BCBS Medicaid,CPT,27599,Leg surgery procedure,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27605,Incision of achilles tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,27700,Revision of ankle joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
BCBS Medicaid,CPT,27702,Reconstruct ankle joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
BCBS Medicaid,CPT,27703,Reconstruction ankle joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
BCBS Medicaid,CPT,27720,Repair of tibia,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,27722,Repair/graft of tibia,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,27724,Repair/graft of tibia,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,27726,Repair fibula nonunion,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,27750,Treatment of tibia fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27752,Treatment of tibia fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27756,Treatment of tibia fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,27758,Treatment of tibia fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,27759,Treatment of tibia fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,27760,Cltx medial ankle fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27762,Cltx med ankle fx w/mnpj,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27766,Optx medial ankle fx,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,27767,Cltx post ankle fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27768,Cltx post ankle fx w/mnpj,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27769,Optx post ankle fx,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,27780,Treatment of fibula fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27781,Treatment of fibula fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27784,Treatment of fibula fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,27786,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27788,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27792,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,27808,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27810,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27814,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,27816,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27818,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27822,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,27823,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,27824,Treat lower leg fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27825,Treat lower leg fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27826,Treat lower leg fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,27827,Treat lower leg fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,27828,Treat lower leg fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,27829,Treat lower leg joint,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,27830,Treat lower leg dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27831,Treat lower leg dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27832,Treat lower leg dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,27840,Treat ankle dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,27842,Treat ankle dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
BCBS Medicaid,CPT,27846,Treat ankle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,27848,Treat ankle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,27860,Fixation of ankle joint,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
BCBS Medicaid,CPT,27899,Leg/ankle surgery procedure,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,28001,Drainage of bursa of foot,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28002,Treatment of foot infection,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28005,Treat foot bone lesion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28008,Incision of foot fascia,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28010,Incision of toe tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28011,Incision of toe tendons,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28020,Exploration of foot joint,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28022,Exploration of foot joint,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28024,Exploration of toe joint,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28039,Exc foot/toe tum sc 1.5 cm/>,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28041,Exc foot/toe tum dep 1.5cm/>,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28045,Exc foot/toe tum deep <1.5cm,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28046,Resect foot/toe tumor < 3 cm,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28047,Resect foot/toe tumor 3 cm/>,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28050,Biopsy of foot joint lining,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28052,Biopsy of foot joint lining,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28054,Biopsy of toe joint lining,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28055,Neurectomy foot,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28060,Partial removal foot fascia,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28062,Removal of foot fascia,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28070,Removal of foot joint lining,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28072,Removal of foot joint lining,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28080,Removal of foot lesion,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28086,Excise foot tendon sheath,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28088,Excise foot tendon sheath,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28090,Removal of foot lesion,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28092,Removal of toe lesions,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28100,Removal of ankle/heel lesion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28102,Remove/graft foot lesion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28103,Remove/graft foot lesion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28104,Removal of foot lesion,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28106,Remove/graft foot lesion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28107,Remove/graft foot lesion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28108,Removal of toe lesions,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28110,Part removal of metatarsal,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28111,Part removal of metatarsal,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28112,Part removal of metatarsal,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28113,Part removal of metatarsal,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28114,Removal of metatarsal heads,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28116,Revision of foot,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28118,Removal of heel bone,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28119,Removal of heel spur,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28120,Part removal of ankle/heel,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28122,Partial removal of foot bone,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28124,Partial removal of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28126,Partial removal of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28130,Removal of ankle bone,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28140,Removal of metatarsal,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28150,Removal of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28153,Partial removal of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28160,Partial removal of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28171,Resect tarsal tumor,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28173,Resect metatarsal tumor,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28175,Resect phalanx of toe tumor,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28190,Removal of foot foreign body,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,28193,Removal of foot foreign body,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28200,Repair of foot tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28202,Repair/graft of foot tendon,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28208,Repair of foot tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28210,Repair/graft of foot tendon,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28220,Release of foot tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28222,Release of foot tendons,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28225,Release of foot tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28226,Release of foot tendons,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28230,Incision of foot tendon(s),Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28232,Incision of toe tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28234,Incision of foot tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28238,Revision of foot tendon,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28240,Release of big toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28250,Revision of foot fascia,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28260,Release of midfoot joint,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28261,Revision of foot tendon,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28262,Revision of foot and ankle,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28264,Release of midfoot joint,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28270,Release of foot contracture,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28272,Release of toe joint each,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28280,Fusion of toes,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28285,Repair of hammertoe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28286,Repair of hammertoe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28288,Partial removal of foot bone,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28289,Corrj halux rigdus w/o implt,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28290,Correction of bunion,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28291,Corrj halux rigdus w/implt,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28292,Correction hallux valgus,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28293,Correction of bunion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28294,Correction of bunion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28295,Correction hallux valgus,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28296,Correction hallux valgus,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28297,Correction hallux valgus,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28298,Correction hallux valgus,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28299,Correction hallux valgus,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28300,Incision of heel bone,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28302,Incision of ankle bone,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28304,Incision of midfoot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28305,Incise/graft midfoot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28306,Incision of metatarsal,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28307,Incision of metatarsal,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28308,Incision of metatarsal,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28309,Incision of metatarsals,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28310,Revision of big toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28312,Revision of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28313,Repair deformity of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28315,Removal of sesamoid bone,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28320,Repair of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28322,Repair of metatarsals,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28340,Resect enlarged toe tissue,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28341,Resect enlarged toe,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28344,Repair extra toe(s),Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28345,Repair webbed toe(s),Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28360,Reconstruct cleft foot,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28400,Treatment of heel fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,28405,Treatment of heel fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,28406,Treatment of heel fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,28415,Treat heel fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,28420,Treat/graft heel fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,28430,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,28435,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,28436,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,28445,Treat ankle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,28446,Osteochondral talus autogrft,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28450,Treat midfoot fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,28455,Treat midfoot fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,28456,Treat midfoot fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,28465,Treat midfoot fracture each,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,28470,Treat metatarsal fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,28475,Treat metatarsal fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,28476,Treat metatarsal fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,28485,Treat metatarsal fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,28490,Treat big toe fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,28495,Treat big toe fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,28496,Treat big toe fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,28505,Treat big toe fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,28510,Treatment of toe fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,28515,Treatment of toe fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,28525,Treat toe fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,28530,Treat sesamoid bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,28531,Treat sesamoid bone fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,28540,Treat foot dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,28545,Treat foot dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
BCBS Medicaid,CPT,28546,Treat foot dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,28555,Repair foot dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,28570,Treat foot dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,28575,Treat foot dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
BCBS Medicaid,CPT,28576,Treat foot dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,28585,Repair foot dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,28600,Treat foot dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,28605,Treat foot dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
BCBS Medicaid,CPT,28606,Treat foot dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,28615,Repair foot dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,28630,Treat toe dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,28635,Treat toe dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
BCBS Medicaid,CPT,28636,Treat toe dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,28645,Repair toe dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,28660,Treat toe dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,28665,Treat toe dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
BCBS Medicaid,CPT,28666,Treat toe dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,28675,Repair of toe dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,28705,Fusion of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28715,Fusion of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28725,Fusion of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28730,Fusion of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28735,Fusion of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28737,Revision of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28740,Fusion of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28750,Fusion of big toe joint,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28755,Fusion of big toe joint,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28760,Fusion of big toe joint,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28805,Amputation thru metatarsal,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28810,Amputation toe & metatarsal,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,28820,Amputation of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28825,Partial amputation of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28890,Hi enrgy eswt plantar fascia,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,28899,Foot/toes surgery procedure,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,29000,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
BCBS Medicaid,CPT,29010,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
BCBS Medicaid,CPT,29015,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
BCBS Medicaid,CPT,29035,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
BCBS Medicaid,CPT,29040,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
BCBS Medicaid,CPT,29044,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
BCBS Medicaid,CPT,29046,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
BCBS Medicaid,CPT,29049,Application of figure eight,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
BCBS Medicaid,CPT,29055,Application of shoulder cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
BCBS Medicaid,CPT,29058,Application of shoulder cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
BCBS Medicaid,CPT,29065,Application of long arm cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
BCBS Medicaid,CPT,29075,Application of forearm cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
BCBS Medicaid,CPT,29085,Apply hand/wrist cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
BCBS Medicaid,CPT,29086,Apply finger cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
BCBS Medicaid,CPT,29105,Apply long arm splint,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
BCBS Medicaid,CPT,29125,Apply forearm splint,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
BCBS Medicaid,CPT,29126,Apply forearm splint,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
BCBS Medicaid,CPT,29130,Application of finger splint,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
BCBS Medicaid,CPT,29131,Application of finger splint,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
BCBS Medicaid,CPT,29200,Strapping of chest,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
BCBS Medicaid,CPT,29240,Strapping of shoulder,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
BCBS Medicaid,CPT,29260,Strapping of elbow or wrist,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
BCBS Medicaid,CPT,29280,Strapping of hand or finger,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
BCBS Medicaid,CPT,29305,Application of hip cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
BCBS Medicaid,CPT,29325,Application of hip casts,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
BCBS Medicaid,CPT,29345,Application of long leg cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
BCBS Medicaid,CPT,29355,Application of long leg cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
BCBS Medicaid,CPT,29358,Apply long leg cast brace,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
BCBS Medicaid,CPT,29365,Application of long leg cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
BCBS Medicaid,CPT,29405,Apply short leg cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
BCBS Medicaid,CPT,29425,Apply short leg cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
BCBS Medicaid,CPT,29435,Apply short leg cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
BCBS Medicaid,CPT,29440,Addition of walker to cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
BCBS Medicaid,CPT,29445,Apply rigid leg cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
BCBS Medicaid,CPT,29450,Application of leg cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
BCBS Medicaid,CPT,29505,Application long leg splint,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
BCBS Medicaid,CPT,29515,Application lower leg splint,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
BCBS Medicaid,CPT,29520,Strapping of hip,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
BCBS Medicaid,CPT,29530,Strapping of knee,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
BCBS Medicaid,CPT,29540,Strapping of ankle and/or ft,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
BCBS Medicaid,CPT,29550,Strapping of toes,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
BCBS Medicaid,CPT,29580,Application of paste boot,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
BCBS Medicaid,CPT,29581,Apply multlay comprs lwr leg,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
BCBS Medicaid,CPT,29582,Apply multlay comprs upr leg,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
BCBS Medicaid,CPT,29583,Apply multlay comprs upr arm,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
BCBS Medicaid,CPT,29584,Appl multlay comprs arm/hand,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
BCBS Medicaid,CPT,29700,Removal/revision of cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
BCBS Medicaid,CPT,29705,Removal/revision of cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
BCBS Medicaid,CPT,29710,Removal/revision of cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
BCBS Medicaid,CPT,29720,Repair of body cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
BCBS Medicaid,CPT,29730,Windowing of cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
BCBS Medicaid,CPT,29740,Wedging of cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
BCBS Medicaid,CPT,29750,Wedging of clubfoot cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
BCBS Medicaid,CPT,29799,Casting/strapping procedure,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
BCBS Medicaid,CPT,29800,Jaw arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29804,Jaw arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29805,Sho arthrs dx +- synovial bx,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29806,Sho arthrs srg capsulorpaphy,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
BCBS Medicaid,CPT,29807,Sho arthrs srg rpr slap les,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
BCBS Medicaid,CPT,29819,Sho arthrs srg rmvl loose/fb,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29820,Sho arthrs srg prtl synvct,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29821,Sho arthrs srg compl synvct,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
BCBS Medicaid,CPT,29822,Sho arthrs srg lmtd dbrdmt,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29823,Sho arthrs srg xtnsv dbrdmt,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29824,Sho arthrs srg dstl claviclc,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29825,Sho arthrs srg lss&rescj ads,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29826,Sho arthrs srg decompression,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29827,Sho arthrs srg rt8tr cuf rpr,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
BCBS Medicaid,CPT,29828,Sho arthrs srg bicp tenodsis,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
BCBS Medicaid,CPT,29830,Elbow arthroscopy,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29834,Elbow arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29835,Elbow arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29836,Elbow arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
BCBS Medicaid,CPT,29837,Elbow arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29838,Elbow arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29840,Wrist arthroscopy,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29843,Wrist arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29844,Wrist arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29845,Wrist arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29846,Wrist arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29847,Wrist arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
BCBS Medicaid,CPT,29848,Wrist endoscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29850,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29851,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29855,Tibial arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
BCBS Medicaid,CPT,29856,Tibial arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
BCBS Medicaid,CPT,29860,Hip arthroscopy dx,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
BCBS Medicaid,CPT,29861,Hip arthro w/fb removal,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29862,Hip arthr0 w/debridement,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
BCBS Medicaid,CPT,29863,Hip arthr0 w/synovectomy,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29866,Autgrft implnt knee w/scope,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
BCBS Medicaid,CPT,29867,Allgrft implnt knee w/scope,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
BCBS Medicaid,CPT,29868,Meniscal trnspl knee w/scpe,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
BCBS Medicaid,CPT,29870,Knee arthroscopy dx,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29871,Knee arthroscopy/drainage,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29873,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29874,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29875,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29876,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29877,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29879,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29880,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29881,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29882,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29883,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29884,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29885,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
BCBS Medicaid,CPT,29886,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29887,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
BCBS Medicaid,CPT,29888,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
BCBS Medicaid,CPT,29889,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
BCBS Medicaid,CPT,29891,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29892,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
BCBS Medicaid,CPT,29893,Scope plantar fasciotomy,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,29894,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29895,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29897,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29898,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29899,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
BCBS Medicaid,CPT,29900,Mcp joint arthroscopy dx,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29901,Mcp joint arthroscopy surg,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29902,Mcp joint arthroscopy surg,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29904,Subtalar arthro w/fb rmvl,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29905,Subtalar arthro w/exc,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29906,Subtalar arthro w/deb,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,29907,Subtalar arthro w/fusion,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
BCBS Medicaid,CPT,29914,Hip arthro w/femoroplasty,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
BCBS Medicaid,CPT,29915,Hip arthro acetabuloplasty,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
BCBS Medicaid,CPT,29916,Hip arthro w/labral repair,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
BCBS Medicaid,CPT,29999,Arthroscopy of joint,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,30020,Drainage of nose lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,30100,Intranasal biopsy,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,30110,Removal of nose polyp(s),Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,30115,Removal of nose polyp(s),Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,30117,Removal of intranasal lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,30118,Removal of intranasal lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,30120,Revision of nose,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,30124,Removal of nose lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,30125,Removal of nose lesion,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,30130,Excise inferior turbinate,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,30140,Resect inferior turbinate,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,30150,Partial removal of nose,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,30160,Removal of nose,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,30200,Injection treatment of nose,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,30220,Insert nasal septal button,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,30310,Remove nasal foreign body,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,30320,Remove nasal foreign body,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,30400,Reconstruction of nose,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,30410,Reconstruction of nose,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,30420,Reconstruction of nose,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,30430,Revision of nose,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,30435,Revision of nose,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,30450,Revision of nose,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,30460,Revision of nose,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,30462,Revision of nose,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,30465,Repair nasal stenosis,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,30468,Rpr nsl vlv collapse w/implt,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,30520,Repair of nasal septum,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,30540,Repair nasal defect,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,30560,Release of nasal adhesions,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,30580,Repair upper jaw fistula,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,30600,Repair mouth/nose fistula,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,30620,Intranasal reconstruction,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,30630,Repair nasal septum defect,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,30801,Ablate inf turbinate superf,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,30802,Ablate inf turbinate submuc,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,30915,Ligation nasal sinus artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
BCBS Medicaid,CPT,30920,Ligation upper jaw artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
BCBS Medicaid,CPT,30930,Ther fx nasal inf turbinate,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,30999,Nasal surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,31000,Irrigation maxillary sinus,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,31002,Irrigation sphenoid sinus,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,31020,Exploration maxillary sinus,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,31030,Exploration maxillary sinus,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,31032,Explore sinus remove polyps,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,31050,Exploration sphenoid sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,31051,Sphenoid sinus surgery,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,31070,Exploration of frontal sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,31075,Exploration of frontal sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,31080,Removal of frontal sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,31081,Removal of frontal sinus,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,31084,Removal of frontal sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,31085,Removal of frontal sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,31086,Removal of frontal sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,31087,Removal of frontal sinus,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,31090,Exploration of sinuses,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,31200,Removal of ethmoid sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,31201,Removal of ethmoid sinus,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,31205,Removal of ethmoid sinus,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,31225,Removal of upper jaw,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
BCBS Medicaid,CPT,31233,Nsl/sins ndsc dx max sinusc,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
BCBS Medicaid,CPT,31235,Nsl/sins ndsc dx sphn sinusc,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
BCBS Medicaid,CPT,31237,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
BCBS Medicaid,CPT,31238,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
BCBS Medicaid,CPT,31239,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
BCBS Medicaid,CPT,31240,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
BCBS Medicaid,CPT,31241,Nsl/sins ndsc w/artery lig,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
BCBS Medicaid,CPT,31253,Nsl/sins ndsc total,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,31254,Nsl/sins ndsc w/prtl ethmdct,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
BCBS Medicaid,CPT,31255,Nsl/sins ndsc w/tot ethmdct,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
BCBS Medicaid,CPT,31256,Exploration maxillary sinus,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
BCBS Medicaid,CPT,31257,Nsl/sins ndsc tot w/sphendt,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,31259,Nsl/sins ndsc sphn tiss rmvl,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,31267,Endoscopy maxillary sinus,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
BCBS Medicaid,CPT,31276,Nsl/sins ndsc frnt tiss rmvl,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
BCBS Medicaid,CPT,31287,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
BCBS Medicaid,CPT,31288,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
BCBS Medicaid,CPT,31290,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
BCBS Medicaid,CPT,31291,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
BCBS Medicaid,CPT,31292,Nsl/sins ndsc med/inf dcmprn,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
BCBS Medicaid,CPT,31293,Nsl/sins ndsc med&inf dcmprn,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
BCBS Medicaid,CPT,31294,Nsl/sins ndsc surg on dcmprn,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
BCBS Medicaid,CPT,31295,Nsl/sins ndsc surg max sins,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
BCBS Medicaid,CPT,31296,Nsl/sins ndsc surg frnt sins,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
BCBS Medicaid,CPT,31297,Nsl/sins ndsc surg sphn sins,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
BCBS Medicaid,CPT,31298,Nsl/sins ndsc surg frnt&sphn,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
BCBS Medicaid,CPT,31299,Sinus surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,31300,Removal of larynx lesion,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,31320,Diagnostic incision larynx,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,31375,Partial removal of larynx,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,31400,Revision of larynx,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,31420,Removal of epiglottis,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,31500,Insert emergency airway,General Medicine,Per Unit,$385.17 ,OP,385.17,385.17,,,,,,
BCBS Medicaid,CPT,31510,Laryngoscopy with biopsy,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
BCBS Medicaid,CPT,31512,Removal of larynx lesion,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
BCBS Medicaid,CPT,31513,Injection into vocal cord,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
BCBS Medicaid,CPT,31515,Laryngoscopy for aspiration,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
BCBS Medicaid,CPT,31520,Dx laryngoscopy newborn,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
BCBS Medicaid,CPT,31525,Dx laryngoscopy excl nb,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
BCBS Medicaid,CPT,31526,Dx laryngoscopy w/oper scope,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
BCBS Medicaid,CPT,31527,Laryngoscopy for treatment,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
BCBS Medicaid,CPT,31528,Laryngoscopy and dilation,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
BCBS Medicaid,CPT,31529,Laryngoscopy and dilation,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
BCBS Medicaid,CPT,31530,Laryngoscopy w/fb removal,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
BCBS Medicaid,CPT,31531,Laryngoscopy w/fb & op scope,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
BCBS Medicaid,CPT,31535,Laryngoscopy w/biopsy,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
BCBS Medicaid,CPT,31536,Laryngoscopy w/bx & op scope,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
BCBS Medicaid,CPT,31540,Laryngoscopy w/exc of tumor,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
BCBS Medicaid,CPT,31541,Larynscop w/tumr exc + scope,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
BCBS Medicaid,CPT,31545,Remove vc lesion w/scope,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
BCBS Medicaid,CPT,31546,Remove vc lesion scope/graft,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
BCBS Medicaid,CPT,31551,Laryngoplasty laryngeal sten,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,31552,Laryngoplasty laryngeal sten,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,31553,Laryngoplasty laryngeal sten,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,31554,Laryngoplasty laryngeal sten,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,31560,Laryngoscop w/arytenoidectom,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
BCBS Medicaid,CPT,31561,Larynscop remve cart + scop,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
BCBS Medicaid,CPT,31570,Laryngoscope w/vc inj,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
BCBS Medicaid,CPT,31571,Laryngoscop w/vc inj + scope,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
BCBS Medicaid,CPT,31572,Largsc w/laser dstrj les,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
BCBS Medicaid,CPT,31573,Largsc w/ther injection,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
BCBS Medicaid,CPT,31574,Largsc w/njx augmentation,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
BCBS Medicaid,CPT,31576,Laryngoscopy with biopsy,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
BCBS Medicaid,CPT,31577,Largsc w/rmvl foreign bdy(s),Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
BCBS Medicaid,CPT,31578,Largsc w/removal lesion,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
BCBS Medicaid,CPT,31579,Laryngoscopy telescopic,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
BCBS Medicaid,CPT,31580,Laryngoplasty laryngeal web,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,31582,Revision of larynx,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,31584,Laryngoplasty fx rdctj fixj,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,31587,Laryngoplasty cricoid split,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,31588,Revision of larynx,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,31590,Reinnervate larynx,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,31591,Laryngoplasty medialization,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,31595,Larynx nerve surgery,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,31599,Larynx surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,31615,Visualization of windpipe,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
BCBS Medicaid,CPT,31622,Dx bronchoscope/wash,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
BCBS Medicaid,CPT,31623,Dx bronchoscope/brush,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
BCBS Medicaid,CPT,31624,Dx bronchoscope/lavage,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
BCBS Medicaid,CPT,31625,Bronchoscopy w/biopsy(s),Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
BCBS Medicaid,CPT,31626,Bronchoscopy w/markers,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
BCBS Medicaid,CPT,31627,Navigational bronchoscopy,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,31628,Bronchoscopy/lung bx each,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
BCBS Medicaid,CPT,31629,Bronchoscopy/needle bx each,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
BCBS Medicaid,CPT,31632,Bronchoscopy/lung bx addl,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
BCBS Medicaid,CPT,31633,Bronchoscopy/needle bx addl,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
BCBS Medicaid,CPT,31635,Bronchoscopy w/fb removal,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
BCBS Medicaid,CPT,31643,Diag bronchoscope/catheter,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
BCBS Medicaid,CPT,31645,Brnchsc w/ther aspir 1st,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
BCBS Medicaid,CPT,31646,Brnchsc w/ther aspir sbsq,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
BCBS Medicaid,CPT,31720,Clearance of airways,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
BCBS Medicaid,CPT,31725,Clearance of airways,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
BCBS Medicaid,CPT,31899,Airways surgical procedure,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
BCBS Medicaid,CPT,33206,Insert heart pm atrial,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
BCBS Medicaid,CPT,33207,Insert heart pm ventricular,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
BCBS Medicaid,CPT,33208,Insrt heart pm atrial & vent,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
BCBS Medicaid,CPT,33212,Insert pulse gen sngl lead,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
BCBS Medicaid,CPT,33213,Insert pulse gen dual leads,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
BCBS Medicaid,CPT,33214,Upgrade of pacemaker system,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
BCBS Medicaid,CPT,33221,Insert pulse gen mult leads,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
BCBS Medicaid,CPT,33224,Insert pacing lead & connect,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
BCBS Medicaid,CPT,33225,L ventric pacing lead add-on,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
BCBS Medicaid,CPT,33226,Reposition l ventric lead,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
BCBS Medicaid,CPT,33227,Remove&replace pm gen singl,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
BCBS Medicaid,CPT,33228,Remv&replc pm gen dual lead,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
BCBS Medicaid,CPT,33229,Remv&replc pm gen mult leads,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
BCBS Medicaid,CPT,33230,Insrt pulse gen w/dual leads,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
BCBS Medicaid,CPT,33231,Insrt pulse gen w/mult leads,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
BCBS Medicaid,CPT,33233,Removal of pm generator,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
BCBS Medicaid,CPT,33240,Insrt pulse gen w/singl lead,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
BCBS Medicaid,CPT,33241,Remove pulse generator,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
BCBS Medicaid,CPT,33249,Insj/rplcmt defib w/lead(s),Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
BCBS Medicaid,CPT,33262,Rmvl& replc pulse gen 1 lead,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
BCBS Medicaid,CPT,33263,Rmvl & rplcmt dfb gen 2 lead,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
BCBS Medicaid,CPT,33264,Rmvl & rplcmt dfb gen mlt ld,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
BCBS Medicaid,CPT,33270,Ins/rep subq defibrillator,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
BCBS Medicaid,CPT,33274,Tcat insj/rpl perm ldls pm,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
BCBS Medicaid,CPT,33275,Tcat rmvl perm ldls pm w/img,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
BCBS Medicaid,CPT,33282,Implant pat-active ht record,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
BCBS Medicaid,CPT,33285,Insj subq car rhythm mntr,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
BCBS Medicaid,CPT,33289,Tcat impl wrls p-art prs snr,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
BCBS Medicaid,CPT,33889,Artery transpose/endovas taa,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,33967,Insert i-aort percut device,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
BCBS Medicaid,CPT,33968,Remove aortic assist device,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
BCBS Medicaid,CPT,33990,Insj perq vad l hrt arterial,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
BCBS Medicaid,CPT,33991,Insj perq vad l hrt artl&ven,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
BCBS Medicaid,CPT,33992,Rmvl perq left heart vad,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
BCBS Medicaid,CPT,33993,Reposg perq r/l hrt vad,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
BCBS Medicaid,CPT,33995,Insj perq vad r hrt venous,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
BCBS Medicaid,CPT,33997,Rmvl perq right heart vad,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
BCBS Medicaid,CPT,33999,Cardiac surgery procedure,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
BCBS Medicaid,CPT,34001,Removal of artery clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,34101,Removal of artery clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,34111,Removal of arm artery clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,34201,Removal of artery clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,34203,Removal of leg artery clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,34421,Removal of vein clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,34471,Removal of vein clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,34490,Removal of vein clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,34501,Repair valve femoral vein,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,34510,Transposition of vein valve,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,34520,Cross-over vein graft,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,34530,Leg vein fusion,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,34714,Opn fem art expos cndt crtj,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,34715,Opn ax/subcla art expos,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,34716,Opn ax/subcla art expos cndt,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,34812,Opn fem art expos,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,34834,Opn brach art expos,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,35011,Repair defect of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,35013,Repair artery rupture arm,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,35045,Repair defect of arm artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,35180,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
BCBS Medicaid,CPT,35184,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
BCBS Medicaid,CPT,35188,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
BCBS Medicaid,CPT,35190,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
BCBS Medicaid,CPT,35201,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
BCBS Medicaid,CPT,35206,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
BCBS Medicaid,CPT,35207,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
BCBS Medicaid,CPT,35226,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
BCBS Medicaid,CPT,35231,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
BCBS Medicaid,CPT,35236,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
BCBS Medicaid,CPT,35256,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,35261,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,35266,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
BCBS Medicaid,CPT,35301,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,35302,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,35303,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,35304,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,35305,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,35306,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,35321,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,35355,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,35371,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,35372,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,35390,Reoperation carotid add-on,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,35400,Angioscopy,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,35452,Repair arterial blockage,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
BCBS Medicaid,CPT,35472,Repair arterial blockage,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
BCBS Medicaid,CPT,35694,Art trnsposj subclav carotid,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,35697,Reimplant artery each,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,35700,Reoperation bypass graft,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,35701,Expl n/flwd surg neck art,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,35702,Expl n/flwd surg uxtr art,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,35703,Expl n/flwd surg lxtr art,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,35721,Exploration femoral artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,35741,Exploration popliteal artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,35761,Exploration of artery/vein,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,35800,Explore neck vessels,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,35820,Explore chest vessels,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,35860,Explore limb vessels,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,35875,Removal of clot in graft,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,35876,Removal of clot in graft,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,35901,Excision graft neck,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,35903,Excision graft extremity,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
BCBS Medicaid,CPT,36005,Injection ext venography,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
BCBS Medicaid,CPT,36010,Place catheter in vein,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
BCBS Medicaid,CPT,36011,Place catheter in vein,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
BCBS Medicaid,CPT,36012,Place catheter in vein,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
BCBS Medicaid,CPT,36013,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
BCBS Medicaid,CPT,36014,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
BCBS Medicaid,CPT,36015,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
BCBS Medicaid,CPT,36100,Establish access to artery,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
BCBS Medicaid,CPT,36120,Establish access to artery,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
BCBS Medicaid,CPT,36140,Intro ndl icath upr/lxtr art,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
BCBS Medicaid,CPT,36160,Establish access to aorta,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
BCBS Medicaid,CPT,36200,Place catheter in aorta,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
BCBS Medicaid,CPT,36215,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
BCBS Medicaid,CPT,36216,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
BCBS Medicaid,CPT,36217,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
BCBS Medicaid,CPT,36218,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
BCBS Medicaid,CPT,36221,Place cath thoracic aorta,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
BCBS Medicaid,CPT,36222,Place cath carotid/inom art,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
BCBS Medicaid,CPT,36223,Place cath carotid/inom art,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
BCBS Medicaid,CPT,36224,Place cath carotd art,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
BCBS Medicaid,CPT,36225,Place cath subclavian art,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
BCBS Medicaid,CPT,36226,Place cath vertebral art,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
BCBS Medicaid,CPT,36227,Place cath xtrnl carotid,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
BCBS Medicaid,CPT,36228,Place cath intracranial art,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
BCBS Medicaid,CPT,36245,Ins cath abd/l-ext art 1st,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
BCBS Medicaid,CPT,36246,Ins cath abd/l-ext art 2nd,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
BCBS Medicaid,CPT,36247,Ins cath abd/l-ext art 3rd,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
BCBS Medicaid,CPT,36248,Ins cath abd/l-ext art addl,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
BCBS Medicaid,CPT,36251,Ins cath ren art 1st unilat,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
BCBS Medicaid,CPT,36252,Ins cath ren art 1st bilat,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
BCBS Medicaid,CPT,36253,Ins cath ren art 2nd+ unilat,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
BCBS Medicaid,CPT,36254,Ins cath ren art 2nd+ bilat,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
BCBS Medicaid,CPT,36260,Insertion of infusion pump,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
BCBS Medicaid,CPT,36299,Vessel injection procedure,Vascular Surgery,Per Unit,$500.46 ,OP,500.46,500.46,,,,,,
BCBS Medicaid,CPT,36430,Blood transfusion service,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,36440,Bl push transfuse 2 yr/<,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,36450,Bl exchange/transfuse nb,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,36455,Bl exchange/transfuse non-nb,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,36456,Prtl exchange transfuse nb,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,36460,Transfusion service fetal,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,36465,Njx noncmpnd sclrsnt 1 vein,Vascular Surgery,Per Unit,$500.46 ,OP,500.46,500.46,,,,,,
BCBS Medicaid,CPT,36466,Njx noncmpnd sclrsnt mlt vn,Vascular Surgery,Per Unit,$500.46 ,OP,500.46,500.46,,,,,,
BCBS Medicaid,CPT,36468,Njx sclrsnt spider veins,Vascular Surgery,Per Unit,$500.46 ,OP,500.46,500.46,,,,,,
BCBS Medicaid,CPT,36470,Njx sclrsnt 1 incmptnt vein,Vascular Surgery,Per Unit,$500.46 ,OP,500.46,500.46,,,,,,
BCBS Medicaid,CPT,36471,Njx sclrsnt mlt incmptnt vn,Vascular Surgery,Per Unit,$500.46 ,OP,500.46,500.46,,,,,,
BCBS Medicaid,CPT,36481,Insertion of catheter vein,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
BCBS Medicaid,CPT,36500,Insertion of catheter vein,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
BCBS Medicaid,CPT,36511,Apheresis wbc,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
BCBS Medicaid,CPT,36512,Apheresis rbc,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
BCBS Medicaid,CPT,36513,Apheresis platelets,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,36514,Apheresis plasma,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
BCBS Medicaid,CPT,36515,Apheresis adsorp/reinfuse,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
BCBS Medicaid,CPT,36516,Apheresis immunoads slctv,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
BCBS Medicaid,CPT,36522,Photopheresis,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
BCBS Medicaid,CPT,36557,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
BCBS Medicaid,CPT,36558,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
BCBS Medicaid,CPT,36560,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
BCBS Medicaid,CPT,36561,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
BCBS Medicaid,CPT,36563,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
BCBS Medicaid,CPT,36565,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
BCBS Medicaid,CPT,36566,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
BCBS Medicaid,CPT,36581,Replace tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
BCBS Medicaid,CPT,36582,Replace tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
BCBS Medicaid,CPT,36583,Replace tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
BCBS Medicaid,CPT,36593,Declot vascular device,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
BCBS Medicaid,CPT,36620,Insertion catheter artery,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
BCBS Medicaid,CPT,36625,Insertion catheter artery,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
BCBS Medicaid,CPT,36640,Insertion catheter artery,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
BCBS Medicaid,CPT,36680,Insert needle bone cavity,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
BCBS Medicaid,CPT,36800,Insertion of cannula,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
BCBS Medicaid,CPT,36810,Insertion of cannula,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
BCBS Medicaid,CPT,36815,Insertion of cannula,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
BCBS Medicaid,CPT,36823,Insertion of cannula(s),Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,36838,Dist revas ligation hemo,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,36860,External cannula declotting,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
BCBS Medicaid,CPT,36903,Intro cath dialysis circuit,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,36905,Thrmbc/nfs dialysis circuit,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,36906,Thrmbc/nfs dialysis circuit,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,36907,Balo angiop ctr dialysis seg,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,36908,Stent plmt ctr dialysis seg,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,36909,Dialysis circuit embolj,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,37145,Revision of circulation,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,37182,Insert hepatic shunt (tips),Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,37183,Remove hepatic shunt (tips),Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,37184,Prim art m-thrmbc 1st vsl,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,37185,Prim art m-thrmbc sbsq vsl,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,37186,Sec art thrombectomy add-on,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,37195,Thrombolytic therapy stroke,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
BCBS Medicaid,CPT,37202,Transcatheter therapy infuse,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
BCBS Medicaid,CPT,37215,Transcath stent cca w/eps,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,37216,Transcath stent cca w/o eps,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,37217,Stent placemt retro carotid,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,37218,Stent placemt ante carotid,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,37220,Iliac revasc,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,37221,Iliac revasc w/stent,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,37222,Iliac revasc add-on,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,37223,Iliac revasc w/stent add-on,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,37224,Fem/popl revas w/tla,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,37225,Fem/popl revas w/ather,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,37226,Fem/popl revasc w/stent,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,37227,Fem/popl revasc stnt & ather,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,37228,Tib/per revasc w/tla,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,37229,Tib/per revasc w/ather,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,37230,Tib/per revasc w/stent,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,37231,Tib/per revasc stent & ather,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,37232,Tib/per revasc add-on,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,37233,Tibper revasc w/ather add-on,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,37234,Revsc opn/prq tib/pero stent,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,37235,Tib/per revasc stnt & ather,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,37236,Open/perq place stent 1st,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,37237,Open/perq place stent ea add,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,37238,Open/perq place stent same,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,37239,Open/perq place stent ea add,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,37241,Vasc embolize/occlude venous,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,37242,Vasc embolize/occlude artery,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,37243,Vasc embolize/occlude organ,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,37244,Vasc embolize/occlude bleed,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,37247,Trluml balo angiop addl art,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,37249,Trluml balo angiop addl vein,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,37250,Iv us first vessel add-on,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
BCBS Medicaid,CPT,37251,Iv us each add vessel add-on,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
BCBS Medicaid,CPT,37500,Endoscopy ligate perf veins,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,37501,Vascular endoscopy procedure,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,37565,Ligation of neck vein,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
BCBS Medicaid,CPT,37600,Ligation of neck artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
BCBS Medicaid,CPT,37605,Ligation of neck artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
BCBS Medicaid,CPT,37606,Ligation of neck artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
BCBS Medicaid,CPT,37607,Ligation of a-v fistula,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
BCBS Medicaid,CPT,37609,Temporal artery procedure,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
BCBS Medicaid,CPT,37615,Ligation of neck artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
BCBS Medicaid,CPT,37618,Ligation of extremity artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
BCBS Medicaid,CPT,37619,Ligation of inf vena cava,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,37650,Revision of major vein,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
BCBS Medicaid,CPT,37790,Penile venous occlusion,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,37799,Vascular surgery procedure,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
BCBS Medicaid,CPT,38102,Removal of spleen total,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,38120,Laparoscopy splenectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
BCBS Medicaid,CPT,38129,Laparoscope proc spleen,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
BCBS Medicaid,CPT,38205,Harvest allogeneic stem cell,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
BCBS Medicaid,CPT,38206,Harvest auto stem cells,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
BCBS Medicaid,CPT,38207,Cryopreserve stem cells,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
BCBS Medicaid,CPT,38208,Thaw preserved stem cells,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,38209,Wash harvest stem cells,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
BCBS Medicaid,CPT,38210,T-cell depletion of harvest,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,38211,Tumor cell deplete of harvst,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,38212,Rbc depletion of harvest,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,38213,Platelet deplete of harvest,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,38214,Volume deplete of harvest,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
BCBS Medicaid,CPT,38215,Harvest stem cell concentrte,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
BCBS Medicaid,CPT,38230,Bone marrow harvest allogen,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
BCBS Medicaid,CPT,38232,Bone marrow harvest autolog,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
BCBS Medicaid,CPT,38240,Transplt allo hct/donor,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
BCBS Medicaid,CPT,38241,Transplt autol hct/donor,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
BCBS Medicaid,CPT,38242,Transplt allo lymphocytes,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
BCBS Medicaid,CPT,38243,Transplj hematopoietic boost,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
BCBS Medicaid,CPT,38300,Drainage lymph node lesion,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
BCBS Medicaid,CPT,38305,Drainage lymph node lesion,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
BCBS Medicaid,CPT,38308,Incision of lymph channels,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
BCBS Medicaid,CPT,38380,Thoracic duct procedure,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,38500,Biopsy/removal lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
BCBS Medicaid,CPT,38505,Needle biopsy lymph nodes,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
BCBS Medicaid,CPT,38510,Biopsy/removal lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
BCBS Medicaid,CPT,38520,Biopsy/removal lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
BCBS Medicaid,CPT,38525,Biopsy/removal lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
BCBS Medicaid,CPT,38530,Biopsy/removal lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
BCBS Medicaid,CPT,38531,Open bx/exc inguinofem nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
BCBS Medicaid,CPT,38542,Explore deep node(s) neck,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,38550,Removal neck/armpit lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,38555,Removal neck/armpit lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,38562,Removal pelvic lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
BCBS Medicaid,CPT,38570,Laparoscopy lymph node biop,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
BCBS Medicaid,CPT,38571,Laparoscopy lymphadenectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
BCBS Medicaid,CPT,38572,Laparoscopy lymphadenectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
BCBS Medicaid,CPT,38573,Laps pelvic lymphadec,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
BCBS Medicaid,CPT,38589,Laparoscope proc lymphatic,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
BCBS Medicaid,CPT,38700,Removal of lymph nodes neck,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,38720,Removal of lymph nodes neck,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,38724,Removal of lymph nodes neck,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
BCBS Medicaid,CPT,38740,Remove armpit lymph nodes,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
BCBS Medicaid,CPT,38745,Remove armpit lymph nodes,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
BCBS Medicaid,CPT,38747,Remove abdominal lymph nodes,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,38760,Remove groin lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
BCBS Medicaid,CPT,38792,Ra tracer id of sentinl node,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,38794,Access thoracic lymph duct,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
BCBS Medicaid,CPT,38999,Blood/lymph system procedure,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
BCBS Medicaid,CPT,39545,Revision of diaphragm,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,39599,Diaphragm surgery procedure,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
BCBS Medicaid,CPT,40490,Biopsy of lip,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,40500,Partial excision of lip,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,40510,Partial excision of lip,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,40520,Partial excision of lip,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,40525,Reconstruct lip with flap,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,40527,Reconstruct lip with flap,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,40530,Partial removal of lip,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,40650,Repair lip,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,40652,Repair lip,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,40654,Repair lip,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,40799,Lip surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,40801,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,40805,Removal foreign body mouth,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,40806,Incision of lip fold,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,40808,Biopsy of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,40810,Excision of mouth lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,40812,Excise/repair mouth lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,40814,Excise/repair mouth lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,40816,Excision of mouth lesion,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,40818,Excise oral mucosa for graft,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,40819,Excise lip or cheek fold,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,40820,Treatment of mouth lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,40830,Repair mouth laceration,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,40831,Repair mouth laceration,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,40840,Reconstruction of mouth,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,40842,Reconstruction of mouth,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,40843,Reconstruction of mouth,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,40844,Reconstruction of mouth,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,40845,Reconstruction of mouth,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,40899,Mouth surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,41000,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,41005,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,41006,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,41007,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,41008,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,41009,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,41010,Incision of tongue fold,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,41015,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,41016,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,41017,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,41018,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,41100,Biopsy of tongue,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,41105,Biopsy of tongue,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,41108,Biopsy of floor of mouth,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,41110,Excision of tongue lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,41112,Excision of tongue lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,41113,Excision of tongue lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,41114,Excision of tongue lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,41115,Excision of tongue fold,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,41116,Excision of mouth lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,41120,Partial removal of tongue,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,41130,Partial removal of tongue,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,41135,Tongue and neck surgery,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,41150,Tongue mouth jaw surgery,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,41500,Fixation of tongue,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,41510,Tongue to lip surgery,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,41512,Tongue suspension,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,41520,Reconstruction tongue fold,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,41530,Tongue base vol reduction,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,41599,Tongue and mouth surgery,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,41805,Removal foreign body gum,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,41806,Removal foreign body jawbone,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
BCBS Medicaid,CPT,41820,Excision gum each quadrant,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
BCBS Medicaid,CPT,41821,Excision of gum flap,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,41822,Excision of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,41823,Excision of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,41825,Excision of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
BCBS Medicaid,CPT,41826,Excision of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
BCBS Medicaid,CPT,41827,Excision of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
BCBS Medicaid,CPT,41828,Excision of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
BCBS Medicaid,CPT,41830,Removal of gum tissue,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
BCBS Medicaid,CPT,41850,Treatment of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
BCBS Medicaid,CPT,41870,Gum graft,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,41872,Repair gum,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
BCBS Medicaid,CPT,41874,Repair tooth socket,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,41899,Dental surgery procedure,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,42100,Biopsy roof of mouth,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,42104,Excision lesion mouth roof,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,42106,Excision lesion mouth roof,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,42107,Excision lesion mouth roof,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,42120,Remove palate/lesion,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,42140,Excision of uvula,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,42160,Treatment mouth roof lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,42180,Repair palate,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,42182,Repair palate,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,42260,Repair nose to lip fistula,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,42280,Preparation palate mold,Dental,Per Unit,$30.61 ,OP,30.61,30.61,,,,,,
BCBS Medicaid,CPT,42281,Insertion palate prosthesis,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,42299,Palate/uvula surgery,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,42300,Drainage of salivary gland,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,42305,Drainage of salivary gland,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,42310,Drainage of salivary gland,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,42320,Drainage of salivary gland,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,42330,Removal of salivary stone,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,42335,Removal of salivary stone,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,42340,Removal of salivary stone,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,42400,Biopsy of salivary gland,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,42405,Biopsy of salivary gland,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,42408,Excision of salivary cyst,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,42409,Drainage of salivary cyst,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,42410,Excise parotid gland/lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,42415,Excise parotid gland/lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,42420,Excise parotid gland/lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,42425,Excise parotid gland/lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,42426,Excise parotid gland/lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,42440,Excise submaxillary gland,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,42450,Excise sublingual gland,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,42500,Repair salivary duct,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,42505,Repair salivary duct,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,42507,Parotid duct diversion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,42509,Parotid duct diversion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,42510,Parotid duct diversion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,42600,Closure of salivary fistula,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,42650,Dilation of salivary duct,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,42660,Dilation of salivary duct,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,42665,Ligation of salivary duct,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,42699,Salivary surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,42720,Drainage of throat abscess,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,42725,Drainage of throat abscess,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,42800,Biopsy of throat,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,42804,Biopsy of upper nose/throat,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,42806,Biopsy of upper nose/throat,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,42808,Excise pharynx lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,42810,Excision of neck cyst,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,42815,Excision of neck cyst,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,42820,Remove tonsils and adenoids,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
BCBS Medicaid,CPT,42821,Remove tonsils and adenoids,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
BCBS Medicaid,CPT,42825,Removal of tonsils,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
BCBS Medicaid,CPT,42826,Removal of tonsils,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
BCBS Medicaid,CPT,42830,Removal of adenoids,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
BCBS Medicaid,CPT,42831,Removal of adenoids,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
BCBS Medicaid,CPT,42835,Removal of adenoids,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
BCBS Medicaid,CPT,42836,Removal of adenoids,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
BCBS Medicaid,CPT,42842,Extensive surgery of throat,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
BCBS Medicaid,CPT,42844,Extensive surgery of throat,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
BCBS Medicaid,CPT,42860,Excision of tonsil tags,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
BCBS Medicaid,CPT,42870,Excision of lingual tonsil,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
BCBS Medicaid,CPT,42890,Partial removal of pharynx,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,42892,Revision of pharyngeal walls,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,42900,Repair throat wound,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,42950,Reconstruction of throat,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,42953,Repair throat esophagus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,42955,Surgical opening of throat,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,42960,Control throat bleeding,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,42962,Control throat bleeding,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,42970,Control nose/throat bleeding,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,42972,Control nose/throat bleeding,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,42999,Throat surgery procedure,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
BCBS Medicaid,CPT,43020,Incision of esophagus,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,43030,Throat muscle surgery,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,43100,Excision of esophagus lesion,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,43130,Removal of esophagus pouch,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,43191,Esophagoscopy rigid trnso dx,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
BCBS Medicaid,CPT,43192,Esophagoscp rig trnso inject,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
BCBS Medicaid,CPT,43193,Esophagoscp rig trnso biopsy,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
BCBS Medicaid,CPT,43194,Esophagoscp rig trnso rem fb,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
BCBS Medicaid,CPT,43196,Esophagoscp guide wire dilat,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
BCBS Medicaid,CPT,43197,Esophagoscopy flex dx brush,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
BCBS Medicaid,CPT,43198,Esophagosc flex trnsn biopsy,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
BCBS Medicaid,CPT,43200,Esophagoscopy flexible brush,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
BCBS Medicaid,CPT,43201,Esoph scope w/submucous inj,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
BCBS Medicaid,CPT,43202,Esophagoscopy flex biopsy,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
BCBS Medicaid,CPT,43204,Esoph scope w/sclerosis inj,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
BCBS Medicaid,CPT,43205,Esophagus endoscopy/ligation,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
BCBS Medicaid,CPT,43206,Esoph optical endomicroscopy,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
BCBS Medicaid,CPT,43211,Esophagoscop mucosal resect,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
BCBS Medicaid,CPT,43213,Esophagoscopy retro balloon,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
BCBS Medicaid,CPT,43214,Esophagosc dilate balloon 30,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
BCBS Medicaid,CPT,43215,Esophagoscopy flex remove fb,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
BCBS Medicaid,CPT,43216,Esophagoscopy lesion removal,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
BCBS Medicaid,CPT,43217,Esophagoscopy snare les remv,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
BCBS Medicaid,CPT,43220,Esophagoscopy balloon <30mm,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
BCBS Medicaid,CPT,43226,Esoph endoscopy dilation,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
BCBS Medicaid,CPT,43227,Esophagoscopy control bleed,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
BCBS Medicaid,CPT,43229,Esophagoscopy lesion ablate,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
BCBS Medicaid,CPT,43231,Esophagoscop ultrasound exam,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
BCBS Medicaid,CPT,43232,Esophagoscopy w/us needle bx,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
BCBS Medicaid,CPT,43233,Egd balloon dil esoph30 mm/>,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
BCBS Medicaid,CPT,43235,Egd diagnostic brush wash,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
BCBS Medicaid,CPT,43236,Uppr gi scope w/submuc inj,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
BCBS Medicaid,CPT,43237,Endoscopic us exam esoph,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
BCBS Medicaid,CPT,43238,Egd us fine needle bx/aspir,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
BCBS Medicaid,CPT,43239,Egd biopsy single/multiple,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
BCBS Medicaid,CPT,43241,Egd tube/cath insertion,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
BCBS Medicaid,CPT,43242,Egd us fine needle bx/aspir,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
BCBS Medicaid,CPT,43243,Egd injection varices,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
BCBS Medicaid,CPT,43244,Egd varices ligation,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
BCBS Medicaid,CPT,43245,Egd dilate stricture,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
BCBS Medicaid,CPT,43246,Egd place gastrostomy tube,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
BCBS Medicaid,CPT,43247,Egd remove foreign body,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
BCBS Medicaid,CPT,43248,Egd guide wire insertion,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
BCBS Medicaid,CPT,43249,Esoph egd dilation <30 mm,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
BCBS Medicaid,CPT,43250,Egd cautery tumor polyp,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
BCBS Medicaid,CPT,43251,Egd remove lesion snare,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
BCBS Medicaid,CPT,43253,Egd us transmural injxn/mark,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
BCBS Medicaid,CPT,43254,Egd endo mucosal resection,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
BCBS Medicaid,CPT,43255,Egd control bleeding any,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
BCBS Medicaid,CPT,43257,Egd w/thrml txmnt gerd,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
BCBS Medicaid,CPT,43259,Egd us exam duodenum/jejunum,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
BCBS Medicaid,CPT,43260,Ercp w/specimen collection,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
BCBS Medicaid,CPT,43261,Endo cholangiopancreatograph,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
BCBS Medicaid,CPT,43262,Endo cholangiopancreatograph,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
BCBS Medicaid,CPT,43263,Ercp sphincter pressure meas,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
BCBS Medicaid,CPT,43270,Egd lesion ablation,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
BCBS Medicaid,CPT,43275,Ercp remove forgn body duct,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
BCBS Medicaid,CPT,43276,Ercp stent exchange w/dilate,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
BCBS Medicaid,CPT,43277,Ercp ea duct/ampulla dilate,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
BCBS Medicaid,CPT,43279,Lap myotomy heller,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
BCBS Medicaid,CPT,43280,Laparoscopy fundoplasty,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
BCBS Medicaid,CPT,43281,Lap paraesophag hern repair,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
BCBS Medicaid,CPT,43282,Lap paraesoph her rpr w/mesh,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
BCBS Medicaid,CPT,43283,Lap esoph lengthening,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
BCBS Medicaid,CPT,43284,Laps esophgl sphnctr agmntj,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
BCBS Medicaid,CPT,43285,Rmvl esophgl sphnctr dev,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
BCBS Medicaid,CPT,43289,Laparoscope proc esoph,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
BCBS Medicaid,CPT,43300,Repair of esophagus,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,43305,Repair esophagus and fistula,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,43320,Fuse esophagus & stomach,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,43332,Transab esoph hiat hern rpr,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
BCBS Medicaid,CPT,43333,Transab esoph hiat hern rpr,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
BCBS Medicaid,CPT,43334,Transthor diaphrag hern rpr,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
BCBS Medicaid,CPT,43335,Transthor diaphrag hern rpr,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
BCBS Medicaid,CPT,43336,Thorabd diaphr hern repair,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
BCBS Medicaid,CPT,43337,Thorabd diaphr hern repair,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
BCBS Medicaid,CPT,43338,Esoph lengthening,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
BCBS Medicaid,CPT,43401,Esophagus surgery for veins,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,43410,Repair esophagus wound,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,43420,Repair esophagus opening,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,43450,Dilate esophagus 1/mult pass,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
BCBS Medicaid,CPT,43453,Dilate esophagus,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
BCBS Medicaid,CPT,43499,Esophagus surgery procedure,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
BCBS Medicaid,CPT,43500,Surgical opening of stomach,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,43510,Surgical opening of stomach,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
BCBS Medicaid,CPT,43520,Incision of pyloric muscle,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
BCBS Medicaid,CPT,43610,Excision of stomach lesion,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,43644,Lap gastric bypass/roux-en-y,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
BCBS Medicaid,CPT,43645,Lap gastr bypass incl smll i,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
BCBS Medicaid,CPT,43647,Lap impl electrode antrum,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
BCBS Medicaid,CPT,43648,Lap revise/remv eltrd antrum,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
BCBS Medicaid,CPT,43651,Laparoscopy vagus nerve,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
BCBS Medicaid,CPT,43652,Laparoscopy vagus nerve,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
BCBS Medicaid,CPT,43653,Laparoscopy gastrostomy,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
BCBS Medicaid,CPT,43659,Laparoscope proc stom,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
BCBS Medicaid,CPT,43752,Nasal/orogastric w/tube plmt,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
BCBS Medicaid,CPT,43753,Tx gastro intub w/asp,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
BCBS Medicaid,CPT,43754,Dx gastr intub w/asp spec,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
BCBS Medicaid,CPT,43755,Dx gastr intub w/asp specs,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
BCBS Medicaid,CPT,43756,Dx duod intub w/asp spec,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
BCBS Medicaid,CPT,43757,Dx duod intub w/asp specs,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
BCBS Medicaid,CPT,43760,Change gastrostomy tube,Gastroenterology,Per Unit,$119.18 ,OP,119.18,119.18,,,,,,
BCBS Medicaid,CPT,43761,Reposition gastrostomy tube,Gastroenterology,Per Unit,$119.18 ,OP,119.18,119.18,,,,,,
BCBS Medicaid,CPT,43762,Rplc gtube no revj trc,Gastroenterology,Per Unit,$119.18 ,OP,119.18,119.18,,,,,,
BCBS Medicaid,CPT,43763,Rplc gtube revj gstrst trc,Gastroenterology,Per Unit,$119.18 ,OP,119.18,119.18,,,,,,
BCBS Medicaid,CPT,43770,Lap place gastr adj device,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
BCBS Medicaid,CPT,43771,Lap revise gastr adj device,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
BCBS Medicaid,CPT,43772,Lap rmvl gastr adj device,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
BCBS Medicaid,CPT,43773,Lap replace gastr adj device,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
BCBS Medicaid,CPT,43774,Lap rmvl gastr adj all parts,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
BCBS Medicaid,CPT,43775,Lap sleeve gastrectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
BCBS Medicaid,CPT,43830,Place gastrostomy tube,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
BCBS Medicaid,CPT,43831,Place gastrostomy tube,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
BCBS Medicaid,CPT,43832,Place gastrostomy tube,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,43842,V-band gastroplasty,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
BCBS Medicaid,CPT,43843,Gastroplasty w/o v-band,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,43848,Revision gastroplasty,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,43860,Revise stomach-bowel fusion,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,43870,Repair stomach opening,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
BCBS Medicaid,CPT,43880,Repair stomach-bowel fistula,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,43881,Impl/redo electrd antrum,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,43882,Revise/remove electrd antrum,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,43886,Revise gastric port open,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
BCBS Medicaid,CPT,43887,Remove gastric port open,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
BCBS Medicaid,CPT,43888,Change gastric port open,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
BCBS Medicaid,CPT,43999,Stomach surgery procedure,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
BCBS Medicaid,CPT,44005,Freeing of bowel adhesion,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,44015,Insert needle cath bowel,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
BCBS Medicaid,CPT,44020,Explore small intestine,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,44050,Reduce bowel obstruction,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,44055,Correct malrotation of bowel,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,44100,Biopsy of bowel,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,44110,Excise intestine lesion(s),General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,44111,Excision of bowel lesion(s),General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,44125,Removal of small intestine,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,44130,Bowel to bowel fusion,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,44139,Mobilization of colon,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,44141,Partial removal of colon,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,44143,Partial removal of colon,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,44180,Lap enterolysis,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
BCBS Medicaid,CPT,44186,Lap jejunostomy,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
BCBS Medicaid,CPT,44187,Lap ileo/jejuno-stomy,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
BCBS Medicaid,CPT,44188,Lap colostomy,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
BCBS Medicaid,CPT,44204,Laparo partial colectomy,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
BCBS Medicaid,CPT,44206,Lap part colectomy w/stoma,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
BCBS Medicaid,CPT,44207,L colectomy/coloproctostomy,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
BCBS Medicaid,CPT,44208,L colectomy/coloproctostomy,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
BCBS Medicaid,CPT,44213,Lap mobil splenic fl add-on,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
BCBS Medicaid,CPT,44238,Laparoscope proc intestine,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
BCBS Medicaid,CPT,44300,Open bowel to skin,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,44312,Revision of ileostomy,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,44320,Colostomy,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,44340,Revision of colostomy,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,44346,Revision of colostomy,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,44360,Small bowel endoscopy,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
BCBS Medicaid,CPT,44361,Small bowel endoscopy/biopsy,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
BCBS Medicaid,CPT,44363,Small bowel endoscopy,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
BCBS Medicaid,CPT,44364,Small bowel endoscopy,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
BCBS Medicaid,CPT,44365,Small bowel endoscopy,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
BCBS Medicaid,CPT,44366,Small bowel endoscopy,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
BCBS Medicaid,CPT,44369,Small bowel endoscopy,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
BCBS Medicaid,CPT,44370,Small bowel endoscopy/stent,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
BCBS Medicaid,CPT,44372,Small bowel endoscopy,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
BCBS Medicaid,CPT,44373,Small bowel endoscopy,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
BCBS Medicaid,CPT,44376,Small bowel endoscopy,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
BCBS Medicaid,CPT,44377,Small bowel endoscopy/biopsy,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
BCBS Medicaid,CPT,44378,Small bowel endoscopy,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
BCBS Medicaid,CPT,44379,S bowel endoscope w/stent,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
BCBS Medicaid,CPT,44380,Small bowel endoscopy br/wa,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,44381,Small bowel endoscopy br/wa,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,44382,Small bowel endoscopy,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,44384,Small bowel endoscopy,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
BCBS Medicaid,CPT,44385,Endoscopy of bowel pouch,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,44386,Endoscopy bowel pouch/biop,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,44388,Colonoscopy thru stoma spx,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,44389,Colonoscopy with biopsy,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,44390,Colonoscopy for foreign body,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,44391,Colonoscopy for bleeding,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,44392,Colonoscopy & polypectomy,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,44394,Colonoscopy w/snare,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,44401,Colonoscopy with ablation,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,44402,Colonoscopy w/stent plcmt,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
BCBS Medicaid,CPT,44403,Colonoscopy w/resection,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,44404,Colonoscopy w/injection,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,44405,Colonoscopy w/dilation,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,44406,Colonoscopy w/ultrasound,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,44407,Colonoscopy w/ndl aspir/bx,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,44408,Colonoscopy w/decompression,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,44500,Intro gastrointestinal tube,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
BCBS Medicaid,CPT,44602,Suture small intestine,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,44603,Suture small intestine,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,44615,Intestinal stricturoplasty,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,44620,Repair bowel opening,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,44640,Repair bowel-skin fistula,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,44650,Repair bowel fistula,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,44799,Unlisted px small intestine,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
BCBS Medicaid,CPT,44800,Excision of bowel pouch,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,44820,Excision of mesentery lesion,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,44850,Repair of mesentery,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,44899,Bowel surgery procedure,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
BCBS Medicaid,CPT,44900,Drain appendix abscess open,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,44950,Appendectomy,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,44955,Appendectomy add-on,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,44960,Appendectomy,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,44970,Laparoscopy appendectomy,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
BCBS Medicaid,CPT,44979,Laparoscope proc app,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
BCBS Medicaid,CPT,45000,Drainage of pelvic abscess,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,45005,Drainage of rectal abscess,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
BCBS Medicaid,CPT,45020,Drainage of rectal abscess,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,45100,Biopsy of rectum,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
BCBS Medicaid,CPT,45108,Removal of anorectal lesion,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,45113,Partial proctectomy,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,45123,Partial proctectomy,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,45130,Excision of rectal prolapse,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,45136,Excise ileoanal reservior,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,45150,Excision of rectal stricture,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,45160,Excision of rectal lesion,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,45171,Exc rect tum transanal part,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,45172,Exc rect tum transanal full,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,45190,Destruction rectal tumor,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,45300,Proctosigmoidoscopy dx,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,45303,Proctosigmoidoscopy dilate,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
BCBS Medicaid,CPT,45305,Proctosigmoidoscopy w/bx,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,45307,Proctosigmoidoscopy fb,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,45308,Proctosigmoidoscopy removal,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
BCBS Medicaid,CPT,45309,Proctosigmoidoscopy removal,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,45315,Proctosigmoidoscopy removal,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,45317,Proctosigmoidoscopy bleed,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
BCBS Medicaid,CPT,45320,Proctosigmoidoscopy ablate,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
BCBS Medicaid,CPT,45321,Proctosigmoidoscopy volvul,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
BCBS Medicaid,CPT,45327,Proctosigmoidoscopy w/stent,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
BCBS Medicaid,CPT,45330,Diagnostic sigmoidoscopy,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,45331,Sigmoidoscopy and biopsy,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,45332,Sigmoidoscopy w/fb removal,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,45333,Sigmoidoscopy & polypectomy,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,45334,Sigmoidoscopy for bleeding,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,45335,Sigmoidoscopy w/submuc inj,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,45337,Sigmoidoscopy & decompress,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,45338,Sigmoidoscopy w/tumr remove,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,45340,Sig w/tndsc balloon dilation,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,45341,Sigmoidoscopy w/ultrasound,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,45342,Sigmoidoscopy w/us guide bx,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,45346,Sigmoidoscopy w/ablation,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,45347,Sigmoidoscopy w/plcmt stent,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
BCBS Medicaid,CPT,45349,Sigmoidoscopy w/resection,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
BCBS Medicaid,CPT,45350,Sgmdsc w/band ligation,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,45378,Diagnostic colonoscopy,Preventive Care,Per Unit,$387.00 ,OP,387,387,,,,,,
BCBS Medicaid,CPT,45379,Colonoscopy w/fb removal,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,45380,Colonoscopy and biopsy,Preventive Care,Per Unit,$387.00 ,OP,387,387,,,,,,
BCBS Medicaid,CPT,45381,Colonoscopy submucous njx,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,45382,Colonoscopy w/control bleed,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,45384,Colonoscopy w/lesion removal,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,45385,Colonoscopy w/lesion removal,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,45386,Colonoscopy w/balloon dilat,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,45388,Colonoscopy w/ablation,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,45389,Colonoscopy w/stent plcmt,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
BCBS Medicaid,CPT,45390,Colonoscopy w/resection,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
BCBS Medicaid,CPT,45391,Colonoscopy w/endoscope us,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,45392,Colonoscopy w/endoscopic fnb,Preventive Care,Per Unit,$387.00 ,OP,387,387,,,,,,
BCBS Medicaid,CPT,45393,Colonoscopy w/decompression,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,45398,Colonoscopy w/band ligation,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,45399,Unlisted procedure colon,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,45400,Laparoscopic proc,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
BCBS Medicaid,CPT,45402,Lap proctopexy w/sig resect,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
BCBS Medicaid,CPT,45499,Laparoscope proc rectum,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
BCBS Medicaid,CPT,45500,Repair of rectum,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,45505,Repair of rectum,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,45520,Treatment of rectal prolapse,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
BCBS Medicaid,CPT,45541,Correct rectal prolapse,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,45560,Repair of rectocele,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,45562,Exploration/repair of rectum,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,45800,Repair rect/bladder fistula,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,45820,Repair rectourethral fistula,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,45900,Reduction of rectal prolapse,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
BCBS Medicaid,CPT,45905,Dilation of anal sphincter,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
BCBS Medicaid,CPT,45910,Dilation of rectal narrowing,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
BCBS Medicaid,CPT,45915,Remove rectal obstruction,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
BCBS Medicaid,CPT,45990,Surg dx exam anorectal,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
BCBS Medicaid,CPT,45999,Rectum surgery procedure,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
BCBS Medicaid,CPT,46020,Placement of seton,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
BCBS Medicaid,CPT,46030,Removal of rectal marker,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
BCBS Medicaid,CPT,46040,Incision of rectal abscess,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
BCBS Medicaid,CPT,46045,Incision of rectal abscess,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,46050,Incision of anal abscess,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
BCBS Medicaid,CPT,46060,Incision of rectal abscess,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,46070,Incision of anal septum,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
BCBS Medicaid,CPT,46080,Incision of anal sphincter,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
BCBS Medicaid,CPT,46083,Incise external hemorrhoid,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
BCBS Medicaid,CPT,46200,Removal of anal fissure,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
BCBS Medicaid,CPT,46220,Excise anal ext tag/papilla,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
BCBS Medicaid,CPT,46221,Ligation of hemorrhoid(s),General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
BCBS Medicaid,CPT,46230,Removal of anal tags,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
BCBS Medicaid,CPT,46250,Remove ext hem groups 2+,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,46255,Remove int/ext hem 1 group,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,46257,Remove in/ex hem grp & fiss,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,46258,Remove in/ex hem grp w/fistu,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,46260,Remove in/ex hem groups 2+,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,46261,Remove in/ex hem grps & fiss,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,46262,Remove in/ex hem grps w/fist,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,46270,Remove anal fist subq,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,46275,Remove anal fist inter,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,46280,Remove anal fist complex,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,46285,Remove anal fist 2 stage,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
BCBS Medicaid,CPT,46288,Repair anal fistula,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,46320,Removal of hemorrhoid clot,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
BCBS Medicaid,CPT,46500,Injection into hemorrhoid(s),General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
BCBS Medicaid,CPT,46505,Chemodenervation anal musc,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
BCBS Medicaid,CPT,46600,Diagnostic anoscopy spx,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,46601,Diagnostic anoscopy,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,46604,Anoscopy and dilation,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,46606,Anoscopy and biopsy,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,46607,Diagnostic anoscopy & biopsy,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
BCBS Medicaid,CPT,46608,Anoscopy remove for body,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,46610,Anoscopy remove lesion,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
BCBS Medicaid,CPT,46611,Anoscopy,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,46612,Anoscopy remove lesions,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
BCBS Medicaid,CPT,46614,Anoscopy control bleeding,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,46615,Anoscopy,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
BCBS Medicaid,CPT,46700,Repair of anal stricture,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,46705,Repair of anal stricture,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,46706,Repr of anal fistula w/glue,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
BCBS Medicaid,CPT,46707,Repair anorectal fist w/plug,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
BCBS Medicaid,CPT,46710,Repr per/vag pouch sngl proc,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,46712,Repr per/vag pouch dbl proc,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,46715,Rep perf anoper fistu,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,46716,Rep perf anoper/vestib fistu,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,46740,Construction of absent anus,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,46750,Repair of anal sphincter,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,46751,Repair of anal sphincter,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,46753,Reconstruction of anus,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,46754,Removal of suture from anus,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
BCBS Medicaid,CPT,46760,Repair of anal sphincter,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,46761,Repair of anal sphincter,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,46762,Implant artificial sphincter,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,46900,Destruction anal lesion(s),General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
BCBS Medicaid,CPT,46910,Destruction anal lesion(s),General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
BCBS Medicaid,CPT,46916,Cryosurgery anal lesion(s),General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
BCBS Medicaid,CPT,46917,Laser surgery anal lesions,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
BCBS Medicaid,CPT,46922,Excision of anal lesion(s),General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
BCBS Medicaid,CPT,46924,Destruction anal lesion(s),General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
BCBS Medicaid,CPT,46930,Destroy internal hemorrhoids,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
BCBS Medicaid,CPT,46940,Treatment of anal fissure,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
BCBS Medicaid,CPT,46942,Treatment of anal fissure,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
BCBS Medicaid,CPT,46945,Int hrhc lig 1 hroid w/o img,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
BCBS Medicaid,CPT,46946,Int hrhc lig 2+hroid w/o img,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
BCBS Medicaid,CPT,46947,Hemorrhoidopexy by stapling,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,46948,Int hrhc tranal dartlzj 2+,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,46999,Anus surgery procedure,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
BCBS Medicaid,CPT,47370,Laparo ablate liver tumor rf,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
BCBS Medicaid,CPT,47371,Laparo ablate liver cryosurg,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
BCBS Medicaid,CPT,47379,Laparoscope procedure liver,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
BCBS Medicaid,CPT,47510,Insert catheter bile duct,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
BCBS Medicaid,CPT,47511,Insert bile duct drain,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
BCBS Medicaid,CPT,47525,Change bile duct catheter,Gastroenterology,Per Unit,$119.18 ,OP,119.18,119.18,,,,,,
BCBS Medicaid,CPT,47530,Revise/reinsert bile tube,Gastroenterology,Per Unit,$119.18 ,OP,119.18,119.18,,,,,,
BCBS Medicaid,CPT,47537,Removal biliary drg cath,Gastroenterology,Per Unit,$119.18 ,OP,119.18,119.18,,,,,,
BCBS Medicaid,CPT,47560,Laparoscopy w/cholangio,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
BCBS Medicaid,CPT,47561,Laparo w/cholangio/biopsy,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
BCBS Medicaid,CPT,47562,Laparoscopic cholecystectomy,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
BCBS Medicaid,CPT,47563,Laparo cholecystectomy/graph,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
BCBS Medicaid,CPT,47564,Laparo cholecystectomy/explr,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
BCBS Medicaid,CPT,47570,Laparo cholecystoenterostomy,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
BCBS Medicaid,CPT,47579,Laparoscope proc biliary,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
BCBS Medicaid,CPT,47630,Remove bile duct stone,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
BCBS Medicaid,CPT,48550,Donor pancreatectomy,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,49000,Exploration of abdomen,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,49002,Reopening of abdomen,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,49010,Exploration behind abdomen,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,49203,Exc abd tum 5 cm or less,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,49204,Exc abd tum over 5 cm,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,49205,Exc abd tum over 10 cm,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,49215,Excise sacral spine tumor,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,49220,Multiple surgery abdomen,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,49250,Excision of umbilicus,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
BCBS Medicaid,CPT,49255,Removal of omentum,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,49320,Diag laparo separate proc,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
BCBS Medicaid,CPT,49321,Laparoscopy biopsy,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
BCBS Medicaid,CPT,49322,Laparoscopy aspiration,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
BCBS Medicaid,CPT,49323,Laparo drain lymphocele,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
BCBS Medicaid,CPT,49324,Lap insert tunnel ip cath,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
BCBS Medicaid,CPT,49325,Lap revision perm ip cath,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
BCBS Medicaid,CPT,49326,Lap w/omentopexy add-on,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
BCBS Medicaid,CPT,49329,Laparo proc abdm/per/oment,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
BCBS Medicaid,CPT,49402,Remove foreign body adbomen,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
BCBS Medicaid,CPT,49425,Insert abdomen-venous drain,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,49426,Revise abdomen-venous shunt,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
BCBS Medicaid,CPT,49428,Ligation of shunt,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,49429,Removal of shunt,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
BCBS Medicaid,CPT,49440,Place gastrostomy tube perc,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
BCBS Medicaid,CPT,49441,Place duod/jej tube perc,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
BCBS Medicaid,CPT,49442,Place cecostomy tube perc,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,49446,Change g-tube to g-j perc,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
BCBS Medicaid,CPT,49450,Replace g/c tube perc,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
BCBS Medicaid,CPT,49451,Replace duod/jej tube perc,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
BCBS Medicaid,CPT,49452,Replace g-j tube perc,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
BCBS Medicaid,CPT,49460,Fix g/colon tube w/device,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
BCBS Medicaid,CPT,49491,Rpr hern preemie reduc,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
BCBS Medicaid,CPT,49492,Rpr ing hern premie blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
BCBS Medicaid,CPT,49495,Rpr ing hernia baby reduc,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
BCBS Medicaid,CPT,49496,Rpr ing hernia baby blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
BCBS Medicaid,CPT,49500,Rpr ing hernia init reduce,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
BCBS Medicaid,CPT,49501,Rpr ing hernia init blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
BCBS Medicaid,CPT,49505,Prp i/hern init reduc >5 yr,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
BCBS Medicaid,CPT,49507,Prp i/hern init block >5 yr,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
BCBS Medicaid,CPT,49520,Rerepair ing hernia reduce,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
BCBS Medicaid,CPT,49521,Rerepair ing hernia blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
BCBS Medicaid,CPT,49525,Repair ing hernia sliding,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
BCBS Medicaid,CPT,49540,Repair lumbar hernia,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
BCBS Medicaid,CPT,49550,Rpr rem hernia init reduce,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
BCBS Medicaid,CPT,49553,Rpr fem hernia init blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
BCBS Medicaid,CPT,49555,Rerepair fem hernia reduce,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
BCBS Medicaid,CPT,49557,Rerepair fem hernia blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
BCBS Medicaid,CPT,49560,Rpr ventral hern init reduc,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
BCBS Medicaid,CPT,49561,Rpr ventral hern init block,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
BCBS Medicaid,CPT,49565,Rerepair ventrl hern reduce,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
BCBS Medicaid,CPT,49566,Rerepair ventrl hern block,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
BCBS Medicaid,CPT,49568,Hernia repair w/mesh,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
BCBS Medicaid,CPT,49570,Rpr epigastric hern reduce,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
BCBS Medicaid,CPT,49572,Rpr epigastric hern blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
BCBS Medicaid,CPT,49580,Rpr umbil hern reduc < 5 yr,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
BCBS Medicaid,CPT,49582,Rpr umbil hern block < 5 yr,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
BCBS Medicaid,CPT,49585,Rpr umbil hern reduc > 5 yr,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
BCBS Medicaid,CPT,49587,Rpr umbil hern block > 5 yr,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
BCBS Medicaid,CPT,49590,Repair spigelian hernia,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
BCBS Medicaid,CPT,49600,Repair umbilical lesion,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
BCBS Medicaid,CPT,49606,Repair umbilical lesion,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
BCBS Medicaid,CPT,49610,Repair umbilical lesion,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
BCBS Medicaid,CPT,49650,Lap ing hernia repair init,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
BCBS Medicaid,CPT,49651,Lap ing hernia repair recur,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
BCBS Medicaid,CPT,49652,Lap vent/abd hernia repair,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
BCBS Medicaid,CPT,49653,Lap vent/abd hern proc comp,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
BCBS Medicaid,CPT,49654,Lap inc hernia repair,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
BCBS Medicaid,CPT,49655,Lap inc hern repair comp,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
BCBS Medicaid,CPT,49656,Lap inc hernia repair recur,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
BCBS Medicaid,CPT,49657,Lap inc hern recur comp,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
BCBS Medicaid,CPT,49659,Laparo proc hernia repair,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
BCBS Medicaid,CPT,49900,Repair of abdominal wall,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,49904,Omental flap extra-abdom,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
BCBS Medicaid,CPT,49905,Omental flap intra-abdom,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
BCBS Medicaid,CPT,49906,Free omental flap microvasc,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
BCBS Medicaid,CPT,49999,Abdomen surgery procedure,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
BCBS Medicaid,CPT,50389,Remove renal tube w/fluoro,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
BCBS Medicaid,CPT,50390,Drainage of kidney lesion,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
BCBS Medicaid,CPT,50391,Instll rx agnt into rnal tub,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
BCBS Medicaid,CPT,50396,Measure kidney pressure,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
BCBS Medicaid,CPT,50398,Change kidney tube,Gastroenterology,Per Unit,$119.18 ,OP,119.18,119.18,,,,,,
BCBS Medicaid,CPT,50430,Njx px nfrosgrm &/urtrgrm,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
BCBS Medicaid,CPT,50431,Njx px nfrosgrm &/urtrgrm,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
BCBS Medicaid,CPT,50541,Laparo ablate renal cyst,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
BCBS Medicaid,CPT,50542,Laparo ablate renal mass,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
BCBS Medicaid,CPT,50543,Laparo partial nephrectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
BCBS Medicaid,CPT,50544,Laparoscopy pyeloplasty,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
BCBS Medicaid,CPT,50549,Laparoscope proc renal,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
BCBS Medicaid,CPT,50945,Laparoscopy ureterolithotomy,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
BCBS Medicaid,CPT,50947,Laparo new ureter/bladder,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
BCBS Medicaid,CPT,50948,Laparo new ureter/bladder,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
BCBS Medicaid,CPT,50949,Laparoscope proc ureter,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
BCBS Medicaid,CPT,51100,Drain bladder by needle,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
BCBS Medicaid,CPT,51500,Removal of bladder cyst,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
BCBS Medicaid,CPT,51705,Change of bladder tube,Gastroenterology,Per Unit,$119.18 ,OP,119.18,119.18,,,,,,
BCBS Medicaid,CPT,51710,Change of bladder tube,Gastroenterology,Per Unit,$119.18 ,OP,119.18,119.18,,,,,,
BCBS Medicaid,CPT,51715,Endoscopic injection/implant,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
BCBS Medicaid,CPT,51720,Treatment of bladder lesion,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
BCBS Medicaid,CPT,51725,Simple cystometrogram,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
BCBS Medicaid,CPT,51726,Complex cystometrogram,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
BCBS Medicaid,CPT,51727,Cystometrogram w/up,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
BCBS Medicaid,CPT,51728,Cystometrogram w/vp,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
BCBS Medicaid,CPT,51729,Cystometrogram w/vp&up,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
BCBS Medicaid,CPT,51741,Electro-uroflowmetry first,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
BCBS Medicaid,CPT,51784,Anal/urinary muscle study,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,51785,Anal/urinary muscle study,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,51792,Urinary reflex study,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
BCBS Medicaid,CPT,51990,Laparo urethral suspension,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
BCBS Medicaid,CPT,51992,Laparo sling operation,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
BCBS Medicaid,CPT,51999,Laparoscope proc bla,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
BCBS Medicaid,CPT,52010,Cystoscopy & duct catheter,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
BCBS Medicaid,CPT,52270,Cystoscopy & revise urethra,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
BCBS Medicaid,CPT,52275,Cystoscopy & revise urethra,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
BCBS Medicaid,CPT,52276,Cystoscopy and treatment,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
BCBS Medicaid,CPT,52277,Cystoscopy and treatment,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
BCBS Medicaid,CPT,52282,Cystoscopy implant stent,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
BCBS Medicaid,CPT,52283,Cystoscopy and treatment,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
BCBS Medicaid,CPT,52285,Cystoscopy and treatment,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
BCBS Medicaid,CPT,52400,Cystouretero w/congen repr,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
BCBS Medicaid,CPT,52402,Cystourethro cut ejacul duct,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
BCBS Medicaid,CPT,52442,Cystourethro w/addl implant,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
BCBS Medicaid,CPT,52601,Prostatectomy (turp),Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
BCBS Medicaid,CPT,52630,Remove prostate regrowth,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
BCBS Medicaid,CPT,52647,Laser surgery of prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
BCBS Medicaid,CPT,52648,Laser surgery of prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
BCBS Medicaid,CPT,52649,Prostate laser enucleation,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
BCBS Medicaid,CPT,53000,Incision of urethra,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
BCBS Medicaid,CPT,53010,Incision of urethra,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
BCBS Medicaid,CPT,53020,Incision of urethra,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
BCBS Medicaid,CPT,53025,Incision of urethra,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
BCBS Medicaid,CPT,53040,Drainage of urethra abscess,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
BCBS Medicaid,CPT,53060,Drainage of urethra abscess,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
BCBS Medicaid,CPT,53080,Drainage of urinary leakage,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
BCBS Medicaid,CPT,53085,Drainage of urinary leakage,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
BCBS Medicaid,CPT,53200,Biopsy of urethra,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
BCBS Medicaid,CPT,53210,Removal of urethra,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
BCBS Medicaid,CPT,53215,Removal of urethra,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
BCBS Medicaid,CPT,53220,Treatment of urethra lesion,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
BCBS Medicaid,CPT,53230,Removal of urethra lesion,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
BCBS Medicaid,CPT,53235,Removal of urethra lesion,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
BCBS Medicaid,CPT,53240,Surgery for urethra pouch,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
BCBS Medicaid,CPT,53250,Removal of urethra gland,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
BCBS Medicaid,CPT,53260,Treatment of urethra lesion,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
BCBS Medicaid,CPT,53265,Treatment of urethra lesion,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
BCBS Medicaid,CPT,53270,Removal of urethra gland,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
BCBS Medicaid,CPT,53275,Repair of urethra defect,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
BCBS Medicaid,CPT,53400,Revise urethra stage 1,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
BCBS Medicaid,CPT,53405,Revise urethra stage 2,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
BCBS Medicaid,CPT,53410,Reconstruction of urethra,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
BCBS Medicaid,CPT,53415,Reconstruction of urethra,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
BCBS Medicaid,CPT,53420,Reconstruct urethra stage 1,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
BCBS Medicaid,CPT,53425,Reconstruct urethra stage 2,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
BCBS Medicaid,CPT,53430,Reconstruction of urethra,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
BCBS Medicaid,CPT,53431,Reconstruct urethra/bladder,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
BCBS Medicaid,CPT,53440,Male sling procedure,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
BCBS Medicaid,CPT,53442,Remove/revise male sling,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
BCBS Medicaid,CPT,53444,Insert tandem cuff,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
BCBS Medicaid,CPT,53446,Remove uro sphincter,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
BCBS Medicaid,CPT,53448,Remov/replc ur sphinctr comp,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
BCBS Medicaid,CPT,53449,Repair uro sphincter,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
BCBS Medicaid,CPT,53450,Revision of urethra,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
BCBS Medicaid,CPT,53460,Revision of urethra,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
BCBS Medicaid,CPT,53500,Urethrlys transvag w/ scope,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
BCBS Medicaid,CPT,53502,Repair of urethra injury,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
BCBS Medicaid,CPT,53505,Repair of urethra injury,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
BCBS Medicaid,CPT,53510,Repair of urethra injury,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
BCBS Medicaid,CPT,53515,Repair of urethra injury,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
BCBS Medicaid,CPT,53520,Repair of urethra defect,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
BCBS Medicaid,CPT,53605,Dilate urethra stricture,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
BCBS Medicaid,CPT,53620,Dilate urethra stricture,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
BCBS Medicaid,CPT,53621,Dilate urethra stricture,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
BCBS Medicaid,CPT,53665,Dilation of urethra,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
BCBS Medicaid,CPT,53855,Insert prost urethral stent,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
BCBS Medicaid,CPT,53860,Transurethral rf treatment,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
BCBS Medicaid,CPT,54000,Slitting of prepuce,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
BCBS Medicaid,CPT,54001,Slitting of prepuce,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,54015,Drain penis lesion,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,54050,Destruction penis lesion(s),Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
BCBS Medicaid,CPT,54055,Destruction penis lesion(s),Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,54056,Cryosurgery penis lesion(s),Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
BCBS Medicaid,CPT,54057,Laser surg penis lesion(s),Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,54060,Excision of penis lesion(s),Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,54065,Destruction penis lesion(s),Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,54100,Biopsy of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,54105,Biopsy of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,54110,Treatment of penis lesion,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,54115,Treatment of penis lesion,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,54150,Circumcision w/regionl block,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,54160,Circumcision neonate,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,54161,Circum 28 days or older,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,54162,Lysis penil circumic lesion,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,54163,Repair of circumcision,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,54164,Frenulotomy of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,54230,Prepare penis study,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,54231,Dynamic cavernosometry,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,54300,Revision of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,54304,Revision of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,54340,Secondary urethral surgery,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,54360,Penis plastic surgery,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,54380,Repair penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,54385,Repair penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,54400,Insert semi-rigid prosthesis,Urological Surgery,Per Unit,"$6,916.67 ",OP,"6,916.67","6,916.67",,,,,,
BCBS Medicaid,CPT,54401,Insert self-contd prosthesis,Urological Surgery,Per Unit,"$6,916.67 ",OP,"6,916.67","6,916.67",,,,,,
BCBS Medicaid,CPT,54405,Insert multi-comp penis pros,Urological Surgery,Per Unit,"$6,916.67 ",OP,"6,916.67","6,916.67",,,,,,
BCBS Medicaid,CPT,54406,Remove muti-comp penis pros,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,54408,Repair multi-comp penis pros,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,54410,Remove/replace penis prosth,Urological Surgery,Per Unit,"$6,916.67 ",OP,"6,916.67","6,916.67",,,,,,
BCBS Medicaid,CPT,54411,Remov/replc penis pros comp,Urological Surgery,Per Unit,"$6,916.67 ",OP,"6,916.67","6,916.67",,,,,,
BCBS Medicaid,CPT,54415,Remove self-contd penis pros,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,54416,Remv/repl penis contain pros,Urological Surgery,Per Unit,"$6,916.67 ",OP,"6,916.67","6,916.67",,,,,,
BCBS Medicaid,CPT,54417,Remv/replc penis pros compl,Urological Surgery,Per Unit,"$6,916.67 ",OP,"6,916.67","6,916.67",,,,,,
BCBS Medicaid,CPT,54420,Revision of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,54430,Revision of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,54435,Revision of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,54440,Repair of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,54450,Preputial stretching,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
BCBS Medicaid,CPT,54500,Biopsy of testis,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
BCBS Medicaid,CPT,54505,Biopsy of testis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,54512,Excise lesion testis,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
BCBS Medicaid,CPT,54520,Removal of testis,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
BCBS Medicaid,CPT,54522,Orchiectomy partial,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,54530,Removal of testis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,54535,Extensive testis surgery,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,54550,Exploration for testis,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
BCBS Medicaid,CPT,54560,Exploration for testis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,54600,Reduce testis torsion,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
BCBS Medicaid,CPT,54620,Suspension of testis,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
BCBS Medicaid,CPT,54640,Orchiopexy ingun/scrot appr,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
BCBS Medicaid,CPT,54650,Orchiopexy (fowler-stephens),Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,54660,Revision of testis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,54670,Repair testis injury,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
BCBS Medicaid,CPT,54680,Relocation of testis(es),Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,54690,Laparoscopy orchiectomy,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,54692,Laparoscopy orchiopexy,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,54699,Laparoscope proc testis,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
BCBS Medicaid,CPT,54700,Drainage of scrotum,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
BCBS Medicaid,CPT,54800,Biopsy of epididymis,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
BCBS Medicaid,CPT,54830,Remove epididymis lesion,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
BCBS Medicaid,CPT,54840,Remove epididymis lesion,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
BCBS Medicaid,CPT,54860,Removal of epididymis,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
BCBS Medicaid,CPT,54861,Removal of epididymis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,54865,Explore epididymis,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
BCBS Medicaid,CPT,54900,Fusion of spermatic ducts,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
BCBS Medicaid,CPT,54901,Fusion of spermatic ducts,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,55040,Removal of hydrocele,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,55041,Removal of hydroceles,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,55060,Repair of hydrocele,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
BCBS Medicaid,CPT,55100,Drainage of scrotum abscess,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
BCBS Medicaid,CPT,55110,Explore scrotum,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,55120,Removal of scrotum lesion,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
BCBS Medicaid,CPT,55150,Removal of scrotum,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
BCBS Medicaid,CPT,55175,Revision of scrotum,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
BCBS Medicaid,CPT,55180,Revision of scrotum,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,55200,Incision of sperm duct,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
BCBS Medicaid,CPT,55250,Removal of sperm duct(s),Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
BCBS Medicaid,CPT,55400,Repair of sperm duct,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,55450,Ligation of sperm duct,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
BCBS Medicaid,CPT,55500,Removal of hydrocele,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
BCBS Medicaid,CPT,55520,Removal of sperm cord lesion,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
BCBS Medicaid,CPT,55530,Revise spermatic cord veins,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,55535,Revise spermatic cord veins,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
BCBS Medicaid,CPT,55540,Revise hernia & sperm veins,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,55550,Laparo ligate spermatic vein,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,55559,Laparo proc spermatic cord,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
BCBS Medicaid,CPT,55600,Incise sperm duct pouch,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
BCBS Medicaid,CPT,55605,Incise sperm duct pouch,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,55650,Remove sperm duct pouch,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,55680,Remove sperm pouch lesion,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
BCBS Medicaid,CPT,55801,Removal of prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
BCBS Medicaid,CPT,55810,Extensive prostate surgery,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
BCBS Medicaid,CPT,55815,Extensive prostate surgery,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
BCBS Medicaid,CPT,55821,Removal of prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
BCBS Medicaid,CPT,55831,Removal of prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
BCBS Medicaid,CPT,55840,Extensive prostate surgery,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
BCBS Medicaid,CPT,55842,Extensive prostate surgery,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
BCBS Medicaid,CPT,55845,Extensive prostate surgery,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
BCBS Medicaid,CPT,55860,Surgical exposure prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
BCBS Medicaid,CPT,55866,Laparo radical prostatectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
BCBS Medicaid,CPT,55870,Electroejaculation,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
BCBS Medicaid,CPT,55873,Cryoablate prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
BCBS Medicaid,CPT,55874,Tprnl plmt biodegrdabl matrl,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
BCBS Medicaid,CPT,55880,Abltj mal prst8 tiss hifu,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
BCBS Medicaid,CPT,55899,Genital surgery procedure,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
BCBS Medicaid,CPT,56405,I & d of vulva/perineum,Gynecology,Per Unit,$102.34 ,OP,102.34,102.34,,,,,,
BCBS Medicaid,CPT,56420,Drainage of gland abscess,Gynecology,Per Unit,$102.34 ,OP,102.34,102.34,,,,,,
BCBS Medicaid,CPT,56820,Exam of vulva w/scope,Gynecology,Per Unit,$102.34 ,OP,102.34,102.34,,,,,,
BCBS Medicaid,CPT,57150,Treat vagina infection,Gynecology,Per Unit,$102.34 ,OP,102.34,102.34,,,,,,
BCBS Medicaid,CPT,57160,Insert pessary/other device,Gynecology,Per Unit,$102.34 ,OP,102.34,102.34,,,,,,
BCBS Medicaid,CPT,57170,Fitting of diaphragm/cap,Gynecology,Per Unit,$102.34 ,OP,102.34,102.34,,,,,,
BCBS Medicaid,CPT,57220,Revision of urethra,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
BCBS Medicaid,CPT,57230,Repair of urethral lesion,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
BCBS Medicaid,CPT,57240,Anterior colporrhaphy,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
BCBS Medicaid,CPT,57250,Repair rectum & vagina,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
BCBS Medicaid,CPT,57260,Cmbn ant pst colprhy,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
BCBS Medicaid,CPT,57265,Cmbn ap colprhy w/ntrcl rpr,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
BCBS Medicaid,CPT,57267,Insert mesh/pelvic flr addon,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
BCBS Medicaid,CPT,57268,Repair of bowel bulge,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
BCBS Medicaid,CPT,57270,Repair of bowel pouch,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
BCBS Medicaid,CPT,57287,Revise/remove sling repair,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
BCBS Medicaid,CPT,57288,Repair bladder defect,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
BCBS Medicaid,CPT,57289,Repair bladder & vagina,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
BCBS Medicaid,CPT,57410,Pelvic examination,Gynecology,Per Unit,$102.34 ,OP,102.34,102.34,,,,,,
BCBS Medicaid,CPT,58300,Insert intrauterine device,Gynecology,Per Unit,$102.34 ,OP,102.34,102.34,,,,,,
BCBS Medicaid,CPT,58301,Remove intrauterine device,Gynecology,Per Unit,$102.34 ,OP,102.34,102.34,,,,,,
BCBS Medicaid,CPT,58321,Artificial insemination,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
BCBS Medicaid,CPT,58322,Artificial insemination,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
BCBS Medicaid,CPT,58323,Sperm washing,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
BCBS Medicaid,CPT,58970,Retrieval of oocyte,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
BCBS Medicaid,CPT,58974,Transfer of embryo,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
BCBS Medicaid,CPT,58976,Transfer of embryo,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
BCBS Medicaid,CPT,59020,Fetal contract stress test,Obstetrics,Per Unit,$139.58 ,OP,139.58,139.58,,,,,,
BCBS Medicaid,CPT,59025,Fetal non-stress test,Obstetrics,Per Unit,$139.58 ,OP,139.58,139.58,,,,,,
BCBS Medicaid,CPT,59030,Fetal scalp blood sample,Obstetrics,Per Unit,$139.58 ,OP,139.58,139.58,,,,,,
BCBS Medicaid,CPT,59050,Fetal monitor w/report,Obstetrics,Per Unit,$139.58 ,OP,139.58,139.58,,,,,,
BCBS Medicaid,CPT,59072,Umbilical cord occlud w/us,Obstetrics,Per Unit,$482.07 ,OP,482.07,482.07,,,,,,
BCBS Medicaid,CPT,59074,Fetal fluid drainage w/us,Obstetrics,Per Unit,$139.58 ,OP,139.58,139.58,,,,,,
BCBS Medicaid,CPT,59076,Fetal shunt placement w/us,Obstetrics,Per Unit,$482.07 ,OP,482.07,482.07,,,,,,
BCBS Medicaid,CPT,59400,Obstetrical care,Obstetrics,Per Unit,"$1,075.20 ",OP,"1,075.20","1,075.20",,,,,,
BCBS Medicaid,CPT,59409,Obstetrical care,Obstetrics,Per Unit,"$1,075.20 ",OP,"1,075.20","1,075.20",,,,,,
BCBS Medicaid,CPT,59410,Obstetrical care,Obstetrics,Per Unit,"$1,075.20 ",OP,"1,075.20","1,075.20",,,,,,
BCBS Medicaid,CPT,59610,Vbac delivery,Obstetrics,Per Unit,"$1,075.20 ",OP,"1,075.20","1,075.20",,,,,,
BCBS Medicaid,CPT,59612,Vbac delivery only,Obstetrics,Per Unit,"$1,075.20 ",OP,"1,075.20","1,075.20",,,,,,
BCBS Medicaid,CPT,59614,Vbac care after delivery,Obstetrics,Per Unit,"$1,075.20 ",OP,"1,075.20","1,075.20",,,,,,
BCBS Medicaid,CPT,59812,Treatment of miscarriage,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
BCBS Medicaid,CPT,59820,Care of miscarriage,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
BCBS Medicaid,CPT,59821,Treatment of miscarriage,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
BCBS Medicaid,CPT,59830,Treat uterus infection,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
BCBS Medicaid,CPT,59840,Abortion,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
BCBS Medicaid,CPT,59841,Abortion,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
BCBS Medicaid,CPT,59850,Abortion,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
BCBS Medicaid,CPT,59851,Abortion,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
BCBS Medicaid,CPT,59852,Abortion,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
BCBS Medicaid,CPT,59855,Abortion,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
BCBS Medicaid,CPT,59856,Abortion,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
BCBS Medicaid,CPT,59857,Abortion,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
BCBS Medicaid,CPT,59866,Abortion (mpr),Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
BCBS Medicaid,CPT,59897,Fetal invas px w/us,Obstetrics,Per Unit,$139.58 ,OP,139.58,139.58,,,,,,
BCBS Medicaid,CPT,60000,Drain thyroid/tongue cyst,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,60100,Biopsy of thyroid,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,60300,Aspir/inj thyroid cyst,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,60650,Laparoscopy adrenalectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
BCBS Medicaid,CPT,60659,Laparo proc endocrine,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
BCBS Medicaid,CPT,60699,Endocrine surgery procedure,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
BCBS Medicaid,CPT,61000,Remove cranial cavity fluid,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
BCBS Medicaid,CPT,61001,Remove cranial cavity fluid,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
BCBS Medicaid,CPT,61020,Remove brain cavity fluid,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
BCBS Medicaid,CPT,61026,Injection into brain canal,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
BCBS Medicaid,CPT,61070,Brain canal shunt procedure,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
BCBS Medicaid,CPT,61215,Insert brain-fluid device,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,61623,Endovasc tempory vessel occl,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,61624,Transcath occlusion cns,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,61626,Transcath occlusion non-cns,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,61630,Intracranial angioplasty,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,61635,Intracran angioplsty w/stent,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,61640,Dilate ic vasospasm init,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,61641,Dilat ic vspsm ea vsl sm ter,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,61642,Dilat ic vspsm ea diff ter,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,61645,Perq art m-thrombect &/nfs,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,61651,Evasc prlng admn rx agnt add,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,61720,Incise skull/brain surgery,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,61770,Incise skull for treatment,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,61790,Treat trigeminal nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,61791,Treat trigeminal tract,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,61796,Srs cranial lesion simple,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"2,592.65","2,592.65",,,,,,
BCBS Medicaid,CPT,61797,Srs cran les simple addl,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"2,592.65","2,592.65",,,,,,
BCBS Medicaid,CPT,61798,Srs cranial lesion complex,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"2,592.65","2,592.65",,,,,,
BCBS Medicaid,CPT,61799,Srs cran les complex addl,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"2,592.65","2,592.65",,,,,,
BCBS Medicaid,CPT,61800,Apply srs headframe add-on,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"2,592.65","2,592.65",,,,,,
BCBS Medicaid,CPT,61850,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
BCBS Medicaid,CPT,61880,Revise/remove neuroelectrode,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,61885,Insrt/redo neurostim 1 array,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
BCBS Medicaid,CPT,61886,Implant neurostim arrays,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
BCBS Medicaid,CPT,61888,Revise/remove neuroreceiver,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,62000,Treat skull fracture,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,62194,Replace/irrigate catheter,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,62225,Replace/irrigate catheter,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,62230,Replace/revise brain shunt,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,62252,Csf shunt reprogram,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,62292,Njx chemonucleolysis lmbr,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,62302,Myelography lumbar injection,Diagnostic Radiology,Per Unit,$345.35 ,OP,345.35,345.35,,,,,,
BCBS Medicaid,CPT,62303,Myelography lumbar injection,Diagnostic Radiology,Per Unit,$345.35 ,OP,345.35,345.35,,,,,,
BCBS Medicaid,CPT,62304,Myelography lumbar injection,Diagnostic Radiology,Per Unit,$345.35 ,OP,345.35,345.35,,,,,,
BCBS Medicaid,CPT,62305,Myelography lumbar injection,Diagnostic Radiology,Per Unit,$345.35 ,OP,345.35,345.35,,,,,,
BCBS Medicaid,CPT,62310,Inject spine cerv/thoracic,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
BCBS Medicaid,CPT,62311,Inject spine lumbar/sacral,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
BCBS Medicaid,CPT,62318,Inject spine w/cath crv/thrc,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
BCBS Medicaid,CPT,62319,Inject spine w/cath lmb/scrl,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
BCBS Medicaid,CPT,62350,Implant spinal canal cath,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,62355,Remove spinal canal catheter,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,62360,Insert spine infusion device,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"7,098.75","7,098.75",,,,,,
BCBS Medicaid,CPT,62361,Implant spine infusion pump,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"7,098.75","7,098.75",,,,,,
BCBS Medicaid,CPT,62362,Implant spine infusion pump,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"7,098.75","7,098.75",,,,,,
BCBS Medicaid,CPT,62365,Remove spine infusion device,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,62367,Analyze spine infus pump,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
BCBS Medicaid,CPT,62368,Analyze sp inf pump w/reprog,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
BCBS Medicaid,CPT,62369,Anal sp inf pmp w/reprg&fill,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
BCBS Medicaid,CPT,62370,Anl sp inf pmp w/mdreprg&fil,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
BCBS Medicaid,CPT,63600,Remove spinal cord lesion,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,63610,Stimulation of spinal cord,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,63615,Remove lesion of spinal cord,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,63620,Srs spinal lesion,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"2,592.65","2,592.65",,,,,,
BCBS Medicaid,CPT,63621,Srs spinal lesion addl,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"2,592.65","2,592.65",,,,,,
BCBS Medicaid,CPT,63650,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,63661,Remove spine eltrd perq aray,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,63662,Remove spine eltrd plate,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,63663,Revise spine eltrd perq aray,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,63664,Revise spine eltrd plate,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
BCBS Medicaid,CPT,63685,Insrt/redo spine n generator,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
BCBS Medicaid,CPT,63688,Revise/remove neuroreceiver,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,63707,Repair spinal fluid leakage,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,63741,Install spinal shunt,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,63744,Revision of spinal shunt,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,63746,Removal of spinal shunt,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64400,Njx aa&/strd trigeminal nrv,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
BCBS Medicaid,CPT,64402,N block inj facial,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
BCBS Medicaid,CPT,64405,Njx aa&/strd gr ocpl nrv,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
BCBS Medicaid,CPT,64408,Njx aa&/strd vagus nrv,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
BCBS Medicaid,CPT,64410,N block inj phrenic,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
BCBS Medicaid,CPT,64412,N block inj spinal accessor,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
BCBS Medicaid,CPT,64413,N block inj cervical plexus,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
BCBS Medicaid,CPT,64415,Njx aa&/strd brach plexus,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
BCBS Medicaid,CPT,64416,Njx aa&/strd brach plex nfs,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
BCBS Medicaid,CPT,64417,Njx aa&/strd axillary nrv,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
BCBS Medicaid,CPT,64418,Njx aa&/strd sprscap nrv,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
BCBS Medicaid,CPT,64420,Njx aa&/strd ntrcost nrv 1,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
BCBS Medicaid,CPT,64421,Njx aa&/strd ntrcost nrv ea,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
BCBS Medicaid,CPT,64425,Njx aa&/strd ii ih nerves,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
BCBS Medicaid,CPT,64430,Njx aa&/strd pudendal nerve,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
BCBS Medicaid,CPT,64435,Njx aa&/strd paracrv nrv,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
BCBS Medicaid,CPT,64445,Njx aa&/strd sciatic nerve,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
BCBS Medicaid,CPT,64446,Njx aa&/strd sciatic nrv nfs,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
BCBS Medicaid,CPT,64447,Njx aa&/strd femoral nerve,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
BCBS Medicaid,CPT,64448,Njx aa&/strd fem nerve nfs,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
BCBS Medicaid,CPT,64449,Njx aa&/strd lmbr plex nfs,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
BCBS Medicaid,CPT,64450,Njx aa&/strd other pn/branch,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
BCBS Medicaid,CPT,64454,Njx aa&/strd gnclr nrv brnch,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
BCBS Medicaid,CPT,64455,Njx aa&/strd pltr com dg nrv,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
BCBS Medicaid,CPT,64486,Tap block unil by injection,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
BCBS Medicaid,CPT,64487,Tap block uni by infusion,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
BCBS Medicaid,CPT,64488,Tap block bi injection,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
BCBS Medicaid,CPT,64489,Tap block bi by infusion,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
BCBS Medicaid,CPT,64505,N block spenopalatine gangl,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
BCBS Medicaid,CPT,64508,N block carotid sinus s/p,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
BCBS Medicaid,CPT,64510,N block stellate ganglion,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
BCBS Medicaid,CPT,64517,N block inj hypogas plxs,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
BCBS Medicaid,CPT,64530,N block inj celiac pelus,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
BCBS Medicaid,CPT,64550,Appl surface neurostimulator,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,64553,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,64555,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,64561,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,64565,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,64566,Neuroeltrd stim post tibial,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
BCBS Medicaid,CPT,64568,Inc for vagus n elect impl,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
BCBS Medicaid,CPT,64569,Revise/repl vagus n eltrd,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
BCBS Medicaid,CPT,64570,Remove vagus n eltrd,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64575,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
BCBS Medicaid,CPT,64580,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"7,098.75","7,098.75",,,,,,
BCBS Medicaid,CPT,64581,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"7,098.75","7,098.75",,,,,,
BCBS Medicaid,CPT,64585,Revise/remove neuroelectrode,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64590,Insrt/redo pn/gastr stimul,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"7,098.75","7,098.75",,,,,,
BCBS Medicaid,CPT,64595,Revise/rmv pn/gastr stimul,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,64600,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
BCBS Medicaid,CPT,64605,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
BCBS Medicaid,CPT,64610,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
BCBS Medicaid,CPT,64611,Chemodenerv saliv glands,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
BCBS Medicaid,CPT,64612,Destroy nerve face muscle,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
BCBS Medicaid,CPT,64615,Chemodenerv musc migraine,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
BCBS Medicaid,CPT,64616,Chemodenerv musc neck dyston,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
BCBS Medicaid,CPT,64617,Chemodener muscle larynx emg,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
BCBS Medicaid,CPT,64620,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
BCBS Medicaid,CPT,64624,Dstrj nulyt agt gnclr nrv,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
BCBS Medicaid,CPT,64625,Rf abltj nrv nrvtg si jt,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64630,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
BCBS Medicaid,CPT,64632,N block inj common digit,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
BCBS Medicaid,CPT,64640,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
BCBS Medicaid,CPT,64642,Chemodenerv 1 extremity 1-4,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
BCBS Medicaid,CPT,64643,Chemodenerv 1 extrem 1-4 ea,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
BCBS Medicaid,CPT,64644,Chemodenerv 1 extrem 5/> mus,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
BCBS Medicaid,CPT,64645,Chemodenerv 1 extrem 5/> ea,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
BCBS Medicaid,CPT,64646,Chemodenerv trunk musc 1-5,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
BCBS Medicaid,CPT,64647,Chemodenerv trunk musc 6/>,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
BCBS Medicaid,CPT,64650,Chemodenerv eccrine glands,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
BCBS Medicaid,CPT,64653,Chemodenerv eccrine glands,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
BCBS Medicaid,CPT,64680,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
BCBS Medicaid,CPT,64681,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
BCBS Medicaid,CPT,64702,Revise finger/toe nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64704,Revise hand/foot nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64708,Revise arm/leg nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64712,Revision of sciatic nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64713,Revision of arm nerve(s),Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,64714,Revise low back nerve(s),Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,64716,Revision of cranial nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,64718,Revise ulnar nerve at elbow,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64719,Revise ulnar nerve at wrist,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64721,Carpal tunnel surgery,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64722,Relieve pressure on nerve(s),Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64726,Release foot/toe nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64727,Internal nerve revision,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,64732,Incision of brow nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64734,Incision of cheek nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,64736,Incision of chin nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64738,Incision of jaw nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64740,Incision of tongue nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64742,Incision of facial nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,64744,Incise nerve back of head,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64746,Incise diaphragm nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,64763,Incise hip/thigh nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64766,Incise hip/thigh nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64771,Sever cranial nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64772,Incision of spinal nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64774,Remove skin nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64776,Remove digit nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64778,Digit nerve surgery add-on,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64782,Remove limb nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64783,Limb nerve surgery add-on,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64784,Remove nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64786,Remove sciatic nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64787,Implant nerve end,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64788,Remove skin nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64790,Removal of nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64792,Removal of nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64795,Biopsy of nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64802,Sympathectomy cervical,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64804,Remove sympathetic nerves,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64818,Remove sympathetic nerves,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64820,Sympathectomy digital artery,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64821,Remove sympathetic nerves,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,64822,Remove sympathetic nerves,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,64823,Sympathectomy supfc palmar,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,64831,Repair of digit nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64832,Repair nerve add-on,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64834,Repair of hand or foot nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64835,Repair of hand or foot nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64836,Repair of hand or foot nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64837,Repair nerve add-on,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64840,Repair of leg nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,64856,Repair/transpose nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64857,Repair arm/leg nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64858,Repair sciatic nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,64859,Nerve surgery,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,64861,Repair of arm nerves,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64862,Repair of low back nerves,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,64864,Repair of facial nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,64865,Repair of facial nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,64866,Fusion of facial/other nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,64868,Fusion of facial/other nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,64872,Subsequent repair of nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64874,Repair & revise nerve add-on,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64876,Repair nerve/shorten bone,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64885,Nerve graft head/neck </4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,64886,Nerve graft head/neck >4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,64890,Nerve graft hand/foot </4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,64891,Nerve graft hand/foot >4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,64892,Nerve graft arm/leg <4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,64893,Nerve graft arm/leg >4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,64895,Nerve graft hand/foot </4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,64896,Nerve graft hand/foot >4 cm,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"7,098.75","7,098.75",,,,,,
BCBS Medicaid,CPT,64897,Nerve graft arm/leg </4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,64898,Nerve graft arm/leg >4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,64901,Nerve graft add-on,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,64902,Nerve graft add-on,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,64905,Nerve pedicle transfer,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,64907,Nerve pedicle transfer,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,64910,Nerve repair w/allograft,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,64911,Neurorraphy w/vein autograft,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,64912,Nrv rpr w/nrv algrft 1st,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,64913,Nrv rpr w/nrv algrft ea addl,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,64999,Nervous system surgery,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
BCBS Medicaid,CPT,65091,Revise eye,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,65093,Revise eye with implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,65101,Removal of eye,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,65103,Remove eye/insert implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,65105,Remove eye/attach implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,65110,Removal of eye,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,65112,Remove eye/revise socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,65114,Remove eye/revise socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,65125,Revise ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,65130,Insert ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,65135,Insert ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,65140,Attach ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,65150,Revise ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,65155,Reinsert ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,65175,Removal of ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,65205,Remove foreign body from eye,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,65210,Remove foreign body from eye,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,65220,Remove foreign body from eye,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,65222,Remove foreign body from eye,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,65235,Remove foreign body from eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
BCBS Medicaid,CPT,65260,Remove foreign body from eye,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
BCBS Medicaid,CPT,65265,Remove foreign body from eye,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
BCBS Medicaid,CPT,65270,Repair of eye wound,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
BCBS Medicaid,CPT,65272,Repair of eye wound,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
BCBS Medicaid,CPT,65275,Repair of eye wound,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
BCBS Medicaid,CPT,65280,Repair of eye wound,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
BCBS Medicaid,CPT,65285,Repair of eye wound,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
BCBS Medicaid,CPT,65286,Repair of eye wound,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
BCBS Medicaid,CPT,65290,Repair of eye socket wound,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
BCBS Medicaid,CPT,65400,Removal of eye lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
BCBS Medicaid,CPT,65410,Biopsy of cornea,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
BCBS Medicaid,CPT,65420,Removal of eye lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
BCBS Medicaid,CPT,65426,Removal of eye lesion,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
BCBS Medicaid,CPT,65430,Corneal smear,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
BCBS Medicaid,CPT,65435,Curette/treat cornea,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
BCBS Medicaid,CPT,65436,Curette/treat cornea,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
BCBS Medicaid,CPT,65450,Treatment of corneal lesion,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
BCBS Medicaid,CPT,65600,Revision of cornea,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
BCBS Medicaid,CPT,65710,Corneal transplant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
BCBS Medicaid,CPT,65730,Corneal transplant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
BCBS Medicaid,CPT,65750,Corneal transplant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
BCBS Medicaid,CPT,65755,Corneal transplant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
BCBS Medicaid,CPT,65756,Corneal trnspl endothelial,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
BCBS Medicaid,CPT,65757,Prep corneal endo allograft,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
BCBS Medicaid,CPT,65760,Revision of cornea,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
BCBS Medicaid,CPT,65765,Revision of cornea,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
BCBS Medicaid,CPT,65767,Corneal tissue transplant,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
BCBS Medicaid,CPT,65770,Revise cornea with implant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
BCBS Medicaid,CPT,65771,Radial keratotomy,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
BCBS Medicaid,CPT,65772,Correction of astigmatism,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
BCBS Medicaid,CPT,65775,Correction of astigmatism,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
BCBS Medicaid,CPT,65778,Cover eye w/membrane,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
BCBS Medicaid,CPT,65779,Cover eye w/membrane suture,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
BCBS Medicaid,CPT,65780,Ocular reconst transplant,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
BCBS Medicaid,CPT,65781,Ocular reconst transplant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
BCBS Medicaid,CPT,65782,Ocular reconst transplant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
BCBS Medicaid,CPT,65785,Impltj ntrstrml crnl rng seg,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
BCBS Medicaid,CPT,65800,Drainage of eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
BCBS Medicaid,CPT,65810,Drainage of eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
BCBS Medicaid,CPT,65815,Drainage of eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
BCBS Medicaid,CPT,65820,Relieve inner eye pressure,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
BCBS Medicaid,CPT,65850,Incision of eye,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
BCBS Medicaid,CPT,65855,Trabeculoplasty laser surg,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
BCBS Medicaid,CPT,65860,Incise inner eye adhesions,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
BCBS Medicaid,CPT,65865,Incise inner eye adhesions,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
BCBS Medicaid,CPT,65870,Incise inner eye adhesions,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
BCBS Medicaid,CPT,65875,Incise inner eye adhesions,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
BCBS Medicaid,CPT,65880,Incise inner eye adhesions,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
BCBS Medicaid,CPT,65900,Remove eye lesion,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
BCBS Medicaid,CPT,65920,Remove implant of eye,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
BCBS Medicaid,CPT,65930,Remove blood clot from eye,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
BCBS Medicaid,CPT,66020,Injection treatment of eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
BCBS Medicaid,CPT,66030,Injection treatment of eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
BCBS Medicaid,CPT,66130,Remove eye lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
BCBS Medicaid,CPT,66150,Glaucoma surgery,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
BCBS Medicaid,CPT,66155,Glaucoma surgery,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
BCBS Medicaid,CPT,66160,Glaucoma surgery,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
BCBS Medicaid,CPT,66170,Glaucoma surgery,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
BCBS Medicaid,CPT,66172,Incision of eye,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
BCBS Medicaid,CPT,66174,Translum dil eye canal,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
BCBS Medicaid,CPT,66175,Trnslum dil eye canal w/stnt,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
BCBS Medicaid,CPT,66179,Aqueous shunt eye w/o graft,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
BCBS Medicaid,CPT,66180,Aqueous shunt eye w/graft,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
BCBS Medicaid,CPT,66183,Insert ant drainage device,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
BCBS Medicaid,CPT,66184,Revision of aqueous shunt,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
BCBS Medicaid,CPT,66185,Revise aqueous shunt eye,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
BCBS Medicaid,CPT,66220,Repair eye lesion,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
BCBS Medicaid,CPT,66225,Repair/graft eye lesion,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
BCBS Medicaid,CPT,66250,Follow-up surgery of eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
BCBS Medicaid,CPT,66500,Incision of iris,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
BCBS Medicaid,CPT,66505,Incision of iris,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
BCBS Medicaid,CPT,66600,Remove iris and lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
BCBS Medicaid,CPT,66605,Removal of iris,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
BCBS Medicaid,CPT,66625,Removal of iris,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
BCBS Medicaid,CPT,66630,Removal of iris,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
BCBS Medicaid,CPT,66635,Removal of iris,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
BCBS Medicaid,CPT,66680,Repair iris & ciliary body,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
BCBS Medicaid,CPT,66682,Repair iris & ciliary body,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
BCBS Medicaid,CPT,66700,Destruction ciliary body,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
BCBS Medicaid,CPT,66710,Ciliary transsleral therapy,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
BCBS Medicaid,CPT,66711,Ecp ciliary body destruction,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
BCBS Medicaid,CPT,66720,Destruction ciliary body,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
BCBS Medicaid,CPT,66740,Destruction ciliary body,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
BCBS Medicaid,CPT,66761,Revision of iris,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
BCBS Medicaid,CPT,66762,Revision of iris,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
BCBS Medicaid,CPT,66770,Removal of inner eye lesion,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
BCBS Medicaid,CPT,66820,Incision secondary cataract,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
BCBS Medicaid,CPT,66821,After cataract laser surgery,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
BCBS Medicaid,CPT,66825,Reposition intraocular lens,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
BCBS Medicaid,CPT,66830,Removal of lens lesion,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
BCBS Medicaid,CPT,66840,Removal of lens material,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
BCBS Medicaid,CPT,66850,Removal of lens material,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
BCBS Medicaid,CPT,66852,Removal of lens material,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
BCBS Medicaid,CPT,66920,Extraction of lens,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
BCBS Medicaid,CPT,66930,Extraction of lens,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
BCBS Medicaid,CPT,66940,Extraction of lens,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
BCBS Medicaid,CPT,66982,Xcapsl ctrc rmvl cplx wo ecp,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
BCBS Medicaid,CPT,66983,Cataract surg w/iol 1 stage,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
BCBS Medicaid,CPT,66984,Xcapsl ctrc rmvl w/o ecp,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
BCBS Medicaid,CPT,66985,Insert lens prosthesis,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
BCBS Medicaid,CPT,66986,Exchange lens prosthesis,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
BCBS Medicaid,CPT,66987,Xcapsl ctrc rmvl cplx w/ecp,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
BCBS Medicaid,CPT,66988,Xcapsl ctrc rmvl w/ecp,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
BCBS Medicaid,CPT,66999,Eye surgery procedure,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
BCBS Medicaid,CPT,67005,Partial removal of eye fluid,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
BCBS Medicaid,CPT,67010,Partial removal of eye fluid,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
BCBS Medicaid,CPT,67015,Release of eye fluid,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
BCBS Medicaid,CPT,67025,Replace eye fluid,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
BCBS Medicaid,CPT,67027,Implant eye drug system,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
BCBS Medicaid,CPT,67028,Injection eye drug,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
BCBS Medicaid,CPT,67030,Incise inner eye strands,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
BCBS Medicaid,CPT,67031,Laser surgery eye strands,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
BCBS Medicaid,CPT,67036,Removal of inner eye fluid,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
BCBS Medicaid,CPT,67039,Laser treatment of retina,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
BCBS Medicaid,CPT,67040,Laser treatment of retina,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
BCBS Medicaid,CPT,67041,Vit for macular pucker,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
BCBS Medicaid,CPT,67042,Vit for macular hole,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
BCBS Medicaid,CPT,67043,Vit for membrane dissect,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
BCBS Medicaid,CPT,67101,Repair detached retina crtx,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
BCBS Medicaid,CPT,67105,Repair detached retina pc,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
BCBS Medicaid,CPT,67107,Repair detached retina,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
BCBS Medicaid,CPT,67108,Repair detached retina,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
BCBS Medicaid,CPT,67110,Repair detached retina,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
BCBS Medicaid,CPT,67112,Rerepair detached retina,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
BCBS Medicaid,CPT,67113,Repair retinal detach cplx,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
BCBS Medicaid,CPT,67115,Release encircling material,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
BCBS Medicaid,CPT,67120,Remove eye implant material,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
BCBS Medicaid,CPT,67121,Remove eye implant material,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
BCBS Medicaid,CPT,67141,Treatment of retina,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
BCBS Medicaid,CPT,67145,Treatment of retina,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
BCBS Medicaid,CPT,67208,Treatment of retinal lesion,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
BCBS Medicaid,CPT,67210,Treatment of retinal lesion,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
BCBS Medicaid,CPT,67218,Treatment of retinal lesion,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
BCBS Medicaid,CPT,67220,Treatment of choroid lesion,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
BCBS Medicaid,CPT,67221,Ocular photodynamic ther,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
BCBS Medicaid,CPT,67225,Eye photodynamic ther add-on,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
BCBS Medicaid,CPT,67227,Dstrj extensive retinopathy,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
BCBS Medicaid,CPT,67228,Treatment x10sv retinopathy,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
BCBS Medicaid,CPT,67229,Tr retinal les preterm inf,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
BCBS Medicaid,CPT,67250,Reinforce eye wall,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
BCBS Medicaid,CPT,67255,Reinforce/graft eye wall,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
BCBS Medicaid,CPT,67299,Eye surgery procedure,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
BCBS Medicaid,CPT,67311,Revise eye muscle,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
BCBS Medicaid,CPT,67312,Revise two eye muscles,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
BCBS Medicaid,CPT,67314,Revise eye muscle,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
BCBS Medicaid,CPT,67316,Revise two eye muscles,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
BCBS Medicaid,CPT,67318,Revise eye muscle(s),Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
BCBS Medicaid,CPT,67320,Revise eye muscle(s) add-on,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
BCBS Medicaid,CPT,67331,Eye surgery follow-up add-on,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
BCBS Medicaid,CPT,67332,Rerevise eye muscles add-on,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
BCBS Medicaid,CPT,67334,Revise eye muscle w/suture,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
BCBS Medicaid,CPT,67335,Eye suture during surgery,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
BCBS Medicaid,CPT,67340,Revise eye muscle add-on,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
BCBS Medicaid,CPT,67343,Release eye tissue,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
BCBS Medicaid,CPT,67345,Destroy nerve of eye muscle,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
BCBS Medicaid,CPT,67346,Biopsy eye muscle,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
BCBS Medicaid,CPT,67399,Unlisted px extraocular musc,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
BCBS Medicaid,CPT,67400,Explore/biopsy eye socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,67405,Explore/drain eye socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,67412,Explore/treat eye socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,67413,Explore/treat eye socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,67414,Explr/decompress eye socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,67415,Aspiration orbital contents,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
BCBS Medicaid,CPT,67445,Explr/decompress eye socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,67500,Inject/treat eye socket,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
BCBS Medicaid,CPT,67505,Inject/treat eye socket,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
BCBS Medicaid,CPT,67515,Inject/treat eye socket,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
BCBS Medicaid,CPT,67550,Insert eye socket implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,67560,Revise eye socket implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,67570,Decompress optic nerve,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,67599,Orbit surgery procedure,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
BCBS Medicaid,CPT,67700,Drainage of eyelid abscess,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
BCBS Medicaid,CPT,67710,Incision of eyelid,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
BCBS Medicaid,CPT,67715,Incision of eyelid fold,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
BCBS Medicaid,CPT,67800,Remove eyelid lesion,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
BCBS Medicaid,CPT,67801,Remove eyelid lesions,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
BCBS Medicaid,CPT,67805,Remove eyelid lesions,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
BCBS Medicaid,CPT,67808,Remove eyelid lesion(s),Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
BCBS Medicaid,CPT,67810,Biopsy eyelid & lid margin,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
BCBS Medicaid,CPT,67820,Revise eyelashes,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
BCBS Medicaid,CPT,67825,Revise eyelashes,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
BCBS Medicaid,CPT,67830,Revise eyelashes,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
BCBS Medicaid,CPT,67835,Revise eyelashes,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,67840,Remove eyelid lesion,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
BCBS Medicaid,CPT,67850,Treat eyelid lesion,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
BCBS Medicaid,CPT,67875,Closure of eyelid by suture,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
BCBS Medicaid,CPT,67880,Revision of eyelid,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
BCBS Medicaid,CPT,67882,Revision of eyelid,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
BCBS Medicaid,CPT,67900,Repair brow defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,67901,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,67902,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,67903,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,67904,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,67906,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,67908,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,67909,Revise eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,67911,Revise eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,67912,Correction eyelid w/implant,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
BCBS Medicaid,CPT,67914,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
BCBS Medicaid,CPT,67915,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
BCBS Medicaid,CPT,67916,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
BCBS Medicaid,CPT,67917,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,67921,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
BCBS Medicaid,CPT,67922,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
BCBS Medicaid,CPT,67923,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
BCBS Medicaid,CPT,67924,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,67930,Repair eyelid wound,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
BCBS Medicaid,CPT,67935,Repair eyelid wound,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
BCBS Medicaid,CPT,67938,Remove eyelid foreign body,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
BCBS Medicaid,CPT,67950,Revision of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,67961,Revision of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,67966,Revision of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,67971,Reconstruction of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,67973,Reconstruction of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,67974,Reconstruction of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,67975,Reconstruction of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,67999,Revision of eyelid,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
BCBS Medicaid,CPT,68020,Incise/drain eyelid lining,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
BCBS Medicaid,CPT,68040,Treatment of eyelid lesions,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
BCBS Medicaid,CPT,68100,Biopsy of eyelid lining,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
BCBS Medicaid,CPT,68110,Remove eyelid lining lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
BCBS Medicaid,CPT,68115,Remove eyelid lining lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
BCBS Medicaid,CPT,68130,Remove eyelid lining lesion,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
BCBS Medicaid,CPT,68135,Remove eyelid lining lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
BCBS Medicaid,CPT,68200,Treat eyelid by injection,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
BCBS Medicaid,CPT,68320,Revise/graft eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
BCBS Medicaid,CPT,68325,Revise/graft eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
BCBS Medicaid,CPT,68326,Revise/graft eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
BCBS Medicaid,CPT,68328,Revise/graft eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
BCBS Medicaid,CPT,68330,Revise eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
BCBS Medicaid,CPT,68335,Revise/graft eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
BCBS Medicaid,CPT,68340,Separate eyelid adhesions,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
BCBS Medicaid,CPT,68360,Revise eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
BCBS Medicaid,CPT,68362,Revise eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
BCBS Medicaid,CPT,68371,Harvest eye tissue alograft,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
BCBS Medicaid,CPT,68399,Eyelid lining surgery,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
BCBS Medicaid,CPT,68400,Incise/drain tear gland,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
BCBS Medicaid,CPT,68420,Incise/drain tear sac,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
BCBS Medicaid,CPT,68440,Incise tear duct opening,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
BCBS Medicaid,CPT,68500,Removal of tear gland,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,68505,Partial removal tear gland,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,68510,Biopsy of tear gland,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
BCBS Medicaid,CPT,68520,Removal of tear sac,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,68525,Biopsy of tear sac,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
BCBS Medicaid,CPT,68530,Clearance of tear duct,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
BCBS Medicaid,CPT,68540,Remove tear gland lesion,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,68550,Remove tear gland lesion,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,68700,Repair tear ducts,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,68705,Revise tear duct opening,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
BCBS Medicaid,CPT,68720,Create tear sac drain,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,68745,Create tear duct drain,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,68750,Create tear duct drain,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,68760,Close tear duct opening,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
BCBS Medicaid,CPT,68761,Close tear duct opening,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
BCBS Medicaid,CPT,68770,Close tear system fistula,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
BCBS Medicaid,CPT,68801,Dilate tear duct opening,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
BCBS Medicaid,CPT,68810,Probe nasolacrimal duct,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
BCBS Medicaid,CPT,68811,Probe nasolacrimal duct,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
BCBS Medicaid,CPT,68815,Probe nasolacrimal duct,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
BCBS Medicaid,CPT,68816,Probe nl duct w/balloon,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
BCBS Medicaid,CPT,68840,Explore/irrigate tear ducts,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
BCBS Medicaid,CPT,68899,Tear duct system surgery,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
BCBS Medicaid,CPT,69005,Drain external ear lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,69100,Biopsy of external ear,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,69105,Biopsy of external ear canal,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,69110,Remove external ear partial,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,69120,Removal of external ear,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,69140,Remove ear canal lesion(s),Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,69145,Remove ear canal lesion(s),Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,69150,Extensive ear canal surgery,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,69155,Extensive ear/neck surgery,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,69205,Clear outer ear canal,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,69222,Clean out mastoid cavity,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,69300,Revise external ear,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,69310,Rebuild outer ear canal,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,69320,Rebuild outer ear canal,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,69399,Outer ear surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,69421,Incision of eardrum,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,69424,Remove ventilating tube,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,69433,Create eardrum opening,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,69436,Create eardrum opening,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,69440,Exploration of middle ear,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,69450,Eardrum revision,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,69501,Mastoidectomy,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,69502,Mastoidectomy,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,69505,Remove mastoid structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,69511,Extensive mastoid surgery,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,69530,Extensive mastoid surgery,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,69540,Remove ear lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,69550,Remove ear lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,69552,Remove ear lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,69601,Mastoid surgery revision,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,69602,Mastoid surgery revision,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,69603,Mastoid surgery revision,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,69604,Mastoid surgery revision,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,69605,Mastoid surgery revision,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,69610,Repair of eardrum,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,69620,Repair of eardrum,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,69631,Repair eardrum structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,69632,Rebuild eardrum structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,69633,Rebuild eardrum structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,69635,Repair eardrum structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,69636,Rebuild eardrum structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,69637,Rebuild eardrum structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,69641,Revise middle ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,69642,Revise middle ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,69643,Revise middle ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,69644,Revise middle ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,69645,Revise middle ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,69646,Revise middle ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,69650,Release middle ear bone,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,69660,Revise middle ear bone,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,69661,Revise middle ear bone,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,69662,Revise middle ear bone,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,69666,Repair middle ear structures,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,69667,Repair middle ear structures,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,69670,Remove mastoid air cells,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,69676,Remove middle ear nerve,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,69700,Close mastoid fistula,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,69705,Nps surg dilat eust tube uni,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
BCBS Medicaid,CPT,69706,Nps surg dilat eust tube bi,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
BCBS Medicaid,CPT,69710,Implant/replace hearing aid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,69711,Remove/repair hearing aid,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,69714,Implant temple bone w/stimul,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,69715,Temple bne implnt w/stimulat,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,69717,Temple bone implant revision,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,69718,Revise temple bone implant,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,69720,Release facial nerve,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,69725,Release facial nerve,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,69740,Repair facial nerve,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,69745,Repair facial nerve,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,69799,Middle ear surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,69801,Incise inner ear,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,69805,Explore inner ear,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,69806,Explore inner ear,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,69820,Establish inner ear window,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,69840,Revise inner ear window,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,69905,Remove inner ear,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
BCBS Medicaid,CPT,69910,Remove inner ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,69915,Incise inner ear nerve,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,69930,Implant cochlear device,Otolaryngology Surgery,Per Unit,"$15,529.51 ",OP,"15,529.51","15,529.51",,,,,,
BCBS Medicaid,CPT,69949,Inner ear surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,69955,Release facial nerve,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,69960,Release inner ear canal,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
BCBS Medicaid,CPT,70010,Contrast x-ray of brain,Diagnostic Radiology,Per Unit,$345.35 ,OP,345.35,345.35,,,,,,
BCBS Medicaid,CPT,70015,Contrast x-ray of brain,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
BCBS Medicaid,CPT,70030,X-ray eye for foreign body,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,70100,X-ray exam of jaw <4views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,70110,X-ray exam of jaw 4/> views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,70120,X-ray exam of mastoids,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,70130,X-ray exam of mastoids,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,70134,X-ray exam of middle ear,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,70140,X-ray exam of facial bones,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,70150,X-ray exam of facial bones,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,70160,X-ray exam of nasal bones,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,70190,X-ray exam of eye sockets,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,70200,X-ray exam of eye sockets,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,70210,X-ray exam of sinuses,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,70220,X-ray exam of sinuses,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,70240,X-ray exam pituitary saddle,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,70250,X-ray exam of skull,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,70260,X-ray exam of skull,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,70300,X-ray exam of teeth,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,70310,X-ray exam of teeth,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,70320,Full mouth x-ray of teeth,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,70328,X-ray exam of jaw joint,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,70330,X-ray exam of jaw joints,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,70336,Magnetic image jaw joint,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
BCBS Medicaid,CPT,70350,X-ray head for orthodontia,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,70355,Panoramic x-ray of jaws,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,70360,X-ray exam of neck,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,70370,Throat x-ray & fluoroscopy,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,70373,Contrast x-ray of larynx,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,70380,X-ray exam of salivary gland,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,70450,Ct head/brain w/o dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
BCBS Medicaid,CPT,70460,Ct head/brain w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
BCBS Medicaid,CPT,70470,Ct head/brain w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
BCBS Medicaid,CPT,70480,Ct orbit/ear/fossa w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
BCBS Medicaid,CPT,70481,Ct orbit/ear/fossa w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
BCBS Medicaid,CPT,70482,Ct orbit/ear/fossa w/o&w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
BCBS Medicaid,CPT,70486,Ct maxillofacial w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
BCBS Medicaid,CPT,70487,Ct maxillofacial w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
BCBS Medicaid,CPT,70488,Ct maxillofacial w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
BCBS Medicaid,CPT,70490,Ct soft tissue neck w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
BCBS Medicaid,CPT,70491,Ct soft tissue neck w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
BCBS Medicaid,CPT,70492,Ct sft tsue nck w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
BCBS Medicaid,CPT,70496,Ct angiography head,Interventional Radiology,Per Unit,$178.94 ,OP,178.94,178.94,,,,,,
BCBS Medicaid,CPT,70498,Ct angiography neck,Interventional Radiology,Per Unit,$178.94 ,OP,178.94,178.94,,,,,,
BCBS Medicaid,CPT,70540,Mri orbit/face/neck w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
BCBS Medicaid,CPT,70542,Mri orbit/face/neck w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
BCBS Medicaid,CPT,70543,Mri orbt/fac/nck w/o &w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
BCBS Medicaid,CPT,70544,Mr angiography head w/o dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
BCBS Medicaid,CPT,70545,Mr angiography head w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
BCBS Medicaid,CPT,70546,Mr angiograph head w/o&w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
BCBS Medicaid,CPT,70547,Mr angiography neck w/o dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
BCBS Medicaid,CPT,70548,Mr angiography neck w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
BCBS Medicaid,CPT,70549,Mr angiograph neck w/o&w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
BCBS Medicaid,CPT,70551,Mri brain stem w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
BCBS Medicaid,CPT,70552,Mri brain stem w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
BCBS Medicaid,CPT,70553,Mri brain stem w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
BCBS Medicaid,CPT,70554,Fmri brain by tech,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
BCBS Medicaid,CPT,70555,Fmri brain by phys/psych,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
BCBS Medicaid,CPT,70557,Mri brain w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
BCBS Medicaid,CPT,70558,Mri brain w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
BCBS Medicaid,CPT,70559,Mri brain w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
BCBS Medicaid,CPT,71010,Chest x-ray 1 view frontal,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,71015,Chest x-ray stereo frontal,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,71020,Chest x-ray 2vw frontal&latl,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,71021,Chest x-ray frnt lat lordotc,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,71022,Chest x-ray frnt lat oblique,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,71023,Chest x-ray and fluoroscopy,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,71030,Chest x-ray 4/> views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,71034,Chest x-ray&fluoro 4/> views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,71035,Chest x-ray special views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,71045,X-ray exam chest 1 view,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,71046,X-ray exam chest 2 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,71047,X-ray exam chest 3 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,71048,X-ray exam chest 4+ views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,71100,X-ray exam ribs uni 2 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,71101,X-ray exam unilat ribs/chest,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,71110,X-ray exam ribs bil 3 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,71111,X-ray exam ribs/chest4/> vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,71120,X-ray exam breastbone 2/>vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,71130,X-ray strenoclavic jt 3/>vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,71250,Ct thorax dx c-,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
BCBS Medicaid,CPT,71260,Ct thorax dx c+,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
BCBS Medicaid,CPT,71270,Ct thorax dx c-/c+,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
BCBS Medicaid,CPT,71271,Ct thorax lung cancer scr c-,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
BCBS Medicaid,CPT,71275,Ct angiography chest,Interventional Radiology,Per Unit,$178.94 ,OP,178.94,178.94,,,,,,
BCBS Medicaid,CPT,71550,Mri chest w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
BCBS Medicaid,CPT,71551,Mri chest w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
BCBS Medicaid,CPT,71552,Mri chest w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
BCBS Medicaid,CPT,71555,Mri angio chest w or w/o dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
BCBS Medicaid,CPT,72010,X-ray exam spine ap&lat,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,72020,X-ray exam of spine 1 view,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,72040,X-ray exam neck spine 2-3 vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,72050,X-ray exam neck spine 4/5vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,72052,X-ray exam neck spine 6/>vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,72069,X-ray exam trunk spine stand,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,72070,X-ray exam thorac spine 2vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,72072,X-ray exam thorac spine 3vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,72074,X-ray exam thorac spine4/>vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,72080,X-ray exam thoracolmb 2/> vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,72081,X-ray exam entire spi 1 vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,72082,X-ray exam entire spi 2/3 vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,72083,X-ray exam entire spi 4/5 vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,72084,X-ray exam entire spi 6/> vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,72090,X-ray exam scloiosis erect,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,72100,X-ray exam l-s spine 2/3 vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,72110,X-ray exam l-2 spine 4/>vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,72114,X-ray exam l-s spine bending,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,72120,X-ray bend only l-s spine,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,72125,Ct neck spine w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
BCBS Medicaid,CPT,72126,Ct neck spine w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
BCBS Medicaid,CPT,72127,Ct neck spine w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
BCBS Medicaid,CPT,72128,Ct chest spine w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
BCBS Medicaid,CPT,72129,Ct chest spine w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
BCBS Medicaid,CPT,72130,Ct chest spine w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
BCBS Medicaid,CPT,72131,Ct lumbar spine w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
BCBS Medicaid,CPT,72132,Ct lumbar spine w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
BCBS Medicaid,CPT,72133,Ct lumbar spine w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
BCBS Medicaid,CPT,72141,Mri neck spine w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
BCBS Medicaid,CPT,72142,Mri neck spine w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
BCBS Medicaid,CPT,72146,Mri chest spine w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
BCBS Medicaid,CPT,72147,Mri chest spine w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
BCBS Medicaid,CPT,72148,Mri lumbar spine w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
BCBS Medicaid,CPT,72149,Mri lumbar spine w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
BCBS Medicaid,CPT,72156,Mri neck spine w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
BCBS Medicaid,CPT,72157,Mri chest spine w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
BCBS Medicaid,CPT,72158,Mri lumbar spine w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
BCBS Medicaid,CPT,72159,Mr angio spine w/o&w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
BCBS Medicaid,CPT,72170,X-ray exam of pelvis,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,72190,X-ray exam of pelvis,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,72191,Ct angiograph pelv w/o&w/dye,Interventional Radiology,Per Unit,$178.94 ,OP,178.94,178.94,,,,,,
BCBS Medicaid,CPT,72192,Ct pelvis w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
BCBS Medicaid,CPT,72193,Ct pelvis w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
BCBS Medicaid,CPT,72194,Ct pelvis w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
BCBS Medicaid,CPT,72195,Mri pelvis w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
BCBS Medicaid,CPT,72196,Mri pelvis w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
BCBS Medicaid,CPT,72197,Mri pelvis w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
BCBS Medicaid,CPT,72198,Mr angio pelvis w/o & w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
BCBS Medicaid,CPT,72200,X-ray exam si joints,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,72202,X-ray exam si joints 3/> vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,72220,X-ray exam sacrum tailbone,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,72240,Myelography neck spine,Diagnostic Radiology,Per Unit,$345.35 ,OP,345.35,345.35,,,,,,
BCBS Medicaid,CPT,72255,Myelography thoracic spine,Diagnostic Radiology,Per Unit,$345.35 ,OP,345.35,345.35,,,,,,
BCBS Medicaid,CPT,72265,Myelography l-s spine,Diagnostic Radiology,Per Unit,$345.35 ,OP,345.35,345.35,,,,,,
BCBS Medicaid,CPT,72270,Myelogphy 2/> spine regions,Diagnostic Radiology,Per Unit,$345.35 ,OP,345.35,345.35,,,,,,
BCBS Medicaid,CPT,72275,Epidurography,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,72285,Discography cerv/thor spine,Diagnostic Radiology,Per Unit,$345.35 ,OP,345.35,345.35,,,,,,
BCBS Medicaid,CPT,72295,X-ray of lower spine disk,Diagnostic Radiology,Per Unit,$345.35 ,OP,345.35,345.35,,,,,,
BCBS Medicaid,CPT,73000,X-ray exam of collar bone,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,73010,X-ray exam of shoulder blade,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,73020,X-ray exam of shoulder,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,73030,X-ray exam of shoulder,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,73050,X-ray exam of shoulders,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,73060,X-ray exam of humerus,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,73070,X-ray exam of elbow,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,73080,X-ray exam of elbow,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,73090,X-ray exam of forearm,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,73092,X-ray exam of arm infant,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,73100,X-ray exam of wrist,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,73110,X-ray exam of wrist,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,73120,X-ray exam of hand,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,73130,X-ray exam of hand,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,73140,X-ray exam of finger(s),Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,73200,Ct upper extremity w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
BCBS Medicaid,CPT,73201,Ct upper extremity w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
BCBS Medicaid,CPT,73202,Ct uppr extremity w/o&w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
BCBS Medicaid,CPT,73206,Ct angio upr extrm w/o&w/dye,Interventional Radiology,Per Unit,$178.94 ,OP,178.94,178.94,,,,,,
BCBS Medicaid,CPT,73218,Mri upper extremity w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
BCBS Medicaid,CPT,73219,Mri upper extremity w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
BCBS Medicaid,CPT,73220,Mri uppr extremity w/o&w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
BCBS Medicaid,CPT,73221,Mri joint upr extrem w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
BCBS Medicaid,CPT,73222,Mri joint upr extrem w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
BCBS Medicaid,CPT,73223,Mri joint upr extr w/o&w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
BCBS Medicaid,CPT,73225,Mr angio upr extr w/o&w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
BCBS Medicaid,CPT,73500,X-ray exam of hip,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,73501,X-ray exam hip uni 1 view,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,73502,X-ray exam hip uni 2-3 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,73503,X-ray exam hip uni 4/> views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,73510,X-ray exam of hip,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,73520,X-ray exam of hips,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,73521,X-ray exam hips bi 2 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,73522,X-ray exam hips bi 3-4 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,73523,X-ray exam hips bi 5/> views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,73530,X-ray exam of hip,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,73540,X-ray exam of pelvis & hips,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,73550,X-ray exam of thigh,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,73551,X-ray exam of femur 1,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,73552,X-ray exam of femur 2/>,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,73560,X-ray exam of knee 1 or 2,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,73562,X-ray exam of knee 3,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,73564,X-ray exam knee 4 or more,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,73565,X-ray exam of knees,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,73590,X-ray exam of lower leg,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,73592,X-ray exam of leg infant,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,73600,X-ray exam of ankle,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,73610,X-ray exam of ankle,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,73620,X-ray exam of foot,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,73630,X-ray exam of foot,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,73650,X-ray exam of heel,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,73660,X-ray exam of toe(s),Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,73700,Ct lower extremity w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
BCBS Medicaid,CPT,73701,Ct lower extremity w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
BCBS Medicaid,CPT,73702,Ct lwr extremity w/o&w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
BCBS Medicaid,CPT,73706,Ct angio lwr extr w/o&w/dye,Interventional Radiology,Per Unit,$178.94 ,OP,178.94,178.94,,,,,,
BCBS Medicaid,CPT,73718,Mri lower extremity w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
BCBS Medicaid,CPT,73719,Mri lower extremity w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
BCBS Medicaid,CPT,73720,Mri lwr extremity w/o&w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
BCBS Medicaid,CPT,73721,Mri jnt of lwr extre w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
BCBS Medicaid,CPT,73722,Mri joint of lwr extr w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
BCBS Medicaid,CPT,73723,Mri joint lwr extr w/o&w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
BCBS Medicaid,CPT,73725,Mr ang lwr ext w or w/o dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
BCBS Medicaid,CPT,74000,X-ray exam of abdomen,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,74010,X-ray exam of abdomen,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,74018,X-ray exam abdomen 1 view,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,74019,X-ray exam abdomen 2 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,74020,X-ray exam of abdomen,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,74021,X-ray exam abdomen 3+ views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,74022,X-ray exam complete abdomen,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,74150,Ct abdomen w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
BCBS Medicaid,CPT,74160,Ct abdomen w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
BCBS Medicaid,CPT,74170,Ct abdomen w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
BCBS Medicaid,CPT,74174,Ct angio abd&pelv w/o&w/dye,Interventional Radiology,Per Unit,$178.94 ,OP,178.94,178.94,,,,,,
BCBS Medicaid,CPT,74175,Ct angio abdom w/o & w/dye,Interventional Radiology,Per Unit,$178.94 ,OP,178.94,178.94,,,,,,
BCBS Medicaid,CPT,74176,Ct abd & pelvis w/o contrast,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
BCBS Medicaid,CPT,74177,Ct abd & pelv w/contrast,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
BCBS Medicaid,CPT,74178,Ct abd & pelv 1/> regns,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
BCBS Medicaid,CPT,74181,Mri abdomen w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
BCBS Medicaid,CPT,74182,Mri abdomen w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
BCBS Medicaid,CPT,74183,Mri abdomen w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
BCBS Medicaid,CPT,74185,Mri angio abdom w orw/o dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
BCBS Medicaid,CPT,74210,X-ray xm phrnx&/crv esoph c+,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,74220,X-ray xm esophagus 1cntrst,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,74235,Remove esophagus obstruction,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,74261,Ct colonography dx,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
BCBS Medicaid,CPT,74262,Ct colonography dx w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
BCBS Medicaid,CPT,74263,Ct colonography screening,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
BCBS Medicaid,CPT,74300,X-ray bile ducts/pancreas,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,74301,X-rays at surgery add-on,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,74305,X-ray bile ducts/pancreas,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,74320,Contrast x-ray of bile ducts,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,74327,X-ray bile stone removal,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,74328,X-ray bile duct endoscopy,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,74329,X-ray for pancreas endoscopy,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,74330,X-ray bile/panc endoscopy,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,74340,X-ray guide for gi tube,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,74355,X-ray guide intestinal tube,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,74360,X-ray guide gi dilation,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,74363,X-ray bile duct dilation,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,74475,X-ray control cath insert,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,74480,X-ray control cath insert,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,74485,Dilation urtr/urt rs&i,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,74710,X-ray measurement of pelvis,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,74712,Mri fetal sngl/1st gestation,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
BCBS Medicaid,CPT,74713,Mri fetal ea addl gestation,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
BCBS Medicaid,CPT,74742,X-ray fallopian tube,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,75557,Cardiac mri for morph,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
BCBS Medicaid,CPT,75559,Cardiac mri w/stress img,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
BCBS Medicaid,CPT,75561,Cardiac mri for morph w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
BCBS Medicaid,CPT,75563,Card mri w/stress img & dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
BCBS Medicaid,CPT,75565,Card mri veloc flow mapping,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
BCBS Medicaid,CPT,75571,Ct hrt w/o dye w/ca test,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
BCBS Medicaid,CPT,75572,Ct hrt w/3d image,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
BCBS Medicaid,CPT,75573,Ct hrt w/3d image congen,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
BCBS Medicaid,CPT,75574,Ct angio hrt w/3d image,Interventional Radiology,Per Unit,$178.94 ,OP,178.94,178.94,,,,,,
BCBS Medicaid,CPT,75605,Contrast exam thoracic aorta,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
BCBS Medicaid,CPT,75635,Ct angio abdominal arteries,Interventional Radiology,Per Unit,$178.94 ,OP,178.94,178.94,,,,,,
BCBS Medicaid,CPT,75705,Artery x-rays spine,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
BCBS Medicaid,CPT,75726,Artery x-rays abdomen,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
BCBS Medicaid,CPT,75736,Artery x-rays pelvis,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
BCBS Medicaid,CPT,75774,Artery x-ray each vessel,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
BCBS Medicaid,CPT,75791,Av dialysis shunt imaging,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,75842,Vein x-ray adrenal glands,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
BCBS Medicaid,CPT,75893,Venous sampling by catheter,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
BCBS Medicaid,CPT,75894,X-rays transcath therapy,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,75896,X-rays transcath therapy,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,75901,Remove cva device obstruct,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,75902,Remove cva lumen obstruct,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,75945,Intravascular us,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
BCBS Medicaid,CPT,75946,Intravascular us add-on,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
BCBS Medicaid,CPT,75952,Endovasc repair abdom aorta,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,75953,Abdom aneurysm endovas rpr,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,75954,Iliac aneurysm endovas rpr,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,75956,Xray endovasc thor ao repr,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,75957,Xray endovasc thor ao repr,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,75958,Xray place prox ext thor ao,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,75959,Xray place dist ext thor ao,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,75962,Repair arterial blockage,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,75964,Repair artery blockage each,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,75966,Repair arterial blockage,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,75968,Repair artery blockage each,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,75970,Vascular biopsy,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,75980,Contrast xray exam bile duct,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,75982,Contrast xray exam bile duct,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,75984,Xray control catheter change,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,75989,Abscess drainage under x-ray,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,76010,X-ray nose to rectum,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,76100,X-ray exam of body section,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,76101,Complex body section x-ray,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,76102,Complex body section x-rays,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,76120,Cine/video x-rays,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,76125,Cine/video x-rays add-on,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,76145,Med physic dos eval rad exps,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
BCBS Medicaid,CPT,76380,Cat scan follow-up study,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
BCBS Medicaid,CPT,76390,Mr spectroscopy,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
BCBS Medicaid,CPT,76391,Mr elastography,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
BCBS Medicaid,CPT,76496,Fluoroscopic procedure,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,76497,Ct procedure,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
BCBS Medicaid,CPT,76498,Mri procedure,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
BCBS Medicaid,CPT,76499,Radiographic procedure,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,76506,Echo exam of head,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,76510,Oph us dx b-scan&quan a-scan,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,76511,Oph us dx quan a-scan only,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,76512,Oph us dx b-scan,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,76513,Oph us dx ant sgm us uni/bi,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,76514,Echo exam of eye thickness,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,76516,Echo exam of eye,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,76519,Echo exam of eye,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,76529,Echo exam of eye,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,76536,Us exam of head and neck,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,76604,Us exam chest,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,76641,Ultrasound breast complete,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,76642,Ultrasound breast limited,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,76700,Us exam abdom complete,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
BCBS Medicaid,CPT,76705,Echo exam of abdomen,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,76706,Us abdl aorta screen aaa,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,76770,Us exam abdo back wall comp,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
BCBS Medicaid,CPT,76775,Us exam abdo back wall lim,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,76776,Us exam k transpl w/doppler,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,76800,Us exam spinal canal,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,76801,Ob us < 14 wks single fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
BCBS Medicaid,CPT,76802,Ob us < 14 wks addl fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
BCBS Medicaid,CPT,76805,Ob us >= 14 wks sngl fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
BCBS Medicaid,CPT,76810,Ob us >= 14 wks addl fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
BCBS Medicaid,CPT,76811,Ob us detailed sngl fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
BCBS Medicaid,CPT,76812,Ob us detailed addl fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
BCBS Medicaid,CPT,76813,Ob us nuchal meas 1 gest,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
BCBS Medicaid,CPT,76814,Ob us nuchal meas add-on,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
BCBS Medicaid,CPT,76815,Ob us limited fetus(s),Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
BCBS Medicaid,CPT,76816,Ob us follow-up per fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
BCBS Medicaid,CPT,76817,Transvaginal us obstetric,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
BCBS Medicaid,CPT,76818,Fetal biophys profile w/nst,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
BCBS Medicaid,CPT,76819,Fetal biophys profil w/o nst,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
BCBS Medicaid,CPT,76820,Umbilical artery echo,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
BCBS Medicaid,CPT,76821,Middle cerebral artery echo,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
BCBS Medicaid,CPT,76825,Echo exam of fetal heart,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
BCBS Medicaid,CPT,76826,Echo exam of fetal heart,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
BCBS Medicaid,CPT,76827,Echo exam of fetal heart,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
BCBS Medicaid,CPT,76828,Echo exam of fetal heart,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
BCBS Medicaid,CPT,76830,Transvaginal us non-ob,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,76831,Echo exam uterus,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
BCBS Medicaid,CPT,76856,Us exam pelvic complete,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
BCBS Medicaid,CPT,76857,Us exam pelvic limited,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,76870,Us exam scrotum,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,76872,Us transrectal,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,76873,Echograp trans r pros study,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
BCBS Medicaid,CPT,76881,Us compl joint r-t w/img,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,76882,Us lmtd jt/nonvasc xtr strux,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,76885,Us exam infant hips dynamic,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,76886,Us exam infant hips static,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,76930,Echo guide cardiocentesis,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
BCBS Medicaid,CPT,76932,Echo guide for heart biopsy,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
BCBS Medicaid,CPT,76936,Echo guide for artery repair,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,76937,Us guide vascular access,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
BCBS Medicaid,CPT,76940,Us guide tissue ablation,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
BCBS Medicaid,CPT,76941,Echo guide for transfusion,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
BCBS Medicaid,CPT,76942,Echo guide for biopsy,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
BCBS Medicaid,CPT,76945,Echo guide villus sampling,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
BCBS Medicaid,CPT,76946,Echo guide for amniocentesis,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
BCBS Medicaid,CPT,76948,Echo guide ova aspiration,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
BCBS Medicaid,CPT,76965,Echo guidance radiotherapy,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
BCBS Medicaid,CPT,76970,Ultrasound exam follow-up,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,76975,Gi endoscopic ultrasound,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
BCBS Medicaid,CPT,76977,Us bone density measure,Diagnostic Radiology,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
BCBS Medicaid,CPT,76978,Us trgt dyn mbubb 1st les,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
BCBS Medicaid,CPT,76979,Us trgt dyn mbubb ea addl,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
BCBS Medicaid,CPT,76981,Use parenchyma,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,76982,Use 1st target lesion,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,76983,Use ea addl target lesion,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,76998,Us guide intraop,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
BCBS Medicaid,CPT,76999,Echo examination procedure,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,77001,Fluoroguide for vein device,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,77002,Needle localization by xray,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,77003,Fluoroguide for spine inject,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,77011,Ct scan for localization,Interventional Radiology,Per Unit,$61.07 ,OP,61.07,61.07,,,,,,
BCBS Medicaid,CPT,77012,Ct scan for needle biopsy,Interventional Radiology,Per Unit,$61.07 ,OP,61.07,61.07,,,,,,
BCBS Medicaid,CPT,77013,Ct guide for tissue ablation,Interventional Radiology,Per Unit,$61.07 ,OP,61.07,61.07,,,,,,
BCBS Medicaid,CPT,77014,Ct scan for therapy guide,Interventional Radiology,Per Unit,$61.07 ,OP,61.07,61.07,,,,,,
BCBS Medicaid,CPT,77021,Mri guidance ndl plmt rs&i,Interventional Radiology,Per Unit,$108.13 ,OP,108.13,108.13,,,,,,
BCBS Medicaid,CPT,77022,Mri gdn parnchyma tiss abltj,Interventional Radiology,Per Unit,$108.13 ,OP,108.13,108.13,,,,,,
BCBS Medicaid,CPT,77046,Mri breast c- unilateral,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
BCBS Medicaid,CPT,77047,Mri breast c- bilateral,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
BCBS Medicaid,CPT,77048,Mri breast c-+ w/cad uni,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
BCBS Medicaid,CPT,77049,Mri breast c-+ w/cad bi,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
BCBS Medicaid,CPT,77055,Mammogram one breast,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
BCBS Medicaid,CPT,77056,Mammogram both breasts,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
BCBS Medicaid,CPT,77057,Mammogram screening,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
BCBS Medicaid,CPT,77058,Mri one breast,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
BCBS Medicaid,CPT,77059,Mri both breasts,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
BCBS Medicaid,CPT,77061,Breast tomosynthesis uni,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
BCBS Medicaid,CPT,77062,Breast tomosynthesis bi,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
BCBS Medicaid,CPT,77063,Breast tomosynthesis bi,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
BCBS Medicaid,CPT,77065,Dx mammo incl cad uni,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
BCBS Medicaid,CPT,77066,Dx mammo incl cad bi,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
BCBS Medicaid,CPT,77067,Scr mammo bi incl cad,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
BCBS Medicaid,CPT,77072,X-rays for bone age,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,77073,X-rays bone length studies,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,77074,X-rays bone survey limited,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,77076,X-rays bone survey infant,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,77077,Joint survey single view,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,77078,Ct bone density axial,Diagnostic Radiology,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
BCBS Medicaid,CPT,77080,Dxa bone density axial,Diagnostic Radiology,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
BCBS Medicaid,CPT,77081,Dxa bone density/peripheral,Diagnostic Radiology,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
BCBS Medicaid,CPT,77084,Magnetic image bone marrow,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
BCBS Medicaid,CPT,77085,Dxa bone density study,Diagnostic Radiology,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
BCBS Medicaid,CPT,77086,Fracture assessment via dxa,Diagnostic Radiology,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
BCBS Medicaid,CPT,77261,Radiation therapy planning,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
BCBS Medicaid,CPT,77262,Radiation therapy planning,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
BCBS Medicaid,CPT,77263,Radiation therapy planning,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
BCBS Medicaid,CPT,77280,Set radiation therapy field,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
BCBS Medicaid,CPT,77285,Set radiation therapy field,Therapeutic Radiology,Per Unit,$434.17 ,OP,434.17,434.17,,,,,,
BCBS Medicaid,CPT,77290,Set radiation therapy field,Therapeutic Radiology,Per Unit,$434.17 ,OP,434.17,434.17,,,,,,
BCBS Medicaid,CPT,77293,Respirator motion mgmt simul,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
BCBS Medicaid,CPT,77295,3-d radiotherapy plan,Therapeutic Radiology,Per Unit,$68.45 ,OP,68.45,68.45,,,,,,
BCBS Medicaid,CPT,77299,Radiation therapy planning,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
BCBS Medicaid,CPT,77300,Radiation therapy dose plan,Therapeutic Radiology,Per Unit,$434.17 ,OP,434.17,434.17,,,,,,
BCBS Medicaid,CPT,77301,Radiotherapy dose plan imrt,Therapeutic Radiology,Per Unit,$68.45 ,OP,68.45,68.45,,,,,,
BCBS Medicaid,CPT,77306,Telethx isodose plan simple,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
BCBS Medicaid,CPT,77307,Telethx isodose plan cplx,Therapeutic Radiology,Per Unit,$434.17 ,OP,434.17,434.17,,,,,,
BCBS Medicaid,CPT,77316,Brachytx isodose plan simple,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
BCBS Medicaid,CPT,77317,Brachytx isodose intermed,Therapeutic Radiology,Per Unit,$434.17 ,OP,434.17,434.17,,,,,,
BCBS Medicaid,CPT,77318,Brachytx isodose complex,Therapeutic Radiology,Per Unit,$434.17 ,OP,434.17,434.17,,,,,,
BCBS Medicaid,CPT,77321,Special teletx port plan,Therapeutic Radiology,Per Unit,$434.17 ,OP,434.17,434.17,,,,,,
BCBS Medicaid,CPT,77331,Special radiation dosimetry,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
BCBS Medicaid,CPT,77332,Radiation treatment aid(s),Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
BCBS Medicaid,CPT,77333,Radiation treatment aid(s),Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
BCBS Medicaid,CPT,77334,Radiation treatment aid(s),Therapeutic Radiology,Per Unit,$434.17 ,OP,434.17,434.17,,,,,,
BCBS Medicaid,CPT,77336,Radiation physics consult,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
BCBS Medicaid,CPT,77338,Design mlc device for imrt,Therapeutic Radiology,Per Unit,$434.17 ,OP,434.17,434.17,,,,,,
BCBS Medicaid,CPT,77370,Radiation physics consult,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
BCBS Medicaid,CPT,77371,Srs multisource,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"2,592.65","2,592.65",,,,,,
BCBS Medicaid,CPT,77372,Srs linear based,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"2,592.65","2,592.65",,,,,,
BCBS Medicaid,CPT,77373,Sbrt delivery,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
BCBS Medicaid,CPT,77385,Ntsty modul rad tx dlvr smpl,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
BCBS Medicaid,CPT,77386,Ntsty modul rad tx dlvr cplx,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
BCBS Medicaid,CPT,77387,Guidance for radj tx dlvr,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
BCBS Medicaid,CPT,77399,External radiation dosimetry,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
BCBS Medicaid,CPT,77401,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
BCBS Medicaid,CPT,77402,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
BCBS Medicaid,CPT,77407,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
BCBS Medicaid,CPT,77412,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
BCBS Medicaid,CPT,77417,Radiology port images(s),Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,77422,Neutron beam tx simple,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
BCBS Medicaid,CPT,77423,Neutron beam tx complex,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
BCBS Medicaid,CPT,77424,Io rad tx delivery by x-ray,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
BCBS Medicaid,CPT,77425,Io rad tx deliver by elctrns,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
BCBS Medicaid,CPT,77427,Radiation tx management x5,Therapeutic Radiology,Per Unit,$70.25 ,OP,70.25,70.25,,,,,,
BCBS Medicaid,CPT,77431,Radiation therapy management,Therapeutic Radiology,Per Unit,$70.25 ,OP,70.25,70.25,,,,,,
BCBS Medicaid,CPT,77432,Stereotactic radiation trmt,Therapeutic Radiology,Per Unit,$70.25 ,OP,70.25,70.25,,,,,,
BCBS Medicaid,CPT,77435,Sbrt management,Therapeutic Radiology,Per Unit,$70.25 ,OP,70.25,70.25,,,,,,
BCBS Medicaid,CPT,77469,Io radiation tx management,Therapeutic Radiology,Per Unit,$70.25 ,OP,70.25,70.25,,,,,,
BCBS Medicaid,CPT,77470,Special radiation treatment,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
BCBS Medicaid,CPT,77499,Radiation therapy management,Therapeutic Radiology,Per Unit,$70.25 ,OP,70.25,70.25,,,,,,
BCBS Medicaid,CPT,77520,Proton trmt simple w/o comp,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
BCBS Medicaid,CPT,77522,Proton trmt simple w/comp,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
BCBS Medicaid,CPT,77523,Proton trmt intermediate,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
BCBS Medicaid,CPT,77525,Proton treatment complex,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
BCBS Medicaid,CPT,77600,Hyperthermia treatment,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
BCBS Medicaid,CPT,77605,Hyperthermia treatment,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
BCBS Medicaid,CPT,77610,Hyperthermia treatment,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
BCBS Medicaid,CPT,77615,Hyperthermia treatment,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
BCBS Medicaid,CPT,77620,Hyperthermia treatment,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
BCBS Medicaid,CPT,77750,Infuse radioactive materials,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
BCBS Medicaid,CPT,77761,Apply intrcav radiat simple,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
BCBS Medicaid,CPT,77762,Apply intrcav radiat interm,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
BCBS Medicaid,CPT,77763,Apply intrcav radiat compl,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
BCBS Medicaid,CPT,77767,Hdr rdncl skn surf brachytx,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
BCBS Medicaid,CPT,77768,Hdr rdncl skn surf brachytx,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
BCBS Medicaid,CPT,77770,Hdr rdncl ntrstl/icav brchtx,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
BCBS Medicaid,CPT,77771,Hdr rdncl ntrstl/icav brchtx,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
BCBS Medicaid,CPT,77772,Hdr rdncl ntrstl/icav brchtx,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
BCBS Medicaid,CPT,77776,Apply interstit radiat simpl,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
BCBS Medicaid,CPT,77777,Apply interstit radiat inter,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
BCBS Medicaid,CPT,77778,Apply interstit radiat compl,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
BCBS Medicaid,CPT,77785,Hdr brachytx 1 channel,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
BCBS Medicaid,CPT,77786,Hdr brachytx 2-12 channel,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
BCBS Medicaid,CPT,77787,Hdr brachytx over 12 chan,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
BCBS Medicaid,CPT,77789,Apply surf ldr radionuclide,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
BCBS Medicaid,CPT,77790,Radiation handling,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
BCBS Medicaid,CPT,77799,Radium/radioisotope therapy,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
BCBS Medicaid,CPT,78012,Thyroid uptake measurement,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78013,Thyroid imaging w/blood flow,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78014,Thyroid imaging w/blood flow,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78015,Thyroid met imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78016,Thyroid met imaging/studies,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78018,Thyroid met imaging body,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78020,Thyroid met uptake,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78070,Parathyroid planar imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
BCBS Medicaid,CPT,78071,Parathyrd planar w/wo subtrj,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78072,Parathyrd planar w/spect&ct,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78075,Adrenal cortex & medulla img,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
BCBS Medicaid,CPT,78099,Endocrine nuclear procedure,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78102,Bone marrow imaging ltd,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78103,Bone marrow imaging mult,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78104,Bone marrow imaging body,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78110,Plasma volume single,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
BCBS Medicaid,CPT,78111,Plasma volume multiple,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
BCBS Medicaid,CPT,78120,Red cell mass single,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78121,Red cell mass multiple,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78122,Blood volume,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
BCBS Medicaid,CPT,78130,Red cell survival study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78135,Red cell survival kinetics,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78140,Red cell sequestration,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78185,Spleen imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78190,Platelet survival kinetics,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78191,Platelet survival,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78195,Lymph system imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
BCBS Medicaid,CPT,78199,Blood/lymph nuclear exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78201,Liver imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
BCBS Medicaid,CPT,78202,Liver imaging with flow,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
BCBS Medicaid,CPT,78205,Liver imaging (3d),Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
BCBS Medicaid,CPT,78206,Liver image (3d) with flow,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
BCBS Medicaid,CPT,78215,Liver and spleen imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
BCBS Medicaid,CPT,78216,Liver & spleen image/flow,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
BCBS Medicaid,CPT,78226,Hepatobiliary system imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78227,Hepatobil syst image w/drug,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78230,Salivary gland imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78231,Serial salivary imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78232,Salivary gland function exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78258,Esophageal motility study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78261,Gastric mucosa imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78262,Gastroesophageal reflux exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78264,Gastric emptying imag study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78265,Gastric emptying imag study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78266,Gastric emptying imag study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78267,Breath tst attain/anal c-14,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,78270,Vit b-12 absorption exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78271,Vit b-12 absrp exam int fac,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78272,Vit b-12 absorp combined,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78278,Acute gi blood loss imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
BCBS Medicaid,CPT,78282,Gi protein loss exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78290,Meckels divert exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78291,Leveen/shunt patency exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78299,Gi nuclear procedure,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78300,Bone imaging limited area,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78305,Bone imaging multiple areas,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78306,Bone imaging whole body,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78315,Bone imaging 3 phase,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78320,Bone imaging (3d),Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78350,Bone mineral single photon,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78351,Bone mineral dual photon,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78399,Musculoskeletal nuclear exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78414,Non-imaging heart function,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78428,Cardiac shunt imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78429,Myocrd img pet 1 std w/ct,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
BCBS Medicaid,CPT,78430,Myocrd img pet rst/strs w/ct,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
BCBS Medicaid,CPT,78431,Myocrd img pet rst&strs ct,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
BCBS Medicaid,CPT,78432,Myocrd img pet 2rtracer,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
BCBS Medicaid,CPT,78433,Myocrd img pet 2rtracer ct,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
BCBS Medicaid,CPT,78434,Aqmbf pet rest & rx stress,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
BCBS Medicaid,CPT,78445,Vascular flow imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78451,Ht muscle image spect sing,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
BCBS Medicaid,CPT,78452,Ht muscle image spect mult,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
BCBS Medicaid,CPT,78453,Ht muscle image planar sing,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
BCBS Medicaid,CPT,78454,Ht musc image planar mult,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
BCBS Medicaid,CPT,78456,Acute venous thrombus image,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78457,Venous thrombosis imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
BCBS Medicaid,CPT,78458,Ven thrombosis images bilat,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78459,Myocrd img pet single study,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
BCBS Medicaid,CPT,78466,Heart infarct image,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78468,Heart infarct image (ef),Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78469,Heart infarct image (3d),Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
BCBS Medicaid,CPT,78472,Gated heart planar single,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78473,Gated heart multiple,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78481,Heart first pass single,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78483,Heart first pass multiple,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
BCBS Medicaid,CPT,78491,Myocrd img pet 1std rst/strs,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
BCBS Medicaid,CPT,78492,Myocrd img pet mlt rst&strs,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
BCBS Medicaid,CPT,78494,Heart image spect,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78496,Heart first pass add-on,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78499,Cardiovascular nuclear exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78579,Lung ventilation imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
BCBS Medicaid,CPT,78580,Lung perfusion imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
BCBS Medicaid,CPT,78582,Lung ventilat&perfus imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
BCBS Medicaid,CPT,78597,Lung perfusion differential,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
BCBS Medicaid,CPT,78598,Lung perf&ventilat diferentl,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
BCBS Medicaid,CPT,78599,Respiratory nuclear exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78600,Brain image < 4 views,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78601,Brain image w/flow < 4 views,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78605,Brain image 4+ views,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78606,Brain image w/flow 4 + views,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78607,Brain imaging (3d),Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
BCBS Medicaid,CPT,78608,Brain imaging (pet),Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
BCBS Medicaid,CPT,78609,Brain imaging (pet),Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
BCBS Medicaid,CPT,78610,Brain flow imaging only,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78630,Cerebrospinal fluid scan,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
BCBS Medicaid,CPT,78635,Csf ventriculography,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78645,Csf shunt evaluation,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
BCBS Medicaid,CPT,78647,Cerebrospinal fluid scan,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
BCBS Medicaid,CPT,78650,Csf leakage imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
BCBS Medicaid,CPT,78660,Nuclear exam of tear flow,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78699,Nervous system nuclear exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78700,Kidney imaging morphol,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78701,Kidney imaging with flow,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78707,K flow/funct image w/o drug,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78708,K flow/funct image w/drug,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78709,K flow/funct image multiple,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78710,Kidney imaging (3d),Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78725,Kidney function study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78730,Urinary bladder retention,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78740,Ureteral reflux study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78761,Testicular imaging w/flow,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78799,Genitourinary nuclear exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78800,Rp loclzj tum 1 area 1 d img,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
BCBS Medicaid,CPT,78801,Rp loclzj tum 2+area 1+d img,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
BCBS Medicaid,CPT,78802,Rp loclzj tum whbdy 1 d img,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
BCBS Medicaid,CPT,78803,Rp loclzj tum spect 1 area,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
BCBS Medicaid,CPT,78804,Rp loclzj tum whbdy 2+d img,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
BCBS Medicaid,CPT,78805,Abscess imaging ltd area,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
BCBS Medicaid,CPT,78806,Abscess imaging whole body,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
BCBS Medicaid,CPT,78807,Nuclear localization/abscess,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
BCBS Medicaid,CPT,78811,Pet image ltd area,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
BCBS Medicaid,CPT,78812,Pet image skull-thigh,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
BCBS Medicaid,CPT,78813,Pet image full body,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
BCBS Medicaid,CPT,78814,Pet image w/ct lmtd,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
BCBS Medicaid,CPT,78815,Pet image w/ct skull-thigh,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
BCBS Medicaid,CPT,78816,Pet image w/ct full body,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
BCBS Medicaid,CPT,78830,Rp loclzj tum spect w/ct 1,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
BCBS Medicaid,CPT,78831,Rp loclzj tum spect 2 areas,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
BCBS Medicaid,CPT,78832,Rp loclzj tum spect w/ct 2,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
BCBS Medicaid,CPT,78835,Rp quan meas single area,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,78999,Nuclear diagnostic exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,79005,Nuclear rx oral admin,Therapeutic Radiology,Per Unit,$174.28 ,OP,174.28,174.28,,,,,,
BCBS Medicaid,CPT,79101,Nuclear rx iv admin,Therapeutic Radiology,Per Unit,$174.28 ,OP,174.28,174.28,,,,,,
BCBS Medicaid,CPT,79200,Nuclear rx intracav admin,Therapeutic Radiology,Per Unit,$174.28 ,OP,174.28,174.28,,,,,,
BCBS Medicaid,CPT,79300,Nuclr rx interstit colloid,Therapeutic Radiology,Per Unit,$174.28 ,OP,174.28,174.28,,,,,,
BCBS Medicaid,CPT,79403,Hematopoietic nuclear tx,Therapeutic Radiology,Per Unit,$174.28 ,OP,174.28,174.28,,,,,,
BCBS Medicaid,CPT,79440,Nuclear rx intra-articular,Therapeutic Radiology,Per Unit,$174.28 ,OP,174.28,174.28,,,,,,
BCBS Medicaid,CPT,79445,Nuclear rx intra-arterial,Therapeutic Radiology,Per Unit,$174.28 ,OP,174.28,174.28,,,,,,
BCBS Medicaid,CPT,79999,Nuclear medicine therapy,Therapeutic Radiology,Per Unit,$174.28 ,OP,174.28,174.28,,,,,,
BCBS Medicaid,CPT,80047,Metabolic panel ionized ca,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
BCBS Medicaid,CPT,80048,Metabolic panel total ca,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
BCBS Medicaid,CPT,80050,General health panel,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
BCBS Medicaid,CPT,80051,Electrolyte panel,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
BCBS Medicaid,CPT,80053,Comprehen metabolic panel,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
BCBS Medicaid,CPT,80055,Obstetric panel,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
BCBS Medicaid,CPT,80061,Lipid panel,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
BCBS Medicaid,CPT,80069,Renal function panel,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
BCBS Medicaid,CPT,80074,Acute hepatitis panel,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
BCBS Medicaid,CPT,80076,Hepatic function panel,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
BCBS Medicaid,CPT,80081,Obstetric panel,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
BCBS Medicaid,CPT,80143,Drug assay acetaminophen,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80145,Drug assay adalimumab,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80150,Assay of amikacin,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80151,Drug assay amiodarone,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80155,Drug assay caffeine,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80156,Assay carbamazepine total,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80157,Assay carbamazepine free,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80158,Drug assay cyclosporine,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80159,Drug assay clozapine,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80161,"Asy carbamazepin 10,11-epxid",Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80162,Assay of digoxin total,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80163,Assay of digoxin free,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80164,Assay dipropylacetic acd tot,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80165,Dipropylacetic acid free,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80167,Drug assay felbamate,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80168,Assay of ethosuximide,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80169,Drug assay everolimus,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80170,Assay of gentamicin,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80171,Drug screen quant gabapentin,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80173,Assay of haloperidol,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80175,Drug screen quan lamotrigine,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80176,Assay of lidocaine,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80177,Drug scrn quan levetiracetam,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80178,Assay of lithium,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80179,Drug assay salicylate,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80180,Drug scrn quan mycophenolate,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80181,Drug assay flecainide,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80183,Drug scrn quant oxcarbazepin,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80184,Assay of phenobarbital,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80185,Assay of phenytoin total,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80186,Assay of phenytoin free,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80187,Drug assay posaconazole,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80188,Assay of primidone,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80189,Drug assay itraconzaole,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80190,Assay of procainamide,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80192,Assay of procainamide,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80193,Drug assay leflunomide,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80194,Assay of quinidine,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80195,Assay of sirolimus,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80197,Assay of tacrolimus,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80198,Assay of theophylline,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80199,Drug screen quant tiagabine,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80200,Assay of tobramycin,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80201,Assay of topiramate,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80202,Assay of vancomycin,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80203,Drug screen quant zonisamide,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80204,Drug assay methotrexate,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80210,Drug assay rufinamide,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80230,Drug assay infliximab,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80235,Drug assay lacosamide,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80280,Drug assay vedolizumab,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80285,Drug assay voriconazole,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80299,Quantitative assay drug,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80300,Drug screen non tlc devices,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
BCBS Medicaid,CPT,80301,Drug screen class list a,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
BCBS Medicaid,CPT,80302,Drug screen prsmptv 1 class,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,80303,Drug screen one/mult class,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
BCBS Medicaid,CPT,80304,Drug screen one/mult class,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
BCBS Medicaid,CPT,80305,Drug test prsmv dir opt obs,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,80306,Drug test prsmv instrmnt,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,80307,Drug test prsmv chem anlyzr,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,80320,Drug screen quantalcohols,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,80321,Alcohols biomarkers 1or 2,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,80322,Alcohols biomarkers 3/more,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,80323,Alkaloids nos,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,80324,Drug screen amphetamines 1/2,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,80325,Amphetamines 3or 4,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,80326,Amphetamines 5 or more,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,80327,Anabolic steroid 1 or 2,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,80328,Anabolic steroid 3 or more,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,80329,Analgesics non-opioid 1 or 2,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,80330,Analgesics non-opioid 3-5,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,80331,Analgesics non-opioid 6/more,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,80332,Antidepressants class 1 or 2,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,80333,Antidepressants class 3-5,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,80334,Antidepressants class 6/more,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,80335,Antidepressant tricyclic 1/2,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,80336,Antidepressant tricyclic 3-5,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,80337,Tricyclic & cyclicals 6/more,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,80338,Antidepressant not specified,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,80339,Antiepileptics nos 1-3,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,80340,Antiepileptics nos 4-6,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,80341,Antiepileptics nos 7/more,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,80342,Antipsychotics nos 1-3,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,80343,Antipsychotics nos 4-6,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,80344,Antipsychotics nos 7/more,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,80345,Drug screening barbiturates,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,80346,Benzodiazepines1-12,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,80347,Benzodiazepines 13 or more,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,80348,Drug screening buprenorphine,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,80349,Cannabinoids natural,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,80350,Cannabinoids synthetic 1-3,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,80351,Cannabinoids synthetic 4-6,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,80352,Cannabinoid synthetic 7/more,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,80353,Drug screening cocaine,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,80354,Drug screening fentanyl,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,80355,Gabapentin non-blood,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,80356,Heroin metabolite,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,80357,Ketamine and norketamine,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,80358,Drug screening methadone,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,80359,Methylenedioxyamphetamines,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,80360,Methylphenidate,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,80361,Opiates 1 or more,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,80362,Opioids & opiate analogs 1/2,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,80363,Opioids & opiate analogs 3/4,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,80364,Opioid &opiate analog 5/more,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,80365,Drug screening oxycodone,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,80366,Drug screening pregabalin,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,80367,Drug screening propoxyphene,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,80368,Sedative hypnotics,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,80369,Skeletal muscle relaxant 1/2,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,80370,Skel musc relaxant 3 or more,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,80371,Stimulants synthetic,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,80372,Drug screening tapentadol,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,80373,Drug screening tramadol,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,80374,Stereoisomer analysis,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,80375,Drug/substance nos 1-3,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,80376,Drug/substance nos 4-6,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,80377,Drug/substance nos 7/more,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,80400,Acth stimulation panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
BCBS Medicaid,CPT,80402,Acth stimulation panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
BCBS Medicaid,CPT,80406,Acth stimulation panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
BCBS Medicaid,CPT,80408,Aldosterone suppression eval,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
BCBS Medicaid,CPT,80410,Calcitonin stimul panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
BCBS Medicaid,CPT,80412,Crh stimulation panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
BCBS Medicaid,CPT,80414,Testosterone response panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
BCBS Medicaid,CPT,80415,Tot estradiol response panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
BCBS Medicaid,CPT,80416,Renin stimulation panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
BCBS Medicaid,CPT,80417,Renin stimulation panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
BCBS Medicaid,CPT,80418,Pituitary evaluation panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
BCBS Medicaid,CPT,80420,Dexamethasone panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
BCBS Medicaid,CPT,80422,Glucagon tolerance panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
BCBS Medicaid,CPT,80424,Glucagon tolerance panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
BCBS Medicaid,CPT,80426,Gonadotropin hormone panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
BCBS Medicaid,CPT,80428,Growth hormone panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
BCBS Medicaid,CPT,80430,Growth hormone panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
BCBS Medicaid,CPT,80432,Insulin suppression panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
BCBS Medicaid,CPT,80434,Insulin tolerance panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
BCBS Medicaid,CPT,80435,Insulin tolerance panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
BCBS Medicaid,CPT,80436,Metyrapone panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
BCBS Medicaid,CPT,80438,Trh stimulation panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
BCBS Medicaid,CPT,80439,Trh stimulation panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
BCBS Medicaid,CPT,80500,Lab pathology consultation,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,80502,Lab pathology consultation,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,81000,Urinalysis nonauto w/scope,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
BCBS Medicaid,CPT,81001,Urinalysis auto w/scope,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
BCBS Medicaid,CPT,81002,Urinalysis nonauto w/o scope,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
BCBS Medicaid,CPT,81003,Urinalysis auto w/o scope,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
BCBS Medicaid,CPT,81005,Urinalysis,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
BCBS Medicaid,CPT,81007,Urine screen for bacteria,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
BCBS Medicaid,CPT,81015,Microscopic exam of urine,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
BCBS Medicaid,CPT,81020,Urinalysis glass test,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
BCBS Medicaid,CPT,81025,Urine pregnancy test,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
BCBS Medicaid,CPT,81050,Urinalysis volume measure,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
BCBS Medicaid,CPT,81099,Urinalysis test procedure,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
BCBS Medicaid,CPT,81105,Hpa-1 genotyping,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81106,Hpa-2 genotyping,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81107,Hpa-3 genotyping,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81108,Hpa-4 genotyping,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81109,Hpa-5 genotyping,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81110,Hpa-6 genotyping,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81111,Hpa-9 genotyping,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81112,Hpa-15 genotyping,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81120,Idh1 common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81121,Idh2 common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81161,Dmd dup/delet analysis,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81162,Brca1&2 gen full seq dup/del,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81163,Brca1&2 gene full seq alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81164,Brca1&2 gen ful dup/del alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81165,Brca1 gene full seq alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81166,Brca1 gene full dup/del alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81167,Brca2 gene full dup/del alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81168,Ccnd1/igh translocation alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81170,Abl1 gene,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81171,Aff2 gene detc abnor alleles,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81172,Aff2 gene charac alleles,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81173,Ar gene full gene sequence,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81174,Ar gene known famil variant,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81175,Asxl1 full gene sequence,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81176,Asxl1 gene target seq alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81177,Atn1 gene detc abnor alleles,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81178,Atxn1 gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81179,Atxn2 gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81180,Atxn3 gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81181,Atxn7 gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81182,Atxn8os gen detc abnor allel,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81183,Atxn10 gene detc abnor allel,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81184,Cacna1a gen detc abnor allel,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81185,Cacna1a gene full gene seq,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81186,Cacna1a gen known famil vrnt,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81187,Cnbp gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81188,Cstb gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81189,Cstb gene full gene sequence,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81190,Cstb gene known famil vrnt,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81191,Ntrk1 translocation analysis,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81192,Ntrk2 translocation analysis,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81193,Ntrk3 translocation analysis,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81194,Ntrk translocation analysis,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81200,Aspa gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81201,Apc gene full sequence,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81202,Apc gene known fam variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81203,Apc gene dup/delet variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81204,Ar gene charac alleles,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81205,Bckdhb gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81206,Bcr/abl1 gene major bp,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81207,Bcr/abl1 gene minor bp,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81208,Bcr/abl1 gene other bp,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81209,Blm gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81210,Braf gene,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81211,Brca1&2 seq & com dup/del,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81212,Brca1&2 185&5385&6174 vrnt,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81213,Brca1&2 uncom dup/del var,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81214,Brca1 full seq & com dup/del,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81215,Brca1 gene known famil vrnt,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81216,Brca2 gene full seq alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81217,Brca2 gene known famil vrnt,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81218,Cebpa gene full sequence,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81219,Calr gene com variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81220,Cftr gene com variants,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81221,Cftr gene known fam variants,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81222,Cftr gene dup/delet variants,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81223,Cftr gene full sequence,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81224,Cftr gene intron poly t,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81225,Cyp2c19 gene com variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81226,Cyp2d6 gene com variants,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81227,Cyp2c9 gene com variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81228,Cytogen micrarray copy nmbr,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81229,Cytogen m array copy no&snp,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81230,Cyp3a4 gene common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81231,Cyp3a5 gene common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81232,Dpyd gene common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81233,Btk gene common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81234,Dmpk gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81235,Egfr gene com variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81236,Ezh2 gene full gene sequence,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81237,Ezh2 gene common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81238,F9 full gene sequence,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81239,Dmpk gene charac alleles,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81240,F2 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81241,F5 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81242,Fancc gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81243,Fmr1 gene detection,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81244,Fmr1 gene charac alleles,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81245,Flt3 gene,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81246,Flt3 gene analysis,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81247,G6pd gene alys cmn variant,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81248,G6pd known familial variant,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81249,G6pd full gene sequence,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81250,G6pc gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81251,Gba gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81252,Gjb2 gene full sequence,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81253,Gjb2 gene known fam variants,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81254,Gjb6 gene com variants,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81255,Hexa gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81256,Hfe gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81257,Hba1/hba2 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81258,Hba1/hba2 gene fam vrnt,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81259,Hba1/hba2 full gene sequence,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81260,Ikbkap gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81261,Igh gene rearrange amp meth,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81262,Igh gene rearrang dir probe,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81263,Igh vari regional mutation,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81264,Igk rearrangeabn clonal pop,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81265,Str markers specimen anal,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81266,Str markers spec anal addl,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81267,Chimerism anal no cell selec,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81268,Chimerism anal w/cell select,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81269,Hba1/hba2 gene dup/del vrnts,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81270,Jak2 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81271,Htt gene detc abnor alleles,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81272,Kit gene targeted seq analys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81273,Kit gene analys d816 variant,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81274,Htt gene charac alleles,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81275,Kras gene variants exon 2,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81276,Kras gene addl variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81277,Cytogenomic neo microra alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81278,Igh/bcl2 translocation alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81279,Jak2 gene trgt sequence alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81280,Long qt synd gene full seq,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81281,Long qt synd known fam var,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81282,Long qt syn gene dup/dlt var,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81283,Ifnl3 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81284,Fxn gene detc abnor alleles,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81285,Fxn gene charac alleles,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81286,Fxn gene full gene sequence,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81287,Mgmt gene prmtr mthyltn alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81288,Mlh1 gene,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81289,Fxn gene known famil variant,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81290,Mcoln1 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81291,Mthfr gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81292,Mlh1 gene full seq,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81293,Mlh1 gene known variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81294,Mlh1 gene dup/delete variant,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81295,Msh2 gene full seq,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81296,Msh2 gene known variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81297,Msh2 gene dup/delete variant,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81298,Msh6 gene full seq,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81299,Msh6 gene known variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81300,Msh6 gene dup/delete variant,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81301,Microsatellite instability,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81302,Mecp2 gene full seq,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81303,Mecp2 gene known variant,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81304,Mecp2 gene dup/delet variant,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81305,Myd88 gene p.leu265pro vrnt,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81306,Nudt15 gene common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81307,Palb2 gene full gene seq,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81308,Palb2 gene known famil vrnt,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81309,Pik3ca gene trgt seq alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81310,Npm1 gene,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81311,Nras gene variants exon 2&3,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81312,Pabpn1 gene detc abnor allel,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81313,Pca3/klk3 antigen,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81314,Pdgfra gene,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81315,Pml/raralpha com breakpoints,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81316,Pml/raralpha 1 breakpoint,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81317,Pms2 gene full seq analysis,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81318,Pms2 known familial variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81319,Pms2 gene dup/delet variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81320,Plcg2 gene common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81321,Pten gene full sequence,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81322,Pten gene known fam variant,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81323,Pten gene dup/delet variant,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81324,Pmp22 gene dup/delet,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81325,Pmp22 gene full sequence,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81326,Pmp22 gene known fam variant,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81327,Sept9 gen prmtr mthyltn alys,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81328,Slco1b1 gene com variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81329,Smn1 gene dos/deletion alys,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81330,Smpd1 gene common variants,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81331,Snrpn/ube3a gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81332,Serpina1 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81333,Tgfbi gene common variants,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81334,Runx1 gene targeted seq alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81335,Tpmt gene com variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81336,Smn1 gene full gene sequence,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81337,Smn1 gen nown famil seq vrnt,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81338,Mpl gene common variants,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81339,Mpl gene seq alys exon 10,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81340,Trb@ gene rearrange amplify,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81341,Trb@ gene rearrange dirprobe,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81342,Trg gene rearrangement anal,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81343,Ppp2r2b gen detc abnor allel,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81344,Tbp gene detc abnor alleles,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81345,Tert gene targeted seq alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81346,Tyms gene com variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81347,Sf3b1 gene common variants,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81348,Srsf2 gene common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81350,Ugt1a1 gene common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81351,Tp53 gene full gene sequence,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81352,Tp53 gene trgt sequence alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81353,Tp53 gene known famil vrnt,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81355,Vkorc1 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81357,U2af1 gene common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81360,Zrsr2 gene common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81361,Hbb gene com variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81362,Hbb gene known fam variant,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81363,Hbb gene dup/del variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81364,Hbb full gene sequence,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81370,Hla i & ii typing lr,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81371,Hla i & ii type verify lr,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81372,Hla i typing complete lr,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81373,Hla i typing 1 locus lr,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81374,Hla i typing 1 antigen lr,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81375,Hla ii typing ag equiv lr,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81376,Hla ii typing 1 locus lr,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81377,Hla ii type 1 ag equiv lr,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81378,Hla i & ii typing hr,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81379,Hla i typing complete hr,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81380,Hla i typing 1 locus hr,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81381,Hla i typing 1 allele hr,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81382,Hla ii typing 1 loc hr,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81383,Hla ii typing 1 allele hr,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81400,Mopath procedure level 1,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81401,Mopath procedure level 2,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81402,Mopath procedure level 3,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81403,Mopath procedure level 4,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81404,Mopath procedure level 5,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81405,Mopath procedure level 6,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81406,Mopath procedure level 7,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81407,Mopath procedure level 8,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81408,Mopath procedure level 9,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81410,Aortic dysfunction/dilation,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81411,Aortic dysfunction/dilation,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81412,Ashkenazi jewish assoc dis,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81413,Car ion chnnlpath inc 10 gns,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81414,Car ion chnnlpath inc 2 gns,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81415,Exome sequence analysis,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81416,Exome sequence analysis,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81417,Exome re-evaluation,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81419,Epilepsy gen seq alys panel,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81420,Fetal chrmoml aneuploidy,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81422,Fetal chrmoml microdeltj,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81425,Genome sequence analysis,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81426,Genome sequence analysis,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81427,Genome re-evaluation,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81430,Hearing loss sequence analys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81431,Hearing loss dup/del analys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81432,Hrdtry brst ca-rlatd dsordrs,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81433,Hrdtry brst ca-rlatd dsordrs,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81434,Hereditary retinal disorders,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81435,Hereditary colon ca dsordrs,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81436,Hereditary colon ca dsordrs,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81437,Heredtry nurondcrn tum dsrdr,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81438,Heredtry nurondcrn tum dsrdr,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81439,Hrdtry cardmypy gene panel,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81440,Mitochondrial gene,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81442,Noonan spectrum disorders,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81443,Genetic tstg severe inh cond,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81445,Targeted genomic seq analys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81448,Hrdtry perph neurphy panel,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81450,Targeted genomic seq analys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81455,Targeted genomic seq analys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81460,Whole mitochondrial genome,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81465,Whole mitochondrial genome,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81470,X-linked intellectual dblt,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81471,X-linked intellectual dblt,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81479,Unlisted molecular pathology,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81490,Autoimmune rheumatoid arthr,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81493,Cor artery disease mrna,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81500,Onco (ovar) two proteins,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81503,Onco (ovar) five proteins,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81504,Oncology tissue of origin,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81506,Endo assay seven anal,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81507,Fetal aneuploidy trisom risk,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81508,Ftl cgen abnor two proteins,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81509,Ftl cgen abnor 3 proteins,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81510,Ftl cgen abnor three anal,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81511,Ftl cgen abnor four anal,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81512,Ftl cgen abnor five anal,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81513,Nfct ds bv rna vag flu alg,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81514,Nfct ds bv&vaginitis dna alg,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81518,Onc brst mrna 11 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81519,Oncology breast mrna,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81520,Onc breast mrna 58 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81521,Onc breast mrna 70 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81522,Onc breast mrna 12 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81525,Oncology colon mrna,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81528,Oncology colorectal scr,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81529,Onc cutan mlnma mrna 31 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81535,Oncology gynecologic,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81536,Oncology gynecologic,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81538,Oncology lung,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81539,Oncology prostate prob score,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81540,Oncology tum unknown origin,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81541,Onc prostate mrna 46 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81542,Onc prostate mrna 22 cnt gen,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81545,Oncology thyroid,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81546,"Onc thyr mrna 10,196 gen alg",Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81551,Onc prostate 3 genes,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81552,Onc uveal mlnma mrna 15 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81554,Pulm ds ipf mrna 190 gen alg,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,81595,Cardiology hrt trnspl mrna,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,81596,Nfct ds chrnc hcv 6 assays,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,81599,Unlisted maaa,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,82009,Test for acetone/ketones,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,82010,Acetone assay,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82013,Acetylcholinesterase assay,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82016,Acylcarnitines qual,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82017,Acylcarnitines quant,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82024,Assay of acth,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
BCBS Medicaid,CPT,82030,Assay of adp & amp,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,82040,Assay of serum albumin,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,82042,Other source albumin quan ea,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,82043,Ur albumin quantitative,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
BCBS Medicaid,CPT,82044,Ur albumin semiquantitative,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
BCBS Medicaid,CPT,82045,Albumin ischemia modified,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,82075,Assay of breath ethanol,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82077,Assay spec xcp ur&breath ia,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82085,Assay of aldolase,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82088,Assay of aldosterone,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
BCBS Medicaid,CPT,82103,Alpha-1-antitrypsin total,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82104,Alpha-1-antitrypsin pheno,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82105,Alpha-fetoprotein serum,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82106,Alpha-fetoprotein amniotic,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82107,Alpha-fetoprotein l3,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,82108,Assay of aluminum,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
BCBS Medicaid,CPT,82120,Amines vaginal fluid qual,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,82127,Amino acid single qual,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82128,Amino acids mult qual,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82131,Amino acids single quant,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82135,Assay aminolevulinic acid,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82136,Amino acids quant 2-5,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82139,Amino acids quan 6 or more,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82140,Assay of ammonia,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82143,Amniotic fluid scan,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,82150,Assay of amylase,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,82154,Androstanediol glucuronide,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,82157,Assay of androstenedione,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,82160,Assay of androsterone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,82163,Assay of angiotensin ii,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,82164,Angiotensin i enzyme test,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82172,Assay of apolipoprotein,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82175,Assay of arsenic,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
BCBS Medicaid,CPT,82180,Assay of ascorbic acid,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82190,Atomic absorption,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82232,Assay of beta-2 protein,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,82239,Bile acids total,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82240,Bile acids cholylglycine,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82247,Bilirubin total,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,82248,Bilirubin direct,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,82252,Fecal bilirubin test,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,82261,Assay of biotinidase,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82270,Occult blood feces,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,82271,Occult blood other sources,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,82272,Occult bld feces 1-3 tests,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,82274,Assay test for blood fecal,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82286,Assay of bradykinin,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,82300,Assay of cadmium,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
BCBS Medicaid,CPT,82306,Vitamin d 25 hydroxy,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,82308,Assay of calcitonin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,82310,Assay of calcium,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,82330,Assay of calcium,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82331,Calcium infusion test,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82340,Assay of calcium in urine,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,82355,Calculus analysis qual,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82360,Calculus assay quant,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82365,Calculus spectroscopy,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82370,X-ray assay calculus,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82373,Assay c-d transfer measure,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82374,Assay blood carbon dioxide,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,82375,Assay carboxyhb quant,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82376,Assay carboxyhb qual,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82378,Carcinoembryonic antigen,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82379,Assay of carnitine,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82380,Assay of carotene,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82382,Assay urine catecholamines,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,82383,Assay blood catecholamines,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,82384,Assay three catecholamines,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,82387,Assay of cathepsin-d,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82390,Assay of ceruloplasmin,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82397,Chemiluminescent assay,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82415,Assay of chloramphenicol,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,82435,Assay of blood chloride,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,82436,Assay of urine chloride,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,82438,Assay other fluid chlorides,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,82441,Test for chlorohydrocarbons,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
BCBS Medicaid,CPT,82465,Assay bld/serum cholesterol,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,82480,Assay serum cholinesterase,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,82482,Assay rbc cholinesterase,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,82485,Assay chondroitin sulfate,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,82486,Gas/liquid chromatography,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,82487,Paper chromatography,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,82488,Paper chromatography,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,82489,Thin layer chromatography,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,82491,Chromotography quant sing,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82492,Chromotography quant mult,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,82495,Assay of chromium,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
BCBS Medicaid,CPT,82507,Assay of citrate,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82523,Collagen crosslinks,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82525,Assay of copper,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
BCBS Medicaid,CPT,82528,Assay of corticosterone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,82530,Cortisol free,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82533,Total cortisol,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,82540,Assay of creatine,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,82541,Column chromotography qual,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,82542,Col chromotography qual/quan,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82543,Column chromotograph/isotope,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,82544,Column chromotograph/isotope,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,82550,Assay of ck (cpk),Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,82552,Assay of cpk in blood,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82553,Creatine mb fraction,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82554,Creatine isoforms,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82565,Assay of creatinine,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,82570,Assay of urine creatinine,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,82575,Creatinine clearance test,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82585,Assay of cryofibrinogen,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82595,Assay of cryoglobulin,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,82600,Assay of cyanide,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
BCBS Medicaid,CPT,82607,Vitamin b-12,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,82608,B-12 binding capacity,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82610,Cystatin c,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82615,Test for urine cystines,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82626,Dehydroepiandrosterone,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82627,Dehydroepiandrosterone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,82633,Desoxycorticosterone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,82634,Deoxycortisol,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,82638,Assay of dibucaine number,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82642,Dihydrotestosterone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,82652,Vit d 1 25-dihydroxy,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,82656,Pancreatic elastase fecal,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82657,Enzyme cell activity,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82658,Enzyme cell activity ra,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,82664,Electrophoretic test,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,82668,Assay of erythropoietin,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82670,Assay of total estradiol,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,82671,Assay of estrogens,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,82672,Assay of estrogen,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,82677,Assay of estriol,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,82679,Assay of estrone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,82681,Assay dir meas fr estradiol,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,82693,Assay of ethylene glycol,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
BCBS Medicaid,CPT,82696,Assay of etiocholanolone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,82705,Fats/lipids feces qual,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,82710,Fats/lipids feces quant,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82715,Assay of fecal fat,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82725,Assay of blood fatty acids,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82726,Long chain fatty acids,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82728,Assay of ferritin,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82731,Assay of fetal fibronectin,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,82735,Assay of fluoride,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
BCBS Medicaid,CPT,82746,Assay of folic acid serum,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82747,Assay of folic acid rbc,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
BCBS Medicaid,CPT,82757,Assay of semen fructose,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82759,Assay of rbc galactokinase,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82760,Assay of galactose,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82775,Assay galactose transferase,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82776,Galactose transferase test,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82777,Galectin-3,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,82784,Assay iga/igd/igg/igm each,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82785,Assay of ige,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82787,Igg 1 2 3 or 4 each,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82800,Blood ph,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82803,Blood gases any combination,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82805,Blood gases w/o2 saturation,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,82810,Blood gases o2 sat only,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82820,Hemoglobin-oxygen affinity,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
BCBS Medicaid,CPT,82930,Gastric analy w/ph ea spec,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,82938,Gastrin test,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,82941,Assay of gastrin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,82943,Assay of glucagon,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,82945,Glucose other fluid,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,82946,Glucagon tolerance test,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82947,Assay glucose blood quant,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,82948,Reagent strip/blood glucose,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,82950,Glucose test,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,82951,Glucose tolerance test (gtt),Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82952,Gtt-added samples,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,82955,Assay of g6pd enzyme,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82960,Test for g6pd enzyme,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,82962,Glucose blood test,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,82963,Assay of glucosidase,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82965,Assay of gdh enzyme,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82977,Assay of ggt,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,82978,Assay of glutathione,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82979,Assay rbc glutathione,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,82985,Assay of glycated protein,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,83001,Assay of gonadotropin (fsh),Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,83002,Assay of gonadotropin (lh),Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,83003,Assay growth hormone (hgh),Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,83006,Growth stimulation gene 2,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
BCBS Medicaid,CPT,83009,H pylori (c-13) blood,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,83010,Assay of haptoglobin quant,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,83012,Assay of haptoglobins,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,83013,H pylori (c-13) breath,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,83014,H pylori drug admin,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,83015,Heavy metal qual any anal,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
BCBS Medicaid,CPT,83018,Heavy metal quant each nes,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
BCBS Medicaid,CPT,83020,Hemoglobin electrophoresis,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,83021,Hemoglobin chromotography,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
BCBS Medicaid,CPT,83026,Hemoglobin copper sulfate,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
BCBS Medicaid,CPT,83030,Fetal hemoglobin chemical,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,83033,Fetal hemoglobin assay qual,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,83036,Glycosylated hemoglobin test,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,83037,Glycosylated hb home device,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,83045,Blood methemoglobin test,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,83050,Blood methemoglobin assay,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,83051,Assay of plasma hemoglobin,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,83060,Blood sulfhemoglobin assay,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,83065,Assay of hemoglobin heat,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,83068,Hemoglobin stability screen,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,83069,Assay of urine hemoglobin,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,83070,Assay of hemosiderin qual,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,83080,Assay of b hexosaminidase,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,83088,Assay of histamine,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,83090,Assay of homocystine,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,83150,Assay of homovanillic acid,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,83491,Assay of corticosteroids 17,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,83497,Assay of 5-hiaa,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,83498,Assay of progesterone 17-d,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,83499,Assay of progesterone 20-,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
BCBS Medicaid,CPT,83500,Assay free hydroxyproline,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,83505,Assay total hydroxyproline,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,83516,Immunoassay nonantibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,83518,Immunoassay dipstick,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,83519,Ria nonantibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,83520,Immunoassay quant nos nonab,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,83525,Assay of insulin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,83527,Assay of insulin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,83528,Assay of intrinsic factor,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,83540,Assay of iron,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,83550,Iron binding test,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,83570,Assay of idh enzyme,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,83582,Assay of ketogenic steroids,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,83586,Assay 17- ketosteroids,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,83593,Fractionation ketosteroids,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,83605,Assay of lactic acid,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,83615,Lactate (ld) (ldh) enzyme,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,83625,Assay of ldh enzymes,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,83630,Lactoferrin fecal (qual),Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,83631,Lactoferrin fecal (quant),Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,83632,Placental lactogen,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,83633,Test urine for lactose,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,83655,Assay of lead,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
BCBS Medicaid,CPT,83661,L/s ratio fetal lung,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,83662,Foam stability fetal lung,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,83663,Fluoro polarize fetal lung,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,83664,Lamellar bdy fetal lung,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,83670,Assay of lap enzyme,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,83690,Assay of lipase,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,83695,Assay of lipoprotein(a),Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,83698,Assay lipoprotein pla2,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,83700,Lipopro bld electrophoretic,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,83701,Lipoprotein bld hr fraction,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,83704,Lipoprotein bld quan part,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,83718,Assay of lipoprotein,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,83719,Assay of blood lipoprotein,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,83721,Assay of blood lipoprotein,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,83722,Lipoprtn dir meas sd ldl chl,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,83727,Assay of lrh hormone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,83735,Assay of magnesium,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,83775,Assay malate dehydrogenase,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,83785,Assay of manganese,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
BCBS Medicaid,CPT,83788,Mass spectrometry qual,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,83789,Mass spectrometry qual/quan,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,83825,Assay of mercury,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
BCBS Medicaid,CPT,83835,Assay of metanephrines,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,83857,Assay of methemalbumin,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,83861,Microfluid analy tears,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,83864,Mucopolysaccharides,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,83872,Assay synovial fluid mucin,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,83873,Assay of csf protein,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,83874,Assay of myoglobin,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,83876,Assay myeloperoxidase,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,83880,Assay of natriuretic peptide,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,83883,Assay nephelometry not spec,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,83885,Assay of nickel,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
BCBS Medicaid,CPT,83915,Assay of nucleotidase,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,83916,Oligoclonal bands,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,83918,Organic acids total quant,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
BCBS Medicaid,CPT,83919,Organic acids qual each,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,83921,Organic acid single quant,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,83930,Assay of blood osmolality,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,83935,Assay of urine osmolality,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,83937,Assay of osteocalcin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,83945,Assay of oxalate,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,83950,Oncoprotein her-2/neu,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,83951,Oncoprotein dcp,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,83970,Assay of parathormone,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
BCBS Medicaid,CPT,83986,Assay ph body fluid nos,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,83987,Exhaled breath condensate,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,83992,Assay for phencyclidine,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
BCBS Medicaid,CPT,83993,Assay for calprotectin fecal,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,84030,Assay of blood pku,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,84035,Assay of phenylketones,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,84060,Assay acid phosphatase,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,84061,Phosphatase forensic exam,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,84066,Assay prostate phosphatase,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,84075,Assay alkaline phosphatase,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,84078,Assay alkaline phosphatase,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,84080,Assay alkaline phosphatases,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,84081,Assay phosphatidylglycerol,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,84085,Assay of rbc pg6d enzyme,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,84087,Assay phosphohexose enzymes,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,84100,Assay of phosphorus,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,84105,Assay of urine phosphorus,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,84106,Test for porphobilinogen,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,84110,Assay of porphobilinogen,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,84112,Eval amniotic fluid protein,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,84119,Test urine for porphyrins,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,84120,Assay of urine porphyrins,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,84126,Assay of feces porphyrins,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,84132,Assay of serum potassium,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,84133,Assay of urine potassium,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,84134,Assay of prealbumin,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,84135,Assay of pregnanediol,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,84138,Assay of pregnanetriol,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,84140,Assay of pregnenolone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,84143,Assay of 17-hydroxypregneno,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,84144,Assay of progesterone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,84145,Procalcitonin (pct),Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,84146,Assay of prolactin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,84150,Assay of prostaglandin,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
BCBS Medicaid,CPT,84152,Assay of psa complexed,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,84153,Assay of psa total,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,84154,Assay of psa free,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,84155,Assay of protein serum,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,84156,Assay of protein urine,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,84157,Assay of protein other,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,84160,Assay of protein any source,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,84163,Pappa serum,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,84165,Protein e-phoresis serum,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,84166,Protein e-phoresis/urine/csf,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,84181,Western blot test,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,84182,Protein western blot test,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,84202,Assay rbc protoporphyrin,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,84203,Test rbc protoporphyrin,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,84206,Assay of proinsulin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,84207,Assay of vitamin b-6,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,84210,Assay of pyruvate,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,84220,Assay of pyruvate kinase,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,84228,Assay of quinine,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,84233,Assay of estrogen,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
BCBS Medicaid,CPT,84234,Assay of progesterone,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
BCBS Medicaid,CPT,84235,Assay of endocrine hormone,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
BCBS Medicaid,CPT,84238,Assay nonendocrine receptor,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,84244,Assay of renin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,84252,Assay of vitamin b-2,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,84255,Assay of selenium,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,84260,Assay of serotonin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,84270,Assay of sex hormone globul,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,84275,Assay of sialic acid,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,84285,Assay of silica,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
BCBS Medicaid,CPT,84295,Assay of serum sodium,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,84300,Assay of urine sodium,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,84302,Assay of sweat sodium,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,84305,Assay of somatomedin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,84307,Assay of somatostatin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,84311,Spectrophotometry,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,84315,Body fluid specific gravity,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,84375,Chromatogram assay sugars,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,84376,Sugars single qual,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,84377,Sugars multiple qual,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,84378,Sugars single quant,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,84379,Sugars multiple quant,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,84392,Assay of urine sulfate,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
BCBS Medicaid,CPT,84402,Assay of free testosterone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,84403,Assay of total testosterone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,84410,Testosterone bioavailable,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
BCBS Medicaid,CPT,84425,Assay of vitamin b-1,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,84430,Assay of thiocyanate,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
BCBS Medicaid,CPT,84431,Thromboxane urine,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,84432,Assay of thyroglobulin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,84436,Assay of total thyroxine,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,84437,Assay of neonatal thyroxine,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,84439,Assay of free thyroxine,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,84442,Assay of thyroid activity,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,84443,Assay thyroid stim hormone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,84445,Assay of tsi globulin,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
BCBS Medicaid,CPT,84446,Assay of vitamin e,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,84449,Assay of transcortin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,84450,Transferase (ast) (sgot),Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,84460,Alanine amino (alt) (sgpt),Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,84466,Assay of transferrin,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,84478,Assay of triglycerides,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,84479,Assay of thyroid (t3 or t4),Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,84480,Assay triiodothyronine (t3),Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,84481,Free assay (ft-3),Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,84482,T3 reverse,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,84484,Assay of troponin quant,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,84485,Assay duodenal fluid trypsin,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,84488,Test feces for trypsin,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,84490,Assay of feces for trypsin,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,84510,Assay of tyrosine,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,84512,Assay of troponin qual,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,84520,Assay of urea nitrogen,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,84525,Urea nitrogen semi-quant,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,84540,Assay of urine/urea-n,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,84545,Urea-n clearance test,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,84550,Assay of blood/uric acid,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,84560,Assay of urine/uric acid,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,84577,Assay of feces/urobilinogen,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,84578,Test urine urobilinogen,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,84580,Assay of urine urobilinogen,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,84583,Assay of urine urobilinogen,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,84585,Assay of urine vma,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,84586,Assay of vip,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
BCBS Medicaid,CPT,84588,Assay of vasopressin,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
BCBS Medicaid,CPT,84590,Assay of vitamin a,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,84591,Assay of nos vitamin,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,84597,Assay of vitamin k,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,84600,Assay of volatiles,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,84620,Xylose tolerance test,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,84630,Assay of zinc,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
BCBS Medicaid,CPT,84681,Assay of c-peptide,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,84702,Chorionic gonadotropin test,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,84703,Chorionic gonadotropin assay,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,84704,Hcg free betachain test,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,84830,Ovulation tests,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,84999,Clinical chemistry test,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,85002,Bleeding time test,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
BCBS Medicaid,CPT,85004,Automated diff wbc count,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
BCBS Medicaid,CPT,85007,Bl smear w/diff wbc count,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
BCBS Medicaid,CPT,85008,Bl smear w/o diff wbc count,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
BCBS Medicaid,CPT,85009,Manual diff wbc count b-coat,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
BCBS Medicaid,CPT,85013,Spun microhematocrit,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
BCBS Medicaid,CPT,85014,Hematocrit,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
BCBS Medicaid,CPT,85018,Hemoglobin,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
BCBS Medicaid,CPT,85025,Complete cbc w/auto diff wbc,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
BCBS Medicaid,CPT,85027,Complete cbc automated,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
BCBS Medicaid,CPT,85032,Manual cell count each,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
BCBS Medicaid,CPT,85041,Automated rbc count,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
BCBS Medicaid,CPT,85044,Manual reticulocyte count,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
BCBS Medicaid,CPT,85045,Automated reticulocyte count,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
BCBS Medicaid,CPT,85046,Reticyte/hgb concentrate,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
BCBS Medicaid,CPT,85048,Automated leukocyte count,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
BCBS Medicaid,CPT,85049,Automated platelet count,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
BCBS Medicaid,CPT,85055,Reticulated platelet assay,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
BCBS Medicaid,CPT,85060,Blood smear interpretation,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,85097,Bone marrow interpretation,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,85130,Chromogenic substrate assay,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
BCBS Medicaid,CPT,85170,Blood clot retraction,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
BCBS Medicaid,CPT,85175,Blood clot lysis time,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
BCBS Medicaid,CPT,85210,Clot factor ii prothrom spec,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
BCBS Medicaid,CPT,85220,Blooc clot factor v test,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
BCBS Medicaid,CPT,85230,Clot factor vii proconvertin,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
BCBS Medicaid,CPT,85240,Clot factor viii ahg 1 stage,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
BCBS Medicaid,CPT,85244,Clot factor viii reltd antgn,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
BCBS Medicaid,CPT,85245,Clot factor viii vw ristoctn,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
BCBS Medicaid,CPT,85246,Clot factor viii vw antigen,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
BCBS Medicaid,CPT,85247,Clot factor viii multimetric,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
BCBS Medicaid,CPT,85250,Clot factor ix ptc/chrstmas,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
BCBS Medicaid,CPT,85260,Clot factor x stuart-power,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
BCBS Medicaid,CPT,85270,Clot factor xi pta,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
BCBS Medicaid,CPT,85280,Clot factor xii hageman,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
BCBS Medicaid,CPT,85290,Clot factor xiii fibrin stab,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
BCBS Medicaid,CPT,85291,Clot factor xiii fibrin scrn,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
BCBS Medicaid,CPT,85292,Clot factor fletcher fact,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
BCBS Medicaid,CPT,85293,Clot factor wght kininogen,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
BCBS Medicaid,CPT,85300,Antithrombin iii activity,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
BCBS Medicaid,CPT,85301,Antithrombin iii antigen,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
BCBS Medicaid,CPT,85302,Clot inhibit prot c antigen,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
BCBS Medicaid,CPT,85303,Clot inhibit prot c activity,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
BCBS Medicaid,CPT,85305,Clot inhibit prot s total,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
BCBS Medicaid,CPT,85306,Clot inhibit prot s free,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
BCBS Medicaid,CPT,85307,Assay activated protein c,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,85335,Factor inhibitor test,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
BCBS Medicaid,CPT,85337,Thrombomodulin,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
BCBS Medicaid,CPT,85345,Coagulation time lee & white,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
BCBS Medicaid,CPT,85347,Coagulation time activated,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
BCBS Medicaid,CPT,85348,Coagulation time otr method,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
BCBS Medicaid,CPT,85360,Euglobulin lysis,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
BCBS Medicaid,CPT,85362,Fibrin degradation products,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
BCBS Medicaid,CPT,85366,Fibrinogen test,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
BCBS Medicaid,CPT,85370,Fibrinogen test,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
BCBS Medicaid,CPT,85378,Fibrin degrade semiquant,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
BCBS Medicaid,CPT,85379,Fibrin degradation quant,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
BCBS Medicaid,CPT,85380,Fibrin degradj d-dimer,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
BCBS Medicaid,CPT,85384,Fibrinogen activity,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
BCBS Medicaid,CPT,85385,Fibrinogen antigen,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
BCBS Medicaid,CPT,85390,Fibrinolysins screen i&r,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
BCBS Medicaid,CPT,85396,Clotting assay whole blood,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
BCBS Medicaid,CPT,85397,Clotting funct activity,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
BCBS Medicaid,CPT,85400,Fibrinolytic plasmin,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
BCBS Medicaid,CPT,85410,Fibrinolytic antiplasmin,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
BCBS Medicaid,CPT,85415,Fibrinolytic plasminogen,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
BCBS Medicaid,CPT,85420,Fibrinolytic plasminogen,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
BCBS Medicaid,CPT,85421,Fibrinolytic plasminogen,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
BCBS Medicaid,CPT,85441,Heinz bodies direct,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
BCBS Medicaid,CPT,85445,Heinz bodies induced,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
BCBS Medicaid,CPT,85460,Hemoglobin fetal,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
BCBS Medicaid,CPT,85461,Hemoglobin fetal,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
BCBS Medicaid,CPT,85475,Hemolysin acid,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
BCBS Medicaid,CPT,85520,Heparin assay,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
BCBS Medicaid,CPT,85525,Heparin neutralization,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
BCBS Medicaid,CPT,85530,Heparin-protamine tolerance,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
BCBS Medicaid,CPT,85536,Iron stain peripheral blood,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
BCBS Medicaid,CPT,85540,Wbc alkaline phosphatase,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
BCBS Medicaid,CPT,85547,Rbc mechanical fragility,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
BCBS Medicaid,CPT,85549,Muramidase,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,85555,Rbc osmotic fragility,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
BCBS Medicaid,CPT,85557,Rbc osmotic fragility,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
BCBS Medicaid,CPT,85576,Blood platelet aggregation,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
BCBS Medicaid,CPT,85597,Phospholipid pltlt neutraliz,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
BCBS Medicaid,CPT,85598,Hexagnal phosph pltlt neutrl,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
BCBS Medicaid,CPT,85610,Prothrombin time,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
BCBS Medicaid,CPT,85611,Prothrombin test,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
BCBS Medicaid,CPT,85612,Viper venom prothrombin time,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
BCBS Medicaid,CPT,85613,Russell viper venom diluted,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
BCBS Medicaid,CPT,85635,Reptilase test,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
BCBS Medicaid,CPT,85651,Rbc sed rate nonautomated,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
BCBS Medicaid,CPT,85652,Rbc sed rate automated,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
BCBS Medicaid,CPT,85660,Rbc sickle cell test,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
BCBS Medicaid,CPT,85670,Thrombin time plasma,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
BCBS Medicaid,CPT,85675,Thrombin time titer,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
BCBS Medicaid,CPT,85705,Thromboplastin inhibition,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
BCBS Medicaid,CPT,85730,Thromboplastin time partial,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
BCBS Medicaid,CPT,85732,Thromboplastin time partial,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
BCBS Medicaid,CPT,85810,Blood viscosity examination,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
BCBS Medicaid,CPT,85999,Hematology procedure,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
BCBS Medicaid,CPT,86000,Agglutinins febrile antigen,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86001,Allergen specific igg,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86003,Allg spec ige crude xtrc ea,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86005,Allg spec ige multiallg scr,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86008,Allg spec ige recomb ea,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86021,Wbc antibody identification,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86022,Platelet antibodies,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86023,Immunoglobulin assay,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86038,Antinuclear antibodies,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86039,Antinuclear antibodies (ana),Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86060,Antistreptolysin o titer,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86063,Antistreptolysin o screen,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86140,C-reactive protein,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86141,C-reactive protein hs,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86146,Beta-2 glycoprotein antibody,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,86147,Cardiolipin antibody ea ig,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
BCBS Medicaid,CPT,86148,Anti-phospholipid antibody,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,86152,Cell enumeration & id,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
BCBS Medicaid,CPT,86153,Cell enumeration phys interp,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86155,Chemotaxis assay,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86156,Cold agglutinin screen,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86157,Cold agglutinin titer,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86160,Complement antigen,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86161,Complement/function activity,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86162,Complement total (ch50),Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86171,Complement fixation each,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86185,Counterimmunoelectrophoresis,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86200,Ccp antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86215,Deoxyribonuclease antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86225,Dna antibody native,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86226,Dna antibody single strand,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86235,Nuclear antigen antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86243,Fc receptor,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
BCBS Medicaid,CPT,86255,Fluorescent antibody screen,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86256,Fluorescent antibody titer,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86277,Growth hormone antibody,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,86280,Hemagglutination inhibition,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86294,Immunoassay tumor qual,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,86300,Immunoassay tumor ca 15-3,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,86301,Immunoassay tumor ca 19-9,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,86304,Immunoassay tumor ca 125,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,86305,Human epididymis protein 4,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,86308,Heterophile antibody screen,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86309,Heterophile antibody titer,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86310,Heterophile antibody absrbj,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86316,Immunoassay tumor other,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,86317,Immunoassay infectious agent,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86318,Ia infectious agent antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86320,Serum immunoelectrophoresis,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,86325,Other immunoelectrophoresis,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,86327,Immunoelectrophoresis assay,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,86328,Ia nfct ab sarscov2 covid19,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86329,Immunodiffusion nes,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86331,Immunodiffusion ouchterlony,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86332,Immune complex assay,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
BCBS Medicaid,CPT,86334,Immunofix e-phoresis serum,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86335,Immunfix e-phorsis/urine/csf,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
BCBS Medicaid,CPT,86336,Inhibin a,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,86337,Insulin antibodies,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,86340,Intrinsic factor antibody,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,86341,Islet cell antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86343,Leukocyte histamine release,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86344,Leukocyte phagocytosis,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86352,Cell function assay w/stim,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
BCBS Medicaid,CPT,86353,Lymphocyte transformation,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
BCBS Medicaid,CPT,86355,B cells total count,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
BCBS Medicaid,CPT,86356,Mononuclear cell antigen,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
BCBS Medicaid,CPT,86357,Nk cells total count,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
BCBS Medicaid,CPT,86359,T cells total count,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
BCBS Medicaid,CPT,86360,T cell absolute count/ratio,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
BCBS Medicaid,CPT,86361,T cell absolute count,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
BCBS Medicaid,CPT,86367,Stem cells total count,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
BCBS Medicaid,CPT,86376,Microsomal antibody each,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,86378,Migration inhibitory factor,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
BCBS Medicaid,CPT,86382,Neutralization test viral,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86384,Nitroblue tetrazolium dye,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86386,Nuclear matrix protein 22,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86403,Particle agglut antbdy scrn,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86406,Particle agglut antbdy titr,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86408,Neutrlzg antb sarscov2 scr,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86409,Neutrlzg antb sarscov2 titer,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86413,Sars-cov-2 antb quantitative,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86430,Rheumatoid factor test qual,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86431,Rheumatoid factor quant,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86480,Tb test cell immun measure,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
BCBS Medicaid,CPT,86481,Tb ag response t-cell susp,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
BCBS Medicaid,CPT,86485,Skin test candida,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
BCBS Medicaid,CPT,86486,Skin test nos antigen,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86490,Coccidioidomycosis skin test,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
BCBS Medicaid,CPT,86510,Histoplasmosis skin test,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
BCBS Medicaid,CPT,86580,Tb intradermal test,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86590,Streptokinase antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86592,Syphilis test non-trep qual,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86593,Syphilis test non-trep quant,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86602,Antinomyces antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86603,Adenovirus antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86606,Aspergillus antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86609,Bacterium antibody,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,86611,Bartonella antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86612,Blastomyces antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86615,Bordetella antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86617,Lyme disease antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86618,Lyme disease antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86619,Borrelia antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86622,Brucella antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86625,Campylobacter antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86628,Candida antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86631,Chlamydia antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86632,Chlamydia igm antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86635,Coccidioides antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86638,Q fever antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86641,Cryptococcus antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86644,Cmv antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86645,Cmv antibody igm,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86648,Diphtheria antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86651,Encephalitis californ antbdy,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86652,Encephaltis east eqne anbdy,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86653,Encephaltis st louis antbody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86654,Encephaltis west eqne antbdy,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86658,Enterovirus antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86663,Epstein-barr antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86664,Epstein-barr nuclear antigen,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86665,Epstein-barr capsid vca,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86666,Ehrlichia antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86668,Francisella tularensis,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86671,Fungus nes antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86674,Giardia lamblia antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86677,Helicobacter pylori antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86682,Helminth antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86684,Hemophilus influenza antibdy,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86687,Htlv-i antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86688,Htlv-ii antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86689,Htlv/hiv confirmj antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86692,Hepatitis delta agent antbdy,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86694,Herpes simplex nes antbdy,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86695,Herpes simplex type 1 test,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86696,Herpes simplex type 2 test,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86698,Histoplasma antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86701,Hiv-1antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86702,Hiv-2 antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86703,Hiv-1/hiv-2 1 result antbdy,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86704,Hep b core antibody total,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86705,Hep b core antibody igm,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86706,Hep b surface antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86707,Hepatitis be antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86708,Hepatitis a antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86709,Hepatitis a igm antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86710,Influenza virus antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86711,John cunningham antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86713,Legionella antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86717,Leishmania antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86720,Leptospira antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86723,Listeria monocytogenes,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86727,Lymph choriomeningitis ab,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86729,Lympho venereum antibody,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
BCBS Medicaid,CPT,86732,Mucormycosis antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86735,Mumps antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86738,Mycoplasma antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86741,Neisseria meningitidis,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86744,Nocardia antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86747,Parvovirus antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86750,Malaria antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86753,Protozoa antibody nos,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86756,Respiratory virus antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86757,Rickettsia antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86759,Rotavirus antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86762,Rubella antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86765,Rubeola antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86768,Salmonella antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86769,Sars-cov-2 covid-19 antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86771,Shigella antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86774,Tetanus antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86777,Toxoplasma antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86778,Toxoplasma antibody igm,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86780,Treponema pallidum,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86784,Trichinella antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86787,Varicella-zoster antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86788,West nile virus ab igm,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86789,West nile virus antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86790,Virus antibody nos,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86793,Yersinia antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86794,Zika virus igm antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86800,Thyroglobulin antibody,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
BCBS Medicaid,CPT,86803,Hepatitis c ab test,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86804,Hep c ab test confirm,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,86805,Lymphocytotoxicity assay,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
BCBS Medicaid,CPT,86806,Lymphocytotoxicity assay,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
BCBS Medicaid,CPT,86807,Cytotoxic antibody screening,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
BCBS Medicaid,CPT,86808,Cytotoxic antibody screening,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
BCBS Medicaid,CPT,86812,Hla typing a b or c,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
BCBS Medicaid,CPT,86813,Hla typing a b or c,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
BCBS Medicaid,CPT,86816,Hla typing dr/dq,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
BCBS Medicaid,CPT,86817,Hla typing dr/dq,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
BCBS Medicaid,CPT,86821,Lymphocyte culture mixed,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
BCBS Medicaid,CPT,86822,Lymphocyte culture primed,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
BCBS Medicaid,CPT,86825,Hla x-math non-cytotoxic,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
BCBS Medicaid,CPT,86826,Hla x-match noncytotoxc addl,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
BCBS Medicaid,CPT,86828,Hla class i&ii antibody qual,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
BCBS Medicaid,CPT,86829,Hla class i/ii antibody qual,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
BCBS Medicaid,CPT,86830,Hla class i phenotype qual,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
BCBS Medicaid,CPT,86831,Hla class ii phenotype qual,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
BCBS Medicaid,CPT,86832,Hla class i high defin qual,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
BCBS Medicaid,CPT,86833,Hla class ii high defin qual,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
BCBS Medicaid,CPT,86834,Hla class i semiquant panel,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
BCBS Medicaid,CPT,86835,Hla class ii semiquant panel,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
BCBS Medicaid,CPT,86849,Immunology procedure,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86850,Rbc antibody screen,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
BCBS Medicaid,CPT,86860,Rbc antibody elution,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
BCBS Medicaid,CPT,86870,Rbc antibody identification,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
BCBS Medicaid,CPT,86880,Coombs test direct,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
BCBS Medicaid,CPT,86885,Coombs test indirect qual,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
BCBS Medicaid,CPT,86886,Coombs test indirect titer,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
BCBS Medicaid,CPT,86900,Blood typing serologic abo,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
BCBS Medicaid,CPT,86901,Blood typing serologic rh(d),Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
BCBS Medicaid,CPT,86902,Blood type antigen donor ea,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
BCBS Medicaid,CPT,86904,Blood typing patient serum,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
BCBS Medicaid,CPT,86905,Blood typing rbc antigens,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
BCBS Medicaid,CPT,86906,Bld typing serologic rh phnt,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
BCBS Medicaid,CPT,86910,Blood typing paternity test,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
BCBS Medicaid,CPT,86911,Blood typing antigen system,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
BCBS Medicaid,CPT,86920,Compatibility test spin,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
BCBS Medicaid,CPT,86921,Compatibility test incubate,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
BCBS Medicaid,CPT,86922,Compatibility test antiglob,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
BCBS Medicaid,CPT,86923,Compatibility test electric,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
BCBS Medicaid,CPT,86940,Hemolysins/agglutinins auto,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86941,Hemolysins/agglutinins,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,86999,Transfusion procedure,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
BCBS Medicaid,CPT,87003,Small animal inoculation,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87015,Specimen infect agnt concntj,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87040,Blood culture for bacteria,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87045,Feces culture aerobic bact,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87046,Stool cultr aerobic bact ea,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87070,Culture othr specimn aerobic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87071,Culture aerobic quant other,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87073,Culture bacteria anaerobic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87075,Cultr bacteria except blood,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87076,Culture anaerobe ident each,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87077,Culture aerobic identify,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87081,Culture screen only,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87084,Culture of specimen by kit,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87086,Urine culture/colony count,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87088,Urine bacteria culture,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87101,Skin fungi culture,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87102,Fungus isolation culture,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87103,Blood fungus culture,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87106,Fungi identification yeast,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87107,Fungi identification mold,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87109,Mycoplasma,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87110,Chlamydia culture,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87116,Mycobacteria culture,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87118,Mycobacteric identification,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87140,Culture type immunofluoresc,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87143,Culture typing glc/hplc,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87147,Culture type immunologic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87149,Dna/rna direct probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87150,Dna/rna amplified probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87152,Culture type pulse field gel,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87158,Culture typing added method,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87164,Dark field examination,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87166,Dark field examination,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87168,Macroscopic exam arthropod,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87169,Macroscopic exam parasite,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87172,Pinworm exam,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87176,Tissue homogenization cultr,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87177,Ova and parasites smears,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87181,Microbe susceptible diffuse,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87184,Microbe susceptible disk,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87185,Microbe susceptible enzyme,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87186,Microbe susceptible mic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87187,Microbe susceptible mlc,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87188,Microbe suscept macrobroth,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87190,Microbe suscept mycobacteri,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87197,Bactericidal level serum,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87205,Smear gram stain,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87206,Smear fluorescent/acid stai,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87207,Smear special stain,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87209,Smear complex stain,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87210,Smear wet mount saline/ink,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87220,Tissue exam for fungi,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87230,Assay toxin or antitoxin,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87250,Virus inoculate eggs/animal,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87252,Virus inoculation tissue,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87253,Virus inoculate tissue addl,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87254,Virus inoculation shell via,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87255,Genet virus isolate hsv,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87260,Adenovirus ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87265,Pertussis ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87267,Enterovirus antibody dfa,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87269,Giardia ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87270,Chlamydia trachomatis ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87271,Cytomegalovirus dfa,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87272,Cryptosporidium ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87273,Herpes simplex 2 ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87274,Herpes simplex 1 ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87275,Influenza b ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87276,Influenza a ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87277,Legionella micdadei ag if,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,87278,Legion pneumophilia ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87279,Parainfluenza ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87280,Respiratory syncytial ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87281,Pneumocystis carinii ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87283,Rubeola ag if,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87285,Treponema pallidum ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87290,Varicella zoster ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87299,Antibody detection nos if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87300,Ag detection polyval if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87301,Adenovirus ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87305,Aspergillus ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87320,Chylmd trach ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87324,Clostridium ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87327,Cryptococcus neoform ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87328,Cryptosporidium ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87329,Giardia ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87332,Cytomegalovirus ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87335,E coli 0157 ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87336,Entamoeb hist dispr ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87337,Entamoeb hist group ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87338,Hpylori stool ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87339,H pylori ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87340,Hepatitis b surface ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87341,Hepatitis b surface ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87350,Hepatitis be ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87380,Hepatitis delta agent ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87385,Histoplasma capsul ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87389,Hiv-1 ag w/hiv-1&2 ab ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87390,Hiv-1 ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87391,Hiv-2 ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87400,Influenza a/b each ag ia,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,87420,Resp syncytial virus ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87425,Rotavirus ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87426,Sarscov coronavirus ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87427,Shiga-like toxin ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87428,Sarscov & inf vir a&b ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87430,Strep a ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87449,Nos each organism ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87450,Ag detect nos ia single,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87451,Polyvalent mult org ea ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87470,Bartonella dna dir probe,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,87471,Bartonella dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87472,Bartonella dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87475,Lyme dis dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87476,Lyme dis dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87477,Lyme dis dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87480,Candida dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87481,Candida dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87482,Candida dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87485,Chylmd pneum dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87486,Chylmd pneum dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87487,Chylmd pneum dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87490,Chylmd trach dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87491,Chylmd trach dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87492,Chylmd trach dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87493,C diff amplified probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87495,Cytomeg dna dir probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87496,Cytomeg dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87497,Cytomeg dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87498,Enterovirus probe&revrs trns,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87500,Vanomycin dna amp probe,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
BCBS Medicaid,CPT,87501,Influenza dna amp prob 1+,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87502,Influenza dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87503,Influenza dna amp prob addl,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
BCBS Medicaid,CPT,87510,Gardner vag dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87511,Gardner vag dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87512,Gardner vag dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87515,Hepatitis b dna dir probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87516,Hepatitis b dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87517,Hepatitis b dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87520,Hepatitis c rna dir probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87521,Hepatitis c probe&rvrs trnsc,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87522,Hepatitis c revrs trnscrpj,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87525,Hepatitis g dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87526,Hepatitis g dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87527,Hepatitis g dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87528,Hsv dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87529,Hsv dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87530,Hsv dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87531,Hhv-6 dna dir probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87532,Hhv-6 dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87533,Hhv-6 dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87534,Hiv-1 dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87535,Hiv-1 probe&reverse trnscrpj,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87536,Hiv-1 quant&revrse trnscrpj,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87537,Hiv-2 dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87538,Hiv-2 probe&revrse trnscripj,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87539,Hiv-2 quant&revrse trnscripj,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87540,Legion pneumo dna dir prob,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87541,Legion pneumo dna amp prob,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87542,Legion pneumo dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87550,Mycobacteria dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87551,Mycobacteria dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87552,Mycobacteria dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87555,M.tuberculo dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87556,M.tuberculo dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87557,M.tuberculo dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87560,M.avium-intra dna dir prob,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87561,M.avium-intra dna amp prob,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87562,M.avium-intra dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87563,M. genitalium amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87580,M.pneumon dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87581,M.pneumon dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87590,N.gonorrhoeae dna dir prob,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87591,N.gonorrhoeae dna amp prob,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87592,N.gonorrhoeae dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87623,Hpv low-risk types,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87624,Hpv high-risk types,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87625,Hpv types 16 & 18 only,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87634,Rsv dna/rna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87635,Sars-cov-2 covid-19 amp prb,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87636,Sarscov2 & inf a&b amp prb,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87637,Sarscov2&inf a&b&rsv amp prb,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87640,Staph a dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87641,Mr-staph dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87650,Strep a dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87651,Strep a dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87652,Strep a dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87653,Strep b dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87660,Trichomonas vagin dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87661,Trichomonas vaginalis amplif,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87662,Zika virus dna/rna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87797,Detect agent nos dna dir,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87798,Detect agent nos dna amp,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87799,Detect agent nos dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87800,Detect agnt mult dna direc,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87801,Detect agnt mult dna ampli,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87802,Strep b assay w/optic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87803,Clostridium toxin a w/optic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87804,Influenza assay w/optic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87806,Hiv w/hiv1&2 antb w/optic,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87807,Rsv assay w/optic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87808,Trichomonas assay w/optic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87809,Adenovirus assay w/optic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87810,Chylmd trach assay w/optic,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87811,Sars-cov-2 covid19 w/optic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87850,N. gonorrhoeae assay w/optic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87880,Strep a assay w/optic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87899,Agent nos assay w/optic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87904,Phenotype dna hiv w/clt add,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,87905,Sialidase enzyme assay,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,87999,Microbiology procedure,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,88104,Cytopath fl nongyn smears,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,88106,Cytopath fl nongyn filter,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,88108,Cytopath concentrate tech,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,88112,Cytopath cell enhance tech,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,88120,Cytp urne 3-5 probes ea spec,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,88125,Forensic cytopathology,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,88130,Sex chromatin identification,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,88140,Sex chromatin identification,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,88141,Cytopath c/v interpret,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
BCBS Medicaid,CPT,88142,Cytopath c/v thin layer,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
BCBS Medicaid,CPT,88143,Cytopath c/v thin layer redo,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
BCBS Medicaid,CPT,88147,Cytopath c/v automated,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
BCBS Medicaid,CPT,88148,Cytopath c/v auto rescreen,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
BCBS Medicaid,CPT,88150,Cytopath c/v manual,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
BCBS Medicaid,CPT,88152,Cytopath c/v auto redo,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
BCBS Medicaid,CPT,88153,Cytopath c/v redo,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
BCBS Medicaid,CPT,88154,Cytopath c/v select,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
BCBS Medicaid,CPT,88155,Cytopath c/v index add-on,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
BCBS Medicaid,CPT,88160,Cytopath smear other source,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,88161,Cytopath smear other source,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,88162,Cytopath smear other source,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,88164,Cytopath tbs c/v manual,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
BCBS Medicaid,CPT,88165,Cytopath tbs c/v redo,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
BCBS Medicaid,CPT,88166,Cytopath tbs c/v auto redo,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
BCBS Medicaid,CPT,88167,Cytopath tbs c/v select,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
BCBS Medicaid,CPT,88172,Cytp dx eval fna 1st ea site,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,88173,Cytopath eval fna report,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,88174,Cytopath c/v auto in fluid,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
BCBS Medicaid,CPT,88175,Cytopath c/v auto fluid redo,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
BCBS Medicaid,CPT,88177,Cytp fna eval ea addl,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,88182,Cell marker study,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,88184,Flowcytometry/ tc 1 marker,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,88187,Flowcytometry/read 2-8,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,88188,Flowcytometry/read 9-15,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,88189,Flowcytometry/read 16 & >,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,88199,Cytopathology procedure,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,88240,Cell cryopreserve/storage,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,88241,Frozen cell preparation,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,88245,Chromosome analysis 20-25,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,88248,Chromosome analysis 50-100,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,88249,Chromosome analysis 100,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,88261,Chromosome analysis 5,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,88262,Chromosome analysis 15-20,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,88263,Chromosome analysis 45,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,88264,Chromosome analysis 20-25,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,88267,Chromosome analys placenta,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,88269,Chromosome analys amniotic,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,88271,Cytogenetics dna probe,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,88272,Cytogenetics 3-5,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,88273,Cytogenetics 10-30,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,88274,Cytogenetics 25-99,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,88275,Cytogenetics 100-300,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,88280,Chromosome karyotype study,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,88283,Chromosome banding study,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,88285,Chromosome count additional,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,88289,Chromosome study additional,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,88291,Cyto/molecular report,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,88299,Cytogenetic study,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,88300,Surgical path gross,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,88302,Tissue exam by pathologist,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,88304,Tissue exam by pathologist,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,88305,Tissue exam by pathologist,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,88311,Decalcify tissue,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,88312,Special stains group 1,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,88313,Special stains group 2,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,88314,Histochemical stains add-on,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,88321,Microslide consultation,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,88323,Microslide consultation,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,88325,Comprehensive review of data,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,88329,Path consult introp,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,88331,Path consult intraop 1 bloc,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,88332,Path consult intraop addl,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,88333,Intraop cyto path consult 1,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,88334,Intraop cyto path consult 2,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,88342,Immunohisto antb 1st stain,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,88346,Immunofluor antb 1st stain,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,88347,Immunofluorescent study,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,88355,Analysis skeletal muscle,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,88356,Analysis nerve,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,88358,Analysis tumor,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,88363,Xm archive tissue molec anal,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,88364,Insitu hybridization (fish),Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,88369,M/phmtrc alysishquant/semiq,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,88371,Protein western blot tissue,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,88372,Protein analysis w/probe,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,88373,M/phmtrc alys ishquant/semiq,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,88374,M/phmtrc alys ishquant/semiq,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,88375,Optical endomicroscpy interp,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,88377,M/phmtrc alys ishquant/semiq,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,88380,Microdissection laser,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,88381,Microdissection manual,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,88387,Tiss exam molecular study,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,88388,Tiss ex molecul study add-on,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,88399,Surgical pathology procedure,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,88720,Bilirubin total transcut,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,88738,Hgb quant transcutaneous,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
BCBS Medicaid,CPT,88740,Transcutaneous carboxyhb,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
BCBS Medicaid,CPT,88741,Transcutaneous methb,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
BCBS Medicaid,CPT,88749,In vivo lab service,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,89050,Body fluid cell count,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,89051,Body fluid cell count,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,89055,Leukocyte assessment fecal,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
BCBS Medicaid,CPT,89060,Exam synovial fluid crystals,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,89125,Specimen fat stain,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,89160,Exam feces for meat fibers,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,89190,Nasal smear for eosinophils,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,89220,Sputum specimen collection,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,89230,Collect sweat for test,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,89240,Pathology lab procedure,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,89250,Cultr oocyte/embryo <4 days,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,89253,Embryo hatching,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,89254,Oocyte identification,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,89255,Prepare embryo for transfer,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,89257,Sperm identification,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,89260,Sperm isolation simple,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,89261,Sperm isolation complex,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,89264,Identify sperm tissue,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,89281,Assist oocyte fertilization,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,89290,Biopsy oocyte polar body,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,89291,Biopsy oocyte polar body,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,89300,Semen analysis w/huhner,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,89310,Semen analysis w/count,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,89320,Semen anal vol/count/mot,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,89321,Semen anal sperm detection,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,89322,Semen anal strict criteria,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,89325,Sperm antibody test,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,89329,Sperm evaluation test,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,89330,Evaluation cervical mucus,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,89331,Retrograde ejaculation anal,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,89335,Cryopreserve testicular tiss,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,89353,Thawing cryopresrved sperm,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,89398,Unlisted reprod med lab proc,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,90287,Botulinum antitoxin,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,90288,Botulism ig iv,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,90291,Cmv ig iv,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,90371,Hep b ig im,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
BCBS Medicaid,CPT,90375,Rabies ig im/sc,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
BCBS Medicaid,CPT,90376,Rabies ig heat treated,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
BCBS Medicaid,CPT,90377,Rabies ig ht&sol human im/sc,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
BCBS Medicaid,CPT,90378,Rsv mab im 50mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
BCBS Medicaid,CPT,90384,Rh ig full-dose im,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,90386,Rh ig iv,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
BCBS Medicaid,CPT,90389,Tetanus ig im,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,90393,Vaccina ig im,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,90396,Varicella-zoster ig im,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,90460,Im admin 1st/only component,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,90461,Im admin each addl component,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,90471,Immunization admin,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,90472,Immunization admin each add,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,90473,Immune admin oral/nasal,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,90474,Immune admin oral/nasal addl,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,90476,Adenovirus vaccine type 4,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90477,Adenovirus vaccine type 7,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90581,Anthrax vaccine sc or im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
BCBS Medicaid,CPT,90585,Bcg vaccine percut,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90586,Bcg vaccine intravesical,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
BCBS Medicaid,CPT,90587,Dengue vacc quad 3 dose subq,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
BCBS Medicaid,CPT,90619,Menacwy-tt vaccine im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
BCBS Medicaid,CPT,90620,Menb-4c vacc 2 dose im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
BCBS Medicaid,CPT,90621,Menb-fhbp vacc 2/3 dose im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
BCBS Medicaid,CPT,90625,Cholera vaccine live oral,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90630,Flu vacc iiv4 no preserv id,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90632,Hepa vaccine adult im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90633,Hepa vacc ped/adol 2 dose im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90634,Hepa vacc ped/adol 3 dose,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90636,Hep a/hep b vacc adult im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
BCBS Medicaid,CPT,90644,Hib-mency vacc 6wk-18m0 im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
BCBS Medicaid,CPT,90645,Hib vaccine hboc im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
BCBS Medicaid,CPT,90646,Hib vaccine prp-d im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
BCBS Medicaid,CPT,90647,Hib prp-omp vacc 3 dose im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90648,Hib prp-t vaccine 4 dose im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90649,4vhpv vaccine 3 dose im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
BCBS Medicaid,CPT,90650,2vhpv vaccine 3 dose im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90651,9vhpv vaccine 2/3 dose im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
BCBS Medicaid,CPT,90653,Iiv adjuvant vaccine im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90654,Flu vacc iiv3 no preserv id,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90655,Iiv3 vacc no prsv 0.25 ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90656,Iiv3 vacc no prsv 0.5 ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90657,Iiv3 vaccine splt 0.25 ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90658,Iiv3 vaccine splt 0.5 ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90660,Laiv3 vaccine intranasal,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90661,Cciiv3 vac no prsv 0.5 ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90662,Iiv no prsv increased ag im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90664,Laiv vacc pandemic intranasl,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90666,Flu vac pandem prsrv free im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90667,Iiv vacc pandemic adjuvt im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90668,Iiv vaccine pandemic im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90669,Pneumococcal vacc 7 val im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
BCBS Medicaid,CPT,90670,Pcv13 vaccine im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
BCBS Medicaid,CPT,90672,Laiv4 vaccine intranasal,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90673,Riv3 vaccine no preserv im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90674,Cciiv4 vac no prsv 0.5 ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90675,Rabies vaccine im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
BCBS Medicaid,CPT,90676,Rabies vaccine id,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
BCBS Medicaid,CPT,90680,Rv5 vacc 3 dose live oral,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
BCBS Medicaid,CPT,90681,Rv1 vacc 2 dose live oral,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90682,Riv4 vacc recombinant dna im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90685,Iiv4 vacc no prsv 0.25 ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90686,Iiv4 vacc no prsv 0.5 ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90687,Iiv4 vaccine splt 0.25 ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90688,Iiv4 vaccine splt 0.5 ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90689,Vacc iiv4 no prsrv 0.25ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90690,Typhoid vaccine oral,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90691,Typhoid vaccine im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90692,Typhoid vaccine h-p sc/id,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90693,Typhoid vaccine akd sc,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90694,Vacc aiiv4 no prsrv 0.5ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90696,Dtap-ipv vaccine 4-6 yrs im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90697,Dtap-ipv-hib-hepb vaccine im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90698,Dtap-ipv/hib vaccine im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90700,Dtap vaccine < 7 yrs im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90702,Dt vaccine under 7 yrs im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90703,Tetanus vaccine im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90704,Mumps vaccine sc,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90705,Measles vaccine sc,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90706,Rubella vaccine sc,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90707,Mmr vaccine sc,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90708,Measles-rubella vaccine sc,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90710,Mmrv vaccine sc,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90712,Oral poliovirus vaccine,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
BCBS Medicaid,CPT,90713,Poliovirus ipv sc/im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90714,Td vacc no presv 7 yrs+ im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90715,Tdap vaccine 7 yrs/> im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90716,Var vaccine live subq,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
BCBS Medicaid,CPT,90717,Yellow fever vaccine subq,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
BCBS Medicaid,CPT,90719,Diphtheria vaccine im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90720,Dtp/hib vaccine im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
BCBS Medicaid,CPT,90721,Dtap/hib vaccine im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
BCBS Medicaid,CPT,90723,Dtap-hep b-ipv vaccine im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90725,Cholera vaccine injectable,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90727,Plague vaccine im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
BCBS Medicaid,CPT,90732,Ppsv23 vacc 2 yrs+ subq/im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90733,Mpsv4 vaccine subq,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
BCBS Medicaid,CPT,90734,Menacwyd/menacwycrm vacc im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
BCBS Medicaid,CPT,90735,Encephalitis vaccine sc,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
BCBS Medicaid,CPT,90736,Hzv vaccine live subq,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
BCBS Medicaid,CPT,90738,Inactivated je vacc im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
BCBS Medicaid,CPT,90739,Hepb vacc 2 dose adult im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90740,Hepb vacc 3 dose immunsup im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
BCBS Medicaid,CPT,90743,Hepb vacc 2 dose adolesc im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90744,Hepb vacc 3 dose ped/adol im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90746,Hepb vaccine 3 dose adult im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90747,Hepb vacc 4 dose immunsup im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
BCBS Medicaid,CPT,90748,Hib-hepb vaccine im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90749,Vaccine toxoid,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90750,Hzv vacc recombinant im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
BCBS Medicaid,CPT,90756,Cciiv4 vacc abx free im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,90785,Psytx complex interactive,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
BCBS Medicaid,CPT,90791,Psych diagnostic evaluation,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
BCBS Medicaid,CPT,90792,Psych diag eval w/med srvcs,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
BCBS Medicaid,CPT,90832,Psytx w pt 30 minutes,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
BCBS Medicaid,CPT,90833,Psytx w pt w e/m 30 min,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
BCBS Medicaid,CPT,90834,Psytx w pt 45 minutes,Behavioral Health,Per Unit,$84.55 ,OP,84.55,84.55,,,,,,
BCBS Medicaid,CPT,90836,Psytx w pt w e/m 45 min,Behavioral Health,Per Unit,$84.55 ,OP,84.55,84.55,,,,,,
BCBS Medicaid,CPT,90837,Psytx w pt 60 minutes,Behavioral Health,Per Unit,$84.55 ,OP,84.55,84.55,,,,,,
BCBS Medicaid,CPT,90838,Psytx w pt w e/m 60 min,Behavioral Health,Per Unit,$84.55 ,OP,84.55,84.55,,,,,,
BCBS Medicaid,CPT,90839,Psytx crisis initial 60 min,Behavioral Health,Per Unit,$84.55 ,OP,84.55,84.55,,,,,,
BCBS Medicaid,CPT,90840,Psytx crisis ea addl 30 min,Behavioral Health,Per Unit,$84.55 ,OP,84.55,84.55,,,,,,
BCBS Medicaid,CPT,90845,Psychoanalysis,Behavioral Health,Per Unit,$84.55 ,OP,84.55,84.55,,,,,,
BCBS Medicaid,CPT,90846,Family psytx w/o pt 50 min,Behavioral Health,Per Unit,$89.14 ,OP,89.14,89.14,,,,,,
BCBS Medicaid,CPT,90847,Family psytx w/pt 50 min,Behavioral Health,Per Unit,$89.14 ,OP,89.14,89.14,,,,,,
BCBS Medicaid,CPT,90849,Multiple family group psytx,Behavioral Health,Per Unit,$119.88 ,OP,119.88,119.88,,,,,,
BCBS Medicaid,CPT,90853,Group psychotherapy,Behavioral Health,Per Unit,$119.88 ,OP,119.88,119.88,,,,,,
BCBS Medicaid,CPT,90863,Pharmacologic mgmt w/psytx,Behavioral Health,Per Unit,$80.13 ,OP,80.13,80.13,,,,,,
BCBS Medicaid,CPT,90865,Narcosynthesis,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
BCBS Medicaid,CPT,90867,Tcranial magn stim tx plan,Behavioral Health,Per Unit,$276.44 ,OP,276.44,276.44,,,,,,
BCBS Medicaid,CPT,90868,Tcranial magn stim tx deli,Behavioral Health,Per Unit,$276.44 ,OP,276.44,276.44,,,,,,
BCBS Medicaid,CPT,90869,Tcran magn stim redetemine,Behavioral Health,Per Unit,$276.44 ,OP,276.44,276.44,,,,,,
BCBS Medicaid,CPT,90870,Electroconvulsive therapy,Behavioral Health,Per Unit,$276.44 ,OP,276.44,276.44,,,,,,
BCBS Medicaid,CPT,90875,Psychophysiological therapy,Ancillary Services,Per Unit,$123.52 ,OP,123.52,123.52,,,,,,
BCBS Medicaid,CPT,90876,Psychophysiological therapy,Ancillary Services,Per Unit,$123.52 ,OP,123.52,123.52,,,,,,
BCBS Medicaid,CPT,90880,Hypnotherapy,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
BCBS Medicaid,CPT,90882,Environmental manipulation,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
BCBS Medicaid,CPT,90885,Psy evaluation of records,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
BCBS Medicaid,CPT,90887,Consultation with family,Behavioral Health,Per Unit,$89.14 ,OP,89.14,89.14,,,,,,
BCBS Medicaid,CPT,90889,Preparation of report,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
BCBS Medicaid,CPT,90899,Psychiatric service/therapy,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
BCBS Medicaid,CPT,90901,Biofeedback train any meth,Ancillary Services,Per Unit,$123.52 ,OP,123.52,123.52,,,,,,
BCBS Medicaid,CPT,90911,Biofeedback peri/uro/rectal,Ancillary Services,Per Unit,$123.52 ,OP,123.52,123.52,,,,,,
BCBS Medicaid,CPT,90912,Bfb training 1st 15 min,Ancillary Services,Per Unit,$123.52 ,OP,123.52,123.52,,,,,,
BCBS Medicaid,CPT,90913,Bfb training ea addl 15 min,Ancillary Services,Per Unit,$123.52 ,OP,123.52,123.52,,,,,,
BCBS Medicaid,CPT,90935,Hemodialysis one evaluation,Nephrology,Per Unit,$540.95 ,OP,540.95,540.95,,,,,,
BCBS Medicaid,CPT,90937,Hemodialysis repeated eval,Nephrology,Per Unit,$540.95 ,OP,540.95,540.95,,,,,,
BCBS Medicaid,CPT,90940,Hemodialysis access study,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
BCBS Medicaid,CPT,90945,Dialysis one evaluation,Nephrology,Per Unit,$540.95 ,OP,540.95,540.95,,,,,,
BCBS Medicaid,CPT,90947,Dialysis repeated eval,Nephrology,Per Unit,$540.95 ,OP,540.95,540.95,,,,,,
BCBS Medicaid,CPT,90989,Dialysis training complete,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
BCBS Medicaid,CPT,90993,Dialysis training incompl,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
BCBS Medicaid,CPT,90997,Hemoperfusion,Nephrology,Per Unit,$540.95 ,OP,540.95,540.95,,,,,,
BCBS Medicaid,CPT,90999,Dialysis procedure,Nephrology,Per Unit,$540.95 ,OP,540.95,540.95,,,,,,
BCBS Medicaid,CPT,91010,Esophagus motility study,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
BCBS Medicaid,CPT,91013,Esophgl motil w/stim/perfus,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
BCBS Medicaid,CPT,91020,Gastric motility studies,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
BCBS Medicaid,CPT,91022,Duodenal motility study,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
BCBS Medicaid,CPT,91030,Acid perfusion of esophagus,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
BCBS Medicaid,CPT,91034,Gastroesophageal reflux test,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
BCBS Medicaid,CPT,91035,G-esoph reflx tst w/electrod,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
BCBS Medicaid,CPT,91037,Esoph imped function test,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
BCBS Medicaid,CPT,91038,Esoph imped funct test > 1hr,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
BCBS Medicaid,CPT,91040,Esoph balloon distension tst,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
BCBS Medicaid,CPT,91110,Gi tract capsule endoscopy,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
BCBS Medicaid,CPT,91111,Esophageal capsule endoscopy,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
BCBS Medicaid,CPT,91112,Gi wireless capsule measure,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
BCBS Medicaid,CPT,91117,Colon motility 6 hr study,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
BCBS Medicaid,CPT,91120,Rectal sensation test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,91122,Anal pressure record,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,91132,Electrogastrography,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,91133,Electrogastrography w/test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,91200,Liver elastography,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,91299,Gastroenterology procedure,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
BCBS Medicaid,CPT,91300,Sarscov2 vac 30mcg/0.3ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,91301,Sarscov2 vac 100mcg/0.5ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,91302,Coronavirus vaccine 3,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,91303,Coronavirus vaccine 4,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,91304,Coronavirus vaccine 5,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,91305,Coronavirus vaccine 6,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,91306,Coronavirus vaccine 7,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,91307,Coronavirus vaccine 8,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,91308,Coronavirus vaccine 9,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,91309,Coronavirus vaccine 10,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,91310,Coronavirus vaccine 11,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,92015,Determine refractive state,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92018,New eye exam & treatment,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
BCBS Medicaid,CPT,92019,Eye exam & treatment,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
BCBS Medicaid,CPT,92020,Special eye evaluation,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92025,Corneal topography,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92060,Special eye evaluation,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92065,Orthoptic/pleoptic training,Ancillary Services,Per Unit,$123.52 ,OP,123.52,123.52,,,,,,
BCBS Medicaid,CPT,92071,Contact lens fitting for tx,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92072,Fit contac lens for managmnt,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92081,Visual field examination(s),Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92082,Visual field examination(s),Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92083,Visual field examination(s),Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92100,Serial tonometry exam(s),Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92132,Cmptr ophth dx img ant segmt,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92133,Cmptr ophth img optic nerve,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92134,Cptr ophth dx img post segmt,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92136,Ophthalmic biometry,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92140,Glaucoma provocative tests,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92145,Corneal hysteresis deter,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92201,Opscpy extnd rta draw uni/bi,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92202,Opscpy extnd on/mac draw,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92225,Special eye exam initial,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92226,Special eye exam subsequent,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92227,Img rta detcj/mntr ds staff,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92228,Img rta detc/mntr ds phy/qhp,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
BCBS Medicaid,CPT,92229,Img rta detc/mntr ds poc aly,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92230,Eye exam with photos,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
BCBS Medicaid,CPT,92235,Fluorescein angrph uni/bi,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
BCBS Medicaid,CPT,92240,Icg angiography uni/bi,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
BCBS Medicaid,CPT,92242,Fluorescein icg angiography,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
BCBS Medicaid,CPT,92250,Eye exam with photos,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92260,Ophthalmoscopy/dynamometry,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92265,Eye muscle evaluation,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92270,Electro-oculography,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
BCBS Medicaid,CPT,92273,Full field erg w/i&r,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
BCBS Medicaid,CPT,92274,Multifocal erg w/i&r,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
BCBS Medicaid,CPT,92275,Electroretinography,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
BCBS Medicaid,CPT,92283,Color vision examination,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92284,Dark adaptation eye exam,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92285,Eye photography,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92286,Internal eye photography,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92287,Internal eye photography,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92310,Contact lens fitting,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92311,Contact lens fitting,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92312,Contact lens fitting,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92313,Contact lens fitting,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92314,Prescription of contact lens,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92315,Rx cntact lens aphakia 1 eye,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92316,Rx cntact lens aphakia 2 eye,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92317,Rx corneoscleral cntact lens,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92325,Modification of contact lens,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92326,Replacement of contact lens,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92340,Fit spectacles monofocal,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92341,Fit spectacles bifocal,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92342,Fit spectacles multifocal,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92352,Fit aphakia spectcl monofocl,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92353,Fit aphakia spectcl multifoc,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92354,Fit spectacles single system,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92355,Fit spectacles compound lens,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92358,Aphakia prosth service temp,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92370,Repair & adjust spectacles,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92371,Repair & adjust spectacles,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92499,Eye service or procedure,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,92507,Speech/hearing therapy,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
BCBS Medicaid,CPT,92516,Facial nerve function test,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
BCBS Medicaid,CPT,92517,Vemp test i&r cervical,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
BCBS Medicaid,CPT,92518,Vemp test i&r ocular,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
BCBS Medicaid,CPT,92519,Vemp tst i&r cervical&ocular,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
BCBS Medicaid,CPT,92520,Laryngeal function studies,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
BCBS Medicaid,CPT,92521,Evaluation of speech fluency,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
BCBS Medicaid,CPT,92522,Evaluate speech production,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
BCBS Medicaid,CPT,92523,Speech sound lang comprehen,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
BCBS Medicaid,CPT,92524,Behavral qualit analys voice,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
BCBS Medicaid,CPT,92534,Optokinetic nystagmus test,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
BCBS Medicaid,CPT,92537,Caloric vstblr test w/rec,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
BCBS Medicaid,CPT,92538,Caloric vstblr test w/rec,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
BCBS Medicaid,CPT,92540,Basic vestibular evaluation,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
BCBS Medicaid,CPT,92543,Caloric vestibular test,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
BCBS Medicaid,CPT,92546,Sinusoidal rotational test,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
BCBS Medicaid,CPT,92547,Supplemental electrical test,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
BCBS Medicaid,CPT,92548,Cdp-sot 6 cond w/i&r,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
BCBS Medicaid,CPT,92549,Cdp-sot 6 cond w/i&r mct&adt,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
BCBS Medicaid,CPT,92550,Tympanometry & reflex thresh,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
BCBS Medicaid,CPT,92553,Audiometry air & bone,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
BCBS Medicaid,CPT,92557,Comprehensive hearing test,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
BCBS Medicaid,CPT,92558,Evoked auditory test qual,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
BCBS Medicaid,CPT,92570,Acoustic immitance testing,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
BCBS Medicaid,CPT,92572,Staggered spondaic word test,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
BCBS Medicaid,CPT,92577,Stenger test speech,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
BCBS Medicaid,CPT,92579,Visual audiometry (vra),Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
BCBS Medicaid,CPT,92582,Conditioning play audiometry,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
BCBS Medicaid,CPT,92584,Electrocochleography,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
BCBS Medicaid,CPT,92585,Auditor evoke potent compre,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
BCBS Medicaid,CPT,92586,Auditor evoke potent limit,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
BCBS Medicaid,CPT,92587,Evoked auditory test limited,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
BCBS Medicaid,CPT,92588,Evoked auditory tst complete,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
BCBS Medicaid,CPT,92597,Oral speech device eval,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
BCBS Medicaid,CPT,92601,Cochlear implt f/up exam <7,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,92602,Reprogram cochlear implt <7,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,92603,Cochlear implt f/up exam 7/>,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,92604,Reprogram cochlear implt 7/>,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,92605,Ex for nonspeech device rx,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
BCBS Medicaid,CPT,92606,Non-speech device service,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,92607,Ex for speech device rx 1hr,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
BCBS Medicaid,CPT,92608,Ex for speech device rx addl,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
BCBS Medicaid,CPT,92610,Evaluate swallowing function,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
BCBS Medicaid,CPT,92618,Ex for nonspeech dev rx add,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
BCBS Medicaid,CPT,92620,Auditory function 60 min,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
BCBS Medicaid,CPT,92621,Auditory function + 15 min,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
BCBS Medicaid,CPT,92625,Tinnitus assessment,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
BCBS Medicaid,CPT,92626,Eval aud funcj 1st hour,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
BCBS Medicaid,CPT,92627,Eval aud funcj ea addl 15,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
BCBS Medicaid,CPT,92630,Aud rehab pre-ling hear loss,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,92633,Aud rehab postling hear loss,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,92651,Aep hearing status deter i&r,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
BCBS Medicaid,CPT,92652,Aep thrshld est mlt freq i&r,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
BCBS Medicaid,CPT,92653,Aep neurodiagnostic i&r,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
BCBS Medicaid,CPT,92920,Prq cardiac angioplast 1 art,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
BCBS Medicaid,CPT,92921,Prq cardiac angio addl art,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
BCBS Medicaid,CPT,92924,Prq card angio/athrect 1 art,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
BCBS Medicaid,CPT,92925,Prq card angio/athrect addl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
BCBS Medicaid,CPT,92928,Prq card stent w/angio 1 vsl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
BCBS Medicaid,CPT,92929,Prq card stent w/angio addl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
BCBS Medicaid,CPT,92933,Prq card stent/ath/angio,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
BCBS Medicaid,CPT,92934,Prq card stent/ath/angio,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
BCBS Medicaid,CPT,92937,Prq revasc byp graft 1 vsl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
BCBS Medicaid,CPT,92938,Prq revasc byp graft addl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
BCBS Medicaid,CPT,92941,Prq card revasc mi 1 vsl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
BCBS Medicaid,CPT,92943,Prq card revasc chronic 1vsl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
BCBS Medicaid,CPT,92944,Prq card revasc chronic addl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
BCBS Medicaid,CPT,92950,Heart/lung resuscitation cpr,General Medicine,Per Unit,$385.17 ,OP,385.17,385.17,,,,,,
BCBS Medicaid,CPT,92953,Temporary external pacing,Cardiology,Per Unit,$347.43 ,OP,347.43,347.43,,,,,,
BCBS Medicaid,CPT,92960,Cardioversion electric ext,Cardiology,Per Unit,$347.43 ,OP,347.43,347.43,,,,,,
BCBS Medicaid,CPT,92961,Cardioversion electric int,Cardiology,Per Unit,$347.43 ,OP,347.43,347.43,,,,,,
BCBS Medicaid,CPT,92971,Cardioassist external,Cardiology,Per Unit,$347.43 ,OP,347.43,347.43,,,,,,
BCBS Medicaid,CPT,92973,Prq coronary mech thrombect,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
BCBS Medicaid,CPT,92975,Dissolve clot heart vessel,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
BCBS Medicaid,CPT,92977,Dissolve clot heart vessel,General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
BCBS Medicaid,CPT,92978,Endoluminl ivus oct c 1st,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,92979,Endoluminl ivus oct c ea,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,92986,Revision of aortic valve,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
BCBS Medicaid,CPT,92987,Revision of mitral valve,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
BCBS Medicaid,CPT,92990,Revision of pulmonary valve,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
BCBS Medicaid,CPT,92997,Pul art balloon repr percut,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
BCBS Medicaid,CPT,92998,Pul art balloon repr percut,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
BCBS Medicaid,CPT,93000,Electrocardiogram complete,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
BCBS Medicaid,CPT,93005,Electrocardiogram tracing,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
BCBS Medicaid,CPT,93010,Electrocardiogram report,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
BCBS Medicaid,CPT,93015,Cardiovascular stress test,Cardiology,Per Unit,$174.07 ,OP,174.07,174.07,,,,,,
BCBS Medicaid,CPT,93016,Cardiovascular stress test,Cardiology,Per Unit,$174.07 ,OP,174.07,174.07,,,,,,
BCBS Medicaid,CPT,93017,Cardiovascular stress test,Cardiology,Per Unit,$174.07 ,OP,174.07,174.07,,,,,,
BCBS Medicaid,CPT,93018,Cardiovascular stress test,Cardiology,Per Unit,$174.07 ,OP,174.07,174.07,,,,,,
BCBS Medicaid,CPT,93024,Cardiac drug stress test,Cardiology,Per Unit,$174.07 ,OP,174.07,174.07,,,,,,
BCBS Medicaid,CPT,93025,Microvolt t-wave assess,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,93040,Rhythm ecg with report,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
BCBS Medicaid,CPT,93041,Rhythm ecg tracing,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
BCBS Medicaid,CPT,93042,Rhythm ecg report,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
BCBS Medicaid,CPT,93050,Art pressure waveform analys,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,93224,Ecg monit/reprt up to 48 hrs,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,93225,Ecg monit/reprt up to 48 hrs,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,93226,Ecg monit/reprt up to 48 hrs,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,93227,Ecg monit/reprt up to 48 hrs,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,93228,Remote 30 day ecg rev/report,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,93229,Remote 30 day ecg tech supp,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,93241,Ext ecg>48hr<7d rec scan a/r,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,93242,Ext ecg>48hr<7d recording,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,93243,Ext ecg>48hr<7d scan a/r,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,93244,Ext ecg>48hr<7d rev&interpj,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,93245,Ext ecg>7d<15d rec scan a/r,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,93246,Ext ecg>7d<15d recording,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,93247,Ext ecg>7d<15d scan a/r,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,93248,Ext ecg>7d<15d rev&interpj,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,93260,Prgrmg dev eval impltbl sys,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,93261,Interrogate subq defib,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,93264,Rem mntr wrls p-art prs snr,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,93268,Ecg record/review,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,93270,Remote 30 day ecg rev/report,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,93271,Ecg/monitoring and analysis,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,93272,Ecg/review interpret only,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,93278,Ecg/signal-averaged,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
BCBS Medicaid,CPT,93279,Prgrmg dev eval pm/ldls pm,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,93280,Pm device progr eval dual,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,93281,Pm device progr eval multi,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,93282,Prgrmg eval implantable dfb,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,93283,Prgrmg eval implantable dfb,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,93284,Prgrmg eval implantable dfb,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,93285,Prgrmg dev eval scrms ip,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,93286,Peri-px eval pm/ldls pm ip,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,93287,Peri-px device eval & prgr,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,93288,Interrog evl pm/ldls pm ip,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,93289,Interrog device eval heart,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,93290,Interrog dev eval icpms ip,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,93291,Interrog dev eval scrms ip,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,93292,Wcd device interrogate,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,93293,Pm phone r-strip device eval,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,93294,Rem interrog evl pm/ldls pm,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,93295,Dev interrog remote 1/2/mlt,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,93296,Rem interrog evl pm/ids,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,93297,Rem interrog dev eval icpms,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,93298,Rem interrog dev eval scrms,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,93299,Interrog eval icpms/scrms,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,93303,Echo transthoracic,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
BCBS Medicaid,CPT,93304,Echo transthoracic,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
BCBS Medicaid,CPT,93306,Tte w/doppler complete,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
BCBS Medicaid,CPT,93307,Tte w/o doppler complete,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
BCBS Medicaid,CPT,93308,Tte f-up or lmtd,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
BCBS Medicaid,CPT,93312,Echo transesophageal,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
BCBS Medicaid,CPT,93313,Echo transesophageal,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
BCBS Medicaid,CPT,93314,Echo transesophageal,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
BCBS Medicaid,CPT,93315,Echo transesophageal,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
BCBS Medicaid,CPT,93316,Echo transesophageal,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
BCBS Medicaid,CPT,93317,Echo transesophageal,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
BCBS Medicaid,CPT,93318,Echo transesophageal intraop,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
BCBS Medicaid,CPT,93320,Doppler echo exam heart,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
BCBS Medicaid,CPT,93321,Doppler echo exam heart,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
BCBS Medicaid,CPT,93325,Doppler color flow add-on,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,93350,Stress tte only,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
BCBS Medicaid,CPT,93351,Stress tte complete,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
BCBS Medicaid,CPT,93352,Admin ecg contrast agent,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
BCBS Medicaid,CPT,93355,Echo transesophageal (tee),Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
BCBS Medicaid,CPT,93356,Myocrd strain img spckl trck,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
BCBS Medicaid,CPT,93451,Right heart cath,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
BCBS Medicaid,CPT,93452,Left hrt cath w/ventrclgrphy,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
BCBS Medicaid,CPT,93453,R&l hrt cath w/ventriclgrphy,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
BCBS Medicaid,CPT,93454,Coronary artery angio s&i,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
BCBS Medicaid,CPT,93455,Coronary art/grft angio s&i,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
BCBS Medicaid,CPT,93456,R hrt coronary artery angio,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
BCBS Medicaid,CPT,93457,R hrt art/grft angio,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
BCBS Medicaid,CPT,93458,L hrt artery/ventricle angio,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
BCBS Medicaid,CPT,93459,L hrt art/grft angio,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
BCBS Medicaid,CPT,93460,R&l hrt art/ventricle angio,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
BCBS Medicaid,CPT,93461,R&l hrt art/ventricle angio,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
BCBS Medicaid,CPT,93462,L hrt cath trnsptl puncture,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
BCBS Medicaid,CPT,93464,Exercise w/hemodynamic meas,Cardiology,Per Unit,$174.07 ,OP,174.07,174.07,,,,,,
BCBS Medicaid,CPT,93505,Biopsy of heart lining,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
BCBS Medicaid,CPT,93530,Rt heart cath congenital,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
BCBS Medicaid,CPT,93531,R & l heart cath congenital,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
BCBS Medicaid,CPT,93532,R & l heart cath congenital,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
BCBS Medicaid,CPT,93533,R & l heart cath congenital,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
BCBS Medicaid,CPT,93600,Bundle of his recording,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
BCBS Medicaid,CPT,93602,Intra-atrial recording,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
BCBS Medicaid,CPT,93603,Right ventricular recording,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
BCBS Medicaid,CPT,93609,Map tachycardia add-on,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
BCBS Medicaid,CPT,93610,Intra-atrial pacing,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
BCBS Medicaid,CPT,93612,Intraventricular pacing,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
BCBS Medicaid,CPT,93613,Electrophys map 3d add-on,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
BCBS Medicaid,CPT,93615,Esophageal recording,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
BCBS Medicaid,CPT,93616,Esophageal recording,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
BCBS Medicaid,CPT,93618,Heart rhythm pacing,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
BCBS Medicaid,CPT,93619,Electrophysiology evaluation,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
BCBS Medicaid,CPT,93620,Electrophysiology evaluation,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
BCBS Medicaid,CPT,93621,Electrophysiology evaluation,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
BCBS Medicaid,CPT,93622,Electrophysiology evaluation,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
BCBS Medicaid,CPT,93623,Stimulation pacing heart,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
BCBS Medicaid,CPT,93624,Electrophysiologic study,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
BCBS Medicaid,CPT,93631,Heart pacing mapping,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
BCBS Medicaid,CPT,93640,Evaluation heart device,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
BCBS Medicaid,CPT,93641,Electrophysiology evaluation,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
BCBS Medicaid,CPT,93642,Electrophysiology evaluation,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
BCBS Medicaid,CPT,93644,Electrophysiology evaluation,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
BCBS Medicaid,CPT,93650,Ablate heart dysrhythm focus,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
BCBS Medicaid,CPT,93653,Ep & ablate supravent arrhyt,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
BCBS Medicaid,CPT,93654,Ep & ablate ventric tachy,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
BCBS Medicaid,CPT,93655,Ablate arrhythmia add on,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
BCBS Medicaid,CPT,93656,Tx atrial fib pulm vein isol,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
BCBS Medicaid,CPT,93657,Tx l/r atrial fib addl,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
BCBS Medicaid,CPT,93660,Tilt table evaluation,Cardiology,Per Unit,$174.07 ,OP,174.07,174.07,,,,,,
BCBS Medicaid,CPT,93662,Intracardiac ecg (ice),Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
BCBS Medicaid,CPT,93668,Peripheral vascular rehab,Cardiology,Per Unit,$174.07 ,OP,174.07,174.07,,,,,,
BCBS Medicaid,CPT,93701,Bioimpedance cv analysis,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,93702,Bis xtracell fluid analysis,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,93724,Analyze pacemaker system,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
BCBS Medicaid,CPT,93745,Set-up cardiovert-defibrill,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,93750,Interrogation vad in person,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,93770,Measure venous pressure,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,93784,Ambl bp mntr w/software,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,93786,Ambl bp mntr w/sw rec only,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,93788,Ambl bp mntr w/sw a/r,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,93790,Ambl bp mntr w/sw i&r,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,93792,Pt/caregiver traing home inr,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
BCBS Medicaid,CPT,93793,Anticoag mgmt pt warfarin,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,93797,Cardiac rehab,Rehabilitation,Per Unit,$274.82 ,OP,274.82,274.82,,,,,,
BCBS Medicaid,CPT,93798,Cardiac rehab/monitor,Rehabilitation,Per Unit,$274.82 ,OP,274.82,274.82,,,,,,
BCBS Medicaid,CPT,93799,Cardiovascular procedure,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
BCBS Medicaid,CPT,93880,Extracranial bilat study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,93882,Extracranial uni/ltd study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,93886,Intracranial complete study,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
BCBS Medicaid,CPT,93888,Intracranial limited study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,93890,Tcd vasoreactivity study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,93892,Tcd emboli detect w/o inj,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
BCBS Medicaid,CPT,93893,Tcd emboli detect w/inj,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,93895,Carotid intima atheroma eval,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,93922,Upr/l xtremity art 2 levels,Cardiology,Per Unit,$174.07 ,OP,174.07,174.07,,,,,,
BCBS Medicaid,CPT,93923,Upr/lxtr art stdy 3+ lvls,Cardiology,Per Unit,$174.07 ,OP,174.07,174.07,,,,,,
BCBS Medicaid,CPT,93924,Lwr xtr vasc stdy bilat,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,93925,Lower extremity study,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
BCBS Medicaid,CPT,93926,Lower extremity study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,93930,Upper extremity study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,93931,Upper extremity study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,93965,Extremity study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,93970,Extremity study,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
BCBS Medicaid,CPT,93971,Extremity study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,93975,Vascular study,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
BCBS Medicaid,CPT,93976,Vascular study,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
BCBS Medicaid,CPT,93978,Vascular study,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
BCBS Medicaid,CPT,93979,Vascular study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,93980,Penile vascular study,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
BCBS Medicaid,CPT,93981,Penile vascular study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,93982,Aneurysm pressure sens study,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,93985,Dup-scan hemo compl bi std,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,93986,Dup-scan hemo compl uni std,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,93990,Doppler flow testing,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,93998,Noninvas vasc dx study proc,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,94002,Vent mgmt inpat init day,Pulmonary,Per Unit,$417.61 ,OP,417.61,417.61,,,,,,
BCBS Medicaid,CPT,94003,Vent mgmt inpat subq day,Pulmonary,Per Unit,$417.61 ,OP,417.61,417.61,,,,,,
BCBS Medicaid,CPT,94004,Vent mgmt nf per day,Pulmonary,Per Unit,$417.61 ,OP,417.61,417.61,,,,,,
BCBS Medicaid,CPT,94005,Home vent mgmt supervision,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,94010,Breathing capacity test,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
BCBS Medicaid,CPT,94011,Spirometry up to 2 yrs old,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
BCBS Medicaid,CPT,94012,Spirmtry w/brnchdil inf-2 yr,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
BCBS Medicaid,CPT,94013,Meas lung vol thru 2 yrs,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
BCBS Medicaid,CPT,94014,Patient recorded spirometry,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
BCBS Medicaid,CPT,94015,Patient recorded spirometry,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
BCBS Medicaid,CPT,94016,Review patient spirometry,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
BCBS Medicaid,CPT,94060,Evaluation of wheezing,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
BCBS Medicaid,CPT,94070,Evaluation of wheezing,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
BCBS Medicaid,CPT,94150,Vital capacity test,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
BCBS Medicaid,CPT,94200,Lung function test (mbc/mvv),Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
BCBS Medicaid,CPT,94250,Expired gas collection,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
BCBS Medicaid,CPT,94375,Respiratory flow volume loop,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
BCBS Medicaid,CPT,94400,Co2 breathing response curve,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
BCBS Medicaid,CPT,94450,Hypoxia response curve,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
BCBS Medicaid,CPT,94452,Hast w/report,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
BCBS Medicaid,CPT,94453,Hast w/oxygen titrate,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
BCBS Medicaid,CPT,94610,Surfactant admin thru tube,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
BCBS Medicaid,CPT,94617,Exercise tst brncspsm w/ecg,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
BCBS Medicaid,CPT,94618,Pulmonary stress testing,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
BCBS Medicaid,CPT,94619,Exercise tst brncspsm wo ecg,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
BCBS Medicaid,CPT,94620,Pulmonary stress test/simple,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
BCBS Medicaid,CPT,94621,Cardiopulm exercise testing,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
BCBS Medicaid,CPT,94640,Airway inhalation treatment,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
BCBS Medicaid,CPT,94642,Aerosol inhalation treatment,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
BCBS Medicaid,CPT,94644,Cbt 1st hour,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
BCBS Medicaid,CPT,94645,Cbt each addl hour,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
BCBS Medicaid,CPT,94660,Pos airway pressure cpap,Pulmonary,Per Unit,$417.61 ,OP,417.61,417.61,,,,,,
BCBS Medicaid,CPT,94662,Neg press ventilation cnp,Pulmonary,Per Unit,$417.61 ,OP,417.61,417.61,,,,,,
BCBS Medicaid,CPT,94664,Evaluate pt use of inhaler,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
BCBS Medicaid,CPT,94667,Chest wall manipulation,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
BCBS Medicaid,CPT,94668,Chest wall manipulation,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
BCBS Medicaid,CPT,94669,Mechanical chest wall oscill,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
BCBS Medicaid,CPT,94680,Exhaled air analysis o2,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
BCBS Medicaid,CPT,94681,Exhaled air analysis o2/co2,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
BCBS Medicaid,CPT,94690,Exhaled air analysis,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
BCBS Medicaid,CPT,94726,Pulm funct tst plethysmograp,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
BCBS Medicaid,CPT,94727,Pulm function test by gas,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
BCBS Medicaid,CPT,94728,Airwy resist by oscillometry,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
BCBS Medicaid,CPT,94729,Co/membane diffuse capacity,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
BCBS Medicaid,CPT,94750,Pulmonary compliance study,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
BCBS Medicaid,CPT,94762,Measure blood oxygen level,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
BCBS Medicaid,CPT,94770,Exhaled carbon dioxide test,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
BCBS Medicaid,CPT,94772,Breath recording infant,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
BCBS Medicaid,CPT,94774,Ped home apnea rec compl,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
BCBS Medicaid,CPT,94775,Ped home apnea rec hk-up,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
BCBS Medicaid,CPT,94776,Ped home apnea rec downld,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
BCBS Medicaid,CPT,94777,Ped home apnea rec report,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
BCBS Medicaid,CPT,94780,Cars/bd tst inft-12mo 60 min,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
BCBS Medicaid,CPT,94781,Cars/bd tst inft-12mo +30min,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
BCBS Medicaid,CPT,94799,Pulmonary service/procedure,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
BCBS Medicaid,CPT,95004,Percut allergy skin tests,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
BCBS Medicaid,CPT,95012,Exhaled nitric oxide meas,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
BCBS Medicaid,CPT,95017,Perq & icut allg test venoms,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
BCBS Medicaid,CPT,95018,Perq&ic allg test drugs/biol,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
BCBS Medicaid,CPT,95024,Icut allergy test drug/bug,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
BCBS Medicaid,CPT,95027,Icut allergy titrate-airborn,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
BCBS Medicaid,CPT,95028,Icut allergy test-delayed,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
BCBS Medicaid,CPT,95044,Allergy patch tests,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
BCBS Medicaid,CPT,95052,Photo patch test,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
BCBS Medicaid,CPT,95056,Photosensitivity tests,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
BCBS Medicaid,CPT,95060,Eye allergy tests,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
BCBS Medicaid,CPT,95065,Nose allergy test,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
BCBS Medicaid,CPT,95070,Bronchial allergy tests,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
BCBS Medicaid,CPT,95071,Bronchial allergy tests,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
BCBS Medicaid,CPT,95076,Ingest challenge ini 120 min,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
BCBS Medicaid,CPT,95079,Ingest challenge addl 60 min,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
BCBS Medicaid,CPT,95115,Immunotherapy one injection,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
BCBS Medicaid,CPT,95117,Immunotherapy injections,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
BCBS Medicaid,CPT,95120,Immunotherapy one injection,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
BCBS Medicaid,CPT,95125,Immunotherapy 2/> injections,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
BCBS Medicaid,CPT,95130,Immntx 1 sting insect,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
BCBS Medicaid,CPT,95131,Immntx 2 sting insects,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
BCBS Medicaid,CPT,95132,Immntx 3 sting insects,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
BCBS Medicaid,CPT,95133,Immntx 4 sting insects,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
BCBS Medicaid,CPT,95134,Immntx 5 sting insects,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
BCBS Medicaid,CPT,95144,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
BCBS Medicaid,CPT,95145,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
BCBS Medicaid,CPT,95146,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
BCBS Medicaid,CPT,95147,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
BCBS Medicaid,CPT,95148,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
BCBS Medicaid,CPT,95149,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
BCBS Medicaid,CPT,95165,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
BCBS Medicaid,CPT,95170,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
BCBS Medicaid,CPT,95180,Rapid desensitization,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
BCBS Medicaid,CPT,95199,Allergy immunology services,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
BCBS Medicaid,CPT,95249,Cont gluc mntr pt prov eqp,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,95250,Cont gluc mntr phys/qhp eqp,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,95251,Cont gluc mntr analysis i&r,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,95700,Eeg cont rec w/vid eeg tech,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
BCBS Medicaid,CPT,95705,Eeg w/o vid 2-12 hr unmntr,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
BCBS Medicaid,CPT,95706,Eeg wo vid 2-12hr intmt mntr,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
BCBS Medicaid,CPT,95707,Eeg w/o vid 2-12hr cont mntr,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
BCBS Medicaid,CPT,95708,Eeg wo vid ea 12-26hr unmntr,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
BCBS Medicaid,CPT,95709,Eeg w/o vid ea 12-26hr intmt,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
BCBS Medicaid,CPT,95710,Eeg w/o vid ea 12-26hr cont,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
BCBS Medicaid,CPT,95711,Veeg 2-12 hr unmonitored,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
BCBS Medicaid,CPT,95712,Veeg 2-12 hr intmt mntr,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
BCBS Medicaid,CPT,95713,Veeg 2-12 hr cont mntr,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
BCBS Medicaid,CPT,95714,Veeg ea 12-26 hr unmntr,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
BCBS Medicaid,CPT,95715,Veeg ea 12-26hr intmt mntr,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
BCBS Medicaid,CPT,95716,Veeg ea 12-26hr cont mntr,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
BCBS Medicaid,CPT,95717,Eeg phys/qhp 2-12 hr w/o vid,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
BCBS Medicaid,CPT,95718,Eeg phys/qhp 2-12 hr w/veeg,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
BCBS Medicaid,CPT,95719,Eeg phys/qhp ea incr w/o vid,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
BCBS Medicaid,CPT,95720,Eeg phy/qhp ea incr w/veeg,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
BCBS Medicaid,CPT,95721,Eeg phy/qhp>36<60 hr w/o vid,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
BCBS Medicaid,CPT,95722,Eeg phy/qhp>36<60 hr w/veeg,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
BCBS Medicaid,CPT,95723,Eeg phy/qhp>60<84 hr w/o vid,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
BCBS Medicaid,CPT,95724,Eeg phy/qhp>60<84 hr w/veeg,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
BCBS Medicaid,CPT,95725,Eeg phy/qhp>84 hr w/o vid,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
BCBS Medicaid,CPT,95726,Eeg phy/qhp>84 hr w/veeg,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
BCBS Medicaid,CPT,95782,Polysom <6 yrs 4/> paramtrs,Pulmonary,Per Unit,$437.56 ,OP,437.56,437.56,,,,,,
BCBS Medicaid,CPT,95783,Polysom <6 yrs cpap/bilvl,Pulmonary,Per Unit,$437.56 ,OP,437.56,437.56,,,,,,
BCBS Medicaid,CPT,95803,Actigraphy testing,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,95805,Multiple sleep latency test,Pulmonary,Per Unit,$437.56 ,OP,437.56,437.56,,,,,,
BCBS Medicaid,CPT,95807,Sleep study attended,Pulmonary,Per Unit,$437.56 ,OP,437.56,437.56,,,,,,
BCBS Medicaid,CPT,95808,Polysom any age 1-3> param,Pulmonary,Per Unit,$437.56 ,OP,437.56,437.56,,,,,,
BCBS Medicaid,CPT,95810,Polysom 6/> yrs 4/> param,Pulmonary,Per Unit,$437.56 ,OP,437.56,437.56,,,,,,
BCBS Medicaid,CPT,95811,Polysom 6/>yrs cpap 4/> parm,Pulmonary,Per Unit,$437.56 ,OP,437.56,437.56,,,,,,
BCBS Medicaid,CPT,95812,Eeg 41-60 minutes,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
BCBS Medicaid,CPT,95813,Eeg extnd mntr 61-119 min,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
BCBS Medicaid,CPT,95816,Eeg awake and drowsy,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
BCBS Medicaid,CPT,95819,Eeg awake and asleep,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
BCBS Medicaid,CPT,95822,Eeg coma or sleep only,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
BCBS Medicaid,CPT,95824,Eeg cerebral death only,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
BCBS Medicaid,CPT,95827,Eeg all night recording,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
BCBS Medicaid,CPT,95829,Surgery electrocorticogram,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
BCBS Medicaid,CPT,95836,Ecog impltd brn npgt <30 d,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
BCBS Medicaid,CPT,95857,Cholinesterase challenge,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,95860,Muscle test one limb,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,95861,Muscle test 2 limbs,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,95863,Muscle test 3 limbs,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,95864,Muscle test 4 limbs,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,95865,Muscle test larynx,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,95866,Muscle test hemidiaphragm,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,95867,Muscle test cran nerv unilat,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,95868,Muscle test cran nerve bilat,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,95869,Muscle test thor paraspinal,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,95870,Muscle test nonparaspinal,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,95872,Muscle test one fiber,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,95873,Guide nerv destr elec stim,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
BCBS Medicaid,CPT,95874,Guide nerv destr needle emg,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
BCBS Medicaid,CPT,95875,Limb exercise test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,95885,Musc tst done w/nerv tst lim,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,95886,Musc test done w/n test comp,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,95887,Musc tst done w/n tst nonext,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,95905,Motor &/ sens nrve cndj test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,95907,Nvr cndj tst 1-2 studies,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,95908,Nrv cndj tst 3-4 studies,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,95909,Nrv cndj tst 5-6 studies,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,95910,Nrv cndj test 7-8 studies,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,95911,Nrv cndj test 9-10 studies,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,95912,Nrv cndj test 11-12 studies,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,95913,Nrv cndj test 13/> studies,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,95921,Autonomic nrv parasym inervj,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,95922,Autonomic nrv adrenrg inervj,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,95923,Autonomic nrv syst funj test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,95924,Ans parasymp & symp w/tilt,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,95925,Somatosensory testing,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,95926,Somatosensory testing,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,95927,Somatosensory testing,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,95928,C motor evoked uppr limbs,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,95929,C motor evoked lwr limbs,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,95930,Visual ep test cns w/i&r,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,95933,Blink reflex test,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,95937,Neuromuscular junction test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,95938,Somatosensory testing,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,95939,C motor evoked upr&lwr limbs,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,95943,Parasymp&symp hrt rate test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,95950,Ambulatory eeg monitoring,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
BCBS Medicaid,CPT,95951,Eeg monitoring/videorecord,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
BCBS Medicaid,CPT,95953,Eeg monitoring/computer,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
BCBS Medicaid,CPT,95954,Eeg monitoring/giving drugs,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
BCBS Medicaid,CPT,95955,Eeg during surgery,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
BCBS Medicaid,CPT,95956,Eeg monitor technol attended,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
BCBS Medicaid,CPT,95957,Eeg digital analysis,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,95958,Eeg monitoring/function test,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
BCBS Medicaid,CPT,95965,Meg spontaneous,Diagnostic Radiology,Per Unit,$221.34 ,OP,221.34,221.34,,,,,,
BCBS Medicaid,CPT,95966,Meg evoked single,Diagnostic Radiology,Per Unit,$221.34 ,OP,221.34,221.34,,,,,,
BCBS Medicaid,CPT,95967,Meg evoked each addl,Diagnostic Radiology,Per Unit,$221.34 ,OP,221.34,221.34,,,,,,
BCBS Medicaid,CPT,95970,Alys npgt w/o prgrmg,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
BCBS Medicaid,CPT,95971,Alys smpl sp/pn npgt w/prgrm,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
BCBS Medicaid,CPT,95972,Alys cplx sp/pn npgt w/prgrm,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
BCBS Medicaid,CPT,95973,Analyze neurostim complex,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
BCBS Medicaid,CPT,95974,Cranial neurostim complex,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
BCBS Medicaid,CPT,95975,Cranial neurostim complex,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
BCBS Medicaid,CPT,95976,Alys smpl cn npgt prgrmg,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
BCBS Medicaid,CPT,95977,Alys cplx cn npgt prgrmg,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
BCBS Medicaid,CPT,95978,Analyze neurostim brain/1h,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
BCBS Medicaid,CPT,95979,Analyz neurostim brain addon,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
BCBS Medicaid,CPT,95980,Io anal gast n-stim init,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
BCBS Medicaid,CPT,95981,Io anal gast n-stim subsq,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,95982,Io ga n-stim subsq w/reprog,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,95983,Alys brn npgt prgrmg 15 min,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
BCBS Medicaid,CPT,95984,Alys brn npgt prgrmg addl 15,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
BCBS Medicaid,CPT,95999,Neurological procedure,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
BCBS Medicaid,CPT,96000,Motion analysis video/3d,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,96001,Motion test w/ft press meas,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,96002,Dynamic surface emg,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,96003,Dynamic fine wire emg,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,96020,Functional brain mapping,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
BCBS Medicaid,CPT,96101,Psycho testing by psych/phys,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
BCBS Medicaid,CPT,96102,Psycho testing by technician,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
BCBS Medicaid,CPT,96103,Psycho testing admin by comp,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
BCBS Medicaid,CPT,96105,Assessment of aphasia,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
BCBS Medicaid,CPT,96110,Developmental screen w/score,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
BCBS Medicaid,CPT,96111,Developmental test extend,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
BCBS Medicaid,CPT,96112,Devel tst phys/qhp 1st hr,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
BCBS Medicaid,CPT,96113,Devel tst phys/qhp ea addl,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
BCBS Medicaid,CPT,96116,Nubhvl xm phys/qhp 1st hr,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
BCBS Medicaid,CPT,96118,Neuropsych tst by psych/phys,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
BCBS Medicaid,CPT,96119,Neuropsych testing by tec,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
BCBS Medicaid,CPT,96120,Neuropsych tst admin w/comp,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
BCBS Medicaid,CPT,96121,Nubhvl xm phy/qhp ea addl hr,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
BCBS Medicaid,CPT,96125,Cognitive test by hc pro,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
BCBS Medicaid,CPT,96127,Brief emotional/behav assmt,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
BCBS Medicaid,CPT,96130,Psycl tst eval phys/qhp 1st,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
BCBS Medicaid,CPT,96131,Psycl tst eval phys/qhp ea,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
BCBS Medicaid,CPT,96132,Nrpsyc tst eval phys/qhp 1st,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
BCBS Medicaid,CPT,96133,Nrpsyc tst eval phys/qhp ea,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
BCBS Medicaid,CPT,96136,Psycl/nrpsyc tst phy/qhp 1st,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
BCBS Medicaid,CPT,96137,Psycl/nrpsyc tst phy/qhp ea,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
BCBS Medicaid,CPT,96138,Psycl/nrpsyc tech 1st,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
BCBS Medicaid,CPT,96139,Psycl/nrpsyc tst tech ea,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
BCBS Medicaid,CPT,96146,Psycl/nrpsyc tst auto result,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
BCBS Medicaid,CPT,96150,Assess hlth/behave init,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
BCBS Medicaid,CPT,96151,Assess hlth/behave subseq,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
BCBS Medicaid,CPT,96153,Intervene hlth/behave group,Behavioral Health,Per Unit,$119.88 ,OP,119.88,119.88,,,,,,
BCBS Medicaid,CPT,96154,Interv hlth/behav fam w/pt,Behavioral Health,Per Unit,$89.14 ,OP,89.14,89.14,,,,,,
BCBS Medicaid,CPT,96155,Interv hlth/behav fam no pt,Behavioral Health,Per Unit,$89.14 ,OP,89.14,89.14,,,,,,
BCBS Medicaid,CPT,96156,Hlth bhv assmt/reassessment,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
BCBS Medicaid,CPT,96160,Pt-focused hlth risk assmt,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
BCBS Medicaid,CPT,96161,Caregiver health risk assmt,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
BCBS Medicaid,CPT,96360,Hydration iv infusion init,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
BCBS Medicaid,CPT,96361,Hydrate iv infusion add-on,General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
BCBS Medicaid,CPT,96365,Ther/proph/diag iv inf init,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
BCBS Medicaid,CPT,96366,Ther/proph/diag iv inf addon,General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
BCBS Medicaid,CPT,96367,Tx/proph/dg addl seq iv inf,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
BCBS Medicaid,CPT,96368,Ther/diag concurrent inf,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
BCBS Medicaid,CPT,96369,Sc ther infusion up to 1 hr,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
BCBS Medicaid,CPT,96370,Sc ther infusion addl hr,General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
BCBS Medicaid,CPT,96371,Sc ther infusion reset pump,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
BCBS Medicaid,CPT,96413,Chemo iv infusion 1 hr,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
BCBS Medicaid,CPT,96415,Chemo iv infusion addl hr,General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
BCBS Medicaid,CPT,96416,Chemo prolong infuse w/pump,General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
BCBS Medicaid,CPT,96417,Chemo iv infus each addl seq,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
BCBS Medicaid,CPT,96422,Chemo ia infusion up to 1 hr,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
BCBS Medicaid,CPT,96423,Chemo ia infuse each addl hr,General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
BCBS Medicaid,CPT,96425,Chemotherapy infusion method,General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
BCBS Medicaid,CPT,96446,Chemotx admn prtl cavity,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
BCBS Medicaid,CPT,96450,Chemotherapy into cns,General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
BCBS Medicaid,CPT,96549,Chemotherapy unspecified,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
BCBS Medicaid,CPT,96567,Pdt dstr prmlg les skn,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,96570,Photodynmc tx 30 min add-on,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,96571,Photodynamic tx addl 15 min,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,96573,Pdt dstr prmlg les phys/qhp,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,96574,Dbrdmt prmlg les w/pdt,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,96900,Ultraviolet light therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,96902,Trichogram,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,96913,Photochemotherapy uv-a or b,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,96920,Laser tx skin < 250 sq cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,96921,Laser tx skin 250-500 sq cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,96922,Laser tx skin >500 sq cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,96931,Rcm celulr subcelulr img skn,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,96932,Rcm celulr subcelulr img skn,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,96933,Rcm celulr subcelulr img skn,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,96934,Rcm celulr subcelulr img skn,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,96935,Rcm celulr subcelulr img skn,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,96936,Rcm celulr subcelulr img skn,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,96999,Dermatological procedure,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,97001,Pt evaluation,Rehabilitation,Per Unit,$192.71 ,OP,192.71,192.71,,,,,,
BCBS Medicaid,CPT,97002,Pt re-evaluation,Rehabilitation,Per Unit,$192.71 ,OP,192.71,192.71,,,,,,
BCBS Medicaid,CPT,97003,Ot evaluation,Rehabilitation,Per Unit,$306.55 ,OP,306.55,306.55,,,,,,
BCBS Medicaid,CPT,97004,Ot re-evaluation,Rehabilitation,Per Unit,$306.55 ,OP,306.55,306.55,,,,,,
BCBS Medicaid,CPT,97010,Hot or cold packs therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,97012,Mechanical traction therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,97014,Electric stimulation therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,97016,Vasopneumatic device therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,97018,Paraffin bath therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,97022,Whirlpool therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,97024,Diathermy eg microwave,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,97026,Infrared therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,97028,Ultraviolet therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,97032,Electrical stimulation,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,97033,Electric current therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,97034,Contrast bath therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,97035,Ultrasound therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,97039,Physical therapy treatment,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,97116,Gait training therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,97124,Massage therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,97139,Physical medicine procedure,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,97161,Pt eval low complex 20 min,Rehabilitation,Per Unit,$192.71 ,OP,192.71,192.71,,,,,,
BCBS Medicaid,CPT,97162,Pt eval mod complex 30 min,Rehabilitation,Per Unit,$192.71 ,OP,192.71,192.71,,,,,,
BCBS Medicaid,CPT,97163,Pt eval high complex 45 min,Rehabilitation,Per Unit,$192.71 ,OP,192.71,192.71,,,,,,
BCBS Medicaid,CPT,97164,Pt re-eval est plan care,Rehabilitation,Per Unit,$192.71 ,OP,192.71,192.71,,,,,,
BCBS Medicaid,CPT,97165,Ot eval low complex 30 min,Rehabilitation,Per Unit,$306.55 ,OP,306.55,306.55,,,,,,
BCBS Medicaid,CPT,97166,Ot eval mod complex 45 min,Rehabilitation,Per Unit,$306.55 ,OP,306.55,306.55,,,,,,
BCBS Medicaid,CPT,97167,Ot eval high complex 60 min,Rehabilitation,Per Unit,$306.55 ,OP,306.55,306.55,,,,,,
BCBS Medicaid,CPT,97168,Ot re-eval est plan care,Rehabilitation,Per Unit,$306.55 ,OP,306.55,306.55,,,,,,
BCBS Medicaid,CPT,97535,Self care mngment training,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,97545,Work hardening,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,97546,Work hardening add-on,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,97755,Assistive technology assess,Rehabilitation,Per Unit,$192.71 ,OP,192.71,192.71,,,,,,
BCBS Medicaid,CPT,97762,C/o for orthotic/prosth use,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,97799,Physical medicine procedure,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,97802,Medical nutrition indiv in,Ancillary Services,Per Unit,$100.15 ,OP,100.15,100.15,,,,,,
BCBS Medicaid,CPT,97803,Med nutrition indiv subseq,Ancillary Services,Per Unit,$100.15 ,OP,100.15,100.15,,,,,,
BCBS Medicaid,CPT,97804,Medical nutrition group,Ancillary Services,Per Unit,$100.15 ,OP,100.15,100.15,,,,,,
BCBS Medicaid,CPT,97810,Acupunct w/o stimul 15 min,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,97811,Acupunct w/o stimul addl 15m,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,97813,Acupunct w/stimul 15 min,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,97814,Acupunct w/stimul addl 15m,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,98925,Osteopath manj 1-2 regions,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,98926,Osteopath manj 3-4 regions,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,98927,Osteopath manj 5-6 regions,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,98928,Osteopath manj 7-8 regions,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,98929,Osteopath manj 9-10 regions,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,98940,Chiropract manj 1-2 regions,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,98941,Chiropract manj 3-4 regions,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,98942,Chiropractic manj 5 regions,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,98943,Chiropract manj xtrspinl 1/>,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,98960,Self-mgmt educ & train 1 pt,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
BCBS Medicaid,CPT,98961,Self-mgmt educ/train 2-4 pt,Preventive Care,Per Unit,$26.23 ,OP,26.23,26.23,,,,,,
BCBS Medicaid,CPT,98962,Self-mgmt educ/train 5-8 pt,Preventive Care,Per Unit,$26.23 ,OP,26.23,26.23,,,,,,
BCBS Medicaid,CPT,99050,Medical services after hrs,Ancillary Services,Per Unit,$26.19 ,OP,26.19,26.19,,,,,,
BCBS Medicaid,CPT,99051,Med serv eve/wkend/holiday,Ancillary Services,Per Unit,$26.19 ,OP,26.19,26.19,,,,,,
BCBS Medicaid,CPT,99053,Med serv 10pm-8am 24 hr fac,Ancillary Services,Per Unit,$26.19 ,OP,26.19,26.19,,,,,,
BCBS Medicaid,CPT,99058,Office emergency care,Ancillary Services,Per Unit,$26.19 ,OP,26.19,26.19,,,,,,
BCBS Medicaid,CPT,99060,Out of office emerg med serv,Ancillary Services,Per Unit,$26.19 ,OP,26.19,26.19,,,,,,
BCBS Medicaid,CPT,99078,Group health education,Preventive Care,Per Unit,$26.23 ,OP,26.23,26.23,,,,,,
BCBS Medicaid,CPT,99091,Collj & interpj data ea 30 d,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,99100,Special anesthesia service,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,99116,Anesthesia with hypothermia,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,99135,Special anesthesia procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,99140,Emergency anesthesia,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,99143,Mod sedat phys/qhp <5 yrs,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,99144,Mod sedat phys/qhp 5yrs/>,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,99145,Mod sedat phys/qhp ea 15 min,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,99148,Mod sed diff phys/qhp<5 yrs,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,99149,Mod sed diff phys/qhp 5/>yrs,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,99150,Mod sed diff phys/qhp add on,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,99151,Mod sed same phys/qhp <5 yrs,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,99152,Mod sed same phys/qhp 5/>yrs,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,99153,Mod sed same phys/qhp ea,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,99155,Mod sed oth phys/qhp <5 yrs,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,99156,Mod sed oth phys/qhp 5/>yrs,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,99157,Mod sed other phys/qhp ea,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,99172,Ocular function screen,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,99173,Visual acuity screen,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,99174,Ocular instrumnt screen bil,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,99175,Induction of vomiting,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
BCBS Medicaid,CPT,99177,Ocular instrumnt screen bil,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,99188,App topical fluoride varnish,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
BCBS Medicaid,CPT,99238,Hospital discharge day,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,99239,Hospital discharge day,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,99363,Anticoagulant mgmt initial,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,99364,Anticoagulant mgmt subseq,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,99366,Team conf w/pat by hc prof,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,99367,Team conf w/o pat by phys,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,99368,Team conf w/o pat by hc pro,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,99374,Home health care supervision,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,99375,Home health care supervision,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,99377,Hospice care supervision,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,99378,Hospice care supervision,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,99379,Nursing fac care supervision,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,99380,Nursing fac care supervision,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,99406,Behav chng smoking 3-10 min,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
BCBS Medicaid,CPT,99407,Behav chng smoking > 10 min,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
BCBS Medicaid,CPT,99408,Audit/dast 15-30 min,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
BCBS Medicaid,CPT,99409,Audit/dast over 30 min,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
BCBS Medicaid,CPT,99439,Chrnc care mgmt svc ea addl,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,99453,Rem mntr physiol param setup,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
BCBS Medicaid,CPT,99454,Rem mntr physiol param dev,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,99457,Rem physiol mntr 1st 20 min,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,99458,Rem physiol mntr ea addl 20,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,99465,Nb resuscitation,General Medicine,Per Unit,$385.17 ,OP,385.17,385.17,,,,,,
BCBS Medicaid,CPT,99473,Self-meas bp pt educaj/train,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,99474,Self-meas bp 2 readg bid 30d,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,99483,Assmt & care pln pt cog imp,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
BCBS Medicaid,CPT,99484,Care mgmt svc bhvl hlth cond,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
BCBS Medicaid,CPT,99487,Cplx chrnc care 1st 60 min,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,99489,Cplx chrnc care ea addl 30,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,99490,Chrnc care mgmt svc 1st 20,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,99491,Chrnc care mgmt svc 30 min,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,99492,1st psyc collab care mgmt,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
BCBS Medicaid,CPT,99493,Sbsq psyc collab care mgmt,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
BCBS Medicaid,CPT,99494,1st/sbsq psyc collab care,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
BCBS Medicaid,CPT,99495,Trans care mgmt 14 day disch,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,99496,Trans care mgmt 7 day disch,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,99497,Advncd care plan 30 min,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,99498,Advncd care plan addl 30 min,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,99503,Home visit resp therapy,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
BCBS Medicaid,CPT,99504,Home visit mech ventilator,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
BCBS Medicaid,CPT,0001A,Adm sarscov2 30mcg/0.3ml 1st,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,0001M,Nfct ds chrnc hcv 6 assays,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,0001U,Rbc dna hea 35 ag 11 bld grp,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0002A,Adm sarscov2 30mcg/0.3ml 2nd,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,0002M,Liver dis 10 assays w/ash,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0002U,Onc clrct 3 ur metab alg plp,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0003A,Fee covid-19 vac 1 booster,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,0003M,Liver dis 10 assays w/nash,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0003U,Onc ovar 5 prtn ser alg scor,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0004A,Fee covid-19 vac 1 res,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,0004M,Scoliosis dna alys,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0004U,Nfct ds dna 27 resist genes,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0005U,Onco prst8 3 gene ur alg,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0006M,Onc hep gene risk classifier,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0006U,Detc ia meds 120+ analytes,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,0007M,Onc gastro 51 gene nomogram,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,0008M,Onc breast risk score,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0008U,Hpylori detcj abx rstnc dna,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
BCBS Medicaid,CPT,0009M,Fetal aneuploidy trisom risk,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0009U,Onc brst ca erbb2 amp/nonamp,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0010M,Onc prostate prob score,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0010U,Nfct ds strn typ whl gen seq,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0011A,Adm sarscov2 100mcg/0.5ml1st,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,0011M,Onc prst8 ca mrna 12 gen alg,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0011U,Rx mntr lc-ms/ms oral fluid,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,0012A,Adm sarscov2 100mcg/0.5ml2nd,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,0012M,Onc mrna 5 gen rsk urthl ca,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0012U,Germln do gene reargmt detcj,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0013A,Fee covid-19 vac 2 booster,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,0013M,Onc mrna 5 gen recr urthl ca,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0013U,Onc sld org neo gene reargmt,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0014A,Fee covid-19 vac 2 res,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,0014M,Liver ds alys 3 bmrk srm alg,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0014U,Hem hmtlmf neo gene reargmt,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0015M,Adrnl cortcl tum bchm asy 25,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0015U,Rx metab advrs rx rxn dna,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0016M,Onc bladder mrna 209 gen alg,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0016U,Onc hmtlmf neo rna bcr/abl1,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,0017M,Onc dlbcl mrna 20 genes alg,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0017U,Onc hmtlmf neo jak2 mut dna,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0018U,Onc thyr 10 microrna seq alg,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0019T,Extracorp shock wv tx ms nos,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,0019U,Onc rna tiss predict alg,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0020U,Rx test prsmv ur w/def conf,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,0021A,Fee covid-19 vac 3 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,0021U,Onc prst8 detcj 8 autoantb,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0022A,Fee covid-19 vac 3 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,0022U,Trgt gen seq dna&rna 23 gene,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0023A,Fee covid-19 vac 3 booster,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,0023U,Onc aml dna detcj/nondetcj,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,0024A,Fee covid-19 vac 3 res,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,0024U,Glyca nuc mr spectrsc quan,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,0025U,Tenofovir liq chrom ur quan,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,0026U,Onc thyr dna&mrna 112 genes,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0027U,Jak2 gene trgt seq alys,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0028U,Cyp2d6 gene cpy nmr cmn vrnt,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0029U,Rx metab advrs trgt seq alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0030U,Rx metab warf trgt seq alys,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0031A,Fee covid-19 vac 4 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,0031U,Cyp1a2 gene,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,0032A,Fee covid-19 vac 4 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,0032U,Comt gene,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,0033A,Fee covid-19 vac 4 booster,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,0033U,Htr2a htr2c genes,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0034A,Fee covid-19 vac 4 res,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,0034U,Tpmt nudt15 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0035U,Neuro csf prion prtn qual,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0036U,Xome tum & nml spec seq alys,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0037U,Trgt gen seq dna 324 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0038U,Vitamin d srm microsamp quan,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,0039U,Dna antb 2strand hi avidity,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,0040U,Bcr/abl1 gene major bp quan,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0041A,Fee covid-19 vac 5 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,0041U,B brgdrferi antb 5 prtn igm,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
BCBS Medicaid,CPT,0042A,Fee covid-19 vac 5 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,0042T,Ct perfusion w/contrast cbf,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
BCBS Medicaid,CPT,0042U,B brgdrferi antb 12 prtn igg,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
BCBS Medicaid,CPT,0043A,Fee covid-19 vac 5 booster,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,0043U,Tbrf b grp antb 4 prtn igm,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,0044A,Fee covid-19 vac 5 res,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,0044U,Tbrf b grp antb 4 prtn igg,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,0045U,Onc brst dux carc is 12 gene,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,0046U,Flt3 gene itd variants quan,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,0047U,Onc prst8 mrna 17 gene alg,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0048U,Onc sld org neo dna 468 gene,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0049U,Npm1 gene analysis quan,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,0050U,Trgt gen seq dna 194 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0051A,Fee covid-19 vac 6 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,0051U,Rx mntr lc-ms/ms ur 31 pnl,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,0052A,Fee covid-19 vac 6 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,0052U,Lpoprtn bld w/5 maj classes,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,0053A,Fee covid-19 vac 6 booster,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,0053U,Onc prst8 ca fish alys 4 gen,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0054A,Fee covid-19 vac 6 res,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,0054U,Rx mntr 14+ drugs & sbsts,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,0055U,Card hrt trnspl 96 dna seq,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0056U,Hem aml dna gene reargmt,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0057U,Onc sld org neo mrna 51 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0058T,Cryopreservation ovary tiss,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,0058U,Onc merkel cll carc srm quan,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
BCBS Medicaid,CPT,0059U,Onc merkel cll carc srm +/-,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
BCBS Medicaid,CPT,0060U,Twn zyg gen seq alys chrms2,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0061A,Fee covid-19 vac 7 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,0061U,Tc meas 5 bmrk sfdi m-s alys,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
BCBS Medicaid,CPT,0062A,Fee covid-19 vac 7 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,0062U,Ai sle igg&igm alys 80 bmrk,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,0063A,Fee covid-19 vac 7 booster,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,0063U,Neuro autism 32 amines alg,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0064A,Fee covid-19 vac 7 res,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,0064U,Antb tp total&rpr ia qual,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,0065U,Syfls tst nontreponemal antb,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,0066U,Pamg-1 ia cervico-vag fluid,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,0067U,Onc brst imhchem prfl 4 bmrk,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,0069U,Onc clrct microrna mir-31-3p,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,0070U,Cyp2d6 gen com&slct rar vrnt,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0071A,Fee covid-19 vac 8 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,0071U,Cyp2d6 full gene sequence,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,0072A,Fee covid-19 vac 8 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,0072U,Cyp2d6 gen cyp2d6-2d7 hybrid,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0073A,Fee covid-19 vac 8 booster,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,0073U,Cyp2d6 gen cyp2d7-2d6 hybrid,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0074A,Fee covid-19 vac 8 res,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,0074U,Cyp2d6 nonduplicated gene,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0075T,Perq stent/chest vert art,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,0075U,Cyp2d6 5' gene dup/mlt,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0076T,S&i stent/chest vert art,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,0076U,Cyp2d6 3' gene dup/mlt,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0077U,Ig paraprotein qual bld/ur,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
BCBS Medicaid,CPT,0078U,Pain mgt opi use gnotyp pnl,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,0079U,Cmprtv dna alys mlt snps,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0080U,Onc lng 5 clin rsk factr alg,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0081A,Fee covid-19 vac 9 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,0081U,Onc uveal mlnma mrna 15 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0082A,Fee covid-19 vac 9 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,0083A,Fee covid-19 vac 9 booster,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,0083U,Onc rspse chemo cntrst tomog,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,0084A,Fee covid-19 vac 9 res,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,0084U,Rbc dna gnotyp 10 bld groups,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0085T,Breath test heart reject,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,0085U,Cdtb&vinculin igg antb ia,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
BCBS Medicaid,CPT,0086U,Nfct ds bact&fng org id 6+,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,0087U,Crd hrt trnspl mrna 1283 gen,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0088U,Trnsplj kdn algrft rej 1494,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0089U,Onc mlnma prame & linc00518,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0090U,Onc cutan mlnma mrna 23 gene,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0091A,Fee covid-19 vac 10 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,0091U,Onc clrct scr whl bld alg,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
BCBS Medicaid,CPT,0092A,Fee covid-19 vac 10 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,0092U,Onc lng 3 prtn bmrk plsm alg,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0093A,Fee covid-19 vac 10 booster,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,0093U,Rx mntr 65 com drugs urine,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,0094A,Fee covid-19 vac 10 res,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,0094U,Genome rapid sequence alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0095U,Inflm ee elisa alys alg,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0096U,Hpv hi risk types male urine,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,0099T,Implant corneal ring,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
BCBS Medicaid,CPT,0100T,Prosth retina receive&gen,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
BCBS Medicaid,CPT,0101A,Fee covid-19 vac 11 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,0101T,Extracorp shockwv tx hi enrg,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
BCBS Medicaid,CPT,0101U,Hered colon ca do 15 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0102A,Fee covid-19 vac 11 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,0102U,Hered brst ca rltd do 17 gen,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0103A,Fee covid-19 vac 11 booster,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,0103T,Holotranscobalamin,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,0103U,Hered ova ca pnl 24 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0104A,Fee covid-19 vac 11 res,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,0104U,Hered pan ca pnl 32 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0105U,Neph ckd mult eclia tum nec,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0106T,Touch quant sensory test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,0107T,Vibrate quant sensory test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,0107U,C diff tox ag detcj ia stool,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,0108T,Cool quant sensory test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,0108U,Gi barrett esoph 9 prtn bmrk,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0109T,Heat quant sensory test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,0109U,Id aspergillus dna 4 species,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,0110T,Nos quant sensory test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,0110U,Rx mntr 1+oral onc rx&sbsts,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,0111T,Rbc membranes fatty acids,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
BCBS Medicaid,CPT,0111U,Onc colon ca kras&nras alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0112U,Iadi 16s&18s rrna genes,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,0113U,Onc prst8 pca3&tmprss2-erg,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0114U,Gi barretts esoph vim&ccna1,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0115U,Respir iadna 18 viral&2 bact,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,0116U,Rx mntr nzm ia 35+oral flu,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,0117U,Pain mgmt 11 endogenous anal,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0118U,Trnsplj don-drv cll-fr dna,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0119U,Crd ceramides liq chrom plsm,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,0120U,Onc b cll lymphm mrna 58 gen,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0121U,Sc dis vcam-1 whole blood,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
BCBS Medicaid,CPT,0122U,Sc dis p-selectin whl blood,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
BCBS Medicaid,CPT,0123T,Scleral fistulization,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
BCBS Medicaid,CPT,0123U,Mchnl fragility rbc prflg,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
BCBS Medicaid,CPT,0124U,Ftl cgen abnor 3 analytes,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0125U,Ftl cgen abnor prnt comp 5,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0126T,Chd risk imt study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,0126U,Ftl cgen abnor prnt comp 5 y,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0127U,Ob pe 3 analytes,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0128U,Ob pe 3 analytes y chrmsm,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0129U,Hered brst ca rltd do panel,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0130U,Hered colon ca do mrna pnl,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0131U,Hered brst ca rltd do pnl 13,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0132U,Hered ova ca rltd do pnl 17,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0133U,Hered prst8 ca rltd do 11,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0134U,Hered pan ca mrna pnl 18 gen,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0135U,Hered gyn ca mrna pnl 12 gen,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0136U,Atm mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0137U,Palb2 mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0138U,Brca1 brca2 mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0139U,Neuro austm meas 6 c metablt,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0140U,Nfct ds fungi dna 15 trgt,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,0141U,Nfct ds bact&fng gram pos,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,0142U,Nfct ds bact&fng gram neg,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,0145U,Drug assay 65+ rx/metablt,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,0146U,Drug assay 80+ rx/metablt,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,0147U,Drug assay 85+ rx/metablt,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,0148U,Drug assay 100+ rx/metablt,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,0149U,Drug assay 60+ rx/metablt,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,0151U,Nfct bct/vir resp nfctj 33,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,0152U,Nfct ds dna untrgt ngnrj seq,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,0153U,Onc breast mrna 101 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0154U,Onc urthl ca rna fgfr3 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0155U,Onc brst ca dna pik3ca gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0156U,Copy number sequence alys,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0157U,Apc mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0158U,Mlh1 mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0159U,Msh2 mrna seq alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,0160U,Msh6 mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0161U,Pms2 mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0162U,Hered colon ca trgt mrna pnl,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0163U,Onc clrct scr 3 prtn alg,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0164U,Gi ibs ia anti-cdtb&vinculin,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,0165U,Peanut allg asmt epi,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
BCBS Medicaid,CPT,0166U,Liver ds 10 biochem asy srm,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0167U,Chornc gonadotropin hcg ia,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
BCBS Medicaid,CPT,0168U,Ftl aneuploidy dna seq alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0169U,Nudt15&tpmt gene com vrnt,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,0170U,Neuro asd rna next gen seq,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0171U,Trgt gen seq alys pnl dna 23,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0172T,Lumbar spine process addl,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"7,098.75","7,098.75",,,,,,
BCBS Medicaid,CPT,0172U,Onc sld tum alys brca1 brca2,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0173U,Psyc gen alys panel 14 genes,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0174U,Onc solid tumor 30 prtn trgt,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0175U,Psyc gen alys panel 15 genes,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0176U,Cdtb&vinculin igg antb ia,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0177U,Onc brst ca dna pik3ca 11,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0178T,64 lead ecg w/i&r,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
BCBS Medicaid,CPT,0178U,Peanut allg asmt epi clin rx,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
BCBS Medicaid,CPT,0179T,64 lead ecg w/tracing,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
BCBS Medicaid,CPT,0179U,Onc nonsm cll lng ca alys 23,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0180U,Abo gnotyp abo 7 exons,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0181U,Co gnotyp aqp1 exon 1,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0182T,Hdr elect brachytherapy,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
BCBS Medicaid,CPT,0182U,Crom gnotyp cd55 exons 1-10,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0183U,Di gnotyp slc4a1 exon 19,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0184T,Exc rectal tumor endoscopic,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
BCBS Medicaid,CPT,0184U,Do gnotyp art4 exon 2,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0185U,Fut1 gnotyp fut1 exon 4,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0186U,Fut2 gnotyp fut2 exon 2,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0187U,Fy gnotyp ackr1 exons 1-2,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0188U,Ge gnotyp gypc exons 1-4,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0189U,Gypa gnotyp ntrns 1 5 exon 2,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0190U,Gypb gnotyp ntrns 1 5 seux 3,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0191T,Insert ant segment drain int,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
BCBS Medicaid,CPT,0191U,In gnotyp cd44 exons 2 3 6,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0192U,Jk gnotyp slc14a1 exon 9,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0193U,Jr gnotyp abcg2 exons 2-26,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0194U,Kel gnotyp kel exon 8,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0195U,Klf1 targeted sequencing,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0196U,Lu gnotyp bcam exon 3,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0197U,Lw gnotyp icam4 exon 1,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0198T,Ocular blood flow measure,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,0198U,Rhd&rhce gntyp rhd1-10&rhce5,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0199U,Sc gnotyp ermap exons 4 12,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0200U,Xk gnotyp xk exons 1-3,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0201U,Yt gnotyp ache exon 2,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0203U,Ai ibd mrna xprsn prfl 17,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0204U,Onc thyr mrna xprsn alys 593,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0205T,Inirs each vessel add-on,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,0205U,Oph amd alys 3 gene variants,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0206T,Cptr dbs alys car elec dta,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,0206U,Neuro alzheimer cell aggregj,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0207T,Clear eyelid gland w/heat,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,0207U,Neuro alzheimer quan imaging,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,0208U,Onc mtc mrna xprsn alys 108,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0209U,Cytog const alys interrog,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0210U,Syphilis tst antb ia quan,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,0211U,Onc pan-tum dna&rna gnrj seq,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0212T,Compre audiometry evaluation,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
BCBS Medicaid,CPT,0212U,Rare ds gen dna alys proband,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0213U,Rare ds gen dna alys ea comp,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0214U,Rare ds xom dna alys proband,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0215T,Njx paravert w/us cer/thor,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
BCBS Medicaid,CPT,0215U,Rare ds xom dna alys ea comp,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0216U,Neuro inh ataxia dna 12 com,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0217U,Neuro inh ataxia dna 51 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0218U,Neuro musc dys dmd seq alys,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0219U,Nfct agt hiv gnrj seq alys,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
BCBS Medicaid,CPT,0220U,Onc brst ca ai assmt 12 feat,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,0221U,Abo gnotyp next gnrj seq abo,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0222U,Rhd&rhce gntyp next gnrj seq,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0223T,Acoustic ecg w/i&r,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
BCBS Medicaid,CPT,0224T,Acoustic ecg 1+ analysis,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,0224U,Antibody sars-cov-2 titer(s),Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,0225T,Acoustic ecg analy & reprog,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,0226U,Svnt sarscov2 elisa plsm srm,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
BCBS Medicaid,CPT,0227U,Rx asy prsmv30+rx/metablt,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,0228T,Njx tfrml eprl w/us cer/thor,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
BCBS Medicaid,CPT,0228U,Onc prst8 ma molec prfl alg,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0229T,Njx tfrml eprl w/us cer/thor,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
BCBS Medicaid,CPT,0229U,Bcat1 promoter mthyltn alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,0230U,Ar full sequence analysis,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0231U,Cacna1a full gene analysis,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0232T,Njx platelet plasma,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,0232U,Cstb full gene analysis,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0233T,Skin glycation spectroscopy,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,0233U,Fxn gene analysis,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,0234U,Mecp2 full gene analysis,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0235T,Trluml perip athrc visceral,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,0235U,Pten full gene analysis,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0236T,Trluml perip athrc abd aorta,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,0236U,Smn1&smn2 full gene analysis,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
BCBS Medicaid,CPT,0237T,Trluml perip athrc brchiocph,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,0237U,Car ion chnlpthy gen seq pnl,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0238T,Trluml perip athrc iliac art,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,0238U,Onc lnch syn gen dna seq aly,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0239U,Trgt gen seq alys pnl 311+,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,0240T,Esoph motility 3d topography,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
BCBS Medicaid,CPT,0241T,Esoph motility w/stim/perf,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
BCBS Medicaid,CPT,0243T,Intm msr bronchodil wheeze,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
BCBS Medicaid,CPT,0244T,Cont msr bronchodil wheeze,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
BCBS Medicaid,CPT,0249T,Ligation hemorrhoid w/us,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
BCBS Medicaid,CPT,0253T,Insert aqueous drain device,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
BCBS Medicaid,CPT,0255T,Evasc rpr iliac art bifr s&i,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
BCBS Medicaid,CPT,0263T,Im b1 mrw cel ther cmpl,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
BCBS Medicaid,CPT,0264T,Im b1 mrw cel ther xcl hrvst,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
BCBS Medicaid,CPT,0265T,Im b1 mrw cel ther hrvst onl,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
BCBS Medicaid,CPT,0266T,Implt/rpl crtd sns dev total,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
BCBS Medicaid,CPT,0267T,Implt/rpl crtd sns dev lead,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,0268T,Implt/rpl crtd sns dev gen,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
BCBS Medicaid,CPT,0269T,Rev/remvl crtd sns dev total,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,0270T,Rev/remvl crtd sns dev lead,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,0271T,Rev/remvl crtd sns dev gen,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,0272T,Interrogate crtd sns dev,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,0273T,Interrogate crtd sns w/pgrmg,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,0278T,Tempr,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,0282T,Periph field stimul trial,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,0283T,Periph field stimul perm,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
BCBS Medicaid,CPT,0284T,Periph field stimul revise,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,0285T,Periph field stimul analys,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,0286T,Near ifr spectrsc of wounds,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,0288T,Anoscopy w/rf delivery,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
BCBS Medicaid,CPT,0289T,Laser inc for pkp/lkp donor,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
BCBS Medicaid,CPT,0290T,Laser inc for pkp/lkp recip,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
BCBS Medicaid,CPT,0294T,Ins lt atrl mont pres lead,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
BCBS Medicaid,CPT,0295T,Ext ecg complete,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,0296T,Ext ecg recording,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,0297T,Ext ecg scan w/report,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,0298T,Ext ecg review and interp,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,0301T,Mw therapy for breast tumor,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
BCBS Medicaid,CPT,0302T,Icar ischm mntrng sys compl,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
BCBS Medicaid,CPT,0303T,Icar ischm mntrng sys eltrd,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
BCBS Medicaid,CPT,0304T,Icar ischm mntrng sys device,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
BCBS Medicaid,CPT,0305T,Icar ischm mntrng prgrm eval,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,0306T,Icar ischm mntr interr eval,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,0307T,Rmvl icar ischm mntrng dvce,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
BCBS Medicaid,CPT,0308T,Insj ocular telescope prosth,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
BCBS Medicaid,CPT,0310T,Motor function mapping ntms,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,0311T,Cal & alys cntrl artl press,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,0312T,Laps impltj nstim vagus,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
BCBS Medicaid,CPT,0313T,Laps rmvl nstim array vagus,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,0314T,Laps rmvl vgl arry&pls gen,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,0315T,Rmvl vagus nerve pls gen,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,0316T,Replc vagus nerve pls gen,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
BCBS Medicaid,CPT,0317T,Elec alys vagus nrv pls gen,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,0329T,Mntr io press 24hrs/> uni/bi,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
BCBS Medicaid,CPT,0330T,Tear film img uni/bi w/i&r,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
BCBS Medicaid,CPT,0331T,Heart symp image plnr,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
BCBS Medicaid,CPT,0332T,Heart symp image plnr spect,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
BCBS Medicaid,CPT,0333T,Visual ep scr acuity auto,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,0335T,Insj sinus tarsi implant,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,0337T,Endothel fxnassmnt non-invas,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,0341T,Quant pupillometry w/ rprt,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,0342T,Thxp apheresis w/hdl delip,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
BCBS Medicaid,CPT,0346T,Ultrasound elastography,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,0348T,Rsa spine exam,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,0349T,Rsa upper extr exam,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,0350T,Rsa lower extr exam,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,0352T,Oct brst/node i&r per spec,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,0354T,Oct breast surg cavity i&r,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,0355T,Gi tract capsule endoscopy,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,0356T,Insrt drug device for iop,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
BCBS Medicaid,CPT,0357T,Cryopreservation oocyte(s),Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,0358T,Bia whole body,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,0362T,Bhv id suprt assmt ea 15 min,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
BCBS Medicaid,CPT,0373T,Adapt bhv tx ea 15 min,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
BCBS Medicaid,CPT,0376T,Insert ant segment drain int,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
BCBS Medicaid,CPT,0377T,Anoscpy inj agent for incont,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
BCBS Medicaid,CPT,0378T,Visual field assmnt rev/rprt,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,0379T,Vis field assmnt tech suppt,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,0380T,Comp animat ret imag series,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,0381T,Ext h rate epi sz 14 days,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,0382T,Ext h rate sz 14 day ri only,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,0383T,Ext h rate sz up to 30 days,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,0384T,Ex h rate sz 30 day ri only,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,0385T,Ex h rate for sz ovr 30 day,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,0386T,Ex h rate sz 30+ day ri only,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,0387T,Leadless c pm ins/rpl ventr,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
BCBS Medicaid,CPT,0388T,Leadless c pm remove ventr,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
BCBS Medicaid,CPT,0389T,Prog eval inper leadls pm,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,0390T,Periproc eval inper ledls pm,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,0391T,Intergt eval inper leadls pm,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,0392T,Lap es sph augment dev place,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
BCBS Medicaid,CPT,0393T,Es sph augmnt device removal,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
BCBS Medicaid,CPT,0394T,Hdr elctrnc skn surf brchytx,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
BCBS Medicaid,CPT,0395T,Hdr elctr ntrst/ntrcv brchtx,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
BCBS Medicaid,CPT,0398T,Mrgfus strtctc les abltj,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
BCBS Medicaid,CPT,0399T,Myocardial strain imaging,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
BCBS Medicaid,CPT,0400T,Mltispectrl digital les alys,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,0401T,Mltispectrl digital les alys,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,0402T,Colgn cross-link crn med sep,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
BCBS Medicaid,CPT,0403T,Diabetes prev standard curr,Preventive Care,Per Unit,$26.23 ,OP,26.23,26.23,,,,,,
BCBS Medicaid,CPT,0406T,Sin ndsc plmt drg elut mplnt,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
BCBS Medicaid,CPT,0407T,Sin ndsc plmt drg elut mplnt,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
BCBS Medicaid,CPT,0408T,Insj/rplc cardiac modulj sys,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
BCBS Medicaid,CPT,0409T,Insj/rplc car modulj pls gn,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
BCBS Medicaid,CPT,0412T,Rmvl cardiac modulj pls gen,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
BCBS Medicaid,CPT,0414T,Rmvl & rpl car modulj pls gn,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
BCBS Medicaid,CPT,0417T,Prgrmg eval cardiac modulj,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,0418T,Interro eval cardiac modulj,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,0419T,Dstrj neurofibroma xtnsv,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,0420T,Dstrj neurofibroma xtnsv,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,0421T,Waterjet prostate abltj cmpl,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
BCBS Medicaid,CPT,0422T,Tactile breast img uni/bi,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
BCBS Medicaid,CPT,0423T,Assay secretory type ii pla2,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,0424T,Insj/rplc nstim apnea compl,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
BCBS Medicaid,CPT,0425T,Insj/rplc nstim apnea sen ld,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,0426T,Insj/rplc nstim apnea stm ld,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
BCBS Medicaid,CPT,0427T,Insj/rplc nstim apnea pls gn,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"7,098.75","7,098.75",,,,,,
BCBS Medicaid,CPT,0428T,Rmvl nstim apnea pls gen,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,0429T,Rmvl nstim apnea sen ld,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,0430T,Rmvl nstim apnea stimj ld,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,0431T,Rmvl/rplc nstim apnea pls gn,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"7,098.75","7,098.75",,,,,,
BCBS Medicaid,CPT,0432T,Repos nstim apnea stimj ld,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,0433T,Repos nstim apnea sensing ld,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,0434T,Interro eval npgs apnea,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,0435T,Prgrmg eval npgs apnea 1 ses,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,0436T,Prgrmg eval npgs apnea study,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,0437T,Impltj synth rnfcmt abdl wal,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
BCBS Medicaid,CPT,0438T,Tprnl plmt biodegrdabl matrl,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
BCBS Medicaid,CPT,0439T,Myocrd contrast prfuj echo,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
BCBS Medicaid,CPT,0440T,Abltj perc uxtr/perph nrv,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,0441T,Abltj perc lxtr/perph nrv,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,0442T,Abltj perc plex/trncl nrv,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,0443T,R-t spctrl alys prst8 tiss,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,0446T,Insj impltbl glucose sensor,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,0447T,Rmvl impltbl glucose sensor,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,0448T,Remvl insj impltbl gluc sens,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
BCBS Medicaid,CPT,0449T,Insj aqueous drain dev 1st,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
BCBS Medicaid,CPT,0450T,Insj aqueous drain dev each,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
BCBS Medicaid,CPT,0453T,Insj/rplcmt mech-elec ntrfce,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
BCBS Medicaid,CPT,0457T,Remvl mech-elec skin ntrfce,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
BCBS Medicaid,CPT,0462T,Prgrmg eval aortic ventr sys,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,0463T,Interrog aortic ventr sys,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,0464T,Visual ep test for glaucoma,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
BCBS Medicaid,CPT,0466T,Insj ch wal respir eltrd/ra,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
BCBS Medicaid,CPT,0467T,Revj/rplmnt ch respir eltrd,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,0468T,Rmvl ch wal respir eltrd/ra,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
BCBS Medicaid,CPT,0469T,Rta polarize scan oc scr bi,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
BCBS Medicaid,CPT,0470T,Oct skn img acquisj i&r 1st,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
BCBS Medicaid,CPT,0471T,Oct skn img acquisj i&r addl,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
BCBS Medicaid,CPT,0472T,Prgrmg io rta eltrd ra,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,0473T,Reprgrmg io rta eltrd ra,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,0474T,Insj aqueous drg dev io rsvr,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
BCBS Medicaid,CPT,0475T,Rec ftl car sgl 3 ch i&r,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
BCBS Medicaid,CPT,0476T,Rec ftl car sgl elec tr data,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
BCBS Medicaid,CPT,0477T,Rec ftl car sgl xrtj alys,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
BCBS Medicaid,CPT,0478T,Rec ftl car 3 ch rev i&r,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
BCBS Medicaid,CPT,0481T,Njx autol wbc concentrate,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,0482T,Absl quan myocrd bld flo pet,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
BCBS Medicaid,CPT,0485T,Oct mid ear i&r unilateral,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,0486T,Oct mid ear i&r bilateral,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,0487T,Trvg biomchn mapg w/reprt,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,0488T,Diabetes prev online/elec,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
BCBS Medicaid,CPT,0489T,Regn cell tx scldr hands,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,0490T,Regn cell tx scldr h mlt inj,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,0497T,Xtrnl pt act ecg in-off conn,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
BCBS Medicaid,CPT,0498T,Xtrnl pt act ecg r&i pr 30 d,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
BCBS Medicaid,CPT,0499T,Cysto f/urtl strix/stenosis,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
BCBS Medicaid,CPT,0500T,Hpv 5+ hi risk hpv types,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,0501T,Cor ffr derived cor cta data,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
BCBS Medicaid,CPT,0502T,Cor ffr data prep & transmis,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
BCBS Medicaid,CPT,0503T,Cor ffr alys gnrj ffr mdl,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
BCBS Medicaid,CPT,0504T,Cor ffr data review i&r,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
BCBS Medicaid,CPT,0505T,Ev fempop artl revsc,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,0506T,Mac pgmt opt dns meas hfp,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,0507T,Near ifr 2img mibmn glnd i&r,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,0508T,Pls echo us b1 dns meas tib,Diagnostic Radiology,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
BCBS Medicaid,CPT,0509T,Pattern erg w/i&r,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
BCBS Medicaid,CPT,0510T,Rmvl sinus tarsi implant,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
BCBS Medicaid,CPT,0511T,Rmvl&rinsj sinus tarsi implt,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
BCBS Medicaid,CPT,0514T,Intraop vis axis id pt fixj,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,0515T,Insj wcs lv compl sys,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
BCBS Medicaid,CPT,0517T,Insj wcs lv pg compnt,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
BCBS Medicaid,CPT,0518T,Rmvl pg compnt wcs,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
BCBS Medicaid,CPT,0519T,Rmvl & rplcmt pg compnt wcs,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
BCBS Medicaid,CPT,0520T,Rmvl&rplcmt pg wcs new eltrd,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
BCBS Medicaid,CPT,0521T,Interrog dev eval wcs ip,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,0522T,Prgrmg dev eval wcs ip,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,0525T,Insj/rplcmt compl iims,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
BCBS Medicaid,CPT,0527T,Insj/rplcmt iims implt mntr,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
BCBS Medicaid,CPT,0528T,Prgrmg dev eval iims ip,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,0529T,Interrog dev eval iims ip,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,0530T,Removal complete iims,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
BCBS Medicaid,CPT,0532T,Removal iims implt mntr only,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
BCBS Medicaid,CPT,0533T,Cont rec mvmt do 6-10 days,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,0534T,Cont rec mvmt do setup&train,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,0535T,Cont rec mvmt do reprt cnfig,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,0536T,Cont rec mvmt do dl w/i&r,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,0541T,Myocardial imaging mcg,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
BCBS Medicaid,CPT,0542T,Myocardial imaging mcg i&r,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
BCBS Medicaid,CPT,0546T,Rf spectrsc ntraop mrgn asmt,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,0547T,B1 matrl qual tst mcrind tib,Diagnostic Radiology,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
BCBS Medicaid,CPT,0548T,Tprnl balo cntnc dev bi,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
BCBS Medicaid,CPT,0549T,Tprnl balo cntnc dev uni,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
BCBS Medicaid,CPT,0550T,Tprnl balo cntnc dev rmvl ea,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
BCBS Medicaid,CPT,0551T,Tprnl balo cntnc dev adjmt,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
BCBS Medicaid,CPT,0552T,Low-level laser therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,0553T,Perq tcat iliac anast implt,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,0554T,B1 str & fx rsk analysis,Diagnostic Radiology,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
BCBS Medicaid,CPT,0556T,B1 str & fx rsk assessment,Diagnostic Radiology,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
BCBS Medicaid,CPT,0558T,Ct scan f/biomchn ct alys,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
BCBS Medicaid,CPT,0563T,Evac meibomian glnd heat bi,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,0564T,Onc chemo rx cytotox csc 14,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,0566T,Autol cell implt adps njx,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
BCBS Medicaid,CPT,0568T,Intro mix saline&air f/ssg,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,0571T,Insj/rplcmt icds ss eltrd,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
BCBS Medicaid,CPT,0575T,Prgrmg dev eval icds ss ip,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,0576T,Interrog dev eval icds ss ip,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,0577T,Ephys eval icds ss,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
BCBS Medicaid,CPT,0578T,Rem interrog dev icds phys,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,0579T,Rem interrog dev icds tech,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,0581T,Abltj mal brst tum perq crtx,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
BCBS Medicaid,CPT,0582T,Trurl abltj mal prst8 tiss,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
BCBS Medicaid,CPT,0583T,Tmpst auto tube dlvr sys,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,0587T,Perq impltj/rplcmt isdns ptn,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
BCBS Medicaid,CPT,0588T,Revision/removal isdns ptn,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
BCBS Medicaid,CPT,0589T,Elec alys smpl prgrmg iins,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
BCBS Medicaid,CPT,0590T,Elec alys cplx prgrmg iins,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
BCBS Medicaid,CPT,0591T,Hlth&wb coaching indiv 1st,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
BCBS Medicaid,CPT,0592T,Hlth&wb coaching indiv f-up,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
BCBS Medicaid,CPT,0593T,Hlth&wb coaching group,Preventive Care,Per Unit,$26.23 ,OP,26.23,26.23,,,,,,
BCBS Medicaid,CPT,0596T,Temp fml iu vlv-pmp 1st insj,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
BCBS Medicaid,CPT,0597T,Temp fml iu valve-pmp rplcmt,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
BCBS Medicaid,CPT,0602T,Transdermal gfr measurements,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,0603T,Transdermal gfr monitoring,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,0604T,Rem oct rta dev setup&educaj,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,0605T,Rem oct rta techl sprt min 8,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,0607T,Rem mntr pulm flu mntr setup,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,0608T,Rem mntr pulm flu mntr alys,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,0609T,Mrs disc pain acquisj data,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
BCBS Medicaid,CPT,0610T,Mrs disc pain transmis data,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,0611T,Mrs disc pain alg alys data,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,0614T,Rmvl&rplcmt ss impl dfb pg,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
BCBS Medicaid,CPT,0615T,Eye mvmt alys w/o calbrj i&r,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,0616T,Insertion of iris prosthesis,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
BCBS Medicaid,CPT,0617T,Insj iris prosth w/rmvl&insj,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
BCBS Medicaid,CPT,0618T,Insj iris prosth sec io lens,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
BCBS Medicaid,CPT,0619T,Cysto w/prst8 commissurotomy,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
BCBS Medicaid,CPT,0620T,Evasc ven artlz tibl/prnl vn,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,0621T,Trabeculostomy interno laser,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
BCBS Medicaid,CPT,0622T,Trabeculostomy int lsr w/scp,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
BCBS Medicaid,CPT,0623T,Auto quantification c plaque,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
BCBS Medicaid,CPT,0632T,Perq tcat us abltj nrv p-art,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
BCBS Medicaid,CPT,0633T,Ct breast w/3d uni c-,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
BCBS Medicaid,CPT,0634T,Ct breast w/3d uni c+,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
BCBS Medicaid,CPT,0635T,Ct breast w/3d uni c-/c+,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
BCBS Medicaid,CPT,0636T,Ct breast w/3d bi c-,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
BCBS Medicaid,CPT,0637T,Ct breast w/3d bi c+,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
BCBS Medicaid,CPT,0638T,Ct breast w/3d bi c-/c+,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
BCBS Medicaid,CPT,0639T,Wrls skn snr anisotropy meas,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,C1762,"Conn tiss, human(inc fascia)",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,C1763,"Conn tiss, non-human",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,C1849,"Skin substitute, synthetic",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,C1878,Matrl for vocal cord,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,C2615,"Sealant, pulmonary, liquid",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,C8900,"Mra w/cont, abd",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
BCBS Medicaid,CPT,C8901,"Mra w/o cont, abd",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
BCBS Medicaid,CPT,C8902,"Mra w/o fol w/cont, abd",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
BCBS Medicaid,CPT,C8903,"Mri w/cont, breast, uni",Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
BCBS Medicaid,CPT,C8904,"Mri w/o cont, breast, uni",Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
BCBS Medicaid,CPT,C8905,"Mri w/o fol w/cont, brst, un",Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
BCBS Medicaid,CPT,C8906,"Mri w/cont, breast, bi",Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
BCBS Medicaid,CPT,C8907,"Mri w/o cont, breast, bi",Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
BCBS Medicaid,CPT,C8908,"Mri w/o fol w/cont, breast,",Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
BCBS Medicaid,CPT,C8909,"Mra w/cont, chest",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
BCBS Medicaid,CPT,C8910,"Mra w/o cont, chest",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
BCBS Medicaid,CPT,C8911,"Mra w/o fol w/cont, chest",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
BCBS Medicaid,CPT,C8912,"Mra w/cont, lwr ext",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
BCBS Medicaid,CPT,C8913,"Mra w/o cont, lwr ext",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
BCBS Medicaid,CPT,C8914,"Mra w/o fol w/cont, lwr ext",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
BCBS Medicaid,CPT,C8918,"Mra w/cont, pelvis",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
BCBS Medicaid,CPT,C8919,"Mra w/o cont, pelvis",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
BCBS Medicaid,CPT,C8920,"Mra w/o fol w/cont, pelvis",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
BCBS Medicaid,CPT,C8921,"Tte w or w/o fol w/cont, com",Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
BCBS Medicaid,CPT,C8922,"Tte w or w/o fol w/cont, f/u",Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
BCBS Medicaid,CPT,C8923,"2d tte w or w/o fol w/con,co",Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
BCBS Medicaid,CPT,C8924,"2d tte w or w/o fol w/con,fu",Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
BCBS Medicaid,CPT,C8925,"2d tee w or w/o fol w/con,in",Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
BCBS Medicaid,CPT,C8926,"Tee w or w/o fol w/cont,cong",Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
BCBS Medicaid,CPT,C8927,"Tee w or w/o fol w/cont, mon",Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
BCBS Medicaid,CPT,C8928,"Tte w or w/o fol w/con,stres",Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
BCBS Medicaid,CPT,C8929,"Tte w or wo fol wcon,doppler",Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
BCBS Medicaid,CPT,C8930,"Tte w or w/o contr, cont ecg",Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
BCBS Medicaid,CPT,C8931,"Mra, w/dye, spinal canal",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
BCBS Medicaid,CPT,C8932,"Mra, w/o dye, spinal canal",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
BCBS Medicaid,CPT,C8933,"Mra, w/o&w/dye, spinal canal",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
BCBS Medicaid,CPT,C8934,"Mra, w/dye, upper extremity",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
BCBS Medicaid,CPT,C8935,"Mra, w/o dye, upper extr",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
BCBS Medicaid,CPT,C8936,"Mra, w/o&w/dye, upper extr",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
BCBS Medicaid,CPT,C8957,"Prolonged iv inf, req pump",General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
BCBS Medicaid,CPT,C9014,"Injection, cerliponase alfa",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,C9015,"C-1 esterase, haegarda",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,C9016,"Inj, triptorelin ext rel",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,C9024,"Inj, daunorubicin-cytarabine",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
BCBS Medicaid,CPT,C9025,"Injection, ramucirumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,C9026,"Injection, vedolizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,C9027,"Injection, pembrolizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
BCBS Medicaid,CPT,C9028,Inj. inotuzumab ozogamicin,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
BCBS Medicaid,CPT,C9029,"Injection, guselkumab",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
BCBS Medicaid,CPT,C9030,Inj copanlisib,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,C9031,"Lutetium Lu 177 dotatate, tx",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,C9032,Voretigene neparvovec-rzyl,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,C9033,"Inj, akynzeo",Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,189.67,189.67,,,,,,
BCBS Medicaid,CPT,C9034,"Injection, dexamethasone 9%",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,C9035,"Injection, Aristada Initio",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
BCBS Medicaid,CPT,C9036,"Injection, patisiran",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,C9037,"Injection, risperidone",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,C9038,Inj mogamulizumab-kpkc,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,C9040,"Injection, fremanezumab-vfrm",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,C9041,"Inj, coagulation factor xa",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,C9042,"Inj., belrapzo 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,C9043,"Injection, levoleucovorin",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
BCBS Medicaid,CPT,C9044,"Injection, cemiplimab-rwlc",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,C9045,Moxetumomab pasudotox-tdfk,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,C9047,"Injection, caplacizumab-yhdp",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,C9048,Dexamethasone ophth insert,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,C9049,"Injection, tagraxofusp-erzs",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,C9050,"Injection, emapalumab-lzsg",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
BCBS Medicaid,CPT,C9051,"Injection, omadacycline",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
BCBS Medicaid,CPT,C9052,"Injection, ravulizumab-cwv",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,C9053,"Inj, crizanlizumab-tmca",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
BCBS Medicaid,CPT,C9054,"Injection, lefamulin",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,C9055,"Inj, brexanolone",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,C9056,"Injection, givosiran",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,C9057,Inj cetirizine hydrochloride,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,C9058,"Injection,pegfilgrastim-bmez",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,C9059,"Injection, meloxicam",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,C9061,"Injection, teprotumumab-trbw",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,C9062,Daratumumab hyaluronidase,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,C9063,"Injection, eptinezumab-jjmr",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,C9064,Mitomycin pyelocalyceal inst,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,C9065,Romidepsin non-lyophilized,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,C9066,Sacituzumab govitecan-hziy,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,C9069,Belantamab mafodontin-blmf,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
BCBS Medicaid,CPT,C9070,"Injection, tafasitamab-cxix",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,C9071,"Injection, viltolarsen",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,C9072,"Inj, imm glob asceniv",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
BCBS Medicaid,CPT,C9121,"Injection, argatroban",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
BCBS Medicaid,CPT,C9122,Mometasone furoate (sinuva),Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
BCBS Medicaid,CPT,C9132,"Kcentra, per i.u.",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,C9137,Adynovate Factor VIII recom,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,C9138,Nuwiq Factor VIII recomb,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,C9139,"Idelvion, 1 i.u.",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,C9140,Afstyla factor viii recomb,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,C9141,Factor viii pegylated-aucl,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,C9248,"Inj, clevidipine butyrate",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,C9250,Artiss fibrin sealant,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,C9257,Bevacizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
BCBS Medicaid,CPT,C9293,"Injection, glucarpidase",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,C9349,"Puraply, puraply antimic",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,C9352,"Neuragen nerve guide, per cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,C9353,"Neurawrap nerve protector,cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,C9354,"Veritas collagen matrix, cm2",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,C9355,"Neuromatrix nerve cuff, cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,C9356,"Tenoglide tendon prot, cm2",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,C9358,"Surgimend, fetal",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,C9359,"Implnt,bon void filler-putty",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,C9360,"Surgimend, neonatal",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,C9361,Neuromend nerve wrap,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,C9362,"Implnt,bon void filler-strip",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,C9363,Integra meshed bil wound mat,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,C9364,"Porcine implant, permacol",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,C9408,"Iodine i-131 iobenguane, tx",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,C9442,"Injection, belinostat",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,C9443,"Injection, dalbavancin",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
BCBS Medicaid,CPT,C9444,"Injection, oritavancin",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
BCBS Medicaid,CPT,C9445,"C-1 esterase, Ruconest",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,C9446,"Inj, tedizolid phosphate",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,C9447,"Inj, phenylephrine ketorolac",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,C9448,Oral netupitant palonosetron,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
BCBS Medicaid,CPT,C9449,"Inj, blinatumomab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,C9450,Fluocinolone acetonide implt,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,C9451,"Injection, peramivir",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
BCBS Medicaid,CPT,C9452,"Inj, ceftolozane/tazobactam",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,C9453,"Injection, nivolumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,C9454,"Inj, pasireotide long acting",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,C9455,"Injection, siltuximab",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
BCBS Medicaid,CPT,C9456,"Inj, isavuconazonium sulfate",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,C9460,"Injection, cangrelor",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,C9465,"Injection, Durolane",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,C9466,"Injection, benralizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,C9467,Inj rituximab hyaluronidase,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,C9468,"Inj, factor ix, Rebinyn",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,C9469,Inj triamcinolone acetonide,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,C9470,Aripiprazole lauroxil im,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,C9471,"Hymovis, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
BCBS Medicaid,CPT,C9472,Inj talimogene laherparepvec,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,C9473,"Injection, mepolizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
BCBS Medicaid,CPT,C9474,"Inj, irinotecan liposome",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,C9475,"Injection, necitumumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,C9476,"Injection, daratumumab",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
BCBS Medicaid,CPT,C9477,"Injection, elotuzumab",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
BCBS Medicaid,CPT,C9478,"Injection, sebelipase alfa",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,C9480,"Injection, trabectedin",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,C9481,"Injection, reslizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
BCBS Medicaid,CPT,C9482,Sotalol hydrochloride iv,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,C9483,"Injection, atezolizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,C9484,"Injection, eteplirsen",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,C9485,"Injection, olaratumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,C9487,"Ustekinumab IV inj, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
BCBS Medicaid,CPT,C9488,Conivaptan hcl,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,C9489,"Injection, nusinersen",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,C9490,"Injection, bezlotoxumab",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
BCBS Medicaid,CPT,C9491,"Injection, avelumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,C9492,"Injection, durvalumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,C9493,"Injection, edaravone",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
BCBS Medicaid,CPT,C9494,"Injection, ocrelizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,C9497,"Loxapine, inhalation powder",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,C9600,Perc drug-el cor stent sing,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
BCBS Medicaid,CPT,C9601,Perc drug-el cor stent bran,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
BCBS Medicaid,CPT,C9602,Perc d-e cor stent ather s,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
BCBS Medicaid,CPT,C9603,Perc d-e cor stent ather br,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
BCBS Medicaid,CPT,C9604,Perc d-e cor revasc t cabg s,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
BCBS Medicaid,CPT,C9605,Perc d-e cor revasc t cabg b,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
BCBS Medicaid,CPT,C9606,Perc d-e cor revasc w ami s,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
BCBS Medicaid,CPT,C9607,Perc d-e cor revasc chro sin,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
BCBS Medicaid,CPT,C9608,Perc d-e cor revasc chro add,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
BCBS Medicaid,CPT,C9724,Eps stomach plic,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
BCBS Medicaid,CPT,C9726,Rxt breast appl place/remov,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
BCBS Medicaid,CPT,C9728,"Place device/marker, non pro",Therapeutic Radiology,Per Unit,$68.45 ,OP,68.45,68.45,,,,,,
BCBS Medicaid,CPT,C9734,"U/s trtmt, not leiomyomata",General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
BCBS Medicaid,CPT,C9737,Lap esoph augmentation,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
BCBS Medicaid,CPT,C9739,Cystoscopy prostatic imp 1-3,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
BCBS Medicaid,CPT,C9740,Cysto impl 4 or more,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
BCBS Medicaid,CPT,C9741,Impl pressure sensor w/angio,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
BCBS Medicaid,CPT,C9742,Laryngoscopy with injection,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
BCBS Medicaid,CPT,C9743,Bulking/spacer material impl,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,C9744,Abd us w/contrast,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
BCBS Medicaid,CPT,C9745,Nasal endo eustachian tube,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
BCBS Medicaid,CPT,C9747,"Ablation, hifu, prostate",Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
BCBS Medicaid,CPT,C9749,Repair nasal stenosis w/imp,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,C9750,Ins/rem-replace compl iims,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
BCBS Medicaid,CPT,C9762,Cardiac mri seg dys strain,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
BCBS Medicaid,CPT,C9763,Cardiac mri seg dys stress,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
BCBS Medicaid,CPT,C9765,Revasc intra lithotrip-stent,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,C9767,Revasc lithotrip-stent-ather,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,C9768,Endo us-guide hep porto grad,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
BCBS Medicaid,CPT,C9769,Cysto w/temp pros implant,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
BCBS Medicaid,CPT,C9770,"Vitrec/mech pars, subret inj",Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
BCBS Medicaid,CPT,C9771,Nsl/sins cryo post nasal tis,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
BCBS Medicaid,CPT,C9772,Revasc lithotrip tibi/perone,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,C9773,Revasc lithotr-stent tib/per,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,C9774,Revasc lithotr-ather tib/per,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,C9775,Revasc lith-sten-ath tib/per,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
BCBS Medicaid,CPT,C9803,Hopd covid-19 spec collect,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,D0120,Periodic oral evaluation,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
BCBS Medicaid,CPT,D0140,Limit oral eval problm focus,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
BCBS Medicaid,CPT,D0145,"Oral evaluation, pt < 3yrs",Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
BCBS Medicaid,CPT,D0150,Comprehensve oral evaluation,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
BCBS Medicaid,CPT,D0160,Extensv oral eval prob focus,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
BCBS Medicaid,CPT,D0170,"Re-eval,est pt,problem focus",Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
BCBS Medicaid,CPT,D0171,Re-eval post-op visit,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
BCBS Medicaid,CPT,D0180,Comp periodontal evaluation,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
BCBS Medicaid,CPT,D0190,Screening of a patient,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
BCBS Medicaid,CPT,D0191,Assessment of a patient,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
BCBS Medicaid,CPT,D0210,Intraor complete film series,Dental,Per Unit,$87.62 ,OP,87.62,87.62,,,,,,
BCBS Medicaid,CPT,D0220,Intraoral periapical first,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
BCBS Medicaid,CPT,D0230,Intraoral periapical ea add,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
BCBS Medicaid,CPT,D0240,Intraoral occlusal film,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
BCBS Medicaid,CPT,D0250,Extraoral 2d project image,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
BCBS Medicaid,CPT,D0251,Extraoral posterior image,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
BCBS Medicaid,CPT,D0260,Extraoral ea additional film,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
BCBS Medicaid,CPT,D0270,Dental bitewing single image,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
BCBS Medicaid,CPT,D0272,Dental bitewings two images,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
BCBS Medicaid,CPT,D0273,Bitewings - three images,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
BCBS Medicaid,CPT,D0274,Bitewings four images,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
BCBS Medicaid,CPT,D0277,Vert bitewings 7 to 8 images,Dental,Per Unit,$87.62 ,OP,87.62,87.62,,,,,,
BCBS Medicaid,CPT,D0290,Skull/facial bone image,Dental,Per Unit,$87.62 ,OP,87.62,87.62,,,,,,
BCBS Medicaid,CPT,D0310,Dental saliography,Dental,Per Unit,$87.62 ,OP,87.62,87.62,,,,,,
BCBS Medicaid,CPT,D0320,Dental tmj arthrogram incl i,Dental,Per Unit,$87.62 ,OP,87.62,87.62,,,,,,
BCBS Medicaid,CPT,D0321,Other tmj images by report,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
BCBS Medicaid,CPT,D0322,Dental tomographic survey,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
BCBS Medicaid,CPT,D0330,Panoramic image,Dental,Per Unit,$87.62 ,OP,87.62,87.62,,,,,,
BCBS Medicaid,CPT,D0340,2d cephalometric image,Dental,Per Unit,$87.62 ,OP,87.62,87.62,,,,,,
BCBS Medicaid,CPT,D0350,Oral/facial photo images,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
BCBS Medicaid,CPT,D0351,3d photographic image,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
BCBS Medicaid,CPT,D0364,Cone beam ct capt & interp,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
BCBS Medicaid,CPT,D0365,Cone beam ct interprete man,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
BCBS Medicaid,CPT,D0366,Cone beam ct interprete max,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
BCBS Medicaid,CPT,D0367,Cone beam ct interp both jaw,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
BCBS Medicaid,CPT,D0368,Cone beam ct interprete tmj,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
BCBS Medicaid,CPT,D0369,Max mri capture & interprete,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
BCBS Medicaid,CPT,D0370,Max ultrasound capt & interp,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,D0371,Sialoendoscopy capt & interp,Dental,Per Unit,$87.62 ,OP,87.62,87.62,,,,,,
BCBS Medicaid,CPT,D0380,Cone beam ct capture limited,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
BCBS Medicaid,CPT,D0381,Cone beam ct capt mandible,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
BCBS Medicaid,CPT,D0382,Cone beam ct capt maxilla,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
BCBS Medicaid,CPT,D0383,Cone beam ct both jaws,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
BCBS Medicaid,CPT,D0384,Cone beam ct capture tmj,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
BCBS Medicaid,CPT,D0385,Max mri image capture,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
BCBS Medicaid,CPT,D0386,Max ultrasound image capture,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,D0391,Imterprete diagnostic image,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
BCBS Medicaid,CPT,D0393,Trtmnt simulation 3d image,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
BCBS Medicaid,CPT,D0394,Digital sub 2 or more images,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
BCBS Medicaid,CPT,D0395,Fusion 2 or more 3d images,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
BCBS Medicaid,CPT,D0411,Hba1c in office testing,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,D0412,Blood glucose level test,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,D0414,Lab process microbial spec,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,D0415,Collection of microorganisms,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,D0416,Viral culture,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,D0418,Analysis of saliva sample,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,D0419,Assess of salivary flow,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
BCBS Medicaid,CPT,D0421,Gen tst suscept oral disease,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,D0422,Collect & prep genetic samp,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,D0423,Genetic test spec analysis,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,D0425,Caries susceptibility test,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,D0431,Diag tst detect mucos abnorm,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
BCBS Medicaid,CPT,D0460,Pulp vitality test,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
BCBS Medicaid,CPT,D0470,Diagnostic casts,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
BCBS Medicaid,CPT,D0472,"Gross exam, prep & report",Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,D0473,"Micro exam, prep & report",Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,D0474,Micro w exam of surg margins,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D0475,Decalcification procedure,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,D0476,Spec stains for microorganis,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,D0477,Spec stains not for microorg,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,D0478,Immunohistochemical stains,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,D0479,Tissue in-situ hybridization,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,D0480,Cytopath smear prep & report,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,D0481,Electron microscopy,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,D0482,Direct immunofluorescence,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,D0483,Indirect immunofluorescence,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,D0484,Consult slides prep elsewher,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
BCBS Medicaid,CPT,D0485,Consult inc prep of slides,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D0486,Access of transep cytol samp,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,D0502,Other oral pathology procedu,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
BCBS Medicaid,CPT,D0600,Non-ionizing diag proc,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
BCBS Medicaid,CPT,D0601,Caries risk assess low risk,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
BCBS Medicaid,CPT,D0602,Caries risk assess mod risk,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
BCBS Medicaid,CPT,D0603,Caries risk assess high risk,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
BCBS Medicaid,CPT,D0604,Antigen test pub hlth pathog,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,D0605,Antibody test pub hlth path,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,D0701,Pano radio image,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
BCBS Medicaid,CPT,D0702,2d cephal radio image,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
BCBS Medicaid,CPT,D0703,2d oral/facial photo image,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
BCBS Medicaid,CPT,D0704,3d photo image capture only,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
BCBS Medicaid,CPT,D0705,Extra oral post radio image,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
BCBS Medicaid,CPT,D0706,Intraoral occlus radio image,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
BCBS Medicaid,CPT,D0707,Intraoral periap radio image,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
BCBS Medicaid,CPT,D0708,Intraoral bite radio image,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
BCBS Medicaid,CPT,D0709,Intraoral cmplt radio images,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
BCBS Medicaid,CPT,D0999,Unspecified diagnostic proce,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
BCBS Medicaid,CPT,D1110,Dental prophylaxis adult,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
BCBS Medicaid,CPT,D1120,Dental prophylaxis child,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
BCBS Medicaid,CPT,D1206,Topical fluoride varnish,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
BCBS Medicaid,CPT,D1208,Topical app fluorid ex vrnsh,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
BCBS Medicaid,CPT,D1310,Nutri counsel-control caries,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
BCBS Medicaid,CPT,D1320,Tobacco counseling,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
BCBS Medicaid,CPT,D1321,Couns for high risk sub use,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
BCBS Medicaid,CPT,D1330,Oral hygiene instruction,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
BCBS Medicaid,CPT,D1351,Dental sealant per tooth,Dental,Per Unit,$24.50 ,OP,24.5,24.5,,,,,,
BCBS Medicaid,CPT,D1352,"Prev resin rest, perm tooth",Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
BCBS Medicaid,CPT,D1353,Sealant repair per tooth,Dental,Per Unit,$24.50 ,OP,24.5,24.5,,,,,,
BCBS Medicaid,CPT,D1354,Int caries med app per tooth,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
BCBS Medicaid,CPT,D1355,Caries med app per tooth,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
BCBS Medicaid,CPT,D1510,Space maintainer fxd unilat,Dental,Per Unit,$156.21 ,OP,156.21,156.21,,,,,,
BCBS Medicaid,CPT,D1515,Fixed bilat space maintainer,Dental,Per Unit,$156.21 ,OP,156.21,156.21,,,,,,
BCBS Medicaid,CPT,D1516,"Fixed bilat space maint, max",Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
BCBS Medicaid,CPT,D1517,"Fixed bilat space maint, man",Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
BCBS Medicaid,CPT,D1520,Remove unilat space maintain,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
BCBS Medicaid,CPT,D1525,Remove bilat space maintain,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
BCBS Medicaid,CPT,D1526,"Remove bilat space main, max",Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
BCBS Medicaid,CPT,D1527,"Remove bilat space main, man",Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
BCBS Medicaid,CPT,D1550,Recement space maintainer,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D1551,Recement space maint - max,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
BCBS Medicaid,CPT,D1552,Recement space maint - man,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
BCBS Medicaid,CPT,D1553,Recement unilat space maint,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
BCBS Medicaid,CPT,D1555,Remove fix space maintainer,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
BCBS Medicaid,CPT,D1556,Rem fixed unilat space maint,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
BCBS Medicaid,CPT,D1557,Remove fixed bilat maint max,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
BCBS Medicaid,CPT,D1558,Remove fixed bilat man,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
BCBS Medicaid,CPT,D1575,"Dist space maint, fixed unil",Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
BCBS Medicaid,CPT,D1999,Unspecified preventive proc,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
BCBS Medicaid,CPT,D2140,Amalgam one surface permanen,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2150,Amalgam two surfaces permane,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2160,Amalgam three surfaces perma,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
BCBS Medicaid,CPT,D2161,Amalgam 4 or > surfaces perm,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
BCBS Medicaid,CPT,D2330,Resin one surface-anterior,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2331,Resin two surfaces-anterior,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2332,Resin three surfaces-anterio,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2335,Resin 4/> surf or w incis an,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
BCBS Medicaid,CPT,D2390,Ant resin-based cmpst crown,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2391,Post 1 srfc resinbased cmpst,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2392,Post 2 srfc resinbased cmpst,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2393,Post 3 srfc resinbased cmpst,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2394,Post >=4srfc resinbase cmpst,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2410,Dental gold foil one surface,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2420,Dental gold foil two surface,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2430,Dental gold foil three surfa,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2510,Dental inlay metalic 1 surf,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2520,Dental inlay metallic 2 surf,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2530,Dental inlay metl 3/more sur,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2542,Dental onlay metallic 2 surf,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2543,Dental onlay metallic 3 surf,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2544,Dental onlay metl 4/more sur,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2610,Inlay porcelain/ceramic 1 su,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2620,Inlay porcelain/ceramic 2 su,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2630,Dental onlay porc 3/more sur,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
BCBS Medicaid,CPT,D2642,Dental onlay porcelin 2 surf,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2643,Dental onlay porcelin 3 surf,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2644,Dental onlay porc 4/more sur,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2650,Inlay composite/resin one su,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2651,Inlay composite/resin two su,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2652,Dental inlay resin 3/mre sur,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2662,Dental onlay resin 2 surface,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2663,Dental onlay resin 3 surface,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2664,Dental onlay resin 4/mre sur,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2710,Crown resin-based indirect,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
BCBS Medicaid,CPT,D2712,Crown 3/4 resin-based compos,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
BCBS Medicaid,CPT,D2720,Crown resin w/ high noble me,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
BCBS Medicaid,CPT,D2721,Crown resin w/ base metal,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
BCBS Medicaid,CPT,D2722,Crown resin w/ noble metal,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
BCBS Medicaid,CPT,D2740,Crown porcelain/ceramic,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
BCBS Medicaid,CPT,D2750,Crown porcelain w/ h noble m,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
BCBS Medicaid,CPT,D2751,Crown porcelain fused base m,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
BCBS Medicaid,CPT,D2752,Crown porcelain w/ noble met,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
BCBS Medicaid,CPT,D2753,Crown porc fused to titanium,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
BCBS Medicaid,CPT,D2780,Crown 3/4 cast hi noble met,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
BCBS Medicaid,CPT,D2781,Crown 3/4 cast base metal,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
BCBS Medicaid,CPT,D2782,Crown 3/4 cast noble metal,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
BCBS Medicaid,CPT,D2783,Crown 3/4 porcelain/ceramic,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
BCBS Medicaid,CPT,D2790,Crown full cast high noble m,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
BCBS Medicaid,CPT,D2791,Crown full cast base metal,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
BCBS Medicaid,CPT,D2792,Crown full cast noble metal,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
BCBS Medicaid,CPT,D2794,Crown-titanium,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
BCBS Medicaid,CPT,D2799,Provisional crown,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2910,Recement inlay onlay or part,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2915,Recement cast or prefab post,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2920,Re-cement or re-bond crown,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2921,Reattach tooth fragment,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2928,Prefab porc/cer crown perm,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
BCBS Medicaid,CPT,D2929,Prefab porc/ceram crown pri,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
BCBS Medicaid,CPT,D2930,Prefab stnlss steel crwn pri,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
BCBS Medicaid,CPT,D2931,Prefab stnlss steel crown pe,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
BCBS Medicaid,CPT,D2932,Prefabricated resin crown,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
BCBS Medicaid,CPT,D2933,Prefab stainless steel crown,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
BCBS Medicaid,CPT,D2934,Prefab steel crown primary,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
BCBS Medicaid,CPT,D2941,Int therapeutic restoration,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
BCBS Medicaid,CPT,D2950,Core build-up incl any pins,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
BCBS Medicaid,CPT,D2951,Tooth pin retention,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
BCBS Medicaid,CPT,D2952,Post and core cast + crown,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
BCBS Medicaid,CPT,D2953,Each addtnl cast post,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
BCBS Medicaid,CPT,D2954,Prefab post/core + crown,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
BCBS Medicaid,CPT,D2955,Post removal,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2957,Each addtnl prefab post,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
BCBS Medicaid,CPT,D2960,Labial veneer resin direct,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2961,Labial veneer resin indirect,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2962,Labial veneer porc indirect,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2970,Temp crown (fractured tooth),Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2971,Add proc construct new crown,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2975,Coping,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2980,Crown repair,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2981,Inlay repair,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2982,Onlay repair,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2983,Veneer repair,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2990,Resin infiltration of lesion,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D2999,Dental unspec restorative pr,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
BCBS Medicaid,CPT,D3110,Pulp cap direct,Dental,Per Unit,$74.70 ,OP,74.7,74.7,,,,,,
BCBS Medicaid,CPT,D3120,Pulp cap indirect,Dental,Per Unit,$74.70 ,OP,74.7,74.7,,,,,,
BCBS Medicaid,CPT,D3220,Therapeutic pulpotomy,Dental,Per Unit,$74.70 ,OP,74.7,74.7,,,,,,
BCBS Medicaid,CPT,D3221,Gross pulpal debridement,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
BCBS Medicaid,CPT,D3222,Part pulp for apexogenesis,Dental,Per Unit,$74.70 ,OP,74.7,74.7,,,,,,
BCBS Medicaid,CPT,D3230,Pulpal therapy anterior prim,Dental,Per Unit,$74.70 ,OP,74.7,74.7,,,,,,
BCBS Medicaid,CPT,D3240,Pulpal therapy posterior pri,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
BCBS Medicaid,CPT,D3310,"End thxpy, anterior tooth",Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
BCBS Medicaid,CPT,D3320,"End thxpy, premolar tooth",Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
BCBS Medicaid,CPT,D3330,"End thxpy, molar tooth",Dental,Per Unit,$135.31 ,OP,135.31,135.31,,,,,,
BCBS Medicaid,CPT,D3331,Non-surg tx root canal obs,Dental,Per Unit,$135.31 ,OP,135.31,135.31,,,,,,
BCBS Medicaid,CPT,D3332,Incomplete endodontic tx,Dental,Per Unit,$135.31 ,OP,135.31,135.31,,,,,,
BCBS Medicaid,CPT,D3333,Internal root repair,Dental,Per Unit,$135.31 ,OP,135.31,135.31,,,,,,
BCBS Medicaid,CPT,D3346,Retreat root canal anterior,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
BCBS Medicaid,CPT,D3347,Retreat root canal premolar,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
BCBS Medicaid,CPT,D3348,Retreat root canal molar,Dental,Per Unit,$135.31 ,OP,135.31,135.31,,,,,,
BCBS Medicaid,CPT,D3351,Apexification/recalc initial,Dental,Per Unit,$74.70 ,OP,74.7,74.7,,,,,,
BCBS Medicaid,CPT,D3352,Apexification/recalc interim,Dental,Per Unit,$74.70 ,OP,74.7,74.7,,,,,,
BCBS Medicaid,CPT,D3353,Apexification/recalc final,Dental,Per Unit,$74.70 ,OP,74.7,74.7,,,,,,
BCBS Medicaid,CPT,D3355,Pulpal regeneration initial,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
BCBS Medicaid,CPT,D3356,Pulpal regeneration interim,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
BCBS Medicaid,CPT,D3357,Pulpal regeneration complete,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
BCBS Medicaid,CPT,D3410,Apicoectomy - anterior,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
BCBS Medicaid,CPT,D3421,Root surgery premolar,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
BCBS Medicaid,CPT,D3425,Root surgery molar,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
BCBS Medicaid,CPT,D3426,Root surgery ea add root,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
BCBS Medicaid,CPT,D3427,Periradicular surgery,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
BCBS Medicaid,CPT,D3428,Bone graft peri per tooth,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
BCBS Medicaid,CPT,D3429,Bone graft peri each addl,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
BCBS Medicaid,CPT,D3430,Retrograde filling,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
BCBS Medicaid,CPT,D3431,Biological materials,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
BCBS Medicaid,CPT,D3432,Guided tissue regeneration,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
BCBS Medicaid,CPT,D3450,Root amputation,Dental,Per Unit,$135.31 ,OP,135.31,135.31,,,,,,
BCBS Medicaid,CPT,D3460,Endodontic endosseous implan,Dental,Per Unit,$135.31 ,OP,135.31,135.31,,,,,,
BCBS Medicaid,CPT,D3470,Intentional replantation,Dental,Per Unit,$135.31 ,OP,135.31,135.31,,,,,,
BCBS Medicaid,CPT,D3471,Surg rep root res anterior,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
BCBS Medicaid,CPT,D3472,Surg rep root res premolar,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
BCBS Medicaid,CPT,D3473,Surg rep root res molar,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
BCBS Medicaid,CPT,D3501,Surg exp root surf anterior,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
BCBS Medicaid,CPT,D3502,Surg exp root surf premolar,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
BCBS Medicaid,CPT,D3503,Surg exp root surf molar,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
BCBS Medicaid,CPT,D3910,Isolation- tooth w rubb dam,Dental,Per Unit,$135.31 ,OP,135.31,135.31,,,,,,
BCBS Medicaid,CPT,D3920,Tooth splitting,Dental,Per Unit,$135.31 ,OP,135.31,135.31,,,,,,
BCBS Medicaid,CPT,D3950,Canal prep/fitting of dowel,Dental,Per Unit,$135.31 ,OP,135.31,135.31,,,,,,
BCBS Medicaid,CPT,D3999,Endodontic procedure,Dental,Per Unit,$74.70 ,OP,74.7,74.7,,,,,,
BCBS Medicaid,CPT,D4210,Gingivectomy/plasty 4 or mor,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
BCBS Medicaid,CPT,D4211,Gingivectomy/plasty 1 to 3,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
BCBS Medicaid,CPT,D4212,Gingivectomy/plasty rest,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
BCBS Medicaid,CPT,D4230,Ana crown exp 4 or> per quad,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
BCBS Medicaid,CPT,D4231,Ana crown exp 1-3 per quad,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
BCBS Medicaid,CPT,D4240,Gingival flap proc w/ planin,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
BCBS Medicaid,CPT,D4241,Gngvl flap w rootplan 1-3 th,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
BCBS Medicaid,CPT,D4245,Apically positioned flap,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
BCBS Medicaid,CPT,D4249,Crown lengthen hard tissue,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
BCBS Medicaid,CPT,D4260,Osseous surgery 4 or more,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
BCBS Medicaid,CPT,D4261,Osseous surg 1 to 3 teeth,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
BCBS Medicaid,CPT,D4263,Bone replce graft first site,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
BCBS Medicaid,CPT,D4264,Bone replce graft each add,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
BCBS Medicaid,CPT,D4265,Bio mtrls to aid soft/os reg,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
BCBS Medicaid,CPT,D4266,Guided tiss regen resorble,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
BCBS Medicaid,CPT,D4267,Guided tiss regen nonresorb,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
BCBS Medicaid,CPT,D4268,Surgical revision procedure,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
BCBS Medicaid,CPT,D4270,Pedicle soft tissue graft pr,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
BCBS Medicaid,CPT,D4273,Auto tissue graft 1st tooth,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
BCBS Medicaid,CPT,D4274,Mesial/distal wedge proc,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
BCBS Medicaid,CPT,D4275,Non-auto graft 1st tooth,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
BCBS Medicaid,CPT,D4276,Con tissue w dble ped graft,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
BCBS Medicaid,CPT,D4277,Soft tissue graft firsttooth,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
BCBS Medicaid,CPT,D4278,Soft tissue graft addl tooth,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
BCBS Medicaid,CPT,D4283,Auto tissue graft addl tooth,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
BCBS Medicaid,CPT,D4285,Non-auto graft addl tooth,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
BCBS Medicaid,CPT,D4320,Provision splnt intracoronal,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
BCBS Medicaid,CPT,D4321,Provisional splint extracoro,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
BCBS Medicaid,CPT,D4341,Periodontal scaling & root,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
BCBS Medicaid,CPT,D4342,Periodontal scaling 1-3teeth,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
BCBS Medicaid,CPT,D4346,Scaling gingiv inflammation,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
BCBS Medicaid,CPT,D4355,Full mouth debridement,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
BCBS Medicaid,CPT,D4381,Localized delivery antimicro,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
BCBS Medicaid,CPT,D4910,Periodontal maint procedures,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
BCBS Medicaid,CPT,D4920,Unscheduled dressing change,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
BCBS Medicaid,CPT,D4921,Gingival irrigation per quad,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
BCBS Medicaid,CPT,D4999,Unspecified periodontal proc,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
BCBS Medicaid,CPT,D5110,Dentures complete maxillary,Dental,Per Unit,$162.24 ,OP,162.24,162.24,,,,,,
BCBS Medicaid,CPT,D5120,Dentures complete mandible,Dental,Per Unit,$162.24 ,OP,162.24,162.24,,,,,,
BCBS Medicaid,CPT,D5130,Dentures immediat maxillary,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
BCBS Medicaid,CPT,D5140,Dentures immediat mandible,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
BCBS Medicaid,CPT,D5211,Dentures maxill part resin,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
BCBS Medicaid,CPT,D5212,Dentures mand part resin,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
BCBS Medicaid,CPT,D5213,Dentures maxill part metal,Dental,Per Unit,$162.24 ,OP,162.24,162.24,,,,,,
BCBS Medicaid,CPT,D5214,Dentures mandibl part metal,Dental,Per Unit,$162.24 ,OP,162.24,162.24,,,,,,
BCBS Medicaid,CPT,D5221,Immed max part denture resin,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
BCBS Medicaid,CPT,D5222,Immed man part denture resin,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
BCBS Medicaid,CPT,D5223,Immed max part dent metal,Dental,Per Unit,$162.24 ,OP,162.24,162.24,,,,,,
BCBS Medicaid,CPT,D5224,Immed mand part dent metal,Dental,Per Unit,$162.24 ,OP,162.24,162.24,,,,,,
BCBS Medicaid,CPT,D5225,Maxillary part denture flex,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
BCBS Medicaid,CPT,D5226,Mandibular part denture flex,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
BCBS Medicaid,CPT,D5281,Removable partial denture,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
BCBS Medicaid,CPT,D5282,"Remove unil part denture,max",Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
BCBS Medicaid,CPT,D5283,"Remove unil part denture,man",Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
BCBS Medicaid,CPT,D5284,Rem unilat dent flex base,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
BCBS Medicaid,CPT,D5286,Rem unilat dent 1 pc resin,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
BCBS Medicaid,CPT,D5410,Dentures adjust cmplt maxil,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D5411,Dentures adjust cmplt mand,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D5421,Dentures adjust part maxill,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D5422,Dentures adjust part mandbl,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D5510,Dentur repr broken compl bas,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
BCBS Medicaid,CPT,D5511,Rep broke comp dent base man,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
BCBS Medicaid,CPT,D5512,Rep broke comp dent base max,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
BCBS Medicaid,CPT,D5520,Replace denture teeth complt,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
BCBS Medicaid,CPT,D5610,Dentures repair resin base,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
BCBS Medicaid,CPT,D5611,Rep resin part dent base man,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
BCBS Medicaid,CPT,D5612,Rep resin part dent base max,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
BCBS Medicaid,CPT,D5620,Rep part denture cast frame,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
BCBS Medicaid,CPT,D5621,Rep cast part frame man,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
BCBS Medicaid,CPT,D5622,Rep cast part frame max,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
BCBS Medicaid,CPT,D5630,Rep partial denture clasp,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
BCBS Medicaid,CPT,D5640,Replace part denture teeth,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
BCBS Medicaid,CPT,D5650,Add tooth to partial denture,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
BCBS Medicaid,CPT,D5660,Add clasp to partial denture,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
BCBS Medicaid,CPT,D5670,Replc tth&acrlc on mtl frmwk,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
BCBS Medicaid,CPT,D5671,Replc tth&acrlc mandibular,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
BCBS Medicaid,CPT,D5710,Dentures rebase cmplt maxil,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
BCBS Medicaid,CPT,D5711,Dentures rebase cmplt mand,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
BCBS Medicaid,CPT,D5720,Dentures rebase part maxill,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
BCBS Medicaid,CPT,D5721,Dentures rebase part mandbl,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
BCBS Medicaid,CPT,D5730,Denture reln cmplt max dir,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
BCBS Medicaid,CPT,D5731,Denture reln cmplt mand dir,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
BCBS Medicaid,CPT,D5740,Denture reln part max dir,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
BCBS Medicaid,CPT,D5741,Denture reln part mand dir,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
BCBS Medicaid,CPT,D5750,Denture reln cmplt max indir,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
BCBS Medicaid,CPT,D5751,Denture reln cmplt mand ind,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
BCBS Medicaid,CPT,D5760,Denture reln part max indir,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
BCBS Medicaid,CPT,D5761,Denture reln part mand indir,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
BCBS Medicaid,CPT,D5810,Denture interm cmplt maxill,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
BCBS Medicaid,CPT,D5811,Denture interm cmplt mandbl,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
BCBS Medicaid,CPT,D5820,Denture interm part maxill,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
BCBS Medicaid,CPT,D5821,Denture interm part mandbl,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
BCBS Medicaid,CPT,D5850,Denture tiss conditn maxill,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
BCBS Medicaid,CPT,D5851,Denture tiss condtin mandbl,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
BCBS Medicaid,CPT,D5862,Precision attachment,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
BCBS Medicaid,CPT,D5863,Overdenture complete max,Dental,Per Unit,$162.24 ,OP,162.24,162.24,,,,,,
BCBS Medicaid,CPT,D5864,Overdenture partial max,Dental,Per Unit,$162.24 ,OP,162.24,162.24,,,,,,
BCBS Medicaid,CPT,D5865,Overdenture complete mandib,Dental,Per Unit,$162.24 ,OP,162.24,162.24,,,,,,
BCBS Medicaid,CPT,D5866,Overdenture partial mandib,Dental,Per Unit,$162.24 ,OP,162.24,162.24,,,,,,
BCBS Medicaid,CPT,D5867,Replacement of precision att,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
BCBS Medicaid,CPT,D5875,Prosthesis modification,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
BCBS Medicaid,CPT,D5876,Add metal sub to acrylc dent,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
BCBS Medicaid,CPT,D5899,Removable prosthodontic proc,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
BCBS Medicaid,CPT,D5911,Facial moulage sectional,Dental,Per Unit,$30.61 ,OP,30.61,30.61,,,,,,
BCBS Medicaid,CPT,D5912,Facial moulage complete,Dental,Per Unit,$30.61 ,OP,30.61,30.61,,,,,,
BCBS Medicaid,CPT,D5913,Nasal prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
BCBS Medicaid,CPT,D5914,Auricular prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
BCBS Medicaid,CPT,D5915,Orbital prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
BCBS Medicaid,CPT,D5916,Ocular prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
BCBS Medicaid,CPT,D5919,Facial prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
BCBS Medicaid,CPT,D5922,Nasal septal prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
BCBS Medicaid,CPT,D5923,Ocular prosthesis interim,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
BCBS Medicaid,CPT,D5924,Cranial prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
BCBS Medicaid,CPT,D5925,Facial augmentation implant,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
BCBS Medicaid,CPT,D5926,Replacement nasal prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
BCBS Medicaid,CPT,D5927,Auricular replacement,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
BCBS Medicaid,CPT,D5928,Orbital replacement,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
BCBS Medicaid,CPT,D5929,Facial replacement,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
BCBS Medicaid,CPT,D5931,Surgical obturator,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
BCBS Medicaid,CPT,D5932,Postsurgical obturator,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
BCBS Medicaid,CPT,D5933,Refitting of obturator,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
BCBS Medicaid,CPT,D5934,Mandibular flange prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
BCBS Medicaid,CPT,D5935,Mandibular denture prosth,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
BCBS Medicaid,CPT,D5936,Temp obturator prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
BCBS Medicaid,CPT,D5937,Trismus appliance,Dental,Per Unit,$30.61 ,OP,30.61,30.61,,,,,,
BCBS Medicaid,CPT,D5951,Feeding aid,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
BCBS Medicaid,CPT,D5952,Pediatric speech aid,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
BCBS Medicaid,CPT,D5953,Adult speech aid,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
BCBS Medicaid,CPT,D5954,Superimposed prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
BCBS Medicaid,CPT,D5955,Palatal lift prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
BCBS Medicaid,CPT,D5958,Intraoral con def inter plt,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
BCBS Medicaid,CPT,D5959,Intraoral con def mod palat,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
BCBS Medicaid,CPT,D5960,Modify speech aid prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
BCBS Medicaid,CPT,D5982,Surgical stent,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
BCBS Medicaid,CPT,D5983,Radiation applicator,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
BCBS Medicaid,CPT,D5984,Radiation shield,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
BCBS Medicaid,CPT,D5985,Radiation cone locator,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
BCBS Medicaid,CPT,D5986,Fluoride applicator,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D5987,Commissure splint,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
BCBS Medicaid,CPT,D5988,Surgical splint,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
BCBS Medicaid,CPT,D5991,Vesiculobullous disease carr,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D5992,Adjust max prost appliance,Dental,Per Unit,$30.61 ,OP,30.61,30.61,,,,,,
BCBS Medicaid,CPT,D5993,Main/clean max prosthesis,Dental,Per Unit,$30.61 ,OP,30.61,30.61,,,,,,
BCBS Medicaid,CPT,D5994,Peridontal medicament,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
BCBS Medicaid,CPT,D5995,"Peri medicament w/seal, max",Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
BCBS Medicaid,CPT,D5996,"Peri medicament w/seal, mand",Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
BCBS Medicaid,CPT,D5999,Maxillofacial prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
BCBS Medicaid,CPT,D6010,Odontics endosteal implant,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
BCBS Medicaid,CPT,D6011,Second stage implant surgery,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
BCBS Medicaid,CPT,D6012,Endosteal implant,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
BCBS Medicaid,CPT,D6013,Surgical place mini implant,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
BCBS Medicaid,CPT,D6040,Odontics eposteal implant,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
BCBS Medicaid,CPT,D6050,Odontics transosteal implnt,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
BCBS Medicaid,CPT,D6051,Interim abutment,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6055,Implant connecting bar,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6056,Prefabricated abutment,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6057,Custom abutment,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6058,Abutment supported crown,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6059,Abutment supported mtl crown,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6060,Abutment supported mtl crown,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6061,Abutment supported mtl crown,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6062,Abutment supported mtl crown,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6063,Abutment supported mtl crown,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6064,Abutment supported mtl crown,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6065,Implant supported crown,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6066,Implant supported mtl crown,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6067,Implant supported mtl crown,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6068,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6069,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6070,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6071,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6072,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6073,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6074,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6075,Implant supported retainer,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6076,Implant supported retainer,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6077,Implant supported retainer,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6080,Implant maintenance,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
BCBS Medicaid,CPT,D6081,"Scale & debride, single imp",Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
BCBS Medicaid,CPT,D6082,Imp crown porc to base alloy,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6083,Imp crown porc to noble allo,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6084,Imp crown porc to titanium,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6085,Provisional implant crown,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
BCBS Medicaid,CPT,D6086,Imp crown base alloys,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6087,Implant crown noble alloys,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6088,Imp crown titanium alloys,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6090,Repair implant,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
BCBS Medicaid,CPT,D6091,Repl semi/precision attach,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
BCBS Medicaid,CPT,D6092,Recement supp crown,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
BCBS Medicaid,CPT,D6093,Recement supp part denture,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
BCBS Medicaid,CPT,D6094,Abut support crown titanium,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6095,Odontics repr abutment,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
BCBS Medicaid,CPT,D6096,Remove broken imp ret screw,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
BCBS Medicaid,CPT,D6097,Abut crown porc to titanium,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6098,Imp retain porc to base allo,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6099,Imp retainer for fpd,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6100,Removal of implant,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
BCBS Medicaid,CPT,D6101,Debridement of a periimplant,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
BCBS Medicaid,CPT,D6102,Debridement & contouring,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
BCBS Medicaid,CPT,D6103,Bone graft repair perimplant,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
BCBS Medicaid,CPT,D6104,Bone graft time of implant,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
BCBS Medicaid,CPT,D6110,Implnt/abut remov dent max,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6111,Implnt/abut remov dent mand,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6112,Imp/abut rem dent part max,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6113,Imp/abut rem dent part mand,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6114,Implnt/abut fixed dent max,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6115,Implnt/abut fixed dent mand,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6116,Imp/abut fixed dent part max,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6117,Imp/abut fixed dent part man,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6118,Imp/abut int fixed dent man,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6119,Int/abut int fixed dent max,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6120,Imp retain porc to titanium,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6121,Retain metal fpd base alloys,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6122,Retain metal fpd noble alloy,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6123,Retain metal fpd titanium,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6190,Radio/surgical implant index,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
BCBS Medicaid,CPT,D6191,Semi precision abutment,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
BCBS Medicaid,CPT,D6192,Semi precision attachment,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
BCBS Medicaid,CPT,D6194,Abut support retainer titani,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6195,Abut retain porc to titanium,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
BCBS Medicaid,CPT,D6199,Implant procedure,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
BCBS Medicaid,CPT,D6205,Pontic-indirect resin based,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
BCBS Medicaid,CPT,D6210,Prosthodont high noble metal,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
BCBS Medicaid,CPT,D6211,Bridge base metal cast,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
BCBS Medicaid,CPT,D6212,Bridge noble metal cast,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
BCBS Medicaid,CPT,D6214,Pontic titanium,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
BCBS Medicaid,CPT,D6240,Bridge porcelain high noble,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
BCBS Medicaid,CPT,D6241,Bridge porcelain base metal,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
BCBS Medicaid,CPT,D6242,Bridge porcelain nobel metal,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
BCBS Medicaid,CPT,D6243,Pontic porcelain to titanium,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
BCBS Medicaid,CPT,D6245,Bridge porcelain/ceramic,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
BCBS Medicaid,CPT,D6250,Bridge resin w/high noble,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
BCBS Medicaid,CPT,D6251,Bridge resin base metal,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
BCBS Medicaid,CPT,D6252,Bridge resin w/noble metal,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
BCBS Medicaid,CPT,D6253,Provisional pontic,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
BCBS Medicaid,CPT,D6545,Dental retainr cast metl,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
BCBS Medicaid,CPT,D6548,Porcelain/ceramic retainer,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
BCBS Medicaid,CPT,D6549,Resin retainer,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
BCBS Medicaid,CPT,D6600,Porcelain/ceramic inlay 2srf,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
BCBS Medicaid,CPT,D6601,Porc/ceram inlay >= 3 surfac,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
BCBS Medicaid,CPT,D6602,Cst hgh nble mtl inlay 2 srf,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
BCBS Medicaid,CPT,D6603,Cst hgh nble mtl inlay >=3sr,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
BCBS Medicaid,CPT,D6604,Cst bse mtl inlay 2 surfaces,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
BCBS Medicaid,CPT,D6605,Cst bse mtl inlay >= 3 surfa,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
BCBS Medicaid,CPT,D6606,Cast noble metal inlay 2 sur,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
BCBS Medicaid,CPT,D6607,Cst noble mtl inlay >=3 surf,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
BCBS Medicaid,CPT,D6608,Onlay porc/crmc 2 surfaces,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
BCBS Medicaid,CPT,D6609,Onlay porc/crmc >=3 surfaces,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
BCBS Medicaid,CPT,D6610,Onlay cst hgh nbl mtl 2 srfc,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
BCBS Medicaid,CPT,D6611,Onlay cst hgh nbl mtl >=3srf,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
BCBS Medicaid,CPT,D6612,Onlay cst base mtl 2 surface,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
BCBS Medicaid,CPT,D6613,Onlay cst base mtl >=3 surfa,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
BCBS Medicaid,CPT,D6614,Onlay cst nbl mtl 2 surfaces,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
BCBS Medicaid,CPT,D6615,Onlay cst nbl mtl >=3 surfac,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
BCBS Medicaid,CPT,D6624,Inlay titanium,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
BCBS Medicaid,CPT,D6634,Onlay titanium,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
BCBS Medicaid,CPT,D6710,Crown-indirect resin based,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
BCBS Medicaid,CPT,D6720,Retain crown resin w hi nble,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
BCBS Medicaid,CPT,D6721,Crown resin w/base metal,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
BCBS Medicaid,CPT,D6722,Crown resin w/noble metal,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
BCBS Medicaid,CPT,D6740,Crown porcelain/ceramic,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
BCBS Medicaid,CPT,D6750,Crown porcelain high noble,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
BCBS Medicaid,CPT,D6751,Crown porcelain base metal,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
BCBS Medicaid,CPT,D6752,Crown porcelain noble metal,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
BCBS Medicaid,CPT,D6753,Retain crown porc to titaniu,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
BCBS Medicaid,CPT,D6780,Crown 3/4 high noble metal,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
BCBS Medicaid,CPT,D6781,Crown 3/4 cast based metal,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
BCBS Medicaid,CPT,D6782,Crown 3/4 cast noble metal,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
BCBS Medicaid,CPT,D6783,Crown 3/4 porcelain/ceramic,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
BCBS Medicaid,CPT,D6784,Retainer crown 3/4 titanium,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
BCBS Medicaid,CPT,D6790,Crown full high noble metal,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
BCBS Medicaid,CPT,D6791,Crown full base metal cast,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
BCBS Medicaid,CPT,D6792,Crown full noble metal cast,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
BCBS Medicaid,CPT,D6793,Provisional retainer crown,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
BCBS Medicaid,CPT,D6794,Crown titanium,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
BCBS Medicaid,CPT,D6920,Dental connector bar,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
BCBS Medicaid,CPT,D6930,Recement/bond part denture,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
BCBS Medicaid,CPT,D6940,Stress breaker,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
BCBS Medicaid,CPT,D6950,Precision attachment,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
BCBS Medicaid,CPT,D6980,Fixed partial repair,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
BCBS Medicaid,CPT,D6985,Pediatric partial denture fx,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
BCBS Medicaid,CPT,D6999,Fixed prosthodontic proc,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
BCBS Medicaid,CPT,D7111,Extraction coronal remnants,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7140,Extraction erupted tooth/exr,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7210,Rem imp tooth w mucoper flp,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7220,Impact tooth remov soft tiss,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7230,Impact tooth remov part bony,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7240,Impact tooth remov comp bony,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7241,Impact tooth rem bony w/comp,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
BCBS Medicaid,CPT,D7250,Tooth root removal,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7251,Coronectomy,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
BCBS Medicaid,CPT,D7260,Oral antral fistula closure,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7261,Primary closure sinus perf,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
BCBS Medicaid,CPT,D7270,Tooth reimplantation,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7272,Tooth transplantation,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7280,Exposure of unerupted tooth,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
BCBS Medicaid,CPT,D7282,Mobilize erupted/malpos toot,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7283,Place device impacted tooth,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7285,Biopsy of oral tissue hard,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7286,Biopsy of oral tissue soft,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D7287,Exfoliative cytolog collect,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7288,Brush biopsy,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7290,Repositioning of teeth,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D7291,Transseptal fiberotomy,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7292,Screw retained plate,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7293,Temp anchorage dev w flap,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7294,Temp anchorage dev w/o flap,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7295,"Bone harvest,auto graft proc",Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7296,"Corticotomy, 1-3 teeth",Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
BCBS Medicaid,CPT,D7297,"Corticotomy, 4 or more teeth",Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
BCBS Medicaid,CPT,D7310,Alveoplasty w/ extraction,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7311,Alveoloplasty w/extract 1-3,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7320,Alveoplasty w/o extraction,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7321,Alveoloplasty not w/extracts,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7340,Vestibuloplasty ridge extens,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
BCBS Medicaid,CPT,D7350,Vestibuloplasty exten graft,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,D7410,Rad exc lesion up to 1.25 cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7411,Excision benign lesion>1.25c,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7412,Excision benign lesion compl,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7413,Excision malig lesion<=1.25c,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7414,Excision malig lesion>1.25cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7415,Excision malig les complicat,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7440,Malig tumor exc to 1.25 cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7441,Malig tumor > 1.25 cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7450,Rem odontogen cyst to 1.25cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7451,Rem odontogen cyst > 1.25 cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7460,Rem nonodonto cyst to 1.25cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7461,Rem nonodonto cyst > 1.25 cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7465,Lesion destruction,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7471,Rem exostosis any site,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7472,Removal of torus palatinus,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
BCBS Medicaid,CPT,D7473,Remove torus mandibularis,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7485,Surg reduct osseoustuberosit,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7490,Maxilla or mandible resectio,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
BCBS Medicaid,CPT,D7510,I&d absc intraoral soft tiss,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D7511,Incision/drain abscess intra,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7520,I&d abscess extraoral,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7521,Incision/drain abscess extra,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7530,Removal fb skin/areolar tiss,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7540,Removal of fb reaction,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
BCBS Medicaid,CPT,D7550,Removal of sloughed off bone,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7560,Maxillary sinusotomy,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
BCBS Medicaid,CPT,D7610,Maxilla open reduct simple,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,D7620,Clsd reduct simpl maxilla fx,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
BCBS Medicaid,CPT,D7630,Open red simpl mandible fx,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,D7640,Clsd red simpl mandible fx,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
BCBS Medicaid,CPT,D7650,Open red simp malar/zygom fx,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
BCBS Medicaid,CPT,D7660,Clsd red simp malar/zygom fx,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7670,Closd rductn splint alveolus,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7671,Alveolus open reduction,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7680,Reduct simple facial bone fx,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
BCBS Medicaid,CPT,D7710,Maxilla open reduct compound,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,D7720,Clsd reduct compd maxilla fx,Dental,Per Unit,$156.21 ,OP,156.21,156.21,,,,,,
BCBS Medicaid,CPT,D7730,Open reduct compd mandble fx,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,D7740,Clsd reduct compd mandble fx,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
BCBS Medicaid,CPT,D7750,Open red comp malar/zygma fx,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
BCBS Medicaid,CPT,D7760,Clsd red comp malar/zygma fx,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7770,Open reduc compd alveolus fx,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7771,Alveolus clsd reduc stblz te,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7780,Reduct compnd facial bone fx,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7810,Tmj open reduct-dislocation,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,D7820,Closed tmp manipulation,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7830,Tmj manipulation under anest,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7840,Removal of tmj condyle,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,D7850,Tmj meniscectomy,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,D7852,Tmj repair of joint disc,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,D7854,Tmj excisn of joint membrane,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,D7856,Tmj cutting of a muscle,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,D7858,Tmj reconstruction,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,D7860,Tmj cutting into joint,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,D7865,Tmj reshaping components,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,D7870,Tmj aspiration joint fluid,Dental,Per Unit,$156.21 ,OP,156.21,156.21,,,,,,
BCBS Medicaid,CPT,D7871,Lysis + lavage w catheters,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7872,Tmj diagnostic arthroscopy,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D7873,Tmj arthroscopy lysis adhesn,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,D7874,Tmj arthroscopy disc reposit,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,D7875,Tmj arthroscopy synovectomy,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,D7876,Tmj arthroscopy discectomy,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,D7877,Tmj arthroscopy debridement,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,D7880,Occlusal orthotic appliance,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7881,Occ orthotic device adjust,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D7899,Tmj unspecified therapy,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7910,Dent sutur recent wnd to 5cm,Dental,Per Unit,$156.21 ,OP,156.21,156.21,,,,,,
BCBS Medicaid,CPT,D7911,Dental suture wound to 5 cm,Dental,Per Unit,$156.21 ,OP,156.21,156.21,,,,,,
BCBS Medicaid,CPT,D7912,Suture complicate wnd > 5 cm,Dental,Per Unit,$156.21 ,OP,156.21,156.21,,,,,,
BCBS Medicaid,CPT,D7920,Dental skin graft,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7921,Collect & appl blood product,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7922,Place intra-socket bio dress,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7940,Reshaping bone orthognathic,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7941,Bone cutting ramus closed,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,D7943,Cutting ramus open w/graft,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,D7944,Bone cutting segmented,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,D7945,Bone cutting body mandible,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,D7946,Reconstruction maxilla total,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,D7947,Reconstruct maxilla segment,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,D7948,Reconstruct midface no graft,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,D7949,Reconstruct midface w/graft,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,D7950,Mandible graft,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
BCBS Medicaid,CPT,D7951,Sinus aug w bone or bone sub,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
BCBS Medicaid,CPT,D7952,Sinus augmentation vertical,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
BCBS Medicaid,CPT,D7953,Bone replacement graft,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
BCBS Medicaid,CPT,D7955,Repair maxillofacial defects,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
BCBS Medicaid,CPT,D7960,Frenulectomy/frenectomy,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D7961,Buccal/labial frenectomy,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7962,Lingual frenectomy,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7963,Frenuloplasty,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7970,Excision hyperplastic tissue,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
BCBS Medicaid,CPT,D7971,Excision pericoronal gingiva,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7972,Surg redct fibrous tuberosit,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7979,Non-surgical sialolithotomy,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7980,Surgical sialolithotomy,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
BCBS Medicaid,CPT,D7981,Excision of salivary gland,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7982,Sialodochoplasty,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,D7983,Closure of salivary fistula,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7990,Emergency tracheotomy,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,D7991,Dental coronoidectomy,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
BCBS Medicaid,CPT,D7993,Surg place craniofacial impl,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
BCBS Medicaid,CPT,D7994,Surg place zygomatic impl,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
BCBS Medicaid,CPT,D7995,Synthetic graft facial bones,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7996,Implant mandible for augment,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
BCBS Medicaid,CPT,D7997,Appliance removal,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7998,Intraoral place of fix dev,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D7999,Oral surgery procedure,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
BCBS Medicaid,CPT,D8010,Limited dental tx primary,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
BCBS Medicaid,CPT,D8020,Limited dental tx transition,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
BCBS Medicaid,CPT,D8030,Limited dental tx adolescent,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
BCBS Medicaid,CPT,D8040,Limited dental tx adult,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
BCBS Medicaid,CPT,D8050,Intercep dental tx primary,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
BCBS Medicaid,CPT,D8060,Intercep dental tx transitn,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
BCBS Medicaid,CPT,D8070,Compre dental tx transition,Dental,Per Unit,$195.04 ,OP,195.04,195.04,,,,,,
BCBS Medicaid,CPT,D8080,Compre dental tx adolescent,Dental,Per Unit,$195.04 ,OP,195.04,195.04,,,,,,
BCBS Medicaid,CPT,D8090,Compre dental tx adult,Dental,Per Unit,$195.04 ,OP,195.04,195.04,,,,,,
BCBS Medicaid,CPT,D8210,Orthodontic rem appliance tx,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
BCBS Medicaid,CPT,D8220,Fixed appliance therapy habt,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
BCBS Medicaid,CPT,D8660,Preorthodontic tx visit,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
BCBS Medicaid,CPT,D8670,Periodic orthodontc tx visit,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
BCBS Medicaid,CPT,D8680,Orthodontic retention,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
BCBS Medicaid,CPT,D8681,Removable retainer adjust,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D8690,Orthodontic treatment,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
BCBS Medicaid,CPT,D8691,Repair ortho appliance,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
BCBS Medicaid,CPT,D8692,Replacement retainer,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
BCBS Medicaid,CPT,D8693,Rebond/recement retainers,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
BCBS Medicaid,CPT,D8694,Repair fixed retainers,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
BCBS Medicaid,CPT,D8695,Remove fixed ortho appliance,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
BCBS Medicaid,CPT,D8696,Rep of ortho appliance max,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
BCBS Medicaid,CPT,D8697,Rep of ortho appliance man,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
BCBS Medicaid,CPT,D8698,Recement fixed retainer max,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
BCBS Medicaid,CPT,D8699,Recement fixed retainer man,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
BCBS Medicaid,CPT,D8701,Repair fixed retainer max,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
BCBS Medicaid,CPT,D8702,Repair of fixed retainer man,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
BCBS Medicaid,CPT,D8703,Replace broken retainer max,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
BCBS Medicaid,CPT,D8704,Replace broken retainer man,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
BCBS Medicaid,CPT,D8999,Orthodontic procedure,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
BCBS Medicaid,CPT,D9110,Tx dental pain minor proc,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D9120,Fix partial denture section,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
BCBS Medicaid,CPT,D9130,Temporomandibular joint dysf,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,D9210,Dent anesthesia w/o surgery,Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
BCBS Medicaid,CPT,D9211,Regional block anesthesia,Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
BCBS Medicaid,CPT,D9212,Trigeminal block anesthesia,Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
BCBS Medicaid,CPT,D9215,Local anesthesia,Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
BCBS Medicaid,CPT,D9219,Eval mod/deep sed/gen anest,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
BCBS Medicaid,CPT,D9220,General anesthesia,Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
BCBS Medicaid,CPT,D9221,General anesthesia ea ad 15m,Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
BCBS Medicaid,CPT,D9222,"Deep anest, 1st 15 min",Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
BCBS Medicaid,CPT,D9223,General anesth ea addl 15 mi,Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
BCBS Medicaid,CPT,D9230,Analgesia,Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
BCBS Medicaid,CPT,D9239,"Iv mod sedation, 1st 15 min",Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
BCBS Medicaid,CPT,D9241,Intravenous sedation,Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
BCBS Medicaid,CPT,D9242,Iv sedation ea ad 15 m,Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
BCBS Medicaid,CPT,D9243,Iv sedation ea addl 15m,Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
BCBS Medicaid,CPT,D9248,Sedation (non-iv),Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
BCBS Medicaid,CPT,D9310,Dental consultation,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D9311,Consult w/med hlth care prof,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D9410,Dental house call,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D9420,Hospital/asc call,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D9430,Office visit during hours,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D9440,Office visit after hours,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D9450,Case presentation tx plan,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,D9610,Dent therapeutic drug inject,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D9612,Thera par drugs 2 or > admin,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D9613,Infiltration thera drug,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D9630,Drugs/meds disp for home use,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D9910,Dent appl desensitizing med,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D9911,Appl desensitizing resin,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D9920,Behavior management,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D9930,Treatment of complications,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D9931,Clean/inspect rem appliance,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D9932,Clean & inspect rem dent max,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D9933,Clean & inspect rem dent man,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D9934,Clean rem part denture max,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D9935,Clean rem part denture mand,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D9940,Dental occlusal guard,Dental,Per Unit,$156.21 ,OP,156.21,156.21,,,,,,
BCBS Medicaid,CPT,D9941,Fabrication athletic guard,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D9942,Repair/reline occlusal guard,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D9943,Occlusal guard adjustment,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D9944,"Occ guard, hard, full arch",Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D9945,"Occ guard, soft, full arch",Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D9946,"Occ guard, hard, part arch",Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D9950,Occlusion analysis,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D9951,Limited occlusal adjustment,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D9952,Complete occlusal adjustment,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D9970,Enamel microabrasion,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D9971,Odontoplasty per tooth,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D9972,Extrnl bleaching per arch,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D9973,Extrnl bleaching per tooth,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D9974,Intrnl bleaching per tooth,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D9975,External bleaching home app,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D9991,"Case mgmt, appt barriers",Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,D9992,"Case mgmt, care coordination",Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,D9993,"Case mgmt, interviewing",Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,D9994,"Case mgmt, pt education",Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
BCBS Medicaid,CPT,D9995,Teledentistry real-time,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D9996,Teledentistry dent review,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,D9997,Dent case mgmt special needs,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,D9999,Adjunctive procedure,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
BCBS Medicaid,CPT,G0008,Admin influenza virus vac,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,G0009,Admin pneumococcal vaccine,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,G0010,Admin hepatitis b vaccine,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
BCBS Medicaid,CPT,G0027,Semen analysis,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,G0068,Adm iv infusion drug in home,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
BCBS Medicaid,CPT,G0069,Adm sq infusion drug in home,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
BCBS Medicaid,CPT,G0070,Adm of chemo drug in home,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
BCBS Medicaid,CPT,G0071,Comm svcs by rhc/fqhc 5 min,Ancillary Services,Per Unit,$26.19 ,OP,26.19,26.19,,,,,,
BCBS Medicaid,CPT,G0076,Care manag h vst new pt 20 m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,G0077,Care manag h vst new pt 30 m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,G0078,Care manag h vst new pt 45 m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,G0079,Care manag h vst new pt 60 m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,G0080,Care manag h vst new pt 75 m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,G0081,Care man h v ext pt 20 mi,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,G0082,Care man h v ext pt 30 m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,G0083,Care man h v ext pt 45 m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,G0084,Care man h v ext pt 60 m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,G0085,Care man h v ext pt 75 m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,G0086,Care man home care plan 30 m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,G0087,Care man home care plan 60 m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,G0088,Adm iv drug 1st home visit,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
BCBS Medicaid,CPT,G0089,Adm subq drug 1st home visit,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
BCBS Medicaid,CPT,G0090,Adm iv chemo 1st home visit,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
BCBS Medicaid,CPT,G0103,Psa screening,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,G0104,Ca screen;flexi sigmoidscope,Preventive Care,Per Unit,$387.00 ,OP,387,387,,,,,,
BCBS Medicaid,CPT,G0105,Colorectal scrn; hi risk ind,Preventive Care,Per Unit,$387.00 ,OP,387,387,,,,,,
BCBS Medicaid,CPT,G0108,Diab manage trn per indiv,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
BCBS Medicaid,CPT,G0109,Diab manage trn ind/group,Preventive Care,Per Unit,$26.23 ,OP,26.23,26.23,,,,,,
BCBS Medicaid,CPT,G0117,Glaucoma scrn hgh risk direc,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,G0118,Glaucoma scrn hgh risk direc,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,G0121,Colon ca scrn not hi rsk ind,Preventive Care,Per Unit,$387.00 ,OP,387,387,,,,,,
BCBS Medicaid,CPT,G0122,Colon ca scrn; barium enema,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
BCBS Medicaid,CPT,G0123,Screen cerv/vag thin layer,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
BCBS Medicaid,CPT,G0124,Screen c/v thin layer by md,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
BCBS Medicaid,CPT,G0127,Trim nail(s),General Surgery,Per Unit,$46.77 ,OP,46.77,46.77,,,,,,
BCBS Medicaid,CPT,G0128,Corf skilled nursing service,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,G0130,Single energy x-ray study,Diagnostic Radiology,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
BCBS Medicaid,CPT,G0141,"Scr c/v cyto,autosys and md",Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
BCBS Medicaid,CPT,G0143,"Scr c/v cyto,thinlayer,rescr",Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
BCBS Medicaid,CPT,G0144,"Scr c/v cyto,thinlayer,rescr",Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
BCBS Medicaid,CPT,G0145,"Scr c/v cyto,thinlayer,rescr",Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
BCBS Medicaid,CPT,G0147,"Scr c/v cyto, automated sys",Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
BCBS Medicaid,CPT,G0148,"Scr c/v cyto, autosys, rescr",Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
BCBS Medicaid,CPT,G0151,"Hhcp-serv of pt,ea 15 min",Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,G0152,"Hhcp-serv of ot,ea 15 min",Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,G0153,"Hhcp-svs of s/l path,ea 15mn",Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,G0155,"Hhcp-svs of csw,ea 15 min",Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,G0157,Hhc pt assistant ea 15,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,G0158,Hhc ot assistant ea 15,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,G0159,Hhc pt maint ea 15 min,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,G0160,Hhc occup therapy ea 15,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,G0161,Hhc slp ea 15 min,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,G0162,"Hhc rn e&m plan svs, 15 min",Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,G0166,"Extrnl counterpulse, per tx",Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,G0175,"Opps service,sched team conf",Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,G0176,Opps/php;activity therapy,Behavioral Health,Per Unit,$48.15 ,OP,48.15,48.15,,,,,,
BCBS Medicaid,CPT,G0177,Opps/php; train & educ serv,Behavioral Health,Per Unit,$48.15 ,OP,48.15,48.15,,,,,,
BCBS Medicaid,CPT,G0179,Md recertification hha pt,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,G0180,Md certification hha patient,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,G0181,Home health care supervision,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,G0182,Hospice care supervision,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,G0186,"Dstry eye lesn,fdr vssl tech",Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
BCBS Medicaid,CPT,G0202,Scr mammo bi incl cad,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
BCBS Medicaid,CPT,G0204,Dx mammo incl cad bi,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
BCBS Medicaid,CPT,G0206,Dx mammo incl cad uni,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
BCBS Medicaid,CPT,G0219,Pet img wholbod melano nonco,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
BCBS Medicaid,CPT,G0235,Pet not otherwise specified,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
BCBS Medicaid,CPT,G0237,Therapeutic procd strg endur,Rehabilitation,Per Unit,$73.11 ,OP,73.11,73.11,,,,,,
BCBS Medicaid,CPT,G0238,"Oth resp proc, indiv",Rehabilitation,Per Unit,$73.11 ,OP,73.11,73.11,,,,,,
BCBS Medicaid,CPT,G0239,"Oth resp proc, group",Rehabilitation,Per Unit,$73.11 ,OP,73.11,73.11,,,,,,
BCBS Medicaid,CPT,G0248,Demonstrate use home inr mon,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
BCBS Medicaid,CPT,G0252,Pet imaging initial dx,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
BCBS Medicaid,CPT,G0255,Current percep threshold tst,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,G0257,Unsched dialysis esrd pt hos,Nephrology,Per Unit,$540.95 ,OP,540.95,540.95,,,,,,
BCBS Medicaid,CPT,G0270,Mnt subs tx for change dx,Ancillary Services,Per Unit,$100.15 ,OP,100.15,100.15,,,,,,
BCBS Medicaid,CPT,G0271,Group mnt 2 or more 30 mins,Ancillary Services,Per Unit,$100.15 ,OP,100.15,100.15,,,,,,
BCBS Medicaid,CPT,G0278,"Iliac art angio,cardiac cath",Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
BCBS Medicaid,CPT,G0279,"Tomosynthesis, mammo",Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
BCBS Medicaid,CPT,G0283,Elec stim other than wound,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,G0289,"Arthro, loose body + chondro",Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,G0293,"Non-cov surg proc,clin trial",Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,G0297,Ldct for lung ca screen,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
BCBS Medicaid,CPT,G0306,Cbc/diffwbc w/o platelet,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
BCBS Medicaid,CPT,G0307,Cbc without platelet,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
BCBS Medicaid,CPT,G0328,Fecal blood scrn immunoassay,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,G0339,"Robot lin-radsurg com, first",Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"2,592.65","2,592.65",,,,,,
BCBS Medicaid,CPT,G0340,Robt lin-radsurg fractx 2-5,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"2,592.65","2,592.65",,,,,,
BCBS Medicaid,CPT,G0365,Vessel mapping hemo access,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
BCBS Medicaid,CPT,G0378,Hospital observation per hr,Ancillary Services,Per Unit,$651.20 ,OP,651.2,651.2,,,,,,
BCBS Medicaid,CPT,G0389,Ultrasound exam aaa screen,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,G0396,Alcohol/subs interv 15-30mn,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
BCBS Medicaid,CPT,G0397,Alcohol/subs interv >30 min,Behavioral Health,Per Unit,$84.55 ,OP,84.55,84.55,,,,,,
BCBS Medicaid,CPT,G0403,Ekg for initial prevent exam,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
BCBS Medicaid,CPT,G0404,Ekg tracing for initial prev,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
BCBS Medicaid,CPT,G0405,Ekg interpret & report preve,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
BCBS Medicaid,CPT,G0409,Corf related serv 15 mins ea,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
BCBS Medicaid,CPT,G0410,Grp psych partial hosp 45-50,Behavioral Health,Per Unit,$119.88 ,OP,119.88,119.88,,,,,,
BCBS Medicaid,CPT,G0411,Inter active grp psych parti,Behavioral Health,Per Unit,$119.88 ,OP,119.88,119.88,,,,,,
BCBS Medicaid,CPT,G0412,Open tx iliac spine uni/bil,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,G0413,Pelvic ring fracture uni/bil,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,G0414,Pelvic ring fx treat int fix,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,G0415,Open tx post pelvic fxcture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
BCBS Medicaid,CPT,G0420,Ed svc ckd ind per session,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
BCBS Medicaid,CPT,G0421,Ed svc ckd grp per session,Preventive Care,Per Unit,$26.23 ,OP,26.23,26.23,,,,,,
BCBS Medicaid,CPT,G0422,Intens cardiac rehab w/exerc,Rehabilitation,Per Unit,$274.82 ,OP,274.82,274.82,,,,,,
BCBS Medicaid,CPT,G0423,Intens cardiac rehab no exer,Rehabilitation,Per Unit,$274.82 ,OP,274.82,274.82,,,,,,
BCBS Medicaid,CPT,G0424,Pulmonary rehab w exer,Rehabilitation,Per Unit,$73.11 ,OP,73.11,73.11,,,,,,
BCBS Medicaid,CPT,G0431,Drug screen multiple class,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,G0432,Eia hiv-1/hiv-2 screen,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,G0433,Elisa hiv-1/hiv-2 screen,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,G0434,Drug screen multi drug class,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,G0435,Oral hiv-1/hiv-2 screen,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,G0436,Tobacco-use counsel 3-10 min,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
BCBS Medicaid,CPT,G0437,Tobacco-use counsel>10min,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
BCBS Medicaid,CPT,G0442,Annual alcohol screen 15 min,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
BCBS Medicaid,CPT,G0443,Brief alcohol misuse counsel,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
BCBS Medicaid,CPT,G0444,Depression screen annual,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
BCBS Medicaid,CPT,G0445,High inten beh couns std 30m,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
BCBS Medicaid,CPT,G0446,Intens behave ther cardio dx,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
BCBS Medicaid,CPT,G0447,Behavior counsel obesity 15m,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
BCBS Medicaid,CPT,G0448,Place perm pacing cardiovert,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
BCBS Medicaid,CPT,G0451,Devlopment test interpt&rep,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
BCBS Medicaid,CPT,G0452,Molecular pathology interpr,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
BCBS Medicaid,CPT,G0459,Telehealth inpt pharm mgmt,Behavioral Health,Per Unit,$80.13 ,OP,80.13,80.13,,,,,,
BCBS Medicaid,CPT,G0464,"Colorec CA scr, sto bas DNA",Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
BCBS Medicaid,CPT,G0472,Hep c screen high risk/other,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,G0473,Group behave couns 2-10,Behavioral Health,Per Unit,$119.88 ,OP,119.88,119.88,,,,,,
BCBS Medicaid,CPT,G0475,Hiv combination assay,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,G0476,Hpv combo assay ca screen,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,G0477,Drug test presump optical,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,G0478,Drug test presump opt inst,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,G0479,Drug test presump not opt,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,G0480,Drug test def 1-7 classes,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,G0491,Dialysis acu kidney no esrd,Nephrology,Per Unit,$540.95 ,OP,540.95,540.95,,,,,,
BCBS Medicaid,CPT,G0492,Md/oth eval acut kid no esrd,Nephrology,Per Unit,$540.95 ,OP,540.95,540.95,,,,,,
BCBS Medicaid,CPT,G0495,Rn care train/edu in hh,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
BCBS Medicaid,CPT,G0496,Lpn care train/edu in hh,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
BCBS Medicaid,CPT,G0498,Chemo extend iv infus w/pump,General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
BCBS Medicaid,CPT,G0499,Hepb screen high risk indiv,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,G0500,Mod sedat endo service >5yrs,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
BCBS Medicaid,CPT,G0502,"Init psych care manag, 70min",Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
BCBS Medicaid,CPT,G0503,"Subseq  psych care man,60mi",Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
BCBS Medicaid,CPT,G0504,Init/sub psych care add 30 m,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
BCBS Medicaid,CPT,G0506,Comp asses care plan ccm svc,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,G0507,Care manage serv minimum 20,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
BCBS Medicaid,CPT,G0511,Ccm/bhi by rhc/fqhc 20min mo,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,G0512,Cocm by rhc/fqhc 60 min mo,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
BCBS Medicaid,CPT,G0515,Cognitive skills development,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,G0516,"Insert drug del implant, >=4",General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,G0517,Remove drug implant,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
BCBS Medicaid,CPT,G0518,Remove w insert drug implant,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
BCBS Medicaid,CPT,G0659,Drug test def simple all cl,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
BCBS Medicaid,CPT,G2000,Blinded conv. tx mdd clin tr,Behavioral Health,Per Unit,$276.44 ,OP,276.44,276.44,,,,,,
BCBS Medicaid,CPT,G2010,Remot image submit by pt,Ancillary Services,Per Unit,$26.19 ,OP,26.19,26.19,,,,,,
BCBS Medicaid,CPT,G2011,Alcohol/sub misuse assess,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
BCBS Medicaid,CPT,G2012,Brief check in by md/qhp,Ancillary Services,Per Unit,$26.19 ,OP,26.19,26.19,,,,,,
BCBS Medicaid,CPT,G2014,Post-d/c care plan overs 30m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,G2015,Post-d/c care plan overs 60m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,G2058,Ccm add 20min,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,G2064,Md mang high risk dx 30,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,G2065,Clin mang h risk dx 30,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,G2066,Inter devc remote 30d,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
BCBS Medicaid,CPT,G2082,Visit esketamine 56m or less,Behavioral Health,Per Unit,$80.13 ,OP,80.13,80.13,,,,,,
BCBS Medicaid,CPT,G2083,"Visit esketamine, > 56m",Behavioral Health,Per Unit,$80.13 ,OP,80.13,80.13,,,,,,
BCBS Medicaid,CPT,G2168,Svs by pt in home health,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,G2169,Svs by ot in home health,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,G2213,Initiat med assist tx in er,Behavioral Health,Per Unit,$80.13 ,OP,80.13,80.13,,,,,,
BCBS Medicaid,CPT,G2214,Init/sub psych care m 1st 30,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
BCBS Medicaid,CPT,G2250,"Remot img sub by pt, non e/m",Ancillary Services,Per Unit,$26.19 ,OP,26.19,26.19,,,,,,
BCBS Medicaid,CPT,G2251,"Brief chkin, 5-10, non-e/m",Ancillary Services,Per Unit,$26.19 ,OP,26.19,26.19,,,,,,
BCBS Medicaid,CPT,G2252,"Brief chkin by md/qhp, 11-20",Ancillary Services,Per Unit,$26.19 ,OP,26.19,26.19,,,,,,
BCBS Medicaid,CPT,G3001,"Admin + supply, tositumomab",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
BCBS Medicaid,CPT,G6001,Echo guidance radiotherapy,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
BCBS Medicaid,CPT,G6002,Stereoscopic x-ray guidance,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
BCBS Medicaid,CPT,G6003,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
BCBS Medicaid,CPT,G6004,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
BCBS Medicaid,CPT,G6005,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
BCBS Medicaid,CPT,G6006,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
BCBS Medicaid,CPT,G6007,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
BCBS Medicaid,CPT,G6008,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
BCBS Medicaid,CPT,G6009,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
BCBS Medicaid,CPT,G6010,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
BCBS Medicaid,CPT,G6011,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
BCBS Medicaid,CPT,G6012,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
BCBS Medicaid,CPT,G6013,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
BCBS Medicaid,CPT,G6014,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
BCBS Medicaid,CPT,G6015,Radiation tx delivery imrt,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
BCBS Medicaid,CPT,G6016,Delivery comp imrt,Therapeutic Radiology,Per Unit,$434.17 ,OP,434.17,434.17,,,,,,
BCBS Medicaid,CPT,G6018,Ileoscopy w/stent,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
BCBS Medicaid,CPT,G6019,Colonoscopy lesion removal,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
BCBS Medicaid,CPT,G6020,Colonoscopy w/stent,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
BCBS Medicaid,CPT,G6021,Unlisted px small intestine,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
BCBS Medicaid,CPT,G6022,Sigmoidoscopy w/ablate tumr,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,G6023,Sigmoidoscopy w/stent,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
BCBS Medicaid,CPT,G6024,Lesion removal colonoscopy,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,G6025,Colonoscopy w/stent,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
BCBS Medicaid,CPT,G6027,Anoscopy hra w/spec collect,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,G6028,Anoscopy hra w/biopsy,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
BCBS Medicaid,CPT,G6030,Assay of amitriptyline,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,G6031,Assay of benzodiazepines,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,G6032,Assay of desipramine,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,G6034,Assay of doxepin,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,G6035,Assay of  gold,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,G6036,Assay of Imipramine,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,G6037,Assay of nortiptyline,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,G6038,Assay of salicylate,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
BCBS Medicaid,CPT,G6039,Assay of acetaminophen,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
BCBS Medicaid,CPT,G6040,Assay of ethanol,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
BCBS Medicaid,CPT,G6041,Assay of urine alkaloids,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
BCBS Medicaid,CPT,G6042,Assay of amphetamines,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
BCBS Medicaid,CPT,G6043,Assay of barbiturates,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
BCBS Medicaid,CPT,G6044,Assay of cocaine,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
BCBS Medicaid,CPT,G6045,Assay of dihydrocodeinone,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
BCBS Medicaid,CPT,G6046,Assay of dihydromorphinone,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
BCBS Medicaid,CPT,G6047,Assay of dihydrotestosterone,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
BCBS Medicaid,CPT,G6048,Assay of dimethadione,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
BCBS Medicaid,CPT,G6049,Assay of Epiandrosterone,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
BCBS Medicaid,CPT,G6050,Assay of Ethchlorvynol,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
BCBS Medicaid,CPT,G6051,Assay of flurazepam,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
BCBS Medicaid,CPT,G6052,Assay of meprobamate,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
BCBS Medicaid,CPT,G6053,Assay of methadone,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
BCBS Medicaid,CPT,G6054,Assay of methsuximide,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
BCBS Medicaid,CPT,G6055,Assay of nicotine,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
BCBS Medicaid,CPT,G6056,Assay of opiates,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
BCBS Medicaid,CPT,G6057,Assay of phenothiazine,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
BCBS Medicaid,CPT,G6058,Drug confirmation,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
BCBS Medicaid,CPT,G9012,Other specified case mgmt,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,G9016,Demo-smoking cessation coun,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
BCBS Medicaid,CPT,G9020,Rimantadine hcl 100mg oral,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,G9034,"Zanamivir, inh pwdr, brand",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
BCBS Medicaid,CPT,G9035,"Oseltamivir phosp, brand",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
BCBS Medicaid,CPT,G9143,Warfarin respon genetic test,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,G9147,Outpt iv insulin tx any mea,General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
BCBS Medicaid,CPT,G9157,Transesoph doppl cardiac mon,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
BCBS Medicaid,CPT,G9187,Bpci home visit,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,G9477,Care coord at hospice,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,G9686,Nursing facility conference,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,G9873,1 em core session,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
BCBS Medicaid,CPT,G9874,4 em core sessions,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
BCBS Medicaid,CPT,G9875,9 em core sessions,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
BCBS Medicaid,CPT,G9876,2 em core ms mo 7-9 no wl,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
BCBS Medicaid,CPT,G9877,2 em core ms mo 10-12 no wl,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
BCBS Medicaid,CPT,G9878,2 em core ms mo 7-9 wl,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
BCBS Medicaid,CPT,G9879,2 em core ms mo 10-12 wl,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
BCBS Medicaid,CPT,G9880,Em 5 percent wl,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
BCBS Medicaid,CPT,G9881,Em 9 percent wl,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
BCBS Medicaid,CPT,G9882,2 em ongoing ms mo 13-15 wl,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
BCBS Medicaid,CPT,G9883,2 em ongoing ms mo 16-18 wl,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
BCBS Medicaid,CPT,G9884,2 em ongoing ms mo 19-21 wl,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
BCBS Medicaid,CPT,G9885,2 em ongoing ms mo 22-24 wl,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
BCBS Medicaid,CPT,G9890,Em bridge payment,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
BCBS Medicaid,CPT,G9987,Bpci advanced in home visit,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,H0001,Alcohol and/or drug assess,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
BCBS Medicaid,CPT,H0002,Alcohol and/or drug screenin,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
BCBS Medicaid,CPT,H0003,Alcohol and/or drug screenin,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,H0004,Alcohol and/or drug services,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
BCBS Medicaid,CPT,H0005,Alcohol and/or drug services,Behavioral Health,Per Unit,$119.88 ,OP,119.88,119.88,,,,,,
BCBS Medicaid,CPT,H0006,Alcohol and/or drug services,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
BCBS Medicaid,CPT,H0007,Alcohol and/or drug services,Behavioral Health,Per Unit,$135.70 ,OP,135.7,135.7,,,,,,
BCBS Medicaid,CPT,H0014,Alcohol and/or drug services,Behavioral Health,Per Unit,$80.13 ,OP,80.13,80.13,,,,,,
BCBS Medicaid,CPT,H0015,Alcohol and/or drug services,Behavioral Health,Per Unit,$339.88 ,OP,339.88,339.88,,,,,,
BCBS Medicaid,CPT,H0020,Alcohol and/or drug services,Behavioral Health,Per Unit,$80.13 ,OP,80.13,80.13,,,,,,
BCBS Medicaid,CPT,H0022,Alcohol and/or drug interven,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
BCBS Medicaid,CPT,H0031,Mh health assess by non-md,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
BCBS Medicaid,CPT,H0032,Mh svc plan dev by non-md,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
BCBS Medicaid,CPT,H0033,Oral med adm direct observe,Behavioral Health,Per Unit,$80.13 ,OP,80.13,80.13,,,,,,
BCBS Medicaid,CPT,H0034,Med trng & support per 15min,Behavioral Health,Per Unit,$80.13 ,OP,80.13,80.13,,,,,,
BCBS Medicaid,CPT,H0035,Mh partial hosp tx under 24h,Behavioral Health,Per Unit,$220.60 ,OP,220.6,220.6,,,,,,
BCBS Medicaid,CPT,H0037,Comm psy sup tx pgm per diem,Behavioral Health,Per Unit,$220.60 ,OP,220.6,220.6,,,,,,
BCBS Medicaid,CPT,H0046,"Mental health service, nos",Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
BCBS Medicaid,CPT,H0047,Alcohol/drug abuse svc nos,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
BCBS Medicaid,CPT,H0049,Alcohol/drug screening,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
BCBS Medicaid,CPT,H0050,Alcohol/drug service 15 min,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
BCBS Medicaid,CPT,H1002,Carecoordination prenatal,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,H1003,Prenatal at risk education,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
BCBS Medicaid,CPT,H1011,Family assessment,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
BCBS Medicaid,CPT,H2000,Comp multidisipln evaluation,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
BCBS Medicaid,CPT,H2001,Rehabilitation program 1/2 d,Behavioral Health,Per Unit,$166.94 ,OP,166.94,166.94,,,,,,
BCBS Medicaid,CPT,H2010,Comprehensive med svc 15 min,Behavioral Health,Per Unit,$80.13 ,OP,80.13,80.13,,,,,,
BCBS Medicaid,CPT,H2011,"Crisis interven svc, 15 min",Behavioral Health,Per Unit,$135.70 ,OP,135.7,135.7,,,,,,
BCBS Medicaid,CPT,H2012,"Behav hlth day treat, per hr",Behavioral Health,Per Unit,$276.34 ,OP,276.34,276.34,,,,,,
BCBS Medicaid,CPT,H2014,"Skills train and dev, 15 min",Behavioral Health,Per Unit,$48.15 ,OP,48.15,48.15,,,,,,
BCBS Medicaid,CPT,H2017,"Psysoc rehab svc, per 15 min",Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
BCBS Medicaid,CPT,H2018,"Psysoc rehab svc, per diem",Behavioral Health,Per Unit,$220.60 ,OP,220.6,220.6,,,,,,
BCBS Medicaid,CPT,H2019,"Ther behav svc, per 15 min",Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
BCBS Medicaid,CPT,H2020,"Ther behav svc, per diem",Behavioral Health,Per Unit,$220.60 ,OP,220.6,220.6,,,,,,
BCBS Medicaid,CPT,H2027,"Psychoed svc, per 15 min",Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
BCBS Medicaid,CPT,H2028,"Sex offend tx svc, 15 min",Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
BCBS Medicaid,CPT,H2029,"Sex offend tx svc, per diem",Behavioral Health,Per Unit,$220.60 ,OP,220.6,220.6,,,,,,
BCBS Medicaid,CPT,H2032,"Activity therapy, per 15 min",Behavioral Health,Per Unit,$48.15 ,OP,48.15,48.15,,,,,,
BCBS Medicaid,CPT,H2033,Multisys ther/juvenile 15min,Behavioral Health,Per Unit,$48.15 ,OP,48.15,48.15,,,,,,
BCBS Medicaid,CPT,H2035,"A/d tx program, per hour",Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
BCBS Medicaid,CPT,H2036,"A/d tx program, per diem",Behavioral Health,Per Unit,$220.60 ,OP,220.6,220.6,,,,,,
BCBS Medicaid,CPT,J0121,"Inj., omadacycline, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
BCBS Medicaid,CPT,J0122,"Inj., eravacycline, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,J0129,Abatacept injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
BCBS Medicaid,CPT,J0130,Abciximab injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
BCBS Medicaid,CPT,J0135,Adalimumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,518.96,518.96,,,,,,
BCBS Medicaid,CPT,J0178,Aflibercept injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
BCBS Medicaid,CPT,J0179,"Inj, brolucizumab-dbll, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
BCBS Medicaid,CPT,J0180,Agalsidase beta injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
BCBS Medicaid,CPT,J0185,"Inj., aprepitant, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
BCBS Medicaid,CPT,J0202,"Injection, alemtuzumab",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,J0205,Alglucerase injection,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
BCBS Medicaid,CPT,J0207,Amifostine,Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,244.88,244.88,,,,,,
BCBS Medicaid,CPT,J0210,Methyldopate hcl injection,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
BCBS Medicaid,CPT,J0215,Alefacept,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
BCBS Medicaid,CPT,J0220,Alglucosidase alfa injection,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,J0221,Lumizyme injection,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,J0222,"Inj., patisiran, 0.1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,J0223,Inj givosiran 0.5 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,J0256,Alpha 1 proteinase inhibitor,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
BCBS Medicaid,CPT,J0257,Glassia injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
BCBS Medicaid,CPT,J0287,Amphotericin b lipid complex,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,J0288,Ampho b cholesteryl sulfate,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,J0289,Amphotericin b liposome inj,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,J0291,"Inj., plazomicin, 5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,J0348,Anidulafungin injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,J0350,Injection anistreplase 30 u,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,J0364,Apomorphine hydrochloride,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,J0365,"Aprotonin, 10,000 kiu",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
BCBS Medicaid,CPT,J0401,Inj aripiprazole ext rel 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
BCBS Medicaid,CPT,J0475,Baclofen 10 mg injection,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,384.11,384.11,,,,,,
BCBS Medicaid,CPT,J0480,Basiliximab,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
BCBS Medicaid,CPT,J0485,Belatacept injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
BCBS Medicaid,CPT,J0490,Belimumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
BCBS Medicaid,CPT,J0517,"Inj., benralizumab, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,J0558,Peng benzathine/procaine inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,J0561,Penicillin g benzathine inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,J0565,"Inj, bezlotoxumab, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
BCBS Medicaid,CPT,J0567,"Inj., cerliponase alfa 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,J0570,Buprenorphine implant 74.2mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
BCBS Medicaid,CPT,J0583,Bivalirudin,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,J0584,"Injection, burosumab-twza 1m",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,J0585,"Injection,onabotulinumtoxina",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,J0586,Abobotulinumtoxina,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,384.11,384.11,,,,,,
BCBS Medicaid,CPT,J0587,"Inj, rimabotulinumtoxinb",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,J0588,Incobotulinumtoxin a,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,J0591,"Inj deoxycholic acid, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,J0593,"Inj., lanadelumab-flyo, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,J0594,Busulfan injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
BCBS Medicaid,CPT,J0596,"Injection, ruconest",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J0597,"C-1 esterase, berinert",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,J0598,"C-1 esterase, cinryze",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,J0599,"Inj., haegarda 10 units",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,J0600,Edetate calcium disodium inj,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J0604,"Cinacalcet, esrd on dialysis",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,J0606,"Inj, etelcalcetide, 0.1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,J0630,Calcitonin salmon injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
BCBS Medicaid,CPT,J0637,Caspofungin acetate,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,J0638,Canakinumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
BCBS Medicaid,CPT,J0641,Inj levoleucovorin nos 0.5mg,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
BCBS Medicaid,CPT,J0642,"Injection, khapzory, 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,J0691,Inj lefamulin 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
BCBS Medicaid,CPT,J0693,"Inj., cefiderocol, 5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
BCBS Medicaid,CPT,J0695,Inj ceftolozane tazobactam,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
BCBS Medicaid,CPT,J0712,Ceftaroline fosamil inj,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
BCBS Medicaid,CPT,J0714,Ceftazidime and avibactam,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,J0716,Centruroides immune f(ab),Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
BCBS Medicaid,CPT,J0717,Certolizumab pegol inj 1mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
BCBS Medicaid,CPT,J0740,Cidofovir injection,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
BCBS Medicaid,CPT,J0742,Inj imip 4 cilas 4 releb 2mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
BCBS Medicaid,CPT,J0775,"Collagenase, clost hist inj",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
BCBS Medicaid,CPT,J0791,Inj crizanlizumab-tmca 5mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
BCBS Medicaid,CPT,J0795,Corticorelin ovine triflutal,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
BCBS Medicaid,CPT,J0800,Corticotropin injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,J0833,Cosyntropin injection nos,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,J0840,Crotalidae poly immune fab,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
BCBS Medicaid,CPT,J0841,Inj crotalidae im f(ab')2 eq,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
BCBS Medicaid,CPT,J0850,Cytomegalovirus imm iv /vial,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
BCBS Medicaid,CPT,J0875,"Injection, dalbavancin",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,J0878,Daptomycin injection,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,189.67,189.67,,,,,,
BCBS Medicaid,CPT,J0881,"Darbepoetin alfa, non-esrd",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,J0882,"Darbepoetin alfa, esrd use",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
BCBS Medicaid,CPT,J0883,Argatroban nonesrd use 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,J0884,Argatroban esrd dialysis 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,J0885,"Epoetin alfa, non-esrd",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,J0886,Epoetin alfa 1000 units esrd,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,J0890,Peginesatide injection,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
BCBS Medicaid,CPT,J0894,Decitabine injection,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
BCBS Medicaid,CPT,J0896,Inj luspatercept-aamt 0.25mg,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
BCBS Medicaid,CPT,J0897,Denosumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,518.96,518.96,,,,,,
BCBS Medicaid,CPT,J1095,"Injection, dexamethasone 9%",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,J1096,Dexametha opth insert 0.1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,J1097,Phenylep ketorolac opth soln,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,J1162,Digoxin immune fab (ovine),Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J1190,Dexrazoxane hcl injection,Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,244.88,244.88,,,,,,
BCBS Medicaid,CPT,J1201,Inj. cetirizine hcl 0.5mg,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,J1205,Chlorothiazide sodium inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,J1212,Dimethyl sulfoxide 50% 50 ml,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,J1267,Doripenem injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,J1290,Ecallantide injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
BCBS Medicaid,CPT,J1300,Eculizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,J1301,"Injection, edaravone, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
BCBS Medicaid,CPT,J1303,"Inj., ravulizumab-cwvz 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,J1322,"Elosulfase alfa, injection",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,J1327,Eptifibatide injection,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
BCBS Medicaid,CPT,J1410,Inj estrogen conjugate 25 mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
BCBS Medicaid,CPT,J1428,"Inj, eteplirsen, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,J1429,Inj golodirsen 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,J1430,Ethanolamine oleate 100 mg,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,384.11,384.11,,,,,,
BCBS Medicaid,CPT,J1436,Etidronate disodium inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,J1437,Inj. fe derisomaltose 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,J1438,Etanercept injection,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,J1439,Inj ferric carboxymaltos 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,J1442,Inj filgrastim excl biosimil,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,J1446,"Inj, tbo-filgrastim, 5 mcg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,J1447,Inj tbo filgrastim 1 microg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,J1451,"Fomepizole, 15 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,J1452,Intraocular fomivirsen na,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,J1453,Fosaprepitant injection,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
BCBS Medicaid,CPT,J1454,"Inj fosnetupitant, palonoset",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,J1455,Foscarnet sodium injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,J1457,Gallium nitrate injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,J1458,Galsulfase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,J1459,Inj ivig privigen 500 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
BCBS Medicaid,CPT,J1460,Gamma globulin 1 cc inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,J1555,"Inj cuvitru, 100 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
BCBS Medicaid,CPT,J1556,"Inj, imm glob bivigam, 500mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,J1557,Gammaplex injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,J1558,"Inj. xembify, 100 mg",Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,384.11,384.11,,,,,,
BCBS Medicaid,CPT,J1559,Hizentra injection,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,384.11,384.11,,,,,,
BCBS Medicaid,CPT,J1560,Gamma globulin > 10 cc inj,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,J1561,Gamunex-c/gammaked,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
BCBS Medicaid,CPT,J1562,"Vivaglobin, inj",Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,384.11,384.11,,,,,,
BCBS Medicaid,CPT,J1566,"Immune globulin, powder",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
BCBS Medicaid,CPT,J1568,Octagam injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
BCBS Medicaid,CPT,J1569,Gammagard liquid injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
BCBS Medicaid,CPT,J1570,Ganciclovir sodium injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,J1571,Hepagam b im injection,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,J1572,Flebogamma injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
BCBS Medicaid,CPT,J1573,"Hepagam b intravenous, inj",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,J1575,Hyqvia 100mg immuneglobulin,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,J1595,Injection glatiramer acetate,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,J1599,"Ivig non-lyophilized, nos",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
BCBS Medicaid,CPT,J1602,Golimumab for iv use 1mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
BCBS Medicaid,CPT,J1610,Glucagon hydrochloride/1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
BCBS Medicaid,CPT,J1628,"Inj., guselkumab, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
BCBS Medicaid,CPT,J1632,"Inj., brexanolone, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J1640,"Hemin, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J1670,Tetanus immune globulin inj,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,J1675,Histrelin acetate,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
BCBS Medicaid,CPT,J1738,Inj. meloxicam 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,J1740,Ibandronate sodium injection,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
BCBS Medicaid,CPT,J1742,Ibutilide fumarate injection,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
BCBS Medicaid,CPT,J1743,Idursulfase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
BCBS Medicaid,CPT,J1744,Icatibant injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J1745,Infliximab not biosimil 10mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
BCBS Medicaid,CPT,J1746,"Inj., ibalizumab-uiyk, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J1750,Inj iron dextran,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,J1756,Iron sucrose injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,J1786,Imuglucerase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
BCBS Medicaid,CPT,J1823,"Inj. inebilizumab-cdon, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,J1826,Interferon beta-1a inj,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
BCBS Medicaid,CPT,J1830,Interferon beta-1b / .25 mg,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,J1833,"Injection, isavuconazonium",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,J1930,Lanreotide injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,J1931,Laronidase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
BCBS Medicaid,CPT,J1942,Aripiprazole lauroxil 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
BCBS Medicaid,CPT,J1943,"Inj., aristada initio, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
BCBS Medicaid,CPT,J1944,Aripirazole lauroxil 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
BCBS Medicaid,CPT,J1945,Lepirudin,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
BCBS Medicaid,CPT,J1950,Leuprolide acetate /3.75 mg,Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,244.88,244.88,,,,,,
BCBS Medicaid,CPT,J2062,Loxapine for inhalation 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,J2170,Mecasermin injection,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,J2182,"Injection, mepolizumab, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
BCBS Medicaid,CPT,J2186,"Inj., meropenem, vaborbactam",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
BCBS Medicaid,CPT,J2248,Micafungin sodium injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,J2278,Ziconotide injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
BCBS Medicaid,CPT,J2315,"Naltrexone, depot form",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
BCBS Medicaid,CPT,J2323,Natalizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,J2325,Nesiritide injection,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,384.11,384.11,,,,,,
BCBS Medicaid,CPT,J2326,"Inj, nusinersen, 0.1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,J2350,"Injection, ocrelizumab, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,J2353,"Octreotide injection, depot",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,J2355,Oprelvekin injection,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,J2357,Omalizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
BCBS Medicaid,CPT,J2407,"Injection, oritavancin",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
BCBS Medicaid,CPT,J2425,Palifermin injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
BCBS Medicaid,CPT,J2426,Paliperidone palmitate inj,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
BCBS Medicaid,CPT,J2469,Palonosetron hcl,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
BCBS Medicaid,CPT,J2502,"Inj, pasireotide long acting",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,J2503,Pegaptanib sodium injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
BCBS Medicaid,CPT,J2504,"Pegademase bovine, 25 iu",Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,518.96,518.96,,,,,,
BCBS Medicaid,CPT,J2505,"Injection, pegfilgrastim 6mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,J2507,Pegloticase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
BCBS Medicaid,CPT,J2513,Pentastarch 10% solution,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
BCBS Medicaid,CPT,J2515,Pentobarbital sodium inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,J2545,Pentamidine non-comp unit,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,J2547,"Injection, peramivir",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
BCBS Medicaid,CPT,J2562,Plerixafor injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J2597,Inj desmopressin acetate,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
BCBS Medicaid,CPT,J2724,Protein c concentrate,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
BCBS Medicaid,CPT,J2730,Pralidoxime chloride inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,J2770,Quinupristin/dalfopristin,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,189.67,189.67,,,,,,
BCBS Medicaid,CPT,J2778,Ranibizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
BCBS Medicaid,CPT,J2783,Rasburicase,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
BCBS Medicaid,CPT,J2786,"Injection, reslizumab, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
BCBS Medicaid,CPT,J2790,Rho d immune globulin inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,J2791,Rhophylac injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,J2792,"Rho(d) immune globulin h, sd",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,J2793,Rilonacept injection,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,J2794,"Inj risperdal consta, 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,J2796,Romiplostim injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
BCBS Medicaid,CPT,J2797,"Inj., rolapitant, 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
BCBS Medicaid,CPT,J2798,"Inj., perseris, 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,J2805,Sincalide injection,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
BCBS Medicaid,CPT,J2820,Sargramostim injection,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,J2840,Inj sebelipase alfa 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,J2850,Inj secretin synthetic human,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,J2860,"Injection, siltuximab",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
BCBS Medicaid,CPT,J2993,Reteplase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,J2997,Alteplase recombinant,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,J3031,"Inj., fremanezumab-vfrm 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,J3032,Inj. eptinezumab-jjmr 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,J3060,"Inj, taliglucerase alfa 10 u",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
BCBS Medicaid,CPT,J3090,Inj tedizolid phosphate,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
BCBS Medicaid,CPT,J3095,Telavancin injection,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,J3101,Tenecteplase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J3110,Teriparatide injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
BCBS Medicaid,CPT,J3111,Inj. romosozumab-aqqg 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
BCBS Medicaid,CPT,J3145,Testosterone undecanoate 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,J3240,Thyrotropin injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
BCBS Medicaid,CPT,J3241,Inj. teprotumumab-trbw 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,J3243,Tigecycline injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,J3245,"Inj., tildrakizumab, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
BCBS Medicaid,CPT,J3246,Tirofiban hcl,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
BCBS Medicaid,CPT,J3262,Tocilizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
BCBS Medicaid,CPT,J3285,Treprostinil injection,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,J3300,Triamcinolone a inj prs-free,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,J3304,Inj triamcinolone ace xr 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,J3315,Triptorelin pamoate,Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,244.88,244.88,,,,,,
BCBS Medicaid,CPT,J3316,"Inj., triptorelin xr 3.75 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,J3355,"Urofollitropin, 75 iu",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
BCBS Medicaid,CPT,J3357,"Ustekinumab sub cu inj, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
BCBS Medicaid,CPT,J3358,"Ustekinumab, iv inject, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J3365,"Urokinase 250,000 iu inj",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,J3380,"Injection, vedolizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,J3385,Velaglucerase alfa,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
BCBS Medicaid,CPT,J3396,Verteporfin injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
BCBS Medicaid,CPT,J3397,"Inj., vestronidase alfa-vjbk",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,J3398,Inj luxturna 1 billion vec g,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,J3399,Inj onase abepar-xioi treat,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,J3470,Hyaluronidase injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,J3471,"Ovine, up to 999 usp units",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,J3472,"Ovine, 1000 usp units",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,J3473,Hyaluronidase recombinant,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,J7169,"Inj andexxa, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,J7170,"Inj., emicizumab-kxwh 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,J7175,"Inj, factor x, (human), 1iu",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,J7177,"Inj., fibryga, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
BCBS Medicaid,CPT,J7178,Inj human fibrinogen con nos,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
BCBS Medicaid,CPT,J7179,Vonvendi inj 1 iu vwf:rco,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J7180,Factor xiii anti-hem factor,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,J7181,Factor xiii recomb a-subunit,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,J7182,Factor viii recomb novoeight,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J7183,Wilate injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J7185,Xyntha inj,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J7186,Antihemophilic viii/vwf comp,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J7187,"Humate-p, inj",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J7188,Factor viii recomb obizur,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J7189,Factor viia recomb novoseven,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J7190,Factor viii,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J7191,Factor viii (porcine),Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J7192,Factor viii recombinant nos,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J7193,Factor ix non-recombinant,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J7194,Factor ix complex,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J7195,Factor ix recombinant nos,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J7196,Antithrombin recombinant,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,J7197,Antithrombin iii injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J7198,Anti-inhibitor,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
BCBS Medicaid,CPT,J7199,Hemophilia clot factor noc,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
BCBS Medicaid,CPT,J7200,Factor ix recombinan rixubis,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J7201,Factor ix alprolix recomb,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J7202,Factor ix idelvion inj,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J7203,Factor ix recomb gly rebinyn,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J7204,Inj recombin esperoct per iu,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J7205,Factor viii fc fusion recomb,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J7207,Factor viii pegylated recomb,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J7208,Inj. jivi 1 iu,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J7209,Factor viii nuwiq recomb 1iu,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J7210,"Inj, afstyla, 1 i.u.",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J7211,"Inj, kovaltry, 1 i.u.",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J7212,Factor viia recomb sevenfact,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J7296,"Kyleena, 19.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,J7297,"Liletta, 52 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,J7298,"Mirena, 52 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,J7300,Intraut copper contraceptive,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,J7301,"Skyla, 13.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,J7302,Levonorgestrel iu 52 mg,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,J7303,Contraceptive vaginal ring,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,J7304,Contraceptive hormone patch,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,J7306,Levonorgestrel implant sys,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
BCBS Medicaid,CPT,J7307,Etonogestrel implant system,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,J7308,Aminolevulinic acid hcl top,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,J7309,"Methyl aminolevulinate, top",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,J7310,Ganciclovir long act implant,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,J7311,"Inj., retisert, 0.01 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,J7312,Dexamethasone intra implant,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
BCBS Medicaid,CPT,J7313,"Inj., iluvien, 0.01 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J7314,"Inj., yutiq, 0.01 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J7315,Ophthalmic mitomycin,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,J7316,"Inj, ocriplasmin, 0.125 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,J7318,"Inj, durolane 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,J7320,"Genvisc 850, inj, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
BCBS Medicaid,CPT,J7321,Hyalgan or supartz inj dose,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,J7322,Hymovis injection 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
BCBS Medicaid,CPT,J7323,Euflexxa inj per dose,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
BCBS Medicaid,CPT,J7324,Orthovisc inj per dose,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
BCBS Medicaid,CPT,J7325,Synvisc or synvisc-one,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,J7326,Gel-one,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,J7327,Monovisc inj per dose,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,384.11,384.11,,,,,,
BCBS Medicaid,CPT,J7328,Gelsyn-3 injection 0.1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
BCBS Medicaid,CPT,J7329,"Inj, trivisc 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,J7330,Cultured chondrocytes implnt,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,J7331,"Synojoynt, inj., 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,J7332,"Inj., triluron, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,J7333,Visco-3 inj dose,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,J7336,Capsaicin 8% patch,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,J7340,Carbidopa levodopa ent 100ml,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,J7345,"Aminolevulinic acid, 10% gel",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,J7351,Inj bimatoprost itc imp1mcg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
BCBS Medicaid,CPT,J7352,"Afamelanotide implant, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,J7401,Mometasone furoate sinus imp,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,384.11,384.11,,,,,,
BCBS Medicaid,CPT,J7501,Azathioprine parenteral,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
BCBS Medicaid,CPT,J7504,Lymphocyte immune globulin,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J7505,Monoclonal antibodies,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,518.96,518.96,,,,,,
BCBS Medicaid,CPT,J7511,Antithymocyte globuln rabbit,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
BCBS Medicaid,CPT,J7513,"Daclizumab, parenteral",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
BCBS Medicaid,CPT,J7525,Tacrolimus injection,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
BCBS Medicaid,CPT,J7639,Dornase alfa non-comp unit,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,J7685,Tobramycin comp unit,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,J7686,"Treprostinil, non-comp unit",Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
BCBS Medicaid,CPT,J8501,Oral aprepitant,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
BCBS Medicaid,CPT,J8560,Etoposide oral 50 mg,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
BCBS Medicaid,CPT,J8562,Oral fludarabine phosphate,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
BCBS Medicaid,CPT,J8565,Gefitinib oral,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
BCBS Medicaid,CPT,J8655,"Oral netupitant, palonosetro",Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,189.67,189.67,,,,,,
BCBS Medicaid,CPT,J8670,"Rolapitant, oral, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
BCBS Medicaid,CPT,J8705,Topotecan oral,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,J9010,Alemtuzumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
BCBS Medicaid,CPT,J9015,Aldesleukin injection,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,518.96,518.96,,,,,,
BCBS Medicaid,CPT,J9017,Arsenic trioxide injection,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
BCBS Medicaid,CPT,J9019,Erwinaze injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
BCBS Medicaid,CPT,J9020,"Asparaginase, nos",Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
BCBS Medicaid,CPT,J9022,"Inj, atezolizumab,10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
BCBS Medicaid,CPT,J9023,"Injection, avelumab, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J9025,Azacitidine injection,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
BCBS Medicaid,CPT,J9027,Clofarabine injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,J9030,Bcg live intravesical 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
BCBS Medicaid,CPT,J9031,Bcg live intravesical vac,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
BCBS Medicaid,CPT,J9032,"Injection, belinostat, 10mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,J9033,"Inj., treanda 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,J9034,"Inj., bendeka 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,J9035,Bevacizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,J9036,Inj. belrapzo/bendamustine,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,J9039,"Injection, blinatumomab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,J9040,Bleomycin sulfate injection,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
BCBS Medicaid,CPT,J9041,"Inj., velcade 0.1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,244.88,244.88,,,,,,
BCBS Medicaid,CPT,J9042,Brentuximab vedotin inj,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
BCBS Medicaid,CPT,J9043,Cabazitaxel injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J9044,"Inj, bortezomib, nos, 0.1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
BCBS Medicaid,CPT,J9047,"Injection, carfilzomib, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
BCBS Medicaid,CPT,J9050,Carmustine injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J9055,Cetuximab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
BCBS Medicaid,CPT,J9057,"Inj., copanlisib, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,J9065,Inj cladribine per 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,189.67,189.67,,,,,,
BCBS Medicaid,CPT,J9070,Cyclophosphamide 100 mg inj,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
BCBS Medicaid,CPT,J9098,Cytarabine liposome inj,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
BCBS Medicaid,CPT,J9118,Inj. calaspargase pegol-mknl,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
BCBS Medicaid,CPT,J9119,"Inj., cemiplimab-rwlc, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J9120,Dactinomycin injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
BCBS Medicaid,CPT,J9144,"Daratumumab, hyaluronidase",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,J9145,"Injection, daratumumab 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,J9150,Daunorubicin injection,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,189.67,189.67,,,,,,
BCBS Medicaid,CPT,J9151,Daunorubicin citrate inj,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
BCBS Medicaid,CPT,J9153,"Inj daunorubicin, cytarabine",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
BCBS Medicaid,CPT,J9155,Degarelix injection,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,189.67,189.67,,,,,,
BCBS Medicaid,CPT,J9160,Denileukin diftitox inj,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J9171,Docetaxel injection,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
BCBS Medicaid,CPT,J9173,"Inj., durvalumab, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J9176,"Injection, elotuzumab, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,J9177,Inj enfort vedo-ejfv 0.25mg,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J9179,Eribulin mesylate injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
BCBS Medicaid,CPT,J9185,Fludarabine phosphate inj,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
BCBS Medicaid,CPT,J9198,"Inj. infugem, 100 mg",Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,189.67,189.67,,,,,,
BCBS Medicaid,CPT,J9199,"Injection, infugem, 200 mg",Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,189.67,189.67,,,,,,
BCBS Medicaid,CPT,J9200,Floxuridine injection,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
BCBS Medicaid,CPT,J9202,Goserelin acetate implant,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
BCBS Medicaid,CPT,J9203,Gemtuzumab ozogamicin 0.1 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J9204,"Inj mogamulizumab-kpkc, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
BCBS Medicaid,CPT,J9205,Inj irinotecan liposome 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,J9207,Ixabepilone injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
BCBS Medicaid,CPT,J9208,Ifosfamide injection,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
BCBS Medicaid,CPT,J9210,"Inj., emapalumab-lzsg, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,J9211,Idarubicin hcl injection,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
BCBS Medicaid,CPT,J9213,Interferon alfa-2a inj,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
BCBS Medicaid,CPT,J9214,Interferon alfa-2b inj,Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,244.88,244.88,,,,,,
BCBS Medicaid,CPT,J9216,Interferon gamma 1-b inj,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
BCBS Medicaid,CPT,J9217,Leuprolide acetate suspnsion,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
BCBS Medicaid,CPT,J9219,Leuprolide acetate implant,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J9223,"Inj. lurbinectedin, 0.1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,J9225,Vantas implant,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,J9226,Supprelin la implant,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,J9227,Inj. isatuximab-irfc 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,J9228,Ipilimumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,J9229,Inj inotuzumab ozogam 0.1 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
BCBS Medicaid,CPT,J9230,Mechlorethamine hcl inj,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
BCBS Medicaid,CPT,J9245,Inj melpha hydroch nos 50 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J9246,"Inj., evomela, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J9261,Nelarabine injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J9262,"Inj, omacetaxine mep, 0.01mg",Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
BCBS Medicaid,CPT,J9264,Paclitaxel protein bound,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
BCBS Medicaid,CPT,J9266,Pegaspargase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
BCBS Medicaid,CPT,J9268,Pentostatin injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
BCBS Medicaid,CPT,J9269,Inj. tagraxofusp-erzs 10 mcg,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,J9270,Plicamycin (mithramycin) inj,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
BCBS Medicaid,CPT,J9271,Inj pembrolizumab,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
BCBS Medicaid,CPT,J9280,Mitomycin injection,Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,244.88,244.88,,,,,,
BCBS Medicaid,CPT,J9281,Mitomycin instillation,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,J9285,"Inj, olaratumab, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J9293,Mitoxantrone hydrochl / 5 mg,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
BCBS Medicaid,CPT,J9295,"Injection, necitumumab, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J9299,"Injection, nivolumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J9300,Gemtuzumab ozogamicin inj,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J9301,Obinutuzumab inj,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J9302,Ofatumumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
BCBS Medicaid,CPT,J9303,Panitumumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,J9304,"Inj. pemetrexed, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J9305,Inj. pemetrexed nos 10mg,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J9306,"Injection, pertuzumab, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,J9307,Pralatrexate injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J9308,"Injection, ramucirumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,J9309,"Inj, polatuzumab vedotin 1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
BCBS Medicaid,CPT,J9310,Rituximab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,J9311,"Inj rituximab, hyaluronidase",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J9312,"Inj., rituximab, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J9313,"Inj., lumoxiti, 0.01 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J9315,Romidepsin injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J9316,"Pertuzu, trastuzu, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,J9317,Sacituzumab govitecan-hziy,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,518.96,518.96,,,,,,
BCBS Medicaid,CPT,J9320,Streptozocin injection,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,189.67,189.67,,,,,,
BCBS Medicaid,CPT,J9325,Inj talimogene laherparepvec,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J9328,Temozolomide injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
BCBS Medicaid,CPT,J9330,Temsirolimus injection,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,518.96,518.96,,,,,,
BCBS Medicaid,CPT,J9340,Thiotepa injection,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,189.67,189.67,,,,,,
BCBS Medicaid,CPT,J9352,Injection trabectedin 0.1mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,J9354,"Inj, ado-trastuzumab emt 1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J9355,Inj trastuzumab excl biosimi,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,J9356,"Inj. herceptin hylecta, 10mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,J9357,Valrubicin injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,J9358,Inj fam-trastu deru-nxki 1mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,J9371,"Inj, vincristine sul lip 1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,J9395,"Injection, fulvestrant",Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,518.96,518.96,,,,,,
BCBS Medicaid,CPT,J9400,"Inj, ziv-aflibercept, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
BCBS Medicaid,CPT,J9600,Porfimer sodium injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,L8604,Dextranomer/hyaluronic acid,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,L8605,Inj bulking agent anal canal,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,L8607,Inj vocal cord bulking agent,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,M0239,Bamlanivimab-xxxx infusion,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
BCBS Medicaid,CPT,M0243,Casirivi and imdevi infusion,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
BCBS Medicaid,CPT,P2028,Cephalin floculation test,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,P2029,Congo red blood test,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,P2031,Hair analysis,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,P2033,Blood thymol turbidity,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,P2038,Blood mucoprotein,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,P3000,Screen pap by tech w md supv,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
BCBS Medicaid,CPT,P3001,Screening pap smear by phys,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
BCBS Medicaid,CPT,P7001,Culture bacterial urine,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,P9010,Whole blood for transfusion,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,P9011,Blood split unit,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,P9012,Cryoprecipitate each unit,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,P9016,Rbc leukocytes reduced,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,P9017,Plasma 1 donor frz w/in 8 hr,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,P9019,"Platelets, each unit",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,P9020,Plaelet rich plasma unit,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,P9021,Red blood cells unit,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,P9022,Washed red blood cells unit,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,P9023,"Frozen plasma, pooled, sd",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,P9031,Platelets leukocytes reduced,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,P9032,"Platelets, irradiated",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,P9033,Platelets leukoreduced irrad,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,P9034,"Platelets, pheresis",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,P9035,Platelet pheres leukoreduced,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,P9036,Platelet pheresis irradiated,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,P9037,Plate pheres leukoredu irrad,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,P9038,Rbc irradiated,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,P9039,Rbc deglycerolized,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,P9040,Rbc leukoreduced irradiated,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,P9041,"Albumin (human),5%, 50ml",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,P9043,"Plasma protein fract,5%,50ml",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,P9044,Cryoprecipitatereducedplasma,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,P9045,"Albumin (human), 5%, 250 ml",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,P9046,"Albumin (human), 25%, 20 ml",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,P9047,"Albumin (human), 25%, 50ml",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,P9048,"Plasmaprotein fract,5%,250ml",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,P9050,"Granulocytes, pheresis unit",Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
BCBS Medicaid,CPT,P9051,"Blood, l/r, cmv-neg",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,P9052,"Platelets, hla-m, l/r, unit",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,P9053,"Plt, pher, l/r cmv-neg, irr",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,P9054,"Blood, l/r, froz/degly/wash",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,P9055,"Plt, aph/pher, l/r, cmv-neg",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,P9056,"Blood, l/r, irradiated",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,P9057,"Rbc, frz/deg/wsh, l/r, irrad",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,P9058,"Rbc, l/r, cmv-neg, irrad",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,P9059,"Plasma, frz between 8-24hour",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,P9060,Fr frz plasma donor retested,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,P9070,Pathogen reduced plasma pool,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,P9071,Pathogen reduced plasma sing,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,P9072,Plate path red/rapid bac tes,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,P9073,Platelets pheresis path redu,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,P9099,Blood component/product noc,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,P9100,Pathogen test for platelets,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,Q0035,Cardiokymography,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
BCBS Medicaid,CPT,Q0081,Infusion ther other than che,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
BCBS Medicaid,CPT,Q0084,Chemotherapy by infusion,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
BCBS Medicaid,CPT,Q0085,Chemo by both infusion and o,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
BCBS Medicaid,CPT,Q0091,Obtaining screen pap smear,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
BCBS Medicaid,CPT,Q0111,Wet mounts/ w preparations,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,Q0112,Potassium hydroxide preps,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,Q0113,Pinworm examinations,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,Q0114,Fern test,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
BCBS Medicaid,CPT,Q0115,Post-coital mucous exam,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,Q0138,"Ferumoxytol, non-esrd",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,Q0139,"Ferumoxytol, esrd use",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,Q0239,Bamlanivimab-xxxx,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
BCBS Medicaid,CPT,Q0243,Casirivimab and imdevimab,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
BCBS Medicaid,CPT,Q0515,Sermorelin acetate injection,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,518.96,518.96,,,,,,
BCBS Medicaid,CPT,Q2017,"Teniposide, 50 mg",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
BCBS Medicaid,CPT,Q2028,"Inj, sculptra, 0.5mg",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q2034,Agriflu vaccine,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,Q2035,"Afluria vacc, 3 yrs & >, im",Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,Q2036,"Flulaval vacc, 3 yrs & >, im",Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,Q2037,"Fluvirin vacc, 3 yrs & >, im",Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,Q2038,"Fluzone vacc, 3 yrs & >, im",Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,Q2039,"Influenza virus vaccine, nos",Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
BCBS Medicaid,CPT,Q2040,Tisagenlecleucel car-pos t,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,Q2043,Sipuleucel-t auto cd54+,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,Q2049,Imported lipodox inj,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,Q2050,Doxorubicin inj 10mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
BCBS Medicaid,CPT,Q3014,Telehealth facility fee,Ancillary Services,Per Unit,$8.33 ,OP,8.33,8.33,,,,,,
BCBS Medicaid,CPT,Q3027,Inj beta interferon im 1 mcg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
BCBS Medicaid,CPT,Q3028,Inj beta interferon sq 1 mcg,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,Q4074,Iloprost non-comp unit dose,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,Q4081,"Epoetin alfa, 100 units esrd",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,Q4100,"Skin substitute, nos",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4101,Apligraf,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4102,Oasis wound matrix,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4103,Oasis burn matrix,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4104,Integra bmwd,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4105,Integra drt or omnigraft,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4106,Dermagraft,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4107,Graftjacket,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4108,Integra matrix,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4110,Primatrix,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4111,Gammagraft,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4112,Cymetra injectable,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4113,Graftjacket xpress,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4114,Integra flowable wound matri,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4115,Alloskin,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4116,Alloderm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4117,Hyalomatrix,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4118,Matristem micromatrix,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4119,Matristem wound matrix,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4120,Matristem burn matrix,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4121,Theraskin,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4122,"Dermacell, awm, porous sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4123,Alloskin,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4124,Oasis tri-layer wound matrix,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4125,Arthroflex,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4126,Memoderm/derma/tranz/integup,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4127,Talymed,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4128,Flexhd/allopatchhd/matrixhd,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4129,Unite biomatrix,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4130,Strattice tm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4131,Epifix or epicord,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4132,"Grafix core, grafixpl core",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4133,Grafix stravix prime pl sqcm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4134,Hmatrix,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4135,Mediskin,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4136,Ezderm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4137,Amnioexcel biodexcel 1sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4138,"Biodfence dryflex, 1cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4139,"Amnio or biodmatrix, inj 1cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4140,Biodfence 1cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4141,"Alloskin ac, 1 cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4142,Xcm biologic tiss matrix 1cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4143,"Repriza, 1cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4145,"Epifix, inj, 1mg",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4146,"Tensix, 1cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4147,Architect ecm px fx 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4148,Neox neox rt or clarix cord,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4149,"Excellagen, 0.1 cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4150,Allowrap ds or dry 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4151,"Amnioband, guardian 1 sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4152,Dermapure 1 square cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4153,"Dermavest, plurivest sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4154,Biovance 1 square cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4155,Neoxflo or clarixflo 1 mg,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4156,Neox 100 or clarix 100,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4157,Revitalon 1 square cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4158,"Kerecis omega3, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4159,Affinity1 square cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4160,Nushield 1 square cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4161,Bio-connekt per square cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4162,"Wndex flw, bioskn flw, 0.5cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4163,"Woundex, bioskin, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4164,"Helicoll, per square cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4165,"Keramatrix, kerasorb sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4166,"Cytal, per square centimeter",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4167,"Truskin, per sq centimeter",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4168,"Amnioband, 1 mg",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4169,"Artacent wound, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4170,"Cygnus, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4171,"Interfyl, 1 mg",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4172,Puraply or puraply am,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4173,Palingen or palingen xplus,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4174,Palingen or promatrx,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4175,Miroderm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4176,"Neopatch or therion, 1 sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4177,"Floweramnioflo, 0.1 cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4178,"Floweramniopatch, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4179,"Flowerderm, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4180,"Revita, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4181,"Amnio wound, per square cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4182,"Transcyte, per sq centimeter",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4183,"Surgigraft, 1 sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4184,Cellesta or duo per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4185,Cellesta flowab amnion 0.5cc,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4186,Epifix 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4187,Epicord 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4188,Amnioarmor 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4189,"Artacent ac, 1 mg",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4190,Artacent ac 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4191,Restorigin 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4192,"Restorigin, 1 cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4193,Coll-e-derm 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4194,Novachor 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4195,Puraply 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4196,Puraply am 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4197,Puraply xt 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4198,Genesis amnio membrane 1sqcm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4200,Skin te 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4201,Matrion 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4202,"Keroxx (2.5g/cc), 1cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4203,"Derma-gide, 1 sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4204,Xwrap 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4205,Membrane graft or wrap sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4206,Fluid flow or fluid gf 1 cc,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4208,Novafix per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4209,Surgraft per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4210,Axolotl graf dualgraf sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4211,Amnion bio or axobio sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4212,"Allogen, per cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4213,"Ascent, 0.5 mg",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4214,Cellesta cord per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4215,"Axolotl ambient, cryo 0.1 mg",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4216,Artacent cord per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4217,Woundfix biowound plus xplus,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4218,Surgicord per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4219,Surgigraft dual per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4220,"Bellacell hd, surederm sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4221,Amniowrap2 per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4222,"Progenamatrix, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4226,Myown harv prep proc sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4227,Amniocore per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4228,"Bionextpatch, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4229,Cogenex amnio memb per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4230,Cogenex flow amnion 0.5 cc,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4231,"Corplex p, per cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4232,"Corplex, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4233,Surfactor /nudyn per 0.5 cc,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4234,"Xcellerate, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4235,Amniorepair or altiply sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4236,Carepatch per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4237,"Cryo-cord, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4238,"Derm-maxx, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4239,Amnio-maxx or lite per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4240,Corecyte topical only 0.5 cc,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4241,"Polycyte, topical only 0.5cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4242,"Amniocyte plus, per 0.5 cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4244,"Procenta, per 200 mg",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4245,"Amniotext, per cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4246,"Coretext or protext, per cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4247,"Amniotext patch, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4248,Dermacyte amn mem allo sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4249,"Amniply, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4250,Amnioamp-mp per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4254,Novafix dl per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q4255,"Reguard, topical use per sq",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,Q5101,"Injection, zarxio",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,Q5102,"Inj., infliximab biosimilar",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
BCBS Medicaid,CPT,Q5103,"Injection, inflectra",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
BCBS Medicaid,CPT,Q5104,"Injection, renflexis",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
BCBS Medicaid,CPT,Q5105,Inj retacrit esrd on dialysi,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,Q5106,Inj retacrit non-esrd use,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,Q5107,Inj mvasi 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,Q5108,"Injection, fulphila",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,Q5109,"Injection, ixifi, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,Q5110,Nivestym,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
BCBS Medicaid,CPT,Q5111,"Injection, udenyca 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,Q5112,Inj ontruzant 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,Q5113,Inj herzuma 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,Q5114,Inj ogivri 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,Q5115,Inj truxima 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,Q5116,"Inj., trazimera, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,Q5117,"Inj., kanjinti, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,Q5118,"Inj., zirabev, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,Q5119,"Inj ruxience, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,Q5120,Inj pegfilgrastim-bmez 0.5mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,Q5121,"Inj. avsola, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
BCBS Medicaid,CPT,Q5122,"Inj, nyvepria",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
BCBS Medicaid,CPT,Q9975,Factor VIII FC Fusion Recomb,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
BCBS Medicaid,CPT,Q9979,"Injection, Alemtuzumab",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
BCBS Medicaid,CPT,Q9980,"Genvisc, inj, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
BCBS Medicaid,CPT,Q9984,Kyleena,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,Q9987,Pathogen test for platelets,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,Q9988,Platelet pheresis path reduc,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,Q9989,"Ustekinumab IV Inj, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
BCBS Medicaid,CPT,Q9991,Buprenorph xr 100 mg or less,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,Q9992,Buprenorphine xr over 100 mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
BCBS Medicaid,CPT,Q9993,"Inj., triamcinolone ext rel",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,Q9995,"inj. emicizumab-kxwh, 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
BCBS Medicaid,CPT,S0013,"Esketamine, nasal spray",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
BCBS Medicaid,CPT,S0040,"Injection, ticarcillin disod",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
BCBS Medicaid,CPT,S0088,Imatinib 100 mg,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
BCBS Medicaid,CPT,S0126,Inj follitropin alfa 75 iu,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,S0132,Inj ganirelix acetat 250 mcg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
BCBS Medicaid,CPT,S0140,"Saquinavir, 200 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
BCBS Medicaid,CPT,S0142,Colistimethate inh sol mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
BCBS Medicaid,CPT,S0145,Peg interferon alfa-2a/180,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,S0148,Peg interferon alfa-2b/10,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
BCBS Medicaid,CPT,S0155,Epoprostenol dilutant,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
BCBS Medicaid,CPT,S0166,Inj olanzapine 2.5mg,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,S0175,Flutamide 125 mg,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
BCBS Medicaid,CPT,S0178,Lomustine 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
BCBS Medicaid,CPT,S0190,"Mifepristone, oral, 200 mg",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
BCBS Medicaid,CPT,S0195,Pneumo vaccine 5-9 yrs,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
BCBS Medicaid,CPT,S0199,Med abortion inc all ex drug,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
BCBS Medicaid,CPT,S0201,Partial hospitalization serv,Behavioral Health,Per Unit,$220.60 ,OP,220.6,220.6,,,,,,
BCBS Medicaid,CPT,S0220,Medical conference by physic,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,S0221,"Medical conference, 60 min",Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,S0250,Comp geriatr assmt team,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,S0257,End of life counseling,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,S0271,Home hospice case 30 days,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,S0280,"Medical home, initial plan",Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,S0281,"Medical home, maintenance",Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,S0311,Comp mgmt care coord adv ill,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,S0315,Disease management program,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,S0316,Follow-up/reassessment,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,S0340,Lifestyle mod 1st stage,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,S0353,Cancer treatmentplan initial,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,S0354,Cancer treatment plan change,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,S0390,Rout foot care per visit,General Surgery,Per Unit,$46.77 ,OP,46.77,46.77,,,,,,
BCBS Medicaid,CPT,S0395,Impression casting ft,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
BCBS Medicaid,CPT,S0592,Comp cont lens eval,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
BCBS Medicaid,CPT,S0601,Screening proctoscopy,Preventive Care,Per Unit,$387.00 ,OP,387,387,,,,,,
BCBS Medicaid,CPT,S0618,Audiometry for hearing aid,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
BCBS Medicaid,CPT,S0800,Laser in situ keratomileusis,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
BCBS Medicaid,CPT,S0810,Photorefractive keratectomy,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
BCBS Medicaid,CPT,S0812,Phototherap keratect,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
BCBS Medicaid,CPT,S2066,Breast gap flap reconst,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
BCBS Medicaid,CPT,S2067,"Breast ""stacked"" diep/gap",General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
BCBS Medicaid,CPT,S2068,Breast diep or siea flap,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
BCBS Medicaid,CPT,S2083,Adjustment gastric band,Gastroenterology,Per Unit,$119.18 ,OP,119.18,119.18,,,,,,
BCBS Medicaid,CPT,S2112,Knee arthroscp harv,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,S2202,Echosclerotherapy,Vascular Surgery,Per Unit,$500.46 ,OP,500.46,500.46,,,,,,
BCBS Medicaid,CPT,S2225,Myringotomy laser-assist,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
BCBS Medicaid,CPT,S2230,Implant semi-imp hear,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,S2235,Implant auditory brain imp,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,S2260,Induced abortion 17-24 weeks,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
BCBS Medicaid,CPT,S2265,Induced abortion 25-28 wks,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
BCBS Medicaid,CPT,S2266,Induced abortion 29-31 wks,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
BCBS Medicaid,CPT,S2267,Induced abortion 32 or more,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
BCBS Medicaid,CPT,S2300,"Arthroscopy, shoulder, surgi",Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
BCBS Medicaid,CPT,S2340,Chemodenervation of abductor,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,S2341,Chemodenerv adduct vocal,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
BCBS Medicaid,CPT,S2342,Nasal endoscop po debrid,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
BCBS Medicaid,CPT,S2400,Fetal surg congen hernia,Obstetrics,Per Unit,$139.58 ,OP,139.58,139.58,,,,,,
BCBS Medicaid,CPT,S2401,Fetal surg urin trac obstr,Obstetrics,Per Unit,$482.07 ,OP,482.07,482.07,,,,,,
BCBS Medicaid,CPT,S2402,Fetal surg cong cyst malf,Obstetrics,Per Unit,$482.07 ,OP,482.07,482.07,,,,,,
BCBS Medicaid,CPT,S2403,Fetal surg pulmon sequest,Obstetrics,Per Unit,$482.07 ,OP,482.07,482.07,,,,,,
BCBS Medicaid,CPT,S2404,Fetal surg myelomeningo,Obstetrics,Per Unit,$482.07 ,OP,482.07,482.07,,,,,,
BCBS Medicaid,CPT,S2405,Fetal surg sacrococ teratoma,Obstetrics,Per Unit,$139.58 ,OP,139.58,139.58,,,,,,
BCBS Medicaid,CPT,S2409,Fetal surg noc,Obstetrics,Per Unit,$139.58 ,OP,139.58,139.58,,,,,,
BCBS Medicaid,CPT,S2411,Fetoscop laser ther ttts,Obstetrics,Per Unit,$139.58 ,OP,139.58,139.58,,,,,,
BCBS Medicaid,CPT,S3620,Newborn metabolic screening,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
BCBS Medicaid,CPT,S3630,Eosinophil blood count,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
BCBS Medicaid,CPT,S3645,Hiv-1 antibody testing of or,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,S3650,"Saliva test, hormone level;",Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,S3652,"Saliva test, hormone level;",Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,S3655,Antisperm antibodies test,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
BCBS Medicaid,CPT,S3708,Gastrointestinal fat absorpt,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,S3721,Pca3 testing,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
BCBS Medicaid,CPT,S3722,Dose optimization auc - 5fu,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
BCBS Medicaid,CPT,S3800,Genetic testing als,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,S3840,Dna analysis ret-oncogene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,S3841,Gene test retinoblastoma,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,S3842,Gene test hippel-lindau,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,S3844,Dna analysis deafness,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,S3845,Gene test alpha-thalassemia,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,S3846,Gene test beta-thalassemia,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,S3849,Gene test niemann-pick,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,S3850,Gene test sickle cell,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,S3852,Dna analysis apoe alzheimer,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,S3853,Gene test myo musclr dyst,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,S3854,Gene profile panel breast,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,S3861,Genetic test brugada,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,S3865,Comp genet test hyp cardiomy,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,S3866,Spec gene test hyp cardiomy,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,S3870,Cgh test developmental delay,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,S3890,Fecal dna analysis,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
BCBS Medicaid,CPT,S3900,Surface emg,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,S3902,Ballistocardiogram,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,S3904,Masters two step,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
BCBS Medicaid,CPT,S4011,Ivf package,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
BCBS Medicaid,CPT,S4013,Compl gift case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
BCBS Medicaid,CPT,S4014,Compl zift case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
BCBS Medicaid,CPT,S4015,Complete ivf nos case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
BCBS Medicaid,CPT,S4016,Frozen ivf case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
BCBS Medicaid,CPT,S4017,Ivf canc a stim case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
BCBS Medicaid,CPT,S4018,F emb trns canc case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
BCBS Medicaid,CPT,S4020,Ivf canc a aspir case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
BCBS Medicaid,CPT,S4021,Ivf canc p aspir case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
BCBS Medicaid,CPT,S4022,Asst oocyte fert case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
BCBS Medicaid,CPT,S4023,Incompl donor egg case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
BCBS Medicaid,CPT,S4025,Donor serv ivf case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
BCBS Medicaid,CPT,S4026,Procure donor sperm,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
BCBS Medicaid,CPT,S4027,Store prev froz embryos,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
BCBS Medicaid,CPT,S4028,Microsurg epi sperm asp,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
BCBS Medicaid,CPT,S4030,Sperm procure init visit,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
BCBS Medicaid,CPT,S4031,Sperm procure subs visit,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
BCBS Medicaid,CPT,S4035,Stimulated iui case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
BCBS Medicaid,CPT,S4037,Cryo embryo transf case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
BCBS Medicaid,CPT,S4040,Monit store cryo embryo 30 d,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
BCBS Medicaid,CPT,S4042,Ovulation mgmt per cycle,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,S4981,Insert levonorgestrel ius,Gynecology,Per Unit,$102.34 ,OP,102.34,102.34,,,,,,
BCBS Medicaid,CPT,S4989,Contracept iud,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
BCBS Medicaid,CPT,S5180,Hh respiratory thrpy in eval,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
BCBS Medicaid,CPT,S5181,Hh respiratory thrpy nos/day,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
BCBS Medicaid,CPT,S8032,Low dose CT lung screening,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
BCBS Medicaid,CPT,S8035,Magnetic source imaging,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
BCBS Medicaid,CPT,S8037,Mrcp,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
BCBS Medicaid,CPT,S8055,Us guidance fetal reduct,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
BCBS Medicaid,CPT,S8080,Scintimammography,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
BCBS Medicaid,CPT,S8092,Electron beam computed tomog,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
BCBS Medicaid,CPT,S8110,Peak expiratory flow rate (p,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
BCBS Medicaid,CPT,S8930,Auricular electrostimulation,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
BCBS Medicaid,CPT,S8940,Hippotherapy per session,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,S8948,Low-level laser trmt 15 min,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,S8950,"Complex lymphedema therapy,",Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,S8990,Pt or manip for maint,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,S9015,Automated eeg monitoring,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
BCBS Medicaid,CPT,S9024,Paranasal sinus ultrasound,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
BCBS Medicaid,CPT,S9061,Medical supplies and equipme,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,S9090,Vertebral axial decompressio,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,S9098,Home phototherapy visit,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,S9128,"Speech therapy, in the home,",Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
BCBS Medicaid,CPT,S9129,"Occupational therapy, in the",Rehabilitation,Per Unit,$306.55 ,OP,306.55,306.55,,,,,,
BCBS Medicaid,CPT,S9131,Pt in the home per diem,Rehabilitation,Per Unit,$192.71 ,OP,192.71,192.71,,,,,,
BCBS Medicaid,CPT,S9140,"Diabetic management program,",Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
BCBS Medicaid,CPT,S9141,"Diabetic management program,",Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
BCBS Medicaid,CPT,S9145,Insulin pump initiation,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
BCBS Medicaid,CPT,S9152,"Speech therapy, re-eval",Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
BCBS Medicaid,CPT,S9211,Home mgmt gest hypertension,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,S9213,Hm preeclamp per diem,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,S9214,Hm gest dm per diem,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,S9335,Ht hemodialysis diem,Nephrology,Per Unit,$540.95 ,OP,540.95,540.95,,,,,,
BCBS Medicaid,CPT,S9339,Hit periton dialysis diem,Nephrology,Per Unit,$540.95 ,OP,540.95,540.95,,,,,,
BCBS Medicaid,CPT,S9370,Ht inj antiemetic diem,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,S9372,Ht inj anticoag diem,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,S9445,Pt education noc individ,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
BCBS Medicaid,CPT,S9446,Pt education noc group,Preventive Care,Per Unit,$26.23 ,OP,26.23,26.23,,,,,,
BCBS Medicaid,CPT,S9452,Nutrition class,Preventive Care,Per Unit,$26.23 ,OP,26.23,26.23,,,,,,
BCBS Medicaid,CPT,S9453,Smoking cessation class,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
BCBS Medicaid,CPT,S9455,"Diabetic management program,",Preventive Care,Per Unit,$26.23 ,OP,26.23,26.23,,,,,,
BCBS Medicaid,CPT,S9465,"Diabetic management program,",Ancillary Services,Per Unit,$100.15 ,OP,100.15,100.15,,,,,,
BCBS Medicaid,CPT,S9470,"Nutritional counseling, diet",Ancillary Services,Per Unit,$100.15 ,OP,100.15,100.15,,,,,,
BCBS Medicaid,CPT,S9472,Cardiac rehabilitation progr,Rehabilitation,Per Unit,$274.82 ,OP,274.82,274.82,,,,,,
BCBS Medicaid,CPT,S9473,Pulmonary rehabilitation pro,Rehabilitation,Per Unit,$73.11 ,OP,73.11,73.11,,,,,,
BCBS Medicaid,CPT,S9475,Ambulatory setting substance,Behavioral Health,Per Unit,$220.60 ,OP,220.6,220.6,,,,,,
BCBS Medicaid,CPT,S9476,Vestibular rehab per diem,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
BCBS Medicaid,CPT,S9480,Intensive outpatient psychia,Behavioral Health,Per Unit,$339.88 ,OP,339.88,339.88,,,,,,
BCBS Medicaid,CPT,S9482,Family stabilization 15 min,Behavioral Health,Per Unit,$89.14 ,OP,89.14,89.14,,,,,,
BCBS Medicaid,CPT,S9484,Crisis intervention per hour,Behavioral Health,Per Unit,$135.70 ,OP,135.7,135.7,,,,,,
BCBS Medicaid,CPT,S9485,Crisis intervention mental h,Behavioral Health,Per Unit,$220.60 ,OP,220.6,220.6,,,,,,
BCBS Medicaid,CPT,S9537,Ht hem horm inj diem,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,S9538,Hit blood products diem,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
BCBS Medicaid,CPT,S9558,Ht inj growth horm diem,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,S9559,Hit inj interferon diem,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,S9560,Ht inj hormone diem,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,S9562,Ht inj palivizumab diem,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,T1006,Family/couple counseling,Behavioral Health,Per Unit,$89.14 ,OP,89.14,89.14,,,,,,
BCBS Medicaid,CPT,T1007,Treatment plan development,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
BCBS Medicaid,CPT,T1012,Alcohol/substance abuse skil,Behavioral Health,Per Unit,$48.15 ,OP,48.15,48.15,,,,,,
BCBS Medicaid,CPT,T1016,Case management,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,T1017,Targeted case management,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,T1023,Program intake assessment,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
BCBS Medicaid,CPT,T1040,Comm bh clinic svc per diem,Behavioral Health,Per Unit,$220.60 ,OP,220.6,220.6,,,,,,
BCBS Medicaid,CPT,T2022,"Case management, per month",Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,T2023,Targeted case mgmt per month,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
BCBS Medicaid,CPT,U0001,2019-ncov diagnostic p,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
BCBS Medicaid,CPT,U0002,Covid-19 lab test non-cdc,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,U0005,Infec agen detec ampli probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
BCBS Medicaid,CPT,V2785,Corneal tissue processing,Ophthalmology,Per Unit,"$1,390.89 ",OP,"1,390.89","1,390.89",,,,,,
BCBS Medicaid,CPT,V2790,Amniotic membrane,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
BCBS Medicaid,CPT,V5362,Speech screening,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,V5363,Language screening,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS Medicaid,CPT,V5364,Dysphagia screening,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
BCBS PPO,DRG,MS-001,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W MCC,Surgical,Relative Weights,"$308,311.42 ",IP,"17,718.00","557,099.42",,,,,,
BCBS PPO,DRG,MS-002,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W/O MCC,Surgical,Relative Weights,"$156,350.85 ",IP,"17,718.00","282,516.19",,,,,,
BCBS PPO,DRG,MS-003,ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITH MAJOR O.R. PROCEDURES,Surgical,Relative Weights,"$211,468.66 ",IP,"111,577.60","382,110.62",,,,,,
BCBS PPO,DRG,MS-004,TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES,Surgical,Relative Weights,"$128,794.18 ",IP,"69,628.33","232,723.01",,,,,,
BCBS PPO,DRG,MS-005,LIVER TRANSPLANT W MCC OR INTESTINAL TRANSPLANT,Surgical,Relative Weights,"$115,058.79 ",IP,"59,773.19","207,904.03",,,,,,
BCBS PPO,DRG,MS-006,LIVER TRANSPLANT W/O MCC,Surgical,Relative Weights,"$54,355.79 ",IP,"27,427.34","98,217.50",,,,,,
BCBS PPO,DRG,MS-007,LUNG TRANSPLANT,Surgical,Relative Weights,"$120,342.75 ",IP,"67,628.10","217,451.81",,,,,,
BCBS PPO,DRG,MS-008,SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,Surgical,Relative Weights,"$62,658.83 ",IP,"31,730.89","113,220.58",,,,,,
BCBS PPO,DRG,MS-010,PANCREAS TRANSPLANT,Surgical,Relative Weights,"$44,361.35 ",IP,"2,420.00","80,158.18",,,,,,
BCBS PPO,DRG,MS-011,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC,Surgical,Relative Weights,"$55,157.98 ",IP,"2,420.00","99,667.01",,,,,,
BCBS PPO,DRG,MS-012,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC,Surgical,Relative Weights,"$42,106.52 ",IP,"2,420.00","76,083.84",,,,,,
BCBS PPO,DRG,MS-013,TRACHEOSTOMY FOR FACE -  MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC,Surgical,Relative Weights,"$27,059.07 ",IP,"2,420.00","48,894.05",,,,,,
BCBS PPO,DRG,MS-014,ALLOGENEIC BONE MARROW TRANSPLANT,Surgical,Relative Weights,"$142,305.30 ",IP,"2,420.00","257,136.77",,,,,,
BCBS PPO,DRG,MS-016,AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,Surgical,Relative Weights,"$76,818.18 ",IP,"2,420.00","138,805.63",,,,,,
BCBS PPO,DRG,MS-017,AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,Surgical,Relative Weights,"$49,619.64 ",IP,"2,420.00","89,659.58",,,,,,
BCBS PPO,DRG,MS-020,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,Surgical,Relative Weights,"$120,729.90 ",IP,"2,420.00","218,151.36",,,,,,
BCBS PPO,DRG,MS-021,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,Surgical,Relative Weights,"$92,309.67 ",IP,"2,420.00","166,797.79",,,,,,
BCBS PPO,DRG,MS-022,INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W/O CC/MCC,Surgical,Relative Weights,"$55,024.09 ",IP,"2,420.00","99,425.09",,,,,,
BCBS PPO,DRG,MS-023,CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX CNS PDX W MCC OR CHEMO IMPLANT,Surgical,Relative Weights,"$62,669.98 ",IP,"2,420.00","113,240.74",,,,,,
BCBS PPO,DRG,MS-024,CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,Surgical,Relative Weights,"$44,812.09 ",IP,"2,420.00","80,972.64",,,,,,
BCBS PPO,DRG,MS-025,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$49,029.44 ",IP,"2,420.00","88,593.12",,,,,,
BCBS PPO,DRG,MS-026,CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC,Surgical,Relative Weights,"$33,981.99 ",IP,"2,420.00","61,403.33",,,,,,
BCBS PPO,DRG,MS-027,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$26,739.98 ",IP,"2,420.00","48,317.47",,,,,,
BCBS PPO,DRG,MS-028,SPINAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$62,372.09 ",IP,"2,420.00","112,702.46",,,,,,
BCBS PPO,DRG,MS-029,SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,Surgical,Relative Weights,"$35,780.50 ",IP,"2,420.00","64,653.12",,,,,,
BCBS PPO,DRG,MS-030,SPINAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$25,349.82 ",IP,"2,420.00","45,805.54",,,,,,
BCBS PPO,DRG,MS-031,VENTRICULAR SHUNT PROCEDURES WITH MCC,Surgical,Relative Weights,"$48,806.30 ",IP,"2,420.00","88,189.92",,,,,,
BCBS PPO,DRG,MS-032,VENTRICULAR SHUNT PROCEDURES WITH CC,Surgical,Relative Weights,"$24,457.26 ",IP,"2,420.00","44,192.74",,,,,,
BCBS PPO,DRG,MS-033,VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$18,976.94 ",IP,"2,420.00","34,290.14",,,,,,
BCBS PPO,DRG,MS-034,CAROTID ARTERY STENT PROCEDURE W MCC,Surgical,Relative Weights,"$41,880.03 ",IP,"2,420.00","75,674.59",,,,,,
BCBS PPO,DRG,MS-035,CAROTID ARTERY STENT PROCEDURES WITH CC,Surgical,Relative Weights,"$25,685.65 ",IP,"2,420.00","46,412.35",,,,,,
BCBS PPO,DRG,MS-036,CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$19,535.91 ",IP,"2,420.00","35,300.16",,,,,,
BCBS PPO,DRG,MS-037,EXTRACRANIAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$36,185.50 ",IP,"2,420.00","65,384.93",,,,,,
BCBS PPO,DRG,MS-038,EXTRACRANIAL PROCEDURES WITH CC,Surgical,Relative Weights,"$18,690.21 ",IP,"2,420.00","33,772.03",,,,,,
BCBS PPO,DRG,MS-039,EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$12,621.91 ",IP,"2,420.00","22,807.01",,,,,,
BCBS PPO,DRG,MS-040,PERIPHERAL- CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC,Surgical,Relative Weights,"$43,963.04 ",IP,"2,420.00","79,438.46",,,,,,
BCBS PPO,DRG,MS-041,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W CC OR PERIPH NEUROSTIM,Surgical,Relative Weights,"$26,458.83 ",IP,"2,420.00","47,809.44",,,,,,
BCBS PPO,DRG,MS-042,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W/O CC/MCC,Surgical,Relative Weights,"$20,621.48 ",IP,"2,420.00","37,261.73",,,,,,
BCBS PPO,DRG,MS-052,SPINAL DISORDERS AND INJURIES WITH CC/MCC,Surgical,Relative Weights,"$18,173.64 ",IP,"2,420.00","32,838.62",,,,,,
BCBS PPO,DRG,MS-053,SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,778.78 ",IP,"2,420.00","19,476.58",,,,,,
BCBS PPO,DRG,MS-054,NERVOUS SYSTEM NEOPLASMS WITH MCC,Surgical,Relative Weights,"$14,951.50 ",IP,"2,420.00","27,016.42",,,,,,
BCBS PPO,DRG,MS-055,NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,Surgical,Relative Weights,"$11,000.80 ",IP,"2,420.00","19,877.76",,,,,,
BCBS PPO,DRG,MS-056,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,Surgical,Relative Weights,"$24,460.61 ",IP,"2,420.00","44,198.78",,,,,,
BCBS PPO,DRG,MS-057,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,Surgical,Relative Weights,"$13,508.90 ",IP,"2,420.00","24,409.73",,,,,,
BCBS PPO,DRG,MS-058,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,Surgical,Relative Weights,"$21,808.59 ",IP,"2,420.00","39,406.75",,,,,,
BCBS PPO,DRG,MS-059,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,Surgical,Relative Weights,"$12,166.71 ",IP,"2,420.00","21,984.48",,,,,,
BCBS PPO,DRG,MS-060,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,Surgical,Relative Weights,"$9,837.13 ",IP,"2,420.00","17,775.07",,,,,,
BCBS PPO,DRG,MS-061,ISCHEMIC STROKE -  PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC,Surgical,Relative Weights,"$31,167.08 ",IP,"2,420.00","56,316.96",,,,,,
BCBS PPO,DRG,MS-062,ISCHEMIC STROKE -  PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC,Surgical,Relative Weights,"$22,438.96 ",IP,"2,420.00","40,545.79",,,,,,
BCBS PPO,DRG,MS-063,ISCHEMIC STROKE- PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC,Surgical,Relative Weights,"$18,752.69 ",IP,"2,420.00","33,884.93",,,,,,
BCBS PPO,DRG,MS-064,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,Surgical,Relative Weights,"$20,917.14 ",IP,"2,420.00","37,795.97",,,,,,
BCBS PPO,DRG,MS-065,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC,Surgical,Relative Weights,"$11,466.05 ",IP,"2,420.00","20,718.43",,,,,,
BCBS PPO,DRG,MS-066,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,Surgical,Relative Weights,"$7,999.57 ",IP,"2,420.00","14,454.72",,,,,,
BCBS PPO,DRG,MS-067,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,Surgical,Relative Weights,"$16,339.43 ",IP,"2,420.00","29,524.32",,,,,,
BCBS PPO,DRG,MS-068,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,Surgical,Relative Weights,"$10,079.23 ",IP,"2,420.00","18,212.54",,,,,,
BCBS PPO,DRG,MS-069,TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,Surgical,Relative Weights,"$8,705.81 ",IP,"2,420.00","15,730.85",,,,,,
BCBS PPO,DRG,MS-070,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC,Surgical,Relative Weights,"$18,664.55 ",IP,"2,420.00","33,725.66",,,,,,
BCBS PPO,DRG,MS-071,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC,Surgical,Relative Weights,"$11,097.87 ",IP,"2,420.00","20,053.15",,,,,,
BCBS PPO,DRG,MS-072,NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$8,239.44 ",IP,"2,420.00","14,888.16",,,,,,
BCBS PPO,DRG,MS-073,CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,Surgical,Relative Weights,"$15,793.85 ",IP,"2,420.00","28,538.50",,,,,,
BCBS PPO,DRG,MS-074,CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,Surgical,Relative Weights,"$11,024.23 ",IP,"2,420.00","19,920.10",,,,,,
BCBS PPO,DRG,MS-075,VIRAL MENINGITIS WITH CC/MCC,Surgical,Relative Weights,"$17,942.69 ",IP,"2,420.00","32,421.31",,,,,,
BCBS PPO,DRG,MS-076,VIRAL MENINGITIS WITHOUT CC/MCC,Surgical,Relative Weights,"$10,069.19 ",IP,"2,420.00","18,194.40",,,,,,
BCBS PPO,DRG,MS-077,HYPERTENSIVE ENCEPHALOPATHY WITH MCC,Surgical,Relative Weights,"$17,209.67 ",IP,"2,420.00","31,096.80",,,,,,
BCBS PPO,DRG,MS-078,HYPERTENSIVE ENCEPHALOPATHY WITH CC,Surgical,Relative Weights,"$10,733.03 ",IP,"2,420.00","19,393.92",,,,,,
BCBS PPO,DRG,MS-079,HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC,Surgical,Relative Weights,"$8,268.45 ",IP,"2,420.00","14,940.58",,,,,,
BCBS PPO,DRG,MS-080,NONTRAUMATIC STUPOR & COMA W MCC,Surgical,Relative Weights,"$21,380.16 ",IP,"2,420.00","38,632.61",,,,,,
BCBS PPO,DRG,MS-081,NONTRAUMATIC STUPOR & COMA W/O MCC,Surgical,Relative Weights,"$9,808.12 ",IP,"2,420.00","17,722.66",,,,,,
BCBS PPO,DRG,MS-082,TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,Surgical,Relative Weights,"$25,123.33 ",IP,"2,420.00","45,396.29",,,,,,
BCBS PPO,DRG,MS-083,TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,Surgical,Relative Weights,"$14,623.48 ",IP,"2,420.00","26,423.71",,,,,,
BCBS PPO,DRG,MS-084,TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,Surgical,Relative Weights,"$10,011.18 ",IP,"2,420.00","18,089.57",,,,,,
BCBS PPO,DRG,MS-085,TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,Surgical,Relative Weights,"$25,056.39 ",IP,"2,420.00","45,275.33",,,,,,
BCBS PPO,DRG,MS-086,TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,Surgical,Relative Weights,"$13,810.13 ",IP,"2,420.00","24,954.05",,,,,,
BCBS PPO,DRG,MS-087,TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,Surgical,Relative Weights,"$9,362.95 ",IP,"2,420.00","16,918.27",,,,,,
BCBS PPO,DRG,MS-088,CONCUSSION WITH MCC,Surgical,Relative Weights,"$15,498.19 ",IP,"2,420.00","28,004.26",,,,,,
BCBS PPO,DRG,MS-089,CONCUSSION WITH CC,Surgical,Relative Weights,"$11,004.15 ",IP,"2,420.00","19,883.81",,,,,,
BCBS PPO,DRG,MS-090,CONCUSSION WITHOUT CC/MCC,Surgical,Relative Weights,"$9,464.48 ",IP,"2,420.00","17,101.73",,,,,,
BCBS PPO,DRG,MS-091,OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,Surgical,Relative Weights,"$17,461.82 ",IP,"2,420.00","31,552.42",,,,,,
BCBS PPO,DRG,MS-092,OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,Surgical,Relative Weights,"$10,778.78 ",IP,"2,420.00","19,476.58",,,,,,
BCBS PPO,DRG,MS-093,OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,Surgical,Relative Weights,"$8,492.71 ",IP,"2,420.00","15,345.79",,,,,,
BCBS PPO,DRG,MS-094,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,Surgical,Relative Weights,"$39,995.61 ",IP,"2,420.00","72,269.57",,,,,,
BCBS PPO,DRG,MS-095,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,Surgical,Relative Weights,"$26,856.01 ",IP,"2,420.00","48,527.14",,,,,,
BCBS PPO,DRG,MS-096,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,Surgical,Relative Weights,"$25,238.25 ",IP,"2,420.00","45,603.94",,,,,,
BCBS PPO,DRG,MS-097,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,Surgical,Relative Weights,"$39,896.32 ",IP,"2,420.00","72,090.14",,,,,,
BCBS PPO,DRG,MS-098,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,Surgical,Relative Weights,"$21,811.94 ",IP,"2,420.00","39,412.80",,,,,,
BCBS PPO,DRG,MS-099,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,Surgical,Relative Weights,"$14,307.74 ",IP,"2,420.00","25,853.18",,,,,,
BCBS PPO,DRG,MS-100,SEIZURES WITH MCC,Surgical,Relative Weights,"$20,307.97 ",IP,"2,420.00","36,695.23",,,,,,
BCBS PPO,DRG,MS-101,SEIZURES WITHOUT MCC,Surgical,Relative Weights,"$9,850.52 ",IP,"2,420.00","17,799.26",,,,,,
BCBS PPO,DRG,MS-102,HEADACHES WITH MCC,Surgical,Relative Weights,"$13,305.84 ",IP,"2,420.00","24,042.82",,,,,,
BCBS PPO,DRG,MS-103,HEADACHES W/O MCC,Surgical,Relative Weights,"$8,920.02 ",IP,"2,420.00","16,117.92",,,,,,
BCBS PPO,DRG,MS-113,ORBITAL PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$23,787.84 ",IP,"2,420.00","42,983.14",,,,,,
BCBS PPO,DRG,MS-114,ORBITAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$13,285.76 ",IP,"2,420.00","24,006.53",,,,,,
BCBS PPO,DRG,MS-115,EXTRAOCULAR PROCEDURES EXCEPT ORBIT,Surgical,Relative Weights,"$16,579.30 ",IP,"2,420.00","29,957.76",,,,,,
BCBS PPO,DRG,MS-116,INTRAOCULAR PROCEDURES W CC/MCC,Surgical,Relative Weights,"$21,097.89 ",IP,"2,420.00","38,122.56",,,,,,
BCBS PPO,DRG,MS-117,INTRAOCULAR PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$12,235.88 ",IP,"2,420.00","22,109.47",,,,,,
BCBS PPO,DRG,MS-121,ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,Surgical,Relative Weights,"$14,144.84 ",IP,"2,420.00","25,558.85",,,,,,
BCBS PPO,DRG,MS-122,ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,Surgical,Relative Weights,"$8,619.90 ",IP,"2,420.00","15,575.62",,,,,,
BCBS PPO,DRG,MS-123,NEUROLOGICAL EYE DISORDERS,Surgical,Relative Weights,"$8,711.39 ",IP,"2,420.00","15,740.93",,,,,,
BCBS PPO,DRG,MS-124,OTHER DISORDERS OF THE EYE WITH MCC,Surgical,Relative Weights,"$15,501.54 ",IP,"2,420.00","28,010.30",,,,,,
BCBS PPO,DRG,MS-125,OTHER DISORDERS OF THE EYE WITHOUT MCC,Surgical,Relative Weights,"$8,807.34 ",IP,"2,420.00","15,914.30",,,,,,
BCBS PPO,DRG,MS-129,MAJOR HEAD & NECK PROCEDURES W CC/MCC OR MAJOR DEVICE,Surgical,Relative Weights,"$25,541.72 ",IP,"21,710.46","46,152.29",,,,,,
BCBS PPO,DRG,MS-130,MAJOR HEAD & NECK PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$16,128.56 ",IP,"13,709.28","29,143.30",,,,,,
BCBS PPO,DRG,MS-131,CRANIAL/FACIAL PROCEDURES W CC/MCC,Surgical,Relative Weights,"$30,004.52 ",IP,"25,503.84","54,216.29",,,,,,
BCBS PPO,DRG,MS-132,CRANIAL/FACIAL PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$17,734.05 ",IP,"15,073.94","32,044.32",,,,,,
BCBS PPO,DRG,MS-133,OTHER EAR - NOSE - MOUTH & THROAT O.R. PROCEDURES W CC/MCC,Surgical,Relative Weights,"$23,952.96 ",IP,"20,360.02","43,281.50",,,,,,
BCBS PPO,DRG,MS-134,OTHER EAR - NOSE - MOUTH & THROAT O.R. PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$13,489.93 ",IP,"11,466.44","24,375.46",,,,,,
BCBS PPO,DRG,MS-135,SINUS AND MASTOID PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$25,489.28 ",IP,"2,420.00","46,057.54",,,,,,
BCBS PPO,DRG,MS-136,SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$13,276.83 ",IP,"2,420.00","23,990.40",,,,,,
BCBS PPO,DRG,MS-137,MOUTH PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$14,875.63 ",IP,"2,420.00","26,879.33",,,,,,
BCBS PPO,DRG,MS-138,MOUTH PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$9,610.64 ",IP,"2,420.00","17,365.82",,,,,,
BCBS PPO,DRG,MS-139,SALIVARY GLAND PROCEDURES,Surgical,Relative Weights,"$13,771.09 ",IP,"2,420.00","24,883.49",,,,,,
BCBS PPO,DRG,MS-146,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH MCC,Surgical,Relative Weights,"$21,517.39 ",IP,"2,420.00","38,880.58",,,,,,
BCBS PPO,DRG,MS-147,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH CC,Surgical,Relative Weights,"$13,844.72 ",IP,"2,420.00","25,016.54",,,,,,
BCBS PPO,DRG,MS-148,EAR - NOSE - MOUTH & THROAT MALIGNANCY W/O CC/MCC,Surgical,Relative Weights,"$8,483.78 ",IP,"2,420.00","15,329.66",,,,,,
BCBS PPO,DRG,MS-149,DYSEQUILIBRIUM,Surgical,Relative Weights,"$8,150.19 ",IP,"2,420.00","14,726.88",,,,,,
BCBS PPO,DRG,MS-150,EPISTAXIS WITH MCC,Surgical,Relative Weights,"$14,409.27 ",IP,"2,420.00","26,036.64",,,,,,
BCBS PPO,DRG,MS-151,EPISTAXIS WITHOUT MCC,Surgical,Relative Weights,"$7,799.86 ",IP,"2,420.00","14,093.86",,,,,,
BCBS PPO,DRG,MS-152,OTITIS MEDIA AND URI WITH MCC,Surgical,Relative Weights,"$11,592.12 ",IP,"2,420.00","20,946.24",,,,,,
BCBS PPO,DRG,MS-153,OTITIS MEDIA AND URI WITHOUT MCC,Surgical,Relative Weights,"$7,881.30 ",IP,"2,420.00","14,241.02",,,,,,
BCBS PPO,DRG,MS-154,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH MCC,Surgical,Relative Weights,"$16,032.61 ",IP,"2,420.00","28,969.92",,,,,,
BCBS PPO,DRG,MS-155,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH CC,Surgical,Relative Weights,"$10,053.57 ",IP,"2,420.00","18,166.18",,,,,,
BCBS PPO,DRG,MS-156,OTHER EAR -  NOSE -  MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,302.26 ",IP,"2,420.00","13,194.72",,,,,,
BCBS PPO,DRG,MS-157,DENTAL AND ORAL DISEASES WITH MCC,Surgical,Relative Weights,"$17,437.28 ",IP,"2,420.00","31,508.06",,,,,,
BCBS PPO,DRG,MS-158,DENTAL AND ORAL DISEASES WITH CC,Surgical,Relative Weights,"$9,668.66 ",IP,"2,420.00","17,470.66",,,,,,
BCBS PPO,DRG,MS-159,DENTAL AND ORAL DISEASES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,507.55 ",IP,"2,420.00","13,565.66",,,,,,
BCBS PPO,DRG,MS-163,MAJOR CHEST PROCEDURES WITH MCC,Surgical,Relative Weights,"$54,375.87 ",IP,"2,420.00","98,253.79",,,,,,
BCBS PPO,DRG,MS-164,MAJOR CHEST PROCEDURES WITH CC,Surgical,Relative Weights,"$28,245.06 ",IP,"2,420.00","51,037.06",,,,,,
BCBS PPO,DRG,MS-165,MAJOR CHEST PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$20,631.52 ",IP,"2,420.00","37,279.87",,,,,,
BCBS PPO,DRG,MS-166,OTHER RESP SYSTEM O.R. PROCEDURES W MCC,Surgical,Relative Weights,"$41,623.42 ",IP,"2,420.00","75,210.91",,,,,,
BCBS PPO,DRG,MS-167,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$21,358.96 ",IP,"2,420.00","38,594.30",,,,,,
BCBS PPO,DRG,MS-168,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$14,801.99 ",IP,"2,420.00","26,746.27",,,,,,
BCBS PPO,DRG,MS-175,PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,Surgical,Relative Weights,"$16,115.17 ",IP,"2,420.00","29,119.10",,,,,,
BCBS PPO,DRG,MS-176,PULMONARY EMBOLISM WITHOUT MCC,Surgical,Relative Weights,"$9,465.60 ",IP,"2,420.00","17,103.74",,,,,,
BCBS PPO,DRG,MS-177,RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC,Surgical,Relative Weights,"$21,100.12 ",IP,"2,420.00","38,126.59",,,,,,
BCBS PPO,DRG,MS-178,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,Surgical,Relative Weights,"$13,871.50 ",IP,"2,420.00","25,064.93",,,,,,
BCBS PPO,DRG,MS-179,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,Surgical,Relative Weights,"$9,663.08 ",IP,"2,420.00","17,460.58",,,,,,
BCBS PPO,DRG,MS-180,RESPIRATORY NEOPLASMS WITH MCC,Surgical,Relative Weights,"$19,244.71 ",IP,"2,420.00","34,773.98",,,,,,
BCBS PPO,DRG,MS-181,RESPIRATORY NEOPLASMS WITH CC,Surgical,Relative Weights,"$12,852.86 ",IP,"2,420.00","23,224.32",,,,,,
BCBS PPO,DRG,MS-182,RESPIRATORY NEOPLASMS WITHOUT CC/MCC,Surgical,Relative Weights,"$9,403.12 ",IP,"2,420.00","16,990.85",,,,,,
BCBS PPO,DRG,MS-183,MAJOR CHEST TRAUMA WITH MCC,Surgical,Relative Weights,"$16,838.14 ",IP,"2,420.00","30,425.47",,,,,,
BCBS PPO,DRG,MS-184,MAJOR CHEST TRAUMA WITH CC,Surgical,Relative Weights,"$11,360.06 ",IP,"2,420.00","20,526.91",,,,,,
BCBS PPO,DRG,MS-185,MAJOR CHEST TRAUMA W/O CC/MCC,Surgical,Relative Weights,"$8,189.24 ",IP,"2,420.00","14,797.44",,,,,,
BCBS PPO,DRG,MS-186,PLEURAL EFFUSION WITH MCC,Surgical,Relative Weights,"$17,214.14 ",IP,"2,420.00","31,104.86",,,,,,
BCBS PPO,DRG,MS-187,PLEURAL EFFUSION WITH CC,Surgical,Relative Weights,"$11,468.28 ",IP,"2,420.00","20,722.46",,,,,,
BCBS PPO,DRG,MS-188,PLEURAL EFFUSION WITHOUT CC/MCC,Surgical,Relative Weights,"$8,154.65 ",IP,"2,420.00","14,734.94",,,,,,
BCBS PPO,DRG,MS-189,PULMONARY EDEMA AND RESPIRATORY FAILURE,Surgical,Relative Weights,"$13,563.56 ",IP,"2,420.00","24,508.51",,,,,,
BCBS PPO,DRG,MS-190,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,Surgical,Relative Weights,"$12,763.61 ",IP,"2,420.00","23,063.04",,,,,,
BCBS PPO,DRG,MS-191,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,Surgical,Relative Weights,"$9,960.97 ",IP,"2,420.00","17,998.85",,,,,,
BCBS PPO,DRG,MS-192,CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC,Surgical,Relative Weights,"$7,912.54 ",IP,"2,420.00","14,297.47",,,,,,
BCBS PPO,DRG,MS-193,SIMPLE PNEUMONIA & PLEURISY W MCC,Surgical,Relative Weights,"$14,877.86 ",IP,"2,420.00","26,883.36",,,,,,
BCBS PPO,DRG,MS-194,SIMPLE PNEUMONIA AND PLEURISY WITH CC,Surgical,Relative Weights,"$9,914.11 ",IP,"2,420.00","17,914.18",,,,,,
BCBS PPO,DRG,MS-195,SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,Surgical,Relative Weights,"$7,610.19 ",IP,"2,420.00","13,751.14",,,,,,
BCBS PPO,DRG,MS-196,INTERSTITIAL LUNG DISEASE WITH MCC,Surgical,Relative Weights,"$18,692.44 ",IP,"2,420.00","33,776.06",,,,,,
BCBS PPO,DRG,MS-197,INTERSTITIAL LUNG DISEASE WITH CC,Surgical,Relative Weights,"$11,396.88 ",IP,"2,420.00","20,593.44",,,,,,
BCBS PPO,DRG,MS-198,INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,Surgical,Relative Weights,"$8,423.54 ",IP,"2,420.00","15,220.80",,,,,,
BCBS PPO,DRG,MS-199,PNEUMOTHORAX WITH MCC,Surgical,Relative Weights,"$20,016.77 ",IP,"2,420.00","36,169.06",,,,,,
BCBS PPO,DRG,MS-200,PNEUMOTHORAX WITH CC,Surgical,Relative Weights,"$12,072.99 ",IP,"2,420.00","21,815.14",,,,,,
BCBS PPO,DRG,MS-201,PNEUMOTHORAX WITHOUT CC/MCC,Surgical,Relative Weights,"$8,010.73 ",IP,"2,420.00","14,474.88",,,,,,
BCBS PPO,DRG,MS-202,BRONCHITIS AND ASTHMA WITH CC/MCC,Surgical,Relative Weights,"$10,576.84 ",IP,"2,420.00","19,111.68",,,,,,
BCBS PPO,DRG,MS-203,BRONCHITIS AND ASTHMA WITHOUT CC/MCC,Surgical,Relative Weights,"$7,740.73 ",IP,"2,420.00","13,987.01",,,,,,
BCBS PPO,DRG,MS-204,RESPIRATORY SIGNS AND SYMPTOMS,Surgical,Relative Weights,"$9,065.06 ",IP,"2,420.00","16,380.00",,,,,,
BCBS PPO,DRG,MS-205,OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,Surgical,Relative Weights,"$18,232.77 ",IP,"2,420.00","32,945.47",,,,,,
BCBS PPO,DRG,MS-206,OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,Surgical,Relative Weights,"$9,734.48 ",IP,"2,420.00","17,589.60",,,,,,
BCBS PPO,DRG,MS-207,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS,Surgical,Relative Weights,"$63,992.09 ",IP,"2,420.00","115,629.70",,,,,,
BCBS PPO,DRG,MS-208,RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,Surgical,Relative Weights,"$27,715.10 ",IP,"2,420.00","50,079.46",,,,,,
BCBS PPO,DRG,MS-215,OTHER HEART ASSIST SYSTEM IMPLANT,Surgical,Relative Weights,"$143,770.22 ",IP,"61,661.88","259,783.78",,,,,,
BCBS PPO,DRG,MS-216,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$112,043.06 ",IP,"58,630.29","202,454.78",,,,,,
BCBS PPO,DRG,MS-217,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,Surgical,Relative Weights,"$74,211.90 ",IP,"37,864.14","134,096.26",,,,,,
BCBS PPO,DRG,MS-218,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,Surgical,Relative Weights,"$60,263.42 ",IP,"35,678.79","108,892.22",,,,,,
BCBS PPO,DRG,MS-219,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$87,472.00 ",IP,"47,057.01","158,056.42",,,,,,
BCBS PPO,DRG,MS-220,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,Surgical,Relative Weights,"$59,197.93 ",IP,"31,567.37","106,966.94",,,,,,
BCBS PPO,DRG,MS-221,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,Surgical,Relative Weights,"$51,279.80 ",IP,"26,746.97","92,659.39",,,,,,
BCBS PPO,DRG,MS-222,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITH MCC,Surgical,Relative Weights,"$93,100.70 ",IP,"46,434.46","168,227.14",,,,,,
BCBS PPO,DRG,MS-223,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITHOUT MCC,Surgical,Relative Weights,"$66,974.36 ",IP,"33,864.27","121,018.46",,,,,,
BCBS PPO,DRG,MS-224,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITH MCC,Surgical,Relative Weights,"$82,519.40 ",IP,"43,912.13","149,107.39",,,,,,
BCBS PPO,DRG,MS-225,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITHOUT MCC,Surgical,Relative Weights,"$63,023.66 ",IP,"32,808.39","113,879.81",,,,,,
BCBS PPO,DRG,MS-226,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$74,614.67 ",IP,"25,420.00","134,824.03",,,,,,
BCBS PPO,DRG,MS-227,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Surgical,Relative Weights,"$58,342.18 ",IP,"25,420.00","105,420.67",,,,,,
BCBS PPO,DRG,MS-228,OTHER CARDIOTHORACIC PROCEDURES WITH MCC,Surgical,Relative Weights,"$70,136.25 ",IP,"31,129.37","126,731.81",,,,,,
BCBS PPO,DRG,MS-229,OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$45,798.37 ",IP,"20,096.88","82,754.78",,,,,,
BCBS PPO,DRG,MS-231,CORONARY BYPASS W PTCA W MCC,Surgical,Relative Weights,"$91,615.71 ",IP,"50,901.53","165,543.84",,,,,,
BCBS PPO,DRG,MS-232,CORONARY BYPASS W PTCA W/O MCC,Surgical,Relative Weights,"$66,791.38 ",IP,"34,770.65","120,687.84",,,,,,
BCBS PPO,DRG,MS-233,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,Surgical,Relative Weights,"$86,677.62 ",IP,"42,365.00","156,621.02",,,,,,
BCBS PPO,DRG,MS-234,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,Surgical,Relative Weights,"$58,086.69 ",IP,"31,162.65","104,959.01",,,,,,
BCBS PPO,DRG,MS-235,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$65,654.48 ",IP,"32,351.00","118,633.54",,,,,,
BCBS PPO,DRG,MS-236,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Surgical,Relative Weights,"$44,952.67 ",IP,"23,926.80","81,226.66",,,,,,
BCBS PPO,DRG,MS-239,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,Surgical,Relative Weights,"$52,099.84 ",IP,"2,420.00","94,141.15",,,,,,
BCBS PPO,DRG,MS-240,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,Surgical,Relative Weights,"$30,793.32 ",IP,"2,420.00","55,641.60",,,,,,
BCBS PPO,DRG,MS-241,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,Surgical,Relative Weights,"$16,917.36 ",IP,"2,420.00","30,568.61",,,,,,
BCBS PPO,DRG,MS-242,PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,Surgical,Relative Weights,"$41,404.74 ",IP,"15,407.00","74,815.78",,,,,,
BCBS PPO,DRG,MS-243,PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,Surgical,Relative Weights,"$28,220.52 ",IP,"14,708.24","50,992.70",,,,,,
BCBS PPO,DRG,MS-244,PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,Surgical,Relative Weights,"$23,155.24 ",IP,"12,049.83","41,840.06",,,,,,
BCBS PPO,DRG,MS-245,AICD GENERATOR PROCEDURES,Surgical,Relative Weights,"$58,103.42 ",IP,"15,407.00","104,989.25",,,,,,
BCBS PPO,DRG,MS-246,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Surgical,Relative Weights,"$35,398.93 ",IP,"18,246.15","63,963.65",,,,,,
BCBS PPO,DRG,MS-247,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITHOUT MCC,Surgical,Relative Weights,"$22,701.15 ",IP,"11,523.64","41,019.55",,,,,,
BCBS PPO,DRG,MS-248,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Surgical,Relative Weights,"$34,547.65 ",IP,"18,467.49","62,425.44",,,,,,
BCBS PPO,DRG,MS-249,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITHOUT MCC,Surgical,Relative Weights,"$21,383.51 ",IP,"10,942.55","38,638.66",,,,,,
BCBS PPO,DRG,MS-250,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT CORONARY ARTERY STENT WITH MCC,Surgical,Relative Weights,"$28,451.47 ",IP,"14,727.51","51,410.02",,,,,,
BCBS PPO,DRG,MS-251,PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W/O MCC,Surgical,Relative Weights,"$18,777.23 ",IP,"2,420.00","33,929.28",,,,,,
BCBS PPO,DRG,MS-252,OTHER VASCULAR PROCEDURES W MCC,Surgical,Relative Weights,"$36,599.42 ",IP,"2,420.00","66,132.86",,,,,,
BCBS PPO,DRG,MS-253,OTHER VASCULAR PROCEDURES WITH CC,Surgical,Relative Weights,"$29,081.84 ",IP,"2,420.00","52,549.06",,,,,,
BCBS PPO,DRG,MS-254,OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$20,306.86 ",IP,"2,420.00","36,693.22",,,,,,
BCBS PPO,DRG,MS-255,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,Surgical,Relative Weights,"$29,561.59 ",IP,"2,420.00","53,415.94",,,,,,
BCBS PPO,DRG,MS-256,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,Surgical,Relative Weights,"$19,150.99 ",IP,"2,420.00","34,604.64",,,,,,
BCBS PPO,DRG,MS-257,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$12,656.50 ",IP,"2,420.00","22,869.50",,,,,,
BCBS PPO,DRG,MS-258,CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,Surgical,Relative Weights,"$34,125.92 ",IP,"11,861.00","61,663.39",,,,,,
BCBS PPO,DRG,MS-259,CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,Surgical,Relative Weights,"$23,235.57 ",IP,"11,861.00","41,985.22",,,,,,
BCBS PPO,DRG,MS-260,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,Surgical,Relative Weights,"$41,276.44 ",IP,"10,167.00","74,583.94",,,,,,
BCBS PPO,DRG,MS-261,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,Surgical,Relative Weights,"$21,739.41 ",IP,"10,167.00","39,281.76",,,,,,
BCBS PPO,DRG,MS-262,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,Surgical,Relative Weights,"$18,716.98 ",IP,"9,964.34","33,820.42",,,,,,
BCBS PPO,DRG,MS-263,VEIN LIGATION AND STRIPPING,Surgical,Relative Weights,"$26,320.48 ",IP,"2,420.00","47,559.46",,,,,,
BCBS PPO,DRG,MS-264,OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,Surgical,Relative Weights,"$36,126.37 ",IP,"2,420.00","65,278.08",,,,,,
BCBS PPO,DRG,MS-265,AICD LEAD PROCEDURES,Surgical,Relative Weights,"$34,824.34 ",IP,"2,420.00","62,925.41",,,,,,
BCBS PPO,DRG,MS-266,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,Surgical,Relative Weights,"$79,453.46 ",IP,"41,160.28","143,567.42",,,,,,
BCBS PPO,DRG,MS-267,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$63,322.67 ",IP,"32,692.75","114,420.10",,,,,,
BCBS PPO,DRG,MS-268,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,Surgical,Relative Weights,"$75,673.47 ",IP,"32,968.00","136,737.22",,,,,,
BCBS PPO,DRG,MS-269,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,Surgical,Relative Weights,"$47,600.22 ",IP,"25,200.52","86,010.62",,,,,,
BCBS PPO,DRG,MS-270,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,Surgical,Relative Weights,"$57,014.50 ",IP,"30,292.48","103,021.63",,,,,,
BCBS PPO,DRG,MS-271,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,Surgical,Relative Weights,"$39,585.04 ",IP,"20,822.21","71,527.68",,,,,,
BCBS PPO,DRG,MS-272,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$29,022.70 ",IP,"15,699.88","52,442.21",,,,,,
BCBS PPO,DRG,MS-273,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,Surgical,Relative Weights,"$41,395.82 ",IP,"16,176.00","74,799.65",,,,,,
BCBS PPO,DRG,MS-274,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$35,253.89 ",IP,"16,176.00","63,701.57",,,,,,
BCBS PPO,DRG,MS-280,ACUTE MYOCARDIAL INFARCTION - DISCHARGED ALIVE W MCC,Surgical,Relative Weights,"$18,195.95 ",IP,"2,420.00","32,878.94",,,,,,
BCBS PPO,DRG,MS-281,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITH CC,Surgical,Relative Weights,"$10,807.79 ",IP,"2,420.00","19,528.99",,,,,,
BCBS PPO,DRG,MS-282,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITHOUT CC/MCC,Surgical,Relative Weights,"$8,232.75 ",IP,"2,420.00","14,876.06",,,,,,
BCBS PPO,DRG,MS-283,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH MCC,Surgical,Relative Weights,"$20,079.25 ",IP,"2,420.00","36,281.95",,,,,,
BCBS PPO,DRG,MS-284,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH CC,Surgical,Relative Weights,"$8,092.17 ",IP,"2,420.00","14,622.05",,,,,,
BCBS PPO,DRG,MS-285,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITHOUT CC/MCC,Surgical,Relative Weights,"$5,777.09 ",IP,"2,420.00","10,438.85",,,,,,
BCBS PPO,DRG,MS-286,CIRCULATORY DISORDERS EXCEPT AMI- WITH CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$24,516.39 ",IP,"2,420.00","44,299.58",,,,,,
BCBS PPO,DRG,MS-287,CIRCULATORY DISORDERS EXCEPT AMI -  WITH CARDIAC CATHETERIZATION WITHOUT MCC,Surgical,Relative Weights,"$12,855.10 ",IP,"6,512.27","23,228.35",,,,,,
BCBS PPO,DRG,MS-288,ACUTE & SUBACUTE ENDOCARDITIS W MCC,Surgical,Relative Weights,"$29,648.61 ",IP,"2,420.00","53,573.18",,,,,,
BCBS PPO,DRG,MS-289,ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,Surgical,Relative Weights,"$18,563.02 ",IP,"9,181.00","33,542.21",,,,,,
BCBS PPO,DRG,MS-290,ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,Surgical,Relative Weights,"$11,163.69 ",IP,"2,420.00","20,172.10",,,,,,
BCBS PPO,DRG,MS-291,HEART FAILURE AND SHOCK WITH MCC,Surgical,Relative Weights,"$15,015.09 ",IP,"2,420.00","27,131.33",,,,,,
BCBS PPO,DRG,MS-292,HEART FAILURE AND SHOCK WITH CC,Surgical,Relative Weights,"$10,102.66 ",IP,"2,420.00","18,254.88",,,,,,
BCBS PPO,DRG,MS-293,HEART FAILURE AND SHOCK WITHOUT CC/MCC,Surgical,Relative Weights,"$7,311.18 ",IP,"2,420.00","13,210.85",,,,,,
BCBS PPO,DRG,MS-294,DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC,Surgical,Relative Weights,"$14,190.59 ",IP,"2,420.00","25,641.50",,,,,,
BCBS PPO,DRG,MS-295,DEEP VEIN THROMBOPHLEBITIS W/O CC/MCC,Surgical,Relative Weights,"$6,437.59 ",IP,"2,420.00","11,632.32",,,,,,
BCBS PPO,DRG,MS-296,CARDIAC ARREST - UNEXPLAINED W MCC,Surgical,Relative Weights,"$17,520.95 ",IP,"2,420.00","31,659.26",,,,,,
BCBS PPO,DRG,MS-297,CARDIAC ARREST- UNEXPLAINED WITH CC,Surgical,Relative Weights,"$8,066.51 ",IP,"2,420.00","14,575.68",,,,,,
BCBS PPO,DRG,MS-298,CARDIAC ARREST- UNEXPLAINED WITHOUT CC/MCC,Surgical,Relative Weights,"$5,614.20 ",IP,"2,420.00","10,144.51",,,,,,
BCBS PPO,DRG,MS-299,PERIPHERAL VASCULAR DISORDERS WITH MCC,Surgical,Relative Weights,"$16,174.30 ",IP,"2,420.00","29,225.95",,,,,,
BCBS PPO,DRG,MS-300,PERIPHERAL VASCULAR DISORDERS WITH CC,Surgical,Relative Weights,"$11,464.93 ",IP,"2,420.00","20,716.42",,,,,,
BCBS PPO,DRG,MS-301,PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$8,097.75 ",IP,"2,420.00","14,632.13",,,,,,
BCBS PPO,DRG,MS-302,ATHEROSCLEROSIS WITH MCC,Surgical,Relative Weights,"$12,298.36 ",IP,"2,420.00","22,222.37",,,,,,
BCBS PPO,DRG,MS-303,ATHEROSCLEROSIS WITHOUT MCC,Surgical,Relative Weights,"$7,538.78 ",IP,"2,420.00","13,622.11",,,,,,
BCBS PPO,DRG,MS-304,HYPERTENSION WITH MCC,Surgical,Relative Weights,"$12,177.87 ",IP,"2,420.00","22,004.64",,,,,,
BCBS PPO,DRG,MS-305,HYPERTENSION WITHOUT MCC,Surgical,Relative Weights,"$8,161.35 ",IP,"2,420.00","14,747.04",,,,,,
BCBS PPO,DRG,MS-306,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,Surgical,Relative Weights,"$15,781.58 ",IP,"2,420.00","28,516.32",,,,,,
BCBS PPO,DRG,MS-307,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,Surgical,Relative Weights,"$9,842.71 ",IP,"2,420.00","17,785.15",,,,,,
BCBS PPO,DRG,MS-308,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,Surgical,Relative Weights,"$13,251.17 ",IP,"2,420.00","23,944.03",,,,,,
BCBS PPO,DRG,MS-309,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,Surgical,Relative Weights,"$8,438.04 ",IP,"2,420.00","15,247.01",,,,,,
BCBS PPO,DRG,MS-310,CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC,Surgical,Relative Weights,"$6,240.11 ",IP,"2,420.00","11,275.49",,,,,,
BCBS PPO,DRG,MS-311,ANGINA PECTORIS,Surgical,Relative Weights,"$7,642.55 ",IP,"2,420.00","13,809.60",,,,,,
BCBS PPO,DRG,MS-312,SYNCOPE AND COLLAPSE,Surgical,Relative Weights,"$9,110.81 ",IP,"2,420.00","16,462.66",,,,,,
BCBS PPO,DRG,MS-313,CHEST PAIN,Surgical,Relative Weights,"$7,980.60 ",IP,"2,420.00","14,420.45",,,,,,
BCBS PPO,DRG,MS-314,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,Surgical,Relative Weights,"$22,643.13 ",IP,"2,420.00","40,914.72",,,,,,
BCBS PPO,DRG,MS-315,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,Surgical,Relative Weights,"$10,826.75 ",IP,"2,420.00","19,563.26",,,,,,
BCBS PPO,DRG,MS-316,OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,280.73 ",IP,"2,420.00","14,962.75",,,,,,
BCBS PPO,DRG,MS-319,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,Surgical,Relative Weights,"$45,751.51 ",IP,"2,420.00","82,670.11",,,,,,
BCBS PPO,DRG,MS-320,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$26,193.29 ",IP,"2,420.00","47,329.63",,,,,,
BCBS PPO,DRG,MS-326,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$58,802.97 ",IP,"2,420.00","106,253.28",,,,,,
BCBS PPO,DRG,MS-327,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC,Surgical,Relative Weights,"$28,705.85 ",IP,"2,420.00","51,869.66",,,,,,
BCBS PPO,DRG,MS-328,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$17,572.28 ",IP,"2,420.00","31,752.00",,,,,,
BCBS PPO,DRG,MS-329,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Surgical,Relative Weights,"$54,749.63 ",IP,"2,420.00","98,929.15",,,,,,
BCBS PPO,DRG,MS-330,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Surgical,Relative Weights,"$28,191.51 ",IP,"2,420.00","50,940.29",,,,,,
BCBS PPO,DRG,MS-331,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$18,846.40 ",IP,"2,420.00","34,054.27",,,,,,
BCBS PPO,DRG,MS-332,RECTAL RESECTION WITH MCC,Surgical,Relative Weights,"$38,959.13 ",IP,"2,420.00","70,396.70",,,,,,
BCBS PPO,DRG,MS-333,RECTAL RESECTION WITH CC,Surgical,Relative Weights,"$25,250.52 ",IP,"2,420.00","45,626.11",,,,,,
BCBS PPO,DRG,MS-334,RECTAL RESECTION WITHOUT CC/MCC,Surgical,Relative Weights,"$17,185.13 ",IP,"2,420.00","31,052.45",,,,,,
BCBS PPO,DRG,MS-335,PERITONEAL ADHESIOLYSIS WITH MCC,Surgical,Relative Weights,"$45,131.18 ",IP,"2,420.00","81,549.22",,,,,,
BCBS PPO,DRG,MS-336,PERITONEAL ADHESIOLYSIS WITH CC,Surgical,Relative Weights,"$25,283.99 ",IP,"2,420.00","45,686.59",,,,,,
BCBS PPO,DRG,MS-337,PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$18,294.13 ",IP,"2,420.00","33,056.35",,,,,,
BCBS PPO,DRG,MS-338,APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$32,467.99 ",IP,"2,420.00","58,667.62",,,,,,
BCBS PPO,DRG,MS-339,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W CC,Surgical,Relative Weights,"$19,146.53 ",IP,"2,420.00","34,596.58",,,,,,
BCBS PPO,DRG,MS-340,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC/MCC,Surgical,Relative Weights,"$13,806.79 ",IP,"2,420.00","24,948.00",,,,,,
BCBS PPO,DRG,MS-341,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$28,540.72 ",IP,"2,420.00","51,571.30",,,,,,
BCBS PPO,DRG,MS-342,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH CC,Surgical,Relative Weights,"$17,966.12 ",IP,"2,420.00","32,463.65",,,,,,
BCBS PPO,DRG,MS-343,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$12,848.40 ",IP,"2,420.00","23,216.26",,,,,,
BCBS PPO,DRG,MS-344,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Surgical,Relative Weights,"$33,416.33 ",IP,"2,420.00","60,381.22",,,,,,
BCBS PPO,DRG,MS-345,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Surgical,Relative Weights,"$18,222.73 ",IP,"2,420.00","32,927.33",,,,,,
BCBS PPO,DRG,MS-346,MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$14,311.08 ",IP,"2,420.00","25,859.23",,,,,,
BCBS PPO,DRG,MS-347,ANAL AND STOMAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$29,414.31 ",IP,"2,420.00","53,149.82",,,,,,
BCBS PPO,DRG,MS-348,ANAL AND STOMAL PROCEDURES WITH CC,Surgical,Relative Weights,"$15,723.56 ",IP,"2,420.00","28,411.49",,,,,,
BCBS PPO,DRG,MS-349,ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,943.90 ",IP,"2,420.00","19,774.94",,,,,,
BCBS PPO,DRG,MS-350,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,Surgical,Relative Weights,"$27,215.27 ",IP,"2,420.00","49,176.29",,,,,,
BCBS PPO,DRG,MS-351,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,Surgical,Relative Weights,"$16,270.25 ",IP,"2,420.00","29,399.33",,,,,,
BCBS PPO,DRG,MS-352,INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$12,013.86 ",IP,"2,420.00","21,708.29",,,,,,
BCBS PPO,DRG,MS-353,HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,Surgical,Relative Weights,"$33,101.70 ",IP,"2,420.00","59,812.70",,,,,,
BCBS PPO,DRG,MS-354,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W CC,Surgical,Relative Weights,"$19,213.47 ",IP,"2,420.00","34,717.54",,,,,,
BCBS PPO,DRG,MS-355,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W/O CC/MCC,Surgical,Relative Weights,"$15,311.87 ",IP,"2,420.00","27,667.58",,,,,,
BCBS PPO,DRG,MS-356,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$45,489.32 ",IP,"2,420.00","82,196.35",,,,,,
BCBS PPO,DRG,MS-357,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$25,107.71 ",IP,"2,420.00","45,368.06",,,,,,
BCBS PPO,DRG,MS-358,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$15,304.06 ",IP,"2,420.00","27,653.47",,,,,,
BCBS PPO,DRG,MS-368,MAJOR ESOPHAGEAL DISORDERS WITH MCC,Surgical,Relative Weights,"$21,238.47 ",IP,"2,420.00","38,376.58",,,,,,
BCBS PPO,DRG,MS-369,MAJOR ESOPHAGEAL DISORDERS WITH CC,Surgical,Relative Weights,"$11,861.01 ",IP,"2,420.00","21,432.10",,,,,,
BCBS PPO,DRG,MS-370,MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$8,337.63 ",IP,"2,420.00","15,065.57",,,,,,
BCBS PPO,DRG,MS-371,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,Surgical,Relative Weights,"$19,251.40 ",IP,"2,420.00","34,786.08",,,,,,
BCBS PPO,DRG,MS-372,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,Surgical,Relative Weights,"$11,408.03 ",IP,"2,420.00","20,613.60",,,,,,
BCBS PPO,DRG,MS-373,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,Surgical,Relative Weights,"$8,276.26 ",IP,"2,420.00","14,954.69",,,,,,
BCBS PPO,DRG,MS-374,DIGESTIVE MALIGNANCY WITH MCC,Surgical,Relative Weights,"$22,286.11 ",IP,"2,420.00","40,269.60",,,,,,
BCBS PPO,DRG,MS-375,DIGESTIVE MALIGNANCY WITH CC,Surgical,Relative Weights,"$13,469.85 ",IP,"2,420.00","24,339.17",,,,,,
BCBS PPO,DRG,MS-376,DIGESTIVE MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$11,171.50 ",IP,"2,420.00","20,186.21",,,,,,
BCBS PPO,DRG,MS-377,GASTROINTESTINAL HEMORRHAGE WITH MCC,Surgical,Relative Weights,"$19,746.77 ",IP,"2,420.00","35,681.18",,,,,,
BCBS PPO,DRG,MS-378,GASTROINTESTINAL HEMORRHAGE WITH CC,Surgical,Relative Weights,"$11,024.23 ",IP,"2,420.00","19,920.10",,,,,,
BCBS PPO,DRG,MS-379,GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,Surgical,Relative Weights,"$7,204.07 ",IP,"2,420.00","13,017.31",,,,,,
BCBS PPO,DRG,MS-380,COMPLICATED PEPTIC ULCER WITH MCC,Surgical,Relative Weights,"$21,059.95 ",IP,"2,420.00","38,054.02",,,,,,
BCBS PPO,DRG,MS-381,COMPLICATED PEPTIC ULCER WITH CC,Surgical,Relative Weights,"$12,012.74 ",IP,"2,420.00","21,706.27",,,,,,
BCBS PPO,DRG,MS-382,COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,Surgical,Relative Weights,"$8,829.65 ",IP,"2,420.00","15,954.62",,,,,,
BCBS PPO,DRG,MS-383,UNCOMPLICATED PEPTIC ULCER WITH MCC,Surgical,Relative Weights,"$14,797.53 ",IP,"2,420.00","26,738.21",,,,,,
BCBS PPO,DRG,MS-384,UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,Surgical,Relative Weights,"$9,708.82 ",IP,"2,420.00","17,543.23",,,,,,
BCBS PPO,DRG,MS-385,INFLAMMATORY BOWEL DISEASE WITH MCC,Surgical,Relative Weights,"$17,966.12 ",IP,"2,420.00","32,463.65",,,,,,
BCBS PPO,DRG,MS-386,INFLAMMATORY BOWEL DISEASE W CC,Surgical,Relative Weights,"$10,991.88 ",IP,"2,420.00","19,861.63",,,,,,
BCBS PPO,DRG,MS-387,INFLAMMATORY BOWEL DISEASE W/O CC/MCC,Surgical,Relative Weights,"$7,817.71 ",IP,"2,420.00","14,126.11",,,,,,
BCBS PPO,DRG,MS-388,GASTROINTESTINAL OBSTRUCTION WITH MCC,Surgical,Relative Weights,"$17,015.54 ",IP,"2,420.00","30,746.02",,,,,,
BCBS PPO,DRG,MS-389,GASTROINTESTINAL OBSTRUCTION WITH CC,Surgical,Relative Weights,"$9,368.53 ",IP,"2,420.00","16,928.35",,,,,,
BCBS PPO,DRG,MS-390,GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,Surgical,Relative Weights,"$6,466.60 ",IP,"2,420.00","11,684.74",,,,,,
BCBS PPO,DRG,MS-391,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC,Surgical,Relative Weights,"$13,778.90 ",IP,"2,420.00","24,897.60",,,,,,
BCBS PPO,DRG,MS-392,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC,Surgical,Relative Weights,"$8,496.06 ",IP,"2,420.00","15,351.84",,,,,,
BCBS PPO,DRG,MS-393,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,Surgical,Relative Weights,"$18,124.55 ",IP,"2,420.00","32,749.92",,,,,,
BCBS PPO,DRG,MS-394,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,Surgical,Relative Weights,"$10,466.38 ",IP,"2,420.00","18,912.10",,,,,,
BCBS PPO,DRG,MS-395,OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,301.14 ",IP,"2,420.00","13,192.70",,,,,,
BCBS PPO,DRG,MS-405,PANCREAS- LIVER AND SHUNT PROCEDURES WITH MCC,Surgical,Relative Weights,"$60,551.27 ",IP,"2,420.00","109,412.35",,,,,,
BCBS PPO,DRG,MS-406,PANCREAS -  LIVER AND SHUNT PROCEDURES WITH CC,Surgical,Relative Weights,"$31,138.07 ",IP,"2,420.00","56,264.54",,,,,,
BCBS PPO,DRG,MS-407,PANCREAS -  LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$23,276.85 ",IP,"2,420.00","42,059.81",,,,,,
BCBS PPO,DRG,MS-408,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,Surgical,Relative Weights,"$39,759.09 ",IP,"2,420.00","71,842.18",,,,,,
BCBS PPO,DRG,MS-409,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,Surgical,Relative Weights,"$26,707.63 ",IP,"2,420.00","48,259.01",,,,,,
BCBS PPO,DRG,MS-410,BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W/O CC/MCC,Surgical,Relative Weights,"$18,520.62 ",IP,"2,420.00","33,465.60",,,,,,
BCBS PPO,DRG,MS-411,CHOLECYSTECTOMY W C.D.E. W MCC,Surgical,Relative Weights,"$42,735.77 ",IP,"2,420.00","77,220.86",,,,,,
BCBS PPO,DRG,MS-412,CHOLECYSTECTOMY WITH C.D.E. WITH CC,Surgical,Relative Weights,"$26,520.19 ",IP,"2,420.00","47,920.32",,,,,,
BCBS PPO,DRG,MS-413,CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,Surgical,Relative Weights,"$18,044.22 ",IP,"2,420.00","32,604.77",,,,,,
BCBS PPO,DRG,MS-414,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,Surgical,Relative Weights,"$38,116.77 ",IP,"2,420.00","68,874.62",,,,,,
BCBS PPO,DRG,MS-415,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,Surgical,Relative Weights,"$22,890.82 ",IP,"2,420.00","41,362.27",,,,,,
BCBS PPO,DRG,MS-416,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,Surgical,Relative Weights,"$15,065.30 ",IP,"2,420.00","27,222.05",,,,,,
BCBS PPO,DRG,MS-417,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,Surgical,Relative Weights,"$26,896.18 ",IP,"2,420.00","48,599.71",,,,,,
BCBS PPO,DRG,MS-418,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,Surgical,Relative Weights,"$18,619.92 ",IP,"2,420.00","33,645.02",,,,,,
BCBS PPO,DRG,MS-419,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,Surgical,Relative Weights,"$14,579.97 ",IP,"2,420.00","26,345.09",,,,,,
BCBS PPO,DRG,MS-420,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,Surgical,Relative Weights,"$38,322.06 ",IP,"2,420.00","69,245.57",,,,,,
BCBS PPO,DRG,MS-421,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,Surgical,Relative Weights,"$20,542.27 ",IP,"2,420.00","37,118.59",,,,,,
BCBS PPO,DRG,MS-422,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$15,670.01 ",IP,"2,420.00","28,314.72",,,,,,
BCBS PPO,DRG,MS-423,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$47,285.60 ",IP,"2,420.00","85,442.11",,,,,,
BCBS PPO,DRG,MS-424,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$25,118.87 ",IP,"2,420.00","45,388.22",,,,,,
BCBS PPO,DRG,MS-425,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$16,305.96 ",IP,"2,420.00","29,463.84",,,,,,
BCBS PPO,DRG,MS-432,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,Surgical,Relative Weights,"$20,343.67 ",IP,"2,420.00","36,759.74",,,,,,
BCBS PPO,DRG,MS-433,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,Surgical,Relative Weights,"$11,514.02 ",IP,"2,420.00","20,805.12",,,,,,
BCBS PPO,DRG,MS-434,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Surgical,Relative Weights,"$7,139.36 ",IP,"2,420.00","12,900.38",,,,,,
BCBS PPO,DRG,MS-435,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,Surgical,Relative Weights,"$18,934.54 ",IP,"2,420.00","34,213.54",,,,,,
BCBS PPO,DRG,MS-436,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,Surgical,Relative Weights,"$12,559.43 ",IP,"2,420.00","22,694.11",,,,,,
BCBS PPO,DRG,MS-437,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,Surgical,Relative Weights,"$9,794.73 ",IP,"2,420.00","17,698.46",,,,,,
BCBS PPO,DRG,MS-438,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,Surgical,Relative Weights,"$18,278.51 ",IP,"2,420.00","33,028.13",,,,,,
BCBS PPO,DRG,MS-439,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,Surgical,Relative Weights,"$9,452.21 ",IP,"2,420.00","17,079.55",,,,,,
BCBS PPO,DRG,MS-440,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$6,868.25 ",IP,"2,420.00","12,410.50",,,,,,
BCBS PPO,DRG,MS-441,DISORDERS OF LIVER EXCEPT MALIGNANCY- CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC,Surgical,Relative Weights,"$20,646.03 ",IP,"2,420.00","37,306.08",,,,,,
BCBS PPO,DRG,MS-442,DISORDERS OF LIVER EXCEPT MALIGNANCY -  CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC,Surgical,Relative Weights,"$10,413.94 ",IP,"2,420.00","18,817.34",,,,,,
BCBS PPO,DRG,MS-443,DISORDERS OF LIVER EXCEPT MALIGNANCY -  CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Surgical,Relative Weights,"$7,590.11 ",IP,"2,420.00","13,714.85",,,,,,
BCBS PPO,DRG,MS-444,DISORDERS OF THE BILIARY TRACT WITH MCC,Surgical,Relative Weights,"$18,142.40 ",IP,"2,420.00","32,782.18",,,,,,
BCBS PPO,DRG,MS-445,DISORDERS OF THE BILIARY TRACT WITH CC,Surgical,Relative Weights,"$11,988.20 ",IP,"2,420.00","21,661.92",,,,,,
BCBS PPO,DRG,MS-446,DISORDERS OF THE BILIARY TRACT W/O CC/MCC,Surgical,Relative Weights,"$9,067.29 ",IP,"2,420.00","16,384.03",,,,,,
BCBS PPO,DRG,MS-453,COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W MCC,Surgical,Relative Weights,"$104,953.90 ",IP,"2,420.00","189,645.12",,,,,,
BCBS PPO,DRG,MS-454,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC,Surgical,Relative Weights,"$68,336.63 ",IP,"2,420.00","123,480.00",,,,,,
BCBS PPO,DRG,MS-455,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CC/MCC,Surgical,Relative Weights,"$53,701.99 ",IP,"2,420.00","97,036.13",,,,,,
BCBS PPO,DRG,MS-456,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH MCC,Surgical,Relative Weights,"$101,318.95 ",IP,"2,420.00","183,076.99",,,,,,
BCBS PPO,DRG,MS-457,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH CC,Surgical,Relative Weights,"$72,668.89 ",IP,"2,420.00","131,308.13",,,,,,
BCBS PPO,DRG,MS-458,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC,Surgical,Relative Weights,"$52,369.84 ",IP,"2,420.00","94,629.02",,,,,,
BCBS PPO,DRG,MS-459,SPINAL FUSION EXCEPT CERVICAL WITH MCC,Surgical,Relative Weights,"$76,447.76 ",IP,"21,658.00","138,136.32",,,,,,
BCBS PPO,DRG,MS-460,SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,Surgical,Relative Weights,"$44,186.18 ",IP,"21,658.00","79,841.66",,,,,,
BCBS PPO,DRG,MS-461,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,Surgical,Relative Weights,"$60,011.27 ",IP,"2,420.00","108,436.61",,,,,,
BCBS PPO,DRG,MS-462,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,Surgical,Relative Weights,"$34,992.81 ",IP,"2,420.00","63,229.82",,,,,,
BCBS PPO,DRG,MS-463,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,Surgical,Relative Weights,"$58,326.56 ",IP,"2,420.00","105,392.45",,,,,,
BCBS PPO,DRG,MS-464,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,Surgical,Relative Weights,"$32,943.27 ",IP,"2,420.00","59,526.43",,,,,,
BCBS PPO,DRG,MS-465,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$21,367.89 ",IP,"2,420.00","38,610.43",,,,,,
BCBS PPO,DRG,MS-466,REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,Surgical,Relative Weights,"$56,890.66 ",IP,"2,420.00","102,797.86",,,,,,
BCBS PPO,DRG,MS-467,REVISION OF HIP OR KNEE REPLACEMENT W CC,Surgical,Relative Weights,"$39,184.50 ",IP,"2,420.00","70,803.94",,,,,,
BCBS PPO,DRG,MS-468,REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,Surgical,Relative Weights,"$31,374.60 ",IP,"2,420.00","56,691.94",,,,,,
BCBS PPO,DRG,MS-469,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,Surgical,Relative Weights,"$35,031.86 ",IP,"2,420.00","63,300.38",,,,,,
BCBS PPO,DRG,MS-470,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,Surgical,Relative Weights,"$21,961.44 ",IP,"2,420.00","39,682.94",,,,,,
BCBS PPO,DRG,MS-471,CERVICAL SPINAL FUSION WITH MCC,Surgical,Relative Weights,"$55,722.52 ",IP,"15,407.00","100,687.10",,,,,,
BCBS PPO,DRG,MS-472,CERVICAL SPINAL FUSION WITH CC,Surgical,Relative Weights,"$33,934.02 ",IP,"15,407.00","61,316.64",,,,,,
BCBS PPO,DRG,MS-473,CERVICAL SPINAL FUSION WITHOUT CC/MCC,Surgical,Relative Weights,"$28,030.85 ",IP,"14,827.96","50,649.98",,,,,,
BCBS PPO,DRG,MS-474,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,Surgical,Relative Weights,"$43,232.26 ",IP,"2,420.00","78,117.98",,,,,,
BCBS PPO,DRG,MS-475,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,Surgical,Relative Weights,"$23,440.86 ",IP,"2,420.00","42,356.16",,,,,,
BCBS PPO,DRG,MS-476,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$12,994.56 ",IP,"2,420.00","23,480.35",,,,,,
BCBS PPO,DRG,MS-477,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Surgical,Relative Weights,"$36,319.38 ",IP,"2,420.00","65,626.85",,,,,,
BCBS PPO,DRG,MS-478,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Surgical,Relative Weights,"$25,851.88 ",IP,"2,420.00","46,712.74",,,,,,
BCBS PPO,DRG,MS-479,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Surgical,Relative Weights,"$19,884.01 ",IP,"2,420.00","35,929.15",,,,,,
BCBS PPO,DRG,MS-480,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,Surgical,Relative Weights,"$33,677.40 ",IP,"2,420.00","60,852.96",,,,,,
BCBS PPO,DRG,MS-481,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,Surgical,Relative Weights,"$23,293.58 ",IP,"2,420.00","42,090.05",,,,,,
BCBS PPO,DRG,MS-482,HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC,Surgical,Relative Weights,"$18,356.61 ",IP,"2,420.00","33,169.25",,,,,,
BCBS PPO,DRG,MS-483,MAJOR JOINT & LIMB REATTACHMENT PROC OF UPPER EXTREMITY W CC/MCC,Surgical,Relative Weights,"$26,688.66 ",IP,"2,420.00","48,224.74",,,,,,
BCBS PPO,DRG,MS-485,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,Surgical,Relative Weights,"$36,583.80 ",IP,"2,420.00","66,104.64",,,,,,
BCBS PPO,DRG,MS-486,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,Surgical,Relative Weights,"$23,994.24 ",IP,"2,420.00","43,356.10",,,,,,
BCBS PPO,DRG,MS-487,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Surgical,Relative Weights,"$17,931.53 ",IP,"2,420.00","32,401.15",,,,,,
BCBS PPO,DRG,MS-488,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,Surgical,Relative Weights,"$21,970.36 ",IP,"2,420.00","39,699.07",,,,,,
BCBS PPO,DRG,MS-489,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Surgical,Relative Weights,"$14,046.66 ",IP,"2,420.00","25,381.44",,,,,,
BCBS PPO,DRG,MS-492,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH MCC,Surgical,Relative Weights,"$38,439.21 ",IP,"2,420.00","69,457.25",,,,,,
BCBS PPO,DRG,MS-493,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH CC,Surgical,Relative Weights,"$25,683.41 ",IP,"2,420.00","46,408.32",,,,,,
BCBS PPO,DRG,MS-494,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITHOUT CC/MCC,Surgical,Relative Weights,"$20,209.79 ",IP,"2,420.00","36,517.82",,,,,,
BCBS PPO,DRG,MS-495,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,Surgical,Relative Weights,"$38,297.52 ",IP,"2,420.00","69,201.22",,,,,,
BCBS PPO,DRG,MS-496,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,Surgical,Relative Weights,"$22,765.86 ",IP,"2,420.00","41,136.48",,,,,,
BCBS PPO,DRG,MS-497,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,Surgical,Relative Weights,"$16,392.98 ",IP,"2,420.00","29,621.09",,,,,,
BCBS PPO,DRG,MS-498,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,Surgical,Relative Weights,"$27,313.45 ",IP,"2,420.00","49,353.70",,,,,,
BCBS PPO,DRG,MS-499,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,Surgical,Relative Weights,"$12,840.59 ",IP,"2,420.00","23,202.14",,,,,,
BCBS PPO,DRG,MS-500,SOFT TISSUE PROCEDURES WITH MCC,Surgical,Relative Weights,"$33,640.59 ",IP,"2,420.00","60,786.43",,,,,,
BCBS PPO,DRG,MS-501,SOFT TISSUE PROCEDURES WITH CC,Surgical,Relative Weights,"$18,721.45 ",IP,"2,420.00","33,828.48",,,,,,
BCBS PPO,DRG,MS-502,SOFT TISSUE PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$14,735.05 ",IP,"2,420.00","26,625.31",,,,,,
BCBS PPO,DRG,MS-503,FOOT PROCEDURES WITH MCC,Surgical,Relative Weights,"$30,309.11 ",IP,"2,420.00","54,766.66",,,,,,
BCBS PPO,DRG,MS-504,FOOT PROCEDURES WITH CC,Surgical,Relative Weights,"$19,374.13 ",IP,"2,420.00","35,007.84",,,,,,
BCBS PPO,DRG,MS-505,FOOT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$18,760.50 ",IP,"2,420.00","33,899.04",,,,,,
BCBS PPO,DRG,MS-506,MAJOR THUMB OR JOINT PROCEDURES,Surgical,Relative Weights,"$14,934.76 ",IP,"2,420.00","26,986.18",,,,,,
BCBS PPO,DRG,MS-507,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W CC/MCC,Surgical,Relative Weights,"$23,429.70 ",IP,"2,420.00","42,336.00",,,,,,
BCBS PPO,DRG,MS-508,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$17,387.07 ",IP,"2,420.00","31,417.34",,,,,,
BCBS PPO,DRG,MS-509,ARTHROSCOPY,Surgical,Relative Weights,"$15,527.20 ",IP,"2,420.00","28,056.67",,,,,,
BCBS PPO,DRG,MS-510,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH MCC,Surgical,Relative Weights,"$31,105.72 ",IP,"2,420.00","56,206.08",,,,,,
BCBS PPO,DRG,MS-511,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH CC,Surgical,Relative Weights,"$21,022.02 ",IP,"2,420.00","37,985.47",,,,,,
BCBS PPO,DRG,MS-512,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$16,889.47 ",IP,"2,420.00","30,518.21",,,,,,
BCBS PPO,DRG,MS-513,HAND OR WRIST PROCEDURES- EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$17,595.70 ",IP,"2,420.00","31,794.34",,,,,,
BCBS PPO,DRG,MS-514,HAND OR WRIST PROCEDURES -  EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$11,902.29 ",IP,"2,420.00","21,506.69",,,,,,
BCBS PPO,DRG,MS-515,OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W MCC,Surgical,Relative Weights,"$35,189.18 ",IP,"2,420.00","63,584.64",,,,,,
BCBS PPO,DRG,MS-516,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$21,634.54 ",IP,"2,420.00","39,092.26",,,,,,
BCBS PPO,DRG,MS-517,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$15,790.50 ",IP,"2,420.00","28,532.45",,,,,,
BCBS PPO,DRG,MS-518,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,Surgical,Relative Weights,"$38,029.75 ",IP,"10,289.00","68,717.38",,,,,,
BCBS PPO,DRG,MS-519,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,Surgical,Relative Weights,"$21,295.37 ",IP,"10,289.00","38,479.39",,,,,,
BCBS PPO,DRG,MS-520,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,Surgical,Relative Weights,"$14,928.07 ",IP,"8,282.98","26,974.08",,,,,,
BCBS PPO,DRG,MS-533,FRACTURES OF FEMUR WITH MCC,Surgical,Relative Weights,"$16,282.53 ",IP,"2,420.00","29,421.50",,,,,,
BCBS PPO,DRG,MS-534,FRACTURES OF FEMUR WITHOUT MCC,Surgical,Relative Weights,"$8,677.91 ",IP,"2,420.00","15,680.45",,,,,,
BCBS PPO,DRG,MS-535,FRACTURES OF HIP AND PELVIS WITH MCC,Surgical,Relative Weights,"$13,690.75 ",IP,"2,420.00","24,738.34",,,,,,
BCBS PPO,DRG,MS-536,FRACTURES OF HIP AND PELVIS WITHOUT MCC,Surgical,Relative Weights,"$8,462.58 ",IP,"2,420.00","15,291.36",,,,,,
BCBS PPO,DRG,MS-537,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITH CC/MCC,Surgical,Relative Weights,"$10,162.91 ",IP,"2,420.00","18,363.74",,,,,,
BCBS PPO,DRG,MS-538,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITHOUT CC/MCC,Surgical,Relative Weights,"$8,044.20 ",IP,"2,420.00","14,535.36",,,,,,
BCBS PPO,DRG,MS-539,OSTEOMYELITIS WITH MCC,Surgical,Relative Weights,"$21,033.18 ",IP,"2,420.00","38,005.63",,,,,,
BCBS PPO,DRG,MS-540,OSTEOMYELITIS WITH CC,Surgical,Relative Weights,"$14,504.10 ",IP,"2,420.00","26,208.00",,,,,,
BCBS PPO,DRG,MS-541,OSTEOMYELITIS WITHOUT CC/MCC,Surgical,Relative Weights,"$10,116.05 ",IP,"2,420.00","18,279.07",,,,,,
BCBS PPO,DRG,MS-542,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,Surgical,Relative Weights,"$20,359.29 ",IP,"2,420.00","36,787.97",,,,,,
BCBS PPO,DRG,MS-543,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,Surgical,Relative Weights,"$11,785.14 ",IP,"2,420.00","21,295.01",,,,,,
BCBS PPO,DRG,MS-544,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$8,461.47 ",IP,"2,420.00","15,289.34",,,,,,
BCBS PPO,DRG,MS-545,CONNECTIVE TISSUE DISORDERS WITH MCC,Surgical,Relative Weights,"$28,204.90 ",IP,"2,420.00","50,964.48",,,,,,
BCBS PPO,DRG,MS-546,CONNECTIVE TISSUE DISORDERS WITH CC,Surgical,Relative Weights,"$13,426.33 ",IP,"2,420.00","24,260.54",,,,,,
BCBS PPO,DRG,MS-547,CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$9,038.29 ",IP,"2,420.00","16,331.62",,,,,,
BCBS PPO,DRG,MS-548,SEPTIC ARTHRITIS WITH MCC,Surgical,Relative Weights,"$22,127.68 ",IP,"2,420.00","39,983.33",,,,,,
BCBS PPO,DRG,MS-549,SEPTIC ARTHRITIS W CC,Surgical,Relative Weights,"$13,311.42 ",IP,"2,420.00","24,052.90",,,,,,
BCBS PPO,DRG,MS-550,SEPTIC ARTHRITIS W/O CC/MCC,Surgical,Relative Weights,"$9,639.65 ",IP,"2,420.00","17,418.24",,,,,,
BCBS PPO,DRG,MS-551,MEDICAL BACK PROBLEMS WITH MCC,Surgical,Relative Weights,"$17,732.94 ",IP,"2,420.00","32,042.30",,,,,,
BCBS PPO,DRG,MS-552,MEDICAL BACK PROBLEMS WITHOUT MCC,Surgical,Relative Weights,"$10,174.07 ",IP,"2,420.00","18,383.90",,,,,,
BCBS PPO,DRG,MS-553,BONE DISEASES AND ARTHROPATHIES WITH MCC,Surgical,Relative Weights,"$14,342.32 ",IP,"2,420.00","25,915.68",,,,,,
BCBS PPO,DRG,MS-554,BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,Surgical,Relative Weights,"$8,782.79 ",IP,"2,420.00","15,869.95",,,,,,
BCBS PPO,DRG,MS-555,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Surgical,Relative Weights,"$14,674.80 ",IP,"2,420.00","26,516.45",,,,,,
BCBS PPO,DRG,MS-556,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,Surgical,Relative Weights,"$8,834.11 ",IP,"2,420.00","15,962.69",,,,,,
BCBS PPO,DRG,MS-557,TENDONITIS -  MYOSITIS AND BURSITIS WITH MCC,Surgical,Relative Weights,"$16,269.14 ",IP,"2,420.00","29,397.31",,,,,,
BCBS PPO,DRG,MS-558,TENDONITIS- MYOSITIS AND BURSITIS WITHOUT MCC,Surgical,Relative Weights,"$9,610.64 ",IP,"2,420.00","17,365.82",,,,,,
BCBS PPO,DRG,MS-559,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Surgical,Relative Weights,"$20,102.68 ",IP,"2,420.00","36,324.29",,,,,,
BCBS PPO,DRG,MS-560,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Surgical,Relative Weights,"$11,642.33 ",IP,"2,420.00","21,036.96",,,,,,
BCBS PPO,DRG,MS-561,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Surgical,Relative Weights,"$8,338.74 ",IP,"2,420.00","15,067.58",,,,,,
BCBS PPO,DRG,MS-562,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITH MCC,Surgical,Relative Weights,"$15,029.59 ",IP,"2,420.00","27,157.54",,,,,,
BCBS PPO,DRG,MS-563,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITHOUT MCC,Surgical,Relative Weights,"$9,528.08 ",IP,"2,420.00","17,216.64",,,,,,
BCBS PPO,DRG,MS-564,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,Surgical,Relative Weights,"$16,869.38 ",IP,"2,420.00","30,481.92",,,,,,
BCBS PPO,DRG,MS-565,OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W CC,Surgical,Relative Weights,"$10,939.44 ",IP,"2,420.00","19,766.88",,,,,,
BCBS PPO,DRG,MS-566,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,453.66 ",IP,"2,420.00","15,275.23",,,,,,
BCBS PPO,DRG,MS-570,SKIN DEBRIDEMENT WITH MCC,Surgical,Relative Weights,"$32,056.29 ",IP,"2,420.00","57,923.71",,,,,,
BCBS PPO,DRG,MS-571,SKIN DEBRIDEMENT WITH CC,Surgical,Relative Weights,"$18,657.85 ",IP,"2,420.00","33,713.57",,,,,,
BCBS PPO,DRG,MS-572,SKIN DEBRIDEMENT WITHOUT CC/MCC,Surgical,Relative Weights,"$12,514.81 ",IP,"2,420.00","22,613.47",,,,,,
BCBS PPO,DRG,MS-573,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,Surgical,Relative Weights,"$59,302.80 ",IP,"2,420.00","107,156.45",,,,,,
BCBS PPO,DRG,MS-574,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,Surgical,Relative Weights,"$34,829.92 ",IP,"2,420.00","62,935.49",,,,,,
BCBS PPO,DRG,MS-575,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS W/O CC/MCC,Surgical,Relative Weights,"$19,602.85 ",IP,"2,420.00","35,421.12",,,,,,
BCBS PPO,DRG,MS-576,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,Surgical,Relative Weights,"$54,102.52 ",IP,"2,420.00","97,759.87",,,,,,
BCBS PPO,DRG,MS-577,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,Surgical,Relative Weights,"$26,950.85 ",IP,"2,420.00","48,698.50",,,,,,
BCBS PPO,DRG,MS-578,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,Surgical,Relative Weights,"$18,156.90 ",IP,"2,420.00","32,808.38",,,,,,
BCBS PPO,DRG,MS-579,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC,Surgical,Relative Weights,"$33,315.92 ",IP,"2,420.00","60,199.78",,,,,,
BCBS PPO,DRG,MS-580,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC,Surgical,Relative Weights,"$17,948.27 ",IP,"2,420.00","32,431.39",,,,,,
BCBS PPO,DRG,MS-581,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$13,999.80 ",IP,"2,420.00","25,296.77",,,,,,
BCBS PPO,DRG,MS-582,MASTECTOMY FOR MALIGNANCY WITH CC/MCC,Surgical,Relative Weights,"$17,613.56 ",IP,"2,420.00","31,826.59",,,,,,
BCBS PPO,DRG,MS-583,MASTECTOMY FOR MALIGNANCY W/O CC/MCC,Surgical,Relative Weights,"$16,304.84 ",IP,"2,420.00","29,461.82",,,,,,
BCBS PPO,DRG,MS-584,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$20,399.46 ",IP,"2,420.00","36,860.54",,,,,,
BCBS PPO,DRG,MS-585,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$18,936.78 ",IP,"2,420.00","34,217.57",,,,,,
BCBS PPO,DRG,MS-592,SKIN ULCERS WITH MCC,Surgical,Relative Weights,"$19,907.44 ",IP,"2,420.00","35,971.49",,,,,,
BCBS PPO,DRG,MS-593,SKIN ULCERS WITH CC,Surgical,Relative Weights,"$12,806.00 ",IP,"2,420.00","23,139.65",,,,,,
BCBS PPO,DRG,MS-594,SKIN ULCERS WITHOUT CC/MCC,Surgical,Relative Weights,"$9,033.82 ",IP,"2,420.00","16,323.55",,,,,,
BCBS PPO,DRG,MS-595,MAJOR SKIN DISORDERS WITH MCC,Surgical,Relative Weights,"$22,677.72 ",IP,"2,420.00","40,977.22",,,,,,
BCBS PPO,DRG,MS-596,MAJOR SKIN DISORDERS W/O MCC,Surgical,Relative Weights,"$10,868.03 ",IP,"2,420.00","19,637.86",,,,,,
BCBS PPO,DRG,MS-597,MALIGNANT BREAST DISORDERS W MCC,Surgical,Relative Weights,"$18,887.69 ",IP,"2,420.00","34,128.86",,,,,,
BCBS PPO,DRG,MS-598,MALIGNANT BREAST DISORDERS WITH CC,Surgical,Relative Weights,"$12,145.51 ",IP,"2,420.00","21,946.18",,,,,,
BCBS PPO,DRG,MS-599,MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$7,758.58 ",IP,"2,420.00","14,019.26",,,,,,
BCBS PPO,DRG,MS-600,NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,Surgical,Relative Weights,"$10,701.79 ",IP,"2,420.00","19,337.47",,,,,,
BCBS PPO,DRG,MS-601,NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$6,903.95 ",IP,"2,420.00","12,475.01",,,,,,
BCBS PPO,DRG,MS-602,CELLULITIS WITH MCC,Surgical,Relative Weights,"$15,952.28 ",IP,"2,420.00","28,824.77",,,,,,
BCBS PPO,DRG,MS-603,CELLULITIS WITHOUT MCC,Surgical,Relative Weights,"$9,410.93 ",IP,"2,420.00","17,004.96",,,,,,
BCBS PPO,DRG,MS-604,TRAUMA TO THE SKIN -  SUBCUTANEOUS TISSUE AND BREAST WITH MCC,Surgical,Relative Weights,"$16,339.43 ",IP,"2,420.00","29,524.32",,,,,,
BCBS PPO,DRG,MS-605,TRAUMA TO THE SKIN- SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC,Surgical,Relative Weights,"$9,770.18 ",IP,"2,420.00","17,654.11",,,,,,
BCBS PPO,DRG,MS-606,MINOR SKIN DISORDERS WITH MCC,Surgical,Relative Weights,"$16,685.29 ",IP,"2,420.00","30,149.28",,,,,,
BCBS PPO,DRG,MS-607,MINOR SKIN DISORDERS WITHOUT MCC,Surgical,Relative Weights,"$9,216.80 ",IP,"2,420.00","16,654.18",,,,,,
BCBS PPO,DRG,MS-614,ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$27,148.33 ",IP,"2,420.00","49,055.33",,,,,,
BCBS PPO,DRG,MS-615,ADRENAL & PITUITARY PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$16,558.10 ",IP,"2,420.00","29,919.46",,,,,,
BCBS PPO,DRG,MS-616,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Surgical,Relative Weights,"$44,636.93 ",IP,"2,420.00","80,656.13",,,,,,
BCBS PPO,DRG,MS-617,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Surgical,Relative Weights,"$22,886.35 ",IP,"2,420.00","41,354.21",,,,,,
BCBS PPO,DRG,MS-618,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$13,996.46 ",IP,"2,420.00","25,290.72",,,,,,
BCBS PPO,DRG,MS-619,O.R. PROCEDURES FOR OBESITY WITH MCC,Surgical,Relative Weights,"$34,346.82 ",IP,"2,420.00","62,062.56",,,,,,
BCBS PPO,DRG,MS-620,O.R. PROCEDURES FOR OBESITY WITH CC,Surgical,Relative Weights,"$20,022.35 ",IP,"2,420.00","36,179.14",,,,,,
BCBS PPO,DRG,MS-621,O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,Surgical,Relative Weights,"$17,538.80 ",IP,"2,420.00","31,691.52",,,,,,
BCBS PPO,DRG,MS-622,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Surgical,Relative Weights,"$42,123.25 ",IP,"2,420.00","76,114.08",,,,,,
BCBS PPO,DRG,MS-623,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE -  NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Surgical,Relative Weights,"$21,785.16 ",IP,"2,420.00","39,364.42",,,,,,
BCBS PPO,DRG,MS-624,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$12,295.01 ",IP,"2,420.00","22,216.32",,,,,,
BCBS PPO,DRG,MS-625,THYROID- PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$32,635.34 ",IP,"2,420.00","58,970.02",,,,,,
BCBS PPO,DRG,MS-626,THYROID -  PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC,Surgical,Relative Weights,"$18,775.00 ",IP,"2,420.00","33,925.25",,,,,,
BCBS PPO,DRG,MS-627,THYROID -  PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$12,737.95 ",IP,"2,420.00","23,016.67",,,,,,
BCBS PPO,DRG,MS-628,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$41,161.52 ",IP,"2,420.00","74,376.29",,,,,,
BCBS PPO,DRG,MS-629,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$25,915.48 ",IP,"2,420.00","46,827.65",,,,,,
BCBS PPO,DRG,MS-630,OTHER ENDOCRINE - NUTRIT & METAB O.R. PROC W/O CC/MCC,Surgical,Relative Weights,"$16,164.26 ",IP,"2,420.00","29,207.81",,,,,,
BCBS PPO,DRG,MS-637,DIABETES WITH MCC,Surgical,Relative Weights,"$15,460.25 ",IP,"2,420.00","27,935.71",,,,,,
BCBS PPO,DRG,MS-638,DIABETES WITH CC,Surgical,Relative Weights,"$9,863.90 ",IP,"2,420.00","17,823.46",,,,,,
BCBS PPO,DRG,MS-639,DIABETES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,841.47 ",IP,"2,420.00","12,362.11",,,,,,
BCBS PPO,DRG,MS-640,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITH MCC,Surgical,Relative Weights,"$13,546.83 ",IP,"2,420.00","24,478.27",,,,,,
BCBS PPO,DRG,MS-641,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITHOUT MCC,Surgical,Relative Weights,"$8,441.39 ",IP,"2,420.00","15,253.06",,,,,,
BCBS PPO,DRG,MS-642,INBORN AND OTHER DISORDERS OF METABOLISM,Surgical,Relative Weights,"$13,564.68 ",IP,"2,420.00","24,510.53",,,,,,
BCBS PPO,DRG,MS-643,ENDOCRINE DISORDERS WITH MCC,Surgical,Relative Weights,"$18,135.70 ",IP,"2,420.00","32,770.08",,,,,,
BCBS PPO,DRG,MS-644,ENDOCRINE DISORDERS WITH CC,Surgical,Relative Weights,"$11,470.51 ",IP,"2,420.00","20,726.50",,,,,,
BCBS PPO,DRG,MS-645,ENDOCRINE DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$8,537.34 ",IP,"2,420.00","15,426.43",,,,,,
BCBS PPO,DRG,MS-652,KIDNEY TRANSPLANT,Surgical,Relative Weights,"$37,765.33 ",IP,"2,420.00","68,239.58",,,,,,
BCBS PPO,DRG,MS-653,MAJOR BLADDER PROCEDURES WITH MCC,Surgical,Relative Weights,"$61,770.73 ",IP,"2,420.00","111,615.84",,,,,,
BCBS PPO,DRG,MS-654,MAJOR BLADDER PROCEDURES WITH CC,Surgical,Relative Weights,"$31,375.72 ",IP,"2,420.00","56,693.95",,,,,,
BCBS PPO,DRG,MS-655,MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$23,010.20 ",IP,"2,420.00","41,577.98",,,,,,
BCBS PPO,DRG,MS-656,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,Surgical,Relative Weights,"$36,378.51 ",IP,"2,420.00","65,733.70",,,,,,
BCBS PPO,DRG,MS-657,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,Surgical,Relative Weights,"$21,579.87 ",IP,"2,420.00","38,993.47",,,,,,
BCBS PPO,DRG,MS-658,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,Surgical,Relative Weights,"$17,515.37 ",IP,"2,420.00","31,649.18",,,,,,
BCBS PPO,DRG,MS-659,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,Surgical,Relative Weights,"$29,898.53 ",IP,"2,420.00","54,024.77",,,,,,
BCBS PPO,DRG,MS-660,KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC,Surgical,Relative Weights,"$15,850.75 ",IP,"2,420.00","28,641.31",,,,,,
BCBS PPO,DRG,MS-661,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,Surgical,Relative Weights,"$12,162.25 ",IP,"2,420.00","21,976.42",,,,,,
BCBS PPO,DRG,MS-662,MINOR BLADDER PROCEDURES WITH MCC,Surgical,Relative Weights,"$35,308.56 ",IP,"2,420.00","63,800.35",,,,,,
BCBS PPO,DRG,MS-663,MINOR BLADDER PROCEDURES WITH CC,Surgical,Relative Weights,"$16,996.57 ",IP,"2,420.00","30,711.74",,,,,,
BCBS PPO,DRG,MS-664,MINOR BLADDER PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$12,346.34 ",IP,"2,420.00","22,309.06",,,,,,
BCBS PPO,DRG,MS-665,PROSTATECTOMY WITH MCC,Surgical,Relative Weights,"$33,119.55 ",IP,"2,420.00","59,844.96",,,,,,
BCBS PPO,DRG,MS-666,PROSTATECTOMY WITH CC,Surgical,Relative Weights,"$19,737.85 ",IP,"2,420.00","35,665.06",,,,,,
BCBS PPO,DRG,MS-667,PROSTATECTOMY W/O CC/MCC,Surgical,Relative Weights,"$10,473.08 ",IP,"2,420.00","18,924.19",,,,,,
BCBS PPO,DRG,MS-668,TRANSURETHRAL PROCEDURES W MCC,Surgical,Relative Weights,"$31,109.06 ",IP,"2,420.00","56,212.13",,,,,,
BCBS PPO,DRG,MS-669,TRANSURETHRAL PROCEDURES WITH CC,Surgical,Relative Weights,"$17,245.37 ",IP,"2,420.00","31,161.31",,,,,,
BCBS PPO,DRG,MS-670,TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,919.36 ",IP,"2,420.00","19,730.59",,,,,,
BCBS PPO,DRG,MS-671,URETHRAL PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$20,390.53 ",IP,"2,420.00","36,844.42",,,,,,
BCBS PPO,DRG,MS-672,URETHRAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$11,527.41 ",IP,"2,420.00","20,829.31",,,,,,
BCBS PPO,DRG,MS-673,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,Surgical,Relative Weights,"$39,881.81 ",IP,"2,420.00","72,063.94",,,,,,
BCBS PPO,DRG,MS-674,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,Surgical,Relative Weights,"$27,269.94 ",IP,"2,420.00","49,275.07",,,,,,
BCBS PPO,DRG,MS-675,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$18,208.22 ",IP,"2,420.00","32,901.12",,,,,,
BCBS PPO,DRG,MS-682,RENAL FAILURE WITH MCC,Surgical,Relative Weights,"$16,490.05 ",IP,"2,420.00","29,796.48",,,,,,
BCBS PPO,DRG,MS-683,RENAL FAILURE WITH CC,Surgical,Relative Weights,"$10,011.18 ",IP,"2,420.00","18,089.57",,,,,,
BCBS PPO,DRG,MS-684,RENAL FAILURE WITHOUT CC/MCC,Surgical,Relative Weights,"$6,864.90 ",IP,"2,420.00","12,404.45",,,,,,
BCBS PPO,DRG,MS-686,KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,Surgical,Relative Weights,"$19,592.81 ",IP,"2,420.00","35,402.98",,,,,,
BCBS PPO,DRG,MS-687,KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,Surgical,Relative Weights,"$11,743.86 ",IP,"2,420.00","21,220.42",,,,,,
BCBS PPO,DRG,MS-688,KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,Surgical,Relative Weights,"$8,605.39 ",IP,"2,420.00","15,549.41",,,,,,
BCBS PPO,DRG,MS-689,KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,Surgical,Relative Weights,"$12,480.22 ",IP,"2,420.00","22,550.98",,,,,,
BCBS PPO,DRG,MS-690,KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,Surgical,Relative Weights,"$8,822.96 ",IP,"2,420.00","15,942.53",,,,,,
BCBS PPO,DRG,MS-693,URINARY STONES WITH MCC,Surgical,Relative Weights,"$15,098.77 ",IP,"2,420.00","27,282.53",,,,,,
BCBS PPO,DRG,MS-694,URINARY STONES WITHOUT MCC,Surgical,Relative Weights,"$8,260.64 ",IP,"2,420.00","14,926.46",,,,,,
BCBS PPO,DRG,MS-695,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,Surgical,Relative Weights,"$13,079.35 ",IP,"2,420.00","23,633.57",,,,,,
BCBS PPO,DRG,MS-696,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,Surgical,Relative Weights,"$7,580.07 ",IP,"2,420.00","13,696.70",,,,,,
BCBS PPO,DRG,MS-697,URETHRAL STRICTURE,Surgical,Relative Weights,"$10,865.80 ",IP,"2,420.00","19,633.82",,,,,,
BCBS PPO,DRG,MS-698,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,Surgical,Relative Weights,"$18,058.72 ",IP,"2,420.00","32,630.98",,,,,,
BCBS PPO,DRG,MS-699,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,Surgical,Relative Weights,"$11,521.83 ",IP,"2,420.00","20,819.23",,,,,,
BCBS PPO,DRG,MS-700,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,275.15 ",IP,"2,420.00","14,952.67",,,,,,
BCBS PPO,DRG,MS-707,MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$20,862.47 ",IP,"2,420.00","37,697.18",,,,,,
BCBS PPO,DRG,MS-708,MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$16,199.96 ",IP,"2,420.00","29,272.32",,,,,,
BCBS PPO,DRG,MS-709,PENIS PROCEDURES W CC/MCC,Surgical,Relative Weights,"$26,839.28 ",IP,"2,420.00","48,496.90",,,,,,
BCBS PPO,DRG,MS-710,PENIS PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$17,134.92 ",IP,"2,420.00","30,961.73",,,,,,
BCBS PPO,DRG,MS-711,TESTES PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$23,911.68 ",IP,"2,420.00","43,206.91",,,,,,
BCBS PPO,DRG,MS-712,TESTES PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$11,382.37 ",IP,"2,420.00","20,567.23",,,,,,
BCBS PPO,DRG,MS-713,TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,Surgical,Relative Weights,"$16,311.53 ",IP,"2,420.00","29,473.92",,,,,,
BCBS PPO,DRG,MS-714,TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,Surgical,Relative Weights,"$10,213.12 ",IP,"2,420.00","18,454.46",,,,,,
BCBS PPO,DRG,MS-715,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,Surgical,Relative Weights,"$23,836.93 ",IP,"2,420.00","43,071.84",,,,,,
BCBS PPO,DRG,MS-716,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$16,350.58 ",IP,"2,420.00","29,544.48",,,,,,
BCBS PPO,DRG,MS-717,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,Surgical,Relative Weights,"$19,684.30 ",IP,"2,420.00","35,568.29",,,,,,
BCBS PPO,DRG,MS-718,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$13,604.85 ",IP,"2,420.00","24,583.10",,,,,,
BCBS PPO,DRG,MS-722,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH MCC,Surgical,Relative Weights,"$20,137.27 ",IP,"2,420.00","36,386.78",,,,,,
BCBS PPO,DRG,MS-723,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH CC,Surgical,Relative Weights,"$12,355.26 ",IP,"2,420.00","22,325.18",,,,,,
BCBS PPO,DRG,MS-724,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Surgical,Relative Weights,"$6,587.09 ",IP,"2,420.00","11,902.46",,,,,,
BCBS PPO,DRG,MS-725,BENIGN PROSTATIC HYPERTROPHY WITH MCC,Surgical,Relative Weights,"$14,006.50 ",IP,"2,420.00","25,308.86",,,,,,
BCBS PPO,DRG,MS-726,BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,Surgical,Relative Weights,"$8,531.76 ",IP,"2,420.00","15,416.35",,,,,,
BCBS PPO,DRG,MS-727,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,Surgical,Relative Weights,"$15,924.39 ",IP,"2,420.00","28,774.37",,,,,,
BCBS PPO,DRG,MS-728,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,Surgical,Relative Weights,"$8,953.49 ",IP,"2,420.00","16,178.40",,,,,,
BCBS PPO,DRG,MS-729,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,Surgical,Relative Weights,"$11,981.50 ",IP,"2,420.00","21,649.82",,,,,,
BCBS PPO,DRG,MS-730,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,046.76 ",IP,"2,420.00","12,733.06",,,,,,
BCBS PPO,DRG,MS-734,PELVIC EVISCERATION -  RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC,Surgical,Relative Weights,"$24,455.03 ",IP,"2,420.00","44,188.70",,,,,,
BCBS PPO,DRG,MS-735,PELVIC EVISCERATION -  RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC,Surgical,Relative Weights,"$15,331.95 ",IP,"2,420.00","27,703.87",,,,,,
BCBS PPO,DRG,MS-736,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,Surgical,Relative Weights,"$48,208.28 ",IP,"2,420.00","87,109.34",,,,,,
BCBS PPO,DRG,MS-737,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,Surgical,Relative Weights,"$22,170.07 ",IP,"2,420.00","40,059.94",,,,,,
BCBS PPO,DRG,MS-738,UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY W/O CC/MCC,Surgical,Relative Weights,"$15,384.39 ",IP,"2,420.00","27,798.62",,,,,,
BCBS PPO,DRG,MS-739,UTERINE -ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W MCC,Surgical,Relative Weights,"$41,777.39 ",IP,"2,420.00","75,489.12",,,,,,
BCBS PPO,DRG,MS-740,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,Surgical,Relative Weights,"$19,914.13 ",IP,"2,420.00","35,983.58",,,,,,
BCBS PPO,DRG,MS-741,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$14,833.23 ",IP,"2,420.00","26,802.72",,,,,,
BCBS PPO,DRG,MS-742,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,Surgical,Relative Weights,"$18,849.75 ",IP,"2,420.00","34,060.32",,,,,,
BCBS PPO,DRG,MS-743,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$12,813.81 ",IP,"2,420.00","23,153.76",,,,,,
BCBS PPO,DRG,MS-744,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC,Surgical,Relative Weights,"$19,418.76 ",IP,"2,420.00","35,088.48",,,,,,
BCBS PPO,DRG,MS-745,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC,Surgical,Relative Weights,"$11,885.55 ",IP,"2,420.00","21,476.45",,,,,,
BCBS PPO,DRG,MS-746,VAGINA -  CERVIX AND VULVA PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$18,197.07 ",IP,"2,420.00","32,880.96",,,,,,
BCBS PPO,DRG,MS-747,VAGINA- CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,400.56 ",IP,"2,420.00","18,793.15",,,,,,
BCBS PPO,DRG,MS-748,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,Surgical,Relative Weights,"$14,746.21 ",IP,"2,420.00","26,645.47",,,,,,
BCBS PPO,DRG,MS-749,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$28,921.18 ",IP,"2,420.00","52,258.75",,,,,,
BCBS PPO,DRG,MS-750,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$14,852.20 ",IP,"2,420.00","26,836.99",,,,,,
BCBS PPO,DRG,MS-754,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH MCC,Surgical,Relative Weights,"$19,657.52 ",IP,"2,420.00","35,519.90",,,,,,
BCBS PPO,DRG,MS-755,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH CC,Surgical,Relative Weights,"$11,422.54 ",IP,"2,420.00","20,639.81",,,,,,
BCBS PPO,DRG,MS-756,MALIGNANCY - FEMALE REPRODUCTIVE SYSTEM W/O CC/MCC,Surgical,Relative Weights,"$9,782.46 ",IP,"2,420.00","17,676.29",,,,,,
BCBS PPO,DRG,MS-757,INFECTIONS - FEMALE REPRODUCTIVE SYSTEM W MCC,Surgical,Relative Weights,"$15,846.29 ",IP,"2,420.00","28,633.25",,,,,,
BCBS PPO,DRG,MS-758,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITH CC,Surgical,Relative Weights,"$10,770.97 ",IP,"2,420.00","19,462.46",,,,,,
BCBS PPO,DRG,MS-759,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Surgical,Relative Weights,"$7,366.97 ",IP,"2,420.00","13,311.65",,,,,,
BCBS PPO,DRG,MS-760,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,Surgical,Relative Weights,"$10,069.19 ",IP,"2,420.00","18,194.40",,,,,,
BCBS PPO,DRG,MS-761,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$6,308.17 ",IP,"2,420.00","11,398.46",,,,,,
BCBS PPO,DRG,MS-768,VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C,Surgical,Relative Weights,"$11,240.68 ",IP,"2,420.00","20,311.20",,,,,,
BCBS PPO,DRG,MS-769,POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,Surgical,Relative Weights,"$16,099.55 ",IP,"2,420.00","29,090.88",,,,,,
BCBS PPO,DRG,MS-770,ABORTION WITH D&C- ASPIRATION CURETTAGE OR HYSTEROTOMY,Surgical,Relative Weights,"$8,772.75 ",IP,"2,420.00","15,851.81",,,,,,
BCBS PPO,DRG,MS-776,POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,Surgical,Relative Weights,"$7,920.35 ",IP,"2,420.00","14,311.58",,,,,,
BCBS PPO,DRG,MS-779,ABORTION WITHOUT D&C,Surgical,Relative Weights,"$12,739.06 ",IP,"2,420.00","23,018.69",,,,,,
BCBS PPO,DRG,MS-783,CESAREAN SECTION WITH STERILIZATION WITH MCC,Surgical,Relative Weights,"$23,929.53 ",IP,"2,420.00","43,239.17",,,,,,
BCBS PPO,DRG,MS-784,CESAREAN SECTION WITH STERILIZATION WITH CC,Surgical,Relative Weights,"$11,661.30 ",IP,"2,420.00","21,071.23",,,,,,
BCBS PPO,DRG,MS-785,CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,Surgical,Relative Weights,"$9,577.17 ",IP,"2,420.00","17,305.34",,,,,,
BCBS PPO,DRG,MS-786,CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,Surgical,Relative Weights,"$19,128.68 ",IP,"2,420.00","34,564.32",,,,,,
BCBS PPO,DRG,MS-787,CESAREAN SECTION WITHOUT STERILIZATION WITH CC,Surgical,Relative Weights,"$11,664.64 ",IP,"2,420.00","21,077.28",,,,,,
BCBS PPO,DRG,MS-788,CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,Surgical,Relative Weights,"$10,110.47 ",IP,"2,420.00","18,268.99",,,,,,
BCBS PPO,DRG,MS-789,NEONATES- DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY,Surgical,Relative Weights,"$18,855.33 ",IP,"2,420.00","34,070.40",,,,,,
BCBS PPO,DRG,MS-790,EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME- NEONATE,Surgical,Relative Weights,"$62,177.96 ",IP,"2,420.00","112,351.68",,,,,,
BCBS PPO,DRG,MS-791,PREMATURITY W MAJOR PROBLEMS,Surgical,Relative Weights,"$42,465.77 ",IP,"2,420.00","76,732.99",,,,,,
BCBS PPO,DRG,MS-792,PREMATURITY W/O MAJOR PROBLEMS,Surgical,Relative Weights,"$25,622.05 ",IP,"2,420.00","46,297.44",,,,,,
BCBS PPO,DRG,MS-793,FULL TERM NEONATE WITH MAJOR PROBLEMS,Surgical,Relative Weights,"$43,620.52 ",IP,"2,420.00","78,819.55",,,,,,
BCBS PPO,DRG,MS-794,NEONATE WITH OTHER SIGNIFICANT PROBLEMS,Surgical,Relative Weights,"$15,439.06 ",IP,"2,420.00","27,897.41",,,,,,
BCBS PPO,DRG,MS-795,NORMAL NEWBORN,Surgical,Relative Weights,"$2,089.71 ",IP,"1,113.70","3,775.97",,,,,,
BCBS PPO,DRG,MS-796,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,Surgical,Relative Weights,"$22,004.95 ",IP,"2,420.00","39,761.57",,,,,,
BCBS PPO,DRG,MS-797,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,Surgical,Relative Weights,"$9,626.26 ",IP,"2,420.00","17,394.05",,,,,,
BCBS PPO,DRG,MS-798,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,Surgical,Relative Weights,"$9,626.26 ",IP,"2,420.00","17,394.05",,,,,,
BCBS PPO,DRG,MS-799,SPLENECTOMY WITH MCC,Surgical,Relative Weights,"$55,163.56 ",IP,"2,420.00","99,677.09",,,,,,
BCBS PPO,DRG,MS-800,SPLENECTOMY WITH CC,Surgical,Relative Weights,"$31,708.19 ",IP,"2,420.00","57,294.72",,,,,,
BCBS PPO,DRG,MS-801,SPLENECTOMY WITHOUT CC/MCC,Surgical,Relative Weights,"$20,899.29 ",IP,"2,420.00","37,763.71",,,,,,
BCBS PPO,DRG,MS-802,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,Surgical,Relative Weights,"$35,171.33 ",IP,"2,420.00","63,552.38",,,,,,
BCBS PPO,DRG,MS-803,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,Surgical,Relative Weights,"$19,877.31 ",IP,"2,420.00","35,917.06",,,,,,
BCBS PPO,DRG,MS-804,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,Surgical,Relative Weights,"$15,202.53 ",IP,"2,420.00","27,470.02",,,,,,
BCBS PPO,DRG,MS-805,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,Surgical,Relative Weights,"$11,611.09 ",IP,"2,420.00","20,980.51",,,,,,
BCBS PPO,DRG,MS-806,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,Surgical,Relative Weights,"$7,912.54 ",IP,"2,420.00","14,297.47",,,,,,
BCBS PPO,DRG,MS-807,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,Surgical,Relative Weights,"$6,993.21 ",IP,"2,420.00","12,636.29",,,,,,
BCBS PPO,DRG,MS-808,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,Surgical,Relative Weights,"$23,759.95 ",IP,"2,420.00","42,932.74",,,,,,
BCBS PPO,DRG,MS-809,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,Surgical,Relative Weights,"$13,565.80 ",IP,"2,420.00","24,512.54",,,,,,
BCBS PPO,DRG,MS-810,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$10,436.26 ",IP,"2,420.00","18,857.66",,,,,,
BCBS PPO,DRG,MS-811,RED BLOOD CELL DISORDERS WITH MCC,Surgical,Relative Weights,"$14,953.73 ",IP,"2,420.00","27,020.45",,,,,,
BCBS PPO,DRG,MS-812,RED BLOOD CELL DISORDERS WITHOUT MCC,Surgical,Relative Weights,"$9,714.40 ",IP,"2,420.00","17,553.31",,,,,,
BCBS PPO,DRG,MS-813,COAGULATION DISORDERS,Surgical,Relative Weights,"$17,686.08 ",IP,"2,420.00","31,957.63",,,,,,
BCBS PPO,DRG,MS-814,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,Surgical,Relative Weights,"$19,514.71 ",IP,"2,420.00","35,261.86",,,,,,
BCBS PPO,DRG,MS-815,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,Surgical,Relative Weights,"$11,299.81 ",IP,"2,420.00","20,418.05",,,,,,
BCBS PPO,DRG,MS-816,RETICULOENDOTHELIAL & IMMUNITY DISORDERS W/O CC/MCC,Surgical,Relative Weights,"$7,987.30 ",IP,"2,420.00","14,432.54",,,,,,
BCBS PPO,DRG,MS-817,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$28,073.24 ",IP,"2,420.00","50,726.59",,,,,,
BCBS PPO,DRG,MS-818,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$14,212.90 ",IP,"2,420.00","25,681.82",,,,,,
BCBS PPO,DRG,MS-819,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,902.17 ",IP,"2,420.00","16,085.66",,,,,,
BCBS PPO,DRG,MS-820,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$63,781.22 ",IP,"2,420.00","115,248.67",,,,,,
BCBS PPO,DRG,MS-821,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$24,905.77 ",IP,"2,420.00","45,003.17",,,,,,
BCBS PPO,DRG,MS-822,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$14,106.91 ",IP,"2,420.00","25,490.30",,,,,,
BCBS PPO,DRG,MS-823,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,Surgical,Relative Weights,"$47,196.34 ",IP,"2,420.00","85,280.83",,,,,,
BCBS PPO,DRG,MS-824,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,Surgical,Relative Weights,"$25,941.14 ",IP,"2,420.00","46,874.02",,,,,,
BCBS PPO,DRG,MS-825,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$15,112.16 ",IP,"2,420.00","27,306.72",,,,,,
BCBS PPO,DRG,MS-826,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$55,952.36 ",IP,"2,420.00","101,102.40",,,,,,
BCBS PPO,DRG,MS-827,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$25,841.84 ",IP,"2,420.00","46,694.59",,,,,,
BCBS PPO,DRG,MS-828,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$18,422.44 ",IP,"2,420.00","33,288.19",,,,,,
BCBS PPO,DRG,MS-829,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$35,031.86 ",IP,"2,420.00","63,300.38",,,,,,
BCBS PPO,DRG,MS-830,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$15,383.27 ",IP,"2,420.00","27,796.61",,,,,,
BCBS PPO,DRG,MS-831,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$12,032.82 ",IP,"2,420.00","21,742.56",,,,,,
BCBS PPO,DRG,MS-832,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$7,982.83 ",IP,"2,420.00","14,424.48",,,,,,
BCBS PPO,DRG,MS-833,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$5,936.64 ",IP,"2,420.00","10,727.14",,,,,,
BCBS PPO,DRG,MS-834,ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W MCC,Surgical,Relative Weights,"$65,184.77 ",IP,"2,420.00","117,784.80",,,,,,
BCBS PPO,DRG,MS-835,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$22,628.63 ",IP,"2,420.00","40,888.51",,,,,,
BCBS PPO,DRG,MS-836,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$14,700.46 ",IP,"2,420.00","26,562.82",,,,,,
BCBS PPO,DRG,MS-837,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,Surgical,Relative Weights,"$66,839.36 ",IP,"2,420.00","120,774.53",,,,,,
BCBS PPO,DRG,MS-838,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,Surgical,Relative Weights,"$24,410.40 ",IP,"2,420.00","44,108.06",,,,,,
BCBS PPO,DRG,MS-839,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$14,238.56 ",IP,"2,420.00","25,728.19",,,,,,
BCBS PPO,DRG,MS-840,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,Surgical,Relative Weights,"$35,648.85 ",IP,"2,420.00","64,415.23",,,,,,
BCBS PPO,DRG,MS-841,LYMPHOMA & NON-ACUTE LEUKEMIA W CC,Surgical,Relative Weights,"$17,981.74 ",IP,"2,420.00","32,491.87",,,,,,
BCBS PPO,DRG,MS-842,LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,Surgical,Relative Weights,"$12,792.62 ",IP,"2,420.00","23,115.46",,,,,,
BCBS PPO,DRG,MS-843,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,Surgical,Relative Weights,"$21,285.32 ",IP,"2,420.00","38,461.25",,,,,,
BCBS PPO,DRG,MS-844,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,Surgical,Relative Weights,"$13,477.66 ",IP,"2,420.00","24,353.28",,,,,,
BCBS PPO,DRG,MS-845,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,Surgical,Relative Weights,"$9,660.85 ",IP,"2,420.00","17,456.54",,,,,,
BCBS PPO,DRG,MS-846,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$29,304.98 ",IP,"2,420.00","52,952.26",,,,,,
BCBS PPO,DRG,MS-847,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,Surgical,Relative Weights,"$14,681.50 ",IP,"2,420.00","26,528.54",,,,,,
BCBS PPO,DRG,MS-848,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$10,949.48 ",IP,"2,420.00","19,785.02",,,,,,
BCBS PPO,DRG,MS-849,RADIOTHERAPY,Surgical,Relative Weights,"$23,717.55 ",IP,"2,420.00","42,856.13",,,,,,
BCBS PPO,DRG,MS-853,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$56,885.08 ",IP,"2,420.00","102,787.78",,,,,,
BCBS PPO,DRG,MS-854,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$24,112.51 ",IP,"2,420.00","43,569.79",,,,,,
BCBS PPO,DRG,MS-855,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$17,888.02 ",IP,"2,420.00","32,322.53",,,,,,
BCBS PPO,DRG,MS-856,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$49,377.53 ",IP,"2,420.00","89,222.11",,,,,,
BCBS PPO,DRG,MS-857,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$22,685.53 ",IP,"2,420.00","40,991.33",,,,,,
BCBS PPO,DRG,MS-858,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$15,356.49 ",IP,"2,420.00","27,748.22",,,,,,
BCBS PPO,DRG,MS-862,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W MCC,Surgical,Relative Weights,"$20,647.14 ",IP,"2,420.00","37,308.10",,,,,,
BCBS PPO,DRG,MS-863,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W/O MCC,Surgical,Relative Weights,"$11,023.12 ",IP,"2,420.00","19,918.08",,,,,,
BCBS PPO,DRG,MS-864,FEVER AND INFLAMMATORY CONDITIONS,Surgical,Relative Weights,"$9,454.44 ",IP,"2,420.00","17,083.58",,,,,,
BCBS PPO,DRG,MS-865,VIRAL ILLNESS WITH MCC,Surgical,Relative Weights,"$15,545.05 ",IP,"2,420.00","28,088.93",,,,,,
BCBS PPO,DRG,MS-866,VIRAL ILLNESS WITHOUT MCC,Surgical,Relative Weights,"$9,134.24 ",IP,"2,420.00","16,504.99",,,,,,
BCBS PPO,DRG,MS-867,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,Surgical,Relative Weights,"$24,380.28 ",IP,"2,420.00","44,053.63",,,,,,
BCBS PPO,DRG,MS-868,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,Surgical,Relative Weights,"$12,239.23 ",IP,"2,420.00","22,115.52",,,,,,
BCBS PPO,DRG,MS-869,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,284.07 ",IP,"2,420.00","14,968.80",,,,,,
BCBS PPO,DRG,MS-870,SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,Surgical,Relative Weights,"$70,560.22 ",IP,"2,420.00","127,497.89",,,,,,
BCBS PPO,DRG,MS-871,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,Surgical,Relative Weights,"$20,822.31 ",IP,"2,420.00","37,624.61",,,,,,
BCBS PPO,DRG,MS-872,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,Surgical,Relative Weights,"$11,595.47 ",IP,"2,420.00","20,952.29",,,,,,
BCBS PPO,DRG,MS-876,O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,Surgical,Relative Weights,"$40,611.48 ",IP,"2,420.00","73,382.40",,,,,,
BCBS PPO,DRG,MS-880,ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,Surgical,Relative Weights,"$9,560.43 ",IP,"2,420.00","17,275.10",,,,,,
BCBS PPO,DRG,MS-881,DEPRESSIVE NEUROSES,Surgical,Relative Weights,"$9,140.93 ",IP,"2,420.00","16,517.09",,,,,,
BCBS PPO,DRG,MS-882,NEUROSES EXCEPT DEPRESSIVE,Surgical,Relative Weights,"$8,811.80 ",IP,"2,420.00","15,922.37",,,,,,
BCBS PPO,DRG,MS-883,DISORDERS OF PERSONALITY & IMPULSE CONTROL,Surgical,Relative Weights,"$14,912.45 ",IP,"2,420.00","26,945.86",,,,,,
BCBS PPO,DRG,MS-884,ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,Surgical,Relative Weights,"$16,043.77 ",IP,"2,420.00","28,990.08",,,,,,
BCBS PPO,DRG,MS-885,PSYCHOSES,Surgical,Relative Weights,"$13,560.22 ",IP,"2,420.00","24,502.46",,,,,,
BCBS PPO,DRG,MS-886,BEHAVIORAL AND DEVELOPMENTAL DISORDERS,Surgical,Relative Weights,"$15,012.86 ",IP,"2,420.00","27,127.30",,,,,,
BCBS PPO,DRG,MS-887,OTHER MENTAL DISORDER DIAGNOSES,Surgical,Relative Weights,"$12,139.93 ",IP,"2,420.00","21,936.10",,,,,,
BCBS PPO,DRG,MS-894,ALCOHOL- DRUG ABUSE OR DEPENDENCE- LEFT AMA,Surgical,Relative Weights,"$6,475.52 ",IP,"2,420.00","11,700.86",,,,,,
BCBS PPO,DRG,MS-895,ALCOHOL- DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY,Surgical,Relative Weights,"$18,151.32 ",IP,"2,420.00","32,798.30",,,,,,
BCBS PPO,DRG,MS-896,ALCOHOL -  DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC,Surgical,Relative Weights,"$19,186.69 ",IP,"2,420.00","34,669.15",,,,,,
BCBS PPO,DRG,MS-897,ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC,Surgical,Relative Weights,"$9,168.82 ",IP,"2,420.00","16,567.49",,,,,,
BCBS PPO,DRG,MS-901,WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,Surgical,Relative Weights,"$48,278.57 ",IP,"2,420.00","87,236.35",,,,,,
BCBS PPO,DRG,MS-902,WOUND DEBRIDEMENTS FOR INJURIES WITH CC,Surgical,Relative Weights,"$21,944.70 ",IP,"2,420.00","39,652.70",,,,,,
BCBS PPO,DRG,MS-903,WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,Surgical,Relative Weights,"$12,763.61 ",IP,"2,420.00","23,063.04",,,,,,
BCBS PPO,DRG,MS-904,SKIN GRAFTS FOR INJURIES WITH CC/MCC,Surgical,Relative Weights,"$39,466.77 ",IP,"2,420.00","71,313.98",,,,,,
BCBS PPO,DRG,MS-905,SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,Surgical,Relative Weights,"$18,569.71 ",IP,"2,420.00","33,554.30",,,,,,
BCBS PPO,DRG,MS-906,HAND PROCEDURES FOR INJURIES,Surgical,Relative Weights,"$19,423.22 ",IP,"2,420.00","35,096.54",,,,,,
BCBS PPO,DRG,MS-907,OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,Surgical,Relative Weights,"$44,511.97 ",IP,"2,420.00","80,430.34",,,,,,
BCBS PPO,DRG,MS-908,OTHER O.R. PROCEDURES FOR INJURIES WITH CC,Surgical,Relative Weights,"$23,018.01 ",IP,"2,420.00","41,592.10",,,,,,
BCBS PPO,DRG,MS-909,OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,Surgical,Relative Weights,"$14,712.74 ",IP,"2,420.00","26,584.99",,,,,,
BCBS PPO,DRG,MS-913,TRAUMATIC INJURY WITH MCC,Surgical,Relative Weights,"$16,471.08 ",IP,"2,420.00","29,762.21",,,,,,
BCBS PPO,DRG,MS-914,TRAUMATIC INJURY WITHOUT MCC,Surgical,Relative Weights,"$9,613.99 ",IP,"2,420.00","17,371.87",,,,,,
BCBS PPO,DRG,MS-915,ALLERGIC REACTIONS WITH MCC,Surgical,Relative Weights,"$18,956.86 ",IP,"2,420.00","34,253.86",,,,,,
BCBS PPO,DRG,MS-916,ALLERGIC REACTIONS WITHOUT MCC,Surgical,Relative Weights,"$7,064.61 ",IP,"2,420.00","12,765.31",,,,,,
BCBS PPO,DRG,MS-917,POISONING & TOXIC EFFECTS OF DRUGS W MCC,Surgical,Relative Weights,"$16,324.92 ",IP,"2,420.00","29,498.11",,,,,,
BCBS PPO,DRG,MS-918,POISONING & TOXIC EFFECTS OF DRUGS W/O MCC,Surgical,Relative Weights,"$8,747.09 ",IP,"2,420.00","15,805.44",,,,,,
BCBS PPO,DRG,MS-919,COMPLICATIONS OF TREATMENT WITH MCC,Surgical,Relative Weights,"$20,364.87 ",IP,"2,420.00","36,798.05",,,,,,
BCBS PPO,DRG,MS-920,COMPLICATIONS OF TREATMENT WITH CC,Surgical,Relative Weights,"$11,240.68 ",IP,"2,420.00","20,311.20",,,,,,
BCBS PPO,DRG,MS-921,COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,Surgical,Relative Weights,"$7,705.02 ",IP,"2,420.00","13,922.50",,,,,,
BCBS PPO,DRG,MS-922,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC,Surgical,Relative Weights,"$17,891.37 ",IP,"2,420.00","32,328.58",,,,,,
BCBS PPO,DRG,MS-923,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC,Surgical,Relative Weights,"$9,656.38 ",IP,"2,420.00","17,448.48",,,,,,
BCBS PPO,DRG,MS-927,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,Surgical,Relative Weights,"$222,509.63 ",IP,"2,420.00","402,060.96",,,,,,
BCBS PPO,DRG,MS-928,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,Surgical,Relative Weights,"$69,116.50 ",IP,"2,420.00","124,889.18",,,,,,
BCBS PPO,DRG,MS-929,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,Surgical,Relative Weights,"$32,818.32 ",IP,"2,420.00","59,300.64",,,,,,
BCBS PPO,DRG,MS-933,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,Surgical,Relative Weights,"$35,035.21 ",IP,"2,420.00","63,306.43",,,,,,
BCBS PPO,DRG,MS-934,FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,Surgical,Relative Weights,"$20,191.94 ",IP,"2,420.00","36,485.57",,,,,,
BCBS PPO,DRG,MS-935,NON-EXTENSIVE BURNS,Surgical,Relative Weights,"$21,558.67 ",IP,"2,420.00","38,955.17",,,,,,
BCBS PPO,DRG,MS-939,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,Surgical,Relative Weights,"$40,772.14 ",IP,"2,420.00","73,672.70",,,,,,
BCBS PPO,DRG,MS-940,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,Surgical,Relative Weights,"$25,346.47 ",IP,"2,420.00","45,799.49",,,,,,
BCBS PPO,DRG,MS-941,O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W/O CC/MCC,Surgical,Relative Weights,"$21,540.82 ",IP,"2,420.00","38,922.91",,,,,,
BCBS PPO,DRG,MS-945,REHABILITATION WITH CC/MCC,Surgical,Relative Weights,"$16,236.78 ",IP,"2,420.00","29,338.85",,,,,,
BCBS PPO,DRG,MS-946,REHABILITATION WITHOUT CC/MCC,Surgical,Relative Weights,"$12,127.66 ",IP,"2,420.00","21,913.92",,,,,,
BCBS PPO,DRG,MS-947,SIGNS AND SYMPTOMS WITH MCC,Surgical,Relative Weights,"$13,358.28 ",IP,"2,420.00","24,137.57",,,,,,
BCBS PPO,DRG,MS-948,SIGNS AND SYMPTOMS WITHOUT MCC,Surgical,Relative Weights,"$8,698.00 ",IP,"2,420.00","15,716.74",,,,,,
BCBS PPO,DRG,MS-949,AFTERCARE WITH CC/MCC,Surgical,Relative Weights,"$12,148.86 ",IP,"2,420.00","21,952.22",,,,,,
BCBS PPO,DRG,MS-950,AFTERCARE WITHOUT CC/MCC,Surgical,Relative Weights,"$8,266.22 ",IP,"2,420.00","14,936.54",,,,,,
BCBS PPO,DRG,MS-951,OTHER FACTORS INFLUENCING HEALTH STATUS,Surgical,Relative Weights,"$6,543.58 ",IP,"2,420.00","11,823.84",,,,,,
BCBS PPO,DRG,MS-955,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,Surgical,Relative Weights,"$67,840.14 ",IP,"2,420.00","122,582.88",,,,,,
BCBS PPO,DRG,MS-956,LIMB REATTACHMENT- HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,Surgical,Relative Weights,"$43,772.26 ",IP,"2,420.00","79,093.73",,,,,,
BCBS PPO,DRG,MS-957,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Surgical,Relative Weights,"$84,053.49 ",IP,"2,420.00","151,879.39",,,,,,
BCBS PPO,DRG,MS-958,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,Surgical,Relative Weights,"$46,757.87 ",IP,"2,420.00","84,488.54",,,,,,
BCBS PPO,DRG,MS-959,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,Surgical,Relative Weights,"$31,245.18 ",IP,"2,420.00","56,458.08",,,,,,
BCBS PPO,DRG,MS-963,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Surgical,Relative Weights,"$30,403.94 ",IP,"2,420.00","54,938.02",,,,,,
BCBS PPO,DRG,MS-964,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,Surgical,Relative Weights,"$16,662.98 ",IP,"2,420.00","30,108.96",,,,,,
BCBS PPO,DRG,MS-965,OTHER MULTIPLE SIGNIFICANT TRAUMA W/O CC/MCC,Surgical,Relative Weights,"$10,232.08 ",IP,"2,420.00","18,488.74",,,,,,
BCBS PPO,DRG,MS-969,HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$64,740.72 ",IP,"2,420.00","116,982.43",,,,,,
BCBS PPO,DRG,MS-970,HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$32,544.97 ",IP,"2,420.00","58,806.72",,,,,,
BCBS PPO,DRG,MS-974,HIV WITH MAJOR RELATED CONDITION WITH MCC,Surgical,Relative Weights,"$29,832.70 ",IP,"2,420.00","53,905.82",,,,,,
BCBS PPO,DRG,MS-975,HIV WITH MAJOR RELATED CONDITION WITH CC,Surgical,Relative Weights,"$14,972.69 ",IP,"2,420.00","27,054.72",,,,,,
BCBS PPO,DRG,MS-976,HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,Surgical,Relative Weights,"$10,199.73 ",IP,"2,420.00","18,430.27",,,,,,
BCBS PPO,DRG,MS-977,HIV WITH OR WITHOUT OTHER RELATED CONDITION,Surgical,Relative Weights,"$14,509.68 ",IP,"2,420.00","26,218.08",,,,,,
BCBS PPO,DRG,MS-981,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$50,102.74 ",IP,"2,420.00","90,532.51",,,,,,
BCBS PPO,DRG,MS-982,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Surgical,Relative Weights,"$27,201.88 ",IP,"2,420.00","49,152.10",,,,,,
BCBS PPO,DRG,MS-983,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$18,265.12 ",IP,"2,420.00","33,003.94",,,,,,
BCBS PPO,DRG,MS-987,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$37,194.09 ",IP,"2,420.00","67,207.39",,,,,,
BCBS PPO,DRG,MS-988,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Surgical,Relative Weights,"$19,171.07 ",IP,"2,420.00","34,640.93",,,,,,
BCBS PPO,DRG,MS-989,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$12,857.33 ",IP,"2,420.00","23,232.38",,,,,,
BCBS PPO,CPT,1996,,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,,,,,,,,
BCBS PPO,CPT,11970,Rplcmt tiss xpndr perm implt,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,11970,Rplcmt tiss xpndr perm implt,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,15732,Muscle-skin graft head/neck,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,15732,Muscle-skin graft head/neck,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,15733,Musc myoq/fscq flp h&n pedcl,,Per Case,"$4,871.00 ",OP,"3,604.28","9,201.00",,,,,,
BCBS PPO,CPT,15733,Musc myoq/fscq flp h&n pedcl,,Per Case,"$9,201.00 ",OP,"3,604.28","9,201.00",,,,,,
BCBS PPO,CPT,15830,Exc skin abd,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,15830,Exc skin abd,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,19297,Place breast cath for rad,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,19297,Place breast cath for rad,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,19300,Removal of breast tissue,,Per Case,"$4,871.00 ",OP,"3,231.37","9,201.00",,,,,,
BCBS PPO,CPT,19300,Removal of breast tissue,,Per Case,"$9,201.00 ",OP,"3,231.37","9,201.00",,,,,,
BCBS PPO,CPT,19307,Mast mod rad,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,19307,Mast mod rad,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,19318,Breast reduction,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,19318,Breast reduction,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,19340,Insj breast implt sm d mast,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,19340,Insj breast implt sm d mast,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,19357,Tiss xpndr plmt brst rcnstj,,Per Case,"$4,871.00 ",OP,"4,140.35","15,276.83",,,,,,
BCBS PPO,CPT,19357,Tiss xpndr plmt brst rcnstj,,Per Case,"$9,201.00 ",OP,"4,140.35","15,276.83",,,,,,
BCBS PPO,CPT,21193,Reconst lwr jaw w/o graft,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,21193,Reconst lwr jaw w/o graft,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,21462,Treat lower jaw fracture,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,21462,Treat lower jaw fracture,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,22510,Perq cervicothoracic inject,,Per Case,"$9,201.00 ",OP,"2,896.40","15,496.26",,,,,,
BCBS PPO,CPT,22510,Perq cervicothoracic inject,All Other,Per Unit,"$15,496.26 ",OP,"2,896.40","15,496.26",,,,,,
BCBS PPO,CPT,22510,Perq cervicothoracic inject,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,896.40","15,496.26",,,,,,
BCBS PPO,CPT,22511,Perq lumbosacral injection,,Per Case,"$4,871.00 ",OP,"2,896.40","9,201.00",,,,,,
BCBS PPO,CPT,22511,Perq lumbosacral injection,,Per Case,"$9,201.00 ",OP,"2,896.40","9,201.00",,,,,,
BCBS PPO,CPT,22512,Vertebroplasty addl inject,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,612.76","4,314.00",,,,,,
BCBS PPO,CPT,22551,Neck spine fuse&remov bel c2,,Per Case,"$4,871.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS PPO,CPT,22551,Neck spine fuse&remov bel c2,,Per Case,"$9,201.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS PPO,CPT,22856,Cerv artific diskectomy,,Per Case,"$4,871.00 ",OP,"4,140.35","16,238.16",,,,,,
BCBS PPO,CPT,22856,Cerv artific diskectomy,,Per Case,"$9,201.00 ",OP,"4,140.35","16,238.16",,,,,,
BCBS PPO,CPT,23410,Repair rotator cuff acute,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,23410,Repair rotator cuff acute,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,23412,Repair rotator cuff chronic,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,23412,Repair rotator cuff chronic,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,23420,Repair of shoulder,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,23420,Repair of shoulder,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,23460,Repair shoulder capsule,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,23460,Repair shoulder capsule,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,23515,Treat clavicle fracture,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,23515,Treat clavicle fracture,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,23585,Treat scapula fracture,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,23585,Treat scapula fracture,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,23615,Treat humerus fracture,,Per Case,"$4,871.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS PPO,CPT,23615,Treat humerus fracture,,Per Case,"$9,201.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS PPO,CPT,24515,Treat humerus fracture,,Per Case,"$4,871.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS PPO,CPT,24515,Treat humerus fracture,,Per Case,"$9,201.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS PPO,CPT,24545,Treat humerus fracture,,Per Case,"$4,871.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS PPO,CPT,24545,Treat humerus fracture,,Per Case,"$9,201.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS PPO,CPT,24666,Treat radius fracture,,Per Case,"$4,871.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS PPO,CPT,24666,Treat radius fracture,,Per Case,"$9,201.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS PPO,CPT,25151,Partial removal of radius,,Per Case,"$4,871.00 ",OP,"2,896.40","9,201.00",,,,,,
BCBS PPO,CPT,25151,Partial removal of radius,,Per Case,"$9,201.00 ",OP,"2,896.40","9,201.00",,,,,,
BCBS PPO,CPT,25607,Treat fx rad extra-articul,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,25607,Treat fx rad extra-articul,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,25608,Treat fx rad intra-articul,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,25608,Treat fx rad intra-articul,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,25609,Treat fx radial 3+ frag,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,25609,Treat fx radial 3+ frag,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,26370,Repair finger/hand tendon,,Per Case,"$4,871.00 ",OP,"2,896.40","9,201.00",,,,,,
BCBS PPO,CPT,26370,Repair finger/hand tendon,,Per Case,"$9,201.00 ",OP,"2,896.40","9,201.00",,,,,,
BCBS PPO,CPT,27405,Repair of knee ligament,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,27405,Repair of knee ligament,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,27407,Repair of knee ligament,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,27407,Repair of knee ligament,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,27409,Repair of knee ligaments,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,27409,Repair of knee ligaments,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,27427,Reconstruction knee,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,27427,Reconstruction knee,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,27428,Reconstruction knee,,Per Case,"$4,871.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS PPO,CPT,27428,Reconstruction knee,,Per Case,"$9,201.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS PPO,CPT,27429,Reconstruction knee,,Per Case,"$4,871.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS PPO,CPT,27429,Reconstruction knee,,Per Case,"$9,201.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS PPO,CPT,27446,Revision of knee joint,,Per Case,"$4,871.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS PPO,CPT,27446,Revision of knee joint,,Per Case,"$9,201.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS PPO,CPT,27652,Repair/graft achilles tendon,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,27652,Repair/graft achilles tendon,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,27654,Repair of achilles tendon,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,27654,Repair of achilles tendon,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,27691,Revise lower leg tendon,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,27691,Revise lower leg tendon,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,27724,Repair/graft of tibia,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,27724,Repair/graft of tibia,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,27726,Repair fibula nonunion,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,27726,Repair fibula nonunion,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,27758,Treatment of tibia fracture,,Per Case,"$4,871.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS PPO,CPT,27758,Treatment of tibia fracture,,Per Case,"$9,201.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS PPO,CPT,27814,Treatment of ankle fracture,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,27814,Treatment of ankle fracture,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,27828,Treat lower leg fracture,,Per Case,"$4,871.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS PPO,CPT,27828,Treat lower leg fracture,,Per Case,"$9,201.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS PPO,CPT,27870,Fusion of ankle joint open,,Per Case,"$4,871.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS PPO,CPT,27870,Fusion of ankle joint open,,Per Case,"$9,201.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS PPO,CPT,27871,Fusion of tibiofibular joint,,Per Case,"$4,871.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS PPO,CPT,27871,Fusion of tibiofibular joint,,Per Case,"$9,201.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS PPO,CPT,28238,Revision of foot tendon,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,28238,Revision of foot tendon,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,28300,Incision of heel bone,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,28300,Incision of heel bone,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,28715,Fusion of foot bones,,Per Case,"$4,871.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS PPO,CPT,28715,Fusion of foot bones,,Per Case,"$9,201.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS PPO,CPT,28725,Fusion of foot bones,,Per Case,"$4,871.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS PPO,CPT,28725,Fusion of foot bones,,Per Case,"$9,201.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS PPO,CPT,28730,Fusion of foot bones,,Per Case,"$4,871.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS PPO,CPT,28730,Fusion of foot bones,,Per Case,"$9,201.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS PPO,CPT,28740,Fusion of foot bones,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,28740,Fusion of foot bones,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,28750,Fusion of big toe joint,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,28750,Fusion of big toe joint,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,29000,Application of body cast,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,246.8,"4,314.00",,,,,,
BCBS PPO,CPT,29010,Application of body cast,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,246.8,"4,314.00",,,,,,
BCBS PPO,CPT,29015,Application of body cast,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,246.8,"4,314.00",,,,,,
BCBS PPO,CPT,29020,Application of body cast,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,277.26","4,314.00",,,,,,
BCBS PPO,CPT,29025,Application of body cast,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,483.14","4,314.00",,,,,,
BCBS PPO,CPT,29035,Application of body cast,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,246.8,"4,314.00",,,,,,
BCBS PPO,CPT,29040,Application of body cast,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,246.8,"4,314.00",,,,,,
BCBS PPO,CPT,29044,Application of body cast,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,144.47,"4,314.00",,,,,,
BCBS PPO,CPT,29046,Application of body cast,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,246.8,"4,314.00",,,,,,
BCBS PPO,CPT,29049,Application of figure eight,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,246.8,"4,314.00",,,,,,
BCBS PPO,CPT,29055,Application of shoulder cast,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,246.8,"4,314.00",,,,,,
BCBS PPO,CPT,29058,Application of shoulder cast,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,246.8,"4,314.00",,,,,,
BCBS PPO,CPT,29065,Application of long arm cast,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,246.8,"4,314.00",,,,,,
BCBS PPO,CPT,29075,Application of forearm cast,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,246.8,"4,314.00",,,,,,
BCBS PPO,CPT,29085,Apply hand/wrist cast,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,144.47,"4,314.00",,,,,,
BCBS PPO,CPT,29086,Apply finger cast,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,144.47,"4,314.00",,,,,,
BCBS PPO,CPT,29105,Apply long arm splint,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,144.47,"4,314.00",,,,,,
BCBS PPO,CPT,29125,Apply forearm splint,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,"4,314.00",,,,,,
BCBS PPO,CPT,29126,Apply forearm splint,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,"4,314.00",,,,,,
BCBS PPO,CPT,29130,Application of finger splint,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,"4,314.00",,,,,,
BCBS PPO,CPT,29131,Application of finger splint,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,56.95,"4,314.00",,,,,,
BCBS PPO,CPT,29200,Strapping of chest,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,144.47,"4,314.00",,,,,,
BCBS PPO,CPT,29220,Strapping of low back,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,301.2,"4,314.00",,,,,,
BCBS PPO,CPT,29240,Strapping of shoulder,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,"4,314.00",,,,,,
BCBS PPO,CPT,29260,Strapping of elbow or wrist,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,56.95,"4,314.00",,,,,,
BCBS PPO,CPT,29280,Strapping of hand or finger,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,56.95,"4,314.00",,,,,,
BCBS PPO,CPT,29305,Application of hip cast,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,246.8,"4,314.00",,,,,,
BCBS PPO,CPT,29325,Application of hip casts,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,246.8,"4,314.00",,,,,,
BCBS PPO,CPT,29345,Application of long leg cast,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,246.8,"4,314.00",,,,,,
BCBS PPO,CPT,29355,Application of long leg cast,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,246.8,"4,314.00",,,,,,
BCBS PPO,CPT,29358,Apply long leg cast brace,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,246.8,"4,314.00",,,,,,
BCBS PPO,CPT,29365,Application of long leg cast,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,246.8,"4,314.00",,,,,,
BCBS PPO,CPT,29405,Apply short leg cast,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,246.8,"4,314.00",,,,,,
BCBS PPO,CPT,29425,Apply short leg cast,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,246.8,"4,314.00",,,,,,
BCBS PPO,CPT,29435,Apply short leg cast,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,246.8,"4,314.00",,,,,,
BCBS PPO,CPT,29440,Addition of walker to cast,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,144.47,"4,314.00",,,,,,
BCBS PPO,CPT,29445,Apply rigid leg cast,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,246.8,"4,314.00",,,,,,
BCBS PPO,CPT,29450,Application of leg cast,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,144.47,"4,314.00",,,,,,
BCBS PPO,CPT,29505,Application long leg splint,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,144.47,"4,314.00",,,,,,
BCBS PPO,CPT,29515,Application lower leg splint,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,144.47,"4,314.00",,,,,,
BCBS PPO,CPT,29530,Strapping of knee,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,"4,314.00",,,,,,
BCBS PPO,CPT,29540,Strapping of ankle and/or ft,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,144.47,"4,314.00",,,,,,
BCBS PPO,CPT,29550,Strapping of toes,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,56.95,"4,314.00",,,,,,
BCBS PPO,CPT,29580,Application of paste boot,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,144.47,"4,314.00",,,,,,
BCBS PPO,CPT,29590,Application of foot splint,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,324.09,"4,314.00",,,,,,
BCBS PPO,CPT,29700,Removal/revision of cast,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,246.8,"4,314.00",,,,,,
BCBS PPO,CPT,29705,Removal/revision of cast,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,246.8,"4,314.00",,,,,,
BCBS PPO,CPT,29710,Removal/revision of cast,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,246.8,"4,314.00",,,,,,
BCBS PPO,CPT,29715,Removal/revision of cast,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,499.47,"4,314.00",,,,,,
BCBS PPO,CPT,29720,Repair of body cast,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,144.47,"4,314.00",,,,,,
BCBS PPO,CPT,29730,Windowing of cast,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,144.47,"4,314.00",,,,,,
BCBS PPO,CPT,29740,Wedging of cast,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,246.8,"4,314.00",,,,,,
BCBS PPO,CPT,29750,Wedging of clubfoot cast,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,246.8,"4,314.00",,,,,,
BCBS PPO,CPT,29806,Sho arthrs srg capsulorpaphy,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,29806,Sho arthrs srg capsulorpaphy,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,29807,Sho arthrs srg rpr slap les,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,29807,Sho arthrs srg rpr slap les,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,29827,Sho arthrs srg rt8tr cuf rpr,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,29827,Sho arthrs srg rt8tr cuf rpr,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,29861,Hip arthro w/fb removal,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,29861,Hip arthro w/fb removal,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,29888,Knee arthroscopy/surgery,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,29888,Knee arthroscopy/surgery,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,29889,Knee arthroscopy/surgery,,Per Case,"$4,871.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS PPO,CPT,29889,Knee arthroscopy/surgery,,Per Case,"$9,201.00 ",OP,"4,140.35","12,601.93",,,,,,
BCBS PPO,CPT,29914,Hip arthro w/femoroplasty,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,29914,Hip arthro w/femoroplasty,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,29915,Hip arthro acetabuloplasty,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,29915,Hip arthro acetabuloplasty,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,29916,Hip arthro w/labral repair,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,29916,Hip arthro w/labral repair,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,31253,Nsl/sins ndsc total,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,31253,Nsl/sins ndsc total,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,31255,Nsl/sins ndsc w/tot ethmdct,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,31255,Nsl/sins ndsc w/tot ethmdct,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,31257,Nsl/sins ndsc tot w/sphendt,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,31257,Nsl/sins ndsc tot w/sphendt,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,31259,Nsl/sins ndsc sphn tiss rmvl,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,31259,Nsl/sins ndsc sphn tiss rmvl,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,31276,Nsl/sins ndsc frnt tiss rmvl,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,31276,Nsl/sins ndsc frnt tiss rmvl,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,31287,Nasal/sinus endoscopy surg,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,31287,Nasal/sinus endoscopy surg,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,31288,Nasal/sinus endoscopy surg,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,31288,Nasal/sinus endoscopy surg,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,31296,Nsl/sins ndsc surg frnt sins,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,31296,Nsl/sins ndsc surg frnt sins,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,31298,Nsl/sins ndsc surg frnt&sphn,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,31298,Nsl/sins ndsc surg frnt&sphn,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,33228,Remv&replc pm gen dual lead,,Per Case,"$4,871.00 ",OP,"4,140.35","10,642.67",,,,,,
BCBS PPO,CPT,33228,Remv&replc pm gen dual lead,,Per Case,"$9,201.00 ",OP,"4,140.35","10,642.67",,,,,,
BCBS PPO,CPT,33240,Insrt pulse gen w/singl lead,,Per Case,"$4,871.00 ",OP,"4,140.35","23,577.44",,,,,,
BCBS PPO,CPT,33240,Insrt pulse gen w/singl lead,,Per Case,"$9,201.00 ",OP,"4,140.35","23,577.44",,,,,,
BCBS PPO,CPT,33249,Insj/rplcmt defib w/lead(s),,Per Case,"$4,871.00 ",OP,"4,140.35","33,604.66",,,,,,
BCBS PPO,CPT,33249,Insj/rplcmt defib w/lead(s),,Per Case,"$9,201.00 ",OP,"4,140.35","33,604.66",,,,,,
BCBS PPO,CPT,33263,Rmvl & rplcmt dfb gen 2 lead,,Per Case,"$4,871.00 ",OP,"4,140.35","23,577.44",,,,,,
BCBS PPO,CPT,33263,Rmvl & rplcmt dfb gen 2 lead,,Per Case,"$9,201.00 ",OP,"4,140.35","23,577.44",,,,,,
BCBS PPO,CPT,36013,Place catheter in artery,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,36013,Place catheter in artery,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,36821,Av fusion direct any site,,Per Case,"$4,871.00 ",OP,"2,928.39","9,201.00",,,,,,
BCBS PPO,CPT,36821,Av fusion direct any site,,Per Case,"$9,201.00 ",OP,"2,928.39","9,201.00",,,,,,
BCBS PPO,CPT,36906,Thrmbc/nfs dialysis circuit,,Per Case,"$4,871.00 ",OP,"4,140.35","16,438.60",,,,,,
BCBS PPO,CPT,36906,Thrmbc/nfs dialysis circuit,,Per Case,"$9,201.00 ",OP,"4,140.35","16,438.60",,,,,,
BCBS PPO,CPT,37187,Venous mech thrombectomy,,Per Case,"$4,871.00 ",OP,"4,140.35","10,277.14",,,,,,
BCBS PPO,CPT,37187,Venous mech thrombectomy,,Per Case,"$9,201.00 ",OP,"4,140.35","10,277.14",,,,,,
BCBS PPO,CPT,37221,Iliac revasc w/stent,,Per Case,"$4,871.00 ",OP,"4,140.35","10,277.14",,,,,,
BCBS PPO,CPT,37221,Iliac revasc w/stent,,Per Case,"$9,201.00 ",OP,"4,140.35","10,277.14",,,,,,
BCBS PPO,CPT,37226,Fem/popl revasc w/stent,,Per Case,"$4,871.00 ",OP,"4,140.35","10,277.14",,,,,,
BCBS PPO,CPT,37226,Fem/popl revasc w/stent,,Per Case,"$9,201.00 ",OP,"4,140.35","10,277.14",,,,,,
BCBS PPO,CPT,37238,Open/perq place stent same,,Per Case,"$4,871.00 ",OP,"4,140.35","10,277.14",,,,,,
BCBS PPO,CPT,37238,Open/perq place stent same,,Per Case,"$9,201.00 ",OP,"4,140.35","10,277.14",,,,,,
BCBS PPO,CPT,37239,Open/perq place stent ea add,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,37239,Open/perq place stent ea add,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,37242,Vasc embolize/occlude artery,,Per Case,"$4,871.00 ",OP,"4,140.35","10,277.14",,,,,,
BCBS PPO,CPT,37242,Vasc embolize/occlude artery,,Per Case,"$9,201.00 ",OP,"4,140.35","10,277.14",,,,,,
BCBS PPO,CPT,37244,Vasc embolize/occlude bleed,,Per Case,"$4,871.00 ",OP,"4,140.35","10,277.14",,,,,,
BCBS PPO,CPT,37244,Vasc embolize/occlude bleed,,Per Case,"$9,201.00 ",OP,"4,140.35","10,277.14",,,,,,
BCBS PPO,CPT,38571,Laparoscopy lymphadenectomy,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,38571,Laparoscopy lymphadenectomy,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,38572,Laparoscopy lymphadenectomy,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,38572,Laparoscopy lymphadenectomy,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,38573,Laps pelvic lymphadec,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,38573,Laps pelvic lymphadec,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,43770,Lap place gastr adj device,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,43770,Lap place gastr adj device,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,44238,Laparoscope proc intestine,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,44238,Laparoscope proc intestine,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,47379,Laparoscope procedure liver,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,47379,Laparoscope procedure liver,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,47562,Laparoscopic cholecystectomy,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,47562,Laparoscopic cholecystectomy,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,47563,Laparo cholecystectomy/graph,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,47563,Laparo cholecystectomy/graph,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,47564,Laparo cholecystectomy/explr,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,47564,Laparo cholecystectomy/explr,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,47600,Removal of gallbladder,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,47600,Removal of gallbladder,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,47605,Removal of gallbladder,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,47605,Removal of gallbladder,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,47610,Removal of gallbladder,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,47610,Removal of gallbladder,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,47612,Removal of gallbladder,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,47612,Removal of gallbladder,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,47620,Removal of gallbladder,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,47620,Removal of gallbladder,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,49329,Laparo proc abdm/per/oment,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,49329,Laparo proc abdm/per/oment,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,49491,Rpr hern preemie reduc,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,49491,Rpr hern preemie reduc,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,49492,Rpr ing hern premie blocked,,Per Case,"$4,871.00 ",OP,"3,257.65","9,201.00",,,,,,
BCBS PPO,CPT,49492,Rpr ing hern premie blocked,,Per Case,"$9,201.00 ",OP,"3,257.65","9,201.00",,,,,,
BCBS PPO,CPT,49495,Rpr ing hernia baby reduc,,Per Case,"$4,871.00 ",OP,"3,257.65","9,201.00",,,,,,
BCBS PPO,CPT,49495,Rpr ing hernia baby reduc,,Per Case,"$9,201.00 ",OP,"3,257.65","9,201.00",,,,,,
BCBS PPO,CPT,49496,Rpr ing hernia baby blocked,,Per Case,"$4,871.00 ",OP,"3,257.65","9,201.00",,,,,,
BCBS PPO,CPT,49496,Rpr ing hernia baby blocked,,Per Case,"$9,201.00 ",OP,"3,257.65","9,201.00",,,,,,
BCBS PPO,CPT,49500,Rpr ing hernia init reduce,,Per Case,"$4,871.00 ",OP,"3,257.65","9,201.00",,,,,,
BCBS PPO,CPT,49500,Rpr ing hernia init reduce,,Per Case,"$9,201.00 ",OP,"3,257.65","9,201.00",,,,,,
BCBS PPO,CPT,49501,Rpr ing hernia init blocked,,Per Case,"$4,871.00 ",OP,"3,257.65","9,201.00",,,,,,
BCBS PPO,CPT,49501,Rpr ing hernia init blocked,,Per Case,"$9,201.00 ",OP,"3,257.65","9,201.00",,,,,,
BCBS PPO,CPT,49505,Prp i/hern init reduc >5 yr,,Per Case,"$4,871.00 ",OP,"3,257.65","9,201.00",,,,,,
BCBS PPO,CPT,49505,Prp i/hern init reduc >5 yr,,Per Case,"$9,201.00 ",OP,"3,257.65","9,201.00",,,,,,
BCBS PPO,CPT,49507,Prp i/hern init block >5 yr,,Per Case,"$4,871.00 ",OP,"3,257.65","9,201.00",,,,,,
BCBS PPO,CPT,49507,Prp i/hern init block >5 yr,,Per Case,"$9,201.00 ",OP,"3,257.65","9,201.00",,,,,,
BCBS PPO,CPT,49520,Rerepair ing hernia reduce,,Per Case,"$4,871.00 ",OP,"3,257.65","9,201.00",,,,,,
BCBS PPO,CPT,49520,Rerepair ing hernia reduce,,Per Case,"$9,201.00 ",OP,"3,257.65","9,201.00",,,,,,
BCBS PPO,CPT,49521,Rerepair ing hernia blocked,,Per Case,"$4,871.00 ",OP,"3,257.65","9,201.00",,,,,,
BCBS PPO,CPT,49521,Rerepair ing hernia blocked,,Per Case,"$9,201.00 ",OP,"3,257.65","9,201.00",,,,,,
BCBS PPO,CPT,49525,Repair ing hernia sliding,,Per Case,"$4,871.00 ",OP,"3,257.65","9,201.00",,,,,,
BCBS PPO,CPT,49525,Repair ing hernia sliding,,Per Case,"$9,201.00 ",OP,"3,257.65","9,201.00",,,,,,
BCBS PPO,CPT,49560,Rpr ventral hern init reduc,,Per Case,"$4,871.00 ",OP,"3,257.65","9,201.00",,,,,,
BCBS PPO,CPT,49560,Rpr ventral hern init reduc,,Per Case,"$9,201.00 ",OP,"3,257.65","9,201.00",,,,,,
BCBS PPO,CPT,49561,Rpr ventral hern init block,,Per Case,"$4,871.00 ",OP,"3,257.65","9,201.00",,,,,,
BCBS PPO,CPT,49561,Rpr ventral hern init block,,Per Case,"$9,201.00 ",OP,"3,257.65","9,201.00",,,,,,
BCBS PPO,CPT,49565,Rerepair ventrl hern reduce,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,49565,Rerepair ventrl hern reduce,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,49566,Rerepair ventrl hern block,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,49566,Rerepair ventrl hern block,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,49568,Hernia repair w/mesh,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,49568,Hernia repair w/mesh,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,49650,Lap ing hernia repair init,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,49650,Lap ing hernia repair init,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,49651,Lap ing hernia repair recur,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,49651,Lap ing hernia repair recur,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,49652,Lap vent/abd hernia repair,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,49652,Lap vent/abd hernia repair,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,49654,Lap inc hernia repair,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,49654,Lap inc hernia repair,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,50544,Laparoscopy pyeloplasty,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,50544,Laparoscopy pyeloplasty,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,50949,Laparoscope proc ureter,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,50949,Laparoscope proc ureter,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,53440,Male sling procedure,,Per Case,"$4,871.00 ",OP,"4,140.35","11,755.91",,,,,,
BCBS PPO,CPT,53440,Male sling procedure,,Per Case,"$9,201.00 ",OP,"4,140.35","11,755.91",,,,,,
BCBS PPO,CPT,53445,Insert uro/ves nck sphincter,,Per Case,"$4,871.00 ",OP,"4,140.35","18,684.12",,,,,,
BCBS PPO,CPT,53445,Insert uro/ves nck sphincter,,Per Case,"$9,201.00 ",OP,"4,140.35","18,684.12",,,,,,
BCBS PPO,CPT,54405,Insert multi-comp penis pros,,Per Case,"$4,871.00 ",OP,"4,140.35","18,684.12",,,,,,
BCBS PPO,CPT,54405,Insert multi-comp penis pros,,Per Case,"$9,201.00 ",OP,"4,140.35","18,684.12",,,,,,
BCBS PPO,CPT,54410,Remove/replace penis prosth,,Per Case,"$4,871.00 ",OP,"4,140.35","18,684.12",,,,,,
BCBS PPO,CPT,54410,Remove/replace penis prosth,,Per Case,"$9,201.00 ",OP,"4,140.35","18,684.12",,,,,,
BCBS PPO,CPT,55540,Revise hernia & sperm veins,,Per Case,"$4,871.00 ",OP,"3,257.65","9,201.00",,,,,,
BCBS PPO,CPT,55540,Revise hernia & sperm veins,,Per Case,"$9,201.00 ",OP,"3,257.65","9,201.00",,,,,,
BCBS PPO,CPT,57282,Colpopexy extraperitoneal,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,57282,Colpopexy extraperitoneal,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,57283,Colpopexy intraperitoneal,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,57283,Colpopexy intraperitoneal,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,57285,Repair paravag defect vag,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,57285,Repair paravag defect vag,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,57288,Repair bladder defect,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,57288,Repair bladder defect,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,57425,Laparoscopy surg colpopexy,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,57425,Laparoscopy surg colpopexy,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58140,Myomectomy abdom method,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58140,Myomectomy abdom method,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58145,Myomectomy vag method,,Per Case,"$4,871.00 ",OP,"2,684.38","9,201.00",,,,,,
BCBS PPO,CPT,58145,Myomectomy vag method,,Per Case,"$9,201.00 ",OP,"2,684.38","9,201.00",,,,,,
BCBS PPO,CPT,58146,Myomectomy abdom complex,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58146,Myomectomy abdom complex,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58150,Total hysterectomy,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58150,Total hysterectomy,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58152,Total hysterectomy,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58152,Total hysterectomy,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58200,Extensive hysterectomy,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58200,Extensive hysterectomy,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58540,Revision of uterus,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58540,Revision of uterus,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58542,Lsh w/t/o ut 250 g or less,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58542,Lsh w/t/o ut 250 g or less,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58543,Lsh uterus above 250 g,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58543,Lsh uterus above 250 g,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58544,Lsh w/t/o uterus above 250 g,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58544,Lsh w/t/o uterus above 250 g,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58545,Laparoscopic myomectomy,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58545,Laparoscopic myomectomy,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58546,Laparo-myomectomy complex,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58546,Laparo-myomectomy complex,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58550,Laparo-asst vag hysterectomy,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58550,Laparo-asst vag hysterectomy,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58552,Laparo-vag hyst incl t/o,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58552,Laparo-vag hyst incl t/o,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58553,Laparo-vag hyst complex,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58553,Laparo-vag hyst complex,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58554,Laparo-vag hyst w/t/o compl,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58554,Laparo-vag hyst w/t/o compl,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58558,Hysteroscopy biopsy,,Per Case,"$4,871.00 ",OP,"2,684.38","9,201.00",,,,,,
BCBS PPO,CPT,58558,Hysteroscopy biopsy,,Per Case,"$9,201.00 ",OP,"2,684.38","9,201.00",,,,,,
BCBS PPO,CPT,58559,Hysteroscopy lysis,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58559,Hysteroscopy lysis,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58560,Hysteroscopy resect septum,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58560,Hysteroscopy resect septum,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58561,Hysteroscopy remove myoma,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58561,Hysteroscopy remove myoma,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58565,Hysteroscopy sterilization,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58565,Hysteroscopy sterilization,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58570,Tlh uterus 250 g or less,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58570,Tlh uterus 250 g or less,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58571,Tlh w/t/o 250 g or less,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58571,Tlh w/t/o 250 g or less,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58572,Tlh uterus over 250 g,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58572,Tlh uterus over 250 g,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58573,Tlh w/t/o uterus over 250 g,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58573,Tlh w/t/o uterus over 250 g,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58578,Laparo proc uterus,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58578,Laparo proc uterus,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58662,Laparoscopy excise lesions,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58662,Laparoscopy excise lesions,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58674,Laps abltj uterine fibroids,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58674,Laps abltj uterine fibroids,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58679,Laparo proc oviduct-ovary,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58679,Laparo proc oviduct-ovary,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58951,Resect ovarian malignancy,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58951,Resect ovarian malignancy,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58956,Bso omentectomy w/tah,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,58956,Bso omentectomy w/tah,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,59135,Treat ectopic pregnancy,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,59135,Treat ectopic pregnancy,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,59136,Treat ectopic pregnancy,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,59136,Treat ectopic pregnancy,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,59140,Treat ectopic pregnancy,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,59140,Treat ectopic pregnancy,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,59525,Remove uterus after cesarean,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,59525,Remove uterus after cesarean,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,60240,Removal of thyroid,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,60240,Removal of thyroid,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,60252,Removal of thyroid,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,60252,Removal of thyroid,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,61885,Insrt/redo neurostim 1 array,,Per Case,"$4,871.00 ",OP,"4,140.35","20,957.35",,,,,,
BCBS PPO,CPT,61885,Insrt/redo neurostim 1 array,,Per Case,"$9,201.00 ",OP,"4,140.35","20,957.35",,,,,,
BCBS PPO,CPT,62302,Myelography lumbar injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,731.85,"4,314.00",,,,,,
BCBS PPO,CPT,62303,Myelography lumbar injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,731.85,"4,314.00",,,,,,
BCBS PPO,CPT,62304,Myelography lumbar injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,731.85,"4,314.00",,,,,,
BCBS PPO,CPT,62305,Myelography lumbar injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,731.85,"4,314.00",,,,,,
BCBS PPO,CPT,62362,Implant spine infusion pump,,Per Case,"$4,871.00 ",OP,"4,140.35","17,429.07",,,,,,
BCBS PPO,CPT,62362,Implant spine infusion pump,,Per Case,"$9,201.00 ",OP,"4,140.35","17,429.07",,,,,,
BCBS PPO,CPT,63042,Laminotomy single lumbar,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,63042,Laminotomy single lumbar,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,63047,Remove spine lamina 1 lmbr,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,63047,Remove spine lamina 1 lmbr,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,63650,Implant neuroelectrodes,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,63650,Implant neuroelectrodes,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,63655,Implant neuroelectrodes,,Per Case,"$4,871.00 ",OP,"4,140.35","20,957.35",,,,,,
BCBS PPO,CPT,63655,Implant neuroelectrodes,,Per Case,"$9,201.00 ",OP,"4,140.35","20,957.35",,,,,,
BCBS PPO,CPT,63685,Insrt/redo spine n generator,,Per Case,"$4,871.00 ",OP,"4,140.35","30,131.14",,,,,,
BCBS PPO,CPT,63685,Insrt/redo spine n generator,,Per Case,"$9,201.00 ",OP,"4,140.35","30,131.14",,,,,,
BCBS PPO,CPT,64561,Implant neuroelectrodes,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,64561,Implant neuroelectrodes,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,64568,Inc for vagus n elect impl,,Per Case,"$4,871.00 ",OP,"4,140.35","30,131.14",,,,,,
BCBS PPO,CPT,64568,Inc for vagus n elect impl,,Per Case,"$9,201.00 ",OP,"4,140.35","30,131.14",,,,,,
BCBS PPO,CPT,64581,Implant neuroelectrodes,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,64581,Implant neuroelectrodes,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,64590,Insrt/redo pn/gastr stimul,,Per Case,"$4,871.00 ",OP,"4,140.35","20,957.35",,,,,,
BCBS PPO,CPT,64590,Insrt/redo pn/gastr stimul,,Per Case,"$9,201.00 ",OP,"4,140.35","20,957.35",,,,,,
BCBS PPO,CPT,65730,Corneal transplant,,Per Case,"$4,871.00 ",OP,"4,009.10","9,201.00",,,,,,
BCBS PPO,CPT,65730,Corneal transplant,,Per Case,"$9,201.00 ",OP,"4,009.10","9,201.00",,,,,,
BCBS PPO,CPT,65756,Corneal trnspl endothelial,,Per Case,"$4,871.00 ",OP,"4,009.10","9,201.00",,,,,,
BCBS PPO,CPT,65756,Corneal trnspl endothelial,,Per Case,"$9,201.00 ",OP,"4,009.10","9,201.00",,,,,,
BCBS PPO,CPT,66180,Aqueous shunt eye w/graft,,Per Case,"$4,871.00 ",OP,"4,009.10","9,201.00",,,,,,
BCBS PPO,CPT,66180,Aqueous shunt eye w/graft,,Per Case,"$9,201.00 ",OP,"4,009.10","9,201.00",,,,,,
BCBS PPO,CPT,67108,Repair detached retina,,Per Case,"$4,871.00 ",OP,"4,009.10","9,201.00",,,,,,
BCBS PPO,CPT,67108,Repair detached retina,,Per Case,"$9,201.00 ",OP,"4,009.10","9,201.00",,,,,,
BCBS PPO,CPT,67113,Repair retinal detach cplx,,Per Case,"$4,871.00 ",OP,"4,009.10","9,201.00",,,,,,
BCBS PPO,CPT,67113,Repair retinal detach cplx,,Per Case,"$9,201.00 ",OP,"4,009.10","9,201.00",,,,,,
BCBS PPO,CPT,69930,Implant cochlear device,,Per Case,"$4,871.00 ",OP,"4,140.35","35,230.37",,,,,,
BCBS PPO,CPT,69930,Implant cochlear device,,Per Case,"$9,201.00 ",OP,"4,140.35","35,230.37",,,,,,
BCBS PPO,CPT,70010,Contrast x-ray of brain,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,376.7,899.79,,,,,,
BCBS PPO,CPT,70015,Contrast x-ray of brain,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,731.85,735.85,,,,,,
BCBS PPO,CPT,70030,X-ray eye for foreign body,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,144.88,,,,,,
BCBS PPO,CPT,70100,X-ray exam of jaw <4views,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,156.32,,,,,,
BCBS PPO,CPT,70110,X-ray exam of jaw 4/> views,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,202.07,,,,,,
BCBS PPO,CPT,70120,X-ray exam of mastoids,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,171.58,,,,,,
BCBS PPO,CPT,70130,X-ray exam of mastoids,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,282.14,,,,,,
BCBS PPO,CPT,70134,X-ray exam of middle ear,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,244.01,494.15,,,,,,
BCBS PPO,CPT,70140,X-ray exam of facial bones,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,156.32,,,,,,
BCBS PPO,CPT,70150,X-ray exam of facial bones,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,221.14,,,,,,
BCBS PPO,CPT,70160,X-ray exam of nasal bones,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,163.95,,,,,,
BCBS PPO,CPT,70170,X-ray exam of tear duct,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,274.51,,,,,,
BCBS PPO,CPT,70190,X-ray exam of eye sockets,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,183.02,,,,,,
BCBS PPO,CPT,70200,X-ray exam of eye sockets,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,228.77,,,,,,
BCBS PPO,CPT,70210,X-ray exam of sinuses,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,156.32,,,,,,
BCBS PPO,CPT,70220,X-ray exam of sinuses,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,202.07,,,,,,
BCBS PPO,CPT,70240,X-ray exam pituitary saddle,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,148.69,,,,,,
BCBS PPO,CPT,70250,X-ray exam of skull,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,186.82,,,,,,
BCBS PPO,CPT,70260,X-ray exam of skull,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,251.64,,,,,,
BCBS PPO,CPT,70300,X-ray exam of teeth,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.26,82.79,,,,,,
BCBS PPO,CPT,70320,Full mouth x-ray of teeth,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,247.83,,,,,,
BCBS PPO,CPT,70328,X-ray exam of jaw joint,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,152.51,,,,,,
BCBS PPO,CPT,70330,X-ray exam of jaw joints,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,244.01,,,,,,
BCBS PPO,CPT,70332,X-ray exam of jaw joint,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,446.08,,,,,,
BCBS PPO,CPT,70336,Magnetic image jaw joint,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,"1,507.00",,,,,,
BCBS PPO,CPT,70350,X-ray head for orthodontia,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,106.76,,,,,,
BCBS PPO,CPT,70355,Panoramic x-ray of jaws,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,122,,,,,,
BCBS PPO,CPT,70360,X-ray exam of neck,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,137.25,,,,,,
BCBS PPO,CPT,70370,Throat x-ray & fluoroscopy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,381.27,,,,,,
BCBS PPO,CPT,70371,Speech evaluation complex,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,510.9,,,,,,
BCBS PPO,CPT,70373,Contrast x-ray of larynx,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,423.22,423.22,,,,,,
BCBS PPO,CPT,70380,X-ray exam of salivary gland,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,190.64,,,,,,
BCBS PPO,CPT,70450,Ct head/brain w/o dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,927,,,,,,
BCBS PPO,CPT,70460,Ct head/brain w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,182.72,965.53,,,,,,
BCBS PPO,CPT,70470,Ct head/brain w/o & w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,182.72,965.53,,,,,,
BCBS PPO,CPT,70480,Ct orbit/ear/fossa w/o dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,927,,,,,,
BCBS PPO,CPT,70481,Ct orbit/ear/fossa w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,182.72,965.53,,,,,,
BCBS PPO,CPT,70482,Ct orbit/ear/fossa w/o&w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,182.72,965.53,,,,,,
BCBS PPO,CPT,70486,Ct maxillofacial w/o dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,927,,,,,,
BCBS PPO,CPT,70487,Ct maxillofacial w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,182.72,965.53,,,,,,
BCBS PPO,CPT,70488,Ct maxillofacial w/o & w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,182.72,965.53,,,,,,
BCBS PPO,CPT,70490,Ct soft tissue neck w/o dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,927,,,,,,
BCBS PPO,CPT,70491,Ct soft tissue neck w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,182.72,965.53,,,,,,
BCBS PPO,CPT,70492,Ct sft tsue nck w/o & w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,182.72,965.53,,,,,,
BCBS PPO,CPT,70496,Ct angiography head,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,182.72,965.53,,,,,,
BCBS PPO,CPT,70498,Ct angiography neck,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,182.72,965.53,,,,,,
BCBS PPO,CPT,70540,Mri orbit/face/neck w/o dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,"1,507.00",,,,,,
BCBS PPO,CPT,70542,Mri orbit/face/neck w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,376.7,"1,609.22",,,,,,
BCBS PPO,CPT,70543,Mri orbt/fac/nck w/o &w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,376.7,"1,609.22",,,,,,
BCBS PPO,CPT,70544,Mr angiography head w/o dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,"1,507.00",,,,,,
BCBS PPO,CPT,70545,Mr angiography head w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,376.7,"1,609.22",,,,,,
BCBS PPO,CPT,70546,Mr angiograph head w/o&w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,376.7,"1,609.22",,,,,,
BCBS PPO,CPT,70547,Mr angiography neck w/o dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,"1,507.00",,,,,,
BCBS PPO,CPT,70548,Mr angiography neck w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,376.7,"1,609.22",,,,,,
BCBS PPO,CPT,70549,Mr angiograph neck w/o&w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,376.7,"1,609.22",,,,,,
BCBS PPO,CPT,70551,Mri brain stem w/o dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,"1,507.00",,,,,,
BCBS PPO,CPT,70552,Mri brain stem w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,376.7,"1,609.22",,,,,,
BCBS PPO,CPT,70553,Mri brain stem w/o & w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,376.7,"1,609.22",,,,,,
BCBS PPO,CPT,70554,Fmri brain by tech,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,"1,507.00",,,,,,
BCBS PPO,CPT,70555,Fmri brain by phys/psych,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,"1,507.00",,,,,,
BCBS PPO,CPT,70557,Mri brain w/o dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,494.15,"1,149.44",,,,,,
BCBS PPO,CPT,70558,Mri brain w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,182.72,"1,609.22",,,,,,
BCBS PPO,CPT,70559,Mri brain w/o & w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,182.72,"1,609.22",,,,,,
BCBS PPO,CPT,71010,Chest x-ray,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,129.64,129.64,,,,,,
BCBS PPO,CPT,71015,Chest x-ray,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,152.51,152.51,,,,,,
BCBS PPO,CPT,71020,Chest x-ray,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,167.76,167.76,,,,,,
BCBS PPO,CPT,71021,Chest x-ray,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,202.07,202.07,,,,,,
BCBS PPO,CPT,71022,Chest x-ray,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,240.2,240.2,,,,,,
BCBS PPO,CPT,71023,Chest x-ray and fluoroscopy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,343.14,343.14,,,,,,
BCBS PPO,CPT,71030,Chest x-ray,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,240.2,240.2,,,,,,
BCBS PPO,CPT,71034,Chest x-ray and fluoroscopy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,472.78,472.78,,,,,,
BCBS PPO,CPT,71035,Chest x-ray,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,175.39,175.39,,,,,,
BCBS PPO,CPT,71040,Contrast x-ray of bronchi,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,495.65,495.65,,,,,,
BCBS PPO,CPT,71045,X-ray exam chest 1 view,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,152.51,,,,,,
BCBS PPO,CPT,71046,X-ray exam chest 2 views,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,167.76,,,,,,
BCBS PPO,CPT,71047,X-ray exam chest 3 views,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,240.2,,,,,,
BCBS PPO,CPT,71048,X-ray exam chest 4+ views,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,240.2,,,,,,
BCBS PPO,CPT,71060,Contrast x-ray of bronchi,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,720.6,720.6,,,,,,
BCBS PPO,CPT,71090,X-ray & pacemaker insertion,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,514.72,514.72,,,,,,
BCBS PPO,CPT,71100,X-ray exam ribs uni 2 views,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,171.58,,,,,,
BCBS PPO,CPT,71101,X-ray exam unilat ribs/chest,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,202.07,,,,,,
BCBS PPO,CPT,71110,X-ray exam ribs bil 3 views,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,213.51,,,,,,
BCBS PPO,CPT,71111,X-ray exam ribs/chest4/> vws,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,270.71,,,,,,
BCBS PPO,CPT,71120,X-ray exam breastbone 2/>vws,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,171.58,,,,,,
BCBS PPO,CPT,71130,X-ray strenoclavic jt 3/>vws,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,194.45,,,,,,
BCBS PPO,CPT,71250,Ct thorax dx c-,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,927,,,,,,
BCBS PPO,CPT,71260,Ct thorax dx c+,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,182.72,965.53,,,,,,
BCBS PPO,CPT,71270,Ct thorax dx c-/c+,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,182.72,965.53,,,,,,
BCBS PPO,CPT,71275,Ct angiography chest,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,182.72,965.53,,,,,,
BCBS PPO,CPT,71550,Mri chest w/o dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,"1,507.00",,,,,,
BCBS PPO,CPT,71551,Mri chest w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,731.85,"1,609.22",,,,,,
BCBS PPO,CPT,71552,Mri chest w/o & w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,376.7,"1,609.22",,,,,,
BCBS PPO,CPT,71555,Mri angio chest w or w/o dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,507.00","1,609.22",,,,,,
BCBS PPO,CPT,72010,X-ray exam of spine,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,354.58,354.58,,,,,,
BCBS PPO,CPT,72020,X-ray exam of spine 1 view,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,122,,,,,,
BCBS PPO,CPT,72040,X-ray exam neck spine 2-3 vw,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,190.64,,,,,,
BCBS PPO,CPT,72050,X-ray exam neck spine 4/5vws,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,293.57,,,,,,
BCBS PPO,CPT,72052,X-ray exam neck spine 6/>vws,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,339.33,,,,,,
BCBS PPO,CPT,72069,X-ray exam of trunk spine,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,175.39,175.39,,,,,,
BCBS PPO,CPT,72070,X-ray exam thorac spine 2vws,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,175.39,,,,,,
BCBS PPO,CPT,72072,X-ray exam thorac spine 3vws,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,202.07,,,,,,
BCBS PPO,CPT,72074,X-ray exam thorac spine4/>vw,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,236.38,,,,,,
BCBS PPO,CPT,72080,X-ray exam thoracolmb 2/> vw,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,183.02,,,,,,
BCBS PPO,CPT,72081,X-ray exam entire spi 1 vw,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,354.58,,,,,,
BCBS PPO,CPT,72082,X-ray exam entire spi 2/3 vw,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,354.58,,,,,,
BCBS PPO,CPT,72083,X-ray exam entire spi 4/5 vw,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,354.58,,,,,,
BCBS PPO,CPT,72084,X-ray exam entire spi 6/> vw,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,354.58,,,,,,
BCBS PPO,CPT,72090,X-ray exam of trunk spine,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,240.2,240.2,,,,,,
BCBS PPO,CPT,72100,X-ray exam l-s spine 2/3 vws,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,202.07,,,,,,
BCBS PPO,CPT,72110,X-ray exam l-2 spine 4/>vws,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,301.2,,,,,,
BCBS PPO,CPT,72114,X-ray exam l-s spine bending,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,362.21,,,,,,
BCBS PPO,CPT,72120,X-ray bend only l-s spine,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,251.64,,,,,,
BCBS PPO,CPT,72125,Ct neck spine w/o dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,927,,,,,,
BCBS PPO,CPT,72126,Ct neck spine w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,376.7,965.53,,,,,,
BCBS PPO,CPT,72127,Ct neck spine w/o & w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,182.72,965.53,,,,,,
BCBS PPO,CPT,72128,Ct chest spine w/o dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,927,,,,,,
BCBS PPO,CPT,72129,Ct chest spine w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,182.72,965.53,,,,,,
BCBS PPO,CPT,72130,Ct chest spine w/o & w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,182.72,965.53,,,,,,
BCBS PPO,CPT,72131,Ct lumbar spine w/o dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,927,,,,,,
BCBS PPO,CPT,72132,Ct lumbar spine w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,376.7,965.53,,,,,,
BCBS PPO,CPT,72133,Ct lumbar spine w/o & w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,182.72,965.53,,,,,,
BCBS PPO,CPT,72141,Mri neck spine w/o dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,"1,507.00",,,,,,
BCBS PPO,CPT,72142,Mri neck spine w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,376.7,"1,609.22",,,,,,
BCBS PPO,CPT,72146,Mri chest spine w/o dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,"1,507.00",,,,,,
BCBS PPO,CPT,72147,Mri chest spine w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,376.7,"1,609.22",,,,,,
BCBS PPO,CPT,72148,Mri lumbar spine w/o dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,"1,507.00",,,,,,
BCBS PPO,CPT,72149,Mri lumbar spine w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,376.7,"1,609.22",,,,,,
BCBS PPO,CPT,72156,Mri neck spine w/o & w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,376.7,"1,609.22",,,,,,
BCBS PPO,CPT,72157,Mri chest spine w/o & w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,376.7,"1,609.22",,,,,,
BCBS PPO,CPT,72158,Mri lumbar spine w/o & w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,376.7,"1,609.22",,,,,,
BCBS PPO,CPT,72159,Mr angio spine w/o&w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,507.00","1,609.22",,,,,,
BCBS PPO,CPT,72170,X-ray exam of pelvis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,133.45,,,,,,
BCBS PPO,CPT,72190,X-ray exam of pelvis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,205.88,,,,,,
BCBS PPO,CPT,72191,Ct angiograph pelv w/o&w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,182.72,965.53,,,,,,
BCBS PPO,CPT,72192,Ct pelvis w/o dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,927,,,,,,
BCBS PPO,CPT,72193,Ct pelvis w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,182.72,965.53,,,,,,
BCBS PPO,CPT,72194,Ct pelvis w/o & w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,182.72,965.53,,,,,,
BCBS PPO,CPT,72195,Mri pelvis w/o dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,"1,507.00",,,,,,
BCBS PPO,CPT,72196,Mri pelvis w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,376.7,"1,609.22",,,,,,
BCBS PPO,CPT,72197,Mri pelvis w/o & w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,376.7,"1,609.22",,,,,,
BCBS PPO,CPT,72200,X-ray exam si joints,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,148.69,,,,,,
BCBS PPO,CPT,72202,X-ray exam si joints 3/> vws,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,183.02,,,,,,
BCBS PPO,CPT,72220,X-ray exam sacrum tailbone,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,156.32,,,,,,
BCBS PPO,CPT,72240,Myelography neck spine,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,731.85,842.61,,,,,,
BCBS PPO,CPT,72255,Myelography thoracic spine,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,731.85,766.35,,,,,,
BCBS PPO,CPT,72265,Myelography l-s spine,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,731.85,781.61,,,,,,
BCBS PPO,CPT,72270,Myelogphy 2/> spine regions,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,731.85,"1,216.24",,,,,,
BCBS PPO,CPT,72285,Discography cerv/thor spine,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,976.05,"1,795.30",,,,,,
BCBS PPO,CPT,72292,Perq verte/sacroplsty ct,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,635.64","1,635.64",,,,,,
BCBS PPO,CPT,72295,X-ray of lower spine disk,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,873.11,"1,795.30",,,,,,
BCBS PPO,CPT,73000,X-ray exam of collar bone,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,141.07,,,,,,
BCBS PPO,CPT,73010,X-ray exam of shoulder blade,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,144.88,,,,,,
BCBS PPO,CPT,73020,X-ray exam of shoulder,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,122,,,,,,
BCBS PPO,CPT,73030,X-ray exam of shoulder,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,163.95,,,,,,
BCBS PPO,CPT,73040,Contrast x-ray of shoulder,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,376.7,552.84,,,,,,
BCBS PPO,CPT,73050,X-ray exam of shoulders,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,186.82,,,,,,
BCBS PPO,CPT,73060,X-ray exam of humerus,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,152.51,,,,,,
BCBS PPO,CPT,73070,X-ray exam of elbow,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,137.25,,,,,,
BCBS PPO,CPT,73080,X-ray exam of elbow,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,179.2,,,,,,
BCBS PPO,CPT,73085,Contrast x-ray of elbow,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,376.7,503.28,,,,,,
BCBS PPO,CPT,73090,X-ray exam of forearm,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,137.25,,,,,,
BCBS PPO,CPT,73092,X-ray exam of arm infant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,141.07,,,,,,
BCBS PPO,CPT,73100,X-ray exam of wrist,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,144.88,,,,,,
BCBS PPO,CPT,73110,X-ray exam of wrist,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,171.58,,,,,,
BCBS PPO,CPT,73115,Contrast x-ray of wrist,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,376.7,526.16,,,,,,
BCBS PPO,CPT,73120,X-ray exam of hand,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,137.25,,,,,,
BCBS PPO,CPT,73130,X-ray exam of hand,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,156.32,,,,,,
BCBS PPO,CPT,73140,X-ray exam of finger(s),Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,160.13,,,,,,
BCBS PPO,CPT,73200,Ct upper extremity w/o dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,927,,,,,,
BCBS PPO,CPT,73201,Ct upper extremity w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,376.7,965.53,,,,,,
BCBS PPO,CPT,73202,Ct uppr extremity w/o&w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,182.72,965.53,,,,,,
BCBS PPO,CPT,73206,Ct angio upr extrm w/o&w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,182.72,965.53,,,,,,
BCBS PPO,CPT,73218,Mri upper extremity w/o dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,"1,507.00",,,,,,
BCBS PPO,CPT,73219,Mri upper extremity w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,376.7,"1,609.22",,,,,,
BCBS PPO,CPT,73220,Mri uppr extremity w/o&w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,376.7,"1,609.22",,,,,,
BCBS PPO,CPT,73221,Mri joint upr extrem w/o dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,"1,507.00",,,,,,
BCBS PPO,CPT,73222,Mri joint upr extrem w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,731.85,"1,609.22",,,,,,
BCBS PPO,CPT,73223,Mri joint upr extr w/o&w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,376.7,"1,609.22",,,,,,
BCBS PPO,CPT,73225,Mr angio upr extr w/o&w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,507.00","1,609.22",,,,,,
BCBS PPO,CPT,73500,X-ray exam of hip,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,129.64,129.64,,,,,,
BCBS PPO,CPT,73501,X-ray exam hip uni 1 view,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,129.64,,,,,,
BCBS PPO,CPT,73502,X-ray exam hip uni 2-3 views,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,198.25,,,,,,
BCBS PPO,CPT,73503,X-ray exam hip uni 4/> views,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,198.25,,,,,,
BCBS PPO,CPT,73510,X-ray exam of hip,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,198.25,198.25,,,,,,
BCBS PPO,CPT,73520,X-ray exam of hips,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,202.07,202.07,,,,,,
BCBS PPO,CPT,73521,X-ray exam hips bi 2 views,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,202.07,,,,,,
BCBS PPO,CPT,73522,X-ray exam hips bi 3-4 views,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,202.07,,,,,,
BCBS PPO,CPT,73523,X-ray exam hips bi 5/> views,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,202.07,,,,,,
BCBS PPO,CPT,73525,Contrast x-ray of hip,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,376.7,503.28,,,,,,
BCBS PPO,CPT,73540,X-ray exam of pelvis & hips,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,190.64,190.64,,,,,,
BCBS PPO,CPT,73542,X-ray exam sacroiliac joint,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,419.4,419.4,,,,,,
BCBS PPO,CPT,73550,X-ray exam of thigh,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,148.69,148.69,,,,,,
BCBS PPO,CPT,73551,X-ray exam of femur 1,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,148.69,,,,,,
BCBS PPO,CPT,73552,X-ray exam of femur 2/>,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,148.69,,,,,,
BCBS PPO,CPT,73560,X-ray exam of knee 1 or 2,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,144.88,,,,,,
BCBS PPO,CPT,73562,X-ray exam of knee 3,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,186.82,,,,,,
BCBS PPO,CPT,73564,X-ray exam knee 4 or more,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,205.88,,,,,,
BCBS PPO,CPT,73565,X-ray exam of knees,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,152.51,,,,,,
BCBS PPO,CPT,73580,Contrast x-ray of knee joint,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,376.7,625.29,,,,,,
BCBS PPO,CPT,73590,X-ray exam of lower leg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,137.25,,,,,,
BCBS PPO,CPT,73592,X-ray exam of leg infant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,141.07,,,,,,
BCBS PPO,CPT,73600,X-ray exam of ankle,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,137.25,,,,,,
BCBS PPO,CPT,73610,X-ray exam of ankle,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,156.32,,,,,,
BCBS PPO,CPT,73620,X-ray exam of foot,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,133.45,,,,,,
BCBS PPO,CPT,73630,X-ray exam of foot,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,156.32,,,,,,
BCBS PPO,CPT,73650,X-ray exam of heel,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,137.25,,,,,,
BCBS PPO,CPT,73660,X-ray exam of toe(s),Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,141.07,,,,,,
BCBS PPO,CPT,73700,Ct lower extremity w/o dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,927,,,,,,
BCBS PPO,CPT,73701,Ct lower extremity w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,182.72,965.53,,,,,,
BCBS PPO,CPT,73702,Ct lwr extremity w/o&w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,182.72,965.53,,,,,,
BCBS PPO,CPT,73706,Ct angio lwr extr w/o&w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,182.72,965.53,,,,,,
BCBS PPO,CPT,73718,Mri lower extremity w/o dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,"1,507.00",,,,,,
BCBS PPO,CPT,73719,Mri lower extremity w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,376.7,"1,609.22",,,,,,
BCBS PPO,CPT,73720,Mri lwr extremity w/o&w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,376.7,"1,609.22",,,,,,
BCBS PPO,CPT,73721,Mri jnt of lwr extre w/o dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,"1,507.00",,,,,,
BCBS PPO,CPT,73722,Mri joint of lwr extr w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,731.85,"1,609.22",,,,,,
BCBS PPO,CPT,73723,Mri joint lwr extr w/o&w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,376.7,"1,609.22",,,,,,
BCBS PPO,CPT,73725,Mr ang lwr ext w or w/o dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,507.00","1,609.22",,,,,,
BCBS PPO,CPT,74000,X-ray exam of abdomen,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,137.25,137.25,,,,,,
BCBS PPO,CPT,74010,X-ray exam of abdomen,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,194.45,194.45,,,,,,
BCBS PPO,CPT,74018,X-ray exam abdomen 1 view,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,137.25,,,,,,
BCBS PPO,CPT,74019,X-ray exam abdomen 2 views,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,194.45,,,,,,
BCBS PPO,CPT,74020,X-ray exam of abdomen,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,205.88,205.88,,,,,,
BCBS PPO,CPT,74021,X-ray exam abdomen 3+ views,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,205.88,,,,,,
BCBS PPO,CPT,74022,X-ray exam complete abdomen,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,251.64,,,,,,
BCBS PPO,CPT,74150,Ct abdomen w/o dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,927,,,,,,
BCBS PPO,CPT,74160,Ct abdomen w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,182.72,965.53,,,,,,
BCBS PPO,CPT,74170,Ct abdomen w/o & w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,182.72,965.53,,,,,,
BCBS PPO,CPT,74174,Ct angio abd&pelv w/o&w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,376.7,965.53,,,,,,
BCBS PPO,CPT,74175,Ct angio abdom w/o & w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,182.72,965.53,,,,,,
BCBS PPO,CPT,74176,Ct abd & pelvis w/o contrast,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,927,,,,,,
BCBS PPO,CPT,74177,Ct abd & pelv w/contrast,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,376.7,965.53,,,,,,
BCBS PPO,CPT,74178,Ct abd & pelv 1/> regns,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,376.7,927,,,,,,
BCBS PPO,CPT,74181,Mri abdomen w/o dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,"1,507.00",,,,,,
BCBS PPO,CPT,74182,Mri abdomen w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,376.7,"1,609.22",,,,,,
BCBS PPO,CPT,74183,Mri abdomen w/o & w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,376.7,"1,609.22",,,,,,
BCBS PPO,CPT,74185,Mri angio abdom w orw/o dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,507.00","1,609.22",,,,,,
BCBS PPO,CPT,74190,X-ray exam of peritoneum,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,400.34,494.15,,,,,,
BCBS PPO,CPT,74220,X-ray xm esophagus 1cntrst,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,182.72,446.08,,,,,,
BCBS PPO,CPT,74221,X-ray xm esophagus 2cntrst,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,182.72,446.08,,,,,,
BCBS PPO,CPT,74230,X-ray xm swlng funcj c+,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,182.72,457.52,,,,,,
BCBS PPO,CPT,74235,Remove esophagus obstruction,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,922.67,922.67,,,,,,
BCBS PPO,CPT,74240,X-ray xm upr gi trc 1cntrst,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,182.72,552.84,,,,,,
BCBS PPO,CPT,74241,X-ray upper gi delay w/kub,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,587.16,587.16,,,,,,
BCBS PPO,CPT,74245,X-ray upper gi&small intest,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,884.55,884.55,,,,,,
BCBS PPO,CPT,74246,X-ray xm upr gi trc 2cntrst,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,182.72,632.91,,,,,,
BCBS PPO,CPT,74247,Contrst x-ray uppr gi tract,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,697.72,697.72,,,,,,
BCBS PPO,CPT,74248,X-ray sm int f-thru std,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,321.29,321.29,,,,,,
BCBS PPO,CPT,74249,Contrst x-ray uppr gi tract,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,945.56,945.56,,,,,,
BCBS PPO,CPT,74250,X-ray xm sm int 1cntrst std,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,182.72,518.52,,,,,,
BCBS PPO,CPT,74251,X-ray xm sm int 2cntrst std,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,182.72,"1,593.72",,,,,,
BCBS PPO,CPT,74260,X-ray exam of small bowel,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,330.63","1,330.63",,,,,,
BCBS PPO,CPT,74270,X-ray xm colon 1cntrst std,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,182.72,747.28,,,,,,
BCBS PPO,CPT,74280,X-ray xm colon 2cntrst std,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,182.72,"1,029.43",,,,,,
BCBS PPO,CPT,74290,Contrast x-ray gallbladder,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,182.72,331.7,,,,,,
BCBS PPO,CPT,74291,Contrast x-rays gallbladder,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,282.14,282.14,,,,,,
BCBS PPO,CPT,74300,X-ray bile ducts/pancreas,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,274.51,274.51,,,,,,
BCBS PPO,CPT,74301,X-rays at surgery add-on,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,163.95,163.95,,,,,,
BCBS PPO,CPT,74305,X-ray bile ducts/pancreas,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,274.51,274.51,,,,,,
BCBS PPO,CPT,74320,Contrast x-ray of bile ducts,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,606.21,606.21,,,,,,
BCBS PPO,CPT,74327,X-ray bile stone removal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,671.03,671.03,,,,,,
BCBS PPO,CPT,74328,X-ray bile duct endoscopy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,861.67,861.67,,,,,,
BCBS PPO,CPT,74329,X-ray for pancreas endoscopy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,537.6,537.6,,,,,,
BCBS PPO,CPT,74330,X-ray bile/panc endoscopy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,896,896,,,,,,
BCBS PPO,CPT,74355,X-ray guide intestinal tube,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,754.91,754.91,,,,,,
BCBS PPO,CPT,74360,X-ray guide gi dilation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,831.17,831.17,,,,,,
BCBS PPO,CPT,74363,X-ray bile duct dilation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,678.66,678.66,,,,,,
BCBS PPO,CPT,74400,Urography iv +-kub tomog,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,182.72,568.09,,,,,,
BCBS PPO,CPT,74410,Urography nfs drip&/bolus,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,182.72,598.59,,,,,,
BCBS PPO,CPT,74415,Urography nfs drip&/bls w/nf,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,182.72,682.47,,,,,,
BCBS PPO,CPT,74420,Urography rtrgr +-kub,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,376.7,659.6,,,,,,
BCBS PPO,CPT,74425,Urography antegrade rs&i,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,366.02,376.7,,,,,,
BCBS PPO,CPT,74430,Contrast x-ray bladder,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,376.7,404.14,,,,,,
BCBS PPO,CPT,74440,X-ray male genital tract,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,434.65,,,,,,
BCBS PPO,CPT,74445,X-ray exam of penis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,545.21,,,,,,
BCBS PPO,CPT,74450,X-ray urethra/bladder,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,396.52,,,,,,
BCBS PPO,CPT,74455,X-ray urethra/bladder,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,472.78,,,,,,
BCBS PPO,CPT,74470,X-ray exam of kidney lesion,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,400.34,494.15,,,,,,
BCBS PPO,CPT,74475,X-ray control cath insert,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,663.41,663.41,,,,,,
BCBS PPO,CPT,74485,Dilation urtr/urt rs&i,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,629.1,"1,834.80",,,,,,
BCBS PPO,CPT,74710,X-ray measurement of pelvis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,232.58,,,,,,
BCBS PPO,CPT,74712,Mri fetal sngl/1st gestation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,"1,507.00",,,,,,
BCBS PPO,CPT,74713,Mri fetal ea addl gestation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,149.44","1,507.00",,,,,,
BCBS PPO,CPT,74740,X-ray female genital tract,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,404.14,,,,,,
BCBS PPO,CPT,74742,X-ray fallopian tube,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,461.34,461.34,,,,,,
BCBS PPO,CPT,74775,X-ray exam of perineum,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,457.52,,,,,,
BCBS PPO,CPT,75557,Cardiac mri for morph,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,"1,507.00",,,,,,
BCBS PPO,CPT,75561,Cardiac mri for morph w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,376.7,"1,609.22",,,,,,
BCBS PPO,CPT,75562,Card mri flow/vel w/dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,507.00","4,266.40",,,,,,
BCBS PPO,CPT,75563,Card mri w/stress img & dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,731.85,"1,609.22",,,,,,
BCBS PPO,CPT,75564,Ht mri w/flo/vel/strs & dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,507.00","5,017.50",,,,,,
BCBS PPO,CPT,75600,Contrast exam thoracic aorta,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,742.41","2,928.39",,,,,,
BCBS PPO,CPT,75605,Contrast exam thoracic aorta,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,506.03","4,881.61",,,,,,
BCBS PPO,CPT,75625,Contrast exam abdominl aorta,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,486.95","2,928.39",,,,,,
BCBS PPO,CPT,75635,Ct angio abdominal arteries,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,182.72,965.53,,,,,,
BCBS PPO,CPT,75650,Artery x-rays head & neck,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,586.08","1,586.08",,,,,,
BCBS PPO,CPT,75658,Artery x-rays arm,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,570.83","1,570.83",,,,,,
BCBS PPO,CPT,75662,Artery x-rays head & neck,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,807.23","1,807.23",,,,,,
BCBS PPO,CPT,75671,Artery x-rays head & neck,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,833.90","1,833.90",,,,,,
BCBS PPO,CPT,75680,Artery x-rays neck,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,765.27","1,765.27",,,,,,
BCBS PPO,CPT,75685,Artery x-rays spine,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,597.52","1,597.52",,,,,,
BCBS PPO,CPT,75705,Artery x-rays spine,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,826.28","4,881.61",,,,,,
BCBS PPO,CPT,75710,Artery x-rays arm/leg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,567.02","2,928.39",,,,,,
BCBS PPO,CPT,75716,Artery x-rays arms/legs,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,730.97","2,928.39",,,,,,
BCBS PPO,CPT,75722,Artery x-rays kidney,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,547.95","1,547.95",,,,,,
BCBS PPO,CPT,75724,Artery x-rays kidneys,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,776.71","1,776.71",,,,,,
BCBS PPO,CPT,75726,Artery x-rays abdomen,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,547.95","4,881.61",,,,,,
BCBS PPO,CPT,75731,Artery x-rays adrenal gland,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,601.33","2,928.39",,,,,,
BCBS PPO,CPT,75733,Artery x-rays adrenals,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,795.78","2,928.39",,,,,,
BCBS PPO,CPT,75736,Artery x-rays pelvis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,563.20","4,881.61",,,,,,
BCBS PPO,CPT,75741,Artery x-rays lung,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,506.03","2,928.39",,,,,,
BCBS PPO,CPT,75743,Artery x-rays lungs,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,635.64","2,928.39",,,,,,
BCBS PPO,CPT,75746,Artery x-rays lung,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,517.46","2,928.39",,,,,,
BCBS PPO,CPT,75756,Artery x-rays chest,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,601.33","2,928.39",,,,,,
BCBS PPO,CPT,75774,Artery x-ray each vessel,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,208.62","1,208.62",,,,,,
BCBS PPO,CPT,75790,Visualize A-V shunt,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,899.79,899.79,,,,,,
BCBS PPO,CPT,75791,Av dialysis shunt imaging,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,899.79,899.79,,,,,,
BCBS PPO,CPT,75801,Lymph vessel x-ray arm/leg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,554.25,"1,281.07",,,,,,
BCBS PPO,CPT,75803,Lymph vessel x-ray arms/legs,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,437.39","1,438.93",,,,,,
BCBS PPO,CPT,75805,Lymph vessel x-ray trunk,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,483.14","2,928.39",,,,,,
BCBS PPO,CPT,75807,Lymph vessel x-ray trunk,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,582.28","2,928.39",,,,,,
BCBS PPO,CPT,75809,Nonvascular shunt x-ray,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,446.08,,,,,,
BCBS PPO,CPT,75810,Vein x-ray spleen/liver,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,836.65","2,928.39",,,,,,
BCBS PPO,CPT,75820,Vein x-ray arm/leg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,610.03,"1,438.93",,,,,,
BCBS PPO,CPT,75822,Vein x-ray arms/legs,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,747.28,"1,438.93",,,,,,
BCBS PPO,CPT,75825,Vein x-ray trunk,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,441.20","2,928.39",,,,,,
BCBS PPO,CPT,75827,Vein x-ray chest,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,433.58","1,438.93",,,,,,
BCBS PPO,CPT,75831,Vein x-ray kidney,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,456.44","2,928.39",,,,,,
BCBS PPO,CPT,75833,Vein x-ray kidneys,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,608.95","2,928.39",,,,,,
BCBS PPO,CPT,75840,Vein x-ray adrenal gland,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,445.01","2,928.39",,,,,,
BCBS PPO,CPT,75842,Vein x-ray adrenal glands,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,616.58","4,881.61",,,,,,
BCBS PPO,CPT,75860,Vein x-ray neck,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,479.33","2,928.39",,,,,,
BCBS PPO,CPT,75870,Vein x-ray skull,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,467.89","2,928.39",,,,,,
BCBS PPO,CPT,75872,Vein x-ray skull epidural,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,554.25,"1,608.95",,,,,,
BCBS PPO,CPT,75880,Vein x-ray eye socket,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,554.25,613.85,,,,,,
BCBS PPO,CPT,75885,Vein x-ray liver w/hemodynam,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,536.51","2,928.39",,,,,,
BCBS PPO,CPT,75887,Vein x-ray liver w/o hemodyn,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,547.95","2,928.39",,,,,,
BCBS PPO,CPT,75889,Vein x-ray liver w/hemodynam,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,456.44","2,928.39",,,,,,
BCBS PPO,CPT,75891,Vein x-ray liver,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,456.44","2,928.39",,,,,,
BCBS PPO,CPT,75893,Venous sampling by catheter,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,296.32","4,881.61",,,,,,
BCBS PPO,CPT,75894,X-rays transcath therapy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"5,124.26","5,124.26",,,,,,
BCBS PPO,CPT,75896,X-rays transcath therapy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"4,476.10","4,476.10",,,,,,
BCBS PPO,CPT,75898,Follow-up angiography,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,655.78,"2,928.39",,,,,,
BCBS PPO,CPT,75900,Intravascular cath exchange,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,888.36,888.36,,,,,,
BCBS PPO,CPT,75901,Remove cva device obstruct,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,006.55","1,006.55",,,,,,
BCBS PPO,CPT,75902,Remove cva lumen obstruct,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,640.54,640.54,,,,,,
BCBS PPO,CPT,75940,X-ray placement vein filter,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,943.39","2,943.39",,,,,,
BCBS PPO,CPT,75945,Intravascular us,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,021.81","1,021.81",,,,,,
BCBS PPO,CPT,75946,Intravascular us add-on,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,006.55","1,006.55",,,,,,
BCBS PPO,CPT,75952,Endovasc repair abdom aorta,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,185.76","1,185.76",,,,,,
BCBS PPO,CPT,75953,Abdom aneurysm endovas rpr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,358.39,358.39,,,,,,
BCBS PPO,CPT,75954,Iliac aneurysm endovas rpr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,571.91,571.91,,,,,,
BCBS PPO,CPT,75957,Xray endovasc thor ao repr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,597.52","8,948.83",,,,,,
BCBS PPO,CPT,75958,Xray place prox ext thor ao,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,052.29","8,948.83",,,,,,
BCBS PPO,CPT,75959,Xray place dist ext thor ao,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,926.48,"8,948.83",,,,,,
BCBS PPO,CPT,75960,Transcath iv stent rs&i,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,479.33","1,479.33",,,,,,
BCBS PPO,CPT,75961,Retrieval broken catheter,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,192.31","2,192.31",,,,,,
BCBS PPO,CPT,75962,Repair arterial blockage,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,582.28","1,582.28",,,,,,
BCBS PPO,CPT,75964,Repair artery blockage each,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,922.67,922.67,,,,,,
BCBS PPO,CPT,75966,Repair arterial blockage,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,826.28","1,826.28",,,,,,
BCBS PPO,CPT,75968,Repair artery blockage each,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,922.67,922.67,,,,,,
BCBS PPO,CPT,75970,Vascular biopsy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,520.20","2,520.20",,,,,,
BCBS PPO,CPT,75980,Contrast xray exam bile duct,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,486.95","1,486.95",,,,,,
BCBS PPO,CPT,75982,Contrast xray exam bile duct,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,685.20","1,685.20",,,,,,
BCBS PPO,CPT,75984,Xray control catheter change,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,594.77,594.77,,,,,,
BCBS PPO,CPT,75989,Abscess drainage under x-ray,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,922.43,927,,,,,,
BCBS PPO,CPT,75992,Atherectomy - x-ray exam,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,774.56","3,774.56",,,,,,
BCBS PPO,CPT,75993,Atherectomy - x-ray exam,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,482.06","2,482.06",,,,,,
BCBS PPO,CPT,75994,Atherectomy - x-ray exam,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,313.22","3,313.22",,,,,,
BCBS PPO,CPT,75995,Atherectomy - x-ray exam,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,503.86","3,503.86",,,,,,
BCBS PPO,CPT,75996,Atherectomy - x-ray exam,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,972.25,972.25,,,,,,
BCBS PPO,CPT,76000,Fluoroscopy <1 hr phys/qhp,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,495.65,,,,,,
BCBS PPO,CPT,76001,Fluoroscope exam extensive,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,735.85,735.85,,,,,,
BCBS PPO,CPT,76010,X-ray nose to rectum,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,144.88,,,,,,
BCBS PPO,CPT,76080,X-ray exam of fistula,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,331.7,494.15,,,,,,
BCBS PPO,CPT,76098,X-ray exam surgical specimen,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,102.95,494.15,,,,,,
BCBS PPO,CPT,76100,X-ray exam of body section,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,690.1,,,,,,
BCBS PPO,CPT,76101,Complex body section x-ray,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,949.36,,,,,,
BCBS PPO,CPT,76120,Cine/video x-rays,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,392.7,,,,,,
BCBS PPO,CPT,76125,Cine/video x-rays add-on,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,244.01,244.01,,,,,,
BCBS PPO,CPT,76140,X-ray consultation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,83.87,83.87,,,,,,
BCBS PPO,CPT,76150,X-ray exam - dry process,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,95.32,95.32,,,,,,
BCBS PPO,CPT,76350,Special x-ray contrast study,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,213.51,213.51,,,,,,
BCBS PPO,CPT,76376,3d render w/intrp postproces,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,922.43,922.43,,,,,,
BCBS PPO,CPT,76377,3d render w/intrp postproces,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,922.43,922.43,,,,,,
BCBS PPO,CPT,76380,Cat scan follow-up study,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,689.66,,,,,,
BCBS PPO,CPT,76390,Mr spectroscopy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,"1,507.00",,,,,,
BCBS PPO,CPT,76506,Echo exam of head,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,602.41,,,,,,
BCBS PPO,CPT,76510,Oph us dx b-scan&quan a-scan,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,751.1,,,,,,
BCBS PPO,CPT,76511,Oph us dx quan a-scan only,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,495.65,,,,,,
BCBS PPO,CPT,76512,Oph us dx b-scan,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,468.96,,,,,,
BCBS PPO,CPT,76513,Oph us dx ant sgm us uni/bi,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,438.47,,,,,,
BCBS PPO,CPT,76514,Echo exam of eye thickness,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,25.25,64.82,,,,,,
BCBS PPO,CPT,76516,Echo exam of eye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,346.96,,,,,,
BCBS PPO,CPT,76519,Echo exam of eye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,369.83,,,,,,
BCBS PPO,CPT,76529,Echo exam of eye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,354.58,,,,,,
BCBS PPO,CPT,76536,Us exam of head and neck,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,594.77,,,,,,
BCBS PPO,CPT,76604,Us exam chest,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,446.08,,,,,,
BCBS PPO,CPT,76641,Ultrasound breast complete,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,174.71,,,,,,
BCBS PPO,CPT,76642,Ultrasound breast limited,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,174.71,,,,,,
BCBS PPO,CPT,76645,Us exam breast(s),Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,174.71,174.71,,,,,,
BCBS PPO,CPT,76700,Us exam abdom complete,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,739.67,,,,,,
BCBS PPO,CPT,76705,Echo exam of abdomen,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,537.6,,,,,,
BCBS PPO,CPT,76706,Us abdl aorta screen aaa,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,575.73,,,,,,
BCBS PPO,CPT,76770,Us exam abdo back wall comp,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,678.66,,,,,,
BCBS PPO,CPT,76775,Us exam abdo back wall lim,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,602.41,,,,,,
BCBS PPO,CPT,76776,Us exam k transpl w/doppler,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,751.1,,,,,,
BCBS PPO,CPT,76800,Us exam spinal canal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,632.91,,,,,,
BCBS PPO,CPT,76801,Ob us < 14 wks single fetus,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,712.98,,,,,,
BCBS PPO,CPT,76802,Ob us < 14 wks addl fetus,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,396.52,396.52,,,,,,
BCBS PPO,CPT,76805,Ob us >= 14 wks sngl fetus,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,789.23,,,,,,
BCBS PPO,CPT,76810,Ob us >= 14 wks addl fetus,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,549.03,549.03,,,,,,
BCBS PPO,CPT,76811,Ob us detailed sngl fetus,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,"1,204.81",,,,,,
BCBS PPO,CPT,76812,Ob us detailed addl fetus,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,090.43","1,090.43",,,,,,
BCBS PPO,CPT,76813,Ob us nuchal meas 1 gest,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,667.22,,,,,,
BCBS PPO,CPT,76814,Ob us nuchal meas add-on,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,446.08,446.08,,,,,,
BCBS PPO,CPT,76815,Ob us limited fetus(s),Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,472.78,,,,,,
BCBS PPO,CPT,76816,Ob us follow-up per fetus,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,571.91,,,,,,
BCBS PPO,CPT,76817,Transvaginal us obstetric,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,560.47,,,,,,
BCBS PPO,CPT,76818,Fetal biophys profile w/nst,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,625.29,,,,,,
BCBS PPO,CPT,76819,Fetal biophys profil w/o nst,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,526.16,,,,,,
BCBS PPO,CPT,76820,Umbilical artery echo,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,297.39,,,,,,
BCBS PPO,CPT,76821,Middle cerebral artery echo,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,510.9,,,,,,
BCBS PPO,CPT,76825,Echo exam of fetal heart,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,494.15,"1,067.55",,,,,,
BCBS PPO,CPT,76826,Echo exam of fetal heart,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,587.16,,,,,,
BCBS PPO,CPT,76827,Echo exam of fetal heart,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,381.27,,,,,,
BCBS PPO,CPT,76828,Echo exam of fetal heart,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,282.14,,,,,,
BCBS PPO,CPT,76830,Transvaginal us non-ob,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,651.97,,,,,,
BCBS PPO,CPT,76831,Echo exam uterus,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,621.47,,,,,,
BCBS PPO,CPT,76856,Us exam pelvic complete,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,655.78,,,,,,
BCBS PPO,CPT,76857,Us exam pelvic limited,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,518.52,,,,,,
BCBS PPO,CPT,76870,Us exam scrotum,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,621.47,,,,,,
BCBS PPO,CPT,76872,Us transrectal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,735.85,,,,,,
BCBS PPO,CPT,76873,Echograp trans r pros study,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,934.12,,,,,,
BCBS PPO,CPT,76880,Us exam - extremity,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,644.34,644.34,,,,,,
BCBS PPO,CPT,76881,Us compl joint r-t w/img,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,644.34,,,,,,
BCBS PPO,CPT,76882,Us lmtd jt/nonvasc xtr strux,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,644.34,,,,,,
BCBS PPO,CPT,76885,Us exam infant hips dynamic,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,701.54,,,,,,
BCBS PPO,CPT,76886,Us exam infant hips static,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,518.52,,,,,,
BCBS PPO,CPT,76930,Echo guide cardiocentesis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,510.9,510.9,,,,,,
BCBS PPO,CPT,76932,Echo guide for heart biopsy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,510.9,510.9,,,,,,
BCBS PPO,CPT,76936,Echo guide for artery repair,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,270.61,"1,654.72",,,,,,
BCBS PPO,CPT,76937,Us guide vascular access,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,202.07,202.07,,,,,,
BCBS PPO,CPT,76940,Us guide tissue ablation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,930.3,930.3,,,,,,
BCBS PPO,CPT,76941,Echo guide for transfusion,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,640.54,640.54,,,,,,
BCBS PPO,CPT,76942,Echo guide for biopsy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,995.12,995.12,,,,,,
BCBS PPO,CPT,76945,Echo guide villus sampling,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,480.4,480.4,,,,,,
BCBS PPO,CPT,76946,Echo guide for amniocentesis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,244.01,244.01,,,,,,
BCBS PPO,CPT,76950,Echo guidance radiotherapy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,369.83,369.83,,,,,,
BCBS PPO,CPT,76965,Echo guidance radiotherapy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,800.67,800.67,,,,,,
BCBS PPO,CPT,76970,Ultrasound exam follow-up,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,430.83,430.83,,,,,,
BCBS PPO,CPT,76975,Gi endoscopic ultrasound,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,529.96,,,,,,
BCBS PPO,CPT,76977,Us bone density measure,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,80.07,111.51,,,,,,
BCBS PPO,CPT,76998,Us guide intraop,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,324.09,324.09,,,,,,
BCBS PPO,CPT,77001,Fluoroguide for vein device,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,541.4,541.4,,,,,,
BCBS PPO,CPT,77002,Needle localization by xray,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,369.83,369.83,,,,,,
BCBS PPO,CPT,77003,Fluoroguide for spine inject,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,312.64,312.64,,,,,,
BCBS PPO,CPT,77011,Ct scan for localization,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,927,"3,500.05",,,,,,
BCBS PPO,CPT,77012,Ct scan for needle biopsy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,689.66,927,,,,,,
BCBS PPO,CPT,77013,Ct guide for tissue ablation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,689.66,927,,,,,,
BCBS PPO,CPT,77014,Ct scan for therapy guide,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,689.66,927,,,,,,
BCBS PPO,CPT,77021,Mri guidance ndl plmt rs&i,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,507.00","2,363.88",,,,,,
BCBS PPO,CPT,77022,Mri gdn parnchyma tiss abltj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,507.00","3,637.31",,,,,,
BCBS PPO,CPT,77031,Stereotact guide for brst bx,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,044.69","1,044.69",,,,,,
BCBS PPO,CPT,77032,Guidance for needle breast,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,312.64,312.64,,,,,,
BCBS PPO,CPT,77046,Mri breast c- unilateral,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,"1,507.00",,,,,,
BCBS PPO,CPT,77047,Mri breast c- bilateral,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,"1,507.00",,,,,,
BCBS PPO,CPT,77048,Mri breast c-+ w/cad uni,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,149.44","1,507.00",,,,,,
BCBS PPO,CPT,77049,Mri breast c-+ w/cad bi,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,149.44","1,507.00",,,,,,
BCBS PPO,CPT,77051,Computer dx mammogram add-on,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,45.98,45.98,,,,,,
BCBS PPO,CPT,77052,Comp screen mammogram add-on,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,45.98,45.98,,,,,,
BCBS PPO,CPT,77053,X-ray of mammary duct,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,411.78,,,,,,
BCBS PPO,CPT,77055,Mammogram one breast,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,183.91,183.91,,,,,,
BCBS PPO,CPT,77056,Mammogram both breasts,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,183.91,183.91,,,,,,
BCBS PPO,CPT,77057,Mammogram screening,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,183.91,183.91,,,,,,
BCBS PPO,CPT,77058,Mri one breast,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,149.44","1,149.44",,,,,,
BCBS PPO,CPT,77059,Mri both breasts,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,149.44","1,149.44",,,,,,
BCBS PPO,CPT,77065,Dx mammo incl cad uni,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,83.47,275.87,,,,,,
BCBS PPO,CPT,77066,Dx mammo incl cad bi,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,106.7,275.87,,,,,,
BCBS PPO,CPT,77067,Scr mammo bi incl cad,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,88.24,275.87,,,,,,
BCBS PPO,CPT,77071,X-ray stress view,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,205.88,,,,,,
BCBS PPO,CPT,77072,X-rays for bone age,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,122,,,,,,
BCBS PPO,CPT,77073,X-rays bone length studies,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,198.25,,,,,,
BCBS PPO,CPT,77074,X-rays bone survey limited,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,358.39,,,,,,
BCBS PPO,CPT,77075,X-rays bone survey complete,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,514.72,,,,,,
BCBS PPO,CPT,77076,X-rays bone survey infant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,476.6,,,,,,
BCBS PPO,CPT,77077,Joint survey single view,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,224.95,,,,,,
BCBS PPO,CPT,77078,Ct bone density axial,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,927,,,,,,
BCBS PPO,CPT,77079,Ct bone density peripheral,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,301.2,301.2,,,,,,
BCBS PPO,CPT,77080,Dxa bone density axial,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,537.6,,,,,,
BCBS PPO,CPT,77081,Dxa bone density/peripheral,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,167.76,,,,,,
BCBS PPO,CPT,77082,Dxa bone density vert fx,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,213.51,213.51,,,,,,
BCBS PPO,CPT,77083,Radiographic absorptiometry,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,144.88,144.88,,,,,,
BCBS PPO,CPT,77084,Magnetic image bone marrow,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,"1,507.00",,,,,,
BCBS PPO,CPT,77086,Fracture assessment via dxa,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.79,213.51,,,,,,
BCBS PPO,CPT,77261,Radiation therapy planning,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,358.39,358.39,,,,,,
BCBS PPO,CPT,77262,Radiation therapy planning,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,541.4,541.4,,,,,,
BCBS PPO,CPT,77263,Radiation therapy planning,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,800.67,800.67,,,,,,
BCBS PPO,CPT,77280,Set radiation therapy field,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,129.83,964.61,,,,,,
BCBS PPO,CPT,77285,Set radiation therapy field,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,346.58,"1,662.33",,,,,,
BCBS PPO,CPT,77290,Set radiation therapy field,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,346.58,"2,558.32",,,,,,
BCBS PPO,CPT,77293,Respirator motion mgmt simul,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,,,,,,,,
BCBS PPO,CPT,77295,3-d radiotherapy plan,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,291.62","3,736.44",,,,,,
BCBS PPO,CPT,77300,Radiation therapy dose plan,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,129.83,388.89,,,,,,
BCBS PPO,CPT,77301,Radiotherapy dose plan imrt,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,291.62","11,205.50",,,,,,
BCBS PPO,CPT,77305,Teletx isodose plan simple,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,392.7,392.7,,,,,,
BCBS PPO,CPT,77306,Telethx isodose plan simple,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,346.58,392.7,,,,,,
BCBS PPO,CPT,77307,Telethx isodose plan cplx,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,346.58,777.79,,,,,,
BCBS PPO,CPT,77310,Teletx isodose plan intermed,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,537.6,537.6,,,,,,
BCBS PPO,CPT,77315,Teletx isodose plan complex,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,777.79,777.79,,,,,,
BCBS PPO,CPT,77316,Brachytx isodose plan simple,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,346.58,747.28,,,,,,
BCBS PPO,CPT,77317,Brachytx isodose intermed,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,346.58,"1,059.93",,,,,,
BCBS PPO,CPT,77318,Brachytx isodose complex,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,346.58,"1,456.44",,,,,,
BCBS PPO,CPT,77321,Special teletx port plan,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,346.58,659.6,,,,,,
BCBS PPO,CPT,77326,Brachytx isodose calc simp,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,747.28,747.28,,,,,,
BCBS PPO,CPT,77327,Brachytx isodose calc interm,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,059.93","1,059.93",,,,,,
BCBS PPO,CPT,77328,Brachytx isodose plan compl,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,456.44","1,456.44",,,,,,
BCBS PPO,CPT,77331,Special radiation dosimetry,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,129.83,320.27,,,,,,
BCBS PPO,CPT,77332,Radiation treatment aid(s),Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,129.83,407.96,,,,,,
BCBS PPO,CPT,77333,Radiation treatment aid(s),Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,129.83,369.83,,,,,,
BCBS PPO,CPT,77334,Radiation treatment aid(s),Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,346.58,869.3,,,,,,
BCBS PPO,CPT,77336,Radiation physics consult,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,129.83,343.14,,,,,,
BCBS PPO,CPT,77370,Radiation physics consult,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,129.83,629.1,,,,,,
BCBS PPO,CPT,77371,Srs multisource,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"6,969.60","7,954.01",,,,,,
BCBS PPO,CPT,77372,Srs linear based,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"4,148.22","7,954.01",,,,,,
BCBS PPO,CPT,77373,Sbrt delivery,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,774.17","13,221.44",,,,,,
BCBS PPO,CPT,77385,Ntsty modul rad tx dlvr smpl,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,555.2,"1,379.33",,,,,,
BCBS PPO,CPT,77386,Ntsty modul rad tx dlvr cplx,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,555.2,"1,379.33",,,,,,
BCBS PPO,CPT,77387,Guidance for radj tx dlvr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,632.91,632.91,,,,,,
BCBS PPO,CPT,77401,Radiation treatment delivery,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,123.36,183.02,,,,,,
BCBS PPO,CPT,77403,Radiation treatment delivery,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,625.29,625.29,,,,,,
BCBS PPO,CPT,77404,Radiation treatment delivery,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,686.28,686.28,,,,,,
BCBS PPO,CPT,77408,Radiation treatment delivery,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,831.17,831.17,,,,,,
BCBS PPO,CPT,77409,Radiation treatment delivery,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,915.04,915.04,,,,,,
BCBS PPO,CPT,77411,Radiation treatment delivery,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,911.23,911.23,,,,,,
BCBS PPO,CPT,77412,Radiation treatment delivery,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,247.32,"1,067.55",,,,,,
BCBS PPO,CPT,77413,Radiation treatment delivery,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,294.26,294.26,,,,,,
BCBS PPO,CPT,77414,Radiation treatment delivery,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,189.56","1,189.56",,,,,,
BCBS PPO,CPT,77416,Radiation treatment delivery,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,197.20","1,197.20",,,,,,
BCBS PPO,CPT,77417,Radiology port images(s),Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,95.32,95.32,,,,,,
BCBS PPO,CPT,77418,Radiation tx delivery imrt,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,379.33","1,379.33",,,,,,
BCBS PPO,CPT,77421,Stereoscopic x-ray guidance,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,632.91,632.91,,,,,,
BCBS PPO,CPT,77422,Neutron beam tx simple,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,078.99","1,078.99",,,,,,
BCBS PPO,CPT,77423,Neutron beam tx complex,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,555.2,"1,235.32",,,,,,
BCBS PPO,CPT,77427,Radiation tx management x5,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,017.99","1,017.99",,,,,,
BCBS PPO,CPT,77431,Radiation therapy management,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,522.34,522.34,,,,,,
BCBS PPO,CPT,77432,Stereotactic radiation trmt,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,177.05","2,177.05",,,,,,
BCBS PPO,CPT,77435,Sbrt management,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,610.62","3,610.62",,,,,,
BCBS PPO,CPT,77470,Special radiation treatment,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,555.2,"1,509.83",,,,,,
BCBS PPO,CPT,77600,Hyperthermia treatment,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,247.32,"1,902.54",,,,,,
BCBS PPO,CPT,77605,Hyperthermia treatment,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,724.98,"3,397.11",,,,,,
BCBS PPO,CPT,77610,Hyperthermia treatment,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,555.2,"3,156.91",,,,,,
BCBS PPO,CPT,77615,Hyperthermia treatment,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,555.2,"4,464.67",,,,,,
BCBS PPO,CPT,77620,Hyperthermia treatment,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,555.2,"2,013.11",,,,,,
BCBS PPO,CPT,77750,Infuse radioactive materials,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,247.32,"1,730.97",,,,,,
BCBS PPO,CPT,77761,Apply intrcav radiat simple,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,555.2,"1,803.41",,,,,,
BCBS PPO,CPT,77762,Apply intrcav radiat interm,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,555.2,"2,463.00",,,,,,
BCBS PPO,CPT,77770,Hdr rdncl ntrstl/icav brchtx,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,724.98,964.61,,,,,,
BCBS PPO,CPT,77771,Hdr rdncl ntrstl/icav brchtx,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,724.98,"2,882.39",,,,,,
BCBS PPO,CPT,77772,Hdr rdncl ntrstl/icav brchtx,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,724.98,"4,285.47",,,,,,
BCBS PPO,CPT,77776,Apply interstit radiat simpl,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,154.18","2,154.18",,,,,,
BCBS PPO,CPT,77777,Apply interstit radiat inter,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,947.21","2,947.21",,,,,,
BCBS PPO,CPT,77778,Apply interstit radiat compl,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,724.98,"4,209.21",,,,,,
BCBS PPO,CPT,77785,Hdr brachytx 1 channel,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,964.61,964.61,,,,,,
BCBS PPO,CPT,77786,Hdr brachytx 2-12 channel,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,882.39","2,882.39",,,,,,
BCBS PPO,CPT,77787,Hdr brachytx over 12 chan,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"4,285.47","4,285.47",,,,,,
BCBS PPO,CPT,77789,Apply surf ldr radionuclide,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,123.36,533.78,,,,,,
BCBS PPO,CPT,77790,Radiation handling,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,446.08,446.08,,,,,,
BCBS PPO,CPT,78000,Thyroid single uptake,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,358.39,358.39,,,,,,
BCBS PPO,CPT,78001,Thyroid multiple uptakes,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,453.71,453.71,,,,,,
BCBS PPO,CPT,78003,Thyroid suppress/stimul,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,392.7,392.7,,,,,,
BCBS PPO,CPT,78006,Thyroid imaging with uptake,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,105.68","1,105.68",,,,,,
BCBS PPO,CPT,78007,Thyroid image mult uptakes,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,686.28,686.28,,,,,,
BCBS PPO,CPT,78010,Thyroid imaging,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,773.98,773.98,,,,,,
BCBS PPO,CPT,78011,Thyroid imaging with flow,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,884.55,884.55,,,,,,
BCBS PPO,CPT,78012,Thyroid uptake measurement,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,453.71,,,,,,
BCBS PPO,CPT,78013,Thyroid imaging w/blood flow,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,884.55,,,,,,
BCBS PPO,CPT,78014,Thyroid imaging w/blood flow,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,"1,105.68",,,,,,
BCBS PPO,CPT,78015,Thyroid met imaging,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,"1,044.69",,,,,,
BCBS PPO,CPT,78016,Thyroid met imaging/studies,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,"1,578.46",,,,,,
BCBS PPO,CPT,78018,Thyroid met imaging body,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,500.81,"1,616.58",,,,,,
BCBS PPO,CPT,78020,Thyroid met uptake,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,480.4,480.4,,,,,,
BCBS PPO,CPT,78070,Parathyroid planar imaging,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,884.55,,,,,,
BCBS PPO,CPT,78071,Parathyrd planar w/wo subtrj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,884.55,,,,,,
BCBS PPO,CPT,78072,Parathyrd planar w/spect&ct,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,500.81,884.55,,,,,,
BCBS PPO,CPT,78075,Adrenal cortex & medulla img,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,336.39","2,085.54",,,,,,
BCBS PPO,CPT,78103,Bone marrow imaging mult,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,"1,109.50",,,,,,
BCBS PPO,CPT,78104,Bone marrow imaging body,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,"1,273.44",,,,,,
BCBS PPO,CPT,78111,Plasma volume multiple,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,518.52,"1,336.39",,,,,,
BCBS PPO,CPT,78121,Red cell mass multiple,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,500.81,552.84,,,,,,
BCBS PPO,CPT,78122,Blood volume,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,500.81,701.54,,,,,,
BCBS PPO,CPT,78130,Red cell survival study,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,793.05,,,,,,
BCBS PPO,CPT,78135,Red cell survival kinetics,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,643.28","1,643.28",,,,,,
BCBS PPO,CPT,78140,Red cell sequestration,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,781.61,,,,,,
BCBS PPO,CPT,78190,Platelet survival kinetics,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,891.10","1,891.10",,,,,,
BCBS PPO,CPT,78191,Platelet survival,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,"1,067.55",,,,,,
BCBS PPO,CPT,78195,Lymph system imaging,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,500.81,"1,704.28",,,,,,
BCBS PPO,CPT,78201,Liver imaging,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,500.81,884.55,,,,,,
BCBS PPO,CPT,78202,Liver imaging with flow,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,500.81,"1,014.17",,,,,,
BCBS PPO,CPT,78205,Liver imaging (3d),Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,242.94","1,242.94",,,,,,
BCBS PPO,CPT,78215,Liver and spleen imaging,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,941.74,,,,,,
BCBS PPO,CPT,78216,Liver & spleen image/flow,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,728.23,,,,,,
BCBS PPO,CPT,78220,Liver function study,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,758.72,758.72,,,,,,
BCBS PPO,CPT,78223,Hepatobiliary imaging,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,570.83","1,570.83",,,,,,
BCBS PPO,CPT,78226,Hepatobiliary system imaging,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,"1,570.83",,,,,,
BCBS PPO,CPT,78227,Hepatobil syst image w/drug,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,500.81,"1,570.83",,,,,,
BCBS PPO,CPT,78230,Salivary gland imaging,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,804.48,,,,,,
BCBS PPO,CPT,78231,Serial salivary imaging,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,697.72,,,,,,
BCBS PPO,CPT,78232,Salivary gland function exam,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,712.98,,,,,,
BCBS PPO,CPT,78258,Esophageal motility study,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,"1,113.30",,,,,,
BCBS PPO,CPT,78261,Gastric mucosa imaging,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,"1,242.94",,,,,,
BCBS PPO,CPT,78262,Gastroesophageal reflux exam,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,"1,227.68",,,,,,
BCBS PPO,CPT,78264,Gastric emptying imag study,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,"1,403.08",,,,,,
BCBS PPO,CPT,78265,Gastric emptying imag study,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,"1,403.08",,,,,,
BCBS PPO,CPT,78266,Gastric emptying imag study,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,500.81,"1,403.08",,,,,,
BCBS PPO,CPT,78268,Breath test analysis c-14,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,94.41,301.2,,,,,,
BCBS PPO,CPT,78270,Vit b-12 absorption exam,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,415.59,415.59,,,,,,
BCBS PPO,CPT,78271,Vit b-12 absrp exam int fac,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,419.4,419.4,,,,,,
BCBS PPO,CPT,78272,Vit b-12 absorp combined,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,476.6,476.6,,,,,,
BCBS PPO,CPT,78282,Gi protein loss exam,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,407.96,,,,,,
BCBS PPO,CPT,78290,Meckels divert exam,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,"1,498.39",,,,,,
BCBS PPO,CPT,78291,Leveen/shunt patency exam,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,"1,227.68",,,,,,
BCBS PPO,CPT,78300,Bone imaging limited area,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,869.3,,,,,,
BCBS PPO,CPT,78305,Bone imaging multiple areas,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,"1,155.24",,,,,,
BCBS PPO,CPT,78306,Bone imaging whole body,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,"1,281.07",,,,,,
BCBS PPO,CPT,78315,Bone imaging 3 phase,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,"1,692.84",,,,,,
BCBS PPO,CPT,78320,Bone imaging (3d),Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,326.82","1,326.82",,,,,,
BCBS PPO,CPT,78350,Bone mineral single photon,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,179.2,179.2,,,,,,
BCBS PPO,CPT,78351,Bone mineral dual photon,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.26,76.26,,,,,,
BCBS PPO,CPT,78414,Non-imaging heart function,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,377.46,500.81,,,,,,
BCBS PPO,CPT,78428,Cardiac shunt imaging,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,998.92,,,,,,
BCBS PPO,CPT,78429,Myocrd img pet 1 std w/ct,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,514.86","7,240.30",,,,,,
BCBS PPO,CPT,78430,Myocrd img pet rst/strs w/ct,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,514.86","7,217.42",,,,,,
BCBS PPO,CPT,78431,Myocrd img pet rst&strs ct,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,150.30","7,339.44",,,,,,
BCBS PPO,CPT,78432,Myocrd img pet 2rtracer,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,628.05","8,030.21",,,,,,
BCBS PPO,CPT,78433,Myocrd img pet 2rtracer ct,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,628.05","8,778.55",,,,,,
BCBS PPO,CPT,78445,Vascular flow imaging,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,838.79,,,,,,
BCBS PPO,CPT,78451,Ht muscle image spect sing,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,336.39","2,116.06",,,,,,
BCBS PPO,CPT,78452,Ht muscle image spect mult,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,336.39","3,343.73",,,,,,
BCBS PPO,CPT,78453,Ht muscle image planar sing,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,336.39","1,631.84",,,,,,
BCBS PPO,CPT,78454,Ht musc image planar mult,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,336.39","1,772.90",,,,,,
BCBS PPO,CPT,78456,Acute venous thrombus image,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,336.39","1,784.34",,,,,,
BCBS PPO,CPT,78457,Venous thrombosis imaging,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,500.81,964.61,,,,,,
BCBS PPO,CPT,78458,Ven thrombosis images bilat,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,"1,078.99",,,,,,
BCBS PPO,CPT,78459,Myocrd img pet single study,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,336.39","7,240.30",,,,,,
BCBS PPO,CPT,78460,Heart muscle blood - single,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,964.61,964.61,,,,,,
BCBS PPO,CPT,78461,Heart muscle blood - multiple,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,105.68","1,105.68",,,,,,
BCBS PPO,CPT,78464,Heart image (3d) - single,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,448.82","1,448.82",,,,,,
BCBS PPO,CPT,78465,Heart image (3d) - multiple,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,676.51","2,676.51",,,,,,
BCBS PPO,CPT,78466,Heart infarct image,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,922.67,,,,,,
BCBS PPO,CPT,78468,Heart infarct image (ef),Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,500.81,"1,166.68",,,,,,
BCBS PPO,CPT,78469,Heart infarct image (3d),Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,500.81,"1,338.26",,,,,,
BCBS PPO,CPT,78472,Gated heart planar single,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,"1,368.75",,,,,,
BCBS PPO,CPT,78473,Gated heart multiple,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,"1,872.03",,,,,,
BCBS PPO,CPT,78481,Heart first pass single,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,500.81,"1,201.00",,,,,,
BCBS PPO,CPT,78483,Heart first pass multiple,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,500.81,"1,700.46",,,,,,
BCBS PPO,CPT,78491,Myocrd img pet 1std rst/strs,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,514.86","7,217.42",,,,,,
BCBS PPO,CPT,78492,Myocrd img pet mlt rst&strs,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,514.86","7,339.44",,,,,,
BCBS PPO,CPT,78494,Heart image spect,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,"1,486.95",,,,,,
BCBS PPO,CPT,78496,Heart first pass add-on,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,648.16,648.16,,,,,,
BCBS PPO,CPT,78579,Lung ventilation imaging,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,"1,155.24",,,,,,
BCBS PPO,CPT,78580,Lung perfusion imaging,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,"1,071.37",,,,,,
BCBS PPO,CPT,78582,Lung ventilat&perfus imaging,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,500.81,"1,769.09",,,,,,
BCBS PPO,CPT,78584,Lung V/Q image single breath,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,819.73,819.73,,,,,,
BCBS PPO,CPT,78585,Lung V/Q imaging,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,769.09","1,769.09",,,,,,
BCBS PPO,CPT,78587,Aerosol lung image multiple,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,021.81","1,021.81",,,,,,
BCBS PPO,CPT,78588,Perfusion lung image,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,620.40","1,620.40",,,,,,
BCBS PPO,CPT,78591,Vent image 1 breath 1 proj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,831.17,831.17,,,,,,
BCBS PPO,CPT,78593,Vent image 1 proj gas,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,979.86,979.86,,,,,,
BCBS PPO,CPT,78594,Vent image mult proj gas,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,155.24","1,155.24",,,,,,
BCBS PPO,CPT,78596,Lung differential function,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,906.36","1,906.36",,,,,,
BCBS PPO,CPT,78597,Lung perfusion differential,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,"1,906.36",,,,,,
BCBS PPO,CPT,78598,Lung perf&ventilat diferentl,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,500.81,"1,906.36",,,,,,
BCBS PPO,CPT,78600,Brain image < 4 views,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,888.36,,,,,,
BCBS PPO,CPT,78601,Brain image w/flow < 4 views,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,"1,059.93",,,,,,
BCBS PPO,CPT,78605,Brain image 4+ views,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,500.81,991.29,,,,,,
BCBS PPO,CPT,78606,Brain image w/flow 4 + views,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,500.81,"1,540.33",,,,,,
BCBS PPO,CPT,78607,Brain imaging (3d),Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,868.22","1,868.22",,,,,,
BCBS PPO,CPT,78608,Brain imaging (pet),Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,514.86","7,209.80",,,,,,
BCBS PPO,CPT,78609,Brain imaging (pet),Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"7,194.56","7,194.56",,,,,,
BCBS PPO,CPT,78610,Brain flow imaging only,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,500.81,888.36,,,,,,
BCBS PPO,CPT,78630,Cerebrospinal fluid scan,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,500.81,"1,647.08",,,,,,
BCBS PPO,CPT,78635,Csf ventriculography,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,500.81,"1,475.51",,,,,,
BCBS PPO,CPT,78645,Csf shunt evaluation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,500.81,"1,502.21",,,,,,
BCBS PPO,CPT,78647,Cerebrospinal fluid scan,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,742.41","1,742.41",,,,,,
BCBS PPO,CPT,78650,Csf leakage imaging,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,336.39","1,601.33",,,,,,
BCBS PPO,CPT,78660,Nuclear exam of tear flow,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,831.17,,,,,,
BCBS PPO,CPT,78700,Kidney imaging morphol,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,884.55,,,,,,
BCBS PPO,CPT,78701,Kidney imaging with flow,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,"1,056.11",,,,,,
BCBS PPO,CPT,78707,K flow/funct image w/o drug,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,500.81,"1,235.32",,,,,,
BCBS PPO,CPT,78708,K flow/funct image w/drug,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,500.81,"1,014.17",,,,,,
BCBS PPO,CPT,78709,K flow/funct image multiple,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,500.81,"1,795.78",,,,,,
BCBS PPO,CPT,78710,Kidney imaging (3d),Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,235.32","1,235.32",,,,,,
BCBS PPO,CPT,78725,Kidney function study,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,518.52,,,,,,
BCBS PPO,CPT,78730,Urinary bladder retention,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,400.34,400.34,,,,,,
BCBS PPO,CPT,78740,Ureteral reflux study,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,"1,040.87",,,,,,
BCBS PPO,CPT,78761,Testicular imaging w/flow,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,"1,052.29",,,,,,
BCBS PPO,CPT,78800,Rp loclzj tum 1 area 1 d img,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,949.36,,,,,,
BCBS PPO,CPT,78801,Rp loclzj tum 2+area 1+d img,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,"1,265.81",,,,,,
BCBS PPO,CPT,78802,Rp loclzj tum whbdy 1 d img,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,336.39","1,654.72",,,,,,
BCBS PPO,CPT,78803,Rp loclzj tum spect 1 area,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,336.39","1,826.28",,,,,,
BCBS PPO,CPT,78804,Rp loclzj tum whbdy 2+d img,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,336.39","2,870.96",,,,,,
BCBS PPO,CPT,78805,Abscess imaging ltd area,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,949.36,949.36,,,,,,
BCBS PPO,CPT,78806,Abscess imaging whole body,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,738.59","1,738.59",,,,,,
BCBS PPO,CPT,78807,Nuclear localization/abscess,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,830.09","1,830.09",,,,,,
BCBS PPO,CPT,78812,Pet image skull-thigh,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,514.86","7,347.07",,,,,,
BCBS PPO,CPT,78813,Pet image full body,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,514.86","7,354.67",,,,,,
BCBS PPO,CPT,78814,Pet image w/ct lmtd,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,514.86","7,404.24",,,,,,
BCBS PPO,CPT,78815,Pet image w/ct skull-thigh,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,514.86","7,446.19",,,,,,
BCBS PPO,CPT,78816,Pet image w/ct full body,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,514.86","7,461.44",,,,,,
BCBS PPO,CPT,78830,Rp loclzj tum spect w/ct 1,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,927,"2,600.43",,,,,,
BCBS PPO,CPT,78831,Rp loclzj tum spect 2 areas,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,927,"3,860.65",,,,,,
BCBS PPO,CPT,78832,Rp loclzj tum spect w/ct 2,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,927,"5,097.10",,,,,,
BCBS PPO,CPT,79005,Nuclear rx oral admin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,255.45,800.67,,,,,,
BCBS PPO,CPT,79101,Nuclear rx iv admin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,255.45,896,,,,,,
BCBS PPO,CPT,79200,Nuclear rx intracav admin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,255.45,911.23,,,,,,
BCBS PPO,CPT,79300,Nuclr rx interstit colloid,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,255.45,724.42,,,,,,
BCBS PPO,CPT,79403,Hematopoietic nuclear tx,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,255.45,"1,132.37",,,,,,
BCBS PPO,CPT,79440,Nuclear rx intra-articular,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,255.45,838.79,,,,,,
BCBS PPO,CPT,79445,Nuclear rx intra-arterial,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,255.45,"1,162.87",,,,,,
BCBS PPO,CPT,80047,Metabolic panel ionized ca,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.73,41.94,,,,,,
BCBS PPO,CPT,80048,Metabolic panel total ca,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,8.46,132.19,,,,,,
BCBS PPO,CPT,80050,General health panel,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,266.89,266.89,,,,,,
BCBS PPO,CPT,80051,Electrolyte panel,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.01,34.31,,,,,,
BCBS PPO,CPT,80053,Comprehen metabolic panel,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,10.56,172.42,,,,,,
BCBS PPO,CPT,80055,Obstetric panel,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,47.81,301.2,,,,,,
BCBS PPO,CPT,80061,Lipid panel,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.39,68.63,,,,,,
BCBS PPO,CPT,80069,Renal function panel,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,8.68,38.13,,,,,,
BCBS PPO,CPT,80074,Acute hepatitis panel,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,47.63,213.51,,,,,,
BCBS PPO,CPT,80076,Hepatic function panel,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,8.17,126.44,,,,,,
BCBS PPO,CPT,80100,Drug screen qualitate/multi,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,64.82,64.82,,,,,,
BCBS PPO,CPT,80101,Drug screen single,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,92.24,92.24,,,,,,
BCBS PPO,CPT,80102,Drug confirmation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,57.19,57.19,,,,,,
BCBS PPO,CPT,80103,Drug analysis tissue prep,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.39,114.39,,,,,,
BCBS PPO,CPT,80150,Assay of amikacin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.08,49.56,,,,,,
BCBS PPO,CPT,80152,Assay of amitriptyline,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,80.07,80.07,,,,,,
BCBS PPO,CPT,80154,Assay of benzodiazepines,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,53.38,53.38,,,,,,
BCBS PPO,CPT,80156,Assay carbamazepine total,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.57,64.82,,,,,,
BCBS PPO,CPT,80157,Assay carbamazepine free,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.25,57.19,,,,,,
BCBS PPO,CPT,80158,Drug assay cyclosporine,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,18.05,80.07,,,,,,
BCBS PPO,CPT,80160,Assay of desipramine,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.26,76.26,,,,,,
BCBS PPO,CPT,80162,Assay of digoxin total,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.28,61,,,,,,
BCBS PPO,CPT,80163,Assay of digoxin free,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.28,61,,,,,,
BCBS PPO,CPT,80164,Assay dipropylacetic acd tot,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.54,61,,,,,,
BCBS PPO,CPT,80165,Dipropylacetic acid free,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.54,61,,,,,,
BCBS PPO,CPT,80166,Assay of doxepin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,68.63,68.63,,,,,,
BCBS PPO,CPT,80168,Assay of ethosuximide,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16.34,72.44,,,,,,
BCBS PPO,CPT,80170,Assay of gentamicin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16.38,72.44,,,,,,
BCBS PPO,CPT,80172,Assay of gold,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,72.44,72.44,,,,,,
BCBS PPO,CPT,80174,Assay of imipramine,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.26,76.26,,,,,,
BCBS PPO,CPT,80176,Assay of lidocaine,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.69,64.82,,,,,,
BCBS PPO,CPT,80178,Assay of lithium,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,6.61,30.51,,,,,,
BCBS PPO,CPT,80182,Assay of nortriptyline,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,61,61,,,,,,
BCBS PPO,CPT,80184,Assay of phenobarbital,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.3,49.56,,,,,,
BCBS PPO,CPT,80185,Assay of phenytoin total,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.25,57.19,,,,,,
BCBS PPO,CPT,80186,Assay of phenytoin free,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.76,61,,,,,,
BCBS PPO,CPT,80188,Assay of primidone,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16.59,72.44,,,,,,
BCBS PPO,CPT,80190,Assay of procainamide,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,60,76.26,,,,,,
BCBS PPO,CPT,80192,Assay of procainamide,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16.75,76.26,,,,,,
BCBS PPO,CPT,80194,Assay of quinidine,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.6,64.82,,,,,,
BCBS PPO,CPT,80195,Assay of sirolimus,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.73,61,,,,,,
BCBS PPO,CPT,80196,Assay of salicylate,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,30.51,30.51,,,,,,
BCBS PPO,CPT,80197,Assay of tacrolimus,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.73,61,,,,,,
BCBS PPO,CPT,80198,Assay of theophylline,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.14,64.82,,,,,,
BCBS PPO,CPT,80200,Assay of tobramycin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16.13,49.56,,,,,,
BCBS PPO,CPT,80201,Assay of topiramate,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.92,53.38,,,,,,
BCBS PPO,CPT,80202,Assay of vancomycin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.54,61,,,,,,
BCBS PPO,CPT,80299,Quantitative assay drug,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,18.64,61,,,,,,
BCBS PPO,CPT,80300,,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,,,,,,,,
BCBS PPO,CPT,80301,System Added,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,92.24,92.24,,,,,,
BCBS PPO,CPT,80305,Drug test prsmv dir opt obs,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.6,64.82,,,,,,
BCBS PPO,CPT,80306,Drug test prsmv instrmnt,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,17.14,64.82,,,,,,
BCBS PPO,CPT,80320,Drug screen quantalcohols,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,49.56,49.56,,,,,,
BCBS PPO,CPT,80323,Alkaloids nos,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,99.13,99.13,,,,,,
BCBS PPO,CPT,80324,Drug screen amphetamines 1/2,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,68.63,68.63,,,,,,
BCBS PPO,CPT,80325,Amphetamines 3or 4,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,68.63,68.63,,,,,,
BCBS PPO,CPT,80326,Amphetamines 5 or more,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,68.63,68.63,,,,,,
BCBS PPO,CPT,80327,Anabolic steroid 1 or 2,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.39,114.39,,,,,,
BCBS PPO,CPT,80328,Anabolic steroid 3 or more,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.39,114.39,,,,,,
BCBS PPO,CPT,80329,Analgesics non-opioid 1 or 2,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,60.35,60.35,,,,,,
BCBS PPO,CPT,80335,Antidepressant tricyclic 1/2,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.26,76.26,,,,,,
BCBS PPO,CPT,80336,Antidepressant tricyclic 3-5,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.26,76.26,,,,,,
BCBS PPO,CPT,80337,Tricyclic & cyclicals 6/more,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.26,76.26,,,,,,
BCBS PPO,CPT,80339,Antiepileptics nos 1-3,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,64.82,64.82,,,,,,
BCBS PPO,CPT,80340,Antiepileptics nos 4-6,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,64.82,64.82,,,,,,
BCBS PPO,CPT,80341,Antiepileptics nos 7/more,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,64.82,64.82,,,,,,
BCBS PPO,CPT,80342,Antipsychotics nos 1-3,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,68.63,68.63,,,,,,
BCBS PPO,CPT,80343,Antipsychotics nos 4-6,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,68.63,68.63,,,,,,
BCBS PPO,CPT,80344,Antipsychotics nos 7/more,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,68.63,68.63,,,,,,
BCBS PPO,CPT,80345,Drug screening barbiturates,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,49.56,49.56,,,,,,
BCBS PPO,CPT,80346,Benzodiazepines1-12,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,53.38,53.38,,,,,,
BCBS PPO,CPT,80347,Benzodiazepines 13 or more,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,53.38,53.38,,,,,,
BCBS PPO,CPT,80353,Drug screening cocaine,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,68.63,68.63,,,,,,
BCBS PPO,CPT,80358,Drug screening methadone,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,72.44,72.44,,,,,,
BCBS PPO,CPT,80361,Opiates 1 or more,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,91.51,91.51,,,,,,
BCBS PPO,CPT,80363,Opioids & opiate analogs 3/4,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,91.51,91.51,,,,,,
BCBS PPO,CPT,80364,Opioid &opiate analog 5/more,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,91.51,91.51,,,,,,
BCBS PPO,CPT,80400,Acth stimulation panel,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,32.62,144.88,,,,,,
BCBS PPO,CPT,80402,Acth stimulation panel,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,86.96,388.89,,,,,,
BCBS PPO,CPT,80406,Acth stimulation panel,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,78.26,346.96,,,,,,
BCBS PPO,CPT,80408,Aldosterone suppression eval,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,125.5,560.47,,,,,,
BCBS PPO,CPT,80410,Calcitonin stimul panel,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,80.37,358.39,,,,,,
BCBS PPO,CPT,80412,Crh stimulation panel,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,801.62,"1,467.89",,,,,,
BCBS PPO,CPT,80414,Testosterone response panel,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,51.64,228.77,,,,,,
BCBS PPO,CPT,80415,Tot estradiol response panel,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,55.89,99.13,,,,,,
BCBS PPO,CPT,80416,Renin stimulation panel,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,209.32,587.16,,,,,,
BCBS PPO,CPT,80417,Renin stimulation panel,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,43.99,194.45,,,,,,
BCBS PPO,CPT,80418,Pituitary evaluation panel,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,579.48,"2,573.58",,,,,,
BCBS PPO,CPT,80420,Dexamethasone panel,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,161.88,320.27,,,,,,
BCBS PPO,CPT,80422,Glucagon tolerance panel,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,46.07,205.88,,,,,,
BCBS PPO,CPT,80424,Glucagon tolerance panel,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,50.5,224.95,,,,,,
BCBS PPO,CPT,80426,Gonadotropin hormone panel,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,148.41,659.6,,,,,,
BCBS PPO,CPT,80428,Growth hormone panel,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,66.7,289.76,,,,,,
BCBS PPO,CPT,80430,Growth hormone panel,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,129.33,343.14,,,,,,
BCBS PPO,CPT,80432,Insulin suppression panel,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,165.61,602.41,,,,,,
BCBS PPO,CPT,80434,Insulin tolerance panel,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,285.03,449.9,,,,,,
BCBS PPO,CPT,80435,Insulin tolerance panel,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,103,449.9,,,,,,
BCBS PPO,CPT,80436,Metyrapone panel,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,91.16,301.2,,,,,,
BCBS PPO,CPT,80438,Trh stimulation panel,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,50.41,224.95,,,,,,
BCBS PPO,CPT,80439,Trh stimulation panel,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,67.21,297.39,,,,,,
BCBS PPO,CPT,80440,TRH stimulation panel,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,259.27,259.27,,,,,,
BCBS PPO,CPT,80502,Lab pathology consultation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,152.64,320.27,,,,,,
BCBS PPO,CPT,81000,Urinalysis nonauto w/scope,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,4.02,15.26,,,,,,
BCBS PPO,CPT,81001,Urinalysis auto w/scope,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.17,15.26,,,,,,
BCBS PPO,CPT,81002,Urinalysis nonauto w/o scope,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.48,11.44,,,,,,
BCBS PPO,CPT,81003,Urinalysis auto w/o scope,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,2.25,11.44,,,,,,
BCBS PPO,CPT,81005,Urinalysis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,2.17,11.44,,,,,,
BCBS PPO,CPT,81007,Urine screen for bacteria,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.44,29.98,,,,,,
BCBS PPO,CPT,81015,Microscopic exam of urine,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.05,15.26,,,,,,
BCBS PPO,CPT,81020,Urinalysis glass test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,4.7,15.26,,,,,,
BCBS PPO,CPT,81025,Urine pregnancy test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,8.61,30.51,,,,,,
BCBS PPO,CPT,81050,Urinalysis volume measure,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.64,11.44,,,,,,
BCBS PPO,CPT,81500,Onco (ovar) two proteins,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,91.51,260.5,,,,,,
BCBS PPO,CPT,81503,Onco (ovar) five proteins,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,91.51,897,,,,,,
BCBS PPO,CPT,81506,Endo assay seven anal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,57.19,68.92,,,,,,
BCBS PPO,CPT,81508,Ftl cgen abnor two proteins,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,54.3,144.88,,,,,,
BCBS PPO,CPT,81509,Ftl cgen abnor 3 proteins,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,213.51,"1,487.37",,,,,,
BCBS PPO,CPT,81510,Ftl cgen abnor three anal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,55.54,202.07,,,,,,
BCBS PPO,CPT,81511,Ftl cgen abnor four anal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,153.5,270.71,,,,,,
BCBS PPO,CPT,81512,Ftl cgen abnor five anal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,69.52,270.71,,,,,,
BCBS PPO,CPT,82000,Assay of blood acetaldehyde,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,45.74,45.74,,,,,,
BCBS PPO,CPT,82003,Assay of acetaminophen,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,87.69,87.69,,,,,,
BCBS PPO,CPT,82009,Test for acetone/ketones,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,4.52,19.07,,,,,,
BCBS PPO,CPT,82010,Acetone assay,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,8.17,41.94,,,,,,
BCBS PPO,CPT,82016,Acylcarnitines qual,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16.49,61,,,,,,
BCBS PPO,CPT,82017,Acylcarnitines quant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16.87,76.26,,,,,,
BCBS PPO,CPT,82024,Assay of acth,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.62,171.58,,,,,,
BCBS PPO,CPT,82030,Assay of adp & amp,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,25.8,99.13,,,,,,
BCBS PPO,CPT,82040,Assay of serum albumin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,4.95,22.88,,,,,,
BCBS PPO,CPT,82042,Other source albumin quan ea,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.78,26.7,,,,,,
BCBS PPO,CPT,82043,Ur albumin quantitative,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.78,26.7,,,,,,
BCBS PPO,CPT,82044,Ur albumin semiquantitative,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,6.23,22.88,,,,,,
BCBS PPO,CPT,82045,Albumin ischemia modified,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,33.94,125.82,,,,,,
BCBS PPO,CPT,82055,Assay of ethanol,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,49.56,49.56,,,,,,
BCBS PPO,CPT,82075,Assay of breath ethanol,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,30,45.74,,,,,,
BCBS PPO,CPT,82085,Assay of aldolase,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,9.71,41.94,,,,,,
BCBS PPO,CPT,82088,Assay of aldosterone,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,40.75,183.02,,,,,,
BCBS PPO,CPT,82101,Assay of urine alkaloids,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,99.13,99.13,,,,,,
BCBS PPO,CPT,82103,Alpha-1-antitrypsin total,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.44,61,,,,,,
BCBS PPO,CPT,82104,Alpha-1-antitrypsin pheno,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.46,64.82,,,,,,
BCBS PPO,CPT,82105,Alpha-fetoprotein serum,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16.77,76.26,,,,,,
BCBS PPO,CPT,82106,Alpha-fetoprotein amniotic,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,17,76.26,,,,,,
BCBS PPO,CPT,82107,Alpha-fetoprotein l3,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,64.41,209.7,,,,,,
BCBS PPO,CPT,82108,Assay of aluminum,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,25.48,114.39,,,,,,
BCBS PPO,CPT,82120,Amines vaginal fluid qual,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.99,19.07,,,,,,
BCBS PPO,CPT,82127,Amino acid single qual,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.18,61,,,,,,
BCBS PPO,CPT,82128,Amino acids mult qual,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.87,61,,,,,,
BCBS PPO,CPT,82131,Amino acids single quant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.98,76.26,,,,,,
BCBS PPO,CPT,82135,Assay aminolevulinic acid,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16.45,64.82,,,,,,
BCBS PPO,CPT,82136,Amino acids quant 2-5,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.61,76.26,,,,,,
BCBS PPO,CPT,82140,Assay of ammonia,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.57,64.82,,,,,,
BCBS PPO,CPT,82143,Amniotic fluid scan,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,9.35,30.51,,,,,,
BCBS PPO,CPT,82145,Assay of amphetamines,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,68.63,68.63,,,,,,
BCBS PPO,CPT,82150,Assay of amylase,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,6.48,34.31,,,,,,
BCBS PPO,CPT,82157,Assay of androstenedione,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,29.28,129.64,,,,,,
BCBS PPO,CPT,82160,Assay of androsterone,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,25.55,110.57,,,,,,
BCBS PPO,CPT,82163,Assay of angiotensin ii,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,20.52,91.51,,,,,,
BCBS PPO,CPT,82164,Angiotensin i enzyme test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.6,64.82,,,,,,
BCBS PPO,CPT,82172,Assay of apolipoprotein,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,21.09,68.63,,,,,,
BCBS PPO,CPT,82175,Assay of arsenic,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,18.97,83.87,,,,,,
BCBS PPO,CPT,82190,Atomic absorption,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.9,64.82,,,,,,
BCBS PPO,CPT,82205,Assay of barbiturates,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,49.56,49.56,,,,,,
BCBS PPO,CPT,82232,Assay of beta-2 protein,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16.18,72.44,,,,,,
BCBS PPO,CPT,82239,Bile acids total,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,17.12,76.26,,,,,,
BCBS PPO,CPT,82240,Bile acids cholylglycine,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.58,64.82,,,,,,
BCBS PPO,CPT,82247,Bilirubin total,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.02,26.7,,,,,,
BCBS PPO,CPT,82248,Bilirubin direct,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.02,26.7,,,,,,
BCBS PPO,CPT,82252,Fecal bilirubin test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,4.56,19.07,,,,,,
BCBS PPO,CPT,82261,Assay of biotinidase,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16.87,76.26,,,,,,
BCBS PPO,CPT,82270,Occult blood feces,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,4.38,15.26,,,,,,
BCBS PPO,CPT,82271,Occult blood other sources,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.32,15.26,,,,,,
BCBS PPO,CPT,82272,Occult bld feces 1-3 tests,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,4.23,15.26,,,,,,
BCBS PPO,CPT,82274,Assay test for blood fecal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.92,80.07,,,,,,
BCBS PPO,CPT,82286,Assay of bradykinin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.16,30.51,,,,,,
BCBS PPO,CPT,82300,Assay of cadmium,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,23.64,102.95,,,,,,
BCBS PPO,CPT,82306,Vitamin d 25 hydroxy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,29.6,356.68,,,,,,
BCBS PPO,CPT,82307,Assay of vitamin D,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,144.88,144.88,,,,,,
BCBS PPO,CPT,82308,Assay of calcitonin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.79,118.19,,,,,,
BCBS PPO,CPT,82310,Assay of calcium,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.16,22.88,,,,,,
BCBS PPO,CPT,82330,Assay of calcium,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.68,61,,,,,,
BCBS PPO,CPT,82331,Calcium infusion test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.34,22.88,,,,,,
BCBS PPO,CPT,82340,Assay of calcium in urine,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,6.03,26.7,,,,,,
BCBS PPO,CPT,82355,Calculus analysis qual,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.58,53.38,,,,,,
BCBS PPO,CPT,82360,Calculus assay quant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.87,45.74,,,,,,
BCBS PPO,CPT,82365,Calculus spectroscopy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.9,45.74,,,,,,
BCBS PPO,CPT,82370,X-ray assay calculus,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.52,45.74,,,,,,
BCBS PPO,CPT,82373,Assay c-d transfer measure,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,18.06,80.07,,,,,,
BCBS PPO,CPT,82374,Assay blood carbon dioxide,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,4.88,22.88,,,,,,
BCBS PPO,CPT,82375,Assay carboxyhb quant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.32,26.7,,,,,,
BCBS PPO,CPT,82376,Assay carboxyhb qual,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.07,26.7,,,,,,
BCBS PPO,CPT,82378,Carcinoembryonic antigen,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,18.96,83.87,,,,,,
BCBS PPO,CPT,82379,Assay of carnitine,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16.87,76.26,,,,,,
BCBS PPO,CPT,82380,Assay of carotene,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,9.22,41.94,,,,,,
BCBS PPO,CPT,82382,Assay urine catecholamines,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,27.3,76.26,,,,,,
BCBS PPO,CPT,82383,Assay blood catecholamines,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,29.08,110.57,,,,,,
BCBS PPO,CPT,82384,Assay three catecholamines,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,25.25,110.57,,,,,,
BCBS PPO,CPT,82387,Assay of cathepsin-d,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,18.06,91.51,,,,,,
BCBS PPO,CPT,82390,Assay of ceruloplasmin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,10.74,49.56,,,,,,
BCBS PPO,CPT,82397,Chemiluminescent assay,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.12,64.82,,,,,,
BCBS PPO,CPT,82415,Assay of chloramphenicol,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.67,57.19,,,,,,
BCBS PPO,CPT,82435,Assay of blood chloride,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,4.6,19.07,,,,,,
BCBS PPO,CPT,82436,Assay of urine chloride,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.75,22.88,,,,,,
BCBS PPO,CPT,82441,Test for chlorohydrocarbons,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,6.01,26.7,,,,,,
BCBS PPO,CPT,82465,Assay bld/serum cholesterol,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,4.35,22.88,,,,,,
BCBS PPO,CPT,82480,Assay serum cholinesterase,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.87,34.31,,,,,,
BCBS PPO,CPT,82482,Assay rbc cholinesterase,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,9.81,34.31,,,,,,
BCBS PPO,CPT,82485,Assay chondroitin sulfate,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,20.65,91.51,,,,,,
BCBS PPO,CPT,82486,Gas/liquid chromatography,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,80.07,80.07,,,,,,
BCBS PPO,CPT,82487,Paper chromatography,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,72.44,72.44,,,,,,
BCBS PPO,CPT,82488,Paper chromatography,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,95.32,95.32,,,,,,
BCBS PPO,CPT,82489,Thin layer chromatography,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,83.87,83.87,,,,,,
BCBS PPO,CPT,82491,Chromotography quant sing,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,80.07,80.07,,,,,,
BCBS PPO,CPT,82492,Chromotography quant mult,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,80.07,80.07,,,,,,
BCBS PPO,CPT,82495,Assay of chromium,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,20.28,91.51,,,,,,
BCBS PPO,CPT,82507,Assay of citrate,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,27.8,57.19,,,,,,
BCBS PPO,CPT,82520,Assay of cocaine,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,68.63,68.63,,,,,,
BCBS PPO,CPT,82523,Collagen crosslinks,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,18.68,95.32,,,,,,
BCBS PPO,CPT,82525,Assay of copper,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.41,53.38,,,,,,
BCBS PPO,CPT,82528,Assay of corticosterone,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.52,99.13,,,,,,
BCBS PPO,CPT,82530,Cortisol free,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16.71,76.26,,,,,,
BCBS PPO,CPT,82533,Total cortisol,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16.3,72.44,,,,,,
BCBS PPO,CPT,82540,Assay of creatine,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,4.64,19.07,,,,,,
BCBS PPO,CPT,82541,Column chromotography qual,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,80.07,80.07,,,,,,
BCBS PPO,CPT,82542,Col chromotography qual/quan,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,24.09,80.07,,,,,,
BCBS PPO,CPT,82543,Column chromotograph/isotope,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,80.07,80.07,,,,,,
BCBS PPO,CPT,82544,Column chromotograph/isotope,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,80.07,80.07,,,,,,
BCBS PPO,CPT,82550,Assay of ck (cpk),Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,6.51,30.51,,,,,,
BCBS PPO,CPT,82552,Assay of cpk in blood,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.39,61,,,,,,
BCBS PPO,CPT,82553,Creatine mb fraction,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.55,49.56,,,,,,
BCBS PPO,CPT,82554,Creatine isoforms,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.87,53.38,,,,,,
BCBS PPO,CPT,82565,Assay of creatinine,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.12,22.88,,,,,,
BCBS PPO,CPT,82570,Assay of urine creatinine,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.18,26.7,,,,,,
BCBS PPO,CPT,82575,Creatinine clearance test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,9.46,41.94,,,,,,
BCBS PPO,CPT,82585,Assay of cryofibrinogen,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.14,38.13,,,,,,
BCBS PPO,CPT,82595,Assay of cryoglobulin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,6.47,30.51,,,,,,
BCBS PPO,CPT,82607,Vitamin b-12,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.08,68.63,,,,,,
BCBS PPO,CPT,82610,Cystatin c,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,18.52,61,,,,,,
BCBS PPO,CPT,82615,Test for urine cystines,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,9.55,38.13,,,,,,
BCBS PPO,CPT,82626,Dehydroepiandrosterone,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,25.27,114.39,,,,,,
BCBS PPO,CPT,82627,Dehydroepiandrosterone,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.23,99.13,,,,,,
BCBS PPO,CPT,82633,Desoxycorticosterone,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,30.98,122,,,,,,
BCBS PPO,CPT,82634,Deoxycortisol,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,29.28,76.26,,,,,,
BCBS PPO,CPT,82638,Assay of dibucaine number,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.25,53.38,,,,,,
BCBS PPO,CPT,82642,Dihydrotestosterone,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,29.28,114.39,,,,,,
BCBS PPO,CPT,82646,Assay of dihydrocodeinone,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,91.51,91.51,,,,,,
BCBS PPO,CPT,82649,Assay of dihydromorphinone,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,91.51,91.51,,,,,,
BCBS PPO,CPT,82651,Assay of dihydrotestosterone,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.39,114.39,,,,,,
BCBS PPO,CPT,82652,Vit d 1 25-dihydroxy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.5,171.58,,,,,,
BCBS PPO,CPT,82654,Assay of dimethadione,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,61,61,,,,,,
BCBS PPO,CPT,82657,Enzyme cell activity,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.17,80.07,,,,,,
BCBS PPO,CPT,82664,Electrophoretic test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,61.5,122,,,,,,
BCBS PPO,CPT,82666,Assay of epiandrosterone,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,83.87,83.87,,,,,,
BCBS PPO,CPT,82668,Assay of erythropoietin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,18.79,83.87,,,,,,
BCBS PPO,CPT,82670,Assay of total estradiol,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,27.94,49.56,,,,,,
BCBS PPO,CPT,82671,Assay of estrogens,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,32.3,114.39,,,,,,
BCBS PPO,CPT,82672,Assay of estrogen,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,21.7,95.32,,,,,,
BCBS PPO,CPT,82677,Assay of estriol,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,24.18,49.56,,,,,,
BCBS PPO,CPT,82679,Assay of estrone,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,24.95,57.19,,,,,,
BCBS PPO,CPT,82690,Assay of ethchlorvynol,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.26,76.26,,,,,,
BCBS PPO,CPT,82693,Assay of ethylene glycol,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.9,64.82,,,,,,
BCBS PPO,CPT,82696,Assay of etiocholanolone,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.24,64.82,,,,,,
BCBS PPO,CPT,82715,Assay of fecal fat,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.26,22.97,,,,,,
BCBS PPO,CPT,82726,Long chain fatty acids,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.75,80.07,,,,,,
BCBS PPO,CPT,82728,Assay of ferritin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.63,61,,,,,,
BCBS PPO,CPT,82731,Assay of fetal fibronectin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,64.41,236.38,,,,,,
BCBS PPO,CPT,82735,Assay of fluoride,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,18.54,83.87,,,,,,
BCBS PPO,CPT,82742,Assay of flurazepam,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,87.69,87.69,,,,,,
BCBS PPO,CPT,82746,Assay of folic acid serum,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.7,64.82,,,,,,
BCBS PPO,CPT,82747,Assay of folic acid rbc,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,17.65,76.26,,,,,,
BCBS PPO,CPT,82757,Assay of semen fructose,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,17.34,76.26,,,,,,
BCBS PPO,CPT,82759,Assay of rbc galactokinase,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,21.48,95.32,,,,,,
BCBS PPO,CPT,82760,Assay of galactose,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.2,49.56,,,,,,
BCBS PPO,CPT,82775,Assay galactose transferase,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,21.07,80.07,,,,,,
BCBS PPO,CPT,82776,Galactose transferase test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.74,26.7,,,,,,
BCBS PPO,CPT,82784,Assay iga/igd/igg/igm each,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,9.3,41.94,,,,,,
BCBS PPO,CPT,82785,Assay of ige,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16.46,72.44,,,,,,
BCBS PPO,CPT,82787,Igg 1 2 3 or 4 each,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,8.02,34.31,,,,,,
BCBS PPO,CPT,82800,Blood ph,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11,30.51,,,,,,
BCBS PPO,CPT,82803,Blood gases any combination,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.07,61,,,,,,
BCBS PPO,CPT,82805,Blood gases w/o2 saturation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,78.77,141.07,,,,,,
BCBS PPO,CPT,82820,Hemoglobin-oxygen affinity,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.34,49.56,,,,,,
BCBS PPO,CPT,82926,Assay of gastric acid,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.88,22.88,,,,,,
BCBS PPO,CPT,82928,Assay of gastric acid,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,30.51,30.51,,,,,,
BCBS PPO,CPT,82938,Gastrin test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,17.69,80.07,,,,,,
BCBS PPO,CPT,82941,Assay of gastrin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,17.63,80.07,,,,,,
BCBS PPO,CPT,82943,Assay of glucagon,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.29,34.31,,,,,,
BCBS PPO,CPT,82945,Glucose other fluid,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.93,19.07,,,,,,
BCBS PPO,CPT,82946,Glucagon tolerance test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,17.77,68.63,,,,,,
BCBS PPO,CPT,82947,Assay glucose blood quant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.93,19.07,,,,,,
BCBS PPO,CPT,82948,Reagent strip/blood glucose,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.04,15.26,,,,,,
BCBS PPO,CPT,82950,Glucose test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,4.75,22.88,,,,,,
BCBS PPO,CPT,82951,Glucose tolerance test (gtt),Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.87,64.82,,,,,,
BCBS PPO,CPT,82952,Gtt-added samples,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.92,19.07,,,,,,
BCBS PPO,CPT,82953,Glucose-tolbutamide test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,68.63,68.63,,,,,,
BCBS PPO,CPT,82955,Assay of g6pd enzyme,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,9.7,41.94,,,,,,
BCBS PPO,CPT,82962,Glucose blood test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.28,11.44,,,,,,
BCBS PPO,CPT,82963,Assay of glucosidase,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,21.48,80.07,,,,,,
BCBS PPO,CPT,82965,Assay of gdh enzyme,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.15,34.31,,,,,,
BCBS PPO,CPT,82975,Assay of glutamine,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,72.44,72.44,,,,,,
BCBS PPO,CPT,82977,Assay of ggt,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.2,34.31,,,,,,
BCBS PPO,CPT,82978,Assay of glutathione,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.45,64.82,,,,,,
BCBS PPO,CPT,82979,Assay rbc glutathione,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,9.44,30.51,,,,,,
BCBS PPO,CPT,82980,Assay of glutethimide,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,80.07,80.07,,,,,,
BCBS PPO,CPT,82985,Assay of glycated protein,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16.76,76.26,,,,,,
BCBS PPO,CPT,83001,Assay of gonadotropin (fsh),Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,18.58,91.51,,,,,,
BCBS PPO,CPT,83002,Assay of gonadotropin (lh),Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,18.52,91.51,,,,,,
BCBS PPO,CPT,83003,Assay growth hormone (hgh),Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16.67,72.44,,,,,,
BCBS PPO,CPT,83008,Assay of guanosine,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.26,76.26,,,,,,
BCBS PPO,CPT,83009,H pylori (c-13) blood,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,67.36,301.2,,,,,,
BCBS PPO,CPT,83010,Assay of haptoglobin quant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.58,57.19,,,,,,
BCBS PPO,CPT,83012,Assay of haptoglobins,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.89,72.44,,,,,,
BCBS PPO,CPT,83013,H pylori (c-13) breath,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,67.36,301.2,,,,,,
BCBS PPO,CPT,83014,H pylori drug admin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.86,34.31,,,,,,
BCBS PPO,CPT,83015,Heavy metal qual any anal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,20.94,83.87,,,,,,
BCBS PPO,CPT,83018,Heavy metal quant each nes,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,21.96,99.13,,,,,,
BCBS PPO,CPT,83020,Hemoglobin electrophoresis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.87,45.74,,,,,,
BCBS PPO,CPT,83021,Hemoglobin chromotography,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,18.06,80.07,,,,,,
BCBS PPO,CPT,83036,Glycosylated hemoglobin test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,9.71,49.56,,,,,,
BCBS PPO,CPT,83037,Glycosylated hb home device,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,9.71,41.94,,,,,,
BCBS PPO,CPT,83045,Blood methemoglobin test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,6.49,22.88,,,,,,
BCBS PPO,CPT,83050,Blood methemoglobin assay,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,8.2,15.26,,,,,,
BCBS PPO,CPT,83055,Blood sulfhemoglobin test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.26,15.26,,,,,,
BCBS PPO,CPT,83060,Blood sulfhemoglobin assay,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,8.8,15.26,,,,,,
BCBS PPO,CPT,83065,Assay of hemoglobin heat,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,9,15.26,,,,,,
BCBS PPO,CPT,83069,Assay of urine hemoglobin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.95,7.62,,,,,,
BCBS PPO,CPT,83070,Assay of hemosiderin qual,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,4.75,15.26,,,,,,
BCBS PPO,CPT,83071,Assay of hemosiderin quant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.26,15.26,,,,,,
BCBS PPO,CPT,83080,Assay of b hexosaminidase,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16.87,76.26,,,,,,
BCBS PPO,CPT,83088,Assay of histamine,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,29.53,129.64,,,,,,
BCBS PPO,CPT,83090,Assay of homocystine,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,17.92,76.26,,,,,,
BCBS PPO,CPT,83150,Assay of homovanillic acid,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.41,87.69,,,,,,
BCBS PPO,CPT,83491,Assay of corticosteroids 17,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,17.9,76.26,,,,,,
BCBS PPO,CPT,83497,Assay of 5-hiaa,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.9,57.19,,,,,,
BCBS PPO,CPT,83498,Assay of progesterone 17-d,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,27.17,122,,,,,,
BCBS PPO,CPT,83499,Assay of progesterone,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,110.57,110.57,,,,,,
BCBS PPO,CPT,83500,Assay free hydroxyproline,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.65,99.13,,,,,,
BCBS PPO,CPT,83505,Assay total hydroxyproline,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,24.3,106.76,,,,,,
BCBS PPO,CPT,83516,Immunoassay nonantibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.53,49.56,,,,,,
BCBS PPO,CPT,83519,Ria nonantibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,18.4,61,,,,,,
BCBS PPO,CPT,83520,Immunoassay quant nos nonab,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,17.27,57.19,,,,,,
BCBS PPO,CPT,83525,Assay of insulin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.43,49.56,,,,,,
BCBS PPO,CPT,83527,Assay of insulin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.95,57.19,,,,,,
BCBS PPO,CPT,83528,Assay of intrinsic factor,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.82,72.44,,,,,,
BCBS PPO,CPT,83540,Assay of iron,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,6.47,30.51,,,,,,
BCBS PPO,CPT,83550,Iron binding test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,8.74,38.13,,,,,,
BCBS PPO,CPT,83570,Assay of idh enzyme,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,8.85,38.13,,,,,,
BCBS PPO,CPT,83586,Assay 17- ketosteroids,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.8,57.19,,,,,,
BCBS PPO,CPT,83593,Fractionation ketosteroids,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,28.5,118.19,,,,,,
BCBS PPO,CPT,83605,Assay of lactic acid,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.57,53.38,,,,,,
BCBS PPO,CPT,83615,Lactate (ld) (ldh) enzyme,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,6.04,26.7,,,,,,
BCBS PPO,CPT,83625,Assay of ldh enzymes,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.79,49.56,,,,,,
BCBS PPO,CPT,83630,Lactoferrin fecal (qual),Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.7,87.69,,,,,,
BCBS PPO,CPT,83631,Lactoferrin fecal (quant),Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.63,87.69,,,,,,
BCBS PPO,CPT,83632,Placental lactogen,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,20.22,91.51,,,,,,
BCBS PPO,CPT,83633,Test urine for lactose,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.25,22.88,,,,,,
BCBS PPO,CPT,83634,Assay of urine for lactose,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,49.56,49.56,,,,,,
BCBS PPO,CPT,83655,Assay of lead,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.11,53.38,,,,,,
BCBS PPO,CPT,83661,L/s ratio fetal lung,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,21.99,99.13,,,,,,
BCBS PPO,CPT,83662,Foam stability fetal lung,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,18.91,83.87,,,,,,
BCBS PPO,CPT,83663,Fluoro polarize fetal lung,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,18.91,83.87,,,,,,
BCBS PPO,CPT,83664,Lamellar bdy fetal lung,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.32,83.87,,,,,,
BCBS PPO,CPT,83670,Assay of lap enzyme,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,9.81,41.94,,,,,,
BCBS PPO,CPT,83690,Assay of lipase,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,6.89,61.5,,,,,,
BCBS PPO,CPT,83695,Assay of lipoprotein(a),Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.32,57.19,,,,,,
BCBS PPO,CPT,83698,Assay lipoprotein pla2,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,46.31,125.82,,,,,,
BCBS PPO,CPT,83700,Lipopro bld electrophoretic,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.26,49.56,,,,,,
BCBS PPO,CPT,83701,Lipoprotein bld hr fraction,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,33.86,110.57,,,,,,
BCBS PPO,CPT,83704,Lipoprotein bld quan part,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.19,141.07,,,,,,
BCBS PPO,CPT,83718,Assay of lipoprotein,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,8.19,41.94,,,,,,
BCBS PPO,CPT,83719,Assay of blood lipoprotein,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.75,53.38,,,,,,
BCBS PPO,CPT,83721,Assay of blood lipoprotein,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,10.5,41.94,,,,,,
BCBS PPO,CPT,83722,Lipoprtn dir meas sd ldl chl,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.19,141.07,,,,,,
BCBS PPO,CPT,83727,Assay of lrh hormone,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,17.19,76.26,,,,,,
BCBS PPO,CPT,83735,Assay of magnesium,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,6.7,34.31,,,,,,
BCBS PPO,CPT,83775,Assay malate dehydrogenase,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.37,34.31,,,,,,
BCBS PPO,CPT,83785,Assay of manganese,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.65,110.57,,,,,,
BCBS PPO,CPT,83789,Mass spectrometry qual/quan,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,24.11,80.07,,,,,,
BCBS PPO,CPT,83805,Assay of meprobamate,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,80.07,80.07,,,,,,
BCBS PPO,CPT,83825,Assay of mercury,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16.26,72.44,,,,,,
BCBS PPO,CPT,83835,Assay of metanephrines,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16.94,76.26,,,,,,
BCBS PPO,CPT,83840,Assay of methadone,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,72.44,72.44,,,,,,
BCBS PPO,CPT,83857,Assay of methemalbumin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,10.74,49.56,,,,,,
BCBS PPO,CPT,83858,Assay of methsuximide,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,64.82,64.82,,,,,,
BCBS PPO,CPT,83864,Mucopolysaccharides,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,28.5,87.69,,,,,,
BCBS PPO,CPT,83872,Assay synovial fluid mucin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.86,26.7,,,,,,
BCBS PPO,CPT,83873,Assay of csf protein,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,17.2,72.44,,,,,,
BCBS PPO,CPT,83874,Assay of myoglobin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.92,57.19,,,,,,
BCBS PPO,CPT,83876,Assay myeloperoxidase,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,50.86,57.19,,,,,,
BCBS PPO,CPT,83880,Assay of natriuretic peptide,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,39.26,245.98,,,,,,
BCBS PPO,CPT,83883,Assay nephelometry not spec,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.6,61,,,,,,
BCBS PPO,CPT,83885,Assay of nickel,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,24.51,45.74,,,,,,
BCBS PPO,CPT,83887,Assay of nicotine,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,91.51,91.51,,,,,,
BCBS PPO,CPT,83891,Molecule isolate nucleic,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,19.07,,,,,,
BCBS PPO,CPT,83892,Molecular diagnostics,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,19.07,,,,,,
BCBS PPO,CPT,83893,Molecule dot/slot/blot,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,19.07,,,,,,
BCBS PPO,CPT,83894,Molecule gel electrophor,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,19.07,,,,,,
BCBS PPO,CPT,83896,Molecular diagnostics,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,19.07,,,,,,
BCBS PPO,CPT,83898,Molecule nucleic ampli each,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.26,76.26,,,,,,
BCBS PPO,CPT,83900,Molecule nucleic ampli 2 seq,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,148.69,148.69,,,,,,
BCBS PPO,CPT,83901,Molecule nucleic ampli addon,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.26,76.26,,,,,,
BCBS PPO,CPT,83902,Molecular diagnostics,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,64.82,64.82,,,,,,
BCBS PPO,CPT,83903,Molecule mutation scan,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.26,76.26,,,,,,
BCBS PPO,CPT,83904,Molecule mutation identify,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.26,76.26,,,,,,
BCBS PPO,CPT,83905,Molecule mutation identify,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.26,76.26,,,,,,
BCBS PPO,CPT,83906,Molecule mutation identify,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.26,76.26,,,,,,
BCBS PPO,CPT,83907,Lyse cells for nucleic ext,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,61,61,,,,,,
BCBS PPO,CPT,83908,Nucleic acid signal ampli,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.26,76.26,,,,,,
BCBS PPO,CPT,83909,Nucleic acid high resolute,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.26,76.26,,,,,,
BCBS PPO,CPT,83912,Genetic examination,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,30.51,30.51,,,,,,
BCBS PPO,CPT,83913,Molecular rna stabilization,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,61,61,,,,,,
BCBS PPO,CPT,83914,Mutation ident ola/sbce/aspe,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.26,76.26,,,,,,
BCBS PPO,CPT,83916,Oligoclonal bands,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,27.39,87.69,,,,,,
BCBS PPO,CPT,83918,Organic acids total quant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,23.6,72.44,,,,,,
BCBS PPO,CPT,83921,Organic acid single quant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,21.21,72.44,,,,,,
BCBS PPO,CPT,83925,Assay of opiates,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,87.69,87.69,,,,,,
BCBS PPO,CPT,83930,Assay of blood osmolality,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,6.61,26.7,,,,,,
BCBS PPO,CPT,83935,Assay of urine osmolality,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,6.82,30.51,,,,,,
BCBS PPO,CPT,83937,Assay of osteocalcin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,29.85,133.45,,,,,,
BCBS PPO,CPT,83945,Assay of oxalate,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.45,57.19,,,,,,
BCBS PPO,CPT,83950,Oncoprotein her-2/neu,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,64.41,209.7,,,,,,
BCBS PPO,CPT,83951,Oncoprotein dcp,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,64.41,209.7,,,,,,
BCBS PPO,CPT,83970,Assay of parathormone,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,41.28,183.02,,,,,,
BCBS PPO,CPT,83986,Assay ph body fluid nos,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.58,19.07,,,,,,
BCBS PPO,CPT,83992,Assay for phencyclidine,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,64.82,64.82,,,,,,
BCBS PPO,CPT,83993,Assay for calprotectin fecal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.63,87.69,,,,,,
BCBS PPO,CPT,84022,Assay of phenothiazine,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,68.63,68.63,,,,,,
BCBS PPO,CPT,84030,Assay of blood pku,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.5,26.7,,,,,,
BCBS PPO,CPT,84035,Assay of phenylketones,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.98,15.26,,,,,,
BCBS PPO,CPT,84060,Assay acid phosphatase,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.64,34.31,,,,,,
BCBS PPO,CPT,84061,Phosphatase forensic exam,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.31,34.31,,,,,,
BCBS PPO,CPT,84066,Assay prostate phosphatase,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,9.66,41.94,,,,,,
BCBS PPO,CPT,84075,Assay alkaline phosphatase,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.18,26.7,,,,,,
BCBS PPO,CPT,84078,Assay alkaline phosphatase,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,8.26,34.31,,,,,,
BCBS PPO,CPT,84080,Assay alkaline phosphatases,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.78,64.82,,,,,,
BCBS PPO,CPT,84081,Assay phosphatidylglycerol,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16.52,72.44,,,,,,
BCBS PPO,CPT,84085,Assay of rbc pg6d enzyme,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,9.44,30.51,,,,,,
BCBS PPO,CPT,84087,Assay phosphohexose enzymes,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,10.73,45.74,,,,,,
BCBS PPO,CPT,84100,Assay of phosphorus,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,4.74,22.88,,,,,,
BCBS PPO,CPT,84105,Assay of urine phosphorus,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.78,22.88,,,,,,
BCBS PPO,CPT,84106,Test for porphobilinogen,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.82,19.07,,,,,,
BCBS PPO,CPT,84110,Assay of porphobilinogen,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,8.44,38.13,,,,,,
BCBS PPO,CPT,84120,Assay of urine porphyrins,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.71,64.82,,,,,,
BCBS PPO,CPT,84126,Assay of feces porphyrins,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,39.11,114.39,,,,,,
BCBS PPO,CPT,84127,Assay of feces porphyrins,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,53.38,53.38,,,,,,
BCBS PPO,CPT,84132,Assay of serum potassium,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,4.76,22.88,,,,,,
BCBS PPO,CPT,84133,Assay of urine potassium,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,4.73,19.07,,,,,,
BCBS PPO,CPT,84134,Assay of prealbumin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.59,64.82,,,,,,
BCBS PPO,CPT,84135,Assay of pregnanediol,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,21.27,57.19,,,,,,
BCBS PPO,CPT,84138,Assay of pregnanetriol,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,21.05,83.87,,,,,,
BCBS PPO,CPT,84140,Assay of pregnenolone,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,20.67,91.51,,,,,,
BCBS PPO,CPT,84143,Assay of 17-hydroxypregneno,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.81,102.95,,,,,,
BCBS PPO,CPT,84144,Assay of progesterone,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,20.86,91.51,,,,,,
BCBS PPO,CPT,84146,Assay of prolactin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.38,87.69,,,,,,
BCBS PPO,CPT,84152,Assay of psa complexed,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,18.39,80.07,,,,,,
BCBS PPO,CPT,84153,Assay of psa total,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,18.39,80.07,,,,,,
BCBS PPO,CPT,84154,Assay of psa free,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,18.39,80.07,,,,,,
BCBS PPO,CPT,84155,Assay of protein serum,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.67,15.26,,,,,,
BCBS PPO,CPT,84156,Assay of protein urine,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.67,15.26,,,,,,
BCBS PPO,CPT,84157,Assay of protein other,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,4,19.07,,,,,,
BCBS PPO,CPT,84160,Assay of protein any source,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.61,22.88,,,,,,
BCBS PPO,CPT,84163,Pappa serum,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.05,68.63,,,,,,
BCBS PPO,CPT,84165,Protein e-phoresis serum,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,10.74,49.56,,,,,,
BCBS PPO,CPT,84166,Protein e-phoresis/urine/csf,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,17.83,80.07,,,,,,
BCBS PPO,CPT,84181,Western blot test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,17.03,118.19,,,,,,
BCBS PPO,CPT,84182,Protein western blot test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,29.21,129.64,,,,,,
BCBS PPO,CPT,84202,Assay rbc protoporphyrin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.35,64.82,,,,,,
BCBS PPO,CPT,84203,Test rbc protoporphyrin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,9.74,38.13,,,,,,
BCBS PPO,CPT,84206,Assay of proinsulin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.69,80.07,,,,,,
BCBS PPO,CPT,84207,Assay of vitamin b-6,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,28.1,125.82,,,,,,
BCBS PPO,CPT,84210,Assay of pyruvate,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.48,49.56,,,,,,
BCBS PPO,CPT,84220,Assay of pyruvate kinase,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,9.44,41.94,,,,,,
BCBS PPO,CPT,84228,Assay of quinine,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.63,53.38,,,,,,
BCBS PPO,CPT,84233,Assay of estrogen,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,87.88,209.7,,,,,,
BCBS PPO,CPT,84234,Assay of progesterone,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,64.88,183.02,,,,,,
BCBS PPO,CPT,84235,Assay of endocrine hormone,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,71.23,163.95,,,,,,
BCBS PPO,CPT,84238,Assay nonendocrine receptor,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,36.57,163.95,,,,,,
BCBS PPO,CPT,84244,Assay of renin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,21.99,99.13,,,,,,
BCBS PPO,CPT,84255,Assay of selenium,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,25.53,114.39,,,,,,
BCBS PPO,CPT,84270,Assay of sex hormone globul,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,21.73,95.32,,,,,,
BCBS PPO,CPT,84285,Assay of silica,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,25.21,38.13,,,,,,
BCBS PPO,CPT,84295,Assay of serum sodium,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,4.81,22.88,,,,,,
BCBS PPO,CPT,84300,Assay of urine sodium,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.06,22.88,,,,,,
BCBS PPO,CPT,84302,Assay of sweat sodium,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,4.86,22.88,,,,,,
BCBS PPO,CPT,84305,Assay of somatomedin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,21.26,95.32,,,,,,
BCBS PPO,CPT,84307,Assay of somatostatin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,18.28,80.07,,,,,,
BCBS PPO,CPT,84311,Spectrophotometry,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,8.1,30.51,,,,,,
BCBS PPO,CPT,84315,Body fluid specific gravity,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.28,11.44,,,,,,
BCBS PPO,CPT,84376,Sugars single qual,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.5,22.88,,,,,,
BCBS PPO,CPT,84377,Sugars multiple qual,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.5,22.88,,,,,,
BCBS PPO,CPT,84378,Sugars single quant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.53,49.56,,,,,,
BCBS PPO,CPT,84379,Sugars multiple quant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.53,49.56,,,,,,
BCBS PPO,CPT,84392,Assay of urine sulfate,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.49,22.88,,,,,,
BCBS PPO,CPT,84402,Assay of free testosterone,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,25.47,114.39,,,,,,
BCBS PPO,CPT,84403,Assay of total testosterone,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,25.81,114.39,,,,,,
BCBS PPO,CPT,84425,Assay of vitamin b-1,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,21.23,95.32,,,,,,
BCBS PPO,CPT,84430,Assay of thiocyanate,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.63,53.38,,,,,,
BCBS PPO,CPT,84432,Assay of thyroglobulin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16.06,72.44,,,,,,
BCBS PPO,CPT,84436,Assay of total thyroxine,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,6.87,30.51,,,,,,
BCBS PPO,CPT,84437,Assay of neonatal thyroxine,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,6.47,30.51,,,,,,
BCBS PPO,CPT,84439,Assay of free thyroxine,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,9.02,41.94,,,,,,
BCBS PPO,CPT,84442,Assay of thyroid activity,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.78,64.82,,,,,,
BCBS PPO,CPT,84443,Assay thyroid stim hormone,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16.8,76.26,,,,,,
BCBS PPO,CPT,84445,Assay of tsi globulin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,50.86,224.95,,,,,,
BCBS PPO,CPT,84446,Assay of vitamin e,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.18,64.82,,,,,,
BCBS PPO,CPT,84449,Assay of transcortin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,18,80.07,,,,,,
BCBS PPO,CPT,84450,Transferase (ast) (sgot),Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.18,22.88,,,,,,
BCBS PPO,CPT,84460,Alanine amino (alt) (sgpt),Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.3,26.7,,,,,,
BCBS PPO,CPT,84466,Assay of transferrin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.76,57.19,,,,,,
BCBS PPO,CPT,84478,Assay of triglycerides,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.74,30.51,,,,,,
BCBS PPO,CPT,84479,Assay of thyroid (t3 or t4),Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,6.47,30.51,,,,,,
BCBS PPO,CPT,84480,Assay triiodothyronine (t3),Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.18,49.56,,,,,,
BCBS PPO,CPT,84481,Free assay (ft-3),Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16.94,49.56,,,,,,
BCBS PPO,CPT,84482,T3 reverse,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.76,68.63,,,,,,
BCBS PPO,CPT,84484,Assay of troponin quant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.47,92.24,,,,,,
BCBS PPO,CPT,84488,Test feces for trypsin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.3,34.31,,,,,,
BCBS PPO,CPT,84490,Assay of feces for trypsin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,9.93,26.7,,,,,,
BCBS PPO,CPT,84510,Assay of tyrosine,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,10.63,45.74,,,,,,
BCBS PPO,CPT,84512,Assay of troponin qual,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,10.09,34.31,,,,,,
BCBS PPO,CPT,84520,Assay of urea nitrogen,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.95,19.07,,,,,,
BCBS PPO,CPT,84525,Urea nitrogen semi-quant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.13,15.26,,,,,,
BCBS PPO,CPT,84540,Assay of urine/urea-n,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.56,22.88,,,,,,
BCBS PPO,CPT,84545,Urea-n clearance test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.2,19.07,,,,,,
BCBS PPO,CPT,84550,Assay of blood/uric acid,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,4.52,19.07,,,,,,
BCBS PPO,CPT,84560,Assay of urine/uric acid,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.08,22.88,,,,,,
BCBS PPO,CPT,84577,Assay of feces/urobilinogen,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16.8,57.19,,,,,,
BCBS PPO,CPT,84578,Test urine urobilinogen,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,4.47,15.26,,,,,,
BCBS PPO,CPT,84580,Assay of urine urobilinogen,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,9.55,19.07,,,,,,
BCBS PPO,CPT,84583,Assay of urine urobilinogen,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,6.05,22.88,,,,,,
BCBS PPO,CPT,84585,Assay of urine vma,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.5,68.63,,,,,,
BCBS PPO,CPT,84586,Assay of vip,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,35.33,156.32,,,,,,
BCBS PPO,CPT,84588,Assay of vasopressin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,33.94,125.82,,,,,,
BCBS PPO,CPT,84590,Assay of vitamin a,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.61,53.38,,,,,,
BCBS PPO,CPT,84591,Assay of nos vitamin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,17.06,53.38,,,,,,
BCBS PPO,CPT,84597,Assay of vitamin k,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.72,49.56,,,,,,
BCBS PPO,CPT,84600,Assay of volatiles,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,17.11,72.44,,,,,,
BCBS PPO,CPT,84620,Xylose tolerance test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.91,38.13,,,,,,
BCBS PPO,CPT,84630,Assay of zinc,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.39,49.56,,,,,,
BCBS PPO,CPT,84681,Assay of c-peptide,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,20.81,91.51,,,,,,
BCBS PPO,CPT,84702,Chorionic gonadotropin test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.05,76.26,,,,,,
BCBS PPO,CPT,84703,Chorionic gonadotropin assay,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.52,38.13,,,,,,
BCBS PPO,CPT,84704,Hcg free betachain test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.29,68.63,,,,,,
BCBS PPO,CPT,84830,Ovulation tests,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.7,49.56,,,,,,
BCBS PPO,CPT,85002,Bleeding time test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,4.82,22.88,,,,,,
BCBS PPO,CPT,85004,Automated diff wbc count,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,6.47,34.31,,,,,,
BCBS PPO,CPT,85007,Bl smear w/diff wbc count,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.8,19.07,,,,,,
BCBS PPO,CPT,85008,Bl smear w/o diff wbc count,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.43,19.07,,,,,,
BCBS PPO,CPT,85009,Manual diff wbc count b-coat,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.07,19.07,,,,,,
BCBS PPO,CPT,85014,Hematocrit,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,2.37,11.44,,,,,,
BCBS PPO,CPT,85018,Hemoglobin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,2.37,11.44,,,,,,
BCBS PPO,CPT,85025,Complete cbc w/auto diff wbc,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.77,67.65,,,,,,
BCBS PPO,CPT,85027,Complete cbc automated,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,6.47,34.31,,,,,,
BCBS PPO,CPT,85032,Manual cell count each,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,4.31,22.88,,,,,,
BCBS PPO,CPT,85041,Automated rbc count,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.02,11.44,,,,,,
BCBS PPO,CPT,85045,Automated reticulocyte count,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.99,19.07,,,,,,
BCBS PPO,CPT,85046,Reticyte/hgb concentrate,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.57,26.7,,,,,,
BCBS PPO,CPT,85048,Automated leukocyte count,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,2.54,11.44,,,,,,
BCBS PPO,CPT,85049,Automated platelet count,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,4.48,22.88,,,,,,
BCBS PPO,CPT,85055,Reticulated platelet assay,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,35.74,61,,,,,,
BCBS PPO,CPT,85060,Blood smear interpretation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.39,114.39,,,,,,
BCBS PPO,CPT,85097,Bone marrow interpretation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,438.47,671.45,,,,,,
BCBS PPO,CPT,85130,Chromogenic substrate assay,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.89,53.38,,,,,,
BCBS PPO,CPT,85175,Blood clot lysis time,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,20.37,,,,,,
BCBS PPO,CPT,85210,Clot factor ii prothrom spec,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.98,64.82,,,,,,
BCBS PPO,CPT,85220,Blooc clot factor v test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,17.65,80.07,,,,,,
BCBS PPO,CPT,85230,Clot factor vii proconvertin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,17.9,80.07,,,,,,
BCBS PPO,CPT,85240,Clot factor viii ahg 1 stage,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,17.9,80.07,,,,,,
BCBS PPO,CPT,85244,Clot factor viii reltd antgn,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,20.42,91.51,,,,,,
BCBS PPO,CPT,85245,Clot factor viii vw ristoctn,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.94,64.82,,,,,,
BCBS PPO,CPT,85246,Clot factor viii vw antigen,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.94,64.82,,,,,,
BCBS PPO,CPT,85250,Clot factor ix ptc/chrstmas,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.04,83.87,,,,,,
BCBS PPO,CPT,85260,Clot factor x stuart-power,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,17.9,80.07,,,,,,
BCBS PPO,CPT,85270,Clot factor xi pta,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,17.9,80.07,,,,,,
BCBS PPO,CPT,85280,Clot factor xii hageman,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.35,87.69,,,,,,
BCBS PPO,CPT,85290,Clot factor xiii fibrin stab,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16.34,72.44,,,,,,
BCBS PPO,CPT,85291,Clot factor xiii fibrin scrn,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,9.11,38.13,,,,,,
BCBS PPO,CPT,85292,Clot factor fletcher fact,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,18.93,83.87,,,,,,
BCBS PPO,CPT,85293,Clot factor wght kininogen,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,18.93,83.87,,,,,,
BCBS PPO,CPT,85300,Antithrombin iii activity,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.85,53.38,,,,,,
BCBS PPO,CPT,85301,Antithrombin iii antigen,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,10.81,49.56,,,,,,
BCBS PPO,CPT,85302,Clot inhibit prot c antigen,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.01,53.38,,,,,,
BCBS PPO,CPT,85303,Clot inhibit prot c activity,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.84,61,,,,,,
BCBS PPO,CPT,85305,Clot inhibit prot s total,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.61,53.38,,,,,,
BCBS PPO,CPT,85306,Clot inhibit prot s free,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.32,68.63,,,,,,
BCBS PPO,CPT,85307,Assay activated protein c,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.32,68.63,,,,,,
BCBS PPO,CPT,85337,Thrombomodulin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,17.27,45.74,,,,,,
BCBS PPO,CPT,85347,Coagulation time activated,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,4.28,15.26,,,,,,
BCBS PPO,CPT,85348,Coagulation time otr method,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,4.49,15.26,,,,,,
BCBS PPO,CPT,85360,Euglobulin lysis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,8.41,38.13,,,,,,
BCBS PPO,CPT,85362,Fibrin degradation products,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,6.89,30.51,,,,,,
BCBS PPO,CPT,85366,Fibrinogen test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,30.51,80.46,,,,,,
BCBS PPO,CPT,85370,Fibrinogen test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.43,49.56,,,,,,
BCBS PPO,CPT,85378,Fibrin degrade semiquant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,9.72,30.51,,,,,,
BCBS PPO,CPT,85379,Fibrin degradation quant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,10.18,135.29,,,,,,
BCBS PPO,CPT,85380,Fibrin degradj d-dimer,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,10.18,45.74,,,,,,
BCBS PPO,CPT,85384,Fibrinogen activity,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,9.72,38.13,,,,,,
BCBS PPO,CPT,85385,Fibrinogen antigen,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.46,38.13,,,,,,
BCBS PPO,CPT,85390,Fibrinolysins screen i&r,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.48,38.13,,,,,,
BCBS PPO,CPT,85396,Clotting assay whole blood,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,99.13,99.13,,,,,,
BCBS PPO,CPT,85400,Fibrinolytic plasmin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.71,38.13,,,,,,
BCBS PPO,CPT,85410,Fibrinolytic antiplasmin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.71,34.31,,,,,,
BCBS PPO,CPT,85415,Fibrinolytic plasminogen,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,17.19,76.26,,,,,,
BCBS PPO,CPT,85421,Fibrinolytic plasminogen,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,10.18,45.74,,,,,,
BCBS PPO,CPT,85441,Heinz bodies direct,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,4.2,19.07,,,,,,
BCBS PPO,CPT,85445,Heinz bodies induced,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,6.82,30.51,,,,,,
BCBS PPO,CPT,85461,Hemoglobin fetal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,9.36,30.51,,,,,,
BCBS PPO,CPT,85475,Hemolysin acid,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,8.87,38.13,,,,,,
BCBS PPO,CPT,85520,Heparin assay,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.09,57.19,,,,,,
BCBS PPO,CPT,85525,Heparin neutralization,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.84,53.38,,,,,,
BCBS PPO,CPT,85530,Heparin-protamine tolerance,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.09,48.46,,,,,,
BCBS PPO,CPT,85536,Iron stain peripheral blood,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,6.88,30.51,,,,,,
BCBS PPO,CPT,85540,Wbc alkaline phosphatase,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,8.6,38.13,,,,,,
BCBS PPO,CPT,85547,Rbc mechanical fragility,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,8.6,11.44,,,,,,
BCBS PPO,CPT,85549,Muramidase,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,18.75,83.87,,,,,,
BCBS PPO,CPT,85555,Rbc osmotic fragility,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.47,30.51,,,,,,
BCBS PPO,CPT,85576,Blood platelet aggregation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,24.91,95.32,,,,,,
BCBS PPO,CPT,85597,Phospholipid pltlt neutraliz,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,17.98,80.07,,,,,,
BCBS PPO,CPT,85610,Prothrombin time,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,4.29,19.07,,,,,,
BCBS PPO,CPT,85611,Prothrombin test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.94,19.07,,,,,,
BCBS PPO,CPT,85613,Russell viper venom diluted,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,9.58,41.94,,,,,,
BCBS PPO,CPT,85635,Reptilase test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,9.85,19.07,,,,,,
BCBS PPO,CPT,85651,Rbc sed rate nonautomated,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,4.27,19.07,,,,,,
BCBS PPO,CPT,85652,Rbc sed rate automated,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,2.7,15.26,,,,,,
BCBS PPO,CPT,85660,Rbc sickle cell test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.51,22.88,,,,,,
BCBS PPO,CPT,85670,Thrombin time plasma,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.77,26.7,,,,,,
BCBS PPO,CPT,85675,Thrombin time titer,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,6.85,30.51,,,,,,
BCBS PPO,CPT,85705,Thromboplastin inhibition,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,9.63,41.94,,,,,,
BCBS PPO,CPT,85730,Thromboplastin time partial,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,6.01,30.51,,,,,,
BCBS PPO,CPT,85732,Thromboplastin time partial,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,6.47,30.51,,,,,,
BCBS PPO,CPT,85810,Blood viscosity examination,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.67,53.38,,,,,,
BCBS PPO,CPT,86001,Allergen specific igg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.82,22.88,,,,,,
BCBS PPO,CPT,86003,Allg spec ige crude xtrc ea,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.22,22.88,,,,,,
BCBS PPO,CPT,86008,Allg spec ige recomb ea,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,17.93,80.07,,,,,,
BCBS PPO,CPT,86021,Wbc antibody identification,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.05,68.63,,,,,,
BCBS PPO,CPT,86022,Platelet antibodies,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,18.37,64.82,,,,,,
BCBS PPO,CPT,86023,Immunoglobulin assay,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.46,57.19,,,,,,
BCBS PPO,CPT,86038,Antinuclear antibodies,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.09,53.38,,,,,,
BCBS PPO,CPT,86039,Antinuclear antibodies (ana),Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.16,49.56,,,,,,
BCBS PPO,CPT,86060,Antistreptolysin o titer,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.3,34.31,,,,,,
BCBS PPO,CPT,86063,Antistreptolysin o screen,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.77,26.7,,,,,,
BCBS PPO,CPT,86077,Phys blood bank serv xmatch,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,25.25,244.01,,,,,,
BCBS PPO,CPT,86078,Phys blood bank serv reactj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,152.64,247.83,,,,,,
BCBS PPO,CPT,86079,Phys blood bank serv authrj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,50.92,251.64,,,,,,
BCBS PPO,CPT,86140,C-reactive protein,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.18,22.88,,,,,,
BCBS PPO,CPT,86141,C-reactive protein hs,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.95,57.19,,,,,,
BCBS PPO,CPT,86146,Beta-2 glycoprotein antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,25.45,114.39,,,,,,
BCBS PPO,CPT,86147,Cardiolipin antibody ea ig,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,25.45,114.39,,,,,,
BCBS PPO,CPT,86148,Anti-phospholipid antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16.07,72.44,,,,,,
BCBS PPO,CPT,86155,Chemotaxis assay,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.99,72.44,,,,,,
BCBS PPO,CPT,86156,Cold agglutinin screen,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,8.07,30.51,,,,,,
BCBS PPO,CPT,86157,Cold agglutinin titer,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,8.06,34.31,,,,,,
BCBS PPO,CPT,86160,Complement antigen,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12,53.38,,,,,,
BCBS PPO,CPT,86161,Complement/function activity,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12,53.38,,,,,,
BCBS PPO,CPT,86162,Complement total (ch50),Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,20.32,91.51,,,,,,
BCBS PPO,CPT,86171,Complement fixation each,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,10.01,45.74,,,,,,
BCBS PPO,CPT,86185,Counterimmunoelectrophoresis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.13,38.13,,,,,,
BCBS PPO,CPT,86200,Ccp antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.95,57.19,,,,,,
BCBS PPO,CPT,86215,Deoxyribonuclease antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.25,57.19,,,,,,
BCBS PPO,CPT,86225,Dna antibody native,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.74,61,,,,,,
BCBS PPO,CPT,86226,Dna antibody single strand,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.11,53.38,,,,,,
BCBS PPO,CPT,86235,Nuclear antigen antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,17.93,80.07,,,,,,
BCBS PPO,CPT,86243,Fc receptor,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,91.51,91.51,,,,,,
BCBS PPO,CPT,86255,Fluorescent antibody screen,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.05,53.38,,,,,,
BCBS PPO,CPT,86256,Fluorescent antibody titer,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.05,53.38,,,,,,
BCBS PPO,CPT,86277,Growth hormone antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.74,68.63,,,,,,
BCBS PPO,CPT,86294,Immunoassay tumor qual,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,25.57,80.07,,,,,,
BCBS PPO,CPT,86300,Immunoassay tumor ca 15-3,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,20.81,91.51,,,,,,
BCBS PPO,CPT,86301,Immunoassay tumor ca 19-9,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,20.81,91.51,,,,,,
BCBS PPO,CPT,86304,Immunoassay tumor ca 125,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,20.81,91.51,,,,,,
BCBS PPO,CPT,86308,Heterophile antibody screen,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.18,26.7,,,,,,
BCBS PPO,CPT,86309,Heterophile antibody titer,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,6.47,30.51,,,,,,
BCBS PPO,CPT,86316,Immunoassay tumor other,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,20.81,91.51,,,,,,
BCBS PPO,CPT,86317,Immunoassay infectious agent,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.99,68.63,,,,,,
BCBS PPO,CPT,86318,Ia infectious agent antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,18.09,64.82,,,,,,
BCBS PPO,CPT,86320,Serum immunoelectrophoresis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,29.92,99.13,,,,,,
BCBS PPO,CPT,86325,Other immunoelectrophoresis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,23.13,99.13,,,,,,
BCBS PPO,CPT,86327,Immunoelectrophoresis assay,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,29.92,72.44,,,,,,
BCBS PPO,CPT,86328,Ia nfct ab sarscov2 covid19,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,45.23,64.82,,,,,,
BCBS PPO,CPT,86331,Immunodiffusion ouchterlony,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.98,53.38,,,,,,
BCBS PPO,CPT,86332,Immune complex assay,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,24.37,106.76,,,,,,
BCBS PPO,CPT,86334,Immunofix e-phoresis serum,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.34,99.13,,,,,,
BCBS PPO,CPT,86335,Immunfix e-phorsis/urine/csf,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,29.35,129.64,,,,,,
BCBS PPO,CPT,86336,Inhibin a,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.59,68.63,,,,,,
BCBS PPO,CPT,86337,Insulin antibodies,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,21.41,95.32,,,,,,
BCBS PPO,CPT,86340,Intrinsic factor antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.08,68.63,,,,,,
BCBS PPO,CPT,86341,Islet cell antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,23.57,87.69,,,,,,
BCBS PPO,CPT,86343,Leukocyte histamine release,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.46,57.19,,,,,,
BCBS PPO,CPT,86344,Leukocyte phagocytosis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,10.39,34.31,,,,,,
BCBS PPO,CPT,86353,Lymphocyte transformation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,49.03,217.32,,,,,,
BCBS PPO,CPT,86355,B cells total count,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,37.73,167.76,,,,,,
BCBS PPO,CPT,86356,Mononuclear cell antigen,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.78,61,,,,,,
BCBS PPO,CPT,86357,Nk cells total count,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,37.73,167.76,,,,,,
BCBS PPO,CPT,86359,T cells total count,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,37.73,167.76,,,,,,
BCBS PPO,CPT,86360,T cell absolute count/ratio,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,46.98,209.7,,,,,,
BCBS PPO,CPT,86361,T cell absolute count,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.78,61,,,,,,
BCBS PPO,CPT,86367,Stem cells total count,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,77.78,167.76,,,,,,
BCBS PPO,CPT,86376,Microsomal antibody each,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.55,64.82,,,,,,
BCBS PPO,CPT,86382,Neutralization test viral,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16.91,76.26,,,,,,
BCBS PPO,CPT,86403,Particle agglut antbdy scrn,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.54,26.7,,,,,,
BCBS PPO,CPT,86406,Particle agglut antbdy titr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,10.64,45.74,,,,,,
BCBS PPO,CPT,86430,Rheumatoid factor test qual,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,6.14,26.7,,,,,,
BCBS PPO,CPT,86431,Rheumatoid factor quant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.67,26.7,,,,,,
BCBS PPO,CPT,86480,Tb test cell immun measure,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,61.98,274.51,,,,,,
BCBS PPO,CPT,86485,Skin test candida,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,25.25,61,,,,,,
BCBS PPO,CPT,86486,Skin test nos antigen,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,25.25,30.51,,,,,,
BCBS PPO,CPT,86490,Coccidioidomycosis skin test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.13,56.95,,,,,,
BCBS PPO,CPT,86510,Histoplasmosis skin test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.13,56.95,,,,,,
BCBS PPO,CPT,86580,Tb intradermal test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,25.25,38.13,,,,,,
BCBS PPO,CPT,86590,Streptokinase antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.66,49.56,,,,,,
BCBS PPO,CPT,86592,Syphilis test non-trep qual,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,4.27,19.07,,,,,,
BCBS PPO,CPT,86593,Syphilis test non-trep quant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,4.4,19.07,,,,,,
BCBS PPO,CPT,86602,Antinomyces antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,10.18,45.74,,,,,,
BCBS PPO,CPT,86606,Aspergillus antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.05,68.63,,,,,,
BCBS PPO,CPT,86609,Bacterium antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.88,57.19,,,,,,
BCBS PPO,CPT,86611,Bartonella antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,10.18,45.74,,,,,,
BCBS PPO,CPT,86612,Blastomyces antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.9,57.19,,,,,,
BCBS PPO,CPT,86615,Bordetella antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.19,57.19,,,,,,
BCBS PPO,CPT,86617,Lyme disease antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.49,68.63,,,,,,
BCBS PPO,CPT,86618,Lyme disease antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,17.03,83.87,,,,,,
BCBS PPO,CPT,86619,Borrelia antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.38,61,,,,,,
BCBS PPO,CPT,86622,Brucella antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,8.93,38.13,,,,,,
BCBS PPO,CPT,86625,Campylobacter antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.12,57.19,,,,,,
BCBS PPO,CPT,86628,Candida antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.01,53.38,,,,,,
BCBS PPO,CPT,86631,Chlamydia antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.82,53.38,,,,,,
BCBS PPO,CPT,86632,Chlamydia igm antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.68,57.19,,,,,,
BCBS PPO,CPT,86635,Coccidioides antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.47,49.56,,,,,,
BCBS PPO,CPT,86638,Q fever antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.12,53.38,,,,,,
BCBS PPO,CPT,86641,Cryptococcus antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.41,64.82,,,,,,
BCBS PPO,CPT,86644,Cmv antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.39,64.82,,,,,,
BCBS PPO,CPT,86645,Cmv antibody igm,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16.85,76.26,,,,,,
BCBS PPO,CPT,86648,Diphtheria antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.21,68.63,,,,,,
BCBS PPO,CPT,86651,Encephalitis californ antbdy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.19,57.19,,,,,,
BCBS PPO,CPT,86652,Encephaltis east eqne anbdy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.19,57.19,,,,,,
BCBS PPO,CPT,86653,Encephaltis st louis antbody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.19,57.19,,,,,,
BCBS PPO,CPT,86654,Encephaltis west eqne antbdy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.19,57.19,,,,,,
BCBS PPO,CPT,86658,Enterovirus antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.03,57.19,,,,,,
BCBS PPO,CPT,86663,Epstein-barr antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.12,57.19,,,,,,
BCBS PPO,CPT,86664,Epstein-barr nuclear antigen,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.29,68.63,,,,,,
BCBS PPO,CPT,86665,Epstein-barr capsid vca,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,18.14,80.07,,,,,,
BCBS PPO,CPT,86666,Ehrlichia antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,10.18,45.74,,,,,,
BCBS PPO,CPT,86668,Francisella tularensis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.16,45.74,,,,,,
BCBS PPO,CPT,86671,Fungus nes antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.25,53.38,,,,,,
BCBS PPO,CPT,86677,Helicobacter pylori antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16.85,64.82,,,,,,
BCBS PPO,CPT,86682,Helminth antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.01,57.19,,,,,,
BCBS PPO,CPT,86684,Hemophilus influenza antibdy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.84,72.44,,,,,,
BCBS PPO,CPT,86687,Htlv-i antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,9.09,38.13,,,,,,
BCBS PPO,CPT,86688,Htlv-ii antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14,61,,,,,,
BCBS PPO,CPT,86689,Htlv/hiv confirmj antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.35,87.69,,,,,,
BCBS PPO,CPT,86692,Hepatitis delta agent antbdy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,17.16,76.26,,,,,,
BCBS PPO,CPT,86694,Herpes simplex nes antbdy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.39,64.82,,,,,,
BCBS PPO,CPT,86695,Herpes simplex type 1 test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.19,57.19,,,,,,
BCBS PPO,CPT,86696,Herpes simplex type 2 test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.35,87.69,,,,,,
BCBS PPO,CPT,86698,Histoplasma antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.79,57.19,,,,,,
BCBS PPO,CPT,86701,Hiv-1antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,8.89,38.13,,,,,,
BCBS PPO,CPT,86702,Hiv-2 antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.52,61,,,,,,
BCBS PPO,CPT,86703,Hiv-1/hiv-2 1 result antbdy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.71,61,,,,,,
BCBS PPO,CPT,86704,Hep b core antibody total,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.05,53.38,,,,,,
BCBS PPO,CPT,86705,Hep b core antibody igm,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.77,53.38,,,,,,
BCBS PPO,CPT,86706,Hep b surface antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,10.74,49.56,,,,,,
BCBS PPO,CPT,86707,Hepatitis be antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.57,53.38,,,,,,
BCBS PPO,CPT,86708,Hepatitis a antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.39,53.38,,,,,,
BCBS PPO,CPT,86709,Hepatitis a igm antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.26,49.56,,,,,,
BCBS PPO,CPT,86710,Influenza virus antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.55,68.63,,,,,,
BCBS PPO,CPT,86713,Legionella antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.3,68.63,,,,,,
BCBS PPO,CPT,86717,Leishmania antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.25,53.38,,,,,,
BCBS PPO,CPT,86720,Leptospira antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16.2,57.19,,,,,,
BCBS PPO,CPT,86727,Lymph choriomeningitis ab,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.87,57.19,,,,,,
BCBS PPO,CPT,86729,Lympho venereum antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,53.38,53.38,,,,,,
BCBS PPO,CPT,86732,Mucormycosis antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15,57.19,,,,,,
BCBS PPO,CPT,86735,Mumps antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.05,57.19,,,,,,
BCBS PPO,CPT,86738,Mycoplasma antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.24,57.19,,,,,,
BCBS PPO,CPT,86741,Neisseria meningitidis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.19,57.19,,,,,,
BCBS PPO,CPT,86744,Nocardia antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.99,57.19,,,,,,
BCBS PPO,CPT,86747,Parvovirus antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.03,68.63,,,,,,
BCBS PPO,CPT,86750,Malaria antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.19,57.19,,,,,,
BCBS PPO,CPT,86753,Protozoa antibody nos,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.39,53.38,,,,,,
BCBS PPO,CPT,86756,Respiratory virus antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.89,57.19,,,,,,
BCBS PPO,CPT,86757,Rickettsia antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.35,87.69,,,,,,
BCBS PPO,CPT,86759,Rotavirus antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,18.23,57.19,,,,,,
BCBS PPO,CPT,86762,Rubella antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.39,64.82,,,,,,
BCBS PPO,CPT,86765,Rubeola antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.88,57.19,,,,,,
BCBS PPO,CPT,86769,Sars-cov-2 covid-19 antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,42.13,57.19,,,,,,
BCBS PPO,CPT,86771,Shigella antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,24.48,57.19,,,,,,
BCBS PPO,CPT,86774,Tetanus antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.8,64.82,,,,,,
BCBS PPO,CPT,86777,Toxoplasma antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.39,64.82,,,,,,
BCBS PPO,CPT,86778,Toxoplasma antibody igm,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.41,64.82,,,,,,
BCBS PPO,CPT,86781,Treponema pallidum - confirm,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,57.19,57.19,,,,,,
BCBS PPO,CPT,86787,Varicella-zoster antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.88,57.19,,,,,,
BCBS PPO,CPT,86788,West nile virus ab igm,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16.85,76.26,,,,,,
BCBS PPO,CPT,86789,West nile virus antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.39,64.82,,,,,,
BCBS PPO,CPT,86790,Virus antibody nos,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.88,57.19,,,,,,
BCBS PPO,CPT,86793,Yersinia antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.19,57.19,,,,,,
BCBS PPO,CPT,86800,Thyroglobulin antibody,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.91,72.44,,,,,,
BCBS PPO,CPT,86803,Hepatitis c ab test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.27,64.82,,,,,,
BCBS PPO,CPT,86804,Hep c ab test confirm,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.49,68.63,,,,,,
BCBS PPO,CPT,86805,Lymphocytotoxicity assay,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,189.51,232.58,,,,,,
BCBS PPO,CPT,86806,Lymphocytotoxicity assay,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,47.59,213.51,,,,,,
BCBS PPO,CPT,86807,Cytotoxic antibody screening,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,78.65,175.39,,,,,,
BCBS PPO,CPT,86808,Cytotoxic antibody screening,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,29.68,133.45,,,,,,
BCBS PPO,CPT,86812,Hla typing a b or c,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,25.81,114.39,,,,,,
BCBS PPO,CPT,86813,Hla typing a b or c,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,58,247.83,,,,,,
BCBS PPO,CPT,86816,Hla typing dr/dq,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,30.17,102.95,,,,,,
BCBS PPO,CPT,86817,Hla typing dr/dq,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,106.14,247.83,,,,,,
BCBS PPO,CPT,86821,Lymphocyte culture mixed,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,36.56,251.64,,,,,,
BCBS PPO,CPT,86822,Lymphocyte culture primed,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,163.95,163.95,,,,,,
BCBS PPO,CPT,86850,Rbc antibody screen,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,50.92,76.26,,,,,,
BCBS PPO,CPT,86860,Rbc antibody elution,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,91.51,152.64,,,,,,
BCBS PPO,CPT,86870,Rbc antibody identification,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,141.07,298.05,,,,,,
BCBS PPO,CPT,86880,Coombs test direct,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.88,56.95,,,,,,
BCBS PPO,CPT,86886,Coombs test indirect titer,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.88,152.64,,,,,,
BCBS PPO,CPT,86890,Autologous blood process,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,152.64,308.83,,,,,,
BCBS PPO,CPT,86891,Autologous blood op salvage,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,480.4,671.45,,,,,,
BCBS PPO,CPT,86900,Blood typing serologic abo,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.44,114.56,,,,,,
BCBS PPO,CPT,86901,Blood typing serologic rh(d),Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.88,34.63,,,,,,
BCBS PPO,CPT,86902,Blood type antigen donor ea,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,41.94,298.05,,,,,,
BCBS PPO,CPT,86903,Blood typing - antigen screen,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,41.94,41.94,,,,,,
BCBS PPO,CPT,86904,Blood typing patient serum,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.63,41.94,,,,,,
BCBS PPO,CPT,86905,Blood typing rbc antigens,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.26,298.05,,,,,,
BCBS PPO,CPT,86906,Bld typing serologic rh phnt,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.31,34.63,,,,,,
BCBS PPO,CPT,86910,Blood typing paternity test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,83.87,83.87,,,,,,
BCBS PPO,CPT,86911,Blood typing antigen system,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,72.44,72.44,,,,,,
BCBS PPO,CPT,86920,Compatibility test spin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,125.82,152.64,,,,,,
BCBS PPO,CPT,86921,Compatibility test incubate,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,102.95,152.64,,,,,,
BCBS PPO,CPT,86922,Compatibility test antiglob,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,118.19,152.64,,,,,,
BCBS PPO,CPT,86923,Compatibility test electric,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,91.51,152.64,,,,,,
BCBS PPO,CPT,86927,Plasma fresh frozen,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,49.56,152.64,,,,,,
BCBS PPO,CPT,86930,Frozen blood prep,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,298.05,385.09,,,,,,
BCBS PPO,CPT,86931,Frozen blood thaw,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,289.76,298.05,,,,,,
BCBS PPO,CPT,86932,Frozen blood freeze/thaw,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.63,385.09,,,,,,
BCBS PPO,CPT,86940,Hemolysins/agglutinins auto,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,8.77,38.13,,,,,,
BCBS PPO,CPT,86941,Hemolysins/agglutinins,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.11,53.38,,,,,,
BCBS PPO,CPT,86945,Blood product/irradiation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.63,110.57,,,,,,
BCBS PPO,CPT,86950,Leukacyte transfusion,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,152.64,240.2,,,,,,
BCBS PPO,CPT,86960,Vol reduction of blood/prod,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,110.57,152.64,,,,,,
BCBS PPO,CPT,86965,Pooling blood platelets,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,95.32,152.64,,,,,,
BCBS PPO,CPT,86970,Rbc pretx incubatj w/chemicl,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.63,76.26,,,,,,
BCBS PPO,CPT,86972,Rbc pretx incubatj w/density,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,122,152.64,,,,,,
BCBS PPO,CPT,86975,Rbc serum pretx incubj drugs,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,102.95,276.53,,,,,,
BCBS PPO,CPT,86976,Rbc serum pretx id dilution,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,25.25,118.19,,,,,,
BCBS PPO,CPT,86978,Rbc pretreatment serum,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.63,102.95,,,,,,
BCBS PPO,CPT,86985,Split blood or products,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.26,152.64,,,,,,
BCBS PPO,CPT,87001,Small animal inoculation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,57.19,57.19,,,,,,
BCBS PPO,CPT,87003,Small animal inoculation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16.84,76.26,,,,,,
BCBS PPO,CPT,87015,Specimen infect agnt concntj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,6.68,30.51,,,,,,
BCBS PPO,CPT,87040,Blood culture for bacteria,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,10.32,45.74,,,,,,
BCBS PPO,CPT,87045,Feces culture aerobic bact,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,9.44,41.94,,,,,,
BCBS PPO,CPT,87046,Stool cultr aerobic bact ea,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,9.44,41.94,,,,,,
BCBS PPO,CPT,87070,Culture othr specimn aerobic,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,8.62,41.94,,,,,,
BCBS PPO,CPT,87071,Culture aerobic quant other,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,9.89,41.94,,,,,,
BCBS PPO,CPT,87073,Culture bacteria anaerobic,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,9.66,41.94,,,,,,
BCBS PPO,CPT,87075,Cultr bacteria except blood,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,9.47,41.94,,,,,,
BCBS PPO,CPT,87076,Culture anaerobe ident each,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,8.08,19.07,,,,,,
BCBS PPO,CPT,87077,Culture aerobic identify,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,8.08,22.88,,,,,,
BCBS PPO,CPT,87081,Culture screen only,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,6.63,34.31,,,,,,
BCBS PPO,CPT,87084,Culture of specimen by kit,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.88,27.07,,,,,,
BCBS PPO,CPT,87086,Urine culture/colony count,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,8.07,41.94,,,,,,
BCBS PPO,CPT,87088,Urine bacteria culture,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,8.09,41.94,,,,,,
BCBS PPO,CPT,87101,Skin fungi culture,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.71,34.31,,,,,,
BCBS PPO,CPT,87102,Fungus isolation culture,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,8.41,38.13,,,,,,
BCBS PPO,CPT,87103,Blood fungus culture,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,20.46,41.94,,,,,,
BCBS PPO,CPT,87106,Fungi identification yeast,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,10.32,45.74,,,,,,
BCBS PPO,CPT,87107,Fungi identification mold,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,10.32,45.74,,,,,,
BCBS PPO,CPT,87109,Mycoplasma,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.39,68.63,,,,,,
BCBS PPO,CPT,87110,Chlamydia culture,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.6,87.69,,,,,,
BCBS PPO,CPT,87116,Mycobacteria culture,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,10.8,49.56,,,,,,
BCBS PPO,CPT,87118,Mycobacteric identification,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.61,49.56,,,,,,
BCBS PPO,CPT,87140,Culture type immunofluoresc,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.57,26.7,,,,,,
BCBS PPO,CPT,87143,Culture typing glc/hplc,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.52,57.19,,,,,,
BCBS PPO,CPT,87147,Culture type immunologic,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.18,22.88,,,,,,
BCBS PPO,CPT,87149,Dna/rna direct probe,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,20.05,87.69,,,,,,
BCBS PPO,CPT,87152,Culture type pulse field gel,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.74,22.88,,,,,,
BCBS PPO,CPT,87164,Dark field examination,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,10.74,49.56,,,,,,
BCBS PPO,CPT,87166,Dark field examination,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.3,49.56,,,,,,
BCBS PPO,CPT,87168,Macroscopic exam arthropod,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,4.27,19.07,,,,,,
BCBS PPO,CPT,87169,Macroscopic exam parasite,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,4.31,19.07,,,,,,
BCBS PPO,CPT,87172,Pinworm exam,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,4.27,22.88,,,,,,
BCBS PPO,CPT,87176,Tissue homogenization cultr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.88,26.7,,,,,,
BCBS PPO,CPT,87177,Ova and parasites smears,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,8.9,41.94,,,,,,
BCBS PPO,CPT,87181,Microbe susceptible diffuse,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,4.75,22.88,,,,,,
BCBS PPO,CPT,87184,Microbe susceptible disk,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.48,34.31,,,,,,
BCBS PPO,CPT,87185,Microbe susceptible enzyme,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,4.75,22.88,,,,,,
BCBS PPO,CPT,87186,Microbe susceptible mic,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,8.65,38.13,,,,,,
BCBS PPO,CPT,87187,Microbe susceptible mlc,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,40.17,45.74,,,,,,
BCBS PPO,CPT,87188,Microbe suscept macrobroth,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,6.64,30.51,,,,,,
BCBS PPO,CPT,87190,Microbe suscept mycobacteri,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.31,26.7,,,,,,
BCBS PPO,CPT,87197,Bactericidal level serum,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.02,68.63,,,,,,
BCBS PPO,CPT,87205,Smear gram stain,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,4.27,22.88,,,,,,
BCBS PPO,CPT,87206,Smear fluorescent/acid stai,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.39,26.7,,,,,,
BCBS PPO,CPT,87207,Smear special stain,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.99,41.94,,,,,,
BCBS PPO,CPT,87209,Smear complex stain,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,17.98,80.07,,,,,,
BCBS PPO,CPT,87210,Smear wet mount saline/ink,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.82,22.88,,,,,,
BCBS PPO,CPT,87220,Tissue exam for fungi,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,4.27,22.88,,,,,,
BCBS PPO,CPT,87230,Assay toxin or antitoxin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.74,87.69,,,,,,
BCBS PPO,CPT,87250,Virus inoculate eggs/animal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.56,87.69,,,,,,
BCBS PPO,CPT,87252,Virus inoculation tissue,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.07,102.95,,,,,,
BCBS PPO,CPT,87253,Virus inoculate tissue addl,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,20.2,91.51,,,,,,
BCBS PPO,CPT,87254,Virus inoculation shell via,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.56,87.69,,,,,,
BCBS PPO,CPT,87255,Genet virus isolate hsv,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,33.86,152.51,,,,,,
BCBS PPO,CPT,87265,Pertussis ag if,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.98,53.38,,,,,,
BCBS PPO,CPT,87267,Enterovirus antibody dfa,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.42,53.38,,,,,,
BCBS PPO,CPT,87269,Giardia ag if,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.61,53.38,,,,,,
BCBS PPO,CPT,87270,Chlamydia trachomatis ag if,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.98,53.38,,,,,,
BCBS PPO,CPT,87271,Cytomegalovirus dfa,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.42,53.38,,,,,,
BCBS PPO,CPT,87272,Cryptosporidium ag if,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.98,53.38,,,,,,
BCBS PPO,CPT,87275,Influenza b ag if,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.25,53.38,,,,,,
BCBS PPO,CPT,87276,Influenza a ag if,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16.07,53.38,,,,,,
BCBS PPO,CPT,87277,Legionella micdadei ag if,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,53.38,53.38,,,,,,
BCBS PPO,CPT,87278,Legion pneumophilia ag if,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.6,53.38,,,,,,
BCBS PPO,CPT,87279,Parainfluenza ag if,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16.43,53.38,,,,,,
BCBS PPO,CPT,87280,Respiratory syncytial ag if,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.42,53.38,,,,,,
BCBS PPO,CPT,87281,Pneumocystis carinii ag if,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.98,53.38,,,,,,
BCBS PPO,CPT,87283,Rubeola ag if,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,53.38,60.8,,,,,,
BCBS PPO,CPT,87285,Treponema pallidum ag if,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.18,53.38,,,,,,
BCBS PPO,CPT,87290,Varicella zoster ag if,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.42,53.38,,,,,,
BCBS PPO,CPT,87299,Antibody detection nos if,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16.1,53.38,,,,,,
BCBS PPO,CPT,87301,Adenovirus ag ia,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.98,53.38,,,,,,
BCBS PPO,CPT,87305,Aspergillus ag ia,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.98,53.38,,,,,,
BCBS PPO,CPT,87320,Chylmd trach ag ia,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15,53.38,,,,,,
BCBS PPO,CPT,87324,Clostridium ag ia,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.98,53.38,,,,,,
BCBS PPO,CPT,87327,Cryptococcus neoform ag ia,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.42,53.38,,,,,,
BCBS PPO,CPT,87328,Cryptosporidium ag ia,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.82,53.38,,,,,,
BCBS PPO,CPT,87329,Giardia ag ia,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.98,53.38,,,,,,
BCBS PPO,CPT,87332,Cytomegalovirus ag ia,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.98,53.38,,,,,,
BCBS PPO,CPT,87335,E coli 0157 ag ia,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.66,53.38,,,,,,
BCBS PPO,CPT,87336,Entamoeb hist dispr ag ia,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16,53.38,,,,,,
BCBS PPO,CPT,87337,Entamoeb hist group ag ia,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.98,53.38,,,,,,
BCBS PPO,CPT,87338,Hpylori stool ag ia,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.38,64.82,,,,,,
BCBS PPO,CPT,87339,H pylori ag ia,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16,53.38,,,,,,
BCBS PPO,CPT,87340,Hepatitis b surface ag ia,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,10.33,45.74,,,,,,
BCBS PPO,CPT,87341,Hepatitis b surface ag ia,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,10.33,45.74,,,,,,
BCBS PPO,CPT,87350,Hepatitis be ag ia,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.53,49.56,,,,,,
BCBS PPO,CPT,87380,Hepatitis delta agent ag ia,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,18.36,72.44,,,,,,
BCBS PPO,CPT,87385,Histoplasma capsul ag ia,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.25,53.38,,,,,,
BCBS PPO,CPT,87391,Hiv-2 ag ia,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,21.9,80.07,,,,,,
BCBS PPO,CPT,87400,Influenza a/b each ag ia,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.13,61,,,,,,
BCBS PPO,CPT,87420,Resp syncytial virus ag ia,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.91,53.38,,,,,,
BCBS PPO,CPT,87425,Rotavirus ag ia,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.98,53.38,,,,,,
BCBS PPO,CPT,87427,Shiga-like toxin ag ia,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.98,53.38,,,,,,
BCBS PPO,CPT,87430,Strep a ag ia,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16.81,61,,,,,,
BCBS PPO,CPT,87449,Nos each organism ag ia,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.98,61,,,,,,
BCBS PPO,CPT,87450,Ag detect nos ia single,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,41.94,41.94,,,,,,
BCBS PPO,CPT,87451,Polyvalent mult org ea ag ia,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,10.51,41.94,,,,,,
BCBS PPO,CPT,87470,Bartonella dna dir probe,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,87.69,87.69,,,,,,
BCBS PPO,CPT,87472,Bartonella dna quant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,42.84,190.64,,,,,,
BCBS PPO,CPT,87475,Lyme dis dna dir probe,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,20.05,87.69,,,,,,
BCBS PPO,CPT,87476,Lyme dis dna amp probe,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,35.09,156.32,,,,,,
BCBS PPO,CPT,87477,Lyme dis dna quant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,190.64,190.64,,,,,,
BCBS PPO,CPT,87480,Candida dna dir probe,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,20.05,99.13,,,,,,
BCBS PPO,CPT,87481,Candida dna amp probe,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,35.09,156.32,,,,,,
BCBS PPO,CPT,87482,Candida dna quant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,55.74,186.82,,,,,,
BCBS PPO,CPT,87485,Chylmd pneum dna dir probe,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,20.05,87.69,,,,,,
BCBS PPO,CPT,87486,Chylmd pneum dna amp probe,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,35.09,156.32,,,,,,
BCBS PPO,CPT,87487,Chylmd pneum dna quant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,42.84,190.64,,,,,,
BCBS PPO,CPT,87490,Chylmd trach dna dir probe,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.75,99.13,,,,,,
BCBS PPO,CPT,87491,Chylmd trach dna amp probe,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,35.09,156.32,,,,,,
BCBS PPO,CPT,87492,Chylmd trach dna quant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,53.47,156.32,,,,,,
BCBS PPO,CPT,87496,Cytomeg dna amp probe,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,35.09,156.32,,,,,,
BCBS PPO,CPT,87497,Cytomeg dna quant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,42.84,190.64,,,,,,
BCBS PPO,CPT,87498,Enterovirus probe&revrs trns,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,35.09,156.32,,,,,,
BCBS PPO,CPT,87500,Vanomycin dna amp probe,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,35.09,156.32,,,,,,
BCBS PPO,CPT,87510,Gardner vag dna dir probe,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,20.05,99.13,,,,,,
BCBS PPO,CPT,87511,Gardner vag dna amp probe,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,35.09,156.32,,,,,,
BCBS PPO,CPT,87512,Gardner vag dna quant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,41.76,186.82,,,,,,
BCBS PPO,CPT,87515,Hepatitis b dna dir probe,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,87.69,87.69,,,,,,
BCBS PPO,CPT,87516,Hepatitis b dna amp probe,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,35.09,156.32,,,,,,
BCBS PPO,CPT,87517,Hepatitis b dna quant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,42.84,190.64,,,,,,
BCBS PPO,CPT,87520,Hepatitis c rna dir probe,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,31.22,87.69,,,,,,
BCBS PPO,CPT,87521,Hepatitis c probe&rvrs trnsc,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,35.09,156.32,,,,,,
BCBS PPO,CPT,87522,Hepatitis c revrs trnscrpj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,42.84,190.64,,,,,,
BCBS PPO,CPT,87525,Hepatitis g dna dir probe,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,29.8,87.69,,,,,,
BCBS PPO,CPT,87526,Hepatitis g dna amp probe,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,39.26,156.32,,,,,,
BCBS PPO,CPT,87527,Hepatitis g dna quant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,41.76,186.82,,,,,,
BCBS PPO,CPT,87528,Hsv dna dir probe,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,20.05,87.69,,,,,,
BCBS PPO,CPT,87529,Hsv dna amp probe,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,35.09,156.32,,,,,,
BCBS PPO,CPT,87530,Hsv dna quant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,42.84,190.64,,,,,,
BCBS PPO,CPT,87531,Hhv-6 dna dir probe,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,58,87.69,,,,,,
BCBS PPO,CPT,87533,Hhv-6 dna quant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,41.76,186.82,,,,,,
BCBS PPO,CPT,87534,Hiv-1 dna dir probe,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,21.92,87.69,,,,,,
BCBS PPO,CPT,87535,Hiv-1 probe&reverse trnscrpj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,35.09,156.32,,,,,,
BCBS PPO,CPT,87536,Hiv-1 quant&revrse trnscrpj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,85.1,377.46,,,,,,
BCBS PPO,CPT,87537,Hiv-2 dna dir probe,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,21.92,87.69,,,,,,
BCBS PPO,CPT,87538,Hiv-2 probe&revrse trnscripj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,35.09,156.32,,,,,,
BCBS PPO,CPT,87539,Hiv-2 quant&revrse trnscripj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,58.62,190.64,,,,,,
BCBS PPO,CPT,87540,Legion pneumo dna dir prob,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,20.05,87.69,,,,,,
BCBS PPO,CPT,87541,Legion pneumo dna amp prob,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,35.09,156.32,,,,,,
BCBS PPO,CPT,87542,Legion pneumo dna quant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,41.76,186.82,,,,,,
BCBS PPO,CPT,87550,Mycobacteria dna dir probe,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,20.05,87.69,,,,,,
BCBS PPO,CPT,87551,Mycobacteria dna amp probe,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,48.24,156.32,,,,,,
BCBS PPO,CPT,87552,Mycobacteria dna quant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,42.84,190.64,,,,,,
BCBS PPO,CPT,87555,M.tuberculo dna dir probe,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.88,87.69,,,,,,
BCBS PPO,CPT,87556,M.tuberculo dna amp probe,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,41.68,156.32,,,,,,
BCBS PPO,CPT,87557,M.tuberculo dna quant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,42.84,190.64,,,,,,
BCBS PPO,CPT,87560,M.avium-intra dna dir prob,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,27.29,87.69,,,,,,
BCBS PPO,CPT,87561,M.avium-intra dna amp prob,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,35.09,156.32,,,,,,
BCBS PPO,CPT,87562,M.avium-intra dna quant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,42.84,190.64,,,,,,
BCBS PPO,CPT,87563,M. genitalium amp probe,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,35.09,156.32,,,,,,
BCBS PPO,CPT,87580,M.pneumon dna dir probe,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,20.05,87.69,,,,,,
BCBS PPO,CPT,87581,M.pneumon dna amp probe,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,35.09,156.32,,,,,,
BCBS PPO,CPT,87582,M.pneumon dna quant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,186.82,302.62,,,,,,
BCBS PPO,CPT,87590,N.gonorrhoeae dna dir prob,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.88,99.13,,,,,,
BCBS PPO,CPT,87591,N.gonorrhoeae dna amp prob,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,35.09,156.32,,,,,,
BCBS PPO,CPT,87620,Hpv dna dir probe,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,87.69,87.69,,,,,,
BCBS PPO,CPT,87621,Hpv dna amp probe,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,156.32,156.32,,,,,,
BCBS PPO,CPT,87622,Hpv dna quant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,186.82,186.82,,,,,,
BCBS PPO,CPT,87623,Hpv low-risk types,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,35.09,93.87,,,,,,
BCBS PPO,CPT,87624,Hpv high-risk types,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,35.09,93.87,,,,,,
BCBS PPO,CPT,87625,Hpv types 16 & 18 only,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,40.55,93.87,,,,,,
BCBS PPO,CPT,87640,Staph a dna amp probe,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,35.09,156.32,,,,,,
BCBS PPO,CPT,87641,Mr-staph dna amp probe,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,35.09,156.32,,,,,,
BCBS PPO,CPT,87650,Strep a dna dir probe,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,20.05,87.69,,,,,,
BCBS PPO,CPT,87651,Strep a dna amp probe,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,35.09,156.32,,,,,,
BCBS PPO,CPT,87652,Strep a dna quant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,41.76,186.82,,,,,,
BCBS PPO,CPT,87660,Trichomonas vagin dir probe,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,20.05,87.69,,,,,,
BCBS PPO,CPT,87661,Trichomonas vaginalis amplif,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,35.09,87.69,,,,,,
BCBS PPO,CPT,87797,Detect agent nos dna dir,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,30.03,99.13,,,,,,
BCBS PPO,CPT,87798,Detect agent nos dna amp,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,35.09,156.32,,,,,,
BCBS PPO,CPT,87799,Detect agent nos dna quant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,42.84,190.64,,,,,,
BCBS PPO,CPT,87800,Detect agnt mult dna direc,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,43.67,179.2,,,,,,
BCBS PPO,CPT,87801,Detect agnt mult dna ampli,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,70.2,312.64,,,,,,
BCBS PPO,CPT,87802,Strep b assay w/optic,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.73,61,,,,,,
BCBS PPO,CPT,87803,Clostridium toxin a w/optic,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16,61,,,,,,
BCBS PPO,CPT,87804,Influenza assay w/optic,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16.55,61,,,,,,
BCBS PPO,CPT,87806,Hiv w/hiv1&2 antb w/optic,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,32.77,61,,,,,,
BCBS PPO,CPT,87807,Rsv assay w/optic,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.1,53.38,,,,,,
BCBS PPO,CPT,87808,Trichomonas assay w/optic,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.29,61,,,,,,
BCBS PPO,CPT,87809,Adenovirus assay w/optic,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,21.76,53.38,,,,,,
BCBS PPO,CPT,87810,Chylmd trach assay w/optic,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,35.29,53.38,,,,,,
BCBS PPO,CPT,87850,N. gonorrhoeae assay w/optic,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,24.56,53.38,,,,,,
BCBS PPO,CPT,87880,Strep a assay w/optic,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16.53,61,,,,,,
BCBS PPO,CPT,87899,Agent nos assay w/optic,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16.07,61,,,,,,
BCBS PPO,CPT,87900,Phenotype infect agent drug,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,130.35,518.52,,,,,,
BCBS PPO,CPT,87901,Genotype dna hiv reverse t,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,257.45,"1,147.62",,,,,,
BCBS PPO,CPT,87902,Genotype dna/rna hep c,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,257.45,"1,147.62",,,,,,
BCBS PPO,CPT,87905,Sialidase enzyme assay,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.22,53.38,,,,,,
BCBS PPO,CPT,88104,Cytopath fl nongyn smears,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.63,175.39,,,,,,
BCBS PPO,CPT,88106,Cytopath fl nongyn filter,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,25.25,247.83,,,,,,
BCBS PPO,CPT,88107,Cytopath fl nongyn sm/fltr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,293.57,293.57,,,,,,
BCBS PPO,CPT,88108,Cytopath concentrate tech,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.63,228.77,,,,,,
BCBS PPO,CPT,88112,Cytopath cell enhance tech,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,50.92,232.58,,,,,,
BCBS PPO,CPT,88125,Forensic cytopathology,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,45.74,50.92,,,,,,
BCBS PPO,CPT,88130,Sex chromatin identification,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,17.98,68.63,,,,,,
BCBS PPO,CPT,88140,Sex chromatin identification,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.99,34.31,,,,,,
BCBS PPO,CPT,88141,Cytopath c/v interpret,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,137.25,137.25,,,,,,
BCBS PPO,CPT,88142,Cytopath c/v thin layer,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,20.26,91.51,,,,,,
BCBS PPO,CPT,88143,Cytopath c/v thin layer redo,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,23.04,91.51,,,,,,
BCBS PPO,CPT,88147,Cytopath c/v automated,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,45.74,50.56,,,,,,
BCBS PPO,CPT,88148,Cytopath c/v auto rescreen,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16,45.74,,,,,,
BCBS PPO,CPT,88150,Cytopath c/v manual,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.15,45.74,,,,,,
BCBS PPO,CPT,88152,Cytopath c/v auto redo,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,27.64,45.74,,,,,,
BCBS PPO,CPT,88153,Cytopath c/v redo,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,24.03,45.74,,,,,,
BCBS PPO,CPT,88154,Cytopath c/v select,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,45.74,45.74,,,,,,
BCBS PPO,CPT,88155,Cytopath c/v index add-on,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.65,26.7,,,,,,
BCBS PPO,CPT,88160,Cytopath smear other source,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,25.25,141.07,,,,,,
BCBS PPO,CPT,88161,Cytopath smear other source,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,25.25,152.51,,,,,,
BCBS PPO,CPT,88162,Cytopath smear other source,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,50.92,205.88,,,,,,
BCBS PPO,CPT,88164,Cytopath tbs c/v manual,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.15,45.74,,,,,,
BCBS PPO,CPT,88165,Cytopath tbs c/v redo,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,42.22,45.74,,,,,,
BCBS PPO,CPT,88166,Cytopath tbs c/v auto redo,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.15,45.74,,,,,,
BCBS PPO,CPT,88167,Cytopath tbs c/v select,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.15,45.74,,,,,,
BCBS PPO,CPT,88172,Cytp dx eval fna 1st ea site,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,118.19,152.64,,,,,,
BCBS PPO,CPT,88173,Cytopath eval fna report,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,50.92,327.9,,,,,,
BCBS PPO,CPT,88174,Cytopath c/v auto in fluid,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,25.37,95.32,,,,,,
BCBS PPO,CPT,88175,Cytopath c/v auto fluid redo,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.61,118.19,,,,,,
BCBS PPO,CPT,88182,Cell marker study,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,50.92,339.33,,,,,,
BCBS PPO,CPT,88184,Flowcytometry/ tc 1 marker,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,298.05,404.14,,,,,,
BCBS PPO,CPT,88185,Flowcytometry/tc add-on,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,240.2,240.2,,,,,,
BCBS PPO,CPT,88187,Flowcytometry/read 2-8,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,316.46,316.46,,,,,,
BCBS PPO,CPT,88188,Flowcytometry/read 9-15,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,388.89,388.89,,,,,,
BCBS PPO,CPT,88189,Flowcytometry/read 16 & >,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,495.65,495.65,,,,,,
BCBS PPO,CPT,88230,Tissue culture lymphocyte,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,116.49,518.52,,,,,,
BCBS PPO,CPT,88233,Tissue culture skin/biopsy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,140.73,625.29,,,,,,
BCBS PPO,CPT,88235,Tissue culture placenta,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,150.3,655.78,,,,,,
BCBS PPO,CPT,88237,Tissue culture bone marrow,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,143.75,564.29,,,,,,
BCBS PPO,CPT,88239,Tissue culture tumor,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,147.52,655.78,,,,,,
BCBS PPO,CPT,88240,Cell cryopreserve/storage,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.07,45.74,,,,,,
BCBS PPO,CPT,88241,Frozen cell preparation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.09,45.74,,,,,,
BCBS PPO,CPT,88245,Chromosome analysis 20-25,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,173.17,648.16,,,,,,
BCBS PPO,CPT,88248,Chromosome analysis 50-100,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,173.17,770.16,,,,,,
BCBS PPO,CPT,88249,Chromosome analysis 100,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,173.17,770.16,,,,,,
BCBS PPO,CPT,88261,Chromosome analysis 5,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,264.34,785.42,,,,,,
BCBS PPO,CPT,88262,Chromosome analysis 15-20,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,125.49,556.65,,,,,,
BCBS PPO,CPT,88263,Chromosome analysis 45,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,150.29,671.03,,,,,,
BCBS PPO,CPT,88264,Chromosome analysis 20-25,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,144.61,556.65,,,,,,
BCBS PPO,CPT,88267,Chromosome analys placenta,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,188.57,800.67,,,,,,
BCBS PPO,CPT,88269,Chromosome analys amniotic,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,173.66,739.67,,,,,,
BCBS PPO,CPT,88271,Cytogenetics dna probe,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,21.42,64.82,,,,,,
BCBS PPO,CPT,88272,Cytogenetics 3-5,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,40.7,114.39,,,,,,
BCBS PPO,CPT,88273,Cytogenetics 10-30,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.81,144.88,,,,,,
BCBS PPO,CPT,88274,Cytogenetics 25-99,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,42.38,156.32,,,,,,
BCBS PPO,CPT,88275,Cytogenetics 100-300,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,51.19,179.2,,,,,,
BCBS PPO,CPT,88280,Chromosome karyotype study,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,33.47,110.57,,,,,,
BCBS PPO,CPT,88285,Chromosome count additional,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.91,83.87,,,,,,
BCBS PPO,CPT,88289,Chromosome study additional,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.43,129.64,,,,,,
BCBS PPO,CPT,88291,Cyto/molecular report,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,144.88,144.88,,,,,,
BCBS PPO,CPT,88300,Surgical path gross,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,25.25,99.13,,,,,,
BCBS PPO,CPT,88302,Tissue exam by pathologist,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,25.25,217.32,,,,,,
BCBS PPO,CPT,88304,Tissue exam by pathologist,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,50.92,263.08,,,,,,
BCBS PPO,CPT,88305,Tissue exam by pathologist,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,50.92,362.21,,,,,,
BCBS PPO,CPT,88307,Tissue exam by pathologist,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,298.05,671.03,,,,,,
BCBS PPO,CPT,88309,Tissue exam by pathologist,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,671.45,911.23,,,,,,
BCBS PPO,CPT,88311,Decalcify tissue,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,30.51,30.51,,,,,,
BCBS PPO,CPT,88312,Special stains group 1,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,50.92,366.02,,,,,,
BCBS PPO,CPT,88313,Special stains group 2,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.63,308.83,,,,,,
BCBS PPO,CPT,88314,Histochemical stains add-on,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,335.53,335.53,,,,,,
BCBS PPO,CPT,88319,Enzyme histochemistry,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,568.09,671.45,,,,,,
BCBS PPO,CPT,88321,Microslide consultation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.63,438.47,,,,,,
BCBS PPO,CPT,88323,Microslide consultation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,50.92,289.76,,,,,,
BCBS PPO,CPT,88325,Comprehensive review of data,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,152.64,949.36,,,,,,
BCBS PPO,CPT,88329,Path consult introp,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.63,247.83,,,,,,
BCBS PPO,CPT,88331,Path consult intraop 1 bloc,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,152.51,152.64,,,,,,
BCBS PPO,CPT,88332,Path consult intraop addl,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,53.38,53.38,,,,,,
BCBS PPO,CPT,88333,Intraop cyto path consult 1,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,163.95,671.45,,,,,,
BCBS PPO,CPT,88334,Intraop cyto path consult 2,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,99.13,99.13,,,,,,
BCBS PPO,CPT,88341,Immunohisto antb addl slide,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,297.39,297.39,,,,,,
BCBS PPO,CPT,88342,Immunohisto antb 1st stain,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,152.64,297.39,,,,,,
BCBS PPO,CPT,88343,,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,,,,,,,,
BCBS PPO,CPT,88344,Immunohisto antibody slide,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,297.39,298.05,,,,,,
BCBS PPO,CPT,88346,Immunofluor antb 1st stain,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,293.57,298.05,,,,,,
BCBS PPO,CPT,88347,Immunofluorescent study,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,194.45,194.45,,,,,,
BCBS PPO,CPT,88348,Electron microscopy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,671.45,"2,794.70",,,,,,
BCBS PPO,CPT,88349,Scanning electron microscopy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,319.19","1,319.19",,,,,,
BCBS PPO,CPT,88350,Immunofluor antb addl stain,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,293.57,293.57,,,,,,
BCBS PPO,CPT,88355,Analysis skeletal muscle,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,152.64,777.79,,,,,,
BCBS PPO,CPT,88356,Analysis nerve,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,50.92,766.35,,,,,,
BCBS PPO,CPT,88358,Analysis tumor,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,152.64,171.58,,,,,,
BCBS PPO,CPT,88360,Tumor immunohistochem/manual,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,152.64,335.53,,,,,,
BCBS PPO,CPT,88361,Tumor immunohistochem/comput,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,298.05,484.22,,,,,,
BCBS PPO,CPT,88362,Nerve teasing preparations,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,671.45,793.05,,,,,,
BCBS PPO,CPT,88364,Insitu hybridization (fish),Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,499.47,499.47,,,,,,
BCBS PPO,CPT,88365,Insitu hybridization (fish),Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,152.64,499.47,,,,,,
BCBS PPO,CPT,88366,Insitu hybridization (fish),Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,298.05,499.47,,,,,,
BCBS PPO,CPT,88367,Insitu hybridization auto,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,298.05,907.42,,,,,,
BCBS PPO,CPT,88368,Insitu hybridization manual,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,298.05,747.28,,,,,,
BCBS PPO,CPT,88369,M/phmtrc alysishquant/semiq,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,747.28,747.28,,,,,,
BCBS PPO,CPT,88371,Protein western blot tissue,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,156.32,156.32,,,,,,
BCBS PPO,CPT,88372,Protein analysis w/probe,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,160.13,160.13,,,,,,
BCBS PPO,CPT,88373,M/phmtrc alys ishquant/semiq,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,907.42,907.42,,,,,,
BCBS PPO,CPT,88374,M/phmtrc alys ishquant/semiq,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,152.64,907.42,,,,,,
BCBS PPO,CPT,88377,M/phmtrc alys ishquant/semiq,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,152.64,747.28,,,,,,
BCBS PPO,CPT,88380,Microdissection laser,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,613.85,613.85,,,,,,
BCBS PPO,CPT,88381,Microdissection manual,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,789.23,789.23,,,,,,
BCBS PPO,CPT,88384,Eval molecular probes 11-50,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,875.84","1,875.84",,,,,,
BCBS PPO,CPT,88385,Eval molecul probes 51-250,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,306.68","2,306.68",,,,,,
BCBS PPO,CPT,88386,Eval molecul probes 251-500,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,912.91","2,912.91",,,,,,
BCBS PPO,CPT,88720,Bilirubin total transcut,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.02,22.88,,,,,,
BCBS PPO,CPT,88740,Transcutaneous carboxyhb,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,9.37,22.88,,,,,,
BCBS PPO,CPT,88741,Transcutaneous methb,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,9.37,22.88,,,,,,
BCBS PPO,CPT,89049,Chct for mal hyperthermia,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,152.64,"1,201.00",,,,,,
BCBS PPO,CPT,89050,Body fluid cell count,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,4.72,22.88,,,,,,
BCBS PPO,CPT,89051,Body fluid cell count,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.6,26.7,,,,,,
BCBS PPO,CPT,89055,Leukocyte assessment fecal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,4.27,22.88,,,,,,
BCBS PPO,CPT,89060,Exam synovial fluid crystals,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.33,30.51,,,,,,
BCBS PPO,CPT,89100,Sample intestinal contents,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,220.06","1,220.06",,,,,,
BCBS PPO,CPT,89105,Sample intestinal contents,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,254.37","1,254.37",,,,,,
BCBS PPO,CPT,89125,Specimen fat stain,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.88,11.44,,,,,,
BCBS PPO,CPT,89130,Sample stomach contents,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,063.73","1,063.73",,,,,,
BCBS PPO,CPT,89132,Sample stomach contents,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,212.43","1,212.43",,,,,,
BCBS PPO,CPT,89135,Sample stomach contents,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,445.01","1,445.01",,,,,,
BCBS PPO,CPT,89136,Sample stomach contents,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,025.61","1,025.61",,,,,,
BCBS PPO,CPT,89140,Sample stomach contents,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,201.00","1,201.00",,,,,,
BCBS PPO,CPT,89141,Sample stomach contents,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,239.13","1,239.13",,,,,,
BCBS PPO,CPT,89160,Exam feces for meat fibers,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,4.85,15.26,,,,,,
BCBS PPO,CPT,89190,Nasal smear for eosinophils,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.79,22.88,,,,,,
BCBS PPO,CPT,89220,Sputum specimen collection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,80.07,152.64,,,,,,
BCBS PPO,CPT,89225,Starch granules - feces,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.26,15.26,,,,,,
BCBS PPO,CPT,89235,Water load test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.88,22.88,,,,,,
BCBS PPO,CPT,89300,Semen analysis w/huhner,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,9.84,45.74,,,,,,
BCBS PPO,CPT,89310,Semen analysis w/count,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,8.61,30.51,,,,,,
BCBS PPO,CPT,89320,Semen anal vol/count/mot,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.31,49.56,,,,,,
BCBS PPO,CPT,89321,Semen anal sperm detection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.05,49.56,,,,,,
BCBS PPO,CPT,89322,Semen anal strict criteria,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.5,61,,,,,,
BCBS PPO,CPT,89329,Sperm evaluation test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.59,91.51,,,,,,
BCBS PPO,CPT,89330,Evaluation cervical mucus,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,10.38,45.74,,,,,,
BCBS PPO,CPT,89331,Retrograde ejaculation anal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.59,83.87,,,,,,
BCBS PPO,CPT,90281,Human ig im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,80.07,80.07,,,,,,
BCBS PPO,CPT,90283,Human ig iv,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,72.44,72.44,,,,,,
BCBS PPO,CPT,90284,Human ig sc,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.31,34.31,,,,,,
BCBS PPO,CPT,90287,Botulinum antitoxin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,252.22","3,252.22",,,,,,
BCBS PPO,CPT,90291,Cmv ig iv,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,129.64,129.64,,,,,,
BCBS PPO,CPT,90296,Diphtheria antitoxin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,692.84","1,692.84",,,,,,
BCBS PPO,CPT,90371,Hep b ig im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,130.31,735.85,,,,,,
BCBS PPO,CPT,90375,Rabies ig im/sc,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,267.3,617.65,,,,,,
BCBS PPO,CPT,90376,Rabies ig heat treated,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,287.38,617.65,,,,,,
BCBS PPO,CPT,90378,Rsv mab im 50mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,185.67","3,154.20",,,,,,
BCBS PPO,CPT,90379,Rsv ig - iv,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,95.32,95.32,,,,,,
BCBS PPO,CPT,90384,Rh ig full-dose im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.79,13.79,,,,,,
BCBS PPO,CPT,90385,Rh ig minidose im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,151.41,202.07,,,,,,
BCBS PPO,CPT,90386,Rh ig iv,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,758.72,758.72,,,,,,
BCBS PPO,CPT,90396,Varicella-zoster ig im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,495.65,"1,965.97",,,,,,
BCBS PPO,CPT,90465,Immune admin 1 inj - < 8 yrs,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,99.13,99.13,,,,,,
BCBS PPO,CPT,90466,Immune admin addl inj - < 8 y,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,49.56,49.56,,,,,,
BCBS PPO,CPT,90467,Immune admin o or n - < 8 yrs,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,64.82,64.82,,,,,,
BCBS PPO,CPT,90468,Immune admin o/n - addl < 8 y,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,49.56,49.56,,,,,,
BCBS PPO,CPT,90471,Immunization admin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,57.19,63.42,,,,,,
BCBS PPO,CPT,90472,Immunization admin each add,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,30.51,30.51,,,,,,
BCBS PPO,CPT,90473,Immune admin oral/nasal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,57.19,63.42,,,,,,
BCBS PPO,CPT,90586,Bcg vaccine intravesical,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,976.05,976.05,,,,,,
BCBS PPO,CPT,90619,Menacwy-tt vaccine im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,610.03,610.03,,,,,,
BCBS PPO,CPT,90632,Hepa vaccine adult im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,388.89,388.89,,,,,,
BCBS PPO,CPT,90633,Hepa vacc ped/adol 2 dose im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,194.45,194.45,,,,,,
BCBS PPO,CPT,90634,Hepa vacc ped/adol 3 dose,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,175.39,175.39,,,,,,
BCBS PPO,CPT,90636,Hep a/hep b vacc adult im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,533.78,533.78,,,,,,
BCBS PPO,CPT,90645,Hib vaccine hboc im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,141.07,141.07,,,,,,
BCBS PPO,CPT,90646,Hib vaccine prp-d im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,141.07,141.07,,,,,,
BCBS PPO,CPT,90647,Hib prp-omp vacc 3 dose im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,141.07,141.07,,,,,,
BCBS PPO,CPT,90648,Hib prp-t vaccine 4 dose im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,141.07,141.07,,,,,,
BCBS PPO,CPT,90649,4vhpv vaccine 3 dose im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,598.59,598.59,,,,,,
BCBS PPO,CPT,90655,Iiv3 vacc no prsv 0.25 ml im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,68.63,68.63,,,,,,
BCBS PPO,CPT,90656,Iiv3 vacc no prsv 0.5 ml im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.26,76.26,,,,,,
BCBS PPO,CPT,90657,Iiv3 vaccine splt 0.25 ml im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,110.57,110.57,,,,,,
BCBS PPO,CPT,90658,Iiv3 vaccine splt 0.5 ml im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,110.57,110.57,,,,,,
BCBS PPO,CPT,90660,Laiv3 vaccine intranasal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,122,122,,,,,,
BCBS PPO,CPT,90665,Lyme disease vaccine im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,320.27,320.27,,,,,,
BCBS PPO,CPT,90669,Pneumococcal vacc 7 val im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,427.03,427.03,,,,,,
BCBS PPO,CPT,90675,Rabies vaccine im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,327.53,945.56,,,,,,
BCBS PPO,CPT,90676,Rabies vaccine id,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,189.63,945.56,,,,,,
BCBS PPO,CPT,90680,Rv5 vacc 3 dose live oral,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,438.47,438.47,,,,,,
BCBS PPO,CPT,90681,Rv1 vacc 2 dose live oral,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,632.91,632.91,,,,,,
BCBS PPO,CPT,90690,Typhoid vaccine oral,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,240.2,240.2,,,,,,
BCBS PPO,CPT,90691,Typhoid vaccine im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,289.76,289.76,,,,,,
BCBS PPO,CPT,90692,Typhoid vaccine h-p sc/id,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,61,61,,,,,,
BCBS PPO,CPT,90696,Dtap-ipv vaccine 4-6 yrs im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,293.57,293.57,,,,,,
BCBS PPO,CPT,90698,Dtap-ipv/hib vaccine im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,446.08,446.08,,,,,,
BCBS PPO,CPT,90700,Dtap vaccine < 7 yrs im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,141.07,141.07,,,,,,
BCBS PPO,CPT,90701,Dtp vaccine im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,125.82,125.82,,,,,,
BCBS PPO,CPT,90703,Tetanus vaccine im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,133.45,133.45,,,,,,
BCBS PPO,CPT,90704,Mumps vaccine sc,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,137.25,137.25,,,,,,
BCBS PPO,CPT,90705,Measles vaccine sc,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,106.76,106.76,,,,,,
BCBS PPO,CPT,90706,Rubella vaccine sc,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,118.19,118.19,,,,,,
BCBS PPO,CPT,90707,Mmr vaccine sc,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,297.39,297.39,,,,,,
BCBS PPO,CPT,90708,Measles-rubella vaccine sc,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,125.82,125.82,,,,,,
BCBS PPO,CPT,90710,Mmrv vaccine sc,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,610.03,610.03,,,,,,
BCBS PPO,CPT,90712,Oral poliovirus vaccine,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,102.95,102.95,,,,,,
BCBS PPO,CPT,90713,Poliovirus ipv sc/im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,171.58,171.58,,,,,,
BCBS PPO,CPT,90714,Td vacc no presv 7 yrs+ im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,118.19,118.19,,,,,,
BCBS PPO,CPT,90715,Tdap vaccine 7 yrs/> im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,228.77,228.77,,,,,,
BCBS PPO,CPT,90716,Var vaccine live subq,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,522.34,522.34,,,,,,
BCBS PPO,CPT,90717,Yellow fever vaccine subq,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,461.34,461.34,,,,,,
BCBS PPO,CPT,90718,Td vaccine > 7 im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,118.19,118.19,,,,,,
BCBS PPO,CPT,90719,Diphtheria vaccine im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,190.64,190.64,,,,,,
BCBS PPO,CPT,90720,Dtp/hib vaccine im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,152.51,152.51,,,,,,
BCBS PPO,CPT,90721,Dtap/hib vaccine im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,274.51,274.51,,,,,,
BCBS PPO,CPT,90723,Dtap-hep b-ipv vaccine im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,453.71,453.71,,,,,,
BCBS PPO,CPT,90725,Cholera vaccine injectable,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.88,22.88,,,,,,
BCBS PPO,CPT,90727,Plague vaccine im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.13,38.13,,,,,,
BCBS PPO,CPT,90732,Ppsv23 vacc 2 yrs+ subq/im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,228.77,228.77,,,,,,
BCBS PPO,CPT,90733,Mpsv4 vaccine subq,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,621.47,621.47,,,,,,
BCBS PPO,CPT,90734,Menacwyd/menacwycrm vacc im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,610.03,610.03,,,,,,
BCBS PPO,CPT,90735,Encephalitis vaccine sc,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,594.77,594.77,,,,,,
BCBS PPO,CPT,90736,Hzv vaccine live subq,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,770.16,770.16,,,,,,
BCBS PPO,CPT,90740,Hepb vacc 3 dose immunsup im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,029.43","1,029.43",,,,,,
BCBS PPO,CPT,90743,Hepb vacc 2 dose adolesc im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,141.07,141.07,,,,,,
BCBS PPO,CPT,90744,Hepb vacc 3 dose ped/adol im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,141.07,141.07,,,,,,
BCBS PPO,CPT,90746,Hepb vaccine 3 dose adult im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,369.83,369.83,,,,,,
BCBS PPO,CPT,90747,Hepb vacc 4 dose immunsup im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,029.43","1,029.43",,,,,,
BCBS PPO,CPT,90748,Hib-hepb vaccine im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,266.89,266.89,,,,,,
BCBS PPO,CPT,90785,Psytx complex interactive,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,68.63,68.63,,,,,,
BCBS PPO,CPT,90791,Psych diagnostic evaluation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,136.74,789.23,,,,,,
BCBS PPO,CPT,90792,Psych diag eval w/med srvcs,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,136.74,789.23,,,,,,
BCBS PPO,CPT,90801,Psy dx interview,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,789.23,789.23,,,,,,
BCBS PPO,CPT,90802,Intac psy dx interview,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,842.61,842.61,,,,,,
BCBS PPO,CPT,90804,Psytx office 20-30 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,331.7,331.7,,,,,,
BCBS PPO,CPT,90805,Psytx off 20-30 min w/e&m,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,366.02,366.02,,,,,,
BCBS PPO,CPT,90806,Psytx off 45-50 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,480.4,480.4,,,,,,
BCBS PPO,CPT,90807,Psytx off 45-50 min w/e&m,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,537.6,537.6,,,,,,
BCBS PPO,CPT,90808,Psytx office 75-80 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,705.35,705.35,,,,,,
BCBS PPO,CPT,90809,Psytx off 75-80 w/e&m,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,728.23,728.23,,,,,,
BCBS PPO,CPT,90810,Intac psytx off 20-30 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,350.76,350.76,,,,,,
BCBS PPO,CPT,90811,Intac psytx 20-30 w/e&m,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,407.96,407.96,,,,,,
BCBS PPO,CPT,90813,Intac psytx 45-50 min w/e&m,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,556.65,556.65,,,,,,
BCBS PPO,CPT,90814,Intac psytx off 75-80 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,724.42,724.42,,,,,,
BCBS PPO,CPT,90815,Intac psytx 75-80 w/e&m,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,770.16,770.16,,,,,,
BCBS PPO,CPT,90816,Psytx hosp 20-30 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,305.01,305.01,,,,,,
BCBS PPO,CPT,90817,Psytx hosp 20-30 min w/e&m,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,339.33,339.33,,,,,,
BCBS PPO,CPT,90818,Psytx hosp 45-50 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,453.71,453.71,,,,,,
BCBS PPO,CPT,90819,Psytx hosp 45-50 min w/e&m,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,488.04,488.04,,,,,,
BCBS PPO,CPT,90821,Psytx hosp 75-80 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,667.22,667.22,,,,,,
BCBS PPO,CPT,90822,Psytx hosp 75-80 min w/e&m,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,705.35,705.35,,,,,,
BCBS PPO,CPT,90823,Intac psytx hosp 20-30 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,327.9,327.9,,,,,,
BCBS PPO,CPT,90824,Intac psytx hsp 20-30 w/e&m,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,366.02,366.02,,,,,,
BCBS PPO,CPT,90826,Intac psytx hosp 45-50 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,480.4,480.4,,,,,,
BCBS PPO,CPT,90827,Intac psytx hsp 45-50 w/e&m,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,510.9,510.9,,,,,,
BCBS PPO,CPT,90828,Intac psytx hosp 75-80 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,693.9,693.9,,,,,,
BCBS PPO,CPT,90829,Intac psytx hsp 75-80 w/e&m,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,724.42,724.42,,,,,,
BCBS PPO,CPT,90832,Psytx w pt 30 minutes,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,136.74,331.7,,,,,,
BCBS PPO,CPT,90833,Psytx w pt w e/m 30 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,366.02,366.02,,,,,,
BCBS PPO,CPT,90834,Psytx w pt 45 minutes,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,136.74,480.4,,,,,,
BCBS PPO,CPT,90836,Psytx w pt w e/m 45 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,537.6,537.6,,,,,,
BCBS PPO,CPT,90837,Psytx w pt 60 minutes,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,136.74,705.35,,,,,,
BCBS PPO,CPT,90838,Psytx w pt w e/m 60 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,728.23,728.23,,,,,,
BCBS PPO,CPT,90845,Psychoanalysis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,136.74,423.22,,,,,,
BCBS PPO,CPT,90846,Family psytx w/o pt 50 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,136.74,449.9,,,,,,
BCBS PPO,CPT,90847,Family psytx w/pt 50 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,136.74,583.35,,,,,,
BCBS PPO,CPT,90849,Multiple family group psytx,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,136.74,171.58,,,,,,
BCBS PPO,CPT,90853,Group psychotherapy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.62,368.97,,,,,,
BCBS PPO,CPT,90857,Intac group psytx,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,179.2,179.2,,,,,,
BCBS PPO,CPT,90862,Medication management,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,285.96,285.96,,,,,,
BCBS PPO,CPT,90863,Pharmacologic mgmt w/psytx,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,285.96,285.96,,,,,,
BCBS PPO,CPT,90865,Narcosynthesis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,136.74,808.29,,,,,,
BCBS PPO,CPT,90870,Electroconvulsive therapy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,499.16,709.16,,,,,,
BCBS PPO,CPT,90875,Psychophysiological therapy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,369.83,369.83,,,,,,
BCBS PPO,CPT,90876,Psychophysiological therapy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,545.21,545.21,,,,,,
BCBS PPO,CPT,90880,Hypnotherapy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.62,545.21,,,,,,
BCBS PPO,CPT,90882,Environmental manipulation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,457.52,457.52,,,,,,
BCBS PPO,CPT,90887,Consultation with family,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,434.65,434.65,,,,,,
BCBS PPO,CPT,90911,Biofeedback peri/uro/rectal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,476.6,476.6,,,,,,
BCBS PPO,CPT,90912,Bfb training 1st 15 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,43.33,476.6,,,,,,
BCBS PPO,CPT,90913,Bfb training ea addl 15 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,24.51,264.78,,,,,,
BCBS PPO,CPT,90935,Hemodialysis one evaluation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,373.65,669.6,,,,,,
BCBS PPO,CPT,90937,Hemodialysis repeated eval,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,613.85,613.85,,,,,,
BCBS PPO,CPT,90940,Hemodialysis access study,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,327.9,327.9,,,,,,
BCBS PPO,CPT,90945,Dialysis one evaluation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,372.22,388.89,,,,,,
BCBS PPO,CPT,90947,Dialysis repeated eval,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,629.1,629.1,,,,,,
BCBS PPO,CPT,90951,Esrd serv 4 visits p mo <2yr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"5,429.27","5,429.27",,,,,,
BCBS PPO,CPT,90952,Esrd serv 2-3 vsts p mo <2yr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"4,117.71","4,117.71",,,,,,
BCBS PPO,CPT,90953,Esrd serv 1 visit p mo <2yrs,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,745.14","2,745.14",,,,,,
BCBS PPO,CPT,90954,Esrd serv 4 vsts p mo 2-11,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"4,449.42","4,449.42",,,,,,
BCBS PPO,CPT,90955,Esrd srv 2-3 vsts p mo 2-11,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,524.00","2,524.00",,,,,,
BCBS PPO,CPT,90956,Esrd srv 1 visit p mo 2-11,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,708.09","1,708.09",,,,,,
BCBS PPO,CPT,90957,Esrd srv 4 vsts p mo 12-19,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,568.68","3,568.68",,,,,,
BCBS PPO,CPT,90958,Esrd srv 2-3 vsts p mo 12-19,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,413.44","2,413.44",,,,,,
BCBS PPO,CPT,90959,Esrd serv 1 vst p mo 12-19,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,578.46","1,578.46",,,,,,
BCBS PPO,CPT,90960,Esrd srv 4 visits p mo 20+,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,589.90","1,589.90",,,,,,
BCBS PPO,CPT,90961,Esrd srv 2-3 vsts p mo 20+,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,281.07","1,281.07",,,,,,
BCBS PPO,CPT,90962,Esrd serv 1 visit p mo 20+,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,926.48,926.48,,,,,,
BCBS PPO,CPT,90963,Esrd home pt serv p mo <2yrs,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,065.41","3,065.41",,,,,,
BCBS PPO,CPT,90964,Esrd home pt serv p mo 2-11,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,558.32","2,558.32",,,,,,
BCBS PPO,CPT,90965,Esrd home pt serv p mo 12-19,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,424.87","2,424.87",,,,,,
BCBS PPO,CPT,90966,Esrd home pt serv p mo 20+,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,269.63","1,269.63",,,,,,
BCBS PPO,CPT,90967,Esrd svc pr day pt <2,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,110.57,110.57,,,,,,
BCBS PPO,CPT,90968,Esrd svc pr day pt 2-11,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,83.87,83.87,,,,,,
BCBS PPO,CPT,90969,Esrd svc pr day pt 12-19,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,83.87,83.87,,,,,,
BCBS PPO,CPT,90970,Esrd svc pr day pt 20+,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,45.74,45.74,,,,,,
BCBS PPO,CPT,90989,Dialysis training complete,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,058.86","2,058.86",,,,,,
BCBS PPO,CPT,90993,Dialysis training incompl,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,446.08,446.08,,,,,,
BCBS PPO,CPT,90997,Hemoperfusion,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,499.47,499.47,,,,,,
BCBS PPO,CPT,91000,Esophageal intubation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,488.04,488.04,,,,,,
BCBS PPO,CPT,91011,Esophagus motility study,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,391.64","1,391.64",,,,,,
BCBS PPO,CPT,91012,Esophagus motility study,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,414.51","1,414.51",,,,,,
BCBS PPO,CPT,91020,Gastric motility studies,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,499.16,"1,265.81",,,,,,
BCBS PPO,CPT,91022,Duodenal motility study,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,499.16,"1,044.69",,,,,,
BCBS PPO,CPT,91030,Acid perfusion of esophagus,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,499.16,754.91,,,,,,
BCBS PPO,CPT,91052,Gastric analysis test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,671.03,671.03,,,,,,
BCBS PPO,CPT,91055,Gastric intubation for smear,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,728.23,728.23,,,,,,
BCBS PPO,CPT,91105,Gastric intubation treatment,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,434.65,434.65,,,,,,
BCBS PPO,CPT,91132,Electrogastrography,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,244.01,270.61,,,,,,
BCBS PPO,CPT,91133,Electrogastrography w/test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,312.64,,,,,,
BCBS PPO,CPT,92002,Eye exam new patient,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,121.51,354.58,,,,,,
BCBS PPO,CPT,92004,Eye exam new patient,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,121.51,663.41,,,,,,
BCBS PPO,CPT,92012,Eye exam establish patient,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,121.51,373.65,,,,,,
BCBS PPO,CPT,92014,Eye exam&tx estab pt 1/>vst,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,121.51,545.21,,,,,,
BCBS PPO,CPT,92015,Determine refractive state,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,167.76,167.76,,,,,,
BCBS PPO,CPT,92018,New eye exam & treatment,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,671.03,"2,049.05",,,,,,
BCBS PPO,CPT,92019,Eye exam & treatment,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,331.7,"2,049.05",,,,,,
BCBS PPO,CPT,92020,Special eye evaluation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,125.82,,,,,,
BCBS PPO,CPT,92025,Corneal topography,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,56.95,167.76,,,,,,
BCBS PPO,CPT,92060,Special eye evaluation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,56.95,285.96,,,,,,
BCBS PPO,CPT,92065,Orthoptic/pleoptic training,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,56.95,224.95,,,,,,
BCBS PPO,CPT,92070,Fitting of contact lens,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,320.27,320.27,,,,,,
BCBS PPO,CPT,92071,Contact lens fitting for tx,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,320.27,320.27,,,,,,
BCBS PPO,CPT,92072,Fit contac lens for managmnt,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,320.27,320.27,,,,,,
BCBS PPO,CPT,92081,Visual field examination(s),Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,56.95,255.45,,,,,,
BCBS PPO,CPT,92082,Visual field examination(s),Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,56.95,339.33,,,,,,
BCBS PPO,CPT,92083,Visual field examination(s),Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,385.09,,,,,,
BCBS PPO,CPT,92100,Serial tonometry exam(s),Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,427.03,427.03,,,,,,
BCBS PPO,CPT,92120,Tonography & eye evaluation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,350.76,350.76,,,,,,
BCBS PPO,CPT,92130,Water provocation tonography,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,388.89,388.89,,,,,,
BCBS PPO,CPT,92133,Cmptr ophth img optic nerve,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,56.95,224.95,,,,,,
BCBS PPO,CPT,92134,Cptr ophth dx img post segmt,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,56.95,224.95,,,,,,
BCBS PPO,CPT,92135,Ophth dx imaging post seg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,224.95,224.95,,,,,,
BCBS PPO,CPT,92136,Ophthalmic biometry,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,411.78,,,,,,
BCBS PPO,CPT,92140,Glaucoma provocative tests,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,274.51,274.51,,,,,,
BCBS PPO,CPT,92201,Opscpy extnd rta draw uni/bi,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,56.95,118.19,,,,,,
BCBS PPO,CPT,92202,Opscpy extnd on/mac draw,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,56.95,76.37,,,,,,
BCBS PPO,CPT,92225,Special eye exam initial,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,118.19,118.19,,,,,,
BCBS PPO,CPT,92226,Special eye exam subsequent,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,106.76,106.76,,,,,,
BCBS PPO,CPT,92230,Eye exam with photos,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,289.76,499.16,,,,,,
BCBS PPO,CPT,92235,Fluorescein angrph uni/bi,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,270.61,629.1,,,,,,
BCBS PPO,CPT,92240,Icg angiography uni/bi,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,270.61,"1,162.87",,,,,,
BCBS PPO,CPT,92242,Fluorescein icg angiography,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,270.61,"1,791.98",,,,,,
BCBS PPO,CPT,92250,Eye exam with photos,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,346.96,,,,,,
BCBS PPO,CPT,92260,Ophthalmoscopy/dynamometry,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.63,87.69,,,,,,
BCBS PPO,CPT,92265,Eye muscle evaluation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,56.95,381.27,,,,,,
BCBS PPO,CPT,92270,Electro-oculography,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,438.47,,,,,,
BCBS PPO,CPT,92273,Full field erg w/i&r,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,270.61,648.16,,,,,,
BCBS PPO,CPT,92274,Multifocal erg w/i&r,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,142.8,386.03,,,,,,
BCBS PPO,CPT,92275,Electroretinography,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,648.16,648.16,,,,,,
BCBS PPO,CPT,92283,Color vision examination,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,56.95,224.95,,,,,,
BCBS PPO,CPT,92285,Eye photography,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,56.95,205.88,,,,,,
BCBS PPO,CPT,92286,Internal eye photography,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,583.35,,,,,,
BCBS PPO,CPT,92287,Internal eye photography,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,549.03,,,,,,
BCBS PPO,CPT,92310,Contact lens fitting,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,465.15,465.15,,,,,,
BCBS PPO,CPT,92311,Contact lens fitting,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,276.53,449.9,,,,,,
BCBS PPO,CPT,92312,Contact lens fitting,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,510.9,,,,,,
BCBS PPO,CPT,92313,Contact lens fitting,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,434.65,,,,,,
BCBS PPO,CPT,92314,Prescription of contact lens,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,366.02,366.02,,,,,,
BCBS PPO,CPT,92315,Rx cntact lens aphakia 1 eye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,312.64,,,,,,
BCBS PPO,CPT,92316,Rx cntact lens aphakia 2 eye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,411.78,,,,,,
BCBS PPO,CPT,92317,Rx corneoscleral cntact lens,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.63,324.09,,,,,,
BCBS PPO,CPT,92325,Modification of contact lens,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,141.07,,,,,,
BCBS PPO,CPT,92326,Replacement of contact lens,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,56.95,205.88,,,,,,
BCBS PPO,CPT,92340,Fit spectacles monofocal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,179.2,179.2,,,,,,
BCBS PPO,CPT,92341,Fit spectacles bifocal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,205.88,205.88,,,,,,
BCBS PPO,CPT,92342,Fit spectacles multifocal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,221.14,221.14,,,,,,
BCBS PPO,CPT,92352,Fit aphakia spectcl monofocl,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,56.95,198.25,,,,,,
BCBS PPO,CPT,92353,Fit aphakia spectcl multifoc,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,56.95,232.58,,,,,,
BCBS PPO,CPT,92354,Fit spectacles single system,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.63,510.9,,,,,,
BCBS PPO,CPT,92355,Fit spectacles compound lens,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.63,285.96,,,,,,
BCBS PPO,CPT,92358,Aphakia prosth service temp,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,56.95,102.95,,,,,,
BCBS PPO,CPT,92370,Repair & adjust spectacles,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,160.13,160.13,,,,,,
BCBS PPO,CPT,92371,Repair & adjust spectacles,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,56.95,76.26,,,,,,
BCBS PPO,CPT,92502,Ear and throat examination,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,462.91,526.16,,,,,,
BCBS PPO,CPT,92504,Ear microscopy examination,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,160.13,160.13,,,,,,
BCBS PPO,CPT,92506,Speech/hearing evaluation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,857.86,857.86,,,,,,
BCBS PPO,CPT,92507,Speech/hearing therapy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,75.75,354.58,,,,,,
BCBS PPO,CPT,92508,Speech/hearing therapy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,23.07,171.58,,,,,,
BCBS PPO,CPT,92511,Nasopharyngoscopy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,168.23,842.61,,,,,,
BCBS PPO,CPT,92512,Nasal function studies,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,270.61,331.7,,,,,,
BCBS PPO,CPT,92520,Laryngeal function studies,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,339.33,,,,,,
BCBS PPO,CPT,92521,Evaluation of speech fluency,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,132.47,857.86,,,,,,
BCBS PPO,CPT,92522,Evaluate speech production,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.22,857.86,,,,,,
BCBS PPO,CPT,92523,Speech sound lang comprehen,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,227.69,857.86,,,,,,
BCBS PPO,CPT,92524,Behavral qualit analys voice,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,108.89,857.86,,,,,,
BCBS PPO,CPT,92526,Oral function therapy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,83.51,453.71,,,,,,
BCBS PPO,CPT,92531,Spontaneous nystagmus study,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,171.58,171.58,,,,,,
BCBS PPO,CPT,92532,Positional nystagmus test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,152.51,152.51,,,,,,
BCBS PPO,CPT,92533,Caloric vestibular test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,244.01,244.01,,,,,,
BCBS PPO,CPT,92534,Optokinetic nystagmus test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,125.82,125.82,,,,,,
BCBS PPO,CPT,92537,Caloric vstblr test w/rec,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,142.8,163.95,,,,,,
BCBS PPO,CPT,92538,Caloric vstblr test w/rec,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,142.8,163.95,,,,,,
BCBS PPO,CPT,92541,Spontaneous nystagmus test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,335.53,,,,,,
BCBS PPO,CPT,92542,Positional nystagmus test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,346.96,,,,,,
BCBS PPO,CPT,92543,Caloric vestibular test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,163.95,163.95,,,,,,
BCBS PPO,CPT,92544,Optokinetic nystagmus test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,142.8,282.14,,,,,,
BCBS PPO,CPT,92545,Oscillating tracking test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,263.08,270.61,,,,,,
BCBS PPO,CPT,92546,Sinusoidal rotational test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,142.8,468.96,,,,,,
BCBS PPO,CPT,92547,Supplemental electrical test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,41.94,41.94,,,,,,
BCBS PPO,CPT,92548,Cdp-sot 6 cond w/i&r,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,556.65,,,,,,
BCBS PPO,CPT,92549,Cdp-sot 6 cond w/i&r mct&adt,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,556.65,,,,,,
BCBS PPO,CPT,92552,Pure tone audiometry air,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,129.64,,,,,,
BCBS PPO,CPT,92553,Audiometry air & bone,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,142.8,175.39,,,,,,
BCBS PPO,CPT,92555,Speech threshold audiometry,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.63,99.13,,,,,,
BCBS PPO,CPT,92556,Speech audiometry complete,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,56.95,152.51,,,,,,
BCBS PPO,CPT,92557,Comprehensive hearing test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,142.8,278.32,,,,,,
BCBS PPO,CPT,92559,Group audiometric testing,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,152.51,152.51,,,,,,
BCBS PPO,CPT,92560,Bekesy audiometry screen,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,91.51,91.51,,,,,,
BCBS PPO,CPT,92561,Bekesy audiometry diagnosis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,171.58,,,,,,
BCBS PPO,CPT,92562,Loudness balance test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,137.25,142.8,,,,,,
BCBS PPO,CPT,92563,Tone decay hearing test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.63,125.82,,,,,,
BCBS PPO,CPT,92564,Sisi hearing test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,25.25,122,,,,,,
BCBS PPO,CPT,92565,Stenger test pure tone,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.63,80.07,,,,,,
BCBS PPO,CPT,92567,Tympanometry,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.63,110.57,,,,,,
BCBS PPO,CPT,92568,Acoustic refl threshold tst,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.63,110.57,,,,,,
BCBS PPO,CPT,92569,Acoustic reflex decay test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,87.69,87.69,,,,,,
BCBS PPO,CPT,92571,Filtered speech hearing test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.63,102.95,,,,,,
BCBS PPO,CPT,92572,Staggered spondaic word test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,99.13,142.8,,,,,,
BCBS PPO,CPT,92575,Sensorineural acuity test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.63,202.07,,,,,,
BCBS PPO,CPT,92576,Synthetic sentence test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.63,129.64,,,,,,
BCBS PPO,CPT,92577,Stenger test speech,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.39,499.16,,,,,,
BCBS PPO,CPT,92579,Visual audiometry (vra),Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,142.8,259.27,,,,,,
BCBS PPO,CPT,92582,Conditioning play audiometry,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,142.8,247.83,,,,,,
BCBS PPO,CPT,92583,Select picture audiometry,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,56.95,205.88,,,,,,
BCBS PPO,CPT,92584,Electrocochleography,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,142.8,427.03,,,,,,
BCBS PPO,CPT,92585,Auditor evoke potent compre,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,606.21,606.21,,,,,,
BCBS PPO,CPT,92586,Auditor evoke potent limit,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.09,385.09,,,,,,
BCBS PPO,CPT,92587,Evoked auditory test limited,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,244.01,270.61,,,,,,
BCBS PPO,CPT,92588,Evoked auditory tst complete,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,270.61,385.09,,,,,,
BCBS PPO,CPT,92590,Hearing aid exam one ear,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,289.76,289.76,,,,,,
BCBS PPO,CPT,92591,Hearing aid exam both ears,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,289.76,289.76,,,,,,
BCBS PPO,CPT,92592,Hearing aid check one ear,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,99.13,99.13,,,,,,
BCBS PPO,CPT,92593,Hearing aid check both ears,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,99.13,99.13,,,,,,
BCBS PPO,CPT,92594,Electro hearng aid test one,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,289.76,289.76,,,,,,
BCBS PPO,CPT,92597,Oral speech device eval,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,70.53,583.35,,,,,,
BCBS PPO,CPT,92607,Ex for speech device rx 1hr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,122.72,804.48,,,,,,
BCBS PPO,CPT,92608,Ex for speech device rx addl,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,49.31,163.95,,,,,,
BCBS PPO,CPT,92609,Use of speech device service,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,102.45,430.83,,,,,,
BCBS PPO,CPT,92610,Evaluate swallowing function,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,69.06,423.22,,,,,,
BCBS PPO,CPT,92611,Motion fluoroscopy/swallow,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,90.57,461.34,,,,,,
BCBS PPO,CPT,92612,Endoscopy swallow (fees) vid,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,65.56,796.85,,,,,,
BCBS PPO,CPT,92613,Endoscopy swallow (fees) i&r,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,202.07,202.07,,,,,,
BCBS PPO,CPT,92614,Laryngoscopic sensory vid,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,64.93,709.16,,,,,,
BCBS PPO,CPT,92615,Laryngoscopic sensory i&r,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,183.02,183.02,,,,,,
BCBS PPO,CPT,92616,Fees w/laryngeal sense test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,97.82,972.25,,,,,,
BCBS PPO,CPT,92617,Fees w/laryngeal sense i&r,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,221.14,221.14,,,,,,
BCBS PPO,CPT,92621,Auditory function + 15 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,87.69,87.69,,,,,,
BCBS PPO,CPT,92625,Tinnitus assessment,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,142.8,293.57,,,,,,
BCBS PPO,CPT,92626,Eval aud funcj 1st hour,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,142.8,407.96,,,,,,
BCBS PPO,CPT,92627,Eval aud funcj ea addl 15,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,99.13,99.13,,,,,,
BCBS PPO,CPT,92640,Aud brainstem implt programg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,142.8,385.09,,,,,,
BCBS PPO,CPT,92920,Prq cardiac angioplast 1 art,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,92920,Prq cardiac angioplast 1 art,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,92921,Prq cardiac angio addl art,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,92921,Prq cardiac angio addl art,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,92924,Prq card angio/athrect 1 art,,Per Case,"$4,871.00 ",OP,"4,140.35","10,277.14",,,,,,
BCBS PPO,CPT,92924,Prq card angio/athrect 1 art,,Per Case,"$9,201.00 ",OP,"4,140.35","10,277.14",,,,,,
BCBS PPO,CPT,92925,Prq card angio/athrect addl,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,92925,Prq card angio/athrect addl,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,92950,Heart/lung resuscitation cpr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,270.61,"1,567.02",,,,,,
BCBS PPO,CPT,92960,Cardioversion electric ext,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,575.01,"1,460.26",,,,,,
BCBS PPO,CPT,92961,Cardioversion electric int,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,575.01,"1,513.64",,,,,,
BCBS PPO,CPT,92970,Cardioassist internal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,040.87","8,948.83",,,,,,
BCBS PPO,CPT,92971,Cardioassist external,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,590.97,"8,948.83",,,,,,
BCBS PPO,CPT,92973,Prq coronary mech thrombect,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,078.99","1,078.99",,,,,,
BCBS PPO,CPT,92974,Cath place cardio brachytx,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,987.49,987.49,,,,,,
BCBS PPO,CPT,92975,Dissolve clot heart vessel,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,367.69","8,948.83",,,,,,
BCBS PPO,CPT,92977,Dissolve clot heart vessel,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,318,850.23,,,,,,
BCBS PPO,CPT,92978,Endoluminl ivus oct c 1st,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,677.58","1,677.58",,,,,,
BCBS PPO,CPT,92979,Endoluminl ivus oct c ea,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,025.61","1,025.61",,,,,,
BCBS PPO,CPT,92986,Revision of aortic valve,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"5,072.43","8,048.60",,,,,,
BCBS PPO,CPT,92987,Revision of mitral valve,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"8,338.36","10,277.14",,,,,,
BCBS PPO,CPT,92990,Revision of pulmonary valve,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"6,409.14","10,277.14",,,,,,
BCBS PPO,CPT,92992,Revision of heart chamber,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"5,940.18","5,940.18",,,,,,
BCBS PPO,CPT,92993,Revision of heart chamber,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"4,701.06","4,701.06",,,,,,
BCBS PPO,CPT,92996,Coronary atherectomy add-on,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,025.61","1,025.61",,,,,,
BCBS PPO,CPT,92997,Pul art balloon repr percut,,Per Case,"$9,201.00 ",OP,"4,140.35","10,277.14",,,,,,
BCBS PPO,CPT,92997,Pul art balloon repr percut,All Other,Per Unit,"$4,254.41 ",OP,"4,140.35","10,277.14",,,,,,
BCBS PPO,CPT,92997,Pul art balloon repr percut,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"4,140.35","10,277.14",,,,,,
BCBS PPO,CPT,92998,Pul art balloon repr percut,,Per Case,"$9,201.00 ",OP,"2,203.50","9,201.00",,,,,,
BCBS PPO,CPT,92998,Pul art balloon repr percut,All Other,Per Unit,"$2,203.50 ",OP,"2,203.50","9,201.00",,,,,,
BCBS PPO,CPT,92998,Pul art balloon repr percut,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,203.50","9,201.00",,,,,,
BCBS PPO,CPT,93000,Electrocardiogram complete,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,125.82,125.82,,,,,,
BCBS PPO,CPT,93005,Electrocardiogram tracing,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,56.95,72.44,,,,,,
BCBS PPO,CPT,93010,Electrocardiogram report,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,53.38,53.38,,,,,,
BCBS PPO,CPT,93012,Transmission of ecg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,082.81","1,082.81",,,,,,
BCBS PPO,CPT,93014,Report on transmitted ecg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,160.13,160.13,,,,,,
BCBS PPO,CPT,93015,Cardiovascular stress test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,594.77,594.77,,,,,,
BCBS PPO,CPT,93016,Cardiovascular stress test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,141.07,141.07,,,,,,
BCBS PPO,CPT,93017,Cardiovascular stress test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,270.61,362.21,,,,,,
BCBS PPO,CPT,93018,Cardiovascular stress test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,91.51,91.51,,,,,,
BCBS PPO,CPT,93024,Cardiac drug stress test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,276.53,712.98,,,,,,
BCBS PPO,CPT,93025,Microvolt t-wave assess,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,142.8,"1,246.76",,,,,,
BCBS PPO,CPT,93042,Rhythm ecg report,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,45.74,45.74,,,,,,
BCBS PPO,CPT,93224,Ecg monit/reprt up to 48 hrs,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,743.48,743.48,,,,,,
BCBS PPO,CPT,93225,Ecg monit/reprt up to 48 hrs,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,224.95,,,,,,
BCBS PPO,CPT,93226,Ecg monit/reprt up to 48 hrs,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,926.48,,,,,,
BCBS PPO,CPT,93227,Ecg monit/reprt up to 48 hrs,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,163.95,163.95,,,,,,
BCBS PPO,CPT,93228,Remote 30 day ecg rev/report,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,144.88,144.88,,,,,,
BCBS PPO,CPT,93230,ECG monitor/report - 24 hrs,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,743.48,743.48,,,,,,
BCBS PPO,CPT,93231,Ecg monitor/record - 24 hrs,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,224.95,224.95,,,,,,
BCBS PPO,CPT,93232,ECG monitor/report - 24 hrs,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,362.21,362.21,,,,,,
BCBS PPO,CPT,93233,ECG monitor/review - 24 hrs,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,156.32,156.32,,,,,,
BCBS PPO,CPT,93235,ECG monitor/report - 24 hrs,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,476.6,476.6,,,,,,
BCBS PPO,CPT,93236,ECG monitor/report - 24 hrs,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,926.48,926.48,,,,,,
BCBS PPO,CPT,93237,ECG monitor/review - 24 hrs,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,141.07,141.07,,,,,,
BCBS PPO,CPT,93268,Ecg record/review,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,574.64","1,574.64",,,,,,
BCBS PPO,CPT,93270,Remote 30 day ecg rev/report,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.02,137.25,,,,,,
BCBS PPO,CPT,93271,Ecg/monitoring and analysis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,102.65,"1,281.07",,,,,,
BCBS PPO,CPT,93272,Ecg/review interpret only,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,156.32,156.32,,,,,,
BCBS PPO,CPT,93278,Ecg/signal-averaged,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,56.95,251.64,,,,,,
BCBS PPO,CPT,93279,Prgrmg dev eval pm/ldls pm,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.02,327.9,,,,,,
BCBS PPO,CPT,93280,Pm device progr eval dual,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.02,381.27,,,,,,
BCBS PPO,CPT,93281,Pm device progr eval multi,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.02,446.08,,,,,,
BCBS PPO,CPT,93282,Prgrmg eval implantable dfb,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.02,415.59,,,,,,
BCBS PPO,CPT,93283,Prgrmg eval implantable dfb,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.02,503.28,,,,,,
BCBS PPO,CPT,93284,Prgrmg eval implantable dfb,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.02,587.16,,,,,,
BCBS PPO,CPT,93285,Prgrmg dev eval scrms ip,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.02,282.14,,,,,,
BCBS PPO,CPT,93286,Peri-px eval pm/ldls pm ip,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,160.13,160.13,,,,,,
BCBS PPO,CPT,93287,Peri-px device eval & prgr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,213.51,213.51,,,,,,
BCBS PPO,CPT,93288,Interrog evl pm/ldls pm ip,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.02,255.45,,,,,,
BCBS PPO,CPT,93289,Interrog device eval heart,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.02,385.09,,,,,,
BCBS PPO,CPT,93290,Interrog dev eval icpms ip,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.02,190.64,,,,,,
BCBS PPO,CPT,93291,Interrog dev eval scrms ip,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,25.25,244.01,,,,,,
BCBS PPO,CPT,93293,Pm phone r-strip device eval,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.02,366.02,,,,,,
BCBS PPO,CPT,93295,Dev interrog remote 1/2/mlt,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,377.46,377.46,,,,,,
BCBS PPO,CPT,93296,Rem interrog evl pm/ids,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.02,213.51,,,,,,
BCBS PPO,CPT,93297,Rem interrog dev eval icpms,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,144.88,144.88,,,,,,
BCBS PPO,CPT,93298,Rem interrog dev eval scrms,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,167.76,167.76,,,,,,
BCBS PPO,CPT,93303,Echo transthoracic,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,494.15,"1,292.50",,,,,,
BCBS PPO,CPT,93304,Echo transthoracic,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,494.15,796.85,,,,,,
BCBS PPO,CPT,93306,Tte w/doppler complete,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,494.15,"1,593.72",,,,,,
BCBS PPO,CPT,93307,Tte w/o doppler complete,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,"1,056.11",,,,,,
BCBS PPO,CPT,93308,Tte f-up or lmtd,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,667.22,,,,,,
BCBS PPO,CPT,93312,Echo transesophageal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,494.15,"1,921.59",,,,,,
BCBS PPO,CPT,93314,Echo transesophageal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,662.33","1,662.33",,,,,,
BCBS PPO,CPT,93315,Echo transesophageal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,494.15,"1,738.59",,,,,,
BCBS PPO,CPT,93316,Echo transesophageal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,259.27,494.15,,,,,,
BCBS PPO,CPT,93317,Echo transesophageal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,082.81","1,082.81",,,,,,
BCBS PPO,CPT,93318,Echo transesophageal intraop,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,494.15,"1,330.63",,,,,,
BCBS PPO,CPT,93320,Doppler echo exam heart,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,468.96,468.96,,,,,,
BCBS PPO,CPT,93321,Doppler echo exam heart,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,217.32,217.32,,,,,,
BCBS PPO,CPT,93325,Doppler color flow add-on,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,346.96,346.96,,,,,,
BCBS PPO,CPT,93350,Stress tte only,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,494.15,"1,239.13",,,,,,
BCBS PPO,CPT,93351,Stress tte complete,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,494.15,"1,635.64",,,,,,
BCBS PPO,CPT,93352,Admin ecg contrast agent,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,228.77,228.77,,,,,,
BCBS PPO,CPT,93451,Right heart cath,,Per Case,"$4,871.00 ",OP,"2,966.62","9,201.00",,,,,,
BCBS PPO,CPT,93451,Right heart cath,,Per Case,"$9,201.00 ",OP,"2,966.62","9,201.00",,,,,,
BCBS PPO,CPT,93452,Left hrt cath w/ventrclgrphy,,Per Case,"$4,871.00 ",OP,"2,966.62","9,201.00",,,,,,
BCBS PPO,CPT,93452,Left hrt cath w/ventrclgrphy,,Per Case,"$9,201.00 ",OP,"2,966.62","9,201.00",,,,,,
BCBS PPO,CPT,93453,R&l hrt cath w/ventriclgrphy,,Per Case,"$4,871.00 ",OP,"2,966.62","9,201.00",,,,,,
BCBS PPO,CPT,93453,R&l hrt cath w/ventriclgrphy,,Per Case,"$9,201.00 ",OP,"2,966.62","9,201.00",,,,,,
BCBS PPO,CPT,93456,R hrt coronary artery angio,,Per Case,"$4,871.00 ",OP,"2,966.62","9,201.00",,,,,,
BCBS PPO,CPT,93456,R hrt coronary artery angio,,Per Case,"$9,201.00 ",OP,"2,966.62","9,201.00",,,,,,
BCBS PPO,CPT,93457,R hrt art/grft angio,,Per Case,"$4,871.00 ",OP,"2,966.62","9,201.00",,,,,,
BCBS PPO,CPT,93457,R hrt art/grft angio,,Per Case,"$9,201.00 ",OP,"2,966.62","9,201.00",,,,,,
BCBS PPO,CPT,93458,L hrt artery/ventricle angio,,Per Case,"$4,871.00 ",OP,"2,966.62","9,201.00",,,,,,
BCBS PPO,CPT,93458,L hrt artery/ventricle angio,,Per Case,"$9,201.00 ",OP,"2,966.62","9,201.00",,,,,,
BCBS PPO,CPT,93459,L hrt art/grft angio,,Per Case,"$4,871.00 ",OP,"2,966.62","9,201.00",,,,,,
BCBS PPO,CPT,93459,L hrt art/grft angio,,Per Case,"$9,201.00 ",OP,"2,966.62","9,201.00",,,,,,
BCBS PPO,CPT,93460,R&l hrt art/ventricle angio,,Per Case,"$4,871.00 ",OP,"2,966.62","9,201.00",,,,,,
BCBS PPO,CPT,93460,R&l hrt art/ventricle angio,,Per Case,"$9,201.00 ",OP,"2,966.62","9,201.00",,,,,,
BCBS PPO,CPT,93461,R&l hrt art/ventricle angio,,Per Case,"$4,871.00 ",OP,"2,966.62","9,201.00",,,,,,
BCBS PPO,CPT,93461,R&l hrt art/ventricle angio,,Per Case,"$9,201.00 ",OP,"2,966.62","9,201.00",,,,,,
BCBS PPO,CPT,93503,Insert/place heart catheter,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,651.97,"1,438.93",,,,,,
BCBS PPO,CPT,93505,Biopsy of heart lining,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,928.39","4,346.47",,,,,,
BCBS PPO,CPT,93508,Cath placement - angiography,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"6,241.38","6,241.38",,,,,,
BCBS PPO,CPT,93514,Left heart catheterization,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"10,763.23","10,763.23",,,,,,
BCBS PPO,CPT,93524,Left heart catheterization,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"13,977.33","13,977.33",,,,,,
BCBS PPO,CPT,93528,Rt & Lt heart catheters,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"14,011.66","14,011.66",,,,,,
BCBS PPO,CPT,93529,Rt - lt heart catheterization,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"12,661.95","12,661.95",,,,,,
BCBS PPO,CPT,93530,Rt heart cath congenital,,Per Case,"$9,201.00 ",OP,"2,966.62","9,201.00",,,,,,
BCBS PPO,CPT,93530,Rt heart cath congenital,All Other,Per Unit,"$6,323.26 ",OP,"2,966.62","9,201.00",,,,,,
BCBS PPO,CPT,93530,Rt heart cath congenital,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,966.62","9,201.00",,,,,,
BCBS PPO,CPT,93531,R & l heart cath congenital,,Per Case,"$9,201.00 ",OP,"2,966.62","16,124.56",,,,,,
BCBS PPO,CPT,93531,R & l heart cath congenital,All Other,Per Unit,"$16,124.56 ",OP,"2,966.62","16,124.56",,,,,,
BCBS PPO,CPT,93531,R & l heart cath congenital,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,966.62","16,124.56",,,,,,
BCBS PPO,CPT,93532,R & l heart cath congenital,,Per Case,"$9,201.00 ",OP,"2,966.62","16,600.26",,,,,,
BCBS PPO,CPT,93532,R & l heart cath congenital,All Other,Per Unit,"$16,600.26 ",OP,"2,966.62","16,600.26",,,,,,
BCBS PPO,CPT,93532,R & l heart cath congenital,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,966.62","16,600.26",,,,,,
BCBS PPO,CPT,93533,R & l heart cath congenital,,Per Case,"$9,201.00 ",OP,"2,966.62","16,111.09",,,,,,
BCBS PPO,CPT,93533,R & l heart cath congenital,All Other,Per Unit,"$16,111.09 ",OP,"2,966.62","16,111.09",,,,,,
BCBS PPO,CPT,93533,R & l heart cath congenital,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,966.62","16,111.09",,,,,,
BCBS PPO,CPT,93541,Injection for lung angiogram,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.26,76.26,,,,,,
BCBS PPO,CPT,93542,Injection for heart x-rays,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,709.16,709.16,,,,,,
BCBS PPO,CPT,93545,Inject for coronary x-rays,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,815.92,815.92,,,,,,
BCBS PPO,CPT,93556,Imaging - cardiac cath,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,033.25","1,033.25",,,,,,
BCBS PPO,CPT,93561,Cardiac output measurement,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,255.45,255.45,,,,,,
BCBS PPO,CPT,93562,Card output measure subsq,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,118.19,118.19,,,,,,
BCBS PPO,CPT,93571,Heart flow reserve measure,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,673.76","1,673.76",,,,,,
BCBS PPO,CPT,93572,Heart flow reserve measure,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,968.43,968.43,,,,,,
BCBS PPO,CPT,93580,Transcath closure of asd,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"5,905.86","16,438.60",,,,,,
BCBS PPO,CPT,93581,Transcath closure of vsd,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"7,739.77","16,438.60",,,,,,
BCBS PPO,CPT,93602,Intra-atrial recording,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,968.43,"6,220.22",,,,,,
BCBS PPO,CPT,93603,Right ventricular recording,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,117.12","1,138.72",,,,,,
BCBS PPO,CPT,93609,Map tachycardia add-on,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,287.62","2,287.62",,,,,,
BCBS PPO,CPT,93610,Intra-atrial pacing,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,323.01","6,220.22",,,,,,
BCBS PPO,CPT,93612,Intraventricular pacing,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,376.38","6,220.22",,,,,,
BCBS PPO,CPT,93613,Electrophys map 3d add-on,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,291.44","2,291.44",,,,,,
BCBS PPO,CPT,93615,Esophageal recording,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,392.7,"1,138.72",,,,,,
BCBS PPO,CPT,93618,Heart rhythm pacing,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,138.72","2,367.69",,,,,,
BCBS PPO,CPT,93619,Electrophysiology evaluation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"4,312.16","6,220.22",,,,,,
BCBS PPO,CPT,93620,Electrophysiology evaluation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"5,112.83","6,220.22",,,,,,
BCBS PPO,CPT,93621,Electrophysiology evaluation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,930.3,930.3,,,,,,
BCBS PPO,CPT,93622,Electrophysiology evaluation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,353.52","1,353.52",,,,,,
BCBS PPO,CPT,93623,Stimulation pacing heart,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,254.37","1,254.37",,,,,,
BCBS PPO,CPT,93624,Electrophysiologic study,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,051.24","6,220.22",,,,,,
BCBS PPO,CPT,93631,Heart pacing mapping,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,256.04","3,256.04",,,,,,
BCBS PPO,CPT,93640,Evaluation heart device,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,920.52","2,920.52",,,,,,
BCBS PPO,CPT,93641,Electrophysiology evaluation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,713.56","3,713.56",,,,,,
BCBS PPO,CPT,93642,Electrophysiology evaluation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,138.72","2,775.65",,,,,,
BCBS PPO,CPT,93650,Ablate heart dysrhythm focus,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,488.62","6,220.22",,,,,,
BCBS PPO,CPT,93651,Ablate heart dysrhythm focus,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"5,307.27","5,307.27",,,,,,
BCBS PPO,CPT,93652,Ablate heart dysrhythm focus,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"5,776.24","5,776.24",,,,,,
BCBS PPO,CPT,93653,Ep & ablate supravent arrhyt,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"10,420.09","21,964.94",,,,,,
BCBS PPO,CPT,93654,Ep & ablate ventric tachy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"10,889.05","21,964.94",,,,,,
BCBS PPO,CPT,93656,Tx atrial fib pulm vein isol,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"10,420.09","21,964.94",,,,,,
BCBS PPO,CPT,93660,Tilt table evaluation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,499.16,983.68,,,,,,
BCBS PPO,CPT,93662,Intracardiac ecg (ice),Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,181.94","1,181.94",,,,,,
BCBS PPO,CPT,93668,Peripheral vascular rehab,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,56.95,99.13,,,,,,
BCBS PPO,CPT,93701,Bioimpedance cv analysis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,198.25,,,,,,
BCBS PPO,CPT,93720,Total body plethysmography,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,278.32,278.32,,,,,,
BCBS PPO,CPT,93721,Plethysmography tracing,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,228.77,228.77,,,,,,
BCBS PPO,CPT,93722,Plethysmography report,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,49.56,49.56,,,,,,
BCBS PPO,CPT,93724,Analyze pacemaker system,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,278.82,"1,948.29",,,,,,
BCBS PPO,CPT,93740,Temperature gradient studies,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,57.19,142.8,,,,,,
BCBS PPO,CPT,93770,Measure venous pressure,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,53.38,53.38,,,,,,
BCBS PPO,CPT,93784,Ambl bp mntr w/software,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,377.46,377.46,,,,,,
BCBS PPO,CPT,93786,Ambl bp mntr w/sw rec only,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,171.58,,,,,,
BCBS PPO,CPT,93790,Ambl bp mntr w/sw i&r,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,106.76,106.76,,,,,,
BCBS PPO,CPT,93792,Pt/caregiver traing home inr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,644.34,644.34,,,,,,
BCBS PPO,CPT,93793,Anticoag mgmt pt warfarin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,224.95,224.95,,,,,,
BCBS PPO,CPT,93797,Cardiac rehab,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,102.95,118.77,,,,,,
BCBS PPO,CPT,93798,Cardiac rehab/monitor,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,118.77,148.69,,,,,,
BCBS PPO,CPT,93875,Extracranial study,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,499.47,499.47,,,,,,
BCBS PPO,CPT,93880,Extracranial bilat study,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,"1,239.13",,,,,,
BCBS PPO,CPT,93882,Extracranial uni/ltd study,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,815.92,,,,,,
BCBS PPO,CPT,93886,Intracranial complete study,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,"1,483.14",,,,,,
BCBS PPO,CPT,93888,Intracranial limited study,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,"1,010.37",,,,,,
BCBS PPO,CPT,93890,Tcd vasoreactivity study,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,"1,307.75",,,,,,
BCBS PPO,CPT,93892,Tcd emboli detect w/o inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,"1,425.95",,,,,,
BCBS PPO,CPT,93893,Tcd emboli detect w/inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,"1,422.14",,,,,,
BCBS PPO,CPT,93922,Upr/l xtremity art 2 levels,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,594.77,,,,,,
BCBS PPO,CPT,93923,Upr/lxtr art stdy 3+ lvls,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,142.8,922.67,,,,,,
BCBS PPO,CPT,93924,Lwr xtr vasc stdy bilat,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,270.61,"1,136.19",,,,,,
BCBS PPO,CPT,93925,Lower extremity study,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,"1,525.07",,,,,,
BCBS PPO,CPT,93926,Lower extremity study,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,976.05,,,,,,
BCBS PPO,CPT,93930,Upper extremity study,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,"1,223.88",,,,,,
BCBS PPO,CPT,93931,Upper extremity study,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,815.92,,,,,,
BCBS PPO,CPT,93965,Extremity study,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,606.21,606.21,,,,,,
BCBS PPO,CPT,93970,Extremity study,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,"1,273.44",,,,,,
BCBS PPO,CPT,93971,Extremity study,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,842.61,,,,,,
BCBS PPO,CPT,93975,Vascular study,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,367.82,,,,,,
BCBS PPO,CPT,93976,Vascular study,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,"1,082.81",,,,,,
BCBS PPO,CPT,93978,Vascular study,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,"1,197.20",,,,,,
BCBS PPO,CPT,93979,Vascular study,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,823.54,,,,,,
BCBS PPO,CPT,93980,Penile vascular study,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,934.12,,,,,,
BCBS PPO,CPT,93981,Penile vascular study,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,667.22,,,,,,
BCBS PPO,CPT,93982,Aneurysm pressure sens study,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,190.64,190.64,,,,,,
BCBS PPO,CPT,93985,Dup-scan hemo compl bi std,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,235.49,"1,136.19",,,,,,
BCBS PPO,CPT,93986,Dup-scan hemo compl uni std,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,646.72,,,,,,
BCBS PPO,CPT,93990,Doppler flow testing,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,956.99,,,,,,
BCBS PPO,CPT,94002,Vent mgmt inpat init day,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,496.58,541.4,,,,,,
BCBS PPO,CPT,94004,Vent mgmt nf per day,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,285.96,285.96,,,,,,
BCBS PPO,CPT,94005,Home vent mgmt supervision,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,545.21,545.21,,,,,,
BCBS PPO,CPT,94010,Breathing capacity test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,142.8,209.7,,,,,,
BCBS PPO,CPT,94014,Patient recorded spirometry,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,276.53,301.2,,,,,,
BCBS PPO,CPT,94015,Patient recorded spirometry,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,148.69,270.61,,,,,,
BCBS PPO,CPT,94016,Review patient spirometry,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,24.7,152.51,,,,,,
BCBS PPO,CPT,94060,Evaluation of wheezing,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,270.61,369.83,,,,,,
BCBS PPO,CPT,94070,Evaluation of wheezing,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,270.61,392.7,,,,,,
BCBS PPO,CPT,94150,Vital capacity test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,141.07,142.8,,,,,,
BCBS PPO,CPT,94200,Lung function test (mbc/mvv),Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,56.95,144.88,,,,,,
BCBS PPO,CPT,94240,Residual lung capacity,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,251.64,251.64,,,,,,
BCBS PPO,CPT,94250,Expired gas collection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,152.51,152.51,,,,,,
BCBS PPO,CPT,94260,Thoracic gas volume,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,202.07,202.07,,,,,,
BCBS PPO,CPT,94350,Lung nitrogen washout curve,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,221.14,221.14,,,,,,
BCBS PPO,CPT,94360,Measure airflow resistance,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,282.14,282.14,,,,,,
BCBS PPO,CPT,94370,Breath airway closing volume,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,209.7,209.7,,,,,,
BCBS PPO,CPT,94375,Respiratory flow volume loop,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,232.58,270.61,,,,,,
BCBS PPO,CPT,94400,Co2 breathing response curve,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,339.33,339.33,,,,,,
BCBS PPO,CPT,94450,Hypoxia response curve,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,270.61,316.46,,,,,,
BCBS PPO,CPT,94452,Hast w/report,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,346.96,,,,,,
BCBS PPO,CPT,94453,Hast w/oxygen titrate,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,461.34,,,,,,
BCBS PPO,CPT,94610,Surfactant admin thru tube,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,192.26,438.47,,,,,,
BCBS PPO,CPT,94617,Exercise tst brncspsm w/ecg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,465.15,,,,,,
BCBS PPO,CPT,94618,Pulmonary stress testing,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,465.15,,,,,,
BCBS PPO,CPT,94620,Pulmonary stress test/simple,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,465.15,465.15,,,,,,
BCBS PPO,CPT,94621,Cardiopulm exercise testing,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,270.61,"1,017.99",,,,,,
BCBS PPO,CPT,94640,Airway inhalation treatment,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,87.69,192.26,,,,,,
BCBS PPO,CPT,94642,Aerosol inhalation treatment,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,192.26,255.45,,,,,,
BCBS PPO,CPT,94644,Cbt 1st hour,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,217.32,,,,,,
BCBS PPO,CPT,94645,Cbt each addl hour,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,87.69,87.69,,,,,,
BCBS PPO,CPT,94660,Pos airway pressure cpap,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,192.26,346.96,,,,,,
BCBS PPO,CPT,94662,Neg press ventilation cnp,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,221.14,496.58,,,,,,
BCBS PPO,CPT,94664,Evaluate pt use of inhaler,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,99.13,192.26,,,,,,
BCBS PPO,CPT,94667,Chest wall manipulation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,137.25,,,,,,
BCBS PPO,CPT,94680,Exhaled air analysis o2,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,142.8,369.83,,,,,,
BCBS PPO,CPT,94690,Exhaled air analysis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,56.95,320.27,,,,,,
BCBS PPO,CPT,94720,Monoxide diffusing capacity,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,331.7,331.7,,,,,,
BCBS PPO,CPT,94725,Membrane diffusion capacity,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,438.47,438.47,,,,,,
BCBS PPO,CPT,94726,Pulm funct tst plethysmograp,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,270.61,282.14,,,,,,
BCBS PPO,CPT,94727,Pulm function test by gas,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,142.8,221.14,,,,,,
BCBS PPO,CPT,94728,Airwy resist by oscillometry,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,270.61,282.14,,,,,,
BCBS PPO,CPT,94729,Co/membane diffuse capacity,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,438.47,438.47,,,,,,
BCBS PPO,CPT,94750,Pulmonary compliance study,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,446.08,446.08,,,,,,
BCBS PPO,CPT,94760,Measure blood oxygen level,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.88,22.88,,,,,,
BCBS PPO,CPT,94761,Measure blood oxygen level,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,45.74,45.74,,,,,,
BCBS PPO,CPT,94762,Measure blood oxygen level,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,142.8,202.07,,,,,,
BCBS PPO,CPT,94770,Exhaled carbon dioxide test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,240.2,240.2,,,,,,
BCBS PPO,CPT,95004,Percut allergy skin tests,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,30.51,941.27,,,,,,
BCBS PPO,CPT,95010,Percut allergy titrate test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,87.69,87.69,,,,,,
BCBS PPO,CPT,95012,Exhaled nitric oxide meas,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.63,102.95,,,,,,
BCBS PPO,CPT,95015,Id allergy titrate-drug/bug,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,64.82,64.82,,,,,,
BCBS PPO,CPT,95017,Perq & icut allg test venoms,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,25.25,87.69,,,,,,
BCBS PPO,CPT,95018,Perq&ic allg test drugs/biol,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.63,87.69,,,,,,
BCBS PPO,CPT,95024,Icut allergy test drug/bug,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.13,56.95,,,,,,
BCBS PPO,CPT,95027,Icut allergy titrate-airborn,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,25.25,26.7,,,,,,
BCBS PPO,CPT,95028,Icut allergy test-delayed,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.63,57.19,,,,,,
BCBS PPO,CPT,95044,Allergy patch tests,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.31,941.27,,,,,,
BCBS PPO,CPT,95052,Photo patch test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.13,56.95,,,,,,
BCBS PPO,CPT,95056,Photosensitivity tests,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,179.2,,,,,,
BCBS PPO,CPT,95060,Eye allergy tests,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,122,,,,,,
BCBS PPO,CPT,95065,Nose allergy test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.63,110.57,,,,,,
BCBS PPO,CPT,95071,Bronchial allergy tests,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,278.32,278.32,,,,,,
BCBS PPO,CPT,95075,Ingestion challenge test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,320.27,320.27,,,,,,
BCBS PPO,CPT,95076,Ingest challenge ini 120 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,320.27,499.16,,,,,,
BCBS PPO,CPT,95115,Immunotherapy one injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,40.93,57.19,,,,,,
BCBS PPO,CPT,95117,Immunotherapy injections,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,40.93,68.63,,,,,,
BCBS PPO,CPT,95125,Immunotherapy 2/> injections,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,83.87,83.87,,,,,,
BCBS PPO,CPT,95130,Immntx 1 sting insect,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.39,114.39,,,,,,
BCBS PPO,CPT,95133,Immntx 4 sting insects,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,213.51,213.51,,,,,,
BCBS PPO,CPT,95134,Immntx 5 sting insects,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,255.45,255.45,,,,,,
BCBS PPO,CPT,95144,Antigen therapy services,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,40.93,61,,,,,,
BCBS PPO,CPT,95145,Antigen therapy services,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,40.93,80.07,,,,,,
BCBS PPO,CPT,95146,Antigen therapy services,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,40.93,129.64,,,,,,
BCBS PPO,CPT,95147,Antigen therapy services,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,63.42,125.82,,,,,,
BCBS PPO,CPT,95148,Antigen therapy services,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,63.42,179.2,,,,,,
BCBS PPO,CPT,95149,Antigen therapy services,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,63.42,232.58,,,,,,
BCBS PPO,CPT,95165,Antigen therapy services,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,40.93,61,,,,,,
BCBS PPO,CPT,95170,Antigen therapy services,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,40.93,49.56,,,,,,
BCBS PPO,CPT,95249,Cont gluc mntr pt prov eqp,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,56.95,686.28,,,,,,
BCBS PPO,CPT,95250,Cont gluc mntr phys/qhp eqp,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,121.51,686.28,,,,,,
BCBS PPO,CPT,95251,Cont gluc mntr analysis i&r,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,205.88,205.88,,,,,,
BCBS PPO,CPT,95782,Polysom <6 yrs 4/> paramtrs,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,941.27,"4,472.29",,,,,,
BCBS PPO,CPT,95783,Polysom <6 yrs cpap/bilvl,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,941.27,"4,472.29",,,,,,
BCBS PPO,CPT,95805,Multiple sleep latency test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,499.16,"2,249.49",,,,,,
BCBS PPO,CPT,95806,Sleep study unatt&resp efft,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,142.8,413.8,,,,,,
BCBS PPO,CPT,95807,Sleep study attended,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,499.16,"2,638.38",,,,,,
BCBS PPO,CPT,95810,Polysom 6/> yrs 4/> param,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,941.27,"1,103.46",,,,,,
BCBS PPO,CPT,95811,Polysom 6/>yrs cpap 4/> parm,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,941.27,"1,103.46",,,,,,
BCBS PPO,CPT,95812,Eeg 41-60 minutes,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,270.61,"1,242.94",,,,,,
BCBS PPO,CPT,95813,Eeg extnd mntr 61-119 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,270.61,"1,521.26",,,,,,
BCBS PPO,CPT,95816,Eeg awake and drowsy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,270.61,"1,139.99",,,,,,
BCBS PPO,CPT,95819,Eeg awake and asleep,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,270.61,"1,223.88",,,,,,
BCBS PPO,CPT,95822,Eeg coma or sleep only,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,270.61,"1,223.88",,,,,,
BCBS PPO,CPT,95824,Eeg cerebral death only,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,499.16,503.28,,,,,,
BCBS PPO,CPT,95827,Eeg all night recording,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,967.35","1,967.35",,,,,,
BCBS PPO,CPT,95829,Surgery electrocorticogram,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"6,275.69","6,275.69",,,,,,
BCBS PPO,CPT,95830,Insert electrodes for eeg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,911.23,911.23,,,,,,
BCBS PPO,CPT,95831,Limb muscle testing manual,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,129.64,129.64,,,,,,
BCBS PPO,CPT,95833,Body muscle testing manual,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,183.02,183.02,,,,,,
BCBS PPO,CPT,95834,Body muscle testing manual,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,217.32,217.32,,,,,,
BCBS PPO,CPT,95851,Range of motion measurements,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.59,83.87,,,,,,
BCBS PPO,CPT,95852,Range of motion measurements,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.52,64.82,,,,,,
BCBS PPO,CPT,95857,Cholinesterase challenge,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,209.7,270.61,,,,,,
BCBS PPO,CPT,95860,Muscle test one limb,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,423.22,,,,,,
BCBS PPO,CPT,95861,Muscle test 2 limbs,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,613.85,,,,,,
BCBS PPO,CPT,95863,Muscle test 3 limbs,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,142.8,732.04,,,,,,
BCBS PPO,CPT,95864,Muscle test 4 limbs,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,142.8,850.23,,,,,,
BCBS PPO,CPT,95865,Muscle test larynx,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,439,,,,,,
BCBS PPO,CPT,95866,Muscle test hemidiaphragm,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,142.8,480.4,,,,,,
BCBS PPO,CPT,95867,Muscle test cran nerv unilat,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,270.61,369.83,,,,,,
BCBS PPO,CPT,95868,Muscle test cran nerve bilat,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,270.61,503.28,,,,,,
BCBS PPO,CPT,95869,Muscle test thor paraspinal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,142.8,236.38,,,,,,
BCBS PPO,CPT,95870,Muscle test nonparaspinal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,228.77,,,,,,
BCBS PPO,CPT,95872,Muscle test one fiber,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,142.8,635.69,,,,,,
BCBS PPO,CPT,95873,Guide nerv destr elec stim,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,179.59,179.59,,,,,,
BCBS PPO,CPT,95874,Guide nerv destr needle emg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,168.19,168.19,,,,,,
BCBS PPO,CPT,95875,Limb exercise test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,142.8,364.88,,,,,,
BCBS PPO,CPT,95900,Motor nerve conduction test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,205.25,205.25,,,,,,
BCBS PPO,CPT,95903,Motor nerve conduction test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,324.09,324.09,,,,,,
BCBS PPO,CPT,95904,Sense nerve conduction test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,244.01,244.01,,,,,,
BCBS PPO,CPT,95920,Intraop nerve test add-on,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,796.85,796.85,,,,,,
BCBS PPO,CPT,95921,Autonomic nrv parasym inervj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,142.8,282.21,,,,,,
BCBS PPO,CPT,95923,Autonomic nrv syst funj test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,447.55,,,,,,
BCBS PPO,CPT,95925,Somatosensory testing,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,270.61,461.8,,,,,,
BCBS PPO,CPT,95926,Somatosensory testing,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,270.61,602.41,,,,,,
BCBS PPO,CPT,95927,Somatosensory testing,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,270.61,621.47,,,,,,
BCBS PPO,CPT,95928,C motor evoked uppr limbs,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,941.27,964.61,,,,,,
BCBS PPO,CPT,95929,C motor evoked lwr limbs,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,499.16,"1,017.99",,,,,,
BCBS PPO,CPT,95930,Visual ep test cns w/i&r,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,270.61,537.6,,,,,,
BCBS PPO,CPT,95933,Blink reflex test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,56.95,339.33,,,,,,
BCBS PPO,CPT,95934,H-reflex test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,247.83,247.83,,,,,,
BCBS PPO,CPT,95936,H-reflex test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,221.14,221.14,,,,,,
BCBS PPO,CPT,95937,Neuromuscular junction test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,142.8,305.01,,,,,,
BCBS PPO,CPT,95950,Ambulatory eeg monitoring,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,303.93","1,303.93",,,,,,
BCBS PPO,CPT,95951,Eeg monitoring/videorecord,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,980.46","3,980.46",,,,,,
BCBS PPO,CPT,95953,Eeg monitoring/computer,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,142.73","2,142.73",,,,,,
BCBS PPO,CPT,95954,Eeg monitoring/giving drugs,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,499.16,"1,277.26",,,,,,
BCBS PPO,CPT,95955,Eeg during surgery,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,739.67,739.67,,,,,,
BCBS PPO,CPT,95956,Eeg monitor technol attended,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,721.19","3,721.19",,,,,,
BCBS PPO,CPT,95957,Eeg digital analysis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,357.32","1,357.32",,,,,,
BCBS PPO,CPT,95958,Eeg monitoring/function test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,941.27,"1,982.60",,,,,,
BCBS PPO,CPT,95961,Electrode stimulation brain,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,941.27,"1,265.81",,,,,,
BCBS PPO,CPT,95962,Electrode stim brain add-on,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,136.19","1,136.19",,,,,,
BCBS PPO,CPT,95965,Meg spontaneous,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,941.27,"10,992.00",,,,,,
BCBS PPO,CPT,95966,Meg evoked single,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,941.27,"5,455.97",,,,,,
BCBS PPO,CPT,95967,Meg evoked each addl,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"4,666.74","4,666.74",,,,,,
BCBS PPO,CPT,95970,Alys npgt w/o prgrmg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,255.45,,,,,,
BCBS PPO,CPT,95971,Alys smpl sp/pn npgt w/prgrm,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,102.65,297.39,,,,,,
BCBS PPO,CPT,95972,Alys cplx sp/pn npgt w/prgrm,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,102.65,533.78,,,,,,
BCBS PPO,CPT,95973,Analyze neurostim complex,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,289.76,289.76,,,,,,
BCBS PPO,CPT,95974,Cranial neurostim complex,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,876.92,876.92,,,,,,
BCBS PPO,CPT,95975,Cranial neurostim complex,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,491.83,491.83,,,,,,
BCBS PPO,CPT,95976,Alys smpl cn npgt prgrmg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.02,657.7,,,,,,
BCBS PPO,CPT,95977,Alys cplx cn npgt prgrmg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,102.65,876.92,,,,,,
BCBS PPO,CPT,95978,Analyze neurostim brain/1h,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,040.87","1,040.87",,,,,,
BCBS PPO,CPT,95980,Io anal gast n-stim init,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,213.51,213.51,,,,,,
BCBS PPO,CPT,95981,Io anal gast n-stim subsq,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,144.88,,,,,,
BCBS PPO,CPT,95982,Io ga n-stim subsq w/reprog,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.02,224.95,,,,,,
BCBS PPO,CPT,95983,Alys brn npgt prgrmg 15 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,102.65,260.22,,,,,,
BCBS PPO,CPT,95984,Alys brn npgt prgrmg addl 15,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,227.69,227.69,,,,,,
BCBS PPO,CPT,95990,Spin/brain pump refil & main,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,312.64,318,,,,,,
BCBS PPO,CPT,95991,Spin/brain pump refil & main,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,267.26,453.71,,,,,,
BCBS PPO,CPT,96000,Motion analysis video/3d,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,449.9,499.16,,,,,,
BCBS PPO,CPT,96001,Motion test w/ft press meas,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,526.16,941.27,,,,,,
BCBS PPO,CPT,96003,Dynamic fine wire emg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,91.51,270.61,,,,,,
BCBS PPO,CPT,96004,Phys review of motion tests,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,568.09,568.09,,,,,,
BCBS PPO,CPT,96020,Functional brain mapping,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,922.67,922.67,,,,,,
BCBS PPO,CPT,96040,Genetic counseling 30 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,209.7,209.7,,,,,,
BCBS PPO,CPT,96101,Psycho testing by psych/phys,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,438.47,438.47,,,,,,
BCBS PPO,CPT,96102,Psycho testing by technician,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,266.89,266.89,,,,,,
BCBS PPO,CPT,96103,Psycho testing admin by comp,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,244.01,244.01,,,,,,
BCBS PPO,CPT,96105,Assessment of aphasia,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,98.92,419.4,,,,,,
BCBS PPO,CPT,96110,Developmental screen w/score,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,95.32,95.32,,,,,,
BCBS PPO,CPT,96111,Developmental test extend,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,693.9,693.9,,,,,,
BCBS PPO,CPT,96112,Devel tst phys/qhp 1st hr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,270.61,693.9,,,,,,
BCBS PPO,CPT,96113,Devel tst phys/qhp ea addl,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,317.16,317.16,,,,,,
BCBS PPO,CPT,96116,Nubhvl xm phys/qhp 1st hr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,270.61,518.52,,,,,,
BCBS PPO,CPT,96118,Neuropsych tst by psych/phys,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,583.35,583.35,,,,,,
BCBS PPO,CPT,96119,Neuropsych testing by tec,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,415.59,415.59,,,,,,
BCBS PPO,CPT,96120,Neuropsych tst admin w/comp,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,362.21,362.21,,,,,,
BCBS PPO,CPT,96121,Nubhvl xm phy/qhp ea addl hr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,475.49,475.49,,,,,,
BCBS PPO,CPT,96125,Cognitive test by hc pro,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,103.76,510.9,,,,,,
BCBS PPO,CPT,96130,Psycl tst eval phys/qhp 1st,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,270.61,438.47,,,,,,
BCBS PPO,CPT,96131,Psycl tst eval phys/qhp ea,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,333.8,333.8,,,,,,
BCBS PPO,CPT,96132,Nrpsyc tst eval phys/qhp 1st,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,270.61,583.35,,,,,,
BCBS PPO,CPT,96133,Nrpsyc tst eval phys/qhp ea,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,447.11,447.11,,,,,,
BCBS PPO,CPT,96136,Psycl/nrpsyc tst phy/qhp 1st,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,219.24,,,,,,
BCBS PPO,CPT,96137,Psycl/nrpsyc tst phy/qhp ea,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,172.25,172.25,,,,,,
BCBS PPO,CPT,96138,Psycl/nrpsyc tech 1st,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,133.45,276.53,,,,,,
BCBS PPO,CPT,96139,Psycl/nrpsyc tst tech ea,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,133.45,133.45,,,,,,
BCBS PPO,CPT,96146,Psycl/nrpsyc tst auto result,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,18.8,25.25,,,,,,
BCBS PPO,CPT,96150,Assess hlth/behave init,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,129.64,129.64,,,,,,
BCBS PPO,CPT,96151,Assess hlth/behave subseq,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,125.82,125.82,,,,,,
BCBS PPO,CPT,96152,Intervene hlth/behave indiv,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,118.19,118.19,,,,,,
BCBS PPO,CPT,96153,Intervene hlth/behave group,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,30.51,30.51,,,,,,
BCBS PPO,CPT,96154,Interv hlth/behav fam w/pt,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,118.19,118.19,,,,,,
BCBS PPO,CPT,96156,Hlth bhv assmt/reassessment,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.62,526.34,,,,,,
BCBS PPO,CPT,96158,Hlth bhv ivntj indiv 1st 30,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.62,236.39,,,,,,
BCBS PPO,CPT,96159,Hlth bhv ivntj indiv ea addl,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,81.57,81.57,,,,,,
BCBS PPO,CPT,96164,Hlth bhv ivntj grp 1st 30,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.84,61.03,,,,,,
BCBS PPO,CPT,96165,Hlth bhv ivntj grp ea addl,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,30.51,30.51,,,,,,
BCBS PPO,CPT,96167,Hlth bhv ivntj fam 1st 30,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.84,236.39,,,,,,
BCBS PPO,CPT,96168,Hlth bhv ivntj fam ea addl,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,118.19,118.19,,,,,,
BCBS PPO,CPT,96360,Hydration iv infusion init,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,208.24,293.57,,,,,,
BCBS PPO,CPT,96361,Hydrate iv infusion add-on,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,40.93,122.99,,,,,,
BCBS PPO,CPT,96365,Ther/proph/diag iv inf init,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,208.24,354.58,,,,,,
BCBS PPO,CPT,96366,Ther/proph/diag iv inf addon,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,40.93,114.39,,,,,,
BCBS PPO,CPT,96367,Tx/proph/dg addl seq iv inf,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,63.42,179.2,,,,,,
BCBS PPO,CPT,96368,Ther/diag concurrent inf,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,106.76,106.76,,,,,,
BCBS PPO,CPT,96369,Sc ther infusion up to 1 hr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,208.24,758.72,,,,,,
BCBS PPO,CPT,96370,Sc ther infusion addl hr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,40.93,83.87,,,,,,
BCBS PPO,CPT,96371,Sc ther infusion reset pump,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,63.42,366.02,,,,,,
BCBS PPO,CPT,96372,Ther/proph/diag inj sc/im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,63.42,106.76,,,,,,
BCBS PPO,CPT,96374,Ther/proph/diag inj iv push,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,208.24,278.32,,,,,,
BCBS PPO,CPT,96375,Tx/pro/dx inj new drug addon,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,40.93,202.94,,,,,,
BCBS PPO,CPT,96376,Tx/pro/dx inj same drug adon,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,184.49,184.49,,,,,,
BCBS PPO,CPT,96401,Chemo anti-neopl sq/im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,63.42,377.46,,,,,,
BCBS PPO,CPT,96402,Chemo hormon antineopl sq/im,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,63.42,205.88,,,,,,
BCBS PPO,CPT,96405,Chemo intralesional up to 7,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,63.42,468.96,,,,,,
BCBS PPO,CPT,96406,Chemo intralesional over 7,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,208.24,648.16,,,,,,
BCBS PPO,CPT,96409,Chemo iv push sngl drug,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,208.24,629.1,,,,,,
BCBS PPO,CPT,96411,Chemo iv push addl drug,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,63.42,362.21,,,,,,
BCBS PPO,CPT,96413,Chemo iv infusion 1 hr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,133.34,318,,,,,,
BCBS PPO,CPT,96415,Chemo iv infusion addl hr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,63.42,202.07,,,,,,
BCBS PPO,CPT,96416,Chemo prolong infuse w/pump,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,318,926.48,,,,,,
BCBS PPO,CPT,96417,Chemo iv infus each addl seq,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,63.42,427.03,,,,,,
BCBS PPO,CPT,96420,Chemo ia push tecnique,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,318,613.85,,,,,,
BCBS PPO,CPT,96422,Chemo ia infusion up to 1 hr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,208.24,979.86,,,,,,
BCBS PPO,CPT,96423,Chemo ia infuse each addl hr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,40.93,434.65,,,,,,
BCBS PPO,CPT,96425,Chemotherapy infusion method,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,318,968.43,,,,,,
BCBS PPO,CPT,96440,Chemotherapy intracavitary,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,318,"3,339.91",,,,,,
BCBS PPO,CPT,96445,Chemotherapy - intracavitary,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,589.90","1,589.90",,,,,,
BCBS PPO,CPT,96450,Chemotherapy into cns,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,318,"1,159.06",,,,,,
BCBS PPO,CPT,96521,Refill/maint portable pump,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,208.24,716.79,,,,,,
BCBS PPO,CPT,96522,Refill/maint pump/resvr syst,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,208.24,610.03,,,,,,
BCBS PPO,CPT,96523,Irrig drug delivery device,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,56.95,141.07,,,,,,
BCBS PPO,CPT,96542,Chemotherapy injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,208.24,751.1,,,,,,
BCBS PPO,CPT,96570,Photodynmc tx 30 min add-on,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,331.7,331.7,,,,,,
BCBS PPO,CPT,96571,Photodynamic tx addl 15 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,152.51,152.51,,,,,,
BCBS PPO,CPT,96900,Ultraviolet light therapy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.63,114.39,,,,,,
BCBS PPO,CPT,96902,Trichogram,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,118.19,118.19,,,,,,
BCBS PPO,CPT,96904,Whole body photography,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,366.02,366.02,,,,,,
BCBS PPO,CPT,96910,Photochemotherapy with uv-b,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,56.95,335.53,,,,,,
BCBS PPO,CPT,96912,Photochemotherapy with uv-a,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,56.95,430.83,,,,,,
BCBS PPO,CPT,96913,Photochemotherapy uv-a or b,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,353.91,651.97,,,,,,
BCBS PPO,CPT,96922,Laser tx skin >500 sq cm,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,353.91,"1,307.75",,,,,,
BCBS PPO,CPT,97001,Pt evaluation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,331.7,331.7,,,,,,
BCBS PPO,CPT,97002,Pt re-evaluation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,175.39,175.39,,,,,,
BCBS PPO,CPT,97003,Ot evaluation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,354.58,354.58,,,,,,
BCBS PPO,CPT,97004,Ot re-evaluation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,202.07,202.07,,,,,,
BCBS PPO,CPT,97006,Athletic train reeval,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,137.25,137.25,,,,,,
BCBS PPO,CPT,97010,Hot or cold packs therapy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.88,22.88,,,,,,
BCBS PPO,CPT,97012,Mechanical traction therapy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.55,68.63,,,,,,
BCBS PPO,CPT,97014,Electric stimulation therapy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,64.82,64.82,,,,,,
BCBS PPO,CPT,97016,Vasopneumatic device therapy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.78,72.44,,,,,,
BCBS PPO,CPT,97022,Whirlpool therapy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,17.16,83.87,,,,,,
BCBS PPO,CPT,97024,Diathermy eg microwave,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,6.96,26.7,,,,,,
BCBS PPO,CPT,97026,Infrared therapy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,6.32,26.7,,,,,,
BCBS PPO,CPT,97032,Electrical stimulation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.55,76.26,,,,,,
BCBS PPO,CPT,97033,Electric current therapy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.67,114.39,,,,,,
BCBS PPO,CPT,97034,Contrast bath therapy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.42,68.63,,,,,,
BCBS PPO,CPT,97035,Ultrasound therapy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.1,53.38,,,,,,
BCBS PPO,CPT,97036,Hydrotherapy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,33.09,118.19,,,,,,
BCBS PPO,CPT,97110,Therapeutic exercises,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,29.26,133.45,,,,,,
BCBS PPO,CPT,97112,Neuromuscular reeducation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,33.86,137.25,,,,,,
BCBS PPO,CPT,97113,Aquatic therapy/exercises,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,36.67,160.13,,,,,,
BCBS PPO,CPT,97116,Gait training therapy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,29.26,114.39,,,,,,
BCBS PPO,CPT,97124,Massage therapy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,28.22,106.76,,,,,,
BCBS PPO,CPT,97127,Ther ivntj w/focus cog funcj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.39,114.39,,,,,,
BCBS PPO,CPT,97129,Ther ivntj 1st 15 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,23.04,114.39,,,,,,
BCBS PPO,CPT,97130,Ther ivntj ea addl 15 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.35,110.97,,,,,,
BCBS PPO,CPT,97140,Manual therapy 1/> regions,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.97,122,,,,,,
BCBS PPO,CPT,97150,Group therapeutic procedures,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,17.53,83.87,,,,,,
BCBS PPO,CPT,97161,Pt eval low complex 20 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,98.12,330.81,,,,,,
BCBS PPO,CPT,97162,Pt eval mod complex 30 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,98.12,331.7,,,,,,
BCBS PPO,CPT,97163,Pt eval high complex 45 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,98.12,331.7,,,,,,
BCBS PPO,CPT,97164,Pt re-eval est plan care,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,66.97,175.39,,,,,,
BCBS PPO,CPT,97165,Ot eval low complex 30 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,95.26,354.58,,,,,,
BCBS PPO,CPT,97166,Ot eval mod complex 45 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,95.26,354.58,,,,,,
BCBS PPO,CPT,97167,Ot eval high complex 60 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,95.26,354.58,,,,,,
BCBS PPO,CPT,97168,Ot re-eval est plan care,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,64.11,202.07,,,,,,
BCBS PPO,CPT,97172,Athletic trn re-eval plan cr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,137.25,137.25,,,,,,
BCBS PPO,CPT,97530,Therapeutic activities,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,37.5,137.25,,,,,,
BCBS PPO,CPT,97532,Cognitive skills development,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.39,114.39,,,,,,
BCBS PPO,CPT,97533,Sensory integration,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,57.03,122,,,,,,
BCBS PPO,CPT,97535,Self care mngment training,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,32.44,137.25,,,,,,
BCBS PPO,CPT,97537,Community/work reintegration,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,31.26,125.82,,,,,,
BCBS PPO,CPT,97542,Wheelchair mngment training,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,31.58,125.82,,,,,,
BCBS PPO,CPT,97545,Work hardening,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,564.29,564.29,,,,,,
BCBS PPO,CPT,97546,Work hardening add-on,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,224.95,224.95,,,,,,
BCBS PPO,CPT,97597,Rmvl devital tis 20 cm/<,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,183.73,282.14,,,,,,
BCBS PPO,CPT,97598,Rmvl devital tis addl 20cm/<,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,343.14,343.14,,,,,,
BCBS PPO,CPT,97602,Wound(s) care non-selective,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,171.58,183.73,,,,,,
BCBS PPO,CPT,97605,Neg press wound tx <=50 cm,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,163.95,183.73,,,,,,
BCBS PPO,CPT,97606,Neg press wound tx >50 cm,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,175.39,353.91,,,,,,
BCBS PPO,CPT,97607,Neg press wnd tx <=50 sq cm,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,163.95,353.91,,,,,,
BCBS PPO,CPT,97608,Neg press wound tx >50 cm,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,175.39,353.91,,,,,,
BCBS PPO,CPT,97750,Physical performance test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,33.07,137.25,,,,,,
BCBS PPO,CPT,97755,Assistive technology assess,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,37.42,156.32,,,,,,
BCBS PPO,CPT,97760,Orthotic mgmt&traing 1st enc,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,47.55,152.51,,,,,,
BCBS PPO,CPT,97761,Prosthetic traing 1st enc,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,40.55,133.45,,,,,,
BCBS PPO,CPT,97762,C/o for orthotic/prosth use,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,160.13,160.13,,,,,,
BCBS PPO,CPT,97763,Orthc/prostc mgmt sbsq enc,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,51.94,160.13,,,,,,
BCBS PPO,CPT,97802,Medical nutrition indiv in,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,30.75,148.69,,,,,,
BCBS PPO,CPT,97803,Med nutrition indiv subseq,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,31.17,129.64,,,,,,
BCBS PPO,CPT,97804,Medical nutrition group,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16.45,64.82,,,,,,
BCBS PPO,CPT,97810,Acupunct w/o stimul 15 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,25.25,186.82,,,,,,
BCBS PPO,CPT,97813,Acupunct w/stimul 15 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,25.25,198.25,,,,,,
BCBS PPO,CPT,97814,Acupunct w/stimul addl 15m,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,160.13,160.13,,,,,,
BCBS PPO,CPT,98925,Osteopath manj 1-2 regions,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,27.17,141.07,,,,,,
BCBS PPO,CPT,98927,Osteopath manj 5-6 regions,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,27.17,251.64,,,,,,
BCBS PPO,CPT,98928,Osteopath manj 7-8 regions,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,27.17,297.39,,,,,,
BCBS PPO,CPT,98929,Osteopath manj 9-10 regions,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,27.17,343.14,,,,,,
BCBS PPO,CPT,98940,Chiropract manj 1-2 regions,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,27.17,125.82,,,,,,
BCBS PPO,CPT,98941,Chiropract manj 3-4 regions,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,27.17,171.58,,,,,,
BCBS PPO,CPT,98942,Chiropractic manj 5 regions,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,27.17,224.95,,,,,,
BCBS PPO,CPT,98943,Chiropract manj xtrspinl 1/>,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,118.19,118.19,,,,,,
BCBS PPO,CPT,98960,Self-mgmt educ & train 1 pt,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,122,122,,,,,,
BCBS PPO,CPT,98962,Self-mgmt educ/train 5-8 pt,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,45.74,45.74,,,,,,
BCBS PPO,CPT,98966,Hc pro phone call 5-10 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.73,61,,,,,,
BCBS PPO,CPT,98967,Hc pro phone call 11-20 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,25.14,118.19,,,,,,
BCBS PPO,CPT,98968,Hc pro phone call 21-30 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,37.46,171.58,,,,,,
BCBS PPO,CPT,99000,Specimen handling office-lab,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.7,26.7,,,,,,
BCBS PPO,CPT,99001,Specimen handling pt-lab,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.31,34.31,,,,,,
BCBS PPO,CPT,99002,Device handling phys/qhp,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.31,34.31,,,,,,
BCBS PPO,CPT,99050,Medical services after hrs,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,91.51,91.51,,,,,,
BCBS PPO,CPT,99051,Med serv eve/wkend/holiday,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,110.57,110.57,,,,,,
BCBS PPO,CPT,99053,Med serv 10pm-8am 24 hr fac,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,190.64,190.64,,,,,,
BCBS PPO,CPT,99056,Med service out of office,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,87.69,87.69,,,,,,
BCBS PPO,CPT,99060,Out of office emerg med serv,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,122,122,,,,,,
BCBS PPO,CPT,99078,Group health education,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,183.02,183.02,,,,,,
BCBS PPO,CPT,99090,Computer data analysis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,388.89,388.89,,,,,,
BCBS PPO,CPT,99091,Collj & interpj data ea 30 d,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,240.2,240.2,,,,,,
BCBS PPO,CPT,99143,Mod cs by same phys < 5 yrs,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,274.51,274.51,,,,,,
BCBS PPO,CPT,99144,Mod cs by same phys 5 yrs +,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,228.77,228.77,,,,,,
BCBS PPO,CPT,99145,Mod cs by same phys add-on,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,91.51,91.51,,,,,,
BCBS PPO,CPT,99148,Mod cs diff phys < 5 yrs,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,247.83,247.83,,,,,,
BCBS PPO,CPT,99149,Mod cs diff phys 5 yrs +,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,202.07,202.07,,,,,,
BCBS PPO,CPT,99150,Mod cs diff phys add-on,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,91.51,91.51,,,,,,
BCBS PPO,CPT,99151,Mod sed same phys/qhp <5 yrs,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,183,183,,,,,,
BCBS PPO,CPT,99152,Mod sed same phys/qhp 5/>yrs,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,137.26,137.26,,,,,,
BCBS PPO,CPT,99153,Mod sed same phys/qhp ea,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,91.51,91.51,,,,,,
BCBS PPO,CPT,99155,Mod sed oth phys/qhp <5 yrs,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,156.32,156.32,,,,,,
BCBS PPO,CPT,99156,Mod sed oth phys/qhp 5/>yrs,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,110.56,110.56,,,,,,
BCBS PPO,CPT,99157,Mod sed other phys/qhp ea,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,91.51,91.51,,,,,,
BCBS PPO,CPT,99170,Anogenital exam child w imag,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,174.29,663.41,,,,,,
BCBS PPO,CPT,99172,Ocular function screen,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,91.51,91.51,,,,,,
BCBS PPO,CPT,99174,Ocular instrumnt screen bil,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,118.19,118.19,,,,,,
BCBS PPO,CPT,99175,Induction of vomiting,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,137.25,137.25,,,,,,
BCBS PPO,CPT,99177,Ocular instrumnt screen bil,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,118.19,118.19,,,,,,
BCBS PPO,CPT,99183,Hyperbaric oxygen therapy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,892.18,892.18,,,,,,
BCBS PPO,CPT,99185,Regional hypothermia,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,270.71,270.71,,,,,,
BCBS PPO,CPT,99190,Special pump services,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,299.05","8,948.83",,,,,,
BCBS PPO,CPT,99191,Special pump services,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,612.76","8,948.83",,,,,,
BCBS PPO,CPT,99192,Special pump services,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,151.42","8,948.83",,,,,,
BCBS PPO,CPT,99195,Phlebotomy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.56,331.7,,,,,,
BCBS PPO,CPT,99201,Office/outpatient visit new,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,81.84,81.84,,,,,,
BCBS PPO,CPT,99202,Office o/p new sf 15-29 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,81.84,81.84,,,,,,
BCBS PPO,CPT,99203,Office o/p new low 30-44 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,81.84,81.84,,,,,,
BCBS PPO,CPT,99204,Office o/p new mod 45-59 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,81.84,81.84,,,,,,
BCBS PPO,CPT,99205,Office o/p new hi 60-74 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,81.84,81.84,,,,,,
BCBS PPO,CPT,99211,Office o/p est minimal prob,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,109.47,109.47,,,,,,
BCBS PPO,CPT,99212,Office o/p est sf 10-19 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,81.84,81.84,,,,,,
BCBS PPO,CPT,99213,Office o/p est low 20-29 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,81.84,81.84,,,,,,
BCBS PPO,CPT,99214,Office o/p est mod 30-39 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,81.84,81.84,,,,,,
BCBS PPO,CPT,99215,Office o/p est hi 40-54 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,81.84,81.84,,,,,,
BCBS PPO,CPT,99217,Observation care discharge,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,335.53,335.53,,,,,,
BCBS PPO,CPT,99218,Initial observation care,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,316.46,316.46,,,,,,
BCBS PPO,CPT,99219,Initial observation care,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,522.34,522.34,,,,,,
BCBS PPO,CPT,99220,Initial observation care,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,735.85,735.85,,,,,,
BCBS PPO,CPT,99221,Initial hospital care,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,404.14,404.14,,,,,,
BCBS PPO,CPT,99222,Initial hospital care,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,552.84,552.84,,,,,,
BCBS PPO,CPT,99223,Initial hospital care,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,812.11,812.11,,,,,,
BCBS PPO,CPT,99232,Subsequent hospital care,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,297.39,297.39,,,,,,
BCBS PPO,CPT,99233,Subsequent hospital care,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,427.03,427.03,,,,,,
BCBS PPO,CPT,99234,Observ/hosp same date,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,579.53,579.53,,,,,,
BCBS PPO,CPT,99235,Observ/hosp same date,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,754.91,754.91,,,,,,
BCBS PPO,CPT,99236,Observ/hosp same date,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,937.93,937.93,,,,,,
BCBS PPO,CPT,99238,Hospital discharge day,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,301.2,301.2,,,,,,
BCBS PPO,CPT,99239,Hospital discharge day,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,434.65,434.65,,,,,,
BCBS PPO,CPT,99241,Office consultation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,228.77,228.77,,,,,,
BCBS PPO,CPT,99242,Office consultation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,427.03,427.03,,,,,,
BCBS PPO,CPT,99243,Office consultation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,587.16,587.16,,,,,,
BCBS PPO,CPT,99244,Office consultation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,857.86,857.86,,,,,,
BCBS PPO,CPT,99245,Office consultation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,056.11","1,056.11",,,,,,
BCBS PPO,CPT,99251,Inpatient consultation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,224.95,224.95,,,,,,
BCBS PPO,CPT,99252,Inpatient consultation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,354.58,354.58,,,,,,
BCBS PPO,CPT,99253,Inpatient consultation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,533.78,533.78,,,,,,
BCBS PPO,CPT,99254,Inpatient consultation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,766.35,766.35,,,,,,
BCBS PPO,CPT,99255,Inpatient consultation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,934.12,934.12,,,,,,
BCBS PPO,CPT,99281,Emergency dept visit,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,74.29,245.98,,,,,,
BCBS PPO,CPT,99282,Emergency dept visit,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,134.66,368.97,,,,,,
BCBS PPO,CPT,99283,Emergency dept visit,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,237,737.94,,,,,,
BCBS PPO,CPT,99284,Emergency dept visit,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,372.22,"1,291.40",,,,,,
BCBS PPO,CPT,99285,Emergency dept visit,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,534.29,"1,967.84",,,,,,
BCBS PPO,CPT,99288,Direct advanced life support,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,812.11,812.11,,,,,,
BCBS PPO,CPT,99291,Critical care first hour,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,708.83,"1,197.20",,,,,,
BCBS PPO,CPT,99292,Critical care addl 30 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,541.4,541.4,,,,,,
BCBS PPO,CPT,99304,Nursing facility care init,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,430.83,430.83,,,,,,
BCBS PPO,CPT,99305,Nursing facility care init,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,598.59,598.59,,,,,,
BCBS PPO,CPT,99307,Nursing fac care subseq,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,213.51,213.51,,,,,,
BCBS PPO,CPT,99308,Nursing fac care subseq,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,327.9,327.9,,,,,,
BCBS PPO,CPT,99309,Nursing fac care subseq,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,434.65,434.65,,,,,,
BCBS PPO,CPT,99310,Nursing fac care subseq,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,636.73,636.73,,,,,,
BCBS PPO,CPT,99315,Nursing fac discharge day,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,312.64,312.64,,,,,,
BCBS PPO,CPT,99316,Nursing fac discharge day,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,407.96,407.96,,,,,,
BCBS PPO,CPT,99318,Annual nursing fac assessmnt,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,449.9,449.9,,,,,,
BCBS PPO,CPT,99324,Domicil/r-home visit new pat,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,308.83,308.83,,,,,,
BCBS PPO,CPT,99325,Domicil/r-home visit new pat,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,446.08,446.08,,,,,,
BCBS PPO,CPT,99326,Domicil/r-home visit new pat,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,732.04,732.04,,,,,,
BCBS PPO,CPT,99327,Domicil/r-home visit new pat,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,953.17,953.17,,,,,,
BCBS PPO,CPT,99328,Domicil/r-home visit new pat,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,120.94","1,120.94",,,,,,
BCBS PPO,CPT,99334,Domicil/r-home visit est pat,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,312.64,312.64,,,,,,
BCBS PPO,CPT,99335,Domicil/r-home visit est pat,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,484.22,484.22,,,,,,
BCBS PPO,CPT,99336,Domicil/r-home visit est pat,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,682.47,682.47,,,,,,
BCBS PPO,CPT,99337,Domicil/r-home visit est pat,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,976.05,976.05,,,,,,
BCBS PPO,CPT,99339,Domicil/r-home care supervis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,419.4,419.4,,,,,,
BCBS PPO,CPT,99340,Domicil/r-home care supervis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,583.35,583.35,,,,,,
BCBS PPO,CPT,99341,Home visit new patient,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,278.32,278.32,,,,,,
BCBS PPO,CPT,99342,Home visit new patient,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,404.14,404.14,,,,,,
BCBS PPO,CPT,99343,Home visit new patient,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,648.16,648.16,,,,,,
BCBS PPO,CPT,99344,Home visit new patient,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,850.23,850.23,,,,,,
BCBS PPO,CPT,99345,Home visit new patient,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,021.81","1,021.81",,,,,,
BCBS PPO,CPT,99347,Home visit est patient,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,270.71,270.71,,,,,,
BCBS PPO,CPT,99348,Home visit est patient,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,407.96,407.96,,,,,,
BCBS PPO,CPT,99349,Home visit est patient,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,590.97,590.97,,,,,,
BCBS PPO,CPT,99350,Home visit est patient,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,827.35,827.35,,,,,,
BCBS PPO,CPT,99354,Prolng svc o/p 1st hour,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,549.03,549.03,,,,,,
BCBS PPO,CPT,99355,Prolng svc o/p ea addl 30,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,541.4,541.4,,,,,,
BCBS PPO,CPT,99356,Prolng svc i/p/obs 1st hour,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,499.47,"8,948.83",,,,,,
BCBS PPO,CPT,99357,Prolng svc i/p/obs ea addl,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,507.08,"8,948.83",,,,,,
BCBS PPO,CPT,99358,Prolong service w/o contact,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,903.6,903.6,,,,,,
BCBS PPO,CPT,99359,Prolong serv w/o contact add,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,434.65,434.65,,,,,,
BCBS PPO,CPT,99360,Physician standby services,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,354.58,354.58,,,,,,
BCBS PPO,CPT,99363,Anticoag mgmt init,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,644.34,644.34,,,,,,
BCBS PPO,CPT,99364,Anticoag mgmt subseq,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,224.95,224.95,,,,,,
BCBS PPO,CPT,99366,Team conf w/pat by hc prof,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,232.58,232.58,,,,,,
BCBS PPO,CPT,99367,Team conf w/o pat by phys,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,297.39,297.39,,,,,,
BCBS PPO,CPT,99368,Team conf w/o pat by hc pro,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,194.45,194.45,,,,,,
BCBS PPO,CPT,99374,Home health care supervision,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,407.96,407.96,,,,,,
BCBS PPO,CPT,99375,Home health care supervision,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,644.34,644.34,,,,,,
BCBS PPO,CPT,99377,Hospice care supervision,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,407.96,407.96,,,,,,
BCBS PPO,CPT,99378,Hospice care supervision,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,667.22,667.22,,,,,,
BCBS PPO,CPT,99379,Nursing fac care supervision,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,404.14,404.14,,,,,,
BCBS PPO,CPT,99380,Nursing fac care supervision,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,610.03,610.03,,,,,,
BCBS PPO,CPT,99381,Init pm e/m new pat infant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,522.34,522.34,,,,,,
BCBS PPO,CPT,99382,Init pm e/m new pat 1-4 yrs,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,564.29,564.29,,,,,,
BCBS PPO,CPT,99383,Prev visit new age 5-11,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,560.47,560.47,,,,,,
BCBS PPO,CPT,99384,Prev visit new age 12-17,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,610.03,610.03,,,,,,
BCBS PPO,CPT,99385,Prev visit new age 18-39,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,610.03,610.03,,,,,,
BCBS PPO,CPT,99386,Prev visit new age 40-64,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,712.98,712.98,,,,,,
BCBS PPO,CPT,99387,Init pm e/m new pat 65+ yrs,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,781.61,781.61,,,,,,
BCBS PPO,CPT,99391,Per pm reeval est pat infant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,434.65,434.65,,,,,,
BCBS PPO,CPT,99392,Prev visit est age 1-4,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,484.22,484.22,,,,,,
BCBS PPO,CPT,99393,Prev visit est age 5-11,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,480.4,480.4,,,,,,
BCBS PPO,CPT,99394,Prev visit est age 12-17,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,526.16,526.16,,,,,,
BCBS PPO,CPT,99395,Prev visit est age 18-39,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,529.96,529.96,,,,,,
BCBS PPO,CPT,99396,Prev visit est age 40-64,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,579.53,579.53,,,,,,
BCBS PPO,CPT,99397,Per pm reeval est pat 65+ yr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,648.16,648.16,,,,,,
BCBS PPO,CPT,99401,Preventive counseling indiv,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,179.2,179.2,,,,,,
BCBS PPO,CPT,99402,Preventive counseling indiv,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,305.01,305.01,,,,,,
BCBS PPO,CPT,99403,Preventive counseling indiv,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,430.83,430.83,,,,,,
BCBS PPO,CPT,99404,Preventive counseling indiv,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,552.84,552.84,,,,,,
BCBS PPO,CPT,99406,Behav chng smoking 3-10 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.84,64.82,,,,,,
BCBS PPO,CPT,99407,Behav chng smoking > 10 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.84,125.82,,,,,,
BCBS PPO,CPT,99408,Audit/dast 15-30 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,167.76,167.76,,,,,,
BCBS PPO,CPT,99409,Audit/dast over 30 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,327.9,327.9,,,,,,
BCBS PPO,CPT,99412,Preventive counseling group,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,99.13,99.13,,,,,,
BCBS PPO,CPT,99441,Phone e/m phys/qhp 5-10 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.26,76.26,,,,,,
BCBS PPO,CPT,99442,Phone e/m phys/qhp 11-20 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,141.07,141.07,,,,,,
BCBS PPO,CPT,99443,Phone e/m phys/qhp 21-30 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,205.88,205.88,,,,,,
BCBS PPO,CPT,99455,Work related disability exam,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,334.45","1,334.45",,,,,,
BCBS PPO,CPT,99456,Disability examination,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,287.62","2,287.62",,,,,,
BCBS PPO,CPT,99460,Init nb em per day hosp,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,121.51,305.01,,,,,,
BCBS PPO,CPT,99461,Init nb em per day non-fac,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,457.52,457.52,,,,,,
BCBS PPO,CPT,99462,Sbsq nb em per day hosp,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,160.13,"8,948.83",,,,,,
BCBS PPO,CPT,99463,Same day nb discharge,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,121.51,404.14,,,,,,
BCBS PPO,CPT,99464,Attendance at delivery,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,476.6,476.6,,,,,,
BCBS PPO,CPT,99465,Nb resuscitation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,575.01,781.61,,,,,,
BCBS PPO,CPT,99466,Ped crit care transport,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,193.38","1,193.38",,,,,,
BCBS PPO,CPT,99467,Ped crit care transport addl,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,594.77,594.77,,,,,,
BCBS PPO,CPT,99468,Neonate crit care initial,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"4,510.41","8,948.83",,,,,,
BCBS PPO,CPT,99469,Neonate crit care subsq,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,936.85","8,948.83",,,,,,
BCBS PPO,CPT,99471,Ped critical care initial,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"4,049.07","8,948.83",,,,,,
BCBS PPO,CPT,99472,Ped critical care subsq,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,982.60","8,948.83",,,,,,
BCBS PPO,CPT,99475,Ped crit care age 2-5 init,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,790.89","8,948.83",,,,,,
BCBS PPO,CPT,99476,Ped crit care age 2-5 subsq,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,643.28","8,948.83",,,,,,
BCBS PPO,CPT,99477,Init day hosp neonate care,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,734.78","8,948.83",,,,,,
BCBS PPO,CPT,99478,Ic lbw inf < 1500 gm subsq,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,716.79,"8,948.83",,,,,,
BCBS PPO,CPT,99479,Ic lbw inf 1500-2500 g subsq,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,629.1,"8,948.83",,,,,,
BCBS PPO,CPT,99480,Ic inf pbw 2501-5000 g subsq,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,606.21,"8,948.83",,,,,,
BCBS PPO,CPT,99510,Home visit sing/m/fam couns,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,133.45,133.45,,,,,,
BCBS PPO,CPT,99601,Home infusion/visit 2 hrs,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,343.14,343.14,,,,,,
BCBS PPO,CPT,99602,Home infusion each addtl hr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,171.58,171.58,,,,,,
BCBS PPO,CPT,0144T,CT heart wo dye - qual calc,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,705.35,705.35,,,,,,
BCBS PPO,CPT,0145T,CT heart w/wo dye funct,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,977.72","2,977.72",,,,,,
BCBS PPO,CPT,0146T,CCTA w/wo dye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,897.65","2,897.65",,,,,,
BCBS PPO,CPT,0147T,CCTA w/wo - quan calcium,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,023.47","3,023.47",,,,,,
BCBS PPO,CPT,0148T,CCTA w/wo - strxr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,660.19","3,660.19",,,,,,
BCBS PPO,CPT,0149T,CCTA w/wo - strxr quan calc,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,680.32","2,680.32",,,,,,
BCBS PPO,CPT,0150T,CCTA w/wo - disease strxr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,156.91","3,156.91",,,,,,
BCBS PPO,CPT,0151T,CT heart funct add-on,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,178.12","1,178.12",,,,,,
BCBS PPO,CPT,0331T,Heart symp image plnr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,922.67,"1,336.39",,,,,,
BCBS PPO,CPT,0332T,Heart symp image plnr spect,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,336.39","1,338.26",,,,,,
BCBS PPO,CPT,0333T,Visual ep scr acuity auto,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,537.6,537.6,,,,,,
BCBS PPO,CPT,0336T,,,Per Case,"$9,201.00 ",OP,"7,820.85","9,201.00",,,,,,
BCBS PPO,CPT,0389T,Prog eval inper leadls pm,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,378.39,378.39,,,,,,
BCBS PPO,CPT,0390T,Periproc eval inper ledls pm,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,186.82,186.82,,,,,,
BCBS PPO,CPT,0391T,Intergt eval inper leadls pm,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.09,385.09,,,,,,
BCBS PPO,CPT,0404T,Trnscrv uterin fibroid abltj,,Per Case,"$4,871.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,0404T,Trnscrv uterin fibroid abltj,,Per Case,"$9,201.00 ",OP,"4,140.35","9,201.00",,,,,,
BCBS PPO,CPT,0497T,Xtrnl pt act ecg in-off conn,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.02,"1,574.64",,,,,,
BCBS PPO,CPT,0498T,Xtrnl pt act ecg r&i pr 30 d,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,574.64","1,574.64",,,,,,
BCBS PPO,CPT,0500T,Hpv 5+ hi risk hpv types,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,93.87,93.87,,,,,,
BCBS PPO,CPT,0509T,Pattern erg w/i&r,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,270.61,386.03,,,,,,
BCBS PPO,CPT,0577T,Ephys eval icds ss,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,138.72","2,775.65",,,,,,
BCBS PPO,CPT,0579T,Rem interrog dev icds tech,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.02,213.51,,,,,,
BCBS PPO,CPT,0584T,Perq islet cell transplant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,508.76","8,948.83",,,,,,
BCBS PPO,CPT,0585T,Laps islet cell transplant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"4,254.96","8,948.83",,,,,,
BCBS PPO,CPT,0586T,Open islet cell transplant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"6,965.79","8,948.83",,,,,,
BCBS PPO,CPT,0589T,Elec alys smpl prgrmg iins,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,102.65,255.45,,,,,,
BCBS PPO,CPT,0590T,Elec alys cplx prgrmg iins,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,102.65,255.45,,,,,,
BCBS PPO,CPT,A0110,Nonemergency transport bus,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,152.51,152.51,,,,,,
BCBS PPO,CPT,A0225,Neonatal emergency transport,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,001.67","2,001.67",,,,,,
BCBS PPO,CPT,A0368,ADV ER NO SERV SEP MILE,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,467.89","1,467.89",,,,,,
BCBS PPO,CPT,A0380,Basic life support mileage,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,278.32,278.32,,,,,,
BCBS PPO,CPT,A0382,Basic support routine suppls,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.39,114.39,,,,,,
BCBS PPO,CPT,A0384,Bls defibrillation supplies,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,152.51,152.51,,,,,,
BCBS PPO,CPT,A0390,Advanced life support mileag,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,324.09,324.09,,,,,,
BCBS PPO,CPT,A0392,Als defibrillation supplies,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,343.14,343.14,,,,,,
BCBS PPO,CPT,A0394,Als iv drug therapy supplies,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,190.64,190.64,,,,,,
BCBS PPO,CPT,A0396,Als esophageal intub suppls,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,221.14,221.14,,,,,,
BCBS PPO,CPT,A0398,Als routine disposble suppls,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,190.64,190.64,,,,,,
BCBS PPO,CPT,A0420,Ambulance waiting 1/2 hr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,945.56,945.56,,,,,,
BCBS PPO,CPT,A0422,Ambulance 02 life sustaining,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,285.96,285.96,,,,,,
BCBS PPO,CPT,A0426,Als 1,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,231.98,"2,249.49",,,,,,
BCBS PPO,CPT,A0427,Als1-emergency,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,231.98,"2,287.62",,,,,,
BCBS PPO,CPT,A0429,Bls-emergency,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,231.98,"1,883.47",,,,,,
BCBS PPO,CPT,A0433,Als 2,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,231.98,"2,859.52",,,,,,
BCBS PPO,CPT,A0434,Specialty care transport,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,231.98,"6,100.31",,,,,,
BCBS PPO,CPT,A4206,1 cc sterile syringe&needle,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,A4207,2 cc sterile syringe&needle,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,19.07,,,,,,
BCBS PPO,CPT,A4208,3 cc sterile syringe&needle,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.7,26.7,,,,,,
BCBS PPO,CPT,A4209,5+ cc sterile syringe&needle,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.26,15.26,,,,,,
BCBS PPO,CPT,A4210,Nonneedle injection device,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.13,38.13,,,,,,
BCBS PPO,CPT,A4211,Supp for self-adm injections,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,19.07,,,,,,
BCBS PPO,CPT,A4212,Non coring needle or stylet,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.39,114.39,,,,,,
BCBS PPO,CPT,A4213,20+ cc syringe only,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.31,34.31,,,,,,
BCBS PPO,CPT,A4217,Sterile water/saline- 500 ml,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.44,11.44,,,,,,
BCBS PPO,CPT,A4218,Sterile saline or water,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,A4220,Infusion pump refill kit,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,381.27,381.27,,,,,,
BCBS PPO,CPT,A4221,Supp non-insulin inf cath/wk,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,91.51,91.51,,,,,,
BCBS PPO,CPT,A4222,Infusion supplies with pump,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,179.2,179.2,,,,,,
BCBS PPO,CPT,A4230,Infus insulin pump non needl,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,45.74,45.74,,,,,,
BCBS PPO,CPT,A4231,Infusion insulin pump needle,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.7,26.7,,,,,,
BCBS PPO,CPT,A4232,Syringe w/needle insulin 3cc,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.44,11.44,,,,,,
BCBS PPO,CPT,A4244,Alcohol or peroxide per pint,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,19.07,,,,,,
BCBS PPO,CPT,A4246,Betadine/phisohex solution,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.13,38.13,,,,,,
BCBS PPO,CPT,A4247,Betadine/iodine swabs/wipes,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.31,34.31,,,,,,
BCBS PPO,CPT,A4248,Chlorhexidine antisept,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,45.74,45.74,,,,,,
BCBS PPO,CPT,A4250,Urine reagent strips/tablets,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.26,76.26,,,,,,
BCBS PPO,CPT,A4255,Glucose monitor platforms,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.26,15.26,,,,,,
BCBS PPO,CPT,A4256,Calibrator solution/chips,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,45.74,45.74,,,,,,
BCBS PPO,CPT,A4257,Replace lensshield cartridge,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,49.56,49.56,,,,,,
BCBS PPO,CPT,A4258,Lancet device each,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,72.44,72.44,,,,,,
BCBS PPO,CPT,A4259,Lancets per box,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,49.56,49.56,,,,,,
BCBS PPO,CPT,A4262,Temporary tear duct plug,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,571.91,571.91,,,,,,
BCBS PPO,CPT,A4263,Permanent tear duct plug,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,571.91,571.91,,,,,,
BCBS PPO,CPT,A4265,Paraffin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.26,15.26,,,,,,
BCBS PPO,CPT,A4270,Disposable endoscope sheath,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,133.45,133.45,,,,,,
BCBS PPO,CPT,A4280,Brst prsths adhsv attchmnt,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.88,22.88,,,,,,
BCBS PPO,CPT,A4290,Sacral nerve stim test lead,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,800.67,800.67,,,,,,
BCBS PPO,CPT,A4300,Cath impl vasc access portal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,571.91,571.91,,,,,,
BCBS PPO,CPT,A4305,Drug delivery system >=50 ml,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,152.51,152.51,,,,,,
BCBS PPO,CPT,A4306,Drug delivery system <=50 ml,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,301.2,301.2,,,,,,
BCBS PPO,CPT,A4310,Insert tray w/o bag/cath,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,30.51,30.51,,,,,,
BCBS PPO,CPT,A4311,Catheter w/o bag 2-way latex,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,61,61,,,,,,
BCBS PPO,CPT,A4312,Cath w/o bag 2-way silicone,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,72.44,72.44,,,,,,
BCBS PPO,CPT,A4313,Catheter w/bag 3-way,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,72.44,72.44,,,,,,
BCBS PPO,CPT,A4314,Cath w/drainage 2-way latex,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,102.95,102.95,,,,,,
BCBS PPO,CPT,A4316,Cath w/drainage 3-way,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.39,114.39,,,,,,
BCBS PPO,CPT,A4320,Irrigation tray,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,19.07,,,,,,
BCBS PPO,CPT,A4326,Male external catheter,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,41.94,41.94,,,,,,
BCBS PPO,CPT,A4327,Fem urinary collect dev cup,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,179.2,179.2,,,,,,
BCBS PPO,CPT,A4328,Fem urinary collect pouch,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,41.94,41.94,,,,,,
BCBS PPO,CPT,A4330,Stool collection pouch,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.7,26.7,,,,,,
BCBS PPO,CPT,A4331,Extension drainage tubing,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.44,11.44,,,,,,
BCBS PPO,CPT,A4332,Lube sterile packet,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.9,1.9,,,,,,
BCBS PPO,CPT,A4333,Urinary cath anchor device,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.62,7.62,,,,,,
BCBS PPO,CPT,A4334,Urinary cath leg strap,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,19.07,,,,,,
BCBS PPO,CPT,A4335,Incontinence supply,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,122,122,,,,,,
BCBS PPO,CPT,A4338,Indwelling catheter latex,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,49.56,49.56,,,,,,
BCBS PPO,CPT,A4344,Cath indw foley 2 way silicn,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,53.38,53.38,,,,,,
BCBS PPO,CPT,A4346,Cath indw foley 3 way,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,80.07,80.07,,,,,,
BCBS PPO,CPT,A4349,Disposable male external cat,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.62,7.62,,,,,,
BCBS PPO,CPT,A4352,Coude tip urinary catheter,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.88,22.88,,,,,,
BCBS PPO,CPT,A4354,Cath insertion tray w/bag,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,45.74,45.74,,,,,,
BCBS PPO,CPT,A4355,Bladder irrigation tubing,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.31,34.31,,,,,,
BCBS PPO,CPT,A4356,Ext ureth clmp or compr dvc,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,183.02,183.02,,,,,,
BCBS PPO,CPT,A4357,Bedside drainage bag,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.13,38.13,,,,,,
BCBS PPO,CPT,A4358,Urinary leg or abdomen bag,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.7,26.7,,,,,,
BCBS PPO,CPT,A4361,Ostomy face plate,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,95.32,95.32,,,,,,
BCBS PPO,CPT,A4362,Solid skin barrier,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.26,15.26,,,,,,
BCBS PPO,CPT,A4363,Ostomy clamp- replacement,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.44,11.44,,,,,,
BCBS PPO,CPT,A4364,Adhesive- liquid or equal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.44,11.44,,,,,,
BCBS PPO,CPT,A4365,Adhesive remover wipes,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,57.19,57.19,,,,,,
BCBS PPO,CPT,A4366,Ostomy vent,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.62,7.62,,,,,,
BCBS PPO,CPT,A4367,Ostomy belt,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.13,38.13,,,,,,
BCBS PPO,CPT,A4368,Ostomy filter,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.9,1.9,,,,,,
BCBS PPO,CPT,A4369,Skin barrier liquid per oz,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.44,11.44,,,,,,
BCBS PPO,CPT,A4371,Skin barrier powder per oz,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,19.07,,,,,,
BCBS PPO,CPT,A4372,Skin barrier solid 4x4 equiv,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.88,22.88,,,,,,
BCBS PPO,CPT,A4373,Skin barrier with flange,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.31,34.31,,,,,,
BCBS PPO,CPT,A4375,Drainable plastic pch w fcpl,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,87.69,87.69,,,,,,
BCBS PPO,CPT,A4376,Drainable rubber pch w fcplt,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,247.83,247.83,,,,,,
BCBS PPO,CPT,A4377,Drainable plstic pch w/o fp,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.88,22.88,,,,,,
BCBS PPO,CPT,A4378,Drainable rubber pch w/o fp,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,160.13,160.13,,,,,,
BCBS PPO,CPT,A4379,Urinary plastic pouch w fcpl,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,80.07,80.07,,,,,,
BCBS PPO,CPT,A4380,Urinary rubber pouch w fcplt,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,194.45,194.45,,,,,,
BCBS PPO,CPT,A4381,Urinary plastic pouch w/o fp,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.88,22.88,,,,,,
BCBS PPO,CPT,A4382,Urinary hvy plstc pch w/o fp,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,129.64,129.64,,,,,,
BCBS PPO,CPT,A4383,Urinary rubber pouch w/o fp,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,144.88,144.88,,,,,,
BCBS PPO,CPT,A4384,Ostomy faceplt/silicone ring,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,49.56,49.56,,,,,,
BCBS PPO,CPT,A4385,Ost skn barrier sld ext wear,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.7,26.7,,,,,,
BCBS PPO,CPT,A4387,Ost clsd pouch w att st barr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,19.07,,,,,,
BCBS PPO,CPT,A4388,Drainable pch w ex wear barr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.88,22.88,,,,,,
BCBS PPO,CPT,A4389,Drainable pch w st wear barr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,30.51,30.51,,,,,,
BCBS PPO,CPT,A4390,Drainable pch ex wear convex,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,49.56,49.56,,,,,,
BCBS PPO,CPT,A4391,Urinary pouch w ex wear barr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.13,38.13,,,,,,
BCBS PPO,CPT,A4392,Urinary pouch w st wear barr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,41.94,41.94,,,,,,
BCBS PPO,CPT,A4393,Urine pch w ex wear bar conv,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,45.74,45.74,,,,,,
BCBS PPO,CPT,A4394,Ostomy pouch liq deodorant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.26,15.26,,,,,,
BCBS PPO,CPT,A4395,Ostomy pouch solid deodorant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.9,1.9,,,,,,
BCBS PPO,CPT,A4396,Peristomal hernia supprt blt,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,209.7,209.7,,,,,,
BCBS PPO,CPT,A4397,Irrigation supply sleeve,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.7,26.7,,,,,,
BCBS PPO,CPT,A4398,Ostomy irrigation bag,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,72.44,72.44,,,,,,
BCBS PPO,CPT,A4399,Ostomy irrig cone/cath w brs,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,64.82,64.82,,,,,,
BCBS PPO,CPT,A4400,Ostomy irrigation set,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,228.77,228.77,,,,,,
BCBS PPO,CPT,A4402,Lubricant per ounce,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.62,7.62,,,,,,
BCBS PPO,CPT,A4404,Ostomy ring each,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.62,7.62,,,,,,
BCBS PPO,CPT,A4405,Nonpectin based ostomy paste,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,19.07,,,,,,
BCBS PPO,CPT,A4406,Pectin based ostomy paste,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,30.51,30.51,,,,,,
BCBS PPO,CPT,A4407,Ext wear ost skn barr <=4sq,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,45.74,45.74,,,,,,
BCBS PPO,CPT,A4408,Ext wear ost skn barr >4sq,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,49.56,49.56,,,,,,
BCBS PPO,CPT,A4409,Ost skn barr convex <=4 sq i,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,30.51,30.51,,,,,,
BCBS PPO,CPT,A4410,Ost skn barr extnd >4 sq,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,45.74,45.74,,,,,,
BCBS PPO,CPT,A4411,Ost skn barr extnd =4sq,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.7,26.7,,,,,,
BCBS PPO,CPT,A4412,Ost pouch drain high output,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.26,15.26,,,,,,
BCBS PPO,CPT,A4413,2 pc drainable ost pouch,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,30.51,30.51,,,,,,
BCBS PPO,CPT,A4414,Ost sknbar w/o conv<=4 sq in,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.7,26.7,,,,,,
BCBS PPO,CPT,A4415,Ost skn barr w/o conv >4 sqi,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,30.51,30.51,,,,,,
BCBS PPO,CPT,A4416,Ost pch clsd w barrier/filtr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.26,15.26,,,,,,
BCBS PPO,CPT,A4417,Ost pch w bar/bltinconv/fltr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,19.07,,,,,,
BCBS PPO,CPT,A4418,Ost pch clsd w/o bar w filtr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.62,7.62,,,,,,
BCBS PPO,CPT,A4419,Ost pch for bar w flange/flt,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.62,7.62,,,,,,
BCBS PPO,CPT,A4422,Ost pouch absorbent material,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.9,1.9,,,,,,
BCBS PPO,CPT,A4423,Ost pch for bar w lk fl/fltr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.44,11.44,,,,,,
BCBS PPO,CPT,A4424,Ost pch drain w bar & filter,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.88,22.88,,,,,,
BCBS PPO,CPT,A4425,Ost pch drain for barrier fl,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,19.07,,,,,,
BCBS PPO,CPT,A4426,Ost pch drain 2 piece system,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.26,15.26,,,,,,
BCBS PPO,CPT,A4427,Ost pch drain/barr lk flng/f,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.26,15.26,,,,,,
BCBS PPO,CPT,A4428,Urine ost pouch w faucet/tap,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.31,34.31,,,,,,
BCBS PPO,CPT,A4429,Urine ost pouch w bltinconv,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,41.94,41.94,,,,,,
BCBS PPO,CPT,A4430,Ost urine pch w b/bltin conv,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,45.74,45.74,,,,,,
BCBS PPO,CPT,A4431,Ost pch urine w barrier/tapv,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,30.51,30.51,,,,,,
BCBS PPO,CPT,A4432,Os pch urine w bar/fange/tap,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,19.07,,,,,,
BCBS PPO,CPT,A4433,Urine ost pch bar w lock fln,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,19.07,,,,,,
BCBS PPO,CPT,A4434,Ost pch urine w lock flng/ft,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,19.07,,,,,,
BCBS PPO,CPT,A4450,Non-waterproof tape,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.9,1.9,,,,,,
BCBS PPO,CPT,A4452,Waterproof tape,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.9,1.9,,,,,,
BCBS PPO,CPT,A4455,Adhesive remover per ounce,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,A4461,Surgicl dress hold non-reuse,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.44,11.44,,,,,,
BCBS PPO,CPT,A4463,Surgical dress holder reuse,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,53.38,53.38,,,,,,
BCBS PPO,CPT,A4465,Non-elastic extremity binder,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.39,114.39,,,,,,
BCBS PPO,CPT,A4480,Vabra aspirator,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,64.82,64.82,,,,,,
BCBS PPO,CPT,A4481,Tracheostoma filter,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.9,1.9,,,,,,
BCBS PPO,CPT,A4483,Moisture exchanger,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,41.94,41.94,,,,,,
BCBS PPO,CPT,A4500,Below knee surgical stocking,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,247.83,247.83,,,,,,
BCBS PPO,CPT,A4510,Full length surg stocking,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,343.14,343.14,,,,,,
BCBS PPO,CPT,A4520,Incontinence garment anytype,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.62,7.62,,,,,,
BCBS PPO,CPT,A4550,Surgical trays,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,571.91,571.91,,,,,,
BCBS PPO,CPT,A4554,Disposable underpads,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,A4555,Ca tx e-stim electr/transduc,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,41.94,41.94,,,,,,
BCBS PPO,CPT,A4556,Electrodes- pair,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,41.94,41.94,,,,,,
BCBS PPO,CPT,A4557,Lead wires- pair,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,72.44,72.44,,,,,,
BCBS PPO,CPT,A4558,Conductive gel or paste,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,19.07,,,,,,
BCBS PPO,CPT,A4559,Coupling gel or paste,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.9,1.9,,,,,,
BCBS PPO,CPT,A4561,Pessary rubber- any type,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,83.87,83.87,,,,,,
BCBS PPO,CPT,A4562,Pessary- non rubber-any type,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,202.07,202.07,,,,,,
BCBS PPO,CPT,A4565,Slings,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,30.51,30.51,,,,,,
BCBS PPO,CPT,A4580,Cast supplies (plaster),Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,457.52,457.52,,,,,,
BCBS PPO,CPT,A4590,Special casting material,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,358.39,358.39,,,,,,
BCBS PPO,CPT,A4595,Tens suppl 2 lead per month,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.39,114.39,,,,,,
BCBS PPO,CPT,A4606,Oxygen probe used w oximeter,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,266.89,266.89,,,,,,
BCBS PPO,CPT,A4608,Transtracheal oxygen cath,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,202.07,202.07,,,,,,
BCBS PPO,CPT,A4614,Hand-held pefr meter,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,95.32,95.32,,,,,,
BCBS PPO,CPT,A4616,Tubing (oxygen) per foot,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.9,1.9,,,,,,
BCBS PPO,CPT,A4617,Mouth piece,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.44,11.44,,,,,,
BCBS PPO,CPT,A4619,Face tent,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,A4620,Variable concentration mask,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,A4623,Tracheostomy inner cannula,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.88,22.88,,,,,,
BCBS PPO,CPT,A4625,Trach care kit for new trach,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.7,26.7,,,,,,
BCBS PPO,CPT,A4626,Tracheostomy cleaning brush,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.44,11.44,,,,,,
BCBS PPO,CPT,A4627,Spacer bag/reservoir,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,171.58,171.58,,,,,,
BCBS PPO,CPT,A4629,Tracheostomy care kit,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,19.07,,,,,,
BCBS PPO,CPT,A4641,Radiopharm dx agent noc,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,571.91,571.91,,,,,,
BCBS PPO,CPT,A4657,Syringe w/wo needle,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.26,15.26,,,,,,
BCBS PPO,CPT,A4660,Sphyg/bp app w cuff and stet,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,366.02,366.02,,,,,,
BCBS PPO,CPT,A4670,Automatic bp monitor- dial,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,415.59,415.59,,,,,,
BCBS PPO,CPT,A4671,Disposable cycler set,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,152.51,152.51,,,,,,
BCBS PPO,CPT,A4672,Drainage ext line- dialysis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.31,34.31,,,,,,
BCBS PPO,CPT,A4680,Activated carbon filter- ea,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,68.63,68.63,,,,,,
BCBS PPO,CPT,A4690,Dialyzer- each,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,212.43","1,212.43",,,,,,
BCBS PPO,CPT,A4737,Inj anesthetic per 10 ml,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,30.51,30.51,,,,,,
BCBS PPO,CPT,A4750,Art or venous blood tubing,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,57.19,57.19,,,,,,
BCBS PPO,CPT,A4770,Blood collection tube/vacuum,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,19.07,,,,,,
BCBS PPO,CPT,A4772,Blood glucose test strips,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,137.25,137.25,,,,,,
BCBS PPO,CPT,A4773,Occult blood test strips,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.7,26.7,,,,,,
BCBS PPO,CPT,A4860,Disposable catheter tips,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,19.07,,,,,,
BCBS PPO,CPT,A4913,Misc dialysis supplies noc,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.13,38.13,,,,,,
BCBS PPO,CPT,A4927,Non-sterile gloves,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,61,61,,,,,,
BCBS PPO,CPT,A4928,Surgical mask,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,64.82,64.82,,,,,,
BCBS PPO,CPT,A4930,Sterile- gloves per pair,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,57.19,57.19,,,,,,
BCBS PPO,CPT,A5051,Pouch clsd w barr attached,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.62,7.62,,,,,,
BCBS PPO,CPT,A5052,Clsd ostomy pouch w/o barr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.62,7.62,,,,,,
BCBS PPO,CPT,A5053,Clsd ostomy pouch faceplate,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.62,7.62,,,,,,
BCBS PPO,CPT,A5054,Clsd ostomy pouch w/flange,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.62,7.62,,,,,,
BCBS PPO,CPT,A5055,Stoma cap,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.62,7.62,,,,,,
BCBS PPO,CPT,A5061,Pouch drainable w barrier at,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.26,15.26,,,,,,
BCBS PPO,CPT,A5062,Drnble ostomy pouch w/o barr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.62,7.62,,,,,,
BCBS PPO,CPT,A5063,Drain ostomy pouch w/flange,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.44,11.44,,,,,,
BCBS PPO,CPT,A5071,Urinary pouch w/barrier,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.88,22.88,,,,,,
BCBS PPO,CPT,A5072,Urinary pouch w/o barrier,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.26,15.26,,,,,,
BCBS PPO,CPT,A5073,Urinary pouch on barr w/flng,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.44,11.44,,,,,,
BCBS PPO,CPT,A5081,Stoma plug or seal- any type,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.44,11.44,,,,,,
BCBS PPO,CPT,A5082,Continent stoma catheter,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,45.74,45.74,,,,,,
BCBS PPO,CPT,A5083,Stoma absorptive cover,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,A5093,Ostomy accessory convex inse,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.62,7.62,,,,,,
BCBS PPO,CPT,A5102,Bedside drain btl w/wo tube,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,91.51,91.51,,,,,,
BCBS PPO,CPT,A5105,Urinary suspensory,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,163.95,163.95,,,,,,
BCBS PPO,CPT,A5112,Urinary leg bag,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,137.25,137.25,,,,,,
BCBS PPO,CPT,A5113,Latex leg strap,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,19.07,,,,,,
BCBS PPO,CPT,A5114,Foam/fabric leg strap,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,30.51,30.51,,,,,,
BCBS PPO,CPT,A5120,Skin barrier- wipe or swab,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.9,1.9,,,,,,
BCBS PPO,CPT,A5121,Solid skin barrier 6x6,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,30.51,30.51,,,,,,
BCBS PPO,CPT,A5122,Solid skin barrier 8x8,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,49.56,49.56,,,,,,
BCBS PPO,CPT,A5126,Disk/foam pad +or- adhesive,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,A5131,Appliance cleaner,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,57.19,57.19,,,,,,
BCBS PPO,CPT,A5200,Percutaneous catheter anchor,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,45.74,45.74,,,,,,
BCBS PPO,CPT,A5500,Diab shoe for density insert,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,255.45,255.45,,,,,,
BCBS PPO,CPT,A5501,Diabetic custom molded shoe,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,762.54,762.54,,,,,,
BCBS PPO,CPT,A5503,Diabetic shoe w/roller/rockr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.39,114.39,,,,,,
BCBS PPO,CPT,A5504,Diabetic shoe with wedge,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.39,114.39,,,,,,
BCBS PPO,CPT,A5505,Diab shoe w/metatarsal bar,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.39,114.39,,,,,,
BCBS PPO,CPT,A5506,Diabetic shoe w/off set heel,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.39,114.39,,,,,,
BCBS PPO,CPT,A5507,Modification diabetic shoe,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.39,114.39,,,,,,
BCBS PPO,CPT,A5512,Multi den insert direct form,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,102.95,102.95,,,,,,
BCBS PPO,CPT,A5513,Multi den insert custom mold,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,156.32,156.32,,,,,,
BCBS PPO,CPT,A6010,Collagen based wound filler,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,125.82,125.82,,,,,,
BCBS PPO,CPT,A6011,Collagen gel/paste wound fil,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.62,7.62,,,,,,
BCBS PPO,CPT,A6021,Collagen dressing <=16 sq in,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,83.87,83.87,,,,,,
BCBS PPO,CPT,A6022,Collagen drsg>16<=48 sq in,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,83.87,83.87,,,,,,
BCBS PPO,CPT,A6023,Collagen dressing >48 sq in,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,762.54,762.54,,,,,,
BCBS PPO,CPT,A6024,Collagen dsg wound filler,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.7,26.7,,,,,,
BCBS PPO,CPT,A6025,Silicone gel sheet- each,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,95.32,95.32,,,,,,
BCBS PPO,CPT,A6154,Wound pouch each,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,57.19,57.19,,,,,,
BCBS PPO,CPT,A6196,Alginate dressing <=16 sq in,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,30.51,30.51,,,,,,
BCBS PPO,CPT,A6197,Alginate drsg >16 <=48 sq in,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,64.82,64.82,,,,,,
BCBS PPO,CPT,A6199,Alginate drsg wound filler,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.88,22.88,,,,,,
BCBS PPO,CPT,A6200,Compos drsg <=16 no border,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.13,38.13,,,,,,
BCBS PPO,CPT,A6201,Compos drsg >16<=48 no bdr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,80.07,80.07,,,,,,
BCBS PPO,CPT,A6202,Compos drsg >48 no border,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,133.45,133.45,,,,,,
BCBS PPO,CPT,A6203,Composite drsg <= 16 sq in,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.26,15.26,,,,,,
BCBS PPO,CPT,A6204,Composite drsg >16<=48 sq in,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.7,26.7,,,,,,
BCBS PPO,CPT,A6209,Foam drsg <=16 sq in w/o bdr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,30.51,30.51,,,,,,
BCBS PPO,CPT,A6210,Foam drg >16<=48 sq in w/o b,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,80.07,80.07,,,,,,
BCBS PPO,CPT,A6211,Foam drg > 48 sq in w/o brdr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,118.19,118.19,,,,,,
BCBS PPO,CPT,A6214,Foam drg > 48 sq in w/border,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,41.94,41.94,,,,,,
BCBS PPO,CPT,A6218,Non-sterile gauze > 48 sq in,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,A6219,Gauze <= 16 sq in w/border,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,A6220,Gauze >16 <=48 sq in w/bordr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.44,11.44,,,,,,
BCBS PPO,CPT,A6221,Gauze > 48 sq in w/border,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,152.51,152.51,,,,,,
BCBS PPO,CPT,A6222,Gauze <=16 in no w/sal w/o b,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.62,7.62,,,,,,
BCBS PPO,CPT,A6223,Gauze >16<=48 no w/sal w/o b,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.44,11.44,,,,,,
BCBS PPO,CPT,A6224,Gauze > 48 in no w/sal w/o b,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.26,15.26,,,,,,
BCBS PPO,CPT,A6228,Gauze <= 16 sq in water/sal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,745.14","2,745.14",,,,,,
BCBS PPO,CPT,A6231,Hydrogel dsg<=16 sq in,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,19.07,,,,,,
BCBS PPO,CPT,A6232,Hydrogel dsg>16<=48 sq in,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.7,26.7,,,,,,
BCBS PPO,CPT,A6233,Hydrogel dressing >48 sq in,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.26,76.26,,,,,,
BCBS PPO,CPT,A6234,Hydrocolld drg <=16 w/o bdr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.7,26.7,,,,,,
BCBS PPO,CPT,A6235,Hydrocolld drg >16<=48 w/o b,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,68.63,68.63,,,,,,
BCBS PPO,CPT,A6236,Hydrocolld drg > 48 in w/o b,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,110.57,110.57,,,,,,
BCBS PPO,CPT,A6237,Hydrocolld drg <=16 in w/bdr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,30.51,30.51,,,,,,
BCBS PPO,CPT,A6238,Hydrocolld drg >16<=48 w/bdr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,91.51,91.51,,,,,,
BCBS PPO,CPT,A6240,Hydrocolld drg filler paste,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,49.56,49.56,,,,,,
BCBS PPO,CPT,A6241,Hydrocolloid drg filler dry,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.44,11.44,,,,,,
BCBS PPO,CPT,A6242,Hydrogel drg <=16 in w/o bdr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.88,22.88,,,,,,
BCBS PPO,CPT,A6243,Hydrogel drg >16<=48 w/o bdr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,49.56,49.56,,,,,,
BCBS PPO,CPT,A6244,Hydrogel drg >48 in w/o bdr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,156.32,156.32,,,,,,
BCBS PPO,CPT,A6245,Hydrogel drg <= 16 in w/bdr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,30.51,30.51,,,,,,
BCBS PPO,CPT,A6246,Hydrogel drg >16<=48 in w/b,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.13,38.13,,,,,,
BCBS PPO,CPT,A6247,Hydrogel drg > 48 sq in w/b,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,95.32,95.32,,,,,,
BCBS PPO,CPT,A6248,Hydrogel drsg gel filler,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,64.82,64.82,,,,,,
BCBS PPO,CPT,A6250,Skin seal protect moisturizr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,64.82,64.82,,,,,,
BCBS PPO,CPT,A6251,Absorpt drg <=16 sq in w/o b,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.62,7.62,,,,,,
BCBS PPO,CPT,A6252,Absorpt drg >16 <=48 w/o bdr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.44,11.44,,,,,,
BCBS PPO,CPT,A6253,Absorpt drg > 48 sq in w/o b,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.7,26.7,,,,,,
BCBS PPO,CPT,A6255,Absorpt drg >16<=48 in w/bdr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.44,11.44,,,,,,
BCBS PPO,CPT,A6258,Transparent film >16<=48 in,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,19.07,,,,,,
BCBS PPO,CPT,A6259,Transparent film > 48 sq in,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,41.94,41.94,,,,,,
BCBS PPO,CPT,A6260,Wound cleanser any type/size,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,57.19,57.19,,,,,,
BCBS PPO,CPT,A6266,Impreg gauze no h20/sal/yard,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.62,7.62,,,,,,
BCBS PPO,CPT,A6402,Sterile gauze <= 16 sq in,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.9,1.9,,,,,,
BCBS PPO,CPT,A6403,Sterile gauze>16 <= 48 sq in,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.9,1.9,,,,,,
BCBS PPO,CPT,A6404,Sterile gauze > 48 sq in,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,152.51,152.51,,,,,,
BCBS PPO,CPT,A6407,Packing strips- non-impreg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.62,7.62,,,,,,
BCBS PPO,CPT,A6410,Sterile eye pad,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.9,1.9,,,,,,
BCBS PPO,CPT,A6412,Occlusive eye patch,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,72.44,72.44,,,,,,
BCBS PPO,CPT,A6441,Pad band w>=3,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,A6442,Conform band n/s w<3,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.9,1.9,,,,,,
BCBS PPO,CPT,A6443,Conform band n/s w>=3,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.9,1.9,,,,,,
BCBS PPO,CPT,A6444,Conform band n/s w>=5,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,A6445,Conform band s w <3,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.9,1.9,,,,,,
BCBS PPO,CPT,A6446,Conform band s w>=3,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.9,1.9,,,,,,
BCBS PPO,CPT,A6447,Conform band s w >=5,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,A6448,Lt compres band <3,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,A6450,Lt compres band >=5,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,49.56,49.56,,,,,,
BCBS PPO,CPT,A6451,Mod compres band w>=3,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.26,76.26,,,,,,
BCBS PPO,CPT,A6452,High compres band w>=3,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.88,22.88,,,,,,
BCBS PPO,CPT,A6453,Self-adher band w <3,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,A6454,Self-adher band w>=3,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,A6455,Self-adher band >=5,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,A6456,Zinc paste band w >=3,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,A6457,Tubular dressing,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,A6530,Compression stocking bk18-30,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,266.89,266.89,,,,,,
BCBS PPO,CPT,A6531,Compression stocking bk30-40,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,266.89,266.89,,,,,,
BCBS PPO,CPT,A6532,Compression stocking bk40-50,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,335.53,335.53,,,,,,
BCBS PPO,CPT,A6533,Gc stocking thighlngth 18-30,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,366.02,366.02,,,,,,
BCBS PPO,CPT,A6534,Gc stocking thighlngth 30-40,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,373.65,373.65,,,,,,
BCBS PPO,CPT,A6535,Gc stocking thighlngth 40-50,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,377.46,377.46,,,,,,
BCBS PPO,CPT,A6536,Gc stocking full lngth 18-30,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,285.96,285.96,,,,,,
BCBS PPO,CPT,A6537,Gc stocking full lngth 30-40,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,285.96,285.96,,,,,,
BCBS PPO,CPT,A6539,Gc stocking waistlngth 18-30,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,476.6,476.6,,,,,,
BCBS PPO,CPT,A6540,Gc stocking waistlngth 30-40,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,468.96,468.96,,,,,,
BCBS PPO,CPT,A6541,Gc stocking waistlngth 40-50,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,636.73,636.73,,,,,,
BCBS PPO,CPT,A6544,Gc stocking garter belt,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,221.14,221.14,,,,,,
BCBS PPO,CPT,A6550,Neg pres wound ther drsg set,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,137.25,137.25,,,,,,
BCBS PPO,CPT,A7018,Water distilled w/nebulizer,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.9,1.9,,,,,,
BCBS PPO,CPT,A7040,One way chest drain valve,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,160.13,160.13,,,,,,
BCBS PPO,CPT,A7041,Water seal drain container,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,305.01,305.01,,,,,,
BCBS PPO,CPT,A7042,Implanted pleural catheter,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,773.98,773.98,,,,,,
BCBS PPO,CPT,A7043,Vacuum drainagebottle/tubing,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.39,114.39,,,,,,
BCBS PPO,CPT,A7501,Tracheostoma valve w diaphra,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,419.4,419.4,,,,,,
BCBS PPO,CPT,A7502,Replacement diaphragm/fplate,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,198.25,198.25,,,,,,
BCBS PPO,CPT,A7503,Hmes filter holder or cap,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,45.74,45.74,,,,,,
BCBS PPO,CPT,A7504,Tracheostoma hmes filter,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,A7505,Hmes or trach valve housing,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,19.07,,,,,,
BCBS PPO,CPT,A7506,Hmes/trachvalve adhesivedisk,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.9,1.9,,,,,,
BCBS PPO,CPT,A7507,Integrated filter & holder,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.44,11.44,,,,,,
BCBS PPO,CPT,A7508,Housing & integrated adhesiv,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.44,11.44,,,,,,
BCBS PPO,CPT,A7509,Heat & moisture exchange sys,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,A7520,Trach/laryn tube non-cuffed,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,190.64,190.64,,,,,,
BCBS PPO,CPT,A7521,Trach/laryn tube cuffed,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,186.82,186.82,,,,,,
BCBS PPO,CPT,A7522,Trach/laryn tube stainless,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,179.2,179.2,,,,,,
BCBS PPO,CPT,A7524,Tracheostoma stent/stud/bttn,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,308.83,308.83,,,,,,
BCBS PPO,CPT,A7525,Tracheostomy mask,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.62,7.62,,,,,,
BCBS PPO,CPT,A7526,Tracheostomy tube collar,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.26,15.26,,,,,,
BCBS PPO,CPT,A7527,Trach/laryn tube plug/stop,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.26,15.26,,,,,,
BCBS PPO,CPT,A9276,Disposable sensor- cgm sys,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,41.94,41.94,,,,,,
BCBS PPO,CPT,A9277,External transmitter- cgm,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,276.18","2,276.18",,,,,,
BCBS PPO,CPT,A9278,External receiver- cgm sys,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,929.22","1,929.22",,,,,,
BCBS PPO,CPT,A9300,Exercise equipment,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,57.19,57.19,,,,,,
BCBS PPO,CPT,A9500,Tc99m sestamibi,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,275.87,275.87,,,,,,
BCBS PPO,CPT,A9502,Tc99m tetrofosmin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,143.81","1,143.81",,,,,,
BCBS PPO,CPT,A9503,Tc99m medronate,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,217.32,217.32,,,,,,
BCBS PPO,CPT,A9504,Tc99m apcitide,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,173.23","2,173.23",,,,,,
BCBS PPO,CPT,A9505,Tl201 thallium,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,228.77,228.77,,,,,,
BCBS PPO,CPT,A9507,In111 capromab,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"10,031.20","10,031.20",,,,,,
BCBS PPO,CPT,A9510,Tc99m disofenin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,259.27,259.27,,,,,,
BCBS PPO,CPT,A9516,Iodine i-123 sod iodide mic,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,297.39,297.39,,,,,,
BCBS PPO,CPT,A9517,I131 iodide cap- rx,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,20.12,32.18,,,,,,
BCBS PPO,CPT,A9520,Tc99 tilmanocept diag 0.5mci,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,8.66,8.66,,,,,,
BCBS PPO,CPT,A9521,Tc99m exametazime,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"4,075.77","4,075.77",,,,,,
BCBS PPO,CPT,A9524,I131 serum albumin- dx,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,240.2,240.2,,,,,,
BCBS PPO,CPT,A9552,F18 fdg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,525.07","1,525.07",,,,,,
BCBS PPO,CPT,A9575,Inj gadoterate meglumi 0.1ml,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.15,1.15,,,,,,
BCBS PPO,CPT,A9576,Inj prohance multipack,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.44,11.44,,,,,,
BCBS PPO,CPT,A9577,Inj multihance,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.44,11.44,,,,,,
BCBS PPO,CPT,A9578,Inj multihance multipack,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.44,11.44,,,,,,
BCBS PPO,CPT,A9579,Gad-base mr contrast nos-1ml,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.44,11.44,,,,,,
BCBS PPO,CPT,A9600,Sr89 strontium,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,975.00","4,407.46",,,,,,
BCBS PPO,CPT,A9605,Sm 153 lexidronm,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"4,666.74","4,666.74",,,,,,
BCBS PPO,CPT,A9700,Echocardiography contrast,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,915.04,915.04,,,,,,
BCBS PPO,CPT,B4034,Enter feed supkit syr by day,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.7,26.7,,,,,,
BCBS PPO,CPT,B4035,Enteral feed supp pump per d,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,45.74,45.74,,,,,,
BCBS PPO,CPT,B4036,Enteral feed sup kit grav by,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.31,34.31,,,,,,
BCBS PPO,CPT,B4081,Enteral ng tubing w/ stylet,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,87.69,87.69,,,,,,
BCBS PPO,CPT,B4083,Enteral stomach tube levine,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.44,11.44,,,,,,
BCBS PPO,CPT,B4087,Gastro/jejuno tube- std,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,144.88,144.88,,,,,,
BCBS PPO,CPT,B4149,Ef blenderized foods,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.62,7.62,,,,,,
BCBS PPO,CPT,B4150,Ef complet w/intact nutrient,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,B4152,Ef calorie dense>/=1.5kcal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,B4153,Ef hydrolyzed/amino acids,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.62,7.62,,,,,,
BCBS PPO,CPT,B4154,Ef spec metabolic noninherit,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,B4155,Ef incomplete/modular,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,B4157,Ef special metabolic inherit,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,B4158,Ef ped complete intact nut,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,B4159,Ef ped complete soy based,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,B4160,Ef ped caloric dense>/=0.7kc,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,B4161,Ef ped hydrolyzed/amino acid,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.62,7.62,,,,,,
BCBS PPO,CPT,B4162,Ef ped specmetabolic inherit,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,B4164,Parenteral 50% dextrose solu,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,68.63,68.63,,,,,,
BCBS PPO,CPT,B4168,Parenteral sol amino acid 3.,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,99.13,99.13,,,,,,
BCBS PPO,CPT,B4176,Parenteral sol amino acid 7-,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,190.64,190.64,,,,,,
BCBS PPO,CPT,B4178,Parenteral sol amino acid >,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,228.77,228.77,,,,,,
BCBS PPO,CPT,B4180,Parenteral sol carb > 50%,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,95.32,95.32,,,,,,
BCBS PPO,CPT,B4185,Pn soln nos 10 grams lipids,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,45.74,45.74,,,,,,
BCBS PPO,CPT,B4189,Parenteral sol amino acid &,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,705.35,705.35,,,,,,
BCBS PPO,CPT,B4193,Parenteral sol 52-73 gm prot,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,911.23,911.23,,,,,,
BCBS PPO,CPT,B4197,Parenteral sol 74-100 gm pro,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,105.68","1,105.68",,,,,,
BCBS PPO,CPT,B4199,Parenteral sol > 100gm prote,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,265.81","1,265.81",,,,,,
BCBS PPO,CPT,B4216,Parenteral nutrition additiv,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,30.51,30.51,,,,,,
BCBS PPO,CPT,B4220,Parenteral supply kit premix,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,30.51,30.51,,,,,,
BCBS PPO,CPT,B4222,Parenteral supply kit homemi,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.13,38.13,,,,,,
BCBS PPO,CPT,B4224,Parenteral administration ki,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,99.13,99.13,,,,,,
BCBS PPO,CPT,B5000,Parenteral sol renal-amirosy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,45.74,45.74,,,,,,
BCBS PPO,CPT,B5100,Parenteral solution hepatic,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,19.07,,,,,,
BCBS PPO,CPT,D7210,Rem imp tooth w mucoper flp,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,953.17,"1,426.03",,,,,,
BCBS PPO,CPT,D7220,Impact tooth remov soft tiss,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,953.17,"1,426.03",,,,,,
BCBS PPO,CPT,D7230,Impact tooth remov part bony,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,391.64","1,426.03",,,,,,
BCBS PPO,CPT,D7240,Impact tooth remov comp bony,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,426.03","1,715.71",,,,,,
BCBS PPO,CPT,D7241,Impact tooth rem bony w/comp,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,426.03","2,001.67",,,,,,
BCBS PPO,CPT,D9430,Office visit during hours,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,190.64,190.64,,,,,,
BCBS PPO,CPT,E0441,Stationary o2 contents- gas,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,293.57,293.57,,,,,,
BCBS PPO,CPT,E0442,Stationary o2 contents- liq,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,293.57,293.57,,,,,,
BCBS PPO,CPT,E0443,Portable 02 contents- gas,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,293.57,293.57,,,,,,
BCBS PPO,CPT,E0444,Portable 02 contents- liquid,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,293.57,293.57,,,,,,
BCBS PPO,CPT,E0785,Replacement impl pump cathet,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,891.10","1,891.10",,,,,,
BCBS PPO,CPT,E1701,Repl cushions for jaw motion,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,41.94,41.94,,,,,,
BCBS PPO,CPT,E1702,Repl measr scales jaw motion,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,91.51,91.51,,,,,,
BCBS PPO,CPT,E1902,Aac non-electronic board,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,186.82,186.82,,,,,,
BCBS PPO,CPT,G0008,Admin influenza virus vac,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,40.93,57.19,,,,,,
BCBS PPO,CPT,G0009,Admin pneumococcal vaccine,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,40.93,57.19,,,,,,
BCBS PPO,CPT,G0010,Admin hepatitis b vaccine,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,40.93,57.19,,,,,,
BCBS PPO,CPT,G0027,Semen analysis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,6.5,34.31,,,,,,
BCBS PPO,CPT,G0101,Ca screen-pelvic/breast exam,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.62,186.82,,,,,,
BCBS PPO,CPT,G0102,Prostate ca screening- dre,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,102.95,102.95,,,,,,
BCBS PPO,CPT,G0103,Psa screening,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.31,80.07,,,,,,
BCBS PPO,CPT,G0104,Ca screen-flexi sigmoidscope,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,678.66,812.16,,,,,,
BCBS PPO,CPT,G0106,Colon ca screen-barium enema,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,182.72,"1,090.43",,,,,,
BCBS PPO,CPT,G0108,Diab manage trn  per indiv,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,54.47,125.82,,,,,,
BCBS PPO,CPT,G0109,Diab manage trn ind/group,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.18,72.44,,,,,,
BCBS PPO,CPT,G0117,Glaucoma scrn hgh risk direc,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,25.25,232.58,,,,,,
BCBS PPO,CPT,G0118,Glaucoma scrn hgh risk direc,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.63,160.13,,,,,,
BCBS PPO,CPT,G0120,Colon ca scrn- barium enema,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,376.7,"1,090.43",,,,,,
BCBS PPO,CPT,G0122,Colon ca scrn- barium enema,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,292.50","1,292.50",,,,,,
BCBS PPO,CPT,G0123,Screen cerv/vag thin layer,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,20.26,91.51,,,,,,
BCBS PPO,CPT,G0124,Screen c/v thin layer by md,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,137.25,137.25,,,,,,
BCBS PPO,CPT,G0128,Corf skilled nursing service,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,45.74,45.74,,,,,,
BCBS PPO,CPT,G0130,Single energy x-ray study,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,111.51,171.58,,,,,,
BCBS PPO,CPT,G0141,Scr c/v cyto-autosys and md,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,137.25,137.25,,,,,,
BCBS PPO,CPT,G0143,Scr c/v cyto-thinlayer-rescr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,27.05,91.51,,,,,,
BCBS PPO,CPT,G0144,Scr c/v cyto-thinlayer-rescr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,43.97,95.32,,,,,,
BCBS PPO,CPT,G0145,Scr c/v cyto-thinlayer-rescr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.49,118.19,,,,,,
BCBS PPO,CPT,G0147,Scr c/v cyto- automated sys,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.15,45.74,,,,,,
BCBS PPO,CPT,G0148,Scr c/v cyto- autosys- rescr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,31.94,45.74,,,,,,
BCBS PPO,CPT,G0168,Wound closure by adhesive,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,434.65,434.65,,,,,,
BCBS PPO,CPT,G0175,Opps service-sched team conf,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,372.22,392.7,,,,,,
BCBS PPO,CPT,G0179,Md recertification hha pt,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,209.7,209.7,,,,,,
BCBS PPO,CPT,G0180,Md certification hha patient,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,278.32,278.32,,,,,,
BCBS PPO,CPT,G0181,Home health care supervision,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,537.6,537.6,,,,,,
BCBS PPO,CPT,G0182,Hospice care supervision,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,549.03,549.03,,,,,,
BCBS PPO,CPT,G0202,Screeningmammographydigital,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,275.87,275.87,,,,,,
BCBS PPO,CPT,G0204,Diagnosticmammographydigital,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,275.87,275.87,,,,,,
BCBS PPO,CPT,G0206,Diagnosticmammographydigital,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,275.87,275.87,,,,,,
BCBS PPO,CPT,G0235,Pet not otherwise specified,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.91,"7,236.50",,,,,,
BCBS PPO,CPT,G0237,Therapeutic procd strg endur,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,25.25,61,,,,,,
BCBS PPO,CPT,G0238,Oth resp proc- indiv,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,25.25,64.82,,,,,,
BCBS PPO,CPT,G0239,Oth resp proc- group,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.63,64.82,,,,,,
BCBS PPO,CPT,G0245,Initial foot exam pt lops,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,121.51,339.33,,,,,,
BCBS PPO,CPT,G0246,Followup eval of foot pt lop,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,121.51,198.25,,,,,,
BCBS PPO,CPT,G0247,Routine footcare pt w lops,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,183.73,232.58,,,,,,
BCBS PPO,CPT,G0248,Demonstrate use home inr mon,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,121.51,804.48,,,,,,
BCBS PPO,CPT,G0249,Provide inr test mater/equip,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,121.51,686.28,,,,,,
BCBS PPO,CPT,G0250,Md inr test revie inter mgmt,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,49.56,49.56,,,,,,
BCBS PPO,CPT,G0268,Removal of impacted wax md,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,285.96,285.96,,,,,,
BCBS PPO,CPT,G0270,Mnt subs tx for change dx,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.49,122,,,,,,
BCBS PPO,CPT,G0271,Group mnt 2 or more 30 mins,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.98,68.63,,,,,,
BCBS PPO,CPT,G0275,Renal angio - cardiac cath,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.26,76.26,,,,,,
BCBS PPO,CPT,G0278,Iliac art angio-cardiac cath,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.26,76.26,,,,,,
BCBS PPO,CPT,G0281,Elec stim unattend for press,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.74,61,,,,,,
BCBS PPO,CPT,G0283,Elec stim other than wound,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.74,61,,,,,,
BCBS PPO,CPT,G0289,Arthro- loose body + chondro,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,568.09,568.09,,,,,,
BCBS PPO,CPT,G0306,Cbc/diffwbc w/o platelet,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.77,34.31,,,,,,
BCBS PPO,CPT,G0307,Cbc without platelet,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,6.47,30.51,,,,,,
BCBS PPO,CPT,G0328,Fecal blood scrn immunoassay,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,18.05,72.44,,,,,,
BCBS PPO,CPT,G0329,Electromagntic tx for ulcers,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,10.46,45.74,,,,,,
BCBS PPO,CPT,G0333,Dispense fee initial 30 day,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,217.32,217.32,,,,,,
BCBS PPO,CPT,G0337,Hospice evaluation preelecti,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,369.83,369.83,,,,,,
BCBS PPO,CPT,G0341,Percutaneous islet celltrans,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,508.76","8,948.83",,,,,,
BCBS PPO,CPT,G0342,Laparoscopy islet cell trans,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"4,254.96","8,948.83",,,,,,
BCBS PPO,CPT,G0343,Laparotomy islet cell transp,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"6,965.79","8,948.83",,,,,,
BCBS PPO,CPT,G0364,Bone marrow aspirate &biopsy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,80.07,80.07,,,,,,
BCBS PPO,CPT,G0365,Vessel mapping hemo access,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,136.19","1,136.19",,,,,,
BCBS PPO,CPT,G0372,Md service required for pmd,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,61,61,,,,,,
BCBS PPO,CPT,G0389,Ultrasound exam AAA screen,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,575.73,575.73,,,,,,
BCBS PPO,CPT,G0392,AV fistula or graft arterial,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"12,292.12","12,292.12",,,,,,
BCBS PPO,CPT,G0393,AV fistula or graft venous,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"9,268.66","9,268.66",,,,,,
BCBS PPO,CPT,G0396,Alcohol/subs interv 15-30mn,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.84,163.95,,,,,,
BCBS PPO,CPT,G0398,Home sleep test/type 2 porta,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,142.8,367.82,,,,,,
BCBS PPO,CPT,G0400,Home sleep test/type 4 porta,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,270.61,367.82,,,,,,
BCBS PPO,CPT,G0402,Initial preventive exam,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,121.51,491.83,,,,,,
BCBS PPO,CPT,G0403,Ekg for initial prevent exam,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,122,122,,,,,,
BCBS PPO,CPT,G0405,Ekg interpret & report preve,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,45.74,45.74,,,,,,
BCBS PPO,CPT,G0406,Inpt/tele follow up 15,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,194.45,194.45,,,,,,
BCBS PPO,CPT,G0407,Inpt/tele follow up 25,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,346.96,346.96,,,,,,
BCBS PPO,CPT,G0408,Inpt/tele follow up 35,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,495.65,495.65,,,,,,
BCBS PPO,CPT,G0409,Corf related serv 15 mins ea,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,45.74,45.74,,,,,,
BCBS PPO,CPT,G0412,Open tx iliac spine uni/bil,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"4,510.41","6,411.04",,,,,,
BCBS PPO,CPT,G0413,Pelvic ring fracture uni/bil,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"6,411.04","6,527.33",,,,,,
BCBS PPO,CPT,G0414,Pelvic ring fx treat int fix,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"6,161.31","12,601.93",,,,,,
BCBS PPO,CPT,G0415,Open tx post pelvic fxcture,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"8,452.74","12,601.93",,,,,,
BCBS PPO,CPT,G0416,Prostate biopsy- any mthd,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,298.05,"3,297.99",,,,,,
BCBS PPO,CPT,G0417,Sat biopsy prostate 21-40,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"6,412.95","6,412.95",,,,,,
BCBS PPO,CPT,G0418,Sat biopsy prostate 41-60,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"10,999.63","10,999.63",,,,,,
BCBS PPO,CPT,G0419,Sat biopsy prostate: >60,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"13,066.10","13,066.10",,,,,,
BCBS PPO,CPT,G0459,Telehealth inpt pharm mgmt,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,285.96,285.96,,,,,,
BCBS PPO,CPT,G0461,,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,,,,,,,,
BCBS PPO,CPT,G0462,,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,,,,,,,,
BCBS PPO,CPT,G0463,Hospital outpt clinic visit,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,95.32,121.51,,,,,,
BCBS PPO,CPT,G2023,Specimen collect covid-19,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,80.07,80.07,,,,,,
BCBS PPO,CPT,G2024,Spec coll snf/lab covid-19,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,80.07,80.07,,,,,,
BCBS PPO,CPT,G9041,Low vision rehab occupationa,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,118.19,118.19,,,,,,
BCBS PPO,CPT,G9042,Low vision rehab orient/mobi,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,41.94,41.94,,,,,,
BCBS PPO,CPT,G9043,Low vision lowvision therapi,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.13,38.13,,,,,,
BCBS PPO,CPT,G9044,Low vision rehabilate teache,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.13,38.13,,,,,,
BCBS PPO,CPT,J0128,Abarelix injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,331.7,331.7,,,,,,
BCBS PPO,CPT,J0129,Abatacept injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,45.27,73.44,,,,,,
BCBS PPO,CPT,J0132,Acetylcysteine injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.44,11.44,,,,,,
BCBS PPO,CPT,J0133,Acyclovir injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.9,1.9,,,,,,
BCBS PPO,CPT,J0150,Injection adenosine 6 MG,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,49.56,49.56,,,,,,
BCBS PPO,CPT,J0151,INJ ADENOSINE 90 MG,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.44,11.44,,,,,,
BCBS PPO,CPT,J0152,Adenosine injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,343.14,343.14,,,,,,
BCBS PPO,CPT,J0153,Adenosine inj 1mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.44,11.44,,,,,,
BCBS PPO,CPT,J0180,Agalsidase beta injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,198.14,508.92,,,,,,
BCBS PPO,CPT,J0200,Alatrofloxacin mesylate,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,83.87,83.87,,,,,,
BCBS PPO,CPT,J0202,Injection- alemtuzumab,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,277.19,"2,086.32",,,,,,
BCBS PPO,CPT,J0205,Alglucerase injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,202.07,202.07,,,,,,
BCBS PPO,CPT,J0207,Amifostine,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,135.69","1,985.16",,,,,,
BCBS PPO,CPT,J0210,Methyldopate hcl injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,133.45,133.45,,,,,,
BCBS PPO,CPT,J0215,Alefacept,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,110.76,110.76,,,,,,
BCBS PPO,CPT,J0220,Alglucosidase alfa injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,117.07,474.68,,,,,,
BCBS PPO,CPT,J0256,Alpha 1 proteinase inhibitor,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,4.54,7.9,,,,,,
BCBS PPO,CPT,J0270,Alprostadil for injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,J0275,Alprostadil urethral suppos,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,118.19,118.19,,,,,,
BCBS PPO,CPT,J0285,Amphotericin b,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,64.82,64.82,,,,,,
BCBS PPO,CPT,J0287,Amphotericin b lipid complex,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,9.5,49.56,,,,,,
BCBS PPO,CPT,J0288,Ampho b cholesteryl sulfate,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,68.63,68.63,,,,,,
BCBS PPO,CPT,J0289,Amphotericin b liposome inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,28.75,118.19,,,,,,
BCBS PPO,CPT,J0300,Amobarbital 125 mg inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,30.51,125.22,,,,,,
BCBS PPO,CPT,J0330,Succinycholine chloride inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.9,1.9,,,,,,
BCBS PPO,CPT,J0350,Injection anistreplase 30 u,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"11,014.86","11,014.86",,,,,,
BCBS PPO,CPT,J0364,Apomorphine hydrochloride,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,17.3,17.3,,,,,,
BCBS PPO,CPT,J0365,Aprotonin- 10-000 kiu,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.44,11.44,,,,,,
BCBS PPO,CPT,J0380,Inj metaraminol bitartrate,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,J0390,Chloroquine injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,83.87,165.22,,,,,,
BCBS PPO,CPT,J0395,Arbutamine hcl injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,777.79,777.79,,,,,,
BCBS PPO,CPT,J0400,Aripiprazole injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.9,1.9,,,,,,
BCBS PPO,CPT,J0401,Inj aripiprazole ext rel 1mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,6.01,7.62,,,,,,
BCBS PPO,CPT,J0470,Dimecaprol injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,129.64,129.64,,,,,,
BCBS PPO,CPT,J0475,Baclofen 10 mg injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,177.43,826.29,,,,,,
BCBS PPO,CPT,J0476,Baclofen intrathecal trial,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,350.76,350.76,,,,,,
BCBS PPO,CPT,J0480,Basiliximab,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"4,013.08","7,724.52",,,,,,
BCBS PPO,CPT,J0500,Dicyclomine injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,87.69,87.69,,,,,,
BCBS PPO,CPT,J0515,Inj benztropine mesylate,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,152.51,152.51,,,,,,
BCBS PPO,CPT,J0520,Bethanechol chloride inject,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,72.44,72.44,,,,,,
BCBS PPO,CPT,J0530,Penicillin g benzathine inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,72.44,72.44,,,,,,
BCBS PPO,CPT,J0540,Penicillin g benzathine inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,167.76,167.76,,,,,,
BCBS PPO,CPT,J0560,Penicillin g benzathine inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,122,122,,,,,,
BCBS PPO,CPT,J0570,Buprenorphine implant 74.2mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,209.7,"1,311.75",,,,,,
BCBS PPO,CPT,J0580,Penicillin g benzathine inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,240.2,240.2,,,,,,
BCBS PPO,CPT,J0583,Bivalirudin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.44,11.44,,,,,,
BCBS PPO,CPT,J0587,Inj- rimabotulinumtoxinb,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.05,39.5,,,,,,
BCBS PPO,CPT,J0592,Buprenorphine hydrochloride,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,J0594,Busulfan injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.71,61,,,,,,
BCBS PPO,CPT,J0600,Edetate calcium disodium inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,362.21,"5,708.59",,,,,,
BCBS PPO,CPT,J0610,Calcium gluconate injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.9,1.9,,,,,,
BCBS PPO,CPT,J0620,Calcium glycer & lact/10 ml,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,41.94,41.94,,,,,,
BCBS PPO,CPT,J0630,Calcitonin salmon injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,191.13,"3,100.79",,,,,,
BCBS PPO,CPT,J0636,Inj calcitriol per 0.1 mcg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,J0637,Caspofungin acetate,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,61,61,,,,,,
BCBS PPO,CPT,J0670,Inj mepivacaine hcl/10 ml,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.62,7.62,,,,,,
BCBS PPO,CPT,J0694,Cefoxitin sodium injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,45.74,45.74,,,,,,
BCBS PPO,CPT,J0698,Cefotaxime sodium injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,19.07,,,,,,
BCBS PPO,CPT,J0702,Betamethasone acet&sod phosp,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,30.51,30.51,,,,,,
BCBS PPO,CPT,J0715,Ceftizoxime sodium / 500 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.7,26.7,,,,,,
BCBS PPO,CPT,J0720,Chloramphenicol sodium injec,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,83.87,83.87,,,,,,
BCBS PPO,CPT,J0735,Clonidine hydrochloride,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,331.7,331.7,,,,,,
BCBS PPO,CPT,J0740,Cidofovir injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,563.76,"3,694.50",,,,,,
BCBS PPO,CPT,J0745,Inj codeine phosphate /30 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.62,135.64,,,,,,
BCBS PPO,CPT,J0760,Colchicine injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,30.51,30.51,,,,,,
BCBS PPO,CPT,J0770,Colistimethate sodium inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,87.69,87.69,,,,,,
BCBS PPO,CPT,J0795,Corticorelin ovine triflutal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,9.67,22.88,,,,,,
BCBS PPO,CPT,J0800,Corticotropin injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"9,315.32","9,315.32",,,,,,
BCBS PPO,CPT,J0835,Inj cosyntropin per 0.25 MG,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,461.34,461.34,,,,,,
BCBS PPO,CPT,J0850,Cytomegalovirus imm iv /vial,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,538.70","4,266.40",,,,,,
BCBS PPO,CPT,J0878,Daptomycin injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,J0881,Darbepoetin alfa- non-esrd,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.15,15.26,,,,,,
BCBS PPO,CPT,J0882,Darbepoetin alfa- esrd use,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.15,15.26,,,,,,
BCBS PPO,CPT,J0885,Epoetin alfa- non-esrd,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,8.15,45.74,,,,,,
BCBS PPO,CPT,J0900,Testosterone enanthate inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.7,5.7,,,,,,
BCBS PPO,CPT,J0945,Brompheniramine maleate inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,J0970,Estradiol valerate injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,171.58,171.58,,,,,,
BCBS PPO,CPT,J1000,Depo-estradiol cypionate inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,30.51,30.51,,,,,,
BCBS PPO,CPT,J1030,Methylprednisolone 40 mg inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,19.07,,,,,,
BCBS PPO,CPT,J1040,Methylprednisolone 80 mg inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.13,38.13,,,,,,
BCBS PPO,CPT,J1050,Medroxyprogesterone acetate,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.31,3.31,,,,,,
BCBS PPO,CPT,J1051,Medroxyprogesterone inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.31,34.31,,,,,,
BCBS PPO,CPT,J1055,Medrxyprogester acetate inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,305.01,305.01,,,,,,
BCBS PPO,CPT,J1056,MA/EC contraceptiveinjection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,110.57,110.57,,,,,,
BCBS PPO,CPT,J1070,Testosterone cypionat 100 MG,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,25.59,25.59,,,,,,
BCBS PPO,CPT,J1080,Testosterone cypionat 200 MG,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,95.55,95.55,,,,,,
BCBS PPO,CPT,J1094,Inj dexamethasone acetate,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.9,1.9,,,,,,
BCBS PPO,CPT,J1120,Acetazolamid sodium injectio,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,160.13,160.13,,,,,,
BCBS PPO,CPT,J1160,Digoxin injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.62,7.62,,,,,,
BCBS PPO,CPT,J1162,Digoxin immune fab (ovine),Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,344.81","4,128.19",,,,,,
BCBS PPO,CPT,J1180,Dyphylline injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.13,38.13,,,,,,
BCBS PPO,CPT,J1190,Dexrazoxane hcl injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,192.33,"1,849.16",,,,,,
BCBS PPO,CPT,J1212,Dimethyl sulfoxide 50% 50 ml,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,339.33,637.11,,,,,,
BCBS PPO,CPT,J1260,Dolasetron mesylate,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.71,15.71,,,,,,
BCBS PPO,CPT,J1270,Injection- doxercalciferol,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.26,15.26,,,,,,
BCBS PPO,CPT,J1300,Eculizumab injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,229.23,679.45,,,,,,
BCBS PPO,CPT,J1320,Amitriptyline injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.44,11.44,,,,,,
BCBS PPO,CPT,J1324,Enfuvirtide injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,129.64,129.64,,,,,,
BCBS PPO,CPT,J1325,Epoprostenol injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,64.85,64.85,,,,,,
BCBS PPO,CPT,J1327,Eptifibatide injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,87.69,87.69,,,,,,
BCBS PPO,CPT,J1335,Ertapenem injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,125.82,125.82,,,,,,
BCBS PPO,CPT,J1364,Erythro lactobionate /500 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.13,77.75,,,,,,
BCBS PPO,CPT,J1380,Estradiol valerate 10 mg inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,49.56,49.56,,,,,,
BCBS PPO,CPT,J1390,Estradiol valerate 20 MG inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,95.32,95.32,,,,,,
BCBS PPO,CPT,J1410,Inj estrogen conjugate 25 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,341.46,381.27,,,,,,
BCBS PPO,CPT,J1430,Ethanolamine oleate 100 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,444.1,728.23,,,,,,
BCBS PPO,CPT,J1435,Injection estrone per 1 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.9,1.9,,,,,,
BCBS PPO,CPT,J1436,Etidronate disodium inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,366.02,366.02,,,,,,
BCBS PPO,CPT,J1438,Etanercept injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,714.31,790.78,,,,,,
BCBS PPO,CPT,J1440,Filgrastim 300 mcg injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,927.93,927.93,,,,,,
BCBS PPO,CPT,J1441,Filgrastim 480 mcg injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,478.04","1,478.04",,,,,,
BCBS PPO,CPT,J1442,Inj filgrastim excl biosimil,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,0.97,3.09,,,,,,
BCBS PPO,CPT,J1446,,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,,,,,,,,
BCBS PPO,CPT,J1447,Inj tbo filgrastim 1 microg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,0.46,3.1,,,,,,
BCBS PPO,CPT,J1451,Fomepizole- 15 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.98,49.56,,,,,,
BCBS PPO,CPT,J1452,Intraocular fomivirsen na,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,029.43","1,029.43",,,,,,
BCBS PPO,CPT,J1453,Fosaprepitant injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,0.24,7.62,,,,,,
BCBS PPO,CPT,J1455,Foscarnet sodium injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,49.56,72.86,,,,,,
BCBS PPO,CPT,J1457,Gallium nitrate injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.62,7.62,,,,,,
BCBS PPO,CPT,J1458,Galsulfase injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,411.92,"1,289.57",,,,,,
BCBS PPO,CPT,J1459,Inj ivig privigen 500 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,44.48,143.18,,,,,,
BCBS PPO,CPT,J1460,Gamma globulin 1 cc inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,44.13,61,,,,,,
BCBS PPO,CPT,J1470,Gamma globulin 2 CC inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,125.82,125.82,,,,,,
BCBS PPO,CPT,J1480,Gamma globulin 3 CC inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,186.82,186.82,,,,,,
BCBS PPO,CPT,J1490,Gamma globulin 4 CC inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,247.83,247.83,,,,,,
BCBS PPO,CPT,J1500,Gamma globulin 5 CC inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,312.64,312.64,,,,,,
BCBS PPO,CPT,J1510,Gamma globulin 6 CC inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,373.65,373.65,,,,,,
BCBS PPO,CPT,J1520,Gamma globulin 7 CC inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,434.65,434.65,,,,,,
BCBS PPO,CPT,J1530,Gamma globulin 8 CC inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,499.47,499.47,,,,,,
BCBS PPO,CPT,J1540,Gamma globulin 9 CC inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,560.47,560.47,,,,,,
BCBS PPO,CPT,J1550,Gamma globulin 10 CC inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,621.47,621.47,,,,,,
BCBS PPO,CPT,J1560,Gamma globulin > 10 cc inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,441.31,621.47,,,,,,
BCBS PPO,CPT,J1561,Gamunex-c/gammaked,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,48.22,158.91,,,,,,
BCBS PPO,CPT,J1562,Vivaglobin- inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.31,34.31,,,,,,
BCBS PPO,CPT,J1565,RSV-ivig,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,80.07,80.07,,,,,,
BCBS PPO,CPT,J1566,Immune globulin- powder,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,65.49,152.51,,,,,,
BCBS PPO,CPT,J1569,Gammagard liquid injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,44.49,171.58,,,,,,
BCBS PPO,CPT,J1570,Ganciclovir sodium injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,217.32,217.32,,,,,,
BCBS PPO,CPT,J1571,Hepagam b im injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,70.94,213.51,,,,,,
BCBS PPO,CPT,J1572,Flebogamma injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,36.8,171.58,,,,,,
BCBS PPO,CPT,J1573,Hepagam b intravenous- inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,71.24,213.51,,,,,,
BCBS PPO,CPT,J1590,Gatifloxacin injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,J1595,Injection glatiramer acetate,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,141.29,298.68,,,,,,
BCBS PPO,CPT,J1600,Gold sodium thiomaleate inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.13,38.13,,,,,,
BCBS PPO,CPT,J1610,Glucagon hydrochloride/1 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,171.74,343.14,,,,,,
BCBS PPO,CPT,J1620,Gonadorelin hydroch/ 100 mcg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,876.92,876.92,,,,,,
BCBS PPO,CPT,J1640,Hemin- 1 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.64,38.13,,,,,,
BCBS PPO,CPT,J1642,Inj heparin sodium per 10 u,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.9,1.9,,,,,,
BCBS PPO,CPT,J1645,Dalteparin sodium,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,53.38,53.38,,,,,,
BCBS PPO,CPT,J1650,Inj enoxaparin sodium,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,28.36,28.36,,,,,,
BCBS PPO,CPT,J1652,Fondaparinux sodium,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,28.48,28.48,,,,,,
BCBS PPO,CPT,J1655,Tinzaparin sodium injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.44,11.44,,,,,,
BCBS PPO,CPT,J1670,Tetanus immune globulin inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,441.7,"1,040.87",,,,,,
BCBS PPO,CPT,J1700,Hydrocortisone acetate inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,J1710,Hydrocortisone sodium ph inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.88,22.88,,,,,,
BCBS PPO,CPT,J1720,Hydrocortisone sodium succ i,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.88,14.88,,,,,,
BCBS PPO,CPT,J1730,Diazoxide injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,541.4,541.4,,,,,,
BCBS PPO,CPT,J1740,Ibandronate sodium injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,37.09,674.85,,,,,,
BCBS PPO,CPT,J1742,Ibutilide fumarate injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,205.06,"1,898.73",,,,,,
BCBS PPO,CPT,J1743,Idursulfase injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,753.57","1,753.57",,,,,,
BCBS PPO,CPT,J1745,Infliximab not biosimil 10mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,39.53,301.32,,,,,,
BCBS PPO,CPT,J1756,Iron sucrose injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,J1785,Injection imiglucerase /unit,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.71,15.71,,,,,,
BCBS PPO,CPT,J1800,Propranolol injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,19.07,,,,,,
BCBS PPO,CPT,J1810,Droperidol/fentanyl inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,30.51,30.51,,,,,,
BCBS PPO,CPT,J1817,Insulin for insulin pump use,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.26,15.26,,,,,,
BCBS PPO,CPT,J1825,Interferon beta-1a,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,262.80","2,262.80",,,,,,
BCBS PPO,CPT,J1830,Interferon beta-1b / .25 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,406.24,538.7,,,,,,
BCBS PPO,CPT,J1835,Itraconazole injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,205.88,205.88,,,,,,
BCBS PPO,CPT,J1850,Kanamycin sulfate 75 mg inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,J1890,Cephalothin sodium injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,41.94,41.94,,,,,,
BCBS PPO,CPT,J1930,Lanreotide injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,67.64,129.64,,,,,,
BCBS PPO,CPT,J1931,Laronidase injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.75,95.46,,,,,,
BCBS PPO,CPT,J1945,Lepirudin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,865.48,865.48,,,,,,
BCBS PPO,CPT,J1950,Leuprolide acetate /3.75 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,406.37","1,525.07",,,,,,
BCBS PPO,CPT,J1953,Levetiracetam injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,J1955,Inj levocarnitine per 1 gm,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,30.51,30.51,,,,,,
BCBS PPO,CPT,J1960,Levorphanol tartrate inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.26,15.26,,,,,,
BCBS PPO,CPT,J1980,Hyoscyamine sulfate inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,49.56,49.56,,,,,,
BCBS PPO,CPT,J1990,Chlordiazepoxide injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,102.95,102.95,,,,,,
BCBS PPO,CPT,J2001,Lidocaine injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.9,1.9,,,,,,
BCBS PPO,CPT,J2010,Lincomycin injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.88,22.88,,,,,,
BCBS PPO,CPT,J2020,Linezolid injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,148.69,148.69,,,,,,
BCBS PPO,CPT,J2170,Mecasermin injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,87.69,87.69,,,,,,
BCBS PPO,CPT,J2180,Meperidine/promethazine inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,19.07,,,,,,
BCBS PPO,CPT,J2210,Methylergonovin maleate inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.7,26.7,,,,,,
BCBS PPO,CPT,J2275,Morphine sulfate injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.26,15.26,,,,,,
BCBS PPO,CPT,J2278,Ziconotide injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,8.69,30.51,,,,,,
BCBS PPO,CPT,J2310,Inj naloxone hydrochloride,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.88,22.88,,,,,,
BCBS PPO,CPT,J2320,Nandrolone decanoate 50 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,19.07,,,,,,
BCBS PPO,CPT,J2321,Nandrolone decanoate 100 MG,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.31,34.31,,,,,,
BCBS PPO,CPT,J2322,Nandrolone decanoate 200 MG,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,72.44,72.44,,,,,,
BCBS PPO,CPT,J2323,Natalizumab injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,23.24,103.45,,,,,,
BCBS PPO,CPT,J2325,Nesiritide injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,167.76,167.76,,,,,,
BCBS PPO,CPT,J2353,Octreotide injection- depot,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,205.37,408.99,,,,,,
BCBS PPO,CPT,J2354,Octreotide inj- non-depot,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.62,7.62,,,,,,
BCBS PPO,CPT,J2357,Omalizumab injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,37.67,70.74,,,,,,
BCBS PPO,CPT,J2360,Orphenadrine injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.13,38.13,,,,,,
BCBS PPO,CPT,J2410,Oxymorphone hcl injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.44,11.44,,,,,,
BCBS PPO,CPT,J2460,Oxytetracycline injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,J2469,Palonosetron hcl,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,83.87,83.87,,,,,,
BCBS PPO,CPT,J2501,Paricalcitol,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,19.07,,,,,,
BCBS PPO,CPT,J2503,Pegaptanib sodium injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,983.27","3,983.27",,,,,,
BCBS PPO,CPT,J2504,Pegademase bovine- 25 iu,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,4.06,"1,098.07",,,,,,
BCBS PPO,CPT,J2505,Injection- pegfilgrastim 6mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,221.63","10,481.09",,,,,,
BCBS PPO,CPT,J2513,Pentastarch 10% solution,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,61,61,,,,,,
BCBS PPO,CPT,J2543,Piperacillin/tazobactam,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.7,26.7,,,,,,
BCBS PPO,CPT,J2545,Pentamidine non-comp unit,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,205.88,205.88,,,,,,
BCBS PPO,CPT,J2650,Prednisolone acetate inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.9,1.9,,,,,,
BCBS PPO,CPT,J2670,Totazoline hcl injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.26,15.26,,,,,,
BCBS PPO,CPT,J2675,Inj progesterone per 50 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.62,7.62,,,,,,
BCBS PPO,CPT,J2680,Fluphenazine decanoate 25 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.7,26.7,,,,,,
BCBS PPO,CPT,J2710,Neostigmine methylslfte inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.9,1.9,,,,,,
BCBS PPO,CPT,J2720,Inj protamine sulfate/10 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,J2724,Protein c concentrate,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.13,61,,,,,,
BCBS PPO,CPT,J2725,Inj protirelin per 250 mcg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,106.76,106.76,,,,,,
BCBS PPO,CPT,J2730,Pralidoxime chloride inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,446.08,446.08,,,,,,
BCBS PPO,CPT,J2760,Phentolaine mesylate inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,255.45,416,,,,,,
BCBS PPO,CPT,J2770,Quinupristin/dalfopristin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,444.67,712.98,,,,,,
BCBS PPO,CPT,J2780,Ranitidine hydrochloride inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.62,7.62,,,,,,
BCBS PPO,CPT,J2783,Rasburicase,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,315.06,804.48,,,,,,
BCBS PPO,CPT,J2785,Regadenoson injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,244.01,244.01,,,,,,
BCBS PPO,CPT,J2788,Rho d immune globulin 50 mcg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,129.64,129.64,,,,,,
BCBS PPO,CPT,J2790,Rho d immune globulin inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,424.36,424.36,,,,,,
BCBS PPO,CPT,J2791,Rhophylac injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.7,26.7,,,,,,
BCBS PPO,CPT,J2792,Rho(d) immune globulin h- sd,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,31.42,80.07,,,,,,
BCBS PPO,CPT,J2794,Inj risperdal consta- 0.5 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.04,19.71,,,,,,
BCBS PPO,CPT,J2795,Ropivacaine hcl injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.9,1.9,,,,,,
BCBS PPO,CPT,J2800,Methocarbamol injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,122,122,,,,,,
BCBS PPO,CPT,J2805,Sincalide injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,297.39,297.39,,,,,,
BCBS PPO,CPT,J2810,Inj theophylline per 40 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.9,1.9,,,,,,
BCBS PPO,CPT,J2820,Sargramostim injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,51.55,122,,,,,,
BCBS PPO,CPT,J2850,Inj secretin synthetic human,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.78,129.64,,,,,,
BCBS PPO,CPT,J2910,Aurothioglucose injeciton,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,118.19,118.19,,,,,,
BCBS PPO,CPT,J2916,Na ferric gluconate complex,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.88,22.88,,,,,,
BCBS PPO,CPT,J2940,Somatrem injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,205.88,205.88,,,,,,
BCBS PPO,CPT,J2941,Somatropin injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,36.54,226.93,,,,,,
BCBS PPO,CPT,J2993,Reteplase injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,506.51","4,712.48",,,,,,
BCBS PPO,CPT,J2995,Inj streptokinase /250000 iu,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.09,385.09,,,,,,
BCBS PPO,CPT,J2997,Alteplase recombinant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,87.75,163.95,,,,,,
BCBS PPO,CPT,J3000,Streptomycin injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.31,34.31,,,,,,
BCBS PPO,CPT,J3030,Sumatriptan succinate / 6 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,411.78,411.78,,,,,,
BCBS PPO,CPT,J3070,Pentazocine injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.13,38.13,,,,,,
BCBS PPO,CPT,J3101,Tenecteplase injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,134.74,202.07,,,,,,
BCBS PPO,CPT,J3110,Teriparatide injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,39.16,39.16,,,,,,
BCBS PPO,CPT,J3130,Testosterone enanthate inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,66.26,66.26,,,,,,
BCBS PPO,CPT,J3150,Testosteron propionate inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,J3230,Chlorpromazine hcl injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.13,38.13,,,,,,
BCBS PPO,CPT,J3240,Thyrotropin injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,837.25","3,617.49",,,,,,
BCBS PPO,CPT,J3243,Tigecycline injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.12,3.82,,,,,,
BCBS PPO,CPT,J3250,Trimethobenzamide hcl inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.88,22.88,,,,,,
BCBS PPO,CPT,J3265,Injection torsemide 10 mg/ml,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.44,11.44,,,,,,
BCBS PPO,CPT,J3280,Thiethylperazine maleate inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.88,22.88,,,,,,
BCBS PPO,CPT,J3285,Treprostinil injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,59.68,238.44,,,,,,
BCBS PPO,CPT,J3301,Triamcinolone acet inj nos,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.62,7.62,,,,,,
BCBS PPO,CPT,J3305,Inj trimetrexate glucoronate,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,728.23,728.23,,,,,,
BCBS PPO,CPT,J3310,Perphenazine injeciton,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.26,15.26,,,,,,
BCBS PPO,CPT,J3320,Spectinomycn di-hcl inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,144.88,144.88,,,,,,
BCBS PPO,CPT,J3355,Urofollitropin- 75 iu,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,265.1,265.1,,,,,,
BCBS PPO,CPT,J3365,Urokinase 250-000 iu inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,222.79","2,222.79",,,,,,
BCBS PPO,CPT,J3396,Verteporfin injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.25,37.64,,,,,,
BCBS PPO,CPT,J3400,Triflupromazine hcl inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,57.19,57.19,,,,,,
BCBS PPO,CPT,J3430,Vitamin k phytonadione inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,19.07,,,,,,
BCBS PPO,CPT,J3465,Injection- voriconazole,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.7,26.7,,,,,,
BCBS PPO,CPT,J3472,Ovine- 1000 usp units,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,621.47,621.47,,,,,,
BCBS PPO,CPT,J3473,Hyaluronidase recombinant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,J3486,Ziprasidone mesylate,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.7,26.7,,,,,,
BCBS PPO,CPT,J3487,Zoledronic acid,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,851.58,851.58,,,,,,
BCBS PPO,CPT,J3488,Reclast injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,840.55,840.55,,,,,,
BCBS PPO,CPT,J3489,Zoledronic acid 1mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,851.58,851.58,,,,,,
BCBS PPO,CPT,J3520,Edetate disodium per 150 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,J3535,Metered dose inhaler drug,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,57.19,57.19,,,,,,
BCBS PPO,CPT,J7100,Dextran 40 infusion,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,102.95,102.95,,,,,,
BCBS PPO,CPT,J7110,Dextran 75 infusion,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,83.87,83.87,,,,,,
BCBS PPO,CPT,J7186,Antihemophilic viii/vwf comp,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.14,3.82,,,,,,
BCBS PPO,CPT,J7187,Humate-p- inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.26,2.98,,,,,,
BCBS PPO,CPT,J7190,Factor viii,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.12,3.02,,,,,,
BCBS PPO,CPT,J7191,Factor viii (porcine),Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.62,7.62,,,,,,
BCBS PPO,CPT,J7192,Factor viii recombinant nos,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.43,3.85,,,,,,
BCBS PPO,CPT,J7193,Factor ix non-recombinant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.17,3.36,,,,,,
BCBS PPO,CPT,J7194,Factor ix complex,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.54,2.52,,,,,,
BCBS PPO,CPT,J7195,Factor ix recombinant nos,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.61,3.57,,,,,,
BCBS PPO,CPT,J7197,Antithrombin iii injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.2,10.61,,,,,,
BCBS PPO,CPT,J7198,Anti-inhibitor,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,2.21,5.2,,,,,,
BCBS PPO,CPT,J7300,Intraut copper contraceptive,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,883.47","1,883.47",,,,,,
BCBS PPO,CPT,J7303,Contraceptive vaginal ring,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,122,122,,,,,,
BCBS PPO,CPT,J7304,Contraceptive hormone patch,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,49.56,49.56,,,,,,
BCBS PPO,CPT,J7307,Etonogestrel implant system,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,836.65","2,836.65",,,,,,
BCBS PPO,CPT,J7310,Ganciclovir long act implant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"82,354.16","82,354.16",,,,,,
BCBS PPO,CPT,J7311,Inj.- retisert- 0.01 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,339,"93,937.12",,,,,,
BCBS PPO,CPT,J7321,Hyalgan supartz visco-3 dose,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,480.55,480.55,,,,,,
BCBS PPO,CPT,J7322,Hymovis injection 1 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,31.67,903.6,,,,,,
BCBS PPO,CPT,J7323,Euflexxa inj per dose,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,138.82,590.67,,,,,,
BCBS PPO,CPT,J7324,Orthovisc inj per dose,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,148.74,880.74,,,,,,
BCBS PPO,CPT,J7330,Cultured chondrocytes implnt,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"117,621.56","117,621.56",,,,,,
BCBS PPO,CPT,J7500,Azathioprine oral 50mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.9,1.9,,,,,,
BCBS PPO,CPT,J7501,Azathioprine parenteral,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,245.02,442.27,,,,,,
BCBS PPO,CPT,J7503,Tacrol envarsus ex rel oral,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.91,3.91,,,,,,
BCBS PPO,CPT,J7504,Lymphocyte immune globulin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,245.67","2,355.53",,,,,,
BCBS PPO,CPT,J7505,Monoclonal antibodies,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"5,223.39","5,223.39",,,,,,
BCBS PPO,CPT,J7506,Prednisone oral,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.9,1.9,,,,,,
BCBS PPO,CPT,J7507,Tacrolimus imme rel oral 1mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.71,15.71,,,,,,
BCBS PPO,CPT,J7508,Tacrol astagraf ex rel oral,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.56,1.56,,,,,,
BCBS PPO,CPT,J7511,Antithymocyte globuln rabbit,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,837.42,"1,807.23",,,,,,
BCBS PPO,CPT,J7512,Prednisone ir or dr oral 1mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,0.38,0.38,,,,,,
BCBS PPO,CPT,J7513,Daclizumab- parenteral,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,730.97","1,730.97",,,,,,
BCBS PPO,CPT,J7516,Cyclosporin parenteral 250mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,81.79,81.79,,,,,,
BCBS PPO,CPT,J7518,Mycophenolic acid,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.82,11.82,,,,,,
BCBS PPO,CPT,J7520,Sirolimus- oral,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,33.59,33.59,,,,,,
BCBS PPO,CPT,J7525,Tacrolimus injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,219.33,540.46,,,,,,
BCBS PPO,CPT,J7605,Arformoterol non-comp unit,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.88,22.88,,,,,,
BCBS PPO,CPT,J7606,Formoterol fumarate- inh,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.88,22.88,,,,,,
BCBS PPO,CPT,J7608,Acetylcysteine non-comp unit,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.62,7.62,,,,,,
BCBS PPO,CPT,J7611,Albuterol non-comp con,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.9,1.9,,,,,,
BCBS PPO,CPT,J7626,Budesonide non-comp unit,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.7,26.7,,,,,,
BCBS PPO,CPT,J7631,Cromolyn sodium noncomp unit,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,J7639,Dornase alfa non-comp unit,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,91.86,91.86,,,,,,
BCBS PPO,CPT,J7669,Metaproterenol non-comp unit,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.9,1.9,,,,,,
BCBS PPO,CPT,J7674,Methacholine chloride- neb,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,J7682,Tobramycin non-comp unit,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,308.83,308.83,,,,,,
BCBS PPO,CPT,J8501,Oral aprepitant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.7,26.7,,,,,,
BCBS PPO,CPT,J8510,Oral busulfan,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.26,15.26,,,,,,
BCBS PPO,CPT,J8515,Cabergoline- oral 0.25mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,61,61,,,,,,
BCBS PPO,CPT,J8520,Capecitabine- oral- 150 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,23.4,23.4,,,,,,
BCBS PPO,CPT,J8521,Capecitabine- oral- 500 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,78.02,78.02,,,,,,
BCBS PPO,CPT,J8530,Cyclophosphamide oral 25 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,J8540,Oral dexamethasone,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.9,1.9,,,,,,
BCBS PPO,CPT,J8565,Gefitinib oral,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,228.45,228.45,,,,,,
BCBS PPO,CPT,J8600,Melphalan oral 2 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.88,22.88,,,,,,
BCBS PPO,CPT,J8610,Methotrexate oral 2.5 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.9,1.9,,,,,,
BCBS PPO,CPT,J8650,Nabilone oral,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.26,76.26,,,,,,
BCBS PPO,CPT,J8700,Temozolomide,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,32.68,32.68,,,,,,
BCBS PPO,CPT,J8705,Topotecan oral,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,331.7,331.7,,,,,,
BCBS PPO,CPT,J9001,Doxorubicin hcl liposome inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,719.01","1,719.01",,,,,,
BCBS PPO,CPT,J9002,,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,,,,,,,,
BCBS PPO,CPT,J9010,Alemtuzumab injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,771.83","2,771.83",,,,,,
BCBS PPO,CPT,J9017,Arsenic trioxide injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,13.11,179.2,,,,,,
BCBS PPO,CPT,J9020,Asparaginase- nos,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,282.14,282.14,,,,,,
BCBS PPO,CPT,J9025,Azacitidine injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,0.93,22.88,,,,,,
BCBS PPO,CPT,J9027,Clofarabine injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,53.15,564.29,,,,,,
BCBS PPO,CPT,J9030,Bcg live intravesical 1mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.51,11.51,,,,,,
BCBS PPO,CPT,J9031,Bcg live intravesical vac,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,575.73,575.73,,,,,,
BCBS PPO,CPT,J9033,Inj.- treanda 1 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.01,91.51,,,,,,
BCBS PPO,CPT,J9035,Bevacizumab injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,70.41,278.32,,,,,,
BCBS PPO,CPT,J9041,Inj.- velcade 0.1 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,45.16,175.39,,,,,,
BCBS PPO,CPT,J9055,Cetuximab injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,66.71,240.2,,,,,,
BCBS PPO,CPT,J9060,Cisplatin 10 mg injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,134.21,134.21,,,,,,
BCBS PPO,CPT,J9062,Cisplatin 50 MG injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,61,61,,,,,,
BCBS PPO,CPT,J9065,Inj cladribine per 1 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,18.02,144.88,,,,,,
BCBS PPO,CPT,J9070,Cyclophosphamide 100 mg inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,29.15,,,,,,
BCBS PPO,CPT,J9080,Cyclophosphamide 200 MG inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.31,34.31,,,,,,
BCBS PPO,CPT,J9090,Cyclophosphamide 500 MG inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,91.51,91.51,,,,,,
BCBS PPO,CPT,J9091,Cyclophosphamide 1.0 grm inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,179.2,179.2,,,,,,
BCBS PPO,CPT,J9092,Cyclophosphamide 2.0 grm inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,362.21,362.21,,,,,,
BCBS PPO,CPT,J9093,Cyclophosphamide lyophilized,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.44,11.44,,,,,,
BCBS PPO,CPT,J9096,Cyclophosphamide lyophilized,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,106.76,106.76,,,,,,
BCBS PPO,CPT,J9097,Cyclophosphamide lyophilized,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,217.32,217.32,,,,,,
BCBS PPO,CPT,J9098,Cytarabine liposome inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,177.05","2,177.05",,,,,,
BCBS PPO,CPT,J9120,Dactinomycin injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,890.64,"2,634.57",,,,,,
BCBS PPO,CPT,J9130,Dacarbazine 100 mg inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,19.07,,,,,,
BCBS PPO,CPT,J9140,Dacarbazine 200 MG inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.13,38.13,,,,,,
BCBS PPO,CPT,J9150,Daunorubicin injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,40.36,80.07,,,,,,
BCBS PPO,CPT,J9151,Daunorubicin citrate inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,270.71,270.71,,,,,,
BCBS PPO,CPT,J9165,Diethylstilbestrol injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,57.19,57.19,,,,,,
BCBS PPO,CPT,J9170,Docetaxel,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,423.47","1,423.47",,,,,,
BCBS PPO,CPT,J9175,Elliotts b solution per ml,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,19.07,,,,,,
BCBS PPO,CPT,J9178,Inj- epirubicin hcl- 2 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,98.98,98.98,,,,,,
BCBS PPO,CPT,J9185,Fludarabine phosphate inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,716.79,716.79,,,,,,
BCBS PPO,CPT,J9199,"Injection, infugem, 200 mg",Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,548.88,548.88,,,,,,
BCBS PPO,CPT,J9200,Floxuridine injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,282.14,282.14,,,,,,
BCBS PPO,CPT,J9201,In gemcitabine hcl nos 200mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,548.88,548.88,,,,,,
BCBS PPO,CPT,J9202,Goserelin acetate implant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,525.21,915.04,,,,,,
BCBS PPO,CPT,J9206,Irinotecan injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,482.59,482.59,,,,,,
BCBS PPO,CPT,J9207,Ixabepilone injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,112.12,308.83,,,,,,
BCBS PPO,CPT,J9209,Mesna injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,80.07,80.07,,,,,,
BCBS PPO,CPT,J9211,Idarubicin hcl injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,629.1,629.1,,,,,,
BCBS PPO,CPT,J9212,Interferon alfacon-1 inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,27.26,27.26,,,,,,
BCBS PPO,CPT,J9214,Interferon alfa-2b inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,33.24,72.44,,,,,,
BCBS PPO,CPT,J9215,Interferon alfa-n3 inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,41.94,41.94,,,,,,
BCBS PPO,CPT,J9216,Interferon gamma 1-b inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,772.90","1,772.90",,,,,,
BCBS PPO,CPT,J9217,Leuprolide acetate suspnsion,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,139.09,987.49,,,,,,
BCBS PPO,CPT,J9219,Leuprolide acetate implant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"23,402.31","23,402.31",,,,,,
BCBS PPO,CPT,J9225,Vantas implant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"5,166.29","7,613.94",,,,,,
BCBS PPO,CPT,J9226,Supprelin la implant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"43,467.03","71,949.32",,,,,,
BCBS PPO,CPT,J9230,Mechlorethamine hcl inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.74,712.98,,,,,,
BCBS PPO,CPT,J9245,Inj melpha hydroch nos 50 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,208.41,"7,888.46",,,,,,
BCBS PPO,CPT,J9261,Nelarabine injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,155.9,488.04,,,,,,
BCBS PPO,CPT,J9263,Oxaliplatin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,45.74,45.74,,,,,,
BCBS PPO,CPT,J9264,Paclitaxel protein bound,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.08,45.74,,,,,,
BCBS PPO,CPT,J9266,Pegaspargase injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"12,715.34","21,561.05",,,,,,
BCBS PPO,CPT,J9268,Pentostatin injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,880.67","7,030.61",,,,,,
BCBS PPO,CPT,J9270,Plicamycin (mithramycin) inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,115.4,385.09,,,,,,
BCBS PPO,CPT,J9280,Mitomycin injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.63,76.26,,,,,,
BCBS PPO,CPT,J9290,Mitomycin 20 MG inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,305.01,305.01,,,,,,
BCBS PPO,CPT,J9291,Mitomycin 40 MG inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,610.03,610.03,,,,,,
BCBS PPO,CPT,J9293,Mitoxantrone hydrochl / 5 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.29,392.7,,,,,,
BCBS PPO,CPT,J9305,Inj. pemetrexed nos 10mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,74.93,232.58,,,,,,
BCBS PPO,CPT,J9310,Rituximab injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,096.91","2,096.91",,,,,,
BCBS PPO,CPT,J9320,Streptozocin injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,348.51,"1,372.57",,,,,,
BCBS PPO,CPT,J9340,Thiotepa injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,305.84,446.08,,,,,,
BCBS PPO,CPT,J9350,Topotecan injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"4,647.67","4,647.67",,,,,,
BCBS PPO,CPT,J9351,Topotecan injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,116.21,116.21,,,,,,
BCBS PPO,CPT,J9355,Inj trastuzumab excl biosimi,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,89.81,238.1,,,,,,
BCBS PPO,CPT,J9357,Valrubicin injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,425.37","1,795.78",,,,,,
BCBS PPO,CPT,J9370,Vincristine sulfate 1 mg inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,28.22,28.22,,,,,,
BCBS PPO,CPT,J9371,Inj- vincristine sul lip 1mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,28.22,"3,370.23",,,,,,
BCBS PPO,CPT,J9380,Vincristine sulfate 5 MG inj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,141.07,141.07,,,,,,
BCBS PPO,CPT,J9395,Injection- fulvestrant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.98,396.52,,,,,,
BCBS PPO,CPT,J9600,Porfimer sodium injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"13,169.04","21,856.35",,,,,,
BCBS PPO,CPT,K0552,Sup/ext non-ins inf pump syr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.44,11.44,,,,,,
BCBS PPO,CPT,K0609,Repl electrode for aed,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,225.54","3,225.54",,,,,,
BCBS PPO,CPT,L0112,Cranial cervical orthosis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,404.96","4,830.68",,,,,,
BCBS PPO,CPT,L0120,Cerv flex n/adj foam pre ots,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.55,91.51,,,,,,
BCBS PPO,CPT,L0130,Flex thermoplastic collar mo,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,153.23,526.16,,,,,,
BCBS PPO,CPT,L0140,Cervical semi-rigid adjustab,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,60.09,205.88,,,,,,
BCBS PPO,CPT,L0150,Cerv semi-rig adj molded chn,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,107.45,369.83,,,,,,
BCBS PPO,CPT,L0160,Cerv sr wire occ/man pre ots,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,156.89,541.4,,,,,,
BCBS PPO,CPT,L0170,Cervical collar molded to pt,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,807.1,"2,775.65",,,,,,
BCBS PPO,CPT,L0172,Cerv col sr foam 2pc pre ots,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,142.17,488.04,,,,,,
BCBS PPO,CPT,L0174,Cerv sr 2pc thor ext pre ots,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,279.55,960.8,,,,,,
BCBS PPO,CPT,L0180,Cer post col occ/man sup adj,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,452.88,"1,559.39",,,,,,
BCBS PPO,CPT,L0190,Cerv collar supp adj cerv ba,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,534.12,"1,837.71",,,,,,
BCBS PPO,CPT,L0200,Cerv col supp adj bar & thor,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,619.54,"2,131.30",,,,,,
BCBS PPO,CPT,L0220,Thor rib belt custom fabrica,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,129.68,446.08,,,,,,
BCBS PPO,CPT,L0430,Dewall posture protector,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"5,261.52","5,261.52",,,,,,
BCBS PPO,CPT,L0450,Tlso flex trunk/thor pre ots,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,128.11,560.47,,,,,,
BCBS PPO,CPT,L0454,Tlso trnk sj-t9 pre cst,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,348.14,"1,197.20",,,,,,
BCBS PPO,CPT,L0456,Tlso flex trnk sj-ss pre cst,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,998.38,"3,435.25",,,,,,
BCBS PPO,CPT,L0458,Tlso 2mod symphis-xipho pre,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,895.27,"3,080.66",,,,,,
BCBS PPO,CPT,L0460,Tlso 2 shl symphys-stern cst,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,007.68","3,465.73",,,,,,
BCBS PPO,CPT,L0462,Tlso 3mod sacro-scap pre,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,253.37","4,312.16",,,,,,
BCBS PPO,CPT,L0464,Tlso 4mod sacro-scap pre,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,492.13","5,131.88",,,,,,
BCBS PPO,CPT,L0466,Tlso r fram soft ant pre cst,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,380.86,"1,311.56",,,,,,
BCBS PPO,CPT,L0468,Tlso rig fram pelvic pre cst,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,477.29,"1,643.28",,,,,,
BCBS PPO,CPT,L0470,Tlso rigid frame pre subclav,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,660.47,"2,272.36",,,,,,
BCBS PPO,CPT,L0472,Tlso rigid frame hyperex pre,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,406.41,"1,399.26",,,,,,
BCBS PPO,CPT,L0480,Tlso rigid plastic custom fa,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,516.23","5,215.77",,,,,,
BCBS PPO,CPT,L0482,Tlso rigid lined custom fab,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,693.64","5,825.80",,,,,,
BCBS PPO,CPT,L0484,Tlso rigid plastic cust fab,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,829.06","6,290.94",,,,,,
BCBS PPO,CPT,L0486,Tlso rigidlined cust fab two,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,054.11","7,064.92",,,,,,
BCBS PPO,CPT,L0488,Tlso rigid lined pre one pie,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,007.68","3,465.73",,,,,,
BCBS PPO,CPT,L0490,Tlso rigid plastic pre one,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,283.96,976.05,,,,,,
BCBS PPO,CPT,L0491,Tlso 2 piece rigid shell,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,770.93,"2,649.83",,,,,,
BCBS PPO,CPT,L0492,Tlso 3 piece rigid shell,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,502.01,"1,727.15",,,,,,
BCBS PPO,CPT,L0621,Sio flex pelvic/sacr pre ots,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,67.68,446.08,,,,,,
BCBS PPO,CPT,L0622,Sio flex pelvisacral custom,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,268.31,"1,384.01",,,,,,
BCBS PPO,CPT,L0625,Lo flex l1-below l5 pre ots,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,39.58,285.96,,,,,,
BCBS PPO,CPT,L0626,Lo sag rig pnl stays pre cst,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,78.25,404.14,,,,,,
BCBS PPO,CPT,L0627,Lo sag ri an/pos pnl pre cst,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,412.59,"2,127.49",,,,,,
BCBS PPO,CPT,L0628,Lso flex no ri stays pre ots,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,60.27,434.65,,,,,,
BCBS PPO,CPT,L0630,Lso r post pnl sj-t9 pre cst,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,162.59,838.79,,,,,,
BCBS PPO,CPT,L0631,Lso sag r an/pos pnl pre cst,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,030.49","5,314.90",,,,,,
BCBS PPO,CPT,L0633,Lso sc r pos/lat pnl pre cst,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,287.85,"1,483.14",,,,,,
BCBS PPO,CPT,L0635,Lso sagit rigid panel prefab,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,003.05","5,173.83",,,,,,
BCBS PPO,CPT,L0636,Lso sagittal rigid panel cus,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,360.98","7,019.17",,,,,,
BCBS PPO,CPT,L0637,Lso sc r ant/pos pnl pre cst,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,300.47","6,710.34",,,,,,
BCBS PPO,CPT,L0638,Lso sag-coronal panel custom,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,323.97","6,828.54",,,,,,
BCBS PPO,CPT,L0639,Lso s/c shell/panel prefab,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,300.47","6,710.34",,,,,,
BCBS PPO,CPT,L0640,Lso s/c shell/panel custom,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,050.39","5,417.84",,,,,,
BCBS PPO,CPT,L0700,Ctlso a-p-l control molded,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,998.37","6,874.29",,,,,,
BCBS PPO,CPT,L0710,Ctlso a-p-l control w/ inter,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,196.75","7,552.94",,,,,,
BCBS PPO,CPT,L0810,Halo cervical into jckt vest,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,683.14","9,226.72",,,,,,
BCBS PPO,CPT,L0820,Halo cervical into body jack,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,110.65","7,259.37",,,,,,
BCBS PPO,CPT,L0830,Halo cerv into milwaukee typ,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,229.60","11,106.37",,,,,,
BCBS PPO,CPT,L0859,Mri compatible system,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,143.45","3,930.89",,,,,,
BCBS PPO,CPT,L0861,Halo repl liner/interface,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,216.37,743.48,,,,,,
BCBS PPO,CPT,L0970,Tlso corset front,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,107.27,369.83,,,,,,
BCBS PPO,CPT,L0972,Lso corset front,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,97.64,335.53,,,,,,
BCBS PPO,CPT,L0974,Tlso full corset,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,175.42,602.41,,,,,,
BCBS PPO,CPT,L0978,Axillary crutch extension,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,188.9,648.16,,,,,,
BCBS PPO,CPT,L0980,Peroneal straps pair pre ots,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,17.15,57.19,,,,,,
BCBS PPO,CPT,L0982,Stocking sup grips 4 pre ots,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.7,53.38,,,,,,
BCBS PPO,CPT,L0984,Protect body sock ea pre ots,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,67.93,232.58,,,,,,
BCBS PPO,CPT,L1000,Ctlso milwauke initial model,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,035.53","7,000.10",,,,,,
BCBS PPO,CPT,L1005,Tension based scoliosis orth,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,212.88","11,049.19",,,,,,
BCBS PPO,CPT,L1010,Ctlso axilla sling,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,83.99,289.76,,,,,,
BCBS PPO,CPT,L1020,Kyphosis pad,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,108.17,373.65,,,,,,
BCBS PPO,CPT,L1025,Kyphosis pad floating,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,156.06,537.6,,,,,,
BCBS PPO,CPT,L1030,Lumbar bolster pad,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,78.6,270.71,,,,,,
BCBS PPO,CPT,L1040,Lumbar or lumbar rib pad,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,89,305.01,,,,,,
BCBS PPO,CPT,L1050,Sternal pad,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,100.72,346.96,,,,,,
BCBS PPO,CPT,L1060,Thoracic pad,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,108.72,373.65,,,,,,
BCBS PPO,CPT,L1070,Trapezius sling,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,112.62,388.89,,,,,,
BCBS PPO,CPT,L1080,Outrigger,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,52.52,179.2,,,,,,
BCBS PPO,CPT,L1085,Outrigger bil w/ vert extens,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,175.83,606.21,,,,,,
BCBS PPO,CPT,L1090,Lumbar sling,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,101.01,346.96,,,,,,
BCBS PPO,CPT,L1100,Ring flange plastic/leather,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,190.64,655.78,,,,,,
BCBS PPO,CPT,L1110,Ring flange plas/leather mol,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,319.63,"1,098.07",,,,,,
BCBS PPO,CPT,L1120,Covers for upright each,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.18,129.64,,,,,,
BCBS PPO,CPT,L1200,Furnsh initial orthosis only,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,796.37","6,176.57",,,,,,
BCBS PPO,CPT,L1210,Lateral thoracic extension,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,245.6,846.41,,,,,,
BCBS PPO,CPT,L1220,Anterior thoracic extension,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,239.05,823.54,,,,,,
BCBS PPO,CPT,L1230,Milwaukee type superstructur,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,669.67,"2,302.87",,,,,,
BCBS PPO,CPT,L1240,Lumbar derotation pad,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,91.29,312.64,,,,,,
BCBS PPO,CPT,L1250,Anterior asis pad,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,79.39,274.51,,,,,,
BCBS PPO,CPT,L1260,Anterior thoracic derotation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,94.68,324.09,,,,,,
BCBS PPO,CPT,L1270,Abdominal pad,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,83.2,285.96,,,,,,
BCBS PPO,CPT,L1280,Rib gusset (elastic) each,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,87.71,301.2,,,,,,
BCBS PPO,CPT,L1290,Lateral trochanteric pad,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,78,266.89,,,,,,
BCBS PPO,CPT,L1300,Body jacket mold to patient,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,730.06","5,951.62",,,,,,
BCBS PPO,CPT,L1310,Post-operative body jacket,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,802.00","6,195.63",,,,,,
BCBS PPO,CPT,L1500,Thkao mobility frame,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"6,664.59","6,664.59",,,,,,
BCBS PPO,CPT,L1510,Thkao standing frame,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"4,106.27","4,106.27",,,,,,
BCBS PPO,CPT,L1520,Thkao swivel walker,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"7,362.31","7,362.31",,,,,,
BCBS PPO,CPT,L1600,Ho flex frejka w/cov pre cst,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,129.35,446.08,,,,,,
BCBS PPO,CPT,L1610,Ho frejka cov only pre cst,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,54.94,190.64,,,,,,
BCBS PPO,CPT,L1620,Ho flex pavlik harns pre cst,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,157.73,541.4,,,,,,
BCBS PPO,CPT,L1630,Abduct control hip semi-flex,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,212.06,728.23,,,,,,
BCBS PPO,CPT,L1640,Pelv band/spread bar thigh c,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,475.2,"1,635.64",,,,,,
BCBS PPO,CPT,L1650,Ho abduction hip adjustable,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,247.55,850.23,,,,,,
BCBS PPO,CPT,L1652,Ho bi thighcuffs w sprdr bar,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,357.83,"1,231.50",,,,,,
BCBS PPO,CPT,L1660,Ho abduction static plastic,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,181.4,625.29,,,,,,
BCBS PPO,CPT,L1680,Pelvic & hip control thigh c,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,143.62","3,934.69",,,,,,
BCBS PPO,CPT,L1685,Post-op hip abduct custom fa,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,116.47","3,839.39",,,,,,
BCBS PPO,CPT,L1686,Ho post-op hip abduction,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,940.6,"3,233.17",,,,,,
BCBS PPO,CPT,L1690,Combination bilateral ho,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,941.15","6,676.03",,,,,,
BCBS PPO,CPT,L1700,Leg perthes orth toronto typ,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,561.78","5,372.08",,,,,,
BCBS PPO,CPT,L1710,Legg perthes orth newington,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,988.75","6,839.98",,,,,,
BCBS PPO,CPT,L1720,Legg perthes orthosis trilat,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,480.82","5,093.76",,,,,,
BCBS PPO,CPT,L1730,Legg perthes orth scottish r,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,250.14","4,300.73",,,,,,
BCBS PPO,CPT,L1755,Legg perthes patten bottom t,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,797.35","6,180.39",,,,,,
BCBS PPO,CPT,L1800,Knee orthoses elas w stays,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,217.32,217.32,,,,,,
BCBS PPO,CPT,L1825,Ko elastic knee cap,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,205.88,205.88,,,,,,
BCBS PPO,CPT,L1830,Ko immob canvas long pre ots,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,71.04,285.96,,,,,,
BCBS PPO,CPT,L1831,Knee orth pos locking joint,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,295.44,"1,017.99",,,,,,
BCBS PPO,CPT,L1832,Ko adj jnt pos r sup pre cst,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,691.44,"2,379.12",,,,,,
BCBS PPO,CPT,L1834,Ko w/0 joint rigid molded to,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,728.61,"2,504.94",,,,,,
BCBS PPO,CPT,L1840,Ko derot ant cruciate custom,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,944,"3,248.41",,,,,,
BCBS PPO,CPT,L1843,Ko single upright pre cst,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,900.7,"3,095.90",,,,,,
BCBS PPO,CPT,L1844,Ko w/adj jt rot cntrl molded,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,528.66","5,257.70",,,,,,
BCBS PPO,CPT,L1847,Ko dbl upright w/air pre cst,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,577.37,"1,986.41",,,,,,
BCBS PPO,CPT,L1850,Ko swedish type pre ots,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,234.85,983.68,,,,,,
BCBS PPO,CPT,L1860,Ko supracondylar socket mold,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,251.75","4,304.53",,,,,,
BCBS PPO,CPT,L1900,Afo sprng wir drsflx calf bd,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,286.39,983.68,,,,,,
BCBS PPO,CPT,L1901,Prefab ankle orthosis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,61,61,,,,,,
BCBS PPO,CPT,L1902,Afo ankle gauntlet pre ots,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,74.93,259.27,,,,,,
BCBS PPO,CPT,L1904,Afo molded ankle gauntlet,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,453.09,"1,559.39",,,,,,
BCBS PPO,CPT,L1906,Afo multilig ank sup pre ots,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,112.88,388.89,,,,,,
BCBS PPO,CPT,L1907,Afo supramalleolar custom,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,564.86,"1,944.48",,,,,,
BCBS PPO,CPT,L1910,Afo sing bar clasp attach sh,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,281.51,968.43,,,,,,
BCBS PPO,CPT,L1920,Afo sing upright w/ adjust s,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,412.37,"1,418.32",,,,,,
BCBS PPO,CPT,L1930,Afo plastic,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,252.89,869.3,,,,,,
BCBS PPO,CPT,L1932,Afo rig ant tib prefab tcf/=,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,895.75,"3,080.66",,,,,,
BCBS PPO,CPT,L1940,Afo molded to patient plasti,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,488.84,"1,681.40",,,,,,
BCBS PPO,CPT,L1945,Afo molded plas rig ant tib,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,126.77","3,873.69",,,,,,
BCBS PPO,CPT,L1950,Afo spiral molded to pt plas,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,772,"2,653.63",,,,,,
BCBS PPO,CPT,L1951,Afo spiral prefabricated,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,843.02,"2,897.65",,,,,,
BCBS PPO,CPT,L1960,Afo pos solid ank plastic mo,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,622.25,"2,138.93",,,,,,
BCBS PPO,CPT,L1970,Afo plastic molded w/ankle j,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,694.78,"2,390.56",,,,,,
BCBS PPO,CPT,L1971,Afo w/ankle joint- prefab,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,470.55,"1,616.58",,,,,,
BCBS PPO,CPT,L1980,Afo sing solid stirrup calf,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,405.31,"1,395.45",,,,,,
BCBS PPO,CPT,L1990,Afo doub solid stirrup calf,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,469.1,"1,612.76",,,,,,
BCBS PPO,CPT,L2000,Kafo sing fre stirr thi/calf,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,122.95","3,862.25",,,,,,
BCBS PPO,CPT,L2005,Kafo sng/dbl mechanical act,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"4,113.39","14,145.09",,,,,,
BCBS PPO,CPT,L2006,Kaf sng/dbl swg/stn mcpr cus,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"14,145.09","14,145.09",,,,,,
BCBS PPO,CPT,L2010,Kafo sng solid stirrup w/o j,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,875.89,"3,012.03",,,,,,
BCBS PPO,CPT,L2020,Kafo dbl solid stirrup band/,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,106.22","3,805.07",,,,,,
BCBS PPO,CPT,L2030,Kafo dbl solid stirrup w/o j,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,087.33","3,740.26",,,,,,
BCBS PPO,CPT,L2034,Kafo pla sin up w/wo k/a cus,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,039.24","7,011.54",,,,,,
BCBS PPO,CPT,L2035,Kafo plastic pediatric size,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,173.91,598.59,,,,,,
BCBS PPO,CPT,L2036,Kafo plas doub free knee mol,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,861.04","6,401.51",,,,,,
BCBS PPO,CPT,L2037,Kafo plas sing free knee mol,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,664.67","5,726.65",,,,,,
BCBS PPO,CPT,L2038,Kafo w/o joint multi-axis an,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,341.97","4,613.36",,,,,,
BCBS PPO,CPT,L2040,Hkafo torsion bil rot straps,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,203.08,697.72,,,,,,
BCBS PPO,CPT,L2050,Hkafo torsion cable hip pelv,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,489.17,"1,681.40",,,,,,
BCBS PPO,CPT,L2060,Hkafo torsion ball bearing j,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,611.86,"2,104.61",,,,,,
BCBS PPO,CPT,L2070,Hkafo torsion unilat rot str,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,155.8,537.6,,,,,,
BCBS PPO,CPT,L2080,Hkafo unilat torsion cable,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,374.61,"1,288.69",,,,,,
BCBS PPO,CPT,L2090,Hkafo unilat torsion ball br,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,499.12,"1,715.71",,,,,,
BCBS PPO,CPT,L2106,Afo tib fx cast plaster mold,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,791.23,"2,722.27",,,,,,
BCBS PPO,CPT,L2108,Afo tib fx cast molded to pt,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,154.03","3,969.02",,,,,,
BCBS PPO,CPT,L2112,Afo tibial fracture soft,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,506.43,"1,742.41",,,,,,
BCBS PPO,CPT,L2126,Kafo fem fx cast thermoplas,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,281.77","4,407.46",,,,,,
BCBS PPO,CPT,L2128,Kafo fem fx cast molded to p,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,609.47","5,536.03",,,,,,
BCBS PPO,CPT,L2132,Kafo femoral fx cast soft,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,976.92,"3,358.99",,,,,,
BCBS PPO,CPT,L2134,Kafo fem fx cast semi-rigid,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,156.80","3,976.64",,,,,,
BCBS PPO,CPT,L2136,Kafo femoral fx cast rigid,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,265.95","4,354.09",,,,,,
BCBS PPO,CPT,L2180,Plas shoe insert w ank joint,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,133.08,457.52,,,,,,
BCBS PPO,CPT,L2182,Drop lock knee,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.71,392.7,,,,,,
BCBS PPO,CPT,L2184,Limited motion knee joint,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,116.27,400.34,,,,,,
BCBS PPO,CPT,L2186,Adj motion knee jnt lerman t,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,154.63,529.96,,,,,,
BCBS PPO,CPT,L2188,Quadrilateral brim,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,281.1,968.43,,,,,,
BCBS PPO,CPT,L2190,Waist belt,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,85.62,293.57,,,,,,
BCBS PPO,CPT,L2192,Pelvic band & belt thigh fla,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,334.67,"1,151.42",,,,,,
BCBS PPO,CPT,L2200,Limited ankle motion ea jnt,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,50.44,175.39,,,,,,
BCBS PPO,CPT,L2210,Dorsiflexion assist each joi,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,63.09,217.32,,,,,,
BCBS PPO,CPT,L2220,Dorsi & plantar flex ass/res,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,81.22,278.32,,,,,,
BCBS PPO,CPT,L2230,Split flat caliper stirr & p,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,96.02,331.7,,,,,,
BCBS PPO,CPT,L2232,Rocker bottom- contact afo,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,97.51,335.53,,,,,,
BCBS PPO,CPT,L2240,Round caliper and plate atta,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,95.58,327.9,,,,,,
BCBS PPO,CPT,L2250,Foot plate molded stirrup at,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,335.3,"1,151.42",,,,,,
BCBS PPO,CPT,L2260,Reinforced solid stirrup,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,188.16,648.16,,,,,,
BCBS PPO,CPT,L2265,Long tongue stirrup,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,134.94,465.15,,,,,,
BCBS PPO,CPT,L2270,Varus/valgus strap padded/li,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,61.87,213.51,,,,,,
BCBS PPO,CPT,L2275,Plastic mod low ext pad/line,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,130.85,449.9,,,,,,
BCBS PPO,CPT,L2280,Molded inner boot,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,566.69,"1,948.29",,,,,,
BCBS PPO,CPT,L2300,Abduction bar jointed adjust,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,252.72,869.3,,,,,,
BCBS PPO,CPT,L2310,Abduction bar-straight,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,115.47,396.52,,,,,,
BCBS PPO,CPT,L2320,Non-molded lacer,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,193.64,667.22,,,,,,
BCBS PPO,CPT,L2330,Lacer molded to patient mode,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,368.55,"1,265.81",,,,,,
BCBS PPO,CPT,L2335,Anterior swing band,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,282.18,972.25,,,,,,
BCBS PPO,CPT,L2340,Pre-tibial shell molded to p,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,419.5,"1,441.20",,,,,,
BCBS PPO,CPT,L2350,Prosthetic type socket molde,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,836.35,"2,874.78",,,,,,
BCBS PPO,CPT,L2360,Extended steel shank,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,51.76,179.2,,,,,,
BCBS PPO,CPT,L2370,Patten bottom,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,321.26,"1,105.68",,,,,,
BCBS PPO,CPT,L2375,Torsion ank & half solid sti,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,123.52,423.22,,,,,,
BCBS PPO,CPT,L2380,Torsion straight knee joint,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,129.54,446.08,,,,,,
BCBS PPO,CPT,L2385,Straight knee joint heavy du,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,147.5,507.08,,,,,,
BCBS PPO,CPT,L2387,Add le poly knee custom kafo,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,191.63,659.6,,,,,,
BCBS PPO,CPT,L2390,Offset knee joint each,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,102.75,354.58,,,,,,
BCBS PPO,CPT,L2395,Offset knee joint heavy duty,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,146.86,503.28,,,,,,
BCBS PPO,CPT,L2397,Suspension sleeve lower ext,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,122.52,423.22,,,,,,
BCBS PPO,CPT,L2405,Knee joint drop lock ea jnt,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,87.52,301.2,,,,,,
BCBS PPO,CPT,L2415,Knee joint cam lock each joi,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,121.95,419.4,,,,,,
BCBS PPO,CPT,L2425,Knee disc/dial lock/adj flex,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,143.9,495.65,,,,,,
BCBS PPO,CPT,L2430,Knee jnt ratchet lock ea jnt,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,143.9,495.65,,,,,,
BCBS PPO,CPT,L2492,Knee lift loop drop lock rin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,117.74,404.14,,,,,,
BCBS PPO,CPT,L2500,Thi/glut/ischia wgt bearing,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,314.13,"1,078.99",,,,,,
BCBS PPO,CPT,L2510,Th/wght bear quad-lat brim m,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,809.6,"2,783.26",,,,,,
BCBS PPO,CPT,L2520,Th/wght bear quad-lat brim c,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,539.56,"1,856.79",,,,,,
BCBS PPO,CPT,L2525,Th/wght bear nar m-l brim mo,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,144.16","3,934.69",,,,,,
BCBS PPO,CPT,L2526,Th/wght bear nar m-l brim cu,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,642.9,"2,211.37",,,,,,
BCBS PPO,CPT,L2530,Thigh/wght bear lacer non-mo,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,240.74,827.35,,,,,,
BCBS PPO,CPT,L2540,Thigh/wght bear lacer molded,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,455.54,"1,567.02",,,,,,
BCBS PPO,CPT,L2550,Thigh/wght bear high roll cu,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,341.55,"1,174.31",,,,,,
BCBS PPO,CPT,L2570,Hip clevis type 2 posit jnt,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,447.07,"1,536.51",,,,,,
BCBS PPO,CPT,L2580,Pelvic control pelvic sling,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,435.62,"1,498.39",,,,,,
BCBS PPO,CPT,L2600,Hip clevis/thrust bearing fr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,214.1,735.85,,,,,,
BCBS PPO,CPT,L2610,Hip clevis/thrust bearing lo,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,236.58,812.11,,,,,,
BCBS PPO,CPT,L2620,Pelvic control hip heavy dut,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,250.96,861.67,,,,,,
BCBS PPO,CPT,L2622,Hip joint adjustable flexion,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,319.42,"1,098.07",,,,,,
BCBS PPO,CPT,L2624,Hip adj flex ext abduct cont,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,391.68,"1,345.89",,,,,,
BCBS PPO,CPT,L2627,Plastic mold recipro hip & c,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,145.41","7,377.56",,,,,,
BCBS PPO,CPT,L2628,Metal frame recipro hip & ca,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,572.54","5,406.41",,,,,,
BCBS PPO,CPT,L2630,Pelvic control band & belt u,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,232.43,800.67,,,,,,
BCBS PPO,CPT,L2640,Pelvic control band & belt b,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,315.42,"1,086.62",,,,,,
BCBS PPO,CPT,L2650,Pelv & thor control gluteal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,138.91,476.6,,,,,,
BCBS PPO,CPT,L2660,Thoracic control thoracic ba,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,179.86,617.65,,,,,,
BCBS PPO,CPT,L2670,Thorac cont paraspinal uprig,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,160.11,549.03,,,,,,
BCBS PPO,CPT,L2680,Thorac cont lat support upri,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,146.88,503.28,,,,,,
BCBS PPO,CPT,L2750,Plating chrome/nickel pr bar,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,78.45,270.71,,,,,,
BCBS PPO,CPT,L2755,Carbon graphite lamination,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,131.16,449.9,,,,,,
BCBS PPO,CPT,L2760,Extension per extension per,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,57.03,194.45,,,,,,
BCBS PPO,CPT,L2768,Ortho sidebar disconnect,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,130.78,449.9,,,,,,
BCBS PPO,CPT,L2770,Low ext orthosis per bar/jnt,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,198.25,198.25,,,,,,
BCBS PPO,CPT,L2780,Non-corrosive finish,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,63.53,217.32,,,,,,
BCBS PPO,CPT,L2785,Drop lock retainer each,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,29.75,102.95,,,,,,
BCBS PPO,CPT,L2795,Knee control full kneecap,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82.32,282.14,,,,,,
BCBS PPO,CPT,L2810,Knee control condylar pad,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,81.98,282.14,,,,,,
BCBS PPO,CPT,L2820,Soft interface below knee se,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,81.51,282.14,,,,,,
BCBS PPO,CPT,L2830,Soft interface above knee se,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,88.18,305.01,,,,,,
BCBS PPO,CPT,L2840,Tibial length sock fx or equ,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,43.3,148.69,,,,,,
BCBS PPO,CPT,L2850,Femoral lgth sock fx or equa,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,60.72,209.7,,,,,,
BCBS PPO,CPT,L3000,Ft insert ucb berkeley shell,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,315.34,"1,082.81",,,,,,
BCBS PPO,CPT,L3001,Foot insert remov molded spe,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,132.78,686.28,,,,,,
BCBS PPO,CPT,L3002,Foot insert plastazote or eq,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,162.12,834.98,,,,,,
BCBS PPO,CPT,L3003,Foot insert silicone gel eac,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,174.89,903.6,,,,,,
BCBS PPO,CPT,L3010,Foot longitudinal arch suppo,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,174.89,903.6,,,,,,
BCBS PPO,CPT,L3020,Foot longitud/metatarsal sup,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,199.16,"1,025.61",,,,,,
BCBS PPO,CPT,L3030,Foot arch support remov prem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.59,"1,239.13",,,,,,
BCBS PPO,CPT,L3031,Foot lamin/prepreg composite,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,122.94,"1,334.45",,,,,,
BCBS PPO,CPT,L3040,Ft arch suprt premold longit,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,47.25,163.95,,,,,,
BCBS PPO,CPT,L3050,Foot arch supp premold metat,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,47.25,163.95,,,,,,
BCBS PPO,CPT,L3060,Foot arch supp longitud/meta,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,74.04,255.45,,,,,,
BCBS PPO,CPT,L3070,Arch suprt att to sho longit,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,31.91,110.57,,,,,,
BCBS PPO,CPT,L3080,Arch supp att to shoe metata,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,31.91,110.57,,,,,,
BCBS PPO,CPT,L3090,Arch supp att to shoe long/m,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,40.86,141.07,,,,,,
BCBS PPO,CPT,L3100,Hallus-valgus nt dyn pre ots,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,43.43,148.69,,,,,,
BCBS PPO,CPT,L3140,Abduction rotation bar shoe,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,89.37,308.83,,,,,,
BCBS PPO,CPT,L3150,Abduct rotation bar w/o shoe,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,81.72,282.14,,,,,,
BCBS PPO,CPT,L3160,Shoe styled positioning dev,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,541.4,541.4,,,,,,
BCBS PPO,CPT,L3170,Foot plas heel stabi pre ots,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,51.06,175.39,,,,,,
BCBS PPO,CPT,L3201,Oxford w supinat/pronat inf,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,266.89,266.89,,,,,,
BCBS PPO,CPT,L3202,Oxford w/ supinat/pronator c,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,427.03,427.03,,,,,,
BCBS PPO,CPT,L3203,Oxford w/ supinator/pronator,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,266.89,266.89,,,,,,
BCBS PPO,CPT,L3204,Hightop w/ supp/pronator inf,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,495.65,495.65,,,,,,
BCBS PPO,CPT,L3206,Hightop w/ supp/pronator chi,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,339.33,339.33,,,,,,
BCBS PPO,CPT,L3207,Hightop w/ supp/pronator jun,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,343.14,343.14,,,,,,
BCBS PPO,CPT,L3208,Surgical boot each infant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,247.83,247.83,,,,,,
BCBS PPO,CPT,L3209,Surgical boot each child,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,171.58,171.58,,,,,,
BCBS PPO,CPT,L3211,Surgical boot each junior,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,156.32,156.32,,,,,,
BCBS PPO,CPT,L3212,Benesch boot pair infant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,247.83,247.83,,,,,,
BCBS PPO,CPT,L3213,Benesch boot pair child,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,285.96,285.96,,,,,,
BCBS PPO,CPT,L3214,Benesch boot pair junior,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,381.27,381.27,,,,,,
BCBS PPO,CPT,L3215,Orthopedic ftwear ladies oxf,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,762.54,762.54,,,,,,
BCBS PPO,CPT,L3216,Orthoped ladies shoes dpth i,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,430.83,430.83,,,,,,
BCBS PPO,CPT,L3217,Ladies shoes hightop depth i,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,381.27,381.27,,,,,,
BCBS PPO,CPT,L3221,Orthopedic mens shoes dpth i,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,953.17,953.17,,,,,,
BCBS PPO,CPT,L3224,Woman's shoe oxford brace,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,67.83,232.58,,,,,,
BCBS PPO,CPT,L3225,Man's shoe oxford brace,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,74.09,255.45,,,,,,
BCBS PPO,CPT,L3250,Custom mold shoe remov prost,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,906.36","1,906.36",,,,,,
BCBS PPO,CPT,L3253,Shoe molded plastazote cust,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,190.64,190.64,,,,,,
BCBS PPO,CPT,L3254,Orth foot non-stndard size/w,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,133.45,133.45,,,,,,
BCBS PPO,CPT,L3255,Orth foot non-standard size/,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,133.45,133.45,,,,,,
BCBS PPO,CPT,L3257,Orth foot add charge split s,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,247.83,247.83,,,,,,
BCBS PPO,CPT,L3260,Ambulatory surgical boot eac,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,190.64,190.64,,,,,,
BCBS PPO,CPT,L3265,Plastazote sandal each,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,133.45,133.45,,,,,,
BCBS PPO,CPT,L3300,Sho lift taper to metatarsal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,52.35,179.2,,,,,,
BCBS PPO,CPT,L3310,Shoe lift elev heel/sole neo,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,81.72,282.14,,,,,,
BCBS PPO,CPT,L3320,Shoe lift elev heel/sole cor,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,45.74,45.74,,,,,,
BCBS PPO,CPT,L3330,Lifts elevation metal extens,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,568.1,"1,952.10",,,,,,
BCBS PPO,CPT,L3332,Shoe lifts tapered to one-ha,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,74.04,255.45,,,,,,
BCBS PPO,CPT,L3334,Shoe lifts elevation heel /i,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.28,133.45,,,,,,
BCBS PPO,CPT,L3340,Shoe wedge sach,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,85.56,293.57,,,,,,
BCBS PPO,CPT,L3350,Shoe heel wedge,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.96,80.07,,,,,,
BCBS PPO,CPT,L3360,Shoe sole wedge outside sole,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,35.74,122,,,,,,
BCBS PPO,CPT,L3370,Shoe sole wedge between sole,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,49.79,171.58,,,,,,
BCBS PPO,CPT,L3380,Shoe clubfoot wedge,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,49.79,171.58,,,,,,
BCBS PPO,CPT,L3390,Shoe outflare wedge,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,49.79,171.58,,,,,,
BCBS PPO,CPT,L3400,Shoe metatarsal bar wedge ro,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,40.86,141.07,,,,,,
BCBS PPO,CPT,L3410,Shoe metatarsal bar between,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,93.19,320.27,,,,,,
BCBS PPO,CPT,L3420,Full sole/heel wedge btween,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,54.9,190.64,,,,,,
BCBS PPO,CPT,L3430,Sho heel count plast reinfor,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,160.86,552.84,,,,,,
BCBS PPO,CPT,L3440,Heel leather reinforced,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.59,263.08,,,,,,
BCBS PPO,CPT,L3455,Shoe heel new leather standa,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,40.86,141.07,,,,,,
BCBS PPO,CPT,L3460,Shoe heel new rubber standar,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.49,118.19,,,,,,
BCBS PPO,CPT,L3465,Shoe heel thomas with wedge,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,58.76,202.07,,,,,,
BCBS PPO,CPT,L3470,Shoe heel thomas extend to b,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,62.54,213.51,,,,,,
BCBS PPO,CPT,L3480,Shoe heel pad & depress for,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,62.54,213.51,,,,,,
BCBS PPO,CPT,L3485,Shoe heel pad removable for,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,190.64,190.64,,,,,,
BCBS PPO,CPT,L3500,Ortho shoe add leather insol,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,29.35,99.13,,,,,,
BCBS PPO,CPT,L3510,Orthopedic shoe add rub insl,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,29.35,99.13,,,,,,
BCBS PPO,CPT,L3520,O shoe add felt w leath insl,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,31.91,110.57,,,,,,
BCBS PPO,CPT,L3530,Ortho shoe add half sole,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,31.91,110.57,,,,,,
BCBS PPO,CPT,L3540,Ortho shoe add full sole,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,51.06,175.39,,,,,,
BCBS PPO,CPT,L3550,O shoe add standard toe tap,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,8.97,30.51,,,,,,
BCBS PPO,CPT,L3560,O shoe add horseshoe toe tap,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.96,80.07,,,,,,
BCBS PPO,CPT,L3570,O shoe add instep extension,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,85.56,293.57,,,,,,
BCBS PPO,CPT,L3580,O shoe add instep velcro clo,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,65.11,224.95,,,,,,
BCBS PPO,CPT,L3590,O shoe convert to sof counte,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,53.63,183.02,,,,,,
BCBS PPO,CPT,L3595,Ortho shoe add march bar,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,42.1,144.88,,,,,,
BCBS PPO,CPT,L3600,Trans shoe calip plate exist,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.59,263.08,,,,,,
BCBS PPO,CPT,L3610,Trans shoe caliper plate new,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,100.86,346.96,,,,,,
BCBS PPO,CPT,L3620,Trans shoe solid stirrup exi,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.59,263.08,,,,,,
BCBS PPO,CPT,L3630,Trans shoe solid stirrup new,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,100.86,346.96,,,,,,
BCBS PPO,CPT,L3640,Shoe dennis browne splint bo,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,43.43,148.69,,,,,,
BCBS PPO,CPT,L3650,So 8 abd restraint pre ots,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,65.83,224.95,,,,,,
BCBS PPO,CPT,L3651,Prefab shoulder orthosis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,205.88,205.88,,,,,,
BCBS PPO,CPT,L3652,Prefab dbl shoulder orthosis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,625.29,625.29,,,,,,
BCBS PPO,CPT,L3660,So 8 ab rstr can/web pre ots,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,94.4,324.09,,,,,,
BCBS PPO,CPT,L3670,So acro/clav can web pre ots,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,103.86,358.39,,,,,,
BCBS PPO,CPT,L3671,So cap design w/o jnts cf,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,823.17,"2,832.83",,,,,,
BCBS PPO,CPT,L3672,SO airplane w/o jnts CF,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,519.12","3,519.12",,,,,,
BCBS PPO,CPT,L3673,SO airplane w/joint CF,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,835.57","3,835.57",,,,,,
BCBS PPO,CPT,L3675,So vest canvas/web pre ots,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,160.35,552.84,,,,,,
BCBS PPO,CPT,L3700,Elbow orthoses elas w stays,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,240.2,240.2,,,,,,
BCBS PPO,CPT,L3701,Prefab elbow orthosis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,64.82,64.82,,,,,,
BCBS PPO,CPT,L3702,Eo w/o joints cf,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,263.81,907.42,,,,,,
BCBS PPO,CPT,L3710,Eo elas w/metal jnts pre ots,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,130.45,449.9,,,,,,
BCBS PPO,CPT,L3720,Forearm/arm cuffs free motio,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,624.22,"2,146.54",,,,,,
BCBS PPO,CPT,L3730,Forearm/arm cuffs ext/flex a,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,827.96,"2,848.08",,,,,,
BCBS PPO,CPT,L3740,Cuffs adj lock w/ active con,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,981.62,"3,374.24",,,,,,
BCBS PPO,CPT,L3760,Eo adj jt prefab custom fit,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,456.89,"1,570.83",,,,,,
BCBS PPO,CPT,L3762,Eo rigid w/o joints pre ots,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,98.22,339.33,,,,,,
BCBS PPO,CPT,L3763,Ewho rigid w/o jnts cf,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,683.66,"2,352.44",,,,,,
BCBS PPO,CPT,L3764,Ewho w/joint(s) cf,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,715.47,"2,459.19",,,,,,
BCBS PPO,CPT,L3765,Ewhfo rigid w/o jnts cf,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,171.43","4,030.02",,,,,,
BCBS PPO,CPT,L3766,Ewhfo w/joint(s) cf,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,240.47","4,266.40",,,,,,
BCBS PPO,CPT,L3806,Whfo w/joint(s) custom fab,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,414.97,"1,425.95",,,,,,
BCBS PPO,CPT,L3807,Whfo w/o joints pre cst,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,228.43,785.42,,,,,,
BCBS PPO,CPT,L3808,Whfo- rigid w/o joints,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,325.43,"1,120.94",,,,,,
BCBS PPO,CPT,L3900,Hinge extension/flex wrist/f,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,479.93","5,089.95",,,,,,
BCBS PPO,CPT,L3901,Hinge ext/flex wrist finger,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,939.53","6,668.40",,,,,,
BCBS PPO,CPT,L3904,Whfo electric custom fitted,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,083.64","10,603.11",,,,,,
BCBS PPO,CPT,L3905,Who w/nontorsion jnt(s) cf,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,905.97,"3,114.97",,,,,,
BCBS PPO,CPT,L3906,Who w/o joints cf,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,462.97,"1,593.72",,,,,,
BCBS PPO,CPT,L3908,Who cock-up nonmolde pre ots,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,66.98,228.77,,,,,,
BCBS PPO,CPT,L3909,Prefab wrist orthosis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,45.74,45.74,,,,,,
BCBS PPO,CPT,L3911,Prefab hand finger orthosis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.26,76.26,,,,,,
BCBS PPO,CPT,L3912,Hfo flexion glove pre ots,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,96.25,331.7,,,,,,
BCBS PPO,CPT,L3913,Hfo w/o joints cf,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,247.41,850.23,,,,,,
BCBS PPO,CPT,L3915,Who nontorsion jnts pre cst,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,485.63,"1,669.97",,,,,,
BCBS PPO,CPT,L3917,Metacarp fx orthosis pre cst,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,96.47,331.7,,,,,,
BCBS PPO,CPT,L3919,Ho w/o joints cf,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,247.41,850.23,,,,,,
BCBS PPO,CPT,L3921,Hfo w/joint(s) cf,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,293.46,"1,010.37",,,,,,
BCBS PPO,CPT,L3923,Hfo without joints pre cst,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,88.25,305.01,,,,,,
BCBS PPO,CPT,L3925,Fo pip dip jnt/sprng pre ots,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,60.01,205.88,,,,,,
BCBS PPO,CPT,L3927,Fo pip dip no jt spr pre ots,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,31.98,110.57,,,,,,
BCBS PPO,CPT,L3929,Hfo nontorsion jnts pre cst,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,83.44,285.96,,,,,,
BCBS PPO,CPT,L3931,Whfo nontorsion joint prefab,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,190.48,655.78,,,,,,
BCBS PPO,CPT,L3933,Fo w/o joints cf,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,194.93,671.03,,,,,,
BCBS PPO,CPT,L3935,Fo nontorsion joint cf,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,201.82,693.9,,,,,,
BCBS PPO,CPT,L3960,Sewho airplan desig abdu pos,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,728.64,"2,504.94",,,,,,
BCBS PPO,CPT,L3961,Sewho cap design w/o jnts cf,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,534.92","5,280.58",,,,,,
BCBS PPO,CPT,L3962,Sewho erbs palsey design abd,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,659,"2,264.75",,,,,,
BCBS PPO,CPT,L3967,Sewho airplane w/o jnts cf,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,812.20","6,233.76",,,,,,
BCBS PPO,CPT,L3971,Sewho cap design w/jnt(s) cf,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,720.20","5,917.29",,,,,,
BCBS PPO,CPT,L3973,Sewho airplane w/jnt(s) cf,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,812.20","6,233.76",,,,,,
BCBS PPO,CPT,L3975,Sewhfo cap design w/o jnt cf,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,534.92","5,280.58",,,,,,
BCBS PPO,CPT,L3976,Sewhfo airplane w/o jnts cf,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,534.92","5,280.58",,,,,,
BCBS PPO,CPT,L3977,Sewhfo cap desgn w/jnt(s) cf,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,720.20","5,917.29",,,,,,
BCBS PPO,CPT,L3978,Sewhfo airplane w/jnt(s) cf,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,812.20","6,233.76",,,,,,
BCBS PPO,CPT,L3980,Up ext fx orthos humeral nos,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,353.43,"1,216.24",,,,,,
BCBS PPO,CPT,L3982,Upper ext fx orthosis rad/ul,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,358.87,"1,235.32",,,,,,
BCBS PPO,CPT,L3984,Upper ext fx orthosis wrist,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,316.13,"1,086.62",,,,,,
BCBS PPO,CPT,L3995,Sock fracture or equal each,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,37.51,129.64,,,,,,
BCBS PPO,CPT,L4000,Repl girdle milwaukee orth,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,326.47","4,559.97",,,,,,
BCBS PPO,CPT,L4002,Replace strap- any orthosis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.39,114.39,,,,,,
BCBS PPO,CPT,L4010,Replace trilateral socket br,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,806.25,"2,771.83",,,,,,
BCBS PPO,CPT,L4020,Replace quadlat socket brim,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,968.52,"3,332.30",,,,,,
BCBS PPO,CPT,L4030,Replace socket brim cust fit,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,615.47,"2,116.06",,,,,,
BCBS PPO,CPT,L4040,Replace molded thigh lacer,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,416.8,"1,433.58",,,,,,
BCBS PPO,CPT,L4045,Replace non-molded thigh lac,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,307.89,"1,059.93",,,,,,
BCBS PPO,CPT,L4050,Replace molded calf lacer,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,412.8,"1,418.32",,,,,,
BCBS PPO,CPT,L4055,Replace non-molded calf lace,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,250.92,861.67,,,,,,
BCBS PPO,CPT,L4060,Replace high roll cuff,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,326.17,"1,120.94",,,,,,
BCBS PPO,CPT,L4070,Replace prox & dist upright,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,264.15,907.42,,,,,,
BCBS PPO,CPT,L4080,Repl met band kafo-afo prox,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,99.72,343.14,,,,,,
BCBS PPO,CPT,L4090,Repl met band kafo-afo calf/,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,84.84,293.57,,,,,,
BCBS PPO,CPT,L4100,Repl leath cuff kafo prox th,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,101.94,350.76,,,,,,
BCBS PPO,CPT,L4110,Repl leath cuff kafo-afo cal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,79.6,274.51,,,,,,
BCBS PPO,CPT,L4130,Replace pretibial shell,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,481.14,"1,654.72",,,,,,
BCBS PPO,CPT,L4205,Ortho dvc repair per 15 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,701.54,701.54,,,,,,
BCBS PPO,CPT,L4210,Orth dev repair/repl minor p,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,362.21,362.21,,,,,,
BCBS PPO,CPT,L4350,Ankle control ortho pre ots,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,97.13,335.53,,,,,,
BCBS PPO,CPT,L4360,Pneumat walking boot pre cst,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,259.89,892.18,,,,,,
BCBS PPO,CPT,L4370,Pneum full leg splnt pre ots,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,236.26,812.11,,,,,,
BCBS PPO,CPT,L4380,Pneumatic knee splint,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,396.52,396.52,,,,,,
BCBS PPO,CPT,L4386,Non-pneum walk boot pre cst,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,159.16,549.03,,,,,,
BCBS PPO,CPT,L4392,Replace afo soft interface,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,23.62,80.07,,,,,,
BCBS PPO,CPT,L4394,Replace foot drop spint,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,17.23,61,,,,,,
BCBS PPO,CPT,L4396,Static or dynami afo pre cst,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,168.46,579.53,,,,,,
BCBS PPO,CPT,L4398,Foot drop splint pre ots,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,77.54,266.89,,,,,,
BCBS PPO,CPT,L5000,Sho insert w arch toe filler,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,576.42,"1,982.60",,,,,,
BCBS PPO,CPT,L5010,Mold socket ank hgt w/ toe f,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,610.60","5,539.84",,,,,,
BCBS PPO,CPT,L5020,Tibial tubercle hgt w/ toe f,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,523.29","8,677.68",,,,,,
BCBS PPO,CPT,L5050,Ank symes mold sckt sach ft,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,755.91","9,478.35",,,,,,
BCBS PPO,CPT,L5060,Symes met fr leath socket ar,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,397.24","11,682.09",,,,,,
BCBS PPO,CPT,L5100,Molded socket shin sach foot,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,744.12","9,436.43",,,,,,
BCBS PPO,CPT,L5105,Plast socket jts/thgh lacer,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,872.55","13,317.74",,,,,,
BCBS PPO,CPT,L5150,Mold sckt ext knee shin sach,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"4,305.35","14,804.69",,,,,,
BCBS PPO,CPT,L5160,Mold socket bent knee shin s,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"4,727.07","16,257.32",,,,,,
BCBS PPO,CPT,L5200,Kne sing axis fric shin sach,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,656.04","12,574.26",,,,,,
BCBS PPO,CPT,L5210,No knee/ankle joints w/ ft b,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,902.89","9,981.64",,,,,,
BCBS PPO,CPT,L5220,No knee joint with artic ali,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,197.74","10,995.81",,,,,,
BCBS PPO,CPT,L5230,Fem focal defic constant fri,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"4,796.11","16,493.71",,,,,,
BCBS PPO,CPT,L5250,Hip canad sing axi cons fric,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"5,623.57","19,341.79",,,,,,
BCBS PPO,CPT,L5270,Tilt table locking hip sing,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"6,265.76","21,549.33",,,,,,
BCBS PPO,CPT,L5280,Hemipelvect canad sing axis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"6,090.55","20,946.94",,,,,,
BCBS PPO,CPT,L5301,Bk mold socket sach ft endo,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,694.66","9,268.66",,,,,,
BCBS PPO,CPT,L5311,"Knee disart, SACH ft, endo",Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"14,602.61","14,602.61",,,,,,
BCBS PPO,CPT,L5321,Ak open end sach,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,593.24","12,356.94",,,,,,
BCBS PPO,CPT,L5331,Hip disart canadian sach ft,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"5,262.80","18,098.85",,,,,,
BCBS PPO,CPT,L5341,Hemipelvectomy canadian sach,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"5,594.28","19,238.85",,,,,,
BCBS PPO,CPT,L5400,Postop dress & 1 cast chg bk,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,604.68","5,516.97",,,,,,
BCBS PPO,CPT,L5410,Postop dsg bk ea add cast ch,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,443.32,"1,525.07",,,,,,
BCBS PPO,CPT,L5420,Postop dsg & 1 cast chg ak/d,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,026.64","6,969.60",,,,,,
BCBS PPO,CPT,L5430,Postop dsg ak ea add cast ch,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,550.12,"1,891.10",,,,,,
BCBS PPO,CPT,L5450,Postop app non-wgt bear dsg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,475.67,"1,635.64",,,,,,
BCBS PPO,CPT,L5460,Postop app non-wgt bear dsg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,623.89,"2,146.54",,,,,,
BCBS PPO,CPT,L5500,Init bk ptb plaster direct,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,483.19","5,101.39",,,,,,
BCBS PPO,CPT,L5505,Init ak ischal plstr direct,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,086.44","7,175.49",,,,,,
BCBS PPO,CPT,L5510,Prep bk ptb plaster molded,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,771.18","6,092.69",,,,,,
BCBS PPO,CPT,L5520,Perp bk ptb thermopls direct,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,587.65","5,459.77",,,,,,
BCBS PPO,CPT,L5530,Prep bk ptb thermopls molded,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,087.07","7,179.30",,,,,,
BCBS PPO,CPT,L5535,Prep bk ptb open end socket,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,945.59","6,691.29",,,,,,
BCBS PPO,CPT,L5540,Prep bk ptb laminated socket,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,060.66","7,087.80",,,,,,
BCBS PPO,CPT,L5560,Prep ak ischial plast molded,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,348.01","8,075.28",,,,,,
BCBS PPO,CPT,L5570,Prep ak ischial direct form,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,278.83","7,838.89",,,,,,
BCBS PPO,CPT,L5580,Prep ak ischial thermo mold,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,828.36","9,726.18",,,,,,
BCBS PPO,CPT,L5585,Prep ak ischial open end,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,312.24","11,392.33",,,,,,
BCBS PPO,CPT,L5590,Prep ak ischial laminated,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,948.85","10,141.77",,,,,,
BCBS PPO,CPT,L5595,Hip disartic sach thermopls,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"4,608.29","15,849.36",,,,,,
BCBS PPO,CPT,L5600,Hip disart sach laminat mold,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"5,244.91","18,037.85",,,,,,
BCBS PPO,CPT,L5610,Above knee hydracadence,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,529.59","8,700.56",,,,,,
BCBS PPO,CPT,L5611,Ak 4 bar link w/fric swing,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,611.13","5,539.84",,,,,,
BCBS PPO,CPT,L5613,Ak 4 bar ling w/hydraul swig,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,450.64","8,429.87",,,,,,
BCBS PPO,CPT,L5614,4-bar link above knee w/swng,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,697.23","5,837.23",,,,,,
BCBS PPO,CPT,L5616,Ak univ multiplex sys frict,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,477.66","5,082.32",,,,,,
BCBS PPO,CPT,L5617,Ak/bk self-aligning unit ea,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,562.74,"1,936.85",,,,,,
BCBS PPO,CPT,L5618,Test socket symes,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,336.06,"1,155.24",,,,,,
BCBS PPO,CPT,L5620,Test socket below knee,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,298.16,"1,025.61",,,,,,
BCBS PPO,CPT,L5622,Test socket knee disarticula,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,401.7,"1,380.19",,,,,,
BCBS PPO,CPT,L5624,Test socket above knee,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,401.54,"1,380.19",,,,,,
BCBS PPO,CPT,L5626,Test socket hip disarticulat,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,635.7,"2,184.67",,,,,,
BCBS PPO,CPT,L5628,Test socket hemipelvectomy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,643.74,"2,215.19",,,,,,
BCBS PPO,CPT,L5629,Below knee acrylic socket,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,317.79,"1,094.25",,,,,,
BCBS PPO,CPT,L5630,Syme typ expandabl wall sckt,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,552.17,"1,898.73",,,,,,
BCBS PPO,CPT,L5631,Ak/knee disartic acrylic soc,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,439.37,"1,509.83",,,,,,
BCBS PPO,CPT,L5632,Symes type ptb brim design s,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,270.81,930.3,,,,,,
BCBS PPO,CPT,L5634,Symes type poster opening so,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,338.66,"1,162.87",,,,,,
BCBS PPO,CPT,L5636,Symes type medial opening so,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,258.86,888.36,,,,,,
BCBS PPO,CPT,L5637,Below knee total contact,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.17,"1,323.01",,,,,,
BCBS PPO,CPT,L5638,Below knee leather socket,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,648.87,"2,230.43",,,,,,
BCBS PPO,CPT,L5639,Below knee wood socket,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,121.15","3,854.63",,,,,,
BCBS PPO,CPT,L5640,Knee disarticulat leather so,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,736.94,"2,535.44",,,,,,
BCBS PPO,CPT,L5642,Above knee leather socket,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,683.11,"2,348.62",,,,,,
BCBS PPO,CPT,L5643,Hip flex inner socket ext fr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,014.84","6,927.67",,,,,,
BCBS PPO,CPT,L5644,Above knee wood socket,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,590.63,"2,032.17",,,,,,
BCBS PPO,CPT,L5645,Bk flex inner socket ext fra,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,979.82,"3,370.43",,,,,,
BCBS PPO,CPT,L5646,Below knee cushion socket,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,620.93,"2,135.11",,,,,,
BCBS PPO,CPT,L5647,Below knee suction socket,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,795.44,"2,733.70",,,,,,
BCBS PPO,CPT,L5648,Above knee cushion socket,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,733.68,"2,524.00",,,,,,
BCBS PPO,CPT,L5649,Isch containmt/narrow m-l so,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,465.24","8,479.43",,,,,,
BCBS PPO,CPT,L5650,Tot contact ak/knee disart s,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,488.17,"1,677.58",,,,,,
BCBS PPO,CPT,L5651,Ak flex inner socket ext fra,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,430.29","4,918.37",,,,,,
BCBS PPO,CPT,L5652,Suction susp ak/knee disart,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,435.97,"1,498.39",,,,,,
BCBS PPO,CPT,L5653,Knee disart expand wall sock,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,680.24,"2,341.00",,,,,,
BCBS PPO,CPT,L5654,Socket insert symes,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,394.33,"1,357.32",,,,,,
BCBS PPO,CPT,L5655,Socket insert below knee,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,284.71,979.86,,,,,,
BCBS PPO,CPT,L5656,Socket insert knee articulat,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,432.53,"1,486.95",,,,,,
BCBS PPO,CPT,L5658,Socket insert above knee,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,456.55,"1,570.83",,,,,,
BCBS PPO,CPT,L5661,Multi-durometer symes,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,655.04,"2,253.31",,,,,,
BCBS PPO,CPT,L5665,Multi-durometer below knee,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,582.36,"2,001.67",,,,,,
BCBS PPO,CPT,L5666,Below knee cuff suspension,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,77.11,266.89,,,,,,
BCBS PPO,CPT,L5668,Bk molded distal cushion,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.86,396.52,,,,,,
BCBS PPO,CPT,L5670,Bk molded supracondylar susp,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,271.35,934.12,,,,,,
BCBS PPO,CPT,L5671,Bk/ak locking mechanism,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,497.4,"1,711.89",,,,,,
BCBS PPO,CPT,L5672,Bk removable medial brim sus,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,359.07,"1,235.32",,,,,,
BCBS PPO,CPT,L5673,Socket insert w lock mech,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,790.52,"2,718.45",,,,,,
BCBS PPO,CPT,L5676,Bk knee joints single axis p,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,362.36,"1,246.76",,,,,,
BCBS PPO,CPT,L5677,Bk knee joints polycentric p,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,554.97,"1,910.16",,,,,,
BCBS PPO,CPT,L5678,Bk joint covers pair,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,39.7,137.25,,,,,,
BCBS PPO,CPT,L5679,Socket insert w/o lock mech,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,658.75,"2,264.75",,,,,,
BCBS PPO,CPT,L5680,Bk thigh lacer non-molded,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,304.37,"1,048.50",,,,,,
BCBS PPO,CPT,L5681,Intl custm cong/latyp insert,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,323.02","4,548.54",,,,,,
BCBS PPO,CPT,L5682,Bk thigh lacer glut/ischia m,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,625.37,"2,150.36",,,,,,
BCBS PPO,CPT,L5683,Initial custom socket insert,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,323.02","4,548.54",,,,,,
BCBS PPO,CPT,L5684,Bk fork strap,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,48.13,163.95,,,,,,
BCBS PPO,CPT,L5685,Below knee sus/seal sleeve,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,128.85,442.27,,,,,,
BCBS PPO,CPT,L5686,Bk back check,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,57.89,198.25,,,,,,
BCBS PPO,CPT,L5688,Bk waist belt webbing,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,61.48,209.7,,,,,,
BCBS PPO,CPT,L5690,Bk waist belt padded and lin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,125.5,430.83,,,,,,
BCBS PPO,CPT,L5692,Ak pelvic control belt light,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,132.88,457.52,,,,,,
BCBS PPO,CPT,L5694,Ak pelvic control belt pad/l,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,181.41,625.29,,,,,,
BCBS PPO,CPT,L5695,Ak sleeve susp neoprene/equa,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,163.08,560.47,,,,,,
BCBS PPO,CPT,L5696,Ak/knee disartic pelvic join,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,196.99,678.66,,,,,,
BCBS PPO,CPT,L5697,Ak/knee disartic pelvic band,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,93.55,320.27,,,,,,
BCBS PPO,CPT,L5698,Ak/knee disartic silesian ba,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,120.01,411.78,,,,,,
BCBS PPO,CPT,L5699,Shoulder harness,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,205.11,705.35,,,,,,
BCBS PPO,CPT,L5700,Replace socket below knee,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,085.07","10,610.72",,,,,,
BCBS PPO,CPT,L5701,Replace socket above knee,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,827.32","13,161.41",,,,,,
BCBS PPO,CPT,L5702,Replace socket hip,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"4,823.75","16,589.03",,,,,,
BCBS PPO,CPT,L5703,Symes ankle w/o (sach) foot,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,537.43","8,727.25",,,,,,
BCBS PPO,CPT,L5704,Custom shape cover bk,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,629.03,"2,161.80",,,,,,
BCBS PPO,CPT,L5705,Custom shape cover ak,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,153.25","3,965.20",,,,,,
BCBS PPO,CPT,L5706,Custom shape cvr knee disart,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,124.85","3,869.89",,,,,,
BCBS PPO,CPT,L5707,Custom shape cvr hip disart,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,511.27","5,196.70",,,,,,
BCBS PPO,CPT,L5710,Kne-shin exo sng axi mnl loc,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,359.65,"1,235.32",,,,,,
BCBS PPO,CPT,L5711,Knee-shin exo mnl lock ultra,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,603.6,"2,074.10",,,,,,
BCBS PPO,CPT,L5712,Knee-shin exo frict swg & st,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,430.88,"1,483.14",,,,,,
BCBS PPO,CPT,L5714,Knee-shin exo variable frict,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,438.43,"1,506.03",,,,,,
BCBS PPO,CPT,L5716,Knee-shin exo mech stance ph,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,866.93,"2,981.52",,,,,,
BCBS PPO,CPT,L5718,Knee-shin exo frct swg & sta,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,927.01,"3,187.41",,,,,,
BCBS PPO,CPT,L5722,Knee-shin pneum swg frct exo,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,127.32","3,877.51",,,,,,
BCBS PPO,CPT,L5724,Knee-shin exo fluid swing ph,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,737.57","5,974.48",,,,,,
BCBS PPO,CPT,L5726,Knee-shin ext jnts fld swg e,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,068.65","7,114.49",,,,,,
BCBS PPO,CPT,L5728,Knee-shin fluid swg & stance,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,424.23","8,338.36",,,,,,
BCBS PPO,CPT,L5780,Knee-shin pneum/hydra pneum,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,334.72","4,590.49",,,,,,
BCBS PPO,CPT,L5781,Lower limb pros vacuum pump,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"4,024.33","13,840.07",,,,,,
BCBS PPO,CPT,L5782,Hd low limb pros vacuum pump,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"4,242.55","14,591.17",,,,,,
BCBS PPO,CPT,L5785,Exoskeletal bk ultralt mater,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,519.54,"1,788.15",,,,,,
BCBS PPO,CPT,L5790,Exoskeletal ak ultra-light m,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,749.83,"2,577.38",,,,,,
BCBS PPO,CPT,L5795,Exoskel hip ultra-light mate,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,073.66","3,690.70",,,,,,
BCBS PPO,CPT,L5810,Endoskel knee-shin mnl lock,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,572.04,"1,967.35",,,,,,
BCBS PPO,CPT,L5811,Endo knee-shin mnl lck ultra,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,789.42,"2,714.64",,,,,,
BCBS PPO,CPT,L5812,Endo knee-shin frct swg & st,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,594.07,"2,043.61",,,,,,
BCBS PPO,CPT,L5814,Endo knee-shin hydral swg ph,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,735.37","12,844.96",,,,,,
BCBS PPO,CPT,L5816,Endo knee-shin polyc mch sta,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,850.43,"2,924.33",,,,,,
BCBS PPO,CPT,L5818,Endo knee-shin frct swg & st,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,960.3,"3,301.79",,,,,,
BCBS PPO,CPT,L5822,Endo knee-shin pneum swg frc,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,761.65","6,058.37",,,,,,
BCBS PPO,CPT,L5824,Endo knee-shin fluid swing p,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,665.27","5,726.65",,,,,,
BCBS PPO,CPT,L5826,Miniature knee joint,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,140.97","10,801.35",,,,,,
BCBS PPO,CPT,L5828,Endo knee-shin fluid swg/sta,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,963.78","10,191.33",,,,,,
BCBS PPO,CPT,L5830,Endo knee-shin pneum/swg pha,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,998.37","6,874.29",,,,,,
BCBS PPO,CPT,L5840,Multi-axial knee/shin system,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,922.28","13,489.32",,,,,,
BCBS PPO,CPT,L5845,Knee-shin sys stance flexion,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,802.73","6,199.43",,,,,,
BCBS PPO,CPT,L5848,Knee-shin sys hydraul stance,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,081.55","3,721.19",,,,,,
BCBS PPO,CPT,L5850,Endo ak/hip knee extens assi,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,127.92,438.47,,,,,,
BCBS PPO,CPT,L5855,Mech hip extension assist,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,308.82,"1,063.73",,,,,,
BCBS PPO,CPT,L5856,Elec knee-shin swing/stance,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"24,144.68","83,036.63",,,,,,
BCBS PPO,CPT,L5857,Elec knee-shin swing only,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"8,567.44","29,464.49",,,,,,
BCBS PPO,CPT,L5858,Stance phase only,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"18,692.70","64,285.82",,,,,,
BCBS PPO,CPT,L5910,Endo below knee alignable sy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,362.17,"1,246.76",,,,,,
BCBS PPO,CPT,L5920,Endo ak/hip alignable system,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,530.58,"1,826.28",,,,,,
BCBS PPO,CPT,L5925,Above knee manual lock,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,336,"1,155.24",,,,,,
BCBS PPO,CPT,L5930,High activity knee frame,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,385.39","11,643.96",,,,,,
BCBS PPO,CPT,L5940,Endo bk ultra-light material,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,501.6,"1,723.33",,,,,,
BCBS PPO,CPT,L5950,Endo ak ultra-light material,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,777.99,"2,676.51",,,,,,
BCBS PPO,CPT,L5960,Endo hip ultra-light materia,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,163.29","3,999.51",,,,,,
BCBS PPO,CPT,L5962,Below knee flex cover system,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,587.78,"2,020.72",,,,,,
BCBS PPO,CPT,L5964,Above knee flex cover system,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,127.47","3,877.51",,,,,,
BCBS PPO,CPT,L5966,Hip flexible cover system,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,452.38","4,994.63",,,,,,
BCBS PPO,CPT,L5968,Multiaxial ankle w dorsiflex,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,654.91","12,570.45",,,,,,
BCBS PPO,CPT,L5970,Foot external keel sach foot,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,218.47,751.1,,,,,,
BCBS PPO,CPT,L5971,Sach foot- replacement,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,218.47,751.1,,,,,,
BCBS PPO,CPT,L5972,Flexible keel foot,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,397.97,"1,368.75",,,,,,
BCBS PPO,CPT,L5974,Foot single axis ankle/foot,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,233.03,800.67,,,,,,
BCBS PPO,CPT,L5975,Combo ankle/foot prosthesis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,466.28,"1,605.15",,,,,,
BCBS PPO,CPT,L5976,Energy storing foot,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,591.07,"2,032.17",,,,,,
BCBS PPO,CPT,L5978,Ft prosth multiaxial ankl/ft,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,313.2,"1,078.99",,,,,,
BCBS PPO,CPT,L5979,Multi-axial ankle/ft prosth,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,507.69","8,624.30",,,,,,
BCBS PPO,CPT,L5980,Flex foot system,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,820.69","13,138.54",,,,,,
BCBS PPO,CPT,L5981,Flex-walk sys low ext prosth,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,431.91","11,804.09",,,,,,
BCBS PPO,CPT,L5982,Exoskeletal axial rotation u,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,644.71,"2,218.98",,,,,,
BCBS PPO,CPT,L5984,Endoskeletal axial rotation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,646.71,"2,222.79",,,,,,
BCBS PPO,CPT,L5985,Lwr ext dynamic prosth pylon,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,284.02,976.05,,,,,,
BCBS PPO,CPT,L5986,Multi-axial rotation unit,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,780.11,"2,684.14",,,,,,
BCBS PPO,CPT,L5987,Shank ft w vert load pylon,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"7,235.38","24,881.63",,,,,,
BCBS PPO,CPT,L5988,Vertical shock reducing pylo,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,009.25","6,908.59",,,,,,
BCBS PPO,CPT,L5990,User adjustable heel height,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,824.64","6,275.69",,,,,,
BCBS PPO,CPT,L6000,Part hand thumb rem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,771.55","6,092.69",,,,,,
BCBS PPO,CPT,L6010,Part hand little/ring,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,971.44","6,778.98",,,,,,
BCBS PPO,CPT,L6020,Part hand no fingers,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,838.05","6,321.45",,,,,,
BCBS PPO,CPT,L6025,Part hand disart myoelectric,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"27,680.15","27,680.15",,,,,,
BCBS PPO,CPT,L6050,Wrst mld sck flx hng tri pad,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,500.12","8,597.63",,,,,,
BCBS PPO,CPT,L6055,Wrst mold sock w/exp interfa,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,189.04","10,969.11",,,,,,
BCBS PPO,CPT,L6100,Elb mold sock flex hinge pad,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,530.04","8,700.56",,,,,,
BCBS PPO,CPT,L6110,Elbow mold sock suspension t,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,676.61","9,203.84",,,,,,
BCBS PPO,CPT,L6120,Elbow mold doub splt soc ste,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,027.26","10,412.46",,,,,,
BCBS PPO,CPT,L6130,Elbow stump activated lock h,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,193.82","10,984.37",,,,,,
BCBS PPO,CPT,L6200,Elbow mold outsid lock hinge,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,290.01","11,316.08",,,,,,
BCBS PPO,CPT,L6205,Elbow molded w/ expand inter,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"4,538.50","15,609.16",,,,,,
BCBS PPO,CPT,L6250,Elbow inter loc elbow forarm,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,236.79","11,133.06",,,,,,
BCBS PPO,CPT,L6300,Shlder disart int lock elbow,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"4,464.43","15,353.72",,,,,,
BCBS PPO,CPT,L6310,Shoulder passive restor comp,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"4,046.04","13,916.32",,,,,,
BCBS PPO,CPT,L6320,Shoulder passive restor cap,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,108.67","7,251.74",,,,,,
BCBS PPO,CPT,L6350,Thoracic intern lock elbow,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"4,891.63","16,821.60",,,,,,
BCBS PPO,CPT,L6360,Thoracic passive restor comp,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"4,246.80","14,606.43",,,,,,
BCBS PPO,CPT,L6370,Thoracic passive restor cap,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,462.85","8,471.79",,,,,,
BCBS PPO,CPT,L6380,Postop dsg cast chg wrst/elb,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,424.44","4,899.32",,,,,,
BCBS PPO,CPT,L6382,Postop dsg cast chg elb dis/,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,695.74","5,833.42",,,,,,
BCBS PPO,CPT,L6384,Postop dsg cast chg shlder/t,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,145.20","7,377.56",,,,,,
BCBS PPO,CPT,L6386,Postop ea cast chg & realign,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,470.24,"1,616.58",,,,,,
BCBS PPO,CPT,L6388,Postop applicat rigid dsg on,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,517.85,"1,780.53",,,,,,
BCBS PPO,CPT,L6400,Below elbow prosth tiss shap,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,736.86","9,413.54",,,,,,
BCBS PPO,CPT,L6450,Elb disart prosth tiss shap,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,576.94","12,299.74",,,,,,
BCBS PPO,CPT,L6500,Above elbow prosth tiss shap,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,512.48","12,078.62",,,,,,
BCBS PPO,CPT,L6550,Shldr disar prosth tiss shap,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"4,549.39","15,647.29",,,,,,
BCBS PPO,CPT,L6570,Scap thorac prosth tiss shap,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"5,078.79","17,465.96",,,,,,
BCBS PPO,CPT,L6580,Wrist/elbow bowden cable mol,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,030.62","6,984.85",,,,,,
BCBS PPO,CPT,L6582,Wrist/elbow bowden cbl dir f,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,705.44","5,863.93",,,,,,
BCBS PPO,CPT,L6584,Elbow fair lead cable molded,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,525.30","8,685.31",,,,,,
BCBS PPO,CPT,L6586,Elbow fair lead cable dir fo,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,250.20","7,739.77",,,,,,
BCBS PPO,CPT,L6588,Shdr fair lead cable molded,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,583.73","12,326.44",,,,,,
BCBS PPO,CPT,L6590,Shdr fair lead cable direct,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,123.36","10,740.36",,,,,,
BCBS PPO,CPT,L6600,Polycentric hinge pair,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,228.13,785.42,,,,,,
BCBS PPO,CPT,L6605,Single pivot hinge pair,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,234.81,808.29,,,,,,
BCBS PPO,CPT,L6610,Flexible metal hinge pair,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,221.98,762.54,,,,,,
BCBS PPO,CPT,L6611,Additional switch- ext power,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,414.1,"1,425.95",,,,,,
BCBS PPO,CPT,L6615,Disconnect locking wrist uni,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,215.48,739.67,,,,,,
BCBS PPO,CPT,L6616,Disconnect insert locking wr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,64.86,224.95,,,,,,
BCBS PPO,CPT,L6620,Flexion/extension wrist unit,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,376.69,"1,296.32",,,,,,
BCBS PPO,CPT,L6621,Flex/ext wrist w/wo friction,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,300.54","7,911.34",,,,,,
BCBS PPO,CPT,L6623,Spring-ass rot wrst w/ latch,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,717.59,"2,466.81",,,,,,
BCBS PPO,CPT,L6624,Flex/ext/rotation wrist unit,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,787.86","13,027.98",,,,,,
BCBS PPO,CPT,L6625,Rotation wrst w/ cable lock,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,531.84,"1,830.09",,,,,,
BCBS PPO,CPT,L6628,Quick disconn hook adapter o,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,572.47,"1,967.35",,,,,,
BCBS PPO,CPT,L6629,Lamination collar w/ couplin,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,195.07,671.03,,,,,,
BCBS PPO,CPT,L6630,Stainless steel any wrist,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,287.35,987.49,,,,,,
BCBS PPO,CPT,L6632,Latex suspension sleeve each,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,64.97,224.95,,,,,,
BCBS PPO,CPT,L6635,Lift assist for elbow,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,207.68,712.98,,,,,,
BCBS PPO,CPT,L6637,Nudge control elbow lock,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,406.6,"1,399.26",,,,,,
BCBS PPO,CPT,L6638,Elec lock on manual pw elbow,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,515.20","8,651.00",,,,,,
BCBS PPO,CPT,L6639,Heavy duty elbow feature,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"5,276.76","5,276.76",,,,,,
BCBS PPO,CPT,L6640,Shoulder abduction joint pai,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,338.63,"1,162.87",,,,,,
BCBS PPO,CPT,L6641,Excursion amplifier pulley t,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,197.18,678.66,,,,,,
BCBS PPO,CPT,L6642,Excursion amplifier lever ty,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,289.92,998.92,,,,,,
BCBS PPO,CPT,L6645,Shoulder flexion-abduction j,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,366.21,"1,258.19",,,,,,
BCBS PPO,CPT,L6646,Multipo locking shoulder jnt,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,172.24","10,908.12",,,,,,
BCBS PPO,CPT,L6647,Shoulder lock actuator,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,522.26,"1,795.78",,,,,,
BCBS PPO,CPT,L6648,Ext pwrd shlder lock/unlock,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,271.71","11,251.26",,,,,,
BCBS PPO,CPT,L6650,Shoulder universal joint,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,397.2,"1,364.94",,,,,,
BCBS PPO,CPT,L6655,Standard control cable extra,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,77.05,263.08,,,,,,
BCBS PPO,CPT,L6660,Heavy duty control cable,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,103.11,354.58,,,,,,
BCBS PPO,CPT,L6665,Teflon or equal cable lining,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,46.05,160.13,,,,,,
BCBS PPO,CPT,L6670,Hook to hand cable adapter,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,47.96,163.95,,,,,,
BCBS PPO,CPT,L6672,Harness chest/shlder saddle,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,220.08,758.72,,,,,,
BCBS PPO,CPT,L6675,Harness figure of 8 sing con,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,120.09,411.78,,,,,,
BCBS PPO,CPT,L6676,Harness figure of 8 dual con,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,125.64,430.83,,,,,,
BCBS PPO,CPT,L6677,Ue triple control harness,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,298.35,"1,025.61",,,,,,
BCBS PPO,CPT,L6680,Test sock wrist disart/bel e,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,309.33,"1,063.73",,,,,,
BCBS PPO,CPT,L6682,Test sock elbw disart/above,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,342.01,"1,178.12",,,,,,
BCBS PPO,CPT,L6684,Test socket shldr disart/tho,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,464.75,"1,597.52",,,,,,
BCBS PPO,CPT,L6686,Suction socket,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,689.63,"2,371.49",,,,,,
BCBS PPO,CPT,L6687,Frame typ socket bel elbow/w,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,576.8,"1,982.60",,,,,,
BCBS PPO,CPT,L6688,Frame typ sock above elb/dis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,638.36,"2,196.11",,,,,,
BCBS PPO,CPT,L6689,Frame typ socket shoulder di,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,760.81,"2,615.51",,,,,,
BCBS PPO,CPT,L6690,Frame typ sock interscap-tho,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,895.74,"3,080.66",,,,,,
BCBS PPO,CPT,L6691,Removable insert each,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,353.58,"1,216.24",,,,,,
BCBS PPO,CPT,L6692,Silicone gel insert or equal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,643.25,"2,211.37",,,,,,
BCBS PPO,CPT,L6693,Lockingelbow forearm cntrbal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,855.43","9,821.50",,,,,,
BCBS PPO,CPT,L6694,Elbow socket ins use w/lock,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,790.52,"2,718.45",,,,,,
BCBS PPO,CPT,L6695,Elbow socket ins use w/o lck,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,658.75,"2,264.75",,,,,,
BCBS PPO,CPT,L6696,Cus elbo skt in for con/atyp,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,323.02","4,548.54",,,,,,
BCBS PPO,CPT,L6697,Cus elbo skt in not con/atyp,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,323.02","4,548.54",,,,,,
BCBS PPO,CPT,L6698,Below/above elbow lock mech,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,497.4,"1,711.89",,,,,,
BCBS PPO,CPT,L6703,Term dev- passive hand mitt,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,351.79,"1,208.62",,,,,,
BCBS PPO,CPT,L6704,Term dev- sport/rec/work att,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,679.06,"2,337.18",,,,,,
BCBS PPO,CPT,L6706,Term dev mech hook vol open,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,421.4,"1,448.82",,,,,,
BCBS PPO,CPT,L6707,Term dev mech hook vol close,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,490.70","5,128.07",,,,,,
BCBS PPO,CPT,L6708,Term dev mech hand vol open,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,985.41,"3,389.47",,,,,,
BCBS PPO,CPT,L6709,Term dev mech hand vol close,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,398.55","4,811.61",,,,,,
BCBS PPO,CPT,L6711,Ped term dev- hook- vol open,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,676.19,"2,325.74",,,,,,
BCBS PPO,CPT,L6712,Ped term dev- hook- vol clos,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,245.05","4,281.66",,,,,,
BCBS PPO,CPT,L6713,Ped term dev- hand- vol open,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,571.33","5,402.59",,,,,,
BCBS PPO,CPT,L6714,Ped term dev- hand- vol clos,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,330.91","4,579.05",,,,,,
BCBS PPO,CPT,L6721,Hook/hand- hvy dty- vol open,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,365.59","8,136.28",,,,,,
BCBS PPO,CPT,L6722,Hook/hand- hvy dty- vol clos,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,039.28","7,011.54",,,,,,
BCBS PPO,CPT,L6805,Term dev modifier wrist unit,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,385.75,"1,326.82",,,,,,
BCBS PPO,CPT,L6810,Term dev precision pinch dev,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,205.07,705.35,,,,,,
BCBS PPO,CPT,L6881,Term dev auto grasp feature,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"4,111.91","14,141.27",,,,,,
BCBS PPO,CPT,L6882,Microprocessor control uplmb,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,119.08","10,725.10",,,,,,
BCBS PPO,CPT,L6883,Replc sockt below e/w disa,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,997.96","6,870.47",,,,,,
BCBS PPO,CPT,L6884,Replc sockt above elbow disa,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,733.67","9,402.10",,,,,,
BCBS PPO,CPT,L6885,Replc sockt shldr dis/interc,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"4,246.80","14,606.43",,,,,,
BCBS PPO,CPT,L6890,Prefab glove for term device,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,200.88,690.1,,,,,,
BCBS PPO,CPT,L6895,Custom glove for term device,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,671.68,"2,310.49",,,,,,
BCBS PPO,CPT,L6900,Hand restorat thumb/1 finger,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,950.52","6,706.52",,,,,,
BCBS PPO,CPT,L6905,Hand restoration multiple fi,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,930.47","6,637.91",,,,,,
BCBS PPO,CPT,L6910,Hand restoration no fingers,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,897.78","6,527.33",,,,,,
BCBS PPO,CPT,L6915,Hand restoration replacmnt g,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,815.4,"2,806.14",,,,,,
BCBS PPO,CPT,L6920,Wrist disarticul switch ctrl,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"8,425.39","28,976.47",,,,,,
BCBS PPO,CPT,L6925,Wrist disart myoelectronic c,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"9,001.12","30,955.25",,,,,,
BCBS PPO,CPT,L6930,Below elbow switch control,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"8,114.82","27,908.91",,,,,,
BCBS PPO,CPT,L6935,Below elbow myoelectronic ct,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"8,958.82","30,810.37",,,,,,
BCBS PPO,CPT,L6940,Elbow disarticulation switch,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"10,478.90","36,037.57",,,,,,
BCBS PPO,CPT,L6945,Elbow disart myoelectronic c,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"11,690.57","40,204.84",,,,,,
BCBS PPO,CPT,L6950,Above elbow switch control,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"10,459.47","35,972.77",,,,,,
BCBS PPO,CPT,L6955,Above elbow myoelectronic ct,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"12,129.70","41,714.68",,,,,,
BCBS PPO,CPT,L6960,Shldr disartic switch contro,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"12,759.97","43,884.09",,,,,,
BCBS PPO,CPT,L6965,Shldr disartic myoelectronic,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"15,116.16","51,986.07",,,,,,
BCBS PPO,CPT,L6970,Interscapular-thor switch ct,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"16,180.17","55,646.26",,,,,,
BCBS PPO,CPT,L6975,Interscap-thor myoelectronic,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"17,834.37","61,334.79",,,,,,
BCBS PPO,CPT,L7007,Adult electric hand,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,673.63","12,635.27",,,,,,
BCBS PPO,CPT,L7008,Pediatric electric hand,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"5,696.71","19,593.43",,,,,,
BCBS PPO,CPT,L7009,Adult electric hook,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,758.57","12,925.03",,,,,,
BCBS PPO,CPT,L7040,Prehensile actuator,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,059.23","10,519.22",,,,,,
BCBS PPO,CPT,L7045,Pediatric electric hook,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,616.29","5,558.92",,,,,,
BCBS PPO,CPT,L7170,Electronic elbow hosmer swit,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"6,050.00","20,805.87",,,,,,
BCBS PPO,CPT,L7180,Electronic elbow sequential,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"39,141.46","134,610.92",,,,,,
BCBS PPO,CPT,L7181,Electronic elbo simultaneous,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"40,299.84","138,595.19",,,,,,
BCBS PPO,CPT,L7185,Electron elbow adolescent sw,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"6,360.51","21,873.42",,,,,,
BCBS PPO,CPT,L7186,Electron elbow child switch,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"10,692.92","36,773.42",,,,,,
BCBS PPO,CPT,L7190,Elbow adolescent myoelectron,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"8,439.80","29,026.03",,,,,,
BCBS PPO,CPT,L7191,Elbow child myoelectronic ct,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"11,247.26","38,679.77",,,,,,
BCBS PPO,CPT,L7260,Electron wrist rotator otto,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"7,552.94","7,552.94",,,,,,
BCBS PPO,CPT,L7261,Electron wrist rotator utah,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"16,261.14","16,261.14",,,,,,
BCBS PPO,CPT,L7266,Servo control steeper or equ,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,480.99","3,480.99",,,,,,
BCBS PPO,CPT,L7272,Analogue control unb or equa,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"8,162.98","8,162.98",,,,,,
BCBS PPO,CPT,L7274,Proportional ctl 12 volt uta,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"25,316.28","25,316.28",,,,,,
BCBS PPO,CPT,L7360,Six volt bat otto bock/eq ea,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,266.08,915.04,,,,,,
BCBS PPO,CPT,L7362,Battery chrgr six volt otto,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,290.68,998.92,,,,,,
BCBS PPO,CPT,L7364,Twelve volt battery utah/equ,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,514.33,"1,769.09",,,,,,
BCBS PPO,CPT,L7366,Battery chrgr 12 volt utah/e,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,707.34,"2,432.50",,,,,,
BCBS PPO,CPT,L7367,Replacemnt lithium ionbatter,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,391.59,"1,345.89",,,,,,
BCBS PPO,CPT,L7368,Lithium ion battery charger,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,507.61,"1,746.22",,,,,,
BCBS PPO,CPT,L7400,Add ue prost be/wd- ultlite,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,308.25,"1,059.93",,,,,,
BCBS PPO,CPT,L7401,Add ue prost a/e ultlite mat,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,345.06,"1,185.76",,,,,,
BCBS PPO,CPT,L7402,Add ue prost s/d ultlite mat,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,372.68,"1,281.07",,,,,,
BCBS PPO,CPT,L7403,Add ue prost b/e acrylic,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,370.41,"1,273.44",,,,,,
BCBS PPO,CPT,L7404,Add ue prost a/e acrylic,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,559.06,"1,921.59",,,,,,
BCBS PPO,CPT,L7405,Add ue prost s/d acrylic,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,731.1,"2,512.57",,,,,,
BCBS PPO,CPT,L7520,Repair prosthesis per 15 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,152.51,152.51,,,,,,
BCBS PPO,CPT,L7900,Male vacuum erection system,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,818.66","1,818.66",,,,,,
BCBS PPO,CPT,L8000,Mastectomy bra,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,42.59,144.88,,,,,,
BCBS PPO,CPT,L8001,Breast prosthesis bra & form,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,126.18,434.65,,,,,,
BCBS PPO,CPT,L8002,Brst prsth bra & bilat form,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,165.94,571.91,,,,,,
BCBS PPO,CPT,L8010,Mastectomy sleeve,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,373.65,373.65,,,,,,
BCBS PPO,CPT,L8015,Ext breastprosthesis garment,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,60.29,205.88,,,,,,
BCBS PPO,CPT,L8020,Mastectomy form,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,227.4,781.61,,,,,,
BCBS PPO,CPT,L8030,Breast prosthes w/o adhesive,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,351.55,"1,208.62",,,,,,
BCBS PPO,CPT,L8035,Custom breast prosthesis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,684.79","12,673.39",,,,,,
BCBS PPO,CPT,L8040,Nasal prosthesis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,493.50","8,574.74",,,,,,
BCBS PPO,CPT,L8041,Midfacial prosthesis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,005.20","10,336.21",,,,,,
BCBS PPO,CPT,L8042,Orbital prosthesis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,376.62","11,613.47",,,,,,
BCBS PPO,CPT,L8043,Upper facial prosthesis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,781.84","13,005.10",,,,,,
BCBS PPO,CPT,L8044,Hemi-facial prosthesis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"4,187.02","14,400.54",,,,,,
BCBS PPO,CPT,L8045,Auricular prosthesis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,278.72","11,274.13",,,,,,
BCBS PPO,CPT,L8046,Partial facial prosthesis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,701.33","9,291.53",,,,,,
BCBS PPO,CPT,L8047,Nasal septal prosthesis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,384.42","4,762.05",,,,,,
BCBS PPO,CPT,L8049,Repair maxillofacial prosth,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,61,61,,,,,,
BCBS PPO,CPT,L8300,Truss single w/ standard pad,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,84.35,289.76,,,,,,
BCBS PPO,CPT,L8310,Truss double w/ standard pad,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,149.44,514.72,,,,,,
BCBS PPO,CPT,L8320,Truss addition to std pad wa,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,62,213.51,,,,,,
BCBS PPO,CPT,L8330,Truss add to std pad scrotal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,49.37,171.58,,,,,,
BCBS PPO,CPT,L8400,Sheath below knee,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.74,53.38,,,,,,
BCBS PPO,CPT,L8410,Sheath above knee,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,20.72,72.44,,,,,,
BCBS PPO,CPT,L8415,Sheath upper limb,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,21.44,72.44,,,,,,
BCBS PPO,CPT,L8417,Pros sheath/sock w gel cushn,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,75.64,259.27,,,,,,
BCBS PPO,CPT,L8420,Prosthetic sock multi ply bk,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,20.98,72.44,,,,,,
BCBS PPO,CPT,L8430,Prosthetic sock multi ply ak,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,23.76,80.07,,,,,,
BCBS PPO,CPT,L8435,Pros sock multi ply upper lm,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.58,76.26,,,,,,
BCBS PPO,CPT,L8440,Shrinker below knee,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,46.88,160.13,,,,,,
BCBS PPO,CPT,L8460,Shrinker above knee,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,66.65,228.77,,,,,,
BCBS PPO,CPT,L8465,Shrinker upper limb,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,61.6,213.51,,,,,,
BCBS PPO,CPT,L8470,Pros sock single ply bk,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,6.67,22.88,,,,,,
BCBS PPO,CPT,L8480,Pros sock single ply ak,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,9.2,30.51,,,,,,
BCBS PPO,CPT,L8485,Pros sock single ply upper l,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.39,41.94,,,,,,
BCBS PPO,CPT,L8500,Artificial larynx,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,661.87,"2,276.18",,,,,,
BCBS PPO,CPT,L8501,Tracheostomy speaking valve,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,120.8,415.59,,,,,,
BCBS PPO,CPT,L8507,Trach-esoph voice pros pt in,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,42.11,144.88,,,,,,
BCBS PPO,CPT,L8509,Trach-esoph voice pros md in,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,109.85,377.46,,,,,,
BCBS PPO,CPT,L8510,Voice amplifier,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,254.17,873.11,,,,,,
BCBS PPO,CPT,L8511,Indwelling trach insert,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,73.14,251.64,,,,,,
BCBS PPO,CPT,L8512,Gel cap for trach voice pros,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,2.19,7.62,,,,,,
BCBS PPO,CPT,L8513,Trach pros cleaning device,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.22,19.07,,,,,,
BCBS PPO,CPT,L8514,Repl trach puncture dilator,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,94.85,327.9,,,,,,
BCBS PPO,CPT,L8515,Gel cap app device for trach,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,63.49,217.32,,,,,,
BCBS PPO,CPT,L8606,Synthetic implnt urinary 1ml,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,709.16,709.16,,,,,,
BCBS PPO,CPT,L8609,Artificial cornea,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"22,536.83","22,536.83",,,,,,
BCBS PPO,CPT,L8610,Ocular implant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,352.44","2,352.44",,,,,,
BCBS PPO,CPT,L8612,Aqueous shunt prosthesis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,737.52","2,737.52",,,,,,
BCBS PPO,CPT,L8613,Ossicular implant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,174.31","1,174.31",,,,,,
BCBS PPO,CPT,L8614,Cochlear device,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"67,724.86","67,724.86",,,,,,
BCBS PPO,CPT,L8615,Coch implant headset replace,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,453.62,"1,559.39",,,,,,
BCBS PPO,CPT,L8616,Coch implant microphone repl,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,105.64,362.21,,,,,,
BCBS PPO,CPT,L8618,Coch implant tran cable repl,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.38,91.51,,,,,,
BCBS PPO,CPT,L8619,Coch imp ext proc/contr rplc,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"8,454.02","29,075.59",,,,,,
BCBS PPO,CPT,L8621,Repl zinc air battery,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,0.62,3.82,,,,,,
BCBS PPO,CPT,L8622,Repl alkaline battery,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,0.32,1.9,,,,,,
BCBS PPO,CPT,L8624,Lith ion batt cid- ear level,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,162.2,556.65,,,,,,
BCBS PPO,CPT,L8630,Metacarpophalangeal implant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,544.15","1,544.15",,,,,,
BCBS PPO,CPT,L8631,Mcp joint repl 2 pc or more,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"7,610.13","7,610.13",,,,,,
BCBS PPO,CPT,L8641,Metatarsal joint implant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,204.81","1,204.81",,,,,,
BCBS PPO,CPT,L8642,Hallux implant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,075.18","1,075.18",,,,,,
BCBS PPO,CPT,L8658,Interphalangeal joint spacer,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,048.50","1,048.50",,,,,,
BCBS PPO,CPT,L8659,Interphalangeal joint repl,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"6,676.03","6,676.03",,,,,,
BCBS PPO,CPT,L8670,Vascular graft- synthetic,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,913.96","1,913.96",,,,,,
BCBS PPO,CPT,L8680,Implt neurostim elctr each,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,631.84","1,631.84",,,,,,
BCBS PPO,CPT,L8681,Pt prgrm for implt neurostim,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,147.11","3,946.14",,,,,,
BCBS PPO,CPT,L8682,Implt neurostim radiofq rec,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"21,175.69","21,175.69",,,,,,
BCBS PPO,CPT,L8683,Radiofq trsmtr for implt neu,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"5,420.03","18,640.24",,,,,,
BCBS PPO,CPT,L8684,Radiof trsmtr implt scrl neu,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,850.48,"2,924.33",,,,,,
BCBS PPO,CPT,L8685,Implt nrostm pls gen sng rec,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"46,450.03","46,450.03",,,,,,
BCBS PPO,CPT,L8686,Implt nrostm pls gen sng non,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"29,639.87","29,639.87",,,,,,
BCBS PPO,CPT,L8687,Implt nrostm pls gen dua rec,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"60,450.24","60,450.24",,,,,,
BCBS PPO,CPT,L8688,Implt nrostm pls gen dua non,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"38,573.01","38,573.01",,,,,,
BCBS PPO,CPT,L8689,External recharg sys intern,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,734.92","5,966.87",,,,,,
BCBS PPO,CPT,L8690,Aud osseo dev- int/ext comp,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"16,455.58","16,455.58",,,,,,
BCBS PPO,CPT,L8691,Aoi snd proc repl excl actua,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,732.10","9,222.90",,,,,,
BCBS PPO,CPT,L8695,External recharg sys extern,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16.77,57.19,,,,,,
BCBS PPO,CPT,L9900,O&p supply/accessory/service,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,144.88,144.88,,,,,,
BCBS PPO,CPT,M0064,Visit for drug monitoring,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,217.32,217.32,,,,,,
BCBS PPO,CPT,M0076,Prolotherapy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,358.39,358.39,,,,,,
BCBS PPO,CPT,M0300,Iv chelationtherapy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,305.01,305.01,,,,,,
BCBS PPO,CPT,P2038,Blood mucoprotein,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,4.95,22.88,,,,,,
BCBS PPO,CPT,P3000,Screen pap by tech w md supv,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.15,45.74,,,,,,
BCBS PPO,CPT,P3001,Screening pap smear by phys,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,137.25,137.25,,,,,,
BCBS PPO,CPT,P7001,Culture bacterial urine,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,19.07,,,,,,
BCBS PPO,CPT,P9043,Plasma protein fract-5%-50ml,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,9.16,106.76,,,,,,
BCBS PPO,CPT,P9045,Albumin (human)- 5%- 250 ml,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,52.45,274.51,,,,,,
BCBS PPO,CPT,P9046,Albumin (human)- 25%- 20 ml,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,20.98,129.64,,,,,,
BCBS PPO,CPT,P9047,Albumin (human)- 25%- 50ml,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,52.45,255.45,,,,,,
BCBS PPO,CPT,P9048,Plasmaprotein fract-5%-250ml,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,183.92,198.25,,,,,,
BCBS PPO,CPT,P9615,Urine specimen collect mult,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.62,7.62,,,,,,
BCBS PPO,CPT,Q0035,Cardiokymography,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.63,106.76,,,,,,
BCBS PPO,CPT,Q0091,Obtaining screen pap smear,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,25.25,205.88,,,,,,
BCBS PPO,CPT,Q0092,Set up port xray equipment,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,83.87,83.87,,,,,,
BCBS PPO,CPT,Q0112,Potassium hydroxide preps,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,5.83,22.88,,,,,,
BCBS PPO,CPT,Q0113,Pinworm examinations,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,4.27,26.7,,,,,,
BCBS PPO,CPT,Q0114,Fern test,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,9.74,34.31,,,,,,
BCBS PPO,CPT,Q0115,Post-coital mucous exam,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,25,49.56,,,,,,
BCBS PPO,CPT,Q0144,Azithromycin dihydrate- oral,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,133.45,133.45,,,,,,
BCBS PPO,CPT,Q0161,Chlorpromazine hcl 5mg oral,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,0.38,0.38,,,,,,
BCBS PPO,CPT,Q0167,Dronabinol 2.5mg oral,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.7,26.7,,,,,,
BCBS PPO,CPT,Q0168,Dronabinol 5mg oral,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,57.19,57.19,,,,,,
BCBS PPO,CPT,Q0169,Promethazine hcl 12.5mg oral,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,Q0170,Promethazine HCl 25 mg oral,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.9,1.9,,,,,,
BCBS PPO,CPT,Q0172,Chlorpromazine HCl 25mg oral,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.9,1.9,,,,,,
BCBS PPO,CPT,Q0173,Trimethobenzamide hcl 250mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,Q0174,Thiethylperazine maleate10mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,Q0175,Perphenazine 4mg oral,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,Q0176,Perphenazine 8mg oral,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,Q0177,Hydroxyzine pamoate 25mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.9,1.9,,,,,,
BCBS PPO,CPT,Q0180,Dolasetron mesylate oral,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,244.01,244.01,,,,,,
BCBS PPO,CPT,Q0480,Driver pneumatic vad- rep,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"90,585.51","311,531.29",,,,,,
BCBS PPO,CPT,Q0481,Microprcsr cu elec vad- rep,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"14,614.95","50,262.72",,,,,,
BCBS PPO,CPT,Q0482,Microprcsr cu combo vad- rep,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"4,577.67","15,742.60",,,,,,
BCBS PPO,CPT,Q0483,Monitor elec vad- rep,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"18,857.93","64,853.90",,,,,,
BCBS PPO,CPT,Q0484,Monitor elec or comb vad rep,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,662.14","12,593.32",,,,,,
BCBS PPO,CPT,Q0485,Monitor cable elec vad- rep,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,353.6,"1,216.24",,,,,,
BCBS PPO,CPT,Q0486,Mon cable elec/pneum vad rep,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,294.28,"1,010.37",,,,,,
BCBS PPO,CPT,Q0487,Leads any type vad- rep only,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,343.31,"1,181.94",,,,,,
BCBS PPO,CPT,Q0489,Pwr pck base combo vad- rep,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"16,348.80","56,225.77",,,,,,
BCBS PPO,CPT,Q0490,Emr pwr source elec vad- rep,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,707.17,"2,432.50",,,,,,
BCBS PPO,CPT,Q0491,Emr pwr source combo vad rep,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,111.75","3,824.13",,,,,,
BCBS PPO,CPT,Q0492,Emr pwr cbl elec vad- rep,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,89.58,308.83,,,,,,
BCBS PPO,CPT,Q0493,Emr pwr cbl combo vad- rep,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,255.02,876.92,,,,,,
BCBS PPO,CPT,Q0494,Emr hd pmp elec/combo- rep,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,215.79,743.48,,,,,,
BCBS PPO,CPT,Q0495,Charger elec/combo vad- rep,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"4,201.23","14,450.10",,,,,,
BCBS PPO,CPT,Q0496,Battery elec/combo vad- rep,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,507.90","5,185.26",,,,,,
BCBS PPO,CPT,Q0497,Bat clps elec/comb vad- rep,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,470.84,"1,620.40",,,,,,
BCBS PPO,CPT,Q0498,Holster elec/combo vad- rep,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,516.61,"1,776.71",,,,,,
BCBS PPO,CPT,Q0499,Belt/vest elec/combo vad rep,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,167.86,575.73,,,,,,
BCBS PPO,CPT,Q0500,Filters elec/combo vad- rep,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,30.69,106.76,,,,,,
BCBS PPO,CPT,Q0501,Shwr cov elec/combo vad- rep,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,513.63,"1,765.27",,,,,,
BCBS PPO,CPT,Q0502,Mobility cart pneum vad- rep,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,653.97,"2,249.49",,,,,,
BCBS PPO,CPT,Q0503,Battery pneum vad replacemnt,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,307.87","4,498.98",,,,,,
BCBS PPO,CPT,Q0504,Pwr adpt pneum vad- rep veh,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,690.16,"2,375.30",,,,,,
BCBS PPO,CPT,Q0510,Dispens fee immunosupressive,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,190.64,190.64,,,,,,
BCBS PPO,CPT,Q0511,Sup fee antiem-antica-immuno,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,91.51,91.51,,,,,,
BCBS PPO,CPT,Q0512,Px sup fee anti-can sub pres,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,61,61,,,,,,
BCBS PPO,CPT,Q0513,Disp fee inhal drugs/30 days,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,125.82,125.82,,,,,,
BCBS PPO,CPT,Q0514,Disp fee inhal drugs/90 days,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,251.64,251.64,,,,,,
BCBS PPO,CPT,Q0515,Sermorelin acetate injection,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.62,7.62,,,,,,
BCBS PPO,CPT,Q2017,Teniposide- 50 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,582.28","2,645.71",,,,,,
BCBS PPO,CPT,Q2050,Doxorubicin inj 10mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,234.03,"1,719.01",,,,,,
BCBS PPO,CPT,Q3025,IM inj interferon beta 1-a,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,815.92,815.92,,,,,,
BCBS PPO,CPT,Q3026,Subc inj interferon beta-1a,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,178.51,178.51,,,,,,
BCBS PPO,CPT,Q3027,Inj beta interferon im 1 mcg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,55.29,74.17,,,,,,
BCBS PPO,CPT,Q3028,Inj beta interferon sq 1 mcg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16.24,16.24,,,,,,
BCBS PPO,CPT,Q4001,Cast sup body cast plaster,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,167.76,167.76,,,,,,
BCBS PPO,CPT,Q4002,Cast sup body cast fiberglas,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,636.73,636.73,,,,,,
BCBS PPO,CPT,Q4003,Cast sup shoulder cast plstr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,122,122,,,,,,
BCBS PPO,CPT,Q4004,Cast sup shoulder cast fbrgl,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,419.4,419.4,,,,,,
BCBS PPO,CPT,Q4005,Cast sup long arm adult plst,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,45.74,45.74,,,,,,
BCBS PPO,CPT,Q4006,Cast sup long arm adult fbrg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,99.13,99.13,,,,,,
BCBS PPO,CPT,Q4007,Cast sup long arm ped plster,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.88,22.88,,,,,,
BCBS PPO,CPT,Q4008,Cast sup long arm ped fbrgls,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,49.56,49.56,,,,,,
BCBS PPO,CPT,Q4009,Cast sup sht arm adult plstr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,30.51,30.51,,,,,,
BCBS PPO,CPT,Q4010,Cast sup sht arm adult fbrgl,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,68.63,68.63,,,,,,
BCBS PPO,CPT,Q4011,Cast sup sht arm ped plaster,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.26,15.26,,,,,,
BCBS PPO,CPT,Q4012,Cast sup sht arm ped fbrglas,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.31,34.31,,,,,,
BCBS PPO,CPT,Q4013,Cast sup gauntlet plaster,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,53.38,53.38,,,,,,
BCBS PPO,CPT,Q4014,Cast sup gauntlet fiberglass,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,91.51,91.51,,,,,,
BCBS PPO,CPT,Q4015,Cast sup gauntlet ped plster,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.7,26.7,,,,,,
BCBS PPO,CPT,Q4016,Cast sup gauntlet ped fbrgls,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,45.74,45.74,,,,,,
BCBS PPO,CPT,Q4017,Cast sup lng arm splint plst,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,30.51,30.51,,,,,,
BCBS PPO,CPT,Q4018,Cast sup lng arm splint fbrg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,49.56,49.56,,,,,,
BCBS PPO,CPT,Q4019,Cast sup lng arm splnt ped p,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.26,15.26,,,,,,
BCBS PPO,CPT,Q4020,Cast sup lng arm splnt ped f,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.7,26.7,,,,,,
BCBS PPO,CPT,Q4021,Cast sup sht arm splint plst,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.88,22.88,,,,,,
BCBS PPO,CPT,Q4022,Cast sup sht arm splint fbrg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,41.94,41.94,,,,,,
BCBS PPO,CPT,Q4023,Cast sup sht arm splnt ped p,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.44,11.44,,,,,,
BCBS PPO,CPT,Q4024,Cast sup sht arm splnt ped f,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,19.07,,,,,,
BCBS PPO,CPT,Q4025,Cast sup hip spica plaster,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,129.64,129.64,,,,,,
BCBS PPO,CPT,Q4026,Cast sup hip spica fiberglas,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,404.14,404.14,,,,,,
BCBS PPO,CPT,Q4027,Cast sup hip spica ped plstr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,64.82,64.82,,,,,,
BCBS PPO,CPT,Q4028,Cast sup hip spica ped fbrgl,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,202.07,202.07,,,,,,
BCBS PPO,CPT,Q4029,Cast sup long leg plaster,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,99.13,99.13,,,,,,
BCBS PPO,CPT,Q4030,Cast sup long leg fiberglass,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,263.08,263.08,,,,,,
BCBS PPO,CPT,Q4031,Cast sup lng leg ped plaster,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,49.56,49.56,,,,,,
BCBS PPO,CPT,Q4032,Cast sup lng leg ped fbrgls,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,129.64,129.64,,,,,,
BCBS PPO,CPT,Q4033,Cast sup lng leg cylinder pl,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,91.51,91.51,,,,,,
BCBS PPO,CPT,Q4034,Cast sup lng leg cylinder fb,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,228.77,228.77,,,,,,
BCBS PPO,CPT,Q4035,Cast sup lngleg cylndr ped p,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,45.74,45.74,,,,,,
BCBS PPO,CPT,Q4036,Cast sup lngleg cylndr ped f,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.39,114.39,,,,,,
BCBS PPO,CPT,Q4037,Cast sup shrt leg plaster,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,57.19,57.19,,,,,,
BCBS PPO,CPT,Q4038,Cast sup shrt leg fiberglass,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,141.07,141.07,,,,,,
BCBS PPO,CPT,Q4039,Cast sup shrt leg ped plster,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.7,26.7,,,,,,
BCBS PPO,CPT,Q4040,Cast sup shrt leg ped fbrgls,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,72.44,72.44,,,,,,
BCBS PPO,CPT,Q4041,Cast sup lng leg splnt plstr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,68.63,68.63,,,,,,
BCBS PPO,CPT,Q4042,Cast sup lng leg splnt fbrgl,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,118.19,118.19,,,,,,
BCBS PPO,CPT,Q4043,Cast sup lng leg splnt ped p,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.31,34.31,,,,,,
BCBS PPO,CPT,Q4044,Cast sup lng leg splnt ped f,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,57.19,57.19,,,,,,
BCBS PPO,CPT,Q4045,Cast sup sht leg splnt plstr,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.13,38.13,,,,,,
BCBS PPO,CPT,Q4046,Cast sup sht leg splnt fbrgl,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,64.82,64.82,,,,,,
BCBS PPO,CPT,Q4047,Cast sup sht leg splnt ped p,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,19.07,,,,,,
BCBS PPO,CPT,Q4048,Cast sup sht leg splnt ped f,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,30.51,30.51,,,,,,
BCBS PPO,CPT,Q4049,Finger splint- static,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.62,7.62,,,,,,
BCBS PPO,CPT,Q4080,Iloprost non-comp unit dose,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,236.38,236.38,,,,,,
BCBS PPO,CPT,Q4081,Epoetin alfa- 100 units esrd,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,Q4101,Apligraf,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,152.51,152.51,,,,,,
BCBS PPO,CPT,Q4102,Oasis wound matrix,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,19.07,,,,,,
BCBS PPO,CPT,Q4103,Oasis burn matrix,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,19.07,,,,,,
BCBS PPO,CPT,Q4104,Integra bmwd,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,57.19,57.19,,,,,,
BCBS PPO,CPT,Q4105,Integra drt or omnigraft,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,57.19,57.19,,,,,,
BCBS PPO,CPT,Q4106,Dermagraft,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,186.82,186.82,,,,,,
BCBS PPO,CPT,Q4108,Integra matrix,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,91.51,91.51,,,,,,
BCBS PPO,CPT,Q4109,Tissuemend skin sub,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,354.58,354.58,,,,,,
BCBS PPO,CPT,Q4110,Primatrix,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,175.39,175.39,,,,,,
BCBS PPO,CPT,Q4111,Gammagraft,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,34.31,34.31,,,,,,
BCBS PPO,CPT,Q4112,Cymetra injectable,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,502.21","1,502.21",,,,,,
BCBS PPO,CPT,Q4113,Graftjacket xpress,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,502.21","1,502.21",,,,,,
BCBS PPO,CPT,Q4114,Integra flowable wound matri,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"4,373.16","4,373.16",,,,,,
BCBS PPO,CPT,Q9951,Locm >= 400 mg/ml iodine-1ml,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.44,11.44,,,,,,
BCBS PPO,CPT,Q9953,Inj fe-based mr contrast-1ml,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,148.69,148.69,,,,,,
BCBS PPO,CPT,Q9954,Oral mr contrast- 100 ml,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,45.74,45.74,,,,,,
BCBS PPO,CPT,Q9955,Inj perflexane lip micros-ml,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,64.82,64.82,,,,,,
BCBS PPO,CPT,Q9956,Inj octafluoropropane mic-ml,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,202.07,202.07,,,,,,
BCBS PPO,CPT,Q9957,Inj perflutren lip micros-ml,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,301.2,301.2,,,,,,
BCBS PPO,CPT,Q9958,Hocm <=149 mg/ml iodine- 1ml,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,2.46,2.46,,,,,,
BCBS PPO,CPT,Q9960,Hocm 200-249mg/ml iodine-1ml,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,2.46,2.46,,,,,,
BCBS PPO,CPT,Q9961,Hocm 250-299mg/ml iodine-1ml,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,2.46,2.46,,,,,,
BCBS PPO,CPT,Q9963,Hocm 350-399mg/ml iodine-1ml,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,2.46,2.46,,,,,,
BCBS PPO,CPT,Q9964,Hocm>= 400mg/ml iodine- 1ml,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,2.46,2.46,,,,,,
BCBS PPO,CPT,Q9966,Locm 200-299mg/ml iodine-1ml,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,2.46,2.46,,,,,,
BCBS PPO,CPT,Q9967,Locm 300-399mg/ml iodine-1ml,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,2.46,2.46,,,,,,
BCBS PPO,CPT,R0070,Transport portable x-ray,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,152.51,152.51,,,,,,
BCBS PPO,CPT,R0075,Transport port x-ray multipl,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,137.25,137.25,,,,,,
BCBS PPO,CPT,R0076,Transport portable ekg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,137.25,137.25,,,,,,
BCBS PPO,CPT,S0012,Butorphanol tartrate nasal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,285.96,285.96,,,,,,
BCBS PPO,CPT,S0014,Tacrine hydrochloride 10 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.44,11.44,,,,,,
BCBS PPO,CPT,S0017,Injection aminocaproic acid,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,S0020,Injection bupivicaine hydro,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.44,11.44,,,,,,
BCBS PPO,CPT,S0021,Injection cefoperazone sod,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,68.63,68.63,,,,,,
BCBS PPO,CPT,S0023,Injection cimetidine hydroc,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.44,11.44,,,,,,
BCBS PPO,CPT,S0028,Injection famotidine 20 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,19.07,,,,,,
BCBS PPO,CPT,S0030,Injection metronidazole,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,19.07,,,,,,
BCBS PPO,CPT,S0034,Injection ofloxacin 400 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,11.44,11.44,,,,,,
BCBS PPO,CPT,S0039,Injection sulfamethoxazole,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.88,22.88,,,,,,
BCBS PPO,CPT,S0040,Injection ticarcillin disod,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,72.44,72.44,,,,,,
BCBS PPO,CPT,S0074,Injection cefotetan disodiu,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.7,26.7,,,,,,
BCBS PPO,CPT,S0080,Injection pentamidine iseth,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,205.88,205.88,,,,,,
BCBS PPO,CPT,S0081,Injection piperacillin sodi,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.62,7.62,,,,,,
BCBS PPO,CPT,S0088,Imatinib 100 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,118.99,118.99,,,,,,
BCBS PPO,CPT,S0090,Sildenafil citrate 25 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,64.82,64.82,,,,,,
BCBS PPO,CPT,S0091,Granisetron 1mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,45.74,45.74,,,,,,
BCBS PPO,CPT,S0092,Hydromorphone 250 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,457.52,457.52,,,,,,
BCBS PPO,CPT,S0093,Morphine 500 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,87.69,87.69,,,,,,
BCBS PPO,CPT,S0104,Zidovudine oral 100 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,61,61,,,,,,
BCBS PPO,CPT,S0106,Bupropion hcl sr 60 tablets,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,491.83,491.83,,,,,,
BCBS PPO,CPT,S0108,Mercaptopurine 50 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,6.72,6.72,,,,,,
BCBS PPO,CPT,S0109,Methadone oral 5mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.9,1.9,,,,,,
BCBS PPO,CPT,S0117,Tretinoin topical 5 g,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,49.56,49.56,,,,,,
BCBS PPO,CPT,S0122,Inj menotropins 75 iu,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,278.67,278.67,,,,,,
BCBS PPO,CPT,S0126,Inj follitropin alfa 75 iu,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,339.52,339.52,,,,,,
BCBS PPO,CPT,S0128,Inj follitropin beta 75 iu,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,331.25,331.25,,,,,,
BCBS PPO,CPT,S0132,Inj ganirelix acetat 250 mcg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,465.15,465.15,,,,,,
BCBS PPO,CPT,S0136,Clozapine 25 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,S0137,Didanosine 25 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,S0138,Finasteride 5 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.26,15.26,,,,,,
BCBS PPO,CPT,S0139,Minoxidil 10 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.62,7.62,,,,,,
BCBS PPO,CPT,S0140,Saquinavir 200 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.62,7.62,,,,,,
BCBS PPO,CPT,S0146,Peg interferon alfa-2b/10,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,324.5,324.5,,,,,,
BCBS PPO,CPT,S0155,Epoprostenol dilutant,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,61,61,,,,,,
BCBS PPO,CPT,S0156,Exemestane 25 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,41.33,41.33,,,,,,
BCBS PPO,CPT,S0157,Becaplermin gel 1% 0.5 gm,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,80.07,80.07,,,,,,
BCBS PPO,CPT,S0160,Dextroamphetamine,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,S0161,Calcitrol,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.62,7.62,,,,,,
BCBS PPO,CPT,S0162,Injection efalizumab,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,549.75","1,549.75",,,,,,
BCBS PPO,CPT,S0164,Injection pantroprazole,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,57.19,57.19,,,,,,
BCBS PPO,CPT,S0166,Inj olanzapine 2.5mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,30.51,30.51,,,,,,
BCBS PPO,CPT,S0170,Anastrozole 1 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,49.56,49.56,,,,,,
BCBS PPO,CPT,S0171,Bumetanide 0.5 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.62,7.62,,,,,,
BCBS PPO,CPT,S0172,Chlorambucil 2 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,15.26,15.26,,,,,,
BCBS PPO,CPT,S0174,Dolasetron 50 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,228.77,228.77,,,,,,
BCBS PPO,CPT,S0175,Flutamide 125 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.62,7.62,,,,,,
BCBS PPO,CPT,S0176,Hydroxyurea 500 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.62,7.62,,,,,,
BCBS PPO,CPT,S0177,Levamisole 50 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,22.88,22.88,,,,,,
BCBS PPO,CPT,S0178,Lomustine 10 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,41.94,41.94,,,,,,
BCBS PPO,CPT,S0181,ONDANSETRON HYDROCHLORIDE ORAL 4 MG,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,89.98,89.98,,,,,,
BCBS PPO,CPT,S0182,Procarbazine oral,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,176.19,176.19,,,,,,
BCBS PPO,CPT,S0183,Prochlorperazine 5 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,S0187,Tamoxifen 10 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.62,7.62,,,,,,
BCBS PPO,CPT,S0189,Testosterone pellet 75 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,285.96,285.96,,,,,,
BCBS PPO,CPT,S0190,Mifepristone oral 200 mg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,343.14,343.14,,,,,,
BCBS PPO,CPT,S0191,Misoprostol oral 200 mcg,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,7.62,7.62,,,,,,
BCBS PPO,CPT,S0195,PNEUMCOCCL VAC IM 5-9 YR NOT PREV,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,427.03,427.03,,,,,,
BCBS PPO,CPT,S0199,Med abortion inc all ex drug,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,600.26","2,600.26",,,,,,
BCBS PPO,CPT,S0220,Medical conference by physic,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,228.77,228.77,,,,,,
BCBS PPO,CPT,S0221,Medical conference 60 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,293.57,293.57,,,,,,
BCBS PPO,CPT,S0345,Electrocardiographic monitoring utilizing a home computerized telemetry station,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,19.07,,,,,,
BCBS PPO,CPT,S0395,Impression casting ft,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,362.21,362.21,,,,,,
BCBS PPO,CPT,S0400,Global eswl kidney,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"7,007.73","7,007.73",,,,,,
BCBS PPO,CPT,S0592,Comp cont lens eval,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,449.9,449.9,,,,,,
BCBS PPO,CPT,S0601,Screening proctoscopy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,427.03,427.03,,,,,,
BCBS PPO,CPT,S0605,Digital rectal examination-,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,102.95,102.95,,,,,,
BCBS PPO,CPT,S0610,Annual gynecological examina,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,335.53,335.53,,,,,,
BCBS PPO,CPT,S0612,Annual gynecological examina,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,198.25,198.25,,,,,,
BCBS PPO,CPT,S0613,Ann breast exam,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.07,19.07,,,,,,
BCBS PPO,CPT,S0618,Audiometry for hearing aid,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,571.91,571.91,,,,,,
BCBS PPO,CPT,S0620,Routine ophthalmological exa,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,411.78,411.78,,,,,,
BCBS PPO,CPT,S0621,Routine ophthalmological exa,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,434.65,434.65,,,,,,
BCBS PPO,CPT,S0625,Digital screening retina,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,476.6,476.6,,,,,,
BCBS PPO,CPT,S0800,Laser in situ keratomileusis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"7,625.38","7,625.38",,,,,,
BCBS PPO,CPT,S0810,Photorefractive keratectomy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,435.25","3,435.25",,,,,,
BCBS PPO,CPT,S1015,Iv tubing extension set,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,122,122,,,,,,
BCBS PPO,CPT,S1040,Cranial remolding orthosis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"7,625.38","7,625.38",,,,,,
BCBS PPO,CPT,S2060,Lobar lung transplantation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"15,876.06","15,876.06",,,,,,
BCBS PPO,CPT,S2112,Knee arthroscp harv,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,286.54","3,286.54",,,,,,
BCBS PPO,CPT,S2120,Low density lipoprotein(ldl),Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"11,903.22","11,903.22",,,,,,
BCBS PPO,CPT,S2140,Cord blood harvesting,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,953.17,953.17,,,,,,
BCBS PPO,CPT,S2202,Echosclerotherapy,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,567.02","1,567.02",,,,,,
BCBS PPO,CPT,S2205,Minimally invasive direct co,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"11,175.00","11,175.00",,,,,,
BCBS PPO,CPT,S2206,Minimally invasive direct co,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"12,841.16","12,841.16",,,,,,
BCBS PPO,CPT,S2207,Minimally invasive direct co,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"11,403.76","11,403.76",,,,,,
BCBS PPO,CPT,S2300,Arthroscopy shoulder surgi,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"3,515.30","3,515.30",,,,,,
BCBS PPO,CPT,S2350,Diskectomy anterior with d,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"9,935.88","9,935.88",,,,,,
BCBS PPO,CPT,S2351,Diskectomy anterior with d,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,780.53","1,780.53",,,,,,
BCBS PPO,CPT,S2360,PERQ VERTPLSTY 1 VERT BDY UNILAT/BILAT INJ-CERV,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"13,165.23","13,165.23",,,,,,
BCBS PPO,CPT,S2361,EACH ADDITIONAL CERVICAL VERTEBRAL BODY,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,612.76","1,612.76",,,,,,
BCBS PPO,CPT,S2900,Robotic surgical system,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"9,531.74","9,531.74",,,,,,
BCBS PPO,CPT,S3645,Hiv-1 antibody testing of or,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,167.76,167.76,,,,,,
BCBS PPO,CPT,S3835,CMPL GENE SEQ ANALY CYSTIC FIBROSIS GENETIC TST,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,345.89","1,345.89",,,,,,
BCBS PPO,CPT,S3902,Ballistocardiogram,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.39,114.39,,,,,,
BCBS PPO,CPT,S3904,Masters two step,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.39,114.39,,,,,,
BCBS PPO,CPT,S4981,Insert levonorgestrel ius,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"2,161.80","2,161.80",,,,,,
BCBS PPO,CPT,S4989,Contracept iud,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,639.46","1,639.46",,,,,,
BCBS PPO,CPT,S5498,Hit simple cath care,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,30.51,30.51,,,,,,
BCBS PPO,CPT,S5501,Hit complex cath care,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,57.19,57.19,,,,,,
BCBS PPO,CPT,S5502,Hit interim cath care,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,57.19,57.19,,,,,,
BCBS PPO,CPT,S5517,Hit declotting kit,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.26,76.26,,,,,,
BCBS PPO,CPT,S5520,Hit picc insert kit,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,571.91,571.91,,,,,,
BCBS PPO,CPT,S5521,Hit midline cath insert kit,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,495.65,495.65,,,,,,
BCBS PPO,CPT,S5522,Hit picc insert no supp,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,495.65,495.65,,,,,,
BCBS PPO,CPT,S5523,Hip midline cath insert kit,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,495.65,495.65,,,,,,
BCBS PPO,CPT,S8096,Portable peak flow meter,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,91.51,91.51,,,,,,
BCBS PPO,CPT,S8101,Spacer with mask,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,247.83,247.83,,,,,,
BCBS PPO,CPT,S8110,Peak expiratory flow rate (p,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,122,122,,,,,,
BCBS PPO,CPT,S8421,Ready gradient sleev/glov,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,392.7,392.7,,,,,,
BCBS PPO,CPT,S8424,Ready gradient sleeve,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,453.71,453.71,,,,,,
BCBS PPO,CPT,S8427,Ready gradient glove,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,629.1,629.1,,,,,,
BCBS PPO,CPT,S8428,Ready gradient gauntlet,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,247.83,247.83,,,,,,
BCBS PPO,CPT,S8431,Compression bandage,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,57.19,57.19,,,,,,
BCBS PPO,CPT,S8450,Splint digit,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,110.57,110.57,,,,,,
BCBS PPO,CPT,S8451,Splint wrist or ankle,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,183.02,183.02,,,,,,
BCBS PPO,CPT,S8452,Splint elbow,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,133.45,133.45,,,,,,
BCBS PPO,CPT,S8948,Low-level laser trmt 15 min,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,266.89,266.89,,,,,,
BCBS PPO,CPT,S8990,Pt or manip for maint,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,133.45,133.45,,,,,,
BCBS PPO,CPT,S9015,Automated EEG monitoring,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,349.70","1,349.70",,,,,,
BCBS PPO,CPT,S9025,Omnicardiogram/cardiointegra,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.39,114.39,,,,,,
BCBS PPO,CPT,S9061,Medical supplies and equipme,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,400.34,400.34,,,,,,
BCBS PPO,CPT,S9088,Services provided in urgent,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,1.9,1.9,,,,,,
BCBS PPO,CPT,S9090,Vertebral axial decompressio,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,762.54,762.54,,,,,,
BCBS PPO,CPT,S9122,Home health aide or certifie,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,87.69,87.69,,,,,,
BCBS PPO,CPT,S9123,Nursing care in home rn,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,209.7,209.7,,,,,,
BCBS PPO,CPT,S9124,Nursing care in the home; b,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,183.02,183.02,,,,,,
BCBS PPO,CPT,S9128,Speech therapy in the home,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,327.9,327.9,,,,,,
BCBS PPO,CPT,S9129,Occupational therapy in the,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,400.34,400.34,,,,,,
BCBS PPO,CPT,S9131,Pt in the home per diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,667.22,667.22,,,,,,
BCBS PPO,CPT,S9140,Diabetic management program,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,125.82,125.82,,,,,,
BCBS PPO,CPT,S9141,Diabetic management program,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,125.82,125.82,,,,,,
BCBS PPO,CPT,S9208,Home mgmt preterm labor,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,388.89,388.89,,,,,,
BCBS PPO,CPT,S9209,Home mgmt pprom,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,754.91,754.91,,,,,,
BCBS PPO,CPT,S9211,Home mgmt gest hypertension,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,179.2,179.2,,,,,,
BCBS PPO,CPT,S9212,Hm postpar hyper per diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,388.89,388.89,,,,,,
BCBS PPO,CPT,S9213,Hm preeclamp per diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,388.89,388.89,,,,,,
BCBS PPO,CPT,S9214,Hm gest dm per diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,571.91,571.91,,,,,,
BCBS PPO,CPT,S9325,Hit pain mgmt per diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,228.77,228.77,,,,,,
BCBS PPO,CPT,S9326,Hit cont pain per diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,285.96,285.96,,,,,,
BCBS PPO,CPT,S9327,Hit int pain per diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,228.77,228.77,,,,,,
BCBS PPO,CPT,S9329,Hit chemo per diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,305.01,305.01,,,,,,
BCBS PPO,CPT,S9330,Hit cont chem diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,305.01,305.01,,,,,,
BCBS PPO,CPT,S9331,Hit intermit chemo diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,305.01,305.01,,,,,,
BCBS PPO,CPT,S9336,Hit cont anticoag diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,285.96,285.96,,,,,,
BCBS PPO,CPT,S9338,Hit immunotherapy diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,381.27,381.27,,,,,,
BCBS PPO,CPT,S9340,Hit enteral per diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,95.32,95.32,,,,,,
BCBS PPO,CPT,S9341,Hit enteral grav diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,114.39,114.39,,,,,,
BCBS PPO,CPT,S9342,Hit enteral pump diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,171.58,171.58,,,,,,
BCBS PPO,CPT,S9343,Hit enteral bolus nurs,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,95.32,95.32,,,,,,
BCBS PPO,CPT,S9345,Hit anti-hemophil diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,95.32,95.32,,,,,,
BCBS PPO,CPT,S9346,Hit alpha-1-proteinas diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,266.89,266.89,,,,,,
BCBS PPO,CPT,S9347,Hit longterm infusion diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,343.14,343.14,,,,,,
BCBS PPO,CPT,S9348,Hit sympathomim diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,667.22,667.22,,,,,,
BCBS PPO,CPT,S9349,Hit tocolysis diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,285.96,285.96,,,,,,
BCBS PPO,CPT,S9351,Hit cont antiemetic diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,305.01,305.01,,,,,,
BCBS PPO,CPT,S9353,Hit cont insulin diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,285.96,285.96,,,,,,
BCBS PPO,CPT,S9355,Hit chelation diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,285.96,285.96,,,,,,
BCBS PPO,CPT,S9357,Hit enzyme replace diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,285.96,285.96,,,,,,
BCBS PPO,CPT,S9359,Hit anti-tnf per diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,305.01,305.01,,,,,,
BCBS PPO,CPT,S9361,Hit diuretic infus diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,95.32,95.32,,,,,,
BCBS PPO,CPT,S9363,Hit anti-spasmotic diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,95.32,95.32,,,,,,
BCBS PPO,CPT,S9364,Hit tpn total diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,648.16,648.16,,,,,,
BCBS PPO,CPT,S9365,Hit tpn 1 liter diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,648.16,648.16,,,,,,
BCBS PPO,CPT,S9366,Hit tpn 2 liter diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,915.04,915.04,,,,,,
BCBS PPO,CPT,S9367,Hit tpn 3 liter diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,105.68","1,105.68",,,,,,
BCBS PPO,CPT,S9368,Hit tpn over 3l diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,296.32","1,296.32",,,,,,
BCBS PPO,CPT,S9370,Ht inj antiemetic diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,266.89,266.89,,,,,,
BCBS PPO,CPT,S9372,Ht inj anticoag diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.26,76.26,,,,,,
BCBS PPO,CPT,S9373,Hit hydra total diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,152.51,152.51,,,,,,
BCBS PPO,CPT,S9374,Hit hydra 1 liter diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,152.51,152.51,,,,,,
BCBS PPO,CPT,S9375,Hit hydra 2 liter diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,190.64,190.64,,,,,,
BCBS PPO,CPT,S9376,Hit hydra 3 liter diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,228.77,228.77,,,,,,
BCBS PPO,CPT,S9377,Hit hydra over 3l diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,266.89,266.89,,,,,,
BCBS PPO,CPT,S9430,Pharmacy comp/disp serv,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,3.82,3.82,,,,,,
BCBS PPO,CPT,S9455,Diabetic management program,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,72.44,72.44,,,,,,
BCBS PPO,CPT,S9460,Diabetic management program,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,125.82,125.82,,,,,,
BCBS PPO,CPT,S9465,Diabetic management program,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,125.82,125.82,,,,,,
BCBS PPO,CPT,S9470,Nutritional counseling diet,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,228.77,228.77,,,,,,
BCBS PPO,CPT,S9480,Intensive outpatient psychia,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,468.96,468.96,,,,,,
BCBS PPO,CPT,S9490,Hit corticosteroid/diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,228.77,228.77,,,,,,
BCBS PPO,CPT,S9494,Hit antibiotic total diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,228.77,228.77,,,,,,
BCBS PPO,CPT,S9497,Hit antibiotic q3h diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,324.09,324.09,,,,,,
BCBS PPO,CPT,S9500,Hit antibiotic q24h diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,266.89,266.89,,,,,,
BCBS PPO,CPT,S9501,Hit antibiotic q12h diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,266.89,266.89,,,,,,
BCBS PPO,CPT,S9502,Hit antibiotic q8h diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,266.89,266.89,,,,,,
BCBS PPO,CPT,S9503,Hit antibiotic q6h diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,305.01,305.01,,,,,,
BCBS PPO,CPT,S9504,Hit antibiotic q4h diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,305.01,305.01,,,,,,
BCBS PPO,CPT,S9529,Venipuncture home/snf,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,38.13,38.13,,,,,,
BCBS PPO,CPT,S9537,Ht hem horm inj diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.26,76.26,,,,,,
BCBS PPO,CPT,S9538,Hit blood products diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,305.01,305.01,,,,,,
BCBS PPO,CPT,S9542,Ht inj noc per diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.26,76.26,,,,,,
BCBS PPO,CPT,S9558,Ht inj growth horm diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.26,76.26,,,,,,
BCBS PPO,CPT,S9559,Hit inj interferon diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.26,76.26,,,,,,
BCBS PPO,CPT,S9560,Ht inj hormone diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.26,76.26,,,,,,
BCBS PPO,CPT,S9562,Ht inj palivizumab diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.26,76.26,,,,,,
BCBS PPO,CPT,S9590,Ht irrigation diem,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.26,76.26,,,,,,
BCBS PPO,CPT,V2020,Vision svcs frames purchases,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,75.22,388.89,,,,,,
BCBS PPO,CPT,V2100,Lens spher single plano 4.00,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,46.49,240.2,,,,,,
BCBS PPO,CPT,V2101,Single visn sphere 4.12-7.00,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,44.67,228.77,,,,,,
BCBS PPO,CPT,V2102,Singl visn sphere 7.12-20.00,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,77.24,400.34,,,,,,
BCBS PPO,CPT,V2103,Spherocylindr 4.00d/12-2.00d,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,39.13,202.07,,,,,,
BCBS PPO,CPT,V2104,Spherocylindr 4.00d/2.12-4d,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,40.34,209.7,,,,,,
BCBS PPO,CPT,V2105,Spherocylinder 4.00d/4.25-6d,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,47.98,247.83,,,,,,
BCBS PPO,CPT,V2106,Spherocylinder 4.00d/>6.00d,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,53.15,274.51,,,,,,
BCBS PPO,CPT,V2107,Spherocylinder 4.25d/12-2d,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,47.33,244.01,,,,,,
BCBS PPO,CPT,V2108,Spherocylinder 4.25d/2.12-4d,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,47.46,244.01,,,,,,
BCBS PPO,CPT,V2109,Spherocylinder 4.25d/4.25-6d,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,66.1,339.33,,,,,,
BCBS PPO,CPT,V2110,Spherocylinder 4.25d/over 6d,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,53.39,274.51,,,,,,
BCBS PPO,CPT,V2111,Spherocylindr 7.25d/.25-2.25,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,64.7,335.53,,,,,,
BCBS PPO,CPT,V2112,Spherocylindr 7.25d/2.25-4d,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,73.09,377.46,,,,,,
BCBS PPO,CPT,V2113,Spherocylindr 7.25d/4.25-6d,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,73.91,381.27,,,,,,
BCBS PPO,CPT,V2114,Spherocylinder over 12.00d,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,87.57,453.71,,,,,,
BCBS PPO,CPT,V2115,Lens lenticular bifocal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,88.27,453.71,,,,,,
BCBS PPO,CPT,V2118,Lens aniseikonic single,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,96.05,495.65,,,,,,
BCBS PPO,CPT,V2121,Lenticular lens- single,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,86.61,446.08,,,,,,
BCBS PPO,CPT,V2200,Lens spher bifoc plano 4.00d,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,52.35,270.71,,,,,,
BCBS PPO,CPT,V2201,Lens sphere bifocal 4.12-7.0,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,56.09,289.76,,,,,,
BCBS PPO,CPT,V2202,Lens sphere bifocal 7.12-20.,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,69.53,358.39,,,,,,
BCBS PPO,CPT,V2203,Lens sphcyl bifocal 4.00d/.1,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,53.92,278.32,,,,,,
BCBS PPO,CPT,V2204,Lens sphcy bifocal 4.00d/2.1,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,55.48,285.96,,,,,,
BCBS PPO,CPT,V2205,Lens sphcy bifocal 4.00d/4.2,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,61.51,316.46,,,,,,
BCBS PPO,CPT,V2206,Lens sphcy bifocal 4.00d/ove,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,72.21,373.65,,,,,,
BCBS PPO,CPT,V2207,Lens sphcy bifocal 4.25-7d/.,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,61.03,316.46,,,,,,
BCBS PPO,CPT,V2208,Lens sphcy bifocal 4.25-7/2.,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,59.97,308.83,,,,,,
BCBS PPO,CPT,V2209,Lens sphcy bifocal 4.25-7/4.,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,70.4,362.21,,,,,,
BCBS PPO,CPT,V2210,Lens sphcy bifocal 4.25-7/ov,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,75.86,392.7,,,,,,
BCBS PPO,CPT,V2211,Lens sphcy bifo 7.25-12/.25-,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,73.85,381.27,,,,,,
BCBS PPO,CPT,V2212,Lens sphcyl bifo 7.25-12/2.2,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,77.3,400.34,,,,,,
BCBS PPO,CPT,V2213,Lens sphcyl bifo 7.25-12/4.2,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,81.28,419.4,,,,,,
BCBS PPO,CPT,V2214,Lens sphcyl bifocal over 12.,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,84.95,438.47,,,,,,
BCBS PPO,CPT,V2215,Lens lenticular bifocal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,106.06,549.03,,,,,,
BCBS PPO,CPT,V2218,Lens aniseikonic bifocal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,108.09,556.65,,,,,,
BCBS PPO,CPT,V2219,Lens bifocal seg width over,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,49.86,255.45,,,,,,
BCBS PPO,CPT,V2220,Lens bifocal add over 3.25d,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,44.28,228.77,,,,,,
BCBS PPO,CPT,V2221,Lenticular lens- bifocal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,88.33,457.52,,,,,,
BCBS PPO,CPT,V2300,Lens sphere trifocal 4.00d,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,71.57,369.83,,,,,,
BCBS PPO,CPT,V2301,Lens sphere trifocal 4.12-7.,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,87.77,453.71,,,,,,
BCBS PPO,CPT,V2302,Lens sphere trifocal 7.12-20,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,82,423.22,,,,,,
BCBS PPO,CPT,V2303,Lens sphcy trifocal 4.0/.12-,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,68.89,354.58,,,,,,
BCBS PPO,CPT,V2304,Lens sphcy trifocal 4.0/2.25,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,69.7,358.39,,,,,,
BCBS PPO,CPT,V2305,Lens sphcy trifocal 4.0/4.25,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,77.86,400.34,,,,,,
BCBS PPO,CPT,V2306,Lens sphcyl trifocal 4.00/>6,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,80.17,411.78,,,,,,
BCBS PPO,CPT,V2307,Lens sphcy trifocal 4.25-7/.,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,76.33,392.7,,,,,,
BCBS PPO,CPT,V2308,Lens sphc trifocal 4.25-7/2.,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,83.26,430.83,,,,,,
BCBS PPO,CPT,V2309,Lens sphc trifocal 4.25-7/4.,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,87.13,449.9,,,,,,
BCBS PPO,CPT,V2310,Lens sphc trifocal 4.25-7/>6,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,91.01,468.96,,,,,,
BCBS PPO,CPT,V2311,Lens sphc trifo 7.25-12/.25-,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,105.08,541.4,,,,,,
BCBS PPO,CPT,V2312,Lens sphc trifo 7.25-12/2.25,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,96.32,495.65,,,,,,
BCBS PPO,CPT,V2313,Lens sphc trifo 7.25-12/4.25,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,105.15,541.4,,,,,,
BCBS PPO,CPT,V2314,Lens sphcyl trifocal over 12,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,107.48,552.84,,,,,,
BCBS PPO,CPT,V2315,Lens lenticular trifocal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,119.32,613.85,,,,,,
BCBS PPO,CPT,V2318,Lens aniseikonic trifocal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,146.68,754.91,,,,,,
BCBS PPO,CPT,V2319,Lens trifocal seg width > 28,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,66.22,343.14,,,,,,
BCBS PPO,CPT,V2320,Lens trifocal add over 3.25d,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,69.85,362.21,,,,,,
BCBS PPO,CPT,V2321,Lenticular lens- trifocal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,117.61,606.21,,,,,,
BCBS PPO,CPT,V2410,Lens variab asphericity sing,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,102.83,529.96,,,,,,
BCBS PPO,CPT,V2430,Lens variable asphericity bi,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,108.84,560.47,,,,,,
BCBS PPO,CPT,V2501,Cntct lens pmma-toric/prism,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,130.56,674.85,,,,,,
BCBS PPO,CPT,V2502,Contact lens pmma bifocal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,176.91,911.23,,,,,,
BCBS PPO,CPT,V2503,Cntct lens pmma color vision,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,170.87,880.74,,,,,,
BCBS PPO,CPT,V2510,Cntct gas permeable sphericl,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,122.68,632.91,,,,,,
BCBS PPO,CPT,V2511,Cntct toric prism ballast,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,181.84,937.93,,,,,,
BCBS PPO,CPT,V2512,Cntct lens gas permbl bifocl,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,209.31,"1,078.99",,,,,,
BCBS PPO,CPT,V2513,Contact lens extended wear,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,210.87,"1,086.62",,,,,,
BCBS PPO,CPT,V2520,Contact lens hydrophilic,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,122.25,629.1,,,,,,
BCBS PPO,CPT,V2521,Cntct lens hydrophilic toric,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,242.09,"1,250.57",,,,,,
BCBS PPO,CPT,V2522,Cntct lens hydrophil bifocl,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,177.16,915.04,,,,,,
BCBS PPO,CPT,V2523,Cntct lens hydrophil extend,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,186,960.8,,,,,,
BCBS PPO,CPT,V2530,Contact lens gas impermeable,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,297.37,"1,532.70",,,,,,
BCBS PPO,CPT,V2531,Contact lens gas permeable,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,544.58,"2,809.96",,,,,,
BCBS PPO,CPT,V2623,Plastic eye prosth custom,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,942.94,"4,864.99",,,,,,
BCBS PPO,CPT,V2624,Polishing artifical eye,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,60.88,312.64,,,,,,
BCBS PPO,CPT,V2625,Enlargemnt of eye prosthesis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,482.12,"2,485.87",,,,,,
BCBS PPO,CPT,V2626,Reduction of eye prosthesis,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,199.51,"1,029.43",,,,,,
BCBS PPO,CPT,V2627,Scleral cover shell,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,430.28","7,377.56",,,,,,
BCBS PPO,CPT,V2628,Fabrication & fitting,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,304.24,"1,570.83",,,,,,
BCBS PPO,CPT,V2630,Anter chamber intraocul lens,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,849.16","1,849.16",,,,,,
BCBS PPO,CPT,V2631,Iris support intraoclr lens,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,849.16","1,849.16",,,,,,
BCBS PPO,CPT,V2632,Post chmbr intraocular lens,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,"1,849.16","1,849.16",,,,,,
BCBS PPO,CPT,V2700,Balance lens,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,44.84,232.58,,,,,,
BCBS PPO,CPT,V2710,Glass/plastic slab off prism,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,73.51,377.46,,,,,,
BCBS PPO,CPT,V2715,Prism lens/es,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,14.41,72.44,,,,,,
BCBS PPO,CPT,V2718,Fresnell prism press-on lens,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,31.12,160.13,,,,,,
BCBS PPO,CPT,V2730,Special base curve,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,26.06,133.45,,,,,,
BCBS PPO,CPT,V2744,Tint photochromatic lens/es,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,17.83,91.51,,,,,,
BCBS PPO,CPT,V2745,Tint- any color/solid/grad,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,10.27,53.38,,,,,,
BCBS PPO,CPT,V2750,Anti-reflective coating,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,20.02,102.95,,,,,,
BCBS PPO,CPT,V2755,Uv lens/es,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,16.76,87.69,,,,,,
BCBS PPO,CPT,V2760,Scratch resistant coating,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,83.87,83.87,,,,,,
BCBS PPO,CPT,V2762,Polarization- any lens,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,308.83,308.83,,,,,,
BCBS PPO,CPT,V2770,Occluder lens/es,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,19.52,99.13,,,,,,
BCBS PPO,CPT,V2780,Oversize lens/es,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,12.53,64.82,,,,,,
BCBS PPO,CPT,V2782,Lens- 1.54-1.65 p/1.60-1.79g,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,64.75,335.53,,,,,,
BCBS PPO,CPT,V2783,Lens- >= 1.66 p/>=1.80 g,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,73.02,377.46,,,,,,
BCBS PPO,CPT,V2784,Lens polycarb or equal,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,47.48,244.01,,,,,,
BCBS PPO,CPT,V5008,Hearing screening,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,354.58,354.58,,,,,,
BCBS PPO,CPT,V5010,Assessment for hearing aid,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,648.16,648.16,,,,,,
BCBS PPO,CPT,V5014,Hearing aid repair/modifying,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,953.17,953.17,,,,,,
BCBS PPO,CPT,V5020,Conformity evaluation,Non-Surgical/Non-Observation,Straight Discount,93.90%,OP,190.64,190.64,,,,,,
BCBS PPO,ExceptRevenueCode,274,Medical/Surgical Supplies: Prosthetic/Orthotic devices,Implants,Straight Discount,33.30%,OP,,,,,,,,
BCBS PPO,ExceptRevenueCode,275,Medical/Surgical Supplies: Pacemaker,Implants,Straight Discount,33.30%,OP,,,,,,,,
BCBS PPO,ExceptRevenueCode,276,Medical/Surgical Supplies: Intraocular lens,Implants,Straight Discount,33.30%,OP,,,,,,,,
BCBS PPO,ExceptRevenueCode,278,Medical/Surgical Supplies: Other implants,Implants,Straight Discount,33.30%,OP,,,,,,,,
BCBS PPO,ExceptRevenueCode,760,Treatment/Observation Room,Observation,Per Case,"$3,464.00 ",OP,"2,420.00","3,464.00",,,,,,
BCBS PPO,ExceptRevenueCode,762,Treatment/Observation Room: Observation room,Observation,Per Case,"$3,464.00 ",OP,"2,420.00","3,464.00",,,,,,
BCBS PPO,ExceptRevenueCode,769,Treatment/Observation Room: Other treatment room,Observation,Per Case,"$3,464.00 ",OP,"2,944.00","3,464.00",,,,,,
BCBS PPO,,,,All Other,Straight Discount,78.20%,OP,,,,,,,,
Cigna,DRG,MS-001,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W MCC,Surgical,Relative Weights,"$303,972.90 ",IP,"17,718.00","557,099.42",,,,,,
Cigna,DRG,MS-002,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W/O MCC,Surgical,Relative Weights,"$154,150.70 ",IP,"17,718.00","282,516.19",,,,,,
Cigna,DRG,MS-003,ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITH MAJOR O.R. PROCEDURES,Surgical,Relative Weights,"$208,492.90 ",IP,"111,577.60","382,110.62",,,,,,
Cigna,DRG,MS-004,TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES,Surgical,Relative Weights,"$126,981.80 ",IP,"69,628.33","232,723.01",,,,,,
Cigna,DRG,MS-005,LIVER TRANSPLANT W MCC OR INTESTINAL TRANSPLANT,Surgical,Relative Weights,"$113,439.70 ",IP,"59,773.19","207,904.03",,,,,,
Cigna,DRG,MS-006,LIVER TRANSPLANT W/O MCC,Surgical,Relative Weights,"$53,590.90 ",IP,"27,427.34","98,217.50",,,,,,
Cigna,DRG,MS-007,LUNG TRANSPLANT,Surgical,Relative Weights,"$118,649.30 ",IP,"67,628.10","217,451.81",,,,,,
Cigna,DRG,MS-008,SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,Surgical,Relative Weights,"$61,777.10 ",IP,"31,730.89","113,220.58",,,,,,
Cigna,DRG,MS-010,PANCREAS TRANSPLANT,Surgical,Relative Weights,"$43,737.10 ",IP,"2,420.00","80,158.18",,,,,,
Cigna,DRG,MS-011,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC,Surgical,Relative Weights,"$54,381.80 ",IP,"2,420.00","99,667.01",,,,,,
Cigna,DRG,MS-012,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC,Surgical,Relative Weights,"$41,514.00 ",IP,"2,420.00","76,083.84",,,,,,
Cigna,DRG,MS-013,TRACHEOSTOMY FOR FACE -  MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC,Surgical,Relative Weights,"$26,678.30 ",IP,"2,420.00","48,894.05",,,,,,
Cigna,DRG,MS-014,ALLOGENEIC BONE MARROW TRANSPLANT,Surgical,Relative Weights,"$140,302.80 ",IP,"2,420.00","257,136.77",,,,,,
Cigna,DRG,MS-016,AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,Surgical,Relative Weights,"$75,737.20 ",IP,"2,420.00","138,805.63",,,,,,
Cigna,DRG,MS-017,AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,Surgical,Relative Weights,"$48,921.40 ",IP,"2,420.00","89,659.58",,,,,,
Cigna,DRG,MS-020,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,Surgical,Relative Weights,"$119,031.00 ",IP,"2,420.00","218,151.36",,,,,,
Cigna,DRG,MS-021,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,Surgical,Relative Weights,"$91,010.70 ",IP,"2,420.00","166,797.79",,,,,,
Cigna,DRG,MS-022,INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W/O CC/MCC,Surgical,Relative Weights,"$54,249.80 ",IP,"2,420.00","99,425.09",,,,,,
Cigna,DRG,MS-023,CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX CNS PDX W MCC OR CHEMO IMPLANT,Surgical,Relative Weights,"$61,788.10 ",IP,"2,420.00","113,240.74",,,,,,
Cigna,DRG,MS-024,CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,Surgical,Relative Weights,"$44,181.50 ",IP,"2,420.00","80,972.64",,,,,,
Cigna,DRG,MS-025,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$48,339.50 ",IP,"2,420.00","88,593.12",,,,,,
Cigna,DRG,MS-026,CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC,Surgical,Relative Weights,"$33,503.80 ",IP,"2,420.00","61,403.33",,,,,,
Cigna,DRG,MS-027,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$26,363.70 ",IP,"2,420.00","48,317.47",,,,,,
Cigna,DRG,MS-028,SPINAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$61,494.40 ",IP,"2,420.00","112,702.46",,,,,,
Cigna,DRG,MS-029,SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,Surgical,Relative Weights,"$35,277.00 ",IP,"2,420.00","64,653.12",,,,,,
Cigna,DRG,MS-030,SPINAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$24,993.10 ",IP,"2,420.00","45,805.54",,,,,,
Cigna,DRG,MS-031,VENTRICULAR SHUNT PROCEDURES WITH MCC,Surgical,Relative Weights,"$48,119.50 ",IP,"2,420.00","88,189.92",,,,,,
Cigna,DRG,MS-032,VENTRICULAR SHUNT PROCEDURES WITH CC,Surgical,Relative Weights,"$24,113.10 ",IP,"2,420.00","44,192.74",,,,,,
Cigna,DRG,MS-033,VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$18,709.90 ",IP,"2,420.00","34,290.14",,,,,,
Cigna,DRG,MS-034,CAROTID ARTERY STENT PROCEDURE W MCC,Surgical,Relative Weights,"$41,290.70 ",IP,"2,420.00","75,674.59",,,,,,
Cigna,DRG,MS-035,CAROTID ARTERY STENT PROCEDURES WITH CC,Surgical,Relative Weights,"$25,324.20 ",IP,"2,420.00","46,412.35",,,,,,
Cigna,DRG,MS-036,CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$19,261.00 ",IP,"2,420.00","35,300.16",,,,,,
Cigna,DRG,MS-037,EXTRACRANIAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$35,676.30 ",IP,"2,420.00","65,384.93",,,,,,
Cigna,DRG,MS-038,EXTRACRANIAL PROCEDURES WITH CC,Surgical,Relative Weights,"$18,427.20 ",IP,"2,420.00","33,772.03",,,,,,
Cigna,DRG,MS-039,EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$12,444.30 ",IP,"2,420.00","22,807.01",,,,,,
Cigna,DRG,MS-040,PERIPHERAL- CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC,Surgical,Relative Weights,"$43,344.40 ",IP,"2,420.00","79,438.46",,,,,,
Cigna,DRG,MS-041,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W CC OR PERIPH NEUROSTIM,Surgical,Relative Weights,"$26,086.50 ",IP,"2,420.00","47,809.44",,,,,,
Cigna,DRG,MS-042,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W/O CC/MCC,Surgical,Relative Weights,"$20,331.30 ",IP,"2,420.00","37,261.73",,,,,,
Cigna,DRG,MS-052,SPINAL DISORDERS AND INJURIES WITH CC/MCC,Surgical,Relative Weights,"$17,917.90 ",IP,"2,420.00","32,838.62",,,,,,
Cigna,DRG,MS-053,SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,627.10 ",IP,"2,420.00","19,476.58",,,,,,
Cigna,DRG,MS-054,NERVOUS SYSTEM NEOPLASMS WITH MCC,Surgical,Relative Weights,"$14,741.10 ",IP,"2,420.00","27,016.42",,,,,,
Cigna,DRG,MS-055,NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,Surgical,Relative Weights,"$10,846.00 ",IP,"2,420.00","19,877.76",,,,,,
Cigna,DRG,MS-056,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,Surgical,Relative Weights,"$24,116.40 ",IP,"2,420.00","44,198.78",,,,,,
Cigna,DRG,MS-057,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,Surgical,Relative Weights,"$13,318.80 ",IP,"2,420.00","24,409.73",,,,,,
Cigna,DRG,MS-058,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,Surgical,Relative Weights,"$21,501.70 ",IP,"2,420.00","39,406.75",,,,,,
Cigna,DRG,MS-059,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,Surgical,Relative Weights,"$11,995.50 ",IP,"2,420.00","21,984.48",,,,,,
Cigna,DRG,MS-060,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,Surgical,Relative Weights,"$9,698.70 ",IP,"2,420.00","17,775.07",,,,,,
Cigna,DRG,MS-061,ISCHEMIC STROKE -  PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC,Surgical,Relative Weights,"$30,728.50 ",IP,"2,420.00","56,316.96",,,,,,
Cigna,DRG,MS-062,ISCHEMIC STROKE -  PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC,Surgical,Relative Weights,"$22,123.20 ",IP,"2,420.00","40,545.79",,,,,,
Cigna,DRG,MS-063,ISCHEMIC STROKE- PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC,Surgical,Relative Weights,"$18,488.80 ",IP,"2,420.00","33,884.93",,,,,,
Cigna,DRG,MS-064,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,Surgical,Relative Weights,"$20,622.80 ",IP,"2,420.00","37,795.97",,,,,,
Cigna,DRG,MS-065,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC,Surgical,Relative Weights,"$11,304.70 ",IP,"2,420.00","20,718.43",,,,,,
Cigna,DRG,MS-066,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,Surgical,Relative Weights,"$7,887.00 ",IP,"2,420.00","14,454.72",,,,,,
Cigna,DRG,MS-067,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,Surgical,Relative Weights,"$16,109.50 ",IP,"2,420.00","29,524.32",,,,,,
Cigna,DRG,MS-068,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,Surgical,Relative Weights,"$9,937.40 ",IP,"2,420.00","18,212.54",,,,,,
Cigna,DRG,MS-069,TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,Surgical,Relative Weights,"$8,583.30 ",IP,"2,420.00","15,730.85",,,,,,
Cigna,DRG,MS-070,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC,Surgical,Relative Weights,"$18,401.90 ",IP,"2,420.00","33,725.66",,,,,,
Cigna,DRG,MS-071,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC,Surgical,Relative Weights,"$10,941.70 ",IP,"2,420.00","20,053.15",,,,,,
Cigna,DRG,MS-072,NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$8,123.50 ",IP,"2,420.00","14,888.16",,,,,,
Cigna,DRG,MS-073,CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,Surgical,Relative Weights,"$15,571.60 ",IP,"2,420.00","28,538.50",,,,,,
Cigna,DRG,MS-074,CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,Surgical,Relative Weights,"$10,869.10 ",IP,"2,420.00","19,920.10",,,,,,
Cigna,DRG,MS-075,VIRAL MENINGITIS WITH CC/MCC,Surgical,Relative Weights,"$17,690.20 ",IP,"2,420.00","32,421.31",,,,,,
Cigna,DRG,MS-076,VIRAL MENINGITIS WITHOUT CC/MCC,Surgical,Relative Weights,"$9,927.50 ",IP,"2,420.00","18,194.40",,,,,,
Cigna,DRG,MS-077,HYPERTENSIVE ENCEPHALOPATHY WITH MCC,Surgical,Relative Weights,"$16,967.50 ",IP,"2,420.00","31,096.80",,,,,,
Cigna,DRG,MS-078,HYPERTENSIVE ENCEPHALOPATHY WITH CC,Surgical,Relative Weights,"$10,582.00 ",IP,"2,420.00","19,393.92",,,,,,
Cigna,DRG,MS-079,HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC,Surgical,Relative Weights,"$8,152.10 ",IP,"2,420.00","14,940.58",,,,,,
Cigna,DRG,MS-080,NONTRAUMATIC STUPOR & COMA W MCC,Surgical,Relative Weights,"$21,079.30 ",IP,"2,420.00","38,632.61",,,,,,
Cigna,DRG,MS-081,NONTRAUMATIC STUPOR & COMA W/O MCC,Surgical,Relative Weights,"$9,670.10 ",IP,"2,420.00","17,722.66",,,,,,
Cigna,DRG,MS-082,TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,Surgical,Relative Weights,"$24,769.80 ",IP,"2,420.00","45,396.29",,,,,,
Cigna,DRG,MS-083,TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,Surgical,Relative Weights,"$14,417.70 ",IP,"2,420.00","26,423.71",,,,,,
Cigna,DRG,MS-084,TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,Surgical,Relative Weights,"$9,870.30 ",IP,"2,420.00","18,089.57",,,,,,
Cigna,DRG,MS-085,TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,Surgical,Relative Weights,"$24,703.80 ",IP,"2,420.00","45,275.33",,,,,,
Cigna,DRG,MS-086,TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,Surgical,Relative Weights,"$13,615.80 ",IP,"2,420.00","24,954.05",,,,,,
Cigna,DRG,MS-087,TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,Surgical,Relative Weights,"$9,231.20 ",IP,"2,420.00","16,918.27",,,,,,
Cigna,DRG,MS-088,CONCUSSION WITH MCC,Surgical,Relative Weights,"$15,280.10 ",IP,"2,420.00","28,004.26",,,,,,
Cigna,DRG,MS-089,CONCUSSION WITH CC,Surgical,Relative Weights,"$10,849.30 ",IP,"2,420.00","19,883.81",,,,,,
Cigna,DRG,MS-090,CONCUSSION WITHOUT CC/MCC,Surgical,Relative Weights,"$9,331.30 ",IP,"2,420.00","17,101.73",,,,,,
Cigna,DRG,MS-091,OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,Surgical,Relative Weights,"$17,216.10 ",IP,"2,420.00","31,552.42",,,,,,
Cigna,DRG,MS-092,OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,Surgical,Relative Weights,"$10,627.10 ",IP,"2,420.00","19,476.58",,,,,,
Cigna,DRG,MS-093,OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,Surgical,Relative Weights,"$8,373.20 ",IP,"2,420.00","15,345.79",,,,,,
Cigna,DRG,MS-094,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,Surgical,Relative Weights,"$39,432.80 ",IP,"2,420.00","72,269.57",,,,,,
Cigna,DRG,MS-095,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,Surgical,Relative Weights,"$26,478.10 ",IP,"2,420.00","48,527.14",,,,,,
Cigna,DRG,MS-096,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,Surgical,Relative Weights,"$24,883.10 ",IP,"2,420.00","45,603.94",,,,,,
Cigna,DRG,MS-097,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,Surgical,Relative Weights,"$39,334.90 ",IP,"2,420.00","72,090.14",,,,,,
Cigna,DRG,MS-098,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,Surgical,Relative Weights,"$21,505.00 ",IP,"2,420.00","39,412.80",,,,,,
Cigna,DRG,MS-099,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,Surgical,Relative Weights,"$14,106.40 ",IP,"2,420.00","25,853.18",,,,,,
Cigna,DRG,MS-100,SEIZURES WITH MCC,Surgical,Relative Weights,"$20,022.20 ",IP,"2,420.00","36,695.23",,,,,,
Cigna,DRG,MS-101,SEIZURES WITHOUT MCC,Surgical,Relative Weights,"$9,711.90 ",IP,"2,420.00","17,799.26",,,,,,
Cigna,DRG,MS-102,HEADACHES WITH MCC,Surgical,Relative Weights,"$13,118.60 ",IP,"2,420.00","24,042.82",,,,,,
Cigna,DRG,MS-103,HEADACHES W/O MCC,Surgical,Relative Weights,"$8,794.50 ",IP,"2,420.00","16,117.92",,,,,,
Cigna,DRG,MS-113,ORBITAL PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$23,453.10 ",IP,"2,420.00","42,983.14",,,,,,
Cigna,DRG,MS-114,ORBITAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$13,098.80 ",IP,"2,420.00","24,006.53",,,,,,
Cigna,DRG,MS-115,EXTRAOCULAR PROCEDURES EXCEPT ORBIT,Surgical,Relative Weights,"$16,346.00 ",IP,"2,420.00","29,957.76",,,,,,
Cigna,DRG,MS-116,INTRAOCULAR PROCEDURES W CC/MCC,Surgical,Relative Weights,"$20,801.00 ",IP,"2,420.00","38,122.56",,,,,,
Cigna,DRG,MS-117,INTRAOCULAR PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$12,063.70 ",IP,"2,420.00","22,109.47",,,,,,
Cigna,DRG,MS-121,ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,Surgical,Relative Weights,"$13,945.80 ",IP,"2,420.00","25,558.85",,,,,,
Cigna,DRG,MS-122,ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,Surgical,Relative Weights,"$8,498.60 ",IP,"2,420.00","15,575.62",,,,,,
Cigna,DRG,MS-123,NEUROLOGICAL EYE DISORDERS,Surgical,Relative Weights,"$8,588.80 ",IP,"2,420.00","15,740.93",,,,,,
Cigna,DRG,MS-124,OTHER DISORDERS OF THE EYE WITH MCC,Surgical,Relative Weights,"$15,283.40 ",IP,"2,420.00","28,010.30",,,,,,
Cigna,DRG,MS-125,OTHER DISORDERS OF THE EYE WITHOUT MCC,Surgical,Relative Weights,"$8,683.40 ",IP,"2,420.00","15,914.30",,,,,,
Cigna,DRG,MS-129,MAJOR HEAD & NECK PROCEDURES W CC/MCC OR MAJOR DEVICE,Surgical,Relative Weights,"$25,182.30 ",IP,"21,710.46","46,152.29",,,,,,
Cigna,DRG,MS-130,MAJOR HEAD & NECK PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$15,901.60 ",IP,"13,709.28","29,143.30",,,,,,
Cigna,DRG,MS-131,CRANIAL/FACIAL PROCEDURES W CC/MCC,Surgical,Relative Weights,"$29,582.30 ",IP,"25,503.84","54,216.29",,,,,,
Cigna,DRG,MS-132,CRANIAL/FACIAL PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$17,484.50 ",IP,"15,073.94","32,044.32",,,,,,
Cigna,DRG,MS-133,OTHER EAR - NOSE - MOUTH & THROAT O.R. PROCEDURES W CC/MCC,Surgical,Relative Weights,"$23,615.90 ",IP,"20,360.02","43,281.50",,,,,,
Cigna,DRG,MS-134,OTHER EAR - NOSE - MOUTH & THROAT O.R. PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$13,300.10 ",IP,"11,466.44","24,375.46",,,,,,
Cigna,DRG,MS-135,SINUS AND MASTOID PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$25,130.60 ",IP,"2,420.00","46,057.54",,,,,,
Cigna,DRG,MS-136,SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$13,090.00 ",IP,"2,420.00","23,990.40",,,,,,
Cigna,DRG,MS-137,MOUTH PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$14,666.30 ",IP,"2,420.00","26,879.33",,,,,,
Cigna,DRG,MS-138,MOUTH PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$9,475.40 ",IP,"2,420.00","17,365.82",,,,,,
Cigna,DRG,MS-139,SALIVARY GLAND PROCEDURES,Surgical,Relative Weights,"$13,577.30 ",IP,"2,420.00","24,883.49",,,,,,
Cigna,DRG,MS-146,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH MCC,Surgical,Relative Weights,"$21,214.60 ",IP,"2,420.00","38,880.58",,,,,,
Cigna,DRG,MS-147,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH CC,Surgical,Relative Weights,"$13,649.90 ",IP,"2,420.00","25,016.54",,,,,,
Cigna,DRG,MS-148,EAR - NOSE - MOUTH & THROAT MALIGNANCY W/O CC/MCC,Surgical,Relative Weights,"$8,364.40 ",IP,"2,420.00","15,329.66",,,,,,
Cigna,DRG,MS-149,DYSEQUILIBRIUM,Surgical,Relative Weights,"$8,035.50 ",IP,"2,420.00","14,726.88",,,,,,
Cigna,DRG,MS-150,EPISTAXIS WITH MCC,Surgical,Relative Weights,"$14,206.50 ",IP,"2,420.00","26,036.64",,,,,,
Cigna,DRG,MS-151,EPISTAXIS WITHOUT MCC,Surgical,Relative Weights,"$7,690.10 ",IP,"2,420.00","14,093.86",,,,,,
Cigna,DRG,MS-152,OTITIS MEDIA AND URI WITH MCC,Surgical,Relative Weights,"$11,429.00 ",IP,"2,420.00","20,946.24",,,,,,
Cigna,DRG,MS-153,OTITIS MEDIA AND URI WITHOUT MCC,Surgical,Relative Weights,"$7,770.40 ",IP,"2,420.00","14,241.02",,,,,,
Cigna,DRG,MS-154,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH MCC,Surgical,Relative Weights,"$15,807.00 ",IP,"2,420.00","28,969.92",,,,,,
Cigna,DRG,MS-155,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH CC,Surgical,Relative Weights,"$9,912.10 ",IP,"2,420.00","18,166.18",,,,,,
Cigna,DRG,MS-156,OTHER EAR -  NOSE -  MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,199.50 ",IP,"2,420.00","13,194.72",,,,,,
Cigna,DRG,MS-157,DENTAL AND ORAL DISEASES WITH MCC,Surgical,Relative Weights,"$17,191.90 ",IP,"2,420.00","31,508.06",,,,,,
Cigna,DRG,MS-158,DENTAL AND ORAL DISEASES WITH CC,Surgical,Relative Weights,"$9,532.60 ",IP,"2,420.00","17,470.66",,,,,,
Cigna,DRG,MS-159,DENTAL AND ORAL DISEASES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,401.90 ",IP,"2,420.00","13,565.66",,,,,,
Cigna,DRG,MS-163,MAJOR CHEST PROCEDURES WITH MCC,Surgical,Relative Weights,"$53,610.70 ",IP,"2,420.00","98,253.79",,,,,,
Cigna,DRG,MS-164,MAJOR CHEST PROCEDURES WITH CC,Surgical,Relative Weights,"$27,847.60 ",IP,"2,420.00","51,037.06",,,,,,
Cigna,DRG,MS-165,MAJOR CHEST PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$20,341.20 ",IP,"2,420.00","37,279.87",,,,,,
Cigna,DRG,MS-166,OTHER RESP SYSTEM O.R. PROCEDURES W MCC,Surgical,Relative Weights,"$41,037.70 ",IP,"2,420.00","75,210.91",,,,,,
Cigna,DRG,MS-167,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$21,058.40 ",IP,"2,420.00","38,594.30",,,,,,
Cigna,DRG,MS-168,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$14,593.70 ",IP,"2,420.00","26,746.27",,,,,,
Cigna,DRG,MS-175,PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,Surgical,Relative Weights,"$15,888.40 ",IP,"2,420.00","29,119.10",,,,,,
Cigna,DRG,MS-176,PULMONARY EMBOLISM WITHOUT MCC,Surgical,Relative Weights,"$9,332.40 ",IP,"2,420.00","17,103.74",,,,,,
Cigna,DRG,MS-177,RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC,Surgical,Relative Weights,"$20,803.20 ",IP,"2,420.00","38,126.59",,,,,,
Cigna,DRG,MS-178,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,Surgical,Relative Weights,"$13,676.30 ",IP,"2,420.00","25,064.93",,,,,,
Cigna,DRG,MS-179,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,Surgical,Relative Weights,"$9,527.10 ",IP,"2,420.00","17,460.58",,,,,,
Cigna,DRG,MS-180,RESPIRATORY NEOPLASMS WITH MCC,Surgical,Relative Weights,"$18,973.90 ",IP,"2,420.00","34,773.98",,,,,,
Cigna,DRG,MS-181,RESPIRATORY NEOPLASMS WITH CC,Surgical,Relative Weights,"$12,672.00 ",IP,"2,420.00","23,224.32",,,,,,
Cigna,DRG,MS-182,RESPIRATORY NEOPLASMS WITHOUT CC/MCC,Surgical,Relative Weights,"$9,270.80 ",IP,"2,420.00","16,990.85",,,,,,
Cigna,DRG,MS-183,MAJOR CHEST TRAUMA WITH MCC,Surgical,Relative Weights,"$16,601.20 ",IP,"2,420.00","30,425.47",,,,,,
Cigna,DRG,MS-184,MAJOR CHEST TRAUMA WITH CC,Surgical,Relative Weights,"$11,200.20 ",IP,"2,420.00","20,526.91",,,,,,
Cigna,DRG,MS-185,MAJOR CHEST TRAUMA W/O CC/MCC,Surgical,Relative Weights,"$8,074.00 ",IP,"2,420.00","14,797.44",,,,,,
Cigna,DRG,MS-186,PLEURAL EFFUSION WITH MCC,Surgical,Relative Weights,"$16,971.90 ",IP,"2,420.00","31,104.86",,,,,,
Cigna,DRG,MS-187,PLEURAL EFFUSION WITH CC,Surgical,Relative Weights,"$11,306.90 ",IP,"2,420.00","20,722.46",,,,,,
Cigna,DRG,MS-188,PLEURAL EFFUSION WITHOUT CC/MCC,Surgical,Relative Weights,"$8,039.90 ",IP,"2,420.00","14,734.94",,,,,,
Cigna,DRG,MS-189,PULMONARY EDEMA AND RESPIRATORY FAILURE,Surgical,Relative Weights,"$13,372.70 ",IP,"2,420.00","24,508.51",,,,,,
Cigna,DRG,MS-190,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,Surgical,Relative Weights,"$12,584.00 ",IP,"2,420.00","23,063.04",,,,,,
Cigna,DRG,MS-191,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,Surgical,Relative Weights,"$9,820.80 ",IP,"2,420.00","17,998.85",,,,,,
Cigna,DRG,MS-192,CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC,Surgical,Relative Weights,"$7,801.20 ",IP,"2,420.00","14,297.47",,,,,,
Cigna,DRG,MS-193,SIMPLE PNEUMONIA & PLEURISY W MCC,Surgical,Relative Weights,"$14,668.50 ",IP,"2,420.00","26,883.36",,,,,,
Cigna,DRG,MS-194,SIMPLE PNEUMONIA AND PLEURISY WITH CC,Surgical,Relative Weights,"$9,774.60 ",IP,"2,420.00","17,914.18",,,,,,
Cigna,DRG,MS-195,SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,Surgical,Relative Weights,"$7,503.10 ",IP,"2,420.00","13,751.14",,,,,,
Cigna,DRG,MS-196,INTERSTITIAL LUNG DISEASE WITH MCC,Surgical,Relative Weights,"$18,429.40 ",IP,"2,420.00","33,776.06",,,,,,
Cigna,DRG,MS-197,INTERSTITIAL LUNG DISEASE WITH CC,Surgical,Relative Weights,"$11,236.50 ",IP,"2,420.00","20,593.44",,,,,,
Cigna,DRG,MS-198,INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,Surgical,Relative Weights,"$8,305.00 ",IP,"2,420.00","15,220.80",,,,,,
Cigna,DRG,MS-199,PNEUMOTHORAX WITH MCC,Surgical,Relative Weights,"$19,735.10 ",IP,"2,420.00","36,169.06",,,,,,
Cigna,DRG,MS-200,PNEUMOTHORAX WITH CC,Surgical,Relative Weights,"$11,903.10 ",IP,"2,420.00","21,815.14",,,,,,
Cigna,DRG,MS-201,PNEUMOTHORAX WITHOUT CC/MCC,Surgical,Relative Weights,"$7,898.00 ",IP,"2,420.00","14,474.88",,,,,,
Cigna,DRG,MS-202,BRONCHITIS AND ASTHMA WITH CC/MCC,Surgical,Relative Weights,"$10,428.00 ",IP,"2,420.00","19,111.68",,,,,,
Cigna,DRG,MS-203,BRONCHITIS AND ASTHMA WITHOUT CC/MCC,Surgical,Relative Weights,"$7,631.80 ",IP,"2,420.00","13,987.01",,,,,,
Cigna,DRG,MS-204,RESPIRATORY SIGNS AND SYMPTOMS,Surgical,Relative Weights,"$8,937.50 ",IP,"2,420.00","16,380.00",,,,,,
Cigna,DRG,MS-205,OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,Surgical,Relative Weights,"$17,976.20 ",IP,"2,420.00","32,945.47",,,,,,
Cigna,DRG,MS-206,OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,Surgical,Relative Weights,"$9,597.50 ",IP,"2,420.00","17,589.60",,,,,,
Cigna,DRG,MS-207,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS,Surgical,Relative Weights,"$63,091.60 ",IP,"2,420.00","115,629.70",,,,,,
Cigna,DRG,MS-208,RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,Surgical,Relative Weights,"$27,325.10 ",IP,"2,420.00","50,079.46",,,,,,
Cigna,DRG,MS-215,OTHER HEART ASSIST SYSTEM IMPLANT,Surgical,Relative Weights,"$141,747.10 ",IP,"61,661.88","259,783.78",,,,,,
Cigna,DRG,MS-216,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$110,466.40 ",IP,"58,630.29","202,454.78",,,,,,
Cigna,DRG,MS-217,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,Surgical,Relative Weights,"$73,167.60 ",IP,"37,864.14","134,096.26",,,,,,
Cigna,DRG,MS-218,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,Surgical,Relative Weights,"$59,415.40 ",IP,"35,678.79","108,892.22",,,,,,
Cigna,DRG,MS-219,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$86,241.10 ",IP,"47,057.01","158,056.42",,,,,,
Cigna,DRG,MS-220,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,Surgical,Relative Weights,"$58,364.90 ",IP,"31,567.37","106,966.94",,,,,,
Cigna,DRG,MS-221,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,Surgical,Relative Weights,"$50,558.20 ",IP,"26,746.97","92,659.39",,,,,,
Cigna,DRG,MS-222,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITH MCC,Surgical,Relative Weights,"$91,790.60 ",IP,"46,434.46","168,227.14",,,,,,
Cigna,DRG,MS-223,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITHOUT MCC,Surgical,Relative Weights,"$66,031.90 ",IP,"33,864.27","121,018.46",,,,,,
Cigna,DRG,MS-224,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITH MCC,Surgical,Relative Weights,"$81,358.20 ",IP,"43,912.13","149,107.39",,,,,,
Cigna,DRG,MS-225,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITHOUT MCC,Surgical,Relative Weights,"$62,136.80 ",IP,"32,808.39","113,879.81",,,,,,
Cigna,DRG,MS-226,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$73,564.70 ",IP,"25,420.00","134,824.03",,,,,,
Cigna,DRG,MS-227,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Surgical,Relative Weights,"$57,521.20 ",IP,"25,420.00","105,420.67",,,,,,
Cigna,DRG,MS-228,OTHER CARDIOTHORACIC PROCEDURES WITH MCC,Surgical,Relative Weights,"$69,149.30 ",IP,"31,129.37","126,731.81",,,,,,
Cigna,DRG,MS-229,OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$45,153.90 ",IP,"20,096.88","82,754.78",,,,,,
Cigna,DRG,MS-231,CORONARY BYPASS W PTCA W MCC,Surgical,Relative Weights,"$90,326.50 ",IP,"50,901.53","165,543.84",,,,,,
Cigna,DRG,MS-232,CORONARY BYPASS W PTCA W/O MCC,Surgical,Relative Weights,"$65,851.50 ",IP,"34,770.65","120,687.84",,,,,,
Cigna,DRG,MS-233,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,Surgical,Relative Weights,"$85,457.90 ",IP,"42,365.00","156,621.02",,,,,,
Cigna,DRG,MS-234,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,Surgical,Relative Weights,"$57,269.30 ",IP,"31,162.65","104,959.01",,,,,,
Cigna,DRG,MS-235,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$64,730.60 ",IP,"32,351.00","118,633.54",,,,,,
Cigna,DRG,MS-236,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Surgical,Relative Weights,"$44,320.10 ",IP,"23,926.80","81,226.66",,,,,,
Cigna,DRG,MS-239,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,Surgical,Relative Weights,"$51,366.70 ",IP,"2,420.00","94,141.15",,,,,,
Cigna,DRG,MS-240,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,Surgical,Relative Weights,"$30,360.00 ",IP,"2,420.00","55,641.60",,,,,,
Cigna,DRG,MS-241,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,Surgical,Relative Weights,"$16,679.30 ",IP,"2,420.00","30,568.61",,,,,,
Cigna,DRG,MS-242,PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,Surgical,Relative Weights,"$40,822.10 ",IP,"15,407.00","74,815.78",,,,,,
Cigna,DRG,MS-243,PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,Surgical,Relative Weights,"$27,823.40 ",IP,"14,708.24","50,992.70",,,,,,
Cigna,DRG,MS-244,PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,Surgical,Relative Weights,"$22,829.40 ",IP,"12,049.83","41,840.06",,,,,,
Cigna,DRG,MS-245,AICD GENERATOR PROCEDURES,Surgical,Relative Weights,"$57,285.80 ",IP,"15,407.00","104,989.25",,,,,,
Cigna,DRG,MS-246,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Surgical,Relative Weights,"$34,900.80 ",IP,"18,246.15","63,963.65",,,,,,
Cigna,DRG,MS-247,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITHOUT MCC,Surgical,Relative Weights,"$22,381.70 ",IP,"11,523.64","41,019.55",,,,,,
Cigna,DRG,MS-248,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Surgical,Relative Weights,"$34,061.50 ",IP,"18,467.49","62,425.44",,,,,,
Cigna,DRG,MS-249,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITHOUT MCC,Surgical,Relative Weights,"$21,082.60 ",IP,"10,942.55","38,638.66",,,,,,
Cigna,DRG,MS-250,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT CORONARY ARTERY STENT WITH MCC,Surgical,Relative Weights,"$28,051.10 ",IP,"14,727.51","51,410.02",,,,,,
Cigna,DRG,MS-251,PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W/O MCC,Surgical,Relative Weights,"$18,513.00 ",IP,"2,420.00","33,929.28",,,,,,
Cigna,DRG,MS-252,OTHER VASCULAR PROCEDURES W MCC,Surgical,Relative Weights,"$36,084.40 ",IP,"2,420.00","66,132.86",,,,,,
Cigna,DRG,MS-253,OTHER VASCULAR PROCEDURES WITH CC,Surgical,Relative Weights,"$28,672.60 ",IP,"2,420.00","52,549.06",,,,,,
Cigna,DRG,MS-254,OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$20,021.10 ",IP,"2,420.00","36,693.22",,,,,,
Cigna,DRG,MS-255,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,Surgical,Relative Weights,"$29,145.60 ",IP,"2,420.00","53,415.94",,,,,,
Cigna,DRG,MS-256,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,Surgical,Relative Weights,"$18,881.50 ",IP,"2,420.00","34,604.64",,,,,,
Cigna,DRG,MS-257,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$12,478.40 ",IP,"2,420.00","22,869.50",,,,,,
Cigna,DRG,MS-258,CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,Surgical,Relative Weights,"$33,645.70 ",IP,"11,861.00","61,663.39",,,,,,
Cigna,DRG,MS-259,CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,Surgical,Relative Weights,"$22,908.60 ",IP,"11,861.00","41,985.22",,,,,,
Cigna,DRG,MS-260,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,Surgical,Relative Weights,"$40,695.60 ",IP,"10,167.00","74,583.94",,,,,,
Cigna,DRG,MS-261,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,Surgical,Relative Weights,"$21,433.50 ",IP,"10,167.00","39,281.76",,,,,,
Cigna,DRG,MS-262,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,Surgical,Relative Weights,"$18,453.60 ",IP,"9,964.34","33,820.42",,,,,,
Cigna,DRG,MS-263,VEIN LIGATION AND STRIPPING,Surgical,Relative Weights,"$25,950.10 ",IP,"2,420.00","47,559.46",,,,,,
Cigna,DRG,MS-264,OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,Surgical,Relative Weights,"$35,618.00 ",IP,"2,420.00","65,278.08",,,,,,
Cigna,DRG,MS-265,AICD LEAD PROCEDURES,Surgical,Relative Weights,"$34,334.30 ",IP,"2,420.00","62,925.41",,,,,,
Cigna,DRG,MS-266,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,Surgical,Relative Weights,"$78,335.40 ",IP,"41,160.28","143,567.42",,,,,,
Cigna,DRG,MS-267,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$62,431.60 ",IP,"32,692.75","114,420.10",,,,,,
Cigna,DRG,MS-268,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,Surgical,Relative Weights,"$74,608.60 ",IP,"32,968.00","136,737.22",,,,,,
Cigna,DRG,MS-269,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,Surgical,Relative Weights,"$46,930.40 ",IP,"25,200.52","86,010.62",,,,,,
Cigna,DRG,MS-270,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,Surgical,Relative Weights,"$56,212.20 ",IP,"30,292.48","103,021.63",,,,,,
Cigna,DRG,MS-271,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,Surgical,Relative Weights,"$39,028.00 ",IP,"20,822.21","71,527.68",,,,,,
Cigna,DRG,MS-272,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$28,614.30 ",IP,"15,699.88","52,442.21",,,,,,
Cigna,DRG,MS-273,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,Surgical,Relative Weights,"$40,813.30 ",IP,"16,176.00","74,799.65",,,,,,
Cigna,DRG,MS-274,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$34,757.80 ",IP,"16,176.00","63,701.57",,,,,,
Cigna,DRG,MS-280,ACUTE MYOCARDIAL INFARCTION - DISCHARGED ALIVE W MCC,Surgical,Relative Weights,"$17,939.90 ",IP,"2,420.00","32,878.94",,,,,,
Cigna,DRG,MS-281,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITH CC,Surgical,Relative Weights,"$10,655.70 ",IP,"2,420.00","19,528.99",,,,,,
Cigna,DRG,MS-282,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITHOUT CC/MCC,Surgical,Relative Weights,"$8,116.90 ",IP,"2,420.00","14,876.06",,,,,,
Cigna,DRG,MS-283,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH MCC,Surgical,Relative Weights,"$19,796.70 ",IP,"2,420.00","36,281.95",,,,,,
Cigna,DRG,MS-284,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH CC,Surgical,Relative Weights,"$7,978.30 ",IP,"2,420.00","14,622.05",,,,,,
Cigna,DRG,MS-285,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITHOUT CC/MCC,Surgical,Relative Weights,"$5,695.80 ",IP,"2,420.00","10,438.85",,,,,,
Cigna,DRG,MS-286,CIRCULATORY DISORDERS EXCEPT AMI- WITH CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$24,171.40 ",IP,"2,420.00","44,299.58",,,,,,
Cigna,DRG,MS-287,CIRCULATORY DISORDERS EXCEPT AMI -  WITH CARDIAC CATHETERIZATION WITHOUT MCC,Surgical,Relative Weights,"$12,674.20 ",IP,"6,512.27","23,228.35",,,,,,
Cigna,DRG,MS-288,ACUTE & SUBACUTE ENDOCARDITIS W MCC,Surgical,Relative Weights,"$29,231.40 ",IP,"2,420.00","53,573.18",,,,,,
Cigna,DRG,MS-289,ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,Surgical,Relative Weights,"$18,301.80 ",IP,"9,181.00","33,542.21",,,,,,
Cigna,DRG,MS-290,ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,Surgical,Relative Weights,"$11,006.60 ",IP,"2,420.00","20,172.10",,,,,,
Cigna,DRG,MS-291,HEART FAILURE AND SHOCK WITH MCC,Surgical,Relative Weights,"$14,803.80 ",IP,"2,420.00","27,131.33",,,,,,
Cigna,DRG,MS-292,HEART FAILURE AND SHOCK WITH CC,Surgical,Relative Weights,"$9,960.50 ",IP,"2,420.00","18,254.88",,,,,,
Cigna,DRG,MS-293,HEART FAILURE AND SHOCK WITHOUT CC/MCC,Surgical,Relative Weights,"$7,208.30 ",IP,"2,420.00","13,210.85",,,,,,
Cigna,DRG,MS-294,DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC,Surgical,Relative Weights,"$13,990.90 ",IP,"2,420.00","25,641.50",,,,,,
Cigna,DRG,MS-295,DEEP VEIN THROMBOPHLEBITIS W/O CC/MCC,Surgical,Relative Weights,"$6,347.00 ",IP,"2,420.00","11,632.32",,,,,,
Cigna,DRG,MS-296,CARDIAC ARREST - UNEXPLAINED W MCC,Surgical,Relative Weights,"$17,274.40 ",IP,"2,420.00","31,659.26",,,,,,
Cigna,DRG,MS-297,CARDIAC ARREST- UNEXPLAINED WITH CC,Surgical,Relative Weights,"$7,953.00 ",IP,"2,420.00","14,575.68",,,,,,
Cigna,DRG,MS-298,CARDIAC ARREST- UNEXPLAINED WITHOUT CC/MCC,Surgical,Relative Weights,"$5,535.20 ",IP,"2,420.00","10,144.51",,,,,,
Cigna,DRG,MS-299,PERIPHERAL VASCULAR DISORDERS WITH MCC,Surgical,Relative Weights,"$15,946.70 ",IP,"2,420.00","29,225.95",,,,,,
Cigna,DRG,MS-300,PERIPHERAL VASCULAR DISORDERS WITH CC,Surgical,Relative Weights,"$11,303.60 ",IP,"2,420.00","20,716.42",,,,,,
Cigna,DRG,MS-301,PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$7,983.80 ",IP,"2,420.00","14,632.13",,,,,,
Cigna,DRG,MS-302,ATHEROSCLEROSIS WITH MCC,Surgical,Relative Weights,"$12,125.30 ",IP,"2,420.00","22,222.37",,,,,,
Cigna,DRG,MS-303,ATHEROSCLEROSIS WITHOUT MCC,Surgical,Relative Weights,"$7,432.70 ",IP,"2,420.00","13,622.11",,,,,,
Cigna,DRG,MS-304,HYPERTENSION WITH MCC,Surgical,Relative Weights,"$12,006.50 ",IP,"2,420.00","22,004.64",,,,,,
Cigna,DRG,MS-305,HYPERTENSION WITHOUT MCC,Surgical,Relative Weights,"$8,046.50 ",IP,"2,420.00","14,747.04",,,,,,
Cigna,DRG,MS-306,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,Surgical,Relative Weights,"$15,559.50 ",IP,"2,420.00","28,516.32",,,,,,
Cigna,DRG,MS-307,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,Surgical,Relative Weights,"$9,704.20 ",IP,"2,420.00","17,785.15",,,,,,
Cigna,DRG,MS-308,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,Surgical,Relative Weights,"$13,064.70 ",IP,"2,420.00","23,944.03",,,,,,
Cigna,DRG,MS-309,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,Surgical,Relative Weights,"$8,319.30 ",IP,"2,420.00","15,247.01",,,,,,
Cigna,DRG,MS-310,CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC,Surgical,Relative Weights,"$6,152.30 ",IP,"2,420.00","11,275.49",,,,,,
Cigna,DRG,MS-311,ANGINA PECTORIS,Surgical,Relative Weights,"$7,535.00 ",IP,"2,420.00","13,809.60",,,,,,
Cigna,DRG,MS-312,SYNCOPE AND COLLAPSE,Surgical,Relative Weights,"$8,982.60 ",IP,"2,420.00","16,462.66",,,,,,
Cigna,DRG,MS-313,CHEST PAIN,Surgical,Relative Weights,"$7,868.30 ",IP,"2,420.00","14,420.45",,,,,,
Cigna,DRG,MS-314,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,Surgical,Relative Weights,"$22,324.50 ",IP,"2,420.00","40,914.72",,,,,,
Cigna,DRG,MS-315,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,Surgical,Relative Weights,"$10,674.40 ",IP,"2,420.00","19,563.26",,,,,,
Cigna,DRG,MS-316,OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,164.20 ",IP,"2,420.00","14,962.75",,,,,,
Cigna,DRG,MS-319,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,Surgical,Relative Weights,"$45,107.70 ",IP,"2,420.00","82,670.11",,,,,,
Cigna,DRG,MS-320,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$25,824.70 ",IP,"2,420.00","47,329.63",,,,,,
Cigna,DRG,MS-326,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$57,975.50 ",IP,"2,420.00","106,253.28",,,,,,
Cigna,DRG,MS-327,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC,Surgical,Relative Weights,"$28,301.90 ",IP,"2,420.00","51,869.66",,,,,,
Cigna,DRG,MS-328,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$17,325.00 ",IP,"2,420.00","31,752.00",,,,,,
Cigna,DRG,MS-329,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Surgical,Relative Weights,"$53,979.20 ",IP,"2,420.00","98,929.15",,,,,,
Cigna,DRG,MS-330,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Surgical,Relative Weights,"$27,794.80 ",IP,"2,420.00","50,940.29",,,,,,
Cigna,DRG,MS-331,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$18,581.20 ",IP,"2,420.00","34,054.27",,,,,,
Cigna,DRG,MS-332,RECTAL RESECTION WITH MCC,Surgical,Relative Weights,"$38,410.90 ",IP,"2,420.00","70,396.70",,,,,,
Cigna,DRG,MS-333,RECTAL RESECTION WITH CC,Surgical,Relative Weights,"$24,895.20 ",IP,"2,420.00","45,626.11",,,,,,
Cigna,DRG,MS-334,RECTAL RESECTION WITHOUT CC/MCC,Surgical,Relative Weights,"$16,943.30 ",IP,"2,420.00","31,052.45",,,,,,
Cigna,DRG,MS-335,PERITONEAL ADHESIOLYSIS WITH MCC,Surgical,Relative Weights,"$44,496.10 ",IP,"2,420.00","81,549.22",,,,,,
Cigna,DRG,MS-336,PERITONEAL ADHESIOLYSIS WITH CC,Surgical,Relative Weights,"$24,928.20 ",IP,"2,420.00","45,686.59",,,,,,
Cigna,DRG,MS-337,PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$18,036.70 ",IP,"2,420.00","33,056.35",,,,,,
Cigna,DRG,MS-338,APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$32,011.10 ",IP,"2,420.00","58,667.62",,,,,,
Cigna,DRG,MS-339,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W CC,Surgical,Relative Weights,"$18,877.10 ",IP,"2,420.00","34,596.58",,,,,,
Cigna,DRG,MS-340,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC/MCC,Surgical,Relative Weights,"$13,612.50 ",IP,"2,420.00","24,948.00",,,,,,
Cigna,DRG,MS-341,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$28,139.10 ",IP,"2,420.00","51,571.30",,,,,,
Cigna,DRG,MS-342,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH CC,Surgical,Relative Weights,"$17,713.30 ",IP,"2,420.00","32,463.65",,,,,,
Cigna,DRG,MS-343,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$12,667.60 ",IP,"2,420.00","23,216.26",,,,,,
Cigna,DRG,MS-344,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Surgical,Relative Weights,"$32,946.10 ",IP,"2,420.00","60,381.22",,,,,,
Cigna,DRG,MS-345,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Surgical,Relative Weights,"$17,966.30 ",IP,"2,420.00","32,927.33",,,,,,
Cigna,DRG,MS-346,MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$14,109.70 ",IP,"2,420.00","25,859.23",,,,,,
Cigna,DRG,MS-347,ANAL AND STOMAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$29,000.40 ",IP,"2,420.00","53,149.82",,,,,,
Cigna,DRG,MS-348,ANAL AND STOMAL PROCEDURES WITH CC,Surgical,Relative Weights,"$15,502.30 ",IP,"2,420.00","28,411.49",,,,,,
Cigna,DRG,MS-349,ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,789.90 ",IP,"2,420.00","19,774.94",,,,,,
Cigna,DRG,MS-350,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,Surgical,Relative Weights,"$26,832.30 ",IP,"2,420.00","49,176.29",,,,,,
Cigna,DRG,MS-351,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,Surgical,Relative Weights,"$16,041.30 ",IP,"2,420.00","29,399.33",,,,,,
Cigna,DRG,MS-352,INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$11,844.80 ",IP,"2,420.00","21,708.29",,,,,,
Cigna,DRG,MS-353,HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,Surgical,Relative Weights,"$32,635.90 ",IP,"2,420.00","59,812.70",,,,,,
Cigna,DRG,MS-354,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W CC,Surgical,Relative Weights,"$18,943.10 ",IP,"2,420.00","34,717.54",,,,,,
Cigna,DRG,MS-355,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W/O CC/MCC,Surgical,Relative Weights,"$15,096.40 ",IP,"2,420.00","27,667.58",,,,,,
Cigna,DRG,MS-356,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$44,849.20 ",IP,"2,420.00","82,196.35",,,,,,
Cigna,DRG,MS-357,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$24,754.40 ",IP,"2,420.00","45,368.06",,,,,,
Cigna,DRG,MS-358,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$15,088.70 ",IP,"2,420.00","27,653.47",,,,,,
Cigna,DRG,MS-368,MAJOR ESOPHAGEAL DISORDERS WITH MCC,Surgical,Relative Weights,"$20,939.60 ",IP,"2,420.00","38,376.58",,,,,,
Cigna,DRG,MS-369,MAJOR ESOPHAGEAL DISORDERS WITH CC,Surgical,Relative Weights,"$11,694.10 ",IP,"2,420.00","21,432.10",,,,,,
Cigna,DRG,MS-370,MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$8,220.30 ",IP,"2,420.00","15,065.57",,,,,,
Cigna,DRG,MS-371,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,Surgical,Relative Weights,"$18,980.50 ",IP,"2,420.00","34,786.08",,,,,,
Cigna,DRG,MS-372,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,Surgical,Relative Weights,"$11,247.50 ",IP,"2,420.00","20,613.60",,,,,,
Cigna,DRG,MS-373,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,Surgical,Relative Weights,"$8,159.80 ",IP,"2,420.00","14,954.69",,,,,,
Cigna,DRG,MS-374,DIGESTIVE MALIGNANCY WITH MCC,Surgical,Relative Weights,"$21,972.50 ",IP,"2,420.00","40,269.60",,,,,,
Cigna,DRG,MS-375,DIGESTIVE MALIGNANCY WITH CC,Surgical,Relative Weights,"$13,280.30 ",IP,"2,420.00","24,339.17",,,,,,
Cigna,DRG,MS-376,DIGESTIVE MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$11,014.30 ",IP,"2,420.00","20,186.21",,,,,,
Cigna,DRG,MS-377,GASTROINTESTINAL HEMORRHAGE WITH MCC,Surgical,Relative Weights,"$19,468.90 ",IP,"2,420.00","35,681.18",,,,,,
Cigna,DRG,MS-378,GASTROINTESTINAL HEMORRHAGE WITH CC,Surgical,Relative Weights,"$10,869.10 ",IP,"2,420.00","19,920.10",,,,,,
Cigna,DRG,MS-379,GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,Surgical,Relative Weights,"$7,102.70 ",IP,"2,420.00","13,017.31",,,,,,
Cigna,DRG,MS-380,COMPLICATED PEPTIC ULCER WITH MCC,Surgical,Relative Weights,"$20,763.60 ",IP,"2,420.00","38,054.02",,,,,,
Cigna,DRG,MS-381,COMPLICATED PEPTIC ULCER WITH CC,Surgical,Relative Weights,"$11,843.70 ",IP,"2,420.00","21,706.27",,,,,,
Cigna,DRG,MS-382,COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,Surgical,Relative Weights,"$8,705.40 ",IP,"2,420.00","15,954.62",,,,,,
Cigna,DRG,MS-383,UNCOMPLICATED PEPTIC ULCER WITH MCC,Surgical,Relative Weights,"$14,589.30 ",IP,"2,420.00","26,738.21",,,,,,
Cigna,DRG,MS-384,UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,Surgical,Relative Weights,"$9,572.20 ",IP,"2,420.00","17,543.23",,,,,,
Cigna,DRG,MS-385,INFLAMMATORY BOWEL DISEASE WITH MCC,Surgical,Relative Weights,"$17,713.30 ",IP,"2,420.00","32,463.65",,,,,,
Cigna,DRG,MS-386,INFLAMMATORY BOWEL DISEASE W CC,Surgical,Relative Weights,"$10,837.20 ",IP,"2,420.00","19,861.63",,,,,,
Cigna,DRG,MS-387,INFLAMMATORY BOWEL DISEASE W/O CC/MCC,Surgical,Relative Weights,"$7,707.70 ",IP,"2,420.00","14,126.11",,,,,,
Cigna,DRG,MS-388,GASTROINTESTINAL OBSTRUCTION WITH MCC,Surgical,Relative Weights,"$16,776.10 ",IP,"2,420.00","30,746.02",,,,,,
Cigna,DRG,MS-389,GASTROINTESTINAL OBSTRUCTION WITH CC,Surgical,Relative Weights,"$9,236.70 ",IP,"2,420.00","16,928.35",,,,,,
Cigna,DRG,MS-390,GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,Surgical,Relative Weights,"$6,375.60 ",IP,"2,420.00","11,684.74",,,,,,
Cigna,DRG,MS-391,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC,Surgical,Relative Weights,"$13,585.00 ",IP,"2,420.00","24,897.60",,,,,,
Cigna,DRG,MS-392,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC,Surgical,Relative Weights,"$8,376.50 ",IP,"2,420.00","15,351.84",,,,,,
Cigna,DRG,MS-393,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,Surgical,Relative Weights,"$17,869.50 ",IP,"2,420.00","32,749.92",,,,,,
Cigna,DRG,MS-394,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,Surgical,Relative Weights,"$10,319.10 ",IP,"2,420.00","18,912.10",,,,,,
Cigna,DRG,MS-395,OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,198.40 ",IP,"2,420.00","13,192.70",,,,,,
Cigna,DRG,MS-405,PANCREAS- LIVER AND SHUNT PROCEDURES WITH MCC,Surgical,Relative Weights,"$59,699.20 ",IP,"2,420.00","109,412.35",,,,,,
Cigna,DRG,MS-406,PANCREAS -  LIVER AND SHUNT PROCEDURES WITH CC,Surgical,Relative Weights,"$30,699.90 ",IP,"2,420.00","56,264.54",,,,,,
Cigna,DRG,MS-407,PANCREAS -  LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$22,949.30 ",IP,"2,420.00","42,059.81",,,,,,
Cigna,DRG,MS-408,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,Surgical,Relative Weights,"$39,199.60 ",IP,"2,420.00","71,842.18",,,,,,
Cigna,DRG,MS-409,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,Surgical,Relative Weights,"$26,331.80 ",IP,"2,420.00","48,259.01",,,,,,
Cigna,DRG,MS-410,BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W/O CC/MCC,Surgical,Relative Weights,"$18,260.00 ",IP,"2,420.00","33,465.60",,,,,,
Cigna,DRG,MS-411,CHOLECYSTECTOMY W C.D.E. W MCC,Surgical,Relative Weights,"$42,134.40 ",IP,"2,420.00","77,220.86",,,,,,
Cigna,DRG,MS-412,CHOLECYSTECTOMY WITH C.D.E. WITH CC,Surgical,Relative Weights,"$26,147.00 ",IP,"2,420.00","47,920.32",,,,,,
Cigna,DRG,MS-413,CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,Surgical,Relative Weights,"$17,790.30 ",IP,"2,420.00","32,604.77",,,,,,
Cigna,DRG,MS-414,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,Surgical,Relative Weights,"$37,580.40 ",IP,"2,420.00","68,874.62",,,,,,
Cigna,DRG,MS-415,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,Surgical,Relative Weights,"$22,568.70 ",IP,"2,420.00","41,362.27",,,,,,
Cigna,DRG,MS-416,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,Surgical,Relative Weights,"$14,853.30 ",IP,"2,420.00","27,222.05",,,,,,
Cigna,DRG,MS-417,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,Surgical,Relative Weights,"$26,517.70 ",IP,"2,420.00","48,599.71",,,,,,
Cigna,DRG,MS-418,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,Surgical,Relative Weights,"$18,357.90 ",IP,"2,420.00","33,645.02",,,,,,
Cigna,DRG,MS-419,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,Surgical,Relative Weights,"$14,374.80 ",IP,"2,420.00","26,345.09",,,,,,
Cigna,DRG,MS-420,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,Surgical,Relative Weights,"$37,782.80 ",IP,"2,420.00","69,245.57",,,,,,
Cigna,DRG,MS-421,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,Surgical,Relative Weights,"$20,253.20 ",IP,"2,420.00","37,118.59",,,,,,
Cigna,DRG,MS-422,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$15,449.50 ",IP,"2,420.00","28,314.72",,,,,,
Cigna,DRG,MS-423,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$46,620.20 ",IP,"2,420.00","85,442.11",,,,,,
Cigna,DRG,MS-424,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$24,765.40 ",IP,"2,420.00","45,388.22",,,,,,
Cigna,DRG,MS-425,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$16,076.50 ",IP,"2,420.00","29,463.84",,,,,,
Cigna,DRG,MS-432,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,Surgical,Relative Weights,"$20,057.40 ",IP,"2,420.00","36,759.74",,,,,,
Cigna,DRG,MS-433,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,Surgical,Relative Weights,"$11,352.00 ",IP,"2,420.00","20,805.12",,,,,,
Cigna,DRG,MS-434,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Surgical,Relative Weights,"$7,038.90 ",IP,"2,420.00","12,900.38",,,,,,
Cigna,DRG,MS-435,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,Surgical,Relative Weights,"$18,668.10 ",IP,"2,420.00","34,213.54",,,,,,
Cigna,DRG,MS-436,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,Surgical,Relative Weights,"$12,382.70 ",IP,"2,420.00","22,694.11",,,,,,
Cigna,DRG,MS-437,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,Surgical,Relative Weights,"$9,656.90 ",IP,"2,420.00","17,698.46",,,,,,
Cigna,DRG,MS-438,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,Surgical,Relative Weights,"$18,021.30 ",IP,"2,420.00","33,028.13",,,,,,
Cigna,DRG,MS-439,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,Surgical,Relative Weights,"$9,319.20 ",IP,"2,420.00","17,079.55",,,,,,
Cigna,DRG,MS-440,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$6,771.60 ",IP,"2,420.00","12,410.50",,,,,,
Cigna,DRG,MS-441,DISORDERS OF LIVER EXCEPT MALIGNANCY- CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC,Surgical,Relative Weights,"$20,355.50 ",IP,"2,420.00","37,306.08",,,,,,
Cigna,DRG,MS-442,DISORDERS OF LIVER EXCEPT MALIGNANCY -  CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC,Surgical,Relative Weights,"$10,267.40 ",IP,"2,420.00","18,817.34",,,,,,
Cigna,DRG,MS-443,DISORDERS OF LIVER EXCEPT MALIGNANCY -  CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Surgical,Relative Weights,"$7,483.30 ",IP,"2,420.00","13,714.85",,,,,,
Cigna,DRG,MS-444,DISORDERS OF THE BILIARY TRACT WITH MCC,Surgical,Relative Weights,"$17,887.10 ",IP,"2,420.00","32,782.18",,,,,,
Cigna,DRG,MS-445,DISORDERS OF THE BILIARY TRACT WITH CC,Surgical,Relative Weights,"$11,819.50 ",IP,"2,420.00","21,661.92",,,,,,
Cigna,DRG,MS-446,DISORDERS OF THE BILIARY TRACT W/O CC/MCC,Surgical,Relative Weights,"$8,939.70 ",IP,"2,420.00","16,384.03",,,,,,
Cigna,DRG,MS-453,COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W MCC,Surgical,Relative Weights,"$103,477.00 ",IP,"2,420.00","189,645.12",,,,,,
Cigna,DRG,MS-454,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC,Surgical,Relative Weights,"$67,375.00 ",IP,"2,420.00","123,480.00",,,,,,
Cigna,DRG,MS-455,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CC/MCC,Surgical,Relative Weights,"$52,946.30 ",IP,"2,420.00","97,036.13",,,,,,
Cigna,DRG,MS-456,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH MCC,Surgical,Relative Weights,"$99,893.20 ",IP,"2,420.00","183,076.99",,,,,,
Cigna,DRG,MS-457,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH CC,Surgical,Relative Weights,"$71,646.30 ",IP,"2,420.00","131,308.13",,,,,,
Cigna,DRG,MS-458,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC,Surgical,Relative Weights,"$51,632.90 ",IP,"2,420.00","94,629.02",,,,,,
Cigna,DRG,MS-459,SPINAL FUSION EXCEPT CERVICAL WITH MCC,Surgical,Relative Weights,"$75,372.00 ",IP,"21,658.00","138,136.32",,,,,,
Cigna,DRG,MS-460,SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,Surgical,Relative Weights,"$43,564.40 ",IP,"21,658.00","79,841.66",,,,,,
Cigna,DRG,MS-461,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,Surgical,Relative Weights,"$59,166.80 ",IP,"2,420.00","108,436.61",,,,,,
Cigna,DRG,MS-462,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,Surgical,Relative Weights,"$34,500.40 ",IP,"2,420.00","63,229.82",,,,,,
Cigna,DRG,MS-463,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,Surgical,Relative Weights,"$57,505.80 ",IP,"2,420.00","105,392.45",,,,,,
Cigna,DRG,MS-464,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,Surgical,Relative Weights,"$32,479.70 ",IP,"2,420.00","59,526.43",,,,,,
Cigna,DRG,MS-465,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$21,067.20 ",IP,"2,420.00","38,610.43",,,,,,
Cigna,DRG,MS-466,REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,Surgical,Relative Weights,"$56,090.10 ",IP,"2,420.00","102,797.86",,,,,,
Cigna,DRG,MS-467,REVISION OF HIP OR KNEE REPLACEMENT W CC,Surgical,Relative Weights,"$38,633.10 ",IP,"2,420.00","70,803.94",,,,,,
Cigna,DRG,MS-468,REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,Surgical,Relative Weights,"$30,933.10 ",IP,"2,420.00","56,691.94",,,,,,
Cigna,DRG,MS-469,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,Surgical,Relative Weights,"$34,538.90 ",IP,"2,420.00","63,300.38",,,,,,
Cigna,DRG,MS-470,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,Surgical,Relative Weights,"$21,652.40 ",IP,"2,420.00","39,682.94",,,,,,
Cigna,DRG,MS-471,CERVICAL SPINAL FUSION WITH MCC,Surgical,Relative Weights,"$54,938.40 ",IP,"15,407.00","100,687.10",,,,,,
Cigna,DRG,MS-472,CERVICAL SPINAL FUSION WITH CC,Surgical,Relative Weights,"$33,456.50 ",IP,"15,407.00","61,316.64",,,,,,
Cigna,DRG,MS-473,CERVICAL SPINAL FUSION WITHOUT CC/MCC,Surgical,Relative Weights,"$27,636.40 ",IP,"14,827.96","50,649.98",,,,,,
Cigna,DRG,MS-474,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,Surgical,Relative Weights,"$42,623.90 ",IP,"2,420.00","78,117.98",,,,,,
Cigna,DRG,MS-475,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,Surgical,Relative Weights,"$23,111.00 ",IP,"2,420.00","42,356.16",,,,,,
Cigna,DRG,MS-476,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$12,811.70 ",IP,"2,420.00","23,480.35",,,,,,
Cigna,DRG,MS-477,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Surgical,Relative Weights,"$35,808.30 ",IP,"2,420.00","65,626.85",,,,,,
Cigna,DRG,MS-478,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Surgical,Relative Weights,"$25,488.10 ",IP,"2,420.00","46,712.74",,,,,,
Cigna,DRG,MS-479,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Surgical,Relative Weights,"$19,604.20 ",IP,"2,420.00","35,929.15",,,,,,
Cigna,DRG,MS-480,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,Surgical,Relative Weights,"$33,203.50 ",IP,"2,420.00","60,852.96",,,,,,
Cigna,DRG,MS-481,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,Surgical,Relative Weights,"$22,965.80 ",IP,"2,420.00","42,090.05",,,,,,
Cigna,DRG,MS-482,HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC,Surgical,Relative Weights,"$18,098.30 ",IP,"2,420.00","33,169.25",,,,,,
Cigna,DRG,MS-483,MAJOR JOINT & LIMB REATTACHMENT PROC OF UPPER EXTREMITY W CC/MCC,Surgical,Relative Weights,"$26,313.10 ",IP,"2,420.00","48,224.74",,,,,,
Cigna,DRG,MS-485,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,Surgical,Relative Weights,"$36,069.00 ",IP,"2,420.00","66,104.64",,,,,,
Cigna,DRG,MS-486,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,Surgical,Relative Weights,"$23,656.60 ",IP,"2,420.00","43,356.10",,,,,,
Cigna,DRG,MS-487,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Surgical,Relative Weights,"$17,679.20 ",IP,"2,420.00","32,401.15",,,,,,
Cigna,DRG,MS-488,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,Surgical,Relative Weights,"$21,661.20 ",IP,"2,420.00","39,699.07",,,,,,
Cigna,DRG,MS-489,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Surgical,Relative Weights,"$13,849.00 ",IP,"2,420.00","25,381.44",,,,,,
Cigna,DRG,MS-492,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH MCC,Surgical,Relative Weights,"$37,898.30 ",IP,"2,420.00","69,457.25",,,,,,
Cigna,DRG,MS-493,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH CC,Surgical,Relative Weights,"$25,322.00 ",IP,"2,420.00","46,408.32",,,,,,
Cigna,DRG,MS-494,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITHOUT CC/MCC,Surgical,Relative Weights,"$19,925.40 ",IP,"2,420.00","36,517.82",,,,,,
Cigna,DRG,MS-495,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,Surgical,Relative Weights,"$37,758.60 ",IP,"2,420.00","69,201.22",,,,,,
Cigna,DRG,MS-496,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,Surgical,Relative Weights,"$22,445.50 ",IP,"2,420.00","41,136.48",,,,,,
Cigna,DRG,MS-497,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,Surgical,Relative Weights,"$16,162.30 ",IP,"2,420.00","29,621.09",,,,,,
Cigna,DRG,MS-498,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,Surgical,Relative Weights,"$26,929.10 ",IP,"2,420.00","49,353.70",,,,,,
Cigna,DRG,MS-499,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,Surgical,Relative Weights,"$12,659.90 ",IP,"2,420.00","23,202.14",,,,,,
Cigna,DRG,MS-500,SOFT TISSUE PROCEDURES WITH MCC,Surgical,Relative Weights,"$33,167.20 ",IP,"2,420.00","60,786.43",,,,,,
Cigna,DRG,MS-501,SOFT TISSUE PROCEDURES WITH CC,Surgical,Relative Weights,"$18,458.00 ",IP,"2,420.00","33,828.48",,,,,,
Cigna,DRG,MS-502,SOFT TISSUE PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$14,527.70 ",IP,"2,420.00","26,625.31",,,,,,
Cigna,DRG,MS-503,FOOT PROCEDURES WITH MCC,Surgical,Relative Weights,"$29,882.60 ",IP,"2,420.00","54,766.66",,,,,,
Cigna,DRG,MS-504,FOOT PROCEDURES WITH CC,Surgical,Relative Weights,"$19,101.50 ",IP,"2,420.00","35,007.84",,,,,,
Cigna,DRG,MS-505,FOOT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$18,496.50 ",IP,"2,420.00","33,899.04",,,,,,
Cigna,DRG,MS-506,MAJOR THUMB OR JOINT PROCEDURES,Surgical,Relative Weights,"$14,724.60 ",IP,"2,420.00","26,986.18",,,,,,
Cigna,DRG,MS-507,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W CC/MCC,Surgical,Relative Weights,"$23,100.00 ",IP,"2,420.00","42,336.00",,,,,,
Cigna,DRG,MS-508,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$17,142.40 ",IP,"2,420.00","31,417.34",,,,,,
Cigna,DRG,MS-509,ARTHROSCOPY,Surgical,Relative Weights,"$15,308.70 ",IP,"2,420.00","28,056.67",,,,,,
Cigna,DRG,MS-510,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH MCC,Surgical,Relative Weights,"$30,668.00 ",IP,"2,420.00","56,206.08",,,,,,
Cigna,DRG,MS-511,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH CC,Surgical,Relative Weights,"$20,726.20 ",IP,"2,420.00","37,985.47",,,,,,
Cigna,DRG,MS-512,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$16,651.80 ",IP,"2,420.00","30,518.21",,,,,,
Cigna,DRG,MS-513,HAND OR WRIST PROCEDURES- EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$17,348.10 ",IP,"2,420.00","31,794.34",,,,,,
Cigna,DRG,MS-514,HAND OR WRIST PROCEDURES -  EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$11,734.80 ",IP,"2,420.00","21,506.69",,,,,,
Cigna,DRG,MS-515,OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W MCC,Surgical,Relative Weights,"$34,694.00 ",IP,"2,420.00","63,584.64",,,,,,
Cigna,DRG,MS-516,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$21,330.10 ",IP,"2,420.00","39,092.26",,,,,,
Cigna,DRG,MS-517,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$15,568.30 ",IP,"2,420.00","28,532.45",,,,,,
Cigna,DRG,MS-518,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,Surgical,Relative Weights,"$37,494.60 ",IP,"10,289.00","68,717.38",,,,,,
Cigna,DRG,MS-519,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,Surgical,Relative Weights,"$20,995.70 ",IP,"10,289.00","38,479.39",,,,,,
Cigna,DRG,MS-520,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,Surgical,Relative Weights,"$14,718.00 ",IP,"8,282.98","26,974.08",,,,,,
Cigna,DRG,MS-533,FRACTURES OF FEMUR WITH MCC,Surgical,Relative Weights,"$16,053.40 ",IP,"2,420.00","29,421.50",,,,,,
Cigna,DRG,MS-534,FRACTURES OF FEMUR WITHOUT MCC,Surgical,Relative Weights,"$8,555.80 ",IP,"2,420.00","15,680.45",,,,,,
Cigna,DRG,MS-535,FRACTURES OF HIP AND PELVIS WITH MCC,Surgical,Relative Weights,"$13,498.10 ",IP,"2,420.00","24,738.34",,,,,,
Cigna,DRG,MS-536,FRACTURES OF HIP AND PELVIS WITHOUT MCC,Surgical,Relative Weights,"$8,343.50 ",IP,"2,420.00","15,291.36",,,,,,
Cigna,DRG,MS-537,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITH CC/MCC,Surgical,Relative Weights,"$10,019.90 ",IP,"2,420.00","18,363.74",,,,,,
Cigna,DRG,MS-538,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITHOUT CC/MCC,Surgical,Relative Weights,"$7,931.00 ",IP,"2,420.00","14,535.36",,,,,,
Cigna,DRG,MS-539,OSTEOMYELITIS WITH MCC,Surgical,Relative Weights,"$20,737.20 ",IP,"2,420.00","38,005.63",,,,,,
Cigna,DRG,MS-540,OSTEOMYELITIS WITH CC,Surgical,Relative Weights,"$14,300.00 ",IP,"2,420.00","26,208.00",,,,,,
Cigna,DRG,MS-541,OSTEOMYELITIS WITHOUT CC/MCC,Surgical,Relative Weights,"$9,973.70 ",IP,"2,420.00","18,279.07",,,,,,
Cigna,DRG,MS-542,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,Surgical,Relative Weights,"$20,072.80 ",IP,"2,420.00","36,787.97",,,,,,
Cigna,DRG,MS-543,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,Surgical,Relative Weights,"$11,619.30 ",IP,"2,420.00","21,295.01",,,,,,
Cigna,DRG,MS-544,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$8,342.40 ",IP,"2,420.00","15,289.34",,,,,,
Cigna,DRG,MS-545,CONNECTIVE TISSUE DISORDERS WITH MCC,Surgical,Relative Weights,"$27,808.00 ",IP,"2,420.00","50,964.48",,,,,,
Cigna,DRG,MS-546,CONNECTIVE TISSUE DISORDERS WITH CC,Surgical,Relative Weights,"$13,237.40 ",IP,"2,420.00","24,260.54",,,,,,
Cigna,DRG,MS-547,CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$8,911.10 ",IP,"2,420.00","16,331.62",,,,,,
Cigna,DRG,MS-548,SEPTIC ARTHRITIS WITH MCC,Surgical,Relative Weights,"$21,816.30 ",IP,"2,420.00","39,983.33",,,,,,
Cigna,DRG,MS-549,SEPTIC ARTHRITIS W CC,Surgical,Relative Weights,"$13,124.10 ",IP,"2,420.00","24,052.90",,,,,,
Cigna,DRG,MS-550,SEPTIC ARTHRITIS W/O CC/MCC,Surgical,Relative Weights,"$9,504.00 ",IP,"2,420.00","17,418.24",,,,,,
Cigna,DRG,MS-551,MEDICAL BACK PROBLEMS WITH MCC,Surgical,Relative Weights,"$17,483.40 ",IP,"2,420.00","32,042.30",,,,,,
Cigna,DRG,MS-552,MEDICAL BACK PROBLEMS WITHOUT MCC,Surgical,Relative Weights,"$10,030.90 ",IP,"2,420.00","18,383.90",,,,,,
Cigna,DRG,MS-553,BONE DISEASES AND ARTHROPATHIES WITH MCC,Surgical,Relative Weights,"$14,140.50 ",IP,"2,420.00","25,915.68",,,,,,
Cigna,DRG,MS-554,BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,Surgical,Relative Weights,"$8,659.20 ",IP,"2,420.00","15,869.95",,,,,,
Cigna,DRG,MS-555,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Surgical,Relative Weights,"$14,468.30 ",IP,"2,420.00","26,516.45",,,,,,
Cigna,DRG,MS-556,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,Surgical,Relative Weights,"$8,709.80 ",IP,"2,420.00","15,962.69",,,,,,
Cigna,DRG,MS-557,TENDONITIS -  MYOSITIS AND BURSITIS WITH MCC,Surgical,Relative Weights,"$16,040.20 ",IP,"2,420.00","29,397.31",,,,,,
Cigna,DRG,MS-558,TENDONITIS- MYOSITIS AND BURSITIS WITHOUT MCC,Surgical,Relative Weights,"$9,475.40 ",IP,"2,420.00","17,365.82",,,,,,
Cigna,DRG,MS-559,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Surgical,Relative Weights,"$19,819.80 ",IP,"2,420.00","36,324.29",,,,,,
Cigna,DRG,MS-560,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Surgical,Relative Weights,"$11,478.50 ",IP,"2,420.00","21,036.96",,,,,,
Cigna,DRG,MS-561,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Surgical,Relative Weights,"$8,221.40 ",IP,"2,420.00","15,067.58",,,,,,
Cigna,DRG,MS-562,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITH MCC,Surgical,Relative Weights,"$14,818.10 ",IP,"2,420.00","27,157.54",,,,,,
Cigna,DRG,MS-563,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITHOUT MCC,Surgical,Relative Weights,"$9,394.00 ",IP,"2,420.00","17,216.64",,,,,,
Cigna,DRG,MS-564,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,Surgical,Relative Weights,"$16,632.00 ",IP,"2,420.00","30,481.92",,,,,,
Cigna,DRG,MS-565,OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W CC,Surgical,Relative Weights,"$10,785.50 ",IP,"2,420.00","19,766.88",,,,,,
Cigna,DRG,MS-566,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,334.70 ",IP,"2,420.00","15,275.23",,,,,,
Cigna,DRG,MS-570,SKIN DEBRIDEMENT WITH MCC,Surgical,Relative Weights,"$31,605.20 ",IP,"2,420.00","57,923.71",,,,,,
Cigna,DRG,MS-571,SKIN DEBRIDEMENT WITH CC,Surgical,Relative Weights,"$18,395.30 ",IP,"2,420.00","33,713.57",,,,,,
Cigna,DRG,MS-572,SKIN DEBRIDEMENT WITHOUT CC/MCC,Surgical,Relative Weights,"$12,338.70 ",IP,"2,420.00","22,613.47",,,,,,
Cigna,DRG,MS-573,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,Surgical,Relative Weights,"$58,468.30 ",IP,"2,420.00","107,156.45",,,,,,
Cigna,DRG,MS-574,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,Surgical,Relative Weights,"$34,339.80 ",IP,"2,420.00","62,935.49",,,,,,
Cigna,DRG,MS-575,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS W/O CC/MCC,Surgical,Relative Weights,"$19,327.00 ",IP,"2,420.00","35,421.12",,,,,,
Cigna,DRG,MS-576,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,Surgical,Relative Weights,"$53,341.20 ",IP,"2,420.00","97,759.87",,,,,,
Cigna,DRG,MS-577,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,Surgical,Relative Weights,"$26,571.60 ",IP,"2,420.00","48,698.50",,,,,,
Cigna,DRG,MS-578,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,Surgical,Relative Weights,"$17,901.40 ",IP,"2,420.00","32,808.38",,,,,,
Cigna,DRG,MS-579,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC,Surgical,Relative Weights,"$32,847.10 ",IP,"2,420.00","60,199.78",,,,,,
Cigna,DRG,MS-580,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC,Surgical,Relative Weights,"$17,695.70 ",IP,"2,420.00","32,431.39",,,,,,
Cigna,DRG,MS-581,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$13,802.80 ",IP,"2,420.00","25,296.77",,,,,,
Cigna,DRG,MS-582,MASTECTOMY FOR MALIGNANCY WITH CC/MCC,Surgical,Relative Weights,"$17,365.70 ",IP,"2,420.00","31,826.59",,,,,,
Cigna,DRG,MS-583,MASTECTOMY FOR MALIGNANCY W/O CC/MCC,Surgical,Relative Weights,"$16,075.40 ",IP,"2,420.00","29,461.82",,,,,,
Cigna,DRG,MS-584,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$20,112.40 ",IP,"2,420.00","36,860.54",,,,,,
Cigna,DRG,MS-585,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$18,670.30 ",IP,"2,420.00","34,217.57",,,,,,
Cigna,DRG,MS-592,SKIN ULCERS WITH MCC,Surgical,Relative Weights,"$19,627.30 ",IP,"2,420.00","35,971.49",,,,,,
Cigna,DRG,MS-593,SKIN ULCERS WITH CC,Surgical,Relative Weights,"$12,625.80 ",IP,"2,420.00","23,139.65",,,,,,
Cigna,DRG,MS-594,SKIN ULCERS WITHOUT CC/MCC,Surgical,Relative Weights,"$8,906.70 ",IP,"2,420.00","16,323.55",,,,,,
Cigna,DRG,MS-595,MAJOR SKIN DISORDERS WITH MCC,Surgical,Relative Weights,"$22,358.60 ",IP,"2,420.00","40,977.22",,,,,,
Cigna,DRG,MS-596,MAJOR SKIN DISORDERS W/O MCC,Surgical,Relative Weights,"$10,715.10 ",IP,"2,420.00","19,637.86",,,,,,
Cigna,DRG,MS-597,MALIGNANT BREAST DISORDERS W MCC,Surgical,Relative Weights,"$18,621.90 ",IP,"2,420.00","34,128.86",,,,,,
Cigna,DRG,MS-598,MALIGNANT BREAST DISORDERS WITH CC,Surgical,Relative Weights,"$11,974.60 ",IP,"2,420.00","21,946.18",,,,,,
Cigna,DRG,MS-599,MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$7,649.40 ",IP,"2,420.00","14,019.26",,,,,,
Cigna,DRG,MS-600,NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,Surgical,Relative Weights,"$10,551.20 ",IP,"2,420.00","19,337.47",,,,,,
Cigna,DRG,MS-601,NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$6,806.80 ",IP,"2,420.00","12,475.01",,,,,,
Cigna,DRG,MS-602,CELLULITIS WITH MCC,Surgical,Relative Weights,"$15,727.80 ",IP,"2,420.00","28,824.77",,,,,,
Cigna,DRG,MS-603,CELLULITIS WITHOUT MCC,Surgical,Relative Weights,"$9,278.50 ",IP,"2,420.00","17,004.96",,,,,,
Cigna,DRG,MS-604,TRAUMA TO THE SKIN -  SUBCUTANEOUS TISSUE AND BREAST WITH MCC,Surgical,Relative Weights,"$16,109.50 ",IP,"2,420.00","29,524.32",,,,,,
Cigna,DRG,MS-605,TRAUMA TO THE SKIN- SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC,Surgical,Relative Weights,"$9,632.70 ",IP,"2,420.00","17,654.11",,,,,,
Cigna,DRG,MS-606,MINOR SKIN DISORDERS WITH MCC,Surgical,Relative Weights,"$16,450.50 ",IP,"2,420.00","30,149.28",,,,,,
Cigna,DRG,MS-607,MINOR SKIN DISORDERS WITHOUT MCC,Surgical,Relative Weights,"$9,087.10 ",IP,"2,420.00","16,654.18",,,,,,
Cigna,DRG,MS-614,ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$26,766.30 ",IP,"2,420.00","49,055.33",,,,,,
Cigna,DRG,MS-615,ADRENAL & PITUITARY PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$16,325.10 ",IP,"2,420.00","29,919.46",,,,,,
Cigna,DRG,MS-616,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Surgical,Relative Weights,"$44,008.80 ",IP,"2,420.00","80,656.13",,,,,,
Cigna,DRG,MS-617,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Surgical,Relative Weights,"$22,564.30 ",IP,"2,420.00","41,354.21",,,,,,
Cigna,DRG,MS-618,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$13,799.50 ",IP,"2,420.00","25,290.72",,,,,,
Cigna,DRG,MS-619,O.R. PROCEDURES FOR OBESITY WITH MCC,Surgical,Relative Weights,"$33,863.50 ",IP,"2,420.00","62,062.56",,,,,,
Cigna,DRG,MS-620,O.R. PROCEDURES FOR OBESITY WITH CC,Surgical,Relative Weights,"$19,740.60 ",IP,"2,420.00","36,179.14",,,,,,
Cigna,DRG,MS-621,O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,Surgical,Relative Weights,"$17,292.00 ",IP,"2,420.00","31,691.52",,,,,,
Cigna,DRG,MS-622,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Surgical,Relative Weights,"$41,530.50 ",IP,"2,420.00","76,114.08",,,,,,
Cigna,DRG,MS-623,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE -  NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Surgical,Relative Weights,"$21,478.60 ",IP,"2,420.00","39,364.42",,,,,,
Cigna,DRG,MS-624,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$12,122.00 ",IP,"2,420.00","22,216.32",,,,,,
Cigna,DRG,MS-625,THYROID- PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$32,176.10 ",IP,"2,420.00","58,970.02",,,,,,
Cigna,DRG,MS-626,THYROID -  PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC,Surgical,Relative Weights,"$18,510.80 ",IP,"2,420.00","33,925.25",,,,,,
Cigna,DRG,MS-627,THYROID -  PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$12,558.70 ",IP,"2,420.00","23,016.67",,,,,,
Cigna,DRG,MS-628,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$40,582.30 ",IP,"2,420.00","74,376.29",,,,,,
Cigna,DRG,MS-629,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$25,550.80 ",IP,"2,420.00","46,827.65",,,,,,
Cigna,DRG,MS-630,OTHER ENDOCRINE - NUTRIT & METAB O.R. PROC W/O CC/MCC,Surgical,Relative Weights,"$15,936.80 ",IP,"2,420.00","29,207.81",,,,,,
Cigna,DRG,MS-637,DIABETES WITH MCC,Surgical,Relative Weights,"$15,242.70 ",IP,"2,420.00","27,935.71",,,,,,
Cigna,DRG,MS-638,DIABETES WITH CC,Surgical,Relative Weights,"$9,725.10 ",IP,"2,420.00","17,823.46",,,,,,
Cigna,DRG,MS-639,DIABETES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,745.20 ",IP,"2,420.00","12,362.11",,,,,,
Cigna,DRG,MS-640,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITH MCC,Surgical,Relative Weights,"$13,356.20 ",IP,"2,420.00","24,478.27",,,,,,
Cigna,DRG,MS-641,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITHOUT MCC,Surgical,Relative Weights,"$8,322.60 ",IP,"2,420.00","15,253.06",,,,,,
Cigna,DRG,MS-642,INBORN AND OTHER DISORDERS OF METABOLISM,Surgical,Relative Weights,"$13,373.80 ",IP,"2,420.00","24,510.53",,,,,,
Cigna,DRG,MS-643,ENDOCRINE DISORDERS WITH MCC,Surgical,Relative Weights,"$17,880.50 ",IP,"2,420.00","32,770.08",,,,,,
Cigna,DRG,MS-644,ENDOCRINE DISORDERS WITH CC,Surgical,Relative Weights,"$11,309.10 ",IP,"2,420.00","20,726.50",,,,,,
Cigna,DRG,MS-645,ENDOCRINE DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$8,417.20 ",IP,"2,420.00","15,426.43",,,,,,
Cigna,DRG,MS-652,KIDNEY TRANSPLANT,Surgical,Relative Weights,"$37,233.90 ",IP,"2,420.00","68,239.58",,,,,,
Cigna,DRG,MS-653,MAJOR BLADDER PROCEDURES WITH MCC,Surgical,Relative Weights,"$60,901.50 ",IP,"2,420.00","111,615.84",,,,,,
Cigna,DRG,MS-654,MAJOR BLADDER PROCEDURES WITH CC,Surgical,Relative Weights,"$30,934.20 ",IP,"2,420.00","56,693.95",,,,,,
Cigna,DRG,MS-655,MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$22,686.40 ",IP,"2,420.00","41,577.98",,,,,,
Cigna,DRG,MS-656,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,Surgical,Relative Weights,"$35,866.60 ",IP,"2,420.00","65,733.70",,,,,,
Cigna,DRG,MS-657,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,Surgical,Relative Weights,"$21,276.20 ",IP,"2,420.00","38,993.47",,,,,,
Cigna,DRG,MS-658,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,Surgical,Relative Weights,"$17,268.90 ",IP,"2,420.00","31,649.18",,,,,,
Cigna,DRG,MS-659,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,Surgical,Relative Weights,"$29,477.80 ",IP,"2,420.00","54,024.77",,,,,,
Cigna,DRG,MS-660,KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC,Surgical,Relative Weights,"$15,627.70 ",IP,"2,420.00","28,641.31",,,,,,
Cigna,DRG,MS-661,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,Surgical,Relative Weights,"$11,991.10 ",IP,"2,420.00","21,976.42",,,,,,
Cigna,DRG,MS-662,MINOR BLADDER PROCEDURES WITH MCC,Surgical,Relative Weights,"$34,811.70 ",IP,"2,420.00","63,800.35",,,,,,
Cigna,DRG,MS-663,MINOR BLADDER PROCEDURES WITH CC,Surgical,Relative Weights,"$16,757.40 ",IP,"2,420.00","30,711.74",,,,,,
Cigna,DRG,MS-664,MINOR BLADDER PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$12,172.60 ",IP,"2,420.00","22,309.06",,,,,,
Cigna,DRG,MS-665,PROSTATECTOMY WITH MCC,Surgical,Relative Weights,"$32,653.50 ",IP,"2,420.00","59,844.96",,,,,,
Cigna,DRG,MS-666,PROSTATECTOMY WITH CC,Surgical,Relative Weights,"$19,460.10 ",IP,"2,420.00","35,665.06",,,,,,
Cigna,DRG,MS-667,PROSTATECTOMY W/O CC/MCC,Surgical,Relative Weights,"$10,325.70 ",IP,"2,420.00","18,924.19",,,,,,
Cigna,DRG,MS-668,TRANSURETHRAL PROCEDURES W MCC,Surgical,Relative Weights,"$30,671.30 ",IP,"2,420.00","56,212.13",,,,,,
Cigna,DRG,MS-669,TRANSURETHRAL PROCEDURES WITH CC,Surgical,Relative Weights,"$17,002.70 ",IP,"2,420.00","31,161.31",,,,,,
Cigna,DRG,MS-670,TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,765.70 ",IP,"2,420.00","19,730.59",,,,,,
Cigna,DRG,MS-671,URETHRAL PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$20,103.60 ",IP,"2,420.00","36,844.42",,,,,,
Cigna,DRG,MS-672,URETHRAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$11,365.20 ",IP,"2,420.00","20,829.31",,,,,,
Cigna,DRG,MS-673,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,Surgical,Relative Weights,"$39,320.60 ",IP,"2,420.00","72,063.94",,,,,,
Cigna,DRG,MS-674,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,Surgical,Relative Weights,"$26,886.20 ",IP,"2,420.00","49,275.07",,,,,,
Cigna,DRG,MS-675,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$17,952.00 ",IP,"2,420.00","32,901.12",,,,,,
Cigna,DRG,MS-682,RENAL FAILURE WITH MCC,Surgical,Relative Weights,"$16,258.00 ",IP,"2,420.00","29,796.48",,,,,,
Cigna,DRG,MS-683,RENAL FAILURE WITH CC,Surgical,Relative Weights,"$9,870.30 ",IP,"2,420.00","18,089.57",,,,,,
Cigna,DRG,MS-684,RENAL FAILURE WITHOUT CC/MCC,Surgical,Relative Weights,"$6,768.30 ",IP,"2,420.00","12,404.45",,,,,,
Cigna,DRG,MS-686,KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,Surgical,Relative Weights,"$19,317.10 ",IP,"2,420.00","35,402.98",,,,,,
Cigna,DRG,MS-687,KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,Surgical,Relative Weights,"$11,578.60 ",IP,"2,420.00","21,220.42",,,,,,
Cigna,DRG,MS-688,KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,Surgical,Relative Weights,"$8,484.30 ",IP,"2,420.00","15,549.41",,,,,,
Cigna,DRG,MS-689,KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,Surgical,Relative Weights,"$12,304.60 ",IP,"2,420.00","22,550.98",,,,,,
Cigna,DRG,MS-690,KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,Surgical,Relative Weights,"$8,698.80 ",IP,"2,420.00","15,942.53",,,,,,
Cigna,DRG,MS-693,URINARY STONES WITH MCC,Surgical,Relative Weights,"$14,886.30 ",IP,"2,420.00","27,282.53",,,,,,
Cigna,DRG,MS-694,URINARY STONES WITHOUT MCC,Surgical,Relative Weights,"$8,144.40 ",IP,"2,420.00","14,926.46",,,,,,
Cigna,DRG,MS-695,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,Surgical,Relative Weights,"$12,895.30 ",IP,"2,420.00","23,633.57",,,,,,
Cigna,DRG,MS-696,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,Surgical,Relative Weights,"$7,473.40 ",IP,"2,420.00","13,696.70",,,,,,
Cigna,DRG,MS-697,URETHRAL STRICTURE,Surgical,Relative Weights,"$10,712.90 ",IP,"2,420.00","19,633.82",,,,,,
Cigna,DRG,MS-698,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,Surgical,Relative Weights,"$17,804.60 ",IP,"2,420.00","32,630.98",,,,,,
Cigna,DRG,MS-699,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,Surgical,Relative Weights,"$11,359.70 ",IP,"2,420.00","20,819.23",,,,,,
Cigna,DRG,MS-700,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,158.70 ",IP,"2,420.00","14,952.67",,,,,,
Cigna,DRG,MS-707,MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$20,568.90 ",IP,"2,420.00","37,697.18",,,,,,
Cigna,DRG,MS-708,MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$15,972.00 ",IP,"2,420.00","29,272.32",,,,,,
Cigna,DRG,MS-709,PENIS PROCEDURES W CC/MCC,Surgical,Relative Weights,"$26,461.60 ",IP,"2,420.00","48,496.90",,,,,,
Cigna,DRG,MS-710,PENIS PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$16,893.80 ",IP,"2,420.00","30,961.73",,,,,,
Cigna,DRG,MS-711,TESTES PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$23,575.20 ",IP,"2,420.00","43,206.91",,,,,,
Cigna,DRG,MS-712,TESTES PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$11,222.20 ",IP,"2,420.00","20,567.23",,,,,,
Cigna,DRG,MS-713,TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,Surgical,Relative Weights,"$16,082.00 ",IP,"2,420.00","29,473.92",,,,,,
Cigna,DRG,MS-714,TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,Surgical,Relative Weights,"$10,069.40 ",IP,"2,420.00","18,454.46",,,,,,
Cigna,DRG,MS-715,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,Surgical,Relative Weights,"$23,501.50 ",IP,"2,420.00","43,071.84",,,,,,
Cigna,DRG,MS-716,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$16,120.50 ",IP,"2,420.00","29,544.48",,,,,,
Cigna,DRG,MS-717,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,Surgical,Relative Weights,"$19,407.30 ",IP,"2,420.00","35,568.29",,,,,,
Cigna,DRG,MS-718,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$13,413.40 ",IP,"2,420.00","24,583.10",,,,,,
Cigna,DRG,MS-722,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH MCC,Surgical,Relative Weights,"$19,853.90 ",IP,"2,420.00","36,386.78",,,,,,
Cigna,DRG,MS-723,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH CC,Surgical,Relative Weights,"$12,181.40 ",IP,"2,420.00","22,325.18",,,,,,
Cigna,DRG,MS-724,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Surgical,Relative Weights,"$6,494.40 ",IP,"2,420.00","11,902.46",,,,,,
Cigna,DRG,MS-725,BENIGN PROSTATIC HYPERTROPHY WITH MCC,Surgical,Relative Weights,"$13,809.40 ",IP,"2,420.00","25,308.86",,,,,,
Cigna,DRG,MS-726,BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,Surgical,Relative Weights,"$8,411.70 ",IP,"2,420.00","15,416.35",,,,,,
Cigna,DRG,MS-727,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,Surgical,Relative Weights,"$15,700.30 ",IP,"2,420.00","28,774.37",,,,,,
Cigna,DRG,MS-728,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,Surgical,Relative Weights,"$8,827.50 ",IP,"2,420.00","16,178.40",,,,,,
Cigna,DRG,MS-729,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,Surgical,Relative Weights,"$11,812.90 ",IP,"2,420.00","21,649.82",,,,,,
Cigna,DRG,MS-730,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,947.60 ",IP,"2,420.00","12,733.06",,,,,,
Cigna,DRG,MS-734,PELVIC EVISCERATION -  RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC,Surgical,Relative Weights,"$24,110.90 ",IP,"2,420.00","44,188.70",,,,,,
Cigna,DRG,MS-735,PELVIC EVISCERATION -  RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC,Surgical,Relative Weights,"$15,116.20 ",IP,"2,420.00","27,703.87",,,,,,
Cigna,DRG,MS-736,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,Surgical,Relative Weights,"$47,529.90 ",IP,"2,420.00","87,109.34",,,,,,
Cigna,DRG,MS-737,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,Surgical,Relative Weights,"$21,858.10 ",IP,"2,420.00","40,059.94",,,,,,
Cigna,DRG,MS-738,UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY W/O CC/MCC,Surgical,Relative Weights,"$15,167.90 ",IP,"2,420.00","27,798.62",,,,,,
Cigna,DRG,MS-739,UTERINE -ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W MCC,Surgical,Relative Weights,"$41,189.50 ",IP,"2,420.00","75,489.12",,,,,,
Cigna,DRG,MS-740,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,Surgical,Relative Weights,"$19,633.90 ",IP,"2,420.00","35,983.58",,,,,,
Cigna,DRG,MS-741,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$14,624.50 ",IP,"2,420.00","26,802.72",,,,,,
Cigna,DRG,MS-742,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,Surgical,Relative Weights,"$18,584.50 ",IP,"2,420.00","34,060.32",,,,,,
Cigna,DRG,MS-743,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$12,633.50 ",IP,"2,420.00","23,153.76",,,,,,
Cigna,DRG,MS-744,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC,Surgical,Relative Weights,"$19,145.50 ",IP,"2,420.00","35,088.48",,,,,,
Cigna,DRG,MS-745,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC,Surgical,Relative Weights,"$11,718.30 ",IP,"2,420.00","21,476.45",,,,,,
Cigna,DRG,MS-746,VAGINA -  CERVIX AND VULVA PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$17,941.00 ",IP,"2,420.00","32,880.96",,,,,,
Cigna,DRG,MS-747,VAGINA- CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,254.20 ",IP,"2,420.00","18,793.15",,,,,,
Cigna,DRG,MS-748,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,Surgical,Relative Weights,"$14,538.70 ",IP,"2,420.00","26,645.47",,,,,,
Cigna,DRG,MS-749,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$28,514.20 ",IP,"2,420.00","52,258.75",,,,,,
Cigna,DRG,MS-750,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$14,643.20 ",IP,"2,420.00","26,836.99",,,,,,
Cigna,DRG,MS-754,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH MCC,Surgical,Relative Weights,"$19,380.90 ",IP,"2,420.00","35,519.90",,,,,,
Cigna,DRG,MS-755,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH CC,Surgical,Relative Weights,"$11,261.80 ",IP,"2,420.00","20,639.81",,,,,,
Cigna,DRG,MS-756,MALIGNANCY - FEMALE REPRODUCTIVE SYSTEM W/O CC/MCC,Surgical,Relative Weights,"$9,644.80 ",IP,"2,420.00","17,676.29",,,,,,
Cigna,DRG,MS-757,INFECTIONS - FEMALE REPRODUCTIVE SYSTEM W MCC,Surgical,Relative Weights,"$15,623.30 ",IP,"2,420.00","28,633.25",,,,,,
Cigna,DRG,MS-758,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITH CC,Surgical,Relative Weights,"$10,619.40 ",IP,"2,420.00","19,462.46",,,,,,
Cigna,DRG,MS-759,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Surgical,Relative Weights,"$7,263.30 ",IP,"2,420.00","13,311.65",,,,,,
Cigna,DRG,MS-760,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,Surgical,Relative Weights,"$9,927.50 ",IP,"2,420.00","18,194.40",,,,,,
Cigna,DRG,MS-761,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$6,219.40 ",IP,"2,420.00","11,398.46",,,,,,
Cigna,DRG,MS-768,VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C,Surgical,Relative Weights,"$11,082.50 ",IP,"2,420.00","20,311.20",,,,,,
Cigna,DRG,MS-769,POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,Surgical,Relative Weights,"$15,873.00 ",IP,"2,420.00","29,090.88",,,,,,
Cigna,DRG,MS-770,ABORTION WITH D&C- ASPIRATION CURETTAGE OR HYSTEROTOMY,Surgical,Relative Weights,"$8,649.30 ",IP,"2,420.00","15,851.81",,,,,,
Cigna,DRG,MS-776,POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,Surgical,Relative Weights,"$7,808.90 ",IP,"2,420.00","14,311.58",,,,,,
Cigna,DRG,MS-779,ABORTION WITHOUT D&C,Surgical,Relative Weights,"$12,559.80 ",IP,"2,420.00","23,018.69",,,,,,
Cigna,DRG,MS-783,CESAREAN SECTION WITH STERILIZATION WITH MCC,Surgical,Relative Weights,"$23,592.80 ",IP,"2,420.00","43,239.17",,,,,,
Cigna,DRG,MS-784,CESAREAN SECTION WITH STERILIZATION WITH CC,Surgical,Relative Weights,"$11,497.20 ",IP,"2,420.00","21,071.23",,,,,,
Cigna,DRG,MS-785,CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,Surgical,Relative Weights,"$9,442.40 ",IP,"2,420.00","17,305.34",,,,,,
Cigna,DRG,MS-786,CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,Surgical,Relative Weights,"$18,859.50 ",IP,"2,420.00","34,564.32",,,,,,
Cigna,DRG,MS-787,CESAREAN SECTION WITHOUT STERILIZATION WITH CC,Surgical,Relative Weights,"$11,500.50 ",IP,"2,420.00","21,077.28",,,,,,
Cigna,DRG,MS-788,CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,Surgical,Relative Weights,"$9,968.20 ",IP,"2,420.00","18,268.99",,,,,,
Cigna,DRG,MS-789,NEONATES- DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY,Surgical,Relative Weights,"$18,590.00 ",IP,"2,420.00","34,070.40",,,,,,
Cigna,DRG,MS-790,EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME- NEONATE,Surgical,Relative Weights,"$61,303.00 ",IP,"2,420.00","112,351.68",,,,,,
Cigna,DRG,MS-791,PREMATURITY W MAJOR PROBLEMS,Surgical,Relative Weights,"$41,868.20 ",IP,"2,420.00","76,732.99",,,,,,
Cigna,DRG,MS-792,PREMATURITY W/O MAJOR PROBLEMS,Surgical,Relative Weights,"$25,261.50 ",IP,"2,420.00","46,297.44",,,,,,
Cigna,DRG,MS-793,FULL TERM NEONATE WITH MAJOR PROBLEMS,Surgical,Relative Weights,"$43,006.70 ",IP,"2,420.00","78,819.55",,,,,,
Cigna,DRG,MS-794,NEONATE WITH OTHER SIGNIFICANT PROBLEMS,Surgical,Relative Weights,"$15,221.80 ",IP,"2,420.00","27,897.41",,,,,,
Cigna,DRG,MS-795,NORMAL NEWBORN,Surgical,Relative Weights,"$2,060.30 ",IP,"1,113.70","3,775.97",,,,,,
Cigna,DRG,MS-796,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,Surgical,Relative Weights,"$21,695.30 ",IP,"2,420.00","39,761.57",,,,,,
Cigna,DRG,MS-797,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,Surgical,Relative Weights,"$9,490.80 ",IP,"2,420.00","17,394.05",,,,,,
Cigna,DRG,MS-798,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,Surgical,Relative Weights,"$9,490.80 ",IP,"2,420.00","17,394.05",,,,,,
Cigna,DRG,MS-799,SPLENECTOMY WITH MCC,Surgical,Relative Weights,"$54,387.30 ",IP,"2,420.00","99,677.09",,,,,,
Cigna,DRG,MS-800,SPLENECTOMY WITH CC,Surgical,Relative Weights,"$31,262.00 ",IP,"2,420.00","57,294.72",,,,,,
Cigna,DRG,MS-801,SPLENECTOMY WITHOUT CC/MCC,Surgical,Relative Weights,"$20,605.20 ",IP,"2,420.00","37,763.71",,,,,,
Cigna,DRG,MS-802,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,Surgical,Relative Weights,"$34,676.40 ",IP,"2,420.00","63,552.38",,,,,,
Cigna,DRG,MS-803,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,Surgical,Relative Weights,"$19,597.60 ",IP,"2,420.00","35,917.06",,,,,,
Cigna,DRG,MS-804,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,Surgical,Relative Weights,"$14,988.60 ",IP,"2,420.00","27,470.02",,,,,,
Cigna,DRG,MS-805,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,Surgical,Relative Weights,"$11,447.70 ",IP,"2,420.00","20,980.51",,,,,,
Cigna,DRG,MS-806,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,Surgical,Relative Weights,"$7,801.20 ",IP,"2,420.00","14,297.47",,,,,,
Cigna,DRG,MS-807,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,Surgical,Relative Weights,"$6,894.80 ",IP,"2,420.00","12,636.29",,,,,,
Cigna,DRG,MS-808,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,Surgical,Relative Weights,"$23,425.60 ",IP,"2,420.00","42,932.74",,,,,,
Cigna,DRG,MS-809,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,Surgical,Relative Weights,"$13,374.90 ",IP,"2,420.00","24,512.54",,,,,,
Cigna,DRG,MS-810,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$10,289.40 ",IP,"2,420.00","18,857.66",,,,,,
Cigna,DRG,MS-811,RED BLOOD CELL DISORDERS WITH MCC,Surgical,Relative Weights,"$14,743.30 ",IP,"2,420.00","27,020.45",,,,,,
Cigna,DRG,MS-812,RED BLOOD CELL DISORDERS WITHOUT MCC,Surgical,Relative Weights,"$9,577.70 ",IP,"2,420.00","17,553.31",,,,,,
Cigna,DRG,MS-813,COAGULATION DISORDERS,Surgical,Relative Weights,"$17,437.20 ",IP,"2,420.00","31,957.63",,,,,,
Cigna,DRG,MS-814,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,Surgical,Relative Weights,"$19,240.10 ",IP,"2,420.00","35,261.86",,,,,,
Cigna,DRG,MS-815,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,Surgical,Relative Weights,"$11,140.80 ",IP,"2,420.00","20,418.05",,,,,,
Cigna,DRG,MS-816,RETICULOENDOTHELIAL & IMMUNITY DISORDERS W/O CC/MCC,Surgical,Relative Weights,"$7,874.90 ",IP,"2,420.00","14,432.54",,,,,,
Cigna,DRG,MS-817,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$27,678.20 ",IP,"2,420.00","50,726.59",,,,,,
Cigna,DRG,MS-818,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$14,012.90 ",IP,"2,420.00","25,681.82",,,,,,
Cigna,DRG,MS-819,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,776.90 ",IP,"2,420.00","16,085.66",,,,,,
Cigna,DRG,MS-820,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$62,883.70 ",IP,"2,420.00","115,248.67",,,,,,
Cigna,DRG,MS-821,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$24,555.30 ",IP,"2,420.00","45,003.17",,,,,,
Cigna,DRG,MS-822,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$13,908.40 ",IP,"2,420.00","25,490.30",,,,,,
Cigna,DRG,MS-823,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,Surgical,Relative Weights,"$46,532.20 ",IP,"2,420.00","85,280.83",,,,,,
Cigna,DRG,MS-824,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,Surgical,Relative Weights,"$25,576.10 ",IP,"2,420.00","46,874.02",,,,,,
Cigna,DRG,MS-825,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$14,899.50 ",IP,"2,420.00","27,306.72",,,,,,
Cigna,DRG,MS-826,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$55,165.00 ",IP,"2,420.00","101,102.40",,,,,,
Cigna,DRG,MS-827,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$25,478.20 ",IP,"2,420.00","46,694.59",,,,,,
Cigna,DRG,MS-828,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$18,163.20 ",IP,"2,420.00","33,288.19",,,,,,
Cigna,DRG,MS-829,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$34,538.90 ",IP,"2,420.00","63,300.38",,,,,,
Cigna,DRG,MS-830,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$15,166.80 ",IP,"2,420.00","27,796.61",,,,,,
Cigna,DRG,MS-831,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$11,863.50 ",IP,"2,420.00","21,742.56",,,,,,
Cigna,DRG,MS-832,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$7,870.50 ",IP,"2,420.00","14,424.48",,,,,,
Cigna,DRG,MS-833,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$5,853.10 ",IP,"2,420.00","10,727.14",,,,,,
Cigna,DRG,MS-834,ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W MCC,Surgical,Relative Weights,"$64,267.50 ",IP,"2,420.00","117,784.80",,,,,,
Cigna,DRG,MS-835,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$22,310.20 ",IP,"2,420.00","40,888.51",,,,,,
Cigna,DRG,MS-836,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$14,493.60 ",IP,"2,420.00","26,562.82",,,,,,
Cigna,DRG,MS-837,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,Surgical,Relative Weights,"$65,898.80 ",IP,"2,420.00","120,774.53",,,,,,
Cigna,DRG,MS-838,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,Surgical,Relative Weights,"$24,066.90 ",IP,"2,420.00","44,108.06",,,,,,
Cigna,DRG,MS-839,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$14,038.20 ",IP,"2,420.00","25,728.19",,,,,,
Cigna,DRG,MS-840,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,Surgical,Relative Weights,"$35,147.20 ",IP,"2,420.00","64,415.23",,,,,,
Cigna,DRG,MS-841,LYMPHOMA & NON-ACUTE LEUKEMIA W CC,Surgical,Relative Weights,"$17,728.70 ",IP,"2,420.00","32,491.87",,,,,,
Cigna,DRG,MS-842,LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,Surgical,Relative Weights,"$12,612.60 ",IP,"2,420.00","23,115.46",,,,,,
Cigna,DRG,MS-843,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,Surgical,Relative Weights,"$20,985.80 ",IP,"2,420.00","38,461.25",,,,,,
Cigna,DRG,MS-844,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,Surgical,Relative Weights,"$13,288.00 ",IP,"2,420.00","24,353.28",,,,,,
Cigna,DRG,MS-845,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,Surgical,Relative Weights,"$9,524.90 ",IP,"2,420.00","17,456.54",,,,,,
Cigna,DRG,MS-846,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$28,892.60 ",IP,"2,420.00","52,952.26",,,,,,
Cigna,DRG,MS-847,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,Surgical,Relative Weights,"$14,474.90 ",IP,"2,420.00","26,528.54",,,,,,
Cigna,DRG,MS-848,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$10,795.40 ",IP,"2,420.00","19,785.02",,,,,,
Cigna,DRG,MS-849,RADIOTHERAPY,Surgical,Relative Weights,"$23,383.80 ",IP,"2,420.00","42,856.13",,,,,,
Cigna,DRG,MS-853,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$56,084.60 ",IP,"2,420.00","102,787.78",,,,,,
Cigna,DRG,MS-854,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$23,773.20 ",IP,"2,420.00","43,569.79",,,,,,
Cigna,DRG,MS-855,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$17,636.30 ",IP,"2,420.00","32,322.53",,,,,,
Cigna,DRG,MS-856,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$48,682.70 ",IP,"2,420.00","89,222.11",,,,,,
Cigna,DRG,MS-857,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$22,366.30 ",IP,"2,420.00","40,991.33",,,,,,
Cigna,DRG,MS-858,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$15,140.40 ",IP,"2,420.00","27,748.22",,,,,,
Cigna,DRG,MS-862,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W MCC,Surgical,Relative Weights,"$20,356.60 ",IP,"2,420.00","37,308.10",,,,,,
Cigna,DRG,MS-863,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W/O MCC,Surgical,Relative Weights,"$10,868.00 ",IP,"2,420.00","19,918.08",,,,,,
Cigna,DRG,MS-864,FEVER AND INFLAMMATORY CONDITIONS,Surgical,Relative Weights,"$9,321.40 ",IP,"2,420.00","17,083.58",,,,,,
Cigna,DRG,MS-865,VIRAL ILLNESS WITH MCC,Surgical,Relative Weights,"$15,326.30 ",IP,"2,420.00","28,088.93",,,,,,
Cigna,DRG,MS-866,VIRAL ILLNESS WITHOUT MCC,Surgical,Relative Weights,"$9,005.70 ",IP,"2,420.00","16,504.99",,,,,,
Cigna,DRG,MS-867,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,Surgical,Relative Weights,"$24,037.20 ",IP,"2,420.00","44,053.63",,,,,,
Cigna,DRG,MS-868,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,Surgical,Relative Weights,"$12,067.00 ",IP,"2,420.00","22,115.52",,,,,,
Cigna,DRG,MS-869,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,167.50 ",IP,"2,420.00","14,968.80",,,,,,
Cigna,DRG,MS-870,SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,Surgical,Relative Weights,"$69,567.30 ",IP,"2,420.00","127,497.89",,,,,,
Cigna,DRG,MS-871,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,Surgical,Relative Weights,"$20,529.30 ",IP,"2,420.00","37,624.61",,,,,,
Cigna,DRG,MS-872,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,Surgical,Relative Weights,"$11,432.30 ",IP,"2,420.00","20,952.29",,,,,,
Cigna,DRG,MS-876,O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,Surgical,Relative Weights,"$40,040.00 ",IP,"2,420.00","73,382.40",,,,,,
Cigna,DRG,MS-880,ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,Surgical,Relative Weights,"$9,425.90 ",IP,"2,420.00","17,275.10",,,,,,
Cigna,DRG,MS-881,DEPRESSIVE NEUROSES,Surgical,Relative Weights,"$9,012.30 ",IP,"2,420.00","16,517.09",,,,,,
Cigna,DRG,MS-882,NEUROSES EXCEPT DEPRESSIVE,Surgical,Relative Weights,"$8,687.80 ",IP,"2,420.00","15,922.37",,,,,,
Cigna,DRG,MS-883,DISORDERS OF PERSONALITY & IMPULSE CONTROL,Surgical,Relative Weights,"$14,702.60 ",IP,"2,420.00","26,945.86",,,,,,
Cigna,DRG,MS-884,ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,Surgical,Relative Weights,"$15,818.00 ",IP,"2,420.00","28,990.08",,,,,,
Cigna,DRG,MS-885,PSYCHOSES,Surgical,Relative Weights,"$13,369.40 ",IP,"2,420.00","24,502.46",,,,,,
Cigna,DRG,MS-886,BEHAVIORAL AND DEVELOPMENTAL DISORDERS,Surgical,Relative Weights,"$14,801.60 ",IP,"2,420.00","27,127.30",,,,,,
Cigna,DRG,MS-887,OTHER MENTAL DISORDER DIAGNOSES,Surgical,Relative Weights,"$11,969.10 ",IP,"2,420.00","21,936.10",,,,,,
Cigna,DRG,MS-894,ALCOHOL- DRUG ABUSE OR DEPENDENCE- LEFT AMA,Surgical,Relative Weights,"$6,384.40 ",IP,"2,420.00","11,700.86",,,,,,
Cigna,DRG,MS-895,ALCOHOL- DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY,Surgical,Relative Weights,"$17,895.90 ",IP,"2,420.00","32,798.30",,,,,,
Cigna,DRG,MS-896,ALCOHOL -  DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC,Surgical,Relative Weights,"$18,916.70 ",IP,"2,420.00","34,669.15",,,,,,
Cigna,DRG,MS-897,ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC,Surgical,Relative Weights,"$9,039.80 ",IP,"2,420.00","16,567.49",,,,,,
Cigna,DRG,MS-901,WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,Surgical,Relative Weights,"$47,599.20 ",IP,"2,420.00","87,236.35",,,,,,
Cigna,DRG,MS-902,WOUND DEBRIDEMENTS FOR INJURIES WITH CC,Surgical,Relative Weights,"$21,635.90 ",IP,"2,420.00","39,652.70",,,,,,
Cigna,DRG,MS-903,WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,Surgical,Relative Weights,"$12,584.00 ",IP,"2,420.00","23,063.04",,,,,,
Cigna,DRG,MS-904,SKIN GRAFTS FOR INJURIES WITH CC/MCC,Surgical,Relative Weights,"$38,911.40 ",IP,"2,420.00","71,313.98",,,,,,
Cigna,DRG,MS-905,SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,Surgical,Relative Weights,"$18,308.40 ",IP,"2,420.00","33,554.30",,,,,,
Cigna,DRG,MS-906,HAND PROCEDURES FOR INJURIES,Surgical,Relative Weights,"$19,149.90 ",IP,"2,420.00","35,096.54",,,,,,
Cigna,DRG,MS-907,OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,Surgical,Relative Weights,"$43,885.60 ",IP,"2,420.00","80,430.34",,,,,,
Cigna,DRG,MS-908,OTHER O.R. PROCEDURES FOR INJURIES WITH CC,Surgical,Relative Weights,"$22,694.10 ",IP,"2,420.00","41,592.10",,,,,,
Cigna,DRG,MS-909,OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,Surgical,Relative Weights,"$14,505.70 ",IP,"2,420.00","26,584.99",,,,,,
Cigna,DRG,MS-913,TRAUMATIC INJURY WITH MCC,Surgical,Relative Weights,"$16,239.30 ",IP,"2,420.00","29,762.21",,,,,,
Cigna,DRG,MS-914,TRAUMATIC INJURY WITHOUT MCC,Surgical,Relative Weights,"$9,478.70 ",IP,"2,420.00","17,371.87",,,,,,
Cigna,DRG,MS-915,ALLERGIC REACTIONS WITH MCC,Surgical,Relative Weights,"$18,690.10 ",IP,"2,420.00","34,253.86",,,,,,
Cigna,DRG,MS-916,ALLERGIC REACTIONS WITHOUT MCC,Surgical,Relative Weights,"$6,965.20 ",IP,"2,420.00","12,765.31",,,,,,
Cigna,DRG,MS-917,POISONING & TOXIC EFFECTS OF DRUGS W MCC,Surgical,Relative Weights,"$16,095.20 ",IP,"2,420.00","29,498.11",,,,,,
Cigna,DRG,MS-918,POISONING & TOXIC EFFECTS OF DRUGS W/O MCC,Surgical,Relative Weights,"$8,624.00 ",IP,"2,420.00","15,805.44",,,,,,
Cigna,DRG,MS-919,COMPLICATIONS OF TREATMENT WITH MCC,Surgical,Relative Weights,"$20,078.30 ",IP,"2,420.00","36,798.05",,,,,,
Cigna,DRG,MS-920,COMPLICATIONS OF TREATMENT WITH CC,Surgical,Relative Weights,"$11,082.50 ",IP,"2,420.00","20,311.20",,,,,,
Cigna,DRG,MS-921,COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,Surgical,Relative Weights,"$7,596.60 ",IP,"2,420.00","13,922.50",,,,,,
Cigna,DRG,MS-922,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC,Surgical,Relative Weights,"$17,639.60 ",IP,"2,420.00","32,328.58",,,,,,
Cigna,DRG,MS-923,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC,Surgical,Relative Weights,"$9,520.50 ",IP,"2,420.00","17,448.48",,,,,,
Cigna,DRG,MS-927,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,Surgical,Relative Weights,"$219,378.50 ",IP,"2,420.00","402,060.96",,,,,,
Cigna,DRG,MS-928,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,Surgical,Relative Weights,"$68,143.90 ",IP,"2,420.00","124,889.18",,,,,,
Cigna,DRG,MS-929,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,Surgical,Relative Weights,"$32,356.50 ",IP,"2,420.00","59,300.64",,,,,,
Cigna,DRG,MS-933,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,Surgical,Relative Weights,"$34,542.20 ",IP,"2,420.00","63,306.43",,,,,,
Cigna,DRG,MS-934,FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,Surgical,Relative Weights,"$19,907.80 ",IP,"2,420.00","36,485.57",,,,,,
Cigna,DRG,MS-935,NON-EXTENSIVE BURNS,Surgical,Relative Weights,"$21,255.30 ",IP,"2,420.00","38,955.17",,,,,,
Cigna,DRG,MS-939,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,Surgical,Relative Weights,"$40,198.40 ",IP,"2,420.00","73,672.70",,,,,,
Cigna,DRG,MS-940,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,Surgical,Relative Weights,"$24,989.80 ",IP,"2,420.00","45,799.49",,,,,,
Cigna,DRG,MS-941,O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W/O CC/MCC,Surgical,Relative Weights,"$21,237.70 ",IP,"2,420.00","38,922.91",,,,,,
Cigna,DRG,MS-945,REHABILITATION WITH CC/MCC,Surgical,Relative Weights,"$16,008.30 ",IP,"2,420.00","29,338.85",,,,,,
Cigna,DRG,MS-946,REHABILITATION WITHOUT CC/MCC,Surgical,Relative Weights,"$11,957.00 ",IP,"2,420.00","21,913.92",,,,,,
Cigna,DRG,MS-947,SIGNS AND SYMPTOMS WITH MCC,Surgical,Relative Weights,"$13,170.30 ",IP,"2,420.00","24,137.57",,,,,,
Cigna,DRG,MS-948,SIGNS AND SYMPTOMS WITHOUT MCC,Surgical,Relative Weights,"$8,575.60 ",IP,"2,420.00","15,716.74",,,,,,
Cigna,DRG,MS-949,AFTERCARE WITH CC/MCC,Surgical,Relative Weights,"$11,977.90 ",IP,"2,420.00","21,952.22",,,,,,
Cigna,DRG,MS-950,AFTERCARE WITHOUT CC/MCC,Surgical,Relative Weights,"$8,149.90 ",IP,"2,420.00","14,936.54",,,,,,
Cigna,DRG,MS-951,OTHER FACTORS INFLUENCING HEALTH STATUS,Surgical,Relative Weights,"$6,451.50 ",IP,"2,420.00","11,823.84",,,,,,
Cigna,DRG,MS-955,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,Surgical,Relative Weights,"$66,885.50 ",IP,"2,420.00","122,582.88",,,,,,
Cigna,DRG,MS-956,LIMB REATTACHMENT- HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,Surgical,Relative Weights,"$43,156.30 ",IP,"2,420.00","79,093.73",,,,,,
Cigna,DRG,MS-957,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Surgical,Relative Weights,"$82,870.70 ",IP,"2,420.00","151,879.39",,,,,,
Cigna,DRG,MS-958,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,Surgical,Relative Weights,"$46,099.90 ",IP,"2,420.00","84,488.54",,,,,,
Cigna,DRG,MS-959,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,Surgical,Relative Weights,"$30,805.50 ",IP,"2,420.00","56,458.08",,,,,,
Cigna,DRG,MS-963,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Surgical,Relative Weights,"$29,976.10 ",IP,"2,420.00","54,938.02",,,,,,
Cigna,DRG,MS-964,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,Surgical,Relative Weights,"$16,428.50 ",IP,"2,420.00","30,108.96",,,,,,
Cigna,DRG,MS-965,OTHER MULTIPLE SIGNIFICANT TRAUMA W/O CC/MCC,Surgical,Relative Weights,"$10,088.10 ",IP,"2,420.00","18,488.74",,,,,,
Cigna,DRG,MS-969,HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$63,829.70 ",IP,"2,420.00","116,982.43",,,,,,
Cigna,DRG,MS-970,HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$32,087.00 ",IP,"2,420.00","58,806.72",,,,,,
Cigna,DRG,MS-974,HIV WITH MAJOR RELATED CONDITION WITH MCC,Surgical,Relative Weights,"$29,412.90 ",IP,"2,420.00","53,905.82",,,,,,
Cigna,DRG,MS-975,HIV WITH MAJOR RELATED CONDITION WITH CC,Surgical,Relative Weights,"$14,762.00 ",IP,"2,420.00","27,054.72",,,,,,
Cigna,DRG,MS-976,HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,Surgical,Relative Weights,"$10,056.20 ",IP,"2,420.00","18,430.27",,,,,,
Cigna,DRG,MS-977,HIV WITH OR WITHOUT OTHER RELATED CONDITION,Surgical,Relative Weights,"$14,305.50 ",IP,"2,420.00","26,218.08",,,,,,
Cigna,DRG,MS-981,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$49,397.70 ",IP,"2,420.00","90,532.51",,,,,,
Cigna,DRG,MS-982,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Surgical,Relative Weights,"$26,819.10 ",IP,"2,420.00","49,152.10",,,,,,
Cigna,DRG,MS-983,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$18,008.10 ",IP,"2,420.00","33,003.94",,,,,,
Cigna,DRG,MS-987,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$36,670.70 ",IP,"2,420.00","67,207.39",,,,,,
Cigna,DRG,MS-988,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Surgical,Relative Weights,"$18,901.30 ",IP,"2,420.00","34,640.93",,,,,,
Cigna,DRG,MS-989,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$12,676.40 ",IP,"2,420.00","23,232.38",,,,,,
Cigna,ExceptCPT,59000,Amniocentesis diagnostic,Amniocentesis,Straight Discount,65.00%,OP,,,,,,,,
Cigna,ExceptCPT,59001,Amniocentesis therapeutic,Amniocentesis,Straight Discount,65.00%,OP,,,,,,,,
Cigna,ExceptCPT,70336,Magnetic image jaw joint,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,70450,Ct head/brain w/o dye,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,70460,Ct head/brain w/dye,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,70470,Ct head/brain w/o & w/dye,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,70480,Ct orbit/ear/fossa w/o dye,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,70481,Ct orbit/ear/fossa w/dye,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,70482,Ct orbit/ear/fossa w/o&w/dye,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,70486,Ct maxillofacial w/o dye,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,70487,Ct maxillofacial w/dye,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,70488,Ct maxillofacial w/o & w/dye,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,70490,Ct soft tissue neck w/o dye,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,70491,Ct soft tissue neck w/dye,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,70492,Ct sft tsue nck w/o & w/dye,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,70496,Ct angiography head,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,70498,Ct angiography neck,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,70540,Mri orbit/face/neck w/o dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,70542,Mri orbit/face/neck w/dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,70543,Mri orbt/fac/nck w/o &w/dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,70544,Mr angiography head w/o dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,70545,Mr angiography head w/dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,70546,Mr angiograph head w/o&w/dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,70547,Mr angiography neck w/o dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,70548,Mr angiography neck w/dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,70549,Mr angiograph neck w/o&w/dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,70551,Mri brain stem w/o dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,70552,Mri brain stem w/dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,70553,Mri brain stem w/o & w/dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,70554,Fmri brain by tech,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,70555,Fmri brain by phys/psych,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,70557,Mri brain w/o dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,70558,Mri brain w/dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,70559,Mri brain w/o & w/dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,71250,Ct thorax dx c-,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,71260,Ct thorax dx c+,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,71270,Ct thorax dx c-/c+,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,71275,Ct angiography chest,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,71550,Mri chest w/o dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,71551,Mri chest w/dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,71552,Mri chest w/o & w/dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,71555,Mri angio chest w or w/o dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,72125,Ct neck spine w/o dye,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,72126,Ct neck spine w/dye,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,72127,Ct neck spine w/o & w/dye,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,72128,Ct chest spine w/o dye,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,72129,Ct chest spine w/dye,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,72130,Ct chest spine w/o & w/dye,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,72131,Ct lumbar spine w/o dye,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,72132,Ct lumbar spine w/dye,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,72133,Ct lumbar spine w/o & w/dye,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,72141,Mri neck spine w/o dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,72142,Mri neck spine w/dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,72146,Mri chest spine w/o dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,72147,Mri chest spine w/dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,72148,Mri lumbar spine w/o dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,72149,Mri lumbar spine w/dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,72156,Mri neck spine w/o & w/dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,72157,Mri chest spine w/o & w/dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,72158,Mri lumbar spine w/o & w/dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,72159,Mr angio spine w/o&w/dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,72191,Ct angiograph pelv w/o&w/dye,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,72192,Ct pelvis w/o dye,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,72193,Ct pelvis w/dye,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,72194,Ct pelvis w/o & w/dye,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,72195,Mri pelvis w/o dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,72196,Mri pelvis w/dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,72197,Mri pelvis w/o & w/dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,72198,Mr angio pelvis w/o & w/dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,73200,Ct upper extremity w/o dye,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,73201,Ct upper extremity w/dye,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,73202,Ct uppr extremity w/o&w/dye,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,73206,Ct angio upr extrm w/o&w/dye,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,73218,Mri upper extremity w/o dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,73219,Mri upper extremity w/dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,73220,Mri uppr extremity w/o&w/dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,73221,Mri joint upr extrem w/o dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,73222,Mri joint upr extrem w/dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,73223,Mri joint upr extr w/o&w/dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,73225,Mr angio upr extr w/o&w/dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,73700,Ct lower extremity w/o dye,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,73701,Ct lower extremity w/dye,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,73702,Ct lwr extremity w/o&w/dye,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,73706,Ct angio lwr extr w/o&w/dye,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,73718,Mri lower extremity w/o dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,73719,Mri lower extremity w/dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,73720,Mri lwr extremity w/o&w/dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,73721,Mri jnt of lwr extre w/o dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,73722,Mri joint of lwr extr w/dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,73723,Mri joint lwr extr w/o&w/dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,73725,Mr ang lwr ext w or w/o dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,74150,Ct abdomen w/o dye,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,74160,Ct abdomen w/dye,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,74170,Ct abdomen w/o & w/dye,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,74174,Ct angio abd&pelv w/o&w/dye,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,74175,Ct angio abdom w/o & w/dye,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,74176,Ct abd & pelvis w/o contrast,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,74177,Ct abd & pelv w/contrast,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,74178,Ct abd & pelv 1/> regns,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,74181,Mri abdomen w/o dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,74182,Mri abdomen w/dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,74183,Mri abdomen w/o & w/dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,74185,Mri angio abdom w orw/o dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,74261,Ct colonography dx,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,74262,Ct colonography dx w/dye,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,74263,Ct colonography screening,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,74712,Mri fetal sngl/1st gestation,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,74713,Mri fetal ea addl gestation,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,75557,Cardiac mri for morph,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,75559,Cardiac mri w/stress img,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,75561,Cardiac mri for morph w/dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,75563,Card mri w/stress img & dye,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,75565,Card mri veloc flow mapping,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,75571,Ct hrt w/o dye w/ca test,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,75572,Ct hrt w/3d image,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,75573,Ct hrt w/3d image congen,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,75574,Ct angio hrt w/3d image,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,75635,Ct angio abdominal arteries,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,76380,Cat scan follow-up study,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,76390,Mr spectroscopy,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,76391,Mr elastography,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,76497,Ct procedure,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,76498,Mri procedure,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,77046,Mri breast c- unilateral,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,77047,Mri breast c- bilateral,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,77048,Mri breast c-+ w/cad uni,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,77049,Mri breast c-+ w/cad bi,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,77078,Ct bone density axial,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,77084,Magnetic image bone marrow,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,93880,Extracranial bilat study,Radiology Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,ExceptCPT,93882,Extracranial uni/ltd study,Radiology Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,ExceptCPT,93886,Intracranial complete study,Radiology Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,ExceptCPT,93888,Intracranial limited study,Radiology Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,ExceptCPT,93922,Upr/l xtremity art 2 levels,Radiology Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,ExceptCPT,93923,Upr/lxtr art stdy 3+ lvls,Radiology Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,ExceptCPT,93924,Lwr xtr vasc stdy bilat,Radiology Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,ExceptCPT,93925,Lower extremity study,Radiology Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,ExceptCPT,93926,Lower extremity study,Radiology Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,ExceptCPT,93930,Upper extremity study,Radiology Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,ExceptCPT,93931,Upper extremity study,Radiology Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,ExceptCPT,93970,Extremity study,Radiology Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,ExceptCPT,93971,Extremity study,Radiology Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,ExceptCPT,93975,Vascular study,Radiology Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,ExceptCPT,93976,Vascular study,Radiology Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,ExceptCPT,93978,Vascular study,Radiology Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,ExceptCPT,93979,Vascular study,Radiology Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,ExceptCPT,93980,Penile vascular study,Radiology Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,ExceptCPT,93981,Penile vascular study,Radiology Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,ExceptCPT,93985,Dup-scan hemo compl bi std,Radiology Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,ExceptCPT,93986,Dup-scan hemo compl uni std,Radiology Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,ExceptCPT,93990,Doppler flow testing,Radiology Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,ExceptCPT,0558T,Ct scan f/biomchn ct alys,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,ExceptCPT,C8900,Mra w/cont- abd,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,C8901,Mra w/o cont- abd,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,C8902,Mra w/o fol w/cont- abd,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,C8903,Mri w/cont- breast-  uni,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,C8905,Mri w/o fol w/cont- brst- un,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,C8906,Mri w/cont- breast-  bi,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,C8908,Mri w/o fol w/cont- breast-,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,C8909,Mra w/cont- chest,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,C8910,Mra w/o cont- chest,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,C8911,Mra w/o fol w/cont- chest,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,C8912,Mra w/cont- lwr ext,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,C8913,Mra w/o cont- lwr ext,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,C8914,Mra w/o fol w/cont- lwr ext,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,C8918,Mra w/cont- pelvis,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,C8919,Mra w/o cont- pelvis,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,C8920,Mra w/o fol w/cont- pelvis,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,C8931,Mra- w/dye- spinal canal,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,C8932,Mra- w/o dye- spinal canal,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,C8933,Mra- w/o&w/dye- spinal canal,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,C8934,Mra- w/dye- upper extremity,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,C8935,Mra- w/o dye- upper extr,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,C8936,Mra- w/o&w/dye- upper extr,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,ExceptCPT,G0297,Ldct for lung ca screen,CT/CTA Scan,Per Unit,$600.00 ,OP,600,600,,,,,,
Cigna,RevenueCode,300,Laboratory - Clinical Diagnostic,Clinical and Anatomical Lab Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,301,Laboratory - Clinical Diagnostic: Chemistry,Clinical and Anatomical Lab Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,302,Laboratory - Clinical Diagnostic: Immunology,Clinical and Anatomical Lab Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,303,Laboratory - Clinical Diagnostic: Renal patient (home),Clinical and Anatomical Lab Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,304,Laboratory - Clinical Diagnostic: Nonroutine dialysis,Clinical and Anatomical Lab Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,305,Laboratory - Clinical Diagnostic: Hematology,Clinical and Anatomical Lab Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,306,Laboratory - Clinical Diagnostic: Bacteriology/microbiology,Clinical and Anatomical Lab Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,307,Laboratory - Clinical Diagnostic: Urology,Clinical and Anatomical Lab Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,309,Laboratory - Clinical Diagnostic: Other laboratory,Clinical and Anatomical Lab Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,310,Laboratory - Pathology,Clinical and Anatomical Lab Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,311,Laboratory - Pathology: Cytology,Clinical and Anatomical Lab Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,312,Laboratory - Pathology: Histology,Clinical and Anatomical Lab Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,314,Laboratory - Pathology: Biopsy,Clinical and Anatomical Lab Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,319,Laboratory - Pathology: Other,Clinical and Anatomical Lab Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,320,Radiology - Diagnostic,Radiology Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,321,Radiology - Diagnostic: Angiocardiography,Radiology Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,322,Radiology - Diagnostic: Arthrography,Radiology Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,323,Radiology - Diagnostic: Arteriography,Radiology Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,324,Radiology - Diagnostic: Chest X-ray,Radiology Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,329,Radiology - Diagnostic: Other,Radiology Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,330,Radiology - Therapeutic,Radiology Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,331,Radiology - Therapeutic: Chemotherapy - injected,Chemotherapy Administration Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,332,Radiology - Therapeutic: Chemotherapy - oral,Chemotherapy Administration Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,333,Radiology - Therapeutic: Radiation therapy,Radiation Therapy,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,335,Radiology - Therapeutic: Chemotherapy - IV,Chemotherapy Administration Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,339,Radiology - Therapeutic: Other,Radiology Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,340,Nuclear Medicine,Nuclear Medicine Scan,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,341,Nuclear Medicine: Diagnostic,Nuclear Medicine Scan,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,342,Nuclear Medicine: Therapeutic,Nuclear Medicine Scan,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,349,Nuclear Medicine: Other,Nuclear Medicine Scan,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,350,CT Scan,CT/CTA Scan,Per Unit,$600.00 ,OP,600,"1,700.00",,,,,,
Cigna,RevenueCode,351,CT Scan: Head,CT/CTA Scan,Per Unit,$600.00 ,OP,600,"1,700.00",,,,,,
Cigna,RevenueCode,352,CT Scan: Body,CT/CTA Scan,Per Unit,$600.00 ,OP,600,"1,700.00",,,,,,
Cigna,RevenueCode,359,CT Scan: Other CT scans,CT/CTA Scan,Per Unit,$600.00 ,OP,600,"1,700.00",,,,,,
Cigna,RevenueCode,360,Operating Room Services,Ambulatory Surgery,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,361,Operating Room Services: Minor surgery,Ambulatory Surgery,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,369,Operating Room Services: Other operating room services,Ambulatory Surgery,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,400,Other Imaging Services,Radiology Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,401,Other Imaging Services: Diagnostic mammography,Radiology Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,402,Other Imaging Services: Ultrasound,Radiology Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,403,Other Imaging Services: Screening mammography,Radiology Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,404,Other Imaging Services: PET scan,PET Scan,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,409,Other Imaging Services: Other imaging services,Radiology Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,410,Respiratory Services,Respiratory Therapy,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,412,Respiratory Services: Inhalation services,Respiratory Therapy,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,419,Respiratory Services: Other respiratory services,Respiratory Therapy,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,420,Physical Therapy,Physical Therapy,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,421,Physical Therapy: Visit charge,Physical Therapy,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,422,Physical Therapy: Hourly charge,Physical Therapy,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,423,Physical Therapy: Group rate,Physical Therapy,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,424,Physical Therapy: Evaluation/re-evaluation,Physical Therapy,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,429,Physical Therapy: Other physical therapy,Physical Therapy,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,430,Occupational Therapy,Occupational Therapy,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,431,Occupational Therapy: Visit charge,Occupational Therapy,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,432,Occupational Therapy: Hourly charge,Occupational Therapy,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,433,Occupational Therapy: Group rate,Occupational Therapy,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,434,Occupational Therapy: Evaluation/re-evaluation,Occupational Therapy,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,439,Occupational Therapy: Other occupational therapy,Occupational Therapy,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,440,Speech-Language Pathology,Speech Therapy,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,441,Speech-Language Pathology: Visit charge,Speech Therapy,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,442,Speech-Language Pathology: Hourly charge,Speech Therapy,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,443,Speech-Language Pathology: Group rate,Speech Therapy,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,444,Speech-Language Pathology: Evaluation/ re-evaluation,Speech Therapy,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,449,Speech-Language Pathology: Other speech language pathology,Speech Therapy,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,450,Emergency Room,ER,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,451,Emergency Room: EM/EMTALA,ER,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,452,Emergency Room: ER/ Beyond EMTALA,ER,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,456,Emergency Room: Urgent care,Urgent Care,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,459,Emergency Room: Other emergency room,ER,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,481,Cardiology: Cardiac catheter lab,Cardiac Cath Lab Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,490,Ambulatory Surgery,Ambulatory Surgery,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,499,Ambulatory Surgery: Other ambulatory surgical care,Ambulatory Surgery,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,510,Clinic,Clinic Visit,Per Unit,$82.00 ,OP,82,82,,,,,,
Cigna,RevenueCode,511,Clinic: Chronic pain center,Clinic Visit,Per Unit,$82.00 ,OP,82,82,,,,,,
Cigna,RevenueCode,512,Clinic: Dental clinic,Clinic Visit,Per Unit,$82.00 ,OP,82,82,,,,,,
Cigna,RevenueCode,513,Clinic: Psychiatric clinic,Clinic Visit,Per Unit,$82.00 ,OP,82,82,,,,,,
Cigna,RevenueCode,514,Clinic: OB/GYN clinic,Clinic Visit,Per Unit,$82.00 ,OP,82,82,,,,,,
Cigna,RevenueCode,515,Clinic: Pediatric clinic,Clinic Visit,Per Unit,$82.00 ,OP,82,82,,,,,,
Cigna,RevenueCode,516,Clinic: Urgent care clinic,Urgent Care- Free Standing,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,517,Clinic: Family clinic,Clinic Visit,Per Unit,$82.00 ,OP,82,82,,,,,,
Cigna,RevenueCode,519,Clinic: Other clinic,Clinic Visit,Per Unit,$82.00 ,OP,82,82,,,,,,
Cigna,RevenueCode,520,Free-Standing Clinic,Clinic Visit,Per Unit,$82.00 ,OP,82,82,,,,,,
Cigna,RevenueCode,521,Rural health-clinic,Clinic Visit,Per Unit,$82.00 ,OP,82,82,,,,,,
Cigna,RevenueCode,522,Rural health-home,Clinic Visit,Per Unit,$82.00 ,OP,82,82,,,,,,
Cigna,RevenueCode,523,Free-Standing Clinic: Family Practice Clinic,Clinic Visit,Per Unit,$82.00 ,OP,82,82,,,,,,
Cigna,RevenueCode,524,System Added,Clinic Visit,Per Unit,$82.00 ,OP,82,82,,,,,,
Cigna,RevenueCode,526,Free-Standing Clinic: Urgent Care Clinic,Urgent Care- Free Standing,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,529,Free-Standing Clinic: Other,Chemotherapy Administration Services,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,610,Magnetic Resonance Tech. (MRT),MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","2,200.00",,,,,,
Cigna,RevenueCode,611,Magnetic Resonance Tech. (MRT): Brain (incl. Brainstem),MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","2,200.00",,,,,,
Cigna,RevenueCode,612,Magnetic Resonance Tech. (MRT): Spinal cord (incl. spine),MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","2,200.00",,,,,,
Cigna,RevenueCode,614,Magnetic Resonance Tech. (MRT): MRI - Other,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","2,200.00",,,,,,
Cigna,RevenueCode,615,Magnetic Resonance Tech. (MRT): MRA - Head and Neck,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","1,200.00",,,,,,
Cigna,RevenueCode,616,Magnetic Resonance Tech. (MRT): MRA - Lower Ext,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","2,200.00",,,,,,
Cigna,RevenueCode,618,Magnetic Resonance Tech. (MRT): MRA - Other,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","2,200.00",,,,,,
Cigna,RevenueCode,619,Magnetic Resonance Tech. (MRT): Other MRI,MRI/MRA Scan,Per Unit,"$1,200.00 ",OP,"1,200.00","2,200.00",,,,,,
Cigna,RevenueCode,750,Gastrointestinal,Ambulatory Surgery,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,761,Treatment/Observation Room: Treatment room,Ambulatory Surgery,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,762,Treatment/Observation Room: Observation room,Observation,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,790,Extra-Corp Shock Wage Therapy,Ambulatory Surgery,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,821,Hemo OPD/Home: Hemodialysis comp or other rate,Dialysis,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,831,Peritoneal OPD/Home: Peritoneal comp or other rate,Dialysis,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,841,CAPD OPD/Home: CAPD comp or other rate,Dialysis,Straight Discount,65.00%,OP,,,,,,,,
Cigna,RevenueCode,851,CCPD OPD/Home: CCPD comp or other rate,Dialysis,Straight Discount,65.00%,OP,,,,,,,,
Cigna,,,,All Other,Straight Discount,65.00%,OP,,,,,,,,
Health Alliance FI HMO/POS,DRG,MS-001,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W MCC,Medical/Surgical,Relative Weights,"$298,296.91 ",IP,"17,718.00","557,099.42",,,,,,
Health Alliance FI HMO/POS,DRG,MS-002,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W/O MCC,Medical/Surgical,Relative Weights,"$154,446.22 ",IP,"17,718.00","282,516.19",,,,,,
Health Alliance FI HMO/POS,DRG,MS-003,ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITH MAJOR O.R. PROCEDURES,Medical/Surgical,Relative Weights,"$197,111.06 ",IP,"111,577.60","382,110.62",,,,,,
Health Alliance FI HMO/POS,DRG,MS-004,TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES,Medical/Surgical,Relative Weights,"$123,004.19 ",IP,"69,628.33","232,723.01",,,,,,
Health Alliance FI HMO/POS,DRG,MS-005,LIVER TRANSPLANT W MCC OR INTESTINAL TRANSPLANT,Medical/Surgical,Relative Weights,"$105,594.29 ",IP,"59,773.19","207,904.03",,,,,,
Health Alliance FI HMO/POS,DRG,MS-006,LIVER TRANSPLANT W/O MCC,Medical/Surgical,Relative Weights,"$48,452.66 ",IP,"27,427.34","98,217.50",,,,,,
Health Alliance FI HMO/POS,DRG,MS-007,LUNG TRANSPLANT,Medical/Surgical,Relative Weights,"$119,470.63 ",IP,"67,628.10","217,451.81",,,,,,
Health Alliance FI HMO/POS,DRG,MS-008,SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,Medical/Surgical,Relative Weights,"$56,055.25 ",IP,"31,730.89","113,220.58",,,,,,
Health Alliance FI HMO/POS,DRG,MS-010,PANCREAS TRANSPLANT,Medical/Surgical,Relative Weights,"$37,347.47 ",IP,"2,420.00","80,158.18",,,,,,
Health Alliance FI HMO/POS,DRG,MS-011,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC,Medical/Surgical,Relative Weights,"$51,805.68 ",IP,"2,420.00","99,667.01",,,,,,
Health Alliance FI HMO/POS,DRG,MS-012,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC,Medical/Surgical,Relative Weights,"$39,542.92 ",IP,"2,420.00","76,083.84",,,,,,
Health Alliance FI HMO/POS,DRG,MS-013,TRACHEOSTOMY FOR FACE -  MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$28,101.39 ",IP,"2,420.00","48,894.05",,,,,,
Health Alliance FI HMO/POS,DRG,MS-014,ALLOGENEIC BONE MARROW TRANSPLANT,Medical/Surgical,Relative Weights,"$110,154.40 ",IP,"2,420.00","257,136.77",,,,,,
Health Alliance FI HMO/POS,DRG,MS-016,AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,Medical/Surgical,Relative Weights,"$69,498.27 ",IP,"2,420.00","138,805.63",,,,,,
Health Alliance FI HMO/POS,DRG,MS-017,AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$50,096.16 ",IP,"2,420.00","89,659.58",,,,,,
Health Alliance FI HMO/POS,DRG,MS-018,CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,Medical/Surgical,Relative Weights,"$386,371.93 ",IP,"2,420.00","386,371.93",,,,,,
Health Alliance FI HMO/POS,DRG,MS-019,SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,Medical/Surgical,Relative Weights,"$68,914.33 ",IP,"2,420.00","68,914.33",,,,,,
Health Alliance FI HMO/POS,DRG,MS-020,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,Medical/Surgical,Relative Weights,"$106,646.62 ",IP,"2,420.00","218,151.36",,,,,,
Health Alliance FI HMO/POS,DRG,MS-021,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,Medical/Surgical,Relative Weights,"$77,826.14 ",IP,"2,420.00","166,797.79",,,,,,
Health Alliance FI HMO/POS,DRG,MS-022,INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W/O CC/MCC,Medical/Surgical,Relative Weights,"$49,963.07 ",IP,"2,420.00","99,425.09",,,,,,
Health Alliance FI HMO/POS,DRG,MS-023,CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX CNS PDX W MCC OR CHEMO IMPLANT,Medical/Surgical,Relative Weights,"$58,516.88 ",IP,"2,420.00","113,240.74",,,,,,
Health Alliance FI HMO/POS,DRG,MS-024,CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,Medical/Surgical,Relative Weights,"$40,638.58 ",IP,"2,420.00","80,972.64",,,,,,
Health Alliance FI HMO/POS,DRG,MS-025,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$46,399.59 ",IP,"2,420.00","88,593.12",,,,,,
Health Alliance FI HMO/POS,DRG,MS-026,CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC,Medical/Surgical,Relative Weights,"$31,590.59 ",IP,"2,420.00","61,403.33",,,,,,
Health Alliance FI HMO/POS,DRG,MS-027,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$25,939.98 ",IP,"2,420.00","48,317.47",,,,,,
Health Alliance FI HMO/POS,DRG,MS-028,SPINAL PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$60,076.81 ",IP,"2,420.00","112,702.46",,,,,,
Health Alliance FI HMO/POS,DRG,MS-029,SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,Medical/Surgical,Relative Weights,"$34,013.02 ",IP,"2,420.00","64,653.12",,,,,,
Health Alliance FI HMO/POS,DRG,MS-030,SPINAL PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$24,315.06 ",IP,"2,420.00","45,805.54",,,,,,
Health Alliance FI HMO/POS,DRG,MS-031,VENTRICULAR SHUNT PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$45,102.74 ",IP,"2,420.00","88,189.92",,,,,,
Health Alliance FI HMO/POS,DRG,MS-032,VENTRICULAR SHUNT PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$22,867.59 ",IP,"2,420.00","44,192.74",,,,,,
Health Alliance FI HMO/POS,DRG,MS-033,VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$17,767.90 ",IP,"2,420.00","34,290.14",,,,,,
Health Alliance FI HMO/POS,DRG,MS-034,CAROTID ARTERY STENT PROCEDURE W MCC,Medical/Surgical,Relative Weights,"$41,041.98 ",IP,"2,420.00","75,674.59",,,,,,
Health Alliance FI HMO/POS,DRG,MS-035,CAROTID ARTERY STENT PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$24,138.64 ",IP,"2,420.00","46,412.35",,,,,,
Health Alliance FI HMO/POS,DRG,MS-036,CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$19,110.14 ",IP,"2,420.00","35,300.16",,,,,,
Health Alliance FI HMO/POS,DRG,MS-037,EXTRACRANIAL PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$33,814.93 ",IP,"2,420.00","65,384.93",,,,,,
Health Alliance FI HMO/POS,DRG,MS-038,EXTRACRANIAL PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$17,113.81 ",IP,"2,420.00","33,772.03",,,,,,
Health Alliance FI HMO/POS,DRG,MS-039,EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$11,752.07 ",IP,"2,420.00","22,807.01",,,,,,
Health Alliance FI HMO/POS,DRG,MS-040,PERIPHERAL- CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$39,873.06 ",IP,"2,420.00","79,438.46",,,,,,
Health Alliance FI HMO/POS,DRG,MS-041,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W CC OR PERIPH NEUROSTIM,Medical/Surgical,Relative Weights,"$24,241.81 ",IP,"2,420.00","47,809.44",,,,,,
Health Alliance FI HMO/POS,DRG,MS-042,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W/O CC/MCC,Medical/Surgical,Relative Weights,"$19,614.64 ",IP,"2,420.00","37,261.73",,,,,,
Health Alliance FI HMO/POS,DRG,MS-052,SPINAL DISORDERS AND INJURIES WITH CC/MCC,Medical/Surgical,Relative Weights,"$19,122.52 ",IP,"2,420.00","32,838.62",,,,,,
Health Alliance FI HMO/POS,DRG,MS-053,SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$11,724.22 ",IP,"2,420.00","19,476.58",,,,,,
Health Alliance FI HMO/POS,DRG,MS-054,NERVOUS SYSTEM NEOPLASMS WITH MCC,Medical/Surgical,Relative Weights,"$14,116.72 ",IP,"2,420.00","27,016.42",,,,,,
Health Alliance FI HMO/POS,DRG,MS-055,NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,Medical/Surgical,Relative Weights,"$10,777.12 ",IP,"2,420.00","19,877.76",,,,,,
Health Alliance FI HMO/POS,DRG,MS-056,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,Medical/Surgical,Relative Weights,"$22,648.87 ",IP,"2,420.00","44,198.78",,,,,,
Health Alliance FI HMO/POS,DRG,MS-057,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,Medical/Surgical,Relative Weights,"$13,076.77 ",IP,"2,420.00","24,409.73",,,,,,
Health Alliance FI HMO/POS,DRG,MS-058,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,Medical/Surgical,Relative Weights,"$17,928.85 ",IP,"2,420.00","39,406.75",,,,,,
Health Alliance FI HMO/POS,DRG,MS-059,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,Medical/Surgical,Relative Weights,"$11,630.33 ",IP,"2,420.00","21,984.48",,,,,,
Health Alliance FI HMO/POS,DRG,MS-060,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$9,467.89 ",IP,"2,420.00","17,775.07",,,,,,
Health Alliance FI HMO/POS,DRG,MS-061,ISCHEMIC STROKE -  PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC,Medical/Surgical,Relative Weights,"$29,828.45 ",IP,"2,420.00","56,316.96",,,,,,
Health Alliance FI HMO/POS,DRG,MS-062,ISCHEMIC STROKE -  PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC,Medical/Surgical,Relative Weights,"$20,513.25 ",IP,"2,420.00","40,545.79",,,,,,
Health Alliance FI HMO/POS,DRG,MS-063,ISCHEMIC STROKE- PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$17,638.94 ",IP,"2,420.00","33,884.93",,,,,,
Health Alliance FI HMO/POS,DRG,MS-064,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,Medical/Surgical,Relative Weights,"$19,797.25 ",IP,"2,420.00","37,795.97",,,,,,
Health Alliance FI HMO/POS,DRG,MS-065,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC,Medical/Surgical,Relative Weights,"$10,523.32 ",IP,"2,420.00","20,718.43",,,,,,
Health Alliance FI HMO/POS,DRG,MS-066,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$7,341.56 ",IP,"2,420.00","14,454.72",,,,,,
Health Alliance FI HMO/POS,DRG,MS-067,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,Medical/Surgical,Relative Weights,"$14,709.95 ",IP,"2,420.00","29,524.32",,,,,,
Health Alliance FI HMO/POS,DRG,MS-068,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,Medical/Surgical,Relative Weights,"$9,170.76 ",IP,"2,420.00","18,212.54",,,,,,
Health Alliance FI HMO/POS,DRG,MS-069,TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,Medical/Surgical,Relative Weights,"$8,120.50 ",IP,"2,420.00","15,730.85",,,,,,
Health Alliance FI HMO/POS,DRG,MS-070,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC,Medical/Surgical,Relative Weights,"$17,328.40 ",IP,"2,420.00","33,725.66",,,,,,
Health Alliance FI HMO/POS,DRG,MS-071,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC,Medical/Surgical,Relative Weights,"$10,438.72 ",IP,"2,420.00","20,053.15",,,,,,
Health Alliance FI HMO/POS,DRG,MS-072,NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$7,961.61 ",IP,"2,420.00","14,888.16",,,,,,
Health Alliance FI HMO/POS,DRG,MS-073,CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,Medical/Surgical,Relative Weights,"$14,989.54 ",IP,"2,420.00","28,538.50",,,,,,
Health Alliance FI HMO/POS,DRG,MS-074,CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,Medical/Surgical,Relative Weights,"$10,513.00 ",IP,"2,420.00","19,920.10",,,,,,
Health Alliance FI HMO/POS,DRG,MS-075,VIRAL MENINGITIS WITH CC/MCC,Medical/Surgical,Relative Weights,"$16,785.73 ",IP,"2,420.00","32,421.31",,,,,,
Health Alliance FI HMO/POS,DRG,MS-076,VIRAL MENINGITIS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$10,161.19 ",IP,"2,420.00","18,194.40",,,,,,
Health Alliance FI HMO/POS,DRG,MS-077,HYPERTENSIVE ENCEPHALOPATHY WITH MCC,Medical/Surgical,Relative Weights,"$15,814.90 ",IP,"2,420.00","31,096.80",,,,,,
Health Alliance FI HMO/POS,DRG,MS-078,HYPERTENSIVE ENCEPHALOPATHY WITH CC,Medical/Surgical,Relative Weights,"$9,800.10 ",IP,"2,420.00","19,393.92",,,,,,
Health Alliance FI HMO/POS,DRG,MS-079,HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$7,519.02 ",IP,"2,420.00","14,940.58",,,,,,
Health Alliance FI HMO/POS,DRG,MS-080,NONTRAUMATIC STUPOR & COMA W MCC,Medical/Surgical,Relative Weights,"$21,618.20 ",IP,"2,420.00","38,632.61",,,,,,
Health Alliance FI HMO/POS,DRG,MS-081,NONTRAUMATIC STUPOR & COMA W/O MCC,Medical/Surgical,Relative Weights,"$7,977.09 ",IP,"2,420.00","17,722.66",,,,,,
Health Alliance FI HMO/POS,DRG,MS-082,TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,Medical/Surgical,Relative Weights,"$23,356.61 ",IP,"2,420.00","45,396.29",,,,,,
Health Alliance FI HMO/POS,DRG,MS-083,TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,Medical/Surgical,Relative Weights,"$13,866.02 ",IP,"2,420.00","26,423.71",,,,,,
Health Alliance FI HMO/POS,DRG,MS-084,TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$9,343.06 ",IP,"2,420.00","18,089.57",,,,,,
Health Alliance FI HMO/POS,DRG,MS-085,TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,Medical/Surgical,Relative Weights,"$23,849.76 ",IP,"2,420.00","45,275.33",,,,,,
Health Alliance FI HMO/POS,DRG,MS-086,TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,Medical/Surgical,Relative Weights,"$13,148.99 ",IP,"2,420.00","24,954.05",,,,,,
Health Alliance FI HMO/POS,DRG,MS-087,TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$8,909.74 ",IP,"2,420.00","16,918.27",,,,,,
Health Alliance FI HMO/POS,DRG,MS-088,CONCUSSION WITH MCC,Medical/Surgical,Relative Weights,"$15,013.27 ",IP,"2,420.00","28,004.26",,,,,,
Health Alliance FI HMO/POS,DRG,MS-089,CONCUSSION WITH CC,Medical/Surgical,Relative Weights,"$10,972.11 ",IP,"2,420.00","19,883.81",,,,,,
Health Alliance FI HMO/POS,DRG,MS-090,CONCUSSION WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$8,816.89 ",IP,"2,420.00","17,101.73",,,,,,
Health Alliance FI HMO/POS,DRG,MS-091,OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,Medical/Surgical,Relative Weights,"$17,031.27 ",IP,"2,420.00","31,552.42",,,,,,
Health Alliance FI HMO/POS,DRG,MS-092,OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,Medical/Surgical,Relative Weights,"$10,202.46 ",IP,"2,420.00","19,476.58",,,,,,
Health Alliance FI HMO/POS,DRG,MS-093,OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$8,069.94 ",IP,"2,420.00","15,345.79",,,,,,
Health Alliance FI HMO/POS,DRG,MS-094,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,Medical/Surgical,Relative Weights,"$37,532.14 ",IP,"2,420.00","72,269.57",,,,,,
Health Alliance FI HMO/POS,DRG,MS-095,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,Medical/Surgical,Relative Weights,"$25,867.76 ",IP,"2,420.00","48,527.14",,,,,,
Health Alliance FI HMO/POS,DRG,MS-096,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$24,066.42 ",IP,"2,420.00","45,603.94",,,,,,
Health Alliance FI HMO/POS,DRG,MS-097,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,Medical/Surgical,Relative Weights,"$38,795.97 ",IP,"2,420.00","72,090.14",,,,,,
Health Alliance FI HMO/POS,DRG,MS-098,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,Medical/Surgical,Relative Weights,"$21,794.62 ",IP,"2,420.00","39,412.80",,,,,,
Health Alliance FI HMO/POS,DRG,MS-099,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$14,463.37 ",IP,"2,420.00","25,853.18",,,,,,
Health Alliance FI HMO/POS,DRG,MS-100,SEIZURES WITH MCC,Medical/Surgical,Relative Weights,"$19,358.78 ",IP,"2,420.00","36,695.23",,,,,,
Health Alliance FI HMO/POS,DRG,MS-101,SEIZURES WITHOUT MCC,Medical/Surgical,Relative Weights,"$9,165.61 ",IP,"2,420.00","17,799.26",,,,,,
Health Alliance FI HMO/POS,DRG,MS-102,HEADACHES WITH MCC,Medical/Surgical,Relative Weights,"$11,896.51 ",IP,"2,420.00","24,042.82",,,,,,
Health Alliance FI HMO/POS,DRG,MS-103,HEADACHES W/O MCC,Medical/Surgical,Relative Weights,"$8,557.93 ",IP,"2,420.00","16,117.92",,,,,,
Health Alliance FI HMO/POS,DRG,MS-113,ORBITAL PROCEDURES WITH CC/MCC,Medical/Surgical,Relative Weights,"$22,639.58 ",IP,"2,420.00","42,983.14",,,,,,
Health Alliance FI HMO/POS,DRG,MS-114,ORBITAL PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$14,934.86 ",IP,"2,420.00","24,006.53",,,,,,
Health Alliance FI HMO/POS,DRG,MS-115,EXTRAOCULAR PROCEDURES EXCEPT ORBIT,Medical/Surgical,Relative Weights,"$15,027.71 ",IP,"2,420.00","29,957.76",,,,,,
Health Alliance FI HMO/POS,DRG,MS-116,INTRAOCULAR PROCEDURES W CC/MCC,Medical/Surgical,Relative Weights,"$19,423.78 ",IP,"2,420.00","38,122.56",,,,,,
Health Alliance FI HMO/POS,DRG,MS-117,INTRAOCULAR PROCEDURES W/O CC/MCC,Medical/Surgical,Relative Weights,"$10,742.04 ",IP,"2,420.00","22,109.47",,,,,,
Health Alliance FI HMO/POS,DRG,MS-121,ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,Medical/Surgical,Relative Weights,"$12,283.40 ",IP,"2,420.00","25,558.85",,,,,,
Health Alliance FI HMO/POS,DRG,MS-122,ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$6,659.61 ",IP,"2,420.00","15,575.62",,,,,,
Health Alliance FI HMO/POS,DRG,MS-123,NEUROLOGICAL EYE DISORDERS,Medical/Surgical,Relative Weights,"$7,911.06 ",IP,"2,420.00","15,740.93",,,,,,
Health Alliance FI HMO/POS,DRG,MS-124,OTHER DISORDERS OF THE EYE WITH MCC,Medical/Surgical,Relative Weights,"$14,464.41 ",IP,"2,420.00","28,010.30",,,,,,
Health Alliance FI HMO/POS,DRG,MS-125,OTHER DISORDERS OF THE EYE WITHOUT MCC,Medical/Surgical,Relative Weights,"$8,635.31 ",IP,"2,420.00","15,914.30",,,,,,
Health Alliance FI HMO/POS,DRG,MS-135,SINUS AND MASTOID PROCEDURES WITH CC/MCC,Medical/Surgical,Relative Weights,"$22,114.45 ",IP,"2,420.00","46,057.54",,,,,,
Health Alliance FI HMO/POS,DRG,MS-136,SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$12,952.97 ",IP,"2,420.00","23,990.40",,,,,,
Health Alliance FI HMO/POS,DRG,MS-137,MOUTH PROCEDURES WITH CC/MCC,Medical/Surgical,Relative Weights,"$15,575.54 ",IP,"2,420.00","26,879.33",,,,,,
Health Alliance FI HMO/POS,DRG,MS-138,MOUTH PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$8,836.49 ",IP,"2,420.00","17,365.82",,,,,,
Health Alliance FI HMO/POS,DRG,MS-139,SALIVARY GLAND PROCEDURES,Medical/Surgical,Relative Weights,"$12,732.19 ",IP,"2,420.00","24,883.49",,,,,,
Health Alliance FI HMO/POS,DRG,MS-140,MAJOR HEAD AND NECK PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$41,039.91 ",IP,"2,420.00","41,039.91",,,,,,
Health Alliance FI HMO/POS,DRG,MS-141,MAJOR HEAD AND NECK PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$22,760.29 ",IP,"2,420.00","22,760.29",,,,,,
Health Alliance FI HMO/POS,DRG,MS-142,MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$16,559.78 ",IP,"2,420.00","16,559.78",,,,,,
Health Alliance FI HMO/POS,DRG,MS-143,OTHER EAR- NOSE- MOUTH AND THROAT O.R. PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$30,742.54 ",IP,"2,420.00","30,742.54",,,,,,
Health Alliance FI HMO/POS,DRG,MS-144,HERNIA PROCEDURES AGE 0-17,Medical/Surgical,Relative Weights,"$18,173.36 ",IP,"2,420.00","18,173.36",,,,,,
Health Alliance FI HMO/POS,DRG,MS-145,OTHER EAR -  NOSE -  MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$12,634.17 ",IP,"2,420.00","12,634.17",,,,,,
Health Alliance FI HMO/POS,DRG,MS-146,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH MCC,Medical/Surgical,Relative Weights,"$21,057.99 ",IP,"2,420.00","38,880.58",,,,,,
Health Alliance FI HMO/POS,DRG,MS-147,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH CC,Medical/Surgical,Relative Weights,"$13,423.42 ",IP,"2,420.00","25,016.54",,,,,,
Health Alliance FI HMO/POS,DRG,MS-148,EAR - NOSE - MOUTH & THROAT MALIGNANCY W/O CC/MCC,Medical/Surgical,Relative Weights,"$8,119.46 ",IP,"2,420.00","15,329.66",,,,,,
Health Alliance FI HMO/POS,DRG,MS-149,DYSEQUILIBRIUM,Medical/Surgical,Relative Weights,"$7,603.61 ",IP,"2,420.00","14,726.88",,,,,,
Health Alliance FI HMO/POS,DRG,MS-150,EPISTAXIS WITH MCC,Medical/Surgical,Relative Weights,"$13,695.79 ",IP,"2,420.00","26,036.64",,,,,,
Health Alliance FI HMO/POS,DRG,MS-151,EPISTAXIS WITHOUT MCC,Medical/Surgical,Relative Weights,"$7,618.06 ",IP,"2,420.00","14,093.86",,,,,,
Health Alliance FI HMO/POS,DRG,MS-152,OTITIS MEDIA AND URI WITH MCC,Medical/Surgical,Relative Weights,"$11,147.50 ",IP,"2,420.00","20,946.24",,,,,,
Health Alliance FI HMO/POS,DRG,MS-153,OTITIS MEDIA AND URI WITHOUT MCC,Medical/Surgical,Relative Weights,"$7,358.07 ",IP,"2,420.00","14,241.02",,,,,,
Health Alliance FI HMO/POS,DRG,MS-154,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH MCC,Medical/Surgical,Relative Weights,"$15,958.30 ",IP,"2,420.00","28,969.92",,,,,,
Health Alliance FI HMO/POS,DRG,MS-155,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH CC,Medical/Surgical,Relative Weights,"$9,383.29 ",IP,"2,420.00","18,166.18",,,,,,
Health Alliance FI HMO/POS,DRG,MS-156,OTHER EAR -  NOSE -  MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$6,792.70 ",IP,"2,420.00","13,194.72",,,,,,
Health Alliance FI HMO/POS,DRG,MS-157,DENTAL AND ORAL DISEASES WITH MCC,Medical/Surgical,Relative Weights,"$16,261.62 ",IP,"2,420.00","31,508.06",,,,,,
Health Alliance FI HMO/POS,DRG,MS-158,DENTAL AND ORAL DISEASES WITH CC,Medical/Surgical,Relative Weights,"$9,287.35 ",IP,"2,420.00","17,470.66",,,,,,
Health Alliance FI HMO/POS,DRG,MS-159,DENTAL AND ORAL DISEASES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$6,841.19 ",IP,"2,420.00","13,565.66",,,,,,
Health Alliance FI HMO/POS,DRG,MS-163,MAJOR CHEST PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$51,655.06 ",IP,"2,420.00","98,253.79",,,,,,
Health Alliance FI HMO/POS,DRG,MS-164,MAJOR CHEST PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$27,397.77 ",IP,"2,420.00","51,037.06",,,,,,
Health Alliance FI HMO/POS,DRG,MS-165,MAJOR CHEST PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$19,773.52 ",IP,"2,420.00","37,279.87",,,,,,
Health Alliance FI HMO/POS,DRG,MS-166,OTHER RESP SYSTEM O.R. PROCEDURES W MCC,Medical/Surgical,Relative Weights,"$38,415.28 ",IP,"2,420.00","75,210.91",,,,,,
Health Alliance FI HMO/POS,DRG,MS-167,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$18,763.49 ",IP,"2,420.00","38,594.30",,,,,,
Health Alliance FI HMO/POS,DRG,MS-168,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$13,973.32 ",IP,"2,420.00","26,746.27",,,,,,
Health Alliance FI HMO/POS,DRG,MS-175,PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,Medical/Surgical,Relative Weights,"$15,950.05 ",IP,"2,420.00","29,119.10",,,,,,
Health Alliance FI HMO/POS,DRG,MS-176,PULMONARY EMBOLISM WITHOUT MCC,Medical/Surgical,Relative Weights,"$9,159.41 ",IP,"2,420.00","17,103.74",,,,,,
Health Alliance FI HMO/POS,DRG,MS-177,RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC,Medical/Surgical,Relative Weights,"$19,077.13 ",IP,"2,420.00","38,126.59",,,,,,
Health Alliance FI HMO/POS,DRG,MS-178,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,Medical/Surgical,Relative Weights,"$12,460.85 ",IP,"2,420.00","25,064.93",,,,,,
Health Alliance FI HMO/POS,DRG,MS-179,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$9,003.63 ",IP,"2,420.00","17,460.58",,,,,,
Health Alliance FI HMO/POS,DRG,MS-180,RESPIRATORY NEOPLASMS WITH MCC,Medical/Surgical,Relative Weights,"$17,950.51 ",IP,"2,420.00","34,773.98",,,,,,
Health Alliance FI HMO/POS,DRG,MS-181,RESPIRATORY NEOPLASMS WITH CC,Medical/Surgical,Relative Weights,"$11,556.05 ",IP,"2,420.00","23,224.32",,,,,,
Health Alliance FI HMO/POS,DRG,MS-182,RESPIRATORY NEOPLASMS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$8,171.05 ",IP,"2,420.00","16,990.85",,,,,,
Health Alliance FI HMO/POS,DRG,MS-183,MAJOR CHEST TRAUMA WITH MCC,Medical/Surgical,Relative Weights,"$16,083.14 ",IP,"2,420.00","30,425.47",,,,,,
Health Alliance FI HMO/POS,DRG,MS-184,MAJOR CHEST TRAUMA WITH CC,Medical/Surgical,Relative Weights,"$10,738.94 ",IP,"2,420.00","20,526.91",,,,,,
Health Alliance FI HMO/POS,DRG,MS-185,MAJOR CHEST TRAUMA W/O CC/MCC,Medical/Surgical,Relative Weights,"$7,994.63 ",IP,"2,420.00","14,797.44",,,,,,
Health Alliance FI HMO/POS,DRG,MS-186,PLEURAL EFFUSION WITH MCC,Medical/Surgical,Relative Weights,"$15,927.35 ",IP,"2,420.00","31,104.86",,,,,,
Health Alliance FI HMO/POS,DRG,MS-187,PLEURAL EFFUSION WITH CC,Medical/Surgical,Relative Weights,"$10,656.41 ",IP,"2,420.00","20,722.46",,,,,,
Health Alliance FI HMO/POS,DRG,MS-188,PLEURAL EFFUSION WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$7,526.24 ",IP,"2,420.00","14,734.94",,,,,,
Health Alliance FI HMO/POS,DRG,MS-189,PULMONARY EDEMA AND RESPIRATORY FAILURE,Medical/Surgical,Relative Weights,"$12,649.65 ",IP,"2,420.00","24,508.51",,,,,,
Health Alliance FI HMO/POS,DRG,MS-190,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,Medical/Surgical,Relative Weights,"$11,607.63 ",IP,"2,420.00","23,063.04",,,,,,
Health Alliance FI HMO/POS,DRG,MS-191,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,Medical/Surgical,Relative Weights,"$9,123.31 ",IP,"2,420.00","17,998.85",,,,,,
Health Alliance FI HMO/POS,DRG,MS-192,CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC,Medical/Surgical,Relative Weights,"$7,176.49 ",IP,"2,420.00","14,297.47",,,,,,
Health Alliance FI HMO/POS,DRG,MS-193,SIMPLE PNEUMONIA & PLEURISY W MCC,Medical/Surgical,Relative Weights,"$13,535.88 ",IP,"2,420.00","26,883.36",,,,,,
Health Alliance FI HMO/POS,DRG,MS-194,SIMPLE PNEUMONIA AND PLEURISY WITH CC,Medical/Surgical,Relative Weights,"$8,912.84 ",IP,"2,420.00","17,914.18",,,,,,
Health Alliance FI HMO/POS,DRG,MS-195,SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$6,869.05 ",IP,"2,420.00","13,751.14",,,,,,
Health Alliance FI HMO/POS,DRG,MS-196,INTERSTITIAL LUNG DISEASE WITH MCC,Medical/Surgical,Relative Weights,"$17,937.10 ",IP,"2,420.00","33,776.06",,,,,,
Health Alliance FI HMO/POS,DRG,MS-197,INTERSTITIAL LUNG DISEASE WITH CC,Medical/Surgical,Relative Weights,"$10,389.20 ",IP,"2,420.00","20,593.44",,,,,,
Health Alliance FI HMO/POS,DRG,MS-198,INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$7,669.64 ",IP,"2,420.00","15,220.80",,,,,,
Health Alliance FI HMO/POS,DRG,MS-199,PNEUMOTHORAX WITH MCC,Medical/Surgical,Relative Weights,"$18,467.39 ",IP,"2,420.00","36,169.06",,,,,,
Health Alliance FI HMO/POS,DRG,MS-200,PNEUMOTHORAX WITH CC,Medical/Surgical,Relative Weights,"$11,106.23 ",IP,"2,420.00","21,815.14",,,,,,
Health Alliance FI HMO/POS,DRG,MS-201,PNEUMOTHORAX WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$7,320.93 ",IP,"2,420.00","14,474.88",,,,,,
Health Alliance FI HMO/POS,DRG,MS-202,BRONCHITIS AND ASTHMA WITH CC/MCC,Medical/Surgical,Relative Weights,"$9,976.52 ",IP,"2,420.00","19,111.68",,,,,,
Health Alliance FI HMO/POS,DRG,MS-203,BRONCHITIS AND ASTHMA WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$7,294.10 ",IP,"2,420.00","13,987.01",,,,,,
Health Alliance FI HMO/POS,DRG,MS-204,RESPIRATORY SIGNS AND SYMPTOMS,Medical/Surgical,Relative Weights,"$8,187.56 ",IP,"2,420.00","16,380.00",,,,,,
Health Alliance FI HMO/POS,DRG,MS-205,OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,Medical/Surgical,Relative Weights,"$17,382.05 ",IP,"2,420.00","32,945.47",,,,,,
Health Alliance FI HMO/POS,DRG,MS-206,OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,Medical/Surgical,Relative Weights,"$9,140.84 ",IP,"2,420.00","17,589.60",,,,,,
Health Alliance FI HMO/POS,DRG,MS-207,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS,Medical/Surgical,Relative Weights,"$59,179.23 ",IP,"2,420.00","115,629.70",,,,,,
Health Alliance FI HMO/POS,DRG,MS-208,RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,Medical/Surgical,Relative Weights,"$26,254.65 ",IP,"2,420.00","50,079.46",,,,,,
Health Alliance FI HMO/POS,DRG,MS-215,OTHER HEART ASSIST SYSTEM IMPLANT,Medical/Surgical,Relative Weights,"$108,930.80 ",IP,"61,661.88","259,783.78",,,,,,
Health Alliance FI HMO/POS,DRG,MS-216,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,Medical/Surgical,Relative Weights,"$103,575.26 ",IP,"58,630.29","202,454.78",,,,,,
Health Alliance FI HMO/POS,DRG,MS-217,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,Medical/Surgical,Relative Weights,"$66,890.14 ",IP,"37,864.14","134,096.26",,,,,,
Health Alliance FI HMO/POS,DRG,MS-218,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$63,029.53 ",IP,"35,678.79","108,892.22",,,,,,
Health Alliance FI HMO/POS,DRG,MS-219,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,Medical/Surgical,Relative Weights,"$83,130.10 ",IP,"47,057.01","158,056.42",,,,,,
Health Alliance FI HMO/POS,DRG,MS-220,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,Medical/Surgical,Relative Weights,"$55,766.37 ",IP,"31,567.37","106,966.94",,,,,,
Health Alliance FI HMO/POS,DRG,MS-221,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$47,250.74 ",IP,"26,746.97","92,659.39",,,,,,
Health Alliance FI HMO/POS,DRG,MS-222,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITH MCC,Medical/Surgical,Relative Weights,"$82,030.31 ",IP,"46,434.46","168,227.14",,,,,,
Health Alliance FI HMO/POS,DRG,MS-223,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITHOUT MCC,Medical/Surgical,Relative Weights,"$59,824.04 ",IP,"33,864.27","121,018.46",,,,,,
Health Alliance FI HMO/POS,DRG,MS-224,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITH MCC,Medical/Surgical,Relative Weights,"$77,574.40 ",IP,"43,912.13","149,107.39",,,,,,
Health Alliance FI HMO/POS,DRG,MS-225,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITHOUT MCC,Medical/Surgical,Relative Weights,"$57,958.73 ",IP,"32,808.39","113,879.81",,,,,,
Health Alliance FI HMO/POS,DRG,MS-226,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITH MCC,Medical/Surgical,Relative Weights,"$67,730.97 ",IP,"25,420.00","134,824.03",,,,,,
Health Alliance FI HMO/POS,DRG,MS-227,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Medical/Surgical,Relative Weights,"$53,773.13 ",IP,"25,420.00","105,420.67",,,,,,
Health Alliance FI HMO/POS,DRG,MS-228,OTHER CARDIOTHORACIC PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$54,992.60 ",IP,"31,129.37","126,731.81",,,,,,
Health Alliance FI HMO/POS,DRG,MS-229,OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,Medical/Surgical,Relative Weights,"$35,502.79 ",IP,"20,096.88","82,754.78",,,,,,
Health Alliance FI HMO/POS,DRG,MS-231,CORONARY BYPASS W PTCA W MCC,Medical/Surgical,Relative Weights,"$89,921.77 ",IP,"50,901.53","165,543.84",,,,,,
Health Alliance FI HMO/POS,DRG,MS-232,CORONARY BYPASS W PTCA W/O MCC,Medical/Surgical,Relative Weights,"$61,425.24 ",IP,"34,770.65","120,687.84",,,,,,
Health Alliance FI HMO/POS,DRG,MS-233,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,Medical/Surgical,Relative Weights,"$81,734.21 ",IP,"42,365.00","156,621.02",,,,,,
Health Alliance FI HMO/POS,DRG,MS-234,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,Medical/Surgical,Relative Weights,"$55,051.41 ",IP,"31,162.65","104,959.01",,,,,,
Health Alliance FI HMO/POS,DRG,MS-235,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,Medical/Surgical,Relative Weights,"$62,975.88 ",IP,"32,351.00","118,633.54",,,,,,
Health Alliance FI HMO/POS,DRG,MS-236,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Medical/Surgical,Relative Weights,"$42,268.67 ",IP,"23,926.80","81,226.66",,,,,,
Health Alliance FI HMO/POS,DRG,MS-239,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,Medical/Surgical,Relative Weights,"$49,686.58 ",IP,"2,420.00","94,141.15",,,,,,
Health Alliance FI HMO/POS,DRG,MS-240,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,Medical/Surgical,Relative Weights,"$28,771.99 ",IP,"2,420.00","55,641.60",,,,,,
Health Alliance FI HMO/POS,DRG,MS-241,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$16,428.76 ",IP,"2,420.00","30,568.61",,,,,,
Health Alliance FI HMO/POS,DRG,MS-242,PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,Medical/Surgical,Relative Weights,"$38,457.57 ",IP,"15,407.00","74,815.78",,,,,,
Health Alliance FI HMO/POS,DRG,MS-243,PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,Medical/Surgical,Relative Weights,"$25,983.31 ",IP,"14,708.24","50,992.70",,,,,,
Health Alliance FI HMO/POS,DRG,MS-244,PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$21,287.02 ",IP,"12,049.83","41,840.06",,,,,,
Health Alliance FI HMO/POS,DRG,MS-245,AICD GENERATOR PROCEDURES,Medical/Surgical,Relative Weights,"$55,895.33 ",IP,"15,407.00","104,989.25",,,,,,
Health Alliance FI HMO/POS,DRG,MS-246,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Medical/Surgical,Relative Weights,"$32,233.34 ",IP,"18,246.15","63,963.65",,,,,,
Health Alliance FI HMO/POS,DRG,MS-247,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITHOUT MCC,Medical/Surgical,Relative Weights,"$20,357.46 ",IP,"11,523.64","41,019.55",,,,,,
Health Alliance FI HMO/POS,DRG,MS-248,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Medical/Surgical,Relative Weights,"$32,624.35 ",IP,"18,467.49","62,425.44",,,,,,
Health Alliance FI HMO/POS,DRG,MS-249,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITHOUT MCC,Medical/Surgical,Relative Weights,"$19,330.93 ",IP,"10,942.55","38,638.66",,,,,,
Health Alliance FI HMO/POS,DRG,MS-250,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT CORONARY ARTERY STENT WITH MCC,Medical/Surgical,Relative Weights,"$26,017.36 ",IP,"14,727.51","51,410.02",,,,,,
Health Alliance FI HMO/POS,DRG,MS-251,PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W/O MCC,Medical/Surgical,Relative Weights,"$17,109.68 ",IP,"2,420.00","33,929.28",,,,,,
Health Alliance FI HMO/POS,DRG,MS-252,OTHER VASCULAR PROCEDURES W MCC,Medical/Surgical,Relative Weights,"$34,311.18 ",IP,"2,420.00","66,132.86",,,,,,
Health Alliance FI HMO/POS,DRG,MS-253,OTHER VASCULAR PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$27,377.14 ",IP,"2,420.00","52,549.06",,,,,,
Health Alliance FI HMO/POS,DRG,MS-254,OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$18,734.60 ",IP,"2,420.00","36,693.22",,,,,,
Health Alliance FI HMO/POS,DRG,MS-255,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,Medical/Surgical,Relative Weights,"$26,156.64 ",IP,"2,420.00","53,415.94",,,,,,
Health Alliance FI HMO/POS,DRG,MS-256,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,Medical/Surgical,Relative Weights,"$16,963.18 ",IP,"2,420.00","34,604.64",,,,,,
Health Alliance FI HMO/POS,DRG,MS-257,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$12,021.35 ",IP,"2,420.00","22,869.50",,,,,,
Health Alliance FI HMO/POS,DRG,MS-258,CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,Medical/Surgical,Relative Weights,"$32,685.22 ",IP,"11,861.00","61,663.39",,,,,,
Health Alliance FI HMO/POS,DRG,MS-259,CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,Medical/Surgical,Relative Weights,"$21,554.23 ",IP,"11,861.00","41,985.22",,,,,,
Health Alliance FI HMO/POS,DRG,MS-260,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,Medical/Surgical,Relative Weights,"$36,803.76 ",IP,"10,167.00","74,583.94",,,,,,
Health Alliance FI HMO/POS,DRG,MS-261,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,Medical/Surgical,Relative Weights,"$20,571.03 ",IP,"10,167.00","39,281.76",,,,,,
Health Alliance FI HMO/POS,DRG,MS-262,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$17,602.83 ",IP,"9,964.34","33,820.42",,,,,,
Health Alliance FI HMO/POS,DRG,MS-263,VEIN LIGATION AND STRIPPING,Medical/Surgical,Relative Weights,"$23,865.24 ",IP,"2,420.00","47,559.46",,,,,,
Health Alliance FI HMO/POS,DRG,MS-264,OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,Medical/Surgical,Relative Weights,"$33,567.33 ",IP,"2,420.00","65,278.08",,,,,,
Health Alliance FI HMO/POS,DRG,MS-265,AICD LEAD PROCEDURES,Medical/Surgical,Relative Weights,"$34,721.80 ",IP,"2,420.00","62,925.41",,,,,,
Health Alliance FI HMO/POS,DRG,MS-266,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$72,713.04 ",IP,"41,160.28","143,567.42",,,,,,
Health Alliance FI HMO/POS,DRG,MS-267,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,Medical/Surgical,Relative Weights,"$57,754.45 ",IP,"32,692.75","114,420.10",,,,,,
Health Alliance FI HMO/POS,DRG,MS-268,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,Medical/Surgical,Relative Weights,"$71,840.23 ",IP,"32,968.00","136,737.22",,,,,,
Health Alliance FI HMO/POS,DRG,MS-269,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,Medical/Surgical,Relative Weights,"$44,518.80 ",IP,"25,200.52","86,010.62",,,,,,
Health Alliance FI HMO/POS,DRG,MS-270,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$53,514.18 ",IP,"30,292.48","103,021.63",,,,,,
Health Alliance FI HMO/POS,DRG,MS-271,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$36,784.16 ",IP,"20,822.21","71,527.68",,,,,,
Health Alliance FI HMO/POS,DRG,MS-272,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$27,735.14 ",IP,"15,699.88","52,442.21",,,,,,
Health Alliance FI HMO/POS,DRG,MS-273,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$39,479.99 ",IP,"16,176.00","74,799.65",,,,,,
Health Alliance FI HMO/POS,DRG,MS-274,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,Medical/Surgical,Relative Weights,"$33,907.79 ",IP,"16,176.00","63,701.57",,,,,,
Health Alliance FI HMO/POS,DRG,MS-280,ACUTE MYOCARDIAL INFARCTION - DISCHARGED ALIVE W MCC,Medical/Surgical,Relative Weights,"$16,578.36 ",IP,"2,420.00","32,878.94",,,,,,
Health Alliance FI HMO/POS,DRG,MS-281,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITH CC,Medical/Surgical,Relative Weights,"$9,600.98 ",IP,"2,420.00","19,528.99",,,,,,
Health Alliance FI HMO/POS,DRG,MS-282,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$7,491.16 ",IP,"2,420.00","14,876.06",,,,,,
Health Alliance FI HMO/POS,DRG,MS-283,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH MCC,Medical/Surgical,Relative Weights,"$19,238.07 ",IP,"2,420.00","36,281.95",,,,,,
Health Alliance FI HMO/POS,DRG,MS-284,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH CC,Medical/Surgical,Relative Weights,"$7,463.30 ",IP,"2,420.00","14,622.05",,,,,,
Health Alliance FI HMO/POS,DRG,MS-285,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$5,103.81 ",IP,"2,420.00","10,438.85",,,,,,
Health Alliance FI HMO/POS,DRG,MS-286,CIRCULATORY DISORDERS EXCEPT AMI- WITH CARDIAC CATHETERIZATION WITH MCC,Medical/Surgical,Relative Weights,"$22,040.16 ",IP,"2,420.00","44,299.58",,,,,,
Health Alliance FI HMO/POS,DRG,MS-287,CIRCULATORY DISORDERS EXCEPT AMI -  WITH CARDIAC CATHETERIZATION WITHOUT MCC,Medical/Surgical,Relative Weights,"$11,504.46 ",IP,"6,512.27","23,228.35",,,,,,
Health Alliance FI HMO/POS,DRG,MS-288,ACUTE & SUBACUTE ENDOCARDITIS W MCC,Medical/Surgical,Relative Weights,"$27,705.22 ",IP,"2,420.00","53,573.18",,,,,,
Health Alliance FI HMO/POS,DRG,MS-289,ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,Medical/Surgical,Relative Weights,"$16,956.99 ",IP,"9,181.00","33,542.21",,,,,,
Health Alliance FI HMO/POS,DRG,MS-290,ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$10,594.51 ",IP,"2,420.00","20,172.10",,,,,,
Health Alliance FI HMO/POS,DRG,MS-291,HEART FAILURE AND SHOCK WITH MCC,Medical/Surgical,Relative Weights,"$13,085.03 ",IP,"2,420.00","27,131.33",,,,,,
Health Alliance FI HMO/POS,DRG,MS-292,HEART FAILURE AND SHOCK WITH CC,Medical/Surgical,Relative Weights,"$8,908.71 ",IP,"2,420.00","18,254.88",,,,,,
Health Alliance FI HMO/POS,DRG,MS-293,HEART FAILURE AND SHOCK WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$6,085.99 ",IP,"2,420.00","13,210.85",,,,,,
Health Alliance FI HMO/POS,DRG,MS-294,DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC,Medical/Surgical,Relative Weights,"$13,234.62 ",IP,"2,420.00","25,641.50",,,,,,
Health Alliance FI HMO/POS,DRG,MS-295,DEEP VEIN THROMBOPHLEBITIS W/O CC/MCC,Medical/Surgical,Relative Weights,"$10,152.94 ",IP,"2,420.00","11,632.32",,,,,,
Health Alliance FI HMO/POS,DRG,MS-296,CARDIAC ARREST - UNEXPLAINED W MCC,Medical/Surgical,Relative Weights,"$16,457.65 ",IP,"2,420.00","31,659.26",,,,,,
Health Alliance FI HMO/POS,DRG,MS-297,CARDIAC ARREST- UNEXPLAINED WITH CC,Medical/Surgical,Relative Weights,"$7,294.10 ",IP,"2,420.00","14,575.68",,,,,,
Health Alliance FI HMO/POS,DRG,MS-298,CARDIAC ARREST- UNEXPLAINED WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$5,042.94 ",IP,"2,420.00","10,144.51",,,,,,
Health Alliance FI HMO/POS,DRG,MS-299,PERIPHERAL VASCULAR DISORDERS WITH MCC,Medical/Surgical,Relative Weights,"$15,811.80 ",IP,"2,420.00","29,225.95",,,,,,
Health Alliance FI HMO/POS,DRG,MS-300,PERIPHERAL VASCULAR DISORDERS WITH CC,Medical/Surgical,Relative Weights,"$10,768.86 ",IP,"2,420.00","20,716.42",,,,,,
Health Alliance FI HMO/POS,DRG,MS-301,PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$7,666.55 ",IP,"2,420.00","14,632.13",,,,,,
Health Alliance FI HMO/POS,DRG,MS-302,ATHEROSCLEROSIS WITH MCC,Medical/Surgical,Relative Weights,"$11,295.03 ",IP,"2,420.00","22,222.37",,,,,,
Health Alliance FI HMO/POS,DRG,MS-303,ATHEROSCLEROSIS WITHOUT MCC,Medical/Surgical,Relative Weights,"$6,990.79 ",IP,"2,420.00","13,622.11",,,,,,
Health Alliance FI HMO/POS,DRG,MS-304,HYPERTENSION WITH MCC,Medical/Surgical,Relative Weights,"$11,317.73 ",IP,"2,420.00","22,004.64",,,,,,
Health Alliance FI HMO/POS,DRG,MS-305,HYPERTENSION WITHOUT MCC,Medical/Surgical,Relative Weights,"$7,633.53 ",IP,"2,420.00","14,747.04",,,,,,
Health Alliance FI HMO/POS,DRG,MS-306,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,Medical/Surgical,Relative Weights,"$15,551.82 ",IP,"2,420.00","28,516.32",,,,,,
Health Alliance FI HMO/POS,DRG,MS-307,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,Medical/Surgical,Relative Weights,"$8,979.90 ",IP,"2,420.00","17,785.15",,,,,,
Health Alliance FI HMO/POS,DRG,MS-308,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,Medical/Surgical,Relative Weights,"$12,389.66 ",IP,"2,420.00","23,944.03",,,,,,
Health Alliance FI HMO/POS,DRG,MS-309,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,Medical/Surgical,Relative Weights,"$7,742.89 ",IP,"2,420.00","15,247.01",,,,,,
Health Alliance FI HMO/POS,DRG,MS-310,CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC,Medical/Surgical,Relative Weights,"$5,769.26 ",IP,"2,420.00","11,275.49",,,,,,
Health Alliance FI HMO/POS,DRG,MS-311,ANGINA PECTORIS,Medical/Surgical,Relative Weights,"$7,206.41 ",IP,"2,420.00","13,809.60",,,,,,
Health Alliance FI HMO/POS,DRG,MS-312,SYNCOPE AND COLLAPSE,Medical/Surgical,Relative Weights,"$8,652.85 ",IP,"2,420.00","16,462.66",,,,,,
Health Alliance FI HMO/POS,DRG,MS-313,CHEST PAIN,Medical/Surgical,Relative Weights,"$7,442.67 ",IP,"2,420.00","14,420.45",,,,,,
Health Alliance FI HMO/POS,DRG,MS-314,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,Medical/Surgical,Relative Weights,"$21,507.81 ",IP,"2,420.00","40,914.72",,,,,,
Health Alliance FI HMO/POS,DRG,MS-315,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,Medical/Surgical,Relative Weights,"$10,042.55 ",IP,"2,420.00","19,563.26",,,,,,
Health Alliance FI HMO/POS,DRG,MS-316,OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$7,463.30 ",IP,"2,420.00","14,962.75",,,,,,
Health Alliance FI HMO/POS,DRG,MS-319,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$44,547.69 ",IP,"2,420.00","82,670.11",,,,,,
Health Alliance FI HMO/POS,DRG,MS-320,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,Medical/Surgical,Relative Weights,"$24,818.53 ",IP,"2,420.00","47,329.63",,,,,,
Health Alliance FI HMO/POS,DRG,MS-326,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$54,848.16 ",IP,"2,420.00","106,253.28",,,,,,
Health Alliance FI HMO/POS,DRG,MS-327,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$26,459.96 ",IP,"2,420.00","51,869.66",,,,,,
Health Alliance FI HMO/POS,DRG,MS-328,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$17,197.37 ",IP,"2,420.00","31,752.00",,,,,,
Health Alliance FI HMO/POS,DRG,MS-329,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$50,410.83 ",IP,"2,420.00","98,929.15",,,,,,
Health Alliance FI HMO/POS,DRG,MS-330,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$26,301.08 ",IP,"2,420.00","50,940.29",,,,,,
Health Alliance FI HMO/POS,DRG,MS-331,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$17,647.19 ",IP,"2,420.00","34,054.27",,,,,,
Health Alliance FI HMO/POS,DRG,MS-332,RECTAL RESECTION WITH MCC,Medical/Surgical,Relative Weights,"$42,934.11 ",IP,"2,420.00","70,396.70",,,,,,
Health Alliance FI HMO/POS,DRG,MS-333,RECTAL RESECTION WITH CC,Medical/Surgical,Relative Weights,"$22,091.75 ",IP,"2,420.00","45,626.11",,,,,,
Health Alliance FI HMO/POS,DRG,MS-334,RECTAL RESECTION WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$16,595.89 ",IP,"2,420.00","31,052.45",,,,,,
Health Alliance FI HMO/POS,DRG,MS-335,PERITONEAL ADHESIOLYSIS WITH MCC,Medical/Surgical,Relative Weights,"$40,375.50 ",IP,"2,420.00","81,549.22",,,,,,
Health Alliance FI HMO/POS,DRG,MS-336,PERITONEAL ADHESIOLYSIS WITH CC,Medical/Surgical,Relative Weights,"$23,639.30 ",IP,"2,420.00","45,686.59",,,,,,
Health Alliance FI HMO/POS,DRG,MS-337,PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$16,891.99 ",IP,"2,420.00","33,056.35",,,,,,
Health Alliance FI HMO/POS,DRG,MS-338,APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Medical/Surgical,Relative Weights,"$28,859.69 ",IP,"2,420.00","58,667.62",,,,,,
Health Alliance FI HMO/POS,DRG,MS-339,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W CC,Medical/Surgical,Relative Weights,"$17,512.04 ",IP,"2,420.00","34,596.58",,,,,,
Health Alliance FI HMO/POS,DRG,MS-340,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC/MCC,Medical/Surgical,Relative Weights,"$12,672.35 ",IP,"2,420.00","24,948.00",,,,,,
Health Alliance FI HMO/POS,DRG,MS-341,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Medical/Surgical,Relative Weights,"$23,960.15 ",IP,"2,420.00","51,571.30",,,,,,
Health Alliance FI HMO/POS,DRG,MS-342,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH CC,Medical/Surgical,Relative Weights,"$14,783.20 ",IP,"2,420.00","32,463.65",,,,,,
Health Alliance FI HMO/POS,DRG,MS-343,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$11,437.40 ",IP,"2,420.00","23,216.26",,,,,,
Health Alliance FI HMO/POS,DRG,MS-344,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$29,077.38 ",IP,"2,420.00","60,381.22",,,,,,
Health Alliance FI HMO/POS,DRG,MS-345,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$16,288.45 ",IP,"2,420.00","32,927.33",,,,,,
Health Alliance FI HMO/POS,DRG,MS-346,MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$13,158.28 ",IP,"2,420.00","25,859.23",,,,,,
Health Alliance FI HMO/POS,DRG,MS-347,ANAL AND STOMAL PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$25,428.26 ",IP,"2,420.00","53,149.82",,,,,,
Health Alliance FI HMO/POS,DRG,MS-348,ANAL AND STOMAL PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$13,908.32 ",IP,"2,420.00","28,411.49",,,,,,
Health Alliance FI HMO/POS,DRG,MS-349,ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$10,103.42 ",IP,"2,420.00","19,774.94",,,,,,
Health Alliance FI HMO/POS,DRG,MS-350,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$25,326.12 ",IP,"2,420.00","49,176.29",,,,,,
Health Alliance FI HMO/POS,DRG,MS-351,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$15,400.16 ",IP,"2,420.00","29,399.33",,,,,,
Health Alliance FI HMO/POS,DRG,MS-352,INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$11,394.07 ",IP,"2,420.00","21,708.29",,,,,,
Health Alliance FI HMO/POS,DRG,MS-353,HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,Medical/Surgical,Relative Weights,"$31,207.83 ",IP,"2,420.00","59,812.70",,,,,,
Health Alliance FI HMO/POS,DRG,MS-354,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W CC,Medical/Surgical,Relative Weights,"$18,413.75 ",IP,"2,420.00","34,717.54",,,,,,
Health Alliance FI HMO/POS,DRG,MS-355,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W/O CC/MCC,Medical/Surgical,Relative Weights,"$14,033.16 ",IP,"2,420.00","27,667.58",,,,,,
Health Alliance FI HMO/POS,DRG,MS-356,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$44,443.49 ",IP,"2,420.00","82,196.35",,,,,,
Health Alliance FI HMO/POS,DRG,MS-357,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$23,404.07 ",IP,"2,420.00","45,368.06",,,,,,
Health Alliance FI HMO/POS,DRG,MS-358,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$13,918.64 ",IP,"2,420.00","27,653.47",,,,,,
Health Alliance FI HMO/POS,DRG,MS-368,MAJOR ESOPHAGEAL DISORDERS WITH MCC,Medical/Surgical,Relative Weights,"$20,108.83 ",IP,"2,420.00","38,376.58",,,,,,
Health Alliance FI HMO/POS,DRG,MS-369,MAJOR ESOPHAGEAL DISORDERS WITH CC,Medical/Surgical,Relative Weights,"$11,113.45 ",IP,"2,420.00","21,432.10",,,,,,
Health Alliance FI HMO/POS,DRG,MS-370,MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$7,718.13 ",IP,"2,420.00","15,065.57",,,,,,
Health Alliance FI HMO/POS,DRG,MS-371,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,Medical/Surgical,Relative Weights,"$17,860.76 ",IP,"2,420.00","34,786.08",,,,,,
Health Alliance FI HMO/POS,DRG,MS-372,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,Medical/Surgical,Relative Weights,"$10,619.27 ",IP,"2,420.00","20,613.60",,,,,,
Health Alliance FI HMO/POS,DRG,MS-373,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$7,682.02 ",IP,"2,420.00","14,954.69",,,,,,
Health Alliance FI HMO/POS,DRG,MS-374,DIGESTIVE MALIGNANCY WITH MCC,Medical/Surgical,Relative Weights,"$21,394.32 ",IP,"2,420.00","40,269.60",,,,,,
Health Alliance FI HMO/POS,DRG,MS-375,DIGESTIVE MALIGNANCY WITH CC,Medical/Surgical,Relative Weights,"$12,458.79 ",IP,"2,420.00","24,339.17",,,,,,
Health Alliance FI HMO/POS,DRG,MS-376,DIGESTIVE MALIGNANCY WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$9,273.93 ",IP,"2,420.00","20,186.21",,,,,,
Health Alliance FI HMO/POS,DRG,MS-377,GASTROINTESTINAL HEMORRHAGE WITH MCC,Medical/Surgical,Relative Weights,"$18,582.94 ",IP,"2,420.00","35,681.18",,,,,,
Health Alliance FI HMO/POS,DRG,MS-378,GASTROINTESTINAL HEMORRHAGE WITH CC,Medical/Surgical,Relative Weights,"$10,249.92 ",IP,"2,420.00","19,920.10",,,,,,
Health Alliance FI HMO/POS,DRG,MS-379,GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$6,573.98 ",IP,"2,420.00","13,017.31",,,,,,
Health Alliance FI HMO/POS,DRG,MS-380,COMPLICATED PEPTIC ULCER WITH MCC,Medical/Surgical,Relative Weights,"$19,464.01 ",IP,"2,420.00","38,054.02",,,,,,
Health Alliance FI HMO/POS,DRG,MS-381,COMPLICATED PEPTIC ULCER WITH CC,Medical/Surgical,Relative Weights,"$10,928.78 ",IP,"2,420.00","21,706.27",,,,,,
Health Alliance FI HMO/POS,DRG,MS-382,COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$7,929.63 ",IP,"2,420.00","15,954.62",,,,,,
Health Alliance FI HMO/POS,DRG,MS-383,UNCOMPLICATED PEPTIC ULCER WITH MCC,Medical/Surgical,Relative Weights,"$13,542.07 ",IP,"2,420.00","26,738.21",,,,,,
Health Alliance FI HMO/POS,DRG,MS-384,UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,Medical/Surgical,Relative Weights,"$9,211.00 ",IP,"2,420.00","17,543.23",,,,,,
Health Alliance FI HMO/POS,DRG,MS-385,INFLAMMATORY BOWEL DISEASE WITH MCC,Medical/Surgical,Relative Weights,"$16,737.24 ",IP,"2,420.00","32,463.65",,,,,,
Health Alliance FI HMO/POS,DRG,MS-386,INFLAMMATORY BOWEL DISEASE W CC,Medical/Surgical,Relative Weights,"$10,266.43 ",IP,"2,420.00","19,861.63",,,,,,
Health Alliance FI HMO/POS,DRG,MS-387,INFLAMMATORY BOWEL DISEASE W/O CC/MCC,Medical/Surgical,Relative Weights,"$7,373.55 ",IP,"2,420.00","14,126.11",,,,,,
Health Alliance FI HMO/POS,DRG,MS-388,GASTROINTESTINAL OBSTRUCTION WITH MCC,Medical/Surgical,Relative Weights,"$15,626.10 ",IP,"2,420.00","30,746.02",,,,,,
Health Alliance FI HMO/POS,DRG,MS-389,GASTROINTESTINAL OBSTRUCTION WITH CC,Medical/Surgical,Relative Weights,"$8,492.94 ",IP,"2,420.00","16,928.35",,,,,,
Health Alliance FI HMO/POS,DRG,MS-390,GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$6,015.83 ",IP,"2,420.00","11,684.74",,,,,,
Health Alliance FI HMO/POS,DRG,MS-391,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC,Medical/Surgical,Relative Weights,"$12,887.97 ",IP,"2,420.00","24,897.60",,,,,,
Health Alliance FI HMO/POS,DRG,MS-392,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC,Medical/Surgical,Relative Weights,"$7,900.74 ",IP,"2,420.00","15,351.84",,,,,,
Health Alliance FI HMO/POS,DRG,MS-393,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,Medical/Surgical,Relative Weights,"$17,138.57 ",IP,"2,420.00","32,749.92",,,,,,
Health Alliance FI HMO/POS,DRG,MS-394,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,Medical/Surgical,Relative Weights,"$9,707.25 ",IP,"2,420.00","18,912.10",,,,,,
Health Alliance FI HMO/POS,DRG,MS-395,OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$6,721.51 ",IP,"2,420.00","13,192.70",,,,,,
Health Alliance FI HMO/POS,DRG,MS-405,PANCREAS- LIVER AND SHUNT PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$59,194.70 ",IP,"2,420.00","109,412.35",,,,,,
Health Alliance FI HMO/POS,DRG,MS-406,PANCREAS -  LIVER AND SHUNT PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$29,722.19 ",IP,"2,420.00","56,264.54",,,,,,
Health Alliance FI HMO/POS,DRG,MS-407,PANCREAS -  LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$21,851.36 ",IP,"2,420.00","42,059.81",,,,,,
Health Alliance FI HMO/POS,DRG,MS-408,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,Medical/Surgical,Relative Weights,"$38,718.59 ",IP,"2,420.00","71,842.18",,,,,,
Health Alliance FI HMO/POS,DRG,MS-409,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,Medical/Surgical,Relative Weights,"$21,834.86 ",IP,"2,420.00","48,259.01",,,,,,
Health Alliance FI HMO/POS,DRG,MS-410,BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W/O CC/MCC,Medical/Surgical,Relative Weights,"$16,180.12 ",IP,"2,420.00","33,465.60",,,,,,
Health Alliance FI HMO/POS,DRG,MS-411,CHOLECYSTECTOMY W C.D.E. W MCC,Medical/Surgical,Relative Weights,"$38,724.78 ",IP,"2,420.00","77,220.86",,,,,,
Health Alliance FI HMO/POS,DRG,MS-412,CHOLECYSTECTOMY WITH C.D.E. WITH CC,Medical/Surgical,Relative Weights,"$23,496.92 ",IP,"2,420.00","47,920.32",,,,,,
Health Alliance FI HMO/POS,DRG,MS-413,CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$17,857.66 ",IP,"2,420.00","32,604.77",,,,,,
Health Alliance FI HMO/POS,DRG,MS-414,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,Medical/Surgical,Relative Weights,"$37,433.10 ",IP,"2,420.00","68,874.62",,,,,,
Health Alliance FI HMO/POS,DRG,MS-415,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,Medical/Surgical,Relative Weights,"$20,961.01 ",IP,"2,420.00","41,362.27",,,,,,
Health Alliance FI HMO/POS,DRG,MS-416,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$14,673.84 ",IP,"2,420.00","27,222.05",,,,,,
Health Alliance FI HMO/POS,DRG,MS-417,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,Medical/Surgical,Relative Weights,"$25,011.45 ",IP,"2,420.00","48,599.71",,,,,,
Health Alliance FI HMO/POS,DRG,MS-418,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,Medical/Surgical,Relative Weights,"$17,425.38 ",IP,"2,420.00","33,645.02",,,,,,
Health Alliance FI HMO/POS,DRG,MS-419,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$13,569.92 ",IP,"2,420.00","26,345.09",,,,,,
Health Alliance FI HMO/POS,DRG,MS-420,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$36,279.66 ",IP,"2,420.00","69,245.57",,,,,,
Health Alliance FI HMO/POS,DRG,MS-421,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$19,679.64 ",IP,"2,420.00","37,118.59",,,,,,
Health Alliance FI HMO/POS,DRG,MS-422,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$14,996.76 ",IP,"2,420.00","28,314.72",,,,,,
Health Alliance FI HMO/POS,DRG,MS-423,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$43,185.85 ",IP,"2,420.00","85,442.11",,,,,,
Health Alliance FI HMO/POS,DRG,MS-424,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$23,565.01 ",IP,"2,420.00","45,388.22",,,,,,
Health Alliance FI HMO/POS,DRG,MS-425,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES W/O CC/MCC,Medical/Surgical,Relative Weights,"$15,916.01 ",IP,"2,420.00","29,463.84",,,,,,
Health Alliance FI HMO/POS,DRG,MS-432,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,Medical/Surgical,Relative Weights,"$19,404.18 ",IP,"2,420.00","36,759.74",,,,,,
Health Alliance FI HMO/POS,DRG,MS-433,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,Medical/Surgical,Relative Weights,"$10,625.46 ",IP,"2,420.00","20,805.12",,,,,,
Health Alliance FI HMO/POS,DRG,MS-434,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$6,403.75 ",IP,"2,420.00","12,900.38",,,,,,
Health Alliance FI HMO/POS,DRG,MS-435,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,Medical/Surgical,Relative Weights,"$18,089.79 ",IP,"2,420.00","34,213.54",,,,,,
Health Alliance FI HMO/POS,DRG,MS-436,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,Medical/Surgical,Relative Weights,"$11,570.49 ",IP,"2,420.00","22,694.11",,,,,,
Health Alliance FI HMO/POS,DRG,MS-437,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$9,242.98 ",IP,"2,420.00","17,698.46",,,,,,
Health Alliance FI HMO/POS,DRG,MS-438,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,Medical/Surgical,Relative Weights,"$16,484.47 ",IP,"2,420.00","33,028.13",,,,,,
Health Alliance FI HMO/POS,DRG,MS-439,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,Medical/Surgical,Relative Weights,"$8,719.91 ",IP,"2,420.00","17,079.55",,,,,,
Health Alliance FI HMO/POS,DRG,MS-440,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$6,255.19 ",IP,"2,420.00","12,410.50",,,,,,
Health Alliance FI HMO/POS,DRG,MS-441,DISORDERS OF LIVER EXCEPT MALIGNANCY- CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC,Medical/Surgical,Relative Weights,"$19,390.76 ",IP,"2,420.00","37,306.08",,,,,,
Health Alliance FI HMO/POS,DRG,MS-442,DISORDERS OF LIVER EXCEPT MALIGNANCY -  CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC,Medical/Surgical,Relative Weights,"$9,594.79 ",IP,"2,420.00","18,817.34",,,,,,
Health Alliance FI HMO/POS,DRG,MS-443,DISORDERS OF LIVER EXCEPT MALIGNANCY -  CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$6,842.22 ",IP,"2,420.00","13,714.85",,,,,,
Health Alliance FI HMO/POS,DRG,MS-444,DISORDERS OF THE BILIARY TRACT WITH MCC,Medical/Surgical,Relative Weights,"$17,245.86 ",IP,"2,420.00","32,782.18",,,,,,
Health Alliance FI HMO/POS,DRG,MS-445,DISORDERS OF THE BILIARY TRACT WITH CC,Medical/Surgical,Relative Weights,"$11,116.55 ",IP,"2,420.00","21,661.92",,,,,,
Health Alliance FI HMO/POS,DRG,MS-446,DISORDERS OF THE BILIARY TRACT W/O CC/MCC,Medical/Surgical,Relative Weights,"$8,424.85 ",IP,"2,420.00","16,384.03",,,,,,
Health Alliance FI HMO/POS,DRG,MS-453,COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W MCC,Medical/Surgical,Relative Weights,"$94,792.41 ",IP,"2,420.00","189,645.12",,,,,,
Health Alliance FI HMO/POS,DRG,MS-454,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC,Medical/Surgical,Relative Weights,"$62,862.39 ",IP,"2,420.00","123,480.00",,,,,,
Health Alliance FI HMO/POS,DRG,MS-455,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$49,328.58 ",IP,"2,420.00","97,036.13",,,,,,
Health Alliance FI HMO/POS,DRG,MS-456,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH MCC,Medical/Surgical,Relative Weights,"$88,726.03 ",IP,"2,420.00","183,076.99",,,,,,
Health Alliance FI HMO/POS,DRG,MS-457,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH CC,Medical/Surgical,Relative Weights,"$67,018.07 ",IP,"2,420.00","131,308.13",,,,,,
Health Alliance FI HMO/POS,DRG,MS-458,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$51,663.31 ",IP,"2,420.00","94,629.02",,,,,,
Health Alliance FI HMO/POS,DRG,MS-459,SPINAL FUSION EXCEPT CERVICAL WITH MCC,Medical/Surgical,Relative Weights,"$69,469.38 ",IP,"21,658.00","138,136.32",,,,,,
Health Alliance FI HMO/POS,DRG,MS-460,SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,Medical/Surgical,Relative Weights,"$40,552.95 ",IP,"21,658.00","79,841.66",,,,,,
Health Alliance FI HMO/POS,DRG,MS-461,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,Medical/Surgical,Relative Weights,"$62,744.78 ",IP,"2,420.00","108,436.61",,,,,,
Health Alliance FI HMO/POS,DRG,MS-462,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,Medical/Surgical,Relative Weights,"$32,409.76 ",IP,"2,420.00","63,229.82",,,,,,
Health Alliance FI HMO/POS,DRG,MS-463,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,Medical/Surgical,Relative Weights,"$55,405.28 ",IP,"2,420.00","105,392.45",,,,,,
Health Alliance FI HMO/POS,DRG,MS-464,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,Medical/Surgical,Relative Weights,"$30,702.30 ",IP,"2,420.00","59,526.43",,,,,,
Health Alliance FI HMO/POS,DRG,MS-465,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$19,025.54 ",IP,"2,420.00","38,610.43",,,,,,
Health Alliance FI HMO/POS,DRG,MS-466,REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,Medical/Surgical,Relative Weights,"$55,151.48 ",IP,"2,420.00","102,797.86",,,,,,
Health Alliance FI HMO/POS,DRG,MS-467,REVISION OF HIP OR KNEE REPLACEMENT W CC,Medical/Surgical,Relative Weights,"$36,909.00 ",IP,"2,420.00","70,803.94",,,,,,
Health Alliance FI HMO/POS,DRG,MS-468,REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$28,912.30 ",IP,"2,420.00","56,691.94",,,,,,
Health Alliance FI HMO/POS,DRG,MS-469,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,Medical/Surgical,Relative Weights,"$31,837.17 ",IP,"2,420.00","63,300.38",,,,,,
Health Alliance FI HMO/POS,DRG,MS-470,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,Medical/Surgical,Relative Weights,"$19,605.36 ",IP,"2,420.00","39,682.94",,,,,,
Health Alliance FI HMO/POS,DRG,MS-471,CERVICAL SPINAL FUSION WITH MCC,Medical/Surgical,Relative Weights,"$51,788.14 ",IP,"15,407.00","100,687.10",,,,,,
Health Alliance FI HMO/POS,DRG,MS-472,CERVICAL SPINAL FUSION WITH CC,Medical/Surgical,Relative Weights,"$31,504.96 ",IP,"15,407.00","61,316.64",,,,,,
Health Alliance FI HMO/POS,DRG,MS-473,CERVICAL SPINAL FUSION WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$26,194.81 ",IP,"14,827.96","50,649.98",,,,,,
Health Alliance FI HMO/POS,DRG,MS-474,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,Medical/Surgical,Relative Weights,"$42,053.04 ",IP,"2,420.00","78,117.98",,,,,,
Health Alliance FI HMO/POS,DRG,MS-475,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,Medical/Surgical,Relative Weights,"$22,659.18 ",IP,"2,420.00","42,356.16",,,,,,
Health Alliance FI HMO/POS,DRG,MS-476,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$11,970.79 ",IP,"2,420.00","23,480.35",,,,,,
Health Alliance FI HMO/POS,DRG,MS-477,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Medical/Surgical,Relative Weights,"$34,653.70 ",IP,"2,420.00","65,626.85",,,,,,
Health Alliance FI HMO/POS,DRG,MS-478,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Medical/Surgical,Relative Weights,"$24,331.57 ",IP,"2,420.00","46,712.74",,,,,,
Health Alliance FI HMO/POS,DRG,MS-479,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$18,668.58 ",IP,"2,420.00","35,929.15",,,,,,
Health Alliance FI HMO/POS,DRG,MS-480,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,Medical/Surgical,Relative Weights,"$31,217.12 ",IP,"2,420.00","60,852.96",,,,,,
Health Alliance FI HMO/POS,DRG,MS-481,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,Medical/Surgical,Relative Weights,"$21,625.42 ",IP,"2,420.00","42,090.05",,,,,,
Health Alliance FI HMO/POS,DRG,MS-482,HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC,Medical/Surgical,Relative Weights,"$16,979.69 ",IP,"2,420.00","33,169.25",,,,,,
Health Alliance FI HMO/POS,DRG,MS-483,MAJOR JOINT & LIMB REATTACHMENT PROC OF UPPER EXTREMITY W CC/MCC,Medical/Surgical,Relative Weights,"$24,613.22 ",IP,"2,420.00","48,224.74",,,,,,
Health Alliance FI HMO/POS,DRG,MS-485,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,Medical/Surgical,Relative Weights,"$35,176.78 ",IP,"2,420.00","66,104.64",,,,,,
Health Alliance FI HMO/POS,DRG,MS-486,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,Medical/Surgical,Relative Weights,"$22,175.32 ",IP,"2,420.00","43,356.10",,,,,,
Health Alliance FI HMO/POS,DRG,MS-487,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$16,921.91 ",IP,"2,420.00","32,401.15",,,,,,
Health Alliance FI HMO/POS,DRG,MS-488,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,Medical/Surgical,Relative Weights,"$20,383.26 ",IP,"2,420.00","39,699.07",,,,,,
Health Alliance FI HMO/POS,DRG,MS-489,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$13,393.50 ",IP,"2,420.00","25,381.44",,,,,,
Health Alliance FI HMO/POS,DRG,MS-492,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH MCC,Medical/Surgical,Relative Weights,"$35,799.92 ",IP,"2,420.00","69,457.25",,,,,,
Health Alliance FI HMO/POS,DRG,MS-493,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH CC,Medical/Surgical,Relative Weights,"$23,995.23 ",IP,"2,420.00","46,408.32",,,,,,
Health Alliance FI HMO/POS,DRG,MS-494,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$19,103.95 ",IP,"2,420.00","36,517.82",,,,,,
Health Alliance FI HMO/POS,DRG,MS-495,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,Medical/Surgical,Relative Weights,"$37,573.41 ",IP,"2,420.00","69,201.22",,,,,,
Health Alliance FI HMO/POS,DRG,MS-496,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,Medical/Surgical,Relative Weights,"$20,493.65 ",IP,"2,420.00","41,136.48",,,,,,
Health Alliance FI HMO/POS,DRG,MS-497,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$14,975.10 ",IP,"2,420.00","29,621.09",,,,,,
Health Alliance FI HMO/POS,DRG,MS-498,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,Medical/Surgical,Relative Weights,"$26,655.98 ",IP,"2,420.00","49,353.70",,,,,,
Health Alliance FI HMO/POS,DRG,MS-499,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$12,370.06 ",IP,"2,420.00","23,202.14",,,,,,
Health Alliance FI HMO/POS,DRG,MS-500,SOFT TISSUE PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$32,906.01 ",IP,"2,420.00","60,786.43",,,,,,
Health Alliance FI HMO/POS,DRG,MS-501,SOFT TISSUE PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$18,097.01 ",IP,"2,420.00","33,828.48",,,,,,
Health Alliance FI HMO/POS,DRG,MS-502,SOFT TISSUE PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$13,750.47 ",IP,"2,420.00","26,625.31",,,,,,
Health Alliance FI HMO/POS,DRG,MS-503,FOOT PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$27,243.02 ",IP,"2,420.00","54,766.66",,,,,,
Health Alliance FI HMO/POS,DRG,MS-504,FOOT PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$18,312.64 ",IP,"2,420.00","35,007.84",,,,,,
Health Alliance FI HMO/POS,DRG,MS-505,FOOT PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$18,312.64 ",IP,"2,420.00","33,899.04",,,,,,
Health Alliance FI HMO/POS,DRG,MS-506,MAJOR THUMB OR JOINT PROCEDURES,Medical/Surgical,Relative Weights,"$15,306.27 ",IP,"2,420.00","26,986.18",,,,,,
Health Alliance FI HMO/POS,DRG,MS-507,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W CC/MCC,Medical/Surgical,Relative Weights,"$21,262.26 ",IP,"2,420.00","42,336.00",,,,,,
Health Alliance FI HMO/POS,DRG,MS-508,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W/O CC/MCC,Medical/Surgical,Relative Weights,"$14,543.85 ",IP,"2,420.00","31,417.34",,,,,,
Health Alliance FI HMO/POS,DRG,MS-509,ARTHROSCOPY,Medical/Surgical,Relative Weights,"$17,399.59 ",IP,"2,420.00","28,056.67",,,,,,
Health Alliance FI HMO/POS,DRG,MS-510,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$28,306.70 ",IP,"2,420.00","56,206.08",,,,,,
Health Alliance FI HMO/POS,DRG,MS-511,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$20,297.63 ",IP,"2,420.00","37,985.47",,,,,,
Health Alliance FI HMO/POS,DRG,MS-512,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$16,037.75 ",IP,"2,420.00","30,518.21",,,,,,
Health Alliance FI HMO/POS,DRG,MS-513,HAND OR WRIST PROCEDURES- EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC,Medical/Surgical,Relative Weights,"$16,218.29 ",IP,"2,420.00","31,794.34",,,,,,
Health Alliance FI HMO/POS,DRG,MS-514,HAND OR WRIST PROCEDURES -  EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$10,307.69 ",IP,"2,420.00","21,506.69",,,,,,
Health Alliance FI HMO/POS,DRG,MS-515,OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W MCC,Medical/Surgical,Relative Weights,"$32,401.51 ",IP,"2,420.00","63,584.64",,,,,,
Health Alliance FI HMO/POS,DRG,MS-516,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$20,250.17 ",IP,"2,420.00","39,092.26",,,,,,
Health Alliance FI HMO/POS,DRG,MS-517,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$14,425.20 ",IP,"2,420.00","28,532.45",,,,,,
Health Alliance FI HMO/POS,DRG,MS-518,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,Medical/Surgical,Relative Weights,"$37,005.98 ",IP,"10,289.00","68,717.38",,,,,,
Health Alliance FI HMO/POS,DRG,MS-519,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,Medical/Surgical,Relative Weights,"$20,221.28 ",IP,"10,289.00","38,479.39",,,,,,
Health Alliance FI HMO/POS,DRG,MS-520,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$14,632.57 ",IP,"8,282.98","26,974.08",,,,,,
Health Alliance FI HMO/POS,DRG,MS-521,HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,Medical/Surgical,Relative Weights,"$31,633.92 ",IP,"2,420.00","31,633.92",,,,,,
Health Alliance FI HMO/POS,DRG,MS-522,HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,Medical/Surgical,Relative Weights,"$22,588.00 ",IP,"2,420.00","22,588.00",,,,,,
Health Alliance FI HMO/POS,DRG,MS-533,FRACTURES OF FEMUR WITH MCC,Medical/Surgical,Relative Weights,"$14,610.91 ",IP,"2,420.00","29,421.50",,,,,,
Health Alliance FI HMO/POS,DRG,MS-534,FRACTURES OF FEMUR WITHOUT MCC,Medical/Surgical,Relative Weights,"$8,152.48 ",IP,"2,420.00","15,680.45",,,,,,
Health Alliance FI HMO/POS,DRG,MS-535,FRACTURES OF HIP AND PELVIS WITH MCC,Medical/Surgical,Relative Weights,"$12,718.77 ",IP,"2,420.00","24,738.34",,,,,,
Health Alliance FI HMO/POS,DRG,MS-536,FRACTURES OF HIP AND PELVIS WITHOUT MCC,Medical/Surgical,Relative Weights,"$7,961.61 ",IP,"2,420.00","15,291.36",,,,,,
Health Alliance FI HMO/POS,DRG,MS-537,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITH CC/MCC,Medical/Surgical,Relative Weights,"$9,650.50 ",IP,"2,420.00","18,363.74",,,,,,
Health Alliance FI HMO/POS,DRG,MS-538,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$7,461.24 ",IP,"2,420.00","14,535.36",,,,,,
Health Alliance FI HMO/POS,DRG,MS-539,OSTEOMYELITIS WITH MCC,Medical/Surgical,Relative Weights,"$20,094.38 ",IP,"2,420.00","38,005.63",,,,,,
Health Alliance FI HMO/POS,DRG,MS-540,OSTEOMYELITIS WITH CC,Medical/Surgical,Relative Weights,"$13,428.58 ",IP,"2,420.00","26,208.00",,,,,,
Health Alliance FI HMO/POS,DRG,MS-541,OSTEOMYELITIS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$8,699.28 ",IP,"2,420.00","18,279.07",,,,,,
Health Alliance FI HMO/POS,DRG,MS-542,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,Medical/Surgical,Relative Weights,"$18,665.48 ",IP,"2,420.00","36,787.97",,,,,,
Health Alliance FI HMO/POS,DRG,MS-543,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,Medical/Surgical,Relative Weights,"$10,783.31 ",IP,"2,420.00","21,295.01",,,,,,
Health Alliance FI HMO/POS,DRG,MS-544,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$8,023.52 ",IP,"2,420.00","15,289.34",,,,,,
Health Alliance FI HMO/POS,DRG,MS-545,CONNECTIVE TISSUE DISORDERS WITH MCC,Medical/Surgical,Relative Weights,"$25,824.43 ",IP,"2,420.00","50,964.48",,,,,,
Health Alliance FI HMO/POS,DRG,MS-546,CONNECTIVE TISSUE DISORDERS WITH CC,Medical/Surgical,Relative Weights,"$12,462.91 ",IP,"2,420.00","24,260.54",,,,,,
Health Alliance FI HMO/POS,DRG,MS-547,CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$8,600.23 ",IP,"2,420.00","16,331.62",,,,,,
Health Alliance FI HMO/POS,DRG,MS-548,SEPTIC ARTHRITIS WITH MCC,Medical/Surgical,Relative Weights,"$21,158.06 ",IP,"2,420.00","39,983.33",,,,,,
Health Alliance FI HMO/POS,DRG,MS-549,SEPTIC ARTHRITIS W CC,Medical/Surgical,Relative Weights,"$12,895.19 ",IP,"2,420.00","24,052.90",,,,,,
Health Alliance FI HMO/POS,DRG,MS-550,SEPTIC ARTHRITIS W/O CC/MCC,Medical/Surgical,Relative Weights,"$9,067.59 ",IP,"2,420.00","17,418.24",,,,,,
Health Alliance FI HMO/POS,DRG,MS-551,MEDICAL BACK PROBLEMS WITH MCC,Medical/Surgical,Relative Weights,"$16,789.85 ",IP,"2,420.00","32,042.30",,,,,,
Health Alliance FI HMO/POS,DRG,MS-552,MEDICAL BACK PROBLEMS WITHOUT MCC,Medical/Surgical,Relative Weights,"$9,733.04 ",IP,"2,420.00","18,383.90",,,,,,
Health Alliance FI HMO/POS,DRG,MS-553,BONE DISEASES AND ARTHROPATHIES WITH MCC,Medical/Surgical,Relative Weights,"$13,118.04 ",IP,"2,420.00","25,915.68",,,,,,
Health Alliance FI HMO/POS,DRG,MS-554,BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,Medical/Surgical,Relative Weights,"$8,176.21 ",IP,"2,420.00","15,869.95",,,,,,
Health Alliance FI HMO/POS,DRG,MS-555,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Medical/Surgical,Relative Weights,"$14,118.79 ",IP,"2,420.00","26,516.45",,,,,,
Health Alliance FI HMO/POS,DRG,MS-556,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,Medical/Surgical,Relative Weights,"$8,343.34 ",IP,"2,420.00","15,962.69",,,,,,
Health Alliance FI HMO/POS,DRG,MS-557,TENDONITIS -  MYOSITIS AND BURSITIS WITH MCC,Medical/Surgical,Relative Weights,"$14,434.49 ",IP,"2,420.00","29,397.31",,,,,,
Health Alliance FI HMO/POS,DRG,MS-558,TENDONITIS- MYOSITIS AND BURSITIS WITHOUT MCC,Medical/Surgical,Relative Weights,"$8,887.05 ",IP,"2,420.00","17,365.82",,,,,,
Health Alliance FI HMO/POS,DRG,MS-559,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Medical/Surgical,Relative Weights,"$19,244.26 ",IP,"2,420.00","36,324.29",,,,,,
Health Alliance FI HMO/POS,DRG,MS-560,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Medical/Surgical,Relative Weights,"$11,101.07 ",IP,"2,420.00","21,036.96",,,,,,
Health Alliance FI HMO/POS,DRG,MS-561,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$8,175.18 ",IP,"2,420.00","15,067.58",,,,,,
Health Alliance FI HMO/POS,DRG,MS-562,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITH MCC,Medical/Surgical,Relative Weights,"$14,565.51 ",IP,"2,420.00","27,157.54",,,,,,
Health Alliance FI HMO/POS,DRG,MS-563,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITHOUT MCC,Medical/Surgical,Relative Weights,"$8,998.47 ",IP,"2,420.00","17,216.64",,,,,,
Health Alliance FI HMO/POS,DRG,MS-564,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,Medical/Surgical,Relative Weights,"$15,718.95 ",IP,"2,420.00","30,481.92",,,,,,
Health Alliance FI HMO/POS,DRG,MS-565,OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W CC,Medical/Surgical,Relative Weights,"$10,412.93 ",IP,"2,420.00","19,766.88",,,,,,
Health Alliance FI HMO/POS,DRG,MS-566,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$7,757.34 ",IP,"2,420.00","15,275.23",,,,,,
Health Alliance FI HMO/POS,DRG,MS-570,SKIN DEBRIDEMENT WITH MCC,Medical/Surgical,Relative Weights,"$29,317.76 ",IP,"2,420.00","57,923.71",,,,,,
Health Alliance FI HMO/POS,DRG,MS-571,SKIN DEBRIDEMENT WITH CC,Medical/Surgical,Relative Weights,"$16,872.39 ",IP,"2,420.00","33,713.57",,,,,,
Health Alliance FI HMO/POS,DRG,MS-572,SKIN DEBRIDEMENT WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$11,394.07 ",IP,"2,420.00","22,613.47",,,,,,
Health Alliance FI HMO/POS,DRG,MS-573,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,Medical/Surgical,Relative Weights,"$57,146.78 ",IP,"2,420.00","107,156.45",,,,,,
Health Alliance FI HMO/POS,DRG,MS-574,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,Medical/Surgical,Relative Weights,"$33,494.08 ",IP,"2,420.00","62,935.49",,,,,,
Health Alliance FI HMO/POS,DRG,MS-575,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS W/O CC/MCC,Medical/Surgical,Relative Weights,"$18,190.90 ",IP,"2,420.00","35,421.12",,,,,,
Health Alliance FI HMO/POS,DRG,MS-576,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,Medical/Surgical,Relative Weights,"$52,242.09 ",IP,"2,420.00","97,759.87",,,,,,
Health Alliance FI HMO/POS,DRG,MS-577,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,Medical/Surgical,Relative Weights,"$26,304.17 ",IP,"2,420.00","48,698.50",,,,,,
Health Alliance FI HMO/POS,DRG,MS-578,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$16,457.65 ",IP,"2,420.00","32,808.38",,,,,,
Health Alliance FI HMO/POS,DRG,MS-579,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$32,445.87 ",IP,"2,420.00","60,199.78",,,,,,
Health Alliance FI HMO/POS,DRG,MS-580,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$17,836.00 ",IP,"2,420.00","32,431.39",,,,,,
Health Alliance FI HMO/POS,DRG,MS-581,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$14,204.42 ",IP,"2,420.00","25,296.77",,,,,,
Health Alliance FI HMO/POS,DRG,MS-582,MASTECTOMY FOR MALIGNANCY WITH CC/MCC,Medical/Surgical,Relative Weights,"$16,951.83 ",IP,"2,420.00","31,826.59",,,,,,
Health Alliance FI HMO/POS,DRG,MS-583,MASTECTOMY FOR MALIGNANCY W/O CC/MCC,Medical/Surgical,Relative Weights,"$15,903.62 ",IP,"2,420.00","29,461.82",,,,,,
Health Alliance FI HMO/POS,DRG,MS-584,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC,Medical/Surgical,Relative Weights,"$18,949.20 ",IP,"2,420.00","36,860.54",,,,,,
Health Alliance FI HMO/POS,DRG,MS-585,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$17,947.42 ",IP,"2,420.00","34,217.57",,,,,,
Health Alliance FI HMO/POS,DRG,MS-592,SKIN ULCERS WITH MCC,Medical/Surgical,Relative Weights,"$17,480.06 ",IP,"2,420.00","35,971.49",,,,,,
Health Alliance FI HMO/POS,DRG,MS-593,SKIN ULCERS WITH CC,Medical/Surgical,Relative Weights,"$11,767.55 ",IP,"2,420.00","23,139.65",,,,,,
Health Alliance FI HMO/POS,DRG,MS-594,SKIN ULCERS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$8,418.66 ",IP,"2,420.00","16,323.55",,,,,,
Health Alliance FI HMO/POS,DRG,MS-595,MAJOR SKIN DISORDERS WITH MCC,Medical/Surgical,Relative Weights,"$20,804.19 ",IP,"2,420.00","40,977.22",,,,,,
Health Alliance FI HMO/POS,DRG,MS-596,MAJOR SKIN DISORDERS W/O MCC,Medical/Surgical,Relative Weights,"$10,262.30 ",IP,"2,420.00","19,637.86",,,,,,
Health Alliance FI HMO/POS,DRG,MS-597,MALIGNANT BREAST DISORDERS W MCC,Medical/Surgical,Relative Weights,"$16,961.12 ",IP,"2,420.00","34,128.86",,,,,,
Health Alliance FI HMO/POS,DRG,MS-598,MALIGNANT BREAST DISORDERS WITH CC,Medical/Surgical,Relative Weights,"$11,481.77 ",IP,"2,420.00","21,946.18",,,,,,
Health Alliance FI HMO/POS,DRG,MS-599,MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$6,926.82 ",IP,"2,420.00","14,019.26",,,,,,
Health Alliance FI HMO/POS,DRG,MS-600,NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,Medical/Surgical,Relative Weights,"$10,285.00 ",IP,"2,420.00","19,337.47",,,,,,
Health Alliance FI HMO/POS,DRG,MS-601,NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$7,085.70 ",IP,"2,420.00","12,475.01",,,,,,
Health Alliance FI HMO/POS,DRG,MS-602,CELLULITIS WITH MCC,Medical/Surgical,Relative Weights,"$14,959.62 ",IP,"2,420.00","28,824.77",,,,,,
Health Alliance FI HMO/POS,DRG,MS-603,CELLULITIS WITHOUT MCC,Medical/Surgical,Relative Weights,"$8,806.57 ",IP,"2,420.00","17,004.96",,,,,,
Health Alliance FI HMO/POS,DRG,MS-604,TRAUMA TO THE SKIN -  SUBCUTANEOUS TISSUE AND BREAST WITH MCC,Medical/Surgical,Relative Weights,"$15,247.46 ",IP,"2,420.00","29,524.32",,,,,,
Health Alliance FI HMO/POS,DRG,MS-605,TRAUMA TO THE SKIN- SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC,Medical/Surgical,Relative Weights,"$9,325.52 ",IP,"2,420.00","17,654.11",,,,,,
Health Alliance FI HMO/POS,DRG,MS-606,MINOR SKIN DISORDERS WITH MCC,Medical/Surgical,Relative Weights,"$15,600.31 ",IP,"2,420.00","30,149.28",,,,,,
Health Alliance FI HMO/POS,DRG,MS-607,MINOR SKIN DISORDERS WITHOUT MCC,Medical/Surgical,Relative Weights,"$8,544.52 ",IP,"2,420.00","16,654.18",,,,,,
Health Alliance FI HMO/POS,DRG,MS-614,ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,Medical/Surgical,Relative Weights,"$24,654.49 ",IP,"2,420.00","49,055.33",,,,,,
Health Alliance FI HMO/POS,DRG,MS-615,ADRENAL & PITUITARY PROCEDURES W/O CC/MCC,Medical/Surgical,Relative Weights,"$16,249.24 ",IP,"2,420.00","29,919.46",,,,,,
Health Alliance FI HMO/POS,DRG,MS-616,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Medical/Surgical,Relative Weights,"$40,919.21 ",IP,"2,420.00","80,656.13",,,,,,
Health Alliance FI HMO/POS,DRG,MS-617,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Medical/Surgical,Relative Weights,"$20,941.41 ",IP,"2,420.00","41,354.21",,,,,,
Health Alliance FI HMO/POS,DRG,MS-618,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$13,445.09 ",IP,"2,420.00","25,290.72",,,,,,
Health Alliance FI HMO/POS,DRG,MS-619,O.R. PROCEDURES FOR OBESITY WITH MCC,Medical/Surgical,Relative Weights,"$31,587.50 ",IP,"2,420.00","62,062.56",,,,,,
Health Alliance FI HMO/POS,DRG,MS-620,O.R. PROCEDURES FOR OBESITY WITH CC,Medical/Surgical,Relative Weights,"$18,185.74 ",IP,"2,420.00","36,179.14",,,,,,
Health Alliance FI HMO/POS,DRG,MS-621,O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$16,477.25 ",IP,"2,420.00","31,691.52",,,,,,
Health Alliance FI HMO/POS,DRG,MS-622,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Medical/Surgical,Relative Weights,"$37,294.85 ",IP,"2,420.00","76,114.08",,,,,,
Health Alliance FI HMO/POS,DRG,MS-623,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE -  NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Medical/Surgical,Relative Weights,"$19,308.23 ",IP,"2,420.00","39,364.42",,,,,,
Health Alliance FI HMO/POS,DRG,MS-624,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$11,337.33 ",IP,"2,420.00","22,216.32",,,,,,
Health Alliance FI HMO/POS,DRG,MS-625,THYROID- PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$29,302.29 ",IP,"2,420.00","58,970.02",,,,,,
Health Alliance FI HMO/POS,DRG,MS-626,THYROID -  PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$17,052.94 ",IP,"2,420.00","33,925.25",,,,,,
Health Alliance FI HMO/POS,DRG,MS-627,THYROID -  PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$12,202.92 ",IP,"2,420.00","23,016.67",,,,,,
Health Alliance FI HMO/POS,DRG,MS-628,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$37,960.30 ",IP,"2,420.00","74,376.29",,,,,,
Health Alliance FI HMO/POS,DRG,MS-629,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$24,196.41 ",IP,"2,420.00","46,827.65",,,,,,
Health Alliance FI HMO/POS,DRG,MS-630,OTHER ENDOCRINE - NUTRIT & METAB O.R. PROC W/O CC/MCC,Medical/Surgical,Relative Weights,"$14,539.72 ",IP,"2,420.00","29,207.81",,,,,,
Health Alliance FI HMO/POS,DRG,MS-637,DIABETES WITH MCC,Medical/Surgical,Relative Weights,"$14,202.35 ",IP,"2,420.00","27,935.71",,,,,,
Health Alliance FI HMO/POS,DRG,MS-638,DIABETES WITH CC,Medical/Surgical,Relative Weights,"$9,072.75 ",IP,"2,420.00","17,823.46",,,,,,
Health Alliance FI HMO/POS,DRG,MS-639,DIABETES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$6,289.23 ",IP,"2,420.00","12,362.11",,,,,,
Health Alliance FI HMO/POS,DRG,MS-640,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITH MCC,Medical/Surgical,Relative Weights,"$12,698.14 ",IP,"2,420.00","24,478.27",,,,,,
Health Alliance FI HMO/POS,DRG,MS-641,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITHOUT MCC,Medical/Surgical,Relative Weights,"$7,781.07 ",IP,"2,420.00","15,253.06",,,,,,
Health Alliance FI HMO/POS,DRG,MS-642,INBORN AND OTHER DISORDERS OF METABOLISM,Medical/Surgical,Relative Weights,"$13,306.84 ",IP,"2,420.00","24,510.53",,,,,,
Health Alliance FI HMO/POS,DRG,MS-643,ENDOCRINE DISORDERS WITH MCC,Medical/Surgical,Relative Weights,"$17,205.63 ",IP,"2,420.00","32,770.08",,,,,,
Health Alliance FI HMO/POS,DRG,MS-644,ENDOCRINE DISORDERS WITH CC,Medical/Surgical,Relative Weights,"$10,521.26 ",IP,"2,420.00","20,726.50",,,,,,
Health Alliance FI HMO/POS,DRG,MS-645,ENDOCRINE DISORDERS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$7,929.63 ",IP,"2,420.00","15,426.43",,,,,,
Health Alliance FI HMO/POS,DRG,MS-650,KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,Medical/Surgical,Relative Weights,"$46,639.97 ",IP,"2,420.00","46,639.97",,,,,,
Health Alliance FI HMO/POS,DRG,MS-651,KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,Medical/Surgical,Relative Weights,"$38,156.32 ",IP,"2,420.00","38,156.32",,,,,,
Health Alliance FI HMO/POS,DRG,MS-652,KIDNEY TRANSPLANT,Medical/Surgical,Relative Weights,"$32,860.61 ",IP,"2,420.00","68,239.58",,,,,,
Health Alliance FI HMO/POS,DRG,MS-653,MAJOR BLADDER PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$56,322.46 ",IP,"2,420.00","111,615.84",,,,,,
Health Alliance FI HMO/POS,DRG,MS-654,MAJOR BLADDER PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$29,948.13 ",IP,"2,420.00","56,693.95",,,,,,
Health Alliance FI HMO/POS,DRG,MS-655,MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$21,462.41 ",IP,"2,420.00","41,577.98",,,,,,
Health Alliance FI HMO/POS,DRG,MS-656,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,Medical/Surgical,Relative Weights,"$33,891.28 ",IP,"2,420.00","65,733.70",,,,,,
Health Alliance FI HMO/POS,DRG,MS-657,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,Medical/Surgical,Relative Weights,"$19,960.26 ",IP,"2,420.00","38,993.47",,,,,,
Health Alliance FI HMO/POS,DRG,MS-658,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$16,279.16 ",IP,"2,420.00","31,649.18",,,,,,
Health Alliance FI HMO/POS,DRG,MS-659,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,Medical/Surgical,Relative Weights,"$27,509.20 ",IP,"2,420.00","54,024.77",,,,,,
Health Alliance FI HMO/POS,DRG,MS-660,KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC,Medical/Surgical,Relative Weights,"$14,888.43 ",IP,"2,420.00","28,641.31",,,,,,
Health Alliance FI HMO/POS,DRG,MS-661,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$10,974.17 ",IP,"2,420.00","21,976.42",,,,,,
Health Alliance FI HMO/POS,DRG,MS-662,MINOR BLADDER PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$30,304.07 ",IP,"2,420.00","63,800.35",,,,,,
Health Alliance FI HMO/POS,DRG,MS-663,MINOR BLADDER PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$16,502.01 ",IP,"2,420.00","30,711.74",,,,,,
Health Alliance FI HMO/POS,DRG,MS-664,MINOR BLADDER PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$12,213.24 ",IP,"2,420.00","22,309.06",,,,,,
Health Alliance FI HMO/POS,DRG,MS-665,PROSTATECTOMY WITH MCC,Medical/Surgical,Relative Weights,"$31,381.16 ",IP,"2,420.00","59,844.96",,,,,,
Health Alliance FI HMO/POS,DRG,MS-666,PROSTATECTOMY WITH CC,Medical/Surgical,Relative Weights,"$17,948.45 ",IP,"2,420.00","35,665.06",,,,,,
Health Alliance FI HMO/POS,DRG,MS-667,PROSTATECTOMY W/O CC/MCC,Medical/Surgical,Relative Weights,"$10,291.19 ",IP,"2,420.00","18,924.19",,,,,,
Health Alliance FI HMO/POS,DRG,MS-668,TRANSURETHRAL PROCEDURES W MCC,Medical/Surgical,Relative Weights,"$28,952.54 ",IP,"2,420.00","56,212.13",,,,,,
Health Alliance FI HMO/POS,DRG,MS-669,TRANSURETHRAL PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$16,130.60 ",IP,"2,420.00","31,161.31",,,,,,
Health Alliance FI HMO/POS,DRG,MS-670,TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$10,095.16 ",IP,"2,420.00","19,730.59",,,,,,
Health Alliance FI HMO/POS,DRG,MS-671,URETHRAL PROCEDURES WITH CC/MCC,Medical/Surgical,Relative Weights,"$18,377.64 ",IP,"2,420.00","36,844.42",,,,,,
Health Alliance FI HMO/POS,DRG,MS-672,URETHRAL PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$11,868.65 ",IP,"2,420.00","20,829.31",,,,,,
Health Alliance FI HMO/POS,DRG,MS-673,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$35,782.38 ",IP,"2,420.00","72,063.94",,,,,,
Health Alliance FI HMO/POS,DRG,MS-674,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$24,587.43 ",IP,"2,420.00","49,275.07",,,,,,
Health Alliance FI HMO/POS,DRG,MS-675,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$18,103.20 ",IP,"2,420.00","32,901.12",,,,,,
Health Alliance FI HMO/POS,DRG,MS-682,RENAL FAILURE WITH MCC,Medical/Surgical,Relative Weights,"$15,193.82 ",IP,"2,420.00","29,796.48",,,,,,
Health Alliance FI HMO/POS,DRG,MS-683,RENAL FAILURE WITH CC,Medical/Surgical,Relative Weights,"$9,071.72 ",IP,"2,420.00","18,089.57",,,,,,
Health Alliance FI HMO/POS,DRG,MS-684,RENAL FAILURE WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$6,271.69 ",IP,"2,420.00","12,404.45",,,,,,
Health Alliance FI HMO/POS,DRG,MS-686,KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,Medical/Surgical,Relative Weights,"$19,347.43 ",IP,"2,420.00","35,402.98",,,,,,
Health Alliance FI HMO/POS,DRG,MS-687,KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,Medical/Surgical,Relative Weights,"$10,833.86 ",IP,"2,420.00","21,220.42",,,,,,
Health Alliance FI HMO/POS,DRG,MS-688,KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$7,075.38 ",IP,"2,420.00","15,549.41",,,,,,
Health Alliance FI HMO/POS,DRG,MS-689,KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,Medical/Surgical,Relative Weights,"$11,495.18 ",IP,"2,420.00","22,550.98",,,,,,
Health Alliance FI HMO/POS,DRG,MS-690,KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,Medical/Surgical,Relative Weights,"$8,191.68 ",IP,"2,420.00","15,942.53",,,,,,
Health Alliance FI HMO/POS,DRG,MS-693,URINARY STONES WITH MCC,Medical/Surgical,Relative Weights,"$13,778.33 ",IP,"2,420.00","27,282.53",,,,,,
Health Alliance FI HMO/POS,DRG,MS-694,URINARY STONES WITHOUT MCC,Medical/Surgical,Relative Weights,"$7,956.46 ",IP,"2,420.00","14,926.46",,,,,,
Health Alliance FI HMO/POS,DRG,MS-695,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,Medical/Surgical,Relative Weights,"$11,737.63 ",IP,"2,420.00","23,633.57",,,,,,
Health Alliance FI HMO/POS,DRG,MS-696,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,Medical/Surgical,Relative Weights,"$7,138.32 ",IP,"2,420.00","13,696.70",,,,,,
Health Alliance FI HMO/POS,DRG,MS-697,URETHRAL STRICTURE,Medical/Surgical,Relative Weights,"$10,309.76 ",IP,"2,420.00","19,633.82",,,,,,
Health Alliance FI HMO/POS,DRG,MS-698,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,Medical/Surgical,Relative Weights,"$16,616.53 ",IP,"2,420.00","32,630.98",,,,,,
Health Alliance FI HMO/POS,DRG,MS-699,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,Medical/Surgical,Relative Weights,"$10,595.54 ",IP,"2,420.00","20,819.23",,,,,,
Health Alliance FI HMO/POS,DRG,MS-700,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$7,701.63 ",IP,"2,420.00","14,952.67",,,,,,
Health Alliance FI HMO/POS,DRG,MS-707,MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,Medical/Surgical,Relative Weights,"$19,831.30 ",IP,"2,420.00","37,697.18",,,,,,
Health Alliance FI HMO/POS,DRG,MS-708,MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$15,384.68 ",IP,"2,420.00","29,272.32",,,,,,
Health Alliance FI HMO/POS,DRG,MS-709,PENIS PROCEDURES W CC/MCC,Medical/Surgical,Relative Weights,"$23,893.09 ",IP,"2,420.00","48,496.90",,,,,,
Health Alliance FI HMO/POS,DRG,MS-710,PENIS PROCEDURES W/O CC/MCC,Medical/Surgical,Relative Weights,"$16,523.68 ",IP,"2,420.00","30,961.73",,,,,,
Health Alliance FI HMO/POS,DRG,MS-711,TESTES PROCEDURES WITH CC/MCC,Medical/Surgical,Relative Weights,"$21,991.67 ",IP,"2,420.00","43,206.91",,,,,,
Health Alliance FI HMO/POS,DRG,MS-712,TESTES PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$10,936.00 ",IP,"2,420.00","20,567.23",,,,,,
Health Alliance FI HMO/POS,DRG,MS-713,TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,Medical/Surgical,Relative Weights,"$15,407.38 ",IP,"2,420.00","29,473.92",,,,,,
Health Alliance FI HMO/POS,DRG,MS-714,TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$9,582.41 ",IP,"2,420.00","18,454.46",,,,,,
Health Alliance FI HMO/POS,DRG,MS-715,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,Medical/Surgical,Relative Weights,"$20,856.81 ",IP,"2,420.00","43,071.84",,,,,,
Health Alliance FI HMO/POS,DRG,MS-716,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$13,162.40 ",IP,"2,420.00","29,544.48",,,,,,
Health Alliance FI HMO/POS,DRG,MS-717,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,Medical/Surgical,Relative Weights,"$18,576.75 ",IP,"2,420.00","35,568.29",,,,,,
Health Alliance FI HMO/POS,DRG,MS-718,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$12,737.34 ",IP,"2,420.00","24,583.10",,,,,,
Health Alliance FI HMO/POS,DRG,MS-722,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH MCC,Medical/Surgical,Relative Weights,"$17,668.86 ",IP,"2,420.00","36,386.78",,,,,,
Health Alliance FI HMO/POS,DRG,MS-723,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH CC,Medical/Surgical,Relative Weights,"$11,265.11 ",IP,"2,420.00","22,325.18",,,,,,
Health Alliance FI HMO/POS,DRG,MS-724,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$6,686.43 ",IP,"2,420.00","11,902.46",,,,,,
Health Alliance FI HMO/POS,DRG,MS-725,BENIGN PROSTATIC HYPERTROPHY WITH MCC,Medical/Surgical,Relative Weights,"$13,262.48 ",IP,"2,420.00","25,308.86",,,,,,
Health Alliance FI HMO/POS,DRG,MS-726,BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,Medical/Surgical,Relative Weights,"$7,683.06 ",IP,"2,420.00","15,416.35",,,,,,
Health Alliance FI HMO/POS,DRG,MS-727,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,Medical/Surgical,Relative Weights,"$14,660.43 ",IP,"2,420.00","28,774.37",,,,,,
Health Alliance FI HMO/POS,DRG,MS-728,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,Medical/Surgical,Relative Weights,"$8,312.39 ",IP,"2,420.00","16,178.40",,,,,,
Health Alliance FI HMO/POS,DRG,MS-729,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,Medical/Surgical,Relative Weights,"$10,394.36 ",IP,"2,420.00","21,649.82",,,,,,
Health Alliance FI HMO/POS,DRG,MS-730,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$5,869.33 ",IP,"2,420.00","12,733.06",,,,,,
Health Alliance FI HMO/POS,DRG,MS-734,PELVIC EVISCERATION -  RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC,Medical/Surgical,Relative Weights,"$22,948.06 ",IP,"2,420.00","44,188.70",,,,,,
Health Alliance FI HMO/POS,DRG,MS-735,PELVIC EVISCERATION -  RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$14,584.08 ",IP,"2,420.00","27,703.87",,,,,,
Health Alliance FI HMO/POS,DRG,MS-736,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,Medical/Surgical,Relative Weights,"$43,957.56 ",IP,"2,420.00","87,109.34",,,,,,
Health Alliance FI HMO/POS,DRG,MS-737,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,Medical/Surgical,Relative Weights,"$21,233.38 ",IP,"2,420.00","40,059.94",,,,,,
Health Alliance FI HMO/POS,DRG,MS-738,UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY W/O CC/MCC,Medical/Surgical,Relative Weights,"$15,226.83 ",IP,"2,420.00","27,798.62",,,,,,
Health Alliance FI HMO/POS,DRG,MS-739,UTERINE -ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W MCC,Medical/Surgical,Relative Weights,"$39,452.13 ",IP,"2,420.00","75,489.12",,,,,,
Health Alliance FI HMO/POS,DRG,MS-740,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,Medical/Surgical,Relative Weights,"$18,587.07 ",IP,"2,420.00","35,983.58",,,,,,
Health Alliance FI HMO/POS,DRG,MS-741,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$13,204.70 ",IP,"2,420.00","26,802.72",,,,,,
Health Alliance FI HMO/POS,DRG,MS-742,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,Medical/Surgical,Relative Weights,"$17,725.60 ",IP,"2,420.00","34,060.32",,,,,,
Health Alliance FI HMO/POS,DRG,MS-743,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$11,687.07 ",IP,"2,420.00","23,153.76",,,,,,
Health Alliance FI HMO/POS,DRG,MS-744,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC,Medical/Surgical,Relative Weights,"$18,523.11 ",IP,"2,420.00","35,088.48",,,,,,
Health Alliance FI HMO/POS,DRG,MS-745,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$12,070.87 ",IP,"2,420.00","21,476.45",,,,,,
Health Alliance FI HMO/POS,DRG,MS-746,VAGINA -  CERVIX AND VULVA PROCEDURES WITH CC/MCC,Medical/Surgical,Relative Weights,"$16,625.81 ",IP,"2,420.00","32,880.96",,,,,,
Health Alliance FI HMO/POS,DRG,MS-747,VAGINA- CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$9,688.68 ",IP,"2,420.00","18,793.15",,,,,,
Health Alliance FI HMO/POS,DRG,MS-748,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,Medical/Surgical,Relative Weights,"$13,903.16 ",IP,"2,420.00","26,645.47",,,,,,
Health Alliance FI HMO/POS,DRG,MS-749,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,Medical/Surgical,Relative Weights,"$27,998.22 ",IP,"2,420.00","52,258.75",,,,,,
Health Alliance FI HMO/POS,DRG,MS-750,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$15,102.00 ",IP,"2,420.00","26,836.99",,,,,,
Health Alliance FI HMO/POS,DRG,MS-754,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH MCC,Medical/Surgical,Relative Weights,"$18,840.87 ",IP,"2,420.00","35,519.90",,,,,,
Health Alliance FI HMO/POS,DRG,MS-755,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH CC,Medical/Surgical,Relative Weights,"$11,650.97 ",IP,"2,420.00","20,639.81",,,,,,
Health Alliance FI HMO/POS,DRG,MS-756,MALIGNANCY - FEMALE REPRODUCTIVE SYSTEM W/O CC/MCC,Medical/Surgical,Relative Weights,"$9,475.11 ",IP,"2,420.00","17,676.29",,,,,,
Health Alliance FI HMO/POS,DRG,MS-757,INFECTIONS - FEMALE REPRODUCTIVE SYSTEM W MCC,Medical/Surgical,Relative Weights,"$15,730.30 ",IP,"2,420.00","28,633.25",,,,,,
Health Alliance FI HMO/POS,DRG,MS-758,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITH CC,Medical/Surgical,Relative Weights,"$10,004.38 ",IP,"2,420.00","19,462.46",,,,,,
Health Alliance FI HMO/POS,DRG,MS-759,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$7,050.62 ",IP,"2,420.00","13,311.65",,,,,,
Health Alliance FI HMO/POS,DRG,MS-760,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,Medical/Surgical,Relative Weights,"$9,492.65 ",IP,"2,420.00","18,194.40",,,,,,
Health Alliance FI HMO/POS,DRG,MS-761,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$6,095.27 ",IP,"2,420.00","11,398.46",,,,,,
Health Alliance FI HMO/POS,DRG,MS-768,VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C,Medical/Surgical,Relative Weights,"$12,066.74 ",IP,"2,420.00","20,311.20",,,,,,
Health Alliance FI HMO/POS,DRG,MS-769,POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,Medical/Surgical,Relative Weights,"$16,688.75 ",IP,"2,420.00","29,090.88",,,,,,
Health Alliance FI HMO/POS,DRG,MS-770,ABORTION WITH D&C- ASPIRATION CURETTAGE OR HYSTEROTOMY,Medical/Surgical,Relative Weights,"$9,180.05 ",IP,"2,420.00","15,851.81",,,,,,
Health Alliance FI HMO/POS,DRG,MS-776,POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,Medical/Surgical,Relative Weights,"$7,990.50 ",IP,"2,420.00","14,311.58",,,,,,
Health Alliance FI HMO/POS,DRG,MS-779,ABORTION WITHOUT D&C,Medical/Surgical,Relative Weights,"$10,925.68 ",IP,"2,420.00","23,018.69",,,,,,
Health Alliance FI HMO/POS,DRG,MS-783,CESAREAN SECTION WITH STERILIZATION WITH MCC,Medical/Surgical,Relative Weights,"$19,343.31 ",IP,"2,420.00","43,239.17",,,,,,
Health Alliance FI HMO/POS,DRG,MS-784,CESAREAN SECTION WITH STERILIZATION WITH CC,Medical/Surgical,Relative Weights,"$11,306.38 ",IP,"2,420.00","21,071.23",,,,,,
Health Alliance FI HMO/POS,DRG,MS-785,CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$9,458.61 ",IP,"2,420.00","17,305.34",,,,,,
Health Alliance FI HMO/POS,DRG,MS-786,CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,Medical/Surgical,Relative Weights,"$16,449.39 ",IP,"2,420.00","34,564.32",,,,,,
Health Alliance FI HMO/POS,DRG,MS-787,CESAREAN SECTION WITHOUT STERILIZATION WITH CC,Medical/Surgical,Relative Weights,"$10,981.39 ",IP,"2,420.00","21,077.28",,,,,,
Health Alliance FI HMO/POS,DRG,MS-788,CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$9,155.29 ",IP,"2,420.00","18,268.99",,,,,,
Health Alliance FI HMO/POS,DRG,MS-789,NEONATES- DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY,Medical/Surgical,Relative Weights,"$17,745.21 ",IP,"2,420.00","34,070.40",,,,,,
Health Alliance FI HMO/POS,DRG,MS-790,EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME- NEONATE,Medical/Surgical,Relative Weights,"$58,518.94 ",IP,"2,420.00","112,351.68",,,,,,
Health Alliance FI HMO/POS,DRG,MS-791,PREMATURITY W MAJOR PROBLEMS,Medical/Surgical,Relative Weights,"$39,965.92 ",IP,"2,420.00","76,732.99",,,,,,
Health Alliance FI HMO/POS,DRG,MS-792,PREMATURITY W/O MAJOR PROBLEMS,Medical/Surgical,Relative Weights,"$24,114.91 ",IP,"2,420.00","46,297.44",,,,,,
Health Alliance FI HMO/POS,DRG,MS-793,FULL TERM NEONATE WITH MAJOR PROBLEMS,Medical/Surgical,Relative Weights,"$41,053.33 ",IP,"2,420.00","78,819.55",,,,,,
Health Alliance FI HMO/POS,DRG,MS-794,NEONATE WITH OTHER SIGNIFICANT PROBLEMS,Medical/Surgical,Relative Weights,"$14,530.43 ",IP,"2,420.00","27,897.41",,,,,,
Health Alliance FI HMO/POS,DRG,MS-795,NORMAL NEWBORN,Medical/Surgical,Relative Weights,"$1,967.45 ",IP,"1,113.70","3,775.97",,,,,,
Health Alliance FI HMO/POS,DRG,MS-796,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,Medical/Surgical,Relative Weights,"$11,047.42 ",IP,"2,420.00","39,761.57",,,,,,
Health Alliance FI HMO/POS,DRG,MS-797,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,Medical/Surgical,Relative Weights,"$9,485.43 ",IP,"2,420.00","17,394.05",,,,,,
Health Alliance FI HMO/POS,DRG,MS-798,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$8,537.30 ",IP,"2,420.00","17,394.05",,,,,,
Health Alliance FI HMO/POS,DRG,MS-799,SPLENECTOMY WITH MCC,Medical/Surgical,Relative Weights,"$53,105.62 ",IP,"2,420.00","99,677.09",,,,,,
Health Alliance FI HMO/POS,DRG,MS-800,SPLENECTOMY WITH CC,Medical/Surgical,Relative Weights,"$30,475.33 ",IP,"2,420.00","57,294.72",,,,,,
Health Alliance FI HMO/POS,DRG,MS-801,SPLENECTOMY WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$17,373.79 ",IP,"2,420.00","37,763.71",,,,,,
Health Alliance FI HMO/POS,DRG,MS-802,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,Medical/Surgical,Relative Weights,"$38,293.53 ",IP,"2,420.00","63,552.38",,,,,,
Health Alliance FI HMO/POS,DRG,MS-803,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,Medical/Surgical,Relative Weights,"$19,462.98 ",IP,"2,420.00","35,917.06",,,,,,
Health Alliance FI HMO/POS,DRG,MS-804,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$14,091.96 ",IP,"2,420.00","27,470.02",,,,,,
Health Alliance FI HMO/POS,DRG,MS-805,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,Medical/Surgical,Relative Weights,"$10,625.46 ",IP,"2,420.00","20,980.51",,,,,,
Health Alliance FI HMO/POS,DRG,MS-806,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,Medical/Surgical,Relative Weights,"$7,578.85 ",IP,"2,420.00","14,297.47",,,,,,
Health Alliance FI HMO/POS,DRG,MS-807,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$6,626.60 ",IP,"2,420.00","12,636.29",,,,,,
Health Alliance FI HMO/POS,DRG,MS-808,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,Medical/Surgical,Relative Weights,"$22,550.85 ",IP,"2,420.00","42,932.74",,,,,,
Health Alliance FI HMO/POS,DRG,MS-809,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,Medical/Surgical,Relative Weights,"$12,621.79 ",IP,"2,420.00","24,512.54",,,,,,
Health Alliance FI HMO/POS,DRG,MS-810,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$9,921.84 ",IP,"2,420.00","18,857.66",,,,,,
Health Alliance FI HMO/POS,DRG,MS-811,RED BLOOD CELL DISORDERS WITH MCC,Medical/Surgical,Relative Weights,"$14,230.21 ",IP,"2,420.00","27,020.45",,,,,,
Health Alliance FI HMO/POS,DRG,MS-812,RED BLOOD CELL DISORDERS WITHOUT MCC,Medical/Surgical,Relative Weights,"$9,082.04 ",IP,"2,420.00","17,553.31",,,,,,
Health Alliance FI HMO/POS,DRG,MS-813,COAGULATION DISORDERS,Medical/Surgical,Relative Weights,"$15,940.77 ",IP,"2,420.00","31,957.63",,,,,,
Health Alliance FI HMO/POS,DRG,MS-814,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,Medical/Surgical,Relative Weights,"$19,516.63 ",IP,"2,420.00","35,261.86",,,,,,
Health Alliance FI HMO/POS,DRG,MS-815,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,Medical/Surgical,Relative Weights,"$10,248.89 ",IP,"2,420.00","20,418.05",,,,,,
Health Alliance FI HMO/POS,DRG,MS-816,RETICULOENDOTHELIAL & IMMUNITY DISORDERS W/O CC/MCC,Medical/Surgical,Relative Weights,"$6,820.56 ",IP,"2,420.00","14,432.54",,,,,,
Health Alliance FI HMO/POS,DRG,MS-817,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$23,799.21 ",IP,"2,420.00","50,726.59",,,,,,
Health Alliance FI HMO/POS,DRG,MS-818,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$14,029.03 ",IP,"2,420.00","25,681.82",,,,,,
Health Alliance FI HMO/POS,DRG,MS-819,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$10,184.92 ",IP,"2,420.00","16,085.66",,,,,,
Health Alliance FI HMO/POS,DRG,MS-820,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$58,721.16 ",IP,"2,420.00","115,248.67",,,,,,
Health Alliance FI HMO/POS,DRG,MS-821,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$22,235.16 ",IP,"2,420.00","45,003.17",,,,,,
Health Alliance FI HMO/POS,DRG,MS-822,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$12,911.70 ",IP,"2,420.00","25,490.30",,,,,,
Health Alliance FI HMO/POS,DRG,MS-823,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$46,444.98 ",IP,"2,420.00","85,280.83",,,,,,
Health Alliance FI HMO/POS,DRG,MS-824,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$24,393.47 ",IP,"2,420.00","46,874.02",,,,,,
Health Alliance FI HMO/POS,DRG,MS-825,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$14,459.25 ",IP,"2,420.00","27,306.72",,,,,,
Health Alliance FI HMO/POS,DRG,MS-826,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$52,044.01 ",IP,"2,420.00","101,102.40",,,,,,
Health Alliance FI HMO/POS,DRG,MS-827,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$25,798.64 ",IP,"2,420.00","46,694.59",,,,,,
Health Alliance FI HMO/POS,DRG,MS-828,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$17,270.62 ",IP,"2,420.00","33,288.19",,,,,,
Health Alliance FI HMO/POS,DRG,MS-829,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,Medical/Surgical,Relative Weights,"$33,101.00 ",IP,"2,420.00","63,300.38",,,,,,
Health Alliance FI HMO/POS,DRG,MS-830,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$15,289.76 ",IP,"2,420.00","27,796.61",,,,,,
Health Alliance FI HMO/POS,DRG,MS-831,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$11,573.59 ",IP,"2,420.00","21,742.56",,,,,,
Health Alliance FI HMO/POS,DRG,MS-832,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$8,029.71 ",IP,"2,420.00","14,424.48",,,,,,
Health Alliance FI HMO/POS,DRG,MS-833,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$5,540.22 ",IP,"2,420.00","10,727.14",,,,,,
Health Alliance FI HMO/POS,DRG,MS-834,ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W MCC,Medical/Surgical,Relative Weights,"$62,440.43 ",IP,"2,420.00","117,784.80",,,,,,
Health Alliance FI HMO/POS,DRG,MS-835,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$21,807.00 ",IP,"2,420.00","40,888.51",,,,,,
Health Alliance FI HMO/POS,DRG,MS-836,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$12,106.98 ",IP,"2,420.00","26,562.82",,,,,,
Health Alliance FI HMO/POS,DRG,MS-837,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,Medical/Surgical,Relative Weights,"$58,799.56 ",IP,"2,420.00","120,774.53",,,,,,
Health Alliance FI HMO/POS,DRG,MS-838,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,Medical/Surgical,Relative Weights,"$23,318.44 ",IP,"2,420.00","44,108.06",,,,,,
Health Alliance FI HMO/POS,DRG,MS-839,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$15,343.41 ",IP,"2,420.00","25,728.19",,,,,,
Health Alliance FI HMO/POS,DRG,MS-840,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,Medical/Surgical,Relative Weights,"$33,225.83 ",IP,"2,420.00","64,415.23",,,,,,
Health Alliance FI HMO/POS,DRG,MS-841,LYMPHOMA & NON-ACUTE LEUKEMIA W CC,Medical/Surgical,Relative Weights,"$16,730.01 ",IP,"2,420.00","32,491.87",,,,,,
Health Alliance FI HMO/POS,DRG,MS-842,LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$11,317.73 ",IP,"2,420.00","23,115.46",,,,,,
Health Alliance FI HMO/POS,DRG,MS-843,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,Medical/Surgical,Relative Weights,"$19,680.67 ",IP,"2,420.00","38,461.25",,,,,,
Health Alliance FI HMO/POS,DRG,MS-844,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,Medical/Surgical,Relative Weights,"$12,217.37 ",IP,"2,420.00","24,353.28",,,,,,
Health Alliance FI HMO/POS,DRG,MS-845,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$8,758.08 ",IP,"2,420.00","17,456.54",,,,,,
Health Alliance FI HMO/POS,DRG,MS-846,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,Medical/Surgical,Relative Weights,"$27,576.26 ",IP,"2,420.00","52,952.26",,,,,,
Health Alliance FI HMO/POS,DRG,MS-847,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,Medical/Surgical,Relative Weights,"$13,784.52 ",IP,"2,420.00","26,528.54",,,,,,
Health Alliance FI HMO/POS,DRG,MS-848,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$10,650.22 ",IP,"2,420.00","19,785.02",,,,,,
Health Alliance FI HMO/POS,DRG,MS-849,RADIOTHERAPY,Medical/Surgical,Relative Weights,"$25,726.42 ",IP,"2,420.00","42,856.13",,,,,,
Health Alliance FI HMO/POS,DRG,MS-853,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$51,252.69 ",IP,"2,420.00","102,787.78",,,,,,
Health Alliance FI HMO/POS,DRG,MS-854,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$21,894.70 ",IP,"2,420.00","43,569.79",,,,,,
Health Alliance FI HMO/POS,DRG,MS-855,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$15,679.75 ",IP,"2,420.00","32,322.53",,,,,,
Health Alliance FI HMO/POS,DRG,MS-856,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$48,117.36 ",IP,"2,420.00","89,222.11",,,,,,
Health Alliance FI HMO/POS,DRG,MS-857,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$21,690.42 ",IP,"2,420.00","40,991.33",,,,,,
Health Alliance FI HMO/POS,DRG,MS-858,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$14,026.97 ",IP,"2,420.00","27,748.22",,,,,,
Health Alliance FI HMO/POS,DRG,MS-862,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W MCC,Medical/Surgical,Relative Weights,"$19,568.22 ",IP,"2,420.00","37,308.10",,,,,,
Health Alliance FI HMO/POS,DRG,MS-863,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W/O MCC,Medical/Surgical,Relative Weights,"$10,434.59 ",IP,"2,420.00","19,918.08",,,,,,
Health Alliance FI HMO/POS,DRG,MS-864,FEVER AND INFLAMMATORY CONDITIONS,Medical/Surgical,Relative Weights,"$9,042.83 ",IP,"2,420.00","17,083.58",,,,,,
Health Alliance FI HMO/POS,DRG,MS-865,VIRAL ILLNESS WITH MCC,Medical/Surgical,Relative Weights,"$15,246.43 ",IP,"2,420.00","28,088.93",,,,,,
Health Alliance FI HMO/POS,DRG,MS-866,VIRAL ILLNESS WITHOUT MCC,Medical/Surgical,Relative Weights,"$8,655.95 ",IP,"2,420.00","16,504.99",,,,,,
Health Alliance FI HMO/POS,DRG,MS-867,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,Medical/Surgical,Relative Weights,"$23,080.12 ",IP,"2,420.00","44,053.63",,,,,,
Health Alliance FI HMO/POS,DRG,MS-868,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,Medical/Surgical,Relative Weights,"$10,997.90 ",IP,"2,420.00","22,115.52",,,,,,
Health Alliance FI HMO/POS,DRG,MS-869,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$7,515.92 ",IP,"2,420.00","14,968.80",,,,,,
Health Alliance FI HMO/POS,DRG,MS-870,SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,Medical/Surgical,Relative Weights,"$66,431.03 ",IP,"2,420.00","127,497.89",,,,,,
Health Alliance FI HMO/POS,DRG,MS-871,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,Medical/Surgical,Relative Weights,"$19,315.45 ",IP,"2,420.00","37,624.61",,,,,,
Health Alliance FI HMO/POS,DRG,MS-872,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,Medical/Surgical,Relative Weights,"$10,588.32 ",IP,"2,420.00","20,952.29",,,,,,
Health Alliance FI HMO/POS,DRG,MS-876,O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,Medical/Surgical,Relative Weights,"$33,715.89 ",IP,"2,420.00","73,382.40",,,,,,
Health Alliance FI HMO/POS,DRG,MS-880,ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,Mental Health,Per Diem,$886.74 ,IP,886.74,"17,275.10",,,,,,
Health Alliance FI HMO/POS,DRG,MS-881,DEPRESSIVE NEUROSES,Mental Health,Per Diem,$886.74 ,IP,886.74,"16,517.09",,,,,,
Health Alliance FI HMO/POS,DRG,MS-882,NEUROSES EXCEPT DEPRESSIVE,Mental Health,Per Diem,$886.74 ,IP,886.74,"15,922.37",,,,,,
Health Alliance FI HMO/POS,DRG,MS-883,DISORDERS OF PERSONALITY & IMPULSE CONTROL,Mental Health,Per Diem,$886.74 ,IP,886.74,"26,945.86",,,,,,
Health Alliance FI HMO/POS,DRG,MS-884,ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,Medical/Surgical,Relative Weights,"$14,931.77 ",IP,"2,420.00","28,990.08",,,,,,
Health Alliance FI HMO/POS,DRG,MS-885,PSYCHOSES,Mental Health,Per Diem,$886.74 ,IP,886.74,"24,502.46",,,,,,
Health Alliance FI HMO/POS,DRG,MS-886,BEHAVIORAL AND DEVELOPMENTAL DISORDERS,Mental Health,Per Diem,$886.74 ,IP,886.74,"27,127.30",,,,,,
Health Alliance FI HMO/POS,DRG,MS-887,OTHER MENTAL DISORDER DIAGNOSES,Mental Health,Per Diem,$886.74 ,IP,886.74,"21,936.10",,,,,,
Health Alliance FI HMO/POS,DRG,MS-894,ALCOHOL- DRUG ABUSE OR DEPENDENCE- LEFT AMA,Substance Abuse,Per Diem,$696.72 ,IP,696.72,"11,700.86",,,,,,
Health Alliance FI HMO/POS,DRG,MS-895,ALCOHOL- DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY,Substance Abuse,Per Diem,$696.72 ,IP,696.72,"32,798.30",,,,,,
Health Alliance FI HMO/POS,DRG,MS-896,ALCOHOL -  DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC,Substance Abuse,Per Diem,$696.72 ,IP,696.72,"34,669.15",,,,,,
Health Alliance FI HMO/POS,DRG,MS-897,ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC,Substance Abuse,Per Diem,$696.72 ,IP,696.72,"16,567.49",,,,,,
Health Alliance FI HMO/POS,DRG,MS-901,WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,Medical/Surgical,Relative Weights,"$44,040.09 ",IP,"2,420.00","87,236.35",,,,,,
Health Alliance FI HMO/POS,DRG,MS-902,WOUND DEBRIDEMENTS FOR INJURIES WITH CC,Medical/Surgical,Relative Weights,"$20,265.64 ",IP,"2,420.00","39,652.70",,,,,,
Health Alliance FI HMO/POS,DRG,MS-903,WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$11,712.87 ",IP,"2,420.00","23,063.04",,,,,,
Health Alliance FI HMO/POS,DRG,MS-904,SKIN GRAFTS FOR INJURIES WITH CC/MCC,Medical/Surgical,Relative Weights,"$38,451.38 ",IP,"2,420.00","71,313.98",,,,,,
Health Alliance FI HMO/POS,DRG,MS-905,SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$17,023.02 ",IP,"2,420.00","33,554.30",,,,,,
Health Alliance FI HMO/POS,DRG,MS-906,HAND PROCEDURES FOR INJURIES,Medical/Surgical,Relative Weights,"$18,609.77 ",IP,"2,420.00","35,096.54",,,,,,
Health Alliance FI HMO/POS,DRG,MS-907,OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,Medical/Surgical,Relative Weights,"$40,733.50 ",IP,"2,420.00","80,430.34",,,,,,
Health Alliance FI HMO/POS,DRG,MS-908,OTHER O.R. PROCEDURES FOR INJURIES WITH CC,Medical/Surgical,Relative Weights,"$21,153.94 ",IP,"2,420.00","41,592.10",,,,,,
Health Alliance FI HMO/POS,DRG,MS-909,OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$14,144.58 ",IP,"2,420.00","26,584.99",,,,,,
Health Alliance FI HMO/POS,DRG,MS-913,TRAUMATIC INJURY WITH MCC,Medical/Surgical,Relative Weights,"$16,905.40 ",IP,"2,420.00","29,762.21",,,,,,
Health Alliance FI HMO/POS,DRG,MS-914,TRAUMATIC INJURY WITHOUT MCC,Medical/Surgical,Relative Weights,"$9,150.13 ",IP,"2,420.00","17,371.87",,,,,,
Health Alliance FI HMO/POS,DRG,MS-915,ALLERGIC REACTIONS WITH MCC,Medical/Surgical,Relative Weights,"$17,533.71 ",IP,"2,420.00","34,253.86",,,,,,
Health Alliance FI HMO/POS,DRG,MS-916,ALLERGIC REACTIONS WITHOUT MCC,Medical/Surgical,Relative Weights,"$6,792.70 ",IP,"2,420.00","12,765.31",,,,,,
Health Alliance FI HMO/POS,DRG,MS-917,POISONING & TOXIC EFFECTS OF DRUGS W MCC,Medical/Surgical,Relative Weights,"$15,253.65 ",IP,"2,420.00","29,498.11",,,,,,
Health Alliance FI HMO/POS,DRG,MS-918,POISONING & TOXIC EFFECTS OF DRUGS W/O MCC,Medical/Surgical,Relative Weights,"$8,166.92 ",IP,"2,420.00","15,805.44",,,,,,
Health Alliance FI HMO/POS,DRG,MS-919,COMPLICATIONS OF TREATMENT WITH MCC,Medical/Surgical,Relative Weights,"$19,025.54 ",IP,"2,420.00","36,798.05",,,,,,
Health Alliance FI HMO/POS,DRG,MS-920,COMPLICATIONS OF TREATMENT WITH CC,Medical/Surgical,Relative Weights,"$10,570.78 ",IP,"2,420.00","20,311.20",,,,,,
Health Alliance FI HMO/POS,DRG,MS-921,COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$7,200.22 ",IP,"2,420.00","13,922.50",,,,,,
Health Alliance FI HMO/POS,DRG,MS-922,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC,Medical/Surgical,Relative Weights,"$16,385.43 ",IP,"2,420.00","32,328.58",,,,,,
Health Alliance FI HMO/POS,DRG,MS-923,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC,Medical/Surgical,Relative Weights,"$9,695.90 ",IP,"2,420.00","17,448.48",,,,,,
Health Alliance FI HMO/POS,DRG,MS-927,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,Medical/Surgical,Relative Weights,"$217,598.52 ",IP,"2,420.00","402,060.96",,,,,,
Health Alliance FI HMO/POS,DRG,MS-928,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,Medical/Surgical,Relative Weights,"$67,386.39 ",IP,"2,420.00","124,889.18",,,,,,
Health Alliance FI HMO/POS,DRG,MS-929,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$31,094.35 ",IP,"2,420.00","59,300.64",,,,,,
Health Alliance FI HMO/POS,DRG,MS-933,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,Medical/Surgical,Relative Weights,"$23,346.29 ",IP,"2,420.00","63,306.43",,,,,,
Health Alliance FI HMO/POS,DRG,MS-934,FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,Medical/Surgical,Relative Weights,"$20,024.23 ",IP,"2,420.00","36,485.57",,,,,,
Health Alliance FI HMO/POS,DRG,MS-935,NON-EXTENSIVE BURNS,Medical/Surgical,Relative Weights,"$19,941.69 ",IP,"2,420.00","38,955.17",,,,,,
Health Alliance FI HMO/POS,DRG,MS-939,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,Medical/Surgical,Relative Weights,"$34,815.68 ",IP,"2,420.00","73,672.70",,,,,,
Health Alliance FI HMO/POS,DRG,MS-940,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,Medical/Surgical,Relative Weights,"$22,912.98 ",IP,"2,420.00","45,799.49",,,,,,
Health Alliance FI HMO/POS,DRG,MS-941,O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W/O CC/MCC,Medical/Surgical,Relative Weights,"$19,840.58 ",IP,"2,420.00","38,922.91",,,,,,
Health Alliance FI HMO/POS,DRG,MS-945,REHABILITATION WITH CC/MCC,Medical/Surgical,Relative Weights,"$15,288.73 ",IP,"2,420.00","29,338.85",,,,,,
Health Alliance FI HMO/POS,DRG,MS-946,REHABILITATION WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$11,618.98 ",IP,"2,420.00","21,913.92",,,,,,
Health Alliance FI HMO/POS,DRG,MS-947,SIGNS AND SYMPTOMS WITH MCC,Medical/Surgical,Relative Weights,"$12,318.47 ",IP,"2,420.00","24,137.57",,,,,,
Health Alliance FI HMO/POS,DRG,MS-948,SIGNS AND SYMPTOMS WITHOUT MCC,Medical/Surgical,Relative Weights,"$8,120.50 ",IP,"2,420.00","15,716.74",,,,,,
Health Alliance FI HMO/POS,DRG,MS-949,AFTERCARE WITH CC/MCC,Medical/Surgical,Relative Weights,"$11,450.82 ",IP,"2,420.00","21,952.22",,,,,,
Health Alliance FI HMO/POS,DRG,MS-950,AFTERCARE WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$7,636.63 ",IP,"2,420.00","14,936.54",,,,,,
Health Alliance FI HMO/POS,DRG,MS-951,OTHER FACTORS INFLUENCING HEALTH STATUS,Medical/Surgical,Relative Weights,"$5,773.38 ",IP,"2,420.00","11,823.84",,,,,,
Health Alliance FI HMO/POS,DRG,MS-955,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,Medical/Surgical,Relative Weights,"$64,886.58 ",IP,"2,420.00","122,582.88",,,,,,
Health Alliance FI HMO/POS,DRG,MS-956,LIMB REATTACHMENT- HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,Medical/Surgical,Relative Weights,"$39,720.37 ",IP,"2,420.00","79,093.73",,,,,,
Health Alliance FI HMO/POS,DRG,MS-957,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Medical/Surgical,Relative Weights,"$76,561.28 ",IP,"2,420.00","151,879.39",,,,,,
Health Alliance FI HMO/POS,DRG,MS-958,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,Medical/Surgical,Relative Weights,"$43,390.12 ",IP,"2,420.00","84,488.54",,,,,,
Health Alliance FI HMO/POS,DRG,MS-959,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$28,228.29 ",IP,"2,420.00","56,458.08",,,,,,
Health Alliance FI HMO/POS,DRG,MS-963,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Medical/Surgical,Relative Weights,"$28,164.32 ",IP,"2,420.00","54,938.02",,,,,,
Health Alliance FI HMO/POS,DRG,MS-964,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,Medical/Surgical,Relative Weights,"$15,390.87 ",IP,"2,420.00","30,108.96",,,,,,
Health Alliance FI HMO/POS,DRG,MS-965,OTHER MULTIPLE SIGNIFICANT TRAUMA W/O CC/MCC,Medical/Surgical,Relative Weights,"$9,414.24 ",IP,"2,420.00","18,488.74",,,,,,
Health Alliance FI HMO/POS,DRG,MS-969,HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$60,373.94 ",IP,"2,420.00","116,982.43",,,,,,
Health Alliance FI HMO/POS,DRG,MS-970,HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,Medical/Surgical,Relative Weights,"$30,834.36 ",IP,"2,420.00","58,806.72",,,,,,
Health Alliance FI HMO/POS,DRG,MS-974,HIV WITH MAJOR RELATED CONDITION WITH MCC,Medical/Surgical,Relative Weights,"$27,757.83 ",IP,"2,420.00","53,905.82",,,,,,
Health Alliance FI HMO/POS,DRG,MS-975,HIV WITH MAJOR RELATED CONDITION WITH CC,Medical/Surgical,Relative Weights,"$13,227.40 ",IP,"2,420.00","27,054.72",,,,,,
Health Alliance FI HMO/POS,DRG,MS-976,HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$9,797.00 ",IP,"2,420.00","18,430.27",,,,,,
Health Alliance FI HMO/POS,DRG,MS-977,HIV WITH OR WITHOUT OTHER RELATED CONDITION,Medical/Surgical,Relative Weights,"$13,662.78 ",IP,"2,420.00","26,218.08",,,,,,
Health Alliance FI HMO/POS,DRG,MS-981,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Medical/Surgical,Relative Weights,47607.7042,IP,"2,420.00","90,532.51",,,,,,
Health Alliance FI HMO/POS,DRG,MS-982,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Medical/Surgical,Relative Weights,26170.0515,IP,"2,420.00","49,152.10",,,,,,
Health Alliance FI HMO/POS,DRG,MS-983,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,17046.7461,IP,"2,420.00","33,003.94",,,,,,
Health Alliance FI HMO/POS,DRG,MS-987,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Medical/Surgical,Relative Weights,33797.3948,IP,"2,420.00","67,207.39",,,,,,
Health Alliance FI HMO/POS,DRG,MS-988,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Medical/Surgical,Relative Weights,17604.8947,IP,"2,420.00","34,640.93",,,,,,
Health Alliance FI HMO/POS,DRG,MS-989,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,11592.1587,IP,"2,420.00","23,232.38",,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,350,CT Scan,CT Scan,Per Case,1867.52,OP,"1,867.52","1,867.52",,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,351,CT Scan: Head,CT Scan,Per Case,1867.52,OP,"1,867.52","1,867.52",,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,352,CT Scan: Body,CT Scan,Per Case,1867.52,OP,"1,867.52","1,867.52",,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,353,,CT Scan,Per Case,1867.52,OP,"1,867.52","1,867.52",,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,354,,CT Scan,Per Case,1867.52,OP,"1,867.52","1,867.52",,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,355,,CT Scan,Per Case,1867.52,OP,"1,867.52","1,867.52",,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,356,,CT Scan,Per Case,1867.52,OP,"1,867.52","1,867.52",,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,357,,CT Scan,Per Case,1867.52,OP,"1,867.52","1,867.52",,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,358,,CT Scan,Per Case,1867.52,OP,"1,867.52","1,867.52",,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,359,CT Scan: Other CT scans,CT Scan,Per Case,1867.52,OP,"1,867.52","1,867.52",,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,360,Operating Room Services,Ambulatory Surgery,Per Case,10316.98,OP,"10,316.98","10,316.98",,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,361,Operating Room Services: Minor surgery,Ambulatory Surgery,Per Case,10316.98,OP,"10,316.98","10,316.98",,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,420,Physical Therapy,Therapy,Per Unit,103.75,OP,103.75,103.75,,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,421,Physical Therapy: Visit charge,Therapy,Per Unit,103.75,OP,103.75,103.75,,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,422,Physical Therapy: Hourly charge,Therapy,Per Unit,103.75,OP,103.75,103.75,,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,423,Physical Therapy: Group rate,Therapy,Per Unit,103.75,OP,103.75,103.75,,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,424,Physical Therapy: Evaluation/re-evaluation,Therapy,Per Unit,103.75,OP,103.75,103.75,,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,429,Physical Therapy: Other physical therapy,Therapy,Per Unit,103.75,OP,103.75,103.75,,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,430,Occupational Therapy,Therapy,Per Unit,103.75,OP,103.75,103.75,,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,431,Occupational Therapy: Visit charge,Therapy,Per Unit,103.75,OP,103.75,103.75,,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,432,Occupational Therapy: Hourly charge,Therapy,Per Unit,103.75,OP,103.75,103.75,,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,433,Occupational Therapy: Group rate,Therapy,Per Unit,103.75,OP,103.75,103.75,,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,434,Occupational Therapy: Evaluation/re-evaluation,Therapy,Per Unit,103.75,OP,103.75,103.75,,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,439,Occupational Therapy: Other occupational therapy,Therapy,Per Unit,103.75,OP,103.75,103.75,,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,440,Speech-Language Pathology,Therapy,Per Unit,103.75,OP,103.75,103.75,,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,441,Speech-Language Pathology: Visit charge,Therapy,Per Unit,103.75,OP,103.75,103.75,,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,442,Speech-Language Pathology: Hourly charge,Therapy,Per Unit,103.75,OP,103.75,103.75,,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,443,Speech-Language Pathology: Group rate,Therapy,Per Unit,103.75,OP,103.75,103.75,,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,444,Speech-Language Pathology: Evaluation/ re-evaluation,Therapy,Per Unit,103.75,OP,103.75,103.75,,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,449,Speech-Language Pathology: Other speech language pathology,Therapy,Per Unit,103.75,OP,103.75,103.75,,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,450,Emergency Room,ER,Per Case,5158.5,OP,"5,158.50","5,158.50",,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,481,Cardiology: Cardiac catheter lab,Cardiac Cath,Per Case,24581.68,OP,"2,420.00","24,581.68",,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,490,Ambulatory Surgery,Ambulatory Surgery,Per Case,10316.98,OP,"10,316.98","10,316.98",,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,610,Magnetic Resonance Tech. (MRT),MRI,Per Case,2420.86,OP,"2,420.86","2,420.86",,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,611,Magnetic Resonance Tech. (MRT): Brain (incl. Brainstem),MRI,Per Case,2420.86,OP,"2,420.86","2,420.86",,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,612,Magnetic Resonance Tech. (MRT): Spinal cord (incl. spine),MRI,Per Case,2420.86,OP,"2,420.86","2,420.86",,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,613,,MRI,Per Case,2420.86,OP,"2,420.86","2,420.86",,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,614,Magnetic Resonance Tech. (MRT): MRI - Other,MRI,Per Case,2420.86,OP,"2,420.86","2,420.86",,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,615,Magnetic Resonance Tech. (MRT): MRA - Head and Neck,MRI,Per Case,2420.86,OP,"2,420.86","2,420.86",,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,616,Magnetic Resonance Tech. (MRT): MRA - Lower Ext,MRI,Per Case,2420.86,OP,"2,420.86","2,420.86",,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,617,,MRI,Per Case,2420.86,OP,"2,420.86","2,420.86",,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,618,Magnetic Resonance Tech. (MRT): MRA - Other,MRI,Per Case,2420.86,OP,"2,420.86","2,420.86",,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,619,Magnetic Resonance Tech. (MRT): Other MRI,MRI,Per Case,2420.86,OP,"2,420.86","2,420.86",,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,762,Treatment/Observation Room: Observation room,Observation,Per Case,10316.98,OP,"2,420.00","10,316.98",,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,912,Psychiatric/Psychological Svcs: Partial Hosp - less intensive,Partial Day Hospitalization,Per Case,207.51,OP,207.51,207.51,,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,913,Psychiatric/Psychological Svcs: Partial Hosp - Intensive,Addiction Day Treatment,Per Case,556.09,OP,556.09,556.09,,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,914,Psychiatric/Psychological Svcs: Individual therapy,Individual Counseling,Per Case,193.67,OP,193.67,193.67,,,,,,
Health Alliance FI HMO/POS,ExceptRevenueCode,915,Psychiatric/Psychological Svcs: Group therapy,Group Counseling Aftercare,Per Case,193.67,OP,193.67,193.67,,,,,,
Health Alliance FI HMO/POS,,,,All Other,Straight Discount,57.60%,OP,,,,,,,,
Health Alliance MCR ADV,DRG,MS-001,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W MCC,Surgical,Relative Weights,"$168,855.33 ",IP,"17,718.00","557,099.42",,,,,,
Health Alliance MCR ADV,DRG,MS-002,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W/O MCC,Surgical,Relative Weights,"$87,426.55 ",IP,"17,718.00","282,516.19",,,,,,
Health Alliance MCR ADV,DRG,MS-003,ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITH MAJOR O.R. PROCEDURES,Surgical,Relative Weights,"$111,577.60 ",IP,"111,577.60","382,110.62",,,,,,
Health Alliance MCR ADV,DRG,MS-004,TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES,Surgical,Relative Weights,"$69,628.33 ",IP,"69,628.33","232,723.01",,,,,,
Health Alliance MCR ADV,DRG,MS-005,LIVER TRANSPLANT W MCC OR INTESTINAL TRANSPLANT,Surgical,Relative Weights,"$59,773.19 ",IP,"59,773.19","207,904.03",,,,,,
Health Alliance MCR ADV,DRG,MS-006,LIVER TRANSPLANT W/O MCC,Surgical,Relative Weights,"$27,427.34 ",IP,"27,427.34","98,217.50",,,,,,
Health Alliance MCR ADV,DRG,MS-007,LUNG TRANSPLANT,Surgical,Relative Weights,"$67,628.10 ",IP,"67,628.10","217,451.81",,,,,,
Health Alliance MCR ADV,DRG,MS-008,SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,Surgical,Relative Weights,"$31,730.89 ",IP,"31,730.89","113,220.58",,,,,,
Health Alliance MCR ADV,DRG,MS-010,PANCREAS TRANSPLANT,Surgical,Relative Weights,"$21,141.08 ",IP,"2,420.00","80,158.18",,,,,,
Health Alliance MCR ADV,DRG,MS-011,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC,Surgical,Relative Weights,"$29,325.37 ",IP,"2,420.00","99,667.01",,,,,,
Health Alliance MCR ADV,DRG,MS-012,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC,Surgical,Relative Weights,"$22,383.85 ",IP,"2,420.00","76,083.84",,,,,,
Health Alliance MCR ADV,DRG,MS-013,TRACHEOSTOMY FOR FACE -  MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC,Surgical,Relative Weights,"$15,907.20 ",IP,"2,420.00","48,894.05",,,,,,
Health Alliance MCR ADV,DRG,MS-014,ALLOGENEIC BONE MARROW TRANSPLANT,Surgical,Relative Weights,"$62,354.51 ",IP,"2,420.00","257,136.77",,,,,,
Health Alliance MCR ADV,DRG,MS-016,AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,Surgical,Relative Weights,"$39,340.51 ",IP,"2,420.00","138,805.63",,,,,,
Health Alliance MCR ADV,DRG,MS-017,AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,Surgical,Relative Weights,"$28,357.66 ",IP,"2,420.00","89,659.58",,,,,,
Health Alliance MCR ADV,DRG,MS-018,CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,Medical,Relative Weights,"$218,711.49 ",IP,"2,420.00","218,711.49",,,,,,
Health Alliance MCR ADV,DRG,MS-019,SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,Surgical,Relative Weights,"$39,009.97 ",IP,"2,420.00","39,009.97",,,,,,
Health Alliance MCR ADV,DRG,MS-020,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,Surgical,Relative Weights,"$60,368.88 ",IP,"2,420.00","218,151.36",,,,,,
Health Alliance MCR ADV,DRG,MS-021,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,Surgical,Relative Weights,"$44,054.63 ",IP,"2,420.00","166,797.79",,,,,,
Health Alliance MCR ADV,DRG,MS-022,INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W/O CC/MCC,Surgical,Relative Weights,"$28,282.33 ",IP,"2,420.00","99,425.09",,,,,,
Health Alliance MCR ADV,DRG,MS-023,CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX CNS PDX W MCC OR CHEMO IMPLANT,Surgical,Relative Weights,"$33,124.34 ",IP,"2,420.00","113,240.74",,,,,,
Health Alliance MCR ADV,DRG,MS-024,CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,Surgical,Relative Weights,"$23,004.07 ",IP,"2,420.00","80,972.64",,,,,,
Health Alliance MCR ADV,DRG,MS-025,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$26,265.17 ",IP,"2,420.00","88,593.12",,,,,,
Health Alliance MCR ADV,DRG,MS-026,CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC,Surgical,Relative Weights,"$17,882.32 ",IP,"2,420.00","61,403.33",,,,,,
Health Alliance MCR ADV,DRG,MS-027,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$14,683.71 ",IP,"2,420.00","48,317.47",,,,,,
Health Alliance MCR ADV,DRG,MS-028,SPINAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$34,007.36 ",IP,"2,420.00","112,702.46",,,,,,
Health Alliance MCR ADV,DRG,MS-029,SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,Surgical,Relative Weights,"$19,253.57 ",IP,"2,420.00","64,653.12",,,,,,
Health Alliance MCR ADV,DRG,MS-030,SPINAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$13,763.89 ",IP,"2,420.00","45,805.54",,,,,,
Health Alliance MCR ADV,DRG,MS-031,VENTRICULAR SHUNT PROCEDURES WITH MCC,Surgical,Relative Weights,"$25,531.07 ",IP,"2,420.00","88,189.92",,,,,,
Health Alliance MCR ADV,DRG,MS-032,VENTRICULAR SHUNT PROCEDURES WITH CC,Surgical,Relative Weights,"$12,944.53 ",IP,"2,420.00","44,192.74",,,,,,
Health Alliance MCR ADV,DRG,MS-033,VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,057.78 ",IP,"2,420.00","34,290.14",,,,,,
Health Alliance MCR ADV,DRG,MS-034,CAROTID ARTERY STENT PROCEDURE W MCC,Surgical,Relative Weights,"$23,232.41 ",IP,"2,420.00","75,674.59",,,,,,
Health Alliance MCR ADV,DRG,MS-035,CAROTID ARTERY STENT PROCEDURES WITH CC,Surgical,Relative Weights,"$13,664.03 ",IP,"2,420.00","46,412.35",,,,,,
Health Alliance MCR ADV,DRG,MS-036,CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,817.58 ",IP,"2,420.00","35,300.16",,,,,,
Health Alliance MCR ADV,DRG,MS-037,EXTRACRANIAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$19,141.44 ",IP,"2,420.00","65,384.93",,,,,,
Health Alliance MCR ADV,DRG,MS-038,EXTRACRANIAL PROCEDURES WITH CC,Surgical,Relative Weights,"$9,687.52 ",IP,"2,420.00","33,772.03",,,,,,
Health Alliance MCR ADV,DRG,MS-039,EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,652.43 ",IP,"2,420.00","22,807.01",,,,,,
Health Alliance MCR ADV,DRG,MS-040,PERIPHERAL- CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC,Surgical,Relative Weights,"$22,570.73 ",IP,"2,420.00","79,438.46",,,,,,
Health Alliance MCR ADV,DRG,MS-041,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W CC OR PERIPH NEUROSTIM,Surgical,Relative Weights,"$13,722.43 ",IP,"2,420.00","47,809.44",,,,,,
Health Alliance MCR ADV,DRG,MS-042,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W/O CC/MCC,Surgical,Relative Weights,"$11,103.16 ",IP,"2,420.00","37,261.73",,,,,,
Health Alliance MCR ADV,DRG,MS-052,SPINAL DISORDERS AND INJURIES WITH CC/MCC,Medical,Relative Weights,"$10,824.58 ",IP,"2,420.00","32,838.62",,,,,,
Health Alliance MCR ADV,DRG,MS-053,SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,Medical,Relative Weights,"$6,636.66 ",IP,"2,420.00","19,476.58",,,,,,
Health Alliance MCR ADV,DRG,MS-054,NERVOUS SYSTEM NEOPLASMS WITH MCC,Medical,Relative Weights,"$7,990.98 ",IP,"2,420.00","27,016.42",,,,,,
Health Alliance MCR ADV,DRG,MS-055,NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,Medical,Relative Weights,"$6,100.55 ",IP,"2,420.00","19,877.76",,,,,,
Health Alliance MCR ADV,DRG,MS-056,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,Medical,Relative Weights,"$12,820.72 ",IP,"2,420.00","44,198.78",,,,,,
Health Alliance MCR ADV,DRG,MS-057,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,Medical,Relative Weights,"$7,402.30 ",IP,"2,420.00","24,409.73",,,,,,
Health Alliance MCR ADV,DRG,MS-058,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,Medical,Relative Weights,"$10,148.89 ",IP,"2,420.00","39,406.75",,,,,,
Health Alliance MCR ADV,DRG,MS-059,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,Medical,Relative Weights,"$6,583.52 ",IP,"2,420.00","21,984.48",,,,,,
Health Alliance MCR ADV,DRG,MS-060,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,Medical,Relative Weights,"$5,359.44 ",IP,"2,420.00","17,775.07",,,,,,
Health Alliance MCR ADV,DRG,MS-061,ISCHEMIC STROKE -  PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC,Medical,Relative Weights,"$16,884.83 ",IP,"2,420.00","56,316.96",,,,,,
Health Alliance MCR ADV,DRG,MS-062,ISCHEMIC STROKE -  PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC,Medical,Relative Weights,"$11,611.83 ",IP,"2,420.00","40,545.79",,,,,,
Health Alliance MCR ADV,DRG,MS-063,ISCHEMIC STROKE- PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC,Medical,Relative Weights,"$9,984.78 ",IP,"2,420.00","33,884.93",,,,,,
Health Alliance MCR ADV,DRG,MS-064,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,Medical,Relative Weights,"$11,206.52 ",IP,"2,420.00","37,795.97",,,,,,
Health Alliance MCR ADV,DRG,MS-065,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC,Medical,Relative Weights,"$5,956.88 ",IP,"2,420.00","20,718.43",,,,,,
Health Alliance MCR ADV,DRG,MS-066,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,Medical,Relative Weights,"$4,155.80 ",IP,"2,420.00","14,454.72",,,,,,
Health Alliance MCR ADV,DRG,MS-067,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,Medical,Relative Weights,"$8,326.78 ",IP,"2,420.00","29,524.32",,,,,,
Health Alliance MCR ADV,DRG,MS-068,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,Medical,Relative Weights,"$5,191.24 ",IP,"2,420.00","18,212.54",,,,,,
Health Alliance MCR ADV,DRG,MS-069,TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,Medical,Relative Weights,"$4,596.73 ",IP,"2,420.00","15,730.85",,,,,,
Health Alliance MCR ADV,DRG,MS-070,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC,Medical,Relative Weights,"$9,808.99 ",IP,"2,420.00","33,725.66",,,,,,
Health Alliance MCR ADV,DRG,MS-071,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC,Medical,Relative Weights,"$5,908.99 ",IP,"2,420.00","20,053.15",,,,,,
Health Alliance MCR ADV,DRG,MS-072,NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$4,506.79 ",IP,"2,420.00","14,888.16",,,,,,
Health Alliance MCR ADV,DRG,MS-073,CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,Medical,Relative Weights,"$8,485.05 ",IP,"2,420.00","28,538.50",,,,,,
Health Alliance MCR ADV,DRG,MS-074,CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,Medical,Relative Weights,"$5,951.04 ",IP,"2,420.00","19,920.10",,,,,,
Health Alliance MCR ADV,DRG,MS-075,VIRAL MENINGITIS WITH CC/MCC,Medical,Relative Weights,"$9,501.81 ",IP,"2,420.00","32,421.31",,,,,,
Health Alliance MCR ADV,DRG,MS-076,VIRAL MENINGITIS WITHOUT CC/MCC,Medical,Relative Weights,"$5,751.89 ",IP,"2,420.00","18,194.40",,,,,,
Health Alliance MCR ADV,DRG,MS-077,HYPERTENSIVE ENCEPHALOPATHY WITH MCC,Medical,Relative Weights,"$8,952.25 ",IP,"2,420.00","31,096.80",,,,,,
Health Alliance MCR ADV,DRG,MS-078,HYPERTENSIVE ENCEPHALOPATHY WITH CC,Medical,Relative Weights,"$5,547.49 ",IP,"2,420.00","19,393.92",,,,,,
Health Alliance MCR ADV,DRG,MS-079,HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC,Medical,Relative Weights,"$4,256.25 ",IP,"2,420.00","14,940.58",,,,,,
Health Alliance MCR ADV,DRG,MS-080,NONTRAUMATIC STUPOR & COMA W MCC,Medical,Relative Weights,"$12,237.30 ",IP,"2,420.00","38,632.61",,,,,,
Health Alliance MCR ADV,DRG,MS-081,NONTRAUMATIC STUPOR & COMA W/O MCC,Medical,Relative Weights,"$4,515.55 ",IP,"2,420.00","17,722.66",,,,,,
Health Alliance MCR ADV,DRG,MS-082,TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,Medical,Relative Weights,"$13,221.35 ",IP,"2,420.00","45,396.29",,,,,,
Health Alliance MCR ADV,DRG,MS-083,TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,Medical,Relative Weights,"$7,849.06 ",IP,"2,420.00","26,423.71",,,,,,
Health Alliance MCR ADV,DRG,MS-084,TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,Medical,Relative Weights,"$5,288.77 ",IP,"2,420.00","18,089.57",,,,,,
Health Alliance MCR ADV,DRG,MS-085,TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,Medical,Relative Weights,"$13,500.51 ",IP,"2,420.00","45,275.33",,,,,,
Health Alliance MCR ADV,DRG,MS-086,TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,Medical,Relative Weights,"$7,443.18 ",IP,"2,420.00","24,954.05",,,,,,
Health Alliance MCR ADV,DRG,MS-087,TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,Medical,Relative Weights,"$5,043.49 ",IP,"2,420.00","16,918.27",,,,,,
Health Alliance MCR ADV,DRG,MS-088,CONCUSSION WITH MCC,Medical,Relative Weights,"$8,498.48 ",IP,"2,420.00","28,004.26",,,,,,
Health Alliance MCR ADV,DRG,MS-089,CONCUSSION WITH CC,Medical,Relative Weights,"$6,210.92 ",IP,"2,420.00","19,883.81",,,,,,
Health Alliance MCR ADV,DRG,MS-090,CONCUSSION WITHOUT CC/MCC,Medical,Relative Weights,"$4,990.93 ",IP,"2,420.00","17,101.73",,,,,,
Health Alliance MCR ADV,DRG,MS-091,OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,Medical,Relative Weights,"$9,640.80 ",IP,"2,420.00","31,552.42",,,,,,
Health Alliance MCR ADV,DRG,MS-092,OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,Medical,Relative Weights,"$5,775.25 ",IP,"2,420.00","19,476.58",,,,,,
Health Alliance MCR ADV,DRG,MS-093,OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,Medical,Relative Weights,"$4,568.11 ",IP,"2,420.00","15,345.79",,,,,,
Health Alliance MCR ADV,DRG,MS-094,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,Medical,Relative Weights,"$21,245.62 ",IP,"2,420.00","72,269.57",,,,,,
Health Alliance MCR ADV,DRG,MS-095,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,Medical,Relative Weights,"$14,642.83 ",IP,"2,420.00","48,527.14",,,,,,
Health Alliance MCR ADV,DRG,MS-096,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,Medical,Relative Weights,"$13,623.15 ",IP,"2,420.00","45,603.94",,,,,,
Health Alliance MCR ADV,DRG,MS-097,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,Medical,Relative Weights,"$21,961.03 ",IP,"2,420.00","72,090.14",,,,,,
Health Alliance MCR ADV,DRG,MS-098,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,Medical,Relative Weights,"$12,337.16 ",IP,"2,420.00","39,412.80",,,,,,
Health Alliance MCR ADV,DRG,MS-099,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,Medical,Relative Weights,"$8,187.20 ",IP,"2,420.00","25,853.18",,,,,,
Health Alliance MCR ADV,DRG,MS-100,SEIZURES WITH MCC,Medical,Relative Weights,"$10,958.32 ",IP,"2,420.00","36,695.23",,,,,,
Health Alliance MCR ADV,DRG,MS-101,SEIZURES WITHOUT MCC,Medical,Relative Weights,"$5,188.32 ",IP,"2,420.00","17,799.26",,,,,,
Health Alliance MCR ADV,DRG,MS-102,HEADACHES WITH MCC,Medical,Relative Weights,"$6,734.19 ",IP,"2,420.00","24,042.82",,,,,,
Health Alliance MCR ADV,DRG,MS-103,HEADACHES W/O MCC,Medical,Relative Weights,"$4,844.34 ",IP,"2,420.00","16,117.92",,,,,,
Health Alliance MCR ADV,DRG,MS-113,ORBITAL PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$12,815.47 ",IP,"2,420.00","42,983.14",,,,,,
Health Alliance MCR ADV,DRG,MS-114,ORBITAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,454.10 ",IP,"2,420.00","24,006.53",,,,,,
Health Alliance MCR ADV,DRG,MS-115,EXTRAOCULAR PROCEDURES EXCEPT ORBIT,Surgical,Relative Weights,"$8,506.66 ",IP,"2,420.00","29,957.76",,,,,,
Health Alliance MCR ADV,DRG,MS-116,INTRAOCULAR PROCEDURES W CC/MCC,Surgical,Relative Weights,"$10,995.11 ",IP,"2,420.00","38,122.56",,,,,,
Health Alliance MCR ADV,DRG,MS-117,INTRAOCULAR PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$6,080.69 ",IP,"2,420.00","22,109.47",,,,,,
Health Alliance MCR ADV,DRG,MS-121,ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,Medical,Relative Weights,"$6,953.20 ",IP,"2,420.00","25,558.85",,,,,,
Health Alliance MCR ADV,DRG,MS-122,ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,Medical,Relative Weights,"$3,769.77 ",IP,"2,420.00","15,575.62",,,,,,
Health Alliance MCR ADV,DRG,MS-123,NEUROLOGICAL EYE DISORDERS,Medical,Relative Weights,"$4,478.17 ",IP,"2,420.00","15,740.93",,,,,,
Health Alliance MCR ADV,DRG,MS-124,OTHER DISORDERS OF THE EYE WITH MCC,Medical,Relative Weights,"$8,187.79 ",IP,"2,420.00","28,010.30",,,,,,
Health Alliance MCR ADV,DRG,MS-125,OTHER DISORDERS OF THE EYE WITHOUT MCC,Medical,Relative Weights,"$4,888.14 ",IP,"2,420.00","15,914.30",,,,,,
Health Alliance MCR ADV,DRG,MS-135,SINUS AND MASTOID PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$12,518.21 ",IP,"2,420.00","46,057.54",,,,,,
Health Alliance MCR ADV,DRG,MS-136,SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,332.22 ",IP,"2,420.00","23,990.40",,,,,,
Health Alliance MCR ADV,DRG,MS-137,MOUTH PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$8,816.77 ",IP,"2,420.00","26,879.33",,,,,,
Health Alliance MCR ADV,DRG,MS-138,MOUTH PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$5,002.03 ",IP,"2,420.00","17,365.82",,,,,,
Health Alliance MCR ADV,DRG,MS-139,SALIVARY GLAND PROCEDURES,Surgical,Relative Weights,"$7,207.24 ",IP,"2,420.00","24,883.49",,,,,,
Health Alliance MCR ADV,DRG,MS-140,MAJOR HEAD AND NECK PROCEDURES WITH MCC,Medical,Relative Weights,"$23,231.24 ",IP,"2,420.00","23,231.24",,,,,,
Health Alliance MCR ADV,DRG,MS-141,MAJOR HEAD AND NECK PROCEDURES WITH CC,Medical,Relative Weights,"$12,883.80 ",IP,"2,420.00","12,883.80",,,,,,
Health Alliance MCR ADV,DRG,MS-142,MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,Medical,Relative Weights,"$9,373.91 ",IP,"2,420.00","9,373.91",,,,,,
Health Alliance MCR ADV,DRG,MS-143,OTHER EAR- NOSE- MOUTH AND THROAT O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$17,402.26 ",IP,"2,420.00","17,402.26",,,,,,
Health Alliance MCR ADV,DRG,MS-144,HERNIA PROCEDURES AGE 0-17,Surgical,Relative Weights,"$10,287.30 ",IP,"2,420.00","10,287.30",,,,,,
Health Alliance MCR ADV,DRG,MS-145,OTHER EAR -  NOSE -  MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC,Medical,Relative Weights,"$7,151.76 ",IP,"2,420.00","7,151.76",,,,,,
Health Alliance MCR ADV,DRG,MS-146,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH MCC,Medical,Relative Weights,"$11,920.18 ",IP,"2,420.00","38,880.58",,,,,,
Health Alliance MCR ADV,DRG,MS-147,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH CC,Medical,Relative Weights,"$7,598.52 ",IP,"2,420.00","25,016.54",,,,,,
Health Alliance MCR ADV,DRG,MS-148,EAR - NOSE - MOUTH & THROAT MALIGNANCY W/O CC/MCC,Medical,Relative Weights,"$4,596.14 ",IP,"2,420.00","15,329.66",,,,,,
Health Alliance MCR ADV,DRG,MS-149,DYSEQUILIBRIUM,Medical,Relative Weights,"$4,304.14 ",IP,"2,420.00","14,726.88",,,,,,
Health Alliance MCR ADV,DRG,MS-150,EPISTAXIS WITH MCC,Medical,Relative Weights,"$7,752.70 ",IP,"2,420.00","26,036.64",,,,,,
Health Alliance MCR ADV,DRG,MS-151,EPISTAXIS WITHOUT MCC,Medical,Relative Weights,"$4,312.31 ",IP,"2,420.00","14,093.86",,,,,,
Health Alliance MCR ADV,DRG,MS-152,OTITIS MEDIA AND URI WITH MCC,Medical,Relative Weights,"$6,310.20 ",IP,"2,420.00","20,946.24",,,,,,
Health Alliance MCR ADV,DRG,MS-153,OTITIS MEDIA AND URI WITHOUT MCC,Medical,Relative Weights,"$4,165.14 ",IP,"2,420.00","14,241.02",,,,,,
Health Alliance MCR ADV,DRG,MS-154,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH MCC,Medical,Relative Weights,"$9,033.43 ",IP,"2,420.00","28,969.92",,,,,,
Health Alliance MCR ADV,DRG,MS-155,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH CC,Medical,Relative Weights,"$5,311.55 ",IP,"2,420.00","18,166.18",,,,,,
Health Alliance MCR ADV,DRG,MS-156,OTHER EAR -  NOSE -  MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$3,845.11 ",IP,"2,420.00","13,194.72",,,,,,
Health Alliance MCR ADV,DRG,MS-157,DENTAL AND ORAL DISEASES WITH MCC,Medical,Relative Weights,"$9,205.13 ",IP,"2,420.00","31,508.06",,,,,,
Health Alliance MCR ADV,DRG,MS-158,DENTAL AND ORAL DISEASES WITH CC,Medical,Relative Weights,"$5,257.24 ",IP,"2,420.00","17,470.66",,,,,,
Health Alliance MCR ADV,DRG,MS-159,DENTAL AND ORAL DISEASES WITHOUT CC/MCC,Medical,Relative Weights,"$3,872.56 ",IP,"2,420.00","13,565.66",,,,,,
Health Alliance MCR ADV,DRG,MS-163,MAJOR CHEST PROCEDURES WITH MCC,Surgical,Relative Weights,"$29,240.10 ",IP,"2,420.00","98,253.79",,,,,,
Health Alliance MCR ADV,DRG,MS-164,MAJOR CHEST PROCEDURES WITH CC,Surgical,Relative Weights,"$15,508.91 ",IP,"2,420.00","51,037.06",,,,,,
Health Alliance MCR ADV,DRG,MS-165,MAJOR CHEST PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$11,193.09 ",IP,"2,420.00","37,279.87",,,,,,
Health Alliance MCR ADV,DRG,MS-166,OTHER RESP SYSTEM O.R. PROCEDURES W MCC,Surgical,Relative Weights,"$21,745.53 ",IP,"2,420.00","75,210.91",,,,,,
Health Alliance MCR ADV,DRG,MS-167,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$10,621.35 ",IP,"2,420.00","38,594.30",,,,,,
Health Alliance MCR ADV,DRG,MS-168,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,909.80 ",IP,"2,420.00","26,746.27",,,,,,
Health Alliance MCR ADV,DRG,MS-175,PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,Medical,Relative Weights,"$9,028.76 ",IP,"2,420.00","29,119.10",,,,,,
Health Alliance MCR ADV,DRG,MS-176,PULMONARY EMBOLISM WITHOUT MCC,Medical,Relative Weights,"$5,184.82 ",IP,"2,420.00","17,103.74",,,,,,
Health Alliance MCR ADV,DRG,MS-177,RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC,Medical,Relative Weights,"$10,798.89 ",IP,"2,420.00","38,126.59",,,,,,
Health Alliance MCR ADV,DRG,MS-178,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,Medical,Relative Weights,"$7,053.65 ",IP,"2,420.00","25,064.93",,,,,,
Health Alliance MCR ADV,DRG,MS-179,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,Medical,Relative Weights,"$5,096.64 ",IP,"2,420.00","17,460.58",,,,,,
Health Alliance MCR ADV,DRG,MS-180,RESPIRATORY NEOPLASMS WITH MCC,Medical,Relative Weights,"$10,161.15 ",IP,"2,420.00","34,773.98",,,,,,
Health Alliance MCR ADV,DRG,MS-181,RESPIRATORY NEOPLASMS WITH CC,Medical,Relative Weights,"$6,541.47 ",IP,"2,420.00","23,224.32",,,,,,
Health Alliance MCR ADV,DRG,MS-182,RESPIRATORY NEOPLASMS WITHOUT CC/MCC,Medical,Relative Weights,"$4,625.34 ",IP,"2,420.00","16,990.85",,,,,,
Health Alliance MCR ADV,DRG,MS-183,MAJOR CHEST TRAUMA WITH MCC,Medical,Relative Weights,"$9,104.10 ",IP,"2,420.00","30,425.47",,,,,,
Health Alliance MCR ADV,DRG,MS-184,MAJOR CHEST TRAUMA WITH CC,Medical,Relative Weights,"$6,078.94 ",IP,"2,420.00","20,526.91",,,,,,
Health Alliance MCR ADV,DRG,MS-185,MAJOR CHEST TRAUMA W/O CC/MCC,Medical,Relative Weights,"$4,525.48 ",IP,"2,420.00","14,797.44",,,,,,
Health Alliance MCR ADV,DRG,MS-186,PLEURAL EFFUSION WITH MCC,Medical,Relative Weights,"$9,015.91 ",IP,"2,420.00","31,104.86",,,,,,
Health Alliance MCR ADV,DRG,MS-187,PLEURAL EFFUSION WITH CC,Medical,Relative Weights,"$6,032.22 ",IP,"2,420.00","20,722.46",,,,,,
Health Alliance MCR ADV,DRG,MS-188,PLEURAL EFFUSION WITHOUT CC/MCC,Medical,Relative Weights,"$4,260.34 ",IP,"2,420.00","14,734.94",,,,,,
Health Alliance MCR ADV,DRG,MS-189,PULMONARY EDEMA AND RESPIRATORY FAILURE,Medical,Relative Weights,"$7,160.52 ",IP,"2,420.00","24,508.51",,,,,,
Health Alliance MCR ADV,DRG,MS-190,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,Medical,Relative Weights,"$6,570.67 ",IP,"2,420.00","23,063.04",,,,,,
Health Alliance MCR ADV,DRG,MS-191,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,Medical,Relative Weights,"$5,164.38 ",IP,"2,420.00","17,998.85",,,,,,
Health Alliance MCR ADV,DRG,MS-192,CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC,Medical,Relative Weights,"$4,062.36 ",IP,"2,420.00","14,297.47",,,,,,
Health Alliance MCR ADV,DRG,MS-193,SIMPLE PNEUMONIA & PLEURISY W MCC,Medical,Relative Weights,"$7,662.18 ",IP,"2,420.00","26,883.36",,,,,,
Health Alliance MCR ADV,DRG,MS-194,SIMPLE PNEUMONIA AND PLEURISY WITH CC,Medical,Relative Weights,"$5,045.24 ",IP,"2,420.00","17,914.18",,,,,,
Health Alliance MCR ADV,DRG,MS-195,SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,Medical,Relative Weights,"$3,888.32 ",IP,"2,420.00","13,751.14",,,,,,
Health Alliance MCR ADV,DRG,MS-196,INTERSTITIAL LUNG DISEASE WITH MCC,Medical,Relative Weights,"$10,153.56 ",IP,"2,420.00","33,776.06",,,,,,
Health Alliance MCR ADV,DRG,MS-197,INTERSTITIAL LUNG DISEASE WITH CC,Medical,Relative Weights,"$5,880.96 ",IP,"2,420.00","20,593.44",,,,,,
Health Alliance MCR ADV,DRG,MS-198,INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,Medical,Relative Weights,"$4,341.51 ",IP,"2,420.00","15,220.80",,,,,,
Health Alliance MCR ADV,DRG,MS-199,PNEUMOTHORAX WITH MCC,Medical,Relative Weights,"$10,453.74 ",IP,"2,420.00","36,169.06",,,,,,
Health Alliance MCR ADV,DRG,MS-200,PNEUMOTHORAX WITH CC,Medical,Relative Weights,"$6,286.84 ",IP,"2,420.00","21,815.14",,,,,,
Health Alliance MCR ADV,DRG,MS-201,PNEUMOTHORAX WITHOUT CC/MCC,Medical,Relative Weights,"$4,144.12 ",IP,"2,420.00","14,474.88",,,,,,
Health Alliance MCR ADV,DRG,MS-202,BRONCHITIS AND ASTHMA WITH CC/MCC,Medical,Relative Weights,"$5,647.36 ",IP,"2,420.00","19,111.68",,,,,,
Health Alliance MCR ADV,DRG,MS-203,BRONCHITIS AND ASTHMA WITHOUT CC/MCC,Medical,Relative Weights,"$4,128.93 ",IP,"2,420.00","13,987.01",,,,,,
Health Alliance MCR ADV,DRG,MS-204,RESPIRATORY SIGNS AND SYMPTOMS,Medical,Relative Weights,"$4,634.69 ",IP,"2,420.00","16,380.00",,,,,,
Health Alliance MCR ADV,DRG,MS-205,OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,Medical,Relative Weights,"$9,839.36 ",IP,"2,420.00","32,945.47",,,,,,
Health Alliance MCR ADV,DRG,MS-206,OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,Medical,Relative Weights,"$5,174.31 ",IP,"2,420.00","17,589.60",,,,,,
Health Alliance MCR ADV,DRG,MS-207,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS,Medical,Relative Weights,"$33,499.27 ",IP,"2,420.00","115,629.70",,,,,,
Health Alliance MCR ADV,DRG,MS-208,RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,Medical,Relative Weights,"$14,861.83 ",IP,"2,420.00","50,079.46",,,,,,
Health Alliance MCR ADV,DRG,MS-215,OTHER HEART ASSIST SYSTEM IMPLANT,Surgical,Relative Weights,"$61,661.88 ",IP,"61,661.88","259,783.78",,,,,,
Health Alliance MCR ADV,DRG,MS-216,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$58,630.29 ",IP,"58,630.29","202,454.78",,,,,,
Health Alliance MCR ADV,DRG,MS-217,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,Surgical,Relative Weights,"$37,864.14 ",IP,"37,864.14","134,096.26",,,,,,
Health Alliance MCR ADV,DRG,MS-218,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,Surgical,Relative Weights,"$35,678.79 ",IP,"35,678.79","108,892.22",,,,,,
Health Alliance MCR ADV,DRG,MS-219,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$47,057.01 ",IP,"47,057.01","158,056.42",,,,,,
Health Alliance MCR ADV,DRG,MS-220,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,Surgical,Relative Weights,"$31,567.37 ",IP,"31,567.37","106,966.94",,,,,,
Health Alliance MCR ADV,DRG,MS-221,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,Surgical,Relative Weights,"$26,746.97 ",IP,"26,746.97","92,659.39",,,,,,
Health Alliance MCR ADV,DRG,MS-222,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITH MCC,Surgical,Relative Weights,"$46,434.46 ",IP,"46,434.46","168,227.14",,,,,,
Health Alliance MCR ADV,DRG,MS-223,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITHOUT MCC,Surgical,Relative Weights,"$33,864.27 ",IP,"33,864.27","121,018.46",,,,,,
Health Alliance MCR ADV,DRG,MS-224,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITH MCC,Surgical,Relative Weights,"$43,912.13 ",IP,"43,912.13","149,107.39",,,,,,
Health Alliance MCR ADV,DRG,MS-225,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITHOUT MCC,Surgical,Relative Weights,"$32,808.39 ",IP,"32,808.39","113,879.81",,,,,,
Health Alliance MCR ADV,DRG,MS-226,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$38,340.11 ",IP,"25,420.00","134,824.03",,,,,,
Health Alliance MCR ADV,DRG,MS-227,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Surgical,Relative Weights,"$30,439.07 ",IP,"25,420.00","105,420.67",,,,,,
Health Alliance MCR ADV,DRG,MS-228,OTHER CARDIOTHORACIC PROCEDURES WITH MCC,Surgical,Relative Weights,"$31,129.37 ",IP,"31,129.37","126,731.81",,,,,,
Health Alliance MCR ADV,DRG,MS-229,OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$20,096.88 ",IP,"20,096.88","82,754.78",,,,,,
Health Alliance MCR ADV,DRG,MS-231,CORONARY BYPASS W PTCA W MCC,Surgical,Relative Weights,"$50,901.53 ",IP,"50,901.53","165,543.84",,,,,,
Health Alliance MCR ADV,DRG,MS-232,CORONARY BYPASS W PTCA W/O MCC,Surgical,Relative Weights,"$34,770.65 ",IP,"34,770.65","120,687.84",,,,,,
Health Alliance MCR ADV,DRG,MS-233,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,Surgical,Relative Weights,"$46,266.85 ",IP,"42,365.00","156,621.02",,,,,,
Health Alliance MCR ADV,DRG,MS-234,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,Surgical,Relative Weights,"$31,162.65 ",IP,"31,162.65","104,959.01",,,,,,
Health Alliance MCR ADV,DRG,MS-235,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$35,648.42 ",IP,"32,351.00","118,633.54",,,,,,
Health Alliance MCR ADV,DRG,MS-236,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Surgical,Relative Weights,"$23,926.80 ",IP,"23,926.80","81,226.66",,,,,,
Health Alliance MCR ADV,DRG,MS-239,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,Surgical,Relative Weights,"$28,125.81 ",IP,"2,420.00","94,141.15",,,,,,
Health Alliance MCR ADV,DRG,MS-240,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,Surgical,Relative Weights,"$16,286.81 ",IP,"2,420.00","55,641.60",,,,,,
Health Alliance MCR ADV,DRG,MS-241,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,Surgical,Relative Weights,"$9,299.74 ",IP,"2,420.00","30,568.61",,,,,,
Health Alliance MCR ADV,DRG,MS-242,PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,Surgical,Relative Weights,"$21,769.47 ",IP,"15,407.00","74,815.78",,,,,,
Health Alliance MCR ADV,DRG,MS-243,PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,Surgical,Relative Weights,"$14,708.24 ",IP,"14,708.24","50,992.70",,,,,,
Health Alliance MCR ADV,DRG,MS-244,PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,Surgical,Relative Weights,"$12,049.83 ",IP,"12,049.83","41,840.06",,,,,,
Health Alliance MCR ADV,DRG,MS-245,AICD GENERATOR PROCEDURES,Surgical,Relative Weights,"$31,640.37 ",IP,"15,407.00","104,989.25",,,,,,
Health Alliance MCR ADV,DRG,MS-246,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Surgical,Relative Weights,"$18,246.15 ",IP,"18,246.15","63,963.65",,,,,,
Health Alliance MCR ADV,DRG,MS-247,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITHOUT MCC,Surgical,Relative Weights,"$11,523.64 ",IP,"11,523.64","41,019.55",,,,,,
Health Alliance MCR ADV,DRG,MS-248,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Surgical,Relative Weights,"$18,467.49 ",IP,"18,467.49","62,425.44",,,,,,
Health Alliance MCR ADV,DRG,MS-249,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITHOUT MCC,Surgical,Relative Weights,"$10,942.55 ",IP,"10,942.55","38,638.66",,,,,,
Health Alliance MCR ADV,DRG,MS-250,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT CORONARY ARTERY STENT WITH MCC,Surgical,Relative Weights,"$14,727.51 ",IP,"14,727.51","51,410.02",,,,,,
Health Alliance MCR ADV,DRG,MS-251,PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W/O MCC,Surgical,Relative Weights,"$9,685.18 ",IP,"2,420.00","33,929.28",,,,,,
Health Alliance MCR ADV,DRG,MS-252,OTHER VASCULAR PROCEDURES W MCC,Surgical,Relative Weights,"$19,422.35 ",IP,"2,420.00","66,132.86",,,,,,
Health Alliance MCR ADV,DRG,MS-253,OTHER VASCULAR PROCEDURES WITH CC,Surgical,Relative Weights,"$15,497.23 ",IP,"2,420.00","52,549.06",,,,,,
Health Alliance MCR ADV,DRG,MS-254,OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,605.00 ",IP,"2,420.00","36,693.22",,,,,,
Health Alliance MCR ADV,DRG,MS-255,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,Surgical,Relative Weights,"$14,806.35 ",IP,"2,420.00","53,415.94",,,,,,
Health Alliance MCR ADV,DRG,MS-256,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,Surgical,Relative Weights,"$9,602.26 ",IP,"2,420.00","34,604.64",,,,,,
Health Alliance MCR ADV,DRG,MS-257,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$6,804.86 ",IP,"2,420.00","22,869.50",,,,,,
Health Alliance MCR ADV,DRG,MS-258,CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,Surgical,Relative Weights,"$18,501.95 ",IP,"11,861.00","61,663.39",,,,,,
Health Alliance MCR ADV,DRG,MS-259,CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,Surgical,Relative Weights,"$12,201.09 ",IP,"11,861.00","41,985.22",,,,,,
Health Alliance MCR ADV,DRG,MS-260,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,Surgical,Relative Weights,"$20,833.31 ",IP,"10,167.00","74,583.94",,,,,,
Health Alliance MCR ADV,DRG,MS-261,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,Surgical,Relative Weights,"$11,644.53 ",IP,"10,167.00","39,281.76",,,,,,
Health Alliance MCR ADV,DRG,MS-262,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,Surgical,Relative Weights,"$9,964.34 ",IP,"9,964.34","33,820.42",,,,,,
Health Alliance MCR ADV,DRG,MS-263,VEIN LIGATION AND STRIPPING,Surgical,Relative Weights,"$13,509.27 ",IP,"2,420.00","47,559.46",,,,,,
Health Alliance MCR ADV,DRG,MS-264,OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,Surgical,Relative Weights,"$19,001.28 ",IP,"2,420.00","65,278.08",,,,,,
Health Alliance MCR ADV,DRG,MS-265,AICD LEAD PROCEDURES,Surgical,Relative Weights,"$19,654.78 ",IP,"2,420.00","62,925.41",,,,,,
Health Alliance MCR ADV,DRG,MS-266,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,Surgical,Relative Weights,"$41,160.28 ",IP,"41,160.28","143,567.42",,,,,,
Health Alliance MCR ADV,DRG,MS-267,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$32,692.75 ",IP,"32,692.75","114,420.10",,,,,,
Health Alliance MCR ADV,DRG,MS-268,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,Surgical,Relative Weights,"$40,666.21 ",IP,"32,968.00","136,737.22",,,,,,
Health Alliance MCR ADV,DRG,MS-269,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,Surgical,Relative Weights,"$25,200.52 ",IP,"25,200.52","86,010.62",,,,,,
Health Alliance MCR ADV,DRG,MS-270,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,Surgical,Relative Weights,"$30,292.48 ",IP,"30,292.48","103,021.63",,,,,,
Health Alliance MCR ADV,DRG,MS-271,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,Surgical,Relative Weights,"$20,822.21 ",IP,"20,822.21","71,527.68",,,,,,
Health Alliance MCR ADV,DRG,MS-272,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$15,699.88 ",IP,"15,699.88","52,442.21",,,,,,
Health Alliance MCR ADV,DRG,MS-273,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,Surgical,Relative Weights,"$22,348.22 ",IP,"16,176.00","74,799.65",,,,,,
Health Alliance MCR ADV,DRG,MS-274,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$19,194.00 ",IP,"16,176.00","63,701.57",,,,,,
Health Alliance MCR ADV,DRG,MS-280,ACUTE MYOCARDIAL INFARCTION - DISCHARGED ALIVE W MCC,Medical,Relative Weights,"$9,384.42 ",IP,"2,420.00","32,878.94",,,,,,
Health Alliance MCR ADV,DRG,MS-281,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITH CC,Medical,Relative Weights,"$5,434.78 ",IP,"2,420.00","19,528.99",,,,,,
Health Alliance MCR ADV,DRG,MS-282,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITHOUT CC/MCC,Medical,Relative Weights,"$4,240.48 ",IP,"2,420.00","14,876.06",,,,,,
Health Alliance MCR ADV,DRG,MS-283,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH MCC,Medical,Relative Weights,"$10,889.99 ",IP,"2,420.00","36,281.95",,,,,,
Health Alliance MCR ADV,DRG,MS-284,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH CC,Medical,Relative Weights,"$4,224.71 ",IP,"2,420.00","14,622.05",,,,,,
Health Alliance MCR ADV,DRG,MS-285,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITHOUT CC/MCC,Medical,Relative Weights,"$2,889.09 ",IP,"2,420.00","10,438.85",,,,,,
Health Alliance MCR ADV,DRG,MS-286,CIRCULATORY DISORDERS EXCEPT AMI- WITH CARDIAC CATHETERIZATION WITH MCC,Medical,Relative Weights,"$12,476.16 ",IP,"2,420.00","44,299.58",,,,,,
Health Alliance MCR ADV,DRG,MS-287,CIRCULATORY DISORDERS EXCEPT AMI -  WITH CARDIAC CATHETERIZATION WITHOUT MCC,Medical,Relative Weights,"$6,512.27 ",IP,"6,512.27","23,228.35",,,,,,
Health Alliance MCR ADV,DRG,MS-288,ACUTE & SUBACUTE ENDOCARDITIS W MCC,Medical,Relative Weights,"$15,682.94 ",IP,"2,420.00","53,573.18",,,,,,
Health Alliance MCR ADV,DRG,MS-289,ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,Medical,Relative Weights,"$9,598.75 ",IP,"9,181.00","33,542.21",,,,,,
Health Alliance MCR ADV,DRG,MS-290,ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,Medical,Relative Weights,"$5,997.18 ",IP,"2,420.00","20,172.10",,,,,,
Health Alliance MCR ADV,DRG,MS-291,HEART FAILURE AND SHOCK WITH MCC,Medical,Relative Weights,"$7,406.97 ",IP,"2,420.00","27,131.33",,,,,,
Health Alliance MCR ADV,DRG,MS-292,HEART FAILURE AND SHOCK WITH CC,Medical,Relative Weights,"$5,042.91 ",IP,"2,420.00","18,254.88",,,,,,
Health Alliance MCR ADV,DRG,MS-293,HEART FAILURE AND SHOCK WITHOUT CC/MCC,Medical,Relative Weights,"$3,445.06 ",IP,"2,420.00","13,210.85",,,,,,
Health Alliance MCR ADV,DRG,MS-294,DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC,Medical,Relative Weights,"$7,491.65 ",IP,"2,420.00","25,641.50",,,,,,
Health Alliance MCR ADV,DRG,MS-295,DEEP VEIN THROMBOPHLEBITIS W/O CC/MCC,Medical,Relative Weights,"$5,747.22 ",IP,"2,420.00","11,632.32",,,,,,
Health Alliance MCR ADV,DRG,MS-296,CARDIAC ARREST - UNEXPLAINED W MCC,Medical,Relative Weights,"$9,316.09 ",IP,"2,420.00","31,659.26",,,,,,
Health Alliance MCR ADV,DRG,MS-297,CARDIAC ARREST- UNEXPLAINED WITH CC,Medical,Relative Weights,"$4,128.93 ",IP,"2,420.00","14,575.68",,,,,,
Health Alliance MCR ADV,DRG,MS-298,CARDIAC ARREST- UNEXPLAINED WITHOUT CC/MCC,Medical,Relative Weights,"$2,854.63 ",IP,"2,420.00","10,144.51",,,,,,
Health Alliance MCR ADV,DRG,MS-299,PERIPHERAL VASCULAR DISORDERS WITH MCC,Medical,Relative Weights,"$8,950.50 ",IP,"2,420.00","29,225.95",,,,,,
Health Alliance MCR ADV,DRG,MS-300,PERIPHERAL VASCULAR DISORDERS WITH CC,Medical,Relative Weights,"$6,095.87 ",IP,"2,420.00","20,716.42",,,,,,
Health Alliance MCR ADV,DRG,MS-301,PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$4,339.76 ",IP,"2,420.00","14,632.13",,,,,,
Health Alliance MCR ADV,DRG,MS-302,ATHEROSCLEROSIS WITH MCC,Medical,Relative Weights,"$6,393.72 ",IP,"2,420.00","22,222.37",,,,,,
Health Alliance MCR ADV,DRG,MS-303,ATHEROSCLEROSIS WITHOUT MCC,Medical,Relative Weights,"$3,957.24 ",IP,"2,420.00","13,622.11",,,,,,
Health Alliance MCR ADV,DRG,MS-304,HYPERTENSION WITH MCC,Medical,Relative Weights,"$6,406.57 ",IP,"2,420.00","22,004.64",,,,,,
Health Alliance MCR ADV,DRG,MS-305,HYPERTENSION WITHOUT MCC,Medical,Relative Weights,"$4,321.07 ",IP,"2,420.00","14,747.04",,,,,,
Health Alliance MCR ADV,DRG,MS-306,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,Medical,Relative Weights,"$8,803.33 ",IP,"2,420.00","28,516.32",,,,,,
Health Alliance MCR ADV,DRG,MS-307,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,Medical,Relative Weights,"$5,083.20 ",IP,"2,420.00","17,785.15",,,,,,
Health Alliance MCR ADV,DRG,MS-308,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,Medical,Relative Weights,"$7,013.35 ",IP,"2,420.00","23,944.03",,,,,,
Health Alliance MCR ADV,DRG,MS-309,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,Medical,Relative Weights,"$4,382.98 ",IP,"2,420.00","15,247.01",,,,,,
Health Alliance MCR ADV,DRG,MS-310,CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC,Medical,Relative Weights,"$3,265.77 ",IP,"2,420.00","11,275.49",,,,,,
Health Alliance MCR ADV,DRG,MS-311,ANGINA PECTORIS,Medical,Relative Weights,"$4,079.29 ",IP,"2,420.00","13,809.60",,,,,,
Health Alliance MCR ADV,DRG,MS-312,SYNCOPE AND COLLAPSE,Medical,Relative Weights,"$4,898.07 ",IP,"2,420.00","16,462.66",,,,,,
Health Alliance MCR ADV,DRG,MS-313,CHEST PAIN,Medical,Relative Weights,"$4,213.03 ",IP,"2,420.00","14,420.45",,,,,,
Health Alliance MCR ADV,DRG,MS-314,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,Medical,Relative Weights,"$12,174.81 ",IP,"2,420.00","40,914.72",,,,,,
Health Alliance MCR ADV,DRG,MS-315,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,Medical,Relative Weights,"$5,684.73 ",IP,"2,420.00","19,563.26",,,,,,
Health Alliance MCR ADV,DRG,MS-316,OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$4,224.71 ",IP,"2,420.00","14,962.75",,,,,,
Health Alliance MCR ADV,DRG,MS-319,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,Surgical,Relative Weights,"$25,216.87 ",IP,"2,420.00","82,670.11",,,,,,
Health Alliance MCR ADV,DRG,MS-320,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$14,048.89 ",IP,"2,420.00","47,329.63",,,,,,
Health Alliance MCR ADV,DRG,MS-326,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$31,047.60 ",IP,"2,420.00","106,253.28",,,,,,
Health Alliance MCR ADV,DRG,MS-327,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC,Surgical,Relative Weights,"$14,978.05 ",IP,"2,420.00","51,869.66",,,,,,
Health Alliance MCR ADV,DRG,MS-328,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$9,734.83 ",IP,"2,420.00","31,752.00",,,,,,
Health Alliance MCR ADV,DRG,MS-329,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Surgical,Relative Weights,"$28,535.79 ",IP,"2,420.00","98,929.15",,,,,,
Health Alliance MCR ADV,DRG,MS-330,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Surgical,Relative Weights,"$14,888.11 ",IP,"2,420.00","50,940.29",,,,,,
Health Alliance MCR ADV,DRG,MS-331,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$9,989.45 ",IP,"2,420.00","34,054.27",,,,,,
Health Alliance MCR ADV,DRG,MS-332,RECTAL RESECTION WITH MCC,Surgical,Relative Weights,"$24,303.48 ",IP,"2,420.00","70,396.70",,,,,,
Health Alliance MCR ADV,DRG,MS-333,RECTAL RESECTION WITH CC,Surgical,Relative Weights,"$12,505.36 ",IP,"2,420.00","45,626.11",,,,,,
Health Alliance MCR ADV,DRG,MS-334,RECTAL RESECTION WITHOUT CC/MCC,Surgical,Relative Weights,"$9,394.35 ",IP,"2,420.00","31,052.45",,,,,,
Health Alliance MCR ADV,DRG,MS-335,PERITONEAL ADHESIOLYSIS WITH MCC,Surgical,Relative Weights,"$22,855.14 ",IP,"2,420.00","81,549.22",,,,,,
Health Alliance MCR ADV,DRG,MS-336,PERITONEAL ADHESIOLYSIS WITH CC,Surgical,Relative Weights,"$13,381.37 ",IP,"2,420.00","45,686.59",,,,,,
Health Alliance MCR ADV,DRG,MS-337,PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$9,561.96 ",IP,"2,420.00","33,056.35",,,,,,
Health Alliance MCR ADV,DRG,MS-338,APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$16,336.45 ",IP,"2,420.00","58,667.62",,,,,,
Health Alliance MCR ADV,DRG,MS-339,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W CC,Surgical,Relative Weights,"$9,912.95 ",IP,"2,420.00","34,596.58",,,,,,
Health Alliance MCR ADV,DRG,MS-340,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC/MCC,Surgical,Relative Weights,"$7,173.37 ",IP,"2,420.00","24,948.00",,,,,,
Health Alliance MCR ADV,DRG,MS-341,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$13,563.00 ",IP,"2,420.00","51,571.30",,,,,,
Health Alliance MCR ADV,DRG,MS-342,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH CC,Surgical,Relative Weights,"$8,368.25 ",IP,"2,420.00","32,463.65",,,,,,
Health Alliance MCR ADV,DRG,MS-343,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$6,474.31 ",IP,"2,420.00","23,216.26",,,,,,
Health Alliance MCR ADV,DRG,MS-344,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Surgical,Relative Weights,"$16,459.67 ",IP,"2,420.00","60,381.22",,,,,,
Health Alliance MCR ADV,DRG,MS-345,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Surgical,Relative Weights,"$9,220.31 ",IP,"2,420.00","32,927.33",,,,,,
Health Alliance MCR ADV,DRG,MS-346,MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,448.43 ",IP,"2,420.00","25,859.23",,,,,,
Health Alliance MCR ADV,DRG,MS-347,ANAL AND STOMAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$14,394.04 ",IP,"2,420.00","53,149.82",,,,,,
Health Alliance MCR ADV,DRG,MS-348,ANAL AND STOMAL PROCEDURES WITH CC,Surgical,Relative Weights,"$7,873.01 ",IP,"2,420.00","28,411.49",,,,,,
Health Alliance MCR ADV,DRG,MS-349,ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$5,719.19 ",IP,"2,420.00","19,774.94",,,,,,
Health Alliance MCR ADV,DRG,MS-350,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,Surgical,Relative Weights,"$14,336.22 ",IP,"2,420.00","49,176.29",,,,,,
Health Alliance MCR ADV,DRG,MS-351,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,Surgical,Relative Weights,"$8,717.48 ",IP,"2,420.00","29,399.33",,,,,,
Health Alliance MCR ADV,DRG,MS-352,INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,449.78 ",IP,"2,420.00","21,708.29",,,,,,
Health Alliance MCR ADV,DRG,MS-353,HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,Surgical,Relative Weights,"$17,665.65 ",IP,"2,420.00","59,812.70",,,,,,
Health Alliance MCR ADV,DRG,MS-354,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W CC,Surgical,Relative Weights,"$10,423.37 ",IP,"2,420.00","34,717.54",,,,,,
Health Alliance MCR ADV,DRG,MS-355,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W/O CC/MCC,Surgical,Relative Weights,"$7,943.67 ",IP,"2,420.00","27,667.58",,,,,,
Health Alliance MCR ADV,DRG,MS-356,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$25,157.89 ",IP,"2,420.00","82,196.35",,,,,,
Health Alliance MCR ADV,DRG,MS-357,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$13,248.22 ",IP,"2,420.00","45,368.06",,,,,,
Health Alliance MCR ADV,DRG,MS-358,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,878.85 ",IP,"2,420.00","27,653.47",,,,,,
Health Alliance MCR ADV,DRG,MS-368,MAJOR ESOPHAGEAL DISORDERS WITH MCC,Medical,Relative Weights,"$11,382.90 ",IP,"2,420.00","38,376.58",,,,,,
Health Alliance MCR ADV,DRG,MS-369,MAJOR ESOPHAGEAL DISORDERS WITH CC,Medical,Relative Weights,"$6,290.93 ",IP,"2,420.00","21,432.10",,,,,,
Health Alliance MCR ADV,DRG,MS-370,MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$4,368.96 ",IP,"2,420.00","15,065.57",,,,,,
Health Alliance MCR ADV,DRG,MS-371,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,Medical,Relative Weights,"$10,110.34 ",IP,"2,420.00","34,786.08",,,,,,
Health Alliance MCR ADV,DRG,MS-372,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,Medical,Relative Weights,"$6,011.19 ",IP,"2,420.00","20,613.60",,,,,,
Health Alliance MCR ADV,DRG,MS-373,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,Medical,Relative Weights,"$4,348.52 ",IP,"2,420.00","14,954.69",,,,,,
Health Alliance MCR ADV,DRG,MS-374,DIGESTIVE MALIGNANCY WITH MCC,Medical,Relative Weights,"$12,110.57 ",IP,"2,420.00","40,269.60",,,,,,
Health Alliance MCR ADV,DRG,MS-375,DIGESTIVE MALIGNANCY WITH CC,Medical,Relative Weights,"$7,052.48 ",IP,"2,420.00","24,339.17",,,,,,
Health Alliance MCR ADV,DRG,MS-376,DIGESTIVE MALIGNANCY WITHOUT CC/MCC,Medical,Relative Weights,"$5,249.65 ",IP,"2,420.00","20,186.21",,,,,,
Health Alliance MCR ADV,DRG,MS-377,GASTROINTESTINAL HEMORRHAGE WITH MCC,Medical,Relative Weights,"$10,519.15 ",IP,"2,420.00","35,681.18",,,,,,
Health Alliance MCR ADV,DRG,MS-378,GASTROINTESTINAL HEMORRHAGE WITH CC,Medical,Relative Weights,"$5,802.12 ",IP,"2,420.00","19,920.10",,,,,,
Health Alliance MCR ADV,DRG,MS-379,GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,Medical,Relative Weights,"$3,721.30 ",IP,"2,420.00","13,017.31",,,,,,
Health Alliance MCR ADV,DRG,MS-380,COMPLICATED PEPTIC ULCER WITH MCC,Medical,Relative Weights,"$11,017.89 ",IP,"2,420.00","38,054.02",,,,,,
Health Alliance MCR ADV,DRG,MS-381,COMPLICATED PEPTIC ULCER WITH CC,Medical,Relative Weights,"$6,186.39 ",IP,"2,420.00","21,706.27",,,,,,
Health Alliance MCR ADV,DRG,MS-382,COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,Medical,Relative Weights,"$4,488.68 ",IP,"2,420.00","15,954.62",,,,,,
Health Alliance MCR ADV,DRG,MS-383,UNCOMPLICATED PEPTIC ULCER WITH MCC,Medical,Relative Weights,"$7,665.69 ",IP,"2,420.00","26,738.21",,,,,,
Health Alliance MCR ADV,DRG,MS-384,UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,Medical,Relative Weights,"$5,214.02 ",IP,"2,420.00","17,543.23",,,,,,
Health Alliance MCR ADV,DRG,MS-385,INFLAMMATORY BOWEL DISEASE WITH MCC,Medical,Relative Weights,"$9,474.36 ",IP,"2,420.00","32,463.65",,,,,,
Health Alliance MCR ADV,DRG,MS-386,INFLAMMATORY BOWEL DISEASE W CC,Medical,Relative Weights,"$5,811.46 ",IP,"2,420.00","19,861.63",,,,,,
Health Alliance MCR ADV,DRG,MS-387,INFLAMMATORY BOWEL DISEASE W/O CC/MCC,Medical,Relative Weights,"$4,173.90 ",IP,"2,420.00","14,126.11",,,,,,
Health Alliance MCR ADV,DRG,MS-388,GASTROINTESTINAL OBSTRUCTION WITH MCC,Medical,Relative Weights,"$8,845.38 ",IP,"2,420.00","30,746.02",,,,,,
Health Alliance MCR ADV,DRG,MS-389,GASTROINTESTINAL OBSTRUCTION WITH CC,Medical,Relative Weights,"$4,807.55 ",IP,"2,420.00","16,928.35",,,,,,
Health Alliance MCR ADV,DRG,MS-390,GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,Medical,Relative Weights,"$3,405.35 ",IP,"2,420.00","11,684.74",,,,,,
Health Alliance MCR ADV,DRG,MS-391,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC,Medical,Relative Weights,"$7,295.42 ",IP,"2,420.00","24,897.60",,,,,,
Health Alliance MCR ADV,DRG,MS-392,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC,Medical,Relative Weights,"$4,472.33 ",IP,"2,420.00","15,351.84",,,,,,
Health Alliance MCR ADV,DRG,MS-393,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,Medical,Relative Weights,"$9,701.54 ",IP,"2,420.00","32,749.92",,,,,,
Health Alliance MCR ADV,DRG,MS-394,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,Medical,Relative Weights,"$5,494.93 ",IP,"2,420.00","18,912.10",,,,,,
Health Alliance MCR ADV,DRG,MS-395,OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$3,804.81 ",IP,"2,420.00","13,192.70",,,,,,
Health Alliance MCR ADV,DRG,MS-405,PANCREAS- LIVER AND SHUNT PROCEDURES WITH MCC,Surgical,Relative Weights,"$33,508.03 ",IP,"2,420.00","109,412.35",,,,,,
Health Alliance MCR ADV,DRG,MS-406,PANCREAS -  LIVER AND SHUNT PROCEDURES WITH CC,Surgical,Relative Weights,"$16,824.68 ",IP,"2,420.00","56,264.54",,,,,,
Health Alliance MCR ADV,DRG,MS-407,PANCREAS -  LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$12,369.28 ",IP,"2,420.00","42,059.81",,,,,,
Health Alliance MCR ADV,DRG,MS-408,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,Surgical,Relative Weights,"$21,917.23 ",IP,"2,420.00","71,842.18",,,,,,
Health Alliance MCR ADV,DRG,MS-409,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,Surgical,Relative Weights,"$12,359.94 ",IP,"2,420.00","48,259.01",,,,,,
Health Alliance MCR ADV,DRG,MS-410,BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W/O CC/MCC,Surgical,Relative Weights,"$9,158.99 ",IP,"2,420.00","33,465.60",,,,,,
Health Alliance MCR ADV,DRG,MS-411,CHOLECYSTECTOMY W C.D.E. W MCC,Surgical,Relative Weights,"$21,920.73 ",IP,"2,420.00","77,220.86",,,,,,
Health Alliance MCR ADV,DRG,MS-412,CHOLECYSTECTOMY WITH C.D.E. WITH CC,Surgical,Relative Weights,"$13,300.78 ",IP,"2,420.00","47,920.32",,,,,,
Health Alliance MCR ADV,DRG,MS-413,CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,Surgical,Relative Weights,"$10,108.59 ",IP,"2,420.00","32,604.77",,,,,,
Health Alliance MCR ADV,DRG,MS-414,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,Surgical,Relative Weights,"$21,189.55 ",IP,"2,420.00","68,874.62",,,,,,
Health Alliance MCR ADV,DRG,MS-415,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,Surgical,Relative Weights,"$11,865.29 ",IP,"2,420.00","41,362.27",,,,,,
Health Alliance MCR ADV,DRG,MS-416,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,Surgical,Relative Weights,"$8,306.34 ",IP,"2,420.00","27,222.05",,,,,,
Health Alliance MCR ADV,DRG,MS-417,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,Surgical,Relative Weights,"$14,158.10 ",IP,"2,420.00","48,599.71",,,,,,
Health Alliance MCR ADV,DRG,MS-418,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,Surgical,Relative Weights,"$9,863.89 ",IP,"2,420.00","33,645.02",,,,,,
Health Alliance MCR ADV,DRG,MS-419,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,Surgical,Relative Weights,"$7,681.45 ",IP,"2,420.00","26,345.09",,,,,,
Health Alliance MCR ADV,DRG,MS-420,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,Surgical,Relative Weights,"$20,536.63 ",IP,"2,420.00","69,245.57",,,,,,
Health Alliance MCR ADV,DRG,MS-421,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,Surgical,Relative Weights,"$11,139.95 ",IP,"2,420.00","37,118.59",,,,,,
Health Alliance MCR ADV,DRG,MS-422,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,489.14 ",IP,"2,420.00","28,314.72",,,,,,
Health Alliance MCR ADV,DRG,MS-423,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$24,445.98 ",IP,"2,420.00","85,442.11",,,,,,
Health Alliance MCR ADV,DRG,MS-424,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$13,339.32 ",IP,"2,420.00","45,388.22",,,,,,
Health Alliance MCR ADV,DRG,MS-425,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$9,009.49 ",IP,"2,420.00","29,463.84",,,,,,
Health Alliance MCR ADV,DRG,MS-432,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,Medical,Relative Weights,"$10,984.02 ",IP,"2,420.00","36,759.74",,,,,,
Health Alliance MCR ADV,DRG,MS-433,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,Medical,Relative Weights,"$6,014.70 ",IP,"2,420.00","20,805.12",,,,,,
Health Alliance MCR ADV,DRG,MS-434,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Medical,Relative Weights,"$3,624.94 ",IP,"2,420.00","12,900.38",,,,,,
Health Alliance MCR ADV,DRG,MS-435,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,Medical,Relative Weights,"$10,239.99 ",IP,"2,420.00","34,213.54",,,,,,
Health Alliance MCR ADV,DRG,MS-436,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,Medical,Relative Weights,"$6,549.65 ",IP,"2,420.00","22,694.11",,,,,,
Health Alliance MCR ADV,DRG,MS-437,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,Medical,Relative Weights,"$5,232.13 ",IP,"2,420.00","17,698.46",,,,,,
Health Alliance MCR ADV,DRG,MS-438,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,Medical,Relative Weights,"$9,331.28 ",IP,"2,420.00","33,028.13",,,,,,
Health Alliance MCR ADV,DRG,MS-439,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,Medical,Relative Weights,"$4,936.03 ",IP,"2,420.00","17,079.55",,,,,,
Health Alliance MCR ADV,DRG,MS-440,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,Medical,Relative Weights,"$3,540.84 ",IP,"2,420.00","12,410.50",,,,,,
Health Alliance MCR ADV,DRG,MS-441,DISORDERS OF LIVER EXCEPT MALIGNANCY- CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC,Medical,Relative Weights,"$10,976.43 ",IP,"2,420.00","37,306.08",,,,,,
Health Alliance MCR ADV,DRG,MS-442,DISORDERS OF LIVER EXCEPT MALIGNANCY -  CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC,Medical,Relative Weights,"$5,431.27 ",IP,"2,420.00","18,817.34",,,,,,
Health Alliance MCR ADV,DRG,MS-443,DISORDERS OF LIVER EXCEPT MALIGNANCY -  CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Medical,Relative Weights,"$3,873.14 ",IP,"2,420.00","13,714.85",,,,,,
Health Alliance MCR ADV,DRG,MS-444,DISORDERS OF THE BILIARY TRACT WITH MCC,Medical,Relative Weights,"$9,762.27 ",IP,"2,420.00","32,782.18",,,,,,
Health Alliance MCR ADV,DRG,MS-445,DISORDERS OF THE BILIARY TRACT WITH CC,Medical,Relative Weights,"$6,292.68 ",IP,"2,420.00","21,661.92",,,,,,
Health Alliance MCR ADV,DRG,MS-446,DISORDERS OF THE BILIARY TRACT W/O CC/MCC,Medical,Relative Weights,"$4,769.01 ",IP,"2,420.00","16,384.03",,,,,,
Health Alliance MCR ADV,DRG,MS-453,COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W MCC,Surgical,Relative Weights,"$53,658.63 ",IP,"2,420.00","189,645.12",,,,,,
Health Alliance MCR ADV,DRG,MS-454,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC,Surgical,Relative Weights,"$35,584.18 ",IP,"2,420.00","123,480.00",,,,,,
Health Alliance MCR ADV,DRG,MS-455,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CC/MCC,Surgical,Relative Weights,"$27,923.16 ",IP,"2,420.00","97,036.13",,,,,,
Health Alliance MCR ADV,DRG,MS-456,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH MCC,Surgical,Relative Weights,"$50,224.67 ",IP,"2,420.00","183,076.99",,,,,,
Health Alliance MCR ADV,DRG,MS-457,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH CC,Surgical,Relative Weights,"$37,936.56 ",IP,"2,420.00","131,308.13",,,,,,
Health Alliance MCR ADV,DRG,MS-458,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC,Surgical,Relative Weights,"$29,244.77 ",IP,"2,420.00","94,629.02",,,,,,
Health Alliance MCR ADV,DRG,MS-459,SPINAL FUSION EXCEPT CERVICAL WITH MCC,Surgical,Relative Weights,"$39,324.16 ",IP,"21,658.00","138,136.32",,,,,,
Health Alliance MCR ADV,DRG,MS-460,SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,Surgical,Relative Weights,"$22,955.59 ",IP,"21,658.00","79,841.66",,,,,,
Health Alliance MCR ADV,DRG,MS-461,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,Surgical,Relative Weights,"$35,517.60 ",IP,"2,420.00","108,436.61",,,,,,
Health Alliance MCR ADV,DRG,MS-462,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,Surgical,Relative Weights,"$18,346.02 ",IP,"2,420.00","63,229.82",,,,,,
Health Alliance MCR ADV,DRG,MS-463,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,Surgical,Relative Weights,"$31,362.97 ",IP,"2,420.00","105,392.45",,,,,,
Health Alliance MCR ADV,DRG,MS-464,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,Surgical,Relative Weights,"$17,379.49 ",IP,"2,420.00","59,526.43",,,,,,
Health Alliance MCR ADV,DRG,MS-465,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$10,769.69 ",IP,"2,420.00","38,610.43",,,,,,
Health Alliance MCR ADV,DRG,MS-466,REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,Surgical,Relative Weights,"$31,219.30 ",IP,"2,420.00","102,797.86",,,,,,
Health Alliance MCR ADV,DRG,MS-467,REVISION OF HIP OR KNEE REPLACEMENT W CC,Surgical,Relative Weights,"$20,892.88 ",IP,"2,420.00","70,803.94",,,,,,
Health Alliance MCR ADV,DRG,MS-468,REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,Surgical,Relative Weights,"$16,366.23 ",IP,"2,420.00","56,691.94",,,,,,
Health Alliance MCR ADV,DRG,MS-469,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,Surgical,Relative Weights,"$18,021.90 ",IP,"2,420.00","63,300.38",,,,,,
Health Alliance MCR ADV,DRG,MS-470,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,Surgical,Relative Weights,"$11,097.90 ",IP,"2,420.00","39,682.94",,,,,,
Health Alliance MCR ADV,DRG,MS-471,CERVICAL SPINAL FUSION WITH MCC,Surgical,Relative Weights,"$29,315.44 ",IP,"15,407.00","100,687.10",,,,,,
Health Alliance MCR ADV,DRG,MS-472,CERVICAL SPINAL FUSION WITH CC,Surgical,Relative Weights,"$17,833.84 ",IP,"15,407.00","61,316.64",,,,,,
Health Alliance MCR ADV,DRG,MS-473,CERVICAL SPINAL FUSION WITHOUT CC/MCC,Surgical,Relative Weights,"$14,827.96 ",IP,"14,827.96","50,649.98",,,,,,
Health Alliance MCR ADV,DRG,MS-474,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,Surgical,Relative Weights,"$23,804.74 ",IP,"2,420.00","78,117.98",,,,,,
Health Alliance MCR ADV,DRG,MS-475,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,Surgical,Relative Weights,"$12,826.56 ",IP,"2,420.00","42,356.16",,,,,,
Health Alliance MCR ADV,DRG,MS-476,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$6,776.24 ",IP,"2,420.00","23,480.35",,,,,,
Health Alliance MCR ADV,DRG,MS-477,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Surgical,Relative Weights,"$19,616.24 ",IP,"2,420.00","65,626.85",,,,,,
Health Alliance MCR ADV,DRG,MS-478,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Surgical,Relative Weights,"$13,773.24 ",IP,"2,420.00","46,712.74",,,,,,
Health Alliance MCR ADV,DRG,MS-479,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Surgical,Relative Weights,"$10,567.62 ",IP,"2,420.00","35,929.15",,,,,,
Health Alliance MCR ADV,DRG,MS-480,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,Surgical,Relative Weights,"$17,670.91 ",IP,"2,420.00","60,852.96",,,,,,
Health Alliance MCR ADV,DRG,MS-481,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,Surgical,Relative Weights,"$12,241.39 ",IP,"2,420.00","42,090.05",,,,,,
Health Alliance MCR ADV,DRG,MS-482,HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC,Surgical,Relative Weights,"$9,611.60 ",IP,"2,420.00","33,169.25",,,,,,
Health Alliance MCR ADV,DRG,MS-483,MAJOR JOINT & LIMB REATTACHMENT PROC OF UPPER EXTREMITY W CC/MCC,Surgical,Relative Weights,"$13,932.67 ",IP,"2,420.00","48,224.74",,,,,,
Health Alliance MCR ADV,DRG,MS-485,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,Surgical,Relative Weights,"$19,912.33 ",IP,"2,420.00","66,104.64",,,,,,
Health Alliance MCR ADV,DRG,MS-486,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,Surgical,Relative Weights,"$12,552.66 ",IP,"2,420.00","43,356.10",,,,,,
Health Alliance MCR ADV,DRG,MS-487,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Surgical,Relative Weights,"$9,578.90 ",IP,"2,420.00","32,401.15",,,,,,
Health Alliance MCR ADV,DRG,MS-488,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,Surgical,Relative Weights,"$11,538.24 ",IP,"2,420.00","39,699.07",,,,,,
Health Alliance MCR ADV,DRG,MS-489,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Surgical,Relative Weights,"$7,581.59 ",IP,"2,420.00","25,381.44",,,,,,
Health Alliance MCR ADV,DRG,MS-492,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH MCC,Surgical,Relative Weights,"$20,265.07 ",IP,"2,420.00","69,457.25",,,,,,
Health Alliance MCR ADV,DRG,MS-493,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH CC,Surgical,Relative Weights,"$13,582.85 ",IP,"2,420.00","46,408.32",,,,,,
Health Alliance MCR ADV,DRG,MS-494,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITHOUT CC/MCC,Surgical,Relative Weights,"$10,814.07 ",IP,"2,420.00","36,517.82",,,,,,
Health Alliance MCR ADV,DRG,MS-495,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,Surgical,Relative Weights,"$21,268.98 ",IP,"2,420.00","69,201.22",,,,,,
Health Alliance MCR ADV,DRG,MS-496,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,Surgical,Relative Weights,"$11,600.73 ",IP,"2,420.00","41,136.48",,,,,,
Health Alliance MCR ADV,DRG,MS-497,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,Surgical,Relative Weights,"$8,476.87 ",IP,"2,420.00","29,621.09",,,,,,
Health Alliance MCR ADV,DRG,MS-498,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,Surgical,Relative Weights,"$15,089.01 ",IP,"2,420.00","49,353.70",,,,,,
Health Alliance MCR ADV,DRG,MS-499,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,Surgical,Relative Weights,"$7,002.25 ",IP,"2,420.00","23,202.14",,,,,,
Health Alliance MCR ADV,DRG,MS-500,SOFT TISSUE PROCEDURES WITH MCC,Surgical,Relative Weights,"$18,626.93 ",IP,"2,420.00","60,786.43",,,,,,
Health Alliance MCR ADV,DRG,MS-501,SOFT TISSUE PROCEDURES WITH CC,Surgical,Relative Weights,"$10,244.08 ",IP,"2,420.00","33,828.48",,,,,,
Health Alliance MCR ADV,DRG,MS-502,SOFT TISSUE PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,783.66 ",IP,"2,420.00","26,625.31",,,,,,
Health Alliance MCR ADV,DRG,MS-503,FOOT PROCEDURES WITH MCC,Surgical,Relative Weights,"$15,421.31 ",IP,"2,420.00","54,766.66",,,,,,
Health Alliance MCR ADV,DRG,MS-504,FOOT PROCEDURES WITH CC,Surgical,Relative Weights,"$10,366.14 ",IP,"2,420.00","35,007.84",,,,,,
Health Alliance MCR ADV,DRG,MS-505,FOOT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,366.14 ",IP,"2,420.00","33,899.04",,,,,,
Health Alliance MCR ADV,DRG,MS-506,MAJOR THUMB OR JOINT PROCEDURES,Surgical,Relative Weights,"$8,664.34 ",IP,"2,420.00","26,986.18",,,,,,
Health Alliance MCR ADV,DRG,MS-507,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W CC/MCC,Surgical,Relative Weights,"$12,035.82 ",IP,"2,420.00","42,336.00",,,,,,
Health Alliance MCR ADV,DRG,MS-508,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$8,232.76 ",IP,"2,420.00","31,417.34",,,,,,
Health Alliance MCR ADV,DRG,MS-509,ARTHROSCOPY,Surgical,Relative Weights,"$9,849.29 ",IP,"2,420.00","28,056.67",,,,,,
Health Alliance MCR ADV,DRG,MS-510,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH MCC,Surgical,Relative Weights,"$16,023.42 ",IP,"2,420.00","56,206.08",,,,,,
Health Alliance MCR ADV,DRG,MS-511,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH CC,Surgical,Relative Weights,"$11,489.77 ",IP,"2,420.00","37,985.47",,,,,,
Health Alliance MCR ADV,DRG,MS-512,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$9,078.40 ",IP,"2,420.00","30,518.21",,,,,,
Health Alliance MCR ADV,DRG,MS-513,HAND OR WRIST PROCEDURES- EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$9,180.60 ",IP,"2,420.00","31,794.34",,,,,,
Health Alliance MCR ADV,DRG,MS-514,HAND OR WRIST PROCEDURES -  EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$5,834.82 ",IP,"2,420.00","21,506.69",,,,,,
Health Alliance MCR ADV,DRG,MS-515,OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W MCC,Surgical,Relative Weights,"$18,341.35 ",IP,"2,420.00","63,584.64",,,,,,
Health Alliance MCR ADV,DRG,MS-516,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$11,462.90 ",IP,"2,420.00","39,092.26",,,,,,
Health Alliance MCR ADV,DRG,MS-517,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,165.60 ",IP,"2,420.00","28,532.45",,,,,,
Health Alliance MCR ADV,DRG,MS-518,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,Surgical,Relative Weights,"$20,947.77 ",IP,"10,289.00","68,717.38",,,,,,
Health Alliance MCR ADV,DRG,MS-519,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,Surgical,Relative Weights,"$11,446.55 ",IP,"10,289.00","38,479.39",,,,,,
Health Alliance MCR ADV,DRG,MS-520,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,Surgical,Relative Weights,"$8,282.98 ",IP,"8,282.98","26,974.08",,,,,,
Health Alliance MCR ADV,DRG,MS-521,HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,Surgical,Relative Weights,"$17,906.85 ",IP,"2,420.00","17,906.85",,,,,,
Health Alliance MCR ADV,DRG,MS-522,HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,Surgical,Relative Weights,"$12,786.27 ",IP,"2,420.00","12,786.27",,,,,,
Health Alliance MCR ADV,DRG,MS-533,FRACTURES OF FEMUR WITH MCC,Medical,Relative Weights,"$8,270.72 ",IP,"2,420.00","29,421.50",,,,,,
Health Alliance MCR ADV,DRG,MS-534,FRACTURES OF FEMUR WITHOUT MCC,Medical,Relative Weights,"$4,614.83 ",IP,"2,420.00","15,680.45",,,,,,
Health Alliance MCR ADV,DRG,MS-535,FRACTURES OF HIP AND PELVIS WITH MCC,Medical,Relative Weights,"$7,199.65 ",IP,"2,420.00","24,738.34",,,,,,
Health Alliance MCR ADV,DRG,MS-536,FRACTURES OF HIP AND PELVIS WITHOUT MCC,Medical,Relative Weights,"$4,506.79 ",IP,"2,420.00","15,291.36",,,,,,
Health Alliance MCR ADV,DRG,MS-537,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITH CC/MCC,Medical,Relative Weights,"$5,462.81 ",IP,"2,420.00","18,363.74",,,,,,
Health Alliance MCR ADV,DRG,MS-538,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITHOUT CC/MCC,Medical,Relative Weights,"$4,223.54 ",IP,"2,420.00","14,535.36",,,,,,
Health Alliance MCR ADV,DRG,MS-539,OSTEOMYELITIS WITH MCC,Medical,Relative Weights,"$11,374.72 ",IP,"2,420.00","38,005.63",,,,,,
Health Alliance MCR ADV,DRG,MS-540,OSTEOMYELITIS WITH CC,Medical,Relative Weights,"$7,601.45 ",IP,"2,420.00","26,208.00",,,,,,
Health Alliance MCR ADV,DRG,MS-541,OSTEOMYELITIS WITHOUT CC/MCC,Medical,Relative Weights,"$4,924.35 ",IP,"2,420.00","18,279.07",,,,,,
Health Alliance MCR ADV,DRG,MS-542,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,Medical,Relative Weights,"$10,565.87 ",IP,"2,420.00","36,787.97",,,,,,
Health Alliance MCR ADV,DRG,MS-543,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,Medical,Relative Weights,"$6,104.05 ",IP,"2,420.00","21,295.01",,,,,,
Health Alliance MCR ADV,DRG,MS-544,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,Medical,Relative Weights,"$4,541.83 ",IP,"2,420.00","15,289.34",,,,,,
Health Alliance MCR ADV,DRG,MS-545,CONNECTIVE TISSUE DISORDERS WITH MCC,Medical,Relative Weights,"$14,618.30 ",IP,"2,420.00","50,964.48",,,,,,
Health Alliance MCR ADV,DRG,MS-546,CONNECTIVE TISSUE DISORDERS WITH CC,Medical,Relative Weights,"$7,054.81 ",IP,"2,420.00","24,260.54",,,,,,
Health Alliance MCR ADV,DRG,MS-547,CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$4,868.29 ",IP,"2,420.00","16,331.62",,,,,,
Health Alliance MCR ADV,DRG,MS-548,SEPTIC ARTHRITIS WITH MCC,Medical,Relative Weights,"$11,976.83 ",IP,"2,420.00","39,983.33",,,,,,
Health Alliance MCR ADV,DRG,MS-549,SEPTIC ARTHRITIS W CC,Medical,Relative Weights,"$7,299.51 ",IP,"2,420.00","24,052.90",,,,,,
Health Alliance MCR ADV,DRG,MS-550,SEPTIC ARTHRITIS W/O CC/MCC,Medical,Relative Weights,"$5,132.84 ",IP,"2,420.00","17,418.24",,,,,,
Health Alliance MCR ADV,DRG,MS-551,MEDICAL BACK PROBLEMS WITH MCC,Medical,Relative Weights,"$9,504.14 ",IP,"2,420.00","32,042.30",,,,,,
Health Alliance MCR ADV,DRG,MS-552,MEDICAL BACK PROBLEMS WITHOUT MCC,Medical,Relative Weights,"$5,509.53 ",IP,"2,420.00","18,383.90",,,,,,
Health Alliance MCR ADV,DRG,MS-553,BONE DISEASES AND ARTHROPATHIES WITH MCC,Medical,Relative Weights,"$7,425.66 ",IP,"2,420.00","25,915.68",,,,,,
Health Alliance MCR ADV,DRG,MS-554,BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,Medical,Relative Weights,"$4,628.26 ",IP,"2,420.00","15,869.95",,,,,,
Health Alliance MCR ADV,DRG,MS-555,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Medical,Relative Weights,"$7,992.15 ",IP,"2,420.00","26,516.45",,,,,,
Health Alliance MCR ADV,DRG,MS-556,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,Medical,Relative Weights,"$4,722.87 ",IP,"2,420.00","15,962.69",,,,,,
Health Alliance MCR ADV,DRG,MS-557,TENDONITIS -  MYOSITIS AND BURSITIS WITH MCC,Medical,Relative Weights,"$8,170.85 ",IP,"2,420.00","29,397.31",,,,,,
Health Alliance MCR ADV,DRG,MS-558,TENDONITIS- MYOSITIS AND BURSITIS WITHOUT MCC,Medical,Relative Weights,"$5,030.64 ",IP,"2,420.00","17,365.82",,,,,,
Health Alliance MCR ADV,DRG,MS-559,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Medical,Relative Weights,"$10,893.50 ",IP,"2,420.00","36,324.29",,,,,,
Health Alliance MCR ADV,DRG,MS-560,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Medical,Relative Weights,"$6,283.92 ",IP,"2,420.00","21,036.96",,,,,,
Health Alliance MCR ADV,DRG,MS-561,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Medical,Relative Weights,"$4,627.68 ",IP,"2,420.00","15,067.58",,,,,,
Health Alliance MCR ADV,DRG,MS-562,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITH MCC,Medical,Relative Weights,"$8,245.02 ",IP,"2,420.00","27,157.54",,,,,,
Health Alliance MCR ADV,DRG,MS-563,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITHOUT MCC,Medical,Relative Weights,"$5,093.72 ",IP,"2,420.00","17,216.64",,,,,,
Health Alliance MCR ADV,DRG,MS-564,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,Medical,Relative Weights,"$8,897.94 ",IP,"2,420.00","30,481.92",,,,,,
Health Alliance MCR ADV,DRG,MS-565,OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W CC,Medical,Relative Weights,"$5,894.39 ",IP,"2,420.00","19,766.88",,,,,,
Health Alliance MCR ADV,DRG,MS-566,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$4,391.15 ",IP,"2,420.00","15,275.23",,,,,,
Health Alliance MCR ADV,DRG,MS-570,SKIN DEBRIDEMENT WITH MCC,Surgical,Relative Weights,"$16,595.75 ",IP,"2,420.00","57,923.71",,,,,,
Health Alliance MCR ADV,DRG,MS-571,SKIN DEBRIDEMENT WITH CC,Surgical,Relative Weights,"$9,550.86 ",IP,"2,420.00","33,713.57",,,,,,
Health Alliance MCR ADV,DRG,MS-572,SKIN DEBRIDEMENT WITHOUT CC/MCC,Surgical,Relative Weights,"$6,449.78 ",IP,"2,420.00","22,613.47",,,,,,
Health Alliance MCR ADV,DRG,MS-573,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,Surgical,Relative Weights,"$32,348.77 ",IP,"2,420.00","107,156.45",,,,,,
Health Alliance MCR ADV,DRG,MS-574,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,Surgical,Relative Weights,"$18,959.81 ",IP,"2,420.00","62,935.49",,,,,,
Health Alliance MCR ADV,DRG,MS-575,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS W/O CC/MCC,Surgical,Relative Weights,"$10,297.22 ",IP,"2,420.00","35,421.12",,,,,,
Health Alliance MCR ADV,DRG,MS-576,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,Surgical,Relative Weights,"$29,572.40 ",IP,"2,420.00","97,759.87",,,,,,
Health Alliance MCR ADV,DRG,MS-577,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,Surgical,Relative Weights,"$14,889.86 ",IP,"2,420.00","48,698.50",,,,,,
Health Alliance MCR ADV,DRG,MS-578,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,Surgical,Relative Weights,"$9,316.09 ",IP,"2,420.00","32,808.38",,,,,,
Health Alliance MCR ADV,DRG,MS-579,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC,Surgical,Relative Weights,"$18,366.46 ",IP,"2,420.00","60,199.78",,,,,,
Health Alliance MCR ADV,DRG,MS-580,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC,Surgical,Relative Weights,"$10,096.33 ",IP,"2,420.00","32,431.39",,,,,,
Health Alliance MCR ADV,DRG,MS-581,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,040.62 ",IP,"2,420.00","25,296.77",,,,,,
Health Alliance MCR ADV,DRG,MS-582,MASTECTOMY FOR MALIGNANCY WITH CC/MCC,Surgical,Relative Weights,"$9,595.83 ",IP,"2,420.00","31,826.59",,,,,,
Health Alliance MCR ADV,DRG,MS-583,MASTECTOMY FOR MALIGNANCY W/O CC/MCC,Surgical,Relative Weights,"$9,002.48 ",IP,"2,420.00","29,461.82",,,,,,
Health Alliance MCR ADV,DRG,MS-584,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$10,726.47 ",IP,"2,420.00","36,860.54",,,,,,
Health Alliance MCR ADV,DRG,MS-585,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,159.40 ",IP,"2,420.00","34,217.57",,,,,,
Health Alliance MCR ADV,DRG,MS-592,SKIN ULCERS WITH MCC,Medical,Relative Weights,"$9,894.84 ",IP,"2,420.00","35,971.49",,,,,,
Health Alliance MCR ADV,DRG,MS-593,SKIN ULCERS WITH CC,Medical,Relative Weights,"$6,661.19 ",IP,"2,420.00","23,139.65",,,,,,
Health Alliance MCR ADV,DRG,MS-594,SKIN ULCERS WITHOUT CC/MCC,Medical,Relative Weights,"$4,765.50 ",IP,"2,420.00","16,323.55",,,,,,
Health Alliance MCR ADV,DRG,MS-595,MAJOR SKIN DISORDERS WITH MCC,Medical,Relative Weights,"$11,776.52 ",IP,"2,420.00","40,977.22",,,,,,
Health Alliance MCR ADV,DRG,MS-596,MAJOR SKIN DISORDERS W/O MCC,Medical,Relative Weights,"$5,809.13 ",IP,"2,420.00","19,637.86",,,,,,
Health Alliance MCR ADV,DRG,MS-597,MALIGNANT BREAST DISORDERS W MCC,Medical,Relative Weights,"$9,601.09 ",IP,"2,420.00","34,128.86",,,,,,
Health Alliance MCR ADV,DRG,MS-598,MALIGNANT BREAST DISORDERS WITH CC,Medical,Relative Weights,"$6,499.42 ",IP,"2,420.00","21,946.18",,,,,,
Health Alliance MCR ADV,DRG,MS-599,MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$3,921.03 ",IP,"2,420.00","14,019.26",,,,,,
Health Alliance MCR ADV,DRG,MS-600,NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,Medical,Relative Weights,"$5,821.97 ",IP,"2,420.00","19,337.47",,,,,,
Health Alliance MCR ADV,DRG,MS-601,NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$4,010.97 ",IP,"2,420.00","12,475.01",,,,,,
Health Alliance MCR ADV,DRG,MS-602,CELLULITIS WITH MCC,Medical,Relative Weights,"$8,468.11 ",IP,"2,420.00","28,824.77",,,,,,
Health Alliance MCR ADV,DRG,MS-603,CELLULITIS WITHOUT MCC,Medical,Relative Weights,"$4,985.09 ",IP,"2,420.00","17,004.96",,,,,,
Health Alliance MCR ADV,DRG,MS-604,TRAUMA TO THE SKIN -  SUBCUTANEOUS TISSUE AND BREAST WITH MCC,Medical,Relative Weights,"$8,631.05 ",IP,"2,420.00","29,524.32",,,,,,
Health Alliance MCR ADV,DRG,MS-605,TRAUMA TO THE SKIN- SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC,Medical,Relative Weights,"$5,278.85 ",IP,"2,420.00","17,654.11",,,,,,
Health Alliance MCR ADV,DRG,MS-606,MINOR SKIN DISORDERS WITH MCC,Medical,Relative Weights,"$8,830.78 ",IP,"2,420.00","30,149.28",,,,,,
Health Alliance MCR ADV,DRG,MS-607,MINOR SKIN DISORDERS WITHOUT MCC,Medical,Relative Weights,"$4,836.75 ",IP,"2,420.00","16,654.18",,,,,,
Health Alliance MCR ADV,DRG,MS-614,ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$13,956.03 ",IP,"2,420.00","49,055.33",,,,,,
Health Alliance MCR ADV,DRG,MS-615,ADRENAL & PITUITARY PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$9,198.12 ",IP,"2,420.00","29,919.46",,,,,,
Health Alliance MCR ADV,DRG,MS-616,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Surgical,Relative Weights,"$23,162.92 ",IP,"2,420.00","80,656.13",,,,,,
Health Alliance MCR ADV,DRG,MS-617,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Surgical,Relative Weights,"$11,854.19 ",IP,"2,420.00","41,354.21",,,,,,
Health Alliance MCR ADV,DRG,MS-618,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$7,610.79 ",IP,"2,420.00","25,290.72",,,,,,
Health Alliance MCR ADV,DRG,MS-619,O.R. PROCEDURES FOR OBESITY WITH MCC,Surgical,Relative Weights,"$17,880.57 ",IP,"2,420.00","62,062.56",,,,,,
Health Alliance MCR ADV,DRG,MS-620,O.R. PROCEDURES FOR OBESITY WITH CC,Surgical,Relative Weights,"$10,294.30 ",IP,"2,420.00","36,179.14",,,,,,
Health Alliance MCR ADV,DRG,MS-621,O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,Surgical,Relative Weights,"$9,327.19 ",IP,"2,420.00","31,691.52",,,,,,
Health Alliance MCR ADV,DRG,MS-622,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Surgical,Relative Weights,"$21,111.30 ",IP,"2,420.00","76,114.08",,,,,,
Health Alliance MCR ADV,DRG,MS-623,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE -  NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Surgical,Relative Weights,"$10,929.71 ",IP,"2,420.00","39,364.42",,,,,,
Health Alliance MCR ADV,DRG,MS-624,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$6,417.66 ",IP,"2,420.00","22,216.32",,,,,,
Health Alliance MCR ADV,DRG,MS-625,THYROID- PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$16,586.99 ",IP,"2,420.00","58,970.02",,,,,,
Health Alliance MCR ADV,DRG,MS-626,THYROID -  PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC,Surgical,Relative Weights,"$9,653.06 ",IP,"2,420.00","33,925.25",,,,,,
Health Alliance MCR ADV,DRG,MS-627,THYROID -  PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,907.64 ",IP,"2,420.00","23,016.67",,,,,,
Health Alliance MCR ADV,DRG,MS-628,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$21,487.98 ",IP,"2,420.00","74,376.29",,,,,,
Health Alliance MCR ADV,DRG,MS-629,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$13,696.73 ",IP,"2,420.00","46,827.65",,,,,,
Health Alliance MCR ADV,DRG,MS-630,OTHER ENDOCRINE - NUTRIT & METAB O.R. PROC W/O CC/MCC,Surgical,Relative Weights,"$8,230.42 ",IP,"2,420.00","29,207.81",,,,,,
Health Alliance MCR ADV,DRG,MS-637,DIABETES WITH MCC,Medical,Relative Weights,"$8,039.45 ",IP,"2,420.00","27,935.71",,,,,,
Health Alliance MCR ADV,DRG,MS-638,DIABETES WITH CC,Medical,Relative Weights,"$5,135.76 ",IP,"2,420.00","17,823.46",,,,,,
Health Alliance MCR ADV,DRG,MS-639,DIABETES WITHOUT CC/MCC,Medical,Relative Weights,"$3,560.11 ",IP,"2,420.00","12,362.11",,,,,,
Health Alliance MCR ADV,DRG,MS-640,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITH MCC,Medical,Relative Weights,"$7,187.97 ",IP,"2,420.00","24,478.27",,,,,,
Health Alliance MCR ADV,DRG,MS-641,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITHOUT MCC,Medical,Relative Weights,"$4,404.59 ",IP,"2,420.00","15,253.06",,,,,,
Health Alliance MCR ADV,DRG,MS-642,INBORN AND OTHER DISORDERS OF METABOLISM,Medical,Relative Weights,"$7,532.53 ",IP,"2,420.00","24,510.53",,,,,,
Health Alliance MCR ADV,DRG,MS-643,ENDOCRINE DISORDERS WITH MCC,Medical,Relative Weights,"$9,739.50 ",IP,"2,420.00","32,770.08",,,,,,
Health Alliance MCR ADV,DRG,MS-644,ENDOCRINE DISORDERS WITH CC,Medical,Relative Weights,"$5,955.71 ",IP,"2,420.00","20,726.50",,,,,,
Health Alliance MCR ADV,DRG,MS-645,ENDOCRINE DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$4,488.68 ",IP,"2,420.00","15,426.43",,,,,,
Health Alliance MCR ADV,DRG,MS-650,KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,Neonate,Relative Weights,"$26,401.24 ",IP,"2,420.00","26,401.24",,,,,,
Health Alliance MCR ADV,DRG,MS-651,KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,Neonate,Relative Weights,"$21,598.94 ",IP,"2,420.00","21,598.94",,,,,,
Health Alliance MCR ADV,DRG,MS-652,KIDNEY TRANSPLANT,Surgical,Relative Weights,"$18,601.23 ",IP,"2,420.00","68,239.58",,,,,,
Health Alliance MCR ADV,DRG,MS-653,MAJOR BLADDER PROCEDURES WITH MCC,Surgical,Relative Weights,"$31,882.15 ",IP,"2,420.00","111,615.84",,,,,,
Health Alliance MCR ADV,DRG,MS-654,MAJOR BLADDER PROCEDURES WITH CC,Surgical,Relative Weights,"$16,952.58 ",IP,"2,420.00","56,693.95",,,,,,
Health Alliance MCR ADV,DRG,MS-655,MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$12,149.11 ",IP,"2,420.00","41,577.98",,,,,,
Health Alliance MCR ADV,DRG,MS-656,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,Surgical,Relative Weights,"$19,184.65 ",IP,"2,420.00","65,733.70",,,,,,
Health Alliance MCR ADV,DRG,MS-657,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,Surgical,Relative Weights,"$11,298.80 ",IP,"2,420.00","38,993.47",,,,,,
Health Alliance MCR ADV,DRG,MS-658,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,Surgical,Relative Weights,"$9,215.06 ",IP,"2,420.00","31,649.18",,,,,,
Health Alliance MCR ADV,DRG,MS-659,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,Surgical,Relative Weights,"$15,571.98 ",IP,"2,420.00","54,024.77",,,,,,
Health Alliance MCR ADV,DRG,MS-660,KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC,Surgical,Relative Weights,"$8,427.82 ",IP,"2,420.00","28,641.31",,,,,,
Health Alliance MCR ADV,DRG,MS-661,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,Surgical,Relative Weights,"$6,212.09 ",IP,"2,420.00","21,976.42",,,,,,
Health Alliance MCR ADV,DRG,MS-662,MINOR BLADDER PROCEDURES WITH MCC,Surgical,Relative Weights,"$17,154.06 ",IP,"2,420.00","63,800.35",,,,,,
Health Alliance MCR ADV,DRG,MS-663,MINOR BLADDER PROCEDURES WITH CC,Surgical,Relative Weights,"$9,341.20 ",IP,"2,420.00","30,711.74",,,,,,
Health Alliance MCR ADV,DRG,MS-664,MINOR BLADDER PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,913.48 ",IP,"2,420.00","22,309.06",,,,,,
Health Alliance MCR ADV,DRG,MS-665,PROSTATECTOMY WITH MCC,Surgical,Relative Weights,"$17,763.76 ",IP,"2,420.00","59,844.96",,,,,,
Health Alliance MCR ADV,DRG,MS-666,PROSTATECTOMY WITH CC,Surgical,Relative Weights,"$10,159.98 ",IP,"2,420.00","35,665.06",,,,,,
Health Alliance MCR ADV,DRG,MS-667,PROSTATECTOMY W/O CC/MCC,Surgical,Relative Weights,"$5,825.48 ",IP,"2,420.00","18,924.19",,,,,,
Health Alliance MCR ADV,DRG,MS-668,TRANSURETHRAL PROCEDURES W MCC,Surgical,Relative Weights,"$16,389.01 ",IP,"2,420.00","56,212.13",,,,,,
Health Alliance MCR ADV,DRG,MS-669,TRANSURETHRAL PROCEDURES WITH CC,Surgical,Relative Weights,"$9,130.96 ",IP,"2,420.00","31,161.31",,,,,,
Health Alliance MCR ADV,DRG,MS-670,TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$5,714.52 ",IP,"2,420.00","19,730.59",,,,,,
Health Alliance MCR ADV,DRG,MS-671,URETHRAL PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$10,402.93 ",IP,"2,420.00","36,844.42",,,,,,
Health Alliance MCR ADV,DRG,MS-672,URETHRAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,718.43 ",IP,"2,420.00","20,829.31",,,,,,
Health Alliance MCR ADV,DRG,MS-673,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,Surgical,Relative Weights,"$20,255.14 ",IP,"2,420.00","72,063.94",,,,,,
Health Alliance MCR ADV,DRG,MS-674,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,Surgical,Relative Weights,"$13,918.07 ",IP,"2,420.00","49,275.07",,,,,,
Health Alliance MCR ADV,DRG,MS-675,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,247.58 ",IP,"2,420.00","32,901.12",,,,,,
Health Alliance MCR ADV,DRG,MS-682,RENAL FAILURE WITH MCC,Medical,Relative Weights,"$8,600.68 ",IP,"2,420.00","29,796.48",,,,,,
Health Alliance MCR ADV,DRG,MS-683,RENAL FAILURE WITH CC,Medical,Relative Weights,"$5,135.18 ",IP,"2,420.00","18,089.57",,,,,,
Health Alliance MCR ADV,DRG,MS-684,RENAL FAILURE WITHOUT CC/MCC,Medical,Relative Weights,"$3,550.18 ",IP,"2,420.00","12,404.45",,,,,,
Health Alliance MCR ADV,DRG,MS-686,KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,Medical,Relative Weights,"$10,951.90 ",IP,"2,420.00","35,402.98",,,,,,
Health Alliance MCR ADV,DRG,MS-687,KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,Medical,Relative Weights,"$6,132.67 ",IP,"2,420.00","21,220.42",,,,,,
Health Alliance MCR ADV,DRG,MS-688,KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,Medical,Relative Weights,"$4,005.13 ",IP,"2,420.00","15,549.41",,,,,,
Health Alliance MCR ADV,DRG,MS-689,KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,Medical,Relative Weights,"$6,507.01 ",IP,"2,420.00","22,550.98",,,,,,
Health Alliance MCR ADV,DRG,MS-690,KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,Medical,Relative Weights,"$4,637.02 ",IP,"2,420.00","15,942.53",,,,,,
Health Alliance MCR ADV,DRG,MS-693,URINARY STONES WITH MCC,Medical,Relative Weights,"$7,799.42 ",IP,"2,420.00","27,282.53",,,,,,
Health Alliance MCR ADV,DRG,MS-694,URINARY STONES WITHOUT MCC,Medical,Relative Weights,"$4,503.87 ",IP,"2,420.00","14,926.46",,,,,,
Health Alliance MCR ADV,DRG,MS-695,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,Medical,Relative Weights,"$6,644.26 ",IP,"2,420.00","23,633.57",,,,,,
Health Alliance MCR ADV,DRG,MS-696,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,Medical,Relative Weights,"$4,040.75 ",IP,"2,420.00","13,696.70",,,,,,
Health Alliance MCR ADV,DRG,MS-697,URETHRAL STRICTURE,Medical,Relative Weights,"$5,835.99 ",IP,"2,420.00","19,633.82",,,,,,
Health Alliance MCR ADV,DRG,MS-698,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,Medical,Relative Weights,"$9,406.03 ",IP,"2,420.00","32,630.98",,,,,,
Health Alliance MCR ADV,DRG,MS-699,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,Medical,Relative Weights,"$5,997.76 ",IP,"2,420.00","20,819.23",,,,,,
Health Alliance MCR ADV,DRG,MS-700,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$4,359.62 ",IP,"2,420.00","14,952.67",,,,,,
Health Alliance MCR ADV,DRG,MS-707,MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$11,225.80 ",IP,"2,420.00","37,697.18",,,,,,
Health Alliance MCR ADV,DRG,MS-708,MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,708.72 ",IP,"2,420.00","29,272.32",,,,,,
Health Alliance MCR ADV,DRG,MS-709,PENIS PROCEDURES W CC/MCC,Surgical,Relative Weights,"$13,525.04 ",IP,"2,420.00","48,496.90",,,,,,
Health Alliance MCR ADV,DRG,MS-710,PENIS PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$9,353.47 ",IP,"2,420.00","30,961.73",,,,,,
Health Alliance MCR ADV,DRG,MS-711,TESTES PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$12,448.71 ",IP,"2,420.00","43,206.91",,,,,,
Health Alliance MCR ADV,DRG,MS-712,TESTES PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,190.48 ",IP,"2,420.00","20,567.23",,,,,,
Health Alliance MCR ADV,DRG,MS-713,TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,Surgical,Relative Weights,"$8,721.57 ",IP,"2,420.00","29,473.92",,,,,,
Health Alliance MCR ADV,DRG,MS-714,TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,Surgical,Relative Weights,"$5,424.26 ",IP,"2,420.00","18,454.46",,,,,,
Health Alliance MCR ADV,DRG,MS-715,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,Surgical,Relative Weights,"$11,806.30 ",IP,"2,420.00","43,071.84",,,,,,
Health Alliance MCR ADV,DRG,MS-716,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$7,450.77 ",IP,"2,420.00","29,544.48",,,,,,
Health Alliance MCR ADV,DRG,MS-717,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,Surgical,Relative Weights,"$10,515.64 ",IP,"2,420.00","35,568.29",,,,,,
Health Alliance MCR ADV,DRG,MS-718,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$7,210.16 ",IP,"2,420.00","24,583.10",,,,,,
Health Alliance MCR ADV,DRG,MS-722,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH MCC,Medical,Relative Weights,"$10,001.72 ",IP,"2,420.00","36,386.78",,,,,,
Health Alliance MCR ADV,DRG,MS-723,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH CC,Medical,Relative Weights,"$6,376.78 ",IP,"2,420.00","22,325.18",,,,,,
Health Alliance MCR ADV,DRG,MS-724,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Medical,Relative Weights,"$3,784.95 ",IP,"2,420.00","11,902.46",,,,,,
Health Alliance MCR ADV,DRG,MS-725,BENIGN PROSTATIC HYPERTROPHY WITH MCC,Medical,Relative Weights,"$7,507.42 ",IP,"2,420.00","25,308.86",,,,,,
Health Alliance MCR ADV,DRG,MS-726,BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,Medical,Relative Weights,"$4,349.11 ",IP,"2,420.00","15,416.35",,,,,,
Health Alliance MCR ADV,DRG,MS-727,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,Medical,Relative Weights,"$8,298.75 ",IP,"2,420.00","28,774.37",,,,,,
Health Alliance MCR ADV,DRG,MS-728,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,Medical,Relative Weights,"$4,705.35 ",IP,"2,420.00","16,178.40",,,,,,
Health Alliance MCR ADV,DRG,MS-729,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,Medical,Relative Weights,"$5,883.88 ",IP,"2,420.00","21,649.82",,,,,,
Health Alliance MCR ADV,DRG,MS-730,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$3,322.42 ",IP,"2,420.00","12,733.06",,,,,,
Health Alliance MCR ADV,DRG,MS-734,PELVIC EVISCERATION -  RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC,Surgical,Relative Weights,"$12,990.08 ",IP,"2,420.00","44,188.70",,,,,,
Health Alliance MCR ADV,DRG,MS-735,PELVIC EVISCERATION -  RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC,Surgical,Relative Weights,"$8,255.53 ",IP,"2,420.00","27,703.87",,,,,,
Health Alliance MCR ADV,DRG,MS-736,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,Surgical,Relative Weights,"$24,882.82 ",IP,"2,420.00","87,109.34",,,,,,
Health Alliance MCR ADV,DRG,MS-737,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,Surgical,Relative Weights,"$12,019.46 ",IP,"2,420.00","40,059.94",,,,,,
Health Alliance MCR ADV,DRG,MS-738,UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY W/O CC/MCC,Surgical,Relative Weights,"$8,619.37 ",IP,"2,420.00","27,798.62",,,,,,
Health Alliance MCR ADV,DRG,MS-739,UTERINE -ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W MCC,Surgical,Relative Weights,"$22,332.46 ",IP,"2,420.00","75,489.12",,,,,,
Health Alliance MCR ADV,DRG,MS-740,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,Surgical,Relative Weights,"$10,521.48 ",IP,"2,420.00","35,983.58",,,,,,
Health Alliance MCR ADV,DRG,MS-741,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$7,474.72 ",IP,"2,420.00","26,802.72",,,,,,
Health Alliance MCR ADV,DRG,MS-742,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,Surgical,Relative Weights,"$10,033.84 ",IP,"2,420.00","34,060.32",,,,,,
Health Alliance MCR ADV,DRG,MS-743,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$6,615.64 ",IP,"2,420.00","23,153.76",,,,,,
Health Alliance MCR ADV,DRG,MS-744,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC,Surgical,Relative Weights,"$10,485.28 ",IP,"2,420.00","35,088.48",,,,,,
Health Alliance MCR ADV,DRG,MS-745,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC,Surgical,Relative Weights,"$6,832.89 ",IP,"2,420.00","21,476.45",,,,,,
Health Alliance MCR ADV,DRG,MS-746,VAGINA -  CERVIX AND VULVA PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$9,411.29 ",IP,"2,420.00","32,880.96",,,,,,
Health Alliance MCR ADV,DRG,MS-747,VAGINA- CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$5,484.42 ",IP,"2,420.00","18,793.15",,,,,,
Health Alliance MCR ADV,DRG,MS-748,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,Surgical,Relative Weights,"$7,870.09 ",IP,"2,420.00","26,645.47",,,,,,
Health Alliance MCR ADV,DRG,MS-749,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$15,848.80 ",IP,"2,420.00","52,258.75",,,,,,
Health Alliance MCR ADV,DRG,MS-750,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,548.71 ",IP,"2,420.00","26,836.99",,,,,,
Health Alliance MCR ADV,DRG,MS-754,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH MCC,Medical,Relative Weights,"$10,665.15 ",IP,"2,420.00","35,519.90",,,,,,
Health Alliance MCR ADV,DRG,MS-755,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH CC,Medical,Relative Weights,"$6,595.20 ",IP,"2,420.00","20,639.81",,,,,,
Health Alliance MCR ADV,DRG,MS-756,MALIGNANCY - FEMALE REPRODUCTIVE SYSTEM W/O CC/MCC,Medical,Relative Weights,"$5,363.53 ",IP,"2,420.00","17,676.29",,,,,,
Health Alliance MCR ADV,DRG,MS-757,INFECTIONS - FEMALE REPRODUCTIVE SYSTEM W MCC,Medical,Relative Weights,"$8,904.37 ",IP,"2,420.00","28,633.25",,,,,,
Health Alliance MCR ADV,DRG,MS-758,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITH CC,Medical,Relative Weights,"$5,663.12 ",IP,"2,420.00","19,462.46",,,,,,
Health Alliance MCR ADV,DRG,MS-759,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Medical,Relative Weights,"$3,991.11 ",IP,"2,420.00","13,311.65",,,,,,
Health Alliance MCR ADV,DRG,MS-760,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,Medical,Relative Weights,"$5,373.46 ",IP,"2,420.00","18,194.40",,,,,,
Health Alliance MCR ADV,DRG,MS-761,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$3,450.32 ",IP,"2,420.00","11,398.46",,,,,,
Health Alliance MCR ADV,DRG,MS-768,VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C,Surgical,Relative Weights,"$6,830.55 ",IP,"2,420.00","20,311.20",,,,,,
Health Alliance MCR ADV,DRG,MS-769,POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,Surgical,Relative Weights,"$9,446.91 ",IP,"2,420.00","29,090.88",,,,,,
Health Alliance MCR ADV,DRG,MS-770,ABORTION WITH D&C- ASPIRATION CURETTAGE OR HYSTEROTOMY,Surgical,Relative Weights,"$5,196.50 ",IP,"2,420.00","15,851.81",,,,,,
Health Alliance MCR ADV,DRG,MS-776,POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,Medical,Relative Weights,"$4,523.14 ",IP,"2,420.00","14,311.58",,,,,,
Health Alliance MCR ADV,DRG,MS-779,ABORTION WITHOUT D&C,Medical,Relative Weights,"$6,184.64 ",IP,"2,420.00","23,018.69",,,,,,
Health Alliance MCR ADV,DRG,MS-783,CESAREAN SECTION WITH STERILIZATION WITH MCC,C-Section,Relative Weights,"$10,949.56 ",IP,"2,420.00","43,239.17",,,,,,
Health Alliance MCR ADV,DRG,MS-784,CESAREAN SECTION WITH STERILIZATION WITH CC,C-Section,Relative Weights,"$6,400.14 ",IP,"2,420.00","21,071.23",,,,,,
Health Alliance MCR ADV,DRG,MS-785,CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,C-Section,Relative Weights,"$5,354.18 ",IP,"2,420.00","17,305.34",,,,,,
Health Alliance MCR ADV,DRG,MS-786,CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,C-Section,Relative Weights,"$9,311.42 ",IP,"2,420.00","34,564.32",,,,,,
Health Alliance MCR ADV,DRG,MS-787,CESAREAN SECTION WITHOUT STERILIZATION WITH CC,C-Section,Relative Weights,"$6,216.18 ",IP,"2,420.00","21,077.28",,,,,,
Health Alliance MCR ADV,DRG,MS-788,CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,C-Section,Relative Weights,"$5,182.48 ",IP,"2,420.00","18,268.99",,,,,,
Health Alliance MCR ADV,DRG,MS-789,NEONATES- DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY,Medical,Relative Weights,"$10,044.93 ",IP,"2,420.00","34,070.40",,,,,,
Health Alliance MCR ADV,DRG,MS-790,EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME- NEONATE,Medical,Relative Weights,"$33,125.50 ",IP,"2,420.00","112,351.68",,,,,,
Health Alliance MCR ADV,DRG,MS-791,PREMATURITY W MAJOR PROBLEMS,Medical,Relative Weights,"$22,623.29 ",IP,"2,420.00","76,732.99",,,,,,
Health Alliance MCR ADV,DRG,MS-792,PREMATURITY W/O MAJOR PROBLEMS,Medical,Relative Weights,"$13,650.60 ",IP,"2,420.00","46,297.44",,,,,,
Health Alliance MCR ADV,DRG,MS-793,FULL TERM NEONATE WITH MAJOR PROBLEMS,Medical,Relative Weights,"$23,238.84 ",IP,"2,420.00","78,819.55",,,,,,
Health Alliance MCR ADV,DRG,MS-794,NEONATE WITH OTHER SIGNIFICANT PROBLEMS,Medical,Relative Weights,"$8,225.17 ",IP,"2,420.00","27,897.41",,,,,,
Health Alliance MCR ADV,DRG,MS-795,NORMAL NEWBORN,Medical,Relative Weights,"$1,113.70 ",IP,"1,113.70","3,775.97",,,,,,
Health Alliance MCR ADV,DRG,MS-796,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,Vaginal Delivery,Relative Weights,"$6,253.56 ",IP,"2,420.00","39,761.57",,,,,,
Health Alliance MCR ADV,DRG,MS-797,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,Vaginal Delivery,Relative Weights,"$5,369.37 ",IP,"2,420.00","17,394.05",,,,,,
Health Alliance MCR ADV,DRG,MS-798,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,Vaginal Delivery,Relative Weights,"$4,832.66 ",IP,"2,420.00","17,394.05",,,,,,
Health Alliance MCR ADV,DRG,MS-799,SPLENECTOMY WITH MCC,Surgical,Relative Weights,"$30,061.22 ",IP,"2,420.00","99,677.09",,,,,,
Health Alliance MCR ADV,DRG,MS-800,SPLENECTOMY WITH CC,Surgical,Relative Weights,"$17,251.01 ",IP,"2,420.00","57,294.72",,,,,,
Health Alliance MCR ADV,DRG,MS-801,SPLENECTOMY WITHOUT CC/MCC,Surgical,Relative Weights,"$9,834.69 ",IP,"2,420.00","37,763.71",,,,,,
Health Alliance MCR ADV,DRG,MS-802,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,Surgical,Relative Weights,"$21,676.62 ",IP,"2,420.00","63,552.38",,,,,,
Health Alliance MCR ADV,DRG,MS-803,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,Surgical,Relative Weights,"$11,017.31 ",IP,"2,420.00","35,917.06",,,,,,
Health Alliance MCR ADV,DRG,MS-804,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,Surgical,Relative Weights,"$7,976.96 ",IP,"2,420.00","27,470.02",,,,,,
Health Alliance MCR ADV,DRG,MS-805,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,Vaginal Delivery,Relative Weights,"$6,014.70 ",IP,"2,420.00","20,980.51",,,,,,
Health Alliance MCR ADV,DRG,MS-806,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,Vaginal Delivery,Relative Weights,"$4,290.12 ",IP,"2,420.00","14,297.47",,,,,,
Health Alliance MCR ADV,DRG,MS-807,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,Vaginal Delivery,Relative Weights,"$3,751.08 ",IP,"2,420.00","12,636.29",,,,,,
Health Alliance MCR ADV,DRG,MS-808,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,Medical,Relative Weights,"$12,765.24 ",IP,"2,420.00","42,932.74",,,,,,
Health Alliance MCR ADV,DRG,MS-809,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,Medical,Relative Weights,"$7,144.75 ",IP,"2,420.00","24,512.54",,,,,,
Health Alliance MCR ADV,DRG,MS-810,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$5,616.40 ",IP,"2,420.00","18,857.66",,,,,,
Health Alliance MCR ADV,DRG,MS-811,RED BLOOD CELL DISORDERS WITH MCC,Medical,Relative Weights,"$8,055.22 ",IP,"2,420.00","27,020.45",,,,,,
Health Alliance MCR ADV,DRG,MS-812,RED BLOOD CELL DISORDERS WITHOUT MCC,Medical,Relative Weights,"$5,141.02 ",IP,"2,420.00","17,553.31",,,,,,
Health Alliance MCR ADV,DRG,MS-813,COAGULATION DISORDERS,Medical,Relative Weights,"$9,023.50 ",IP,"2,420.00","31,957.63",,,,,,
Health Alliance MCR ADV,DRG,MS-814,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,Medical,Relative Weights,"$11,047.67 ",IP,"2,420.00","35,261.86",,,,,,
Health Alliance MCR ADV,DRG,MS-815,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,Medical,Relative Weights,"$5,801.53 ",IP,"2,420.00","20,418.05",,,,,,
Health Alliance MCR ADV,DRG,MS-816,RETICULOENDOTHELIAL & IMMUNITY DISORDERS W/O CC/MCC,Medical,Relative Weights,"$3,860.88 ",IP,"2,420.00","14,432.54",,,,,,
Health Alliance MCR ADV,DRG,MS-817,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$13,471.89 ",IP,"2,420.00","50,726.59",,,,,,
Health Alliance MCR ADV,DRG,MS-818,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$7,941.34 ",IP,"2,420.00","25,681.82",,,,,,
Health Alliance MCR ADV,DRG,MS-819,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$5,765.32 ",IP,"2,420.00","16,085.66",,,,,,
Health Alliance MCR ADV,DRG,MS-820,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$33,239.97 ",IP,"2,420.00","115,248.67",,,,,,
Health Alliance MCR ADV,DRG,MS-821,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$12,586.54 ",IP,"2,420.00","45,003.17",,,,,,
Health Alliance MCR ADV,DRG,MS-822,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,308.86 ",IP,"2,420.00","25,490.30",,,,,,
Health Alliance MCR ADV,DRG,MS-823,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,Surgical,Relative Weights,"$26,290.86 ",IP,"2,420.00","85,280.83",,,,,,
Health Alliance MCR ADV,DRG,MS-824,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,Surgical,Relative Weights,"$13,808.28 ",IP,"2,420.00","46,874.02",,,,,,
Health Alliance MCR ADV,DRG,MS-825,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,184.87 ",IP,"2,420.00","27,306.72",,,,,,
Health Alliance MCR ADV,DRG,MS-826,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$29,460.27 ",IP,"2,420.00","101,102.40",,,,,,
Health Alliance MCR ADV,DRG,MS-827,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$14,603.70 ",IP,"2,420.00","46,694.59",,,,,,
Health Alliance MCR ADV,DRG,MS-828,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$9,776.29 ",IP,"2,420.00","33,288.19",,,,,,
Health Alliance MCR ADV,DRG,MS-829,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$18,737.31 ",IP,"2,420.00","63,300.38",,,,,,
Health Alliance MCR ADV,DRG,MS-830,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,655.00 ",IP,"2,420.00","27,796.61",,,,,,
Health Alliance MCR ADV,DRG,MS-831,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,Medical,Relative Weights,"$6,551.40 ",IP,"2,420.00","21,742.56",,,,,,
Health Alliance MCR ADV,DRG,MS-832,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,Medical,Relative Weights,"$4,545.33 ",IP,"2,420.00","14,424.48",,,,,,
Health Alliance MCR ADV,DRG,MS-833,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,Medical,Relative Weights,"$3,136.12 ",IP,"2,420.00","10,727.14",,,,,,
Health Alliance MCR ADV,DRG,MS-834,ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W MCC,Medical,Relative Weights,"$35,345.32 ",IP,"2,420.00","117,784.80",,,,,,
Health Alliance MCR ADV,DRG,MS-835,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC,Medical,Relative Weights,"$12,344.17 ",IP,"2,420.00","40,888.51",,,,,,
Health Alliance MCR ADV,DRG,MS-836,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Medical,Relative Weights,"$6,853.33 ",IP,"2,420.00","26,562.82",,,,,,
Health Alliance MCR ADV,DRG,MS-837,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,Medical,Relative Weights,"$33,284.35 ",IP,"2,420.00","120,774.53",,,,,,
Health Alliance MCR ADV,DRG,MS-838,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,Medical,Relative Weights,"$13,199.74 ",IP,"2,420.00","44,108.06",,,,,,
Health Alliance MCR ADV,DRG,MS-839,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Medical,Relative Weights,"$8,685.36 ",IP,"2,420.00","25,728.19",,,,,,
Health Alliance MCR ADV,DRG,MS-840,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,Medical,Relative Weights,"$18,807.97 ",IP,"2,420.00","64,415.23",,,,,,
Health Alliance MCR ADV,DRG,MS-841,LYMPHOMA & NON-ACUTE LEUKEMIA W CC,Medical,Relative Weights,"$9,470.27 ",IP,"2,420.00","32,491.87",,,,,,
Health Alliance MCR ADV,DRG,MS-842,LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,Medical,Relative Weights,"$6,406.57 ",IP,"2,420.00","23,115.46",,,,,,
Health Alliance MCR ADV,DRG,MS-843,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,Medical,Relative Weights,"$11,140.53 ",IP,"2,420.00","38,461.25",,,,,,
Health Alliance MCR ADV,DRG,MS-844,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,Medical,Relative Weights,"$6,915.82 ",IP,"2,420.00","24,353.28",,,,,,
Health Alliance MCR ADV,DRG,MS-845,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$4,957.64 ",IP,"2,420.00","17,456.54",,,,,,
Health Alliance MCR ADV,DRG,MS-846,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,Medical,Relative Weights,"$15,609.94 ",IP,"2,420.00","52,952.26",,,,,,
Health Alliance MCR ADV,DRG,MS-847,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,Medical,Relative Weights,"$7,802.93 ",IP,"2,420.00","26,528.54",,,,,,
Health Alliance MCR ADV,DRG,MS-848,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Medical,Relative Weights,"$6,028.71 ",IP,"2,420.00","19,785.02",,,,,,
Health Alliance MCR ADV,DRG,MS-849,RADIOTHERAPY,Medical,Relative Weights,"$14,562.82 ",IP,"2,420.00","42,856.13",,,,,,
Health Alliance MCR ADV,DRG,MS-853,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$29,012.34 ",IP,"2,420.00","102,787.78",,,,,,
Health Alliance MCR ADV,DRG,MS-854,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$12,393.81 ",IP,"2,420.00","43,569.79",,,,,,
Health Alliance MCR ADV,DRG,MS-855,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,875.75 ",IP,"2,420.00","32,322.53",,,,,,
Health Alliance MCR ADV,DRG,MS-856,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$27,237.54 ",IP,"2,420.00","89,222.11",,,,,,
Health Alliance MCR ADV,DRG,MS-857,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$12,278.18 ",IP,"2,420.00","40,991.33",,,,,,
Health Alliance MCR ADV,DRG,MS-858,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,940.17 ",IP,"2,420.00","27,748.22",,,,,,
Health Alliance MCR ADV,DRG,MS-862,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W MCC,Medical,Relative Weights,"$11,076.88 ",IP,"2,420.00","37,308.10",,,,,,
Health Alliance MCR ADV,DRG,MS-863,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W/O MCC,Medical,Relative Weights,"$5,906.65 ",IP,"2,420.00","19,918.08",,,,,,
Health Alliance MCR ADV,DRG,MS-864,FEVER AND INFLAMMATORY CONDITIONS,Medical,Relative Weights,"$5,118.83 ",IP,"2,420.00","17,083.58",,,,,,
Health Alliance MCR ADV,DRG,MS-865,VIRAL ILLNESS WITH MCC,Medical,Relative Weights,"$8,630.47 ",IP,"2,420.00","28,088.93",,,,,,
Health Alliance MCR ADV,DRG,MS-866,VIRAL ILLNESS WITHOUT MCC,Medical,Relative Weights,"$4,899.83 ",IP,"2,420.00","16,504.99",,,,,,
Health Alliance MCR ADV,DRG,MS-867,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,Medical,Relative Weights,"$13,064.84 ",IP,"2,420.00","44,053.63",,,,,,
Health Alliance MCR ADV,DRG,MS-868,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,Medical,Relative Weights,"$6,225.52 ",IP,"2,420.00","22,115.52",,,,,,
Health Alliance MCR ADV,DRG,MS-869,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$4,254.50 ",IP,"2,420.00","14,968.80",,,,,,
Health Alliance MCR ADV,DRG,MS-870,SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,Medical,Relative Weights,"$37,604.26 ",IP,"2,420.00","127,497.89",,,,,,
Health Alliance MCR ADV,DRG,MS-871,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,Medical,Relative Weights,"$10,933.79 ",IP,"2,420.00","37,624.61",,,,,,
Health Alliance MCR ADV,DRG,MS-872,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,Medical,Relative Weights,"$5,993.67 ",IP,"2,420.00","20,952.29",,,,,,
Health Alliance MCR ADV,DRG,MS-876,O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,Surgical,Relative Weights,"$19,085.37 ",IP,"2,420.00","73,382.40",,,,,,
Health Alliance MCR ADV,DRG,MS-880,ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,Medical,Relative Weights,"$5,048.75 ",IP,"2,420.00","17,275.10",,,,,,
Health Alliance MCR ADV,DRG,MS-881,DEPRESSIVE NEUROSES,Medical,Relative Weights,"$4,683.74 ",IP,"2,420.00","16,517.09",,,,,,
Health Alliance MCR ADV,DRG,MS-882,NEUROSES EXCEPT DEPRESSIVE,Medical,Relative Weights,"$4,809.89 ",IP,"2,420.00","15,922.37",,,,,,
Health Alliance MCR ADV,DRG,MS-883,DISORDERS OF PERSONALITY & IMPULSE CONTROL,Medical,Relative Weights,"$9,237.83 ",IP,"2,420.00","26,945.86",,,,,,
Health Alliance MCR ADV,DRG,MS-884,ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,Medical,Relative Weights,"$8,452.34 ",IP,"2,420.00","28,990.08",,,,,,
Health Alliance MCR ADV,DRG,MS-885,PSYCHOSES,Medical,Relative Weights,"$7,238.19 ",IP,"2,420.00","24,502.46",,,,,,
Health Alliance MCR ADV,DRG,MS-886,BEHAVIORAL AND DEVELOPMENTAL DISORDERS,Medical,Relative Weights,"$7,146.50 ",IP,"2,420.00","27,127.30",,,,,,
Health Alliance MCR ADV,DRG,MS-887,OTHER MENTAL DISORDER DIAGNOSES,Medical,Relative Weights,"$6,306.12 ",IP,"2,420.00","21,936.10",,,,,,
Health Alliance MCR ADV,DRG,MS-894,ALCOHOL- DRUG ABUSE OR DEPENDENCE- LEFT AMA,Medical,Relative Weights,"$3,206.20 ",IP,"2,420.00","11,700.86",,,,,,
Health Alliance MCR ADV,DRG,MS-895,ALCOHOL- DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY,Medical,Relative Weights,"$9,339.45 ",IP,"2,420.00","32,798.30",,,,,,
Health Alliance MCR ADV,DRG,MS-896,ALCOHOL -  DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC,Medical,Relative Weights,"$10,397.09 ",IP,"2,420.00","34,669.15",,,,,,
Health Alliance MCR ADV,DRG,MS-897,ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC,Medical,Relative Weights,"$4,829.74 ",IP,"2,420.00","16,567.49",,,,,,
Health Alliance MCR ADV,DRG,MS-901,WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,Surgical,Relative Weights,"$24,929.54 ",IP,"2,420.00","87,236.35",,,,,,
Health Alliance MCR ADV,DRG,MS-902,WOUND DEBRIDEMENTS FOR INJURIES WITH CC,Surgical,Relative Weights,"$11,471.66 ",IP,"2,420.00","39,652.70",,,,,,
Health Alliance MCR ADV,DRG,MS-903,WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,630.24 ",IP,"2,420.00","23,063.04",,,,,,
Health Alliance MCR ADV,DRG,MS-904,SKIN GRAFTS FOR INJURIES WITH CC/MCC,Surgical,Relative Weights,"$21,765.97 ",IP,"2,420.00","71,313.98",,,,,,
Health Alliance MCR ADV,DRG,MS-905,SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,Surgical,Relative Weights,"$9,636.13 ",IP,"2,420.00","33,554.30",,,,,,
Health Alliance MCR ADV,DRG,MS-906,HAND PROCEDURES FOR INJURIES,Surgical,Relative Weights,"$10,534.33 ",IP,"2,420.00","35,096.54",,,,,,
Health Alliance MCR ADV,DRG,MS-907,OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,Surgical,Relative Weights,"$23,057.79 ",IP,"2,420.00","80,430.34",,,,,,
Health Alliance MCR ADV,DRG,MS-908,OTHER O.R. PROCEDURES FOR INJURIES WITH CC,Surgical,Relative Weights,"$11,974.50 ",IP,"2,420.00","41,592.10",,,,,,
Health Alliance MCR ADV,DRG,MS-909,OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,006.75 ",IP,"2,420.00","26,584.99",,,,,,
Health Alliance MCR ADV,DRG,MS-913,TRAUMATIC INJURY WITH MCC,Medical,Relative Weights,"$9,569.55 ",IP,"2,420.00","29,762.21",,,,,,
Health Alliance MCR ADV,DRG,MS-914,TRAUMATIC INJURY WITHOUT MCC,Medical,Relative Weights,"$5,179.56 ",IP,"2,420.00","17,371.87",,,,,,
Health Alliance MCR ADV,DRG,MS-915,ALLERGIC REACTIONS WITH MCC,Medical,Relative Weights,"$9,925.21 ",IP,"2,420.00","34,253.86",,,,,,
Health Alliance MCR ADV,DRG,MS-916,ALLERGIC REACTIONS WITHOUT MCC,Medical,Relative Weights,"$3,845.11 ",IP,"2,420.00","12,765.31",,,,,,
Health Alliance MCR ADV,DRG,MS-917,POISONING & TOXIC EFFECTS OF DRUGS W MCC,Medical,Relative Weights,"$8,634.55 ",IP,"2,420.00","29,498.11",,,,,,
Health Alliance MCR ADV,DRG,MS-918,POISONING & TOXIC EFFECTS OF DRUGS W/O MCC,Medical,Relative Weights,"$4,623.01 ",IP,"2,420.00","15,805.44",,,,,,
Health Alliance MCR ADV,DRG,MS-919,COMPLICATIONS OF TREATMENT WITH MCC,Medical,Relative Weights,"$10,769.69 ",IP,"2,420.00","36,798.05",,,,,,
Health Alliance MCR ADV,DRG,MS-920,COMPLICATIONS OF TREATMENT WITH CC,Medical,Relative Weights,"$5,983.74 ",IP,"2,420.00","20,311.20",,,,,,
Health Alliance MCR ADV,DRG,MS-921,COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,Medical,Relative Weights,"$4,075.79 ",IP,"2,420.00","13,922.50",,,,,,
Health Alliance MCR ADV,DRG,MS-922,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC,Medical,Relative Weights,"$9,275.21 ",IP,"2,420.00","32,328.58",,,,,,
Health Alliance MCR ADV,DRG,MS-923,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC,Medical,Relative Weights,"$5,488.50 ",IP,"2,420.00","17,448.48",,,,,,
Health Alliance MCR ADV,DRG,MS-927,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,Surgical,Relative Weights,"$123,174.83 ",IP,"2,420.00","402,060.96",,,,,,
Health Alliance MCR ADV,DRG,MS-928,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,Surgical,Relative Weights,"$38,145.05 ",IP,"2,420.00","124,889.18",,,,,,
Health Alliance MCR ADV,DRG,MS-929,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,Surgical,Relative Weights,"$17,601.41 ",IP,"2,420.00","59,300.64",,,,,,
Health Alliance MCR ADV,DRG,MS-933,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,Medical,Relative Weights,"$13,215.51 ",IP,"2,420.00","63,306.43",,,,,,
Health Alliance MCR ADV,DRG,MS-934,FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,Medical,Relative Weights,"$11,335.01 ",IP,"2,420.00","36,485.57",,,,,,
Health Alliance MCR ADV,DRG,MS-935,NON-EXTENSIVE BURNS,Medical,Relative Weights,"$11,288.29 ",IP,"2,420.00","38,955.17",,,,,,
Health Alliance MCR ADV,DRG,MS-939,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,Surgical,Relative Weights,"$19,707.93 ",IP,"2,420.00","73,672.70",,,,,,
Health Alliance MCR ADV,DRG,MS-940,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,Surgical,Relative Weights,"$12,970.23 ",IP,"2,420.00","45,799.49",,,,,,
Health Alliance MCR ADV,DRG,MS-941,O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W/O CC/MCC,Surgical,Relative Weights,"$11,231.05 ",IP,"2,420.00","38,922.91",,,,,,
Health Alliance MCR ADV,DRG,MS-945,REHABILITATION WITH CC/MCC,Medical,Relative Weights,"$8,654.41 ",IP,"2,420.00","29,338.85",,,,,,
Health Alliance MCR ADV,DRG,MS-946,REHABILITATION WITHOUT CC/MCC,Medical,Relative Weights,"$6,577.10 ",IP,"2,420.00","21,913.92",,,,,,
Health Alliance MCR ADV,DRG,MS-947,SIGNS AND SYMPTOMS WITH MCC,Medical,Relative Weights,"$6,973.05 ",IP,"2,420.00","24,137.57",,,,,,
Health Alliance MCR ADV,DRG,MS-948,SIGNS AND SYMPTOMS WITHOUT MCC,Medical,Relative Weights,"$4,596.73 ",IP,"2,420.00","15,716.74",,,,,,
Health Alliance MCR ADV,DRG,MS-949,AFTERCARE WITH CC/MCC,Medical,Relative Weights,"$6,481.90 ",IP,"2,420.00","21,952.22",,,,,,
Health Alliance MCR ADV,DRG,MS-950,AFTERCARE WITHOUT CC/MCC,Medical,Relative Weights,"$4,322.83 ",IP,"2,420.00","14,936.54",,,,,,
Health Alliance MCR ADV,DRG,MS-951,OTHER FACTORS INFLUENCING HEALTH STATUS,Medical,Relative Weights,"$3,268.11 ",IP,"2,420.00","11,823.84",,,,,,
Health Alliance MCR ADV,DRG,MS-955,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,Surgical,Relative Weights,"$36,730.00 ",IP,"2,420.00","122,582.88",,,,,,
Health Alliance MCR ADV,DRG,MS-956,LIMB REATTACHMENT- HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,Surgical,Relative Weights,"$22,484.30 ",IP,"2,420.00","79,093.73",,,,,,
Health Alliance MCR ADV,DRG,MS-957,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Surgical,Relative Weights,"$43,338.63 ",IP,"2,420.00","151,879.39",,,,,,
Health Alliance MCR ADV,DRG,MS-958,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,Surgical,Relative Weights,"$24,561.61 ",IP,"2,420.00","84,488.54",,,,,,
Health Alliance MCR ADV,DRG,MS-959,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,Surgical,Relative Weights,"$15,979.04 ",IP,"2,420.00","56,458.08",,,,,,
Health Alliance MCR ADV,DRG,MS-963,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Medical,Relative Weights,"$15,942.83 ",IP,"2,420.00","54,938.02",,,,,,
Health Alliance MCR ADV,DRG,MS-964,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,Medical,Relative Weights,"$8,712.23 ",IP,"2,420.00","30,108.96",,,,,,
Health Alliance MCR ADV,DRG,MS-965,OTHER MULTIPLE SIGNIFICANT TRAUMA W/O CC/MCC,Medical,Relative Weights,"$5,329.07 ",IP,"2,420.00","18,488.74",,,,,,
Health Alliance MCR ADV,DRG,MS-969,HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$34,175.55 ",IP,"2,420.00","116,982.43",,,,,,
Health Alliance MCR ADV,DRG,MS-970,HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$17,454.24 ",IP,"2,420.00","58,806.72",,,,,,
Health Alliance MCR ADV,DRG,MS-974,HIV WITH MAJOR RELATED CONDITION WITH MCC,Medical,Relative Weights,"$15,712.73 ",IP,"2,420.00","53,905.82",,,,,,
Health Alliance MCR ADV,DRG,MS-975,HIV WITH MAJOR RELATED CONDITION WITH CC,Medical,Relative Weights,"$7,487.56 ",IP,"2,420.00","27,054.72",,,,,,
Health Alliance MCR ADV,DRG,MS-976,HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,Medical,Relative Weights,"$5,545.74 ",IP,"2,420.00","18,430.27",,,,,,
Health Alliance MCR ADV,DRG,MS-977,HIV WITH OR WITHOUT OTHER RELATED CONDITION,Medical,Relative Weights,"$7,734.01 ",IP,"2,420.00","26,218.08",,,,,,
Health Alliance MCR ADV,DRG,MS-981,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$26,949.04 ",IP,"2,420.00","90,532.51",,,,,,
Health Alliance MCR ADV,DRG,MS-982,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Surgical,Relative Weights,"$14,813.94 ",IP,"2,420.00","49,152.10",,,,,,
Health Alliance MCR ADV,DRG,MS-983,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$9,649.56 ",IP,"2,420.00","33,003.94",,,,,,
Health Alliance MCR ADV,DRG,MS-987,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$19,131.51 ",IP,"2,420.00","67,207.39",,,,,,
Health Alliance MCR ADV,DRG,MS-988,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Surgical,Relative Weights,"$9,965.51 ",IP,"2,420.00","34,640.93",,,,,,
Health Alliance MCR ADV,DRG,MS-989,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$6,561.91 ",IP,"2,420.00","23,232.38",,,,,,
Health Alliance MCR ADV,CPT,176,Anesth pharyngeal surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,211,Anesth cran surg hemotoma,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,214,Anesth skull drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,215,Anesth skull repair/fract,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,524,Anesth chest drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,540,Anesth chest surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,542,Anesthesia removal pleura,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,546,Anesth lung chest wall surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,560,Anesth heart surg w/o pump,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,561,Anesth heart surg <1 yr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,562,Anesth hrt surg w/pmp age 1+,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,567,Anesth cabg w/pump,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,580,Anesth heart/lung transplnt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,632,Anesth removal of nerves,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,792,Anesth hemorr/excise liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,794,Anesth pancreas removal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,796,Anesth for liver transplant,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,844,Anesth pelvis surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,846,Anesth hysterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,848,Anesth pelvic organ surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,864,Anesth removal of bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,866,Anesth removal of adrenal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,868,Anesth kidney transplant,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,882,Anesth major vein ligation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,908,Anesth removal of prostate,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,932,Anesth amputation of penis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,934,Anesth penis nodes removal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,936,Anesth penis nodes removal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,1272,Anesth femoral artery surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,1442,Anesth knee artery surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,1444,Anesth knee artery repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,1502,Anesth lwr leg embolectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,1652,Anesth shoulder vessel surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,1654,Anesth shoulder vessel surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,1656,Anesth arm-leg vessel surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,1990,Support for organ donor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,10005,Fna bx w/us gdn 1st les,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,10007,Fna bx w/fluor gdn 1st les,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,10009,Fna bx w/ct gdn 1st les,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,10011,Fna bx w/mr gdn 1st les,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,10021,Fna bx w/o img gdn 1st les,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,10030,Guide cathet fluid drainage,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,10035,Perq dev soft tiss 1st imag,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,10040,Acne surgery,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,10060,Drainage of skin abscess,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,10061,Drainage of skin abscess,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,10080,Drainage of pilonidal cyst,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,10081,Drainage of pilonidal cyst,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,10120,Remove foreign body,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,10121,Remove foreign body,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,10140,Drainage of hematoma/fluid,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,10160,Puncture drainage of lesion,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,10180,Complex drainage wound,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11000,Debride infected skin,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11004,Debride genitalia & perineum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,11005,Debride abdom wall,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,11006,Debride genit/per/abdom wall,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,11008,Remove mesh from abd wall,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,11010,Debride skin at fx site,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11011,Debride skin musc at fx site,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11012,Deb skin bone at fx site,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11042,Deb subq tissue 20 sq cm/<,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11043,Deb musc/fascia 20 sq cm/<,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11044,Deb bone 20 sq cm/<,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11055,Trim skin lesion,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11056,Trim skin lesions 2 to 4,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11057,Trim skin lesions over 4,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11102,Tangntl bx skin single les,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11104,Punch bx skin single lesion,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11106,Incal bx skn single les,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11200,Removal of skin tags <w/15,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11300,Shave skin lesion 0.5 cm/<,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11301,Shave skin lesion 0.6-1.0 cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11302,Shave skin lesion 1.1-2.0 cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11303,Shave skin lesion >2.0 cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11305,Shave skin lesion 0.5 cm/<,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11306,Shave skin lesion 0.6-1.0 cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11307,Shave skin lesion 1.1-2.0 cm,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11308,Shave skin lesion >2.0 cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11310,Shave skin lesion 0.5 cm/<,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11311,Shave skin lesion 0.6-1.0 cm,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11312,Shave skin lesion 1.1-2.0 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11313,Shave skin lesion >2.0 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11400,Exc tr-ext b9+marg 0.5 cm<,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11401,Exc tr-ext b9+marg 0.6-1 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11402,Exc tr-ext b9+marg 1.1-2 cm,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11403,Exc tr-ext b9+marg 2.1-3cm,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11404,Exc tr-ext b9+marg 3.1-4 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11406,Exc tr-ext b9+marg >4.0 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11420,Exc h-f-nk-sp b9+marg 0.5/<,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11421,Exc h-f-nk-sp b9+marg 0.6-1,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11422,Exc h-f-nk-sp b9+marg 1.1-2,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11423,Exc h-f-nk-sp b9+marg 2.1-3,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11424,Exc h-f-nk-sp b9+marg 3.1-4,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11426,Exc h-f-nk-sp b9+marg >4 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11440,Exc face-mm b9+marg 0.5 cm/<,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11441,Exc face-mm b9+marg 0.6-1 cm,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11442,Exc face-mm b9+marg 1.1-2 cm,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11443,Exc face-mm b9+marg 2.1-3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11444,Exc face-mm b9+marg 3.1-4 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11446,Exc face-mm b9+marg >4 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11450,Removal sweat gland lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11451,Removal sweat gland lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11462,Removal sweat gland lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11463,Removal sweat gland lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11470,Removal sweat gland lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11471,Removal sweat gland lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11600,Exc tr-ext mal+marg 0.5 cm/<,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11601,Exc tr-ext mal+marg 0.6-1 cm,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11602,Exc tr-ext mal+marg 1.1-2 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11603,Exc tr-ext mal+marg 2.1-3 cm,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11604,Exc tr-ext mal+marg 3.1-4 cm,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11606,Exc tr-ext mal+marg >4 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11620,Exc h-f-nk-sp mal+marg 0.5/<,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11621,Exc s/n/h/f/g mal+mrg 0.6-1,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11622,Exc s/n/h/f/g mal+mrg 1.1-2,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11623,Exc s/n/h/f/g mal+mrg 2.1-3,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11624,Exc s/n/h/f/g mal+mrg 3.1-4,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11626,Exc s/n/h/f/g mal+mrg >4 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11640,Exc f/e/e/n/l mal+mrg 0.5cm<,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11641,Exc f/e/e/n/l mal+mrg 0.6-1,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11642,Exc f/e/e/n/l mal+mrg 1.1-2,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11643,Exc f/e/e/n/l mal+mrg 2.1-3,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11644,Exc f/e/e/n/l mal+mrg 3.1-4,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11646,Exc f/e/e/n/l mal+mrg >4 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11719,Trim nail(s) any number,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11720,Debride nail 1-5,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11721,Debride nail 6 or more,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11730,Removal of nail plate,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11740,Drain blood from under nail,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11750,Removal of nail bed,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11755,Biopsy nail unit,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11760,Repair of nail bed,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11762,Reconstruction of nail bed,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11765,Excision of nail fold toe,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11770,Remove pilonidal cyst simple,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11771,Remove pilonidal cyst exten,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11772,Remove pilonidal cyst compl,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11900,Inject skin lesions </w 7,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11901,Inject skin lesions >7,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11920,Correct skin color 6.0 cm/<,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11921,Correct skn color 6.1-20.0cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11950,Tx contour defects 1 cc/<,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11951,Tx contour defects 1.1-5.0cc,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11952,Tx contour defects 5.1-10cc,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11954,Tx contour defects >10.0 cc,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11960,Insert tissue expander(s),APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11970,Rplcmt tiss xpndr perm implt,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,11971,Rmvl tis xpndr wo insj implt,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11976,Remove contraceptive capsule,APC 5071,RVU Per Case,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11980,Implant hormone pellet(s),APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11981,Insert drug implant device,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11982,Remove drug implant device,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,11983,Remove/insert drug implant,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,12001,Rpr s/n/ax/gen/trnk 2.5cm/<,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,12002,Rpr s/n/ax/gen/trnk2.6-7.5cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,12004,Rpr s/n/ax/gen/trk7.6-12.5cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,12005,Rpr s/n/a/gen/trk12.6-20.0cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,12006,Rpr s/n/a/gen/trk20.1-30.0cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,12007,Rpr s/n/ax/gen/trnk >30.0 cm,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,12011,Rpr f/e/e/n/l/m 2.5 cm/<,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,12013,Rpr f/e/e/n/l/m 2.6-5.0 cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,12014,Rpr f/e/e/n/l/m 5.1-7.5 cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,12015,Rpr f/e/e/n/l/m 7.6-12.5 cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,12016,Rpr fe/e/en/l/m 12.6-20.0 cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,12017,Rpr fe/e/en/l/m 20.1-30.0 cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,12018,Rpr f/e/e/n/l/m >30.0 cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,12020,Closure of split wound,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,12021,Closure of split wound,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,12031,Intmd rpr s/a/t/ext 2.5 cm/<,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,12032,Intmd rpr s/a/t/ext 2.6-7.5,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,12034,Intmd rpr s/tr/ext 7.6-12.5,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,12035,Intmd rpr s/a/t/ext 12.6-20,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,12036,Intmd rpr s/a/t/ext 20.1-30,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,12037,Intmd rpr s/tr/ext >30.0 cm,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,12041,Intmd rpr n-hf/genit 2.5cm/<,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,12042,Intmd rpr n-hf/genit2.6-7.5,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,12044,Intmd rpr n-hf/genit7.6-12.5,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,12045,Intmd rpr n-hf/genit12.6-20,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,12046,Intmd rpr n-hf/genit20.1-30,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,12047,Intmd rpr n-hf/genit >30.0cm,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,12051,Intmd rpr face/mm 2.5 cm/<,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,12052,Intmd rpr face/mm 2.6-5.0 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,12053,Intmd rpr face/mm 5.1-7.5 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,12054,Intmd rpr face/mm 7.6-12.5cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,12055,Intmd rpr face/mm 12.6-20 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,12056,Intmd rpr face/mm 20.1-30.0,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,12057,Intmd rpr face/mm >30.0 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,13100,Cmplx rpr trunk 1.1-2.5 cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,13101,Cmplx rpr trunk 2.6-7.5 cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,13120,Cmplx rpr s/a/l 1.1-2.5 cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,13121,Cmplx rpr s/a/l 2.6-7.5 cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,13131,Cmplx rpr f/c/c/m/n/ax/g/h/f,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,13132,Cmplx rpr f/c/c/m/n/ax/g/h/f,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,13151,Cmplx rpr e/n/e/l 1.1-2.5 cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,13152,Cmplx rpr e/n/e/l 2.6-7.5 cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,13160,Late closure of wound,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,14000,Tis trnfr trunk 10 sq cm/<,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,14001,Tis trnfr trunk 10.1-30sqcm,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,14020,Tis trnfr s/a/l 10 sq cm/<,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,14021,Tis trnfr s/a/l 10.1-30 sqcm,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,14040,Tis trnfr f/c/c/m/n/a/g/h/f,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,14041,Tis trnfr f/c/c/m/n/a/g/h/f,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,14060,Tis trnfr e/n/e/l 10 sq cm/<,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,14061,Tis trnfr e/n/e/l10.1-30sqcm,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,14301,Tis trnfr any 30.1-60 sq cm,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,14350,Filleted finger/toe flap,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15002,Wound prep trk/arm/leg,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15004,Wound prep f/n/hf/g,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15040,Harvest cultured skin graft,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15050,Skin pinch graft,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15100,Skin splt grft trnk/arm/leg,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15110,Epidrm autogrft trnk/arm/leg,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15115,Epidrm a-grft face/nck/hf/g,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15120,Skn splt a-grft fac/nck/hf/g,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15130,Derm autograft trnk/arm/leg,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15135,Derm autograft face/nck/hf/g,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15150,Cult skin grft t/arm/leg,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15155,Cult skin graft f/n/hf/g,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15200,Skin full graft trunk,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15220,Skin full graft sclp/arm/leg,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15240,Skin full grft face/genit/hf,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15260,Skin full graft een & lips,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15271,Skin sub graft trnk/arm/leg,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15273,Skin sub grft t/arm/lg child,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15275,Skin sub graft face/nk/hf/g,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15277,Skn sub grft f/n/hf/g child,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15570,Skin pedicle flap trunk,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15572,Skin pedicle flap arms/legs,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15574,Pedcle fh/ch/ch/m/n/ax/g/h/f,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15576,Pedicle e/n/e/l/ntroral,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15600,Delay flap trunk,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15610,Delay flap arms/legs,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15620,Delay flap f/c/c/n/ax/g/h/f,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15630,Delay flap eye/nos/ear/lip,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15650,Transfer skin pedicle flap,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15730,Mdfc flap w/prsrv vasc pedcl,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15731,Forehead flap w/vasc pedicle,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15733,Musc myoq/fscq flp h&n pedcl,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,15734,Muscle-skin graft trunk,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15736,Muscle-skin graft arm,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15738,Muscle-skin graft leg,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15740,Island pedicle flap graft,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15750,Neurovascular pedicle flap,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15756,Free myo/skin flap microvasc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,15757,Free skin flap microvasc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,15758,Free fascial flap microvasc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,15760,Composite skin graft,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15769,Grfg autol soft tiss dir exc,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15770,Derma-fat-fascia graft,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15771,Grfg autol fat lipo 50 cc/<,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15773,Grfg autol fat lipo 25 cc/<,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15775,Hair trnspl 1-15 punch grfts,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15776,Hair trnspl >15 punch grafts,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15780,Dermabrasion total face,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15781,Dermabrasion segmental face,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15782,Dermabrasion other than face,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15783,Dermabrasion suprfl any site,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15786,Abrasion lesion single,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15788,Chemical peel face epiderm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15789,Chemical peel face dermal,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15792,Chemical peel nonfacial,APC 5053,RVU Per Case,$536.39 ,OP,536.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15793,Chemical peel nonfacial,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15819,Plastic surgery neck,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15820,Revision of lower eyelid,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15821,Revision of lower eyelid,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15822,Revision of upper eyelid,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15823,Revision of upper eyelid,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15824,Removal of forehead wrinkles,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15825,Removal of neck wrinkles,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15826,Removal of brow wrinkles,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15828,Removal of face wrinkles,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15829,Removal of skin wrinkles,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15830,Exc skin abd,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,15832,Excise excessive skin thigh,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15833,Excise excessive skin leg,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15834,Excise excessive skin hip,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15835,Excise excessive skin buttck,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15836,Excise excessive skin arm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15837,Excise excess skin arm/hand,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15838,Excise excess skin fat pad,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15839,Excise excess skin & tissue,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15840,Nerve palsy fascial graft,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15841,Nerve palsy muscle graft,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15842,Nerve palsy microsurg graft,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15845,Skin and muscle repair face,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15850,Remove sutures same surgeon,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15851,Remove sutures diff surgeon,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15852,Dressing change not for burn,APC 5053,RVU Per Case,$536.39 ,OP,536.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15860,Test for blood flow in graft,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15876,Suction lipectomy head&neck,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15877,Suction lipectomy trunk,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15878,Suction lipectomy upr extrem,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15879,Suction lipectomy lwr extrem,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15920,Removal of tail bone ulcer,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15922,Removal of tail bone ulcer,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15931,Remove sacrum pressure sore,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15933,Remove sacrum pressure sore,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15934,Remove sacrum pressure sore,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15935,Remove sacrum pressure sore,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15936,Remove sacrum pressure sore,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15937,Remove sacrum pressure sore,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15940,Remove hip pressure sore,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15941,Remove hip pressure sore,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15944,Remove hip pressure sore,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15945,Remove hip pressure sore,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15946,Remove hip pressure sore,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15950,Remove thigh pressure sore,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15951,Remove thigh pressure sore,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15952,Remove thigh pressure sore,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15953,Remove thigh pressure sore,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15956,Remove thigh pressure sore,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15958,Remove thigh pressure sore,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,15999,Removal of pressure sore,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,16000,Initial treatment of burn(s),APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,16020,Dress/debrid p-thick burn s,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,16025,Dress/debrid p-thick burn m,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,16030,Dress/debrid p-thick burn l,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,16035,Incision of burn scab initi,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,16036,Escharotomy addl incision,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,17000,Destruct premalg lesion,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,17004,Destroy premal lesions 15/>,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,17106,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,17107,Destruction of skin lesions,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,17108,Destruction of skin lesions,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,17110,Destruct b9 lesion 1-14,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,17111,Destruct lesion 15 or more,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,17250,Chem caut of granltj tissue,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,17260,Destruction of skin lesions,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,17261,Destruction of skin lesions,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,17262,Destruction of skin lesions,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,17263,Destruction of skin lesions,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,17264,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,17266,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,17270,Destruction of skin lesions,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,17271,Destruction of skin lesions,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,17272,Destruction of skin lesions,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,17273,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,17274,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,17276,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,17280,Destruction of skin lesions,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,17281,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,17282,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,17283,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,17284,Destruction of skin lesions,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,17286,Destruction of skin lesions,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,17311,Mohs 1 stage h/n/hf/g,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,17313,Mohs 1 stage t/a/l,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,17340,Cryotherapy of skin,APC 5732,RVU Per Case,$34.63 ,OP,34.63,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,17360,Skin peel therapy,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,17380,Hair removal by electrolysis,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,17999,Skin tissue procedure,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,19000,Drainage of breast lesion,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,19020,Incision of breast lesion,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,19081,Bx breast 1st lesion strtctc,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,19083,Bx breast 1st lesion us imag,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,19085,Bx breast 1st lesion mr imag,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,19100,Bx breast percut w/o image,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,19101,Biopsy of breast open,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,19105,Cryosurg ablate fa each,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,19110,Nipple exploration,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,19112,Excise breast duct fistula,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,19120,Removal of breast lesion,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,19125,Excision breast lesion,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,19281,Perq device breast 1st imag,APC 5071,RVU Per Case,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,19283,Perq dev breast 1st strtctc,APC 5071,RVU Per Case,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,19285,Perq dev breast 1st us imag,APC 5071,RVU Per Case,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,19287,Perq dev breast 1st mr guide,APC 5071,RVU Per Case,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,19296,Place po breast cath for rad,APC 5093,RVU Per Case,"$9,128.05 ",OP,"4,314.00","9,128.05",,,,,,
Health Alliance MCR ADV,CPT,19298,Place breast rad tube/caths,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
Health Alliance MCR ADV,CPT,19300,Removal of breast tissue,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,19301,Partial mastectomy,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,19302,P-mastectomy w/ln removal,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
Health Alliance MCR ADV,CPT,19303,Mast simple complete,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
Health Alliance MCR ADV,CPT,19305,Mast radical,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,19306,Mast rad urban type,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,19307,Mast mod rad,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,19316,Suspension of breast,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
Health Alliance MCR ADV,CPT,19318,Breast reduction,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,19325,Breast augmentation w/implt,APC 5093,RVU Per Case,"$9,128.05 ",OP,"4,314.00","9,128.05",,,,,,
Health Alliance MCR ADV,CPT,19328,Rmvl intact breast implant,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,19330,Rmvl ruptured breast implant,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,19340,Insj breast implt sm d mast,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,19342,Insj/rplcmt brst implt sep d,APC 5093,RVU Per Case,"$9,128.05 ",OP,"4,314.00","9,128.05",,,,,,
Health Alliance MCR ADV,CPT,19350,Breast reconstruction,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,19355,Correct inverted nipple(s),APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,19357,Tiss xpndr plmt brst rcnstj,APC 5094,RVU Per Case,"$15,276.83 ",OP,"4,140.35","15,276.83",,,,,,
Health Alliance MCR ADV,CPT,19361,Brst rcnstj latsms drsi flap,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,19364,Brst rcnstj free flap,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,19367,Brst rcnstj 1 pdcl tram flap,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,19368,Brst rcnstj 1pdcl tram anast,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,19369,Brst rcnstj 2 pdcl tram flap,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,19370,Revj peri-implt capsule brst,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,19371,Peri-implt capslc brst compl,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,19380,Revj reconstructed breast,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
Health Alliance MCR ADV,CPT,19396,Design custom breast implant,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,19499,Breast surgery procedure,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20100,Explore wound neck,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20101,Explore wound chest,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20102,Explore wound abdomen,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20103,Explore wound extremity,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20150,Excise epiphyseal bar,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20200,Muscle biopsy,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20205,Deep muscle biopsy,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20206,Needle biopsy muscle,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20220,Bone biopsy trocar/needle,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20225,Bone biopsy trocar/needle,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20240,Bone biopsy open superficial,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20245,Bone biopsy open deep,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20250,Open bone biopsy,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20251,Open bone biopsy,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,20500,Injection of sinus tract,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20520,Removal of foreign body,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20525,Removal of foreign body,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20526,Ther injection carp tunnel,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20527,Inj dupuytren cord w/enzyme,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20550,Inj tendon sheath/ligament,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20551,Inj tendon origin/insertion,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20552,Inj trigger point 1/2 muscl,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20553,Inject trigger points 3/>,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20555,Place ndl musc/tis for rt,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20560,Ndl insj w/o njx 1 or 2 musc,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20561,Ndl insj w/o njx 3+ musc,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20600,Drain/inj joint/bursa w/o us,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20604,Drain/inj joint/bursa w/us,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20605,Drain/inj joint/bursa w/o us,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20606,Drain/inj joint/bursa w/us,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20610,Drain/inj joint/bursa w/o us,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20611,Drain/inj joint/bursa w/us,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20612,Aspirate/inj ganglion cyst,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20615,Treatment of bone cyst,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20650,Insert and remove bone pin,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20660,Apply rem fixation device,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20661,Application of head brace,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20662,Application of pelvis brace,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20663,Application of thigh brace,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20664,Application of halo,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20665,Removal of fixation device,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20670,Removal of support implant,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20680,Removal of support implant,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20690,Apply bone fixation device,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,20692,Apply bone fixation device,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,20693,Adjust bone fixation device,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,20694,Remove bone fixation device,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20696,Comp multiplane ext fixation,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,20697,Comp ext fixate strut change,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20802,Replantation arm complete,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,20805,Replant forearm complete,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,20808,Replantation hand complete,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,20816,Replantation digit complete,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,20822,Replantation digit complete,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20824,Replantation thumb complete,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,20827,Replantation thumb complete,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,20838,Replantation foot complete,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,20900,Removal of bone for graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,20902,Removal of bone for graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,20910,Remove cartilage for graft,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20912,Remove cartilage for graft,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20920,Removal of fascia for graft,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20922,Removal of fascia for graft,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20924,Removal of tendon for graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,20950,Fluid pressure muscle,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20955,Fibula bone graft microvasc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,20956,Iliac bone graft microvasc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,20957,Mt bone graft microvasc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,20962,Other bone graft microvasc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,20969,Bone/skin graft microvasc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,20970,Bone/skin graft iliac crest,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,20972,Bone/skin graft metatarsal,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,20973,Bone/skin graft great toe,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,20974,Electrical bone stimulation,Physician,Per Unit,$50.41 ,OP,50.41,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20979,Us bone stimulation,APC 5731,RVU Per Case,$25.25 ,OP,25.25,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,20982,Ablate bone tumor(s) perq,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,20983,Ablate bone tumor(s) perq,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,20999,Musculoskeletal surgery,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21010,Incision of jaw joint,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21011,Exc face les sc <2 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21012,Exc face les sbq 2 cm/>,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21013,Exc face tum deep < 2 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21014,Exc face tum deep 2 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21015,Resect face/scalp tum < 2 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21016,Resect face/scalp tum 2 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21025,Excision of bone lower jaw,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21026,Excision of facial bone(s),APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21029,Contour of face bone lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21030,Excise max/zygoma b9 tumor,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21031,Remove exostosis mandible,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21032,Remove exostosis maxilla,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21034,Excise max/zygoma mal tumor,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21040,Excise mandible lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21044,Removal of jaw bone lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21045,Extensive jaw surgery,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21046,Remove mandible cyst complex,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21047,Excise lwr jaw cyst w/repair,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21048,Remove maxilla cyst complex,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21049,Excis uppr jaw cyst w/repair,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21050,Removal of jaw joint,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21060,Remove jaw joint cartilage,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21070,Remove coronoid process,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21073,Mnpj of tmj w/anesth,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21076,Prepare face/oral prosthesis,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21077,Prepare face/oral prosthesis,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21079,Prepare face/oral prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21080,Prepare face/oral prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21081,Prepare face/oral prosthesis,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21082,Prepare face/oral prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21083,Prepare face/oral prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21084,Prepare face/oral prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21085,Prepare face/oral prosthesis,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21086,Prepare face/oral prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21087,Prepare face/oral prosthesis,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21088,Prepare face/oral prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21089,Prepare face/oral prosthesis,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21100,Maxillofacial fixation,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21110,Interdental fixation,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21120,Reconstruction of chin,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21121,Reconstruction of chin,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21122,Reconstruction of chin,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21123,Reconstruction of chin,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21125,Augmentation lower jaw bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21127,Augmentation lower jaw bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21137,Reduction of forehead,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21138,Reduction of forehead,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21139,Reduction of forehead,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21141,Lefort i-1 piece w/o graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21142,Lefort i-2 piece w/o graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21143,Lefort i-3/> piece w/o graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21145,Lefort i-1 piece w/ graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21146,Lefort i-2 piece w/ graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21147,Lefort i-3/> piece w/ graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21150,Lefort ii anterior intrusion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21151,Lefort ii w/bone grafts,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21154,Lefort iii w/o lefort i,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21155,Lefort iii w/ lefort i,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21159,Lefort iii w/fhdw/o lefort i,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21160,Lefort iii w/fhd w/ lefort i,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21172,Reconstruct orbit/forehead,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21175,Reconstruct orbit/forehead,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21179,Reconstruct entire forehead,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21180,Reconstruct entire forehead,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21181,Contour cranial bone lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21182,Reconstruct cranial bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21183,Reconstruct cranial bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21184,Reconstruct cranial bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21188,Reconstruction of midface,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21193,Reconst lwr jaw w/o graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,21194,Reconst lwr jaw w/graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21195,Reconst lwr jaw w/o fixation,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21196,Reconst lwr jaw w/fixation,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21198,Reconstr lwr jaw segment,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21199,Reconstr lwr jaw w/advance,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21206,Reconstruct upper jaw bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21208,Augmentation of facial bones,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21209,Reduction of facial bones,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21210,Face bone graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21215,Lower jaw bone graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21230,Rib cartilage graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21235,Ear cartilage graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21240,Reconstruction of jaw joint,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21242,Reconstruction of jaw joint,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21243,Reconstruction of jaw joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,21244,Reconstruction of lower jaw,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21245,Reconstruction of jaw,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21246,Reconstruction of jaw,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21247,Reconstruct lower jaw bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21248,Reconstruction of jaw,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21249,Reconstruction of jaw,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21255,Reconstruct lower jaw bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21256,Reconstruction of orbit,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21260,Revise eye sockets,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21261,Revise eye sockets,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21263,Revise eye sockets,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21267,Revise eye sockets,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21268,Revise eye sockets,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21270,Augmentation cheek bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21275,Revision orbitofacial bones,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21280,Revision of eyelid,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21282,Revision of eyelid,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21295,Revision of jaw muscle/bone,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21296,Revision of jaw muscle/bone,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21299,Cranio/maxillofacial surgery,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21310,Closed tx nose fx w/o manj,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21315,Closed tx nose fx w/o stablj,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21320,Closed tx nose fx w/ stablj,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21325,Open tx nose fx uncomplicatd,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21330,Open tx nose fx w/skele fixj,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21335,Open tx nose & septal fx,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21336,Open tx septal fx w/wo stabj,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21337,Closed tx septal&nose fx,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21338,Open nasoethmoid fx w/o fixj,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21339,Open nasoethmoid fx w/ fixj,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21340,Perq tx nasoethmoid fx,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21343,Open tx dprsd front sinus fx,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21344,Open tx compl front sinus fx,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21345,Closed tx nose/jaw fx,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21346,Opn tx nasomax fx w/fixj,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21347,Opn tx nasomax fx multple,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21348,Opn tx nasomax fx w/graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21355,Perq tx malar fracture,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21356,Opn tx dprsd zygomatic arch,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21360,Opn tx dprsd malar fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21365,Opn tx complx malar fx,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21366,Opn tx complx malar w/grft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21385,Opn tx orbit fx transantral,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21386,Opn tx orbit fx periorbital,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21387,Opn tx orbit fx combined,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21390,Opn tx orbit periorbtl implt,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21395,Opn tx orbit periorbt w/grft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21400,Closed tx orbit w/o manipulj,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21401,Closed tx orbit w/manipulj,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21406,Opn tx orbit fx w/o implant,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21407,Opn tx orbit fx w/implant,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21408,Opn tx orbit fx w/bone grft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21421,Treat mouth roof fracture,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21422,Treat mouth roof fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21423,Treat mouth roof fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21431,Treat craniofacial fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21432,Treat craniofacial fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21433,Treat craniofacial fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21435,Treat craniofacial fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21436,Treat craniofacial fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21440,Treat dental ridge fracture,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21445,Treat dental ridge fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21450,Treat lower jaw fracture,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21451,Treat lower jaw fracture,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21452,Treat lower jaw fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21453,Treat lower jaw fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21454,Treat lower jaw fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21461,Treat lower jaw fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21462,Treat lower jaw fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,21465,Treat lower jaw fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21470,Treat lower jaw fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21480,Reset dislocated jaw,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21485,Reset dislocated jaw,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21490,Repair dislocated jaw,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21497,Interdental wiring,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21499,Head surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21501,Drain neck/chest lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21502,Drain chest lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21510,Drainage of bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,21550,Biopsy of neck/chest,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21552,Exc neck les sc 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21554,Exc neck tum deep 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21555,Exc neck les sc < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21556,Exc neck tum deep < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21557,Resect neck thorax tumor<5cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21558,Resect neck tumor 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21600,Partial removal of rib,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,21601,Exc chest wall tumor w/ribs,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21602,Exc ch wal tum w/o lymphadec,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,21603,Exc ch wal tum w/lymphadec,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,21610,Partial removal of rib,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21615,Removal of rib,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,21616,Removal of rib and nerves,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,21620,Partial removal of sternum,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,21627,Sternal debridement,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,21630,Extensive sternum surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,21632,Extensive sternum surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,21685,Hyoid myotomy & suspension,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,21700,Revision of neck muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,21705,Revision of neck muscle/rib,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,21720,Revision of neck muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21725,Revision of neck muscle,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21740,Reconstruction of sternum,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,21742,Repair stern/nuss w/o scope,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21743,Repair sternum/nuss w/scope,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21750,Repair of sternum separation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,21811,Optx of rib fx w/fixj scope,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,21812,Treatment of rib fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,21813,Treatment of rib fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21820,Treat sternum fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21825,Treat sternum fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,21899,Neck/chest surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21920,Biopsy soft tissue of back,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21925,Biopsy soft tissue of back,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21930,Exc back les sc < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21931,Exc back les sc 3 cm/>,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21932,Exc back tum deep < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21933,Exc back tum deep 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21935,Resect back tum < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,21936,Resect back tum 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,22010,I&d p-spine c/t/cerv-thor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,22015,I&d abscess p-spine l/s/ls,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,22100,Remove part of neck vertebra,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,22101,Remove part thorax vertebra,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,22102,Remove part lumbar vertebra,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,22110,Remove part of neck vertebra,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,22112,Remove part thorax vertebra,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,22114,Remove part lumbar vertebra,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,22206,Incis spine 3 column thorac,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,22207,Incis spine 3 column lumbar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,22210,Incis 1 vertebral seg cerv,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,22212,Incis 1 vertebral seg thorac,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,22214,Incis 1 vertebral seg lumbar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,22220,Incis w/discectomy cervical,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,22222,Incis w/discectomy thoracic,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,22224,Incis w/discectomy lumbar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,22310,Closed tx vert fx w/o manj,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,22315,Closed tx vert fx w/manj,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,22318,Treat odontoid fx w/o graft,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,22319,Treat odontoid fx w/graft,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,22325,Treat spine fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,22326,Treat neck spine fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,22327,Treat thorax spine fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,22505,Manipulation of spine,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,22510,Perq cervicothoracic inject,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","15,496.26",,,,,,
Health Alliance MCR ADV,CPT,22511,Perq lumbosacral injection,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,22513,Perq vertebral augmentation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,22514,Perq vertebral augmentation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,22532,Lat thorax spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,22533,Lat lumbar spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,22548,Neck spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,22551,Neck spine fuse&remov bel c2,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,22554,Neck spine fusion,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,22556,Thorax spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,22558,Lumbar spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,22586,Prescrl fuse w/ instr l5-s1,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,22590,Spine & skull spinal fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,22595,Neck spinal fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,22600,Neck spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,22610,Thorax spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,22612,Lumbar spine fusion,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,22630,Lumbar spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,22633,Lumbar spine fusion combined,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,22800,Post fusion </6 vert seg,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,22802,Post fusion 7-12 vert seg,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,22804,Post fusion 13/> vert seg,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,22808,Ant fusion 2-3 vert seg,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,22810,Ant fusion 4-7 vert seg,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,22812,Ant fusion 8/> vert seg,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,22818,Kyphectomy 1-2 segments,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,22819,Kyphectomy 3 or more,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,22830,Exploration of spinal fusion,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,22849,Reinsert spinal fixation,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,22850,Remove spine fixation device,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,22852,Remove spine fixation device,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,22855,Remove spine fixation device,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,22856,Cerv artific diskectomy,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,140.35","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,22857,Lumbar artif diskectomy,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,22861,Revise cerv artific disc,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,22862,Revise lumbar artif disc,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,22864,Remove cerv artif disc,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,22865,Remove lumb artif disc,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,22867,Insj stablj dev w/dcmprn,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,22869,Insj stablj dev w/o dcmprn,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,22899,Spine surgery procedure,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,22900,Exc abdl tum deep < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,22901,Exc abdl tum deep 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,22902,Exc abd les sc < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,22903,Exc abd les sc 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,22904,Radical resect abd tumor<5cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,22905,Rad resect abd tumor 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,22999,Abdomen surgery procedure,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23000,Removal of calcium deposits,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23020,Release shoulder joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23030,Drain shoulder lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23031,Drain shoulder bursa,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23035,Drain shoulder bone lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23040,Exploratory shoulder surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23044,Exploratory shoulder surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23065,Biopsy shoulder tissues,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23066,Biopsy shoulder tissues,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23071,Exc shoulder les sc 3 cm/>,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23073,Exc shoulder tum deep 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23075,Exc shoulder les sc < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23076,Exc shoulder tum deep < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23077,Resect shoulder tumor < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23078,Resect shoulder tumor 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23100,Biopsy of shoulder joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23101,Shoulder joint surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23105,Remove shoulder joint lining,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,23106,Incision of collarbone joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23107,Explore treat shoulder joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,23120,Partial removal collar bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23125,Removal of collar bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23130,Remove shoulder bone part,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23140,Removal of bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23145,Removal of bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23146,Removal of bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,23150,Removal of humerus lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23155,Removal of humerus lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,23156,Removal of humerus lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,23170,Remove collar bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23172,Remove shoulder blade lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23174,Remove humerus lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,23180,Remove collar bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,23182,Remove shoulder blade lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,23184,Remove humerus lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,23190,Partial removal of scapula,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23195,Removal of head of humerus,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,23200,Resect clavicle tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,23210,Resect scapula tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,23220,Resect prox humerus tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,23330,Remove shoulder foreign body,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23333,Remove shoulder fb deep,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23334,Shoulder prosthesis removal,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23335,Shoulder prosthesis removal,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23395,Muscle transfer shoulder/arm,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,23397,Muscle transfers,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,23400,Fixation of shoulder blade,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,23405,Incision of tendon & muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,23406,Incise tendon(s) & muscle(s),APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,23410,Repair rotator cuff acute,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,23412,Repair rotator cuff chronic,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,23415,Release of shoulder ligament,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,23420,Repair of shoulder,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,23430,Repair biceps tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,23440,Remove/transplant tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,23450,Repair shoulder capsule,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,23455,Repair shoulder capsule,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,23460,Repair shoulder capsule,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,23462,Repair shoulder capsule,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,23465,Repair shoulder capsule,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,23466,Repair shoulder capsule,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,23470,Reconstruct shoulder joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,23472,Reconstruct shoulder joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,23473,Revis reconst shoulder joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,23474,Revis reconst shoulder joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,23480,Revision of collar bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,23485,Revision of collar bone,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,23490,Reinforce clavicle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,23491,Reinforce shoulder bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,23500,Treat clavicle fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23505,Treat clavicle fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23515,Treat clavicle fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,23520,Treat clavicle dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23525,Treat clavicle dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23530,Treat clavicle dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,23532,Treat clavicle dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,23540,Treat clavicle dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23545,Treat clavicle dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23550,Treat clavicle dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,23552,Treat clavicle dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,23570,Treat shoulder blade fx,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23575,Treat shoulder blade fx,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23585,Treat scapula fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,23600,Treat humerus fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23605,Treat humerus fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23615,Treat humerus fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,23616,Treat humerus fracture,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,23620,Treat humerus fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23625,Treat humerus fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23630,Treat humerus fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,23650,Treat shoulder dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23655,Treat shoulder dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23660,Treat shoulder dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,23665,Treat dislocation/fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23670,Treat dislocation/fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,23675,Treat dislocation/fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23680,Treat dislocation/fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,23700,Fixation of shoulder,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23800,Fusion of shoulder joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,23802,Fusion of shoulder joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,23900,Amputation of arm & girdle,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,23920,Amputation at shoulder joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,23921,Amputation follow-up surgery,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23929,Shoulder surgery procedure,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23930,Drainage of arm lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23931,Drainage of arm bursa,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,23935,Drain arm/elbow bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24000,Exploratory elbow surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24006,Release elbow joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24065,Biopsy arm/elbow soft tissue,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24066,Biopsy arm/elbow soft tissue,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24071,Exc arm/elbow les sc 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24073,Ex arm/elbow tum deep 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24075,Exc arm/elbow les sc < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24076,Ex arm/elbow tum deep < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24077,Resect arm/elbow tum < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24079,Resect arm/elbow tum 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24100,Biopsy elbow joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24101,Explore/treat elbow joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24102,Remove elbow joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24105,Removal of elbow bursa,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24110,Remove humerus lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24115,Remove/graft bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,24116,Remove/graft bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,24120,Remove elbow lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24125,Remove/graft bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24126,Remove/graft bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,24130,Removal of head of radius,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24134,Removal of arm bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,24136,Remove radius bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24138,Remove elbow bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,24140,Partial removal of arm bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24145,Partial removal of radius,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,24147,Partial removal of elbow,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24149,Radical resection of elbow,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,24150,Resect distal humerus tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,24152,Resect radius tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,24155,Removal of elbow joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24160,Remove elbow joint implant,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24164,Remove radius head implant,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24200,Removal of arm foreign body,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24201,Removal of arm foreign body,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24300,Manipulate elbow w/anesth,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24301,Muscle/tendon transfer,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,24305,Arm tendon lengthening,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24310,Revision of arm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24320,Repair of arm tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,24330,Revision of arm muscles,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,24331,Revision of arm muscles,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,24332,Tenolysis triceps,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24340,Repair of biceps tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,24341,Repair arm tendon/muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,24342,Repair of ruptured tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,24343,Repr elbow lat ligmnt w/tiss,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24344,Reconstruct elbow lat ligmnt,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,24345,Repr elbw med ligmnt w/tissu,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,24346,Reconstruct elbow med ligmnt,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,24357,Repair elbow perc,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24358,Repair elbow w/deb open,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24359,Repair elbow deb/attch open,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24360,Reconstruct elbow joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,24361,Reconstruct elbow joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,24362,Reconstruct elbow joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,24363,Replace elbow joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,24365,Reconstruct head of radius,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,24366,Reconstruct head of radius,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,24370,Revise reconst elbow joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,24371,Revise reconst elbow joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,24400,Revision of humerus,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,24410,Revision of humerus,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,24420,Revision of humerus,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,24430,Repair of humerus,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,24435,Repair humerus with graft,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,24470,Revision of elbow joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24495,Decompression of forearm,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,24498,Reinforce humerus,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,24500,Treat humerus fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24505,Treat humerus fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24515,Treat humerus fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,24516,Treat humerus fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,24530,Treat humerus fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24535,Treat humerus fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24538,Treat humerus fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,24545,Treat humerus fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,24546,Treat humerus fracture,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,24560,Treat humerus fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24565,Treat humerus fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24566,Treat humerus fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24575,Treat humerus fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,24576,Treat humerus fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24577,Treat humerus fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24579,Treat humerus fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,24582,Treat humerus fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,24586,Treat elbow fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,24587,Treat elbow fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,24600,Treat elbow dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24605,Treat elbow dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24615,Treat elbow dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,24620,Treat elbow fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24635,Treat elbow fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,24640,Treat elbow dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24650,Treat radius fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24655,Treat radius fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24665,Treat radius fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,24666,Treat radius fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,24670,Treat ulnar fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24675,Treat ulnar fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24685,Treat ulnar fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,24800,Fusion of elbow joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,24802,Fusion/graft of elbow joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,24900,Amputation of upper arm,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,24920,Amputation of upper arm,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,24925,Amputation follow-up surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,24930,Amputation follow-up surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,24931,Amputate upper arm & implant,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,24935,Revision of amputation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,24940,Revision of upper arm,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,24999,Upper arm/elbow surgery,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25000,Incision of tendon sheath,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25001,Incise flexor carpi radialis,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25020,Decompress forearm 1 space,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25023,Decompress forearm 1 space,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25024,Decompress forearm 2 spaces,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25025,Decompress forearm 2 spaces,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25028,Drainage of forearm lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25031,Drainage of forearm bursa,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25035,Treat forearm bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,25040,Explore/treat wrist joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25065,Biopsy forearm soft tissues,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25066,Biopsy forearm soft tissues,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25071,Exc forearm les sc 3 cm/>,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25073,Exc forearm tum deep 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25075,Exc forearm les sc < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25076,Exc forearm tum deep < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25077,Resect forearm/wrist tum<3cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25078,Resect forarm/wrist tum 3cm>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25085,Incision of wrist capsule,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25100,Biopsy of wrist joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25101,Explore/treat wrist joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25105,Remove wrist joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25107,Remove wrist joint cartilage,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25109,Excise tendon forearm/wrist,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25110,Remove wrist tendon lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25111,Remove wrist tendon lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25112,Reremove wrist tendon lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25115,Remove wrist/forearm lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25116,Remove wrist/forearm lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25118,Excise wrist tendon sheath,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25119,Partial removal of ulna,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25120,Removal of forearm lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25125,Remove/graft forearm lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25126,Remove/graft forearm lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25130,Removal of wrist lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25135,Remove & graft wrist lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,25136,Remove & graft wrist lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,25145,Remove forearm bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25150,Partial removal of ulna,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25151,Partial removal of radius,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,25170,Resect radius/ulnar tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,25210,Removal of wrist bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25215,Removal of wrist bones,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25230,Partial removal of radius,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25240,Partial removal of ulna,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25248,Remove forearm foreign body,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25250,Removal of wrist prosthesis,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25251,Removal of wrist prosthesis,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25259,Manipulate wrist w/anesthes,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25260,Repair forearm tendon/muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25263,Repair forearm tendon/muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,25265,Repair forearm tendon/muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25270,Repair forearm tendon/muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25272,Repair forearm tendon/muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25274,Repair forearm tendon/muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25275,Repair forearm tendon sheath,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25280,Revise wrist/forearm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25290,Incise wrist/forearm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25295,Release wrist/forearm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25300,Fusion of tendons at wrist,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25301,Fusion of tendons at wrist,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25310,Transplant forearm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25312,Transplant forearm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25315,Revise palsy hand tendon(s),APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,25316,Revise palsy hand tendon(s),APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,25320,Repair/revise wrist joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,25332,Revise wrist joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25335,Realignment of hand,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25337,Reconstruct ulna/radioulnar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,25350,Revision of radius,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,25355,Revision of radius,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25360,Revision of ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,25365,Revise radius & ulna,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,25370,Revise radius or ulna,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25375,Revise radius & ulna,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25390,Shorten radius or ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,25391,Lengthen radius or ulna,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,25392,Shorten radius & ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,25393,Lengthen radius & ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,25394,Repair carpal bone shorten,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25400,Repair radius or ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,25405,Repair/graft radius or ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,25415,Repair radius & ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,25420,Repair/graft radius & ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,25425,Repair/graft radius or ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,25426,Repair/graft radius & ulna,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25430,Vasc graft into carpal bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25431,Repair nonunion carpal bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,25440,Repair/graft wrist bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,25441,Reconstruct wrist joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,25442,Reconstruct wrist joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,25443,Reconstruct wrist joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,25444,Reconstruct wrist joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,25445,Reconstruct wrist joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,25446,Wrist replacement,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,25447,Repair wrist joints,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25449,Remove wrist joint implant,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,25450,Revision of wrist joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25455,Revision of wrist joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25490,Reinforce radius,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,25491,Reinforce ulna,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,25492,Reinforce radius and ulna,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25500,Treat fracture of radius,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25505,Treat fracture of radius,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25515,Treat fracture of radius,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,25520,Treat fracture of radius,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25525,Treat fracture of radius,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,25526,Treat fracture of radius,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,25530,Treat fracture of ulna,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25535,Treat fracture of ulna,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25545,Treat fracture of ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,25560,Treat fracture radius & ulna,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25565,Treat fracture radius & ulna,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25574,Treat fracture radius & ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,25575,Treat fracture radius/ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,25600,Treat fracture radius/ulna,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25605,Treat fracture radius/ulna,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25606,Treat fx distal radial,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25607,Treat fx rad extra-articul,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,25608,Treat fx rad intra-articul,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,25609,Treat fx radial 3+ frag,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,25622,Treat wrist bone fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25624,Treat wrist bone fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25628,Treat wrist bone fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,25630,Treat wrist bone fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25635,Treat wrist bone fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25645,Treat wrist bone fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25650,Treat wrist bone fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25651,Pin ulnar styloid fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25652,Treat fracture ulnar styloid,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,25660,Treat wrist dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25670,Treat wrist dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,25671,Pin radioulnar dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25675,Treat wrist dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25676,Treat wrist dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,25680,Treat wrist fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25685,Treat wrist fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,25690,Treat wrist dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25695,Treat wrist dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,25800,Fusion of wrist joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,25805,Fusion/graft of wrist joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,25810,Fusion/graft of wrist joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,25820,Fusion of hand bones,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,25825,Fuse hand bones with graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,25830,Fusion radioulnar jnt/ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,25900,Amputation of forearm,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,25905,Amputation of forearm,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,25907,Amputation follow-up surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25909,Amputation follow-up surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,25915,Amputation of forearm,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,25920,Amputate hand at wrist,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,25922,Amputate hand at wrist,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25924,Amputation follow-up surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,25927,Amputation of hand,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25929,Amputation follow-up surgery,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25931,Amputation follow-up surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,25999,Forearm or wrist surgery,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26010,Drainage of finger abscess,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26011,Drainage of finger abscess,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26020,Drain hand tendon sheath,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26025,Drainage of palm bursa,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26030,Drainage of palm bursas,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26034,Treat hand bone lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26035,Decompress fingers/hand,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26037,Decompress fingers/hand,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26040,Release palm contracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26045,Release palm contracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26055,Incise finger tendon sheath,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26060,Incision of finger tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26070,Explore/treat hand joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26075,Explore/treat finger joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26080,Explore/treat finger joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26100,Biopsy hand joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26105,Biopsy finger joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26110,Biopsy finger joint lining,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26111,Exc hand les sc 1.5 cm/>,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26113,Exc hand tum deep 1.5 cm/>,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26115,Exc hand les sc < 1.5 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26116,Exc hand tum deep < 1.5 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26117,Rad resect hand tumor < 3 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26118,Rad resect hand tumor 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26121,Release palm contracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26123,Release palm contracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26130,Remove wrist joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26135,Revise finger joint each,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26140,Revise finger joint each,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26145,Tendon excision palm/finger,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26160,Remove tendon sheath lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26170,Removal of palm tendon each,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26180,Removal of finger tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26185,Remove finger bone,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26200,Remove hand bone lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26205,Remove/graft bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,26210,Removal of finger lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26215,Remove/graft finger lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26230,Partial removal of hand bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26235,Partial removal finger bone,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26236,Partial removal finger bone,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26250,Extensive hand surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26260,Resect prox finger tumor,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26262,Resect distal finger tumor,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26320,Removal of implant from hand,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26340,Manipulate finger w/anesth,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26341,Manipulat palm cord post inj,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26350,Repair finger/hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26352,Repair/graft hand tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,26356,Repair finger/hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26357,Repair finger/hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26358,Repair/graft hand tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,26370,Repair finger/hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,26372,Repair/graft hand tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,26373,Repair finger/hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26390,Revise hand/finger tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,26392,Repair/graft hand tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,26410,Repair hand tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26412,Repair/graft hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26415,Excision hand/finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26416,Graft hand or finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26418,Repair finger tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26420,Repair/graft finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26426,Repair finger/hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26428,Repair/graft finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26432,Repair finger tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26433,Repair finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26434,Repair/graft finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26437,Realignment of tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26440,Release palm/finger tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26442,Release palm & finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26445,Release hand/finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26449,Release forearm/hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26450,Incision of palm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26455,Incision of finger tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26460,Incise hand/finger tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26471,Fusion of finger tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26474,Fusion of finger tendons,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26476,Tendon lengthening,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26477,Tendon shortening,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26478,Lengthening of hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26479,Shortening of hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26480,Transplant hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26483,Transplant/graft hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26485,Transplant palm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26489,Transplant/graft palm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26490,Revise thumb tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26492,Tendon transfer with graft,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26494,Hand tendon/muscle transfer,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26496,Revise thumb tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26497,Finger tendon transfer,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26498,Finger tendon transfer,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26499,Revision of finger,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26500,Hand tendon reconstruction,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,26502,Hand tendon reconstruction,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26508,Release thumb contracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26510,Thumb tendon transfer,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26516,Fusion of knuckle joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26517,Fusion of knuckle joints,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26518,Fusion of knuckle joints,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,26520,Release knuckle contracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26525,Release finger contracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26530,Revise knuckle joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,26531,Revise knuckle with implant,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,26535,Revise finger joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26536,Revise/implant finger joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,26540,Repair hand joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26541,Repair hand joint with graft,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26542,Repair hand joint with graft,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26545,Reconstruct finger joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26546,Repair nonunion hand,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,26548,Reconstruct finger joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26550,Construct thumb replacement,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26551,Great toe-hand transfer,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,26553,Single transfer toe-hand,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,26554,Double transfer toe-hand,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,26555,Positional change of finger,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,26556,Toe joint transfer,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,26560,Repair of web finger,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26561,Repair of web finger,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26562,Repair of web finger,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26565,Correct metacarpal flaw,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26567,Correct finger deformity,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26568,Lengthen metacarpal/finger,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,26580,Repair hand deformity,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26587,Reconstruct extra finger,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26590,Repair finger deformity,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26591,Repair muscles of hand,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26593,Release muscles of hand,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26596,Excision constricting tissue,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26600,Treat metacarpal fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26605,Treat metacarpal fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26607,Treat metacarpal fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26608,Treat metacarpal fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26615,Treat metacarpal fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26641,Treat thumb dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26645,Treat thumb fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26650,Treat thumb fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26665,Treat thumb fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26670,Treat hand dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26675,Treat hand dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26676,Pin hand dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26685,Treat hand dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26686,Treat hand dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26700,Treat knuckle dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26705,Treat knuckle dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26706,Pin knuckle dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26715,Treat knuckle dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26720,Treat finger fracture each,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26725,Treat finger fracture each,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26727,Treat finger fracture each,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26735,Treat finger fracture each,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26740,Treat finger fracture each,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26742,Treat finger fracture each,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26746,Treat finger fracture each,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26750,Treat finger fracture each,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26755,Treat finger fracture each,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26756,Pin finger fracture each,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26765,Treat finger fracture each,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26770,Treat finger dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26775,Treat finger dislocation,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26776,Pin finger dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26785,Treat finger dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26820,Thumb fusion with graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,26841,Fusion of thumb,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,26842,Thumb fusion with graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,26843,Fusion of hand joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,26844,Fusion/graft of hand joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,26850,Fusion of knuckle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,26852,Fusion of knuckle with graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,26860,Fusion of finger joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26862,Fusion/graft of finger joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26910,Amputate metacarpal bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26951,Amputation of finger/thumb,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26952,Amputation of finger/thumb,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26989,Hand/finger surgery,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26990,Drainage of pelvis lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26991,Drainage of pelvis bursa,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,26992,Drainage of bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27000,Incision of hip tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27001,Incision of hip tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27003,Incision of hip tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27005,Incision of hip tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27006,Incision of hip tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27025,Incision of hip/thigh fascia,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27027,Buttock fasciotomy,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27030,Drainage of hip joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27033,Exploration of hip joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27035,Denervation of hip joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27036,Excision of hip joint/muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27040,Biopsy of soft tissues,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27041,Biopsy of soft tissues,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27043,Exc hip pelvis les sc 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27045,Exc hip/pelv tum deep 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27047,Exc hip/pelvis les sc < 3 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27048,Exc hip/pelv tum deep < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27049,Resect hip/pelv tum < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27050,Biopsy of sacroiliac joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27052,Biopsy of hip joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27054,Removal of hip joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27057,Buttock fasciotomy w/dbrdmt,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27059,Resect hip/pelv tum 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27060,Removal of ischial bursa,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27062,Remove femur lesion/bursa,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27065,Remove hip bone les super,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27066,Remove hip bone les deep,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27067,Remove/graft hip bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27070,Part remove hip bone super,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27071,Part removal hip bone deep,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27075,Resect hip tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27076,Resect hip tum incl acetabul,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27077,Resect hip tum w/innom bone,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,27078,Rsect hip tum incl femur,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,27080,Removal of tail bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27086,Remove hip foreign body,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27087,Remove hip foreign body,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27090,Removal of hip prosthesis,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27091,Removal of hip prosthesis,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27097,Revision of hip tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27098,Transfer tendon to pelvis,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27100,Transfer of abdominal muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27105,Transfer of spinal muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27110,Transfer of iliopsoas muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27111,Transfer of iliopsoas muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27120,Reconstruction of hip socket,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,27122,Reconstruction of hip socket,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,27125,Partial hip replacement,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,27130,Total hip arthroplasty,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,27132,Total hip arthroplasty,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,27134,Revise hip joint replacement,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,27137,Revise hip joint replacement,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,27138,Revise hip joint replacement,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,27140,Transplant femur ridge,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,27146,Incision of hip bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27147,Revision of hip bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27151,Incision of hip bones,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27156,Revision of hip bones,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27158,Revision of pelvis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27161,Incision of neck of femur,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27165,Incision/fixation of femur,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27170,Repair/graft femur head/neck,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27175,Treat slipped epiphysis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27176,Treat slipped epiphysis,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,27177,Treat slipped epiphysis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27178,Treat slipped epiphysis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27179,Revise head/neck of femur,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27181,Treat slipped epiphysis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27185,Revision of femur epiphysis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27187,Reinforce hip bones,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27197,Clsd tx pelvic ring fx,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27198,Clsd tx pelvic ring fx,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27200,Treat tail bone fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27202,Treat tail bone fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27220,Treat hip socket fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27222,Treat hip socket fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27226,Treat hip wall fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27227,Treat hip fracture(s),APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27228,Treat hip fracture(s),APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27230,Treat thigh fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27232,Treat thigh fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27235,Treat thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27236,Treat thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27238,Treat thigh fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27240,Treat thigh fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27244,Treat thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27245,Treat thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27246,Treat thigh fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27248,Treat thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27250,Treat hip dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27252,Treat hip dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27253,Treat hip dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27254,Treat hip dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27256,Treat hip dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27257,Treat hip dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27258,Treat hip dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27259,Treat hip dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27265,Treat hip dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27266,Treat hip dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27267,Cltx thigh fx,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27268,Cltx thigh fx w/mnpj,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27269,Optx thigh fx,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27275,Manipulation of hip joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27279,Arthrodesis sacroiliac joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,27280,Fusion of sacroiliac joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,27282,Fusion of pubic bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,27284,Fusion of hip joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,27286,Fusion of hip joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,27290,Amputation of leg at hip,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,27295,Amputation of leg at hip,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,27299,Pelvis/hip joint surgery,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27301,Drain thigh/knee lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27303,Drainage of bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27305,Incise thigh tendon & fascia,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27306,Incision of thigh tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27307,Incision of thigh tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27310,Exploration of knee joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27323,Biopsy thigh soft tissues,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27324,Biopsy thigh soft tissues,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27325,Neurectomy hamstring,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27326,Neurectomy popliteal,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27327,Exc thigh/knee les sc < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27328,Exc thigh/knee tum deep <5cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27329,Resect thigh/knee tum < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27330,Biopsy knee joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27331,Explore/treat knee joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27332,Removal of knee cartilage,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27333,Removal of knee cartilage,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27334,Remove knee joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27335,Remove knee joint lining,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27337,Exc thigh/knee les sc 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27339,Exc thigh/knee tum dep 5cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27340,Removal of kneecap bursa,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27345,Removal of knee cyst,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27347,Remove knee cyst,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27350,Removal of kneecap,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27355,Remove femur lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27356,Remove femur lesion/graft,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,27357,Remove femur lesion/graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27360,Partial removal leg bone(s),APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27364,Resect thigh/knee tum 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27365,Resect femur/knee tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27372,Removal of foreign body,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27380,Repair of kneecap tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27381,Repair/graft kneecap tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27385,Repair of thigh muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27386,Repair/graft of thigh muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27390,Incision of thigh tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27391,Incision of thigh tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27392,Incision of thigh tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27393,Lengthening of thigh tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27394,Lengthening of thigh tendons,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27395,Lengthening of thigh tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27396,Transplant of thigh tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27397,Transplants of thigh tendons,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27400,Revise thigh muscles/tendons,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27403,Repair of knee cartilage,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27405,Repair of knee ligament,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,27407,Repair of knee ligament,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,27409,Repair of knee ligaments,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,27412,Autochondrocyte implant knee,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27415,Osteochondral knee allograft,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,27416,Osteochondral knee autograft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27418,Repair degenerated kneecap,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27420,Revision of unstable kneecap,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27422,Revision of unstable kneecap,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27424,Revision/removal of kneecap,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27425,Lat retinacular release open,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27427,Reconstruction knee,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,27428,Reconstruction knee,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,27429,Reconstruction knee,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,27430,Revision of thigh muscles,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27435,Incision of knee joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27437,Revise kneecap,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27438,Revise kneecap with implant,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,27440,Revision of knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,27441,Revision of knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,27442,Revision of knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,27443,Revision of knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,27445,Revision of knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,27446,Revision of knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,27447,Total knee arthroplasty,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,27448,Incision of thigh,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27450,Incision of thigh,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27454,Realignment of thigh bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27455,Realignment of knee,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27457,Realignment of knee,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27465,Shortening of thigh bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27466,Lengthening of thigh bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27468,Shorten/lengthen thighs,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27470,Repair of thigh,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27472,Repair/graft of thigh,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27475,Surgery to stop leg growth,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27477,Surgery to stop leg growth,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27479,Surgery to stop leg growth,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27485,Surgery to stop leg growth,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27486,Revise/replace knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,27487,Revise/replace knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,27488,Removal of knee prosthesis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27495,Reinforce thigh,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27496,Decompression of thigh/knee,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27497,Decompression of thigh/knee,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27498,Decompression of thigh/knee,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27499,Decompression of thigh/knee,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27500,Treatment of thigh fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27501,Treatment of thigh fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27502,Treatment of thigh fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27503,Treatment of thigh fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27506,Treatment of thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27507,Treatment of thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27508,Treatment of thigh fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27509,Treatment of thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27510,Treatment of thigh fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27511,Treatment of thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27513,Treatment of thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27514,Treatment of thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27516,Treat thigh fx growth plate,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27517,Treat thigh fx growth plate,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27519,Treat thigh fx growth plate,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27520,Treat kneecap fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27524,Treat kneecap fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27530,Treat knee fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27532,Treat knee fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27535,Treat knee fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27536,Treat knee fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27538,Treat knee fracture(s),APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27540,Treat knee fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27550,Treat knee dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27552,Treat knee dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27556,Treat knee dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27557,Treat knee dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27558,Treat knee dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27560,Treat kneecap dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27562,Treat kneecap dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27566,Treat kneecap dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27570,Fixation of knee joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27580,Fusion of knee,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,27590,Amputate leg at thigh,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,27591,Amputate leg at thigh,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,27592,Amputate leg at thigh,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,27594,Amputation follow-up surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27596,Amputation follow-up surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27598,Amputate lower leg at knee,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,27599,Leg surgery procedure,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27600,Decompression of lower leg,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27601,Decompression of lower leg,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27602,Decompression of lower leg,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27603,Drain lower leg lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27604,Drain lower leg bursa,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27605,Incision of achilles tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27606,Incision of achilles tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27607,Treat lower leg bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27610,Explore/treat ankle joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27612,Exploration of ankle joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27613,Biopsy lower leg soft tissue,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27614,Biopsy lower leg soft tissue,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27615,Resect leg/ankle tum < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27616,Resect leg/ankle tum 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27618,Exc leg/ankle tum < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27619,Exc leg/ankle tum deep <5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27620,Explore/treat ankle joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27625,Remove ankle joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27626,Remove ankle joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27630,Removal of tendon lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27632,Exc leg/ankle les sc 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27634,Exc leg/ankle tum dep 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27635,Remove lower leg bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27637,Remove/graft leg bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27638,Remove/graft leg bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27640,Partial removal of tibia,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27641,Partial removal of fibula,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27645,Resect tibia tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27646,Resect fibula tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27647,Resect talus/calcaneus tum,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27650,Repair achilles tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27652,Repair/graft achilles tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,27654,Repair of achilles tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,27656,Repair leg fascia defect,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27658,Repair of leg tendon each,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27659,Repair of leg tendon each,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27664,Repair of leg tendon each,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27665,Repair of leg tendon each,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27675,Repair lower leg tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27676,Repair lower leg tendons,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27680,Release of lower leg tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27681,Release of lower leg tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27685,Revision of lower leg tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27686,Revise lower leg tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27687,Revision of calf tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27690,Revise lower leg tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27691,Revise lower leg tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,27695,Repair of ankle ligament,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27696,Repair of ankle ligaments,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27698,Repair of ankle ligament,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27700,Revision of ankle joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27702,Reconstruct ankle joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,27703,Reconstruction ankle joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,27704,Removal of ankle implant,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27705,Incision of tibia,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27707,Incision of fibula,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27709,Incision of tibia & fibula,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,27712,Realignment of lower leg,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,27715,Revision of lower leg,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,27720,Repair of tibia,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27722,Repair/graft of tibia,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27724,Repair/graft of tibia,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,27725,Repair of lower leg,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27726,Repair fibula nonunion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,27727,Repair of lower leg,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27730,Repair of tibia epiphysis,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27732,Repair of fibula epiphysis,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27734,Repair lower leg epiphyses,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27740,Repair of leg epiphyses,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27742,Repair of leg epiphyses,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27745,Reinforce tibia,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27750,Treatment of tibia fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27752,Treatment of tibia fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27756,Treatment of tibia fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27758,Treatment of tibia fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,27759,Treatment of tibia fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,27760,Cltx medial ankle fx,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27762,Cltx med ankle fx w/mnpj,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27766,Optx medial ankle fx,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27767,Cltx post ankle fx,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27768,Cltx post ankle fx w/mnpj,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27769,Optx post ankle fx,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27780,Treatment of fibula fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27781,Treatment of fibula fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27784,Treatment of fibula fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27786,Treatment of ankle fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27788,Treatment of ankle fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27792,Treatment of ankle fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27808,Treatment of ankle fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27810,Treatment of ankle fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27814,Treatment of ankle fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,27816,Treatment of ankle fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27818,Treatment of ankle fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27822,Treatment of ankle fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27823,Treatment of ankle fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27824,Treat lower leg fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27825,Treat lower leg fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27826,Treat lower leg fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27827,Treat lower leg fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,27828,Treat lower leg fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,27829,Treat lower leg joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27830,Treat lower leg dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27831,Treat lower leg dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27832,Treat lower leg dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27840,Treat ankle dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27842,Treat ankle dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27846,Treat ankle dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27848,Treat ankle dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27860,Fixation of ankle joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27870,Fusion of ankle joint open,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,27871,Fusion of tibiofibular joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,27880,Amputation of lower leg,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,27881,Amputation of lower leg,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27882,Amputation of lower leg,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27884,Amputation follow-up surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27886,Amputation follow-up surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27888,Amputation of foot at ankle,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,27889,Amputation of foot at ankle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27892,Decompression of leg,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27893,Decompression of leg,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,27894,Decompression of leg,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,27899,Leg/ankle surgery procedure,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28001,Drainage of bursa of foot,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28002,Treatment of foot infection,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28003,Treatment of foot infection,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28005,Treat foot bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28008,Incision of foot fascia,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28010,Incision of toe tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28011,Incision of toe tendons,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28020,Exploration of foot joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28022,Exploration of foot joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28024,Exploration of toe joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28035,Decompression of tibia nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28039,Exc foot/toe tum sc 1.5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28041,Exc foot/toe tum dep 1.5cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28043,Exc foot/toe tum sc < 1.5 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28045,Exc foot/toe tum deep <1.5cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28046,Resect foot/toe tumor < 3 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28047,Resect foot/toe tumor 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28050,Biopsy of foot joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28052,Biopsy of foot joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28054,Biopsy of toe joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28055,Neurectomy foot,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28060,Partial removal foot fascia,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28062,Removal of foot fascia,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28070,Removal of foot joint lining,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,28072,Removal of foot joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28080,Removal of foot lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28086,Excise foot tendon sheath,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28088,Excise foot tendon sheath,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28090,Removal of foot lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28092,Removal of toe lesions,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28100,Removal of ankle/heel lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28102,Remove/graft foot lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,28103,Remove/graft foot lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,28104,Removal of foot lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28106,Remove/graft foot lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,28107,Remove/graft foot lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,28108,Removal of toe lesions,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28110,Part removal of metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28111,Part removal of metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28112,Part removal of metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28113,Part removal of metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28114,Removal of metatarsal heads,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28116,Revision of foot,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28118,Removal of heel bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28119,Removal of heel spur,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28120,Part removal of ankle/heel,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28122,Partial removal of foot bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28124,Partial removal of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28126,Partial removal of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28130,Removal of ankle bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,28140,Removal of metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28150,Removal of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28153,Partial removal of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28160,Partial removal of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28171,Resect tarsal tumor,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28173,Resect metatarsal tumor,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28175,Resect phalanx of toe tumor,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28190,Removal of foot foreign body,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28192,Removal of foot foreign body,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28193,Removal of foot foreign body,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28200,Repair of foot tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28202,Repair/graft of foot tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,28208,Repair of foot tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28210,Repair/graft of foot tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,28220,Release of foot tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28222,Release of foot tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28225,Release of foot tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28226,Release of foot tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28230,Incision of foot tendon(s),APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28232,Incision of toe tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28234,Incision of foot tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28238,Revision of foot tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,28240,Release of big toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28250,Revision of foot fascia,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28260,Release of midfoot joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28261,Revision of foot tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28262,Revision of foot and ankle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,28264,Release of midfoot joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28270,Release of foot contracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28272,Release of toe joint each,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28280,Fusion of toes,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28285,Repair of hammertoe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28286,Repair of hammertoe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28288,Partial removal of foot bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28289,Corrj halux rigdus w/o implt,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28291,Corrj halux rigdus w/implt,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,28292,Correction hallux valgus,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28295,Correction hallux valgus,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28296,Correction hallux valgus,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28297,Correction hallux valgus,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,28298,Correction hallux valgus,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,28299,Correction hallux valgus,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,28300,Incision of heel bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,28302,Incision of ankle bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,28304,Incision of midfoot bones,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,28305,Incise/graft midfoot bones,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,28306,Incision of metatarsal,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,28307,Incision of metatarsal,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,28308,Incision of metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28309,Incision of metatarsals,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,28310,Revision of big toe,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,28312,Revision of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28313,Repair deformity of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28315,Removal of sesamoid bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28320,Repair of foot bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,28322,Repair of metatarsals,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,28340,Resect enlarged toe tissue,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28341,Resect enlarged toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28344,Repair extra toe(s),APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28345,Repair webbed toe(s),APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28360,Reconstruct cleft foot,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,28400,Treatment of heel fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28405,Treatment of heel fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28406,Treatment of heel fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,28415,Treat heel fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,28420,Treat/graft heel fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,28430,Treatment of ankle fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28435,Treatment of ankle fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28436,Treatment of ankle fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,28445,Treat ankle fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,28446,Osteochondral talus autogrft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,28450,Treat midfoot fracture each,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28455,Treat midfoot fracture each,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28456,Treat midfoot fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,28465,Treat midfoot fracture each,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,28470,Treat metatarsal fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28475,Treat metatarsal fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28476,Treat metatarsal fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28485,Treat metatarsal fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,28490,Treat big toe fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28495,Treat big toe fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28496,Treat big toe fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28505,Treat big toe fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28510,Treatment of toe fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28515,Treatment of toe fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28525,Treat toe fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28530,Treat sesamoid bone fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28531,Treat sesamoid bone fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,28540,Treat foot dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28545,Treat foot dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28546,Treat foot dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28555,Repair foot dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,28570,Treat foot dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28575,Treat foot dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28576,Treat foot dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,28585,Repair foot dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,28600,Treat foot dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28605,Treat foot dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28606,Treat foot dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28615,Repair foot dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,28630,Treat toe dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28635,Treat toe dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28636,Treat toe dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28645,Repair toe dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28660,Treat toe dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28665,Treat toe dislocation,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28666,Treat toe dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28675,Repair of toe dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28705,Fusion of foot bones,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,28715,Fusion of foot bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,28725,Fusion of foot bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,28730,Fusion of foot bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,28735,Fusion of foot bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,28737,Revision of foot bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,28740,Fusion of foot bones,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,28750,Fusion of big toe joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,28755,Fusion of big toe joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,28760,Fusion of big toe joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,28800,Amputation of midfoot,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28805,Amputation thru metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28810,Amputation toe & metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28820,Amputation of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28825,Partial amputation of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28890,Hi enrgy eswt plantar fascia,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,28899,Foot/toes surgery procedure,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29000,Application of body cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29010,Application of body cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29015,Application of body cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29035,Application of body cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29040,Application of body cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29044,Application of body cast,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29046,Application of body cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29049,Application of figure eight,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29055,Application of shoulder cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29058,Application of shoulder cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29065,Application of long arm cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29075,Application of forearm cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29085,Apply hand/wrist cast,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29086,Apply finger cast,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29105,Apply long arm splint,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29125,Apply forearm splint,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29126,Apply forearm splint,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29130,Application of finger splint,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29131,Application of finger splint,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29200,Strapping of chest,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29240,Strapping of shoulder,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29260,Strapping of elbow or wrist,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29280,Strapping of hand or finger,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29305,Application of hip cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29325,Application of hip casts,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29345,Application of long leg cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29355,Application of long leg cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29358,Apply long leg cast brace,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29365,Application of long leg cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29405,Apply short leg cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29425,Apply short leg cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29435,Apply short leg cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29440,Addition of walker to cast,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29445,Apply rigid leg cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29450,Application of leg cast,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29505,Application long leg splint,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29515,Application lower leg splint,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29520,Strapping of hip,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29530,Strapping of knee,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29540,Strapping of ankle and/or ft,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29550,Strapping of toes,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29580,Application of paste boot,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29581,Apply multlay comprs lwr leg,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29584,Appl multlay comprs arm/hand,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29700,Removal/revision of cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29705,Removal/revision of cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29710,Removal/revision of cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29720,Repair of body cast,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29730,Windowing of cast,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29740,Wedging of cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29750,Wedging of clubfoot cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29799,Casting/strapping procedure,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29800,Jaw arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29804,Jaw arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29805,Sho arthrs dx +- synovial bx,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29806,Sho arthrs srg capsulorpaphy,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,29807,Sho arthrs srg rpr slap les,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,29819,Sho arthrs srg rmvl loose/fb,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29820,Sho arthrs srg prtl synvct,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,29821,Sho arthrs srg compl synvct,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29822,Sho arthrs srg lmtd dbrdmt,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29823,Sho arthrs srg xtnsv dbrdmt,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29824,Sho arthrs srg dstl claviclc,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29825,Sho arthrs srg lss&rescj ads,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29827,Sho arthrs srg rt8tr cuf rpr,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,29828,Sho arthrs srg bicp tenodsis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,29830,Elbow arthroscopy,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29834,Elbow arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29835,Elbow arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29836,Elbow arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,29837,Elbow arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29838,Elbow arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29840,Wrist arthroscopy,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29843,Wrist arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29844,Wrist arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29845,Wrist arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29846,Wrist arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29847,Wrist arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,29848,Wrist endoscopy/surgery,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29850,Knee arthroscopy/surgery,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29851,Knee arthroscopy/surgery,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29855,Tibial arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,29856,Tibial arthroscopy/surgery,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,29860,Hip arthroscopy dx,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,29861,Hip arthro w/fb removal,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,29862,Hip arthr0 w/debridement,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,29863,Hip arthr0 w/synovectomy,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29866,Autgrft implnt knee w/scope,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,29867,Allgrft implnt knee w/scope,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,29868,Meniscal trnspl knee w/scpe,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,29870,Knee arthroscopy dx,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29871,Knee arthroscopy/drainage,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29873,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29874,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29875,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29876,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29877,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29879,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29880,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29881,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29882,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29883,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29884,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29885,Knee arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,29886,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29887,Knee arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,29888,Knee arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,29889,Knee arthroscopy/surgery,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,29891,Ankle arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29892,Ankle arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,29893,Scope plantar fasciotomy,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29894,Ankle arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29895,Ankle arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29897,Ankle arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29898,Ankle arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29899,Ankle arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,29900,Mcp joint arthroscopy dx,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29901,Mcp joint arthroscopy surg,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29902,Mcp joint arthroscopy surg,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29904,Subtalar arthro w/fb rmvl,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29905,Subtalar arthro w/exc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,29906,Subtalar arthro w/deb,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,29907,Subtalar arthro w/fusion,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,29914,Hip arthro w/femoroplasty,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,29915,Hip arthro acetabuloplasty,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,29916,Hip arthro w/labral repair,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,29999,Arthroscopy of joint,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,30000,Drainage of nose lesion,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,30020,Drainage of nose lesion,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,30100,Intranasal biopsy,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,30110,Removal of nose polyp(s),APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,30115,Removal of nose polyp(s),APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,30117,Removal of intranasal lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,30118,Removal of intranasal lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,30120,Revision of nose,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,30124,Removal of nose lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,30125,Removal of nose lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,30130,Excise inferior turbinate,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,30140,Resect inferior turbinate,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,30150,Partial removal of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,30160,Removal of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,30200,Injection treatment of nose,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,30210,Nasal sinus therapy,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,30220,Insert nasal septal button,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,30300,Remove nasal foreign body,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,30310,Remove nasal foreign body,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,30320,Remove nasal foreign body,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,30400,Reconstruction of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,30410,Reconstruction of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,30420,Reconstruction of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,30430,Revision of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,30435,Revision of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,30450,Revision of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,30460,Revision of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,30462,Revision of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,30465,Repair nasal stenosis,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,30468,Rpr nsl vlv collapse w/implt,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,30520,Repair of nasal septum,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,30540,Repair nasal defect,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,30545,Repair nasal defect,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,30560,Release of nasal adhesions,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,30580,Repair upper jaw fistula,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,30600,Repair mouth/nose fistula,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,30620,Intranasal reconstruction,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,30630,Repair nasal septum defect,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,30801,Ablate inf turbinate superf,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,30802,Ablate inf turbinate submuc,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,30901,Control of nosebleed,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,30903,Control of nosebleed,APC 5734,RVU Per Unit,$114.56 ,OP,114.56,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,30905,Control of nosebleed,APC 5734,RVU Per Unit,$114.56 ,OP,114.56,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,30906,Repeat control of nosebleed,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,30915,Ligation nasal sinus artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,30920,Ligation upper jaw artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,30930,Ther fx nasal inf turbinate,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,30999,Nasal surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31000,Irrigation maxillary sinus,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31002,Irrigation sphenoid sinus,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31020,Exploration maxillary sinus,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31030,Exploration maxillary sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,31032,Explore sinus remove polyps,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,31040,Exploration behind upper jaw,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,31050,Exploration sphenoid sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,31051,Sphenoid sinus surgery,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,31070,Exploration of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,31075,Exploration of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,31080,Removal of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,31081,Removal of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,31084,Removal of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,31085,Removal of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,31086,Removal of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,31087,Removal of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,31090,Exploration of sinuses,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,31200,Removal of ethmoid sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,31201,Removal of ethmoid sinus,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31205,Removal of ethmoid sinus,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31225,Removal of upper jaw,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,31230,Removal of upper jaw,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,31231,Nasal endoscopy dx,APC 5151,RVU Per Unit,$168.23 ,OP,168.23,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31233,Nsl/sins ndsc dx max sinusc,APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31235,Nsl/sins ndsc dx sphn sinusc,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31237,Nasal/sinus endoscopy surg,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31238,Nasal/sinus endoscopy surg,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31239,Nasal/sinus endoscopy surg,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31240,Nasal/sinus endoscopy surg,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31241,Nsl/sins ndsc w/artery lig,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31253,Nsl/sins ndsc total,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,31254,Nsl/sins ndsc w/prtl ethmdct,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Health Alliance MCR ADV,CPT,31255,Nsl/sins ndsc w/tot ethmdct,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,31256,Exploration maxillary sinus,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31257,Nsl/sins ndsc tot w/sphendt,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,31259,Nsl/sins ndsc sphn tiss rmvl,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,31267,Endoscopy maxillary sinus,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Health Alliance MCR ADV,CPT,31276,Nsl/sins ndsc frnt tiss rmvl,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,31287,Nasal/sinus endoscopy surg,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,31288,Nasal/sinus endoscopy surg,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,31290,Nasal/sinus endoscopy surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,31291,Nasal/sinus endoscopy surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,31292,Nsl/sins ndsc med/inf dcmprn,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Health Alliance MCR ADV,CPT,31293,Nsl/sins ndsc med&inf dcmprn,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Health Alliance MCR ADV,CPT,31294,Nsl/sins ndsc surg on dcmprn,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Health Alliance MCR ADV,CPT,31295,Nsl/sins ndsc surg max sins,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Health Alliance MCR ADV,CPT,31296,Nsl/sins ndsc surg frnt sins,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,31297,Nsl/sins ndsc surg sphn sins,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Health Alliance MCR ADV,CPT,31298,Nsl/sins ndsc surg frnt&sphn,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,31299,Sinus surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31300,Removal of larynx lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31360,Removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,31365,Removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,31367,Partial removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,31368,Partial removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,31370,Partial removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,31375,Partial removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,31380,Partial removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,31382,Partial removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,31390,Removal of larynx & pharynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,31395,Reconstruct larynx & pharynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,31400,Revision of larynx,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,31420,Removal of epiglottis,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,31500,Insert emergency airway,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31502,Change of windpipe airway,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31505,Diagnostic laryngoscopy,APC 5151,RVU Per Unit,$168.23 ,OP,168.23,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31510,Laryngoscopy with biopsy,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31511,Remove foreign body larynx,APC 5151,RVU Per Unit,$168.23 ,OP,168.23,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31512,Removal of larynx lesion,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31513,Injection into vocal cord,APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31515,Laryngoscopy for aspiration,APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31520,Dx laryngoscopy newborn,APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31525,Dx laryngoscopy excl nb,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31526,Dx laryngoscopy w/oper scope,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31527,Laryngoscopy for treatment,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31528,Laryngoscopy and dilation,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31529,Laryngoscopy and dilation,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31530,Laryngoscopy w/fb removal,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31531,Laryngoscopy w/fb & op scope,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31535,Laryngoscopy w/biopsy,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31536,Laryngoscopy w/bx & op scope,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31540,Laryngoscopy w/exc of tumor,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31541,Larynscop w/tumr exc + scope,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31545,Remove vc lesion w/scope,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31546,Remove vc lesion scope/graft,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Health Alliance MCR ADV,CPT,31551,Laryngoplasty laryngeal sten,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,31552,Laryngoplasty laryngeal sten,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,31553,Laryngoplasty laryngeal sten,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,31554,Laryngoplasty laryngeal sten,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,31560,Laryngoscop w/arytenoidectom,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Health Alliance MCR ADV,CPT,31561,Larynscop remve cart + scop,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Health Alliance MCR ADV,CPT,31570,Laryngoscope w/vc inj,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31571,Laryngoscop w/vc inj + scope,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31572,Largsc w/laser dstrj les,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31573,Largsc w/ther injection,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31574,Largsc w/njx augmentation,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31575,Diagnostic laryngoscopy,APC 5151,RVU Per Unit,$168.23 ,OP,168.23,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31576,Laryngoscopy with biopsy,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31577,Largsc w/rmvl foreign bdy(s),APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31578,Largsc w/removal lesion,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31579,Laryngoscopy telescopic,APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31580,Laryngoplasty laryngeal web,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,31584,Laryngoplasty fx rdctj fixj,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,31587,Laryngoplasty cricoid split,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,31590,Reinnervate larynx,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,31591,Laryngoplasty medialization,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,31592,Cricotracheal resection,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,31599,Larynx surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31600,Incision of windpipe,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31601,Incision of windpipe,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,31603,Incision of windpipe,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31605,Incision of windpipe,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31610,Incision of windpipe,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,31611,Surgery/speech prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31612,Puncture/clear windpipe,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31613,Repair windpipe opening,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31614,Repair windpipe opening,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,31615,Visualization of windpipe,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31622,Dx bronchoscope/wash,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31623,Dx bronchoscope/brush,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31624,Dx bronchoscope/lavage,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31625,Bronchoscopy w/biopsy(s),APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31626,Bronchoscopy w/markers,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Health Alliance MCR ADV,CPT,31628,Bronchoscopy/lung bx each,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31629,Bronchoscopy/needle bx each,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31630,Bronchoscopy dilate/fx repr,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31631,Bronchoscopy dilate w/stent,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Health Alliance MCR ADV,CPT,31634,Bronch w/balloon occlusion,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Health Alliance MCR ADV,CPT,31635,Bronchoscopy w/fb removal,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31636,Bronchoscopy bronch stents,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Health Alliance MCR ADV,CPT,31638,Bronchoscopy revise stent,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Health Alliance MCR ADV,CPT,31640,Bronchoscopy w/tumor excise,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31641,Bronchoscopy treat blockage,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31643,Diag bronchoscope/catheter,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31645,Brnchsc w/ther aspir 1st,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31646,Brnchsc w/ther aspir sbsq,APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31647,Bronchial valve init insert,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Health Alliance MCR ADV,CPT,31648,Bronchial valve remov init,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31649,Bronchial valve remov addl,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31652,Bronch ebus samplng 1/2 node,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31653,Bronch ebus samplng 3/> node,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31660,Bronch thermoplsty 1 lobe,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Health Alliance MCR ADV,CPT,31661,Bronch thermoplsty 2/> lobes,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Health Alliance MCR ADV,CPT,31717,Bronchial brush biopsy,APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31720,Clearance of airways,APC 5791,RVU Per Case,$192.26 ,OP,192.26,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31725,Clearance of airways,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,31730,Intro windpipe wire/tube,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31750,Repair of windpipe,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,31755,Repair of windpipe,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,31760,Repair of windpipe,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,31766,Reconstruction of windpipe,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,31770,Repair/graft of bronchus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,31775,Reconstruct bronchus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,31780,Reconstruct windpipe,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,31781,Reconstruct windpipe,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,31785,Remove windpipe lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,31786,Remove windpipe lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,31800,Repair of windpipe injury,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,31805,Repair of windpipe injury,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,31820,Closure of windpipe lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31825,Repair of windpipe defect,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31830,Revise windpipe scar,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,31899,Airways surgical procedure,APC 5151,RVU Per Unit,$168.23 ,OP,168.23,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,32035,Thoracostomy w/rib resection,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32036,Thoracostomy w/flap drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32096,Open wedge/bx lung infiltr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32097,Open wedge/bx lung nodule,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32098,Open biopsy of lung pleura,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32100,Exploration of chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32110,Explore/repair chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32120,Re-exploration of chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32124,Explore chest free adhesions,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32140,Removal of lung lesion(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32141,Remove/treat lung lesions,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32150,Removal of lung lesion(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32151,Remove lung foreign body,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32160,Open chest heart massage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32200,Drain open lung lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32215,Treat chest lining,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32220,Release of lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32225,Partial release of lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32310,Removal of chest lining,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32320,Free/remove chest lining,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32400,Needle biopsy chest lining,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,32408,Core ndl bx lng/med perq,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,32440,Remove lung pneumonectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32442,Sleeve pneumonectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32445,Removal of lung extrapleural,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32480,Partial removal of lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32482,Bilobectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32484,Segmentectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32486,Sleeve lobectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32488,Completion pneumonectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32491,Lung volume reduction,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32501,Repair bronchus add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32503,Resect apical lung tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32504,Resect apical lung tum/chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32505,Wedge resect of lung initial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32506,Wedge resect of lung add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32507,Wedge resect of lung diag,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32540,Removal of lung lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32550,Insert pleural cath,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,32551,Insertion of chest tube,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,32552,Remove lung catheter,APC 5181,RVU Per Case,$554.25 ,OP,554.25,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,32553,Ins mark thor for rt perq,APC 5613,RVU Per Unit,"$1,291.62 ",OP,"1,291.62","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,32554,Aspirate pleura w/o imaging,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,32555,Aspirate pleura w/ imaging,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,32556,Insert cath pleura w/o image,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,32557,Insert cath pleura w/ image,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,32560,Treat pleurodesis w/agent,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,32561,Lyse chest fibrin init day,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,32562,Lyse chest fibrin subq day,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,32601,Thoracoscopy diagnostic,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,32604,Thoracoscopy wbx sac,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,32606,Thoracoscopy w/bx med space,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,32607,Thoracoscopy w/bx infiltrate,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,32608,Thoracoscopy w/bx nodule,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,32609,Thoracoscopy w/bx pleura,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,32650,Thoracoscopy w/pleurodesis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32651,Thoracoscopy remove cortex,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32652,Thoracoscopy rem totl cortex,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32653,Thoracoscopy remov fb/fibrin,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32654,Thoracoscopy contrl bleeding,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32655,Thoracoscopy resect bullae,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32656,Thoracoscopy w/pleurectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32658,Thoracoscopy w/sac fb remove,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32659,Thoracoscopy w/sac drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32661,Thoracoscopy w/pericard exc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32662,Thoracoscopy w/mediast exc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32663,Thoracoscopy w/lobectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32664,Thoracoscopy w/ th nrv exc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32665,Thoracoscop w/esoph musc exc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32666,Thoracoscopy w/wedge resect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32667,Thoracoscopy w/w resect addl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32668,Thoracoscopy w/w resect diag,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32669,Thoracoscopy remove segment,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32670,Thoracoscopy bilobectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32671,Thoracoscopy pneumonectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32672,Thoracoscopy for lvrs,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32673,Thoracoscopy w/thymus resect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32674,Thoracoscopy lymph node exc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32800,Repair lung hernia,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32810,Close chest after drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32815,Close bronchial fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32820,Reconstruct injured chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32850,Donor pneumonectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32851,Lung transplant single,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32852,Lung transplant with bypass,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32853,Lung transplant double,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32854,Lung transplant with bypass,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32855,Prepare donor lung single,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32856,Prepare donor lung double,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32900,Removal of rib(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32905,Revise & repair chest wall,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32906,Revise & repair chest wall,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32940,Revision of lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32960,Therapeutic pneumothorax,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,32994,Ablate pulm tumor perq crybl,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,32997,Total lung lavage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,32998,Ablate pulm tumor perq rf,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,32999,Chest surgery procedure,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,33016,Pericardiocentesis w/imaging,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,33017,Prcrd drg 6yr+ w/o cgen car,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33018,Prcrd drg 0-5yr or w/anomly,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33019,Perq prcrd drg insj cath ct,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33020,Incision of heart sac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33025,Incision of heart sac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33030,Partial removal of heart sac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33031,Partial removal of heart sac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33050,Resect heart sac lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33120,Removal of heart lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33130,Removal of heart lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33140,Heart revascularize (tmr),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33141,Heart tmr w/other procedure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33202,Insert epicard eltrd open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33203,Insert epicard eltrd endo,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33206,Insert heart pm atrial,APC 5223,RVU Per Case,"$10,642.67 ",OP,"4,314.00","10,642.67",,,,,,
Health Alliance MCR ADV,CPT,33207,Insert heart pm ventricular,APC 5223,RVU Per Case,"$10,642.67 ",OP,"4,314.00","10,642.67",,,,,,
Health Alliance MCR ADV,CPT,33208,Insrt heart pm atrial & vent,APC 5223,RVU Per Case,"$10,642.67 ",OP,"4,314.00","10,642.67",,,,,,
Health Alliance MCR ADV,CPT,33210,Insert electrd/pm cath sngl,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
Health Alliance MCR ADV,CPT,33211,Insert card electrodes dual,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
Health Alliance MCR ADV,CPT,33212,Insert pulse gen sngl lead,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
Health Alliance MCR ADV,CPT,33213,Insert pulse gen dual leads,APC 5223,RVU Per Case,"$10,642.67 ",OP,"4,314.00","10,642.67",,,,,,
Health Alliance MCR ADV,CPT,33214,Upgrade of pacemaker system,APC 5223,RVU Per Case,"$10,642.67 ",OP,"4,314.00","10,642.67",,,,,,
Health Alliance MCR ADV,CPT,33215,Reposition pacing-defib lead,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,33216,Insert 1 electrode pm-defib,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
Health Alliance MCR ADV,CPT,33217,Insert 2 electrode pm-defib,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
Health Alliance MCR ADV,CPT,33218,Repair lead pace-defib one,APC 5221,RVU Per Unit,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,33220,Repair lead pace-defib dual,APC 5221,RVU Per Unit,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,33221,Insert pulse gen mult leads,APC 5224,RVU Per Case,"$19,045.26 ",OP,"4,314.00","19,045.26",,,,,,
Health Alliance MCR ADV,CPT,33222,Relocation pocket pacemaker,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,33223,Relocate pocket for defib,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,33224,Insert pacing lead & connect,APC 5223,RVU Per Case,"$10,642.67 ",OP,"4,314.00","10,642.67",,,,,,
Health Alliance MCR ADV,CPT,33226,Reposition l ventric lead,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,33227,Remove&replace pm gen singl,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
Health Alliance MCR ADV,CPT,33228,Remv&replc pm gen dual lead,APC 5223,RVU Per Case,"$10,642.67 ",OP,"4,140.35","10,642.67",,,,,,
Health Alliance MCR ADV,CPT,33229,Remv&replc pm gen mult leads,APC 5224,RVU Per Case,"$19,045.26 ",OP,"4,314.00","19,045.26",,,,,,
Health Alliance MCR ADV,CPT,33230,Insrt pulse gen w/dual leads,APC 5231,RVU Per Case,"$23,577.44 ",OP,"4,314.00","23,577.44",,,,,,
Health Alliance MCR ADV,CPT,33231,Insrt pulse gen w/mult leads,APC 5232,RVU Per Case,"$33,604.66 ",OP,"4,314.00","33,604.66",,,,,,
Health Alliance MCR ADV,CPT,33233,Removal of pm generator,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
Health Alliance MCR ADV,CPT,33234,Removal of pacemaker system,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,33235,Removal pacemaker electrode,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,33236,Remove electrode/thoracotomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33237,Remove electrode/thoracotomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33238,Remove electrode/thoracotomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33240,Insrt pulse gen w/singl lead,APC 5231,RVU Per Case,"$23,577.44 ",OP,"4,140.35","23,577.44",,,,,,
Health Alliance MCR ADV,CPT,33241,Remove pulse generator,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,33243,Remove eltrd/thoracotomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33244,Remove elctrd transvenously,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,33249,Insj/rplcmt defib w/lead(s),APC 5232,RVU Per Case,"$33,604.66 ",OP,"4,140.35","33,604.66",,,,,,
Health Alliance MCR ADV,CPT,33250,Ablate heart dysrhythm focus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33251,Ablate heart dysrhythm focus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33254,Ablate atria lmtd,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33255,Ablate atria w/o bypass ext,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33256,Ablate atria w/bypass exten,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33257,Ablate atria lmtd add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33258,Ablate atria x10sv add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33259,Ablate atria w/bypass add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33261,Ablate heart dysrhythm focus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33262,Rmvl& replc pulse gen 1 lead,APC 5231,RVU Per Case,"$23,577.44 ",OP,"4,314.00","23,577.44",,,,,,
Health Alliance MCR ADV,CPT,33263,Rmvl & rplcmt dfb gen 2 lead,APC 5231,RVU Per Case,"$23,577.44 ",OP,"4,140.35","23,577.44",,,,,,
Health Alliance MCR ADV,CPT,33264,Rmvl & rplcmt dfb gen mlt ld,APC 5232,RVU Per Case,"$33,604.66 ",OP,"4,314.00","33,604.66",,,,,,
Health Alliance MCR ADV,CPT,33265,Ablate atria lmtd endo,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33266,Ablate atria x10sv endo,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33270,Ins/rep subq defibrillator,APC 5232,RVU Per Case,"$33,604.66 ",OP,"4,314.00","33,604.66",,,,,,
Health Alliance MCR ADV,CPT,33271,Insj subq impltbl dfb elctrd,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
Health Alliance MCR ADV,CPT,33272,Rmvl of subq defibrillator,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,33273,Repos prev impltbl subq dfb,APC 5221,RVU Per Unit,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,33274,Tcat insj/rpl perm ldls pm,APC 5194,RVU Per Case,"$16,438.60 ",OP,"4,314.00","16,438.60",,,,,,
Health Alliance MCR ADV,CPT,33275,Tcat rmvl perm ldls pm w/img,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,33285,Insj subq car rhythm mntr,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
Health Alliance MCR ADV,CPT,33286,Rmvl subq car rhythm mntr,APC 5071,RVU Per Case,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,33289,Tcat impl wrls p-art prs snr,APC 5200,RVU Per Case,"$29,487.35 ",OP,"4,314.00","29,487.35",,,,,,
Health Alliance MCR ADV,CPT,33300,Repair of heart wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33305,Repair of heart wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33310,Exploratory heart surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33315,Exploratory heart surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33320,Repair major blood vessel(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33321,Repair major vessel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33322,Repair major blood vessel(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33330,Insert major vessel graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33335,Insert major vessel graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33340,Perq clsr tcat l atr apndge,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33361,Replace aortic valve perq,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33362,Replace aortic valve open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33363,Replace aortic valve open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33364,Replace aortic valve open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33365,Replace aortic valve open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33366,Trcath replace aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33367,Replace aortic valve w/byp,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33368,Replace aortic valve w/byp,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33369,Replace aortic valve w/byp,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33390,Valvuloplasty aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33391,Valvuloplasty aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33404,Prepare heart-aorta conduit,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33405,Replacement aortic valve opn,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33406,Replacement aortic valve opn,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33410,Replacement aortic valve opn,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33411,Replacement of aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33412,Replacement of aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33413,Replacement of aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33414,Repair of aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33415,Revision subvalvular tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33416,Revise ventricle muscle,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33417,Repair of aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33418,Repair tcat mitral valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33420,Revision of mitral valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33422,Revision of mitral valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33425,Repair of mitral valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33426,Repair of mitral valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33427,Repair of mitral valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33430,Replacement of mitral valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33440,Rplcmt a-valve tlcj autol pv,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33460,Revision of tricuspid valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33463,Valvuloplasty tricuspid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33464,Valvuloplasty tricuspid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33465,Replace tricuspid valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33468,Revision of tricuspid valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33470,Revision of pulmonary valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33471,Valvotomy pulmonary valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33474,Revision of pulmonary valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33475,Replacement pulmonary valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33476,Revision of heart chamber,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33477,Implant tcat pulm vlv perq,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33478,Revision of heart chamber,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33496,Repair prosth valve clot,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33500,Repair heart vessel fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33501,Repair heart vessel fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33502,Coronary artery correction,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33503,Coronary artery graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33504,Coronary artery graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33505,Repair artery w/tunnel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33506,Repair artery translocation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33507,Repair art intramural,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33510,Cabg vein single,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33511,Cabg vein two,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33512,Cabg vein three,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33513,Cabg vein four,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33514,Cabg vein five,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33516,Cabg vein six or more,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33517,Cabg artery-vein single,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33518,Cabg artery-vein two,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33519,Cabg artery-vein three,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33521,Cabg artery-vein four,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33522,Cabg artery-vein five,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33523,Cabg art-vein six or more,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33530,Coronary artery bypass/reop,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33533,Cabg arterial single,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33534,Cabg arterial two,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33535,Cabg arterial three,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33536,Cabg arterial four or more,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33542,Removal of heart lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33545,Repair of heart damage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33548,Restore/remodel ventricle,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33572,Open coronary endarterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33600,Closure of valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33602,Closure of valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33606,Anastomosis/artery-aorta,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33608,Repair anomaly w/conduit,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33610,Repair by enlargement,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33611,Repair double ventricle,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33612,Repair double ventricle,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33615,Repair modified fontan,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33617,Repair single ventricle,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33619,Repair single ventricle,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33620,Apply r&l pulm art bands,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33621,Transthor cath for stent,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33622,Redo compl cardiac anomaly,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33641,Repair heart septum defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33645,Revision of heart veins,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33647,Repair heart septum defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33660,Repair of heart defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33665,Repair of heart defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33670,Repair of heart chambers,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33675,Close mult vsd,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33676,Close mult vsd w/resection,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33677,Cl mult vsd w/rem pul band,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33681,Repair heart septum defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33684,Repair heart septum defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33688,Repair heart septum defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33690,Reinforce pulmonary artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33692,Repair of heart defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33694,Repair of heart defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33697,Repair of heart defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33702,Repair of heart defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33710,Repair of heart defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33720,Repair of heart defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33722,Repair of heart defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33724,Repair venous anomaly,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33726,Repair pul venous stenosis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33730,Repair heart-vein defect(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33732,Repair heart-vein defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33735,Revision of heart chamber,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33736,Revision of heart chamber,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33737,Revision of heart chamber,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33741,Tas congenital car anomal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33745,Tis cgen car anomal 1st shnt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33746,Tis cgen car anomal ea addl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33750,Major vessel shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33755,Major vessel shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33762,Major vessel shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33764,Major vessel shunt & graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33766,Major vessel shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33767,Major vessel shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33768,Cavopulmonary shunting,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33770,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33771,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33774,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33775,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33776,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33777,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33778,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33779,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33780,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33781,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33782,Nikaidoh proc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33783,Nikaidoh proc w/ostia implt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33786,Repair arterial trunk,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33788,Revision of pulmonary artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33800,Aortic suspension,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33802,Repair vessel defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33803,Repair vessel defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33813,Repair septal defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33814,Repair septal defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33820,Revise major vessel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33822,Revise major vessel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33824,Revise major vessel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33840,Remove aorta constriction,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33845,Remove aorta constriction,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33851,Remove aorta constriction,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33852,Repair septal defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33853,Repair septal defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33858,As-aort grf f/aortic dsj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33859,As-aort grf f/ds oth/thn dsj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33863,Ascending aortic graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33864,Ascending aortic graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33871,Transvrs a-arch grf hypthrm,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33875,Thoracic aortic graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33877,Thoracoabdominal graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33880,Endovasc taa repr incl subcl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33881,Endovasc taa repr w/o subcl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33883,Insert endovasc prosth taa,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33884,Endovasc prosth taa add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33886,Endovasc prosth delayed,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33889,Artery transpose/endovas taa,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33891,Car-car bp grft/endovas taa,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33910,Remove lung artery emboli,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33915,Remove lung artery emboli,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33916,Surgery of great vessel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33917,Repair pulmonary artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33920,Repair pulmonary atresia,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33922,Transect pulmonary artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33924,Remove pulmonary shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33925,Rpr pul art unifocal w/o cpb,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33926,Repr pul art unifocal w/cpb,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33927,Impltj tot rplcmt hrt sys,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33928,Rmvl & rplcmt tot hrt sys,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33929,Rmvl rplcmt hrt sys f/trnspl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33930,Removal of donor heart/lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33933,Prepare donor heart/lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33935,Transplantation heart/lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33940,Removal of donor heart,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33944,Prepare donor heart,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33945,Transplantation of heart,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33946,Ecmo/ecls initiation venous,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33947,Ecmo/ecls initiation artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33948,Ecmo/ecls daily mgmt-venous,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33949,Ecmo/ecls daily mgmt artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33951,Ecmo/ecls insj prph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33952,Ecmo/ecls insj prph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33953,Ecmo/ecls insj prph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33954,Ecmo/ecls insj prph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33955,Ecmo/ecls insj ctr cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33956,Ecmo/ecls insj ctr cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33957,Ecmo/ecls repos perph cnula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33958,Ecmo/ecls repos perph cnula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33959,Ecmo/ecls repos perph cnula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33962,Ecmo/ecls repos perph cnula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33963,Ecmo/ecls repos perph cnula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33964,Ecmo/ecls repos perph cnula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33965,Ecmo/ecls rmvl perph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33966,Ecmo/ecls rmvl prph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33967,Insert i-aort percut device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33968,Remove aortic assist device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33969,Ecmo/ecls rmvl perph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33970,Aortic circulation assist,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33971,Aortic circulation assist,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33973,Insert balloon device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33974,Remove intra-aortic balloon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33975,Implant ventricular device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33976,Implant ventricular device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33977,Remove ventricular device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33978,Remove ventricular device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33979,Insert intracorporeal device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33980,Remove intracorporeal device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33981,Replace vad pump ext,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33982,Replace vad intra w/o bp,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33983,Replace vad intra w/bp,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33984,Ecmo/ecls rmvl prph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33985,Ecmo/ecls rmvl ctr cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33986,Ecmo/ecls rmvl ctr cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33987,Artery expos/graft artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33988,Insertion of left heart vent,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33989,Removal of left heart vent,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33990,Insj perq vad l hrt arterial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33991,Insj perq vad l hrt artl&ven,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33992,Rmvl perq left heart vad,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33993,Reposg perq r/l hrt vad,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33995,Insj perq vad r hrt venous,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33997,Rmvl perq right heart vad,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,33999,Cardiac surgery procedure,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,34001,Removal of artery clot,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,34051,Removal of artery clot,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,34101,Removal of artery clot,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,34111,Removal of arm artery clot,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,34151,Removal of artery clot,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,34201,Removal of artery clot,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,34203,Removal of leg artery clot,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,34401,Removal of vein clot,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,34421,Removal of vein clot,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,34451,Removal of vein clot,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,34471,Removal of vein clot,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,34490,Removal of vein clot,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,34501,Repair valve femoral vein,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,34502,Reconstruct vena cava,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,34510,Transposition of vein valve,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,34520,Cross-over vein graft,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,34530,Leg vein fusion,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,34701,Evasc rpr a-ao ndgft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,34702,Evasc rpr a-ao ndgft rpt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,34703,Evasc rpr a-unilac ndgft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,34704,Evasc rpr a-unilac ndgft rpt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,34705,Evac rpr a-biiliac ndgft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,34706,Evasc rpr a-biiliac rpt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,34707,Evasc rpr ilio-iliac ndgft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,34708,Evasc rpr ilio-iliac rpt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,34709,Plmt xtn prosth evasc rpr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,34710,Dlyd plmt xtn prosth 1st vsl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,34711,Dlyd plmt xtn prosth ea addl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,34712,Tcat dlvr enhncd fixj dev,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,34717,Evasc rpr a-iliac ndgft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,34718,Evasc rpr n/a a-iliac ndgft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,34808,Endovas iliac a device addon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,34812,Opn fem art expos,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,34813,Femoral endovas graft add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,34820,Opn iliac art expos,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,34830,Open aortic tube prosth repr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,34831,Open aortoiliac prosth repr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,34832,Open aortofemor prosth repr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,34833,Opn ilac art expos cndt crtj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,34834,Opn brach art expos,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,34841,Endovasc visc aorta 1 graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,34842,Endovasc visc aorta 2 graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,34843,Endovasc visc aorta 3 graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,34844,Endovasc visc aorta 4 graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,34845,Visc & infraren abd 1 prosth,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,34846,Visc & infraren abd 2 prosth,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,34847,Visc & infraren abd 3 prosth,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,34848,Visc & infraren abd 4+ prost,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35001,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35002,Repair artery rupture neck,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35005,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35011,Repair defect of artery,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,35013,Repair artery rupture arm,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35021,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35022,Repair artery rupture chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35045,Repair defect of arm artery,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,35081,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35082,Repair artery rupture aorta,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35091,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35092,Repair artery rupture aorta,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35102,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35103,Repair artery rupture aorta,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35111,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35112,Repair artery rupture spleen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35121,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35122,Repair artery rupture belly,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35131,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35132,Repair artery rupture groin,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35141,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35142,Repair artery rupture thigh,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35151,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35152,Repair ruptd popliteal art,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35180,Repair blood vessel lesion,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,35182,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35184,Repair blood vessel lesion,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,35188,Repair blood vessel lesion,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,35189,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35190,Repair blood vessel lesion,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,35201,Repair blood vessel lesion,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,35206,Repair blood vessel lesion,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,35207,Repair blood vessel lesion,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,35211,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35216,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35221,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35226,Repair blood vessel lesion,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,35231,Repair blood vessel lesion,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,35236,Repair blood vessel lesion,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,35241,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35246,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35251,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35256,Repair blood vessel lesion,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,35261,Repair blood vessel lesion,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,35266,Repair blood vessel lesion,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,35271,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35276,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35281,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35286,Repair blood vessel lesion,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,35301,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35302,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35303,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35304,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35305,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35306,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35311,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35321,Rechanneling of artery,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,35331,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35341,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35351,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35355,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35361,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35363,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35371,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35372,Rechanneling of artery,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,35390,Reoperation carotid add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35400,Angioscopy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35501,Art byp grft ipsilat carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35506,Art byp grft subclav-carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35508,Art byp grft carotid-vertbrl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35509,Art byp grft contral carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35510,Art byp grft carotid-brchial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35511,Art byp grft subclav-subclav,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35512,Art byp grft subclav-brchial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35515,Art byp grft subclav-vertbrl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35516,Art byp grft subclav-axilary,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35518,Art byp grft axillary-axilry,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35521,Art byp grft axill-femoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35522,Art byp grft axill-brachial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35523,Art byp grft brchl-ulnr-rdl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35525,Art byp grft brachial-brchl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35526,Art byp grft aor/carot/innom,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35531,Art byp grft aorcel/aormesen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35533,Art byp grft axill/fem/fem,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35535,Art byp grft hepatorenal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35536,Art byp grft splenorenal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35537,Art byp grft aortoiliac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35538,Art byp grft aortobi-iliac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35539,Art byp grft aortofemoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35540,Art byp grft aortbifemoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35556,Art byp grft fem-popliteal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35558,Art byp grft fem-femoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35560,Art byp grft aortorenal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35563,Art byp grft ilioiliac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35565,Art byp grft iliofemoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35566,Art byp fem-ant-post tib/prl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35570,Art byp tibial-tib/peroneal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35571,Art byp pop-tibl-prl-other,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35583,Vein byp grft fem-popliteal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35585,Vein byp fem-tibial peroneal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35587,Vein byp pop-tibl peroneal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35600,Harvest art for cabg add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35601,Art byp common ipsi carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35606,Art byp carotid-subclavian,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35612,Art byp subclav-subclavian,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35616,Art byp subclav-axillary,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35621,Art byp axillary-femoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35623,Art byp axillary-pop-tibial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35626,Art byp aorsubcl/carot/innom,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35631,Art byp aor-celiac-msn-renal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35632,Art byp ilio-celiac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35633,Art byp ilio-mesenteric,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35634,Art byp iliorenal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35636,Art byp spenorenal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35637,Art byp aortoiliac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35638,Art byp aortobi-iliac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35642,Art byp carotid-vertebral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35645,Art byp subclav-vertebrl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35646,Art byp aortobifemoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35647,Art byp aortofemoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35650,Art byp axillary-axillary,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35654,Art byp axill-fem-femoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35656,Art byp femoral-popliteal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35661,Art byp femoral-femoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35663,Art byp ilioiliac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35665,Art byp iliofemoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35666,Art byp fem-ant-post tib/prl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35671,Art byp pop-tibl-prl-other,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35681,Composite byp grft pros&vein,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35682,Composite byp grft 2 veins,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35683,Composite byp grft 3/> segmt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35691,Art trnsposj vertbrl carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35693,Art trnsposj subclavian,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35694,Art trnsposj subclav carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35695,Art trnsposj carotid subclav,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35697,Reimplant artery each,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35700,Reoperation bypass graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35701,Expl n/flwd surg neck art,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35702,Expl n/flwd surg uxtr art,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35703,Expl n/flwd surg lxtr art,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35800,Explore neck vessels,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,35820,Explore chest vessels,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35840,Explore abdominal vessels,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35860,Explore limb vessels,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,35870,Repair vessel graft defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35875,Removal of clot in graft,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,35876,Removal of clot in graft,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,35879,Revise graft w/vein,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,35881,Revise graft w/vein,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,35883,Revise graft w/nonauto graft,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,35884,Revise graft w/vein,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,35901,Excision graft neck,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35903,Excision graft extremity,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,35905,Excision graft thorax,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,35907,Excision graft abdomen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,36002,Pseudoaneurysm injection trt,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36221,Place cath thoracic aorta,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36222,Place cath carotid/inom art,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36223,Place cath carotid/inom art,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,36224,Place cath carotd art,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,36225,Place cath subclavian art,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36226,Place cath vertebral art,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,36251,Ins cath ren art 1st unilat,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36252,Ins cath ren art 1st bilat,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36253,Ins cath ren art 2nd+ unilat,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,36254,Ins cath ren art 2nd+ bilat,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36260,Insertion of infusion pump,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,36261,Revision of infusion pump,APC 5221,RVU Per Unit,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36262,Removal of infusion pump,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36415,Routine venipuncture,Lab Services,Per Unit,$3.00 ,OP,3,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36420,Vein access cutdown < 1 yr,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36425,Vein access cutdown > 1 yr,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36430,Blood transfusion service,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36440,Bl push transfuse 2 yr/<,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36450,Bl exchange/transfuse nb,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36455,Bl exchange/transfuse non-nb,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36456,Prtl exchange transfuse nb,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36460,Transfusion service fetal,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36465,Njx noncmpnd sclrsnt 1 vein,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36466,Njx noncmpnd sclrsnt mlt vn,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36468,Njx sclrsnt spider veins,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36470,Njx sclrsnt 1 incmptnt vein,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36471,Njx sclrsnt mlt incmptnt vn,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36473,Endovenous mchnchem 1st vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36475,Endovenous rf 1st vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36478,Endovenous laser 1st vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36482,Endoven ther chem adhes 1st,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,36511,Apheresis wbc,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36512,Apheresis rbc,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36513,Apheresis platelets,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36514,Apheresis plasma,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36516,Apheresis immunoads slctv,APC 5243,RVU Per Unit,"$4,131.87 ",OP,"4,131.87","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36522,Photopheresis,APC 5243,RVU Per Unit,"$4,131.87 ",OP,"4,131.87","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36555,Insert non-tunnel cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36556,Insert non-tunnel cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36557,Insert tunneled cv cath,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,36558,Insert tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36560,Insert tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36561,Insert tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36563,Insert tunneled cv cath,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,36565,Insert tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36566,Insert tunneled cv cath,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,36568,Insj picc <5 yr w/o imaging,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36569,Insj picc 5 yr+ w/o imaging,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36570,Insert picvad cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36571,Insert picvad cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36572,Insj picc rs&i <5 yr,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36573,Insj picc rs&i 5 yr+,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36575,Repair tunneled cv cath,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36576,Repair tunneled cv cath,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36578,Replace tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36580,Replace cvad cath,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36581,Replace tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36582,Replace tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36583,Replace tunneled cv cath,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,36584,Compl rplcmt picc rs&i,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36585,Replace picvad cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36589,Removal tunneled cv cath,APC 5181,RVU Per Case,$554.25 ,OP,554.25,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36590,Removal tunneled cv cath,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36591,Draw blood off venous device,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36592,Collect blood from picc,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36593,Declot vascular device,APC 5694,RVU Per Unit,$318.00 ,OP,318,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36595,Mech remov tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36596,Mech remov tunneled cv cath,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36597,Reposition venous catheter,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36598,Inj w/fluor eval cv device,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36600,Withdrawal of arterial blood,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36640,Insertion catheter artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36660,Insertion catheter artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,36680,Insert needle bone cavity,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36800,Insertion of cannula,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,36810,Insertion of cannula,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36815,Insertion of cannula,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,36818,Av fuse uppr arm cephalic,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,36819,Av fuse uppr arm basilic,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,36820,Av fusion/forearm vein,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,36821,Av fusion direct any site,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,36823,Insertion of cannula(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,36825,Artery-vein autograft,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,36830,Artery-vein nonautograft,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,36831,Open thrombect av fistula,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,36832,Av fistula revision open,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,36833,Av fistula revision,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,36835,Artery to vein shunt,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36838,Dist revas ligation hemo,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,36860,External cannula declotting,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36861,Cannula declotting,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,36901,Intro cath dialysis circuit,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,36902,Intro cath dialysis circuit,APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,314.00","5,072.43",,,,,,
Health Alliance MCR ADV,CPT,36903,Intro cath dialysis circuit,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Health Alliance MCR ADV,CPT,36904,Thrmbc/nfs dialysis circuit,APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,314.00","5,072.43",,,,,,
Health Alliance MCR ADV,CPT,36905,Thrmbc/nfs dialysis circuit,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Health Alliance MCR ADV,CPT,36906,Thrmbc/nfs dialysis circuit,APC 5194,RVU Per Case,"$16,438.60 ",OP,"4,140.35","16,438.60",,,,,,
Health Alliance MCR ADV,CPT,37140,Revision of circulation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,37145,Revision of circulation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,37160,Revision of circulation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,37180,Revision of circulation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,37181,Splice spleen/kidney veins,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,37182,Insert hepatic shunt (tips),APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Health Alliance MCR ADV,CPT,37183,Remove hepatic shunt (tips),APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,314.00","5,072.43",,,,,,
Health Alliance MCR ADV,CPT,37184,Prim art m-thrmbc 1st vsl,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Health Alliance MCR ADV,CPT,37187,Venous mech thrombectomy,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
Health Alliance MCR ADV,CPT,37188,Ven mechnl thrmbc repeat tx,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,37191,Ins endovas vena cava filtr,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,37192,Redo endovas vena cava filtr,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,37193,Rem endovas vena cava filter,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,37195,Thrombolytic therapy stroke,APC 5694,RVU Per Unit,$318.00 ,OP,318,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,37197,Remove intrvas foreign body,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,37200,Transcatheter biopsy,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,37211,Thrombolytic art therapy,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,37212,Thrombolytic venous therapy,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,37213,Thromblytic art/ven therapy,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,37214,Cessj therapy cath removal,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,37215,Transcath stent cca w/eps,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,37217,Stent placemt retro carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,37218,Stent placemt ante carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,37220,Iliac revasc,APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,314.00","5,072.43",,,,,,
Health Alliance MCR ADV,CPT,37221,Iliac revasc w/stent,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
Health Alliance MCR ADV,CPT,37224,Fem/popl revas w/tla,APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,314.00","5,072.43",,,,,,
Health Alliance MCR ADV,CPT,37225,Fem/popl revas w/ather,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Health Alliance MCR ADV,CPT,37226,Fem/popl revasc w/stent,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
Health Alliance MCR ADV,CPT,37227,Fem/popl revasc stnt & ather,APC 5194,RVU Per Case,"$16,438.60 ",OP,"4,314.00","16,438.60",,,,,,
Health Alliance MCR ADV,CPT,37228,Tib/per revasc w/tla,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Health Alliance MCR ADV,CPT,37229,Tib/per revasc w/ather,APC 5194,RVU Per Case,"$16,438.60 ",OP,"4,314.00","16,438.60",,,,,,
Health Alliance MCR ADV,CPT,37230,Tib/per revasc w/stent,APC 5194,RVU Per Case,"$16,438.60 ",OP,"4,314.00","16,438.60",,,,,,
Health Alliance MCR ADV,CPT,37231,Tib/per revasc stent & ather,APC 5194,RVU Per Case,"$16,438.60 ",OP,"4,314.00","16,438.60",,,,,,
Health Alliance MCR ADV,CPT,37236,Open/perq place stent 1st,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Health Alliance MCR ADV,CPT,37238,Open/perq place stent same,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
Health Alliance MCR ADV,CPT,37241,Vasc embolize/occlude venous,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Health Alliance MCR ADV,CPT,37242,Vasc embolize/occlude artery,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
Health Alliance MCR ADV,CPT,37243,Vasc embolize/occlude organ,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Health Alliance MCR ADV,CPT,37244,Vasc embolize/occlude bleed,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
Health Alliance MCR ADV,CPT,37246,Trluml balo angiop 1st art,APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,314.00","5,072.43",,,,,,
Health Alliance MCR ADV,CPT,37248,Trluml balo angiop 1st vein,APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,314.00","5,072.43",,,,,,
Health Alliance MCR ADV,CPT,37500,Endoscopy ligate perf veins,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,37501,Vascular endoscopy procedure,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,37565,Ligation of neck vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,37600,Ligation of neck artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,37605,Ligation of neck artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,37606,Ligation of neck artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,37607,Ligation of a-v fistula,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,37609,Temporal artery procedure,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,37615,Ligation of neck artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,37616,Ligation of chest artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,37617,Ligation of abdomen artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,37618,Ligation of extremity artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,37619,Ligation of inf vena cava,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,37650,Revision of major vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,37660,Revision of major vein,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,37700,Revise leg vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,37718,Ligate/strip short leg vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,37722,Ligate/strip long leg vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,37735,Removal of leg veins/lesion,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,37760,Ligate leg veins radical,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,37761,Ligate leg veins open,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,37765,Stab phleb veins xtr 10-20,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,37766,Phleb veins - extrem 20+,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,37780,Revision of leg vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,37785,Ligate/divide/excise vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,37788,Revascularization penis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,37790,Penile venous occlusion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,37799,Vascular surgery procedure,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,38100,Removal of spleen total,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,38101,Removal of spleen partial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,38102,Removal of spleen total,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,38115,Repair of ruptured spleen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,38120,Laparoscopy splenectomy,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Health Alliance MCR ADV,CPT,38129,Laparoscope proc spleen,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,38206,Harvest auto stem cells,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,38207,Cryopreserve stem cells,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,38208,Thaw preserved stem cells,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,38209,Wash harvest stem cells,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,38210,T-cell depletion of harvest,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,38211,Tumor cell deplete of harvst,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,38212,Rbc depletion of harvest,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,38213,Platelet deplete of harvest,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,38214,Volume deplete of harvest,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,38215,Harvest stem cell concentrte,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,38220,Dx bone marrow aspirations,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,38221,Dx bone marrow biopsies,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,38222,Dx bone marrow bx & aspir,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,38230,Bone marrow harvest allogen,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,38232,Bone marrow harvest autolog,APC 5243,RVU Per Unit,"$4,131.87 ",OP,"4,131.87","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,38240,Transplt allo hct/donor,APC 5244,RVU Per Case,"$32,580.57 ",OP,"4,314.00","32,580.57",,,,,,
Health Alliance MCR ADV,CPT,38241,Transplt autol hct/donor,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,38242,Transplt allo lymphocytes,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,38243,Transplj hematopoietic boost,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,38300,Drainage lymph node lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,38305,Drainage lymph node lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,38308,Incision of lymph channels,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,38380,Thoracic duct procedure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,38381,Thoracic duct procedure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,38382,Thoracic duct procedure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,38500,Biopsy/removal lymph nodes,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,38505,Needle biopsy lymph nodes,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,38510,Biopsy/removal lymph nodes,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,38520,Biopsy/removal lymph nodes,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,38525,Biopsy/removal lymph nodes,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,38530,Biopsy/removal lymph nodes,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,38531,Open bx/exc inguinofem nodes,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,38542,Explore deep node(s) neck,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,38550,Removal neck/armpit lesion,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,38555,Removal neck/armpit lesion,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
Health Alliance MCR ADV,CPT,38562,Removal pelvic lymph nodes,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Health Alliance MCR ADV,CPT,38564,Removal abdomen lymph nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,38570,Laparoscopy lymph node biop,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,38571,Laparoscopy lymphadenectomy,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,38572,Laparoscopy lymphadenectomy,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,38573,Laps pelvic lymphadec,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,38589,Laparoscope proc lymphatic,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,38700,Removal of lymph nodes neck,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
Health Alliance MCR ADV,CPT,38720,Removal of lymph nodes neck,APC 5093,RVU Per Case,"$9,128.05 ",OP,"4,314.00","9,128.05",,,,,,
Health Alliance MCR ADV,CPT,38724,Removal of lymph nodes neck,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,38740,Remove armpit lymph nodes,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,38745,Remove armpit lymph nodes,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,38746,Remove thoracic lymph nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,38747,Remove abdominal lymph nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,38760,Remove groin lymph nodes,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
Health Alliance MCR ADV,CPT,38765,Remove groin lymph nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,38770,Remove pelvis lymph nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,38780,Remove abdomen lymph nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,38792,Ra tracer id of sentinl node,APC 5591,RVU Per Case,$385.91 ,OP,385.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,38999,Blood/lymph system procedure,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,39000,Exploration of chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,39010,Exploration of chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,39200,Resect mediastinal cyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,39220,Resect mediastinal tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,39401,Mediastinoscpy w/medstnl bx,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,39402,Mediastinoscpy w/lmph nod bx,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,39499,Chest procedure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,39501,Repair diaphragm laceration,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,39503,Repair of diaphragm hernia,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,39540,Repair of diaphragm hernia,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,39541,Repair of diaphragm hernia,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,39545,Revision of diaphragm,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,39560,Resect diaphragm simple,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,39561,Resect diaphragm complex,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,39599,Diaphragm surgery procedure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,40490,Biopsy of lip,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,40500,Partial excision of lip,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,40510,Partial excision of lip,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,40520,Partial excision of lip,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,40525,Reconstruct lip with flap,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,40527,Reconstruct lip with flap,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,40530,Partial removal of lip,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,40650,Repair lip,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,40652,Repair lip,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,40654,Repair lip,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,40700,Repair cleft lip/nasal,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,40701,Repair cleft lip/nasal,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,40702,Repair cleft lip/nasal,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,40720,Repair cleft lip/nasal,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,40761,Repair cleft lip/nasal,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,40799,Lip surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,40800,Drainage of mouth lesion,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,40801,Drainage of mouth lesion,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,40804,Removal foreign body mouth,APC 5301,RVU Per Case,$828.48 ,OP,828.48,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,40805,Removal foreign body mouth,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,40806,Incision of lip fold,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,40808,Biopsy of mouth lesion,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,40810,Excision of mouth lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,40812,Excise/repair mouth lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,40814,Excise/repair mouth lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,40816,Excision of mouth lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,40818,Excise oral mucosa for graft,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,40819,Excise lip or cheek fold,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,40820,Treatment of mouth lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,40830,Repair mouth laceration,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,40831,Repair mouth laceration,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,40840,Reconstruction of mouth,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,40842,Reconstruction of mouth,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,40843,Reconstruction of mouth,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,40844,Reconstruction of mouth,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,40845,Reconstruction of mouth,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,40899,Mouth surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,41000,Drainage of mouth lesion,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,41005,Drainage of mouth lesion,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,41006,Drainage of mouth lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,41007,Drainage of mouth lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,41008,Drainage of mouth lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,41009,Drainage of mouth lesion,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,41010,Incision of tongue fold,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,41015,Drainage of mouth lesion,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,41016,Drainage of mouth lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,41017,Drainage of mouth lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,41018,Drainage of mouth lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,41019,Place needles h&n for rt,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,41100,Biopsy of tongue,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,41105,Biopsy of tongue,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,41108,Biopsy of floor of mouth,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,41110,Excision of tongue lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,41112,Excision of tongue lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,41113,Excision of tongue lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,41114,Excision of tongue lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,41115,Excision of tongue fold,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,41116,Excision of mouth lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,41120,Partial removal of tongue,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,41130,Partial removal of tongue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,41135,Tongue and neck surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,41140,Removal of tongue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,41145,Tongue removal neck surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,41150,Tongue mouth jaw surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,41153,Tongue mouth neck surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,41155,Tongue jaw & neck surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,41250,Repair tongue laceration,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,41251,Repair tongue laceration,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,41252,Repair tongue laceration,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,41510,Tongue to lip surgery,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,41512,Tongue suspension,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,41520,Reconstruction tongue fold,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,41530,Tongue base vol reduction,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,41599,Tongue and mouth surgery,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,41800,Drainage of gum lesion,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,41805,Removal foreign body gum,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,41806,Removal foreign body jawbone,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,41820,Excision gum each quadrant,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,41821,Excision of gum flap,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,41822,Excision of gum lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,41823,Excision of gum lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,41825,Excision of gum lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,41826,Excision of gum lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,41827,Excision of gum lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,41828,Excision of gum lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,41830,Removal of gum tissue,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,41850,Treatment of gum lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,41870,Gum graft,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,41872,Repair gum,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,41874,Repair tooth socket,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,41899,Dental surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42000,Drainage mouth roof lesion,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42100,Biopsy roof of mouth,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42104,Excision lesion mouth roof,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42106,Excision lesion mouth roof,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42107,Excision lesion mouth roof,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,42120,Remove palate/lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,42140,Excision of uvula,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42145,Repair palate pharynx/uvula,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,42160,Treatment mouth roof lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42180,Repair palate,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42182,Repair palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,42200,Reconstruct cleft palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,42205,Reconstruct cleft palate,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42210,Reconstruct cleft palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,42215,Reconstruct cleft palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,42220,Reconstruct cleft palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,42225,Reconstruct cleft palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,42226,Lengthening of palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,42227,Lengthening of palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,42235,Repair palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,42260,Repair nose to lip fistula,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,42280,Preparation palate mold,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42281,Insertion palate prosthesis,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,42299,Palate/uvula surgery,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42300,Drainage of salivary gland,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42305,Drainage of salivary gland,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42310,Drainage of salivary gland,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42320,Drainage of salivary gland,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42330,Removal of salivary stone,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42335,Removal of salivary stone,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42340,Removal of salivary stone,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42400,Biopsy of salivary gland,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42405,Biopsy of salivary gland,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42408,Excision of salivary cyst,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42409,Drainage of salivary cyst,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42410,Excise parotid gland/lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,42415,Excise parotid gland/lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,42420,Excise parotid gland/lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,42425,Excise parotid gland/lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,42426,Excise parotid gland/lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,42440,Excise submaxillary gland,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,42450,Excise sublingual gland,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,42500,Repair salivary duct,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,42505,Repair salivary duct,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,42507,Parotid duct diversion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,42509,Parotid duct diversion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,42510,Parotid duct diversion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42600,Closure of salivary fistula,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42650,Dilation of salivary duct,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42660,Dilation of salivary duct,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42665,Ligation of salivary duct,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42699,Salivary surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42700,Drainage of tonsil abscess,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42720,Drainage of throat abscess,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42725,Drainage of throat abscess,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,42800,Biopsy of throat,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42804,Biopsy of upper nose/throat,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42806,Biopsy of upper nose/throat,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42808,Excise pharynx lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42809,Remove pharynx foreign body,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42810,Excision of neck cyst,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42815,Excision of neck cyst,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,42820,Remove tonsils and adenoids,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,42821,Remove tonsils and adenoids,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42825,Removal of tonsils,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,42826,Removal of tonsils,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42830,Removal of adenoids,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42831,Removal of adenoids,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42835,Removal of adenoids,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42836,Removal of adenoids,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42842,Extensive surgery of throat,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,42844,Extensive surgery of throat,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,42845,Extensive surgery of throat,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,42860,Excision of tonsil tags,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42870,Excision of lingual tonsil,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,42890,Partial removal of pharynx,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,42892,Revision of pharyngeal walls,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,42894,Revision of pharyngeal walls,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,42900,Repair throat wound,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42950,Reconstruction of throat,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,42953,Repair throat esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,42955,Surgical opening of throat,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42960,Control throat bleeding,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42961,Control throat bleeding,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,42962,Control throat bleeding,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42970,Control nose/throat bleeding,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42971,Control nose/throat bleeding,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,42972,Control nose/throat bleeding,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,42999,Throat surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43020,Incision of esophagus,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43030,Throat muscle surgery,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,43045,Incision of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43100,Excision of esophagus lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43101,Excision of esophagus lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43107,Removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43108,Removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43112,Esphg tot w/thrcm,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43113,Removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43116,Partial removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43117,Partial removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43118,Partial removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43121,Partial removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43122,Partial removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43123,Partial removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43124,Removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43130,Removal of esophagus pouch,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,43135,Removal of esophagus pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43180,Esophagoscopy rigid trnso,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,43191,Esophagoscopy rigid trnso dx,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43192,Esophagoscp rig trnso inject,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43193,Esophagoscp rig trnso biopsy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43194,Esophagoscp rig trnso rem fb,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43195,Esophagoscopy rigid balloon,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43196,Esophagoscp guide wire dilat,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43197,Esophagoscopy flex dx brush,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43198,Esophagosc flex trnsn biopsy,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43200,Esophagoscopy flexible brush,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43201,Esoph scope w/submucous inj,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43202,Esophagoscopy flex biopsy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43204,Esoph scope w/sclerosis inj,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43205,Esophagus endoscopy/ligation,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43206,Esoph optical endomicroscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43210,Egd esophagogastrc fndoplsty,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Health Alliance MCR ADV,CPT,43211,Esophagoscop mucosal resect,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43212,Esophagoscop stent placement,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Health Alliance MCR ADV,CPT,43213,Esophagoscopy retro balloon,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43214,Esophagosc dilate balloon 30,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43215,Esophagoscopy flex remove fb,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43216,Esophagoscopy lesion removal,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43217,Esophagoscopy snare les remv,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43220,Esophagoscopy balloon <30mm,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43226,Esoph endoscopy dilation,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43227,Esophagoscopy control bleed,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43229,Esophagoscopy lesion ablate,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43231,Esophagoscop ultrasound exam,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43232,Esophagoscopy w/us needle bx,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43233,Egd balloon dil esoph30 mm/>,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43235,Egd diagnostic brush wash,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43236,Uppr gi scope w/submuc inj,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43237,Endoscopic us exam esoph,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43238,Egd us fine needle bx/aspir,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43239,Egd biopsy single/multiple,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43240,Egd w/transmural drain cyst,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43241,Egd tube/cath insertion,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43242,Egd us fine needle bx/aspir,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43243,Egd injection varices,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43244,Egd varices ligation,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43245,Egd dilate stricture,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43246,Egd place gastrostomy tube,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43247,Egd remove foreign body,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43248,Egd guide wire insertion,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43249,Esoph egd dilation <30 mm,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43250,Egd cautery tumor polyp,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43251,Egd remove lesion snare,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43252,Egd optical endomicroscopy,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43253,Egd us transmural injxn/mark,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43254,Egd endo mucosal resection,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43255,Egd control bleeding any,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43257,Egd w/thrml txmnt gerd,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43259,Egd us exam duodenum/jejunum,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43260,Ercp w/specimen collection,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43261,Endo cholangiopancreatograph,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43262,Endo cholangiopancreatograph,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43263,Ercp sphincter pressure meas,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43264,Ercp remove duct calculi,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43265,Ercp lithotripsy calculi,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Health Alliance MCR ADV,CPT,43266,Egd endoscopic stent place,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Health Alliance MCR ADV,CPT,43270,Egd lesion ablation,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43274,Ercp duct stent placement,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Health Alliance MCR ADV,CPT,43275,Ercp remove forgn body duct,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43276,Ercp stent exchange w/dilate,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Health Alliance MCR ADV,CPT,43277,Ercp ea duct/ampulla dilate,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43278,Ercp lesion ablate w/dilate,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43279,Lap myotomy heller,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43280,Laparoscopy fundoplasty,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Health Alliance MCR ADV,CPT,43281,Lap paraesophag hern repair,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Health Alliance MCR ADV,CPT,43282,Lap paraesoph her rpr w/mesh,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Health Alliance MCR ADV,CPT,43283,Lap esoph lengthening,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43284,Laps esophgl sphnctr agmntj,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Health Alliance MCR ADV,CPT,43285,Rmvl esophgl sphnctr dev,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,43286,Esphg tot w/laps moblj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43287,Esphg dstl 2/3 w/laps moblj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43288,Esphg thrsc moblj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43289,Laparoscope proc esoph,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,43300,Repair of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43305,Repair esophagus and fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43310,Repair of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43312,Repair esophagus and fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43313,Esophagoplasty congenital,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43314,Tracheo-esophagoplasty cong,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43320,Fuse esophagus & stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43325,Revise esophagus & stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43327,Esoph fundoplasty lap,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43328,Esoph fundoplasty thor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43330,Esophagomyotomy abdominal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43331,Esophagomyotomy thoracic,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43332,Transab esoph hiat hern rpr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43333,Transab esoph hiat hern rpr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43334,Transthor diaphrag hern rpr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43335,Transthor diaphrag hern rpr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43336,Thorabd diaphr hern repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43337,Thorabd diaphr hern repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43338,Esoph lengthening,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43340,Fuse esophagus & intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43341,Fuse esophagus & intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43351,Surgical opening esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43352,Surgical opening esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43360,Gastrointestinal repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43361,Gastrointestinal repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43400,Ligate esophagus veins,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43405,Ligate/staple esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43410,Repair esophagus wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43415,Repair esophagus wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43420,Repair esophagus opening,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43425,Repair esophagus opening,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43450,Dilate esophagus 1/mult pass,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43453,Dilate esophagus,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43460,Pressure treatment esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43496,Free jejunum flap microvasc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43499,Esophagus surgery procedure,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43500,Surgical opening of stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43501,Surgical repair of stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43502,Surgical repair of stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43510,Surgical opening of stomach,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43520,Incision of pyloric muscle,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43605,Biopsy of stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43610,Excision of stomach lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43611,Excision of stomach lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43620,Removal of stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43621,Removal of stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43622,Removal of stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43631,Removal of stomach partial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43632,Removal of stomach partial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43633,Removal of stomach partial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43634,Removal of stomach partial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43635,Removal of stomach partial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43640,Vagotomy & pylorus repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43641,Vagotomy & pylorus repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43644,Lap gastric bypass/roux-en-y,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43645,Lap gastr bypass incl smll i,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43647,Lap impl electrode antrum,APC 5463,RVU Per Case,"$11,498.23 ",OP,"4,314.00","11,498.23",,,,,,
Health Alliance MCR ADV,CPT,43648,Lap revise/remv eltrd antrum,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,43651,Laparoscopy vagus nerve,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,43652,Laparoscopy vagus nerve,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,43653,Laparoscopy gastrostomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,43659,Laparoscope proc stom,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,43752,Nasal/orogastric w/tube plmt,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43753,Tx gastro intub w/asp,APC 5722,RVU Per Case,$270.61 ,OP,270.61,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43754,Dx gastr intub w/asp spec,APC 5722,RVU Per Case,$270.61 ,OP,270.61,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43755,Dx gastr intub w/asp specs,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43756,Dx duod intub w/asp spec,APC 5301,RVU Per Case,$828.48 ,OP,828.48,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43757,Dx duod intub w/asp specs,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43761,Reposition gastrostomy tube,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43762,Rplc gtube no revj trc,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43763,Rplc gtube revj gstrst trc,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43770,Lap place gastr adj device,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,43771,Lap revise gastr adj device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43772,Lap rmvl gastr adj device,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43773,Lap replace gastr adj device,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,43774,Lap rmvl gastr adj all parts,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43775,Lap sleeve gastrectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43800,Reconstruction of pylorus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43810,Fusion of stomach and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43820,Fusion of stomach and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43825,Fusion of stomach and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43830,Place gastrostomy tube,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43831,Place gastrostomy tube,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43832,Place gastrostomy tube,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43840,Repair of stomach lesion,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Health Alliance MCR ADV,CPT,43843,Gastroplasty w/o v-band,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43845,Gastroplasty duodenal switch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43846,Gastric bypass for obesity,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43847,Gastric bypass incl small i,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43848,Revision gastroplasty,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43850,Revise stomach-bowel fusion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43855,Revise stomach-bowel fusion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43860,Revise stomach-bowel fusion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43865,Revise stomach-bowel fusion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43870,Repair stomach opening,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43880,Repair stomach-bowel fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43881,Impl/redo electrd antrum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43882,Revise/remove electrd antrum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,43886,Revise gastric port open,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43887,Remove gastric port open,APC 5054,RVU Per Case,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43888,Change gastric port open,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,43999,Stomach surgery procedure,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,44005,Freeing of bowel adhesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44010,Incision of small bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44015,Insert needle cath bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44020,Explore small intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44021,Decompress small bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44025,Incision of large bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44050,Reduce bowel obstruction,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44055,Correct malrotation of bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44100,Biopsy of bowel,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,44110,Excise intestine lesion(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44111,Excision of bowel lesion(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44120,Removal of small intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44121,Removal of small intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44125,Removal of small intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44126,Enterectomy w/o taper cong,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44127,Enterectomy w/taper cong,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44128,Enterectomy cong add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44130,Bowel to bowel fusion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44132,Enterectomy cadaver donor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44133,Enterectomy live donor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44135,Intestine transplnt cadaver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44136,Intestine transplant live,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44137,Remove intestinal allograft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44139,Mobilization of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44140,Partial removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44141,Partial removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44143,Partial removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44144,Partial removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44145,Partial removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44146,Partial removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44147,Partial removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44150,Removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44151,Removal of colon/ileostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44155,Removal of colon/ileostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44156,Removal of colon/ileostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44157,Colectomy w/ileoanal anast,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44158,Colectomy w/neo-rectum pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44160,Removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44180,Lap enterolysis,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,44186,Lap jejunostomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,44187,Lap ileo/jejuno-stomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44188,Lap colostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44202,Lap enterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44203,Lap resect s/intestine addl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44204,Laparo partial colectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44205,Lap colectomy part w/ileum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44206,Lap part colectomy w/stoma,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44207,L colectomy/coloproctostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44208,L colectomy/coloproctostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44210,Laparo total proctocolectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44211,Lap colectomy w/proctectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44212,Laparo total proctocolectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44213,Lap mobil splenic fl add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44227,Lap close enterostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44238,Laparoscope proc intestine,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,44300,Open bowel to skin,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,44310,Ileostomy/jejunostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44312,Revision of ileostomy,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,44314,Revision of ileostomy,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,44316,Devise bowel pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44320,Colostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44322,Colostomy with biopsies,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44340,Revision of colostomy,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,44345,Revision of colostomy,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,44346,Revision of colostomy,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,44360,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,44361,Small bowel endoscopy/biopsy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,44363,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,44364,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,44365,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,44366,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,44369,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,44370,Small bowel endoscopy/stent,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Health Alliance MCR ADV,CPT,44372,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,44373,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,44376,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,44377,Small bowel endoscopy/biopsy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,44378,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,44379,S bowel endoscope w/stent,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Health Alliance MCR ADV,CPT,44380,Small bowel endoscopy br/wa,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,44381,Small bowel endoscopy br/wa,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,44382,Small bowel endoscopy,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,44384,Small bowel endoscopy,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,44385,Endoscopy of bowel pouch,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,44386,Endoscopy bowel pouch/biop,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,44388,Colonoscopy thru stoma spx,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,44389,Colonoscopy with biopsy,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,44390,Colonoscopy for foreign body,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,44391,Colonoscopy for bleeding,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,44392,Colonoscopy & polypectomy,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,44394,Colonoscopy w/snare,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,44401,Colonoscopy with ablation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,44402,Colonoscopy w/stent plcmt,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Health Alliance MCR ADV,CPT,44403,Colonoscopy w/resection,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,44404,Colonoscopy w/injection,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,44405,Colonoscopy w/dilation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,44406,Colonoscopy w/ultrasound,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,44407,Colonoscopy w/ndl aspir/bx,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,44408,Colonoscopy w/decompression,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,44500,Intro gastrointestinal tube,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,44602,Suture small intestine,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,44603,Suture small intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44604,Suture large intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44605,Repair of bowel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44615,Intestinal stricturoplasty,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44620,Repair bowel opening,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44625,Repair bowel opening,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44626,Repair bowel opening,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44640,Repair bowel-skin fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44650,Repair bowel fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44660,Repair bowel-bladder fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44661,Repair bowel-bladder fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44680,Surgical revision intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44700,Suspend bowel w/prosthesis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44715,Prepare donor intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44720,Prep donor intestine/venous,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44721,Prep donor intestine/artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44799,Unlisted px small intestine,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,44800,Excision of bowel pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44820,Excision of mesentery lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44850,Repair of mesentery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44899,Bowel surgery procedure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44900,Drain appendix abscess open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44950,Appendectomy,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,44960,Appendectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,44970,Laparoscopy appendectomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,44979,Laparoscope proc app,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,45000,Drainage of pelvic abscess,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45005,Drainage of rectal abscess,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45020,Drainage of rectal abscess,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45100,Biopsy of rectum,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45108,Removal of anorectal lesion,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45110,Removal of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,45111,Partial removal of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,45112,Removal of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,45113,Partial proctectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,45114,Partial removal of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,45116,Partial removal of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,45119,Remove rectum w/reservoir,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,45120,Removal of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,45121,Removal of rectum and colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,45123,Partial proctectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,45126,Pelvic exenteration,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,45130,Excision of rectal prolapse,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,45135,Excision of rectal prolapse,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,45136,Excise ileoanal reservior,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,45150,Excision of rectal stricture,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45160,Excision of rectal lesion,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45171,Exc rect tum transanal part,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45172,Exc rect tum transanal full,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45190,Destruction rectal tumor,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45300,Proctosigmoidoscopy dx,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45303,Proctosigmoidoscopy dilate,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45305,Proctosigmoidoscopy w/bx,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45307,Proctosigmoidoscopy fb,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45308,Proctosigmoidoscopy removal,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45309,Proctosigmoidoscopy removal,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45315,Proctosigmoidoscopy removal,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45317,Proctosigmoidoscopy bleed,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45320,Proctosigmoidoscopy ablate,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45321,Proctosigmoidoscopy volvul,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45327,Proctosigmoidoscopy w/stent,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Health Alliance MCR ADV,CPT,45330,Diagnostic sigmoidoscopy,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45331,Sigmoidoscopy and biopsy,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45332,Sigmoidoscopy w/fb removal,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45333,Sigmoidoscopy & polypectomy,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45334,Sigmoidoscopy for bleeding,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45335,Sigmoidoscopy w/submuc inj,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45337,Sigmoidoscopy & decompress,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45338,Sigmoidoscopy w/tumr remove,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45340,Sig w/tndsc balloon dilation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45341,Sigmoidoscopy w/ultrasound,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45342,Sigmoidoscopy w/us guide bx,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45346,Sigmoidoscopy w/ablation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45347,Sigmoidoscopy w/plcmt stent,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Health Alliance MCR ADV,CPT,45349,Sigmoidoscopy w/resection,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45350,Sgmdsc w/band ligation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45378,Diagnostic colonoscopy,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45379,Colonoscopy w/fb removal,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45380,Colonoscopy and biopsy,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45381,Colonoscopy submucous njx,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45382,Colonoscopy w/control bleed,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45384,Colonoscopy w/lesion removal,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45385,Colonoscopy w/lesion removal,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45386,Colonoscopy w/balloon dilat,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45388,Colonoscopy w/ablation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45389,Colonoscopy w/stent plcmt,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Health Alliance MCR ADV,CPT,45390,Colonoscopy w/resection,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45391,Colonoscopy w/endoscope us,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45392,Colonoscopy w/endoscopic fnb,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45393,Colonoscopy w/decompression,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45395,Lap removal of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,45397,Lap remove rectum w/pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,45398,Colonoscopy w/band ligation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45399,Unlisted procedure colon,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45400,Laparoscopic proc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,45402,Lap proctopexy w/sig resect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,45499,Laparoscope proc rectum,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,45500,Repair of rectum,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45505,Repair of rectum,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45520,Treatment of rectal prolapse,APC 5311,RVU Per Case,$812.16 ,OP,812.16,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45540,Correct rectal prolapse,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,45541,Correct rectal prolapse,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45550,Repair rectum/remove sigmoid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,45560,Repair of rectocele,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45562,Exploration/repair of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,45563,Exploration/repair of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,45800,Repair rect/bladder fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,45805,Repair fistula w/colostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,45820,Repair rectourethral fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,45825,Repair fistula w/colostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,45900,Reduction of rectal prolapse,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45905,Dilation of anal sphincter,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45910,Dilation of rectal narrowing,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45915,Remove rectal obstruction,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45990,Surg dx exam anorectal,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,45999,Rectum surgery procedure,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46020,Placement of seton,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46030,Removal of rectal marker,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46040,Incision of rectal abscess,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46045,Incision of rectal abscess,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46050,Incision of anal abscess,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46060,Incision of rectal abscess,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46070,Incision of anal septum,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46080,Incision of anal sphincter,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46083,Incise external hemorrhoid,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46200,Removal of anal fissure,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46220,Excise anal ext tag/papilla,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46221,Ligation of hemorrhoid(s),APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46230,Removal of anal tags,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46250,Remove ext hem groups 2+,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46255,Remove int/ext hem 1 group,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46257,Remove in/ex hem grp & fiss,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46258,Remove in/ex hem grp w/fistu,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46260,Remove in/ex hem groups 2+,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46261,Remove in/ex hem grps & fiss,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46262,Remove in/ex hem grps w/fist,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46270,Remove anal fist subq,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46275,Remove anal fist inter,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46280,Remove anal fist complex,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46285,Remove anal fist 2 stage,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46288,Repair anal fistula,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46320,Removal of hemorrhoid clot,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46500,Injection into hemorrhoid(s),APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46505,Chemodenervation anal musc,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46600,Diagnostic anoscopy spx,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46601,Diagnostic anoscopy,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46604,Anoscopy and dilation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46606,Anoscopy and biopsy,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46607,Diagnostic anoscopy & biopsy,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46608,Anoscopy remove for body,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46610,Anoscopy remove lesion,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46611,Anoscopy,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46612,Anoscopy remove lesions,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46614,Anoscopy control bleeding,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46615,Anoscopy,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46700,Repair of anal stricture,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46705,Repair of anal stricture,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,46706,Repr of anal fistula w/glue,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46707,Repair anorectal fist w/plug,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46710,Repr per/vag pouch sngl proc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,46712,Repr per/vag pouch dbl proc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,46715,Rep perf anoper fistu,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,46716,Rep perf anoper/vestib fistu,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,46730,Construction of absent anus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,46735,Construction of absent anus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,46740,Construction of absent anus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,46742,Repair of imperforated anus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,46744,Repair of cloacal anomaly,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,46746,Repair of cloacal anomaly,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,46748,Repair of cloacal anomaly,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,46750,Repair of anal sphincter,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46751,Repair of anal sphincter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,46753,Reconstruction of anus,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46754,Removal of suture from anus,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46760,Repair of anal sphincter,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46761,Repair of anal sphincter,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46900,Destruction anal lesion(s),APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46910,Destruction anal lesion(s),APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46916,Cryosurgery anal lesion(s),APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46917,Laser surgery anal lesions,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46922,Excision of anal lesion(s),APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46924,Destruction anal lesion(s),APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46930,Destroy internal hemorrhoids,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46940,Treatment of anal fissure,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46942,Treatment of anal fissure,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46945,Int hrhc lig 1 hroid w/o img,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46946,Int hrhc lig 2+hroid w/o img,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46947,Hemorrhoidopexy by stapling,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46948,Int hrhc tranal dartlzj 2+,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,46999,Anus surgery procedure,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,47000,Needle biopsy of liver,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,47010,Open drainage liver lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47015,Inject/aspirate liver cyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47100,Wedge biopsy of liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47120,Partial removal of liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47122,Extensive removal of liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47125,Partial removal of liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47130,Partial removal of liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47133,Removal of donor liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47135,Transplantation of liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47140,Partial removal donor liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47141,Partial removal donor liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47142,Partial removal donor liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47143,Prep donor liver whole,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47144,Prep donor liver 3-segment,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47145,Prep donor liver lobe split,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47146,Prep donor liver/venous,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47147,Prep donor liver/arterial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47300,Surgery for liver lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47350,Repair liver wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47360,Repair liver wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47361,Repair liver wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47362,Repair liver wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47370,Laparo ablate liver tumor rf,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Health Alliance MCR ADV,CPT,47371,Laparo ablate liver cryosurg,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Health Alliance MCR ADV,CPT,47379,Laparoscope procedure liver,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,47380,Open ablate liver tumor rf,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47381,Open ablate liver tumor cryo,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47382,Percut ablate liver rf,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,47383,Perq abltj lvr cryoablation,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,47399,Liver surgery procedure,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,47400,Incision of liver duct,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47420,Incision of bile duct,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47425,Incision of bile duct,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47460,Incise bile duct sphincter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47480,Incision of gallbladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47490,Incision of gallbladder,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,47531,Injection for cholangiogram,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,47532,Injection for cholangiogram,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,47533,Plmt biliary drainage cath,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,47534,Plmt biliary drainage cath,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,47535,Conversion ext bil drg cath,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,47536,Exchange biliary drg cath,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,47537,Removal biliary drg cath,APC 5301,RVU Per Case,$828.48 ,OP,828.48,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,47538,Perq plmt bile duct stent,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,47539,Perq plmt bile duct stent,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,47540,Perq plmt bile duct stent,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,47541,Plmt access bil tree sm bwl,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,47550,Bile duct endoscopy add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47552,Biliary endo perq dx w/speci,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,47553,Biliary endoscopy thru skin,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,47554,Biliary endoscopy thru skin,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,47555,Biliary endoscopy thru skin,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,47556,Biliary endoscopy thru skin,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,47562,Laparoscopic cholecystectomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,47563,Laparo cholecystectomy/graph,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,47564,Laparo cholecystectomy/explr,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,47570,Laparo cholecystoenterostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47579,Laparoscope proc biliary,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,47600,Removal of gallbladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,47605,Removal of gallbladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,47610,Removal of gallbladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,47612,Removal of gallbladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,47620,Removal of gallbladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,47700,Exploration of bile ducts,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47701,Bile duct revision,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47711,Excision of bile duct tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47712,Excision of bile duct tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47715,Excision of bile duct cyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47720,Fuse gallbladder & bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47721,Fuse upper gi structures,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47740,Fuse gallbladder & bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47741,Fuse gallbladder & bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47760,Fuse bile ducts and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47765,Fuse liver ducts & bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47780,Fuse bile ducts and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47785,Fuse bile ducts and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47800,Reconstruction of bile ducts,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47801,Placement bile duct support,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47802,Fuse liver duct & intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47900,Suture bile duct injury,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,47999,Bile tract surgery procedure,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,48000,Drainage of abdomen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,48001,Placement of drain pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,48020,Removal of pancreatic stone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,48100,Biopsy of pancreas open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,48102,Needle biopsy pancreas,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,48105,Resect/debride pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,48120,Removal of pancreas lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,48140,Partial removal of pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,48145,Partial removal of pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,48146,Pancreatectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,48148,Removal of pancreatic duct,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,48150,Partial removal of pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,48152,Pancreatectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,48153,Pancreatectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,48154,Pancreatectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,48155,Removal of pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,48400,Injection intraop add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,48500,Surgery of pancreatic cyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,48510,Drain pancreatic pseudocyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,48520,Fuse pancreas cyst and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,48540,Fuse pancreas cyst and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,48545,Pancreatorrhaphy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,48547,Duodenal exclusion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,48548,Fuse pancreas and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,48551,Prep donor pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,48552,Prep donor pancreas/venous,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,48554,Transpl allograft pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,48556,Removal allograft pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,48999,Pancreas surgery procedure,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,49000,Exploration of abdomen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,49002,Reopening of abdomen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,49010,Exploration behind abdomen,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,49013,Prpertl pel pack hemrrg trma,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,49014,Reexploration pelvic wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,49020,Drainage abdom abscess open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,49040,Drain open abdom abscess,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,49060,Drain open retroperi abscess,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,49062,Drain to peritoneal cavity,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,49082,Abd paracentesis,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,49083,Abd paracentesis w/imaging,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,49084,Peritoneal lavage,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,49180,Biopsy abdominal mass,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,49185,Sclerotx fluid collection,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,49203,Exc abd tum 5 cm or less,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,49204,Exc abd tum over 5 cm,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,49205,Exc abd tum over 10 cm,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,49215,Excise sacral spine tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,49250,Excision of umbilicus,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,49255,Removal of omentum,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,49320,Diag laparo separate proc,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,49321,Laparoscopy biopsy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,49322,Laparoscopy aspiration,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,49323,Laparo drain lymphocele,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,49324,Lap insert tunnel ip cath,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,49325,Lap revision perm ip cath,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,49329,Laparo proc abdm/per/oment,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,49402,Remove foreign body adbomen,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,49405,Image cath fluid colxn visc,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,49406,Image cath fluid peri/retro,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,49407,Image cath fluid trns/vgnl,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,49411,Ins mark abd/pel for rt perq,APC 5613,RVU Per Unit,"$1,291.62 ",OP,"1,291.62","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,49412,Ins device for rt guide open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,49418,Insert tun ip cath perc,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,49419,Insert tun ip cath w/port,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,49421,Ins tun ip cath for dial opn,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,49422,Remove tunneled ip cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,49423,Exchange drainage catheter,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,49425,Insert abdomen-venous drain,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,49426,Revise abdomen-venous shunt,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,49428,Ligation of shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,49429,Removal of shunt,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,49436,Embedded ip cath exit-site,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,49440,Place gastrostomy tube perc,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,49441,Place duod/jej tube perc,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,49442,Place cecostomy tube perc,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,49446,Change g-tube to g-j perc,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,49450,Replace g/c tube perc,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,49451,Replace duod/jej tube perc,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,49452,Replace g-j tube perc,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,49460,Fix g/colon tube w/device,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,49465,Fluoro exam of g/colon tube,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,49491,Rpr hern preemie reduc,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,49492,Rpr ing hern premie blocked,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,49495,Rpr ing hernia baby reduc,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,49496,Rpr ing hernia baby blocked,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,49500,Rpr ing hernia init reduce,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,49501,Rpr ing hernia init blocked,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,49505,Prp i/hern init reduc >5 yr,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,49507,Prp i/hern init block >5 yr,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,49520,Rerepair ing hernia reduce,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,49521,Rerepair ing hernia blocked,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,49525,Repair ing hernia sliding,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,49540,Repair lumbar hernia,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,49550,Rpr rem hernia init reduce,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,49553,Rpr fem hernia init blocked,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,49555,Rerepair fem hernia reduce,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,49557,Rerepair fem hernia blocked,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,49560,Rpr ventral hern init reduc,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,49561,Rpr ventral hern init block,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,49565,Rerepair ventrl hern reduce,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,49566,Rerepair ventrl hern block,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,49570,Rpr epigastric hern reduce,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,49572,Rpr epigastric hern blocked,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,49580,Rpr umbil hern reduc < 5 yr,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,49582,Rpr umbil hern block < 5 yr,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,49585,Rpr umbil hern reduc > 5 yr,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,49587,Rpr umbil hern block > 5 yr,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,49590,Repair spigelian hernia,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,49600,Repair umbilical lesion,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,49605,Repair umbilical lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,49606,Repair umbilical lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,49610,Repair umbilical lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,49611,Repair umbilical lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,49650,Lap ing hernia repair init,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,49651,Lap ing hernia repair recur,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,49652,Lap vent/abd hernia repair,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,49653,Lap vent/abd hern proc comp,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,49654,Lap inc hernia repair,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,49655,Lap inc hern repair comp,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Health Alliance MCR ADV,CPT,49656,Lap inc hernia repair recur,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Health Alliance MCR ADV,CPT,49657,Lap inc hern recur comp,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Health Alliance MCR ADV,CPT,49659,Laparo proc hernia repair,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,49900,Repair of abdominal wall,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,49904,Omental flap extra-abdom,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,49905,Omental flap intra-abdom,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,49906,Free omental flap microvasc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,49999,Abdomen surgery procedure,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,50010,Exploration of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50020,Renal abscess open drain,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,50040,Drainage of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50045,Exploration of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50060,Removal of kidney stone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50065,Incision of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50070,Incision of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50075,Removal of kidney stone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50080,Removal of kidney stone,APC 5376,RVU Per Case,"$8,450.70 ",OP,"4,314.00","8,450.70",,,,,,
Health Alliance MCR ADV,CPT,50081,Removal of kidney stone,APC 5376,RVU Per Case,"$8,450.70 ",OP,"4,314.00","8,450.70",,,,,,
Health Alliance MCR ADV,CPT,50100,Revise kidney blood vessels,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50120,Exploration of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50125,Explore and drain kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50130,Removal of kidney stone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50135,Exploration of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50200,Renal biopsy perq,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,50205,Renal biopsy open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50220,Remove kidney open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50225,Removal kidney open complex,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50230,Removal kidney open radical,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50234,Removal of kidney & ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50236,Removal of kidney & ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50240,Partial removal of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50250,Cryoablate renal mass open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50280,Removal of kidney lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50290,Removal of kidney lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50300,Remove cadaver donor kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50320,Remove kidney living donor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50323,Prep cadaver renal allograft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50325,Prep donor renal graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50327,Prep renal graft/venous,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50328,Prep renal graft/arterial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50329,Prep renal graft/ureteral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50340,Removal of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50360,Transplantation of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50365,Transplantation of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50370,Remove transplanted kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50380,Reimplantation of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50382,Change ureter stent percut,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,50384,Remove ureter stent percut,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,50385,Change stent via transureth,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,50386,Remove stent via transureth,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,50387,Change nephroureteral cath,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,50389,Remove renal tube w/fluoro,APC 5372,RVU Per Case,$588.17 ,OP,588.17,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,50390,Drainage of kidney lesion,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,50391,Instll rx agnt into rnal tub,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,50396,Measure kidney pressure,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,50400,Revision of kidney/ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50405,Revision of kidney/ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50430,Njx px nfrosgrm &/urtrgrm,APC 5372,RVU Per Case,$588.17 ,OP,588.17,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,50431,Njx px nfrosgrm &/urtrgrm,APC 5372,RVU Per Case,$588.17 ,OP,588.17,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,50432,Plmt nephrostomy catheter,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,50433,Plmt nephroureteral catheter,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,50434,Convert nephrostomy catheter,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,50435,Exchange nephrostomy cath,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,50436,Dilat xst trc ndurlgc px,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,50437,Dilat xst trc new access rcs,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,50500,Repair of kidney wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50520,Close kidney-skin fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50525,Close nephrovisceral fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50526,Close nephrovisceral fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50540,Revision of horseshoe kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50541,Laparo ablate renal cyst,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,50542,Laparo ablate renal mass,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Health Alliance MCR ADV,CPT,50543,Laparo partial nephrectomy,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Health Alliance MCR ADV,CPT,50544,Laparoscopy pyeloplasty,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,50545,Laparo radical nephrectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50546,Laparoscopic nephrectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50547,Laparo removal donor kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50548,Laparo remove w/ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50549,Laparoscope proc renal,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,50551,Kidney endoscopy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,50553,Kidney endoscopy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,50555,Kidney endoscopy & biopsy,APC 5376,RVU Per Case,"$8,450.70 ",OP,"4,314.00","8,450.70",,,,,,
Health Alliance MCR ADV,CPT,50557,Kidney endoscopy & treatment,APC 5376,RVU Per Case,"$8,450.70 ",OP,"4,314.00","8,450.70",,,,,,
Health Alliance MCR ADV,CPT,50561,Kidney endoscopy & treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,50562,Renal scope w/tumor resect,APC 5376,RVU Per Case,"$8,450.70 ",OP,"4,314.00","8,450.70",,,,,,
Health Alliance MCR ADV,CPT,50570,Kidney endoscopy,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,50572,Kidney endoscopy,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,50574,Kidney endoscopy & biopsy,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,50575,Kidney endoscopy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,50576,Kidney endoscopy & treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,50580,Kidney endoscopy & treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,50590,Fragmenting of kidney stone,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,50592,Perc rf ablate renal tumor,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,50593,Perc cryo ablate renal tum,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Health Alliance MCR ADV,CPT,50600,Exploration of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50605,Insert ureteral support,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50610,Removal of ureter stone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50620,Removal of ureter stone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50630,Removal of ureter stone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50650,Removal of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50660,Removal of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50686,Measure ureter pressure,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,50688,Change of ureter tube/stent,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,50693,Plmt ureteral stent prq,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,50694,Plmt ureteral stent prq,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,50695,Plmt ureteral stent prq,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,50700,Revision of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50715,Release of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50722,Release of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50725,Release/revise ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50727,Revise ureter,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,50728,Revise ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50740,Fusion of ureter & kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50750,Fusion of ureter & kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50760,Fusion of ureters,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50770,Splicing of ureters,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50780,Reimplant ureter in bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50782,Reimplant ureter in bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50783,Reimplant ureter in bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50785,Reimplant ureter in bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50800,Implant ureter in bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50810,Fusion of ureter & bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50815,Urine shunt to intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50820,Construct bowel bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50825,Construct bowel bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50830,Revise urine flow,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50840,Replace ureter by bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50845,Appendico-vesicostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50860,Transplant ureter to skin,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50900,Repair of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50920,Closure ureter/skin fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50930,Closure ureter/bowel fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50940,Release of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,50945,Laparoscopy ureterolithotomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,50947,Laparo new ureter/bladder,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,50948,Laparo new ureter/bladder,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Health Alliance MCR ADV,CPT,50949,Laparoscope proc ureter,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,50951,Endoscopy of ureter,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,50953,Endoscopy of ureter,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,50955,Ureter endoscopy & biopsy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,50957,Ureter endoscopy & treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,50961,Ureter endoscopy & treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,50970,Ureter endoscopy,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,50972,Ureter endoscopy & catheter,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,50974,Ureter endoscopy & biopsy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,50976,Ureter endoscopy & treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,50980,Ureter endoscopy & treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,51020,Incise & treat bladder,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,51030,Incise & treat bladder,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,51040,Incise & drain bladder,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,51045,Incise bladder/drain ureter,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,51050,Removal of bladder stone,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,51060,Removal of ureter stone,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,51065,Remove ureter calculus,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,51080,Drainage of bladder abscess,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,51100,Drain bladder by needle,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,51101,Drain bladder by trocar/cath,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,51102,Drain bl w/cath insertion,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,51500,Removal of bladder cyst,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,51520,Removal of bladder lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,51525,Removal of bladder lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,51530,Removal of bladder lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,51535,Repair of ureter lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,51550,Partial removal of bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,51555,Partial removal of bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,51565,Revise bladder & ureter(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,51570,Removal of bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,51575,Removal of bladder & nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,51580,Remove bladder/revise tract,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,51585,Removal of bladder & nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,51590,Remove bladder/revise tract,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,51595,Remove bladder/revise tract,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,51596,Remove bladder/create pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,51597,Removal of pelvic structures,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,51700,Irrigation of bladder,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,51701,Insert bladder catheter,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,51702,Insert temp bladder cath,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,51703,Insert bladder cath complex,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,51705,Change of bladder tube,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,51710,Change of bladder tube,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,51715,Endoscopic injection/implant,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,51720,Treatment of bladder lesion,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,51725,Simple cystometrogram,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,51726,Complex cystometrogram,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,51727,Cystometrogram w/up,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,51728,Cystometrogram w/vp,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,51729,Cystometrogram w/vp&up,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,51736,Urine flow measurement,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,51741,Electro-uroflowmetry first,APC 5721,RVU Per Case,$142.80 ,OP,142.8,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,51784,Anal/urinary muscle study,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,51785,Anal/urinary muscle study,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,51792,Urinary reflex study,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,51798,Us urine capacity measure,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,51800,Revision of bladder/urethra,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,51820,Revision of urinary tract,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,51840,Attach bladder/urethra,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Health Alliance MCR ADV,CPT,51841,Attach bladder/urethra,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,51845,Repair bladder neck,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Health Alliance MCR ADV,CPT,51860,Repair of bladder wound,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,51865,Repair of bladder wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,51880,Repair of bladder opening,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,51900,Repair bladder/vagina lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,51920,Close bladder-uterus fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,51925,Hysterectomy/bladder repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,51940,Correction of bladder defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,51960,Revision of bladder & bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,51980,Construct bladder opening,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,51990,Laparo urethral suspension,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,51992,Laparo sling operation,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,51999,Laparoscope proc bla,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,52000,Cystoscopy,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,52001,Cystoscopy removal of clots,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,52005,Cystoscopy & ureter catheter,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,52007,Cystoscopy and biopsy,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,52010,Cystoscopy & duct catheter,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,52204,Cystoscopy w/biopsy(s),APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,52214,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,52224,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,52234,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,52235,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,52240,Cystoscopy and treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,52250,Cystoscopy and radiotracer,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,52260,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,52265,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,52270,Cystoscopy & revise urethra,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,52275,Cystoscopy & revise urethra,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,52276,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,52277,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,52281,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,52282,Cystoscopy implant stent,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,52283,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,52285,Cystoscopy and treatment,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,52287,Cystoscopy chemodenervation,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,52290,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,52300,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,52301,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,52305,Cystoscopy and treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,52310,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,52315,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,52317,Remove bladder stone,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,52318,Remove bladder stone,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,52320,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,52325,Cystoscopy stone removal,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,52327,Cystoscopy inject material,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,52330,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,52332,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,52334,Create passage to kidney,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,52341,Cysto w/ureter stricture tx,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,52342,Cysto w/up stricture tx,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,52343,Cysto w/renal stricture tx,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,52344,Cysto/uretero stricture tx,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,52345,Cysto/uretero w/up stricture,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,52346,Cystouretero w/renal strict,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,52351,Cystouretero & or pyeloscope,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,52352,Cystouretero w/stone remove,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,52353,Cystouretero w/lithotripsy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,52354,Cystouretero w/biopsy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,52355,Cystouretero w/excise tumor,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,52356,Cysto/uretero w/lithotripsy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,52400,Cystouretero w/congen repr,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,52402,Cystourethro cut ejacul duct,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,52450,Incision of prostate,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,52500,Revision of bladder neck,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,52601,Prostatectomy (turp),APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,52630,Remove prostate regrowth,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,52640,Relieve bladder contracture,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,52647,Laser surgery of prostate,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,52648,Laser surgery of prostate,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,52649,Prostate laser enucleation,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,52700,Drainage of prostate abscess,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,53000,Incision of urethra,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,53010,Incision of urethra,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,53020,Incision of urethra,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,53025,Incision of urethra,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,53040,Drainage of urethra abscess,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,53060,Drainage of urethra abscess,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,53080,Drainage of urinary leakage,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,53085,Drainage of urinary leakage,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,53200,Biopsy of urethra,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,53210,Removal of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,53215,Removal of urethra,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,53220,Treatment of urethra lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,53230,Removal of urethra lesion,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,53235,Removal of urethra lesion,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,53240,Surgery for urethra pouch,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,53250,Removal of urethra gland,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,53260,Treatment of urethra lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,53265,Treatment of urethra lesion,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,53270,Removal of urethra gland,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,53275,Repair of urethra defect,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,53400,Revise urethra stage 1,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,53405,Revise urethra stage 2,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,53410,Reconstruction of urethra,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,53415,Reconstruction of urethra,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,53420,Reconstruct urethra stage 1,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,53425,Reconstruct urethra stage 2,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,53430,Reconstruction of urethra,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,53431,Reconstruct urethra/bladder,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,53440,Male sling procedure,APC 5377,RVU Per Case,"$11,755.91 ",OP,"4,140.35","11,755.91",,,,,,
Health Alliance MCR ADV,CPT,53442,Remove/revise male sling,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,53444,Insert tandem cuff,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,314.00","18,684.12",,,,,,
Health Alliance MCR ADV,CPT,53445,Insert uro/ves nck sphincter,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,140.35","18,684.12",,,,,,
Health Alliance MCR ADV,CPT,53446,Remove uro sphincter,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,53447,Remove/replace ur sphincter,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,314.00","18,684.12",,,,,,
Health Alliance MCR ADV,CPT,53448,Remov/replc ur sphinctr comp,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,53449,Repair uro sphincter,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,53450,Revision of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,53460,Revision of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,53500,Urethrlys transvag w/ scope,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,53502,Repair of urethra injury,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,53505,Repair of urethra injury,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,53510,Repair of urethra injury,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,53515,Repair of urethra injury,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,53520,Repair of urethra defect,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,53600,Dilate urethra stricture,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,53601,Dilate urethra stricture,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,53605,Dilate urethra stricture,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,53620,Dilate urethra stricture,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,53621,Dilate urethra stricture,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,53660,Dilation of urethra,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,53661,Dilation of urethra,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,53665,Dilation of urethra,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,53850,Prostatic microwave thermotx,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,53852,Prostatic rf thermotx,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,53854,Trurl dstrj prst8 tiss rf wv,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,53855,Insert prost urethral stent,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,53860,Transurethral rf treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,53899,Urology surgery procedure,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54000,Slitting of prepuce,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54001,Slitting of prepuce,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54015,Drain penis lesion,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54050,Destruction penis lesion(s),APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54055,Destruction penis lesion(s),APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54056,Cryosurgery penis lesion(s),APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54057,Laser surg penis lesion(s),APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54060,Excision of penis lesion(s),APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54065,Destruction penis lesion(s),APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54100,Biopsy of penis,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54105,Biopsy of penis,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54110,Treatment of penis lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54111,Treat penis lesion graft,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,54112,Treat penis lesion graft,APC 5376,RVU Per Case,"$8,450.70 ",OP,"4,314.00","8,450.70",,,,,,
Health Alliance MCR ADV,CPT,54115,Treatment of penis lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54120,Partial removal of penis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54125,Removal of penis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,54130,Remove penis & nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,54135,Remove penis & nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,54150,Circumcision w/regionl block,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54160,Circumcision neonate,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54161,Circum 28 days or older,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54162,Lysis penil circumic lesion,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54163,Repair of circumcision,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54164,Frenulotomy of penis,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54200,Treatment of penis lesion,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54205,Treatment of penis lesion,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,54220,Treatment of penis lesion,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54231,Dynamic cavernosometry,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54235,Penile injection,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54240,Penis study,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54250,Penis study,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54300,Revision of penis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54304,Revision of penis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54308,Reconstruction of urethra,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,54312,Reconstruction of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54316,Reconstruction of urethra,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,54318,Reconstruction of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54322,Reconstruction of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54324,Reconstruction of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54326,Reconstruction of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54328,Revise penis/urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54332,Revise penis/urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54336,Revise penis/urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54340,Secondary urethral surgery,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54344,Secondary urethral surgery,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,54348,Secondary urethral surgery,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,54352,Reconstruct urethra/penis,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,54360,Penis plastic surgery,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54380,Repair penis,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54385,Repair penis,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54390,Repair penis and bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,54400,Insert semi-rigid prosthesis,APC 5377,RVU Per Case,"$11,755.91 ",OP,"4,314.00","11,755.91",,,,,,
Health Alliance MCR ADV,CPT,54401,Insert self-contd prosthesis,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,314.00","18,684.12",,,,,,
Health Alliance MCR ADV,CPT,54405,Insert multi-comp penis pros,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,140.35","18,684.12",,,,,,
Health Alliance MCR ADV,CPT,54406,Remove muti-comp penis pros,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54408,Repair multi-comp penis pros,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,54410,Remove/replace penis prosth,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,140.35","18,684.12",,,,,,
Health Alliance MCR ADV,CPT,54411,Remov/replc penis pros comp,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,314.00","18,684.12",,,,,,
Health Alliance MCR ADV,CPT,54415,Remove self-contd penis pros,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54416,Remv/repl penis contain pros,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,314.00","18,684.12",,,,,,
Health Alliance MCR ADV,CPT,54417,Remv/replc penis pros compl,APC 5377,RVU Per Case,"$11,755.91 ",OP,"4,314.00","11,755.91",,,,,,
Health Alliance MCR ADV,CPT,54420,Revision of penis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54430,Revision of penis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,54435,Revision of penis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54437,Repair corporeal tear,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54438,Replantation of penis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,54440,Repair of penis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54450,Preputial stretching,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54500,Biopsy of testis,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54505,Biopsy of testis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54512,Excise lesion testis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54520,Removal of testis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54522,Orchiectomy partial,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54530,Removal of testis,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54535,Extensive testis surgery,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54550,Exploration for testis,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54560,Exploration for testis,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54600,Reduce testis torsion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54620,Suspension of testis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54640,Orchiopexy ingun/scrot appr,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54650,Orchiopexy (fowler-stephens),APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54660,Revision of testis,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,54670,Repair testis injury,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54680,Relocation of testis(es),APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54690,Laparoscopy orchiectomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,54692,Laparoscopy orchiopexy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,54699,Laparoscope proc testis,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,54700,Drainage of scrotum,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54800,Biopsy of epididymis,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54830,Remove epididymis lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54840,Remove epididymis lesion,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54860,Removal of epididymis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54861,Removal of epididymis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54865,Explore epididymis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54900,Fusion of spermatic ducts,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,54901,Fusion of spermatic ducts,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,55000,Drainage of hydrocele,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,55040,Removal of hydrocele,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,55041,Removal of hydroceles,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,55060,Repair of hydrocele,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,55100,Drainage of scrotum abscess,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,55110,Explore scrotum,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,55120,Removal of scrotum lesion,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,55150,Removal of scrotum,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,55175,Revision of scrotum,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,55180,Revision of scrotum,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,55200,Incision of sperm duct,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,55250,Removal of sperm duct(s),APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,55400,Repair of sperm duct,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,55500,Removal of hydrocele,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,55520,Removal of sperm cord lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,55530,Revise spermatic cord veins,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,55535,Revise spermatic cord veins,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,55540,Revise hernia & sperm veins,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,55550,Laparo ligate spermatic vein,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,55559,Laparo proc spermatic cord,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,55600,Incise sperm duct pouch,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,55605,Incise sperm duct pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,55650,Remove sperm duct pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,55680,Remove sperm pouch lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,55700,Biopsy of prostate,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,55705,Biopsy of prostate,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,55706,Prostate saturation sampling,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,55720,Drainage of prostate abscess,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,55725,Drainage of prostate abscess,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,55801,Removal of prostate,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,55810,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,55812,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,55815,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,55821,Removal of prostate,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,55831,Removal of prostate,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,55840,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,55842,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,55845,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,55860,Surgical exposure prostate,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,55862,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,55865,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,55866,Laparo radical prostatectomy,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Health Alliance MCR ADV,CPT,55870,Electroejaculation,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,55873,Cryoablate prostate,APC 5376,RVU Per Case,"$8,450.70 ",OP,"4,314.00","8,450.70",,,,,,
Health Alliance MCR ADV,CPT,55874,Tprnl plmt biodegrdabl matrl,APC 5375,RVU Per Unit,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,55875,Transperi needle place pros,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,55876,Place rt device/marker pros,APC 5613,RVU Per Unit,"$1,291.62 ",OP,"1,291.62","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,55880,Abltj mal prst8 tiss hifu,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,55899,Genital surgery procedure,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,55920,Place needles pelvic for rt,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Health Alliance MCR ADV,CPT,55970,Sex transformation m to f,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Health Alliance MCR ADV,CPT,55980,Sex transformation f to m,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,56405,I & d of vulva/perineum,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,56420,Drainage of gland abscess,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,56440,Surgery for vulva lesion,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,56441,Lysis of labial lesion(s),APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,56442,Hymenotomy,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,56501,Destroy vulva lesions sim,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,56515,Destroy vulva lesion/s compl,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,56605,Biopsy of vulva/perineum,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,56620,Partial removal of vulva,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,56625,Complete removal of vulva,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,56630,Extensive vulva surgery,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Health Alliance MCR ADV,CPT,56631,Extensive vulva surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,56632,Extensive vulva surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,56633,Extensive vulva surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,56634,Extensive vulva surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,56637,Extensive vulva surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,56640,Extensive vulva surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,56700,Partial removal of hymen,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,56740,Remove vagina gland lesion,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,56800,Repair of vagina,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,56805,Repair clitoris,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,56810,Repair of perineum,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,56820,Exam of vulva w/scope,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,56821,Exam/biopsy of vulva w/scope,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,57000,Exploration of vagina,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,57010,Drainage of pelvic abscess,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,57020,Drainage of pelvic fluid,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Health Alliance MCR ADV,CPT,57022,I & d vaginal hematoma pp,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,57023,I & d vag hematoma non-ob,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,57061,Destroy vag lesions simple,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,57065,Destroy vag lesions complex,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,57100,Biopsy of vagina,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,57105,Biopsy of vagina,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,57106,Remove vagina wall partial,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,57107,Remove vagina tissue part,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,57109,Vaginectomy partial w/nodes,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,57110,Remove vagina wall complete,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,57111,Remove vagina tissue compl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,57120,Closure of vagina,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Health Alliance MCR ADV,CPT,57130,Remove vagina lesion,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,57135,Remove vagina lesion,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,57150,Treat vagina infection,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,57155,Insert uteri tandem/ovoids,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Health Alliance MCR ADV,CPT,57156,Ins vag brachytx device,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,57160,Insert pessary/other device,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,57170,Fitting of diaphragm/cap,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,57180,Treat vaginal bleeding,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,57200,Repair of vagina,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,57210,Repair vagina/perineum,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,57220,Revision of urethra,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Health Alliance MCR ADV,CPT,57230,Repair of urethral lesion,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,57240,Anterior colporrhaphy,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Health Alliance MCR ADV,CPT,57250,Repair rectum & vagina,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Health Alliance MCR ADV,CPT,57260,Cmbn ant pst colprhy,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Health Alliance MCR ADV,CPT,57265,Cmbn ap colprhy w/ntrcl rpr,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Health Alliance MCR ADV,CPT,57268,Repair of bowel bulge,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Health Alliance MCR ADV,CPT,57270,Repair of bowel pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,57280,Suspension of vagina,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,57282,Colpopexy extraperitoneal,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,57283,Colpopexy intraperitoneal,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,57284,Repair paravag defect open,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Health Alliance MCR ADV,CPT,57285,Repair paravag defect vag,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,57287,Revise/remove sling repair,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,57288,Repair bladder defect,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,57289,Repair bladder & vagina,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,314.00","6,952.74",,,,,,
Health Alliance MCR ADV,CPT,57291,Construction of vagina,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Health Alliance MCR ADV,CPT,57292,Construct vagina with graft,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Health Alliance MCR ADV,CPT,57295,Revise vag graft via vagina,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,57296,Revise vag graft open abd,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,57300,Repair rectum-vagina fistula,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,57305,Repair rectum-vagina fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,57307,Fistula repair & colostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,57308,Fistula repair transperine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,57310,Repair urethrovaginal lesion,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,314.00","6,952.74",,,,,,
Health Alliance MCR ADV,CPT,57311,Repair urethrovaginal lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,57320,Repair bladder-vagina lesion,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Health Alliance MCR ADV,CPT,57330,Repair bladder-vagina lesion,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,314.00","6,952.74",,,,,,
Health Alliance MCR ADV,CPT,57335,Repair vagina,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Health Alliance MCR ADV,CPT,57400,Dilation of vagina,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,57410,Pelvic examination,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,57415,Remove vaginal foreign body,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,57420,Exam of vagina w/scope,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,57421,Exam/biopsy of vag w/scope,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,57423,Repair paravag defect lap,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Health Alliance MCR ADV,CPT,57425,Laparoscopy surg colpopexy,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,57426,Revise prosth vag graft lap,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,314.00","6,952.74",,,,,,
Health Alliance MCR ADV,CPT,57452,Exam of cervix w/scope,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,57454,Bx/curett of cervix w/scope,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,57455,Biopsy of cervix w/scope,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,57456,Endocerv curettage w/scope,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,57460,Bx of cervix w/scope leep,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,57461,Conz of cervix w/scope leep,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,57500,Biopsy of cervix,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,57505,Endocervical curettage,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,57510,Cauterization of cervix,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,57511,Cryocautery of cervix,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,57513,Laser surgery of cervix,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,57520,Conization of cervix,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,57522,Conization of cervix,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,57530,Removal of cervix,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Health Alliance MCR ADV,CPT,57531,Removal of cervix radical,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,57540,Removal of residual cervix,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,57545,Remove cervix/repair pelvis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,57550,Removal of residual cervix,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Health Alliance MCR ADV,CPT,57555,Remove cervix/repair vagina,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Health Alliance MCR ADV,CPT,57556,Remove cervix repair bowel,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Health Alliance MCR ADV,CPT,57558,D&c of cervical stump,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,57700,Revision of cervix,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,57720,Revision of cervix,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,57800,Dilation of cervical canal,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,58100,Biopsy of uterus lining,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,58120,Dilation and curettage,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,58140,Myomectomy abdom method,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,58145,Myomectomy vag method,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,58146,Myomectomy abdom complex,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,58150,Total hysterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,58152,Total hysterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,58180,Partial hysterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,58200,Extensive hysterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,58210,Extensive hysterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,58240,Removal of pelvis contents,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,58260,Vaginal hysterectomy,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Health Alliance MCR ADV,CPT,58262,Vag hyst including t/o,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Health Alliance MCR ADV,CPT,58263,Vag hyst w/t/o & vag repair,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Health Alliance MCR ADV,CPT,58267,Vag hyst w/urinary repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,58270,Vag hyst w/enterocele repair,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Health Alliance MCR ADV,CPT,58275,Hysterectomy/revise vagina,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,58280,Hysterectomy/revise vagina,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,58285,Extensive hysterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,58290,Vag hyst complex,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,314.00","6,952.74",,,,,,
Health Alliance MCR ADV,CPT,58291,Vag hyst incl t/o complex,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Health Alliance MCR ADV,CPT,58292,Vag hyst t/o & repair compl,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,314.00","6,952.74",,,,,,
Health Alliance MCR ADV,CPT,58294,Vag hyst w/enterocele compl,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Health Alliance MCR ADV,CPT,58301,Remove intrauterine device,APC 5412,RVU Per Case,$288.05 ,OP,288.05,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,58321,Artificial insemination,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,58322,Artificial insemination,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,58323,Sperm washing,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,58345,Reopen fallopian tube,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,58346,Insert heyman uteri capsule,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Health Alliance MCR ADV,CPT,58350,Reopen fallopian tube,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Health Alliance MCR ADV,CPT,58353,Endometr ablate thermal,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Health Alliance MCR ADV,CPT,58356,Endometrial cryoablation,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Health Alliance MCR ADV,CPT,58400,Suspension of uterus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,58410,Suspension of uterus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,58520,Repair of ruptured uterus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,58540,Revision of uterus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,58541,Lsh uterus 250 g or less,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,58542,Lsh w/t/o ut 250 g or less,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,58543,Lsh uterus above 250 g,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,58544,Lsh w/t/o uterus above 250 g,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,58545,Laparoscopic myomectomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,58546,Laparo-myomectomy complex,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,58548,Lap radical hyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,58550,Laparo-asst vag hysterectomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,58552,Laparo-vag hyst incl t/o,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,58553,Laparo-vag hyst complex,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,58554,Laparo-vag hyst w/t/o compl,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,58555,Hysteroscopy dx sep proc,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,58558,Hysteroscopy biopsy,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,58559,Hysteroscopy lysis,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,58560,Hysteroscopy resect septum,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,58561,Hysteroscopy remove myoma,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,58562,Hysteroscopy remove fb,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,58563,Hysteroscopy ablation,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Health Alliance MCR ADV,CPT,58565,Hysteroscopy sterilization,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,58570,Tlh uterus 250 g or less,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,58571,Tlh w/t/o 250 g or less,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,58572,Tlh uterus over 250 g,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,58573,Tlh w/t/o uterus over 250 g,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,58575,Laps tot hyst resj mal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,58578,Laparo proc uterus,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,58579,Hysteroscope procedure,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,58600,Division of fallopian tube,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,58605,Division of fallopian tube,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,58611,Ligate oviduct(s) add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,58615,Occlude fallopian tube(s),APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,58660,Laparoscopy lysis,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,58661,Laparoscopy remove adnexa,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,58662,Laparoscopy excise lesions,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,58670,Laparoscopy tubal cautery,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,58671,Laparoscopy tubal block,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,58672,Laparoscopy fimbrioplasty,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,58673,Laparoscopy salpingostomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,58674,Laps abltj uterine fibroids,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,58679,Laparo proc oviduct-ovary,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,58700,Removal of fallopian tube,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,58720,Removal of ovary/tube(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,58740,Adhesiolysis tube ovary,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,58750,Repair oviduct,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,58752,Revise ovarian tube(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,58760,Fimbrioplasty,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,58770,Create new tubal opening,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,58800,Drainage of ovarian cyst(s),APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,58805,Drainage of ovarian cyst(s),APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,58820,Drain ovary abscess open,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,58822,Drain ovary abscess percut,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,58825,Transposition ovary(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,58900,Biopsy of ovary(s),APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,58920,Partial removal of ovary(s),APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,314.00","6,952.74",,,,,,
Health Alliance MCR ADV,CPT,58925,Removal of ovarian cyst(s),APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Health Alliance MCR ADV,CPT,58940,Removal of ovary(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,58943,Removal of ovary(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,58950,Resect ovarian malignancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,58951,Resect ovarian malignancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,58952,Resect ovarian malignancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,58953,Tah rad dissect for debulk,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,58954,Tah rad debulk/lymph remove,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,58956,Bso omentectomy w/tah,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,58957,Resect recurrent gyn mal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,58958,Resect recur gyn mal w/lym,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,58960,Exploration of abdomen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,58970,Retrieval of oocyte,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,58974,Transfer of embryo,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,58976,Transfer of embryo,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,58999,Genital surgery procedure,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,59000,Amniocentesis diagnostic,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,59001,Amniocentesis therapeutic,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,59012,Fetal cord puncture prenatal,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,59015,Chorion biopsy,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,59020,Fetal contract stress test,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,59025,Fetal non-stress test,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,59030,Fetal scalp blood sample,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,59070,Transabdom amnioinfus w/us,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,59072,Umbilical cord occlud w/us,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,59074,Fetal fluid drainage w/us,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,59076,Fetal shunt placement w/us,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,59100,Remove uterus lesion,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Health Alliance MCR ADV,CPT,59120,Treat ectopic pregnancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,59121,Treat ectopic pregnancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,59130,Treat ectopic pregnancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,59135,Treat ectopic pregnancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,59136,Treat ectopic pregnancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,59140,Treat ectopic pregnancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,59150,Treat ectopic pregnancy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,59151,Treat ectopic pregnancy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,59160,D & c after delivery,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,59200,Insert cervical dilator,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,59300,Episiotomy or vaginal repair,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,59320,Revision of cervix,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,59325,Revision of cervix,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,59350,Repair of uterus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,59409,Obstetrical care,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,59412,Antepartum manipulation,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,59414,Deliver placenta,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,59514,Cesarean delivery only,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,59525,Remove uterus after cesarean,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,59612,Vbac delivery only,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,59620,Attempted vbac delivery only,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,59812,Treatment of miscarriage,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,59820,Care of miscarriage,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,59821,Treatment of miscarriage,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,59830,Treat uterus infection,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,59840,Abortion,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,59841,Abortion,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,59850,Abortion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,59851,Abortion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,59852,Abortion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,59855,Abortion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,59856,Abortion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,59857,Abortion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,59866,Abortion (mpr),APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,59870,Evacuate mole of uterus,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,59871,Remove cerclage suture,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,59897,Fetal invas px w/us,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,59898,Laparo proc ob care/deliver,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,59899,Maternity care procedure,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,60000,Drain thyroid/tongue cyst,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,60100,Biopsy of thyroid,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,60200,Remove thyroid lesion,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,60210,Partial thyroid excision,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,60212,Partial thyroid excision,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,60220,Partial removal of thyroid,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,60225,Partial removal of thyroid,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,60240,Removal of thyroid,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,60252,Removal of thyroid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,60254,Extensive thyroid surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,60260,Repeat thyroid surgery,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,60270,Removal of thyroid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,60271,Removal of thyroid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,60280,Remove thyroid duct lesion,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,60281,Remove thyroid duct lesion,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,60300,Aspir/inj thyroid cyst,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,60500,Explore parathyroid glands,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,60502,Re-explore parathyroids,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,60505,Explore parathyroid glands,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,60520,Removal of thymus gland,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,60521,Removal of thymus gland,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,60522,Removal of thymus gland,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,60540,Explore adrenal gland,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,60545,Explore adrenal gland,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,60600,Remove carotid body lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,60605,Remove carotid body lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,60650,Laparoscopy adrenalectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,60659,Laparo proc endocrine,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,60699,Endocrine surgery procedure,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Health Alliance MCR ADV,CPT,61000,Remove cranial cavity fluid,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,61001,Remove cranial cavity fluid,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,61020,Remove brain cavity fluid,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,61026,Injection into brain canal,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,61050,Remove brain canal fluid,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,61055,Injection into brain canal,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,61070,Brain canal shunt procedure,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,61105,Twist drill hole,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61107,Drill skull for implantation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61108,Drill skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61120,Burr hole for puncture,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61140,Pierce skull for biopsy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61150,Pierce skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61151,Pierce skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61154,Pierce skull & remove clot,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61156,Pierce skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61210,Pierce skull implant device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61215,Insert brain-fluid device,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Health Alliance MCR ADV,CPT,61250,Pierce skull & explore,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61253,Pierce skull & explore,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61304,Open skull for exploration,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61305,Open skull for exploration,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61312,Open skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61313,Open skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61314,Open skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61315,Open skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61316,Implt cran bone flap to abdo,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61320,Open skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61321,Open skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61322,Decompressive craniotomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61323,Decompressive lobectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61330,Decompress eye socket,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,61333,Explore orbit/remove lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61340,Subtemporal decompression,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61343,Incise skull (press relief),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61345,Relieve cranial pressure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61450,Incise skull for surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61458,Incise skull for brain wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61460,Incise skull for surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61500,Removal of skull lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61501,Remove infected skull bone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61510,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61512,Remove brain lining lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61514,Removal of brain abscess,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61516,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61517,Implt brain chemotx add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61518,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61519,Remove brain lining lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61520,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61521,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61522,Removal of brain abscess,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61524,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61526,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61530,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61531,Implant brain electrodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61533,Implant brain electrodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61534,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61535,Remove brain electrodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61536,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61537,Removal of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61538,Removal of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61539,Removal of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61540,Removal of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61541,Incision of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61543,Removal of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61544,Remove & treat brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61545,Excision of brain tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61546,Removal of pituitary gland,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61548,Removal of pituitary gland,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61550,Release of skull seams,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61552,Release of skull seams,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61556,Incise skull/sutures,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61557,Incise skull/sutures,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61558,Excision of skull/sutures,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61559,Excision of skull/sutures,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61563,Excision of skull tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61564,Excision of skull tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61566,Removal of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61567,Incision of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61570,Remove foreign body brain,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61571,Incise skull for brain wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61575,Skull base/brainstem surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61576,Skull base/brainstem surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61580,Craniofacial approach skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61581,Craniofacial approach skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61582,Craniofacial approach skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61583,Craniofacial approach skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61584,Orbitocranial approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61585,Orbitocranial approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61586,Resect nasopharynx skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61590,Infratemporal approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61591,Infratemporal approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61592,Orbitocranial approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61595,Transtemporal approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61596,Transcochlear approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61597,Transcondylar approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61598,Transpetrosal approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61600,Resect/excise cranial lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61601,Resect/excise cranial lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61605,Resect/excise cranial lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61606,Resect/excise cranial lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61607,Resect/excise cranial lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61608,Resect/excise cranial lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61611,Transect artery sinus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61613,Remove aneurysm sinus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61615,Resect/excise lesion skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61616,Resect/excise lesion skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61618,Repair dura,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61619,Repair dura,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61623,Endovasc tempory vessel occl,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Health Alliance MCR ADV,CPT,61624,Transcath occlusion cns,APC 5194,RVU Per Case,"$16,438.60 ",OP,"4,314.00","16,438.60",,,,,,
Health Alliance MCR ADV,CPT,61626,Transcath occlusion non-cns,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Health Alliance MCR ADV,CPT,61630,Intracranial angioplasty,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61635,Intracran angioplsty w/stent,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61645,Perq art m-thrombect &/nfs,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61650,Evasc prlng admn rx agnt 1st,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61651,Evasc prlng admn rx agnt add,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61680,Intracranial vessel surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61682,Intracranial vessel surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61684,Intracranial vessel surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61686,Intracranial vessel surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61690,Intracranial vessel surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61692,Intracranial vessel surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61697,Brain aneurysm repr complx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61698,Brain aneurysm repr complx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61700,Brain aneurysm repr simple,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61702,Inner skull vessel surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61703,Clamp neck artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61705,Revise circulation to head,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61708,Revise circulation to head,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61710,Revise circulation to head,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61711,Fusion of skull arteries,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61720,Incise skull/brain surgery,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Health Alliance MCR ADV,CPT,61735,Incise skull/brain surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61750,Incise skull/brain biopsy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61751,Brain biopsy w/ct/mr guide,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61760,Implant brain electrodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61770,Incise skull for treatment,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Health Alliance MCR ADV,CPT,61790,Treat trigeminal nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,61791,Treat trigeminal tract,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,61850,Implant neuroelectrodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61860,Implant neuroelectrodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61863,Implant neuroelectrode,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61864,Implant neuroelectrde addl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61867,Implant neuroelectrode,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61868,Implant neuroelectrde addl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,61880,Revise/remove neuroelectrode,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,61885,Insrt/redo neurostim 1 array,APC 5464,RVU Per Case,"$20,957.35 ",OP,"4,140.35","20,957.35",,,,,,
Health Alliance MCR ADV,CPT,61886,Implant neurostim arrays,APC 5465,RVU Per Case,"$30,131.14 ",OP,"4,314.00","30,131.14",,,,,,
Health Alliance MCR ADV,CPT,61888,Revise/remove neuroreceiver,APC 5463,RVU Per Case,"$11,498.23 ",OP,"4,314.00","11,498.23",,,,,,
Health Alliance MCR ADV,CPT,62000,Treat skull fracture,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,62005,Treat skull fracture,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,62010,Treatment of head injury,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,62100,Repair brain fluid leakage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,62115,Reduction of skull defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,62117,Reduction of skull defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,62120,Repair skull cavity lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,62121,Incise skull repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,62140,Repair of skull defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,62141,Repair of skull defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,62142,Remove skull plate/flap,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,62143,Replace skull plate/flap,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,62145,Repair of skull & brain,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,62146,Repair of skull with graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,62147,Repair of skull with graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,62148,Retr bone flap to fix skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,62161,Dissect brain w/scope,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,62162,Remove colloid cyst w/scope,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,62164,Remove brain tumor w/scope,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,62165,Remove pituit tumor w/scope,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,62180,Establish brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,62190,Establish brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,62192,Establish brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,62194,Replace/irrigate catheter,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,62200,Establish brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,62201,Brain cavity shunt w/scope,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,62220,Establish brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,62223,Establish brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,62225,Replace/irrigate catheter,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Health Alliance MCR ADV,CPT,62230,Replace/revise brain shunt,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Health Alliance MCR ADV,CPT,62252,Csf shunt reprogram,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,62256,Remove brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,62258,Replace brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,62263,Epidural lysis mult sessions,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,62264,Epidural lysis on single day,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,62267,Interdiscal perq aspir dx,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,62268,Drain spinal cord cyst,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,62269,Needle biopsy spinal cord,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,62270,Dx lmbr spi pnxr,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,62272,Ther spi pnxr drg csf,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,62273,Inject epidural patch,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,62280,Treat spinal cord lesion,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,62281,Treat spinal cord lesion,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,62282,Treat spinal canal lesion,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,62287,Percutaneous diskectomy,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,62292,Njx chemonucleolysis lmbr,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,62294,Injection into spinal artery,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,62302,Myelography lumbar injection,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,62303,Myelography lumbar injection,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,62304,Myelography lumbar injection,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,62305,Myelography lumbar injection,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,62320,Njx interlaminar crv/thrc,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,62321,Njx interlaminar crv/thrc,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,62322,Njx interlaminar lmbr/sac,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,62323,Njx interlaminar lmbr/sac,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,62324,Njx interlaminar crv/thrc,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,62325,Njx interlaminar crv/thrc,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,62326,Njx interlaminar lmbr/sac,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,62327,Njx interlaminar lmbr/sac,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,62328,Dx lmbr spi pnxr w/fluor/ct,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,62329,Ther spi pnxr csf fluor/ct,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,62350,Implant spinal canal cath,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Health Alliance MCR ADV,CPT,62351,Implant spinal canal cath,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,62355,Remove spinal canal catheter,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,62360,Insert spine infusion device,APC 5471,RVU Per Case,"$17,429.07 ",OP,"4,314.00","17,429.07",,,,,,
Health Alliance MCR ADV,CPT,62361,Implant spine infusion pump,APC 5471,RVU Per Case,"$17,429.07 ",OP,"4,314.00","17,429.07",,,,,,
Health Alliance MCR ADV,CPT,62362,Implant spine infusion pump,APC 5471,RVU Per Case,"$17,429.07 ",OP,"4,140.35","17,429.07",,,,,,
Health Alliance MCR ADV,CPT,62365,Remove spine infusion device,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Health Alliance MCR ADV,CPT,62367,Analyze spine infus pump,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,62368,Analyze sp inf pump w/reprog,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,62369,Anal sp inf pmp w/reprg&fill,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,62370,Anl sp inf pmp w/mdreprg&fil,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,62380,Ndsc dcmprn 1 ntrspc lumbar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,63001,Remove spine lamina 1/2 crvl,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,63003,Remove spine lamina 1/2 thrc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,63005,Remove spine lamina 1/2 lmbr,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,63011,Remove spine lamina 1/2 scrl,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,63012,Remove lamina/facets lumbar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,63015,Remove spine lamina >2 crvcl,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,63016,Remove spine lamina >2 thrc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,63017,Remove spine lamina >2 lmbr,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,63020,Neck spine disk surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,63030,Low back disk surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,63040,Laminotomy single cervical,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,63042,Laminotomy single lumbar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,63045,Remove spine lamina 1 crvl,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,63046,Remove spine lamina 1 thrc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,63047,Remove spine lamina 1 lmbr,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,63050,Cervical laminoplsty 2/> seg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63051,C-laminoplasty w/graft/plate,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63055,Decompress spinal cord thrc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,63056,Decompress spinal cord lmbr,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,63064,Decompress spinal cord thrc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,63075,Neck spine disk surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,63077,Spine disk surgery thorax,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63078,Spine disk surgery thorax,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63081,Remove vert body dcmprn crvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63082,Remove vertebral body add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63085,Remove vert body dcmprn thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63086,Remove vertebral body add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63087,Remov vertbr dcmprn thrclmbr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63088,Remove vertebral body add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63090,Remove vert body dcmprn lmbr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63091,Remove vertebral body add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63101,Remove vert body dcmprn thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63102,Remove vert body dcmprn lmbr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63103,Remove vertebral body add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63170,Incise spinal cord tract(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63172,Drainage of spinal cyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63173,Drainage of spinal cyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63185,Incise spine nrv half segmnt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63190,Incise spine nrv >2 segmnts,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63191,Incise spine accessory nerve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63194,Incise spine & cord cervical,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63195,Incise spine & cord thoracic,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63196,Incise spine&cord 2 trx crvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63197,Incise spine&cord 2 trx thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63198,Incise spin&cord 2 stgs crvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63199,Incise spin&cord 2 stgs thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63200,Release spinal cord lumbar,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63250,Revise spinal cord vsls crvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63251,Revise spinal cord vsls thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63252,Revise spine cord vsl thrlmb,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63265,Excise intraspinl lesion crv,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,63266,Excise intrspinl lesion thrc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,63267,Excise intrspinl lesion lmbr,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,63268,Excise intrspinl lesion scrl,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,63270,Excise intrspinl lesion crvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63271,Excise intrspinl lesion thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63272,Excise intrspinl lesion lmbr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63273,Excise intrspinl lesion scrl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63275,Bx/exc xdrl spine lesn crvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63276,Bx/exc xdrl spine lesn thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63277,Bx/exc xdrl spine lesn lmbr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63278,Bx/exc xdrl spine lesn scrl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63280,Bx/exc idrl spine lesn crvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63281,Bx/exc idrl spine lesn thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63282,Bx/exc idrl spine lesn lmbr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63283,Bx/exc idrl spine lesn scrl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63285,Bx/exc idrl imed lesn cervl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63286,Bx/exc idrl imed lesn thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63287,Bx/exc idrl imed lesn thrlmb,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63290,Bx/exc xdrl/idrl lsn any lvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63295,Repair laminectomy defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63300,Remove vert xdrl body crvcl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63301,Remove vert xdrl body thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63302,Remove vert xdrl body thrlmb,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63303,Remov vert xdrl bdy lmbr/sac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63304,Remove vert idrl body crvcl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63305,Remove vert idrl body thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63306,Remov vert idrl bdy thrclmbr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63307,Remov vert idrl bdy lmbr/sac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63308,Remove vertebral body add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63600,Remove spinal cord lesion,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,63610,Stimulation of spinal cord,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,63650,Implant neuroelectrodes,APC 5462,RVU Per Case,"$6,304.35 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,63655,Implant neuroelectrodes,APC 5464,RVU Per Case,"$20,957.35 ",OP,"4,140.35","20,957.35",,,,,,
Health Alliance MCR ADV,CPT,63661,Remove spine eltrd perq aray,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,63662,Remove spine eltrd plate,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,63663,Revise spine eltrd perq aray,APC 5462,RVU Per Case,"$6,304.35 ",OP,"4,314.00","6,304.35",,,,,,
Health Alliance MCR ADV,CPT,63664,Revise spine eltrd plate,APC 5463,RVU Per Case,"$11,498.23 ",OP,"4,314.00","11,498.23",,,,,,
Health Alliance MCR ADV,CPT,63685,Insrt/redo spine n generator,APC 5465,RVU Per Case,"$30,131.14 ",OP,"4,140.35","30,131.14",,,,,,
Health Alliance MCR ADV,CPT,63688,Revise/remove neuroreceiver,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,63700,Repair of spinal herniation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63702,Repair of spinal herniation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63704,Repair of spinal herniation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63706,Repair of spinal herniation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63707,Repair spinal fluid leakage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63709,Repair spinal fluid leakage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63710,Graft repair of spine defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63740,Install spinal shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,63741,Install spinal shunt,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Health Alliance MCR ADV,CPT,63744,Revision of spinal shunt,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Health Alliance MCR ADV,CPT,63746,Removal of spinal shunt,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64400,Njx aa&/strd trigeminal nrv,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64405,Njx aa&/strd gr ocpl nrv,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64408,Njx aa&/strd vagus nrv,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64415,Njx aa&/strd brach plexus,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64416,Njx aa&/strd brach plex nfs,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64417,Njx aa&/strd axillary nrv,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64418,Njx aa&/strd sprscap nrv,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64420,Njx aa&/strd ntrcost nrv 1,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64421,Njx aa&/strd ntrcost nrv ea,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64425,Njx aa&/strd ii ih nerves,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64430,Njx aa&/strd pudendal nerve,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64435,Njx aa&/strd paracrv nrv,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64445,Njx aa&/strd sciatic nerve,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64446,Njx aa&/strd sciatic nrv nfs,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64447,Njx aa&/strd femoral nerve,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64448,Njx aa&/strd fem nerve nfs,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64449,Njx aa&/strd lmbr plex nfs,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64450,Njx aa&/strd other pn/branch,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64451,Njx aa&/strd nrv nrvtg si jt,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64454,Njx aa&/strd gnclr nrv brnch,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64455,Njx aa&/strd pltr com dg nrv,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64461,Pvb thoracic single inj site,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64463,Pvb thoracic cont infusion,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64479,Njx aa&/strd tfrm epi c/t 1,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64483,Njx aa&/strd tfrm epi l/s 1,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64490,Inj paravert f jnt c/t 1 lev,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64493,Inj paravert f jnt l/s 1 lev,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64505,N block spenopalatine gangl,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64510,N block stellate ganglion,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64517,N block inj hypogas plxs,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64520,N block lumbar/thoracic,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64530,N block inj celiac pelus,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64553,Implant neuroelectrodes,APC 5463,RVU Per Case,"$11,498.23 ",OP,"4,314.00","11,498.23",,,,,,
Health Alliance MCR ADV,CPT,64555,Implant neuroelectrodes,APC 5462,RVU Per Case,"$6,304.35 ",OP,"4,314.00","6,304.35",,,,,,
Health Alliance MCR ADV,CPT,64561,Implant neuroelectrodes,APC 5462,RVU Per Case,"$6,304.35 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,64566,Neuroeltrd stim post tibial,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64568,Inc for vagus n elect impl,APC 5465,RVU Per Case,"$30,131.14 ",OP,"4,140.35","30,131.14",,,,,,
Health Alliance MCR ADV,CPT,64569,Revise/repl vagus n eltrd,APC 5463,RVU Per Case,"$11,498.23 ",OP,"4,314.00","11,498.23",,,,,,
Health Alliance MCR ADV,CPT,64570,Remove vagus n eltrd,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Health Alliance MCR ADV,CPT,64575,Implant neuroelectrodes,APC 5463,RVU Per Case,"$11,498.23 ",OP,"4,314.00","11,498.23",,,,,,
Health Alliance MCR ADV,CPT,64580,Implant neuroelectrodes,APC 5464,RVU Per Case,"$20,957.35 ",OP,"4,314.00","20,957.35",,,,,,
Health Alliance MCR ADV,CPT,64581,Implant neuroelectrodes,APC 5462,RVU Per Case,"$6,304.35 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,64585,Revise/remove neuroelectrode,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64590,Insrt/redo pn/gastr stimul,APC 5464,RVU Per Case,"$20,957.35 ",OP,"4,140.35","20,957.35",,,,,,
Health Alliance MCR ADV,CPT,64595,Revise/rmv pn/gastr stimul,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64600,Injection treatment of nerve,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64605,Injection treatment of nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64610,Injection treatment of nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64611,Chemodenerv saliv glands,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64612,Destroy nerve face muscle,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64615,Chemodenerv musc migraine,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64616,Chemodenerv musc neck dyston,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64617,Chemodener muscle larynx emg,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64620,Injection treatment of nerve,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64624,Dstrj nulyt agt gnclr nrv,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64625,Rf abltj nrv nrvtg si jt,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64630,Injection treatment of nerve,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64632,N block inj common digit,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64633,Destroy cerv/thor facet jnt,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64635,Destroy lumb/sac facet jnt,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64640,Injection treatment of nerve,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64642,Chemodenerv 1 extremity 1-4,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64644,Chemodenerv 1 extrem 5/> mus,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64646,Chemodenerv trunk musc 1-5,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64647,Chemodenerv trunk musc 6/>,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64650,Chemodenerv eccrine glands,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64653,Chemodenerv eccrine glands,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64680,Injection treatment of nerve,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64681,Injection treatment of nerve,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64702,Revise finger/toe nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64704,Revise hand/foot nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64708,Revise arm/leg nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64712,Revision of sciatic nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64713,Revision of arm nerve(s),APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64714,Revise low back nerve(s),APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64716,Revision of cranial nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64718,Revise ulnar nerve at elbow,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64719,Revise ulnar nerve at wrist,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64721,Carpal tunnel surgery,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64722,Relieve pressure on nerve(s),APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64726,Release foot/toe nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64732,Incision of brow nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64734,Incision of cheek nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64736,Incision of chin nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64738,Incision of jaw nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64740,Incision of tongue nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64742,Incision of facial nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64744,Incise nerve back of head,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64746,Incise diaphragm nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64755,Incision of stomach nerves,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,64760,Incision of vagus nerve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,64763,Incise hip/thigh nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64766,Incise hip/thigh nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64771,Sever cranial nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64772,Incision of spinal nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64774,Remove skin nerve lesion,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64776,Remove digit nerve lesion,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64782,Remove limb nerve lesion,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64784,Remove nerve lesion,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64786,Remove sciatic nerve lesion,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Health Alliance MCR ADV,CPT,64788,Remove skin nerve lesion,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64790,Removal of nerve lesion,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64792,Removal of nerve lesion,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Health Alliance MCR ADV,CPT,64795,Biopsy of nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64802,Sympathectomy cervical,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64804,Remove sympathetic nerves,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64809,Remove sympathetic nerves,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,64818,Remove sympathetic nerves,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,64820,Sympathectomy digital artery,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64821,Remove sympathetic nerves,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64822,Remove sympathetic nerves,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64823,Sympathectomy supfc palmar,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64831,Repair of digit nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64834,Repair of hand or foot nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Health Alliance MCR ADV,CPT,64835,Repair of hand or foot nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Health Alliance MCR ADV,CPT,64836,Repair of hand or foot nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Health Alliance MCR ADV,CPT,64840,Repair of leg nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Health Alliance MCR ADV,CPT,64856,Repair/transpose nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Health Alliance MCR ADV,CPT,64857,Repair arm/leg nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Health Alliance MCR ADV,CPT,64858,Repair sciatic nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64861,Repair of arm nerves,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,64862,Repair of low back nerves,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Health Alliance MCR ADV,CPT,64864,Repair of facial nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Health Alliance MCR ADV,CPT,64865,Repair of facial nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Health Alliance MCR ADV,CPT,64866,Fusion of facial/other nerve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,64868,Fusion of facial/other nerve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,64885,Nerve graft head/neck </4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Health Alliance MCR ADV,CPT,64886,Nerve graft head/neck >4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Health Alliance MCR ADV,CPT,64890,Nerve graft hand/foot </4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Health Alliance MCR ADV,CPT,64891,Nerve graft hand/foot >4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Health Alliance MCR ADV,CPT,64892,Nerve graft arm/leg <4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Health Alliance MCR ADV,CPT,64893,Nerve graft arm/leg >4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Health Alliance MCR ADV,CPT,64895,Nerve graft hand/foot </4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Health Alliance MCR ADV,CPT,64896,Nerve graft hand/foot >4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Health Alliance MCR ADV,CPT,64897,Nerve graft arm/leg </4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Health Alliance MCR ADV,CPT,64898,Nerve graft arm/leg >4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Health Alliance MCR ADV,CPT,64905,Nerve pedicle transfer,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Health Alliance MCR ADV,CPT,64907,Nerve pedicle transfer,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Health Alliance MCR ADV,CPT,64910,Nerve repair w/allograft,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Health Alliance MCR ADV,CPT,64911,Neurorraphy w/vein autograft,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Health Alliance MCR ADV,CPT,64912,Nrv rpr w/nrv algrft 1st,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Health Alliance MCR ADV,CPT,64999,Nervous system surgery,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65091,Revise eye,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65093,Revise eye with implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65101,Removal of eye,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65103,Remove eye/insert implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65105,Remove eye/attach implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65110,Removal of eye,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65112,Remove eye/revise socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65114,Remove eye/revise socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65125,Revise ocular implant,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65130,Insert ocular implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65135,Insert ocular implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65140,Attach ocular implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65150,Revise ocular implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65155,Reinsert ocular implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65175,Removal of ocular implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65205,Remove foreign body from eye,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65210,Remove foreign body from eye,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65220,Remove foreign body from eye,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65222,Remove foreign body from eye,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65235,Remove foreign body from eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65260,Remove foreign body from eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65265,Remove foreign body from eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65270,Repair of eye wound,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65272,Repair of eye wound,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65273,Repair of eye wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,65275,Repair of eye wound,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65280,Repair of eye wound,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65285,Repair of eye wound,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65286,Repair of eye wound,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65290,Repair of eye socket wound,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65400,Removal of eye lesion,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65410,Biopsy of cornea,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65420,Removal of eye lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65426,Removal of eye lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65430,Corneal smear,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65435,Curette/treat cornea,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65436,Curette/treat cornea,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65450,Treatment of corneal lesion,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65600,Revision of cornea,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65710,Corneal transplant,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65730,Corneal transplant,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,65750,Corneal transplant,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65755,Corneal transplant,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65756,Corneal trnspl endothelial,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,65770,Revise cornea with implant,APC 5493,RVU Per Case,"$7,506.93 ",OP,"4,314.00","7,506.93",,,,,,
Health Alliance MCR ADV,CPT,65772,Correction of astigmatism,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65775,Correction of astigmatism,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65778,Cover eye w/membrane,APC 5502,RVU Per Case,$828.42 ,OP,828.42,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65779,Cover eye w/membrane suture,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65780,Ocular reconst transplant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65781,Ocular reconst transplant,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65782,Ocular reconst transplant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65785,Impltj ntrstrml crnl rng seg,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65800,Drainage of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65810,Drainage of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65815,Drainage of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65820,Relieve inner eye pressure,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65850,Incision of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65855,Trabeculoplasty laser surg,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65860,Incise inner eye adhesions,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65865,Incise inner eye adhesions,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65870,Incise inner eye adhesions,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65875,Incise inner eye adhesions,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65880,Incise inner eye adhesions,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65900,Remove eye lesion,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65920,Remove implant of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,65930,Remove blood clot from eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66020,Injection treatment of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66030,Injection treatment of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66130,Remove eye lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66150,Glaucoma surgery,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66155,Glaucoma surgery,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66160,Glaucoma surgery,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66170,Glaucoma surgery,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66172,Incision of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66174,Translum dil eye canal,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66175,Trnslum dil eye canal w/stnt,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66179,Aqueous shunt eye w/o graft,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66180,Aqueous shunt eye w/graft,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,66183,Insert ant drainage device,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66184,Revision of aqueous shunt,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66185,Revise aqueous shunt eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66225,Repair/graft eye lesion,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66250,Follow-up surgery of eye,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66500,Incision of iris,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66505,Incision of iris,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66600,Remove iris and lesion,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66605,Removal of iris,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66625,Removal of iris,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66630,Removal of iris,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66635,Removal of iris,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66680,Repair iris & ciliary body,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66682,Repair iris & ciliary body,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66700,Destruction ciliary body,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66710,Ciliary transsleral therapy,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66711,Ecp ciliary body destruction,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66720,Destruction ciliary body,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66740,Destruction ciliary body,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66761,Revision of iris,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66762,Revision of iris,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66770,Removal of inner eye lesion,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66820,Incision secondary cataract,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66821,After cataract laser surgery,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66825,Reposition intraocular lens,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66830,Removal of lens lesion,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66840,Removal of lens material,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66850,Removal of lens material,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66852,Removal of lens material,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66920,Extraction of lens,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66930,Extraction of lens,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66940,Extraction of lens,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66982,Xcapsl ctrc rmvl cplx wo ecp,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66983,Cataract surg w/iol 1 stage,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66984,Xcapsl ctrc rmvl w/o ecp,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66985,Insert lens prosthesis,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66986,Exchange lens prosthesis,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66987,Xcapsl ctrc rmvl cplx w/ecp,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66988,Xcapsl ctrc rmvl w/ecp,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,66999,Eye surgery procedure,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67005,Partial removal of eye fluid,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67010,Partial removal of eye fluid,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67015,Release of eye fluid,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67025,Replace eye fluid,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67027,Implant eye drug system,APC 5494,RVU Per Case,"$15,359.39 ",OP,"4,314.00","15,359.39",,,,,,
Health Alliance MCR ADV,CPT,67028,Injection eye drug,APC 5694,RVU Per Unit,$318.00 ,OP,318,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67030,Incise inner eye strands,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67031,Laser surgery eye strands,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67036,Removal of inner eye fluid,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67039,Laser treatment of retina,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67040,Laser treatment of retina,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67041,Vit for macular pucker,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67042,Vit for macular hole,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67043,Vit for membrane dissect,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67101,Repair detached retina crtx,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67105,Repair detached retina pc,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67107,Repair detached retina,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67108,Repair detached retina,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,67110,Repair detached retina,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67113,Repair retinal detach cplx,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,67115,Release encircling material,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67120,Remove eye implant material,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67121,Remove eye implant material,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67141,Treatment of retina,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67145,Treatment of retina,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67208,Treatment of retinal lesion,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67210,Treatment of retinal lesion,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67218,Treatment of retinal lesion,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67220,Treatment of choroid lesion,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67221,Ocular photodynamic ther,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67227,Dstrj extensive retinopathy,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67228,Treatment x10sv retinopathy,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67229,Tr retinal les preterm inf,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67250,Reinforce eye wall,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67255,Reinforce/graft eye wall,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67299,Eye surgery procedure,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67311,Revise eye muscle,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67312,Revise two eye muscles,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67314,Revise eye muscle,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67316,Revise two eye muscles,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67318,Revise eye muscle(s),APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67343,Release eye tissue,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67345,Destroy nerve of eye muscle,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67346,Biopsy eye muscle,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67399,Unlisted px extraocular musc,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67400,Explore/biopsy eye socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67405,Explore/drain eye socket,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67412,Explore/treat eye socket,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67413,Explore/treat eye socket,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67414,Explr/decompress eye socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67415,Aspiration orbital contents,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67420,Explore/treat eye socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67430,Explore/treat eye socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67440,Explore/drain eye socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67445,Explr/decompress eye socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67450,Explore/biopsy eye socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67500,Inject/treat eye socket,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67505,Inject/treat eye socket,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67515,Inject/treat eye socket,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67550,Insert eye socket implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67560,Revise eye socket implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67570,Decompress optic nerve,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67599,Orbit surgery procedure,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67700,Drainage of eyelid abscess,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67710,Incision of eyelid,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67715,Incision of eyelid fold,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67800,Remove eyelid lesion,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67801,Remove eyelid lesions,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67805,Remove eyelid lesions,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67808,Remove eyelid lesion(s),APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67810,Biopsy eyelid & lid margin,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67820,Revise eyelashes,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67825,Revise eyelashes,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67830,Revise eyelashes,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67835,Revise eyelashes,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67840,Remove eyelid lesion,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67850,Treat eyelid lesion,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67875,Closure of eyelid by suture,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67880,Revision of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67882,Revision of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67900,Repair brow defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67901,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67902,Repair eyelid defect,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67903,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67904,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67906,Repair eyelid defect,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67908,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67909,Revise eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67911,Revise eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67912,Correction eyelid w/implant,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67914,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67915,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67916,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67917,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67921,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67922,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67923,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67924,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67930,Repair eyelid wound,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67935,Repair eyelid wound,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67938,Remove eyelid foreign body,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67950,Revision of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67961,Revision of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67966,Revision of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67971,Reconstruction of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67973,Reconstruction of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67974,Reconstruction of eyelid,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67975,Reconstruction of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,67999,Revision of eyelid,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,68020,Incise/drain eyelid lining,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,68040,Treatment of eyelid lesions,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,68100,Biopsy of eyelid lining,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,68110,Remove eyelid lining lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,68115,Remove eyelid lining lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,68130,Remove eyelid lining lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,68135,Remove eyelid lining lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,68200,Treat eyelid by injection,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,68320,Revise/graft eyelid lining,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,68325,Revise/graft eyelid lining,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,68326,Revise/graft eyelid lining,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,68328,Revise/graft eyelid lining,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,68330,Revise eyelid lining,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,68335,Revise/graft eyelid lining,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,68340,Separate eyelid adhesions,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,68360,Revise eyelid lining,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,68362,Revise eyelid lining,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,68371,Harvest eye tissue alograft,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,68399,Eyelid lining surgery,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,68400,Incise/drain tear gland,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,68420,Incise/drain tear sac,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,68440,Incise tear duct opening,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,68500,Removal of tear gland,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,68505,Partial removal tear gland,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,68510,Biopsy of tear gland,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,68520,Removal of tear sac,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,68525,Biopsy of tear sac,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,68530,Clearance of tear duct,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,68540,Remove tear gland lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,68550,Remove tear gland lesion,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,68700,Repair tear ducts,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,68705,Revise tear duct opening,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,68720,Create tear sac drain,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,68745,Create tear duct drain,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,68750,Create tear duct drain,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,68760,Close tear duct opening,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,68761,Close tear duct opening,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,68770,Close tear system fistula,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,68801,Dilate tear duct opening,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,68810,Probe nasolacrimal duct,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,68811,Probe nasolacrimal duct,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,68815,Probe nasolacrimal duct,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,68816,Probe nl duct w/balloon,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,68840,Explore/irrigate tear ducts,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,68899,Tear duct system surgery,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,69000,Drain external ear lesion,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,69005,Drain external ear lesion,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,69020,Drain outer ear canal lesion,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,69100,Biopsy of external ear,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,69105,Biopsy of external ear canal,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,69110,Remove external ear partial,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,69120,Removal of external ear,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,69140,Remove ear canal lesion(s),APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,69145,Remove ear canal lesion(s),APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,69150,Extensive ear canal surgery,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,69155,Extensive ear/neck surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,69200,Clear outer ear canal,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,69205,Clear outer ear canal,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,69209,Remove impacted ear wax uni,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,69210,Remove impacted ear wax uni,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,69220,Clean out mastoid cavity,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,69222,Clean out mastoid cavity,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,69300,Revise external ear,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,69310,Rebuild outer ear canal,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,69320,Rebuild outer ear canal,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,69399,Outer ear surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,69420,Incision of eardrum,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,69421,Incision of eardrum,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,69424,Remove ventilating tube,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,69433,Create eardrum opening,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,69436,Create eardrum opening,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,69440,Exploration of middle ear,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,69450,Eardrum revision,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,69501,Mastoidectomy,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,69502,Mastoidectomy,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,69505,Remove mastoid structures,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,69511,Extensive mastoid surgery,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,69530,Extensive mastoid surgery,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,69535,Remove part of temporal bone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,69540,Remove ear lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,69550,Remove ear lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,69552,Remove ear lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,69554,Remove ear lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,69601,Mastoid surgery revision,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,69602,Mastoid surgery revision,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,69603,Mastoid surgery revision,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,69604,Mastoid surgery revision,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,69610,Repair of eardrum,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,69620,Repair of eardrum,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,69631,Repair eardrum structures,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,69632,Rebuild eardrum structures,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,69633,Rebuild eardrum structures,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,69635,Repair eardrum structures,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,69636,Rebuild eardrum structures,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,69637,Rebuild eardrum structures,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,69641,Revise middle ear & mastoid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,69642,Revise middle ear & mastoid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,69643,Revise middle ear & mastoid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,69644,Revise middle ear & mastoid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,69645,Revise middle ear & mastoid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,69646,Revise middle ear & mastoid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,69650,Release middle ear bone,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,69660,Revise middle ear bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,69661,Revise middle ear bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,69662,Revise middle ear bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,69666,Repair middle ear structures,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,69667,Repair middle ear structures,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,69670,Remove mastoid air cells,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,69676,Remove middle ear nerve,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,69700,Close mastoid fistula,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,69705,Nps surg dilat eust tube uni,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,69706,Nps surg dilat eust tube bi,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,69711,Remove/repair hearing aid,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,69714,Implant temple bone w/stimul,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,69715,Temple bne implnt w/stimulat,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Health Alliance MCR ADV,CPT,69717,Temple bone implant revision,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,69718,Revise temple bone implant,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,69720,Release facial nerve,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,69725,Release facial nerve,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,69740,Repair facial nerve,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,69745,Repair facial nerve,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,69799,Middle ear surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,69801,Incise inner ear,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,69805,Explore inner ear,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,69806,Explore inner ear,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,69905,Remove inner ear,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,69910,Remove inner ear & mastoid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,69915,Incise inner ear nerve,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Health Alliance MCR ADV,CPT,69930,Implant cochlear device,APC 5166,RVU Per Case,"$35,230.37 ",OP,"4,140.35","35,230.37",,,,,,
Health Alliance MCR ADV,CPT,69949,Inner ear surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,69950,Incise inner ear nerve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,69955,Release facial nerve,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,69960,Release inner ear canal,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,69970,Remove inner ear lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Health Alliance MCR ADV,CPT,69979,Temporal bone surgery,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Health Alliance MCR ADV,CPT,70010,Contrast x-ray of brain,APC 5572,RVU Per Case,$376.70 ,OP,376.7,899.79,,,,,,
Health Alliance MCR ADV,CPT,70015,Contrast x-ray of brain,APC 5573,RVU Per Case,$731.85 ,OP,731.85,735.85,,,,,,
Health Alliance MCR ADV,CPT,70030,X-ray eye for foreign body,APC 5521,RVU Per Case,$82.79 ,OP,82.79,144.88,,,,,,
Health Alliance MCR ADV,CPT,70100,X-ray exam of jaw <4views,APC 5521,RVU Per Case,$82.79 ,OP,82.79,156.32,,,,,,
Health Alliance MCR ADV,CPT,70110,X-ray exam of jaw 4/> views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,202.07,,,,,,
Health Alliance MCR ADV,CPT,70120,X-ray exam of mastoids,APC 5522,RVU Per Case,$111.51 ,OP,111.51,171.58,,,,,,
Health Alliance MCR ADV,CPT,70130,X-ray exam of mastoids,APC 5522,RVU Per Case,$111.51 ,OP,111.51,282.14,,,,,,
Health Alliance MCR ADV,CPT,70134,X-ray exam of middle ear,APC 5524,RVU Per Case,$494.15 ,OP,244.01,494.15,,,,,,
Health Alliance MCR ADV,CPT,70140,X-ray exam of facial bones,APC 5521,RVU Per Case,$82.79 ,OP,82.79,156.32,,,,,,
Health Alliance MCR ADV,CPT,70150,X-ray exam of facial bones,APC 5522,RVU Per Case,$111.51 ,OP,111.51,221.14,,,,,,
Health Alliance MCR ADV,CPT,70160,X-ray exam of nasal bones,APC 5521,RVU Per Case,$82.79 ,OP,82.79,163.95,,,,,,
Health Alliance MCR ADV,CPT,70170,X-ray exam of tear duct,APC 5523,RVU Per Case,$235.49 ,OP,235.49,274.51,,,,,,
Health Alliance MCR ADV,CPT,70190,X-ray exam of eye sockets,APC 5521,RVU Per Case,$82.79 ,OP,82.79,183.02,,,,,,
Health Alliance MCR ADV,CPT,70200,X-ray exam of eye sockets,APC 5522,RVU Per Case,$111.51 ,OP,111.51,228.77,,,,,,
Health Alliance MCR ADV,CPT,70210,X-ray exam of sinuses,APC 5521,RVU Per Case,$82.79 ,OP,82.79,156.32,,,,,,
Health Alliance MCR ADV,CPT,70220,X-ray exam of sinuses,APC 5521,RVU Per Case,$82.79 ,OP,82.79,202.07,,,,,,
Health Alliance MCR ADV,CPT,70240,X-ray exam pituitary saddle,APC 5521,RVU Per Case,$82.79 ,OP,82.79,148.69,,,,,,
Health Alliance MCR ADV,CPT,70250,X-ray exam of skull,APC 5522,RVU Per Case,$111.51 ,OP,111.51,186.82,,,,,,
Health Alliance MCR ADV,CPT,70260,X-ray exam of skull,APC 5522,RVU Per Case,$111.51 ,OP,111.51,251.64,,,,,,
Health Alliance MCR ADV,CPT,70300,X-ray exam of teeth,APC 5521,RVU Per Case,$82.79 ,OP,76.26,82.79,,,,,,
Health Alliance MCR ADV,CPT,70310,X-ray exam of teeth,APC 5523,RVU Per Case,$235.49 ,OP,235.49,235.49,,,,,,
Health Alliance MCR ADV,CPT,70320,Full mouth x-ray of teeth,APC 5523,RVU Per Case,$235.49 ,OP,235.49,247.83,,,,,,
Health Alliance MCR ADV,CPT,70328,X-ray exam of jaw joint,APC 5521,RVU Per Case,$82.79 ,OP,82.79,152.51,,,,,,
Health Alliance MCR ADV,CPT,70330,X-ray exam of jaw joints,APC 5521,RVU Per Case,$82.79 ,OP,82.79,244.01,,,,,,
Health Alliance MCR ADV,CPT,70332,X-ray exam of jaw joint,APC 5523,RVU Per Case,$235.49 ,OP,235.49,446.08,,,,,,
Health Alliance MCR ADV,CPT,70336,Magnetic image jaw joint,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,70350,X-ray head for orthodontia,APC 5521,RVU Per Case,$82.79 ,OP,82.79,106.76,,,,,,
Health Alliance MCR ADV,CPT,70355,Panoramic x-ray of jaws,APC 5521,RVU Per Case,$82.79 ,OP,82.79,122,,,,,,
Health Alliance MCR ADV,CPT,70360,X-ray exam of neck,APC 5521,RVU Per Case,$82.79 ,OP,82.79,137.25,,,,,,
Health Alliance MCR ADV,CPT,70370,Throat x-ray & fluoroscopy,APC 5521,RVU Per Case,$82.79 ,OP,82.79,381.27,,,,,,
Health Alliance MCR ADV,CPT,70371,Speech evaluation complex,APC 5523,RVU Per Case,$235.49 ,OP,235.49,510.9,,,,,,
Health Alliance MCR ADV,CPT,70380,X-ray exam of salivary gland,APC 5521,RVU Per Case,$82.79 ,OP,82.79,190.64,,,,,,
Health Alliance MCR ADV,CPT,70390,X-ray exam of salivary duct,APC 5523,RVU Per Case,$235.49 ,OP,235.49,235.49,,,,,,
Health Alliance MCR ADV,CPT,70450,Ct head/brain w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Health Alliance MCR ADV,CPT,70460,Ct head/brain w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Health Alliance MCR ADV,CPT,70470,Ct head/brain w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Health Alliance MCR ADV,CPT,70480,Ct orbit/ear/fossa w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Health Alliance MCR ADV,CPT,70481,Ct orbit/ear/fossa w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Health Alliance MCR ADV,CPT,70482,Ct orbit/ear/fossa w/o&w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Health Alliance MCR ADV,CPT,70486,Ct maxillofacial w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Health Alliance MCR ADV,CPT,70487,Ct maxillofacial w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Health Alliance MCR ADV,CPT,70488,Ct maxillofacial w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Health Alliance MCR ADV,CPT,70490,Ct soft tissue neck w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Health Alliance MCR ADV,CPT,70491,Ct soft tissue neck w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Health Alliance MCR ADV,CPT,70492,Ct sft tsue nck w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Health Alliance MCR ADV,CPT,70496,Ct angiography head,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Health Alliance MCR ADV,CPT,70498,Ct angiography neck,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Health Alliance MCR ADV,CPT,70540,Mri orbit/face/neck w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,70542,Mri orbit/face/neck w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Health Alliance MCR ADV,CPT,70543,Mri orbt/fac/nck w/o &w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Health Alliance MCR ADV,CPT,70544,Mr angiography head w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,70545,Mr angiography head w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Health Alliance MCR ADV,CPT,70546,Mr angiograph head w/o&w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Health Alliance MCR ADV,CPT,70547,Mr angiography neck w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,70548,Mr angiography neck w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Health Alliance MCR ADV,CPT,70549,Mr angiograph neck w/o&w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Health Alliance MCR ADV,CPT,70551,Mri brain stem w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,70552,Mri brain stem w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Health Alliance MCR ADV,CPT,70553,Mri brain stem w/o & w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Health Alliance MCR ADV,CPT,70554,Fmri brain by tech,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,70555,Fmri brain by phys/psych,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,70557,Mri brain w/o dye,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,149.44",,,,,,
Health Alliance MCR ADV,CPT,70558,Mri brain w/dye,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,"1,609.22",,,,,,
Health Alliance MCR ADV,CPT,70559,Mri brain w/o & w/dye,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,"1,609.22",,,,,,
Health Alliance MCR ADV,CPT,71045,X-ray exam chest 1 view,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,152.51,,,,,,
Health Alliance MCR ADV,CPT,71046,X-ray exam chest 2 views,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,167.76,,,,,,
Health Alliance MCR ADV,CPT,71047,X-ray exam chest 3 views,APC 5521,RVU Per Case,$82.79 ,OP,82.79,240.2,,,,,,
Health Alliance MCR ADV,CPT,71048,X-ray exam chest 4+ views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,240.2,,,,,,
Health Alliance MCR ADV,CPT,71100,X-ray exam ribs uni 2 views,APC 5521,RVU Per Case,$82.79 ,OP,82.79,171.58,,,,,,
Health Alliance MCR ADV,CPT,71101,X-ray exam unilat ribs/chest,APC 5522,RVU Per Case,$111.51 ,OP,111.51,202.07,,,,,,
Health Alliance MCR ADV,CPT,71110,X-ray exam ribs bil 3 views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,213.51,,,,,,
Health Alliance MCR ADV,CPT,71111,X-ray exam ribs/chest4/> vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,270.71,,,,,,
Health Alliance MCR ADV,CPT,71120,X-ray exam breastbone 2/>vws,APC 5521,RVU Per Case,$82.79 ,OP,82.79,171.58,,,,,,
Health Alliance MCR ADV,CPT,71130,X-ray strenoclavic jt 3/>vws,APC 5521,RVU Per Case,$82.79 ,OP,82.79,194.45,,,,,,
Health Alliance MCR ADV,CPT,71250,Ct thorax dx c-,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Health Alliance MCR ADV,CPT,71260,Ct thorax dx c+,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Health Alliance MCR ADV,CPT,71270,Ct thorax dx c-/c+,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Health Alliance MCR ADV,CPT,71271,Ct thorax lung cancer scr c-,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,927,,,,,,
Health Alliance MCR ADV,CPT,71275,Ct angiography chest,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Health Alliance MCR ADV,CPT,71550,Mri chest w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,71551,Mri chest w/dye,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"1,609.22",,,,,,
Health Alliance MCR ADV,CPT,71552,Mri chest w/o & w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Health Alliance MCR ADV,CPT,72020,X-ray exam of spine 1 view,APC 5521,RVU Per Case,$82.79 ,OP,82.79,122,,,,,,
Health Alliance MCR ADV,CPT,72040,X-ray exam neck spine 2-3 vw,APC 5521,RVU Per Case,$82.79 ,OP,82.79,190.64,,,,,,
Health Alliance MCR ADV,CPT,72050,X-ray exam neck spine 4/5vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,293.57,,,,,,
Health Alliance MCR ADV,CPT,72052,X-ray exam neck spine 6/>vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,339.33,,,,,,
Health Alliance MCR ADV,CPT,72070,X-ray exam thorac spine 2vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,175.39,,,,,,
Health Alliance MCR ADV,CPT,72072,X-ray exam thorac spine 3vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,202.07,,,,,,
Health Alliance MCR ADV,CPT,72074,X-ray exam thorac spine4/>vw,APC 5522,RVU Per Case,$111.51 ,OP,111.51,236.38,,,,,,
Health Alliance MCR ADV,CPT,72080,X-ray exam thoracolmb 2/> vw,APC 5521,RVU Per Case,$82.79 ,OP,82.79,183.02,,,,,,
Health Alliance MCR ADV,CPT,72081,X-ray exam entire spi 1 vw,APC 5521,RVU Per Case,$82.79 ,OP,82.79,354.58,,,,,,
Health Alliance MCR ADV,CPT,72082,X-ray exam entire spi 2/3 vw,APC 5522,RVU Per Case,$111.51 ,OP,111.51,354.58,,,,,,
Health Alliance MCR ADV,CPT,72083,X-ray exam entire spi 4/5 vw,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,354.58,,,,,,
Health Alliance MCR ADV,CPT,72084,X-ray exam entire spi 6/> vw,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,354.58,,,,,,
Health Alliance MCR ADV,CPT,72100,X-ray exam l-s spine 2/3 vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,202.07,,,,,,
Health Alliance MCR ADV,CPT,72110,X-ray exam l-2 spine 4/>vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,301.2,,,,,,
Health Alliance MCR ADV,CPT,72114,X-ray exam l-s spine bending,APC 5522,RVU Per Case,$111.51 ,OP,111.51,362.21,,,,,,
Health Alliance MCR ADV,CPT,72120,X-ray bend only l-s spine,APC 5522,RVU Per Case,$111.51 ,OP,111.51,251.64,,,,,,
Health Alliance MCR ADV,CPT,72125,Ct neck spine w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Health Alliance MCR ADV,CPT,72126,Ct neck spine w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,965.53,,,,,,
Health Alliance MCR ADV,CPT,72127,Ct neck spine w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Health Alliance MCR ADV,CPT,72128,Ct chest spine w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Health Alliance MCR ADV,CPT,72129,Ct chest spine w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Health Alliance MCR ADV,CPT,72130,Ct chest spine w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Health Alliance MCR ADV,CPT,72131,Ct lumbar spine w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Health Alliance MCR ADV,CPT,72132,Ct lumbar spine w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,965.53,,,,,,
Health Alliance MCR ADV,CPT,72133,Ct lumbar spine w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Health Alliance MCR ADV,CPT,72141,Mri neck spine w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,72142,Mri neck spine w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Health Alliance MCR ADV,CPT,72146,Mri chest spine w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,72147,Mri chest spine w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Health Alliance MCR ADV,CPT,72148,Mri lumbar spine w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,72149,Mri lumbar spine w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Health Alliance MCR ADV,CPT,72156,Mri neck spine w/o & w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Health Alliance MCR ADV,CPT,72157,Mri chest spine w/o & w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Health Alliance MCR ADV,CPT,72158,Mri lumbar spine w/o & w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Health Alliance MCR ADV,CPT,72170,X-ray exam of pelvis,APC 5522,RVU Per Case,$111.51 ,OP,111.51,133.45,,,,,,
Health Alliance MCR ADV,CPT,72190,X-ray exam of pelvis,APC 5522,RVU Per Case,$111.51 ,OP,111.51,205.88,,,,,,
Health Alliance MCR ADV,CPT,72191,Ct angiograph pelv w/o&w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Health Alliance MCR ADV,CPT,72192,Ct pelvis w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Health Alliance MCR ADV,CPT,72193,Ct pelvis w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Health Alliance MCR ADV,CPT,72194,Ct pelvis w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Health Alliance MCR ADV,CPT,72195,Mri pelvis w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,72196,Mri pelvis w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Health Alliance MCR ADV,CPT,72197,Mri pelvis w/o & w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Health Alliance MCR ADV,CPT,72200,X-ray exam si joints,APC 5522,RVU Per Case,$111.51 ,OP,111.51,148.69,,,,,,
Health Alliance MCR ADV,CPT,72202,X-ray exam si joints 3/> vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,183.02,,,,,,
Health Alliance MCR ADV,CPT,72220,X-ray exam sacrum tailbone,APC 5521,RVU Per Case,$82.79 ,OP,82.79,156.32,,,,,,
Health Alliance MCR ADV,CPT,72240,Myelography neck spine,APC 5573,RVU Per Case,$731.85 ,OP,731.85,842.61,,,,,,
Health Alliance MCR ADV,CPT,72255,Myelography thoracic spine,APC 5573,RVU Per Case,$731.85 ,OP,731.85,766.35,,,,,,
Health Alliance MCR ADV,CPT,72265,Myelography l-s spine,APC 5573,RVU Per Case,$731.85 ,OP,731.85,781.61,,,,,,
Health Alliance MCR ADV,CPT,72270,Myelogphy 2/> spine regions,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"1,216.24",,,,,,
Health Alliance MCR ADV,CPT,72285,Discography cerv/thor spine,APC 5431,RVU Per Case,"$1,795.30 ",OP,976.05,"1,795.30",,,,,,
Health Alliance MCR ADV,CPT,72295,X-ray of lower spine disk,APC 5431,RVU Per Case,"$1,795.30 ",OP,873.11,"1,795.30",,,,,,
Health Alliance MCR ADV,CPT,73000,X-ray exam of collar bone,APC 5521,RVU Per Case,$82.79 ,OP,82.79,141.07,,,,,,
Health Alliance MCR ADV,CPT,73010,X-ray exam of shoulder blade,APC 5522,RVU Per Case,$111.51 ,OP,111.51,144.88,,,,,,
Health Alliance MCR ADV,CPT,73020,X-ray exam of shoulder,APC 5521,RVU Per Case,$82.79 ,OP,82.79,122,,,,,,
Health Alliance MCR ADV,CPT,73030,X-ray exam of shoulder,APC 5521,RVU Per Case,$82.79 ,OP,82.79,163.95,,,,,,
Health Alliance MCR ADV,CPT,73040,Contrast x-ray of shoulder,APC 5572,RVU Per Case,$376.70 ,OP,376.7,552.84,,,,,,
Health Alliance MCR ADV,CPT,73050,X-ray exam of shoulders,APC 5521,RVU Per Case,$82.79 ,OP,82.79,186.82,,,,,,
Health Alliance MCR ADV,CPT,73060,X-ray exam of humerus,APC 5521,RVU Per Case,$82.79 ,OP,82.79,152.51,,,,,,
Health Alliance MCR ADV,CPT,73070,X-ray exam of elbow,APC 5521,RVU Per Case,$82.79 ,OP,82.79,137.25,,,,,,
Health Alliance MCR ADV,CPT,73080,X-ray exam of elbow,APC 5521,RVU Per Case,$82.79 ,OP,82.79,179.2,,,,,,
Health Alliance MCR ADV,CPT,73085,Contrast x-ray of elbow,APC 5572,RVU Per Case,$376.70 ,OP,376.7,503.28,,,,,,
Health Alliance MCR ADV,CPT,73090,X-ray exam of forearm,APC 5521,RVU Per Case,$82.79 ,OP,82.79,137.25,,,,,,
Health Alliance MCR ADV,CPT,73092,X-ray exam of arm infant,APC 5522,RVU Per Case,$111.51 ,OP,111.51,141.07,,,,,,
Health Alliance MCR ADV,CPT,73100,X-ray exam of wrist,APC 5521,RVU Per Case,$82.79 ,OP,82.79,144.88,,,,,,
Health Alliance MCR ADV,CPT,73110,X-ray exam of wrist,APC 5521,RVU Per Case,$82.79 ,OP,82.79,171.58,,,,,,
Health Alliance MCR ADV,CPT,73115,Contrast x-ray of wrist,APC 5572,RVU Per Case,$376.70 ,OP,376.7,526.16,,,,,,
Health Alliance MCR ADV,CPT,73120,X-ray exam of hand,APC 5522,RVU Per Case,$111.51 ,OP,111.51,137.25,,,,,,
Health Alliance MCR ADV,CPT,73130,X-ray exam of hand,APC 5521,RVU Per Case,$82.79 ,OP,82.79,156.32,,,,,,
Health Alliance MCR ADV,CPT,73140,X-ray exam of finger(s),APC 5521,RVU Per Case,$82.79 ,OP,82.79,160.13,,,,,,
Health Alliance MCR ADV,CPT,73200,Ct upper extremity w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Health Alliance MCR ADV,CPT,73201,Ct upper extremity w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,965.53,,,,,,
Health Alliance MCR ADV,CPT,73202,Ct uppr extremity w/o&w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Health Alliance MCR ADV,CPT,73206,Ct angio upr extrm w/o&w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Health Alliance MCR ADV,CPT,73218,Mri upper extremity w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,73219,Mri upper extremity w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Health Alliance MCR ADV,CPT,73220,Mri uppr extremity w/o&w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Health Alliance MCR ADV,CPT,73221,Mri joint upr extrem w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,73222,Mri joint upr extrem w/dye,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"1,609.22",,,,,,
Health Alliance MCR ADV,CPT,73223,Mri joint upr extr w/o&w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Health Alliance MCR ADV,CPT,73501,X-ray exam hip uni 1 view,APC 5521,RVU Per Case,$82.79 ,OP,82.79,129.64,,,,,,
Health Alliance MCR ADV,CPT,73502,X-ray exam hip uni 2-3 views,APC 5521,RVU Per Case,$82.79 ,OP,82.79,198.25,,,,,,
Health Alliance MCR ADV,CPT,73503,X-ray exam hip uni 4/> views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,198.25,,,,,,
Health Alliance MCR ADV,CPT,73521,X-ray exam hips bi 2 views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,202.07,,,,,,
Health Alliance MCR ADV,CPT,73522,X-ray exam hips bi 3-4 views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,202.07,,,,,,
Health Alliance MCR ADV,CPT,73523,X-ray exam hips bi 5/> views,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,202.07,,,,,,
Health Alliance MCR ADV,CPT,73525,Contrast x-ray of hip,APC 5572,RVU Per Case,$376.70 ,OP,376.7,503.28,,,,,,
Health Alliance MCR ADV,CPT,73551,X-ray exam of femur 1,APC 5521,RVU Per Case,$82.79 ,OP,82.79,148.69,,,,,,
Health Alliance MCR ADV,CPT,73552,X-ray exam of femur 2/>,APC 5521,RVU Per Case,$82.79 ,OP,82.79,148.69,,,,,,
Health Alliance MCR ADV,CPT,73560,X-ray exam of knee 1 or 2,APC 5521,RVU Per Case,$82.79 ,OP,82.79,144.88,,,,,,
Health Alliance MCR ADV,CPT,73562,X-ray exam of knee 3,APC 5521,RVU Per Case,$82.79 ,OP,82.79,186.82,,,,,,
Health Alliance MCR ADV,CPT,73564,X-ray exam knee 4 or more,APC 5522,RVU Per Case,$111.51 ,OP,111.51,205.88,,,,,,
Health Alliance MCR ADV,CPT,73565,X-ray exam of knees,APC 5521,RVU Per Case,$82.79 ,OP,82.79,152.51,,,,,,
Health Alliance MCR ADV,CPT,73580,Contrast x-ray of knee joint,APC 5572,RVU Per Case,$376.70 ,OP,376.7,625.29,,,,,,
Health Alliance MCR ADV,CPT,73590,X-ray exam of lower leg,APC 5521,RVU Per Case,$82.79 ,OP,82.79,137.25,,,,,,
Health Alliance MCR ADV,CPT,73592,X-ray exam of leg infant,APC 5521,RVU Per Case,$82.79 ,OP,82.79,141.07,,,,,,
Health Alliance MCR ADV,CPT,73600,X-ray exam of ankle,APC 5521,RVU Per Case,$82.79 ,OP,82.79,137.25,,,,,,
Health Alliance MCR ADV,CPT,73610,X-ray exam of ankle,APC 5521,RVU Per Case,$82.79 ,OP,82.79,156.32,,,,,,
Health Alliance MCR ADV,CPT,73615,Contrast x-ray of ankle,APC 5572,RVU Per Case,$376.70 ,OP,376.7,376.7,,,,,,
Health Alliance MCR ADV,CPT,73620,X-ray exam of foot,APC 5521,RVU Per Case,$82.79 ,OP,82.79,133.45,,,,,,
Health Alliance MCR ADV,CPT,73630,X-ray exam of foot,APC 5521,RVU Per Case,$82.79 ,OP,82.79,156.32,,,,,,
Health Alliance MCR ADV,CPT,73650,X-ray exam of heel,APC 5521,RVU Per Case,$82.79 ,OP,82.79,137.25,,,,,,
Health Alliance MCR ADV,CPT,73660,X-ray exam of toe(s),APC 5521,RVU Per Case,$82.79 ,OP,82.79,141.07,,,,,,
Health Alliance MCR ADV,CPT,73700,Ct lower extremity w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Health Alliance MCR ADV,CPT,73701,Ct lower extremity w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Health Alliance MCR ADV,CPT,73702,Ct lwr extremity w/o&w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Health Alliance MCR ADV,CPT,73706,Ct angio lwr extr w/o&w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Health Alliance MCR ADV,CPT,73718,Mri lower extremity w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,73719,Mri lower extremity w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Health Alliance MCR ADV,CPT,73720,Mri lwr extremity w/o&w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Health Alliance MCR ADV,CPT,73721,Mri jnt of lwr extre w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,73722,Mri joint of lwr extr w/dye,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"1,609.22",,,,,,
Health Alliance MCR ADV,CPT,73723,Mri joint lwr extr w/o&w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Health Alliance MCR ADV,CPT,74018,X-ray exam abdomen 1 view,APC 5521,RVU Per Case,$82.79 ,OP,82.79,137.25,,,,,,
Health Alliance MCR ADV,CPT,74019,X-ray exam abdomen 2 views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,194.45,,,,,,
Health Alliance MCR ADV,CPT,74021,X-ray exam abdomen 3+ views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,205.88,,,,,,
Health Alliance MCR ADV,CPT,74022,X-ray exam complete abdomen,APC 5522,RVU Per Case,$111.51 ,OP,111.51,251.64,,,,,,
Health Alliance MCR ADV,CPT,74150,Ct abdomen w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Health Alliance MCR ADV,CPT,74160,Ct abdomen w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Health Alliance MCR ADV,CPT,74170,Ct abdomen w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Health Alliance MCR ADV,CPT,74174,Ct angio abd&pelv w/o&w/dye,APC 5572,RVU Per Unit,$376.70 ,OP,376.7,965.53,,,,,,
Health Alliance MCR ADV,CPT,74175,Ct angio abdom w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Health Alliance MCR ADV,CPT,74176,Ct abd & pelvis w/o contrast,APC 5523,RVU Per Case,$235.49 ,OP,235.49,927,,,,,,
Health Alliance MCR ADV,CPT,74177,Ct abd & pelv w/contrast,APC 5572,RVU Per Case,$376.70 ,OP,376.7,965.53,,,,,,
Health Alliance MCR ADV,CPT,74178,Ct abd & pelv 1/> regns,APC 5572,RVU Per Case,$376.70 ,OP,376.7,927,,,,,,
Health Alliance MCR ADV,CPT,74181,Mri abdomen w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,74182,Mri abdomen w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Health Alliance MCR ADV,CPT,74183,Mri abdomen w/o & w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Health Alliance MCR ADV,CPT,74190,X-ray exam of peritoneum,APC 5524,RVU Per Case,$494.15 ,OP,400.34,494.15,,,,,,
Health Alliance MCR ADV,CPT,74210,X-ray xm phrnx&/crv esoph c+,APC 5571,RVU Per Case,$182.72 ,OP,182.72,182.72,,,,,,
Health Alliance MCR ADV,CPT,74220,X-ray xm esophagus 1cntrst,APC 5571,RVU Per Case,$182.72 ,OP,182.72,446.08,,,,,,
Health Alliance MCR ADV,CPT,74221,X-ray xm esophagus 2cntrst,APC 5571,RVU Per Case,$182.72 ,OP,182.72,446.08,,,,,,
Health Alliance MCR ADV,CPT,74230,X-ray xm swlng funcj c+,APC 5571,RVU Per Case,$182.72 ,OP,182.72,457.52,,,,,,
Health Alliance MCR ADV,CPT,74240,X-ray xm upr gi trc 1cntrst,APC 5571,RVU Per Case,$182.72 ,OP,182.72,552.84,,,,,,
Health Alliance MCR ADV,CPT,74246,X-ray xm upr gi trc 2cntrst,APC 5571,RVU Per Case,$182.72 ,OP,182.72,632.91,,,,,,
Health Alliance MCR ADV,CPT,74250,X-ray xm sm int 1cntrst std,APC 5571,RVU Per Case,$182.72 ,OP,182.72,518.52,,,,,,
Health Alliance MCR ADV,CPT,74251,X-ray xm sm int 2cntrst std,APC 5571,RVU Per Case,$182.72 ,OP,182.72,"1,593.72",,,,,,
Health Alliance MCR ADV,CPT,74261,Ct colonography dx,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Health Alliance MCR ADV,CPT,74262,Ct colonography dx w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,182.72,,,,,,
Health Alliance MCR ADV,CPT,74270,X-ray xm colon 1cntrst std,APC 5571,RVU Per Case,$182.72 ,OP,182.72,747.28,,,,,,
Health Alliance MCR ADV,CPT,74280,X-ray xm colon 2cntrst std,APC 5571,RVU Per Case,$182.72 ,OP,182.72,"1,029.43",,,,,,
Health Alliance MCR ADV,CPT,74283,Ther nma rdctj intus/obstrcj,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,182.72,,,,,,
Health Alliance MCR ADV,CPT,74290,Contrast x-ray gallbladder,APC 5571,RVU Per Case,$182.72 ,OP,182.72,331.7,,,,,,
Health Alliance MCR ADV,CPT,74400,Urography iv +-kub tomog,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,568.09,,,,,,
Health Alliance MCR ADV,CPT,74410,Urography nfs drip&/bolus,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,598.59,,,,,,
Health Alliance MCR ADV,CPT,74415,Urography nfs drip&/bls w/nf,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,682.47,,,,,,
Health Alliance MCR ADV,CPT,74420,Urography rtrgr +-kub,APC 5572,RVU Per Unit,$376.70 ,OP,376.7,659.6,,,,,,
Health Alliance MCR ADV,CPT,74425,Urography antegrade rs&i,APC 5572,RVU Per Case,$376.70 ,OP,366.02,376.7,,,,,,
Health Alliance MCR ADV,CPT,74430,Contrast x-ray bladder,APC 5572,RVU Per Case,$376.70 ,OP,376.7,404.14,,,,,,
Health Alliance MCR ADV,CPT,74440,X-ray male genital tract,APC 5523,RVU Per Case,$235.49 ,OP,235.49,434.65,,,,,,
Health Alliance MCR ADV,CPT,74445,X-ray exam of penis,APC 5522,RVU Per Case,$111.51 ,OP,111.51,545.21,,,,,,
Health Alliance MCR ADV,CPT,74450,X-ray urethra/bladder,APC 5523,RVU Per Case,$235.49 ,OP,235.49,396.52,,,,,,
Health Alliance MCR ADV,CPT,74455,X-ray urethra/bladder,APC 5523,RVU Per Case,$235.49 ,OP,235.49,472.78,,,,,,
Health Alliance MCR ADV,CPT,74470,X-ray exam of kidney lesion,APC 5524,RVU Per Case,$494.15 ,OP,400.34,494.15,,,,,,
Health Alliance MCR ADV,CPT,74485,Dilation urtr/urt rs&i,APC 5373,RVU Per Case,"$1,834.80 ",OP,629.1,"1,834.80",,,,,,
Health Alliance MCR ADV,CPT,74710,X-ray measurement of pelvis,APC 5521,RVU Per Case,$82.79 ,OP,82.79,232.58,,,,,,
Health Alliance MCR ADV,CPT,74712,Mri fetal sngl/1st gestation,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,74740,X-ray female genital tract,APC 5523,RVU Per Case,$235.49 ,OP,235.49,404.14,,,,,,
Health Alliance MCR ADV,CPT,74775,X-ray exam of perineum,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,457.52,,,,,,
Health Alliance MCR ADV,CPT,75557,Cardiac mri for morph,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,75559,Cardiac mri w/stress img,APC 5524,RVU Per Case,$494.15 ,OP,494.15,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,75561,Cardiac mri for morph w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Health Alliance MCR ADV,CPT,75563,Card mri w/stress img & dye,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"1,609.22",,,,,,
Health Alliance MCR ADV,CPT,75571,Ct hrt w/o dye w/ca test,APC 5521,RVU Per Case,$82.79 ,OP,82.79,927,,,,,,
Health Alliance MCR ADV,CPT,75572,Ct hrt w/3d image,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,927,,,,,,
Health Alliance MCR ADV,CPT,75573,Ct hrt w/3d image congen,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,927,,,,,,
Health Alliance MCR ADV,CPT,75574,Ct angio hrt w/3d image,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,927,,,,,,
Health Alliance MCR ADV,CPT,75600,Contrast exam thoracic aorta,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,742.41","2,928.39",,,,,,
Health Alliance MCR ADV,CPT,75605,Contrast exam thoracic aorta,APC 5184,RVU Per Case,"$4,881.61 ",OP,"1,506.03","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,75625,Contrast exam abdominl aorta,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,486.95","2,928.39",,,,,,
Health Alliance MCR ADV,CPT,75630,X-ray aorta leg arteries,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","2,928.39",,,,,,
Health Alliance MCR ADV,CPT,75635,Ct angio abdominal arteries,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Health Alliance MCR ADV,CPT,75705,Artery x-rays spine,APC 5184,RVU Per Case,"$4,881.61 ",OP,"1,826.28","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,75710,Artery x-rays arm/leg,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,567.02","2,928.39",,,,,,
Health Alliance MCR ADV,CPT,75716,Artery x-rays arms/legs,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,730.97","2,928.39",,,,,,
Health Alliance MCR ADV,CPT,75726,Artery x-rays abdomen,APC 5184,RVU Per Case,"$4,881.61 ",OP,"1,547.95","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,75731,Artery x-rays adrenal gland,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,601.33","2,928.39",,,,,,
Health Alliance MCR ADV,CPT,75733,Artery x-rays adrenals,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,795.78","2,928.39",,,,,,
Health Alliance MCR ADV,CPT,75736,Artery x-rays pelvis,APC 5184,RVU Per Case,"$4,881.61 ",OP,"1,563.20","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,75741,Artery x-rays lung,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,506.03","2,928.39",,,,,,
Health Alliance MCR ADV,CPT,75743,Artery x-rays lungs,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,635.64","2,928.39",,,,,,
Health Alliance MCR ADV,CPT,75746,Artery x-rays lung,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,517.46","2,928.39",,,,,,
Health Alliance MCR ADV,CPT,75756,Artery x-rays chest,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,601.33","2,928.39",,,,,,
Health Alliance MCR ADV,CPT,75801,Lymph vessel x-ray arm/leg,APC 5181,RVU Per Case,$554.25 ,OP,554.25,"1,281.07",,,,,,
Health Alliance MCR ADV,CPT,75803,Lymph vessel x-ray arms/legs,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,437.39","1,438.93",,,,,,
Health Alliance MCR ADV,CPT,75805,Lymph vessel x-ray trunk,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,483.14","2,928.39",,,,,,
Health Alliance MCR ADV,CPT,75807,Lymph vessel x-ray trunk,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,582.28","2,928.39",,,,,,
Health Alliance MCR ADV,CPT,75809,Nonvascular shunt x-ray,APC 5522,RVU Per Case,$111.51 ,OP,111.51,446.08,,,,,,
Health Alliance MCR ADV,CPT,75810,Vein x-ray spleen/liver,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,836.65","2,928.39",,,,,,
Health Alliance MCR ADV,CPT,75820,Vein x-ray arm/leg,APC 5182,RVU Per Case,"$1,438.93 ",OP,610.03,"1,438.93",,,,,,
Health Alliance MCR ADV,CPT,75822,Vein x-ray arms/legs,APC 5182,RVU Per Case,"$1,438.93 ",OP,747.28,"1,438.93",,,,,,
Health Alliance MCR ADV,CPT,75825,Vein x-ray trunk,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,441.20","2,928.39",,,,,,
Health Alliance MCR ADV,CPT,75827,Vein x-ray chest,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,433.58","1,438.93",,,,,,
Health Alliance MCR ADV,CPT,75831,Vein x-ray kidney,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,456.44","2,928.39",,,,,,
Health Alliance MCR ADV,CPT,75833,Vein x-ray kidneys,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,608.95","2,928.39",,,,,,
Health Alliance MCR ADV,CPT,75840,Vein x-ray adrenal gland,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,445.01","2,928.39",,,,,,
Health Alliance MCR ADV,CPT,75842,Vein x-ray adrenal glands,APC 5184,RVU Per Case,"$4,881.61 ",OP,"1,616.58","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,75860,Vein x-ray neck,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,479.33","2,928.39",,,,,,
Health Alliance MCR ADV,CPT,75870,Vein x-ray skull,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,467.89","2,928.39",,,,,,
Health Alliance MCR ADV,CPT,75872,Vein x-ray skull epidural,APC 5181,RVU Per Case,$554.25 ,OP,554.25,"1,608.95",,,,,,
Health Alliance MCR ADV,CPT,75880,Vein x-ray eye socket,APC 5181,RVU Per Case,$554.25 ,OP,554.25,613.85,,,,,,
Health Alliance MCR ADV,CPT,75885,Vein x-ray liver w/hemodynam,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,536.51","2,928.39",,,,,,
Health Alliance MCR ADV,CPT,75887,Vein x-ray liver w/o hemodyn,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,547.95","2,928.39",,,,,,
Health Alliance MCR ADV,CPT,75889,Vein x-ray liver w/hemodynam,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,456.44","2,928.39",,,,,,
Health Alliance MCR ADV,CPT,75891,Vein x-ray liver,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,456.44","2,928.39",,,,,,
Health Alliance MCR ADV,CPT,75893,Venous sampling by catheter,APC 5184,RVU Per Case,"$4,881.61 ",OP,"1,296.32","4,881.61",,,,,,
Health Alliance MCR ADV,CPT,75898,Follow-up angiography,APC 5183,RVU Per Case,"$2,928.39 ",OP,655.78,"2,928.39",,,,,,
Health Alliance MCR ADV,CPT,75956,Xray endovasc thor ao repr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,75957,Xray endovasc thor ao repr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,597.52","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,75958,Xray place prox ext thor ao,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,052.29","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,75959,Xray place dist ext thor ao,APC 5881,RVU Per Case,"$8,948.83 ",OP,926.48,"8,948.83",,,,,,
Health Alliance MCR ADV,CPT,76000,Fluoroscopy <1 hr phys/qhp,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,495.65,,,,,,
Health Alliance MCR ADV,CPT,76010,X-ray nose to rectum,APC 5521,RVU Per Case,$82.79 ,OP,82.79,144.88,,,,,,
Health Alliance MCR ADV,CPT,76080,X-ray exam of fistula,APC 5524,RVU Per Case,$494.15 ,OP,331.7,494.15,,,,,,
Health Alliance MCR ADV,CPT,76098,X-ray exam surgical specimen,APC 5524,RVU Per Case,$494.15 ,OP,102.95,494.15,,,,,,
Health Alliance MCR ADV,CPT,76100,X-ray exam of body section,APC 5522,RVU Per Case,$111.51 ,OP,111.51,690.1,,,,,,
Health Alliance MCR ADV,CPT,76101,Complex body section x-ray,APC 5522,RVU Per Case,$111.51 ,OP,111.51,949.36,,,,,,
Health Alliance MCR ADV,CPT,76102,Complex body section x-rays,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,111.51,,,,,,
Health Alliance MCR ADV,CPT,76120,Cine/video x-rays,APC 5522,RVU Per Case,$111.51 ,OP,111.51,392.7,,,,,,
Health Alliance MCR ADV,CPT,76145,Med physic dos eval rad exps,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,129.83,,,,,,
Health Alliance MCR ADV,CPT,76380,Cat scan follow-up study,APC 5521,RVU Per Case,$82.79 ,OP,82.79,689.66,,,,,,
Health Alliance MCR ADV,CPT,76390,Mr spectroscopy,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,76391,Mr elastography,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,76496,Fluoroscopic procedure,APC 5521,RVU Per Case,$82.79 ,OP,82.79,82.79,,,,,,
Health Alliance MCR ADV,CPT,76497,Ct procedure,APC 5521,RVU Per Case,$82.79 ,OP,82.79,927,,,,,,
Health Alliance MCR ADV,CPT,76498,Mri procedure,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,76499,Radiographic procedure,APC 5521,RVU Per Case,$82.79 ,OP,82.79,82.79,,,,,,
Health Alliance MCR ADV,CPT,76506,Echo exam of head,APC 5522,RVU Per Case,$111.51 ,OP,111.51,602.41,,,,,,
Health Alliance MCR ADV,CPT,76510,Oph us dx b-scan&quan a-scan,APC 5734,RVU Per Case,$114.56 ,OP,114.56,751.1,,,,,,
Health Alliance MCR ADV,CPT,76511,Oph us dx quan a-scan only,APC 5522,RVU Per Case,$111.51 ,OP,111.51,495.65,,,,,,
Health Alliance MCR ADV,CPT,76512,Oph us dx b-scan,APC 5522,RVU Per Case,$111.51 ,OP,111.51,468.96,,,,,,
Health Alliance MCR ADV,CPT,76513,Oph us dx ant sgm us uni/bi,APC 5522,RVU Per Case,$111.51 ,OP,111.51,438.47,,,,,,
Health Alliance MCR ADV,CPT,76514,Echo exam of eye thickness,APC 5731,RVU Per Case,$25.25 ,OP,25.25,64.82,,,,,,
Health Alliance MCR ADV,CPT,76516,Echo exam of eye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,346.96,,,,,,
Health Alliance MCR ADV,CPT,76519,Echo exam of eye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,369.83,,,,,,
Health Alliance MCR ADV,CPT,76529,Echo exam of eye,APC 5521,RVU Per Case,$82.79 ,OP,82.79,354.58,,,,,,
Health Alliance MCR ADV,CPT,76536,Us exam of head and neck,APC 5522,RVU Per Case,$111.51 ,OP,111.51,594.77,,,,,,
Health Alliance MCR ADV,CPT,76604,Us exam chest,APC 5522,RVU Per Case,$111.51 ,OP,111.51,446.08,,,,,,
Health Alliance MCR ADV,CPT,76641,Ultrasound breast complete,APC 5522,RVU Per Case,$111.51 ,OP,111.51,174.71,,,,,,
Health Alliance MCR ADV,CPT,76642,Ultrasound breast limited,APC 5521,RVU Per Case,$82.79 ,OP,82.79,174.71,,,,,,
Health Alliance MCR ADV,CPT,76700,Us exam abdom complete,APC 5522,RVU Per Case,$111.51 ,OP,111.51,739.67,,,,,,
Health Alliance MCR ADV,CPT,76705,Echo exam of abdomen,APC 5522,RVU Per Case,$111.51 ,OP,111.51,537.6,,,,,,
Health Alliance MCR ADV,CPT,76706,Us abdl aorta screen aaa,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,575.73,,,,,,
Health Alliance MCR ADV,CPT,76770,Us exam abdo back wall comp,APC 5522,RVU Per Case,$111.51 ,OP,111.51,678.66,,,,,,
Health Alliance MCR ADV,CPT,76775,Us exam abdo back wall lim,APC 5522,RVU Per Case,$111.51 ,OP,111.51,602.41,,,,,,
Health Alliance MCR ADV,CPT,76776,Us exam k transpl w/doppler,APC 5522,RVU Per Case,$111.51 ,OP,111.51,751.1,,,,,,
Health Alliance MCR ADV,CPT,76800,Us exam spinal canal,APC 5522,RVU Per Case,$111.51 ,OP,111.51,632.91,,,,,,
Health Alliance MCR ADV,CPT,76801,Ob us < 14 wks single fetus,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,712.98,,,,,,
Health Alliance MCR ADV,CPT,76805,Ob us >= 14 wks sngl fetus,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,789.23,,,,,,
Health Alliance MCR ADV,CPT,76811,Ob us detailed sngl fetus,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,204.81",,,,,,
Health Alliance MCR ADV,CPT,76813,Ob us nuchal meas 1 gest,APC 5522,RVU Per Case,$111.51 ,OP,111.51,667.22,,,,,,
Health Alliance MCR ADV,CPT,76815,Ob us limited fetus(s),APC 5522,RVU Per Case,$111.51 ,OP,111.51,472.78,,,,,,
Health Alliance MCR ADV,CPT,76816,Ob us follow-up per fetus,APC 5522,RVU Per Case,$111.51 ,OP,111.51,571.91,,,,,,
Health Alliance MCR ADV,CPT,76817,Transvaginal us obstetric,APC 5522,RVU Per Case,$111.51 ,OP,111.51,560.47,,,,,,
Health Alliance MCR ADV,CPT,76818,Fetal biophys profile w/nst,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,625.29,,,,,,
Health Alliance MCR ADV,CPT,76819,Fetal biophys profil w/o nst,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,526.16,,,,,,
Health Alliance MCR ADV,CPT,76820,Umbilical artery echo,APC 5522,RVU Per Case,$111.51 ,OP,111.51,297.39,,,,,,
Health Alliance MCR ADV,CPT,76821,Middle cerebral artery echo,APC 5522,RVU Per Case,$111.51 ,OP,111.51,510.9,,,,,,
Health Alliance MCR ADV,CPT,76825,Echo exam of fetal heart,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,067.55",,,,,,
Health Alliance MCR ADV,CPT,76826,Echo exam of fetal heart,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,587.16,,,,,,
Health Alliance MCR ADV,CPT,76827,Echo exam of fetal heart,APC 5522,RVU Per Case,$111.51 ,OP,111.51,381.27,,,,,,
Health Alliance MCR ADV,CPT,76828,Echo exam of fetal heart,APC 5522,RVU Per Case,$111.51 ,OP,111.51,282.14,,,,,,
Health Alliance MCR ADV,CPT,76830,Transvaginal us non-ob,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,651.97,,,,,,
Health Alliance MCR ADV,CPT,76831,Echo exam uterus,APC 5523,RVU Per Case,$235.49 ,OP,235.49,621.47,,,,,,
Health Alliance MCR ADV,CPT,76856,Us exam pelvic complete,APC 5522,RVU Per Case,$111.51 ,OP,111.51,655.78,,,,,,
Health Alliance MCR ADV,CPT,76857,Us exam pelvic limited,APC 5522,RVU Per Case,$111.51 ,OP,111.51,518.52,,,,,,
Health Alliance MCR ADV,CPT,76870,Us exam scrotum,APC 5522,RVU Per Case,$111.51 ,OP,111.51,621.47,,,,,,
Health Alliance MCR ADV,CPT,76872,Us transrectal,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,735.85,,,,,,
Health Alliance MCR ADV,CPT,76873,Echograp trans r pros study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,934.12,,,,,,
Health Alliance MCR ADV,CPT,76881,Us compl joint r-t w/img,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,644.34,,,,,,
Health Alliance MCR ADV,CPT,76882,Us lmtd jt/nonvasc xtr strux,APC 5522,RVU Per Case,$111.51 ,OP,111.51,644.34,,,,,,
Health Alliance MCR ADV,CPT,76885,Us exam infant hips dynamic,APC 5521,RVU Per Case,$82.79 ,OP,82.79,701.54,,,,,,
Health Alliance MCR ADV,CPT,76886,Us exam infant hips static,APC 5521,RVU Per Case,$82.79 ,OP,82.79,518.52,,,,,,
Health Alliance MCR ADV,CPT,76936,Echo guide for artery repair,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,654.72",,,,,,
Health Alliance MCR ADV,CPT,76975,Gi endoscopic ultrasound,APC 5523,RVU Per Case,$235.49 ,OP,235.49,529.96,,,,,,
Health Alliance MCR ADV,CPT,76977,Us bone density measure,APC 5522,RVU Per Unit,$111.51 ,OP,80.07,111.51,,,,,,
Health Alliance MCR ADV,CPT,76978,Us trgt dyn mbubb 1st les,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,182.72,,,,,,
Health Alliance MCR ADV,CPT,76981,Use parenchyma,APC 5522,RVU Per Case,$111.51 ,OP,111.51,111.51,,,,,,
Health Alliance MCR ADV,CPT,76982,Use 1st target lesion,APC 5522,RVU Per Case,$111.51 ,OP,111.51,111.51,,,,,,
Health Alliance MCR ADV,CPT,76999,Echo examination procedure,APC 5521,RVU Per Case,$82.79 ,OP,82.79,82.79,,,,,,
Health Alliance MCR ADV,CPT,77046,Mri breast c- unilateral,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,77047,Mri breast c- bilateral,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,77053,X-ray of mammary duct,APC 5523,RVU Per Case,$235.49 ,OP,235.49,411.78,,,,,,
Health Alliance MCR ADV,CPT,77054,X-ray of mammary ducts,APC 5523,RVU Per Case,$235.49 ,OP,235.49,235.49,,,,,,
Health Alliance MCR ADV,CPT,77063,Breast tomosynthesis bi,Physician,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Health Alliance MCR ADV,CPT,77065,Dx mammo incl cad uni,Physician,Per Unit,$83.47 ,OP,83.47,275.87,,,,,,
Health Alliance MCR ADV,CPT,77066,Dx mammo incl cad bi,Physician,Per Unit,$106.70 ,OP,106.7,275.87,,,,,,
Health Alliance MCR ADV,CPT,77067,Scr mammo bi incl cad,Physician,Per Unit,$88.24 ,OP,88.24,275.87,,,,,,
Health Alliance MCR ADV,CPT,77071,X-ray stress view,APC 5521,RVU Per Case,$82.79 ,OP,82.79,205.88,,,,,,
Health Alliance MCR ADV,CPT,77072,X-rays for bone age,APC 5522,RVU Per Case,$111.51 ,OP,111.51,122,,,,,,
Health Alliance MCR ADV,CPT,77073,X-rays bone length studies,APC 5522,RVU Per Case,$111.51 ,OP,111.51,198.25,,,,,,
Health Alliance MCR ADV,CPT,77074,X-rays bone survey limited,APC 5522,RVU Per Case,$111.51 ,OP,111.51,358.39,,,,,,
Health Alliance MCR ADV,CPT,77075,X-rays bone survey complete,APC 5522,RVU Per Case,$111.51 ,OP,111.51,514.72,,,,,,
Health Alliance MCR ADV,CPT,77076,X-rays bone survey infant,APC 5522,RVU Per Case,$111.51 ,OP,111.51,476.6,,,,,,
Health Alliance MCR ADV,CPT,77077,Joint survey single view,APC 5522,RVU Per Case,$111.51 ,OP,111.51,224.95,,,,,,
Health Alliance MCR ADV,CPT,77078,Ct bone density axial,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,927,,,,,,
Health Alliance MCR ADV,CPT,77080,Dxa bone density axial,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,537.6,,,,,,
Health Alliance MCR ADV,CPT,77081,Dxa bone density/peripheral,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,167.76,,,,,,
Health Alliance MCR ADV,CPT,77084,Magnetic image bone marrow,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,77085,Dxa bone density study,APC 5522,RVU Per Case,$111.51 ,OP,111.51,111.51,,,,,,
Health Alliance MCR ADV,CPT,77086,Fracture assessment via dxa,APC 5521,RVU Per Case,$82.79 ,OP,82.79,213.51,,,,,,
Health Alliance MCR ADV,CPT,77280,Set radiation therapy field,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,964.61,,,,,,
Health Alliance MCR ADV,CPT,77285,Set radiation therapy field,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,"1,662.33",,,,,,
Health Alliance MCR ADV,CPT,77290,Set radiation therapy field,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,"2,558.32",,,,,,
Health Alliance MCR ADV,CPT,77295,3-d radiotherapy plan,APC 5613,RVU Per Unit,"$1,291.62 ",OP,"1,291.62","3,736.44",,,,,,
Health Alliance MCR ADV,CPT,77299,Radiation therapy planning,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,129.83,,,,,,
Health Alliance MCR ADV,CPT,77300,Radiation therapy dose plan,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,388.89,,,,,,
Health Alliance MCR ADV,CPT,77301,Radiotherapy dose plan imrt,APC 5613,RVU Per Unit,"$1,291.62 ",OP,"1,291.62","11,205.50",,,,,,
Health Alliance MCR ADV,CPT,77306,Telethx isodose plan simple,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,392.7,,,,,,
Health Alliance MCR ADV,CPT,77307,Telethx isodose plan cplx,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,777.79,,,,,,
Health Alliance MCR ADV,CPT,77316,Brachytx isodose plan simple,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,747.28,,,,,,
Health Alliance MCR ADV,CPT,77317,Brachytx isodose intermed,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,"1,059.93",,,,,,
Health Alliance MCR ADV,CPT,77318,Brachytx isodose complex,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,"1,456.44",,,,,,
Health Alliance MCR ADV,CPT,77321,Special teletx port plan,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,659.6,,,,,,
Health Alliance MCR ADV,CPT,77331,Special radiation dosimetry,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,320.27,,,,,,
Health Alliance MCR ADV,CPT,77332,Radiation treatment aid(s),APC 5611,RVU Per Unit,$129.83 ,OP,129.83,407.96,,,,,,
Health Alliance MCR ADV,CPT,77333,Radiation treatment aid(s),APC 5611,RVU Per Unit,$129.83 ,OP,129.83,369.83,,,,,,
Health Alliance MCR ADV,CPT,77334,Radiation treatment aid(s),APC 5612,RVU Per Unit,$346.58 ,OP,346.58,869.3,,,,,,
Health Alliance MCR ADV,CPT,77336,Radiation physics consult,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,343.14,,,,,,
Health Alliance MCR ADV,CPT,77338,Design mlc device for imrt,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,346.58,,,,,,
Health Alliance MCR ADV,CPT,77370,Radiation physics consult,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,629.1,,,,,,
Health Alliance MCR ADV,CPT,77371,Srs multisource,APC 5627,RVU Per Case,"$7,954.01 ",OP,"6,969.60","7,954.01",,,,,,
Health Alliance MCR ADV,CPT,77372,Srs linear based,APC 5627,RVU Per Case,"$7,954.01 ",OP,"4,148.22","7,954.01",,,,,,
Health Alliance MCR ADV,CPT,77373,Sbrt delivery,APC 5626,RVU Per Unit,"$1,774.17 ",OP,"1,774.17","13,221.44",,,,,,
Health Alliance MCR ADV,CPT,77385,Ntsty modul rad tx dlvr smpl,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"1,379.33",,,,,,
Health Alliance MCR ADV,CPT,77386,Ntsty modul rad tx dlvr cplx,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"1,379.33",,,,,,
Health Alliance MCR ADV,CPT,77399,External radiation dosimetry,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,129.83,,,,,,
Health Alliance MCR ADV,CPT,77401,Radiation treatment delivery,APC 5621,RVU Per Unit,$123.36 ,OP,123.36,183.02,,,,,,
Health Alliance MCR ADV,CPT,77402,Radiation treatment delivery,APC 5621,RVU Per Unit,$123.36 ,OP,123.36,123.36,,,,,,
Health Alliance MCR ADV,CPT,77407,Radiation treatment delivery,APC 5622,RVU Per Unit,$247.32 ,OP,247.32,247.32,,,,,,
Health Alliance MCR ADV,CPT,77412,Radiation treatment delivery,APC 5622,RVU Per Unit,$247.32 ,OP,247.32,"1,067.55",,,,,,
Health Alliance MCR ADV,CPT,77423,Neutron beam tx complex,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"1,235.32",,,,,,
Health Alliance MCR ADV,CPT,77424,Io rad tx delivery by x-ray,APC 5627,RVU Per Case,"$7,954.01 ",OP,"7,954.01","7,954.01",,,,,,
Health Alliance MCR ADV,CPT,77425,Io rad tx deliver by elctrns,APC 5627,RVU Per Case,"$7,954.01 ",OP,"7,954.01","7,954.01",,,,,,
Health Alliance MCR ADV,CPT,77470,Special radiation treatment,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"1,509.83",,,,,,
Health Alliance MCR ADV,CPT,77520,Proton trmt simple w/o comp,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,555.2,,,,,,
Health Alliance MCR ADV,CPT,77522,Proton trmt simple w/comp,APC 5625,RVU Per Unit,"$1,328.18 ",OP,"1,328.18","1,328.18",,,,,,
Health Alliance MCR ADV,CPT,77523,Proton trmt intermediate,APC 5625,RVU Per Unit,"$1,328.18 ",OP,"1,328.18","1,328.18",,,,,,
Health Alliance MCR ADV,CPT,77525,Proton treatment complex,APC 5625,RVU Per Unit,"$1,328.18 ",OP,"1,328.18","1,328.18",,,,,,
Health Alliance MCR ADV,CPT,77600,Hyperthermia treatment,APC 5622,RVU Per Unit,$247.32 ,OP,247.32,"1,902.54",,,,,,
Health Alliance MCR ADV,CPT,77605,Hyperthermia treatment,APC 5624,RVU Per Unit,$724.98 ,OP,724.98,"3,397.11",,,,,,
Health Alliance MCR ADV,CPT,77610,Hyperthermia treatment,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"3,156.91",,,,,,
Health Alliance MCR ADV,CPT,77615,Hyperthermia treatment,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"4,464.67",,,,,,
Health Alliance MCR ADV,CPT,77620,Hyperthermia treatment,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"2,013.11",,,,,,
Health Alliance MCR ADV,CPT,77750,Infuse radioactive materials,APC 5622,RVU Per Unit,$247.32 ,OP,247.32,"1,730.97",,,,,,
Health Alliance MCR ADV,CPT,77761,Apply intrcav radiat simple,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"1,803.41",,,,,,
Health Alliance MCR ADV,CPT,77762,Apply intrcav radiat interm,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"2,463.00",,,,,,
Health Alliance MCR ADV,CPT,77763,Apply intrcav radiat compl,APC 5624,RVU Per Unit,$724.98 ,OP,724.98,724.98,,,,,,
Health Alliance MCR ADV,CPT,77767,Hdr rdncl skn surf brachytx,APC 5622,RVU Per Unit,$247.32 ,OP,247.32,247.32,,,,,,
Health Alliance MCR ADV,CPT,77768,Hdr rdncl skn surf brachytx,APC 5622,RVU Per Unit,$247.32 ,OP,247.32,247.32,,,,,,
Health Alliance MCR ADV,CPT,77770,Hdr rdncl ntrstl/icav brchtx,APC 5624,RVU Per Unit,$724.98 ,OP,724.98,964.61,,,,,,
Health Alliance MCR ADV,CPT,77771,Hdr rdncl ntrstl/icav brchtx,APC 5624,RVU Per Unit,$724.98 ,OP,724.98,"2,882.39",,,,,,
Health Alliance MCR ADV,CPT,77772,Hdr rdncl ntrstl/icav brchtx,APC 5624,RVU Per Unit,$724.98 ,OP,724.98,"4,285.47",,,,,,
Health Alliance MCR ADV,CPT,77778,Apply interstit radiat compl,APC 5624,RVU Per Unit,$724.98 ,OP,724.98,"4,209.21",,,,,,
Health Alliance MCR ADV,CPT,77789,Apply surf ldr radionuclide,APC 5621,RVU Per Unit,$123.36 ,OP,123.36,533.78,,,,,,
Health Alliance MCR ADV,CPT,77799,Radium/radioisotope therapy,APC 5621,RVU Per Unit,$123.36 ,OP,123.36,123.36,,,,,,
Health Alliance MCR ADV,CPT,78012,Thyroid uptake measurement,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,453.71,,,,,,
Health Alliance MCR ADV,CPT,78013,Thyroid imaging w/blood flow,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,884.55,,,,,,
Health Alliance MCR ADV,CPT,78014,Thyroid imaging w/blood flow,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,105.68",,,,,,
Health Alliance MCR ADV,CPT,78015,Thyroid met imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,044.69",,,,,,
Health Alliance MCR ADV,CPT,78016,Thyroid met imaging/studies,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,578.46",,,,,,
Health Alliance MCR ADV,CPT,78018,Thyroid met imaging body,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,616.58",,,,,,
Health Alliance MCR ADV,CPT,78070,Parathyroid planar imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,884.55,,,,,,
Health Alliance MCR ADV,CPT,78071,Parathyrd planar w/wo subtrj,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,884.55,,,,,,
Health Alliance MCR ADV,CPT,78072,Parathyrd planar w/spect&ct,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,884.55,,,,,,
Health Alliance MCR ADV,CPT,78075,Adrenal cortex & medulla img,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","2,085.54",,,,,,
Health Alliance MCR ADV,CPT,78099,Endocrine nuclear procedure,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Health Alliance MCR ADV,CPT,78102,Bone marrow imaging ltd,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Health Alliance MCR ADV,CPT,78103,Bone marrow imaging mult,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,109.50",,,,,,
Health Alliance MCR ADV,CPT,78104,Bone marrow imaging body,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,273.44",,,,,,
Health Alliance MCR ADV,CPT,78110,Plasma volume single,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,336.39",,,,,,
Health Alliance MCR ADV,CPT,78111,Plasma volume multiple,APC 5593,RVU Per Unit,"$1,336.39 ",OP,518.52,"1,336.39",,,,,,
Health Alliance MCR ADV,CPT,78120,Red cell mass single,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Health Alliance MCR ADV,CPT,78121,Red cell mass multiple,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,552.84,,,,,,
Health Alliance MCR ADV,CPT,78122,Blood volume,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,701.54,,,,,,
Health Alliance MCR ADV,CPT,78130,Red cell survival study,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,793.05,,,,,,
Health Alliance MCR ADV,CPT,78140,Red cell sequestration,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,781.61,,,,,,
Health Alliance MCR ADV,CPT,78185,Spleen imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Health Alliance MCR ADV,CPT,78191,Platelet survival,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,067.55",,,,,,
Health Alliance MCR ADV,CPT,78195,Lymph system imaging,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,704.28",,,,,,
Health Alliance MCR ADV,CPT,78199,Blood/lymph nuclear exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Health Alliance MCR ADV,CPT,78201,Liver imaging,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,884.55,,,,,,
Health Alliance MCR ADV,CPT,78202,Liver imaging with flow,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,014.17",,,,,,
Health Alliance MCR ADV,CPT,78215,Liver and spleen imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,941.74,,,,,,
Health Alliance MCR ADV,CPT,78216,Liver & spleen image/flow,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,728.23,,,,,,
Health Alliance MCR ADV,CPT,78226,Hepatobiliary system imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,570.83",,,,,,
Health Alliance MCR ADV,CPT,78227,Hepatobil syst image w/drug,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,570.83",,,,,,
Health Alliance MCR ADV,CPT,78230,Salivary gland imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,804.48,,,,,,
Health Alliance MCR ADV,CPT,78231,Serial salivary imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,697.72,,,,,,
Health Alliance MCR ADV,CPT,78232,Salivary gland function exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,712.98,,,,,,
Health Alliance MCR ADV,CPT,78258,Esophageal motility study,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,113.30",,,,,,
Health Alliance MCR ADV,CPT,78261,Gastric mucosa imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,242.94",,,,,,
Health Alliance MCR ADV,CPT,78262,Gastroesophageal reflux exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,227.68",,,,,,
Health Alliance MCR ADV,CPT,78264,Gastric emptying imag study,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,403.08",,,,,,
Health Alliance MCR ADV,CPT,78265,Gastric emptying imag study,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,403.08",,,,,,
Health Alliance MCR ADV,CPT,78266,Gastric emptying imag study,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,403.08",,,,,,
Health Alliance MCR ADV,CPT,78267,Breath tst attain/anal c-14,Lab Services,Per Unit,$11.06 ,OP,11.06,11.06,,,,,,
Health Alliance MCR ADV,CPT,78268,Breath test analysis c-14,Lab Services,Per Unit,$94.41 ,OP,94.41,301.2,,,,,,
Health Alliance MCR ADV,CPT,78278,Acute gi blood loss imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Health Alliance MCR ADV,CPT,78282,Gi protein loss exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,407.96,,,,,,
Health Alliance MCR ADV,CPT,78290,Meckels divert exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,498.39",,,,,,
Health Alliance MCR ADV,CPT,78291,Leveen/shunt patency exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,227.68",,,,,,
Health Alliance MCR ADV,CPT,78299,Gi nuclear procedure,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Health Alliance MCR ADV,CPT,78300,Bone imaging limited area,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,869.3,,,,,,
Health Alliance MCR ADV,CPT,78305,Bone imaging multiple areas,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,155.24",,,,,,
Health Alliance MCR ADV,CPT,78306,Bone imaging whole body,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,281.07",,,,,,
Health Alliance MCR ADV,CPT,78315,Bone imaging 3 phase,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,692.84",,,,,,
Health Alliance MCR ADV,CPT,78399,Musculoskeletal nuclear exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Health Alliance MCR ADV,CPT,78414,Non-imaging heart function,APC 5592,RVU Per Unit,$500.81 ,OP,377.46,500.81,,,,,,
Health Alliance MCR ADV,CPT,78428,Cardiac shunt imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,998.92,,,,,,
Health Alliance MCR ADV,CPT,78429,Myocrd img pet 1 std w/ct,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,240.30",,,,,,
Health Alliance MCR ADV,CPT,78430,Myocrd img pet rst/strs w/ct,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,217.42",,,,,,
Health Alliance MCR ADV,CPT,78431,Myocrd img pet rst&strs ct,APC 1522,RVU Per Unit,"$2,302.98 ",OP,"2,150.30","7,339.44",,,,,,
Health Alliance MCR ADV,CPT,78432,Myocrd img pet 2rtracer,APC 1523,RVU Per Unit,"$2,814.64 ",OP,"2,628.05","8,030.21",,,,,,
Health Alliance MCR ADV,CPT,78433,Myocrd img pet 2rtracer ct,APC 1523,RVU Per Unit,"$2,814.64 ",OP,"2,628.05","8,778.55",,,,,,
Health Alliance MCR ADV,CPT,78445,Vascular flow imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,838.79,,,,,,
Health Alliance MCR ADV,CPT,78451,Ht muscle image spect sing,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","2,116.06",,,,,,
Health Alliance MCR ADV,CPT,78452,Ht muscle image spect mult,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","3,343.73",,,,,,
Health Alliance MCR ADV,CPT,78453,Ht muscle image planar sing,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,631.84",,,,,,
Health Alliance MCR ADV,CPT,78454,Ht musc image planar mult,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,772.90",,,,,,
Health Alliance MCR ADV,CPT,78456,Acute venous thrombus image,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,784.34",,,,,,
Health Alliance MCR ADV,CPT,78457,Venous thrombosis imaging,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,964.61,,,,,,
Health Alliance MCR ADV,CPT,78458,Ven thrombosis images bilat,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,078.99",,,,,,
Health Alliance MCR ADV,CPT,78459,Myocrd img pet single study,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","7,240.30",,,,,,
Health Alliance MCR ADV,CPT,78466,Heart infarct image,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,922.67,,,,,,
Health Alliance MCR ADV,CPT,78468,Heart infarct image (ef),APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,166.68",,,,,,
Health Alliance MCR ADV,CPT,78469,Heart infarct image (3d),APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,338.26",,,,,,
Health Alliance MCR ADV,CPT,78472,Gated heart planar single,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,368.75",,,,,,
Health Alliance MCR ADV,CPT,78473,Gated heart multiple,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,872.03",,,,,,
Health Alliance MCR ADV,CPT,78481,Heart first pass single,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,201.00",,,,,,
Health Alliance MCR ADV,CPT,78483,Heart first pass multiple,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,700.46",,,,,,
Health Alliance MCR ADV,CPT,78491,Myocrd img pet 1std rst/strs,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,217.42",,,,,,
Health Alliance MCR ADV,CPT,78492,Myocrd img pet mlt rst&strs,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,339.44",,,,,,
Health Alliance MCR ADV,CPT,78494,Heart image spect,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,486.95",,,,,,
Health Alliance MCR ADV,CPT,78499,Cardiovascular nuclear exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Health Alliance MCR ADV,CPT,78579,Lung ventilation imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,155.24",,,,,,
Health Alliance MCR ADV,CPT,78580,Lung perfusion imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,071.37",,,,,,
Health Alliance MCR ADV,CPT,78582,Lung ventilat&perfus imaging,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,769.09",,,,,,
Health Alliance MCR ADV,CPT,78597,Lung perfusion differential,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,906.36",,,,,,
Health Alliance MCR ADV,CPT,78598,Lung perf&ventilat diferentl,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,906.36",,,,,,
Health Alliance MCR ADV,CPT,78599,Respiratory nuclear exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Health Alliance MCR ADV,CPT,78600,Brain image < 4 views,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,888.36,,,,,,
Health Alliance MCR ADV,CPT,78601,Brain image w/flow < 4 views,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,059.93",,,,,,
Health Alliance MCR ADV,CPT,78605,Brain image 4+ views,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,991.29,,,,,,
Health Alliance MCR ADV,CPT,78606,Brain image w/flow 4 + views,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,540.33",,,,,,
Health Alliance MCR ADV,CPT,78608,Brain imaging (pet),APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,209.80",,,,,,
Health Alliance MCR ADV,CPT,78610,Brain flow imaging only,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,888.36,,,,,,
Health Alliance MCR ADV,CPT,78630,Cerebrospinal fluid scan,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,647.08",,,,,,
Health Alliance MCR ADV,CPT,78635,Csf ventriculography,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,475.51",,,,,,
Health Alliance MCR ADV,CPT,78645,Csf shunt evaluation,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,502.21",,,,,,
Health Alliance MCR ADV,CPT,78650,Csf leakage imaging,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,601.33",,,,,,
Health Alliance MCR ADV,CPT,78660,Nuclear exam of tear flow,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,831.17,,,,,,
Health Alliance MCR ADV,CPT,78699,Nervous system nuclear exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Health Alliance MCR ADV,CPT,78700,Kidney imaging morphol,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,884.55,,,,,,
Health Alliance MCR ADV,CPT,78701,Kidney imaging with flow,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,056.11",,,,,,
Health Alliance MCR ADV,CPT,78707,K flow/funct image w/o drug,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,235.32",,,,,,
Health Alliance MCR ADV,CPT,78708,K flow/funct image w/drug,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,014.17",,,,,,
Health Alliance MCR ADV,CPT,78709,K flow/funct image multiple,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,795.78",,,,,,
Health Alliance MCR ADV,CPT,78725,Kidney function study,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,518.52,,,,,,
Health Alliance MCR ADV,CPT,78740,Ureteral reflux study,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,040.87",,,,,,
Health Alliance MCR ADV,CPT,78761,Testicular imaging w/flow,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,052.29",,,,,,
Health Alliance MCR ADV,CPT,78799,Genitourinary nuclear exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Health Alliance MCR ADV,CPT,78800,Rp loclzj tum 1 area 1 d img,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,949.36,,,,,,
Health Alliance MCR ADV,CPT,78801,Rp loclzj tum 2+area 1+d img,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,265.81",,,,,,
Health Alliance MCR ADV,CPT,78802,Rp loclzj tum whbdy 1 d img,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,654.72",,,,,,
Health Alliance MCR ADV,CPT,78803,Rp loclzj tum spect 1 area,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,826.28",,,,,,
Health Alliance MCR ADV,CPT,78804,Rp loclzj tum whbdy 2+d img,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","2,870.96",,,,,,
Health Alliance MCR ADV,CPT,78808,Iv inj ra drug dx study,APC 5591,RVU Per Case,$385.91 ,OP,385.91,385.91,,,,,,
Health Alliance MCR ADV,CPT,78811,Pet image ltd area,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,336.39",,,,,,
Health Alliance MCR ADV,CPT,78812,Pet image skull-thigh,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,347.07",,,,,,
Health Alliance MCR ADV,CPT,78813,Pet image full body,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,354.67",,,,,,
Health Alliance MCR ADV,CPT,78814,Pet image w/ct lmtd,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,404.24",,,,,,
Health Alliance MCR ADV,CPT,78815,Pet image w/ct skull-thigh,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,446.19",,,,,,
Health Alliance MCR ADV,CPT,78816,Pet image w/ct full body,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,461.44",,,,,,
Health Alliance MCR ADV,CPT,78830,Rp loclzj tum spect w/ct 1,APC 5593,RVU Per Unit,"$1,336.39 ",OP,927,"2,600.43",,,,,,
Health Alliance MCR ADV,CPT,78831,Rp loclzj tum spect 2 areas,APC 5593,RVU Per Unit,"$1,336.39 ",OP,927,"3,860.65",,,,,,
Health Alliance MCR ADV,CPT,78832,Rp loclzj tum spect w/ct 2,APC 5594,RVU Per Unit,"$1,514.86 ",OP,927,"5,097.10",,,,,,
Health Alliance MCR ADV,CPT,78999,Nuclear diagnostic exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Health Alliance MCR ADV,CPT,79005,Nuclear rx oral admin,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,800.67,,,,,,
Health Alliance MCR ADV,CPT,79101,Nuclear rx iv admin,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,896,,,,,,
Health Alliance MCR ADV,CPT,79200,Nuclear rx intracav admin,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,911.23,,,,,,
Health Alliance MCR ADV,CPT,79300,Nuclr rx interstit colloid,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,724.42,,,,,,
Health Alliance MCR ADV,CPT,79403,Hematopoietic nuclear tx,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,"1,132.37",,,,,,
Health Alliance MCR ADV,CPT,79440,Nuclear rx intra-articular,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,838.79,,,,,,
Health Alliance MCR ADV,CPT,79445,Nuclear rx intra-arterial,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,"1,162.87",,,,,,
Health Alliance MCR ADV,CPT,79999,Nuclear medicine therapy,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,255.45,,,,,,
Health Alliance MCR ADV,CPT,80047,Metabolic panel ionized ca,Lab Services,Per Unit,$13.73 ,OP,13.73,41.94,,,,,,
Health Alliance MCR ADV,CPT,80048,Metabolic panel total ca,Lab Services,Per Unit,$8.46 ,OP,8.46,132.19,,,,,,
Health Alliance MCR ADV,CPT,80051,Electrolyte panel,Lab Services,Per Unit,$7.01 ,OP,7.01,34.31,,,,,,
Health Alliance MCR ADV,CPT,80053,Comprehen metabolic panel,Lab Services,Per Unit,$10.56 ,OP,10.56,172.42,,,,,,
Health Alliance MCR ADV,CPT,80055,Obstetric panel,Lab Services,Per Unit,$47.81 ,OP,47.81,301.2,,,,,,
Health Alliance MCR ADV,CPT,80061,Lipid panel,Lab Services,Per Unit,$13.39 ,OP,13.39,68.63,,,,,,
Health Alliance MCR ADV,CPT,80069,Renal function panel,Lab Services,Per Unit,$8.68 ,OP,8.68,38.13,,,,,,
Health Alliance MCR ADV,CPT,80074,Acute hepatitis panel,Lab Services,Per Unit,$47.63 ,OP,47.63,213.51,,,,,,
Health Alliance MCR ADV,CPT,80076,Hepatic function panel,Lab Services,Per Unit,$8.17 ,OP,8.17,126.44,,,,,,
Health Alliance MCR ADV,CPT,80081,Obstetric panel,Lab Services,Per Unit,$74.86 ,OP,74.86,74.86,,,,,,
Health Alliance MCR ADV,CPT,80143,Drug assay acetaminophen,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,
Health Alliance MCR ADV,CPT,80145,Drug assay adalimumab,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,
Health Alliance MCR ADV,CPT,80150,Assay of amikacin,Lab Services,Per Unit,$15.08 ,OP,15.08,49.56,,,,,,
Health Alliance MCR ADV,CPT,80151,Drug assay amiodarone,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,
Health Alliance MCR ADV,CPT,80155,Drug assay caffeine,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,
Health Alliance MCR ADV,CPT,80156,Assay carbamazepine total,Lab Services,Per Unit,$14.57 ,OP,14.57,64.82,,,,,,
Health Alliance MCR ADV,CPT,80157,Assay carbamazepine free,Lab Services,Per Unit,$13.25 ,OP,13.25,57.19,,,,,,
Health Alliance MCR ADV,CPT,80158,Drug assay cyclosporine,Lab Services,Per Unit,$18.05 ,OP,18.05,80.07,,,,,,
Health Alliance MCR ADV,CPT,80159,Drug assay clozapine,Lab Services,Per Unit,$20.15 ,OP,20.15,20.15,,,,,,
Health Alliance MCR ADV,CPT,80161,Asy carbamazepin 10-11-epxid,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,
Health Alliance MCR ADV,CPT,80162,Assay of digoxin total,Lab Services,Per Unit,$13.28 ,OP,13.28,61,,,,,,
Health Alliance MCR ADV,CPT,80163,Assay of digoxin free,Lab Services,Per Unit,$13.28 ,OP,13.28,61,,,,,,
Health Alliance MCR ADV,CPT,80164,Assay dipropylacetic acd tot,Lab Services,Per Unit,$13.54 ,OP,13.54,61,,,,,,
Health Alliance MCR ADV,CPT,80165,Dipropylacetic acid free,Lab Services,Per Unit,$13.54 ,OP,13.54,61,,,,,,
Health Alliance MCR ADV,CPT,80167,Drug assay felbamate,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,
Health Alliance MCR ADV,CPT,80168,Assay of ethosuximide,Lab Services,Per Unit,$16.34 ,OP,16.34,72.44,,,,,,
Health Alliance MCR ADV,CPT,80169,Drug assay everolimus,Lab Services,Per Unit,$13.73 ,OP,13.73,13.73,,,,,,
Health Alliance MCR ADV,CPT,80170,Assay of gentamicin,Lab Services,Per Unit,$16.38 ,OP,16.38,72.44,,,,,,
Health Alliance MCR ADV,CPT,80171,Drug screen quant gabapentin,Lab Services,Per Unit,$21.67 ,OP,21.67,21.67,,,,,,
Health Alliance MCR ADV,CPT,80173,Assay of haloperidol,Lab Services,Per Unit,$15.78 ,OP,15.78,15.78,,,,,,
Health Alliance MCR ADV,CPT,80175,Drug screen quan lamotrigine,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,
Health Alliance MCR ADV,CPT,80176,Assay of lidocaine,Lab Services,Per Unit,$14.69 ,OP,14.69,64.82,,,,,,
Health Alliance MCR ADV,CPT,80177,Drug scrn quan levetiracetam,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,
Health Alliance MCR ADV,CPT,80178,Assay of lithium,Lab Services,Per Unit,$6.61 ,OP,6.61,30.51,,,,,,
Health Alliance MCR ADV,CPT,80179,Drug assay salicylate,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,
Health Alliance MCR ADV,CPT,80180,Drug scrn quan mycophenolate,Lab Services,Per Unit,$18.05 ,OP,18.05,18.05,,,,,,
Health Alliance MCR ADV,CPT,80181,Drug assay flecainide,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,
Health Alliance MCR ADV,CPT,80183,Drug scrn quant oxcarbazepin,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,
Health Alliance MCR ADV,CPT,80184,Assay of phenobarbital,Lab Services,Per Unit,$15.30 ,OP,15.3,49.56,,,,,,
Health Alliance MCR ADV,CPT,80185,Assay of phenytoin total,Lab Services,Per Unit,$13.25 ,OP,13.25,57.19,,,,,,
Health Alliance MCR ADV,CPT,80186,Assay of phenytoin free,Lab Services,Per Unit,$13.76 ,OP,13.76,61,,,,,,
Health Alliance MCR ADV,CPT,80187,Drug assay posaconazole,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,
Health Alliance MCR ADV,CPT,80188,Assay of primidone,Lab Services,Per Unit,$16.59 ,OP,16.59,72.44,,,,,,
Health Alliance MCR ADV,CPT,80189,Drug assay itraconzaole,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,
Health Alliance MCR ADV,CPT,80190,Assay of procainamide,Lab Services,Per Unit,$60.00 ,OP,60,76.26,,,,,,
Health Alliance MCR ADV,CPT,80192,Assay of procainamide,Lab Services,Per Unit,$16.75 ,OP,16.75,76.26,,,,,,
Health Alliance MCR ADV,CPT,80193,Drug assay leflunomide,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,
Health Alliance MCR ADV,CPT,80194,Assay of quinidine,Lab Services,Per Unit,$14.60 ,OP,14.6,64.82,,,,,,
Health Alliance MCR ADV,CPT,80195,Assay of sirolimus,Lab Services,Per Unit,$13.73 ,OP,13.73,61,,,,,,
Health Alliance MCR ADV,CPT,80197,Assay of tacrolimus,Lab Services,Per Unit,$13.73 ,OP,13.73,61,,,,,,
Health Alliance MCR ADV,CPT,80198,Assay of theophylline,Lab Services,Per Unit,$14.14 ,OP,14.14,64.82,,,,,,
Health Alliance MCR ADV,CPT,80199,Drug screen quant tiagabine,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,
Health Alliance MCR ADV,CPT,80200,Assay of tobramycin,Lab Services,Per Unit,$16.13 ,OP,16.13,49.56,,,,,,
Health Alliance MCR ADV,CPT,80201,Assay of topiramate,Lab Services,Per Unit,$11.92 ,OP,11.92,53.38,,,,,,
Health Alliance MCR ADV,CPT,80202,Assay of vancomycin,Lab Services,Per Unit,$13.54 ,OP,13.54,61,,,,,,
Health Alliance MCR ADV,CPT,80203,Drug screen quant zonisamide,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,
Health Alliance MCR ADV,CPT,80204,Drug assay methotrexate,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,
Health Alliance MCR ADV,CPT,80210,Drug assay rufinamide,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,
Health Alliance MCR ADV,CPT,80230,Drug assay infliximab,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,
Health Alliance MCR ADV,CPT,80235,Drug assay lacosamide,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,
Health Alliance MCR ADV,CPT,80280,Drug assay vedolizumab,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,
Health Alliance MCR ADV,CPT,80285,Drug assay voriconazole,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,
Health Alliance MCR ADV,CPT,80299,Quantitative assay drug,Lab Services,Per Unit,$18.64 ,OP,18.64,61,,,,,,
Health Alliance MCR ADV,CPT,80305,Drug test prsmv dir opt obs,Lab Services,Per Unit,$12.60 ,OP,12.6,64.82,,,,,,
Health Alliance MCR ADV,CPT,80306,Drug test prsmv instrmnt,Lab Services,Per Unit,$17.14 ,OP,17.14,64.82,,,,,,
Health Alliance MCR ADV,CPT,80307,Drug test prsmv chem anlyzr,Lab Services,Per Unit,$62.14 ,OP,62.14,62.14,,,,,,
Health Alliance MCR ADV,CPT,80400,Acth stimulation panel,Lab Services,Per Unit,$32.62 ,OP,32.62,144.88,,,,,,
Health Alliance MCR ADV,CPT,80402,Acth stimulation panel,Lab Services,Per Unit,$86.96 ,OP,86.96,388.89,,,,,,
Health Alliance MCR ADV,CPT,80406,Acth stimulation panel,Lab Services,Per Unit,$78.26 ,OP,78.26,346.96,,,,,,
Health Alliance MCR ADV,CPT,80408,Aldosterone suppression eval,Lab Services,Per Unit,$125.50 ,OP,125.5,560.47,,,,,,
Health Alliance MCR ADV,CPT,80410,Calcitonin stimul panel,Lab Services,Per Unit,$80.37 ,OP,80.37,358.39,,,,,,
Health Alliance MCR ADV,CPT,80412,Crh stimulation panel,Lab Services,Per Unit,$801.62 ,OP,801.62,"1,467.89",,,,,,
Health Alliance MCR ADV,CPT,80414,Testosterone response panel,Lab Services,Per Unit,$51.64 ,OP,51.64,228.77,,,,,,
Health Alliance MCR ADV,CPT,80415,Tot estradiol response panel,Lab Services,Per Unit,$55.89 ,OP,55.89,99.13,,,,,,
Health Alliance MCR ADV,CPT,80416,Renin stimulation panel,Lab Services,Per Unit,$209.32 ,OP,209.32,587.16,,,,,,
Health Alliance MCR ADV,CPT,80417,Renin stimulation panel,Lab Services,Per Unit,$43.99 ,OP,43.99,194.45,,,,,,
Health Alliance MCR ADV,CPT,80418,Pituitary evaluation panel,Lab Services,Per Unit,$579.48 ,OP,579.48,"2,573.58",,,,,,
Health Alliance MCR ADV,CPT,80420,Dexamethasone panel,Lab Services,Per Unit,$161.88 ,OP,161.88,320.27,,,,,,
Health Alliance MCR ADV,CPT,80422,Glucagon tolerance panel,Lab Services,Per Unit,$46.07 ,OP,46.07,205.88,,,,,,
Health Alliance MCR ADV,CPT,80424,Glucagon tolerance panel,Lab Services,Per Unit,$50.50 ,OP,50.5,224.95,,,,,,
Health Alliance MCR ADV,CPT,80426,Gonadotropin hormone panel,Lab Services,Per Unit,$148.41 ,OP,148.41,659.6,,,,,,
Health Alliance MCR ADV,CPT,80428,Growth hormone panel,Lab Services,Per Unit,$66.70 ,OP,66.7,289.76,,,,,,
Health Alliance MCR ADV,CPT,80430,Growth hormone panel,Lab Services,Per Unit,$129.33 ,OP,129.33,343.14,,,,,,
Health Alliance MCR ADV,CPT,80432,Insulin suppression panel,Lab Services,Per Unit,$165.61 ,OP,165.61,602.41,,,,,,
Health Alliance MCR ADV,CPT,80434,Insulin tolerance panel,Lab Services,Per Unit,$285.03 ,OP,285.03,449.9,,,,,,
Health Alliance MCR ADV,CPT,80435,Insulin tolerance panel,Lab Services,Per Unit,$103.00 ,OP,103,449.9,,,,,,
Health Alliance MCR ADV,CPT,80436,Metyrapone panel,Lab Services,Per Unit,$91.16 ,OP,91.16,301.2,,,,,,
Health Alliance MCR ADV,CPT,80438,Trh stimulation panel,Lab Services,Per Unit,$50.41 ,OP,50.41,224.95,,,,,,
Health Alliance MCR ADV,CPT,80439,Trh stimulation panel,Lab Services,Per Unit,$67.21 ,OP,67.21,297.39,,,,,,
Health Alliance MCR ADV,CPT,80500,Lab pathology consultation,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Health Alliance MCR ADV,CPT,80502,Lab pathology consultation,APC 5672,RVU Per Case,$152.64 ,OP,152.64,320.27,,,,,,
Health Alliance MCR ADV,CPT,81000,Urinalysis nonauto w/scope,Lab Services,Per Unit,$4.02 ,OP,4.02,15.26,,,,,,
Health Alliance MCR ADV,CPT,81001,Urinalysis auto w/scope,Lab Services,Per Unit,$3.17 ,OP,3.17,15.26,,,,,,
Health Alliance MCR ADV,CPT,81002,Urinalysis nonauto w/o scope,Lab Services,Per Unit,$3.48 ,OP,3.48,11.44,,,,,,
Health Alliance MCR ADV,CPT,81003,Urinalysis auto w/o scope,Lab Services,Per Unit,$2.25 ,OP,2.25,11.44,,,,,,
Health Alliance MCR ADV,CPT,81005,Urinalysis,Lab Services,Per Unit,$2.17 ,OP,2.17,11.44,,,,,,
Health Alliance MCR ADV,CPT,81007,Urine screen for bacteria,Lab Services,Per Unit,$29.98 ,OP,11.44,29.98,,,,,,
Health Alliance MCR ADV,CPT,81015,Microscopic exam of urine,Lab Services,Per Unit,$3.05 ,OP,3.05,15.26,,,,,,
Health Alliance MCR ADV,CPT,81020,Urinalysis glass test,Lab Services,Per Unit,$4.70 ,OP,4.7,15.26,,,,,,
Health Alliance MCR ADV,CPT,81025,Urine pregnancy test,Lab Services,Per Unit,$8.61 ,OP,8.61,30.51,,,,,,
Health Alliance MCR ADV,CPT,81050,Urinalysis volume measure,Lab Services,Per Unit,$3.64 ,OP,3.64,11.44,,,,,,
Health Alliance MCR ADV,CPT,81105,Hpa-1 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
Health Alliance MCR ADV,CPT,81106,Hpa-2 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
Health Alliance MCR ADV,CPT,81107,Hpa-3 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
Health Alliance MCR ADV,CPT,81108,Hpa-4 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
Health Alliance MCR ADV,CPT,81109,Hpa-5 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
Health Alliance MCR ADV,CPT,81110,Hpa-6 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
Health Alliance MCR ADV,CPT,81111,Hpa-9 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
Health Alliance MCR ADV,CPT,81112,Hpa-15 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
Health Alliance MCR ADV,CPT,81120,Idh1 common variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,
Health Alliance MCR ADV,CPT,81121,Idh2 common variants,Lab Services,Per Unit,$295.79 ,OP,295.79,295.79,,,,,,
Health Alliance MCR ADV,CPT,81161,Dmd dup/delet analysis,Lab Services,Per Unit,$279.00 ,OP,279,279,,,,,,
Health Alliance MCR ADV,CPT,81162,Brca1&2 gen full seq dup/del,Lab Services,Per Unit,"$1,824.88 ",OP,"1,824.88","1,824.88",,,,,,
Health Alliance MCR ADV,CPT,81163,Brca1&2 gene full seq alys,Lab Services,Per Unit,$468.00 ,OP,468,468,,,,,,
Health Alliance MCR ADV,CPT,81164,Brca1&2 gen ful dup/del alys,Lab Services,Per Unit,$584.23 ,OP,584.23,584.23,,,,,,
Health Alliance MCR ADV,CPT,81165,Brca1 gene full seq alys,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,
Health Alliance MCR ADV,CPT,81166,Brca1 gene full dup/del alys,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,
Health Alliance MCR ADV,CPT,81167,Brca2 gene full dup/del alys,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,
Health Alliance MCR ADV,CPT,81168,Ccnd1/igh translocation alys,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,
Health Alliance MCR ADV,CPT,81170,Abl1 gene,Lab Services,Per Unit,$300.00 ,OP,300,300,,,,,,
Health Alliance MCR ADV,CPT,81171,Aff2 gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Health Alliance MCR ADV,CPT,81172,Aff2 gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Health Alliance MCR ADV,CPT,81173,Ar gene full gene sequence,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,
Health Alliance MCR ADV,CPT,81174,Ar gene known famil variant,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Health Alliance MCR ADV,CPT,81175,Asxl1 full gene sequence,Lab Services,Per Unit,$676.50 ,OP,676.5,676.5,,,,,,
Health Alliance MCR ADV,CPT,81176,Asxl1 gene target seq alys,Lab Services,Per Unit,$241.90 ,OP,241.9,241.9,,,,,,
Health Alliance MCR ADV,CPT,81177,Atn1 gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Health Alliance MCR ADV,CPT,81178,Atxn1 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Health Alliance MCR ADV,CPT,81179,Atxn2 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Health Alliance MCR ADV,CPT,81180,Atxn3 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Health Alliance MCR ADV,CPT,81181,Atxn7 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Health Alliance MCR ADV,CPT,81182,Atxn8os gen detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Health Alliance MCR ADV,CPT,81183,Atxn10 gene detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Health Alliance MCR ADV,CPT,81184,Cacna1a gen detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Health Alliance MCR ADV,CPT,81185,Cacna1a gene full gene seq,Lab Services,Per Unit,$846.27 ,OP,846.27,846.27,,,,,,
Health Alliance MCR ADV,CPT,81186,Cacna1a gen known famil vrnt,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Health Alliance MCR ADV,CPT,81187,Cnbp gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Health Alliance MCR ADV,CPT,81188,Cstb gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Health Alliance MCR ADV,CPT,81189,Cstb gene full gene sequence,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Health Alliance MCR ADV,CPT,81190,Cstb gene known famil vrnt,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Health Alliance MCR ADV,CPT,81191,Ntrk1 translocation analysis,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,
Health Alliance MCR ADV,CPT,81192,Ntrk2 translocation analysis,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,
Health Alliance MCR ADV,CPT,81193,Ntrk3 translocation analysis,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,
Health Alliance MCR ADV,CPT,81194,Ntrk translocation analysis,Lab Services,Per Unit,$518.28 ,OP,518.28,518.28,,,,,,
Health Alliance MCR ADV,CPT,81200,Aspa gene,Lab Services,Per Unit,$47.25 ,OP,47.25,47.25,,,,,,
Health Alliance MCR ADV,CPT,81201,Apc gene full sequence,Lab Services,Per Unit,$780.00 ,OP,780,780,,,,,,
Health Alliance MCR ADV,CPT,81202,Apc gene known fam variants,Lab Services,Per Unit,$280.00 ,OP,280,280,,,,,,
Health Alliance MCR ADV,CPT,81203,Apc gene dup/delet variants,Lab Services,Per Unit,$200.00 ,OP,200,200,,,,,,
Health Alliance MCR ADV,CPT,81204,Ar gene charac alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Health Alliance MCR ADV,CPT,81205,Bckdhb gene,Lab Services,Per Unit,$94.99 ,OP,94.99,94.99,,,,,,
Health Alliance MCR ADV,CPT,81206,Bcr/abl1 gene major bp,Lab Services,Per Unit,$163.96 ,OP,163.96,163.96,,,,,,
Health Alliance MCR ADV,CPT,81207,Bcr/abl1 gene minor bp,Lab Services,Per Unit,$144.84 ,OP,144.84,144.84,,,,,,
Health Alliance MCR ADV,CPT,81208,Bcr/abl1 gene other bp,Lab Services,Per Unit,$214.62 ,OP,214.62,214.62,,,,,,
Health Alliance MCR ADV,CPT,81209,Blm gene,Lab Services,Per Unit,$39.31 ,OP,39.31,39.31,,,,,,
Health Alliance MCR ADV,CPT,81210,Braf gene,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,
Health Alliance MCR ADV,CPT,81212,Brca1&2 185&5385&6174 vrnt,Lab Services,Per Unit,$440.00 ,OP,440,440,,,,,,
Health Alliance MCR ADV,CPT,81215,Brca1 gene known famil vrnt,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,
Health Alliance MCR ADV,CPT,81216,Brca2 gene full seq alys,Lab Services,Per Unit,$185.12 ,OP,185.12,185.12,,,,,,
Health Alliance MCR ADV,CPT,81217,Brca2 gene known famil vrnt,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,
Health Alliance MCR ADV,CPT,81218,Cebpa gene full sequence,Lab Services,Per Unit,$241.90 ,OP,241.9,241.9,,,,,,
Health Alliance MCR ADV,CPT,81219,Calr gene com variants,Lab Services,Per Unit,$121.63 ,OP,121.63,121.63,,,,,,
Health Alliance MCR ADV,CPT,81220,Cftr gene com variants,Lab Services,Per Unit,$556.60 ,OP,556.6,556.6,,,,,,
Health Alliance MCR ADV,CPT,81221,Cftr gene known fam variants,Lab Services,Per Unit,$97.22 ,OP,97.22,97.22,,,,,,
Health Alliance MCR ADV,CPT,81222,Cftr gene dup/delet variants,Lab Services,Per Unit,$435.07 ,OP,435.07,435.07,,,,,,
Health Alliance MCR ADV,CPT,81223,Cftr gene full sequence,Lab Services,Per Unit,$499.00 ,OP,499,499,,,,,,
Health Alliance MCR ADV,CPT,81224,Cftr gene intron poly t,Lab Services,Per Unit,$168.75 ,OP,168.75,168.75,,,,,,
Health Alliance MCR ADV,CPT,81225,Cyp2c19 gene com variants,Lab Services,Per Unit,$291.36 ,OP,291.36,291.36,,,,,,
Health Alliance MCR ADV,CPT,81226,Cyp2d6 gene com variants,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,
Health Alliance MCR ADV,CPT,81227,Cyp2c9 gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Health Alliance MCR ADV,CPT,81228,Cytogen micrarray copy nmbr,Lab Services,Per Unit,$900.00 ,OP,900,900,,,,,,
Health Alliance MCR ADV,CPT,81229,Cytogen m array copy no&snp,Lab Services,Per Unit,"$1,160.00 ",OP,"1,160.00","1,160.00",,,,,,
Health Alliance MCR ADV,CPT,81230,Cyp3a4 gene common variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Health Alliance MCR ADV,CPT,81231,Cyp3a5 gene common variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Health Alliance MCR ADV,CPT,81232,Dpyd gene common variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Health Alliance MCR ADV,CPT,81233,Btk gene common variants,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,
Health Alliance MCR ADV,CPT,81234,Dmpk gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Health Alliance MCR ADV,CPT,81235,Egfr gene com variants,Lab Services,Per Unit,$324.58 ,OP,324.58,324.58,,,,,,
Health Alliance MCR ADV,CPT,81236,Ezh2 gene full gene sequence,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,
Health Alliance MCR ADV,CPT,81237,Ezh2 gene common variants,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,
Health Alliance MCR ADV,CPT,81238,F9 full gene sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,
Health Alliance MCR ADV,CPT,81239,Dmpk gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Health Alliance MCR ADV,CPT,81240,F2 gene,Lab Services,Per Unit,$65.69 ,OP,65.69,65.69,,,,,,
Health Alliance MCR ADV,CPT,81241,F5 gene,Lab Services,Per Unit,$73.37 ,OP,73.37,73.37,,,,,,
Health Alliance MCR ADV,CPT,81242,Fancc gene,Lab Services,Per Unit,$36.62 ,OP,36.62,36.62,,,,,,
Health Alliance MCR ADV,CPT,81243,Fmr1 gene detection,Lab Services,Per Unit,$57.04 ,OP,57.04,57.04,,,,,,
Health Alliance MCR ADV,CPT,81244,Fmr1 gene charac alleles,Lab Services,Per Unit,$44.89 ,OP,44.89,44.89,,,,,,
Health Alliance MCR ADV,CPT,81245,Flt3 gene,Lab Services,Per Unit,$165.51 ,OP,165.51,165.51,,,,,,
Health Alliance MCR ADV,CPT,81246,Flt3 gene analysis,Lab Services,Per Unit,$83.00 ,OP,83,83,,,,,,
Health Alliance MCR ADV,CPT,81247,G6pd gene alys cmn variant,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Health Alliance MCR ADV,CPT,81248,G6pd known familial variant,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,
Health Alliance MCR ADV,CPT,81249,G6pd full gene sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,
Health Alliance MCR ADV,CPT,81250,G6pc gene,Lab Services,Per Unit,$58.49 ,OP,58.49,58.49,,,,,,
Health Alliance MCR ADV,CPT,81251,Gba gene,Lab Services,Per Unit,$47.25 ,OP,47.25,47.25,,,,,,
Health Alliance MCR ADV,CPT,81252,Gjb2 gene full sequence,Lab Services,Per Unit,$101.12 ,OP,101.12,101.12,,,,,,
Health Alliance MCR ADV,CPT,81253,Gjb2 gene known fam variants,Lab Services,Per Unit,$61.52 ,OP,61.52,61.52,,,,,,
Health Alliance MCR ADV,CPT,81254,Gjb6 gene com variants,Lab Services,Per Unit,$35.00 ,OP,35,35,,,,,,
Health Alliance MCR ADV,CPT,81255,Hexa gene,Lab Services,Per Unit,$51.45 ,OP,51.45,51.45,,,,,,
Health Alliance MCR ADV,CPT,81256,Hfe gene,Lab Services,Per Unit,$65.36 ,OP,65.36,65.36,,,,,,
Health Alliance MCR ADV,CPT,81257,Hba1/hba2 gene,Lab Services,Per Unit,$102.26 ,OP,102.26,102.26,,,,,,
Health Alliance MCR ADV,CPT,81258,Hba1/hba2 gene fam vrnt,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,
Health Alliance MCR ADV,CPT,81259,Hba1/hba2 full gene sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,
Health Alliance MCR ADV,CPT,81260,Ikbkap gene,Lab Services,Per Unit,$39.31 ,OP,39.31,39.31,,,,,,
Health Alliance MCR ADV,CPT,81261,Igh gene rearrange amp meth,Lab Services,Per Unit,$197.99 ,OP,197.99,197.99,,,,,,
Health Alliance MCR ADV,CPT,81262,Igh gene rearrang dir probe,Lab Services,Per Unit,$68.55 ,OP,68.55,68.55,,,,,,
Health Alliance MCR ADV,CPT,81263,Igh vari regional mutation,Lab Services,Per Unit,$294.52 ,OP,294.52,294.52,,,,,,
Health Alliance MCR ADV,CPT,81264,Igk rearrangeabn clonal pop,Lab Services,Per Unit,$172.73 ,OP,172.73,172.73,,,,,,
Health Alliance MCR ADV,CPT,81265,Str markers specimen anal,Lab Services,Per Unit,$233.07 ,OP,233.07,233.07,,,,,,
Health Alliance MCR ADV,CPT,81266,Str markers spec anal addl,Lab Services,Per Unit,$304.81 ,OP,304.81,304.81,,,,,,
Health Alliance MCR ADV,CPT,81267,Chimerism anal no cell selec,Lab Services,Per Unit,$207.46 ,OP,207.46,207.46,,,,,,
Health Alliance MCR ADV,CPT,81268,Chimerism anal w/cell select,Lab Services,Per Unit,$260.79 ,OP,260.79,260.79,,,,,,
Health Alliance MCR ADV,CPT,81269,Hba1/hba2 gene dup/del vrnts,Lab Services,Per Unit,$202.40 ,OP,202.4,202.4,,,,,,
Health Alliance MCR ADV,CPT,81270,Jak2 gene,Lab Services,Per Unit,$91.66 ,OP,91.66,91.66,,,,,,
Health Alliance MCR ADV,CPT,81271,Htt gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Health Alliance MCR ADV,CPT,81272,Kit gene targeted seq analys,Lab Services,Per Unit,$329.51 ,OP,329.51,329.51,,,,,,
Health Alliance MCR ADV,CPT,81273,Kit gene analys d816 variant,Lab Services,Per Unit,$124.87 ,OP,124.87,124.87,,,,,,
Health Alliance MCR ADV,CPT,81274,Htt gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Health Alliance MCR ADV,CPT,81275,Kras gene variants exon 2,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,
Health Alliance MCR ADV,CPT,81276,Kras gene addl variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,
Health Alliance MCR ADV,CPT,81277,Cytogenomic neo microra alys,Lab Services,Per Unit,"$1,160.00 ",OP,"1,160.00","1,160.00",,,,,,
Health Alliance MCR ADV,CPT,81278,Igh@/bcl2 translocation alys,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,
Health Alliance MCR ADV,CPT,81279,Jak2 gene trgt sequence alys,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Health Alliance MCR ADV,CPT,81283,Ifnl3 gene,Lab Services,Per Unit,$73.37 ,OP,73.37,73.37,,,,,,
Health Alliance MCR ADV,CPT,81284,Fxn gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Health Alliance MCR ADV,CPT,81285,Fxn gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Health Alliance MCR ADV,CPT,81286,Fxn gene full gene sequence,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Health Alliance MCR ADV,CPT,81287,Mgmt gene prmtr mthyltn alys,Lab Services,Per Unit,$124.64 ,OP,124.64,124.64,,,,,,
Health Alliance MCR ADV,CPT,81288,Mlh1 gene,Lab Services,Per Unit,$192.32 ,OP,192.32,192.32,,,,,,
Health Alliance MCR ADV,CPT,81289,Fxn gene known famil variant,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Health Alliance MCR ADV,CPT,81290,Mcoln1 gene,Lab Services,Per Unit,$39.31 ,OP,39.31,39.31,,,,,,
Health Alliance MCR ADV,CPT,81291,Mthfr gene,Lab Services,Per Unit,$65.34 ,OP,65.34,65.34,,,,,,
Health Alliance MCR ADV,CPT,81292,Mlh1 gene full seq,Lab Services,Per Unit,$675.40 ,OP,675.4,675.4,,,,,,
Health Alliance MCR ADV,CPT,81293,Mlh1 gene known variants,Lab Services,Per Unit,$331.00 ,OP,331,331,,,,,,
Health Alliance MCR ADV,CPT,81294,Mlh1 gene dup/delete variant,Lab Services,Per Unit,$202.40 ,OP,202.4,202.4,,,,,,
Health Alliance MCR ADV,CPT,81295,Msh2 gene full seq,Lab Services,Per Unit,$381.70 ,OP,381.7,381.7,,,,,,
Health Alliance MCR ADV,CPT,81296,Msh2 gene known variants,Lab Services,Per Unit,$337.73 ,OP,337.73,337.73,,,,,,
Health Alliance MCR ADV,CPT,81297,Msh2 gene dup/delete variant,Lab Services,Per Unit,$213.30 ,OP,213.3,213.3,,,,,,
Health Alliance MCR ADV,CPT,81298,Msh6 gene full seq,Lab Services,Per Unit,$641.85 ,OP,641.85,641.85,,,,,,
Health Alliance MCR ADV,CPT,81299,Msh6 gene known variants,Lab Services,Per Unit,$308.00 ,OP,308,308,,,,,,
Health Alliance MCR ADV,CPT,81300,Msh6 gene dup/delete variant,Lab Services,Per Unit,$238.00 ,OP,238,238,,,,,,
Health Alliance MCR ADV,CPT,81301,Microsatellite instability,Lab Services,Per Unit,$348.56 ,OP,348.56,348.56,,,,,,
Health Alliance MCR ADV,CPT,81302,Mecp2 gene full seq,Lab Services,Per Unit,$527.87 ,OP,527.87,527.87,,,,,,
Health Alliance MCR ADV,CPT,81303,Mecp2 gene known variant,Lab Services,Per Unit,$120.00 ,OP,120,120,,,,,,
Health Alliance MCR ADV,CPT,81304,Mecp2 gene dup/delet variant,Lab Services,Per Unit,$150.00 ,OP,150,150,,,,,,
Health Alliance MCR ADV,CPT,81305,Myd88 gene p.leu265pro vrnt,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,
Health Alliance MCR ADV,CPT,81306,Nudt15 gene common variants,Lab Services,Per Unit,$291.36 ,OP,291.36,291.36,,,,,,
Health Alliance MCR ADV,CPT,81307,Palb2 gene full gene seq,Lab Services,Per Unit,$676.50 ,OP,676.5,676.5,,,,,,
Health Alliance MCR ADV,CPT,81308,Palb2 gene known famil vrnt,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,
Health Alliance MCR ADV,CPT,81309,Pik3ca gene trgt seq alys,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Health Alliance MCR ADV,CPT,81310,Npm1 gene,Lab Services,Per Unit,$246.52 ,OP,246.52,246.52,,,,,,
Health Alliance MCR ADV,CPT,81311,Nras gene variants exon 2&3,Lab Services,Per Unit,$295.79 ,OP,295.79,295.79,,,,,,
Health Alliance MCR ADV,CPT,81312,Pabpn1 gene detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Health Alliance MCR ADV,CPT,81313,Pca3/klk3 antigen,Lab Services,Per Unit,$255.05 ,OP,255.05,255.05,,,,,,
Health Alliance MCR ADV,CPT,81314,Pdgfra gene,Lab Services,Per Unit,$329.51 ,OP,329.51,329.51,,,,,,
Health Alliance MCR ADV,CPT,81315,Pml/raralpha com breakpoints,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,
Health Alliance MCR ADV,CPT,81316,Pml/raralpha 1 breakpoint,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,
Health Alliance MCR ADV,CPT,81317,Pms2 gene full seq analysis,Lab Services,Per Unit,$676.50 ,OP,676.5,676.5,,,,,,
Health Alliance MCR ADV,CPT,81318,Pms2 known familial variants,Lab Services,Per Unit,$331.00 ,OP,331,331,,,,,,
Health Alliance MCR ADV,CPT,81319,Pms2 gene dup/delet variants,Lab Services,Per Unit,$203.50 ,OP,203.5,203.5,,,,,,
Health Alliance MCR ADV,CPT,81320,Plcg2 gene common variants,Lab Services,Per Unit,$291.36 ,OP,291.36,291.36,,,,,,
Health Alliance MCR ADV,CPT,81321,Pten gene full sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,
Health Alliance MCR ADV,CPT,81322,Pten gene known fam variant,Lab Services,Per Unit,$46.60 ,OP,46.6,46.6,,,,,,
Health Alliance MCR ADV,CPT,81323,Pten gene dup/delet variant,Lab Services,Per Unit,$300.00 ,OP,300,300,,,,,,
Health Alliance MCR ADV,CPT,81324,Pmp22 gene dup/delet,Lab Services,Per Unit,$758.36 ,OP,758.36,758.36,,,,,,
Health Alliance MCR ADV,CPT,81325,Pmp22 gene full sequence,Lab Services,Per Unit,$769.58 ,OP,769.58,769.58,,,,,,
Health Alliance MCR ADV,CPT,81326,Pmp22 gene known fam variant,Lab Services,Per Unit,$46.60 ,OP,46.6,46.6,,,,,,
Health Alliance MCR ADV,CPT,81327,Sept9 gen prmtr mthyltn alys,Lab Services,Per Unit,$192.00 ,OP,192,192,,,,,,
Health Alliance MCR ADV,CPT,81328,Slco1b1 gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Health Alliance MCR ADV,CPT,81329,Smn1 gene dos/deletion alys,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Health Alliance MCR ADV,CPT,81330,Smpd1 gene common variants,Lab Services,Per Unit,$47.00 ,OP,47,47,,,,,,
Health Alliance MCR ADV,CPT,81331,Snrpn/ube3a gene,Lab Services,Per Unit,$51.07 ,OP,51.07,51.07,,,,,,
Health Alliance MCR ADV,CPT,81332,Serpina1 gene,Lab Services,Per Unit,$43.65 ,OP,43.65,43.65,,,,,,
Health Alliance MCR ADV,CPT,81333,Tgfbi gene common variants,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Health Alliance MCR ADV,CPT,81334,Runx1 gene targeted seq alys,Lab Services,Per Unit,$329.51 ,OP,329.51,329.51,,,,,,
Health Alliance MCR ADV,CPT,81335,Tpmt gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Health Alliance MCR ADV,CPT,81336,Smn1 gene full gene sequence,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,
Health Alliance MCR ADV,CPT,81337,Smn1 gen nown famil seq vrnt,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Health Alliance MCR ADV,CPT,81338,Mpl gene common variants,Lab Services,Per Unit,$150.33 ,OP,150.33,150.33,,,,,,
Health Alliance MCR ADV,CPT,81339,Mpl gene seq alys exon 10,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Health Alliance MCR ADV,CPT,81340,Trb@ gene rearrange amplify,Lab Services,Per Unit,$208.92 ,OP,208.92,208.92,,,,,,
Health Alliance MCR ADV,CPT,81341,Trb@ gene rearrange dirprobe,Lab Services,Per Unit,$49.59 ,OP,49.59,49.59,,,,,,
Health Alliance MCR ADV,CPT,81342,Trg gene rearrangement anal,Lab Services,Per Unit,$201.50 ,OP,201.5,201.5,,,,,,
Health Alliance MCR ADV,CPT,81343,Ppp2r2b gen detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Health Alliance MCR ADV,CPT,81344,Tbp gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Health Alliance MCR ADV,CPT,81345,Tert gene targeted seq alys,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Health Alliance MCR ADV,CPT,81346,Tyms gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Health Alliance MCR ADV,CPT,81347,Sf3b1 gene common variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,
Health Alliance MCR ADV,CPT,81348,Srsf2 gene common variants,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,
Health Alliance MCR ADV,CPT,81350,Ugt1a1 gene common variants,Lab Services,Per Unit,$234.00 ,OP,234,234,,,,,,
Health Alliance MCR ADV,CPT,81351,Tp53 gene full gene sequence,Lab Services,Per Unit,$641.85 ,OP,641.85,641.85,,,,,,
Health Alliance MCR ADV,CPT,81352,Tp53 gene trgt sequence alys,Lab Services,Per Unit,$329.51 ,OP,329.51,329.51,,,,,,
Health Alliance MCR ADV,CPT,81353,Tp53 gene known famil vrnt,Lab Services,Per Unit,$308.00 ,OP,308,308,,,,,,
Health Alliance MCR ADV,CPT,81355,Vkorc1 gene,Lab Services,Per Unit,$88.20 ,OP,88.2,88.2,,,,,,
Health Alliance MCR ADV,CPT,81357,U2af1 gene common variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,
Health Alliance MCR ADV,CPT,81360,Zrsr2 gene common variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,
Health Alliance MCR ADV,CPT,81361,Hbb gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Health Alliance MCR ADV,CPT,81362,Hbb gene known fam variant,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,
Health Alliance MCR ADV,CPT,81363,Hbb gene dup/del variants,Lab Services,Per Unit,$202.40 ,OP,202.4,202.4,,,,,,
Health Alliance MCR ADV,CPT,81364,Hbb full gene sequence,Lab Services,Per Unit,$324.58 ,OP,324.58,324.58,,,,,,
Health Alliance MCR ADV,CPT,81370,Hla i & ii typing lr,Lab Services,Per Unit,$402.12 ,OP,402.12,402.12,,,,,,
Health Alliance MCR ADV,CPT,81371,Hla i & ii type verify lr,Lab Services,Per Unit,$404.52 ,OP,404.52,404.52,,,,,,
Health Alliance MCR ADV,CPT,81372,Hla i typing complete lr,Lab Services,Per Unit,$403.59 ,OP,403.59,403.59,,,,,,
Health Alliance MCR ADV,CPT,81373,Hla i typing 1 locus lr,Lab Services,Per Unit,$127.43 ,OP,127.43,127.43,,,,,,
Health Alliance MCR ADV,CPT,81374,Hla i typing 1 antigen lr,Lab Services,Per Unit,$74.33 ,OP,74.33,74.33,,,,,,
Health Alliance MCR ADV,CPT,81375,Hla ii typing ag equiv lr,Lab Services,Per Unit,$220.74 ,OP,220.74,220.74,,,,,,
Health Alliance MCR ADV,CPT,81376,Hla ii typing 1 locus lr,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
Health Alliance MCR ADV,CPT,81377,Hla ii type 1 ag equiv lr,Lab Services,Per Unit,$94.74 ,OP,94.74,94.74,,,,,,
Health Alliance MCR ADV,CPT,81378,Hla i & ii typing hr,Lab Services,Per Unit,$345.57 ,OP,345.57,345.57,,,,,,
Health Alliance MCR ADV,CPT,81379,Hla i typing complete hr,Lab Services,Per Unit,$335.38 ,OP,335.38,335.38,,,,,,
Health Alliance MCR ADV,CPT,81380,Hla i typing 1 locus hr,Lab Services,Per Unit,$177.25 ,OP,177.25,177.25,,,,,,
Health Alliance MCR ADV,CPT,81381,Hla i typing 1 allele hr,Lab Services,Per Unit,$169.90 ,OP,169.9,169.9,,,,,,
Health Alliance MCR ADV,CPT,81382,Hla ii typing 1 loc hr,Lab Services,Per Unit,$123.68 ,OP,123.68,123.68,,,,,,
Health Alliance MCR ADV,CPT,81383,Hla ii typing 1 allele hr,Lab Services,Per Unit,$109.13 ,OP,109.13,109.13,,,,,,
Health Alliance MCR ADV,CPT,81400,Mopath procedure level 1,Lab Services,Per Unit,$63.96 ,OP,63.96,63.96,,,,,,
Health Alliance MCR ADV,CPT,81401,Mopath procedure level 2,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Health Alliance MCR ADV,CPT,81402,Mopath procedure level 3,Lab Services,Per Unit,$150.33 ,OP,150.33,150.33,,,,,,
Health Alliance MCR ADV,CPT,81403,Mopath procedure level 4,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Health Alliance MCR ADV,CPT,81404,Mopath procedure level 5,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Health Alliance MCR ADV,CPT,81405,Mopath procedure level 6,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,
Health Alliance MCR ADV,CPT,81406,Mopath procedure level 7,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,
Health Alliance MCR ADV,CPT,81407,Mopath procedure level 8,Lab Services,Per Unit,$846.27 ,OP,846.27,846.27,,,,,,
Health Alliance MCR ADV,CPT,81408,Mopath procedure level 9,Lab Services,Per Unit,"$2,000.00 ",OP,"2,000.00","2,000.00",,,,,,
Health Alliance MCR ADV,CPT,81410,Aortic dysfunction/dilation,Lab Services,Per Unit,$504.00 ,OP,504,504,,,,,,
Health Alliance MCR ADV,CPT,81411,Aortic dysfunction/dilation,Lab Services,Per Unit,"$1,350.19 ",OP,"1,350.19","1,350.19",,,,,,
Health Alliance MCR ADV,CPT,81412,Ashkenazi jewish assoc dis,Lab Services,Per Unit,"$2,448.56 ",OP,"2,448.56","2,448.56",,,,,,
Health Alliance MCR ADV,CPT,81413,Car ion chnnlpath inc 10 gns,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,
Health Alliance MCR ADV,CPT,81414,Car ion chnnlpath inc 2 gns,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,
Health Alliance MCR ADV,CPT,81415,Exome sequence analysis,Lab Services,Per Unit,"$4,780.00 ",OP,"4,780.00","4,780.00",,,,,,
Health Alliance MCR ADV,CPT,81416,Exome sequence analysis,Lab Services,Per Unit,"$12,000.00 ",OP,"12,000.00","12,000.00",,,,,,
Health Alliance MCR ADV,CPT,81417,Exome re-evaluation,Lab Services,Per Unit,$320.00 ,OP,320,320,,,,,,
Health Alliance MCR ADV,CPT,81419,Epilepsy gen seq alys panel,Lab Services,Per Unit,"$2,448.56 ",OP,"2,448.56","2,448.56",,,,,,
Health Alliance MCR ADV,CPT,81420,Fetal chrmoml aneuploidy,Lab Services,Per Unit,$759.05 ,OP,759.05,759.05,,,,,,
Health Alliance MCR ADV,CPT,81422,Fetal chrmoml microdeltj,Lab Services,Per Unit,$759.05 ,OP,759.05,759.05,,,,,,
Health Alliance MCR ADV,CPT,81425,Genome sequence analysis,Lab Services,Per Unit,"$5,031.20 ",OP,"5,031.20","5,031.20",,,,,,
Health Alliance MCR ADV,CPT,81426,Genome sequence analysis,Lab Services,Per Unit,"$2,709.95 ",OP,"2,709.95","2,709.95",,,,,,
Health Alliance MCR ADV,CPT,81427,Genome re-evaluation,Lab Services,Per Unit,"$2,337.65 ",OP,"2,337.65","2,337.65",,,,,,
Health Alliance MCR ADV,CPT,81430,Hearing loss sequence analys,Lab Services,Per Unit,"$1,625.00 ",OP,"1,625.00","1,625.00",,,,,,
Health Alliance MCR ADV,CPT,81431,Hearing loss dup/del analys,Lab Services,Per Unit,$679.57 ,OP,679.57,679.57,,,,,,
Health Alliance MCR ADV,CPT,81432,Hrdtry brst ca-rlatd dsordrs,Lab Services,Per Unit,$679.05 ,OP,679.05,679.05,,,,,,
Health Alliance MCR ADV,CPT,81433,Hrdtry brst ca-rlatd dsordrs,Lab Services,Per Unit,$438.93 ,OP,438.93,438.93,,,,,,
Health Alliance MCR ADV,CPT,81434,Hereditary retinal disorders,Lab Services,Per Unit,$597.91 ,OP,597.91,597.91,,,,,,
Health Alliance MCR ADV,CPT,81435,Hereditary colon ca dsordrs,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,
Health Alliance MCR ADV,CPT,81436,Hereditary colon ca dsordrs,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,
Health Alliance MCR ADV,CPT,81437,Heredtry nurondcrn tum dsrdr,Lab Services,Per Unit,$438.93 ,OP,438.93,438.93,,,,,,
Health Alliance MCR ADV,CPT,81438,Heredtry nurondcrn tum dsrdr,Lab Services,Per Unit,$438.93 ,OP,438.93,438.93,,,,,,
Health Alliance MCR ADV,CPT,81439,Hrdtry cardmypy gene panel,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,
Health Alliance MCR ADV,CPT,81440,Mitochondrial gene,Lab Services,Per Unit,"$3,324.00 ",OP,"3,324.00","3,324.00",,,,,,
Health Alliance MCR ADV,CPT,81442,Noonan spectrum disorders,Lab Services,Per Unit,"$2,143.60 ",OP,"2,143.60","2,143.60",,,,,,
Health Alliance MCR ADV,CPT,81443,Genetic tstg severe inh cond,Lab Services,Per Unit,"$2,448.56 ",OP,"2,448.56","2,448.56",,,,,,
Health Alliance MCR ADV,CPT,81445,Targeted genomic seq analys,Lab Services,Per Unit,$597.91 ,OP,597.91,597.91,,,,,,
Health Alliance MCR ADV,CPT,81448,Hrdtry perph neurphy panel,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,
Health Alliance MCR ADV,CPT,81450,Targeted genomic seq analys,Lab Services,Per Unit,$759.53 ,OP,759.53,759.53,,,,,,
Health Alliance MCR ADV,CPT,81455,Targeted genomic seq analys,Lab Services,Per Unit,"$2,919.60 ",OP,"2,919.60","2,919.60",,,,,,
Health Alliance MCR ADV,CPT,81460,Whole mitochondrial genome,Lab Services,Per Unit,"$1,287.00 ",OP,"1,287.00","1,287.00",,,,,,
Health Alliance MCR ADV,CPT,81465,Whole mitochondrial genome,Lab Services,Per Unit,$936.00 ,OP,936,936,,,,,,
Health Alliance MCR ADV,CPT,81470,X-linked intellectual dblt,Lab Services,Per Unit,$914.00 ,OP,914,914,,,,,,
Health Alliance MCR ADV,CPT,81471,X-linked intellectual dblt,Lab Services,Per Unit,$914.00 ,OP,914,914,,,,,,
Health Alliance MCR ADV,CPT,81490,Autoimmune rheumatoid arthr,Lab Services,Per Unit,$840.65 ,OP,840.65,840.65,,,,,,
Health Alliance MCR ADV,CPT,81493,Cor artery disease mrna,Lab Services,Per Unit,"$1,050.00 ",OP,"1,050.00","1,050.00",,,,,,
Health Alliance MCR ADV,CPT,81500,Onco (ovar) two proteins,Lab Services,Per Unit,$260.50 ,OP,91.51,260.5,,,,,,
Health Alliance MCR ADV,CPT,81503,Onco (ovar) five proteins,Lab Services,Per Unit,$897.00 ,OP,91.51,897,,,,,,
Health Alliance MCR ADV,CPT,81504,Oncology tissue of origin,Lab Services,Per Unit,$520.00 ,OP,520,520,,,,,,
Health Alliance MCR ADV,CPT,81506,Endo assay seven anal,Lab Services,Per Unit,$68.92 ,OP,57.19,68.92,,,,,,
Health Alliance MCR ADV,CPT,81507,Fetal aneuploidy trisom risk,Lab Services,Per Unit,$795.00 ,OP,795,795,,,,,,
Health Alliance MCR ADV,CPT,81508,Ftl cgen abnor two proteins,Lab Services,Per Unit,$54.30 ,OP,54.3,144.88,,,,,,
Health Alliance MCR ADV,CPT,81509,Ftl cgen abnor 3 proteins,Lab Services,Per Unit,"$1,487.37 ",OP,213.51,"1,487.37",,,,,,
Health Alliance MCR ADV,CPT,81510,Ftl cgen abnor three anal,Lab Services,Per Unit,$55.54 ,OP,55.54,202.07,,,,,,
Health Alliance MCR ADV,CPT,81511,Ftl cgen abnor four anal,Lab Services,Per Unit,$153.50 ,OP,153.5,270.71,,,,,,
Health Alliance MCR ADV,CPT,81512,Ftl cgen abnor five anal,Lab Services,Per Unit,$69.52 ,OP,69.52,270.71,,,,,,
Health Alliance MCR ADV,CPT,81513,Nfct ds bv rna vag flu alg,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
Health Alliance MCR ADV,CPT,81514,Nfct ds bv&vaginitis dna alg,Lab Services,Per Unit,$262.99 ,OP,262.99,262.99,,,,,,
Health Alliance MCR ADV,CPT,81518,Onc brst mrna 11 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
Health Alliance MCR ADV,CPT,81519,Oncology breast mrna,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
Health Alliance MCR ADV,CPT,81520,Onc breast mrna 58 genes,Lab Services,Per Unit,"$2,510.21 ",OP,"2,510.21","2,510.21",,,,,,
Health Alliance MCR ADV,CPT,81521,Onc breast mrna 70 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
Health Alliance MCR ADV,CPT,81522,Onc breast mrna 12 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
Health Alliance MCR ADV,CPT,81525,Oncology colon mrna,Lab Services,Per Unit,"$3,116.00 ",OP,"3,116.00","3,116.00",,,,,,
Health Alliance MCR ADV,CPT,81528,Oncology colorectal scr,Lab Services,Per Unit,$508.87 ,OP,508.87,508.87,,,,,,
Health Alliance MCR ADV,CPT,81529,Onc cutan mlnma mrna 31 gene,Lab Services,Per Unit,"$7,193.00 ",OP,"7,193.00","7,193.00",,,,,,
Health Alliance MCR ADV,CPT,81535,Oncology gynecologic,Lab Services,Per Unit,$579.46 ,OP,579.46,579.46,,,,,,
Health Alliance MCR ADV,CPT,81536,Oncology gynecologic,Lab Services,Per Unit,$177.56 ,OP,177.56,177.56,,,,,,
Health Alliance MCR ADV,CPT,81538,Oncology lung,Lab Services,Per Unit,"$2,871.00 ",OP,"2,871.00","2,871.00",,,,,,
Health Alliance MCR ADV,CPT,81539,Oncology prostate prob score,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
Health Alliance MCR ADV,CPT,81540,Oncology tum unknown origin,Lab Services,Per Unit,"$3,750.00 ",OP,"3,750.00","3,750.00",,,,,,
Health Alliance MCR ADV,CPT,81541,Onc prostate mrna 46 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
Health Alliance MCR ADV,CPT,81542,Onc prostate mrna 22 cnt gen,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
Health Alliance MCR ADV,CPT,81546,Onc thyr mrna 10-196 gen alg,Lab Services,Per Unit,"$3,600.00 ",OP,"3,600.00","3,600.00",,,,,,
Health Alliance MCR ADV,CPT,81551,Onc prostate 3 genes,Lab Services,Per Unit,"$2,030.00 ",OP,"2,030.00","2,030.00",,,,,,
Health Alliance MCR ADV,CPT,81552,Onc uveal mlnma mrna 15 gene,Lab Services,Per Unit,"$7,776.00 ",OP,"7,776.00","7,776.00",,,,,,
Health Alliance MCR ADV,CPT,81554,Pulm ds ipf mrna 190 gen alg,Lab Services,Per Unit,"$5,500.00 ",OP,"5,500.00","5,500.00",,,,,,
Health Alliance MCR ADV,CPT,81595,Cardiology hrt trnspl mrna,Lab Services,Per Unit,"$3,240.00 ",OP,"3,240.00","3,240.00",,,,,,
Health Alliance MCR ADV,CPT,81596,Nfct ds chrnc hcv 6 assays,Lab Services,Per Unit,$72.19 ,OP,72.19,72.19,,,,,,
Health Alliance MCR ADV,CPT,82009,Test for acetone/ketones,Lab Services,Per Unit,$4.52 ,OP,4.52,19.07,,,,,,
Health Alliance MCR ADV,CPT,82010,Acetone assay,Lab Services,Per Unit,$8.17 ,OP,8.17,41.94,,,,,,
Health Alliance MCR ADV,CPT,82013,Acetylcholinesterase assay,Lab Services,Per Unit,$12.29 ,OP,12.29,12.29,,,,,,
Health Alliance MCR ADV,CPT,82016,Acylcarnitines qual,Lab Services,Per Unit,$16.49 ,OP,16.49,61,,,,,,
Health Alliance MCR ADV,CPT,82017,Acylcarnitines quant,Lab Services,Per Unit,$16.87 ,OP,16.87,76.26,,,,,,
Health Alliance MCR ADV,CPT,82024,Assay of acth,Lab Services,Per Unit,$38.62 ,OP,38.62,171.58,,,,,,
Health Alliance MCR ADV,CPT,82030,Assay of adp & amp,Lab Services,Per Unit,$25.80 ,OP,25.8,99.13,,,,,,
Health Alliance MCR ADV,CPT,82040,Assay of serum albumin,Lab Services,Per Unit,$4.95 ,OP,4.95,22.88,,,,,,
Health Alliance MCR ADV,CPT,82042,Other source albumin quan ea,Lab Services,Per Unit,$7.78 ,OP,7.78,26.7,,,,,,
Health Alliance MCR ADV,CPT,82043,Ur albumin quantitative,Lab Services,Per Unit,$5.78 ,OP,5.78,26.7,,,,,,
Health Alliance MCR ADV,CPT,82044,Ur albumin semiquantitative,Lab Services,Per Unit,$6.23 ,OP,6.23,22.88,,,,,,
Health Alliance MCR ADV,CPT,82045,Albumin ischemia modified,Lab Services,Per Unit,$33.94 ,OP,33.94,125.82,,,,,,
Health Alliance MCR ADV,CPT,82075,Assay of breath ethanol,Lab Services,Per Unit,$30.00 ,OP,30,45.74,,,,,,
Health Alliance MCR ADV,CPT,82077,Assay spec xcp ur&breath ia,Lab Services,Per Unit,$17.27 ,OP,17.27,17.27,,,,,,
Health Alliance MCR ADV,CPT,82085,Assay of aldolase,Lab Services,Per Unit,$9.71 ,OP,9.71,41.94,,,,,,
Health Alliance MCR ADV,CPT,82088,Assay of aldosterone,Lab Services,Per Unit,$40.75 ,OP,40.75,183.02,,,,,,
Health Alliance MCR ADV,CPT,82103,Alpha-1-antitrypsin total,Lab Services,Per Unit,$13.44 ,OP,13.44,61,,,,,,
Health Alliance MCR ADV,CPT,82104,Alpha-1-antitrypsin pheno,Lab Services,Per Unit,$14.46 ,OP,14.46,64.82,,,,,,
Health Alliance MCR ADV,CPT,82105,Alpha-fetoprotein serum,Lab Services,Per Unit,$16.77 ,OP,16.77,76.26,,,,,,
Health Alliance MCR ADV,CPT,82106,Alpha-fetoprotein amniotic,Lab Services,Per Unit,$17.00 ,OP,17,76.26,,,,,,
Health Alliance MCR ADV,CPT,82107,Alpha-fetoprotein l3,Lab Services,Per Unit,$64.41 ,OP,64.41,209.7,,,,,,
Health Alliance MCR ADV,CPT,82108,Assay of aluminum,Lab Services,Per Unit,$25.48 ,OP,25.48,114.39,,,,,,
Health Alliance MCR ADV,CPT,82120,Amines vaginal fluid qual,Lab Services,Per Unit,$5.99 ,OP,5.99,19.07,,,,,,
Health Alliance MCR ADV,CPT,82127,Amino acid single qual,Lab Services,Per Unit,$14.18 ,OP,14.18,61,,,,,,
Health Alliance MCR ADV,CPT,82128,Amino acids mult qual,Lab Services,Per Unit,$13.87 ,OP,13.87,61,,,,,,
Health Alliance MCR ADV,CPT,82131,Amino acids single quant,Lab Services,Per Unit,$22.98 ,OP,22.98,76.26,,,,,,
Health Alliance MCR ADV,CPT,82135,Assay aminolevulinic acid,Lab Services,Per Unit,$16.45 ,OP,16.45,64.82,,,,,,
Health Alliance MCR ADV,CPT,82136,Amino acids quant 2-5,Lab Services,Per Unit,$19.61 ,OP,19.61,76.26,,,,,,
Health Alliance MCR ADV,CPT,82139,Amino acids quan 6 or more,Lab Services,Per Unit,$16.87 ,OP,16.87,16.87,,,,,,
Health Alliance MCR ADV,CPT,82140,Assay of ammonia,Lab Services,Per Unit,$14.57 ,OP,14.57,64.82,,,,,,
Health Alliance MCR ADV,CPT,82143,Amniotic fluid scan,Lab Services,Per Unit,$9.35 ,OP,9.35,30.51,,,,,,
Health Alliance MCR ADV,CPT,82150,Assay of amylase,Lab Services,Per Unit,$6.48 ,OP,6.48,34.31,,,,,,
Health Alliance MCR ADV,CPT,82154,Androstanediol glucuronide,Lab Services,Per Unit,$28.83 ,OP,28.83,28.83,,,,,,
Health Alliance MCR ADV,CPT,82157,Assay of androstenedione,Lab Services,Per Unit,$29.28 ,OP,29.28,129.64,,,,,,
Health Alliance MCR ADV,CPT,82160,Assay of androsterone,Lab Services,Per Unit,$25.55 ,OP,25.55,110.57,,,,,,
Health Alliance MCR ADV,CPT,82163,Assay of angiotensin ii,Lab Services,Per Unit,$20.52 ,OP,20.52,91.51,,,,,,
Health Alliance MCR ADV,CPT,82164,Angiotensin i enzyme test,Lab Services,Per Unit,$14.60 ,OP,14.6,64.82,,,,,,
Health Alliance MCR ADV,CPT,82172,Assay of apolipoprotein,Lab Services,Per Unit,$21.09 ,OP,21.09,68.63,,,,,,
Health Alliance MCR ADV,CPT,82175,Assay of arsenic,Lab Services,Per Unit,$18.97 ,OP,18.97,83.87,,,,,,
Health Alliance MCR ADV,CPT,82180,Assay of ascorbic acid,Lab Services,Per Unit,$9.89 ,OP,9.89,9.89,,,,,,
Health Alliance MCR ADV,CPT,82190,Atomic absorption,Lab Services,Per Unit,$15.90 ,OP,15.9,64.82,,,,,,
Health Alliance MCR ADV,CPT,82232,Assay of beta-2 protein,Lab Services,Per Unit,$16.18 ,OP,16.18,72.44,,,,,,
Health Alliance MCR ADV,CPT,82239,Bile acids total,Lab Services,Per Unit,$17.12 ,OP,17.12,76.26,,,,,,
Health Alliance MCR ADV,CPT,82240,Bile acids cholylglycine,Lab Services,Per Unit,$26.58 ,OP,26.58,64.82,,,,,,
Health Alliance MCR ADV,CPT,82247,Bilirubin total,Lab Services,Per Unit,$5.02 ,OP,5.02,26.7,,,,,,
Health Alliance MCR ADV,CPT,82248,Bilirubin direct,Lab Services,Per Unit,$5.02 ,OP,5.02,26.7,,,,,,
Health Alliance MCR ADV,CPT,82252,Fecal bilirubin test,Lab Services,Per Unit,$4.56 ,OP,4.56,19.07,,,,,,
Health Alliance MCR ADV,CPT,82261,Assay of biotinidase,Lab Services,Per Unit,$16.87 ,OP,16.87,76.26,,,,,,
Health Alliance MCR ADV,CPT,82270,Occult blood feces,Lab Services,Per Unit,$4.38 ,OP,4.38,15.26,,,,,,
Health Alliance MCR ADV,CPT,82271,Occult blood other sources,Lab Services,Per Unit,$5.32 ,OP,5.32,15.26,,,,,,
Health Alliance MCR ADV,CPT,82272,Occult bld feces 1-3 tests,Lab Services,Per Unit,$4.23 ,OP,4.23,15.26,,,,,,
Health Alliance MCR ADV,CPT,82274,Assay test for blood fecal,Lab Services,Per Unit,$15.92 ,OP,15.92,80.07,,,,,,
Health Alliance MCR ADV,CPT,82286,Assay of bradykinin,Lab Services,Per Unit,$5.16 ,OP,5.16,30.51,,,,,,
Health Alliance MCR ADV,CPT,82300,Assay of cadmium,Lab Services,Per Unit,$23.64 ,OP,23.64,102.95,,,,,,
Health Alliance MCR ADV,CPT,82306,Vitamin d 25 hydroxy,Lab Services,Per Unit,$29.60 ,OP,29.6,356.68,,,,,,
Health Alliance MCR ADV,CPT,82308,Assay of calcitonin,Lab Services,Per Unit,$26.79 ,OP,26.79,118.19,,,,,,
Health Alliance MCR ADV,CPT,82310,Assay of calcium,Lab Services,Per Unit,$5.16 ,OP,5.16,22.88,,,,,,
Health Alliance MCR ADV,CPT,82330,Assay of calcium,Lab Services,Per Unit,$13.68 ,OP,13.68,61,,,,,,
Health Alliance MCR ADV,CPT,82331,Calcium infusion test,Lab Services,Per Unit,$13.34 ,OP,13.34,22.88,,,,,,
Health Alliance MCR ADV,CPT,82340,Assay of calcium in urine,Lab Services,Per Unit,$6.03 ,OP,6.03,26.7,,,,,,
Health Alliance MCR ADV,CPT,82355,Calculus analysis qual,Lab Services,Per Unit,$11.58 ,OP,11.58,53.38,,,,,,
Health Alliance MCR ADV,CPT,82360,Calculus assay quant,Lab Services,Per Unit,$12.87 ,OP,12.87,45.74,,,,,,
Health Alliance MCR ADV,CPT,82365,Calculus spectroscopy,Lab Services,Per Unit,$12.90 ,OP,12.9,45.74,,,,,,
Health Alliance MCR ADV,CPT,82370,X-ray assay calculus,Lab Services,Per Unit,$12.52 ,OP,12.52,45.74,,,,,,
Health Alliance MCR ADV,CPT,82373,Assay c-d transfer measure,Lab Services,Per Unit,$18.06 ,OP,18.06,80.07,,,,,,
Health Alliance MCR ADV,CPT,82374,Assay blood carbon dioxide,Lab Services,Per Unit,$4.88 ,OP,4.88,22.88,,,,,,
Health Alliance MCR ADV,CPT,82375,Assay carboxyhb quant,Lab Services,Per Unit,$12.32 ,OP,12.32,26.7,,,,,,
Health Alliance MCR ADV,CPT,82376,Assay carboxyhb qual,Lab Services,Per Unit,$14.07 ,OP,14.07,26.7,,,,,,
Health Alliance MCR ADV,CPT,82378,Carcinoembryonic antigen,Lab Services,Per Unit,$18.96 ,OP,18.96,83.87,,,,,,
Health Alliance MCR ADV,CPT,82379,Assay of carnitine,Lab Services,Per Unit,$16.87 ,OP,16.87,76.26,,,,,,
Health Alliance MCR ADV,CPT,82380,Assay of carotene,Lab Services,Per Unit,$9.22 ,OP,9.22,41.94,,,,,,
Health Alliance MCR ADV,CPT,82382,Assay urine catecholamines,Lab Services,Per Unit,$27.30 ,OP,27.3,76.26,,,,,,
Health Alliance MCR ADV,CPT,82383,Assay blood catecholamines,Lab Services,Per Unit,$29.08 ,OP,29.08,110.57,,,,,,
Health Alliance MCR ADV,CPT,82384,Assay three catecholamines,Lab Services,Per Unit,$25.25 ,OP,25.25,110.57,,,,,,
Health Alliance MCR ADV,CPT,82387,Assay of cathepsin-d,Lab Services,Per Unit,$18.06 ,OP,18.06,91.51,,,,,,
Health Alliance MCR ADV,CPT,82390,Assay of ceruloplasmin,Lab Services,Per Unit,$10.74 ,OP,10.74,49.56,,,,,,
Health Alliance MCR ADV,CPT,82397,Chemiluminescent assay,Lab Services,Per Unit,$14.12 ,OP,14.12,64.82,,,,,,
Health Alliance MCR ADV,CPT,82415,Assay of chloramphenicol,Lab Services,Per Unit,$12.67 ,OP,12.67,57.19,,,,,,
Health Alliance MCR ADV,CPT,82435,Assay of blood chloride,Lab Services,Per Unit,$4.60 ,OP,4.6,19.07,,,,,,
Health Alliance MCR ADV,CPT,82436,Assay of urine chloride,Lab Services,Per Unit,$5.75 ,OP,5.75,22.88,,,,,,
Health Alliance MCR ADV,CPT,82438,Assay other fluid chlorides,Lab Services,Per Unit,$5.00 ,OP,5,5,,,,,,
Health Alliance MCR ADV,CPT,82441,Test for chlorohydrocarbons,Lab Services,Per Unit,$6.01 ,OP,6.01,26.7,,,,,,
Health Alliance MCR ADV,CPT,82465,Assay bld/serum cholesterol,Lab Services,Per Unit,$4.35 ,OP,4.35,22.88,,,,,,
Health Alliance MCR ADV,CPT,82480,Assay serum cholinesterase,Lab Services,Per Unit,$7.87 ,OP,7.87,34.31,,,,,,
Health Alliance MCR ADV,CPT,82482,Assay rbc cholinesterase,Lab Services,Per Unit,$9.81 ,OP,9.81,34.31,,,,,,
Health Alliance MCR ADV,CPT,82485,Assay chondroitin sulfate,Lab Services,Per Unit,$20.65 ,OP,20.65,91.51,,,,,,
Health Alliance MCR ADV,CPT,82495,Assay of chromium,Lab Services,Per Unit,$20.28 ,OP,20.28,91.51,,,,,,
Health Alliance MCR ADV,CPT,82507,Assay of citrate,Lab Services,Per Unit,$27.80 ,OP,27.8,57.19,,,,,,
Health Alliance MCR ADV,CPT,82523,Collagen crosslinks,Lab Services,Per Unit,$18.68 ,OP,18.68,95.32,,,,,,
Health Alliance MCR ADV,CPT,82525,Assay of copper,Lab Services,Per Unit,$12.41 ,OP,12.41,53.38,,,,,,
Health Alliance MCR ADV,CPT,82528,Assay of corticosterone,Lab Services,Per Unit,$22.52 ,OP,22.52,99.13,,,,,,
Health Alliance MCR ADV,CPT,82530,Cortisol free,Lab Services,Per Unit,$16.71 ,OP,16.71,76.26,,,,,,
Health Alliance MCR ADV,CPT,82533,Total cortisol,Lab Services,Per Unit,$16.30 ,OP,16.3,72.44,,,,,,
Health Alliance MCR ADV,CPT,82540,Assay of creatine,Lab Services,Per Unit,$4.64 ,OP,4.64,19.07,,,,,,
Health Alliance MCR ADV,CPT,82542,Col chromotography qual/quan,Lab Services,Per Unit,$24.09 ,OP,24.09,80.07,,,,,,
Health Alliance MCR ADV,CPT,82550,Assay of ck (cpk),Lab Services,Per Unit,$6.51 ,OP,6.51,30.51,,,,,,
Health Alliance MCR ADV,CPT,82552,Assay of cpk in blood,Lab Services,Per Unit,$13.39 ,OP,13.39,61,,,,,,
Health Alliance MCR ADV,CPT,82553,Creatine mb fraction,Lab Services,Per Unit,$11.55 ,OP,11.55,49.56,,,,,,
Health Alliance MCR ADV,CPT,82554,Creatine isoforms,Lab Services,Per Unit,$11.87 ,OP,11.87,53.38,,,,,,
Health Alliance MCR ADV,CPT,82565,Assay of creatinine,Lab Services,Per Unit,$5.12 ,OP,5.12,22.88,,,,,,
Health Alliance MCR ADV,CPT,82570,Assay of urine creatinine,Lab Services,Per Unit,$5.18 ,OP,5.18,26.7,,,,,,
Health Alliance MCR ADV,CPT,82575,Creatinine clearance test,Lab Services,Per Unit,$9.46 ,OP,9.46,41.94,,,,,,
Health Alliance MCR ADV,CPT,82585,Assay of cryofibrinogen,Lab Services,Per Unit,$14.14 ,OP,14.14,38.13,,,,,,
Health Alliance MCR ADV,CPT,82595,Assay of cryoglobulin,Lab Services,Per Unit,$6.47 ,OP,6.47,30.51,,,,,,
Health Alliance MCR ADV,CPT,82600,Assay of cyanide,Lab Services,Per Unit,$19.40 ,OP,19.4,19.4,,,,,,
Health Alliance MCR ADV,CPT,82607,Vitamin b-12,Lab Services,Per Unit,$15.08 ,OP,15.08,68.63,,,,,,
Health Alliance MCR ADV,CPT,82608,B-12 binding capacity,Lab Services,Per Unit,$14.32 ,OP,14.32,14.32,,,,,,
Health Alliance MCR ADV,CPT,82610,Cystatin c,Lab Services,Per Unit,$18.52 ,OP,18.52,61,,,,,,
Health Alliance MCR ADV,CPT,82615,Test for urine cystines,Lab Services,Per Unit,$9.55 ,OP,9.55,38.13,,,,,,
Health Alliance MCR ADV,CPT,82626,Dehydroepiandrosterone,Lab Services,Per Unit,$25.27 ,OP,25.27,114.39,,,,,,
Health Alliance MCR ADV,CPT,82627,Dehydroepiandrosterone,Lab Services,Per Unit,$22.23 ,OP,22.23,99.13,,,,,,
Health Alliance MCR ADV,CPT,82633,Desoxycorticosterone,Lab Services,Per Unit,$30.98 ,OP,30.98,122,,,,,,
Health Alliance MCR ADV,CPT,82634,Deoxycortisol,Lab Services,Per Unit,$29.28 ,OP,29.28,76.26,,,,,,
Health Alliance MCR ADV,CPT,82638,Assay of dibucaine number,Lab Services,Per Unit,$12.25 ,OP,12.25,53.38,,,,,,
Health Alliance MCR ADV,CPT,82642,Dihydrotestosterone,Lab Services,Per Unit,$29.28 ,OP,29.28,114.39,,,,,,
Health Alliance MCR ADV,CPT,82652,Vit d 1 25-dihydroxy,Lab Services,Per Unit,$38.50 ,OP,38.5,171.58,,,,,,
Health Alliance MCR ADV,CPT,82656,Pancreatic elastase fecal,Lab Services,Per Unit,$11.53 ,OP,11.53,11.53,,,,,,
Health Alliance MCR ADV,CPT,82657,Enzyme cell activity,Lab Services,Per Unit,$22.17 ,OP,22.17,80.07,,,,,,
Health Alliance MCR ADV,CPT,82658,Enzyme cell activity ra,Lab Services,Per Unit,$44.03 ,OP,44.03,44.03,,,,,,
Health Alliance MCR ADV,CPT,82664,Electrophoretic test,Lab Services,Per Unit,$61.50 ,OP,61.5,122,,,,,,
Health Alliance MCR ADV,CPT,82668,Assay of erythropoietin,Lab Services,Per Unit,$18.79 ,OP,18.79,83.87,,,,,,
Health Alliance MCR ADV,CPT,82670,Assay of total estradiol,Lab Services,Per Unit,$27.94 ,OP,27.94,49.56,,,,,,
Health Alliance MCR ADV,CPT,82671,Assay of estrogens,Lab Services,Per Unit,$32.30 ,OP,32.3,114.39,,,,,,
Health Alliance MCR ADV,CPT,82672,Assay of estrogen,Lab Services,Per Unit,$21.70 ,OP,21.7,95.32,,,,,,
Health Alliance MCR ADV,CPT,82677,Assay of estriol,Lab Services,Per Unit,$24.18 ,OP,24.18,49.56,,,,,,
Health Alliance MCR ADV,CPT,82679,Assay of estrone,Lab Services,Per Unit,$24.95 ,OP,24.95,57.19,,,,,,
Health Alliance MCR ADV,CPT,82681,Assay dir meas fr estradiol,Lab Services,Per Unit,$27.94 ,OP,27.94,27.94,,,,,,
Health Alliance MCR ADV,CPT,82693,Assay of ethylene glycol,Lab Services,Per Unit,$14.90 ,OP,14.9,64.82,,,,,,
Health Alliance MCR ADV,CPT,82696,Assay of etiocholanolone,Lab Services,Per Unit,$26.24 ,OP,26.24,64.82,,,,,,
Health Alliance MCR ADV,CPT,82705,Fats/lipids feces qual,Lab Services,Per Unit,$5.10 ,OP,5.1,5.1,,,,,,
Health Alliance MCR ADV,CPT,82710,Fats/lipids feces quant,Lab Services,Per Unit,$16.80 ,OP,16.8,16.8,,,,,,
Health Alliance MCR ADV,CPT,82715,Assay of fecal fat,Lab Services,Per Unit,$22.97 ,OP,15.26,22.97,,,,,,
Health Alliance MCR ADV,CPT,82725,Assay of blood fatty acids,Lab Services,Per Unit,$18.77 ,OP,18.77,18.77,,,,,,
Health Alliance MCR ADV,CPT,82726,Long chain fatty acids,Lab Services,Per Unit,$19.75 ,OP,19.75,80.07,,,,,,
Health Alliance MCR ADV,CPT,82728,Assay of ferritin,Lab Services,Per Unit,$13.63 ,OP,13.63,61,,,,,,
Health Alliance MCR ADV,CPT,82731,Assay of fetal fibronectin,Lab Services,Per Unit,$64.41 ,OP,64.41,236.38,,,,,,
Health Alliance MCR ADV,CPT,82735,Assay of fluoride,Lab Services,Per Unit,$18.54 ,OP,18.54,83.87,,,,,,
Health Alliance MCR ADV,CPT,82746,Assay of folic acid serum,Lab Services,Per Unit,$14.70 ,OP,14.7,64.82,,,,,,
Health Alliance MCR ADV,CPT,82747,Assay of folic acid rbc,Lab Services,Per Unit,$17.65 ,OP,17.65,76.26,,,,,,
Health Alliance MCR ADV,CPT,82757,Assay of semen fructose,Lab Services,Per Unit,$17.34 ,OP,17.34,76.26,,,,,,
Health Alliance MCR ADV,CPT,82759,Assay of rbc galactokinase,Lab Services,Per Unit,$21.48 ,OP,21.48,95.32,,,,,,
Health Alliance MCR ADV,CPT,82760,Assay of galactose,Lab Services,Per Unit,$11.20 ,OP,11.2,49.56,,,,,,
Health Alliance MCR ADV,CPT,82775,Assay galactose transferase,Lab Services,Per Unit,$21.07 ,OP,21.07,80.07,,,,,,
Health Alliance MCR ADV,CPT,82776,Galactose transferase test,Lab Services,Per Unit,$11.74 ,OP,11.74,26.7,,,,,,
Health Alliance MCR ADV,CPT,82777,Galectin-3,Lab Services,Per Unit,$44.25 ,OP,44.25,44.25,,,,,,
Health Alliance MCR ADV,CPT,82784,Assay iga/igd/igg/igm each,Lab Services,Per Unit,$9.30 ,OP,9.3,41.94,,,,,,
Health Alliance MCR ADV,CPT,82785,Assay of ige,Lab Services,Per Unit,$16.46 ,OP,16.46,72.44,,,,,,
Health Alliance MCR ADV,CPT,82787,Igg 1 2 3 or 4 each,Lab Services,Per Unit,$8.02 ,OP,8.02,34.31,,,,,,
Health Alliance MCR ADV,CPT,82800,Blood ph,Lab Services,Per Unit,$11.00 ,OP,11,30.51,,,,,,
Health Alliance MCR ADV,CPT,82803,Blood gases any combination,Lab Services,Per Unit,$26.07 ,OP,26.07,61,,,,,,
Health Alliance MCR ADV,CPT,82805,Blood gases w/o2 saturation,Lab Services,Per Unit,$78.77 ,OP,78.77,141.07,,,,,,
Health Alliance MCR ADV,CPT,82810,Blood gases o2 sat only,Lab Services,Per Unit,$9.77 ,OP,9.77,9.77,,,,,,
Health Alliance MCR ADV,CPT,82820,Hemoglobin-oxygen affinity,Lab Services,Per Unit,$13.34 ,OP,13.34,49.56,,,,,,
Health Alliance MCR ADV,CPT,82930,Gastric analy w/ph ea spec,Lab Services,Per Unit,$6.71 ,OP,6.71,6.71,,,,,,
Health Alliance MCR ADV,CPT,82938,Gastrin test,Lab Services,Per Unit,$17.69 ,OP,17.69,80.07,,,,,,
Health Alliance MCR ADV,CPT,82941,Assay of gastrin,Lab Services,Per Unit,$17.63 ,OP,17.63,80.07,,,,,,
Health Alliance MCR ADV,CPT,82943,Assay of glucagon,Lab Services,Per Unit,$14.29 ,OP,14.29,34.31,,,,,,
Health Alliance MCR ADV,CPT,82945,Glucose other fluid,Lab Services,Per Unit,$3.93 ,OP,3.93,19.07,,,,,,
Health Alliance MCR ADV,CPT,82946,Glucagon tolerance test,Lab Services,Per Unit,$17.77 ,OP,17.77,68.63,,,,,,
Health Alliance MCR ADV,CPT,82947,Assay glucose blood quant,Lab Services,Per Unit,$3.93 ,OP,3.93,19.07,,,,,,
Health Alliance MCR ADV,CPT,82948,Reagent strip/blood glucose,Lab Services,Per Unit,$5.04 ,OP,5.04,15.26,,,,,,
Health Alliance MCR ADV,CPT,82950,Glucose test,Lab Services,Per Unit,$4.75 ,OP,4.75,22.88,,,,,,
Health Alliance MCR ADV,CPT,82951,Glucose tolerance test (gtt),Lab Services,Per Unit,$12.87 ,OP,12.87,64.82,,,,,,
Health Alliance MCR ADV,CPT,82952,Gtt-added samples,Lab Services,Per Unit,$3.92 ,OP,3.92,19.07,,,,,,
Health Alliance MCR ADV,CPT,82955,Assay of g6pd enzyme,Lab Services,Per Unit,$9.70 ,OP,9.7,41.94,,,,,,
Health Alliance MCR ADV,CPT,82960,Test for g6pd enzyme,Lab Services,Per Unit,$6.05 ,OP,6.05,6.05,,,,,,
Health Alliance MCR ADV,CPT,82962,Glucose blood test,Lab Services,Per Unit,$3.28 ,OP,3.28,11.44,,,,,,
Health Alliance MCR ADV,CPT,82963,Assay of glucosidase,Lab Services,Per Unit,$21.48 ,OP,21.48,80.07,,,,,,
Health Alliance MCR ADV,CPT,82965,Assay of gdh enzyme,Lab Services,Per Unit,$13.15 ,OP,13.15,34.31,,,,,,
Health Alliance MCR ADV,CPT,82977,Assay of ggt,Lab Services,Per Unit,$7.20 ,OP,7.2,34.31,,,,,,
Health Alliance MCR ADV,CPT,82978,Assay of glutathione,Lab Services,Per Unit,$15.45 ,OP,15.45,64.82,,,,,,
Health Alliance MCR ADV,CPT,82979,Assay rbc glutathione,Lab Services,Per Unit,$9.44 ,OP,9.44,30.51,,,,,,
Health Alliance MCR ADV,CPT,82985,Assay of glycated protein,Lab Services,Per Unit,$16.76 ,OP,16.76,76.26,,,,,,
Health Alliance MCR ADV,CPT,83001,Assay of gonadotropin (fsh),Lab Services,Per Unit,$18.58 ,OP,18.58,91.51,,,,,,
Health Alliance MCR ADV,CPT,83002,Assay of gonadotropin (lh),Lab Services,Per Unit,$18.52 ,OP,18.52,91.51,,,,,,
Health Alliance MCR ADV,CPT,83003,Assay growth hormone (hgh),Lab Services,Per Unit,$16.67 ,OP,16.67,72.44,,,,,,
Health Alliance MCR ADV,CPT,83006,Growth stimulation gene 2,Lab Services,Per Unit,$75.60 ,OP,75.6,75.6,,,,,,
Health Alliance MCR ADV,CPT,83009,H pylori (c-13) blood,Lab Services,Per Unit,$67.36 ,OP,67.36,301.2,,,,,,
Health Alliance MCR ADV,CPT,83010,Assay of haptoglobin quant,Lab Services,Per Unit,$12.58 ,OP,12.58,57.19,,,,,,
Health Alliance MCR ADV,CPT,83012,Assay of haptoglobins,Lab Services,Per Unit,$26.89 ,OP,26.89,72.44,,,,,,
Health Alliance MCR ADV,CPT,83013,H pylori (c-13) breath,Lab Services,Per Unit,$67.36 ,OP,67.36,301.2,,,,,,
Health Alliance MCR ADV,CPT,83014,H pylori drug admin,Lab Services,Per Unit,$7.86 ,OP,7.86,34.31,,,,,,
Health Alliance MCR ADV,CPT,83015,Heavy metal qual any anal,Lab Services,Per Unit,$20.94 ,OP,20.94,83.87,,,,,,
Health Alliance MCR ADV,CPT,83018,Heavy metal quant each nes,Lab Services,Per Unit,$21.96 ,OP,21.96,99.13,,,,,,
Health Alliance MCR ADV,CPT,83020,Hemoglobin electrophoresis,Lab Services,Per Unit,$12.87 ,OP,12.87,45.74,,,,,,
Health Alliance MCR ADV,CPT,83021,Hemoglobin chromotography,Lab Services,Per Unit,$18.06 ,OP,18.06,80.07,,,,,,
Health Alliance MCR ADV,CPT,83026,Hemoglobin copper sulfate,Lab Services,Per Unit,$4.01 ,OP,4.01,4.01,,,,,,
Health Alliance MCR ADV,CPT,83030,Fetal hemoglobin chemical,Lab Services,Per Unit,$10.74 ,OP,10.74,10.74,,,,,,
Health Alliance MCR ADV,CPT,83033,Fetal hemoglobin assay qual,Lab Services,Per Unit,$8.00 ,OP,8,8,,,,,,
Health Alliance MCR ADV,CPT,83036,Glycosylated hemoglobin test,Lab Services,Per Unit,$9.71 ,OP,9.71,49.56,,,,,,
Health Alliance MCR ADV,CPT,83037,Glycosylated hb home device,Lab Services,Per Unit,$9.71 ,OP,9.71,41.94,,,,,,
Health Alliance MCR ADV,CPT,83045,Blood methemoglobin test,Lab Services,Per Unit,$6.49 ,OP,6.49,22.88,,,,,,
Health Alliance MCR ADV,CPT,83050,Blood methemoglobin assay,Lab Services,Per Unit,$8.20 ,OP,8.2,15.26,,,,,,
Health Alliance MCR ADV,CPT,83051,Assay of plasma hemoglobin,Lab Services,Per Unit,$7.31 ,OP,7.31,7.31,,,,,,
Health Alliance MCR ADV,CPT,83060,Blood sulfhemoglobin assay,Lab Services,Per Unit,$8.80 ,OP,8.8,15.26,,,,,,
Health Alliance MCR ADV,CPT,83065,Assay of hemoglobin heat,Lab Services,Per Unit,$9.00 ,OP,9,15.26,,,,,,
Health Alliance MCR ADV,CPT,83068,Hemoglobin stability screen,Lab Services,Per Unit,$9.47 ,OP,9.47,9.47,,,,,,
Health Alliance MCR ADV,CPT,83069,Assay of urine hemoglobin,Lab Services,Per Unit,$3.95 ,OP,3.95,7.62,,,,,,
Health Alliance MCR ADV,CPT,83070,Assay of hemosiderin qual,Lab Services,Per Unit,$4.75 ,OP,4.75,15.26,,,,,,
Health Alliance MCR ADV,CPT,83080,Assay of b hexosaminidase,Lab Services,Per Unit,$16.87 ,OP,16.87,76.26,,,,,,
Health Alliance MCR ADV,CPT,83088,Assay of histamine,Lab Services,Per Unit,$29.53 ,OP,29.53,129.64,,,,,,
Health Alliance MCR ADV,CPT,83090,Assay of homocystine,Lab Services,Per Unit,$17.92 ,OP,17.92,76.26,,,,,,
Health Alliance MCR ADV,CPT,83150,Assay of homovanillic acid,Lab Services,Per Unit,$22.41 ,OP,22.41,87.69,,,,,,
Health Alliance MCR ADV,CPT,83491,Assay of corticosteroids 17,Lab Services,Per Unit,$17.90 ,OP,17.9,76.26,,,,,,
Health Alliance MCR ADV,CPT,83497,Assay of 5-hiaa,Lab Services,Per Unit,$12.90 ,OP,12.9,57.19,,,,,,
Health Alliance MCR ADV,CPT,83498,Assay of progesterone 17-d,Lab Services,Per Unit,$27.17 ,OP,27.17,122,,,,,,
Health Alliance MCR ADV,CPT,83500,Assay free hydroxyproline,Lab Services,Per Unit,$22.65 ,OP,22.65,99.13,,,,,,
Health Alliance MCR ADV,CPT,83505,Assay total hydroxyproline,Lab Services,Per Unit,$24.30 ,OP,24.3,106.76,,,,,,
Health Alliance MCR ADV,CPT,83516,Immunoassay nonantibody,Lab Services,Per Unit,$11.53 ,OP,11.53,49.56,,,,,,
Health Alliance MCR ADV,CPT,83518,Immunoassay dipstick,Lab Services,Per Unit,$9.64 ,OP,9.64,9.64,,,,,,
Health Alliance MCR ADV,CPT,83519,Ria nonantibody,Lab Services,Per Unit,$18.40 ,OP,18.4,61,,,,,,
Health Alliance MCR ADV,CPT,83520,Immunoassay quant nos nonab,Lab Services,Per Unit,$17.27 ,OP,17.27,57.19,,,,,,
Health Alliance MCR ADV,CPT,83525,Assay of insulin,Lab Services,Per Unit,$11.43 ,OP,11.43,49.56,,,,,,
Health Alliance MCR ADV,CPT,83527,Assay of insulin,Lab Services,Per Unit,$12.95 ,OP,12.95,57.19,,,,,,
Health Alliance MCR ADV,CPT,83528,Assay of intrinsic factor,Lab Services,Per Unit,$19.82 ,OP,19.82,72.44,,,,,,
Health Alliance MCR ADV,CPT,83540,Assay of iron,Lab Services,Per Unit,$6.47 ,OP,6.47,30.51,,,,,,
Health Alliance MCR ADV,CPT,83550,Iron binding test,Lab Services,Per Unit,$8.74 ,OP,8.74,38.13,,,,,,
Health Alliance MCR ADV,CPT,83570,Assay of idh enzyme,Lab Services,Per Unit,$8.85 ,OP,8.85,38.13,,,,,,
Health Alliance MCR ADV,CPT,83582,Assay of ketogenic steroids,Lab Services,Per Unit,$15.47 ,OP,15.47,15.47,,,,,,
Health Alliance MCR ADV,CPT,83586,Assay 17- ketosteroids,Lab Services,Per Unit,$12.80 ,OP,12.8,57.19,,,,,,
Health Alliance MCR ADV,CPT,83593,Fractionation ketosteroids,Lab Services,Per Unit,$28.50 ,OP,28.5,118.19,,,,,,
Health Alliance MCR ADV,CPT,83605,Assay of lactic acid,Lab Services,Per Unit,$11.57 ,OP,11.57,53.38,,,,,,
Health Alliance MCR ADV,CPT,83615,Lactate (ld) (ldh) enzyme,Lab Services,Per Unit,$6.04 ,OP,6.04,26.7,,,,,,
Health Alliance MCR ADV,CPT,83625,Assay of ldh enzymes,Lab Services,Per Unit,$12.79 ,OP,12.79,49.56,,,,,,
Health Alliance MCR ADV,CPT,83630,Lactoferrin fecal (qual),Lab Services,Per Unit,$19.70 ,OP,19.7,87.69,,,,,,
Health Alliance MCR ADV,CPT,83631,Lactoferrin fecal (quant),Lab Services,Per Unit,$19.63 ,OP,19.63,87.69,,,,,,
Health Alliance MCR ADV,CPT,83632,Placental lactogen,Lab Services,Per Unit,$20.22 ,OP,20.22,91.51,,,,,,
Health Alliance MCR ADV,CPT,83633,Test urine for lactose,Lab Services,Per Unit,$11.25 ,OP,11.25,22.88,,,,,,
Health Alliance MCR ADV,CPT,83655,Assay of lead,Lab Services,Per Unit,$12.11 ,OP,12.11,53.38,,,,,,
Health Alliance MCR ADV,CPT,83661,L/s ratio fetal lung,Lab Services,Per Unit,$21.99 ,OP,21.99,99.13,,,,,,
Health Alliance MCR ADV,CPT,83662,Foam stability fetal lung,Lab Services,Per Unit,$18.91 ,OP,18.91,83.87,,,,,,
Health Alliance MCR ADV,CPT,83663,Fluoro polarize fetal lung,Lab Services,Per Unit,$18.91 ,OP,18.91,83.87,,,,,,
Health Alliance MCR ADV,CPT,83664,Lamellar bdy fetal lung,Lab Services,Per Unit,$19.32 ,OP,19.32,83.87,,,,,,
Health Alliance MCR ADV,CPT,83670,Assay of lap enzyme,Lab Services,Per Unit,$9.81 ,OP,9.81,41.94,,,,,,
Health Alliance MCR ADV,CPT,83690,Assay of lipase,Lab Services,Per Unit,$6.89 ,OP,6.89,61.5,,,,,,
Health Alliance MCR ADV,CPT,83695,Assay of lipoprotein(a),Lab Services,Per Unit,$14.32 ,OP,14.32,57.19,,,,,,
Health Alliance MCR ADV,CPT,83698,Assay lipoprotein pla2,Lab Services,Per Unit,$46.31 ,OP,46.31,125.82,,,,,,
Health Alliance MCR ADV,CPT,83700,Lipopro bld electrophoretic,Lab Services,Per Unit,$11.26 ,OP,11.26,49.56,,,,,,
Health Alliance MCR ADV,CPT,83701,Lipoprotein bld hr fraction,Lab Services,Per Unit,$33.86 ,OP,33.86,110.57,,,,,,
Health Alliance MCR ADV,CPT,83704,Lipoprotein bld quan part,Lab Services,Per Unit,$34.19 ,OP,34.19,141.07,,,,,,
Health Alliance MCR ADV,CPT,83718,Assay of lipoprotein,Lab Services,Per Unit,$8.19 ,OP,8.19,41.94,,,,,,
Health Alliance MCR ADV,CPT,83719,Assay of blood lipoprotein,Lab Services,Per Unit,$12.75 ,OP,12.75,53.38,,,,,,
Health Alliance MCR ADV,CPT,83721,Assay of blood lipoprotein,Lab Services,Per Unit,$10.50 ,OP,10.5,41.94,,,,,,
Health Alliance MCR ADV,CPT,83722,Lipoprtn dir meas sd ldl chl,Lab Services,Per Unit,$34.19 ,OP,34.19,141.07,,,,,,
Health Alliance MCR ADV,CPT,83727,Assay of lrh hormone,Lab Services,Per Unit,$17.19 ,OP,17.19,76.26,,,,,,
Health Alliance MCR ADV,CPT,83735,Assay of magnesium,Lab Services,Per Unit,$6.70 ,OP,6.7,34.31,,,,,,
Health Alliance MCR ADV,CPT,83775,Assay malate dehydrogenase,Lab Services,Per Unit,$7.37 ,OP,7.37,34.31,,,,,,
Health Alliance MCR ADV,CPT,83785,Assay of manganese,Lab Services,Per Unit,$26.65 ,OP,26.65,110.57,,,,,,
Health Alliance MCR ADV,CPT,83789,Mass spectrometry qual/quan,Lab Services,Per Unit,$24.11 ,OP,24.11,80.07,,,,,,
Health Alliance MCR ADV,CPT,83825,Assay of mercury,Lab Services,Per Unit,$16.26 ,OP,16.26,72.44,,,,,,
Health Alliance MCR ADV,CPT,83835,Assay of metanephrines,Lab Services,Per Unit,$16.94 ,OP,16.94,76.26,,,,,,
Health Alliance MCR ADV,CPT,83857,Assay of methemalbumin,Lab Services,Per Unit,$10.74 ,OP,10.74,49.56,,,,,,
Health Alliance MCR ADV,CPT,83861,Microfluid analy tears,Lab Services,Per Unit,$22.48 ,OP,22.48,22.48,,,,,,
Health Alliance MCR ADV,CPT,83864,Mucopolysaccharides,Lab Services,Per Unit,$28.50 ,OP,28.5,87.69,,,,,,
Health Alliance MCR ADV,CPT,83872,Assay synovial fluid mucin,Lab Services,Per Unit,$5.86 ,OP,5.86,26.7,,,,,,
Health Alliance MCR ADV,CPT,83873,Assay of csf protein,Lab Services,Per Unit,$17.20 ,OP,17.2,72.44,,,,,,
Health Alliance MCR ADV,CPT,83874,Assay of myoglobin,Lab Services,Per Unit,$12.92 ,OP,12.92,57.19,,,,,,
Health Alliance MCR ADV,CPT,83876,Assay myeloperoxidase,Lab Services,Per Unit,$50.86 ,OP,50.86,57.19,,,,,,
Health Alliance MCR ADV,CPT,83880,Assay of natriuretic peptide,Lab Services,Per Unit,$39.26 ,OP,39.26,245.98,,,,,,
Health Alliance MCR ADV,CPT,83883,Assay nephelometry not spec,Lab Services,Per Unit,$13.60 ,OP,13.6,61,,,,,,
Health Alliance MCR ADV,CPT,83885,Assay of nickel,Lab Services,Per Unit,$24.51 ,OP,24.51,45.74,,,,,,
Health Alliance MCR ADV,CPT,83915,Assay of nucleotidase,Lab Services,Per Unit,$11.15 ,OP,11.15,11.15,,,,,,
Health Alliance MCR ADV,CPT,83916,Oligoclonal bands,Lab Services,Per Unit,$27.39 ,OP,27.39,87.69,,,,,,
Health Alliance MCR ADV,CPT,83918,Organic acids total quant,Lab Services,Per Unit,$23.60 ,OP,23.6,72.44,,,,,,
Health Alliance MCR ADV,CPT,83919,Organic acids qual each,Lab Services,Per Unit,$16.45 ,OP,16.45,16.45,,,,,,
Health Alliance MCR ADV,CPT,83921,Organic acid single quant,Lab Services,Per Unit,$21.21 ,OP,21.21,72.44,,,,,,
Health Alliance MCR ADV,CPT,83930,Assay of blood osmolality,Lab Services,Per Unit,$6.61 ,OP,6.61,26.7,,,,,,
Health Alliance MCR ADV,CPT,83935,Assay of urine osmolality,Lab Services,Per Unit,$6.82 ,OP,6.82,30.51,,,,,,
Health Alliance MCR ADV,CPT,83937,Assay of osteocalcin,Lab Services,Per Unit,$29.85 ,OP,29.85,133.45,,,,,,
Health Alliance MCR ADV,CPT,83945,Assay of oxalate,Lab Services,Per Unit,$14.45 ,OP,14.45,57.19,,,,,,
Health Alliance MCR ADV,CPT,83950,Oncoprotein her-2/neu,Lab Services,Per Unit,$64.41 ,OP,64.41,209.7,,,,,,
Health Alliance MCR ADV,CPT,83951,Oncoprotein dcp,Lab Services,Per Unit,$64.41 ,OP,64.41,209.7,,,,,,
Health Alliance MCR ADV,CPT,83970,Assay of parathormone,Lab Services,Per Unit,$41.28 ,OP,41.28,183.02,,,,,,
Health Alliance MCR ADV,CPT,83986,Assay ph body fluid nos,Lab Services,Per Unit,$3.58 ,OP,3.58,19.07,,,,,,
Health Alliance MCR ADV,CPT,83987,Exhaled breath condensate,Lab Services,Per Unit,$3.58 ,OP,3.58,3.58,,,,,,
Health Alliance MCR ADV,CPT,83993,Assay for calprotectin fecal,Lab Services,Per Unit,$19.63 ,OP,19.63,87.69,,,,,,
Health Alliance MCR ADV,CPT,84030,Assay of blood pku,Lab Services,Per Unit,$5.50 ,OP,5.5,26.7,,,,,,
Health Alliance MCR ADV,CPT,84035,Assay of phenylketones,Lab Services,Per Unit,$3.98 ,OP,3.98,15.26,,,,,,
Health Alliance MCR ADV,CPT,84060,Assay acid phosphatase,Lab Services,Per Unit,$7.64 ,OP,7.64,34.31,,,,,,
Health Alliance MCR ADV,CPT,84066,Assay prostate phosphatase,Lab Services,Per Unit,$9.66 ,OP,9.66,41.94,,,,,,
Health Alliance MCR ADV,CPT,84075,Assay alkaline phosphatase,Lab Services,Per Unit,$5.18 ,OP,5.18,26.7,,,,,,
Health Alliance MCR ADV,CPT,84078,Assay alkaline phosphatase,Lab Services,Per Unit,$8.26 ,OP,8.26,34.31,,,,,,
Health Alliance MCR ADV,CPT,84080,Assay alkaline phosphatases,Lab Services,Per Unit,$14.78 ,OP,14.78,64.82,,,,,,
Health Alliance MCR ADV,CPT,84081,Assay phosphatidylglycerol,Lab Services,Per Unit,$16.52 ,OP,16.52,72.44,,,,,,
Health Alliance MCR ADV,CPT,84085,Assay of rbc pg6d enzyme,Lab Services,Per Unit,$9.44 ,OP,9.44,30.51,,,,,,
Health Alliance MCR ADV,CPT,84087,Assay phosphohexose enzymes,Lab Services,Per Unit,$10.73 ,OP,10.73,45.74,,,,,,
Health Alliance MCR ADV,CPT,84100,Assay of phosphorus,Lab Services,Per Unit,$4.74 ,OP,4.74,22.88,,,,,,
Health Alliance MCR ADV,CPT,84105,Assay of urine phosphorus,Lab Services,Per Unit,$5.78 ,OP,5.78,22.88,,,,,,
Health Alliance MCR ADV,CPT,84106,Test for porphobilinogen,Lab Services,Per Unit,$5.82 ,OP,5.82,19.07,,,,,,
Health Alliance MCR ADV,CPT,84110,Assay of porphobilinogen,Lab Services,Per Unit,$8.44 ,OP,8.44,38.13,,,,,,
Health Alliance MCR ADV,CPT,84112,Eval amniotic fluid protein,Lab Services,Per Unit,$98.11 ,OP,98.11,98.11,,,,,,
Health Alliance MCR ADV,CPT,84119,Test urine for porphyrins,Lab Services,Per Unit,$13.36 ,OP,13.36,13.36,,,,,,
Health Alliance MCR ADV,CPT,84120,Assay of urine porphyrins,Lab Services,Per Unit,$14.71 ,OP,14.71,64.82,,,,,,
Health Alliance MCR ADV,CPT,84126,Assay of feces porphyrins,Lab Services,Per Unit,$39.11 ,OP,39.11,114.39,,,,,,
Health Alliance MCR ADV,CPT,84132,Assay of serum potassium,Lab Services,Per Unit,$4.76 ,OP,4.76,22.88,,,,,,
Health Alliance MCR ADV,CPT,84133,Assay of urine potassium,Lab Services,Per Unit,$4.73 ,OP,4.73,19.07,,,,,,
Health Alliance MCR ADV,CPT,84134,Assay of prealbumin,Lab Services,Per Unit,$14.59 ,OP,14.59,64.82,,,,,,
Health Alliance MCR ADV,CPT,84135,Assay of pregnanediol,Lab Services,Per Unit,$21.27 ,OP,21.27,57.19,,,,,,
Health Alliance MCR ADV,CPT,84138,Assay of pregnanetriol,Lab Services,Per Unit,$21.05 ,OP,21.05,83.87,,,,,,
Health Alliance MCR ADV,CPT,84140,Assay of pregnenolone,Lab Services,Per Unit,$20.67 ,OP,20.67,91.51,,,,,,
Health Alliance MCR ADV,CPT,84143,Assay of 17-hydroxypregneno,Lab Services,Per Unit,$22.81 ,OP,22.81,102.95,,,,,,
Health Alliance MCR ADV,CPT,84144,Assay of progesterone,Lab Services,Per Unit,$20.86 ,OP,20.86,91.51,,,,,,
Health Alliance MCR ADV,CPT,84145,Procalcitonin (pct),Lab Services,Per Unit,$27.22 ,OP,27.22,27.22,,,,,,
Health Alliance MCR ADV,CPT,84146,Assay of prolactin,Lab Services,Per Unit,$19.38 ,OP,19.38,87.69,,,,,,
Health Alliance MCR ADV,CPT,84150,Assay of prostaglandin,Lab Services,Per Unit,$41.77 ,OP,41.77,41.77,,,,,,
Health Alliance MCR ADV,CPT,84152,Assay of psa complexed,Lab Services,Per Unit,$18.39 ,OP,18.39,80.07,,,,,,
Health Alliance MCR ADV,CPT,84153,Assay of psa total,Lab Services,Per Unit,$18.39 ,OP,18.39,80.07,,,,,,
Health Alliance MCR ADV,CPT,84154,Assay of psa free,Lab Services,Per Unit,$18.39 ,OP,18.39,80.07,,,,,,
Health Alliance MCR ADV,CPT,84155,Assay of protein serum,Lab Services,Per Unit,$3.67 ,OP,3.67,15.26,,,,,,
Health Alliance MCR ADV,CPT,84156,Assay of protein urine,Lab Services,Per Unit,$3.67 ,OP,3.67,15.26,,,,,,
Health Alliance MCR ADV,CPT,84157,Assay of protein other,Lab Services,Per Unit,$4.00 ,OP,4,19.07,,,,,,
Health Alliance MCR ADV,CPT,84160,Assay of protein any source,Lab Services,Per Unit,$5.61 ,OP,5.61,22.88,,,,,,
Health Alliance MCR ADV,CPT,84163,Pappa serum,Lab Services,Per Unit,$15.05 ,OP,15.05,68.63,,,,,,
Health Alliance MCR ADV,CPT,84165,Protein e-phoresis serum,Lab Services,Per Unit,$10.74 ,OP,10.74,49.56,,,,,,
Health Alliance MCR ADV,CPT,84166,Protein e-phoresis/urine/csf,Lab Services,Per Unit,$17.83 ,OP,17.83,80.07,,,,,,
Health Alliance MCR ADV,CPT,84181,Western blot test,Lab Services,Per Unit,$17.03 ,OP,17.03,118.19,,,,,,
Health Alliance MCR ADV,CPT,84182,Protein western blot test,Lab Services,Per Unit,$29.21 ,OP,29.21,129.64,,,,,,
Health Alliance MCR ADV,CPT,84202,Assay rbc protoporphyrin,Lab Services,Per Unit,$14.35 ,OP,14.35,64.82,,,,,,
Health Alliance MCR ADV,CPT,84203,Test rbc protoporphyrin,Lab Services,Per Unit,$9.74 ,OP,9.74,38.13,,,,,,
Health Alliance MCR ADV,CPT,84206,Assay of proinsulin,Lab Services,Per Unit,$26.69 ,OP,26.69,80.07,,,,,,
Health Alliance MCR ADV,CPT,84207,Assay of vitamin b-6,Lab Services,Per Unit,$28.10 ,OP,28.1,125.82,,,,,,
Health Alliance MCR ADV,CPT,84210,Assay of pyruvate,Lab Services,Per Unit,$14.48 ,OP,14.48,49.56,,,,,,
Health Alliance MCR ADV,CPT,84220,Assay of pyruvate kinase,Lab Services,Per Unit,$9.44 ,OP,9.44,41.94,,,,,,
Health Alliance MCR ADV,CPT,84228,Assay of quinine,Lab Services,Per Unit,$11.63 ,OP,11.63,53.38,,,,,,
Health Alliance MCR ADV,CPT,84233,Assay of estrogen,Lab Services,Per Unit,$87.88 ,OP,87.88,209.7,,,,,,
Health Alliance MCR ADV,CPT,84234,Assay of progesterone,Lab Services,Per Unit,$64.88 ,OP,64.88,183.02,,,,,,
Health Alliance MCR ADV,CPT,84235,Assay of endocrine hormone,Lab Services,Per Unit,$71.23 ,OP,71.23,163.95,,,,,,
Health Alliance MCR ADV,CPT,84238,Assay nonendocrine receptor,Lab Services,Per Unit,$36.57 ,OP,36.57,163.95,,,,,,
Health Alliance MCR ADV,CPT,84244,Assay of renin,Lab Services,Per Unit,$21.99 ,OP,21.99,99.13,,,,,,
Health Alliance MCR ADV,CPT,84252,Assay of vitamin b-2,Lab Services,Per Unit,$20.24 ,OP,20.24,20.24,,,,,,
Health Alliance MCR ADV,CPT,84255,Assay of selenium,Lab Services,Per Unit,$25.53 ,OP,25.53,114.39,,,,,,
Health Alliance MCR ADV,CPT,84260,Assay of serotonin,Lab Services,Per Unit,$30.98 ,OP,30.98,30.98,,,,,,
Health Alliance MCR ADV,CPT,84270,Assay of sex hormone globul,Lab Services,Per Unit,$21.73 ,OP,21.73,95.32,,,,,,
Health Alliance MCR ADV,CPT,84275,Assay of sialic acid,Lab Services,Per Unit,$13.44 ,OP,13.44,13.44,,,,,,
Health Alliance MCR ADV,CPT,84285,Assay of silica,Lab Services,Per Unit,$25.21 ,OP,25.21,38.13,,,,,,
Health Alliance MCR ADV,CPT,84295,Assay of serum sodium,Lab Services,Per Unit,$4.81 ,OP,4.81,22.88,,,,,,
Health Alliance MCR ADV,CPT,84300,Assay of urine sodium,Lab Services,Per Unit,$5.06 ,OP,5.06,22.88,,,,,,
Health Alliance MCR ADV,CPT,84302,Assay of sweat sodium,Lab Services,Per Unit,$4.86 ,OP,4.86,22.88,,,,,,
Health Alliance MCR ADV,CPT,84305,Assay of somatomedin,Lab Services,Per Unit,$21.26 ,OP,21.26,95.32,,,,,,
Health Alliance MCR ADV,CPT,84307,Assay of somatostatin,Lab Services,Per Unit,$18.28 ,OP,18.28,80.07,,,,,,
Health Alliance MCR ADV,CPT,84311,Spectrophotometry,Lab Services,Per Unit,$8.10 ,OP,8.1,30.51,,,,,,
Health Alliance MCR ADV,CPT,84315,Body fluid specific gravity,Lab Services,Per Unit,$3.28 ,OP,3.28,11.44,,,,,,
Health Alliance MCR ADV,CPT,84375,Chromatogram assay sugars,Lab Services,Per Unit,$39.00 ,OP,39,39,,,,,,
Health Alliance MCR ADV,CPT,84376,Sugars single qual,Lab Services,Per Unit,$5.50 ,OP,5.5,22.88,,,,,,
Health Alliance MCR ADV,CPT,84377,Sugars multiple qual,Lab Services,Per Unit,$5.50 ,OP,5.5,22.88,,,,,,
Health Alliance MCR ADV,CPT,84378,Sugars single quant,Lab Services,Per Unit,$11.53 ,OP,11.53,49.56,,,,,,
Health Alliance MCR ADV,CPT,84379,Sugars multiple quant,Lab Services,Per Unit,$11.53 ,OP,11.53,49.56,,,,,,
Health Alliance MCR ADV,CPT,84392,Assay of urine sulfate,Lab Services,Per Unit,$5.49 ,OP,5.49,22.88,,,,,,
Health Alliance MCR ADV,CPT,84402,Assay of free testosterone,Lab Services,Per Unit,$25.47 ,OP,25.47,114.39,,,,,,
Health Alliance MCR ADV,CPT,84403,Assay of total testosterone,Lab Services,Per Unit,$25.81 ,OP,25.81,114.39,,,,,,
Health Alliance MCR ADV,CPT,84410,Testosterone bioavailable,Lab Services,Per Unit,$51.28 ,OP,51.28,51.28,,,,,,
Health Alliance MCR ADV,CPT,84425,Assay of vitamin b-1,Lab Services,Per Unit,$21.23 ,OP,21.23,95.32,,,,,,
Health Alliance MCR ADV,CPT,84430,Assay of thiocyanate,Lab Services,Per Unit,$11.63 ,OP,11.63,53.38,,,,,,
Health Alliance MCR ADV,CPT,84431,Thromboxane urine,Lab Services,Per Unit,$35.11 ,OP,35.11,35.11,,,,,,
Health Alliance MCR ADV,CPT,84432,Assay of thyroglobulin,Lab Services,Per Unit,$16.06 ,OP,16.06,72.44,,,,,,
Health Alliance MCR ADV,CPT,84436,Assay of total thyroxine,Lab Services,Per Unit,$6.87 ,OP,6.87,30.51,,,,,,
Health Alliance MCR ADV,CPT,84437,Assay of neonatal thyroxine,Lab Services,Per Unit,$6.47 ,OP,6.47,30.51,,,,,,
Health Alliance MCR ADV,CPT,84439,Assay of free thyroxine,Lab Services,Per Unit,$9.02 ,OP,9.02,41.94,,,,,,
Health Alliance MCR ADV,CPT,84442,Assay of thyroid activity,Lab Services,Per Unit,$14.78 ,OP,14.78,64.82,,,,,,
Health Alliance MCR ADV,CPT,84443,Assay thyroid stim hormone,Lab Services,Per Unit,$16.80 ,OP,16.8,76.26,,,,,,
Health Alliance MCR ADV,CPT,84445,Assay of tsi globulin,Lab Services,Per Unit,$50.86 ,OP,50.86,224.95,,,,,,
Health Alliance MCR ADV,CPT,84446,Assay of vitamin e,Lab Services,Per Unit,$14.18 ,OP,14.18,64.82,,,,,,
Health Alliance MCR ADV,CPT,84449,Assay of transcortin,Lab Services,Per Unit,$18.00 ,OP,18,80.07,,,,,,
Health Alliance MCR ADV,CPT,84450,Transferase (ast) (sgot),Lab Services,Per Unit,$5.18 ,OP,5.18,22.88,,,,,,
Health Alliance MCR ADV,CPT,84460,Alanine amino (alt) (sgpt),Lab Services,Per Unit,$5.30 ,OP,5.3,26.7,,,,,,
Health Alliance MCR ADV,CPT,84466,Assay of transferrin,Lab Services,Per Unit,$12.76 ,OP,12.76,57.19,,,,,,
Health Alliance MCR ADV,CPT,84478,Assay of triglycerides,Lab Services,Per Unit,$5.74 ,OP,5.74,30.51,,,,,,
Health Alliance MCR ADV,CPT,84479,Assay of thyroid (t3 or t4),Lab Services,Per Unit,$6.47 ,OP,6.47,30.51,,,,,,
Health Alliance MCR ADV,CPT,84480,Assay triiodothyronine (t3),Lab Services,Per Unit,$14.18 ,OP,14.18,49.56,,,,,,
Health Alliance MCR ADV,CPT,84481,Free assay (ft-3),Lab Services,Per Unit,$16.94 ,OP,16.94,49.56,,,,,,
Health Alliance MCR ADV,CPT,84482,T3 reverse,Lab Services,Per Unit,$15.76 ,OP,15.76,68.63,,,,,,
Health Alliance MCR ADV,CPT,84484,Assay of troponin quant,Lab Services,Per Unit,$12.47 ,OP,12.47,92.24,,,,,,
Health Alliance MCR ADV,CPT,84485,Assay duodenal fluid trypsin,Lab Services,Per Unit,$7.20 ,OP,7.2,7.2,,,,,,
Health Alliance MCR ADV,CPT,84488,Test feces for trypsin,Lab Services,Per Unit,$7.30 ,OP,7.3,34.31,,,,,,
Health Alliance MCR ADV,CPT,84490,Assay of feces for trypsin,Lab Services,Per Unit,$9.93 ,OP,9.93,26.7,,,,,,
Health Alliance MCR ADV,CPT,84510,Assay of tyrosine,Lab Services,Per Unit,$10.63 ,OP,10.63,45.74,,,,,,
Health Alliance MCR ADV,CPT,84512,Assay of troponin qual,Lab Services,Per Unit,$10.09 ,OP,10.09,34.31,,,,,,
Health Alliance MCR ADV,CPT,84520,Assay of urea nitrogen,Lab Services,Per Unit,$3.95 ,OP,3.95,19.07,,,,,,
Health Alliance MCR ADV,CPT,84525,Urea nitrogen semi-quant,Lab Services,Per Unit,$5.13 ,OP,5.13,15.26,,,,,,
Health Alliance MCR ADV,CPT,84540,Assay of urine/urea-n,Lab Services,Per Unit,$5.56 ,OP,5.56,22.88,,,,,,
Health Alliance MCR ADV,CPT,84545,Urea-n clearance test,Lab Services,Per Unit,$7.20 ,OP,7.2,19.07,,,,,,
Health Alliance MCR ADV,CPT,84550,Assay of blood/uric acid,Lab Services,Per Unit,$4.52 ,OP,4.52,19.07,,,,,,
Health Alliance MCR ADV,CPT,84560,Assay of urine/uric acid,Lab Services,Per Unit,$5.08 ,OP,5.08,22.88,,,,,,
Health Alliance MCR ADV,CPT,84577,Assay of feces/urobilinogen,Lab Services,Per Unit,$16.80 ,OP,16.8,57.19,,,,,,
Health Alliance MCR ADV,CPT,84578,Test urine urobilinogen,Lab Services,Per Unit,$4.47 ,OP,4.47,15.26,,,,,,
Health Alliance MCR ADV,CPT,84580,Assay of urine urobilinogen,Lab Services,Per Unit,$9.55 ,OP,9.55,19.07,,,,,,
Health Alliance MCR ADV,CPT,84583,Assay of urine urobilinogen,Lab Services,Per Unit,$6.05 ,OP,6.05,22.88,,,,,,
Health Alliance MCR ADV,CPT,84585,Assay of urine vma,Lab Services,Per Unit,$15.50 ,OP,15.5,68.63,,,,,,
Health Alliance MCR ADV,CPT,84586,Assay of vip,Lab Services,Per Unit,$35.33 ,OP,35.33,156.32,,,,,,
Health Alliance MCR ADV,CPT,84588,Assay of vasopressin,Lab Services,Per Unit,$33.94 ,OP,33.94,125.82,,,,,,
Health Alliance MCR ADV,CPT,84590,Assay of vitamin a,Lab Services,Per Unit,$11.61 ,OP,11.61,53.38,,,,,,
Health Alliance MCR ADV,CPT,84591,Assay of nos vitamin,Lab Services,Per Unit,$17.06 ,OP,17.06,53.38,,,,,,
Health Alliance MCR ADV,CPT,84597,Assay of vitamin k,Lab Services,Per Unit,$13.72 ,OP,13.72,49.56,,,,,,
Health Alliance MCR ADV,CPT,84600,Assay of volatiles,Lab Services,Per Unit,$17.11 ,OP,17.11,72.44,,,,,,
Health Alliance MCR ADV,CPT,84620,Xylose tolerance test,Lab Services,Per Unit,$12.91 ,OP,12.91,38.13,,,,,,
Health Alliance MCR ADV,CPT,84630,Assay of zinc,Lab Services,Per Unit,$11.39 ,OP,11.39,49.56,,,,,,
Health Alliance MCR ADV,CPT,84681,Assay of c-peptide,Lab Services,Per Unit,$20.81 ,OP,20.81,91.51,,,,,,
Health Alliance MCR ADV,CPT,84702,Chorionic gonadotropin test,Lab Services,Per Unit,$15.05 ,OP,15.05,76.26,,,,,,
Health Alliance MCR ADV,CPT,84703,Chorionic gonadotropin assay,Lab Services,Per Unit,$7.52 ,OP,7.52,38.13,,,,,,
Health Alliance MCR ADV,CPT,84704,Hcg free betachain test,Lab Services,Per Unit,$15.29 ,OP,15.29,68.63,,,,,,
Health Alliance MCR ADV,CPT,84830,Ovulation tests,Lab Services,Per Unit,$12.70 ,OP,12.7,49.56,,,,,,
Health Alliance MCR ADV,CPT,85002,Bleeding time test,Lab Services,Per Unit,$4.82 ,OP,4.82,22.88,,,,,,
Health Alliance MCR ADV,CPT,85004,Automated diff wbc count,Lab Services,Per Unit,$6.47 ,OP,6.47,34.31,,,,,,
Health Alliance MCR ADV,CPT,85007,Bl smear w/diff wbc count,Lab Services,Per Unit,$3.80 ,OP,3.8,19.07,,,,,,
Health Alliance MCR ADV,CPT,85008,Bl smear w/o diff wbc count,Lab Services,Per Unit,$3.43 ,OP,3.43,19.07,,,,,,
Health Alliance MCR ADV,CPT,85009,Manual diff wbc count b-coat,Lab Services,Per Unit,$5.07 ,OP,5.07,19.07,,,,,,
Health Alliance MCR ADV,CPT,85013,Spun microhematocrit,Lab Services,Per Unit,$7.00 ,OP,7,7,,,,,,
Health Alliance MCR ADV,CPT,85014,Hematocrit,Lab Services,Per Unit,$2.37 ,OP,2.37,11.44,,,,,,
Health Alliance MCR ADV,CPT,85018,Hemoglobin,Lab Services,Per Unit,$2.37 ,OP,2.37,11.44,,,,,,
Health Alliance MCR ADV,CPT,85025,Complete cbc w/auto diff wbc,Lab Services,Per Unit,$7.77 ,OP,7.77,67.65,,,,,,
Health Alliance MCR ADV,CPT,85027,Complete cbc automated,Lab Services,Per Unit,$6.47 ,OP,6.47,34.31,,,,,,
Health Alliance MCR ADV,CPT,85032,Manual cell count each,Lab Services,Per Unit,$4.31 ,OP,4.31,22.88,,,,,,
Health Alliance MCR ADV,CPT,85041,Automated rbc count,Lab Services,Per Unit,$3.02 ,OP,3.02,11.44,,,,,,
Health Alliance MCR ADV,CPT,85044,Manual reticulocyte count,Lab Services,Per Unit,$4.31 ,OP,4.31,4.31,,,,,,
Health Alliance MCR ADV,CPT,85045,Automated reticulocyte count,Lab Services,Per Unit,$3.99 ,OP,3.99,19.07,,,,,,
Health Alliance MCR ADV,CPT,85046,Reticyte/hgb concentrate,Lab Services,Per Unit,$5.57 ,OP,5.57,26.7,,,,,,
Health Alliance MCR ADV,CPT,85048,Automated leukocyte count,Lab Services,Per Unit,$2.54 ,OP,2.54,11.44,,,,,,
Health Alliance MCR ADV,CPT,85049,Automated platelet count,Lab Services,Per Unit,$4.48 ,OP,4.48,22.88,,,,,,
Health Alliance MCR ADV,CPT,85055,Reticulated platelet assay,Lab Services,Per Unit,$35.74 ,OP,35.74,61,,,,,,
Health Alliance MCR ADV,CPT,85097,Bone marrow interpretation,APC 5674,RVU Per Case,$671.45 ,OP,438.47,671.45,,,,,,
Health Alliance MCR ADV,CPT,85130,Chromogenic substrate assay,Lab Services,Per Unit,$11.89 ,OP,11.89,53.38,,,,,,
Health Alliance MCR ADV,CPT,85170,Blood clot retraction,Lab Services,Per Unit,$16.30 ,OP,16.3,16.3,,,,,,
Health Alliance MCR ADV,CPT,85175,Blood clot lysis time,Lab Services,Per Unit,$20.37 ,OP,19.07,20.37,,,,,,
Health Alliance MCR ADV,CPT,85210,Clot factor ii prothrom spec,Lab Services,Per Unit,$12.98 ,OP,12.98,64.82,,,,,,
Health Alliance MCR ADV,CPT,85220,Blooc clot factor v test,Lab Services,Per Unit,$17.65 ,OP,17.65,80.07,,,,,,
Health Alliance MCR ADV,CPT,85230,Clot factor vii proconvertin,Lab Services,Per Unit,$17.90 ,OP,17.9,80.07,,,,,,
Health Alliance MCR ADV,CPT,85240,Clot factor viii ahg 1 stage,Lab Services,Per Unit,$17.90 ,OP,17.9,80.07,,,,,,
Health Alliance MCR ADV,CPT,85244,Clot factor viii reltd antgn,Lab Services,Per Unit,$20.42 ,OP,20.42,91.51,,,,,,
Health Alliance MCR ADV,CPT,85245,Clot factor viii vw ristoctn,Lab Services,Per Unit,$22.94 ,OP,22.94,64.82,,,,,,
Health Alliance MCR ADV,CPT,85246,Clot factor viii vw antigen,Lab Services,Per Unit,$22.94 ,OP,22.94,64.82,,,,,,
Health Alliance MCR ADV,CPT,85247,Clot factor viii multimetric,Lab Services,Per Unit,$22.94 ,OP,22.94,22.94,,,,,,
Health Alliance MCR ADV,CPT,85250,Clot factor ix ptc/chrstmas,Lab Services,Per Unit,$19.04 ,OP,19.04,83.87,,,,,,
Health Alliance MCR ADV,CPT,85260,Clot factor x stuart-power,Lab Services,Per Unit,$17.90 ,OP,17.9,80.07,,,,,,
Health Alliance MCR ADV,CPT,85270,Clot factor xi pta,Lab Services,Per Unit,$17.90 ,OP,17.9,80.07,,,,,,
Health Alliance MCR ADV,CPT,85280,Clot factor xii hageman,Lab Services,Per Unit,$19.35 ,OP,19.35,87.69,,,,,,
Health Alliance MCR ADV,CPT,85290,Clot factor xiii fibrin stab,Lab Services,Per Unit,$16.34 ,OP,16.34,72.44,,,,,,
Health Alliance MCR ADV,CPT,85291,Clot factor xiii fibrin scrn,Lab Services,Per Unit,$9.11 ,OP,9.11,38.13,,,,,,
Health Alliance MCR ADV,CPT,85292,Clot factor fletcher fact,Lab Services,Per Unit,$18.93 ,OP,18.93,83.87,,,,,,
Health Alliance MCR ADV,CPT,85293,Clot factor wght kininogen,Lab Services,Per Unit,$18.93 ,OP,18.93,83.87,,,,,,
Health Alliance MCR ADV,CPT,85300,Antithrombin iii activity,Lab Services,Per Unit,$11.85 ,OP,11.85,53.38,,,,,,
Health Alliance MCR ADV,CPT,85301,Antithrombin iii antigen,Lab Services,Per Unit,$10.81 ,OP,10.81,49.56,,,,,,
Health Alliance MCR ADV,CPT,85302,Clot inhibit prot c antigen,Lab Services,Per Unit,$12.01 ,OP,12.01,53.38,,,,,,
Health Alliance MCR ADV,CPT,85303,Clot inhibit prot c activity,Lab Services,Per Unit,$13.84 ,OP,13.84,61,,,,,,
Health Alliance MCR ADV,CPT,85305,Clot inhibit prot s total,Lab Services,Per Unit,$11.61 ,OP,11.61,53.38,,,,,,
Health Alliance MCR ADV,CPT,85306,Clot inhibit prot s free,Lab Services,Per Unit,$15.32 ,OP,15.32,68.63,,,,,,
Health Alliance MCR ADV,CPT,85307,Assay activated protein c,Lab Services,Per Unit,$15.32 ,OP,15.32,68.63,,,,,,
Health Alliance MCR ADV,CPT,85335,Factor inhibitor test,Lab Services,Per Unit,$12.87 ,OP,12.87,12.87,,,,,,
Health Alliance MCR ADV,CPT,85337,Thrombomodulin,Lab Services,Per Unit,$17.27 ,OP,17.27,45.74,,,,,,
Health Alliance MCR ADV,CPT,85345,Coagulation time lee & white,Lab Services,Per Unit,$4.69 ,OP,4.69,4.69,,,,,,
Health Alliance MCR ADV,CPT,85347,Coagulation time activated,Lab Services,Per Unit,$4.28 ,OP,4.28,15.26,,,,,,
Health Alliance MCR ADV,CPT,85348,Coagulation time otr method,Lab Services,Per Unit,$4.49 ,OP,4.49,15.26,,,,,,
Health Alliance MCR ADV,CPT,85360,Euglobulin lysis,Lab Services,Per Unit,$8.41 ,OP,8.41,38.13,,,,,,
Health Alliance MCR ADV,CPT,85362,Fibrin degradation products,Lab Services,Per Unit,$6.89 ,OP,6.89,30.51,,,,,,
Health Alliance MCR ADV,CPT,85366,Fibrinogen test,Lab Services,Per Unit,$80.46 ,OP,30.51,80.46,,,,,,
Health Alliance MCR ADV,CPT,85370,Fibrinogen test,Lab Services,Per Unit,$12.43 ,OP,12.43,49.56,,,,,,
Health Alliance MCR ADV,CPT,85378,Fibrin degrade semiquant,Lab Services,Per Unit,$9.72 ,OP,9.72,30.51,,,,,,
Health Alliance MCR ADV,CPT,85379,Fibrin degradation quant,Lab Services,Per Unit,$10.18 ,OP,10.18,135.29,,,,,,
Health Alliance MCR ADV,CPT,85380,Fibrin degradj d-dimer,Lab Services,Per Unit,$10.18 ,OP,10.18,45.74,,,,,,
Health Alliance MCR ADV,CPT,85384,Fibrinogen activity,Lab Services,Per Unit,$9.72 ,OP,9.72,38.13,,,,,,
Health Alliance MCR ADV,CPT,85385,Fibrinogen antigen,Lab Services,Per Unit,$14.46 ,OP,14.46,38.13,,,,,,
Health Alliance MCR ADV,CPT,85390,Fibrinolysins screen i&r,Lab Services,Per Unit,$15.48 ,OP,15.48,38.13,,,,,,
Health Alliance MCR ADV,CPT,85397,Clotting funct activity,Lab Services,Per Unit,$30.86 ,OP,30.86,30.86,,,,,,
Health Alliance MCR ADV,CPT,85400,Fibrinolytic plasmin,Lab Services,Per Unit,$7.71 ,OP,7.71,38.13,,,,,,
Health Alliance MCR ADV,CPT,85410,Fibrinolytic antiplasmin,Lab Services,Per Unit,$7.71 ,OP,7.71,34.31,,,,,,
Health Alliance MCR ADV,CPT,85415,Fibrinolytic plasminogen,Lab Services,Per Unit,$17.19 ,OP,17.19,76.26,,,,,,
Health Alliance MCR ADV,CPT,85420,Fibrinolytic plasminogen,Lab Services,Per Unit,$6.53 ,OP,6.53,6.53,,,,,,
Health Alliance MCR ADV,CPT,85421,Fibrinolytic plasminogen,Lab Services,Per Unit,$10.18 ,OP,10.18,45.74,,,,,,
Health Alliance MCR ADV,CPT,85441,Heinz bodies direct,Lab Services,Per Unit,$4.20 ,OP,4.2,19.07,,,,,,
Health Alliance MCR ADV,CPT,85445,Heinz bodies induced,Lab Services,Per Unit,$6.82 ,OP,6.82,30.51,,,,,,
Health Alliance MCR ADV,CPT,85460,Hemoglobin fetal,Lab Services,Per Unit,$7.73 ,OP,7.73,7.73,,,,,,
Health Alliance MCR ADV,CPT,85461,Hemoglobin fetal,Lab Services,Per Unit,$9.36 ,OP,9.36,30.51,,,,,,
Health Alliance MCR ADV,CPT,85475,Hemolysin acid,Lab Services,Per Unit,$8.87 ,OP,8.87,38.13,,,,,,
Health Alliance MCR ADV,CPT,85520,Heparin assay,Lab Services,Per Unit,$13.09 ,OP,13.09,57.19,,,,,,
Health Alliance MCR ADV,CPT,85525,Heparin neutralization,Lab Services,Per Unit,$11.84 ,OP,11.84,53.38,,,,,,
Health Alliance MCR ADV,CPT,85530,Heparin-protamine tolerance,Lab Services,Per Unit,$13.09 ,OP,13.09,48.46,,,,,,
Health Alliance MCR ADV,CPT,85536,Iron stain peripheral blood,Lab Services,Per Unit,$6.88 ,OP,6.88,30.51,,,,,,
Health Alliance MCR ADV,CPT,85540,Wbc alkaline phosphatase,Lab Services,Per Unit,$8.60 ,OP,8.6,38.13,,,,,,
Health Alliance MCR ADV,CPT,85547,Rbc mechanical fragility,Lab Services,Per Unit,$8.60 ,OP,8.6,11.44,,,,,,
Health Alliance MCR ADV,CPT,85549,Muramidase,Lab Services,Per Unit,$18.75 ,OP,18.75,83.87,,,,,,
Health Alliance MCR ADV,CPT,85555,Rbc osmotic fragility,Lab Services,Per Unit,$7.47 ,OP,7.47,30.51,,,,,,
Health Alliance MCR ADV,CPT,85557,Rbc osmotic fragility,Lab Services,Per Unit,$13.36 ,OP,13.36,13.36,,,,,,
Health Alliance MCR ADV,CPT,85576,Blood platelet aggregation,Lab Services,Per Unit,$24.91 ,OP,24.91,95.32,,,,,,
Health Alliance MCR ADV,CPT,85597,Phospholipid pltlt neutraliz,Lab Services,Per Unit,$17.98 ,OP,17.98,80.07,,,,,,
Health Alliance MCR ADV,CPT,85598,Hexagnal phosph pltlt neutrl,Lab Services,Per Unit,$17.98 ,OP,17.98,17.98,,,,,,
Health Alliance MCR ADV,CPT,85610,Prothrombin time,Lab Services,Per Unit,$4.29 ,OP,4.29,19.07,,,,,,
Health Alliance MCR ADV,CPT,85611,Prothrombin test,Lab Services,Per Unit,$3.94 ,OP,3.94,19.07,,,,,,
Health Alliance MCR ADV,CPT,85612,Viper venom prothrombin time,Lab Services,Per Unit,$17.49 ,OP,17.49,17.49,,,,,,
Health Alliance MCR ADV,CPT,85613,Russell viper venom diluted,Lab Services,Per Unit,$9.58 ,OP,9.58,41.94,,,,,,
Health Alliance MCR ADV,CPT,85635,Reptilase test,Lab Services,Per Unit,$9.85 ,OP,9.85,19.07,,,,,,
Health Alliance MCR ADV,CPT,85651,Rbc sed rate nonautomated,Lab Services,Per Unit,$4.27 ,OP,4.27,19.07,,,,,,
Health Alliance MCR ADV,CPT,85652,Rbc sed rate automated,Lab Services,Per Unit,$2.70 ,OP,2.7,15.26,,,,,,
Health Alliance MCR ADV,CPT,85660,Rbc sickle cell test,Lab Services,Per Unit,$5.51 ,OP,5.51,22.88,,,,,,
Health Alliance MCR ADV,CPT,85670,Thrombin time plasma,Lab Services,Per Unit,$5.77 ,OP,5.77,26.7,,,,,,
Health Alliance MCR ADV,CPT,85675,Thrombin time titer,Lab Services,Per Unit,$6.85 ,OP,6.85,30.51,,,,,,
Health Alliance MCR ADV,CPT,85705,Thromboplastin inhibition,Lab Services,Per Unit,$9.63 ,OP,9.63,41.94,,,,,,
Health Alliance MCR ADV,CPT,85730,Thromboplastin time partial,Lab Services,Per Unit,$6.01 ,OP,6.01,30.51,,,,,,
Health Alliance MCR ADV,CPT,85732,Thromboplastin time partial,Lab Services,Per Unit,$6.47 ,OP,6.47,30.51,,,,,,
Health Alliance MCR ADV,CPT,85810,Blood viscosity examination,Lab Services,Per Unit,$11.67 ,OP,11.67,53.38,,,,,,
Health Alliance MCR ADV,CPT,86000,Agglutinins febrile antigen,Lab Services,Per Unit,$6.98 ,OP,6.98,6.98,,,,,,
Health Alliance MCR ADV,CPT,86001,Allergen specific igg,Lab Services,Per Unit,$7.82 ,OP,7.82,22.88,,,,,,
Health Alliance MCR ADV,CPT,86003,Allg spec ige crude xtrc ea,Lab Services,Per Unit,$5.22 ,OP,5.22,22.88,,,,,,
Health Alliance MCR ADV,CPT,86005,Allg spec ige multiallg scr,Lab Services,Per Unit,$7.97 ,OP,7.97,7.97,,,,,,
Health Alliance MCR ADV,CPT,86008,Allg spec ige recomb ea,Lab Services,Per Unit,$17.93 ,OP,17.93,80.07,,,,,,
Health Alliance MCR ADV,CPT,86021,Wbc antibody identification,Lab Services,Per Unit,$15.05 ,OP,15.05,68.63,,,,,,
Health Alliance MCR ADV,CPT,86022,Platelet antibodies,Lab Services,Per Unit,$18.37 ,OP,18.37,64.82,,,,,,
Health Alliance MCR ADV,CPT,86023,Immunoglobulin assay,Lab Services,Per Unit,$12.46 ,OP,12.46,57.19,,,,,,
Health Alliance MCR ADV,CPT,86038,Antinuclear antibodies,Lab Services,Per Unit,$12.09 ,OP,12.09,53.38,,,,,,
Health Alliance MCR ADV,CPT,86039,Antinuclear antibodies (ana),Lab Services,Per Unit,$11.16 ,OP,11.16,49.56,,,,,,
Health Alliance MCR ADV,CPT,86060,Antistreptolysin o titer,Lab Services,Per Unit,$7.30 ,OP,7.3,34.31,,,,,,
Health Alliance MCR ADV,CPT,86063,Antistreptolysin o screen,Lab Services,Per Unit,$5.77 ,OP,5.77,26.7,,,,,,
Health Alliance MCR ADV,CPT,86077,Phys blood bank serv xmatch,APC 5731,RVU Per Case,$25.25 ,OP,25.25,244.01,,,,,,
Health Alliance MCR ADV,CPT,86078,Phys blood bank serv reactj,APC 5672,RVU Per Case,$152.64 ,OP,152.64,247.83,,,,,,
Health Alliance MCR ADV,CPT,86079,Phys blood bank serv authrj,APC 5671,RVU Per Case,$50.92 ,OP,50.92,251.64,,,,,,
Health Alliance MCR ADV,CPT,86140,C-reactive protein,Lab Services,Per Unit,$5.18 ,OP,5.18,22.88,,,,,,
Health Alliance MCR ADV,CPT,86141,C-reactive protein hs,Lab Services,Per Unit,$12.95 ,OP,12.95,57.19,,,,,,
Health Alliance MCR ADV,CPT,86146,Beta-2 glycoprotein antibody,Lab Services,Per Unit,$25.45 ,OP,25.45,114.39,,,,,,
Health Alliance MCR ADV,CPT,86147,Cardiolipin antibody ea ig,Lab Services,Per Unit,$25.45 ,OP,25.45,114.39,,,,,,
Health Alliance MCR ADV,CPT,86148,Anti-phospholipid antibody,Lab Services,Per Unit,$16.07 ,OP,16.07,72.44,,,,,,
Health Alliance MCR ADV,CPT,86152,Cell enumeration & id,Lab Services,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Health Alliance MCR ADV,CPT,86155,Chemotaxis assay,Lab Services,Per Unit,$15.99 ,OP,15.99,72.44,,,,,,
Health Alliance MCR ADV,CPT,86156,Cold agglutinin screen,Lab Services,Per Unit,$8.07 ,OP,8.07,30.51,,,,,,
Health Alliance MCR ADV,CPT,86157,Cold agglutinin titer,Lab Services,Per Unit,$8.06 ,OP,8.06,34.31,,,,,,
Health Alliance MCR ADV,CPT,86160,Complement antigen,Lab Services,Per Unit,$12.00 ,OP,12,53.38,,,,,,
Health Alliance MCR ADV,CPT,86161,Complement/function activity,Lab Services,Per Unit,$12.00 ,OP,12,53.38,,,,,,
Health Alliance MCR ADV,CPT,86162,Complement total (ch50),Lab Services,Per Unit,$20.32 ,OP,20.32,91.51,,,,,,
Health Alliance MCR ADV,CPT,86171,Complement fixation each,Lab Services,Per Unit,$10.01 ,OP,10.01,45.74,,,,,,
Health Alliance MCR ADV,CPT,86200,Ccp antibody,Lab Services,Per Unit,$12.95 ,OP,12.95,57.19,,,,,,
Health Alliance MCR ADV,CPT,86215,Deoxyribonuclease antibody,Lab Services,Per Unit,$13.25 ,OP,13.25,57.19,,,,,,
Health Alliance MCR ADV,CPT,86225,Dna antibody native,Lab Services,Per Unit,$13.74 ,OP,13.74,61,,,,,,
Health Alliance MCR ADV,CPT,86226,Dna antibody single strand,Lab Services,Per Unit,$12.11 ,OP,12.11,53.38,,,,,,
Health Alliance MCR ADV,CPT,86235,Nuclear antigen antibody,Lab Services,Per Unit,$17.93 ,OP,17.93,80.07,,,,,,
Health Alliance MCR ADV,CPT,86255,Fluorescent antibody screen,Lab Services,Per Unit,$12.05 ,OP,12.05,53.38,,,,,,
Health Alliance MCR ADV,CPT,86256,Fluorescent antibody titer,Lab Services,Per Unit,$12.05 ,OP,12.05,53.38,,,,,,
Health Alliance MCR ADV,CPT,86277,Growth hormone antibody,Lab Services,Per Unit,$15.74 ,OP,15.74,68.63,,,,,,
Health Alliance MCR ADV,CPT,86280,Hemagglutination inhibition,Lab Services,Per Unit,$8.19 ,OP,8.19,8.19,,,,,,
Health Alliance MCR ADV,CPT,86294,Immunoassay tumor qual,Lab Services,Per Unit,$25.57 ,OP,25.57,80.07,,,,,,
Health Alliance MCR ADV,CPT,86300,Immunoassay tumor ca 15-3,Lab Services,Per Unit,$20.81 ,OP,20.81,91.51,,,,,,
Health Alliance MCR ADV,CPT,86301,Immunoassay tumor ca 19-9,Lab Services,Per Unit,$20.81 ,OP,20.81,91.51,,,,,,
Health Alliance MCR ADV,CPT,86304,Immunoassay tumor ca 125,Lab Services,Per Unit,$20.81 ,OP,20.81,91.51,,,,,,
Health Alliance MCR ADV,CPT,86305,Human epididymis protein 4,Lab Services,Per Unit,$20.81 ,OP,20.81,20.81,,,,,,
Health Alliance MCR ADV,CPT,86308,Heterophile antibody screen,Lab Services,Per Unit,$5.18 ,OP,5.18,26.7,,,,,,
Health Alliance MCR ADV,CPT,86309,Heterophile antibody titer,Lab Services,Per Unit,$6.47 ,OP,6.47,30.51,,,,,,
Health Alliance MCR ADV,CPT,86310,Heterophile antibody absrbj,Lab Services,Per Unit,$7.37 ,OP,7.37,7.37,,,,,,
Health Alliance MCR ADV,CPT,86316,Immunoassay tumor other,Lab Services,Per Unit,$20.81 ,OP,20.81,91.51,,,,,,
Health Alliance MCR ADV,CPT,86317,Immunoassay infectious agent,Lab Services,Per Unit,$14.99 ,OP,14.99,68.63,,,,,,
Health Alliance MCR ADV,CPT,86318,Ia infectious agent antibody,Lab Services,Per Unit,$18.09 ,OP,18.09,64.82,,,,,,
Health Alliance MCR ADV,CPT,86320,Serum immunoelectrophoresis,Lab Services,Per Unit,$29.92 ,OP,29.92,99.13,,,,,,
Health Alliance MCR ADV,CPT,86325,Other immunoelectrophoresis,Lab Services,Per Unit,$23.13 ,OP,23.13,99.13,,,,,,
Health Alliance MCR ADV,CPT,86327,Immunoelectrophoresis assay,Lab Services,Per Unit,$29.92 ,OP,29.92,72.44,,,,,,
Health Alliance MCR ADV,CPT,86328,Ia nfct ab sarscov2 covid19,Lab Services,Per Unit,$45.23 ,OP,45.23,64.82,,,,,,
Health Alliance MCR ADV,CPT,86329,Immunodiffusion nes,Lab Services,Per Unit,$14.05 ,OP,14.05,14.05,,,,,,
Health Alliance MCR ADV,CPT,86331,Immunodiffusion ouchterlony,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Health Alliance MCR ADV,CPT,86332,Immune complex assay,Lab Services,Per Unit,$24.37 ,OP,24.37,106.76,,,,,,
Health Alliance MCR ADV,CPT,86334,Immunofix e-phoresis serum,Lab Services,Per Unit,$22.34 ,OP,22.34,99.13,,,,,,
Health Alliance MCR ADV,CPT,86335,Immunfix e-phorsis/urine/csf,Lab Services,Per Unit,$29.35 ,OP,29.35,129.64,,,,,,
Health Alliance MCR ADV,CPT,86336,Inhibin a,Lab Services,Per Unit,$15.59 ,OP,15.59,68.63,,,,,,
Health Alliance MCR ADV,CPT,86337,Insulin antibodies,Lab Services,Per Unit,$21.41 ,OP,21.41,95.32,,,,,,
Health Alliance MCR ADV,CPT,86340,Intrinsic factor antibody,Lab Services,Per Unit,$15.08 ,OP,15.08,68.63,,,,,,
Health Alliance MCR ADV,CPT,86341,Islet cell antibody,Lab Services,Per Unit,$23.57 ,OP,23.57,87.69,,,,,,
Health Alliance MCR ADV,CPT,86343,Leukocyte histamine release,Lab Services,Per Unit,$12.46 ,OP,12.46,57.19,,,,,,
Health Alliance MCR ADV,CPT,86344,Leukocyte phagocytosis,Lab Services,Per Unit,$10.39 ,OP,10.39,34.31,,,,,,
Health Alliance MCR ADV,CPT,86352,Cell function assay w/stim,Lab Services,Per Unit,$135.86 ,OP,135.86,135.86,,,,,,
Health Alliance MCR ADV,CPT,86353,Lymphocyte transformation,Lab Services,Per Unit,$49.03 ,OP,49.03,217.32,,,,,,
Health Alliance MCR ADV,CPT,86355,B cells total count,Lab Services,Per Unit,$37.73 ,OP,37.73,167.76,,,,,,
Health Alliance MCR ADV,CPT,86356,Mononuclear cell antigen,Lab Services,Per Unit,$26.78 ,OP,26.78,61,,,,,,
Health Alliance MCR ADV,CPT,86357,Nk cells total count,Lab Services,Per Unit,$37.73 ,OP,37.73,167.76,,,,,,
Health Alliance MCR ADV,CPT,86359,T cells total count,Lab Services,Per Unit,$37.73 ,OP,37.73,167.76,,,,,,
Health Alliance MCR ADV,CPT,86360,T cell absolute count/ratio,Lab Services,Per Unit,$46.98 ,OP,46.98,209.7,,,,,,
Health Alliance MCR ADV,CPT,86361,T cell absolute count,Lab Services,Per Unit,$26.78 ,OP,26.78,61,,,,,,
Health Alliance MCR ADV,CPT,86367,Stem cells total count,Lab Services,Per Unit,$77.78 ,OP,77.78,167.76,,,,,,
Health Alliance MCR ADV,CPT,86376,Microsomal antibody each,Lab Services,Per Unit,$14.55 ,OP,14.55,64.82,,,,,,
Health Alliance MCR ADV,CPT,86382,Neutralization test viral,Lab Services,Per Unit,$16.91 ,OP,16.91,76.26,,,,,,
Health Alliance MCR ADV,CPT,86384,Nitroblue tetrazolium dye,Lab Services,Per Unit,$13.61 ,OP,13.61,13.61,,,,,,
Health Alliance MCR ADV,CPT,86386,Nuclear matrix protein 22,Lab Services,Per Unit,$21.78 ,OP,21.78,21.78,,,,,,
Health Alliance MCR ADV,CPT,86403,Particle agglut antbdy scrn,Lab Services,Per Unit,$11.54 ,OP,11.54,26.7,,,,,,
Health Alliance MCR ADV,CPT,86406,Particle agglut antbdy titr,Lab Services,Per Unit,$10.64 ,OP,10.64,45.74,,,,,,
Health Alliance MCR ADV,CPT,86408,Neutrlzg antb sarscov2 scr,Lab Services,Per Unit,$42.13 ,OP,42.13,42.13,,,,,,
Health Alliance MCR ADV,CPT,86409,Neutrlzg antb sarscov2 titer,Lab Services,Per Unit,$105.33 ,OP,105.33,105.33,,,,,,
Health Alliance MCR ADV,CPT,86413,Sars-cov-2 antb quantitative,Lab Services,Per Unit,$51.43 ,OP,51.43,51.43,,,,,,
Health Alliance MCR ADV,CPT,86430,Rheumatoid factor test qual,Lab Services,Per Unit,$6.14 ,OP,6.14,26.7,,,,,,
Health Alliance MCR ADV,CPT,86431,Rheumatoid factor quant,Lab Services,Per Unit,$5.67 ,OP,5.67,26.7,,,,,,
Health Alliance MCR ADV,CPT,86480,Tb test cell immun measure,Lab Services,Per Unit,$61.98 ,OP,61.98,274.51,,,,,,
Health Alliance MCR ADV,CPT,86481,Tb ag response t-cell susp,Lab Services,Per Unit,$100.00 ,OP,100,100,,,,,,
Health Alliance MCR ADV,CPT,86485,Skin test candida,APC 5731,RVU Per Case,$25.25 ,OP,25.25,61,,,,,,
Health Alliance MCR ADV,CPT,86486,Skin test nos antigen,APC 5731,RVU Per Case,$25.25 ,OP,25.25,30.51,,,,,,
Health Alliance MCR ADV,CPT,86490,Coccidioidomycosis skin test,APC 5733,RVU Per Case,$56.95 ,OP,38.13,56.95,,,,,,
Health Alliance MCR ADV,CPT,86510,Histoplasmosis skin test,APC 5733,RVU Per Case,$56.95 ,OP,38.13,56.95,,,,,,
Health Alliance MCR ADV,CPT,86580,Tb intradermal test,APC 5731,RVU Per Case,$25.25 ,OP,25.25,38.13,,,,,,
Health Alliance MCR ADV,CPT,86590,Streptokinase antibody,Lab Services,Per Unit,$12.66 ,OP,12.66,49.56,,,,,,
Health Alliance MCR ADV,CPT,86592,Syphilis test non-trep qual,Lab Services,Per Unit,$4.27 ,OP,4.27,19.07,,,,,,
Health Alliance MCR ADV,CPT,86593,Syphilis test non-trep quant,Lab Services,Per Unit,$4.40 ,OP,4.4,19.07,,,,,,
Health Alliance MCR ADV,CPT,86602,Antinomyces antibody,Lab Services,Per Unit,$10.18 ,OP,10.18,45.74,,,,,,
Health Alliance MCR ADV,CPT,86603,Adenovirus antibody,Lab Services,Per Unit,$12.87 ,OP,12.87,12.87,,,,,,
Health Alliance MCR ADV,CPT,86606,Aspergillus antibody,Lab Services,Per Unit,$15.05 ,OP,15.05,68.63,,,,,,
Health Alliance MCR ADV,CPT,86609,Bacterium antibody,Lab Services,Per Unit,$12.88 ,OP,12.88,57.19,,,,,,
Health Alliance MCR ADV,CPT,86611,Bartonella antibody,Lab Services,Per Unit,$10.18 ,OP,10.18,45.74,,,,,,
Health Alliance MCR ADV,CPT,86612,Blastomyces antibody,Lab Services,Per Unit,$12.90 ,OP,12.9,57.19,,,,,,
Health Alliance MCR ADV,CPT,86615,Bordetella antibody,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
Health Alliance MCR ADV,CPT,86617,Lyme disease antibody,Lab Services,Per Unit,$15.49 ,OP,15.49,68.63,,,,,,
Health Alliance MCR ADV,CPT,86618,Lyme disease antibody,Lab Services,Per Unit,$17.03 ,OP,17.03,83.87,,,,,,
Health Alliance MCR ADV,CPT,86619,Borrelia antibody,Lab Services,Per Unit,$13.38 ,OP,13.38,61,,,,,,
Health Alliance MCR ADV,CPT,86622,Brucella antibody,Lab Services,Per Unit,$8.93 ,OP,8.93,38.13,,,,,,
Health Alliance MCR ADV,CPT,86625,Campylobacter antibody,Lab Services,Per Unit,$13.12 ,OP,13.12,57.19,,,,,,
Health Alliance MCR ADV,CPT,86628,Candida antibody,Lab Services,Per Unit,$12.01 ,OP,12.01,53.38,,,,,,
Health Alliance MCR ADV,CPT,86631,Chlamydia antibody,Lab Services,Per Unit,$11.82 ,OP,11.82,53.38,,,,,,
Health Alliance MCR ADV,CPT,86632,Chlamydia igm antibody,Lab Services,Per Unit,$12.68 ,OP,12.68,57.19,,,,,,
Health Alliance MCR ADV,CPT,86635,Coccidioides antibody,Lab Services,Per Unit,$11.47 ,OP,11.47,49.56,,,,,,
Health Alliance MCR ADV,CPT,86638,Q fever antibody,Lab Services,Per Unit,$12.12 ,OP,12.12,53.38,,,,,,
Health Alliance MCR ADV,CPT,86641,Cryptococcus antibody,Lab Services,Per Unit,$14.41 ,OP,14.41,64.82,,,,,,
Health Alliance MCR ADV,CPT,86644,Cmv antibody,Lab Services,Per Unit,$14.39 ,OP,14.39,64.82,,,,,,
Health Alliance MCR ADV,CPT,86645,Cmv antibody igm,Lab Services,Per Unit,$16.85 ,OP,16.85,76.26,,,,,,
Health Alliance MCR ADV,CPT,86648,Diphtheria antibody,Lab Services,Per Unit,$15.21 ,OP,15.21,68.63,,,,,,
Health Alliance MCR ADV,CPT,86651,Encephalitis californ antbdy,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
Health Alliance MCR ADV,CPT,86652,Encephaltis east eqne anbdy,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
Health Alliance MCR ADV,CPT,86653,Encephaltis st louis antbody,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
Health Alliance MCR ADV,CPT,86654,Encephaltis west eqne antbdy,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
Health Alliance MCR ADV,CPT,86658,Enterovirus antibody,Lab Services,Per Unit,$13.03 ,OP,13.03,57.19,,,,,,
Health Alliance MCR ADV,CPT,86663,Epstein-barr antibody,Lab Services,Per Unit,$13.12 ,OP,13.12,57.19,,,,,,
Health Alliance MCR ADV,CPT,86664,Epstein-barr nuclear antigen,Lab Services,Per Unit,$15.29 ,OP,15.29,68.63,,,,,,
Health Alliance MCR ADV,CPT,86665,Epstein-barr capsid vca,Lab Services,Per Unit,$18.14 ,OP,18.14,80.07,,,,,,
Health Alliance MCR ADV,CPT,86666,Ehrlichia antibody,Lab Services,Per Unit,$10.18 ,OP,10.18,45.74,,,,,,
Health Alliance MCR ADV,CPT,86668,Francisella tularensis,Lab Services,Per Unit,$14.16 ,OP,14.16,45.74,,,,,,
Health Alliance MCR ADV,CPT,86671,Fungus nes antibody,Lab Services,Per Unit,$12.25 ,OP,12.25,53.38,,,,,,
Health Alliance MCR ADV,CPT,86674,Giardia lamblia antibody,Lab Services,Per Unit,$14.72 ,OP,14.72,14.72,,,,,,
Health Alliance MCR ADV,CPT,86677,Helicobacter pylori antibody,Lab Services,Per Unit,$16.85 ,OP,16.85,64.82,,,,,,
Health Alliance MCR ADV,CPT,86682,Helminth antibody,Lab Services,Per Unit,$13.01 ,OP,13.01,57.19,,,,,,
Health Alliance MCR ADV,CPT,86684,Hemophilus influenza antibdy,Lab Services,Per Unit,$15.84 ,OP,15.84,72.44,,,,,,
Health Alliance MCR ADV,CPT,86687,Htlv-i antibody,Lab Services,Per Unit,$9.09 ,OP,9.09,38.13,,,,,,
Health Alliance MCR ADV,CPT,86688,Htlv-ii antibody,Lab Services,Per Unit,$14.00 ,OP,14,61,,,,,,
Health Alliance MCR ADV,CPT,86689,Htlv/hiv confirmj antibody,Lab Services,Per Unit,$19.35 ,OP,19.35,87.69,,,,,,
Health Alliance MCR ADV,CPT,86692,Hepatitis delta agent antbdy,Lab Services,Per Unit,$17.16 ,OP,17.16,76.26,,,,,,
Health Alliance MCR ADV,CPT,86694,Herpes simplex nes antbdy,Lab Services,Per Unit,$14.39 ,OP,14.39,64.82,,,,,,
Health Alliance MCR ADV,CPT,86695,Herpes simplex type 1 test,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
Health Alliance MCR ADV,CPT,86696,Herpes simplex type 2 test,Lab Services,Per Unit,$19.35 ,OP,19.35,87.69,,,,,,
Health Alliance MCR ADV,CPT,86698,Histoplasma antibody,Lab Services,Per Unit,$13.79 ,OP,13.79,57.19,,,,,,
Health Alliance MCR ADV,CPT,86701,Hiv-1antibody,Lab Services,Per Unit,$8.89 ,OP,8.89,38.13,,,,,,
Health Alliance MCR ADV,CPT,86702,Hiv-2 antibody,Lab Services,Per Unit,$13.52 ,OP,13.52,61,,,,,,
Health Alliance MCR ADV,CPT,86703,Hiv-1/hiv-2 1 result antbdy,Lab Services,Per Unit,$13.71 ,OP,13.71,61,,,,,,
Health Alliance MCR ADV,CPT,86704,Hep b core antibody total,Lab Services,Per Unit,$12.05 ,OP,12.05,53.38,,,,,,
Health Alliance MCR ADV,CPT,86705,Hep b core antibody igm,Lab Services,Per Unit,$11.77 ,OP,11.77,53.38,,,,,,
Health Alliance MCR ADV,CPT,86706,Hep b surface antibody,Lab Services,Per Unit,$10.74 ,OP,10.74,49.56,,,,,,
Health Alliance MCR ADV,CPT,86707,Hepatitis be antibody,Lab Services,Per Unit,$11.57 ,OP,11.57,53.38,,,,,,
Health Alliance MCR ADV,CPT,86708,Hepatitis a antibody,Lab Services,Per Unit,$12.39 ,OP,12.39,53.38,,,,,,
Health Alliance MCR ADV,CPT,86709,Hepatitis a igm antibody,Lab Services,Per Unit,$11.26 ,OP,11.26,49.56,,,,,,
Health Alliance MCR ADV,CPT,86710,Influenza virus antibody,Lab Services,Per Unit,$13.55 ,OP,13.55,68.63,,,,,,
Health Alliance MCR ADV,CPT,86711,John cunningham antibody,Lab Services,Per Unit,$16.89 ,OP,16.89,16.89,,,,,,
Health Alliance MCR ADV,CPT,86713,Legionella antibody,Lab Services,Per Unit,$15.30 ,OP,15.3,68.63,,,,,,
Health Alliance MCR ADV,CPT,86717,Leishmania antibody,Lab Services,Per Unit,$12.25 ,OP,12.25,53.38,,,,,,
Health Alliance MCR ADV,CPT,86720,Leptospira antibody,Lab Services,Per Unit,$16.20 ,OP,16.2,57.19,,,,,,
Health Alliance MCR ADV,CPT,86723,Listeria monocytogenes,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,
Health Alliance MCR ADV,CPT,86727,Lymph choriomeningitis ab,Lab Services,Per Unit,$12.87 ,OP,12.87,57.19,,,,,,
Health Alliance MCR ADV,CPT,86732,Mucormycosis antibody,Lab Services,Per Unit,$15.00 ,OP,15,57.19,,,,,,
Health Alliance MCR ADV,CPT,86735,Mumps antibody,Lab Services,Per Unit,$13.05 ,OP,13.05,57.19,,,,,,
Health Alliance MCR ADV,CPT,86738,Mycoplasma antibody,Lab Services,Per Unit,$13.24 ,OP,13.24,57.19,,,,,,
Health Alliance MCR ADV,CPT,86741,Neisseria meningitidis,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
Health Alliance MCR ADV,CPT,86744,Nocardia antibody,Lab Services,Per Unit,$15.99 ,OP,15.99,57.19,,,,,,
Health Alliance MCR ADV,CPT,86747,Parvovirus antibody,Lab Services,Per Unit,$15.03 ,OP,15.03,68.63,,,,,,
Health Alliance MCR ADV,CPT,86750,Malaria antibody,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
Health Alliance MCR ADV,CPT,86753,Protozoa antibody nos,Lab Services,Per Unit,$12.39 ,OP,12.39,53.38,,,,,,
Health Alliance MCR ADV,CPT,86756,Respiratory virus antibody,Lab Services,Per Unit,$15.89 ,OP,15.89,57.19,,,,,,
Health Alliance MCR ADV,CPT,86757,Rickettsia antibody,Lab Services,Per Unit,$19.35 ,OP,19.35,87.69,,,,,,
Health Alliance MCR ADV,CPT,86759,Rotavirus antibody,Lab Services,Per Unit,$18.23 ,OP,18.23,57.19,,,,,,
Health Alliance MCR ADV,CPT,86762,Rubella antibody,Lab Services,Per Unit,$14.39 ,OP,14.39,64.82,,,,,,
Health Alliance MCR ADV,CPT,86765,Rubeola antibody,Lab Services,Per Unit,$12.88 ,OP,12.88,57.19,,,,,,
Health Alliance MCR ADV,CPT,86768,Salmonella antibody,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,
Health Alliance MCR ADV,CPT,86769,Sars-cov-2 covid-19 antibody,Lab Services,Per Unit,$42.13 ,OP,42.13,57.19,,,,,,
Health Alliance MCR ADV,CPT,86771,Shigella antibody,Lab Services,Per Unit,$24.48 ,OP,24.48,57.19,,,,,,
Health Alliance MCR ADV,CPT,86774,Tetanus antibody,Lab Services,Per Unit,$14.80 ,OP,14.8,64.82,,,,,,
Health Alliance MCR ADV,CPT,86777,Toxoplasma antibody,Lab Services,Per Unit,$14.39 ,OP,14.39,64.82,,,,,,
Health Alliance MCR ADV,CPT,86778,Toxoplasma antibody igm,Lab Services,Per Unit,$14.41 ,OP,14.41,64.82,,,,,,
Health Alliance MCR ADV,CPT,86780,Treponema pallidum,Lab Services,Per Unit,$13.24 ,OP,13.24,13.24,,,,,,
Health Alliance MCR ADV,CPT,86784,Trichinella antibody,Lab Services,Per Unit,$12.56 ,OP,12.56,12.56,,,,,,
Health Alliance MCR ADV,CPT,86787,Varicella-zoster antibody,Lab Services,Per Unit,$12.88 ,OP,12.88,57.19,,,,,,
Health Alliance MCR ADV,CPT,86788,West nile virus ab igm,Lab Services,Per Unit,$16.85 ,OP,16.85,76.26,,,,,,
Health Alliance MCR ADV,CPT,86789,West nile virus antibody,Lab Services,Per Unit,$14.39 ,OP,14.39,64.82,,,,,,
Health Alliance MCR ADV,CPT,86790,Virus antibody nos,Lab Services,Per Unit,$12.88 ,OP,12.88,57.19,,,,,,
Health Alliance MCR ADV,CPT,86793,Yersinia antibody,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
Health Alliance MCR ADV,CPT,86794,Zika virus igm antibody,Lab Services,Per Unit,$16.85 ,OP,16.85,16.85,,,,,,
Health Alliance MCR ADV,CPT,86800,Thyroglobulin antibody,Lab Services,Per Unit,$15.91 ,OP,15.91,72.44,,,,,,
Health Alliance MCR ADV,CPT,86803,Hepatitis c ab test,Lab Services,Per Unit,$14.27 ,OP,14.27,64.82,,,,,,
Health Alliance MCR ADV,CPT,86804,Hep c ab test confirm,Lab Services,Per Unit,$15.49 ,OP,15.49,68.63,,,,,,
Health Alliance MCR ADV,CPT,86805,Lymphocytotoxicity assay,Lab Services,Per Unit,$189.51 ,OP,189.51,232.58,,,,,,
Health Alliance MCR ADV,CPT,86806,Lymphocytotoxicity assay,Lab Services,Per Unit,$47.59 ,OP,47.59,213.51,,,,,,
Health Alliance MCR ADV,CPT,86807,Cytotoxic antibody screening,Lab Services,Per Unit,$78.65 ,OP,78.65,175.39,,,,,,
Health Alliance MCR ADV,CPT,86808,Cytotoxic antibody screening,Lab Services,Per Unit,$29.68 ,OP,29.68,133.45,,,,,,
Health Alliance MCR ADV,CPT,86812,Hla typing a b or c,Lab Services,Per Unit,$25.81 ,OP,25.81,114.39,,,,,,
Health Alliance MCR ADV,CPT,86813,Hla typing a b or c,Lab Services,Per Unit,$58.00 ,OP,58,247.83,,,,,,
Health Alliance MCR ADV,CPT,86816,Hla typing dr/dq,Lab Services,Per Unit,$30.17 ,OP,30.17,102.95,,,,,,
Health Alliance MCR ADV,CPT,86817,Hla typing dr/dq,Lab Services,Per Unit,$106.14 ,OP,106.14,247.83,,,,,,
Health Alliance MCR ADV,CPT,86821,Lymphocyte culture mixed,Lab Services,Per Unit,$36.56 ,OP,36.56,251.64,,,,,,
Health Alliance MCR ADV,CPT,86825,Hla x-math non-cytotoxic,Lab Services,Per Unit,$109.49 ,OP,109.49,109.49,,,,,,
Health Alliance MCR ADV,CPT,86826,Hla x-match noncytotoxc addl,Lab Services,Per Unit,$36.53 ,OP,36.53,36.53,,,,,,
Health Alliance MCR ADV,CPT,86828,Hla class i&ii antibody qual,Lab Services,Per Unit,$64.19 ,OP,64.19,64.19,,,,,,
Health Alliance MCR ADV,CPT,86829,Hla class i/ii antibody qual,Lab Services,Per Unit,$64.19 ,OP,64.19,64.19,,,,,,
Health Alliance MCR ADV,CPT,86830,Hla class i phenotype qual,Lab Services,Per Unit,$95.52 ,OP,95.52,95.52,,,,,,
Health Alliance MCR ADV,CPT,86831,Hla class ii phenotype qual,Lab Services,Per Unit,$81.88 ,OP,81.88,81.88,,,,,,
Health Alliance MCR ADV,CPT,86832,Hla class i high defin qual,Lab Services,Per Unit,$323.75 ,OP,323.75,323.75,,,,,,
Health Alliance MCR ADV,CPT,86833,Hla class ii high defin qual,Lab Services,Per Unit,$325.80 ,OP,325.8,325.8,,,,,,
Health Alliance MCR ADV,CPT,86834,Hla class i semiquant panel,Lab Services,Per Unit,$357.56 ,OP,357.56,357.56,,,,,,
Health Alliance MCR ADV,CPT,86835,Hla class ii semiquant panel,Lab Services,Per Unit,$322.96 ,OP,322.96,322.96,,,,,,
Health Alliance MCR ADV,CPT,86850,Rbc antibody screen,APC 5671,RVU Per Case,$50.92 ,OP,50.92,76.26,,,,,,
Health Alliance MCR ADV,CPT,86860,Rbc antibody elution,APC 5672,RVU Per Case,$152.64 ,OP,91.51,152.64,,,,,,
Health Alliance MCR ADV,CPT,86870,Rbc antibody identification,APC 5673,RVU Per Case,$298.05 ,OP,141.07,298.05,,,,,,
Health Alliance MCR ADV,CPT,86880,Coombs test direct,APC 5733,RVU Per Case,$56.95 ,OP,22.88,56.95,,,,,,
Health Alliance MCR ADV,CPT,86885,Coombs test indirect qual,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Health Alliance MCR ADV,CPT,86886,Coombs test indirect titer,APC 5672,RVU Per Case,$152.64 ,OP,22.88,152.64,,,,,,
Health Alliance MCR ADV,CPT,86890,Autologous blood process,APC 5672,RVU Per Case,$152.64 ,OP,152.64,308.83,,,,,,
Health Alliance MCR ADV,CPT,86891,Autologous blood op salvage,APC 5674,RVU Per Case,$671.45 ,OP,480.4,671.45,,,,,,
Health Alliance MCR ADV,CPT,86900,Blood typing serologic abo,APC 5734,RVU Per Case,$114.56 ,OP,11.44,114.56,,,,,,
Health Alliance MCR ADV,CPT,86901,Blood typing serologic rh(d),APC 5732,RVU Per Case,$34.63 ,OP,22.88,34.63,,,,,,
Health Alliance MCR ADV,CPT,86902,Blood type antigen donor ea,APC 5673,RVU Per Case,$298.05 ,OP,41.94,298.05,,,,,,
Health Alliance MCR ADV,CPT,86904,Blood typing patient serum,APC 5732,RVU Per Case,$34.63 ,OP,34.63,41.94,,,,,,
Health Alliance MCR ADV,CPT,86905,Blood typing rbc antigens,APC 5673,RVU Per Case,$298.05 ,OP,15.26,298.05,,,,,,
Health Alliance MCR ADV,CPT,86906,Bld typing serologic rh phnt,APC 5732,RVU Per Case,$34.63 ,OP,34.31,34.63,,,,,,
Health Alliance MCR ADV,CPT,86920,Compatibility test spin,APC 5672,RVU Per Case,$152.64 ,OP,125.82,152.64,,,,,,
Health Alliance MCR ADV,CPT,86921,Compatibility test incubate,APC 5672,RVU Per Case,$152.64 ,OP,102.95,152.64,,,,,,
Health Alliance MCR ADV,CPT,86922,Compatibility test antiglob,APC 5672,RVU Per Case,$152.64 ,OP,118.19,152.64,,,,,,
Health Alliance MCR ADV,CPT,86923,Compatibility test electric,APC 5672,RVU Per Case,$152.64 ,OP,91.51,152.64,,,,,,
Health Alliance MCR ADV,CPT,86927,Plasma fresh frozen,APC 5672,RVU Per Unit,$152.64 ,OP,49.56,152.64,,,,,,
Health Alliance MCR ADV,CPT,86930,Frozen blood prep,APC 5673,RVU Per Case,$298.05 ,OP,298.05,385.09,,,,,,
Health Alliance MCR ADV,CPT,86931,Frozen blood thaw,APC 5673,RVU Per Case,$298.05 ,OP,289.76,298.05,,,,,,
Health Alliance MCR ADV,CPT,86932,Frozen blood freeze/thaw,APC 5732,RVU Per Case,$34.63 ,OP,34.63,385.09,,,,,,
Health Alliance MCR ADV,CPT,86940,Hemolysins/agglutinins auto,Lab Services,Per Unit,$8.77 ,OP,8.77,38.13,,,,,,
Health Alliance MCR ADV,CPT,86941,Hemolysins/agglutinins,Lab Services,Per Unit,$12.11 ,OP,12.11,53.38,,,,,,
Health Alliance MCR ADV,CPT,86945,Blood product/irradiation,APC 5732,RVU Per Case,$34.63 ,OP,34.63,110.57,,,,,,
Health Alliance MCR ADV,CPT,86950,Leukacyte transfusion,APC 5672,RVU Per Case,$152.64 ,OP,152.64,240.2,,,,,,
Health Alliance MCR ADV,CPT,86960,Vol reduction of blood/prod,APC 5672,RVU Per Case,$152.64 ,OP,110.57,152.64,,,,,,
Health Alliance MCR ADV,CPT,86965,Pooling blood platelets,APC 5672,RVU Per Case,$152.64 ,OP,95.32,152.64,,,,,,
Health Alliance MCR ADV,CPT,86970,Rbc pretx incubatj w/chemicl,APC 5732,RVU Per Case,$34.63 ,OP,34.63,76.26,,,,,,
Health Alliance MCR ADV,CPT,86971,Rbc pretx incubatj w/enzymes,APC 5673,RVU Per Case,$298.05 ,OP,298.05,298.05,,,,,,
Health Alliance MCR ADV,CPT,86972,Rbc pretx incubatj w/density,APC 5672,RVU Per Case,$152.64 ,OP,122,152.64,,,,,,
Health Alliance MCR ADV,CPT,86975,Rbc serum pretx incubj drugs,APC 5735,RVU Per Case,$276.53 ,OP,102.95,276.53,,,,,,
Health Alliance MCR ADV,CPT,86976,Rbc serum pretx id dilution,APC 5731,RVU Per Case,$25.25 ,OP,25.25,118.19,,,,,,
Health Alliance MCR ADV,CPT,86977,Rbc serum pretx incubj/inhib,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Health Alliance MCR ADV,CPT,86978,Rbc pretreatment serum,APC 5732,RVU Per Case,$34.63 ,OP,34.63,102.95,,,,,,
Health Alliance MCR ADV,CPT,86985,Split blood or products,APC 5672,RVU Per Case,$152.64 ,OP,76.26,152.64,,,,,,
Health Alliance MCR ADV,CPT,86999,Transfusion procedure,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Health Alliance MCR ADV,CPT,87003,Small animal inoculation,Lab Services,Per Unit,$16.84 ,OP,16.84,76.26,,,,,,
Health Alliance MCR ADV,CPT,87015,Specimen infect agnt concntj,Lab Services,Per Unit,$6.68 ,OP,6.68,30.51,,,,,,
Health Alliance MCR ADV,CPT,87040,Blood culture for bacteria,Lab Services,Per Unit,$10.32 ,OP,10.32,45.74,,,,,,
Health Alliance MCR ADV,CPT,87045,Feces culture aerobic bact,Lab Services,Per Unit,$9.44 ,OP,9.44,41.94,,,,,,
Health Alliance MCR ADV,CPT,87046,Stool cultr aerobic bact ea,Lab Services,Per Unit,$9.44 ,OP,9.44,41.94,,,,,,
Health Alliance MCR ADV,CPT,87070,Culture othr specimn aerobic,Lab Services,Per Unit,$8.62 ,OP,8.62,41.94,,,,,,
Health Alliance MCR ADV,CPT,87071,Culture aerobic quant other,Lab Services,Per Unit,$9.89 ,OP,9.89,41.94,,,,,,
Health Alliance MCR ADV,CPT,87073,Culture bacteria anaerobic,Lab Services,Per Unit,$9.66 ,OP,9.66,41.94,,,,,,
Health Alliance MCR ADV,CPT,87075,Cultr bacteria except blood,Lab Services,Per Unit,$9.47 ,OP,9.47,41.94,,,,,,
Health Alliance MCR ADV,CPT,87076,Culture anaerobe ident each,Lab Services,Per Unit,$8.08 ,OP,8.08,19.07,,,,,,
Health Alliance MCR ADV,CPT,87077,Culture aerobic identify,Lab Services,Per Unit,$8.08 ,OP,8.08,22.88,,,,,,
Health Alliance MCR ADV,CPT,87081,Culture screen only,Lab Services,Per Unit,$6.63 ,OP,6.63,34.31,,,,,,
Health Alliance MCR ADV,CPT,87084,Culture of specimen by kit,Lab Services,Per Unit,$27.07 ,OP,22.88,27.07,,,,,,
Health Alliance MCR ADV,CPT,87086,Urine culture/colony count,Lab Services,Per Unit,$8.07 ,OP,8.07,41.94,,,,,,
Health Alliance MCR ADV,CPT,87088,Urine bacteria culture,Lab Services,Per Unit,$8.09 ,OP,8.09,41.94,,,,,,
Health Alliance MCR ADV,CPT,87101,Skin fungi culture,Lab Services,Per Unit,$7.71 ,OP,7.71,34.31,,,,,,
Health Alliance MCR ADV,CPT,87102,Fungus isolation culture,Lab Services,Per Unit,$8.41 ,OP,8.41,38.13,,,,,,
Health Alliance MCR ADV,CPT,87103,Blood fungus culture,Lab Services,Per Unit,$20.46 ,OP,20.46,41.94,,,,,,
Health Alliance MCR ADV,CPT,87106,Fungi identification yeast,Lab Services,Per Unit,$10.32 ,OP,10.32,45.74,,,,,,
Health Alliance MCR ADV,CPT,87107,Fungi identification mold,Lab Services,Per Unit,$10.32 ,OP,10.32,45.74,,,,,,
Health Alliance MCR ADV,CPT,87109,Mycoplasma,Lab Services,Per Unit,$15.39 ,OP,15.39,68.63,,,,,,
Health Alliance MCR ADV,CPT,87110,Chlamydia culture,Lab Services,Per Unit,$19.60 ,OP,19.6,87.69,,,,,,
Health Alliance MCR ADV,CPT,87116,Mycobacteria culture,Lab Services,Per Unit,$10.80 ,OP,10.8,49.56,,,,,,
Health Alliance MCR ADV,CPT,87118,Mycobacteric identification,Lab Services,Per Unit,$14.61 ,OP,14.61,49.56,,,,,,
Health Alliance MCR ADV,CPT,87140,Culture type immunofluoresc,Lab Services,Per Unit,$5.57 ,OP,5.57,26.7,,,,,,
Health Alliance MCR ADV,CPT,87143,Culture typing glc/hplc,Lab Services,Per Unit,$12.52 ,OP,12.52,57.19,,,,,,
Health Alliance MCR ADV,CPT,87147,Culture type immunologic,Lab Services,Per Unit,$5.18 ,OP,5.18,22.88,,,,,,
Health Alliance MCR ADV,CPT,87149,Dna/rna direct probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
Health Alliance MCR ADV,CPT,87150,Dna/rna amplified probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,
Health Alliance MCR ADV,CPT,87152,Culture type pulse field gel,Lab Services,Per Unit,$7.74 ,OP,7.74,22.88,,,,,,
Health Alliance MCR ADV,CPT,87153,Dna/rna sequencing,Lab Services,Per Unit,$115.36 ,OP,115.36,115.36,,,,,,
Health Alliance MCR ADV,CPT,87158,Culture typing added method,Lab Services,Per Unit,$7.74 ,OP,7.74,7.74,,,,,,
Health Alliance MCR ADV,CPT,87164,Dark field examination,Lab Services,Per Unit,$10.74 ,OP,10.74,49.56,,,,,,
Health Alliance MCR ADV,CPT,87166,Dark field examination,Lab Services,Per Unit,$11.30 ,OP,11.3,49.56,,,,,,
Health Alliance MCR ADV,CPT,87168,Macroscopic exam arthropod,Lab Services,Per Unit,$4.27 ,OP,4.27,19.07,,,,,,
Health Alliance MCR ADV,CPT,87169,Macroscopic exam parasite,Lab Services,Per Unit,$4.31 ,OP,4.31,19.07,,,,,,
Health Alliance MCR ADV,CPT,87172,Pinworm exam,Lab Services,Per Unit,$4.27 ,OP,4.27,22.88,,,,,,
Health Alliance MCR ADV,CPT,87176,Tissue homogenization cultr,Lab Services,Per Unit,$5.88 ,OP,5.88,26.7,,,,,,
Health Alliance MCR ADV,CPT,87177,Ova and parasites smears,Lab Services,Per Unit,$8.90 ,OP,8.9,41.94,,,,,,
Health Alliance MCR ADV,CPT,87181,Microbe susceptible diffuse,Lab Services,Per Unit,$4.75 ,OP,4.75,22.88,,,,,,
Health Alliance MCR ADV,CPT,87184,Microbe susceptible disk,Lab Services,Per Unit,$7.48 ,OP,7.48,34.31,,,,,,
Health Alliance MCR ADV,CPT,87185,Microbe susceptible enzyme,Lab Services,Per Unit,$4.75 ,OP,4.75,22.88,,,,,,
Health Alliance MCR ADV,CPT,87186,Microbe susceptible mic,Lab Services,Per Unit,$8.65 ,OP,8.65,38.13,,,,,,
Health Alliance MCR ADV,CPT,87187,Microbe susceptible mlc,Lab Services,Per Unit,$40.17 ,OP,40.17,45.74,,,,,,
Health Alliance MCR ADV,CPT,87188,Microbe suscept macrobroth,Lab Services,Per Unit,$6.64 ,OP,6.64,30.51,,,,,,
Health Alliance MCR ADV,CPT,87190,Microbe suscept mycobacteri,Lab Services,Per Unit,$7.31 ,OP,7.31,26.7,,,,,,
Health Alliance MCR ADV,CPT,87197,Bactericidal level serum,Lab Services,Per Unit,$15.02 ,OP,15.02,68.63,,,,,,
Health Alliance MCR ADV,CPT,87205,Smear gram stain,Lab Services,Per Unit,$4.27 ,OP,4.27,22.88,,,,,,
Health Alliance MCR ADV,CPT,87206,Smear fluorescent/acid stai,Lab Services,Per Unit,$5.39 ,OP,5.39,26.7,,,,,,
Health Alliance MCR ADV,CPT,87207,Smear special stain,Lab Services,Per Unit,$5.99 ,OP,5.99,41.94,,,,,,
Health Alliance MCR ADV,CPT,87209,Smear complex stain,Lab Services,Per Unit,$17.98 ,OP,17.98,80.07,,,,,,
Health Alliance MCR ADV,CPT,87210,Smear wet mount saline/ink,Lab Services,Per Unit,$5.82 ,OP,5.82,22.88,,,,,,
Health Alliance MCR ADV,CPT,87220,Tissue exam for fungi,Lab Services,Per Unit,$4.27 ,OP,4.27,22.88,,,,,,
Health Alliance MCR ADV,CPT,87230,Assay toxin or antitoxin,Lab Services,Per Unit,$19.74 ,OP,19.74,87.69,,,,,,
Health Alliance MCR ADV,CPT,87250,Virus inoculate eggs/animal,Lab Services,Per Unit,$19.56 ,OP,19.56,87.69,,,,,,
Health Alliance MCR ADV,CPT,87252,Virus inoculation tissue,Lab Services,Per Unit,$26.07 ,OP,26.07,102.95,,,,,,
Health Alliance MCR ADV,CPT,87253,Virus inoculate tissue addl,Lab Services,Per Unit,$20.20 ,OP,20.2,91.51,,,,,,
Health Alliance MCR ADV,CPT,87254,Virus inoculation shell via,Lab Services,Per Unit,$19.56 ,OP,19.56,87.69,,,,,,
Health Alliance MCR ADV,CPT,87255,Genet virus isolate hsv,Lab Services,Per Unit,$33.86 ,OP,33.86,152.51,,,,,,
Health Alliance MCR ADV,CPT,87260,Adenovirus ag if,Lab Services,Per Unit,$14.43 ,OP,14.43,14.43,,,,,,
Health Alliance MCR ADV,CPT,87265,Pertussis ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Health Alliance MCR ADV,CPT,87267,Enterovirus antibody dfa,Lab Services,Per Unit,$13.42 ,OP,13.42,53.38,,,,,,
Health Alliance MCR ADV,CPT,87269,Giardia ag if,Lab Services,Per Unit,$13.61 ,OP,13.61,53.38,,,,,,
Health Alliance MCR ADV,CPT,87270,Chlamydia trachomatis ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Health Alliance MCR ADV,CPT,87271,Cytomegalovirus dfa,Lab Services,Per Unit,$13.42 ,OP,13.42,53.38,,,,,,
Health Alliance MCR ADV,CPT,87272,Cryptosporidium ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Health Alliance MCR ADV,CPT,87273,Herpes simplex 2 ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,
Health Alliance MCR ADV,CPT,87274,Herpes simplex 1 ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,
Health Alliance MCR ADV,CPT,87275,Influenza b ag if,Lab Services,Per Unit,$12.25 ,OP,12.25,53.38,,,,,,
Health Alliance MCR ADV,CPT,87276,Influenza a ag if,Lab Services,Per Unit,$16.07 ,OP,16.07,53.38,,,,,,
Health Alliance MCR ADV,CPT,87278,Legion pneumophilia ag if,Lab Services,Per Unit,$15.60 ,OP,15.6,53.38,,,,,,
Health Alliance MCR ADV,CPT,87279,Parainfluenza ag if,Lab Services,Per Unit,$16.43 ,OP,16.43,53.38,,,,,,
Health Alliance MCR ADV,CPT,87280,Respiratory syncytial ag if,Lab Services,Per Unit,$13.42 ,OP,13.42,53.38,,,,,,
Health Alliance MCR ADV,CPT,87281,Pneumocystis carinii ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Health Alliance MCR ADV,CPT,87283,Rubeola ag if,Lab Services,Per Unit,$60.80 ,OP,53.38,60.8,,,,,,
Health Alliance MCR ADV,CPT,87285,Treponema pallidum ag if,Lab Services,Per Unit,$12.18 ,OP,12.18,53.38,,,,,,
Health Alliance MCR ADV,CPT,87290,Varicella zoster ag if,Lab Services,Per Unit,$13.42 ,OP,13.42,53.38,,,,,,
Health Alliance MCR ADV,CPT,87299,Antibody detection nos if,Lab Services,Per Unit,$16.10 ,OP,16.1,53.38,,,,,,
Health Alliance MCR ADV,CPT,87300,Ag detection polyval if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,
Health Alliance MCR ADV,CPT,87301,Adenovirus ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Health Alliance MCR ADV,CPT,87305,Aspergillus ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Health Alliance MCR ADV,CPT,87320,Chylmd trach ag ia,Lab Services,Per Unit,$15.00 ,OP,15,53.38,,,,,,
Health Alliance MCR ADV,CPT,87324,Clostridium ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Health Alliance MCR ADV,CPT,87327,Cryptococcus neoform ag ia,Lab Services,Per Unit,$13.42 ,OP,13.42,53.38,,,,,,
Health Alliance MCR ADV,CPT,87328,Cryptosporidium ag ia,Lab Services,Per Unit,$13.82 ,OP,13.82,53.38,,,,,,
Health Alliance MCR ADV,CPT,87329,Giardia ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Health Alliance MCR ADV,CPT,87332,Cytomegalovirus ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Health Alliance MCR ADV,CPT,87335,E coli 0157 ag ia,Lab Services,Per Unit,$12.66 ,OP,12.66,53.38,,,,,,
Health Alliance MCR ADV,CPT,87336,Entamoeb hist dispr ag ia,Lab Services,Per Unit,$16.00 ,OP,16,53.38,,,,,,
Health Alliance MCR ADV,CPT,87337,Entamoeb hist group ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Health Alliance MCR ADV,CPT,87338,Hpylori stool ag ia,Lab Services,Per Unit,$14.38 ,OP,14.38,64.82,,,,,,
Health Alliance MCR ADV,CPT,87339,H pylori ag ia,Lab Services,Per Unit,$16.00 ,OP,16,53.38,,,,,,
Health Alliance MCR ADV,CPT,87340,Hepatitis b surface ag ia,Lab Services,Per Unit,$10.33 ,OP,10.33,45.74,,,,,,
Health Alliance MCR ADV,CPT,87341,Hepatitis b surface ag ia,Lab Services,Per Unit,$10.33 ,OP,10.33,45.74,,,,,,
Health Alliance MCR ADV,CPT,87350,Hepatitis be ag ia,Lab Services,Per Unit,$11.53 ,OP,11.53,49.56,,,,,,
Health Alliance MCR ADV,CPT,87380,Hepatitis delta agent ag ia,Lab Services,Per Unit,$18.36 ,OP,18.36,72.44,,,,,,
Health Alliance MCR ADV,CPT,87385,Histoplasma capsul ag ia,Lab Services,Per Unit,$13.25 ,OP,13.25,53.38,,,,,,
Health Alliance MCR ADV,CPT,87389,Hiv-1 ag w/hiv-1&2 ab ag ia,Lab Services,Per Unit,$24.08 ,OP,24.08,24.08,,,,,,
Health Alliance MCR ADV,CPT,87390,Hiv-1 ag ia,Lab Services,Per Unit,$24.06 ,OP,24.06,24.06,,,,,,
Health Alliance MCR ADV,CPT,87391,Hiv-2 ag ia,Lab Services,Per Unit,$21.90 ,OP,21.9,80.07,,,,,,
Health Alliance MCR ADV,CPT,87400,Influenza a/b each ag ia,Lab Services,Per Unit,$14.13 ,OP,14.13,61,,,,,,
Health Alliance MCR ADV,CPT,87420,Resp syncytial virus ag ia,Lab Services,Per Unit,$13.91 ,OP,13.91,53.38,,,,,,
Health Alliance MCR ADV,CPT,87425,Rotavirus ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Health Alliance MCR ADV,CPT,87426,Sarscov coronavirus ag ia,Lab Services,Per Unit,$35.33 ,OP,35.33,35.33,,,,,,
Health Alliance MCR ADV,CPT,87427,Shiga-like toxin ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Health Alliance MCR ADV,CPT,87428,Sarscov & inf vir a&b ag ia,Lab Services,Per Unit,$63.59 ,OP,63.59,63.59,,,,,,
Health Alliance MCR ADV,CPT,87430,Strep a ag ia,Lab Services,Per Unit,$16.81 ,OP,16.81,61,,,,,,
Health Alliance MCR ADV,CPT,87449,Nos each organism ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,61,,,,,,
Health Alliance MCR ADV,CPT,87451,Polyvalent mult org ea ag ia,Lab Services,Per Unit,$10.51 ,OP,10.51,41.94,,,,,,
Health Alliance MCR ADV,CPT,87471,Bartonella dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,
Health Alliance MCR ADV,CPT,87472,Bartonella dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Health Alliance MCR ADV,CPT,87475,Lyme dis dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
Health Alliance MCR ADV,CPT,87476,Lyme dis dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Health Alliance MCR ADV,CPT,87480,Candida dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,99.13,,,,,,
Health Alliance MCR ADV,CPT,87481,Candida dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Health Alliance MCR ADV,CPT,87482,Candida dna quant,Lab Services,Per Unit,$55.74 ,OP,55.74,186.82,,,,,,
Health Alliance MCR ADV,CPT,87483,Cns dna amp probe type 12-25,Lab Services,Per Unit,$416.78 ,OP,416.78,416.78,,,,,,
Health Alliance MCR ADV,CPT,87485,Chylmd pneum dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
Health Alliance MCR ADV,CPT,87486,Chylmd pneum dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Health Alliance MCR ADV,CPT,87487,Chylmd pneum dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Health Alliance MCR ADV,CPT,87490,Chylmd trach dna dir probe,Lab Services,Per Unit,$22.75 ,OP,22.75,99.13,,,,,,
Health Alliance MCR ADV,CPT,87491,Chylmd trach dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Health Alliance MCR ADV,CPT,87492,Chylmd trach dna quant,Lab Services,Per Unit,$53.47 ,OP,53.47,156.32,,,,,,
Health Alliance MCR ADV,CPT,87493,C diff amplified probe,Lab Services,Per Unit,$37.27 ,OP,37.27,37.27,,,,,,
Health Alliance MCR ADV,CPT,87495,Cytomeg dna dir probe,Lab Services,Per Unit,$30.03 ,OP,30.03,30.03,,,,,,
Health Alliance MCR ADV,CPT,87496,Cytomeg dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Health Alliance MCR ADV,CPT,87497,Cytomeg dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Health Alliance MCR ADV,CPT,87498,Enterovirus probe&revrs trns,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Health Alliance MCR ADV,CPT,87500,Vanomycin dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Health Alliance MCR ADV,CPT,87501,Influenza dna amp prob 1+,Lab Services,Per Unit,$51.31 ,OP,51.31,51.31,,,,,,
Health Alliance MCR ADV,CPT,87502,Influenza dna amp probe,Lab Services,Per Unit,$95.80 ,OP,95.8,95.8,,,,,,
Health Alliance MCR ADV,CPT,87503,Influenza dna amp prob addl,Lab Services,Per Unit,$29.22 ,OP,29.22,29.22,,,,,,
Health Alliance MCR ADV,CPT,87505,Nfct agent detection gi,Lab Services,Per Unit,$128.29 ,OP,128.29,128.29,,,,,,
Health Alliance MCR ADV,CPT,87506,Iadna-dna/rna probe tq 6-11,Lab Services,Per Unit,$262.99 ,OP,262.99,262.99,,,,,,
Health Alliance MCR ADV,CPT,87507,Iadna-dna/rna probe tq 12-25,Lab Services,Per Unit,$416.78 ,OP,416.78,416.78,,,,,,
Health Alliance MCR ADV,CPT,87510,Gardner vag dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,99.13,,,,,,
Health Alliance MCR ADV,CPT,87511,Gardner vag dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Health Alliance MCR ADV,CPT,87512,Gardner vag dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,186.82,,,,,,
Health Alliance MCR ADV,CPT,87516,Hepatitis b dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Health Alliance MCR ADV,CPT,87517,Hepatitis b dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Health Alliance MCR ADV,CPT,87520,Hepatitis c rna dir probe,Lab Services,Per Unit,$31.22 ,OP,31.22,87.69,,,,,,
Health Alliance MCR ADV,CPT,87521,Hepatitis c probe&rvrs trnsc,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Health Alliance MCR ADV,CPT,87522,Hepatitis c revrs trnscrpj,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Health Alliance MCR ADV,CPT,87525,Hepatitis g dna dir probe,Lab Services,Per Unit,$29.80 ,OP,29.8,87.69,,,,,,
Health Alliance MCR ADV,CPT,87526,Hepatitis g dna amp probe,Lab Services,Per Unit,$39.26 ,OP,39.26,156.32,,,,,,
Health Alliance MCR ADV,CPT,87527,Hepatitis g dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,186.82,,,,,,
Health Alliance MCR ADV,CPT,87528,Hsv dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
Health Alliance MCR ADV,CPT,87529,Hsv dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Health Alliance MCR ADV,CPT,87530,Hsv dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Health Alliance MCR ADV,CPT,87531,Hhv-6 dna dir probe,Lab Services,Per Unit,$58.00 ,OP,58,87.69,,,,,,
Health Alliance MCR ADV,CPT,87532,Hhv-6 dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,
Health Alliance MCR ADV,CPT,87533,Hhv-6 dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,186.82,,,,,,
Health Alliance MCR ADV,CPT,87534,Hiv-1 dna dir probe,Lab Services,Per Unit,$21.92 ,OP,21.92,87.69,,,,,,
Health Alliance MCR ADV,CPT,87535,Hiv-1 probe&reverse trnscrpj,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Health Alliance MCR ADV,CPT,87536,Hiv-1 quant&revrse trnscrpj,Lab Services,Per Unit,$85.10 ,OP,85.1,377.46,,,,,,
Health Alliance MCR ADV,CPT,87537,Hiv-2 dna dir probe,Lab Services,Per Unit,$21.92 ,OP,21.92,87.69,,,,,,
Health Alliance MCR ADV,CPT,87538,Hiv-2 probe&revrse trnscripj,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Health Alliance MCR ADV,CPT,87539,Hiv-2 quant&revrse trnscripj,Lab Services,Per Unit,$58.62 ,OP,58.62,190.64,,,,,,
Health Alliance MCR ADV,CPT,87540,Legion pneumo dna dir prob,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
Health Alliance MCR ADV,CPT,87541,Legion pneumo dna amp prob,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Health Alliance MCR ADV,CPT,87542,Legion pneumo dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,186.82,,,,,,
Health Alliance MCR ADV,CPT,87550,Mycobacteria dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
Health Alliance MCR ADV,CPT,87551,Mycobacteria dna amp probe,Lab Services,Per Unit,$48.24 ,OP,48.24,156.32,,,,,,
Health Alliance MCR ADV,CPT,87552,Mycobacteria dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Health Alliance MCR ADV,CPT,87555,M.tuberculo dna dir probe,Lab Services,Per Unit,$26.88 ,OP,26.88,87.69,,,,,,
Health Alliance MCR ADV,CPT,87556,M.tuberculo dna amp probe,Lab Services,Per Unit,$41.68 ,OP,41.68,156.32,,,,,,
Health Alliance MCR ADV,CPT,87557,M.tuberculo dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Health Alliance MCR ADV,CPT,87560,M.avium-intra dna dir prob,Lab Services,Per Unit,$27.29 ,OP,27.29,87.69,,,,,,
Health Alliance MCR ADV,CPT,87561,M.avium-intra dna amp prob,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Health Alliance MCR ADV,CPT,87562,M.avium-intra dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Health Alliance MCR ADV,CPT,87563,M. genitalium amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Health Alliance MCR ADV,CPT,87580,M.pneumon dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
Health Alliance MCR ADV,CPT,87581,M.pneumon dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Health Alliance MCR ADV,CPT,87582,M.pneumon dna quant,Lab Services,Per Unit,$302.62 ,OP,186.82,302.62,,,,,,
Health Alliance MCR ADV,CPT,87590,N.gonorrhoeae dna dir prob,Lab Services,Per Unit,$26.88 ,OP,26.88,99.13,,,,,,
Health Alliance MCR ADV,CPT,87591,N.gonorrhoeae dna amp prob,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Health Alliance MCR ADV,CPT,87592,N.gonorrhoeae dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,
Health Alliance MCR ADV,CPT,87623,Hpv low-risk types,Lab Services,Per Unit,$35.09 ,OP,35.09,93.87,,,,,,
Health Alliance MCR ADV,CPT,87624,Hpv high-risk types,Lab Services,Per Unit,$35.09 ,OP,35.09,93.87,,,,,,
Health Alliance MCR ADV,CPT,87625,Hpv types 16 & 18 only,Lab Services,Per Unit,$40.55 ,OP,40.55,93.87,,,,,,
Health Alliance MCR ADV,CPT,87631,Resp virus 3-5 targets,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
Health Alliance MCR ADV,CPT,87632,Resp virus 6-11 targets,Lab Services,Per Unit,$218.06 ,OP,218.06,218.06,,,,,,
Health Alliance MCR ADV,CPT,87633,Resp virus 12-25 targets,Lab Services,Per Unit,$416.78 ,OP,416.78,416.78,,,,,,
Health Alliance MCR ADV,CPT,87634,Rsv dna/rna amp probe,Lab Services,Per Unit,$70.20 ,OP,70.2,70.2,,,,,,
Health Alliance MCR ADV,CPT,87635,Sars-cov-2 covid-19 amp prb,Lab Services,Per Unit,$51.31 ,OP,51.31,51.31,,,,,,
Health Alliance MCR ADV,CPT,87636,Sarscov2 & inf a&b amp prb,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
Health Alliance MCR ADV,CPT,87637,Sarscov2&inf a&b&rsv amp prb,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
Health Alliance MCR ADV,CPT,87640,Staph a dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Health Alliance MCR ADV,CPT,87641,Mr-staph dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Health Alliance MCR ADV,CPT,87650,Strep a dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
Health Alliance MCR ADV,CPT,87651,Strep a dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Health Alliance MCR ADV,CPT,87652,Strep a dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,186.82,,,,,,
Health Alliance MCR ADV,CPT,87653,Strep b dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,
Health Alliance MCR ADV,CPT,87660,Trichomonas vagin dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
Health Alliance MCR ADV,CPT,87661,Trichomonas vaginalis amplif,Lab Services,Per Unit,$35.09 ,OP,35.09,87.69,,,,,,
Health Alliance MCR ADV,CPT,87662,Zika virus dna/rna amp probe,Lab Services,Per Unit,$51.31 ,OP,51.31,51.31,,,,,,
Health Alliance MCR ADV,CPT,87797,Detect agent nos dna dir,Lab Services,Per Unit,$30.03 ,OP,30.03,99.13,,,,,,
Health Alliance MCR ADV,CPT,87798,Detect agent nos dna amp,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Health Alliance MCR ADV,CPT,87799,Detect agent nos dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Health Alliance MCR ADV,CPT,87800,Detect agnt mult dna direc,Lab Services,Per Unit,$43.67 ,OP,43.67,179.2,,,,,,
Health Alliance MCR ADV,CPT,87801,Detect agnt mult dna ampli,Lab Services,Per Unit,$70.20 ,OP,70.2,312.64,,,,,,
Health Alliance MCR ADV,CPT,87802,Strep b assay w/optic,Lab Services,Per Unit,$12.73 ,OP,12.73,61,,,,,,
Health Alliance MCR ADV,CPT,87803,Clostridium toxin a w/optic,Lab Services,Per Unit,$16.00 ,OP,16,61,,,,,,
Health Alliance MCR ADV,CPT,87804,Influenza assay w/optic,Lab Services,Per Unit,$16.55 ,OP,16.55,61,,,,,,
Health Alliance MCR ADV,CPT,87806,Hiv w/hiv1&2 antb w/optic,Lab Services,Per Unit,$32.77 ,OP,32.77,61,,,,,,
Health Alliance MCR ADV,CPT,87807,Rsv assay w/optic,Lab Services,Per Unit,$13.10 ,OP,13.1,53.38,,,,,,
Health Alliance MCR ADV,CPT,87808,Trichomonas assay w/optic,Lab Services,Per Unit,$15.29 ,OP,15.29,61,,,,,,
Health Alliance MCR ADV,CPT,87809,Adenovirus assay w/optic,Lab Services,Per Unit,$21.76 ,OP,21.76,53.38,,,,,,
Health Alliance MCR ADV,CPT,87810,Chylmd trach assay w/optic,Lab Services,Per Unit,$35.29 ,OP,35.29,53.38,,,,,,
Health Alliance MCR ADV,CPT,87811,Sars-cov-2 covid19 w/optic,Lab Services,Per Unit,$41.38 ,OP,41.38,41.38,,,,,,
Health Alliance MCR ADV,CPT,87850,N. gonorrhoeae assay w/optic,Lab Services,Per Unit,$24.56 ,OP,24.56,53.38,,,,,,
Health Alliance MCR ADV,CPT,87880,Strep a assay w/optic,Lab Services,Per Unit,$16.53 ,OP,16.53,61,,,,,,
Health Alliance MCR ADV,CPT,87899,Agent nos assay w/optic,Lab Services,Per Unit,$16.07 ,OP,16.07,61,,,,,,
Health Alliance MCR ADV,CPT,87900,Phenotype infect agent drug,Lab Services,Per Unit,$130.35 ,OP,130.35,518.52,,,,,,
Health Alliance MCR ADV,CPT,87901,Genotype dna hiv reverse t,Lab Services,Per Unit,$257.45 ,OP,257.45,"1,147.62",,,,,,
Health Alliance MCR ADV,CPT,87902,Genotype dna/rna hep c,Lab Services,Per Unit,$257.45 ,OP,257.45,"1,147.62",,,,,,
Health Alliance MCR ADV,CPT,87903,Phenotype dna hiv w/culture,Lab Services,Per Unit,$488.66 ,OP,488.66,488.66,,,,,,
Health Alliance MCR ADV,CPT,87904,Phenotype dna hiv w/clt add,Lab Services,Per Unit,$26.07 ,OP,26.07,26.07,,,,,,
Health Alliance MCR ADV,CPT,87905,Sialidase enzyme assay,Lab Services,Per Unit,$12.22 ,OP,12.22,53.38,,,,,,
Health Alliance MCR ADV,CPT,87906,Genotype dna/rna hiv,Lab Services,Per Unit,$128.73 ,OP,128.73,128.73,,,,,,
Health Alliance MCR ADV,CPT,87910,Genotype cytomegalovirus,Lab Services,Per Unit,$257.45 ,OP,257.45,257.45,,,,,,
Health Alliance MCR ADV,CPT,87912,Genotype dna hepatitis b,Lab Services,Per Unit,$257.45 ,OP,257.45,257.45,,,,,,
Health Alliance MCR ADV,CPT,88104,Cytopath fl nongyn smears,APC 5732,RVU Per Case,$34.63 ,OP,34.63,175.39,,,,,,
Health Alliance MCR ADV,CPT,88106,Cytopath fl nongyn filter,APC 5731,RVU Per Case,$25.25 ,OP,25.25,247.83,,,,,,
Health Alliance MCR ADV,CPT,88108,Cytopath concentrate tech,APC 5732,RVU Per Case,$34.63 ,OP,34.63,228.77,,,,,,
Health Alliance MCR ADV,CPT,88112,Cytopath cell enhance tech,APC 5671,RVU Per Case,$50.92 ,OP,50.92,232.58,,,,,,
Health Alliance MCR ADV,CPT,88120,Cytp urne 3-5 probes ea spec,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Health Alliance MCR ADV,CPT,88121,Cytp urine 3-5 probes cmptr,APC 5673,RVU Per Case,$298.05 ,OP,298.05,298.05,,,,,,
Health Alliance MCR ADV,CPT,88125,Forensic cytopathology,APC 5671,RVU Per Case,$50.92 ,OP,45.74,50.92,,,,,,
Health Alliance MCR ADV,CPT,88130,Sex chromatin identification,Lab Services,Per Unit,$17.98 ,OP,17.98,68.63,,,,,,
Health Alliance MCR ADV,CPT,88140,Sex chromatin identification,Lab Services,Per Unit,$7.99 ,OP,7.99,34.31,,,,,,
Health Alliance MCR ADV,CPT,88142,Cytopath c/v thin layer,Lab Services,Per Unit,$20.26 ,OP,20.26,91.51,,,,,,
Health Alliance MCR ADV,CPT,88143,Cytopath c/v thin layer redo,Lab Services,Per Unit,$23.04 ,OP,23.04,91.51,,,,,,
Health Alliance MCR ADV,CPT,88147,Cytopath c/v automated,Lab Services,Per Unit,$50.56 ,OP,45.74,50.56,,,,,,
Health Alliance MCR ADV,CPT,88148,Cytopath c/v auto rescreen,Lab Services,Per Unit,$16.00 ,OP,16,45.74,,,,,,
Health Alliance MCR ADV,CPT,88150,Cytopath c/v manual,Lab Services,Per Unit,$15.15 ,OP,15.15,45.74,,,,,,
Health Alliance MCR ADV,CPT,88152,Cytopath c/v auto redo,Lab Services,Per Unit,$27.64 ,OP,27.64,45.74,,,,,,
Health Alliance MCR ADV,CPT,88153,Cytopath c/v redo,Lab Services,Per Unit,$24.03 ,OP,24.03,45.74,,,,,,
Health Alliance MCR ADV,CPT,88155,Cytopath c/v index add-on,Lab Services,Per Unit,$14.65 ,OP,14.65,26.7,,,,,,
Health Alliance MCR ADV,CPT,88160,Cytopath smear other source,APC 5731,RVU Per Case,$25.25 ,OP,25.25,141.07,,,,,,
Health Alliance MCR ADV,CPT,88161,Cytopath smear other source,APC 5731,RVU Per Case,$25.25 ,OP,25.25,152.51,,,,,,
Health Alliance MCR ADV,CPT,88162,Cytopath smear other source,APC 5671,RVU Per Case,$50.92 ,OP,50.92,205.88,,,,,,
Health Alliance MCR ADV,CPT,88164,Cytopath tbs c/v manual,Lab Services,Per Unit,$15.15 ,OP,15.15,45.74,,,,,,
Health Alliance MCR ADV,CPT,88165,Cytopath tbs c/v redo,Lab Services,Per Unit,$42.22 ,OP,42.22,45.74,,,,,,
Health Alliance MCR ADV,CPT,88166,Cytopath tbs c/v auto redo,Lab Services,Per Unit,$15.15 ,OP,15.15,45.74,,,,,,
Health Alliance MCR ADV,CPT,88167,Cytopath tbs c/v select,Lab Services,Per Unit,$15.15 ,OP,15.15,45.74,,,,,,
Health Alliance MCR ADV,CPT,88172,Cytp dx eval fna 1st ea site,APC 5672,RVU Per Case,$152.64 ,OP,118.19,152.64,,,,,,
Health Alliance MCR ADV,CPT,88173,Cytopath eval fna report,APC 5671,RVU Per Case,$50.92 ,OP,50.92,327.9,,,,,,
Health Alliance MCR ADV,CPT,88174,Cytopath c/v auto in fluid,Lab Services,Per Unit,$25.37 ,OP,25.37,95.32,,,,,,
Health Alliance MCR ADV,CPT,88175,Cytopath c/v auto fluid redo,Lab Services,Per Unit,$26.61 ,OP,26.61,118.19,,,,,,
Health Alliance MCR ADV,CPT,88182,Cell marker study,APC 5671,RVU Per Case,$50.92 ,OP,50.92,339.33,,,,,,
Health Alliance MCR ADV,CPT,88184,Flowcytometry/ tc 1 marker,APC 5673,RVU Per Case,$298.05 ,OP,298.05,404.14,,,,,,
Health Alliance MCR ADV,CPT,88199,Cytopathology procedure,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Health Alliance MCR ADV,CPT,88230,Tissue culture lymphocyte,Lab Services,Per Unit,$116.49 ,OP,116.49,518.52,,,,,,
Health Alliance MCR ADV,CPT,88233,Tissue culture skin/biopsy,Lab Services,Per Unit,$140.73 ,OP,140.73,625.29,,,,,,
Health Alliance MCR ADV,CPT,88235,Tissue culture placenta,Lab Services,Per Unit,$150.30 ,OP,150.3,655.78,,,,,,
Health Alliance MCR ADV,CPT,88237,Tissue culture bone marrow,Lab Services,Per Unit,$143.75 ,OP,143.75,564.29,,,,,,
Health Alliance MCR ADV,CPT,88239,Tissue culture tumor,Lab Services,Per Unit,$147.52 ,OP,147.52,655.78,,,,,,
Health Alliance MCR ADV,CPT,88240,Cell cryopreserve/storage,Lab Services,Per Unit,$13.07 ,OP,13.07,45.74,,,,,,
Health Alliance MCR ADV,CPT,88241,Frozen cell preparation,Lab Services,Per Unit,$12.09 ,OP,12.09,45.74,,,,,,
Health Alliance MCR ADV,CPT,88245,Chromosome analysis 20-25,Lab Services,Per Unit,$173.17 ,OP,173.17,648.16,,,,,,
Health Alliance MCR ADV,CPT,88248,Chromosome analysis 50-100,Lab Services,Per Unit,$173.17 ,OP,173.17,770.16,,,,,,
Health Alliance MCR ADV,CPT,88249,Chromosome analysis 100,Lab Services,Per Unit,$173.17 ,OP,173.17,770.16,,,,,,
Health Alliance MCR ADV,CPT,88261,Chromosome analysis 5,Lab Services,Per Unit,$264.34 ,OP,264.34,785.42,,,,,,
Health Alliance MCR ADV,CPT,88262,Chromosome analysis 15-20,Lab Services,Per Unit,$125.49 ,OP,125.49,556.65,,,,,,
Health Alliance MCR ADV,CPT,88263,Chromosome analysis 45,Lab Services,Per Unit,$150.29 ,OP,150.29,671.03,,,,,,
Health Alliance MCR ADV,CPT,88264,Chromosome analysis 20-25,Lab Services,Per Unit,$144.61 ,OP,144.61,556.65,,,,,,
Health Alliance MCR ADV,CPT,88267,Chromosome analys placenta,Lab Services,Per Unit,$188.57 ,OP,188.57,800.67,,,,,,
Health Alliance MCR ADV,CPT,88269,Chromosome analys amniotic,Lab Services,Per Unit,$173.66 ,OP,173.66,739.67,,,,,,
Health Alliance MCR ADV,CPT,88271,Cytogenetics dna probe,Lab Services,Per Unit,$21.42 ,OP,21.42,64.82,,,,,,
Health Alliance MCR ADV,CPT,88272,Cytogenetics 3-5,Lab Services,Per Unit,$40.70 ,OP,40.7,114.39,,,,,,
Health Alliance MCR ADV,CPT,88273,Cytogenetics 10-30,Lab Services,Per Unit,$34.81 ,OP,34.81,144.88,,,,,,
Health Alliance MCR ADV,CPT,88274,Cytogenetics 25-99,Lab Services,Per Unit,$42.38 ,OP,42.38,156.32,,,,,,
Health Alliance MCR ADV,CPT,88275,Cytogenetics 100-300,Lab Services,Per Unit,$51.19 ,OP,51.19,179.2,,,,,,
Health Alliance MCR ADV,CPT,88280,Chromosome karyotype study,Lab Services,Per Unit,$33.47 ,OP,33.47,110.57,,,,,,
Health Alliance MCR ADV,CPT,88283,Chromosome banding study,Lab Services,Per Unit,$68.60 ,OP,68.6,68.6,,,,,,
Health Alliance MCR ADV,CPT,88285,Chromosome count additional,Lab Services,Per Unit,$26.91 ,OP,26.91,83.87,,,,,,
Health Alliance MCR ADV,CPT,88289,Chromosome study additional,Lab Services,Per Unit,$34.43 ,OP,34.43,129.64,,,,,,
Health Alliance MCR ADV,CPT,88299,Cytogenetic study,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Health Alliance MCR ADV,CPT,88300,Surgical path gross,APC 5731,RVU Per Case,$25.25 ,OP,25.25,99.13,,,,,,
Health Alliance MCR ADV,CPT,88302,Tissue exam by pathologist,APC 5731,RVU Per Case,$25.25 ,OP,25.25,217.32,,,,,,
Health Alliance MCR ADV,CPT,88304,Tissue exam by pathologist,APC 5671,RVU Per Case,$50.92 ,OP,50.92,263.08,,,,,,
Health Alliance MCR ADV,CPT,88305,Tissue exam by pathologist,APC 5671,RVU Per Case,$50.92 ,OP,50.92,362.21,,,,,,
Health Alliance MCR ADV,CPT,88307,Tissue exam by pathologist,APC 5673,RVU Per Case,$298.05 ,OP,298.05,671.03,,,,,,
Health Alliance MCR ADV,CPT,88309,Tissue exam by pathologist,APC 5674,RVU Per Case,$671.45 ,OP,671.45,911.23,,,,,,
Health Alliance MCR ADV,CPT,88312,Special stains group 1,APC 5671,RVU Per Case,$50.92 ,OP,50.92,366.02,,,,,,
Health Alliance MCR ADV,CPT,88313,Special stains group 2,APC 5732,RVU Per Case,$34.63 ,OP,34.63,308.83,,,,,,
Health Alliance MCR ADV,CPT,88319,Enzyme histochemistry,APC 5674,RVU Per Case,$671.45 ,OP,568.09,671.45,,,,,,
Health Alliance MCR ADV,CPT,88321,Microslide consultation,APC 5732,RVU Per Case,$34.63 ,OP,34.63,438.47,,,,,,
Health Alliance MCR ADV,CPT,88323,Microslide consultation,APC 5671,RVU Per Case,$50.92 ,OP,50.92,289.76,,,,,,
Health Alliance MCR ADV,CPT,88325,Comprehensive review of data,APC 5672,RVU Per Case,$152.64 ,OP,152.64,949.36,,,,,,
Health Alliance MCR ADV,CPT,88329,Path consult introp,APC 5732,RVU Per Case,$34.63 ,OP,34.63,247.83,,,,,,
Health Alliance MCR ADV,CPT,88331,Path consult intraop 1 bloc,APC 5672,RVU Per Case,$152.64 ,OP,152.51,152.64,,,,,,
Health Alliance MCR ADV,CPT,88333,Intraop cyto path consult 1,APC 5674,RVU Per Case,$671.45 ,OP,163.95,671.45,,,,,,
Health Alliance MCR ADV,CPT,88342,Immunohisto antb 1st stain,APC 5672,RVU Per Case,$152.64 ,OP,152.64,297.39,,,,,,
Health Alliance MCR ADV,CPT,88344,Immunohisto antibody slide,APC 5673,RVU Per Case,$298.05 ,OP,297.39,298.05,,,,,,
Health Alliance MCR ADV,CPT,88346,Immunofluor antb 1st stain,APC 5673,RVU Per Case,$298.05 ,OP,293.57,298.05,,,,,,
Health Alliance MCR ADV,CPT,88348,Electron microscopy,APC 5674,RVU Per Case,$671.45 ,OP,671.45,"2,794.70",,,,,,
Health Alliance MCR ADV,CPT,88355,Analysis skeletal muscle,APC 5672,RVU Per Case,$152.64 ,OP,152.64,777.79,,,,,,
Health Alliance MCR ADV,CPT,88356,Analysis nerve,APC 5671,RVU Per Case,$50.92 ,OP,50.92,766.35,,,,,,
Health Alliance MCR ADV,CPT,88358,Analysis tumor,APC 5672,RVU Per Case,$152.64 ,OP,152.64,171.58,,,,,,
Health Alliance MCR ADV,CPT,88360,Tumor immunohistochem/manual,APC 5672,RVU Per Case,$152.64 ,OP,152.64,335.53,,,,,,
Health Alliance MCR ADV,CPT,88361,Tumor immunohistochem/comput,APC 5673,RVU Per Case,$298.05 ,OP,298.05,484.22,,,,,,
Health Alliance MCR ADV,CPT,88362,Nerve teasing preparations,APC 5674,RVU Per Case,$671.45 ,OP,671.45,793.05,,,,,,
Health Alliance MCR ADV,CPT,88363,Xm archive tissue molec anal,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Health Alliance MCR ADV,CPT,88365,Insitu hybridization (fish),APC 5672,RVU Per Case,$152.64 ,OP,152.64,499.47,,,,,,
Health Alliance MCR ADV,CPT,88366,Insitu hybridization (fish),APC 5673,RVU Per Case,$298.05 ,OP,298.05,499.47,,,,,,
Health Alliance MCR ADV,CPT,88367,Insitu hybridization auto,APC 5673,RVU Per Case,$298.05 ,OP,298.05,907.42,,,,,,
Health Alliance MCR ADV,CPT,88368,Insitu hybridization manual,APC 5673,RVU Per Case,$298.05 ,OP,298.05,747.28,,,,,,
Health Alliance MCR ADV,CPT,88374,M/phmtrc alys ishquant/semiq,APC 5672,RVU Per Case,$152.64 ,OP,152.64,907.42,,,,,,
Health Alliance MCR ADV,CPT,88377,M/phmtrc alys ishquant/semiq,APC 5672,RVU Per Case,$152.64 ,OP,152.64,747.28,,,,,,
Health Alliance MCR ADV,CPT,88399,Surgical pathology procedure,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Health Alliance MCR ADV,CPT,88720,Bilirubin total transcut,Lab Services,Per Unit,$5.02 ,OP,5.02,22.88,,,,,,
Health Alliance MCR ADV,CPT,88738,Hgb quant transcutaneous,Lab Services,Per Unit,$5.02 ,OP,5.02,5.02,,,,,,
Health Alliance MCR ADV,CPT,88740,Transcutaneous carboxyhb,Lab Services,Per Unit,$9.37 ,OP,9.37,22.88,,,,,,
Health Alliance MCR ADV,CPT,88741,Transcutaneous methb,Lab Services,Per Unit,$9.37 ,OP,9.37,22.88,,,,,,
Health Alliance MCR ADV,CPT,89049,Chct for mal hyperthermia,APC 5672,RVU Per Case,$152.64 ,OP,152.64,"1,201.00",,,,,,
Health Alliance MCR ADV,CPT,89050,Body fluid cell count,Lab Services,Per Unit,$4.72 ,OP,4.72,22.88,,,,,,
Health Alliance MCR ADV,CPT,89051,Body fluid cell count,Lab Services,Per Unit,$5.60 ,OP,5.6,26.7,,,,,,
Health Alliance MCR ADV,CPT,89055,Leukocyte assessment fecal,Lab Services,Per Unit,$4.27 ,OP,4.27,22.88,,,,,,
Health Alliance MCR ADV,CPT,89060,Exam synovial fluid crystals,Lab Services,Per Unit,$7.33 ,OP,7.33,30.51,,,,,,
Health Alliance MCR ADV,CPT,89125,Specimen fat stain,Lab Services,Per Unit,$5.88 ,OP,5.88,11.44,,,,,,
Health Alliance MCR ADV,CPT,89160,Exam feces for meat fibers,Lab Services,Per Unit,$4.85 ,OP,4.85,15.26,,,,,,
Health Alliance MCR ADV,CPT,89190,Nasal smear for eosinophils,Lab Services,Per Unit,$5.79 ,OP,5.79,22.88,,,,,,
Health Alliance MCR ADV,CPT,89220,Sputum specimen collection,APC 5672,RVU Per Case,$152.64 ,OP,80.07,152.64,,,,,,
Health Alliance MCR ADV,CPT,89230,Collect sweat for test,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Health Alliance MCR ADV,CPT,89240,Pathology lab procedure,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Health Alliance MCR ADV,CPT,89250,Cultr oocyte/embryo <4 days,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Health Alliance MCR ADV,CPT,89251,Cultr oocyte/embryo <4 days,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Health Alliance MCR ADV,CPT,89253,Embryo hatching,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Health Alliance MCR ADV,CPT,89254,Oocyte identification,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Health Alliance MCR ADV,CPT,89255,Prepare embryo for transfer,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Health Alliance MCR ADV,CPT,89257,Sperm identification,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Health Alliance MCR ADV,CPT,89258,Cryopreservation embryo(s),APC 5674,RVU Per Case,$671.45 ,OP,671.45,671.45,,,,,,
Health Alliance MCR ADV,CPT,89259,Cryopreservation sperm,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Health Alliance MCR ADV,CPT,89260,Sperm isolation simple,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Health Alliance MCR ADV,CPT,89261,Sperm isolation complex,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Health Alliance MCR ADV,CPT,89264,Identify sperm tissue,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Health Alliance MCR ADV,CPT,89268,Insemination of oocytes,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Health Alliance MCR ADV,CPT,89272,Extended culture of oocytes,APC 5674,RVU Per Case,$671.45 ,OP,671.45,671.45,,,,,,
Health Alliance MCR ADV,CPT,89280,Assist oocyte fertilization,APC 5674,RVU Per Case,$671.45 ,OP,671.45,671.45,,,,,,
Health Alliance MCR ADV,CPT,89281,Assist oocyte fertilization,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Health Alliance MCR ADV,CPT,89290,Biopsy oocyte polar body,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Health Alliance MCR ADV,CPT,89291,Biopsy oocyte polar body,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Health Alliance MCR ADV,CPT,89300,Semen analysis w/huhner,Lab Services,Per Unit,$9.84 ,OP,9.84,45.74,,,,,,
Health Alliance MCR ADV,CPT,89310,Semen analysis w/count,Lab Services,Per Unit,$8.61 ,OP,8.61,30.51,,,,,,
Health Alliance MCR ADV,CPT,89320,Semen anal vol/count/mot,Lab Services,Per Unit,$12.31 ,OP,12.31,49.56,,,,,,
Health Alliance MCR ADV,CPT,89321,Semen anal sperm detection,Lab Services,Per Unit,$12.05 ,OP,12.05,49.56,,,,,,
Health Alliance MCR ADV,CPT,89322,Semen anal strict criteria,Lab Services,Per Unit,$15.50 ,OP,15.5,61,,,,,,
Health Alliance MCR ADV,CPT,89325,Sperm antibody test,Lab Services,Per Unit,$10.67 ,OP,10.67,10.67,,,,,,
Health Alliance MCR ADV,CPT,89329,Sperm evaluation test,Lab Services,Per Unit,$19.59 ,OP,19.59,91.51,,,,,,
Health Alliance MCR ADV,CPT,89330,Evaluation cervical mucus,Lab Services,Per Unit,$10.38 ,OP,10.38,45.74,,,,,,
Health Alliance MCR ADV,CPT,89331,Retrograde ejaculation anal,Lab Services,Per Unit,$19.59 ,OP,19.59,83.87,,,,,,
Health Alliance MCR ADV,CPT,89335,Cryopreserve testicular tiss,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Health Alliance MCR ADV,CPT,89337,Cryopreservation oocyte(s),APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Health Alliance MCR ADV,CPT,89342,Storage/year embryo(s),APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Health Alliance MCR ADV,CPT,89343,Storage/year sperm/semen,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Health Alliance MCR ADV,CPT,89344,Storage/year reprod tissue,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Health Alliance MCR ADV,CPT,89346,Storage/year oocyte(s),APC 5673,RVU Per Case,$298.05 ,OP,298.05,298.05,,,,,,
Health Alliance MCR ADV,CPT,89352,Thawing cryopresrved embryo,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Health Alliance MCR ADV,CPT,89353,Thawing cryopresrved sperm,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Health Alliance MCR ADV,CPT,89354,Thaw cryoprsvrd reprod tiss,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Health Alliance MCR ADV,CPT,89356,Thawing cryopresrved oocyte,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Health Alliance MCR ADV,CPT,89398,Unlisted reprod med lab proc,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Health Alliance MCR ADV,CPT,90371,Hep b ig im,APC 1630,Per Unit,$130.31 ,OP,130.31,735.85,,,,,,
Health Alliance MCR ADV,CPT,90375,Rabies ig im/sc,APC 9133,Per Unit,$267.30 ,OP,267.3,617.65,,,,,,
Health Alliance MCR ADV,CPT,90376,Rabies ig heat treated,APC 9134,Per Unit,$287.38 ,OP,287.38,617.65,,,,,,
Health Alliance MCR ADV,CPT,90378,Rsv mab im 50mg,APC 9003,Per Unit,"$1,185.67 ",OP,"1,185.67","3,154.20",,,,,,
Health Alliance MCR ADV,CPT,90385,Rh ig minidose im,APC 9063,Per Unit,$151.41 ,OP,151.41,202.07,,,,,,
Health Alliance MCR ADV,CPT,90396,Varicella-zoster ig im,APC 9135,Per Unit,"$1,965.97 ",OP,495.65,"1,965.97",,,,,,
Health Alliance MCR ADV,CPT,90471,Immunization admin,APC 5692,RVU Per Case,$63.42 ,OP,57.19,63.42,,,,,,
Health Alliance MCR ADV,CPT,90473,Immune admin oral/nasal,APC 5692,RVU Per Case,$63.42 ,OP,57.19,63.42,,,,,,
Health Alliance MCR ADV,CPT,90630,Flu vacc iiv4 no preserv id,Other,Straight Discount,29.70%,OP,,,,,,,,
Health Alliance MCR ADV,CPT,90653,Iiv adjuvant vaccine im,Other,Straight Discount,29.70%,OP,,,,,,,,
Health Alliance MCR ADV,CPT,90654,Flu vacc iiv3 no preserv id,Other,Straight Discount,29.70%,OP,,,,,,,,
Health Alliance MCR ADV,CPT,90655,Iiv3 vacc no prsv 0.25 ml im,Other,Straight Discount,29.70%,OP,68.63,68.63,,,,,,
Health Alliance MCR ADV,CPT,90656,Iiv3 vacc no prsv 0.5 ml im,Other,Straight Discount,29.70%,OP,76.26,76.26,,,,,,
Health Alliance MCR ADV,CPT,90657,Iiv3 vaccine splt 0.25 ml im,Other,Straight Discount,29.70%,OP,110.57,110.57,,,,,,
Health Alliance MCR ADV,CPT,90660,Laiv3 vaccine intranasal,Other,Straight Discount,29.70%,OP,122,122,,,,,,
Health Alliance MCR ADV,CPT,90661,Cciiv3 vac no prsv 0.5 ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Health Alliance MCR ADV,CPT,90662,Iiv no prsv increased ag im,Other,Straight Discount,29.70%,OP,,,,,,,,
Health Alliance MCR ADV,CPT,90670,Pcv13 vaccine im,Other,Straight Discount,29.70%,OP,,,,,,,,
Health Alliance MCR ADV,CPT,90672,Laiv4 vaccine intranasal,Other,Straight Discount,29.70%,OP,,,,,,,,
Health Alliance MCR ADV,CPT,90673,Riv3 vaccine no preserv im,Other,Straight Discount,29.70%,OP,,,,,,,,
Health Alliance MCR ADV,CPT,90674,Cciiv4 vac no prsv 0.5 ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Health Alliance MCR ADV,CPT,90675,Rabies vaccine im,APC 9139,Per Unit,$327.53 ,OP,327.53,945.56,,,,,,
Health Alliance MCR ADV,CPT,90676,Rabies vaccine id,APC 9140,Per Unit,$189.63 ,OP,189.63,945.56,,,,,,
Health Alliance MCR ADV,CPT,90677,Pcv20 vaccine im,Other,Straight Discount,29.70%,OP,,,,,,,,
Health Alliance MCR ADV,CPT,90682,Riv4 vacc recombinant dna im,Other,Straight Discount,29.70%,OP,,,,,,,,
Health Alliance MCR ADV,CPT,90685,Iiv4 vacc no prsv 0.25 ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Health Alliance MCR ADV,CPT,90686,Iiv4 vacc no prsv 0.5 ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Health Alliance MCR ADV,CPT,90687,Iiv4 vaccine splt 0.25 ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Health Alliance MCR ADV,CPT,90688,Iiv4 vaccine splt 0.5 ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Health Alliance MCR ADV,CPT,90689,Vacc iiv4 no prsrv 0.25ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Health Alliance MCR ADV,CPT,90694,Vacc aiiv4 no prsrv 0.5ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Health Alliance MCR ADV,CPT,90732,Ppsv23 vacc 2 yrs+ subq/im,Other,Straight Discount,29.70%,OP,228.77,228.77,,,,,,
Health Alliance MCR ADV,CPT,90739,Hepb vacc 2 dose adult im,Other,Straight Discount,29.70%,OP,,,,,,,,
Health Alliance MCR ADV,CPT,90740,Hepb vacc 3 dose immunsup im,Other,Straight Discount,29.70%,OP,"1,029.43","1,029.43",,,,,,
Health Alliance MCR ADV,CPT,90743,Hepb vacc 2 dose adolesc im,Other,Straight Discount,29.70%,OP,141.07,141.07,,,,,,
Health Alliance MCR ADV,CPT,90744,Hepb vacc 3 dose ped/adol im,Other,Straight Discount,29.70%,OP,141.07,141.07,,,,,,
Health Alliance MCR ADV,CPT,90746,Hepb vaccine 3 dose adult im,Other,Straight Discount,29.70%,OP,369.83,369.83,,,,,,
Health Alliance MCR ADV,CPT,90747,Hepb vacc 4 dose immunsup im,Other,Straight Discount,29.70%,OP,"1,029.43","1,029.43",,,,,,
Health Alliance MCR ADV,CPT,90756,Cciiv4 vacc abx free im,Other,Straight Discount,29.70%,OP,,,,,,,,
Health Alliance MCR ADV,CPT,90791,Psych diagnostic evaluation,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,789.23,,,,,,
Health Alliance MCR ADV,CPT,90792,Psych diag eval w/med srvcs,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,789.23,,,,,,
Health Alliance MCR ADV,CPT,90832,Psytx w pt 30 minutes,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,331.7,,,,,,
Health Alliance MCR ADV,CPT,90834,Psytx w pt 45 minutes,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,480.4,,,,,,
Health Alliance MCR ADV,CPT,90837,Psytx w pt 60 minutes,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,705.35,,,,,,
Health Alliance MCR ADV,CPT,90839,Psytx crisis initial 60 min,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,136.74,,,,,,
Health Alliance MCR ADV,CPT,90845,Psychoanalysis,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,423.22,,,,,,
Health Alliance MCR ADV,CPT,90846,Family psytx w/o pt 50 min,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,449.9,,,,,,
Health Alliance MCR ADV,CPT,90847,Family psytx w/pt 50 min,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,583.35,,,,,,
Health Alliance MCR ADV,CPT,90849,Multiple family group psytx,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,171.58,,,,,,
Health Alliance MCR ADV,CPT,90853,Group psychotherapy,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,368.97,,,,,,
Health Alliance MCR ADV,CPT,90865,Narcosynthesis,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,808.29,,,,,,
Health Alliance MCR ADV,CPT,90867,Tcranial magn stim tx plan,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Health Alliance MCR ADV,CPT,90868,Tcranial magn stim tx deli,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Health Alliance MCR ADV,CPT,90869,Tcran magn stim redetemine,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Health Alliance MCR ADV,CPT,90870,Electroconvulsive therapy,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,709.16,,,,,,
Health Alliance MCR ADV,CPT,90880,Hypnotherapy,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,545.21,,,,,,
Health Alliance MCR ADV,CPT,90899,Psychiatric service/therapy,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Health Alliance MCR ADV,CPT,90901,Biofeedback train any meth,Physician,Per Unit,$19.59 ,OP,19.59,19.59,,,,,,
Health Alliance MCR ADV,CPT,90912,Bfb training 1st 15 min,Physician,Per Unit,$43.33 ,OP,43.33,476.6,,,,,,
Health Alliance MCR ADV,CPT,90913,Bfb training ea addl 15 min,Physician,Per Unit,$24.51 ,OP,24.51,264.78,,,,,,
Health Alliance MCR ADV,CPT,90935,Hemodialysis one evaluation,APC 5401,RVU Per Unit,$669.60 ,OP,373.65,669.6,,,,,,
Health Alliance MCR ADV,CPT,90945,Dialysis one evaluation,APC 5024,RVU Per Unit,$372.22 ,OP,372.22,388.89,,,,,,
Health Alliance MCR ADV,CPT,91010,Esophagus motility study,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Health Alliance MCR ADV,CPT,91020,Gastric motility studies,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,"1,265.81",,,,,,
Health Alliance MCR ADV,CPT,91022,Duodenal motility study,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,"1,044.69",,,,,,
Health Alliance MCR ADV,CPT,91030,Acid perfusion of esophagus,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,754.91,,,,,,
Health Alliance MCR ADV,CPT,91034,Gastroesophageal reflux test,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Health Alliance MCR ADV,CPT,91035,G-esoph reflx tst w/electrod,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Health Alliance MCR ADV,CPT,91037,Esoph imped function test,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Health Alliance MCR ADV,CPT,91038,Esoph imped funct test > 1hr,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Health Alliance MCR ADV,CPT,91040,Esoph balloon distension tst,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Health Alliance MCR ADV,CPT,91065,Breath hydrogen/methane test,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Health Alliance MCR ADV,CPT,91110,Gi tract capsule endoscopy,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,828.48,,,,,,
Health Alliance MCR ADV,CPT,91111,Esophageal capsule endoscopy,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,828.48,,,,,,
Health Alliance MCR ADV,CPT,91112,Gi wireless capsule measure,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,828.48,,,,,,
Health Alliance MCR ADV,CPT,91117,Colon motility 6 hr study,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,272.35,,,,,,
Health Alliance MCR ADV,CPT,91120,Rectal sensation test,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Health Alliance MCR ADV,CPT,91122,Anal pressure record,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,272.35,,,,,,
Health Alliance MCR ADV,CPT,91132,Electrogastrography,APC 5722,RVU Per Unit,$270.61 ,OP,244.01,270.61,,,,,,
Health Alliance MCR ADV,CPT,91133,Electrogastrography w/test,APC 5734,RVU Per Case,$114.56 ,OP,114.56,312.64,,,,,,
Health Alliance MCR ADV,CPT,91200,Liver elastography,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
Health Alliance MCR ADV,CPT,91299,Gastroenterology procedure,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Health Alliance MCR ADV,CPT,91300,Sarscov2 vac 30mcg/0.3ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Health Alliance MCR ADV,CPT,91301,Sarscov2 vac 100mcg/0.5ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Health Alliance MCR ADV,CPT,91303,Sarscov2 vac ad26 .5ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Health Alliance MCR ADV,CPT,92002,Eye exam new patient,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,354.58,,,,,,
Health Alliance MCR ADV,CPT,92004,Eye exam new patient,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,663.41,,,,,,
Health Alliance MCR ADV,CPT,92012,Eye exam establish patient,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,373.65,,,,,,
Health Alliance MCR ADV,CPT,92014,Eye exam&tx estab pt 1/>vst,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,545.21,,,,,,
Health Alliance MCR ADV,CPT,92018,New eye exam & treatment,APC 5503,RVU Per Case,"$2,049.05 ",OP,671.03,"2,049.05",,,,,,
Health Alliance MCR ADV,CPT,92019,Eye exam & treatment,APC 5503,RVU Per Case,"$2,049.05 ",OP,331.7,"2,049.05",,,,,,
Health Alliance MCR ADV,CPT,92020,Special eye evaluation,APC 5734,RVU Per Case,$114.56 ,OP,114.56,125.82,,,,,,
Health Alliance MCR ADV,CPT,92025,Corneal topography,APC 5733,RVU Per Case,$56.95 ,OP,56.95,167.76,,,,,,
Health Alliance MCR ADV,CPT,92060,Special eye evaluation,APC 5733,RVU Per Case,$56.95 ,OP,56.95,285.96,,,,,,
Health Alliance MCR ADV,CPT,92065,Orthoptic/pleoptic training,APC 5733,RVU Per Case,$56.95 ,OP,56.95,224.95,,,,,,
Health Alliance MCR ADV,CPT,92081,Visual field examination(s),APC 5733,RVU Per Case,$56.95 ,OP,56.95,255.45,,,,,,
Health Alliance MCR ADV,CPT,92082,Visual field examination(s),APC 5733,RVU Per Case,$56.95 ,OP,56.95,339.33,,,,,,
Health Alliance MCR ADV,CPT,92083,Visual field examination(s),APC 5734,RVU Per Case,$114.56 ,OP,114.56,385.09,,,,,,
Health Alliance MCR ADV,CPT,92132,Cmptr ophth dx img ant segmt,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Health Alliance MCR ADV,CPT,92133,Cmptr ophth img optic nerve,APC 5733,RVU Per Case,$56.95 ,OP,56.95,224.95,,,,,,
Health Alliance MCR ADV,CPT,92134,Cptr ophth dx img post segmt,APC 5733,RVU Per Case,$56.95 ,OP,56.95,224.95,,,,,,
Health Alliance MCR ADV,CPT,92136,Ophthalmic biometry,APC 5734,RVU Per Case,$114.56 ,OP,114.56,411.78,,,,,,
Health Alliance MCR ADV,CPT,92145,Corneal hysteresis deter,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Health Alliance MCR ADV,CPT,92201,Opscpy extnd rta draw uni/bi,APC 5733,RVU Per Case,$56.95 ,OP,56.95,118.19,,,,,,
Health Alliance MCR ADV,CPT,92202,Opscpy extnd on/mac draw,APC 5733,RVU Per Case,$56.95 ,OP,56.95,76.37,,,,,,
Health Alliance MCR ADV,CPT,92227,Img rta detcj/mntr ds staff,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Health Alliance MCR ADV,CPT,92228,Img rta detc/mntr ds phy/qhp,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Health Alliance MCR ADV,CPT,92229,Img rta detc/mntr ds poc aly,APC 5733,RVU Per Unit,$56.95 ,OP,56.95,56.95,,,,,,
Health Alliance MCR ADV,CPT,92230,Eye exam with photos,APC 5723,RVU Per Case,$499.16 ,OP,289.76,499.16,,,,,,
Health Alliance MCR ADV,CPT,92235,Fluorescein angrph uni/bi,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,629.1,,,,,,
Health Alliance MCR ADV,CPT,92240,Icg angiography uni/bi,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,162.87",,,,,,
Health Alliance MCR ADV,CPT,92242,Fluorescein icg angiography,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,791.98",,,,,,
Health Alliance MCR ADV,CPT,92250,Eye exam with photos,APC 5734,RVU Per Case,$114.56 ,OP,114.56,346.96,,,,,,
Health Alliance MCR ADV,CPT,92260,Ophthalmoscopy/dynamometry,APC 5732,RVU Per Case,$34.63 ,OP,34.63,87.69,,,,,,
Health Alliance MCR ADV,CPT,92265,Eye muscle evaluation,APC 5733,RVU Per Case,$56.95 ,OP,56.95,381.27,,,,,,
Health Alliance MCR ADV,CPT,92270,Electro-oculography,APC 5734,RVU Per Case,$114.56 ,OP,114.56,438.47,,,,,,
Health Alliance MCR ADV,CPT,92273,Full field erg w/i&r,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,648.16,,,,,,
Health Alliance MCR ADV,CPT,92274,Multifocal erg w/i&r,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,386.03,,,,,,
Health Alliance MCR ADV,CPT,92283,Color vision examination,APC 5733,RVU Per Case,$56.95 ,OP,56.95,224.95,,,,,,
Health Alliance MCR ADV,CPT,92284,Dark adaptation eye exam,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
Health Alliance MCR ADV,CPT,92285,Eye photography,APC 5733,RVU Per Case,$56.95 ,OP,56.95,205.88,,,,,,
Health Alliance MCR ADV,CPT,92286,Internal eye photography,APC 5734,RVU Per Case,$114.56 ,OP,114.56,583.35,,,,,,
Health Alliance MCR ADV,CPT,92287,Internal eye photography,APC 5734,RVU Per Case,$114.56 ,OP,114.56,549.03,,,,,,
Health Alliance MCR ADV,CPT,92311,Contact lens fitting,APC 5735,RVU Per Case,$276.53 ,OP,276.53,449.9,,,,,,
Health Alliance MCR ADV,CPT,92312,Contact lens fitting,APC 5734,RVU Per Case,$114.56 ,OP,114.56,510.9,,,,,,
Health Alliance MCR ADV,CPT,92313,Contact lens fitting,APC 5734,RVU Per Case,$114.56 ,OP,114.56,434.65,,,,,,
Health Alliance MCR ADV,CPT,92315,Rx cntact lens aphakia 1 eye,APC 5734,RVU Per Case,$114.56 ,OP,114.56,312.64,,,,,,
Health Alliance MCR ADV,CPT,92316,Rx cntact lens aphakia 2 eye,APC 5734,RVU Per Case,$114.56 ,OP,114.56,411.78,,,,,,
Health Alliance MCR ADV,CPT,92317,Rx corneoscleral cntact lens,APC 5732,RVU Per Case,$34.63 ,OP,34.63,324.09,,,,,,
Health Alliance MCR ADV,CPT,92325,Modification of contact lens,APC 5734,RVU Per Case,$114.56 ,OP,114.56,141.07,,,,,,
Health Alliance MCR ADV,CPT,92326,Replacement of contact lens,APC 5733,RVU Per Case,$56.95 ,OP,56.95,205.88,,,,,,
Health Alliance MCR ADV,CPT,92352,Fit aphakia spectcl monofocl,APC 5733,RVU Per Case,$56.95 ,OP,56.95,198.25,,,,,,
Health Alliance MCR ADV,CPT,92353,Fit aphakia spectcl multifoc,APC 5733,RVU Per Case,$56.95 ,OP,56.95,232.58,,,,,,
Health Alliance MCR ADV,CPT,92354,Fit spectacles single system,APC 5732,RVU Per Case,$34.63 ,OP,34.63,510.9,,,,,,
Health Alliance MCR ADV,CPT,92355,Fit spectacles compound lens,APC 5732,RVU Per Case,$34.63 ,OP,34.63,285.96,,,,,,
Health Alliance MCR ADV,CPT,92358,Aphakia prosth service temp,APC 5733,RVU Per Case,$56.95 ,OP,56.95,102.95,,,,,,
Health Alliance MCR ADV,CPT,92371,Repair & adjust spectacles,APC 5733,RVU Per Case,$56.95 ,OP,56.95,76.26,,,,,,
Health Alliance MCR ADV,CPT,92499,Eye service or procedure,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Health Alliance MCR ADV,CPT,92502,Ear and throat examination,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,526.16,,,,,,
Health Alliance MCR ADV,CPT,92507,Speech/hearing therapy,Physician,Per Unit,$75.75 ,OP,75.75,354.58,,,,,,
Health Alliance MCR ADV,CPT,92508,Speech/hearing therapy,Physician,Per Unit,$23.07 ,OP,23.07,171.58,,,,,,
Health Alliance MCR ADV,CPT,92511,Nasopharyngoscopy,APC 5151,RVU Per Unit,$168.23 ,OP,168.23,842.61,,,,,,
Health Alliance MCR ADV,CPT,92512,Nasal function studies,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,331.7,,,,,,
Health Alliance MCR ADV,CPT,92516,Facial nerve function test,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Health Alliance MCR ADV,CPT,92517,Vemp test i&r cervical,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Health Alliance MCR ADV,CPT,92518,Vemp test i&r ocular,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Health Alliance MCR ADV,CPT,92519,Vemp tst i&r cervical&ocular,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Health Alliance MCR ADV,CPT,92520,Laryngeal function studies,APC 5734,RVU Per Case,$114.56 ,OP,114.56,339.33,,,,,,
Health Alliance MCR ADV,CPT,92521,Evaluation of speech fluency,Physician,Per Unit,$132.47 ,OP,132.47,857.86,,,,,,
Health Alliance MCR ADV,CPT,92522,Evaluate speech production,Physician,Per Unit,$111.22 ,OP,111.22,857.86,,,,,,
Health Alliance MCR ADV,CPT,92523,Speech sound lang comprehen,Physician,Per Unit,$227.69 ,OP,227.69,857.86,,,,,,
Health Alliance MCR ADV,CPT,92524,Behavral qualit analys voice,Physician,Per Unit,$108.89 ,OP,108.89,857.86,,,,,,
Health Alliance MCR ADV,CPT,92526,Oral function therapy,Physician,Per Unit,$83.51 ,OP,83.51,453.71,,,,,,
Health Alliance MCR ADV,CPT,92537,Caloric vstblr test w/rec,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,163.95,,,,,,
Health Alliance MCR ADV,CPT,92538,Caloric vstblr test w/rec,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,163.95,,,,,,
Health Alliance MCR ADV,CPT,92540,Basic vestibular evaluation,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Health Alliance MCR ADV,CPT,92541,Spontaneous nystagmus test,APC 5734,RVU Per Case,$114.56 ,OP,114.56,335.53,,,,,,
Health Alliance MCR ADV,CPT,92542,Positional nystagmus test,APC 5734,RVU Per Case,$114.56 ,OP,114.56,346.96,,,,,,
Health Alliance MCR ADV,CPT,92544,Optokinetic nystagmus test,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,282.14,,,,,,
Health Alliance MCR ADV,CPT,92545,Oscillating tracking test,APC 5722,RVU Per Unit,$270.61 ,OP,263.08,270.61,,,,,,
Health Alliance MCR ADV,CPT,92546,Sinusoidal rotational test,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,468.96,,,,,,
Health Alliance MCR ADV,CPT,92548,Cdp-sot 6 cond w/i&r,APC 5734,RVU Per Case,$114.56 ,OP,114.56,556.65,,,,,,
Health Alliance MCR ADV,CPT,92549,Cdp-sot 6 cond w/i&r mct&adt,APC 5734,RVU Per Case,$114.56 ,OP,114.56,556.65,,,,,,
Health Alliance MCR ADV,CPT,92550,Tympanometry & reflex thresh,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
Health Alliance MCR ADV,CPT,92552,Pure tone audiometry air,APC 5734,RVU Per Case,$114.56 ,OP,114.56,129.64,,,,,,
Health Alliance MCR ADV,CPT,92553,Audiometry air & bone,APC 5721,RVU Per Case,$142.80 ,OP,142.8,175.39,,,,,,
Health Alliance MCR ADV,CPT,92555,Speech threshold audiometry,APC 5732,RVU Per Case,$34.63 ,OP,34.63,99.13,,,,,,
Health Alliance MCR ADV,CPT,92556,Speech audiometry complete,APC 5733,RVU Per Case,$56.95 ,OP,56.95,152.51,,,,,,
Health Alliance MCR ADV,CPT,92557,Comprehensive hearing test,APC 5721,RVU Per Case,$142.80 ,OP,142.8,278.32,,,,,,
Health Alliance MCR ADV,CPT,92561,Bekesy audiometry diagnosis,APC 5734,RVU Per Case,$114.56 ,OP,114.56,171.58,,,,,,
Health Alliance MCR ADV,CPT,92562,Loudness balance test,APC 5721,RVU Per Case,$142.80 ,OP,137.25,142.8,,,,,,
Health Alliance MCR ADV,CPT,92563,Tone decay hearing test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,125.82,,,,,,
Health Alliance MCR ADV,CPT,92564,Sisi hearing test,APC 5731,RVU Per Case,$25.25 ,OP,25.25,122,,,,,,
Health Alliance MCR ADV,CPT,92565,Stenger test pure tone,APC 5732,RVU Per Case,$34.63 ,OP,34.63,80.07,,,,,,
Health Alliance MCR ADV,CPT,92567,Tympanometry,APC 5732,RVU Per Case,$34.63 ,OP,34.63,110.57,,,,,,
Health Alliance MCR ADV,CPT,92568,Acoustic refl threshold tst,APC 5732,RVU Per Case,$34.63 ,OP,34.63,110.57,,,,,,
Health Alliance MCR ADV,CPT,92570,Acoustic immitance testing,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
Health Alliance MCR ADV,CPT,92571,Filtered speech hearing test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,102.95,,,,,,
Health Alliance MCR ADV,CPT,92572,Staggered spondaic word test,APC 5721,RVU Per Case,$142.80 ,OP,99.13,142.8,,,,,,
Health Alliance MCR ADV,CPT,92575,Sensorineural acuity test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,202.07,,,,,,
Health Alliance MCR ADV,CPT,92576,Synthetic sentence test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,129.64,,,,,,
Health Alliance MCR ADV,CPT,92577,Stenger test speech,APC 5723,RVU Per Case,$499.16 ,OP,114.39,499.16,,,,,,
Health Alliance MCR ADV,CPT,92579,Visual audiometry (vra),APC 5721,RVU Per Case,$142.80 ,OP,142.8,259.27,,,,,,
Health Alliance MCR ADV,CPT,92582,Conditioning play audiometry,APC 5721,RVU Per Case,$142.80 ,OP,142.8,247.83,,,,,,
Health Alliance MCR ADV,CPT,92583,Select picture audiometry,APC 5733,RVU Per Case,$56.95 ,OP,56.95,205.88,,,,,,
Health Alliance MCR ADV,CPT,92584,Electrocochleography,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,427.03,,,,,,
Health Alliance MCR ADV,CPT,92587,Evoked auditory test limited,APC 5722,RVU Per Unit,$270.61 ,OP,244.01,270.61,,,,,,
Health Alliance MCR ADV,CPT,92588,Evoked auditory tst complete,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,385.09,,,,,,
Health Alliance MCR ADV,CPT,92596,Ear protector evaluation,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Health Alliance MCR ADV,CPT,92597,Oral speech device eval,Physician,Per Unit,$70.53 ,OP,70.53,583.35,,,,,,
Health Alliance MCR ADV,CPT,92601,Cochlear implt f/up exam <7,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Health Alliance MCR ADV,CPT,92602,Reprogram cochlear implt <7,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Health Alliance MCR ADV,CPT,92603,Cochlear implt f/up exam 7/>,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Health Alliance MCR ADV,CPT,92604,Reprogram cochlear implt 7/>,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Health Alliance MCR ADV,CPT,92607,Ex for speech device rx 1hr,Physician,Per Unit,$122.72 ,OP,122.72,804.48,,,,,,
Health Alliance MCR ADV,CPT,92608,Ex for speech device rx addl,Physician,Per Unit,$49.31 ,OP,49.31,163.95,,,,,,
Health Alliance MCR ADV,CPT,92609,Use of speech device service,Physician,Per Unit,$102.45 ,OP,102.45,430.83,,,,,,
Health Alliance MCR ADV,CPT,92610,Evaluate swallowing function,Physician,Per Unit,$69.06 ,OP,69.06,423.22,,,,,,
Health Alliance MCR ADV,CPT,92611,Motion fluoroscopy/swallow,Physician,Per Unit,$90.57 ,OP,90.57,461.34,,,,,,
Health Alliance MCR ADV,CPT,92612,Endoscopy swallow (fees) vid,Physician,Per Unit,$65.56 ,OP,65.56,796.85,,,,,,
Health Alliance MCR ADV,CPT,92614,Laryngoscopic sensory vid,Physician,Per Unit,$64.93 ,OP,64.93,709.16,,,,,,
Health Alliance MCR ADV,CPT,92616,Fees w/laryngeal sense test,Physician,Per Unit,$97.82 ,OP,97.82,972.25,,,,,,
Health Alliance MCR ADV,CPT,92620,Auditory function 60 min,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
Health Alliance MCR ADV,CPT,92625,Tinnitus assessment,APC 5721,RVU Per Case,$142.80 ,OP,142.8,293.57,,,,,,
Health Alliance MCR ADV,CPT,92626,Eval aud funcj 1st hour,APC 5721,RVU Per Case,$142.80 ,OP,142.8,407.96,,,,,,
Health Alliance MCR ADV,CPT,92640,Aud brainstem implt programg,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,385.09,,,,,,
Health Alliance MCR ADV,CPT,92651,Aep hearing status deter i&r,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Health Alliance MCR ADV,CPT,92652,Aep thrshld est mlt freq i&r,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Health Alliance MCR ADV,CPT,92653,Aep neurodiagnostic i&r,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Health Alliance MCR ADV,CPT,92700,Ent procedure/service,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Health Alliance MCR ADV,CPT,92920,Prq cardiac angioplast 1 art,APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,92924,Prq card angio/athrect 1 art,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
Health Alliance MCR ADV,CPT,92928,Prq card stent w/angio 1 vsl,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Health Alliance MCR ADV,CPT,92933,Prq card stent/ath/angio,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Health Alliance MCR ADV,CPT,92937,Prq revasc byp graft 1 vsl,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Health Alliance MCR ADV,CPT,92941,Prq card revasc mi 1 vsl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,92943,Prq card revasc chronic 1vsl,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Health Alliance MCR ADV,CPT,92950,Heart/lung resuscitation cpr,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,567.02",,,,,,
Health Alliance MCR ADV,CPT,92953,Temporary external pacing,APC 5781,RVU Per Unit,$575.01 ,OP,575.01,575.01,,,,,,
Health Alliance MCR ADV,CPT,92960,Cardioversion electric ext,APC 5781,RVU Per Unit,$575.01 ,OP,575.01,"1,460.26",,,,,,
Health Alliance MCR ADV,CPT,92961,Cardioversion electric int,APC 5781,RVU Per Unit,$575.01 ,OP,575.01,"1,513.64",,,,,,
Health Alliance MCR ADV,CPT,92970,Cardioassist internal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,040.87","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,92971,Cardioassist external,APC 5881,RVU Per Case,"$8,948.83 ",OP,590.97,"8,948.83",,,,,,
Health Alliance MCR ADV,CPT,92975,Dissolve clot heart vessel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"2,367.69","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,92977,Dissolve clot heart vessel,APC 5694,RVU Per Unit,$318.00 ,OP,318,850.23,,,,,,
Health Alliance MCR ADV,CPT,92986,Revision of aortic valve,APC 5192,RVU Per Case,"$5,072.43 ",OP,"5,072.43","8,048.60",,,,,,
Health Alliance MCR ADV,CPT,92987,Revision of mitral valve,APC 5193,RVU Per Case,"$10,277.14 ",OP,"8,338.36","10,277.14",,,,,,
Health Alliance MCR ADV,CPT,92990,Revision of pulmonary valve,APC 5193,RVU Per Case,"$10,277.14 ",OP,"6,409.14","10,277.14",,,,,,
Health Alliance MCR ADV,CPT,92997,Pul art balloon repr percut,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
Health Alliance MCR ADV,CPT,93005,Electrocardiogram tracing,APC 5733,RVU Per Case,$56.95 ,OP,56.95,72.44,,,,,,
Health Alliance MCR ADV,CPT,93017,Cardiovascular stress test,APC 5722,RVU Per Case,$270.61 ,OP,270.61,362.21,,,,,,
Health Alliance MCR ADV,CPT,93024,Cardiac drug stress test,APC 5735,RVU Per Case,$276.53 ,OP,276.53,712.98,,,,,,
Health Alliance MCR ADV,CPT,93025,Microvolt t-wave assess,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,"1,246.76",,,,,,
Health Alliance MCR ADV,CPT,93041,Rhythm ecg tracing,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Health Alliance MCR ADV,CPT,93050,Art pressure waveform analys,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Health Alliance MCR ADV,CPT,93225,Ecg monit/reprt up to 48 hrs,APC 5734,RVU Per Case,$114.56 ,OP,114.56,224.95,,,,,,
Health Alliance MCR ADV,CPT,93226,Ecg monit/reprt up to 48 hrs,APC 5734,RVU Per Case,$114.56 ,OP,114.56,926.48,,,,,,
Health Alliance MCR ADV,CPT,93229,Remote 30 day ecg tech supp,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Health Alliance MCR ADV,CPT,93242,Ext ecg>48hr<7d recording,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Health Alliance MCR ADV,CPT,93243,Ext ecg>48hr<7d scan a/r,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Health Alliance MCR ADV,CPT,93246,Ext ecg>7d<15d recording,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Health Alliance MCR ADV,CPT,93247,Ext ecg>7d<15d scan a/r,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Health Alliance MCR ADV,CPT,93260,Prgrmg dev eval impltbl sys,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Health Alliance MCR ADV,CPT,93261,Interrogate subq defib,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Health Alliance MCR ADV,CPT,93270,Remote 30 day ecg rev/report,APC 5741,RVU Per Case,$38.02 ,OP,38.02,137.25,,,,,,
Health Alliance MCR ADV,CPT,93271,Ecg/monitoring and analysis,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,"1,281.07",,,,,,
Health Alliance MCR ADV,CPT,93278,Ecg/signal-averaged,APC 5733,RVU Per Case,$56.95 ,OP,56.95,251.64,,,,,,
Health Alliance MCR ADV,CPT,93279,Prgrmg dev eval pm/ldls pm,APC 5741,RVU Per Case,$38.02 ,OP,38.02,327.9,,,,,,
Health Alliance MCR ADV,CPT,93280,Pm device progr eval dual,APC 5741,RVU Per Case,$38.02 ,OP,38.02,381.27,,,,,,
Health Alliance MCR ADV,CPT,93281,Pm device progr eval multi,APC 5741,RVU Per Case,$38.02 ,OP,38.02,446.08,,,,,,
Health Alliance MCR ADV,CPT,93282,Prgrmg eval implantable dfb,APC 5741,RVU Per Case,$38.02 ,OP,38.02,415.59,,,,,,
Health Alliance MCR ADV,CPT,93283,Prgrmg eval implantable dfb,APC 5741,RVU Per Case,$38.02 ,OP,38.02,503.28,,,,,,
Health Alliance MCR ADV,CPT,93284,Prgrmg eval implantable dfb,APC 5741,RVU Per Case,$38.02 ,OP,38.02,587.16,,,,,,
Health Alliance MCR ADV,CPT,93285,Prgrmg dev eval scrms ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,282.14,,,,,,
Health Alliance MCR ADV,CPT,93288,Interrog evl pm/ldls pm ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,255.45,,,,,,
Health Alliance MCR ADV,CPT,93289,Interrog device eval heart,APC 5741,RVU Per Case,$38.02 ,OP,38.02,385.09,,,,,,
Health Alliance MCR ADV,CPT,93290,Interrog dev eval icpms ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,190.64,,,,,,
Health Alliance MCR ADV,CPT,93291,Interrog dev eval scrms ip,APC 5731,RVU Per Case,$25.25 ,OP,25.25,244.01,,,,,,
Health Alliance MCR ADV,CPT,93292,Wcd device interrogate,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Health Alliance MCR ADV,CPT,93293,Pm phone r-strip device eval,APC 5741,RVU Per Case,$38.02 ,OP,38.02,366.02,,,,,,
Health Alliance MCR ADV,CPT,93296,Rem interrog evl pm/ids,APC 5741,RVU Per Case,$38.02 ,OP,38.02,213.51,,,,,,
Health Alliance MCR ADV,CPT,93303,Echo transthoracic,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,292.50",,,,,,
Health Alliance MCR ADV,CPT,93304,Echo transthoracic,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,796.85,,,,,,
Health Alliance MCR ADV,CPT,93306,Tte w/doppler complete,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,593.72",,,,,,
Health Alliance MCR ADV,CPT,93307,Tte w/o doppler complete,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,056.11",,,,,,
Health Alliance MCR ADV,CPT,93308,Tte f-up or lmtd,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,667.22,,,,,,
Health Alliance MCR ADV,CPT,93312,Echo transesophageal,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,921.59",,,,,,
Health Alliance MCR ADV,CPT,93313,Echo transesophageal,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,494.15,,,,,,
Health Alliance MCR ADV,CPT,93315,Echo transesophageal,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,738.59",,,,,,
Health Alliance MCR ADV,CPT,93316,Echo transesophageal,APC 5524,RVU Per Unit,$494.15 ,OP,259.27,494.15,,,,,,
Health Alliance MCR ADV,CPT,93318,Echo transesophageal intraop,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,330.63",,,,,,
Health Alliance MCR ADV,CPT,93350,Stress tte only,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,239.13",,,,,,
Health Alliance MCR ADV,CPT,93351,Stress tte complete,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,635.64",,,,,,
Health Alliance MCR ADV,CPT,93451,Right heart cath,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,93452,Left hrt cath w/ventrclgrphy,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,93453,R&l hrt cath w/ventriclgrphy,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,93454,Coronary artery angio s&i,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","2,966.62",,,,,,
Health Alliance MCR ADV,CPT,93455,Coronary art/grft angio s&i,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","2,966.62",,,,,,
Health Alliance MCR ADV,CPT,93456,R hrt coronary artery angio,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,93457,R hrt art/grft angio,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,93458,L hrt artery/ventricle angio,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,93459,L hrt art/grft angio,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,93460,R&l hrt art/ventricle angio,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,93461,R&l hrt art/ventricle angio,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,93503,Insert/place heart catheter,APC 5182,RVU Per Case,"$1,438.93 ",OP,651.97,"1,438.93",,,,,,
Health Alliance MCR ADV,CPT,93505,Biopsy of heart lining,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,346.47",,,,,,
Health Alliance MCR ADV,CPT,93530,Rt heart cath congenital,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,93531,R & l heart cath congenital,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","16,124.56",,,,,,
Health Alliance MCR ADV,CPT,93532,R & l heart cath congenital,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","16,600.26",,,,,,
Health Alliance MCR ADV,CPT,93533,R & l heart cath congenital,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","16,111.09",,,,,,
Health Alliance MCR ADV,CPT,93580,Transcath closure of asd,APC 5194,RVU Per Case,"$16,438.60 ",OP,"5,905.86","16,438.60",,,,,,
Health Alliance MCR ADV,CPT,93581,Transcath closure of vsd,APC 5194,RVU Per Case,"$16,438.60 ",OP,"7,739.77","16,438.60",,,,,,
Health Alliance MCR ADV,CPT,93582,Perq transcath closure pda,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Health Alliance MCR ADV,CPT,93583,Perq transcath septal reduxn,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,93590,Perq transcath cls mitral,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Health Alliance MCR ADV,CPT,93591,Perq transcath cls aortic,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Health Alliance MCR ADV,CPT,93600,Bundle of his recording,APC 5212,RVU Per Case,"$6,220.22 ",OP,"6,220.22","6,220.22",,,,,,
Health Alliance MCR ADV,CPT,93602,Intra-atrial recording,APC 5212,RVU Per Case,"$6,220.22 ",OP,968.43,"6,220.22",,,,,,
Health Alliance MCR ADV,CPT,93603,Right ventricular recording,APC 5211,RVU Per Case,"$1,138.72 ",OP,"1,117.12","1,138.72",,,,,,
Health Alliance MCR ADV,CPT,93610,Intra-atrial pacing,APC 5212,RVU Per Case,"$6,220.22 ",OP,"1,323.01","6,220.22",,,,,,
Health Alliance MCR ADV,CPT,93612,Intraventricular pacing,APC 5212,RVU Per Case,"$6,220.22 ",OP,"1,376.38","6,220.22",,,,,,
Health Alliance MCR ADV,CPT,93615,Esophageal recording,APC 5211,RVU Per Case,"$1,138.72 ",OP,392.7,"1,138.72",,,,,,
Health Alliance MCR ADV,CPT,93616,Esophageal recording,APC 5211,RVU Per Case,"$1,138.72 ",OP,"1,138.72","1,138.72",,,,,,
Health Alliance MCR ADV,CPT,93618,Heart rhythm pacing,APC 5211,RVU Per Case,"$1,138.72 ",OP,"1,138.72","2,367.69",,,,,,
Health Alliance MCR ADV,CPT,93619,Electrophysiology evaluation,APC 5212,RVU Per Case,"$6,220.22 ",OP,"4,312.16","6,220.22",,,,,,
Health Alliance MCR ADV,CPT,93620,Electrophysiology evaluation,APC 5212,RVU Per Case,"$6,220.22 ",OP,"5,112.83","6,220.22",,,,,,
Health Alliance MCR ADV,CPT,93624,Electrophysiologic study,APC 5212,RVU Per Case,"$6,220.22 ",OP,"2,051.24","6,220.22",,,,,,
Health Alliance MCR ADV,CPT,93642,Electrophysiology evaluation,APC 5211,RVU Per Case,"$1,138.72 ",OP,"1,138.72","2,775.65",,,,,,
Health Alliance MCR ADV,CPT,93650,Ablate heart dysrhythm focus,APC 5212,RVU Per Case,"$6,220.22 ",OP,"3,488.62","6,220.22",,,,,,
Health Alliance MCR ADV,CPT,93653,Ep & ablate supravent arrhyt,APC 5213,RVU Per Case,"$21,964.94 ",OP,"10,420.09","21,964.94",,,,,,
Health Alliance MCR ADV,CPT,93654,Ep & ablate ventric tachy,APC 5213,RVU Per Case,"$21,964.94 ",OP,"10,889.05","21,964.94",,,,,,
Health Alliance MCR ADV,CPT,93656,Tx atrial fib pulm vein isol,APC 5213,RVU Per Case,"$21,964.94 ",OP,"10,420.09","21,964.94",,,,,,
Health Alliance MCR ADV,CPT,93660,Tilt table evaluation,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,983.68,,,,,,
Health Alliance MCR ADV,CPT,93668,Peripheral vascular rehab,APC 5733,RVU Per Unit,$56.95 ,OP,56.95,99.13,,,,,,
Health Alliance MCR ADV,CPT,93701,Bioimpedance cv analysis,APC 5734,RVU Per Case,$114.56 ,OP,114.56,198.25,,,,,,
Health Alliance MCR ADV,CPT,93702,Bis xtracell fluid analysis,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Health Alliance MCR ADV,CPT,93724,Analyze pacemaker system,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,"1,948.29",,,,,,
Health Alliance MCR ADV,CPT,93740,Temperature gradient studies,APC 5721,RVU Per Case,$142.80 ,OP,57.19,142.8,,,,,,
Health Alliance MCR ADV,CPT,93745,Set-up cardiovert-defibrill,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,278.82,,,,,,
Health Alliance MCR ADV,CPT,93750,Interrogation vad in person,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,102.65,,,,,,
Health Alliance MCR ADV,CPT,93786,Ambl bp mntr w/sw rec only,APC 5734,RVU Per Case,$114.56 ,OP,114.56,171.58,,,,,,
Health Alliance MCR ADV,CPT,93788,Ambl bp mntr w/sw a/r,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Health Alliance MCR ADV,CPT,93797,Cardiac rehab,APC 5771,RVU Per Unit,$118.77 ,OP,102.95,118.77,,,,,,
Health Alliance MCR ADV,CPT,93798,Cardiac rehab/monitor,APC 5771,RVU Per Unit,$118.77 ,OP,118.77,148.69,,,,,,
Health Alliance MCR ADV,CPT,93799,Cardiovascular procedure,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Health Alliance MCR ADV,CPT,93880,Extracranial bilat study,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,239.13",,,,,,
Health Alliance MCR ADV,CPT,93882,Extracranial uni/ltd study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,815.92,,,,,,
Health Alliance MCR ADV,CPT,93886,Intracranial complete study,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,483.14",,,,,,
Health Alliance MCR ADV,CPT,93888,Intracranial limited study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,"1,010.37",,,,,,
Health Alliance MCR ADV,CPT,93890,Tcd vasoreactivity study,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,307.75",,,,,,
Health Alliance MCR ADV,CPT,93892,Tcd emboli detect w/o inj,APC 5522,RVU Per Case,$111.51 ,OP,111.51,"1,425.95",,,,,,
Health Alliance MCR ADV,CPT,93893,Tcd emboli detect w/inj,APC 5522,RVU Per Case,$111.51 ,OP,111.51,"1,422.14",,,,,,
Health Alliance MCR ADV,CPT,93922,Upr/l xtremity art 2 levels,APC 5734,RVU Per Case,$114.56 ,OP,114.56,594.77,,,,,,
Health Alliance MCR ADV,CPT,93923,Upr/lxtr art stdy 3+ lvls,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,922.67,,,,,,
Health Alliance MCR ADV,CPT,93924,Lwr xtr vasc stdy bilat,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,136.19",,,,,,
Health Alliance MCR ADV,CPT,93925,Lower extremity study,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,525.07",,,,,,
Health Alliance MCR ADV,CPT,93926,Lower extremity study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,976.05,,,,,,
Health Alliance MCR ADV,CPT,93930,Upper extremity study,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,223.88",,,,,,
Health Alliance MCR ADV,CPT,93931,Upper extremity study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,815.92,,,,,,
Health Alliance MCR ADV,CPT,93970,Extremity study,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,273.44",,,,,,
Health Alliance MCR ADV,CPT,93971,Extremity study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,842.61,,,,,,
Health Alliance MCR ADV,CPT,93975,Vascular study,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,367.82,,,,,,
Health Alliance MCR ADV,CPT,93976,Vascular study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,"1,082.81",,,,,,
Health Alliance MCR ADV,CPT,93978,Vascular study,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,197.20",,,,,,
Health Alliance MCR ADV,CPT,93979,Vascular study,APC 5522,RVU Per Case,$111.51 ,OP,111.51,823.54,,,,,,
Health Alliance MCR ADV,CPT,93980,Penile vascular study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,934.12,,,,,,
Health Alliance MCR ADV,CPT,93981,Penile vascular study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,667.22,,,,,,
Health Alliance MCR ADV,CPT,93985,Dup-scan hemo compl bi std,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,136.19",,,,,,
Health Alliance MCR ADV,CPT,93986,Dup-scan hemo compl uni std,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,646.72,,,,,,
Health Alliance MCR ADV,CPT,93990,Doppler flow testing,APC 5522,RVU Per Case,$111.51 ,OP,111.51,956.99,,,,,,
Health Alliance MCR ADV,CPT,93998,Noninvas vasc dx study proc,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Health Alliance MCR ADV,CPT,94002,Vent mgmt inpat init day,APC 5801,RVU Per Unit,$496.58 ,OP,496.58,541.4,,,,,,
Health Alliance MCR ADV,CPT,94003,Vent mgmt inpat subq day,APC 5801,RVU Per Unit,$496.58 ,OP,496.58,496.58,,,,,,
Health Alliance MCR ADV,CPT,94010,Breathing capacity test,APC 5721,RVU Per Case,$142.80 ,OP,142.8,209.7,,,,,,
Health Alliance MCR ADV,CPT,94011,Spirometry up to 2 yrs old,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
Health Alliance MCR ADV,CPT,94012,Spirmtry w/brnchdil inf-2 yr,APC 5722,RVU Per Case,$270.61 ,OP,270.61,270.61,,,,,,
Health Alliance MCR ADV,CPT,94013,Meas lung vol thru 2 yrs,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Health Alliance MCR ADV,CPT,94014,Patient recorded spirometry,APC 5735,RVU Per Case,$276.53 ,OP,276.53,301.2,,,,,,
Health Alliance MCR ADV,CPT,94015,Patient recorded spirometry,APC 5722,RVU Per Case,$270.61 ,OP,148.69,270.61,,,,,,
Health Alliance MCR ADV,CPT,94016,Review patient spirometry,Physician,Per Unit,$24.70 ,OP,24.7,152.51,,,,,,
Health Alliance MCR ADV,CPT,94060,Evaluation of wheezing,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,369.83,,,,,,
Health Alliance MCR ADV,CPT,94070,Evaluation of wheezing,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,392.7,,,,,,
Health Alliance MCR ADV,CPT,94150,Vital capacity test,APC 5721,RVU Per Case,$142.80 ,OP,141.07,142.8,,,,,,
Health Alliance MCR ADV,CPT,94200,Lung function test (mbc/mvv),APC 5733,RVU Per Case,$56.95 ,OP,56.95,144.88,,,,,,
Health Alliance MCR ADV,CPT,94375,Respiratory flow volume loop,APC 5722,RVU Per Case,$270.61 ,OP,232.58,270.61,,,,,,
Health Alliance MCR ADV,CPT,94450,Hypoxia response curve,APC 5722,RVU Per Case,$270.61 ,OP,270.61,316.46,,,,,,
Health Alliance MCR ADV,CPT,94452,Hast w/report,APC 5734,RVU Per Case,$114.56 ,OP,114.56,346.96,,,,,,
Health Alliance MCR ADV,CPT,94453,Hast w/oxygen titrate,APC 5734,RVU Per Case,$114.56 ,OP,114.56,461.34,,,,,,
Health Alliance MCR ADV,CPT,94610,Surfactant admin thru tube,APC 5791,RVU Per Case,$192.26 ,OP,192.26,438.47,,,,,,
Health Alliance MCR ADV,CPT,94617,Exercise tst brncspsm w/ecg,APC 5734,RVU Per Case,$114.56 ,OP,114.56,465.15,,,,,,
Health Alliance MCR ADV,CPT,94618,Pulmonary stress testing,APC 5734,RVU Per Case,$114.56 ,OP,114.56,465.15,,,,,,
Health Alliance MCR ADV,CPT,94619,Exercise tst brncspsm wo ecg,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Health Alliance MCR ADV,CPT,94621,Cardiopulm exercise testing,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,017.99",,,,,,
Health Alliance MCR ADV,CPT,94640,Airway inhalation treatment,APC 5791,RVU Per Case,$192.26 ,OP,87.69,192.26,,,,,,
Health Alliance MCR ADV,CPT,94642,Aerosol inhalation treatment,APC 5791,RVU Per Case,$192.26 ,OP,192.26,255.45,,,,,,
Health Alliance MCR ADV,CPT,94644,Cbt 1st hour,APC 5734,RVU Per Case,$114.56 ,OP,114.56,217.32,,,,,,
Health Alliance MCR ADV,CPT,94660,Pos airway pressure cpap,APC 5791,RVU Per Case,$192.26 ,OP,192.26,346.96,,,,,,
Health Alliance MCR ADV,CPT,94662,Neg press ventilation cnp,APC 5801,RVU Per Unit,$496.58 ,OP,221.14,496.58,,,,,,
Health Alliance MCR ADV,CPT,94664,Evaluate pt use of inhaler,APC 5791,RVU Per Case,$192.26 ,OP,99.13,192.26,,,,,,
Health Alliance MCR ADV,CPT,94667,Chest wall manipulation,APC 5734,RVU Per Case,$114.56 ,OP,114.56,137.25,,,,,,
Health Alliance MCR ADV,CPT,94668,Chest wall manipulation,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Health Alliance MCR ADV,CPT,94669,Mechanical chest wall oscill,APC 5791,RVU Per Case,$192.26 ,OP,192.26,192.26,,,,,,
Health Alliance MCR ADV,CPT,94680,Exhaled air analysis o2,APC 5721,RVU Per Case,$142.80 ,OP,142.8,369.83,,,,,,
Health Alliance MCR ADV,CPT,94681,Exhaled air analysis o2/co2,APC 5722,RVU Per Case,$270.61 ,OP,270.61,270.61,,,,,,
Health Alliance MCR ADV,CPT,94690,Exhaled air analysis,APC 5733,RVU Per Case,$56.95 ,OP,56.95,320.27,,,,,,
Health Alliance MCR ADV,CPT,94726,Pulm funct tst plethysmograp,APC 5722,RVU Per Case,$270.61 ,OP,270.61,282.14,,,,,,
Health Alliance MCR ADV,CPT,94727,Pulm function test by gas,APC 5721,RVU Per Case,$142.80 ,OP,142.8,221.14,,,,,,
Health Alliance MCR ADV,CPT,94728,Airwy resist by oscillometry,APC 5722,RVU Per Case,$270.61 ,OP,270.61,282.14,,,,,,
Health Alliance MCR ADV,CPT,94762,Measure blood oxygen level,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,202.07,,,,,,
Health Alliance MCR ADV,CPT,94772,Breath recording infant,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Health Alliance MCR ADV,CPT,94775,Ped home apnea rec hk-up,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Health Alliance MCR ADV,CPT,94776,Ped home apnea rec downld,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Health Alliance MCR ADV,CPT,94780,Cars/bd tst inft-12mo 60 min,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Health Alliance MCR ADV,CPT,94799,Pulmonary service/procedure,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
Health Alliance MCR ADV,CPT,95004,Percut allergy skin tests,APC 5724,RVU Per Case,$941.27 ,OP,30.51,941.27,,,,,,
Health Alliance MCR ADV,CPT,95012,Exhaled nitric oxide meas,APC 5732,RVU Per Case,$34.63 ,OP,34.63,102.95,,,,,,
Health Alliance MCR ADV,CPT,95017,Perq & icut allg test venoms,APC 5731,RVU Per Case,$25.25 ,OP,25.25,87.69,,,,,,
Health Alliance MCR ADV,CPT,95018,Perq&ic allg test drugs/biol,APC 5732,RVU Per Case,$34.63 ,OP,34.63,87.69,,,,,,
Health Alliance MCR ADV,CPT,95024,Icut allergy test drug/bug,APC 5733,RVU Per Case,$56.95 ,OP,38.13,56.95,,,,,,
Health Alliance MCR ADV,CPT,95027,Icut allergy titrate-airborn,APC 5731,RVU Per Case,$25.25 ,OP,25.25,26.7,,,,,,
Health Alliance MCR ADV,CPT,95028,Icut allergy test-delayed,APC 5732,RVU Per Case,$34.63 ,OP,34.63,57.19,,,,,,
Health Alliance MCR ADV,CPT,95044,Allergy patch tests,APC 5724,RVU Per Case,$941.27 ,OP,34.31,941.27,,,,,,
Health Alliance MCR ADV,CPT,95052,Photo patch test,APC 5733,RVU Per Case,$56.95 ,OP,38.13,56.95,,,,,,
Health Alliance MCR ADV,CPT,95056,Photosensitivity tests,APC 5734,RVU Per Case,$114.56 ,OP,114.56,179.2,,,,,,
Health Alliance MCR ADV,CPT,95060,Eye allergy tests,APC 5734,RVU Per Case,$114.56 ,OP,114.56,122,,,,,,
Health Alliance MCR ADV,CPT,95065,Nose allergy test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,110.57,,,,,,
Health Alliance MCR ADV,CPT,95070,Bronchial allergy tests,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Health Alliance MCR ADV,CPT,95076,Ingest challenge ini 120 min,APC 5723,RVU Per Unit,$499.16 ,OP,320.27,499.16,,,,,,
Health Alliance MCR ADV,CPT,95115,Immunotherapy one injection,APC 5691,RVU Per Case,$40.93 ,OP,40.93,57.19,,,,,,
Health Alliance MCR ADV,CPT,95117,Immunotherapy injections,APC 5691,RVU Per Case,$40.93 ,OP,40.93,68.63,,,,,,
Health Alliance MCR ADV,CPT,95144,Antigen therapy services,APC 5691,RVU Per Case,$40.93 ,OP,40.93,61,,,,,,
Health Alliance MCR ADV,CPT,95145,Antigen therapy services,APC 5691,RVU Per Case,$40.93 ,OP,40.93,80.07,,,,,,
Health Alliance MCR ADV,CPT,95146,Antigen therapy services,APC 5691,RVU Per Case,$40.93 ,OP,40.93,129.64,,,,,,
Health Alliance MCR ADV,CPT,95147,Antigen therapy services,APC 5692,RVU Per Case,$63.42 ,OP,63.42,125.82,,,,,,
Health Alliance MCR ADV,CPT,95148,Antigen therapy services,APC 5692,RVU Per Case,$63.42 ,OP,63.42,179.2,,,,,,
Health Alliance MCR ADV,CPT,95149,Antigen therapy services,APC 5692,RVU Per Case,$63.42 ,OP,63.42,232.58,,,,,,
Health Alliance MCR ADV,CPT,95165,Antigen therapy services,APC 5691,RVU Per Case,$40.93 ,OP,40.93,61,,,,,,
Health Alliance MCR ADV,CPT,95170,Antigen therapy services,APC 5691,RVU Per Case,$40.93 ,OP,40.93,49.56,,,,,,
Health Alliance MCR ADV,CPT,95180,Rapid desensitization,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
Health Alliance MCR ADV,CPT,95199,Allergy immunology services,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Health Alliance MCR ADV,CPT,95249,Cont gluc mntr pt prov eqp,APC 5733,RVU Per Unit,$56.95 ,OP,56.95,686.28,,,,,,
Health Alliance MCR ADV,CPT,95250,Cont gluc mntr phys/qhp eqp,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,686.28,,,,,,
Health Alliance MCR ADV,CPT,95700,Eeg cont rec w/vid eeg tech,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Health Alliance MCR ADV,CPT,95705,Eeg w/o vid 2-12 hr unmntr,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Health Alliance MCR ADV,CPT,95706,Eeg wo vid 2-12hr intmt mntr,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Health Alliance MCR ADV,CPT,95707,Eeg w/o vid 2-12hr cont mntr,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Health Alliance MCR ADV,CPT,95708,Eeg wo vid ea 12-26hr unmntr,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Health Alliance MCR ADV,CPT,95709,Eeg w/o vid ea 12-26hr intmt,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Health Alliance MCR ADV,CPT,95710,Eeg w/o vid ea 12-26hr cont,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Health Alliance MCR ADV,CPT,95711,Veeg 2-12 hr unmonitored,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Health Alliance MCR ADV,CPT,95712,Veeg 2-12 hr intmt mntr,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Health Alliance MCR ADV,CPT,95713,Veeg 2-12 hr cont mntr,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Health Alliance MCR ADV,CPT,95714,Veeg ea 12-26 hr unmntr,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Health Alliance MCR ADV,CPT,95715,Veeg ea 12-26hr intmt mntr,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Health Alliance MCR ADV,CPT,95716,Veeg ea 12-26hr cont mntr,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,941.27,,,,,,
Health Alliance MCR ADV,CPT,95782,Polysom <6 yrs 4/> paramtrs,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"4,472.29",,,,,,
Health Alliance MCR ADV,CPT,95783,Polysom <6 yrs cpap/bilvl,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"4,472.29",,,,,,
Health Alliance MCR ADV,CPT,95800,Slp stdy unattended,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Health Alliance MCR ADV,CPT,95801,Slp stdy unatnd w/anal,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Health Alliance MCR ADV,CPT,95803,Actigraphy testing,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Health Alliance MCR ADV,CPT,95805,Multiple sleep latency test,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,"2,249.49",,,,,,
Health Alliance MCR ADV,CPT,95806,Sleep study unatt&resp efft,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,413.8,,,,,,
Health Alliance MCR ADV,CPT,95807,Sleep study attended,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,"2,638.38",,,,,,
Health Alliance MCR ADV,CPT,95808,Polysom any age 1-3> param,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,941.27,,,,,,
Health Alliance MCR ADV,CPT,95810,Polysom 6/> yrs 4/> param,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"1,103.46",,,,,,
Health Alliance MCR ADV,CPT,95811,Polysom 6/>yrs cpap 4/> parm,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"1,103.46",,,,,,
Health Alliance MCR ADV,CPT,95812,Eeg 41-60 minutes,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,242.94",,,,,,
Health Alliance MCR ADV,CPT,95813,Eeg extnd mntr 61-119 min,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,521.26",,,,,,
Health Alliance MCR ADV,CPT,95816,Eeg awake and drowsy,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,139.99",,,,,,
Health Alliance MCR ADV,CPT,95819,Eeg awake and asleep,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,223.88",,,,,,
Health Alliance MCR ADV,CPT,95822,Eeg coma or sleep only,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,223.88",,,,,,
Health Alliance MCR ADV,CPT,95824,Eeg cerebral death only,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,503.28,,,,,,
Health Alliance MCR ADV,CPT,95836,Ecog impltd brn npgt <30 d,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Health Alliance MCR ADV,CPT,95851,Range of motion measurements,Physician,Per Unit,$7.59 ,OP,7.59,83.87,,,,,,
Health Alliance MCR ADV,CPT,95852,Range of motion measurements,Physician,Per Unit,$5.52 ,OP,5.52,64.82,,,,,,
Health Alliance MCR ADV,CPT,95857,Cholinesterase challenge,APC 5722,RVU Per Unit,$270.61 ,OP,209.7,270.61,,,,,,
Health Alliance MCR ADV,CPT,95860,Muscle test one limb,APC 5734,RVU Per Case,$114.56 ,OP,114.56,423.22,,,,,,
Health Alliance MCR ADV,CPT,95861,Muscle test 2 limbs,APC 5734,RVU Per Case,$114.56 ,OP,114.56,613.85,,,,,,
Health Alliance MCR ADV,CPT,95863,Muscle test 3 limbs,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,732.04,,,,,,
Health Alliance MCR ADV,CPT,95864,Muscle test 4 limbs,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,850.23,,,,,,
Health Alliance MCR ADV,CPT,95865,Muscle test larynx,APC 5734,RVU Per Case,$114.56 ,OP,114.56,439,,,,,,
Health Alliance MCR ADV,CPT,95866,Muscle test hemidiaphragm,APC 5721,RVU Per Case,$142.80 ,OP,142.8,480.4,,,,,,
Health Alliance MCR ADV,CPT,95867,Muscle test cran nerv unilat,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,369.83,,,,,,
Health Alliance MCR ADV,CPT,95868,Muscle test cran nerve bilat,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,503.28,,,,,,
Health Alliance MCR ADV,CPT,95869,Muscle test thor paraspinal,APC 5721,RVU Per Case,$142.80 ,OP,142.8,236.38,,,,,,
Health Alliance MCR ADV,CPT,95870,Muscle test nonparaspinal,APC 5734,RVU Per Case,$114.56 ,OP,114.56,228.77,,,,,,
Health Alliance MCR ADV,CPT,95872,Muscle test one fiber,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,635.69,,,,,,
Health Alliance MCR ADV,CPT,95875,Limb exercise test,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,364.88,,,,,,
Health Alliance MCR ADV,CPT,95905,Motor &/ sens nrve cndj test,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
Health Alliance MCR ADV,CPT,95907,Nvr cndj tst 1-2 studies,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Health Alliance MCR ADV,CPT,95908,Nrv cndj tst 3-4 studies,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Health Alliance MCR ADV,CPT,95909,Nrv cndj tst 5-6 studies,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Health Alliance MCR ADV,CPT,95910,Nrv cndj test 7-8 studies,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Health Alliance MCR ADV,CPT,95911,Nrv cndj test 9-10 studies,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Health Alliance MCR ADV,CPT,95912,Nrv cndj test 11-12 studies,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Health Alliance MCR ADV,CPT,95913,Nrv cndj test 13/> studies,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Health Alliance MCR ADV,CPT,95921,Autonomic nrv parasym inervj,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,282.21,,,,,,
Health Alliance MCR ADV,CPT,95922,Autonomic nrv adrenrg inervj,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Health Alliance MCR ADV,CPT,95923,Autonomic nrv syst funj test,APC 5734,RVU Per Case,$114.56 ,OP,114.56,447.55,,,,,,
Health Alliance MCR ADV,CPT,95924,Ans parasymp & symp w/tilt,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Health Alliance MCR ADV,CPT,95925,Somatosensory testing,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,461.8,,,,,,
Health Alliance MCR ADV,CPT,95926,Somatosensory testing,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,602.41,,,,,,
Health Alliance MCR ADV,CPT,95927,Somatosensory testing,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,621.47,,,,,,
Health Alliance MCR ADV,CPT,95928,C motor evoked uppr limbs,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,964.61,,,,,,
Health Alliance MCR ADV,CPT,95929,C motor evoked lwr limbs,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,"1,017.99",,,,,,
Health Alliance MCR ADV,CPT,95930,Visual ep test cns w/i&r,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,537.6,,,,,,
Health Alliance MCR ADV,CPT,95933,Blink reflex test,APC 5733,RVU Per Case,$56.95 ,OP,56.95,339.33,,,,,,
Health Alliance MCR ADV,CPT,95937,Neuromuscular junction test,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,305.01,,,,,,
Health Alliance MCR ADV,CPT,95938,Somatosensory testing,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Health Alliance MCR ADV,CPT,95939,C motor evoked upr&lwr limbs,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,941.27,,,,,,
Health Alliance MCR ADV,CPT,95943,Parasymp&symp hrt rate test,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Health Alliance MCR ADV,CPT,95954,Eeg monitoring/giving drugs,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,"1,277.26",,,,,,
Health Alliance MCR ADV,CPT,95958,Eeg monitoring/function test,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"1,982.60",,,,,,
Health Alliance MCR ADV,CPT,95961,Electrode stimulation brain,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"1,265.81",,,,,,
Health Alliance MCR ADV,CPT,95965,Meg spontaneous,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"10,992.00",,,,,,
Health Alliance MCR ADV,CPT,95966,Meg evoked single,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"5,455.97",,,,,,
Health Alliance MCR ADV,CPT,95970,Alys npgt w/o prgrmg,APC 5734,RVU Per Case,$114.56 ,OP,114.56,255.45,,,,,,
Health Alliance MCR ADV,CPT,95971,Alys smpl sp/pn npgt w/prgrm,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,297.39,,,,,,
Health Alliance MCR ADV,CPT,95972,Alys cplx sp/pn npgt w/prgrm,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,533.78,,,,,,
Health Alliance MCR ADV,CPT,95976,Alys smpl cn npgt prgrmg,APC 5741,RVU Per Unit,$38.02 ,OP,38.02,657.7,,,,,,
Health Alliance MCR ADV,CPT,95977,Alys cplx cn npgt prgrmg,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,876.92,,,,,,
Health Alliance MCR ADV,CPT,95981,Io anal gast n-stim subsq,APC 5734,RVU Per Case,$114.56 ,OP,114.56,144.88,,,,,,
Health Alliance MCR ADV,CPT,95982,Io ga n-stim subsq w/reprog,APC 5741,RVU Per Case,$38.02 ,OP,38.02,224.95,,,,,,
Health Alliance MCR ADV,CPT,95983,Alys brn npgt prgrmg 15 min,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,260.22,,,,,,
Health Alliance MCR ADV,CPT,95990,Spin/brain pump refil & main,APC 5694,RVU Per Unit,$318.00 ,OP,312.64,318,,,,,,
Health Alliance MCR ADV,CPT,95991,Spin/brain pump refil & main,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,453.71,,,,,,
Health Alliance MCR ADV,CPT,95992,Canalith repositioning proc,Physician,Per Unit,$36.73 ,OP,36.73,36.73,,,,,,
Health Alliance MCR ADV,CPT,95999,Neurological procedure,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
Health Alliance MCR ADV,CPT,96000,Motion analysis video/3d,APC 5723,RVU Per Unit,$499.16 ,OP,449.9,499.16,,,,,,
Health Alliance MCR ADV,CPT,96001,Motion test w/ft press meas,APC 5724,RVU Per Unit,$941.27 ,OP,526.16,941.27,,,,,,
Health Alliance MCR ADV,CPT,96002,Dynamic surface emg,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Health Alliance MCR ADV,CPT,96003,Dynamic fine wire emg,APC 5722,RVU Per Case,$270.61 ,OP,91.51,270.61,,,,,,
Health Alliance MCR ADV,CPT,96105,Assessment of aphasia,Physician,Per Unit,$98.92 ,OP,98.92,419.4,,,,,,
Health Alliance MCR ADV,CPT,96112,Devel tst phys/qhp 1st hr,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,693.9,,,,,,
Health Alliance MCR ADV,CPT,96116,Nubhvl xm phys/qhp 1st hr,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,518.52,,,,,,
Health Alliance MCR ADV,CPT,96125,Cognitive test by hc pro,Physician,Per Unit,$103.76 ,OP,103.76,510.9,,,,,,
Health Alliance MCR ADV,CPT,96127,Brief emotional/behav assmt,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Health Alliance MCR ADV,CPT,96130,Psycl tst eval phys/qhp 1st,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,438.47,,,,,,
Health Alliance MCR ADV,CPT,96132,Nrpsyc tst eval phys/qhp 1st,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,583.35,,,,,,
Health Alliance MCR ADV,CPT,96136,Psycl/nrpsyc tst phy/qhp 1st,APC 5734,RVU Per Unit,$114.56 ,OP,114.56,219.24,,,,,,
Health Alliance MCR ADV,CPT,96138,Psycl/nrpsyc tech 1st,APC 5735,RVU Per Unit,$276.53 ,OP,133.45,276.53,,,,,,
Health Alliance MCR ADV,CPT,96146,Psycl/nrpsyc tst auto result,APC 5731,RVU Per Unit,$25.25 ,OP,18.8,25.25,,,,,,
Health Alliance MCR ADV,CPT,96156,Hlth bhv assmt/reassessment,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,526.34,,,,,,
Health Alliance MCR ADV,CPT,96158,Hlth bhv ivntj indiv 1st 30,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,236.39,,,,,,
Health Alliance MCR ADV,CPT,96160,Pt-focused hlth risk assmt,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Health Alliance MCR ADV,CPT,96161,Caregiver health risk assmt,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Health Alliance MCR ADV,CPT,96164,Hlth bhv ivntj grp 1st 30,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,61.03,,,,,,
Health Alliance MCR ADV,CPT,96167,Hlth bhv ivntj fam 1st 30,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,236.39,,,,,,
Health Alliance MCR ADV,CPT,96360,Hydration iv infusion init,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,293.57,,,,,,
Health Alliance MCR ADV,CPT,96361,Hydrate iv infusion add-on,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,122.99,,,,,,
Health Alliance MCR ADV,CPT,96365,Ther/proph/diag iv inf init,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,354.58,,,,,,
Health Alliance MCR ADV,CPT,96366,Ther/proph/diag iv inf addon,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,114.39,,,,,,
Health Alliance MCR ADV,CPT,96367,Tx/proph/dg addl seq iv inf,APC 5692,RVU Per Unit,$63.42 ,OP,63.42,179.2,,,,,,
Health Alliance MCR ADV,CPT,96369,Sc ther infusion up to 1 hr,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,758.72,,,,,,
Health Alliance MCR ADV,CPT,96370,Sc ther infusion addl hr,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,83.87,,,,,,
Health Alliance MCR ADV,CPT,96371,Sc ther infusion reset pump,APC 5692,RVU Per Case,$63.42 ,OP,63.42,366.02,,,,,,
Health Alliance MCR ADV,CPT,96372,Ther/proph/diag inj sc/im,APC 5692,RVU Per Case,$63.42 ,OP,63.42,106.76,,,,,,
Health Alliance MCR ADV,CPT,96373,Ther/proph/diag inj ia,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,208.24,,,,,,
Health Alliance MCR ADV,CPT,96374,Ther/proph/diag inj iv push,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,278.32,,,,,,
Health Alliance MCR ADV,CPT,96375,Tx/pro/dx inj new drug addon,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,202.94,,,,,,
Health Alliance MCR ADV,CPT,96377,Applicaton on-body injector,APC 5691,RVU Per Case,$40.93 ,OP,40.93,40.93,,,,,,
Health Alliance MCR ADV,CPT,96379,Ther/prop/diag inj/inf proc,APC 5691,RVU Per Case,$40.93 ,OP,40.93,40.93,,,,,,
Health Alliance MCR ADV,CPT,96401,Chemo anti-neopl sq/im,APC 5692,RVU Per Case,$63.42 ,OP,63.42,377.46,,,,,,
Health Alliance MCR ADV,CPT,96402,Chemo hormon antineopl sq/im,APC 5692,RVU Per Case,$63.42 ,OP,63.42,205.88,,,,,,
Health Alliance MCR ADV,CPT,96405,Chemo intralesional up to 7,APC 5692,RVU Per Case,$63.42 ,OP,63.42,468.96,,,,,,
Health Alliance MCR ADV,CPT,96406,Chemo intralesional over 7,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,648.16,,,,,,
Health Alliance MCR ADV,CPT,96409,Chemo iv push sngl drug,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,629.1,,,,,,
Health Alliance MCR ADV,CPT,96411,Chemo iv push addl drug,APC 5692,RVU Per Unit,$63.42 ,OP,63.42,362.21,,,,,,
Health Alliance MCR ADV,CPT,96413,Chemo iv infusion 1 hr,APC 5694,RVU Per Unit,$318.00 ,OP,133.34,318,,,,,,
Health Alliance MCR ADV,CPT,96415,Chemo iv infusion addl hr,APC 5692,RVU Per Unit,$63.42 ,OP,63.42,202.07,,,,,,
Health Alliance MCR ADV,CPT,96416,Chemo prolong infuse w/pump,APC 5694,RVU Per Unit,$318.00 ,OP,318,926.48,,,,,,
Health Alliance MCR ADV,CPT,96417,Chemo iv infus each addl seq,APC 5692,RVU Per Unit,$63.42 ,OP,63.42,427.03,,,,,,
Health Alliance MCR ADV,CPT,96420,Chemo ia push tecnique,APC 5694,RVU Per Unit,$318.00 ,OP,318,613.85,,,,,,
Health Alliance MCR ADV,CPT,96422,Chemo ia infusion up to 1 hr,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,979.86,,,,,,
Health Alliance MCR ADV,CPT,96423,Chemo ia infuse each addl hr,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,434.65,,,,,,
Health Alliance MCR ADV,CPT,96425,Chemotherapy infusion method,APC 5694,RVU Per Unit,$318.00 ,OP,318,968.43,,,,,,
Health Alliance MCR ADV,CPT,96440,Chemotherapy intracavitary,APC 5694,RVU Per Unit,$318.00 ,OP,318,"3,339.91",,,,,,
Health Alliance MCR ADV,CPT,96446,Chemotx admn prtl cavity,APC 5694,RVU Per Unit,$318.00 ,OP,318,318,,,,,,
Health Alliance MCR ADV,CPT,96450,Chemotherapy into cns,APC 5694,RVU Per Unit,$318.00 ,OP,318,"1,159.06",,,,,,
Health Alliance MCR ADV,CPT,96521,Refill/maint portable pump,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,716.79,,,,,,
Health Alliance MCR ADV,CPT,96522,Refill/maint pump/resvr syst,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,610.03,,,,,,
Health Alliance MCR ADV,CPT,96523,Irrig drug delivery device,APC 5733,RVU Per Case,$56.95 ,OP,56.95,141.07,,,,,,
Health Alliance MCR ADV,CPT,96542,Chemotherapy injection,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,751.1,,,,,,
Health Alliance MCR ADV,CPT,96549,Chemotherapy unspecified,APC 5691,RVU Per Case,$40.93 ,OP,40.93,40.93,,,,,,
Health Alliance MCR ADV,CPT,96567,Pdt dstr prmlg les skn,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
Health Alliance MCR ADV,CPT,96573,Pdt dstr prmlg les phys/qhp,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
Health Alliance MCR ADV,CPT,96574,Dbrdmt prmlg les w/pdt,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
Health Alliance MCR ADV,CPT,96900,Ultraviolet light therapy,APC 5732,RVU Per Case,$34.63 ,OP,34.63,114.39,,,,,,
Health Alliance MCR ADV,CPT,96910,Photochemotherapy with uv-b,APC 5733,RVU Per Case,$56.95 ,OP,56.95,335.53,,,,,,
Health Alliance MCR ADV,CPT,96912,Photochemotherapy with uv-a,APC 5733,RVU Per Case,$56.95 ,OP,56.95,430.83,,,,,,
Health Alliance MCR ADV,CPT,96913,Photochemotherapy uv-a or b,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,651.97,,,,,,
Health Alliance MCR ADV,CPT,96920,Laser tx skin < 250 sq cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
Health Alliance MCR ADV,CPT,96921,Laser tx skin 250-500 sq cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
Health Alliance MCR ADV,CPT,96922,Laser tx skin >500 sq cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"1,307.75",,,,,,
Health Alliance MCR ADV,CPT,96999,Dermatological procedure,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
Health Alliance MCR ADV,CPT,97012,Mechanical traction therapy,Physician,Per Unit,$14.55 ,OP,14.55,68.63,,,,,,
Health Alliance MCR ADV,CPT,97016,Vasopneumatic device therapy,Physician,Per Unit,$11.78 ,OP,11.78,72.44,,,,,,
Health Alliance MCR ADV,CPT,97018,Paraffin bath therapy,Physician,Per Unit,$5.69 ,OP,5.69,5.69,,,,,,
Health Alliance MCR ADV,CPT,97022,Whirlpool therapy,Physician,Per Unit,$17.16 ,OP,17.16,83.87,,,,,,
Health Alliance MCR ADV,CPT,97024,Diathermy eg microwave,Physician,Per Unit,$6.96 ,OP,6.96,26.7,,,,,,
Health Alliance MCR ADV,CPT,97026,Infrared therapy,Physician,Per Unit,$6.32 ,OP,6.32,26.7,,,,,,
Health Alliance MCR ADV,CPT,97028,Ultraviolet therapy,Physician,Per Unit,$7.98 ,OP,7.98,7.98,,,,,,
Health Alliance MCR ADV,CPT,97032,Electrical stimulation,Physician,Per Unit,$14.55 ,OP,14.55,76.26,,,,,,
Health Alliance MCR ADV,CPT,97033,Electric current therapy,Physician,Per Unit,$19.67 ,OP,19.67,114.39,,,,,,
Health Alliance MCR ADV,CPT,97034,Contrast bath therapy,Physician,Per Unit,$14.42 ,OP,14.42,68.63,,,,,,
Health Alliance MCR ADV,CPT,97035,Ultrasound therapy,Physician,Per Unit,$14.10 ,OP,14.1,53.38,,,,,,
Health Alliance MCR ADV,CPT,97036,Hydrotherapy,Physician,Per Unit,$33.09 ,OP,33.09,118.19,,,,,,
Health Alliance MCR ADV,CPT,97110,Therapeutic exercises,Physician,Per Unit,$29.26 ,OP,29.26,133.45,,,,,,
Health Alliance MCR ADV,CPT,97112,Neuromuscular reeducation,Physician,Per Unit,$33.86 ,OP,33.86,137.25,,,,,,
Health Alliance MCR ADV,CPT,97113,Aquatic therapy/exercises,Physician,Per Unit,$36.67 ,OP,36.67,160.13,,,,,,
Health Alliance MCR ADV,CPT,97116,Gait training therapy,Physician,Per Unit,$29.26 ,OP,29.26,114.39,,,,,,
Health Alliance MCR ADV,CPT,97124,Massage therapy,Physician,Per Unit,$28.22 ,OP,28.22,106.76,,,,,,
Health Alliance MCR ADV,CPT,97129,Ther ivntj 1st 15 min,Physician,Per Unit,$23.04 ,OP,23.04,114.39,,,,,,
Health Alliance MCR ADV,CPT,97130,Ther ivntj ea addl 15 min,Physician,Per Unit,$22.35 ,OP,22.35,110.97,,,,,,
Health Alliance MCR ADV,CPT,97140,Manual therapy 1/> regions,Physician,Per Unit,$26.97 ,OP,26.97,122,,,,,,
Health Alliance MCR ADV,CPT,97150,Group therapeutic procedures,Physician,Per Unit,$17.53 ,OP,17.53,83.87,,,,,,
Health Alliance MCR ADV,CPT,97151,Bhv id assmt by phys/qhp,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Health Alliance MCR ADV,CPT,97152,Bhv id suprt assmt by 1 tech,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Health Alliance MCR ADV,CPT,97153,Adaptive behavior tx by tech,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Health Alliance MCR ADV,CPT,97154,Grp adapt bhv tx by tech,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Health Alliance MCR ADV,CPT,97155,Adapt behavior tx phys/qhp,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Health Alliance MCR ADV,CPT,97156,Fam adapt bhv tx gdn phy/qhp,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Health Alliance MCR ADV,CPT,97157,Mult fam adapt bhv tx gdn,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Health Alliance MCR ADV,CPT,97158,Grp adapt bhv tx by phy/qhp,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Health Alliance MCR ADV,CPT,97161,Pt eval low complex 20 min,Physician,Per Unit,$98.12 ,OP,98.12,330.81,,,,,,
Health Alliance MCR ADV,CPT,97162,Pt eval mod complex 30 min,Physician,Per Unit,$98.12 ,OP,98.12,331.7,,,,,,
Health Alliance MCR ADV,CPT,97163,Pt eval high complex 45 min,Physician,Per Unit,$98.12 ,OP,98.12,331.7,,,,,,
Health Alliance MCR ADV,CPT,97164,Pt re-eval est plan care,Physician,Per Unit,$66.97 ,OP,66.97,175.39,,,,,,
Health Alliance MCR ADV,CPT,97165,Ot eval low complex 30 min,Physician,Per Unit,$95.26 ,OP,95.26,354.58,,,,,,
Health Alliance MCR ADV,CPT,97166,Ot eval mod complex 45 min,Physician,Per Unit,$95.26 ,OP,95.26,354.58,,,,,,
Health Alliance MCR ADV,CPT,97167,Ot eval high complex 60 min,Physician,Per Unit,$95.26 ,OP,95.26,354.58,,,,,,
Health Alliance MCR ADV,CPT,97168,Ot re-eval est plan care,Physician,Per Unit,$64.11 ,OP,64.11,202.07,,,,,,
Health Alliance MCR ADV,CPT,97530,Therapeutic activities,Physician,Per Unit,$37.50 ,OP,37.5,137.25,,,,,,
Health Alliance MCR ADV,CPT,97533,Sensory integration,Physician,Per Unit,$57.03 ,OP,57.03,122,,,,,,
Health Alliance MCR ADV,CPT,97535,Self care mngment training,Physician,Per Unit,$32.44 ,OP,32.44,137.25,,,,,,
Health Alliance MCR ADV,CPT,97537,Community/work reintegration,Physician,Per Unit,$31.26 ,OP,31.26,125.82,,,,,,
Health Alliance MCR ADV,CPT,97542,Wheelchair mngment training,Physician,Per Unit,$31.58 ,OP,31.58,125.82,,,,,,
Health Alliance MCR ADV,CPT,97597,Rmvl devital tis 20 cm/<,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,282.14,,,,,,
Health Alliance MCR ADV,CPT,97602,Wound(s) care non-selective,APC 5051,RVU Per Case,$183.73 ,OP,171.58,183.73,,,,,,
Health Alliance MCR ADV,CPT,97605,Neg press wound tx <=50 cm,APC 5051,RVU Per Case,$183.73 ,OP,163.95,183.73,,,,,,
Health Alliance MCR ADV,CPT,97606,Neg press wound tx >50 cm,APC 5052,RVU Per Case,$353.91 ,OP,175.39,353.91,,,,,,
Health Alliance MCR ADV,CPT,97607,Neg press wnd tx <=50 sq cm,APC 5052,RVU Per Unit,$353.91 ,OP,163.95,353.91,,,,,,
Health Alliance MCR ADV,CPT,97608,Neg press wound tx >50 cm,APC 5052,RVU Per Unit,$353.91 ,OP,175.39,353.91,,,,,,
Health Alliance MCR ADV,CPT,97610,Low frequency non-thermal us,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
Health Alliance MCR ADV,CPT,97750,Physical performance test,Physician,Per Unit,$33.07 ,OP,33.07,137.25,,,,,,
Health Alliance MCR ADV,CPT,97755,Assistive technology assess,Physician,Per Unit,$37.42 ,OP,37.42,156.32,,,,,,
Health Alliance MCR ADV,CPT,97760,Orthotic mgmt&traing 1st enc,Physician,Per Unit,$47.55 ,OP,47.55,152.51,,,,,,
Health Alliance MCR ADV,CPT,97761,Prosthetic traing 1st enc,Physician,Per Unit,$40.55 ,OP,40.55,133.45,,,,,,
Health Alliance MCR ADV,CPT,97763,Orthc/prostc mgmt sbsq enc,Physician,Per Unit,$51.94 ,OP,51.94,160.13,,,,,,
Health Alliance MCR ADV,CPT,97802,Medical nutrition indiv in,Physician,Per Unit,$30.75 ,OP,30.75,148.69,,,,,,
Health Alliance MCR ADV,CPT,97803,Med nutrition indiv subseq,Physician,Per Unit,$31.17 ,OP,31.17,129.64,,,,,,
Health Alliance MCR ADV,CPT,97804,Medical nutrition group,Physician,Per Unit,$16.45 ,OP,16.45,64.82,,,,,,
Health Alliance MCR ADV,CPT,97810,Acupunct w/o stimul 15 min,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,186.82,,,,,,
Health Alliance MCR ADV,CPT,97813,Acupunct w/stimul 15 min,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,198.25,,,,,,
Health Alliance MCR ADV,CPT,98925,Osteopath manj 1-2 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,141.07,,,,,,
Health Alliance MCR ADV,CPT,98926,Osteopath manj 3-4 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,27.17,,,,,,
Health Alliance MCR ADV,CPT,98927,Osteopath manj 5-6 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,251.64,,,,,,
Health Alliance MCR ADV,CPT,98928,Osteopath manj 7-8 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,297.39,,,,,,
Health Alliance MCR ADV,CPT,98929,Osteopath manj 9-10 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,343.14,,,,,,
Health Alliance MCR ADV,CPT,98940,Chiropract manj 1-2 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,125.82,,,,,,
Health Alliance MCR ADV,CPT,98941,Chiropract manj 3-4 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,171.58,,,,,,
Health Alliance MCR ADV,CPT,98942,Chiropractic manj 5 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,224.95,,,,,,
Health Alliance MCR ADV,CPT,98966,Hc pro phone call 5-10 min,Physician,Per Unit,$12.73 ,OP,12.73,61,,,,,,
Health Alliance MCR ADV,CPT,98967,Hc pro phone call 11-20 min,Physician,Per Unit,$25.14 ,OP,25.14,118.19,,,,,,
Health Alliance MCR ADV,CPT,98968,Hc pro phone call 21-30 min,Physician,Per Unit,$37.46 ,OP,37.46,171.58,,,,,,
Health Alliance MCR ADV,CPT,98970,Qnhp ol dig assmt&mgmt 5-10,Physician,Per Unit,$11.36 ,OP,11.36,11.36,,,,,,
Health Alliance MCR ADV,CPT,98971,Qnhp ol dig assmt&mgmt 11-20,Physician,Per Unit,$20.31 ,OP,20.31,20.31,,,,,,
Health Alliance MCR ADV,CPT,98972,Qnhp ol dig assmt&mgmt 21+,Physician,Per Unit,$32.41 ,OP,32.41,32.41,,,,,,
Health Alliance MCR ADV,CPT,99170,Anogenital exam child w imag,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,663.41,,,,,,
Health Alliance MCR ADV,CPT,99184,Hypothermia ill neonate,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,99190,Special pump services,APC 5881,RVU Per Case,"$8,948.83 ",OP,"2,299.05","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,99191,Special pump services,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,612.76","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,99192,Special pump services,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,151.42","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,99195,Phlebotomy,APC 5734,RVU Per Case,$114.56 ,OP,114.56,331.7,,,,,,
Health Alliance MCR ADV,CPT,99281,Emergency dept visit,APC 5021,RVU Per Case,$74.29 ,OP,74.29,245.98,,,,,,
Health Alliance MCR ADV,CPT,99282,Emergency dept visit,APC 5022,RVU Per Case,$134.66 ,OP,134.66,368.97,,,,,,
Health Alliance MCR ADV,CPT,99283,Emergency dept visit,APC 5023,RVU Per Case,$237.00 ,OP,237,737.94,,,,,,
Health Alliance MCR ADV,CPT,99284,Emergency dept visit,APC 5024,RVU Per Case,$372.22 ,OP,372.22,"1,291.40",,,,,,
Health Alliance MCR ADV,CPT,99285,Emergency dept visit,APC 5025,RVU Per Case,$534.29 ,OP,534.29,"1,967.84",,,,,,
Health Alliance MCR ADV,CPT,99291,Critical care first hour,APC 5041,RVU Per Case,$708.83 ,OP,708.83,"1,197.20",,,,,,
Health Alliance MCR ADV,CPT,99356,Prolng svc i/p/obs 1st hour,APC 5881,RVU Per Case,"$8,948.83 ",OP,499.47,"8,948.83",,,,,,
Health Alliance MCR ADV,CPT,99357,Prolng svc i/p/obs ea addl,APC 5881,RVU Per Case,"$8,948.83 ",OP,507.08,"8,948.83",,,,,,
Health Alliance MCR ADV,CPT,99406,Behav chng smoking 3-10 min,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,64.82,,,,,,
Health Alliance MCR ADV,CPT,99407,Behav chng smoking > 10 min,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,125.82,,,,,,
Health Alliance MCR ADV,CPT,99453,Rem mntr physiol param setup,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,121.51,,,,,,
Health Alliance MCR ADV,CPT,99454,Rem mntr physiol param dev,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Health Alliance MCR ADV,CPT,99460,Init nb em per day hosp,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,305.01,,,,,,
Health Alliance MCR ADV,CPT,99462,Sbsq nb em per day hosp,APC 5881,RVU Per Case,"$8,948.83 ",OP,160.13,"8,948.83",,,,,,
Health Alliance MCR ADV,CPT,99463,Same day nb discharge,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,404.14,,,,,,
Health Alliance MCR ADV,CPT,99465,Nb resuscitation,APC 5781,RVU Per Unit,$575.01 ,OP,575.01,781.61,,,,,,
Health Alliance MCR ADV,CPT,99468,Neonate crit care initial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,510.41","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,99469,Neonate crit care subsq,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,936.85","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,99471,Ped critical care initial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,049.07","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,99472,Ped critical care subsq,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,982.60","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,99473,Self-meas bp pt educaj/train,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Health Alliance MCR ADV,CPT,99475,Ped crit care age 2-5 init,APC 5881,RVU Per Case,"$8,948.83 ",OP,"2,790.89","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,99476,Ped crit care age 2-5 subsq,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,643.28","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,99477,Init day hosp neonate care,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,734.78","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,99478,Ic lbw inf < 1500 gm subsq,APC 5881,RVU Per Case,"$8,948.83 ",OP,716.79,"8,948.83",,,,,,
Health Alliance MCR ADV,CPT,99479,Ic lbw inf 1500-2500 g subsq,APC 5881,RVU Per Case,"$8,948.83 ",OP,629.1,"8,948.83",,,,,,
Health Alliance MCR ADV,CPT,99480,Ic inf pbw 2501-5000 g subsq,APC 5881,RVU Per Case,"$8,948.83 ",OP,606.21,"8,948.83",,,,,,
Health Alliance MCR ADV,CPT,99483,Assmt & care pln pt cog imp,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Health Alliance MCR ADV,CPT,99484,Care mgmt svc bhvl hlth cond,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Health Alliance MCR ADV,CPT,99487,Cplx chrnc care 1st 60 min,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,136.74,,,,,,
Health Alliance MCR ADV,CPT,99490,Chrnc care mgmt svc 1st 20,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Health Alliance MCR ADV,CPT,99492,1st psyc collab care mgmt,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Health Alliance MCR ADV,CPT,99493,Sbsq psyc collab care mgmt,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Health Alliance MCR ADV,CPT,99495,Trans care mgmt 14 day disch,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,121.51,,,,,,
Health Alliance MCR ADV,CPT,99496,Trans care mgmt 7 day disch,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,121.51,,,,,,
Health Alliance MCR ADV,CPT,99497,Advncd care plan 30 min,APC 5822,RVU Per Case,$76.62 ,OP,76.62,76.62,,,,,,
Health Alliance MCR ADV,CPT,0001A,Adm sarscov2 30mcg/0.3ml 1st,APC 9397,RVU Per Unit,$40.93 ,OP,40.93,40.93,,,,,,
Health Alliance MCR ADV,CPT,0001U,Rbc dna hea 35 ag 11 bld grp,Lab Services,Per Unit,$720.00 ,OP,720,720,,,,,,
Health Alliance MCR ADV,CPT,0002A,Adm sarscov2 30mcg/0.3ml 2nd,APC 9398,RVU Per Unit,$40.93 ,OP,40.93,40.93,,,,,,
Health Alliance MCR ADV,CPT,0002M,Liver dis 10 assays w/ash,Lab Services,Per Unit,$503.40 ,OP,503.4,503.4,,,,,,
Health Alliance MCR ADV,CPT,0002U,Onc clrct 3 ur metab alg plp,Lab Services,Per Unit,$25.00 ,OP,25,25,,,,,,
Health Alliance MCR ADV,CPT,0003A,Adm sarscov2 30mcg/0.3ml 3rd,APC 9398,RVU Per Unit,$40.93 ,OP,40.93,40.93,,,,,,
Health Alliance MCR ADV,CPT,0003M,Liver dis 10 assays w/nash,Lab Services,Per Unit,$503.40 ,OP,503.4,503.4,,,,,,
Health Alliance MCR ADV,CPT,0003U,Onc ovar 5 prtn ser alg scor,Lab Services,Per Unit,$950.00 ,OP,950,950,,,,,,
Health Alliance MCR ADV,CPT,0004M,Scoliosis dna alys,Lab Services,Per Unit,$79.00 ,OP,79,79,,,,,,
Health Alliance MCR ADV,CPT,0005U,Onco prst8 3 gene ur alg,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
Health Alliance MCR ADV,CPT,0006M,Onc hep gene risk classifier,Lab Services,Per Unit,$150.00 ,OP,150,150,,,,,,
Health Alliance MCR ADV,CPT,0007M,Onc gastro 51 gene nomogram,Lab Services,Per Unit,$375.00 ,OP,375,375,,,,,,
Health Alliance MCR ADV,CPT,0007U,Rx test prsmv ur w/def conf,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
Health Alliance MCR ADV,CPT,0008U,Hpylori detcj abx rstnc dna,Lab Services,Per Unit,$597.91 ,OP,597.91,597.91,,,,,,
Health Alliance MCR ADV,CPT,0009U,Onc brst ca erbb2 amp/nonamp,Lab Services,Per Unit,$107.00 ,OP,107,107,,,,,,
Health Alliance MCR ADV,CPT,0010U,Nfct ds strn typ whl gen seq,Lab Services,Per Unit,$427.26 ,OP,427.26,427.26,,,,,,
Health Alliance MCR ADV,CPT,0011A,Adm sarscov2 100mcg/0.5ml1st,APC 9397,RVU Per Unit,$40.93 ,OP,40.93,40.93,,,,,,
Health Alliance MCR ADV,CPT,0011M,Onc prst8 ca mrna 12 gen alg,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
Health Alliance MCR ADV,CPT,0011U,Rx mntr lc-ms/ms oral fluid,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
Health Alliance MCR ADV,CPT,0012A,Adm sarscov2 100mcg/0.5ml2nd,APC 9398,RVU Per Unit,$40.93 ,OP,40.93,40.93,,,,,,
Health Alliance MCR ADV,CPT,0012M,Onc mrna 5 gen rsk urthl ca,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
Health Alliance MCR ADV,CPT,0012U,Germln do gene reargmt detcj,Lab Services,Per Unit,"$2,515.60 ",OP,"2,515.60","2,515.60",,,,,,
Health Alliance MCR ADV,CPT,0013A,Adm sarscov2 100mcg/0.5ml3rd,APC 9398,RVU Per Unit,$40.93 ,OP,40.93,40.93,,,,,,
Health Alliance MCR ADV,CPT,0013M,Onc mrna 5 gen recr urthl ca,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
Health Alliance MCR ADV,CPT,0013U,Onc sld org neo gene reargmt,Lab Services,Per Unit,"$2,515.60 ",OP,"2,515.60","2,515.60",,,,,,
Health Alliance MCR ADV,CPT,0014M,Liver ds alys 3 bmrk srm alg,Lab Services,Per Unit,$176.19 ,OP,176.19,176.19,,,,,,
Health Alliance MCR ADV,CPT,0014U,Hem hmtlmf neo gene reargmt,Lab Services,Per Unit,"$2,515.60 ",OP,"2,515.60","2,515.60",,,,,,
Health Alliance MCR ADV,CPT,0016U,Onc hmtlmf neo rna bcr/abl1,Lab Services,Per Unit,$163.96 ,OP,163.96,163.96,,,,,,
Health Alliance MCR ADV,CPT,0017U,Onc hmtlmf neo jak2 mut dna,Lab Services,Per Unit,$91.66 ,OP,91.66,91.66,,,,,,
Health Alliance MCR ADV,CPT,0018U,Onc thyr 10 microrna seq alg,Lab Services,Per Unit,"$3,002.09 ",OP,"3,002.09","3,002.09",,,,,,
Health Alliance MCR ADV,CPT,0019U,Onc rna tiss predict alg,Lab Services,Per Unit,"$3,675.00 ",OP,"3,675.00","3,675.00",,,,,,
Health Alliance MCR ADV,CPT,0021U,Onc prst8 detcj 8 autoantb,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
Health Alliance MCR ADV,CPT,0022U,Trgt gen seq dna&rna 23 gene,Lab Services,Per Unit,"$1,950.00 ",OP,"1,950.00","1,950.00",,,,,,
Health Alliance MCR ADV,CPT,0023U,Onc aml dna detcj/nondetcj,Lab Services,Per Unit,$248.51 ,OP,248.51,248.51,,,,,,
Health Alliance MCR ADV,CPT,0024U,Glyca nuc mr spectrsc quan,Lab Services,Per Unit,$34.19 ,OP,34.19,34.19,,,,,,
Health Alliance MCR ADV,CPT,0025U,Tenofovir liq chrom ur quan,Lab Services,Per Unit,$85.77 ,OP,85.77,85.77,,,,,,
Health Alliance MCR ADV,CPT,0026U,Onc thyr dna&mrna 112 genes,Lab Services,Per Unit,"$3,600.00 ",OP,"3,600.00","3,600.00",,,,,,
Health Alliance MCR ADV,CPT,0027U,Jak2 gene trgt seq alys,Lab Services,Per Unit,$121.91 ,OP,121.91,121.91,,,,,,
Health Alliance MCR ADV,CPT,0029U,Rx metab advrs trgt seq alys,Lab Services,Per Unit,$742.27 ,OP,742.27,742.27,,,,,,
Health Alliance MCR ADV,CPT,0030U,Rx metab warf trgt seq alys,Lab Services,Per Unit,$134.13 ,OP,134.13,134.13,,,,,,
Health Alliance MCR ADV,CPT,0031A,Adm sarscov2 vac ad26 .5ml,APC 9398,RVU Per Unit,$40.93 ,OP,40.93,40.93,,,,,,
Health Alliance MCR ADV,CPT,0031U,Cyp1a2 gene,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Health Alliance MCR ADV,CPT,0032U,Comt gene,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Health Alliance MCR ADV,CPT,0033U,Htr2a htr2c genes,Lab Services,Per Unit,$349.62 ,OP,349.62,349.62,,,,,,
Health Alliance MCR ADV,CPT,0034U,Tpmt nudt15 genes,Lab Services,Per Unit,$466.17 ,OP,466.17,466.17,,,,,,
Health Alliance MCR ADV,CPT,0035U,Neuro csf prion prtn qual,Lab Services,Per Unit,$540.99 ,OP,540.99,540.99,,,,,,
Health Alliance MCR ADV,CPT,0036U,Xome tum & nml spec seq alys,Lab Services,Per Unit,"$4,780.00 ",OP,"4,780.00","4,780.00",,,,,,
Health Alliance MCR ADV,CPT,0037U,Trgt gen seq dna 324 genes,Lab Services,Per Unit,"$3,500.00 ",OP,"3,500.00","3,500.00",,,,,,
Health Alliance MCR ADV,CPT,0038U,Vitamin d srm microsamp quan,Lab Services,Per Unit,$29.60 ,OP,29.6,29.6,,,,,,
Health Alliance MCR ADV,CPT,0039U,Dna antb 2strand hi avidity,Lab Services,Per Unit,$13.74 ,OP,13.74,13.74,,,,,,
Health Alliance MCR ADV,CPT,0040U,Bcr/abl1 gene major bp quan,Lab Services,Per Unit,$409.90 ,OP,409.9,409.9,,,,,,
Health Alliance MCR ADV,CPT,0041U,B brgdrferi antb 5 prtn igm,Lab Services,Per Unit,$17.21 ,OP,17.21,17.21,,,,,,
Health Alliance MCR ADV,CPT,0042U,B brgdrferi antb 12 prtn igg,Lab Services,Per Unit,$17.21 ,OP,17.21,17.21,,,,,,
Health Alliance MCR ADV,CPT,0043U,Tbrf b grp antb 4 prtn igm,Lab Services,Per Unit,$14.86 ,OP,14.86,14.86,,,,,,
Health Alliance MCR ADV,CPT,0044U,Tbrf b grp antb 4 prtn igg,Lab Services,Per Unit,$14.86 ,OP,14.86,14.86,,,,,,
Health Alliance MCR ADV,CPT,0045U,Onc brst dux carc is 12 gene,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
Health Alliance MCR ADV,CPT,0046U,Flt3 gene itd variants quan,Lab Services,Per Unit,$407.43 ,OP,407.43,407.43,,,,,,
Health Alliance MCR ADV,CPT,0047U,Onc prst8 mrna 17 gene alg,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
Health Alliance MCR ADV,CPT,0048U,Onc sld org neo dna 468 gene,Lab Services,Per Unit,"$2,919.60 ",OP,"2,919.60","2,919.60",,,,,,
Health Alliance MCR ADV,CPT,0049U,Npm1 gene analysis quan,Lab Services,Per Unit,$407.43 ,OP,407.43,407.43,,,,,,
Health Alliance MCR ADV,CPT,0050U,Trgt gen seq dna 194 genes,Lab Services,Per Unit,"$2,916.60 ",OP,"2,916.60","2,916.60",,,,,,
Health Alliance MCR ADV,CPT,0051U,Rx mntr lc-ms/ms ur 31 pnl,Lab Services,Per Unit,$193.71 ,OP,193.71,193.71,,,,,,
Health Alliance MCR ADV,CPT,0052U,Lpoprtn bld w/5 maj classes,Lab Services,Per Unit,$33.86 ,OP,33.86,33.86,,,,,,
Health Alliance MCR ADV,CPT,0053U,Onc prst8 ca fish alys 4 gen,Lab Services,Per Unit,"$2,030.00 ",OP,"2,030.00","2,030.00",,,,,,
Health Alliance MCR ADV,CPT,0054U,Rx mntr 14+ drugs & sbsts,Lab Services,Per Unit,$148.96 ,OP,148.96,148.96,,,,,,
Health Alliance MCR ADV,CPT,0055U,Card hrt trnspl 96 dna seq,Lab Services,Per Unit,"$3,240.00 ",OP,"3,240.00","3,240.00",,,,,,
Health Alliance MCR ADV,CPT,0056U,Hem aml dna gene reargmt,Lab Services,Per Unit,"$2,515.60 ",OP,"2,515.60","2,515.60",,,,,,
Health Alliance MCR ADV,CPT,0058U,Onc merkel cll carc srm quan,Lab Services,Per Unit,$322.96 ,OP,322.96,322.96,,,,,,
Health Alliance MCR ADV,CPT,0059U,Onc merkel cll carc srm +/-,Lab Services,Per Unit,$322.96 ,OP,322.96,322.96,,,,,,
Health Alliance MCR ADV,CPT,0060U,Twn zyg gen seq alys chrms2,Lab Services,Per Unit,$759.05 ,OP,759.05,759.05,,,,,,
Health Alliance MCR ADV,CPT,0061U,Tc meas 5 bmrk sfdi m-s alys,Lab Services,Per Unit,$25.10 ,OP,25.1,25.1,,,,,,
Health Alliance MCR ADV,CPT,0062U,Ai sle igg&igm alys 80 bmrk,Lab Services,Per Unit,$380.72 ,OP,380.72,380.72,,,,,,
Health Alliance MCR ADV,CPT,0063U,Neuro autism 32 amines alg,Lab Services,Per Unit,$750.00 ,OP,750,750,,,,,,
Health Alliance MCR ADV,CPT,0064U,Antb tp total&rpr ia qual,Lab Services,Per Unit,$31.33 ,OP,31.33,31.33,,,,,,
Health Alliance MCR ADV,CPT,0065U,Syfls tst nontreponemal antb,Lab Services,Per Unit,$18.09 ,OP,18.09,18.09,,,,,,
Health Alliance MCR ADV,CPT,0066U,Pamg-1 ia cervico-vag fluid,Lab Services,Per Unit,$15.29 ,OP,15.29,15.29,,,,,,
Health Alliance MCR ADV,CPT,0067U,Onc brst imhchem prfl 4 bmrk,Lab Services,Per Unit,"$1,897.00 ",OP,"1,897.00","1,897.00",,,,,,
Health Alliance MCR ADV,CPT,0068U,Candida species pnl amp prb,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
Health Alliance MCR ADV,CPT,0069U,Onc clrct microrna mir-31-3p,Lab Services,Per Unit,$380.00 ,OP,380,380,,,,,,
Health Alliance MCR ADV,CPT,0070U,Cyp2d6 gen com&slct rar vrnt,Lab Services,Per Unit,$676.37 ,OP,676.37,676.37,,,,,,
Health Alliance MCR ADV,CPT,0071T,Us leiomyomata ablate <200,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","2,684.38",,,,,,
Health Alliance MCR ADV,CPT,0071U,Cyp2d6 full gene sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,
Health Alliance MCR ADV,CPT,0072T,Us leiomyomata ablate >200,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","2,684.38",,,,,,
Health Alliance MCR ADV,CPT,0072U,Cyp2d6 gen cyp2d6-2d7 hybrid,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,
Health Alliance MCR ADV,CPT,0073U,Cyp2d6 gen cyp2d7-2d6 hybrid,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,
Health Alliance MCR ADV,CPT,0074U,Cyp2d6 nonduplicated gene,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,
Health Alliance MCR ADV,CPT,0075T,Perq stent/chest vert art,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,0075U,Cyp2d6 5' gene dup/mlt,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,
Health Alliance MCR ADV,CPT,0076T,S&i stent/chest vert art,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,0076U,Cyp2d6 3' gene dup/mlt,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,
Health Alliance MCR ADV,CPT,0077U,Ig paraprotein qual bld/ur,Lab Services,Per Unit,$43.43 ,OP,43.43,43.43,,,,,,
Health Alliance MCR ADV,CPT,0078U,Pain mgt opi use gnotyp pnl,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,
Health Alliance MCR ADV,CPT,0080U,Onc lng 5 clin rsk factr alg,Lab Services,Per Unit,"$3,520.00 ",OP,"3,520.00","3,520.00",,,,,,
Health Alliance MCR ADV,CPT,0082U,Rx test def 90+ rx/sbsts ur,Lab Services,Per Unit,$246.92 ,OP,246.92,246.92,,,,,,
Health Alliance MCR ADV,CPT,0083U,Onc rspse chemo cntrst tomog,Lab Services,Per Unit,$167.35 ,OP,167.35,167.35,,,,,,
Health Alliance MCR ADV,CPT,0084U,Rbc dna gnotyp 10 bld groups,Lab Services,Per Unit,$720.00 ,OP,720,720,,,,,,
Health Alliance MCR ADV,CPT,0086U,Nfct ds bact&fng org id 6+,Lab Services,Per Unit,$200.00 ,OP,200,200,,,,,,
Health Alliance MCR ADV,CPT,0087U,Crd hrt trnspl mrna 1283 gen,Lab Services,Per Unit,"$3,159.42 ",OP,"3,159.42","3,159.42",,,,,,
Health Alliance MCR ADV,CPT,0088U,Trnsplj kdn algrft rej 1494,Lab Services,Per Unit,"$3,159.42 ",OP,"3,159.42","3,159.42",,,,,,
Health Alliance MCR ADV,CPT,0089U,Onc mlnma prame & linc00518,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
Health Alliance MCR ADV,CPT,0090U,Onc cutan mlnma mrna 23 gene,Lab Services,Per Unit,"$1,755.00 ",OP,"1,755.00","1,755.00",,,,,,
Health Alliance MCR ADV,CPT,0092U,Onc lng 3 prtn bmrk plsm alg,Lab Services,Per Unit,"$2,488.00 ",OP,"2,488.00","2,488.00",,,,,,
Health Alliance MCR ADV,CPT,0093U,Rx mntr 65 com drugs urine,Lab Services,Per Unit,$62.14 ,OP,62.14,62.14,,,,,,
Health Alliance MCR ADV,CPT,0094U,Genome rapid sequence alys,Lab Services,Per Unit,"$7,582.20 ",OP,"7,582.20","7,582.20",,,,,,
Health Alliance MCR ADV,CPT,0095U,Inflm ee elisa alys alg,Lab Services,Per Unit,$771.98 ,OP,771.98,771.98,,,,,,
Health Alliance MCR ADV,CPT,0096U,Hpv hi risk types male urine,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,
Health Alliance MCR ADV,CPT,0097U,Gi pathogen 22 targets,Lab Services,Per Unit,$363.04 ,OP,363.04,363.04,,,,,,
Health Alliance MCR ADV,CPT,0101T,Extracorp shockwv tx hi enrg,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","2,896.40",,,,,,
Health Alliance MCR ADV,CPT,0102T,Extracorp shockwv tx anesth,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","2,896.40",,,,,,
Health Alliance MCR ADV,CPT,0105U,Neph ckd mult eclia tum nec,Lab Services,Per Unit,$950.00 ,OP,950,950,,,,,,
Health Alliance MCR ADV,CPT,0106T,Touch quant sensory test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Health Alliance MCR ADV,CPT,0106U,Gstr emptg 7 timed brth spec,Lab Services,Per Unit,$874.49 ,OP,874.49,874.49,,,,,,
Health Alliance MCR ADV,CPT,0107T,Vibrate quant sensory test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Health Alliance MCR ADV,CPT,0107U,C diff tox ag detcj ia stool,Lab Services,Per Unit,$16.00 ,OP,16,16,,,,,,
Health Alliance MCR ADV,CPT,0108T,Cool quant sensory test,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Health Alliance MCR ADV,CPT,0108U,Gi barrett esoph 9 prtn bmrk,Lab Services,Per Unit,"$2,513.25 ",OP,"2,513.25","2,513.25",,,,,,
Health Alliance MCR ADV,CPT,0109T,Heat quant sensory test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Health Alliance MCR ADV,CPT,0109U,Id aspergillus dna 4 species,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
Health Alliance MCR ADV,CPT,0110T,Nos quant sensory test,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Health Alliance MCR ADV,CPT,0110U,Rx mntr 1+oral onc rx&sbsts,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,
Health Alliance MCR ADV,CPT,0111U,Onc colon ca kras&nras alys,Lab Services,Per Unit,$682.29 ,OP,682.29,682.29,,,,,,
Health Alliance MCR ADV,CPT,0112U,Iadi 16s&18s rrna genes,Lab Services,Per Unit,$356.13 ,OP,356.13,356.13,,,,,,
Health Alliance MCR ADV,CPT,0113U,Onc prst8 pca3&tmprss2-erg,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
Health Alliance MCR ADV,CPT,0114U,Gi barretts esoph vim&ccna1,Lab Services,Per Unit,"$1,938.01 ",OP,"1,938.01","1,938.01",,,,,,
Health Alliance MCR ADV,CPT,0115U,Respir iadna 18 viral&2 bact,Lab Services,Per Unit,$275.35 ,OP,275.35,275.35,,,,,,
Health Alliance MCR ADV,CPT,0116U,Rx mntr nzm ia 35+oral flu,Lab Services,Per Unit,$246.92 ,OP,246.92,246.92,,,,,,
Health Alliance MCR ADV,CPT,0117U,Pain mgmt 11 endogenous anal,Lab Services,Per Unit,$840.65 ,OP,840.65,840.65,,,,,,
Health Alliance MCR ADV,CPT,0118U,Trnsplj don-drv cll-fr dna,Lab Services,Per Unit,"$2,753.25 ",OP,"2,753.25","2,753.25",,,,,,
Health Alliance MCR ADV,CPT,0119U,Crd ceramides liq chrom plsm,Lab Services,Per Unit,$83.76 ,OP,83.76,83.76,,,,,,
Health Alliance MCR ADV,CPT,0120U,Onc b cll lymphm mrna 58 gen,Lab Services,Per Unit,"$2,510.21 ",OP,"2,510.21","2,510.21",,,,,,
Health Alliance MCR ADV,CPT,0121U,Sc dis vcam-1 whole blood,Lab Services,Per Unit,$509.20 ,OP,509.2,509.2,,,,,,
Health Alliance MCR ADV,CPT,0122U,Sc dis p-selectin whl blood,Lab Services,Per Unit,$526.23 ,OP,526.23,526.23,,,,,,
Health Alliance MCR ADV,CPT,0123U,Mchnl fragility rbc prflg,Lab Services,Per Unit,$357.63 ,OP,357.63,357.63,,,,,,
Health Alliance MCR ADV,CPT,0130U,Hered colon ca do mrna pnl,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,
Health Alliance MCR ADV,CPT,0131U,Hered brst ca rltd do pnl 13,Lab Services,Per Unit,$710.00 ,OP,710,710,,,,,,
Health Alliance MCR ADV,CPT,0132U,Hered ova ca rltd do pnl 17,Lab Services,Per Unit,$741.64 ,OP,741.64,741.64,,,,,,
Health Alliance MCR ADV,CPT,0133U,Hered prst8 ca rltd do 11,Lab Services,Per Unit,$690.29 ,OP,690.29,690.29,,,,,,
Health Alliance MCR ADV,CPT,0134U,Hered pan ca mrna pnl 18 gen,Lab Services,Per Unit,$748.39 ,OP,748.39,748.39,,,,,,
Health Alliance MCR ADV,CPT,0135U,Hered gyn ca mrna pnl 12 gen,Lab Services,Per Unit,$700.56 ,OP,700.56,700.56,,,,,,
Health Alliance MCR ADV,CPT,0136U,Atm mrna seq alys,Lab Services,Per Unit,$407.43 ,OP,407.43,407.43,,,,,,
Health Alliance MCR ADV,CPT,0137U,Palb2 mrna seq alys,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,
Health Alliance MCR ADV,CPT,0138U,Brca1 brca2 mrna seq alys,Lab Services,Per Unit,$468.33 ,OP,468.33,468.33,,,,,,
Health Alliance MCR ADV,CPT,0145U,Drug assay 65+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
Health Alliance MCR ADV,CPT,0146U,Drug assay 80+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
Health Alliance MCR ADV,CPT,0147U,Drug assay 85+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
Health Alliance MCR ADV,CPT,0148U,Drug assay 100+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
Health Alliance MCR ADV,CPT,0149U,Drug assay 60+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
Health Alliance MCR ADV,CPT,0150U,Drug assay 120+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
Health Alliance MCR ADV,CPT,0154U,Onc urthl ca rna fgfr3 gene,Lab Services,Per Unit,$482.14 ,OP,482.14,482.14,,,,,,
Health Alliance MCR ADV,CPT,0155U,Onc brst ca dna pik3ca gene,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Health Alliance MCR ADV,CPT,0166U,Liver ds 10 biochem asy srm,Lab Services,Per Unit,$503.40 ,OP,503.4,503.4,,,,,,
Health Alliance MCR ADV,CPT,0167U,Chornc gonadotropin hcg ia,Lab Services,Per Unit,$7.52 ,OP,7.52,7.52,,,,,,
Health Alliance MCR ADV,CPT,0169U,Nudt15&tpmt gene com vrnt,Lab Services,Per Unit,$466.17 ,OP,466.17,466.17,,,,,,
Health Alliance MCR ADV,CPT,0170U,Neuro asd rna next gen seq,Lab Services,Per Unit,"$1,755.00 ",OP,"1,755.00","1,755.00",,,,,,
Health Alliance MCR ADV,CPT,0172U,Onc sld tum alys brca1 brca2,Lab Services,Per Unit,"$3,030.00 ",OP,"3,030.00","3,030.00",,,,,,
Health Alliance MCR ADV,CPT,0176U,Cdtb&vinculin igg antb ia,Lab Services,Per Unit,$64.19 ,OP,64.19,64.19,,,,,,
Health Alliance MCR ADV,CPT,0177U,Onc brst ca dna pik3ca 11,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Health Alliance MCR ADV,CPT,0181U,Co gnotyp aqp1 exon 1,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Health Alliance MCR ADV,CPT,0182U,Crom gnotyp cd55 exons 1-10,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,
Health Alliance MCR ADV,CPT,0183U,Di gnotyp slc4a1 exon 19,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Health Alliance MCR ADV,CPT,0184T,Exc rectal tumor endoscopic,APC 5331,RVU Per Case,"$5,145.78 ",OP,"5,145.78","5,145.78",,,,,,
Health Alliance MCR ADV,CPT,0184U,Do gnotyp art4 exon 2,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Health Alliance MCR ADV,CPT,0185U,Fut1 gnotyp fut1 exon 4,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Health Alliance MCR ADV,CPT,0186U,Fut2 gnotyp fut2 exon 2,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Health Alliance MCR ADV,CPT,0187U,Fy gnotyp ackr1 exons 1-2,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Health Alliance MCR ADV,CPT,0188U,Ge gnotyp gypc exons 1-4,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Health Alliance MCR ADV,CPT,0189U,Gypa gnotyp ntrns 1 5 exon 2,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Health Alliance MCR ADV,CPT,0190U,Gypb gnotyp ntrns 1 5 seux 3,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Health Alliance MCR ADV,CPT,0191T,Insert ant segment drain int,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,009.10",,,,,,
Health Alliance MCR ADV,CPT,0191U,In gnotyp cd44 exons 2 3 6,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Health Alliance MCR ADV,CPT,0192U,Jk gnotyp slc14a1 exon 9,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Health Alliance MCR ADV,CPT,0193U,Jr gnotyp abcg2 exons 2-26,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,
Health Alliance MCR ADV,CPT,0194U,Kel gnotyp kel exon 8,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Health Alliance MCR ADV,CPT,0195U,Klf1 targeted sequencing,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,
Health Alliance MCR ADV,CPT,0196U,Lu gnotyp bcam exon 3,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Health Alliance MCR ADV,CPT,0197U,Lw gnotyp icam4 exon 1,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Health Alliance MCR ADV,CPT,0198T,Ocular blood flow measure,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Health Alliance MCR ADV,CPT,0198U,Rhd&rhce gntyp rhd1-10&rhce5,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,
Health Alliance MCR ADV,CPT,0199U,Sc gnotyp ermap exons 4 12,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Health Alliance MCR ADV,CPT,0200T,Perq sacral augmt unilat inj,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,0200U,Xk gnotyp xk exons 1-3,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Health Alliance MCR ADV,CPT,0201T,Perq sacral augmt bilat inj,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,0201U,Yt gnotyp ache exon 2,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Health Alliance MCR ADV,CPT,0202T,Post vert arthrplst 1 lumbar,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,0202U,Nfct ds 22 trgt sars-cov-2,Lab Services,Per Unit,$416.78 ,OP,416.78,416.78,,,,,,
Health Alliance MCR ADV,CPT,0203U,Ai ibd mrna xprsn prfl 17,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
Health Alliance MCR ADV,CPT,0204U,Onc thyr mrna xprsn alys 593,Lab Services,Per Unit,"$2,919.60 ",OP,"2,919.60","2,919.60",,,,,,
Health Alliance MCR ADV,CPT,0205U,Oph amd alys 3 gene variants,Lab Services,Per Unit,$47.00 ,OP,47,47,,,,,,
Health Alliance MCR ADV,CPT,0207T,Clear eyelid gland w/heat,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Health Alliance MCR ADV,CPT,0208T,Audiometry air only,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Health Alliance MCR ADV,CPT,0209T,Audiometry air & bone,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Health Alliance MCR ADV,CPT,0210T,Speech audiometry threshold,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Health Alliance MCR ADV,CPT,0210U,Syphilis tst antb ia quan,Lab Services,Per Unit,$18.63 ,OP,18.63,18.63,,,,,,
Health Alliance MCR ADV,CPT,0211T,Speech audiom thresh & recog,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Health Alliance MCR ADV,CPT,0212T,Compre audiometry evaluation,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
Health Alliance MCR ADV,CPT,0213T,Njx paravert w/us cer/thor,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,841.63,,,,,,
Health Alliance MCR ADV,CPT,0216T,Njx paravert w/us lumb/sac,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,841.63,,,,,,
Health Alliance MCR ADV,CPT,0218U,Neuro musc dys dmd seq alys,Lab Services,Per Unit,"$2,279.00 ",OP,"2,279.00","2,279.00",,,,,,
Health Alliance MCR ADV,CPT,0219T,Plmt post facet implt cerv,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,0220T,Plmt post facet implt thor,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,0221T,Plmt post facet implt lumb,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,0224U,Antibody sars-cov-2 titer(s),Lab Services,Per Unit,$42.13 ,OP,42.13,42.13,,,,,,
Health Alliance MCR ADV,CPT,0226U,Svnt sarscov2 elisa plsm srm,Lab Services,Per Unit,$42.28 ,OP,42.28,42.28,,,,,,
Health Alliance MCR ADV,CPT,0232T,Njx platelet plasma,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
Health Alliance MCR ADV,CPT,0234T,Trluml perip athrc renal art,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Health Alliance MCR ADV,CPT,0235T,Trluml perip athrc visceral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,0236T,Trluml perip athrc abd aorta,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Health Alliance MCR ADV,CPT,0237T,Trluml perip athrc brchiocph,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Health Alliance MCR ADV,CPT,0238T,Trluml perip athrc iliac art,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Health Alliance MCR ADV,CPT,0239U,Trgt gen seq alys pnl 311+,Lab Services,Per Unit,"$3,500.00 ",OP,"3,500.00","3,500.00",,,,,,
Health Alliance MCR ADV,CPT,0240U,Nfct ds vir resp rna 3 trgt,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
Health Alliance MCR ADV,CPT,0241U,Nfct ds vir resp rna 4 trgt,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
Health Alliance MCR ADV,CPT,0242U,Trgt gen seq alys pnl 55-74,Lab Services,Per Unit,"$5,000.00 ",OP,"5,000.00","5,000.00",,,,,,
Health Alliance MCR ADV,CPT,0253T,Insert aqueous drain device,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,009.10",,,,,,
Health Alliance MCR ADV,CPT,0263T,Im b1 mrw cel ther cmpl,APC 5243,RVU Per Unit,"$4,131.87 ",OP,"4,131.87","4,131.87",,,,,,
Health Alliance MCR ADV,CPT,0264T,Im b1 mrw cel ther xcl hrvst,APC 5243,RVU Per Unit,"$4,131.87 ",OP,"4,131.87","4,131.87",,,,,,
Health Alliance MCR ADV,CPT,0265T,Im b1 mrw cel ther hrvst onl,APC 5243,RVU Per Unit,"$4,131.87 ",OP,"4,131.87","4,131.87",,,,,,
Health Alliance MCR ADV,CPT,0266T,Implt/rpl crtd sns dev total,APC 5465,RVU Per Case,"$30,131.14 ",OP,"30,131.14","30,131.14",,,,,,
Health Alliance MCR ADV,CPT,0267T,Implt/rpl crtd sns dev lead,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Health Alliance MCR ADV,CPT,0268T,Implt/rpl crtd sns dev gen,APC 5465,RVU Per Case,"$30,131.14 ",OP,"30,131.14","30,131.14",,,,,,
Health Alliance MCR ADV,CPT,0269T,Rev/remvl crtd sns dev total,APC 5432,RVU Per Case,"$5,833.22 ",OP,"5,833.22","5,833.22",,,,,,
Health Alliance MCR ADV,CPT,0270T,Rev/remvl crtd sns dev lead,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Health Alliance MCR ADV,CPT,0271T,Rev/remvl crtd sns dev gen,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Health Alliance MCR ADV,CPT,0272T,Interrogate crtd sns dev,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Health Alliance MCR ADV,CPT,0273T,Interrogate crtd sns w/pgrmg,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Health Alliance MCR ADV,CPT,0274T,Perq lamot/lam crv/thrc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,0275T,Perq lamot/lam lumbar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,0278T,Tempr,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
Health Alliance MCR ADV,CPT,0308T,Insj ocular telescope prosth,APC 5495,RVU Per Case,"$21,250.81 ",OP,"21,250.81","21,250.81",,,,,,
Health Alliance MCR ADV,CPT,0312T,Laps impltj nstim vagus,APC 5465,RVU Per Case,"$30,131.14 ",OP,"30,131.14","30,131.14",,,,,,
Health Alliance MCR ADV,CPT,0313T,Laps rmvl nstim array vagus,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Health Alliance MCR ADV,CPT,0314T,Laps rmvl vgl arry&pls gen,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Health Alliance MCR ADV,CPT,0315T,Rmvl vagus nerve pls gen,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Health Alliance MCR ADV,CPT,0316T,Replc vagus nerve pls gen,APC 5465,RVU Per Case,"$30,131.14 ",OP,"30,131.14","30,131.14",,,,,,
Health Alliance MCR ADV,CPT,0317T,Elec alys vagus nrv pls gen,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Health Alliance MCR ADV,CPT,0330T,Tear film img uni/bi w/i&r,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Health Alliance MCR ADV,CPT,0331T,Heart symp image plnr,APC 5593,RVU Per Unit,"$1,336.39 ",OP,922.67,"1,336.39",,,,,,
Health Alliance MCR ADV,CPT,0332T,Heart symp image plnr spect,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,338.26",,,,,,
Health Alliance MCR ADV,CPT,0335T,Insj sinus tarsi implant,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,0338T,Trnscth renal symp denrv unl,APC 5192,RVU Per Case,"$5,072.43 ",OP,"5,072.43","5,072.43",,,,,,
Health Alliance MCR ADV,CPT,0339T,Trnscth renal symp denrv bil,APC 5192,RVU Per Case,"$5,072.43 ",OP,"5,072.43","5,072.43",,,,,,
Health Alliance MCR ADV,CPT,0342T,Thxp apheresis w/hdl delip,APC 5243,RVU Per Unit,"$4,131.87 ",OP,"4,131.87","4,131.87",,,,,,
Health Alliance MCR ADV,CPT,0345T,Transcath mtral vlve repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,0347T,Ins bone device for rsa,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Health Alliance MCR ADV,CPT,0348T,Rsa spine exam,APC 5522,RVU Per Case,$111.51 ,OP,111.51,111.51,,,,,,
Health Alliance MCR ADV,CPT,0349T,Rsa upper extr exam,APC 5522,RVU Per Case,$111.51 ,OP,111.51,111.51,,,,,,
Health Alliance MCR ADV,CPT,0350T,Rsa lower extr exam,APC 5521,RVU Per Case,$82.79 ,OP,82.79,82.79,,,,,,
Health Alliance MCR ADV,CPT,0355T,Gi tract capsule endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","1,662.91",,,,,,
Health Alliance MCR ADV,CPT,0356T,Insrt drug device for iop,APC 5692,RVU Per Case,$63.42 ,OP,63.42,63.42,,,,,,
Health Alliance MCR ADV,CPT,0358T,Bia whole body,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Health Alliance MCR ADV,CPT,0362T,Bhv id suprt assmt ea 15 min,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Health Alliance MCR ADV,CPT,0373T,Adapt bhv tx ea 15 min,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Health Alliance MCR ADV,CPT,0379T,Vis field assmnt tech suppt,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Health Alliance MCR ADV,CPT,0394T,Hdr elctrnc skn surf brchytx,APC 5622,RVU Per Unit,$247.32 ,OP,247.32,247.32,,,,,,
Health Alliance MCR ADV,CPT,0395T,Hdr elctr ntrst/ntrcv brchtx,APC 5624,RVU Per Unit,$724.98 ,OP,724.98,724.98,,,,,,
Health Alliance MCR ADV,CPT,0398T,Mrgfus strtctc les abltj,APC 5463,RVU Per Case,"$11,498.23 ",OP,"11,498.23","11,498.23",,,,,,
Health Alliance MCR ADV,CPT,0402T,Colgn cross-link crn med sep,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","2,049.05",,,,,,
Health Alliance MCR ADV,CPT,0404T,Trnscrv uterin fibroid abltj,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,140.35","9,201.00",,,,,,
Health Alliance MCR ADV,CPT,0408T,Insj/rplc cardiac modulj sys,APC 5231,RVU Per Case,"$23,577.44 ",OP,"23,577.44","23,577.44",,,,,,
Health Alliance MCR ADV,CPT,0409T,Insj/rplc car modulj pls gn,APC 5231,RVU Per Case,"$23,577.44 ",OP,"23,577.44","23,577.44",,,,,,
Health Alliance MCR ADV,CPT,0410T,Insj/rplc car modulj atr elt,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
Health Alliance MCR ADV,CPT,0411T,Insj/rplc car modulj vnt elt,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
Health Alliance MCR ADV,CPT,0412T,Rmvl cardiac modulj pls gen,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Health Alliance MCR ADV,CPT,0413T,Rmvl car modulj tranvns elt,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Health Alliance MCR ADV,CPT,0414T,Rmvl & rpl car modulj pls gn,APC 5231,RVU Per Case,"$23,577.44 ",OP,"23,577.44","23,577.44",,,,,,
Health Alliance MCR ADV,CPT,0415T,Repos car modulj tranvns elt,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,554.25,,,,,,
Health Alliance MCR ADV,CPT,0416T,Reloc skin pocket pls gen,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","1,755.36",,,,,,
Health Alliance MCR ADV,CPT,0417T,Prgrmg eval cardiac modulj,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Health Alliance MCR ADV,CPT,0418T,Interro eval cardiac modulj,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Health Alliance MCR ADV,CPT,0419T,Dstrj neurofibroma xtnsv,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,536.39,,,,,,
Health Alliance MCR ADV,CPT,0420T,Dstrj neurofibroma xtnsv,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,536.39,,,,,,
Health Alliance MCR ADV,CPT,0421T,Waterjet prostate abltj cmpl,APC 5376,RVU Per Case,"$8,450.70 ",OP,"8,450.70","8,450.70",,,,,,
Health Alliance MCR ADV,CPT,0422T,Tactile breast img uni/bi,APC 5521,RVU Per Case,$82.79 ,OP,82.79,82.79,,,,,,
Health Alliance MCR ADV,CPT,0424T,Insj/rplc nstim apnea compl,APC 5465,RVU Per Case,"$30,131.14 ",OP,"30,131.14","30,131.14",,,,,,
Health Alliance MCR ADV,CPT,0425T,Insj/rplc nstim apnea sen ld,APC 5463,RVU Per Case,"$11,498.23 ",OP,"11,498.23","11,498.23",,,,,,
Health Alliance MCR ADV,CPT,0426T,Insj/rplc nstim apnea stm ld,APC 5463,RVU Per Case,"$11,498.23 ",OP,"11,498.23","11,498.23",,,,,,
Health Alliance MCR ADV,CPT,0427T,Insj/rplc nstim apnea pls gn,APC 5465,RVU Per Case,"$30,131.14 ",OP,"30,131.14","30,131.14",,,,,,
Health Alliance MCR ADV,CPT,0428T,Rmvl nstim apnea pls gen,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Health Alliance MCR ADV,CPT,0429T,Rmvl nstim apnea sen ld,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Health Alliance MCR ADV,CPT,0430T,Rmvl nstim apnea stimj ld,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Health Alliance MCR ADV,CPT,0431T,Rmvl/rplc nstim apnea pls gn,APC 5465,RVU Per Case,"$30,131.14 ",OP,"30,131.14","30,131.14",,,,,,
Health Alliance MCR ADV,CPT,0432T,Repos nstim apnea stimj ld,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Health Alliance MCR ADV,CPT,0433T,Repos nstim apnea sensing ld,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Health Alliance MCR ADV,CPT,0434T,Interro eval npgs apnea,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,102.65,,,,,,
Health Alliance MCR ADV,CPT,0435T,Prgrmg eval npgs apnea 1 ses,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,102.65,,,,,,
Health Alliance MCR ADV,CPT,0436T,Prgrmg eval npgs apnea study,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,941.27,,,,,,
Health Alliance MCR ADV,CPT,0440T,Abltj perc uxtr/perph nrv,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","1,795.30",,,,,,
Health Alliance MCR ADV,CPT,0441T,Abltj perc lxtr/perph nrv,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","1,795.30",,,,,,
Health Alliance MCR ADV,CPT,0442T,Abltj perc plex/trncl nrv,APC 5432,RVU Per Case,"$5,833.22 ",OP,"5,833.22","5,833.22",,,,,,
Health Alliance MCR ADV,CPT,0446T,Insj impltbl glucose sensor,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","1,755.36",,,,,,
Health Alliance MCR ADV,CPT,0447T,Rmvl impltbl glucose sensor,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
Health Alliance MCR ADV,CPT,0448T,Remvl insj impltbl gluc sens,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","1,755.36",,,,,,
Health Alliance MCR ADV,CPT,0449T,Insj aqueous drain dev 1st,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,009.10",,,,,,
Health Alliance MCR ADV,CPT,0451T,Insj/rplcmt aortic ventr sys,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,0452T,Insj/rplcmt dev vasc seal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,0453T,Insj/rplcmt mech-elec ntrfce,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
Health Alliance MCR ADV,CPT,0454T,Insj/rplcmt subq electrode,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
Health Alliance MCR ADV,CPT,0455T,Remvl aortic ventr cmpl sys,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,0456T,Remvl aortic dev vasc seal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,0457T,Remvl mech-elec skin ntrfce,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Health Alliance MCR ADV,CPT,0458T,Remvl subq electrode,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Health Alliance MCR ADV,CPT,0459T,Relocaj rplcmt aortic ventr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,0460T,Repos aortic ventr dev eltrd,APC 5221,RVU Per Unit,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Health Alliance MCR ADV,CPT,0461T,Repos aortic contrpulsj dev,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,0462T,Prgrmg eval aortic ventr sys,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,278.82,,,,,,
Health Alliance MCR ADV,CPT,0463T,Interrog aortic ventr sys,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,278.82,,,,,,
Health Alliance MCR ADV,CPT,0464T,Visual ep test for glaucoma,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Health Alliance MCR ADV,CPT,0465T,Supchrdl njx rx w/o supply,APC 5694,RVU Per Unit,$318.00 ,OP,318,318,,,,,,
Health Alliance MCR ADV,CPT,0467T,Revj/rplmnt ch respir eltrd,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Health Alliance MCR ADV,CPT,0468T,Rmvl ch wal respir eltrd/ra,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Health Alliance MCR ADV,CPT,0472T,Prgrmg io rta eltrd ra,APC 5743,RVU Per Case,$278.82 ,OP,278.82,278.82,,,,,,
Health Alliance MCR ADV,CPT,0473T,Reprgrmg io rta eltrd ra,APC 5742,RVU Per Case,$102.65 ,OP,102.65,102.65,,,,,,
Health Alliance MCR ADV,CPT,0476T,Rec ftl car sgl elec tr data,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Health Alliance MCR ADV,CPT,0477T,Rec ftl car sgl xrtj alys,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Health Alliance MCR ADV,CPT,0479T,Fxjl abl lsr 1st 100 sq cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,536.39,,,,,,
Health Alliance MCR ADV,CPT,0481T,Njx autol wbc concentrate,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
Health Alliance MCR ADV,CPT,0483T,Tmvi percutaneous approach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,0484T,Tmvi transthoracic exposure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,0485T,Oct mid ear i&r unilateral,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Health Alliance MCR ADV,CPT,0486T,Oct mid ear i&r bilateral,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Health Alliance MCR ADV,CPT,0487T,Trvg biomchn mapg w/reprt,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Health Alliance MCR ADV,CPT,0491T,Abl lsr opn wnd 1st 20 sqcm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,353.91,,,,,,
Health Alliance MCR ADV,CPT,0494T,Prep & cannulj cdvr don lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,0495T,Mntr cdvr don lng 1st 2 hrs,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,0496T,Mntr cdvr don lng ea addl hr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,0497T,Xtrnl pt act ecg in-off conn,APC 5741,RVU Per Case,$38.02 ,OP,38.02,"1,574.64",,,,,,
Health Alliance MCR ADV,CPT,0499T,Cysto f/urtl strix/stenosis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","3,148.08",,,,,,
Health Alliance MCR ADV,CPT,0503T,Cor ffr alys gnrj ffr mdl,APC 1511,RVU Per Unit,$972.67 ,OP,908.19,972.67,,,,,,
Health Alliance MCR ADV,CPT,0505T,Ev fempop artl revsc,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Health Alliance MCR ADV,CPT,0506T,Mac pgmt opt dns meas hfp,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Health Alliance MCR ADV,CPT,0507T,Near ifr 2img mibmn glnd i&r,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Health Alliance MCR ADV,CPT,0508T,Pls echo us b1 dns meas tib,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,111.51,,,,,,
Health Alliance MCR ADV,CPT,0509T,Pattern erg w/i&r,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,386.03,,,,,,
Health Alliance MCR ADV,CPT,0510T,Rmvl sinus tarsi implant,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","2,896.40",,,,,,
Health Alliance MCR ADV,CPT,0511T,Rmvl&rinsj sinus tarsi implt,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,0512T,Esw integ wnd hlg 1st wnd,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,183.73,,,,,,
Health Alliance MCR ADV,CPT,0515T,Insj wcs lv compl sys,APC 5231,RVU Per Case,"$23,577.44 ",OP,"23,577.44","23,577.44",,,,,,
Health Alliance MCR ADV,CPT,0516T,Insj wcs lv eltrd only,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
Health Alliance MCR ADV,CPT,0517T,Insj wcs lv pg compnt,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
Health Alliance MCR ADV,CPT,0518T,Rmvl pg compnt wcs,APC 5221,RVU Per Unit,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Health Alliance MCR ADV,CPT,0519T,Rmvl & rplcmt pg compnt wcs,APC 5221,RVU Per Unit,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Health Alliance MCR ADV,CPT,0520T,Rmvl&rplcmt pg wcs new eltrd,APC 5231,RVU Per Case,"$23,577.44 ",OP,"23,577.44","23,577.44",,,,,,
Health Alliance MCR ADV,CPT,0521T,Interrog dev eval wcs ip,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Health Alliance MCR ADV,CPT,0522T,Prgrmg dev eval wcs ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Health Alliance MCR ADV,CPT,0524T,Ev cath dir chem abltj w/img,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","2,928.39",,,,,,
Health Alliance MCR ADV,CPT,0525T,Insj/rplcmt compl iims,APC 5223,RVU Per Case,"$10,642.67 ",OP,"10,642.67","10,642.67",,,,,,
Health Alliance MCR ADV,CPT,0526T,Insj/rplcmt iims eltrd only,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
Health Alliance MCR ADV,CPT,0527T,Insj/rplcmt iims implt mntr,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
Health Alliance MCR ADV,CPT,0528T,Prgrmg dev eval iims ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Health Alliance MCR ADV,CPT,0529T,Interrog dev eval iims ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Health Alliance MCR ADV,CPT,0530T,Removal complete iims,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Health Alliance MCR ADV,CPT,0531T,Removal iims electrode only,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Health Alliance MCR ADV,CPT,0532T,Removal iims implt mntr only,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Health Alliance MCR ADV,CPT,0534T,Cont rec mvmt do setup&train,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Health Alliance MCR ADV,CPT,0535T,Cont rec mvmt do reprt cnfig,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Health Alliance MCR ADV,CPT,0540T,Car-t cll admn autologous,APC 5694,RVU Per Unit,$318.00 ,OP,318,318,,,,,,
Health Alliance MCR ADV,CPT,0541T,Myocardial imaging mcg,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Health Alliance MCR ADV,CPT,0543T,Ta mv rpr w/artif chord tend,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,0544T,Tcat mv annulus rcnstj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,0545T,Tcat tv annulus rcnstj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,0548T,Tprnl balo cntnc dev bi,APC 5377,RVU Per Case,"$11,755.91 ",OP,"11,755.91","11,755.91",,,,,,
Health Alliance MCR ADV,CPT,0549T,Tprnl balo cntnc dev uni,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,516.83","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,0550T,Tprnl balo cntnc dev rmvl ea,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","3,148.08",,,,,,
Health Alliance MCR ADV,CPT,0551T,Tprnl balo cntnc dev adjmt,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,272.35,,,,,,
Health Alliance MCR ADV,CPT,0555T,B1 str&fx rsk transmis data,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,25.25,,,,,,
Health Alliance MCR ADV,CPT,0556T,B1 str & fx rsk assessment,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,235.49,,,,,,
Health Alliance MCR ADV,CPT,0558T,Ct scan f/biomchn ct alys,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,927,,,,,,
Health Alliance MCR ADV,CPT,0559T,Antmc mdl 3d print 1st cmpnt,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Health Alliance MCR ADV,CPT,0561T,Antmc guide 3d print 1st gd,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Health Alliance MCR ADV,CPT,0563T,Evac meibomian glnd heat bi,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Health Alliance MCR ADV,CPT,0564T,Onc chemo rx cytotox csc 14,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Health Alliance MCR ADV,CPT,0565T,Autol cell implt adps hrvg,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Health Alliance MCR ADV,CPT,0566T,Autol cell implt adps njx,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,267.26,,,,,,
Health Alliance MCR ADV,CPT,0569T,Ttvr perq appr 1st prosth,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,0570T,Ttvr perq ea addl prosth,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,0571T,Insj/rplcmt icds ss eltrd,APC 5232,RVU Per Case,"$33,604.66 ",OP,"33,604.66","33,604.66",,,,,,
Health Alliance MCR ADV,CPT,0572T,Insertion ss dfb electrode,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
Health Alliance MCR ADV,CPT,0573T,Removal ss dfb electrode,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Health Alliance MCR ADV,CPT,0574T,Repos prev ss impl dfb eltrd,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Health Alliance MCR ADV,CPT,0575T,Prgrmg dev eval icds ss ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Health Alliance MCR ADV,CPT,0576T,Interrog dev eval icds ss ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Health Alliance MCR ADV,CPT,0577T,Ephys eval icds ss,APC 5211,RVU Per Case,"$1,138.72 ",OP,"1,138.72","2,775.65",,,,,,
Health Alliance MCR ADV,CPT,0579T,Rem interrog dev icds tech,APC 5741,RVU Per Case,$38.02 ,OP,38.02,213.51,,,,,,
Health Alliance MCR ADV,CPT,0580T,Rmvl ss impl dfb pg only,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Health Alliance MCR ADV,CPT,0583T,Tmpst auto tube dlvr sys,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","1,384.33",,,,,,
Health Alliance MCR ADV,CPT,0584T,Perq islet cell transplant,APC 5881,RVU Per Case,"$8,948.83 ",OP,"2,508.76","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,0585T,Laps islet cell transplant,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,254.96","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,0586T,Open islet cell transplant,APC 5881,RVU Per Case,"$8,948.83 ",OP,"6,965.79","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,0587T,Perq impltj/rplcmt isdns ptn,APC 5462,RVU Per Case,"$6,304.35 ",OP,"6,304.35","6,304.35",,,,,,
Health Alliance MCR ADV,CPT,0588T,Revision/removal isdns ptn,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Health Alliance MCR ADV,CPT,0589T,Elec alys smpl prgrmg iins,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,255.45,,,,,,
Health Alliance MCR ADV,CPT,0590T,Elec alys cplx prgrmg iins,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,255.45,,,,,,
Health Alliance MCR ADV,CPT,0594T,Osteot hum xtrnl lngth dev,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,0596T,Temp fml iu vlv-pmp 1st insj,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,588.17,,,,,,
Health Alliance MCR ADV,CPT,0597T,Temp fml iu valve-pmp rplcmt,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,588.17,,,,,,
Health Alliance MCR ADV,CPT,0598T,Ncntc r-t fluor wnd img 1st,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Health Alliance MCR ADV,CPT,0600T,Ire abltj 1+tum organ perq,APC 5362,RVU Per Case,"$9,115.38 ",OP,"9,115.38","9,115.38",,,,,,
Health Alliance MCR ADV,CPT,0601T,Ire abltj 1+tumors open,APC 5362,RVU Per Case,"$9,115.38 ",OP,"9,115.38","9,115.38",,,,,,
Health Alliance MCR ADV,CPT,0604T,Rem oct rta dev setup&educaj,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,121.51,,,,,,
Health Alliance MCR ADV,CPT,0605T,Rem oct rta techl sprt min 8,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Health Alliance MCR ADV,CPT,0607T,Rem mntr pulm flu mntr setup,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,121.51,,,,,,
Health Alliance MCR ADV,CPT,0608T,Rem mntr pulm flu mntr alys,APC 5741,RVU Per Unit,$38.02 ,OP,38.02,38.02,,,,,,
Health Alliance MCR ADV,CPT,0609T,Mrs disc pain acquisj data,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,0611T,Mrs disc pain alg alys data,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,0614T,Rmvl&rplcmt ss impl dfb pg,APC 5231,RVU Per Case,"$23,577.44 ",OP,"23,577.44","23,577.44",,,,,,
Health Alliance MCR ADV,CPT,0615T,Eye mvmt alys w/o calbrj i&r,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Health Alliance MCR ADV,CPT,0616T,Insertion of iris prosthesis,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","2,127.64",,,,,,
Health Alliance MCR ADV,CPT,0617T,Insj iris prosth w/rmvl&insj,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,009.10",,,,,,
Health Alliance MCR ADV,CPT,0618T,Insj iris prosth sec io lens,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,009.10",,,,,,
Health Alliance MCR ADV,CPT,0619T,Cysto w/prst8 commissurotomy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,516.83","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,0620T,Evasc ven artlz tibl/prnl vn,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Health Alliance MCR ADV,CPT,0627T,Perq njx algc fluor lmbr 1st,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,0629T,Perq njx algc ct lmbr 1st,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,0631T,Tc vis lit hyperspectral img,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Health Alliance MCR ADV,CPT,0632T,Perq tcat us abltj nrv p-art,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Health Alliance MCR ADV,CPT,0633T,Ct breast w/3d uni c-,APC 5522,RVU Per Case,$111.51 ,OP,111.51,111.51,,,,,,
Health Alliance MCR ADV,CPT,0634T,Ct breast w/3d uni c+,APC 5571,RVU Per Case,$182.72 ,OP,182.72,182.72,,,,,,
Health Alliance MCR ADV,CPT,0635T,Ct breast w/3d uni c-/c+,APC 5571,RVU Per Case,$182.72 ,OP,182.72,182.72,,,,,,
Health Alliance MCR ADV,CPT,0636T,Ct breast w/3d bi c-,APC 5523,RVU Per Case,$235.49 ,OP,235.49,235.49,,,,,,
Health Alliance MCR ADV,CPT,0637T,Ct breast w/3d bi c+,APC 5572,RVU Per Case,$376.70 ,OP,376.7,376.7,,,,,,
Health Alliance MCR ADV,CPT,0638T,Ct breast w/3d bi c-/c+,APC 5572,RVU Per Case,$376.70 ,OP,376.7,376.7,,,,,,
Health Alliance MCR ADV,CPT,0641T,Ncntc nr ifr spctrsc wnd img,APC 5732,RVU Per Unit,$34.63 ,OP,34.63,34.63,,,,,,
Health Alliance MCR ADV,CPT,0644T,Tcat rmvl/dblk icar mas perq,APC 5192,RVU Per Case,"$5,072.43 ",OP,"5,072.43","5,072.43",,,,,,
Health Alliance MCR ADV,CPT,0647T,Insj gtube perq mag gastrpxy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","1,662.91",,,,,,
Health Alliance MCR ADV,CPT,0648T,Quan mr alys tiss w/o mri,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,235.49,,,,,,
Health Alliance MCR ADV,CPT,0650T,Prgrmg dev eval scrms remote,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Health Alliance MCR ADV,CPT,0651T,Mag ctrld capsule endoscopy,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,828.48,,,,,,
Health Alliance MCR ADV,CPT,0652T,Egd flx transnasal dx br/wa,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,828.48,,,,,,
Health Alliance MCR ADV,CPT,0653T,Egd flx transnasal bx 1/ml,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,828.48,,,,,,
Health Alliance MCR ADV,CPT,0654T,Egd flx transnasal tube/cath,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","1,662.91",,,,,,
Health Alliance MCR ADV,CPT,0655T,Tprnl focal abltj mal prst8,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","3,148.08",,,,,,
Health Alliance MCR ADV,CPT,0656T,Vrt bdy tethering ant,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,0657T,Vrt bdy tethering ant 8+ seg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,0658T,Elec impd spectrsc 1+skn les,APC 5733,RVU Per Unit,$56.95 ,OP,56.95,56.95,,,,,,
Health Alliance MCR ADV,CPT,0659T,Tcat intra-c nfs supersat o2,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,0662T,Scalp cool 1st meas&calbrj,APC 5732,RVU Per Unit,$34.63 ,OP,34.63,34.63,,,,,,
Health Alliance MCR ADV,CPT,A0425,Ground mileage,Ambulance,Per Unit,$7.47 ,OP,7.47,7.47,,,,,,
Health Alliance MCR ADV,CPT,A0426,Als 1,Ambulance,Per Case,$231.98 ,OP,231.98,"2,249.49",,,,,,
Health Alliance MCR ADV,CPT,A0427,Als1-emergency,Ambulance,Per Case,$231.98 ,OP,231.98,"2,287.62",,,,,,
Health Alliance MCR ADV,CPT,A0428,Bls,Ambulance,Per Case,$231.98 ,OP,231.98,231.98,,,,,,
Health Alliance MCR ADV,CPT,A0429,Bls-emergency,Ambulance,Per Case,$231.98 ,OP,231.98,"1,883.47",,,,,,
Health Alliance MCR ADV,CPT,A0430,Fixed wing air transport,Ambulance,Per Case,"$3,147.91 ",OP,"3,147.91","3,147.91",,,,,,
Health Alliance MCR ADV,CPT,A0431,Rotary wing air transport,Ambulance,Per Case,"$3,659.92 ",OP,"3,659.92","3,659.92",,,,,,
Health Alliance MCR ADV,CPT,A0432,Pi volunteer ambulance co,Ambulance,Per Case,$231.98 ,OP,231.98,231.98,,,,,,
Health Alliance MCR ADV,CPT,A0433,Als 2,Ambulance,Per Case,$231.98 ,OP,231.98,"2,859.52",,,,,,
Health Alliance MCR ADV,CPT,A0434,Specialty care transport,Ambulance,Per Case,$231.98 ,OP,231.98,"6,100.31",,,,,,
Health Alliance MCR ADV,CPT,A0435,Fixed wing air mileage,Ambulance,Per Unit,$8.93 ,OP,8.93,8.93,,,,,,
Health Alliance MCR ADV,CPT,A0436,Rotary wing air mileage,Ambulance,Per Unit,$23.83 ,OP,23.83,23.83,,,,,,
Health Alliance MCR ADV,CPT,A4563,Vag inser rectal control sys,Durable Medical Equipment,Per Unit,"$1,372.71 ",OP,"1,372.71","1,372.71",,,,,,
Health Alliance MCR ADV,CPT,A9513,Lutetium lu 177 dotatat ther,APC 9067,Per Unit,$274.33 ,OP,274.33,274.33,,,,,,
Health Alliance MCR ADV,CPT,A9517,I131 iodide cap- rx,APC 1064,Per Unit,$20.12 ,OP,20.12,32.18,,,,,,
Health Alliance MCR ADV,CPT,A9527,Iodine i-125 sodium iodide,APC 2632,Per Unit,$30.66 ,OP,30.66,30.66,,,,,,
Health Alliance MCR ADV,CPT,A9530,I131 iodide sol- rx,APC 1150,Per Unit,$13.34 ,OP,13.34,13.34,,,,,,
Health Alliance MCR ADV,CPT,A9543,Y90 ibritumomab- rx,APC 1643,Per Unit,"$59,793.85 ",OP,"59,793.85","59,793.85",,,,,,
Health Alliance MCR ADV,CPT,A9563,P32 na phosphate,APC 1675,Per Unit,$458.34 ,OP,458.34,458.34,,,,,,
Health Alliance MCR ADV,CPT,A9590,Iodine i-131 iobenguane 1mci,APC 9339,Per Unit,$320.12 ,OP,320.12,320.12,,,,,,
Health Alliance MCR ADV,CPT,A9591,Fluoroestradiol f 18,APC 9370,Per Unit,$644.83 ,OP,644.83,644.83,,,,,,
Health Alliance MCR ADV,CPT,A9592,Copper cu 64 dotatate diag,APC 9383,Per Unit,$918.21 ,OP,918.21,918.21,,,,,,
Health Alliance MCR ADV,CPT,A9593,Gallium ga-68 psma-11 ucsf,APC 9409,Per Unit,$732.86 ,OP,732.86,732.86,,,,,,
Health Alliance MCR ADV,CPT,A9594,Gallium ga-68 psma-11- ucla,APC 9410,Per Unit,$717.55 ,OP,717.55,717.55,,,,,,
Health Alliance MCR ADV,CPT,A9600,Sr89 strontium,APC 0701,Per Unit,"$3,975.00 ",OP,"3,975.00","4,407.46",,,,,,
Health Alliance MCR ADV,CPT,A9604,Sm 153 lexidronam,APC 1295,Per Unit,"$17,259.85 ",OP,"17,259.85","17,259.85",,,,,,
Health Alliance MCR ADV,CPT,A9606,Radium ra223 dichloride ther,APC 1745,Per Unit,$145.65 ,OP,145.65,145.65,,,,,,
Health Alliance MCR ADV,CPT,C1052,Hemostatic agent- gi- topic,APC 2031,Straight Discount,29.70%,OP,,,,,,,,
Health Alliance MCR ADV,CPT,C1062,Intravertebral fx aug impl,APC 2032,Straight Discount,29.70%,OP,,,,,,,,
Health Alliance MCR ADV,CPT,C1716,Brachytx- non-str- gold-198,APC 2645,Per Unit,$330.76 ,OP,330.76,330.76,,,,,,
Health Alliance MCR ADV,CPT,C1717,Brachytx- non-str-hdr ir-192,APC 2646,Per Unit,$383.90 ,OP,383.9,383.9,,,,,,
Health Alliance MCR ADV,CPT,C1719,Brachytx- ns- non-hdrir-192,APC 2647,Per Unit,$323.97 ,OP,323.97,323.97,,,,,,
Health Alliance MCR ADV,CPT,C1734,Orth/devic/drug bn/bn-tis/bn,APC 2026,Straight Discount,29.70%,OP,,,,,,,,
Health Alliance MCR ADV,CPT,C1748,Endoscope- single- ugi,APC 2029,Straight Discount,29.70%,OP,,,,,,,,
Health Alliance MCR ADV,CPT,C1761,Cath- trans intra litho/coro,APC 2033,Straight Discount,29.70%,OP,,,,,,,,
Health Alliance MCR ADV,CPT,C1823,Gen- neuro- trans sen/stim,APC 2993,Straight Discount,29.70%,OP,,,,,,,,
Health Alliance MCR ADV,CPT,C1824,Generator- ccm- implant,APC 2024,Straight Discount,29.70%,OP,,,,,,,,
Health Alliance MCR ADV,CPT,C1825,Gen- neuro- carot sinus baro,APC 2030,Straight Discount,29.70%,OP,,,,,,,,
Health Alliance MCR ADV,CPT,C1831,Personalized interbody cage,APC 2034,Straight Discount,29.70%,OP,,,,,,,,
Health Alliance MCR ADV,CPT,C1839,Iris prosthesis,APC 2028,Straight Discount,29.70%,OP,,,,,,,,
Health Alliance MCR ADV,CPT,C1982,Cath- pressure-valve-occlu,APC 2025,Straight Discount,29.70%,OP,,,,,,,,
Health Alliance MCR ADV,CPT,C2596,Probe- robotic- water-jet,APC 2027,Straight Discount,29.70%,OP,,,,,,,,
Health Alliance MCR ADV,CPT,C2616,Brachytx- non-str-yttrium-90,APC 2616,Per Unit,"$19,955.81 ",OP,"19,955.81","19,955.81",,,,,,
Health Alliance MCR ADV,CPT,C2634,Brachytx- non-str- ha- i-125,APC 2634,Per Unit,$169.87 ,OP,169.87,169.87,,,,,,
Health Alliance MCR ADV,CPT,C2635,Brachytx- non-str- ha- p-103,APC 2635,Per Unit,$52.25 ,OP,52.25,52.25,,,,,,
Health Alliance MCR ADV,CPT,C2636,Brachy linear- non-str-p-103,APC 2636,Per Unit,$36.02 ,OP,36.02,36.02,,,,,,
Health Alliance MCR ADV,CPT,C2638,Brachytx- stranded- i-125,APC 2638,Per Unit,$42.90 ,OP,42.9,42.9,,,,,,
Health Alliance MCR ADV,CPT,C2639,Brachytx- non-stranded-i-125,APC 2639,Per Unit,$39.11 ,OP,39.11,39.11,,,,,,
Health Alliance MCR ADV,CPT,C2640,Brachytx- stranded- p-103,APC 2640,Per Unit,$100.65 ,OP,100.65,100.65,,,,,,
Health Alliance MCR ADV,CPT,C2641,Brachytx- non-stranded-p-103,APC 2641,Per Unit,$79.72 ,OP,79.72,79.72,,,,,,
Health Alliance MCR ADV,CPT,C2642,Brachytx- stranded- c-131,APC 2642,Per Unit,$82.43 ,OP,82.43,82.43,,,,,,
Health Alliance MCR ADV,CPT,C2643,Brachytx- non-stranded-c-131,APC 2643,Per Unit,$92.16 ,OP,92.16,92.16,,,,,,
Health Alliance MCR ADV,CPT,C2645,Brachytx planar- p-103,APC 2648,Per Unit,$5.38 ,OP,5.38,5.38,,,,,,
Health Alliance MCR ADV,CPT,C2698,Brachytx- stranded- nos,APC 2698,Per Unit,$42.90 ,OP,42.9,42.9,,,,,,
Health Alliance MCR ADV,CPT,C2699,Brachytx- non-stranded- nos,APC 2699,Per Unit,$36.02 ,OP,36.02,36.02,,,,,,
Health Alliance MCR ADV,CPT,C5271,Low cost skin substitute app,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,536.39,,,,,,
Health Alliance MCR ADV,CPT,C5273,Low cost skin substitute app,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","1,755.36",,,,,,
Health Alliance MCR ADV,CPT,C5275,Low cost skin substitute app,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,536.39,,,,,,
Health Alliance MCR ADV,CPT,C5277,Low cost skin substitute app,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,536.39,,,,,,
Health Alliance MCR ADV,CPT,C8900,Mra w/cont- abd,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,C8901,Mra w/o cont- abd,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,C8902,Mra w/o fol w/cont- abd,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,C8903,Mri w/cont- breast-  uni,APC 5571,RVU Per Case,$182.72 ,OP,182.72,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,C8905,Mri w/o fol w/cont- brst- un,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,C8906,Mri w/cont- breast-  bi,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,C8908,Mri w/o fol w/cont- breast-,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,C8909,Mra w/cont- chest,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,C8910,Mra w/o cont- chest,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,C8911,Mra w/o fol w/cont- chest,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,C8912,Mra w/cont- lwr ext,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,C8913,Mra w/o cont- lwr ext,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,C8914,Mra w/o fol w/cont- lwr ext,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,C8918,Mra w/cont- pelvis,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,C8919,Mra w/o cont- pelvis,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,C8920,Mra w/o fol w/cont- pelvis,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,C8921,Tte w or w/o fol w/cont- com,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
Health Alliance MCR ADV,CPT,C8922,Tte w or w/o fol w/cont- f/u,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
Health Alliance MCR ADV,CPT,C8923,2d tte w or w/o fol w/con-co,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
Health Alliance MCR ADV,CPT,C8924,2d tte w or w/o fol w/con-fu,APC 5572,RVU Per Unit,$376.70 ,OP,376.7,376.7,,,,,,
Health Alliance MCR ADV,CPT,C8925,2d tee w or w/o fol w/con-in,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
Health Alliance MCR ADV,CPT,C8926,Tee w or w/o fol w/cont-cong,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
Health Alliance MCR ADV,CPT,C8927,Tee w or w/o fol w/cont- mon,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
Health Alliance MCR ADV,CPT,C8928,Tte w or w/o fol w/con-stres,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
Health Alliance MCR ADV,CPT,C8929,Tte w or wo fol wcon-doppler,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
Health Alliance MCR ADV,CPT,C8930,Tte w or w/o contr- cont ecg,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
Health Alliance MCR ADV,CPT,C8931,Mra- w/dye- spinal canal,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,C8932,Mra- w/o dye- spinal canal,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,C8933,Mra- w/o&w/dye- spinal canal,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,C8934,Mra- w/dye- upper extremity,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Health Alliance MCR ADV,CPT,C8935,Mra- w/o dye- upper extr,APC 5523,RVU Per Case,$235.49 ,OP,235.49,235.49,,,,,,
Health Alliance MCR ADV,CPT,C8936,Mra- w/o&w/dye- upper extr,APC 5572,RVU Per Case,$376.70 ,OP,376.7,376.7,,,,,,
Health Alliance MCR ADV,CPT,C8957,Prolonged iv inf- req pump,APC 5694,RVU Per Unit,$318.00 ,OP,318,318,,,,,,
Health Alliance MCR ADV,CPT,C9046,Cocaine hcl nasal solution,APC 9307,Per Unit,$1.33 ,OP,1.33,1.33,,,,,,
Health Alliance MCR ADV,CPT,C9047,Injection- caplacizumab-yhdp,APC 9199,Per Unit,$691.29 ,OP,691.29,691.29,,,,,,
Health Alliance MCR ADV,CPT,C9067,Gallium ga-68 dotatoc,APC 9323,Per Unit,$8.64 ,OP,8.64,8.64,,,,,,
Health Alliance MCR ADV,CPT,C9081,Idecabtagene car pos t,APC 9422,Per Unit,"$432,085.00 ",OP,"432,085.00","432,085.00",,,,,,
Health Alliance MCR ADV,CPT,C9082,Inj dostarlimab-gxly- 100 mg,APC 9423,Per Unit,"$2,136.09 ",OP,"2,136.09","2,136.09",,,,,,
Health Alliance MCR ADV,CPT,C9083,Inj- amivantamab-vmjw- 10 mg,APC 9424,Per Unit,$87.89 ,OP,87.89,87.89,,,,,,
Health Alliance MCR ADV,CPT,C9084,loncastuximab-lpyl- 0.1 mg,APC 9425,Per Unit,$242.05 ,OP,242.05,242.05,,,,,,
Health Alliance MCR ADV,CPT,C9248,Inj- clevidipine butyrate,APC 9087,Per Unit,$2.91 ,OP,2.91,2.91,,,,,,
Health Alliance MCR ADV,CPT,C9250,Artiss fibrin sealant,APC 1848,Per Unit,$156.84 ,OP,156.84,156.84,,,,,,
Health Alliance MCR ADV,CPT,C9257,Bevacizumab injection,APC 1281,Per Unit,$1.76 ,OP,1.76,1.76,,,,,,
Health Alliance MCR ADV,CPT,C9460,Injection- cangrelor,APC 9460,Per Unit,$16.32 ,OP,16.32,16.32,,,,,,
Health Alliance MCR ADV,CPT,C9462,Injection- delafloxacin,APC 9462,Per Unit,$0.37 ,OP,0.37,0.37,,,,,,
Health Alliance MCR ADV,CPT,C9482,Sotalol hydrochloride iv,APC 9482,Per Unit,$17.58 ,OP,17.58,17.58,,,,,,
Health Alliance MCR ADV,CPT,C9488,Conivaptan hcl,APC 9488,Per Unit,$43.94 ,OP,43.94,43.94,,,,,,
Health Alliance MCR ADV,CPT,C9600,Perc drug-el cor stent sing,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Health Alliance MCR ADV,CPT,C9602,Perc d-e cor stent ather s,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Health Alliance MCR ADV,CPT,C9604,Perc d-e cor revasc t cabg s,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Health Alliance MCR ADV,CPT,C9606,Perc d-e cor revasc w ami s,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,C9607,Perc d-e cor revasc chro sin,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Health Alliance MCR ADV,CPT,C9725,Place endorectal app,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,812.16,,,,,,
Health Alliance MCR ADV,CPT,C9727,Insert palate implants,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","1,384.33",,,,,,
Health Alliance MCR ADV,CPT,C9728,Place device/marker- non pro,APC 5613,RVU Per Unit,"$1,291.62 ",OP,"1,291.62","1,291.62",,,,,,
Health Alliance MCR ADV,CPT,C9733,Non-ophthalmic fva,APC 5572,RVU Per Case,$376.70 ,OP,376.7,376.7,,,,,,
Health Alliance MCR ADV,CPT,C9734,U/s trtmt- not leiomyomata,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,C9739,Cystoscopy prostatic imp 1-3,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,516.83","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,C9740,Cysto impl 4 or more,APC 5376,RVU Per Case,"$8,450.70 ",OP,"8,450.70","8,450.70",,,,,,
Health Alliance MCR ADV,CPT,C9752,Intraosseous des lumb/sacrum,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,C9757,Spine/lumbar disk surgery,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,C9761,Cysto- litho- vacuum kidney,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,516.83","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,C9762,Cardiac mri seg dys strain,APC 5524,RVU Per Case,$494.15 ,OP,494.15,494.15,,,,,,
Health Alliance MCR ADV,CPT,C9763,Cardiac mri seg dys stress,APC 5524,RVU Per Case,$494.15 ,OP,494.15,494.15,,,,,,
Health Alliance MCR ADV,CPT,C9764,Revasc intravasc lithotripsy,APC 5192,RVU Per Case,"$5,072.43 ",OP,"5,072.43","5,072.43",,,,,,
Health Alliance MCR ADV,CPT,C9765,Revasc intra lithotrip-stent,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Health Alliance MCR ADV,CPT,C9766,Revasc intra lithotrip-ather,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Health Alliance MCR ADV,CPT,C9767,Revasc lithotrip-stent-ather,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Health Alliance MCR ADV,CPT,C9769,Cysto w/temp pros implant,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,516.83","4,516.83",,,,,,
Health Alliance MCR ADV,CPT,C9771,Nsl/sins cryo post nasal tis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","2,800.20",,,,,,
Health Alliance MCR ADV,CPT,C9772,Revasc lithotrip tibi/perone,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Health Alliance MCR ADV,CPT,C9773,Revasc lithotr-stent tib/per,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Health Alliance MCR ADV,CPT,C9774,Revasc lithotr-ather tib/per,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Health Alliance MCR ADV,CPT,C9775,Revasc lith-sten-ath tib/per,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Health Alliance MCR ADV,CPT,C9778,Colpopexy- min/inv- ex-perit,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","2,684.38",,,,,,
Health Alliance MCR ADV,CPT,C9779,ESD endoscopy or colonoscopy,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","2,500.37",,,,,,
Health Alliance MCR ADV,CPT,C9780,Insert cv cath inf & sup app,APC 1534,RVU Per Unit,"$8,442.89 ",OP,"7,883.19","8,442.89",,,,,,
Health Alliance MCR ADV,CPT,C9803,Hopd covid-19 spec collect,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Health Alliance MCR ADV,CPT,D0150,Comprehensve oral evaluation,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D0240,Intraoral occlusal film,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D0250,Extraoral 2d project image,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D0251,Extraoral posterior image,APC 5521,RVU Per Case,$82.79 ,OP,82.79,82.79,,,,,,
Health Alliance MCR ADV,CPT,D0270,Dental bitewing single image,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D0272,Dental bitewings two images,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D0274,Bitewings four images,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D0277,Vert bitewings 7 to 8 images,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D0460,Pulp vitality test,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D0600,Non-ionizing diag proc,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D1510,Space maintainer fxd unilat,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D1516,Fixed bilat space maint- max,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D1517,Fixed bilat space maint- man,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D1520,Remove unilat space maintain,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D1526,Remove bilat space main- max,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D1527,Remove bilat space main- man,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D1551,Recement space maint - max,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D1552,Recement space maint - man,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D1553,Recement unilat space maint,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D1575,Dist space maint- fixed unil,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D2999,Dental unspec restorative pr,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D3460,Endodontic endosseous implan,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D3999,Endodontic procedure,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D4260,Osseous surgery 4 or more,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D4263,Bone replce graft first site,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D4264,Bone replce graft each add,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D4268,Surgical revision procedure,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D4270,Pedicle soft tissue graft pr,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D4273,Auto tissue graft 1st tooth,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D4355,Full mouth debridement,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D4381,Localized delivery antimicro,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D5911,Facial moulage sectional,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D5912,Facial moulage complete,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D5983,Radiation applicator,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D5984,Radiation shield,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D5985,Radiation cone locator,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D5987,Commissure splint,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D6920,Dental connector bar,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D7111,Extraction coronal remnants,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D7140,Extraction erupted tooth/exr,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D7210,Rem imp tooth w mucoper flp,APC 5871,RVU Per Unit,"$1,426.03 ",OP,953.17,"1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D7220,Impact tooth remov soft tiss,APC 5871,RVU Per Unit,"$1,426.03 ",OP,953.17,"1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D7230,Impact tooth remov part bony,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,391.64","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D7240,Impact tooth remov comp bony,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,715.71",,,,,,
Health Alliance MCR ADV,CPT,D7241,Impact tooth rem bony w/comp,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","2,001.67",,,,,,
Health Alliance MCR ADV,CPT,D7250,Tooth root removal,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D7260,Oral antral fistula closure,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D7261,Primary closure sinus perf,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D7291,Transseptal fiberotomy,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D7940,Reshaping bone orthognathic,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D9930,Treatment of complications,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D9944,Occ guard- hard- full arch,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D9945,Occ guard- soft- full arch,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D9946,Occ guard- hard- part arch,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D9950,Occlusion analysis,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D9951,Limited occlusal adjustment,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,D9952,Complete occlusal adjustment,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Health Alliance MCR ADV,CPT,G0008,Admin influenza virus vac,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,57.19,,,,,,
Health Alliance MCR ADV,CPT,G0009,Admin pneumococcal vaccine,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,57.19,,,,,,
Health Alliance MCR ADV,CPT,G0010,Admin hepatitis b vaccine,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,57.19,,,,,,
Health Alliance MCR ADV,CPT,G0027,Semen analysis,Lab Services,Per Unit,$6.50 ,OP,6.5,34.31,,,,,,
Health Alliance MCR ADV,CPT,G0101,Ca screen-pelvic/breast exam,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,186.82,,,,,,
Health Alliance MCR ADV,CPT,G0103,Psa screening,Lab Services,Per Unit,$19.31 ,OP,19.31,80.07,,,,,,
Health Alliance MCR ADV,CPT,G0104,Ca screen-flexi sigmoidscope,APC 5311,RVU Per Unit,$812.16 ,OP,678.66,812.16,,,,,,
Health Alliance MCR ADV,CPT,G0105,Colorectal scrn- hi risk ind,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,812.16,,,,,,
Health Alliance MCR ADV,CPT,G0106,Colon ca screen-barium enema,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,"1,090.43",,,,,,
Health Alliance MCR ADV,CPT,G0108,Diab manage trn  per indiv,Physician,Per Unit,$54.47 ,OP,54.47,125.82,,,,,,
Health Alliance MCR ADV,CPT,G0109,Diab manage trn ind/group,Physician,Per Unit,$15.18 ,OP,15.18,72.44,,,,,,
Health Alliance MCR ADV,CPT,G0117,Glaucoma scrn hgh risk direc,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,232.58,,,,,,
Health Alliance MCR ADV,CPT,G0118,Glaucoma scrn hgh risk direc,APC 5732,RVU Per Unit,$34.63 ,OP,34.63,160.13,,,,,,
Health Alliance MCR ADV,CPT,G0120,Colon ca scrn- barium enema,APC 5572,RVU Per Unit,$376.70 ,OP,376.7,"1,090.43",,,,,,
Health Alliance MCR ADV,CPT,G0121,Colon ca scrn not hi rsk ind,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,812.16,,,,,,
Health Alliance MCR ADV,CPT,G0123,Screen cerv/vag thin layer,Lab Services,Per Unit,$20.26 ,OP,20.26,91.51,,,,,,
Health Alliance MCR ADV,CPT,G0127,Trim nail(s),APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Health Alliance MCR ADV,CPT,G0129,Partial hosp prog service,APC 5853,RVU Per Case,$266.56 ,OP,266.56,266.56,,,,,,
Health Alliance MCR ADV,CPT,G0130,Single energy x-ray study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,171.58,,,,,,
Health Alliance MCR ADV,CPT,G0143,Scr c/v cyto-thinlayer-rescr,Lab Services,Per Unit,$27.05 ,OP,27.05,91.51,,,,,,
Health Alliance MCR ADV,CPT,G0144,Scr c/v cyto-thinlayer-rescr,Lab Services,Per Unit,$43.97 ,OP,43.97,95.32,,,,,,
Health Alliance MCR ADV,CPT,G0145,Scr c/v cyto-thinlayer-rescr,Lab Services,Per Unit,$26.49 ,OP,26.49,118.19,,,,,,
Health Alliance MCR ADV,CPT,G0147,Scr c/v cyto- automated sys,Lab Services,Per Unit,$15.15 ,OP,15.15,45.74,,,,,,
Health Alliance MCR ADV,CPT,G0148,Scr c/v cyto- autosys- rescr,Lab Services,Per Unit,$31.94 ,OP,31.94,45.74,,,,,,
Health Alliance MCR ADV,CPT,G0166,Extrnl counterpulse- per tx,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Health Alliance MCR ADV,CPT,G0175,Opps service-sched team conf,APC 5024,RVU Per Unit,$372.22 ,OP,372.22,392.7,,,,,,
Health Alliance MCR ADV,CPT,G0176,Opps/php-activity therapy,APC 5853,RVU Per Case,$266.56 ,OP,266.56,266.56,,,,,,
Health Alliance MCR ADV,CPT,G0186,Dstry eye lesn-fdr vssl tech,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,515.61,,,,,,
Health Alliance MCR ADV,CPT,G0235,Pet not otherwise specified,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"7,236.50",,,,,,
Health Alliance MCR ADV,CPT,G0237,Therapeutic procd strg endur,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,61,,,,,,
Health Alliance MCR ADV,CPT,G0238,Oth resp proc- indiv,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,64.82,,,,,,
Health Alliance MCR ADV,CPT,G0239,Oth resp proc- group,APC 5732,RVU Per Unit,$34.63 ,OP,34.63,64.82,,,,,,
Health Alliance MCR ADV,CPT,G0245,Initial foot exam pt lops,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,339.33,,,,,,
Health Alliance MCR ADV,CPT,G0246,Followup eval of foot pt lop,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,198.25,,,,,,
Health Alliance MCR ADV,CPT,G0247,Routine footcare pt w lops,APC 5051,RVU Per Case,$183.73 ,OP,183.73,232.58,,,,,,
Health Alliance MCR ADV,CPT,G0248,Demonstrate use home inr mon,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,804.48,,,,,,
Health Alliance MCR ADV,CPT,G0249,Provide inr test mater/equip,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,686.28,,,,,,
Health Alliance MCR ADV,CPT,G0257,Unsched dialysis esrd pt hos,APC 5401,RVU Per Unit,$669.60 ,OP,669.6,669.6,,,,,,
Health Alliance MCR ADV,CPT,G0260,Inj for sacroiliac jt anesth,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,649.39,,,,,,
Health Alliance MCR ADV,CPT,G0270,Mnt subs tx for change dx,Physician,Per Unit,$26.49 ,OP,26.49,122,,,,,,
Health Alliance MCR ADV,CPT,G0271,Group mnt 2 or more 30 mins,Physician,Per Unit,$13.98 ,OP,13.98,68.63,,,,,,
Health Alliance MCR ADV,CPT,G0276,Pild/placebo control clin tr,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,G0277,Hbot- full body chamber- 30m,APC 5061,RVU Per Unit,$122.06 ,OP,122.06,122.06,,,,,,
Health Alliance MCR ADV,CPT,G0279,Tomosynthesis- mammo,Physician,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Health Alliance MCR ADV,CPT,G0281,Elec stim unattend for press,Physician,Per Unit,$12.74 ,OP,12.74,61,,,,,,
Health Alliance MCR ADV,CPT,G0283,Elec stim other than wound,Physician,Per Unit,$12.74 ,OP,12.74,61,,,,,,
Health Alliance MCR ADV,CPT,G0293,Non-cov surg proc-clin trial,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Health Alliance MCR ADV,CPT,G0294,Non-cov proc- clinical trial,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Health Alliance MCR ADV,CPT,G0296,Visit to determ ldct elig,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Health Alliance MCR ADV,CPT,G0302,Pre-op service lvrs complete,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Health Alliance MCR ADV,CPT,G0303,Pre-op service lvrs 10-15dos,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Health Alliance MCR ADV,CPT,G0304,Pre-op service lvrs 1-9 dos,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Health Alliance MCR ADV,CPT,G0305,Post op service lvrs min 6,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Health Alliance MCR ADV,CPT,G0306,Cbc/diffwbc w/o platelet,Lab Services,Per Unit,$7.77 ,OP,7.77,34.31,,,,,,
Health Alliance MCR ADV,CPT,G0307,Cbc without platelet,Lab Services,Per Unit,$6.47 ,OP,6.47,30.51,,,,,,
Health Alliance MCR ADV,CPT,G0328,Fecal blood scrn immunoassay,Lab Services,Per Unit,$18.05 ,OP,18.05,72.44,,,,,,
Health Alliance MCR ADV,CPT,G0329,Electromagntic tx for ulcers,Physician,Per Unit,$10.46 ,OP,10.46,45.74,,,,,,
Health Alliance MCR ADV,CPT,G0341,Percutaneous islet celltrans,APC 5881,RVU Per Case,"$8,948.83 ",OP,"2,508.76","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,G0342,Laparoscopy islet cell trans,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,254.96","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,G0343,Laparotomy islet cell transp,APC 5881,RVU Per Case,"$8,948.83 ",OP,"6,965.79","8,948.83",,,,,,
Health Alliance MCR ADV,CPT,G0379,Direct refer hospital observ,APC 5025,RVU Per Case,$534.29 ,OP,534.29,534.29,,,,,,
Health Alliance MCR ADV,CPT,G0380,Lev 1 hosp type b ed visit,APC 5031,RVU Per Case,$72.19 ,OP,72.19,72.19,,,,,,
Health Alliance MCR ADV,CPT,G0381,Lev 2 hosp type b ed visit,APC 5032,RVU Per Case,$97.63 ,OP,97.63,97.63,,,,,,
Health Alliance MCR ADV,CPT,G0382,Lev 3 hosp type b ed visit,APC 5033,RVU Per Case,$185.19 ,OP,185.19,185.19,,,,,,
Health Alliance MCR ADV,CPT,G0383,Lev 4 hosp type b ed visit,APC 5034,RVU Per Case,$233.92 ,OP,233.92,233.92,,,,,,
Health Alliance MCR ADV,CPT,G0384,Lev 5 hosp type b ed visit,APC 5035,RVU Per Case,$325.81 ,OP,325.81,325.81,,,,,,
Health Alliance MCR ADV,CPT,G0390,Trauma respons w/hosp criti,APC 5045,RVU Per Unit,$964.64 ,OP,964.64,964.64,,,,,,
Health Alliance MCR ADV,CPT,G0396,Alcohol/subs interv 15-30mn,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,163.95,,,,,,
Health Alliance MCR ADV,CPT,G0397,Alcohol/subs interv >30 min,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,136.74,,,,,,
Health Alliance MCR ADV,CPT,G0398,Home sleep test/type 2 porta,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,367.82,,,,,,
Health Alliance MCR ADV,CPT,G0399,Home sleep test/type 3 porta,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Health Alliance MCR ADV,CPT,G0400,Home sleep test/type 4 porta,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,367.82,,,,,,
Health Alliance MCR ADV,CPT,G0402,Initial preventive exam,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,491.83,,,,,,
Health Alliance MCR ADV,CPT,G0404,Ekg tracing for initial prev,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,25.25,,,,,,
Health Alliance MCR ADV,CPT,G0410,Grp psych partial hosp 45-50,APC 5853,RVU Per Case,$266.56 ,OP,266.56,266.56,,,,,,
Health Alliance MCR ADV,CPT,G0411,Inter active grp psych parti,APC 5853,RVU Per Case,$266.56 ,OP,266.56,266.56,,,,,,
Health Alliance MCR ADV,CPT,G0412,Open tx iliac spine uni/bil,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,510.41","6,411.04",,,,,,
Health Alliance MCR ADV,CPT,G0413,Pelvic ring fracture uni/bil,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,527.33",,,,,,
Health Alliance MCR ADV,CPT,G0414,Pelvic ring fx treat int fix,APC 5115,RVU Per Case,"$12,601.93 ",OP,"6,161.31","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,G0415,Open tx post pelvic fxcture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"8,452.74","12,601.93",,,,,,
Health Alliance MCR ADV,CPT,G0416,Prostate biopsy- any mthd,APC 5673,RVU Per Case,$298.05 ,OP,298.05,"3,297.99",,,,,,
Health Alliance MCR ADV,CPT,G0420,Ed svc ckd ind per session,Physician,Per Unit,$111.79 ,OP,111.79,111.79,,,,,,
Health Alliance MCR ADV,CPT,G0421,Ed svc ckd grp per session,Physician,Per Unit,$26.73 ,OP,26.73,26.73,,,,,,
Health Alliance MCR ADV,CPT,G0422,Intens cardiac rehab w/exerc,APC 5771,RVU Per Unit,$118.77 ,OP,118.77,118.77,,,,,,
Health Alliance MCR ADV,CPT,G0423,Intens cardiac rehab no exer,APC 5771,RVU Per Unit,$118.77 ,OP,118.77,118.77,,,,,,
Health Alliance MCR ADV,CPT,G0424,Pulmonary rehab w exer,APC 5733,RVU Per Unit,$56.95 ,OP,56.95,56.95,,,,,,
Health Alliance MCR ADV,CPT,G0429,Dermal filler injection(s),APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","1,755.36",,,,,,
Health Alliance MCR ADV,CPT,G0432,Eia hiv-1/hiv-2 screen,Lab Services,Per Unit,$19.57 ,OP,19.57,19.57,,,,,,
Health Alliance MCR ADV,CPT,G0433,Elisa hiv-1/hiv-2 screen,Lab Services,Per Unit,$18.29 ,OP,18.29,18.29,,,,,,
Health Alliance MCR ADV,CPT,G0435,Oral hiv-1/hiv-2 screen,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,
Health Alliance MCR ADV,CPT,G0438,Ppps- initial visit,Physician,Per Unit,$163.74 ,OP,163.74,163.74,,,,,,
Health Alliance MCR ADV,CPT,G0439,Ppps- subseq visit,Physician,Per Unit,$129.00 ,OP,129,129,,,,,,
Health Alliance MCR ADV,CPT,G0442,Annual alcohol screen 15 min,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Health Alliance MCR ADV,CPT,G0443,Brief alcohol misuse counsel,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Health Alliance MCR ADV,CPT,G0444,Depression screen annual,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Health Alliance MCR ADV,CPT,G0445,High inten beh couns std 30m,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Health Alliance MCR ADV,CPT,G0446,Intens behave ther cardio dx,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Health Alliance MCR ADV,CPT,G0447,Behavior counsel obesity 15m,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Health Alliance MCR ADV,CPT,G0451,Devlopment test interpt&rep,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Health Alliance MCR ADV,CPT,G0455,Fecal microbiota prep instil,APC 5301,RVU Per Case,$828.48 ,OP,828.48,828.48,,,,,,
Health Alliance MCR ADV,CPT,G0460,Autologous prp for ulcers,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","1,755.36",,,,,,
Health Alliance MCR ADV,CPT,G0463,Hospital outpt clinic visit,APC 5012,RVU Per Case,$121.51 ,OP,95.32,121.51,,,,,,
Health Alliance MCR ADV,CPT,G0471,Ven blood coll snf/hha,Lab Services,Per Unit,$5.00 ,OP,5,5,,,,,,
Health Alliance MCR ADV,CPT,G0472,Hep c screen high risk/other,Lab Services,Per Unit,$46.35 ,OP,46.35,46.35,,,,,,
Health Alliance MCR ADV,CPT,G0473,Group behave couns 2-10,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Health Alliance MCR ADV,CPT,G0475,Hiv combination assay,Lab Services,Per Unit,$24.08 ,OP,24.08,24.08,,,,,,
Health Alliance MCR ADV,CPT,G0476,Hpv combo assay ca screen,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,
Health Alliance MCR ADV,CPT,G0480,Drug test def 1-7 classes,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
Health Alliance MCR ADV,CPT,G0481,Drug test def 8-14 classes,Lab Services,Per Unit,$156.59 ,OP,156.59,156.59,,,,,,
Health Alliance MCR ADV,CPT,G0482,Drug test def 15-21 classes,Lab Services,Per Unit,$198.74 ,OP,198.74,198.74,,,,,,
Health Alliance MCR ADV,CPT,G0483,Drug test def 22+ classes,Lab Services,Per Unit,$246.92 ,OP,246.92,246.92,,,,,,
Health Alliance MCR ADV,CPT,G0498,Chemo extend iv infus w/pump,APC 5694,RVU Per Unit,$318.00 ,OP,318,318,,,,,,
Health Alliance MCR ADV,CPT,G0499,Hepb screen high risk indiv,Lab Services,Per Unit,$28.27 ,OP,28.27,28.27,,,,,,
Health Alliance MCR ADV,CPT,G0516,Insert drug del implant- >=4,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
Health Alliance MCR ADV,CPT,G0517,Remove drug implant,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
Health Alliance MCR ADV,CPT,G0518,Remove w insert drug implant,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
Health Alliance MCR ADV,CPT,G0659,Drug test def simple all cl,Lab Services,Per Unit,$62.14 ,OP,62.14,62.14,,,,,,
Health Alliance MCR ADV,CPT,G2000,Blinded conv. tx mdd clin tr,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Health Alliance MCR ADV,CPT,G2011,Alcohol/sub misuse assess,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,25.25,,,,,,
Health Alliance MCR ADV,CPT,G2065,Clin mang h risk dx 30,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Health Alliance MCR ADV,CPT,G2066,Inter devc remote 30d,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Health Alliance MCR ADV,CPT,G2082,Visit esketamine 56m or less,APC 1508,RVU Per Unit,$665.67 ,OP,621.54,665.67,,,,,,
Health Alliance MCR ADV,CPT,G2083,Visit esketamine- > 56m,APC 1511,RVU Per Unit,$972.67 ,OP,972.67,972.67,,,,,,
Health Alliance MCR ADV,CPT,G2086,Off base opioid tx 70min,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,136.74,,,,,,
Health Alliance MCR ADV,CPT,G2087,Off base opioid tx- 60 m,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,136.74,,,,,,
Health Alliance MCR ADV,CPT,G2170,Avf by tissue w thermal e,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Health Alliance MCR ADV,CPT,G2171,Avf use magnetic/art/ven,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Health Alliance MCR ADV,CPT,G2214,Init/sub psych care m 1st 30,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Health Alliance MCR ADV,CPT,G2250,Remot img sub by pt- non e/m,Physician,Per Unit,$9.24 ,OP,9.24,9.24,,,,,,
Health Alliance MCR ADV,CPT,G2251,Brief chkin- 5-10- non-e/m,Physician,Per Unit,$13.05 ,OP,13.05,13.05,,,,,,
Health Alliance MCR ADV,CPT,G2252,Brief chkin by md/qhp- 11-20,Physician,Per Unit,$25.14 ,OP,25.14,25.14,,,,,,
Health Alliance MCR ADV,CPT,J0121,Inj.- omadacycline- 1 mg,APC 9311,Per Unit,$3.30 ,OP,3.3,3.3,,,,,,
Health Alliance MCR ADV,CPT,J0129,Abatacept injection,APC 9230,Per Unit,$45.27 ,OP,45.27,73.44,,,,,,
Health Alliance MCR ADV,CPT,J0135,Adalimumab injection,APC 1083,Per Unit,"$1,581.57 ",OP,"1,581.57","1,581.57",,,,,,
Health Alliance MCR ADV,CPT,J0178,Aflibercept injection,APC 1420,Per Unit,$917.94 ,OP,917.94,917.94,,,,,,
Health Alliance MCR ADV,CPT,J0179,Inj- brolucizumab-dbll- 1 mg,APC 9340,Per Unit,$312.01 ,OP,312.01,312.01,,,,,,
Health Alliance MCR ADV,CPT,J0180,Agalsidase beta injection,APC 9208,Per Unit,$198.14 ,OP,198.14,508.92,,,,,,
Health Alliance MCR ADV,CPT,J0185,Inj.- aprepitant- 1 mg,APC 9463,Per Unit,$1.69 ,OP,1.69,1.69,,,,,,
Health Alliance MCR ADV,CPT,J0202,Injection- alemtuzumab,APC 1809,Per Unit,"$2,086.32 ",OP,277.19,"2,086.32",,,,,,
Health Alliance MCR ADV,CPT,J0207,Amifostine,APC 7000,Per Unit,"$1,135.69 ",OP,"1,135.69","1,985.16",,,,,,
Health Alliance MCR ADV,CPT,J0220,Alglucosidase alfa injection,APC 9234,Per Unit,$117.07 ,OP,117.07,474.68,,,,,,
Health Alliance MCR ADV,CPT,J0221,Lumizyme injection,APC 1413,Per Unit,$180.35 ,OP,180.35,180.35,,,,,,
Health Alliance MCR ADV,CPT,J0222,Inj.- patisiran- 0.1 mg,APC 9180,Per Unit,$97.75 ,OP,97.75,97.75,,,,,,
Health Alliance MCR ADV,CPT,J0223,Inj givosiran 0.5 mg,APC 9343,Per Unit,$106.76 ,OP,106.76,106.76,,,,,,
Health Alliance MCR ADV,CPT,J0224,Inj. lumasiran- 0.5 mg,APC 9407,Per Unit,$302.30 ,OP,302.3,302.3,,,,,,
Health Alliance MCR ADV,CPT,J0256,Alpha 1 proteinase inhibitor,APC 0901,Per Unit,$4.54 ,OP,4.54,7.9,,,,,,
Health Alliance MCR ADV,CPT,J0257,Glassia injection,APC 1415,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,
Health Alliance MCR ADV,CPT,J0287,Amphotericin b lipid complex,APC 9024,Per Unit,$9.50 ,OP,9.5,49.56,,,,,,
Health Alliance MCR ADV,CPT,J0289,Amphotericin b liposome inj,APC 0736,Per Unit,$28.75 ,OP,28.75,118.19,,,,,,
Health Alliance MCR ADV,CPT,J0291,Inj.- plazomicin- 5 mg,APC 9183,Per Unit,$3.05 ,OP,3.05,3.05,,,,,,
Health Alliance MCR ADV,CPT,J0300,Amobarbital 125 mg inj,APC 1341,Per Unit,$125.22 ,OP,30.51,125.22,,,,,,
Health Alliance MCR ADV,CPT,J0390,Chloroquine injection,APC 9352,Per Unit,$165.22 ,OP,83.87,165.22,,,,,,
Health Alliance MCR ADV,CPT,J0401,Inj aripiprazole ext rel 1mg,APC 1468,Per Unit,$6.01 ,OP,6.01,7.62,,,,,,
Health Alliance MCR ADV,CPT,J0475,Baclofen 10 mg injection,APC 9032,Per Unit,$177.43 ,OP,177.43,826.29,,,,,,
Health Alliance MCR ADV,CPT,J0480,Basiliximab,APC 1683,Per Unit,"$4,013.08 ",OP,"4,013.08","7,724.52",,,,,,
Health Alliance MCR ADV,CPT,J0485,Belatacept injection,APC 9286,Per Unit,$3.80 ,OP,3.8,3.8,,,,,,
Health Alliance MCR ADV,CPT,J0490,Belimumab injection,APC 1353,Per Unit,$47.57 ,OP,47.57,47.57,,,,,,
Health Alliance MCR ADV,CPT,J0517,Inj.- benralizumab- 1 mg,APC 9466,Per Unit,$170.80 ,OP,170.8,170.8,,,,,,
Health Alliance MCR ADV,CPT,J0558,Peng benzathine/procaine inj,APC 9088,Per Unit,$11.79 ,OP,11.79,11.79,,,,,,
Health Alliance MCR ADV,CPT,J0561,Penicillin g benzathine inj,APC 1829,Per Unit,$14.95 ,OP,14.95,14.95,,,,,,
Health Alliance MCR ADV,CPT,J0565,Inj- bezlotoxumab- 10 mg,APC 9490,Per Unit,$39.77 ,OP,39.77,39.77,,,,,,
Health Alliance MCR ADV,CPT,J0570,Buprenorphine implant 74.2mg,APC 9058,Per Unit,"$1,311.75 ",OP,209.7,"1,311.75",,,,,,
Health Alliance MCR ADV,CPT,J0584,Injection- burosumab-twza 1m,APC 9187,Per Unit,$369.11 ,OP,369.11,369.11,,,,,,
Health Alliance MCR ADV,CPT,J0585,Injection-onabotulinumtoxina,APC 0902,Per Unit,$6.09 ,OP,6.09,6.09,,,,,,
Health Alliance MCR ADV,CPT,J0586,Abobotulinumtoxina,APC 1289,Per Unit,$8.41 ,OP,8.41,8.41,,,,,,
Health Alliance MCR ADV,CPT,J0587,Inj- rimabotulinumtoxinb,APC 9018,Per Unit,$12.05 ,OP,12.05,39.5,,,,,,
Health Alliance MCR ADV,CPT,J0588,Incobotulinumtoxin a,APC 9278,Per Unit,$5.05 ,OP,5.05,5.05,,,,,,
Health Alliance MCR ADV,CPT,J0594,Busulfan injection,APC 1178,Per Unit,$1.71 ,OP,1.71,61,,,,,,
Health Alliance MCR ADV,CPT,J0596,Injection- ruconest,APC 9445,Per Unit,$29.97 ,OP,29.97,29.97,,,,,,
Health Alliance MCR ADV,CPT,J0597,C-1 esterase- berinert,APC 9269,Per Unit,$57.39 ,OP,57.39,57.39,,,,,,
Health Alliance MCR ADV,CPT,J0598,C-1 esterase- cinryze,APC 9251,Per Unit,$58.93 ,OP,58.93,58.93,,,,,,
Health Alliance MCR ADV,CPT,J0599,Inj.- haegarda 10 units,APC 9015,Per Unit,$10.25 ,OP,10.25,10.25,,,,,,
Health Alliance MCR ADV,CPT,J0600,Edetate calcium disodium inj,APC 1274,Per Unit,"$5,708.59 ",OP,362.21,"5,708.59",,,,,,
Health Alliance MCR ADV,CPT,J0630,Calcitonin salmon injection,APC 1433,Per Unit,"$3,100.79 ",OP,191.13,"3,100.79",,,,,,
Health Alliance MCR ADV,CPT,J0638,Canakinumab injection,APC 1311,Per Unit,$115.61 ,OP,115.61,115.61,,,,,,
Health Alliance MCR ADV,CPT,J0641,Inj levoleucovorin nos 0.5mg,APC 1236,Per Unit,$0.09 ,OP,0.09,0.09,,,,,,
Health Alliance MCR ADV,CPT,J0642,Injection- khapzory- 0.5 mg,APC 9334,Per Unit,$1.86 ,OP,1.86,1.86,,,,,,
Health Alliance MCR ADV,CPT,J0691,Inj lefamulin 1 mg,APC 9332,Per Unit,$0.72 ,OP,0.72,0.72,,,,,,
Health Alliance MCR ADV,CPT,J0695,Inj ceftolozane tazobactam,APC 9452,Per Unit,$6.64 ,OP,6.64,6.64,,,,,,
Health Alliance MCR ADV,CPT,J0699,Inj- cefiderocol- 10 mg,APC 9426,Per Unit,$2.01 ,OP,2.01,2.01,,,,,,
Health Alliance MCR ADV,CPT,J0712,Ceftaroline fosamil inj,APC 1824,Per Unit,$3.51 ,OP,3.51,3.51,,,,,,
Health Alliance MCR ADV,CPT,J0714,Ceftazidime and avibactam,APC 1825,Per Unit,$92.39 ,OP,92.39,92.39,,,,,,
Health Alliance MCR ADV,CPT,J0716,Centruroides immune f(ab),APC 1431,Per Unit,"$5,190.15 ",OP,"5,190.15","5,190.15",,,,,,
Health Alliance MCR ADV,CPT,J0717,Certolizumab pegol inj 1mg,APC 1474,Per Unit,$6.27 ,OP,6.27,6.27,,,,,,
Health Alliance MCR ADV,CPT,J0740,Cidofovir injection,APC 9033,Per Unit,$563.76 ,OP,563.76,"3,694.50",,,,,,
Health Alliance MCR ADV,CPT,J0741,Inj- cabote rilpivir 2mg 3mg,APC 9414,Per Unit,$20.56 ,OP,20.56,20.56,,,,,,
Health Alliance MCR ADV,CPT,J0742,Inj imip 4 cilas 4 releb 2mg,APC 9362,Per Unit,$2.32 ,OP,2.32,2.32,,,,,,
Health Alliance MCR ADV,CPT,J0745,Inj codeine phosphate /30 mg,APC 9393,Per Unit,$135.64 ,OP,7.62,135.64,,,,,,
Health Alliance MCR ADV,CPT,J0775,Collagenase- clost hist inj,APC 1340,Per Unit,$56.66 ,OP,56.66,56.66,,,,,,
Health Alliance MCR ADV,CPT,J0791,Inj crizanlizumab-tmca 5mg,APC 9359,Per Unit,$123.29 ,OP,123.29,123.29,,,,,,
Health Alliance MCR ADV,CPT,J0795,Corticorelin ovine triflutal,APC 1684,Per Unit,$9.67 ,OP,9.67,22.88,,,,,,
Health Alliance MCR ADV,CPT,J0840,Crotalidae poly immune fab,APC 9274,Per Unit,"$2,743.36 ",OP,"2,743.36","2,743.36",,,,,,
Health Alliance MCR ADV,CPT,J0841,Inj crotalidae im f(ab)2 eq,APC 9188,Per Unit,"$1,189.81 ",OP,"1,189.81","1,189.81",,,,,,
Health Alliance MCR ADV,CPT,J0850,Cytomegalovirus imm iv /vial,APC 0903,Per Unit,"$1,538.70 ",OP,"1,538.70","4,266.40",,,,,,
Health Alliance MCR ADV,CPT,J0875,Injection- dalbavancin,APC 1823,Per Unit,$15.89 ,OP,15.89,15.89,,,,,,
Health Alliance MCR ADV,CPT,J0881,Darbepoetin alfa- non-esrd,APC 1685,Per Unit,$3.15 ,OP,3.15,15.26,,,,,,
Health Alliance MCR ADV,CPT,J0882,Darbepoetin alfa- esrd use,APC 1482,Per Unit,$3.15 ,OP,3.15,15.26,,,,,,
Health Alliance MCR ADV,CPT,J0883,Argatroban nonesrd use 1mg,APC 1859,Per Unit,$1.20 ,OP,1.2,1.2,,,,,,
Health Alliance MCR ADV,CPT,J0884,Argatroban esrd dialysis 1mg,APC 9065,Per Unit,$1.20 ,OP,1.2,1.2,,,,,,
Health Alliance MCR ADV,CPT,J0885,Epoetin alfa- non-esrd,APC 1686,Per Unit,$8.15 ,OP,8.15,45.74,,,,,,
Health Alliance MCR ADV,CPT,J0888,Epoetin beta non esrd,APC 9077,Per Unit,$1.51 ,OP,1.51,1.51,,,,,,
Health Alliance MCR ADV,CPT,J0894,Decitabine injection,APC 9231,Per Unit,$3.45 ,OP,3.45,3.45,,,,,,
Health Alliance MCR ADV,CPT,J0896,Inj luspatercept-aamt 0.25mg,APC 9347,Per Unit,$36.85 ,OP,36.85,36.85,,,,,,
Health Alliance MCR ADV,CPT,J0897,Denosumab injection,APC 9272,Per Unit,$21.19 ,OP,21.19,21.19,,,,,,
Health Alliance MCR ADV,CPT,J1095,Injection- dexamethasone 9%,APC 9172,Per Unit,$1.04 ,OP,1.04,1.04,,,,,,
Health Alliance MCR ADV,CPT,J1096,Dexametha opth insert 0.1 mg,APC 9308,Per Unit,$133.30 ,OP,133.3,133.3,,,,,,
Health Alliance MCR ADV,CPT,J1162,Digoxin immune fab (ovine),APC 1687,Per Unit,"$4,128.19 ",OP,"2,344.81","4,128.19",,,,,,
Health Alliance MCR ADV,CPT,J1190,Dexrazoxane hcl injection,APC 0726,Per Unit,$192.33 ,OP,192.33,"1,849.16",,,,,,
Health Alliance MCR ADV,CPT,J1201,Inj. cetirizine hcl 0.5mg,APC 9361,Per Unit,$15.38 ,OP,15.38,15.38,,,,,,
Health Alliance MCR ADV,CPT,J1212,Dimethyl sulfoxide 50% 50 ml,APC 1832,Per Unit,$637.11 ,OP,339.33,637.11,,,,,,
Health Alliance MCR ADV,CPT,J1290,Ecallantide injection,APC 9263,Per Unit,$503.88 ,OP,503.88,503.88,,,,,,
Health Alliance MCR ADV,CPT,J1300,Eculizumab injection,APC 9236,Per Unit,$229.23 ,OP,229.23,679.45,,,,,,
Health Alliance MCR ADV,CPT,J1301,Injection- edaravone- 1 mg,APC 9493,Per Unit,$20.51 ,OP,20.51,20.51,,,,,,
Health Alliance MCR ADV,CPT,J1303,Inj.- ravulizumab-cwvz 10 mg,APC 9312,Per Unit,$224.68 ,OP,224.68,224.68,,,,,,
Health Alliance MCR ADV,CPT,J1305,Inj- evinacumab-dgnb- 5mg,APC 9416,Per Unit,$165.63 ,OP,165.63,165.63,,,,,,
Health Alliance MCR ADV,CPT,J1322,Elosulfase alfa- injection,APC 1480,Per Unit,$250.33 ,OP,250.33,250.33,,,,,,
Health Alliance MCR ADV,CPT,J1364,Erythro lactobionate /500 mg,APC 1669,Per Unit,$77.75 ,OP,38.13,77.75,,,,,,
Health Alliance MCR ADV,CPT,J1410,Inj estrogen conjugate 25 mg,APC 9038,Per Unit,$341.46 ,OP,341.46,381.27,,,,,,
Health Alliance MCR ADV,CPT,J1426,Injection- casimersen- 10 mg,APC 9412,Per Unit,$166.47 ,OP,166.47,166.47,,,,,,
Health Alliance MCR ADV,CPT,J1427,Inj. viltolarsen,APC 9386,Per Unit,$59.05 ,OP,59.05,59.05,,,,,,
Health Alliance MCR ADV,CPT,J1429,Inj golodirsen 10 mg,APC 9356,Per Unit,$166.21 ,OP,166.21,166.21,,,,,,
Health Alliance MCR ADV,CPT,J1430,Ethanolamine oleate 100 mg,APC 1688,Per Unit,$444.10 ,OP,444.1,728.23,,,,,,
Health Alliance MCR ADV,CPT,J1437,Inj. fe derisomaltose 10 mg,APC 9388,Per Unit,$24.87 ,OP,24.87,24.87,,,,,,
Health Alliance MCR ADV,CPT,J1438,Etanercept injection,APC 1608,Per Unit,$790.78 ,OP,714.31,790.78,,,,,,
Health Alliance MCR ADV,CPT,J1439,Inj ferric carboxymaltos 1mg,APC 9441,Per Unit,$1.12 ,OP,1.12,1.12,,,,,,
Health Alliance MCR ADV,CPT,J1442,Inj filgrastim excl biosimil,APC 1469,Per Unit,$0.97 ,OP,0.97,3.09,,,,,,
Health Alliance MCR ADV,CPT,J1447,Inj tbo filgrastim 1 microg,APC 1748,Per Unit,$0.46 ,OP,0.46,3.1,,,,,,
Health Alliance MCR ADV,CPT,J1448,Injection- trilaciclib- 1mg,APC 9415,Per Unit,$4.97 ,OP,4.97,4.97,,,,,,
Health Alliance MCR ADV,CPT,J1451,Fomepizole- 15 mg,APC 1689,Per Unit,$5.98 ,OP,5.98,49.56,,,,,,
Health Alliance MCR ADV,CPT,J1453,Fosaprepitant injection,APC 9242,Per Unit,$0.24 ,OP,0.24,7.62,,,,,,
Health Alliance MCR ADV,CPT,J1454,Inj fosnetupitant- palonoset,APC 9099,Per Unit,$571.22 ,OP,571.22,571.22,,,,,,
Health Alliance MCR ADV,CPT,J1455,Foscarnet sodium injection,APC 1849,Per Unit,$72.86 ,OP,49.56,72.86,,,,,,
Health Alliance MCR ADV,CPT,J1458,Galsulfase injection,APC 9224,Per Unit,$411.92 ,OP,411.92,"1,289.57",,,,,,
Health Alliance MCR ADV,CPT,J1459,Inj ivig privigen 500 mg,APC 1214,Per Unit,$44.48 ,OP,44.48,143.18,,,,,,
Health Alliance MCR ADV,CPT,J1460,Gamma globulin 1 cc inj,APC 1850,Per Unit,$44.13 ,OP,44.13,61,,,,,,
Health Alliance MCR ADV,CPT,J1554,Inj. asceniv,APC 9392,Per Unit,$481.77 ,OP,481.77,481.77,,,,,,
Health Alliance MCR ADV,CPT,J1555,Inj cuvitru- 100 mg,APC 9034,Per Unit,$14.50 ,OP,14.5,14.5,,,,,,
Health Alliance MCR ADV,CPT,J1556,Inj- imm glob bivigam- 500mg,APC 9130,Per Unit,$70.49 ,OP,70.49,70.49,,,,,,
Health Alliance MCR ADV,CPT,J1557,Gammaplex injection,APC 9270,Per Unit,$48.53 ,OP,48.53,48.53,,,,,,
Health Alliance MCR ADV,CPT,J1558,Inj. xembify- 100 mg,APC 9372,Per Unit,$13.61 ,OP,13.61,13.61,,,,,,
Health Alliance MCR ADV,CPT,J1559,Hizentra injection,APC 1312,Per Unit,$11.58 ,OP,11.58,11.58,,,,,,
Health Alliance MCR ADV,CPT,J1560,Gamma globulin > 10 cc inj,APC 1851,Per Unit,$441.31 ,OP,441.31,621.47,,,,,,
Health Alliance MCR ADV,CPT,J1561,Gamunex-c/gammaked,APC 0948,Per Unit,$48.22 ,OP,48.22,158.91,,,,,,
Health Alliance MCR ADV,CPT,J1566,Immune globulin- powder,APC 2731,Per Unit,$65.49 ,OP,65.49,152.51,,,,,,
Health Alliance MCR ADV,CPT,J1568,Octagam injection,APC 0943,Per Unit,$41.63 ,OP,41.63,41.63,,,,,,
Health Alliance MCR ADV,CPT,J1569,Gammagard liquid injection,APC 0944,Per Unit,$44.49 ,OP,44.49,171.58,,,,,,
Health Alliance MCR ADV,CPT,J1571,Hepagam b im injection,APC 0946,Per Unit,$70.94 ,OP,70.94,213.51,,,,,,
Health Alliance MCR ADV,CPT,J1572,Flebogamma injection,APC 0947,Per Unit,$36.80 ,OP,36.8,171.58,,,,,,
Health Alliance MCR ADV,CPT,J1573,Hepagam b intravenous- inj,APC 1138,Per Unit,$71.24 ,OP,71.24,213.51,,,,,,
Health Alliance MCR ADV,CPT,J1575,Hyqvia 100mg immuneglobulin,APC 1826,Per Unit,$15.16 ,OP,15.16,15.16,,,,,,
Health Alliance MCR ADV,CPT,J1595,Injection glatiramer acetate,APC 1015,Per Unit,$141.29 ,OP,141.29,298.68,,,,,,
Health Alliance MCR ADV,CPT,J1602,Golimumab for iv use 1mg,APC 1475,Per Unit,$16.82 ,OP,16.82,16.82,,,,,,
Health Alliance MCR ADV,CPT,J1610,Glucagon hydrochloride/1 mg,APC 9042,Per Unit,$171.74 ,OP,171.74,343.14,,,,,,
Health Alliance MCR ADV,CPT,J1628,Inj.- guselkumab- 1 mg,APC 9029,Per Unit,$82.56 ,OP,82.56,82.56,,,,,,
Health Alliance MCR ADV,CPT,J1632,Inj.- brexanolone- 1 mg,APC 9333,Per Unit,$74.65 ,OP,74.65,74.65,,,,,,
Health Alliance MCR ADV,CPT,J1640,Hemin- 1 mg,APC 1690,Per Unit,$26.64 ,OP,26.64,38.13,,,,,,
Health Alliance MCR ADV,CPT,J1670,Tetanus immune globulin inj,APC 1670,Per Unit,$441.70 ,OP,441.7,"1,040.87",,,,,,
Health Alliance MCR ADV,CPT,J1726,Makena- 10 mg,APC 9074,Per Unit,$16.82 ,OP,16.82,16.82,,,,,,
Health Alliance MCR ADV,CPT,J1729,Inj hydroxyprogst capoat nos,APC 9318,Per Unit,$21.54 ,OP,21.54,21.54,,,,,,
Health Alliance MCR ADV,CPT,J1738,Inj. meloxicam 1 mg,APC 9371,Per Unit,$3.18 ,OP,3.18,3.18,,,,,,
Health Alliance MCR ADV,CPT,J1740,Ibandronate sodium injection,APC 9229,Per Unit,$37.09 ,OP,37.09,674.85,,,,,,
Health Alliance MCR ADV,CPT,J1742,Ibutilide fumarate injection,APC 9044,Per Unit,$205.06 ,OP,205.06,"1,898.73",,,,,,
Health Alliance MCR ADV,CPT,J1744,Icatibant injection,APC 1443,Per Unit,$204.96 ,OP,204.96,204.96,,,,,,
Health Alliance MCR ADV,CPT,J1745,Infliximab not biosimil 10mg,APC 7043,Per Unit,$39.53 ,OP,39.53,301.32,,,,,,
Health Alliance MCR ADV,CPT,J1746,Inj.- ibalizumab-uiyk- 10 mg,APC 9189,Per Unit,$66.39 ,OP,66.39,66.39,,,,,,
Health Alliance MCR ADV,CPT,J1750,Inj iron dextran,APC 1237,Per Unit,$15.84 ,OP,15.84,15.84,,,,,,
Health Alliance MCR ADV,CPT,J1786,Imuglucerase injection,APC 1327,Per Unit,$44.05 ,OP,44.05,44.05,,,,,,
Health Alliance MCR ADV,CPT,J1823,Inj. inebilizumab-cdon- 1 mg,APC 9394,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Health Alliance MCR ADV,CPT,J1826,Interferon beta-1a inj,APC 1852,Per Unit,"$2,293.85 ",OP,"2,293.85","2,293.85",,,,,,
Health Alliance MCR ADV,CPT,J1830,Interferon beta-1b / .25 mg,APC 0910,Per Unit,$406.24 ,OP,406.24,538.7,,,,,,
Health Alliance MCR ADV,CPT,J1833,Injection- isavuconazonium,APC 9456,Per Unit,$0.83 ,OP,0.83,0.83,,,,,,
Health Alliance MCR ADV,CPT,J1930,Lanreotide injection,APC 9237,Per Unit,$67.64 ,OP,67.64,129.64,,,,,,
Health Alliance MCR ADV,CPT,J1931,Laronidase injection,APC 9209,Per Unit,$34.75 ,OP,34.75,95.46,,,,,,
Health Alliance MCR ADV,CPT,J1943,Inj.- aristada initio- 1 mg,APC 9179,Per Unit,$3.05 ,OP,3.05,3.05,,,,,,
Health Alliance MCR ADV,CPT,J1944,Aripirazole lauroxil 1 mg,APC 9470,Per Unit,$2.99 ,OP,2.99,2.99,,,,,,
Health Alliance MCR ADV,CPT,J1950,Leuprolide acetate /3.75 mg,APC 0800,Per Unit,"$1,406.37 ",OP,"1,406.37","1,525.07",,,,,,
Health Alliance MCR ADV,CPT,J1951,Inj fensolvi 0.25 mg,APC 9419,Per Unit,$126.28 ,OP,126.28,126.28,,,,,,
Health Alliance MCR ADV,CPT,J2182,Injection- mepolizumab- 1mg,APC 9473,Per Unit,$28.29 ,OP,28.29,28.29,,,,,,
Health Alliance MCR ADV,CPT,J2186,Inj.- meropenem- vaborbactam,APC 9178,Per Unit,$1.76 ,OP,1.76,1.76,,,,,,
Health Alliance MCR ADV,CPT,J2248,Micafungin sodium injection,APC 9227,Per Unit,$0.97 ,OP,0.97,0.97,,,,,,
Health Alliance MCR ADV,CPT,J2265,Minocycline hydrochloride,APC 1853,Per Unit,$2.00 ,OP,2,2,,,,,,
Health Alliance MCR ADV,CPT,J2278,Ziconotide injection,APC 1694,Per Unit,$8.69 ,OP,8.69,30.51,,,,,,
Health Alliance MCR ADV,CPT,J2315,Naltrexone- depot form,APC 0759,Per Unit,$3.53 ,OP,3.53,3.53,,,,,,
Health Alliance MCR ADV,CPT,J2323,Natalizumab injection,APC 9126,Per Unit,$23.24 ,OP,23.24,103.45,,,,,,
Health Alliance MCR ADV,CPT,J2326,Inj- nusinersen- 0.1mg,APC 9489,Per Unit,"$1,122.13 ",OP,"1,122.13","1,122.13",,,,,,
Health Alliance MCR ADV,CPT,J2350,Injection- ocrelizumab- 1 mg,APC 9494,Per Unit,$58.29 ,OP,58.29,58.29,,,,,,
Health Alliance MCR ADV,CPT,J2353,Octreotide injection- depot,APC 1207,Per Unit,$205.37 ,OP,205.37,408.99,,,,,,
Health Alliance MCR ADV,CPT,J2357,Omalizumab injection,APC 9300,Per Unit,$37.67 ,OP,37.67,70.74,,,,,,
Health Alliance MCR ADV,CPT,J2358,Olanzapine long-acting inj,APC 1331,Per Unit,$2.91 ,OP,2.91,2.91,,,,,,
Health Alliance MCR ADV,CPT,J2406,Injection- oritavancin 10 mg,APC 9427,Per Unit,$41.92 ,OP,41.92,41.92,,,,,,
Health Alliance MCR ADV,CPT,J2407,Injection- oritavancin,APC 1660,Per Unit,$23.63 ,OP,23.63,23.63,,,,,,
Health Alliance MCR ADV,CPT,J2425,Palifermin injection,APC 1696,Per Unit,$23.93 ,OP,23.93,23.93,,,,,,
Health Alliance MCR ADV,CPT,J2426,Paliperidone palmitate inj,APC 9255,Per Unit,$12.66 ,OP,12.66,12.66,,,,,,
Health Alliance MCR ADV,CPT,J2502,Inj- pasireotide long acting,APC 9454,Per Unit,$359.03 ,OP,359.03,359.03,,,,,,
Health Alliance MCR ADV,CPT,J2504,Pegademase bovine- 25 iu,APC 1739,Per Unit,$4.06 ,OP,4.06,"1,098.07",,,,,,
Health Alliance MCR ADV,CPT,J2505,Injection- pegfilgrastim 6mg,APC 9119,Per Unit,"$2,221.63 ",OP,"2,221.63","10,481.09",,,,,,
Health Alliance MCR ADV,CPT,J2507,Pegloticase injection,APC 9281,Per Unit,"$2,960.91 ",OP,"2,960.91","2,960.91",,,,,,
Health Alliance MCR ADV,CPT,J2515,Pentobarbital sodium inj,APC 1854,Per Unit,$26.41 ,OP,26.41,26.41,,,,,,
Health Alliance MCR ADV,CPT,J2547,Injection- peramivir,APC 9451,Per Unit,$1.68 ,OP,1.68,1.68,,,,,,
Health Alliance MCR ADV,CPT,J2560,Phenobarbital sodium inj,APC 9069,Per Unit,$40.22 ,OP,40.22,40.22,,,,,,
Health Alliance MCR ADV,CPT,J2562,Plerixafor injection,APC 9252,Per Unit,$382.85 ,OP,382.85,382.85,,,,,,
Health Alliance MCR ADV,CPT,J2597,Inj desmopressin acetate,APC 1440,Per Unit,$9.40 ,OP,9.4,9.4,,,,,,
Health Alliance MCR ADV,CPT,J2724,Protein c concentrate,APC 1139,Per Unit,$15.13 ,OP,15.13,61,,,,,,
Health Alliance MCR ADV,CPT,J2760,Phentolaine mesylate inj,APC 1458,Per Unit,$416.00 ,OP,255.45,416,,,,,,
Health Alliance MCR ADV,CPT,J2770,Quinupristin/dalfopristin,APC 2770,Per Unit,$444.67 ,OP,444.67,712.98,,,,,,
Health Alliance MCR ADV,CPT,J2778,Ranibizumab injection,APC 9233,Per Unit,$318.47 ,OP,318.47,318.47,,,,,,
Health Alliance MCR ADV,CPT,J2783,Rasburicase,APC 0738,Per Unit,$315.06 ,OP,315.06,804.48,,,,,,
Health Alliance MCR ADV,CPT,J2786,Injection- reslizumab- 1mg,APC 9481,Per Unit,$10.11 ,OP,10.11,10.11,,,,,,
Health Alliance MCR ADV,CPT,J2792,Rho(d) immune globulin h- sd,APC 1609,Per Unit,$31.42 ,OP,31.42,80.07,,,,,,
Health Alliance MCR ADV,CPT,J2794,Inj risperdal consta- 0.5 mg,APC 9125,Per Unit,$11.04 ,OP,11.04,19.71,,,,,,
Health Alliance MCR ADV,CPT,J2796,Romiplostim injection,APC 9245,Per Unit,$83.47 ,OP,83.47,83.47,,,,,,
Health Alliance MCR ADV,CPT,J2798,Inj.- perseris- 0.5 mg,APC 9181,Per Unit,$10.69 ,OP,10.69,10.69,,,,,,
Health Alliance MCR ADV,CPT,J2820,Sargramostim injection,APC 0731,Per Unit,$51.55 ,OP,51.55,122,,,,,,
Health Alliance MCR ADV,CPT,J2840,Inj sebelipase alfa 1 mg,APC 9478,Per Unit,$539.91 ,OP,539.91,539.91,,,,,,
Health Alliance MCR ADV,CPT,J2850,Inj secretin synthetic human,APC 1700,Per Unit,$34.78 ,OP,34.78,129.64,,,,,,
Health Alliance MCR ADV,CPT,J2860,Injection- siltuximab,APC 9455,Per Unit,$124.09 ,OP,124.09,124.09,,,,,,
Health Alliance MCR ADV,CPT,J2941,Somatropin injection,APC 9319,Per Unit,$36.54 ,OP,36.54,226.93,,,,,,
Health Alliance MCR ADV,CPT,J2993,Reteplase injection,APC 9005,Per Unit,"$2,506.51 ",OP,"2,506.51","4,712.48",,,,,,
Health Alliance MCR ADV,CPT,J2997,Alteplase recombinant,APC 7048,Per Unit,$87.75 ,OP,87.75,163.95,,,,,,
Health Alliance MCR ADV,CPT,J3031,Inj.- fremanezumab-vfrm 1 mg,APC 9197,Per Unit,$2.34 ,OP,2.34,2.34,,,,,,
Health Alliance MCR ADV,CPT,J3032,Inj. eptinezumab-jjmr 1 mg,APC 9357,Per Unit,$15.64 ,OP,15.64,15.64,,,,,,
Health Alliance MCR ADV,CPT,J3060,Inj- taliglucerase alfa 10 u,APC 9294,Per Unit,$41.32 ,OP,41.32,41.32,,,,,,
Health Alliance MCR ADV,CPT,J3090,Inj tedizolid phosphate,APC 1662,Per Unit,$1.60 ,OP,1.6,1.6,,,,,,
Health Alliance MCR ADV,CPT,J3095,Telavancin injection,APC 9258,Per Unit,$6.16 ,OP,6.16,6.16,,,,,,
Health Alliance MCR ADV,CPT,J3101,Tenecteplase injection,APC 9002,Per Unit,$134.74 ,OP,134.74,202.07,,,,,,
Health Alliance MCR ADV,CPT,J3111,Inj. romosozumab-aqqg 1 mg,APC 9327,Per Unit,$9.34 ,OP,9.34,9.34,,,,,,
Health Alliance MCR ADV,CPT,J3145,Testosterone undecanoate 1mg,APC 9078,Per Unit,$1.63 ,OP,1.63,1.63,,,,,,
Health Alliance MCR ADV,CPT,J3240,Thyrotropin injection,APC 9108,Per Unit,"$1,837.25 ",OP,"1,837.25","3,617.49",,,,,,
Health Alliance MCR ADV,CPT,J3241,Inj. teprotumumab-trbw 10 mg,APC 9355,Per Unit,$315.88 ,OP,315.88,315.88,,,,,,
Health Alliance MCR ADV,CPT,J3243,Tigecycline injection,APC 9228,Per Unit,$1.12 ,OP,1.12,3.82,,,,,,
Health Alliance MCR ADV,CPT,J3245,Inj.- tildrakizumab- 1 mg,APC 9306,Per Unit,$134.08 ,OP,134.08,134.08,,,,,,
Health Alliance MCR ADV,CPT,J3246,Tirofiban hcl,APC 7041,Per Unit,$3.83 ,OP,3.83,3.83,,,,,,
Health Alliance MCR ADV,CPT,J3262,Tocilizumab injection,APC 9264,Per Unit,$5.55 ,OP,5.55,5.55,,,,,,
Health Alliance MCR ADV,CPT,J3285,Treprostinil injection,APC 1701,Per Unit,$59.68 ,OP,59.68,238.44,,,,,,
Health Alliance MCR ADV,CPT,J3304,Inj triamcinolone ace xr 1mg,APC 9469,Per Unit,$17.75 ,OP,17.75,17.75,,,,,,
Health Alliance MCR ADV,CPT,J3315,Triptorelin pamoate,APC 9122,Per Unit,$379.90 ,OP,379.9,379.9,,,,,,
Health Alliance MCR ADV,CPT,J3316,Inj.- triptorelin xr 3.75 mg,APC 9016,Per Unit,"$3,120.11 ",OP,"3,120.11","3,120.11",,,,,,
Health Alliance MCR ADV,CPT,J3357,Ustekinumab sub cu inj- 1 mg,APC 9261,Per Unit,$176.65 ,OP,176.65,176.65,,,,,,
Health Alliance MCR ADV,CPT,J3358,Ustekinumab- iv inject- 1 mg,APC 9487,Per Unit,$11.68 ,OP,11.68,11.68,,,,,,
Health Alliance MCR ADV,CPT,J3380,Injection- vedolizumab,APC 1489,Per Unit,$21.28 ,OP,21.28,21.28,,,,,,
Health Alliance MCR ADV,CPT,J3385,Velaglucerase alfa,APC 9271,Per Unit,$359.29 ,OP,359.29,359.29,,,,,,
Health Alliance MCR ADV,CPT,J3396,Verteporfin injection,APC 1203,Per Unit,$11.25 ,OP,11.25,37.64,,,,,,
Health Alliance MCR ADV,CPT,J3398,Inj luxturna 1 billion vec g,APC 9070,Per Unit,"$2,953.71 ",OP,"2,953.71","2,953.71",,,,,,
Health Alliance MCR ADV,CPT,J7168,Prothrombin complex kcentra,APC 9132,Per Unit,$1.99 ,OP,1.99,1.99,,,,,,
Health Alliance MCR ADV,CPT,J7169,Inj andexxa- 10 mg,APC 9198,Per Unit,$289.93 ,OP,289.93,289.93,,,,,,
Health Alliance MCR ADV,CPT,J7170,Inj.- emicizumab-kxwh 0.5 mg,APC 9257,Per Unit,$48.88 ,OP,48.88,48.88,,,,,,
Health Alliance MCR ADV,CPT,J7175,Inj- factor x- (human)- 1iu,APC 1857,Per Unit,$8.20 ,OP,8.2,8.2,,,,,,
Health Alliance MCR ADV,CPT,J7178,Inj human fibrinogen con nos,APC 1478,Per Unit,$1.30 ,OP,1.3,1.3,,,,,,
Health Alliance MCR ADV,CPT,J7179,Vonvendi inj 1 iu vwf:rco,APC 9059,Per Unit,$1.85 ,OP,1.85,1.85,,,,,,
Health Alliance MCR ADV,CPT,J7180,Factor xiii anti-hem factor,APC 1416,Per Unit,$9.14 ,OP,9.14,9.14,,,,,,
Health Alliance MCR ADV,CPT,J7181,Factor xiii recomb a-subunit,APC 1746,Per Unit,$15.87 ,OP,15.87,15.87,,,,,,
Health Alliance MCR ADV,CPT,J7182,Factor viii recomb novoeight,APC 1856,Per Unit,$1.51 ,OP,1.51,1.51,,,,,,
Health Alliance MCR ADV,CPT,J7183,Wilate injection,APC 1352,Per Unit,$1.16 ,OP,1.16,1.16,,,,,,
Health Alliance MCR ADV,CPT,J7185,Xyntha inj,APC 1268,Per Unit,$1.33 ,OP,1.33,1.33,,,,,,
Health Alliance MCR ADV,CPT,J7186,Antihemophilic viii/vwf comp,APC 1213,Per Unit,$1.14 ,OP,1.14,3.82,,,,,,
Health Alliance MCR ADV,CPT,J7187,Humate-p- inj,APC 1704,Per Unit,$1.26 ,OP,1.26,2.98,,,,,,
Health Alliance MCR ADV,CPT,J7188,Factor viii recomb obizur,APC 1827,Per Unit,$3.19 ,OP,3.19,3.19,,,,,,
Health Alliance MCR ADV,CPT,J7189,Factor viia recomb novoseven,APC 1705,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Health Alliance MCR ADV,CPT,J7190,Factor viii,APC 0925,Per Unit,$1.12 ,OP,1.12,3.02,,,,,,
Health Alliance MCR ADV,CPT,J7192,Factor viii recombinant nos,APC 0927,Per Unit,$1.43 ,OP,1.43,3.85,,,,,,
Health Alliance MCR ADV,CPT,J7193,Factor ix non-recombinant,APC 0931,Per Unit,$1.17 ,OP,1.17,3.36,,,,,,
Health Alliance MCR ADV,CPT,J7194,Factor ix complex,APC 0928,Per Unit,$1.54 ,OP,1.54,2.52,,,,,,
Health Alliance MCR ADV,CPT,J7195,Factor ix recombinant nos,APC 0932,Per Unit,$1.61 ,OP,1.61,3.57,,,,,,
Health Alliance MCR ADV,CPT,J7197,Antithrombin iii injection,APC 1263,Per Unit,$3.20 ,OP,3.2,10.61,,,,,,
Health Alliance MCR ADV,CPT,J7198,Anti-inhibitor,APC 0929,Per Unit,$2.21 ,OP,2.21,5.2,,,,,,
Health Alliance MCR ADV,CPT,J7200,Factor ix recombinan rixubis,APC 1467,Per Unit,$1.54 ,OP,1.54,1.54,,,,,,
Health Alliance MCR ADV,CPT,J7201,Factor ix alprolix recomb,APC 1486,Per Unit,$3.28 ,OP,3.28,3.28,,,,,,
Health Alliance MCR ADV,CPT,J7202,Factor ix idelvion inj,APC 9171,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Health Alliance MCR ADV,CPT,J7203,Factor ix recomb gly rebinyn,APC 9468,Per Unit,$4.23 ,OP,4.23,4.23,,,,,,
Health Alliance MCR ADV,CPT,J7204,Inj recombin esperoct per iu,APC 9354,Per Unit,$2.23 ,OP,2.23,2.23,,,,,,
Health Alliance MCR ADV,CPT,J7205,Factor viii fc fusion recomb,APC 1656,Per Unit,$2.15 ,OP,2.15,2.15,,,,,,
Health Alliance MCR ADV,CPT,J7207,Factor viii pegylated recomb,APC 1844,Per Unit,$1.92 ,OP,1.92,1.92,,,,,,
Health Alliance MCR ADV,CPT,J7208,Inj. jivi 1 iu,APC 9299,Per Unit,$2.10 ,OP,2.1,2.1,,,,,,
Health Alliance MCR ADV,CPT,J7209,Factor viii nuwiq recomb 1iu,APC 1846,Per Unit,$1.24 ,OP,1.24,1.24,,,,,,
Health Alliance MCR ADV,CPT,J7210,Inj- afstyla- 1 i.u.,APC 9043,Per Unit,$1.36 ,OP,1.36,1.36,,,,,,
Health Alliance MCR ADV,CPT,J7211,Inj- kovaltry- 1 i.u.,APC 9075,Per Unit,$1.24 ,OP,1.24,1.24,,,,,,
Health Alliance MCR ADV,CPT,J7212,Factor viia recomb sevenfact,APC 9395,Per Unit,$2.27 ,OP,2.27,2.27,,,,,,
Health Alliance MCR ADV,CPT,J7308,Aminolevulinic acid hcl top,APC 7308,Per Unit,$392.48 ,OP,392.48,392.48,,,,,,
Health Alliance MCR ADV,CPT,J7311,Inj.- retisert- 0.01 mg,APC 9225,Per Unit,$339.00 ,OP,339,"93,937.12",,,,,,
Health Alliance MCR ADV,CPT,J7312,Dexamethasone intra implant,APC 9256,Per Unit,$199.69 ,OP,199.69,199.69,,,,,,
Health Alliance MCR ADV,CPT,J7313,Inj.- iluvien- 0.01 mg,APC 9450,Per Unit,$490.95 ,OP,490.95,490.95,,,,,,
Health Alliance MCR ADV,CPT,J7314,Inj.- yutiq- 0.01 mg,APC 9328,Per Unit,$513.16 ,OP,513.16,513.16,,,,,,
Health Alliance MCR ADV,CPT,J7316,Inj- ocriplasmin- 0.125 mg,APC 9298,Per Unit,"$1,046.93 ",OP,"1,046.93","1,046.93",,,,,,
Health Alliance MCR ADV,CPT,J7318,Inj- durolane 1 mg,APC 9174,Per Unit,$17.23 ,OP,17.23,17.23,,,,,,
Health Alliance MCR ADV,CPT,J7320,Genvisc 850- inj- 1mg,APC 9079,Per Unit,$16.92 ,OP,16.92,16.92,,,,,,
Health Alliance MCR ADV,CPT,J7322,Hymovis injection 1 mg,APC 9471,Per Unit,$31.67 ,OP,31.67,903.6,,,,,,
Health Alliance MCR ADV,CPT,J7323,Euflexxa inj per dose,APC 0875,Per Unit,$138.82 ,OP,138.82,590.67,,,,,,
Health Alliance MCR ADV,CPT,J7324,Orthovisc inj per dose,APC 0877,Per Unit,$148.74 ,OP,148.74,880.74,,,,,,
Health Alliance MCR ADV,CPT,J7325,Synvisc or synvisc-one,APC 0874,Per Unit,$11.24 ,OP,11.24,11.24,,,,,,
Health Alliance MCR ADV,CPT,J7326,Gel-one,APC 1417,Per Unit,"$1,219.00 ",OP,"1,219.00","1,219.00",,,,,,
Health Alliance MCR ADV,CPT,J7327,Monovisc inj per dose,APC 1747,Per Unit,$762.80 ,OP,762.8,762.8,,,,,,
Health Alliance MCR ADV,CPT,J7328,Gelsyn-3 injection 0.1 mg,APC 1862,Per Unit,$2.18 ,OP,2.18,2.18,,,,,,
Health Alliance MCR ADV,CPT,J7329,Inj- trivisc 1 mg,APC 9196,Per Unit,$19.12 ,OP,19.12,19.12,,,,,,
Health Alliance MCR ADV,CPT,J7331,Synojoynt- inj.- 1 mg,APC 9337,Per Unit,$18.02 ,OP,18.02,18.02,,,,,,
Health Alliance MCR ADV,CPT,J7336,Capsaicin 8% patch,APC 9071,Per Unit,$3.23 ,OP,3.23,3.23,,,,,,
Health Alliance MCR ADV,CPT,J7340,Carbidopa levodopa ent 100ml,APC 9320,Per Unit,$211.70 ,OP,211.7,211.7,,,,,,
Health Alliance MCR ADV,CPT,J7342,Ciprofloxacin otic susp 6 mg,APC 9479,Per Unit,$29.98 ,OP,29.98,29.98,,,,,,
Health Alliance MCR ADV,CPT,J7345,Aminolevulinic acid- 10% gel,APC 9301,Per Unit,$1.59 ,OP,1.59,1.59,,,,,,
Health Alliance MCR ADV,CPT,J7351,Inj bimatoprost itc imp1mcg,APC 9351,Per Unit,$205.63 ,OP,205.63,205.63,,,,,,
Health Alliance MCR ADV,CPT,J7352,Afamelanotide implant- 1 mg,APC 9396,Per Unit,"$3,218.90 ",OP,"3,218.90","3,218.90",,,,,,
Health Alliance MCR ADV,CPT,J7402,Mometasone sinus sinuva,APC 9346,Per Unit,$10.56 ,OP,10.56,10.56,,,,,,
Health Alliance MCR ADV,CPT,J7501,Azathioprine parenteral,APC 0887,Per Unit,$245.02 ,OP,245.02,442.27,,,,,,
Health Alliance MCR ADV,CPT,J7504,Lymphocyte immune globulin,APC 0890,Per Unit,"$2,355.53 ",OP,"2,245.67","2,355.53",,,,,,
Health Alliance MCR ADV,CPT,J7511,Antithymocyte globuln rabbit,APC 9104,Per Unit,$837.42 ,OP,837.42,"1,807.23",,,,,,
Health Alliance MCR ADV,CPT,J7525,Tacrolimus injection,APC 9006,Per Unit,$219.33 ,OP,219.33,540.46,,,,,,
Health Alliance MCR ADV,CPT,J8560,Etoposide oral 50 mg,APC 0802,Per Unit,$75.63 ,OP,75.63,75.63,,,,,,
Health Alliance MCR ADV,CPT,J8655,Oral netupitant- palonosetro,APC 9448,Per Unit,$315.59 ,OP,315.59,315.59,,,,,,
Health Alliance MCR ADV,CPT,J8670,Rolapitant- oral- 1mg,APC 1761,Per Unit,$1.75 ,OP,1.75,1.75,,,,,,
Health Alliance MCR ADV,CPT,J9015,Aldesleukin injection,APC 0807,Per Unit,"$3,795.26 ",OP,"3,795.26","3,795.26",,,,,,
Health Alliance MCR ADV,CPT,J9017,Arsenic trioxide injection,APC 9012,Per Unit,$13.11 ,OP,13.11,179.2,,,,,,
Health Alliance MCR ADV,CPT,J9019,Erwinaze injection,APC 9289,Per Unit,$427.27 ,OP,427.27,427.27,,,,,,
Health Alliance MCR ADV,CPT,J9022,Inj- atezolizumab-10 mg,APC 9483,Per Unit,$79.75 ,OP,79.75,79.75,,,,,,
Health Alliance MCR ADV,CPT,J9023,Injection- avelumab- 10 mg,APC 9491,Per Unit,$86.19 ,OP,86.19,86.19,,,,,,
Health Alliance MCR ADV,CPT,J9025,Azacitidine injection,APC 1709,Per Unit,$0.93 ,OP,0.93,22.88,,,,,,
Health Alliance MCR ADV,CPT,J9027,Clofarabine injection,APC 1710,Per Unit,$53.15 ,OP,53.15,564.29,,,,,,
Health Alliance MCR ADV,CPT,J9032,Injection- belinostat- 10mg,APC 1658,Per Unit,$42.77 ,OP,42.77,42.77,,,,,,
Health Alliance MCR ADV,CPT,J9033,Inj.- treanda 1 mg,APC 9243,Per Unit,$22.01 ,OP,22.01,91.51,,,,,,
Health Alliance MCR ADV,CPT,J9034,Inj.- bendeka 1 mg,APC 1861,Per Unit,$19.65 ,OP,19.65,19.65,,,,,,
Health Alliance MCR ADV,CPT,J9035,Bevacizumab injection,APC 9214,Per Unit,$70.41 ,OP,70.41,278.32,,,,,,
Health Alliance MCR ADV,CPT,J9036,Inj. belrapzo/bendamustine,APC 9313,Per Unit,$21.47 ,OP,21.47,21.47,,,,,,
Health Alliance MCR ADV,CPT,J9037,Inj belantamab mafodont blmf,APC 9384,Per Unit,$42.78 ,OP,42.78,42.78,,,,,,
Health Alliance MCR ADV,CPT,J9039,Injection- blinatumomab,APC 9449,Per Unit,$123.88 ,OP,123.88,123.88,,,,,,
Health Alliance MCR ADV,CPT,J9041,Inj.- velcade 0.1 mg,APC 9207,Per Unit,$45.16 ,OP,45.16,175.39,,,,,,
Health Alliance MCR ADV,CPT,J9042,Brentuximab vedotin inj,APC 9287,Per Unit,$189.34 ,OP,189.34,189.34,,,,,,
Health Alliance MCR ADV,CPT,J9043,Cabazitaxel injection,APC 9276,Per Unit,$189.00 ,OP,189,189,,,,,,
Health Alliance MCR ADV,CPT,J9044,Inj- bortezomib- nos- 0.1 mg,APC 9192,Per Unit,$18.31 ,OP,18.31,18.31,,,,,,
Health Alliance MCR ADV,CPT,J9047,Injection- carfilzomib- 1 mg,APC 9295,Per Unit,$41.10 ,OP,41.1,41.1,,,,,,
Health Alliance MCR ADV,CPT,J9050,Carmustine injection,APC 0812,Per Unit,"$1,234.46 ",OP,"1,234.46","1,234.46",,,,,,
Health Alliance MCR ADV,CPT,J9055,Cetuximab injection,APC 9215,Per Unit,$66.71 ,OP,66.71,240.2,,,,,,
Health Alliance MCR ADV,CPT,J9057,Inj.- copanlisib- 1 mg,APC 9030,Per Unit,$80.96 ,OP,80.96,80.96,,,,,,
Health Alliance MCR ADV,CPT,J9065,Inj cladribine per 1 mg,APC 0858,Per Unit,$18.02 ,OP,18.02,144.88,,,,,,
Health Alliance MCR ADV,CPT,J9070,Cyclophosphamide 100 mg inj,APC 1408,Per Unit,$29.15 ,OP,19.07,29.15,,,,,,
Health Alliance MCR ADV,CPT,J9119,Inj.- cemiplimab-rwlc- 1 mg,APC 9304,Per Unit,$27.54 ,OP,27.54,27.54,,,,,,
Health Alliance MCR ADV,CPT,J9120,Dactinomycin injection,APC 0752,Per Unit,$890.64 ,OP,890.64,"2,634.57",,,,,,
Health Alliance MCR ADV,CPT,J9144,Daratumumab- hyaluronidase,APC 9378,Per Unit,$45.10 ,OP,45.1,45.1,,,,,,
Health Alliance MCR ADV,CPT,J9145,Injection- daratumumab 10 mg,APC 9476,Per Unit,$57.55 ,OP,57.55,57.55,,,,,,
Health Alliance MCR ADV,CPT,J9150,Daunorubicin injection,APC 0820,Per Unit,$40.36 ,OP,40.36,80.07,,,,,,
Health Alliance MCR ADV,CPT,J9153,Inj daunorubicin- cytarabine,APC 9302,Per Unit,$202.60 ,OP,202.6,202.6,,,,,,
Health Alliance MCR ADV,CPT,J9155,Degarelix injection,APC 1296,Per Unit,$4.12 ,OP,4.12,4.12,,,,,,
Health Alliance MCR ADV,CPT,J9173,Inj.- durvalumab- 10 mg,APC 9492,Per Unit,$76.86 ,OP,76.86,76.86,,,,,,
Health Alliance MCR ADV,CPT,J9176,Injection- elotuzumab- 1mg,APC 9477,Per Unit,$6.77 ,OP,6.77,6.77,,,,,,
Health Alliance MCR ADV,CPT,J9177,Inj enfort vedo-ejfv 0.25mg,APC 9364,Per Unit,$30.17 ,OP,30.17,30.17,,,,,,
Health Alliance MCR ADV,CPT,J9179,Eribulin mesylate injection,APC 1426,Per Unit,$123.93 ,OP,123.93,123.93,,,,,,
Health Alliance MCR ADV,CPT,J9198,Inj. infugem- 100 mg,APC 9387,Per Unit,$34.00 ,OP,34,34,,,,,,
Health Alliance MCR ADV,CPT,J9202,Goserelin acetate implant,APC 0810,Per Unit,$525.21 ,OP,525.21,915.04,,,,,,
Health Alliance MCR ADV,CPT,J9203,Gemtuzumab ozogamicin 0.1 mg,APC 9495,Per Unit,$207.99 ,OP,207.99,207.99,,,,,,
Health Alliance MCR ADV,CPT,J9204,Inj mogamulizumab-kpkc- 1 mg,APC 9182,Per Unit,$210.05 ,OP,210.05,210.05,,,,,,
Health Alliance MCR ADV,CPT,J9205,Inj irinotecan liposome 1 mg,APC 9474,Per Unit,$57.20 ,OP,57.2,57.2,,,,,,
Health Alliance MCR ADV,CPT,J9207,Ixabepilone injection,APC 9240,Per Unit,$112.12 ,OP,112.12,308.83,,,,,,
Health Alliance MCR ADV,CPT,J9210,Inj.- emapalumab-lzsg- 1 mg,APC 9310,Per Unit,$376.03 ,OP,376.03,376.03,,,,,,
Health Alliance MCR ADV,CPT,J9214,Interferon alfa-2b inj,APC 0836,Per Unit,$33.24 ,OP,33.24,72.44,,,,,,
Health Alliance MCR ADV,CPT,J9217,Leuprolide acetate suspnsion,APC 9217,Per Unit,$139.09 ,OP,139.09,987.49,,,,,,
Health Alliance MCR ADV,CPT,J9223,Inj. lurbinectedin- 0.1 mg,APC 9389,Per Unit,$174.03 ,OP,174.03,174.03,,,,,,
Health Alliance MCR ADV,CPT,J9225,Vantas implant,APC 1711,Per Unit,"$5,166.29 ",OP,"5,166.29","7,613.94",,,,,,
Health Alliance MCR ADV,CPT,J9226,Supprelin la implant,APC 1142,Per Unit,"$43,467.03 ",OP,"43,467.03","71,949.32",,,,,,
Health Alliance MCR ADV,CPT,J9227,Inj. isatuximab-irfc 10 mg,APC 9377,Per Unit,$67.60 ,OP,67.6,67.6,,,,,,
Health Alliance MCR ADV,CPT,J9228,Ipilimumab injection,APC 9284,Per Unit,$158.65 ,OP,158.65,158.65,,,,,,
Health Alliance MCR ADV,CPT,J9229,Inj inotuzumab ozogam 0.1 mg,APC 9028,Per Unit,"$2,371.62 ",OP,"2,371.62","2,371.62",,,,,,
Health Alliance MCR ADV,CPT,J9230,Mechlorethamine hcl inj,APC 0751,Per Unit,$11.74 ,OP,11.74,712.98,,,,,,
Health Alliance MCR ADV,CPT,J9245,Inj melpha hydroch nos 50 mg,APC 0840,Per Unit,$208.41 ,OP,208.41,"7,888.46",,,,,,
Health Alliance MCR ADV,CPT,J9246,Inj.- evomela- 1 mg,APC 9375,Per Unit,$18.20 ,OP,18.2,18.2,,,,,,
Health Alliance MCR ADV,CPT,J9247,Inj- melphalan flufenami 1mg,APC 9417,Per Unit,$499.86 ,OP,499.86,499.86,,,,,,
Health Alliance MCR ADV,CPT,J9261,Nelarabine injection,APC 0825,Per Unit,$155.90 ,OP,155.9,488.04,,,,,,
Health Alliance MCR ADV,CPT,J9262,Inj- omacetaxine mep- 0.01mg,APC 9297,Per Unit,$3.30 ,OP,3.3,3.3,,,,,,
Health Alliance MCR ADV,CPT,J9264,Paclitaxel protein bound,APC 1712,Per Unit,$14.08 ,OP,14.08,45.74,,,,,,
Health Alliance MCR ADV,CPT,J9266,Pegaspargase injection,APC 0843,Per Unit,"$21,561.05 ",OP,"12,715.34","21,561.05",,,,,,
Health Alliance MCR ADV,CPT,J9268,Pentostatin injection,APC 0844,Per Unit,"$1,880.67 ",OP,"1,880.67","7,030.61",,,,,,
Health Alliance MCR ADV,CPT,J9269,Inj. tagraxofusp-erzs 10 mcg,APC 9309,Per Unit,$290.37 ,OP,290.37,290.37,,,,,,
Health Alliance MCR ADV,CPT,J9270,Plicamycin (mithramycin) inj,APC 9093,Per Unit,$115.40 ,OP,115.4,385.09,,,,,,
Health Alliance MCR ADV,CPT,J9271,Inj pembrolizumab,APC 1490,Per Unit,$52.75 ,OP,52.75,52.75,,,,,,
Health Alliance MCR ADV,CPT,J9280,Mitomycin injection,APC 1232,Per Unit,$38.63 ,OP,38.63,76.26,,,,,,
Health Alliance MCR ADV,CPT,J9281,Mitomycin instillation,APC 9374,Per Unit,$281.88 ,OP,281.88,281.88,,,,,,
Health Alliance MCR ADV,CPT,J9285,Inj- olaratumab- 10 mg,APC 9485,Per Unit,$52.07 ,OP,52.07,52.07,,,,,,
Health Alliance MCR ADV,CPT,J9293,Mitoxantrone hydrochl / 5 mg,APC 0864,Per Unit,$26.29 ,OP,26.29,392.7,,,,,,
Health Alliance MCR ADV,CPT,J9295,Injection- necitumumab- 1 mg,APC 9475,Per Unit,$5.74 ,OP,5.74,5.74,,,,,,
Health Alliance MCR ADV,CPT,J9299,Injection- nivolumab,APC 9453,Per Unit,$28.86 ,OP,28.86,28.86,,,,,,
Health Alliance MCR ADV,CPT,J9301,Obinutuzumab inj,APC 1476,Per Unit,$64.54 ,OP,64.54,64.54,,,,,,
Health Alliance MCR ADV,CPT,J9302,Ofatumumab injection,APC 9260,Per Unit,$63.96 ,OP,63.96,63.96,,,,,,
Health Alliance MCR ADV,CPT,J9303,Panitumumab injection,APC 9235,Per Unit,$130.38 ,OP,130.38,130.38,,,,,,
Health Alliance MCR ADV,CPT,J9305,Inj. pemetrexed nos 10mg,APC 9213,Per Unit,$74.93 ,OP,74.93,232.58,,,,,,
Health Alliance MCR ADV,CPT,J9306,Injection- pertuzumab- 1 mg,APC 1471,Per Unit,$13.56 ,OP,13.56,13.56,,,,,,
Health Alliance MCR ADV,CPT,J9307,Pralatrexate injection,APC 9259,Per Unit,$314.84 ,OP,314.84,314.84,,,,,,
Health Alliance MCR ADV,CPT,J9308,Injection- ramucirumab,APC 1488,Per Unit,$62.69 ,OP,62.69,62.69,,,,,,
Health Alliance MCR ADV,CPT,J9309,Inj- polatuzumab vedotin 1mg,APC 9331,Per Unit,$113.57 ,OP,113.57,113.57,,,,,,
Health Alliance MCR ADV,CPT,J9311,Inj rituximab- hyaluronidase,APC 9467,Per Unit,$37.94 ,OP,37.94,37.94,,,,,,
Health Alliance MCR ADV,CPT,J9312,Inj.- rituximab- 10 mg,APC 9186,Per Unit,$86.94 ,OP,86.94,86.94,,,,,,
Health Alliance MCR ADV,CPT,J9313,Inj.- lumoxiti- 0.01 mg,APC 9305,Per Unit,$23.39 ,OP,23.39,23.39,,,,,,
Health Alliance MCR ADV,CPT,J9316,Pertuzu- trastuzu- 10 mg,APC 9390,Per Unit,$72.15 ,OP,72.15,72.15,,,,,,
Health Alliance MCR ADV,CPT,J9317,Sacituzumab govitecan-hziy,APC 9376,Per Unit,$30.35 ,OP,30.35,30.35,,,,,,
Health Alliance MCR ADV,CPT,J9318,Inj romidepsin non-lyo 0.1mg,APC 9428,Per Unit,$33.91 ,OP,33.91,33.91,,,,,,
Health Alliance MCR ADV,CPT,J9319,Inj romidepsin lyophil 0.1mg,APC 9429,Per Unit,$33.68 ,OP,33.68,33.68,,,,,,
Health Alliance MCR ADV,CPT,J9320,Streptozocin injection,APC 0850,Per Unit,$348.51 ,OP,348.51,"1,372.57",,,,,,
Health Alliance MCR ADV,CPT,J9325,Inj talimogene laherparepvec,APC 9472,Per Unit,$57.26 ,OP,57.26,57.26,,,,,,
Health Alliance MCR ADV,CPT,J9328,Temozolomide injection,APC 9253,Per Unit,$10.41 ,OP,10.41,10.41,,,,,,
Health Alliance MCR ADV,CPT,J9330,Temsirolimus injection,APC 1168,Per Unit,$38.25 ,OP,38.25,38.25,,,,,,
Health Alliance MCR ADV,CPT,J9340,Thiotepa injection,APC 0851,Per Unit,$305.84 ,OP,305.84,446.08,,,,,,
Health Alliance MCR ADV,CPT,J9348,Inj. naxitamab-gqgk- 1 mg,APC 9408,Per Unit,$539.07 ,OP,539.07,539.07,,,,,,
Health Alliance MCR ADV,CPT,J9349,Inj.- tafasitamab-cxix,APC 9385,Per Unit,$12.62 ,OP,12.62,12.62,,,,,,
Health Alliance MCR ADV,CPT,J9352,Injection trabectedin 0.1mg,APC 9480,Per Unit,$325.03 ,OP,325.03,325.03,,,,,,
Health Alliance MCR ADV,CPT,J9353,Inj. margetuximab-cmkb- 5 mg,APC 9418,Per Unit,$42.99 ,OP,42.99,42.99,,,,,,
Health Alliance MCR ADV,CPT,J9354,Inj- ado-trastuzumab emt 1mg,APC 9131,Per Unit,$34.18 ,OP,34.18,34.18,,,,,,
Health Alliance MCR ADV,CPT,J9355,Inj trastuzumab excl biosimi,APC 1613,Per Unit,$89.81 ,OP,89.81,238.1,,,,,,
Health Alliance MCR ADV,CPT,J9356,Inj. herceptin hylecta- 10mg,APC 9314,Per Unit,$71.85 ,OP,71.85,71.85,,,,,,
Health Alliance MCR ADV,CPT,J9357,Valrubicin injection,APC 1235,Per Unit,"$1,425.37 ",OP,"1,425.37","1,795.78",,,,,,
Health Alliance MCR ADV,CPT,J9358,Inj fam-trastu deru-nxki 1mg,APC 9353,Per Unit,$24.27 ,OP,24.27,24.27,,,,,,
Health Alliance MCR ADV,CPT,J9371,Inj- vincristine sul lip 1mg,APC 1466,Per Unit,"$3,370.23 ",OP,28.22,"3,370.23",,,,,,
Health Alliance MCR ADV,CPT,J9395,Injection- fulvestrant,APC 9120,Per Unit,$15.98 ,OP,15.98,396.52,,,,,,
Health Alliance MCR ADV,CPT,J9400,Inj- ziv-aflibercept- 1mg,APC 9296,Per Unit,$8.42 ,OP,8.42,8.42,,,,,,
Health Alliance MCR ADV,CPT,J9600,Porfimer sodium injection,APC 0856,Per Unit,"$21,856.35 ",OP,"13,169.04","21,856.35",,,,,,
Health Alliance MCR ADV,CPT,K0672,Removable soft interface le,Durable Medical Equipment,Per Unit,$85.14 ,OP,85.14,85.14,,,,,,
Health Alliance MCR ADV,CPT,L0112,Cranial cervical orthosis,Durable Medical Equipment,Per Unit,"$1,404.96 ",OP,"1,404.96","4,830.68",,,,,,
Health Alliance MCR ADV,CPT,L0113,Cranial cervical torticollis,Durable Medical Equipment,Per Unit,$286.27 ,OP,286.27,286.27,,,,,,
Health Alliance MCR ADV,CPT,L0120,Cerv flex n/adj foam pre ots,Durable Medical Equipment,Per Unit,$26.55 ,OP,26.55,91.51,,,,,,
Health Alliance MCR ADV,CPT,L0130,Flex thermoplastic collar mo,Durable Medical Equipment,Per Unit,$153.23 ,OP,153.23,526.16,,,,,,
Health Alliance MCR ADV,CPT,L0140,Cervical semi-rigid adjustab,Durable Medical Equipment,Per Unit,$60.09 ,OP,60.09,205.88,,,,,,
Health Alliance MCR ADV,CPT,L0150,Cerv semi-rig adj molded chn,Durable Medical Equipment,Per Unit,$107.45 ,OP,107.45,369.83,,,,,,
Health Alliance MCR ADV,CPT,L0160,Cerv sr wire occ/man pre ots,Durable Medical Equipment,Per Unit,$156.89 ,OP,156.89,541.4,,,,,,
Health Alliance MCR ADV,CPT,L0170,Cervical collar molded to pt,Durable Medical Equipment,Per Unit,$807.10 ,OP,807.1,"2,775.65",,,,,,
Health Alliance MCR ADV,CPT,L0172,Cerv col sr foam 2pc pre ots,Durable Medical Equipment,Per Unit,$142.17 ,OP,142.17,488.04,,,,,,
Health Alliance MCR ADV,CPT,L0174,Cerv sr 2pc thor ext pre ots,Durable Medical Equipment,Per Unit,$279.55 ,OP,279.55,960.8,,,,,,
Health Alliance MCR ADV,CPT,L0180,Cer post col occ/man sup adj,Durable Medical Equipment,Per Unit,$452.88 ,OP,452.88,"1,559.39",,,,,,
Health Alliance MCR ADV,CPT,L0190,Cerv collar supp adj cerv ba,Durable Medical Equipment,Per Unit,$534.12 ,OP,534.12,"1,837.71",,,,,,
Health Alliance MCR ADV,CPT,L0200,Cerv col supp adj bar & thor,Durable Medical Equipment,Per Unit,$619.54 ,OP,619.54,"2,131.30",,,,,,
Health Alliance MCR ADV,CPT,L0220,Thor rib belt custom fabrica,Durable Medical Equipment,Per Unit,$129.68 ,OP,129.68,446.08,,,,,,
Health Alliance MCR ADV,CPT,L0450,Tlso flex trunk/thor pre ots,Durable Medical Equipment,Per Unit,$128.11 ,OP,128.11,560.47,,,,,,
Health Alliance MCR ADV,CPT,L0454,Tlso trnk sj-t9 pre cst,Durable Medical Equipment,Per Unit,$348.14 ,OP,348.14,"1,197.20",,,,,,
Health Alliance MCR ADV,CPT,L0455,Tlso flex trnk sj-t9 pre ots,Durable Medical Equipment,Per Unit,$249.16 ,OP,249.16,249.16,,,,,,
Health Alliance MCR ADV,CPT,L0456,Tlso flex trnk sj-ss pre cst,Durable Medical Equipment,Per Unit,$998.38 ,OP,998.38,"3,435.25",,,,,,
Health Alliance MCR ADV,CPT,L0457,Tlso flex trnk sj-ss pre ots,Durable Medical Equipment,Per Unit,$714.52 ,OP,714.52,714.52,,,,,,
Health Alliance MCR ADV,CPT,L0458,Tlso 2mod symphis-xipho pre,Durable Medical Equipment,Per Unit,$895.27 ,OP,895.27,"3,080.66",,,,,,
Health Alliance MCR ADV,CPT,L0460,Tlso 2 shl symphys-stern cst,Durable Medical Equipment,Per Unit,"$1,007.68 ",OP,"1,007.68","3,465.73",,,,,,
Health Alliance MCR ADV,CPT,L0462,Tlso 3mod sacro-scap pre,Durable Medical Equipment,Per Unit,"$1,253.37 ",OP,"1,253.37","4,312.16",,,,,,
Health Alliance MCR ADV,CPT,L0464,Tlso 4mod sacro-scap pre,Durable Medical Equipment,Per Unit,"$1,492.13 ",OP,"1,492.13","5,131.88",,,,,,
Health Alliance MCR ADV,CPT,L0466,Tlso r fram soft ant pre cst,Durable Medical Equipment,Per Unit,$380.86 ,OP,380.86,"1,311.56",,,,,,
Health Alliance MCR ADV,CPT,L0467,Tlso r fram soft pre ots,Durable Medical Equipment,Per Unit,$277.04 ,OP,277.04,277.04,,,,,,
Health Alliance MCR ADV,CPT,L0468,Tlso rig fram pelvic pre cst,Durable Medical Equipment,Per Unit,$477.29 ,OP,477.29,"1,643.28",,,,,,
Health Alliance MCR ADV,CPT,L0469,Tlso rig fram pelvic pre ots,Durable Medical Equipment,Per Unit,$351.00 ,OP,351,351,,,,,,
Health Alliance MCR ADV,CPT,L0470,Tlso rigid frame pre subclav,Durable Medical Equipment,Per Unit,$660.47 ,OP,660.47,"2,272.36",,,,,,
Health Alliance MCR ADV,CPT,L0472,Tlso rigid frame hyperex pre,Durable Medical Equipment,Per Unit,$406.41 ,OP,406.41,"1,399.26",,,,,,
Health Alliance MCR ADV,CPT,L0480,Tlso rigid plastic custom fa,Durable Medical Equipment,Per Unit,"$1,516.23 ",OP,"1,516.23","5,215.77",,,,,,
Health Alliance MCR ADV,CPT,L0482,Tlso rigid lined custom fab,Durable Medical Equipment,Per Unit,"$1,693.64 ",OP,"1,693.64","5,825.80",,,,,,
Health Alliance MCR ADV,CPT,L0484,Tlso rigid plastic cust fab,Durable Medical Equipment,Per Unit,"$1,829.06 ",OP,"1,829.06","6,290.94",,,,,,
Health Alliance MCR ADV,CPT,L0486,Tlso rigidlined cust fab two,Durable Medical Equipment,Per Unit,"$2,054.11 ",OP,"2,054.11","7,064.92",,,,,,
Health Alliance MCR ADV,CPT,L0488,Tlso rigid lined pre one pie,Durable Medical Equipment,Per Unit,"$1,007.68 ",OP,"1,007.68","3,465.73",,,,,,
Health Alliance MCR ADV,CPT,L0490,Tlso rigid plastic pre one,Durable Medical Equipment,Per Unit,$283.96 ,OP,283.96,976.05,,,,,,
Health Alliance MCR ADV,CPT,L0491,Tlso 2 piece rigid shell,Durable Medical Equipment,Per Unit,$770.93 ,OP,770.93,"2,649.83",,,,,,
Health Alliance MCR ADV,CPT,L0492,Tlso 3 piece rigid shell,Durable Medical Equipment,Per Unit,$502.01 ,OP,502.01,"1,727.15",,,,,,
Health Alliance MCR ADV,CPT,L0621,Sio flex pelvic/sacr pre ots,Durable Medical Equipment,Per Unit,$67.68 ,OP,67.68,446.08,,,,,,
Health Alliance MCR ADV,CPT,L0622,Sio flex pelvisacral custom,Durable Medical Equipment,Per Unit,$268.31 ,OP,268.31,"1,384.01",,,,,,
Health Alliance MCR ADV,CPT,L0623,Sio rig pnl pelv/sac pre ots,Durable Medical Equipment,Per Unit,$126.95 ,OP,126.95,126.95,,,,,,
Health Alliance MCR ADV,CPT,L0625,Lo flex l1-below l5 pre ots,Durable Medical Equipment,Per Unit,$39.58 ,OP,39.58,285.96,,,,,,
Health Alliance MCR ADV,CPT,L0626,Lo sag rig pnl stays pre cst,Durable Medical Equipment,Per Unit,$78.25 ,OP,78.25,404.14,,,,,,
Health Alliance MCR ADV,CPT,L0627,Lo sag ri an/pos pnl pre cst,Durable Medical Equipment,Per Unit,$412.59 ,OP,412.59,"2,127.49",,,,,,
Health Alliance MCR ADV,CPT,L0628,Lso flex no ri stays pre ots,Durable Medical Equipment,Per Unit,$60.27 ,OP,60.27,434.65,,,,,,
Health Alliance MCR ADV,CPT,L0630,Lso r post pnl sj-t9 pre cst,Durable Medical Equipment,Per Unit,$162.59 ,OP,162.59,838.79,,,,,,
Health Alliance MCR ADV,CPT,L0631,Lso sag r an/pos pnl pre cst,Durable Medical Equipment,Per Unit,"$1,030.49 ",OP,"1,030.49","5,314.90",,,,,,
Health Alliance MCR ADV,CPT,L0633,Lso sc r pos/lat pnl pre cst,Durable Medical Equipment,Per Unit,$287.85 ,OP,287.85,"1,483.14",,,,,,
Health Alliance MCR ADV,CPT,L0635,Lso sagit rigid panel prefab,Durable Medical Equipment,Per Unit,"$1,003.05 ",OP,"1,003.05","5,173.83",,,,,,
Health Alliance MCR ADV,CPT,L0636,Lso sagittal rigid panel cus,Durable Medical Equipment,Per Unit,"$1,360.98 ",OP,"1,360.98","7,019.17",,,,,,
Health Alliance MCR ADV,CPT,L0637,Lso sc r ant/pos pnl pre cst,Durable Medical Equipment,Per Unit,"$1,300.47 ",OP,"1,300.47","6,710.34",,,,,,
Health Alliance MCR ADV,CPT,L0638,Lso sag-coronal panel custom,Durable Medical Equipment,Per Unit,"$1,323.97 ",OP,"1,323.97","6,828.54",,,,,,
Health Alliance MCR ADV,CPT,L0639,Lso s/c shell/panel prefab,Durable Medical Equipment,Per Unit,"$1,300.47 ",OP,"1,300.47","6,710.34",,,,,,
Health Alliance MCR ADV,CPT,L0640,Lso s/c shell/panel custom,Durable Medical Equipment,Per Unit,"$1,050.39 ",OP,"1,050.39","5,417.84",,,,,,
Health Alliance MCR ADV,CPT,L0641,Lo rig pos pnl l1-l5 pre ots,Durable Medical Equipment,Per Unit,$56.00 ,OP,56,56,,,,,,
Health Alliance MCR ADV,CPT,L0642,Lo sag ri an/pos pnl pre ots,Durable Medical Equipment,Per Unit,$295.35 ,OP,295.35,295.35,,,,,,
Health Alliance MCR ADV,CPT,L0643,Lso sag ctr rigi pos pre ots,Durable Medical Equipment,Per Unit,$116.37 ,OP,116.37,116.37,,,,,,
Health Alliance MCR ADV,CPT,L0648,Lso sag r an/pos pnl pre ots,Durable Medical Equipment,Per Unit,$737.61 ,OP,737.61,737.61,,,,,,
Health Alliance MCR ADV,CPT,L0649,Lso sc r pos/lat pnl pre ots,Durable Medical Equipment,Per Unit,$206.04 ,OP,206.04,206.04,,,,,,
Health Alliance MCR ADV,CPT,L0650,Lso sc r ant/pos pnl pre ots,Durable Medical Equipment,Per Unit,$880.49 ,OP,880.49,880.49,,,,,,
Health Alliance MCR ADV,CPT,L0651,Lso sag-co shell pnl pre ots,Durable Medical Equipment,Per Unit,$880.49 ,OP,880.49,880.49,,,,,,
Health Alliance MCR ADV,CPT,L0700,Ctlso a-p-l control molded,Durable Medical Equipment,Per Unit,"$1,998.37 ",OP,"1,998.37","6,874.29",,,,,,
Health Alliance MCR ADV,CPT,L0710,Ctlso a-p-l control w/ inter,Durable Medical Equipment,Per Unit,"$2,196.75 ",OP,"2,196.75","7,552.94",,,,,,
Health Alliance MCR ADV,CPT,L0810,Halo cervical into jckt vest,Durable Medical Equipment,Per Unit,"$2,683.14 ",OP,"2,683.14","9,226.72",,,,,,
Health Alliance MCR ADV,CPT,L0820,Halo cervical into body jack,Durable Medical Equipment,Per Unit,"$2,110.65 ",OP,"2,110.65","7,259.37",,,,,,
Health Alliance MCR ADV,CPT,L0830,Halo cerv into milwaukee typ,Durable Medical Equipment,Per Unit,"$3,229.60 ",OP,"3,229.60","11,106.37",,,,,,
Health Alliance MCR ADV,CPT,L0859,Mri compatible system,Durable Medical Equipment,Per Unit,"$1,143.45 ",OP,"1,143.45","3,930.89",,,,,,
Health Alliance MCR ADV,CPT,L0861,Halo repl liner/interface,Durable Medical Equipment,Per Unit,$216.37 ,OP,216.37,743.48,,,,,,
Health Alliance MCR ADV,CPT,L0970,Tlso corset front,Durable Medical Equipment,Per Unit,$107.27 ,OP,107.27,369.83,,,,,,
Health Alliance MCR ADV,CPT,L0972,Lso corset front,Durable Medical Equipment,Per Unit,$97.64 ,OP,97.64,335.53,,,,,,
Health Alliance MCR ADV,CPT,L0974,Tlso full corset,Durable Medical Equipment,Per Unit,$175.42 ,OP,175.42,602.41,,,,,,
Health Alliance MCR ADV,CPT,L0976,Lso full corset,Durable Medical Equipment,Per Unit,$150.09 ,OP,150.09,150.09,,,,,,
Health Alliance MCR ADV,CPT,L0978,Axillary crutch extension,Durable Medical Equipment,Per Unit,$188.90 ,OP,188.9,648.16,,,,,,
Health Alliance MCR ADV,CPT,L0980,Peroneal straps pair pre ots,Durable Medical Equipment,Per Unit,$17.15 ,OP,17.15,57.19,,,,,,
Health Alliance MCR ADV,CPT,L0982,Stocking sup grips 4 pre ots,Durable Medical Equipment,Per Unit,$15.70 ,OP,15.7,53.38,,,,,,
Health Alliance MCR ADV,CPT,L0984,Protect body sock ea pre ots,Durable Medical Equipment,Per Unit,$67.93 ,OP,67.93,232.58,,,,,,
Health Alliance MCR ADV,CPT,L1000,Ctlso milwauke initial model,Durable Medical Equipment,Per Unit,"$2,035.53 ",OP,"2,035.53","7,000.10",,,,,,
Health Alliance MCR ADV,CPT,L1005,Tension based scoliosis orth,Durable Medical Equipment,Per Unit,"$3,212.88 ",OP,"3,212.88","11,049.19",,,,,,
Health Alliance MCR ADV,CPT,L1010,Ctlso axilla sling,Durable Medical Equipment,Per Unit,$83.99 ,OP,83.99,289.76,,,,,,
Health Alliance MCR ADV,CPT,L1020,Kyphosis pad,Durable Medical Equipment,Per Unit,$108.17 ,OP,108.17,373.65,,,,,,
Health Alliance MCR ADV,CPT,L1025,Kyphosis pad floating,Durable Medical Equipment,Per Unit,$156.06 ,OP,156.06,537.6,,,,,,
Health Alliance MCR ADV,CPT,L1030,Lumbar bolster pad,Durable Medical Equipment,Per Unit,$78.60 ,OP,78.6,270.71,,,,,,
Health Alliance MCR ADV,CPT,L1040,Lumbar or lumbar rib pad,Durable Medical Equipment,Per Unit,$89.00 ,OP,89,305.01,,,,,,
Health Alliance MCR ADV,CPT,L1050,Sternal pad,Durable Medical Equipment,Per Unit,$100.72 ,OP,100.72,346.96,,,,,,
Health Alliance MCR ADV,CPT,L1060,Thoracic pad,Durable Medical Equipment,Per Unit,$108.72 ,OP,108.72,373.65,,,,,,
Health Alliance MCR ADV,CPT,L1070,Trapezius sling,Durable Medical Equipment,Per Unit,$112.62 ,OP,112.62,388.89,,,,,,
Health Alliance MCR ADV,CPT,L1080,Outrigger,Durable Medical Equipment,Per Unit,$52.52 ,OP,52.52,179.2,,,,,,
Health Alliance MCR ADV,CPT,L1085,Outrigger bil w/ vert extens,Durable Medical Equipment,Per Unit,$175.83 ,OP,175.83,606.21,,,,,,
Health Alliance MCR ADV,CPT,L1090,Lumbar sling,Durable Medical Equipment,Per Unit,$101.01 ,OP,101.01,346.96,,,,,,
Health Alliance MCR ADV,CPT,L1100,Ring flange plastic/leather,Durable Medical Equipment,Per Unit,$190.64 ,OP,190.64,655.78,,,,,,
Health Alliance MCR ADV,CPT,L1110,Ring flange plas/leather mol,Durable Medical Equipment,Per Unit,$319.63 ,OP,319.63,"1,098.07",,,,,,
Health Alliance MCR ADV,CPT,L1120,Covers for upright each,Durable Medical Equipment,Per Unit,$38.18 ,OP,38.18,129.64,,,,,,
Health Alliance MCR ADV,CPT,L1200,Furnsh initial orthosis only,Durable Medical Equipment,Per Unit,"$1,796.37 ",OP,"1,796.37","6,176.57",,,,,,
Health Alliance MCR ADV,CPT,L1210,Lateral thoracic extension,Durable Medical Equipment,Per Unit,$245.60 ,OP,245.6,846.41,,,,,,
Health Alliance MCR ADV,CPT,L1220,Anterior thoracic extension,Durable Medical Equipment,Per Unit,$239.05 ,OP,239.05,823.54,,,,,,
Health Alliance MCR ADV,CPT,L1230,Milwaukee type superstructur,Durable Medical Equipment,Per Unit,$669.67 ,OP,669.67,"2,302.87",,,,,,
Health Alliance MCR ADV,CPT,L1240,Lumbar derotation pad,Durable Medical Equipment,Per Unit,$91.29 ,OP,91.29,312.64,,,,,,
Health Alliance MCR ADV,CPT,L1250,Anterior asis pad,Durable Medical Equipment,Per Unit,$79.39 ,OP,79.39,274.51,,,,,,
Health Alliance MCR ADV,CPT,L1260,Anterior thoracic derotation,Durable Medical Equipment,Per Unit,$94.68 ,OP,94.68,324.09,,,,,,
Health Alliance MCR ADV,CPT,L1270,Abdominal pad,Durable Medical Equipment,Per Unit,$83.20 ,OP,83.2,285.96,,,,,,
Health Alliance MCR ADV,CPT,L1280,Rib gusset (elastic) each,Durable Medical Equipment,Per Unit,$87.71 ,OP,87.71,301.2,,,,,,
Health Alliance MCR ADV,CPT,L1290,Lateral trochanteric pad,Durable Medical Equipment,Per Unit,$78.00 ,OP,78,266.89,,,,,,
Health Alliance MCR ADV,CPT,L1300,Body jacket mold to patient,Durable Medical Equipment,Per Unit,"$1,730.06 ",OP,"1,730.06","5,951.62",,,,,,
Health Alliance MCR ADV,CPT,L1310,Post-operative body jacket,Durable Medical Equipment,Per Unit,"$1,802.00 ",OP,"1,802.00","6,195.63",,,,,,
Health Alliance MCR ADV,CPT,L1600,Ho flex frejka w/cov pre cst,Durable Medical Equipment,Per Unit,$129.35 ,OP,129.35,446.08,,,,,,
Health Alliance MCR ADV,CPT,L1610,Ho frejka cov only pre cst,Durable Medical Equipment,Per Unit,$54.94 ,OP,54.94,190.64,,,,,,
Health Alliance MCR ADV,CPT,L1620,Ho flex pavlik harns pre cst,Durable Medical Equipment,Per Unit,$157.73 ,OP,157.73,541.4,,,,,,
Health Alliance MCR ADV,CPT,L1630,Abduct control hip semi-flex,Durable Medical Equipment,Per Unit,$212.06 ,OP,212.06,728.23,,,,,,
Health Alliance MCR ADV,CPT,L1640,Pelv band/spread bar thigh c,Durable Medical Equipment,Per Unit,$475.20 ,OP,475.2,"1,635.64",,,,,,
Health Alliance MCR ADV,CPT,L1650,Ho abduction hip adjustable,Durable Medical Equipment,Per Unit,$247.55 ,OP,247.55,850.23,,,,,,
Health Alliance MCR ADV,CPT,L1652,Ho bi thighcuffs w sprdr bar,Durable Medical Equipment,Per Unit,$357.83 ,OP,357.83,"1,231.50",,,,,,
Health Alliance MCR ADV,CPT,L1660,Ho abduction static plastic,Durable Medical Equipment,Per Unit,$181.40 ,OP,181.4,625.29,,,,,,
Health Alliance MCR ADV,CPT,L1680,Pelvic & hip control thigh c,Durable Medical Equipment,Per Unit,"$1,143.62 ",OP,"1,143.62","3,934.69",,,,,,
Health Alliance MCR ADV,CPT,L1685,Post-op hip abduct custom fa,Durable Medical Equipment,Per Unit,"$1,116.47 ",OP,"1,116.47","3,839.39",,,,,,
Health Alliance MCR ADV,CPT,L1686,Ho post-op hip abduction,Durable Medical Equipment,Per Unit,$940.60 ,OP,940.6,"3,233.17",,,,,,
Health Alliance MCR ADV,CPT,L1690,Combination bilateral ho,Durable Medical Equipment,Per Unit,"$1,941.15 ",OP,"1,941.15","6,676.03",,,,,,
Health Alliance MCR ADV,CPT,L1700,Leg perthes orth toronto typ,Durable Medical Equipment,Per Unit,"$1,561.78 ",OP,"1,561.78","5,372.08",,,,,,
Health Alliance MCR ADV,CPT,L1710,Legg perthes orth newington,Durable Medical Equipment,Per Unit,"$1,988.75 ",OP,"1,988.75","6,839.98",,,,,,
Health Alliance MCR ADV,CPT,L1720,Legg perthes orthosis trilat,Durable Medical Equipment,Per Unit,"$1,480.82 ",OP,"1,480.82","5,093.76",,,,,,
Health Alliance MCR ADV,CPT,L1730,Legg perthes orth scottish r,Durable Medical Equipment,Per Unit,"$1,250.14 ",OP,"1,250.14","4,300.73",,,,,,
Health Alliance MCR ADV,CPT,L1755,Legg perthes patten bottom t,Durable Medical Equipment,Per Unit,"$1,797.35 ",OP,"1,797.35","6,180.39",,,,,,
Health Alliance MCR ADV,CPT,L1810,Ko elastic with joints,Durable Medical Equipment,Per Unit,$103.34 ,OP,103.34,103.34,,,,,,
Health Alliance MCR ADV,CPT,L1812,Ko elastic w/joints pre ots,Durable Medical Equipment,Per Unit,$81.50 ,OP,81.5,81.5,,,,,,
Health Alliance MCR ADV,CPT,L1820,Ko elas w/ condyle pads & jo,Durable Medical Equipment,Per Unit,$142.66 ,OP,142.66,142.66,,,,,,
Health Alliance MCR ADV,CPT,L1830,Ko immob canvas long pre ots,Durable Medical Equipment,Per Unit,$71.04 ,OP,71.04,285.96,,,,,,
Health Alliance MCR ADV,CPT,L1831,Knee orth pos locking joint,Durable Medical Equipment,Per Unit,$295.44 ,OP,295.44,"1,017.99",,,,,,
Health Alliance MCR ADV,CPT,L1832,Ko adj jnt pos r sup pre cst,Durable Medical Equipment,Per Unit,$691.44 ,OP,691.44,"2,379.12",,,,,,
Health Alliance MCR ADV,CPT,L1833,Ko adj jnt pos r sup pre ots,Durable Medical Equipment,Per Unit,$534.19 ,OP,534.19,534.19,,,,,,
Health Alliance MCR ADV,CPT,L1834,Ko w/0 joint rigid molded to,Durable Medical Equipment,Per Unit,$728.61 ,OP,728.61,"2,504.94",,,,,,
Health Alliance MCR ADV,CPT,L1836,Ko rigid w/o joints pre ots,Durable Medical Equipment,Per Unit,$104.41 ,OP,104.41,104.41,,,,,,
Health Alliance MCR ADV,CPT,L1840,Ko derot ant cruciate custom,Durable Medical Equipment,Per Unit,$944.00 ,OP,944,"3,248.41",,,,,,
Health Alliance MCR ADV,CPT,L1843,Ko single upright pre cst,Durable Medical Equipment,Per Unit,$900.70 ,OP,900.7,"3,095.90",,,,,,
Health Alliance MCR ADV,CPT,L1844,Ko w/adj jt rot cntrl molded,Durable Medical Equipment,Per Unit,"$1,528.66 ",OP,"1,528.66","5,257.70",,,,,,
Health Alliance MCR ADV,CPT,L1845,Ko double upright pre cst,Durable Medical Equipment,Per Unit,$840.88 ,OP,840.88,840.88,,,,,,
Health Alliance MCR ADV,CPT,L1846,Ko w adj flex/ext rotat mold,Durable Medical Equipment,Per Unit,"$1,174.51 ",OP,"1,174.51","1,174.51",,,,,,
Health Alliance MCR ADV,CPT,L1847,Ko dbl upright w/air pre cst,Durable Medical Equipment,Per Unit,$577.37 ,OP,577.37,"1,986.41",,,,,,
Health Alliance MCR ADV,CPT,L1848,Ko dbl upright w/air pre ots,Durable Medical Equipment,Per Unit,$577.37 ,OP,577.37,577.37,,,,,,
Health Alliance MCR ADV,CPT,L1850,Ko swedish type pre ots,Durable Medical Equipment,Per Unit,$234.85 ,OP,234.85,983.68,,,,,,
Health Alliance MCR ADV,CPT,L1851,Ko single upright prefab ots,Durable Medical Equipment,Per Unit,$702.11 ,OP,702.11,702.11,,,,,,
Health Alliance MCR ADV,CPT,L1852,Ko double upright prefab ots,Durable Medical Equipment,Per Unit,$665.20 ,OP,665.2,665.2,,,,,,
Health Alliance MCR ADV,CPT,L1860,Ko supracondylar socket mold,Durable Medical Equipment,Per Unit,"$1,251.75 ",OP,"1,251.75","4,304.53",,,,,,
Health Alliance MCR ADV,CPT,L1900,Afo sprng wir drsflx calf bd,Durable Medical Equipment,Per Unit,$286.39 ,OP,286.39,983.68,,,,,,
Health Alliance MCR ADV,CPT,L1902,Afo ankle gauntlet pre ots,Durable Medical Equipment,Per Unit,$74.93 ,OP,74.93,259.27,,,,,,
Health Alliance MCR ADV,CPT,L1904,Afo molded ankle gauntlet,Durable Medical Equipment,Per Unit,$453.09 ,OP,453.09,"1,559.39",,,,,,
Health Alliance MCR ADV,CPT,L1906,Afo multilig ank sup pre ots,Durable Medical Equipment,Per Unit,$112.88 ,OP,112.88,388.89,,,,,,
Health Alliance MCR ADV,CPT,L1907,Afo supramalleolar custom,Durable Medical Equipment,Per Unit,$564.86 ,OP,564.86,"1,944.48",,,,,,
Health Alliance MCR ADV,CPT,L1910,Afo sing bar clasp attach sh,Durable Medical Equipment,Per Unit,$281.51 ,OP,281.51,968.43,,,,,,
Health Alliance MCR ADV,CPT,L1920,Afo sing upright w/ adjust s,Durable Medical Equipment,Per Unit,$412.37 ,OP,412.37,"1,418.32",,,,,,
Health Alliance MCR ADV,CPT,L1930,Afo plastic,Durable Medical Equipment,Per Unit,$252.89 ,OP,252.89,869.3,,,,,,
Health Alliance MCR ADV,CPT,L1932,Afo rig ant tib prefab tcf/=,Durable Medical Equipment,Per Unit,$895.75 ,OP,895.75,"3,080.66",,,,,,
Health Alliance MCR ADV,CPT,L1940,Afo molded to patient plasti,Durable Medical Equipment,Per Unit,$488.84 ,OP,488.84,"1,681.40",,,,,,
Health Alliance MCR ADV,CPT,L1945,Afo molded plas rig ant tib,Durable Medical Equipment,Per Unit,"$1,126.77 ",OP,"1,126.77","3,873.69",,,,,,
Health Alliance MCR ADV,CPT,L1950,Afo spiral molded to pt plas,Durable Medical Equipment,Per Unit,$772.00 ,OP,772,"2,653.63",,,,,,
Health Alliance MCR ADV,CPT,L1951,Afo spiral prefabricated,Durable Medical Equipment,Per Unit,$843.02 ,OP,843.02,"2,897.65",,,,,,
Health Alliance MCR ADV,CPT,L1960,Afo pos solid ank plastic mo,Durable Medical Equipment,Per Unit,$622.25 ,OP,622.25,"2,138.93",,,,,,
Health Alliance MCR ADV,CPT,L1970,Afo plastic molded w/ankle j,Durable Medical Equipment,Per Unit,$694.78 ,OP,694.78,"2,390.56",,,,,,
Health Alliance MCR ADV,CPT,L1971,Afo w/ankle joint- prefab,Durable Medical Equipment,Per Unit,$470.55 ,OP,470.55,"1,616.58",,,,,,
Health Alliance MCR ADV,CPT,L1980,Afo sing solid stirrup calf,Durable Medical Equipment,Per Unit,$405.31 ,OP,405.31,"1,395.45",,,,,,
Health Alliance MCR ADV,CPT,L1990,Afo doub solid stirrup calf,Durable Medical Equipment,Per Unit,$469.10 ,OP,469.1,"1,612.76",,,,,,
Health Alliance MCR ADV,CPT,L2000,Kafo sing fre stirr thi/calf,Durable Medical Equipment,Per Unit,"$1,122.95 ",OP,"1,122.95","3,862.25",,,,,,
Health Alliance MCR ADV,CPT,L2005,Kafo sng/dbl mechanical act,Durable Medical Equipment,Per Unit,"$4,113.39 ",OP,"4,113.39","14,145.09",,,,,,
Health Alliance MCR ADV,CPT,L2010,Kafo sng solid stirrup w/o j,Durable Medical Equipment,Per Unit,$875.89 ,OP,875.89,"3,012.03",,,,,,
Health Alliance MCR ADV,CPT,L2020,Kafo dbl solid stirrup band/,Durable Medical Equipment,Per Unit,"$1,106.22 ",OP,"1,106.22","3,805.07",,,,,,
Health Alliance MCR ADV,CPT,L2030,Kafo dbl solid stirrup w/o j,Durable Medical Equipment,Per Unit,"$1,087.33 ",OP,"1,087.33","3,740.26",,,,,,
Health Alliance MCR ADV,CPT,L2034,Kafo pla sin up w/wo k/a cus,Durable Medical Equipment,Per Unit,"$2,039.24 ",OP,"2,039.24","7,011.54",,,,,,
Health Alliance MCR ADV,CPT,L2035,Kafo plastic pediatric size,Durable Medical Equipment,Per Unit,$173.91 ,OP,173.91,598.59,,,,,,
Health Alliance MCR ADV,CPT,L2036,Kafo plas doub free knee mol,Durable Medical Equipment,Per Unit,"$1,861.04 ",OP,"1,861.04","6,401.51",,,,,,
Health Alliance MCR ADV,CPT,L2037,Kafo plas sing free knee mol,Durable Medical Equipment,Per Unit,"$1,664.67 ",OP,"1,664.67","5,726.65",,,,,,
Health Alliance MCR ADV,CPT,L2038,Kafo w/o joint multi-axis an,Durable Medical Equipment,Per Unit,"$1,341.97 ",OP,"1,341.97","4,613.36",,,,,,
Health Alliance MCR ADV,CPT,L2040,Hkafo torsion bil rot straps,Durable Medical Equipment,Per Unit,$203.08 ,OP,203.08,697.72,,,,,,
Health Alliance MCR ADV,CPT,L2050,Hkafo torsion cable hip pelv,Durable Medical Equipment,Per Unit,$489.17 ,OP,489.17,"1,681.40",,,,,,
Health Alliance MCR ADV,CPT,L2060,Hkafo torsion ball bearing j,Durable Medical Equipment,Per Unit,$611.86 ,OP,611.86,"2,104.61",,,,,,
Health Alliance MCR ADV,CPT,L2070,Hkafo torsion unilat rot str,Durable Medical Equipment,Per Unit,$155.80 ,OP,155.8,537.6,,,,,,
Health Alliance MCR ADV,CPT,L2080,Hkafo unilat torsion cable,Durable Medical Equipment,Per Unit,$374.61 ,OP,374.61,"1,288.69",,,,,,
Health Alliance MCR ADV,CPT,L2090,Hkafo unilat torsion ball br,Durable Medical Equipment,Per Unit,$499.12 ,OP,499.12,"1,715.71",,,,,,
Health Alliance MCR ADV,CPT,L2106,Afo tib fx cast plaster mold,Durable Medical Equipment,Per Unit,$791.23 ,OP,791.23,"2,722.27",,,,,,
Health Alliance MCR ADV,CPT,L2108,Afo tib fx cast molded to pt,Durable Medical Equipment,Per Unit,"$1,154.03 ",OP,"1,154.03","3,969.02",,,,,,
Health Alliance MCR ADV,CPT,L2112,Afo tibial fracture soft,Durable Medical Equipment,Per Unit,$506.43 ,OP,506.43,"1,742.41",,,,,,
Health Alliance MCR ADV,CPT,L2114,Afo tib fx semi-rigid,Durable Medical Equipment,Per Unit,$634.33 ,OP,634.33,634.33,,,,,,
Health Alliance MCR ADV,CPT,L2116,Afo tibial fracture rigid,Durable Medical Equipment,Per Unit,$773.69 ,OP,773.69,773.69,,,,,,
Health Alliance MCR ADV,CPT,L2126,Kafo fem fx cast thermoplas,Durable Medical Equipment,Per Unit,"$1,281.77 ",OP,"1,281.77","4,407.46",,,,,,
Health Alliance MCR ADV,CPT,L2128,Kafo fem fx cast molded to p,Durable Medical Equipment,Per Unit,"$1,609.47 ",OP,"1,609.47","5,536.03",,,,,,
Health Alliance MCR ADV,CPT,L2132,Kafo femoral fx cast soft,Durable Medical Equipment,Per Unit,$976.92 ,OP,976.92,"3,358.99",,,,,,
Health Alliance MCR ADV,CPT,L2134,Kafo fem fx cast semi-rigid,Durable Medical Equipment,Per Unit,"$1,156.80 ",OP,"1,156.80","3,976.64",,,,,,
Health Alliance MCR ADV,CPT,L2136,Kafo femoral fx cast rigid,Durable Medical Equipment,Per Unit,"$1,265.95 ",OP,"1,265.95","4,354.09",,,,,,
Health Alliance MCR ADV,CPT,L2180,Plas shoe insert w ank joint,Durable Medical Equipment,Per Unit,$133.08 ,OP,133.08,457.52,,,,,,
Health Alliance MCR ADV,CPT,L2182,Drop lock knee,Durable Medical Equipment,Per Unit,$114.71 ,OP,114.71,392.7,,,,,,
Health Alliance MCR ADV,CPT,L2184,Limited motion knee joint,Durable Medical Equipment,Per Unit,$116.27 ,OP,116.27,400.34,,,,,,
Health Alliance MCR ADV,CPT,L2186,Adj motion knee jnt lerman t,Durable Medical Equipment,Per Unit,$154.63 ,OP,154.63,529.96,,,,,,
Health Alliance MCR ADV,CPT,L2188,Quadrilateral brim,Durable Medical Equipment,Per Unit,$281.10 ,OP,281.1,968.43,,,,,,
Health Alliance MCR ADV,CPT,L2190,Waist belt,Durable Medical Equipment,Per Unit,$85.62 ,OP,85.62,293.57,,,,,,
Health Alliance MCR ADV,CPT,L2192,Pelvic band & belt thigh fla,Durable Medical Equipment,Per Unit,$334.67 ,OP,334.67,"1,151.42",,,,,,
Health Alliance MCR ADV,CPT,L2200,Limited ankle motion ea jnt,Durable Medical Equipment,Per Unit,$50.44 ,OP,50.44,175.39,,,,,,
Health Alliance MCR ADV,CPT,L2210,Dorsiflexion assist each joi,Durable Medical Equipment,Per Unit,$63.09 ,OP,63.09,217.32,,,,,,
Health Alliance MCR ADV,CPT,L2220,Dorsi & plantar flex ass/res,Durable Medical Equipment,Per Unit,$81.22 ,OP,81.22,278.32,,,,,,
Health Alliance MCR ADV,CPT,L2230,Split flat caliper stirr & p,Durable Medical Equipment,Per Unit,$96.02 ,OP,96.02,331.7,,,,,,
Health Alliance MCR ADV,CPT,L2232,Rocker bottom- contact afo,Durable Medical Equipment,Per Unit,$97.51 ,OP,97.51,335.53,,,,,,
Health Alliance MCR ADV,CPT,L2240,Round caliper and plate atta,Durable Medical Equipment,Per Unit,$95.58 ,OP,95.58,327.9,,,,,,
Health Alliance MCR ADV,CPT,L2250,Foot plate molded stirrup at,Durable Medical Equipment,Per Unit,$335.30 ,OP,335.3,"1,151.42",,,,,,
Health Alliance MCR ADV,CPT,L2260,Reinforced solid stirrup,Durable Medical Equipment,Per Unit,$188.16 ,OP,188.16,648.16,,,,,,
Health Alliance MCR ADV,CPT,L2265,Long tongue stirrup,Durable Medical Equipment,Per Unit,$134.94 ,OP,134.94,465.15,,,,,,
Health Alliance MCR ADV,CPT,L2270,Varus/valgus strap padded/li,Durable Medical Equipment,Per Unit,$61.87 ,OP,61.87,213.51,,,,,,
Health Alliance MCR ADV,CPT,L2275,Plastic mod low ext pad/line,Durable Medical Equipment,Per Unit,$130.85 ,OP,130.85,449.9,,,,,,
Health Alliance MCR ADV,CPT,L2280,Molded inner boot,Durable Medical Equipment,Per Unit,$566.69 ,OP,566.69,"1,948.29",,,,,,
Health Alliance MCR ADV,CPT,L2300,Abduction bar jointed adjust,Durable Medical Equipment,Per Unit,$252.72 ,OP,252.72,869.3,,,,,,
Health Alliance MCR ADV,CPT,L2310,Abduction bar-straight,Durable Medical Equipment,Per Unit,$115.47 ,OP,115.47,396.52,,,,,,
Health Alliance MCR ADV,CPT,L2320,Non-molded lacer,Durable Medical Equipment,Per Unit,$193.64 ,OP,193.64,667.22,,,,,,
Health Alliance MCR ADV,CPT,L2330,Lacer molded to patient mode,Durable Medical Equipment,Per Unit,$368.55 ,OP,368.55,"1,265.81",,,,,,
Health Alliance MCR ADV,CPT,L2335,Anterior swing band,Durable Medical Equipment,Per Unit,$282.18 ,OP,282.18,972.25,,,,,,
Health Alliance MCR ADV,CPT,L2340,Pre-tibial shell molded to p,Durable Medical Equipment,Per Unit,$419.50 ,OP,419.5,"1,441.20",,,,,,
Health Alliance MCR ADV,CPT,L2350,Prosthetic type socket molde,Durable Medical Equipment,Per Unit,$836.35 ,OP,836.35,"2,874.78",,,,,,
Health Alliance MCR ADV,CPT,L2360,Extended steel shank,Durable Medical Equipment,Per Unit,$51.76 ,OP,51.76,179.2,,,,,,
Health Alliance MCR ADV,CPT,L2370,Patten bottom,Durable Medical Equipment,Per Unit,$321.26 ,OP,321.26,"1,105.68",,,,,,
Health Alliance MCR ADV,CPT,L2375,Torsion ank & half solid sti,Durable Medical Equipment,Per Unit,$123.52 ,OP,123.52,423.22,,,,,,
Health Alliance MCR ADV,CPT,L2380,Torsion straight knee joint,Durable Medical Equipment,Per Unit,$129.54 ,OP,129.54,446.08,,,,,,
Health Alliance MCR ADV,CPT,L2385,Straight knee joint heavy du,Durable Medical Equipment,Per Unit,$147.50 ,OP,147.5,507.08,,,,,,
Health Alliance MCR ADV,CPT,L2387,Add le poly knee custom kafo,Durable Medical Equipment,Per Unit,$191.63 ,OP,191.63,659.6,,,,,,
Health Alliance MCR ADV,CPT,L2390,Offset knee joint each,Durable Medical Equipment,Per Unit,$102.75 ,OP,102.75,354.58,,,,,,
Health Alliance MCR ADV,CPT,L2395,Offset knee joint heavy duty,Durable Medical Equipment,Per Unit,$146.86 ,OP,146.86,503.28,,,,,,
Health Alliance MCR ADV,CPT,L2397,Suspension sleeve lower ext,Durable Medical Equipment,Per Unit,$122.52 ,OP,122.52,423.22,,,,,,
Health Alliance MCR ADV,CPT,L2405,Knee joint drop lock ea jnt,Durable Medical Equipment,Per Unit,$87.52 ,OP,87.52,301.2,,,,,,
Health Alliance MCR ADV,CPT,L2415,Knee joint cam lock each joi,Durable Medical Equipment,Per Unit,$121.95 ,OP,121.95,419.4,,,,,,
Health Alliance MCR ADV,CPT,L2425,Knee disc/dial lock/adj flex,Durable Medical Equipment,Per Unit,$143.90 ,OP,143.9,495.65,,,,,,
Health Alliance MCR ADV,CPT,L2430,Knee jnt ratchet lock ea jnt,Durable Medical Equipment,Per Unit,$143.90 ,OP,143.9,495.65,,,,,,
Health Alliance MCR ADV,CPT,L2492,Knee lift loop drop lock rin,Durable Medical Equipment,Per Unit,$117.74 ,OP,117.74,404.14,,,,,,
Health Alliance MCR ADV,CPT,L2500,Thi/glut/ischia wgt bearing,Durable Medical Equipment,Per Unit,$314.13 ,OP,314.13,"1,078.99",,,,,,
Health Alliance MCR ADV,CPT,L2510,Th/wght bear quad-lat brim m,Durable Medical Equipment,Per Unit,$809.60 ,OP,809.6,"2,783.26",,,,,,
Health Alliance MCR ADV,CPT,L2520,Th/wght bear quad-lat brim c,Durable Medical Equipment,Per Unit,$539.56 ,OP,539.56,"1,856.79",,,,,,
Health Alliance MCR ADV,CPT,L2525,Th/wght bear nar m-l brim mo,Durable Medical Equipment,Per Unit,"$1,144.16 ",OP,"1,144.16","3,934.69",,,,,,
Health Alliance MCR ADV,CPT,L2526,Th/wght bear nar m-l brim cu,Durable Medical Equipment,Per Unit,$642.90 ,OP,642.9,"2,211.37",,,,,,
Health Alliance MCR ADV,CPT,L2530,Thigh/wght bear lacer non-mo,Durable Medical Equipment,Per Unit,$240.74 ,OP,240.74,827.35,,,,,,
Health Alliance MCR ADV,CPT,L2540,Thigh/wght bear lacer molded,Durable Medical Equipment,Per Unit,$455.54 ,OP,455.54,"1,567.02",,,,,,
Health Alliance MCR ADV,CPT,L2550,Thigh/wght bear high roll cu,Durable Medical Equipment,Per Unit,$341.55 ,OP,341.55,"1,174.31",,,,,,
Health Alliance MCR ADV,CPT,L2570,Hip clevis type 2 posit jnt,Durable Medical Equipment,Per Unit,$447.07 ,OP,447.07,"1,536.51",,,,,,
Health Alliance MCR ADV,CPT,L2580,Pelvic control pelvic sling,Durable Medical Equipment,Per Unit,$435.62 ,OP,435.62,"1,498.39",,,,,,
Health Alliance MCR ADV,CPT,L2600,Hip clevis/thrust bearing fr,Durable Medical Equipment,Per Unit,$214.10 ,OP,214.1,735.85,,,,,,
Health Alliance MCR ADV,CPT,L2610,Hip clevis/thrust bearing lo,Durable Medical Equipment,Per Unit,$236.58 ,OP,236.58,812.11,,,,,,
Health Alliance MCR ADV,CPT,L2620,Pelvic control hip heavy dut,Durable Medical Equipment,Per Unit,$250.96 ,OP,250.96,861.67,,,,,,
Health Alliance MCR ADV,CPT,L2622,Hip joint adjustable flexion,Durable Medical Equipment,Per Unit,$319.42 ,OP,319.42,"1,098.07",,,,,,
Health Alliance MCR ADV,CPT,L2624,Hip adj flex ext abduct cont,Durable Medical Equipment,Per Unit,$391.68 ,OP,391.68,"1,345.89",,,,,,
Health Alliance MCR ADV,CPT,L2627,Plastic mold recipro hip & c,Durable Medical Equipment,Per Unit,"$2,145.41 ",OP,"2,145.41","7,377.56",,,,,,
Health Alliance MCR ADV,CPT,L2628,Metal frame recipro hip & ca,Durable Medical Equipment,Per Unit,"$1,572.54 ",OP,"1,572.54","5,406.41",,,,,,
Health Alliance MCR ADV,CPT,L2630,Pelvic control band & belt u,Durable Medical Equipment,Per Unit,$232.43 ,OP,232.43,800.67,,,,,,
Health Alliance MCR ADV,CPT,L2640,Pelvic control band & belt b,Durable Medical Equipment,Per Unit,$315.42 ,OP,315.42,"1,086.62",,,,,,
Health Alliance MCR ADV,CPT,L2650,Pelv & thor control gluteal,Durable Medical Equipment,Per Unit,$138.91 ,OP,138.91,476.6,,,,,,
Health Alliance MCR ADV,CPT,L2660,Thoracic control thoracic ba,Durable Medical Equipment,Per Unit,$179.86 ,OP,179.86,617.65,,,,,,
Health Alliance MCR ADV,CPT,L2670,Thorac cont paraspinal uprig,Durable Medical Equipment,Per Unit,$160.11 ,OP,160.11,549.03,,,,,,
Health Alliance MCR ADV,CPT,L2680,Thorac cont lat support upri,Durable Medical Equipment,Per Unit,$146.88 ,OP,146.88,503.28,,,,,,
Health Alliance MCR ADV,CPT,L2750,Plating chrome/nickel pr bar,Durable Medical Equipment,Per Unit,$78.45 ,OP,78.45,270.71,,,,,,
Health Alliance MCR ADV,CPT,L2755,Carbon graphite lamination,Durable Medical Equipment,Per Unit,$131.16 ,OP,131.16,449.9,,,,,,
Health Alliance MCR ADV,CPT,L2760,Extension per extension per,Durable Medical Equipment,Per Unit,$57.03 ,OP,57.03,194.45,,,,,,
Health Alliance MCR ADV,CPT,L2768,Ortho sidebar disconnect,Durable Medical Equipment,Per Unit,$130.78 ,OP,130.78,449.9,,,,,,
Health Alliance MCR ADV,CPT,L2780,Non-corrosive finish,Durable Medical Equipment,Per Unit,$63.53 ,OP,63.53,217.32,,,,,,
Health Alliance MCR ADV,CPT,L2785,Drop lock retainer each,Durable Medical Equipment,Per Unit,$29.75 ,OP,29.75,102.95,,,,,,
Health Alliance MCR ADV,CPT,L2795,Knee control full kneecap,Durable Medical Equipment,Per Unit,$82.32 ,OP,82.32,282.14,,,,,,
Health Alliance MCR ADV,CPT,L2800,Knee cap medial or lateral p,Durable Medical Equipment,Per Unit,$101.09 ,OP,101.09,101.09,,,,,,
Health Alliance MCR ADV,CPT,L2810,Knee control condylar pad,Durable Medical Equipment,Per Unit,$81.98 ,OP,81.98,282.14,,,,,,
Health Alliance MCR ADV,CPT,L2820,Soft interface below knee se,Durable Medical Equipment,Per Unit,$81.51 ,OP,81.51,282.14,,,,,,
Health Alliance MCR ADV,CPT,L2830,Soft interface above knee se,Durable Medical Equipment,Per Unit,$88.18 ,OP,88.18,305.01,,,,,,
Health Alliance MCR ADV,CPT,L2840,Tibial length sock fx or equ,Durable Medical Equipment,Per Unit,$43.30 ,OP,43.3,148.69,,,,,,
Health Alliance MCR ADV,CPT,L2850,Femoral lgth sock fx or equa,Durable Medical Equipment,Per Unit,$60.72 ,OP,60.72,209.7,,,,,,
Health Alliance MCR ADV,CPT,L3000,Ft insert ucb berkeley shell,Durable Medical Equipment,Per Unit,$315.34 ,OP,315.34,"1,082.81",,,,,,
Health Alliance MCR ADV,CPT,L3001,Foot insert remov molded spe,Durable Medical Equipment,Per Unit,$132.78 ,OP,132.78,686.28,,,,,,
Health Alliance MCR ADV,CPT,L3002,Foot insert plastazote or eq,Durable Medical Equipment,Per Unit,$162.12 ,OP,162.12,834.98,,,,,,
Health Alliance MCR ADV,CPT,L3003,Foot insert silicone gel eac,Durable Medical Equipment,Per Unit,$174.89 ,OP,174.89,903.6,,,,,,
Health Alliance MCR ADV,CPT,L3010,Foot longitudinal arch suppo,Durable Medical Equipment,Per Unit,$174.89 ,OP,174.89,903.6,,,,,,
Health Alliance MCR ADV,CPT,L3020,Foot longitud/metatarsal sup,Durable Medical Equipment,Per Unit,$199.16 ,OP,199.16,"1,025.61",,,,,,
Health Alliance MCR ADV,CPT,L3030,Foot arch support remov prem,Durable Medical Equipment,Per Unit,$76.59 ,OP,76.59,"1,239.13",,,,,,
Health Alliance MCR ADV,CPT,L3031,Foot lamin/prepreg composite,Durable Medical Equipment,Per Unit,$122.94 ,OP,122.94,"1,334.45",,,,,,
Health Alliance MCR ADV,CPT,L3040,Ft arch suprt premold longit,Durable Medical Equipment,Per Unit,$47.25 ,OP,47.25,163.95,,,,,,
Health Alliance MCR ADV,CPT,L3050,Foot arch supp premold metat,Durable Medical Equipment,Per Unit,$47.25 ,OP,47.25,163.95,,,,,,
Health Alliance MCR ADV,CPT,L3060,Foot arch supp longitud/meta,Durable Medical Equipment,Per Unit,$74.04 ,OP,74.04,255.45,,,,,,
Health Alliance MCR ADV,CPT,L3070,Arch suprt att to sho longit,Durable Medical Equipment,Per Unit,$31.91 ,OP,31.91,110.57,,,,,,
Health Alliance MCR ADV,CPT,L3080,Arch supp att to shoe metata,Durable Medical Equipment,Per Unit,$31.91 ,OP,31.91,110.57,,,,,,
Health Alliance MCR ADV,CPT,L3090,Arch supp att to shoe long/m,Durable Medical Equipment,Per Unit,$40.86 ,OP,40.86,141.07,,,,,,
Health Alliance MCR ADV,CPT,L3100,Hallus-valgus nt dyn pre ots,Durable Medical Equipment,Per Unit,$43.43 ,OP,43.43,148.69,,,,,,
Health Alliance MCR ADV,CPT,L3140,Abduction rotation bar shoe,Durable Medical Equipment,Per Unit,$89.37 ,OP,89.37,308.83,,,,,,
Health Alliance MCR ADV,CPT,L3150,Abduct rotation bar w/o shoe,Durable Medical Equipment,Per Unit,$81.72 ,OP,81.72,282.14,,,,,,
Health Alliance MCR ADV,CPT,L3170,Foot plas heel stabi pre ots,Durable Medical Equipment,Per Unit,$51.06 ,OP,51.06,175.39,,,,,,
Health Alliance MCR ADV,CPT,L3224,Woman's shoe oxford brace,Durable Medical Equipment,Per Unit,$67.83 ,OP,67.83,232.58,,,,,,
Health Alliance MCR ADV,CPT,L3225,Man's shoe oxford brace,Durable Medical Equipment,Per Unit,$74.09 ,OP,74.09,255.45,,,,,,
Health Alliance MCR ADV,CPT,L3300,Sho lift taper to metatarsal,Durable Medical Equipment,Per Unit,$52.35 ,OP,52.35,179.2,,,,,,
Health Alliance MCR ADV,CPT,L3310,Shoe lift elev heel/sole neo,Durable Medical Equipment,Per Unit,$81.72 ,OP,81.72,282.14,,,,,,
Health Alliance MCR ADV,CPT,L3330,Lifts elevation metal extens,Durable Medical Equipment,Per Unit,$568.10 ,OP,568.1,"1,952.10",,,,,,
Health Alliance MCR ADV,CPT,L3332,Shoe lifts tapered to one-ha,Durable Medical Equipment,Per Unit,$74.04 ,OP,74.04,255.45,,,,,,
Health Alliance MCR ADV,CPT,L3334,Shoe lifts elevation heel /i,Durable Medical Equipment,Per Unit,$38.28 ,OP,38.28,133.45,,,,,,
Health Alliance MCR ADV,CPT,L3340,Shoe wedge sach,Durable Medical Equipment,Per Unit,$85.56 ,OP,85.56,293.57,,,,,,
Health Alliance MCR ADV,CPT,L3350,Shoe heel wedge,Durable Medical Equipment,Per Unit,$22.96 ,OP,22.96,80.07,,,,,,
Health Alliance MCR ADV,CPT,L3360,Shoe sole wedge outside sole,Durable Medical Equipment,Per Unit,$35.74 ,OP,35.74,122,,,,,,
Health Alliance MCR ADV,CPT,L3370,Shoe sole wedge between sole,Durable Medical Equipment,Per Unit,$49.79 ,OP,49.79,171.58,,,,,,
Health Alliance MCR ADV,CPT,L3380,Shoe clubfoot wedge,Durable Medical Equipment,Per Unit,$49.79 ,OP,49.79,171.58,,,,,,
Health Alliance MCR ADV,CPT,L3390,Shoe outflare wedge,Durable Medical Equipment,Per Unit,$49.79 ,OP,49.79,171.58,,,,,,
Health Alliance MCR ADV,CPT,L3400,Shoe metatarsal bar wedge ro,Durable Medical Equipment,Per Unit,$40.86 ,OP,40.86,141.07,,,,,,
Health Alliance MCR ADV,CPT,L3410,Shoe metatarsal bar between,Durable Medical Equipment,Per Unit,$93.19 ,OP,93.19,320.27,,,,,,
Health Alliance MCR ADV,CPT,L3420,Full sole/heel wedge btween,Durable Medical Equipment,Per Unit,$54.90 ,OP,54.9,190.64,,,,,,
Health Alliance MCR ADV,CPT,L3430,Sho heel count plast reinfor,Durable Medical Equipment,Per Unit,$160.86 ,OP,160.86,552.84,,,,,,
Health Alliance MCR ADV,CPT,L3440,Heel leather reinforced,Durable Medical Equipment,Per Unit,$76.59 ,OP,76.59,263.08,,,,,,
Health Alliance MCR ADV,CPT,L3450,Shoe heel sach cushion type,Durable Medical Equipment,Per Unit,$105.93 ,OP,105.93,105.93,,,,,,
Health Alliance MCR ADV,CPT,L3455,Shoe heel new leather standa,Durable Medical Equipment,Per Unit,$40.86 ,OP,40.86,141.07,,,,,,
Health Alliance MCR ADV,CPT,L3460,Shoe heel new rubber standar,Durable Medical Equipment,Per Unit,$34.49 ,OP,34.49,118.19,,,,,,
Health Alliance MCR ADV,CPT,L3465,Shoe heel thomas with wedge,Durable Medical Equipment,Per Unit,$58.76 ,OP,58.76,202.07,,,,,,
Health Alliance MCR ADV,CPT,L3470,Shoe heel thomas extend to b,Durable Medical Equipment,Per Unit,$62.54 ,OP,62.54,213.51,,,,,,
Health Alliance MCR ADV,CPT,L3480,Shoe heel pad & depress for,Durable Medical Equipment,Per Unit,$62.54 ,OP,62.54,213.51,,,,,,
Health Alliance MCR ADV,CPT,L3500,Ortho shoe add leather insol,Durable Medical Equipment,Per Unit,$29.35 ,OP,29.35,99.13,,,,,,
Health Alliance MCR ADV,CPT,L3510,Orthopedic shoe add rub insl,Durable Medical Equipment,Per Unit,$29.35 ,OP,29.35,99.13,,,,,,
Health Alliance MCR ADV,CPT,L3520,O shoe add felt w leath insl,Durable Medical Equipment,Per Unit,$31.91 ,OP,31.91,110.57,,,,,,
Health Alliance MCR ADV,CPT,L3530,Ortho shoe add half sole,Durable Medical Equipment,Per Unit,$31.91 ,OP,31.91,110.57,,,,,,
Health Alliance MCR ADV,CPT,L3540,Ortho shoe add full sole,Durable Medical Equipment,Per Unit,$51.06 ,OP,51.06,175.39,,,,,,
Health Alliance MCR ADV,CPT,L3550,O shoe add standard toe tap,Durable Medical Equipment,Per Unit,$8.97 ,OP,8.97,30.51,,,,,,
Health Alliance MCR ADV,CPT,L3560,O shoe add horseshoe toe tap,Durable Medical Equipment,Per Unit,$22.96 ,OP,22.96,80.07,,,,,,
Health Alliance MCR ADV,CPT,L3570,O shoe add instep extension,Durable Medical Equipment,Per Unit,$85.56 ,OP,85.56,293.57,,,,,,
Health Alliance MCR ADV,CPT,L3580,O shoe add instep velcro clo,Durable Medical Equipment,Per Unit,$65.11 ,OP,65.11,224.95,,,,,,
Health Alliance MCR ADV,CPT,L3590,O shoe convert to sof counte,Durable Medical Equipment,Per Unit,$53.63 ,OP,53.63,183.02,,,,,,
Health Alliance MCR ADV,CPT,L3595,Ortho shoe add march bar,Durable Medical Equipment,Per Unit,$42.10 ,OP,42.1,144.88,,,,,,
Health Alliance MCR ADV,CPT,L3600,Trans shoe calip plate exist,Durable Medical Equipment,Per Unit,$76.59 ,OP,76.59,263.08,,,,,,
Health Alliance MCR ADV,CPT,L3610,Trans shoe caliper plate new,Durable Medical Equipment,Per Unit,$100.86 ,OP,100.86,346.96,,,,,,
Health Alliance MCR ADV,CPT,L3620,Trans shoe solid stirrup exi,Durable Medical Equipment,Per Unit,$76.59 ,OP,76.59,263.08,,,,,,
Health Alliance MCR ADV,CPT,L3630,Trans shoe solid stirrup new,Durable Medical Equipment,Per Unit,$100.86 ,OP,100.86,346.96,,,,,,
Health Alliance MCR ADV,CPT,L3640,Shoe dennis browne splint bo,Durable Medical Equipment,Per Unit,$43.43 ,OP,43.43,148.69,,,,,,
Health Alliance MCR ADV,CPT,L3650,So 8 abd restraint pre ots,Durable Medical Equipment,Per Unit,$65.83 ,OP,65.83,224.95,,,,,,
Health Alliance MCR ADV,CPT,L3660,So 8 ab rstr can/web pre ots,Durable Medical Equipment,Per Unit,$94.40 ,OP,94.4,324.09,,,,,,
Health Alliance MCR ADV,CPT,L3670,So acro/clav can web pre ots,Durable Medical Equipment,Per Unit,$103.86 ,OP,103.86,358.39,,,,,,
Health Alliance MCR ADV,CPT,L3671,So cap design w/o jnts cf,Durable Medical Equipment,Per Unit,$823.17 ,OP,823.17,"2,832.83",,,,,,
Health Alliance MCR ADV,CPT,L3674,So airplane w/wo joint cf,Durable Medical Equipment,Per Unit,"$1,079.87 ",OP,"1,079.87","1,079.87",,,,,,
Health Alliance MCR ADV,CPT,L3675,So vest canvas/web pre ots,Durable Medical Equipment,Per Unit,$160.35 ,OP,160.35,552.84,,,,,,
Health Alliance MCR ADV,CPT,L3702,Eo w/o joints cf,Durable Medical Equipment,Per Unit,$263.81 ,OP,263.81,907.42,,,,,,
Health Alliance MCR ADV,CPT,L3710,Eo elas w/metal jnts pre ots,Durable Medical Equipment,Per Unit,$130.45 ,OP,130.45,449.9,,,,,,
Health Alliance MCR ADV,CPT,L3720,Forearm/arm cuffs free motio,Durable Medical Equipment,Per Unit,$624.22 ,OP,624.22,"2,146.54",,,,,,
Health Alliance MCR ADV,CPT,L3730,Forearm/arm cuffs ext/flex a,Durable Medical Equipment,Per Unit,$827.96 ,OP,827.96,"2,848.08",,,,,,
Health Alliance MCR ADV,CPT,L3740,Cuffs adj lock w/ active con,Durable Medical Equipment,Per Unit,$981.62 ,OP,981.62,"3,374.24",,,,,,
Health Alliance MCR ADV,CPT,L3760,Eo adj jt prefab custom fit,Durable Medical Equipment,Per Unit,$456.89 ,OP,456.89,"1,570.83",,,,,,
Health Alliance MCR ADV,CPT,L3761,Eo- adj lock joint prefab ot,Durable Medical Equipment,Per Unit,$456.89 ,OP,456.89,456.89,,,,,,
Health Alliance MCR ADV,CPT,L3762,Eo rigid w/o joints pre ots,Durable Medical Equipment,Per Unit,$98.22 ,OP,98.22,339.33,,,,,,
Health Alliance MCR ADV,CPT,L3763,Ewho rigid w/o jnts cf,Durable Medical Equipment,Per Unit,$683.66 ,OP,683.66,"2,352.44",,,,,,
Health Alliance MCR ADV,CPT,L3764,Ewho w/joint(s) cf,Durable Medical Equipment,Per Unit,$715.47 ,OP,715.47,"2,459.19",,,,,,
Health Alliance MCR ADV,CPT,L3765,Ewhfo rigid w/o jnts cf,Durable Medical Equipment,Per Unit,"$1,171.43 ",OP,"1,171.43","4,030.02",,,,,,
Health Alliance MCR ADV,CPT,L3766,Ewhfo w/joint(s) cf,Durable Medical Equipment,Per Unit,"$1,240.47 ",OP,"1,240.47","4,266.40",,,,,,
Health Alliance MCR ADV,CPT,L3806,Whfo w/joint(s) custom fab,Durable Medical Equipment,Per Unit,$414.97 ,OP,414.97,"1,425.95",,,,,,
Health Alliance MCR ADV,CPT,L3807,Whfo w/o joints pre cst,Durable Medical Equipment,Per Unit,$228.43 ,OP,228.43,785.42,,,,,,
Health Alliance MCR ADV,CPT,L3808,Whfo- rigid w/o joints,Durable Medical Equipment,Per Unit,$325.43 ,OP,325.43,"1,120.94",,,,,,
Health Alliance MCR ADV,CPT,L3809,Whfo w/o joints pre ots,Durable Medical Equipment,Per Unit,$228.43 ,OP,228.43,228.43,,,,,,
Health Alliance MCR ADV,CPT,L3900,Hinge extension/flex wrist/f,Durable Medical Equipment,Per Unit,"$1,479.93 ",OP,"1,479.93","5,089.95",,,,,,
Health Alliance MCR ADV,CPT,L3901,Hinge ext/flex wrist finger,Durable Medical Equipment,Per Unit,"$1,939.53 ",OP,"1,939.53","6,668.40",,,,,,
Health Alliance MCR ADV,CPT,L3904,Whfo electric custom fitted,Durable Medical Equipment,Per Unit,"$3,083.64 ",OP,"3,083.64","10,603.11",,,,,,
Health Alliance MCR ADV,CPT,L3905,Who w/nontorsion jnt(s) cf,Durable Medical Equipment,Per Unit,$905.97 ,OP,905.97,"3,114.97",,,,,,
Health Alliance MCR ADV,CPT,L3906,Who w/o joints cf,Durable Medical Equipment,Per Unit,$462.97 ,OP,462.97,"1,593.72",,,,,,
Health Alliance MCR ADV,CPT,L3908,Who cock-up nonmolde pre ots,Durable Medical Equipment,Per Unit,$66.98 ,OP,66.98,228.77,,,,,,
Health Alliance MCR ADV,CPT,L3912,Hfo flexion glove pre ots,Durable Medical Equipment,Per Unit,$96.25 ,OP,96.25,331.7,,,,,,
Health Alliance MCR ADV,CPT,L3913,Hfo w/o joints cf,Durable Medical Equipment,Per Unit,$247.41 ,OP,247.41,850.23,,,,,,
Health Alliance MCR ADV,CPT,L3915,Who nontorsion jnts pre cst,Durable Medical Equipment,Per Unit,$485.63 ,OP,485.63,"1,669.97",,,,,,
Health Alliance MCR ADV,CPT,L3916,Who nontorsion jnts pre ots,Durable Medical Equipment,Per Unit,$485.63 ,OP,485.63,485.63,,,,,,
Health Alliance MCR ADV,CPT,L3917,Metacarp fx orthosis pre cst,Durable Medical Equipment,Per Unit,$96.47 ,OP,96.47,331.7,,,,,,
Health Alliance MCR ADV,CPT,L3918,Metacarp fx orthosis pre ots,Durable Medical Equipment,Per Unit,$96.47 ,OP,96.47,96.47,,,,,,
Health Alliance MCR ADV,CPT,L3919,Ho w/o joints cf,Durable Medical Equipment,Per Unit,$247.41 ,OP,247.41,850.23,,,,,,
Health Alliance MCR ADV,CPT,L3921,Hfo w/joint(s) cf,Durable Medical Equipment,Per Unit,$293.46 ,OP,293.46,"1,010.37",,,,,,
Health Alliance MCR ADV,CPT,L3923,Hfo without joints pre cst,Durable Medical Equipment,Per Unit,$88.25 ,OP,88.25,305.01,,,,,,
Health Alliance MCR ADV,CPT,L3924,Hfo without joints pre ots,Durable Medical Equipment,Per Unit,$88.25 ,OP,88.25,88.25,,,,,,
Health Alliance MCR ADV,CPT,L3925,Fo pip dip jnt/sprng pre ots,Durable Medical Equipment,Per Unit,$60.01 ,OP,60.01,205.88,,,,,,
Health Alliance MCR ADV,CPT,L3927,Fo pip dip no jt spr pre ots,Durable Medical Equipment,Per Unit,$31.98 ,OP,31.98,110.57,,,,,,
Health Alliance MCR ADV,CPT,L3929,Hfo nontorsion jnts pre cst,Durable Medical Equipment,Per Unit,$83.44 ,OP,83.44,285.96,,,,,,
Health Alliance MCR ADV,CPT,L3930,Hfo nontorsion jnts pre ots,Durable Medical Equipment,Per Unit,$83.44 ,OP,83.44,83.44,,,,,,
Health Alliance MCR ADV,CPT,L3931,Whfo nontorsion joint prefab,Durable Medical Equipment,Per Unit,$190.48 ,OP,190.48,655.78,,,,,,
Health Alliance MCR ADV,CPT,L3933,Fo w/o joints cf,Durable Medical Equipment,Per Unit,$194.93 ,OP,194.93,671.03,,,,,,
Health Alliance MCR ADV,CPT,L3935,Fo nontorsion joint cf,Durable Medical Equipment,Per Unit,$201.82 ,OP,201.82,693.9,,,,,,
Health Alliance MCR ADV,CPT,L3960,Sewho airplan desig abdu pos,Durable Medical Equipment,Per Unit,$728.64 ,OP,728.64,"2,504.94",,,,,,
Health Alliance MCR ADV,CPT,L3961,Sewho cap design w/o jnts cf,Durable Medical Equipment,Per Unit,"$1,534.92 ",OP,"1,534.92","5,280.58",,,,,,
Health Alliance MCR ADV,CPT,L3962,Sewho erbs palsey design abd,Durable Medical Equipment,Per Unit,$659.00 ,OP,659,"2,264.75",,,,,,
Health Alliance MCR ADV,CPT,L3967,Sewho airplane w/o jnts cf,Durable Medical Equipment,Per Unit,"$1,812.20 ",OP,"1,812.20","6,233.76",,,,,,
Health Alliance MCR ADV,CPT,L3971,Sewho cap design w/jnt(s) cf,Durable Medical Equipment,Per Unit,"$1,720.20 ",OP,"1,720.20","5,917.29",,,,,,
Health Alliance MCR ADV,CPT,L3973,Sewho airplane w/jnt(s) cf,Durable Medical Equipment,Per Unit,"$1,812.20 ",OP,"1,812.20","6,233.76",,,,,,
Health Alliance MCR ADV,CPT,L3975,Sewhfo cap design w/o jnt cf,Durable Medical Equipment,Per Unit,"$1,534.92 ",OP,"1,534.92","5,280.58",,,,,,
Health Alliance MCR ADV,CPT,L3976,Sewhfo airplane w/o jnts cf,Durable Medical Equipment,Per Unit,"$1,534.92 ",OP,"1,534.92","5,280.58",,,,,,
Health Alliance MCR ADV,CPT,L3977,Sewhfo cap desgn w/jnt(s) cf,Durable Medical Equipment,Per Unit,"$1,720.20 ",OP,"1,720.20","5,917.29",,,,,,
Health Alliance MCR ADV,CPT,L3978,Sewhfo airplane w/jnt(s) cf,Durable Medical Equipment,Per Unit,"$1,812.20 ",OP,"1,812.20","6,233.76",,,,,,
Health Alliance MCR ADV,CPT,L3980,Up ext fx orthos humeral nos,Durable Medical Equipment,Per Unit,$353.43 ,OP,353.43,"1,216.24",,,,,,
Health Alliance MCR ADV,CPT,L3981,Ue fx orth shoul cap forearm,Durable Medical Equipment,Per Unit,$919.57 ,OP,919.57,919.57,,,,,,
Health Alliance MCR ADV,CPT,L3982,Upper ext fx orthosis rad/ul,Durable Medical Equipment,Per Unit,$358.87 ,OP,358.87,"1,235.32",,,,,,
Health Alliance MCR ADV,CPT,L3984,Upper ext fx orthosis wrist,Durable Medical Equipment,Per Unit,$316.13 ,OP,316.13,"1,086.62",,,,,,
Health Alliance MCR ADV,CPT,L3995,Sock fracture or equal each,Durable Medical Equipment,Per Unit,$37.51 ,OP,37.51,129.64,,,,,,
Health Alliance MCR ADV,CPT,L4000,Repl girdle milwaukee orth,Durable Medical Equipment,Per Unit,"$1,326.47 ",OP,"1,326.47","4,559.97",,,,,,
Health Alliance MCR ADV,CPT,L4010,Replace trilateral socket br,Durable Medical Equipment,Per Unit,$806.25 ,OP,806.25,"2,771.83",,,,,,
Health Alliance MCR ADV,CPT,L4020,Replace quadlat socket brim,Durable Medical Equipment,Per Unit,$968.52 ,OP,968.52,"3,332.30",,,,,,
Health Alliance MCR ADV,CPT,L4030,Replace socket brim cust fit,Durable Medical Equipment,Per Unit,$615.47 ,OP,615.47,"2,116.06",,,,,,
Health Alliance MCR ADV,CPT,L4040,Replace molded thigh lacer,Durable Medical Equipment,Per Unit,$416.80 ,OP,416.8,"1,433.58",,,,,,
Health Alliance MCR ADV,CPT,L4045,Replace non-molded thigh lac,Durable Medical Equipment,Per Unit,$307.89 ,OP,307.89,"1,059.93",,,,,,
Health Alliance MCR ADV,CPT,L4050,Replace molded calf lacer,Durable Medical Equipment,Per Unit,$412.80 ,OP,412.8,"1,418.32",,,,,,
Health Alliance MCR ADV,CPT,L4055,Replace non-molded calf lace,Durable Medical Equipment,Per Unit,$250.92 ,OP,250.92,861.67,,,,,,
Health Alliance MCR ADV,CPT,L4060,Replace high roll cuff,Durable Medical Equipment,Per Unit,$326.17 ,OP,326.17,"1,120.94",,,,,,
Health Alliance MCR ADV,CPT,L4070,Replace prox & dist upright,Durable Medical Equipment,Per Unit,$264.15 ,OP,264.15,907.42,,,,,,
Health Alliance MCR ADV,CPT,L4080,Repl met band kafo-afo prox,Durable Medical Equipment,Per Unit,$99.72 ,OP,99.72,343.14,,,,,,
Health Alliance MCR ADV,CPT,L4090,Repl met band kafo-afo calf/,Durable Medical Equipment,Per Unit,$84.84 ,OP,84.84,293.57,,,,,,
Health Alliance MCR ADV,CPT,L4100,Repl leath cuff kafo prox th,Durable Medical Equipment,Per Unit,$101.94 ,OP,101.94,350.76,,,,,,
Health Alliance MCR ADV,CPT,L4110,Repl leath cuff kafo-afo cal,Durable Medical Equipment,Per Unit,$79.60 ,OP,79.6,274.51,,,,,,
Health Alliance MCR ADV,CPT,L4130,Replace pretibial shell,Durable Medical Equipment,Per Unit,$481.14 ,OP,481.14,"1,654.72",,,,,,
Health Alliance MCR ADV,CPT,L4350,Ankle control ortho pre ots,Durable Medical Equipment,Per Unit,$97.13 ,OP,97.13,335.53,,,,,,
Health Alliance MCR ADV,CPT,L4360,Pneumat walking boot pre cst,Durable Medical Equipment,Per Unit,$259.89 ,OP,259.89,892.18,,,,,,
Health Alliance MCR ADV,CPT,L4361,Pneuma/vac walk boot pre ots,Durable Medical Equipment,Per Unit,$259.89 ,OP,259.89,259.89,,,,,,
Health Alliance MCR ADV,CPT,L4370,Pneum full leg splnt pre ots,Durable Medical Equipment,Per Unit,$236.26 ,OP,236.26,812.11,,,,,,
Health Alliance MCR ADV,CPT,L4386,Non-pneum walk boot pre cst,Durable Medical Equipment,Per Unit,$159.16 ,OP,159.16,549.03,,,,,,
Health Alliance MCR ADV,CPT,L4387,Non-pneum walk boot pre ots,Durable Medical Equipment,Per Unit,$159.16 ,OP,159.16,159.16,,,,,,
Health Alliance MCR ADV,CPT,L4392,Replace afo soft interface,Durable Medical Equipment,Per Unit,$23.62 ,OP,23.62,80.07,,,,,,
Health Alliance MCR ADV,CPT,L4394,Replace foot drop spint,Durable Medical Equipment,Per Unit,$17.23 ,OP,17.23,61,,,,,,
Health Alliance MCR ADV,CPT,L4396,Static or dynami afo pre cst,Durable Medical Equipment,Per Unit,$168.46 ,OP,168.46,579.53,,,,,,
Health Alliance MCR ADV,CPT,L4397,Static or dynami afo pre ots,Durable Medical Equipment,Per Unit,$168.46 ,OP,168.46,168.46,,,,,,
Health Alliance MCR ADV,CPT,L4398,Foot drop splint pre ots,Durable Medical Equipment,Per Unit,$77.54 ,OP,77.54,266.89,,,,,,
Health Alliance MCR ADV,CPT,L4631,Afo- walk boot type- cus fab,Durable Medical Equipment,Per Unit,"$1,479.79 ",OP,"1,479.79","1,479.79",,,,,,
Health Alliance MCR ADV,CPT,L5000,Sho insert w arch toe filler,Durable Medical Equipment,Per Unit,$576.42 ,OP,576.42,"1,982.60",,,,,,
Health Alliance MCR ADV,CPT,L5010,Mold socket ank hgt w/ toe f,Durable Medical Equipment,Per Unit,"$1,610.60 ",OP,"1,610.60","5,539.84",,,,,,
Health Alliance MCR ADV,CPT,L5020,Tibial tubercle hgt w/ toe f,Durable Medical Equipment,Per Unit,"$2,523.29 ",OP,"2,523.29","8,677.68",,,,,,
Health Alliance MCR ADV,CPT,L5050,Ank symes mold sckt sach ft,Durable Medical Equipment,Per Unit,"$2,755.91 ",OP,"2,755.91","9,478.35",,,,,,
Health Alliance MCR ADV,CPT,L5060,Symes met fr leath socket ar,Durable Medical Equipment,Per Unit,"$3,397.24 ",OP,"3,397.24","11,682.09",,,,,,
Health Alliance MCR ADV,CPT,L5100,Molded socket shin sach foot,Durable Medical Equipment,Per Unit,"$2,744.12 ",OP,"2,744.12","9,436.43",,,,,,
Health Alliance MCR ADV,CPT,L5105,Plast socket jts/thgh lacer,Durable Medical Equipment,Per Unit,"$3,872.55 ",OP,"3,872.55","13,317.74",,,,,,
Health Alliance MCR ADV,CPT,L5150,Mold sckt ext knee shin sach,Durable Medical Equipment,Per Unit,"$4,305.35 ",OP,"4,305.35","14,804.69",,,,,,
Health Alliance MCR ADV,CPT,L5160,Mold socket bent knee shin s,Durable Medical Equipment,Per Unit,"$4,727.07 ",OP,"4,727.07","16,257.32",,,,,,
Health Alliance MCR ADV,CPT,L5200,Kne sing axis fric shin sach,Durable Medical Equipment,Per Unit,"$3,656.04 ",OP,"3,656.04","12,574.26",,,,,,
Health Alliance MCR ADV,CPT,L5210,No knee/ankle joints w/ ft b,Durable Medical Equipment,Per Unit,"$2,902.89 ",OP,"2,902.89","9,981.64",,,,,,
Health Alliance MCR ADV,CPT,L5220,No knee joint with artic ali,Durable Medical Equipment,Per Unit,"$3,197.74 ",OP,"3,197.74","10,995.81",,,,,,
Health Alliance MCR ADV,CPT,L5230,Fem focal defic constant fri,Durable Medical Equipment,Per Unit,"$4,796.11 ",OP,"4,796.11","16,493.71",,,,,,
Health Alliance MCR ADV,CPT,L5250,Hip canad sing axi cons fric,Durable Medical Equipment,Per Unit,"$5,623.57 ",OP,"5,623.57","19,341.79",,,,,,
Health Alliance MCR ADV,CPT,L5270,Tilt table locking hip sing,Durable Medical Equipment,Per Unit,"$6,265.76 ",OP,"6,265.76","21,549.33",,,,,,
Health Alliance MCR ADV,CPT,L5280,Hemipelvect canad sing axis,Durable Medical Equipment,Per Unit,"$6,090.55 ",OP,"6,090.55","20,946.94",,,,,,
Health Alliance MCR ADV,CPT,L5301,Bk mold socket sach ft endo,Durable Medical Equipment,Per Unit,"$2,694.66 ",OP,"2,694.66","9,268.66",,,,,,
Health Alliance MCR ADV,CPT,L5312,Knee disart- sach ft- endo,Durable Medical Equipment,Per Unit,"$4,245.62 ",OP,"4,245.62","4,245.62",,,,,,
Health Alliance MCR ADV,CPT,L5321,Ak open end sach,Durable Medical Equipment,Per Unit,"$3,593.24 ",OP,"3,593.24","12,356.94",,,,,,
Health Alliance MCR ADV,CPT,L5331,Hip disart canadian sach ft,Durable Medical Equipment,Per Unit,"$5,262.80 ",OP,"5,262.80","18,098.85",,,,,,
Health Alliance MCR ADV,CPT,L5341,Hemipelvectomy canadian sach,Durable Medical Equipment,Per Unit,"$5,594.28 ",OP,"5,594.28","19,238.85",,,,,,
Health Alliance MCR ADV,CPT,L5400,Postop dress & 1 cast chg bk,Durable Medical Equipment,Per Unit,"$1,604.68 ",OP,"1,604.68","5,516.97",,,,,,
Health Alliance MCR ADV,CPT,L5410,Postop dsg bk ea add cast ch,Durable Medical Equipment,Per Unit,$443.32 ,OP,443.32,"1,525.07",,,,,,
Health Alliance MCR ADV,CPT,L5420,Postop dsg & 1 cast chg ak/d,Durable Medical Equipment,Per Unit,"$2,026.64 ",OP,"2,026.64","6,969.60",,,,,,
Health Alliance MCR ADV,CPT,L5430,Postop dsg ak ea add cast ch,Durable Medical Equipment,Per Unit,$550.12 ,OP,550.12,"1,891.10",,,,,,
Health Alliance MCR ADV,CPT,L5450,Postop app non-wgt bear dsg,Durable Medical Equipment,Per Unit,$475.67 ,OP,475.67,"1,635.64",,,,,,
Health Alliance MCR ADV,CPT,L5460,Postop app non-wgt bear dsg,Durable Medical Equipment,Per Unit,$623.89 ,OP,623.89,"2,146.54",,,,,,
Health Alliance MCR ADV,CPT,L5500,Init bk ptb plaster direct,Durable Medical Equipment,Per Unit,"$1,483.19 ",OP,"1,483.19","5,101.39",,,,,,
Health Alliance MCR ADV,CPT,L5505,Init ak ischal plstr direct,Durable Medical Equipment,Per Unit,"$2,086.44 ",OP,"2,086.44","7,175.49",,,,,,
Health Alliance MCR ADV,CPT,L5510,Prep bk ptb plaster molded,Durable Medical Equipment,Per Unit,"$1,771.18 ",OP,"1,771.18","6,092.69",,,,,,
Health Alliance MCR ADV,CPT,L5520,Perp bk ptb thermopls direct,Durable Medical Equipment,Per Unit,"$1,587.65 ",OP,"1,587.65","5,459.77",,,,,,
Health Alliance MCR ADV,CPT,L5530,Prep bk ptb thermopls molded,Durable Medical Equipment,Per Unit,"$2,087.07 ",OP,"2,087.07","7,179.30",,,,,,
Health Alliance MCR ADV,CPT,L5535,Prep bk ptb open end socket,Durable Medical Equipment,Per Unit,"$1,945.59 ",OP,"1,945.59","6,691.29",,,,,,
Health Alliance MCR ADV,CPT,L5540,Prep bk ptb laminated socket,Durable Medical Equipment,Per Unit,"$2,060.66 ",OP,"2,060.66","7,087.80",,,,,,
Health Alliance MCR ADV,CPT,L5560,Prep ak ischial plast molded,Durable Medical Equipment,Per Unit,"$2,348.01 ",OP,"2,348.01","8,075.28",,,,,,
Health Alliance MCR ADV,CPT,L5570,Prep ak ischial direct form,Durable Medical Equipment,Per Unit,"$2,278.83 ",OP,"2,278.83","7,838.89",,,,,,
Health Alliance MCR ADV,CPT,L5580,Prep ak ischial thermo mold,Durable Medical Equipment,Per Unit,"$2,828.36 ",OP,"2,828.36","9,726.18",,,,,,
Health Alliance MCR ADV,CPT,L5585,Prep ak ischial open end,Durable Medical Equipment,Per Unit,"$3,312.24 ",OP,"3,312.24","11,392.33",,,,,,
Health Alliance MCR ADV,CPT,L5590,Prep ak ischial laminated,Durable Medical Equipment,Per Unit,"$2,948.85 ",OP,"2,948.85","10,141.77",,,,,,
Health Alliance MCR ADV,CPT,L5595,Hip disartic sach thermopls,Durable Medical Equipment,Per Unit,"$4,608.29 ",OP,"4,608.29","15,849.36",,,,,,
Health Alliance MCR ADV,CPT,L5600,Hip disart sach laminat mold,Durable Medical Equipment,Per Unit,"$5,244.91 ",OP,"5,244.91","18,037.85",,,,,,
Health Alliance MCR ADV,CPT,L5610,Above knee hydracadence,Durable Medical Equipment,Per Unit,"$2,529.59 ",OP,"2,529.59","8,700.56",,,,,,
Health Alliance MCR ADV,CPT,L5611,Ak 4 bar link w/fric swing,Durable Medical Equipment,Per Unit,"$1,611.13 ",OP,"1,611.13","5,539.84",,,,,,
Health Alliance MCR ADV,CPT,L5613,Ak 4 bar ling w/hydraul swig,Durable Medical Equipment,Per Unit,"$2,450.64 ",OP,"2,450.64","8,429.87",,,,,,
Health Alliance MCR ADV,CPT,L5614,4-bar link above knee w/swng,Durable Medical Equipment,Per Unit,"$1,697.23 ",OP,"1,697.23","5,837.23",,,,,,
Health Alliance MCR ADV,CPT,L5616,Ak univ multiplex sys frict,Durable Medical Equipment,Per Unit,"$1,477.66 ",OP,"1,477.66","5,082.32",,,,,,
Health Alliance MCR ADV,CPT,L5617,Ak/bk self-aligning unit ea,Durable Medical Equipment,Per Unit,$562.74 ,OP,562.74,"1,936.85",,,,,,
Health Alliance MCR ADV,CPT,L5618,Test socket symes,Durable Medical Equipment,Per Unit,$336.06 ,OP,336.06,"1,155.24",,,,,,
Health Alliance MCR ADV,CPT,L5620,Test socket below knee,Durable Medical Equipment,Per Unit,$298.16 ,OP,298.16,"1,025.61",,,,,,
Health Alliance MCR ADV,CPT,L5622,Test socket knee disarticula,Durable Medical Equipment,Per Unit,$401.70 ,OP,401.7,"1,380.19",,,,,,
Health Alliance MCR ADV,CPT,L5624,Test socket above knee,Durable Medical Equipment,Per Unit,$401.54 ,OP,401.54,"1,380.19",,,,,,
Health Alliance MCR ADV,CPT,L5626,Test socket hip disarticulat,Durable Medical Equipment,Per Unit,$635.70 ,OP,635.7,"2,184.67",,,,,,
Health Alliance MCR ADV,CPT,L5628,Test socket hemipelvectomy,Durable Medical Equipment,Per Unit,$643.74 ,OP,643.74,"2,215.19",,,,,,
Health Alliance MCR ADV,CPT,L5629,Below knee acrylic socket,Durable Medical Equipment,Per Unit,$317.79 ,OP,317.79,"1,094.25",,,,,,
Health Alliance MCR ADV,CPT,L5630,Syme typ expandabl wall sckt,Durable Medical Equipment,Per Unit,$552.17 ,OP,552.17,"1,898.73",,,,,,
Health Alliance MCR ADV,CPT,L5631,Ak/knee disartic acrylic soc,Durable Medical Equipment,Per Unit,$439.37 ,OP,439.37,"1,509.83",,,,,,
Health Alliance MCR ADV,CPT,L5632,Symes type ptb brim design s,Durable Medical Equipment,Per Unit,$270.81 ,OP,270.81,930.3,,,,,,
Health Alliance MCR ADV,CPT,L5634,Symes type poster opening so,Durable Medical Equipment,Per Unit,$338.66 ,OP,338.66,"1,162.87",,,,,,
Health Alliance MCR ADV,CPT,L5636,Symes type medial opening so,Durable Medical Equipment,Per Unit,$258.86 ,OP,258.86,888.36,,,,,,
Health Alliance MCR ADV,CPT,L5637,Below knee total contact,Durable Medical Equipment,Per Unit,$385.17 ,OP,385.17,"1,323.01",,,,,,
Health Alliance MCR ADV,CPT,L5638,Below knee leather socket,Durable Medical Equipment,Per Unit,$648.87 ,OP,648.87,"2,230.43",,,,,,
Health Alliance MCR ADV,CPT,L5639,Below knee wood socket,Durable Medical Equipment,Per Unit,"$1,121.15 ",OP,"1,121.15","3,854.63",,,,,,
Health Alliance MCR ADV,CPT,L5640,Knee disarticulat leather so,Durable Medical Equipment,Per Unit,$736.94 ,OP,736.94,"2,535.44",,,,,,
Health Alliance MCR ADV,CPT,L5642,Above knee leather socket,Durable Medical Equipment,Per Unit,$683.11 ,OP,683.11,"2,348.62",,,,,,
Health Alliance MCR ADV,CPT,L5643,Hip flex inner socket ext fr,Durable Medical Equipment,Per Unit,"$2,014.84 ",OP,"2,014.84","6,927.67",,,,,,
Health Alliance MCR ADV,CPT,L5644,Above knee wood socket,Durable Medical Equipment,Per Unit,$590.63 ,OP,590.63,"2,032.17",,,,,,
Health Alliance MCR ADV,CPT,L5645,Bk flex inner socket ext fra,Durable Medical Equipment,Per Unit,$979.82 ,OP,979.82,"3,370.43",,,,,,
Health Alliance MCR ADV,CPT,L5646,Below knee cushion socket,Durable Medical Equipment,Per Unit,$620.93 ,OP,620.93,"2,135.11",,,,,,
Health Alliance MCR ADV,CPT,L5647,Below knee suction socket,Durable Medical Equipment,Per Unit,$795.44 ,OP,795.44,"2,733.70",,,,,,
Health Alliance MCR ADV,CPT,L5648,Above knee cushion socket,Durable Medical Equipment,Per Unit,$733.68 ,OP,733.68,"2,524.00",,,,,,
Health Alliance MCR ADV,CPT,L5649,Isch containmt/narrow m-l so,Durable Medical Equipment,Per Unit,"$2,465.24 ",OP,"2,465.24","8,479.43",,,,,,
Health Alliance MCR ADV,CPT,L5650,Tot contact ak/knee disart s,Durable Medical Equipment,Per Unit,$488.17 ,OP,488.17,"1,677.58",,,,,,
Health Alliance MCR ADV,CPT,L5651,Ak flex inner socket ext fra,Durable Medical Equipment,Per Unit,"$1,430.29 ",OP,"1,430.29","4,918.37",,,,,,
Health Alliance MCR ADV,CPT,L5652,Suction susp ak/knee disart,Durable Medical Equipment,Per Unit,$435.97 ,OP,435.97,"1,498.39",,,,,,
Health Alliance MCR ADV,CPT,L5653,Knee disart expand wall sock,Durable Medical Equipment,Per Unit,$680.24 ,OP,680.24,"2,341.00",,,,,,
Health Alliance MCR ADV,CPT,L5654,Socket insert symes,Durable Medical Equipment,Per Unit,$394.33 ,OP,394.33,"1,357.32",,,,,,
Health Alliance MCR ADV,CPT,L5655,Socket insert below knee,Durable Medical Equipment,Per Unit,$284.71 ,OP,284.71,979.86,,,,,,
Health Alliance MCR ADV,CPT,L5656,Socket insert knee articulat,Durable Medical Equipment,Per Unit,$432.53 ,OP,432.53,"1,486.95",,,,,,
Health Alliance MCR ADV,CPT,L5658,Socket insert above knee,Durable Medical Equipment,Per Unit,$456.55 ,OP,456.55,"1,570.83",,,,,,
Health Alliance MCR ADV,CPT,L5661,Multi-durometer symes,Durable Medical Equipment,Per Unit,$655.04 ,OP,655.04,"2,253.31",,,,,,
Health Alliance MCR ADV,CPT,L5665,Multi-durometer below knee,Durable Medical Equipment,Per Unit,$582.36 ,OP,582.36,"2,001.67",,,,,,
Health Alliance MCR ADV,CPT,L5666,Below knee cuff suspension,Durable Medical Equipment,Per Unit,$77.11 ,OP,77.11,266.89,,,,,,
Health Alliance MCR ADV,CPT,L5668,Bk molded distal cushion,Durable Medical Equipment,Per Unit,$114.86 ,OP,114.86,396.52,,,,,,
Health Alliance MCR ADV,CPT,L5670,Bk molded supracondylar susp,Durable Medical Equipment,Per Unit,$271.35 ,OP,271.35,934.12,,,,,,
Health Alliance MCR ADV,CPT,L5671,Bk/ak locking mechanism,Durable Medical Equipment,Per Unit,$497.40 ,OP,497.4,"1,711.89",,,,,,
Health Alliance MCR ADV,CPT,L5672,Bk removable medial brim sus,Durable Medical Equipment,Per Unit,$359.07 ,OP,359.07,"1,235.32",,,,,,
Health Alliance MCR ADV,CPT,L5673,Socket insert w lock mech,Durable Medical Equipment,Per Unit,$790.52 ,OP,790.52,"2,718.45",,,,,,
Health Alliance MCR ADV,CPT,L5676,Bk knee joints single axis p,Durable Medical Equipment,Per Unit,$362.36 ,OP,362.36,"1,246.76",,,,,,
Health Alliance MCR ADV,CPT,L5677,Bk knee joints polycentric p,Durable Medical Equipment,Per Unit,$554.97 ,OP,554.97,"1,910.16",,,,,,
Health Alliance MCR ADV,CPT,L5678,Bk joint covers pair,Durable Medical Equipment,Per Unit,$39.70 ,OP,39.7,137.25,,,,,,
Health Alliance MCR ADV,CPT,L5679,Socket insert w/o lock mech,Durable Medical Equipment,Per Unit,$658.75 ,OP,658.75,"2,264.75",,,,,,
Health Alliance MCR ADV,CPT,L5680,Bk thigh lacer non-molded,Durable Medical Equipment,Per Unit,$304.37 ,OP,304.37,"1,048.50",,,,,,
Health Alliance MCR ADV,CPT,L5681,Intl custm cong/latyp insert,Durable Medical Equipment,Per Unit,"$1,323.02 ",OP,"1,323.02","4,548.54",,,,,,
Health Alliance MCR ADV,CPT,L5682,Bk thigh lacer glut/ischia m,Durable Medical Equipment,Per Unit,$625.37 ,OP,625.37,"2,150.36",,,,,,
Health Alliance MCR ADV,CPT,L5683,Initial custom socket insert,Durable Medical Equipment,Per Unit,"$1,323.02 ",OP,"1,323.02","4,548.54",,,,,,
Health Alliance MCR ADV,CPT,L5684,Bk fork strap,Durable Medical Equipment,Per Unit,$48.13 ,OP,48.13,163.95,,,,,,
Health Alliance MCR ADV,CPT,L5685,Below knee sus/seal sleeve,Durable Medical Equipment,Per Unit,$128.85 ,OP,128.85,442.27,,,,,,
Health Alliance MCR ADV,CPT,L5686,Bk back check,Durable Medical Equipment,Per Unit,$57.89 ,OP,57.89,198.25,,,,,,
Health Alliance MCR ADV,CPT,L5688,Bk waist belt webbing,Durable Medical Equipment,Per Unit,$61.48 ,OP,61.48,209.7,,,,,,
Health Alliance MCR ADV,CPT,L5690,Bk waist belt padded and lin,Durable Medical Equipment,Per Unit,$125.50 ,OP,125.5,430.83,,,,,,
Health Alliance MCR ADV,CPT,L5692,Ak pelvic control belt light,Durable Medical Equipment,Per Unit,$132.88 ,OP,132.88,457.52,,,,,,
Health Alliance MCR ADV,CPT,L5694,Ak pelvic control belt pad/l,Durable Medical Equipment,Per Unit,$181.41 ,OP,181.41,625.29,,,,,,
Health Alliance MCR ADV,CPT,L5695,Ak sleeve susp neoprene/equa,Durable Medical Equipment,Per Unit,$163.08 ,OP,163.08,560.47,,,,,,
Health Alliance MCR ADV,CPT,L5696,Ak/knee disartic pelvic join,Durable Medical Equipment,Per Unit,$196.99 ,OP,196.99,678.66,,,,,,
Health Alliance MCR ADV,CPT,L5697,Ak/knee disartic pelvic band,Durable Medical Equipment,Per Unit,$93.55 ,OP,93.55,320.27,,,,,,
Health Alliance MCR ADV,CPT,L5698,Ak/knee disartic silesian ba,Durable Medical Equipment,Per Unit,$120.01 ,OP,120.01,411.78,,,,,,
Health Alliance MCR ADV,CPT,L5699,Shoulder harness,Durable Medical Equipment,Per Unit,$205.11 ,OP,205.11,705.35,,,,,,
Health Alliance MCR ADV,CPT,L5700,Replace socket below knee,Durable Medical Equipment,Per Unit,"$3,085.07 ",OP,"3,085.07","10,610.72",,,,,,
Health Alliance MCR ADV,CPT,L5701,Replace socket above knee,Durable Medical Equipment,Per Unit,"$3,827.32 ",OP,"3,827.32","13,161.41",,,,,,
Health Alliance MCR ADV,CPT,L5702,Replace socket hip,Durable Medical Equipment,Per Unit,"$4,823.75 ",OP,"4,823.75","16,589.03",,,,,,
Health Alliance MCR ADV,CPT,L5703,Symes ankle w/o (sach) foot,Durable Medical Equipment,Per Unit,"$2,537.43 ",OP,"2,537.43","8,727.25",,,,,,
Health Alliance MCR ADV,CPT,L5704,Custom shape cover bk,Durable Medical Equipment,Per Unit,$629.03 ,OP,629.03,"2,161.80",,,,,,
Health Alliance MCR ADV,CPT,L5705,Custom shape cover ak,Durable Medical Equipment,Per Unit,"$1,153.25 ",OP,"1,153.25","3,965.20",,,,,,
Health Alliance MCR ADV,CPT,L5706,Custom shape cvr knee disart,Durable Medical Equipment,Per Unit,"$1,124.85 ",OP,"1,124.85","3,869.89",,,,,,
Health Alliance MCR ADV,CPT,L5707,Custom shape cvr hip disart,Durable Medical Equipment,Per Unit,"$1,511.27 ",OP,"1,511.27","5,196.70",,,,,,
Health Alliance MCR ADV,CPT,L5710,Kne-shin exo sng axi mnl loc,Durable Medical Equipment,Per Unit,$359.65 ,OP,359.65,"1,235.32",,,,,,
Health Alliance MCR ADV,CPT,L5711,Knee-shin exo mnl lock ultra,Durable Medical Equipment,Per Unit,$603.60 ,OP,603.6,"2,074.10",,,,,,
Health Alliance MCR ADV,CPT,L5712,Knee-shin exo frict swg & st,Durable Medical Equipment,Per Unit,$430.88 ,OP,430.88,"1,483.14",,,,,,
Health Alliance MCR ADV,CPT,L5714,Knee-shin exo variable frict,Durable Medical Equipment,Per Unit,$438.43 ,OP,438.43,"1,506.03",,,,,,
Health Alliance MCR ADV,CPT,L5716,Knee-shin exo mech stance ph,Durable Medical Equipment,Per Unit,$866.93 ,OP,866.93,"2,981.52",,,,,,
Health Alliance MCR ADV,CPT,L5718,Knee-shin exo frct swg & sta,Durable Medical Equipment,Per Unit,$927.01 ,OP,927.01,"3,187.41",,,,,,
Health Alliance MCR ADV,CPT,L5722,Knee-shin pneum swg frct exo,Durable Medical Equipment,Per Unit,"$1,127.32 ",OP,"1,127.32","3,877.51",,,,,,
Health Alliance MCR ADV,CPT,L5724,Knee-shin exo fluid swing ph,Durable Medical Equipment,Per Unit,"$1,737.57 ",OP,"1,737.57","5,974.48",,,,,,
Health Alliance MCR ADV,CPT,L5726,Knee-shin ext jnts fld swg e,Durable Medical Equipment,Per Unit,"$2,068.65 ",OP,"2,068.65","7,114.49",,,,,,
Health Alliance MCR ADV,CPT,L5728,Knee-shin fluid swg & stance,Durable Medical Equipment,Per Unit,"$2,424.23 ",OP,"2,424.23","8,338.36",,,,,,
Health Alliance MCR ADV,CPT,L5780,Knee-shin pneum/hydra pneum,Durable Medical Equipment,Per Unit,"$1,334.72 ",OP,"1,334.72","4,590.49",,,,,,
Health Alliance MCR ADV,CPT,L5781,Lower limb pros vacuum pump,Durable Medical Equipment,Per Unit,"$4,024.33 ",OP,"4,024.33","13,840.07",,,,,,
Health Alliance MCR ADV,CPT,L5782,Hd low limb pros vacuum pump,Durable Medical Equipment,Per Unit,"$4,242.55 ",OP,"4,242.55","14,591.17",,,,,,
Health Alliance MCR ADV,CPT,L5785,Exoskeletal bk ultralt mater,Durable Medical Equipment,Per Unit,$519.54 ,OP,519.54,"1,788.15",,,,,,
Health Alliance MCR ADV,CPT,L5790,Exoskeletal ak ultra-light m,Durable Medical Equipment,Per Unit,$749.83 ,OP,749.83,"2,577.38",,,,,,
Health Alliance MCR ADV,CPT,L5795,Exoskel hip ultra-light mate,Durable Medical Equipment,Per Unit,"$1,073.66 ",OP,"1,073.66","3,690.70",,,,,,
Health Alliance MCR ADV,CPT,L5810,Endoskel knee-shin mnl lock,Durable Medical Equipment,Per Unit,$572.04 ,OP,572.04,"1,967.35",,,,,,
Health Alliance MCR ADV,CPT,L5811,Endo knee-shin mnl lck ultra,Durable Medical Equipment,Per Unit,$789.42 ,OP,789.42,"2,714.64",,,,,,
Health Alliance MCR ADV,CPT,L5812,Endo knee-shin frct swg & st,Durable Medical Equipment,Per Unit,$594.07 ,OP,594.07,"2,043.61",,,,,,
Health Alliance MCR ADV,CPT,L5814,Endo knee-shin hydral swg ph,Durable Medical Equipment,Per Unit,"$3,735.37 ",OP,"3,735.37","12,844.96",,,,,,
Health Alliance MCR ADV,CPT,L5816,Endo knee-shin polyc mch sta,Durable Medical Equipment,Per Unit,$850.43 ,OP,850.43,"2,924.33",,,,,,
Health Alliance MCR ADV,CPT,L5818,Endo knee-shin frct swg & st,Durable Medical Equipment,Per Unit,$960.30 ,OP,960.3,"3,301.79",,,,,,
Health Alliance MCR ADV,CPT,L5822,Endo knee-shin pneum swg frc,Durable Medical Equipment,Per Unit,"$1,761.65 ",OP,"1,761.65","6,058.37",,,,,,
Health Alliance MCR ADV,CPT,L5824,Endo knee-shin fluid swing p,Durable Medical Equipment,Per Unit,"$1,665.27 ",OP,"1,665.27","5,726.65",,,,,,
Health Alliance MCR ADV,CPT,L5826,Miniature knee joint,Durable Medical Equipment,Per Unit,"$3,140.97 ",OP,"3,140.97","10,801.35",,,,,,
Health Alliance MCR ADV,CPT,L5828,Endo knee-shin fluid swg/sta,Durable Medical Equipment,Per Unit,"$2,963.78 ",OP,"2,963.78","10,191.33",,,,,,
Health Alliance MCR ADV,CPT,L5830,Endo knee-shin pneum/swg pha,Durable Medical Equipment,Per Unit,"$1,998.37 ",OP,"1,998.37","6,874.29",,,,,,
Health Alliance MCR ADV,CPT,L5840,Multi-axial knee/shin system,Durable Medical Equipment,Per Unit,"$3,922.28 ",OP,"3,922.28","13,489.32",,,,,,
Health Alliance MCR ADV,CPT,L5845,Knee-shin sys stance flexion,Durable Medical Equipment,Per Unit,"$1,802.73 ",OP,"1,802.73","6,199.43",,,,,,
Health Alliance MCR ADV,CPT,L5848,Knee-shin sys hydraul stance,Durable Medical Equipment,Per Unit,"$1,081.55 ",OP,"1,081.55","3,721.19",,,,,,
Health Alliance MCR ADV,CPT,L5850,Endo ak/hip knee extens assi,Durable Medical Equipment,Per Unit,$127.92 ,OP,127.92,438.47,,,,,,
Health Alliance MCR ADV,CPT,L5855,Mech hip extension assist,Durable Medical Equipment,Per Unit,$308.82 ,OP,308.82,"1,063.73",,,,,,
Health Alliance MCR ADV,CPT,L5856,Elec knee-shin swing/stance,Durable Medical Equipment,Per Unit,"$24,144.68 ",OP,"24,144.68","83,036.63",,,,,,
Health Alliance MCR ADV,CPT,L5857,Elec knee-shin swing only,Durable Medical Equipment,Per Unit,"$8,567.44 ",OP,"8,567.44","29,464.49",,,,,,
Health Alliance MCR ADV,CPT,L5858,Stance phase only,Durable Medical Equipment,Per Unit,"$18,692.70 ",OP,"18,692.70","64,285.82",,,,,,
Health Alliance MCR ADV,CPT,L5859,Knee-shin pro flex/ext cont,Durable Medical Equipment,Per Unit,"$14,593.21 ",OP,"14,593.21","14,593.21",,,,,,
Health Alliance MCR ADV,CPT,L5910,Endo below knee alignable sy,Durable Medical Equipment,Per Unit,$362.17 ,OP,362.17,"1,246.76",,,,,,
Health Alliance MCR ADV,CPT,L5920,Endo ak/hip alignable system,Durable Medical Equipment,Per Unit,$530.58 ,OP,530.58,"1,826.28",,,,,,
Health Alliance MCR ADV,CPT,L5925,Above knee manual lock,Durable Medical Equipment,Per Unit,$336.00 ,OP,336,"1,155.24",,,,,,
Health Alliance MCR ADV,CPT,L5930,High activity knee frame,Durable Medical Equipment,Per Unit,"$3,385.39 ",OP,"3,385.39","11,643.96",,,,,,
Health Alliance MCR ADV,CPT,L5940,Endo bk ultra-light material,Durable Medical Equipment,Per Unit,$501.60 ,OP,501.6,"1,723.33",,,,,,
Health Alliance MCR ADV,CPT,L5950,Endo ak ultra-light material,Durable Medical Equipment,Per Unit,$777.99 ,OP,777.99,"2,676.51",,,,,,
Health Alliance MCR ADV,CPT,L5960,Endo hip ultra-light materia,Durable Medical Equipment,Per Unit,"$1,163.29 ",OP,"1,163.29","3,999.51",,,,,,
Health Alliance MCR ADV,CPT,L5961,Endo poly hip- pneu/hyd/rot,Durable Medical Equipment,Per Unit,"$4,800.88 ",OP,"4,800.88","4,800.88",,,,,,
Health Alliance MCR ADV,CPT,L5962,Below knee flex cover system,Durable Medical Equipment,Per Unit,$587.78 ,OP,587.78,"2,020.72",,,,,,
Health Alliance MCR ADV,CPT,L5964,Above knee flex cover system,Durable Medical Equipment,Per Unit,"$1,127.47 ",OP,"1,127.47","3,877.51",,,,,,
Health Alliance MCR ADV,CPT,L5966,Hip flexible cover system,Durable Medical Equipment,Per Unit,"$1,452.38 ",OP,"1,452.38","4,994.63",,,,,,
Health Alliance MCR ADV,CPT,L5968,Multiaxial ankle w dorsiflex,Durable Medical Equipment,Per Unit,"$3,654.91 ",OP,"3,654.91","12,570.45",,,,,,
Health Alliance MCR ADV,CPT,L5970,Foot external keel sach foot,Durable Medical Equipment,Per Unit,$218.47 ,OP,218.47,751.1,,,,,,
Health Alliance MCR ADV,CPT,L5971,Sach foot- replacement,Durable Medical Equipment,Per Unit,$218.47 ,OP,218.47,751.1,,,,,,
Health Alliance MCR ADV,CPT,L5972,Flexible keel foot,Durable Medical Equipment,Per Unit,$397.97 ,OP,397.97,"1,368.75",,,,,,
Health Alliance MCR ADV,CPT,L5973,Ank-foot sys dors-plant flex,Durable Medical Equipment,Per Unit,"$17,757.02 ",OP,"17,757.02","17,757.02",,,,,,
Health Alliance MCR ADV,CPT,L5974,Foot single axis ankle/foot,Durable Medical Equipment,Per Unit,$233.03 ,OP,233.03,800.67,,,,,,
Health Alliance MCR ADV,CPT,L5975,Combo ankle/foot prosthesis,Durable Medical Equipment,Per Unit,$466.28 ,OP,466.28,"1,605.15",,,,,,
Health Alliance MCR ADV,CPT,L5976,Energy storing foot,Durable Medical Equipment,Per Unit,$591.07 ,OP,591.07,"2,032.17",,,,,,
Health Alliance MCR ADV,CPT,L5978,Ft prosth multiaxial ankl/ft,Durable Medical Equipment,Per Unit,$313.20 ,OP,313.2,"1,078.99",,,,,,
Health Alliance MCR ADV,CPT,L5979,Multi-axial ankle/ft prosth,Durable Medical Equipment,Per Unit,"$2,507.69 ",OP,"2,507.69","8,624.30",,,,,,
Health Alliance MCR ADV,CPT,L5980,Flex foot system,Durable Medical Equipment,Per Unit,"$3,820.69 ",OP,"3,820.69","13,138.54",,,,,,
Health Alliance MCR ADV,CPT,L5981,Flex-walk sys low ext prosth,Durable Medical Equipment,Per Unit,"$3,431.91 ",OP,"3,431.91","11,804.09",,,,,,
Health Alliance MCR ADV,CPT,L5982,Exoskeletal axial rotation u,Durable Medical Equipment,Per Unit,$644.71 ,OP,644.71,"2,218.98",,,,,,
Health Alliance MCR ADV,CPT,L5984,Endoskeletal axial rotation,Durable Medical Equipment,Per Unit,$646.71 ,OP,646.71,"2,222.79",,,,,,
Health Alliance MCR ADV,CPT,L5985,Lwr ext dynamic prosth pylon,Durable Medical Equipment,Per Unit,$284.02 ,OP,284.02,976.05,,,,,,
Health Alliance MCR ADV,CPT,L5986,Multi-axial rotation unit,Durable Medical Equipment,Per Unit,$780.11 ,OP,780.11,"2,684.14",,,,,,
Health Alliance MCR ADV,CPT,L5987,Shank ft w vert load pylon,Durable Medical Equipment,Per Unit,"$7,235.38 ",OP,"7,235.38","24,881.63",,,,,,
Health Alliance MCR ADV,CPT,L5988,Vertical shock reducing pylo,Durable Medical Equipment,Per Unit,"$2,009.25 ",OP,"2,009.25","6,908.59",,,,,,
Health Alliance MCR ADV,CPT,L5990,User adjustable heel height,Durable Medical Equipment,Per Unit,"$1,824.64 ",OP,"1,824.64","6,275.69",,,,,,
Health Alliance MCR ADV,CPT,L6000,Part hand thumb rem,Durable Medical Equipment,Per Unit,"$1,771.55 ",OP,"1,771.55","6,092.69",,,,,,
Health Alliance MCR ADV,CPT,L6010,Part hand little/ring,Durable Medical Equipment,Per Unit,"$1,971.44 ",OP,"1,971.44","6,778.98",,,,,,
Health Alliance MCR ADV,CPT,L6020,Part hand no fingers,Durable Medical Equipment,Per Unit,"$1,838.05 ",OP,"1,838.05","6,321.45",,,,,,
Health Alliance MCR ADV,CPT,L6026,Part hand myo exclu term dev,Durable Medical Equipment,Per Unit,"$4,375.03 ",OP,"4,375.03","4,375.03",,,,,,
Health Alliance MCR ADV,CPT,L6050,Wrst mld sck flx hng tri pad,Durable Medical Equipment,Per Unit,"$2,500.12 ",OP,"2,500.12","8,597.63",,,,,,
Health Alliance MCR ADV,CPT,L6055,Wrst mold sock w/exp interfa,Durable Medical Equipment,Per Unit,"$3,189.04 ",OP,"3,189.04","10,969.11",,,,,,
Health Alliance MCR ADV,CPT,L6100,Elb mold sock flex hinge pad,Durable Medical Equipment,Per Unit,"$2,530.04 ",OP,"2,530.04","8,700.56",,,,,,
Health Alliance MCR ADV,CPT,L6110,Elbow mold sock suspension t,Durable Medical Equipment,Per Unit,"$2,676.61 ",OP,"2,676.61","9,203.84",,,,,,
Health Alliance MCR ADV,CPT,L6120,Elbow mold doub splt soc ste,Durable Medical Equipment,Per Unit,"$3,027.26 ",OP,"3,027.26","10,412.46",,,,,,
Health Alliance MCR ADV,CPT,L6130,Elbow stump activated lock h,Durable Medical Equipment,Per Unit,"$3,193.82 ",OP,"3,193.82","10,984.37",,,,,,
Health Alliance MCR ADV,CPT,L6200,Elbow mold outsid lock hinge,Durable Medical Equipment,Per Unit,"$3,290.01 ",OP,"3,290.01","11,316.08",,,,,,
Health Alliance MCR ADV,CPT,L6205,Elbow molded w/ expand inter,Durable Medical Equipment,Per Unit,"$4,538.50 ",OP,"4,538.50","15,609.16",,,,,,
Health Alliance MCR ADV,CPT,L6250,Elbow inter loc elbow forarm,Durable Medical Equipment,Per Unit,"$3,236.79 ",OP,"3,236.79","11,133.06",,,,,,
Health Alliance MCR ADV,CPT,L6300,Shlder disart int lock elbow,Durable Medical Equipment,Per Unit,"$4,464.43 ",OP,"4,464.43","15,353.72",,,,,,
Health Alliance MCR ADV,CPT,L6310,Shoulder passive restor comp,Durable Medical Equipment,Per Unit,"$4,046.04 ",OP,"4,046.04","13,916.32",,,,,,
Health Alliance MCR ADV,CPT,L6320,Shoulder passive restor cap,Durable Medical Equipment,Per Unit,"$2,108.67 ",OP,"2,108.67","7,251.74",,,,,,
Health Alliance MCR ADV,CPT,L6350,Thoracic intern lock elbow,Durable Medical Equipment,Per Unit,"$4,891.63 ",OP,"4,891.63","16,821.60",,,,,,
Health Alliance MCR ADV,CPT,L6360,Thoracic passive restor comp,Durable Medical Equipment,Per Unit,"$4,246.80 ",OP,"4,246.80","14,606.43",,,,,,
Health Alliance MCR ADV,CPT,L6370,Thoracic passive restor cap,Durable Medical Equipment,Per Unit,"$2,462.85 ",OP,"2,462.85","8,471.79",,,,,,
Health Alliance MCR ADV,CPT,L6380,Postop dsg cast chg wrst/elb,Durable Medical Equipment,Per Unit,"$1,424.44 ",OP,"1,424.44","4,899.32",,,,,,
Health Alliance MCR ADV,CPT,L6382,Postop dsg cast chg elb dis/,Durable Medical Equipment,Per Unit,"$1,695.74 ",OP,"1,695.74","5,833.42",,,,,,
Health Alliance MCR ADV,CPT,L6384,Postop dsg cast chg shlder/t,Durable Medical Equipment,Per Unit,"$2,145.20 ",OP,"2,145.20","7,377.56",,,,,,
Health Alliance MCR ADV,CPT,L6386,Postop ea cast chg & realign,Durable Medical Equipment,Per Unit,$470.24 ,OP,470.24,"1,616.58",,,,,,
Health Alliance MCR ADV,CPT,L6388,Postop applicat rigid dsg on,Durable Medical Equipment,Per Unit,$517.85 ,OP,517.85,"1,780.53",,,,,,
Health Alliance MCR ADV,CPT,L6400,Below elbow prosth tiss shap,Durable Medical Equipment,Per Unit,"$2,736.86 ",OP,"2,736.86","9,413.54",,,,,,
Health Alliance MCR ADV,CPT,L6450,Elb disart prosth tiss shap,Durable Medical Equipment,Per Unit,"$3,576.94 ",OP,"3,576.94","12,299.74",,,,,,
Health Alliance MCR ADV,CPT,L6500,Above elbow prosth tiss shap,Durable Medical Equipment,Per Unit,"$3,512.48 ",OP,"3,512.48","12,078.62",,,,,,
Health Alliance MCR ADV,CPT,L6550,Shldr disar prosth tiss shap,Durable Medical Equipment,Per Unit,"$4,549.39 ",OP,"4,549.39","15,647.29",,,,,,
Health Alliance MCR ADV,CPT,L6570,Scap thorac prosth tiss shap,Durable Medical Equipment,Per Unit,"$5,078.79 ",OP,"5,078.79","17,465.96",,,,,,
Health Alliance MCR ADV,CPT,L6580,Wrist/elbow bowden cable mol,Durable Medical Equipment,Per Unit,"$2,030.62 ",OP,"2,030.62","6,984.85",,,,,,
Health Alliance MCR ADV,CPT,L6582,Wrist/elbow bowden cbl dir f,Durable Medical Equipment,Per Unit,"$1,705.44 ",OP,"1,705.44","5,863.93",,,,,,
Health Alliance MCR ADV,CPT,L6584,Elbow fair lead cable molded,Durable Medical Equipment,Per Unit,"$2,525.30 ",OP,"2,525.30","8,685.31",,,,,,
Health Alliance MCR ADV,CPT,L6586,Elbow fair lead cable dir fo,Durable Medical Equipment,Per Unit,"$2,250.20 ",OP,"2,250.20","7,739.77",,,,,,
Health Alliance MCR ADV,CPT,L6588,Shdr fair lead cable molded,Durable Medical Equipment,Per Unit,"$3,583.73 ",OP,"3,583.73","12,326.44",,,,,,
Health Alliance MCR ADV,CPT,L6590,Shdr fair lead cable direct,Durable Medical Equipment,Per Unit,"$3,123.36 ",OP,"3,123.36","10,740.36",,,,,,
Health Alliance MCR ADV,CPT,L6600,Polycentric hinge pair,Durable Medical Equipment,Per Unit,$228.13 ,OP,228.13,785.42,,,,,,
Health Alliance MCR ADV,CPT,L6605,Single pivot hinge pair,Durable Medical Equipment,Per Unit,$234.81 ,OP,234.81,808.29,,,,,,
Health Alliance MCR ADV,CPT,L6610,Flexible metal hinge pair,Durable Medical Equipment,Per Unit,$221.98 ,OP,221.98,762.54,,,,,,
Health Alliance MCR ADV,CPT,L6611,Additional switch- ext power,Durable Medical Equipment,Per Unit,$414.10 ,OP,414.1,"1,425.95",,,,,,
Health Alliance MCR ADV,CPT,L6615,Disconnect locking wrist uni,Durable Medical Equipment,Per Unit,$215.48 ,OP,215.48,739.67,,,,,,
Health Alliance MCR ADV,CPT,L6616,Disconnect insert locking wr,Durable Medical Equipment,Per Unit,$64.86 ,OP,64.86,224.95,,,,,,
Health Alliance MCR ADV,CPT,L6620,Flexion/extension wrist unit,Durable Medical Equipment,Per Unit,$376.69 ,OP,376.69,"1,296.32",,,,,,
Health Alliance MCR ADV,CPT,L6621,Flex/ext wrist w/wo friction,Durable Medical Equipment,Per Unit,"$2,300.54 ",OP,"2,300.54","7,911.34",,,,,,
Health Alliance MCR ADV,CPT,L6623,Spring-ass rot wrst w/ latch,Durable Medical Equipment,Per Unit,$717.59 ,OP,717.59,"2,466.81",,,,,,
Health Alliance MCR ADV,CPT,L6624,Flex/ext/rotation wrist unit,Durable Medical Equipment,Per Unit,"$3,787.86 ",OP,"3,787.86","13,027.98",,,,,,
Health Alliance MCR ADV,CPT,L6625,Rotation wrst w/ cable lock,Durable Medical Equipment,Per Unit,$531.84 ,OP,531.84,"1,830.09",,,,,,
Health Alliance MCR ADV,CPT,L6628,Quick disconn hook adapter o,Durable Medical Equipment,Per Unit,$572.47 ,OP,572.47,"1,967.35",,,,,,
Health Alliance MCR ADV,CPT,L6629,Lamination collar w/ couplin,Durable Medical Equipment,Per Unit,$195.07 ,OP,195.07,671.03,,,,,,
Health Alliance MCR ADV,CPT,L6630,Stainless steel any wrist,Durable Medical Equipment,Per Unit,$287.35 ,OP,287.35,987.49,,,,,,
Health Alliance MCR ADV,CPT,L6632,Latex suspension sleeve each,Durable Medical Equipment,Per Unit,$64.97 ,OP,64.97,224.95,,,,,,
Health Alliance MCR ADV,CPT,L6635,Lift assist for elbow,Durable Medical Equipment,Per Unit,$207.68 ,OP,207.68,712.98,,,,,,
Health Alliance MCR ADV,CPT,L6637,Nudge control elbow lock,Durable Medical Equipment,Per Unit,$406.60 ,OP,406.6,"1,399.26",,,,,,
Health Alliance MCR ADV,CPT,L6638,Elec lock on manual pw elbow,Durable Medical Equipment,Per Unit,"$2,515.20 ",OP,"2,515.20","8,651.00",,,,,,
Health Alliance MCR ADV,CPT,L6640,Shoulder abduction joint pai,Durable Medical Equipment,Per Unit,$338.63 ,OP,338.63,"1,162.87",,,,,,
Health Alliance MCR ADV,CPT,L6641,Excursion amplifier pulley t,Durable Medical Equipment,Per Unit,$197.18 ,OP,197.18,678.66,,,,,,
Health Alliance MCR ADV,CPT,L6642,Excursion amplifier lever ty,Durable Medical Equipment,Per Unit,$289.92 ,OP,289.92,998.92,,,,,,
Health Alliance MCR ADV,CPT,L6645,Shoulder flexion-abduction j,Durable Medical Equipment,Per Unit,$366.21 ,OP,366.21,"1,258.19",,,,,,
Health Alliance MCR ADV,CPT,L6646,Multipo locking shoulder jnt,Durable Medical Equipment,Per Unit,"$3,172.24 ",OP,"3,172.24","10,908.12",,,,,,
Health Alliance MCR ADV,CPT,L6647,Shoulder lock actuator,Durable Medical Equipment,Per Unit,$522.26 ,OP,522.26,"1,795.78",,,,,,
Health Alliance MCR ADV,CPT,L6648,Ext pwrd shlder lock/unlock,Durable Medical Equipment,Per Unit,"$3,271.71 ",OP,"3,271.71","11,251.26",,,,,,
Health Alliance MCR ADV,CPT,L6650,Shoulder universal joint,Durable Medical Equipment,Per Unit,$397.20 ,OP,397.2,"1,364.94",,,,,,
Health Alliance MCR ADV,CPT,L6655,Standard control cable extra,Durable Medical Equipment,Per Unit,$77.05 ,OP,77.05,263.08,,,,,,
Health Alliance MCR ADV,CPT,L6660,Heavy duty control cable,Durable Medical Equipment,Per Unit,$103.11 ,OP,103.11,354.58,,,,,,
Health Alliance MCR ADV,CPT,L6665,Teflon or equal cable lining,Durable Medical Equipment,Per Unit,$46.05 ,OP,46.05,160.13,,,,,,
Health Alliance MCR ADV,CPT,L6670,Hook to hand cable adapter,Durable Medical Equipment,Per Unit,$47.96 ,OP,47.96,163.95,,,,,,
Health Alliance MCR ADV,CPT,L6672,Harness chest/shlder saddle,Durable Medical Equipment,Per Unit,$220.08 ,OP,220.08,758.72,,,,,,
Health Alliance MCR ADV,CPT,L6675,Harness figure of 8 sing con,Durable Medical Equipment,Per Unit,$120.09 ,OP,120.09,411.78,,,,,,
Health Alliance MCR ADV,CPT,L6676,Harness figure of 8 dual con,Durable Medical Equipment,Per Unit,$125.64 ,OP,125.64,430.83,,,,,,
Health Alliance MCR ADV,CPT,L6677,Ue triple control harness,Durable Medical Equipment,Per Unit,$298.35 ,OP,298.35,"1,025.61",,,,,,
Health Alliance MCR ADV,CPT,L6680,Test sock wrist disart/bel e,Durable Medical Equipment,Per Unit,$309.33 ,OP,309.33,"1,063.73",,,,,,
Health Alliance MCR ADV,CPT,L6682,Test sock elbw disart/above,Durable Medical Equipment,Per Unit,$342.01 ,OP,342.01,"1,178.12",,,,,,
Health Alliance MCR ADV,CPT,L6684,Test socket shldr disart/tho,Durable Medical Equipment,Per Unit,$464.75 ,OP,464.75,"1,597.52",,,,,,
Health Alliance MCR ADV,CPT,L6686,Suction socket,Durable Medical Equipment,Per Unit,$689.63 ,OP,689.63,"2,371.49",,,,,,
Health Alliance MCR ADV,CPT,L6687,Frame typ socket bel elbow/w,Durable Medical Equipment,Per Unit,$576.80 ,OP,576.8,"1,982.60",,,,,,
Health Alliance MCR ADV,CPT,L6688,Frame typ sock above elb/dis,Durable Medical Equipment,Per Unit,$638.36 ,OP,638.36,"2,196.11",,,,,,
Health Alliance MCR ADV,CPT,L6689,Frame typ socket shoulder di,Durable Medical Equipment,Per Unit,$760.81 ,OP,760.81,"2,615.51",,,,,,
Health Alliance MCR ADV,CPT,L6690,Frame typ sock interscap-tho,Durable Medical Equipment,Per Unit,$895.74 ,OP,895.74,"3,080.66",,,,,,
Health Alliance MCR ADV,CPT,L6691,Removable insert each,Durable Medical Equipment,Per Unit,$353.58 ,OP,353.58,"1,216.24",,,,,,
Health Alliance MCR ADV,CPT,L6692,Silicone gel insert or equal,Durable Medical Equipment,Per Unit,$643.25 ,OP,643.25,"2,211.37",,,,,,
Health Alliance MCR ADV,CPT,L6693,Lockingelbow forearm cntrbal,Durable Medical Equipment,Per Unit,"$2,855.43 ",OP,"2,855.43","9,821.50",,,,,,
Health Alliance MCR ADV,CPT,L6694,Elbow socket ins use w/lock,Durable Medical Equipment,Per Unit,$790.52 ,OP,790.52,"2,718.45",,,,,,
Health Alliance MCR ADV,CPT,L6695,Elbow socket ins use w/o lck,Durable Medical Equipment,Per Unit,$658.75 ,OP,658.75,"2,264.75",,,,,,
Health Alliance MCR ADV,CPT,L6696,Cus elbo skt in for con/atyp,Durable Medical Equipment,Per Unit,"$1,323.02 ",OP,"1,323.02","4,548.54",,,,,,
Health Alliance MCR ADV,CPT,L6697,Cus elbo skt in not con/atyp,Durable Medical Equipment,Per Unit,"$1,323.02 ",OP,"1,323.02","4,548.54",,,,,,
Health Alliance MCR ADV,CPT,L6698,Below/above elbow lock mech,Durable Medical Equipment,Per Unit,$497.40 ,OP,497.4,"1,711.89",,,,,,
Health Alliance MCR ADV,CPT,L6703,Term dev- passive hand mitt,Durable Medical Equipment,Per Unit,$351.79 ,OP,351.79,"1,208.62",,,,,,
Health Alliance MCR ADV,CPT,L6704,Term dev- sport/rec/work att,Durable Medical Equipment,Per Unit,$679.06 ,OP,679.06,"2,337.18",,,,,,
Health Alliance MCR ADV,CPT,L6706,Term dev mech hook vol open,Durable Medical Equipment,Per Unit,$421.40 ,OP,421.4,"1,448.82",,,,,,
Health Alliance MCR ADV,CPT,L6707,Term dev mech hook vol close,Durable Medical Equipment,Per Unit,"$1,490.70 ",OP,"1,490.70","5,128.07",,,,,,
Health Alliance MCR ADV,CPT,L6708,Term dev mech hand vol open,Durable Medical Equipment,Per Unit,$985.41 ,OP,985.41,"3,389.47",,,,,,
Health Alliance MCR ADV,CPT,L6709,Term dev mech hand vol close,Durable Medical Equipment,Per Unit,"$1,398.55 ",OP,"1,398.55","4,811.61",,,,,,
Health Alliance MCR ADV,CPT,L6711,Ped term dev- hook- vol open,Durable Medical Equipment,Per Unit,$676.19 ,OP,676.19,"2,325.74",,,,,,
Health Alliance MCR ADV,CPT,L6712,Ped term dev- hook- vol clos,Durable Medical Equipment,Per Unit,"$1,245.05 ",OP,"1,245.05","4,281.66",,,,,,
Health Alliance MCR ADV,CPT,L6713,Ped term dev- hand- vol open,Durable Medical Equipment,Per Unit,"$1,571.33 ",OP,"1,571.33","5,402.59",,,,,,
Health Alliance MCR ADV,CPT,L6714,Ped term dev- hand- vol clos,Durable Medical Equipment,Per Unit,"$1,330.91 ",OP,"1,330.91","4,579.05",,,,,,
Health Alliance MCR ADV,CPT,L6715,Term device- multi art digit,Durable Medical Equipment,Per Unit,"$3,175.42 ",OP,"3,175.42","3,175.42",,,,,,
Health Alliance MCR ADV,CPT,L6721,Hook/hand- hvy dty- vol open,Durable Medical Equipment,Per Unit,"$2,365.59 ",OP,"2,365.59","8,136.28",,,,,,
Health Alliance MCR ADV,CPT,L6722,Hook/hand- hvy dty- vol clos,Durable Medical Equipment,Per Unit,"$2,039.28 ",OP,"2,039.28","7,011.54",,,,,,
Health Alliance MCR ADV,CPT,L6805,Term dev modifier wrist unit,Durable Medical Equipment,Per Unit,$385.75 ,OP,385.75,"1,326.82",,,,,,
Health Alliance MCR ADV,CPT,L6810,Term dev precision pinch dev,Durable Medical Equipment,Per Unit,$205.07 ,OP,205.07,705.35,,,,,,
Health Alliance MCR ADV,CPT,L6880,Elec hand ind art digits,Durable Medical Equipment,Per Unit,"$24,030.68 ",OP,"24,030.68","24,030.68",,,,,,
Health Alliance MCR ADV,CPT,L6881,Term dev auto grasp feature,Durable Medical Equipment,Per Unit,"$4,111.91 ",OP,"4,111.91","14,141.27",,,,,,
Health Alliance MCR ADV,CPT,L6882,Microprocessor control uplmb,Durable Medical Equipment,Per Unit,"$3,119.08 ",OP,"3,119.08","10,725.10",,,,,,
Health Alliance MCR ADV,CPT,L6883,Replc sockt below e/w disa,Durable Medical Equipment,Per Unit,"$1,997.96 ",OP,"1,997.96","6,870.47",,,,,,
Health Alliance MCR ADV,CPT,L6884,Replc sockt above elbow disa,Durable Medical Equipment,Per Unit,"$2,733.67 ",OP,"2,733.67","9,402.10",,,,,,
Health Alliance MCR ADV,CPT,L6885,Replc sockt shldr dis/interc,Durable Medical Equipment,Per Unit,"$4,246.80 ",OP,"4,246.80","14,606.43",,,,,,
Health Alliance MCR ADV,CPT,L6890,Prefab glove for term device,Durable Medical Equipment,Per Unit,$200.88 ,OP,200.88,690.1,,,,,,
Health Alliance MCR ADV,CPT,L6895,Custom glove for term device,Durable Medical Equipment,Per Unit,$671.68 ,OP,671.68,"2,310.49",,,,,,
Health Alliance MCR ADV,CPT,L6900,Hand restorat thumb/1 finger,Durable Medical Equipment,Per Unit,"$1,950.52 ",OP,"1,950.52","6,706.52",,,,,,
Health Alliance MCR ADV,CPT,L6905,Hand restoration multiple fi,Durable Medical Equipment,Per Unit,"$1,930.47 ",OP,"1,930.47","6,637.91",,,,,,
Health Alliance MCR ADV,CPT,L6910,Hand restoration no fingers,Durable Medical Equipment,Per Unit,"$1,897.78 ",OP,"1,897.78","6,527.33",,,,,,
Health Alliance MCR ADV,CPT,L6915,Hand restoration replacmnt g,Durable Medical Equipment,Per Unit,$815.40 ,OP,815.4,"2,806.14",,,,,,
Health Alliance MCR ADV,CPT,L6920,Wrist disarticul switch ctrl,Durable Medical Equipment,Per Unit,"$8,425.39 ",OP,"8,425.39","28,976.47",,,,,,
Health Alliance MCR ADV,CPT,L6925,Wrist disart myoelectronic c,Durable Medical Equipment,Per Unit,"$9,001.12 ",OP,"9,001.12","30,955.25",,,,,,
Health Alliance MCR ADV,CPT,L6930,Below elbow switch control,Durable Medical Equipment,Per Unit,"$8,114.82 ",OP,"8,114.82","27,908.91",,,,,,
Health Alliance MCR ADV,CPT,L6935,Below elbow myoelectronic ct,Durable Medical Equipment,Per Unit,"$8,958.82 ",OP,"8,958.82","30,810.37",,,,,,
Health Alliance MCR ADV,CPT,L6940,Elbow disarticulation switch,Durable Medical Equipment,Per Unit,"$10,478.90 ",OP,"10,478.90","36,037.57",,,,,,
Health Alliance MCR ADV,CPT,L6945,Elbow disart myoelectronic c,Durable Medical Equipment,Per Unit,"$11,690.57 ",OP,"11,690.57","40,204.84",,,,,,
Health Alliance MCR ADV,CPT,L6950,Above elbow switch control,Durable Medical Equipment,Per Unit,"$10,459.47 ",OP,"10,459.47","35,972.77",,,,,,
Health Alliance MCR ADV,CPT,L6955,Above elbow myoelectronic ct,Durable Medical Equipment,Per Unit,"$12,129.70 ",OP,"12,129.70","41,714.68",,,,,,
Health Alliance MCR ADV,CPT,L6960,Shldr disartic switch contro,Durable Medical Equipment,Per Unit,"$12,759.97 ",OP,"12,759.97","43,884.09",,,,,,
Health Alliance MCR ADV,CPT,L6965,Shldr disartic myoelectronic,Durable Medical Equipment,Per Unit,"$15,116.16 ",OP,"15,116.16","51,986.07",,,,,,
Health Alliance MCR ADV,CPT,L6970,Interscapular-thor switch ct,Durable Medical Equipment,Per Unit,"$16,180.17 ",OP,"16,180.17","55,646.26",,,,,,
Health Alliance MCR ADV,CPT,L6975,Interscap-thor myoelectronic,Durable Medical Equipment,Per Unit,"$17,834.37 ",OP,"17,834.37","61,334.79",,,,,,
Health Alliance MCR ADV,CPT,L7007,Adult electric hand,Durable Medical Equipment,Per Unit,"$3,673.63 ",OP,"3,673.63","12,635.27",,,,,,
Health Alliance MCR ADV,CPT,L7008,Pediatric electric hand,Durable Medical Equipment,Per Unit,"$5,696.71 ",OP,"5,696.71","19,593.43",,,,,,
Health Alliance MCR ADV,CPT,L7009,Adult electric hook,Durable Medical Equipment,Per Unit,"$3,758.57 ",OP,"3,758.57","12,925.03",,,,,,
Health Alliance MCR ADV,CPT,L7040,Prehensile actuator,Durable Medical Equipment,Per Unit,"$3,059.23 ",OP,"3,059.23","10,519.22",,,,,,
Health Alliance MCR ADV,CPT,L7045,Pediatric electric hook,Durable Medical Equipment,Per Unit,"$1,616.29 ",OP,"1,616.29","5,558.92",,,,,,
Health Alliance MCR ADV,CPT,L7170,Electronic elbow hosmer swit,Durable Medical Equipment,Per Unit,"$6,050.00 ",OP,"6,050.00","20,805.87",,,,,,
Health Alliance MCR ADV,CPT,L7180,Electronic elbow sequential,Durable Medical Equipment,Per Unit,"$39,141.46 ",OP,"39,141.46","134,610.92",,,,,,
Health Alliance MCR ADV,CPT,L7181,Electronic elbo simultaneous,Durable Medical Equipment,Per Unit,"$40,299.84 ",OP,"40,299.84","138,595.19",,,,,,
Health Alliance MCR ADV,CPT,L7185,Electron elbow adolescent sw,Durable Medical Equipment,Per Unit,"$6,360.51 ",OP,"6,360.51","21,873.42",,,,,,
Health Alliance MCR ADV,CPT,L7186,Electron elbow child switch,Durable Medical Equipment,Per Unit,"$10,692.92 ",OP,"10,692.92","36,773.42",,,,,,
Health Alliance MCR ADV,CPT,L7190,Elbow adolescent myoelectron,Durable Medical Equipment,Per Unit,"$8,439.80 ",OP,"8,439.80","29,026.03",,,,,,
Health Alliance MCR ADV,CPT,L7191,Elbow child myoelectronic ct,Durable Medical Equipment,Per Unit,"$11,247.26 ",OP,"11,247.26","38,679.77",,,,,,
Health Alliance MCR ADV,CPT,L7259,Electronic wrist rotator any,Durable Medical Equipment,Per Unit,"$4,121.94 ",OP,"4,121.94","4,121.94",,,,,,
Health Alliance MCR ADV,CPT,L7360,Six volt bat otto bock/eq ea,Durable Medical Equipment,Per Unit,$266.08 ,OP,266.08,915.04,,,,,,
Health Alliance MCR ADV,CPT,L7362,Battery chrgr six volt otto,Durable Medical Equipment,Per Unit,$290.68 ,OP,290.68,998.92,,,,,,
Health Alliance MCR ADV,CPT,L7364,Twelve volt battery utah/equ,Durable Medical Equipment,Per Unit,$514.33 ,OP,514.33,"1,769.09",,,,,,
Health Alliance MCR ADV,CPT,L7366,Battery chrgr 12 volt utah/e,Durable Medical Equipment,Per Unit,$707.34 ,OP,707.34,"2,432.50",,,,,,
Health Alliance MCR ADV,CPT,L7367,Replacemnt lithium ionbatter,Durable Medical Equipment,Per Unit,$391.59 ,OP,391.59,"1,345.89",,,,,,
Health Alliance MCR ADV,CPT,L7368,Lithium ion battery charger,Durable Medical Equipment,Per Unit,$507.61 ,OP,507.61,"1,746.22",,,,,,
Health Alliance MCR ADV,CPT,L7400,Add ue prost be/wd- ultlite,Durable Medical Equipment,Per Unit,$308.25 ,OP,308.25,"1,059.93",,,,,,
Health Alliance MCR ADV,CPT,L7401,Add ue prost a/e ultlite mat,Durable Medical Equipment,Per Unit,$345.06 ,OP,345.06,"1,185.76",,,,,,
Health Alliance MCR ADV,CPT,L7402,Add ue prost s/d ultlite mat,Durable Medical Equipment,Per Unit,$372.68 ,OP,372.68,"1,281.07",,,,,,
Health Alliance MCR ADV,CPT,L7403,Add ue prost b/e acrylic,Durable Medical Equipment,Per Unit,$370.41 ,OP,370.41,"1,273.44",,,,,,
Health Alliance MCR ADV,CPT,L7404,Add ue prost a/e acrylic,Durable Medical Equipment,Per Unit,$559.06 ,OP,559.06,"1,921.59",,,,,,
Health Alliance MCR ADV,CPT,L7405,Add ue prost s/d acrylic,Durable Medical Equipment,Per Unit,$731.10 ,OP,731.1,"2,512.57",,,,,,
Health Alliance MCR ADV,CPT,L7700,Pros soc insert gasket/seal,Durable Medical Equipment,Per Unit,$150.48 ,OP,150.48,150.48,,,,,,
Health Alliance MCR ADV,CPT,L8000,Mastectomy bra,Durable Medical Equipment,Per Unit,$42.59 ,OP,42.59,144.88,,,,,,
Health Alliance MCR ADV,CPT,L8001,Breast prosthesis bra & form,Durable Medical Equipment,Per Unit,$126.18 ,OP,126.18,434.65,,,,,,
Health Alliance MCR ADV,CPT,L8002,Brst prsth bra & bilat form,Durable Medical Equipment,Per Unit,$165.94 ,OP,165.94,571.91,,,,,,
Health Alliance MCR ADV,CPT,L8015,Ext breastprosthesis garment,Durable Medical Equipment,Per Unit,$60.29 ,OP,60.29,205.88,,,,,,
Health Alliance MCR ADV,CPT,L8020,Mastectomy form,Durable Medical Equipment,Per Unit,$227.40 ,OP,227.4,781.61,,,,,,
Health Alliance MCR ADV,CPT,L8030,Breast prosthes w/o adhesive,Durable Medical Equipment,Per Unit,$351.55 ,OP,351.55,"1,208.62",,,,,,
Health Alliance MCR ADV,CPT,L8031,Breast prosthesis w adhesive,Durable Medical Equipment,Per Unit,$351.55 ,OP,351.55,351.55,,,,,,
Health Alliance MCR ADV,CPT,L8032,Reusable nipple prosthesis,Durable Medical Equipment,Per Unit,$39.39 ,OP,39.39,39.39,,,,,,
Health Alliance MCR ADV,CPT,L8035,Custom breast prosthesis,Durable Medical Equipment,Per Unit,"$3,684.79 ",OP,"3,684.79","12,673.39",,,,,,
Health Alliance MCR ADV,CPT,L8040,Nasal prosthesis,Durable Medical Equipment,Per Unit,"$2,493.50 ",OP,"2,493.50","8,574.74",,,,,,
Health Alliance MCR ADV,CPT,L8041,Midfacial prosthesis,Durable Medical Equipment,Per Unit,"$3,005.20 ",OP,"3,005.20","10,336.21",,,,,,
Health Alliance MCR ADV,CPT,L8042,Orbital prosthesis,Durable Medical Equipment,Per Unit,"$3,376.62 ",OP,"3,376.62","11,613.47",,,,,,
Health Alliance MCR ADV,CPT,L8043,Upper facial prosthesis,Durable Medical Equipment,Per Unit,"$3,781.84 ",OP,"3,781.84","13,005.10",,,,,,
Health Alliance MCR ADV,CPT,L8044,Hemi-facial prosthesis,Durable Medical Equipment,Per Unit,"$4,187.02 ",OP,"4,187.02","14,400.54",,,,,,
Health Alliance MCR ADV,CPT,L8045,Auricular prosthesis,Durable Medical Equipment,Per Unit,"$3,278.72 ",OP,"3,278.72","11,274.13",,,,,,
Health Alliance MCR ADV,CPT,L8046,Partial facial prosthesis,Durable Medical Equipment,Per Unit,"$2,701.33 ",OP,"2,701.33","9,291.53",,,,,,
Health Alliance MCR ADV,CPT,L8047,Nasal septal prosthesis,Durable Medical Equipment,Per Unit,"$1,384.42 ",OP,"1,384.42","4,762.05",,,,,,
Health Alliance MCR ADV,CPT,L8300,Truss single w/ standard pad,Durable Medical Equipment,Per Unit,$84.35 ,OP,84.35,289.76,,,,,,
Health Alliance MCR ADV,CPT,L8310,Truss double w/ standard pad,Durable Medical Equipment,Per Unit,$149.44 ,OP,149.44,514.72,,,,,,
Health Alliance MCR ADV,CPT,L8320,Truss addition to std pad wa,Durable Medical Equipment,Per Unit,$62.00 ,OP,62,213.51,,,,,,
Health Alliance MCR ADV,CPT,L8330,Truss add to std pad scrotal,Durable Medical Equipment,Per Unit,$49.37 ,OP,49.37,171.58,,,,,,
Health Alliance MCR ADV,CPT,L8400,Sheath below knee,Durable Medical Equipment,Per Unit,$15.74 ,OP,15.74,53.38,,,,,,
Health Alliance MCR ADV,CPT,L8410,Sheath above knee,Durable Medical Equipment,Per Unit,$20.72 ,OP,20.72,72.44,,,,,,
Health Alliance MCR ADV,CPT,L8415,Sheath upper limb,Durable Medical Equipment,Per Unit,$21.44 ,OP,21.44,72.44,,,,,,
Health Alliance MCR ADV,CPT,L8417,Pros sheath/sock w gel cushn,Durable Medical Equipment,Per Unit,$75.64 ,OP,75.64,259.27,,,,,,
Health Alliance MCR ADV,CPT,L8420,Prosthetic sock multi ply bk,Durable Medical Equipment,Per Unit,$20.98 ,OP,20.98,72.44,,,,,,
Health Alliance MCR ADV,CPT,L8430,Prosthetic sock multi ply ak,Durable Medical Equipment,Per Unit,$23.76 ,OP,23.76,80.07,,,,,,
Health Alliance MCR ADV,CPT,L8435,Pros sock multi ply upper lm,Durable Medical Equipment,Per Unit,$22.58 ,OP,22.58,76.26,,,,,,
Health Alliance MCR ADV,CPT,L8440,Shrinker below knee,Durable Medical Equipment,Per Unit,$46.88 ,OP,46.88,160.13,,,,,,
Health Alliance MCR ADV,CPT,L8460,Shrinker above knee,Durable Medical Equipment,Per Unit,$66.65 ,OP,66.65,228.77,,,,,,
Health Alliance MCR ADV,CPT,L8465,Shrinker upper limb,Durable Medical Equipment,Per Unit,$61.60 ,OP,61.6,213.51,,,,,,
Health Alliance MCR ADV,CPT,L8470,Pros sock single ply bk,Durable Medical Equipment,Per Unit,$6.67 ,OP,6.67,22.88,,,,,,
Health Alliance MCR ADV,CPT,L8480,Pros sock single ply ak,Durable Medical Equipment,Per Unit,$9.20 ,OP,9.2,30.51,,,,,,
Health Alliance MCR ADV,CPT,L8485,Pros sock single ply upper l,Durable Medical Equipment,Per Unit,$12.39 ,OP,12.39,41.94,,,,,,
Health Alliance MCR ADV,CPT,L8500,Artificial larynx,Durable Medical Equipment,Per Unit,$661.87 ,OP,661.87,"2,276.18",,,,,,
Health Alliance MCR ADV,CPT,L8501,Tracheostomy speaking valve,Durable Medical Equipment,Per Unit,$120.80 ,OP,120.8,415.59,,,,,,
Health Alliance MCR ADV,CPT,L8507,Trach-esoph voice pros pt in,Durable Medical Equipment,Per Unit,$42.11 ,OP,42.11,144.88,,,,,,
Health Alliance MCR ADV,CPT,L8509,Trach-esoph voice pros md in,Durable Medical Equipment,Per Unit,$109.85 ,OP,109.85,377.46,,,,,,
Health Alliance MCR ADV,CPT,L8510,Voice amplifier,Durable Medical Equipment,Per Unit,$254.17 ,OP,254.17,873.11,,,,,,
Health Alliance MCR ADV,CPT,L8511,Indwelling trach insert,Durable Medical Equipment,Per Unit,$73.14 ,OP,73.14,251.64,,,,,,
Health Alliance MCR ADV,CPT,L8512,Gel cap for trach voice pros,Durable Medical Equipment,Per Unit,$2.19 ,OP,2.19,7.62,,,,,,
Health Alliance MCR ADV,CPT,L8513,Trach pros cleaning device,Durable Medical Equipment,Per Unit,$5.22 ,OP,5.22,19.07,,,,,,
Health Alliance MCR ADV,CPT,L8514,Repl trach puncture dilator,Durable Medical Equipment,Per Unit,$94.85 ,OP,94.85,327.9,,,,,,
Health Alliance MCR ADV,CPT,L8515,Gel cap app device for trach,Durable Medical Equipment,Per Unit,$63.49 ,OP,63.49,217.32,,,,,,
Health Alliance MCR ADV,CPT,L8615,Coch implant headset replace,Durable Medical Equipment,Per Unit,$453.62 ,OP,453.62,"1,559.39",,,,,,
Health Alliance MCR ADV,CPT,L8616,Coch implant microphone repl,Durable Medical Equipment,Per Unit,$105.64 ,OP,105.64,362.21,,,,,,
Health Alliance MCR ADV,CPT,L8617,Coch implant trans coil repl,Durable Medical Equipment,Per Unit,$92.27 ,OP,92.27,92.27,,,,,,
Health Alliance MCR ADV,CPT,L8618,Coch implant tran cable repl,Durable Medical Equipment,Per Unit,$26.38 ,OP,26.38,91.51,,,,,,
Health Alliance MCR ADV,CPT,L8619,Coch imp ext proc/contr rplc,Durable Medical Equipment,Per Unit,"$8,454.02 ",OP,"8,454.02","29,075.59",,,,,,
Health Alliance MCR ADV,CPT,L8621,Repl zinc air battery,Durable Medical Equipment,Per Unit,$0.62 ,OP,0.62,3.82,,,,,,
Health Alliance MCR ADV,CPT,L8622,Repl alkaline battery,Durable Medical Equipment,Per Unit,$0.32 ,OP,0.32,1.9,,,,,,
Health Alliance MCR ADV,CPT,L8623,Lith ion batt cid-non-earlvl,Durable Medical Equipment,Per Unit,$65.06 ,OP,65.06,65.06,,,,,,
Health Alliance MCR ADV,CPT,L8624,Lith ion batt cid- ear level,Durable Medical Equipment,Per Unit,$162.20 ,OP,162.2,556.65,,,,,,
Health Alliance MCR ADV,CPT,L8625,Charger coch impl/aoi battry,Durable Medical Equipment,Per Unit,$189.97 ,OP,189.97,189.97,,,,,,
Health Alliance MCR ADV,CPT,L8627,Cid ext speech process repl,Durable Medical Equipment,Per Unit,"$7,175.59 ",OP,"7,175.59","7,175.59",,,,,,
Health Alliance MCR ADV,CPT,L8628,Cid ext controller repl,Durable Medical Equipment,Per Unit,"$1,278.42 ",OP,"1,278.42","1,278.42",,,,,,
Health Alliance MCR ADV,CPT,L8629,Cid transmit coil and cable,Durable Medical Equipment,Per Unit,$180.09 ,OP,180.09,180.09,,,,,,
Health Alliance MCR ADV,CPT,L8681,Pt prgrm for implt neurostim,Durable Medical Equipment,Per Unit,"$1,147.11 ",OP,"1,147.11","3,946.14",,,,,,
Health Alliance MCR ADV,CPT,L8683,Radiofq trsmtr for implt neu,Durable Medical Equipment,Per Unit,"$5,420.03 ",OP,"5,420.03","18,640.24",,,,,,
Health Alliance MCR ADV,CPT,L8684,Radiof trsmtr implt scrl neu,Durable Medical Equipment,Per Unit,$850.48 ,OP,850.48,"2,924.33",,,,,,
Health Alliance MCR ADV,CPT,L8689,External recharg sys intern,Durable Medical Equipment,Per Unit,"$1,734.92 ",OP,"1,734.92","5,966.87",,,,,,
Health Alliance MCR ADV,CPT,L8691,Aoi snd proc repl excl actua,Durable Medical Equipment,Per Unit,"$1,732.10 ",OP,"1,732.10","9,222.90",,,,,,
Health Alliance MCR ADV,CPT,L8693,Aud osseo dev- abutment,Durable Medical Equipment,Per Unit,"$1,525.09 ",OP,"1,525.09","1,525.09",,,,,,
Health Alliance MCR ADV,CPT,L8694,Aoi transducer/actuator repl,Durable Medical Equipment,Per Unit,$949.85 ,OP,949.85,949.85,,,,,,
Health Alliance MCR ADV,CPT,L8695,External recharg sys extern,Durable Medical Equipment,Per Unit,$16.77 ,OP,16.77,57.19,,,,,,
Health Alliance MCR ADV,CPT,L8696,Ext antenna phren nerve stim,Durable Medical Equipment,Per Unit,$217.98 ,OP,217.98,217.98,,,,,,
Health Alliance MCR ADV,CPT,M0201,Covid-19 vaccine home admin,APC 1494,RVU Per Unit,$36.33 ,OP,36.33,36.33,,,,,,
Health Alliance MCR ADV,CPT,M0240,Casiri and imdev repeat,APC 1506,RVU Per Unit,$461.00 ,OP,430.44,461,,,,,,
Health Alliance MCR ADV,CPT,M0241,Casiri and imdev repeat hm,APC 1509,RVU Per Unit,$768.00 ,OP,768,768,,,,,,
Health Alliance MCR ADV,CPT,M0243,Casirivi and imdevi inj,APC 1506,RVU Per Unit,$461.00 ,OP,461,461,,,,,,
Health Alliance MCR ADV,CPT,M0244,Casirivi and imdevi inj hm,APC 1509,RVU Per Unit,$768.00 ,OP,717.08,768,,,,,,
Health Alliance MCR ADV,CPT,M0245,Bamlan and etesev infusion,APC 1506,RVU Per Unit,$461.00 ,OP,430.44,461,,,,,,
Health Alliance MCR ADV,CPT,M0246,Bamlan and etesev infus home,APC 1509,RVU Per Unit,$768.00 ,OP,717.08,768,,,,,,
Health Alliance MCR ADV,CPT,M0247,Sotrovimab infusion,APC 1506,RVU Per Unit,$461.00 ,OP,430.44,461,,,,,,
Health Alliance MCR ADV,CPT,M0248,Sotrovimab inf- home admin,APC 1509,RVU Per Unit,$768.00 ,OP,717.08,768,,,,,,
Health Alliance MCR ADV,CPT,M0249,Adm tocilizu covid-19 1st,APC 1506,RVU Per Unit,$461.00 ,OP,430.44,461,,,,,,
Health Alliance MCR ADV,CPT,M0250,Adm tocilizu covid-19 2nd,APC 1506,RVU Per Unit,$461.00 ,OP,430.44,461,,,,,,
Health Alliance MCR ADV,CPT,P2028,Cephalin floculation test,Lab Services,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,
Health Alliance MCR ADV,CPT,P2029,Congo red blood test,Lab Services,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,
Health Alliance MCR ADV,CPT,P2033,Blood thymol turbidity,Lab Services,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,
Health Alliance MCR ADV,CPT,P2038,Blood mucoprotein,Lab Services,Per Unit,$4.95 ,OP,4.95,22.88,,,,,,
Health Alliance MCR ADV,CPT,P3000,Screen pap by tech w md supv,Lab Services,Per Unit,$15.15 ,OP,15.15,45.74,,,,,,
Health Alliance MCR ADV,CPT,P9010,Whole blood for transfusion,APC 9510,Per Unit,$172.22 ,OP,172.22,172.22,,,,,,
Health Alliance MCR ADV,CPT,P9011,Blood split unit,APC 9520,Per Unit,$169.28 ,OP,169.28,169.28,,,,,,
Health Alliance MCR ADV,CPT,P9012,Cryoprecipitate each unit,APC 9511,Per Unit,$91.59 ,OP,91.59,91.59,,,,,,
Health Alliance MCR ADV,CPT,P9016,Rbc leukocytes reduced,APC 9512,Per Unit,$216.23 ,OP,216.23,216.23,,,,,,
Health Alliance MCR ADV,CPT,P9017,Plasma 1 donor frz w/in 8 hr,APC 9508,Per Unit,$94.81 ,OP,94.81,94.81,,,,,,
Health Alliance MCR ADV,CPT,P9019,Platelets- each unit,APC 9515,Per Unit,$81.77 ,OP,81.77,81.77,,,,,,
Health Alliance MCR ADV,CPT,P9020,Plaelet rich plasma unit,APC 9516,Per Unit,$229.41 ,OP,229.41,229.41,,,,,,
Health Alliance MCR ADV,CPT,P9021,Red blood cells unit,APC 9517,Per Unit,$157.87 ,OP,157.87,157.87,,,,,,
Health Alliance MCR ADV,CPT,P9022,Washed red blood cells unit,APC 9518,Per Unit,$435.72 ,OP,435.72,435.72,,,,,,
Health Alliance MCR ADV,CPT,P9023,Frozen plasma- pooled- sd,APC 9509,Per Unit,$102.26 ,OP,102.26,102.26,,,,,,
Health Alliance MCR ADV,CPT,P9025,Plasma cryo redu path each,APC 9538,Per Unit,$75.36 ,OP,75.36,75.36,,,,,,
Health Alliance MCR ADV,CPT,P9026,Cryo fib comp path redu each,APC 9539,Per Unit,$91.59 ,OP,91.59,91.59,,,,,,
Health Alliance MCR ADV,CPT,P9031,Platelets leukocytes reduced,APC 9526,Per Unit,$171.96 ,OP,171.96,171.96,,,,,,
Health Alliance MCR ADV,CPT,P9032,Platelets- irradiated,APC 9500,Per Unit,$162.52 ,OP,162.52,162.52,,,,,,
Health Alliance MCR ADV,CPT,P9033,Platelets leukoreduced irrad,APC 9521,Per Unit,$244.54 ,OP,244.54,244.54,,,,,,
Health Alliance MCR ADV,CPT,P9034,Platelets- pheresis,APC 9507,Per Unit,$371.63 ,OP,371.63,371.63,,,,,,
Health Alliance MCR ADV,CPT,P9035,Platelet pheres leukoreduced,APC 9501,Per Unit,$558.38 ,OP,558.38,558.38,,,,,,
Health Alliance MCR ADV,CPT,P9036,Platelet pheresis irradiated,APC 9502,Per Unit,$693.83 ,OP,693.83,693.83,,,,,,
Health Alliance MCR ADV,CPT,P9037,Plate pheres leukoredu irrad,APC 9530,Per Unit,$708.10 ,OP,708.1,708.1,,,,,,
Health Alliance MCR ADV,CPT,P9038,Rbc irradiated,APC 9505,Per Unit,$194.21 ,OP,194.21,194.21,,,,,,
Health Alliance MCR ADV,CPT,P9039,Rbc deglycerolized,APC 9504,Per Unit,$500.86 ,OP,500.86,500.86,,,,,,
Health Alliance MCR ADV,CPT,P9040,Rbc leukoreduced irradiated,APC 9522,Per Unit,$298.86 ,OP,298.86,298.86,,,,,,
Health Alliance MCR ADV,CPT,P9041,Albumin (human)-5%- 50ml,APC 0961,Per Unit,$10.49 ,OP,10.49,10.49,,,,,,
Health Alliance MCR ADV,CPT,P9043,Plasma protein fract-5%-50ml,APC 9514,Per Unit,$9.16 ,OP,9.16,106.76,,,,,,
Health Alliance MCR ADV,CPT,P9044,Cryoprecipitatereducedplasma,APC 9523,Per Unit,$75.36 ,OP,75.36,75.36,,,,,,
Health Alliance MCR ADV,CPT,P9045,Albumin (human)- 5%- 250 ml,APC 0963,Per Unit,$52.45 ,OP,52.45,274.51,,,,,,
Health Alliance MCR ADV,CPT,P9046,Albumin (human)- 25%- 20 ml,APC 0964,Per Unit,$20.98 ,OP,20.98,129.64,,,,,,
Health Alliance MCR ADV,CPT,P9047,Albumin (human)- 25%- 50ml,APC 0965,Per Unit,$52.45 ,OP,52.45,255.45,,,,,,
Health Alliance MCR ADV,CPT,P9048,Plasmaprotein fract-5%-250ml,APC 9519,Per Unit,$183.92 ,OP,183.92,198.25,,,,,,
Health Alliance MCR ADV,CPT,P9051,Blood- l/r- cmv-neg,APC 9524,Per Unit,$243.44 ,OP,243.44,243.44,,,,,,
Health Alliance MCR ADV,CPT,P9052,Platelets- hla-m- l/r- unit,APC 9525,Per Unit,$923.57 ,OP,923.57,923.57,,,,,,
Health Alliance MCR ADV,CPT,P9053,Plt- pher- l/r cmv-neg- irr,APC 9531,Per Unit,$513.08 ,OP,513.08,513.08,,,,,,
Health Alliance MCR ADV,CPT,P9054,Blood- l/r- froz/degly/wash,APC 9527,Per Unit,$356.39 ,OP,356.39,356.39,,,,,,
Health Alliance MCR ADV,CPT,P9055,Plt- aph/pher- l/r- cmv-neg,APC 9528,Per Unit,$550.63 ,OP,550.63,550.63,,,,,,
Health Alliance MCR ADV,CPT,P9056,Blood- l/r- irradiated,APC 9529,Per Unit,$176.83 ,OP,176.83,176.83,,,,,,
Health Alliance MCR ADV,CPT,P9057,Rbc- frz/deg/wsh- l/r- irrad,APC 9532,Per Unit,$298.91 ,OP,298.91,298.91,,,,,,
Health Alliance MCR ADV,CPT,P9058,Rbc- l/r- cmv-neg- irrad,APC 9533,Per Unit,$279.73 ,OP,279.73,279.73,,,,,,
Health Alliance MCR ADV,CPT,P9059,Plasma- frz between 8-24hour,APC 9513,Per Unit,$81.61 ,OP,81.61,81.61,,,,,,
Health Alliance MCR ADV,CPT,P9060,Fr frz plasma donor retested,APC 9503,Per Unit,$74.65 ,OP,74.65,74.65,,,,,,
Health Alliance MCR ADV,CPT,P9070,Pathogen reduced plasma pool,APC 9534,Per Unit,$60.91 ,OP,60.91,60.91,,,,,,
Health Alliance MCR ADV,CPT,P9071,Pathogen reduced plasma sing,APC 9535,Per Unit,$140.88 ,OP,140.88,140.88,,,,,,
Health Alliance MCR ADV,CPT,P9073,Platelets pheresis path redu,APC 9536,Per Unit,$669.72 ,OP,669.72,669.72,,,,,,
Health Alliance MCR ADV,CPT,P9099,Blood component/product noc,APC 9537,Per Unit,$9.16 ,OP,9.16,9.16,,,,,,
Health Alliance MCR ADV,CPT,P9100,Pathogen test for platelets,APC 5732,RVU Per Unit,$34.63 ,OP,34.63,34.63,,,,,,
Health Alliance MCR ADV,CPT,P9612,Catheterize for urine spec,Lab Services,Per Unit,$3.00 ,OP,3,3,,,,,,
Health Alliance MCR ADV,CPT,Q0035,Cardiokymography,APC 5732,RVU Per Case,$34.63 ,OP,34.63,106.76,,,,,,
Health Alliance MCR ADV,CPT,Q0091,Obtaining screen pap smear,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,205.88,,,,,,
Health Alliance MCR ADV,CPT,Q0111,Wet mounts/ w preparations,Lab Services,Per Unit,$15.15 ,OP,15.15,15.15,,,,,,
Health Alliance MCR ADV,CPT,Q0112,Potassium hydroxide preps,Lab Services,Per Unit,$5.83 ,OP,5.83,22.88,,,,,,
Health Alliance MCR ADV,CPT,Q0113,Pinworm examinations,Lab Services,Per Unit,$4.27 ,OP,4.27,26.7,,,,,,
Health Alliance MCR ADV,CPT,Q0114,Fern test,Lab Services,Per Unit,$9.74 ,OP,9.74,34.31,,,,,,
Health Alliance MCR ADV,CPT,Q0115,Post-coital mucous exam,Lab Services,Per Unit,$25.00 ,OP,25,49.56,,,,,,
Health Alliance MCR ADV,CPT,Q0138,Ferumoxytol- non-esrd,APC 1297,Per Unit,$1.00 ,OP,1,1,,,,,,
Health Alliance MCR ADV,CPT,Q0139,Ferumoxytol- esrd use,APC 1485,Per Unit,$1.00 ,OP,1,1,,,,,,
Health Alliance MCR ADV,CPT,Q0240,Casirivi and imdevi 600 mg,Other,Straight Discount,29.70%,OP,,,,,,,,
Health Alliance MCR ADV,CPT,Q0243,Casirivimab and imdevimab,Other,Straight Discount,29.70%,OP,,,,,,,,
Health Alliance MCR ADV,CPT,Q0244,Casirivi and imdevi 1200 mg,Other,Straight Discount,29.70%,OP,,,,,,,,
Health Alliance MCR ADV,CPT,Q0245,Bamlanivimab and etesevima,Other,Straight Discount,29.70%,OP,,,,,,,,
Health Alliance MCR ADV,CPT,Q0247,Sotrovimab,Other,Straight Discount,29.70%,OP,,,,,,,,
Health Alliance MCR ADV,CPT,Q0249,Tocilizumab for covid-19,Other,Straight Discount,29.70%,OP,,,,,,,,
Health Alliance MCR ADV,CPT,Q0477,Pwr module pt cable lvad rpl,Durable Medical Equipment,Per Unit,$780.34 ,OP,780.34,780.34,,,,,,
Health Alliance MCR ADV,CPT,Q0478,Power adapter- combo vad,Durable Medical Equipment,Per Unit,$184.82 ,OP,184.82,184.82,,,,,,
Health Alliance MCR ADV,CPT,Q0479,Power module combo vad- rep,Durable Medical Equipment,Per Unit,"$12,073.17 ",OP,"12,073.17","12,073.17",,,,,,
Health Alliance MCR ADV,CPT,Q0480,Driver pneumatic vad- rep,Durable Medical Equipment,Per Unit,"$90,585.51 ",OP,"90,585.51","311,531.29",,,,,,
Health Alliance MCR ADV,CPT,Q0481,Microprcsr cu elec vad- rep,Durable Medical Equipment,Per Unit,"$14,614.95 ",OP,"14,614.95","50,262.72",,,,,,
Health Alliance MCR ADV,CPT,Q0482,Microprcsr cu combo vad- rep,Durable Medical Equipment,Per Unit,"$4,577.67 ",OP,"4,577.67","15,742.60",,,,,,
Health Alliance MCR ADV,CPT,Q0483,Monitor elec vad- rep,Durable Medical Equipment,Per Unit,"$18,857.93 ",OP,"18,857.93","64,853.90",,,,,,
Health Alliance MCR ADV,CPT,Q0484,Monitor elec or comb vad rep,Durable Medical Equipment,Per Unit,"$3,662.14 ",OP,"3,662.14","12,593.32",,,,,,
Health Alliance MCR ADV,CPT,Q0485,Monitor cable elec vad- rep,Durable Medical Equipment,Per Unit,$353.60 ,OP,353.6,"1,216.24",,,,,,
Health Alliance MCR ADV,CPT,Q0486,Mon cable elec/pneum vad rep,Durable Medical Equipment,Per Unit,$294.28 ,OP,294.28,"1,010.37",,,,,,
Health Alliance MCR ADV,CPT,Q0487,Leads any type vad- rep only,Durable Medical Equipment,Per Unit,$343.31 ,OP,343.31,"1,181.94",,,,,,
Health Alliance MCR ADV,CPT,Q0489,Pwr pck base combo vad- rep,Durable Medical Equipment,Per Unit,"$16,348.80 ",OP,"16,348.80","56,225.77",,,,,,
Health Alliance MCR ADV,CPT,Q0490,Emr pwr source elec vad- rep,Durable Medical Equipment,Per Unit,$707.17 ,OP,707.17,"2,432.50",,,,,,
Health Alliance MCR ADV,CPT,Q0491,Emr pwr source combo vad rep,Durable Medical Equipment,Per Unit,"$1,111.75 ",OP,"1,111.75","3,824.13",,,,,,
Health Alliance MCR ADV,CPT,Q0492,Emr pwr cbl elec vad- rep,Durable Medical Equipment,Per Unit,$89.58 ,OP,89.58,308.83,,,,,,
Health Alliance MCR ADV,CPT,Q0493,Emr pwr cbl combo vad- rep,Durable Medical Equipment,Per Unit,$255.02 ,OP,255.02,876.92,,,,,,
Health Alliance MCR ADV,CPT,Q0494,Emr hd pmp elec/combo- rep,Durable Medical Equipment,Per Unit,$215.79 ,OP,215.79,743.48,,,,,,
Health Alliance MCR ADV,CPT,Q0495,Charger elec/combo vad- rep,Durable Medical Equipment,Per Unit,"$4,201.23 ",OP,"4,201.23","14,450.10",,,,,,
Health Alliance MCR ADV,CPT,Q0496,Battery elec/combo vad- rep,Durable Medical Equipment,Per Unit,"$1,507.90 ",OP,"1,507.90","5,185.26",,,,,,
Health Alliance MCR ADV,CPT,Q0497,Bat clps elec/comb vad- rep,Durable Medical Equipment,Per Unit,$470.84 ,OP,470.84,"1,620.40",,,,,,
Health Alliance MCR ADV,CPT,Q0498,Holster elec/combo vad- rep,Durable Medical Equipment,Per Unit,$516.61 ,OP,516.61,"1,776.71",,,,,,
Health Alliance MCR ADV,CPT,Q0499,Belt/vest elec/combo vad rep,Durable Medical Equipment,Per Unit,$167.86 ,OP,167.86,575.73,,,,,,
Health Alliance MCR ADV,CPT,Q0500,Filters elec/combo vad- rep,Durable Medical Equipment,Per Unit,$30.69 ,OP,30.69,106.76,,,,,,
Health Alliance MCR ADV,CPT,Q0501,Shwr cov elec/combo vad- rep,Durable Medical Equipment,Per Unit,$513.63 ,OP,513.63,"1,765.27",,,,,,
Health Alliance MCR ADV,CPT,Q0502,Mobility cart pneum vad- rep,Durable Medical Equipment,Per Unit,$653.97 ,OP,653.97,"2,249.49",,,,,,
Health Alliance MCR ADV,CPT,Q0503,Battery pneum vad replacemnt,Durable Medical Equipment,Per Unit,"$1,307.87 ",OP,"1,307.87","4,498.98",,,,,,
Health Alliance MCR ADV,CPT,Q0504,Pwr adpt pneum vad- rep veh,Durable Medical Equipment,Per Unit,$690.16 ,OP,690.16,"2,375.30",,,,,,
Health Alliance MCR ADV,CPT,Q0506,Lith-ion batt elec/pneum vad,Durable Medical Equipment,Per Unit,$859.04 ,OP,859.04,859.04,,,,,,
Health Alliance MCR ADV,CPT,Q2017,Teniposide- 50 mg,APC 7035,Per Unit,"$2,645.71 ",OP,"1,582.28","2,645.71",,,,,,
Health Alliance MCR ADV,CPT,Q2026,Radiesse injection,APC 9094,Per Unit,$257.37 ,OP,257.37,257.37,,,,,,
Health Alliance MCR ADV,CPT,Q2028,Inj- sculptra- 0.5mg,APC 9095,Per Unit,$2.49 ,OP,2.49,2.49,,,,,,
Health Alliance MCR ADV,CPT,Q2034,Agriflu vaccine,Other,Straight Discount,29.70%,OP,,,,,,,,
Health Alliance MCR ADV,CPT,Q2035,Afluria vacc- 3 yrs & >- im,Other,Straight Discount,29.70%,OP,,,,,,,,
Health Alliance MCR ADV,CPT,Q2036,Flulaval vacc- 3 yrs & >- im,Other,Straight Discount,29.70%,OP,,,,,,,,
Health Alliance MCR ADV,CPT,Q2037,Fluvirin vacc- 3 yrs & >- im,Other,Straight Discount,29.70%,OP,,,,,,,,
Health Alliance MCR ADV,CPT,Q2038,Fluzone vacc- 3 yrs & >- im,Other,Straight Discount,29.70%,OP,,,,,,,,
Health Alliance MCR ADV,CPT,Q2039,Influenza virus vaccine- nos,Other,Straight Discount,29.70%,OP,,,,,,,,
Health Alliance MCR ADV,CPT,Q2041,Axicabtagene ciloleucel car+,APC 9035,Per Unit,"$395,380.00 ",OP,"395,380.00","395,380.00",,,,,,
Health Alliance MCR ADV,CPT,Q2042,Tisagenlecleucel car-pos t,APC 9194,Per Unit,"$434,337.60 ",OP,"434,337.60","434,337.60",,,,,,
Health Alliance MCR ADV,CPT,Q2043,Sipuleucel-t auto cd54+,APC 9273,Per Unit,"$53,017.58 ",OP,"53,017.58","53,017.58",,,,,,
Health Alliance MCR ADV,CPT,Q2049,Imported lipodox inj,APC 1421,Per Unit,$311.04 ,OP,311.04,311.04,,,,,,
Health Alliance MCR ADV,CPT,Q2050,Doxorubicin inj 10mg,APC 7046,Per Unit,$234.03 ,OP,234.03,"1,719.01",,,,,,
Health Alliance MCR ADV,CPT,Q2053,Brexucabtagene car pos t,APC 9391,Per Unit,"$395,380.00 ",OP,"395,380.00","395,380.00",,,,,,
Health Alliance MCR ADV,CPT,Q2054,Lisocabtagene mara car pos t,APC 9413,Per Unit,"$422,609.00 ",OP,"422,609.00","422,609.00",,,,,,
Health Alliance MCR ADV,CPT,Q3027,Inj beta interferon im 1 mcg,APC 1472,Per Unit,$55.29 ,OP,55.29,74.17,,,,,,
Health Alliance MCR ADV,CPT,Q5101,Injection- zarxio,APC 1822,Per Unit,$0.32 ,OP,0.32,0.32,,,,,,
Health Alliance MCR ADV,CPT,Q5103,Injection- inflectra,APC 1847,Per Unit,$41.19 ,OP,41.19,41.19,,,,,,
Health Alliance MCR ADV,CPT,Q5104,Injection- renflexis,APC 9036,Per Unit,$38.79 ,OP,38.79,38.79,,,,,,
Health Alliance MCR ADV,CPT,Q5106,Inj retacrit non-esrd use,APC 9097,Per Unit,$8.66 ,OP,8.66,8.66,,,,,,
Health Alliance MCR ADV,CPT,Q5107,Inj mvasi 10 mg,APC 9329,Per Unit,$44.56 ,OP,44.56,44.56,,,,,,
Health Alliance MCR ADV,CPT,Q5108,Injection- fulphila,APC 9173,Per Unit,$211.19 ,OP,211.19,211.19,,,,,,
Health Alliance MCR ADV,CPT,Q5110,Nivestym,APC 9193,Per Unit,$0.33 ,OP,0.33,0.33,,,,,,
Health Alliance MCR ADV,CPT,Q5111,Injection- udenyca 0.5 mg,APC 9195,Per Unit,$222.38 ,OP,222.38,222.38,,,,,,
Health Alliance MCR ADV,CPT,Q5112,Inj ontruzant 10 mg,APC 9382,Per Unit,$66.55 ,OP,66.55,66.55,,,,,,
Health Alliance MCR ADV,CPT,Q5113,Inj herzuma 10 mg,APC 9349,Per Unit,$57.30 ,OP,57.3,57.3,,,,,,
Health Alliance MCR ADV,CPT,Q5114,Inj ogivri 10 mg,APC 9341,Per Unit,$59.91 ,OP,59.91,59.91,,,,,,
Health Alliance MCR ADV,CPT,Q5115,Inj truxima 10 mg,APC 9336,Per Unit,$60.58 ,OP,60.58,60.58,,,,,,
Health Alliance MCR ADV,CPT,Q5116,Inj.- trazimera- 10 mg,APC 9350,Per Unit,$59.93 ,OP,59.93,59.93,,,,,,
Health Alliance MCR ADV,CPT,Q5117,Inj.- kanjinti- 10 mg,APC 9330,Per Unit,$53.18 ,OP,53.18,53.18,,,,,,
Health Alliance MCR ADV,CPT,Q5118,Inj.- zirabev- 10 mg,APC 9348,Per Unit,$52.37 ,OP,52.37,52.37,,,,,,
Health Alliance MCR ADV,CPT,Q5119,Inj ruxience- 10 mg,APC 9367,Per Unit,$58.80 ,OP,58.8,58.8,,,,,,
Health Alliance MCR ADV,CPT,Q5120,Inj pegfilgrastim-bmez 0.5mg,APC 9345,Per Unit,$245.43 ,OP,245.43,245.43,,,,,,
Health Alliance MCR ADV,CPT,Q5121,Inj. avsola- 10 mg,APC 9381,Per Unit,$47.12 ,OP,47.12,47.12,,,,,,
Health Alliance MCR ADV,CPT,Q5122,Inj- nyvepria,APC 9406,Per Unit,$284.69 ,OP,284.69,284.69,,,,,,
Health Alliance MCR ADV,CPT,Q5123,Inj. riabni- 10 mg,APC 9411,Per Unit,$72.23 ,OP,72.23,72.23,,,,,,
Health Alliance MCR ADV,CPT,Q9968,Visualization adjunct,APC 1446,Per Unit,$6.73 ,OP,6.73,6.73,,,,,,
Health Alliance MCR ADV,CPT,Q9969,Non-heu tc-99m add-on/dose,APC 1442,Per Unit,$10.00 ,OP,10,10,,,,,,
Health Alliance MCR ADV,CPT,Q9991,Buprenorph xr 100 mg or less,APC 9073,Per Unit,"$1,796.80 ",OP,"1,796.80","1,796.80",,,,,,
Health Alliance MCR ADV,CPT,Q9992,Buprenorphine xr over 100 mg,APC 9239,Per Unit,"$1,796.80 ",OP,"1,796.80","1,796.80",,,,,,
Health Alliance MCR ADV,CPT,U0001,2019-ncov diagnostic p,Lab Services,Per Unit,$35.91 ,OP,35.91,35.91,,,,,,
Health Alliance MCR ADV,CPT,U0002,Covid-19 lab test non-cdc,Lab Services,Per Unit,$51.31 ,OP,51.31,51.31,,,,,,
Health Alliance MCR ADV,CPT,U0003,Cov-19 amp prb hgh thruput,Lab Services,Per Unit,$75.00 ,OP,75,75,,,,,,
Health Alliance MCR ADV,CPT,U0004,Cov-19 test non-cdc hgh thru,Lab Services,Per Unit,$75.00 ,OP,75,75,,,,,,
Health Alliance MCR ADV,CPT,U0005,Infec agen detec ampli probe,Lab Services,Per Unit,$25.00 ,OP,25,25,,,,,,
Health Alliance MCR ADV,CPT,V2020,Vision svcs frames purchases,Durable Medical Equipment,Per Unit,$75.22 ,OP,75.22,388.89,,,,,,
Health Alliance MCR ADV,CPT,V2100,Lens spher single plano 4.00,Durable Medical Equipment,Per Unit,$46.49 ,OP,46.49,240.2,,,,,,
Health Alliance MCR ADV,CPT,V2101,Single visn sphere 4.12-7.00,Durable Medical Equipment,Per Unit,$44.67 ,OP,44.67,228.77,,,,,,
Health Alliance MCR ADV,CPT,V2102,Singl visn sphere 7.12-20.00,Durable Medical Equipment,Per Unit,$77.24 ,OP,77.24,400.34,,,,,,
Health Alliance MCR ADV,CPT,V2103,Spherocylindr 4.00d/12-2.00d,Durable Medical Equipment,Per Unit,$39.13 ,OP,39.13,202.07,,,,,,
Health Alliance MCR ADV,CPT,V2104,Spherocylindr 4.00d/2.12-4d,Durable Medical Equipment,Per Unit,$40.34 ,OP,40.34,209.7,,,,,,
Health Alliance MCR ADV,CPT,V2105,Spherocylinder 4.00d/4.25-6d,Durable Medical Equipment,Per Unit,$47.98 ,OP,47.98,247.83,,,,,,
Health Alliance MCR ADV,CPT,V2106,Spherocylinder 4.00d/>6.00d,Durable Medical Equipment,Per Unit,$53.15 ,OP,53.15,274.51,,,,,,
Health Alliance MCR ADV,CPT,V2107,Spherocylinder 4.25d/12-2d,Durable Medical Equipment,Per Unit,$47.33 ,OP,47.33,244.01,,,,,,
Health Alliance MCR ADV,CPT,V2108,Spherocylinder 4.25d/2.12-4d,Durable Medical Equipment,Per Unit,$47.46 ,OP,47.46,244.01,,,,,,
Health Alliance MCR ADV,CPT,V2109,Spherocylinder 4.25d/4.25-6d,Durable Medical Equipment,Per Unit,$66.10 ,OP,66.1,339.33,,,,,,
Health Alliance MCR ADV,CPT,V2110,Spherocylinder 4.25d/over 6d,Durable Medical Equipment,Per Unit,$53.39 ,OP,53.39,274.51,,,,,,
Health Alliance MCR ADV,CPT,V2111,Spherocylindr 7.25d/.25-2.25,Durable Medical Equipment,Per Unit,$64.70 ,OP,64.7,335.53,,,,,,
Health Alliance MCR ADV,CPT,V2112,Spherocylindr 7.25d/2.25-4d,Durable Medical Equipment,Per Unit,$73.09 ,OP,73.09,377.46,,,,,,
Health Alliance MCR ADV,CPT,V2113,Spherocylindr 7.25d/4.25-6d,Durable Medical Equipment,Per Unit,$73.91 ,OP,73.91,381.27,,,,,,
Health Alliance MCR ADV,CPT,V2114,Spherocylinder over 12.00d,Durable Medical Equipment,Per Unit,$87.57 ,OP,87.57,453.71,,,,,,
Health Alliance MCR ADV,CPT,V2115,Lens lenticular bifocal,Durable Medical Equipment,Per Unit,$88.27 ,OP,88.27,453.71,,,,,,
Health Alliance MCR ADV,CPT,V2118,Lens aniseikonic single,Durable Medical Equipment,Per Unit,$96.05 ,OP,96.05,495.65,,,,,,
Health Alliance MCR ADV,CPT,V2121,Lenticular lens- single,Durable Medical Equipment,Per Unit,$86.61 ,OP,86.61,446.08,,,,,,
Health Alliance MCR ADV,CPT,V2200,Lens spher bifoc plano 4.00d,Durable Medical Equipment,Per Unit,$52.35 ,OP,52.35,270.71,,,,,,
Health Alliance MCR ADV,CPT,V2201,Lens sphere bifocal 4.12-7.0,Durable Medical Equipment,Per Unit,$56.09 ,OP,56.09,289.76,,,,,,
Health Alliance MCR ADV,CPT,V2202,Lens sphere bifocal 7.12-20.,Durable Medical Equipment,Per Unit,$69.53 ,OP,69.53,358.39,,,,,,
Health Alliance MCR ADV,CPT,V2203,Lens sphcyl bifocal 4.00d/.1,Durable Medical Equipment,Per Unit,$53.92 ,OP,53.92,278.32,,,,,,
Health Alliance MCR ADV,CPT,V2204,Lens sphcy bifocal 4.00d/2.1,Durable Medical Equipment,Per Unit,$55.48 ,OP,55.48,285.96,,,,,,
Health Alliance MCR ADV,CPT,V2205,Lens sphcy bifocal 4.00d/4.2,Durable Medical Equipment,Per Unit,$61.51 ,OP,61.51,316.46,,,,,,
Health Alliance MCR ADV,CPT,V2206,Lens sphcy bifocal 4.00d/ove,Durable Medical Equipment,Per Unit,$72.21 ,OP,72.21,373.65,,,,,,
Health Alliance MCR ADV,CPT,V2207,Lens sphcy bifocal 4.25-7d/.,Durable Medical Equipment,Per Unit,$61.03 ,OP,61.03,316.46,,,,,,
Health Alliance MCR ADV,CPT,V2208,Lens sphcy bifocal 4.25-7/2.,Durable Medical Equipment,Per Unit,$59.97 ,OP,59.97,308.83,,,,,,
Health Alliance MCR ADV,CPT,V2209,Lens sphcy bifocal 4.25-7/4.,Durable Medical Equipment,Per Unit,$70.40 ,OP,70.4,362.21,,,,,,
Health Alliance MCR ADV,CPT,V2210,Lens sphcy bifocal 4.25-7/ov,Durable Medical Equipment,Per Unit,$75.86 ,OP,75.86,392.7,,,,,,
Health Alliance MCR ADV,CPT,V2211,Lens sphcy bifo 7.25-12/.25-,Durable Medical Equipment,Per Unit,$73.85 ,OP,73.85,381.27,,,,,,
Health Alliance MCR ADV,CPT,V2212,Lens sphcyl bifo 7.25-12/2.2,Durable Medical Equipment,Per Unit,$77.30 ,OP,77.3,400.34,,,,,,
Health Alliance MCR ADV,CPT,V2213,Lens sphcyl bifo 7.25-12/4.2,Durable Medical Equipment,Per Unit,$81.28 ,OP,81.28,419.4,,,,,,
Health Alliance MCR ADV,CPT,V2214,Lens sphcyl bifocal over 12.,Durable Medical Equipment,Per Unit,$84.95 ,OP,84.95,438.47,,,,,,
Health Alliance MCR ADV,CPT,V2215,Lens lenticular bifocal,Durable Medical Equipment,Per Unit,$106.06 ,OP,106.06,549.03,,,,,,
Health Alliance MCR ADV,CPT,V2218,Lens aniseikonic bifocal,Durable Medical Equipment,Per Unit,$108.09 ,OP,108.09,556.65,,,,,,
Health Alliance MCR ADV,CPT,V2219,Lens bifocal seg width over,Durable Medical Equipment,Per Unit,$49.86 ,OP,49.86,255.45,,,,,,
Health Alliance MCR ADV,CPT,V2220,Lens bifocal add over 3.25d,Durable Medical Equipment,Per Unit,$44.28 ,OP,44.28,228.77,,,,,,
Health Alliance MCR ADV,CPT,V2221,Lenticular lens- bifocal,Durable Medical Equipment,Per Unit,$88.33 ,OP,88.33,457.52,,,,,,
Health Alliance MCR ADV,CPT,V2300,Lens sphere trifocal 4.00d,Durable Medical Equipment,Per Unit,$71.57 ,OP,71.57,369.83,,,,,,
Health Alliance MCR ADV,CPT,V2301,Lens sphere trifocal 4.12-7.,Durable Medical Equipment,Per Unit,$87.77 ,OP,87.77,453.71,,,,,,
Health Alliance MCR ADV,CPT,V2302,Lens sphere trifocal 7.12-20,Durable Medical Equipment,Per Unit,$82.00 ,OP,82,423.22,,,,,,
Health Alliance MCR ADV,CPT,V2303,Lens sphcy trifocal 4.0/.12-,Durable Medical Equipment,Per Unit,$68.89 ,OP,68.89,354.58,,,,,,
Health Alliance MCR ADV,CPT,V2304,Lens sphcy trifocal 4.0/2.25,Durable Medical Equipment,Per Unit,$69.70 ,OP,69.7,358.39,,,,,,
Health Alliance MCR ADV,CPT,V2305,Lens sphcy trifocal 4.0/4.25,Durable Medical Equipment,Per Unit,$77.86 ,OP,77.86,400.34,,,,,,
Health Alliance MCR ADV,CPT,V2306,Lens sphcyl trifocal 4.00/>6,Durable Medical Equipment,Per Unit,$80.17 ,OP,80.17,411.78,,,,,,
Health Alliance MCR ADV,CPT,V2307,Lens sphcy trifocal 4.25-7/.,Durable Medical Equipment,Per Unit,$76.33 ,OP,76.33,392.7,,,,,,
Health Alliance MCR ADV,CPT,V2308,Lens sphc trifocal 4.25-7/2.,Durable Medical Equipment,Per Unit,$83.26 ,OP,83.26,430.83,,,,,,
Health Alliance MCR ADV,CPT,V2309,Lens sphc trifocal 4.25-7/4.,Durable Medical Equipment,Per Unit,$87.13 ,OP,87.13,449.9,,,,,,
Health Alliance MCR ADV,CPT,V2310,Lens sphc trifocal 4.25-7/>6,Durable Medical Equipment,Per Unit,$91.01 ,OP,91.01,468.96,,,,,,
Health Alliance MCR ADV,CPT,V2311,Lens sphc trifo 7.25-12/.25-,Durable Medical Equipment,Per Unit,$105.08 ,OP,105.08,541.4,,,,,,
Health Alliance MCR ADV,CPT,V2312,Lens sphc trifo 7.25-12/2.25,Durable Medical Equipment,Per Unit,$96.32 ,OP,96.32,495.65,,,,,,
Health Alliance MCR ADV,CPT,V2313,Lens sphc trifo 7.25-12/4.25,Durable Medical Equipment,Per Unit,$105.15 ,OP,105.15,541.4,,,,,,
Health Alliance MCR ADV,CPT,V2314,Lens sphcyl trifocal over 12,Durable Medical Equipment,Per Unit,$107.48 ,OP,107.48,552.84,,,,,,
Health Alliance MCR ADV,CPT,V2315,Lens lenticular trifocal,Durable Medical Equipment,Per Unit,$119.32 ,OP,119.32,613.85,,,,,,
Health Alliance MCR ADV,CPT,V2318,Lens aniseikonic trifocal,Durable Medical Equipment,Per Unit,$146.68 ,OP,146.68,754.91,,,,,,
Health Alliance MCR ADV,CPT,V2319,Lens trifocal seg width > 28,Durable Medical Equipment,Per Unit,$66.22 ,OP,66.22,343.14,,,,,,
Health Alliance MCR ADV,CPT,V2320,Lens trifocal add over 3.25d,Durable Medical Equipment,Per Unit,$69.85 ,OP,69.85,362.21,,,,,,
Health Alliance MCR ADV,CPT,V2321,Lenticular lens- trifocal,Durable Medical Equipment,Per Unit,$117.61 ,OP,117.61,606.21,,,,,,
Health Alliance MCR ADV,CPT,V2410,Lens variab asphericity sing,Durable Medical Equipment,Per Unit,$102.83 ,OP,102.83,529.96,,,,,,
Health Alliance MCR ADV,CPT,V2430,Lens variable asphericity bi,Durable Medical Equipment,Per Unit,$108.84 ,OP,108.84,560.47,,,,,,
Health Alliance MCR ADV,CPT,V2500,Contact lens pmma spherical,Durable Medical Equipment,Per Unit,$92.01 ,OP,92.01,92.01,,,,,,
Health Alliance MCR ADV,CPT,V2501,Cntct lens pmma-toric/prism,Durable Medical Equipment,Per Unit,$130.56 ,OP,130.56,674.85,,,,,,
Health Alliance MCR ADV,CPT,V2502,Contact lens pmma bifocal,Durable Medical Equipment,Per Unit,$176.91 ,OP,176.91,911.23,,,,,,
Health Alliance MCR ADV,CPT,V2503,Cntct lens pmma color vision,Durable Medical Equipment,Per Unit,$170.87 ,OP,170.87,880.74,,,,,,
Health Alliance MCR ADV,CPT,V2510,Cntct gas permeable sphericl,Durable Medical Equipment,Per Unit,$122.68 ,OP,122.68,632.91,,,,,,
Health Alliance MCR ADV,CPT,V2511,Cntct toric prism ballast,Durable Medical Equipment,Per Unit,$181.84 ,OP,181.84,937.93,,,,,,
Health Alliance MCR ADV,CPT,V2512,Cntct lens gas permbl bifocl,Durable Medical Equipment,Per Unit,$209.31 ,OP,209.31,"1,078.99",,,,,,
Health Alliance MCR ADV,CPT,V2513,Contact lens extended wear,Durable Medical Equipment,Per Unit,$210.87 ,OP,210.87,"1,086.62",,,,,,
Health Alliance MCR ADV,CPT,V2520,Contact lens hydrophilic,Durable Medical Equipment,Per Unit,$122.25 ,OP,122.25,629.1,,,,,,
Health Alliance MCR ADV,CPT,V2521,Cntct lens hydrophilic toric,Durable Medical Equipment,Per Unit,$242.09 ,OP,242.09,"1,250.57",,,,,,
Health Alliance MCR ADV,CPT,V2522,Cntct lens hydrophil bifocl,Durable Medical Equipment,Per Unit,$177.16 ,OP,177.16,915.04,,,,,,
Health Alliance MCR ADV,CPT,V2523,Cntct lens hydrophil extend,Durable Medical Equipment,Per Unit,$186.00 ,OP,186,960.8,,,,,,
Health Alliance MCR ADV,CPT,V2530,Contact lens gas impermeable,Durable Medical Equipment,Per Unit,$297.37 ,OP,297.37,"1,532.70",,,,,,
Health Alliance MCR ADV,CPT,V2531,Contact lens gas permeable,Durable Medical Equipment,Per Unit,$544.58 ,OP,544.58,"2,809.96",,,,,,
Health Alliance MCR ADV,CPT,V2623,Plastic eye prosth custom,Durable Medical Equipment,Per Unit,$942.94 ,OP,942.94,"4,864.99",,,,,,
Health Alliance MCR ADV,CPT,V2624,Polishing artifical eye,Durable Medical Equipment,Per Unit,$60.88 ,OP,60.88,312.64,,,,,,
Health Alliance MCR ADV,CPT,V2625,Enlargemnt of eye prosthesis,Durable Medical Equipment,Per Unit,$482.12 ,OP,482.12,"2,485.87",,,,,,
Health Alliance MCR ADV,CPT,V2626,Reduction of eye prosthesis,Durable Medical Equipment,Per Unit,$199.51 ,OP,199.51,"1,029.43",,,,,,
Health Alliance MCR ADV,CPT,V2627,Scleral cover shell,Durable Medical Equipment,Per Unit,"$1,430.28 ",OP,"1,430.28","7,377.56",,,,,,
Health Alliance MCR ADV,CPT,V2628,Fabrication & fitting,Durable Medical Equipment,Per Unit,$304.24 ,OP,304.24,"1,570.83",,,,,,
Health Alliance MCR ADV,CPT,V2700,Balance lens,Durable Medical Equipment,Per Unit,$44.84 ,OP,44.84,232.58,,,,,,
Health Alliance MCR ADV,CPT,V2710,Glass/plastic slab off prism,Durable Medical Equipment,Per Unit,$73.51 ,OP,73.51,377.46,,,,,,
Health Alliance MCR ADV,CPT,V2715,Prism lens/es,Durable Medical Equipment,Per Unit,$14.41 ,OP,14.41,72.44,,,,,,
Health Alliance MCR ADV,CPT,V2718,Fresnell prism press-on lens,Durable Medical Equipment,Per Unit,$31.12 ,OP,31.12,160.13,,,,,,
Health Alliance MCR ADV,CPT,V2730,Special base curve,Durable Medical Equipment,Per Unit,$26.06 ,OP,26.06,133.45,,,,,,
Health Alliance MCR ADV,CPT,V2744,Tint photochromatic lens/es,Durable Medical Equipment,Per Unit,$17.83 ,OP,17.83,91.51,,,,,,
Health Alliance MCR ADV,CPT,V2745,Tint- any color/solid/grad,Durable Medical Equipment,Per Unit,$10.27 ,OP,10.27,53.38,,,,,,
Health Alliance MCR ADV,CPT,V2750,Anti-reflective coating,Durable Medical Equipment,Per Unit,$20.02 ,OP,20.02,102.95,,,,,,
Health Alliance MCR ADV,CPT,V2755,Uv lens/es,Durable Medical Equipment,Per Unit,$16.76 ,OP,16.76,87.69,,,,,,
Health Alliance MCR ADV,CPT,V2770,Occluder lens/es,Durable Medical Equipment,Per Unit,$19.52 ,OP,19.52,99.13,,,,,,
Health Alliance MCR ADV,CPT,V2780,Oversize lens/es,Durable Medical Equipment,Per Unit,$12.53 ,OP,12.53,64.82,,,,,,
Health Alliance MCR ADV,CPT,V2782,Lens- 1.54-1.65 p/1.60-1.79g,Durable Medical Equipment,Per Unit,$64.75 ,OP,64.75,335.53,,,,,,
Health Alliance MCR ADV,CPT,V2783,Lens- >= 1.66 p/>=1.80 g,Durable Medical Equipment,Per Unit,$73.02 ,OP,73.02,377.46,,,,,,
Health Alliance MCR ADV,CPT,V2784,Lens polycarb or equal,Durable Medical Equipment,Per Unit,$47.48 ,OP,47.48,244.01,,,,,,
Health Alliance MCR ADV,CPT,V2785,Corneal tissue processing,Other,Straight Discount,29.70%,OP,,,,,,,,
Humana,DRG,MS-001,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W MCC,Surgical,Relative Weights,"$419,151.00 ",IP,"17,718.00","557,099.42",,,,,,
Humana,DRG,MS-002,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W/O MCC,Surgical,Relative Weights,"$212,559.80 ",IP,"17,718.00","282,516.19",,,,,,
Humana,DRG,MS-003,ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITH MAJOR O.R. PROCEDURES,Surgical,Relative Weights,"$287,492.76 ",IP,"111,577.60","382,110.62",,,,,,
Humana,DRG,MS-004,TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES,Surgical,Relative Weights,"$175,096.36 ",IP,"69,628.33","232,723.01",,,,,,
Humana,DRG,MS-005,LIVER TRANSPLANT W MCC OR INTESTINAL TRANSPLANT,Surgical,Relative Weights,"$156,423.03 ",IP,"59,773.19","207,904.03",,,,,,
Humana,DRG,MS-006,LIVER TRANSPLANT W/O MCC,Surgical,Relative Weights,"$73,896.98 ",IP,"27,427.34","98,217.50",,,,,,
Humana,DRG,MS-007,LUNG TRANSPLANT,Surgical,Relative Weights,"$163,606.60 ",IP,"67,628.10","217,451.81",,,,,,
Humana,DRG,MS-008,SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,Surgical,Relative Weights,"$85,185.00 ",IP,"31,730.89","113,220.58",,,,,,
Humana,DRG,MS-010,PANCREAS TRANSPLANT,Surgical,Relative Weights,"$60,309.48 ",IP,"2,420.00","80,158.18",,,,,,
Humana,DRG,MS-011,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC,Surgical,Relative Weights,"$74,987.56 ",IP,"2,420.00","99,667.01",,,,,,
Humana,DRG,MS-012,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC,Surgical,Relative Weights,"$57,244.03 ",IP,"2,420.00","76,083.84",,,,,,
Humana,DRG,MS-013,TRACHEOSTOMY FOR FACE -  MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC,Surgical,Relative Weights,"$36,786.95 ",IP,"2,420.00","48,894.05",,,,,,
Humana,DRG,MS-014,ALLOGENEIC BONE MARROW TRANSPLANT,Surgical,Relative Weights,"$193,464.81 ",IP,"2,420.00","257,136.77",,,,,,
Humana,DRG,MS-016,AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,Surgical,Relative Weights,"$104,434.71 ",IP,"2,420.00","138,805.63",,,,,,
Humana,DRG,MS-017,AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,Surgical,Relative Weights,"$67,458.16 ",IP,"2,420.00","89,659.58",,,,,,
Humana,DRG,MS-020,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,Surgical,Relative Weights,"$164,132.93 ",IP,"2,420.00","218,151.36",,,,,,
Humana,DRG,MS-021,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,Surgical,Relative Weights,"$125,495.48 ",IP,"2,420.00","166,797.79",,,,,,
Humana,DRG,MS-022,INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W/O CC/MCC,Surgical,Relative Weights,"$74,805.54 ",IP,"2,420.00","99,425.09",,,,,,
Humana,DRG,MS-023,CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX CNS PDX W MCC OR CHEMO IMPLANT,Surgical,Relative Weights,"$85,200.17 ",IP,"2,420.00","113,240.74",,,,,,
Humana,DRG,MS-024,CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,Surgical,Relative Weights,"$60,922.27 ",IP,"2,420.00","80,972.64",,,,,,
Humana,DRG,MS-025,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$66,655.78 ",IP,"2,420.00","88,593.12",,,,,,
Humana,DRG,MS-026,CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC,Surgical,Relative Weights,"$46,198.69 ",IP,"2,420.00","61,403.33",,,,,,
Humana,DRG,MS-027,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$36,353.15 ",IP,"2,420.00","48,317.47",,,,,,
Humana,DRG,MS-028,SPINAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$84,795.19 ",IP,"2,420.00","112,702.46",,,,,,
Humana,DRG,MS-029,SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,Surgical,Relative Weights,"$48,643.78 ",IP,"2,420.00","64,653.12",,,,,,
Humana,DRG,MS-030,SPINAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$34,463.21 ",IP,"2,420.00","45,805.54",,,,,,
Humana,DRG,MS-031,VENTRICULAR SHUNT PROCEDURES WITH MCC,Surgical,Relative Weights,"$66,352.42 ",IP,"2,420.00","88,189.92",,,,,,
Humana,DRG,MS-032,VENTRICULAR SHUNT PROCEDURES WITH CC,Surgical,Relative Weights,"$33,249.77 ",IP,"2,420.00","44,192.74",,,,,,
Humana,DRG,MS-033,VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$25,799.25 ",IP,"2,420.00","34,290.14",,,,,,
Humana,DRG,MS-034,CAROTID ARTERY STENT PROCEDURE W MCC,Surgical,Relative Weights,"$56,936.12 ",IP,"2,420.00","75,674.59",,,,,,
Humana,DRG,MS-035,CAROTID ARTERY STENT PROCEDURES WITH CC,Surgical,Relative Weights,"$34,919.77 ",IP,"2,420.00","46,412.35",,,,,,
Humana,DRG,MS-036,CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$26,559.17 ",IP,"2,420.00","35,300.16",,,,,,
Humana,DRG,MS-037,EXTRACRANIAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$49,194.37 ",IP,"2,420.00","65,384.93",,,,,,
Humana,DRG,MS-038,EXTRACRANIAL PROCEDURES WITH CC,Surgical,Relative Weights,"$25,409.43 ",IP,"2,420.00","33,772.03",,,,,,
Humana,DRG,MS-039,EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$17,159.56 ",IP,"2,420.00","22,807.01",,,,,,
Humana,DRG,MS-040,PERIPHERAL- CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC,Surgical,Relative Weights,"$59,767.99 ",IP,"2,420.00","79,438.46",,,,,,
Humana,DRG,MS-041,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W CC OR PERIPH NEUROSTIM,Surgical,Relative Weights,"$35,970.91 ",IP,"2,420.00","47,809.44",,,,,,
Humana,DRG,MS-042,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W/O CC/MCC,Surgical,Relative Weights,"$28,035.01 ",IP,"2,420.00","37,261.73",,,,,,
Humana,DRG,MS-052,SPINAL DISORDERS AND INJURIES WITH CC/MCC,Surgical,Relative Weights,"$24,707.16 ",IP,"2,420.00","32,838.62",,,,,,
Humana,DRG,MS-053,SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,Surgical,Relative Weights,"$14,653.80 ",IP,"2,420.00","19,476.58",,,,,,
Humana,DRG,MS-054,NERVOUS SYSTEM NEOPLASMS WITH MCC,Surgical,Relative Weights,"$20,326.64 ",IP,"2,420.00","27,016.42",,,,,,
Humana,DRG,MS-055,NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,Surgical,Relative Weights,"$14,955.65 ",IP,"2,420.00","19,877.76",,,,,,
Humana,DRG,MS-056,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,Surgical,Relative Weights,"$33,254.32 ",IP,"2,420.00","44,198.78",,,,,,
Humana,DRG,MS-057,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,Surgical,Relative Weights,"$18,365.41 ",IP,"2,420.00","24,409.73",,,,,,
Humana,DRG,MS-058,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,Surgical,Relative Weights,"$29,648.89 ",IP,"2,420.00","39,406.75",,,,,,
Humana,DRG,MS-059,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,Surgical,Relative Weights,"$16,540.70 ",IP,"2,420.00","21,984.48",,,,,,
Humana,DRG,MS-060,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,Surgical,Relative Weights,"$13,373.63 ",IP,"2,420.00","17,775.07",,,,,,
Humana,DRG,MS-061,ISCHEMIC STROKE -  PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC,Surgical,Relative Weights,"$42,371.81 ",IP,"2,420.00","56,316.96",,,,,,
Humana,DRG,MS-062,ISCHEMIC STROKE -  PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC,Surgical,Relative Weights,"$30,505.88 ",IP,"2,420.00","40,545.79",,,,,,
Humana,DRG,MS-063,ISCHEMIC STROKE- PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC,Surgical,Relative Weights,"$25,494.37 ",IP,"2,420.00","33,884.93",,,,,,
Humana,DRG,MS-064,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,Surgical,Relative Weights,"$28,436.97 ",IP,"2,420.00","37,795.97",,,,,,
Humana,DRG,MS-065,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC,Surgical,Relative Weights,"$15,588.15 ",IP,"2,420.00","20,718.43",,,,,,
Humana,DRG,MS-066,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,Surgical,Relative Weights,"$10,875.46 ",IP,"2,420.00","14,454.72",,,,,,
Humana,DRG,MS-067,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,Surgical,Relative Weights,"$22,213.54 ",IP,"2,420.00","29,524.32",,,,,,
Humana,DRG,MS-068,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,Surgical,Relative Weights,"$13,702.77 ",IP,"2,420.00","18,212.54",,,,,,
Humana,DRG,MS-069,TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,Surgical,Relative Weights,"$11,835.59 ",IP,"2,420.00","15,730.85",,,,,,
Humana,DRG,MS-070,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC,Surgical,Relative Weights,"$25,374.55 ",IP,"2,420.00","33,725.66",,,,,,
Humana,DRG,MS-071,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC,Surgical,Relative Weights,"$15,087.61 ",IP,"2,420.00","20,053.15",,,,,,
Humana,DRG,MS-072,NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$11,201.57 ",IP,"2,420.00","14,888.16",,,,,,
Humana,DRG,MS-073,CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,Surgical,Relative Weights,"$21,471.82 ",IP,"2,420.00","28,538.50",,,,,,
Humana,DRG,MS-074,CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,Surgical,Relative Weights,"$14,987.50 ",IP,"2,420.00","19,920.10",,,,,,
Humana,DRG,MS-075,VIRAL MENINGITIS WITH CC/MCC,Surgical,Relative Weights,"$24,393.18 ",IP,"2,420.00","32,421.31",,,,,,
Humana,DRG,MS-076,VIRAL MENINGITIS WITHOUT CC/MCC,Surgical,Relative Weights,"$13,689.12 ",IP,"2,420.00","18,194.40",,,,,,
Humana,DRG,MS-077,HYPERTENSIVE ENCEPHALOPATHY WITH MCC,Surgical,Relative Weights,"$23,396.64 ",IP,"2,420.00","31,096.80",,,,,,
Humana,DRG,MS-078,HYPERTENSIVE ENCEPHALOPATHY WITH CC,Surgical,Relative Weights,"$14,591.62 ",IP,"2,420.00","19,393.92",,,,,,
Humana,DRG,MS-079,HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC,Surgical,Relative Weights,"$11,241.00 ",IP,"2,420.00","14,940.58",,,,,,
Humana,DRG,MS-080,NONTRAUMATIC STUPOR & COMA W MCC,Surgical,Relative Weights,"$29,066.44 ",IP,"2,420.00","38,632.61",,,,,,
Humana,DRG,MS-081,NONTRAUMATIC STUPOR & COMA W/O MCC,Surgical,Relative Weights,"$13,334.19 ",IP,"2,420.00","17,722.66",,,,,,
Humana,DRG,MS-082,TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,Surgical,Relative Weights,"$34,155.30 ",IP,"2,420.00","45,396.29",,,,,,
Humana,DRG,MS-083,TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,Surgical,Relative Weights,"$19,880.70 ",IP,"2,420.00","26,423.71",,,,,,
Humana,DRG,MS-084,TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,Surgical,Relative Weights,"$13,610.25 ",IP,"2,420.00","18,089.57",,,,,,
Humana,DRG,MS-085,TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,Surgical,Relative Weights,"$34,064.29 ",IP,"2,420.00","45,275.33",,,,,,
Humana,DRG,MS-086,TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,Surgical,Relative Weights,"$18,774.95 ",IP,"2,420.00","24,954.05",,,,,,
Humana,DRG,MS-087,TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,Surgical,Relative Weights,"$12,728.99 ",IP,"2,420.00","16,918.27",,,,,,
Humana,DRG,MS-088,CONCUSSION WITH MCC,Surgical,Relative Weights,"$21,069.87 ",IP,"2,420.00","28,004.26",,,,,,
Humana,DRG,MS-089,CONCUSSION WITH CC,Surgical,Relative Weights,"$14,960.20 ",IP,"2,420.00","19,883.81",,,,,,
Humana,DRG,MS-090,CONCUSSION WITHOUT CC/MCC,Surgical,Relative Weights,"$12,867.01 ",IP,"2,420.00","17,101.73",,,,,,
Humana,DRG,MS-091,OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,Surgical,Relative Weights,"$23,739.44 ",IP,"2,420.00","31,552.42",,,,,,
Humana,DRG,MS-092,OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,Surgical,Relative Weights,"$14,653.80 ",IP,"2,420.00","19,476.58",,,,,,
Humana,DRG,MS-093,OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,Surgical,Relative Weights,"$11,545.88 ",IP,"2,420.00","15,345.79",,,,,,
Humana,DRG,MS-094,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,Surgical,Relative Weights,"$54,374.25 ",IP,"2,420.00","72,269.57",,,,,,
Humana,DRG,MS-095,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,Surgical,Relative Weights,"$36,510.89 ",IP,"2,420.00","48,527.14",,,,,,
Humana,DRG,MS-096,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,Surgical,Relative Weights,"$34,311.53 ",IP,"2,420.00","45,603.94",,,,,,
Humana,DRG,MS-097,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,Surgical,Relative Weights,"$54,239.25 ",IP,"2,420.00","72,090.14",,,,,,
Humana,DRG,MS-098,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,Surgical,Relative Weights,"$29,653.44 ",IP,"2,420.00","39,412.80",,,,,,
Humana,DRG,MS-099,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,Surgical,Relative Weights,"$19,451.44 ",IP,"2,420.00","25,853.18",,,,,,
Humana,DRG,MS-100,SEIZURES WITH MCC,Surgical,Relative Weights,"$27,608.79 ",IP,"2,420.00","36,695.23",,,,,,
Humana,DRG,MS-101,SEIZURES WITHOUT MCC,Surgical,Relative Weights,"$13,391.83 ",IP,"2,420.00","17,799.26",,,,,,
Humana,DRG,MS-102,HEADACHES WITH MCC,Surgical,Relative Weights,"$18,089.36 ",IP,"2,420.00","24,042.82",,,,,,
Humana,DRG,MS-103,HEADACHES W/O MCC,Surgical,Relative Weights,"$12,126.82 ",IP,"2,420.00","16,117.92",,,,,,
Humana,DRG,MS-113,ORBITAL PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$32,339.69 ",IP,"2,420.00","42,983.14",,,,,,
Humana,DRG,MS-114,ORBITAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$18,062.05 ",IP,"2,420.00","24,006.53",,,,,,
Humana,DRG,MS-115,EXTRAOCULAR PROCEDURES EXCEPT ORBIT,Surgical,Relative Weights,"$22,539.65 ",IP,"2,420.00","29,957.76",,,,,,
Humana,DRG,MS-116,INTRAOCULAR PROCEDURES W CC/MCC,Surgical,Relative Weights,"$28,682.69 ",IP,"2,420.00","38,122.56",,,,,,
Humana,DRG,MS-117,INTRAOCULAR PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$16,634.75 ",IP,"2,420.00","22,109.47",,,,,,
Humana,DRG,MS-121,ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,Surgical,Relative Weights,"$19,229.99 ",IP,"2,420.00","25,558.85",,,,,,
Humana,DRG,MS-122,ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,Surgical,Relative Weights,"$11,718.80 ",IP,"2,420.00","15,575.62",,,,,,
Humana,DRG,MS-123,NEUROLOGICAL EYE DISORDERS,Surgical,Relative Weights,"$11,843.17 ",IP,"2,420.00","15,740.93",,,,,,
Humana,DRG,MS-124,OTHER DISORDERS OF THE EYE WITH MCC,Surgical,Relative Weights,"$21,074.42 ",IP,"2,420.00","28,010.30",,,,,,
Humana,DRG,MS-125,OTHER DISORDERS OF THE EYE WITHOUT MCC,Surgical,Relative Weights,"$11,973.62 ",IP,"2,420.00","15,914.30",,,,,,
Humana,DRG,MS-129,MAJOR HEAD & NECK PROCEDURES W CC/MCC OR MAJOR DEVICE,Surgical,Relative Weights,"$34,724.10 ",IP,"21,710.46","46,152.29",,,,,,
Humana,DRG,MS-130,MAJOR HEAD & NECK PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$21,926.86 ",IP,"13,709.28","29,143.30",,,,,,
Humana,DRG,MS-131,CRANIAL/FACIAL PROCEDURES W CC/MCC,Surgical,Relative Weights,"$40,791.30 ",IP,"25,503.84","54,216.29",,,,,,
Humana,DRG,MS-132,CRANIAL/FACIAL PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$24,109.54 ",IP,"15,073.94","32,044.32",,,,,,
Humana,DRG,MS-133,OTHER EAR - NOSE - MOUTH & THROAT O.R. PROCEDURES W CC/MCC,Surgical,Relative Weights,"$32,564.18 ",IP,"20,360.02","43,281.50",,,,,,
Humana,DRG,MS-134,OTHER EAR - NOSE - MOUTH & THROAT O.R. PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$18,339.63 ",IP,"11,466.44","24,375.46",,,,,,
Humana,DRG,MS-135,SINUS AND MASTOID PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$34,652.81 ",IP,"2,420.00","46,057.54",,,,,,
Humana,DRG,MS-136,SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$18,049.92 ",IP,"2,420.00","23,990.40",,,,,,
Humana,DRG,MS-137,MOUTH PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$20,223.49 ",IP,"2,420.00","26,879.33",,,,,,
Humana,DRG,MS-138,MOUTH PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$13,065.72 ",IP,"2,420.00","17,365.82",,,,,,
Humana,DRG,MS-139,SALIVARY GLAND PROCEDURES,Surgical,Relative Weights,"$18,721.86 ",IP,"2,420.00","24,883.49",,,,,,
Humana,DRG,MS-146,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH MCC,Surgical,Relative Weights,"$29,253.00 ",IP,"2,420.00","38,880.58",,,,,,
Humana,DRG,MS-147,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH CC,Surgical,Relative Weights,"$18,821.97 ",IP,"2,420.00","25,016.54",,,,,,
Humana,DRG,MS-148,EAR - NOSE - MOUTH & THROAT MALIGNANCY W/O CC/MCC,Surgical,Relative Weights,"$11,533.75 ",IP,"2,420.00","15,329.66",,,,,,
Humana,DRG,MS-149,DYSEQUILIBRIUM,Surgical,Relative Weights,"$11,080.22 ",IP,"2,420.00","14,726.88",,,,,,
Humana,DRG,MS-150,EPISTAXIS WITH MCC,Surgical,Relative Weights,"$19,589.47 ",IP,"2,420.00","26,036.64",,,,,,
Humana,DRG,MS-151,EPISTAXIS WITHOUT MCC,Surgical,Relative Weights,"$10,603.95 ",IP,"2,420.00","14,093.86",,,,,,
Humana,DRG,MS-152,OTITIS MEDIA AND URI WITH MCC,Surgical,Relative Weights,"$15,759.55 ",IP,"2,420.00","20,946.24",,,,,,
Humana,DRG,MS-153,OTITIS MEDIA AND URI WITHOUT MCC,Surgical,Relative Weights,"$10,714.68 ",IP,"2,420.00","14,241.02",,,,,,
Humana,DRG,MS-154,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH MCC,Surgical,Relative Weights,"$21,796.42 ",IP,"2,420.00","28,969.92",,,,,,
Humana,DRG,MS-155,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH CC,Surgical,Relative Weights,"$13,667.88 ",IP,"2,420.00","18,166.18",,,,,,
Humana,DRG,MS-156,OTHER EAR -  NOSE -  MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC,Surgical,Relative Weights,"$9,927.46 ",IP,"2,420.00","13,194.72",,,,,,
Humana,DRG,MS-157,DENTAL AND ORAL DISEASES WITH MCC,Surgical,Relative Weights,"$23,706.07 ",IP,"2,420.00","31,508.06",,,,,,
Humana,DRG,MS-158,DENTAL AND ORAL DISEASES WITH CC,Surgical,Relative Weights,"$13,144.59 ",IP,"2,420.00","17,470.66",,,,,,
Humana,DRG,MS-159,DENTAL AND ORAL DISEASES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,206.55 ",IP,"2,420.00","13,565.66",,,,,,
Humana,DRG,MS-163,MAJOR CHEST PROCEDURES WITH MCC,Surgical,Relative Weights,"$73,924.28 ",IP,"2,420.00","98,253.79",,,,,,
Humana,DRG,MS-164,MAJOR CHEST PROCEDURES WITH CC,Surgical,Relative Weights,"$38,399.31 ",IP,"2,420.00","51,037.06",,,,,,
Humana,DRG,MS-165,MAJOR CHEST PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$28,048.67 ",IP,"2,420.00","37,279.87",,,,,,
Humana,DRG,MS-166,OTHER RESP SYSTEM O.R. PROCEDURES W MCC,Surgical,Relative Weights,"$56,587.26 ",IP,"2,420.00","75,210.91",,,,,,
Humana,DRG,MS-167,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$29,037.62 ",IP,"2,420.00","38,594.30",,,,,,
Humana,DRG,MS-168,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$20,123.39 ",IP,"2,420.00","26,746.27",,,,,,
Humana,DRG,MS-175,PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,Surgical,Relative Weights,"$21,908.66 ",IP,"2,420.00","29,119.10",,,,,,
Humana,DRG,MS-176,PULMONARY EMBOLISM WITHOUT MCC,Surgical,Relative Weights,"$12,868.53 ",IP,"2,420.00","17,103.74",,,,,,
Humana,DRG,MS-177,RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC,Surgical,Relative Weights,"$28,685.72 ",IP,"2,420.00","38,126.59",,,,,,
Humana,DRG,MS-178,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,Surgical,Relative Weights,"$18,858.37 ",IP,"2,420.00","25,064.93",,,,,,
Humana,DRG,MS-179,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,Surgical,Relative Weights,"$13,137.00 ",IP,"2,420.00","17,460.58",,,,,,
Humana,DRG,MS-180,RESPIRATORY NEOPLASMS WITH MCC,Surgical,Relative Weights,"$26,163.28 ",IP,"2,420.00","34,773.98",,,,,,
Humana,DRG,MS-181,RESPIRATORY NEOPLASMS WITH CC,Surgical,Relative Weights,"$17,473.54 ",IP,"2,420.00","23,224.32",,,,,,
Humana,DRG,MS-182,RESPIRATORY NEOPLASMS WITHOUT CC/MCC,Surgical,Relative Weights,"$12,783.59 ",IP,"2,420.00","16,990.85",,,,,,
Humana,DRG,MS-183,MAJOR CHEST TRAUMA WITH MCC,Surgical,Relative Weights,"$22,891.55 ",IP,"2,420.00","30,425.47",,,,,,
Humana,DRG,MS-184,MAJOR CHEST TRAUMA WITH CC,Surgical,Relative Weights,"$15,444.06 ",IP,"2,420.00","20,526.91",,,,,,
Humana,DRG,MS-185,MAJOR CHEST TRAUMA W/O CC/MCC,Surgical,Relative Weights,"$11,133.31 ",IP,"2,420.00","14,797.44",,,,,,
Humana,DRG,MS-186,PLEURAL EFFUSION WITH MCC,Surgical,Relative Weights,"$23,402.71 ",IP,"2,420.00","31,104.86",,,,,,
Humana,DRG,MS-187,PLEURAL EFFUSION WITH CC,Surgical,Relative Weights,"$15,591.19 ",IP,"2,420.00","20,722.46",,,,,,
Humana,DRG,MS-188,PLEURAL EFFUSION WITHOUT CC/MCC,Surgical,Relative Weights,"$11,086.29 ",IP,"2,420.00","14,734.94",,,,,,
Humana,DRG,MS-189,PULMONARY EDEMA AND RESPIRATORY FAILURE,Surgical,Relative Weights,"$18,439.74 ",IP,"2,420.00","24,508.51",,,,,,
Humana,DRG,MS-190,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,Surgical,Relative Weights,"$17,352.19 ",IP,"2,420.00","23,063.04",,,,,,
Humana,DRG,MS-191,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,Surgical,Relative Weights,"$13,541.99 ",IP,"2,420.00","17,998.85",,,,,,
Humana,DRG,MS-192,CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC,Surgical,Relative Weights,"$10,757.15 ",IP,"2,420.00","14,297.47",,,,,,
Humana,DRG,MS-193,SIMPLE PNEUMONIA & PLEURISY W MCC,Surgical,Relative Weights,"$20,226.53 ",IP,"2,420.00","26,883.36",,,,,,
Humana,DRG,MS-194,SIMPLE PNEUMONIA AND PLEURISY WITH CC,Surgical,Relative Weights,"$13,478.28 ",IP,"2,420.00","17,914.18",,,,,,
Humana,DRG,MS-195,SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,Surgical,Relative Weights,"$10,346.09 ",IP,"2,420.00","13,751.14",,,,,,
Humana,DRG,MS-196,INTERSTITIAL LUNG DISEASE WITH MCC,Surgical,Relative Weights,"$25,412.47 ",IP,"2,420.00","33,776.06",,,,,,
Humana,DRG,MS-197,INTERSTITIAL LUNG DISEASE WITH CC,Surgical,Relative Weights,"$15,494.11 ",IP,"2,420.00","20,593.44",,,,,,
Humana,DRG,MS-198,INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,Surgical,Relative Weights,"$11,451.84 ",IP,"2,420.00","15,220.80",,,,,,
Humana,DRG,MS-199,PNEUMOTHORAX WITH MCC,Surgical,Relative Weights,"$27,212.91 ",IP,"2,420.00","36,169.06",,,,,,
Humana,DRG,MS-200,PNEUMOTHORAX WITH CC,Surgical,Relative Weights,"$16,413.29 ",IP,"2,420.00","21,815.14",,,,,,
Humana,DRG,MS-201,PNEUMOTHORAX WITHOUT CC/MCC,Surgical,Relative Weights,"$10,890.62 ",IP,"2,420.00","14,474.88",,,,,,
Humana,DRG,MS-202,BRONCHITIS AND ASTHMA WITH CC/MCC,Surgical,Relative Weights,"$14,379.26 ",IP,"2,420.00","19,111.68",,,,,,
Humana,DRG,MS-203,BRONCHITIS AND ASTHMA WITHOUT CC/MCC,Surgical,Relative Weights,"$10,523.56 ",IP,"2,420.00","13,987.01",,,,,,
Humana,DRG,MS-204,RESPIRATORY SIGNS AND SYMPTOMS,Surgical,Relative Weights,"$12,324.00 ",IP,"2,420.00","16,380.00",,,,,,
Humana,DRG,MS-205,OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,Surgical,Relative Weights,"$24,787.55 ",IP,"2,420.00","32,945.47",,,,,,
Humana,DRG,MS-206,OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,Surgical,Relative Weights,"$13,234.08 ",IP,"2,420.00","17,589.60",,,,,,
Humana,DRG,MS-207,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS,Surgical,Relative Weights,"$86,997.58 ",IP,"2,420.00","115,629.70",,,,,,
Humana,DRG,MS-208,RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,Surgical,Relative Weights,"$37,678.83 ",IP,"2,420.00","50,079.46",,,,,,
Humana,DRG,MS-215,OTHER HEART ASSIST SYSTEM IMPLANT,Surgical,Relative Weights,"$195,456.36 ",IP,"61,661.88","259,783.78",,,,,,
Humana,DRG,MS-216,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$152,323.12 ",IP,"58,630.29","202,454.78",,,,,,
Humana,DRG,MS-217,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,Surgical,Relative Weights,"$100,891.47 ",IP,"37,864.14","134,096.26",,,,,,
Humana,DRG,MS-218,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,Surgical,Relative Weights,"$81,928.44 ",IP,"35,678.79","108,892.22",,,,,,
Humana,DRG,MS-219,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$118,918.64 ",IP,"47,057.01","158,056.42",,,,,,
Humana,DRG,MS-220,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,Surgical,Relative Weights,"$80,479.89 ",IP,"31,567.37","106,966.94",,,,,,
Humana,DRG,MS-221,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,Surgical,Relative Weights,"$69,715.16 ",IP,"26,746.97","92,659.39",,,,,,
Humana,DRG,MS-222,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITH MCC,Surgical,Relative Weights,"$126,570.89 ",IP,"46,434.46","168,227.14",,,,,,
Humana,DRG,MS-223,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITHOUT MCC,Surgical,Relative Weights,"$91,051.99 ",IP,"33,864.27","121,018.46",,,,,,
Humana,DRG,MS-224,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITH MCC,Surgical,Relative Weights,"$112,185.56 ",IP,"43,912.13","149,107.39",,,,,,
Humana,DRG,MS-225,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITHOUT MCC,Surgical,Relative Weights,"$85,681.00 ",IP,"32,808.39","113,879.81",,,,,,
Humana,DRG,MS-226,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$101,439.03 ",IP,"25,420.00","134,824.03",,,,,,
Humana,DRG,MS-227,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Surgical,Relative Weights,"$79,316.51 ",IP,"25,420.00","105,420.67",,,,,,
Humana,DRG,MS-228,OTHER CARDIOTHORACIC PROCEDURES WITH MCC,Surgical,Relative Weights,"$95,350.60 ",IP,"31,129.37","126,731.81",,,,,,
Humana,DRG,MS-229,OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$62,263.12 ",IP,"20,096.88","82,754.78",,,,,,
Humana,DRG,MS-231,CORONARY BYPASS W PTCA W MCC,Surgical,Relative Weights,"$124,552.03 ",IP,"50,901.53","165,543.84",,,,,,
Humana,DRG,MS-232,CORONARY BYPASS W PTCA W/O MCC,Surgical,Relative Weights,"$90,803.23 ",IP,"34,770.65","120,687.84",,,,,,
Humana,DRG,MS-233,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,Surgical,Relative Weights,"$117,838.68 ",IP,"42,365.00","156,621.02",,,,,,
Humana,DRG,MS-234,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,Surgical,Relative Weights,"$78,969.16 ",IP,"31,162.65","104,959.01",,,,,,
Humana,DRG,MS-235,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$89,257.61 ",IP,"32,351.00","118,633.54",,,,,,
Humana,DRG,MS-236,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Surgical,Relative Weights,"$61,113.39 ",IP,"23,926.80","81,226.66",,,,,,
Humana,DRG,MS-239,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,Surgical,Relative Weights,"$70,830.01 ",IP,"2,420.00","94,141.15",,,,,,
Humana,DRG,MS-240,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,Surgical,Relative Weights,"$41,863.68 ",IP,"2,420.00","55,641.60",,,,,,
Humana,DRG,MS-241,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,Surgical,Relative Weights,"$22,999.24 ",IP,"2,420.00","30,568.61",,,,,,
Humana,DRG,MS-242,PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,Surgical,Relative Weights,"$56,289.96 ",IP,"15,407.00","74,815.78",,,,,,
Humana,DRG,MS-243,PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,Surgical,Relative Weights,"$38,365.94 ",IP,"14,708.24","50,992.70",,,,,,
Humana,DRG,MS-244,PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,Surgical,Relative Weights,"$31,479.67 ",IP,"12,049.83","41,840.06",,,,,,
Humana,DRG,MS-245,AICD GENERATOR PROCEDURES,Surgical,Relative Weights,"$78,991.91 ",IP,"15,407.00","104,989.25",,,,,,
Humana,DRG,MS-246,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Surgical,Relative Weights,"$48,125.03 ",IP,"18,246.15","63,963.65",,,,,,
Humana,DRG,MS-247,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITHOUT MCC,Surgical,Relative Weights,"$30,862.33 ",IP,"11,523.64","41,019.55",,,,,,
Humana,DRG,MS-248,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Surgical,Relative Weights,"$46,967.71 ",IP,"18,467.49","62,425.44",,,,,,
Humana,DRG,MS-249,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITHOUT MCC,Surgical,Relative Weights,"$29,070.99 ",IP,"10,942.55","38,638.66",,,,,,
Humana,DRG,MS-250,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT CORONARY ARTERY STENT WITH MCC,Surgical,Relative Weights,"$38,679.92 ",IP,"14,727.51","51,410.02",,,,,,
Humana,DRG,MS-251,PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W/O MCC,Surgical,Relative Weights,"$25,527.74 ",IP,"2,420.00","33,929.28",,,,,,
Humana,DRG,MS-252,OTHER VASCULAR PROCEDURES W MCC,Surgical,Relative Weights,"$49,757.11 ",IP,"2,420.00","66,132.86",,,,,,
Humana,DRG,MS-253,OTHER VASCULAR PROCEDURES WITH CC,Surgical,Relative Weights,"$39,536.91 ",IP,"2,420.00","52,549.06",,,,,,
Humana,DRG,MS-254,OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$27,607.28 ",IP,"2,420.00","36,693.22",,,,,,
Humana,DRG,MS-255,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,Surgical,Relative Weights,"$40,189.13 ",IP,"2,420.00","53,415.94",,,,,,
Humana,DRG,MS-256,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,Surgical,Relative Weights,"$26,035.87 ",IP,"2,420.00","34,604.64",,,,,,
Humana,DRG,MS-257,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$17,206.58 ",IP,"2,420.00","22,869.50",,,,,,
Humana,DRG,MS-258,CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,Surgical,Relative Weights,"$46,394.36 ",IP,"11,861.00","61,663.39",,,,,,
Humana,DRG,MS-259,CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,Surgical,Relative Weights,"$31,588.88 ",IP,"11,861.00","41,985.22",,,,,,
Humana,DRG,MS-260,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,Surgical,Relative Weights,"$56,115.53 ",IP,"10,167.00","74,583.94",,,,,,
Humana,DRG,MS-261,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,Surgical,Relative Weights,"$29,554.85 ",IP,"10,167.00","39,281.76",,,,,,
Humana,DRG,MS-262,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,Surgical,Relative Weights,"$25,445.84 ",IP,"9,964.34","33,820.42",,,,,,
Humana,DRG,MS-263,VEIN LIGATION AND STRIPPING,Surgical,Relative Weights,"$35,782.83 ",IP,"2,420.00","47,559.46",,,,,,
Humana,DRG,MS-264,OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,Surgical,Relative Weights,"$49,113.98 ",IP,"2,420.00","65,278.08",,,,,,
Humana,DRG,MS-265,AICD LEAD PROCEDURES,Surgical,Relative Weights,"$47,343.88 ",IP,"2,420.00","62,925.41",,,,,,
Humana,DRG,MS-266,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,Surgical,Relative Weights,"$108,017.40 ",IP,"41,160.28","143,567.42",,,,,,
Humana,DRG,MS-267,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$86,087.50 ",IP,"32,692.75","114,420.10",,,,,,
Humana,DRG,MS-268,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,Surgical,Relative Weights,"$102,878.48 ",IP,"32,968.00","136,737.22",,,,,,
Humana,DRG,MS-269,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,Surgical,Relative Weights,"$64,712.76 ",IP,"25,200.52","86,010.62",,,,,,
Humana,DRG,MS-270,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,Surgical,Relative Weights,"$77,511.51 ",IP,"30,292.48","103,021.63",,,,,,
Humana,DRG,MS-271,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,Surgical,Relative Weights,"$53,816.06 ",IP,"20,822.21","71,527.68",,,,,,
Humana,DRG,MS-272,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$39,456.52 ",IP,"15,699.88","52,442.21",,,,,,
Humana,DRG,MS-273,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,Surgical,Relative Weights,"$56,277.83 ",IP,"16,176.00","74,799.65",,,,,,
Humana,DRG,MS-274,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$47,927.85 ",IP,"16,176.00","63,701.57",,,,,,
Humana,DRG,MS-280,ACUTE MYOCARDIAL INFARCTION - DISCHARGED ALIVE W MCC,Surgical,Relative Weights,"$24,737.49 ",IP,"2,420.00","32,878.94",,,,,,
Humana,DRG,MS-281,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITH CC,Surgical,Relative Weights,"$14,693.24 ",IP,"2,420.00","19,528.99",,,,,,
Humana,DRG,MS-282,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITHOUT CC/MCC,Surgical,Relative Weights,"$11,192.47 ",IP,"2,420.00","14,876.06",,,,,,
Humana,DRG,MS-283,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH MCC,Surgical,Relative Weights,"$27,297.85 ",IP,"2,420.00","36,281.95",,,,,,
Humana,DRG,MS-284,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH CC,Surgical,Relative Weights,"$11,001.35 ",IP,"2,420.00","14,622.05",,,,,,
Humana,DRG,MS-285,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITHOUT CC/MCC,Surgical,Relative Weights,"$7,853.99 ",IP,"2,420.00","10,438.85",,,,,,
Humana,DRG,MS-286,CIRCULATORY DISORDERS EXCEPT AMI- WITH CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$33,330.16 ",IP,"2,420.00","44,299.58",,,,,,
Humana,DRG,MS-287,CIRCULATORY DISORDERS EXCEPT AMI -  WITH CARDIAC CATHETERIZATION WITHOUT MCC,Surgical,Relative Weights,"$17,476.57 ",IP,"6,512.27","23,228.35",,,,,,
Humana,DRG,MS-288,ACUTE & SUBACUTE ENDOCARDITIS W MCC,Surgical,Relative Weights,"$40,307.44 ",IP,"2,420.00","53,573.18",,,,,,
Humana,DRG,MS-289,ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,Surgical,Relative Weights,"$25,236.52 ",IP,"9,181.00","33,542.21",,,,,,
Humana,DRG,MS-290,ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,Surgical,Relative Weights,"$15,177.10 ",IP,"2,420.00","20,172.10",,,,,,
Humana,DRG,MS-291,HEART FAILURE AND SHOCK WITH MCC,Surgical,Relative Weights,"$20,413.09 ",IP,"2,420.00","27,131.33",,,,,,
Humana,DRG,MS-292,HEART FAILURE AND SHOCK WITH CC,Surgical,Relative Weights,"$13,734.62 ",IP,"2,420.00","18,254.88",,,,,,
Humana,DRG,MS-293,HEART FAILURE AND SHOCK WITHOUT CC/MCC,Surgical,Relative Weights,"$9,939.59 ",IP,"2,420.00","13,210.85",,,,,,
Humana,DRG,MS-294,DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC,Surgical,Relative Weights,"$19,292.18 ",IP,"2,420.00","25,641.50",,,,,,
Humana,DRG,MS-295,DEEP VEIN THROMBOPHLEBITIS W/O CC/MCC,Surgical,Relative Weights,"$8,751.94 ",IP,"2,420.00","11,632.32",,,,,,
Humana,DRG,MS-296,CARDIAC ARREST - UNEXPLAINED W MCC,Surgical,Relative Weights,"$23,819.83 ",IP,"2,420.00","31,659.26",,,,,,
Humana,DRG,MS-297,CARDIAC ARREST- UNEXPLAINED WITH CC,Surgical,Relative Weights,"$10,966.46 ",IP,"2,420.00","14,575.68",,,,,,
Humana,DRG,MS-298,CARDIAC ARREST- UNEXPLAINED WITHOUT CC/MCC,Surgical,Relative Weights,"$7,632.54 ",IP,"2,420.00","10,144.51",,,,,,
Humana,DRG,MS-299,PERIPHERAL VASCULAR DISORDERS WITH MCC,Surgical,Relative Weights,"$21,989.05 ",IP,"2,420.00","29,225.95",,,,,,
Humana,DRG,MS-300,PERIPHERAL VASCULAR DISORDERS WITH CC,Surgical,Relative Weights,"$15,586.64 ",IP,"2,420.00","20,716.42",,,,,,
Humana,DRG,MS-301,PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$11,008.93 ",IP,"2,420.00","14,632.13",,,,,,
Humana,DRG,MS-302,ATHEROSCLEROSIS WITH MCC,Surgical,Relative Weights,"$16,719.69 ",IP,"2,420.00","22,222.37",,,,,,
Humana,DRG,MS-303,ATHEROSCLEROSIS WITHOUT MCC,Surgical,Relative Weights,"$10,249.02 ",IP,"2,420.00","13,622.11",,,,,,
Humana,DRG,MS-304,HYPERTENSION WITH MCC,Surgical,Relative Weights,"$16,555.87 ",IP,"2,420.00","22,004.64",,,,,,
Humana,DRG,MS-305,HYPERTENSION WITHOUT MCC,Surgical,Relative Weights,"$11,095.39 ",IP,"2,420.00","14,747.04",,,,,,
Humana,DRG,MS-306,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,Surgical,Relative Weights,"$21,455.14 ",IP,"2,420.00","28,516.32",,,,,,
Humana,DRG,MS-307,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,Surgical,Relative Weights,"$13,381.21 ",IP,"2,420.00","17,785.15",,,,,,
Humana,DRG,MS-308,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,Surgical,Relative Weights,"$18,015.03 ",IP,"2,420.00","23,944.03",,,,,,
Humana,DRG,MS-309,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,Surgical,Relative Weights,"$11,471.56 ",IP,"2,420.00","15,247.01",,,,,,
Humana,DRG,MS-310,CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC,Surgical,Relative Weights,"$8,483.46 ",IP,"2,420.00","11,275.49",,,,,,
Humana,DRG,MS-311,ANGINA PECTORIS,Surgical,Relative Weights,"$10,390.08 ",IP,"2,420.00","13,809.60",,,,,,
Humana,DRG,MS-312,SYNCOPE AND COLLAPSE,Surgical,Relative Weights,"$12,386.19 ",IP,"2,420.00","16,462.66",,,,,,
Humana,DRG,MS-313,CHEST PAIN,Surgical,Relative Weights,"$10,849.67 ",IP,"2,420.00","14,420.45",,,,,,
Humana,DRG,MS-314,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,Surgical,Relative Weights,"$30,783.46 ",IP,"2,420.00","40,914.72",,,,,,
Humana,DRG,MS-315,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,Surgical,Relative Weights,"$14,719.03 ",IP,"2,420.00","19,563.26",,,,,,
Humana,DRG,MS-316,OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,Surgical,Relative Weights,"$11,257.69 ",IP,"2,420.00","14,962.75",,,,,,
Humana,DRG,MS-319,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,Surgical,Relative Weights,"$62,199.42 ",IP,"2,420.00","82,670.11",,,,,,
Humana,DRG,MS-320,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$35,609.91 ",IP,"2,420.00","47,329.63",,,,,,
Humana,DRG,MS-326,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$79,942.94 ",IP,"2,420.00","106,253.28",,,,,,
Humana,DRG,MS-327,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC,Surgical,Relative Weights,"$39,025.75 ",IP,"2,420.00","51,869.66",,,,,,
Humana,DRG,MS-328,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$23,889.60 ",IP,"2,420.00","31,752.00",,,,,,
Humana,DRG,MS-329,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Surgical,Relative Weights,"$74,432.41 ",IP,"2,420.00","98,929.15",,,,,,
Humana,DRG,MS-330,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Surgical,Relative Weights,"$38,326.50 ",IP,"2,420.00","50,940.29",,,,,,
Humana,DRG,MS-331,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$25,621.79 ",IP,"2,420.00","34,054.27",,,,,,
Humana,DRG,MS-332,RECTAL RESECTION WITH MCC,Surgical,Relative Weights,"$52,965.14 ",IP,"2,420.00","70,396.70",,,,,,
Humana,DRG,MS-333,RECTAL RESECTION WITH CC,Surgical,Relative Weights,"$34,328.22 ",IP,"2,420.00","45,626.11",,,,,,
Humana,DRG,MS-334,RECTAL RESECTION WITHOUT CC/MCC,Surgical,Relative Weights,"$23,363.27 ",IP,"2,420.00","31,052.45",,,,,,
Humana,DRG,MS-335,PERITONEAL ADHESIOLYSIS WITH MCC,Surgical,Relative Weights,"$61,356.08 ",IP,"2,420.00","81,549.22",,,,,,
Humana,DRG,MS-336,PERITONEAL ADHESIOLYSIS WITH CC,Surgical,Relative Weights,"$34,373.72 ",IP,"2,420.00","45,686.59",,,,,,
Humana,DRG,MS-337,PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$24,870.97 ",IP,"2,420.00","33,056.35",,,,,,
Humana,DRG,MS-338,APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$44,140.40 ",IP,"2,420.00","58,667.62",,,,,,
Humana,DRG,MS-339,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W CC,Surgical,Relative Weights,"$26,029.80 ",IP,"2,420.00","34,596.58",,,,,,
Humana,DRG,MS-340,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC/MCC,Surgical,Relative Weights,"$18,770.40 ",IP,"2,420.00","24,948.00",,,,,,
Humana,DRG,MS-341,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$38,801.26 ",IP,"2,420.00","51,571.30",,,,,,
Humana,DRG,MS-342,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH CC,Surgical,Relative Weights,"$24,425.03 ",IP,"2,420.00","32,463.65",,,,,,
Humana,DRG,MS-343,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$17,467.47 ",IP,"2,420.00","23,216.26",,,,,,
Humana,DRG,MS-344,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Surgical,Relative Weights,"$45,429.68 ",IP,"2,420.00","60,381.22",,,,,,
Humana,DRG,MS-345,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Surgical,Relative Weights,"$24,773.89 ",IP,"2,420.00","32,927.33",,,,,,
Humana,DRG,MS-346,MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$19,455.99 ",IP,"2,420.00","25,859.23",,,,,,
Humana,DRG,MS-347,ANAL AND STOMAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$39,988.92 ",IP,"2,420.00","53,149.82",,,,,,
Humana,DRG,MS-348,ANAL AND STOMAL PROCEDURES WITH CC,Surgical,Relative Weights,"$21,376.26 ",IP,"2,420.00","28,411.49",,,,,,
Humana,DRG,MS-349,ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$14,878.29 ",IP,"2,420.00","19,774.94",,,,,,
Humana,DRG,MS-350,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,Surgical,Relative Weights,"$36,999.30 ",IP,"2,420.00","49,176.29",,,,,,
Humana,DRG,MS-351,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,Surgical,Relative Weights,"$22,119.49 ",IP,"2,420.00","29,399.33",,,,,,
Humana,DRG,MS-352,INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$16,332.90 ",IP,"2,420.00","21,708.29",,,,,,
Humana,DRG,MS-353,HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,Surgical,Relative Weights,"$45,001.94 ",IP,"2,420.00","59,812.70",,,,,,
Humana,DRG,MS-354,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W CC,Surgical,Relative Weights,"$26,120.81 ",IP,"2,420.00","34,717.54",,,,,,
Humana,DRG,MS-355,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W/O CC/MCC,Surgical,Relative Weights,"$20,816.56 ",IP,"2,420.00","27,667.58",,,,,,
Humana,DRG,MS-356,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$61,842.97 ",IP,"2,420.00","82,196.35",,,,,,
Humana,DRG,MS-357,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$34,134.07 ",IP,"2,420.00","45,368.06",,,,,,
Humana,DRG,MS-358,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$20,805.95 ",IP,"2,420.00","27,653.47",,,,,,
Humana,DRG,MS-368,MAJOR ESOPHAGEAL DISORDERS WITH MCC,Surgical,Relative Weights,"$28,873.80 ",IP,"2,420.00","38,376.58",,,,,,
Humana,DRG,MS-369,MAJOR ESOPHAGEAL DISORDERS WITH CC,Surgical,Relative Weights,"$16,125.10 ",IP,"2,420.00","21,432.10",,,,,,
Humana,DRG,MS-370,MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$11,335.05 ",IP,"2,420.00","15,065.57",,,,,,
Humana,DRG,MS-371,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,Surgical,Relative Weights,"$26,172.38 ",IP,"2,420.00","34,786.08",,,,,,
Humana,DRG,MS-372,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,Surgical,Relative Weights,"$15,509.28 ",IP,"2,420.00","20,613.60",,,,,,
Humana,DRG,MS-373,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,Surgical,Relative Weights,"$11,251.62 ",IP,"2,420.00","14,954.69",,,,,,
Humana,DRG,MS-374,DIGESTIVE MALIGNANCY WITH MCC,Surgical,Relative Weights,"$30,298.08 ",IP,"2,420.00","40,269.60",,,,,,
Humana,DRG,MS-375,DIGESTIVE MALIGNANCY WITH CC,Surgical,Relative Weights,"$18,312.33 ",IP,"2,420.00","24,339.17",,,,,,
Humana,DRG,MS-376,DIGESTIVE MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$15,187.72 ",IP,"2,420.00","20,186.21",,,,,,
Humana,DRG,MS-377,GASTROINTESTINAL HEMORRHAGE WITH MCC,Surgical,Relative Weights,"$26,845.84 ",IP,"2,420.00","35,681.18",,,,,,
Humana,DRG,MS-378,GASTROINTESTINAL HEMORRHAGE WITH CC,Surgical,Relative Weights,"$14,987.50 ",IP,"2,420.00","19,920.10",,,,,,
Humana,DRG,MS-379,GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,Surgical,Relative Weights,"$9,793.98 ",IP,"2,420.00","13,017.31",,,,,,
Humana,DRG,MS-380,COMPLICATED PEPTIC ULCER WITH MCC,Surgical,Relative Weights,"$28,631.12 ",IP,"2,420.00","38,054.02",,,,,,
Humana,DRG,MS-381,COMPLICATED PEPTIC ULCER WITH CC,Surgical,Relative Weights,"$16,331.39 ",IP,"2,420.00","21,706.27",,,,,,
Humana,DRG,MS-382,COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,Surgical,Relative Weights,"$12,003.96 ",IP,"2,420.00","15,954.62",,,,,,
Humana,DRG,MS-383,UNCOMPLICATED PEPTIC ULCER WITH MCC,Surgical,Relative Weights,"$20,117.32 ",IP,"2,420.00","26,738.21",,,,,,
Humana,DRG,MS-384,UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,Surgical,Relative Weights,"$13,199.19 ",IP,"2,420.00","17,543.23",,,,,,
Humana,DRG,MS-385,INFLAMMATORY BOWEL DISEASE WITH MCC,Surgical,Relative Weights,"$24,425.03 ",IP,"2,420.00","32,463.65",,,,,,
Humana,DRG,MS-386,INFLAMMATORY BOWEL DISEASE W CC,Surgical,Relative Weights,"$14,943.51 ",IP,"2,420.00","19,861.63",,,,,,
Humana,DRG,MS-387,INFLAMMATORY BOWEL DISEASE W/O CC/MCC,Surgical,Relative Weights,"$10,628.22 ",IP,"2,420.00","14,126.11",,,,,,
Humana,DRG,MS-388,GASTROINTESTINAL OBSTRUCTION WITH MCC,Surgical,Relative Weights,"$23,132.72 ",IP,"2,420.00","30,746.02",,,,,,
Humana,DRG,MS-389,GASTROINTESTINAL OBSTRUCTION WITH CC,Surgical,Relative Weights,"$12,736.57 ",IP,"2,420.00","16,928.35",,,,,,
Humana,DRG,MS-390,GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,Surgical,Relative Weights,"$8,791.37 ",IP,"2,420.00","11,684.74",,,,,,
Humana,DRG,MS-391,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC,Surgical,Relative Weights,"$18,732.48 ",IP,"2,420.00","24,897.60",,,,,,
Humana,DRG,MS-392,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC,Surgical,Relative Weights,"$11,550.43 ",IP,"2,420.00","15,351.84",,,,,,
Humana,DRG,MS-393,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,Surgical,Relative Weights,"$24,640.42 ",IP,"2,420.00","32,749.92",,,,,,
Humana,DRG,MS-394,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,Surgical,Relative Weights,"$14,229.10 ",IP,"2,420.00","18,912.10",,,,,,
Humana,DRG,MS-395,OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Surgical,Relative Weights,"$9,925.94 ",IP,"2,420.00","13,192.70",,,,,,
Humana,DRG,MS-405,PANCREAS- LIVER AND SHUNT PROCEDURES WITH MCC,Surgical,Relative Weights,"$82,319.77 ",IP,"2,420.00","109,412.35",,,,,,
Humana,DRG,MS-406,PANCREAS -  LIVER AND SHUNT PROCEDURES WITH CC,Surgical,Relative Weights,"$42,332.37 ",IP,"2,420.00","56,264.54",,,,,,
Humana,DRG,MS-407,PANCREAS -  LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$31,645.00 ",IP,"2,420.00","42,059.81",,,,,,
Humana,DRG,MS-408,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,Surgical,Relative Weights,"$54,052.68 ",IP,"2,420.00","71,842.18",,,,,,
Humana,DRG,MS-409,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,Surgical,Relative Weights,"$36,309.16 ",IP,"2,420.00","48,259.01",,,,,,
Humana,DRG,MS-410,BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W/O CC/MCC,Surgical,Relative Weights,"$25,178.88 ",IP,"2,420.00","33,465.60",,,,,,
Humana,DRG,MS-411,CHOLECYSTECTOMY W C.D.E. W MCC,Surgical,Relative Weights,"$58,099.51 ",IP,"2,420.00","77,220.86",,,,,,
Humana,DRG,MS-412,CHOLECYSTECTOMY WITH C.D.E. WITH CC,Surgical,Relative Weights,"$36,054.34 ",IP,"2,420.00","47,920.32",,,,,,
Humana,DRG,MS-413,CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,Surgical,Relative Weights,"$24,531.21 ",IP,"2,420.00","32,604.77",,,,,,
Humana,DRG,MS-414,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,Surgical,Relative Weights,"$51,819.96 ",IP,"2,420.00","68,874.62",,,,,,
Humana,DRG,MS-415,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,Surgical,Relative Weights,"$31,120.19 ",IP,"2,420.00","41,362.27",,,,,,
Humana,DRG,MS-416,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,Surgical,Relative Weights,"$20,481.35 ",IP,"2,420.00","27,222.05",,,,,,
Humana,DRG,MS-417,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,Surgical,Relative Weights,"$36,565.50 ",IP,"2,420.00","48,599.71",,,,,,
Humana,DRG,MS-418,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,Surgical,Relative Weights,"$25,313.88 ",IP,"2,420.00","33,645.02",,,,,,
Humana,DRG,MS-419,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,Surgical,Relative Weights,"$19,821.54 ",IP,"2,420.00","26,345.09",,,,,,
Humana,DRG,MS-420,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,Surgical,Relative Weights,"$52,099.05 ",IP,"2,420.00","69,245.57",,,,,,
Humana,DRG,MS-421,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,Surgical,Relative Weights,"$27,927.32 ",IP,"2,420.00","37,118.59",,,,,,
Humana,DRG,MS-422,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$21,303.46 ",IP,"2,420.00","28,314.72",,,,,,
Humana,DRG,MS-423,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$64,285.02 ",IP,"2,420.00","85,442.11",,,,,,
Humana,DRG,MS-424,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$34,149.24 ",IP,"2,420.00","45,388.22",,,,,,
Humana,DRG,MS-425,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$22,168.03 ",IP,"2,420.00","29,463.84",,,,,,
Humana,DRG,MS-432,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,Surgical,Relative Weights,"$27,657.33 ",IP,"2,420.00","36,759.74",,,,,,
Humana,DRG,MS-433,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,Surgical,Relative Weights,"$15,653.38 ",IP,"2,420.00","20,805.12",,,,,,
Humana,DRG,MS-434,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Surgical,Relative Weights,"$9,706.00 ",IP,"2,420.00","12,900.38",,,,,,
Humana,DRG,MS-435,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,Surgical,Relative Weights,"$25,741.61 ",IP,"2,420.00","34,213.54",,,,,,
Humana,DRG,MS-436,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,Surgical,Relative Weights,"$17,074.62 ",IP,"2,420.00","22,694.11",,,,,,
Humana,DRG,MS-437,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,Surgical,Relative Weights,"$13,315.99 ",IP,"2,420.00","17,698.46",,,,,,
Humana,DRG,MS-438,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,Surgical,Relative Weights,"$24,849.73 ",IP,"2,420.00","33,028.13",,,,,,
Humana,DRG,MS-439,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,Surgical,Relative Weights,"$12,850.33 ",IP,"2,420.00","17,079.55",,,,,,
Humana,DRG,MS-440,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$9,337.42 ",IP,"2,420.00","12,410.50",,,,,,
Humana,DRG,MS-441,DISORDERS OF LIVER EXCEPT MALIGNANCY- CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC,Surgical,Relative Weights,"$28,068.38 ",IP,"2,420.00","37,306.08",,,,,,
Humana,DRG,MS-442,DISORDERS OF LIVER EXCEPT MALIGNANCY -  CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC,Surgical,Relative Weights,"$14,157.81 ",IP,"2,420.00","18,817.34",,,,,,
Humana,DRG,MS-443,DISORDERS OF LIVER EXCEPT MALIGNANCY -  CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Surgical,Relative Weights,"$10,318.79 ",IP,"2,420.00","13,714.85",,,,,,
Humana,DRG,MS-444,DISORDERS OF THE BILIARY TRACT WITH MCC,Surgical,Relative Weights,"$24,664.68 ",IP,"2,420.00","32,782.18",,,,,,
Humana,DRG,MS-445,DISORDERS OF THE BILIARY TRACT WITH CC,Surgical,Relative Weights,"$16,298.02 ",IP,"2,420.00","21,661.92",,,,,,
Humana,DRG,MS-446,DISORDERS OF THE BILIARY TRACT W/O CC/MCC,Surgical,Relative Weights,"$12,327.03 ",IP,"2,420.00","16,384.03",,,,,,
Humana,DRG,MS-453,COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W MCC,Surgical,Relative Weights,"$142,685.38 ",IP,"2,420.00","189,645.12",,,,,,
Humana,DRG,MS-454,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC,Surgical,Relative Weights,"$92,904.00 ",IP,"2,420.00","123,480.00",,,,,,
Humana,DRG,MS-455,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CC/MCC,Surgical,Relative Weights,"$73,008.13 ",IP,"2,420.00","97,036.13",,,,,,
Humana,DRG,MS-456,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH MCC,Surgical,Relative Weights,"$137,743.64 ",IP,"2,420.00","183,076.99",,,,,,
Humana,DRG,MS-457,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH CC,Surgical,Relative Weights,"$98,793.73 ",IP,"2,420.00","131,308.13",,,,,,
Humana,DRG,MS-458,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC,Surgical,Relative Weights,"$71,197.08 ",IP,"2,420.00","94,629.02",,,,,,
Humana,DRG,MS-459,SPINAL FUSION EXCEPT CERVICAL WITH MCC,Surgical,Relative Weights,"$103,931.14 ",IP,"21,658.00","138,136.32",,,,,,
Humana,DRG,MS-460,SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,Surgical,Relative Weights,"$60,071.35 ",IP,"21,658.00","79,841.66",,,,,,
Humana,DRG,MS-461,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,Surgical,Relative Weights,"$81,585.64 ",IP,"2,420.00","108,436.61",,,,,,
Humana,DRG,MS-462,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,Surgical,Relative Weights,"$47,572.92 ",IP,"2,420.00","63,229.82",,,,,,
Humana,DRG,MS-463,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,Surgical,Relative Weights,"$79,295.27 ",IP,"2,420.00","105,392.45",,,,,,
Humana,DRG,MS-464,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,Surgical,Relative Weights,"$44,786.55 ",IP,"2,420.00","59,526.43",,,,,,
Humana,DRG,MS-465,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$29,049.75 ",IP,"2,420.00","38,610.43",,,,,,
Humana,DRG,MS-466,REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,Surgical,Relative Weights,"$77,343.15 ",IP,"2,420.00","102,797.86",,,,,,
Humana,DRG,MS-467,REVISION OF HIP OR KNEE REPLACEMENT W CC,Surgical,Relative Weights,"$53,271.53 ",IP,"2,420.00","70,803.94",,,,,,
Humana,DRG,MS-468,REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,Surgical,Relative Weights,"$42,653.93 ",IP,"2,420.00","56,691.94",,,,,,
Humana,DRG,MS-469,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,Surgical,Relative Weights,"$47,626.00 ",IP,"2,420.00","63,300.38",,,,,,
Humana,DRG,MS-470,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,Surgical,Relative Weights,"$29,856.69 ",IP,"2,420.00","39,682.94",,,,,,
Humana,DRG,MS-471,CERVICAL SPINAL FUSION WITH MCC,Surgical,Relative Weights,"$75,755.06 ",IP,"15,407.00","100,687.10",,,,,,
Humana,DRG,MS-472,CERVICAL SPINAL FUSION WITH CC,Surgical,Relative Weights,"$46,133.47 ",IP,"15,407.00","61,316.64",,,,,,
Humana,DRG,MS-473,CERVICAL SPINAL FUSION WITHOUT CC/MCC,Surgical,Relative Weights,"$38,108.08 ",IP,"14,827.96","50,649.98",,,,,,
Humana,DRG,MS-474,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,Surgical,Relative Weights,"$58,774.48 ",IP,"2,420.00","78,117.98",,,,,,
Humana,DRG,MS-475,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,Surgical,Relative Weights,"$31,867.97 ",IP,"2,420.00","42,356.16",,,,,,
Humana,DRG,MS-476,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$17,666.17 ",IP,"2,420.00","23,480.35",,,,,,
Humana,DRG,MS-477,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Surgical,Relative Weights,"$49,376.39 ",IP,"2,420.00","65,626.85",,,,,,
Humana,DRG,MS-478,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Surgical,Relative Weights,"$35,145.77 ",IP,"2,420.00","46,712.74",,,,,,
Humana,DRG,MS-479,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Surgical,Relative Weights,"$27,032.41 ",IP,"2,420.00","35,929.15",,,,,,
Humana,DRG,MS-480,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,Surgical,Relative Weights,"$45,784.61 ",IP,"2,420.00","60,852.96",,,,,,
Humana,DRG,MS-481,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,Surgical,Relative Weights,"$31,667.75 ",IP,"2,420.00","42,090.05",,,,,,
Humana,DRG,MS-482,HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC,Surgical,Relative Weights,"$24,955.91 ",IP,"2,420.00","33,169.25",,,,,,
Humana,DRG,MS-483,MAJOR JOINT & LIMB REATTACHMENT PROC OF UPPER EXTREMITY W CC/MCC,Surgical,Relative Weights,"$36,283.37 ",IP,"2,420.00","48,224.74",,,,,,
Humana,DRG,MS-485,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,Surgical,Relative Weights,"$49,735.87 ",IP,"2,420.00","66,104.64",,,,,,
Humana,DRG,MS-486,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,Surgical,Relative Weights,"$32,620.30 ",IP,"2,420.00","43,356.10",,,,,,
Humana,DRG,MS-487,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Surgical,Relative Weights,"$24,378.01 ",IP,"2,420.00","32,401.15",,,,,,
Humana,DRG,MS-488,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,Surgical,Relative Weights,"$29,868.83 ",IP,"2,420.00","39,699.07",,,,,,
Humana,DRG,MS-489,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Surgical,Relative Weights,"$19,096.51 ",IP,"2,420.00","25,381.44",,,,,,
Humana,DRG,MS-492,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH MCC,Surgical,Relative Weights,"$52,258.31 ",IP,"2,420.00","69,457.25",,,,,,
Humana,DRG,MS-493,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH CC,Surgical,Relative Weights,"$34,916.74 ",IP,"2,420.00","46,408.32",,,,,,
Humana,DRG,MS-494,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITHOUT CC/MCC,Surgical,Relative Weights,"$27,475.32 ",IP,"2,420.00","36,517.82",,,,,,
Humana,DRG,MS-495,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,Surgical,Relative Weights,"$52,065.68 ",IP,"2,420.00","69,201.22",,,,,,
Humana,DRG,MS-496,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,Surgical,Relative Weights,"$30,950.30 ",IP,"2,420.00","41,136.48",,,,,,
Humana,DRG,MS-497,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,Surgical,Relative Weights,"$22,286.34 ",IP,"2,420.00","29,621.09",,,,,,
Humana,DRG,MS-498,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,Surgical,Relative Weights,"$37,132.78 ",IP,"2,420.00","49,353.70",,,,,,
Humana,DRG,MS-499,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,Surgical,Relative Weights,"$17,456.85 ",IP,"2,420.00","23,202.14",,,,,,
Humana,DRG,MS-500,SOFT TISSUE PROCEDURES WITH MCC,Surgical,Relative Weights,"$45,734.55 ",IP,"2,420.00","60,786.43",,,,,,
Humana,DRG,MS-501,SOFT TISSUE PROCEDURES WITH CC,Surgical,Relative Weights,"$25,451.90 ",IP,"2,420.00","33,828.48",,,,,,
Humana,DRG,MS-502,SOFT TISSUE PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$20,032.38 ",IP,"2,420.00","26,625.31",,,,,,
Humana,DRG,MS-503,FOOT PROCEDURES WITH MCC,Surgical,Relative Weights,"$41,205.39 ",IP,"2,420.00","54,766.66",,,,,,
Humana,DRG,MS-504,FOOT PROCEDURES WITH CC,Surgical,Relative Weights,"$26,339.23 ",IP,"2,420.00","35,007.84",,,,,,
Humana,DRG,MS-505,FOOT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$25,504.99 ",IP,"2,420.00","33,899.04",,,,,,
Humana,DRG,MS-506,MAJOR THUMB OR JOINT PROCEDURES,Surgical,Relative Weights,"$20,303.88 ",IP,"2,420.00","26,986.18",,,,,,
Humana,DRG,MS-507,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W CC/MCC,Surgical,Relative Weights,"$31,852.80 ",IP,"2,420.00","42,336.00",,,,,,
Humana,DRG,MS-508,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$23,637.81 ",IP,"2,420.00","31,417.34",,,,,,
Humana,DRG,MS-509,ARTHROSCOPY,Surgical,Relative Weights,"$21,109.31 ",IP,"2,420.00","28,056.67",,,,,,
Humana,DRG,MS-510,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH MCC,Surgical,Relative Weights,"$42,288.38 ",IP,"2,420.00","56,206.08",,,,,,
Humana,DRG,MS-511,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH CC,Surgical,Relative Weights,"$28,579.55 ",IP,"2,420.00","37,985.47",,,,,,
Humana,DRG,MS-512,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$22,961.32 ",IP,"2,420.00","30,518.21",,,,,,
Humana,DRG,MS-513,HAND OR WRIST PROCEDURES- EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$23,921.45 ",IP,"2,420.00","31,794.34",,,,,,
Humana,DRG,MS-514,HAND OR WRIST PROCEDURES -  EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$16,181.22 ",IP,"2,420.00","21,506.69",,,,,,
Humana,DRG,MS-515,OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W MCC,Surgical,Relative Weights,"$47,839.87 ",IP,"2,420.00","63,584.64",,,,,,
Humana,DRG,MS-516,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$29,412.27 ",IP,"2,420.00","39,092.26",,,,,,
Humana,DRG,MS-517,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$21,467.27 ",IP,"2,420.00","28,532.45",,,,,,
Humana,DRG,MS-518,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,Surgical,Relative Weights,"$51,701.64 ",IP,"10,289.00","68,717.38",,,,,,
Humana,DRG,MS-519,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,Surgical,Relative Weights,"$28,951.16 ",IP,"10,289.00","38,479.39",,,,,,
Humana,DRG,MS-520,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,Surgical,Relative Weights,"$20,294.78 ",IP,"8,282.98","26,974.08",,,,,,
Humana,DRG,MS-533,FRACTURES OF FEMUR WITH MCC,Surgical,Relative Weights,"$22,136.18 ",IP,"2,420.00","29,421.50",,,,,,
Humana,DRG,MS-534,FRACTURES OF FEMUR WITHOUT MCC,Surgical,Relative Weights,"$11,797.67 ",IP,"2,420.00","15,680.45",,,,,,
Humana,DRG,MS-535,FRACTURES OF HIP AND PELVIS WITH MCC,Surgical,Relative Weights,"$18,612.65 ",IP,"2,420.00","24,738.34",,,,,,
Humana,DRG,MS-536,FRACTURES OF HIP AND PELVIS WITHOUT MCC,Surgical,Relative Weights,"$11,504.93 ",IP,"2,420.00","15,291.36",,,,,,
Humana,DRG,MS-537,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITH CC/MCC,Surgical,Relative Weights,"$13,816.53 ",IP,"2,420.00","18,363.74",,,,,,
Humana,DRG,MS-538,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITHOUT CC/MCC,Surgical,Relative Weights,"$10,936.13 ",IP,"2,420.00","14,535.36",,,,,,
Humana,DRG,MS-539,OSTEOMYELITIS WITH MCC,Surgical,Relative Weights,"$28,594.71 ",IP,"2,420.00","38,005.63",,,,,,
Humana,DRG,MS-540,OSTEOMYELITIS WITH CC,Surgical,Relative Weights,"$19,718.40 ",IP,"2,420.00","26,208.00",,,,,,
Humana,DRG,MS-541,OSTEOMYELITIS WITHOUT CC/MCC,Surgical,Relative Weights,"$13,752.83 ",IP,"2,420.00","18,279.07",,,,,,
Humana,DRG,MS-542,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,Surgical,Relative Weights,"$27,678.57 ",IP,"2,420.00","36,787.97",,,,,,
Humana,DRG,MS-543,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,Surgical,Relative Weights,"$16,021.96 ",IP,"2,420.00","21,295.01",,,,,,
Humana,DRG,MS-544,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$11,503.41 ",IP,"2,420.00","15,289.34",,,,,,
Humana,DRG,MS-545,CONNECTIVE TISSUE DISORDERS WITH MCC,Surgical,Relative Weights,"$38,344.70 ",IP,"2,420.00","50,964.48",,,,,,
Humana,DRG,MS-546,CONNECTIVE TISSUE DISORDERS WITH CC,Surgical,Relative Weights,"$18,253.17 ",IP,"2,420.00","24,260.54",,,,,,
Humana,DRG,MS-547,CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$12,287.60 ",IP,"2,420.00","16,331.62",,,,,,
Humana,DRG,MS-548,SEPTIC ARTHRITIS WITH MCC,Surgical,Relative Weights,"$30,082.69 ",IP,"2,420.00","39,983.33",,,,,,
Humana,DRG,MS-549,SEPTIC ARTHRITIS W CC,Surgical,Relative Weights,"$18,096.94 ",IP,"2,420.00","24,052.90",,,,,,
Humana,DRG,MS-550,SEPTIC ARTHRITIS W/O CC/MCC,Surgical,Relative Weights,"$13,105.15 ",IP,"2,420.00","17,418.24",,,,,,
Humana,DRG,MS-551,MEDICAL BACK PROBLEMS WITH MCC,Surgical,Relative Weights,"$24,108.02 ",IP,"2,420.00","32,042.30",,,,,,
Humana,DRG,MS-552,MEDICAL BACK PROBLEMS WITHOUT MCC,Surgical,Relative Weights,"$13,831.70 ",IP,"2,420.00","18,383.90",,,,,,
Humana,DRG,MS-553,BONE DISEASES AND ARTHROPATHIES WITH MCC,Surgical,Relative Weights,"$19,498.46 ",IP,"2,420.00","25,915.68",,,,,,
Humana,DRG,MS-554,BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,Surgical,Relative Weights,"$11,940.25 ",IP,"2,420.00","15,869.95",,,,,,
Humana,DRG,MS-555,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Surgical,Relative Weights,"$19,950.47 ",IP,"2,420.00","26,516.45",,,,,,
Humana,DRG,MS-556,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,Surgical,Relative Weights,"$12,010.02 ",IP,"2,420.00","15,962.69",,,,,,
Humana,DRG,MS-557,TENDONITIS -  MYOSITIS AND BURSITIS WITH MCC,Surgical,Relative Weights,"$22,117.98 ",IP,"2,420.00","29,397.31",,,,,,
Humana,DRG,MS-558,TENDONITIS- MYOSITIS AND BURSITIS WITHOUT MCC,Surgical,Relative Weights,"$13,065.72 ",IP,"2,420.00","17,365.82",,,,,,
Humana,DRG,MS-559,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Surgical,Relative Weights,"$27,329.70 ",IP,"2,420.00","36,324.29",,,,,,
Humana,DRG,MS-560,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Surgical,Relative Weights,"$15,827.81 ",IP,"2,420.00","21,036.96",,,,,,
Humana,DRG,MS-561,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Surgical,Relative Weights,"$11,336.56 ",IP,"2,420.00","15,067.58",,,,,,
Humana,DRG,MS-562,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITH MCC,Surgical,Relative Weights,"$20,432.81 ",IP,"2,420.00","27,157.54",,,,,,
Humana,DRG,MS-563,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITHOUT MCC,Surgical,Relative Weights,"$12,953.47 ",IP,"2,420.00","17,216.64",,,,,,
Humana,DRG,MS-564,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,Surgical,Relative Weights,"$22,934.02 ",IP,"2,420.00","30,481.92",,,,,,
Humana,DRG,MS-565,OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W CC,Surgical,Relative Weights,"$14,872.22 ",IP,"2,420.00","19,766.88",,,,,,
Humana,DRG,MS-566,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,Surgical,Relative Weights,"$11,492.79 ",IP,"2,420.00","15,275.23",,,,,,
Humana,DRG,MS-570,SKIN DEBRIDEMENT WITH MCC,Surgical,Relative Weights,"$43,580.70 ",IP,"2,420.00","57,923.71",,,,,,
Humana,DRG,MS-571,SKIN DEBRIDEMENT WITH CC,Surgical,Relative Weights,"$25,365.45 ",IP,"2,420.00","33,713.57",,,,,,
Humana,DRG,MS-572,SKIN DEBRIDEMENT WITHOUT CC/MCC,Surgical,Relative Weights,"$17,013.95 ",IP,"2,420.00","22,613.47",,,,,,
Humana,DRG,MS-573,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,Surgical,Relative Weights,"$80,622.47 ",IP,"2,420.00","107,156.45",,,,,,
Humana,DRG,MS-574,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,Surgical,Relative Weights,"$47,351.46 ",IP,"2,420.00","62,935.49",,,,,,
Humana,DRG,MS-575,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS W/O CC/MCC,Surgical,Relative Weights,"$26,650.18 ",IP,"2,420.00","35,421.12",,,,,,
Humana,DRG,MS-576,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,Surgical,Relative Weights,"$73,552.67 ",IP,"2,420.00","97,759.87",,,,,,
Humana,DRG,MS-577,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,Surgical,Relative Weights,"$36,639.82 ",IP,"2,420.00","48,698.50",,,,,,
Humana,DRG,MS-578,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,Surgical,Relative Weights,"$24,684.40 ",IP,"2,420.00","32,808.38",,,,,,
Humana,DRG,MS-579,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC,Surgical,Relative Weights,"$45,293.16 ",IP,"2,420.00","60,199.78",,,,,,
Humana,DRG,MS-580,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC,Surgical,Relative Weights,"$24,400.76 ",IP,"2,420.00","32,431.39",,,,,,
Humana,DRG,MS-581,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$19,032.81 ",IP,"2,420.00","25,296.77",,,,,,
Humana,DRG,MS-582,MASTECTOMY FOR MALIGNANCY WITH CC/MCC,Surgical,Relative Weights,"$23,945.72 ",IP,"2,420.00","31,826.59",,,,,,
Humana,DRG,MS-583,MASTECTOMY FOR MALIGNANCY W/O CC/MCC,Surgical,Relative Weights,"$22,166.52 ",IP,"2,420.00","29,461.82",,,,,,
Humana,DRG,MS-584,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$27,733.17 ",IP,"2,420.00","36,860.54",,,,,,
Humana,DRG,MS-585,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$25,744.65 ",IP,"2,420.00","34,217.57",,,,,,
Humana,DRG,MS-592,SKIN ULCERS WITH MCC,Surgical,Relative Weights,"$27,064.26 ",IP,"2,420.00","35,971.49",,,,,,
Humana,DRG,MS-593,SKIN ULCERS WITH CC,Surgical,Relative Weights,"$17,409.83 ",IP,"2,420.00","23,139.65",,,,,,
Humana,DRG,MS-594,SKIN ULCERS WITHOUT CC/MCC,Surgical,Relative Weights,"$12,281.53 ",IP,"2,420.00","16,323.55",,,,,,
Humana,DRG,MS-595,MAJOR SKIN DISORDERS WITH MCC,Surgical,Relative Weights,"$30,830.48 ",IP,"2,420.00","40,977.22",,,,,,
Humana,DRG,MS-596,MAJOR SKIN DISORDERS W/O MCC,Surgical,Relative Weights,"$14,775.15 ",IP,"2,420.00","19,637.86",,,,,,
Humana,DRG,MS-597,MALIGNANT BREAST DISORDERS W MCC,Surgical,Relative Weights,"$25,677.91 ",IP,"2,420.00","34,128.86",,,,,,
Humana,DRG,MS-598,MALIGNANT BREAST DISORDERS WITH CC,Surgical,Relative Weights,"$16,511.88 ",IP,"2,420.00","21,946.18",,,,,,
Humana,DRG,MS-599,MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$10,547.83 ",IP,"2,420.00","14,019.26",,,,,,
Humana,DRG,MS-600,NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,Surgical,Relative Weights,"$14,549.15 ",IP,"2,420.00","19,337.47",,,,,,
Humana,DRG,MS-601,NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$9,385.96 ",IP,"2,420.00","12,475.01",,,,,,
Humana,DRG,MS-602,CELLULITIS WITH MCC,Surgical,Relative Weights,"$21,687.21 ",IP,"2,420.00","28,824.77",,,,,,
Humana,DRG,MS-603,CELLULITIS WITHOUT MCC,Surgical,Relative Weights,"$12,794.21 ",IP,"2,420.00","17,004.96",,,,,,
Humana,DRG,MS-604,TRAUMA TO THE SKIN -  SUBCUTANEOUS TISSUE AND BREAST WITH MCC,Surgical,Relative Weights,"$22,213.54 ",IP,"2,420.00","29,524.32",,,,,,
Humana,DRG,MS-605,TRAUMA TO THE SKIN- SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC,Surgical,Relative Weights,"$13,282.62 ",IP,"2,420.00","17,654.11",,,,,,
Humana,DRG,MS-606,MINOR SKIN DISORDERS WITH MCC,Surgical,Relative Weights,"$22,683.74 ",IP,"2,420.00","30,149.28",,,,,,
Humana,DRG,MS-607,MINOR SKIN DISORDERS WITHOUT MCC,Surgical,Relative Weights,"$12,530.28 ",IP,"2,420.00","16,654.18",,,,,,
Humana,DRG,MS-614,ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$36,908.29 ",IP,"2,420.00","49,055.33",,,,,,
Humana,DRG,MS-615,ADRENAL & PITUITARY PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$22,510.83 ",IP,"2,420.00","29,919.46",,,,,,
Humana,DRG,MS-616,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Surgical,Relative Weights,"$60,684.13 ",IP,"2,420.00","80,656.13",,,,,,
Humana,DRG,MS-617,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Surgical,Relative Weights,"$31,114.12 ",IP,"2,420.00","41,354.21",,,,,,
Humana,DRG,MS-618,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$19,028.26 ",IP,"2,420.00","25,290.72",,,,,,
Humana,DRG,MS-619,O.R. PROCEDURES FOR OBESITY WITH MCC,Surgical,Relative Weights,"$46,694.69 ",IP,"2,420.00","62,062.56",,,,,,
Humana,DRG,MS-620,O.R. PROCEDURES FOR OBESITY WITH CC,Surgical,Relative Weights,"$27,220.49 ",IP,"2,420.00","36,179.14",,,,,,
Humana,DRG,MS-621,O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,Surgical,Relative Weights,"$23,844.10 ",IP,"2,420.00","31,691.52",,,,,,
Humana,DRG,MS-622,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Surgical,Relative Weights,"$57,266.78 ",IP,"2,420.00","76,114.08",,,,,,
Humana,DRG,MS-623,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE -  NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Surgical,Relative Weights,"$29,617.04 ",IP,"2,420.00","39,364.42",,,,,,
Humana,DRG,MS-624,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$16,715.14 ",IP,"2,420.00","22,216.32",,,,,,
Humana,DRG,MS-625,THYROID- PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$44,367.92 ",IP,"2,420.00","58,970.02",,,,,,
Humana,DRG,MS-626,THYROID -  PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC,Surgical,Relative Weights,"$25,524.71 ",IP,"2,420.00","33,925.25",,,,,,
Humana,DRG,MS-627,THYROID -  PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$17,317.31 ",IP,"2,420.00","23,016.67",,,,,,
Humana,DRG,MS-628,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$55,959.30 ",IP,"2,420.00","74,376.29",,,,,,
Humana,DRG,MS-629,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$35,232.23 ",IP,"2,420.00","46,827.65",,,,,,
Humana,DRG,MS-630,OTHER ENDOCRINE - NUTRIT & METAB O.R. PROC W/O CC/MCC,Surgical,Relative Weights,"$21,975.40 ",IP,"2,420.00","29,207.81",,,,,,
Humana,DRG,MS-637,DIABETES WITH MCC,Surgical,Relative Weights,"$21,018.30 ",IP,"2,420.00","27,935.71",,,,,,
Humana,DRG,MS-638,DIABETES WITH CC,Surgical,Relative Weights,"$13,410.03 ",IP,"2,420.00","17,823.46",,,,,,
Humana,DRG,MS-639,DIABETES WITHOUT CC/MCC,Surgical,Relative Weights,"$9,301.02 ",IP,"2,420.00","12,362.11",,,,,,
Humana,DRG,MS-640,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITH MCC,Surgical,Relative Weights,"$18,416.99 ",IP,"2,420.00","24,478.27",,,,,,
Humana,DRG,MS-641,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITHOUT MCC,Surgical,Relative Weights,"$11,476.11 ",IP,"2,420.00","15,253.06",,,,,,
Humana,DRG,MS-642,INBORN AND OTHER DISORDERS OF METABOLISM,Surgical,Relative Weights,"$18,441.25 ",IP,"2,420.00","24,510.53",,,,,,
Humana,DRG,MS-643,ENDOCRINE DISORDERS WITH MCC,Surgical,Relative Weights,"$24,655.58 ",IP,"2,420.00","32,770.08",,,,,,
Humana,DRG,MS-644,ENDOCRINE DISORDERS WITH CC,Surgical,Relative Weights,"$15,594.22 ",IP,"2,420.00","20,726.50",,,,,,
Humana,DRG,MS-645,ENDOCRINE DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$11,606.55 ",IP,"2,420.00","15,426.43",,,,,,
Humana,DRG,MS-652,KIDNEY TRANSPLANT,Surgical,Relative Weights,"$51,342.16 ",IP,"2,420.00","68,239.58",,,,,,
Humana,DRG,MS-653,MAJOR BLADDER PROCEDURES WITH MCC,Surgical,Relative Weights,"$83,977.63 ",IP,"2,420.00","111,615.84",,,,,,
Humana,DRG,MS-654,MAJOR BLADDER PROCEDURES WITH CC,Surgical,Relative Weights,"$42,655.45 ",IP,"2,420.00","56,693.95",,,,,,
Humana,DRG,MS-655,MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$31,282.48 ",IP,"2,420.00","41,577.98",,,,,,
Humana,DRG,MS-656,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,Surgical,Relative Weights,"$49,456.78 ",IP,"2,420.00","65,733.70",,,,,,
Humana,DRG,MS-657,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,Surgical,Relative Weights,"$29,337.95 ",IP,"2,420.00","38,993.47",,,,,,
Humana,DRG,MS-658,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,Surgical,Relative Weights,"$23,812.24 ",IP,"2,420.00","31,649.18",,,,,,
Humana,DRG,MS-659,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,Surgical,Relative Weights,"$40,647.21 ",IP,"2,420.00","54,024.77",,,,,,
Humana,DRG,MS-660,KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC,Surgical,Relative Weights,"$21,549.18 ",IP,"2,420.00","28,641.31",,,,,,
Humana,DRG,MS-661,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,Surgical,Relative Weights,"$16,534.64 ",IP,"2,420.00","21,976.42",,,,,,
Humana,DRG,MS-662,MINOR BLADDER PROCEDURES WITH MCC,Surgical,Relative Weights,"$48,002.17 ",IP,"2,420.00","63,800.35",,,,,,
Humana,DRG,MS-663,MINOR BLADDER PROCEDURES WITH CC,Surgical,Relative Weights,"$23,106.93 ",IP,"2,420.00","30,711.74",,,,,,
Humana,DRG,MS-664,MINOR BLADDER PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$16,784.91 ",IP,"2,420.00","22,309.06",,,,,,
Humana,DRG,MS-665,PROSTATECTOMY WITH MCC,Surgical,Relative Weights,"$45,026.21 ",IP,"2,420.00","59,844.96",,,,,,
Humana,DRG,MS-666,PROSTATECTOMY WITH CC,Surgical,Relative Weights,"$26,833.71 ",IP,"2,420.00","35,665.06",,,,,,
Humana,DRG,MS-667,PROSTATECTOMY W/O CC/MCC,Surgical,Relative Weights,"$14,238.20 ",IP,"2,420.00","18,924.19",,,,,,
Humana,DRG,MS-668,TRANSURETHRAL PROCEDURES W MCC,Surgical,Relative Weights,"$42,292.93 ",IP,"2,420.00","56,212.13",,,,,,
Humana,DRG,MS-669,TRANSURETHRAL PROCEDURES WITH CC,Surgical,Relative Weights,"$23,445.18 ",IP,"2,420.00","31,161.31",,,,,,
Humana,DRG,MS-670,TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$14,844.92 ",IP,"2,420.00","19,730.59",,,,,,
Humana,DRG,MS-671,URETHRAL PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$27,721.04 ",IP,"2,420.00","36,844.42",,,,,,
Humana,DRG,MS-672,URETHRAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$15,671.58 ",IP,"2,420.00","20,829.31",,,,,,
Humana,DRG,MS-673,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,Surgical,Relative Weights,"$54,219.53 ",IP,"2,420.00","72,063.94",,,,,,
Humana,DRG,MS-674,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,Surgical,Relative Weights,"$37,073.63 ",IP,"2,420.00","49,275.07",,,,,,
Humana,DRG,MS-675,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$24,754.18 ",IP,"2,420.00","32,901.12",,,,,,
Humana,DRG,MS-682,RENAL FAILURE WITH MCC,Surgical,Relative Weights,"$22,418.30 ",IP,"2,420.00","29,796.48",,,,,,
Humana,DRG,MS-683,RENAL FAILURE WITH CC,Surgical,Relative Weights,"$13,610.25 ",IP,"2,420.00","18,089.57",,,,,,
Humana,DRG,MS-684,RENAL FAILURE WITHOUT CC/MCC,Surgical,Relative Weights,"$9,332.87 ",IP,"2,420.00","12,404.45",,,,,,
Humana,DRG,MS-686,KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,Surgical,Relative Weights,"$26,636.52 ",IP,"2,420.00","35,402.98",,,,,,
Humana,DRG,MS-687,KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,Surgical,Relative Weights,"$15,965.84 ",IP,"2,420.00","21,220.42",,,,,,
Humana,DRG,MS-688,KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,Surgical,Relative Weights,"$11,699.08 ",IP,"2,420.00","15,549.41",,,,,,
Humana,DRG,MS-689,KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,Surgical,Relative Weights,"$16,966.92 ",IP,"2,420.00","22,550.98",,,,,,
Humana,DRG,MS-690,KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,Surgical,Relative Weights,"$11,994.85 ",IP,"2,420.00","15,942.53",,,,,,
Humana,DRG,MS-693,URINARY STONES WITH MCC,Surgical,Relative Weights,"$20,526.85 ",IP,"2,420.00","27,282.53",,,,,,
Humana,DRG,MS-694,URINARY STONES WITHOUT MCC,Surgical,Relative Weights,"$11,230.39 ",IP,"2,420.00","14,926.46",,,,,,
Humana,DRG,MS-695,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,Surgical,Relative Weights,"$17,781.45 ",IP,"2,420.00","23,633.57",,,,,,
Humana,DRG,MS-696,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,Surgical,Relative Weights,"$10,305.14 ",IP,"2,420.00","13,696.70",,,,,,
Humana,DRG,MS-697,URETHRAL STRICTURE,Surgical,Relative Weights,"$14,772.12 ",IP,"2,420.00","19,633.82",,,,,,
Humana,DRG,MS-698,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,Surgical,Relative Weights,"$24,550.92 ",IP,"2,420.00","32,630.98",,,,,,
Humana,DRG,MS-699,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,Surgical,Relative Weights,"$15,663.99 ",IP,"2,420.00","20,819.23",,,,,,
Humana,DRG,MS-700,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,Surgical,Relative Weights,"$11,250.11 ",IP,"2,420.00","14,952.67",,,,,,
Humana,DRG,MS-707,MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$28,362.64 ",IP,"2,420.00","37,697.18",,,,,,
Humana,DRG,MS-708,MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$22,023.94 ",IP,"2,420.00","29,272.32",,,,,,
Humana,DRG,MS-709,PENIS PROCEDURES W CC/MCC,Surgical,Relative Weights,"$36,488.14 ",IP,"2,420.00","48,496.90",,,,,,
Humana,DRG,MS-710,PENIS PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$23,295.01 ",IP,"2,420.00","30,961.73",,,,,,
Humana,DRG,MS-711,TESTES PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$32,508.06 ",IP,"2,420.00","43,206.91",,,,,,
Humana,DRG,MS-712,TESTES PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$15,474.39 ",IP,"2,420.00","20,567.23",,,,,,
Humana,DRG,MS-713,TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,Surgical,Relative Weights,"$22,175.62 ",IP,"2,420.00","29,473.92",,,,,,
Humana,DRG,MS-714,TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,Surgical,Relative Weights,"$13,884.79 ",IP,"2,420.00","18,454.46",,,,,,
Humana,DRG,MS-715,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,Surgical,Relative Weights,"$32,406.43 ",IP,"2,420.00","43,071.84",,,,,,
Humana,DRG,MS-716,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$22,228.70 ",IP,"2,420.00","29,544.48",,,,,,
Humana,DRG,MS-717,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,Surgical,Relative Weights,"$26,760.90 ",IP,"2,420.00","35,568.29",,,,,,
Humana,DRG,MS-718,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$18,495.86 ",IP,"2,420.00","24,583.10",,,,,,
Humana,DRG,MS-722,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH MCC,Surgical,Relative Weights,"$27,376.72 ",IP,"2,420.00","36,386.78",,,,,,
Humana,DRG,MS-723,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH CC,Surgical,Relative Weights,"$16,797.04 ",IP,"2,420.00","22,325.18",,,,,,
Humana,DRG,MS-724,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Surgical,Relative Weights,"$8,955.19 ",IP,"2,420.00","11,902.46",,,,,,
Humana,DRG,MS-725,BENIGN PROSTATIC HYPERTROPHY WITH MCC,Surgical,Relative Weights,"$19,041.91 ",IP,"2,420.00","25,308.86",,,,,,
Humana,DRG,MS-726,BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,Surgical,Relative Weights,"$11,598.97 ",IP,"2,420.00","15,416.35",,,,,,
Humana,DRG,MS-727,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,Surgical,Relative Weights,"$21,649.29 ",IP,"2,420.00","28,774.37",,,,,,
Humana,DRG,MS-728,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,Surgical,Relative Weights,"$12,172.32 ",IP,"2,420.00","16,178.40",,,,,,
Humana,DRG,MS-729,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,Surgical,Relative Weights,"$16,288.92 ",IP,"2,420.00","21,649.82",,,,,,
Humana,DRG,MS-730,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Surgical,Relative Weights,"$9,580.11 ",IP,"2,420.00","12,733.06",,,,,,
Humana,DRG,MS-734,PELVIC EVISCERATION -  RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC,Surgical,Relative Weights,"$33,246.74 ",IP,"2,420.00","44,188.70",,,,,,
Humana,DRG,MS-735,PELVIC EVISCERATION -  RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC,Surgical,Relative Weights,"$20,843.87 ",IP,"2,420.00","27,703.87",,,,,,
Humana,DRG,MS-736,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,Surgical,Relative Weights,"$65,539.41 ",IP,"2,420.00","87,109.34",,,,,,
Humana,DRG,MS-737,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,Surgical,Relative Weights,"$30,140.33 ",IP,"2,420.00","40,059.94",,,,,,
Humana,DRG,MS-738,UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY W/O CC/MCC,Surgical,Relative Weights,"$20,915.16 ",IP,"2,420.00","27,798.62",,,,,,
Humana,DRG,MS-739,UTERINE -ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W MCC,Surgical,Relative Weights,"$56,796.58 ",IP,"2,420.00","75,489.12",,,,,,
Humana,DRG,MS-740,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,Surgical,Relative Weights,"$27,073.36 ",IP,"2,420.00","35,983.58",,,,,,
Humana,DRG,MS-741,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$20,165.86 ",IP,"2,420.00","26,802.72",,,,,,
Humana,DRG,MS-742,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,Surgical,Relative Weights,"$25,626.34 ",IP,"2,420.00","34,060.32",,,,,,
Humana,DRG,MS-743,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$17,420.45 ",IP,"2,420.00","23,153.76",,,,,,
Humana,DRG,MS-744,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC,Surgical,Relative Weights,"$26,399.90 ",IP,"2,420.00","35,088.48",,,,,,
Humana,DRG,MS-745,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC,Surgical,Relative Weights,"$16,158.47 ",IP,"2,420.00","21,476.45",,,,,,
Humana,DRG,MS-746,VAGINA -  CERVIX AND VULVA PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$24,739.01 ",IP,"2,420.00","32,880.96",,,,,,
Humana,DRG,MS-747,VAGINA- CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$14,139.61 ",IP,"2,420.00","18,793.15",,,,,,
Humana,DRG,MS-748,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,Surgical,Relative Weights,"$20,047.55 ",IP,"2,420.00","26,645.47",,,,,,
Humana,DRG,MS-749,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$39,318.49 ",IP,"2,420.00","52,258.75",,,,,,
Humana,DRG,MS-750,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$20,191.64 ",IP,"2,420.00","26,836.99",,,,,,
Humana,DRG,MS-754,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH MCC,Surgical,Relative Weights,"$26,724.50 ",IP,"2,420.00","35,519.90",,,,,,
Humana,DRG,MS-755,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH CC,Surgical,Relative Weights,"$15,529.00 ",IP,"2,420.00","20,639.81",,,,,,
Humana,DRG,MS-756,MALIGNANCY - FEMALE REPRODUCTIVE SYSTEM W/O CC/MCC,Surgical,Relative Weights,"$13,299.30 ",IP,"2,420.00","17,676.29",,,,,,
Humana,DRG,MS-757,INFECTIONS - FEMALE REPRODUCTIVE SYSTEM W MCC,Surgical,Relative Weights,"$21,543.11 ",IP,"2,420.00","28,633.25",,,,,,
Humana,DRG,MS-758,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITH CC,Surgical,Relative Weights,"$14,643.19 ",IP,"2,420.00","19,462.46",,,,,,
Humana,DRG,MS-759,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Surgical,Relative Weights,"$10,015.43 ",IP,"2,420.00","13,311.65",,,,,,
Humana,DRG,MS-760,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,Surgical,Relative Weights,"$13,689.12 ",IP,"2,420.00","18,194.40",,,,,,
Humana,DRG,MS-761,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$8,575.99 ",IP,"2,420.00","11,398.46",,,,,,
Humana,DRG,MS-768,VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C,Surgical,Relative Weights,"$15,281.76 ",IP,"2,420.00","20,311.20",,,,,,
Humana,DRG,MS-769,POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,Surgical,Relative Weights,"$21,887.42 ",IP,"2,420.00","29,090.88",,,,,,
Humana,DRG,MS-770,ABORTION WITH D&C- ASPIRATION CURETTAGE OR HYSTEROTOMY,Surgical,Relative Weights,"$11,926.60 ",IP,"2,420.00","15,851.81",,,,,,
Humana,DRG,MS-776,POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,Surgical,Relative Weights,"$10,767.76 ",IP,"2,420.00","14,311.58",,,,,,
Humana,DRG,MS-779,ABORTION WITHOUT D&C,Surgical,Relative Weights,"$17,318.82 ",IP,"2,420.00","23,018.69",,,,,,
Humana,DRG,MS-783,CESAREAN SECTION WITH STERILIZATION WITH MCC,Surgical,Relative Weights,"$32,532.33 ",IP,"2,420.00","43,239.17",,,,,,
Humana,DRG,MS-784,CESAREAN SECTION WITH STERILIZATION WITH CC,Surgical,Relative Weights,"$15,853.59 ",IP,"2,420.00","21,071.23",,,,,,
Humana,DRG,MS-785,CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,Surgical,Relative Weights,"$13,020.21 ",IP,"2,420.00","17,305.34",,,,,,
Humana,DRG,MS-786,CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,Surgical,Relative Weights,"$26,005.54 ",IP,"2,420.00","34,564.32",,,,,,
Humana,DRG,MS-787,CESAREAN SECTION WITHOUT STERILIZATION WITH CC,Surgical,Relative Weights,"$15,858.14 ",IP,"2,420.00","21,077.28",,,,,,
Humana,DRG,MS-788,CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,Surgical,Relative Weights,"$13,745.24 ",IP,"2,420.00","18,268.99",,,,,,
Humana,DRG,MS-789,NEONATES- DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY,Surgical,Relative Weights,"$25,633.92 ",IP,"2,420.00","34,070.40",,,,,,
Humana,DRG,MS-790,EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME- NEONATE,Surgical,Relative Weights,"$84,531.26 ",IP,"2,420.00","112,351.68",,,,,,
Humana,DRG,MS-791,PREMATURITY W MAJOR PROBLEMS,Surgical,Relative Weights,"$57,732.44 ",IP,"2,420.00","76,732.99",,,,,,
Humana,DRG,MS-792,PREMATURITY W/O MAJOR PROBLEMS,Surgical,Relative Weights,"$34,833.31 ",IP,"2,420.00","46,297.44",,,,,,
Humana,DRG,MS-793,FULL TERM NEONATE WITH MAJOR PROBLEMS,Surgical,Relative Weights,"$59,302.33 ",IP,"2,420.00","78,819.55",,,,,,
Humana,DRG,MS-794,NEONATE WITH OTHER SIGNIFICANT PROBLEMS,Surgical,Relative Weights,"$20,989.48 ",IP,"2,420.00","27,897.41",,,,,,
Humana,DRG,MS-795,NORMAL NEWBORN,Surgical,Relative Weights,"$2,840.97 ",IP,"1,113.70","3,775.97",,,,,,
Humana,DRG,MS-796,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,Surgical,Relative Weights,"$29,915.85 ",IP,"2,420.00","39,761.57",,,,,,
Humana,DRG,MS-797,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,Surgical,Relative Weights,"$13,086.95 ",IP,"2,420.00","17,394.05",,,,,,
Humana,DRG,MS-798,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,Surgical,Relative Weights,"$13,086.95 ",IP,"2,420.00","17,394.05",,,,,,
Humana,DRG,MS-799,SPLENECTOMY WITH MCC,Surgical,Relative Weights,"$74,995.14 ",IP,"2,420.00","99,677.09",,,,,,
Humana,DRG,MS-800,SPLENECTOMY WITH CC,Surgical,Relative Weights,"$43,107.46 ",IP,"2,420.00","57,294.72",,,,,,
Humana,DRG,MS-801,SPLENECTOMY WITHOUT CC/MCC,Surgical,Relative Weights,"$28,412.70 ",IP,"2,420.00","37,763.71",,,,,,
Humana,DRG,MS-802,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,Surgical,Relative Weights,"$47,815.60 ",IP,"2,420.00","63,552.38",,,,,,
Humana,DRG,MS-803,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,Surgical,Relative Weights,"$27,023.31 ",IP,"2,420.00","35,917.06",,,,,,
Humana,DRG,MS-804,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,Surgical,Relative Weights,"$20,667.92 ",IP,"2,420.00","27,470.02",,,,,,
Humana,DRG,MS-805,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,Surgical,Relative Weights,"$15,785.34 ",IP,"2,420.00","20,980.51",,,,,,
Humana,DRG,MS-806,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,Surgical,Relative Weights,"$10,757.15 ",IP,"2,420.00","14,297.47",,,,,,
Humana,DRG,MS-807,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,Surgical,Relative Weights,"$9,507.30 ",IP,"2,420.00","12,636.29",,,,,,
Humana,DRG,MS-808,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,Surgical,Relative Weights,"$32,301.77 ",IP,"2,420.00","42,932.74",,,,,,
Humana,DRG,MS-809,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,Surgical,Relative Weights,"$18,442.77 ",IP,"2,420.00","24,512.54",,,,,,
Humana,DRG,MS-810,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$14,188.15 ",IP,"2,420.00","18,857.66",,,,,,
Humana,DRG,MS-811,RED BLOOD CELL DISORDERS WITH MCC,Surgical,Relative Weights,"$20,329.67 ",IP,"2,420.00","27,020.45",,,,,,
Humana,DRG,MS-812,RED BLOOD CELL DISORDERS WITHOUT MCC,Surgical,Relative Weights,"$13,206.78 ",IP,"2,420.00","17,553.31",,,,,,
Humana,DRG,MS-813,COAGULATION DISORDERS,Surgical,Relative Weights,"$24,044.31 ",IP,"2,420.00","31,957.63",,,,,,
Humana,DRG,MS-814,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,Surgical,Relative Weights,"$26,530.35 ",IP,"2,420.00","35,261.86",,,,,,
Humana,DRG,MS-815,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,Surgical,Relative Weights,"$15,362.15 ",IP,"2,420.00","20,418.05",,,,,,
Humana,DRG,MS-816,RETICULOENDOTHELIAL & IMMUNITY DISORDERS W/O CC/MCC,Surgical,Relative Weights,"$10,858.77 ",IP,"2,420.00","14,432.54",,,,,,
Humana,DRG,MS-817,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$38,165.72 ",IP,"2,420.00","50,726.59",,,,,,
Humana,DRG,MS-818,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$19,322.52 ",IP,"2,420.00","25,681.82",,,,,,
Humana,DRG,MS-819,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$12,102.55 ",IP,"2,420.00","16,085.66",,,,,,
Humana,DRG,MS-820,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$86,710.91 ",IP,"2,420.00","115,248.67",,,,,,
Humana,DRG,MS-821,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$33,859.53 ",IP,"2,420.00","45,003.17",,,,,,
Humana,DRG,MS-822,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$19,178.42 ",IP,"2,420.00","25,490.30",,,,,,
Humana,DRG,MS-823,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,Surgical,Relative Weights,"$64,163.67 ",IP,"2,420.00","85,280.83",,,,,,
Humana,DRG,MS-824,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,Surgical,Relative Weights,"$35,267.12 ",IP,"2,420.00","46,874.02",,,,,,
Humana,DRG,MS-825,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$20,545.06 ",IP,"2,420.00","27,306.72",,,,,,
Humana,DRG,MS-826,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$76,067.52 ",IP,"2,420.00","101,102.40",,,,,,
Humana,DRG,MS-827,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$35,132.12 ",IP,"2,420.00","46,694.59",,,,,,
Humana,DRG,MS-828,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$25,045.40 ",IP,"2,420.00","33,288.19",,,,,,
Humana,DRG,MS-829,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$47,626.00 ",IP,"2,420.00","63,300.38",,,,,,
Humana,DRG,MS-830,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$20,913.64 ",IP,"2,420.00","27,796.61",,,,,,
Humana,DRG,MS-831,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$16,358.69 ",IP,"2,420.00","21,742.56",,,,,,
Humana,DRG,MS-832,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$10,852.70 ",IP,"2,420.00","14,424.48",,,,,,
Humana,DRG,MS-833,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,070.89 ",IP,"2,420.00","10,727.14",,,,,,
Humana,DRG,MS-834,ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W MCC,Surgical,Relative Weights,"$88,619.04 ",IP,"2,420.00","117,784.80",,,,,,
Humana,DRG,MS-835,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$30,763.74 ",IP,"2,420.00","40,888.51",,,,,,
Humana,DRG,MS-836,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$19,985.36 ",IP,"2,420.00","26,562.82",,,,,,
Humana,DRG,MS-837,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,Surgical,Relative Weights,"$90,868.45 ",IP,"2,420.00","120,774.53",,,,,,
Humana,DRG,MS-838,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,Surgical,Relative Weights,"$33,186.07 ",IP,"2,420.00","44,108.06",,,,,,
Humana,DRG,MS-839,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$19,357.40 ",IP,"2,420.00","25,728.19",,,,,,
Humana,DRG,MS-840,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,Surgical,Relative Weights,"$48,464.79 ",IP,"2,420.00","64,415.23",,,,,,
Humana,DRG,MS-841,LYMPHOMA & NON-ACUTE LEUKEMIA W CC,Surgical,Relative Weights,"$24,446.27 ",IP,"2,420.00","32,491.87",,,,,,
Humana,DRG,MS-842,LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,Surgical,Relative Weights,"$17,391.63 ",IP,"2,420.00","23,115.46",,,,,,
Humana,DRG,MS-843,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,Surgical,Relative Weights,"$28,937.51 ",IP,"2,420.00","38,461.25",,,,,,
Humana,DRG,MS-844,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,Surgical,Relative Weights,"$18,322.94 ",IP,"2,420.00","24,353.28",,,,,,
Humana,DRG,MS-845,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,Surgical,Relative Weights,"$13,133.97 ",IP,"2,420.00","17,456.54",,,,,,
Humana,DRG,MS-846,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$39,840.27 ",IP,"2,420.00","52,952.26",,,,,,
Humana,DRG,MS-847,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,Surgical,Relative Weights,"$19,959.57 ",IP,"2,420.00","26,528.54",,,,,,
Humana,DRG,MS-848,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$14,885.88 ",IP,"2,420.00","19,785.02",,,,,,
Humana,DRG,MS-849,RADIOTHERAPY,Surgical,Relative Weights,"$32,244.13 ",IP,"2,420.00","42,856.13",,,,,,
Humana,DRG,MS-853,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$77,335.56 ",IP,"2,420.00","102,787.78",,,,,,
Humana,DRG,MS-854,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$32,781.08 ",IP,"2,420.00","43,569.79",,,,,,
Humana,DRG,MS-855,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$24,318.85 ",IP,"2,420.00","32,322.53",,,,,,
Humana,DRG,MS-856,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$67,129.02 ",IP,"2,420.00","89,222.11",,,,,,
Humana,DRG,MS-857,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$30,841.09 ",IP,"2,420.00","40,991.33",,,,,,
Humana,DRG,MS-858,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$20,877.24 ",IP,"2,420.00","27,748.22",,,,,,
Humana,DRG,MS-862,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W MCC,Surgical,Relative Weights,"$28,069.90 ",IP,"2,420.00","37,308.10",,,,,,
Humana,DRG,MS-863,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W/O MCC,Surgical,Relative Weights,"$14,985.98 ",IP,"2,420.00","19,918.08",,,,,,
Humana,DRG,MS-864,FEVER AND INFLAMMATORY CONDITIONS,Surgical,Relative Weights,"$12,853.36 ",IP,"2,420.00","17,083.58",,,,,,
Humana,DRG,MS-865,VIRAL ILLNESS WITH MCC,Surgical,Relative Weights,"$21,133.57 ",IP,"2,420.00","28,088.93",,,,,,
Humana,DRG,MS-866,VIRAL ILLNESS WITHOUT MCC,Surgical,Relative Weights,"$12,418.04 ",IP,"2,420.00","16,504.99",,,,,,
Humana,DRG,MS-867,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,Surgical,Relative Weights,"$33,145.11 ",IP,"2,420.00","44,053.63",,,,,,
Humana,DRG,MS-868,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,Surgical,Relative Weights,"$16,639.30 ",IP,"2,420.00","22,115.52",,,,,,
Humana,DRG,MS-869,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,Surgical,Relative Weights,"$11,262.24 ",IP,"2,420.00","14,968.80",,,,,,
Humana,DRG,MS-870,SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,Surgical,Relative Weights,"$95,926.98 ",IP,"2,420.00","127,497.89",,,,,,
Humana,DRG,MS-871,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,Surgical,Relative Weights,"$28,308.04 ",IP,"2,420.00","37,624.61",,,,,,
Humana,DRG,MS-872,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,Surgical,Relative Weights,"$15,764.10 ",IP,"2,420.00","20,952.29",,,,,,
Humana,DRG,MS-876,O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,Surgical,Relative Weights,"$55,211.52 ",IP,"2,420.00","73,382.40",,,,,,
Humana,DRG,MS-880,ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,Surgical,Relative Weights,"$12,997.46 ",IP,"2,420.00","17,275.10",,,,,,
Humana,DRG,MS-881,DEPRESSIVE NEUROSES,Surgical,Relative Weights,"$12,427.14 ",IP,"2,420.00","16,517.09",,,,,,
Humana,DRG,MS-882,NEUROSES EXCEPT DEPRESSIVE,Surgical,Relative Weights,"$11,979.69 ",IP,"2,420.00","15,922.37",,,,,,
Humana,DRG,MS-883,DISORDERS OF PERSONALITY & IMPULSE CONTROL,Surgical,Relative Weights,"$20,273.55 ",IP,"2,420.00","26,945.86",,,,,,
Humana,DRG,MS-884,ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,Surgical,Relative Weights,"$21,811.58 ",IP,"2,420.00","28,990.08",,,,,,
Humana,DRG,MS-885,PSYCHOSES,Surgical,Relative Weights,"$18,435.19 ",IP,"2,420.00","24,502.46",,,,,,
Humana,DRG,MS-886,BEHAVIORAL AND DEVELOPMENTAL DISORDERS,Surgical,Relative Weights,"$20,410.06 ",IP,"2,420.00","27,127.30",,,,,,
Humana,DRG,MS-887,OTHER MENTAL DISORDER DIAGNOSES,Surgical,Relative Weights,"$16,504.30 ",IP,"2,420.00","21,936.10",,,,,,
Humana,DRG,MS-894,ALCOHOL- DRUG ABUSE OR DEPENDENCE- LEFT AMA,Surgical,Relative Weights,"$8,803.51 ",IP,"2,420.00","11,700.86",,,,,,
Humana,DRG,MS-895,ALCOHOL- DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY,Surgical,Relative Weights,"$24,676.82 ",IP,"2,420.00","32,798.30",,,,,,
Humana,DRG,MS-896,ALCOHOL -  DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC,Surgical,Relative Weights,"$26,084.41 ",IP,"2,420.00","34,669.15",,,,,,
Humana,DRG,MS-897,ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC,Surgical,Relative Weights,"$12,465.06 ",IP,"2,420.00","16,567.49",,,,,,
Humana,DRG,MS-901,WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,Surgical,Relative Weights,"$65,634.97 ",IP,"2,420.00","87,236.35",,,,,,
Humana,DRG,MS-902,WOUND DEBRIDEMENTS FOR INJURIES WITH CC,Surgical,Relative Weights,"$29,833.94 ",IP,"2,420.00","39,652.70",,,,,,
Humana,DRG,MS-903,WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,Surgical,Relative Weights,"$17,352.19 ",IP,"2,420.00","23,063.04",,,,,,
Humana,DRG,MS-904,SKIN GRAFTS FOR INJURIES WITH CC/MCC,Surgical,Relative Weights,"$53,655.28 ",IP,"2,420.00","71,313.98",,,,,,
Humana,DRG,MS-905,SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,Surgical,Relative Weights,"$25,245.62 ",IP,"2,420.00","33,554.30",,,,,,
Humana,DRG,MS-906,HAND PROCEDURES FOR INJURIES,Surgical,Relative Weights,"$26,405.97 ",IP,"2,420.00","35,096.54",,,,,,
Humana,DRG,MS-907,OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,Surgical,Relative Weights,"$60,514.25 ",IP,"2,420.00","80,430.34",,,,,,
Humana,DRG,MS-908,OTHER O.R. PROCEDURES FOR INJURIES WITH CC,Surgical,Relative Weights,"$31,293.10 ",IP,"2,420.00","41,592.10",,,,,,
Humana,DRG,MS-909,OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,Surgical,Relative Weights,"$20,002.04 ",IP,"2,420.00","26,584.99",,,,,,
Humana,DRG,MS-913,TRAUMATIC INJURY WITH MCC,Surgical,Relative Weights,"$22,392.52 ",IP,"2,420.00","29,762.21",,,,,,
Humana,DRG,MS-914,TRAUMATIC INJURY WITHOUT MCC,Surgical,Relative Weights,"$13,070.27 ",IP,"2,420.00","17,371.87",,,,,,
Humana,DRG,MS-915,ALLERGIC REACTIONS WITH MCC,Surgical,Relative Weights,"$25,771.95 ",IP,"2,420.00","34,253.86",,,,,,
Humana,DRG,MS-916,ALLERGIC REACTIONS WITHOUT MCC,Surgical,Relative Weights,"$9,604.38 ",IP,"2,420.00","12,765.31",,,,,,
Humana,DRG,MS-917,POISONING & TOXIC EFFECTS OF DRUGS W MCC,Surgical,Relative Weights,"$22,193.82 ",IP,"2,420.00","29,498.11",,,,,,
Humana,DRG,MS-918,POISONING & TOXIC EFFECTS OF DRUGS W/O MCC,Surgical,Relative Weights,"$11,891.71 ",IP,"2,420.00","15,805.44",,,,,,
Humana,DRG,MS-919,COMPLICATIONS OF TREATMENT WITH MCC,Surgical,Relative Weights,"$27,686.15 ",IP,"2,420.00","36,798.05",,,,,,
Humana,DRG,MS-920,COMPLICATIONS OF TREATMENT WITH CC,Surgical,Relative Weights,"$15,281.76 ",IP,"2,420.00","20,311.20",,,,,,
Humana,DRG,MS-921,COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,Surgical,Relative Weights,"$10,475.02 ",IP,"2,420.00","13,922.50",,,,,,
Humana,DRG,MS-922,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC,Surgical,Relative Weights,"$24,323.40 ",IP,"2,420.00","32,328.58",,,,,,
Humana,DRG,MS-923,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC,Surgical,Relative Weights,"$13,127.90 ",IP,"2,420.00","17,448.48",,,,,,
Humana,DRG,MS-927,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,Surgical,Relative Weights,"$302,503.01 ",IP,"2,420.00","402,060.96",,,,,,
Humana,DRG,MS-928,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,Surgical,Relative Weights,"$93,964.24 ",IP,"2,420.00","124,889.18",,,,,,
Humana,DRG,MS-929,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,Surgical,Relative Weights,"$44,616.67 ",IP,"2,420.00","59,300.64",,,,,,
Humana,DRG,MS-933,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,Surgical,Relative Weights,"$47,630.55 ",IP,"2,420.00","63,306.43",,,,,,
Humana,DRG,MS-934,FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,Surgical,Relative Weights,"$27,451.05 ",IP,"2,420.00","36,485.57",,,,,,
Humana,DRG,MS-935,NON-EXTENSIVE BURNS,Surgical,Relative Weights,"$29,309.13 ",IP,"2,420.00","38,955.17",,,,,,
Humana,DRG,MS-939,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,Surgical,Relative Weights,"$55,429.94 ",IP,"2,420.00","73,672.70",,,,,,
Humana,DRG,MS-940,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,Surgical,Relative Weights,"$34,458.66 ",IP,"2,420.00","45,799.49",,,,,,
Humana,DRG,MS-941,O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W/O CC/MCC,Surgical,Relative Weights,"$29,284.86 ",IP,"2,420.00","38,922.91",,,,,,
Humana,DRG,MS-945,REHABILITATION WITH CC/MCC,Surgical,Relative Weights,"$22,073.99 ",IP,"2,420.00","29,338.85",,,,,,
Humana,DRG,MS-946,REHABILITATION WITHOUT CC/MCC,Surgical,Relative Weights,"$16,487.62 ",IP,"2,420.00","21,913.92",,,,,,
Humana,DRG,MS-947,SIGNS AND SYMPTOMS WITH MCC,Surgical,Relative Weights,"$18,160.65 ",IP,"2,420.00","24,137.57",,,,,,
Humana,DRG,MS-948,SIGNS AND SYMPTOMS WITHOUT MCC,Surgical,Relative Weights,"$11,824.97 ",IP,"2,420.00","15,716.74",,,,,,
Humana,DRG,MS-949,AFTERCARE WITH CC/MCC,Surgical,Relative Weights,"$16,516.44 ",IP,"2,420.00","21,952.22",,,,,,
Humana,DRG,MS-950,AFTERCARE WITHOUT CC/MCC,Surgical,Relative Weights,"$11,237.97 ",IP,"2,420.00","14,936.54",,,,,,
Humana,DRG,MS-951,OTHER FACTORS INFLUENCING HEALTH STATUS,Surgical,Relative Weights,"$8,896.03 ",IP,"2,420.00","11,823.84",,,,,,
Humana,DRG,MS-955,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,Surgical,Relative Weights,"$92,229.02 ",IP,"2,420.00","122,582.88",,,,,,
Humana,DRG,MS-956,LIMB REATTACHMENT- HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,Surgical,Relative Weights,"$59,508.61 ",IP,"2,420.00","79,093.73",,,,,,
Humana,DRG,MS-957,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Surgical,Relative Weights,"$114,271.16 ",IP,"2,420.00","151,879.39",,,,,,
Humana,DRG,MS-958,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,Surgical,Relative Weights,"$63,567.57 ",IP,"2,420.00","84,488.54",,,,,,
Humana,DRG,MS-959,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,Surgical,Relative Weights,"$42,477.98 ",IP,"2,420.00","56,458.08",,,,,,
Humana,DRG,MS-963,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Surgical,Relative Weights,"$41,334.32 ",IP,"2,420.00","54,938.02",,,,,,
Humana,DRG,MS-964,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,Surgical,Relative Weights,"$22,653.41 ",IP,"2,420.00","30,108.96",,,,,,
Humana,DRG,MS-965,OTHER MULTIPLE SIGNIFICANT TRAUMA W/O CC/MCC,Surgical,Relative Weights,"$13,910.57 ",IP,"2,420.00","18,488.74",,,,,,
Humana,DRG,MS-969,HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$88,015.35 ",IP,"2,420.00","116,982.43",,,,,,
Humana,DRG,MS-970,HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$44,245.06 ",IP,"2,420.00","58,806.72",,,,,,
Humana,DRG,MS-974,HIV WITH MAJOR RELATED CONDITION WITH MCC,Surgical,Relative Weights,"$40,557.72 ",IP,"2,420.00","53,905.82",,,,,,
Humana,DRG,MS-975,HIV WITH MAJOR RELATED CONDITION WITH CC,Surgical,Relative Weights,"$20,355.46 ",IP,"2,420.00","27,054.72",,,,,,
Humana,DRG,MS-976,HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,Surgical,Relative Weights,"$13,866.59 ",IP,"2,420.00","18,430.27",,,,,,
Humana,DRG,MS-977,HIV WITH OR WITHOUT OTHER RELATED CONDITION,Surgical,Relative Weights,"$19,725.98 ",IP,"2,420.00","26,218.08",,,,,,
Humana,DRG,MS-981,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$68,114.94 ",IP,"2,420.00","90,532.51",,,,,,
Humana,DRG,MS-982,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Surgical,Relative Weights,"$36,981.10 ",IP,"2,420.00","49,152.10",,,,,,
Humana,DRG,MS-983,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$24,831.53 ",IP,"2,420.00","33,003.94",,,,,,
Humana,DRG,MS-987,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$50,565.56 ",IP,"2,420.00","67,207.39",,,,,,
Humana,DRG,MS-988,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Surgical,Relative Weights,"$26,063.17 ",IP,"2,420.00","34,640.93",,,,,,
Humana,DRG,MS-989,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$17,479.60 ",IP,"2,420.00","23,232.38",,,,,,
Humana,ExceptCPT,0001U,Rbc dna hea 35 ag 11 bld grp,Lab Services,Per Unit,"$1,440.00 ",OP,"1,440.00","1,440.00",,,,,,
Humana,ExceptCPT,0002M,Liver dis 10 assays w/ash,Lab Services,Per Unit,"$1,006.80 ",OP,"1,006.80","1,006.80",,,,,,
Humana,ExceptCPT,0002U,Onc clrct 3 ur metab alg plp,Lab Services,Per Unit,$50.00 ,OP,50,50,,,,,,
Humana,ExceptCPT,0003M,Liver dis 10 assays w/nash,Lab Services,Per Unit,"$1,006.80 ",OP,"1,006.80","1,006.80",,,,,,
Humana,ExceptCPT,0003U,Onc ovar 5 prtn ser alg scor,Lab Services,Per Unit,"$1,900.00 ",OP,"1,900.00","1,900.00",,,,,,
Humana,ExceptCPT,0004M,Scoliosis dna alys,Lab Services,Per Unit,$158.00 ,OP,158,158,,,,,,
Humana,ExceptCPT,0005U,Onco prst8 3 gene ur alg,Lab Services,Per Unit,"$1,520.00 ",OP,"1,520.00","1,520.00",,,,,,
Humana,ExceptCPT,0006M,Onc hep gene risk classifier,Lab Services,Per Unit,$300.00 ,OP,300,300,,,,,,
Humana,ExceptCPT,0007M,Onc gastro 51 gene nomogram,Lab Services,Per Unit,$750.00 ,OP,750,750,,,,,,
Humana,ExceptCPT,0007U,Rx test prsmv ur w/def conf,Lab Services,Per Unit,$228.86 ,OP,228.86,228.86,,,,,,
Humana,ExceptCPT,0008U,Hpylori detcj abx rstnc dna,Lab Services,Per Unit,"$1,195.82 ",OP,"1,195.82","1,195.82",,,,,,
Humana,ExceptCPT,0009U,Onc brst ca erbb2 amp/nonamp,Lab Services,Per Unit,$214.00 ,OP,214,214,,,,,,
Humana,ExceptCPT,0010U,Nfct ds strn typ whl gen seq,Lab Services,Per Unit,$854.52 ,OP,854.52,854.52,,,,,,
Humana,ExceptCPT,0011M,Onc prst8 ca mrna 12 gen alg,Lab Services,Per Unit,"$1,520.00 ",OP,"1,520.00","1,520.00",,,,,,
Humana,ExceptCPT,0011U,Rx mntr lc-ms/ms oral fluid,Lab Services,Per Unit,$228.86 ,OP,228.86,228.86,,,,,,
Humana,ExceptCPT,0012M,Onc mrna 5 gen rsk urthl ca,Lab Services,Per Unit,"$1,520.00 ",OP,"1,520.00","1,520.00",,,,,,
Humana,ExceptCPT,0012U,Germln do gene reargmt detcj,Lab Services,Per Unit,"$5,031.20 ",OP,"5,031.20","5,031.20",,,,,,
Humana,ExceptCPT,0013M,Onc mrna 5 gen recr urthl ca,Lab Services,Per Unit,"$1,520.00 ",OP,"1,520.00","1,520.00",,,,,,
Humana,ExceptCPT,0013U,Onc sld org neo gene reargmt,Lab Services,Per Unit,"$5,031.20 ",OP,"5,031.20","5,031.20",,,,,,
Humana,ExceptCPT,0014U,Hem hmtlmf neo gene reargmt,Lab Services,Per Unit,"$5,031.20 ",OP,"5,031.20","5,031.20",,,,,,
Humana,ExceptCPT,0016U,Onc hmtlmf neo rna bcr/abl1,Lab Services,Per Unit,$327.92 ,OP,327.92,327.92,,,,,,
Humana,ExceptCPT,0017U,Onc hmtlmf neo jak2 mut dna,Lab Services,Per Unit,$183.32 ,OP,183.32,183.32,,,,,,
Humana,ExceptCPT,0018U,Onc thyr 10 microrna seq alg,Lab Services,Per Unit,"$6,004.18 ",OP,"6,004.18","6,004.18",,,,,,
Humana,ExceptCPT,0019U,Onc rna tiss predict alg,Lab Services,Per Unit,"$7,350.00 ",OP,"7,350.00","7,350.00",,,,,,
Humana,ExceptCPT,0021U,Onc prst8 detcj 8 autoantb,Lab Services,Per Unit,"$1,520.00 ",OP,"1,520.00","1,520.00",,,,,,
Humana,ExceptCPT,0022U,Trgt gen seq dna&rna 23 gene,Lab Services,Per Unit,"$3,900.00 ",OP,"3,900.00","3,900.00",,,,,,
Humana,ExceptCPT,0023U,Onc aml dna detcj/nondetcj,Lab Services,Per Unit,$497.02 ,OP,497.02,497.02,,,,,,
Humana,ExceptCPT,0024U,Glyca nuc mr spectrsc quan,Lab Services,Per Unit,$68.38 ,OP,68.38,68.38,,,,,,
Humana,ExceptCPT,0025U,Tenofovir liq chrom ur quan,Lab Services,Per Unit,$171.54 ,OP,171.54,171.54,,,,,,
Humana,ExceptCPT,0026U,Onc thyr dna&mrna 112 genes,Lab Services,Per Unit,"$7,200.00 ",OP,"7,200.00","7,200.00",,,,,,
Humana,ExceptCPT,0027U,Jak2 gene trgt seq alys,Lab Services,Per Unit,$243.82 ,OP,243.82,243.82,,,,,,
Humana,ExceptCPT,0029U,Rx metab advrs trgt seq alys,Lab Services,Per Unit,"$1,484.54 ",OP,"1,484.54","1,484.54",,,,,,
Humana,ExceptCPT,0030U,Rx metab warf trgt seq alys,Lab Services,Per Unit,$268.26 ,OP,268.26,268.26,,,,,,
Humana,ExceptCPT,0031U,Cyp1a2 gene,Lab Services,Per Unit,$349.62 ,OP,349.62,349.62,,,,,,
Humana,ExceptCPT,0032U,Comt gene,Lab Services,Per Unit,$349.62 ,OP,349.62,349.62,,,,,,
Humana,ExceptCPT,0033U,Htr2a htr2c genes,Lab Services,Per Unit,$699.24 ,OP,699.24,699.24,,,,,,
Humana,ExceptCPT,0034U,Tpmt nudt15 genes,Lab Services,Per Unit,$932.34 ,OP,932.34,932.34,,,,,,
Humana,ExceptCPT,0035U,Neuro csf prion prtn qual,Lab Services,Per Unit,"$1,081.98 ",OP,"1,081.98","1,081.98",,,,,,
Humana,ExceptCPT,0036U,Xome tum & nml spec seq alys,Lab Services,Per Unit,"$9,560.00 ",OP,"9,560.00","9,560.00",,,,,,
Humana,ExceptCPT,0037U,Trgt gen seq dna 324 genes,Lab Services,Per Unit,"$7,000.00 ",OP,"7,000.00","7,000.00",,,,,,
Humana,ExceptCPT,0038U,Vitamin d srm microsamp quan,Lab Services,Per Unit,$59.20 ,OP,59.2,59.2,,,,,,
Humana,ExceptCPT,0039U,Dna antb 2strand hi avidity,Lab Services,Per Unit,$27.48 ,OP,27.48,27.48,,,,,,
Humana,ExceptCPT,0040U,Bcr/abl1 gene major bp quan,Lab Services,Per Unit,$819.80 ,OP,819.8,819.8,,,,,,
Humana,ExceptCPT,0041U,B brgdrferi antb 5 prtn igm,Lab Services,Per Unit,$34.42 ,OP,34.42,34.42,,,,,,
Humana,ExceptCPT,0042U,B brgdrferi antb 12 prtn igg,Lab Services,Per Unit,$34.42 ,OP,34.42,34.42,,,,,,
Humana,ExceptCPT,0043U,Tbrf b grp antb 4 prtn igm,Lab Services,Per Unit,$29.72 ,OP,29.72,29.72,,,,,,
Humana,ExceptCPT,0044U,Tbrf b grp antb 4 prtn igg,Lab Services,Per Unit,$29.72 ,OP,29.72,29.72,,,,,,
Humana,ExceptCPT,0045U,Onc brst dux carc is 12 gene,Lab Services,Per Unit,"$7,746.00 ",OP,"7,746.00","7,746.00",,,,,,
Humana,ExceptCPT,0047U,Onc prst8 mrna 17 gene alg,Lab Services,Per Unit,"$7,746.00 ",OP,"7,746.00","7,746.00",,,,,,
Humana,ExceptCPT,0048U,Onc sld org neo dna 468 gene,Lab Services,Per Unit,"$5,839.20 ",OP,"5,839.20","5,839.20",,,,,,
Humana,ExceptCPT,0050U,Trgt gen seq dna 194 genes,Lab Services,Per Unit,"$5,833.20 ",OP,"5,833.20","5,833.20",,,,,,
Humana,ExceptCPT,0051U,Rx mntr lc-ms/ms ur/bld 31,Lab Services,Per Unit,$387.42 ,OP,387.42,387.42,,,,,,
Humana,ExceptCPT,0052U,Lpoprtn bld w/5 maj classes,Lab Services,Per Unit,$67.72 ,OP,67.72,67.72,,,,,,
Humana,ExceptCPT,0053U,Onc prst8 ca fish alys 4 gen,Lab Services,Per Unit,"$4,060.00 ",OP,"4,060.00","4,060.00",,,,,,
Humana,ExceptCPT,0054U,Rx mntr 14+ drugs & sbsts,Lab Services,Per Unit,$297.92 ,OP,297.92,297.92,,,,,,
Humana,ExceptCPT,0055U,Card hrt trnspl 96 dna seq,Lab Services,Per Unit,"$6,480.00 ",OP,"6,480.00","6,480.00",,,,,,
Humana,ExceptCPT,0056U,Hem aml dna gene reargmt,Lab Services,Per Unit,"$5,031.20 ",OP,"5,031.20","5,031.20",,,,,,
Humana,ExceptCPT,0058U,Onc merkel cll carc srm quan,Lab Services,Per Unit,$645.92 ,OP,645.92,645.92,,,,,,
Humana,ExceptCPT,0059U,Onc merkel cll carc srm +/-,Lab Services,Per Unit,$645.92 ,OP,645.92,645.92,,,,,,
Humana,ExceptCPT,0060U,Twn zyg gen seq alys chrms2,Lab Services,Per Unit,"$1,518.10 ",OP,"1,518.10","1,518.10",,,,,,
Humana,ExceptCPT,0061U,Tc meas 5 bmrk sfdi m-s alys,Lab Services,Per Unit,$50.20 ,OP,50.2,50.2,,,,,,
Humana,ExceptCPT,0064U,Antb tp total&rpr ia qual,Lab Services,Per Unit,$62.66 ,OP,62.66,62.66,,,,,,
Humana,ExceptCPT,0065U,Syfls tst nontreponemal antb,Lab Services,Per Unit,$36.18 ,OP,36.18,36.18,,,,,,
Humana,ExceptCPT,0066U,Pamg-1 ia cervico-vag fluid,Lab Services,Per Unit,$30.58 ,OP,30.58,30.58,,,,,,
Humana,ExceptCPT,0068U,Candida species pnl amp prb,Lab Services,Per Unit,$285.26 ,OP,285.26,285.26,,,,,,
Humana,ExceptCPT,0069U,Onc clrct microrna mir-31-3p,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
Humana,ExceptCPT,0070U,Cyp2d6 gen com&slct rar vrnt,Lab Services,Per Unit,"$1,352.74 ",OP,"1,352.74","1,352.74",,,,,,
Humana,ExceptCPT,0071U,Cyp2d6 full gene sequence,Lab Services,Per Unit,$602.70 ,OP,602.7,602.7,,,,,,
Humana,ExceptCPT,0072U,Cyp2d6 gen cyp2d6-2d7 hybrid,Lab Services,Per Unit,$901.82 ,OP,901.82,901.82,,,,,,
Humana,ExceptCPT,0073U,Cyp2d6 gen cyp2d7-2d6 hybrid,Lab Services,Per Unit,$901.82 ,OP,901.82,901.82,,,,,,
Humana,ExceptCPT,0074U,Cyp2d6 nonduplicated gene,Lab Services,Per Unit,$901.82 ,OP,901.82,901.82,,,,,,
Humana,ExceptCPT,0075T,Perq stent/chest vert art,Medicare Fee Schedule 005-609,Per Unit,"$3,750.45 ",OP,"3,750.45","3,750.45",,,,,,
Humana,ExceptCPT,0075U,Cyp2d6 5' gene dup/mlt,Lab Services,Per Unit,$901.82 ,OP,901.82,901.82,,,,,,
Humana,ExceptCPT,0076T,S&i stent/chest vert art,Medicare Fee Schedule 005-609,Per Unit,"$3,229.00 ",OP,"3,229.00","3,229.00",,,,,,
Humana,ExceptCPT,0076U,Cyp2d6 3' gene dup/mlt,Lab Services,Per Unit,$901.82 ,OP,901.82,901.82,,,,,,
Humana,ExceptCPT,0078U,Pain mgt opi use gnotyp pnl,Lab Services,Per Unit,$901.82 ,OP,901.82,901.82,,,,,,
Humana,ExceptCPT,0080U,Onc lng 5 clin rsk factr alg,Lab Services,Per Unit,"$7,040.00 ",OP,"7,040.00","7,040.00",,,,,,
Humana,ExceptCPT,0082U,Rx test def 90+ rx/sbsts ur,Lab Services,Per Unit,$493.84 ,OP,493.84,493.84,,,,,,
Humana,ExceptCPT,0084U,Rbc dna gnotyp 10 bld groups,Lab Services,Per Unit,"$1,440.00 ",OP,"1,440.00","1,440.00",,,,,,
Humana,ExceptCPT,0089U,Onc mlnma prame & linc00518,Lab Services,Per Unit,"$1,520.00 ",OP,"1,520.00","1,520.00",,,,,,
Humana,ExceptCPT,0090U,Onc cutan mlnma mrna 23 gene,Lab Services,Per Unit,"$3,510.00 ",OP,"3,510.00","3,510.00",,,,,,
Humana,ExceptCPT,0093U,Rx mntr 65 com drugs urine,Lab Services,Per Unit,$124.28 ,OP,124.28,124.28,,,,,,
Humana,ExceptCPT,0096U,Hpv hi risk types male urine,Lab Services,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Humana,ExceptCPT,0101U,Hered colon ca do 15 genes,Lab Services,Per Unit,"$2,339.60 ",OP,"2,339.60","2,339.60",,,,,,
Humana,ExceptCPT,0102U,Hered brst ca rltd do 17 gen,Lab Services,Per Unit,"$2,235.96 ",OP,"2,235.96","2,235.96",,,,,,
Humana,ExceptCPT,0103U,Hered ova ca pnl 24 genes,Lab Services,Per Unit,"$2,235.96 ",OP,"2,235.96","2,235.96",,,,,,
Humana,ExceptCPT,0105U,Neph ckd mult eclia tum nec,Lab Services,Per Unit,"$1,900.00 ",OP,"1,900.00","1,900.00",,,,,,
Humana,ExceptCPT,0107U,C diff tox ag detcj ia stool,Lab Services,Per Unit,$32.00 ,OP,32,32,,,,,,
Humana,ExceptCPT,0109U,Id aspergillus dna 4 species,Lab Services,Per Unit,$285.26 ,OP,285.26,285.26,,,,,,
Humana,ExceptCPT,0110U,Rx mntr 1+oral onc rx&sbsts,Lab Services,Per Unit,$54.22 ,OP,54.22,54.22,,,,,,
Humana,ExceptCPT,0111U,Onc colon ca kras&nras alys,Lab Services,Per Unit,"$1,364.58 ",OP,"1,364.58","1,364.58",,,,,,
Humana,ExceptCPT,0113U,Onc prst8 pca3&tmprss2-erg,Lab Services,Per Unit,"$1,520.00 ",OP,"1,520.00","1,520.00",,,,,,
Humana,ExceptCPT,0116U,Rx mntr nzm ia 35+oral flu,Lab Services,Per Unit,$493.84 ,OP,493.84,493.84,,,,,,
Humana,ExceptCPT,0120U,Onc b cll lymphm mrna 58 gen,Lab Services,Per Unit,"$5,020.42 ",OP,"5,020.42","5,020.42",,,,,,
Humana,ExceptCPT,0129U,Hered brst ca rltd do panel,Lab Services,Per Unit,"$2,235.96 ",OP,"2,235.96","2,235.96",,,,,,
Humana,ExceptCPT,0130U,Hered colon ca do mrna pnl,Lab Services,Per Unit,"$1,169.80 ",OP,"1,169.80","1,169.80",,,,,,
Humana,ExceptCPT,0200T,Perq sacral augmt unilat inj,Medicare Fee Schedule 005-609,Per Unit,"$4,935.78 ",OP,"4,935.78","4,935.78",,,,,,
Humana,ExceptCPT,0201T,Perq sacral augmt bilat inj,Medicare Fee Schedule 005-609,Per Unit,"$4,935.78 ",OP,"4,935.78","4,935.78",,,,,,
Humana,ExceptCPT,0202T,Post vert arthrplst 1 lumbar,Medicare Fee Schedule 005-609,Per Unit,"$6,103.76 ",OP,"6,103.76","6,103.76",,,,,,
Humana,ExceptCPT,0208T,Audiometry air only,Medicare Fee Schedule 005-609,Per Unit,$84.23 ,OP,84.23,84.23,,,,,,
Humana,ExceptCPT,0209T,Audiometry air & bone,Medicare Fee Schedule 005-609,Per Unit,$102.14 ,OP,102.14,102.14,,,,,,
Humana,ExceptCPT,0210T,Speech audiometry threshold,Medicare Fee Schedule 005-609,Per Unit,$84.62 ,OP,84.62,84.62,,,,,,
Humana,ExceptCPT,0212T,Compre audiometry evaluation,Medicare Fee Schedule 005-609,Per Unit,$107.91 ,OP,107.91,107.91,,,,,,
Humana,ExceptRevenueCode,360,Operating Room Services,Outpatient Surgery,Straight Discount,63.80%,OP,"10,316.98","10,316.98",,,,,,
Humana,ExceptRevenueCode,361,Operating Room Services: Minor surgery,Outpatient Surgery,Straight Discount,63.80%,OP,"10,316.98","10,316.98",,,,,,
Humana,ExceptRevenueCode,362,"Operating Room Services: Organ trnsplnt, not kidney",Outpatient Surgery,Straight Discount,63.80%,OP,,,,,,,,
Humana,ExceptRevenueCode,367,Operating Room Services: Kidney transplant,Outpatient Surgery,Straight Discount,63.80%,OP,,,,,,,,
Humana,ExceptRevenueCode,369,Operating Room Services: Other operating room services,Outpatient Surgery,Straight Discount,63.80%,OP,,,,,,,,
Humana,ExceptRevenueCode,401,Other Imaging Services: Diagnostic mammography,Radiology,Per Unit,$218.00 ,OP,218,218,,,,,,
Humana,ExceptRevenueCode,403,Other Imaging Services: Screening mammography,Radiology,Per Unit,$218.00 ,OP,218,218,,,,,,
Humana,ExceptRevenueCode,450,Emergency Room,ER,Straight Discount,63.80%,OP,"5,158.50","5,158.50",,,,,,
Humana,ExceptRevenueCode,451,Emergency Room: EM/EMTALA,ER,Straight Discount,63.80%,OP,,,,,,,,
Humana,ExceptRevenueCode,452,Emergency Room: ER/ Beyond EMTALA,ER,Straight Discount,63.80%,OP,,,,,,,,
Humana,RevenueCode,456,Emergency Room: Urgent care,ER,Straight Discount,63.80%,OP,,,,,,,,
Humana,ExceptRevenueCode,459,Emergency Room: Other emergency room,ER,Straight Discount,63.80%,OP,,,,,,,,
Humana,ExceptCPT,0470T,Oct skn img acquisj i&r 1st,Medicare Fee Schedule 005-609,Per Unit,$112.53 ,OP,112.53,112.53,,,,,,
Humana,ExceptCPT,0471T,Oct skn img acquisj i&r addl,Medicare Fee Schedule 005-609,Per Unit,$38.75 ,OP,38.75,38.75,,,,,,
Humana,ExceptCPT,0475T,Rec ftl car sgl 3 ch i&r,Medicare Fee Schedule 005-609,Per Unit,$348.12 ,OP,348.12,348.12,,,,,,
Humana,ExceptCPT,0476T,Rec ftl car sgl elec tr data,Medicare Fee Schedule 005-609,Per Unit,$134.23 ,OP,134.23,134.23,,,,,,
Humana,ExceptCPT,0477T,Rec ftl car sgl xrtj alys,Medicare Fee Schedule 005-609,Per Unit,$134.23 ,OP,134.23,134.23,,,,,,
Humana,ExceptCPT,0478T,Rec ftl car 3 ch rev i&r,Medicare Fee Schedule 005-609,Per Unit,$155.71 ,OP,155.71,155.71,,,,,,
Humana,ExceptRevenueCode,481,Cardiology: Cardiac catheter lab,Outpatient Surgery,Straight Discount,63.80%,OP,"2,420.00","24,581.68",,,,,,
Humana,ExceptCPT,0486T,Oct mid ear i&r bilateral,Medicare Fee Schedule 005-609,Per Unit,$112.53 ,OP,112.53,112.53,,,,,,
Humana,ExceptCPT,0487T,Trvg biomchn mapg w/reprt,Medicare Fee Schedule 005-609,Per Unit,$312.79 ,OP,312.79,312.79,,,,,,
Humana,ExceptRevenueCode,490,Ambulatory Surgery,Outpatient Surgery,Straight Discount,63.80%,OP,"10,316.98","10,316.98",,,,,,
Humana,ExceptCPT,0497T,Xtrnl pt act ecg in-off conn,Medicare Fee Schedule 005-609,Per Unit,$68.20 ,OP,68.2,68.2,,,,,,
Humana,ExceptRevenueCode,499,Ambulatory Surgery: Other ambulatory surgical care,Outpatient Surgery,Straight Discount,63.80%,OP,,,,,,,,
Humana,ExceptCPT,0508T,Pls echo us b1 dns meas tib,Medicare Fee Schedule 005-609,Per Unit,$56.38 ,OP,56.38,56.38,,,,,,
Humana,ExceptCPT,0509T,Pattern erg w/i&r,Medicare Fee Schedule 005-609,Per Unit,$143.80 ,OP,143.8,143.8,,,,,,
Humana,ExceptCPT,0521T,Interrog dev eval wcs ip,Medicare Fee Schedule 005-609,Per Unit,$74.80 ,OP,74.8,74.8,,,,,,
Humana,ExceptCPT,0522T,Prgrmg dev eval wcs ip,Medicare Fee Schedule 005-609,Per Unit,$76.70 ,OP,76.7,76.7,,,,,,
Humana,ExceptRevenueCode,760,Treatment/Observation Room,Observation,Straight Discount,63.80%,OP,"2,420.00","3,464.00",,,,,,
Humana,ExceptRevenueCode,761,Treatment/Observation Room: Treatment room,Observation,Straight Discount,63.80%,OP,,,,,,,,
Humana,ExceptRevenueCode,762,Treatment/Observation Room: Observation room,Observation,Straight Discount,63.80%,OP,"2,420.00","10,316.98",,,,,,
Humana,ExceptCPT,20697,Comp ext fixate strut change,Medicare Fee Schedule 005-609,Per Unit,"$5,358.51 ",OP,"5,358.51","5,358.51",,,,,,
Humana,ExceptCPT,36415,Routine venipuncture,Medicare Fee Schedule 005-609,Per Unit,$8.25 ,OP,8.25,8.25,,,,,,
Humana,ExceptCPT,36416,Capillary blood draw,Medicare Fee Schedule 005-609,Per Unit,$7.87 ,OP,7.87,7.87,,,,,,
Humana,ExceptCPT,36591,Draw blood off venous device,Medicare Fee Schedule 005-609,Per Unit,$67.65 ,OP,67.65,67.65,,,,,,
Humana,ExceptCPT,36592,Collect blood from picc,Medicare Fee Schedule 005-609,Per Unit,$76.40 ,OP,76.4,76.4,,,,,,
Humana,ExceptCPT,36593,Declot vascular device,Medicare Fee Schedule 005-609,Per Unit,$84.54 ,OP,84.54,84.54,,,,,,
Humana,ExceptCPT,38208,Thaw preserved stem cells,Medicare Fee Schedule 005-609,Per Unit,$78.65 ,OP,78.65,78.65,,,,,,
Humana,ExceptCPT,38209,Wash harvest stem cells,Medicare Fee Schedule 005-609,Per Unit,$33.17 ,OP,33.17,33.17,,,,,,
Humana,ExceptCPT,51725,Simple cystometrogram,Medicare Fee Schedule 005-609,Per Unit,$394.32 ,OP,394.32,394.32,,,,,,
Humana,ExceptCPT,51726,Complex cystometrogram,Medicare Fee Schedule 005-609,Per Unit,$574.59 ,OP,574.59,574.59,,,,,,
Humana,ExceptCPT,51727,Cystometrogram w/up,Medicare Fee Schedule 005-609,Per Unit,$680.49 ,OP,680.49,680.49,,,,,,
Humana,ExceptCPT,51728,Cystometrogram w/vp,Medicare Fee Schedule 005-609,Per Unit,$695.37 ,OP,695.37,695.37,,,,,,
Humana,ExceptCPT,51729,Cystometrogram w/vp&up,Medicare Fee Schedule 005-609,Per Unit,$696.25 ,OP,696.25,696.25,,,,,,
Humana,ExceptCPT,51736,Urine flow measurement,Medicare Fee Schedule 005-609,Per Unit,$13.39 ,OP,13.39,13.39,,,,,,
Humana,ExceptCPT,51741,Electro-uroflowmetry first,Medicare Fee Schedule 005-609,Per Unit,$14.25 ,OP,14.25,14.25,,,,,,
Humana,ExceptCPT,51784,Anal/urinary muscle study,Medicare Fee Schedule 005-609,Per Unit,$74.64 ,OP,74.64,74.64,,,,,,
Humana,ExceptCPT,51785,Anal/urinary muscle study,Medicare Fee Schedule 005-609,Per Unit,$887.01 ,OP,887.01,887.01,,,,,,
Humana,ExceptCPT,51792,Urinary reflex study,Medicare Fee Schedule 005-609,Per Unit,$556.22 ,OP,556.22,556.22,,,,,,
Humana,ExceptCPT,51797,Intraabdominal pressure test,Medicare Fee Schedule 005-609,Per Unit,$383.30 ,OP,383.3,383.3,,,,,,
Humana,ExceptCPT,51798,Us urine capacity measure,Medicare Fee Schedule 005-609,Per Unit,$26.51 ,OP,26.51,26.51,,,,,,
Humana,ExceptCPT,54240,Penis study,Medicare Fee Schedule 005-609,Per Unit,$100.02 ,OP,100.02,100.02,,,,,,
Humana,ExceptCPT,54250,Penis study,Medicare Fee Schedule 005-609,Per Unit,$34.38 ,OP,34.38,34.38,,,,,,
Humana,ExceptCPT,59020,Fetal contract stress test,Medicare Fee Schedule 005-609,Per Unit,$86.90 ,OP,86.9,86.9,,,,,,
Humana,ExceptCPT,59025,Fetal non-stress test,Medicare Fee Schedule 005-609,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
Humana,ExceptCPT,62252,Csf shunt reprogram,Medicare Fee Schedule 005-609,Per Unit,$93.01 ,OP,93.01,93.01,,,,,,
Humana,ExceptCPT,70015,Contrast x-ray of brain,Medicare Fee Schedule 005-609,Per Unit,$289.05 ,OP,289.05,289.05,,,,,,
Humana,ExceptCPT,70030,X-ray eye for foreign body,Medicare Fee Schedule 005-609,Per Unit,$59.76 ,OP,59.76,59.76,,,,,,
Humana,ExceptCPT,70100,X-ray exam of jaw <4views,Medicare Fee Schedule 005-609,Per Unit,$75.52 ,OP,75.52,75.52,,,,,,
Humana,ExceptCPT,70110,X-ray exam of jaw 4/> views,Medicare Fee Schedule 005-609,Per Unit,$80.77 ,OP,80.77,80.77,,,,,,
Humana,ExceptCPT,70120,X-ray exam of mastoids,Medicare Fee Schedule 005-609,Per Unit,$74.64 ,OP,74.64,74.64,,,,,,
Humana,ExceptCPT,70130,X-ray exam of mastoids,Medicare Fee Schedule 005-609,Per Unit,$118.42 ,OP,118.42,118.42,,,,,,
Humana,ExceptCPT,70134,X-ray exam of middle ear,Medicare Fee Schedule 005-609,Per Unit,$108.76 ,OP,108.76,108.76,,,,,,
Humana,ExceptCPT,70140,X-ray exam of facial bones,Medicare Fee Schedule 005-609,Per Unit,$57.12 ,OP,57.12,57.12,,,,,,
Humana,ExceptCPT,70150,X-ray exam of facial bones,Medicare Fee Schedule 005-609,Per Unit,$88.63 ,OP,88.63,88.63,,,,,,
Humana,ExceptCPT,70160,X-ray exam of nasal bones,Medicare Fee Schedule 005-609,Per Unit,$75.52 ,OP,75.52,75.52,,,,,,
Humana,ExceptCPT,70170,X-ray exam of tear duct,Medicare Fee Schedule 005-609,Per Unit,$103.90 ,OP,103.9,103.9,,,,,,
Humana,ExceptCPT,70190,X-ray exam of eye sockets,Medicare Fee Schedule 005-609,Per Unit,$71.14 ,OP,71.14,71.14,,,,,,
Humana,ExceptCPT,70200,X-ray exam of eye sockets,Medicare Fee Schedule 005-609,Per Unit,$88.66 ,OP,88.66,88.66,,,,,,
Humana,ExceptCPT,70210,X-ray exam of sinuses,Medicare Fee Schedule 005-609,Per Unit,$60.64 ,OP,60.64,60.64,,,,,,
Humana,ExceptCPT,70220,X-ray exam of sinuses,Medicare Fee Schedule 005-609,Per Unit,$69.41 ,OP,69.41,69.41,,,,,,
Humana,ExceptCPT,70240,X-ray exam pituitary saddle,Medicare Fee Schedule 005-609,Per Unit,$61.52 ,OP,61.52,61.52,,,,,,
Humana,ExceptCPT,70250,X-ray exam of skull,Medicare Fee Schedule 005-609,Per Unit,$68.53 ,OP,68.53,68.53,,,,,,
Humana,ExceptCPT,70260,X-ray exam of skull,Medicare Fee Schedule 005-609,Per Unit,$79.92 ,OP,79.92,79.92,,,,,,
Humana,ExceptCPT,70300,X-ray exam of teeth,Medicare Fee Schedule 005-609,Per Unit,$20.41 ,OP,20.41,20.41,,,,,,
Humana,ExceptCPT,70310,X-ray exam of teeth,Medicare Fee Schedule 005-609,Per Unit,$79.89 ,OP,79.89,79.89,,,,,,
Humana,ExceptCPT,70320,Full mouth x-ray of teeth,Medicare Fee Schedule 005-609,Per Unit,$115.78 ,OP,115.78,115.78,,,,,,
Humana,ExceptCPT,70328,X-ray exam of jaw joint,Medicare Fee Schedule 005-609,Per Unit,$65.89 ,OP,65.89,65.89,,,,,,
Humana,ExceptCPT,70330,X-ray exam of jaw joints,Medicare Fee Schedule 005-609,Per Unit,$107.03 ,OP,107.03,107.03,,,,,,
Humana,ExceptCPT,70332,X-ray exam of jaw joint,Medicare Fee Schedule 005-609,Per Unit,$152.52 ,OP,152.52,152.52,,,,,,
Humana,ExceptCPT,70336,Magnetic image jaw joint,Medicare Fee Schedule 005-609,Per Unit,$591.22 ,OP,591.22,"1,200.00",,,,,,
Humana,ExceptCPT,70350,X-ray head for orthodontia,Medicare Fee Schedule 005-609,Per Unit,$20.41 ,OP,20.41,20.41,,,,,,
Humana,ExceptCPT,70355,Panoramic x-ray of jaws,Medicare Fee Schedule 005-609,Per Unit,$21.26 ,OP,21.26,21.26,,,,,,
Humana,ExceptCPT,70360,X-ray exam of neck,Medicare Fee Schedule 005-609,Per Unit,$58.03 ,OP,58.03,58.03,,,,,,
Humana,ExceptCPT,70370,Throat x-ray & fluoroscopy,Medicare Fee Schedule 005-609,Per Unit,$210.29 ,OP,210.29,210.29,,,,,,
Humana,ExceptCPT,70371,Speech evaluation complex,Medicare Fee Schedule 005-609,Per Unit,$176.14 ,OP,176.14,176.14,,,,,,
Humana,ExceptCPT,70380,X-ray exam of salivary gland,Medicare Fee Schedule 005-609,Per Unit,$75.54 ,OP,75.54,75.54,,,,,,
Humana,ExceptCPT,70390,X-ray exam of salivary duct,Medicare Fee Schedule 005-609,Per Unit,$260.18 ,OP,260.18,260.18,,,,,,
Humana,ExceptCPT,70450,Ct head/brain w/o dye,Medicare Fee Schedule 005-609,Per Unit,$186.67 ,OP,186.67,600,,,,,,
Humana,ExceptCPT,70460,Ct head/brain w/dye,Medicare Fee Schedule 005-609,Per Unit,$270.66 ,OP,270.66,600,,,,,,
Humana,ExceptCPT,70470,Ct head/brain w/o & w/dye,Medicare Fee Schedule 005-609,Per Unit,$325.82 ,OP,325.82,600,,,,,,
Humana,ExceptCPT,70480,Ct orbit/ear/fossa w/o dye,Medicare Fee Schedule 005-609,Per Unit,$279.43 ,OP,279.43,600,,,,,,
Humana,ExceptCPT,70481,Ct orbit/ear/fossa w/dye,Medicare Fee Schedule 005-609,Per Unit,$364.29 ,OP,364.29,600,,,,,,
Humana,ExceptCPT,70482,Ct orbit/ear/fossa w/o&w/dye,Medicare Fee Schedule 005-609,Per Unit,$437.20 ,OP,437.2,600,,,,,,
Humana,ExceptCPT,70486,Ct maxillofacial w/o dye,Medicare Fee Schedule 005-609,Per Unit,$247.94 ,OP,247.94,600,,,,,,
Humana,ExceptCPT,70487,Ct maxillofacial w/dye,Medicare Fee Schedule 005-609,Per Unit,$282.92 ,OP,282.92,600,,,,,,
Humana,ExceptCPT,70488,Ct maxillofacial w/o & w/dye,Medicare Fee Schedule 005-609,Per Unit,$359.95 ,OP,359.95,600,,,,,,
Humana,ExceptCPT,70490,Ct soft tissue neck w/o dye,Medicare Fee Schedule 005-609,Per Unit,$256.69 ,OP,256.69,600,,,,,,
Humana,ExceptCPT,70491,Ct soft tissue neck w/dye,Medicare Fee Schedule 005-609,Per Unit,$343.28 ,OP,343.28,600,,,,,,
Humana,ExceptCPT,70492,Ct sft tsue nck w/o & w/dye,Medicare Fee Schedule 005-609,Per Unit,$420.31 ,OP,420.31,600,,,,,,
Humana,ExceptCPT,70496,Ct angiography head,Medicare Fee Schedule 005-609,Per Unit,$543.10 ,OP,543.1,600,,,,,,
Humana,ExceptCPT,70498,Ct angiography neck,Medicare Fee Schedule 005-609,Per Unit,$542.22 ,OP,542.22,600,,,,,,
Humana,ExceptCPT,70540,Mri orbit/face/neck w/o dye,Medicare Fee Schedule 005-609,Per Unit,$487.08 ,OP,487.08,"1,200.00",,,,,,
Humana,ExceptCPT,70542,Mri orbit/face/neck w/dye,Medicare Fee Schedule 005-609,Per Unit,$575.49 ,OP,575.49,"1,200.00",,,,,,
Humana,ExceptCPT,70543,Mri orbt/fac/nck w/o &w/dye,Medicare Fee Schedule 005-609,Per Unit,$711.98 ,OP,711.98,"1,200.00",,,,,,
Humana,ExceptCPT,70544,Mr angiography head w/o dye,Medicare Fee Schedule 005-609,Per Unit,$464.34 ,OP,464.34,"1,200.00",,,,,,
Humana,ExceptCPT,70545,Mr angiography head w/dye,Medicare Fee Schedule 005-609,Per Unit,$496.71 ,OP,496.71,"1,200.00",,,,,,
Humana,ExceptCPT,70546,Mr angiograph head w/o&w/dye,Medicare Fee Schedule 005-609,Per Unit,$753.64 ,OP,753.64,"1,200.00",,,,,,
Humana,ExceptCPT,70547,Mr angiography neck w/o dye,Medicare Fee Schedule 005-609,Per Unit,$466.07 ,OP,466.07,"1,200.00",,,,,,
Humana,ExceptCPT,70548,Mr angiography neck w/dye,Medicare Fee Schedule 005-609,Per Unit,$508.09 ,OP,508.09,"1,200.00",,,,,,
Humana,ExceptCPT,70549,Mr angiograph neck w/o&w/dye,Medicare Fee Schedule 005-609,Per Unit,$758.89 ,OP,758.89,"1,200.00",,,,,,
Humana,ExceptCPT,70551,Mri brain stem w/o dye,Medicare Fee Schedule 005-609,Per Unit,$372.46 ,OP,372.46,"1,200.00",,,,,,
Humana,ExceptCPT,70552,Mri brain stem w/dye,Medicare Fee Schedule 005-609,Per Unit,$550.96 ,OP,550.96,"1,200.00",,,,,,
Humana,ExceptCPT,70553,Mri brain stem w/o & w/dye,Medicare Fee Schedule 005-609,Per Unit,$627.11 ,OP,627.11,"1,200.00",,,,,,
Humana,ExceptCPT,70554,Fmri brain by tech,Medicare Fee Schedule 005-609,Per Unit,$823.65 ,OP,823.65,"1,200.00",,,,,,
Humana,ExceptCPT,70555,Fmri brain by phys/psych,Medicare Fee Schedule 005-609,Per Unit,"$1,126.21 ",OP,"1,126.21","1,200.00",,,,,,
Humana,ExceptCPT,70557,Mri brain w/o dye,Medicare Fee Schedule 005-609,Per Unit,$844.66 ,OP,844.66,"1,200.00",,,,,,
Humana,ExceptCPT,70558,Mri brain w/dye,Medicare Fee Schedule 005-609,Per Unit,$448.31 ,OP,448.31,"1,200.00",,,,,,
Humana,ExceptCPT,70559,Mri brain w/o & w/dye,Medicare Fee Schedule 005-609,Per Unit,$448.33 ,OP,448.33,"1,200.00",,,,,,
Humana,ExceptCPT,71045,X-ray exam chest 1 view,Medicare Fee Schedule 005-609,Per Unit,$43.15 ,OP,43.15,43.15,,,,,,
Humana,ExceptCPT,71046,X-ray exam chest 2 views,Medicare Fee Schedule 005-609,Per Unit,$58.91 ,OP,58.91,58.91,,,,,,
Humana,ExceptCPT,71047,X-ray exam chest 3 views,Medicare Fee Schedule 005-609,Per Unit,$74.66 ,OP,74.66,74.66,,,,,,
Humana,ExceptCPT,71048,X-ray exam chest 4+ views,Medicare Fee Schedule 005-609,Per Unit,$77.25 ,OP,77.25,77.25,,,,,,
Humana,ExceptCPT,71100,X-ray exam ribs uni 2 views,Medicare Fee Schedule 005-609,Per Unit,$65.89 ,OP,65.89,65.89,,,,,,
Humana,ExceptCPT,71101,X-ray exam unilat ribs/chest,Medicare Fee Schedule 005-609,Per Unit,$74.64 ,OP,74.64,74.64,,,,,,
Humana,ExceptCPT,71110,X-ray exam ribs bil 3 views,Medicare Fee Schedule 005-609,Per Unit,$76.40 ,OP,76.4,76.4,,,,,,
Humana,ExceptCPT,71111,X-ray exam ribs/chest4/> vws,Medicare Fee Schedule 005-609,Per Unit,$94.77 ,OP,94.77,94.77,,,,,,
Humana,ExceptCPT,71120,X-ray exam breastbone 2/>vws,Medicare Fee Schedule 005-609,Per Unit,$61.52 ,OP,61.52,61.52,,,,,,
Humana,ExceptCPT,71130,X-ray strenoclavic jt 3/>vws,Medicare Fee Schedule 005-609,Per Unit,$79.04 ,OP,79.04,79.04,,,,,,
Humana,ExceptCPT,71250,Ct thorax dx c-,Medicare Fee Schedule 005-609,Per Unit,$233.04 ,OP,233.04,600,,,,,,
Humana,ExceptCPT,71260,Ct thorax dx c+,Medicare Fee Schedule 005-609,Per Unit,$319.69 ,OP,319.69,600,,,,,,
Humana,ExceptCPT,71270,Ct thorax dx c-/c+,Medicare Fee Schedule 005-609,Per Unit,$395.81 ,OP,395.81,600,,,,,,
Humana,ExceptCPT,71271,Ct thorax lung cancer scr c-,Medicare Fee Schedule 005-609,Per Unit,$245.27 ,OP,245.27,245.27,,,,,,
Humana,ExceptCPT,71275,Ct angiography chest,Medicare Fee Schedule 005-609,Per Unit,$550.11 ,OP,550.11,600,,,,,,
Humana,ExceptCPT,71550,Mri chest w/o dye,Medicare Fee Schedule 005-609,Per Unit,$812.65 ,OP,812.65,"1,200.00",,,,,,
Humana,ExceptCPT,71551,Mri chest w/dye,Medicare Fee Schedule 005-609,Per Unit,$881.40 ,OP,881.4,"1,200.00",,,,,,
Humana,ExceptCPT,71552,Mri chest w/o & w/dye,Medicare Fee Schedule 005-609,Per Unit,"$1,109.82 ",OP,"1,109.82","1,200.00",,,,,,
Humana,ExceptCPT,71555,Mri angio chest w or w/o dye,Medicare Fee Schedule 005-609,Per Unit,$743.13 ,OP,743.13,"1,200.00",,,,,,
Humana,ExceptCPT,72020,X-ray exam of spine 1 view,Medicare Fee Schedule 005-609,Per Unit,$43.15 ,OP,43.15,43.15,,,,,,
Humana,ExceptCPT,72040,X-ray exam neck spine 2-3 vw,Medicare Fee Schedule 005-609,Per Unit,$72.90 ,OP,72.9,72.9,,,,,,
Humana,ExceptCPT,72050,X-ray exam neck spine 4/5vws,Medicare Fee Schedule 005-609,Per Unit,$100.90 ,OP,100.9,100.9,,,,,,
Humana,ExceptCPT,72052,X-ray exam neck spine 6/>vws,Medicare Fee Schedule 005-609,Per Unit,$121.91 ,OP,121.91,121.91,,,,,,
Humana,ExceptCPT,72070,X-ray exam thorac spine 2vws,Medicare Fee Schedule 005-609,Per Unit,$58.00 ,OP,58,58,,,,,,
Humana,ExceptCPT,72072,X-ray exam thorac spine 3vws,Medicare Fee Schedule 005-609,Per Unit,$72.02 ,OP,72.02,72.02,,,,,,
Humana,ExceptCPT,72074,X-ray exam thorac spine4/>vw,Medicare Fee Schedule 005-609,Per Unit,$83.41 ,OP,83.41,83.41,,,,,,
Humana,ExceptCPT,72080,X-ray exam thoracolmb 2/> vw,Medicare Fee Schedule 005-609,Per Unit,$62.37 ,OP,62.37,62.37,,,,,,
Humana,ExceptCPT,72081,X-ray exam entire spi 1 vw,Medicare Fee Schedule 005-609,Per Unit,$75.52 ,OP,75.52,75.52,,,,,,
Humana,ExceptCPT,72082,X-ray exam entire spi 2/3 vw,Medicare Fee Schedule 005-609,Per Unit,$140.28 ,OP,140.28,140.28,,,,,,
Humana,ExceptCPT,72083,X-ray exam entire spi 4/5 vw,Medicare Fee Schedule 005-609,Per Unit,$157.77 ,OP,157.77,157.77,,,,,,
Humana,ExceptCPT,72084,X-ray exam entire spi 6/> vw,Medicare Fee Schedule 005-609,Per Unit,$198.06 ,OP,198.06,198.06,,,,,,
Humana,ExceptCPT,72100,X-ray exam l-s spine 2/3 vws,Medicare Fee Schedule 005-609,Per Unit,$73.78 ,OP,73.78,73.78,,,,,,
Humana,ExceptCPT,72110,X-ray exam l-2 spine 4/>vws,Medicare Fee Schedule 005-609,Per Unit,$97.38 ,OP,97.38,97.38,,,,,,
Humana,ExceptCPT,72114,X-ray exam l-s spine bending,Medicare Fee Schedule 005-609,Per Unit,$121.03 ,OP,121.03,121.03,,,,,,
Humana,ExceptCPT,72120,X-ray bend only l-s spine,Medicare Fee Schedule 005-609,Per Unit,$76.40 ,OP,76.4,76.4,,,,,,
Humana,ExceptCPT,72125,Ct neck spine w/o dye,Medicare Fee Schedule 005-609,Per Unit,$235.68 ,OP,235.68,600,,,,,,
Humana,ExceptCPT,72126,Ct neck spine w/dye,Medicare Fee Schedule 005-609,Per Unit,$317.93 ,OP,317.93,600,,,,,,
Humana,ExceptCPT,72127,Ct neck spine w/o & w/dye,Medicare Fee Schedule 005-609,Per Unit,$394.05 ,OP,394.05,600,,,,,,
Humana,ExceptCPT,72128,Ct chest spine w/o dye,Medicare Fee Schedule 005-609,Per Unit,$234.80 ,OP,234.8,600,,,,,,
Humana,ExceptCPT,72129,Ct chest spine w/dye,Medicare Fee Schedule 005-609,Per Unit,$320.57 ,OP,320.57,600,,,,,,
Humana,ExceptCPT,72130,Ct chest spine w/o & w/dye,Medicare Fee Schedule 005-609,Per Unit,$396.69 ,OP,396.69,600,,,,,,
Humana,ExceptCPT,72131,Ct lumbar spine w/o dye,Medicare Fee Schedule 005-609,Per Unit,$233.92 ,OP,233.92,600,,,,,,
Humana,ExceptCPT,72132,Ct lumbar spine w/dye,Medicare Fee Schedule 005-609,Per Unit,$317.93 ,OP,317.93,600,,,,,,
Humana,ExceptCPT,72133,Ct lumbar spine w/o & w/dye,Medicare Fee Schedule 005-609,Per Unit,$394.05 ,OP,394.05,600,,,,,,
Humana,ExceptCPT,72141,Mri neck spine w/o dye,Medicare Fee Schedule 005-609,Per Unit,$359.07 ,OP,359.07,"1,200.00",,,,,,
Humana,ExceptCPT,72142,Mri neck spine w/dye,Medicare Fee Schedule 005-609,Per Unit,$568.45 ,OP,568.45,"1,200.00",,,,,,
Humana,ExceptCPT,72146,Mri chest spine w/o dye,Medicare Fee Schedule 005-609,Per Unit,$359.07 ,OP,359.07,"1,200.00",,,,,,
Humana,ExceptCPT,72147,Mri chest spine w/dye,Medicare Fee Schedule 005-609,Per Unit,$563.20 ,OP,563.2,"1,200.00",,,,,,
Humana,ExceptCPT,72148,Mri lumbar spine w/o dye,Medicare Fee Schedule 005-609,Per Unit,$359.95 ,OP,359.95,"1,200.00",,,,,,
Humana,ExceptCPT,72149,Mri lumbar spine w/dye,Medicare Fee Schedule 005-609,Per Unit,$556.22 ,OP,556.22,"1,200.00",,,,,,
Humana,ExceptCPT,72156,Mri neck spine w/o & w/dye,Medicare Fee Schedule 005-609,Per Unit,$635.86 ,OP,635.86,"1,200.00",,,,,,
Humana,ExceptCPT,72157,Mri chest spine w/o & w/dye,Medicare Fee Schedule 005-609,Per Unit,$637.62 ,OP,637.62,"1,200.00",,,,,,
Humana,ExceptCPT,72158,Mri lumbar spine w/o & w/dye,Medicare Fee Schedule 005-609,Per Unit,$634.12 ,OP,634.12,"1,200.00",,,,,,
Humana,ExceptCPT,72159,Mr angio spine w/o&w/dye,Medicare Fee Schedule 005-609,Per Unit,$773.77 ,OP,773.77,"1,200.00",,,,,,
Humana,ExceptCPT,72170,X-ray exam of pelvis,Medicare Fee Schedule 005-609,Per Unit,$49.28 ,OP,49.28,49.28,,,,,,
Humana,ExceptCPT,72190,X-ray exam of pelvis,Medicare Fee Schedule 005-609,Per Unit,$75.52 ,OP,75.52,75.52,,,,,,
Humana,ExceptCPT,72191,Ct angiograph pelv w/o&w/dye,Medicare Fee Schedule 005-609,Per Unit,$620.10 ,OP,600,620.1,,,,,,
Humana,ExceptCPT,72192,Ct pelvis w/o dye,Medicare Fee Schedule 005-609,Per Unit,$233.04 ,OP,233.04,600,,,,,,
Humana,ExceptCPT,72193,Ct pelvis w/dye,Medicare Fee Schedule 005-609,Per Unit,$493.85 ,OP,493.85,600,,,,,,
Humana,ExceptCPT,72194,Ct pelvis w/o & w/dye,Medicare Fee Schedule 005-609,Per Unit,$559.74 ,OP,559.74,600,,,,,,
Humana,ExceptCPT,72195,Mri pelvis w/o dye,Medicare Fee Schedule 005-609,Per Unit,$482.71 ,OP,482.71,"1,200.00",,,,,,
Humana,ExceptCPT,72196,Mri pelvis w/dye,Medicare Fee Schedule 005-609,Per Unit,$563.20 ,OP,563.2,"1,200.00",,,,,,
Humana,ExceptCPT,72197,Mri pelvis w/o & w/dye,Medicare Fee Schedule 005-609,Per Unit,$705.87 ,OP,705.87,"1,200.00",,,,,,
Humana,ExceptCPT,72198,Mr angio pelvis w/o & w/dye,Medicare Fee Schedule 005-609,Per Unit,$750.15 ,OP,750.15,"1,200.00",,,,,,
Humana,ExceptCPT,72200,X-ray exam si joints,Medicare Fee Schedule 005-609,Per Unit,$63.28 ,OP,63.28,63.28,,,,,,
Humana,ExceptCPT,72202,X-ray exam si joints 3/> vws,Medicare Fee Schedule 005-609,Per Unit,$72.02 ,OP,72.02,72.02,,,,,,
Humana,ExceptCPT,72220,X-ray exam sacrum tailbone,Medicare Fee Schedule 005-609,Per Unit,$60.64 ,OP,60.64,60.64,,,,,,
Humana,ExceptCPT,72240,Myelography neck spine,Medicare Fee Schedule 005-609,Per Unit,$184.06 ,OP,184.06,184.06,,,,,,
Humana,ExceptCPT,72255,Myelography thoracic spine,Medicare Fee Schedule 005-609,Per Unit,$182.30 ,OP,182.3,182.3,,,,,,
Humana,ExceptCPT,72265,Myelography l-s spine,Medicare Fee Schedule 005-609,Per Unit,$176.17 ,OP,176.17,176.17,,,,,,
Humana,ExceptCPT,72270,Myelogphy 2/> spine regions,Medicare Fee Schedule 005-609,Per Unit,$212.91 ,OP,212.91,212.91,,,,,,
Humana,ExceptCPT,72275,Epidurography,Medicare Fee Schedule 005-609,Per Unit,$261.94 ,OP,261.94,261.94,,,,,,
Humana,ExceptCPT,72285,Discography cerv/thor spine,Medicare Fee Schedule 005-609,Per Unit,$177.02 ,OP,177.02,177.02,,,,,,
Humana,ExceptCPT,72295,X-ray of lower spine disk,Medicare Fee Schedule 005-609,Per Unit,$183.15 ,OP,183.15,183.15,,,,,,
Humana,ExceptCPT,73000,X-ray exam of collar bone,Medicare Fee Schedule 005-609,Per Unit,$61.52 ,OP,61.52,61.52,,,,,,
Humana,ExceptCPT,73010,X-ray exam of shoulder blade,Medicare Fee Schedule 005-609,Per Unit,$37.90 ,OP,37.9,37.9,,,,,,
Humana,ExceptCPT,73020,X-ray exam of shoulder,Medicare Fee Schedule 005-609,Per Unit,$36.14 ,OP,36.14,36.14,,,,,,
Humana,ExceptCPT,73030,X-ray exam of shoulder,Medicare Fee Schedule 005-609,Per Unit,$64.13 ,OP,64.13,64.13,,,,,,
Humana,ExceptCPT,73040,Contrast x-ray of shoulder,Medicare Fee Schedule 005-609,Per Unit,$266.31 ,OP,266.31,266.31,,,,,,
Humana,ExceptCPT,73050,X-ray exam of shoulders,Medicare Fee Schedule 005-609,Per Unit,$49.25 ,OP,49.25,49.25,,,,,,
Humana,ExceptCPT,73060,X-ray exam of humerus,Medicare Fee Schedule 005-609,Per Unit,$61.52 ,OP,61.52,61.52,,,,,,
Humana,ExceptCPT,73070,X-ray exam of elbow,Medicare Fee Schedule 005-609,Per Unit,$53.65 ,OP,53.65,53.65,,,,,,
Humana,ExceptCPT,73080,X-ray exam of elbow,Medicare Fee Schedule 005-609,Per Unit,$60.64 ,OP,60.64,60.64,,,,,,
Humana,ExceptCPT,73085,Contrast x-ray of elbow,Medicare Fee Schedule 005-609,Per Unit,$229.54 ,OP,229.54,229.54,,,,,,
Humana,ExceptCPT,73090,X-ray exam of forearm,Medicare Fee Schedule 005-609,Per Unit,$54.53 ,OP,54.53,54.53,,,,,,
Humana,ExceptCPT,73092,X-ray exam of arm infant,Medicare Fee Schedule 005-609,Per Unit,$60.67 ,OP,60.67,60.67,,,,,,
Humana,ExceptCPT,73100,X-ray exam of wrist,Medicare Fee Schedule 005-609,Per Unit,$65.89 ,OP,65.89,65.89,,,,,,
Humana,ExceptCPT,73110,X-ray exam of wrist,Medicare Fee Schedule 005-609,Per Unit,$81.65 ,OP,81.65,81.65,,,,,,
Humana,ExceptCPT,73115,Contrast x-ray of wrist,Medicare Fee Schedule 005-609,Per Unit,$280.31 ,OP,280.31,280.31,,,,,,
Humana,ExceptCPT,73120,X-ray exam of hand,Medicare Fee Schedule 005-609,Per Unit,$58.91 ,OP,58.91,58.91,,,,,,
Humana,ExceptCPT,73130,X-ray exam of hand,Medicare Fee Schedule 005-609,Per Unit,$71.14 ,OP,71.14,71.14,,,,,,
Humana,ExceptCPT,73140,X-ray exam of finger(s),Medicare Fee Schedule 005-609,Per Unit,$78.13 ,OP,78.13,78.13,,,,,,
Humana,ExceptCPT,73200,Ct upper extremity w/o dye,Medicare Fee Schedule 005-609,Per Unit,$331.93 ,OP,331.93,600,,,,,,
Humana,ExceptCPT,73201,Ct upper extremity w/dye,Medicare Fee Schedule 005-609,Per Unit,$423.83 ,OP,423.83,600,,,,,,
Humana,ExceptCPT,73202,Ct uppr extremity w/o&w/dye,Medicare Fee Schedule 005-609,Per Unit,$558.86 ,OP,558.86,600,,,,,,
Humana,ExceptCPT,73206,Ct angio upr extrm w/o&w/dye,Medicare Fee Schedule 005-609,Per Unit,$615.37 ,OP,600,615.37,,,,,,
Humana,ExceptCPT,73218,Mri upper extremity w/o dye,Medicare Fee Schedule 005-609,Per Unit,$721.63 ,OP,721.63,"1,200.00",,,,,,
Humana,ExceptCPT,73219,Mri upper extremity w/dye,Medicare Fee Schedule 005-609,Per Unit,$768.87 ,OP,768.87,"1,200.00",,,,,,
Humana,ExceptCPT,73220,Mri uppr extremity w/o&w/dye,Medicare Fee Schedule 005-609,Per Unit,$936.54 ,OP,936.54,"1,200.00",,,,,,
Humana,ExceptCPT,73221,Mri joint upr extrem w/o dye,Medicare Fee Schedule 005-609,Per Unit,$406.56 ,OP,406.56,"1,200.00",,,,,,
Humana,ExceptCPT,73222,Mri joint upr extrem w/dye,Medicare Fee Schedule 005-609,Per Unit,$716.38 ,OP,716.38,"1,200.00",,,,,,
Humana,ExceptCPT,73223,Mri joint upr extr w/o&w/dye,Medicare Fee Schedule 005-609,Per Unit,$866.91 ,OP,866.91,"1,200.00",,,,,,
Humana,ExceptCPT,73225,Mr angio upr extr w/o&w/dye,Medicare Fee Schedule 005-609,Per Unit,$773.74 ,OP,773.74,"1,200.00",,,,,,
Humana,ExceptCPT,73501,X-ray exam hip uni 1 view,Medicare Fee Schedule 005-609,Per Unit,$58.88 ,OP,58.88,58.88,,,,,,
Humana,ExceptCPT,73502,X-ray exam hip uni 2-3 views,Medicare Fee Schedule 005-609,Per Unit,$91.27 ,OP,91.27,91.27,,,,,,
Humana,ExceptCPT,73503,X-ray exam hip uni 4/> views,Medicare Fee Schedule 005-609,Per Unit,$115.78 ,OP,115.78,115.78,,,,,,
Humana,ExceptCPT,73521,X-ray exam hips bi 2 views,Medicare Fee Schedule 005-609,Per Unit,$77.28 ,OP,77.28,77.28,,,,,,
Humana,ExceptCPT,73522,X-ray exam hips bi 3-4 views,Medicare Fee Schedule 005-609,Per Unit,$100.02 ,OP,100.02,100.02,,,,,,
Humana,ExceptCPT,73523,X-ray exam hips bi 5/> views,Medicare Fee Schedule 005-609,Per Unit,$118.39 ,OP,118.39,118.39,,,,,,
Humana,ExceptCPT,73525,Contrast x-ray of hip,Medicare Fee Schedule 005-609,Per Unit,$271.54 ,OP,271.54,271.54,,,,,,
Humana,ExceptCPT,73551,X-ray exam of femur 1,Medicare Fee Schedule 005-609,Per Unit,$54.53 ,OP,54.53,54.53,,,,,,
Humana,ExceptCPT,73552,X-ray exam of femur 2/>,Medicare Fee Schedule 005-609,Per Unit,$67.65 ,OP,67.65,67.65,,,,,,
Humana,ExceptCPT,73560,X-ray exam of knee 1 or 2,Medicare Fee Schedule 005-609,Per Unit,$66.77 ,OP,66.77,66.77,,,,,,
Humana,ExceptCPT,73562,X-ray exam of knee 3,Medicare Fee Schedule 005-609,Per Unit,$79.89 ,OP,79.89,79.89,,,,,,
Humana,ExceptCPT,73564,X-ray exam knee 4 or more,Medicare Fee Schedule 005-609,Per Unit,$89.54 ,OP,89.54,89.54,,,,,,
Humana,ExceptCPT,73565,X-ray exam of knees,Medicare Fee Schedule 005-609,Per Unit,$82.53 ,OP,82.53,82.53,,,,,,
Humana,ExceptCPT,73580,Contrast x-ray of knee joint,Medicare Fee Schedule 005-609,Per Unit,$303.05 ,OP,303.05,303.05,,,,,,
Humana,ExceptCPT,73590,X-ray exam of lower leg,Medicare Fee Schedule 005-609,Per Unit,$60.67 ,OP,60.67,60.67,,,,,,
Humana,ExceptCPT,73592,X-ray exam of leg infant,Medicare Fee Schedule 005-609,Per Unit,$60.67 ,OP,60.67,60.67,,,,,,
Humana,ExceptCPT,73600,X-ray exam of ankle,Medicare Fee Schedule 005-609,Per Unit,$62.40 ,OP,62.4,62.4,,,,,,
Humana,ExceptCPT,73610,X-ray exam of ankle,Medicare Fee Schedule 005-609,Per Unit,$72.02 ,OP,72.02,72.02,,,,,,
Humana,ExceptCPT,73615,Contrast x-ray of ankle,Medicare Fee Schedule 005-609,Per Unit,$279.43 ,OP,279.43,279.43,,,,,,
Humana,ExceptCPT,73620,X-ray exam of foot,Medicare Fee Schedule 005-609,Per Unit,$53.63 ,OP,53.63,53.63,,,,,,
Humana,ExceptCPT,73630,X-ray exam of foot,Medicare Fee Schedule 005-609,Per Unit,$66.77 ,OP,66.77,66.77,,,,,,
Humana,ExceptCPT,73650,X-ray exam of heel,Medicare Fee Schedule 005-609,Per Unit,$53.65 ,OP,53.65,53.65,,,,,,
Humana,ExceptCPT,73660,X-ray exam of toe(s),Medicare Fee Schedule 005-609,Per Unit,$58.03 ,OP,58.03,58.03,,,,,,
Humana,ExceptCPT,73700,Ct lower extremity w/o dye,Medicare Fee Schedule 005-609,Per Unit,$233.92 ,OP,233.92,600,,,,,,
Humana,ExceptCPT,73701,Ct lower extremity w/dye,Medicare Fee Schedule 005-609,Per Unit,$319.69 ,OP,319.69,600,,,,,,
Humana,ExceptCPT,73702,Ct lwr extremity w/o&w/dye,Medicare Fee Schedule 005-609,Per Unit,$390.56 ,OP,390.56,600,,,,,,
Humana,ExceptCPT,73706,Ct angio lwr extr w/o&w/dye,Medicare Fee Schedule 005-609,Per Unit,$674.03 ,OP,600,674.03,,,,,,
Humana,ExceptCPT,73718,Mri lower extremity w/o dye,Medicare Fee Schedule 005-609,Per Unit,$478.34 ,OP,478.34,"1,200.00",,,,,,
Humana,ExceptCPT,73719,Mri lower extremity w/dye,Medicare Fee Schedule 005-609,Per Unit,$557.98 ,OP,557.98,"1,200.00",,,,,,
Humana,ExceptCPT,73720,Mri lwr extremity w/o&w/dye,Medicare Fee Schedule 005-609,Per Unit,$711.10 ,OP,711.1,"1,200.00",,,,,,
Humana,ExceptCPT,73721,Mri jnt of lwr extre w/o dye,Medicare Fee Schedule 005-609,Per Unit,$405.71 ,OP,405.71,"1,200.00",,,,,,
Humana,ExceptCPT,73722,Mri joint of lwr extr w/dye,Medicare Fee Schedule 005-609,Per Unit,$718.14 ,OP,718.14,"1,200.00",,,,,,
Humana,ExceptCPT,73723,Mri joint lwr extr w/o&w/dye,Medicare Fee Schedule 005-609,Per Unit,$864.24 ,OP,864.24,"1,200.00",,,,,,
Humana,ExceptCPT,73725,Mr ang lwr ext w or w/o dye,Medicare Fee Schedule 005-609,Per Unit,$745.75 ,OP,745.75,"1,200.00",,,,,,
Humana,ExceptCPT,74018,X-ray exam abdomen 1 view,Medicare Fee Schedule 005-609,Per Unit,$53.65 ,OP,53.65,53.65,,,,,,
Humana,ExceptCPT,74019,X-ray exam abdomen 2 views,Medicare Fee Schedule 005-609,Per Unit,$65.89 ,OP,65.89,65.89,,,,,,
Humana,ExceptCPT,74021,X-ray exam abdomen 3+ views,Medicare Fee Schedule 005-609,Per Unit,$76.40 ,OP,76.4,76.4,,,,,,
Humana,ExceptCPT,74022,X-ray exam complete abdomen,Medicare Fee Schedule 005-609,Per Unit,$87.75 ,OP,87.75,87.75,,,,,,
Humana,ExceptCPT,74150,Ct abdomen w/o dye,Medicare Fee Schedule 005-609,Per Unit,$230.42 ,OP,230.42,600,,,,,,
Humana,ExceptCPT,74160,Ct abdomen w/dye,Medicare Fee Schedule 005-609,Per Unit,$492.09 ,OP,492.09,600,,,,,,
Humana,ExceptCPT,74170,Ct abdomen w/o & w/dye,Medicare Fee Schedule 005-609,Per Unit,$557.95 ,OP,557.95,600,,,,,,
Humana,ExceptCPT,74174,Ct angio abd&pelv w/o&w/dye,Medicare Fee Schedule 005-609,Per Unit,$781.63 ,OP,600,781.63,,,,,,
Humana,ExceptCPT,74175,Ct angio abdom w/o & w/dye,Medicare Fee Schedule 005-609,Per Unit,$618.37 ,OP,600,618.37,,,,,,
Humana,ExceptCPT,74176,Ct abd & pelvis w/o contrast,Medicare Fee Schedule 005-609,Per Unit,$288.17 ,OP,288.17,600,,,,,,
Humana,ExceptCPT,74177,Ct abd & pelv w/contrast,Medicare Fee Schedule 005-609,Per Unit,$626.23 ,OP,600,626.23,,,,,,
Humana,ExceptCPT,74178,Ct abd & pelv 1/> regns,Medicare Fee Schedule 005-609,Per Unit,$707.60 ,OP,600,707.6,,,,,,
Humana,ExceptCPT,74181,Mri abdomen w/o dye,Medicare Fee Schedule 005-609,Per Unit,$380.93 ,OP,380.93,"1,200.00",,,,,,
Humana,ExceptCPT,74182,Mri abdomen w/dye,Medicare Fee Schedule 005-609,Per Unit,$664.73 ,OP,664.73,"1,200.00",,,,,,
Humana,ExceptCPT,74183,Mri abdomen w/o & w/dye,Medicare Fee Schedule 005-609,Per Unit,$707.60 ,OP,707.6,"1,200.00",,,,,,
Humana,ExceptCPT,74185,Mri angio abdom w orw/o dye,Medicare Fee Schedule 005-609,Per Unit,$751.00 ,OP,751,"1,200.00",,,,,,
Humana,ExceptCPT,74190,X-ray exam of peritoneum,Medicare Fee Schedule 005-609,Per Unit,$141.43 ,OP,141.43,141.43,,,,,,
Humana,ExceptCPT,74210,X-ray xm phrnx&/crv esoph c+,Medicare Fee Schedule 005-609,Per Unit,$181.42 ,OP,181.42,181.42,,,,,,
Humana,ExceptCPT,74220,X-ray xm esophagus 1cntrst,Medicare Fee Schedule 005-609,Per Unit,$184.03 ,OP,184.03,184.03,,,,,,
Humana,ExceptCPT,74221,X-ray xm esophagus 2cntrst,Medicare Fee Schedule 005-609,Per Unit,$204.16 ,OP,204.16,204.16,,,,,,
Humana,ExceptCPT,74230,X-ray xm swlng funcj c+,Medicare Fee Schedule 005-609,Per Unit,$275.91 ,OP,275.91,275.91,,,,,,
Humana,ExceptCPT,74235,Remove esophagus obstruction,Medicare Fee Schedule 005-609,Per Unit,$283.91 ,OP,283.91,283.91,,,,,,
Humana,ExceptCPT,74240,X-ray xm upr gi trc 1cntrst,Medicare Fee Schedule 005-609,Per Unit,$222.56 ,OP,222.56,222.56,,,,,,
Humana,ExceptCPT,74246,X-ray xm upr gi trc 2cntrst,Medicare Fee Schedule 005-609,Per Unit,$258.42 ,OP,258.42,258.42,,,,,,
Humana,ExceptCPT,74248,X-ray sm int f-thru std,Medicare Fee Schedule 005-609,Per Unit,$131.26 ,OP,131.26,131.26,,,,,,
Humana,ExceptCPT,74250,X-ray xm sm int 1cntrst std,Medicare Fee Schedule 005-609,Per Unit,$222.56 ,OP,222.56,222.56,,,,,,
Humana,ExceptCPT,74251,X-ray xm sm int 2cntrst std,Medicare Fee Schedule 005-609,Per Unit,$899.88 ,OP,899.88,899.88,,,,,,
Humana,ExceptCPT,74261,Ct colonography dx,Medicare Fee Schedule 005-609,Per Unit,$910.64 ,OP,600,910.64,,,,,,
Humana,ExceptCPT,74262,Ct colonography dx w/dye,Medicare Fee Schedule 005-609,Per Unit,"$1,052.40 ",OP,600,"1,052.40",,,,,,
Humana,ExceptCPT,74263,Ct colonography screening,Medicare Fee Schedule 005-609,Per Unit,"$1,658.00 ",OP,600,"1,658.00",,,,,,
Humana,ExceptCPT,74270,X-ray xm colon 1cntrst std,Medicare Fee Schedule 005-609,Per Unit,$280.28 ,OP,280.28,280.28,,,,,,
Humana,ExceptCPT,74280,X-ray xm colon 2cntrst std,Medicare Fee Schedule 005-609,Per Unit,$435.19 ,OP,435.19,435.19,,,,,,
Humana,ExceptCPT,74283,Ther nma rdctj intus/obstrcj,Medicare Fee Schedule 005-609,Per Unit,$418.55 ,OP,418.55,418.55,,,,,,
Humana,ExceptCPT,74290,Contrast x-ray gallbladder,Medicare Fee Schedule 005-609,Per Unit,$185.76 ,OP,185.76,185.76,,,,,,
Humana,ExceptCPT,74300,X-ray bile ducts/pancreas,Medicare Fee Schedule 005-609,Per Unit,$90.04 ,OP,90.04,90.04,,,,,,
Humana,ExceptCPT,74301,X-rays at surgery add-on,Medicare Fee Schedule 005-609,Per Unit,$114.18 ,OP,114.18,114.18,,,,,,
Humana,ExceptCPT,74328,X-ray bile duct endoscopy,Medicare Fee Schedule 005-609,Per Unit,$341.41 ,OP,341.41,341.41,,,,,,
Humana,ExceptCPT,74329,X-ray for pancreas endoscopy,Medicare Fee Schedule 005-609,Per Unit,$341.41 ,OP,341.41,341.41,,,,,,
Humana,ExceptCPT,74330,X-ray bile/panc endoscopy,Medicare Fee Schedule 005-609,Per Unit,$341.41 ,OP,341.41,341.41,,,,,,
Humana,ExceptCPT,74340,X-ray guide for gi tube,Medicare Fee Schedule 005-609,Per Unit,$283.91 ,OP,283.91,283.91,,,,,,
Humana,ExceptCPT,74355,X-ray guide intestinal tube,Medicare Fee Schedule 005-609,Per Unit,$283.91 ,OP,283.91,283.91,,,,,,
Humana,ExceptCPT,74360,X-ray guide gi dilation,Medicare Fee Schedule 005-609,Per Unit,$341.41 ,OP,341.41,341.41,,,,,,
Humana,ExceptCPT,74363,X-ray bile duct dilation,Medicare Fee Schedule 005-609,Per Unit,$283.91 ,OP,283.91,283.91,,,,,,
Humana,ExceptCPT,74400,Urography iv +-kub tomog,Medicare Fee Schedule 005-609,Per Unit,$289.05 ,OP,289.05,289.05,,,,,,
Humana,ExceptCPT,74410,Urography nfs drip&/bolus,Medicare Fee Schedule 005-609,Per Unit,$300.44 ,OP,300.44,300.44,,,,,,
Humana,ExceptCPT,74415,Urography nfs drip&/bls w/nf,Medicare Fee Schedule 005-609,Per Unit,$349.44 ,OP,349.44,349.44,,,,,,
Humana,ExceptCPT,74420,Urography rtrgr +-kub,Medicare Fee Schedule 005-609,Per Unit,$133.27 ,OP,133.27,133.27,,,,,,
Humana,ExceptCPT,74425,Urography antegrade rs&i,Medicare Fee Schedule 005-609,Per Unit,$294.31 ,OP,294.31,294.31,,,,,,
Humana,ExceptCPT,74430,Contrast x-ray bladder,Medicare Fee Schedule 005-609,Per Unit,$65.89 ,OP,65.89,65.89,,,,,,
Humana,ExceptCPT,74440,X-ray male genital tract,Medicare Fee Schedule 005-609,Per Unit,$207.65 ,OP,207.65,207.65,,,,,,
Humana,ExceptCPT,74445,X-ray exam of penis,Medicare Fee Schedule 005-609,Per Unit,$121.99 ,OP,121.99,121.99,,,,,,
Humana,ExceptCPT,74450,X-ray urethra/bladder,Medicare Fee Schedule 005-609,Per Unit,$157.93 ,OP,157.93,157.93,,,,,,
Humana,ExceptCPT,74455,X-ray urethra/bladder,Medicare Fee Schedule 005-609,Per Unit,$231.28 ,OP,231.28,231.28,,,,,,
Humana,ExceptCPT,74470,X-ray exam of kidney lesion,Medicare Fee Schedule 005-609,Per Unit,$135.38 ,OP,135.38,135.38,,,,,,
Humana,ExceptCPT,74485,Dilation urtr/urt rs&i,Medicare Fee Schedule 005-609,Per Unit,$206.77 ,OP,206.77,206.77,,,,,,
Humana,ExceptCPT,74710,X-ray measurement of pelvis,Medicare Fee Schedule 005-609,Per Unit,$60.64 ,OP,60.64,60.64,,,,,,
Humana,ExceptCPT,74712,Mri fetal sngl/1st gestation,Medicare Fee Schedule 005-609,Per Unit,$809.66 ,OP,809.66,"1,200.00",,,,,,
Humana,ExceptCPT,74713,Mri fetal ea addl gestation,Medicare Fee Schedule 005-609,Per Unit,$341.55 ,OP,341.55,"1,200.00",,,,,,
Humana,ExceptCPT,74740,X-ray female genital tract,Medicare Fee Schedule 005-609,Per Unit,$203.28 ,OP,203.28,203.28,,,,,,
Humana,ExceptCPT,74742,X-ray fallopian tube,Medicare Fee Schedule 005-609,Per Unit,$146.91 ,OP,146.91,146.91,,,,,,
Humana,ExceptCPT,74775,X-ray exam of perineum,Medicare Fee Schedule 005-609,Per Unit,$440.88 ,OP,440.88,440.88,,,,,,
Humana,ExceptCPT,75557,Cardiac mri for morph,Medicare Fee Schedule 005-609,Per Unit,$517.47 ,OP,517.47,"1,200.00",,,,,,
Humana,ExceptCPT,75559,Cardiac mri w/stress img,Medicare Fee Schedule 005-609,Per Unit,$764.50 ,OP,764.5,"1,200.00",,,,,,
Humana,ExceptCPT,75561,Cardiac mri for morph w/dye,Medicare Fee Schedule 005-609,Per Unit,$743.49 ,OP,743.49,"1,200.00",,,,,,
Humana,ExceptCPT,75563,Card mri w/stress img & dye,Medicare Fee Schedule 005-609,Per Unit,$885.25 ,OP,885.25,"1,200.00",,,,,,
Humana,ExceptCPT,75565,Card mri veloc flow mapping,Medicare Fee Schedule 005-609,Per Unit,$103.26 ,OP,103.26,"1,200.00",,,,,,
Humana,ExceptCPT,75571,Ct hrt w/o dye w/ca test,Medicare Fee Schedule 005-609,Per Unit,$198.03 ,OP,198.03,600,,,,,,
Humana,ExceptCPT,75572,Ct hrt w/3d image,Medicare Fee Schedule 005-609,Per Unit,$484.44 ,OP,484.44,600,,,,,,
Humana,ExceptCPT,75573,Ct hrt c+ strux cgen hrt ds,Medicare Fee Schedule 005-609,Per Unit,$636.38 ,OP,600,636.38,,,,,,
Humana,ExceptCPT,75574,Ct angio hrt w/3d image,Medicare Fee Schedule 005-609,Per Unit,$726.50 ,OP,600,726.5,,,,,,
Humana,ExceptCPT,75600,Contrast exam thoracic aorta,Medicare Fee Schedule 005-609,Per Unit,$457.08 ,OP,457.08,457.08,,,,,,
Humana,ExceptCPT,75605,Contrast exam thoracic aorta,Medicare Fee Schedule 005-609,Per Unit,$186.67 ,OP,186.67,186.67,,,,,,
Humana,ExceptCPT,75625,Contrast exam abdominl aorta,Medicare Fee Schedule 005-609,Per Unit,$170.03 ,OP,170.03,170.03,,,,,,
Humana,ExceptCPT,75630,X-ray aorta leg arteries,Medicare Fee Schedule 005-609,Per Unit,$180.51 ,OP,180.51,180.51,,,,,,
Humana,ExceptCPT,75635,Ct angio abdominal arteries,Medicare Fee Schedule 005-609,Per Unit,$844.66 ,OP,600,844.66,,,,,,
Humana,ExceptCPT,75705,Artery x-rays spine,Medicare Fee Schedule 005-609,Per Unit,$345.32 ,OP,345.32,345.32,,,,,,
Humana,ExceptCPT,75710,Artery x-rays arm/leg,Medicare Fee Schedule 005-609,Per Unit,$192.80 ,OP,192.8,192.8,,,,,,
Humana,ExceptCPT,75716,Artery x-rays arms/legs,Medicare Fee Schedule 005-609,Per Unit,$198.30 ,OP,198.3,198.3,,,,,,
Humana,ExceptCPT,75726,Artery x-rays abdomen,Medicare Fee Schedule 005-609,Per Unit,$214.03 ,OP,214.03,214.03,,,,,,
Humana,ExceptCPT,75731,Artery x-rays adrenal gland,Medicare Fee Schedule 005-609,Per Unit,$263.04 ,OP,263.04,263.04,,,,,,
Humana,ExceptCPT,75733,Artery x-rays adrenals,Medicare Fee Schedule 005-609,Per Unit,$286.33 ,OP,286.33,286.33,,,,,,
Humana,ExceptCPT,75736,Artery x-rays pelvis,Medicare Fee Schedule 005-609,Per Unit,$239.42 ,OP,239.42,239.42,,,,,,
Humana,ExceptCPT,75741,Artery x-rays lung,Medicare Fee Schedule 005-609,Per Unit,$196.30 ,OP,196.3,196.3,,,,,,
Humana,ExceptCPT,75743,Artery x-rays lungs,Medicare Fee Schedule 005-609,Per Unit,$198.91 ,OP,198.91,198.91,,,,,,
Humana,ExceptCPT,75746,Artery x-rays lung,Medicare Fee Schedule 005-609,Per Unit,$221.93 ,OP,221.93,221.93,,,,,,
Humana,ExceptCPT,75756,Artery x-rays chest,Medicare Fee Schedule 005-609,Per Unit,$274.45 ,OP,274.45,274.45,,,,,,
Humana,ExceptCPT,75774,Artery x-ray each vessel,Medicare Fee Schedule 005-609,Per Unit,$146.38 ,OP,146.38,146.38,,,,,,
Humana,ExceptCPT,75801,Lymph vessel x-ray arm/leg,Medicare Fee Schedule 005-609,Per Unit,$586.30 ,OP,586.3,586.3,,,,,,
Humana,ExceptCPT,75803,Lymph vessel x-ray arms/legs,Medicare Fee Schedule 005-609,Per Unit,$586.30 ,OP,586.3,586.3,,,,,,
Humana,ExceptCPT,75805,Lymph vessel x-ray trunk,Medicare Fee Schedule 005-609,Per Unit,$661.29 ,OP,661.29,661.29,,,,,,
Humana,ExceptCPT,75807,Lymph vessel x-ray trunk,Medicare Fee Schedule 005-609,Per Unit,$992.01 ,OP,992.01,992.01,,,,,,
Humana,ExceptCPT,75809,Nonvascular shunt x-ray,Medicare Fee Schedule 005-609,Per Unit,$168.27 ,OP,168.27,168.27,,,,,,
Humana,ExceptCPT,75810,Vein x-ray spleen/liver,Medicare Fee Schedule 005-609,Per Unit,"$1,361.44 ",OP,"1,361.44","1,361.44",,,,,,
Humana,ExceptCPT,75820,Vein x-ray arm/leg,Medicare Fee Schedule 005-609,Per Unit,$172.65 ,OP,172.65,172.65,,,,,,
Humana,ExceptCPT,75822,Vein x-ray arms/legs,Medicare Fee Schedule 005-609,Per Unit,$183.15 ,OP,183.15,183.15,,,,,,
Humana,ExceptCPT,75825,Vein x-ray trunk,Medicare Fee Schedule 005-609,Per Unit,$172.65 ,OP,172.65,172.65,,,,,,
Humana,ExceptCPT,75827,Vein x-ray chest,Medicare Fee Schedule 005-609,Per Unit,$185.79 ,OP,185.79,185.79,,,,,,
Humana,ExceptCPT,75831,Vein x-ray kidney,Medicare Fee Schedule 005-609,Per Unit,$188.40 ,OP,188.4,188.4,,,,,,
Humana,ExceptCPT,75833,Vein x-ray kidneys,Medicare Fee Schedule 005-609,Per Unit,$210.57 ,OP,210.57,210.57,,,,,,
Humana,ExceptCPT,75840,Vein x-ray adrenal gland,Medicare Fee Schedule 005-609,Per Unit,$206.77 ,OP,206.77,206.77,,,,,,
Humana,ExceptCPT,75842,Vein x-ray adrenal glands,Medicare Fee Schedule 005-609,Per Unit,$238.56 ,OP,238.56,238.56,,,,,,
Humana,ExceptCPT,75860,Vein x-ray neck,Medicare Fee Schedule 005-609,Per Unit,$203.28 ,OP,203.28,203.28,,,,,,
Humana,ExceptCPT,75870,Vein x-ray skull,Medicare Fee Schedule 005-609,Per Unit,$287.29 ,OP,287.29,287.29,,,,,,
Humana,ExceptCPT,75872,Vein x-ray skull epidural,Medicare Fee Schedule 005-609,Per Unit,$206.77 ,OP,206.77,206.77,,,,,,
Humana,ExceptCPT,75880,Vein x-ray eye socket,Medicare Fee Schedule 005-609,Per Unit,$205.92 ,OP,205.92,205.92,,,,,,
Humana,ExceptCPT,75885,Vein x-ray liver w/hemodynam,Medicare Fee Schedule 005-609,Per Unit,$198.91 ,OP,198.91,198.91,,,,,,
Humana,ExceptCPT,75887,Vein x-ray liver w/o hemodyn,Medicare Fee Schedule 005-609,Per Unit,$200.64 ,OP,200.64,200.64,,,,,,
Humana,ExceptCPT,75889,Vein x-ray liver w/hemodynam,Medicare Fee Schedule 005-609,Per Unit,$199.76 ,OP,199.76,199.76,,,,,,
Humana,ExceptCPT,75891,Vein x-ray liver,Medicare Fee Schedule 005-609,Per Unit,$201.55 ,OP,201.55,201.55,,,,,,
Humana,ExceptCPT,75893,Venous sampling by catheter,Medicare Fee Schedule 005-609,Per Unit,$218.16 ,OP,218.16,218.16,,,,,,
Humana,ExceptCPT,75894,X-rays transcath therapy,Medicare Fee Schedule 005-609,Per Unit,"$2,610.16 ",OP,"2,610.16","2,610.16",,,,,,
Humana,ExceptCPT,75898,Follow-up angiography,Medicare Fee Schedule 005-609,Per Unit,$113.96 ,OP,113.96,113.96,,,,,,
Humana,ExceptCPT,75901,Remove cva device obstruct,Medicare Fee Schedule 005-609,Per Unit,$550.96 ,OP,550.96,550.96,,,,,,
Humana,ExceptCPT,75902,Remove cva lumen obstruct,Medicare Fee Schedule 005-609,Per Unit,$188.40 ,OP,188.4,188.4,,,,,,
Humana,ExceptCPT,75970,Vascular biopsy,Medicare Fee Schedule 005-609,Per Unit,"$1,246.96 ",OP,"1,246.96","1,246.96",,,,,,
Humana,ExceptCPT,75984,Xray control catheter change,Medicare Fee Schedule 005-609,Per Unit,$170.03 ,OP,170.03,170.03,,,,,,
Humana,ExceptCPT,75989,Abscess drainage under x-ray,Medicare Fee Schedule 005-609,Per Unit,$162.17 ,OP,162.17,162.17,,,,,,
Humana,ExceptCPT,76000,Fluoroscopy <1 hr phys/qhp,Medicare Fee Schedule 005-609,Per Unit,$70.26 ,OP,70.26,70.26,,,,,,
Humana,ExceptCPT,76010,X-ray nose to rectum,Medicare Fee Schedule 005-609,Per Unit,$53.65 ,OP,53.65,53.65,,,,,,
Humana,ExceptCPT,76080,X-ray exam of fistula,Medicare Fee Schedule 005-609,Per Unit,$90.42 ,OP,90.42,90.42,,,,,,
Humana,ExceptCPT,76098,X-ray exam surgical specimen,Medicare Fee Schedule 005-609,Per Unit,$68.53 ,OP,68.53,68.53,,,,,,
Humana,ExceptCPT,76100,X-ray exam of body section,Medicare Fee Schedule 005-609,Per Unit,$166.51 ,OP,166.51,166.51,,,,,,
Humana,ExceptCPT,76101,Complex body section x-ray,Medicare Fee Schedule 005-609,Per Unit,$195.69 ,OP,195.69,195.69,,,,,,
Humana,ExceptCPT,76102,Complex body section x-rays,Medicare Fee Schedule 005-609,Per Unit,$389.59 ,OP,389.59,389.59,,,,,,
Humana,ExceptCPT,76120,Cine/video x-rays,Medicare Fee Schedule 005-609,Per Unit,$247.06 ,OP,247.06,247.06,,,,,,
Humana,ExceptCPT,76125,Cine/video x-rays add-on,Medicare Fee Schedule 005-609,Per Unit,$85.42 ,OP,85.42,85.42,,,,,,
Humana,ExceptCPT,76376,3d render w/intrp postproces,Medicare Fee Schedule 005-609,Per Unit,$33.52 ,OP,33.52,33.52,,,,,,
Humana,ExceptCPT,76377,3d render w/intrp postproces,Medicare Fee Schedule 005-609,Per Unit,$84.29 ,OP,84.29,84.29,,,,,,
Humana,ExceptCPT,76380,Cat scan follow-up study,Medicare Fee Schedule 005-609,Per Unit,$247.91 ,OP,247.91,600,,,,,,
Humana,ExceptCPT,76390,Mr spectroscopy,Medicare Fee Schedule 005-609,Per Unit,$903.62 ,OP,903.62,"1,200.00",,,,,,
Humana,ExceptCPT,76391,Mr elastography,Medicare Fee Schedule 005-609,Per Unit,$451.22 ,OP,451.22,"1,200.00",,,,,,
Humana,ExceptCPT,76506,Echo exam of head,Medicare Fee Schedule 005-609,Per Unit,$221.68 ,OP,221.68,221.68,,,,,,
Humana,ExceptCPT,76510,Oph us dx b-scan&quan a-scan,Medicare Fee Schedule 005-609,Per Unit,$86.90 ,OP,86.9,86.9,,,,,,
Humana,ExceptCPT,76511,Oph us dx quan a-scan only,Medicare Fee Schedule 005-609,Per Unit,$57.15 ,OP,57.15,57.15,,,,,,
Humana,ExceptCPT,76512,Oph us dx b-scan,Medicare Fee Schedule 005-609,Per Unit,$47.49 ,OP,47.49,47.49,,,,,,
Humana,ExceptCPT,76513,Oph us dx ant sgm us uni/bi,Medicare Fee Schedule 005-609,Per Unit,$119.27 ,OP,119.27,119.27,,,,,,
Humana,ExceptCPT,76514,Echo exam of eye thickness,Medicare Fee Schedule 005-609,Per Unit,$9.90 ,OP,9.9,9.9,,,,,,
Humana,ExceptCPT,76516,Echo exam of eye,Medicare Fee Schedule 005-609,Per Unit,$62.40 ,OP,62.4,62.4,,,,,,
Humana,ExceptCPT,76519,Echo exam of eye,Medicare Fee Schedule 005-609,Per Unit,$94.77 ,OP,94.77,94.77,,,,,,
Humana,ExceptCPT,76529,Echo exam of eye,Medicare Fee Schedule 005-609,Per Unit,$141.16 ,OP,141.16,141.16,,,,,,
Humana,ExceptCPT,76536,Us exam of head and neck,Medicare Fee Schedule 005-609,Per Unit,$228.66 ,OP,228.66,228.66,,,,,,
Humana,ExceptCPT,76604,Us exam chest,Medicare Fee Schedule 005-609,Per Unit,$100.02 ,OP,100.02,100.02,,,,,,
Humana,ExceptCPT,76641,Ultrasound breast complete,Medicare Fee Schedule 005-609,Per Unit,$183.15 ,OP,183.15,183.15,,,,,,
Humana,ExceptCPT,76642,Ultrasound breast limited,Medicare Fee Schedule 005-609,Per Unit,$140.28 ,OP,140.28,140.28,,,,,,
Humana,ExceptCPT,76700,Us exam abdom complete,Medicare Fee Schedule 005-609,Per Unit,$212.91 ,OP,212.91,212.91,,,,,,
Humana,ExceptCPT,76705,Echo exam of abdomen,Medicare Fee Schedule 005-609,Per Unit,$160.41 ,OP,160.41,160.41,,,,,,
Humana,ExceptCPT,76706,Us abdl aorta screen aaa,Medicare Fee Schedule 005-609,Per Unit,$212.91 ,OP,212.91,212.91,,,,,,
Humana,ExceptCPT,76770,Us exam abdo back wall comp,Medicare Fee Schedule 005-609,Per Unit,$198.06 ,OP,198.06,198.06,,,,,,
Humana,ExceptCPT,76775,Us exam abdo back wall lim,Medicare Fee Schedule 005-609,Per Unit,$78.16 ,OP,78.16,78.16,,,,,,
Humana,ExceptCPT,76776,Us exam k transpl w/doppler,Medicare Fee Schedule 005-609,Per Unit,$305.94 ,OP,305.94,305.94,,,,,,
Humana,ExceptCPT,76800,Us exam spinal canal,Medicare Fee Schedule 005-609,Per Unit,$219.92 ,OP,219.92,219.92,,,,,,
Humana,ExceptCPT,76801,Ob us < 14 wks single fetus,Medicare Fee Schedule 005-609,Per Unit,$189.28 ,OP,189.28,189.28,,,,,,
Humana,ExceptCPT,76802,Ob us < 14 wks addl fetus,Medicare Fee Schedule 005-609,Per Unit,$56.87 ,OP,56.87,56.87,,,,,,
Humana,ExceptCPT,76805,Ob us > 14 wks sngl fetus,Medicare Fee Schedule 005-609,Per Unit,$236.53 ,OP,236.53,236.53,,,,,,
Humana,ExceptCPT,76810,Ob us > 14 wks addl fetus,Medicare Fee Schedule 005-609,Per Unit,$112.28 ,OP,112.28,112.28,,,,,,
Humana,ExceptCPT,76811,Ob us detailed sngl fetus,Medicare Fee Schedule 005-609,Per Unit,$216.67 ,OP,216.67,216.67,,,,,,
Humana,ExceptCPT,76812,Ob us detailed addl fetus,Medicare Fee Schedule 005-609,Per Unit,$290.18 ,OP,290.18,290.18,,,,,,
Humana,ExceptCPT,76813,Ob us nuchal meas 1 gest,Medicare Fee Schedule 005-609,Per Unit,$166.54 ,OP,166.54,166.54,,,,,,
Humana,ExceptCPT,76814,Ob us nuchal meas add-on,Medicare Fee Schedule 005-609,Per Unit,$77.25 ,OP,77.25,77.25,,,,,,
Humana,ExceptCPT,76815,Ob us limited fetus(s),Medicare Fee Schedule 005-609,Per Unit,$135.03 ,OP,135.03,135.03,,,,,,
Humana,ExceptCPT,76816,Ob us follow-up per fetus,Medicare Fee Schedule 005-609,Per Unit,$185.79 ,OP,185.79,185.79,,,,,,
Humana,ExceptCPT,76817,Transvaginal us obstetric,Medicare Fee Schedule 005-609,Per Unit,$153.40 ,OP,153.4,153.4,,,,,,
Humana,ExceptCPT,76818,Fetal biophys profile w/nst,Medicare Fee Schedule 005-609,Per Unit,$169.40 ,OP,169.4,169.4,,,,,,
Humana,ExceptCPT,76819,Fetal biophys profil w/o nst,Medicare Fee Schedule 005-609,Per Unit,$125.40 ,OP,125.4,125.4,,,,,,
Humana,ExceptCPT,76820,Umbilical artery echo,Medicare Fee Schedule 005-609,Per Unit,$57.15 ,OP,57.15,57.15,,,,,,
Humana,ExceptCPT,76821,Middle cerebral artery echo,Medicare Fee Schedule 005-609,Per Unit,$148.17 ,OP,148.17,148.17,,,,,,
Humana,ExceptCPT,76825,Echo exam of fetal heart,Medicare Fee Schedule 005-609,Per Unit,$502.48 ,OP,502.48,502.48,,,,,,
Humana,ExceptCPT,76826,Echo exam of fetal heart,Medicare Fee Schedule 005-609,Per Unit,$321.67 ,OP,321.67,321.67,,,,,,
Humana,ExceptCPT,76827,Echo exam of fetal heart,Medicare Fee Schedule 005-609,Per Unit,$117.51 ,OP,117.51,117.51,,,,,,
Humana,ExceptCPT,76828,Echo exam of fetal heart,Medicare Fee Schedule 005-609,Per Unit,$63.25 ,OP,63.25,63.25,,,,,,
Humana,ExceptCPT,76830,Transvaginal us non-ob,Medicare Fee Schedule 005-609,Per Unit,$233.04 ,OP,233.04,233.04,,,,,,
Humana,ExceptCPT,76831,Echo exam uterus,Medicare Fee Schedule 005-609,Per Unit,$220.80 ,OP,220.8,220.8,,,,,,
Humana,ExceptCPT,76856,Us exam pelvic complete,Medicare Fee Schedule 005-609,Per Unit,$196.30 ,OP,196.3,196.3,,,,,,
Humana,ExceptCPT,76857,Us exam pelvic limited,Medicare Fee Schedule 005-609,Per Unit,$62.40 ,OP,62.4,62.4,,,,,,
Humana,ExceptCPT,76870,Us exam scrotum,Medicare Fee Schedule 005-609,Per Unit,$190.16 ,OP,190.16,190.16,,,,,,
Humana,ExceptCPT,76872,Us transrectal,Medicare Fee Schedule 005-609,Per Unit,$399.30 ,OP,399.3,399.3,,,,,,
Humana,ExceptCPT,76873,Echograp trans r pros study,Medicare Fee Schedule 005-609,Per Unit,$259.30 ,OP,259.3,259.3,,,,,,
Humana,ExceptCPT,76881,Us compl joint r-t w/img,Medicare Fee Schedule 005-609,Per Unit,$92.15 ,OP,92.15,92.15,,,,,,
Humana,ExceptCPT,76882,Us lmtd jt/nonvasc xtr strux,Medicare Fee Schedule 005-609,Per Unit,$85.14 ,OP,85.14,85.14,,,,,,
Humana,ExceptCPT,76885,Us exam infant hips dynamic,Medicare Fee Schedule 005-609,Per Unit,$275.94 ,OP,275.94,275.94,,,,,,
Humana,ExceptCPT,76886,Us exam infant hips static,Medicare Fee Schedule 005-609,Per Unit,$191.92 ,OP,191.92,191.92,,,,,,
Humana,ExceptCPT,76932,Echo guide for heart biopsy,Medicare Fee Schedule 005-609,Per Unit,$166.73 ,OP,166.73,166.73,,,,,,
Humana,ExceptCPT,76936,Echo guide for artery repair,Medicare Fee Schedule 005-609,Per Unit,$451.72 ,OP,451.72,451.72,,,,,,
Humana,ExceptCPT,76937,Us guide vascular access,Medicare Fee Schedule 005-609,Per Unit,$63.00 ,OP,63,63,,,,,,
Humana,ExceptCPT,76940,Us guide tissue ablation,Medicare Fee Schedule 005-609,Per Unit,$192.91 ,OP,192.91,192.91,,,,,,
Humana,ExceptCPT,76941,Echo guide for transfusion,Medicare Fee Schedule 005-609,Per Unit,$164.97 ,OP,164.97,164.97,,,,,,
Humana,ExceptCPT,76942,Echo guide for biopsy,Medicare Fee Schedule 005-609,Per Unit,$69.41 ,OP,69.41,69.41,,,,,,
Humana,ExceptCPT,76945,Echo guide villus sampling,Medicare Fee Schedule 005-609,Per Unit,$164.97 ,OP,164.97,164.97,,,,,,
Humana,ExceptCPT,76946,Echo guide for amniocentesis,Medicare Fee Schedule 005-609,Per Unit,$36.14 ,OP,36.14,36.14,,,,,,
Humana,ExceptCPT,76948,Echo guide ova aspiration,Medicare Fee Schedule 005-609,Per Unit,$122.76 ,OP,122.76,122.76,,,,,,
Humana,ExceptCPT,76965,Echo guidance radiotherapy,Medicare Fee Schedule 005-609,Per Unit,$66.77 ,OP,66.77,66.77,,,,,,
Humana,ExceptCPT,76970,Ultrasound exam follow-up,Medicare Fee Schedule 005-609,Per Unit,$178.45 ,OP,178.45,178.45,,,,,,
Humana,ExceptCPT,76975,Gi endoscopic ultrasound,Medicare Fee Schedule 005-609,Per Unit,$166.73 ,OP,166.73,166.73,,,,,,
Humana,ExceptCPT,76977,Us bone density measure,Medicare Fee Schedule 005-609,Per Unit,$11.63 ,OP,11.63,11.63,,,,,,
Humana,ExceptCPT,76978,Us trgt dyn mbubb 1st les,Medicare Fee Schedule 005-609,Per Unit,$611.96 ,OP,611.96,611.96,,,,,,
Humana,ExceptCPT,76979,Us trgt dyn mbubb ea addl,Medicare Fee Schedule 005-609,Per Unit,$449.21 ,OP,449.21,449.21,,,,,,
Humana,ExceptCPT,76981,Use parenchyma,Medicare Fee Schedule 005-609,Per Unit,$201.55 ,OP,201.55,201.55,,,,,,
Humana,ExceptCPT,76982,Use 1st target lesion,Medicare Fee Schedule 005-609,Per Unit,$181.39 ,OP,181.39,181.39,,,,,,
Humana,ExceptCPT,76983,Use ea addl target lesion,Medicare Fee Schedule 005-609,Per Unit,$97.13 ,OP,97.13,97.13,,,,,,
Humana,ExceptCPT,76998,Us guide intraop,Medicare Fee Schedule 005-609,Per Unit,$136.62 ,OP,136.62,136.62,,,,,,
Humana,ExceptCPT,77001,Fluoroguide for vein device,Medicare Fee Schedule 005-609,Per Unit,$216.40 ,OP,216.4,216.4,,,,,,
Humana,ExceptCPT,77002,Needle localization by xray,Medicare Fee Schedule 005-609,Per Unit,$228.66 ,OP,228.66,228.66,,,,,,
Humana,ExceptCPT,77003,Fluoroguide for spine inject,Medicare Fee Schedule 005-609,Per Unit,$194.54 ,OP,194.54,194.54,,,,,,
Humana,ExceptCPT,77011,Ct scan for localization,Medicare Fee Schedule 005-609,Per Unit,$445.69 ,OP,445.69,445.69,,,,,,
Humana,ExceptCPT,77012,Ct scan for needle biopsy,Medicare Fee Schedule 005-609,Per Unit,$197.18 ,OP,197.18,197.18,,,,,,
Humana,ExceptCPT,77013,Ct guide for tissue ablation,Medicare Fee Schedule 005-609,Per Unit,"$1,165.40 ",OP,"1,165.40","1,165.40",,,,,,
Humana,ExceptCPT,77014,Ct scan for therapy guide,Medicare Fee Schedule 005-609,Per Unit,$203.28 ,OP,203.28,203.28,,,,,,
Humana,ExceptCPT,77021,Mri guidance ndl plmt rs&i,Medicare Fee Schedule 005-609,Per Unit,"$1,003.42 ",OP,"1,003.42","1,003.42",,,,,,
Humana,ExceptCPT,77022,Mri gdn parnchyma tiss abltj,Medicare Fee Schedule 005-609,Per Unit,"$1,142.71 ",OP,"1,142.71","1,142.71",,,,,,
Humana,ExceptCPT,77046,Mri breast c- unilateral,Medicare Fee Schedule 005-609,Per Unit,$432.82 ,OP,432.82,"1,200.00",,,,,,
Humana,ExceptCPT,77047,Mri breast c- bilateral,Medicare Fee Schedule 005-609,Per Unit,$431.09 ,OP,431.09,"1,200.00",,,,,,
Humana,ExceptCPT,77048,Mri breast c-+ w/cad uni,Medicare Fee Schedule 005-609,Per Unit,$712.88 ,OP,712.88,"1,200.00",,,,,,
Humana,ExceptCPT,77049,Mri breast c-+ w/cad bi,Medicare Fee Schedule 005-609,Per Unit,$709.36 ,OP,709.36,"1,200.00",,,,,,
Humana,ExceptCPT,77053,X-ray of mammary duct,Medicare Fee Schedule 005-609,Per Unit,$97.41 ,OP,97.41,97.41,,,,,,
Humana,ExceptCPT,77054,X-ray of mammary ducts,Medicare Fee Schedule 005-609,Per Unit,$128.89 ,OP,128.89,128.89,,,,,,
Humana,ExceptCPT,77061,Breast tomosynthesis uni,Medicare Fee Schedule 005-609,Per Unit,$229.54 ,OP,229.54,229.54,,,,,,
Humana,ExceptCPT,77062,Breast tomosynthesis bi,Medicare Fee Schedule 005-609,Per Unit,$293.43 ,OP,293.43,293.43,,,,,,
Humana,ExceptCPT,77063,Breast tomosynthesis bi,Medicare Fee Schedule 005-609,Per Unit,$63.88 ,OP,63.88,63.88,,,,,,
Humana,ExceptCPT,77065,Dx mammo incl cad uni,Medicare Fee Schedule 005-609,Per Unit,$229.54 ,OP,229.54,229.54,,,,,,
Humana,ExceptCPT,77066,Dx mammo incl cad bi,Medicare Fee Schedule 005-609,Per Unit,$293.43 ,OP,293.43,293.43,,,,,,
Humana,ExceptCPT,77067,Scr mammo bi incl cad,Medicare Fee Schedule 005-609,Per Unit,$242.66 ,OP,242.66,242.66,,,,,,
Humana,ExceptCPT,77072,X-rays for bone age,Medicare Fee Schedule 005-609,Per Unit,$43.15 ,OP,43.15,43.15,,,,,,
Humana,ExceptCPT,77073,X-rays bone length studies,Medicare Fee Schedule 005-609,Per Unit,$81.65 ,OP,81.65,81.65,,,,,,
Humana,ExceptCPT,77074,X-rays bone survey limited,Medicare Fee Schedule 005-609,Per Unit,$112.28 ,OP,112.28,112.28,,,,,,
Humana,ExceptCPT,77075,X-rays bone survey complete,Medicare Fee Schedule 005-609,Per Unit,$184.03 ,OP,184.03,184.03,,,,,,
Humana,ExceptCPT,77076,X-rays bone survey infant,Medicare Fee Schedule 005-609,Per Unit,$185.79 ,OP,185.79,185.79,,,,,,
Humana,ExceptCPT,77077,Joint survey single view,Medicare Fee Schedule 005-609,Per Unit,$77.28 ,OP,77.28,77.28,,,,,,
Humana,ExceptCPT,77078,Ct bone density axial,Medicare Fee Schedule 005-609,Per Unit,$260.18 ,OP,260.18,600,,,,,,
Humana,ExceptCPT,77080,Dxa bone density axial,Medicare Fee Schedule 005-609,Per Unit,$72.90 ,OP,72.9,72.9,,,,,,
Humana,ExceptCPT,77081,Dxa bone density/peripheral,Medicare Fee Schedule 005-609,Per Unit,$55.39 ,OP,55.39,55.39,,,,,,
Humana,ExceptCPT,77084,Magnetic image bone marrow,Medicare Fee Schedule 005-609,Per Unit,$730.37 ,OP,730.37,"1,200.00",,,,,,
Humana,ExceptCPT,77085,Dxa bone density study,Medicare Fee Schedule 005-609,Per Unit,$96.53 ,OP,96.53,96.53,,,,,,
Humana,ExceptCPT,77086,Fracture assessment via dxa,Medicare Fee Schedule 005-609,Per Unit,$65.04 ,OP,65.04,65.04,,,,,,
Humana,ExceptCPT,77280,Set radiation therapy field,Medicare Fee Schedule 005-609,Per Unit,$630.36 ,OP,630.36,630.36,,,,,,
Humana,ExceptCPT,77285,Set radiation therapy field,Medicare Fee Schedule 005-609,Per Unit,"$1,059.41 ",OP,"1,059.41","1,059.41",,,,,,
Humana,ExceptCPT,77290,Set radiation therapy field,Medicare Fee Schedule 005-609,Per Unit,"$1,051.55 ",OP,"1,051.55","1,051.55",,,,,,
Humana,ExceptCPT,77293,Respirator motion mgmt simul,Medicare Fee Schedule 005-609,Per Unit,$875.27 ,OP,875.27,875.27,,,,,,
Humana,ExceptCPT,77295,3-d radiotherapy plan,Medicare Fee Schedule 005-609,Per Unit,$664.65 ,OP,664.65,664.65,,,,,,
Humana,ExceptCPT,77300,Radiation therapy dose plan,Medicare Fee Schedule 005-609,Per Unit,$86.87 ,OP,86.87,86.87,,,,,,
Humana,ExceptCPT,77301,Radiotherapy dose plan imrt,Medicare Fee Schedule 005-609,Per Unit,"$3,801.79 ",OP,"3,801.79","3,801.79",,,,,,
Humana,ExceptCPT,77306,Telethx isodose plan simple,Medicare Fee Schedule 005-609,Per Unit,$192.17 ,OP,192.17,192.17,,,,,,
Humana,ExceptCPT,77307,Telethx isodose plan cplx,Medicare Fee Schedule 005-609,Per Unit,$348.45 ,OP,348.45,348.45,,,,,,
Humana,ExceptCPT,77316,Brachytx isodose plan simple,Medicare Fee Schedule 005-609,Per Unit,$408.84 ,OP,408.84,408.84,,,,,,
Humana,ExceptCPT,77317,Brachytx isodose intermed,Medicare Fee Schedule 005-609,Per Unit,$537.76 ,OP,537.76,537.76,,,,,,
Humana,ExceptCPT,77318,Brachytx isodose complex,Medicare Fee Schedule 005-609,Per Unit,$726.17 ,OP,726.17,726.17,,,,,,
Humana,ExceptCPT,77321,Special teletx port plan,Medicare Fee Schedule 005-609,Per Unit,$114.02 ,OP,114.02,114.02,,,,,,
Humana,ExceptCPT,77331,Special radiation dosimetry,Medicare Fee Schedule 005-609,Per Unit,$49.28 ,OP,49.28,49.28,,,,,,
Humana,ExceptCPT,77332,Radiation treatment aid(s),Medicare Fee Schedule 005-609,Per Unit,$46.64 ,OP,46.64,46.64,,,,,,
Humana,ExceptCPT,77333,Radiation treatment aid(s),Medicare Fee Schedule 005-609,Per Unit,$240.02 ,OP,240.02,240.02,,,,,,
Humana,ExceptCPT,77334,Radiation treatment aid(s),Medicare Fee Schedule 005-609,Per Unit,$169.15 ,OP,169.15,169.15,,,,,,
Humana,ExceptCPT,77336,Radiation physics consult,Medicare Fee Schedule 005-609,Per Unit,$208.95 ,OP,208.95,208.95,,,,,,
Humana,ExceptCPT,77338,Design mlc device for imrt,Medicare Fee Schedule 005-609,Per Unit,$638.66 ,OP,638.66,638.66,,,,,,
Humana,ExceptCPT,77370,Radiation physics consult,Medicare Fee Schedule 005-609,Per Unit,$331.54 ,OP,331.54,331.54,,,,,,
Humana,ExceptCPT,77371,Srs multisource,Medicare Fee Schedule 005-609,Per Unit,"$2,851.78 ",OP,"2,851.78","2,851.78",,,,,,
Humana,ExceptCPT,77372,Srs linear based,Medicare Fee Schedule 005-609,Per Unit,"$2,696.62 ",OP,"2,696.62","2,696.62",,,,,,
Humana,ExceptCPT,77373,Sbrt delivery,Medicare Fee Schedule 005-609,Per Unit,"$2,944.98 ",OP,"2,944.98","2,944.98",,,,,,
Humana,ExceptCPT,77385,Ntsty modul rad tx dlvr smpl,Medicare Fee Schedule 005-609,Per Unit,$964.65 ,OP,964.65,964.65,,,,,,
Humana,ExceptCPT,77386,Ntsty modul rad tx dlvr cplx,Medicare Fee Schedule 005-609,Per Unit,$968.06 ,OP,968.06,968.06,,,,,,
Humana,ExceptCPT,77387,Guidance for radj tx dlvr,Medicare Fee Schedule 005-609,Per Unit,$227.78 ,OP,227.78,227.78,,,,,,
Humana,ExceptCPT,77401,Radiation treatment delivery,Medicare Fee Schedule 005-609,Per Unit,$110.52 ,OP,110.52,110.52,,,,,,
Humana,ExceptCPT,77402,Radiation treatment delivery,Medicare Fee Schedule 005-609,Per Unit,$363.44 ,OP,363.44,363.44,,,,,,
Humana,ExceptCPT,77407,Radiation treatment delivery,Medicare Fee Schedule 005-609,Per Unit,$499.95 ,OP,499.95,499.95,,,,,,
Humana,ExceptCPT,77412,Radiation treatment delivery,Medicare Fee Schedule 005-609,Per Unit,$666.49 ,OP,666.49,666.49,,,,,,
Humana,ExceptCPT,77417,Radiology port images(s),Medicare Fee Schedule 005-609,Per Unit,$30.00 ,OP,30,30,,,,,,
Humana,ExceptCPT,77423,Neutron beam tx complex,Medicare Fee Schedule 005-609,Per Unit,$237.93 ,OP,237.93,237.93,,,,,,
Humana,ExceptCPT,77470,Special radiation treatment,Medicare Fee Schedule 005-609,Per Unit,$66.77 ,OP,66.77,66.77,,,,,,
Humana,ExceptCPT,77520,Proton trmt simple w/o comp,Medicare Fee Schedule 005-609,Per Unit,"$1,853.17 ",OP,"1,853.17","1,853.17",,,,,,
Humana,ExceptCPT,77522,Proton trmt simple w/comp,Medicare Fee Schedule 005-609,Per Unit,"$1,903.00 ",OP,"1,903.00","1,903.00",,,,,,
Humana,ExceptCPT,77523,Proton trmt intermediate,Medicare Fee Schedule 005-609,Per Unit,"$2,257.67 ",OP,"2,257.67","2,257.67",,,,,,
Humana,ExceptCPT,77525,Proton treatment complex,Medicare Fee Schedule 005-609,Per Unit,"$2,403.67 ",OP,"2,403.67","2,403.67",,,,,,
Humana,ExceptCPT,77600,Hyperthermia treatment,Medicare Fee Schedule 005-609,Per Unit,"$1,077.70 ",OP,"1,077.70","1,077.70",,,,,,
Humana,ExceptCPT,77605,Hyperthermia treatment,Medicare Fee Schedule 005-609,Per Unit,"$2,354.50 ",OP,"2,354.50","2,354.50",,,,,,
Humana,ExceptCPT,77610,Hyperthermia treatment,Medicare Fee Schedule 005-609,Per Unit,"$1,649.15 ",OP,"1,649.15","1,649.15",,,,,,
Humana,ExceptCPT,77615,Hyperthermia treatment,Medicare Fee Schedule 005-609,Per Unit,"$2,601.58 ",OP,"2,601.58","2,601.58",,,,,,
Humana,ExceptCPT,77620,Hyperthermia treatment,Medicare Fee Schedule 005-609,Per Unit,"$1,458.38 ",OP,"1,458.38","1,458.38",,,,,,
Humana,ExceptCPT,77750,Infuse radioactive materials,Medicare Fee Schedule 005-609,Per Unit,$323.35 ,OP,323.35,323.35,,,,,,
Humana,ExceptCPT,77761,Apply intrcav radiat simple,Medicare Fee Schedule 005-609,Per Unit,$533.36 ,OP,533.36,533.36,,,,,,
Humana,ExceptCPT,77762,Apply intrcav radiat interm,Medicare Fee Schedule 005-609,Per Unit,$612.29 ,OP,612.29,612.29,,,,,,
Humana,ExceptCPT,77763,Apply intrcav radiat compl,Medicare Fee Schedule 005-609,Per Unit,$784.33 ,OP,784.33,784.33,,,,,,
Humana,ExceptCPT,77767,Hdr rdncl skn surf brachytx,Medicare Fee Schedule 005-609,Per Unit,$492.86 ,OP,492.86,492.86,,,,,,
Humana,ExceptCPT,77768,Hdr rdncl skn surf brachytx,Medicare Fee Schedule 005-609,Per Unit,$748.66 ,OP,748.66,748.66,,,,,,
Humana,ExceptCPT,77770,Hdr rdncl ntrstl/icav brchtx,Medicare Fee Schedule 005-609,Per Unit,$629.64 ,OP,629.64,629.64,,,,,,
Humana,ExceptCPT,77771,Hdr rdncl ntrstl/icav brchtx,Medicare Fee Schedule 005-609,Per Unit,"$1,043.74 ",OP,"1,043.74","1,043.74",,,,,,
Humana,ExceptCPT,77772,Hdr rdncl ntrstl/icav brchtx,Medicare Fee Schedule 005-609,Per Unit,"$1,604.49 ",OP,"1,604.49","1,604.49",,,,,,
Humana,ExceptCPT,77778,Apply interstit radiat compl,Medicare Fee Schedule 005-609,Per Unit,"$1,099.26 ",OP,"1,099.26","1,099.26",,,,,,
Humana,ExceptCPT,77789,Apply surf ldr radionuclide,Medicare Fee Schedule 005-609,Per Unit,$182.55 ,OP,182.55,182.55,,,,,,
Humana,ExceptCPT,77790,Radiation handling,Medicare Fee Schedule 005-609,Per Unit,$39.63 ,OP,39.63,39.63,,,,,,
Humana,ExceptCPT,78012,Thyroid uptake measurement,Medicare Fee Schedule 005-609,Per Unit,$188.32 ,OP,188.32,188.32,,,,,,
Humana,ExceptCPT,78013,Thyroid imaging w/blood flow,Medicare Fee Schedule 005-609,Per Unit,$459.61 ,OP,459.61,459.61,,,,,,
Humana,ExceptCPT,78014,Thyroid imaging w/blood flow,Medicare Fee Schedule 005-609,Per Unit,$555.86 ,OP,555.86,555.86,,,,,,
Humana,ExceptCPT,78015,Thyroid met imaging,Medicare Fee Schedule 005-609,Per Unit,$502.48 ,OP,502.48,502.48,,,,,,
Humana,ExceptCPT,78016,Thyroid met imaging/studies,Medicare Fee Schedule 005-609,Per Unit,$645.37 ,OP,645.37,645.37,,,,,,
Humana,ExceptCPT,78018,Thyroid met imaging body,Medicare Fee Schedule 005-609,Per Unit,$706.64 ,OP,706.64,706.64,,,,,,
Humana,ExceptCPT,78020,Thyroid met uptake,Medicare Fee Schedule 005-609,Per Unit,$142.29 ,OP,142.29,142.29,,,,,,
Humana,ExceptCPT,78070,Parathyroid planar imaging,Medicare Fee Schedule 005-609,Per Unit,$663.49 ,OP,663.49,663.49,,,,,,
Humana,ExceptCPT,78071,Parathyrd planar w/wo subtrj,Medicare Fee Schedule 005-609,Per Unit,$763.54 ,OP,763.54,763.54,,,,,,
Humana,ExceptCPT,78072,Parathyrd planar w/spect&ct,Medicare Fee Schedule 005-609,Per Unit,$954.31 ,OP,954.31,954.31,,,,,,
Humana,ExceptCPT,78075,Adrenal cortex & medulla img,Medicare Fee Schedule 005-609,Per Unit,"$1,061.94 ",OP,"1,061.94","1,061.94",,,,,,
Humana,ExceptCPT,78102,Bone marrow imaging ltd,Medicare Fee Schedule 005-609,Per Unit,$379.09 ,OP,379.09,379.09,,,,,,
Humana,ExceptCPT,78103,Bone marrow imaging mult,Medicare Fee Schedule 005-609,Per Unit,$468.35 ,OP,468.35,468.35,,,,,,
Humana,ExceptCPT,78104,Bone marrow imaging body,Medicare Fee Schedule 005-609,Per Unit,$545.35 ,OP,545.35,545.35,,,,,,
Humana,ExceptCPT,78110,Plasma volume single,Medicare Fee Schedule 005-609,Per Unit,$161.18 ,OP,161.18,161.18,,,,,,
Humana,ExceptCPT,78111,Plasma volume multiple,Medicare Fee Schedule 005-609,Per Unit,$169.07 ,OP,169.07,169.07,,,,,,
Humana,ExceptCPT,78120,Red cell mass single,Medicare Fee Schedule 005-609,Per Unit,$161.18 ,OP,161.18,161.18,,,,,,
Humana,ExceptCPT,78121,Red cell mass multiple,Medicare Fee Schedule 005-609,Per Unit,$169.04 ,OP,169.04,169.04,,,,,,
Humana,ExceptCPT,78122,Blood volume,Medicare Fee Schedule 005-609,Per Unit,$199.71 ,OP,199.71,199.71,,,,,,
Humana,ExceptCPT,78130,Red cell survival study,Medicare Fee Schedule 005-609,Per Unit,$261.20 ,OP,261.2,261.2,,,,,,
Humana,ExceptCPT,78135,Red cell survival kinetics,Medicare Fee Schedule 005-609,Per Unit,$659.56 ,OP,659.56,659.56,,,,,,
Humana,ExceptCPT,78140,Red cell sequestration,Medicare Fee Schedule 005-609,Per Unit,$225.06 ,OP,225.06,225.06,,,,,,
Humana,ExceptCPT,78185,Spleen imaging,Medicare Fee Schedule 005-609,Per Unit,$400.95 ,OP,400.95,400.95,,,,,,
Humana,ExceptCPT,78191,Platelet survival,Medicare Fee Schedule 005-609,Per Unit,$261.20 ,OP,261.2,261.2,,,,,,
Humana,ExceptCPT,78195,Lymph system imaging,Medicare Fee Schedule 005-609,Per Unit,$769.67 ,OP,769.67,769.67,,,,,,
Humana,ExceptCPT,78201,Liver imaging,Medicare Fee Schedule 005-609,Per Unit,$439.48 ,OP,439.48,439.48,,,,,,
Humana,ExceptCPT,78202,Liver imaging with flow,Medicare Fee Schedule 005-609,Per Unit,$479.74 ,OP,479.74,479.74,,,,,,
Humana,ExceptCPT,78215,Liver and spleen imaging,Medicare Fee Schedule 005-609,Per Unit,$445.61 ,OP,445.61,445.61,,,,,,
Humana,ExceptCPT,78216,Liver & spleen image/flow,Medicare Fee Schedule 005-609,Per Unit,$266.20 ,OP,266.2,266.2,,,,,,
Humana,ExceptCPT,78226,Hepatobiliary system imaging,Medicare Fee Schedule 005-609,Per Unit,$753.89 ,OP,753.89,753.89,,,,,,
Humana,ExceptCPT,78227,Hepatobil syst image w/drug,Medicare Fee Schedule 005-609,Per Unit,"$1,026.05 ",OP,"1,026.05","1,026.05",,,,,,
Humana,ExceptCPT,78230,Salivary gland imaging,Medicare Fee Schedule 005-609,Per Unit,$396.58 ,OP,396.58,396.58,,,,,,
Humana,ExceptCPT,78231,Serial salivary imaging,Medicare Fee Schedule 005-609,Per Unit,$219.81 ,OP,219.81,219.81,,,,,,
Humana,ExceptCPT,78232,Salivary gland function exam,Medicare Fee Schedule 005-609,Per Unit,$219.81 ,OP,219.81,219.81,,,,,,
Humana,ExceptCPT,78258,Esophageal motility study,Medicare Fee Schedule 005-609,Per Unit,$464.83 ,OP,464.83,464.83,,,,,,
Humana,ExceptCPT,78261,Gastric mucosa imaging,Medicare Fee Schedule 005-609,Per Unit,$456.97 ,OP,456.97,456.97,,,,,,
Humana,ExceptCPT,78262,Gastroesophageal reflux exam,Medicare Fee Schedule 005-609,Per Unit,$541.01 ,OP,541.01,541.01,,,,,,
Humana,ExceptCPT,78264,Gastric emptying imag study,Medicare Fee Schedule 005-609,Per Unit,$760.02 ,OP,760.02,760.02,,,,,,
Humana,ExceptCPT,78265,Gastric emptying imag study,Medicare Fee Schedule 005-609,Per Unit,$892.16 ,OP,892.16,892.16,,,,,,
Humana,ExceptCPT,78266,Gastric emptying imag study,Medicare Fee Schedule 005-609,Per Unit,$998.33 ,OP,998.33,998.33,,,,,,
Humana,ExceptCPT,78267,Breath tst attain/anal c-14,Medicare Fee Schedule 005-609,Per Unit,$30.42 ,OP,30.42,30.42,,,,,,
Humana,ExceptCPT,78268,Breath test analysis c-14,Medicare Fee Schedule 005-609,Per Unit,$259.63 ,OP,259.63,259.63,,,,,,
Humana,ExceptCPT,78278,Acute gi blood loss imaging,Medicare Fee Schedule 005-609,Per Unit,$777.54 ,OP,777.54,777.54,,,,,,
Humana,ExceptCPT,78282,Gi protein loss exam,Medicare Fee Schedule 005-609,Per Unit,$596.17 ,OP,596.17,596.17,,,,,,
Humana,ExceptCPT,78290,Meckels divert exam,Medicare Fee Schedule 005-609,Per Unit,$768.76 ,OP,768.76,768.76,,,,,,
Humana,ExceptCPT,78291,Leveen/shunt patency exam,Medicare Fee Schedule 005-609,Per Unit,$541.86 ,OP,541.86,541.86,,,,,,
Humana,ExceptCPT,78300,Bone imaging limited area,Medicare Fee Schedule 005-609,Per Unit,$515.63 ,OP,515.63,515.63,,,,,,
Humana,ExceptCPT,78305,Bone imaging multiple areas,Medicare Fee Schedule 005-609,Per Unit,$616.25 ,OP,616.25,616.25,,,,,,
Humana,ExceptCPT,78306,Bone imaging whole body,Medicare Fee Schedule 005-609,Per Unit,$666.99 ,OP,666.99,666.99,,,,,,
Humana,ExceptCPT,78315,Bone imaging 3 phase,Medicare Fee Schedule 005-609,Per Unit,$768.76 ,OP,768.76,768.76,,,,,,
Humana,ExceptCPT,78350,Bone mineral single photon,Medicare Fee Schedule 005-609,Per Unit,$54.53 ,OP,54.53,54.53,,,,,,
Humana,ExceptCPT,78351,Bone mineral dual photon,Medicare Fee Schedule 005-609,Per Unit,$41.55 ,OP,41.55,41.55,,,,,,
Humana,ExceptCPT,78414,Non-imaging heart function,Medicare Fee Schedule 005-609,Per Unit,$288.67 ,OP,288.67,288.67,,,,,,
Humana,ExceptCPT,78428,Cardiac shunt imaging,Medicare Fee Schedule 005-609,Per Unit,$386.10 ,OP,386.1,386.1,,,,,,
Humana,ExceptCPT,78429,Myocrd img pet 1 std w/ct,Medicare Fee Schedule 005-609,Per Unit,"$3,713.38 ",OP,"3,713.38","3,713.38",,,,,,
Humana,ExceptCPT,78430,Myocrd img pet rst/strs w/ct,Medicare Fee Schedule 005-609,Per Unit,"$3,713.41 ",OP,"3,713.41","3,713.41",,,,,,
Humana,ExceptCPT,78431,Myocrd img pet rst&strs ct,Medicare Fee Schedule 005-609,Per Unit,"$5,661.26 ",OP,"5,661.26","5,661.26",,,,,,
Humana,ExceptCPT,78432,Myocrd img pet 2rtracer,Medicare Fee Schedule 005-609,Per Unit,"$6,898.82 ",OP,"6,898.82","6,898.82",,,,,,
Humana,ExceptCPT,78433,Myocrd img pet 2rtracer ct,Medicare Fee Schedule 005-609,Per Unit,"$6,898.82 ",OP,"6,898.82","6,898.82",,,,,,
Humana,ExceptCPT,78434,Aqmbf pet rest & rx stress,Medicare Fee Schedule 005-609,Per Unit,$7.04 ,OP,7.04,7.04,,,,,,
Humana,ExceptCPT,78445,Vascular flow imaging,Medicare Fee Schedule 005-609,Per Unit,$465.74 ,OP,465.74,465.74,,,,,,
Humana,ExceptCPT,78451,Ht muscle image spect sing,Medicare Fee Schedule 005-609,Per Unit,$711.01 ,OP,711.01,711.01,,,,,,
Humana,ExceptCPT,78452,Ht muscle image spect mult,Medicare Fee Schedule 005-609,Per Unit,"$1,026.33 ",OP,"1,026.33","1,026.33",,,,,,
Humana,ExceptCPT,78453,Ht muscle image planar sing,Medicare Fee Schedule 005-609,Per Unit,$649.50 ,OP,649.5,649.5,,,,,,
Humana,ExceptCPT,78454,Ht musc image planar mult,Medicare Fee Schedule 005-609,Per Unit,$952.55 ,OP,952.55,952.55,,,,,,
Humana,ExceptCPT,78456,Acute venous thrombus image,Medicare Fee Schedule 005-609,Per Unit,$686.51 ,OP,686.51,686.51,,,,,,
Humana,ExceptCPT,78457,Venous thrombosis imaging,Medicare Fee Schedule 005-609,Per Unit,$367.70 ,OP,367.7,367.7,,,,,,
Humana,ExceptCPT,78458,Ven thrombosis images bilat,Medicare Fee Schedule 005-609,Per Unit,$418.50 ,OP,418.5,418.5,,,,,,
Humana,ExceptCPT,78459,Myocrd img pet single study,Medicare Fee Schedule 005-609,Per Unit,"$3,275.86 ",OP,"3,275.86","3,275.86",,,,,,
Humana,ExceptCPT,78466,Heart infarct image,Medicare Fee Schedule 005-609,Per Unit,$422.84 ,OP,422.84,422.84,,,,,,
Humana,ExceptCPT,78468,Heart infarct image (ef),Medicare Fee Schedule 005-609,Per Unit,$412.34 ,OP,412.34,412.34,,,,,,
Humana,ExceptCPT,78469,Heart infarct image (3d),Medicare Fee Schedule 005-609,Per Unit,$456.12 ,OP,456.12,456.12,,,,,,
Humana,ExceptCPT,78472,Gated heart planar single,Medicare Fee Schedule 005-609,Per Unit,$469.21 ,OP,469.21,469.21,,,,,,
Humana,ExceptCPT,78473,Gated heart multiple,Medicare Fee Schedule 005-609,Per Unit,$568.10 ,OP,568.1,568.1,,,,,,
Humana,ExceptCPT,78481,Heart first pass single,Medicare Fee Schedule 005-609,Per Unit,$337.98 ,OP,337.98,337.98,,,,,,
Humana,ExceptCPT,78483,Heart first pass multiple,Medicare Fee Schedule 005-609,Per Unit,$445.61 ,OP,445.61,445.61,,,,,,
Humana,ExceptCPT,78491,Myocrd img pet 1std rst/strs,Medicare Fee Schedule 005-609,Per Unit,"$1,122.08 ",OP,"1,122.08","1,122.08",,,,,,
Humana,ExceptCPT,78492,Myocrd img pet mlt rst&strs,Medicare Fee Schedule 005-609,Per Unit,"$2,817.71 ",OP,"2,817.71","2,817.71",,,,,,
Humana,ExceptCPT,78494,Heart image spect,Medicare Fee Schedule 005-609,Per Unit,$443.85 ,OP,443.85,443.85,,,,,,
Humana,ExceptCPT,78496,Heart first pass add-on,Medicare Fee Schedule 005-609,Per Unit,$49.28 ,OP,49.28,49.28,,,,,,
Humana,ExceptCPT,78579,Lung ventilation imaging,Medicare Fee Schedule 005-609,Per Unit,$423.72 ,OP,423.72,423.72,,,,,,
Humana,ExceptCPT,78580,Lung perfusion imaging,Medicare Fee Schedule 005-609,Per Unit,$519.97 ,OP,519.97,519.97,,,,,,
Humana,ExceptCPT,78582,Lung ventilat&perfus imaging,Medicare Fee Schedule 005-609,Per Unit,$729.41 ,OP,729.41,729.41,,,,,,
Humana,ExceptCPT,78597,Lung perfusion differential,Medicare Fee Schedule 005-609,Per Unit,$433.35 ,OP,433.35,433.35,,,,,,
Humana,ExceptCPT,78598,Lung perf&ventilat diferentl,Medicare Fee Schedule 005-609,Per Unit,$681.89 ,OP,681.89,681.89,,,,,,
Humana,ExceptCPT,78600,Brain image < 4 views,Medicare Fee Schedule 005-609,Per Unit,$419.35 ,OP,419.35,419.35,,,,,,
Humana,ExceptCPT,78601,Brain image w/flow < 4 views,Medicare Fee Schedule 005-609,Per Unit,$495.47 ,OP,495.47,495.47,,,,,,
Humana,ExceptCPT,78605,Brain image 4+ views,Medicare Fee Schedule 005-609,Per Unit,$449.98 ,OP,449.98,449.98,,,,,,
Humana,ExceptCPT,78606,Brain image w/flow 4 + views,Medicare Fee Schedule 005-609,Per Unit,$776.66 ,OP,776.66,776.66,,,,,,
Humana,ExceptCPT,78608,Brain imaging (pet),Medicare Fee Schedule 005-609,Per Unit,"$5,988.59 ",OP,"5,988.59","5,988.59",,,,,,
Humana,ExceptCPT,78609,Brain imaging (pet),Medicare Fee Schedule 005-609,Per Unit,"$5,977.84 ",OP,"5,977.84","5,977.84",,,,,,
Humana,ExceptCPT,78610,Brain flow imaging only,Medicare Fee Schedule 005-609,Per Unit,$414.10 ,OP,414.1,414.1,,,,,,
Humana,ExceptCPT,78630,Cerebrospinal fluid scan,Medicare Fee Schedule 005-609,Per Unit,$787.13 ,OP,787.13,787.13,,,,,,
Humana,ExceptCPT,78635,Csf ventriculography,Medicare Fee Schedule 005-609,Per Unit,$795.03 ,OP,795.03,795.03,,,,,,
Humana,ExceptCPT,78645,Csf shunt evaluation,Medicare Fee Schedule 005-609,Per Unit,$767.03 ,OP,767.03,767.03,,,,,,
Humana,ExceptCPT,78650,Csf leakage imaging,Medicare Fee Schedule 005-609,Per Unit,$652.38 ,OP,652.38,652.38,,,,,,
Humana,ExceptCPT,78660,Nuclear exam of tear flow,Medicare Fee Schedule 005-609,Per Unit,$423.72 ,OP,423.72,423.72,,,,,,
Humana,ExceptCPT,78700,Kidney imaging morphol,Medicare Fee Schedule 005-609,Per Unit,$388.71 ,OP,388.71,388.71,,,,,,
Humana,ExceptCPT,78701,Kidney imaging with flow,Medicare Fee Schedule 005-609,Per Unit,$508.61 ,OP,508.61,508.61,,,,,,
Humana,ExceptCPT,78707,K flow/funct image w/o drug,Medicare Fee Schedule 005-609,Per Unit,$481.47 ,OP,481.47,481.47,,,,,,
Humana,ExceptCPT,78708,K flow/funct image w/drug,Medicare Fee Schedule 005-609,Per Unit,$310.23 ,OP,310.23,310.23,,,,,,
Humana,ExceptCPT,78709,K flow/funct image multiple,Medicare Fee Schedule 005-609,Per Unit,$779.27 ,OP,779.27,779.27,,,,,,
Humana,ExceptCPT,78725,Kidney function study,Medicare Fee Schedule 005-609,Per Unit,$245.19 ,OP,245.19,245.19,,,,,,
Humana,ExceptCPT,78730,Urinary bladder retention,Medicare Fee Schedule 005-609,Per Unit,$178.78 ,OP,178.78,178.78,,,,,,
Humana,ExceptCPT,78740,Ureteral reflux study,Medicare Fee Schedule 005-609,Per Unit,$500.72 ,OP,500.72,500.72,,,,,,
Humana,ExceptCPT,78761,Testicular imaging w/flow,Medicare Fee Schedule 005-609,Per Unit,$457.85 ,OP,457.85,457.85,,,,,,
Humana,ExceptCPT,78800,Rp loclzj tum 1 area 1 d img,Medicare Fee Schedule 005-609,Per Unit,$580.39 ,OP,580.39,580.39,,,,,,
Humana,ExceptCPT,78801,Rp loclzj tum 2+area 1+d img,Medicare Fee Schedule 005-609,Per Unit,$638.99 ,OP,638.99,638.99,,,,,,
Humana,ExceptCPT,78802,Rp loclzj tum whbdy 1 d img,Medicare Fee Schedule 005-609,Per Unit,$710.77 ,OP,710.77,710.77,,,,,,
Humana,ExceptCPT,78803,Rp loclzj tum spect 1 area,Medicare Fee Schedule 005-609,Per Unit,$868.53 ,OP,868.53,868.53,,,,,,
Humana,ExceptCPT,78804,Rp loclzj tum whbdy 2+d img,Medicare Fee Schedule 005-609,Per Unit,"$1,581.06 ",OP,"1,581.06","1,581.06",,,,,,
Humana,ExceptCPT,78808,Iv inj ra drug dx study,Medicare Fee Schedule 005-609,Per Unit,$106.18 ,OP,106.18,106.18,,,,,,
Humana,ExceptCPT,78811,Pet image ltd area,Medicare Fee Schedule 005-609,Per Unit,"$5,988.59 ",OP,"5,988.59","5,988.59",,,,,,
Humana,ExceptCPT,78812,Pet image skull-thigh,Medicare Fee Schedule 005-609,Per Unit,"$5,988.59 ",OP,"5,988.59","5,988.59",,,,,,
Humana,ExceptCPT,78813,Pet image full body,Medicare Fee Schedule 005-609,Per Unit,"$5,988.59 ",OP,"5,988.59","5,988.59",,,,,,
Humana,ExceptCPT,78814,Pet image w/ct lmtd,Medicare Fee Schedule 005-609,Per Unit,"$7,485.80 ",OP,"7,485.80","7,485.80",,,,,,
Humana,ExceptCPT,78815,Pet image w/ct skull-thigh,Medicare Fee Schedule 005-609,Per Unit,"$7,485.80 ",OP,"7,485.80","7,485.80",,,,,,
Humana,ExceptCPT,78816,Pet image w/ct full body,Medicare Fee Schedule 005-609,Per Unit,"$7,485.80 ",OP,"7,485.80","7,485.80",,,,,,
Humana,ExceptCPT,78830,Rp loclzj tum spect w/ct 1,Medicare Fee Schedule 005-609,Per Unit,"$1,090.82 ",OP,"1,090.82","1,090.82",,,,,,
Humana,ExceptCPT,78831,Rp loclzj tum spect 2 areas,Medicare Fee Schedule 005-609,Per Unit,"$1,614.31 ",OP,"1,614.31","1,614.31",,,,,,
Humana,ExceptCPT,78832,Rp loclzj tum spect w/ct 2,Medicare Fee Schedule 005-609,Per Unit,"$2,129.99 ",OP,"2,129.99","2,129.99",,,,,,
Humana,ExceptCPT,78835,Rp quan meas single area,Medicare Fee Schedule 005-609,Per Unit,$207.65 ,OP,207.65,207.65,,,,,,
Humana,ExceptCPT,79005,Nuclear rx oral admin,Medicare Fee Schedule 005-609,Per Unit,$132.66 ,OP,132.66,132.66,,,,,,
Humana,ExceptCPT,79101,Nuclear rx iv admin,Medicare Fee Schedule 005-609,Per Unit,$137.06 ,OP,137.06,137.06,,,,,,
Humana,ExceptCPT,79200,Nuclear rx intracav admin,Medicare Fee Schedule 005-609,Per Unit,$140.55 ,OP,140.55,140.55,,,,,,
Humana,ExceptCPT,79300,Nuclr rx interstit colloid,Medicare Fee Schedule 005-609,Per Unit,$465.60 ,OP,465.6,465.6,,,,,,
Humana,ExceptCPT,79403,Hematopoietic nuclear tx,Medicare Fee Schedule 005-609,Per Unit,$211.06 ,OP,211.06,211.06,,,,,,
Humana,ExceptCPT,79440,Nuclear rx intra-articular,Medicare Fee Schedule 005-609,Per Unit,$105.55 ,OP,105.55,105.55,,,,,,
Humana,ExceptCPT,79445,Nuclear rx intra-arterial,Medicare Fee Schedule 005-609,Per Unit,$136.43 ,OP,136.43,136.43,,,,,,
Humana,ExceptCPT,80047,Metabolic panel ionized ca,Medicare Fee Schedule 005-609,Per Unit,$37.76 ,OP,37.76,37.76,,,,,,
Humana,ExceptCPT,80048,Metabolic panel total ca,Medicare Fee Schedule 005-609,Per Unit,$23.27 ,OP,23.27,23.27,,,,,,
Humana,ExceptCPT,80050,General health panel,Medicare Fee Schedule 005-609,Per Unit,$113.77 ,OP,113.77,113.77,,,,,,
Humana,ExceptCPT,80051,Electrolyte panel,Medicare Fee Schedule 005-609,Per Unit,$19.28 ,OP,19.28,19.28,,,,,,
Humana,ExceptCPT,80053,Comprehen metabolic panel,Medicare Fee Schedule 005-609,Per Unit,$29.04 ,OP,29.04,29.04,,,,,,
Humana,ExceptCPT,80055,Obstetric panel,Medicare Fee Schedule 005-609,Per Unit,$131.48 ,OP,131.48,131.48,,,,,,
Humana,ExceptCPT,80061,Lipid panel,Medicare Fee Schedule 005-609,Per Unit,$36.82 ,OP,36.82,36.82,,,,,,
Humana,ExceptCPT,80069,Renal function panel,Medicare Fee Schedule 005-609,Per Unit,$23.87 ,OP,23.87,23.87,,,,,,
Humana,ExceptCPT,80074,Acute hepatitis panel,Medicare Fee Schedule 005-609,Per Unit,$130.98 ,OP,130.98,130.98,,,,,,
Humana,ExceptCPT,80076,Hepatic function panel,Medicare Fee Schedule 005-609,Per Unit,$22.47 ,OP,22.47,22.47,,,,,,
Humana,ExceptCPT,80081,Obstetric panel,Medicare Fee Schedule 005-609,Per Unit,$205.87 ,OP,205.87,205.87,,,,,,
Humana,ExceptCPT,80145,Drug assay adalimumab,Medicare Fee Schedule 005-609,Per Unit,$106.07 ,OP,106.07,106.07,,,,,,
Humana,ExceptCPT,80150,Assay of amikacin,Medicare Fee Schedule 005-609,Per Unit,$41.47 ,OP,41.47,41.47,,,,,,
Humana,ExceptCPT,80155,Drug assay caffeine,Medicare Fee Schedule 005-609,Per Unit,$106.07 ,OP,106.07,106.07,,,,,,
Humana,ExceptCPT,80156,Assay carbamazepine total,Medicare Fee Schedule 005-609,Per Unit,$40.07 ,OP,40.07,40.07,,,,,,
Humana,ExceptCPT,80157,Assay carbamazepine free,Medicare Fee Schedule 005-609,Per Unit,$36.44 ,OP,36.44,36.44,,,,,,
Humana,ExceptCPT,80158,Drug assay cyclosporine,Medicare Fee Schedule 005-609,Per Unit,$49.64 ,OP,49.64,49.64,,,,,,
Humana,ExceptCPT,80159,Drug assay clozapine,Medicare Fee Schedule 005-609,Per Unit,$55.41 ,OP,55.41,55.41,,,,,,
Humana,ExceptCPT,80162,Assay of digoxin total,Medicare Fee Schedule 005-609,Per Unit,$36.52 ,OP,36.52,36.52,,,,,,
Humana,ExceptCPT,80163,Assay of digoxin free,Medicare Fee Schedule 005-609,Per Unit,$36.52 ,OP,36.52,36.52,,,,,,
Humana,ExceptCPT,80164,Assay dipropylacetic acd tot,Medicare Fee Schedule 005-609,Per Unit,$37.24 ,OP,37.24,37.24,,,,,,
Humana,ExceptCPT,80165,Dipropylacetic acid free,Medicare Fee Schedule 005-609,Per Unit,$37.24 ,OP,37.24,37.24,,,,,,
Humana,ExceptCPT,80168,Assay of ethosuximide,Medicare Fee Schedule 005-609,Per Unit,$44.94 ,OP,44.94,44.94,,,,,,
Humana,ExceptCPT,80169,Drug assay everolimus,Medicare Fee Schedule 005-609,Per Unit,$37.76 ,OP,37.76,37.76,,,,,,
Humana,ExceptCPT,80170,Assay of gentamicin,Medicare Fee Schedule 005-609,Per Unit,$45.05 ,OP,45.05,45.05,,,,,,
Humana,ExceptCPT,80171,Drug screen quant gabapentin,Medicare Fee Schedule 005-609,Per Unit,$59.59 ,OP,59.59,59.59,,,,,,
Humana,ExceptCPT,80173,Assay of haloperidol,Medicare Fee Schedule 005-609,Per Unit,$43.40 ,OP,43.4,43.4,,,,,,
Humana,ExceptCPT,80175,Drug screen quan lamotrigine,Medicare Fee Schedule 005-609,Per Unit,$36.44 ,OP,36.44,36.44,,,,,,
Humana,ExceptCPT,80176,Assay of lidocaine,Medicare Fee Schedule 005-609,Per Unit,$40.40 ,OP,40.4,40.4,,,,,,
Humana,ExceptCPT,80177,Drug scrn quan levetiracetam,Medicare Fee Schedule 005-609,Per Unit,$36.44 ,OP,36.44,36.44,,,,,,
Humana,ExceptCPT,80178,Assay of lithium,Medicare Fee Schedule 005-609,Per Unit,$18.18 ,OP,18.18,18.18,,,,,,
Humana,ExceptCPT,80180,Drug scrn quan mycophenolate,Medicare Fee Schedule 005-609,Per Unit,$49.64 ,OP,49.64,49.64,,,,,,
Humana,ExceptCPT,80183,Drug scrn quant oxcarbazepin,Medicare Fee Schedule 005-609,Per Unit,$36.44 ,OP,36.44,36.44,,,,,,
Humana,ExceptCPT,80184,Assay of phenobarbital,Medicare Fee Schedule 005-609,Per Unit,$42.08 ,OP,42.08,42.08,,,,,,
Humana,ExceptCPT,80185,Assay of phenytoin total,Medicare Fee Schedule 005-609,Per Unit,$36.44 ,OP,36.44,36.44,,,,,,
Humana,ExceptCPT,80186,Assay of phenytoin free,Medicare Fee Schedule 005-609,Per Unit,$37.84 ,OP,37.84,37.84,,,,,,
Humana,ExceptCPT,80187,Drug assay posaconazole,Medicare Fee Schedule 005-609,Per Unit,$74.55 ,OP,74.55,74.55,,,,,,
Humana,ExceptCPT,80188,Assay of primidone,Medicare Fee Schedule 005-609,Per Unit,$45.62 ,OP,45.62,45.62,,,,,,
Humana,ExceptCPT,80190,Assay of procainamide,Medicare Fee Schedule 005-609,Per Unit,$165.00 ,OP,165,165,,,,,,
Humana,ExceptCPT,80192,Assay of procainamide,Medicare Fee Schedule 005-609,Per Unit,$46.06 ,OP,46.06,46.06,,,,,,
Humana,ExceptCPT,80194,Assay of quinidine,Medicare Fee Schedule 005-609,Per Unit,$40.15 ,OP,40.15,40.15,,,,,,
Humana,ExceptCPT,80195,Assay of sirolimus,Medicare Fee Schedule 005-609,Per Unit,$37.76 ,OP,37.76,37.76,,,,,,
Humana,ExceptCPT,80197,Assay of tacrolimus,Medicare Fee Schedule 005-609,Per Unit,$37.76 ,OP,37.76,37.76,,,,,,
Humana,ExceptCPT,80198,Assay of theophylline,Medicare Fee Schedule 005-609,Per Unit,$38.89 ,OP,38.89,38.89,,,,,,
Humana,ExceptCPT,80199,Drug screen quant tiagabine,Medicare Fee Schedule 005-609,Per Unit,$74.55 ,OP,74.55,74.55,,,,,,
Humana,ExceptCPT,80200,Assay of tobramycin,Medicare Fee Schedule 005-609,Per Unit,$44.36 ,OP,44.36,44.36,,,,,,
Humana,ExceptCPT,80201,Assay of topiramate,Medicare Fee Schedule 005-609,Per Unit,$32.78 ,OP,32.78,32.78,,,,,,
Humana,ExceptCPT,80202,Assay of vancomycin,Medicare Fee Schedule 005-609,Per Unit,$37.24 ,OP,37.24,37.24,,,,,,
Humana,ExceptCPT,80203,Drug screen quant zonisamide,Medicare Fee Schedule 005-609,Per Unit,$36.44 ,OP,36.44,36.44,,,,,,
Humana,ExceptCPT,80230,Drug assay infliximab,Medicare Fee Schedule 005-609,Per Unit,$106.07 ,OP,106.07,106.07,,,,,,
Humana,ExceptCPT,80235,Drug assay lacosamide,Medicare Fee Schedule 005-609,Per Unit,$74.55 ,OP,74.55,74.55,,,,,,
Humana,ExceptCPT,80280,Drug assay vedolizumab,Medicare Fee Schedule 005-609,Per Unit,$106.07 ,OP,106.07,106.07,,,,,,
Humana,ExceptCPT,80285,Drug assay voriconazole,Medicare Fee Schedule 005-609,Per Unit,$74.55 ,OP,74.55,74.55,,,,,,
Humana,ExceptCPT,80299,Quantitative assay drug,Medicare Fee Schedule 005-609,Per Unit,$51.26 ,OP,51.26,51.26,,,,,,
Humana,ExceptCPT,80305,Drug test prsmv dir opt obs,Medicare Fee Schedule 005-609,Per Unit,$34.65 ,OP,34.65,34.65,,,,,,
Humana,ExceptCPT,80306,Drug test prsmv instrmnt,Medicare Fee Schedule 005-609,Per Unit,$47.14 ,OP,47.14,47.14,,,,,,
Humana,ExceptCPT,80307,Drug test prsmv chem anlyzr,Medicare Fee Schedule 005-609,Per Unit,$170.89 ,OP,170.89,170.89,,,,,,
Humana,ExceptCPT,80320,Drug screen quantalcohols,Medicare Fee Schedule 005-609,Per Unit,$60.39 ,OP,60.39,60.39,,,,,,
Humana,ExceptCPT,80321,Alcohols biomarkers 1or 2,Medicare Fee Schedule 005-609,Per Unit,$37.04 ,OP,37.04,37.04,,,,,,
Humana,ExceptCPT,80322,Alcohols biomarkers 3/more,Medicare Fee Schedule 005-609,Per Unit,$31.35 ,OP,31.35,31.35,,,,,,
Humana,ExceptCPT,80323,Alkaloids nos,Medicare Fee Schedule 005-609,Per Unit,$60.39 ,OP,60.39,60.39,,,,,,
Humana,ExceptCPT,80324,Drug screen amphetamines 1/2,Medicare Fee Schedule 005-609,Per Unit,$60.39 ,OP,60.39,60.39,,,,,,
Humana,ExceptCPT,80325,Amphetamines 3or 4,Medicare Fee Schedule 005-609,Per Unit,$35.75 ,OP,35.75,35.75,,,,,,
Humana,ExceptCPT,80326,Amphetamines 5 or more,Medicare Fee Schedule 005-609,Per Unit,$25.38 ,OP,25.38,25.38,,,,,,
Humana,ExceptCPT,80327,Anabolic steroid 1 or 2,Medicare Fee Schedule 005-609,Per Unit,$60.39 ,OP,60.39,60.39,,,,,,
Humana,ExceptCPT,80328,Anabolic steroid 3 or more,Medicare Fee Schedule 005-609,Per Unit,$68.39 ,OP,68.39,68.39,,,,,,
Humana,ExceptCPT,80329,Analgesics non-opioid 1 or 2,Medicare Fee Schedule 005-609,Per Unit,$60.39 ,OP,60.39,60.39,,,,,,
Humana,ExceptCPT,80330,Analgesics non-opioid 3-5,Medicare Fee Schedule 005-609,Per Unit,$14.03 ,OP,14.03,14.03,,,,,,
Humana,ExceptCPT,80331,Analgesics non-opioid 6/more,Medicare Fee Schedule 005-609,Per Unit,$22.41 ,OP,22.41,22.41,,,,,,
Humana,ExceptCPT,80332,Antidepressants class 1 or 2,Medicare Fee Schedule 005-609,Per Unit,$60.39 ,OP,60.39,60.39,,,,,,
Humana,ExceptCPT,80333,Antidepressants class 3-5,Medicare Fee Schedule 005-609,Per Unit,$40.98 ,OP,40.98,40.98,,,,,,
Humana,ExceptCPT,80334,Antidepressants class 6/more,Medicare Fee Schedule 005-609,Per Unit,$26.24 ,OP,26.24,26.24,,,,,,
Humana,ExceptCPT,80335,Antidepressant tricyclic 1/2,Medicare Fee Schedule 005-609,Per Unit,$60.39 ,OP,60.39,60.39,,,,,,
Humana,ExceptCPT,80336,Antidepressant tricyclic 3-5,Medicare Fee Schedule 005-609,Per Unit,$55.83 ,OP,55.83,55.83,,,,,,
Humana,ExceptCPT,80337,Tricyclic & cyclicals 6/more,Medicare Fee Schedule 005-609,Per Unit,$28.46 ,OP,28.46,28.46,,,,,,
Humana,ExceptCPT,80338,Antidepressant not specified,Medicare Fee Schedule 005-609,Per Unit,$35.06 ,OP,35.06,35.06,,,,,,
Humana,ExceptCPT,80339,Antiepileptics nos 1-3,Medicare Fee Schedule 005-609,Per Unit,$60.39 ,OP,60.39,60.39,,,,,,
Humana,ExceptCPT,80340,Antiepileptics nos 4-6,Medicare Fee Schedule 005-609,Per Unit,$21.07 ,OP,21.07,21.07,,,,,,
Humana,ExceptCPT,80341,Antiepileptics nos 7/more,Medicare Fee Schedule 005-609,Per Unit,$18.21 ,OP,18.21,18.21,,,,,,
Humana,ExceptCPT,80342,Antipsychotics nos 1-3,Medicare Fee Schedule 005-609,Per Unit,$60.39 ,OP,60.39,60.39,,,,,,
Humana,ExceptCPT,80343,Antipsychotics nos 4-6,Medicare Fee Schedule 005-609,Per Unit,$88.91 ,OP,88.91,88.91,,,,,,
Humana,ExceptCPT,80344,Antipsychotics nos 7/more,Medicare Fee Schedule 005-609,Per Unit,$22.69 ,OP,22.69,22.69,,,,,,
Humana,ExceptCPT,80345,Drug screening barbiturates,Medicare Fee Schedule 005-609,Per Unit,$60.39 ,OP,60.39,60.39,,,,,,
Humana,ExceptCPT,80346,Benzodiazepines1-12,Medicare Fee Schedule 005-609,Per Unit,$60.39 ,OP,60.39,60.39,,,,,,
Humana,ExceptCPT,80347,Benzodiazepines 13 or more,Medicare Fee Schedule 005-609,Per Unit,$63.36 ,OP,63.36,63.36,,,,,,
Humana,ExceptCPT,80348,Drug screening buprenorphine,Medicare Fee Schedule 005-609,Per Unit,$44.99 ,OP,44.99,44.99,,,,,,
Humana,ExceptCPT,80349,Cannabinoids natural,Medicare Fee Schedule 005-609,Per Unit,$60.39 ,OP,60.39,60.39,,,,,,
Humana,ExceptCPT,80350,Cannabinoids synthetic 1-3,Medicare Fee Schedule 005-609,Per Unit,$60.39 ,OP,60.39,60.39,,,,,,
Humana,ExceptCPT,80351,Cannabinoids synthetic 4-6,Medicare Fee Schedule 005-609,Per Unit,$45.38 ,OP,45.38,45.38,,,,,,
Humana,ExceptCPT,80352,Cannabinoid synthetic 7/more,Medicare Fee Schedule 005-609,Per Unit,$44.28 ,OP,44.28,44.28,,,,,,
Humana,ExceptCPT,80353,Drug screening cocaine,Medicare Fee Schedule 005-609,Per Unit,$60.39 ,OP,60.39,60.39,,,,,,
Humana,ExceptCPT,80354,Drug screening fentanyl,Medicare Fee Schedule 005-609,Per Unit,$60.39 ,OP,60.39,60.39,,,,,,
Humana,ExceptCPT,80355,Gabapentin non-blood,Medicare Fee Schedule 005-609,Per Unit,$60.39 ,OP,60.39,60.39,,,,,,
Humana,ExceptCPT,80356,Heroin metabolite,Medicare Fee Schedule 005-609,Per Unit,$60.39 ,OP,60.39,60.39,,,,,,
Humana,ExceptCPT,80357,Ketamine and norketamine,Medicare Fee Schedule 005-609,Per Unit,$60.39 ,OP,60.39,60.39,,,,,,
Humana,ExceptCPT,80358,Drug screening methadone,Medicare Fee Schedule 005-609,Per Unit,$60.39 ,OP,60.39,60.39,,,,,,
Humana,ExceptCPT,80359,Methylenedioxyamphetamines,Medicare Fee Schedule 005-609,Per Unit,$60.39 ,OP,60.39,60.39,,,,,,
Humana,ExceptCPT,80360,Methylphenidate,Medicare Fee Schedule 005-609,Per Unit,$60.39 ,OP,60.39,60.39,,,,,,
Humana,ExceptCPT,80361,Opiates 1 or more,Medicare Fee Schedule 005-609,Per Unit,$60.39 ,OP,60.39,60.39,,,,,,
Humana,ExceptCPT,80362,Opioids & opiate analogs 1/2,Medicare Fee Schedule 005-609,Per Unit,$60.39 ,OP,60.39,60.39,,,,,,
Humana,ExceptCPT,80363,Opioids & opiate analogs 3/4,Medicare Fee Schedule 005-609,Per Unit,$58.38 ,OP,58.38,58.38,,,,,,
Humana,ExceptCPT,80364,Opioid &opiate analog 5/more,Medicare Fee Schedule 005-609,Per Unit,$43.81 ,OP,43.81,43.81,,,,,,
Humana,ExceptCPT,80365,Drug screening oxycodone,Medicare Fee Schedule 005-609,Per Unit,$60.39 ,OP,60.39,60.39,,,,,,
Humana,ExceptCPT,80366,Drug screening pregabalin,Medicare Fee Schedule 005-609,Per Unit,$60.39 ,OP,60.39,60.39,,,,,,
Humana,ExceptCPT,80367,Drug screening propoxyphene,Medicare Fee Schedule 005-609,Per Unit,$60.39 ,OP,60.39,60.39,,,,,,
Humana,ExceptCPT,80368,Sedative hypnotics,Medicare Fee Schedule 005-609,Per Unit,$60.39 ,OP,60.39,60.39,,,,,,
Humana,ExceptCPT,80369,Skeletal muscle relaxant 1/2,Medicare Fee Schedule 005-609,Per Unit,$60.39 ,OP,60.39,60.39,,,,,,
Humana,ExceptCPT,80370,Skel musc relaxant 3 or more,Medicare Fee Schedule 005-609,Per Unit,$32.42 ,OP,32.42,32.42,,,,,,
Humana,ExceptCPT,80371,Stimulants synthetic,Medicare Fee Schedule 005-609,Per Unit,$60.39 ,OP,60.39,60.39,,,,,,
Humana,ExceptCPT,80372,Drug screening tapentadol,Medicare Fee Schedule 005-609,Per Unit,$60.39 ,OP,60.39,60.39,,,,,,
Humana,ExceptCPT,80373,Drug screening tramadol,Medicare Fee Schedule 005-609,Per Unit,$60.39 ,OP,60.39,60.39,,,,,,
Humana,ExceptCPT,80374,Stereoisomer analysis,Medicare Fee Schedule 005-609,Per Unit,$60.39 ,OP,60.39,60.39,,,,,,
Humana,ExceptCPT,80375,Drug/substance nos 1-3,Medicare Fee Schedule 005-609,Per Unit,$60.39 ,OP,60.39,60.39,,,,,,
Humana,ExceptCPT,80376,Drug/substance nos 4-6,Medicare Fee Schedule 005-609,Per Unit,$60.39 ,OP,60.39,60.39,,,,,,
Humana,ExceptCPT,80377,Drug/substance nos 7/more,Medicare Fee Schedule 005-609,Per Unit,$60.39 ,OP,60.39,60.39,,,,,,
Humana,ExceptCPT,80400,Acth stimulation panel,Medicare Fee Schedule 005-609,Per Unit,$89.71 ,OP,89.71,89.71,,,,,,
Humana,ExceptCPT,80402,Acth stimulation panel,Medicare Fee Schedule 005-609,Per Unit,$239.14 ,OP,239.14,239.14,,,,,,
Humana,ExceptCPT,80406,Acth stimulation panel,Medicare Fee Schedule 005-609,Per Unit,$215.22 ,OP,215.22,215.22,,,,,,
Humana,ExceptCPT,80408,Aldosterone suppression eval,Medicare Fee Schedule 005-609,Per Unit,$345.13 ,OP,345.13,345.13,,,,,,
Humana,ExceptCPT,80410,Calcitonin stimul panel,Medicare Fee Schedule 005-609,Per Unit,$221.02 ,OP,221.02,221.02,,,,,,
Humana,ExceptCPT,80412,Crh stimulation panel,Medicare Fee Schedule 005-609,Per Unit,"$2,204.46 ",OP,"2,204.46","2,204.46",,,,,,
Humana,ExceptCPT,80414,Testosterone response panel,Medicare Fee Schedule 005-609,Per Unit,$142.01 ,OP,142.01,142.01,,,,,,
Humana,ExceptCPT,80415,Tot estradiol response panel,Medicare Fee Schedule 005-609,Per Unit,$153.70 ,OP,153.7,153.7,,,,,,
Humana,ExceptCPT,80416,Renin stimulation panel,Medicare Fee Schedule 005-609,Per Unit,$575.63 ,OP,575.63,575.63,,,,,,
Humana,ExceptCPT,80417,Renin stimulation panel,Medicare Fee Schedule 005-609,Per Unit,$120.97 ,OP,120.97,120.97,,,,,,
Humana,ExceptCPT,80418,Pituitary evaluation panel,Medicare Fee Schedule 005-609,Per Unit,"$1,593.57 ",OP,"1,593.57","1,593.57",,,,,,
Humana,ExceptCPT,80420,Dexamethasone panel,Medicare Fee Schedule 005-609,Per Unit,$445.17 ,OP,445.17,445.17,,,,,,
Humana,ExceptCPT,80422,Glucagon tolerance panel,Medicare Fee Schedule 005-609,Per Unit,$126.69 ,OP,126.69,126.69,,,,,,
Humana,ExceptCPT,80424,Glucagon tolerance panel,Medicare Fee Schedule 005-609,Per Unit,$138.88 ,OP,138.88,138.88,,,,,,
Humana,ExceptCPT,80426,Gonadotropin hormone panel,Medicare Fee Schedule 005-609,Per Unit,$408.13 ,OP,408.13,408.13,,,,,,
Humana,ExceptCPT,80428,Growth hormone panel,Medicare Fee Schedule 005-609,Per Unit,$183.43 ,OP,183.43,183.43,,,,,,
Humana,ExceptCPT,80430,Growth hormone panel,Medicare Fee Schedule 005-609,Per Unit,$355.66 ,OP,355.66,355.66,,,,,,
Humana,ExceptCPT,80432,Insulin suppression panel,Medicare Fee Schedule 005-609,Per Unit,$455.43 ,OP,455.43,455.43,,,,,,
Humana,ExceptCPT,80434,Insulin tolerance panel,Medicare Fee Schedule 005-609,Per Unit,$783.83 ,OP,783.83,783.83,,,,,,
Humana,ExceptCPT,80435,Insulin tolerance panel,Medicare Fee Schedule 005-609,Per Unit,$283.25 ,OP,283.25,283.25,,,,,,
Humana,ExceptCPT,80436,Metyrapone panel,Medicare Fee Schedule 005-609,Per Unit,$250.69 ,OP,250.69,250.69,,,,,,
Humana,ExceptCPT,80438,Trh stimulation panel,Medicare Fee Schedule 005-609,Per Unit,$138.63 ,OP,138.63,138.63,,,,,,
Humana,ExceptCPT,80439,Trh stimulation panel,Medicare Fee Schedule 005-609,Per Unit,$184.83 ,OP,184.83,184.83,,,,,,
Humana,ExceptCPT,81000,Urinalysis nonauto w/scope,Medicare Fee Schedule 005-609,Per Unit,$11.06 ,OP,11.06,11.06,,,,,,
Humana,ExceptCPT,81001,Urinalysis auto w/scope,Medicare Fee Schedule 005-609,Per Unit,$8.72 ,OP,8.72,8.72,,,,,,
Humana,ExceptCPT,81002,Urinalysis nonauto w/o scope,Medicare Fee Schedule 005-609,Per Unit,$9.57 ,OP,9.57,9.57,,,,,,
Humana,ExceptCPT,81003,Urinalysis auto w/o scope,Medicare Fee Schedule 005-609,Per Unit,$6.19 ,OP,6.19,6.19,,,,,,
Humana,ExceptCPT,81005,Urinalysis,Medicare Fee Schedule 005-609,Per Unit,$5.97 ,OP,5.97,5.97,,,,,,
Humana,ExceptCPT,81007,Urine screen for bacteria,Medicare Fee Schedule 005-609,Per Unit,$82.45 ,OP,82.45,82.45,,,,,,
Humana,ExceptCPT,81015,Microscopic exam of urine,Medicare Fee Schedule 005-609,Per Unit,$8.39 ,OP,8.39,8.39,,,,,,
Humana,ExceptCPT,81020,Urinalysis glass test,Medicare Fee Schedule 005-609,Per Unit,$12.93 ,OP,12.93,12.93,,,,,,
Humana,ExceptCPT,81025,Urine pregnancy test,Medicare Fee Schedule 005-609,Per Unit,$23.68 ,OP,23.68,23.68,,,,,,
Humana,ExceptCPT,81050,Urinalysis volume measure,Medicare Fee Schedule 005-609,Per Unit,$10.01 ,OP,10.01,10.01,,,,,,
Humana,ExceptCPT,81105,Hpa-1 genotyping,Medicare Fee Schedule 005-609,Per Unit,$336.11 ,OP,336.11,336.11,,,,,,
Humana,ExceptCPT,81106,Hpa-2 genotyping,Medicare Fee Schedule 005-609,Per Unit,$336.11 ,OP,336.11,336.11,,,,,,
Humana,ExceptCPT,81107,Hpa-3 genotyping,Medicare Fee Schedule 005-609,Per Unit,$336.11 ,OP,336.11,336.11,,,,,,
Humana,ExceptCPT,81108,Hpa-4 genotyping,Medicare Fee Schedule 005-609,Per Unit,$336.11 ,OP,336.11,336.11,,,,,,
Humana,ExceptCPT,81109,Hpa-5 genotyping,Medicare Fee Schedule 005-609,Per Unit,$336.11 ,OP,336.11,336.11,,,,,,
Humana,ExceptCPT,81110,Hpa-6 genotyping,Medicare Fee Schedule 005-609,Per Unit,$336.11 ,OP,336.11,336.11,,,,,,
Humana,ExceptCPT,81111,Hpa-9 genotyping,Medicare Fee Schedule 005-609,Per Unit,$336.11 ,OP,336.11,336.11,,,,,,
Humana,ExceptCPT,81112,Hpa-15 genotyping,Medicare Fee Schedule 005-609,Per Unit,$336.11 ,OP,336.11,336.11,,,,,,
Humana,ExceptCPT,81120,Idh1 common variants,Medicare Fee Schedule 005-609,Per Unit,$531.44 ,OP,531.44,531.44,,,,,,
Humana,ExceptCPT,81121,Idh2 common variants,Medicare Fee Schedule 005-609,Per Unit,$813.42 ,OP,813.42,813.42,,,,,,
Humana,ExceptCPT,81161,Dmd dup/delet analysis,Medicare Fee Schedule 005-609,Per Unit,$767.25 ,OP,767.25,767.25,,,,,,
Humana,ExceptCPT,81162,Brca1&2 gen full seq dup/del,Medicare Fee Schedule 005-609,Per Unit,"$5,018.42 ",OP,"5,018.42","5,018.42",,,,,,
Humana,ExceptCPT,81163,Brca1&2 gene full seq alys,Medicare Fee Schedule 005-609,Per Unit,"$1,287.00 ",OP,"1,287.00","1,287.00",,,,,,
Humana,ExceptCPT,81164,Brca1&2 gen ful dup/del alys,Medicare Fee Schedule 005-609,Per Unit,"$1,606.63 ",OP,"1,606.63","1,606.63",,,,,,
Humana,ExceptCPT,81165,Brca1 gene full seq alys,Medicare Fee Schedule 005-609,Per Unit,$777.92 ,OP,777.92,777.92,,,,,,
Humana,ExceptCPT,81166,Brca1 gene full dup/del alys,Medicare Fee Schedule 005-609,Per Unit,$828.71 ,OP,828.71,828.71,,,,,,
Humana,ExceptCPT,81167,Brca2 gene full dup/del alys,Medicare Fee Schedule 005-609,Per Unit,$777.92 ,OP,777.92,777.92,,,,,,
Humana,ExceptCPT,81170,Abl1 gene,Medicare Fee Schedule 005-609,Per Unit,$825.00 ,OP,825,825,,,,,,
Humana,ExceptCPT,81171,Aff2 gene detc abnor alleles,Medicare Fee Schedule 005-609,Per Unit,$376.75 ,OP,376.75,376.75,,,,,,
Humana,ExceptCPT,81172,Aff2 gene charac alleles,Medicare Fee Schedule 005-609,Per Unit,$755.78 ,OP,755.78,755.78,,,,,,
Humana,ExceptCPT,81173,Ar gene full gene sequence,Medicare Fee Schedule 005-609,Per Unit,$828.71 ,OP,828.71,828.71,,,,,,
Humana,ExceptCPT,81174,Ar gene known famil variant,Medicare Fee Schedule 005-609,Per Unit,$509.30 ,OP,509.3,509.3,,,,,,
Humana,ExceptCPT,81175,Asxl1 full gene sequence,Medicare Fee Schedule 005-609,Per Unit,"$1,860.38 ",OP,"1,860.38","1,860.38",,,,,,
Humana,ExceptCPT,81176,Asxl1 gene target seq alys,Medicare Fee Schedule 005-609,Per Unit,$665.23 ,OP,665.23,665.23,,,,,,
Humana,ExceptCPT,81177,Atn1 gene detc abnor alleles,Medicare Fee Schedule 005-609,Per Unit,$376.75 ,OP,376.75,376.75,,,,,,
Humana,ExceptCPT,81178,Atxn1 gene detc abnor allele,Medicare Fee Schedule 005-609,Per Unit,$376.75 ,OP,376.75,376.75,,,,,,
Humana,ExceptCPT,81179,Atxn2 gene detc abnor allele,Medicare Fee Schedule 005-609,Per Unit,$376.75 ,OP,376.75,376.75,,,,,,
Humana,ExceptCPT,81180,Atxn3 gene detc abnor allele,Medicare Fee Schedule 005-609,Per Unit,$376.75 ,OP,376.75,376.75,,,,,,
Humana,ExceptCPT,81181,Atxn7 gene detc abnor allele,Medicare Fee Schedule 005-609,Per Unit,$376.75 ,OP,376.75,376.75,,,,,,
Humana,ExceptCPT,81182,Atxn8os gen detc abnor allel,Medicare Fee Schedule 005-609,Per Unit,$376.75 ,OP,376.75,376.75,,,,,,
Humana,ExceptCPT,81183,Atxn10 gene detc abnor allel,Medicare Fee Schedule 005-609,Per Unit,$376.75 ,OP,376.75,376.75,,,,,,
Humana,ExceptCPT,81184,Cacna1a gen detc abnor allel,Medicare Fee Schedule 005-609,Per Unit,$376.75 ,OP,376.75,376.75,,,,,,
Humana,ExceptCPT,81185,Cacna1a gene full gene seq,Medicare Fee Schedule 005-609,Per Unit,"$2,327.24 ",OP,"2,327.24","2,327.24",,,,,,
Humana,ExceptCPT,81186,Cacna1a gen known famil vrnt,Medicare Fee Schedule 005-609,Per Unit,$509.30 ,OP,509.3,509.3,,,,,,
Humana,ExceptCPT,81187,Cnbp gene detc abnor allele,Medicare Fee Schedule 005-609,Per Unit,$376.75 ,OP,376.75,376.75,,,,,,
Humana,ExceptCPT,81188,Cstb gene detc abnor allele,Medicare Fee Schedule 005-609,Per Unit,$376.75 ,OP,376.75,376.75,,,,,,
Humana,ExceptCPT,81189,Cstb gene full gene sequence,Medicare Fee Schedule 005-609,Per Unit,$755.78 ,OP,755.78,755.78,,,,,,
Humana,ExceptCPT,81190,Cstb gene known famil vrnt,Medicare Fee Schedule 005-609,Per Unit,$509.30 ,OP,509.3,509.3,,,,,,
Humana,ExceptCPT,81200,Aspa gene,Medicare Fee Schedule 005-609,Per Unit,$129.94 ,OP,129.94,129.94,,,,,,
Humana,ExceptCPT,81201,Apc gene full sequence,Medicare Fee Schedule 005-609,Per Unit,"$2,145.00 ",OP,"2,145.00","2,145.00",,,,,,
Humana,ExceptCPT,81202,Apc gene known fam variants,Medicare Fee Schedule 005-609,Per Unit,$770.00 ,OP,770,770,,,,,,
Humana,ExceptCPT,81203,Apc gene dup/delet variants,Medicare Fee Schedule 005-609,Per Unit,$550.00 ,OP,550,550,,,,,,
Humana,ExceptCPT,81204,Ar gene charac alleles,Medicare Fee Schedule 005-609,Per Unit,$376.75 ,OP,376.75,376.75,,,,,,
Humana,ExceptCPT,81205,Bckdhb gene,Medicare Fee Schedule 005-609,Per Unit,$261.22 ,OP,261.22,261.22,,,,,,
Humana,ExceptCPT,81206,Bcr/abl1 gene major bp,Medicare Fee Schedule 005-609,Per Unit,$450.89 ,OP,450.89,450.89,,,,,,
Humana,ExceptCPT,81207,Bcr/abl1 gene minor bp,Medicare Fee Schedule 005-609,Per Unit,$398.31 ,OP,398.31,398.31,,,,,,
Humana,ExceptCPT,81208,Bcr/abl1 gene other bp,Medicare Fee Schedule 005-609,Per Unit,$590.21 ,OP,590.21,590.21,,,,,,
Humana,ExceptCPT,81209,Blm gene,Medicare Fee Schedule 005-609,Per Unit,$108.10 ,OP,108.1,108.1,,,,,,
Humana,ExceptCPT,81210,Braf gene,Medicare Fee Schedule 005-609,Per Unit,$482.35 ,OP,482.35,482.35,,,,,,
Humana,ExceptCPT,81212,Brca1&2 185&5385&6174 vrnt,Medicare Fee Schedule 005-609,Per Unit,"$1,210.00 ",OP,"1,210.00","1,210.00",,,,,,
Humana,ExceptCPT,81215,Brca1 gene known famil vrnt,Medicare Fee Schedule 005-609,Per Unit,"$1,031.94 ",OP,"1,031.94","1,031.94",,,,,,
Humana,ExceptCPT,81216,Brca2 gene full seq alys,Medicare Fee Schedule 005-609,Per Unit,$509.08 ,OP,509.08,509.08,,,,,,
Humana,ExceptCPT,81217,Brca2 gene known famil vrnt,Medicare Fee Schedule 005-609,Per Unit,"$1,031.94 ",OP,"1,031.94","1,031.94",,,,,,
Humana,ExceptCPT,81218,Cebpa gene full sequence,Medicare Fee Schedule 005-609,Per Unit,$665.23 ,OP,665.23,665.23,,,,,,
Humana,ExceptCPT,81219,Calr gene com variants,Medicare Fee Schedule 005-609,Per Unit,$334.48 ,OP,334.48,334.48,,,,,,
Humana,ExceptCPT,81220,Cftr gene com variants,Medicare Fee Schedule 005-609,Per Unit,"$1,530.65 ",OP,"1,530.65","1,530.65",,,,,,
Humana,ExceptCPT,81221,Cftr gene known fam variants,Medicare Fee Schedule 005-609,Per Unit,$267.36 ,OP,267.36,267.36,,,,,,
Humana,ExceptCPT,81222,Cftr gene dup/delet variants,Medicare Fee Schedule 005-609,Per Unit,"$1,196.44 ",OP,"1,196.44","1,196.44",,,,,,
Humana,ExceptCPT,81223,Cftr gene full sequence,Medicare Fee Schedule 005-609,Per Unit,"$1,372.25 ",OP,"1,372.25","1,372.25",,,,,,
Humana,ExceptCPT,81224,Cftr gene intron poly t,Medicare Fee Schedule 005-609,Per Unit,$464.06 ,OP,464.06,464.06,,,,,,
Humana,ExceptCPT,81225,Cyp2c19 gene com variants,Medicare Fee Schedule 005-609,Per Unit,$801.24 ,OP,801.24,801.24,,,,,,
Humana,ExceptCPT,81226,Cyp2d6 gene com variants,Medicare Fee Schedule 005-609,Per Unit,"$1,240.00 ",OP,"1,240.00","1,240.00",,,,,,
Humana,ExceptCPT,81227,Cyp2c9 gene com variants,Medicare Fee Schedule 005-609,Per Unit,$480.73 ,OP,480.73,480.73,,,,,,
Humana,ExceptCPT,81228,Cytog alys chrml abnr cgh,Medicare Fee Schedule 005-609,Per Unit,"$2,475.00 ",OP,"2,475.00","2,475.00",,,,,,
Humana,ExceptCPT,81229,Cytog alys chrml abnr snpcgh,Medicare Fee Schedule 005-609,Per Unit,"$3,190.00 ",OP,"3,190.00","3,190.00",,,,,,
Humana,ExceptCPT,81230,Cyp3a4 gene common variants,Medicare Fee Schedule 005-609,Per Unit,$480.73 ,OP,480.73,480.73,,,,,,
Humana,ExceptCPT,81231,Cyp3a5 gene common variants,Medicare Fee Schedule 005-609,Per Unit,$480.73 ,OP,480.73,480.73,,,,,,
Humana,ExceptCPT,81232,Dpyd gene common variants,Medicare Fee Schedule 005-609,Per Unit,$480.73 ,OP,480.73,480.73,,,,,,
Humana,ExceptCPT,81233,Btk gene common variants,Medicare Fee Schedule 005-609,Per Unit,$482.35 ,OP,482.35,482.35,,,,,,
Humana,ExceptCPT,81234,Dmpk gene detc abnor allele,Medicare Fee Schedule 005-609,Per Unit,$376.75 ,OP,376.75,376.75,,,,,,
Humana,ExceptCPT,81235,Egfr gene com variants,Medicare Fee Schedule 005-609,Per Unit,$892.60 ,OP,892.6,892.6,,,,,,
Humana,ExceptCPT,81236,Ezh2 gene full gene sequence,Medicare Fee Schedule 005-609,Per Unit,$777.92 ,OP,777.92,777.92,,,,,,
Humana,ExceptCPT,81237,Ezh2 gene common variants,Medicare Fee Schedule 005-609,Per Unit,$482.35 ,OP,482.35,482.35,,,,,,
Humana,ExceptCPT,81238,F9 full gene sequence,Medicare Fee Schedule 005-609,Per Unit,"$1,650.00 ",OP,"1,650.00","1,650.00",,,,,,
Humana,ExceptCPT,81239,Dmpk gene charac alleles,Medicare Fee Schedule 005-609,Per Unit,$755.78 ,OP,755.78,755.78,,,,,,
Humana,ExceptCPT,81240,F2 gene,Medicare Fee Schedule 005-609,Per Unit,$180.65 ,OP,180.65,180.65,,,,,,
Humana,ExceptCPT,81241,F5 gene,Medicare Fee Schedule 005-609,Per Unit,$201.77 ,OP,201.77,201.77,,,,,,
Humana,ExceptCPT,81242,Fancc gene,Medicare Fee Schedule 005-609,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
Humana,ExceptCPT,81243,Fmr1 gene detection,Medicare Fee Schedule 005-609,Per Unit,$156.86 ,OP,156.86,156.86,,,,,,
Humana,ExceptCPT,81244,Fmr1 gene charac alleles,Medicare Fee Schedule 005-609,Per Unit,$123.45 ,OP,123.45,123.45,,,,,,
Humana,ExceptCPT,81245,Flt3 gene,Medicare Fee Schedule 005-609,Per Unit,$455.15 ,OP,455.15,455.15,,,,,,
Humana,ExceptCPT,81246,Flt3 gene analysis,Medicare Fee Schedule 005-609,Per Unit,$228.25 ,OP,228.25,228.25,,,,,,
Humana,ExceptCPT,81247,G6pd gene alys cmn variant,Medicare Fee Schedule 005-609,Per Unit,$480.73 ,OP,480.73,480.73,,,,,,
Humana,ExceptCPT,81248,G6pd known familial variant,Medicare Fee Schedule 005-609,Per Unit,"$1,031.94 ",OP,"1,031.94","1,031.94",,,,,,
Humana,ExceptCPT,81249,G6pd full gene sequence,Medicare Fee Schedule 005-609,Per Unit,"$1,650.00 ",OP,"1,650.00","1,650.00",,,,,,
Humana,ExceptCPT,81250,G6pc gene,Medicare Fee Schedule 005-609,Per Unit,$160.85 ,OP,160.85,160.85,,,,,,
Humana,ExceptCPT,81251,Gba gene,Medicare Fee Schedule 005-609,Per Unit,$129.94 ,OP,129.94,129.94,,,,,,
Humana,ExceptCPT,81252,Gjb2 gene full sequence,Medicare Fee Schedule 005-609,Per Unit,$278.08 ,OP,278.08,278.08,,,,,,
Humana,ExceptCPT,81253,Gjb2 gene known fam variants,Medicare Fee Schedule 005-609,Per Unit,$169.18 ,OP,169.18,169.18,,,,,,
Humana,ExceptCPT,81254,Gjb6 gene com variants,Medicare Fee Schedule 005-609,Per Unit,$96.25 ,OP,96.25,96.25,,,,,,
Humana,ExceptCPT,81255,Hexa gene,Medicare Fee Schedule 005-609,Per Unit,$141.49 ,OP,141.49,141.49,,,,,,
Humana,ExceptCPT,81256,Hfe gene,Medicare Fee Schedule 005-609,Per Unit,$179.74 ,OP,179.74,179.74,,,,,,
Humana,ExceptCPT,81257,Hba1/hba2 gene,Medicare Fee Schedule 005-609,Per Unit,$281.22 ,OP,281.22,281.22,,,,,,
Humana,ExceptCPT,81258,Hba1/hba2 gene fam vrnt,Medicare Fee Schedule 005-609,Per Unit,"$1,031.94 ",OP,"1,031.94","1,031.94",,,,,,
Humana,ExceptCPT,81259,Hba1/hba2 full gene sequence,Medicare Fee Schedule 005-609,Per Unit,"$1,650.00 ",OP,"1,650.00","1,650.00",,,,,,
Humana,ExceptCPT,81260,Ikbkap gene,Medicare Fee Schedule 005-609,Per Unit,$108.10 ,OP,108.1,108.1,,,,,,
Humana,ExceptCPT,81261,Igh gene rearrange amp meth,Medicare Fee Schedule 005-609,Per Unit,$544.47 ,OP,544.47,544.47,,,,,,
Humana,ExceptCPT,81262,Igh gene rearrang dir probe,Medicare Fee Schedule 005-609,Per Unit,$188.51 ,OP,188.51,188.51,,,,,,
Humana,ExceptCPT,81263,Igh vari regional mutation,Medicare Fee Schedule 005-609,Per Unit,$809.93 ,OP,809.93,809.93,,,,,,
Humana,ExceptCPT,81264,Igk rearrangeabn clonal pop,Medicare Fee Schedule 005-609,Per Unit,$475.01 ,OP,475.01,475.01,,,,,,
Humana,ExceptCPT,81265,Str markers specimen anal,Medicare Fee Schedule 005-609,Per Unit,$640.94 ,OP,640.94,640.94,,,,,,
Humana,ExceptCPT,81266,Str markers spec anal addl,Medicare Fee Schedule 005-609,Per Unit,$838.23 ,OP,838.23,838.23,,,,,,
Humana,ExceptCPT,81267,Chimerism anal no cell selec,Medicare Fee Schedule 005-609,Per Unit,$570.52 ,OP,570.52,570.52,,,,,,
Humana,ExceptCPT,81268,Chimerism anal w/cell select,Medicare Fee Schedule 005-609,Per Unit,$717.17 ,OP,717.17,717.17,,,,,,
Humana,ExceptCPT,81269,Hba1/hba2 gene dup/del vrnts,Medicare Fee Schedule 005-609,Per Unit,$556.60 ,OP,556.6,556.6,,,,,,
Humana,ExceptCPT,81270,Jak2 gene,Medicare Fee Schedule 005-609,Per Unit,$252.07 ,OP,252.07,252.07,,,,,,
Humana,ExceptCPT,81271,Htt gene detc abnor alleles,Medicare Fee Schedule 005-609,Per Unit,$376.75 ,OP,376.75,376.75,,,,,,
Humana,ExceptCPT,81272,Kit gene targeted seq analys,Medicare Fee Schedule 005-609,Per Unit,$906.15 ,OP,906.15,906.15,,,,,,
Humana,ExceptCPT,81273,Kit gene analys d816 variant,Medicare Fee Schedule 005-609,Per Unit,$343.39 ,OP,343.39,343.39,,,,,,
Humana,ExceptCPT,81274,Htt gene charac alleles,Medicare Fee Schedule 005-609,Per Unit,$755.78 ,OP,755.78,755.78,,,,,,
Humana,ExceptCPT,81275,Kras gene variants exon 2,Medicare Fee Schedule 005-609,Per Unit,$531.44 ,OP,531.44,531.44,,,,,,
Humana,ExceptCPT,81276,Kras gene addl variants,Medicare Fee Schedule 005-609,Per Unit,$531.44 ,OP,531.44,531.44,,,,,,
Humana,ExceptCPT,81277,Cytogenomic neo microra alys,Medicare Fee Schedule 005-609,Per Unit,"$3,190.00 ",OP,"3,190.00","3,190.00",,,,,,
Humana,ExceptCPT,81283,Ifnl3 gene,Medicare Fee Schedule 005-609,Per Unit,$201.77 ,OP,201.77,201.77,,,,,,
Humana,ExceptCPT,81284,Fxn gene detc abnor alleles,Medicare Fee Schedule 005-609,Per Unit,$376.75 ,OP,376.75,376.75,,,,,,
Humana,ExceptCPT,81285,Fxn gene charac alleles,Medicare Fee Schedule 005-609,Per Unit,$755.78 ,OP,755.78,755.78,,,,,,
Humana,ExceptCPT,81286,Fxn gene full gene sequence,Medicare Fee Schedule 005-609,Per Unit,$755.78 ,OP,755.78,755.78,,,,,,
Humana,ExceptCPT,81287,Mgmt gene prmtr mthyltn alys,Medicare Fee Schedule 005-609,Per Unit,$342.76 ,OP,342.76,342.76,,,,,,
Humana,ExceptCPT,81288,Mlh1 gene,Medicare Fee Schedule 005-609,Per Unit,$528.88 ,OP,528.88,528.88,,,,,,
Humana,ExceptCPT,81289,Fxn gene known famil variant,Medicare Fee Schedule 005-609,Per Unit,$509.30 ,OP,509.3,509.3,,,,,,
Humana,ExceptCPT,81290,Mcoln1 gene,Medicare Fee Schedule 005-609,Per Unit,$108.10 ,OP,108.1,108.1,,,,,,
Humana,ExceptCPT,81291,Mthfr gene,Medicare Fee Schedule 005-609,Per Unit,$179.69 ,OP,179.69,179.69,,,,,,
Humana,ExceptCPT,81292,Mlh1 gene full seq,Medicare Fee Schedule 005-609,Per Unit,"$1,857.35 ",OP,"1,857.35","1,857.35",,,,,,
Humana,ExceptCPT,81293,Mlh1 gene known variants,Medicare Fee Schedule 005-609,Per Unit,$910.25 ,OP,910.25,910.25,,,,,,
Humana,ExceptCPT,81294,Mlh1 gene dup/delete variant,Medicare Fee Schedule 005-609,Per Unit,$556.60 ,OP,556.6,556.6,,,,,,
Humana,ExceptCPT,81295,Msh2 gene full seq,Medicare Fee Schedule 005-609,Per Unit,"$1,049.68 ",OP,"1,049.68","1,049.68",,,,,,
Humana,ExceptCPT,81296,Msh2 gene known variants,Medicare Fee Schedule 005-609,Per Unit,$928.76 ,OP,928.76,928.76,,,,,,
Humana,ExceptCPT,81297,Msh2 gene dup/delete variant,Medicare Fee Schedule 005-609,Per Unit,$586.58 ,OP,586.58,586.58,,,,,,
Humana,ExceptCPT,81298,Msh6 gene full seq,Medicare Fee Schedule 005-609,Per Unit,"$1,765.09 ",OP,"1,765.09","1,765.09",,,,,,
Humana,ExceptCPT,81299,Msh6 gene known variants,Medicare Fee Schedule 005-609,Per Unit,$847.00 ,OP,847,847,,,,,,
Humana,ExceptCPT,81300,Msh6 gene dup/delete variant,Medicare Fee Schedule 005-609,Per Unit,$654.50 ,OP,654.5,654.5,,,,,,
Humana,ExceptCPT,81301,Microsatellite instability,Medicare Fee Schedule 005-609,Per Unit,$958.54 ,OP,958.54,958.54,,,,,,
Humana,ExceptCPT,81302,Mecp2 gene full seq,Medicare Fee Schedule 005-609,Per Unit,"$1,451.64 ",OP,"1,451.64","1,451.64",,,,,,
Humana,ExceptCPT,81303,Mecp2 gene known variant,Medicare Fee Schedule 005-609,Per Unit,$330.00 ,OP,330,330,,,,,,
Humana,ExceptCPT,81304,Mecp2 gene dup/delet variant,Medicare Fee Schedule 005-609,Per Unit,$412.50 ,OP,412.5,412.5,,,,,,
Humana,ExceptCPT,81305,Myd88 gene p.leu265pro vrnt,Medicare Fee Schedule 005-609,Per Unit,$482.35 ,OP,482.35,482.35,,,,,,
Humana,ExceptCPT,81306,Nudt15 gene common variants,Medicare Fee Schedule 005-609,Per Unit,$801.24 ,OP,801.24,801.24,,,,,,
Humana,ExceptCPT,81307,Palb2 gene full gene seq,Medicare Fee Schedule 005-609,Per Unit,"$1,860.38 ",OP,"1,860.38","1,860.38",,,,,,
Humana,ExceptCPT,81308,Palb2 gene known famil vrnt,Medicare Fee Schedule 005-609,Per Unit,$828.71 ,OP,828.71,828.71,,,,,,
Humana,ExceptCPT,81309,Pik3ca gene trgt seq alys,Medicare Fee Schedule 005-609,Per Unit,$755.78 ,OP,755.78,755.78,,,,,,
Humana,ExceptCPT,81310,Npm1 gene,Medicare Fee Schedule 005-609,Per Unit,$677.93 ,OP,677.93,677.93,,,,,,
Humana,ExceptCPT,81311,Nras gene variants exon 2&3,Medicare Fee Schedule 005-609,Per Unit,$813.42 ,OP,813.42,813.42,,,,,,
Humana,ExceptCPT,81312,Pabpn1 gene detc abnor allel,Medicare Fee Schedule 005-609,Per Unit,$376.75 ,OP,376.75,376.75,,,,,,
Humana,ExceptCPT,81313,Pca3/klk3 antigen,Medicare Fee Schedule 005-609,Per Unit,$701.39 ,OP,701.39,701.39,,,,,,
Humana,ExceptCPT,81314,Pdgfra gene,Medicare Fee Schedule 005-609,Per Unit,$906.15 ,OP,906.15,906.15,,,,,,
Humana,ExceptCPT,81315,Pml/raralpha com breakpoints,Medicare Fee Schedule 005-609,Per Unit,$570.10 ,OP,570.1,570.1,,,,,,
Humana,ExceptCPT,81316,Pml/raralpha 1 breakpoint,Medicare Fee Schedule 005-609,Per Unit,$570.10 ,OP,570.1,570.1,,,,,,
Humana,ExceptCPT,81317,Pms2 gene full seq analysis,Medicare Fee Schedule 005-609,Per Unit,"$1,860.38 ",OP,"1,860.38","1,860.38",,,,,,
Humana,ExceptCPT,81318,Pms2 known familial variants,Medicare Fee Schedule 005-609,Per Unit,$910.25 ,OP,910.25,910.25,,,,,,
Humana,ExceptCPT,81319,Pms2 gene dup/delet variants,Medicare Fee Schedule 005-609,Per Unit,$559.63 ,OP,559.63,559.63,,,,,,
Humana,ExceptCPT,81320,Plcg2 gene common variants,Medicare Fee Schedule 005-609,Per Unit,$801.24 ,OP,801.24,801.24,,,,,,
Humana,ExceptCPT,81321,Pten gene full sequence,Medicare Fee Schedule 005-609,Per Unit,"$1,650.00 ",OP,"1,650.00","1,650.00",,,,,,
Humana,ExceptCPT,81322,Pten gene known fam variant,Medicare Fee Schedule 005-609,Per Unit,$128.15 ,OP,128.15,128.15,,,,,,
Humana,ExceptCPT,81323,Pten gene dup/delet variant,Medicare Fee Schedule 005-609,Per Unit,$825.00 ,OP,825,825,,,,,,
Humana,ExceptCPT,81324,Pmp22 gene dup/delet,Medicare Fee Schedule 005-609,Per Unit,"$2,085.49 ",OP,"2,085.49","2,085.49",,,,,,
Humana,ExceptCPT,81325,Pmp22 gene full sequence,Medicare Fee Schedule 005-609,Per Unit,"$2,116.35 ",OP,"2,116.35","2,116.35",,,,,,
Humana,ExceptCPT,81326,Pmp22 gene known fam variant,Medicare Fee Schedule 005-609,Per Unit,$128.15 ,OP,128.15,128.15,,,,,,
Humana,ExceptCPT,81327,Sept9 gen prmtr mthyltn alys,Medicare Fee Schedule 005-609,Per Unit,$528.00 ,OP,528,528,,,,,,
Humana,ExceptCPT,81328,Slco1b1 gene com variants,Medicare Fee Schedule 005-609,Per Unit,$480.73 ,OP,480.73,480.73,,,,,,
Humana,ExceptCPT,81329,Smn1 gene dos/deletion alys,Medicare Fee Schedule 005-609,Per Unit,$376.75 ,OP,376.75,376.75,,,,,,
Humana,ExceptCPT,81330,Smpd1 gene common variants,Medicare Fee Schedule 005-609,Per Unit,$129.25 ,OP,129.25,129.25,,,,,,
Humana,ExceptCPT,81331,Snrpn/ube3a gene,Medicare Fee Schedule 005-609,Per Unit,$140.44 ,OP,140.44,140.44,,,,,,
Humana,ExceptCPT,81332,Serpina1 gene,Medicare Fee Schedule 005-609,Per Unit,$120.04 ,OP,120.04,120.04,,,,,,
Humana,ExceptCPT,81333,Tgfbi gene common variants,Medicare Fee Schedule 005-609,Per Unit,$376.75 ,OP,376.75,376.75,,,,,,
Humana,ExceptCPT,81334,Runx1 gene targeted seq alys,Medicare Fee Schedule 005-609,Per Unit,$906.15 ,OP,906.15,906.15,,,,,,
Humana,ExceptCPT,81335,Tpmt gene com variants,Medicare Fee Schedule 005-609,Per Unit,$480.73 ,OP,480.73,480.73,,,,,,
Humana,ExceptCPT,81336,Smn1 gene full gene sequence,Medicare Fee Schedule 005-609,Per Unit,$828.71 ,OP,828.71,828.71,,,,,,
Humana,ExceptCPT,81337,Smn1 gen nown famil seq vrnt,Medicare Fee Schedule 005-609,Per Unit,$509.30 ,OP,509.3,509.3,,,,,,
Humana,ExceptCPT,81340,Trb@ gene rearrange amplify,Medicare Fee Schedule 005-609,Per Unit,$574.53 ,OP,574.53,574.53,,,,,,
Humana,ExceptCPT,81341,Trb@ gene rearrange dirprobe,Medicare Fee Schedule 005-609,Per Unit,$136.37 ,OP,136.37,136.37,,,,,,
Humana,ExceptCPT,81342,Trg gene rearrangement anal,Medicare Fee Schedule 005-609,Per Unit,$554.13 ,OP,554.13,554.13,,,,,,
Humana,ExceptCPT,81343,Ppp2r2b gen detc abnor allel,Medicare Fee Schedule 005-609,Per Unit,$376.75 ,OP,376.75,376.75,,,,,,
Humana,ExceptCPT,81344,Tbp gene detc abnor alleles,Medicare Fee Schedule 005-609,Per Unit,$376.75 ,OP,376.75,376.75,,,,,,
Humana,ExceptCPT,81345,Tert gene targeted seq alys,Medicare Fee Schedule 005-609,Per Unit,$509.30 ,OP,509.3,509.3,,,,,,
Humana,ExceptCPT,81346,Tyms gene com variants,Medicare Fee Schedule 005-609,Per Unit,$480.73 ,OP,480.73,480.73,,,,,,
Humana,ExceptCPT,81350,Ugt1a1 gene common variants,Medicare Fee Schedule 005-609,Per Unit,$643.50 ,OP,643.5,643.5,,,,,,
Humana,ExceptCPT,81355,Vkorc1 gene,Medicare Fee Schedule 005-609,Per Unit,$242.55 ,OP,242.55,242.55,,,,,,
Humana,ExceptCPT,81361,Hbb gene com variants,Medicare Fee Schedule 005-609,Per Unit,$480.73 ,OP,480.73,480.73,,,,,,
Humana,ExceptCPT,81362,Hbb gene known fam variant,Medicare Fee Schedule 005-609,Per Unit,"$1,031.94 ",OP,"1,031.94","1,031.94",,,,,,
Humana,ExceptCPT,81363,Hbb gene dup/del variants,Medicare Fee Schedule 005-609,Per Unit,$556.60 ,OP,556.6,556.6,,,,,,
Humana,ExceptCPT,81364,Hbb full gene sequence,Medicare Fee Schedule 005-609,Per Unit,$892.60 ,OP,892.6,892.6,,,,,,
Humana,ExceptCPT,81370,Hla i & ii typing lr,Medicare Fee Schedule 005-609,Per Unit,"$1,105.83 ",OP,"1,105.83","1,105.83",,,,,,
Humana,ExceptCPT,81371,Hla i & ii type verify lr,Medicare Fee Schedule 005-609,Per Unit,"$1,112.43 ",OP,"1,112.43","1,112.43",,,,,,
Humana,ExceptCPT,81372,Hla i typing complete lr,Medicare Fee Schedule 005-609,Per Unit,"$1,109.87 ",OP,"1,109.87","1,109.87",,,,,,
Humana,ExceptCPT,81373,Hla i typing 1 locus lr,Medicare Fee Schedule 005-609,Per Unit,$350.43 ,OP,350.43,350.43,,,,,,
Humana,ExceptCPT,81374,Hla i typing 1 antigen lr,Medicare Fee Schedule 005-609,Per Unit,$204.41 ,OP,204.41,204.41,,,,,,
Humana,ExceptCPT,81375,Hla ii typing ag equiv lr,Medicare Fee Schedule 005-609,Per Unit,$607.04 ,OP,607.04,607.04,,,,,,
Humana,ExceptCPT,81376,Hla ii typing 1 locus lr,Medicare Fee Schedule 005-609,Per Unit,$336.11 ,OP,336.11,336.11,,,,,,
Humana,ExceptCPT,81377,Hla ii type 1 ag equiv lr,Medicare Fee Schedule 005-609,Per Unit,$260.54 ,OP,260.54,260.54,,,,,,
Humana,ExceptCPT,81378,Hla i & ii typing hr,Medicare Fee Schedule 005-609,Per Unit,$950.32 ,OP,950.32,950.32,,,,,,
Humana,ExceptCPT,81379,Hla i typing complete hr,Medicare Fee Schedule 005-609,Per Unit,$922.30 ,OP,922.3,922.3,,,,,,
Humana,ExceptCPT,81380,Hla i typing 1 locus hr,Medicare Fee Schedule 005-609,Per Unit,$487.44 ,OP,487.44,487.44,,,,,,
Humana,ExceptCPT,81381,Hla i typing 1 allele hr,Medicare Fee Schedule 005-609,Per Unit,$467.23 ,OP,467.23,467.23,,,,,,
Humana,ExceptCPT,81382,Hla ii typing 1 loc hr,Medicare Fee Schedule 005-609,Per Unit,$340.12 ,OP,340.12,340.12,,,,,,
Humana,ExceptCPT,81383,Hla ii typing 1 allele hr,Medicare Fee Schedule 005-609,Per Unit,$300.11 ,OP,300.11,300.11,,,,,,
Humana,ExceptCPT,81400,Mopath procedure level 1,Medicare Fee Schedule 005-609,Per Unit,$175.89 ,OP,175.89,175.89,,,,,,
Humana,ExceptCPT,81401,Mopath procedure level 2,Medicare Fee Schedule 005-609,Per Unit,$376.75 ,OP,376.75,376.75,,,,,,
Humana,ExceptCPT,81402,Mopath procedure level 3,Medicare Fee Schedule 005-609,Per Unit,$413.41 ,OP,413.41,413.41,,,,,,
Humana,ExceptCPT,81403,Mopath procedure level 4,Medicare Fee Schedule 005-609,Per Unit,$509.30 ,OP,509.3,509.3,,,,,,
Humana,ExceptCPT,81404,Mopath procedure level 5,Medicare Fee Schedule 005-609,Per Unit,$755.78 ,OP,755.78,755.78,,,,,,
Humana,ExceptCPT,81405,Mopath procedure level 6,Medicare Fee Schedule 005-609,Per Unit,$828.71 ,OP,828.71,828.71,,,,,,
Humana,ExceptCPT,81406,Mopath procedure level 7,Medicare Fee Schedule 005-609,Per Unit,$777.92 ,OP,777.92,777.92,,,,,,
Humana,ExceptCPT,81407,Mopath procedure level 8,Medicare Fee Schedule 005-609,Per Unit,"$2,327.24 ",OP,"2,327.24","2,327.24",,,,,,
Humana,ExceptCPT,81408,Mopath procedure level 9,Medicare Fee Schedule 005-609,Per Unit,"$5,500.00 ",OP,"5,500.00","5,500.00",,,,,,
Humana,ExceptCPT,81410,Aortic dysfunction/dilation,Medicare Fee Schedule 005-609,Per Unit,"$1,386.00 ",OP,"1,386.00","1,386.00",,,,,,
Humana,ExceptCPT,81411,Aortic dysfunction/dilation,Medicare Fee Schedule 005-609,Per Unit,"$3,713.02 ",OP,"3,713.02","3,713.02",,,,,,
Humana,ExceptCPT,81412,Ashkenazi jewish assoc dis,Medicare Fee Schedule 005-609,Per Unit,"$6,733.54 ",OP,"6,733.54","6,733.54",,,,,,
Humana,ExceptCPT,81413,Car ion chnnlpath inc 10 gns,Medicare Fee Schedule 005-609,Per Unit,"$1,608.48 ",OP,"1,608.48","1,608.48",,,,,,
Humana,ExceptCPT,81414,Car ion chnnlpath inc 2 gns,Medicare Fee Schedule 005-609,Per Unit,"$1,608.48 ",OP,"1,608.48","1,608.48",,,,,,
Humana,ExceptCPT,81415,Exome sequence analysis,Medicare Fee Schedule 005-609,Per Unit,"$13,145.00 ",OP,"13,145.00","13,145.00",,,,,,
Humana,ExceptCPT,81416,Exome sequence analysis,Medicare Fee Schedule 005-609,Per Unit,"$33,000.00 ",OP,"33,000.00","33,000.00",,,,,,
Humana,ExceptCPT,81417,Exome re-evaluation,Medicare Fee Schedule 005-609,Per Unit,$880.00 ,OP,880,880,,,,,,
Humana,ExceptCPT,81420,Fetal chrmoml aneuploidy,Medicare Fee Schedule 005-609,Per Unit,"$2,087.39 ",OP,"2,087.39","2,087.39",,,,,,
Humana,ExceptCPT,81422,Fetal chrmoml microdeltj,Medicare Fee Schedule 005-609,Per Unit,"$2,087.39 ",OP,"2,087.39","2,087.39",,,,,,
Humana,ExceptCPT,81425,Genome sequence analysis,Medicare Fee Schedule 005-609,Per Unit,"$13,835.80 ",OP,"13,835.80","13,835.80",,,,,,
Humana,ExceptCPT,81426,Genome sequence analysis,Medicare Fee Schedule 005-609,Per Unit,"$7,452.36 ",OP,"7,452.36","7,452.36",,,,,,
Humana,ExceptCPT,81427,Genome re-evaluation,Medicare Fee Schedule 005-609,Per Unit,"$6,428.54 ",OP,"6,428.54","6,428.54",,,,,,
Humana,ExceptCPT,81430,Hearing loss sequence analys,Medicare Fee Schedule 005-609,Per Unit,"$4,468.75 ",OP,"4,468.75","4,468.75",,,,,,
Humana,ExceptCPT,81431,Hearing loss dup/del analys,Medicare Fee Schedule 005-609,Per Unit,"$1,868.82 ",OP,"1,868.82","1,868.82",,,,,,
Humana,ExceptCPT,81432,Hrdtry brst ca-rlatd dsordrs,Medicare Fee Schedule 005-609,Per Unit,"$1,867.39 ",OP,"1,867.39","1,867.39",,,,,,
Humana,ExceptCPT,81433,Hrdtry brst ca-rlatd dsordrs,Medicare Fee Schedule 005-609,Per Unit,"$1,207.06 ",OP,"1,207.06","1,207.06",,,,,,
Humana,ExceptCPT,81434,Hereditary retinal disorders,Medicare Fee Schedule 005-609,Per Unit,"$1,644.25 ",OP,"1,644.25","1,644.25",,,,,,
Humana,ExceptCPT,81435,Hereditary colon ca dsordrs,Medicare Fee Schedule 005-609,Per Unit,"$1,608.48 ",OP,"1,608.48","1,608.48",,,,,,
Humana,ExceptCPT,81436,Hereditary colon ca dsordrs,Medicare Fee Schedule 005-609,Per Unit,"$1,608.48 ",OP,"1,608.48","1,608.48",,,,,,
Humana,ExceptCPT,81437,Heredtry nurondcrn tum dsrdr,Medicare Fee Schedule 005-609,Per Unit,"$1,207.06 ",OP,"1,207.06","1,207.06",,,,,,
Humana,ExceptCPT,81438,Heredtry nurondcrn tum dsrdr,Medicare Fee Schedule 005-609,Per Unit,"$1,207.06 ",OP,"1,207.06","1,207.06",,,,,,
Humana,ExceptCPT,81439,Hrdtry cardmypy gene panel,Medicare Fee Schedule 005-609,Per Unit,"$1,608.48 ",OP,"1,608.48","1,608.48",,,,,,
Humana,ExceptCPT,81440,Mitochondrial gene,Medicare Fee Schedule 005-609,Per Unit,"$9,141.00 ",OP,"9,141.00","9,141.00",,,,,,
Humana,ExceptCPT,81442,Noonan spectrum disorders,Medicare Fee Schedule 005-609,Per Unit,"$5,894.90 ",OP,"5,894.90","5,894.90",,,,,,
Humana,ExceptCPT,81443,Genetic tstg severe inh cond,Medicare Fee Schedule 005-609,Per Unit,"$6,733.54 ",OP,"6,733.54","6,733.54",,,,,,
Humana,ExceptCPT,81445,Targeted genomic seq analys,Medicare Fee Schedule 005-609,Per Unit,"$1,644.25 ",OP,"1,644.25","1,644.25",,,,,,
Humana,ExceptCPT,81448,Hrdtry perph neurphy panel,Medicare Fee Schedule 005-609,Per Unit,"$1,608.48 ",OP,"1,608.48","1,608.48",,,,,,
Humana,ExceptCPT,81450,Targeted genomic seq analys,Medicare Fee Schedule 005-609,Per Unit,"$2,088.71 ",OP,"2,088.71","2,088.71",,,,,,
Humana,ExceptCPT,81455,Targeted genomic seq analys,Medicare Fee Schedule 005-609,Per Unit,"$8,028.90 ",OP,"8,028.90","8,028.90",,,,,,
Humana,ExceptCPT,81460,Whole mitochondrial genome,Medicare Fee Schedule 005-609,Per Unit,"$3,539.25 ",OP,"3,539.25","3,539.25",,,,,,
Humana,ExceptCPT,81465,Whole mitochondrial genome,Medicare Fee Schedule 005-609,Per Unit,"$2,574.00 ",OP,"2,574.00","2,574.00",,,,,,
Humana,ExceptCPT,81470,X-linked intellectual dblt,Medicare Fee Schedule 005-609,Per Unit,"$2,513.50 ",OP,"2,513.50","2,513.50",,,,,,
Humana,ExceptCPT,81471,X-linked intellectual dblt,Medicare Fee Schedule 005-609,Per Unit,"$2,513.50 ",OP,"2,513.50","2,513.50",,,,,,
Humana,ExceptCPT,81490,Autoimmune rheumatoid arthr,Medicare Fee Schedule 005-609,Per Unit,"$2,311.79 ",OP,"2,311.79","2,311.79",,,,,,
Humana,ExceptCPT,81493,Cor artery disease mrna,Medicare Fee Schedule 005-609,Per Unit,"$2,887.50 ",OP,"2,887.50","2,887.50",,,,,,
Humana,ExceptCPT,81500,Onco (ovar) two proteins,Medicare Fee Schedule 005-609,Per Unit,$716.38 ,OP,716.38,716.38,,,,,,
Humana,ExceptCPT,81503,Onco (ovar) five proteins,Medicare Fee Schedule 005-609,Per Unit,"$2,466.75 ",OP,"2,466.75","2,466.75",,,,,,
Humana,ExceptCPT,81504,Oncology tissue of origin,Medicare Fee Schedule 005-609,Per Unit,"$1,430.00 ",OP,"1,430.00","1,430.00",,,,,,
Humana,ExceptCPT,81506,Endo assay seven anal,Medicare Fee Schedule 005-609,Per Unit,$189.53 ,OP,189.53,189.53,,,,,,
Humana,ExceptCPT,81507,Fetal aneuploidy trisom risk,Medicare Fee Schedule 005-609,Per Unit,"$2,186.25 ",OP,"2,186.25","2,186.25",,,,,,
Humana,ExceptCPT,81508,Ftl cgen abnor two proteins,Medicare Fee Schedule 005-609,Per Unit,$149.33 ,OP,149.33,149.33,,,,,,
Humana,ExceptCPT,81509,Ftl cgen abnor 3 proteins,Medicare Fee Schedule 005-609,Per Unit,"$4,090.27 ",OP,"4,090.27","4,090.27",,,,,,
Humana,ExceptCPT,81510,Ftl cgen abnor three anal,Medicare Fee Schedule 005-609,Per Unit,$152.74 ,OP,152.74,152.74,,,,,,
Humana,ExceptCPT,81511,Ftl cgen abnor four anal,Medicare Fee Schedule 005-609,Per Unit,$422.13 ,OP,422.13,422.13,,,,,,
Humana,ExceptCPT,81512,Ftl cgen abnor five anal,Medicare Fee Schedule 005-609,Per Unit,$191.18 ,OP,191.18,191.18,,,,,,
Humana,ExceptCPT,81518,Onc brst mrna 11 genes,Medicare Fee Schedule 005-609,Per Unit,"$10,650.75 ",OP,"10,650.75","10,650.75",,,,,,
Humana,ExceptCPT,81519,Oncology breast mrna,Medicare Fee Schedule 005-609,Per Unit,"$10,650.75 ",OP,"10,650.75","10,650.75",,,,,,
Humana,ExceptCPT,81520,Onc breast mrna 58 genes,Medicare Fee Schedule 005-609,Per Unit,"$6,903.08 ",OP,"6,903.08","6,903.08",,,,,,
Humana,ExceptCPT,81521,Onc breast mrna 70 genes,Medicare Fee Schedule 005-609,Per Unit,"$10,650.75 ",OP,"10,650.75","10,650.75",,,,,,
Humana,ExceptCPT,81522,Onc breast mrna 12 genes,Medicare Fee Schedule 005-609,Per Unit,"$10,650.75 ",OP,"10,650.75","10,650.75",,,,,,
Humana,ExceptCPT,81525,Oncology colon mrna,Medicare Fee Schedule 005-609,Per Unit,"$8,569.00 ",OP,"8,569.00","8,569.00",,,,,,
Humana,ExceptCPT,81528,Oncology colorectal scr,Medicare Fee Schedule 005-609,Per Unit,"$1,399.39 ",OP,"1,399.39","1,399.39",,,,,,
Humana,ExceptCPT,81535,Oncology gynecologic,Medicare Fee Schedule 005-609,Per Unit,"$1,593.52 ",OP,"1,593.52","1,593.52",,,,,,
Humana,ExceptCPT,81536,Oncology gynecologic,Medicare Fee Schedule 005-609,Per Unit,$488.29 ,OP,488.29,488.29,,,,,,
Humana,ExceptCPT,81538,Oncology lung,Medicare Fee Schedule 005-609,Per Unit,"$7,895.25 ",OP,"7,895.25","7,895.25",,,,,,
Humana,ExceptCPT,81539,Oncology prostate prob score,Medicare Fee Schedule 005-609,Per Unit,"$2,090.00 ",OP,"2,090.00","2,090.00",,,,,,
Humana,ExceptCPT,81540,Oncology tum unknown origin,Medicare Fee Schedule 005-609,Per Unit,"$10,312.50 ",OP,"10,312.50","10,312.50",,,,,,
Humana,ExceptCPT,81541,Onc prostate mrna 46 genes,Medicare Fee Schedule 005-609,Per Unit,"$10,650.75 ",OP,"10,650.75","10,650.75",,,,,,
Humana,ExceptCPT,81545,Oncology thyroid,Medicare Fee Schedule 005-609,Per Unit,"$9,900.00 ",OP,"9,900.00","9,900.00",,,,,,
Humana,ExceptCPT,81551,Onc prostate 3 genes,Medicare Fee Schedule 005-609,Per Unit,"$5,582.50 ",OP,"5,582.50","5,582.50",,,,,,
Humana,ExceptCPT,81595,Cardiology hrt trnspl mrna,Medicare Fee Schedule 005-609,Per Unit,"$8,910.00 ",OP,"8,910.00","8,910.00",,,,,,
Humana,ExceptCPT,81596,Nfct ds chrnc hcv 6 assays,Medicare Fee Schedule 005-609,Per Unit,$198.52 ,OP,198.52,198.52,,,,,,
Humana,ExceptCPT,82009,Test for acetone/ketones,Medicare Fee Schedule 005-609,Per Unit,$12.43 ,OP,12.43,12.43,,,,,,
Humana,ExceptCPT,82010,Acetone assay,Medicare Fee Schedule 005-609,Per Unit,$22.47 ,OP,22.47,22.47,,,,,,
Humana,ExceptCPT,82013,Acetylcholinesterase assay,Medicare Fee Schedule 005-609,Per Unit,$33.80 ,OP,33.8,33.8,,,,,,
Humana,ExceptCPT,82016,Acylcarnitines qual,Medicare Fee Schedule 005-609,Per Unit,$45.35 ,OP,45.35,45.35,,,,,,
Humana,ExceptCPT,82017,Acylcarnitines quant,Medicare Fee Schedule 005-609,Per Unit,$46.39 ,OP,46.39,46.39,,,,,,
Humana,ExceptCPT,82024,Assay of acth,Medicare Fee Schedule 005-609,Per Unit,$106.21 ,OP,106.21,106.21,,,,,,
Humana,ExceptCPT,82030,Assay of adp & amp,Medicare Fee Schedule 005-609,Per Unit,$70.95 ,OP,70.95,70.95,,,,,,
Humana,ExceptCPT,82040,Assay of serum albumin,Medicare Fee Schedule 005-609,Per Unit,$13.61 ,OP,13.61,13.61,,,,,,
Humana,ExceptCPT,82042,Other source albumin quan ea,Medicare Fee Schedule 005-609,Per Unit,$21.40 ,OP,21.4,21.4,,,,,,
Humana,ExceptCPT,82043,Ur albumin quantitative,Medicare Fee Schedule 005-609,Per Unit,$15.90 ,OP,15.9,15.9,,,,,,
Humana,ExceptCPT,82044,Ur albumin semiquantitative,Medicare Fee Schedule 005-609,Per Unit,$17.13 ,OP,17.13,17.13,,,,,,
Humana,ExceptCPT,82045,Albumin ischemia modified,Medicare Fee Schedule 005-609,Per Unit,$93.34 ,OP,93.34,93.34,,,,,,
Humana,ExceptCPT,82075,Assay of breath ethanol,Medicare Fee Schedule 005-609,Per Unit,$82.50 ,OP,82.5,82.5,,,,,,
Humana,ExceptCPT,82085,Assay of aldolase,Medicare Fee Schedule 005-609,Per Unit,$26.70 ,OP,26.7,26.7,,,,,,
Humana,ExceptCPT,82088,Assay of aldosterone,Medicare Fee Schedule 005-609,Per Unit,$112.06 ,OP,112.06,112.06,,,,,,
Humana,ExceptCPT,82103,Alpha-1-antitrypsin total,Medicare Fee Schedule 005-609,Per Unit,$36.96 ,OP,36.96,36.96,,,,,,
Humana,ExceptCPT,82104,Alpha-1-antitrypsin pheno,Medicare Fee Schedule 005-609,Per Unit,$39.77 ,OP,39.77,39.77,,,,,,
Humana,ExceptCPT,82105,Alpha-fetoprotein serum,Medicare Fee Schedule 005-609,Per Unit,$46.12 ,OP,46.12,46.12,,,,,,
Humana,ExceptCPT,82106,Alpha-fetoprotein amniotic,Medicare Fee Schedule 005-609,Per Unit,$46.75 ,OP,46.75,46.75,,,,,,
Humana,ExceptCPT,82107,Alpha-fetoprotein l3,Medicare Fee Schedule 005-609,Per Unit,$177.13 ,OP,177.13,177.13,,,,,,
Humana,ExceptCPT,82108,Assay of aluminum,Medicare Fee Schedule 005-609,Per Unit,$70.07 ,OP,70.07,70.07,,,,,,
Humana,ExceptCPT,82120,Amines vaginal fluid qual,Medicare Fee Schedule 005-609,Per Unit,$16.47 ,OP,16.47,16.47,,,,,,
Humana,ExceptCPT,82127,Amino acid single qual,Medicare Fee Schedule 005-609,Per Unit,$39.00 ,OP,39,39,,,,,,
Humana,ExceptCPT,82128,Amino acids mult qual,Medicare Fee Schedule 005-609,Per Unit,$38.14 ,OP,38.14,38.14,,,,,,
Humana,ExceptCPT,82131,Amino acids single quant,Medicare Fee Schedule 005-609,Per Unit,$63.20 ,OP,63.2,63.2,,,,,,
Humana,ExceptCPT,82135,Assay aminolevulinic acid,Medicare Fee Schedule 005-609,Per Unit,$45.24 ,OP,45.24,45.24,,,,,,
Humana,ExceptCPT,82136,Amino acids quant 2-5,Medicare Fee Schedule 005-609,Per Unit,$53.93 ,OP,53.93,53.93,,,,,,
Humana,ExceptCPT,82139,Amino acids quan 6 or more,Medicare Fee Schedule 005-609,Per Unit,$46.39 ,OP,46.39,46.39,,,,,,
Humana,ExceptCPT,82140,Assay of ammonia,Medicare Fee Schedule 005-609,Per Unit,$40.07 ,OP,40.07,40.07,,,,,,
Humana,ExceptCPT,82143,Amniotic fluid scan,Medicare Fee Schedule 005-609,Per Unit,$25.71 ,OP,25.71,25.71,,,,,,
Humana,ExceptCPT,82150,Assay of amylase,Medicare Fee Schedule 005-609,Per Unit,$17.82 ,OP,17.82,17.82,,,,,,
Humana,ExceptCPT,82154,Androstanediol glucuronide,Medicare Fee Schedule 005-609,Per Unit,$79.28 ,OP,79.28,79.28,,,,,,
Humana,ExceptCPT,82157,Assay of androstenedione,Medicare Fee Schedule 005-609,Per Unit,$80.52 ,OP,80.52,80.52,,,,,,
Humana,ExceptCPT,82160,Assay of androsterone,Medicare Fee Schedule 005-609,Per Unit,$70.26 ,OP,70.26,70.26,,,,,,
Humana,ExceptCPT,82163,Assay of angiotensin ii,Medicare Fee Schedule 005-609,Per Unit,$56.43 ,OP,56.43,56.43,,,,,,
Humana,ExceptCPT,82164,Angiotensin i enzyme test,Medicare Fee Schedule 005-609,Per Unit,$40.15 ,OP,40.15,40.15,,,,,,
Humana,ExceptCPT,82172,Assay of apolipoprotein,Medicare Fee Schedule 005-609,Per Unit,$58.00 ,OP,58,58,,,,,,
Humana,ExceptCPT,82175,Assay of arsenic,Medicare Fee Schedule 005-609,Per Unit,$52.17 ,OP,52.17,52.17,,,,,,
Humana,ExceptCPT,82180,Assay of ascorbic acid,Medicare Fee Schedule 005-609,Per Unit,$27.20 ,OP,27.2,27.2,,,,,,
Humana,ExceptCPT,82190,Atomic absorption,Medicare Fee Schedule 005-609,Per Unit,$43.73 ,OP,43.73,43.73,,,,,,
Humana,ExceptCPT,82232,Assay of beta-2 protein,Medicare Fee Schedule 005-609,Per Unit,$44.50 ,OP,44.5,44.5,,,,,,
Humana,ExceptCPT,82239,Bile acids total,Medicare Fee Schedule 005-609,Per Unit,$47.08 ,OP,47.08,47.08,,,,,,
Humana,ExceptCPT,82240,Bile acids cholylglycine,Medicare Fee Schedule 005-609,Per Unit,$73.10 ,OP,73.1,73.1,,,,,,
Humana,ExceptCPT,82247,Bilirubin total,Medicare Fee Schedule 005-609,Per Unit,$13.81 ,OP,13.81,13.81,,,,,,
Humana,ExceptCPT,82248,Bilirubin direct,Medicare Fee Schedule 005-609,Per Unit,$13.81 ,OP,13.81,13.81,,,,,,
Humana,ExceptCPT,82252,Fecal bilirubin test,Medicare Fee Schedule 005-609,Per Unit,$12.54 ,OP,12.54,12.54,,,,,,
Humana,ExceptCPT,82261,Assay of biotinidase,Medicare Fee Schedule 005-609,Per Unit,$46.39 ,OP,46.39,46.39,,,,,,
Humana,ExceptCPT,82270,Occult blood feces,Medicare Fee Schedule 005-609,Per Unit,$12.05 ,OP,12.05,12.05,,,,,,
Humana,ExceptCPT,82271,Occult blood other sources,Medicare Fee Schedule 005-609,Per Unit,$14.63 ,OP,14.63,14.63,,,,,,
Humana,ExceptCPT,82272,Occult bld feces 1-3 tests,Medicare Fee Schedule 005-609,Per Unit,$11.63 ,OP,11.63,11.63,,,,,,
Humana,ExceptCPT,82274,Assay test for blood fecal,Medicare Fee Schedule 005-609,Per Unit,$43.78 ,OP,43.78,43.78,,,,,,
Humana,ExceptCPT,82286,Assay of bradykinin,Medicare Fee Schedule 005-609,Per Unit,$14.19 ,OP,14.19,14.19,,,,,,
Humana,ExceptCPT,82300,Assay of cadmium,Medicare Fee Schedule 005-609,Per Unit,$65.01 ,OP,65.01,65.01,,,,,,
Humana,ExceptCPT,82306,Vitamin d 25 hydroxy,Medicare Fee Schedule 005-609,Per Unit,$81.40 ,OP,81.4,81.4,,,,,,
Humana,ExceptCPT,82308,Assay of calcitonin,Medicare Fee Schedule 005-609,Per Unit,$73.67 ,OP,73.67,73.67,,,,,,
Humana,ExceptCPT,82310,Assay of calcium,Medicare Fee Schedule 005-609,Per Unit,$14.19 ,OP,14.19,14.19,,,,,,
Humana,ExceptCPT,82330,Assay of calcium,Medicare Fee Schedule 005-609,Per Unit,$37.62 ,OP,37.62,37.62,,,,,,
Humana,ExceptCPT,82331,Calcium infusion test,Medicare Fee Schedule 005-609,Per Unit,$36.69 ,OP,36.69,36.69,,,,,,
Humana,ExceptCPT,82340,Assay of calcium in urine,Medicare Fee Schedule 005-609,Per Unit,$16.58 ,OP,16.58,16.58,,,,,,
Humana,ExceptCPT,82355,Calculus analysis qual,Medicare Fee Schedule 005-609,Per Unit,$31.85 ,OP,31.85,31.85,,,,,,
Humana,ExceptCPT,82360,Calculus assay quant,Medicare Fee Schedule 005-609,Per Unit,$35.39 ,OP,35.39,35.39,,,,,,
Humana,ExceptCPT,82365,Calculus spectroscopy,Medicare Fee Schedule 005-609,Per Unit,$35.48 ,OP,35.48,35.48,,,,,,
Humana,ExceptCPT,82370,X-ray assay calculus,Medicare Fee Schedule 005-609,Per Unit,$34.43 ,OP,34.43,34.43,,,,,,
Humana,ExceptCPT,82373,Assay c-d transfer measure,Medicare Fee Schedule 005-609,Per Unit,$49.67 ,OP,49.67,49.67,,,,,,
Humana,ExceptCPT,82374,Assay blood carbon dioxide,Medicare Fee Schedule 005-609,Per Unit,$13.42 ,OP,13.42,13.42,,,,,,
Humana,ExceptCPT,82375,Assay carboxyhb quant,Medicare Fee Schedule 005-609,Per Unit,$33.88 ,OP,33.88,33.88,,,,,,
Humana,ExceptCPT,82376,Assay carboxyhb qual,Medicare Fee Schedule 005-609,Per Unit,$38.69 ,OP,38.69,38.69,,,,,,
Humana,ExceptCPT,82378,Carcinoembryonic antigen,Medicare Fee Schedule 005-609,Per Unit,$52.14 ,OP,52.14,52.14,,,,,,
Humana,ExceptCPT,82379,Assay of carnitine,Medicare Fee Schedule 005-609,Per Unit,$46.39 ,OP,46.39,46.39,,,,,,
Humana,ExceptCPT,82380,Assay of carotene,Medicare Fee Schedule 005-609,Per Unit,$25.36 ,OP,25.36,25.36,,,,,,
Humana,ExceptCPT,82382,Assay urine catecholamines,Medicare Fee Schedule 005-609,Per Unit,$75.08 ,OP,75.08,75.08,,,,,,
Humana,ExceptCPT,82383,Assay blood catecholamines,Medicare Fee Schedule 005-609,Per Unit,$79.97 ,OP,79.97,79.97,,,,,,
Humana,ExceptCPT,82384,Assay three catecholamines,Medicare Fee Schedule 005-609,Per Unit,$69.44 ,OP,69.44,69.44,,,,,,
Humana,ExceptCPT,82387,Assay of cathepsin-d,Medicare Fee Schedule 005-609,Per Unit,$49.67 ,OP,49.67,49.67,,,,,,
Humana,ExceptCPT,82390,Assay of ceruloplasmin,Medicare Fee Schedule 005-609,Per Unit,$29.54 ,OP,29.54,29.54,,,,,,
Humana,ExceptCPT,82397,Chemiluminescent assay,Medicare Fee Schedule 005-609,Per Unit,$38.83 ,OP,38.83,38.83,,,,,,
Humana,ExceptCPT,82415,Assay of chloramphenicol,Medicare Fee Schedule 005-609,Per Unit,$34.84 ,OP,34.84,34.84,,,,,,
Humana,ExceptCPT,82435,Assay of blood chloride,Medicare Fee Schedule 005-609,Per Unit,$12.65 ,OP,12.65,12.65,,,,,,
Humana,ExceptCPT,82436,Assay of urine chloride,Medicare Fee Schedule 005-609,Per Unit,$15.81 ,OP,15.81,15.81,,,,,,
Humana,ExceptCPT,82438,Assay other fluid chlorides,Medicare Fee Schedule 005-609,Per Unit,$13.75 ,OP,13.75,13.75,,,,,,
Humana,ExceptCPT,82441,Test for chlorohydrocarbons,Medicare Fee Schedule 005-609,Per Unit,$16.53 ,OP,16.53,16.53,,,,,,
Humana,ExceptCPT,82465,Assay bld/serum cholesterol,Medicare Fee Schedule 005-609,Per Unit,$11.96 ,OP,11.96,11.96,,,,,,
Humana,ExceptCPT,82480,Assay serum cholinesterase,Medicare Fee Schedule 005-609,Per Unit,$21.64 ,OP,21.64,21.64,,,,,,
Humana,ExceptCPT,82482,Assay rbc cholinesterase,Medicare Fee Schedule 005-609,Per Unit,$26.98 ,OP,26.98,26.98,,,,,,
Humana,ExceptCPT,82485,Assay chondroitin sulfate,Medicare Fee Schedule 005-609,Per Unit,$56.79 ,OP,56.79,56.79,,,,,,
Humana,ExceptCPT,82495,Assay of chromium,Medicare Fee Schedule 005-609,Per Unit,$55.77 ,OP,55.77,55.77,,,,,,
Humana,ExceptCPT,82507,Assay of citrate,Medicare Fee Schedule 005-609,Per Unit,$76.45 ,OP,76.45,76.45,,,,,,
Humana,ExceptCPT,82523,Collagen crosslinks,Medicare Fee Schedule 005-609,Per Unit,$51.37 ,OP,51.37,51.37,,,,,,
Humana,ExceptCPT,82525,Assay of copper,Medicare Fee Schedule 005-609,Per Unit,$34.13 ,OP,34.13,34.13,,,,,,
Humana,ExceptCPT,82528,Assay of corticosterone,Medicare Fee Schedule 005-609,Per Unit,$61.93 ,OP,61.93,61.93,,,,,,
Humana,ExceptCPT,82530,Cortisol free,Medicare Fee Schedule 005-609,Per Unit,$45.95 ,OP,45.95,45.95,,,,,,
Humana,ExceptCPT,82533,Total cortisol,Medicare Fee Schedule 005-609,Per Unit,$44.83 ,OP,44.83,44.83,,,,,,
Humana,ExceptCPT,82540,Assay of creatine,Medicare Fee Schedule 005-609,Per Unit,$12.76 ,OP,12.76,12.76,,,,,,
Humana,ExceptCPT,82542,Col chromotography qual/quan,Medicare Fee Schedule 005-609,Per Unit,$66.25 ,OP,66.25,66.25,,,,,,
Humana,ExceptCPT,82550,Assay of ck (cpk),Medicare Fee Schedule 005-609,Per Unit,$17.90 ,OP,17.9,17.9,,,,,,
Humana,ExceptCPT,82552,Assay of cpk in blood,Medicare Fee Schedule 005-609,Per Unit,$36.82 ,OP,36.82,36.82,,,,,,
Humana,ExceptCPT,82553,Creatine mb fraction,Medicare Fee Schedule 005-609,Per Unit,$31.76 ,OP,31.76,31.76,,,,,,
Humana,ExceptCPT,82554,Creatine isoforms,Medicare Fee Schedule 005-609,Per Unit,$32.64 ,OP,32.64,32.64,,,,,,
Humana,ExceptCPT,82565,Assay of creatinine,Medicare Fee Schedule 005-609,Per Unit,$14.08 ,OP,14.08,14.08,,,,,,
Humana,ExceptCPT,82570,Assay of urine creatinine,Medicare Fee Schedule 005-609,Per Unit,$14.25 ,OP,14.25,14.25,,,,,,
Humana,ExceptCPT,82575,Creatinine clearance test,Medicare Fee Schedule 005-609,Per Unit,$26.02 ,OP,26.02,26.02,,,,,,
Humana,ExceptCPT,82585,Assay of cryofibrinogen,Medicare Fee Schedule 005-609,Per Unit,$38.89 ,OP,38.89,38.89,,,,,,
Humana,ExceptCPT,82595,Assay of cryoglobulin,Medicare Fee Schedule 005-609,Per Unit,$17.79 ,OP,17.79,17.79,,,,,,
Humana,ExceptCPT,82600,Assay of cyanide,Medicare Fee Schedule 005-609,Per Unit,$53.35 ,OP,53.35,53.35,,,,,,
Humana,ExceptCPT,82607,Vitamin b-12,Medicare Fee Schedule 005-609,Per Unit,$41.47 ,OP,41.47,41.47,,,,,,
Humana,ExceptCPT,82608,B-12 binding capacity,Medicare Fee Schedule 005-609,Per Unit,$39.38 ,OP,39.38,39.38,,,,,,
Humana,ExceptCPT,82610,Cystatin c,Medicare Fee Schedule 005-609,Per Unit,$50.93 ,OP,50.93,50.93,,,,,,
Humana,ExceptCPT,82615,Test for urine cystines,Medicare Fee Schedule 005-609,Per Unit,$26.26 ,OP,26.26,26.26,,,,,,
Humana,ExceptCPT,82626,Dehydroepiandrosterone,Medicare Fee Schedule 005-609,Per Unit,$69.49 ,OP,69.49,69.49,,,,,,
Humana,ExceptCPT,82627,Dehydroepiandrosterone,Medicare Fee Schedule 005-609,Per Unit,$61.13 ,OP,61.13,61.13,,,,,,
Humana,ExceptCPT,82633,Desoxycorticosterone,Medicare Fee Schedule 005-609,Per Unit,$85.20 ,OP,85.2,85.2,,,,,,
Humana,ExceptCPT,82634,Deoxycortisol,Medicare Fee Schedule 005-609,Per Unit,$80.52 ,OP,80.52,80.52,,,,,,
Humana,ExceptCPT,82638,Assay of dibucaine number,Medicare Fee Schedule 005-609,Per Unit,$33.69 ,OP,33.69,33.69,,,,,,
Humana,ExceptCPT,82642,Dihydrotestosterone,Medicare Fee Schedule 005-609,Per Unit,$80.52 ,OP,80.52,80.52,,,,,,
Humana,ExceptCPT,82652,Vit d 1 25-dihydroxy,Medicare Fee Schedule 005-609,Per Unit,$105.88 ,OP,105.88,105.88,,,,,,
Humana,ExceptCPT,82656,El-1 fecal qual/semiq,Medicare Fee Schedule 005-609,Per Unit,$31.71 ,OP,31.71,31.71,,,,,,
Humana,ExceptCPT,82657,Enzyme cell activity,Medicare Fee Schedule 005-609,Per Unit,$60.97 ,OP,60.97,60.97,,,,,,
Humana,ExceptCPT,82658,Enzyme cell activity ra,Medicare Fee Schedule 005-609,Per Unit,$121.08 ,OP,121.08,121.08,,,,,,
Humana,ExceptCPT,82664,Electrophoretic test,Medicare Fee Schedule 005-609,Per Unit,$169.13 ,OP,169.13,169.13,,,,,,
Humana,ExceptCPT,82668,Assay of erythropoietin,Medicare Fee Schedule 005-609,Per Unit,$51.67 ,OP,51.67,51.67,,,,,,
Humana,ExceptCPT,82670,Assay of total estradiol,Medicare Fee Schedule 005-609,Per Unit,$76.84 ,OP,76.84,76.84,,,,,,
Humana,ExceptCPT,82671,Assay of estrogens,Medicare Fee Schedule 005-609,Per Unit,$88.83 ,OP,88.83,88.83,,,,,,
Humana,ExceptCPT,82672,Assay of estrogen,Medicare Fee Schedule 005-609,Per Unit,$59.68 ,OP,59.68,59.68,,,,,,
Humana,ExceptCPT,82677,Assay of estriol,Medicare Fee Schedule 005-609,Per Unit,$66.50 ,OP,66.5,66.5,,,,,,
Humana,ExceptCPT,82679,Assay of estrone,Medicare Fee Schedule 005-609,Per Unit,$68.61 ,OP,68.61,68.61,,,,,,
Humana,ExceptCPT,82693,Assay of ethylene glycol,Medicare Fee Schedule 005-609,Per Unit,$40.98 ,OP,40.98,40.98,,,,,,
Humana,ExceptCPT,82696,Assay of etiocholanolone,Medicare Fee Schedule 005-609,Per Unit,$72.16 ,OP,72.16,72.16,,,,,,
Humana,ExceptCPT,82705,Fats/lipids feces qual,Medicare Fee Schedule 005-609,Per Unit,$14.03 ,OP,14.03,14.03,,,,,,
Humana,ExceptCPT,82710,Fats/lipids feces quant,Medicare Fee Schedule 005-609,Per Unit,$46.20 ,OP,46.2,46.2,,,,,,
Humana,ExceptCPT,82715,Assay of fecal fat,Medicare Fee Schedule 005-609,Per Unit,$63.17 ,OP,63.17,63.17,,,,,,
Humana,ExceptCPT,82725,Assay of blood fatty acids,Medicare Fee Schedule 005-609,Per Unit,$51.62 ,OP,51.62,51.62,,,,,,
Humana,ExceptCPT,82726,Long chain fatty acids,Medicare Fee Schedule 005-609,Per Unit,$54.31 ,OP,54.31,54.31,,,,,,
Humana,ExceptCPT,82728,Assay of ferritin,Medicare Fee Schedule 005-609,Per Unit,$37.48 ,OP,37.48,37.48,,,,,,
Humana,ExceptCPT,82731,Assay of fetal fibronectin,Medicare Fee Schedule 005-609,Per Unit,$177.13 ,OP,177.13,177.13,,,,,,
Humana,ExceptCPT,82735,Assay of fluoride,Medicare Fee Schedule 005-609,Per Unit,$50.99 ,OP,50.99,50.99,,,,,,
Humana,ExceptCPT,82746,Assay of folic acid serum,Medicare Fee Schedule 005-609,Per Unit,$40.43 ,OP,40.43,40.43,,,,,,
Humana,ExceptCPT,82747,Assay of folic acid rbc,Medicare Fee Schedule 005-609,Per Unit,$48.54 ,OP,48.54,48.54,,,,,,
Humana,ExceptCPT,82757,Assay of semen fructose,Medicare Fee Schedule 005-609,Per Unit,$47.69 ,OP,47.69,47.69,,,,,,
Humana,ExceptCPT,82759,Assay of rbc galactokinase,Medicare Fee Schedule 005-609,Per Unit,$59.07 ,OP,59.07,59.07,,,,,,
Humana,ExceptCPT,82760,Assay of galactose,Medicare Fee Schedule 005-609,Per Unit,$30.80 ,OP,30.8,30.8,,,,,,
Humana,ExceptCPT,82775,Assay galactose transferase,Medicare Fee Schedule 005-609,Per Unit,$57.94 ,OP,57.94,57.94,,,,,,
Humana,ExceptCPT,82776,Galactose transferase test,Medicare Fee Schedule 005-609,Per Unit,$32.29 ,OP,32.29,32.29,,,,,,
Humana,ExceptCPT,82777,Galectin-3,Medicare Fee Schedule 005-609,Per Unit,$121.69 ,OP,121.69,121.69,,,,,,
Humana,ExceptCPT,82784,Assay iga/igd/igg/igm each,Medicare Fee Schedule 005-609,Per Unit,$25.58 ,OP,25.58,25.58,,,,,,
Humana,ExceptCPT,82785,Assay of ige,Medicare Fee Schedule 005-609,Per Unit,$45.27 ,OP,45.27,45.27,,,,,,
Humana,ExceptCPT,82787,Igg 1 2 3 or 4 each,Medicare Fee Schedule 005-609,Per Unit,$22.06 ,OP,22.06,22.06,,,,,,
Humana,ExceptCPT,82800,Blood ph,Medicare Fee Schedule 005-609,Per Unit,$30.25 ,OP,30.25,30.25,,,,,,
Humana,ExceptCPT,82803,Blood gases any combination,Medicare Fee Schedule 005-609,Per Unit,$71.69 ,OP,71.69,71.69,,,,,,
Humana,ExceptCPT,82805,Blood gases w/o2 saturation,Medicare Fee Schedule 005-609,Per Unit,$216.62 ,OP,216.62,216.62,,,,,,
Humana,ExceptCPT,82810,Blood gases o2 sat only,Medicare Fee Schedule 005-609,Per Unit,$26.87 ,OP,26.87,26.87,,,,,,
Humana,ExceptCPT,82820,Hemoglobin-oxygen affinity,Medicare Fee Schedule 005-609,Per Unit,$36.69 ,OP,36.69,36.69,,,,,,
Humana,ExceptCPT,82930,Gastric analy w/ph ea spec,Medicare Fee Schedule 005-609,Per Unit,$18.45 ,OP,18.45,18.45,,,,,,
Humana,ExceptCPT,82938,Gastrin test,Medicare Fee Schedule 005-609,Per Unit,$48.65 ,OP,48.65,48.65,,,,,,
Humana,ExceptCPT,82941,Assay of gastrin,Medicare Fee Schedule 005-609,Per Unit,$48.48 ,OP,48.48,48.48,,,,,,
Humana,ExceptCPT,82943,Assay of glucagon,Medicare Fee Schedule 005-609,Per Unit,$39.30 ,OP,39.3,39.3,,,,,,
Humana,ExceptCPT,82945,Glucose other fluid,Medicare Fee Schedule 005-609,Per Unit,$10.81 ,OP,10.81,10.81,,,,,,
Humana,ExceptCPT,82946,Glucagon tolerance test,Medicare Fee Schedule 005-609,Per Unit,$48.87 ,OP,48.87,48.87,,,,,,
Humana,ExceptCPT,82947,Assay glucose blood quant,Medicare Fee Schedule 005-609,Per Unit,$10.81 ,OP,10.81,10.81,,,,,,
Humana,ExceptCPT,82948,Reagent strip/blood glucose,Medicare Fee Schedule 005-609,Per Unit,$13.86 ,OP,13.86,13.86,,,,,,
Humana,ExceptCPT,82950,Glucose test,Medicare Fee Schedule 005-609,Per Unit,$13.06 ,OP,13.06,13.06,,,,,,
Humana,ExceptCPT,82951,Glucose tolerance test (gtt),Medicare Fee Schedule 005-609,Per Unit,$35.39 ,OP,35.39,35.39,,,,,,
Humana,ExceptCPT,82952,Gtt-added samples,Medicare Fee Schedule 005-609,Per Unit,$10.78 ,OP,10.78,10.78,,,,,,
Humana,ExceptCPT,82955,Assay of g6pd enzyme,Medicare Fee Schedule 005-609,Per Unit,$26.68 ,OP,26.68,26.68,,,,,,
Humana,ExceptCPT,82960,Test for g6pd enzyme,Medicare Fee Schedule 005-609,Per Unit,$16.64 ,OP,16.64,16.64,,,,,,
Humana,ExceptCPT,82962,Glucose blood test,Medicare Fee Schedule 005-609,Per Unit,$9.02 ,OP,9.02,9.02,,,,,,
Humana,ExceptCPT,82963,Assay of glucosidase,Medicare Fee Schedule 005-609,Per Unit,$59.07 ,OP,59.07,59.07,,,,,,
Humana,ExceptCPT,82965,Assay of gdh enzyme,Medicare Fee Schedule 005-609,Per Unit,$36.16 ,OP,36.16,36.16,,,,,,
Humana,ExceptCPT,82977,Assay of ggt,Medicare Fee Schedule 005-609,Per Unit,$19.80 ,OP,19.8,19.8,,,,,,
Humana,ExceptCPT,82978,Assay of glutathione,Medicare Fee Schedule 005-609,Per Unit,$42.49 ,OP,42.49,42.49,,,,,,
Humana,ExceptCPT,82979,Assay rbc glutathione,Medicare Fee Schedule 005-609,Per Unit,$25.96 ,OP,25.96,25.96,,,,,,
Humana,ExceptCPT,82985,Assay of glycated protein,Medicare Fee Schedule 005-609,Per Unit,$46.09 ,OP,46.09,46.09,,,,,,
Humana,ExceptCPT,83001,Assay of gonadotropin (fsh),Medicare Fee Schedule 005-609,Per Unit,$51.10 ,OP,51.1,51.1,,,,,,
Humana,ExceptCPT,83002,Assay of gonadotropin (lh),Medicare Fee Schedule 005-609,Per Unit,$50.93 ,OP,50.93,50.93,,,,,,
Humana,ExceptCPT,83003,Assay growth hormone (hgh),Medicare Fee Schedule 005-609,Per Unit,$45.84 ,OP,45.84,45.84,,,,,,
Humana,ExceptCPT,83006,Growth stimulation gene 2,Medicare Fee Schedule 005-609,Per Unit,$207.90 ,OP,207.9,207.9,,,,,,
Humana,ExceptCPT,83009,H pylori (c-13) blood,Medicare Fee Schedule 005-609,Per Unit,$185.24 ,OP,185.24,185.24,,,,,,
Humana,ExceptCPT,83010,Assay of haptoglobin quant,Medicare Fee Schedule 005-609,Per Unit,$34.60 ,OP,34.6,34.6,,,,,,
Humana,ExceptCPT,83012,Assay of haptoglobins,Medicare Fee Schedule 005-609,Per Unit,$73.95 ,OP,73.95,73.95,,,,,,
Humana,ExceptCPT,83013,H pylori (c-13) breath,Medicare Fee Schedule 005-609,Per Unit,$185.24 ,OP,185.24,185.24,,,,,,
Humana,ExceptCPT,83014,H pylori drug admin,Medicare Fee Schedule 005-609,Per Unit,$21.62 ,OP,21.62,21.62,,,,,,
Humana,ExceptCPT,83015,Heavy metal qual any anal,Medicare Fee Schedule 005-609,Per Unit,$57.59 ,OP,57.59,57.59,,,,,,
Humana,ExceptCPT,83018,Heavy metal quant each nes,Medicare Fee Schedule 005-609,Per Unit,$60.39 ,OP,60.39,60.39,,,,,,
Humana,ExceptCPT,83020,Hemoglobin electrophoresis,Medicare Fee Schedule 005-609,Per Unit,$35.39 ,OP,35.39,35.39,,,,,,
Humana,ExceptCPT,83021,Hemoglobin chromotography,Medicare Fee Schedule 005-609,Per Unit,$49.67 ,OP,49.67,49.67,,,,,,
Humana,ExceptCPT,83026,Hemoglobin copper sulfate,Medicare Fee Schedule 005-609,Per Unit,$11.03 ,OP,11.03,11.03,,,,,,
Humana,ExceptCPT,83030,Fetal hemoglobin chemical,Medicare Fee Schedule 005-609,Per Unit,$29.54 ,OP,29.54,29.54,,,,,,
Humana,ExceptCPT,83033,Fetal hemoglobin assay qual,Medicare Fee Schedule 005-609,Per Unit,$22.00 ,OP,22,22,,,,,,
Humana,ExceptCPT,83036,Glycosylated hemoglobin test,Medicare Fee Schedule 005-609,Per Unit,$26.70 ,OP,26.7,26.7,,,,,,
Humana,ExceptCPT,83037,Glycosylated hb home device,Medicare Fee Schedule 005-609,Per Unit,$26.70 ,OP,26.7,26.7,,,,,,
Humana,ExceptCPT,83045,Blood methemoglobin test,Medicare Fee Schedule 005-609,Per Unit,$17.85 ,OP,17.85,17.85,,,,,,
Humana,ExceptCPT,83050,Blood methemoglobin assay,Medicare Fee Schedule 005-609,Per Unit,$22.55 ,OP,22.55,22.55,,,,,,
Humana,ExceptCPT,83051,Assay of plasma hemoglobin,Medicare Fee Schedule 005-609,Per Unit,$20.10 ,OP,20.1,20.1,,,,,,
Humana,ExceptCPT,83060,Blood sulfhemoglobin assay,Medicare Fee Schedule 005-609,Per Unit,$24.20 ,OP,24.2,24.2,,,,,,
Humana,ExceptCPT,83065,Assay of hemoglobin heat,Medicare Fee Schedule 005-609,Per Unit,$24.75 ,OP,24.75,24.75,,,,,,
Humana,ExceptCPT,83068,Hemoglobin stability screen,Medicare Fee Schedule 005-609,Per Unit,$26.04 ,OP,26.04,26.04,,,,,,
Humana,ExceptCPT,83069,Assay of urine hemoglobin,Medicare Fee Schedule 005-609,Per Unit,$10.86 ,OP,10.86,10.86,,,,,,
Humana,ExceptCPT,83070,Assay of hemosiderin qual,Medicare Fee Schedule 005-609,Per Unit,$13.06 ,OP,13.06,13.06,,,,,,
Humana,ExceptCPT,83080,Assay of b hexosaminidase,Medicare Fee Schedule 005-609,Per Unit,$46.39 ,OP,46.39,46.39,,,,,,
Humana,ExceptCPT,83088,Assay of histamine,Medicare Fee Schedule 005-609,Per Unit,$81.21 ,OP,81.21,81.21,,,,,,
Humana,ExceptCPT,83090,Assay of homocystine,Medicare Fee Schedule 005-609,Per Unit,$49.28 ,OP,49.28,49.28,,,,,,
Humana,ExceptCPT,83150,Assay of homovanillic acid,Medicare Fee Schedule 005-609,Per Unit,$61.63 ,OP,61.63,61.63,,,,,,
Humana,ExceptCPT,83491,Assay of corticosteroids 17,Medicare Fee Schedule 005-609,Per Unit,$49.23 ,OP,49.23,49.23,,,,,,
Humana,ExceptCPT,83497,Assay of 5-hiaa,Medicare Fee Schedule 005-609,Per Unit,$35.48 ,OP,35.48,35.48,,,,,,
Humana,ExceptCPT,83498,Assay of progesterone 17-d,Medicare Fee Schedule 005-609,Per Unit,$74.72 ,OP,74.72,74.72,,,,,,
Humana,ExceptCPT,83500,Assay free hydroxyproline,Medicare Fee Schedule 005-609,Per Unit,$62.29 ,OP,62.29,62.29,,,,,,
Humana,ExceptCPT,83505,Assay total hydroxyproline,Medicare Fee Schedule 005-609,Per Unit,$66.83 ,OP,66.83,66.83,,,,,,
Humana,ExceptCPT,83516,Immunoassay nonantibody,Medicare Fee Schedule 005-609,Per Unit,$31.71 ,OP,31.71,31.71,,,,,,
Humana,ExceptCPT,83518,Immunoassay dipstick,Medicare Fee Schedule 005-609,Per Unit,$26.51 ,OP,26.51,26.51,,,,,,
Humana,ExceptCPT,83519,Ria nonantibody,Medicare Fee Schedule 005-609,Per Unit,$50.60 ,OP,50.6,50.6,,,,,,
Humana,ExceptCPT,83520,Immunoassay quant nos nonab,Medicare Fee Schedule 005-609,Per Unit,$47.49 ,OP,47.49,47.49,,,,,,
Humana,ExceptCPT,83525,Assay of insulin,Medicare Fee Schedule 005-609,Per Unit,$31.43 ,OP,31.43,31.43,,,,,,
Humana,ExceptCPT,83527,Assay of insulin,Medicare Fee Schedule 005-609,Per Unit,$35.61 ,OP,35.61,35.61,,,,,,
Humana,ExceptCPT,83528,Assay of intrinsic factor,Medicare Fee Schedule 005-609,Per Unit,$54.51 ,OP,54.51,54.51,,,,,,
Humana,ExceptCPT,83540,Assay of iron,Medicare Fee Schedule 005-609,Per Unit,$17.79 ,OP,17.79,17.79,,,,,,
Humana,ExceptCPT,83550,Iron binding test,Medicare Fee Schedule 005-609,Per Unit,$24.04 ,OP,24.04,24.04,,,,,,
Humana,ExceptCPT,83570,Assay of idh enzyme,Medicare Fee Schedule 005-609,Per Unit,$24.34 ,OP,24.34,24.34,,,,,,
Humana,ExceptCPT,83582,Assay of ketogenic steroids,Medicare Fee Schedule 005-609,Per Unit,$42.54 ,OP,42.54,42.54,,,,,,
Humana,ExceptCPT,83586,Assay 17- ketosteroids,Medicare Fee Schedule 005-609,Per Unit,$35.20 ,OP,35.2,35.2,,,,,,
Humana,ExceptCPT,83593,Fractionation ketosteroids,Medicare Fee Schedule 005-609,Per Unit,$78.38 ,OP,78.38,78.38,,,,,,
Humana,ExceptCPT,83605,Assay of lactic acid,Medicare Fee Schedule 005-609,Per Unit,$31.82 ,OP,31.82,31.82,,,,,,
Humana,ExceptCPT,83615,Lactate (ld) (ldh) enzyme,Medicare Fee Schedule 005-609,Per Unit,$16.61 ,OP,16.61,16.61,,,,,,
Humana,ExceptCPT,83625,Assay of ldh enzymes,Medicare Fee Schedule 005-609,Per Unit,$35.17 ,OP,35.17,35.17,,,,,,
Humana,ExceptCPT,83630,Lactoferrin fecal (qual),Medicare Fee Schedule 005-609,Per Unit,$54.18 ,OP,54.18,54.18,,,,,,
Humana,ExceptCPT,83631,Lactoferrin fecal (quant),Medicare Fee Schedule 005-609,Per Unit,$53.98 ,OP,53.98,53.98,,,,,,
Humana,ExceptCPT,83632,Placental lactogen,Medicare Fee Schedule 005-609,Per Unit,$55.61 ,OP,55.61,55.61,,,,,,
Humana,ExceptCPT,83633,Test urine for lactose,Medicare Fee Schedule 005-609,Per Unit,$30.94 ,OP,30.94,30.94,,,,,,
Humana,ExceptCPT,83655,Assay of lead,Medicare Fee Schedule 005-609,Per Unit,$33.30 ,OP,33.3,33.3,,,,,,
Humana,ExceptCPT,83661,L/s ratio fetal lung,Medicare Fee Schedule 005-609,Per Unit,$60.47 ,OP,60.47,60.47,,,,,,
Humana,ExceptCPT,83662,Foam stability fetal lung,Medicare Fee Schedule 005-609,Per Unit,$52.00 ,OP,52,52,,,,,,
Humana,ExceptCPT,83663,Fluoro polarize fetal lung,Medicare Fee Schedule 005-609,Per Unit,$52.00 ,OP,52,52,,,,,,
Humana,ExceptCPT,83664,Lamellar bdy fetal lung,Medicare Fee Schedule 005-609,Per Unit,$53.13 ,OP,53.13,53.13,,,,,,
Humana,ExceptCPT,83670,Assay of lap enzyme,Medicare Fee Schedule 005-609,Per Unit,$26.98 ,OP,26.98,26.98,,,,,,
Humana,ExceptCPT,83690,Assay of lipase,Medicare Fee Schedule 005-609,Per Unit,$18.95 ,OP,18.95,18.95,,,,,,
Humana,ExceptCPT,83695,Assay of lipoprotein(a),Medicare Fee Schedule 005-609,Per Unit,$39.38 ,OP,39.38,39.38,,,,,,
Humana,ExceptCPT,83698,Assay lipoprotein pla2,Medicare Fee Schedule 005-609,Per Unit,$127.35 ,OP,127.35,127.35,,,,,,
Humana,ExceptCPT,83700,Lipopro bld electrophoretic,Medicare Fee Schedule 005-609,Per Unit,$30.97 ,OP,30.97,30.97,,,,,,
Humana,ExceptCPT,83701,Lipoprotein bld hr fraction,Medicare Fee Schedule 005-609,Per Unit,$93.12 ,OP,93.12,93.12,,,,,,
Humana,ExceptCPT,83704,Lipoprotein bld quan part,Medicare Fee Schedule 005-609,Per Unit,$94.02 ,OP,94.02,94.02,,,,,,
Humana,ExceptCPT,83718,Assay of lipoprotein,Medicare Fee Schedule 005-609,Per Unit,$22.52 ,OP,22.52,22.52,,,,,,
Humana,ExceptCPT,83719,Assay of blood lipoprotein,Medicare Fee Schedule 005-609,Per Unit,$35.06 ,OP,35.06,35.06,,,,,,
Humana,ExceptCPT,83721,Assay of blood lipoprotein,Medicare Fee Schedule 005-609,Per Unit,$28.88 ,OP,28.88,28.88,,,,,,
Humana,ExceptCPT,83722,Lipoprtn dir meas sd ldl chl,Medicare Fee Schedule 005-609,Per Unit,$94.02 ,OP,94.02,94.02,,,,,,
Humana,ExceptCPT,83727,Assay of lrh hormone,Medicare Fee Schedule 005-609,Per Unit,$47.27 ,OP,47.27,47.27,,,,,,
Humana,ExceptCPT,83735,Assay of magnesium,Medicare Fee Schedule 005-609,Per Unit,$18.43 ,OP,18.43,18.43,,,,,,
Humana,ExceptCPT,83775,Assay malate dehydrogenase,Medicare Fee Schedule 005-609,Per Unit,$20.27 ,OP,20.27,20.27,,,,,,
Humana,ExceptCPT,83785,Assay of manganese,Medicare Fee Schedule 005-609,Per Unit,$73.29 ,OP,73.29,73.29,,,,,,
Humana,ExceptCPT,83789,Mass spectrometry qual/quan,Medicare Fee Schedule 005-609,Per Unit,$66.30 ,OP,66.3,66.3,,,,,,
Humana,ExceptCPT,83825,Assay of mercury,Medicare Fee Schedule 005-609,Per Unit,$44.72 ,OP,44.72,44.72,,,,,,
Humana,ExceptCPT,83835,Assay of metanephrines,Medicare Fee Schedule 005-609,Per Unit,$46.59 ,OP,46.59,46.59,,,,,,
Humana,ExceptCPT,83857,Assay of methemalbumin,Medicare Fee Schedule 005-609,Per Unit,$29.54 ,OP,29.54,29.54,,,,,,
Humana,ExceptCPT,83861,Microfluid analy tears,Medicare Fee Schedule 005-609,Per Unit,$61.82 ,OP,61.82,61.82,,,,,,
Humana,ExceptCPT,83864,Mucopolysaccharides,Medicare Fee Schedule 005-609,Per Unit,$78.38 ,OP,78.38,78.38,,,,,,
Humana,ExceptCPT,83872,Assay synovial fluid mucin,Medicare Fee Schedule 005-609,Per Unit,$16.12 ,OP,16.12,16.12,,,,,,
Humana,ExceptCPT,83873,Assay of csf protein,Medicare Fee Schedule 005-609,Per Unit,$47.30 ,OP,47.3,47.3,,,,,,
Humana,ExceptCPT,83874,Assay of myoglobin,Medicare Fee Schedule 005-609,Per Unit,$35.53 ,OP,35.53,35.53,,,,,,
Humana,ExceptCPT,83876,Assay myeloperoxidase,Medicare Fee Schedule 005-609,Per Unit,$139.87 ,OP,139.87,139.87,,,,,,
Humana,ExceptCPT,83880,Assay of natriuretic peptide,Medicare Fee Schedule 005-609,Per Unit,$107.97 ,OP,107.97,107.97,,,,,,
Humana,ExceptCPT,83883,Assay nephelometry not spec,Medicare Fee Schedule 005-609,Per Unit,$37.40 ,OP,37.4,37.4,,,,,,
Humana,ExceptCPT,83885,Assay of nickel,Medicare Fee Schedule 005-609,Per Unit,$67.40 ,OP,67.4,67.4,,,,,,
Humana,ExceptCPT,83915,Assay of nucleotidase,Medicare Fee Schedule 005-609,Per Unit,$30.66 ,OP,30.66,30.66,,,,,,
Humana,ExceptCPT,83916,Oligoclonal bands,Medicare Fee Schedule 005-609,Per Unit,$75.32 ,OP,75.32,75.32,,,,,,
Humana,ExceptCPT,83918,Organic acids total quant,Medicare Fee Schedule 005-609,Per Unit,$64.90 ,OP,64.9,64.9,,,,,,
Humana,ExceptCPT,83919,Organic acids qual each,Medicare Fee Schedule 005-609,Per Unit,$45.24 ,OP,45.24,45.24,,,,,,
Humana,ExceptCPT,83921,Organic acid single quant,Medicare Fee Schedule 005-609,Per Unit,$58.33 ,OP,58.33,58.33,,,,,,
Humana,ExceptCPT,83930,Assay of blood osmolality,Medicare Fee Schedule 005-609,Per Unit,$18.18 ,OP,18.18,18.18,,,,,,
Humana,ExceptCPT,83935,Assay of urine osmolality,Medicare Fee Schedule 005-609,Per Unit,$18.76 ,OP,18.76,18.76,,,,,,
Humana,ExceptCPT,83937,Assay of osteocalcin,Medicare Fee Schedule 005-609,Per Unit,$82.09 ,OP,82.09,82.09,,,,,,
Humana,ExceptCPT,83945,Assay of oxalate,Medicare Fee Schedule 005-609,Per Unit,$39.74 ,OP,39.74,39.74,,,,,,
Humana,ExceptCPT,83950,Oncoprotein her-2/neu,Medicare Fee Schedule 005-609,Per Unit,$177.13 ,OP,177.13,177.13,,,,,,
Humana,ExceptCPT,83951,Oncoprotein dcp,Medicare Fee Schedule 005-609,Per Unit,$177.13 ,OP,177.13,177.13,,,,,,
Humana,ExceptCPT,83970,Assay of parathormone,Medicare Fee Schedule 005-609,Per Unit,$113.52 ,OP,113.52,113.52,,,,,,
Humana,ExceptCPT,83986,Assay ph body fluid nos,Medicare Fee Schedule 005-609,Per Unit,$9.85 ,OP,9.85,9.85,,,,,,
Humana,ExceptCPT,83987,Exhaled breath condensate,Medicare Fee Schedule 005-609,Per Unit,$9.85 ,OP,9.85,9.85,,,,,,
Humana,ExceptCPT,83992,Assay for phencyclidine,Medicare Fee Schedule 005-609,Per Unit,$104.14 ,OP,104.14,104.14,,,,,,
Humana,ExceptCPT,83993,Assay for calprotectin fecal,Medicare Fee Schedule 005-609,Per Unit,$53.98 ,OP,53.98,53.98,,,,,,
Humana,ExceptCPT,84030,Assay of blood pku,Medicare Fee Schedule 005-609,Per Unit,$15.13 ,OP,15.13,15.13,,,,,,
Humana,ExceptCPT,84035,Assay of phenylketones,Medicare Fee Schedule 005-609,Per Unit,$10.95 ,OP,10.95,10.95,,,,,,
Humana,ExceptCPT,84060,Assay acid phosphatase,Medicare Fee Schedule 005-609,Per Unit,$21.01 ,OP,21.01,21.01,,,,,,
Humana,ExceptCPT,84066,Assay prostate phosphatase,Medicare Fee Schedule 005-609,Per Unit,$26.57 ,OP,26.57,26.57,,,,,,
Humana,ExceptCPT,84075,Assay alkaline phosphatase,Medicare Fee Schedule 005-609,Per Unit,$14.25 ,OP,14.25,14.25,,,,,,
Humana,ExceptCPT,84078,Assay alkaline phosphatase,Medicare Fee Schedule 005-609,Per Unit,$22.72 ,OP,22.72,22.72,,,,,,
Humana,ExceptCPT,84080,Assay alkaline phosphatases,Medicare Fee Schedule 005-609,Per Unit,$40.65 ,OP,40.65,40.65,,,,,,
Humana,ExceptCPT,84081,Assay phosphatidylglycerol,Medicare Fee Schedule 005-609,Per Unit,$45.43 ,OP,45.43,45.43,,,,,,
Humana,ExceptCPT,84085,Assay of rbc pg6d enzyme,Medicare Fee Schedule 005-609,Per Unit,$25.96 ,OP,25.96,25.96,,,,,,
Humana,ExceptCPT,84087,Assay phosphohexose enzymes,Medicare Fee Schedule 005-609,Per Unit,$29.51 ,OP,29.51,29.51,,,,,,
Humana,ExceptCPT,84100,Assay of phosphorus,Medicare Fee Schedule 005-609,Per Unit,$13.04 ,OP,13.04,13.04,,,,,,
Humana,ExceptCPT,84105,Assay of urine phosphorus,Medicare Fee Schedule 005-609,Per Unit,$15.90 ,OP,15.9,15.9,,,,,,
Humana,ExceptCPT,84106,Test for porphobilinogen,Medicare Fee Schedule 005-609,Per Unit,$16.01 ,OP,16.01,16.01,,,,,,
Humana,ExceptCPT,84110,Assay of porphobilinogen,Medicare Fee Schedule 005-609,Per Unit,$23.21 ,OP,23.21,23.21,,,,,,
Humana,ExceptCPT,84112,Eval amniotic fluid protein,Medicare Fee Schedule 005-609,Per Unit,$269.80 ,OP,269.8,269.8,,,,,,
Humana,ExceptCPT,84119,Test urine for porphyrins,Medicare Fee Schedule 005-609,Per Unit,$36.74 ,OP,36.74,36.74,,,,,,
Humana,ExceptCPT,84120,Assay of urine porphyrins,Medicare Fee Schedule 005-609,Per Unit,$40.45 ,OP,40.45,40.45,,,,,,
Humana,ExceptCPT,84126,Assay of feces porphyrins,Medicare Fee Schedule 005-609,Per Unit,$107.55 ,OP,107.55,107.55,,,,,,
Humana,ExceptCPT,84132,Assay of serum potassium,Medicare Fee Schedule 005-609,Per Unit,$13.09 ,OP,13.09,13.09,,,,,,
Humana,ExceptCPT,84133,Assay of urine potassium,Medicare Fee Schedule 005-609,Per Unit,$13.01 ,OP,13.01,13.01,,,,,,
Humana,ExceptCPT,84134,Assay of prealbumin,Medicare Fee Schedule 005-609,Per Unit,$40.12 ,OP,40.12,40.12,,,,,,
Humana,ExceptCPT,84135,Assay of pregnanediol,Medicare Fee Schedule 005-609,Per Unit,$58.49 ,OP,58.49,58.49,,,,,,
Humana,ExceptCPT,84138,Assay of pregnanetriol,Medicare Fee Schedule 005-609,Per Unit,$57.89 ,OP,57.89,57.89,,,,,,
Humana,ExceptCPT,84140,Assay of pregnenolone,Medicare Fee Schedule 005-609,Per Unit,$56.84 ,OP,56.84,56.84,,,,,,
Humana,ExceptCPT,84143,Assay of 17-hydroxypregneno,Medicare Fee Schedule 005-609,Per Unit,$62.73 ,OP,62.73,62.73,,,,,,
Humana,ExceptCPT,84144,Assay of progesterone,Medicare Fee Schedule 005-609,Per Unit,$57.37 ,OP,57.37,57.37,,,,,,
Humana,ExceptCPT,84145,Procalcitonin (pct),Medicare Fee Schedule 005-609,Per Unit,$74.86 ,OP,74.86,74.86,,,,,,
Humana,ExceptCPT,84146,Assay of prolactin,Medicare Fee Schedule 005-609,Per Unit,$53.30 ,OP,53.3,53.3,,,,,,
Humana,ExceptCPT,84150,Assay of prostaglandin,Medicare Fee Schedule 005-609,Per Unit,$114.87 ,OP,114.87,114.87,,,,,,
Humana,ExceptCPT,84152,Assay of psa complexed,Medicare Fee Schedule 005-609,Per Unit,$50.57 ,OP,50.57,50.57,,,,,,
Humana,ExceptCPT,84153,Assay of psa total,Medicare Fee Schedule 005-609,Per Unit,$50.57 ,OP,50.57,50.57,,,,,,
Humana,ExceptCPT,84154,Assay of psa free,Medicare Fee Schedule 005-609,Per Unit,$50.57 ,OP,50.57,50.57,,,,,,
Humana,ExceptCPT,84155,Assay of protein serum,Medicare Fee Schedule 005-609,Per Unit,$10.09 ,OP,10.09,10.09,,,,,,
Humana,ExceptCPT,84156,Assay of protein urine,Medicare Fee Schedule 005-609,Per Unit,$10.09 ,OP,10.09,10.09,,,,,,
Humana,ExceptCPT,84157,Assay of protein other,Medicare Fee Schedule 005-609,Per Unit,$11.00 ,OP,11,11,,,,,,
Humana,ExceptCPT,84160,Assay of protein any source,Medicare Fee Schedule 005-609,Per Unit,$15.43 ,OP,15.43,15.43,,,,,,
Humana,ExceptCPT,84163,Pappa serum,Medicare Fee Schedule 005-609,Per Unit,$41.39 ,OP,41.39,41.39,,,,,,
Humana,ExceptCPT,84165,Protein e-phoresis serum,Medicare Fee Schedule 005-609,Per Unit,$29.54 ,OP,29.54,29.54,,,,,,
Humana,ExceptCPT,84166,Protein e-phoresis/urine/csf,Medicare Fee Schedule 005-609,Per Unit,$49.03 ,OP,49.03,49.03,,,,,,
Humana,ExceptCPT,84181,Western blot test,Medicare Fee Schedule 005-609,Per Unit,$46.83 ,OP,46.83,46.83,,,,,,
Humana,ExceptCPT,84182,Protein western blot test,Medicare Fee Schedule 005-609,Per Unit,$80.33 ,OP,80.33,80.33,,,,,,
Humana,ExceptCPT,84202,Assay rbc protoporphyrin,Medicare Fee Schedule 005-609,Per Unit,$39.46 ,OP,39.46,39.46,,,,,,
Humana,ExceptCPT,84203,Test rbc protoporphyrin,Medicare Fee Schedule 005-609,Per Unit,$26.79 ,OP,26.79,26.79,,,,,,
Humana,ExceptCPT,84206,Assay of proinsulin,Medicare Fee Schedule 005-609,Per Unit,$73.40 ,OP,73.4,73.4,,,,,,
Humana,ExceptCPT,84207,Assay of vitamin b-6,Medicare Fee Schedule 005-609,Per Unit,$77.28 ,OP,77.28,77.28,,,,,,
Humana,ExceptCPT,84210,Assay of pyruvate,Medicare Fee Schedule 005-609,Per Unit,$39.82 ,OP,39.82,39.82,,,,,,
Humana,ExceptCPT,84220,Assay of pyruvate kinase,Medicare Fee Schedule 005-609,Per Unit,$25.96 ,OP,25.96,25.96,,,,,,
Humana,ExceptCPT,84228,Assay of quinine,Medicare Fee Schedule 005-609,Per Unit,$31.98 ,OP,31.98,31.98,,,,,,
Humana,ExceptCPT,84233,Assay of estrogen,Medicare Fee Schedule 005-609,Per Unit,$241.67 ,OP,241.67,241.67,,,,,,
Humana,ExceptCPT,84234,Assay of progesterone,Medicare Fee Schedule 005-609,Per Unit,$178.42 ,OP,178.42,178.42,,,,,,
Humana,ExceptCPT,84235,Assay of endocrine hormone,Medicare Fee Schedule 005-609,Per Unit,$195.88 ,OP,195.88,195.88,,,,,,
Humana,ExceptCPT,84238,Assay nonendocrine receptor,Medicare Fee Schedule 005-609,Per Unit,$100.57 ,OP,100.57,100.57,,,,,,
Humana,ExceptCPT,84244,Assay of renin,Medicare Fee Schedule 005-609,Per Unit,$60.47 ,OP,60.47,60.47,,,,,,
Humana,ExceptCPT,84252,Assay of vitamin b-2,Medicare Fee Schedule 005-609,Per Unit,$55.66 ,OP,55.66,55.66,,,,,,
Humana,ExceptCPT,84255,Assay of selenium,Medicare Fee Schedule 005-609,Per Unit,$70.21 ,OP,70.21,70.21,,,,,,
Humana,ExceptCPT,84260,Assay of serotonin,Medicare Fee Schedule 005-609,Per Unit,$85.20 ,OP,85.2,85.2,,,,,,
Humana,ExceptCPT,84270,Assay of sex hormone globul,Medicare Fee Schedule 005-609,Per Unit,$59.76 ,OP,59.76,59.76,,,,,,
Humana,ExceptCPT,84275,Assay of sialic acid,Medicare Fee Schedule 005-609,Per Unit,$36.96 ,OP,36.96,36.96,,,,,,
Humana,ExceptCPT,84285,Assay of silica,Medicare Fee Schedule 005-609,Per Unit,$69.33 ,OP,69.33,69.33,,,,,,
Humana,ExceptCPT,84295,Assay of serum sodium,Medicare Fee Schedule 005-609,Per Unit,$13.23 ,OP,13.23,13.23,,,,,,
Humana,ExceptCPT,84300,Assay of urine sodium,Medicare Fee Schedule 005-609,Per Unit,$13.92 ,OP,13.92,13.92,,,,,,
Humana,ExceptCPT,84302,Assay of sweat sodium,Medicare Fee Schedule 005-609,Per Unit,$13.37 ,OP,13.37,13.37,,,,,,
Humana,ExceptCPT,84305,Assay of somatomedin,Medicare Fee Schedule 005-609,Per Unit,$58.47 ,OP,58.47,58.47,,,,,,
Humana,ExceptCPT,84307,Assay of somatostatin,Medicare Fee Schedule 005-609,Per Unit,$50.27 ,OP,50.27,50.27,,,,,,
Humana,ExceptCPT,84311,Spectrophotometry,Medicare Fee Schedule 005-609,Per Unit,$22.28 ,OP,22.28,22.28,,,,,,
Humana,ExceptCPT,84315,Body fluid specific gravity,Medicare Fee Schedule 005-609,Per Unit,$9.02 ,OP,9.02,9.02,,,,,,
Humana,ExceptCPT,84375,Chromatogram assay sugars,Medicare Fee Schedule 005-609,Per Unit,$107.25 ,OP,107.25,107.25,,,,,,
Humana,ExceptCPT,84376,Sugars single qual,Medicare Fee Schedule 005-609,Per Unit,$15.13 ,OP,15.13,15.13,,,,,,
Humana,ExceptCPT,84377,Sugars multiple qual,Medicare Fee Schedule 005-609,Per Unit,$15.13 ,OP,15.13,15.13,,,,,,
Humana,ExceptCPT,84378,Sugars single quant,Medicare Fee Schedule 005-609,Per Unit,$31.71 ,OP,31.71,31.71,,,,,,
Humana,ExceptCPT,84379,Sugars multiple quant,Medicare Fee Schedule 005-609,Per Unit,$31.71 ,OP,31.71,31.71,,,,,,
Humana,ExceptCPT,84392,Assay of urine sulfate,Medicare Fee Schedule 005-609,Per Unit,$15.10 ,OP,15.1,15.1,,,,,,
Humana,ExceptCPT,84402,Assay of free testosterone,Medicare Fee Schedule 005-609,Per Unit,$70.04 ,OP,70.04,70.04,,,,,,
Humana,ExceptCPT,84403,Assay of total testosterone,Medicare Fee Schedule 005-609,Per Unit,$70.98 ,OP,70.98,70.98,,,,,,
Humana,ExceptCPT,84410,Testosterone bioavailable,Medicare Fee Schedule 005-609,Per Unit,$141.02 ,OP,141.02,141.02,,,,,,
Humana,ExceptCPT,84425,Assay of vitamin b-1,Medicare Fee Schedule 005-609,Per Unit,$58.38 ,OP,58.38,58.38,,,,,,
Humana,ExceptCPT,84430,Assay of thiocyanate,Medicare Fee Schedule 005-609,Per Unit,$31.98 ,OP,31.98,31.98,,,,,,
Humana,ExceptCPT,84431,Thromboxane urine,Medicare Fee Schedule 005-609,Per Unit,$96.55 ,OP,96.55,96.55,,,,,,
Humana,ExceptCPT,84432,Assay of thyroglobulin,Medicare Fee Schedule 005-609,Per Unit,$44.17 ,OP,44.17,44.17,,,,,,
Humana,ExceptCPT,84436,Assay of total thyroxine,Medicare Fee Schedule 005-609,Per Unit,$18.89 ,OP,18.89,18.89,,,,,,
Humana,ExceptCPT,84437,Assay of neonatal thyroxine,Medicare Fee Schedule 005-609,Per Unit,$17.79 ,OP,17.79,17.79,,,,,,
Humana,ExceptCPT,84439,Assay of free thyroxine,Medicare Fee Schedule 005-609,Per Unit,$24.81 ,OP,24.81,24.81,,,,,,
Humana,ExceptCPT,84442,Assay of thyroid activity,Medicare Fee Schedule 005-609,Per Unit,$40.65 ,OP,40.65,40.65,,,,,,
Humana,ExceptCPT,84443,Assay thyroid stim hormone,Medicare Fee Schedule 005-609,Per Unit,$46.20 ,OP,46.2,46.2,,,,,,
Humana,ExceptCPT,84445,Assay of tsi globulin,Medicare Fee Schedule 005-609,Per Unit,$139.87 ,OP,139.87,139.87,,,,,,
Humana,ExceptCPT,84446,Assay of vitamin e,Medicare Fee Schedule 005-609,Per Unit,$39.00 ,OP,39,39,,,,,,
Humana,ExceptCPT,84449,Assay of transcortin,Medicare Fee Schedule 005-609,Per Unit,$49.50 ,OP,49.5,49.5,,,,,,
Humana,ExceptCPT,84450,Transferase (ast) (sgot),Medicare Fee Schedule 005-609,Per Unit,$14.25 ,OP,14.25,14.25,,,,,,
Humana,ExceptCPT,84460,Alanine amino (alt) (sgpt),Medicare Fee Schedule 005-609,Per Unit,$14.58 ,OP,14.58,14.58,,,,,,
Humana,ExceptCPT,84466,Assay of transferrin,Medicare Fee Schedule 005-609,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,
Humana,ExceptCPT,84478,Assay of triglycerides,Medicare Fee Schedule 005-609,Per Unit,$15.79 ,OP,15.79,15.79,,,,,,
Humana,ExceptCPT,84479,Assay of thyroid (t3 or t4),Medicare Fee Schedule 005-609,Per Unit,$17.79 ,OP,17.79,17.79,,,,,,
Humana,ExceptCPT,84480,Assay triiodothyronine (t3),Medicare Fee Schedule 005-609,Per Unit,$39.00 ,OP,39,39,,,,,,
Humana,ExceptCPT,84481,Free assay (ft-3),Medicare Fee Schedule 005-609,Per Unit,$46.59 ,OP,46.59,46.59,,,,,,
Humana,ExceptCPT,84482,T3 reverse,Medicare Fee Schedule 005-609,Per Unit,$43.34 ,OP,43.34,43.34,,,,,,
Humana,ExceptCPT,84484,Assay of troponin quant,Medicare Fee Schedule 005-609,Per Unit,$34.29 ,OP,34.29,34.29,,,,,,
Humana,ExceptCPT,84485,Assay duodenal fluid trypsin,Medicare Fee Schedule 005-609,Per Unit,$19.80 ,OP,19.8,19.8,,,,,,
Humana,ExceptCPT,84488,Test feces for trypsin,Medicare Fee Schedule 005-609,Per Unit,$20.08 ,OP,20.08,20.08,,,,,,
Humana,ExceptCPT,84490,Assay of feces for trypsin,Medicare Fee Schedule 005-609,Per Unit,$27.31 ,OP,27.31,27.31,,,,,,
Humana,ExceptCPT,84510,Assay of tyrosine,Medicare Fee Schedule 005-609,Per Unit,$29.23 ,OP,29.23,29.23,,,,,,
Humana,ExceptCPT,84512,Assay of troponin qual,Medicare Fee Schedule 005-609,Per Unit,$27.75 ,OP,27.75,27.75,,,,,,
Humana,ExceptCPT,84520,Assay of urea nitrogen,Medicare Fee Schedule 005-609,Per Unit,$10.86 ,OP,10.86,10.86,,,,,,
Humana,ExceptCPT,84525,Urea nitrogen semi-quant,Medicare Fee Schedule 005-609,Per Unit,$14.11 ,OP,14.11,14.11,,,,,,
Humana,ExceptCPT,84540,Assay of urine/urea-n,Medicare Fee Schedule 005-609,Per Unit,$15.29 ,OP,15.29,15.29,,,,,,
Humana,ExceptCPT,84545,Urea-n clearance test,Medicare Fee Schedule 005-609,Per Unit,$19.80 ,OP,19.8,19.8,,,,,,
Humana,ExceptCPT,84550,Assay of blood/uric acid,Medicare Fee Schedule 005-609,Per Unit,$12.43 ,OP,12.43,12.43,,,,,,
Humana,ExceptCPT,84560,Assay of urine/uric acid,Medicare Fee Schedule 005-609,Per Unit,$13.97 ,OP,13.97,13.97,,,,,,
Humana,ExceptCPT,84577,Assay of feces/urobilinogen,Medicare Fee Schedule 005-609,Per Unit,$46.20 ,OP,46.2,46.2,,,,,,
Humana,ExceptCPT,84578,Test urine urobilinogen,Medicare Fee Schedule 005-609,Per Unit,$12.29 ,OP,12.29,12.29,,,,,,
Humana,ExceptCPT,84580,Assay of urine urobilinogen,Medicare Fee Schedule 005-609,Per Unit,$26.26 ,OP,26.26,26.26,,,,,,
Humana,ExceptCPT,84583,Assay of urine urobilinogen,Medicare Fee Schedule 005-609,Per Unit,$16.64 ,OP,16.64,16.64,,,,,,
Humana,ExceptCPT,84585,Assay of urine vma,Medicare Fee Schedule 005-609,Per Unit,$42.63 ,OP,42.63,42.63,,,,,,
Humana,ExceptCPT,84586,Assay of vip,Medicare Fee Schedule 005-609,Per Unit,$97.16 ,OP,97.16,97.16,,,,,,
Humana,ExceptCPT,84588,Assay of vasopressin,Medicare Fee Schedule 005-609,Per Unit,$93.34 ,OP,93.34,93.34,,,,,,
Humana,ExceptCPT,84590,Assay of vitamin a,Medicare Fee Schedule 005-609,Per Unit,$31.93 ,OP,31.93,31.93,,,,,,
Humana,ExceptCPT,84591,Assay of nos vitamin,Medicare Fee Schedule 005-609,Per Unit,$46.92 ,OP,46.92,46.92,,,,,,
Humana,ExceptCPT,84597,Assay of vitamin k,Medicare Fee Schedule 005-609,Per Unit,$37.73 ,OP,37.73,37.73,,,,,,
Humana,ExceptCPT,84600,Assay of volatiles,Medicare Fee Schedule 005-609,Per Unit,$47.05 ,OP,47.05,47.05,,,,,,
Humana,ExceptCPT,84620,Xylose tolerance test,Medicare Fee Schedule 005-609,Per Unit,$35.50 ,OP,35.5,35.5,,,,,,
Humana,ExceptCPT,84630,Assay of zinc,Medicare Fee Schedule 005-609,Per Unit,$31.32 ,OP,31.32,31.32,,,,,,
Humana,ExceptCPT,84681,Assay of c-peptide,Medicare Fee Schedule 005-609,Per Unit,$57.23 ,OP,57.23,57.23,,,,,,
Humana,ExceptCPT,84702,Chorionic gonadotropin test,Medicare Fee Schedule 005-609,Per Unit,$41.39 ,OP,41.39,41.39,,,,,,
Humana,ExceptCPT,84703,Chorionic gonadotropin assay,Medicare Fee Schedule 005-609,Per Unit,$20.68 ,OP,20.68,20.68,,,,,,
Humana,ExceptCPT,84704,Hcg free betachain test,Medicare Fee Schedule 005-609,Per Unit,$42.05 ,OP,42.05,42.05,,,,,,
Humana,ExceptCPT,84830,Ovulation tests,Medicare Fee Schedule 005-609,Per Unit,$34.93 ,OP,34.93,34.93,,,,,,
Humana,ExceptCPT,85002,Bleeding time test,Medicare Fee Schedule 005-609,Per Unit,$13.26 ,OP,13.26,13.26,,,,,,
Humana,ExceptCPT,85004,Automated diff wbc count,Medicare Fee Schedule 005-609,Per Unit,$17.79 ,OP,17.79,17.79,,,,,,
Humana,ExceptCPT,85007,Bl smear w/diff wbc count,Medicare Fee Schedule 005-609,Per Unit,$10.45 ,OP,10.45,10.45,,,,,,
Humana,ExceptCPT,85008,Bl smear w/o diff wbc count,Medicare Fee Schedule 005-609,Per Unit,$9.43 ,OP,9.43,9.43,,,,,,
Humana,ExceptCPT,85009,Manual diff wbc count b-coat,Medicare Fee Schedule 005-609,Per Unit,$13.94 ,OP,13.94,13.94,,,,,,
Humana,ExceptCPT,85013,Spun microhematocrit,Medicare Fee Schedule 005-609,Per Unit,$19.25 ,OP,19.25,19.25,,,,,,
Humana,ExceptCPT,85014,Hematocrit,Medicare Fee Schedule 005-609,Per Unit,$6.52 ,OP,6.52,6.52,,,,,,
Humana,ExceptCPT,85018,Hemoglobin,Medicare Fee Schedule 005-609,Per Unit,$6.52 ,OP,6.52,6.52,,,,,,
Humana,ExceptCPT,85025,Complete cbc w/auto diff wbc,Medicare Fee Schedule 005-609,Per Unit,$21.37 ,OP,21.37,21.37,,,,,,
Humana,ExceptCPT,85027,Complete cbc automated,Medicare Fee Schedule 005-609,Per Unit,$17.79 ,OP,17.79,17.79,,,,,,
Humana,ExceptCPT,85032,Manual cell count each,Medicare Fee Schedule 005-609,Per Unit,$11.85 ,OP,11.85,11.85,,,,,,
Humana,ExceptCPT,85041,Automated rbc count,Medicare Fee Schedule 005-609,Per Unit,$8.31 ,OP,8.31,8.31,,,,,,
Humana,ExceptCPT,85044,Manual reticulocyte count,Medicare Fee Schedule 005-609,Per Unit,$11.85 ,OP,11.85,11.85,,,,,,
Humana,ExceptCPT,85045,Automated reticulocyte count,Medicare Fee Schedule 005-609,Per Unit,$10.97 ,OP,10.97,10.97,,,,,,
Humana,ExceptCPT,85046,Reticyte/hgb concentrate,Medicare Fee Schedule 005-609,Per Unit,$15.32 ,OP,15.32,15.32,,,,,,
Humana,ExceptCPT,85048,Automated leukocyte count,Medicare Fee Schedule 005-609,Per Unit,$6.99 ,OP,6.99,6.99,,,,,,
Humana,ExceptCPT,85049,Automated platelet count,Medicare Fee Schedule 005-609,Per Unit,$12.32 ,OP,12.32,12.32,,,,,,
Humana,ExceptCPT,85055,Reticulated platelet assay,Medicare Fee Schedule 005-609,Per Unit,$98.29 ,OP,98.29,98.29,,,,,,
Humana,ExceptCPT,85060,Blood smear interpretation,Medicare Fee Schedule 005-609,Per Unit,$66.96 ,OP,66.96,66.96,,,,,,
Humana,ExceptCPT,85130,Chromogenic substrate assay,Medicare Fee Schedule 005-609,Per Unit,$32.70 ,OP,32.7,32.7,,,,,,
Humana,ExceptCPT,85170,Blood clot retraction,Medicare Fee Schedule 005-609,Per Unit,$44.83 ,OP,44.83,44.83,,,,,,
Humana,ExceptCPT,85175,Blood clot lysis time,Medicare Fee Schedule 005-609,Per Unit,$56.02 ,OP,56.02,56.02,,,,,,
Humana,ExceptCPT,85210,Clot factor ii prothrom spec,Medicare Fee Schedule 005-609,Per Unit,$35.70 ,OP,35.7,35.7,,,,,,
Humana,ExceptCPT,85220,Blooc clot factor v test,Medicare Fee Schedule 005-609,Per Unit,$48.54 ,OP,48.54,48.54,,,,,,
Humana,ExceptCPT,85230,Clot factor vii proconvertin,Medicare Fee Schedule 005-609,Per Unit,$49.23 ,OP,49.23,49.23,,,,,,
Humana,ExceptCPT,85240,Clot factor viii ahg 1 stage,Medicare Fee Schedule 005-609,Per Unit,$49.23 ,OP,49.23,49.23,,,,,,
Humana,ExceptCPT,85244,Clot factor viii reltd antgn,Medicare Fee Schedule 005-609,Per Unit,$56.16 ,OP,56.16,56.16,,,,,,
Humana,ExceptCPT,85245,Clot factor viii vw ristoctn,Medicare Fee Schedule 005-609,Per Unit,$63.09 ,OP,63.09,63.09,,,,,,
Humana,ExceptCPT,85246,Clot factor viii vw antigen,Medicare Fee Schedule 005-609,Per Unit,$63.09 ,OP,63.09,63.09,,,,,,
Humana,ExceptCPT,85247,Clot factor viii multimetric,Medicare Fee Schedule 005-609,Per Unit,$63.09 ,OP,63.09,63.09,,,,,,
Humana,ExceptCPT,85250,Clot factor ix ptc/chrstmas,Medicare Fee Schedule 005-609,Per Unit,$52.36 ,OP,52.36,52.36,,,,,,
Humana,ExceptCPT,85260,Clot factor x stuart-power,Medicare Fee Schedule 005-609,Per Unit,$49.23 ,OP,49.23,49.23,,,,,,
Humana,ExceptCPT,85270,Clot factor xi pta,Medicare Fee Schedule 005-609,Per Unit,$49.23 ,OP,49.23,49.23,,,,,,
Humana,ExceptCPT,85280,Clot factor xii hageman,Medicare Fee Schedule 005-609,Per Unit,$53.21 ,OP,53.21,53.21,,,,,,
Humana,ExceptCPT,85290,Clot factor xiii fibrin stab,Medicare Fee Schedule 005-609,Per Unit,$44.94 ,OP,44.94,44.94,,,,,,
Humana,ExceptCPT,85291,Clot factor xiii fibrin scrn,Medicare Fee Schedule 005-609,Per Unit,$25.05 ,OP,25.05,25.05,,,,,,
Humana,ExceptCPT,85292,Clot factor fletcher fact,Medicare Fee Schedule 005-609,Per Unit,$52.06 ,OP,52.06,52.06,,,,,,
Humana,ExceptCPT,85293,Clot factor wght kininogen,Medicare Fee Schedule 005-609,Per Unit,$52.06 ,OP,52.06,52.06,,,,,,
Humana,ExceptCPT,85300,Antithrombin iii activity,Medicare Fee Schedule 005-609,Per Unit,$32.59 ,OP,32.59,32.59,,,,,,
Humana,ExceptCPT,85301,Antithrombin iii antigen,Medicare Fee Schedule 005-609,Per Unit,$29.73 ,OP,29.73,29.73,,,,,,
Humana,ExceptCPT,85302,Clot inhibit prot c antigen,Medicare Fee Schedule 005-609,Per Unit,$33.03 ,OP,33.03,33.03,,,,,,
Humana,ExceptCPT,85303,Clot inhibit prot c activity,Medicare Fee Schedule 005-609,Per Unit,$38.06 ,OP,38.06,38.06,,,,,,
Humana,ExceptCPT,85305,Clot inhibit prot s total,Medicare Fee Schedule 005-609,Per Unit,$31.93 ,OP,31.93,31.93,,,,,,
Humana,ExceptCPT,85306,Clot inhibit prot s free,Medicare Fee Schedule 005-609,Per Unit,$42.13 ,OP,42.13,42.13,,,,,,
Humana,ExceptCPT,85307,Assay activated protein c,Medicare Fee Schedule 005-609,Per Unit,$42.13 ,OP,42.13,42.13,,,,,,
Humana,ExceptCPT,85335,Factor inhibitor test,Medicare Fee Schedule 005-609,Per Unit,$35.39 ,OP,35.39,35.39,,,,,,
Humana,ExceptCPT,85337,Thrombomodulin,Medicare Fee Schedule 005-609,Per Unit,$47.49 ,OP,47.49,47.49,,,,,,
Humana,ExceptCPT,85345,Coagulation time lee & white,Medicare Fee Schedule 005-609,Per Unit,$12.90 ,OP,12.9,12.9,,,,,,
Humana,ExceptCPT,85347,Coagulation time activated,Medicare Fee Schedule 005-609,Per Unit,$11.77 ,OP,11.77,11.77,,,,,,
Humana,ExceptCPT,85348,Coagulation time otr method,Medicare Fee Schedule 005-609,Per Unit,$12.35 ,OP,12.35,12.35,,,,,,
Humana,ExceptCPT,85360,Euglobulin lysis,Medicare Fee Schedule 005-609,Per Unit,$23.13 ,OP,23.13,23.13,,,,,,
Humana,ExceptCPT,85362,Fibrin degradation products,Medicare Fee Schedule 005-609,Per Unit,$18.95 ,OP,18.95,18.95,,,,,,
Humana,ExceptCPT,85366,Fibrinogen test,Medicare Fee Schedule 005-609,Per Unit,$221.27 ,OP,221.27,221.27,,,,,,
Humana,ExceptCPT,85370,Fibrinogen test,Medicare Fee Schedule 005-609,Per Unit,$34.18 ,OP,34.18,34.18,,,,,,
Humana,ExceptCPT,85378,Fibrin degrade semiquant,Medicare Fee Schedule 005-609,Per Unit,$26.73 ,OP,26.73,26.73,,,,,,
Humana,ExceptCPT,85379,Fibrin degradation quant,Medicare Fee Schedule 005-609,Per Unit,$28.00 ,OP,28,28,,,,,,
Humana,ExceptCPT,85380,Fibrin degradj d-dimer,Medicare Fee Schedule 005-609,Per Unit,$28.00 ,OP,28,28,,,,,,
Humana,ExceptCPT,85384,Fibrinogen activity,Medicare Fee Schedule 005-609,Per Unit,$26.73 ,OP,26.73,26.73,,,,,,
Humana,ExceptCPT,85385,Fibrinogen antigen,Medicare Fee Schedule 005-609,Per Unit,$39.77 ,OP,39.77,39.77,,,,,,
Humana,ExceptCPT,85390,Fibrinolysins screen i&r,Medicare Fee Schedule 005-609,Per Unit,$42.57 ,OP,42.57,42.57,,,,,,
Humana,ExceptCPT,85397,Clotting funct activity,Medicare Fee Schedule 005-609,Per Unit,$84.87 ,OP,84.87,84.87,,,,,,
Humana,ExceptCPT,85400,Fibrinolytic plasmin,Medicare Fee Schedule 005-609,Per Unit,$21.20 ,OP,21.2,21.2,,,,,,
Humana,ExceptCPT,85410,Fibrinolytic antiplasmin,Medicare Fee Schedule 005-609,Per Unit,$21.20 ,OP,21.2,21.2,,,,,,
Humana,ExceptCPT,85415,Fibrinolytic plasminogen,Medicare Fee Schedule 005-609,Per Unit,$47.27 ,OP,47.27,47.27,,,,,,
Humana,ExceptCPT,85420,Fibrinolytic plasminogen,Medicare Fee Schedule 005-609,Per Unit,$17.96 ,OP,17.96,17.96,,,,,,
Humana,ExceptCPT,85421,Fibrinolytic plasminogen,Medicare Fee Schedule 005-609,Per Unit,$28.00 ,OP,28,28,,,,,,
Humana,ExceptCPT,85441,Heinz bodies direct,Medicare Fee Schedule 005-609,Per Unit,$11.55 ,OP,11.55,11.55,,,,,,
Humana,ExceptCPT,85445,Heinz bodies induced,Medicare Fee Schedule 005-609,Per Unit,$18.76 ,OP,18.76,18.76,,,,,,
Humana,ExceptCPT,85460,Hemoglobin fetal,Medicare Fee Schedule 005-609,Per Unit,$21.26 ,OP,21.26,21.26,,,,,,
Humana,ExceptCPT,85461,Hemoglobin fetal,Medicare Fee Schedule 005-609,Per Unit,$25.74 ,OP,25.74,25.74,,,,,,
Humana,ExceptCPT,85475,Hemolysin acid,Medicare Fee Schedule 005-609,Per Unit,$24.39 ,OP,24.39,24.39,,,,,,
Humana,ExceptCPT,85520,Heparin assay,Medicare Fee Schedule 005-609,Per Unit,$36.00 ,OP,36,36,,,,,,
Humana,ExceptCPT,85525,Heparin neutralization,Medicare Fee Schedule 005-609,Per Unit,$32.56 ,OP,32.56,32.56,,,,,,
Humana,ExceptCPT,85530,Heparin-protamine tolerance,Medicare Fee Schedule 005-609,Per Unit,$36.00 ,OP,36,36,,,,,,
Humana,ExceptCPT,85536,Iron stain peripheral blood,Medicare Fee Schedule 005-609,Per Unit,$18.92 ,OP,18.92,18.92,,,,,,
Humana,ExceptCPT,85540,Wbc alkaline phosphatase,Medicare Fee Schedule 005-609,Per Unit,$23.65 ,OP,23.65,23.65,,,,,,
Humana,ExceptCPT,85547,Rbc mechanical fragility,Medicare Fee Schedule 005-609,Per Unit,$23.65 ,OP,23.65,23.65,,,,,,
Humana,ExceptCPT,85549,Muramidase,Medicare Fee Schedule 005-609,Per Unit,$51.56 ,OP,51.56,51.56,,,,,,
Humana,ExceptCPT,85555,Rbc osmotic fragility,Medicare Fee Schedule 005-609,Per Unit,$20.54 ,OP,20.54,20.54,,,,,,
Humana,ExceptCPT,85557,Rbc osmotic fragility,Medicare Fee Schedule 005-609,Per Unit,$36.74 ,OP,36.74,36.74,,,,,,
Humana,ExceptCPT,85576,Blood platelet aggregation,Medicare Fee Schedule 005-609,Per Unit,$68.50 ,OP,68.5,68.5,,,,,,
Humana,ExceptCPT,85597,Phospholipid pltlt neutraliz,Medicare Fee Schedule 005-609,Per Unit,$49.45 ,OP,49.45,49.45,,,,,,
Humana,ExceptCPT,85598,Hexagnal phosph pltlt neutrl,Medicare Fee Schedule 005-609,Per Unit,$49.45 ,OP,49.45,49.45,,,,,,
Humana,ExceptCPT,85610,Prothrombin time,Medicare Fee Schedule 005-609,Per Unit,$11.80 ,OP,11.8,11.8,,,,,,
Humana,ExceptCPT,85611,Prothrombin test,Medicare Fee Schedule 005-609,Per Unit,$10.84 ,OP,10.84,10.84,,,,,,
Humana,ExceptCPT,85612,Viper venom prothrombin time,Medicare Fee Schedule 005-609,Per Unit,$48.10 ,OP,48.1,48.1,,,,,,
Humana,ExceptCPT,85613,Russell viper venom diluted,Medicare Fee Schedule 005-609,Per Unit,$26.35 ,OP,26.35,26.35,,,,,,
Humana,ExceptCPT,85635,Reptilase test,Medicare Fee Schedule 005-609,Per Unit,$27.09 ,OP,27.09,27.09,,,,,,
Humana,ExceptCPT,85651,Rbc sed rate nonautomated,Medicare Fee Schedule 005-609,Per Unit,$11.74 ,OP,11.74,11.74,,,,,,
Humana,ExceptCPT,85652,Rbc sed rate automated,Medicare Fee Schedule 005-609,Per Unit,$7.43 ,OP,7.43,7.43,,,,,,
Humana,ExceptCPT,85660,Rbc sickle cell test,Medicare Fee Schedule 005-609,Per Unit,$15.15 ,OP,15.15,15.15,,,,,,
Humana,ExceptCPT,85670,Thrombin time plasma,Medicare Fee Schedule 005-609,Per Unit,$15.87 ,OP,15.87,15.87,,,,,,
Humana,ExceptCPT,85675,Thrombin time titer,Medicare Fee Schedule 005-609,Per Unit,$18.84 ,OP,18.84,18.84,,,,,,
Humana,ExceptCPT,85705,Thromboplastin inhibition,Medicare Fee Schedule 005-609,Per Unit,$26.48 ,OP,26.48,26.48,,,,,,
Humana,ExceptCPT,85730,Thromboplastin time partial,Medicare Fee Schedule 005-609,Per Unit,$16.53 ,OP,16.53,16.53,,,,,,
Humana,ExceptCPT,85732,Thromboplastin time partial,Medicare Fee Schedule 005-609,Per Unit,$17.79 ,OP,17.79,17.79,,,,,,
Humana,ExceptCPT,85810,Blood viscosity examination,Medicare Fee Schedule 005-609,Per Unit,$32.09 ,OP,32.09,32.09,,,,,,
Humana,ExceptCPT,86000,Agglutinins febrile antigen,Medicare Fee Schedule 005-609,Per Unit,$19.20 ,OP,19.2,19.2,,,,,,
Humana,ExceptCPT,86001,Allergen specific igg,Medicare Fee Schedule 005-609,Per Unit,$21.51 ,OP,21.51,21.51,,,,,,
Humana,ExceptCPT,86003,Allg spec ige crude xtrc ea,Medicare Fee Schedule 005-609,Per Unit,$14.36 ,OP,14.36,14.36,,,,,,
Humana,ExceptCPT,86005,Allg spec ige multiallg scr,Medicare Fee Schedule 005-609,Per Unit,$21.92 ,OP,21.92,21.92,,,,,,
Humana,ExceptCPT,86008,Allg spec ige recomb ea,Medicare Fee Schedule 005-609,Per Unit,$49.31 ,OP,49.31,49.31,,,,,,
Humana,ExceptCPT,86021,Wbc antibody identification,Medicare Fee Schedule 005-609,Per Unit,$41.39 ,OP,41.39,41.39,,,,,,
Humana,ExceptCPT,86022,Platelet antibodies,Medicare Fee Schedule 005-609,Per Unit,$50.52 ,OP,50.52,50.52,,,,,,
Humana,ExceptCPT,86023,Immunoglobulin assay,Medicare Fee Schedule 005-609,Per Unit,$34.27 ,OP,34.27,34.27,,,,,,
Humana,ExceptCPT,86038,Antinuclear antibodies,Medicare Fee Schedule 005-609,Per Unit,$33.25 ,OP,33.25,33.25,,,,,,
Humana,ExceptCPT,86039,Antinuclear antibodies (ana),Medicare Fee Schedule 005-609,Per Unit,$30.69 ,OP,30.69,30.69,,,,,,
Humana,ExceptCPT,86060,Antistreptolysin o titer,Medicare Fee Schedule 005-609,Per Unit,$20.08 ,OP,20.08,20.08,,,,,,
Humana,ExceptCPT,86063,Antistreptolysin o screen,Medicare Fee Schedule 005-609,Per Unit,$15.87 ,OP,15.87,15.87,,,,,,
Humana,ExceptCPT,86140,C-reactive protein,Medicare Fee Schedule 005-609,Per Unit,$14.25 ,OP,14.25,14.25,,,,,,
Humana,ExceptCPT,86141,C-reactive protein hs,Medicare Fee Schedule 005-609,Per Unit,$35.61 ,OP,35.61,35.61,,,,,,
Humana,ExceptCPT,86146,Beta-2 glycoprotein antibody,Medicare Fee Schedule 005-609,Per Unit,$69.99 ,OP,69.99,69.99,,,,,,
Humana,ExceptCPT,86147,Cardiolipin antibody ea ig,Medicare Fee Schedule 005-609,Per Unit,$69.99 ,OP,69.99,69.99,,,,,,
Humana,ExceptCPT,86148,Anti-phospholipid antibody,Medicare Fee Schedule 005-609,Per Unit,$44.19 ,OP,44.19,44.19,,,,,,
Humana,ExceptCPT,86152,Cell enumeration & id,Medicare Fee Schedule 005-609,Per Unit,$689.65 ,OP,689.65,689.65,,,,,,
Humana,ExceptCPT,86153,Cell enumeration phys interp,Medicare Fee Schedule 005-609,Per Unit,$94.38 ,OP,94.38,94.38,,,,,,
Humana,ExceptCPT,86155,Chemotaxis assay,Medicare Fee Schedule 005-609,Per Unit,$43.97 ,OP,43.97,43.97,,,,,,
Humana,ExceptCPT,86156,Cold agglutinin screen,Medicare Fee Schedule 005-609,Per Unit,$22.19 ,OP,22.19,22.19,,,,,,
Humana,ExceptCPT,86157,Cold agglutinin titer,Medicare Fee Schedule 005-609,Per Unit,$22.17 ,OP,22.17,22.17,,,,,,
Humana,ExceptCPT,86160,Complement antigen,Medicare Fee Schedule 005-609,Per Unit,$33.00 ,OP,33,33,,,,,,
Humana,ExceptCPT,86161,Complement/function activity,Medicare Fee Schedule 005-609,Per Unit,$33.00 ,OP,33,33,,,,,,
Humana,ExceptCPT,86162,Complement total (ch50),Medicare Fee Schedule 005-609,Per Unit,$55.88 ,OP,55.88,55.88,,,,,,
Humana,ExceptCPT,86171,Complement fixation each,Medicare Fee Schedule 005-609,Per Unit,$27.53 ,OP,27.53,27.53,,,,,,
Humana,ExceptCPT,86200,Ccp antibody,Medicare Fee Schedule 005-609,Per Unit,$35.61 ,OP,35.61,35.61,,,,,,
Humana,ExceptCPT,86215,Deoxyribonuclease antibody,Medicare Fee Schedule 005-609,Per Unit,$36.44 ,OP,36.44,36.44,,,,,,
Humana,ExceptCPT,86225,Dna antibody native,Medicare Fee Schedule 005-609,Per Unit,$37.79 ,OP,37.79,37.79,,,,,,
Humana,ExceptCPT,86226,Dna antibody single strand,Medicare Fee Schedule 005-609,Per Unit,$33.30 ,OP,33.3,33.3,,,,,,
Humana,ExceptCPT,86235,Nuclear antigen antibody,Medicare Fee Schedule 005-609,Per Unit,$49.31 ,OP,49.31,49.31,,,,,,
Humana,ExceptCPT,86255,Fluorescent antibody screen,Medicare Fee Schedule 005-609,Per Unit,$33.14 ,OP,33.14,33.14,,,,,,
Humana,ExceptCPT,86256,Fluorescent antibody titer,Medicare Fee Schedule 005-609,Per Unit,$33.14 ,OP,33.14,33.14,,,,,,
Humana,ExceptCPT,86277,Growth hormone antibody,Medicare Fee Schedule 005-609,Per Unit,$43.29 ,OP,43.29,43.29,,,,,,
Humana,ExceptCPT,86280,Hemagglutination inhibition,Medicare Fee Schedule 005-609,Per Unit,$22.52 ,OP,22.52,22.52,,,,,,
Humana,ExceptCPT,86294,Immunoassay tumor qual,Medicare Fee Schedule 005-609,Per Unit,$70.32 ,OP,70.32,70.32,,,,,,
Humana,ExceptCPT,86300,Immunoassay tumor ca 15-3,Medicare Fee Schedule 005-609,Per Unit,$57.23 ,OP,57.23,57.23,,,,,,
Humana,ExceptCPT,86301,Immunoassay tumor ca 19-9,Medicare Fee Schedule 005-609,Per Unit,$57.23 ,OP,57.23,57.23,,,,,,
Humana,ExceptCPT,86304,Immunoassay tumor ca 125,Medicare Fee Schedule 005-609,Per Unit,$57.23 ,OP,57.23,57.23,,,,,,
Humana,ExceptCPT,86305,Human epididymis protein 4,Medicare Fee Schedule 005-609,Per Unit,$57.23 ,OP,57.23,57.23,,,,,,
Humana,ExceptCPT,86308,Heterophile antibody screen,Medicare Fee Schedule 005-609,Per Unit,$14.25 ,OP,14.25,14.25,,,,,,
Humana,ExceptCPT,86309,Heterophile antibody titer,Medicare Fee Schedule 005-609,Per Unit,$17.79 ,OP,17.79,17.79,,,,,,
Humana,ExceptCPT,86310,Heterophile antibody absrbj,Medicare Fee Schedule 005-609,Per Unit,$20.27 ,OP,20.27,20.27,,,,,,
Humana,ExceptCPT,86316,Immunoassay tumor other,Medicare Fee Schedule 005-609,Per Unit,$57.23 ,OP,57.23,57.23,,,,,,
Humana,ExceptCPT,86317,Immunoassay infectious agent,Medicare Fee Schedule 005-609,Per Unit,$41.22 ,OP,41.22,41.22,,,,,,
Humana,ExceptCPT,86318,Ia infectious agent antibody,Medicare Fee Schedule 005-609,Per Unit,$49.75 ,OP,49.75,49.75,,,,,,
Humana,ExceptCPT,86320,Serum immunoelectrophoresis,Medicare Fee Schedule 005-609,Per Unit,$82.28 ,OP,82.28,82.28,,,,,,
Humana,ExceptCPT,86325,Other immunoelectrophoresis,Medicare Fee Schedule 005-609,Per Unit,$63.61 ,OP,63.61,63.61,,,,,,
Humana,ExceptCPT,86327,Immunoelectrophoresis assay,Medicare Fee Schedule 005-609,Per Unit,$82.28 ,OP,82.28,82.28,,,,,,
Humana,ExceptCPT,86328,Ia nfct ab sarscov2 covid19,Lab Services,Per Unit,$90.46 ,OP,90.46,90.46,,,,,,
Humana,ExceptCPT,86329,Immunodiffusion nes,Medicare Fee Schedule 005-609,Per Unit,$38.64 ,OP,38.64,38.64,,,,,,
Humana,ExceptCPT,86331,Immunodiffusion ouchterlony,Medicare Fee Schedule 005-609,Per Unit,$32.95 ,OP,32.95,32.95,,,,,,
Humana,ExceptCPT,86332,Immune complex assay,Medicare Fee Schedule 005-609,Per Unit,$67.02 ,OP,67.02,67.02,,,,,,
Humana,ExceptCPT,86334,Immunofix e-phoresis serum,Medicare Fee Schedule 005-609,Per Unit,$61.44 ,OP,61.44,61.44,,,,,,
Humana,ExceptCPT,86335,Immunfix e-phorsis/urine/csf,Medicare Fee Schedule 005-609,Per Unit,$80.71 ,OP,80.71,80.71,,,,,,
Humana,ExceptCPT,86336,Inhibin a,Medicare Fee Schedule 005-609,Per Unit,$42.87 ,OP,42.87,42.87,,,,,,
Humana,ExceptCPT,86337,Insulin antibodies,Medicare Fee Schedule 005-609,Per Unit,$58.88 ,OP,58.88,58.88,,,,,,
Humana,ExceptCPT,86340,Intrinsic factor antibody,Medicare Fee Schedule 005-609,Per Unit,$41.47 ,OP,41.47,41.47,,,,,,
Humana,ExceptCPT,86341,Islet cell antibody,Medicare Fee Schedule 005-609,Per Unit,$64.82 ,OP,64.82,64.82,,,,,,
Humana,ExceptCPT,86343,Leukocyte histamine release,Medicare Fee Schedule 005-609,Per Unit,$34.27 ,OP,34.27,34.27,,,,,,
Humana,ExceptCPT,86344,Leukocyte phagocytosis,Medicare Fee Schedule 005-609,Per Unit,$28.57 ,OP,28.57,28.57,,,,,,
Humana,ExceptCPT,86352,Cell function assay w/stim,Medicare Fee Schedule 005-609,Per Unit,$373.62 ,OP,373.62,373.62,,,,,,
Humana,ExceptCPT,86353,Lymphocyte transformation,Medicare Fee Schedule 005-609,Per Unit,$134.83 ,OP,134.83,134.83,,,,,,
Humana,ExceptCPT,86355,B cells total count,Medicare Fee Schedule 005-609,Per Unit,$103.76 ,OP,103.76,103.76,,,,,,
Humana,ExceptCPT,86356,Mononuclear cell antigen,Medicare Fee Schedule 005-609,Per Unit,$73.65 ,OP,73.65,73.65,,,,,,
Humana,ExceptCPT,86357,Nk cells total count,Medicare Fee Schedule 005-609,Per Unit,$103.76 ,OP,103.76,103.76,,,,,,
Humana,ExceptCPT,86359,T cells total count,Medicare Fee Schedule 005-609,Per Unit,$103.76 ,OP,103.76,103.76,,,,,,
Humana,ExceptCPT,86360,T cell absolute count/ratio,Medicare Fee Schedule 005-609,Per Unit,$129.20 ,OP,129.2,129.2,,,,,,
Humana,ExceptCPT,86361,T cell absolute count,Medicare Fee Schedule 005-609,Per Unit,$73.65 ,OP,73.65,73.65,,,,,,
Humana,ExceptCPT,86367,Stem cells total count,Medicare Fee Schedule 005-609,Per Unit,$213.90 ,OP,213.9,213.9,,,,,,
Humana,ExceptCPT,86376,Microsomal antibody each,Medicare Fee Schedule 005-609,Per Unit,$40.01 ,OP,40.01,40.01,,,,,,
Humana,ExceptCPT,86382,Neutralization test viral,Medicare Fee Schedule 005-609,Per Unit,$46.50 ,OP,46.5,46.5,,,,,,
Humana,ExceptCPT,86384,Nitroblue tetrazolium dye,Medicare Fee Schedule 005-609,Per Unit,$37.43 ,OP,37.43,37.43,,,,,,
Humana,ExceptCPT,86386,Nuclear matrix protein 22,Medicare Fee Schedule 005-609,Per Unit,$59.90 ,OP,59.9,59.9,,,,,,
Humana,ExceptCPT,86403,Particle agglut antbdy scrn,Medicare Fee Schedule 005-609,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana,ExceptCPT,86406,Particle agglut antbdy titr,Medicare Fee Schedule 005-609,Per Unit,$29.26 ,OP,29.26,29.26,,,,,,
Humana,ExceptCPT,86430,Rheumatoid factor test qual,Medicare Fee Schedule 005-609,Per Unit,$16.89 ,OP,16.89,16.89,,,,,,
Humana,ExceptCPT,86431,Rheumatoid factor quant,Medicare Fee Schedule 005-609,Per Unit,$15.59 ,OP,15.59,15.59,,,,,,
Humana,ExceptCPT,86480,Tb test cell immun measure,Medicare Fee Schedule 005-609,Per Unit,$170.45 ,OP,170.45,170.45,,,,,,
Humana,ExceptCPT,86481,Tb ag response t-cell susp,Medicare Fee Schedule 005-609,Per Unit,$275.00 ,OP,275,275,,,,,,
Humana,ExceptCPT,86485,Skin test candida,Medicare Fee Schedule 005-609,Per Unit,$31.32 ,OP,31.32,31.32,,,,,,
Humana,ExceptCPT,86486,Skin test nos antigen,Medicare Fee Schedule 005-609,Per Unit,$15.13 ,OP,15.13,15.13,,,,,,
Humana,ExceptCPT,86490,Coccidioidomycosis skin test,Medicare Fee Schedule 005-609,Per Unit,$231.30 ,OP,231.3,231.3,,,,,,
Humana,ExceptCPT,86510,Histoplasmosis skin test,Medicare Fee Schedule 005-609,Per Unit,$18.65 ,OP,18.65,18.65,,,,,,
Humana,ExceptCPT,86580,Tb intradermal test,Medicare Fee Schedule 005-609,Per Unit,$25.63 ,OP,25.63,25.63,,,,,,
Humana,ExceptCPT,86590,Streptokinase antibody,Medicare Fee Schedule 005-609,Per Unit,$34.82 ,OP,34.82,34.82,,,,,,
Humana,ExceptCPT,86592,Syphilis test non-trep qual,Medicare Fee Schedule 005-609,Per Unit,$11.74 ,OP,11.74,11.74,,,,,,
Humana,ExceptCPT,86593,Syphilis test non-trep quant,Medicare Fee Schedule 005-609,Per Unit,$12.10 ,OP,12.1,12.1,,,,,,
Humana,ExceptCPT,86602,Antinomyces antibody,Medicare Fee Schedule 005-609,Per Unit,$28.00 ,OP,28,28,,,,,,
Humana,ExceptCPT,86603,Adenovirus antibody,Medicare Fee Schedule 005-609,Per Unit,$35.39 ,OP,35.39,35.39,,,,,,
Humana,ExceptCPT,86606,Aspergillus antibody,Medicare Fee Schedule 005-609,Per Unit,$41.39 ,OP,41.39,41.39,,,,,,
Humana,ExceptCPT,86609,Bacterium antibody,Medicare Fee Schedule 005-609,Per Unit,$35.42 ,OP,35.42,35.42,,,,,,
Humana,ExceptCPT,86611,Bartonella antibody,Medicare Fee Schedule 005-609,Per Unit,$28.00 ,OP,28,28,,,,,,
Humana,ExceptCPT,86612,Blastomyces antibody,Medicare Fee Schedule 005-609,Per Unit,$35.48 ,OP,35.48,35.48,,,,,,
Humana,ExceptCPT,86615,Bordetella antibody,Medicare Fee Schedule 005-609,Per Unit,$36.27 ,OP,36.27,36.27,,,,,,
Humana,ExceptCPT,86617,Lyme disease antibody,Medicare Fee Schedule 005-609,Per Unit,$42.60 ,OP,42.6,42.6,,,,,,
Humana,ExceptCPT,86618,Lyme disease antibody,Medicare Fee Schedule 005-609,Per Unit,$46.83 ,OP,46.83,46.83,,,,,,
Humana,ExceptCPT,86619,Borrelia antibody,Medicare Fee Schedule 005-609,Per Unit,$36.80 ,OP,36.8,36.8,,,,,,
Humana,ExceptCPT,86622,Brucella antibody,Medicare Fee Schedule 005-609,Per Unit,$24.56 ,OP,24.56,24.56,,,,,,
Humana,ExceptCPT,86625,Campylobacter antibody,Medicare Fee Schedule 005-609,Per Unit,$36.08 ,OP,36.08,36.08,,,,,,
Humana,ExceptCPT,86628,Candida antibody,Medicare Fee Schedule 005-609,Per Unit,$33.03 ,OP,33.03,33.03,,,,,,
Humana,ExceptCPT,86631,Chlamydia antibody,Medicare Fee Schedule 005-609,Per Unit,$32.51 ,OP,32.51,32.51,,,,,,
Humana,ExceptCPT,86632,Chlamydia igm antibody,Medicare Fee Schedule 005-609,Per Unit,$34.87 ,OP,34.87,34.87,,,,,,
Humana,ExceptCPT,86635,Coccidioides antibody,Medicare Fee Schedule 005-609,Per Unit,$31.54 ,OP,31.54,31.54,,,,,,
Humana,ExceptCPT,86638,Q fever antibody,Medicare Fee Schedule 005-609,Per Unit,$33.33 ,OP,33.33,33.33,,,,,,
Humana,ExceptCPT,86641,Cryptococcus antibody,Medicare Fee Schedule 005-609,Per Unit,$39.63 ,OP,39.63,39.63,,,,,,
Humana,ExceptCPT,86644,Cmv antibody,Medicare Fee Schedule 005-609,Per Unit,$39.57 ,OP,39.57,39.57,,,,,,
Humana,ExceptCPT,86645,Cmv antibody igm,Medicare Fee Schedule 005-609,Per Unit,$46.34 ,OP,46.34,46.34,,,,,,
Humana,ExceptCPT,86648,Diphtheria antibody,Medicare Fee Schedule 005-609,Per Unit,$41.83 ,OP,41.83,41.83,,,,,,
Humana,ExceptCPT,86651,Encephalitis californ antbdy,Medicare Fee Schedule 005-609,Per Unit,$36.27 ,OP,36.27,36.27,,,,,,
Humana,ExceptCPT,86652,Encephaltis east eqne anbdy,Medicare Fee Schedule 005-609,Per Unit,$36.27 ,OP,36.27,36.27,,,,,,
Humana,ExceptCPT,86653,Encephaltis st louis antbody,Medicare Fee Schedule 005-609,Per Unit,$36.27 ,OP,36.27,36.27,,,,,,
Humana,ExceptCPT,86654,Encephaltis west eqne antbdy,Medicare Fee Schedule 005-609,Per Unit,$36.27 ,OP,36.27,36.27,,,,,,
Humana,ExceptCPT,86658,Enterovirus antibody,Medicare Fee Schedule 005-609,Per Unit,$35.83 ,OP,35.83,35.83,,,,,,
Humana,ExceptCPT,86663,Epstein-barr antibody,Medicare Fee Schedule 005-609,Per Unit,$36.08 ,OP,36.08,36.08,,,,,,
Humana,ExceptCPT,86664,Epstein-barr nuclear antigen,Medicare Fee Schedule 005-609,Per Unit,$42.05 ,OP,42.05,42.05,,,,,,
Humana,ExceptCPT,86665,Epstein-barr capsid vca,Medicare Fee Schedule 005-609,Per Unit,$49.89 ,OP,49.89,49.89,,,,,,
Humana,ExceptCPT,86666,Ehrlichia antibody,Medicare Fee Schedule 005-609,Per Unit,$28.00 ,OP,28,28,,,,,,
Humana,ExceptCPT,86668,Francisella tularensis,Medicare Fee Schedule 005-609,Per Unit,$38.94 ,OP,38.94,38.94,,,,,,
Humana,ExceptCPT,86671,Fungus nes antibody,Medicare Fee Schedule 005-609,Per Unit,$33.69 ,OP,33.69,33.69,,,,,,
Humana,ExceptCPT,86674,Giardia lamblia antibody,Medicare Fee Schedule 005-609,Per Unit,$40.48 ,OP,40.48,40.48,,,,,,
Humana,ExceptCPT,86677,Helicobacter pylori antibody,Medicare Fee Schedule 005-609,Per Unit,$46.34 ,OP,46.34,46.34,,,,,,
Humana,ExceptCPT,86682,Helminth antibody,Medicare Fee Schedule 005-609,Per Unit,$35.78 ,OP,35.78,35.78,,,,,,
Humana,ExceptCPT,86684,Hemophilus influenza antibdy,Medicare Fee Schedule 005-609,Per Unit,$43.56 ,OP,43.56,43.56,,,,,,
Humana,ExceptCPT,86687,Htlv-i antibody,Medicare Fee Schedule 005-609,Per Unit,$25.00 ,OP,25,25,,,,,,
Humana,ExceptCPT,86688,Htlv-ii antibody,Medicare Fee Schedule 005-609,Per Unit,$38.50 ,OP,38.5,38.5,,,,,,
Humana,ExceptCPT,86689,Htlv/hiv confirmj antibody,Medicare Fee Schedule 005-609,Per Unit,$53.21 ,OP,53.21,53.21,,,,,,
Humana,ExceptCPT,86692,Hepatitis delta agent antbdy,Medicare Fee Schedule 005-609,Per Unit,$47.19 ,OP,47.19,47.19,,,,,,
Humana,ExceptCPT,86694,Herpes simplex nes antbdy,Medicare Fee Schedule 005-609,Per Unit,$39.57 ,OP,39.57,39.57,,,,,,
Humana,ExceptCPT,86695,Herpes simplex type 1 test,Medicare Fee Schedule 005-609,Per Unit,$36.27 ,OP,36.27,36.27,,,,,,
Humana,ExceptCPT,86696,Herpes simplex type 2 test,Medicare Fee Schedule 005-609,Per Unit,$53.21 ,OP,53.21,53.21,,,,,,
Humana,ExceptCPT,86698,Histoplasma antibody,Medicare Fee Schedule 005-609,Per Unit,$37.92 ,OP,37.92,37.92,,,,,,
Humana,ExceptCPT,86701,Hiv-1antibody,Medicare Fee Schedule 005-609,Per Unit,$24.45 ,OP,24.45,24.45,,,,,,
Humana,ExceptCPT,86702,Hiv-2 antibody,Medicare Fee Schedule 005-609,Per Unit,$37.18 ,OP,37.18,37.18,,,,,,
Humana,ExceptCPT,86703,Hiv-1/hiv-2 1 result antbdy,Medicare Fee Schedule 005-609,Per Unit,$37.70 ,OP,37.7,37.7,,,,,,
Humana,ExceptCPT,86704,Hep b core antibody total,Medicare Fee Schedule 005-609,Per Unit,$33.14 ,OP,33.14,33.14,,,,,,
Humana,ExceptCPT,86705,Hep b core antibody igm,Medicare Fee Schedule 005-609,Per Unit,$32.37 ,OP,32.37,32.37,,,,,,
Humana,ExceptCPT,86706,Hep b surface antibody,Medicare Fee Schedule 005-609,Per Unit,$29.54 ,OP,29.54,29.54,,,,,,
Humana,ExceptCPT,86707,Hepatitis be antibody,Medicare Fee Schedule 005-609,Per Unit,$31.82 ,OP,31.82,31.82,,,,,,
Humana,ExceptCPT,86708,Hepatitis a antibody,Medicare Fee Schedule 005-609,Per Unit,$34.07 ,OP,34.07,34.07,,,,,,
Humana,ExceptCPT,86709,Hepatitis a igm antibody,Medicare Fee Schedule 005-609,Per Unit,$30.97 ,OP,30.97,30.97,,,,,,
Humana,ExceptCPT,86710,Influenza virus antibody,Medicare Fee Schedule 005-609,Per Unit,$37.26 ,OP,37.26,37.26,,,,,,
Humana,ExceptCPT,86711,John cunningham antibody,Medicare Fee Schedule 005-609,Per Unit,$46.45 ,OP,46.45,46.45,,,,,,
Humana,ExceptCPT,86713,Legionella antibody,Medicare Fee Schedule 005-609,Per Unit,$42.08 ,OP,42.08,42.08,,,,,,
Humana,ExceptCPT,86717,Leishmania antibody,Medicare Fee Schedule 005-609,Per Unit,$33.69 ,OP,33.69,33.69,,,,,,
Humana,ExceptCPT,86720,Leptospira antibody,Medicare Fee Schedule 005-609,Per Unit,$44.55 ,OP,44.55,44.55,,,,,,
Humana,ExceptCPT,86723,Listeria monocytogenes,Medicare Fee Schedule 005-609,Per Unit,$36.27 ,OP,36.27,36.27,,,,,,
Humana,ExceptCPT,86727,Lymph choriomeningitis ab,Medicare Fee Schedule 005-609,Per Unit,$35.39 ,OP,35.39,35.39,,,,,,
Humana,ExceptCPT,86732,Mucormycosis antibody,Medicare Fee Schedule 005-609,Per Unit,$41.25 ,OP,41.25,41.25,,,,,,
Humana,ExceptCPT,86735,Mumps antibody,Medicare Fee Schedule 005-609,Per Unit,$35.89 ,OP,35.89,35.89,,,,,,
Humana,ExceptCPT,86738,Mycoplasma antibody,Medicare Fee Schedule 005-609,Per Unit,$36.41 ,OP,36.41,36.41,,,,,,
Humana,ExceptCPT,86741,Neisseria meningitidis,Medicare Fee Schedule 005-609,Per Unit,$36.27 ,OP,36.27,36.27,,,,,,
Humana,ExceptCPT,86744,Nocardia antibody,Medicare Fee Schedule 005-609,Per Unit,$43.97 ,OP,43.97,43.97,,,,,,
Humana,ExceptCPT,86747,Parvovirus antibody,Medicare Fee Schedule 005-609,Per Unit,$41.33 ,OP,41.33,41.33,,,,,,
Humana,ExceptCPT,86750,Malaria antibody,Medicare Fee Schedule 005-609,Per Unit,$36.27 ,OP,36.27,36.27,,,,,,
Humana,ExceptCPT,86753,Protozoa antibody nos,Medicare Fee Schedule 005-609,Per Unit,$34.07 ,OP,34.07,34.07,,,,,,
Humana,ExceptCPT,86756,Respiratory virus antibody,Medicare Fee Schedule 005-609,Per Unit,$43.70 ,OP,43.7,43.7,,,,,,
Humana,ExceptCPT,86757,Rickettsia antibody,Medicare Fee Schedule 005-609,Per Unit,$53.21 ,OP,53.21,53.21,,,,,,
Humana,ExceptCPT,86759,Rotavirus antibody,Medicare Fee Schedule 005-609,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
Humana,ExceptCPT,86762,Rubella antibody,Medicare Fee Schedule 005-609,Per Unit,$39.57 ,OP,39.57,39.57,,,,,,
Humana,ExceptCPT,86765,Rubeola antibody,Medicare Fee Schedule 005-609,Per Unit,$35.42 ,OP,35.42,35.42,,,,,,
Humana,ExceptCPT,86768,Salmonella antibody,Medicare Fee Schedule 005-609,Per Unit,$36.27 ,OP,36.27,36.27,,,,,,
Humana,ExceptCPT,86769,Sars-cov-2 covid-19 antibody,Lab Services,Per Unit,$84.26 ,OP,84.26,84.26,,,,,,
Humana,ExceptCPT,86771,Shigella antibody,Medicare Fee Schedule 005-609,Per Unit,$67.32 ,OP,67.32,67.32,,,,,,
Humana,ExceptCPT,86774,Tetanus antibody,Medicare Fee Schedule 005-609,Per Unit,$40.70 ,OP,40.7,40.7,,,,,,
Humana,ExceptCPT,86777,Toxoplasma antibody,Medicare Fee Schedule 005-609,Per Unit,$39.57 ,OP,39.57,39.57,,,,,,
Humana,ExceptCPT,86778,Toxoplasma antibody igm,Medicare Fee Schedule 005-609,Per Unit,$39.63 ,OP,39.63,39.63,,,,,,
Humana,ExceptCPT,86780,Treponema pallidum,Medicare Fee Schedule 005-609,Per Unit,$36.41 ,OP,36.41,36.41,,,,,,
Humana,ExceptCPT,86784,Trichinella antibody,Medicare Fee Schedule 005-609,Per Unit,$34.54 ,OP,34.54,34.54,,,,,,
Humana,ExceptCPT,86787,Varicella-zoster antibody,Medicare Fee Schedule 005-609,Per Unit,$35.42 ,OP,35.42,35.42,,,,,,
Humana,ExceptCPT,86788,West nile virus ab igm,Medicare Fee Schedule 005-609,Per Unit,$46.34 ,OP,46.34,46.34,,,,,,
Humana,ExceptCPT,86789,West nile virus antibody,Medicare Fee Schedule 005-609,Per Unit,$39.57 ,OP,39.57,39.57,,,,,,
Humana,ExceptCPT,86790,Virus antibody nos,Medicare Fee Schedule 005-609,Per Unit,$35.42 ,OP,35.42,35.42,,,,,,
Humana,ExceptCPT,86793,Yersinia antibody,Medicare Fee Schedule 005-609,Per Unit,$36.27 ,OP,36.27,36.27,,,,,,
Humana,ExceptCPT,86794,Zika virus igm antibody,Medicare Fee Schedule 005-609,Per Unit,$46.34 ,OP,46.34,46.34,,,,,,
Humana,ExceptCPT,86800,Thyroglobulin antibody,Medicare Fee Schedule 005-609,Per Unit,$43.75 ,OP,43.75,43.75,,,,,,
Humana,ExceptCPT,86803,Hepatitis c ab test,Medicare Fee Schedule 005-609,Per Unit,$39.24 ,OP,39.24,39.24,,,,,,
Humana,ExceptCPT,86804,Hep c ab test confirm,Medicare Fee Schedule 005-609,Per Unit,$42.60 ,OP,42.6,42.6,,,,,,
Humana,ExceptCPT,86805,Lymphocytotoxicity assay,Medicare Fee Schedule 005-609,Per Unit,$521.15 ,OP,521.15,521.15,,,,,,
Humana,ExceptCPT,86806,Lymphocytotoxicity assay,Medicare Fee Schedule 005-609,Per Unit,$130.87 ,OP,130.87,130.87,,,,,,
Humana,ExceptCPT,86807,Cytotoxic antibody screening,Medicare Fee Schedule 005-609,Per Unit,$216.29 ,OP,216.29,216.29,,,,,,
Humana,ExceptCPT,86808,Cytotoxic antibody screening,Medicare Fee Schedule 005-609,Per Unit,$81.62 ,OP,81.62,81.62,,,,,,
Humana,ExceptCPT,86812,Hla typing a b or c,Medicare Fee Schedule 005-609,Per Unit,$70.98 ,OP,70.98,70.98,,,,,,
Humana,ExceptCPT,86813,Hla typing a b or c,Medicare Fee Schedule 005-609,Per Unit,$159.50 ,OP,159.5,159.5,,,,,,
Humana,ExceptCPT,86816,Hla typing dr/dq,Medicare Fee Schedule 005-609,Per Unit,$82.97 ,OP,82.97,82.97,,,,,,
Humana,ExceptCPT,86817,Hla typing dr/dq,Medicare Fee Schedule 005-609,Per Unit,$291.89 ,OP,291.89,291.89,,,,,,
Humana,ExceptCPT,86821,Lymphocyte culture mixed,Medicare Fee Schedule 005-609,Per Unit,$100.54 ,OP,100.54,100.54,,,,,,
Humana,ExceptCPT,86825,Hla x-math non-cytotoxic,Medicare Fee Schedule 005-609,Per Unit,$301.10 ,OP,301.1,301.1,,,,,,
Humana,ExceptCPT,86826,Hla x-match noncytotoxc addl,Medicare Fee Schedule 005-609,Per Unit,$100.46 ,OP,100.46,100.46,,,,,,
Humana,ExceptCPT,86828,Hla class i&ii antibody qual,Medicare Fee Schedule 005-609,Per Unit,$176.52 ,OP,176.52,176.52,,,,,,
Humana,ExceptCPT,86829,Hla class i/ii antibody qual,Medicare Fee Schedule 005-609,Per Unit,$176.52 ,OP,176.52,176.52,,,,,,
Humana,ExceptCPT,86830,Hla class i phenotype qual,Medicare Fee Schedule 005-609,Per Unit,$262.68 ,OP,262.68,262.68,,,,,,
Humana,ExceptCPT,86831,Hla class ii phenotype qual,Medicare Fee Schedule 005-609,Per Unit,$225.17 ,OP,225.17,225.17,,,,,,
Humana,ExceptCPT,86832,Hla class i high defin qual,Medicare Fee Schedule 005-609,Per Unit,$890.31 ,OP,890.31,890.31,,,,,,
Humana,ExceptCPT,86833,Hla class ii high defin qual,Medicare Fee Schedule 005-609,Per Unit,$895.95 ,OP,895.95,895.95,,,,,,
Humana,ExceptCPT,86834,Hla class i semiquant panel,Medicare Fee Schedule 005-609,Per Unit,$983.29 ,OP,983.29,983.29,,,,,,
Humana,ExceptCPT,86835,Hla class ii semiquant panel,Medicare Fee Schedule 005-609,Per Unit,$888.14 ,OP,888.14,888.14,,,,,,
Humana,ExceptCPT,86850,Rbc antibody screen,Medicare Fee Schedule 005-609,Per Unit,$26.87 ,OP,26.87,26.87,,,,,,
Humana,ExceptCPT,86860,Rbc antibody elution,Medicare Fee Schedule 005-609,Per Unit,$82.25 ,OP,82.25,82.25,,,,,,
Humana,ExceptCPT,86870,Rbc antibody identification,Medicare Fee Schedule 005-609,Per Unit,$112.01 ,OP,112.01,112.01,,,,,,
Humana,ExceptCPT,86880,Coombs test direct,Medicare Fee Schedule 005-609,Per Unit,$14.82 ,OP,14.82,14.82,,,,,,
Humana,ExceptCPT,86885,Coombs test indirect qual,Medicare Fee Schedule 005-609,Per Unit,$15.73 ,OP,15.73,15.73,,,,,,
Humana,ExceptCPT,86886,Coombs test indirect titer,Medicare Fee Schedule 005-609,Per Unit,$14.25 ,OP,14.25,14.25,,,,,,
Humana,ExceptCPT,86890,Autologous blood process,Medicare Fee Schedule 005-609,Per Unit,$258.17 ,OP,258.17,258.17,,,,,,
Humana,ExceptCPT,86891,Autologous blood op salvage,Medicare Fee Schedule 005-609,Per Unit,$364.05 ,OP,364.05,364.05,,,,,,
Humana,ExceptCPT,86900,Blood typing serologic abo,Medicare Fee Schedule 005-609,Per Unit,$8.22 ,OP,8.22,8.22,,,,,,
Humana,ExceptCPT,86901,Blood typing serologic rh(d),Medicare Fee Schedule 005-609,Per Unit,$8.22 ,OP,8.22,8.22,,,,,,
Humana,ExceptCPT,86902,Blood type antigen donor ea,Medicare Fee Schedule 005-609,Per Unit,$17.46 ,OP,17.46,17.46,,,,,,
Humana,ExceptCPT,86904,Blood typing patient serum,Medicare Fee Schedule 005-609,Per Unit,$44.94 ,OP,44.94,44.94,,,,,,
Humana,ExceptCPT,86905,Blood typing rbc antigens,Medicare Fee Schedule 005-609,Per Unit,$10.53 ,OP,10.53,10.53,,,,,,
Humana,ExceptCPT,86906,Bld typing serologic rh phnt,Medicare Fee Schedule 005-609,Per Unit,$21.31 ,OP,21.31,21.31,,,,,,
Humana,ExceptCPT,86910,Blood typing paternity test,Medicare Fee Schedule 005-609,Per Unit,$66.52 ,OP,66.52,66.52,,,,,,
Humana,ExceptCPT,86911,Blood typing antigen system,Medicare Fee Schedule 005-609,Per Unit,$57.75 ,OP,57.75,57.75,,,,,,
Humana,ExceptCPT,86920,Compatibility test spin,Medicare Fee Schedule 005-609,Per Unit,$91.03 ,OP,91.03,91.03,,,,,,
Humana,ExceptCPT,86921,Compatibility test incubate,Medicare Fee Schedule 005-609,Per Unit,$82.25 ,OP,82.25,82.25,,,,,,
Humana,ExceptCPT,86922,Compatibility test antiglob,Medicare Fee Schedule 005-609,Per Unit,$97.13 ,OP,97.13,97.13,,,,,,
Humana,ExceptCPT,86923,Compatibility test electric,Medicare Fee Schedule 005-609,Per Unit,$72.63 ,OP,72.63,72.63,,,,,,
Humana,ExceptCPT,86927,Plasma fresh frozen,Medicare Fee Schedule 005-609,Per Unit,$51.65 ,OP,51.65,51.65,,,,,,
Humana,ExceptCPT,86930,Frozen blood prep,Medicare Fee Schedule 005-609,Per Unit,$303.66 ,OP,303.66,303.66,,,,,,
Humana,ExceptCPT,86931,Frozen blood thaw,Medicare Fee Schedule 005-609,Per Unit,$227.54 ,OP,227.54,227.54,,,,,,
Humana,ExceptCPT,86932,Frozen blood freeze/thaw,Medicare Fee Schedule 005-609,Per Unit,$258.17 ,OP,258.17,258.17,,,,,,
Humana,ExceptCPT,86940,Hemolysins/agglutinins auto,Medicare Fee Schedule 005-609,Per Unit,$24.12 ,OP,24.12,24.12,,,,,,
Humana,ExceptCPT,86941,Hemolysins/agglutinins,Medicare Fee Schedule 005-609,Per Unit,$33.30 ,OP,33.3,33.3,,,,,,
Humana,ExceptCPT,86945,Blood product/irradiation,Medicare Fee Schedule 005-609,Per Unit,$76.15 ,OP,76.15,76.15,,,,,,
Humana,ExceptCPT,86950,Leukacyte transfusion,Medicare Fee Schedule 005-609,Per Unit,$197.78 ,OP,197.78,197.78,,,,,,
Humana,ExceptCPT,86960,Vol reduction of blood/prod,Medicare Fee Schedule 005-609,Per Unit,$84.89 ,OP,84.89,84.89,,,,,,
Humana,ExceptCPT,86965,Pooling blood platelets,Medicare Fee Schedule 005-609,Per Unit,$84.89 ,OP,84.89,84.89,,,,,,
Humana,ExceptCPT,86970,Rbc pretx incubatj w/chemicl,Medicare Fee Schedule 005-609,Per Unit,$76.15 ,OP,76.15,76.15,,,,,,
Humana,ExceptCPT,86971,Rbc pretx incubatj w/enzymes,Medicare Fee Schedule 005-609,Per Unit,$60.39 ,OP,60.39,60.39,,,,,,
Humana,ExceptCPT,86972,Rbc pretx incubatj w/density,Medicare Fee Schedule 005-609,Per Unit,$105.90 ,OP,105.9,105.9,,,,,,
Humana,ExceptCPT,86975,Rbc serum pretx incubj drugs,Medicare Fee Schedule 005-609,Per Unit,$82.25 ,OP,82.25,82.25,,,,,,
Humana,ExceptCPT,86976,Rbc serum pretx id dilution,Medicare Fee Schedule 005-609,Per Unit,$91.03 ,OP,91.03,91.03,,,,,,
Humana,ExceptCPT,86977,Rbc serum pretx incubj/inhib,Medicare Fee Schedule 005-609,Per Unit,$91.03 ,OP,91.03,91.03,,,,,,
Humana,ExceptCPT,86978,Rbc pretreatment serum,Medicare Fee Schedule 005-609,Per Unit,$91.03 ,OP,91.03,91.03,,,,,,
Humana,ExceptCPT,86985,Split blood or products,Medicare Fee Schedule 005-609,Per Unit,$66.52 ,OP,66.52,66.52,,,,,,
Humana,ExceptCPT,87003,Small animal inoculation,Medicare Fee Schedule 005-609,Per Unit,$46.31 ,OP,46.31,46.31,,,,,,
Humana,ExceptCPT,87015,Specimen infect agnt concntj,Medicare Fee Schedule 005-609,Per Unit,$18.37 ,OP,18.37,18.37,,,,,,
Humana,ExceptCPT,87040,Blood culture for bacteria,Medicare Fee Schedule 005-609,Per Unit,$28.38 ,OP,28.38,28.38,,,,,,
Humana,ExceptCPT,87045,Feces culture aerobic bact,Medicare Fee Schedule 005-609,Per Unit,$25.96 ,OP,25.96,25.96,,,,,,
Humana,ExceptCPT,87046,Stool cultr aerobic bact ea,Medicare Fee Schedule 005-609,Per Unit,$25.96 ,OP,25.96,25.96,,,,,,
Humana,ExceptCPT,87070,Culture othr specimn aerobic,Medicare Fee Schedule 005-609,Per Unit,$23.71 ,OP,23.71,23.71,,,,,,
Humana,ExceptCPT,87071,Culture aerobic quant other,Medicare Fee Schedule 005-609,Per Unit,$27.20 ,OP,27.2,27.2,,,,,,
Humana,ExceptCPT,87073,Culture bacteria anaerobic,Medicare Fee Schedule 005-609,Per Unit,$26.57 ,OP,26.57,26.57,,,,,,
Humana,ExceptCPT,87075,Cultr bacteria except blood,Medicare Fee Schedule 005-609,Per Unit,$26.04 ,OP,26.04,26.04,,,,,,
Humana,ExceptCPT,87076,Culture anaerobe ident each,Medicare Fee Schedule 005-609,Per Unit,$22.22 ,OP,22.22,22.22,,,,,,
Humana,ExceptCPT,87077,Culture aerobic identify,Medicare Fee Schedule 005-609,Per Unit,$22.22 ,OP,22.22,22.22,,,,,,
Humana,ExceptCPT,87081,Culture screen only,Medicare Fee Schedule 005-609,Per Unit,$18.23 ,OP,18.23,18.23,,,,,,
Humana,ExceptCPT,87084,Culture of specimen by kit,Medicare Fee Schedule 005-609,Per Unit,$74.44 ,OP,74.44,74.44,,,,,,
Humana,ExceptCPT,87086,Urine culture/colony count,Medicare Fee Schedule 005-609,Per Unit,$22.19 ,OP,22.19,22.19,,,,,,
Humana,ExceptCPT,87088,Urine bacteria culture,Medicare Fee Schedule 005-609,Per Unit,$22.25 ,OP,22.25,22.25,,,,,,
Humana,ExceptCPT,87101,Skin fungi culture,Medicare Fee Schedule 005-609,Per Unit,$21.20 ,OP,21.2,21.2,,,,,,
Humana,ExceptCPT,87102,Fungus isolation culture,Medicare Fee Schedule 005-609,Per Unit,$23.13 ,OP,23.13,23.13,,,,,,
Humana,ExceptCPT,87103,Blood fungus culture,Medicare Fee Schedule 005-609,Per Unit,$56.27 ,OP,56.27,56.27,,,,,,
Humana,ExceptCPT,87106,Fungi identification yeast,Medicare Fee Schedule 005-609,Per Unit,$28.38 ,OP,28.38,28.38,,,,,,
Humana,ExceptCPT,87107,Fungi identification mold,Medicare Fee Schedule 005-609,Per Unit,$28.38 ,OP,28.38,28.38,,,,,,
Humana,ExceptCPT,87109,Mycoplasma,Medicare Fee Schedule 005-609,Per Unit,$42.32 ,OP,42.32,42.32,,,,,,
Humana,ExceptCPT,87110,Chlamydia culture,Medicare Fee Schedule 005-609,Per Unit,$53.90 ,OP,53.9,53.9,,,,,,
Humana,ExceptCPT,87116,Mycobacteria culture,Medicare Fee Schedule 005-609,Per Unit,$29.70 ,OP,29.7,29.7,,,,,,
Humana,ExceptCPT,87118,Mycobacteric identification,Medicare Fee Schedule 005-609,Per Unit,$40.18 ,OP,40.18,40.18,,,,,,
Humana,ExceptCPT,87140,Culture type immunofluoresc,Medicare Fee Schedule 005-609,Per Unit,$15.32 ,OP,15.32,15.32,,,,,,
Humana,ExceptCPT,87143,Culture typing glc/hplc,Medicare Fee Schedule 005-609,Per Unit,$34.43 ,OP,34.43,34.43,,,,,,
Humana,ExceptCPT,87147,Culture type immunologic,Medicare Fee Schedule 005-609,Per Unit,$14.25 ,OP,14.25,14.25,,,,,,
Humana,ExceptCPT,87149,Dna/rna direct probe,Medicare Fee Schedule 005-609,Per Unit,$55.14 ,OP,55.14,55.14,,,,,,
Humana,ExceptCPT,87150,Dna/rna amplified probe,Medicare Fee Schedule 005-609,Per Unit,$96.50 ,OP,96.5,96.5,,,,,,
Humana,ExceptCPT,87152,Culture type pulse field gel,Medicare Fee Schedule 005-609,Per Unit,$21.29 ,OP,21.29,21.29,,,,,,
Humana,ExceptCPT,87153,Dna/rna sequencing,Medicare Fee Schedule 005-609,Per Unit,$317.24 ,OP,317.24,317.24,,,,,,
Humana,ExceptCPT,87158,Culture typing added method,Medicare Fee Schedule 005-609,Per Unit,$21.29 ,OP,21.29,21.29,,,,,,
Humana,ExceptCPT,87164,Dark field examination,Medicare Fee Schedule 005-609,Per Unit,$29.54 ,OP,29.54,29.54,,,,,,
Humana,ExceptCPT,87166,Dark field examination,Medicare Fee Schedule 005-609,Per Unit,$31.08 ,OP,31.08,31.08,,,,,,
Humana,ExceptCPT,87168,Macroscopic exam arthropod,Medicare Fee Schedule 005-609,Per Unit,$11.74 ,OP,11.74,11.74,,,,,,
Humana,ExceptCPT,87169,Macroscopic exam parasite,Medicare Fee Schedule 005-609,Per Unit,$11.85 ,OP,11.85,11.85,,,,,,
Humana,ExceptCPT,87172,Pinworm exam,Medicare Fee Schedule 005-609,Per Unit,$11.74 ,OP,11.74,11.74,,,,,,
Humana,ExceptCPT,87176,Tissue homogenization cultr,Medicare Fee Schedule 005-609,Per Unit,$16.17 ,OP,16.17,16.17,,,,,,
Humana,ExceptCPT,87177,Ova and parasites smears,Medicare Fee Schedule 005-609,Per Unit,$24.48 ,OP,24.48,24.48,,,,,,
Humana,ExceptCPT,87181,Microbe susceptible diffuse,Medicare Fee Schedule 005-609,Per Unit,$13.06 ,OP,13.06,13.06,,,,,,
Humana,ExceptCPT,87184,Microbe susceptible disk,Medicare Fee Schedule 005-609,Per Unit,$20.57 ,OP,20.57,20.57,,,,,,
Humana,ExceptCPT,87185,Microbe susceptible enzyme,Medicare Fee Schedule 005-609,Per Unit,$13.06 ,OP,13.06,13.06,,,,,,
Humana,ExceptCPT,87186,Microbe susceptible mic,Medicare Fee Schedule 005-609,Per Unit,$23.79 ,OP,23.79,23.79,,,,,,
Humana,ExceptCPT,87187,Microbe susceptible mlc,Medicare Fee Schedule 005-609,Per Unit,$110.47 ,OP,110.47,110.47,,,,,,
Humana,ExceptCPT,87188,Microbe suscept macrobroth,Medicare Fee Schedule 005-609,Per Unit,$18.26 ,OP,18.26,18.26,,,,,,
Humana,ExceptCPT,87190,Microbe suscept mycobacteri,Medicare Fee Schedule 005-609,Per Unit,$20.10 ,OP,20.1,20.1,,,,,,
Humana,ExceptCPT,87197,Bactericidal level serum,Medicare Fee Schedule 005-609,Per Unit,$41.31 ,OP,41.31,41.31,,,,,,
Humana,ExceptCPT,87205,Smear gram stain,Medicare Fee Schedule 005-609,Per Unit,$11.74 ,OP,11.74,11.74,,,,,,
Humana,ExceptCPT,87206,Smear fluorescent/acid stai,Medicare Fee Schedule 005-609,Per Unit,$14.82 ,OP,14.82,14.82,,,,,,
Humana,ExceptCPT,87207,Smear special stain,Medicare Fee Schedule 005-609,Per Unit,$16.47 ,OP,16.47,16.47,,,,,,
Humana,ExceptCPT,87209,Smear complex stain,Medicare Fee Schedule 005-609,Per Unit,$49.45 ,OP,49.45,49.45,,,,,,
Humana,ExceptCPT,87210,Smear wet mount saline/ink,Medicare Fee Schedule 005-609,Per Unit,$16.01 ,OP,16.01,16.01,,,,,,
Humana,ExceptCPT,87220,Tissue exam for fungi,Medicare Fee Schedule 005-609,Per Unit,$11.74 ,OP,11.74,11.74,,,,,,
Humana,ExceptCPT,87230,Assay toxin or antitoxin,Medicare Fee Schedule 005-609,Per Unit,$54.29 ,OP,54.29,54.29,,,,,,
Humana,ExceptCPT,87250,Virus inoculate eggs/animal,Medicare Fee Schedule 005-609,Per Unit,$53.79 ,OP,53.79,53.79,,,,,,
Humana,ExceptCPT,87252,Virus inoculation tissue,Medicare Fee Schedule 005-609,Per Unit,$71.69 ,OP,71.69,71.69,,,,,,
Humana,ExceptCPT,87253,Virus inoculate tissue addl,Medicare Fee Schedule 005-609,Per Unit,$55.55 ,OP,55.55,55.55,,,,,,
Humana,ExceptCPT,87254,Virus inoculation shell via,Medicare Fee Schedule 005-609,Per Unit,$53.79 ,OP,53.79,53.79,,,,,,
Humana,ExceptCPT,87255,Genet virus isolate hsv,Medicare Fee Schedule 005-609,Per Unit,$93.12 ,OP,93.12,93.12,,,,,,
Humana,ExceptCPT,87260,Adenovirus ag if,Medicare Fee Schedule 005-609,Per Unit,$39.68 ,OP,39.68,39.68,,,,,,
Humana,ExceptCPT,87265,Pertussis ag if,Medicare Fee Schedule 005-609,Per Unit,$32.95 ,OP,32.95,32.95,,,,,,
Humana,ExceptCPT,87267,Enterovirus antibody dfa,Medicare Fee Schedule 005-609,Per Unit,$36.91 ,OP,36.91,36.91,,,,,,
Humana,ExceptCPT,87269,Giardia ag if,Medicare Fee Schedule 005-609,Per Unit,$37.43 ,OP,37.43,37.43,,,,,,
Humana,ExceptCPT,87270,Chlamydia trachomatis ag if,Medicare Fee Schedule 005-609,Per Unit,$32.95 ,OP,32.95,32.95,,,,,,
Humana,ExceptCPT,87271,Cytomegalovirus dfa,Medicare Fee Schedule 005-609,Per Unit,$36.91 ,OP,36.91,36.91,,,,,,
Humana,ExceptCPT,87272,Cryptosporidium ag if,Medicare Fee Schedule 005-609,Per Unit,$32.95 ,OP,32.95,32.95,,,,,,
Humana,ExceptCPT,87273,Herpes simplex 2 ag if,Medicare Fee Schedule 005-609,Per Unit,$32.95 ,OP,32.95,32.95,,,,,,
Humana,ExceptCPT,87274,Herpes simplex 1 ag if,Medicare Fee Schedule 005-609,Per Unit,$32.95 ,OP,32.95,32.95,,,,,,
Humana,ExceptCPT,87275,Influenza b ag if,Medicare Fee Schedule 005-609,Per Unit,$33.69 ,OP,33.69,33.69,,,,,,
Humana,ExceptCPT,87276,Influenza a ag if,Medicare Fee Schedule 005-609,Per Unit,$44.19 ,OP,44.19,44.19,,,,,,
Humana,ExceptCPT,87278,Legion pneumophilia ag if,Medicare Fee Schedule 005-609,Per Unit,$42.90 ,OP,42.9,42.9,,,,,,
Humana,ExceptCPT,87279,Parainfluenza ag if,Medicare Fee Schedule 005-609,Per Unit,$45.18 ,OP,45.18,45.18,,,,,,
Humana,ExceptCPT,87280,Respiratory syncytial ag if,Medicare Fee Schedule 005-609,Per Unit,$36.91 ,OP,36.91,36.91,,,,,,
Humana,ExceptCPT,87281,Pneumocystis carinii ag if,Medicare Fee Schedule 005-609,Per Unit,$32.95 ,OP,32.95,32.95,,,,,,
Humana,ExceptCPT,87283,Rubeola ag if,Medicare Fee Schedule 005-609,Per Unit,$167.20 ,OP,167.2,167.2,,,,,,
Humana,ExceptCPT,87285,Treponema pallidum ag if,Medicare Fee Schedule 005-609,Per Unit,$33.50 ,OP,33.5,33.5,,,,,,
Humana,ExceptCPT,87290,Varicella zoster ag if,Medicare Fee Schedule 005-609,Per Unit,$36.91 ,OP,36.91,36.91,,,,,,
Humana,ExceptCPT,87299,Antibody detection nos if,Medicare Fee Schedule 005-609,Per Unit,$44.28 ,OP,44.28,44.28,,,,,,
Humana,ExceptCPT,87300,Ag detection polyval if,Medicare Fee Schedule 005-609,Per Unit,$32.95 ,OP,32.95,32.95,,,,,,
Humana,ExceptCPT,87301,Adenovirus ag ia,Medicare Fee Schedule 005-609,Per Unit,$32.95 ,OP,32.95,32.95,,,,,,
Humana,ExceptCPT,87305,Aspergillus ag ia,Medicare Fee Schedule 005-609,Per Unit,$32.95 ,OP,32.95,32.95,,,,,,
Humana,ExceptCPT,87320,Chlmyd trach ag ia,Medicare Fee Schedule 005-609,Per Unit,$41.25 ,OP,41.25,41.25,,,,,,
Humana,ExceptCPT,87324,Clostridium ag ia,Medicare Fee Schedule 005-609,Per Unit,$32.95 ,OP,32.95,32.95,,,,,,
Humana,ExceptCPT,87327,Cryptococcus neoform ag ia,Medicare Fee Schedule 005-609,Per Unit,$36.91 ,OP,36.91,36.91,,,,,,
Humana,ExceptCPT,87328,Cryptosporidium ag ia,Medicare Fee Schedule 005-609,Per Unit,$38.01 ,OP,38.01,38.01,,,,,,
Humana,ExceptCPT,87329,Giardia ag ia,Medicare Fee Schedule 005-609,Per Unit,$32.95 ,OP,32.95,32.95,,,,,,
Humana,ExceptCPT,87332,Cytomegalovirus ag ia,Medicare Fee Schedule 005-609,Per Unit,$32.95 ,OP,32.95,32.95,,,,,,
Humana,ExceptCPT,87335,E coli 0157 ag ia,Medicare Fee Schedule 005-609,Per Unit,$34.82 ,OP,34.82,34.82,,,,,,
Humana,ExceptCPT,87336,Entamoeb hist dispr ag ia,Medicare Fee Schedule 005-609,Per Unit,$44.00 ,OP,44,44,,,,,,
Humana,ExceptCPT,87337,Entamoeb hist group ag ia,Medicare Fee Schedule 005-609,Per Unit,$32.95 ,OP,32.95,32.95,,,,,,
Humana,ExceptCPT,87338,Hpylori stool ag ia,Medicare Fee Schedule 005-609,Per Unit,$39.55 ,OP,39.55,39.55,,,,,,
Humana,ExceptCPT,87339,H pylori ag ia,Medicare Fee Schedule 005-609,Per Unit,$44.00 ,OP,44,44,,,,,,
Humana,ExceptCPT,87340,Hepatitis b surface ag ia,Medicare Fee Schedule 005-609,Per Unit,$28.41 ,OP,28.41,28.41,,,,,,
Humana,ExceptCPT,87341,Hep b surface ag neutrlzj ia,Medicare Fee Schedule 005-609,Per Unit,$28.41 ,OP,28.41,28.41,,,,,,
Humana,ExceptCPT,87350,Hepatitis be ag ia,Medicare Fee Schedule 005-609,Per Unit,$31.71 ,OP,31.71,31.71,,,,,,
Humana,ExceptCPT,87380,Hepatitis delta agent ag ia,Medicare Fee Schedule 005-609,Per Unit,$50.49 ,OP,50.49,50.49,,,,,,
Humana,ExceptCPT,87385,Histoplasma capsul ag ia,Medicare Fee Schedule 005-609,Per Unit,$36.44 ,OP,36.44,36.44,,,,,,
Humana,ExceptCPT,87389,Hiv-1 ag w/hiv-1&-2 ab ag ia,Medicare Fee Schedule 005-609,Per Unit,$66.22 ,OP,66.22,66.22,,,,,,
Humana,ExceptCPT,87390,Hiv-1 ag ia,Medicare Fee Schedule 005-609,Per Unit,$66.17 ,OP,66.17,66.17,,,,,,
Humana,ExceptCPT,87391,Hiv-2 ag ia,Medicare Fee Schedule 005-609,Per Unit,$60.23 ,OP,60.23,60.23,,,,,,
Humana,ExceptCPT,87400,Influenza a/b each ag ia,Medicare Fee Schedule 005-609,Per Unit,$38.86 ,OP,38.86,38.86,,,,,,
Humana,ExceptCPT,87420,Resp syncytial virus ag ia,Medicare Fee Schedule 005-609,Per Unit,$38.25 ,OP,38.25,38.25,,,,,,
Humana,ExceptCPT,87425,Rotavirus ag ia,Medicare Fee Schedule 005-609,Per Unit,$32.95 ,OP,32.95,32.95,,,,,,
Humana,ExceptCPT,87427,Shiga-like toxin ag ia,Medicare Fee Schedule 005-609,Per Unit,$32.95 ,OP,32.95,32.95,,,,,,
Humana,ExceptCPT,87430,Strep a ag ia,Medicare Fee Schedule 005-609,Per Unit,$46.23 ,OP,46.23,46.23,,,,,,
Humana,ExceptCPT,87449,Nos each organism ag ia,Medicare Fee Schedule 005-609,Per Unit,$32.95 ,OP,32.95,32.95,,,,,,
Humana,ExceptCPT,87450,Ag detect nos ia single,Medicare Fee Schedule 005-609,Per Unit,$26.37 ,OP,26.37,26.37,,,,,,
Humana,ExceptCPT,87451,Polyvalent mult org ea ag ia,Medicare Fee Schedule 005-609,Per Unit,$28.90 ,OP,28.9,28.9,,,,,,
Humana,ExceptCPT,87471,Bartonella dna amp probe,Medicare Fee Schedule 005-609,Per Unit,$96.50 ,OP,96.5,96.5,,,,,,
Humana,ExceptCPT,87472,Bartonella dna quant,Medicare Fee Schedule 005-609,Per Unit,$117.81 ,OP,117.81,117.81,,,,,,
Humana,ExceptCPT,87475,Lyme dis dna dir probe,Medicare Fee Schedule 005-609,Per Unit,$55.14 ,OP,55.14,55.14,,,,,,
Humana,ExceptCPT,87476,Lyme dis dna amp probe,Medicare Fee Schedule 005-609,Per Unit,$96.50 ,OP,96.5,96.5,,,,,,
Humana,ExceptCPT,87480,Candida dna dir probe,Medicare Fee Schedule 005-609,Per Unit,$55.14 ,OP,55.14,55.14,,,,,,
Humana,ExceptCPT,87481,Candida dna amp probe,Medicare Fee Schedule 005-609,Per Unit,$96.50 ,OP,96.5,96.5,,,,,,
Humana,ExceptCPT,87482,Candida dna quant,Medicare Fee Schedule 005-609,Per Unit,$153.29 ,OP,153.29,153.29,,,,,,
Humana,ExceptCPT,87483,Cns dna amp probe type 12-25,Medicare Fee Schedule 005-609,Per Unit,"$1,146.15 ",OP,"1,146.15","1,146.15",,,,,,
Humana,ExceptCPT,87485,Chlmyd pneum dna dir probe,Medicare Fee Schedule 005-609,Per Unit,$55.14 ,OP,55.14,55.14,,,,,,
Humana,ExceptCPT,87486,Chlmyd pneum dna amp probe,Medicare Fee Schedule 005-609,Per Unit,$96.50 ,OP,96.5,96.5,,,,,,
Humana,ExceptCPT,87487,Chlmyd pneum dna quant,Medicare Fee Schedule 005-609,Per Unit,$117.81 ,OP,117.81,117.81,,,,,,
Humana,ExceptCPT,87490,Chlmyd trach dna dir probe,Medicare Fee Schedule 005-609,Per Unit,$62.56 ,OP,62.56,62.56,,,,,,
Humana,ExceptCPT,87491,Chlmyd trach dna amp probe,Medicare Fee Schedule 005-609,Per Unit,$96.50 ,OP,96.5,96.5,,,,,,
Humana,ExceptCPT,87492,Chlmyd trach dna quant,Medicare Fee Schedule 005-609,Per Unit,$147.04 ,OP,147.04,147.04,,,,,,
Humana,ExceptCPT,87493,C diff amplified probe,Medicare Fee Schedule 005-609,Per Unit,$102.49 ,OP,102.49,102.49,,,,,,
Humana,ExceptCPT,87495,Cytomeg dna dir probe,Medicare Fee Schedule 005-609,Per Unit,$82.58 ,OP,82.58,82.58,,,,,,
Humana,ExceptCPT,87496,Cytomeg dna amp probe,Medicare Fee Schedule 005-609,Per Unit,$96.50 ,OP,96.5,96.5,,,,,,
Humana,ExceptCPT,87497,Cytomeg dna quant,Medicare Fee Schedule 005-609,Per Unit,$117.81 ,OP,117.81,117.81,,,,,,
Humana,ExceptCPT,87498,Enterovirus probe&revrs trns,Medicare Fee Schedule 005-609,Per Unit,$96.50 ,OP,96.5,96.5,,,,,,
Humana,ExceptCPT,87500,Vanomycin dna amp probe,Medicare Fee Schedule 005-609,Per Unit,$96.50 ,OP,96.5,96.5,,,,,,
Humana,ExceptCPT,87501,Influenza dna amp prob 1+,Medicare Fee Schedule 005-609,Per Unit,$141.10 ,OP,141.1,141.1,,,,,,
Humana,ExceptCPT,87502,Influenza dna amp probe,Medicare Fee Schedule 005-609,Per Unit,$263.45 ,OP,263.45,263.45,,,,,,
Humana,ExceptCPT,87503,Influenza dna amp prob addl,Medicare Fee Schedule 005-609,Per Unit,$80.36 ,OP,80.36,80.36,,,,,,
Humana,ExceptCPT,87505,Nfct agent detection gi,Medicare Fee Schedule 005-609,Per Unit,$352.80 ,OP,352.8,352.8,,,,,,
Humana,ExceptCPT,87506,Iadna-dna/rna probe tq 6-11,Medicare Fee Schedule 005-609,Per Unit,$723.22 ,OP,723.22,723.22,,,,,,
Humana,ExceptCPT,87507,Iadna-dna/rna probe tq 12-25,Medicare Fee Schedule 005-609,Per Unit,"$1,146.15 ",OP,"1,146.15","1,146.15",,,,,,
Humana,ExceptCPT,87510,Gardner vag dna dir probe,Medicare Fee Schedule 005-609,Per Unit,$55.14 ,OP,55.14,55.14,,,,,,
Humana,ExceptCPT,87511,Gardner vag dna amp probe,Medicare Fee Schedule 005-609,Per Unit,$96.50 ,OP,96.5,96.5,,,,,,
Humana,ExceptCPT,87512,Gardner vag dna quant,Medicare Fee Schedule 005-609,Per Unit,$114.84 ,OP,114.84,114.84,,,,,,
Humana,ExceptCPT,87516,Hepatitis b dna amp probe,Medicare Fee Schedule 005-609,Per Unit,$96.50 ,OP,96.5,96.5,,,,,,
Humana,ExceptCPT,87517,Hepatitis b dna quant,Medicare Fee Schedule 005-609,Per Unit,$117.81 ,OP,117.81,117.81,,,,,,
Humana,ExceptCPT,87520,Hepatitis c rna dir probe,Medicare Fee Schedule 005-609,Per Unit,$85.86 ,OP,85.86,85.86,,,,,,
Humana,ExceptCPT,87521,Hepatitis c probe&rvrs trnsc,Medicare Fee Schedule 005-609,Per Unit,$96.50 ,OP,96.5,96.5,,,,,,
Humana,ExceptCPT,87522,Hepatitis c revrs trnscrpj,Medicare Fee Schedule 005-609,Per Unit,$117.81 ,OP,117.81,117.81,,,,,,
Humana,ExceptCPT,87525,Hepatitis g dna dir probe,Medicare Fee Schedule 005-609,Per Unit,$81.95 ,OP,81.95,81.95,,,,,,
Humana,ExceptCPT,87526,Hepatitis g dna amp probe,Medicare Fee Schedule 005-609,Per Unit,$107.97 ,OP,107.97,107.97,,,,,,
Humana,ExceptCPT,87527,Hepatitis g dna quant,Medicare Fee Schedule 005-609,Per Unit,$114.84 ,OP,114.84,114.84,,,,,,
Humana,ExceptCPT,87528,Hsv dna dir probe,Medicare Fee Schedule 005-609,Per Unit,$55.14 ,OP,55.14,55.14,,,,,,
Humana,ExceptCPT,87529,Hsv dna amp probe,Medicare Fee Schedule 005-609,Per Unit,$96.50 ,OP,96.5,96.5,,,,,,
Humana,ExceptCPT,87530,Hsv dna quant,Medicare Fee Schedule 005-609,Per Unit,$117.81 ,OP,117.81,117.81,,,,,,
Humana,ExceptCPT,87531,Hhv-6 dna dir probe,Medicare Fee Schedule 005-609,Per Unit,$159.50 ,OP,159.5,159.5,,,,,,
Humana,ExceptCPT,87532,Hhv-6 dna amp probe,Medicare Fee Schedule 005-609,Per Unit,$96.50 ,OP,96.5,96.5,,,,,,
Humana,ExceptCPT,87533,Hhv-6 dna quant,Medicare Fee Schedule 005-609,Per Unit,$114.84 ,OP,114.84,114.84,,,,,,
Humana,ExceptCPT,87534,Hiv-1 dna dir probe,Medicare Fee Schedule 005-609,Per Unit,$60.28 ,OP,60.28,60.28,,,,,,
Humana,ExceptCPT,87535,Hiv-1 probe&reverse trnscrpj,Medicare Fee Schedule 005-609,Per Unit,$96.50 ,OP,96.5,96.5,,,,,,
Humana,ExceptCPT,87536,Hiv-1 quant&revrse trnscrpj,Medicare Fee Schedule 005-609,Per Unit,$234.03 ,OP,234.03,234.03,,,,,,
Humana,ExceptCPT,87537,Hiv-2 dna dir probe,Medicare Fee Schedule 005-609,Per Unit,$60.28 ,OP,60.28,60.28,,,,,,
Humana,ExceptCPT,87538,Hiv-2 probe&revrse trnscripj,Medicare Fee Schedule 005-609,Per Unit,$96.50 ,OP,96.5,96.5,,,,,,
Humana,ExceptCPT,87539,Hiv-2 quant&revrse trnscripj,Medicare Fee Schedule 005-609,Per Unit,$161.21 ,OP,161.21,161.21,,,,,,
Humana,ExceptCPT,87540,Legion pneumo dna dir prob,Medicare Fee Schedule 005-609,Per Unit,$55.14 ,OP,55.14,55.14,,,,,,
Humana,ExceptCPT,87541,Legion pneumo dna amp prob,Medicare Fee Schedule 005-609,Per Unit,$96.50 ,OP,96.5,96.5,,,,,,
Humana,ExceptCPT,87542,Legion pneumo dna quant,Medicare Fee Schedule 005-609,Per Unit,$114.84 ,OP,114.84,114.84,,,,,,
Humana,ExceptCPT,87550,Mycobacteria dna dir probe,Medicare Fee Schedule 005-609,Per Unit,$55.14 ,OP,55.14,55.14,,,,,,
Humana,ExceptCPT,87551,Mycobacteria dna amp probe,Medicare Fee Schedule 005-609,Per Unit,$132.66 ,OP,132.66,132.66,,,,,,
Humana,ExceptCPT,87552,Mycobacteria dna quant,Medicare Fee Schedule 005-609,Per Unit,$117.81 ,OP,117.81,117.81,,,,,,
Humana,ExceptCPT,87555,M.tuberculo dna dir probe,Medicare Fee Schedule 005-609,Per Unit,$73.92 ,OP,73.92,73.92,,,,,,
Humana,ExceptCPT,87556,M.tuberculo dna amp probe,Medicare Fee Schedule 005-609,Per Unit,$114.62 ,OP,114.62,114.62,,,,,,
Humana,ExceptCPT,87557,M.tuberculo dna quant,Medicare Fee Schedule 005-609,Per Unit,$117.81 ,OP,117.81,117.81,,,,,,
Humana,ExceptCPT,87560,M.avium-intra dna dir prob,Medicare Fee Schedule 005-609,Per Unit,$75.05 ,OP,75.05,75.05,,,,,,
Humana,ExceptCPT,87561,M.avium-intra dna amp prob,Medicare Fee Schedule 005-609,Per Unit,$96.50 ,OP,96.5,96.5,,,,,,
Humana,ExceptCPT,87562,M.avium-intra dna quant,Medicare Fee Schedule 005-609,Per Unit,$117.81 ,OP,117.81,117.81,,,,,,
Humana,ExceptCPT,87563,M. genitalium amp probe,Medicare Fee Schedule 005-609,Per Unit,$96.50 ,OP,96.5,96.5,,,,,,
Humana,ExceptCPT,87580,M.pneumon dna dir probe,Medicare Fee Schedule 005-609,Per Unit,$55.14 ,OP,55.14,55.14,,,,,,
Humana,ExceptCPT,87581,M.pneumon dna amp probe,Medicare Fee Schedule 005-609,Per Unit,$96.50 ,OP,96.5,96.5,,,,,,
Humana,ExceptCPT,87582,M.pneumon dna quant,Medicare Fee Schedule 005-609,Per Unit,$832.21 ,OP,832.21,832.21,,,,,,
Humana,ExceptCPT,87590,N.gonorrhoeae dna dir prob,Medicare Fee Schedule 005-609,Per Unit,$73.92 ,OP,73.92,73.92,,,,,,
Humana,ExceptCPT,87591,N.gonorrhoeae dna amp prob,Medicare Fee Schedule 005-609,Per Unit,$96.50 ,OP,96.5,96.5,,,,,,
Humana,ExceptCPT,87592,N.gonorrhoeae dna quant,Medicare Fee Schedule 005-609,Per Unit,$117.81 ,OP,117.81,117.81,,,,,,
Humana,ExceptCPT,87623,Hpv low-risk types,Medicare Fee Schedule 005-609,Per Unit,$96.50 ,OP,96.5,96.5,,,,,,
Humana,ExceptCPT,87624,Hpv high-risk types,Medicare Fee Schedule 005-609,Per Unit,$96.50 ,OP,96.5,96.5,,,,,,
Humana,ExceptCPT,87625,Hpv types 16 & 18 only,Medicare Fee Schedule 005-609,Per Unit,$111.51 ,OP,111.51,111.51,,,,,,
Humana,ExceptCPT,87631,Resp virus 3-5 targets,Medicare Fee Schedule 005-609,Per Unit,$392.23 ,OP,392.23,392.23,,,,,,
Humana,ExceptCPT,87632,Resp virus 6-11 targets,Medicare Fee Schedule 005-609,Per Unit,$599.67 ,OP,599.67,599.67,,,,,,
Humana,ExceptCPT,87633,Resp virus 12-25 targets,Medicare Fee Schedule 005-609,Per Unit,"$1,146.15 ",OP,"1,146.15","1,146.15",,,,,,
Humana,ExceptCPT,87634,Rsv dna/rna amp probe,Medicare Fee Schedule 005-609,Per Unit,$193.05 ,OP,193.05,193.05,,,,,,
Humana,ExceptCPT,87635,Sars-cov-2 covid-19 amp prb,Lab Services,Per Unit,$102.62 ,OP,102.62,102.62,,,,,,
Humana,ExceptCPT,87640,Staph a dna amp probe,Medicare Fee Schedule 005-609,Per Unit,$96.50 ,OP,96.5,96.5,,,,,,
Humana,ExceptCPT,87641,Mr-staph dna amp probe,Medicare Fee Schedule 005-609,Per Unit,$96.50 ,OP,96.5,96.5,,,,,,
Humana,ExceptCPT,87650,Strep a dna dir probe,Medicare Fee Schedule 005-609,Per Unit,$55.14 ,OP,55.14,55.14,,,,,,
Humana,ExceptCPT,87651,Strep a dna amp probe,Medicare Fee Schedule 005-609,Per Unit,$96.50 ,OP,96.5,96.5,,,,,,
Humana,ExceptCPT,87652,Strep a dna quant,Medicare Fee Schedule 005-609,Per Unit,$114.84 ,OP,114.84,114.84,,,,,,
Humana,ExceptCPT,87653,Strep b dna amp probe,Medicare Fee Schedule 005-609,Per Unit,$96.50 ,OP,96.5,96.5,,,,,,
Humana,ExceptCPT,87660,Trichomonas vagin dir probe,Medicare Fee Schedule 005-609,Per Unit,$55.14 ,OP,55.14,55.14,,,,,,
Humana,ExceptCPT,87661,Trichomonas vaginalis amplif,Medicare Fee Schedule 005-609,Per Unit,$96.50 ,OP,96.5,96.5,,,,,,
Humana,ExceptCPT,87662,Zika virus dna/rna amp probe,Medicare Fee Schedule 005-609,Per Unit,$141.10 ,OP,141.1,141.1,,,,,,
Humana,ExceptCPT,87797,Detect agent nos dna dir,Medicare Fee Schedule 005-609,Per Unit,$82.58 ,OP,82.58,82.58,,,,,,
Humana,ExceptCPT,87798,Detect agent nos dna amp,Medicare Fee Schedule 005-609,Per Unit,$96.50 ,OP,96.5,96.5,,,,,,
Humana,ExceptCPT,87799,Detect agent nos dna quant,Medicare Fee Schedule 005-609,Per Unit,$117.81 ,OP,117.81,117.81,,,,,,
Humana,ExceptCPT,87800,Detect agnt mult dna direc,Medicare Fee Schedule 005-609,Per Unit,$120.09 ,OP,120.09,120.09,,,,,,
Humana,ExceptCPT,87801,Detect agnt mult dna ampli,Medicare Fee Schedule 005-609,Per Unit,$193.05 ,OP,193.05,193.05,,,,,,
Humana,ExceptCPT,87802,Strep b assay w/optic,Medicare Fee Schedule 005-609,Per Unit,$35.01 ,OP,35.01,35.01,,,,,,
Humana,ExceptCPT,87803,Clostridium toxin a w/optic,Medicare Fee Schedule 005-609,Per Unit,$44.00 ,OP,44,44,,,,,,
Humana,ExceptCPT,87804,Influenza assay w/optic,Medicare Fee Schedule 005-609,Per Unit,$45.51 ,OP,45.51,45.51,,,,,,
Humana,ExceptCPT,87806,Hiv ag w/hiv1&2 antb w/optic,Medicare Fee Schedule 005-609,Per Unit,$90.12 ,OP,90.12,90.12,,,,,,
Humana,ExceptCPT,87807,Rsv assay w/optic,Medicare Fee Schedule 005-609,Per Unit,$36.03 ,OP,36.03,36.03,,,,,,
Humana,ExceptCPT,87808,Trichomonas assay w/optic,Medicare Fee Schedule 005-609,Per Unit,$42.05 ,OP,42.05,42.05,,,,,,
Humana,ExceptCPT,87809,Adenovirus assay w/optic,Medicare Fee Schedule 005-609,Per Unit,$59.84 ,OP,59.84,59.84,,,,,,
Humana,ExceptCPT,87810,Chlmyd trach assay w/optic,Medicare Fee Schedule 005-609,Per Unit,$97.05 ,OP,97.05,97.05,,,,,,
Humana,ExceptCPT,87850,N. gonorrhoeae assay w/optic,Medicare Fee Schedule 005-609,Per Unit,$67.54 ,OP,67.54,67.54,,,,,,
Humana,ExceptCPT,87880,Strep a assay w/optic,Medicare Fee Schedule 005-609,Per Unit,$45.46 ,OP,45.46,45.46,,,,,,
Humana,ExceptCPT,87899,Agent nos assay w/optic,Medicare Fee Schedule 005-609,Per Unit,$44.19 ,OP,44.19,44.19,,,,,,
Humana,ExceptCPT,87900,Phenotype infect agent drug,Medicare Fee Schedule 005-609,Per Unit,$358.46 ,OP,358.46,358.46,,,,,,
Humana,ExceptCPT,87901,Genotype dna hiv reverse t,Medicare Fee Schedule 005-609,Per Unit,$707.99 ,OP,707.99,707.99,,,,,,
Humana,ExceptCPT,87902,Genotype dna/rna hep c,Medicare Fee Schedule 005-609,Per Unit,$707.99 ,OP,707.99,707.99,,,,,,
Humana,ExceptCPT,87903,Phenotype dna hiv w/culture,Medicare Fee Schedule 005-609,Per Unit,"$1,343.82 ",OP,"1,343.82","1,343.82",,,,,,
Humana,ExceptCPT,87904,Phenotype dna hiv w/clt add,Medicare Fee Schedule 005-609,Per Unit,$71.69 ,OP,71.69,71.69,,,,,,
Humana,ExceptCPT,87905,Sialidase enzyme assay,Medicare Fee Schedule 005-609,Per Unit,$33.61 ,OP,33.61,33.61,,,,,,
Humana,ExceptCPT,87906,Genotype dna/rna hiv,Medicare Fee Schedule 005-609,Per Unit,$354.01 ,OP,354.01,354.01,,,,,,
Humana,ExceptCPT,87910,Genotype cytomegalovirus,Medicare Fee Schedule 005-609,Per Unit,$707.99 ,OP,707.99,707.99,,,,,,
Humana,ExceptCPT,87912,Genotype dna hepatitis b,Medicare Fee Schedule 005-609,Per Unit,$707.99 ,OP,707.99,707.99,,,,,,
Humana,ExceptCPT,88000,Autopsy (necropsy) gross,Medicare Fee Schedule 005-609,Per Unit,$527.70 ,OP,527.7,527.7,,,,,,
Humana,ExceptCPT,88005,Autopsy (necropsy) gross,Medicare Fee Schedule 005-609,Per Unit,$616.08 ,OP,616.08,616.08,,,,,,
Humana,ExceptCPT,88007,Autopsy (necropsy) gross,Medicare Fee Schedule 005-609,Per Unit,$644.96 ,OP,644.96,644.96,,,,,,
Humana,ExceptCPT,88012,Autopsy (necropsy) gross,Medicare Fee Schedule 005-609,Per Unit,$527.70 ,OP,527.7,527.7,,,,,,
Humana,ExceptCPT,88014,Autopsy (necropsy) gross,Medicare Fee Schedule 005-609,Per Unit,$483.95 ,OP,483.95,483.95,,,,,,
Humana,ExceptCPT,88016,Autopsy (necropsy) gross,Medicare Fee Schedule 005-609,Per Unit,$674.71 ,OP,674.71,674.71,,,,,,
Humana,ExceptCPT,88020,Autopsy (necropsy) complete,Medicare Fee Schedule 005-609,Per Unit,$909.26 ,OP,909.26,909.26,,,,,,
Humana,ExceptCPT,88025,Autopsy (necropsy) complete,Medicare Fee Schedule 005-609,Per Unit,$879.51 ,OP,879.51,879.51,,,,,,
Humana,ExceptCPT,88027,Autopsy (necropsy) complete,Medicare Fee Schedule 005-609,Per Unit,$938.14 ,OP,938.14,938.14,,,,,,
Humana,ExceptCPT,88028,Autopsy (necropsy) complete,Medicare Fee Schedule 005-609,Per Unit,$527.70 ,OP,527.7,527.7,,,,,,
Humana,ExceptCPT,88029,Autopsy (necropsy) complete,Medicare Fee Schedule 005-609,Per Unit,$527.70 ,OP,527.7,527.7,,,,,,
Humana,ExceptCPT,88036,Limited autopsy,Medicare Fee Schedule 005-609,Per Unit,$264.28 ,OP,264.28,264.28,,,,,,
Humana,ExceptCPT,88037,Limited autopsy,Medicare Fee Schedule 005-609,Per Unit,$234.52 ,OP,234.52,234.52,,,,,,
Humana,ExceptCPT,88040,Forensic autopsy (necropsy),Medicare Fee Schedule 005-609,Per Unit,"$1,465.83 ",OP,"1,465.83","1,465.83",,,,,,
Humana,ExceptCPT,88045,Coroners autopsy (necropsy),Medicare Fee Schedule 005-609,Per Unit,$147.02 ,OP,147.02,147.02,,,,,,
Humana,ExceptCPT,88104,Cytopath fl nongyn smears,Medicare Fee Schedule 005-609,Per Unit,$100.05 ,OP,100.05,100.05,,,,,,
Humana,ExceptCPT,88106,Cytopath fl nongyn filter,Medicare Fee Schedule 005-609,Per Unit,$119.27 ,OP,119.27,119.27,,,,,,
Humana,ExceptCPT,88108,Cytopath concentrate tech,Medicare Fee Schedule 005-609,Per Unit,$103.51 ,OP,103.51,103.51,,,,,,
Humana,ExceptCPT,88112,Cytopath cell enhance tech,Medicare Fee Schedule 005-609,Per Unit,$100.02 ,OP,100.02,100.02,,,,,,
Humana,ExceptCPT,88120,Cytp urne 3-5 probes ea spec,Medicare Fee Schedule 005-609,Per Unit,"$1,441.83 ",OP,"1,441.83","1,441.83",,,,,,
Humana,ExceptCPT,88121,Cytp urine 3-5 probes cmptr,Medicare Fee Schedule 005-609,Per Unit,"$1,024.16 ",OP,"1,024.16","1,024.16",,,,,,
Humana,ExceptCPT,88125,Forensic cytopathology,Medicare Fee Schedule 005-609,Per Unit,$32.64 ,OP,32.64,32.64,,,,,,
Humana,ExceptCPT,88130,Sex chromatin identification,Medicare Fee Schedule 005-609,Per Unit,$49.45 ,OP,49.45,49.45,,,,,,
Humana,ExceptCPT,88140,Sex chromatin identification,Medicare Fee Schedule 005-609,Per Unit,$21.97 ,OP,21.97,21.97,,,,,,
Humana,ExceptCPT,88142,Cytopath c/v thin layer,Medicare Fee Schedule 005-609,Per Unit,$55.72 ,OP,55.72,55.72,,,,,,
Humana,ExceptCPT,88143,Cytopath c/v thin layer redo,Medicare Fee Schedule 005-609,Per Unit,$63.36 ,OP,63.36,63.36,,,,,,
Humana,ExceptCPT,88147,Cytopath c/v automated,Medicare Fee Schedule 005-609,Per Unit,$139.04 ,OP,139.04,139.04,,,,,,
Humana,ExceptCPT,88148,Cytopath c/v auto rescreen,Medicare Fee Schedule 005-609,Per Unit,$44.00 ,OP,44,44,,,,,,
Humana,ExceptCPT,88150,Cytopath c/v manual,Medicare Fee Schedule 005-609,Per Unit,$41.66 ,OP,41.66,41.66,,,,,,
Humana,ExceptCPT,88152,Cytopath c/v auto redo,Medicare Fee Schedule 005-609,Per Unit,$76.01 ,OP,76.01,76.01,,,,,,
Humana,ExceptCPT,88153,Cytopath c/v redo,Medicare Fee Schedule 005-609,Per Unit,$66.08 ,OP,66.08,66.08,,,,,,
Humana,ExceptCPT,88155,Cytopath c/v index add-on,Medicare Fee Schedule 005-609,Per Unit,$40.29 ,OP,40.29,40.29,,,,,,
Humana,ExceptCPT,88160,Cytopath smear other source,Medicare Fee Schedule 005-609,Per Unit,$115.78 ,OP,115.78,115.78,,,,,,
Humana,ExceptCPT,88161,Cytopath smear other source,Medicare Fee Schedule 005-609,Per Unit,$116.66 ,OP,116.66,116.66,,,,,,
Humana,ExceptCPT,88162,Cytopath smear other source,Medicare Fee Schedule 005-609,Per Unit,$164.18 ,OP,164.18,164.18,,,,,,
Humana,ExceptCPT,88164,Cytopath tbs c/v manual,Medicare Fee Schedule 005-609,Per Unit,$41.66 ,OP,41.66,41.66,,,,,,
Humana,ExceptCPT,88165,Cytopath tbs c/v redo,Medicare Fee Schedule 005-609,Per Unit,$116.11 ,OP,116.11,116.11,,,,,,
Humana,ExceptCPT,88166,Cytopath tbs c/v auto redo,Medicare Fee Schedule 005-609,Per Unit,$41.66 ,OP,41.66,41.66,,,,,,
Humana,ExceptCPT,88167,Cytopath tbs c/v select,Medicare Fee Schedule 005-609,Per Unit,$41.66 ,OP,41.66,41.66,,,,,,
Humana,ExceptCPT,88172,Cytp dx eval fna 1st ea site,Medicare Fee Schedule 005-609,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
Humana,ExceptCPT,88173,Cytopath eval fna report,Medicare Fee Schedule 005-609,Per Unit,$214.94 ,OP,214.94,214.94,,,,,,
Humana,ExceptCPT,88174,Cytopath c/v auto in fluid,Medicare Fee Schedule 005-609,Per Unit,$69.77 ,OP,69.77,69.77,,,,,,
Humana,ExceptCPT,88175,Cytopath c/v auto fluid redo,Medicare Fee Schedule 005-609,Per Unit,$73.18 ,OP,73.18,73.18,,,,,,
Humana,ExceptCPT,88177,Cytp fna eval ea addl,Medicare Fee Schedule 005-609,Per Unit,$18.37 ,OP,18.37,18.37,,,,,,
Humana,ExceptCPT,88182,Cell marker study,Medicare Fee Schedule 005-609,Per Unit,$256.58 ,OP,256.58,256.58,,,,,,
Humana,ExceptCPT,88184,Flowcytometry/ tc 1 marker,Medicare Fee Schedule 005-609,Per Unit,$175.53 ,OP,175.53,175.53,,,,,,
Humana,ExceptCPT,88185,Flowcytometry/tc add-on,Medicare Fee Schedule 005-609,Per Unit,$57.75 ,OP,57.75,57.75,,,,,,
Humana,ExceptCPT,88230,Tissue culture lymphocyte,Medicare Fee Schedule 005-609,Per Unit,$320.35 ,OP,320.35,320.35,,,,,,
Humana,ExceptCPT,88233,Tissue culture skin/biopsy,Medicare Fee Schedule 005-609,Per Unit,$387.01 ,OP,387.01,387.01,,,,,,
Humana,ExceptCPT,88235,Tissue culture placenta,Medicare Fee Schedule 005-609,Per Unit,$413.33 ,OP,413.33,413.33,,,,,,
Humana,ExceptCPT,88237,Tissue culture bone marrow,Medicare Fee Schedule 005-609,Per Unit,$395.31 ,OP,395.31,395.31,,,,,,
Humana,ExceptCPT,88239,Tissue culture tumor,Medicare Fee Schedule 005-609,Per Unit,$405.68 ,OP,405.68,405.68,,,,,,
Humana,ExceptCPT,88240,Cell cryopreserve/storage,Medicare Fee Schedule 005-609,Per Unit,$35.94 ,OP,35.94,35.94,,,,,,
Humana,ExceptCPT,88241,Frozen cell preparation,Medicare Fee Schedule 005-609,Per Unit,$33.25 ,OP,33.25,33.25,,,,,,
Humana,ExceptCPT,88245,Chromosome analysis 20-25,Medicare Fee Schedule 005-609,Per Unit,$476.22 ,OP,476.22,476.22,,,,,,
Humana,ExceptCPT,88248,Chromosome analysis 50-100,Medicare Fee Schedule 005-609,Per Unit,$476.22 ,OP,476.22,476.22,,,,,,
Humana,ExceptCPT,88249,Chromosome analysis 100,Medicare Fee Schedule 005-609,Per Unit,$476.22 ,OP,476.22,476.22,,,,,,
Humana,ExceptCPT,88261,Chromosome analysis 5,Medicare Fee Schedule 005-609,Per Unit,$726.94 ,OP,726.94,726.94,,,,,,
Humana,ExceptCPT,88262,Chromosome analysis 15-20,Medicare Fee Schedule 005-609,Per Unit,$345.10 ,OP,345.1,345.1,,,,,,
Humana,ExceptCPT,88263,Chromosome analysis 45,Medicare Fee Schedule 005-609,Per Unit,$413.30 ,OP,413.3,413.3,,,,,,
Humana,ExceptCPT,88264,Chromosome analysis 20-25,Medicare Fee Schedule 005-609,Per Unit,$397.68 ,OP,397.68,397.68,,,,,,
Humana,ExceptCPT,88267,Chromosome analys placenta,Medicare Fee Schedule 005-609,Per Unit,$518.57 ,OP,518.57,518.57,,,,,,
Humana,ExceptCPT,88269,Chromosome analys amniotic,Medicare Fee Schedule 005-609,Per Unit,$477.57 ,OP,477.57,477.57,,,,,,
Humana,ExceptCPT,88271,Cytogenetics dna probe,Medicare Fee Schedule 005-609,Per Unit,$58.91 ,OP,58.91,58.91,,,,,,
Humana,ExceptCPT,88272,Cytogenetics 3-5,Medicare Fee Schedule 005-609,Per Unit,$111.93 ,OP,111.93,111.93,,,,,,
Humana,ExceptCPT,88273,Cytogenetics 10-30,Medicare Fee Schedule 005-609,Per Unit,$95.73 ,OP,95.73,95.73,,,,,,
Humana,ExceptCPT,88274,Cytogenetics 25-99,Medicare Fee Schedule 005-609,Per Unit,$116.55 ,OP,116.55,116.55,,,,,,
Humana,ExceptCPT,88275,Cytogenetics 100-300,Medicare Fee Schedule 005-609,Per Unit,$140.77 ,OP,140.77,140.77,,,,,,
Humana,ExceptCPT,88280,Chromosome karyotype study,Medicare Fee Schedule 005-609,Per Unit,$92.04 ,OP,92.04,92.04,,,,,,
Humana,ExceptCPT,88283,Chromosome banding study,Medicare Fee Schedule 005-609,Per Unit,$188.65 ,OP,188.65,188.65,,,,,,
Humana,ExceptCPT,88285,Chromosome count additional,Medicare Fee Schedule 005-609,Per Unit,$74.00 ,OP,74,74,,,,,,
Humana,ExceptCPT,88289,Chromosome study additional,Medicare Fee Schedule 005-609,Per Unit,$94.68 ,OP,94.68,94.68,,,,,,
Humana,ExceptCPT,88300,Surgical path gross,Medicare Fee Schedule 005-609,Per Unit,$28.24 ,OP,28.24,28.24,,,,,,
Humana,ExceptCPT,88302,Tissue exam by pathologist,Medicare Fee Schedule 005-609,Per Unit,$63.25 ,OP,63.25,63.25,,,,,,
Humana,ExceptCPT,88304,Tissue exam by pathologist,Medicare Fee Schedule 005-609,Per Unit,$77.28 ,OP,77.28,77.28,,,,,,
Humana,ExceptCPT,88305,Tissue exam by pathologist,Medicare Fee Schedule 005-609,Per Unit,$85.14 ,OP,85.14,85.14,,,,,,
Humana,ExceptCPT,88307,Tissue exam by pathologist,Medicare Fee Schedule 005-609,Per Unit,$520.00 ,OP,520,520,,,,,,
Humana,ExceptCPT,88309,Tissue exam by pathologist,Medicare Fee Schedule 005-609,Per Unit,$740.52 ,OP,740.52,740.52,,,,,,
Humana,ExceptCPT,88311,Decalcify tissue,Medicare Fee Schedule 005-609,Per Unit,$22.14 ,OP,22.14,22.14,,,,,,
Humana,ExceptCPT,88312,Special stains group 1,Medicare Fee Schedule 005-609,Per Unit,$216.40 ,OP,216.4,216.4,,,,,,
Humana,ExceptCPT,88313,Special stains group 2,Medicare Fee Schedule 005-609,Per Unit,$174.41 ,OP,174.41,174.41,,,,,,
Humana,ExceptCPT,88314,Histochemical stains add-on,Medicare Fee Schedule 005-609,Per Unit,$200.64 ,OP,200.64,200.64,,,,,,
Humana,ExceptCPT,88319,Enzyme histochemistry,Medicare Fee Schedule 005-609,Per Unit,$258.69 ,OP,258.69,258.69,,,,,,
Humana,ExceptCPT,88323,Microslide consultation,Medicare Fee Schedule 005-609,Per Unit,$68.53 ,OP,68.53,68.53,,,,,,
Humana,ExceptCPT,88331,Path consult intraop 1 bloc,Medicare Fee Schedule 005-609,Per Unit,$106.15 ,OP,106.15,106.15,,,,,,
Humana,ExceptCPT,88332,Path consult intraop addl,Medicare Fee Schedule 005-609,Per Unit,$60.64 ,OP,60.64,60.64,,,,,,
Humana,ExceptCPT,88333,Intraop cyto path consult 1,Medicare Fee Schedule 005-609,Per Unit,$85.14 ,OP,85.14,85.14,,,,,,
Humana,ExceptCPT,88334,Intraop cyto path consult 2,Medicare Fee Schedule 005-609,Per Unit,$48.13 ,OP,48.13,48.13,,,,,,
Humana,ExceptCPT,88341,Immunohisto antb addl slide,Medicare Fee Schedule 005-609,Per Unit,$163.65 ,OP,163.65,163.65,,,,,,
Humana,ExceptCPT,88342,Immunohisto antb 1st stain,Medicare Fee Schedule 005-609,Per Unit,$177.93 ,OP,177.93,177.93,,,,,,
Humana,ExceptCPT,88344,Immunohisto antibody slide,Medicare Fee Schedule 005-609,Per Unit,$351.20 ,OP,351.2,351.2,,,,,,
Humana,ExceptCPT,88346,Immunofluor antb 1st stain,Medicare Fee Schedule 005-609,Per Unit,$275.06 ,OP,275.06,275.06,,,,,,
Humana,ExceptCPT,88348,Electron microscopy,Medicare Fee Schedule 005-609,Per Unit,$890.40 ,OP,890.4,890.4,,,,,,
Humana,ExceptCPT,88350,Immunofluor antb addl stain,Medicare Fee Schedule 005-609,Per Unit,$204.16 ,OP,204.16,204.16,,,,,,
Humana,ExceptCPT,88355,Analysis skeletal muscle,Medicare Fee Schedule 005-609,Per Unit,$154.28 ,OP,154.28,154.28,,,,,,
Humana,ExceptCPT,88356,Analysis nerve,Medicare Fee Schedule 005-609,Per Unit,$286.33 ,OP,286.33,286.33,,,,,,
Humana,ExceptCPT,88358,Analysis tumor,Medicare Fee Schedule 005-609,Per Unit,$227.78 ,OP,227.78,227.78,,,,,,
Humana,ExceptCPT,88360,Tumor immunohistochem/manual,Medicare Fee Schedule 005-609,Per Unit,$207.65 ,OP,207.65,207.65,,,,,,
Humana,ExceptCPT,88361,Tumor immunohistochem/comput,Medicare Fee Schedule 005-609,Per Unit,$201.52 ,OP,201.52,201.52,,,,,,
Humana,ExceptCPT,88362,Nerve teasing preparations,Medicare Fee Schedule 005-609,Per Unit,$279.68 ,OP,279.68,279.68,,,,,,
Humana,ExceptCPT,88364,Insitu hybridization (fish),Medicare Fee Schedule 005-609,Per Unit,$275.03 ,OP,275.03,275.03,,,,,,
Humana,ExceptCPT,88365,Insitu hybridization (fish),Medicare Fee Schedule 005-609,Per Unit,$356.68 ,OP,356.68,356.68,,,,,,
Humana,ExceptCPT,88366,Insitu hybridization (fish),Medicare Fee Schedule 005-609,Per Unit,$579.84 ,OP,579.84,579.84,,,,,,
Humana,ExceptCPT,88367,Insitu hybridization auto,Medicare Fee Schedule 005-609,Per Unit,$205.92 ,OP,205.92,205.92,,,,,,
Humana,ExceptCPT,88368,Insitu hybridization manual,Medicare Fee Schedule 005-609,Per Unit,$240.30 ,OP,240.3,240.3,,,,,,
Humana,ExceptCPT,88369,M/phmtrc alysishquant/semiq,Medicare Fee Schedule 005-609,Per Unit,$215.55 ,OP,215.55,215.55,,,,,,
Humana,ExceptCPT,88371,Protein western blot tissue,Medicare Fee Schedule 005-609,Per Unit,$61.13 ,OP,61.13,61.13,,,,,,
Humana,ExceptCPT,88372,Protein analysis w/probe,Medicare Fee Schedule 005-609,Per Unit,$72.11 ,OP,72.11,72.11,,,,,,
Humana,ExceptCPT,88373,M/phmtrc alys ishquant/semiq,Medicare Fee Schedule 005-609,Per Unit,$118.14 ,OP,118.14,118.14,,,,,,
Humana,ExceptCPT,88374,M/phmtrc alys ishquant/semiq,Medicare Fee Schedule 005-609,Per Unit,$773.85 ,OP,773.85,773.85,,,,,,
Humana,ExceptCPT,88377,M/phmtrc alys ishquant/semiq,Medicare Fee Schedule 005-609,Per Unit,$903.65 ,OP,903.65,903.65,,,,,,
Humana,ExceptCPT,88380,Microdissection laser,Medicare Fee Schedule 005-609,Per Unit,$198.28 ,OP,198.28,198.28,,,,,,
Humana,ExceptCPT,88381,Microdissection manual,Medicare Fee Schedule 005-609,Per Unit,$452.60 ,OP,452.6,452.6,,,,,,
Humana,ExceptCPT,88387,Tiss exam molecular study,Medicare Fee Schedule 005-609,Per Unit,$20.38 ,OP,20.38,20.38,,,,,,
Humana,ExceptCPT,88388,Tiss ex molecul study add-on,Medicare Fee Schedule 005-609,Per Unit,$35.26 ,OP,35.26,35.26,,,,,,
Humana,ExceptCPT,88720,Bilirubin total transcut,Medicare Fee Schedule 005-609,Per Unit,$13.81 ,OP,13.81,13.81,,,,,,
Humana,ExceptCPT,88738,Hgb quant transcutaneous,Medicare Fee Schedule 005-609,Per Unit,$13.81 ,OP,13.81,13.81,,,,,,
Humana,ExceptCPT,88740,Transcutaneous carboxyhb,Medicare Fee Schedule 005-609,Per Unit,$25.77 ,OP,25.77,25.77,,,,,,
Humana,ExceptCPT,88741,Transcutaneous methb,Medicare Fee Schedule 005-609,Per Unit,$25.77 ,OP,25.77,25.77,,,,,,
Humana,ExceptCPT,89050,Body fluid cell count,Medicare Fee Schedule 005-609,Per Unit,$12.98 ,OP,12.98,12.98,,,,,,
Humana,ExceptCPT,89051,Body fluid cell count,Medicare Fee Schedule 005-609,Per Unit,$15.40 ,OP,15.4,15.4,,,,,,
Humana,ExceptCPT,89055,Leukocyte assessment fecal,Medicare Fee Schedule 005-609,Per Unit,$11.74 ,OP,11.74,11.74,,,,,,
Humana,ExceptCPT,89060,Exam synovial fluid crystals,Medicare Fee Schedule 005-609,Per Unit,$20.16 ,OP,20.16,20.16,,,,,,
Humana,ExceptCPT,89125,Specimen fat stain,Medicare Fee Schedule 005-609,Per Unit,$16.17 ,OP,16.17,16.17,,,,,,
Humana,ExceptCPT,89160,Exam feces for meat fibers,Medicare Fee Schedule 005-609,Per Unit,$13.34 ,OP,13.34,13.34,,,,,,
Humana,ExceptCPT,89190,Nasal smear for eosinophils,Medicare Fee Schedule 005-609,Per Unit,$15.92 ,OP,15.92,15.92,,,,,,
Humana,ExceptCPT,89220,Sputum specimen collection,Medicare Fee Schedule 005-609,Per Unit,$47.52 ,OP,47.52,47.52,,,,,,
Humana,ExceptCPT,89230,Collect sweat for test,Medicare Fee Schedule 005-609,Per Unit,$6.38 ,OP,6.38,6.38,,,,,,
Humana,ExceptCPT,89250,Cultr oocyte/embryo <4 days,Medicare Fee Schedule 005-609,Per Unit,"$2,608.73 ",OP,"2,608.73","2,608.73",,,,,,
Humana,ExceptCPT,89251,Cultr oocyte/embryo <4 days,Medicare Fee Schedule 005-609,Per Unit,"$2,713.76 ",OP,"2,713.76","2,713.76",,,,,,
Humana,ExceptCPT,89300,Semen analysis w/huhner,Medicare Fee Schedule 005-609,Per Unit,$27.06 ,OP,27.06,27.06,,,,,,
Humana,ExceptCPT,89310,Semen analysis w/count,Medicare Fee Schedule 005-609,Per Unit,$23.68 ,OP,23.68,23.68,,,,,,
Humana,ExceptCPT,89320,Semen anal vol/count/mot,Medicare Fee Schedule 005-609,Per Unit,$33.85 ,OP,33.85,33.85,,,,,,
Humana,ExceptCPT,89321,Semen anal sperm detection,Medicare Fee Schedule 005-609,Per Unit,$33.14 ,OP,33.14,33.14,,,,,,
Humana,ExceptCPT,89322,Semen anal strict criteria,Medicare Fee Schedule 005-609,Per Unit,$42.63 ,OP,42.63,42.63,,,,,,
Humana,ExceptCPT,89325,Sperm antibody test,Medicare Fee Schedule 005-609,Per Unit,$29.34 ,OP,29.34,29.34,,,,,,
Humana,ExceptCPT,89329,Sperm evaluation test,Medicare Fee Schedule 005-609,Per Unit,$53.87 ,OP,53.87,53.87,,,,,,
Humana,ExceptCPT,89330,Evaluation cervical mucus,Medicare Fee Schedule 005-609,Per Unit,$28.55 ,OP,28.55,28.55,,,,,,
Humana,ExceptCPT,89331,Retrograde ejaculation anal,Medicare Fee Schedule 005-609,Per Unit,$53.87 ,OP,53.87,53.87,,,,,,
Humana,ExceptCPT,90653,Iiv adjuvant vaccine im,Medicare Fee Schedule 005-609,Per Unit,$163.71 ,OP,163.71,163.71,,,,,,
Humana,ExceptCPT,90672,Laiv4 vaccine intranasal,Medicare Fee Schedule 005-609,Per Unit,$73.92 ,OP,73.92,73.92,,,,,,
Humana,ExceptCPT,90940,Hemodialysis access study,Medicare Fee Schedule 005-609,Per Unit,$105.60 ,OP,105.6,105.6,,,,,,
Humana,ExceptCPT,91010,Esophagus motility study,Medicare Fee Schedule 005-609,Per Unit,$405.68 ,OP,405.68,405.68,,,,,,
Humana,ExceptCPT,91013,Esophgl motil w/stim/perfus,Medicare Fee Schedule 005-609,Per Unit,$44.63 ,OP,44.63,44.63,,,,,,
Humana,ExceptCPT,91020,Gastric motility studies,Medicare Fee Schedule 005-609,Per Unit,$537.85 ,OP,537.85,537.85,,,,,,
Humana,ExceptCPT,91022,Duodenal motility study,Medicare Fee Schedule 005-609,Per Unit,$264.80 ,OP,264.8,264.8,,,,,,
Humana,ExceptCPT,91030,Acid perfusion of esophagus,Medicare Fee Schedule 005-609,Per Unit,$262.19 ,OP,262.19,262.19,,,,,,
Humana,ExceptCPT,91034,Gastroesophageal reflux test,Medicare Fee Schedule 005-609,Per Unit,$386.21 ,OP,386.21,386.21,,,,,,
Humana,ExceptCPT,91035,G-esoph reflx tst w/electrod,Medicare Fee Schedule 005-609,Per Unit,"$1,088.01 ",OP,"1,088.01","1,088.01",,,,,,
Humana,ExceptCPT,91037,Esoph imped function test,Medicare Fee Schedule 005-609,Per Unit,$323.18 ,OP,323.18,323.18,,,,,,
Humana,ExceptCPT,91038,Esoph imped funct test > 1hr,Medicare Fee Schedule 005-609,Per Unit,"$1,016.26 ",OP,"1,016.26","1,016.26",,,,,,
Humana,ExceptCPT,91040,Esoph balloon distension tst,Medicare Fee Schedule 005-609,Per Unit,"$1,284.91 ",OP,"1,284.91","1,284.91",,,,,,
Humana,ExceptCPT,91065,Breath hydrogen/methane test,Medicare Fee Schedule 005-609,Per Unit,$210.27 ,OP,210.27,210.27,,,,,,
Humana,ExceptCPT,91110,Gi trc img intral esoph-ile,Medicare Fee Schedule 005-609,Per Unit,"$1,899.26 ",OP,"1,899.26","1,899.26",,,,,,
Humana,ExceptCPT,91111,Gi trc img intral esophagus,Medicare Fee Schedule 005-609,Per Unit,"$2,302.71 ",OP,"2,302.71","2,302.71",,,,,,
Humana,ExceptCPT,91112,Gi wireless capsule measure,Medicare Fee Schedule 005-609,Per Unit,"$4,036.29 ",OP,"4,036.29","4,036.29",,,,,,
Humana,ExceptCPT,91120,Rectal sensation test,Medicare Fee Schedule 005-609,Per Unit,"$1,250.81 ",OP,"1,250.81","1,250.81",,,,,,
Humana,ExceptCPT,91122,Anal pressure record,Medicare Fee Schedule 005-609,Per Unit,$475.70 ,OP,475.7,475.7,,,,,,
Humana,ExceptCPT,91132,Electrogastrography,Medicare Fee Schedule 005-609,Per Unit,"$1,006.64 ",OP,"1,006.64","1,006.64",,,,,,
Humana,ExceptCPT,91133,Electrogastrography w/test,Medicare Fee Schedule 005-609,Per Unit,"$1,047.78 ",OP,"1,047.78","1,047.78",,,,,,
Humana,ExceptCPT,91200,Liver elastography,Medicare Fee Schedule 005-609,Per Unit,$54.53 ,OP,54.53,54.53,,,,,,
Humana,ExceptCPT,92025,Corneal topography,Medicare Fee Schedule 005-609,Per Unit,$44.88 ,OP,44.88,44.88,,,,,,
Humana,ExceptCPT,92060,Special eye evaluation,Medicare Fee Schedule 005-609,Per Unit,$67.65 ,OP,67.65,67.65,,,,,,
Humana,ExceptCPT,92065,Orthoptic training,Medicare Fee Schedule 005-609,Per Unit,$92.15 ,OP,92.15,92.15,,,,,,
Humana,ExceptCPT,92081,Visual field examination(s),Medicare Fee Schedule 005-609,Per Unit,$45.79 ,OP,45.79,45.79,,,,,,
Humana,ExceptCPT,92082,Visual field examination(s),Medicare Fee Schedule 005-609,Per Unit,$67.65 ,OP,67.65,67.65,,,,,,
Humana,ExceptCPT,92083,Visual field examination(s),Medicare Fee Schedule 005-609,Per Unit,$93.03 ,OP,93.03,93.03,,,,,,
Humana,ExceptCPT,92132,Cmptr ophth dx img ant segmt,Medicare Fee Schedule 005-609,Per Unit,$39.66 ,OP,39.66,39.66,,,,,,
Humana,ExceptCPT,92133,Cmptr ophth img optic nerve,Medicare Fee Schedule 005-609,Per Unit,$39.63 ,OP,39.63,39.63,,,,,,
Humana,ExceptCPT,92134,Cptr ophth dx img post segmt,Medicare Fee Schedule 005-609,Per Unit,$40.51 ,OP,40.51,40.51,,,,,,
Humana,ExceptCPT,92136,Ophthalmic biometry,Medicare Fee Schedule 005-609,Per Unit,$62.37 ,OP,62.37,62.37,,,,,,
Humana,ExceptCPT,92145,Corneal hysteresis deter,Medicare Fee Schedule 005-609,Per Unit,$18.65 ,OP,18.65,18.65,,,,,,
Humana,ExceptCPT,92227,Img rta detcj/mntr ds staff,Medicare Fee Schedule 005-609,Per Unit,$40.51 ,OP,40.51,40.51,,,,,,
Humana,ExceptCPT,92228,Img rta detc/mntr ds phy/qhp,Medicare Fee Schedule 005-609,Per Unit,$32.64 ,OP,32.64,32.64,,,,,,
Humana,ExceptCPT,92235,Fluorescein angrph uni/bi,Medicare Fee Schedule 005-609,Per Unit,$192.78 ,OP,192.78,192.78,,,,,,
Humana,ExceptCPT,92240,Icg angiography uni/bi,Medicare Fee Schedule 005-609,Per Unit,$401.94 ,OP,401.94,401.94,,,,,,
Humana,ExceptCPT,92242,Fluorescein icg angiography,Medicare Fee Schedule 005-609,Per Unit,$506.96 ,OP,506.96,506.96,,,,,,
Humana,ExceptCPT,92250,Eye exam with photos,Medicare Fee Schedule 005-609,Per Unit,$46.64 ,OP,46.64,46.64,,,,,,
Humana,ExceptCPT,92265,Eye muscle evaluation,Medicare Fee Schedule 005-609,Per Unit,$107.00 ,OP,107,107,,,,,,
Humana,ExceptCPT,92270,Electro-oculography,Medicare Fee Schedule 005-609,Per Unit,$156.89 ,OP,156.89,156.89,,,,,,
Humana,ExceptCPT,92273,Full field erg w/i&r,Medicare Fee Schedule 005-609,Per Unit,$242.94 ,OP,242.94,242.94,,,,,,
Humana,ExceptCPT,92274,Multifocal erg w/i&r,Medicare Fee Schedule 005-609,Per Unit,$145.53 ,OP,145.53,145.53,,,,,,
Humana,ExceptCPT,92283,Color vision examination,Medicare Fee Schedule 005-609,Per Unit,$116.66 ,OP,116.66,116.66,,,,,,
Humana,ExceptCPT,92284,Dark adaptation eye exam,Medicare Fee Schedule 005-609,Per Unit,$120.40 ,OP,120.4,120.4,,,,,,
Humana,ExceptCPT,92285,Eye photography,Medicare Fee Schedule 005-609,Per Unit,$51.01 ,OP,51.01,51.01,,,,,,
Humana,ExceptCPT,92286,Internal eye photography,Medicare Fee Schedule 005-609,Per Unit,$44.88 ,OP,44.88,44.88,,,,,,
Humana,ExceptCPT,92287,Internal eye photography,Medicare Fee Schedule 005-609,Per Unit,$326.92 ,OP,326.92,326.92,,,,,,
Humana,ExceptCPT,92531,Spontaneous nystagmus study,Medicare Fee Schedule 005-609,Per Unit,$41.09 ,OP,41.09,41.09,,,,,,
Humana,ExceptCPT,92532,Positional nystagmus test,Medicare Fee Schedule 005-609,Per Unit,$47.38 ,OP,47.38,47.38,,,,,,
Humana,ExceptCPT,92533,Caloric vestibular test,Medicare Fee Schedule 005-609,Per Unit,$67.49 ,OP,67.49,67.49,,,,,,
Humana,ExceptCPT,92534,Optokinetic nystagmus test,Medicare Fee Schedule 005-609,Per Unit,$51.92 ,OP,51.92,51.92,,,,,,
Humana,ExceptCPT,92537,Caloric vstblr test w/rec,Medicare Fee Schedule 005-609,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana,ExceptCPT,92538,Caloric vstblr test w/rec,Medicare Fee Schedule 005-609,Per Unit,$17.77 ,OP,17.77,17.77,,,,,,
Humana,ExceptCPT,92540,Basic vestibular evaluation,Medicare Fee Schedule 005-609,Per Unit,$82.53 ,OP,82.53,82.53,,,,,,
Humana,ExceptCPT,92541,Spontaneous nystagmus test,Medicare Fee Schedule 005-609,Per Unit,$11.66 ,OP,11.66,11.66,,,,,,
Humana,ExceptCPT,92542,Positional nystagmus test,Medicare Fee Schedule 005-609,Per Unit,$11.63 ,OP,11.63,11.63,,,,,,
Humana,ExceptCPT,92544,Optokinetic nystagmus test,Medicare Fee Schedule 005-609,Per Unit,$9.87 ,OP,9.87,9.87,,,,,,
Humana,ExceptCPT,92545,Oscillating tracking test,Medicare Fee Schedule 005-609,Per Unit,$9.02 ,OP,9.02,9.02,,,,,,
Humana,ExceptCPT,92546,Sinusoidal rotational test,Medicare Fee Schedule 005-609,Per Unit,$267.44 ,OP,267.44,267.44,,,,,,
Humana,ExceptCPT,92547,Supplemental electrical test,Medicare Fee Schedule 005-609,Per Unit,$25.38 ,OP,25.38,25.38,,,,,,
Humana,ExceptCPT,92548,Cdp-sot 6 cond w/i&r,Medicare Fee Schedule 005-609,Per Unit,$39.63 ,OP,39.63,39.63,,,,,,
Humana,ExceptCPT,92549,Cdp-sot 6 cond w/i&r mct&adt,Medicare Fee Schedule 005-609,Per Unit,$48.37 ,OP,48.37,48.37,,,,,,
Humana,ExceptCPT,92551,Pure tone hearing test air,Medicare Fee Schedule 005-609,Per Unit,$30.00 ,OP,30,30,,,,,,
Humana,ExceptCPT,92552,Pure tone audiometry air,Medicare Fee Schedule 005-609,Per Unit,$82.53 ,OP,82.53,82.53,,,,,,
Humana,ExceptCPT,92553,Audiometry air & bone,Medicare Fee Schedule 005-609,Per Unit,$100.90 ,OP,100.9,100.9,,,,,,
Humana,ExceptCPT,92555,Speech threshold audiometry,Medicare Fee Schedule 005-609,Per Unit,$63.28 ,OP,63.28,63.28,,,,,,
Humana,ExceptCPT,92556,Speech audiometry complete,Medicare Fee Schedule 005-609,Per Unit,$100.02 ,OP,100.02,100.02,,,,,,
Humana,ExceptCPT,92558,Evoked auditory test qual,Medicare Fee Schedule 005-609,Per Unit,$26.21 ,OP,26.21,26.21,,,,,,
Humana,ExceptCPT,92559,Group audiometric testing,Medicare Fee Schedule 005-609,Per Unit,$81.02 ,OP,81.02,81.02,,,,,,
Humana,ExceptCPT,92560,Bekesy audiometry screen,Medicare Fee Schedule 005-609,Per Unit,$55.50 ,OP,55.5,55.5,,,,,,
Humana,ExceptCPT,92561,Bekesy audiometry diagnosis,Medicare Fee Schedule 005-609,Per Unit,$101.15 ,OP,101.15,101.15,,,,,,
Humana,ExceptCPT,92562,Loudness balance test,Medicare Fee Schedule 005-609,Per Unit,$118.39 ,OP,118.39,118.39,,,,,,
Humana,ExceptCPT,92563,Tone decay hearing test,Medicare Fee Schedule 005-609,Per Unit,$79.89 ,OP,79.89,79.89,,,,,,
Humana,ExceptCPT,92564,Sisi hearing test,Medicare Fee Schedule 005-609,Per Unit,$60.64 ,OP,60.64,60.64,,,,,,
Humana,ExceptCPT,92565,Stenger test pure tone,Medicare Fee Schedule 005-609,Per Unit,$44.88 ,OP,44.88,44.88,,,,,,
Humana,ExceptCPT,92571,Filtered speech hearing test,Medicare Fee Schedule 005-609,Per Unit,$71.14 ,OP,71.14,71.14,,,,,,
Humana,ExceptCPT,92572,Staggered spondaic word test,Medicare Fee Schedule 005-609,Per Unit,$91.27 ,OP,91.27,91.27,,,,,,
Humana,ExceptCPT,92575,Sensorineural acuity test,Medicare Fee Schedule 005-609,Per Unit,$174.68 ,OP,174.68,174.68,,,,,,
Humana,ExceptCPT,92576,Synthetic sentence test,Medicare Fee Schedule 005-609,Per Unit,$96.53 ,OP,96.53,96.53,,,,,,
Humana,ExceptCPT,92577,Stenger test speech,Medicare Fee Schedule 005-609,Per Unit,$38.78 ,OP,38.78,38.78,,,,,,
Humana,ExceptCPT,92582,Conditioning play audiometry,Medicare Fee Schedule 005-609,Per Unit,$192.17 ,OP,192.17,192.17,,,,,,
Humana,ExceptCPT,92583,Select picture audiometry,Medicare Fee Schedule 005-609,Per Unit,$128.89 ,OP,128.89,128.89,,,,,,
Humana,ExceptCPT,92584,Electrocochleography,Medicare Fee Schedule 005-609,Per Unit,$314.27 ,OP,314.27,314.27,,,,,,
Humana,ExceptCPT,92585,Auditor evoke potent compre,Medicare Fee Schedule 005-609,Per Unit,$278.74 ,OP,278.74,278.74,,,,,,
Humana,ExceptCPT,92586,Auditor evoke potent limit,Medicare Fee Schedule 005-609,Per Unit,$244.20 ,OP,244.2,244.2,,,,,,
Humana,ExceptCPT,92587,Evoked auditory test limited,Medicare Fee Schedule 005-609,Per Unit,$10.78 ,OP,10.78,10.78,,,,,,
Humana,ExceptCPT,92588,Evoked auditory tst complete,Medicare Fee Schedule 005-609,Per Unit,$14.25 ,OP,14.25,14.25,,,,,,
Humana,ExceptCPT,92590,Hearing aid exam one ear,Medicare Fee Schedule 005-609,Per Unit,$148.50 ,OP,148.5,148.5,,,,,,
Humana,ExceptCPT,92591,Hearing aid exam both ears,Medicare Fee Schedule 005-609,Per Unit,$190.47 ,OP,190.47,190.47,,,,,,
Humana,ExceptCPT,92592,Hearing aid check one ear,Medicare Fee Schedule 005-609,Per Unit,$58.22 ,OP,58.22,58.22,,,,,,
Humana,ExceptCPT,92593,Hearing aid check both ears,Medicare Fee Schedule 005-609,Per Unit,$97.46 ,OP,97.46,97.46,,,,,,
Humana,ExceptCPT,92594,Electro hearng aid test one,Medicare Fee Schedule 005-609,Per Unit,$55.50 ,OP,55.5,55.5,,,,,,
Humana,ExceptCPT,92595,Electro hearng aid tst both,Medicare Fee Schedule 005-609,Per Unit,$122.10 ,OP,122.1,122.1,,,,,,
Humana,ExceptCPT,92596,Ear protector evaluation,Medicare Fee Schedule 005-609,Per Unit,$171.79 ,OP,171.79,171.79,,,,,,
Humana,ExceptCPT,92620,Auditory function 60 min,Medicare Fee Schedule 005-609,Per Unit,$250.25 ,OP,250.25,250.25,,,,,,
Humana,ExceptCPT,92621,Auditory function + 15 min,Medicare Fee Schedule 005-609,Per Unit,$60.97 ,OP,60.97,60.97,,,,,,
Humana,ExceptCPT,92625,Tinnitus assessment,Medicare Fee Schedule 005-609,Per Unit,$188.65 ,OP,188.65,188.65,,,,,,
Humana,ExceptCPT,92640,Aud brainstem implt programg,Medicare Fee Schedule 005-609,Per Unit,$305.83 ,OP,305.83,305.83,,,,,,
Humana,ExceptCPT,92978,Endoluminl ivus oct c 1st,Medicare Fee Schedule 005-609,Per Unit,$492.91 ,OP,492.91,492.91,,,,,,
Humana,ExceptCPT,92979,Endoluminl ivus oct c ea,Medicare Fee Schedule 005-609,Per Unit,$249.37 ,OP,249.37,249.37,,,,,,
Humana,ExceptCPT,93000,Electrocardiogram complete,Medicare Fee Schedule 005-609,Per Unit,$39.57 ,OP,39.57,39.57,,,,,,
Humana,ExceptCPT,93005,Electrocardiogram tracing,Medicare Fee Schedule 005-609,Per Unit,$16.89 ,OP,16.89,16.89,,,,,,
Humana,ExceptCPT,93017,Cardiovascular stress test,Medicare Fee Schedule 005-609,Per Unit,$88.91 ,OP,88.91,88.91,,,,,,
Humana,ExceptCPT,93024,Cardiac drug stress test,Medicare Fee Schedule 005-609,Per Unit,$135.30 ,OP,135.3,135.3,,,,,,
Humana,ExceptCPT,93025,Microvolt t-wave assess,Medicare Fee Schedule 005-609,Per Unit,$250.80 ,OP,250.8,250.8,,,,,,
Humana,ExceptCPT,93041,Rhythm ecg tracing,Medicare Fee Schedule 005-609,Per Unit,$15.13 ,OP,15.13,15.13,,,,,,
Humana,ExceptCPT,93050,Art pressure waveform analys,Medicare Fee Schedule 005-609,Per Unit,$20.41 ,OP,20.41,20.41,,,,,,
Humana,ExceptCPT,93225,Ecg monit/reprt up to 48 hrs,Medicare Fee Schedule 005-609,Per Unit,$51.01 ,OP,51.01,51.01,,,,,,
Humana,ExceptCPT,93226,Ecg monit/reprt up to 48 hrs,Medicare Fee Schedule 005-609,Per Unit,$104.39 ,OP,104.39,104.39,,,,,,
Humana,ExceptCPT,93229,Remote 30 day ecg tech supp,Medicare Fee Schedule 005-609,Per Unit,"$1,800.70 ",OP,"1,800.70","1,800.70",,,,,,
Humana,ExceptCPT,93260,Prgrmg dev eval impltbl sys,Medicare Fee Schedule 005-609,Per Unit,$85.14 ,OP,85.14,85.14,,,,,,
Humana,ExceptCPT,93261,Interrogate subq defib,Medicare Fee Schedule 005-609,Per Unit,$84.29 ,OP,84.29,84.29,,,,,,
Humana,ExceptCPT,93270,Remote 30 day ecg rev/report,Medicare Fee Schedule 005-609,Per Unit,$23.02 ,OP,23.02,23.02,,,,,,
Humana,ExceptCPT,93271,Ecg/monitoring and analysis,Medicare Fee Schedule 005-609,Per Unit,$420.31 ,OP,420.31,420.31,,,,,,
Humana,ExceptCPT,93278,Ecg/signal-averaged,Medicare Fee Schedule 005-609,Per Unit,$44.88 ,OP,44.88,44.88,,,,,,
Humana,ExceptCPT,93279,Prgrmg dev eval pm/ldls pm,Medicare Fee Schedule 005-609,Per Unit,$88.66 ,OP,88.66,88.66,,,,,,
Humana,ExceptCPT,93280,Pm device progr eval dual,Medicare Fee Schedule 005-609,Per Unit,$103.54 ,OP,103.54,103.54,,,,,,
Humana,ExceptCPT,93281,Pm device progr eval multi,Medicare Fee Schedule 005-609,Per Unit,$105.27 ,OP,105.27,105.27,,,,,,
Humana,ExceptCPT,93282,Prgrmg eval implantable dfb,Medicare Fee Schedule 005-609,Per Unit,$95.65 ,OP,95.65,95.65,,,,,,
Humana,ExceptCPT,93283,Prgrmg eval implantable dfb,Medicare Fee Schedule 005-609,Per Unit,$104.39 ,OP,104.39,104.39,,,,,,
Humana,ExceptCPT,93284,Prgrmg eval implantable dfb,Medicare Fee Schedule 005-609,Per Unit,$111.38 ,OP,111.38,111.38,,,,,,
Humana,ExceptCPT,93285,Prgrmg dev eval scrms ip,Medicare Fee Schedule 005-609,Per Unit,$86.02 ,OP,86.02,86.02,,,,,,
Humana,ExceptCPT,93286,Peri-px eval pm/ldls pm ip,Medicare Fee Schedule 005-609,Per Unit,$77.28 ,OP,77.28,77.28,,,,,,
Humana,ExceptCPT,93287,Peri-px device eval & prgr,Medicare Fee Schedule 005-609,Per Unit,$77.28 ,OP,77.28,77.28,,,,,,
Humana,ExceptCPT,93288,Interrog evl pm/ldls pm ip,Medicare Fee Schedule 005-609,Per Unit,$87.75 ,OP,87.75,87.75,,,,,,
Humana,ExceptCPT,93289,Interrog device eval heart,Medicare Fee Schedule 005-609,Per Unit,$88.63 ,OP,88.63,88.63,,,,,,
Humana,ExceptCPT,93290,Interrog dev eval icpms ip,Medicare Fee Schedule 005-609,Per Unit,$79.89 ,OP,79.89,79.89,,,,,,
Humana,ExceptCPT,93291,Interrog dev eval scrms ip,Medicare Fee Schedule 005-609,Per Unit,$77.25 ,OP,77.25,77.25,,,,,,
Humana,ExceptCPT,93292,Wcd device interrogate,Medicare Fee Schedule 005-609,Per Unit,$72.90 ,OP,72.9,72.9,,,,,,
Humana,ExceptCPT,93293,Pm phone r-strip device eval,Medicare Fee Schedule 005-609,Per Unit,$92.15 ,OP,92.15,92.15,,,,,,
Humana,ExceptCPT,93296,Rem interrog evl pm/ids,Medicare Fee Schedule 005-609,Per Unit,$65.01 ,OP,65.01,65.01,,,,,,
Humana,ExceptCPT,93303,Echo transthoracic,Medicare Fee Schedule 005-609,Per Unit,$439.84 ,OP,439.84,439.84,,,,,,
Humana,ExceptCPT,93304,Echo transthoracic,Medicare Fee Schedule 005-609,Per Unit,$326.07 ,OP,326.07,326.07,,,,,,
Humana,ExceptCPT,93306,Tte w/doppler complete,Medicare Fee Schedule 005-609,Per Unit,$344.44 ,OP,344.44,344.44,,,,,,
Humana,ExceptCPT,93307,Tte w/o doppler complete,Medicare Fee Schedule 005-609,Per Unit,$255.17 ,OP,255.17,255.17,,,,,,
Humana,ExceptCPT,93308,Tte f-up or lmtd,Medicare Fee Schedule 005-609,Per Unit,$194.54 ,OP,194.54,194.54,,,,,,
Humana,ExceptCPT,93312,Echo transesophageal,Medicare Fee Schedule 005-609,Per Unit,$359.34 ,OP,359.34,359.34,,,,,,
Humana,ExceptCPT,93314,Echo transesophageal,Medicare Fee Schedule 005-609,Per Unit,$382.09 ,OP,382.09,382.09,,,,,,
Humana,ExceptCPT,93315,Echo transesophageal,Medicare Fee Schedule 005-609,Per Unit,$400.32 ,OP,400.32,400.32,,,,,,
Humana,ExceptCPT,93317,Echo transesophageal,Medicare Fee Schedule 005-609,Per Unit,$541.26 ,OP,541.26,541.26,,,,,,
Humana,ExceptCPT,93318,Echo transesophageal intraop,Medicare Fee Schedule 005-609,Per Unit,$784.85 ,OP,784.85,784.85,,,,,,
Humana,ExceptCPT,93320,Doppler echo exam heart,Medicare Fee Schedule 005-609,Per Unit,$91.27 ,OP,91.27,91.27,,,,,,
Humana,ExceptCPT,93321,Doppler echo exam heart,Medicare Fee Schedule 005-609,Per Unit,$49.89 ,OP,49.89,49.89,,,,,,
Humana,ExceptCPT,93325,Doppler color flow add-on,Medicare Fee Schedule 005-609,Per Unit,$56.02 ,OP,56.02,56.02,,,,,,
Humana,ExceptCPT,93350,Stress tte only,Medicare Fee Schedule 005-609,Per Unit,$316.44 ,OP,316.44,316.44,,,,,,
Humana,ExceptCPT,93351,Stress tte complete,Medicare Fee Schedule 005-609,Per Unit,$399.19 ,OP,399.19,399.19,,,,,,
Humana,ExceptCPT,93451,Right heart cath,Medicare Fee Schedule 005-609,Per Unit,"$2,010.33 ",OP,"2,010.33","2,010.33",,,,,,
Humana,ExceptCPT,93452,Left hrt cath w/ventrclgrphy,Medicare Fee Schedule 005-609,Per Unit,"$1,861.56 ",OP,"1,861.56","1,861.56",,,,,,
Humana,ExceptCPT,93453,R&l hrt cath w/ventriclgrphy,Medicare Fee Schedule 005-609,Per Unit,"$2,336.73 ",OP,"2,336.73","2,336.73",,,,,,
Humana,ExceptCPT,93454,Coronary artery angio s&i,Medicare Fee Schedule 005-609,Per Unit,"$1,858.04 ",OP,"1,858.04","1,858.04",,,,,,
Humana,ExceptCPT,93455,Coronary art/grft angio s&i,Medicare Fee Schedule 005-609,Per Unit,"$2,061.07 ",OP,"2,061.07","2,061.07",,,,,,
Humana,ExceptCPT,93456,R hrt coronary artery angio,Medicare Fee Schedule 005-609,Per Unit,"$2,299.11 ",OP,"2,299.11","2,299.11",,,,,,
Humana,ExceptCPT,93457,R hrt art/grft angio,Medicare Fee Schedule 005-609,Per Unit,"$2,499.78 ",OP,"2,499.78","2,499.78",,,,,,
Humana,ExceptCPT,93458,L hrt artery/ventricle angio,Medicare Fee Schedule 005-609,Per Unit,"$2,100.42 ",OP,"2,100.42","2,100.42",,,,,,
Humana,ExceptCPT,93459,L hrt art/grft angio,Medicare Fee Schedule 005-609,Per Unit,"$2,231.10 ",OP,"2,231.10","2,231.10",,,,,,
Humana,ExceptCPT,93460,R&l hrt art/ventricle angio,Medicare Fee Schedule 005-609,Per Unit,"$2,466.50 ",OP,"2,466.50","2,466.50",,,,,,
Humana,ExceptCPT,93461,R&l hrt art/ventricle angio,Medicare Fee Schedule 005-609,Per Unit,"$2,739.55 ",OP,"2,739.55","2,739.55",,,,,,
Humana,ExceptCPT,93464,Exercise w/hemodynamic meas,Medicare Fee Schedule 005-609,Per Unit,$387.94 ,OP,387.94,387.94,,,,,,
Humana,ExceptCPT,93505,Biopsy of heart lining,Medicare Fee Schedule 005-609,Per Unit,"$1,241.43 ",OP,"1,241.43","1,241.43",,,,,,
Humana,ExceptCPT,93530,Rt heart cath congenital,Medicare Fee Schedule 005-609,Per Unit,"$1,850.26 ",OP,"1,850.26","1,850.26",,,,,,
Humana,ExceptCPT,93531,R & l heart cath congenital,Medicare Fee Schedule 005-609,Per Unit,"$5,292.10 ",OP,"5,292.10","5,292.10",,,,,,
Humana,ExceptCPT,93532,R & l heart cath congenital,Medicare Fee Schedule 005-609,Per Unit,"$6,615.13 ",OP,"6,615.13","6,615.13",,,,,,
Humana,ExceptCPT,93533,R & l heart cath congenital,Medicare Fee Schedule 005-609,Per Unit,"$5,292.10 ",OP,"5,292.10","5,292.10",,,,,,
Humana,ExceptCPT,93561,Cardiac output measurement,Medicare Fee Schedule 005-609,Per Unit,$60.56 ,OP,60.56,60.56,,,,,,
Humana,ExceptCPT,93562,Card output measure subsq,Medicare Fee Schedule 005-609,Per Unit,$37.70 ,OP,37.7,37.7,,,,,,
Humana,ExceptCPT,93571,Heart flow reserve measure,Medicare Fee Schedule 005-609,Per Unit,$492.91 ,OP,492.91,492.91,,,,,,
Humana,ExceptCPT,93572,Heart flow reserve measure,Medicare Fee Schedule 005-609,Per Unit,$154.61 ,OP,154.61,154.61,,,,,,
Humana,ExceptCPT,93600,Bundle of his recording,Medicare Fee Schedule 005-609,Per Unit,$215.13 ,OP,215.13,215.13,,,,,,
Humana,ExceptCPT,93602,Intra-atrial recording,Medicare Fee Schedule 005-609,Per Unit,$121.39 ,OP,121.39,121.39,,,,,,
Humana,ExceptCPT,93603,Right ventricular recording,Medicare Fee Schedule 005-609,Per Unit,$184.20 ,OP,184.2,184.2,,,,,,
Humana,ExceptCPT,93609,Map tachycardia add-on,Medicare Fee Schedule 005-609,Per Unit,$298.13 ,OP,298.13,298.13,,,,,,
Humana,ExceptCPT,93610,Intra-atrial pacing,Medicare Fee Schedule 005-609,Per Unit,$149.66 ,OP,149.66,149.66,,,,,,
Humana,ExceptCPT,93612,Intraventricular pacing,Medicare Fee Schedule 005-609,Per Unit,$177.16 ,OP,177.16,177.16,,,,,,
Humana,ExceptCPT,93615,Esophageal recording,Medicare Fee Schedule 005-609,Per Unit,$34.98 ,OP,34.98,34.98,,,,,,
Humana,ExceptCPT,93616,Esophageal recording,Medicare Fee Schedule 005-609,Per Unit,$432.58 ,OP,432.58,432.58,,,,,,
Humana,ExceptCPT,93618,Heart rhythm pacing,Medicare Fee Schedule 005-609,Per Unit,$432.58 ,OP,432.58,432.58,,,,,,
Humana,ExceptCPT,93619,Electrophysiology evaluation,Medicare Fee Schedule 005-609,Per Unit,$841.58 ,OP,841.58,841.58,,,,,,
Humana,ExceptCPT,93620,Electrophysiology evaluation,Medicare Fee Schedule 005-609,Per Unit,$925.76 ,OP,925.76,925.76,,,,,,
Humana,ExceptCPT,93621,Electrophysiology evaluation,Medicare Fee Schedule 005-609,Per Unit,$656.45 ,OP,656.45,656.45,,,,,,
Humana,ExceptCPT,93622,Electrophysiology evaluation,Medicare Fee Schedule 005-609,Per Unit,$962.39 ,OP,962.39,962.39,,,,,,
Humana,ExceptCPT,93623,Stimulation pacing heart,Medicare Fee Schedule 005-609,Per Unit,$639.21 ,OP,639.21,639.21,,,,,,
Humana,ExceptCPT,93624,Electrophysiologic study,Medicare Fee Schedule 005-609,Per Unit,$218.16 ,OP,218.16,218.16,,,,,,
Humana,ExceptCPT,93631,Heart pacing mapping,Medicare Fee Schedule 005-609,Per Unit,"$4,395.41 ",OP,"4,395.41","4,395.41",,,,,,
Humana,ExceptCPT,93640,Evaluation heart device,Medicare Fee Schedule 005-609,Per Unit,$781.36 ,OP,781.36,781.36,,,,,,
Humana,ExceptCPT,93641,Electrophysiology evaluation,Medicare Fee Schedule 005-609,Per Unit,$781.36 ,OP,781.36,781.36,,,,,,
Humana,ExceptCPT,93642,Electrophysiology evaluation,Medicare Fee Schedule 005-609,Per Unit,$214.06 ,OP,214.06,214.06,,,,,,
Humana,ExceptCPT,93644,Electrophysiology evaluation,Medicare Fee Schedule 005-609,Per Unit,$136.79 ,OP,136.79,136.79,,,,,,
Humana,ExceptCPT,93657,Tx l/r atrial fib addl,Medicare Fee Schedule 005-609,Per Unit,"$1,194.38 ",OP,"1,194.38","1,194.38",,,,,,
Humana,ExceptCPT,93660,Tilt table evaluation,Medicare Fee Schedule 005-609,Per Unit,$169.95 ,OP,169.95,169.95,,,,,,
Humana,ExceptCPT,93662,Intracardiac ecg (ice),Medicare Fee Schedule 005-609,Per Unit,$638.06 ,OP,638.06,638.06,,,,,,
Humana,ExceptCPT,93668,Peripheral vascular rehab,Medicare Fee Schedule 005-609,Per Unit,$36.14 ,OP,36.14,36.14,,,,,,
Humana,ExceptCPT,93701,Bioimpedance cv analysis,Medicare Fee Schedule 005-609,Per Unit,$71.14 ,OP,71.14,71.14,,,,,,
Humana,ExceptCPT,93702,Bis xtracell fluid analysis,Medicare Fee Schedule 005-609,Per Unit,$376.83 ,OP,376.83,376.83,,,,,,
Humana,ExceptCPT,93724,Analyze pacemaker system,Medicare Fee Schedule 005-609,Per Unit,$111.40 ,OP,111.4,111.4,,,,,,
Humana,ExceptCPT,93740,Temperature gradient studies,Medicare Fee Schedule 005-609,Per Unit,$21.73 ,OP,21.73,21.73,,,,,,
Humana,ExceptCPT,93745,Set-up cardiovert-defibrill,Medicare Fee Schedule 005-609,Per Unit,$104.50 ,OP,104.5,104.5,,,,,,
Humana,ExceptCPT,93770,Measure venous pressure,Medicare Fee Schedule 005-609,Per Unit,$21.73 ,OP,21.73,21.73,,,,,,
Humana,ExceptCPT,93786,Ambl bp mntr w/sw rec only,Medicare Fee Schedule 005-609,Per Unit,$58.91 ,OP,58.91,58.91,,,,,,
Humana,ExceptCPT,93788,Ambl bp mntr w/sw a/r,Medicare Fee Schedule 005-609,Per Unit,$13.39 ,OP,13.39,13.39,,,,,,
Humana,ExceptCPT,93792,Pt/caregiver traing home inr,Medicare Fee Schedule 005-609,Per Unit,$170.80 ,OP,170.8,170.8,,,,,,
Humana,ExceptCPT,93880,Extracranial bilat study,Medicare Fee Schedule 005-609,Per Unit,$414.45 ,OP,414.45,414.45,,,,,,
Humana,ExceptCPT,93882,Extracranial uni/ltd study,Medicare Fee Schedule 005-609,Per Unit,$271.81 ,OP,271.81,271.81,,,,,,
Humana,ExceptCPT,93886,Intracranial complete study,Medicare Fee Schedule 005-609,Per Unit,$594.72 ,OP,594.72,594.72,,,,,,
Humana,ExceptCPT,93888,Intracranial limited study,Medicare Fee Schedule 005-609,Per Unit,$364.57 ,OP,364.57,364.57,,,,,,
Humana,ExceptCPT,93890,Tcd vasoreactivity study,Medicare Fee Schedule 005-609,Per Unit,$603.98 ,OP,603.98,603.98,,,,,,
Humana,ExceptCPT,93892,Tcd emboli detect w/o inj,Medicare Fee Schedule 005-609,Per Unit,$673.12 ,OP,673.12,673.12,,,,,,
Humana,ExceptCPT,93893,Tcd emboli detect w/inj,Medicare Fee Schedule 005-609,Per Unit,$823.65 ,OP,823.65,823.65,,,,,,
Humana,ExceptCPT,93922,Upr/l xtremity art 2 levels,Medicare Fee Schedule 005-609,Per Unit,$186.64 ,OP,186.64,186.64,,,,,,
Humana,ExceptCPT,93923,Upr/lxtr art stdy 3+ lvls,Medicare Fee Schedule 005-609,Per Unit,$284.05 ,OP,284.05,284.05,,,,,,
Humana,ExceptCPT,93924,Lwr xtr vasc stdy bilat,Medicare Fee Schedule 005-609,Per Unit,$359.32 ,OP,359.32,359.32,,,,,,
Humana,ExceptCPT,93925,Lower extremity study,Medicare Fee Schedule 005-609,Per Unit,$556.74 ,OP,556.74,556.74,,,,,,
Humana,ExceptCPT,93926,Lower extremity study,Medicare Fee Schedule 005-609,Per Unit,$325.19 ,OP,325.19,325.19,,,,,,
Humana,ExceptCPT,93930,Upper extremity study,Medicare Fee Schedule 005-609,Per Unit,$430.73 ,OP,430.73,430.73,,,,,,
Humana,ExceptCPT,93931,Upper extremity study,Medicare Fee Schedule 005-609,Per Unit,$270.05 ,OP,270.05,270.05,,,,,,
Humana,ExceptCPT,93970,Extremity study,Medicare Fee Schedule 005-609,Per Unit,$417.95 ,OP,417.95,417.95,,,,,,
Humana,ExceptCPT,93971,Extremity study,Medicare Fee Schedule 005-609,Per Unit,$261.03 ,OP,261.03,261.03,,,,,,
Humana,ExceptCPT,93975,Vascular study,Medicare Fee Schedule 005-609,Per Unit,$570.74 ,OP,570.74,570.74,,,,,,
Humana,ExceptCPT,93976,Vascular study,Medicare Fee Schedule 005-609,Per Unit,$323.46 ,OP,323.46,323.46,,,,,,
Humana,ExceptCPT,93978,Vascular study,Medicare Fee Schedule 005-609,Per Unit,$385.58 ,OP,385.58,385.58,,,,,,
Humana,ExceptCPT,93979,Vascular study,Medicare Fee Schedule 005-609,Per Unit,$252.56 ,OP,252.56,252.56,,,,,,
Humana,ExceptCPT,93980,Penile vascular study,Medicare Fee Schedule 005-609,Per Unit,$155.16 ,OP,155.16,155.16,,,,,,
Humana,ExceptCPT,93981,Penile vascular study,Medicare Fee Schedule 005-609,Per Unit,$134.15 ,OP,134.15,134.15,,,,,,
Humana,ExceptCPT,93985,Dup-scan hemo compl bi std,Medicare Fee Schedule 005-609,Per Unit,$589.13 ,OP,589.13,589.13,,,,,,
Humana,ExceptCPT,93986,Dup-scan hemo compl uni std,Medicare Fee Schedule 005-609,Per Unit,$336.55 ,OP,336.55,336.55,,,,,,
Humana,ExceptCPT,93990,Doppler flow testing,Medicare Fee Schedule 005-609,Per Unit,$333.93 ,OP,333.93,333.93,,,,,,
Humana,ExceptCPT,94010,Breathing capacity test,Medicare Fee Schedule 005-609,Per Unit,$54.53 ,OP,54.53,54.53,,,,,,
Humana,ExceptCPT,94015,Patient recorded spirometry,Medicare Fee Schedule 005-609,Per Unit,$79.01 ,OP,79.01,79.01,,,,,,
Humana,ExceptCPT,94060,Evaluation of wheezing,Medicare Fee Schedule 005-609,Per Unit,$92.13 ,OP,92.13,92.13,,,,,,
Humana,ExceptCPT,94070,Evaluation of wheezing,Medicare Fee Schedule 005-609,Per Unit,$86.87 ,OP,86.87,86.87,,,,,,
Humana,ExceptCPT,94150,Vital capacity test,Medicare Fee Schedule 005-609,Per Unit,$54.51 ,OP,54.51,54.51,,,,,,
Humana,ExceptCPT,94200,Lung function test (mbc/mvv),Medicare Fee Schedule 005-609,Per Unit,$36.14 ,OP,36.14,36.14,,,,,,
Humana,ExceptCPT,94250,Expired gas collection,Medicare Fee Schedule 005-609,Per Unit,$55.74 ,OP,55.74,55.74,,,,,,
Humana,ExceptCPT,94375,Respiratory flow volume loop,Medicare Fee Schedule 005-609,Per Unit,$62.40 ,OP,62.4,62.4,,,,,,
Humana,ExceptCPT,94400,Co2 breathing response curve,Medicare Fee Schedule 005-609,Per Unit,$95.10 ,OP,95.1,95.1,,,,,,
Humana,ExceptCPT,94450,Hypoxia response curve,Medicare Fee Schedule 005-609,Per Unit,$110.80 ,OP,110.8,110.8,,,,,,
Humana,ExceptCPT,94452,Hast w/report,Medicare Fee Schedule 005-609,Per Unit,$94.79 ,OP,94.79,94.79,,,,,,
Humana,ExceptCPT,94453,Hast w/oxygen titrate,Medicare Fee Schedule 005-609,Per Unit,$132.41 ,OP,132.41,132.41,,,,,,
Humana,ExceptCPT,94617,Exercise tst brncspsm w/ecg,Medicare Fee Schedule 005-609,Per Unit,$155.43 ,OP,155.43,155.43,,,,,,
Humana,ExceptCPT,94618,Pulmonary stress testing,Medicare Fee Schedule 005-609,Per Unit,$28.24 ,OP,28.24,28.24,,,,,,
Humana,ExceptCPT,94619,Exercise tst brncspsm wo ecg,Medicare Fee Schedule 005-609,Per Unit,$127.41 ,OP,127.41,127.41,,,,,,
Humana,ExceptCPT,94621,Cardiopulm exercise testing,Medicare Fee Schedule 005-609,Per Unit,$229.46 ,OP,229.46,229.46,,,,,,
Humana,ExceptCPT,94680,Exhaled air analysis o2,Medicare Fee Schedule 005-609,Per Unit,$104.39 ,OP,104.39,104.39,,,,,,
Humana,ExceptCPT,94681,Exhaled air analysis o2/co2,Medicare Fee Schedule 005-609,Per Unit,$105.27 ,OP,105.27,105.27,,,,,,
Humana,ExceptCPT,94690,Exhaled air analysis,Medicare Fee Schedule 005-609,Per Unit,$102.66 ,OP,102.66,102.66,,,,,,
Humana,ExceptCPT,94726,Pulm funct tst plethysmograp,Medicare Fee Schedule 005-609,Per Unit,$109.04 ,OP,109.04,109.04,,,,,,
Humana,ExceptCPT,94727,Pulm function test by gas,Medicare Fee Schedule 005-609,Per Unit,$81.65 ,OP,81.65,81.65,,,,,,
Humana,ExceptCPT,94728,Airwy resist by oscillometry,Medicare Fee Schedule 005-609,Per Unit,$72.90 ,OP,72.9,72.9,,,,,,
Humana,ExceptCPT,94729,Co/membane diffuse capacity,Medicare Fee Schedule 005-609,Per Unit,$128.89 ,OP,128.89,128.89,,,,,,
Humana,ExceptCPT,94750,Pulmonary compliance study,Medicare Fee Schedule 005-609,Per Unit,$197.53 ,OP,197.53,197.53,,,,,,
Humana,ExceptCPT,94760,Measure blood oxygen level,Medicare Fee Schedule 005-609,Per Unit,$6.38 ,OP,6.38,6.38,,,,,,
Humana,ExceptCPT,94761,Measure blood oxygen level,Medicare Fee Schedule 005-609,Per Unit,$9.87 ,OP,9.87,9.87,,,,,,
Humana,ExceptCPT,94762,Measure blood oxygen level,Medicare Fee Schedule 005-609,Per Unit,$69.38 ,OP,69.38,69.38,,,,,,
Humana,ExceptCPT,94770,Exhaled carbon dioxide test,Medicare Fee Schedule 005-609,Per Unit,$20.63 ,OP,20.63,20.63,,,,,,
Humana,ExceptCPT,94772,Breath recording infant,Medicare Fee Schedule 005-609,Per Unit,$438.19 ,OP,438.19,438.19,,,,,,
Humana,ExceptCPT,94775,Ped home apnea rec hk-up,Medicare Fee Schedule 005-609,Per Unit,$119.41 ,OP,119.41,119.41,,,,,,
Humana,ExceptCPT,94776,Ped home apnea rec downld,Medicare Fee Schedule 005-609,Per Unit,$563.86 ,OP,563.86,563.86,,,,,,
Humana,ExceptCPT,95028,Icut allergy test-delayed,Medicare Fee Schedule 005-609,Per Unit,$33.52 ,OP,33.52,33.52,,,,,,
Humana,ExceptCPT,95060,Eye allergy tests,Medicare Fee Schedule 005-609,Per Unit,$93.03 ,OP,93.03,93.03,,,,,,
Humana,ExceptCPT,95065,Nose allergy test,Medicare Fee Schedule 005-609,Per Unit,$68.53 ,OP,68.53,68.53,,,,,,
Humana,ExceptCPT,95070,Bronchial allergy tests,Medicare Fee Schedule 005-609,Per Unit,$89.79 ,OP,89.79,89.79,,,,,,
Humana,ExceptCPT,95071,Bronchial allergy tests,Medicare Fee Schedule 005-609,Per Unit,$96.64 ,OP,96.64,96.64,,,,,,
Humana,ExceptCPT,95249,Cont gluc mntr pt prov eqp,Medicare Fee Schedule 005-609,Per Unit,$148.06 ,OP,148.06,148.06,,,,,,
Humana,ExceptCPT,95250,Cont gluc mntr phys/qhp eqp,Medicare Fee Schedule 005-609,Per Unit,$395.73 ,OP,395.73,395.73,,,,,,
Humana,ExceptCPT,95782,Polysom <6 yrs 4/> paramtrs,Medicare Fee Schedule 005-609,Per Unit,"$2,063.71 ",OP,"2,063.71","2,063.71",,,,,,
Humana,ExceptCPT,95783,Polysom <6 yrs cpap/bilvl,Medicare Fee Schedule 005-609,Per Unit,"$2,179.24 ",OP,"2,179.24","2,179.24",,,,,,
Humana,ExceptCPT,95800,Slp stdy unattended,Medicare Fee Schedule 005-609,Per Unit,$322.30 ,OP,322.3,322.3,,,,,,
Humana,ExceptCPT,95801,Slp stdy unatnd w/anal,Medicare Fee Schedule 005-609,Per Unit,$124.55 ,OP,124.55,124.55,,,,,,
Humana,ExceptCPT,95803,Actigraphy testing,Medicare Fee Schedule 005-609,Per Unit,$281.19 ,OP,281.19,281.19,,,,,,
Humana,ExceptCPT,95805,Multiple sleep latency test,Medicare Fee Schedule 005-609,Per Unit,$931.73 ,OP,931.73,931.73,,,,,,
Humana,ExceptCPT,95806,Sleep study unatt&resp efft,Medicare Fee Schedule 005-609,Per Unit,$144.05 ,OP,144.05,144.05,,,,,,
Humana,ExceptCPT,95807,Sleep study attended,Medicare Fee Schedule 005-609,Per Unit,$868.70 ,OP,868.7,868.7,,,,,,
Humana,ExceptCPT,95808,Polysom any age 1-3> param,Medicare Fee Schedule 005-609,Per Unit,"$1,475.40 ",OP,"1,475.40","1,475.40",,,,,,
Humana,ExceptCPT,95810,Polysom 6/> yrs 4/> param,Medicare Fee Schedule 005-609,Per Unit,"$1,275.78 ",OP,"1,275.78","1,275.78",,,,,,
Humana,ExceptCPT,95811,Polysom 6/>yrs cpap 4/> parm,Medicare Fee Schedule 005-609,Per Unit,"$1,333.56 ",OP,"1,333.56","1,333.56",,,,,,
Humana,ExceptCPT,95812,Eeg 41-60 minutes,Medicare Fee Schedule 005-609,Per Unit,$742.28 ,OP,742.28,742.28,,,,,,
Humana,ExceptCPT,95813,Eeg extnd mntr 61-119 min,Medicare Fee Schedule 005-609,Per Unit,$870.05 ,OP,870.05,870.05,,,,,,
Humana,ExceptCPT,95816,Eeg awake and drowsy,Medicare Fee Schedule 005-609,Per Unit,$825.41 ,OP,825.41,825.41,,,,,,
Humana,ExceptCPT,95819,Eeg awake and asleep,Medicare Fee Schedule 005-609,Per Unit,"$1,017.94 ",OP,"1,017.94","1,017.94",,,,,,
Humana,ExceptCPT,95822,Eeg coma or sleep only,Medicare Fee Schedule 005-609,Per Unit,$915.53 ,OP,915.53,915.53,,,,,,
Humana,ExceptCPT,95824,Eeg cerebral death only,Medicare Fee Schedule 005-609,Per Unit,$158.10 ,OP,158.1,158.1,,,,,,
Humana,ExceptCPT,95829,Surgery electrocorticogram,Medicare Fee Schedule 005-609,Per Unit,"$4,085.73 ",OP,"4,085.73","4,085.73",,,,,,
Humana,ExceptCPT,95860,Muscle test one limb,Medicare Fee Schedule 005-609,Per Unit,$175.29 ,OP,175.29,175.29,,,,,,
Humana,ExceptCPT,95861,Muscle test 2 limbs,Medicare Fee Schedule 005-609,Per Unit,$233.92 ,OP,233.92,233.92,,,,,,
Humana,ExceptCPT,95863,Muscle test 3 limbs,Medicare Fee Schedule 005-609,Per Unit,$323.18 ,OP,323.18,323.18,,,,,,
Humana,ExceptCPT,95864,Muscle test 4 limbs,Medicare Fee Schedule 005-609,Per Unit,$373.07 ,OP,373.07,373.07,,,,,,
Humana,ExceptCPT,95865,Muscle test larynx,Medicare Fee Schedule 005-609,Per Unit,$191.02 ,OP,191.02,191.02,,,,,,
Humana,ExceptCPT,95866,Muscle test hemidiaphragm,Medicare Fee Schedule 005-609,Per Unit,$183.15 ,OP,183.15,183.15,,,,,,
Humana,ExceptCPT,95867,Muscle test cran nerv unilat,Medicare Fee Schedule 005-609,Per Unit,$181.39 ,OP,181.39,181.39,,,,,,
Humana,ExceptCPT,95868,Muscle test cran nerve bilat,Medicare Fee Schedule 005-609,Per Unit,$216.43 ,OP,216.43,216.43,,,,,,
Humana,ExceptCPT,95869,Muscle test thor paraspinal,Medicare Fee Schedule 005-609,Per Unit,$212.05 ,OP,212.05,212.05,,,,,,
Humana,ExceptCPT,95870,Muscle test nonparaspinal,Medicare Fee Schedule 005-609,Per Unit,$184.91 ,OP,184.91,184.91,,,,,,
Humana,ExceptCPT,95872,Muscle test one fiber,Medicare Fee Schedule 005-609,Per Unit,$137.64 ,OP,137.64,137.64,,,,,,
Humana,ExceptCPT,95873,Guide nerv destr elec stim,Medicare Fee Schedule 005-609,Per Unit,$153.15 ,OP,153.15,153.15,,,,,,
Humana,ExceptCPT,95874,Guide nerv destr needle emg,Medicare Fee Schedule 005-609,Per Unit,$162.77 ,OP,162.77,162.77,,,,,,
Humana,ExceptCPT,95875,Limb exercise test,Medicare Fee Schedule 005-609,Per Unit,$204.16 ,OP,204.16,204.16,,,,,,
Humana,ExceptCPT,95885,Musc tst done w/nerv tst lim,Medicare Fee Schedule 005-609,Per Unit,$123.39 ,OP,123.39,123.39,,,,,,
Humana,ExceptCPT,95886,Musc test done w/n test comp,Medicare Fee Schedule 005-609,Per Unit,$145.28 ,OP,145.28,145.28,,,,,,
Humana,ExceptCPT,95887,Musc tst done w/n tst nonext,Medicare Fee Schedule 005-609,Per Unit,$131.29 ,OP,131.29,131.29,,,,,,
Humana,ExceptCPT,95905,Motor &/ sens nrve cndj test,Medicare Fee Schedule 005-609,Per Unit,$114.92 ,OP,114.92,114.92,,,,,,
Humana,ExceptCPT,95907,Nvr cndj tst 1-2 studies,Medicare Fee Schedule 005-609,Per Unit,$107.91 ,OP,107.91,107.91,,,,,,
Humana,ExceptCPT,95908,Nrv cndj tst 3-4 studies,Medicare Fee Schedule 005-609,Per Unit,$137.67 ,OP,137.67,137.67,,,,,,
Humana,ExceptCPT,95909,Nrv cndj tst 5-6 studies,Medicare Fee Schedule 005-609,Per Unit,$164.78 ,OP,164.78,164.78,,,,,,
Humana,ExceptCPT,95910,Nrv cndj test 7-8 studies,Medicare Fee Schedule 005-609,Per Unit,$210.29 ,OP,210.29,210.29,,,,,,
Humana,ExceptCPT,95911,Nrv cndj test 9-10 studies,Medicare Fee Schedule 005-609,Per Unit,$240.93 ,OP,240.93,240.93,,,,,,
Humana,ExceptCPT,95912,Nrv cndj test 11-12 studies,Medicare Fee Schedule 005-609,Per Unit,$265.68 ,OP,265.68,265.68,,,,,,
Humana,ExceptCPT,95913,Nrv cndj test 13/> studies,Medicare Fee Schedule 005-609,Per Unit,$298.95 ,OP,298.95,298.95,,,,,,
Humana,ExceptCPT,95921,Autonomic nrv parasym inervj,Medicare Fee Schedule 005-609,Per Unit,$114.02 ,OP,114.02,114.02,,,,,,
Humana,ExceptCPT,95922,Autonomic nrv adrenrg inervj,Medicare Fee Schedule 005-609,Per Unit,$151.03 ,OP,151.03,151.03,,,,,,
Humana,ExceptCPT,95923,Autonomic nrv syst funj test,Medicare Fee Schedule 005-609,Per Unit,$220.77 ,OP,220.77,220.77,,,,,,
Humana,ExceptCPT,95924,Ans parasymp & symp w/tilt,Medicare Fee Schedule 005-609,Per Unit,$166.79 ,OP,166.79,166.79,,,,,,
Humana,ExceptCPT,95925,Somatosensory testing,Medicare Fee Schedule 005-609,Per Unit,$332.17 ,OP,332.17,332.17,,,,,,
Humana,ExceptCPT,95926,Somatosensory testing,Medicare Fee Schedule 005-609,Per Unit,$303.33 ,OP,303.33,303.33,,,,,,
Humana,ExceptCPT,95927,Somatosensory testing,Medicare Fee Schedule 005-609,Per Unit,$298.57 ,OP,298.57,298.57,,,,,,
Humana,ExceptCPT,95928,C motor evoked uppr limbs,Medicare Fee Schedule 005-609,Per Unit,$407.19 ,OP,407.19,407.19,,,,,,
Humana,ExceptCPT,95929,C motor evoked lwr limbs,Medicare Fee Schedule 005-609,Per Unit,$426.44 ,OP,426.44,426.44,,,,,,
Humana,ExceptCPT,95930,Visual ep test cns w/i&r,Medicare Fee Schedule 005-609,Per Unit,$125.40 ,OP,125.4,125.4,,,,,,
Humana,ExceptCPT,95933,Blink reflex test,Medicare Fee Schedule 005-609,Per Unit,$141.13 ,OP,141.13,141.13,,,,,,
Humana,ExceptCPT,95937,Neuromuscular junction test,Medicare Fee Schedule 005-609,Per Unit,$180.54 ,OP,180.54,180.54,,,,,,
Humana,ExceptCPT,95938,Somatosensory testing,Medicare Fee Schedule 005-609,Per Unit,$810.54 ,OP,810.54,810.54,,,,,,
Humana,ExceptCPT,95939,C motor evoked upr&lwr limbs,Medicare Fee Schedule 005-609,Per Unit,"$1,100.44 ",OP,"1,100.44","1,100.44",,,,,,
Humana,ExceptCPT,95943,Parasymp&symp hrt rate test,Medicare Fee Schedule 005-609,Per Unit,$151.50 ,OP,151.5,151.5,,,,,,
Humana,ExceptCPT,95954,Eeg monitoring/giving drugs,Medicare Fee Schedule 005-609,Per Unit,$732.02 ,OP,732.02,732.02,,,,,,
Humana,ExceptCPT,95955,Eeg during surgery,Medicare Fee Schedule 005-609,Per Unit,$420.31 ,OP,420.31,420.31,,,,,,
Humana,ExceptCPT,95957,Eeg digital analysis,Medicare Fee Schedule 005-609,Per Unit,$389.59 ,OP,389.59,389.59,,,,,,
Humana,ExceptCPT,95958,Eeg monitoring/function test,Medicare Fee Schedule 005-609,Per Unit,$965.91 ,OP,965.91,965.91,,,,,,
Humana,ExceptCPT,95961,Electrode stimulation brain,Medicare Fee Schedule 005-609,Per Unit,$399.58 ,OP,399.58,399.58,,,,,,
Humana,ExceptCPT,95962,Electrode stim brain add-on,Medicare Fee Schedule 005-609,Per Unit,$236.80 ,OP,236.8,236.8,,,,,,
Humana,ExceptCPT,95965,Meg spontaneous,Medicare Fee Schedule 005-609,Per Unit,"$4,741.63 ",OP,"4,741.63","4,741.63",,,,,,
Humana,ExceptCPT,95966,Meg evoked single,Medicare Fee Schedule 005-609,Per Unit,"$2,375.20 ",OP,"2,375.20","2,375.20",,,,,,
Humana,ExceptCPT,95967,Meg evoked each addl,Medicare Fee Schedule 005-609,Per Unit,"$1,187.64 ",OP,"1,187.64","1,187.64",,,,,,
Humana,ExceptCPT,96020,Functional brain mapping,Medicare Fee Schedule 005-609,Per Unit,$248.13 ,OP,248.13,248.13,,,,,,
Humana,ExceptCPT,96110,Developmental screen w/score,Medicare Fee Schedule 005-609,Per Unit,$25.63 ,OP,25.63,25.63,,,,,,
Humana,ExceptCPT,96127,Brief emotional/behav assmt,Medicare Fee Schedule 005-609,Per Unit,$12.51 ,OP,12.51,12.51,,,,,,
Humana,ExceptCPT,96932,Rcm celulr subcelulr img skn,Medicare Fee Schedule 005-609,Per Unit,$336.30 ,OP,336.3,336.3,,,,,,
Humana,ExceptCPT,96935,Rcm celulr subcelulr img skn,Medicare Fee Schedule 005-609,Per Unit,$183.78 ,OP,183.78,183.78,,,,,,
Humana,ExceptCPT,99000,Specimen handling office-lab,Medicare Fee Schedule 005-609,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Humana,ExceptCPT,99001,Specimen handling pt-lab,Medicare Fee Schedule 005-609,Per Unit,$17.38 ,OP,17.38,17.38,,,,,,
Humana,ExceptCPT,99002,Device handling phys/qhp,Medicare Fee Schedule 005-609,Per Unit,$20.10 ,OP,20.1,20.1,,,,,,
Humana,ExceptCPT,99153,Mod sed same phys/qhp ea,Medicare Fee Schedule 005-609,Per Unit,$27.39 ,OP,27.39,27.39,,,,,,
Humana,ExceptCPT,99172,Ocular function screen,Medicare Fee Schedule 005-609,Per Unit,$37.51 ,OP,37.51,37.51,,,,,,
Humana,ExceptCPT,99415,Prolng clin staff svc 1st hr,Medicare Fee Schedule 005-609,Per Unit,$25.63 ,OP,25.63,25.63,,,,,,
Humana,ExceptCPT,99416,Prolng clin staff svc ea add,Medicare Fee Schedule 005-609,Per Unit,$13.12 ,OP,13.12,13.12,,,,,,
Humana,ExceptCPT,A9515,Choline c-11,Medicare Fee Schedule 005-609,Per Unit,"$16,500.00 ",OP,"16,500.00","16,500.00",,,,,,
Humana,ExceptCPT,A9520,Tc99 tilmanocept diag 0.5mci,Medicare Fee Schedule 005-609,Per Unit,"$1,550.34 ",OP,"1,550.34","1,550.34",,,,,,
Humana,ExceptCPT,A9575,Inj gadoterate meglumi 0.1ml,Medicare Fee Schedule 005-609,Per Unit,$0.44 ,OP,0.44,0.44,,,,,,
Humana,ExceptCPT,A9576,Inj prohance multipack,Medicare Fee Schedule 005-609,Per Unit,$3.91 ,OP,3.91,3.91,,,,,,
Humana,ExceptCPT,A9577,Inj multihance,Medicare Fee Schedule 005-609,Per Unit,$4.98 ,OP,4.98,4.98,,,,,,
Humana,ExceptCPT,A9578,Inj multihance multipack,Medicare Fee Schedule 005-609,Per Unit,$4.84 ,OP,4.84,4.84,,,,,,
Humana,ExceptCPT,A9579,Gad-base mr contrast nos-1ml,Medicare Fee Schedule 005-609,Per Unit,$4.21 ,OP,4.21,4.21,,,,,,
Humana,ExceptCPT,A9581,Gadoxetate disodium inj,Medicare Fee Schedule 005-609,Per Unit,$40.54 ,OP,40.54,40.54,,,,,,
Humana,ExceptCPT,A9582,Iodine i-123 iobenguane,Medicare Fee Schedule 005-609,Per Unit,"$19,483.78 ",OP,"19,483.78","19,483.78",,,,,,
Humana,ExceptCPT,A9583,Gadofosveset trisodium inj,Medicare Fee Schedule 005-609,Per Unit,$57.78 ,OP,57.78,57.78,,,,,,
Humana,ExceptCPT,A9584,Iodine i-123 ioflupane,Medicare Fee Schedule 005-609,Per Unit,"$8,144.40 ",OP,"8,144.40","8,144.40",,,,,,
Humana,ExceptCPT,A9585,Gadobutrol injection,Medicare Fee Schedule 005-609,Per Unit,$0.96 ,OP,0.96,0.96,,,,,,
Humana,ExceptCPT,A9586,Florbetapir f18,Medicare Fee Schedule 005-609,Per Unit,"$9,429.42 ",OP,"9,429.42","9,429.42",,,,,,
Humana,ExceptCPT,A9604,Sm 153 lexidronam,Medicare Fee Schedule 005-609,Per Unit,"$53,733.52 ",OP,"53,733.52","53,733.52",,,,,,
Humana,ExceptCPT,A9606,Radium ra223 dichloride ther,Medicare Fee Schedule 005-609,Per Unit,$465.00 ,OP,465,465,,,,,,
Humana,ExceptCPT,A9700,Echocardiography contrast,Medicare Fee Schedule 005-609,Per Unit,$326.56 ,OP,326.56,326.56,,,,,,
Humana,ExceptCPT,G0027,Semen analysis,Medicare Fee Schedule 005-609,Per Unit,$17.88 ,OP,17.88,17.88,,,,,,
Humana,ExceptCPT,G0103,Psa screening,Medicare Fee Schedule 005-609,Per Unit,$53.10 ,OP,53.1,53.1,,,,,,
Humana,ExceptCPT,G0106,Colon ca screen-barium enema,Medicare Fee Schedule 005-609,Per Unit,$435.19 ,OP,435.19,435.19,,,,,,
Humana,ExceptCPT,G0120,Colon ca scrn- barium enema,Medicare Fee Schedule 005-609,Per Unit,$435.19 ,OP,435.19,435.19,,,,,,
Humana,ExceptCPT,G0122,Colon ca scrn- barium enema,Medicare Fee Schedule 005-609,Per Unit,$735.63 ,OP,735.63,735.63,,,,,,
Humana,ExceptCPT,G0123,Screen cerv/vag thin layer,Medicare Fee Schedule 005-609,Per Unit,$55.72 ,OP,55.72,55.72,,,,,,
Humana,ExceptCPT,G0128,Corf skilled nursing service,Medicare Fee Schedule 005-609,Per Unit,$19.53 ,OP,19.53,19.53,,,,,,
Humana,ExceptCPT,G0130,Single energy x-ray study,Medicare Fee Schedule 005-609,Per Unit,$64.16 ,OP,64.16,64.16,,,,,,
Humana,ExceptCPT,G0143,Scr c/v cyto-thinlayer-rescr,Medicare Fee Schedule 005-609,Per Unit,$74.39 ,OP,74.39,74.39,,,,,,
Humana,ExceptCPT,G0144,Scr c/v cyto-thinlayer-rescr,Medicare Fee Schedule 005-609,Per Unit,$120.92 ,OP,120.92,120.92,,,,,,
Humana,ExceptCPT,G0145,Scr c/v cyto-thinlayer-rescr,Medicare Fee Schedule 005-609,Per Unit,$72.85 ,OP,72.85,72.85,,,,,,
Humana,ExceptCPT,G0147,Scr c/v cyto- automated sys,Medicare Fee Schedule 005-609,Per Unit,$41.66 ,OP,41.66,41.66,,,,,,
Humana,ExceptCPT,G0148,Scr c/v cyto- autosys- rescr,Medicare Fee Schedule 005-609,Per Unit,$87.84 ,OP,87.84,87.84,,,,,,
Humana,ExceptCPT,G0219,Pet img wholbod melano nonco,Medicare Fee Schedule 005-609,Per Unit,"$5,250.52 ",OP,"5,250.52","5,250.52",,,,,,
Humana,ExceptCPT,G0248,Demonstrate use home inr mon,Medicare Fee Schedule 005-609,Per Unit,$168.19 ,OP,168.19,168.19,,,,,,
Humana,ExceptCPT,G0249,Provide inr test mater/equip,Medicare Fee Schedule 005-609,Per Unit,$149.02 ,OP,149.02,149.02,,,,,,
Humana,ExceptCPT,G0252,Pet imaging initial dx,Medicare Fee Schedule 005-609,Per Unit,"$5,983.42 ",OP,"5,983.42","5,983.42",,,,,,
Humana,ExceptCPT,G0277,Hbot- full body chamber- 30m,Medicare Fee Schedule 005-609,Per Unit,$417.95 ,OP,417.95,417.95,,,,,,
Humana,ExceptCPT,G0279,Tomosynthesis- mammo,Medicare Fee Schedule 005-609,Per Unit,$63.88 ,OP,63.88,63.88,,,,,,
Humana,ExceptCPT,G0288,Recon- cta for surg plan,Medicare Fee Schedule 005-609,Per Unit,$92.73 ,OP,92.73,92.73,,,,,,
Humana,ExceptCPT,G0297,Ldct for lung ca screen,Medicare Fee Schedule 005-609,Per Unit,$477.57 ,OP,477.57,600,,,,,,
Humana,ExceptCPT,G0306,Cbc/diffwbc w/o platelet,Medicare Fee Schedule 005-609,Per Unit,$21.37 ,OP,21.37,21.37,,,,,,
Humana,ExceptCPT,G0307,Cbc without platelet,Medicare Fee Schedule 005-609,Per Unit,$17.79 ,OP,17.79,17.79,,,,,,
Humana,ExceptCPT,G0328,Fecal blood scrn immunoassay,Medicare Fee Schedule 005-609,Per Unit,$49.64 ,OP,49.64,49.64,,,,,,
Humana,ExceptCPT,G0398,Home sleep test/type 2 porta,Medicare Fee Schedule 005-609,Per Unit,$334.98 ,OP,334.98,334.98,,,,,,
Humana,ExceptCPT,G0399,Home sleep test/type 3 porta,Medicare Fee Schedule 005-609,Per Unit,$334.98 ,OP,334.98,334.98,,,,,,
Humana,ExceptCPT,G0400,Home sleep test/type 4 porta,Medicare Fee Schedule 005-609,Per Unit,$334.98 ,OP,334.98,334.98,,,,,,
Humana,ExceptCPT,G0404,Ekg tracing for initial prev,Medicare Fee Schedule 005-609,Per Unit,$16.89 ,OP,16.89,16.89,,,,,,
Humana,ExceptCPT,G0416,Prostate biopsy- any mthd,Medicare Fee Schedule 005-609,Per Unit,$441.21 ,OP,441.21,441.21,,,,,,
Humana,ExceptCPT,G0432,Eia hiv-1/hiv-2 screen,Medicare Fee Schedule 005-609,Per Unit,$53.82 ,OP,53.82,53.82,,,,,,
Humana,ExceptCPT,G0433,Elisa hiv-1/hiv-2 screen,Medicare Fee Schedule 005-609,Per Unit,$50.30 ,OP,50.3,50.3,,,,,,
Humana,ExceptCPT,G0435,Oral hiv-1/hiv-2 screen,Medicare Fee Schedule 005-609,Per Unit,$32.95 ,OP,32.95,32.95,,,,,,
Humana,ExceptCPT,G0452,Molecular pathology interpr,Medicare Fee Schedule 005-609,Per Unit,$133.40 ,OP,133.4,133.4,,,,,,
Humana,ExceptCPT,G0471,Ven blood coll snf/hha,Medicare Fee Schedule 005-609,Per Unit,$13.75 ,OP,13.75,13.75,,,,,,
Humana,ExceptCPT,G0472,Hep c screen high risk/other,Medicare Fee Schedule 005-609,Per Unit,$127.46 ,OP,127.46,127.46,,,,,,
Humana,ExceptCPT,G0475,Hiv combination assay,Medicare Fee Schedule 005-609,Per Unit,$66.22 ,OP,66.22,66.22,,,,,,
Humana,ExceptCPT,G0476,Hpv combo assay ca screen,Medicare Fee Schedule 005-609,Per Unit,$96.50 ,OP,96.5,96.5,,,,,,
Humana,ExceptCPT,G0480,Drug test def 1-7 classes,Medicare Fee Schedule 005-609,Per Unit,$314.68 ,OP,314.68,314.68,,,,,,
Humana,ExceptCPT,G0481,Drug test def 8-14 classes,Medicare Fee Schedule 005-609,Per Unit,$430.62 ,OP,430.62,430.62,,,,,,
Humana,ExceptCPT,G0482,Drug test def 15-21 classes,Medicare Fee Schedule 005-609,Per Unit,$546.54 ,OP,546.54,546.54,,,,,,
Humana,ExceptCPT,G0483,Drug test def 22+ classes,Medicare Fee Schedule 005-609,Per Unit,$679.03 ,OP,679.03,679.03,,,,,,
Humana,ExceptCPT,G0499,Hepb screen high risk indiv,Medicare Fee Schedule 005-609,Per Unit,$77.74 ,OP,77.74,77.74,,,,,,
Humana,ExceptCPT,G0659,Drug test def simple all cl,Lab Services,Per Unit,$124.28 ,OP,124.28,124.28,,,,,,
Humana,ExceptCPT,G6001,Echo guidance radiotherapy,Medicare Fee Schedule 005-609,Per Unit,$312.68 ,OP,312.68,312.68,,,,,,
Humana,ExceptCPT,G6002,Stereoscopic x-ray guidance,Medicare Fee Schedule 005-609,Per Unit,$142.01 ,OP,142.01,142.01,,,,,,
Humana,ExceptCPT,G6003,Radiation treatment delivery,Medicare Fee Schedule 005-609,Per Unit,$393.20 ,OP,393.2,393.2,,,,,,
Humana,ExceptCPT,G6004,Radiation treatment delivery,Medicare Fee Schedule 005-609,Per Unit,$363.44 ,OP,363.44,363.44,,,,,,
Humana,ExceptCPT,G6005,Radiation treatment delivery,Medicare Fee Schedule 005-609,Per Unit,$364.32 ,OP,364.32,364.32,,,,,,
Humana,ExceptCPT,G6006,Radiation treatment delivery,Medicare Fee Schedule 005-609,Per Unit,$362.56 ,OP,362.56,362.56,,,,,,
Humana,ExceptCPT,G6007,Radiation treatment delivery,Medicare Fee Schedule 005-609,Per Unit,$690.72 ,OP,690.72,690.72,,,,,,
Humana,ExceptCPT,G6008,Radiation treatment delivery,Medicare Fee Schedule 005-609,Per Unit,$502.59 ,OP,502.59,502.59,,,,,,
Humana,ExceptCPT,G6009,Radiation treatment delivery,Medicare Fee Schedule 005-609,Per Unit,$499.07 ,OP,499.07,499.07,,,,,,
Humana,ExceptCPT,G6010,Radiation treatment delivery,Medicare Fee Schedule 005-609,Per Unit,$498.19 ,OP,498.19,498.19,,,,,,
Humana,ExceptCPT,G6011,Radiation treatment delivery,Medicare Fee Schedule 005-609,Per Unit,$667.98 ,OP,667.98,667.98,,,,,,
Humana,ExceptCPT,G6012,Radiation treatment delivery,Medicare Fee Schedule 005-609,Per Unit,$664.73 ,OP,664.73,664.73,,,,,,
Humana,ExceptCPT,G6013,Radiation treatment delivery,Medicare Fee Schedule 005-609,Per Unit,$666.49 ,OP,666.49,666.49,,,,,,
Humana,ExceptCPT,G6014,Radiation treatment delivery,Medicare Fee Schedule 005-609,Per Unit,$664.73 ,OP,664.73,664.73,,,,,,
Humana,ExceptCPT,G6015,Radiation tx delivery imrt,Medicare Fee Schedule 005-609,Per Unit,$968.06 ,OP,968.06,968.06,,,,,,
Humana,ExceptCPT,G6016,Delivery comp imrt,Medicare Fee Schedule 005-609,Per Unit,$964.65 ,OP,964.65,964.65,,,,,,
Humana,ExceptCPT,G9143,Warfarin respon genetic test,Medicare Fee Schedule 005-609,Per Unit,$331.98 ,OP,331.98,331.98,,,,,,
Humana,ExceptCPT,P2028,Cephalin floculation test,Medicare Fee Schedule 005-609,Per Unit,$13.61 ,OP,13.61,13.61,,,,,,
Humana,ExceptCPT,P2029,Congo red blood test,Medicare Fee Schedule 005-609,Per Unit,$13.61 ,OP,13.61,13.61,,,,,,
Humana,ExceptCPT,P2031,Hair analysis,Medicare Fee Schedule 005-609,Per Unit,$13.61 ,OP,13.61,13.61,,,,,,
Humana,ExceptCPT,P2033,Blood thymol turbidity,Medicare Fee Schedule 005-609,Per Unit,$13.61 ,OP,13.61,13.61,,,,,,
Humana,ExceptCPT,P2038,Blood mucoprotein,Medicare Fee Schedule 005-609,Per Unit,$13.61 ,OP,13.61,13.61,,,,,,
Humana,ExceptCPT,P3000,Screen pap by tech w md supv,Medicare Fee Schedule 005-609,Per Unit,$41.66 ,OP,41.66,41.66,,,,,,
Humana,ExceptCPT,P7001,Culture bacterial urine,Medicare Fee Schedule 005-609,Per Unit,$47.25 ,OP,47.25,47.25,,,,,,
Humana,ExceptCPT,P9031,Platelets leukocytes reduced,Medicare Fee Schedule 005-609,Per Unit,$412.28 ,OP,412.28,412.28,,,,,,
Humana,ExceptCPT,P9032,Platelets- irradiated,Medicare Fee Schedule 005-609,Per Unit,$389.65 ,OP,389.65,389.65,,,,,,
Humana,ExceptCPT,P9033,Platelets leukoreduced irrad,Medicare Fee Schedule 005-609,Per Unit,$586.27 ,OP,586.27,586.27,,,,,,
Humana,ExceptCPT,P9034,Platelets- pheresis,Medicare Fee Schedule 005-609,Per Unit,$890.97 ,OP,890.97,890.97,,,,,,
Humana,ExceptCPT,P9035,Platelet pheres leukoreduced,Medicare Fee Schedule 005-609,Per Unit,"$1,338.70 ",OP,"1,338.70","1,338.70",,,,,,
Humana,ExceptCPT,P9036,Platelet pheresis irradiated,Medicare Fee Schedule 005-609,Per Unit,"$1,663.45 ",OP,"1,663.45","1,663.45",,,,,,
Humana,ExceptCPT,P9037,Plate pheres leukoredu irrad,Medicare Fee Schedule 005-609,Per Unit,"$1,697.66 ",OP,"1,697.66","1,697.66",,,,,,
Humana,ExceptCPT,P9038,Rbc irradiated,Medicare Fee Schedule 005-609,Per Unit,$465.60 ,OP,465.6,465.6,,,,,,
Humana,ExceptCPT,P9039,Rbc deglycerolized,Medicare Fee Schedule 005-609,Per Unit,"$1,200.79 ",OP,"1,200.79","1,200.79",,,,,,
Humana,ExceptCPT,P9040,Rbc leukoreduced irradiated,Medicare Fee Schedule 005-609,Per Unit,$716.51 ,OP,716.51,716.51,,,,,,
Humana,ExceptCPT,P9044,Cryoprecipitatereducedplasma,Medicare Fee Schedule 005-609,Per Unit,$180.68 ,OP,180.68,180.68,,,,,,
Humana,ExceptCPT,P9050,Granulocytes- pheresis unit,Medicare Fee Schedule 005-609,Per Unit,"$4,175.82 ",OP,"4,175.82","4,175.82",,,,,,
Humana,ExceptCPT,P9603,One-way allow prorated miles,Medicare Fee Schedule 005-609,Per Unit,$2.78 ,OP,2.78,2.78,,,,,,
Humana,ExceptCPT,P9604,One-way allow prorated trip,Medicare Fee Schedule 005-609,Per Unit,$27.78 ,OP,27.78,27.78,,,,,,
Humana,ExceptCPT,P9612,Catheterize for urine spec,Medicare Fee Schedule 005-609,Per Unit,$8.25 ,OP,8.25,8.25,,,,,,
Humana,ExceptCPT,P9615,Urine specimen collect mult,Medicare Fee Schedule 005-609,Per Unit,$8.25 ,OP,8.25,8.25,,,,,,
Humana,ExceptCPT,Q0035,Cardiokymography,Medicare Fee Schedule 005-609,Per Unit,$27.39 ,OP,27.39,27.39,,,,,,
Humana,ExceptCPT,Q0083,Chemo by other than infusion,Medicare Fee Schedule 005-609,Per Unit,$116.13 ,OP,116.13,116.13,,,,,,
Humana,ExceptCPT,Q0084,Chemotherapy by infusion,Medicare Fee Schedule 005-609,Per Unit,$248.55 ,OP,248.55,248.55,,,,,,
Humana,ExceptCPT,Q0092,Set up port xray equipment,Medicare Fee Schedule 005-609,Per Unit,$58.91 ,OP,58.91,58.91,,,,,,
Humana,ExceptCPT,Q0111,Wet mounts/ w preparations,Medicare Fee Schedule 005-609,Per Unit,$41.66 ,OP,41.66,41.66,,,,,,
Humana,ExceptCPT,Q0112,Potassium hydroxide preps,Medicare Fee Schedule 005-609,Per Unit,$16.03 ,OP,16.03,16.03,,,,,,
Humana,ExceptCPT,Q0113,Pinworm examinations,Medicare Fee Schedule 005-609,Per Unit,$11.74 ,OP,11.74,11.74,,,,,,
Humana,ExceptCPT,Q0114,Fern test,Medicare Fee Schedule 005-609,Per Unit,$26.79 ,OP,26.79,26.79,,,,,,
Humana,ExceptCPT,Q0115,Post-coital mucous exam,Medicare Fee Schedule 005-609,Per Unit,$68.75 ,OP,68.75,68.75,,,,,,
Humana,ExceptCPT,Q9953,Inj fe-based mr contrast-1ml,Medicare Fee Schedule 005-609,Per Unit,$170.64 ,OP,170.64,170.64,,,,,,
Humana,ExceptCPT,Q9954,Oral mr contrast- 100 ml,Medicare Fee Schedule 005-609,Per Unit,$32.07 ,OP,32.07,32.07,,,,,,
Humana,ExceptCPT,Q9955,Inj perflexane lip micros-ml,Medicare Fee Schedule 005-609,Per Unit,$36.44 ,OP,36.44,36.44,,,,,,
Humana,ExceptCPT,Q9956,Inj octafluoropropane mic-ml,Medicare Fee Schedule 005-609,Per Unit,$86.71 ,OP,86.71,86.71,,,,,,
Humana,ExceptCPT,Q9957,Inj perflutren lip micros-ml,Medicare Fee Schedule 005-609,Per Unit,$130.05 ,OP,130.05,130.05,,,,,,
Humana,ExceptCPT,Q9958,Hocm <149 mg/ml iodine- 1ml,Medicare Fee Schedule 005-609,Per Unit,$0.22 ,OP,0.22,0.22,,,,,,
Humana,ExceptCPT,Q9960,Hocm 200-249mg/ml iodine-1ml,Medicare Fee Schedule 005-609,Per Unit,$0.74 ,OP,0.74,0.74,,,,,,
Humana,ExceptCPT,Q9961,Hocm 250-299mg/ml iodine-1ml,Medicare Fee Schedule 005-609,Per Unit,$0.88 ,OP,0.88,0.88,,,,,,
Humana,ExceptCPT,Q9962,Hocm 300-349mg/ml iodine-1ml,Medicare Fee Schedule 005-609,Per Unit,$0.50 ,OP,0.5,0.5,,,,,,
Humana,ExceptCPT,Q9963,Hocm 350-399mg/ml iodine-1ml,Medicare Fee Schedule 005-609,Per Unit,$0.52 ,OP,0.52,0.52,,,,,,
Humana,ExceptCPT,Q9964,Hocm> 400mg/ml iodine- 1ml,Medicare Fee Schedule 005-609,Per Unit,$0.80 ,OP,0.8,0.8,,,,,,
Humana,ExceptCPT,Q9965,Locm 100-199mg/ml iodine-1ml,Medicare Fee Schedule 005-609,Per Unit,$2.17 ,OP,2.17,2.17,,,,,,
Humana,ExceptCPT,Q9966,Locm 200-299mg/ml iodine-1ml,Medicare Fee Schedule 005-609,Per Unit,$0.88 ,OP,0.88,0.88,,,,,,
Humana,ExceptCPT,Q9967,Locm 300-399mg/ml iodine-1ml,Medicare Fee Schedule 005-609,Per Unit,$0.30 ,OP,0.3,0.3,,,,,,
Humana,ExceptCPT,R0070,Transport portable x-ray,Medicare Fee Schedule 005-609,Per Unit,$352.17 ,OP,352.17,352.17,,,,,,
Humana,ExceptCPT,R0075,Transport port x-ray multipl,Medicare Fee Schedule 005-609,Per Unit,$352.17 ,OP,352.17,352.17,,,,,,
Humana,ExceptCPT,R0076,Transport portable ekg,Medicare Fee Schedule 005-609,Per Unit,$80.52 ,OP,80.52,80.52,,,,,,
Humana,ExceptCPT,U0001,2019-ncov diagnostic p,Lab Services,Per Unit,$71.82 ,OP,71.82,71.82,,,,,,
Humana,ExceptCPT,U0002,Covid-19 lab test non-cdc,Lab Services,Per Unit,$102.62 ,OP,102.62,102.62,,,,,,
Humana,ExceptCPT,U0003,Cov-19 amp prb hgh thruput,Lab Services,Per Unit,$200.00 ,OP,200,200,,,,,,
Humana,ExceptCPT,U0004,Cov-19 test non-cdc hgh thru,Lab Services,Per Unit,$200.00 ,OP,200,200,,,,,,
Humana,,,,All Other,Straight Discount,63.80%,OP,,,,,,,,
Humana MCR ADV,DRG,MS-001,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W MCC,Surgical,Relative Weights,"$168,855.33 ",IP,"17,718.00","557,099.42",,,,,,
Humana MCR ADV,DRG,MS-002,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W/O MCC,Surgical,Relative Weights,"$87,426.55 ",IP,"17,718.00","282,516.19",,,,,,
Humana MCR ADV,DRG,MS-003,ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITH MAJOR O.R. PROCEDURES,Surgical,Relative Weights,"$111,577.60 ",IP,"111,577.60","382,110.62",,,,,,
Humana MCR ADV,DRG,MS-004,TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES,Surgical,Relative Weights,"$69,628.33 ",IP,"69,628.33","232,723.01",,,,,,
Humana MCR ADV,DRG,MS-005,LIVER TRANSPLANT W MCC OR INTESTINAL TRANSPLANT,Surgical,Relative Weights,"$59,773.19 ",IP,"59,773.19","207,904.03",,,,,,
Humana MCR ADV,DRG,MS-006,LIVER TRANSPLANT W/O MCC,Surgical,Relative Weights,"$27,427.34 ",IP,"27,427.34","98,217.50",,,,,,
Humana MCR ADV,DRG,MS-007,LUNG TRANSPLANT,Surgical,Relative Weights,"$67,628.10 ",IP,"67,628.10","217,451.81",,,,,,
Humana MCR ADV,DRG,MS-008,SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,Surgical,Relative Weights,"$31,730.89 ",IP,"31,730.89","113,220.58",,,,,,
Humana MCR ADV,DRG,MS-010,PANCREAS TRANSPLANT,Surgical,Relative Weights,"$21,141.08 ",IP,"2,420.00","80,158.18",,,,,,
Humana MCR ADV,DRG,MS-011,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC,Surgical,Relative Weights,"$29,325.37 ",IP,"2,420.00","99,667.01",,,,,,
Humana MCR ADV,DRG,MS-012,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC,Surgical,Relative Weights,"$22,383.85 ",IP,"2,420.00","76,083.84",,,,,,
Humana MCR ADV,DRG,MS-013,TRACHEOSTOMY FOR FACE -  MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC,Surgical,Relative Weights,"$15,907.20 ",IP,"2,420.00","48,894.05",,,,,,
Humana MCR ADV,DRG,MS-014,ALLOGENEIC BONE MARROW TRANSPLANT,Surgical,Relative Weights,"$62,354.51 ",IP,"2,420.00","257,136.77",,,,,,
Humana MCR ADV,DRG,MS-016,AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,Surgical,Relative Weights,"$39,340.51 ",IP,"2,420.00","138,805.63",,,,,,
Humana MCR ADV,DRG,MS-017,AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,Surgical,Relative Weights,"$28,357.66 ",IP,"2,420.00","89,659.58",,,,,,
Humana MCR ADV,DRG,MS-018,CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,Medical,Relative Weights,"$218,711.49 ",IP,"2,420.00","218,711.49",,,,,,
Humana MCR ADV,DRG,MS-019,SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,Surgical,Relative Weights,"$39,009.97 ",IP,"2,420.00","39,009.97",,,,,,
Humana MCR ADV,DRG,MS-020,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,Surgical,Relative Weights,"$60,368.88 ",IP,"2,420.00","218,151.36",,,,,,
Humana MCR ADV,DRG,MS-021,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,Surgical,Relative Weights,"$44,054.63 ",IP,"2,420.00","166,797.79",,,,,,
Humana MCR ADV,DRG,MS-022,INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W/O CC/MCC,Surgical,Relative Weights,"$28,282.33 ",IP,"2,420.00","99,425.09",,,,,,
Humana MCR ADV,DRG,MS-023,CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX CNS PDX W MCC OR CHEMO IMPLANT,Surgical,Relative Weights,"$33,124.34 ",IP,"2,420.00","113,240.74",,,,,,
Humana MCR ADV,DRG,MS-024,CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,Surgical,Relative Weights,"$23,004.07 ",IP,"2,420.00","80,972.64",,,,,,
Humana MCR ADV,DRG,MS-025,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$26,265.17 ",IP,"2,420.00","88,593.12",,,,,,
Humana MCR ADV,DRG,MS-026,CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC,Surgical,Relative Weights,"$17,882.32 ",IP,"2,420.00","61,403.33",,,,,,
Humana MCR ADV,DRG,MS-027,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$14,683.71 ",IP,"2,420.00","48,317.47",,,,,,
Humana MCR ADV,DRG,MS-028,SPINAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$34,007.36 ",IP,"2,420.00","112,702.46",,,,,,
Humana MCR ADV,DRG,MS-029,SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,Surgical,Relative Weights,"$19,253.57 ",IP,"2,420.00","64,653.12",,,,,,
Humana MCR ADV,DRG,MS-030,SPINAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$13,763.89 ",IP,"2,420.00","45,805.54",,,,,,
Humana MCR ADV,DRG,MS-031,VENTRICULAR SHUNT PROCEDURES WITH MCC,Surgical,Relative Weights,"$25,531.07 ",IP,"2,420.00","88,189.92",,,,,,
Humana MCR ADV,DRG,MS-032,VENTRICULAR SHUNT PROCEDURES WITH CC,Surgical,Relative Weights,"$12,944.53 ",IP,"2,420.00","44,192.74",,,,,,
Humana MCR ADV,DRG,MS-033,VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,057.78 ",IP,"2,420.00","34,290.14",,,,,,
Humana MCR ADV,DRG,MS-034,CAROTID ARTERY STENT PROCEDURE W MCC,Surgical,Relative Weights,"$23,232.41 ",IP,"2,420.00","75,674.59",,,,,,
Humana MCR ADV,DRG,MS-035,CAROTID ARTERY STENT PROCEDURES WITH CC,Surgical,Relative Weights,"$13,664.03 ",IP,"2,420.00","46,412.35",,,,,,
Humana MCR ADV,DRG,MS-036,CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,817.58 ",IP,"2,420.00","35,300.16",,,,,,
Humana MCR ADV,DRG,MS-037,EXTRACRANIAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$19,141.44 ",IP,"2,420.00","65,384.93",,,,,,
Humana MCR ADV,DRG,MS-038,EXTRACRANIAL PROCEDURES WITH CC,Surgical,Relative Weights,"$9,687.52 ",IP,"2,420.00","33,772.03",,,,,,
Humana MCR ADV,DRG,MS-039,EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,652.43 ",IP,"2,420.00","22,807.01",,,,,,
Humana MCR ADV,DRG,MS-040,PERIPHERAL- CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC,Surgical,Relative Weights,"$22,570.73 ",IP,"2,420.00","79,438.46",,,,,,
Humana MCR ADV,DRG,MS-041,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W CC OR PERIPH NEUROSTIM,Surgical,Relative Weights,"$13,722.43 ",IP,"2,420.00","47,809.44",,,,,,
Humana MCR ADV,DRG,MS-042,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W/O CC/MCC,Surgical,Relative Weights,"$11,103.16 ",IP,"2,420.00","37,261.73",,,,,,
Humana MCR ADV,DRG,MS-052,SPINAL DISORDERS AND INJURIES WITH CC/MCC,Medical,Relative Weights,"$10,824.58 ",IP,"2,420.00","32,838.62",,,,,,
Humana MCR ADV,DRG,MS-053,SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,Medical,Relative Weights,"$6,636.66 ",IP,"2,420.00","19,476.58",,,,,,
Humana MCR ADV,DRG,MS-054,NERVOUS SYSTEM NEOPLASMS WITH MCC,Medical,Relative Weights,"$7,990.98 ",IP,"2,420.00","27,016.42",,,,,,
Humana MCR ADV,DRG,MS-055,NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,Medical,Relative Weights,"$6,100.55 ",IP,"2,420.00","19,877.76",,,,,,
Humana MCR ADV,DRG,MS-056,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,Medical,Relative Weights,"$12,820.72 ",IP,"2,420.00","44,198.78",,,,,,
Humana MCR ADV,DRG,MS-057,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,Medical,Relative Weights,"$7,402.30 ",IP,"2,420.00","24,409.73",,,,,,
Humana MCR ADV,DRG,MS-058,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,Medical,Relative Weights,"$10,148.89 ",IP,"2,420.00","39,406.75",,,,,,
Humana MCR ADV,DRG,MS-059,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,Medical,Relative Weights,"$6,583.52 ",IP,"2,420.00","21,984.48",,,,,,
Humana MCR ADV,DRG,MS-060,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,Medical,Relative Weights,"$5,359.44 ",IP,"2,420.00","17,775.07",,,,,,
Humana MCR ADV,DRG,MS-061,ISCHEMIC STROKE -  PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC,Medical,Relative Weights,"$16,884.83 ",IP,"2,420.00","56,316.96",,,,,,
Humana MCR ADV,DRG,MS-062,ISCHEMIC STROKE -  PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC,Medical,Relative Weights,"$11,611.83 ",IP,"2,420.00","40,545.79",,,,,,
Humana MCR ADV,DRG,MS-063,ISCHEMIC STROKE- PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC,Medical,Relative Weights,"$9,984.78 ",IP,"2,420.00","33,884.93",,,,,,
Humana MCR ADV,DRG,MS-064,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,Medical,Relative Weights,"$11,206.52 ",IP,"2,420.00","37,795.97",,,,,,
Humana MCR ADV,DRG,MS-065,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC,Medical,Relative Weights,"$5,956.88 ",IP,"2,420.00","20,718.43",,,,,,
Humana MCR ADV,DRG,MS-066,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,Medical,Relative Weights,"$4,155.80 ",IP,"2,420.00","14,454.72",,,,,,
Humana MCR ADV,DRG,MS-067,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,Medical,Relative Weights,"$8,326.78 ",IP,"2,420.00","29,524.32",,,,,,
Humana MCR ADV,DRG,MS-068,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,Medical,Relative Weights,"$5,191.24 ",IP,"2,420.00","18,212.54",,,,,,
Humana MCR ADV,DRG,MS-069,TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,Medical,Relative Weights,"$4,596.73 ",IP,"2,420.00","15,730.85",,,,,,
Humana MCR ADV,DRG,MS-070,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC,Medical,Relative Weights,"$9,808.99 ",IP,"2,420.00","33,725.66",,,,,,
Humana MCR ADV,DRG,MS-071,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC,Medical,Relative Weights,"$5,908.99 ",IP,"2,420.00","20,053.15",,,,,,
Humana MCR ADV,DRG,MS-072,NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$4,506.79 ",IP,"2,420.00","14,888.16",,,,,,
Humana MCR ADV,DRG,MS-073,CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,Medical,Relative Weights,"$8,485.05 ",IP,"2,420.00","28,538.50",,,,,,
Humana MCR ADV,DRG,MS-074,CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,Medical,Relative Weights,"$5,951.04 ",IP,"2,420.00","19,920.10",,,,,,
Humana MCR ADV,DRG,MS-075,VIRAL MENINGITIS WITH CC/MCC,Medical,Relative Weights,"$9,501.81 ",IP,"2,420.00","32,421.31",,,,,,
Humana MCR ADV,DRG,MS-076,VIRAL MENINGITIS WITHOUT CC/MCC,Medical,Relative Weights,"$5,751.89 ",IP,"2,420.00","18,194.40",,,,,,
Humana MCR ADV,DRG,MS-077,HYPERTENSIVE ENCEPHALOPATHY WITH MCC,Medical,Relative Weights,"$8,952.25 ",IP,"2,420.00","31,096.80",,,,,,
Humana MCR ADV,DRG,MS-078,HYPERTENSIVE ENCEPHALOPATHY WITH CC,Medical,Relative Weights,"$5,547.49 ",IP,"2,420.00","19,393.92",,,,,,
Humana MCR ADV,DRG,MS-079,HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC,Medical,Relative Weights,"$4,256.25 ",IP,"2,420.00","14,940.58",,,,,,
Humana MCR ADV,DRG,MS-080,NONTRAUMATIC STUPOR & COMA W MCC,Medical,Relative Weights,"$12,237.30 ",IP,"2,420.00","38,632.61",,,,,,
Humana MCR ADV,DRG,MS-081,NONTRAUMATIC STUPOR & COMA W/O MCC,Medical,Relative Weights,"$4,515.55 ",IP,"2,420.00","17,722.66",,,,,,
Humana MCR ADV,DRG,MS-082,TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,Medical,Relative Weights,"$13,221.35 ",IP,"2,420.00","45,396.29",,,,,,
Humana MCR ADV,DRG,MS-083,TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,Medical,Relative Weights,"$7,849.06 ",IP,"2,420.00","26,423.71",,,,,,
Humana MCR ADV,DRG,MS-084,TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,Medical,Relative Weights,"$5,288.77 ",IP,"2,420.00","18,089.57",,,,,,
Humana MCR ADV,DRG,MS-085,TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,Medical,Relative Weights,"$13,500.51 ",IP,"2,420.00","45,275.33",,,,,,
Humana MCR ADV,DRG,MS-086,TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,Medical,Relative Weights,"$7,443.18 ",IP,"2,420.00","24,954.05",,,,,,
Humana MCR ADV,DRG,MS-087,TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,Medical,Relative Weights,"$5,043.49 ",IP,"2,420.00","16,918.27",,,,,,
Humana MCR ADV,DRG,MS-088,CONCUSSION WITH MCC,Medical,Relative Weights,"$8,498.48 ",IP,"2,420.00","28,004.26",,,,,,
Humana MCR ADV,DRG,MS-089,CONCUSSION WITH CC,Medical,Relative Weights,"$6,210.92 ",IP,"2,420.00","19,883.81",,,,,,
Humana MCR ADV,DRG,MS-090,CONCUSSION WITHOUT CC/MCC,Medical,Relative Weights,"$4,990.93 ",IP,"2,420.00","17,101.73",,,,,,
Humana MCR ADV,DRG,MS-091,OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,Medical,Relative Weights,"$9,640.80 ",IP,"2,420.00","31,552.42",,,,,,
Humana MCR ADV,DRG,MS-092,OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,Medical,Relative Weights,"$5,775.25 ",IP,"2,420.00","19,476.58",,,,,,
Humana MCR ADV,DRG,MS-093,OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,Medical,Relative Weights,"$4,568.11 ",IP,"2,420.00","15,345.79",,,,,,
Humana MCR ADV,DRG,MS-094,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,Medical,Relative Weights,"$21,245.62 ",IP,"2,420.00","72,269.57",,,,,,
Humana MCR ADV,DRG,MS-095,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,Medical,Relative Weights,"$14,642.83 ",IP,"2,420.00","48,527.14",,,,,,
Humana MCR ADV,DRG,MS-096,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,Medical,Relative Weights,"$13,623.15 ",IP,"2,420.00","45,603.94",,,,,,
Humana MCR ADV,DRG,MS-097,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,Medical,Relative Weights,"$21,961.03 ",IP,"2,420.00","72,090.14",,,,,,
Humana MCR ADV,DRG,MS-098,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,Medical,Relative Weights,"$12,337.16 ",IP,"2,420.00","39,412.80",,,,,,
Humana MCR ADV,DRG,MS-099,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,Medical,Relative Weights,"$8,187.20 ",IP,"2,420.00","25,853.18",,,,,,
Humana MCR ADV,DRG,MS-100,SEIZURES WITH MCC,Medical,Relative Weights,"$10,958.32 ",IP,"2,420.00","36,695.23",,,,,,
Humana MCR ADV,DRG,MS-101,SEIZURES WITHOUT MCC,Medical,Relative Weights,"$5,188.32 ",IP,"2,420.00","17,799.26",,,,,,
Humana MCR ADV,DRG,MS-102,HEADACHES WITH MCC,Medical,Relative Weights,"$6,734.19 ",IP,"2,420.00","24,042.82",,,,,,
Humana MCR ADV,DRG,MS-103,HEADACHES W/O MCC,Medical,Relative Weights,"$4,844.34 ",IP,"2,420.00","16,117.92",,,,,,
Humana MCR ADV,DRG,MS-113,ORBITAL PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$12,815.47 ",IP,"2,420.00","42,983.14",,,,,,
Humana MCR ADV,DRG,MS-114,ORBITAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,454.10 ",IP,"2,420.00","24,006.53",,,,,,
Humana MCR ADV,DRG,MS-115,EXTRAOCULAR PROCEDURES EXCEPT ORBIT,Surgical,Relative Weights,"$8,506.66 ",IP,"2,420.00","29,957.76",,,,,,
Humana MCR ADV,DRG,MS-116,INTRAOCULAR PROCEDURES W CC/MCC,Surgical,Relative Weights,"$10,995.11 ",IP,"2,420.00","38,122.56",,,,,,
Humana MCR ADV,DRG,MS-117,INTRAOCULAR PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$6,080.69 ",IP,"2,420.00","22,109.47",,,,,,
Humana MCR ADV,DRG,MS-121,ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,Medical,Relative Weights,"$6,953.20 ",IP,"2,420.00","25,558.85",,,,,,
Humana MCR ADV,DRG,MS-122,ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,Medical,Relative Weights,"$3,769.77 ",IP,"2,420.00","15,575.62",,,,,,
Humana MCR ADV,DRG,MS-123,NEUROLOGICAL EYE DISORDERS,Medical,Relative Weights,"$4,478.17 ",IP,"2,420.00","15,740.93",,,,,,
Humana MCR ADV,DRG,MS-124,OTHER DISORDERS OF THE EYE WITH MCC,Medical,Relative Weights,"$8,187.79 ",IP,"2,420.00","28,010.30",,,,,,
Humana MCR ADV,DRG,MS-125,OTHER DISORDERS OF THE EYE WITHOUT MCC,Medical,Relative Weights,"$4,888.14 ",IP,"2,420.00","15,914.30",,,,,,
Humana MCR ADV,DRG,MS-135,SINUS AND MASTOID PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$12,518.21 ",IP,"2,420.00","46,057.54",,,,,,
Humana MCR ADV,DRG,MS-136,SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,332.22 ",IP,"2,420.00","23,990.40",,,,,,
Humana MCR ADV,DRG,MS-137,MOUTH PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$8,816.77 ",IP,"2,420.00","26,879.33",,,,,,
Humana MCR ADV,DRG,MS-138,MOUTH PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$5,002.03 ",IP,"2,420.00","17,365.82",,,,,,
Humana MCR ADV,DRG,MS-139,SALIVARY GLAND PROCEDURES,Surgical,Relative Weights,"$7,207.24 ",IP,"2,420.00","24,883.49",,,,,,
Humana MCR ADV,DRG,MS-140,MAJOR HEAD AND NECK PROCEDURES WITH MCC,Medical,Relative Weights,"$23,231.24 ",IP,"2,420.00","23,231.24",,,,,,
Humana MCR ADV,DRG,MS-141,MAJOR HEAD AND NECK PROCEDURES WITH CC,Medical,Relative Weights,"$12,883.80 ",IP,"2,420.00","12,883.80",,,,,,
Humana MCR ADV,DRG,MS-142,MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,Medical,Relative Weights,"$9,373.91 ",IP,"2,420.00","9,373.91",,,,,,
Humana MCR ADV,DRG,MS-143,OTHER EAR- NOSE- MOUTH AND THROAT O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$17,402.26 ",IP,"2,420.00","17,402.26",,,,,,
Humana MCR ADV,DRG,MS-144,HERNIA PROCEDURES AGE 0-17,Surgical,Relative Weights,"$10,287.30 ",IP,"2,420.00","10,287.30",,,,,,
Humana MCR ADV,DRG,MS-145,OTHER EAR -  NOSE -  MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC,Medical,Relative Weights,"$7,151.76 ",IP,"2,420.00","7,151.76",,,,,,
Humana MCR ADV,DRG,MS-146,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH MCC,Medical,Relative Weights,"$11,920.18 ",IP,"2,420.00","38,880.58",,,,,,
Humana MCR ADV,DRG,MS-147,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH CC,Medical,Relative Weights,"$7,598.52 ",IP,"2,420.00","25,016.54",,,,,,
Humana MCR ADV,DRG,MS-148,EAR - NOSE - MOUTH & THROAT MALIGNANCY W/O CC/MCC,Medical,Relative Weights,"$4,596.14 ",IP,"2,420.00","15,329.66",,,,,,
Humana MCR ADV,DRG,MS-149,DYSEQUILIBRIUM,Medical,Relative Weights,"$4,304.14 ",IP,"2,420.00","14,726.88",,,,,,
Humana MCR ADV,DRG,MS-150,EPISTAXIS WITH MCC,Medical,Relative Weights,"$7,752.70 ",IP,"2,420.00","26,036.64",,,,,,
Humana MCR ADV,DRG,MS-151,EPISTAXIS WITHOUT MCC,Medical,Relative Weights,"$4,312.31 ",IP,"2,420.00","14,093.86",,,,,,
Humana MCR ADV,DRG,MS-152,OTITIS MEDIA AND URI WITH MCC,Medical,Relative Weights,"$6,310.20 ",IP,"2,420.00","20,946.24",,,,,,
Humana MCR ADV,DRG,MS-153,OTITIS MEDIA AND URI WITHOUT MCC,Medical,Relative Weights,"$4,165.14 ",IP,"2,420.00","14,241.02",,,,,,
Humana MCR ADV,DRG,MS-154,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH MCC,Medical,Relative Weights,"$9,033.43 ",IP,"2,420.00","28,969.92",,,,,,
Humana MCR ADV,DRG,MS-155,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH CC,Medical,Relative Weights,"$5,311.55 ",IP,"2,420.00","18,166.18",,,,,,
Humana MCR ADV,DRG,MS-156,OTHER EAR -  NOSE -  MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$3,845.11 ",IP,"2,420.00","13,194.72",,,,,,
Humana MCR ADV,DRG,MS-157,DENTAL AND ORAL DISEASES WITH MCC,Medical,Relative Weights,"$9,205.13 ",IP,"2,420.00","31,508.06",,,,,,
Humana MCR ADV,DRG,MS-158,DENTAL AND ORAL DISEASES WITH CC,Medical,Relative Weights,"$5,257.24 ",IP,"2,420.00","17,470.66",,,,,,
Humana MCR ADV,DRG,MS-159,DENTAL AND ORAL DISEASES WITHOUT CC/MCC,Medical,Relative Weights,"$3,872.56 ",IP,"2,420.00","13,565.66",,,,,,
Humana MCR ADV,DRG,MS-163,MAJOR CHEST PROCEDURES WITH MCC,Surgical,Relative Weights,"$29,240.10 ",IP,"2,420.00","98,253.79",,,,,,
Humana MCR ADV,DRG,MS-164,MAJOR CHEST PROCEDURES WITH CC,Surgical,Relative Weights,"$15,508.91 ",IP,"2,420.00","51,037.06",,,,,,
Humana MCR ADV,DRG,MS-165,MAJOR CHEST PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$11,193.09 ",IP,"2,420.00","37,279.87",,,,,,
Humana MCR ADV,DRG,MS-166,OTHER RESP SYSTEM O.R. PROCEDURES W MCC,Surgical,Relative Weights,"$21,745.53 ",IP,"2,420.00","75,210.91",,,,,,
Humana MCR ADV,DRG,MS-167,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$10,621.35 ",IP,"2,420.00","38,594.30",,,,,,
Humana MCR ADV,DRG,MS-168,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,909.80 ",IP,"2,420.00","26,746.27",,,,,,
Humana MCR ADV,DRG,MS-175,PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,Medical,Relative Weights,"$9,028.76 ",IP,"2,420.00","29,119.10",,,,,,
Humana MCR ADV,DRG,MS-176,PULMONARY EMBOLISM WITHOUT MCC,Medical,Relative Weights,"$5,184.82 ",IP,"2,420.00","17,103.74",,,,,,
Humana MCR ADV,DRG,MS-177,RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC,Medical,Relative Weights,"$10,798.89 ",IP,"2,420.00","38,126.59",,,,,,
Humana MCR ADV,DRG,MS-178,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,Medical,Relative Weights,"$7,053.65 ",IP,"2,420.00","25,064.93",,,,,,
Humana MCR ADV,DRG,MS-179,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,Medical,Relative Weights,"$5,096.64 ",IP,"2,420.00","17,460.58",,,,,,
Humana MCR ADV,DRG,MS-180,RESPIRATORY NEOPLASMS WITH MCC,Medical,Relative Weights,"$10,161.15 ",IP,"2,420.00","34,773.98",,,,,,
Humana MCR ADV,DRG,MS-181,RESPIRATORY NEOPLASMS WITH CC,Medical,Relative Weights,"$6,541.47 ",IP,"2,420.00","23,224.32",,,,,,
Humana MCR ADV,DRG,MS-182,RESPIRATORY NEOPLASMS WITHOUT CC/MCC,Medical,Relative Weights,"$4,625.34 ",IP,"2,420.00","16,990.85",,,,,,
Humana MCR ADV,DRG,MS-183,MAJOR CHEST TRAUMA WITH MCC,Medical,Relative Weights,"$9,104.10 ",IP,"2,420.00","30,425.47",,,,,,
Humana MCR ADV,DRG,MS-184,MAJOR CHEST TRAUMA WITH CC,Medical,Relative Weights,"$6,078.94 ",IP,"2,420.00","20,526.91",,,,,,
Humana MCR ADV,DRG,MS-185,MAJOR CHEST TRAUMA W/O CC/MCC,Medical,Relative Weights,"$4,525.48 ",IP,"2,420.00","14,797.44",,,,,,
Humana MCR ADV,DRG,MS-186,PLEURAL EFFUSION WITH MCC,Medical,Relative Weights,"$9,015.91 ",IP,"2,420.00","31,104.86",,,,,,
Humana MCR ADV,DRG,MS-187,PLEURAL EFFUSION WITH CC,Medical,Relative Weights,"$6,032.22 ",IP,"2,420.00","20,722.46",,,,,,
Humana MCR ADV,DRG,MS-188,PLEURAL EFFUSION WITHOUT CC/MCC,Medical,Relative Weights,"$4,260.34 ",IP,"2,420.00","14,734.94",,,,,,
Humana MCR ADV,DRG,MS-189,PULMONARY EDEMA AND RESPIRATORY FAILURE,Medical,Relative Weights,"$7,160.52 ",IP,"2,420.00","24,508.51",,,,,,
Humana MCR ADV,DRG,MS-190,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,Medical,Relative Weights,"$6,570.67 ",IP,"2,420.00","23,063.04",,,,,,
Humana MCR ADV,DRG,MS-191,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,Medical,Relative Weights,"$5,164.38 ",IP,"2,420.00","17,998.85",,,,,,
Humana MCR ADV,DRG,MS-192,CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC,Medical,Relative Weights,"$4,062.36 ",IP,"2,420.00","14,297.47",,,,,,
Humana MCR ADV,DRG,MS-193,SIMPLE PNEUMONIA & PLEURISY W MCC,Medical,Relative Weights,"$7,662.18 ",IP,"2,420.00","26,883.36",,,,,,
Humana MCR ADV,DRG,MS-194,SIMPLE PNEUMONIA AND PLEURISY WITH CC,Medical,Relative Weights,"$5,045.24 ",IP,"2,420.00","17,914.18",,,,,,
Humana MCR ADV,DRG,MS-195,SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,Medical,Relative Weights,"$3,888.32 ",IP,"2,420.00","13,751.14",,,,,,
Humana MCR ADV,DRG,MS-196,INTERSTITIAL LUNG DISEASE WITH MCC,Medical,Relative Weights,"$10,153.56 ",IP,"2,420.00","33,776.06",,,,,,
Humana MCR ADV,DRG,MS-197,INTERSTITIAL LUNG DISEASE WITH CC,Medical,Relative Weights,"$5,880.96 ",IP,"2,420.00","20,593.44",,,,,,
Humana MCR ADV,DRG,MS-198,INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,Medical,Relative Weights,"$4,341.51 ",IP,"2,420.00","15,220.80",,,,,,
Humana MCR ADV,DRG,MS-199,PNEUMOTHORAX WITH MCC,Medical,Relative Weights,"$10,453.74 ",IP,"2,420.00","36,169.06",,,,,,
Humana MCR ADV,DRG,MS-200,PNEUMOTHORAX WITH CC,Medical,Relative Weights,"$6,286.84 ",IP,"2,420.00","21,815.14",,,,,,
Humana MCR ADV,DRG,MS-201,PNEUMOTHORAX WITHOUT CC/MCC,Medical,Relative Weights,"$4,144.12 ",IP,"2,420.00","14,474.88",,,,,,
Humana MCR ADV,DRG,MS-202,BRONCHITIS AND ASTHMA WITH CC/MCC,Medical,Relative Weights,"$5,647.36 ",IP,"2,420.00","19,111.68",,,,,,
Humana MCR ADV,DRG,MS-203,BRONCHITIS AND ASTHMA WITHOUT CC/MCC,Medical,Relative Weights,"$4,128.93 ",IP,"2,420.00","13,987.01",,,,,,
Humana MCR ADV,DRG,MS-204,RESPIRATORY SIGNS AND SYMPTOMS,Medical,Relative Weights,"$4,634.69 ",IP,"2,420.00","16,380.00",,,,,,
Humana MCR ADV,DRG,MS-205,OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,Medical,Relative Weights,"$9,839.36 ",IP,"2,420.00","32,945.47",,,,,,
Humana MCR ADV,DRG,MS-206,OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,Medical,Relative Weights,"$5,174.31 ",IP,"2,420.00","17,589.60",,,,,,
Humana MCR ADV,DRG,MS-207,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS,Medical,Relative Weights,"$33,499.27 ",IP,"2,420.00","115,629.70",,,,,,
Humana MCR ADV,DRG,MS-208,RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,Medical,Relative Weights,"$14,861.83 ",IP,"2,420.00","50,079.46",,,,,,
Humana MCR ADV,DRG,MS-215,OTHER HEART ASSIST SYSTEM IMPLANT,Surgical,Relative Weights,"$61,661.88 ",IP,"61,661.88","259,783.78",,,,,,
Humana MCR ADV,DRG,MS-216,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$58,630.29 ",IP,"58,630.29","202,454.78",,,,,,
Humana MCR ADV,DRG,MS-217,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,Surgical,Relative Weights,"$37,864.14 ",IP,"37,864.14","134,096.26",,,,,,
Humana MCR ADV,DRG,MS-218,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,Surgical,Relative Weights,"$35,678.79 ",IP,"35,678.79","108,892.22",,,,,,
Humana MCR ADV,DRG,MS-219,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$47,057.01 ",IP,"47,057.01","158,056.42",,,,,,
Humana MCR ADV,DRG,MS-220,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,Surgical,Relative Weights,"$31,567.37 ",IP,"31,567.37","106,966.94",,,,,,
Humana MCR ADV,DRG,MS-221,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,Surgical,Relative Weights,"$26,746.97 ",IP,"26,746.97","92,659.39",,,,,,
Humana MCR ADV,DRG,MS-222,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITH MCC,Surgical,Relative Weights,"$46,434.46 ",IP,"46,434.46","168,227.14",,,,,,
Humana MCR ADV,DRG,MS-223,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITHOUT MCC,Surgical,Relative Weights,"$33,864.27 ",IP,"33,864.27","121,018.46",,,,,,
Humana MCR ADV,DRG,MS-224,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITH MCC,Surgical,Relative Weights,"$43,912.13 ",IP,"43,912.13","149,107.39",,,,,,
Humana MCR ADV,DRG,MS-225,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITHOUT MCC,Surgical,Relative Weights,"$32,808.39 ",IP,"32,808.39","113,879.81",,,,,,
Humana MCR ADV,DRG,MS-226,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$38,340.11 ",IP,"25,420.00","134,824.03",,,,,,
Humana MCR ADV,DRG,MS-227,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Surgical,Relative Weights,"$30,439.07 ",IP,"25,420.00","105,420.67",,,,,,
Humana MCR ADV,DRG,MS-228,OTHER CARDIOTHORACIC PROCEDURES WITH MCC,Surgical,Relative Weights,"$31,129.37 ",IP,"31,129.37","126,731.81",,,,,,
Humana MCR ADV,DRG,MS-229,OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$20,096.88 ",IP,"20,096.88","82,754.78",,,,,,
Humana MCR ADV,DRG,MS-231,CORONARY BYPASS W PTCA W MCC,Surgical,Relative Weights,"$50,901.53 ",IP,"50,901.53","165,543.84",,,,,,
Humana MCR ADV,DRG,MS-232,CORONARY BYPASS W PTCA W/O MCC,Surgical,Relative Weights,"$34,770.65 ",IP,"34,770.65","120,687.84",,,,,,
Humana MCR ADV,DRG,MS-233,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,Surgical,Relative Weights,"$46,266.85 ",IP,"42,365.00","156,621.02",,,,,,
Humana MCR ADV,DRG,MS-234,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,Surgical,Relative Weights,"$31,162.65 ",IP,"31,162.65","104,959.01",,,,,,
Humana MCR ADV,DRG,MS-235,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$35,648.42 ",IP,"32,351.00","118,633.54",,,,,,
Humana MCR ADV,DRG,MS-236,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Surgical,Relative Weights,"$23,926.80 ",IP,"23,926.80","81,226.66",,,,,,
Humana MCR ADV,DRG,MS-239,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,Surgical,Relative Weights,"$28,125.81 ",IP,"2,420.00","94,141.15",,,,,,
Humana MCR ADV,DRG,MS-240,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,Surgical,Relative Weights,"$16,286.81 ",IP,"2,420.00","55,641.60",,,,,,
Humana MCR ADV,DRG,MS-241,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,Surgical,Relative Weights,"$9,299.74 ",IP,"2,420.00","30,568.61",,,,,,
Humana MCR ADV,DRG,MS-242,PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,Surgical,Relative Weights,"$21,769.47 ",IP,"15,407.00","74,815.78",,,,,,
Humana MCR ADV,DRG,MS-243,PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,Surgical,Relative Weights,"$14,708.24 ",IP,"14,708.24","50,992.70",,,,,,
Humana MCR ADV,DRG,MS-244,PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,Surgical,Relative Weights,"$12,049.83 ",IP,"12,049.83","41,840.06",,,,,,
Humana MCR ADV,DRG,MS-245,AICD GENERATOR PROCEDURES,Surgical,Relative Weights,"$31,640.37 ",IP,"15,407.00","104,989.25",,,,,,
Humana MCR ADV,DRG,MS-246,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Surgical,Relative Weights,"$18,246.15 ",IP,"18,246.15","63,963.65",,,,,,
Humana MCR ADV,DRG,MS-247,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITHOUT MCC,Surgical,Relative Weights,"$11,523.64 ",IP,"11,523.64","41,019.55",,,,,,
Humana MCR ADV,DRG,MS-248,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Surgical,Relative Weights,"$18,467.49 ",IP,"18,467.49","62,425.44",,,,,,
Humana MCR ADV,DRG,MS-249,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITHOUT MCC,Surgical,Relative Weights,"$10,942.55 ",IP,"10,942.55","38,638.66",,,,,,
Humana MCR ADV,DRG,MS-250,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT CORONARY ARTERY STENT WITH MCC,Surgical,Relative Weights,"$14,727.51 ",IP,"14,727.51","51,410.02",,,,,,
Humana MCR ADV,DRG,MS-251,PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W/O MCC,Surgical,Relative Weights,"$9,685.18 ",IP,"2,420.00","33,929.28",,,,,,
Humana MCR ADV,DRG,MS-252,OTHER VASCULAR PROCEDURES W MCC,Surgical,Relative Weights,"$19,422.35 ",IP,"2,420.00","66,132.86",,,,,,
Humana MCR ADV,DRG,MS-253,OTHER VASCULAR PROCEDURES WITH CC,Surgical,Relative Weights,"$15,497.23 ",IP,"2,420.00","52,549.06",,,,,,
Humana MCR ADV,DRG,MS-254,OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,605.00 ",IP,"2,420.00","36,693.22",,,,,,
Humana MCR ADV,DRG,MS-255,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,Surgical,Relative Weights,"$14,806.35 ",IP,"2,420.00","53,415.94",,,,,,
Humana MCR ADV,DRG,MS-256,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,Surgical,Relative Weights,"$9,602.26 ",IP,"2,420.00","34,604.64",,,,,,
Humana MCR ADV,DRG,MS-257,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$6,804.86 ",IP,"2,420.00","22,869.50",,,,,,
Humana MCR ADV,DRG,MS-258,CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,Surgical,Relative Weights,"$18,501.95 ",IP,"11,861.00","61,663.39",,,,,,
Humana MCR ADV,DRG,MS-259,CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,Surgical,Relative Weights,"$12,201.09 ",IP,"11,861.00","41,985.22",,,,,,
Humana MCR ADV,DRG,MS-260,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,Surgical,Relative Weights,"$20,833.31 ",IP,"10,167.00","74,583.94",,,,,,
Humana MCR ADV,DRG,MS-261,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,Surgical,Relative Weights,"$11,644.53 ",IP,"10,167.00","39,281.76",,,,,,
Humana MCR ADV,DRG,MS-262,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,Surgical,Relative Weights,"$9,964.34 ",IP,"9,964.34","33,820.42",,,,,,
Humana MCR ADV,DRG,MS-263,VEIN LIGATION AND STRIPPING,Surgical,Relative Weights,"$13,509.27 ",IP,"2,420.00","47,559.46",,,,,,
Humana MCR ADV,DRG,MS-264,OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,Surgical,Relative Weights,"$19,001.28 ",IP,"2,420.00","65,278.08",,,,,,
Humana MCR ADV,DRG,MS-265,AICD LEAD PROCEDURES,Surgical,Relative Weights,"$19,654.78 ",IP,"2,420.00","62,925.41",,,,,,
Humana MCR ADV,DRG,MS-266,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,Surgical,Relative Weights,"$41,160.28 ",IP,"41,160.28","143,567.42",,,,,,
Humana MCR ADV,DRG,MS-267,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$32,692.75 ",IP,"32,692.75","114,420.10",,,,,,
Humana MCR ADV,DRG,MS-268,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,Surgical,Relative Weights,"$40,666.21 ",IP,"32,968.00","136,737.22",,,,,,
Humana MCR ADV,DRG,MS-269,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,Surgical,Relative Weights,"$25,200.52 ",IP,"25,200.52","86,010.62",,,,,,
Humana MCR ADV,DRG,MS-270,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,Surgical,Relative Weights,"$30,292.48 ",IP,"30,292.48","103,021.63",,,,,,
Humana MCR ADV,DRG,MS-271,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,Surgical,Relative Weights,"$20,822.21 ",IP,"20,822.21","71,527.68",,,,,,
Humana MCR ADV,DRG,MS-272,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$15,699.88 ",IP,"15,699.88","52,442.21",,,,,,
Humana MCR ADV,DRG,MS-273,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,Surgical,Relative Weights,"$22,348.22 ",IP,"16,176.00","74,799.65",,,,,,
Humana MCR ADV,DRG,MS-274,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$19,194.00 ",IP,"16,176.00","63,701.57",,,,,,
Humana MCR ADV,DRG,MS-280,ACUTE MYOCARDIAL INFARCTION - DISCHARGED ALIVE W MCC,Medical,Relative Weights,"$9,384.42 ",IP,"2,420.00","32,878.94",,,,,,
Humana MCR ADV,DRG,MS-281,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITH CC,Medical,Relative Weights,"$5,434.78 ",IP,"2,420.00","19,528.99",,,,,,
Humana MCR ADV,DRG,MS-282,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITHOUT CC/MCC,Medical,Relative Weights,"$4,240.48 ",IP,"2,420.00","14,876.06",,,,,,
Humana MCR ADV,DRG,MS-283,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH MCC,Medical,Relative Weights,"$10,889.99 ",IP,"2,420.00","36,281.95",,,,,,
Humana MCR ADV,DRG,MS-284,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH CC,Medical,Relative Weights,"$4,224.71 ",IP,"2,420.00","14,622.05",,,,,,
Humana MCR ADV,DRG,MS-285,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITHOUT CC/MCC,Medical,Relative Weights,"$2,889.09 ",IP,"2,420.00","10,438.85",,,,,,
Humana MCR ADV,DRG,MS-286,CIRCULATORY DISORDERS EXCEPT AMI- WITH CARDIAC CATHETERIZATION WITH MCC,Medical,Relative Weights,"$12,476.16 ",IP,"2,420.00","44,299.58",,,,,,
Humana MCR ADV,DRG,MS-287,CIRCULATORY DISORDERS EXCEPT AMI -  WITH CARDIAC CATHETERIZATION WITHOUT MCC,Medical,Relative Weights,"$6,512.27 ",IP,"6,512.27","23,228.35",,,,,,
Humana MCR ADV,DRG,MS-288,ACUTE & SUBACUTE ENDOCARDITIS W MCC,Medical,Relative Weights,"$15,682.94 ",IP,"2,420.00","53,573.18",,,,,,
Humana MCR ADV,DRG,MS-289,ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,Medical,Relative Weights,"$9,598.75 ",IP,"9,181.00","33,542.21",,,,,,
Humana MCR ADV,DRG,MS-290,ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,Medical,Relative Weights,"$5,997.18 ",IP,"2,420.00","20,172.10",,,,,,
Humana MCR ADV,DRG,MS-291,HEART FAILURE AND SHOCK WITH MCC,Medical,Relative Weights,"$7,406.97 ",IP,"2,420.00","27,131.33",,,,,,
Humana MCR ADV,DRG,MS-292,HEART FAILURE AND SHOCK WITH CC,Medical,Relative Weights,"$5,042.91 ",IP,"2,420.00","18,254.88",,,,,,
Humana MCR ADV,DRG,MS-293,HEART FAILURE AND SHOCK WITHOUT CC/MCC,Medical,Relative Weights,"$3,445.06 ",IP,"2,420.00","13,210.85",,,,,,
Humana MCR ADV,DRG,MS-294,DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC,Medical,Relative Weights,"$7,491.65 ",IP,"2,420.00","25,641.50",,,,,,
Humana MCR ADV,DRG,MS-295,DEEP VEIN THROMBOPHLEBITIS W/O CC/MCC,Medical,Relative Weights,"$5,747.22 ",IP,"2,420.00","11,632.32",,,,,,
Humana MCR ADV,DRG,MS-296,CARDIAC ARREST - UNEXPLAINED W MCC,Medical,Relative Weights,"$9,316.09 ",IP,"2,420.00","31,659.26",,,,,,
Humana MCR ADV,DRG,MS-297,CARDIAC ARREST- UNEXPLAINED WITH CC,Medical,Relative Weights,"$4,128.93 ",IP,"2,420.00","14,575.68",,,,,,
Humana MCR ADV,DRG,MS-298,CARDIAC ARREST- UNEXPLAINED WITHOUT CC/MCC,Medical,Relative Weights,"$2,854.63 ",IP,"2,420.00","10,144.51",,,,,,
Humana MCR ADV,DRG,MS-299,PERIPHERAL VASCULAR DISORDERS WITH MCC,Medical,Relative Weights,"$8,950.50 ",IP,"2,420.00","29,225.95",,,,,,
Humana MCR ADV,DRG,MS-300,PERIPHERAL VASCULAR DISORDERS WITH CC,Medical,Relative Weights,"$6,095.87 ",IP,"2,420.00","20,716.42",,,,,,
Humana MCR ADV,DRG,MS-301,PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$4,339.76 ",IP,"2,420.00","14,632.13",,,,,,
Humana MCR ADV,DRG,MS-302,ATHEROSCLEROSIS WITH MCC,Medical,Relative Weights,"$6,393.72 ",IP,"2,420.00","22,222.37",,,,,,
Humana MCR ADV,DRG,MS-303,ATHEROSCLEROSIS WITHOUT MCC,Medical,Relative Weights,"$3,957.24 ",IP,"2,420.00","13,622.11",,,,,,
Humana MCR ADV,DRG,MS-304,HYPERTENSION WITH MCC,Medical,Relative Weights,"$6,406.57 ",IP,"2,420.00","22,004.64",,,,,,
Humana MCR ADV,DRG,MS-305,HYPERTENSION WITHOUT MCC,Medical,Relative Weights,"$4,321.07 ",IP,"2,420.00","14,747.04",,,,,,
Humana MCR ADV,DRG,MS-306,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,Medical,Relative Weights,"$8,803.33 ",IP,"2,420.00","28,516.32",,,,,,
Humana MCR ADV,DRG,MS-307,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,Medical,Relative Weights,"$5,083.20 ",IP,"2,420.00","17,785.15",,,,,,
Humana MCR ADV,DRG,MS-308,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,Medical,Relative Weights,"$7,013.35 ",IP,"2,420.00","23,944.03",,,,,,
Humana MCR ADV,DRG,MS-309,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,Medical,Relative Weights,"$4,382.98 ",IP,"2,420.00","15,247.01",,,,,,
Humana MCR ADV,DRG,MS-310,CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC,Medical,Relative Weights,"$3,265.77 ",IP,"2,420.00","11,275.49",,,,,,
Humana MCR ADV,DRG,MS-311,ANGINA PECTORIS,Medical,Relative Weights,"$4,079.29 ",IP,"2,420.00","13,809.60",,,,,,
Humana MCR ADV,DRG,MS-312,SYNCOPE AND COLLAPSE,Medical,Relative Weights,"$4,898.07 ",IP,"2,420.00","16,462.66",,,,,,
Humana MCR ADV,DRG,MS-313,CHEST PAIN,Medical,Relative Weights,"$4,213.03 ",IP,"2,420.00","14,420.45",,,,,,
Humana MCR ADV,DRG,MS-314,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,Medical,Relative Weights,"$12,174.81 ",IP,"2,420.00","40,914.72",,,,,,
Humana MCR ADV,DRG,MS-315,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,Medical,Relative Weights,"$5,684.73 ",IP,"2,420.00","19,563.26",,,,,,
Humana MCR ADV,DRG,MS-316,OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$4,224.71 ",IP,"2,420.00","14,962.75",,,,,,
Humana MCR ADV,DRG,MS-319,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,Surgical,Relative Weights,"$25,216.87 ",IP,"2,420.00","82,670.11",,,,,,
Humana MCR ADV,DRG,MS-320,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$14,048.89 ",IP,"2,420.00","47,329.63",,,,,,
Humana MCR ADV,DRG,MS-326,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$31,047.60 ",IP,"2,420.00","106,253.28",,,,,,
Humana MCR ADV,DRG,MS-327,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC,Surgical,Relative Weights,"$14,978.05 ",IP,"2,420.00","51,869.66",,,,,,
Humana MCR ADV,DRG,MS-328,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$9,734.83 ",IP,"2,420.00","31,752.00",,,,,,
Humana MCR ADV,DRG,MS-329,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Surgical,Relative Weights,"$28,535.79 ",IP,"2,420.00","98,929.15",,,,,,
Humana MCR ADV,DRG,MS-330,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Surgical,Relative Weights,"$14,888.11 ",IP,"2,420.00","50,940.29",,,,,,
Humana MCR ADV,DRG,MS-331,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$9,989.45 ",IP,"2,420.00","34,054.27",,,,,,
Humana MCR ADV,DRG,MS-332,RECTAL RESECTION WITH MCC,Surgical,Relative Weights,"$24,303.48 ",IP,"2,420.00","70,396.70",,,,,,
Humana MCR ADV,DRG,MS-333,RECTAL RESECTION WITH CC,Surgical,Relative Weights,"$12,505.36 ",IP,"2,420.00","45,626.11",,,,,,
Humana MCR ADV,DRG,MS-334,RECTAL RESECTION WITHOUT CC/MCC,Surgical,Relative Weights,"$9,394.35 ",IP,"2,420.00","31,052.45",,,,,,
Humana MCR ADV,DRG,MS-335,PERITONEAL ADHESIOLYSIS WITH MCC,Surgical,Relative Weights,"$22,855.14 ",IP,"2,420.00","81,549.22",,,,,,
Humana MCR ADV,DRG,MS-336,PERITONEAL ADHESIOLYSIS WITH CC,Surgical,Relative Weights,"$13,381.37 ",IP,"2,420.00","45,686.59",,,,,,
Humana MCR ADV,DRG,MS-337,PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$9,561.96 ",IP,"2,420.00","33,056.35",,,,,,
Humana MCR ADV,DRG,MS-338,APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$16,336.45 ",IP,"2,420.00","58,667.62",,,,,,
Humana MCR ADV,DRG,MS-339,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W CC,Surgical,Relative Weights,"$9,912.95 ",IP,"2,420.00","34,596.58",,,,,,
Humana MCR ADV,DRG,MS-340,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC/MCC,Surgical,Relative Weights,"$7,173.37 ",IP,"2,420.00","24,948.00",,,,,,
Humana MCR ADV,DRG,MS-341,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$13,563.00 ",IP,"2,420.00","51,571.30",,,,,,
Humana MCR ADV,DRG,MS-342,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH CC,Surgical,Relative Weights,"$8,368.25 ",IP,"2,420.00","32,463.65",,,,,,
Humana MCR ADV,DRG,MS-343,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$6,474.31 ",IP,"2,420.00","23,216.26",,,,,,
Humana MCR ADV,DRG,MS-344,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Surgical,Relative Weights,"$16,459.67 ",IP,"2,420.00","60,381.22",,,,,,
Humana MCR ADV,DRG,MS-345,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Surgical,Relative Weights,"$9,220.31 ",IP,"2,420.00","32,927.33",,,,,,
Humana MCR ADV,DRG,MS-346,MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,448.43 ",IP,"2,420.00","25,859.23",,,,,,
Humana MCR ADV,DRG,MS-347,ANAL AND STOMAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$14,394.04 ",IP,"2,420.00","53,149.82",,,,,,
Humana MCR ADV,DRG,MS-348,ANAL AND STOMAL PROCEDURES WITH CC,Surgical,Relative Weights,"$7,873.01 ",IP,"2,420.00","28,411.49",,,,,,
Humana MCR ADV,DRG,MS-349,ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$5,719.19 ",IP,"2,420.00","19,774.94",,,,,,
Humana MCR ADV,DRG,MS-350,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,Surgical,Relative Weights,"$14,336.22 ",IP,"2,420.00","49,176.29",,,,,,
Humana MCR ADV,DRG,MS-351,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,Surgical,Relative Weights,"$8,717.48 ",IP,"2,420.00","29,399.33",,,,,,
Humana MCR ADV,DRG,MS-352,INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,449.78 ",IP,"2,420.00","21,708.29",,,,,,
Humana MCR ADV,DRG,MS-353,HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,Surgical,Relative Weights,"$17,665.65 ",IP,"2,420.00","59,812.70",,,,,,
Humana MCR ADV,DRG,MS-354,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W CC,Surgical,Relative Weights,"$10,423.37 ",IP,"2,420.00","34,717.54",,,,,,
Humana MCR ADV,DRG,MS-355,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W/O CC/MCC,Surgical,Relative Weights,"$7,943.67 ",IP,"2,420.00","27,667.58",,,,,,
Humana MCR ADV,DRG,MS-356,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$25,157.89 ",IP,"2,420.00","82,196.35",,,,,,
Humana MCR ADV,DRG,MS-357,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$13,248.22 ",IP,"2,420.00","45,368.06",,,,,,
Humana MCR ADV,DRG,MS-358,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,878.85 ",IP,"2,420.00","27,653.47",,,,,,
Humana MCR ADV,DRG,MS-368,MAJOR ESOPHAGEAL DISORDERS WITH MCC,Medical,Relative Weights,"$11,382.90 ",IP,"2,420.00","38,376.58",,,,,,
Humana MCR ADV,DRG,MS-369,MAJOR ESOPHAGEAL DISORDERS WITH CC,Medical,Relative Weights,"$6,290.93 ",IP,"2,420.00","21,432.10",,,,,,
Humana MCR ADV,DRG,MS-370,MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$4,368.96 ",IP,"2,420.00","15,065.57",,,,,,
Humana MCR ADV,DRG,MS-371,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,Medical,Relative Weights,"$10,110.34 ",IP,"2,420.00","34,786.08",,,,,,
Humana MCR ADV,DRG,MS-372,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,Medical,Relative Weights,"$6,011.19 ",IP,"2,420.00","20,613.60",,,,,,
Humana MCR ADV,DRG,MS-373,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,Medical,Relative Weights,"$4,348.52 ",IP,"2,420.00","14,954.69",,,,,,
Humana MCR ADV,DRG,MS-374,DIGESTIVE MALIGNANCY WITH MCC,Medical,Relative Weights,"$12,110.57 ",IP,"2,420.00","40,269.60",,,,,,
Humana MCR ADV,DRG,MS-375,DIGESTIVE MALIGNANCY WITH CC,Medical,Relative Weights,"$7,052.48 ",IP,"2,420.00","24,339.17",,,,,,
Humana MCR ADV,DRG,MS-376,DIGESTIVE MALIGNANCY WITHOUT CC/MCC,Medical,Relative Weights,"$5,249.65 ",IP,"2,420.00","20,186.21",,,,,,
Humana MCR ADV,DRG,MS-377,GASTROINTESTINAL HEMORRHAGE WITH MCC,Medical,Relative Weights,"$10,519.15 ",IP,"2,420.00","35,681.18",,,,,,
Humana MCR ADV,DRG,MS-378,GASTROINTESTINAL HEMORRHAGE WITH CC,Medical,Relative Weights,"$5,802.12 ",IP,"2,420.00","19,920.10",,,,,,
Humana MCR ADV,DRG,MS-379,GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,Medical,Relative Weights,"$3,721.30 ",IP,"2,420.00","13,017.31",,,,,,
Humana MCR ADV,DRG,MS-380,COMPLICATED PEPTIC ULCER WITH MCC,Medical,Relative Weights,"$11,017.89 ",IP,"2,420.00","38,054.02",,,,,,
Humana MCR ADV,DRG,MS-381,COMPLICATED PEPTIC ULCER WITH CC,Medical,Relative Weights,"$6,186.39 ",IP,"2,420.00","21,706.27",,,,,,
Humana MCR ADV,DRG,MS-382,COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,Medical,Relative Weights,"$4,488.68 ",IP,"2,420.00","15,954.62",,,,,,
Humana MCR ADV,DRG,MS-383,UNCOMPLICATED PEPTIC ULCER WITH MCC,Medical,Relative Weights,"$7,665.69 ",IP,"2,420.00","26,738.21",,,,,,
Humana MCR ADV,DRG,MS-384,UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,Medical,Relative Weights,"$5,214.02 ",IP,"2,420.00","17,543.23",,,,,,
Humana MCR ADV,DRG,MS-385,INFLAMMATORY BOWEL DISEASE WITH MCC,Medical,Relative Weights,"$9,474.36 ",IP,"2,420.00","32,463.65",,,,,,
Humana MCR ADV,DRG,MS-386,INFLAMMATORY BOWEL DISEASE W CC,Medical,Relative Weights,"$5,811.46 ",IP,"2,420.00","19,861.63",,,,,,
Humana MCR ADV,DRG,MS-387,INFLAMMATORY BOWEL DISEASE W/O CC/MCC,Medical,Relative Weights,"$4,173.90 ",IP,"2,420.00","14,126.11",,,,,,
Humana MCR ADV,DRG,MS-388,GASTROINTESTINAL OBSTRUCTION WITH MCC,Medical,Relative Weights,"$8,845.38 ",IP,"2,420.00","30,746.02",,,,,,
Humana MCR ADV,DRG,MS-389,GASTROINTESTINAL OBSTRUCTION WITH CC,Medical,Relative Weights,"$4,807.55 ",IP,"2,420.00","16,928.35",,,,,,
Humana MCR ADV,DRG,MS-390,GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,Medical,Relative Weights,"$3,405.35 ",IP,"2,420.00","11,684.74",,,,,,
Humana MCR ADV,DRG,MS-391,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC,Medical,Relative Weights,"$7,295.42 ",IP,"2,420.00","24,897.60",,,,,,
Humana MCR ADV,DRG,MS-392,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC,Medical,Relative Weights,"$4,472.33 ",IP,"2,420.00","15,351.84",,,,,,
Humana MCR ADV,DRG,MS-393,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,Medical,Relative Weights,"$9,701.54 ",IP,"2,420.00","32,749.92",,,,,,
Humana MCR ADV,DRG,MS-394,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,Medical,Relative Weights,"$5,494.93 ",IP,"2,420.00","18,912.10",,,,,,
Humana MCR ADV,DRG,MS-395,OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$3,804.81 ",IP,"2,420.00","13,192.70",,,,,,
Humana MCR ADV,DRG,MS-405,PANCREAS- LIVER AND SHUNT PROCEDURES WITH MCC,Surgical,Relative Weights,"$33,508.03 ",IP,"2,420.00","109,412.35",,,,,,
Humana MCR ADV,DRG,MS-406,PANCREAS -  LIVER AND SHUNT PROCEDURES WITH CC,Surgical,Relative Weights,"$16,824.68 ",IP,"2,420.00","56,264.54",,,,,,
Humana MCR ADV,DRG,MS-407,PANCREAS -  LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$12,369.28 ",IP,"2,420.00","42,059.81",,,,,,
Humana MCR ADV,DRG,MS-408,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,Surgical,Relative Weights,"$21,917.23 ",IP,"2,420.00","71,842.18",,,,,,
Humana MCR ADV,DRG,MS-409,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,Surgical,Relative Weights,"$12,359.94 ",IP,"2,420.00","48,259.01",,,,,,
Humana MCR ADV,DRG,MS-410,BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W/O CC/MCC,Surgical,Relative Weights,"$9,158.99 ",IP,"2,420.00","33,465.60",,,,,,
Humana MCR ADV,DRG,MS-411,CHOLECYSTECTOMY W C.D.E. W MCC,Surgical,Relative Weights,"$21,920.73 ",IP,"2,420.00","77,220.86",,,,,,
Humana MCR ADV,DRG,MS-412,CHOLECYSTECTOMY WITH C.D.E. WITH CC,Surgical,Relative Weights,"$13,300.78 ",IP,"2,420.00","47,920.32",,,,,,
Humana MCR ADV,DRG,MS-413,CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,Surgical,Relative Weights,"$10,108.59 ",IP,"2,420.00","32,604.77",,,,,,
Humana MCR ADV,DRG,MS-414,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,Surgical,Relative Weights,"$21,189.55 ",IP,"2,420.00","68,874.62",,,,,,
Humana MCR ADV,DRG,MS-415,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,Surgical,Relative Weights,"$11,865.29 ",IP,"2,420.00","41,362.27",,,,,,
Humana MCR ADV,DRG,MS-416,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,Surgical,Relative Weights,"$8,306.34 ",IP,"2,420.00","27,222.05",,,,,,
Humana MCR ADV,DRG,MS-417,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,Surgical,Relative Weights,"$14,158.10 ",IP,"2,420.00","48,599.71",,,,,,
Humana MCR ADV,DRG,MS-418,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,Surgical,Relative Weights,"$9,863.89 ",IP,"2,420.00","33,645.02",,,,,,
Humana MCR ADV,DRG,MS-419,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,Surgical,Relative Weights,"$7,681.45 ",IP,"2,420.00","26,345.09",,,,,,
Humana MCR ADV,DRG,MS-420,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,Surgical,Relative Weights,"$20,536.63 ",IP,"2,420.00","69,245.57",,,,,,
Humana MCR ADV,DRG,MS-421,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,Surgical,Relative Weights,"$11,139.95 ",IP,"2,420.00","37,118.59",,,,,,
Humana MCR ADV,DRG,MS-422,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,489.14 ",IP,"2,420.00","28,314.72",,,,,,
Humana MCR ADV,DRG,MS-423,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$24,445.98 ",IP,"2,420.00","85,442.11",,,,,,
Humana MCR ADV,DRG,MS-424,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$13,339.32 ",IP,"2,420.00","45,388.22",,,,,,
Humana MCR ADV,DRG,MS-425,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$9,009.49 ",IP,"2,420.00","29,463.84",,,,,,
Humana MCR ADV,DRG,MS-432,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,Medical,Relative Weights,"$10,984.02 ",IP,"2,420.00","36,759.74",,,,,,
Humana MCR ADV,DRG,MS-433,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,Medical,Relative Weights,"$6,014.70 ",IP,"2,420.00","20,805.12",,,,,,
Humana MCR ADV,DRG,MS-434,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Medical,Relative Weights,"$3,624.94 ",IP,"2,420.00","12,900.38",,,,,,
Humana MCR ADV,DRG,MS-435,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,Medical,Relative Weights,"$10,239.99 ",IP,"2,420.00","34,213.54",,,,,,
Humana MCR ADV,DRG,MS-436,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,Medical,Relative Weights,"$6,549.65 ",IP,"2,420.00","22,694.11",,,,,,
Humana MCR ADV,DRG,MS-437,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,Medical,Relative Weights,"$5,232.13 ",IP,"2,420.00","17,698.46",,,,,,
Humana MCR ADV,DRG,MS-438,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,Medical,Relative Weights,"$9,331.28 ",IP,"2,420.00","33,028.13",,,,,,
Humana MCR ADV,DRG,MS-439,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,Medical,Relative Weights,"$4,936.03 ",IP,"2,420.00","17,079.55",,,,,,
Humana MCR ADV,DRG,MS-440,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,Medical,Relative Weights,"$3,540.84 ",IP,"2,420.00","12,410.50",,,,,,
Humana MCR ADV,DRG,MS-441,DISORDERS OF LIVER EXCEPT MALIGNANCY- CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC,Medical,Relative Weights,"$10,976.43 ",IP,"2,420.00","37,306.08",,,,,,
Humana MCR ADV,DRG,MS-442,DISORDERS OF LIVER EXCEPT MALIGNANCY -  CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC,Medical,Relative Weights,"$5,431.27 ",IP,"2,420.00","18,817.34",,,,,,
Humana MCR ADV,DRG,MS-443,DISORDERS OF LIVER EXCEPT MALIGNANCY -  CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Medical,Relative Weights,"$3,873.14 ",IP,"2,420.00","13,714.85",,,,,,
Humana MCR ADV,DRG,MS-444,DISORDERS OF THE BILIARY TRACT WITH MCC,Medical,Relative Weights,"$9,762.27 ",IP,"2,420.00","32,782.18",,,,,,
Humana MCR ADV,DRG,MS-445,DISORDERS OF THE BILIARY TRACT WITH CC,Medical,Relative Weights,"$6,292.68 ",IP,"2,420.00","21,661.92",,,,,,
Humana MCR ADV,DRG,MS-446,DISORDERS OF THE BILIARY TRACT W/O CC/MCC,Medical,Relative Weights,"$4,769.01 ",IP,"2,420.00","16,384.03",,,,,,
Humana MCR ADV,DRG,MS-453,COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W MCC,Surgical,Relative Weights,"$53,658.63 ",IP,"2,420.00","189,645.12",,,,,,
Humana MCR ADV,DRG,MS-454,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC,Surgical,Relative Weights,"$35,584.18 ",IP,"2,420.00","123,480.00",,,,,,
Humana MCR ADV,DRG,MS-455,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CC/MCC,Surgical,Relative Weights,"$27,923.16 ",IP,"2,420.00","97,036.13",,,,,,
Humana MCR ADV,DRG,MS-456,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH MCC,Surgical,Relative Weights,"$50,224.67 ",IP,"2,420.00","183,076.99",,,,,,
Humana MCR ADV,DRG,MS-457,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH CC,Surgical,Relative Weights,"$37,936.56 ",IP,"2,420.00","131,308.13",,,,,,
Humana MCR ADV,DRG,MS-458,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC,Surgical,Relative Weights,"$29,244.77 ",IP,"2,420.00","94,629.02",,,,,,
Humana MCR ADV,DRG,MS-459,SPINAL FUSION EXCEPT CERVICAL WITH MCC,Surgical,Relative Weights,"$39,324.16 ",IP,"21,658.00","138,136.32",,,,,,
Humana MCR ADV,DRG,MS-460,SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,Surgical,Relative Weights,"$22,955.59 ",IP,"21,658.00","79,841.66",,,,,,
Humana MCR ADV,DRG,MS-461,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,Surgical,Relative Weights,"$35,517.60 ",IP,"2,420.00","108,436.61",,,,,,
Humana MCR ADV,DRG,MS-462,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,Surgical,Relative Weights,"$18,346.02 ",IP,"2,420.00","63,229.82",,,,,,
Humana MCR ADV,DRG,MS-463,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,Surgical,Relative Weights,"$31,362.97 ",IP,"2,420.00","105,392.45",,,,,,
Humana MCR ADV,DRG,MS-464,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,Surgical,Relative Weights,"$17,379.49 ",IP,"2,420.00","59,526.43",,,,,,
Humana MCR ADV,DRG,MS-465,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$10,769.69 ",IP,"2,420.00","38,610.43",,,,,,
Humana MCR ADV,DRG,MS-466,REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,Surgical,Relative Weights,"$31,219.30 ",IP,"2,420.00","102,797.86",,,,,,
Humana MCR ADV,DRG,MS-467,REVISION OF HIP OR KNEE REPLACEMENT W CC,Surgical,Relative Weights,"$20,892.88 ",IP,"2,420.00","70,803.94",,,,,,
Humana MCR ADV,DRG,MS-468,REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,Surgical,Relative Weights,"$16,366.23 ",IP,"2,420.00","56,691.94",,,,,,
Humana MCR ADV,DRG,MS-469,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,Surgical,Relative Weights,"$18,021.90 ",IP,"2,420.00","63,300.38",,,,,,
Humana MCR ADV,DRG,MS-470,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,Surgical,Relative Weights,"$11,097.90 ",IP,"2,420.00","39,682.94",,,,,,
Humana MCR ADV,DRG,MS-471,CERVICAL SPINAL FUSION WITH MCC,Surgical,Relative Weights,"$29,315.44 ",IP,"15,407.00","100,687.10",,,,,,
Humana MCR ADV,DRG,MS-472,CERVICAL SPINAL FUSION WITH CC,Surgical,Relative Weights,"$17,833.84 ",IP,"15,407.00","61,316.64",,,,,,
Humana MCR ADV,DRG,MS-473,CERVICAL SPINAL FUSION WITHOUT CC/MCC,Surgical,Relative Weights,"$14,827.96 ",IP,"14,827.96","50,649.98",,,,,,
Humana MCR ADV,DRG,MS-474,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,Surgical,Relative Weights,"$23,804.74 ",IP,"2,420.00","78,117.98",,,,,,
Humana MCR ADV,DRG,MS-475,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,Surgical,Relative Weights,"$12,826.56 ",IP,"2,420.00","42,356.16",,,,,,
Humana MCR ADV,DRG,MS-476,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$6,776.24 ",IP,"2,420.00","23,480.35",,,,,,
Humana MCR ADV,DRG,MS-477,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Surgical,Relative Weights,"$19,616.24 ",IP,"2,420.00","65,626.85",,,,,,
Humana MCR ADV,DRG,MS-478,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Surgical,Relative Weights,"$13,773.24 ",IP,"2,420.00","46,712.74",,,,,,
Humana MCR ADV,DRG,MS-479,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Surgical,Relative Weights,"$10,567.62 ",IP,"2,420.00","35,929.15",,,,,,
Humana MCR ADV,DRG,MS-480,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,Surgical,Relative Weights,"$17,670.91 ",IP,"2,420.00","60,852.96",,,,,,
Humana MCR ADV,DRG,MS-481,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,Surgical,Relative Weights,"$12,241.39 ",IP,"2,420.00","42,090.05",,,,,,
Humana MCR ADV,DRG,MS-482,HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC,Surgical,Relative Weights,"$9,611.60 ",IP,"2,420.00","33,169.25",,,,,,
Humana MCR ADV,DRG,MS-483,MAJOR JOINT & LIMB REATTACHMENT PROC OF UPPER EXTREMITY W CC/MCC,Surgical,Relative Weights,"$13,932.67 ",IP,"2,420.00","48,224.74",,,,,,
Humana MCR ADV,DRG,MS-485,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,Surgical,Relative Weights,"$19,912.33 ",IP,"2,420.00","66,104.64",,,,,,
Humana MCR ADV,DRG,MS-486,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,Surgical,Relative Weights,"$12,552.66 ",IP,"2,420.00","43,356.10",,,,,,
Humana MCR ADV,DRG,MS-487,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Surgical,Relative Weights,"$9,578.90 ",IP,"2,420.00","32,401.15",,,,,,
Humana MCR ADV,DRG,MS-488,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,Surgical,Relative Weights,"$11,538.24 ",IP,"2,420.00","39,699.07",,,,,,
Humana MCR ADV,DRG,MS-489,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Surgical,Relative Weights,"$7,581.59 ",IP,"2,420.00","25,381.44",,,,,,
Humana MCR ADV,DRG,MS-492,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH MCC,Surgical,Relative Weights,"$20,265.07 ",IP,"2,420.00","69,457.25",,,,,,
Humana MCR ADV,DRG,MS-493,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH CC,Surgical,Relative Weights,"$13,582.85 ",IP,"2,420.00","46,408.32",,,,,,
Humana MCR ADV,DRG,MS-494,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITHOUT CC/MCC,Surgical,Relative Weights,"$10,814.07 ",IP,"2,420.00","36,517.82",,,,,,
Humana MCR ADV,DRG,MS-495,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,Surgical,Relative Weights,"$21,268.98 ",IP,"2,420.00","69,201.22",,,,,,
Humana MCR ADV,DRG,MS-496,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,Surgical,Relative Weights,"$11,600.73 ",IP,"2,420.00","41,136.48",,,,,,
Humana MCR ADV,DRG,MS-497,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,Surgical,Relative Weights,"$8,476.87 ",IP,"2,420.00","29,621.09",,,,,,
Humana MCR ADV,DRG,MS-498,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,Surgical,Relative Weights,"$15,089.01 ",IP,"2,420.00","49,353.70",,,,,,
Humana MCR ADV,DRG,MS-499,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,Surgical,Relative Weights,"$7,002.25 ",IP,"2,420.00","23,202.14",,,,,,
Humana MCR ADV,DRG,MS-500,SOFT TISSUE PROCEDURES WITH MCC,Surgical,Relative Weights,"$18,626.93 ",IP,"2,420.00","60,786.43",,,,,,
Humana MCR ADV,DRG,MS-501,SOFT TISSUE PROCEDURES WITH CC,Surgical,Relative Weights,"$10,244.08 ",IP,"2,420.00","33,828.48",,,,,,
Humana MCR ADV,DRG,MS-502,SOFT TISSUE PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,783.66 ",IP,"2,420.00","26,625.31",,,,,,
Humana MCR ADV,DRG,MS-503,FOOT PROCEDURES WITH MCC,Surgical,Relative Weights,"$15,421.31 ",IP,"2,420.00","54,766.66",,,,,,
Humana MCR ADV,DRG,MS-504,FOOT PROCEDURES WITH CC,Surgical,Relative Weights,"$10,366.14 ",IP,"2,420.00","35,007.84",,,,,,
Humana MCR ADV,DRG,MS-505,FOOT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,366.14 ",IP,"2,420.00","33,899.04",,,,,,
Humana MCR ADV,DRG,MS-506,MAJOR THUMB OR JOINT PROCEDURES,Surgical,Relative Weights,"$8,664.34 ",IP,"2,420.00","26,986.18",,,,,,
Humana MCR ADV,DRG,MS-507,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W CC/MCC,Surgical,Relative Weights,"$12,035.82 ",IP,"2,420.00","42,336.00",,,,,,
Humana MCR ADV,DRG,MS-508,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$8,232.76 ",IP,"2,420.00","31,417.34",,,,,,
Humana MCR ADV,DRG,MS-509,ARTHROSCOPY,Surgical,Relative Weights,"$9,849.29 ",IP,"2,420.00","28,056.67",,,,,,
Humana MCR ADV,DRG,MS-510,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH MCC,Surgical,Relative Weights,"$16,023.42 ",IP,"2,420.00","56,206.08",,,,,,
Humana MCR ADV,DRG,MS-511,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH CC,Surgical,Relative Weights,"$11,489.77 ",IP,"2,420.00","37,985.47",,,,,,
Humana MCR ADV,DRG,MS-512,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$9,078.40 ",IP,"2,420.00","30,518.21",,,,,,
Humana MCR ADV,DRG,MS-513,HAND OR WRIST PROCEDURES- EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$9,180.60 ",IP,"2,420.00","31,794.34",,,,,,
Humana MCR ADV,DRG,MS-514,HAND OR WRIST PROCEDURES -  EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$5,834.82 ",IP,"2,420.00","21,506.69",,,,,,
Humana MCR ADV,DRG,MS-515,OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W MCC,Surgical,Relative Weights,"$18,341.35 ",IP,"2,420.00","63,584.64",,,,,,
Humana MCR ADV,DRG,MS-516,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$11,462.90 ",IP,"2,420.00","39,092.26",,,,,,
Humana MCR ADV,DRG,MS-517,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,165.60 ",IP,"2,420.00","28,532.45",,,,,,
Humana MCR ADV,DRG,MS-518,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,Surgical,Relative Weights,"$20,947.77 ",IP,"10,289.00","68,717.38",,,,,,
Humana MCR ADV,DRG,MS-519,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,Surgical,Relative Weights,"$11,446.55 ",IP,"10,289.00","38,479.39",,,,,,
Humana MCR ADV,DRG,MS-520,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,Surgical,Relative Weights,"$8,282.98 ",IP,"8,282.98","26,974.08",,,,,,
Humana MCR ADV,DRG,MS-521,HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,Surgical,Relative Weights,"$17,906.85 ",IP,"2,420.00","17,906.85",,,,,,
Humana MCR ADV,DRG,MS-522,HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,Surgical,Relative Weights,"$12,786.27 ",IP,"2,420.00","12,786.27",,,,,,
Humana MCR ADV,DRG,MS-533,FRACTURES OF FEMUR WITH MCC,Medical,Relative Weights,"$8,270.72 ",IP,"2,420.00","29,421.50",,,,,,
Humana MCR ADV,DRG,MS-534,FRACTURES OF FEMUR WITHOUT MCC,Medical,Relative Weights,"$4,614.83 ",IP,"2,420.00","15,680.45",,,,,,
Humana MCR ADV,DRG,MS-535,FRACTURES OF HIP AND PELVIS WITH MCC,Medical,Relative Weights,"$7,199.65 ",IP,"2,420.00","24,738.34",,,,,,
Humana MCR ADV,DRG,MS-536,FRACTURES OF HIP AND PELVIS WITHOUT MCC,Medical,Relative Weights,"$4,506.79 ",IP,"2,420.00","15,291.36",,,,,,
Humana MCR ADV,DRG,MS-537,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITH CC/MCC,Medical,Relative Weights,"$5,462.81 ",IP,"2,420.00","18,363.74",,,,,,
Humana MCR ADV,DRG,MS-538,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITHOUT CC/MCC,Medical,Relative Weights,"$4,223.54 ",IP,"2,420.00","14,535.36",,,,,,
Humana MCR ADV,DRG,MS-539,OSTEOMYELITIS WITH MCC,Medical,Relative Weights,"$11,374.72 ",IP,"2,420.00","38,005.63",,,,,,
Humana MCR ADV,DRG,MS-540,OSTEOMYELITIS WITH CC,Medical,Relative Weights,"$7,601.45 ",IP,"2,420.00","26,208.00",,,,,,
Humana MCR ADV,DRG,MS-541,OSTEOMYELITIS WITHOUT CC/MCC,Medical,Relative Weights,"$4,924.35 ",IP,"2,420.00","18,279.07",,,,,,
Humana MCR ADV,DRG,MS-542,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,Medical,Relative Weights,"$10,565.87 ",IP,"2,420.00","36,787.97",,,,,,
Humana MCR ADV,DRG,MS-543,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,Medical,Relative Weights,"$6,104.05 ",IP,"2,420.00","21,295.01",,,,,,
Humana MCR ADV,DRG,MS-544,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,Medical,Relative Weights,"$4,541.83 ",IP,"2,420.00","15,289.34",,,,,,
Humana MCR ADV,DRG,MS-545,CONNECTIVE TISSUE DISORDERS WITH MCC,Medical,Relative Weights,"$14,618.30 ",IP,"2,420.00","50,964.48",,,,,,
Humana MCR ADV,DRG,MS-546,CONNECTIVE TISSUE DISORDERS WITH CC,Medical,Relative Weights,"$7,054.81 ",IP,"2,420.00","24,260.54",,,,,,
Humana MCR ADV,DRG,MS-547,CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$4,868.29 ",IP,"2,420.00","16,331.62",,,,,,
Humana MCR ADV,DRG,MS-548,SEPTIC ARTHRITIS WITH MCC,Medical,Relative Weights,"$11,976.83 ",IP,"2,420.00","39,983.33",,,,,,
Humana MCR ADV,DRG,MS-549,SEPTIC ARTHRITIS W CC,Medical,Relative Weights,"$7,299.51 ",IP,"2,420.00","24,052.90",,,,,,
Humana MCR ADV,DRG,MS-550,SEPTIC ARTHRITIS W/O CC/MCC,Medical,Relative Weights,"$5,132.84 ",IP,"2,420.00","17,418.24",,,,,,
Humana MCR ADV,DRG,MS-551,MEDICAL BACK PROBLEMS WITH MCC,Medical,Relative Weights,"$9,504.14 ",IP,"2,420.00","32,042.30",,,,,,
Humana MCR ADV,DRG,MS-552,MEDICAL BACK PROBLEMS WITHOUT MCC,Medical,Relative Weights,"$5,509.53 ",IP,"2,420.00","18,383.90",,,,,,
Humana MCR ADV,DRG,MS-553,BONE DISEASES AND ARTHROPATHIES WITH MCC,Medical,Relative Weights,"$7,425.66 ",IP,"2,420.00","25,915.68",,,,,,
Humana MCR ADV,DRG,MS-554,BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,Medical,Relative Weights,"$4,628.26 ",IP,"2,420.00","15,869.95",,,,,,
Humana MCR ADV,DRG,MS-555,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Medical,Relative Weights,"$7,992.15 ",IP,"2,420.00","26,516.45",,,,,,
Humana MCR ADV,DRG,MS-556,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,Medical,Relative Weights,"$4,722.87 ",IP,"2,420.00","15,962.69",,,,,,
Humana MCR ADV,DRG,MS-557,TENDONITIS -  MYOSITIS AND BURSITIS WITH MCC,Medical,Relative Weights,"$8,170.85 ",IP,"2,420.00","29,397.31",,,,,,
Humana MCR ADV,DRG,MS-558,TENDONITIS- MYOSITIS AND BURSITIS WITHOUT MCC,Medical,Relative Weights,"$5,030.64 ",IP,"2,420.00","17,365.82",,,,,,
Humana MCR ADV,DRG,MS-559,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Medical,Relative Weights,"$10,893.50 ",IP,"2,420.00","36,324.29",,,,,,
Humana MCR ADV,DRG,MS-560,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Medical,Relative Weights,"$6,283.92 ",IP,"2,420.00","21,036.96",,,,,,
Humana MCR ADV,DRG,MS-561,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Medical,Relative Weights,"$4,627.68 ",IP,"2,420.00","15,067.58",,,,,,
Humana MCR ADV,DRG,MS-562,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITH MCC,Medical,Relative Weights,"$8,245.02 ",IP,"2,420.00","27,157.54",,,,,,
Humana MCR ADV,DRG,MS-563,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITHOUT MCC,Medical,Relative Weights,"$5,093.72 ",IP,"2,420.00","17,216.64",,,,,,
Humana MCR ADV,DRG,MS-564,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,Medical,Relative Weights,"$8,897.94 ",IP,"2,420.00","30,481.92",,,,,,
Humana MCR ADV,DRG,MS-565,OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W CC,Medical,Relative Weights,"$5,894.39 ",IP,"2,420.00","19,766.88",,,,,,
Humana MCR ADV,DRG,MS-566,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$4,391.15 ",IP,"2,420.00","15,275.23",,,,,,
Humana MCR ADV,DRG,MS-570,SKIN DEBRIDEMENT WITH MCC,Surgical,Relative Weights,"$16,595.75 ",IP,"2,420.00","57,923.71",,,,,,
Humana MCR ADV,DRG,MS-571,SKIN DEBRIDEMENT WITH CC,Surgical,Relative Weights,"$9,550.86 ",IP,"2,420.00","33,713.57",,,,,,
Humana MCR ADV,DRG,MS-572,SKIN DEBRIDEMENT WITHOUT CC/MCC,Surgical,Relative Weights,"$6,449.78 ",IP,"2,420.00","22,613.47",,,,,,
Humana MCR ADV,DRG,MS-573,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,Surgical,Relative Weights,"$32,348.77 ",IP,"2,420.00","107,156.45",,,,,,
Humana MCR ADV,DRG,MS-574,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,Surgical,Relative Weights,"$18,959.81 ",IP,"2,420.00","62,935.49",,,,,,
Humana MCR ADV,DRG,MS-575,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS W/O CC/MCC,Surgical,Relative Weights,"$10,297.22 ",IP,"2,420.00","35,421.12",,,,,,
Humana MCR ADV,DRG,MS-576,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,Surgical,Relative Weights,"$29,572.40 ",IP,"2,420.00","97,759.87",,,,,,
Humana MCR ADV,DRG,MS-577,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,Surgical,Relative Weights,"$14,889.86 ",IP,"2,420.00","48,698.50",,,,,,
Humana MCR ADV,DRG,MS-578,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,Surgical,Relative Weights,"$9,316.09 ",IP,"2,420.00","32,808.38",,,,,,
Humana MCR ADV,DRG,MS-579,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC,Surgical,Relative Weights,"$18,366.46 ",IP,"2,420.00","60,199.78",,,,,,
Humana MCR ADV,DRG,MS-580,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC,Surgical,Relative Weights,"$10,096.33 ",IP,"2,420.00","32,431.39",,,,,,
Humana MCR ADV,DRG,MS-581,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,040.62 ",IP,"2,420.00","25,296.77",,,,,,
Humana MCR ADV,DRG,MS-582,MASTECTOMY FOR MALIGNANCY WITH CC/MCC,Surgical,Relative Weights,"$9,595.83 ",IP,"2,420.00","31,826.59",,,,,,
Humana MCR ADV,DRG,MS-583,MASTECTOMY FOR MALIGNANCY W/O CC/MCC,Surgical,Relative Weights,"$9,002.48 ",IP,"2,420.00","29,461.82",,,,,,
Humana MCR ADV,DRG,MS-584,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$10,726.47 ",IP,"2,420.00","36,860.54",,,,,,
Humana MCR ADV,DRG,MS-585,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,159.40 ",IP,"2,420.00","34,217.57",,,,,,
Humana MCR ADV,DRG,MS-592,SKIN ULCERS WITH MCC,Medical,Relative Weights,"$9,894.84 ",IP,"2,420.00","35,971.49",,,,,,
Humana MCR ADV,DRG,MS-593,SKIN ULCERS WITH CC,Medical,Relative Weights,"$6,661.19 ",IP,"2,420.00","23,139.65",,,,,,
Humana MCR ADV,DRG,MS-594,SKIN ULCERS WITHOUT CC/MCC,Medical,Relative Weights,"$4,765.50 ",IP,"2,420.00","16,323.55",,,,,,
Humana MCR ADV,DRG,MS-595,MAJOR SKIN DISORDERS WITH MCC,Medical,Relative Weights,"$11,776.52 ",IP,"2,420.00","40,977.22",,,,,,
Humana MCR ADV,DRG,MS-596,MAJOR SKIN DISORDERS W/O MCC,Medical,Relative Weights,"$5,809.13 ",IP,"2,420.00","19,637.86",,,,,,
Humana MCR ADV,DRG,MS-597,MALIGNANT BREAST DISORDERS W MCC,Medical,Relative Weights,"$9,601.09 ",IP,"2,420.00","34,128.86",,,,,,
Humana MCR ADV,DRG,MS-598,MALIGNANT BREAST DISORDERS WITH CC,Medical,Relative Weights,"$6,499.42 ",IP,"2,420.00","21,946.18",,,,,,
Humana MCR ADV,DRG,MS-599,MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$3,921.03 ",IP,"2,420.00","14,019.26",,,,,,
Humana MCR ADV,DRG,MS-600,NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,Medical,Relative Weights,"$5,821.97 ",IP,"2,420.00","19,337.47",,,,,,
Humana MCR ADV,DRG,MS-601,NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$4,010.97 ",IP,"2,420.00","12,475.01",,,,,,
Humana MCR ADV,DRG,MS-602,CELLULITIS WITH MCC,Medical,Relative Weights,"$8,468.11 ",IP,"2,420.00","28,824.77",,,,,,
Humana MCR ADV,DRG,MS-603,CELLULITIS WITHOUT MCC,Medical,Relative Weights,"$4,985.09 ",IP,"2,420.00","17,004.96",,,,,,
Humana MCR ADV,DRG,MS-604,TRAUMA TO THE SKIN -  SUBCUTANEOUS TISSUE AND BREAST WITH MCC,Medical,Relative Weights,"$8,631.05 ",IP,"2,420.00","29,524.32",,,,,,
Humana MCR ADV,DRG,MS-605,TRAUMA TO THE SKIN- SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC,Medical,Relative Weights,"$5,278.85 ",IP,"2,420.00","17,654.11",,,,,,
Humana MCR ADV,DRG,MS-606,MINOR SKIN DISORDERS WITH MCC,Medical,Relative Weights,"$8,830.78 ",IP,"2,420.00","30,149.28",,,,,,
Humana MCR ADV,DRG,MS-607,MINOR SKIN DISORDERS WITHOUT MCC,Medical,Relative Weights,"$4,836.75 ",IP,"2,420.00","16,654.18",,,,,,
Humana MCR ADV,DRG,MS-614,ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$13,956.03 ",IP,"2,420.00","49,055.33",,,,,,
Humana MCR ADV,DRG,MS-615,ADRENAL & PITUITARY PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$9,198.12 ",IP,"2,420.00","29,919.46",,,,,,
Humana MCR ADV,DRG,MS-616,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Surgical,Relative Weights,"$23,162.92 ",IP,"2,420.00","80,656.13",,,,,,
Humana MCR ADV,DRG,MS-617,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Surgical,Relative Weights,"$11,854.19 ",IP,"2,420.00","41,354.21",,,,,,
Humana MCR ADV,DRG,MS-618,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$7,610.79 ",IP,"2,420.00","25,290.72",,,,,,
Humana MCR ADV,DRG,MS-619,O.R. PROCEDURES FOR OBESITY WITH MCC,Surgical,Relative Weights,"$17,880.57 ",IP,"2,420.00","62,062.56",,,,,,
Humana MCR ADV,DRG,MS-620,O.R. PROCEDURES FOR OBESITY WITH CC,Surgical,Relative Weights,"$10,294.30 ",IP,"2,420.00","36,179.14",,,,,,
Humana MCR ADV,DRG,MS-621,O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,Surgical,Relative Weights,"$9,327.19 ",IP,"2,420.00","31,691.52",,,,,,
Humana MCR ADV,DRG,MS-622,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Surgical,Relative Weights,"$21,111.30 ",IP,"2,420.00","76,114.08",,,,,,
Humana MCR ADV,DRG,MS-623,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE -  NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Surgical,Relative Weights,"$10,929.71 ",IP,"2,420.00","39,364.42",,,,,,
Humana MCR ADV,DRG,MS-624,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$6,417.66 ",IP,"2,420.00","22,216.32",,,,,,
Humana MCR ADV,DRG,MS-625,THYROID- PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$16,586.99 ",IP,"2,420.00","58,970.02",,,,,,
Humana MCR ADV,DRG,MS-626,THYROID -  PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC,Surgical,Relative Weights,"$9,653.06 ",IP,"2,420.00","33,925.25",,,,,,
Humana MCR ADV,DRG,MS-627,THYROID -  PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,907.64 ",IP,"2,420.00","23,016.67",,,,,,
Humana MCR ADV,DRG,MS-628,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$21,487.98 ",IP,"2,420.00","74,376.29",,,,,,
Humana MCR ADV,DRG,MS-629,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$13,696.73 ",IP,"2,420.00","46,827.65",,,,,,
Humana MCR ADV,DRG,MS-630,OTHER ENDOCRINE - NUTRIT & METAB O.R. PROC W/O CC/MCC,Surgical,Relative Weights,"$8,230.42 ",IP,"2,420.00","29,207.81",,,,,,
Humana MCR ADV,DRG,MS-637,DIABETES WITH MCC,Medical,Relative Weights,"$8,039.45 ",IP,"2,420.00","27,935.71",,,,,,
Humana MCR ADV,DRG,MS-638,DIABETES WITH CC,Medical,Relative Weights,"$5,135.76 ",IP,"2,420.00","17,823.46",,,,,,
Humana MCR ADV,DRG,MS-639,DIABETES WITHOUT CC/MCC,Medical,Relative Weights,"$3,560.11 ",IP,"2,420.00","12,362.11",,,,,,
Humana MCR ADV,DRG,MS-640,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITH MCC,Medical,Relative Weights,"$7,187.97 ",IP,"2,420.00","24,478.27",,,,,,
Humana MCR ADV,DRG,MS-641,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITHOUT MCC,Medical,Relative Weights,"$4,404.59 ",IP,"2,420.00","15,253.06",,,,,,
Humana MCR ADV,DRG,MS-642,INBORN AND OTHER DISORDERS OF METABOLISM,Medical,Relative Weights,"$7,532.53 ",IP,"2,420.00","24,510.53",,,,,,
Humana MCR ADV,DRG,MS-643,ENDOCRINE DISORDERS WITH MCC,Medical,Relative Weights,"$9,739.50 ",IP,"2,420.00","32,770.08",,,,,,
Humana MCR ADV,DRG,MS-644,ENDOCRINE DISORDERS WITH CC,Medical,Relative Weights,"$5,955.71 ",IP,"2,420.00","20,726.50",,,,,,
Humana MCR ADV,DRG,MS-645,ENDOCRINE DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$4,488.68 ",IP,"2,420.00","15,426.43",,,,,,
Humana MCR ADV,DRG,MS-650,KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,Neonate,Relative Weights,"$26,401.24 ",IP,"2,420.00","26,401.24",,,,,,
Humana MCR ADV,DRG,MS-651,KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,Neonate,Relative Weights,"$21,598.94 ",IP,"2,420.00","21,598.94",,,,,,
Humana MCR ADV,DRG,MS-652,KIDNEY TRANSPLANT,Surgical,Relative Weights,"$18,601.23 ",IP,"2,420.00","68,239.58",,,,,,
Humana MCR ADV,DRG,MS-653,MAJOR BLADDER PROCEDURES WITH MCC,Surgical,Relative Weights,"$31,882.15 ",IP,"2,420.00","111,615.84",,,,,,
Humana MCR ADV,DRG,MS-654,MAJOR BLADDER PROCEDURES WITH CC,Surgical,Relative Weights,"$16,952.58 ",IP,"2,420.00","56,693.95",,,,,,
Humana MCR ADV,DRG,MS-655,MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$12,149.11 ",IP,"2,420.00","41,577.98",,,,,,
Humana MCR ADV,DRG,MS-656,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,Surgical,Relative Weights,"$19,184.65 ",IP,"2,420.00","65,733.70",,,,,,
Humana MCR ADV,DRG,MS-657,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,Surgical,Relative Weights,"$11,298.80 ",IP,"2,420.00","38,993.47",,,,,,
Humana MCR ADV,DRG,MS-658,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,Surgical,Relative Weights,"$9,215.06 ",IP,"2,420.00","31,649.18",,,,,,
Humana MCR ADV,DRG,MS-659,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,Surgical,Relative Weights,"$15,571.98 ",IP,"2,420.00","54,024.77",,,,,,
Humana MCR ADV,DRG,MS-660,KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC,Surgical,Relative Weights,"$8,427.82 ",IP,"2,420.00","28,641.31",,,,,,
Humana MCR ADV,DRG,MS-661,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,Surgical,Relative Weights,"$6,212.09 ",IP,"2,420.00","21,976.42",,,,,,
Humana MCR ADV,DRG,MS-662,MINOR BLADDER PROCEDURES WITH MCC,Surgical,Relative Weights,"$17,154.06 ",IP,"2,420.00","63,800.35",,,,,,
Humana MCR ADV,DRG,MS-663,MINOR BLADDER PROCEDURES WITH CC,Surgical,Relative Weights,"$9,341.20 ",IP,"2,420.00","30,711.74",,,,,,
Humana MCR ADV,DRG,MS-664,MINOR BLADDER PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,913.48 ",IP,"2,420.00","22,309.06",,,,,,
Humana MCR ADV,DRG,MS-665,PROSTATECTOMY WITH MCC,Surgical,Relative Weights,"$17,763.76 ",IP,"2,420.00","59,844.96",,,,,,
Humana MCR ADV,DRG,MS-666,PROSTATECTOMY WITH CC,Surgical,Relative Weights,"$10,159.98 ",IP,"2,420.00","35,665.06",,,,,,
Humana MCR ADV,DRG,MS-667,PROSTATECTOMY W/O CC/MCC,Surgical,Relative Weights,"$5,825.48 ",IP,"2,420.00","18,924.19",,,,,,
Humana MCR ADV,DRG,MS-668,TRANSURETHRAL PROCEDURES W MCC,Surgical,Relative Weights,"$16,389.01 ",IP,"2,420.00","56,212.13",,,,,,
Humana MCR ADV,DRG,MS-669,TRANSURETHRAL PROCEDURES WITH CC,Surgical,Relative Weights,"$9,130.96 ",IP,"2,420.00","31,161.31",,,,,,
Humana MCR ADV,DRG,MS-670,TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$5,714.52 ",IP,"2,420.00","19,730.59",,,,,,
Humana MCR ADV,DRG,MS-671,URETHRAL PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$10,402.93 ",IP,"2,420.00","36,844.42",,,,,,
Humana MCR ADV,DRG,MS-672,URETHRAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,718.43 ",IP,"2,420.00","20,829.31",,,,,,
Humana MCR ADV,DRG,MS-673,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,Surgical,Relative Weights,"$20,255.14 ",IP,"2,420.00","72,063.94",,,,,,
Humana MCR ADV,DRG,MS-674,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,Surgical,Relative Weights,"$13,918.07 ",IP,"2,420.00","49,275.07",,,,,,
Humana MCR ADV,DRG,MS-675,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,247.58 ",IP,"2,420.00","32,901.12",,,,,,
Humana MCR ADV,DRG,MS-682,RENAL FAILURE WITH MCC,Medical,Relative Weights,"$8,600.68 ",IP,"2,420.00","29,796.48",,,,,,
Humana MCR ADV,DRG,MS-683,RENAL FAILURE WITH CC,Medical,Relative Weights,"$5,135.18 ",IP,"2,420.00","18,089.57",,,,,,
Humana MCR ADV,DRG,MS-684,RENAL FAILURE WITHOUT CC/MCC,Medical,Relative Weights,"$3,550.18 ",IP,"2,420.00","12,404.45",,,,,,
Humana MCR ADV,DRG,MS-686,KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,Medical,Relative Weights,"$10,951.90 ",IP,"2,420.00","35,402.98",,,,,,
Humana MCR ADV,DRG,MS-687,KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,Medical,Relative Weights,"$6,132.67 ",IP,"2,420.00","21,220.42",,,,,,
Humana MCR ADV,DRG,MS-688,KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,Medical,Relative Weights,"$4,005.13 ",IP,"2,420.00","15,549.41",,,,,,
Humana MCR ADV,DRG,MS-689,KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,Medical,Relative Weights,"$6,507.01 ",IP,"2,420.00","22,550.98",,,,,,
Humana MCR ADV,DRG,MS-690,KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,Medical,Relative Weights,"$4,637.02 ",IP,"2,420.00","15,942.53",,,,,,
Humana MCR ADV,DRG,MS-693,URINARY STONES WITH MCC,Medical,Relative Weights,"$7,799.42 ",IP,"2,420.00","27,282.53",,,,,,
Humana MCR ADV,DRG,MS-694,URINARY STONES WITHOUT MCC,Medical,Relative Weights,"$4,503.87 ",IP,"2,420.00","14,926.46",,,,,,
Humana MCR ADV,DRG,MS-695,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,Medical,Relative Weights,"$6,644.26 ",IP,"2,420.00","23,633.57",,,,,,
Humana MCR ADV,DRG,MS-696,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,Medical,Relative Weights,"$4,040.75 ",IP,"2,420.00","13,696.70",,,,,,
Humana MCR ADV,DRG,MS-697,URETHRAL STRICTURE,Medical,Relative Weights,"$5,835.99 ",IP,"2,420.00","19,633.82",,,,,,
Humana MCR ADV,DRG,MS-698,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,Medical,Relative Weights,"$9,406.03 ",IP,"2,420.00","32,630.98",,,,,,
Humana MCR ADV,DRG,MS-699,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,Medical,Relative Weights,"$5,997.76 ",IP,"2,420.00","20,819.23",,,,,,
Humana MCR ADV,DRG,MS-700,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$4,359.62 ",IP,"2,420.00","14,952.67",,,,,,
Humana MCR ADV,DRG,MS-707,MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$11,225.80 ",IP,"2,420.00","37,697.18",,,,,,
Humana MCR ADV,DRG,MS-708,MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,708.72 ",IP,"2,420.00","29,272.32",,,,,,
Humana MCR ADV,DRG,MS-709,PENIS PROCEDURES W CC/MCC,Surgical,Relative Weights,"$13,525.04 ",IP,"2,420.00","48,496.90",,,,,,
Humana MCR ADV,DRG,MS-710,PENIS PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$9,353.47 ",IP,"2,420.00","30,961.73",,,,,,
Humana MCR ADV,DRG,MS-711,TESTES PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$12,448.71 ",IP,"2,420.00","43,206.91",,,,,,
Humana MCR ADV,DRG,MS-712,TESTES PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,190.48 ",IP,"2,420.00","20,567.23",,,,,,
Humana MCR ADV,DRG,MS-713,TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,Surgical,Relative Weights,"$8,721.57 ",IP,"2,420.00","29,473.92",,,,,,
Humana MCR ADV,DRG,MS-714,TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,Surgical,Relative Weights,"$5,424.26 ",IP,"2,420.00","18,454.46",,,,,,
Humana MCR ADV,DRG,MS-715,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,Surgical,Relative Weights,"$11,806.30 ",IP,"2,420.00","43,071.84",,,,,,
Humana MCR ADV,DRG,MS-716,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$7,450.77 ",IP,"2,420.00","29,544.48",,,,,,
Humana MCR ADV,DRG,MS-717,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,Surgical,Relative Weights,"$10,515.64 ",IP,"2,420.00","35,568.29",,,,,,
Humana MCR ADV,DRG,MS-718,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$7,210.16 ",IP,"2,420.00","24,583.10",,,,,,
Humana MCR ADV,DRG,MS-722,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH MCC,Medical,Relative Weights,"$10,001.72 ",IP,"2,420.00","36,386.78",,,,,,
Humana MCR ADV,DRG,MS-723,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH CC,Medical,Relative Weights,"$6,376.78 ",IP,"2,420.00","22,325.18",,,,,,
Humana MCR ADV,DRG,MS-724,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Medical,Relative Weights,"$3,784.95 ",IP,"2,420.00","11,902.46",,,,,,
Humana MCR ADV,DRG,MS-725,BENIGN PROSTATIC HYPERTROPHY WITH MCC,Medical,Relative Weights,"$7,507.42 ",IP,"2,420.00","25,308.86",,,,,,
Humana MCR ADV,DRG,MS-726,BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,Medical,Relative Weights,"$4,349.11 ",IP,"2,420.00","15,416.35",,,,,,
Humana MCR ADV,DRG,MS-727,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,Medical,Relative Weights,"$8,298.75 ",IP,"2,420.00","28,774.37",,,,,,
Humana MCR ADV,DRG,MS-728,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,Medical,Relative Weights,"$4,705.35 ",IP,"2,420.00","16,178.40",,,,,,
Humana MCR ADV,DRG,MS-729,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,Medical,Relative Weights,"$5,883.88 ",IP,"2,420.00","21,649.82",,,,,,
Humana MCR ADV,DRG,MS-730,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$3,322.42 ",IP,"2,420.00","12,733.06",,,,,,
Humana MCR ADV,DRG,MS-734,PELVIC EVISCERATION -  RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC,Surgical,Relative Weights,"$12,990.08 ",IP,"2,420.00","44,188.70",,,,,,
Humana MCR ADV,DRG,MS-735,PELVIC EVISCERATION -  RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC,Surgical,Relative Weights,"$8,255.53 ",IP,"2,420.00","27,703.87",,,,,,
Humana MCR ADV,DRG,MS-736,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,Surgical,Relative Weights,"$24,882.82 ",IP,"2,420.00","87,109.34",,,,,,
Humana MCR ADV,DRG,MS-737,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,Surgical,Relative Weights,"$12,019.46 ",IP,"2,420.00","40,059.94",,,,,,
Humana MCR ADV,DRG,MS-738,UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY W/O CC/MCC,Surgical,Relative Weights,"$8,619.37 ",IP,"2,420.00","27,798.62",,,,,,
Humana MCR ADV,DRG,MS-739,UTERINE -ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W MCC,Surgical,Relative Weights,"$22,332.46 ",IP,"2,420.00","75,489.12",,,,,,
Humana MCR ADV,DRG,MS-740,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,Surgical,Relative Weights,"$10,521.48 ",IP,"2,420.00","35,983.58",,,,,,
Humana MCR ADV,DRG,MS-741,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$7,474.72 ",IP,"2,420.00","26,802.72",,,,,,
Humana MCR ADV,DRG,MS-742,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,Surgical,Relative Weights,"$10,033.84 ",IP,"2,420.00","34,060.32",,,,,,
Humana MCR ADV,DRG,MS-743,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$6,615.64 ",IP,"2,420.00","23,153.76",,,,,,
Humana MCR ADV,DRG,MS-744,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC,Surgical,Relative Weights,"$10,485.28 ",IP,"2,420.00","35,088.48",,,,,,
Humana MCR ADV,DRG,MS-745,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC,Surgical,Relative Weights,"$6,832.89 ",IP,"2,420.00","21,476.45",,,,,,
Humana MCR ADV,DRG,MS-746,VAGINA -  CERVIX AND VULVA PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$9,411.29 ",IP,"2,420.00","32,880.96",,,,,,
Humana MCR ADV,DRG,MS-747,VAGINA- CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$5,484.42 ",IP,"2,420.00","18,793.15",,,,,,
Humana MCR ADV,DRG,MS-748,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,Surgical,Relative Weights,"$7,870.09 ",IP,"2,420.00","26,645.47",,,,,,
Humana MCR ADV,DRG,MS-749,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$15,848.80 ",IP,"2,420.00","52,258.75",,,,,,
Humana MCR ADV,DRG,MS-750,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,548.71 ",IP,"2,420.00","26,836.99",,,,,,
Humana MCR ADV,DRG,MS-754,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH MCC,Medical,Relative Weights,"$10,665.15 ",IP,"2,420.00","35,519.90",,,,,,
Humana MCR ADV,DRG,MS-755,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH CC,Medical,Relative Weights,"$6,595.20 ",IP,"2,420.00","20,639.81",,,,,,
Humana MCR ADV,DRG,MS-756,MALIGNANCY - FEMALE REPRODUCTIVE SYSTEM W/O CC/MCC,Medical,Relative Weights,"$5,363.53 ",IP,"2,420.00","17,676.29",,,,,,
Humana MCR ADV,DRG,MS-757,INFECTIONS - FEMALE REPRODUCTIVE SYSTEM W MCC,Medical,Relative Weights,"$8,904.37 ",IP,"2,420.00","28,633.25",,,,,,
Humana MCR ADV,DRG,MS-758,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITH CC,Medical,Relative Weights,"$5,663.12 ",IP,"2,420.00","19,462.46",,,,,,
Humana MCR ADV,DRG,MS-759,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Medical,Relative Weights,"$3,991.11 ",IP,"2,420.00","13,311.65",,,,,,
Humana MCR ADV,DRG,MS-760,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,Medical,Relative Weights,"$5,373.46 ",IP,"2,420.00","18,194.40",,,,,,
Humana MCR ADV,DRG,MS-761,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$3,450.32 ",IP,"2,420.00","11,398.46",,,,,,
Humana MCR ADV,DRG,MS-768,VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C,Surgical,Relative Weights,"$6,830.55 ",IP,"2,420.00","20,311.20",,,,,,
Humana MCR ADV,DRG,MS-769,POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,Surgical,Relative Weights,"$9,446.91 ",IP,"2,420.00","29,090.88",,,,,,
Humana MCR ADV,DRG,MS-770,ABORTION WITH D&C- ASPIRATION CURETTAGE OR HYSTEROTOMY,Surgical,Relative Weights,"$5,196.50 ",IP,"2,420.00","15,851.81",,,,,,
Humana MCR ADV,DRG,MS-776,POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,Medical,Relative Weights,"$4,523.14 ",IP,"2,420.00","14,311.58",,,,,,
Humana MCR ADV,DRG,MS-779,ABORTION WITHOUT D&C,Medical,Relative Weights,"$6,184.64 ",IP,"2,420.00","23,018.69",,,,,,
Humana MCR ADV,DRG,MS-783,CESAREAN SECTION WITH STERILIZATION WITH MCC,C-Section,Relative Weights,"$10,949.56 ",IP,"2,420.00","43,239.17",,,,,,
Humana MCR ADV,DRG,MS-784,CESAREAN SECTION WITH STERILIZATION WITH CC,C-Section,Relative Weights,"$6,400.14 ",IP,"2,420.00","21,071.23",,,,,,
Humana MCR ADV,DRG,MS-785,CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,C-Section,Relative Weights,"$5,354.18 ",IP,"2,420.00","17,305.34",,,,,,
Humana MCR ADV,DRG,MS-786,CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,C-Section,Relative Weights,"$9,311.42 ",IP,"2,420.00","34,564.32",,,,,,
Humana MCR ADV,DRG,MS-787,CESAREAN SECTION WITHOUT STERILIZATION WITH CC,C-Section,Relative Weights,"$6,216.18 ",IP,"2,420.00","21,077.28",,,,,,
Humana MCR ADV,DRG,MS-788,CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,C-Section,Relative Weights,"$5,182.48 ",IP,"2,420.00","18,268.99",,,,,,
Humana MCR ADV,DRG,MS-789,NEONATES- DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY,Medical,Relative Weights,"$10,044.93 ",IP,"2,420.00","34,070.40",,,,,,
Humana MCR ADV,DRG,MS-790,EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME- NEONATE,Medical,Relative Weights,"$33,125.50 ",IP,"2,420.00","112,351.68",,,,,,
Humana MCR ADV,DRG,MS-791,PREMATURITY W MAJOR PROBLEMS,Medical,Relative Weights,"$22,623.29 ",IP,"2,420.00","76,732.99",,,,,,
Humana MCR ADV,DRG,MS-792,PREMATURITY W/O MAJOR PROBLEMS,Medical,Relative Weights,"$13,650.60 ",IP,"2,420.00","46,297.44",,,,,,
Humana MCR ADV,DRG,MS-793,FULL TERM NEONATE WITH MAJOR PROBLEMS,Medical,Relative Weights,"$23,238.84 ",IP,"2,420.00","78,819.55",,,,,,
Humana MCR ADV,DRG,MS-794,NEONATE WITH OTHER SIGNIFICANT PROBLEMS,Medical,Relative Weights,"$8,225.17 ",IP,"2,420.00","27,897.41",,,,,,
Humana MCR ADV,DRG,MS-795,NORMAL NEWBORN,Medical,Relative Weights,"$1,113.70 ",IP,"1,113.70","3,775.97",,,,,,
Humana MCR ADV,DRG,MS-796,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,Vaginal Delivery,Relative Weights,"$6,253.56 ",IP,"2,420.00","39,761.57",,,,,,
Humana MCR ADV,DRG,MS-797,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,Vaginal Delivery,Relative Weights,"$5,369.37 ",IP,"2,420.00","17,394.05",,,,,,
Humana MCR ADV,DRG,MS-798,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,Vaginal Delivery,Relative Weights,"$4,832.66 ",IP,"2,420.00","17,394.05",,,,,,
Humana MCR ADV,DRG,MS-799,SPLENECTOMY WITH MCC,Surgical,Relative Weights,"$30,061.22 ",IP,"2,420.00","99,677.09",,,,,,
Humana MCR ADV,DRG,MS-800,SPLENECTOMY WITH CC,Surgical,Relative Weights,"$17,251.01 ",IP,"2,420.00","57,294.72",,,,,,
Humana MCR ADV,DRG,MS-801,SPLENECTOMY WITHOUT CC/MCC,Surgical,Relative Weights,"$9,834.69 ",IP,"2,420.00","37,763.71",,,,,,
Humana MCR ADV,DRG,MS-802,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,Surgical,Relative Weights,"$21,676.62 ",IP,"2,420.00","63,552.38",,,,,,
Humana MCR ADV,DRG,MS-803,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,Surgical,Relative Weights,"$11,017.31 ",IP,"2,420.00","35,917.06",,,,,,
Humana MCR ADV,DRG,MS-804,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,Surgical,Relative Weights,"$7,976.96 ",IP,"2,420.00","27,470.02",,,,,,
Humana MCR ADV,DRG,MS-805,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,Vaginal Delivery,Relative Weights,"$6,014.70 ",IP,"2,420.00","20,980.51",,,,,,
Humana MCR ADV,DRG,MS-806,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,Vaginal Delivery,Relative Weights,"$4,290.12 ",IP,"2,420.00","14,297.47",,,,,,
Humana MCR ADV,DRG,MS-807,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,Vaginal Delivery,Relative Weights,"$3,751.08 ",IP,"2,420.00","12,636.29",,,,,,
Humana MCR ADV,DRG,MS-808,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,Medical,Relative Weights,"$12,765.24 ",IP,"2,420.00","42,932.74",,,,,,
Humana MCR ADV,DRG,MS-809,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,Medical,Relative Weights,"$7,144.75 ",IP,"2,420.00","24,512.54",,,,,,
Humana MCR ADV,DRG,MS-810,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$5,616.40 ",IP,"2,420.00","18,857.66",,,,,,
Humana MCR ADV,DRG,MS-811,RED BLOOD CELL DISORDERS WITH MCC,Medical,Relative Weights,"$8,055.22 ",IP,"2,420.00","27,020.45",,,,,,
Humana MCR ADV,DRG,MS-812,RED BLOOD CELL DISORDERS WITHOUT MCC,Medical,Relative Weights,"$5,141.02 ",IP,"2,420.00","17,553.31",,,,,,
Humana MCR ADV,DRG,MS-813,COAGULATION DISORDERS,Medical,Relative Weights,"$9,023.50 ",IP,"2,420.00","31,957.63",,,,,,
Humana MCR ADV,DRG,MS-814,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,Medical,Relative Weights,"$11,047.67 ",IP,"2,420.00","35,261.86",,,,,,
Humana MCR ADV,DRG,MS-815,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,Medical,Relative Weights,"$5,801.53 ",IP,"2,420.00","20,418.05",,,,,,
Humana MCR ADV,DRG,MS-816,RETICULOENDOTHELIAL & IMMUNITY DISORDERS W/O CC/MCC,Medical,Relative Weights,"$3,860.88 ",IP,"2,420.00","14,432.54",,,,,,
Humana MCR ADV,DRG,MS-817,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$13,471.89 ",IP,"2,420.00","50,726.59",,,,,,
Humana MCR ADV,DRG,MS-818,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$7,941.34 ",IP,"2,420.00","25,681.82",,,,,,
Humana MCR ADV,DRG,MS-819,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$5,765.32 ",IP,"2,420.00","16,085.66",,,,,,
Humana MCR ADV,DRG,MS-820,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$33,239.97 ",IP,"2,420.00","115,248.67",,,,,,
Humana MCR ADV,DRG,MS-821,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$12,586.54 ",IP,"2,420.00","45,003.17",,,,,,
Humana MCR ADV,DRG,MS-822,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,308.86 ",IP,"2,420.00","25,490.30",,,,,,
Humana MCR ADV,DRG,MS-823,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,Surgical,Relative Weights,"$26,290.86 ",IP,"2,420.00","85,280.83",,,,,,
Humana MCR ADV,DRG,MS-824,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,Surgical,Relative Weights,"$13,808.28 ",IP,"2,420.00","46,874.02",,,,,,
Humana MCR ADV,DRG,MS-825,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,184.87 ",IP,"2,420.00","27,306.72",,,,,,
Humana MCR ADV,DRG,MS-826,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$29,460.27 ",IP,"2,420.00","101,102.40",,,,,,
Humana MCR ADV,DRG,MS-827,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$14,603.70 ",IP,"2,420.00","46,694.59",,,,,,
Humana MCR ADV,DRG,MS-828,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$9,776.29 ",IP,"2,420.00","33,288.19",,,,,,
Humana MCR ADV,DRG,MS-829,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$18,737.31 ",IP,"2,420.00","63,300.38",,,,,,
Humana MCR ADV,DRG,MS-830,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,655.00 ",IP,"2,420.00","27,796.61",,,,,,
Humana MCR ADV,DRG,MS-831,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,Medical,Relative Weights,"$6,551.40 ",IP,"2,420.00","21,742.56",,,,,,
Humana MCR ADV,DRG,MS-832,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,Medical,Relative Weights,"$4,545.33 ",IP,"2,420.00","14,424.48",,,,,,
Humana MCR ADV,DRG,MS-833,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,Medical,Relative Weights,"$3,136.12 ",IP,"2,420.00","10,727.14",,,,,,
Humana MCR ADV,DRG,MS-834,ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W MCC,Medical,Relative Weights,"$35,345.32 ",IP,"2,420.00","117,784.80",,,,,,
Humana MCR ADV,DRG,MS-835,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC,Medical,Relative Weights,"$12,344.17 ",IP,"2,420.00","40,888.51",,,,,,
Humana MCR ADV,DRG,MS-836,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Medical,Relative Weights,"$6,853.33 ",IP,"2,420.00","26,562.82",,,,,,
Humana MCR ADV,DRG,MS-837,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,Medical,Relative Weights,"$33,284.35 ",IP,"2,420.00","120,774.53",,,,,,
Humana MCR ADV,DRG,MS-838,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,Medical,Relative Weights,"$13,199.74 ",IP,"2,420.00","44,108.06",,,,,,
Humana MCR ADV,DRG,MS-839,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Medical,Relative Weights,"$8,685.36 ",IP,"2,420.00","25,728.19",,,,,,
Humana MCR ADV,DRG,MS-840,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,Medical,Relative Weights,"$18,807.97 ",IP,"2,420.00","64,415.23",,,,,,
Humana MCR ADV,DRG,MS-841,LYMPHOMA & NON-ACUTE LEUKEMIA W CC,Medical,Relative Weights,"$9,470.27 ",IP,"2,420.00","32,491.87",,,,,,
Humana MCR ADV,DRG,MS-842,LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,Medical,Relative Weights,"$6,406.57 ",IP,"2,420.00","23,115.46",,,,,,
Humana MCR ADV,DRG,MS-843,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,Medical,Relative Weights,"$11,140.53 ",IP,"2,420.00","38,461.25",,,,,,
Humana MCR ADV,DRG,MS-844,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,Medical,Relative Weights,"$6,915.82 ",IP,"2,420.00","24,353.28",,,,,,
Humana MCR ADV,DRG,MS-845,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$4,957.64 ",IP,"2,420.00","17,456.54",,,,,,
Humana MCR ADV,DRG,MS-846,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,Medical,Relative Weights,"$15,609.94 ",IP,"2,420.00","52,952.26",,,,,,
Humana MCR ADV,DRG,MS-847,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,Medical,Relative Weights,"$7,802.93 ",IP,"2,420.00","26,528.54",,,,,,
Humana MCR ADV,DRG,MS-848,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Medical,Relative Weights,"$6,028.71 ",IP,"2,420.00","19,785.02",,,,,,
Humana MCR ADV,DRG,MS-849,RADIOTHERAPY,Medical,Relative Weights,"$14,562.82 ",IP,"2,420.00","42,856.13",,,,,,
Humana MCR ADV,DRG,MS-853,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$29,012.34 ",IP,"2,420.00","102,787.78",,,,,,
Humana MCR ADV,DRG,MS-854,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$12,393.81 ",IP,"2,420.00","43,569.79",,,,,,
Humana MCR ADV,DRG,MS-855,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,875.75 ",IP,"2,420.00","32,322.53",,,,,,
Humana MCR ADV,DRG,MS-856,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$27,237.54 ",IP,"2,420.00","89,222.11",,,,,,
Humana MCR ADV,DRG,MS-857,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$12,278.18 ",IP,"2,420.00","40,991.33",,,,,,
Humana MCR ADV,DRG,MS-858,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,940.17 ",IP,"2,420.00","27,748.22",,,,,,
Humana MCR ADV,DRG,MS-862,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W MCC,Medical,Relative Weights,"$11,076.88 ",IP,"2,420.00","37,308.10",,,,,,
Humana MCR ADV,DRG,MS-863,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W/O MCC,Medical,Relative Weights,"$5,906.65 ",IP,"2,420.00","19,918.08",,,,,,
Humana MCR ADV,DRG,MS-864,FEVER AND INFLAMMATORY CONDITIONS,Medical,Relative Weights,"$5,118.83 ",IP,"2,420.00","17,083.58",,,,,,
Humana MCR ADV,DRG,MS-865,VIRAL ILLNESS WITH MCC,Medical,Relative Weights,"$8,630.47 ",IP,"2,420.00","28,088.93",,,,,,
Humana MCR ADV,DRG,MS-866,VIRAL ILLNESS WITHOUT MCC,Medical,Relative Weights,"$4,899.83 ",IP,"2,420.00","16,504.99",,,,,,
Humana MCR ADV,DRG,MS-867,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,Medical,Relative Weights,"$13,064.84 ",IP,"2,420.00","44,053.63",,,,,,
Humana MCR ADV,DRG,MS-868,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,Medical,Relative Weights,"$6,225.52 ",IP,"2,420.00","22,115.52",,,,,,
Humana MCR ADV,DRG,MS-869,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$4,254.50 ",IP,"2,420.00","14,968.80",,,,,,
Humana MCR ADV,DRG,MS-870,SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,Medical,Relative Weights,"$37,604.26 ",IP,"2,420.00","127,497.89",,,,,,
Humana MCR ADV,DRG,MS-871,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,Medical,Relative Weights,"$10,933.79 ",IP,"2,420.00","37,624.61",,,,,,
Humana MCR ADV,DRG,MS-872,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,Medical,Relative Weights,"$5,993.67 ",IP,"2,420.00","20,952.29",,,,,,
Humana MCR ADV,DRG,MS-876,O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,Surgical,Relative Weights,"$19,085.37 ",IP,"2,420.00","73,382.40",,,,,,
Humana MCR ADV,DRG,MS-880,ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,Medical,Relative Weights,"$5,048.75 ",IP,"2,420.00","17,275.10",,,,,,
Humana MCR ADV,DRG,MS-881,DEPRESSIVE NEUROSES,Medical,Relative Weights,"$4,683.74 ",IP,"2,420.00","16,517.09",,,,,,
Humana MCR ADV,DRG,MS-882,NEUROSES EXCEPT DEPRESSIVE,Medical,Relative Weights,"$4,809.89 ",IP,"2,420.00","15,922.37",,,,,,
Humana MCR ADV,DRG,MS-883,DISORDERS OF PERSONALITY & IMPULSE CONTROL,Medical,Relative Weights,"$9,237.83 ",IP,"2,420.00","26,945.86",,,,,,
Humana MCR ADV,DRG,MS-884,ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,Medical,Relative Weights,"$8,452.34 ",IP,"2,420.00","28,990.08",,,,,,
Humana MCR ADV,DRG,MS-885,PSYCHOSES,Medical,Relative Weights,"$7,238.19 ",IP,"2,420.00","24,502.46",,,,,,
Humana MCR ADV,DRG,MS-886,BEHAVIORAL AND DEVELOPMENTAL DISORDERS,Medical,Relative Weights,"$7,146.50 ",IP,"2,420.00","27,127.30",,,,,,
Humana MCR ADV,DRG,MS-887,OTHER MENTAL DISORDER DIAGNOSES,Medical,Relative Weights,"$6,306.12 ",IP,"2,420.00","21,936.10",,,,,,
Humana MCR ADV,DRG,MS-894,ALCOHOL- DRUG ABUSE OR DEPENDENCE- LEFT AMA,Medical,Relative Weights,"$3,206.20 ",IP,"2,420.00","11,700.86",,,,,,
Humana MCR ADV,DRG,MS-895,ALCOHOL- DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY,Medical,Relative Weights,"$9,339.45 ",IP,"2,420.00","32,798.30",,,,,,
Humana MCR ADV,DRG,MS-896,ALCOHOL -  DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC,Medical,Relative Weights,"$10,397.09 ",IP,"2,420.00","34,669.15",,,,,,
Humana MCR ADV,DRG,MS-897,ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC,Medical,Relative Weights,"$4,829.74 ",IP,"2,420.00","16,567.49",,,,,,
Humana MCR ADV,DRG,MS-901,WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,Surgical,Relative Weights,"$24,929.54 ",IP,"2,420.00","87,236.35",,,,,,
Humana MCR ADV,DRG,MS-902,WOUND DEBRIDEMENTS FOR INJURIES WITH CC,Surgical,Relative Weights,"$11,471.66 ",IP,"2,420.00","39,652.70",,,,,,
Humana MCR ADV,DRG,MS-903,WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,630.24 ",IP,"2,420.00","23,063.04",,,,,,
Humana MCR ADV,DRG,MS-904,SKIN GRAFTS FOR INJURIES WITH CC/MCC,Surgical,Relative Weights,"$21,765.97 ",IP,"2,420.00","71,313.98",,,,,,
Humana MCR ADV,DRG,MS-905,SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,Surgical,Relative Weights,"$9,636.13 ",IP,"2,420.00","33,554.30",,,,,,
Humana MCR ADV,DRG,MS-906,HAND PROCEDURES FOR INJURIES,Surgical,Relative Weights,"$10,534.33 ",IP,"2,420.00","35,096.54",,,,,,
Humana MCR ADV,DRG,MS-907,OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,Surgical,Relative Weights,"$23,057.79 ",IP,"2,420.00","80,430.34",,,,,,
Humana MCR ADV,DRG,MS-908,OTHER O.R. PROCEDURES FOR INJURIES WITH CC,Surgical,Relative Weights,"$11,974.50 ",IP,"2,420.00","41,592.10",,,,,,
Humana MCR ADV,DRG,MS-909,OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,006.75 ",IP,"2,420.00","26,584.99",,,,,,
Humana MCR ADV,DRG,MS-913,TRAUMATIC INJURY WITH MCC,Medical,Relative Weights,"$9,569.55 ",IP,"2,420.00","29,762.21",,,,,,
Humana MCR ADV,DRG,MS-914,TRAUMATIC INJURY WITHOUT MCC,Medical,Relative Weights,"$5,179.56 ",IP,"2,420.00","17,371.87",,,,,,
Humana MCR ADV,DRG,MS-915,ALLERGIC REACTIONS WITH MCC,Medical,Relative Weights,"$9,925.21 ",IP,"2,420.00","34,253.86",,,,,,
Humana MCR ADV,DRG,MS-916,ALLERGIC REACTIONS WITHOUT MCC,Medical,Relative Weights,"$3,845.11 ",IP,"2,420.00","12,765.31",,,,,,
Humana MCR ADV,DRG,MS-917,POISONING & TOXIC EFFECTS OF DRUGS W MCC,Medical,Relative Weights,"$8,634.55 ",IP,"2,420.00","29,498.11",,,,,,
Humana MCR ADV,DRG,MS-918,POISONING & TOXIC EFFECTS OF DRUGS W/O MCC,Medical,Relative Weights,"$4,623.01 ",IP,"2,420.00","15,805.44",,,,,,
Humana MCR ADV,DRG,MS-919,COMPLICATIONS OF TREATMENT WITH MCC,Medical,Relative Weights,"$10,769.69 ",IP,"2,420.00","36,798.05",,,,,,
Humana MCR ADV,DRG,MS-920,COMPLICATIONS OF TREATMENT WITH CC,Medical,Relative Weights,"$5,983.74 ",IP,"2,420.00","20,311.20",,,,,,
Humana MCR ADV,DRG,MS-921,COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,Medical,Relative Weights,"$4,075.79 ",IP,"2,420.00","13,922.50",,,,,,
Humana MCR ADV,DRG,MS-922,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC,Medical,Relative Weights,"$9,275.21 ",IP,"2,420.00","32,328.58",,,,,,
Humana MCR ADV,DRG,MS-923,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC,Medical,Relative Weights,"$5,488.50 ",IP,"2,420.00","17,448.48",,,,,,
Humana MCR ADV,DRG,MS-927,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,Surgical,Relative Weights,"$123,174.83 ",IP,"2,420.00","402,060.96",,,,,,
Humana MCR ADV,DRG,MS-928,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,Surgical,Relative Weights,"$38,145.05 ",IP,"2,420.00","124,889.18",,,,,,
Humana MCR ADV,DRG,MS-929,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,Surgical,Relative Weights,"$17,601.41 ",IP,"2,420.00","59,300.64",,,,,,
Humana MCR ADV,DRG,MS-933,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,Medical,Relative Weights,"$13,215.51 ",IP,"2,420.00","63,306.43",,,,,,
Humana MCR ADV,DRG,MS-934,FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,Medical,Relative Weights,"$11,335.01 ",IP,"2,420.00","36,485.57",,,,,,
Humana MCR ADV,DRG,MS-935,NON-EXTENSIVE BURNS,Medical,Relative Weights,"$11,288.29 ",IP,"2,420.00","38,955.17",,,,,,
Humana MCR ADV,DRG,MS-939,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,Surgical,Relative Weights,"$19,707.93 ",IP,"2,420.00","73,672.70",,,,,,
Humana MCR ADV,DRG,MS-940,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,Surgical,Relative Weights,"$12,970.23 ",IP,"2,420.00","45,799.49",,,,,,
Humana MCR ADV,DRG,MS-941,O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W/O CC/MCC,Surgical,Relative Weights,"$11,231.05 ",IP,"2,420.00","38,922.91",,,,,,
Humana MCR ADV,DRG,MS-945,REHABILITATION WITH CC/MCC,Medical,Relative Weights,"$8,654.41 ",IP,"2,420.00","29,338.85",,,,,,
Humana MCR ADV,DRG,MS-946,REHABILITATION WITHOUT CC/MCC,Medical,Relative Weights,"$6,577.10 ",IP,"2,420.00","21,913.92",,,,,,
Humana MCR ADV,DRG,MS-947,SIGNS AND SYMPTOMS WITH MCC,Medical,Relative Weights,"$6,973.05 ",IP,"2,420.00","24,137.57",,,,,,
Humana MCR ADV,DRG,MS-948,SIGNS AND SYMPTOMS WITHOUT MCC,Medical,Relative Weights,"$4,596.73 ",IP,"2,420.00","15,716.74",,,,,,
Humana MCR ADV,DRG,MS-949,AFTERCARE WITH CC/MCC,Medical,Relative Weights,"$6,481.90 ",IP,"2,420.00","21,952.22",,,,,,
Humana MCR ADV,DRG,MS-950,AFTERCARE WITHOUT CC/MCC,Medical,Relative Weights,"$4,322.83 ",IP,"2,420.00","14,936.54",,,,,,
Humana MCR ADV,DRG,MS-951,OTHER FACTORS INFLUENCING HEALTH STATUS,Medical,Relative Weights,"$3,268.11 ",IP,"2,420.00","11,823.84",,,,,,
Humana MCR ADV,DRG,MS-955,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,Surgical,Relative Weights,"$36,730.00 ",IP,"2,420.00","122,582.88",,,,,,
Humana MCR ADV,DRG,MS-956,LIMB REATTACHMENT- HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,Surgical,Relative Weights,"$22,484.30 ",IP,"2,420.00","79,093.73",,,,,,
Humana MCR ADV,DRG,MS-957,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Surgical,Relative Weights,"$43,338.63 ",IP,"2,420.00","151,879.39",,,,,,
Humana MCR ADV,DRG,MS-958,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,Surgical,Relative Weights,"$24,561.61 ",IP,"2,420.00","84,488.54",,,,,,
Humana MCR ADV,DRG,MS-959,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,Surgical,Relative Weights,"$15,979.04 ",IP,"2,420.00","56,458.08",,,,,,
Humana MCR ADV,DRG,MS-963,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Medical,Relative Weights,"$15,942.83 ",IP,"2,420.00","54,938.02",,,,,,
Humana MCR ADV,DRG,MS-964,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,Medical,Relative Weights,"$8,712.23 ",IP,"2,420.00","30,108.96",,,,,,
Humana MCR ADV,DRG,MS-965,OTHER MULTIPLE SIGNIFICANT TRAUMA W/O CC/MCC,Medical,Relative Weights,"$5,329.07 ",IP,"2,420.00","18,488.74",,,,,,
Humana MCR ADV,DRG,MS-969,HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$34,175.55 ",IP,"2,420.00","116,982.43",,,,,,
Humana MCR ADV,DRG,MS-970,HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$17,454.24 ",IP,"2,420.00","58,806.72",,,,,,
Humana MCR ADV,DRG,MS-974,HIV WITH MAJOR RELATED CONDITION WITH MCC,Medical,Relative Weights,"$15,712.73 ",IP,"2,420.00","53,905.82",,,,,,
Humana MCR ADV,DRG,MS-975,HIV WITH MAJOR RELATED CONDITION WITH CC,Medical,Relative Weights,"$7,487.56 ",IP,"2,420.00","27,054.72",,,,,,
Humana MCR ADV,DRG,MS-976,HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,Medical,Relative Weights,"$5,545.74 ",IP,"2,420.00","18,430.27",,,,,,
Humana MCR ADV,DRG,MS-977,HIV WITH OR WITHOUT OTHER RELATED CONDITION,Medical,Relative Weights,"$7,734.01 ",IP,"2,420.00","26,218.08",,,,,,
Humana MCR ADV,DRG,MS-981,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$26,949.04 ",IP,"2,420.00","90,532.51",,,,,,
Humana MCR ADV,DRG,MS-982,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Surgical,Relative Weights,"$14,813.94 ",IP,"2,420.00","49,152.10",,,,,,
Humana MCR ADV,DRG,MS-983,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$9,649.56 ",IP,"2,420.00","33,003.94",,,,,,
Humana MCR ADV,DRG,MS-987,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$19,131.51 ",IP,"2,420.00","67,207.39",,,,,,
Humana MCR ADV,DRG,MS-988,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Surgical,Relative Weights,"$9,965.51 ",IP,"2,420.00","34,640.93",,,,,,
Humana MCR ADV,DRG,MS-989,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$6,561.91 ",IP,"2,420.00","23,232.38",,,,,,
Humana MCR ADV,CPT,176,Anesth pharyngeal surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,211,Anesth cran surg hemotoma,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,214,Anesth skull drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,215,Anesth skull repair/fract,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,524,Anesth chest drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,540,Anesth chest surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,542,Anesthesia removal pleura,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,546,Anesth lung chest wall surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,560,Anesth heart surg w/o pump,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,561,Anesth heart surg <1 yr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,562,Anesth hrt surg w/pmp age 1+,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,567,Anesth cabg w/pump,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,580,Anesth heart/lung transplnt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,632,Anesth removal of nerves,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,792,Anesth hemorr/excise liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,794,Anesth pancreas removal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,796,Anesth for liver transplant,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,844,Anesth pelvis surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,846,Anesth hysterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,848,Anesth pelvic organ surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,864,Anesth removal of bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,866,Anesth removal of adrenal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,868,Anesth kidney transplant,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,882,Anesth major vein ligation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,908,Anesth removal of prostate,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,932,Anesth amputation of penis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,934,Anesth penis nodes removal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,936,Anesth penis nodes removal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,1272,Anesth femoral artery surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,1442,Anesth knee artery surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,1444,Anesth knee artery repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,1502,Anesth lwr leg embolectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,1652,Anesth shoulder vessel surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,1654,Anesth shoulder vessel surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,1656,Anesth arm-leg vessel surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,1990,Support for organ donor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,10005,Fna bx w/us gdn 1st les,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,10007,Fna bx w/fluor gdn 1st les,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,10009,Fna bx w/ct gdn 1st les,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,10011,Fna bx w/mr gdn 1st les,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,10021,Fna bx w/o img gdn 1st les,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,10030,Guide cathet fluid drainage,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,10035,Perq dev soft tiss 1st imag,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,10040,Acne surgery,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,10060,Drainage of skin abscess,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,10061,Drainage of skin abscess,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,10080,Drainage of pilonidal cyst,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,10081,Drainage of pilonidal cyst,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,10120,Remove foreign body,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,10121,Remove foreign body,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,10140,Drainage of hematoma/fluid,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,10160,Puncture drainage of lesion,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,10180,Complex drainage wound,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,11000,Debride infected skin,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,11004,Debride genitalia & perineum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,11005,Debride abdom wall,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,11006,Debride genit/per/abdom wall,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,11008,Remove mesh from abd wall,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,11010,Debride skin at fx site,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,11011,Debride skin musc at fx site,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,11012,Deb skin bone at fx site,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,11042,Deb subq tissue 20 sq cm/<,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,11043,Deb musc/fascia 20 sq cm/<,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,11044,Deb bone 20 sq cm/<,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,11055,Trim skin lesion,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,11056,Trim skin lesions 2 to 4,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,11057,Trim skin lesions over 4,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,11102,Tangntl bx skin single les,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,11104,Punch bx skin single lesion,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,11106,Incal bx skn single les,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,11200,Removal of skin tags <w/15,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,11300,Shave skin lesion 0.5 cm/<,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,11301,Shave skin lesion 0.6-1.0 cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,11302,Shave skin lesion 1.1-2.0 cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,11303,Shave skin lesion >2.0 cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,11305,Shave skin lesion 0.5 cm/<,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,11306,Shave skin lesion 0.6-1.0 cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,11307,Shave skin lesion 1.1-2.0 cm,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,11308,Shave skin lesion >2.0 cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,11310,Shave skin lesion 0.5 cm/<,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,11311,Shave skin lesion 0.6-1.0 cm,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,11312,Shave skin lesion 1.1-2.0 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,11313,Shave skin lesion >2.0 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,11400,Exc tr-ext b9+marg 0.5 cm<,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,11401,Exc tr-ext b9+marg 0.6-1 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,11402,Exc tr-ext b9+marg 1.1-2 cm,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,11403,Exc tr-ext b9+marg 2.1-3cm,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,11404,Exc tr-ext b9+marg 3.1-4 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,11406,Exc tr-ext b9+marg >4.0 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,11420,Exc h-f-nk-sp b9+marg 0.5/<,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,11421,Exc h-f-nk-sp b9+marg 0.6-1,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,11422,Exc h-f-nk-sp b9+marg 1.1-2,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,11423,Exc h-f-nk-sp b9+marg 2.1-3,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,11424,Exc h-f-nk-sp b9+marg 3.1-4,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,11426,Exc h-f-nk-sp b9+marg >4 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,11440,Exc face-mm b9+marg 0.5 cm/<,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,11441,Exc face-mm b9+marg 0.6-1 cm,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,11442,Exc face-mm b9+marg 1.1-2 cm,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,11443,Exc face-mm b9+marg 2.1-3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,11444,Exc face-mm b9+marg 3.1-4 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,11446,Exc face-mm b9+marg >4 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,11450,Removal sweat gland lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,11451,Removal sweat gland lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,11462,Removal sweat gland lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,11463,Removal sweat gland lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,11470,Removal sweat gland lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,11471,Removal sweat gland lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,11600,Exc tr-ext mal+marg 0.5 cm/<,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,11601,Exc tr-ext mal+marg 0.6-1 cm,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,11602,Exc tr-ext mal+marg 1.1-2 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,11603,Exc tr-ext mal+marg 2.1-3 cm,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,11604,Exc tr-ext mal+marg 3.1-4 cm,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,11606,Exc tr-ext mal+marg >4 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,11620,Exc h-f-nk-sp mal+marg 0.5/<,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,11621,Exc s/n/h/f/g mal+mrg 0.6-1,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,11622,Exc s/n/h/f/g mal+mrg 1.1-2,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,11623,Exc s/n/h/f/g mal+mrg 2.1-3,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,11624,Exc s/n/h/f/g mal+mrg 3.1-4,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,11626,Exc s/n/h/f/g mal+mrg >4 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,11640,Exc f/e/e/n/l mal+mrg 0.5cm<,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,11641,Exc f/e/e/n/l mal+mrg 0.6-1,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,11642,Exc f/e/e/n/l mal+mrg 1.1-2,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,11643,Exc f/e/e/n/l mal+mrg 2.1-3,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,11644,Exc f/e/e/n/l mal+mrg 3.1-4,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,11646,Exc f/e/e/n/l mal+mrg >4 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,11719,Trim nail(s) any number,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Humana MCR ADV,CPT,11720,Debride nail 1-5,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Humana MCR ADV,CPT,11721,Debride nail 6 or more,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Humana MCR ADV,CPT,11730,Removal of nail plate,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,11740,Drain blood from under nail,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Humana MCR ADV,CPT,11750,Removal of nail bed,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,11755,Biopsy nail unit,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,11760,Repair of nail bed,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,11762,Reconstruction of nail bed,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,11765,Excision of nail fold toe,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,11770,Remove pilonidal cyst simple,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,11771,Remove pilonidal cyst exten,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,11772,Remove pilonidal cyst compl,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,11900,Inject skin lesions </w 7,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,11901,Inject skin lesions >7,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,11920,Correct skin color 6.0 cm/<,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,11921,Correct skn color 6.1-20.0cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,11950,Tx contour defects 1 cc/<,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,11951,Tx contour defects 1.1-5.0cc,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,11952,Tx contour defects 5.1-10cc,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,11954,Tx contour defects >10.0 cc,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,11960,Insert tissue expander(s),APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Humana MCR ADV,CPT,11970,Rplcmt tiss xpndr perm implt,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,11971,Rmvl tis xpndr wo insj implt,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,11976,Remove contraceptive capsule,APC 5071,RVU Per Case,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,11980,Implant hormone pellet(s),APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Humana MCR ADV,CPT,11981,Insert drug implant device,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Humana MCR ADV,CPT,11982,Remove drug implant device,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Humana MCR ADV,CPT,11983,Remove/insert drug implant,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Humana MCR ADV,CPT,12001,Rpr s/n/ax/gen/trnk 2.5cm/<,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,12002,Rpr s/n/ax/gen/trnk2.6-7.5cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,12004,Rpr s/n/ax/gen/trk7.6-12.5cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,12005,Rpr s/n/a/gen/trk12.6-20.0cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,12006,Rpr s/n/a/gen/trk20.1-30.0cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,12007,Rpr s/n/ax/gen/trnk >30.0 cm,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,12011,Rpr f/e/e/n/l/m 2.5 cm/<,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,12013,Rpr f/e/e/n/l/m 2.6-5.0 cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,12014,Rpr f/e/e/n/l/m 5.1-7.5 cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,12015,Rpr f/e/e/n/l/m 7.6-12.5 cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,12016,Rpr fe/e/en/l/m 12.6-20.0 cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,12017,Rpr fe/e/en/l/m 20.1-30.0 cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,12018,Rpr f/e/e/n/l/m >30.0 cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,12020,Closure of split wound,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,12021,Closure of split wound,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,12031,Intmd rpr s/a/t/ext 2.5 cm/<,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,12032,Intmd rpr s/a/t/ext 2.6-7.5,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,12034,Intmd rpr s/tr/ext 7.6-12.5,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,12035,Intmd rpr s/a/t/ext 12.6-20,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,12036,Intmd rpr s/a/t/ext 20.1-30,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,12037,Intmd rpr s/tr/ext >30.0 cm,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,12041,Intmd rpr n-hf/genit 2.5cm/<,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,12042,Intmd rpr n-hf/genit2.6-7.5,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,12044,Intmd rpr n-hf/genit7.6-12.5,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,12045,Intmd rpr n-hf/genit12.6-20,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,12046,Intmd rpr n-hf/genit20.1-30,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,12047,Intmd rpr n-hf/genit >30.0cm,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,12051,Intmd rpr face/mm 2.5 cm/<,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,12052,Intmd rpr face/mm 2.6-5.0 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,12053,Intmd rpr face/mm 5.1-7.5 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,12054,Intmd rpr face/mm 7.6-12.5cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,12055,Intmd rpr face/mm 12.6-20 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,12056,Intmd rpr face/mm 20.1-30.0,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,12057,Intmd rpr face/mm >30.0 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,13100,Cmplx rpr trunk 1.1-2.5 cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,13101,Cmplx rpr trunk 2.6-7.5 cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,13120,Cmplx rpr s/a/l 1.1-2.5 cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,13121,Cmplx rpr s/a/l 2.6-7.5 cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,13131,Cmplx rpr f/c/c/m/n/ax/g/h/f,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,13132,Cmplx rpr f/c/c/m/n/ax/g/h/f,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,13151,Cmplx rpr e/n/e/l 1.1-2.5 cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,13152,Cmplx rpr e/n/e/l 2.6-7.5 cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,13160,Late closure of wound,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,14000,Tis trnfr trunk 10 sq cm/<,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,14001,Tis trnfr trunk 10.1-30sqcm,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,14020,Tis trnfr s/a/l 10 sq cm/<,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,14021,Tis trnfr s/a/l 10.1-30 sqcm,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,14040,Tis trnfr f/c/c/m/n/a/g/h/f,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,14041,Tis trnfr f/c/c/m/n/a/g/h/f,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,14060,Tis trnfr e/n/e/l 10 sq cm/<,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,14061,Tis trnfr e/n/e/l10.1-30sqcm,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,14301,Tis trnfr any 30.1-60 sq cm,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Humana MCR ADV,CPT,14350,Filleted finger/toe flap,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,15002,Wound prep trk/arm/leg,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,15004,Wound prep f/n/hf/g,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,15040,Harvest cultured skin graft,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,15050,Skin pinch graft,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,15100,Skin splt grft trnk/arm/leg,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,15110,Epidrm autogrft trnk/arm/leg,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,15115,Epidrm a-grft face/nck/hf/g,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,15120,Skn splt a-grft fac/nck/hf/g,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Humana MCR ADV,CPT,15130,Derm autograft trnk/arm/leg,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,15135,Derm autograft face/nck/hf/g,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Humana MCR ADV,CPT,15150,Cult skin grft t/arm/leg,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,15155,Cult skin graft f/n/hf/g,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Humana MCR ADV,CPT,15200,Skin full graft trunk,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,15220,Skin full graft sclp/arm/leg,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,15240,Skin full grft face/genit/hf,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,15260,Skin full graft een & lips,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,15271,Skin sub graft trnk/arm/leg,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,15273,Skin sub grft t/arm/lg child,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Humana MCR ADV,CPT,15275,Skin sub graft face/nk/hf/g,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,15277,Skn sub grft f/n/hf/g child,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,15570,Skin pedicle flap trunk,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,15572,Skin pedicle flap arms/legs,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Humana MCR ADV,CPT,15574,Pedcle fh/ch/ch/m/n/ax/g/h/f,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,15576,Pedicle e/n/e/l/ntroral,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,15600,Delay flap trunk,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Humana MCR ADV,CPT,15610,Delay flap arms/legs,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,15620,Delay flap f/c/c/n/ax/g/h/f,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,15630,Delay flap eye/nos/ear/lip,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,15650,Transfer skin pedicle flap,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,15730,Mdfc flap w/prsrv vasc pedcl,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Humana MCR ADV,CPT,15731,Forehead flap w/vasc pedicle,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Humana MCR ADV,CPT,15733,Musc myoq/fscq flp h&n pedcl,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","9,201.00",,,,,,
Humana MCR ADV,CPT,15734,Muscle-skin graft trunk,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Humana MCR ADV,CPT,15736,Muscle-skin graft arm,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,15738,Muscle-skin graft leg,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Humana MCR ADV,CPT,15740,Island pedicle flap graft,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,15750,Neurovascular pedicle flap,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Humana MCR ADV,CPT,15756,Free myo/skin flap microvasc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,15757,Free skin flap microvasc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,15758,Free fascial flap microvasc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,15760,Composite skin graft,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,15769,Grfg autol soft tiss dir exc,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Humana MCR ADV,CPT,15770,Derma-fat-fascia graft,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Humana MCR ADV,CPT,15771,Grfg autol fat lipo 50 cc/<,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Humana MCR ADV,CPT,15773,Grfg autol fat lipo 25 cc/<,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,15775,Hair trnspl 1-15 punch grfts,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,15776,Hair trnspl >15 punch grafts,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,15780,Dermabrasion total face,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,15781,Dermabrasion segmental face,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,15782,Dermabrasion other than face,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,15783,Dermabrasion suprfl any site,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,15786,Abrasion lesion single,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,15788,Chemical peel face epiderm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,15789,Chemical peel face dermal,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,15792,Chemical peel nonfacial,APC 5053,RVU Per Case,$536.39 ,OP,536.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,15793,Chemical peel nonfacial,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,15819,Plastic surgery neck,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,15820,Revision of lower eyelid,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,15821,Revision of lower eyelid,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,15822,Revision of upper eyelid,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,15823,Revision of upper eyelid,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,15824,Removal of forehead wrinkles,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,15825,Removal of neck wrinkles,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Humana MCR ADV,CPT,15826,Removal of brow wrinkles,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Humana MCR ADV,CPT,15828,Removal of face wrinkles,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Humana MCR ADV,CPT,15829,Removal of skin wrinkles,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Humana MCR ADV,CPT,15830,Exc skin abd,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,15832,Excise excessive skin thigh,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,15833,Excise excessive skin leg,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,15834,Excise excessive skin hip,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,15835,Excise excessive skin buttck,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,15836,Excise excessive skin arm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,15837,Excise excess skin arm/hand,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,15838,Excise excess skin fat pad,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,15839,Excise excess skin & tissue,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,15840,Nerve palsy fascial graft,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Humana MCR ADV,CPT,15841,Nerve palsy muscle graft,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Humana MCR ADV,CPT,15842,Nerve palsy microsurg graft,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,15845,Skin and muscle repair face,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Humana MCR ADV,CPT,15850,Remove sutures same surgeon,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,15851,Remove sutures diff surgeon,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,15852,Dressing change not for burn,APC 5053,RVU Per Case,$536.39 ,OP,536.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,15860,Test for blood flow in graft,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Humana MCR ADV,CPT,15876,Suction lipectomy head&neck,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Humana MCR ADV,CPT,15877,Suction lipectomy trunk,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Humana MCR ADV,CPT,15878,Suction lipectomy upr extrem,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,15879,Suction lipectomy lwr extrem,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Humana MCR ADV,CPT,15920,Removal of tail bone ulcer,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,15922,Removal of tail bone ulcer,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Humana MCR ADV,CPT,15931,Remove sacrum pressure sore,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,15933,Remove sacrum pressure sore,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,15934,Remove sacrum pressure sore,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Humana MCR ADV,CPT,15935,Remove sacrum pressure sore,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Humana MCR ADV,CPT,15936,Remove sacrum pressure sore,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,15937,Remove sacrum pressure sore,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,15940,Remove hip pressure sore,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,15941,Remove hip pressure sore,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,15944,Remove hip pressure sore,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Humana MCR ADV,CPT,15945,Remove hip pressure sore,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,15946,Remove hip pressure sore,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,15950,Remove thigh pressure sore,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,15951,Remove thigh pressure sore,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,15952,Remove thigh pressure sore,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,15953,Remove thigh pressure sore,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Humana MCR ADV,CPT,15956,Remove thigh pressure sore,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,15958,Remove thigh pressure sore,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Humana MCR ADV,CPT,15999,Removal of pressure sore,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,16000,Initial treatment of burn(s),APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,16020,Dress/debrid p-thick burn s,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,16025,Dress/debrid p-thick burn m,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,16030,Dress/debrid p-thick burn l,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,16035,Incision of burn scab initi,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,16036,Escharotomy addl incision,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,17000,Destruct premalg lesion,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,17004,Destroy premal lesions 15/>,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,17106,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,17107,Destruction of skin lesions,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,17108,Destruction of skin lesions,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,17110,Destruct b9 lesion 1-14,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,17111,Destruct lesion 15 or more,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,17250,Chem caut of granltj tissue,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,17260,Destruction of skin lesions,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,17261,Destruction of skin lesions,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,17262,Destruction of skin lesions,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,17263,Destruction of skin lesions,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,17264,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,17266,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,17270,Destruction of skin lesions,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,17271,Destruction of skin lesions,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,17272,Destruction of skin lesions,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,17273,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,17274,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,17276,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,17280,Destruction of skin lesions,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,17281,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,17282,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,17283,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,17284,Destruction of skin lesions,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,17286,Destruction of skin lesions,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,17311,Mohs 1 stage h/n/hf/g,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,17313,Mohs 1 stage t/a/l,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,17340,Cryotherapy of skin,APC 5732,RVU Per Case,$34.63 ,OP,34.63,"4,314.00",,,,,,
Humana MCR ADV,CPT,17360,Skin peel therapy,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,17380,Hair removal by electrolysis,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,17999,Skin tissue procedure,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,19000,Drainage of breast lesion,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,19020,Incision of breast lesion,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,19081,Bx breast 1st lesion strtctc,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,19083,Bx breast 1st lesion us imag,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,19085,Bx breast 1st lesion mr imag,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,19100,Bx breast percut w/o image,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,19101,Biopsy of breast open,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Humana MCR ADV,CPT,19105,Cryosurg ablate fa each,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Humana MCR ADV,CPT,19110,Nipple exploration,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Humana MCR ADV,CPT,19112,Excise breast duct fistula,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Humana MCR ADV,CPT,19120,Removal of breast lesion,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Humana MCR ADV,CPT,19125,Excision breast lesion,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Humana MCR ADV,CPT,19281,Perq device breast 1st imag,APC 5071,RVU Per Case,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,19283,Perq dev breast 1st strtctc,APC 5071,RVU Per Case,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,19285,Perq dev breast 1st us imag,APC 5071,RVU Per Case,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,19287,Perq dev breast 1st mr guide,APC 5071,RVU Per Case,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,19296,Place po breast cath for rad,APC 5093,RVU Per Case,"$9,128.05 ",OP,"4,314.00","9,128.05",,,,,,
Humana MCR ADV,CPT,19298,Place breast rad tube/caths,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
Humana MCR ADV,CPT,19300,Removal of breast tissue,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","9,201.00",,,,,,
Humana MCR ADV,CPT,19301,Partial mastectomy,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Humana MCR ADV,CPT,19302,P-mastectomy w/ln removal,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
Humana MCR ADV,CPT,19303,Mast simple complete,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
Humana MCR ADV,CPT,19305,Mast radical,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,19306,Mast rad urban type,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,19307,Mast mod rad,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,19316,Suspension of breast,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
Humana MCR ADV,CPT,19318,Breast reduction,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,19325,Breast augmentation w/implt,APC 5093,RVU Per Case,"$9,128.05 ",OP,"4,314.00","9,128.05",,,,,,
Humana MCR ADV,CPT,19328,Rmvl intact breast implant,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Humana MCR ADV,CPT,19330,Rmvl ruptured breast implant,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Humana MCR ADV,CPT,19340,Insj breast implt sm d mast,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,19342,Insj/rplcmt brst implt sep d,APC 5093,RVU Per Case,"$9,128.05 ",OP,"4,314.00","9,128.05",,,,,,
Humana MCR ADV,CPT,19350,Breast reconstruction,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Humana MCR ADV,CPT,19355,Correct inverted nipple(s),APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Humana MCR ADV,CPT,19357,Tiss xpndr plmt brst rcnstj,APC 5094,RVU Per Case,"$15,276.83 ",OP,"4,140.35","15,276.83",,,,,,
Humana MCR ADV,CPT,19361,Brst rcnstj latsms drsi flap,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,19364,Brst rcnstj free flap,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,19367,Brst rcnstj 1 pdcl tram flap,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,19368,Brst rcnstj 1pdcl tram anast,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,19369,Brst rcnstj 2 pdcl tram flap,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,19370,Revj peri-implt capsule brst,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Humana MCR ADV,CPT,19371,Peri-implt capslc brst compl,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Humana MCR ADV,CPT,19380,Revj reconstructed breast,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
Humana MCR ADV,CPT,19396,Design custom breast implant,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Humana MCR ADV,CPT,19499,Breast surgery procedure,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Humana MCR ADV,CPT,20100,Explore wound neck,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,20101,Explore wound chest,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,20102,Explore wound abdomen,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,20103,Explore wound extremity,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,20150,Excise epiphyseal bar,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,20200,Muscle biopsy,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,20205,Deep muscle biopsy,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,20206,Needle biopsy muscle,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,20220,Bone biopsy trocar/needle,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,20225,Bone biopsy trocar/needle,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,20240,Bone biopsy open superficial,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,20245,Bone biopsy open deep,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,20250,Open bone biopsy,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,20251,Open bone biopsy,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,20500,Injection of sinus tract,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,20520,Removal of foreign body,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,20525,Removal of foreign body,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,20526,Ther injection carp tunnel,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Humana MCR ADV,CPT,20527,Inj dupuytren cord w/enzyme,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Humana MCR ADV,CPT,20550,Inj tendon sheath/ligament,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Humana MCR ADV,CPT,20551,Inj tendon origin/insertion,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Humana MCR ADV,CPT,20552,Inj trigger point 1/2 muscl,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Humana MCR ADV,CPT,20553,Inject trigger points 3/>,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Humana MCR ADV,CPT,20555,Place ndl musc/tis for rt,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,20560,Ndl insj w/o njx 1 or 2 musc,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,"4,314.00",,,,,,
Humana MCR ADV,CPT,20561,Ndl insj w/o njx 3+ musc,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,"4,314.00",,,,,,
Humana MCR ADV,CPT,20600,Drain/inj joint/bursa w/o us,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Humana MCR ADV,CPT,20604,Drain/inj joint/bursa w/us,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Humana MCR ADV,CPT,20605,Drain/inj joint/bursa w/o us,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Humana MCR ADV,CPT,20606,Drain/inj joint/bursa w/us,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,20610,Drain/inj joint/bursa w/o us,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Humana MCR ADV,CPT,20611,Drain/inj joint/bursa w/us,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Humana MCR ADV,CPT,20612,Aspirate/inj ganglion cyst,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Humana MCR ADV,CPT,20615,Treatment of bone cyst,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,20650,Insert and remove bone pin,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,20660,Apply rem fixation device,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,20661,Application of head brace,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,20662,Application of pelvis brace,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,20663,Application of thigh brace,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,20664,Application of halo,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,20665,Removal of fixation device,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Humana MCR ADV,CPT,20670,Removal of support implant,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,20680,Removal of support implant,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,20690,Apply bone fixation device,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,20692,Apply bone fixation device,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,20693,Adjust bone fixation device,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,20694,Remove bone fixation device,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,20696,Comp multiplane ext fixation,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,20697,Comp ext fixate strut change,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,20802,Replantation arm complete,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,20805,Replant forearm complete,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,20808,Replantation hand complete,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,20816,Replantation digit complete,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,20822,Replantation digit complete,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,20824,Replantation thumb complete,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,20827,Replantation thumb complete,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,20838,Replantation foot complete,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,20900,Removal of bone for graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,20902,Removal of bone for graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,20910,Remove cartilage for graft,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,20912,Remove cartilage for graft,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Humana MCR ADV,CPT,20920,Removal of fascia for graft,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,20922,Removal of fascia for graft,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,20924,Removal of tendon for graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,20950,Fluid pressure muscle,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,20955,Fibula bone graft microvasc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,20956,Iliac bone graft microvasc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,20957,Mt bone graft microvasc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,20962,Other bone graft microvasc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,20969,Bone/skin graft microvasc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,20970,Bone/skin graft iliac crest,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,20972,Bone/skin graft metatarsal,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,20973,Bone/skin graft great toe,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,20974,Electrical bone stimulation,Physician,Per Unit,$50.41 ,OP,50.41,"4,314.00",,,,,,
Humana MCR ADV,CPT,20979,Us bone stimulation,APC 5731,RVU Per Case,$25.25 ,OP,25.25,"4,314.00",,,,,,
Humana MCR ADV,CPT,20982,Ablate bone tumor(s) perq,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,20983,Ablate bone tumor(s) perq,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,20999,Musculoskeletal surgery,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,21010,Incision of jaw joint,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,21011,Exc face les sc <2 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,21012,Exc face les sbq 2 cm/>,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,21013,Exc face tum deep < 2 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,21014,Exc face tum deep 2 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,21015,Resect face/scalp tum < 2 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,21016,Resect face/scalp tum 2 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,21025,Excision of bone lower jaw,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21026,Excision of facial bone(s),APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21029,Contour of face bone lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,21030,Excise max/zygoma b9 tumor,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21031,Remove exostosis mandible,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,21032,Remove exostosis maxilla,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,21034,Excise max/zygoma mal tumor,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21040,Excise mandible lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,21044,Removal of jaw bone lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21045,Extensive jaw surgery,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21046,Remove mandible cyst complex,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21047,Excise lwr jaw cyst w/repair,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21048,Remove maxilla cyst complex,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21049,Excis uppr jaw cyst w/repair,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21050,Removal of jaw joint,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21060,Remove jaw joint cartilage,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21070,Remove coronoid process,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21073,Mnpj of tmj w/anesth,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,21076,Prepare face/oral prosthesis,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,21077,Prepare face/oral prosthesis,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21079,Prepare face/oral prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,21080,Prepare face/oral prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,21081,Prepare face/oral prosthesis,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21082,Prepare face/oral prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,21083,Prepare face/oral prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,21084,Prepare face/oral prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,21085,Prepare face/oral prosthesis,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Humana MCR ADV,CPT,21086,Prepare face/oral prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,21087,Prepare face/oral prosthesis,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21088,Prepare face/oral prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,21089,Prepare face/oral prosthesis,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Humana MCR ADV,CPT,21100,Maxillofacial fixation,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21110,Interdental fixation,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,21120,Reconstruction of chin,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21121,Reconstruction of chin,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,21122,Reconstruction of chin,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21123,Reconstruction of chin,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,21125,Augmentation lower jaw bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21127,Augmentation lower jaw bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21137,Reduction of forehead,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,21138,Reduction of forehead,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21139,Reduction of forehead,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21141,Lefort i-1 piece w/o graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21142,Lefort i-2 piece w/o graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21143,Lefort i-3/> piece w/o graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21145,Lefort i-1 piece w/ graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21146,Lefort i-2 piece w/ graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21147,Lefort i-3/> piece w/ graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21150,Lefort ii anterior intrusion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21151,Lefort ii w/bone grafts,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21154,Lefort iii w/o lefort i,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21155,Lefort iii w/ lefort i,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21159,Lefort iii w/fhdw/o lefort i,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21160,Lefort iii w/fhd w/ lefort i,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21172,Reconstruct orbit/forehead,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21175,Reconstruct orbit/forehead,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21179,Reconstruct entire forehead,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21180,Reconstruct entire forehead,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21181,Contour cranial bone lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21182,Reconstruct cranial bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21183,Reconstruct cranial bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21184,Reconstruct cranial bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21188,Reconstruction of midface,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21193,Reconst lwr jaw w/o graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,21194,Reconst lwr jaw w/graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21195,Reconst lwr jaw w/o fixation,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21196,Reconst lwr jaw w/fixation,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21198,Reconstr lwr jaw segment,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21199,Reconstr lwr jaw w/advance,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21206,Reconstruct upper jaw bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21208,Augmentation of facial bones,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21209,Reduction of facial bones,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21210,Face bone graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21215,Lower jaw bone graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21230,Rib cartilage graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21235,Ear cartilage graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21240,Reconstruction of jaw joint,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21242,Reconstruction of jaw joint,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21243,Reconstruction of jaw joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,21244,Reconstruction of lower jaw,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21245,Reconstruction of jaw,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21246,Reconstruction of jaw,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21247,Reconstruct lower jaw bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21248,Reconstruction of jaw,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21249,Reconstruction of jaw,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21255,Reconstruct lower jaw bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21256,Reconstruction of orbit,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21260,Revise eye sockets,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21261,Revise eye sockets,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21263,Revise eye sockets,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21267,Revise eye sockets,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21268,Revise eye sockets,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21270,Augmentation cheek bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21275,Revision orbitofacial bones,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21280,Revision of eyelid,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,21282,Revision of eyelid,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,21295,Revision of jaw muscle/bone,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,21296,Revision of jaw muscle/bone,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,21299,Cranio/maxillofacial surgery,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Humana MCR ADV,CPT,21310,Closed tx nose fx w/o manj,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,21315,Closed tx nose fx w/o stablj,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,21320,Closed tx nose fx w/ stablj,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,21325,Open tx nose fx uncomplicatd,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,21330,Open tx nose fx w/skele fixj,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21335,Open tx nose & septal fx,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,21336,Open tx septal fx w/wo stabj,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,21337,Closed tx septal&nose fx,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,21338,Open nasoethmoid fx w/o fixj,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21339,Open nasoethmoid fx w/ fixj,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21340,Perq tx nasoethmoid fx,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,21343,Open tx dprsd front sinus fx,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21344,Open tx compl front sinus fx,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21345,Closed tx nose/jaw fx,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,21346,Opn tx nasomax fx w/fixj,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21347,Opn tx nasomax fx multple,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21348,Opn tx nasomax fx w/graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21355,Perq tx malar fracture,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,21356,Opn tx dprsd zygomatic arch,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21360,Opn tx dprsd malar fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21365,Opn tx complx malar fx,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21366,Opn tx complx malar w/grft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21385,Opn tx orbit fx transantral,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21386,Opn tx orbit fx periorbital,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21387,Opn tx orbit fx combined,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21390,Opn tx orbit periorbtl implt,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21395,Opn tx orbit periorbt w/grft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21400,Closed tx orbit w/o manipulj,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,21401,Closed tx orbit w/manipulj,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,21406,Opn tx orbit fx w/o implant,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21407,Opn tx orbit fx w/implant,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21408,Opn tx orbit fx w/bone grft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21421,Treat mouth roof fracture,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,21422,Treat mouth roof fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21423,Treat mouth roof fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21431,Treat craniofacial fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21432,Treat craniofacial fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21433,Treat craniofacial fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21435,Treat craniofacial fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21436,Treat craniofacial fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21440,Treat dental ridge fracture,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,21445,Treat dental ridge fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21450,Treat lower jaw fracture,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,21451,Treat lower jaw fracture,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,21452,Treat lower jaw fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21453,Treat lower jaw fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21454,Treat lower jaw fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21461,Treat lower jaw fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21462,Treat lower jaw fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,21465,Treat lower jaw fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21470,Treat lower jaw fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21480,Reset dislocated jaw,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,21485,Reset dislocated jaw,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,21490,Repair dislocated jaw,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,21497,Interdental wiring,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,21499,Head surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Humana MCR ADV,CPT,21501,Drain neck/chest lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,21502,Drain chest lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,21510,Drainage of bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,21550,Biopsy of neck/chest,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,21552,Exc neck les sc 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,21554,Exc neck tum deep 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,21555,Exc neck les sc < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,21556,Exc neck tum deep < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,21557,Resect neck thorax tumor<5cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,21558,Resect neck tumor 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,21600,Partial removal of rib,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,21601,Exc chest wall tumor w/ribs,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,21602,Exc ch wal tum w/o lymphadec,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,21603,Exc ch wal tum w/lymphadec,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,21610,Partial removal of rib,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,21615,Removal of rib,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,21616,Removal of rib and nerves,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,21620,Partial removal of sternum,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,21627,Sternal debridement,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,21630,Extensive sternum surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,21632,Extensive sternum surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,21685,Hyoid myotomy & suspension,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,21700,Revision of neck muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,21705,Revision of neck muscle/rib,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,21720,Revision of neck muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,21725,Revision of neck muscle,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,21740,Reconstruction of sternum,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,21742,Repair stern/nuss w/o scope,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,21743,Repair sternum/nuss w/scope,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,21750,Repair of sternum separation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,21811,Optx of rib fx w/fixj scope,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,21812,Treatment of rib fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,21813,Treatment of rib fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,21820,Treat sternum fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,21825,Treat sternum fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,21899,Neck/chest surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Humana MCR ADV,CPT,21920,Biopsy soft tissue of back,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,21925,Biopsy soft tissue of back,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,21930,Exc back les sc < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,21931,Exc back les sc 3 cm/>,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,21932,Exc back tum deep < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,21933,Exc back tum deep 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,21935,Resect back tum < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,21936,Resect back tum 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,22010,I&d p-spine c/t/cerv-thor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,22015,I&d abscess p-spine l/s/ls,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,22100,Remove part of neck vertebra,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,22101,Remove part thorax vertebra,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,22102,Remove part lumbar vertebra,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,22110,Remove part of neck vertebra,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,22112,Remove part thorax vertebra,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,22114,Remove part lumbar vertebra,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,22206,Incis spine 3 column thorac,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,22207,Incis spine 3 column lumbar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,22210,Incis 1 vertebral seg cerv,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,22212,Incis 1 vertebral seg thorac,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,22214,Incis 1 vertebral seg lumbar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,22220,Incis w/discectomy cervical,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,22222,Incis w/discectomy thoracic,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,22224,Incis w/discectomy lumbar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,22310,Closed tx vert fx w/o manj,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,22315,Closed tx vert fx w/manj,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,22318,Treat odontoid fx w/o graft,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,22319,Treat odontoid fx w/graft,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,22325,Treat spine fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,22326,Treat neck spine fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,22327,Treat thorax spine fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,22505,Manipulation of spine,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,22510,Perq cervicothoracic inject,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","15,496.26",,,,,,
Humana MCR ADV,CPT,22511,Perq lumbosacral injection,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","9,201.00",,,,,,
Humana MCR ADV,CPT,22513,Perq vertebral augmentation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,22514,Perq vertebral augmentation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,22532,Lat thorax spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,22533,Lat lumbar spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,22548,Neck spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,22551,Neck spine fuse&remov bel c2,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Humana MCR ADV,CPT,22554,Neck spine fusion,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,22556,Thorax spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,22558,Lumbar spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,22586,Prescrl fuse w/ instr l5-s1,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,22590,Spine & skull spinal fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,22595,Neck spinal fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,22600,Neck spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,22610,Thorax spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,22612,Lumbar spine fusion,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,22630,Lumbar spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,22633,Lumbar spine fusion combined,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,22800,Post fusion </6 vert seg,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,22802,Post fusion 7-12 vert seg,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,22804,Post fusion 13/> vert seg,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,22808,Ant fusion 2-3 vert seg,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,22810,Ant fusion 4-7 vert seg,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,22812,Ant fusion 8/> vert seg,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,22818,Kyphectomy 1-2 segments,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,22819,Kyphectomy 3 or more,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,22830,Exploration of spinal fusion,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,22849,Reinsert spinal fixation,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,22850,Remove spine fixation device,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,22852,Remove spine fixation device,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,22855,Remove spine fixation device,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,22856,Cerv artific diskectomy,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,140.35","16,238.16",,,,,,
Humana MCR ADV,CPT,22857,Lumbar artif diskectomy,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,22861,Revise cerv artific disc,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,22862,Revise lumbar artif disc,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,22864,Remove cerv artif disc,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,22865,Remove lumb artif disc,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,22867,Insj stablj dev w/dcmprn,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,22869,Insj stablj dev w/o dcmprn,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,22899,Spine surgery procedure,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,22900,Exc abdl tum deep < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,22901,Exc abdl tum deep 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,22902,Exc abd les sc < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,22903,Exc abd les sc 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,22904,Radical resect abd tumor<5cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,22905,Rad resect abd tumor 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,22999,Abdomen surgery procedure,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,23000,Removal of calcium deposits,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,23020,Release shoulder joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,23030,Drain shoulder lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,23031,Drain shoulder bursa,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,23035,Drain shoulder bone lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,23040,Exploratory shoulder surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,23044,Exploratory shoulder surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,23065,Biopsy shoulder tissues,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,23066,Biopsy shoulder tissues,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,23071,Exc shoulder les sc 3 cm/>,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,23073,Exc shoulder tum deep 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,23075,Exc shoulder les sc < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,23076,Exc shoulder tum deep < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,23077,Resect shoulder tumor < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,23078,Resect shoulder tumor 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,23100,Biopsy of shoulder joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,23101,Shoulder joint surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,23105,Remove shoulder joint lining,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,23106,Incision of collarbone joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,23107,Explore treat shoulder joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,23120,Partial removal collar bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,23125,Removal of collar bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,23130,Remove shoulder bone part,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,23140,Removal of bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,23145,Removal of bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,23146,Removal of bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,23150,Removal of humerus lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,23155,Removal of humerus lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,23156,Removal of humerus lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,23170,Remove collar bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,23172,Remove shoulder blade lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,23174,Remove humerus lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,23180,Remove collar bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,23182,Remove shoulder blade lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,23184,Remove humerus lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,23190,Partial removal of scapula,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,23195,Removal of head of humerus,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,23200,Resect clavicle tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,23210,Resect scapula tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,23220,Resect prox humerus tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,23330,Remove shoulder foreign body,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,23333,Remove shoulder fb deep,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,23334,Shoulder prosthesis removal,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,23335,Shoulder prosthesis removal,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,23395,Muscle transfer shoulder/arm,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,23397,Muscle transfers,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,23400,Fixation of shoulder blade,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,23405,Incision of tendon & muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,23406,Incise tendon(s) & muscle(s),APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,23410,Repair rotator cuff acute,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,23412,Repair rotator cuff chronic,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,23415,Release of shoulder ligament,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,23420,Repair of shoulder,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,23430,Repair biceps tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,23440,Remove/transplant tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,23450,Repair shoulder capsule,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,23455,Repair shoulder capsule,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,23460,Repair shoulder capsule,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,23462,Repair shoulder capsule,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,23465,Repair shoulder capsule,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,23466,Repair shoulder capsule,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,23470,Reconstruct shoulder joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,23472,Reconstruct shoulder joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,23473,Revis reconst shoulder joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,23474,Revis reconst shoulder joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,23480,Revision of collar bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,23485,Revision of collar bone,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,23490,Reinforce clavicle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,23491,Reinforce shoulder bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,23500,Treat clavicle fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,23505,Treat clavicle fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,23515,Treat clavicle fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,23520,Treat clavicle dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,23525,Treat clavicle dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,23530,Treat clavicle dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,23532,Treat clavicle dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,23540,Treat clavicle dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,23545,Treat clavicle dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,23550,Treat clavicle dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,23552,Treat clavicle dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,23570,Treat shoulder blade fx,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,23575,Treat shoulder blade fx,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,23585,Treat scapula fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,23600,Treat humerus fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,23605,Treat humerus fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,23615,Treat humerus fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Humana MCR ADV,CPT,23616,Treat humerus fracture,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,23620,Treat humerus fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,23625,Treat humerus fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,23630,Treat humerus fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,23650,Treat shoulder dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,23655,Treat shoulder dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,23660,Treat shoulder dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,23665,Treat dislocation/fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,23670,Treat dislocation/fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,23675,Treat dislocation/fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,23680,Treat dislocation/fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,23700,Fixation of shoulder,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,23800,Fusion of shoulder joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,23802,Fusion of shoulder joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,23900,Amputation of arm & girdle,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,23920,Amputation at shoulder joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,23921,Amputation follow-up surgery,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,23929,Shoulder surgery procedure,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,23930,Drainage of arm lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,23931,Drainage of arm bursa,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,23935,Drain arm/elbow bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,24000,Exploratory elbow surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,24006,Release elbow joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,24065,Biopsy arm/elbow soft tissue,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,24066,Biopsy arm/elbow soft tissue,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,24071,Exc arm/elbow les sc 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,24073,Ex arm/elbow tum deep 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,24075,Exc arm/elbow les sc < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,24076,Ex arm/elbow tum deep < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,24077,Resect arm/elbow tum < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,24079,Resect arm/elbow tum 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,24100,Biopsy elbow joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,24101,Explore/treat elbow joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,24102,Remove elbow joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,24105,Removal of elbow bursa,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,24110,Remove humerus lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,24115,Remove/graft bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,24116,Remove/graft bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,24120,Remove elbow lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,24125,Remove/graft bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,24126,Remove/graft bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,24130,Removal of head of radius,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,24134,Removal of arm bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,24136,Remove radius bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,24138,Remove elbow bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,24140,Partial removal of arm bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,24145,Partial removal of radius,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,24147,Partial removal of elbow,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,24149,Radical resection of elbow,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,24150,Resect distal humerus tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,24152,Resect radius tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,24155,Removal of elbow joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,24160,Remove elbow joint implant,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,24164,Remove radius head implant,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,24200,Removal of arm foreign body,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,24201,Removal of arm foreign body,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,24300,Manipulate elbow w/anesth,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,24301,Muscle/tendon transfer,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,24305,Arm tendon lengthening,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,24310,Revision of arm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,24320,Repair of arm tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,24330,Revision of arm muscles,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,24331,Revision of arm muscles,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,24332,Tenolysis triceps,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,24340,Repair of biceps tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,24341,Repair arm tendon/muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,24342,Repair of ruptured tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,24343,Repr elbow lat ligmnt w/tiss,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,24344,Reconstruct elbow lat ligmnt,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,24345,Repr elbw med ligmnt w/tissu,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,24346,Reconstruct elbow med ligmnt,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,24357,Repair elbow perc,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,24358,Repair elbow w/deb open,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,24359,Repair elbow deb/attch open,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,24360,Reconstruct elbow joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,24361,Reconstruct elbow joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,24362,Reconstruct elbow joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,24363,Replace elbow joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,24365,Reconstruct head of radius,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,24366,Reconstruct head of radius,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,24370,Revise reconst elbow joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,24371,Revise reconst elbow joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,24400,Revision of humerus,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,24410,Revision of humerus,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,24420,Revision of humerus,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,24430,Repair of humerus,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,24435,Repair humerus with graft,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,24470,Revision of elbow joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,24495,Decompression of forearm,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,24498,Reinforce humerus,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,24500,Treat humerus fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,24505,Treat humerus fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,24515,Treat humerus fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Humana MCR ADV,CPT,24516,Treat humerus fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,24530,Treat humerus fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,24535,Treat humerus fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,24538,Treat humerus fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,24545,Treat humerus fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Humana MCR ADV,CPT,24546,Treat humerus fracture,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,24560,Treat humerus fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,24565,Treat humerus fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,24566,Treat humerus fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,24575,Treat humerus fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,24576,Treat humerus fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,24577,Treat humerus fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,24579,Treat humerus fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,24582,Treat humerus fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,24586,Treat elbow fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,24587,Treat elbow fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,24600,Treat elbow dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,24605,Treat elbow dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,24615,Treat elbow dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,24620,Treat elbow fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,24635,Treat elbow fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,24640,Treat elbow dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,24650,Treat radius fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,24655,Treat radius fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,24665,Treat radius fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,24666,Treat radius fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Humana MCR ADV,CPT,24670,Treat ulnar fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,24675,Treat ulnar fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,24685,Treat ulnar fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,24800,Fusion of elbow joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,24802,Fusion/graft of elbow joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,24900,Amputation of upper arm,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,24920,Amputation of upper arm,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,24925,Amputation follow-up surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,24930,Amputation follow-up surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,24931,Amputate upper arm & implant,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,24935,Revision of amputation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,24940,Revision of upper arm,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,24999,Upper arm/elbow surgery,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,25000,Incision of tendon sheath,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,25001,Incise flexor carpi radialis,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25020,Decompress forearm 1 space,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,25023,Decompress forearm 1 space,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25024,Decompress forearm 2 spaces,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25025,Decompress forearm 2 spaces,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,25028,Drainage of forearm lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25031,Drainage of forearm bursa,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,25035,Treat forearm bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,25040,Explore/treat wrist joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25065,Biopsy forearm soft tissues,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,25066,Biopsy forearm soft tissues,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,25071,Exc forearm les sc 3 cm/>,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,25073,Exc forearm tum deep 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,25075,Exc forearm les sc < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,25076,Exc forearm tum deep < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,25077,Resect forearm/wrist tum<3cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,25078,Resect forarm/wrist tum 3cm>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,25085,Incision of wrist capsule,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25100,Biopsy of wrist joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25101,Explore/treat wrist joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25105,Remove wrist joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25107,Remove wrist joint cartilage,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25109,Excise tendon forearm/wrist,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25110,Remove wrist tendon lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,25111,Remove wrist tendon lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,25112,Reremove wrist tendon lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,25115,Remove wrist/forearm lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,25116,Remove wrist/forearm lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25118,Excise wrist tendon sheath,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,25119,Partial removal of ulna,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25120,Removal of forearm lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25125,Remove/graft forearm lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,25126,Remove/graft forearm lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25130,Removal of wrist lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25135,Remove & graft wrist lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,25136,Remove & graft wrist lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,25145,Remove forearm bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25150,Partial removal of ulna,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25151,Partial removal of radius,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","9,201.00",,,,,,
Humana MCR ADV,CPT,25170,Resect radius/ulnar tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,25210,Removal of wrist bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25215,Removal of wrist bones,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25230,Partial removal of radius,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25240,Partial removal of ulna,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25248,Remove forearm foreign body,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,25250,Removal of wrist prosthesis,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,25251,Removal of wrist prosthesis,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25259,Manipulate wrist w/anesthes,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,25260,Repair forearm tendon/muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25263,Repair forearm tendon/muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,25265,Repair forearm tendon/muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25270,Repair forearm tendon/muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25272,Repair forearm tendon/muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25274,Repair forearm tendon/muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25275,Repair forearm tendon sheath,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25280,Revise wrist/forearm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25290,Incise wrist/forearm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25295,Release wrist/forearm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25300,Fusion of tendons at wrist,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25301,Fusion of tendons at wrist,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25310,Transplant forearm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25312,Transplant forearm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25315,Revise palsy hand tendon(s),APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,25316,Revise palsy hand tendon(s),APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,25320,Repair/revise wrist joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,25332,Revise wrist joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25335,Realignment of hand,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25337,Reconstruct ulna/radioulnar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,25350,Revision of radius,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,25355,Revision of radius,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25360,Revision of ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,25365,Revise radius & ulna,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,25370,Revise radius or ulna,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25375,Revise radius & ulna,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25390,Shorten radius or ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,25391,Lengthen radius or ulna,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,25392,Shorten radius & ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,25393,Lengthen radius & ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,25394,Repair carpal bone shorten,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25400,Repair radius or ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,25405,Repair/graft radius or ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,25415,Repair radius & ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,25420,Repair/graft radius & ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,25425,Repair/graft radius or ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,25426,Repair/graft radius & ulna,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25430,Vasc graft into carpal bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25431,Repair nonunion carpal bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,25440,Repair/graft wrist bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,25441,Reconstruct wrist joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,25442,Reconstruct wrist joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,25443,Reconstruct wrist joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,25444,Reconstruct wrist joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,25445,Reconstruct wrist joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,25446,Wrist replacement,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,25447,Repair wrist joints,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25449,Remove wrist joint implant,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,25450,Revision of wrist joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25455,Revision of wrist joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25490,Reinforce radius,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,25491,Reinforce ulna,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,25492,Reinforce radius and ulna,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25500,Treat fracture of radius,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,25505,Treat fracture of radius,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,25515,Treat fracture of radius,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,25520,Treat fracture of radius,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,25525,Treat fracture of radius,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,25526,Treat fracture of radius,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,25530,Treat fracture of ulna,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,25535,Treat fracture of ulna,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,25545,Treat fracture of ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,25560,Treat fracture radius & ulna,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,25565,Treat fracture radius & ulna,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,25574,Treat fracture radius & ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,25575,Treat fracture radius/ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,25600,Treat fracture radius/ulna,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,25605,Treat fracture radius/ulna,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,25606,Treat fx distal radial,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25607,Treat fx rad extra-articul,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,25608,Treat fx rad intra-articul,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,25609,Treat fx radial 3+ frag,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,25622,Treat wrist bone fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,25624,Treat wrist bone fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,25628,Treat wrist bone fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,25630,Treat wrist bone fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,25635,Treat wrist bone fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,25645,Treat wrist bone fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25650,Treat wrist bone fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,25651,Pin ulnar styloid fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25652,Treat fracture ulnar styloid,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,25660,Treat wrist dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,25670,Treat wrist dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,25671,Pin radioulnar dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25675,Treat wrist dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,25676,Treat wrist dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,25680,Treat wrist fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,25685,Treat wrist fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,25690,Treat wrist dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,25695,Treat wrist dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,25800,Fusion of wrist joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,25805,Fusion/graft of wrist joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,25810,Fusion/graft of wrist joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,25820,Fusion of hand bones,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,25825,Fuse hand bones with graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,25830,Fusion radioulnar jnt/ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,25900,Amputation of forearm,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,25905,Amputation of forearm,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,25907,Amputation follow-up surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25909,Amputation follow-up surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,25915,Amputation of forearm,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,25920,Amputate hand at wrist,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,25922,Amputate hand at wrist,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,25924,Amputation follow-up surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,25927,Amputation of hand,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25929,Amputation follow-up surgery,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,25931,Amputation follow-up surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,25999,Forearm or wrist surgery,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,26010,Drainage of finger abscess,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,26011,Drainage of finger abscess,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,26020,Drain hand tendon sheath,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26025,Drainage of palm bursa,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26030,Drainage of palm bursas,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26034,Treat hand bone lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,26035,Decompress fingers/hand,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26037,Decompress fingers/hand,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26040,Release palm contracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,26045,Release palm contracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26055,Incise finger tendon sheath,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,26060,Incision of finger tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,26070,Explore/treat hand joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,26075,Explore/treat finger joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26080,Explore/treat finger joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,26100,Biopsy hand joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26105,Biopsy finger joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26110,Biopsy finger joint lining,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,26111,Exc hand les sc 1.5 cm/>,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,26113,Exc hand tum deep 1.5 cm/>,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,26115,Exc hand les sc < 1.5 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,26116,Exc hand tum deep < 1.5 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,26117,Rad resect hand tumor < 3 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,26118,Rad resect hand tumor 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,26121,Release palm contracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26123,Release palm contracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26130,Remove wrist joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26135,Revise finger joint each,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26140,Revise finger joint each,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,26145,Tendon excision palm/finger,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,26160,Remove tendon sheath lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,26170,Removal of palm tendon each,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,26180,Removal of finger tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,26185,Remove finger bone,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,26200,Remove hand bone lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,26205,Remove/graft bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,26210,Removal of finger lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,26215,Remove/graft finger lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26230,Partial removal of hand bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26235,Partial removal finger bone,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,26236,Partial removal finger bone,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,26250,Extensive hand surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26260,Resect prox finger tumor,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26262,Resect distal finger tumor,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,26320,Removal of implant from hand,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,26340,Manipulate finger w/anesth,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,26341,Manipulat palm cord post inj,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,26350,Repair finger/hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26352,Repair/graft hand tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,26356,Repair finger/hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26357,Repair finger/hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26358,Repair/graft hand tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,26370,Repair finger/hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","9,201.00",,,,,,
Humana MCR ADV,CPT,26372,Repair/graft hand tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,26373,Repair finger/hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26390,Revise hand/finger tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,26392,Repair/graft hand tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,26410,Repair hand tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,26412,Repair/graft hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26415,Excision hand/finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26416,Graft hand or finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26418,Repair finger tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,26420,Repair/graft finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26426,Repair finger/hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26428,Repair/graft finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26432,Repair finger tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,26433,Repair finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26434,Repair/graft finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26437,Realignment of tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26440,Release palm/finger tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,26442,Release palm & finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26445,Release hand/finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26449,Release forearm/hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26450,Incision of palm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26455,Incision of finger tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,26460,Incise hand/finger tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,26471,Fusion of finger tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26474,Fusion of finger tendons,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,26476,Tendon lengthening,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26477,Tendon shortening,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26478,Lengthening of hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26479,Shortening of hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26480,Transplant hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26483,Transplant/graft hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26485,Transplant palm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26489,Transplant/graft palm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26490,Revise thumb tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26492,Tendon transfer with graft,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26494,Hand tendon/muscle transfer,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26496,Revise thumb tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26497,Finger tendon transfer,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26498,Finger tendon transfer,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26499,Revision of finger,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26500,Hand tendon reconstruction,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,26502,Hand tendon reconstruction,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26508,Release thumb contracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26510,Thumb tendon transfer,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26516,Fusion of knuckle joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26517,Fusion of knuckle joints,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26518,Fusion of knuckle joints,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,26520,Release knuckle contracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26525,Release finger contracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,26530,Revise knuckle joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,26531,Revise knuckle with implant,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,26535,Revise finger joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26536,Revise/implant finger joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,26540,Repair hand joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26541,Repair hand joint with graft,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26542,Repair hand joint with graft,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26545,Reconstruct finger joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26546,Repair nonunion hand,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,26548,Reconstruct finger joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26550,Construct thumb replacement,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26551,Great toe-hand transfer,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,26553,Single transfer toe-hand,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,26554,Double transfer toe-hand,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,26555,Positional change of finger,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,26556,Toe joint transfer,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,26560,Repair of web finger,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,26561,Repair of web finger,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26562,Repair of web finger,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26565,Correct metacarpal flaw,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26567,Correct finger deformity,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26568,Lengthen metacarpal/finger,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,26580,Repair hand deformity,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26587,Reconstruct extra finger,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26590,Repair finger deformity,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,26591,Repair muscles of hand,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26593,Release muscles of hand,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26596,Excision constricting tissue,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26600,Treat metacarpal fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,26605,Treat metacarpal fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,26607,Treat metacarpal fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26608,Treat metacarpal fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26615,Treat metacarpal fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26641,Treat thumb dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,26645,Treat thumb fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,26650,Treat thumb fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26665,Treat thumb fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26670,Treat hand dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,26675,Treat hand dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,26676,Pin hand dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26685,Treat hand dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26686,Treat hand dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26700,Treat knuckle dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,26705,Treat knuckle dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,26706,Pin knuckle dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26715,Treat knuckle dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26720,Treat finger fracture each,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,26725,Treat finger fracture each,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,26727,Treat finger fracture each,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26735,Treat finger fracture each,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26740,Treat finger fracture each,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,26742,Treat finger fracture each,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,26746,Treat finger fracture each,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26750,Treat finger fracture each,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,26755,Treat finger fracture each,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,26756,Pin finger fracture each,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26765,Treat finger fracture each,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26770,Treat finger dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,26775,Treat finger dislocation,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Humana MCR ADV,CPT,26776,Pin finger dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26785,Treat finger dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26820,Thumb fusion with graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,26841,Fusion of thumb,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,26842,Thumb fusion with graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,26843,Fusion of hand joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,26844,Fusion/graft of hand joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,26850,Fusion of knuckle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,26852,Fusion of knuckle with graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,26860,Fusion of finger joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26862,Fusion/graft of finger joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26910,Amputate metacarpal bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26951,Amputation of finger/thumb,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26952,Amputation of finger/thumb,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26989,Hand/finger surgery,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,26990,Drainage of pelvis lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,26991,Drainage of pelvis bursa,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,26992,Drainage of bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27000,Incision of hip tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,27001,Incision of hip tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27003,Incision of hip tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27005,Incision of hip tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27006,Incision of hip tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27025,Incision of hip/thigh fascia,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27027,Buttock fasciotomy,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27030,Drainage of hip joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27033,Exploration of hip joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27035,Denervation of hip joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27036,Excision of hip joint/muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27040,Biopsy of soft tissues,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,27041,Biopsy of soft tissues,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,27043,Exc hip pelvis les sc 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,27045,Exc hip/pelv tum deep 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,27047,Exc hip/pelvis les sc < 3 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,27048,Exc hip/pelv tum deep < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,27049,Resect hip/pelv tum < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,27050,Biopsy of sacroiliac joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,27052,Biopsy of hip joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,27054,Removal of hip joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27057,Buttock fasciotomy w/dbrdmt,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,27059,Resect hip/pelv tum 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,27060,Removal of ischial bursa,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27062,Remove femur lesion/bursa,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27065,Remove hip bone les super,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27066,Remove hip bone les deep,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27067,Remove/graft hip bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27070,Part remove hip bone super,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27071,Part removal hip bone deep,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27075,Resect hip tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27076,Resect hip tum incl acetabul,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27077,Resect hip tum w/innom bone,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,27078,Rsect hip tum incl femur,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,27080,Removal of tail bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27086,Remove hip foreign body,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,27087,Remove hip foreign body,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27090,Removal of hip prosthesis,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,27091,Removal of hip prosthesis,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,27097,Revision of hip tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27098,Transfer tendon to pelvis,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27100,Transfer of abdominal muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27105,Transfer of spinal muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27110,Transfer of iliopsoas muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27111,Transfer of iliopsoas muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27120,Reconstruction of hip socket,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,27122,Reconstruction of hip socket,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,27125,Partial hip replacement,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,27130,Total hip arthroplasty,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,27132,Total hip arthroplasty,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,27134,Revise hip joint replacement,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,27137,Revise hip joint replacement,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,27138,Revise hip joint replacement,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,27140,Transplant femur ridge,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,27146,Incision of hip bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27147,Revision of hip bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27151,Incision of hip bones,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27156,Revision of hip bones,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27158,Revision of pelvis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27161,Incision of neck of femur,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27165,Incision/fixation of femur,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27170,Repair/graft femur head/neck,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27175,Treat slipped epiphysis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27176,Treat slipped epiphysis,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,27177,Treat slipped epiphysis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27178,Treat slipped epiphysis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27179,Revise head/neck of femur,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27181,Treat slipped epiphysis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27185,Revision of femur epiphysis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27187,Reinforce hip bones,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27197,Clsd tx pelvic ring fx,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,27198,Clsd tx pelvic ring fx,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,27200,Treat tail bone fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,27202,Treat tail bone fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27220,Treat hip socket fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,27222,Treat hip socket fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,27226,Treat hip wall fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27227,Treat hip fracture(s),APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27228,Treat hip fracture(s),APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27230,Treat thigh fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,27232,Treat thigh fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,27235,Treat thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27236,Treat thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27238,Treat thigh fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,27240,Treat thigh fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,27244,Treat thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27245,Treat thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27246,Treat thigh fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,27248,Treat thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27250,Treat hip dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,27252,Treat hip dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,27253,Treat hip dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27254,Treat hip dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27256,Treat hip dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,27257,Treat hip dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,27258,Treat hip dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27259,Treat hip dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27265,Treat hip dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,27266,Treat hip dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,27267,Cltx thigh fx,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27268,Cltx thigh fx w/mnpj,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27269,Optx thigh fx,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,27275,Manipulation of hip joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,27279,Arthrodesis sacroiliac joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,27280,Fusion of sacroiliac joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,27282,Fusion of pubic bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,27284,Fusion of hip joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,27286,Fusion of hip joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,27290,Amputation of leg at hip,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,27295,Amputation of leg at hip,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,27299,Pelvis/hip joint surgery,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,27301,Drain thigh/knee lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,27303,Drainage of bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27305,Incise thigh tendon & fascia,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27306,Incision of thigh tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27307,Incision of thigh tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27310,Exploration of knee joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27323,Biopsy thigh soft tissues,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,27324,Biopsy thigh soft tissues,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,27325,Neurectomy hamstring,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,27326,Neurectomy popliteal,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,27327,Exc thigh/knee les sc < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,27328,Exc thigh/knee tum deep <5cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,27329,Resect thigh/knee tum < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,27330,Biopsy knee joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27331,Explore/treat knee joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27332,Removal of knee cartilage,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27333,Removal of knee cartilage,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27334,Remove knee joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27335,Remove knee joint lining,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27337,Exc thigh/knee les sc 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,27339,Exc thigh/knee tum dep 5cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,27340,Removal of kneecap bursa,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27345,Removal of knee cyst,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27347,Remove knee cyst,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27350,Removal of kneecap,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27355,Remove femur lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27356,Remove femur lesion/graft,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,27357,Remove femur lesion/graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27360,Partial removal leg bone(s),APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27364,Resect thigh/knee tum 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,27365,Resect femur/knee tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27372,Removal of foreign body,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,27380,Repair of kneecap tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27381,Repair/graft kneecap tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27385,Repair of thigh muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27386,Repair/graft of thigh muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27390,Incision of thigh tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27391,Incision of thigh tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27392,Incision of thigh tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27393,Lengthening of thigh tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27394,Lengthening of thigh tendons,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27395,Lengthening of thigh tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27396,Transplant of thigh tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27397,Transplants of thigh tendons,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27400,Revise thigh muscles/tendons,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27403,Repair of knee cartilage,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27405,Repair of knee ligament,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,27407,Repair of knee ligament,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,27409,Repair of knee ligaments,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,27412,Autochondrocyte implant knee,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27415,Osteochondral knee allograft,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,27416,Osteochondral knee autograft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27418,Repair degenerated kneecap,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27420,Revision of unstable kneecap,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27422,Revision of unstable kneecap,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27424,Revision/removal of kneecap,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27425,Lat retinacular release open,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27427,Reconstruction knee,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,27428,Reconstruction knee,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Humana MCR ADV,CPT,27429,Reconstruction knee,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Humana MCR ADV,CPT,27430,Revision of thigh muscles,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27435,Incision of knee joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27437,Revise kneecap,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27438,Revise kneecap with implant,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,27440,Revision of knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,27441,Revision of knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,27442,Revision of knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,27443,Revision of knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,27445,Revision of knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,27446,Revision of knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Humana MCR ADV,CPT,27447,Total knee arthroplasty,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,27448,Incision of thigh,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27450,Incision of thigh,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27454,Realignment of thigh bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27455,Realignment of knee,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27457,Realignment of knee,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27465,Shortening of thigh bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27466,Lengthening of thigh bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27468,Shorten/lengthen thighs,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27470,Repair of thigh,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27472,Repair/graft of thigh,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27475,Surgery to stop leg growth,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27477,Surgery to stop leg growth,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27479,Surgery to stop leg growth,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27485,Surgery to stop leg growth,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27486,Revise/replace knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,27487,Revise/replace knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,27488,Removal of knee prosthesis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27495,Reinforce thigh,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27496,Decompression of thigh/knee,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27497,Decompression of thigh/knee,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27498,Decompression of thigh/knee,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,27499,Decompression of thigh/knee,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27500,Treatment of thigh fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,27501,Treatment of thigh fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,27502,Treatment of thigh fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,27503,Treatment of thigh fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,27506,Treatment of thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27507,Treatment of thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27508,Treatment of thigh fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,27509,Treatment of thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27510,Treatment of thigh fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,27511,Treatment of thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27513,Treatment of thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27514,Treatment of thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27516,Treat thigh fx growth plate,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,27517,Treat thigh fx growth plate,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,27519,Treat thigh fx growth plate,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27520,Treat kneecap fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,27524,Treat kneecap fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27530,Treat knee fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,27532,Treat knee fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27535,Treat knee fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27536,Treat knee fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27538,Treat knee fracture(s),APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,27540,Treat knee fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27550,Treat knee dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,27552,Treat knee dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,27556,Treat knee dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27557,Treat knee dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27558,Treat knee dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27560,Treat kneecap dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,27562,Treat kneecap dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,27566,Treat kneecap dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27570,Fixation of knee joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,27580,Fusion of knee,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,27590,Amputate leg at thigh,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,27591,Amputate leg at thigh,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,27592,Amputate leg at thigh,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,27594,Amputation follow-up surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27596,Amputation follow-up surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27598,Amputate lower leg at knee,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,27599,Leg surgery procedure,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,27600,Decompression of lower leg,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27601,Decompression of lower leg,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27602,Decompression of lower leg,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27603,Drain lower leg lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,27604,Drain lower leg bursa,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27605,Incision of achilles tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,27606,Incision of achilles tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27607,Treat lower leg bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27610,Explore/treat ankle joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27612,Exploration of ankle joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27613,Biopsy lower leg soft tissue,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,27614,Biopsy lower leg soft tissue,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,27615,Resect leg/ankle tum < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,27616,Resect leg/ankle tum 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,27618,Exc leg/ankle tum < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,27619,Exc leg/ankle tum deep <5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,27620,Explore/treat ankle joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27625,Remove ankle joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27626,Remove ankle joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27630,Removal of tendon lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27632,Exc leg/ankle les sc 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,27634,Exc leg/ankle tum dep 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,27635,Remove lower leg bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27637,Remove/graft leg bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27638,Remove/graft leg bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27640,Partial removal of tibia,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27641,Partial removal of fibula,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27645,Resect tibia tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27646,Resect fibula tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27647,Resect talus/calcaneus tum,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27650,Repair achilles tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27652,Repair/graft achilles tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,27654,Repair of achilles tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,27656,Repair leg fascia defect,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27658,Repair of leg tendon each,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27659,Repair of leg tendon each,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27664,Repair of leg tendon each,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27665,Repair of leg tendon each,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27675,Repair lower leg tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27676,Repair lower leg tendons,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27680,Release of lower leg tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27681,Release of lower leg tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27685,Revision of lower leg tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27686,Revise lower leg tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27687,Revision of calf tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27690,Revise lower leg tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27691,Revise lower leg tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,27695,Repair of ankle ligament,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27696,Repair of ankle ligaments,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27698,Repair of ankle ligament,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27700,Revision of ankle joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27702,Reconstruct ankle joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,27703,Reconstruction ankle joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,27704,Removal of ankle implant,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27705,Incision of tibia,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27707,Incision of fibula,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27709,Incision of tibia & fibula,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,27712,Realignment of lower leg,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,27715,Revision of lower leg,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,27720,Repair of tibia,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27722,Repair/graft of tibia,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27724,Repair/graft of tibia,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,27725,Repair of lower leg,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27726,Repair fibula nonunion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,27727,Repair of lower leg,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27730,Repair of tibia epiphysis,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27732,Repair of fibula epiphysis,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27734,Repair lower leg epiphyses,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27740,Repair of leg epiphyses,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27742,Repair of leg epiphyses,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27745,Reinforce tibia,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27750,Treatment of tibia fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,27752,Treatment of tibia fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,27756,Treatment of tibia fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27758,Treatment of tibia fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Humana MCR ADV,CPT,27759,Treatment of tibia fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,27760,Cltx medial ankle fx,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,27762,Cltx med ankle fx w/mnpj,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,27766,Optx medial ankle fx,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27767,Cltx post ankle fx,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,27768,Cltx post ankle fx w/mnpj,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,27769,Optx post ankle fx,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27780,Treatment of fibula fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,27781,Treatment of fibula fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,27784,Treatment of fibula fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27786,Treatment of ankle fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,27788,Treatment of ankle fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,27792,Treatment of ankle fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27808,Treatment of ankle fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,27810,Treatment of ankle fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,27814,Treatment of ankle fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,27816,Treatment of ankle fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,27818,Treatment of ankle fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,27822,Treatment of ankle fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27823,Treatment of ankle fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27824,Treat lower leg fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,27825,Treat lower leg fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,27826,Treat lower leg fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27827,Treat lower leg fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,27828,Treat lower leg fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Humana MCR ADV,CPT,27829,Treat lower leg joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27830,Treat lower leg dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,27831,Treat lower leg dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27832,Treat lower leg dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27840,Treat ankle dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,27842,Treat ankle dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,27846,Treat ankle dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27848,Treat ankle dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27860,Fixation of ankle joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27870,Fusion of ankle joint open,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Humana MCR ADV,CPT,27871,Fusion of tibiofibular joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Humana MCR ADV,CPT,27880,Amputation of lower leg,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,27881,Amputation of lower leg,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27882,Amputation of lower leg,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27884,Amputation follow-up surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27886,Amputation follow-up surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27888,Amputation of foot at ankle,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,27889,Amputation of foot at ankle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27892,Decompression of leg,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27893,Decompression of leg,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,27894,Decompression of leg,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,27899,Leg/ankle surgery procedure,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,28001,Drainage of bursa of foot,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,28002,Treatment of foot infection,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,28003,Treatment of foot infection,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28005,Treat foot bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28008,Incision of foot fascia,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28010,Incision of toe tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,28011,Incision of toe tendons,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,28020,Exploration of foot joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28022,Exploration of foot joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28024,Exploration of toe joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,28035,Decompression of tibia nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,28039,Exc foot/toe tum sc 1.5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,28041,Exc foot/toe tum dep 1.5cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,28043,Exc foot/toe tum sc < 1.5 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,28045,Exc foot/toe tum deep <1.5cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,28046,Resect foot/toe tumor < 3 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,28047,Resect foot/toe tumor 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,28050,Biopsy of foot joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28052,Biopsy of foot joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28054,Biopsy of toe joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28055,Neurectomy foot,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,28060,Partial removal foot fascia,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28062,Removal of foot fascia,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28070,Removal of foot joint lining,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,28072,Removal of foot joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28080,Removal of foot lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,28086,Excise foot tendon sheath,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28088,Excise foot tendon sheath,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28090,Removal of foot lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,28092,Removal of toe lesions,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,28100,Removal of ankle/heel lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28102,Remove/graft foot lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,28103,Remove/graft foot lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,28104,Removal of foot lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28106,Remove/graft foot lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,28107,Remove/graft foot lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,28108,Removal of toe lesions,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,28110,Part removal of metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28111,Part removal of metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28112,Part removal of metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28113,Part removal of metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28114,Removal of metatarsal heads,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28116,Revision of foot,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28118,Removal of heel bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28119,Removal of heel spur,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28120,Part removal of ankle/heel,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28122,Partial removal of foot bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28124,Partial removal of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28126,Partial removal of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28130,Removal of ankle bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,28140,Removal of metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28150,Removal of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28153,Partial removal of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28160,Partial removal of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28171,Resect tarsal tumor,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28173,Resect metatarsal tumor,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28175,Resect phalanx of toe tumor,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,28190,Removal of foot foreign body,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,28192,Removal of foot foreign body,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,28193,Removal of foot foreign body,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,28200,Repair of foot tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28202,Repair/graft of foot tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,28208,Repair of foot tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28210,Repair/graft of foot tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,28220,Release of foot tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,28222,Release of foot tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28225,Release of foot tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28226,Release of foot tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28230,Incision of foot tendon(s),APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,28232,Incision of toe tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,28234,Incision of foot tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,28238,Revision of foot tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,28240,Release of big toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28250,Revision of foot fascia,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28260,Release of midfoot joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28261,Revision of foot tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,28262,Revision of foot and ankle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,28264,Release of midfoot joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,28270,Release of foot contracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28272,Release of toe joint each,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,28280,Fusion of toes,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28285,Repair of hammertoe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28286,Repair of hammertoe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28288,Partial removal of foot bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28289,Corrj halux rigdus w/o implt,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28291,Corrj halux rigdus w/implt,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,28292,Correction hallux valgus,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28295,Correction hallux valgus,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28296,Correction hallux valgus,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28297,Correction hallux valgus,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,28298,Correction hallux valgus,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,28299,Correction hallux valgus,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,28300,Incision of heel bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,28302,Incision of ankle bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,28304,Incision of midfoot bones,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,28305,Incise/graft midfoot bones,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,28306,Incision of metatarsal,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,28307,Incision of metatarsal,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,28308,Incision of metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28309,Incision of metatarsals,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,28310,Revision of big toe,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,28312,Revision of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28313,Repair deformity of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28315,Removal of sesamoid bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28320,Repair of foot bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,28322,Repair of metatarsals,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,28340,Resect enlarged toe tissue,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28341,Resect enlarged toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28344,Repair extra toe(s),APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28345,Repair webbed toe(s),APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,28360,Reconstruct cleft foot,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,28400,Treatment of heel fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,28405,Treatment of heel fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,28406,Treatment of heel fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,28415,Treat heel fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,28420,Treat/graft heel fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,28430,Treatment of ankle fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,28435,Treatment of ankle fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,28436,Treatment of ankle fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,28445,Treat ankle fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,28446,Osteochondral talus autogrft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,28450,Treat midfoot fracture each,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,28455,Treat midfoot fracture each,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,28456,Treat midfoot fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,28465,Treat midfoot fracture each,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,28470,Treat metatarsal fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,28475,Treat metatarsal fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,28476,Treat metatarsal fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28485,Treat metatarsal fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,28490,Treat big toe fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,28495,Treat big toe fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,28496,Treat big toe fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28505,Treat big toe fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28510,Treatment of toe fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,28515,Treatment of toe fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,28525,Treat toe fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28530,Treat sesamoid bone fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,28531,Treat sesamoid bone fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,28540,Treat foot dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,28545,Treat foot dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28546,Treat foot dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,28555,Repair foot dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,28570,Treat foot dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,28575,Treat foot dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28576,Treat foot dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,28585,Repair foot dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,28600,Treat foot dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,28605,Treat foot dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,28606,Treat foot dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28615,Repair foot dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,28630,Treat toe dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,28635,Treat toe dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,28636,Treat toe dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28645,Repair toe dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28660,Treat toe dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,28665,Treat toe dislocation,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Humana MCR ADV,CPT,28666,Treat toe dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28675,Repair of toe dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28705,Fusion of foot bones,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,28715,Fusion of foot bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Humana MCR ADV,CPT,28725,Fusion of foot bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Humana MCR ADV,CPT,28730,Fusion of foot bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Humana MCR ADV,CPT,28735,Fusion of foot bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,28737,Revision of foot bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,28740,Fusion of foot bones,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,28750,Fusion of big toe joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,28755,Fusion of big toe joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,28760,Fusion of big toe joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,28800,Amputation of midfoot,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28805,Amputation thru metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28810,Amputation toe & metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28820,Amputation of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28825,Partial amputation of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,28890,Hi enrgy eswt plantar fascia,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,28899,Foot/toes surgery procedure,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,29000,Application of body cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Humana MCR ADV,CPT,29010,Application of body cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Humana MCR ADV,CPT,29015,Application of body cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Humana MCR ADV,CPT,29035,Application of body cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Humana MCR ADV,CPT,29040,Application of body cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Humana MCR ADV,CPT,29044,Application of body cast,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,29046,Application of body cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Humana MCR ADV,CPT,29049,Application of figure eight,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Humana MCR ADV,CPT,29055,Application of shoulder cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Humana MCR ADV,CPT,29058,Application of shoulder cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Humana MCR ADV,CPT,29065,Application of long arm cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Humana MCR ADV,CPT,29075,Application of forearm cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Humana MCR ADV,CPT,29085,Apply hand/wrist cast,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,29086,Apply finger cast,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,29105,Apply long arm splint,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,29125,Apply forearm splint,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Humana MCR ADV,CPT,29126,Apply forearm splint,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Humana MCR ADV,CPT,29130,Application of finger splint,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Humana MCR ADV,CPT,29131,Application of finger splint,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Humana MCR ADV,CPT,29200,Strapping of chest,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,29240,Strapping of shoulder,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Humana MCR ADV,CPT,29260,Strapping of elbow or wrist,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Humana MCR ADV,CPT,29280,Strapping of hand or finger,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Humana MCR ADV,CPT,29305,Application of hip cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Humana MCR ADV,CPT,29325,Application of hip casts,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Humana MCR ADV,CPT,29345,Application of long leg cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Humana MCR ADV,CPT,29355,Application of long leg cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Humana MCR ADV,CPT,29358,Apply long leg cast brace,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Humana MCR ADV,CPT,29365,Application of long leg cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Humana MCR ADV,CPT,29405,Apply short leg cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Humana MCR ADV,CPT,29425,Apply short leg cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Humana MCR ADV,CPT,29435,Apply short leg cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Humana MCR ADV,CPT,29440,Addition of walker to cast,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,29445,Apply rigid leg cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Humana MCR ADV,CPT,29450,Application of leg cast,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,29505,Application long leg splint,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,29515,Application lower leg splint,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,29520,Strapping of hip,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Humana MCR ADV,CPT,29530,Strapping of knee,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Humana MCR ADV,CPT,29540,Strapping of ankle and/or ft,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,29550,Strapping of toes,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Humana MCR ADV,CPT,29580,Application of paste boot,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,29581,Apply multlay comprs lwr leg,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,29584,Appl multlay comprs arm/hand,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,29700,Removal/revision of cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Humana MCR ADV,CPT,29705,Removal/revision of cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Humana MCR ADV,CPT,29710,Removal/revision of cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Humana MCR ADV,CPT,29720,Repair of body cast,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,29730,Windowing of cast,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,29740,Wedging of cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Humana MCR ADV,CPT,29750,Wedging of clubfoot cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Humana MCR ADV,CPT,29799,Casting/strapping procedure,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,29800,Jaw arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,29804,Jaw arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,29805,Sho arthrs dx +- synovial bx,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,29806,Sho arthrs srg capsulorpaphy,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,29807,Sho arthrs srg rpr slap les,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,29819,Sho arthrs srg rmvl loose/fb,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,29820,Sho arthrs srg prtl synvct,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,29821,Sho arthrs srg compl synvct,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,29822,Sho arthrs srg lmtd dbrdmt,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,29823,Sho arthrs srg xtnsv dbrdmt,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,29824,Sho arthrs srg dstl claviclc,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,29825,Sho arthrs srg lss&rescj ads,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,29827,Sho arthrs srg rt8tr cuf rpr,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,29828,Sho arthrs srg bicp tenodsis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,29830,Elbow arthroscopy,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,29834,Elbow arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,29835,Elbow arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,29836,Elbow arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,29837,Elbow arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,29838,Elbow arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,29840,Wrist arthroscopy,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,29843,Wrist arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,29844,Wrist arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,29845,Wrist arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,29846,Wrist arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,29847,Wrist arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,29848,Wrist endoscopy/surgery,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,29850,Knee arthroscopy/surgery,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,29851,Knee arthroscopy/surgery,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,29855,Tibial arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,29856,Tibial arthroscopy/surgery,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,29860,Hip arthroscopy dx,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,29861,Hip arthro w/fb removal,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,29862,Hip arthr0 w/debridement,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,29863,Hip arthr0 w/synovectomy,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,29866,Autgrft implnt knee w/scope,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,29867,Allgrft implnt knee w/scope,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,29868,Meniscal trnspl knee w/scpe,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,29870,Knee arthroscopy dx,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,29871,Knee arthroscopy/drainage,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,29873,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,29874,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,29875,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,29876,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,29877,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,29879,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,29880,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,29881,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,29882,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,29883,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,29884,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,29885,Knee arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,29886,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,29887,Knee arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,29888,Knee arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,29889,Knee arthroscopy/surgery,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Humana MCR ADV,CPT,29891,Ankle arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,29892,Ankle arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,29893,Scope plantar fasciotomy,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,29894,Ankle arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,29895,Ankle arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,29897,Ankle arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,29898,Ankle arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,29899,Ankle arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,29900,Mcp joint arthroscopy dx,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,29901,Mcp joint arthroscopy surg,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,29902,Mcp joint arthroscopy surg,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Humana MCR ADV,CPT,29904,Subtalar arthro w/fb rmvl,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,29905,Subtalar arthro w/exc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,29906,Subtalar arthro w/deb,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,29907,Subtalar arthro w/fusion,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,29914,Hip arthro w/femoroplasty,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,29915,Hip arthro acetabuloplasty,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,29916,Hip arthro w/labral repair,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,29999,Arthroscopy of joint,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Humana MCR ADV,CPT,30000,Drainage of nose lesion,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Humana MCR ADV,CPT,30020,Drainage of nose lesion,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,30100,Intranasal biopsy,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,30110,Removal of nose polyp(s),APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,30115,Removal of nose polyp(s),APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,30117,Removal of intranasal lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,30118,Removal of intranasal lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,30120,Revision of nose,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,30124,Removal of nose lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,30125,Removal of nose lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,30130,Excise inferior turbinate,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,30140,Resect inferior turbinate,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,30150,Partial removal of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,30160,Removal of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,30200,Injection treatment of nose,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,30210,Nasal sinus therapy,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,30220,Insert nasal septal button,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,30300,Remove nasal foreign body,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Humana MCR ADV,CPT,30310,Remove nasal foreign body,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,30320,Remove nasal foreign body,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,30400,Reconstruction of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,30410,Reconstruction of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,30420,Reconstruction of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,30430,Revision of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,30435,Revision of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,30450,Revision of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,30460,Revision of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,30462,Revision of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,30465,Repair nasal stenosis,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,30468,Rpr nsl vlv collapse w/implt,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,30520,Repair of nasal septum,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,30540,Repair nasal defect,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,30545,Repair nasal defect,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,30560,Release of nasal adhesions,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,30580,Repair upper jaw fistula,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,30600,Repair mouth/nose fistula,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,30620,Intranasal reconstruction,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,30630,Repair nasal septum defect,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,30801,Ablate inf turbinate superf,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,30802,Ablate inf turbinate submuc,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,30901,Control of nosebleed,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Humana MCR ADV,CPT,30903,Control of nosebleed,APC 5734,RVU Per Unit,$114.56 ,OP,114.56,"4,314.00",,,,,,
Humana MCR ADV,CPT,30905,Control of nosebleed,APC 5734,RVU Per Unit,$114.56 ,OP,114.56,"4,314.00",,,,,,
Humana MCR ADV,CPT,30906,Repeat control of nosebleed,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Humana MCR ADV,CPT,30915,Ligation nasal sinus artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,30920,Ligation upper jaw artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,30930,Ther fx nasal inf turbinate,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,30999,Nasal surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Humana MCR ADV,CPT,31000,Irrigation maxillary sinus,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Humana MCR ADV,CPT,31002,Irrigation sphenoid sinus,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,31020,Exploration maxillary sinus,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,31030,Exploration maxillary sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,31032,Explore sinus remove polyps,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,31040,Exploration behind upper jaw,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,31050,Exploration sphenoid sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,31051,Sphenoid sinus surgery,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,31070,Exploration of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,31075,Exploration of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,31080,Removal of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,31081,Removal of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,31084,Removal of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,31085,Removal of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,31086,Removal of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,31087,Removal of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,31090,Exploration of sinuses,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,31200,Removal of ethmoid sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,31201,Removal of ethmoid sinus,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,31205,Removal of ethmoid sinus,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,31225,Removal of upper jaw,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,31230,Removal of upper jaw,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,31231,Nasal endoscopy dx,APC 5151,RVU Per Unit,$168.23 ,OP,168.23,"4,314.00",,,,,,
Humana MCR ADV,CPT,31233,Nsl/sins ndsc dx max sinusc,APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
Humana MCR ADV,CPT,31235,Nsl/sins ndsc dx sphn sinusc,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Humana MCR ADV,CPT,31237,Nasal/sinus endoscopy surg,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Humana MCR ADV,CPT,31238,Nasal/sinus endoscopy surg,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Humana MCR ADV,CPT,31239,Nasal/sinus endoscopy surg,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Humana MCR ADV,CPT,31240,Nasal/sinus endoscopy surg,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Humana MCR ADV,CPT,31241,Nsl/sins ndsc w/artery lig,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Humana MCR ADV,CPT,31253,Nsl/sins ndsc total,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,31254,Nsl/sins ndsc w/prtl ethmdct,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Humana MCR ADV,CPT,31255,Nsl/sins ndsc w/tot ethmdct,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,31256,Exploration maxillary sinus,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Humana MCR ADV,CPT,31257,Nsl/sins ndsc tot w/sphendt,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,31259,Nsl/sins ndsc sphn tiss rmvl,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,31267,Endoscopy maxillary sinus,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Humana MCR ADV,CPT,31276,Nsl/sins ndsc frnt tiss rmvl,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,31287,Nasal/sinus endoscopy surg,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,31288,Nasal/sinus endoscopy surg,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,31290,Nasal/sinus endoscopy surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,31291,Nasal/sinus endoscopy surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,31292,Nsl/sins ndsc med/inf dcmprn,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Humana MCR ADV,CPT,31293,Nsl/sins ndsc med&inf dcmprn,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Humana MCR ADV,CPT,31294,Nsl/sins ndsc surg on dcmprn,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Humana MCR ADV,CPT,31295,Nsl/sins ndsc surg max sins,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Humana MCR ADV,CPT,31296,Nsl/sins ndsc surg frnt sins,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,31297,Nsl/sins ndsc surg sphn sins,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Humana MCR ADV,CPT,31298,Nsl/sins ndsc surg frnt&sphn,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,31299,Sinus surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Humana MCR ADV,CPT,31300,Removal of larynx lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,31360,Removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,31365,Removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,31367,Partial removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,31368,Partial removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,31370,Partial removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,31375,Partial removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,31380,Partial removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,31382,Partial removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,31390,Removal of larynx & pharynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,31395,Reconstruct larynx & pharynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,31400,Revision of larynx,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,31420,Removal of epiglottis,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,31500,Insert emergency airway,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Humana MCR ADV,CPT,31502,Change of windpipe airway,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Humana MCR ADV,CPT,31505,Diagnostic laryngoscopy,APC 5151,RVU Per Unit,$168.23 ,OP,168.23,"4,314.00",,,,,,
Humana MCR ADV,CPT,31510,Laryngoscopy with biopsy,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Humana MCR ADV,CPT,31511,Remove foreign body larynx,APC 5151,RVU Per Unit,$168.23 ,OP,168.23,"4,314.00",,,,,,
Humana MCR ADV,CPT,31512,Removal of larynx lesion,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Humana MCR ADV,CPT,31513,Injection into vocal cord,APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
Humana MCR ADV,CPT,31515,Laryngoscopy for aspiration,APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
Humana MCR ADV,CPT,31520,Dx laryngoscopy newborn,APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
Humana MCR ADV,CPT,31525,Dx laryngoscopy excl nb,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Humana MCR ADV,CPT,31526,Dx laryngoscopy w/oper scope,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Humana MCR ADV,CPT,31527,Laryngoscopy for treatment,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Humana MCR ADV,CPT,31528,Laryngoscopy and dilation,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Humana MCR ADV,CPT,31529,Laryngoscopy and dilation,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Humana MCR ADV,CPT,31530,Laryngoscopy w/fb removal,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Humana MCR ADV,CPT,31531,Laryngoscopy w/fb & op scope,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Humana MCR ADV,CPT,31535,Laryngoscopy w/biopsy,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Humana MCR ADV,CPT,31536,Laryngoscopy w/bx & op scope,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Humana MCR ADV,CPT,31540,Laryngoscopy w/exc of tumor,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Humana MCR ADV,CPT,31541,Larynscop w/tumr exc + scope,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Humana MCR ADV,CPT,31545,Remove vc lesion w/scope,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Humana MCR ADV,CPT,31546,Remove vc lesion scope/graft,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Humana MCR ADV,CPT,31551,Laryngoplasty laryngeal sten,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,31552,Laryngoplasty laryngeal sten,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,31553,Laryngoplasty laryngeal sten,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,31554,Laryngoplasty laryngeal sten,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,31560,Laryngoscop w/arytenoidectom,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Humana MCR ADV,CPT,31561,Larynscop remve cart + scop,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Humana MCR ADV,CPT,31570,Laryngoscope w/vc inj,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Humana MCR ADV,CPT,31571,Laryngoscop w/vc inj + scope,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Humana MCR ADV,CPT,31572,Largsc w/laser dstrj les,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Humana MCR ADV,CPT,31573,Largsc w/ther injection,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Humana MCR ADV,CPT,31574,Largsc w/njx augmentation,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Humana MCR ADV,CPT,31575,Diagnostic laryngoscopy,APC 5151,RVU Per Unit,$168.23 ,OP,168.23,"4,314.00",,,,,,
Humana MCR ADV,CPT,31576,Laryngoscopy with biopsy,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Humana MCR ADV,CPT,31577,Largsc w/rmvl foreign bdy(s),APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
Humana MCR ADV,CPT,31578,Largsc w/removal lesion,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Humana MCR ADV,CPT,31579,Laryngoscopy telescopic,APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
Humana MCR ADV,CPT,31580,Laryngoplasty laryngeal web,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,31584,Laryngoplasty fx rdctj fixj,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,31587,Laryngoplasty cricoid split,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,31590,Reinnervate larynx,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,31591,Laryngoplasty medialization,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,31592,Cricotracheal resection,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,31599,Larynx surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Humana MCR ADV,CPT,31600,Incision of windpipe,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,31601,Incision of windpipe,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,31603,Incision of windpipe,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,31605,Incision of windpipe,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Humana MCR ADV,CPT,31610,Incision of windpipe,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,31611,Surgery/speech prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,31612,Puncture/clear windpipe,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,31613,Repair windpipe opening,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,31614,Repair windpipe opening,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,31615,Visualization of windpipe,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,31622,Dx bronchoscope/wash,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Humana MCR ADV,CPT,31623,Dx bronchoscope/brush,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Humana MCR ADV,CPT,31624,Dx bronchoscope/lavage,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Humana MCR ADV,CPT,31625,Bronchoscopy w/biopsy(s),APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Humana MCR ADV,CPT,31626,Bronchoscopy w/markers,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Humana MCR ADV,CPT,31628,Bronchoscopy/lung bx each,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Humana MCR ADV,CPT,31629,Bronchoscopy/needle bx each,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Humana MCR ADV,CPT,31630,Bronchoscopy dilate/fx repr,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Humana MCR ADV,CPT,31631,Bronchoscopy dilate w/stent,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Humana MCR ADV,CPT,31634,Bronch w/balloon occlusion,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Humana MCR ADV,CPT,31635,Bronchoscopy w/fb removal,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Humana MCR ADV,CPT,31636,Bronchoscopy bronch stents,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Humana MCR ADV,CPT,31638,Bronchoscopy revise stent,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Humana MCR ADV,CPT,31640,Bronchoscopy w/tumor excise,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Humana MCR ADV,CPT,31641,Bronchoscopy treat blockage,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Humana MCR ADV,CPT,31643,Diag bronchoscope/catheter,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Humana MCR ADV,CPT,31645,Brnchsc w/ther aspir 1st,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Humana MCR ADV,CPT,31646,Brnchsc w/ther aspir sbsq,APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
Humana MCR ADV,CPT,31647,Bronchial valve init insert,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Humana MCR ADV,CPT,31648,Bronchial valve remov init,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Humana MCR ADV,CPT,31649,Bronchial valve remov addl,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Humana MCR ADV,CPT,31652,Bronch ebus samplng 1/2 node,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Humana MCR ADV,CPT,31653,Bronch ebus samplng 3/> node,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Humana MCR ADV,CPT,31660,Bronch thermoplsty 1 lobe,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Humana MCR ADV,CPT,31661,Bronch thermoplsty 2/> lobes,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Humana MCR ADV,CPT,31717,Bronchial brush biopsy,APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
Humana MCR ADV,CPT,31720,Clearance of airways,APC 5791,RVU Per Case,$192.26 ,OP,192.26,"4,314.00",,,,,,
Humana MCR ADV,CPT,31725,Clearance of airways,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,31730,Intro windpipe wire/tube,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Humana MCR ADV,CPT,31750,Repair of windpipe,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,31755,Repair of windpipe,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,31760,Repair of windpipe,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,31766,Reconstruction of windpipe,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,31770,Repair/graft of bronchus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,31775,Reconstruct bronchus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,31780,Reconstruct windpipe,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,31781,Reconstruct windpipe,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,31785,Remove windpipe lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,31786,Remove windpipe lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,31800,Repair of windpipe injury,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,31805,Repair of windpipe injury,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,31820,Closure of windpipe lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,31825,Repair of windpipe defect,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,31830,Revise windpipe scar,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,31899,Airways surgical procedure,APC 5151,RVU Per Unit,$168.23 ,OP,168.23,"4,314.00",,,,,,
Humana MCR ADV,CPT,32035,Thoracostomy w/rib resection,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32036,Thoracostomy w/flap drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32096,Open wedge/bx lung infiltr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32097,Open wedge/bx lung nodule,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32098,Open biopsy of lung pleura,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32100,Exploration of chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32110,Explore/repair chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32120,Re-exploration of chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32124,Explore chest free adhesions,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32140,Removal of lung lesion(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32141,Remove/treat lung lesions,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32150,Removal of lung lesion(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32151,Remove lung foreign body,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32160,Open chest heart massage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32200,Drain open lung lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32215,Treat chest lining,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32220,Release of lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32225,Partial release of lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32310,Removal of chest lining,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32320,Free/remove chest lining,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32400,Needle biopsy chest lining,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,32408,Core ndl bx lng/med perq,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,32440,Remove lung pneumonectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32442,Sleeve pneumonectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32445,Removal of lung extrapleural,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32480,Partial removal of lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32482,Bilobectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32484,Segmentectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32486,Sleeve lobectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32488,Completion pneumonectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32491,Lung volume reduction,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32501,Repair bronchus add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32503,Resect apical lung tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32504,Resect apical lung tum/chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32505,Wedge resect of lung initial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32506,Wedge resect of lung add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32507,Wedge resect of lung diag,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32540,Removal of lung lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32550,Insert pleural cath,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Humana MCR ADV,CPT,32551,Insertion of chest tube,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Humana MCR ADV,CPT,32552,Remove lung catheter,APC 5181,RVU Per Case,$554.25 ,OP,554.25,"4,314.00",,,,,,
Humana MCR ADV,CPT,32553,Ins mark thor for rt perq,APC 5613,RVU Per Unit,"$1,291.62 ",OP,"1,291.62","4,314.00",,,,,,
Humana MCR ADV,CPT,32554,Aspirate pleura w/o imaging,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Humana MCR ADV,CPT,32555,Aspirate pleura w/ imaging,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Humana MCR ADV,CPT,32556,Insert cath pleura w/o image,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,32557,Insert cath pleura w/ image,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Humana MCR ADV,CPT,32560,Treat pleurodesis w/agent,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Humana MCR ADV,CPT,32561,Lyse chest fibrin init day,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Humana MCR ADV,CPT,32562,Lyse chest fibrin subq day,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Humana MCR ADV,CPT,32601,Thoracoscopy diagnostic,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,32604,Thoracoscopy wbx sac,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,32606,Thoracoscopy w/bx med space,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,32607,Thoracoscopy w/bx infiltrate,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,32608,Thoracoscopy w/bx nodule,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,32609,Thoracoscopy w/bx pleura,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,32650,Thoracoscopy w/pleurodesis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32651,Thoracoscopy remove cortex,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32652,Thoracoscopy rem totl cortex,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32653,Thoracoscopy remov fb/fibrin,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32654,Thoracoscopy contrl bleeding,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32655,Thoracoscopy resect bullae,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32656,Thoracoscopy w/pleurectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32658,Thoracoscopy w/sac fb remove,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32659,Thoracoscopy w/sac drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32661,Thoracoscopy w/pericard exc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32662,Thoracoscopy w/mediast exc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32663,Thoracoscopy w/lobectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32664,Thoracoscopy w/ th nrv exc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32665,Thoracoscop w/esoph musc exc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32666,Thoracoscopy w/wedge resect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32667,Thoracoscopy w/w resect addl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32668,Thoracoscopy w/w resect diag,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32669,Thoracoscopy remove segment,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32670,Thoracoscopy bilobectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32671,Thoracoscopy pneumonectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32672,Thoracoscopy for lvrs,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32673,Thoracoscopy w/thymus resect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32674,Thoracoscopy lymph node exc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32800,Repair lung hernia,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32810,Close chest after drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32815,Close bronchial fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32820,Reconstruct injured chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32850,Donor pneumonectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32851,Lung transplant single,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32852,Lung transplant with bypass,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32853,Lung transplant double,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32854,Lung transplant with bypass,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32855,Prepare donor lung single,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32856,Prepare donor lung double,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32900,Removal of rib(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32905,Revise & repair chest wall,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32906,Revise & repair chest wall,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32940,Revision of lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32960,Therapeutic pneumothorax,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Humana MCR ADV,CPT,32994,Ablate pulm tumor perq crybl,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,32997,Total lung lavage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,32998,Ablate pulm tumor perq rf,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,32999,Chest surgery procedure,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Humana MCR ADV,CPT,33016,Pericardiocentesis w/imaging,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Humana MCR ADV,CPT,33017,Prcrd drg 6yr+ w/o cgen car,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33018,Prcrd drg 0-5yr or w/anomly,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33019,Perq prcrd drg insj cath ct,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33020,Incision of heart sac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33025,Incision of heart sac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33030,Partial removal of heart sac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33031,Partial removal of heart sac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33050,Resect heart sac lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33120,Removal of heart lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33130,Removal of heart lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33140,Heart revascularize (tmr),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33141,Heart tmr w/other procedure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33202,Insert epicard eltrd open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33203,Insert epicard eltrd endo,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33206,Insert heart pm atrial,APC 5223,RVU Per Case,"$10,642.67 ",OP,"4,314.00","10,642.67",,,,,,
Humana MCR ADV,CPT,33207,Insert heart pm ventricular,APC 5223,RVU Per Case,"$10,642.67 ",OP,"4,314.00","10,642.67",,,,,,
Humana MCR ADV,CPT,33208,Insrt heart pm atrial & vent,APC 5223,RVU Per Case,"$10,642.67 ",OP,"4,314.00","10,642.67",,,,,,
Humana MCR ADV,CPT,33210,Insert electrd/pm cath sngl,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
Humana MCR ADV,CPT,33211,Insert card electrodes dual,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
Humana MCR ADV,CPT,33212,Insert pulse gen sngl lead,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
Humana MCR ADV,CPT,33213,Insert pulse gen dual leads,APC 5223,RVU Per Case,"$10,642.67 ",OP,"4,314.00","10,642.67",,,,,,
Humana MCR ADV,CPT,33214,Upgrade of pacemaker system,APC 5223,RVU Per Case,"$10,642.67 ",OP,"4,314.00","10,642.67",,,,,,
Humana MCR ADV,CPT,33215,Reposition pacing-defib lead,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,33216,Insert 1 electrode pm-defib,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
Humana MCR ADV,CPT,33217,Insert 2 electrode pm-defib,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
Humana MCR ADV,CPT,33218,Repair lead pace-defib one,APC 5221,RVU Per Unit,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Humana MCR ADV,CPT,33220,Repair lead pace-defib dual,APC 5221,RVU Per Unit,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Humana MCR ADV,CPT,33221,Insert pulse gen mult leads,APC 5224,RVU Per Case,"$19,045.26 ",OP,"4,314.00","19,045.26",,,,,,
Humana MCR ADV,CPT,33222,Relocation pocket pacemaker,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,33223,Relocate pocket for defib,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,33224,Insert pacing lead & connect,APC 5223,RVU Per Case,"$10,642.67 ",OP,"4,314.00","10,642.67",,,,,,
Humana MCR ADV,CPT,33226,Reposition l ventric lead,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,33227,Remove&replace pm gen singl,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
Humana MCR ADV,CPT,33228,Remv&replc pm gen dual lead,APC 5223,RVU Per Case,"$10,642.67 ",OP,"4,140.35","10,642.67",,,,,,
Humana MCR ADV,CPT,33229,Remv&replc pm gen mult leads,APC 5224,RVU Per Case,"$19,045.26 ",OP,"4,314.00","19,045.26",,,,,,
Humana MCR ADV,CPT,33230,Insrt pulse gen w/dual leads,APC 5231,RVU Per Case,"$23,577.44 ",OP,"4,314.00","23,577.44",,,,,,
Humana MCR ADV,CPT,33231,Insrt pulse gen w/mult leads,APC 5232,RVU Per Case,"$33,604.66 ",OP,"4,314.00","33,604.66",,,,,,
Humana MCR ADV,CPT,33233,Removal of pm generator,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
Humana MCR ADV,CPT,33234,Removal of pacemaker system,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Humana MCR ADV,CPT,33235,Removal pacemaker electrode,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Humana MCR ADV,CPT,33236,Remove electrode/thoracotomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33237,Remove electrode/thoracotomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33238,Remove electrode/thoracotomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33240,Insrt pulse gen w/singl lead,APC 5231,RVU Per Case,"$23,577.44 ",OP,"4,140.35","23,577.44",,,,,,
Humana MCR ADV,CPT,33241,Remove pulse generator,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Humana MCR ADV,CPT,33243,Remove eltrd/thoracotomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33244,Remove elctrd transvenously,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Humana MCR ADV,CPT,33249,Insj/rplcmt defib w/lead(s),APC 5232,RVU Per Case,"$33,604.66 ",OP,"4,140.35","33,604.66",,,,,,
Humana MCR ADV,CPT,33250,Ablate heart dysrhythm focus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33251,Ablate heart dysrhythm focus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33254,Ablate atria lmtd,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33255,Ablate atria w/o bypass ext,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33256,Ablate atria w/bypass exten,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33257,Ablate atria lmtd add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33258,Ablate atria x10sv add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33259,Ablate atria w/bypass add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33261,Ablate heart dysrhythm focus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33262,Rmvl& replc pulse gen 1 lead,APC 5231,RVU Per Case,"$23,577.44 ",OP,"4,314.00","23,577.44",,,,,,
Humana MCR ADV,CPT,33263,Rmvl & rplcmt dfb gen 2 lead,APC 5231,RVU Per Case,"$23,577.44 ",OP,"4,140.35","23,577.44",,,,,,
Humana MCR ADV,CPT,33264,Rmvl & rplcmt dfb gen mlt ld,APC 5232,RVU Per Case,"$33,604.66 ",OP,"4,314.00","33,604.66",,,,,,
Humana MCR ADV,CPT,33265,Ablate atria lmtd endo,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33266,Ablate atria x10sv endo,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33270,Ins/rep subq defibrillator,APC 5232,RVU Per Case,"$33,604.66 ",OP,"4,314.00","33,604.66",,,,,,
Humana MCR ADV,CPT,33271,Insj subq impltbl dfb elctrd,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
Humana MCR ADV,CPT,33272,Rmvl of subq defibrillator,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Humana MCR ADV,CPT,33273,Repos prev impltbl subq dfb,APC 5221,RVU Per Unit,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Humana MCR ADV,CPT,33274,Tcat insj/rpl perm ldls pm,APC 5194,RVU Per Case,"$16,438.60 ",OP,"4,314.00","16,438.60",,,,,,
Humana MCR ADV,CPT,33275,Tcat rmvl perm ldls pm w/img,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,33285,Insj subq car rhythm mntr,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
Humana MCR ADV,CPT,33286,Rmvl subq car rhythm mntr,APC 5071,RVU Per Case,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,33289,Tcat impl wrls p-art prs snr,APC 5200,RVU Per Case,"$29,487.35 ",OP,"4,314.00","29,487.35",,,,,,
Humana MCR ADV,CPT,33300,Repair of heart wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33305,Repair of heart wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33310,Exploratory heart surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33315,Exploratory heart surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33320,Repair major blood vessel(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33321,Repair major vessel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33322,Repair major blood vessel(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33330,Insert major vessel graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33335,Insert major vessel graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33340,Perq clsr tcat l atr apndge,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33361,Replace aortic valve perq,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33362,Replace aortic valve open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33363,Replace aortic valve open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33364,Replace aortic valve open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33365,Replace aortic valve open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33366,Trcath replace aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33367,Replace aortic valve w/byp,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33368,Replace aortic valve w/byp,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33369,Replace aortic valve w/byp,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33390,Valvuloplasty aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33391,Valvuloplasty aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33404,Prepare heart-aorta conduit,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33405,Replacement aortic valve opn,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33406,Replacement aortic valve opn,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33410,Replacement aortic valve opn,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33411,Replacement of aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33412,Replacement of aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33413,Replacement of aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33414,Repair of aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33415,Revision subvalvular tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33416,Revise ventricle muscle,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33417,Repair of aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33418,Repair tcat mitral valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33420,Revision of mitral valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33422,Revision of mitral valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33425,Repair of mitral valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33426,Repair of mitral valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33427,Repair of mitral valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33430,Replacement of mitral valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33440,Rplcmt a-valve tlcj autol pv,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33460,Revision of tricuspid valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33463,Valvuloplasty tricuspid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33464,Valvuloplasty tricuspid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33465,Replace tricuspid valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33468,Revision of tricuspid valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33470,Revision of pulmonary valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33471,Valvotomy pulmonary valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33474,Revision of pulmonary valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33475,Replacement pulmonary valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33476,Revision of heart chamber,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33477,Implant tcat pulm vlv perq,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33478,Revision of heart chamber,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33496,Repair prosth valve clot,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33500,Repair heart vessel fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33501,Repair heart vessel fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33502,Coronary artery correction,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33503,Coronary artery graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33504,Coronary artery graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33505,Repair artery w/tunnel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33506,Repair artery translocation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33507,Repair art intramural,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33510,Cabg vein single,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33511,Cabg vein two,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33512,Cabg vein three,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33513,Cabg vein four,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33514,Cabg vein five,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33516,Cabg vein six or more,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33517,Cabg artery-vein single,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33518,Cabg artery-vein two,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33519,Cabg artery-vein three,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33521,Cabg artery-vein four,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33522,Cabg artery-vein five,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33523,Cabg art-vein six or more,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33530,Coronary artery bypass/reop,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33533,Cabg arterial single,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33534,Cabg arterial two,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33535,Cabg arterial three,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33536,Cabg arterial four or more,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33542,Removal of heart lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33545,Repair of heart damage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33548,Restore/remodel ventricle,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33572,Open coronary endarterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33600,Closure of valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33602,Closure of valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33606,Anastomosis/artery-aorta,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33608,Repair anomaly w/conduit,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33610,Repair by enlargement,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33611,Repair double ventricle,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33612,Repair double ventricle,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33615,Repair modified fontan,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33617,Repair single ventricle,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33619,Repair single ventricle,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33620,Apply r&l pulm art bands,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33621,Transthor cath for stent,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33622,Redo compl cardiac anomaly,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33641,Repair heart septum defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33645,Revision of heart veins,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33647,Repair heart septum defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33660,Repair of heart defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33665,Repair of heart defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33670,Repair of heart chambers,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33675,Close mult vsd,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33676,Close mult vsd w/resection,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33677,Cl mult vsd w/rem pul band,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33681,Repair heart septum defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33684,Repair heart septum defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33688,Repair heart septum defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33690,Reinforce pulmonary artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33692,Repair of heart defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33694,Repair of heart defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33697,Repair of heart defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33702,Repair of heart defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33710,Repair of heart defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33720,Repair of heart defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33722,Repair of heart defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33724,Repair venous anomaly,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33726,Repair pul venous stenosis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33730,Repair heart-vein defect(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33732,Repair heart-vein defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33735,Revision of heart chamber,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33736,Revision of heart chamber,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33737,Revision of heart chamber,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33741,Tas congenital car anomal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33745,Tis cgen car anomal 1st shnt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33746,Tis cgen car anomal ea addl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33750,Major vessel shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33755,Major vessel shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33762,Major vessel shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33764,Major vessel shunt & graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33766,Major vessel shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33767,Major vessel shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33768,Cavopulmonary shunting,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33770,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33771,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33774,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33775,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33776,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33777,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33778,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33779,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33780,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33781,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33782,Nikaidoh proc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33783,Nikaidoh proc w/ostia implt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33786,Repair arterial trunk,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33788,Revision of pulmonary artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33800,Aortic suspension,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33802,Repair vessel defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33803,Repair vessel defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33813,Repair septal defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33814,Repair septal defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33820,Revise major vessel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33822,Revise major vessel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33824,Revise major vessel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33840,Remove aorta constriction,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33845,Remove aorta constriction,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33851,Remove aorta constriction,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33852,Repair septal defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33853,Repair septal defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33858,As-aort grf f/aortic dsj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33859,As-aort grf f/ds oth/thn dsj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33863,Ascending aortic graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33864,Ascending aortic graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33871,Transvrs a-arch grf hypthrm,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33875,Thoracic aortic graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33877,Thoracoabdominal graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33880,Endovasc taa repr incl subcl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33881,Endovasc taa repr w/o subcl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33883,Insert endovasc prosth taa,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33884,Endovasc prosth taa add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33886,Endovasc prosth delayed,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33889,Artery transpose/endovas taa,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33891,Car-car bp grft/endovas taa,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33910,Remove lung artery emboli,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33915,Remove lung artery emboli,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33916,Surgery of great vessel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33917,Repair pulmonary artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33920,Repair pulmonary atresia,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33922,Transect pulmonary artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33924,Remove pulmonary shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33925,Rpr pul art unifocal w/o cpb,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33926,Repr pul art unifocal w/cpb,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33927,Impltj tot rplcmt hrt sys,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33928,Rmvl & rplcmt tot hrt sys,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33929,Rmvl rplcmt hrt sys f/trnspl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33930,Removal of donor heart/lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33933,Prepare donor heart/lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33935,Transplantation heart/lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33940,Removal of donor heart,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33944,Prepare donor heart,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33945,Transplantation of heart,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33946,Ecmo/ecls initiation venous,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33947,Ecmo/ecls initiation artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33948,Ecmo/ecls daily mgmt-venous,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33949,Ecmo/ecls daily mgmt artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33951,Ecmo/ecls insj prph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33952,Ecmo/ecls insj prph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33953,Ecmo/ecls insj prph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33954,Ecmo/ecls insj prph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33955,Ecmo/ecls insj ctr cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33956,Ecmo/ecls insj ctr cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33957,Ecmo/ecls repos perph cnula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33958,Ecmo/ecls repos perph cnula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33959,Ecmo/ecls repos perph cnula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33962,Ecmo/ecls repos perph cnula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33963,Ecmo/ecls repos perph cnula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33964,Ecmo/ecls repos perph cnula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33965,Ecmo/ecls rmvl perph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33966,Ecmo/ecls rmvl prph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33967,Insert i-aort percut device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33968,Remove aortic assist device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33969,Ecmo/ecls rmvl perph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33970,Aortic circulation assist,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33971,Aortic circulation assist,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33973,Insert balloon device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33974,Remove intra-aortic balloon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33975,Implant ventricular device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33976,Implant ventricular device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33977,Remove ventricular device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33978,Remove ventricular device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33979,Insert intracorporeal device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33980,Remove intracorporeal device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33981,Replace vad pump ext,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33982,Replace vad intra w/o bp,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33983,Replace vad intra w/bp,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33984,Ecmo/ecls rmvl prph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33985,Ecmo/ecls rmvl ctr cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33986,Ecmo/ecls rmvl ctr cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33987,Artery expos/graft artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33988,Insertion of left heart vent,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33989,Removal of left heart vent,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33990,Insj perq vad l hrt arterial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33991,Insj perq vad l hrt artl&ven,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33992,Rmvl perq left heart vad,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33993,Reposg perq r/l hrt vad,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33995,Insj perq vad r hrt venous,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33997,Rmvl perq right heart vad,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,33999,Cardiac surgery procedure,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Humana MCR ADV,CPT,34001,Removal of artery clot,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,34051,Removal of artery clot,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,34101,Removal of artery clot,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,34111,Removal of arm artery clot,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,34151,Removal of artery clot,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,34201,Removal of artery clot,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,34203,Removal of leg artery clot,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,34401,Removal of vein clot,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,34421,Removal of vein clot,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,34451,Removal of vein clot,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,34471,Removal of vein clot,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Humana MCR ADV,CPT,34490,Removal of vein clot,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,34501,Repair valve femoral vein,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,34502,Reconstruct vena cava,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,34510,Transposition of vein valve,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,34520,Cross-over vein graft,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,34530,Leg vein fusion,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,34701,Evasc rpr a-ao ndgft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,34702,Evasc rpr a-ao ndgft rpt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,34703,Evasc rpr a-unilac ndgft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,34704,Evasc rpr a-unilac ndgft rpt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,34705,Evac rpr a-biiliac ndgft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,34706,Evasc rpr a-biiliac rpt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,34707,Evasc rpr ilio-iliac ndgft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,34708,Evasc rpr ilio-iliac rpt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,34709,Plmt xtn prosth evasc rpr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,34710,Dlyd plmt xtn prosth 1st vsl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,34711,Dlyd plmt xtn prosth ea addl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,34712,Tcat dlvr enhncd fixj dev,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,34717,Evasc rpr a-iliac ndgft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,34718,Evasc rpr n/a a-iliac ndgft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,34808,Endovas iliac a device addon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,34812,Opn fem art expos,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,34813,Femoral endovas graft add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,34820,Opn iliac art expos,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,34830,Open aortic tube prosth repr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,34831,Open aortoiliac prosth repr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,34832,Open aortofemor prosth repr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,34833,Opn ilac art expos cndt crtj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,34834,Opn brach art expos,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,34841,Endovasc visc aorta 1 graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,34842,Endovasc visc aorta 2 graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,34843,Endovasc visc aorta 3 graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,34844,Endovasc visc aorta 4 graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,34845,Visc & infraren abd 1 prosth,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,34846,Visc & infraren abd 2 prosth,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,34847,Visc & infraren abd 3 prosth,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,34848,Visc & infraren abd 4+ prost,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35001,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35002,Repair artery rupture neck,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35005,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35011,Repair defect of artery,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,35013,Repair artery rupture arm,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35021,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35022,Repair artery rupture chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35045,Repair defect of arm artery,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,35081,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35082,Repair artery rupture aorta,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35091,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35092,Repair artery rupture aorta,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35102,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35103,Repair artery rupture aorta,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35111,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35112,Repair artery rupture spleen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35121,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35122,Repair artery rupture belly,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35131,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35132,Repair artery rupture groin,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35141,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35142,Repair artery rupture thigh,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35151,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35152,Repair ruptd popliteal art,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35180,Repair blood vessel lesion,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Humana MCR ADV,CPT,35182,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35184,Repair blood vessel lesion,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,35188,Repair blood vessel lesion,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,35189,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35190,Repair blood vessel lesion,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,35201,Repair blood vessel lesion,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,35206,Repair blood vessel lesion,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,35207,Repair blood vessel lesion,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,35211,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35216,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35221,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35226,Repair blood vessel lesion,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,35231,Repair blood vessel lesion,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,35236,Repair blood vessel lesion,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,35241,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35246,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35251,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35256,Repair blood vessel lesion,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,35261,Repair blood vessel lesion,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,35266,Repair blood vessel lesion,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,35271,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35276,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35281,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35286,Repair blood vessel lesion,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,35301,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35302,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35303,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35304,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35305,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35306,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35311,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35321,Rechanneling of artery,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,35331,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35341,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35351,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35355,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35361,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35363,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35371,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35372,Rechanneling of artery,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,35390,Reoperation carotid add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35400,Angioscopy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35501,Art byp grft ipsilat carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35506,Art byp grft subclav-carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35508,Art byp grft carotid-vertbrl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35509,Art byp grft contral carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35510,Art byp grft carotid-brchial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35511,Art byp grft subclav-subclav,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35512,Art byp grft subclav-brchial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35515,Art byp grft subclav-vertbrl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35516,Art byp grft subclav-axilary,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35518,Art byp grft axillary-axilry,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35521,Art byp grft axill-femoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35522,Art byp grft axill-brachial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35523,Art byp grft brchl-ulnr-rdl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35525,Art byp grft brachial-brchl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35526,Art byp grft aor/carot/innom,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35531,Art byp grft aorcel/aormesen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35533,Art byp grft axill/fem/fem,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35535,Art byp grft hepatorenal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35536,Art byp grft splenorenal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35537,Art byp grft aortoiliac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35538,Art byp grft aortobi-iliac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35539,Art byp grft aortofemoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35540,Art byp grft aortbifemoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35556,Art byp grft fem-popliteal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35558,Art byp grft fem-femoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35560,Art byp grft aortorenal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35563,Art byp grft ilioiliac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35565,Art byp grft iliofemoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35566,Art byp fem-ant-post tib/prl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35570,Art byp tibial-tib/peroneal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35571,Art byp pop-tibl-prl-other,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35583,Vein byp grft fem-popliteal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35585,Vein byp fem-tibial peroneal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35587,Vein byp pop-tibl peroneal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35600,Harvest art for cabg add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35601,Art byp common ipsi carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35606,Art byp carotid-subclavian,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35612,Art byp subclav-subclavian,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35616,Art byp subclav-axillary,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35621,Art byp axillary-femoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35623,Art byp axillary-pop-tibial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35626,Art byp aorsubcl/carot/innom,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35631,Art byp aor-celiac-msn-renal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35632,Art byp ilio-celiac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35633,Art byp ilio-mesenteric,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35634,Art byp iliorenal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35636,Art byp spenorenal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35637,Art byp aortoiliac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35638,Art byp aortobi-iliac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35642,Art byp carotid-vertebral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35645,Art byp subclav-vertebrl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35646,Art byp aortobifemoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35647,Art byp aortofemoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35650,Art byp axillary-axillary,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35654,Art byp axill-fem-femoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35656,Art byp femoral-popliteal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35661,Art byp femoral-femoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35663,Art byp ilioiliac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35665,Art byp iliofemoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35666,Art byp fem-ant-post tib/prl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35671,Art byp pop-tibl-prl-other,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35681,Composite byp grft pros&vein,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35682,Composite byp grft 2 veins,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35683,Composite byp grft 3/> segmt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35691,Art trnsposj vertbrl carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35693,Art trnsposj subclavian,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35694,Art trnsposj subclav carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35695,Art trnsposj carotid subclav,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35697,Reimplant artery each,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35700,Reoperation bypass graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35701,Expl n/flwd surg neck art,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35702,Expl n/flwd surg uxtr art,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35703,Expl n/flwd surg lxtr art,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35800,Explore neck vessels,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,35820,Explore chest vessels,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35840,Explore abdominal vessels,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35860,Explore limb vessels,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,35870,Repair vessel graft defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35875,Removal of clot in graft,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,35876,Removal of clot in graft,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,35879,Revise graft w/vein,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,35881,Revise graft w/vein,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,35883,Revise graft w/nonauto graft,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,35884,Revise graft w/vein,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,35901,Excision graft neck,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35903,Excision graft extremity,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,35905,Excision graft thorax,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,35907,Excision graft abdomen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,36002,Pseudoaneurysm injection trt,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Humana MCR ADV,CPT,36221,Place cath thoracic aorta,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,36222,Place cath carotid/inom art,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,36223,Place cath carotid/inom art,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,36224,Place cath carotd art,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,36225,Place cath subclavian art,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,36226,Place cath vertebral art,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,36251,Ins cath ren art 1st unilat,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,36252,Ins cath ren art 1st bilat,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,36253,Ins cath ren art 2nd+ unilat,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,36254,Ins cath ren art 2nd+ bilat,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,36260,Insertion of infusion pump,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,36261,Revision of infusion pump,APC 5221,RVU Per Unit,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Humana MCR ADV,CPT,36262,Removal of infusion pump,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Humana MCR ADV,CPT,36415,Routine venipuncture,Lab Services,Per Unit,$3.00 ,OP,3,"4,314.00",,,,,,
Humana MCR ADV,CPT,36420,Vein access cutdown < 1 yr,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Humana MCR ADV,CPT,36425,Vein access cutdown > 1 yr,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Humana MCR ADV,CPT,36430,Blood transfusion service,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Humana MCR ADV,CPT,36440,Bl push transfuse 2 yr/<,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Humana MCR ADV,CPT,36450,Bl exchange/transfuse nb,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Humana MCR ADV,CPT,36455,Bl exchange/transfuse non-nb,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Humana MCR ADV,CPT,36456,Prtl exchange transfuse nb,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Humana MCR ADV,CPT,36460,Transfusion service fetal,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Humana MCR ADV,CPT,36465,Njx noncmpnd sclrsnt 1 vein,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,36466,Njx noncmpnd sclrsnt mlt vn,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,36468,Njx sclrsnt spider veins,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,36470,Njx sclrsnt 1 incmptnt vein,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,36471,Njx sclrsnt mlt incmptnt vn,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,36473,Endovenous mchnchem 1st vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,36475,Endovenous rf 1st vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,36478,Endovenous laser 1st vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,36482,Endoven ther chem adhes 1st,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,36511,Apheresis wbc,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
Humana MCR ADV,CPT,36512,Apheresis rbc,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
Humana MCR ADV,CPT,36513,Apheresis platelets,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Humana MCR ADV,CPT,36514,Apheresis plasma,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
Humana MCR ADV,CPT,36516,Apheresis immunoads slctv,APC 5243,RVU Per Unit,"$4,131.87 ",OP,"4,131.87","4,314.00",,,,,,
Humana MCR ADV,CPT,36522,Photopheresis,APC 5243,RVU Per Unit,"$4,131.87 ",OP,"4,131.87","4,314.00",,,,,,
Humana MCR ADV,CPT,36555,Insert non-tunnel cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,36556,Insert non-tunnel cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,36557,Insert tunneled cv cath,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,36558,Insert tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,36560,Insert tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,36561,Insert tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,36563,Insert tunneled cv cath,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,36565,Insert tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,36566,Insert tunneled cv cath,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,36568,Insj picc <5 yr w/o imaging,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Humana MCR ADV,CPT,36569,Insj picc 5 yr+ w/o imaging,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Humana MCR ADV,CPT,36570,Insert picvad cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,36571,Insert picvad cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,36572,Insj picc rs&i <5 yr,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Humana MCR ADV,CPT,36573,Insj picc rs&i 5 yr+,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Humana MCR ADV,CPT,36575,Repair tunneled cv cath,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Humana MCR ADV,CPT,36576,Repair tunneled cv cath,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Humana MCR ADV,CPT,36578,Replace tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,36580,Replace cvad cath,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Humana MCR ADV,CPT,36581,Replace tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,36582,Replace tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,36583,Replace tunneled cv cath,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,36584,Compl rplcmt picc rs&i,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Humana MCR ADV,CPT,36585,Replace picvad cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,36589,Removal tunneled cv cath,APC 5181,RVU Per Case,$554.25 ,OP,554.25,"4,314.00",,,,,,
Humana MCR ADV,CPT,36590,Removal tunneled cv cath,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Humana MCR ADV,CPT,36591,Draw blood off venous device,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Humana MCR ADV,CPT,36592,Collect blood from picc,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Humana MCR ADV,CPT,36593,Declot vascular device,APC 5694,RVU Per Unit,$318.00 ,OP,318,"4,314.00",,,,,,
Humana MCR ADV,CPT,36595,Mech remov tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,36596,Mech remov tunneled cv cath,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Humana MCR ADV,CPT,36597,Reposition venous catheter,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Humana MCR ADV,CPT,36598,Inj w/fluor eval cv device,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,"4,314.00",,,,,,
Humana MCR ADV,CPT,36600,Withdrawal of arterial blood,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Humana MCR ADV,CPT,36640,Insertion catheter artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,36660,Insertion catheter artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,36680,Insert needle bone cavity,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Humana MCR ADV,CPT,36800,Insertion of cannula,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,36810,Insertion of cannula,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,36815,Insertion of cannula,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,36818,Av fuse uppr arm cephalic,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,36819,Av fuse uppr arm basilic,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,36820,Av fusion/forearm vein,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,36821,Av fusion direct any site,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","9,201.00",,,,,,
Humana MCR ADV,CPT,36823,Insertion of cannula(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,36825,Artery-vein autograft,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,36830,Artery-vein nonautograft,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,36831,Open thrombect av fistula,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,36832,Av fistula revision open,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,36833,Av fistula revision,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,36835,Artery to vein shunt,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,36838,Dist revas ligation hemo,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,36860,External cannula declotting,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Humana MCR ADV,CPT,36861,Cannula declotting,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,36901,Intro cath dialysis circuit,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Humana MCR ADV,CPT,36902,Intro cath dialysis circuit,APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,314.00","5,072.43",,,,,,
Humana MCR ADV,CPT,36903,Intro cath dialysis circuit,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Humana MCR ADV,CPT,36904,Thrmbc/nfs dialysis circuit,APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,314.00","5,072.43",,,,,,
Humana MCR ADV,CPT,36905,Thrmbc/nfs dialysis circuit,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Humana MCR ADV,CPT,36906,Thrmbc/nfs dialysis circuit,APC 5194,RVU Per Case,"$16,438.60 ",OP,"4,140.35","16,438.60",,,,,,
Humana MCR ADV,CPT,37140,Revision of circulation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,37145,Revision of circulation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,37160,Revision of circulation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,37180,Revision of circulation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,37181,Splice spleen/kidney veins,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,37182,Insert hepatic shunt (tips),APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Humana MCR ADV,CPT,37183,Remove hepatic shunt (tips),APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,314.00","5,072.43",,,,,,
Humana MCR ADV,CPT,37184,Prim art m-thrmbc 1st vsl,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Humana MCR ADV,CPT,37187,Venous mech thrombectomy,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
Humana MCR ADV,CPT,37188,Ven mechnl thrmbc repeat tx,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,37191,Ins endovas vena cava filtr,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,37192,Redo endovas vena cava filtr,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,37193,Rem endovas vena cava filter,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,37195,Thrombolytic therapy stroke,APC 5694,RVU Per Unit,$318.00 ,OP,318,"4,314.00",,,,,,
Humana MCR ADV,CPT,37197,Remove intrvas foreign body,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,37200,Transcatheter biopsy,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,37211,Thrombolytic art therapy,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,37212,Thrombolytic venous therapy,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,37213,Thromblytic art/ven therapy,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,37214,Cessj therapy cath removal,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,37215,Transcath stent cca w/eps,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,37217,Stent placemt retro carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,37218,Stent placemt ante carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,37220,Iliac revasc,APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,314.00","5,072.43",,,,,,
Humana MCR ADV,CPT,37221,Iliac revasc w/stent,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
Humana MCR ADV,CPT,37224,Fem/popl revas w/tla,APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,314.00","5,072.43",,,,,,
Humana MCR ADV,CPT,37225,Fem/popl revas w/ather,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Humana MCR ADV,CPT,37226,Fem/popl revasc w/stent,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
Humana MCR ADV,CPT,37227,Fem/popl revasc stnt & ather,APC 5194,RVU Per Case,"$16,438.60 ",OP,"4,314.00","16,438.60",,,,,,
Humana MCR ADV,CPT,37228,Tib/per revasc w/tla,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Humana MCR ADV,CPT,37229,Tib/per revasc w/ather,APC 5194,RVU Per Case,"$16,438.60 ",OP,"4,314.00","16,438.60",,,,,,
Humana MCR ADV,CPT,37230,Tib/per revasc w/stent,APC 5194,RVU Per Case,"$16,438.60 ",OP,"4,314.00","16,438.60",,,,,,
Humana MCR ADV,CPT,37231,Tib/per revasc stent & ather,APC 5194,RVU Per Case,"$16,438.60 ",OP,"4,314.00","16,438.60",,,,,,
Humana MCR ADV,CPT,37236,Open/perq place stent 1st,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Humana MCR ADV,CPT,37238,Open/perq place stent same,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
Humana MCR ADV,CPT,37241,Vasc embolize/occlude venous,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Humana MCR ADV,CPT,37242,Vasc embolize/occlude artery,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
Humana MCR ADV,CPT,37243,Vasc embolize/occlude organ,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Humana MCR ADV,CPT,37244,Vasc embolize/occlude bleed,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
Humana MCR ADV,CPT,37246,Trluml balo angiop 1st art,APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,314.00","5,072.43",,,,,,
Humana MCR ADV,CPT,37248,Trluml balo angiop 1st vein,APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,314.00","5,072.43",,,,,,
Humana MCR ADV,CPT,37500,Endoscopy ligate perf veins,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,37501,Vascular endoscopy procedure,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Humana MCR ADV,CPT,37565,Ligation of neck vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,37600,Ligation of neck artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,37605,Ligation of neck artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,37606,Ligation of neck artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,37607,Ligation of a-v fistula,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,37609,Temporal artery procedure,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,37615,Ligation of neck artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,37616,Ligation of chest artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,37617,Ligation of abdomen artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,37618,Ligation of extremity artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,37619,Ligation of inf vena cava,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,37650,Revision of major vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,37660,Revision of major vein,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,37700,Revise leg vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,37718,Ligate/strip short leg vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,37722,Ligate/strip long leg vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,37735,Removal of leg veins/lesion,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,37760,Ligate leg veins radical,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,37761,Ligate leg veins open,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,37765,Stab phleb veins xtr 10-20,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,37766,Phleb veins - extrem 20+,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,37780,Revision of leg vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,37785,Ligate/divide/excise vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,37788,Revascularization penis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,37790,Penile venous occlusion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,37799,Vascular surgery procedure,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Humana MCR ADV,CPT,38100,Removal of spleen total,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,38101,Removal of spleen partial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,38102,Removal of spleen total,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,38115,Repair of ruptured spleen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,38120,Laparoscopy splenectomy,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Humana MCR ADV,CPT,38129,Laparoscope proc spleen,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,38206,Harvest auto stem cells,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
Humana MCR ADV,CPT,38207,Cryopreserve stem cells,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Humana MCR ADV,CPT,38208,Thaw preserved stem cells,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Humana MCR ADV,CPT,38209,Wash harvest stem cells,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Humana MCR ADV,CPT,38210,T-cell depletion of harvest,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Humana MCR ADV,CPT,38211,Tumor cell deplete of harvst,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Humana MCR ADV,CPT,38212,Rbc depletion of harvest,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Humana MCR ADV,CPT,38213,Platelet deplete of harvest,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Humana MCR ADV,CPT,38214,Volume deplete of harvest,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Humana MCR ADV,CPT,38215,Harvest stem cell concentrte,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Humana MCR ADV,CPT,38220,Dx bone marrow aspirations,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,38221,Dx bone marrow biopsies,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,38222,Dx bone marrow bx & aspir,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,38230,Bone marrow harvest allogen,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
Humana MCR ADV,CPT,38232,Bone marrow harvest autolog,APC 5243,RVU Per Unit,"$4,131.87 ",OP,"4,131.87","4,314.00",,,,,,
Humana MCR ADV,CPT,38240,Transplt allo hct/donor,APC 5244,RVU Per Case,"$32,580.57 ",OP,"4,314.00","32,580.57",,,,,,
Humana MCR ADV,CPT,38241,Transplt autol hct/donor,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
Humana MCR ADV,CPT,38242,Transplt allo lymphocytes,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
Humana MCR ADV,CPT,38243,Transplj hematopoietic boost,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
Humana MCR ADV,CPT,38300,Drainage lymph node lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,38305,Drainage lymph node lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,38308,Incision of lymph channels,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Humana MCR ADV,CPT,38380,Thoracic duct procedure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,38381,Thoracic duct procedure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,38382,Thoracic duct procedure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,38500,Biopsy/removal lymph nodes,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Humana MCR ADV,CPT,38505,Needle biopsy lymph nodes,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,38510,Biopsy/removal lymph nodes,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Humana MCR ADV,CPT,38520,Biopsy/removal lymph nodes,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Humana MCR ADV,CPT,38525,Biopsy/removal lymph nodes,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Humana MCR ADV,CPT,38530,Biopsy/removal lymph nodes,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Humana MCR ADV,CPT,38531,Open bx/exc inguinofem nodes,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Humana MCR ADV,CPT,38542,Explore deep node(s) neck,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,38550,Removal neck/armpit lesion,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Humana MCR ADV,CPT,38555,Removal neck/armpit lesion,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
Humana MCR ADV,CPT,38562,Removal pelvic lymph nodes,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Humana MCR ADV,CPT,38564,Removal abdomen lymph nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,38570,Laparoscopy lymph node biop,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,38571,Laparoscopy lymphadenectomy,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,38572,Laparoscopy lymphadenectomy,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,38573,Laps pelvic lymphadec,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,38589,Laparoscope proc lymphatic,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,38700,Removal of lymph nodes neck,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
Humana MCR ADV,CPT,38720,Removal of lymph nodes neck,APC 5093,RVU Per Case,"$9,128.05 ",OP,"4,314.00","9,128.05",,,,,,
Humana MCR ADV,CPT,38724,Removal of lymph nodes neck,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,38740,Remove armpit lymph nodes,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,38745,Remove armpit lymph nodes,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,38746,Remove thoracic lymph nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,38747,Remove abdominal lymph nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,38760,Remove groin lymph nodes,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
Humana MCR ADV,CPT,38765,Remove groin lymph nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,38770,Remove pelvis lymph nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,38780,Remove abdomen lymph nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,38792,Ra tracer id of sentinl node,APC 5591,RVU Per Case,$385.91 ,OP,385.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,38999,Blood/lymph system procedure,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Humana MCR ADV,CPT,39000,Exploration of chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,39010,Exploration of chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,39200,Resect mediastinal cyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,39220,Resect mediastinal tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,39401,Mediastinoscpy w/medstnl bx,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,39402,Mediastinoscpy w/lmph nod bx,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,39499,Chest procedure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,39501,Repair diaphragm laceration,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,39503,Repair of diaphragm hernia,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,39540,Repair of diaphragm hernia,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,39541,Repair of diaphragm hernia,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,39545,Revision of diaphragm,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,39560,Resect diaphragm simple,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,39561,Resect diaphragm complex,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,39599,Diaphragm surgery procedure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,40490,Biopsy of lip,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Humana MCR ADV,CPT,40500,Partial excision of lip,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,40510,Partial excision of lip,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,40520,Partial excision of lip,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,40525,Reconstruct lip with flap,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,40527,Reconstruct lip with flap,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,40530,Partial removal of lip,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,40650,Repair lip,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,40652,Repair lip,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,40654,Repair lip,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,40700,Repair cleft lip/nasal,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,40701,Repair cleft lip/nasal,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,40702,Repair cleft lip/nasal,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,40720,Repair cleft lip/nasal,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,40761,Repair cleft lip/nasal,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,40799,Lip surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Humana MCR ADV,CPT,40800,Drainage of mouth lesion,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,40801,Drainage of mouth lesion,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,40804,Removal foreign body mouth,APC 5301,RVU Per Case,$828.48 ,OP,828.48,"4,314.00",,,,,,
Humana MCR ADV,CPT,40805,Removal foreign body mouth,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,40806,Incision of lip fold,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,40808,Biopsy of mouth lesion,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,40810,Excision of mouth lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,40812,Excise/repair mouth lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,40814,Excise/repair mouth lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,40816,Excision of mouth lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,40818,Excise oral mucosa for graft,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,40819,Excise lip or cheek fold,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,40820,Treatment of mouth lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,40830,Repair mouth laceration,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Humana MCR ADV,CPT,40831,Repair mouth laceration,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,40840,Reconstruction of mouth,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,40842,Reconstruction of mouth,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,40843,Reconstruction of mouth,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,40844,Reconstruction of mouth,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,40845,Reconstruction of mouth,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,40899,Mouth surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Humana MCR ADV,CPT,41000,Drainage of mouth lesion,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,41005,Drainage of mouth lesion,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Humana MCR ADV,CPT,41006,Drainage of mouth lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,41007,Drainage of mouth lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,41008,Drainage of mouth lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,41009,Drainage of mouth lesion,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,41010,Incision of tongue fold,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,41015,Drainage of mouth lesion,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,41016,Drainage of mouth lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,41017,Drainage of mouth lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,41018,Drainage of mouth lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,41019,Place needles h&n for rt,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,41100,Biopsy of tongue,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,41105,Biopsy of tongue,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,41108,Biopsy of floor of mouth,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,41110,Excision of tongue lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,41112,Excision of tongue lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,41113,Excision of tongue lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,41114,Excision of tongue lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,41115,Excision of tongue fold,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,41116,Excision of mouth lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,41120,Partial removal of tongue,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,41130,Partial removal of tongue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,41135,Tongue and neck surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,41140,Removal of tongue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,41145,Tongue removal neck surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,41150,Tongue mouth jaw surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,41153,Tongue mouth neck surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,41155,Tongue jaw & neck surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,41250,Repair tongue laceration,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Humana MCR ADV,CPT,41251,Repair tongue laceration,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Humana MCR ADV,CPT,41252,Repair tongue laceration,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Humana MCR ADV,CPT,41510,Tongue to lip surgery,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,41512,Tongue suspension,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,41520,Reconstruction tongue fold,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,41530,Tongue base vol reduction,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,41599,Tongue and mouth surgery,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Humana MCR ADV,CPT,41800,Drainage of gum lesion,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Humana MCR ADV,CPT,41805,Removal foreign body gum,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,41806,Removal foreign body jawbone,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,41820,Excision gum each quadrant,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,41821,Excision of gum flap,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,41822,Excision of gum lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,41823,Excision of gum lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,41825,Excision of gum lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,41826,Excision of gum lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,41827,Excision of gum lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,41828,Excision of gum lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,41830,Removal of gum tissue,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,41850,Treatment of gum lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,41870,Gum graft,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,41872,Repair gum,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,41874,Repair tooth socket,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,41899,Dental surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Humana MCR ADV,CPT,42000,Drainage mouth roof lesion,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Humana MCR ADV,CPT,42100,Biopsy roof of mouth,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,42104,Excision lesion mouth roof,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,42106,Excision lesion mouth roof,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,42107,Excision lesion mouth roof,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,42120,Remove palate/lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,42140,Excision of uvula,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,42145,Repair palate pharynx/uvula,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,42160,Treatment mouth roof lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,42180,Repair palate,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,42182,Repair palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,42200,Reconstruct cleft palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,42205,Reconstruct cleft palate,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,42210,Reconstruct cleft palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,42215,Reconstruct cleft palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,42220,Reconstruct cleft palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,42225,Reconstruct cleft palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,42226,Lengthening of palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,42227,Lengthening of palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,42235,Repair palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,42260,Repair nose to lip fistula,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,42280,Preparation palate mold,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,42281,Insertion palate prosthesis,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,42299,Palate/uvula surgery,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Humana MCR ADV,CPT,42300,Drainage of salivary gland,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,42305,Drainage of salivary gland,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,42310,Drainage of salivary gland,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,42320,Drainage of salivary gland,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,42330,Removal of salivary stone,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,42335,Removal of salivary stone,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,42340,Removal of salivary stone,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,42400,Biopsy of salivary gland,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,42405,Biopsy of salivary gland,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,42408,Excision of salivary cyst,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,42409,Drainage of salivary cyst,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,42410,Excise parotid gland/lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,42415,Excise parotid gland/lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,42420,Excise parotid gland/lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,42425,Excise parotid gland/lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,42426,Excise parotid gland/lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,42440,Excise submaxillary gland,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,42450,Excise sublingual gland,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,42500,Repair salivary duct,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,42505,Repair salivary duct,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,42507,Parotid duct diversion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,42509,Parotid duct diversion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,42510,Parotid duct diversion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,42600,Closure of salivary fistula,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,42650,Dilation of salivary duct,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,42660,Dilation of salivary duct,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,42665,Ligation of salivary duct,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,42699,Salivary surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Humana MCR ADV,CPT,42700,Drainage of tonsil abscess,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Humana MCR ADV,CPT,42720,Drainage of throat abscess,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,42725,Drainage of throat abscess,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,42800,Biopsy of throat,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,42804,Biopsy of upper nose/throat,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,42806,Biopsy of upper nose/throat,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,42808,Excise pharynx lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,42809,Remove pharynx foreign body,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Humana MCR ADV,CPT,42810,Excision of neck cyst,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,42815,Excision of neck cyst,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,42820,Remove tonsils and adenoids,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,42821,Remove tonsils and adenoids,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,42825,Removal of tonsils,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,42826,Removal of tonsils,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,42830,Removal of adenoids,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,42831,Removal of adenoids,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,42835,Removal of adenoids,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,42836,Removal of adenoids,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,42842,Extensive surgery of throat,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,42844,Extensive surgery of throat,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,42845,Extensive surgery of throat,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,42860,Excision of tonsil tags,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,42870,Excision of lingual tonsil,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,42890,Partial removal of pharynx,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,42892,Revision of pharyngeal walls,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,42894,Revision of pharyngeal walls,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,42900,Repair throat wound,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,42950,Reconstruction of throat,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,42953,Repair throat esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,42955,Surgical opening of throat,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,42960,Control throat bleeding,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,42961,Control throat bleeding,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,42962,Control throat bleeding,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,42970,Control nose/throat bleeding,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Humana MCR ADV,CPT,42971,Control nose/throat bleeding,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,42972,Control nose/throat bleeding,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,42999,Throat surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Humana MCR ADV,CPT,43020,Incision of esophagus,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,43030,Throat muscle surgery,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,43045,Incision of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43100,Excision of esophagus lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43101,Excision of esophagus lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43107,Removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43108,Removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43112,Esphg tot w/thrcm,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43113,Removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43116,Partial removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43117,Partial removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43118,Partial removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43121,Partial removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43122,Partial removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43123,Partial removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43124,Removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43130,Removal of esophagus pouch,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,43135,Removal of esophagus pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43180,Esophagoscopy rigid trnso,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,43191,Esophagoscopy rigid trnso dx,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,43192,Esophagoscp rig trnso inject,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,43193,Esophagoscp rig trnso biopsy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,43194,Esophagoscp rig trnso rem fb,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,43195,Esophagoscopy rigid balloon,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Humana MCR ADV,CPT,43196,Esophagoscp guide wire dilat,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Humana MCR ADV,CPT,43197,Esophagoscopy flex dx brush,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Humana MCR ADV,CPT,43198,Esophagosc flex trnsn biopsy,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Humana MCR ADV,CPT,43200,Esophagoscopy flexible brush,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Humana MCR ADV,CPT,43201,Esoph scope w/submucous inj,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,43202,Esophagoscopy flex biopsy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,43204,Esoph scope w/sclerosis inj,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,43205,Esophagus endoscopy/ligation,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,43206,Esoph optical endomicroscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,43210,Egd esophagogastrc fndoplsty,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Humana MCR ADV,CPT,43211,Esophagoscop mucosal resect,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,43212,Esophagoscop stent placement,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Humana MCR ADV,CPT,43213,Esophagoscopy retro balloon,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,43214,Esophagosc dilate balloon 30,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,43215,Esophagoscopy flex remove fb,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,43216,Esophagoscopy lesion removal,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,43217,Esophagoscopy snare les remv,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,43220,Esophagoscopy balloon <30mm,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,43226,Esoph endoscopy dilation,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,43227,Esophagoscopy control bleed,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,43229,Esophagoscopy lesion ablate,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Humana MCR ADV,CPT,43231,Esophagoscop ultrasound exam,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,43232,Esophagoscopy w/us needle bx,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,43233,Egd balloon dil esoph30 mm/>,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,43235,Egd diagnostic brush wash,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Humana MCR ADV,CPT,43236,Uppr gi scope w/submuc inj,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Humana MCR ADV,CPT,43237,Endoscopic us exam esoph,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,43238,Egd us fine needle bx/aspir,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,43239,Egd biopsy single/multiple,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Humana MCR ADV,CPT,43240,Egd w/transmural drain cyst,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Humana MCR ADV,CPT,43241,Egd tube/cath insertion,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,43242,Egd us fine needle bx/aspir,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,43243,Egd injection varices,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,43244,Egd varices ligation,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,43245,Egd dilate stricture,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,43246,Egd place gastrostomy tube,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,43247,Egd remove foreign body,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Humana MCR ADV,CPT,43248,Egd guide wire insertion,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Humana MCR ADV,CPT,43249,Esoph egd dilation <30 mm,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,43250,Egd cautery tumor polyp,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,43251,Egd remove lesion snare,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,43252,Egd optical endomicroscopy,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Humana MCR ADV,CPT,43253,Egd us transmural injxn/mark,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,43254,Egd endo mucosal resection,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,43255,Egd control bleeding any,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,43257,Egd w/thrml txmnt gerd,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Humana MCR ADV,CPT,43259,Egd us exam duodenum/jejunum,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,43260,Ercp w/specimen collection,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Humana MCR ADV,CPT,43261,Endo cholangiopancreatograph,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Humana MCR ADV,CPT,43262,Endo cholangiopancreatograph,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Humana MCR ADV,CPT,43263,Ercp sphincter pressure meas,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Humana MCR ADV,CPT,43264,Ercp remove duct calculi,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Humana MCR ADV,CPT,43265,Ercp lithotripsy calculi,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Humana MCR ADV,CPT,43266,Egd endoscopic stent place,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Humana MCR ADV,CPT,43270,Egd lesion ablation,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,43274,Ercp duct stent placement,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Humana MCR ADV,CPT,43275,Ercp remove forgn body duct,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Humana MCR ADV,CPT,43276,Ercp stent exchange w/dilate,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Humana MCR ADV,CPT,43277,Ercp ea duct/ampulla dilate,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Humana MCR ADV,CPT,43278,Ercp lesion ablate w/dilate,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Humana MCR ADV,CPT,43279,Lap myotomy heller,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43280,Laparoscopy fundoplasty,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Humana MCR ADV,CPT,43281,Lap paraesophag hern repair,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Humana MCR ADV,CPT,43282,Lap paraesoph her rpr w/mesh,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Humana MCR ADV,CPT,43283,Lap esoph lengthening,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43284,Laps esophgl sphnctr agmntj,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Humana MCR ADV,CPT,43285,Rmvl esophgl sphnctr dev,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,43286,Esphg tot w/laps moblj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43287,Esphg dstl 2/3 w/laps moblj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43288,Esphg thrsc moblj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43289,Laparoscope proc esoph,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,43300,Repair of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43305,Repair esophagus and fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43310,Repair of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43312,Repair esophagus and fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43313,Esophagoplasty congenital,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43314,Tracheo-esophagoplasty cong,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43320,Fuse esophagus & stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43325,Revise esophagus & stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43327,Esoph fundoplasty lap,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43328,Esoph fundoplasty thor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43330,Esophagomyotomy abdominal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43331,Esophagomyotomy thoracic,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43332,Transab esoph hiat hern rpr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43333,Transab esoph hiat hern rpr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43334,Transthor diaphrag hern rpr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43335,Transthor diaphrag hern rpr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43336,Thorabd diaphr hern repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43337,Thorabd diaphr hern repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43338,Esoph lengthening,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43340,Fuse esophagus & intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43341,Fuse esophagus & intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43351,Surgical opening esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43352,Surgical opening esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43360,Gastrointestinal repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43361,Gastrointestinal repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43400,Ligate esophagus veins,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43405,Ligate/staple esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43410,Repair esophagus wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43415,Repair esophagus wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43420,Repair esophagus opening,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,43425,Repair esophagus opening,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43450,Dilate esophagus 1/mult pass,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Humana MCR ADV,CPT,43453,Dilate esophagus,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,43460,Pressure treatment esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43496,Free jejunum flap microvasc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43499,Esophagus surgery procedure,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Humana MCR ADV,CPT,43500,Surgical opening of stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43501,Surgical repair of stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43502,Surgical repair of stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43510,Surgical opening of stomach,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Humana MCR ADV,CPT,43520,Incision of pyloric muscle,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43605,Biopsy of stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43610,Excision of stomach lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43611,Excision of stomach lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43620,Removal of stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43621,Removal of stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43622,Removal of stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43631,Removal of stomach partial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43632,Removal of stomach partial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43633,Removal of stomach partial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43634,Removal of stomach partial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43635,Removal of stomach partial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43640,Vagotomy & pylorus repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43641,Vagotomy & pylorus repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43644,Lap gastric bypass/roux-en-y,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43645,Lap gastr bypass incl smll i,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43647,Lap impl electrode antrum,APC 5463,RVU Per Case,"$11,498.23 ",OP,"4,314.00","11,498.23",,,,,,
Humana MCR ADV,CPT,43648,Lap revise/remv eltrd antrum,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,43651,Laparoscopy vagus nerve,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,43652,Laparoscopy vagus nerve,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,43653,Laparoscopy gastrostomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,43659,Laparoscope proc stom,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,43752,Nasal/orogastric w/tube plmt,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Humana MCR ADV,CPT,43753,Tx gastro intub w/asp,APC 5722,RVU Per Case,$270.61 ,OP,270.61,"4,314.00",,,,,,
Humana MCR ADV,CPT,43754,Dx gastr intub w/asp spec,APC 5722,RVU Per Case,$270.61 ,OP,270.61,"4,314.00",,,,,,
Humana MCR ADV,CPT,43755,Dx gastr intub w/asp specs,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,"4,314.00",,,,,,
Humana MCR ADV,CPT,43756,Dx duod intub w/asp spec,APC 5301,RVU Per Case,$828.48 ,OP,828.48,"4,314.00",,,,,,
Humana MCR ADV,CPT,43757,Dx duod intub w/asp specs,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Humana MCR ADV,CPT,43761,Reposition gastrostomy tube,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Humana MCR ADV,CPT,43762,Rplc gtube no revj trc,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Humana MCR ADV,CPT,43763,Rplc gtube revj gstrst trc,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Humana MCR ADV,CPT,43770,Lap place gastr adj device,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,43771,Lap revise gastr adj device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43772,Lap rmvl gastr adj device,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Humana MCR ADV,CPT,43773,Lap replace gastr adj device,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,43774,Lap rmvl gastr adj all parts,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Humana MCR ADV,CPT,43775,Lap sleeve gastrectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43800,Reconstruction of pylorus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43810,Fusion of stomach and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43820,Fusion of stomach and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43825,Fusion of stomach and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43830,Place gastrostomy tube,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,43831,Place gastrostomy tube,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Humana MCR ADV,CPT,43832,Place gastrostomy tube,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43840,Repair of stomach lesion,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Humana MCR ADV,CPT,43843,Gastroplasty w/o v-band,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43845,Gastroplasty duodenal switch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43846,Gastric bypass for obesity,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43847,Gastric bypass incl small i,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43848,Revision gastroplasty,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43850,Revise stomach-bowel fusion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43855,Revise stomach-bowel fusion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43860,Revise stomach-bowel fusion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43865,Revise stomach-bowel fusion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43870,Repair stomach opening,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Humana MCR ADV,CPT,43880,Repair stomach-bowel fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43881,Impl/redo electrd antrum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43882,Revise/remove electrd antrum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,43886,Revise gastric port open,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Humana MCR ADV,CPT,43887,Remove gastric port open,APC 5054,RVU Per Case,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,43888,Change gastric port open,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Humana MCR ADV,CPT,43999,Stomach surgery procedure,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Humana MCR ADV,CPT,44005,Freeing of bowel adhesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44010,Incision of small bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44015,Insert needle cath bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44020,Explore small intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44021,Decompress small bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44025,Incision of large bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44050,Reduce bowel obstruction,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44055,Correct malrotation of bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44100,Biopsy of bowel,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Humana MCR ADV,CPT,44110,Excise intestine lesion(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44111,Excision of bowel lesion(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44120,Removal of small intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44121,Removal of small intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44125,Removal of small intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44126,Enterectomy w/o taper cong,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44127,Enterectomy w/taper cong,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44128,Enterectomy cong add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44130,Bowel to bowel fusion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44132,Enterectomy cadaver donor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44133,Enterectomy live donor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44135,Intestine transplnt cadaver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44136,Intestine transplant live,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44137,Remove intestinal allograft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44139,Mobilization of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44140,Partial removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44141,Partial removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44143,Partial removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44144,Partial removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44145,Partial removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44146,Partial removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44147,Partial removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44150,Removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44151,Removal of colon/ileostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44155,Removal of colon/ileostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44156,Removal of colon/ileostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44157,Colectomy w/ileoanal anast,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44158,Colectomy w/neo-rectum pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44160,Removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44180,Lap enterolysis,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,44186,Lap jejunostomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,44187,Lap ileo/jejuno-stomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44188,Lap colostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44202,Lap enterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44203,Lap resect s/intestine addl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44204,Laparo partial colectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44205,Lap colectomy part w/ileum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44206,Lap part colectomy w/stoma,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44207,L colectomy/coloproctostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44208,L colectomy/coloproctostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44210,Laparo total proctocolectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44211,Lap colectomy w/proctectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44212,Laparo total proctocolectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44213,Lap mobil splenic fl add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44227,Lap close enterostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44238,Laparoscope proc intestine,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,44300,Open bowel to skin,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,44310,Ileostomy/jejunostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44312,Revision of ileostomy,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Humana MCR ADV,CPT,44314,Revision of ileostomy,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Humana MCR ADV,CPT,44316,Devise bowel pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44320,Colostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44322,Colostomy with biopsies,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44340,Revision of colostomy,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Humana MCR ADV,CPT,44345,Revision of colostomy,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Humana MCR ADV,CPT,44346,Revision of colostomy,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Humana MCR ADV,CPT,44360,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,44361,Small bowel endoscopy/biopsy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,44363,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,44364,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,44365,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,44366,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,44369,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,44370,Small bowel endoscopy/stent,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Humana MCR ADV,CPT,44372,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,44373,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,44376,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,44377,Small bowel endoscopy/biopsy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,44378,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,44379,S bowel endoscope w/stent,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Humana MCR ADV,CPT,44380,Small bowel endoscopy br/wa,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Humana MCR ADV,CPT,44381,Small bowel endoscopy br/wa,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,44382,Small bowel endoscopy,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Humana MCR ADV,CPT,44384,Small bowel endoscopy,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Humana MCR ADV,CPT,44385,Endoscopy of bowel pouch,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Humana MCR ADV,CPT,44386,Endoscopy bowel pouch/biop,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Humana MCR ADV,CPT,44388,Colonoscopy thru stoma spx,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Humana MCR ADV,CPT,44389,Colonoscopy with biopsy,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,44390,Colonoscopy for foreign body,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Humana MCR ADV,CPT,44391,Colonoscopy for bleeding,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,44392,Colonoscopy & polypectomy,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,44394,Colonoscopy w/snare,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,44401,Colonoscopy with ablation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,44402,Colonoscopy w/stent plcmt,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Humana MCR ADV,CPT,44403,Colonoscopy w/resection,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,44404,Colonoscopy w/injection,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,44405,Colonoscopy w/dilation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,44406,Colonoscopy w/ultrasound,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,44407,Colonoscopy w/ndl aspir/bx,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,44408,Colonoscopy w/decompression,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Humana MCR ADV,CPT,44500,Intro gastrointestinal tube,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Humana MCR ADV,CPT,44602,Suture small intestine,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Humana MCR ADV,CPT,44603,Suture small intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44604,Suture large intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44605,Repair of bowel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44615,Intestinal stricturoplasty,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44620,Repair bowel opening,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44625,Repair bowel opening,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44626,Repair bowel opening,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44640,Repair bowel-skin fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44650,Repair bowel fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44660,Repair bowel-bladder fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44661,Repair bowel-bladder fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44680,Surgical revision intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44700,Suspend bowel w/prosthesis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44715,Prepare donor intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44720,Prep donor intestine/venous,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44721,Prep donor intestine/artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44799,Unlisted px small intestine,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Humana MCR ADV,CPT,44800,Excision of bowel pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44820,Excision of mesentery lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44850,Repair of mesentery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44899,Bowel surgery procedure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44900,Drain appendix abscess open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44950,Appendectomy,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Humana MCR ADV,CPT,44960,Appendectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,44970,Laparoscopy appendectomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,44979,Laparoscope proc app,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,45000,Drainage of pelvic abscess,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,45005,Drainage of rectal abscess,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,45020,Drainage of rectal abscess,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,45100,Biopsy of rectum,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,45108,Removal of anorectal lesion,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,45110,Removal of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,45111,Partial removal of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,45112,Removal of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,45113,Partial proctectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,45114,Partial removal of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,45116,Partial removal of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,45119,Remove rectum w/reservoir,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,45120,Removal of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,45121,Removal of rectum and colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,45123,Partial proctectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,45126,Pelvic exenteration,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,45130,Excision of rectal prolapse,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,45135,Excision of rectal prolapse,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,45136,Excise ileoanal reservior,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,45150,Excision of rectal stricture,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,45160,Excision of rectal lesion,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,45171,Exc rect tum transanal part,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,45172,Exc rect tum transanal full,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,45190,Destruction rectal tumor,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,45300,Proctosigmoidoscopy dx,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Humana MCR ADV,CPT,45303,Proctosigmoidoscopy dilate,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,45305,Proctosigmoidoscopy w/bx,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,45307,Proctosigmoidoscopy fb,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,45308,Proctosigmoidoscopy removal,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,45309,Proctosigmoidoscopy removal,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,45315,Proctosigmoidoscopy removal,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,45317,Proctosigmoidoscopy bleed,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,45320,Proctosigmoidoscopy ablate,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,45321,Proctosigmoidoscopy volvul,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,45327,Proctosigmoidoscopy w/stent,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Humana MCR ADV,CPT,45330,Diagnostic sigmoidoscopy,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Humana MCR ADV,CPT,45331,Sigmoidoscopy and biopsy,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Humana MCR ADV,CPT,45332,Sigmoidoscopy w/fb removal,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,45333,Sigmoidoscopy & polypectomy,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Humana MCR ADV,CPT,45334,Sigmoidoscopy for bleeding,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,45335,Sigmoidoscopy w/submuc inj,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Humana MCR ADV,CPT,45337,Sigmoidoscopy & decompress,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Humana MCR ADV,CPT,45338,Sigmoidoscopy w/tumr remove,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,45340,Sig w/tndsc balloon dilation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,45341,Sigmoidoscopy w/ultrasound,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Humana MCR ADV,CPT,45342,Sigmoidoscopy w/us guide bx,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,45346,Sigmoidoscopy w/ablation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,45347,Sigmoidoscopy w/plcmt stent,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Humana MCR ADV,CPT,45349,Sigmoidoscopy w/resection,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,45350,Sgmdsc w/band ligation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,45378,Diagnostic colonoscopy,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Humana MCR ADV,CPT,45379,Colonoscopy w/fb removal,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,45380,Colonoscopy and biopsy,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,45381,Colonoscopy submucous njx,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,45382,Colonoscopy w/control bleed,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,45384,Colonoscopy w/lesion removal,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,45385,Colonoscopy w/lesion removal,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,45386,Colonoscopy w/balloon dilat,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,45388,Colonoscopy w/ablation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,45389,Colonoscopy w/stent plcmt,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Humana MCR ADV,CPT,45390,Colonoscopy w/resection,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,45391,Colonoscopy w/endoscope us,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,45392,Colonoscopy w/endoscopic fnb,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,45393,Colonoscopy w/decompression,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,45395,Lap removal of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,45397,Lap remove rectum w/pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,45398,Colonoscopy w/band ligation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,45399,Unlisted procedure colon,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Humana MCR ADV,CPT,45400,Laparoscopic proc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,45402,Lap proctopexy w/sig resect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,45499,Laparoscope proc rectum,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,45500,Repair of rectum,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,45505,Repair of rectum,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,45520,Treatment of rectal prolapse,APC 5311,RVU Per Case,$812.16 ,OP,812.16,"4,314.00",,,,,,
Humana MCR ADV,CPT,45540,Correct rectal prolapse,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,45541,Correct rectal prolapse,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,45550,Repair rectum/remove sigmoid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,45560,Repair of rectocele,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,45562,Exploration/repair of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,45563,Exploration/repair of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,45800,Repair rect/bladder fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,45805,Repair fistula w/colostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,45820,Repair rectourethral fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,45825,Repair fistula w/colostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,45900,Reduction of rectal prolapse,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Humana MCR ADV,CPT,45905,Dilation of anal sphincter,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,45910,Dilation of rectal narrowing,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,45915,Remove rectal obstruction,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,45990,Surg dx exam anorectal,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,45999,Rectum surgery procedure,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Humana MCR ADV,CPT,46020,Placement of seton,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,46030,Removal of rectal marker,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,46040,Incision of rectal abscess,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,46045,Incision of rectal abscess,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,46050,Incision of anal abscess,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Humana MCR ADV,CPT,46060,Incision of rectal abscess,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,46070,Incision of anal septum,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,46080,Incision of anal sphincter,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,46083,Incise external hemorrhoid,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Humana MCR ADV,CPT,46200,Removal of anal fissure,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,46220,Excise anal ext tag/papilla,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,46221,Ligation of hemorrhoid(s),APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Humana MCR ADV,CPT,46230,Removal of anal tags,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,46250,Remove ext hem groups 2+,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,46255,Remove int/ext hem 1 group,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,46257,Remove in/ex hem grp & fiss,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,46258,Remove in/ex hem grp w/fistu,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,46260,Remove in/ex hem groups 2+,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,46261,Remove in/ex hem grps & fiss,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,46262,Remove in/ex hem grps w/fist,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,46270,Remove anal fist subq,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,46275,Remove anal fist inter,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,46280,Remove anal fist complex,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,46285,Remove anal fist 2 stage,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,46288,Repair anal fistula,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,46320,Removal of hemorrhoid clot,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,46500,Injection into hemorrhoid(s),APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Humana MCR ADV,CPT,46505,Chemodenervation anal musc,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,46600,Diagnostic anoscopy spx,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Humana MCR ADV,CPT,46601,Diagnostic anoscopy,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Humana MCR ADV,CPT,46604,Anoscopy and dilation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,46606,Anoscopy and biopsy,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,46607,Diagnostic anoscopy & biopsy,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,46608,Anoscopy remove for body,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Humana MCR ADV,CPT,46610,Anoscopy remove lesion,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,46611,Anoscopy,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Humana MCR ADV,CPT,46612,Anoscopy remove lesions,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,46614,Anoscopy control bleeding,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,46615,Anoscopy,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,46700,Repair of anal stricture,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,46705,Repair of anal stricture,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,46706,Repr of anal fistula w/glue,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,46707,Repair anorectal fist w/plug,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,46710,Repr per/vag pouch sngl proc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,46712,Repr per/vag pouch dbl proc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,46715,Rep perf anoper fistu,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,46716,Rep perf anoper/vestib fistu,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,46730,Construction of absent anus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,46735,Construction of absent anus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,46740,Construction of absent anus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,46742,Repair of imperforated anus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,46744,Repair of cloacal anomaly,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,46746,Repair of cloacal anomaly,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,46748,Repair of cloacal anomaly,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,46750,Repair of anal sphincter,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,46751,Repair of anal sphincter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,46753,Reconstruction of anus,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,46754,Removal of suture from anus,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,46760,Repair of anal sphincter,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,46761,Repair of anal sphincter,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,46900,Destruction anal lesion(s),APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,46910,Destruction anal lesion(s),APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,46916,Cryosurgery anal lesion(s),APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,46917,Laser surgery anal lesions,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,46922,Excision of anal lesion(s),APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,46924,Destruction anal lesion(s),APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,46930,Destroy internal hemorrhoids,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,46940,Treatment of anal fissure,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,46942,Treatment of anal fissure,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Humana MCR ADV,CPT,46945,Int hrhc lig 1 hroid w/o img,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,46946,Int hrhc lig 2+hroid w/o img,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,46947,Hemorrhoidopexy by stapling,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,46948,Int hrhc tranal dartlzj 2+,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Humana MCR ADV,CPT,46999,Anus surgery procedure,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Humana MCR ADV,CPT,47000,Needle biopsy of liver,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,47010,Open drainage liver lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47015,Inject/aspirate liver cyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47100,Wedge biopsy of liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47120,Partial removal of liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47122,Extensive removal of liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47125,Partial removal of liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47130,Partial removal of liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47133,Removal of donor liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47135,Transplantation of liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47140,Partial removal donor liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47141,Partial removal donor liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47142,Partial removal donor liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47143,Prep donor liver whole,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47144,Prep donor liver 3-segment,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47145,Prep donor liver lobe split,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47146,Prep donor liver/venous,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47147,Prep donor liver/arterial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47300,Surgery for liver lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47350,Repair liver wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47360,Repair liver wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47361,Repair liver wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47362,Repair liver wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47370,Laparo ablate liver tumor rf,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Humana MCR ADV,CPT,47371,Laparo ablate liver cryosurg,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Humana MCR ADV,CPT,47379,Laparoscope procedure liver,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,47380,Open ablate liver tumor rf,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47381,Open ablate liver tumor cryo,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47382,Percut ablate liver rf,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,47383,Perq abltj lvr cryoablation,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,47399,Liver surgery procedure,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,47400,Incision of liver duct,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47420,Incision of bile duct,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47425,Incision of bile duct,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47460,Incise bile duct sphincter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47480,Incision of gallbladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47490,Incision of gallbladder,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Humana MCR ADV,CPT,47531,Injection for cholangiogram,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Humana MCR ADV,CPT,47532,Injection for cholangiogram,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Humana MCR ADV,CPT,47533,Plmt biliary drainage cath,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Humana MCR ADV,CPT,47534,Plmt biliary drainage cath,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Humana MCR ADV,CPT,47535,Conversion ext bil drg cath,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Humana MCR ADV,CPT,47536,Exchange biliary drg cath,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Humana MCR ADV,CPT,47537,Removal biliary drg cath,APC 5301,RVU Per Case,$828.48 ,OP,828.48,"4,314.00",,,,,,
Humana MCR ADV,CPT,47538,Perq plmt bile duct stent,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,47539,Perq plmt bile duct stent,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,47540,Perq plmt bile duct stent,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,47541,Plmt access bil tree sm bwl,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Humana MCR ADV,CPT,47550,Bile duct endoscopy add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47552,Biliary endo perq dx w/speci,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Humana MCR ADV,CPT,47553,Biliary endoscopy thru skin,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Humana MCR ADV,CPT,47554,Biliary endoscopy thru skin,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,47555,Biliary endoscopy thru skin,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Humana MCR ADV,CPT,47556,Biliary endoscopy thru skin,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,47562,Laparoscopic cholecystectomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,47563,Laparo cholecystectomy/graph,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,47564,Laparo cholecystectomy/explr,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,47570,Laparo cholecystoenterostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47579,Laparoscope proc biliary,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,47600,Removal of gallbladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,47605,Removal of gallbladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,47610,Removal of gallbladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,47612,Removal of gallbladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,47620,Removal of gallbladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,47700,Exploration of bile ducts,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47701,Bile duct revision,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47711,Excision of bile duct tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47712,Excision of bile duct tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47715,Excision of bile duct cyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47720,Fuse gallbladder & bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47721,Fuse upper gi structures,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47740,Fuse gallbladder & bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47741,Fuse gallbladder & bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47760,Fuse bile ducts and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47765,Fuse liver ducts & bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47780,Fuse bile ducts and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47785,Fuse bile ducts and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47800,Reconstruction of bile ducts,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47801,Placement bile duct support,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47802,Fuse liver duct & intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47900,Suture bile duct injury,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,47999,Bile tract surgery procedure,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Humana MCR ADV,CPT,48000,Drainage of abdomen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,48001,Placement of drain pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,48020,Removal of pancreatic stone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,48100,Biopsy of pancreas open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,48102,Needle biopsy pancreas,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,48105,Resect/debride pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,48120,Removal of pancreas lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,48140,Partial removal of pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,48145,Partial removal of pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,48146,Pancreatectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,48148,Removal of pancreatic duct,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,48150,Partial removal of pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,48152,Pancreatectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,48153,Pancreatectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,48154,Pancreatectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,48155,Removal of pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,48400,Injection intraop add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,48500,Surgery of pancreatic cyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,48510,Drain pancreatic pseudocyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,48520,Fuse pancreas cyst and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,48540,Fuse pancreas cyst and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,48545,Pancreatorrhaphy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,48547,Duodenal exclusion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,48548,Fuse pancreas and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,48551,Prep donor pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,48552,Prep donor pancreas/venous,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,48554,Transpl allograft pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,48556,Removal allograft pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,48999,Pancreas surgery procedure,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,49000,Exploration of abdomen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,49002,Reopening of abdomen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,49010,Exploration behind abdomen,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Humana MCR ADV,CPT,49013,Prpertl pel pack hemrrg trma,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,49014,Reexploration pelvic wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,49020,Drainage abdom abscess open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,49040,Drain open abdom abscess,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,49060,Drain open retroperi abscess,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,49062,Drain to peritoneal cavity,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,49082,Abd paracentesis,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Humana MCR ADV,CPT,49083,Abd paracentesis w/imaging,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Humana MCR ADV,CPT,49084,Peritoneal lavage,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Humana MCR ADV,CPT,49180,Biopsy abdominal mass,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,49185,Sclerotx fluid collection,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,49203,Exc abd tum 5 cm or less,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,49204,Exc abd tum over 5 cm,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,49205,Exc abd tum over 10 cm,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,49215,Excise sacral spine tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,49250,Excision of umbilicus,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Humana MCR ADV,CPT,49255,Removal of omentum,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Humana MCR ADV,CPT,49320,Diag laparo separate proc,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,49321,Laparoscopy biopsy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,49322,Laparoscopy aspiration,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,49323,Laparo drain lymphocele,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,49324,Lap insert tunnel ip cath,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,49325,Lap revision perm ip cath,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,49329,Laparo proc abdm/per/oment,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,49402,Remove foreign body adbomen,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Humana MCR ADV,CPT,49405,Image cath fluid colxn visc,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,49406,Image cath fluid peri/retro,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,49407,Image cath fluid trns/vgnl,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,49411,Ins mark abd/pel for rt perq,APC 5613,RVU Per Unit,"$1,291.62 ",OP,"1,291.62","4,314.00",,,,,,
Humana MCR ADV,CPT,49412,Ins device for rt guide open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,49418,Insert tun ip cath perc,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Humana MCR ADV,CPT,49419,Insert tun ip cath w/port,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Humana MCR ADV,CPT,49421,Ins tun ip cath for dial opn,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Humana MCR ADV,CPT,49422,Remove tunneled ip cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,49423,Exchange drainage catheter,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,49425,Insert abdomen-venous drain,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,49426,Revise abdomen-venous shunt,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Humana MCR ADV,CPT,49428,Ligation of shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,49429,Removal of shunt,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Humana MCR ADV,CPT,49436,Embedded ip cath exit-site,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,49440,Place gastrostomy tube perc,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,49441,Place duod/jej tube perc,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,49442,Place cecostomy tube perc,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Humana MCR ADV,CPT,49446,Change g-tube to g-j perc,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Humana MCR ADV,CPT,49450,Replace g/c tube perc,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Humana MCR ADV,CPT,49451,Replace duod/jej tube perc,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Humana MCR ADV,CPT,49452,Replace g-j tube perc,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Humana MCR ADV,CPT,49460,Fix g/colon tube w/device,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Humana MCR ADV,CPT,49465,Fluoro exam of g/colon tube,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"4,314.00",,,,,,
Humana MCR ADV,CPT,49491,Rpr hern preemie reduc,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,49492,Rpr ing hern premie blocked,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Humana MCR ADV,CPT,49495,Rpr ing hernia baby reduc,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Humana MCR ADV,CPT,49496,Rpr ing hernia baby blocked,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Humana MCR ADV,CPT,49500,Rpr ing hernia init reduce,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Humana MCR ADV,CPT,49501,Rpr ing hernia init blocked,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Humana MCR ADV,CPT,49505,Prp i/hern init reduc >5 yr,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Humana MCR ADV,CPT,49507,Prp i/hern init block >5 yr,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Humana MCR ADV,CPT,49520,Rerepair ing hernia reduce,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Humana MCR ADV,CPT,49521,Rerepair ing hernia blocked,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Humana MCR ADV,CPT,49525,Repair ing hernia sliding,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Humana MCR ADV,CPT,49540,Repair lumbar hernia,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,49550,Rpr rem hernia init reduce,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Humana MCR ADV,CPT,49553,Rpr fem hernia init blocked,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Humana MCR ADV,CPT,49555,Rerepair fem hernia reduce,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Humana MCR ADV,CPT,49557,Rerepair fem hernia blocked,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Humana MCR ADV,CPT,49560,Rpr ventral hern init reduc,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Humana MCR ADV,CPT,49561,Rpr ventral hern init block,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Humana MCR ADV,CPT,49565,Rerepair ventrl hern reduce,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,49566,Rerepair ventrl hern block,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,49570,Rpr epigastric hern reduce,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Humana MCR ADV,CPT,49572,Rpr epigastric hern blocked,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Humana MCR ADV,CPT,49580,Rpr umbil hern reduc < 5 yr,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Humana MCR ADV,CPT,49582,Rpr umbil hern block < 5 yr,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Humana MCR ADV,CPT,49585,Rpr umbil hern reduc > 5 yr,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Humana MCR ADV,CPT,49587,Rpr umbil hern block > 5 yr,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Humana MCR ADV,CPT,49590,Repair spigelian hernia,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Humana MCR ADV,CPT,49600,Repair umbilical lesion,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Humana MCR ADV,CPT,49605,Repair umbilical lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,49606,Repair umbilical lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,49610,Repair umbilical lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,49611,Repair umbilical lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,49650,Lap ing hernia repair init,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,49651,Lap ing hernia repair recur,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,49652,Lap vent/abd hernia repair,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,49653,Lap vent/abd hern proc comp,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,49654,Lap inc hernia repair,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,49655,Lap inc hern repair comp,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Humana MCR ADV,CPT,49656,Lap inc hernia repair recur,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Humana MCR ADV,CPT,49657,Lap inc hern recur comp,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Humana MCR ADV,CPT,49659,Laparo proc hernia repair,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,49900,Repair of abdominal wall,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,49904,Omental flap extra-abdom,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,49905,Omental flap intra-abdom,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,49906,Free omental flap microvasc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,49999,Abdomen surgery procedure,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Humana MCR ADV,CPT,50010,Exploration of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50020,Renal abscess open drain,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,50040,Drainage of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50045,Exploration of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50060,Removal of kidney stone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50065,Incision of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50070,Incision of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50075,Removal of kidney stone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50080,Removal of kidney stone,APC 5376,RVU Per Case,"$8,450.70 ",OP,"4,314.00","8,450.70",,,,,,
Humana MCR ADV,CPT,50081,Removal of kidney stone,APC 5376,RVU Per Case,"$8,450.70 ",OP,"4,314.00","8,450.70",,,,,,
Humana MCR ADV,CPT,50100,Revise kidney blood vessels,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50120,Exploration of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50125,Explore and drain kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50130,Removal of kidney stone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50135,Exploration of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50200,Renal biopsy perq,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,50205,Renal biopsy open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50220,Remove kidney open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50225,Removal kidney open complex,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50230,Removal kidney open radical,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50234,Removal of kidney & ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50236,Removal of kidney & ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50240,Partial removal of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50250,Cryoablate renal mass open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50280,Removal of kidney lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50290,Removal of kidney lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50300,Remove cadaver donor kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50320,Remove kidney living donor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50323,Prep cadaver renal allograft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50325,Prep donor renal graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50327,Prep renal graft/venous,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50328,Prep renal graft/arterial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50329,Prep renal graft/ureteral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50340,Removal of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50360,Transplantation of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50365,Transplantation of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50370,Remove transplanted kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50380,Reimplantation of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50382,Change ureter stent percut,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,50384,Remove ureter stent percut,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,50385,Change stent via transureth,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,50386,Remove stent via transureth,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,50387,Change nephroureteral cath,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,50389,Remove renal tube w/fluoro,APC 5372,RVU Per Case,$588.17 ,OP,588.17,"4,314.00",,,,,,
Humana MCR ADV,CPT,50390,Drainage of kidney lesion,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,50391,Instll rx agnt into rnal tub,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Humana MCR ADV,CPT,50396,Measure kidney pressure,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Humana MCR ADV,CPT,50400,Revision of kidney/ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50405,Revision of kidney/ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50430,Njx px nfrosgrm &/urtrgrm,APC 5372,RVU Per Case,$588.17 ,OP,588.17,"4,314.00",,,,,,
Humana MCR ADV,CPT,50431,Njx px nfrosgrm &/urtrgrm,APC 5372,RVU Per Case,$588.17 ,OP,588.17,"4,314.00",,,,,,
Humana MCR ADV,CPT,50432,Plmt nephrostomy catheter,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,50433,Plmt nephroureteral catheter,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,50434,Convert nephrostomy catheter,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,50435,Exchange nephrostomy cath,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,50436,Dilat xst trc ndurlgc px,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,50437,Dilat xst trc new access rcs,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,50500,Repair of kidney wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50520,Close kidney-skin fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50525,Close nephrovisceral fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50526,Close nephrovisceral fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50540,Revision of horseshoe kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50541,Laparo ablate renal cyst,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,50542,Laparo ablate renal mass,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Humana MCR ADV,CPT,50543,Laparo partial nephrectomy,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Humana MCR ADV,CPT,50544,Laparoscopy pyeloplasty,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,50545,Laparo radical nephrectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50546,Laparoscopic nephrectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50547,Laparo removal donor kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50548,Laparo remove w/ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50549,Laparoscope proc renal,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,50551,Kidney endoscopy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,50553,Kidney endoscopy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,50555,Kidney endoscopy & biopsy,APC 5376,RVU Per Case,"$8,450.70 ",OP,"4,314.00","8,450.70",,,,,,
Humana MCR ADV,CPT,50557,Kidney endoscopy & treatment,APC 5376,RVU Per Case,"$8,450.70 ",OP,"4,314.00","8,450.70",,,,,,
Humana MCR ADV,CPT,50561,Kidney endoscopy & treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,50562,Renal scope w/tumor resect,APC 5376,RVU Per Case,"$8,450.70 ",OP,"4,314.00","8,450.70",,,,,,
Humana MCR ADV,CPT,50570,Kidney endoscopy,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,50572,Kidney endoscopy,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Humana MCR ADV,CPT,50574,Kidney endoscopy & biopsy,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,50575,Kidney endoscopy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,50576,Kidney endoscopy & treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,50580,Kidney endoscopy & treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,50590,Fragmenting of kidney stone,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,50592,Perc rf ablate renal tumor,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,50593,Perc cryo ablate renal tum,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Humana MCR ADV,CPT,50600,Exploration of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50605,Insert ureteral support,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50610,Removal of ureter stone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50620,Removal of ureter stone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50630,Removal of ureter stone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50650,Removal of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50660,Removal of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50686,Measure ureter pressure,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,"4,314.00",,,,,,
Humana MCR ADV,CPT,50688,Change of ureter tube/stent,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,50693,Plmt ureteral stent prq,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,50694,Plmt ureteral stent prq,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,50695,Plmt ureteral stent prq,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,50700,Revision of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50715,Release of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50722,Release of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50725,Release/revise ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50727,Revise ureter,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,50728,Revise ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50740,Fusion of ureter & kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50750,Fusion of ureter & kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50760,Fusion of ureters,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50770,Splicing of ureters,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50780,Reimplant ureter in bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50782,Reimplant ureter in bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50783,Reimplant ureter in bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50785,Reimplant ureter in bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50800,Implant ureter in bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50810,Fusion of ureter & bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50815,Urine shunt to intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50820,Construct bowel bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50825,Construct bowel bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50830,Revise urine flow,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50840,Replace ureter by bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50845,Appendico-vesicostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50860,Transplant ureter to skin,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50900,Repair of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50920,Closure ureter/skin fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50930,Closure ureter/bowel fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50940,Release of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,50945,Laparoscopy ureterolithotomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,50947,Laparo new ureter/bladder,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,50948,Laparo new ureter/bladder,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Humana MCR ADV,CPT,50949,Laparoscope proc ureter,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,50951,Endoscopy of ureter,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,50953,Endoscopy of ureter,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,50955,Ureter endoscopy & biopsy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,50957,Ureter endoscopy & treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,50961,Ureter endoscopy & treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,50970,Ureter endoscopy,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,50972,Ureter endoscopy & catheter,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,50974,Ureter endoscopy & biopsy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,50976,Ureter endoscopy & treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,50980,Ureter endoscopy & treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,51020,Incise & treat bladder,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,51030,Incise & treat bladder,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,51040,Incise & drain bladder,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,51045,Incise bladder/drain ureter,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,51050,Removal of bladder stone,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,51060,Removal of ureter stone,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,51065,Remove ureter calculus,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,51080,Drainage of bladder abscess,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,51100,Drain bladder by needle,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Humana MCR ADV,CPT,51101,Drain bladder by trocar/cath,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"4,314.00",,,,,,
Humana MCR ADV,CPT,51102,Drain bl w/cath insertion,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,51500,Removal of bladder cyst,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,51520,Removal of bladder lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,51525,Removal of bladder lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,51530,Removal of bladder lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,51535,Repair of ureter lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,51550,Partial removal of bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,51555,Partial removal of bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,51565,Revise bladder & ureter(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,51570,Removal of bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,51575,Removal of bladder & nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,51580,Remove bladder/revise tract,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,51585,Removal of bladder & nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,51590,Remove bladder/revise tract,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,51595,Remove bladder/revise tract,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,51596,Remove bladder/create pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,51597,Removal of pelvic structures,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,51700,Irrigation of bladder,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Humana MCR ADV,CPT,51701,Insert bladder catheter,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Humana MCR ADV,CPT,51702,Insert temp bladder cath,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Humana MCR ADV,CPT,51703,Insert bladder cath complex,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,"4,314.00",,,,,,
Humana MCR ADV,CPT,51705,Change of bladder tube,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Humana MCR ADV,CPT,51710,Change of bladder tube,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Humana MCR ADV,CPT,51715,Endoscopic injection/implant,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,51720,Treatment of bladder lesion,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Humana MCR ADV,CPT,51725,Simple cystometrogram,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Humana MCR ADV,CPT,51726,Complex cystometrogram,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Humana MCR ADV,CPT,51727,Cystometrogram w/up,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Humana MCR ADV,CPT,51728,Cystometrogram w/vp,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Humana MCR ADV,CPT,51729,Cystometrogram w/vp&up,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Humana MCR ADV,CPT,51736,Urine flow measurement,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Humana MCR ADV,CPT,51741,Electro-uroflowmetry first,APC 5721,RVU Per Case,$142.80 ,OP,142.8,"4,314.00",,,,,,
Humana MCR ADV,CPT,51784,Anal/urinary muscle study,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,"4,314.00",,,,,,
Humana MCR ADV,CPT,51785,Anal/urinary muscle study,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Humana MCR ADV,CPT,51792,Urinary reflex study,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Humana MCR ADV,CPT,51798,Us urine capacity measure,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Humana MCR ADV,CPT,51800,Revision of bladder/urethra,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,51820,Revision of urinary tract,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,51840,Attach bladder/urethra,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Humana MCR ADV,CPT,51841,Attach bladder/urethra,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,51845,Repair bladder neck,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Humana MCR ADV,CPT,51860,Repair of bladder wound,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,51865,Repair of bladder wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,51880,Repair of bladder opening,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,51900,Repair bladder/vagina lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,51920,Close bladder-uterus fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,51925,Hysterectomy/bladder repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,51940,Correction of bladder defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,51960,Revision of bladder & bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,51980,Construct bladder opening,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,51990,Laparo urethral suspension,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,51992,Laparo sling operation,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,51999,Laparoscope proc bla,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,52000,Cystoscopy,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Humana MCR ADV,CPT,52001,Cystoscopy removal of clots,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,52005,Cystoscopy & ureter catheter,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,52007,Cystoscopy and biopsy,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,52010,Cystoscopy & duct catheter,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Humana MCR ADV,CPT,52204,Cystoscopy w/biopsy(s),APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,52214,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,52224,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,52234,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,52235,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,52240,Cystoscopy and treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,52250,Cystoscopy and radiotracer,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,52260,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,52265,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,52270,Cystoscopy & revise urethra,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,52275,Cystoscopy & revise urethra,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,52276,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,52277,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,52281,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,52282,Cystoscopy implant stent,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,52283,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,52285,Cystoscopy and treatment,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Humana MCR ADV,CPT,52287,Cystoscopy chemodenervation,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,52290,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,52300,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,52301,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,52305,Cystoscopy and treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,52310,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,52315,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,52317,Remove bladder stone,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,52318,Remove bladder stone,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,52320,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,52325,Cystoscopy stone removal,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,52327,Cystoscopy inject material,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,52330,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,52332,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,52334,Create passage to kidney,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,52341,Cysto w/ureter stricture tx,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,52342,Cysto w/up stricture tx,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,52343,Cysto w/renal stricture tx,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,52344,Cysto/uretero stricture tx,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,52345,Cysto/uretero w/up stricture,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,52346,Cystouretero w/renal strict,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,52351,Cystouretero & or pyeloscope,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,52352,Cystouretero w/stone remove,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,52353,Cystouretero w/lithotripsy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,52354,Cystouretero w/biopsy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,52355,Cystouretero w/excise tumor,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,52356,Cysto/uretero w/lithotripsy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,52400,Cystouretero w/congen repr,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,52402,Cystourethro cut ejacul duct,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,52450,Incision of prostate,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,52500,Revision of bladder neck,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,52601,Prostatectomy (turp),APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,52630,Remove prostate regrowth,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,52640,Relieve bladder contracture,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,52647,Laser surgery of prostate,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,52648,Laser surgery of prostate,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,52649,Prostate laser enucleation,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,52700,Drainage of prostate abscess,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,53000,Incision of urethra,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,53010,Incision of urethra,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,53020,Incision of urethra,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,53025,Incision of urethra,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,53040,Drainage of urethra abscess,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,53060,Drainage of urethra abscess,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,53080,Drainage of urinary leakage,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Humana MCR ADV,CPT,53085,Drainage of urinary leakage,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,53200,Biopsy of urethra,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,53210,Removal of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,53215,Removal of urethra,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,53220,Treatment of urethra lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,53230,Removal of urethra lesion,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,53235,Removal of urethra lesion,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,53240,Surgery for urethra pouch,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,53250,Removal of urethra gland,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,53260,Treatment of urethra lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,53265,Treatment of urethra lesion,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,53270,Removal of urethra gland,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,53275,Repair of urethra defect,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,53400,Revise urethra stage 1,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,53405,Revise urethra stage 2,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,53410,Reconstruction of urethra,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,53415,Reconstruction of urethra,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,53420,Reconstruct urethra stage 1,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,53425,Reconstruct urethra stage 2,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,53430,Reconstruction of urethra,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,53431,Reconstruct urethra/bladder,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,53440,Male sling procedure,APC 5377,RVU Per Case,"$11,755.91 ",OP,"4,140.35","11,755.91",,,,,,
Humana MCR ADV,CPT,53442,Remove/revise male sling,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,53444,Insert tandem cuff,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,314.00","18,684.12",,,,,,
Humana MCR ADV,CPT,53445,Insert uro/ves nck sphincter,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,140.35","18,684.12",,,,,,
Humana MCR ADV,CPT,53446,Remove uro sphincter,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,53447,Remove/replace ur sphincter,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,314.00","18,684.12",,,,,,
Humana MCR ADV,CPT,53448,Remov/replc ur sphinctr comp,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,53449,Repair uro sphincter,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,53450,Revision of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,53460,Revision of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,53500,Urethrlys transvag w/ scope,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,53502,Repair of urethra injury,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,53505,Repair of urethra injury,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,53510,Repair of urethra injury,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,53515,Repair of urethra injury,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,53520,Repair of urethra defect,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,53600,Dilate urethra stricture,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Humana MCR ADV,CPT,53601,Dilate urethra stricture,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Humana MCR ADV,CPT,53605,Dilate urethra stricture,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,53620,Dilate urethra stricture,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Humana MCR ADV,CPT,53621,Dilate urethra stricture,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Humana MCR ADV,CPT,53660,Dilation of urethra,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,"4,314.00",,,,,,
Humana MCR ADV,CPT,53661,Dilation of urethra,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Humana MCR ADV,CPT,53665,Dilation of urethra,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,53850,Prostatic microwave thermotx,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,53852,Prostatic rf thermotx,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,53854,Trurl dstrj prst8 tiss rf wv,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,53855,Insert prost urethral stent,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,53860,Transurethral rf treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,53899,Urology surgery procedure,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Humana MCR ADV,CPT,54000,Slitting of prepuce,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,54001,Slitting of prepuce,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,54015,Drain penis lesion,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,54050,Destruction penis lesion(s),APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,54055,Destruction penis lesion(s),APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,54056,Cryosurgery penis lesion(s),APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,54057,Laser surg penis lesion(s),APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,54060,Excision of penis lesion(s),APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,54065,Destruction penis lesion(s),APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,54100,Biopsy of penis,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,54105,Biopsy of penis,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,54110,Treatment of penis lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,54111,Treat penis lesion graft,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,54112,Treat penis lesion graft,APC 5376,RVU Per Case,"$8,450.70 ",OP,"4,314.00","8,450.70",,,,,,
Humana MCR ADV,CPT,54115,Treatment of penis lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,54120,Partial removal of penis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,54125,Removal of penis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,54130,Remove penis & nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,54135,Remove penis & nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,54150,Circumcision w/regionl block,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,54160,Circumcision neonate,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Humana MCR ADV,CPT,54161,Circum 28 days or older,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,54162,Lysis penil circumic lesion,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,54163,Repair of circumcision,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,54164,Frenulotomy of penis,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,54200,Treatment of penis lesion,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Humana MCR ADV,CPT,54205,Treatment of penis lesion,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,54220,Treatment of penis lesion,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Humana MCR ADV,CPT,54231,Dynamic cavernosometry,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Humana MCR ADV,CPT,54235,Penile injection,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Humana MCR ADV,CPT,54240,Penis study,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"4,314.00",,,,,,
Humana MCR ADV,CPT,54250,Penis study,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Humana MCR ADV,CPT,54300,Revision of penis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,54304,Revision of penis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,54308,Reconstruction of urethra,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,54312,Reconstruction of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,54316,Reconstruction of urethra,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,54318,Reconstruction of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,54322,Reconstruction of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,54324,Reconstruction of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,54326,Reconstruction of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,54328,Revise penis/urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,54332,Revise penis/urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,54336,Revise penis/urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,54340,Secondary urethral surgery,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,54344,Secondary urethral surgery,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,54348,Secondary urethral surgery,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,54352,Reconstruct urethra/penis,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,54360,Penis plastic surgery,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,54380,Repair penis,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,54385,Repair penis,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,54390,Repair penis and bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,54400,Insert semi-rigid prosthesis,APC 5377,RVU Per Case,"$11,755.91 ",OP,"4,314.00","11,755.91",,,,,,
Humana MCR ADV,CPT,54401,Insert self-contd prosthesis,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,314.00","18,684.12",,,,,,
Humana MCR ADV,CPT,54405,Insert multi-comp penis pros,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,140.35","18,684.12",,,,,,
Humana MCR ADV,CPT,54406,Remove muti-comp penis pros,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,54408,Repair multi-comp penis pros,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,54410,Remove/replace penis prosth,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,140.35","18,684.12",,,,,,
Humana MCR ADV,CPT,54411,Remov/replc penis pros comp,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,314.00","18,684.12",,,,,,
Humana MCR ADV,CPT,54415,Remove self-contd penis pros,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,54416,Remv/repl penis contain pros,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,314.00","18,684.12",,,,,,
Humana MCR ADV,CPT,54417,Remv/replc penis pros compl,APC 5377,RVU Per Case,"$11,755.91 ",OP,"4,314.00","11,755.91",,,,,,
Humana MCR ADV,CPT,54420,Revision of penis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,54430,Revision of penis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,54435,Revision of penis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,54437,Repair corporeal tear,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,54438,Replantation of penis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,54440,Repair of penis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,54450,Preputial stretching,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Humana MCR ADV,CPT,54500,Biopsy of testis,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,54505,Biopsy of testis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,54512,Excise lesion testis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,54520,Removal of testis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,54522,Orchiectomy partial,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,54530,Removal of testis,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Humana MCR ADV,CPT,54535,Extensive testis surgery,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,54550,Exploration for testis,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Humana MCR ADV,CPT,54560,Exploration for testis,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,54600,Reduce testis torsion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,54620,Suspension of testis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,54640,Orchiopexy ingun/scrot appr,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Humana MCR ADV,CPT,54650,Orchiopexy (fowler-stephens),APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Humana MCR ADV,CPT,54660,Revision of testis,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,54670,Repair testis injury,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,54680,Relocation of testis(es),APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,54690,Laparoscopy orchiectomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,54692,Laparoscopy orchiopexy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,54699,Laparoscope proc testis,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,54700,Drainage of scrotum,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,54800,Biopsy of epididymis,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,54830,Remove epididymis lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,54840,Remove epididymis lesion,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,54860,Removal of epididymis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,54861,Removal of epididymis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,54865,Explore epididymis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,54900,Fusion of spermatic ducts,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,54901,Fusion of spermatic ducts,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,55000,Drainage of hydrocele,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,55040,Removal of hydrocele,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Humana MCR ADV,CPT,55041,Removal of hydroceles,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Humana MCR ADV,CPT,55060,Repair of hydrocele,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,55100,Drainage of scrotum abscess,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,55110,Explore scrotum,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,55120,Removal of scrotum lesion,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,55150,Removal of scrotum,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,55175,Revision of scrotum,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,55180,Revision of scrotum,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,55200,Incision of sperm duct,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,55250,Removal of sperm duct(s),APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,55400,Repair of sperm duct,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,55500,Removal of hydrocele,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,55520,Removal of sperm cord lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,55530,Revise spermatic cord veins,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,55535,Revise spermatic cord veins,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Humana MCR ADV,CPT,55540,Revise hernia & sperm veins,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Humana MCR ADV,CPT,55550,Laparo ligate spermatic vein,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,55559,Laparo proc spermatic cord,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,55600,Incise sperm duct pouch,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,55605,Incise sperm duct pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,55650,Remove sperm duct pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,55680,Remove sperm pouch lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,55700,Biopsy of prostate,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Humana MCR ADV,CPT,55705,Biopsy of prostate,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,55706,Prostate saturation sampling,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,55720,Drainage of prostate abscess,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,55725,Drainage of prostate abscess,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,55801,Removal of prostate,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,55810,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,55812,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,55815,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,55821,Removal of prostate,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,55831,Removal of prostate,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,55840,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,55842,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,55845,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,55860,Surgical exposure prostate,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,55862,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,55865,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,55866,Laparo radical prostatectomy,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Humana MCR ADV,CPT,55870,Electroejaculation,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Humana MCR ADV,CPT,55873,Cryoablate prostate,APC 5376,RVU Per Case,"$8,450.70 ",OP,"4,314.00","8,450.70",,,,,,
Humana MCR ADV,CPT,55874,Tprnl plmt biodegrdabl matrl,APC 5375,RVU Per Unit,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,55875,Transperi needle place pros,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,55876,Place rt device/marker pros,APC 5613,RVU Per Unit,"$1,291.62 ",OP,"1,291.62","4,314.00",,,,,,
Humana MCR ADV,CPT,55880,Abltj mal prst8 tiss hifu,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Humana MCR ADV,CPT,55899,Genital surgery procedure,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Humana MCR ADV,CPT,55920,Place needles pelvic for rt,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Humana MCR ADV,CPT,55970,Sex transformation m to f,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Humana MCR ADV,CPT,55980,Sex transformation f to m,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Humana MCR ADV,CPT,56405,I & d of vulva/perineum,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Humana MCR ADV,CPT,56420,Drainage of gland abscess,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Humana MCR ADV,CPT,56440,Surgery for vulva lesion,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,56441,Lysis of labial lesion(s),APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,56442,Hymenotomy,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,56501,Destroy vulva lesions sim,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,56515,Destroy vulva lesion/s compl,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Humana MCR ADV,CPT,56605,Biopsy of vulva/perineum,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Humana MCR ADV,CPT,56620,Partial removal of vulva,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,56625,Complete removal of vulva,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,56630,Extensive vulva surgery,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Humana MCR ADV,CPT,56631,Extensive vulva surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,56632,Extensive vulva surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,56633,Extensive vulva surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,56634,Extensive vulva surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,56637,Extensive vulva surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,56640,Extensive vulva surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,56700,Partial removal of hymen,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,56740,Remove vagina gland lesion,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,56800,Repair of vagina,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,56805,Repair clitoris,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,56810,Repair of perineum,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,56820,Exam of vulva w/scope,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Humana MCR ADV,CPT,56821,Exam/biopsy of vulva w/scope,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Humana MCR ADV,CPT,57000,Exploration of vagina,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,57010,Drainage of pelvic abscess,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,57020,Drainage of pelvic fluid,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Humana MCR ADV,CPT,57022,I & d vaginal hematoma pp,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,57023,I & d vag hematoma non-ob,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,57061,Destroy vag lesions simple,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,57065,Destroy vag lesions complex,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,57100,Biopsy of vagina,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Humana MCR ADV,CPT,57105,Biopsy of vagina,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,57106,Remove vagina wall partial,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,57107,Remove vagina tissue part,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,57109,Vaginectomy partial w/nodes,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,57110,Remove vagina wall complete,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,57111,Remove vagina tissue compl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,57120,Closure of vagina,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Humana MCR ADV,CPT,57130,Remove vagina lesion,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,57135,Remove vagina lesion,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,57150,Treat vagina infection,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Humana MCR ADV,CPT,57155,Insert uteri tandem/ovoids,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Humana MCR ADV,CPT,57156,Ins vag brachytx device,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Humana MCR ADV,CPT,57160,Insert pessary/other device,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Humana MCR ADV,CPT,57170,Fitting of diaphragm/cap,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Humana MCR ADV,CPT,57180,Treat vaginal bleeding,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Humana MCR ADV,CPT,57200,Repair of vagina,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,57210,Repair vagina/perineum,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,57220,Revision of urethra,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Humana MCR ADV,CPT,57230,Repair of urethral lesion,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,57240,Anterior colporrhaphy,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Humana MCR ADV,CPT,57250,Repair rectum & vagina,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Humana MCR ADV,CPT,57260,Cmbn ant pst colprhy,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Humana MCR ADV,CPT,57265,Cmbn ap colprhy w/ntrcl rpr,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Humana MCR ADV,CPT,57268,Repair of bowel bulge,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Humana MCR ADV,CPT,57270,Repair of bowel pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,57280,Suspension of vagina,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,57282,Colpopexy extraperitoneal,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,57283,Colpopexy intraperitoneal,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,57284,Repair paravag defect open,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Humana MCR ADV,CPT,57285,Repair paravag defect vag,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,57287,Revise/remove sling repair,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,57288,Repair bladder defect,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,57289,Repair bladder & vagina,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,314.00","6,952.74",,,,,,
Humana MCR ADV,CPT,57291,Construction of vagina,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Humana MCR ADV,CPT,57292,Construct vagina with graft,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Humana MCR ADV,CPT,57295,Revise vag graft via vagina,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,57296,Revise vag graft open abd,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,57300,Repair rectum-vagina fistula,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,57305,Repair rectum-vagina fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,57307,Fistula repair & colostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,57308,Fistula repair transperine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,57310,Repair urethrovaginal lesion,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,314.00","6,952.74",,,,,,
Humana MCR ADV,CPT,57311,Repair urethrovaginal lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,57320,Repair bladder-vagina lesion,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Humana MCR ADV,CPT,57330,Repair bladder-vagina lesion,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,314.00","6,952.74",,,,,,
Humana MCR ADV,CPT,57335,Repair vagina,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Humana MCR ADV,CPT,57400,Dilation of vagina,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,57410,Pelvic examination,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,57415,Remove vaginal foreign body,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,57420,Exam of vagina w/scope,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Humana MCR ADV,CPT,57421,Exam/biopsy of vag w/scope,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Humana MCR ADV,CPT,57423,Repair paravag defect lap,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Humana MCR ADV,CPT,57425,Laparoscopy surg colpopexy,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,57426,Revise prosth vag graft lap,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,314.00","6,952.74",,,,,,
Humana MCR ADV,CPT,57452,Exam of cervix w/scope,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Humana MCR ADV,CPT,57454,Bx/curett of cervix w/scope,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Humana MCR ADV,CPT,57455,Biopsy of cervix w/scope,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Humana MCR ADV,CPT,57456,Endocerv curettage w/scope,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Humana MCR ADV,CPT,57460,Bx of cervix w/scope leep,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,57461,Conz of cervix w/scope leep,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,57500,Biopsy of cervix,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Humana MCR ADV,CPT,57505,Endocervical curettage,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Humana MCR ADV,CPT,57510,Cauterization of cervix,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,57511,Cryocautery of cervix,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Humana MCR ADV,CPT,57513,Laser surgery of cervix,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,57520,Conization of cervix,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,57522,Conization of cervix,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,57530,Removal of cervix,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Humana MCR ADV,CPT,57531,Removal of cervix radical,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,57540,Removal of residual cervix,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,57545,Remove cervix/repair pelvis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,57550,Removal of residual cervix,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Humana MCR ADV,CPT,57555,Remove cervix/repair vagina,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Humana MCR ADV,CPT,57556,Remove cervix repair bowel,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Humana MCR ADV,CPT,57558,D&c of cervical stump,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,57700,Revision of cervix,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,57720,Revision of cervix,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,57800,Dilation of cervical canal,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,58100,Biopsy of uterus lining,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Humana MCR ADV,CPT,58120,Dilation and curettage,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,58140,Myomectomy abdom method,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,58145,Myomectomy vag method,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","9,201.00",,,,,,
Humana MCR ADV,CPT,58146,Myomectomy abdom complex,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,58150,Total hysterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,58152,Total hysterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,58180,Partial hysterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,58200,Extensive hysterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,58210,Extensive hysterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,58240,Removal of pelvis contents,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,58260,Vaginal hysterectomy,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Humana MCR ADV,CPT,58262,Vag hyst including t/o,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Humana MCR ADV,CPT,58263,Vag hyst w/t/o & vag repair,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Humana MCR ADV,CPT,58267,Vag hyst w/urinary repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,58270,Vag hyst w/enterocele repair,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Humana MCR ADV,CPT,58275,Hysterectomy/revise vagina,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,58280,Hysterectomy/revise vagina,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,58285,Extensive hysterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,58290,Vag hyst complex,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,314.00","6,952.74",,,,,,
Humana MCR ADV,CPT,58291,Vag hyst incl t/o complex,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Humana MCR ADV,CPT,58292,Vag hyst t/o & repair compl,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,314.00","6,952.74",,,,,,
Humana MCR ADV,CPT,58294,Vag hyst w/enterocele compl,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Humana MCR ADV,CPT,58301,Remove intrauterine device,APC 5412,RVU Per Case,$288.05 ,OP,288.05,"4,314.00",,,,,,
Humana MCR ADV,CPT,58321,Artificial insemination,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Humana MCR ADV,CPT,58322,Artificial insemination,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Humana MCR ADV,CPT,58323,Sperm washing,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Humana MCR ADV,CPT,58345,Reopen fallopian tube,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,58346,Insert heyman uteri capsule,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Humana MCR ADV,CPT,58350,Reopen fallopian tube,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Humana MCR ADV,CPT,58353,Endometr ablate thermal,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Humana MCR ADV,CPT,58356,Endometrial cryoablation,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Humana MCR ADV,CPT,58400,Suspension of uterus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,58410,Suspension of uterus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,58520,Repair of ruptured uterus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,58540,Revision of uterus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,58541,Lsh uterus 250 g or less,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,58542,Lsh w/t/o ut 250 g or less,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,58543,Lsh uterus above 250 g,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,58544,Lsh w/t/o uterus above 250 g,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,58545,Laparoscopic myomectomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,58546,Laparo-myomectomy complex,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,58548,Lap radical hyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,58550,Laparo-asst vag hysterectomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,58552,Laparo-vag hyst incl t/o,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,58553,Laparo-vag hyst complex,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,58554,Laparo-vag hyst w/t/o compl,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,58555,Hysteroscopy dx sep proc,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,58558,Hysteroscopy biopsy,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","9,201.00",,,,,,
Humana MCR ADV,CPT,58559,Hysteroscopy lysis,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,58560,Hysteroscopy resect septum,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,58561,Hysteroscopy remove myoma,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,58562,Hysteroscopy remove fb,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,58563,Hysteroscopy ablation,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Humana MCR ADV,CPT,58565,Hysteroscopy sterilization,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,58570,Tlh uterus 250 g or less,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,58571,Tlh w/t/o 250 g or less,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,58572,Tlh uterus over 250 g,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,58573,Tlh w/t/o uterus over 250 g,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,58575,Laps tot hyst resj mal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,58578,Laparo proc uterus,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,58579,Hysteroscope procedure,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Humana MCR ADV,CPT,58600,Division of fallopian tube,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,58605,Division of fallopian tube,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,58611,Ligate oviduct(s) add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,58615,Occlude fallopian tube(s),APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,58660,Laparoscopy lysis,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,58661,Laparoscopy remove adnexa,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,58662,Laparoscopy excise lesions,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,58670,Laparoscopy tubal cautery,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,58671,Laparoscopy tubal block,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,58672,Laparoscopy fimbrioplasty,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,58673,Laparoscopy salpingostomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,58674,Laps abltj uterine fibroids,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,58679,Laparo proc oviduct-ovary,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,58700,Removal of fallopian tube,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,58720,Removal of ovary/tube(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,58740,Adhesiolysis tube ovary,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,58750,Repair oviduct,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,58752,Revise ovarian tube(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,58760,Fimbrioplasty,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,58770,Create new tubal opening,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,58800,Drainage of ovarian cyst(s),APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,58805,Drainage of ovarian cyst(s),APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,58820,Drain ovary abscess open,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,58822,Drain ovary abscess percut,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,58825,Transposition ovary(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,58900,Biopsy of ovary(s),APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,58920,Partial removal of ovary(s),APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,314.00","6,952.74",,,,,,
Humana MCR ADV,CPT,58925,Removal of ovarian cyst(s),APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Humana MCR ADV,CPT,58940,Removal of ovary(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,58943,Removal of ovary(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,58950,Resect ovarian malignancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,58951,Resect ovarian malignancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,58952,Resect ovarian malignancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,58953,Tah rad dissect for debulk,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,58954,Tah rad debulk/lymph remove,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,58956,Bso omentectomy w/tah,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,58957,Resect recurrent gyn mal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,58958,Resect recur gyn mal w/lym,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,58960,Exploration of abdomen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,58970,Retrieval of oocyte,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Humana MCR ADV,CPT,58974,Transfer of embryo,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Humana MCR ADV,CPT,58976,Transfer of embryo,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Humana MCR ADV,CPT,58999,Genital surgery procedure,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Humana MCR ADV,CPT,59000,Amniocentesis diagnostic,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Humana MCR ADV,CPT,59001,Amniocentesis therapeutic,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Humana MCR ADV,CPT,59012,Fetal cord puncture prenatal,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Humana MCR ADV,CPT,59015,Chorion biopsy,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Humana MCR ADV,CPT,59020,Fetal contract stress test,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Humana MCR ADV,CPT,59025,Fetal non-stress test,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Humana MCR ADV,CPT,59030,Fetal scalp blood sample,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Humana MCR ADV,CPT,59070,Transabdom amnioinfus w/us,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Humana MCR ADV,CPT,59072,Umbilical cord occlud w/us,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Humana MCR ADV,CPT,59074,Fetal fluid drainage w/us,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Humana MCR ADV,CPT,59076,Fetal shunt placement w/us,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Humana MCR ADV,CPT,59100,Remove uterus lesion,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Humana MCR ADV,CPT,59120,Treat ectopic pregnancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,59121,Treat ectopic pregnancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,59130,Treat ectopic pregnancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,59135,Treat ectopic pregnancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,59136,Treat ectopic pregnancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,59140,Treat ectopic pregnancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,59150,Treat ectopic pregnancy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,59151,Treat ectopic pregnancy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,59160,D & c after delivery,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,59200,Insert cervical dilator,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Humana MCR ADV,CPT,59300,Episiotomy or vaginal repair,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,59320,Revision of cervix,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,59325,Revision of cervix,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,59350,Repair of uterus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,59409,Obstetrical care,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,59412,Antepartum manipulation,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,59414,Deliver placenta,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,59514,Cesarean delivery only,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,59525,Remove uterus after cesarean,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,59612,Vbac delivery only,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,59620,Attempted vbac delivery only,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,59812,Treatment of miscarriage,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,59820,Care of miscarriage,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,59821,Treatment of miscarriage,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,59830,Treat uterus infection,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,59840,Abortion,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,59841,Abortion,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,59850,Abortion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,59851,Abortion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,59852,Abortion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,59855,Abortion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,59856,Abortion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,59857,Abortion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,59866,Abortion (mpr),APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Humana MCR ADV,CPT,59870,Evacuate mole of uterus,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,59871,Remove cerclage suture,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Humana MCR ADV,CPT,59897,Fetal invas px w/us,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Humana MCR ADV,CPT,59898,Laparo proc ob care/deliver,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,59899,Maternity care procedure,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Humana MCR ADV,CPT,60000,Drain thyroid/tongue cyst,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,60100,Biopsy of thyroid,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,60200,Remove thyroid lesion,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,60210,Partial thyroid excision,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,60212,Partial thyroid excision,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,60220,Partial removal of thyroid,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,60225,Partial removal of thyroid,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,60240,Removal of thyroid,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,60252,Removal of thyroid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,60254,Extensive thyroid surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,60260,Repeat thyroid surgery,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,60270,Removal of thyroid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,60271,Removal of thyroid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,60280,Remove thyroid duct lesion,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,60281,Remove thyroid duct lesion,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,60300,Aspir/inj thyroid cyst,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,60500,Explore parathyroid glands,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,60502,Re-explore parathyroids,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,60505,Explore parathyroid glands,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,60520,Removal of thymus gland,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,60521,Removal of thymus gland,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,60522,Removal of thymus gland,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,60540,Explore adrenal gland,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,60545,Explore adrenal gland,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,60600,Remove carotid body lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,60605,Remove carotid body lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,60650,Laparoscopy adrenalectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,60659,Laparo proc endocrine,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,60699,Endocrine surgery procedure,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Humana MCR ADV,CPT,61000,Remove cranial cavity fluid,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,61001,Remove cranial cavity fluid,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,61020,Remove brain cavity fluid,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Humana MCR ADV,CPT,61026,Injection into brain canal,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,61050,Remove brain canal fluid,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Humana MCR ADV,CPT,61055,Injection into brain canal,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Humana MCR ADV,CPT,61070,Brain canal shunt procedure,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,61105,Twist drill hole,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61107,Drill skull for implantation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61108,Drill skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61120,Burr hole for puncture,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61140,Pierce skull for biopsy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61150,Pierce skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61151,Pierce skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61154,Pierce skull & remove clot,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61156,Pierce skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61210,Pierce skull implant device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61215,Insert brain-fluid device,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Humana MCR ADV,CPT,61250,Pierce skull & explore,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61253,Pierce skull & explore,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61304,Open skull for exploration,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61305,Open skull for exploration,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61312,Open skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61313,Open skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61314,Open skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61315,Open skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61316,Implt cran bone flap to abdo,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61320,Open skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61321,Open skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61322,Decompressive craniotomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61323,Decompressive lobectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61330,Decompress eye socket,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,61333,Explore orbit/remove lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61340,Subtemporal decompression,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61343,Incise skull (press relief),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61345,Relieve cranial pressure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61450,Incise skull for surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61458,Incise skull for brain wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61460,Incise skull for surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61500,Removal of skull lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61501,Remove infected skull bone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61510,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61512,Remove brain lining lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61514,Removal of brain abscess,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61516,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61517,Implt brain chemotx add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61518,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61519,Remove brain lining lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61520,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61521,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61522,Removal of brain abscess,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61524,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61526,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61530,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61531,Implant brain electrodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61533,Implant brain electrodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61534,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61535,Remove brain electrodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61536,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61537,Removal of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61538,Removal of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61539,Removal of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61540,Removal of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61541,Incision of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61543,Removal of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61544,Remove & treat brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61545,Excision of brain tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61546,Removal of pituitary gland,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61548,Removal of pituitary gland,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61550,Release of skull seams,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61552,Release of skull seams,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61556,Incise skull/sutures,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61557,Incise skull/sutures,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61558,Excision of skull/sutures,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61559,Excision of skull/sutures,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61563,Excision of skull tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61564,Excision of skull tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61566,Removal of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61567,Incision of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61570,Remove foreign body brain,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61571,Incise skull for brain wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61575,Skull base/brainstem surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61576,Skull base/brainstem surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61580,Craniofacial approach skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61581,Craniofacial approach skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61582,Craniofacial approach skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61583,Craniofacial approach skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61584,Orbitocranial approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61585,Orbitocranial approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61586,Resect nasopharynx skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61590,Infratemporal approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61591,Infratemporal approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61592,Orbitocranial approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61595,Transtemporal approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61596,Transcochlear approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61597,Transcondylar approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61598,Transpetrosal approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61600,Resect/excise cranial lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61601,Resect/excise cranial lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61605,Resect/excise cranial lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61606,Resect/excise cranial lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61607,Resect/excise cranial lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61608,Resect/excise cranial lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61611,Transect artery sinus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61613,Remove aneurysm sinus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61615,Resect/excise lesion skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61616,Resect/excise lesion skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61618,Repair dura,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61619,Repair dura,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61623,Endovasc tempory vessel occl,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Humana MCR ADV,CPT,61624,Transcath occlusion cns,APC 5194,RVU Per Case,"$16,438.60 ",OP,"4,314.00","16,438.60",,,,,,
Humana MCR ADV,CPT,61626,Transcath occlusion non-cns,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Humana MCR ADV,CPT,61630,Intracranial angioplasty,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61635,Intracran angioplsty w/stent,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61645,Perq art m-thrombect &/nfs,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61650,Evasc prlng admn rx agnt 1st,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61651,Evasc prlng admn rx agnt add,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61680,Intracranial vessel surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61682,Intracranial vessel surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61684,Intracranial vessel surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61686,Intracranial vessel surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61690,Intracranial vessel surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61692,Intracranial vessel surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61697,Brain aneurysm repr complx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61698,Brain aneurysm repr complx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61700,Brain aneurysm repr simple,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61702,Inner skull vessel surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61703,Clamp neck artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61705,Revise circulation to head,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61708,Revise circulation to head,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61710,Revise circulation to head,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61711,Fusion of skull arteries,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61720,Incise skull/brain surgery,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Humana MCR ADV,CPT,61735,Incise skull/brain surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61750,Incise skull/brain biopsy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61751,Brain biopsy w/ct/mr guide,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61760,Implant brain electrodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61770,Incise skull for treatment,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Humana MCR ADV,CPT,61790,Treat trigeminal nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,61791,Treat trigeminal tract,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,61850,Implant neuroelectrodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61860,Implant neuroelectrodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61863,Implant neuroelectrode,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61864,Implant neuroelectrde addl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61867,Implant neuroelectrode,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61868,Implant neuroelectrde addl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,61880,Revise/remove neuroelectrode,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","4,314.00",,,,,,
Humana MCR ADV,CPT,61885,Insrt/redo neurostim 1 array,APC 5464,RVU Per Case,"$20,957.35 ",OP,"4,140.35","20,957.35",,,,,,
Humana MCR ADV,CPT,61886,Implant neurostim arrays,APC 5465,RVU Per Case,"$30,131.14 ",OP,"4,314.00","30,131.14",,,,,,
Humana MCR ADV,CPT,61888,Revise/remove neuroreceiver,APC 5463,RVU Per Case,"$11,498.23 ",OP,"4,314.00","11,498.23",,,,,,
Humana MCR ADV,CPT,62000,Treat skull fracture,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,62005,Treat skull fracture,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,62010,Treatment of head injury,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,62100,Repair brain fluid leakage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,62115,Reduction of skull defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,62117,Reduction of skull defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,62120,Repair skull cavity lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,62121,Incise skull repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,62140,Repair of skull defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,62141,Repair of skull defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,62142,Remove skull plate/flap,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,62143,Replace skull plate/flap,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,62145,Repair of skull & brain,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,62146,Repair of skull with graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,62147,Repair of skull with graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,62148,Retr bone flap to fix skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,62161,Dissect brain w/scope,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,62162,Remove colloid cyst w/scope,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,62164,Remove brain tumor w/scope,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,62165,Remove pituit tumor w/scope,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,62180,Establish brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,62190,Establish brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,62192,Establish brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,62194,Replace/irrigate catheter,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,62200,Establish brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,62201,Brain cavity shunt w/scope,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,62220,Establish brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,62223,Establish brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,62225,Replace/irrigate catheter,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Humana MCR ADV,CPT,62230,Replace/revise brain shunt,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Humana MCR ADV,CPT,62252,Csf shunt reprogram,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,"4,314.00",,,,,,
Humana MCR ADV,CPT,62256,Remove brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,62258,Replace brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,62263,Epidural lysis mult sessions,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Humana MCR ADV,CPT,62264,Epidural lysis on single day,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Humana MCR ADV,CPT,62267,Interdiscal perq aspir dx,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,62268,Drain spinal cord cyst,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Humana MCR ADV,CPT,62269,Needle biopsy spinal cord,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,62270,Dx lmbr spi pnxr,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,62272,Ther spi pnxr drg csf,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,62273,Inject epidural patch,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,62280,Treat spinal cord lesion,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Humana MCR ADV,CPT,62281,Treat spinal cord lesion,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Humana MCR ADV,CPT,62282,Treat spinal canal lesion,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Humana MCR ADV,CPT,62287,Percutaneous diskectomy,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,62292,Njx chemonucleolysis lmbr,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,62294,Injection into spinal artery,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Humana MCR ADV,CPT,62302,Myelography lumbar injection,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"4,314.00",,,,,,
Humana MCR ADV,CPT,62303,Myelography lumbar injection,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"4,314.00",,,,,,
Humana MCR ADV,CPT,62304,Myelography lumbar injection,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"4,314.00",,,,,,
Humana MCR ADV,CPT,62305,Myelography lumbar injection,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"4,314.00",,,,,,
Humana MCR ADV,CPT,62320,Njx interlaminar crv/thrc,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,62321,Njx interlaminar crv/thrc,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,62322,Njx interlaminar lmbr/sac,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,62323,Njx interlaminar lmbr/sac,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,62324,Njx interlaminar crv/thrc,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Humana MCR ADV,CPT,62325,Njx interlaminar crv/thrc,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Humana MCR ADV,CPT,62326,Njx interlaminar lmbr/sac,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Humana MCR ADV,CPT,62327,Njx interlaminar lmbr/sac,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Humana MCR ADV,CPT,62328,Dx lmbr spi pnxr w/fluor/ct,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,62329,Ther spi pnxr csf fluor/ct,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,62350,Implant spinal canal cath,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Humana MCR ADV,CPT,62351,Implant spinal canal cath,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,62355,Remove spinal canal catheter,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,62360,Insert spine infusion device,APC 5471,RVU Per Case,"$17,429.07 ",OP,"4,314.00","17,429.07",,,,,,
Humana MCR ADV,CPT,62361,Implant spine infusion pump,APC 5471,RVU Per Case,"$17,429.07 ",OP,"4,314.00","17,429.07",,,,,,
Humana MCR ADV,CPT,62362,Implant spine infusion pump,APC 5471,RVU Per Case,"$17,429.07 ",OP,"4,140.35","17,429.07",,,,,,
Humana MCR ADV,CPT,62365,Remove spine infusion device,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Humana MCR ADV,CPT,62367,Analyze spine infus pump,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,"4,314.00",,,,,,
Humana MCR ADV,CPT,62368,Analyze sp inf pump w/reprog,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,"4,314.00",,,,,,
Humana MCR ADV,CPT,62369,Anal sp inf pmp w/reprg&fill,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,"4,314.00",,,,,,
Humana MCR ADV,CPT,62370,Anl sp inf pmp w/mdreprg&fil,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,"4,314.00",,,,,,
Humana MCR ADV,CPT,62380,Ndsc dcmprn 1 ntrspc lumbar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,63001,Remove spine lamina 1/2 crvl,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,63003,Remove spine lamina 1/2 thrc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,63005,Remove spine lamina 1/2 lmbr,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,63011,Remove spine lamina 1/2 scrl,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,63012,Remove lamina/facets lumbar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,63015,Remove spine lamina >2 crvcl,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,63016,Remove spine lamina >2 thrc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,63017,Remove spine lamina >2 lmbr,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,63020,Neck spine disk surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,63030,Low back disk surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,63040,Laminotomy single cervical,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,63042,Laminotomy single lumbar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,63045,Remove spine lamina 1 crvl,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,63046,Remove spine lamina 1 thrc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,63047,Remove spine lamina 1 lmbr,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,63050,Cervical laminoplsty 2/> seg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63051,C-laminoplasty w/graft/plate,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63055,Decompress spinal cord thrc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,63056,Decompress spinal cord lmbr,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,63064,Decompress spinal cord thrc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,63075,Neck spine disk surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,63077,Spine disk surgery thorax,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63078,Spine disk surgery thorax,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63081,Remove vert body dcmprn crvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63082,Remove vertebral body add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63085,Remove vert body dcmprn thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63086,Remove vertebral body add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63087,Remov vertbr dcmprn thrclmbr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63088,Remove vertebral body add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63090,Remove vert body dcmprn lmbr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63091,Remove vertebral body add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63101,Remove vert body dcmprn thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63102,Remove vert body dcmprn lmbr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63103,Remove vertebral body add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63170,Incise spinal cord tract(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63172,Drainage of spinal cyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63173,Drainage of spinal cyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63185,Incise spine nrv half segmnt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63190,Incise spine nrv >2 segmnts,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63191,Incise spine accessory nerve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63194,Incise spine & cord cervical,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63195,Incise spine & cord thoracic,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63196,Incise spine&cord 2 trx crvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63197,Incise spine&cord 2 trx thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63198,Incise spin&cord 2 stgs crvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63199,Incise spin&cord 2 stgs thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63200,Release spinal cord lumbar,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63250,Revise spinal cord vsls crvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63251,Revise spinal cord vsls thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63252,Revise spine cord vsl thrlmb,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63265,Excise intraspinl lesion crv,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,63266,Excise intrspinl lesion thrc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,63267,Excise intrspinl lesion lmbr,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,63268,Excise intrspinl lesion scrl,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,63270,Excise intrspinl lesion crvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63271,Excise intrspinl lesion thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63272,Excise intrspinl lesion lmbr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63273,Excise intrspinl lesion scrl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63275,Bx/exc xdrl spine lesn crvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63276,Bx/exc xdrl spine lesn thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63277,Bx/exc xdrl spine lesn lmbr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63278,Bx/exc xdrl spine lesn scrl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63280,Bx/exc idrl spine lesn crvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63281,Bx/exc idrl spine lesn thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63282,Bx/exc idrl spine lesn lmbr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63283,Bx/exc idrl spine lesn scrl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63285,Bx/exc idrl imed lesn cervl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63286,Bx/exc idrl imed lesn thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63287,Bx/exc idrl imed lesn thrlmb,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63290,Bx/exc xdrl/idrl lsn any lvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63295,Repair laminectomy defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63300,Remove vert xdrl body crvcl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63301,Remove vert xdrl body thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63302,Remove vert xdrl body thrlmb,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63303,Remov vert xdrl bdy lmbr/sac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63304,Remove vert idrl body crvcl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63305,Remove vert idrl body thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63306,Remov vert idrl bdy thrclmbr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63307,Remov vert idrl bdy lmbr/sac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63308,Remove vertebral body add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63600,Remove spinal cord lesion,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,63610,Stimulation of spinal cord,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,63650,Implant neuroelectrodes,APC 5462,RVU Per Case,"$6,304.35 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,63655,Implant neuroelectrodes,APC 5464,RVU Per Case,"$20,957.35 ",OP,"4,140.35","20,957.35",,,,,,
Humana MCR ADV,CPT,63661,Remove spine eltrd perq aray,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,63662,Remove spine eltrd plate,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","4,314.00",,,,,,
Humana MCR ADV,CPT,63663,Revise spine eltrd perq aray,APC 5462,RVU Per Case,"$6,304.35 ",OP,"4,314.00","6,304.35",,,,,,
Humana MCR ADV,CPT,63664,Revise spine eltrd plate,APC 5463,RVU Per Case,"$11,498.23 ",OP,"4,314.00","11,498.23",,,,,,
Humana MCR ADV,CPT,63685,Insrt/redo spine n generator,APC 5465,RVU Per Case,"$30,131.14 ",OP,"4,140.35","30,131.14",,,,,,
Humana MCR ADV,CPT,63688,Revise/remove neuroreceiver,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","4,314.00",,,,,,
Humana MCR ADV,CPT,63700,Repair of spinal herniation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63702,Repair of spinal herniation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63704,Repair of spinal herniation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63706,Repair of spinal herniation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63707,Repair spinal fluid leakage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63709,Repair spinal fluid leakage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63710,Graft repair of spine defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63740,Install spinal shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,63741,Install spinal shunt,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Humana MCR ADV,CPT,63744,Revision of spinal shunt,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Humana MCR ADV,CPT,63746,Removal of spinal shunt,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,64400,Njx aa&/strd trigeminal nrv,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Humana MCR ADV,CPT,64405,Njx aa&/strd gr ocpl nrv,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Humana MCR ADV,CPT,64408,Njx aa&/strd vagus nrv,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Humana MCR ADV,CPT,64415,Njx aa&/strd brach plexus,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Humana MCR ADV,CPT,64416,Njx aa&/strd brach plex nfs,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Humana MCR ADV,CPT,64417,Njx aa&/strd axillary nrv,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Humana MCR ADV,CPT,64418,Njx aa&/strd sprscap nrv,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,64420,Njx aa&/strd ntrcost nrv 1,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,64421,Njx aa&/strd ntrcost nrv ea,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Humana MCR ADV,CPT,64425,Njx aa&/strd ii ih nerves,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,64430,Njx aa&/strd pudendal nerve,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Humana MCR ADV,CPT,64435,Njx aa&/strd paracrv nrv,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,64445,Njx aa&/strd sciatic nerve,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,64446,Njx aa&/strd sciatic nrv nfs,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Humana MCR ADV,CPT,64447,Njx aa&/strd femoral nerve,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,64448,Njx aa&/strd fem nerve nfs,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Humana MCR ADV,CPT,64449,Njx aa&/strd lmbr plex nfs,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Humana MCR ADV,CPT,64450,Njx aa&/strd other pn/branch,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,64451,Njx aa&/strd nrv nrvtg si jt,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,64454,Njx aa&/strd gnclr nrv brnch,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,64455,Njx aa&/strd pltr com dg nrv,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Humana MCR ADV,CPT,64461,Pvb thoracic single inj site,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,64463,Pvb thoracic cont infusion,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,64479,Njx aa&/strd tfrm epi c/t 1,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Humana MCR ADV,CPT,64483,Njx aa&/strd tfrm epi l/s 1,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Humana MCR ADV,CPT,64490,Inj paravert f jnt c/t 1 lev,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Humana MCR ADV,CPT,64493,Inj paravert f jnt l/s 1 lev,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Humana MCR ADV,CPT,64505,N block spenopalatine gangl,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Humana MCR ADV,CPT,64510,N block stellate ganglion,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Humana MCR ADV,CPT,64517,N block inj hypogas plxs,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Humana MCR ADV,CPT,64520,N block lumbar/thoracic,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Humana MCR ADV,CPT,64530,N block inj celiac pelus,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Humana MCR ADV,CPT,64553,Implant neuroelectrodes,APC 5463,RVU Per Case,"$11,498.23 ",OP,"4,314.00","11,498.23",,,,,,
Humana MCR ADV,CPT,64555,Implant neuroelectrodes,APC 5462,RVU Per Case,"$6,304.35 ",OP,"4,314.00","6,304.35",,,,,,
Humana MCR ADV,CPT,64561,Implant neuroelectrodes,APC 5462,RVU Per Case,"$6,304.35 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,64566,Neuroeltrd stim post tibial,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Humana MCR ADV,CPT,64568,Inc for vagus n elect impl,APC 5465,RVU Per Case,"$30,131.14 ",OP,"4,140.35","30,131.14",,,,,,
Humana MCR ADV,CPT,64569,Revise/repl vagus n eltrd,APC 5463,RVU Per Case,"$11,498.23 ",OP,"4,314.00","11,498.23",,,,,,
Humana MCR ADV,CPT,64570,Remove vagus n eltrd,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Humana MCR ADV,CPT,64575,Implant neuroelectrodes,APC 5463,RVU Per Case,"$11,498.23 ",OP,"4,314.00","11,498.23",,,,,,
Humana MCR ADV,CPT,64580,Implant neuroelectrodes,APC 5464,RVU Per Case,"$20,957.35 ",OP,"4,314.00","20,957.35",,,,,,
Humana MCR ADV,CPT,64581,Implant neuroelectrodes,APC 5462,RVU Per Case,"$6,304.35 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,64585,Revise/remove neuroelectrode,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","4,314.00",,,,,,
Humana MCR ADV,CPT,64590,Insrt/redo pn/gastr stimul,APC 5464,RVU Per Case,"$20,957.35 ",OP,"4,140.35","20,957.35",,,,,,
Humana MCR ADV,CPT,64595,Revise/rmv pn/gastr stimul,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","4,314.00",,,,,,
Humana MCR ADV,CPT,64600,Injection treatment of nerve,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Humana MCR ADV,CPT,64605,Injection treatment of nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,64610,Injection treatment of nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,64611,Chemodenerv saliv glands,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Humana MCR ADV,CPT,64612,Destroy nerve face muscle,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Humana MCR ADV,CPT,64615,Chemodenerv musc migraine,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Humana MCR ADV,CPT,64616,Chemodenerv musc neck dyston,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Humana MCR ADV,CPT,64617,Chemodener muscle larynx emg,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Humana MCR ADV,CPT,64620,Injection treatment of nerve,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Humana MCR ADV,CPT,64624,Dstrj nulyt agt gnclr nrv,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,64625,Rf abltj nrv nrvtg si jt,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,64630,Injection treatment of nerve,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Humana MCR ADV,CPT,64632,N block inj common digit,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Humana MCR ADV,CPT,64633,Destroy cerv/thor facet jnt,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,64635,Destroy lumb/sac facet jnt,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,64640,Injection treatment of nerve,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Humana MCR ADV,CPT,64642,Chemodenerv 1 extremity 1-4,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,64644,Chemodenerv 1 extrem 5/> mus,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,64646,Chemodenerv trunk musc 1-5,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,64647,Chemodenerv trunk musc 6/>,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Humana MCR ADV,CPT,64650,Chemodenerv eccrine glands,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Humana MCR ADV,CPT,64653,Chemodenerv eccrine glands,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Humana MCR ADV,CPT,64680,Injection treatment of nerve,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Humana MCR ADV,CPT,64681,Injection treatment of nerve,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Humana MCR ADV,CPT,64702,Revise finger/toe nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,64704,Revise hand/foot nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,64708,Revise arm/leg nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,64712,Revision of sciatic nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,64713,Revision of arm nerve(s),APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,64714,Revise low back nerve(s),APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,64716,Revision of cranial nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,64718,Revise ulnar nerve at elbow,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,64719,Revise ulnar nerve at wrist,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,64721,Carpal tunnel surgery,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,64722,Relieve pressure on nerve(s),APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,64726,Release foot/toe nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,64732,Incision of brow nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,64734,Incision of cheek nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,64736,Incision of chin nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,64738,Incision of jaw nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,64740,Incision of tongue nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,64742,Incision of facial nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,64744,Incise nerve back of head,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,64746,Incise diaphragm nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,64755,Incision of stomach nerves,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,64760,Incision of vagus nerve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,64763,Incise hip/thigh nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,64766,Incise hip/thigh nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,64771,Sever cranial nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,64772,Incision of spinal nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,64774,Remove skin nerve lesion,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,64776,Remove digit nerve lesion,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,64782,Remove limb nerve lesion,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,64784,Remove nerve lesion,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,64786,Remove sciatic nerve lesion,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Humana MCR ADV,CPT,64788,Remove skin nerve lesion,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,64790,Removal of nerve lesion,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,64792,Removal of nerve lesion,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Humana MCR ADV,CPT,64795,Biopsy of nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,64802,Sympathectomy cervical,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,64804,Remove sympathetic nerves,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,64809,Remove sympathetic nerves,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,64818,Remove sympathetic nerves,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,64820,Sympathectomy digital artery,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,64821,Remove sympathetic nerves,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,64822,Remove sympathetic nerves,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,64823,Sympathectomy supfc palmar,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Humana MCR ADV,CPT,64831,Repair of digit nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,64834,Repair of hand or foot nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Humana MCR ADV,CPT,64835,Repair of hand or foot nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Humana MCR ADV,CPT,64836,Repair of hand or foot nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Humana MCR ADV,CPT,64840,Repair of leg nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Humana MCR ADV,CPT,64856,Repair/transpose nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Humana MCR ADV,CPT,64857,Repair arm/leg nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Humana MCR ADV,CPT,64858,Repair sciatic nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,64861,Repair of arm nerves,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Humana MCR ADV,CPT,64862,Repair of low back nerves,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Humana MCR ADV,CPT,64864,Repair of facial nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Humana MCR ADV,CPT,64865,Repair of facial nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Humana MCR ADV,CPT,64866,Fusion of facial/other nerve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,64868,Fusion of facial/other nerve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,64885,Nerve graft head/neck </4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Humana MCR ADV,CPT,64886,Nerve graft head/neck >4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Humana MCR ADV,CPT,64890,Nerve graft hand/foot </4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Humana MCR ADV,CPT,64891,Nerve graft hand/foot >4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Humana MCR ADV,CPT,64892,Nerve graft arm/leg <4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Humana MCR ADV,CPT,64893,Nerve graft arm/leg >4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Humana MCR ADV,CPT,64895,Nerve graft hand/foot </4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Humana MCR ADV,CPT,64896,Nerve graft hand/foot >4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Humana MCR ADV,CPT,64897,Nerve graft arm/leg </4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Humana MCR ADV,CPT,64898,Nerve graft arm/leg >4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Humana MCR ADV,CPT,64905,Nerve pedicle transfer,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Humana MCR ADV,CPT,64907,Nerve pedicle transfer,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Humana MCR ADV,CPT,64910,Nerve repair w/allograft,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Humana MCR ADV,CPT,64911,Neurorraphy w/vein autograft,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Humana MCR ADV,CPT,64912,Nrv rpr w/nrv algrft 1st,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Humana MCR ADV,CPT,64999,Nervous system surgery,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Humana MCR ADV,CPT,65091,Revise eye,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,65093,Revise eye with implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,65101,Removal of eye,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,65103,Remove eye/insert implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,65105,Remove eye/attach implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,65110,Removal of eye,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,65112,Remove eye/revise socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,65114,Remove eye/revise socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,65125,Revise ocular implant,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,65130,Insert ocular implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,65135,Insert ocular implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,65140,Attach ocular implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,65150,Revise ocular implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,65155,Reinsert ocular implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,65175,Removal of ocular implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,65205,Remove foreign body from eye,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Humana MCR ADV,CPT,65210,Remove foreign body from eye,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Humana MCR ADV,CPT,65220,Remove foreign body from eye,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Humana MCR ADV,CPT,65222,Remove foreign body from eye,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Humana MCR ADV,CPT,65235,Remove foreign body from eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,65260,Remove foreign body from eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,65265,Remove foreign body from eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,65270,Repair of eye wound,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,65272,Repair of eye wound,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,65273,Repair of eye wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,65275,Repair of eye wound,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,65280,Repair of eye wound,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Humana MCR ADV,CPT,65285,Repair of eye wound,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Humana MCR ADV,CPT,65286,Repair of eye wound,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,65290,Repair of eye socket wound,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,65400,Removal of eye lesion,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Humana MCR ADV,CPT,65410,Biopsy of cornea,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,65420,Removal of eye lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,65426,Removal of eye lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,65430,Corneal smear,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Humana MCR ADV,CPT,65435,Curette/treat cornea,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Humana MCR ADV,CPT,65436,Curette/treat cornea,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,65450,Treatment of corneal lesion,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Humana MCR ADV,CPT,65600,Revision of cornea,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,65710,Corneal transplant,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Humana MCR ADV,CPT,65730,Corneal transplant,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","9,201.00",,,,,,
Humana MCR ADV,CPT,65750,Corneal transplant,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Humana MCR ADV,CPT,65755,Corneal transplant,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Humana MCR ADV,CPT,65756,Corneal trnspl endothelial,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","9,201.00",,,,,,
Humana MCR ADV,CPT,65770,Revise cornea with implant,APC 5493,RVU Per Case,"$7,506.93 ",OP,"4,314.00","7,506.93",,,,,,
Humana MCR ADV,CPT,65772,Correction of astigmatism,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Humana MCR ADV,CPT,65775,Correction of astigmatism,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,65778,Cover eye w/membrane,APC 5502,RVU Per Case,$828.42 ,OP,828.42,"4,314.00",,,,,,
Humana MCR ADV,CPT,65779,Cover eye w/membrane suture,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,65780,Ocular reconst transplant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,65781,Ocular reconst transplant,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Humana MCR ADV,CPT,65782,Ocular reconst transplant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,65785,Impltj ntrstrml crnl rng seg,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Humana MCR ADV,CPT,65800,Drainage of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,65810,Drainage of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,65815,Drainage of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,65820,Relieve inner eye pressure,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Humana MCR ADV,CPT,65850,Incision of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,65855,Trabeculoplasty laser surg,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Humana MCR ADV,CPT,65860,Incise inner eye adhesions,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Humana MCR ADV,CPT,65865,Incise inner eye adhesions,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,65870,Incise inner eye adhesions,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,65875,Incise inner eye adhesions,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,65880,Incise inner eye adhesions,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Humana MCR ADV,CPT,65900,Remove eye lesion,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,65920,Remove implant of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,65930,Remove blood clot from eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,66020,Injection treatment of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,66030,Injection treatment of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,66130,Remove eye lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,66150,Glaucoma surgery,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Humana MCR ADV,CPT,66155,Glaucoma surgery,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Humana MCR ADV,CPT,66160,Glaucoma surgery,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,66170,Glaucoma surgery,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,66172,Incision of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,66174,Translum dil eye canal,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Humana MCR ADV,CPT,66175,Trnslum dil eye canal w/stnt,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Humana MCR ADV,CPT,66179,Aqueous shunt eye w/o graft,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Humana MCR ADV,CPT,66180,Aqueous shunt eye w/graft,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","9,201.00",,,,,,
Humana MCR ADV,CPT,66183,Insert ant drainage device,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Humana MCR ADV,CPT,66184,Revision of aqueous shunt,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,66185,Revise aqueous shunt eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,66225,Repair/graft eye lesion,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Humana MCR ADV,CPT,66250,Follow-up surgery of eye,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,66500,Incision of iris,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,66505,Incision of iris,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,66600,Remove iris and lesion,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Humana MCR ADV,CPT,66605,Removal of iris,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,66625,Removal of iris,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,66630,Removal of iris,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,66635,Removal of iris,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,66680,Repair iris & ciliary body,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,66682,Repair iris & ciliary body,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,66700,Destruction ciliary body,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,66710,Ciliary transsleral therapy,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,66711,Ecp ciliary body destruction,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,66720,Destruction ciliary body,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,66740,Destruction ciliary body,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,66761,Revision of iris,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Humana MCR ADV,CPT,66762,Revision of iris,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Humana MCR ADV,CPT,66770,Removal of inner eye lesion,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Humana MCR ADV,CPT,66820,Incision secondary cataract,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,66821,After cataract laser surgery,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Humana MCR ADV,CPT,66825,Reposition intraocular lens,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,66830,Removal of lens lesion,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,66840,Removal of lens material,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,66850,Removal of lens material,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,66852,Removal of lens material,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Humana MCR ADV,CPT,66920,Extraction of lens,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,66930,Extraction of lens,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Humana MCR ADV,CPT,66940,Extraction of lens,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,66982,Xcapsl ctrc rmvl cplx wo ecp,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,66983,Cataract surg w/iol 1 stage,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,66984,Xcapsl ctrc rmvl w/o ecp,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,66985,Insert lens prosthesis,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,66986,Exchange lens prosthesis,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,66987,Xcapsl ctrc rmvl cplx w/ecp,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Humana MCR ADV,CPT,66988,Xcapsl ctrc rmvl w/ecp,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Humana MCR ADV,CPT,66999,Eye surgery procedure,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,67005,Partial removal of eye fluid,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,67010,Partial removal of eye fluid,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,67015,Release of eye fluid,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,67025,Replace eye fluid,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,67027,Implant eye drug system,APC 5494,RVU Per Case,"$15,359.39 ",OP,"4,314.00","15,359.39",,,,,,
Humana MCR ADV,CPT,67028,Injection eye drug,APC 5694,RVU Per Unit,$318.00 ,OP,318,"4,314.00",,,,,,
Humana MCR ADV,CPT,67030,Incise inner eye strands,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,67031,Laser surgery eye strands,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Humana MCR ADV,CPT,67036,Removal of inner eye fluid,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Humana MCR ADV,CPT,67039,Laser treatment of retina,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Humana MCR ADV,CPT,67040,Laser treatment of retina,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Humana MCR ADV,CPT,67041,Vit for macular pucker,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Humana MCR ADV,CPT,67042,Vit for macular hole,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Humana MCR ADV,CPT,67043,Vit for membrane dissect,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Humana MCR ADV,CPT,67101,Repair detached retina crtx,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,67105,Repair detached retina pc,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Humana MCR ADV,CPT,67107,Repair detached retina,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Humana MCR ADV,CPT,67108,Repair detached retina,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","9,201.00",,,,,,
Humana MCR ADV,CPT,67110,Repair detached retina,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,67113,Repair retinal detach cplx,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","9,201.00",,,,,,
Humana MCR ADV,CPT,67115,Release encircling material,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Humana MCR ADV,CPT,67120,Remove eye implant material,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,67121,Remove eye implant material,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,67141,Treatment of retina,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Humana MCR ADV,CPT,67145,Treatment of retina,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Humana MCR ADV,CPT,67208,Treatment of retinal lesion,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Humana MCR ADV,CPT,67210,Treatment of retinal lesion,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Humana MCR ADV,CPT,67218,Treatment of retinal lesion,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,67220,Treatment of choroid lesion,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Humana MCR ADV,CPT,67221,Ocular photodynamic ther,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Humana MCR ADV,CPT,67227,Dstrj extensive retinopathy,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,67228,Treatment x10sv retinopathy,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Humana MCR ADV,CPT,67229,Tr retinal les preterm inf,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Humana MCR ADV,CPT,67250,Reinforce eye wall,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,67255,Reinforce/graft eye wall,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,67299,Eye surgery procedure,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,67311,Revise eye muscle,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,67312,Revise two eye muscles,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,67314,Revise eye muscle,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,67316,Revise two eye muscles,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,67318,Revise eye muscle(s),APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,67343,Release eye tissue,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,67345,Destroy nerve of eye muscle,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Humana MCR ADV,CPT,67346,Biopsy eye muscle,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,67399,Unlisted px extraocular musc,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Humana MCR ADV,CPT,67400,Explore/biopsy eye socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,67405,Explore/drain eye socket,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,67412,Explore/treat eye socket,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,67413,Explore/treat eye socket,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,67414,Explr/decompress eye socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,67415,Aspiration orbital contents,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,67420,Explore/treat eye socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,67430,Explore/treat eye socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,67440,Explore/drain eye socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,67445,Explr/decompress eye socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,67450,Explore/biopsy eye socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,67500,Inject/treat eye socket,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Humana MCR ADV,CPT,67505,Inject/treat eye socket,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Humana MCR ADV,CPT,67515,Inject/treat eye socket,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Humana MCR ADV,CPT,67550,Insert eye socket implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,67560,Revise eye socket implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,67570,Decompress optic nerve,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,67599,Orbit surgery procedure,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Humana MCR ADV,CPT,67700,Drainage of eyelid abscess,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Humana MCR ADV,CPT,67710,Incision of eyelid,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Humana MCR ADV,CPT,67715,Incision of eyelid fold,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,67800,Remove eyelid lesion,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Humana MCR ADV,CPT,67801,Remove eyelid lesions,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Humana MCR ADV,CPT,67805,Remove eyelid lesions,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Humana MCR ADV,CPT,67808,Remove eyelid lesion(s),APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,67810,Biopsy eyelid & lid margin,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Humana MCR ADV,CPT,67820,Revise eyelashes,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Humana MCR ADV,CPT,67825,Revise eyelashes,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Humana MCR ADV,CPT,67830,Revise eyelashes,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Humana MCR ADV,CPT,67835,Revise eyelashes,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,67840,Remove eyelid lesion,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Humana MCR ADV,CPT,67850,Treat eyelid lesion,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Humana MCR ADV,CPT,67875,Closure of eyelid by suture,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Humana MCR ADV,CPT,67880,Revision of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,67882,Revision of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,67900,Repair brow defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,67901,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,67902,Repair eyelid defect,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,67903,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,67904,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,67906,Repair eyelid defect,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,67908,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,67909,Revise eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,67911,Revise eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,67912,Correction eyelid w/implant,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,67914,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,67915,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,67916,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,67917,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,67921,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,67922,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,67923,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,67924,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,67930,Repair eyelid wound,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,67935,Repair eyelid wound,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,67938,Remove eyelid foreign body,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Humana MCR ADV,CPT,67950,Revision of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,67961,Revision of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,67966,Revision of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,67971,Reconstruction of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,67973,Reconstruction of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,67974,Reconstruction of eyelid,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,67975,Reconstruction of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,67999,Revision of eyelid,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Humana MCR ADV,CPT,68020,Incise/drain eyelid lining,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Humana MCR ADV,CPT,68040,Treatment of eyelid lesions,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Humana MCR ADV,CPT,68100,Biopsy of eyelid lining,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,68110,Remove eyelid lining lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,68115,Remove eyelid lining lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,68130,Remove eyelid lining lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,68135,Remove eyelid lining lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,68200,Treat eyelid by injection,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Humana MCR ADV,CPT,68320,Revise/graft eyelid lining,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,68325,Revise/graft eyelid lining,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,68326,Revise/graft eyelid lining,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,68328,Revise/graft eyelid lining,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,68330,Revise eyelid lining,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Humana MCR ADV,CPT,68335,Revise/graft eyelid lining,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,68340,Separate eyelid adhesions,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,68360,Revise eyelid lining,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,68362,Revise eyelid lining,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,68371,Harvest eye tissue alograft,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,68399,Eyelid lining surgery,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Humana MCR ADV,CPT,68400,Incise/drain tear gland,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Humana MCR ADV,CPT,68420,Incise/drain tear sac,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,68440,Incise tear duct opening,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Humana MCR ADV,CPT,68500,Removal of tear gland,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,68505,Partial removal tear gland,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,68510,Biopsy of tear gland,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,68520,Removal of tear sac,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,68525,Biopsy of tear sac,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,68530,Clearance of tear duct,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Humana MCR ADV,CPT,68540,Remove tear gland lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,68550,Remove tear gland lesion,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,68700,Repair tear ducts,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,68705,Revise tear duct opening,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Humana MCR ADV,CPT,68720,Create tear sac drain,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,68745,Create tear duct drain,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,68750,Create tear duct drain,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Humana MCR ADV,CPT,68760,Close tear duct opening,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Humana MCR ADV,CPT,68761,Close tear duct opening,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Humana MCR ADV,CPT,68770,Close tear system fistula,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,68801,Dilate tear duct opening,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Humana MCR ADV,CPT,68810,Probe nasolacrimal duct,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Humana MCR ADV,CPT,68811,Probe nasolacrimal duct,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,68815,Probe nasolacrimal duct,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,68816,Probe nl duct w/balloon,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Humana MCR ADV,CPT,68840,Explore/irrigate tear ducts,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Humana MCR ADV,CPT,68899,Tear duct system surgery,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Humana MCR ADV,CPT,69000,Drain external ear lesion,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,69005,Drain external ear lesion,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,69020,Drain outer ear canal lesion,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Humana MCR ADV,CPT,69100,Biopsy of external ear,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Humana MCR ADV,CPT,69105,Biopsy of external ear canal,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,69110,Remove external ear partial,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,69120,Removal of external ear,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,69140,Remove ear canal lesion(s),APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,69145,Remove ear canal lesion(s),APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Humana MCR ADV,CPT,69150,Extensive ear canal surgery,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,69155,Extensive ear/neck surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,69200,Clear outer ear canal,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Humana MCR ADV,CPT,69205,Clear outer ear canal,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Humana MCR ADV,CPT,69209,Remove impacted ear wax uni,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Humana MCR ADV,CPT,69210,Remove impacted ear wax uni,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Humana MCR ADV,CPT,69220,Clean out mastoid cavity,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Humana MCR ADV,CPT,69222,Clean out mastoid cavity,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,69300,Revise external ear,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,69310,Rebuild outer ear canal,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,69320,Rebuild outer ear canal,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,69399,Outer ear surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Humana MCR ADV,CPT,69420,Incision of eardrum,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Humana MCR ADV,CPT,69421,Incision of eardrum,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,69424,Remove ventilating tube,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,69433,Create eardrum opening,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Humana MCR ADV,CPT,69436,Create eardrum opening,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,69440,Exploration of middle ear,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,69450,Eardrum revision,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,69501,Mastoidectomy,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,69502,Mastoidectomy,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,69505,Remove mastoid structures,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,69511,Extensive mastoid surgery,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,69530,Extensive mastoid surgery,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,69535,Remove part of temporal bone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,69540,Remove ear lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,69550,Remove ear lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,69552,Remove ear lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,69554,Remove ear lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,69601,Mastoid surgery revision,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,69602,Mastoid surgery revision,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,69603,Mastoid surgery revision,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,69604,Mastoid surgery revision,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,69610,Repair of eardrum,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,69620,Repair of eardrum,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,69631,Repair eardrum structures,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,69632,Rebuild eardrum structures,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,69633,Rebuild eardrum structures,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,69635,Repair eardrum structures,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,69636,Rebuild eardrum structures,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,69637,Rebuild eardrum structures,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,69641,Revise middle ear & mastoid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,69642,Revise middle ear & mastoid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,69643,Revise middle ear & mastoid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,69644,Revise middle ear & mastoid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,69645,Revise middle ear & mastoid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,69646,Revise middle ear & mastoid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,69650,Release middle ear bone,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,69660,Revise middle ear bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,69661,Revise middle ear bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,69662,Revise middle ear bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,69666,Repair middle ear structures,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,69667,Repair middle ear structures,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,69670,Remove mastoid air cells,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,69676,Remove middle ear nerve,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,69700,Close mastoid fistula,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,69705,Nps surg dilat eust tube uni,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,69706,Nps surg dilat eust tube bi,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,69711,Remove/repair hearing aid,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,69714,Implant temple bone w/stimul,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,69715,Temple bne implnt w/stimulat,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Humana MCR ADV,CPT,69717,Temple bone implant revision,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Humana MCR ADV,CPT,69718,Revise temple bone implant,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Humana MCR ADV,CPT,69720,Release facial nerve,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,69725,Release facial nerve,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,69740,Repair facial nerve,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,69745,Repair facial nerve,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,69799,Middle ear surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Humana MCR ADV,CPT,69801,Incise inner ear,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Humana MCR ADV,CPT,69805,Explore inner ear,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,69806,Explore inner ear,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,69905,Remove inner ear,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,69910,Remove inner ear & mastoid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,69915,Incise inner ear nerve,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Humana MCR ADV,CPT,69930,Implant cochlear device,APC 5166,RVU Per Case,"$35,230.37 ",OP,"4,140.35","35,230.37",,,,,,
Humana MCR ADV,CPT,69949,Inner ear surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Humana MCR ADV,CPT,69950,Incise inner ear nerve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Humana MCR ADV,CPT,69955,Release facial nerve,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,69960,Release inner ear canal,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,69970,Remove inner ear lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Humana MCR ADV,CPT,69979,Temporal bone surgery,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Humana MCR ADV,CPT,70010,Contrast x-ray of brain,APC 5572,RVU Per Case,$376.70 ,OP,376.7,899.79,,,,,,
Humana MCR ADV,CPT,70015,Contrast x-ray of brain,APC 5573,RVU Per Case,$731.85 ,OP,731.85,735.85,,,,,,
Humana MCR ADV,CPT,70030,X-ray eye for foreign body,APC 5521,RVU Per Case,$82.79 ,OP,82.79,144.88,,,,,,
Humana MCR ADV,CPT,70100,X-ray exam of jaw <4views,APC 5521,RVU Per Case,$82.79 ,OP,82.79,156.32,,,,,,
Humana MCR ADV,CPT,70110,X-ray exam of jaw 4/> views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,202.07,,,,,,
Humana MCR ADV,CPT,70120,X-ray exam of mastoids,APC 5522,RVU Per Case,$111.51 ,OP,111.51,171.58,,,,,,
Humana MCR ADV,CPT,70130,X-ray exam of mastoids,APC 5522,RVU Per Case,$111.51 ,OP,111.51,282.14,,,,,,
Humana MCR ADV,CPT,70134,X-ray exam of middle ear,APC 5524,RVU Per Case,$494.15 ,OP,244.01,494.15,,,,,,
Humana MCR ADV,CPT,70140,X-ray exam of facial bones,APC 5521,RVU Per Case,$82.79 ,OP,82.79,156.32,,,,,,
Humana MCR ADV,CPT,70150,X-ray exam of facial bones,APC 5522,RVU Per Case,$111.51 ,OP,111.51,221.14,,,,,,
Humana MCR ADV,CPT,70160,X-ray exam of nasal bones,APC 5521,RVU Per Case,$82.79 ,OP,82.79,163.95,,,,,,
Humana MCR ADV,CPT,70170,X-ray exam of tear duct,APC 5523,RVU Per Case,$235.49 ,OP,235.49,274.51,,,,,,
Humana MCR ADV,CPT,70190,X-ray exam of eye sockets,APC 5521,RVU Per Case,$82.79 ,OP,82.79,183.02,,,,,,
Humana MCR ADV,CPT,70200,X-ray exam of eye sockets,APC 5522,RVU Per Case,$111.51 ,OP,111.51,228.77,,,,,,
Humana MCR ADV,CPT,70210,X-ray exam of sinuses,APC 5521,RVU Per Case,$82.79 ,OP,82.79,156.32,,,,,,
Humana MCR ADV,CPT,70220,X-ray exam of sinuses,APC 5521,RVU Per Case,$82.79 ,OP,82.79,202.07,,,,,,
Humana MCR ADV,CPT,70240,X-ray exam pituitary saddle,APC 5521,RVU Per Case,$82.79 ,OP,82.79,148.69,,,,,,
Humana MCR ADV,CPT,70250,X-ray exam of skull,APC 5522,RVU Per Case,$111.51 ,OP,111.51,186.82,,,,,,
Humana MCR ADV,CPT,70260,X-ray exam of skull,APC 5522,RVU Per Case,$111.51 ,OP,111.51,251.64,,,,,,
Humana MCR ADV,CPT,70300,X-ray exam of teeth,APC 5521,RVU Per Case,$82.79 ,OP,76.26,82.79,,,,,,
Humana MCR ADV,CPT,70310,X-ray exam of teeth,APC 5523,RVU Per Case,$235.49 ,OP,235.49,235.49,,,,,,
Humana MCR ADV,CPT,70320,Full mouth x-ray of teeth,APC 5523,RVU Per Case,$235.49 ,OP,235.49,247.83,,,,,,
Humana MCR ADV,CPT,70328,X-ray exam of jaw joint,APC 5521,RVU Per Case,$82.79 ,OP,82.79,152.51,,,,,,
Humana MCR ADV,CPT,70330,X-ray exam of jaw joints,APC 5521,RVU Per Case,$82.79 ,OP,82.79,244.01,,,,,,
Humana MCR ADV,CPT,70332,X-ray exam of jaw joint,APC 5523,RVU Per Case,$235.49 ,OP,235.49,446.08,,,,,,
Humana MCR ADV,CPT,70336,Magnetic image jaw joint,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Humana MCR ADV,CPT,70350,X-ray head for orthodontia,APC 5521,RVU Per Case,$82.79 ,OP,82.79,106.76,,,,,,
Humana MCR ADV,CPT,70355,Panoramic x-ray of jaws,APC 5521,RVU Per Case,$82.79 ,OP,82.79,122,,,,,,
Humana MCR ADV,CPT,70360,X-ray exam of neck,APC 5521,RVU Per Case,$82.79 ,OP,82.79,137.25,,,,,,
Humana MCR ADV,CPT,70370,Throat x-ray & fluoroscopy,APC 5521,RVU Per Case,$82.79 ,OP,82.79,381.27,,,,,,
Humana MCR ADV,CPT,70371,Speech evaluation complex,APC 5523,RVU Per Case,$235.49 ,OP,235.49,510.9,,,,,,
Humana MCR ADV,CPT,70380,X-ray exam of salivary gland,APC 5521,RVU Per Case,$82.79 ,OP,82.79,190.64,,,,,,
Humana MCR ADV,CPT,70390,X-ray exam of salivary duct,APC 5523,RVU Per Case,$235.49 ,OP,235.49,235.49,,,,,,
Humana MCR ADV,CPT,70450,Ct head/brain w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Humana MCR ADV,CPT,70460,Ct head/brain w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Humana MCR ADV,CPT,70470,Ct head/brain w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Humana MCR ADV,CPT,70480,Ct orbit/ear/fossa w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Humana MCR ADV,CPT,70481,Ct orbit/ear/fossa w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Humana MCR ADV,CPT,70482,Ct orbit/ear/fossa w/o&w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Humana MCR ADV,CPT,70486,Ct maxillofacial w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Humana MCR ADV,CPT,70487,Ct maxillofacial w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Humana MCR ADV,CPT,70488,Ct maxillofacial w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Humana MCR ADV,CPT,70490,Ct soft tissue neck w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Humana MCR ADV,CPT,70491,Ct soft tissue neck w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Humana MCR ADV,CPT,70492,Ct sft tsue nck w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Humana MCR ADV,CPT,70496,Ct angiography head,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Humana MCR ADV,CPT,70498,Ct angiography neck,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Humana MCR ADV,CPT,70540,Mri orbit/face/neck w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Humana MCR ADV,CPT,70542,Mri orbit/face/neck w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Humana MCR ADV,CPT,70543,Mri orbt/fac/nck w/o &w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Humana MCR ADV,CPT,70544,Mr angiography head w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Humana MCR ADV,CPT,70545,Mr angiography head w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Humana MCR ADV,CPT,70546,Mr angiograph head w/o&w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Humana MCR ADV,CPT,70547,Mr angiography neck w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Humana MCR ADV,CPT,70548,Mr angiography neck w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Humana MCR ADV,CPT,70549,Mr angiograph neck w/o&w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Humana MCR ADV,CPT,70551,Mri brain stem w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Humana MCR ADV,CPT,70552,Mri brain stem w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Humana MCR ADV,CPT,70553,Mri brain stem w/o & w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Humana MCR ADV,CPT,70554,Fmri brain by tech,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Humana MCR ADV,CPT,70555,Fmri brain by phys/psych,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,507.00",,,,,,
Humana MCR ADV,CPT,70557,Mri brain w/o dye,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,149.44",,,,,,
Humana MCR ADV,CPT,70558,Mri brain w/dye,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,"1,609.22",,,,,,
Humana MCR ADV,CPT,70559,Mri brain w/o & w/dye,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,"1,609.22",,,,,,
Humana MCR ADV,CPT,71045,X-ray exam chest 1 view,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,152.51,,,,,,
Humana MCR ADV,CPT,71046,X-ray exam chest 2 views,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,167.76,,,,,,
Humana MCR ADV,CPT,71047,X-ray exam chest 3 views,APC 5521,RVU Per Case,$82.79 ,OP,82.79,240.2,,,,,,
Humana MCR ADV,CPT,71048,X-ray exam chest 4+ views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,240.2,,,,,,
Humana MCR ADV,CPT,71100,X-ray exam ribs uni 2 views,APC 5521,RVU Per Case,$82.79 ,OP,82.79,171.58,,,,,,
Humana MCR ADV,CPT,71101,X-ray exam unilat ribs/chest,APC 5522,RVU Per Case,$111.51 ,OP,111.51,202.07,,,,,,
Humana MCR ADV,CPT,71110,X-ray exam ribs bil 3 views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,213.51,,,,,,
Humana MCR ADV,CPT,71111,X-ray exam ribs/chest4/> vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,270.71,,,,,,
Humana MCR ADV,CPT,71120,X-ray exam breastbone 2/>vws,APC 5521,RVU Per Case,$82.79 ,OP,82.79,171.58,,,,,,
Humana MCR ADV,CPT,71130,X-ray strenoclavic jt 3/>vws,APC 5521,RVU Per Case,$82.79 ,OP,82.79,194.45,,,,,,
Humana MCR ADV,CPT,71250,Ct thorax dx c-,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Humana MCR ADV,CPT,71260,Ct thorax dx c+,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Humana MCR ADV,CPT,71270,Ct thorax dx c-/c+,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Humana MCR ADV,CPT,71271,Ct thorax lung cancer scr c-,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,927,,,,,,
Humana MCR ADV,CPT,71275,Ct angiography chest,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Humana MCR ADV,CPT,71550,Mri chest w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Humana MCR ADV,CPT,71551,Mri chest w/dye,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"1,609.22",,,,,,
Humana MCR ADV,CPT,71552,Mri chest w/o & w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Humana MCR ADV,CPT,72020,X-ray exam of spine 1 view,APC 5521,RVU Per Case,$82.79 ,OP,82.79,122,,,,,,
Humana MCR ADV,CPT,72040,X-ray exam neck spine 2-3 vw,APC 5521,RVU Per Case,$82.79 ,OP,82.79,190.64,,,,,,
Humana MCR ADV,CPT,72050,X-ray exam neck spine 4/5vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,293.57,,,,,,
Humana MCR ADV,CPT,72052,X-ray exam neck spine 6/>vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,339.33,,,,,,
Humana MCR ADV,CPT,72070,X-ray exam thorac spine 2vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,175.39,,,,,,
Humana MCR ADV,CPT,72072,X-ray exam thorac spine 3vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,202.07,,,,,,
Humana MCR ADV,CPT,72074,X-ray exam thorac spine4/>vw,APC 5522,RVU Per Case,$111.51 ,OP,111.51,236.38,,,,,,
Humana MCR ADV,CPT,72080,X-ray exam thoracolmb 2/> vw,APC 5521,RVU Per Case,$82.79 ,OP,82.79,183.02,,,,,,
Humana MCR ADV,CPT,72081,X-ray exam entire spi 1 vw,APC 5521,RVU Per Case,$82.79 ,OP,82.79,354.58,,,,,,
Humana MCR ADV,CPT,72082,X-ray exam entire spi 2/3 vw,APC 5522,RVU Per Case,$111.51 ,OP,111.51,354.58,,,,,,
Humana MCR ADV,CPT,72083,X-ray exam entire spi 4/5 vw,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,354.58,,,,,,
Humana MCR ADV,CPT,72084,X-ray exam entire spi 6/> vw,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,354.58,,,,,,
Humana MCR ADV,CPT,72100,X-ray exam l-s spine 2/3 vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,202.07,,,,,,
Humana MCR ADV,CPT,72110,X-ray exam l-2 spine 4/>vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,301.2,,,,,,
Humana MCR ADV,CPT,72114,X-ray exam l-s spine bending,APC 5522,RVU Per Case,$111.51 ,OP,111.51,362.21,,,,,,
Humana MCR ADV,CPT,72120,X-ray bend only l-s spine,APC 5522,RVU Per Case,$111.51 ,OP,111.51,251.64,,,,,,
Humana MCR ADV,CPT,72125,Ct neck spine w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Humana MCR ADV,CPT,72126,Ct neck spine w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,965.53,,,,,,
Humana MCR ADV,CPT,72127,Ct neck spine w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Humana MCR ADV,CPT,72128,Ct chest spine w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Humana MCR ADV,CPT,72129,Ct chest spine w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Humana MCR ADV,CPT,72130,Ct chest spine w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Humana MCR ADV,CPT,72131,Ct lumbar spine w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Humana MCR ADV,CPT,72132,Ct lumbar spine w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,965.53,,,,,,
Humana MCR ADV,CPT,72133,Ct lumbar spine w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Humana MCR ADV,CPT,72141,Mri neck spine w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Humana MCR ADV,CPT,72142,Mri neck spine w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Humana MCR ADV,CPT,72146,Mri chest spine w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Humana MCR ADV,CPT,72147,Mri chest spine w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Humana MCR ADV,CPT,72148,Mri lumbar spine w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Humana MCR ADV,CPT,72149,Mri lumbar spine w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Humana MCR ADV,CPT,72156,Mri neck spine w/o & w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Humana MCR ADV,CPT,72157,Mri chest spine w/o & w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Humana MCR ADV,CPT,72158,Mri lumbar spine w/o & w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Humana MCR ADV,CPT,72170,X-ray exam of pelvis,APC 5522,RVU Per Case,$111.51 ,OP,111.51,133.45,,,,,,
Humana MCR ADV,CPT,72190,X-ray exam of pelvis,APC 5522,RVU Per Case,$111.51 ,OP,111.51,205.88,,,,,,
Humana MCR ADV,CPT,72191,Ct angiograph pelv w/o&w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Humana MCR ADV,CPT,72192,Ct pelvis w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Humana MCR ADV,CPT,72193,Ct pelvis w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Humana MCR ADV,CPT,72194,Ct pelvis w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Humana MCR ADV,CPT,72195,Mri pelvis w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Humana MCR ADV,CPT,72196,Mri pelvis w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Humana MCR ADV,CPT,72197,Mri pelvis w/o & w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Humana MCR ADV,CPT,72200,X-ray exam si joints,APC 5522,RVU Per Case,$111.51 ,OP,111.51,148.69,,,,,,
Humana MCR ADV,CPT,72202,X-ray exam si joints 3/> vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,183.02,,,,,,
Humana MCR ADV,CPT,72220,X-ray exam sacrum tailbone,APC 5521,RVU Per Case,$82.79 ,OP,82.79,156.32,,,,,,
Humana MCR ADV,CPT,72240,Myelography neck spine,APC 5573,RVU Per Case,$731.85 ,OP,731.85,842.61,,,,,,
Humana MCR ADV,CPT,72255,Myelography thoracic spine,APC 5573,RVU Per Case,$731.85 ,OP,731.85,766.35,,,,,,
Humana MCR ADV,CPT,72265,Myelography l-s spine,APC 5573,RVU Per Case,$731.85 ,OP,731.85,781.61,,,,,,
Humana MCR ADV,CPT,72270,Myelogphy 2/> spine regions,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"1,216.24",,,,,,
Humana MCR ADV,CPT,72285,Discography cerv/thor spine,APC 5431,RVU Per Case,"$1,795.30 ",OP,976.05,"1,795.30",,,,,,
Humana MCR ADV,CPT,72295,X-ray of lower spine disk,APC 5431,RVU Per Case,"$1,795.30 ",OP,873.11,"1,795.30",,,,,,
Humana MCR ADV,CPT,73000,X-ray exam of collar bone,APC 5521,RVU Per Case,$82.79 ,OP,82.79,141.07,,,,,,
Humana MCR ADV,CPT,73010,X-ray exam of shoulder blade,APC 5522,RVU Per Case,$111.51 ,OP,111.51,144.88,,,,,,
Humana MCR ADV,CPT,73020,X-ray exam of shoulder,APC 5521,RVU Per Case,$82.79 ,OP,82.79,122,,,,,,
Humana MCR ADV,CPT,73030,X-ray exam of shoulder,APC 5521,RVU Per Case,$82.79 ,OP,82.79,163.95,,,,,,
Humana MCR ADV,CPT,73040,Contrast x-ray of shoulder,APC 5572,RVU Per Case,$376.70 ,OP,376.7,552.84,,,,,,
Humana MCR ADV,CPT,73050,X-ray exam of shoulders,APC 5521,RVU Per Case,$82.79 ,OP,82.79,186.82,,,,,,
Humana MCR ADV,CPT,73060,X-ray exam of humerus,APC 5521,RVU Per Case,$82.79 ,OP,82.79,152.51,,,,,,
Humana MCR ADV,CPT,73070,X-ray exam of elbow,APC 5521,RVU Per Case,$82.79 ,OP,82.79,137.25,,,,,,
Humana MCR ADV,CPT,73080,X-ray exam of elbow,APC 5521,RVU Per Case,$82.79 ,OP,82.79,179.2,,,,,,
Humana MCR ADV,CPT,73085,Contrast x-ray of elbow,APC 5572,RVU Per Case,$376.70 ,OP,376.7,503.28,,,,,,
Humana MCR ADV,CPT,73090,X-ray exam of forearm,APC 5521,RVU Per Case,$82.79 ,OP,82.79,137.25,,,,,,
Humana MCR ADV,CPT,73092,X-ray exam of arm infant,APC 5522,RVU Per Case,$111.51 ,OP,111.51,141.07,,,,,,
Humana MCR ADV,CPT,73100,X-ray exam of wrist,APC 5521,RVU Per Case,$82.79 ,OP,82.79,144.88,,,,,,
Humana MCR ADV,CPT,73110,X-ray exam of wrist,APC 5521,RVU Per Case,$82.79 ,OP,82.79,171.58,,,,,,
Humana MCR ADV,CPT,73115,Contrast x-ray of wrist,APC 5572,RVU Per Case,$376.70 ,OP,376.7,526.16,,,,,,
Humana MCR ADV,CPT,73120,X-ray exam of hand,APC 5522,RVU Per Case,$111.51 ,OP,111.51,137.25,,,,,,
Humana MCR ADV,CPT,73130,X-ray exam of hand,APC 5521,RVU Per Case,$82.79 ,OP,82.79,156.32,,,,,,
Humana MCR ADV,CPT,73140,X-ray exam of finger(s),APC 5521,RVU Per Case,$82.79 ,OP,82.79,160.13,,,,,,
Humana MCR ADV,CPT,73200,Ct upper extremity w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Humana MCR ADV,CPT,73201,Ct upper extremity w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,965.53,,,,,,
Humana MCR ADV,CPT,73202,Ct uppr extremity w/o&w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Humana MCR ADV,CPT,73206,Ct angio upr extrm w/o&w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Humana MCR ADV,CPT,73218,Mri upper extremity w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Humana MCR ADV,CPT,73219,Mri upper extremity w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Humana MCR ADV,CPT,73220,Mri uppr extremity w/o&w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Humana MCR ADV,CPT,73221,Mri joint upr extrem w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Humana MCR ADV,CPT,73222,Mri joint upr extrem w/dye,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"1,609.22",,,,,,
Humana MCR ADV,CPT,73223,Mri joint upr extr w/o&w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Humana MCR ADV,CPT,73501,X-ray exam hip uni 1 view,APC 5521,RVU Per Case,$82.79 ,OP,82.79,129.64,,,,,,
Humana MCR ADV,CPT,73502,X-ray exam hip uni 2-3 views,APC 5521,RVU Per Case,$82.79 ,OP,82.79,198.25,,,,,,
Humana MCR ADV,CPT,73503,X-ray exam hip uni 4/> views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,198.25,,,,,,
Humana MCR ADV,CPT,73521,X-ray exam hips bi 2 views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,202.07,,,,,,
Humana MCR ADV,CPT,73522,X-ray exam hips bi 3-4 views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,202.07,,,,,,
Humana MCR ADV,CPT,73523,X-ray exam hips bi 5/> views,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,202.07,,,,,,
Humana MCR ADV,CPT,73525,Contrast x-ray of hip,APC 5572,RVU Per Case,$376.70 ,OP,376.7,503.28,,,,,,
Humana MCR ADV,CPT,73551,X-ray exam of femur 1,APC 5521,RVU Per Case,$82.79 ,OP,82.79,148.69,,,,,,
Humana MCR ADV,CPT,73552,X-ray exam of femur 2/>,APC 5521,RVU Per Case,$82.79 ,OP,82.79,148.69,,,,,,
Humana MCR ADV,CPT,73560,X-ray exam of knee 1 or 2,APC 5521,RVU Per Case,$82.79 ,OP,82.79,144.88,,,,,,
Humana MCR ADV,CPT,73562,X-ray exam of knee 3,APC 5521,RVU Per Case,$82.79 ,OP,82.79,186.82,,,,,,
Humana MCR ADV,CPT,73564,X-ray exam knee 4 or more,APC 5522,RVU Per Case,$111.51 ,OP,111.51,205.88,,,,,,
Humana MCR ADV,CPT,73565,X-ray exam of knees,APC 5521,RVU Per Case,$82.79 ,OP,82.79,152.51,,,,,,
Humana MCR ADV,CPT,73580,Contrast x-ray of knee joint,APC 5572,RVU Per Case,$376.70 ,OP,376.7,625.29,,,,,,
Humana MCR ADV,CPT,73590,X-ray exam of lower leg,APC 5521,RVU Per Case,$82.79 ,OP,82.79,137.25,,,,,,
Humana MCR ADV,CPT,73592,X-ray exam of leg infant,APC 5521,RVU Per Case,$82.79 ,OP,82.79,141.07,,,,,,
Humana MCR ADV,CPT,73600,X-ray exam of ankle,APC 5521,RVU Per Case,$82.79 ,OP,82.79,137.25,,,,,,
Humana MCR ADV,CPT,73610,X-ray exam of ankle,APC 5521,RVU Per Case,$82.79 ,OP,82.79,156.32,,,,,,
Humana MCR ADV,CPT,73615,Contrast x-ray of ankle,APC 5572,RVU Per Case,$376.70 ,OP,376.7,376.7,,,,,,
Humana MCR ADV,CPT,73620,X-ray exam of foot,APC 5521,RVU Per Case,$82.79 ,OP,82.79,133.45,,,,,,
Humana MCR ADV,CPT,73630,X-ray exam of foot,APC 5521,RVU Per Case,$82.79 ,OP,82.79,156.32,,,,,,
Humana MCR ADV,CPT,73650,X-ray exam of heel,APC 5521,RVU Per Case,$82.79 ,OP,82.79,137.25,,,,,,
Humana MCR ADV,CPT,73660,X-ray exam of toe(s),APC 5521,RVU Per Case,$82.79 ,OP,82.79,141.07,,,,,,
Humana MCR ADV,CPT,73700,Ct lower extremity w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Humana MCR ADV,CPT,73701,Ct lower extremity w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Humana MCR ADV,CPT,73702,Ct lwr extremity w/o&w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Humana MCR ADV,CPT,73706,Ct angio lwr extr w/o&w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Humana MCR ADV,CPT,73718,Mri lower extremity w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Humana MCR ADV,CPT,73719,Mri lower extremity w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Humana MCR ADV,CPT,73720,Mri lwr extremity w/o&w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Humana MCR ADV,CPT,73721,Mri jnt of lwr extre w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Humana MCR ADV,CPT,73722,Mri joint of lwr extr w/dye,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"1,609.22",,,,,,
Humana MCR ADV,CPT,73723,Mri joint lwr extr w/o&w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Humana MCR ADV,CPT,74018,X-ray exam abdomen 1 view,APC 5521,RVU Per Case,$82.79 ,OP,82.79,137.25,,,,,,
Humana MCR ADV,CPT,74019,X-ray exam abdomen 2 views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,194.45,,,,,,
Humana MCR ADV,CPT,74021,X-ray exam abdomen 3+ views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,205.88,,,,,,
Humana MCR ADV,CPT,74022,X-ray exam complete abdomen,APC 5522,RVU Per Case,$111.51 ,OP,111.51,251.64,,,,,,
Humana MCR ADV,CPT,74150,Ct abdomen w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Humana MCR ADV,CPT,74160,Ct abdomen w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Humana MCR ADV,CPT,74170,Ct abdomen w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Humana MCR ADV,CPT,74174,Ct angio abd&pelv w/o&w/dye,APC 5572,RVU Per Unit,$376.70 ,OP,376.7,965.53,,,,,,
Humana MCR ADV,CPT,74175,Ct angio abdom w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Humana MCR ADV,CPT,74176,Ct abd & pelvis w/o contrast,APC 5523,RVU Per Case,$235.49 ,OP,235.49,927,,,,,,
Humana MCR ADV,CPT,74177,Ct abd & pelv w/contrast,APC 5572,RVU Per Case,$376.70 ,OP,376.7,965.53,,,,,,
Humana MCR ADV,CPT,74178,Ct abd & pelv 1/> regns,APC 5572,RVU Per Case,$376.70 ,OP,376.7,927,,,,,,
Humana MCR ADV,CPT,74181,Mri abdomen w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Humana MCR ADV,CPT,74182,Mri abdomen w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Humana MCR ADV,CPT,74183,Mri abdomen w/o & w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Humana MCR ADV,CPT,74190,X-ray exam of peritoneum,APC 5524,RVU Per Case,$494.15 ,OP,400.34,494.15,,,,,,
Humana MCR ADV,CPT,74210,X-ray xm phrnx&/crv esoph c+,APC 5571,RVU Per Case,$182.72 ,OP,182.72,182.72,,,,,,
Humana MCR ADV,CPT,74220,X-ray xm esophagus 1cntrst,APC 5571,RVU Per Case,$182.72 ,OP,182.72,446.08,,,,,,
Humana MCR ADV,CPT,74221,X-ray xm esophagus 2cntrst,APC 5571,RVU Per Case,$182.72 ,OP,182.72,446.08,,,,,,
Humana MCR ADV,CPT,74230,X-ray xm swlng funcj c+,APC 5571,RVU Per Case,$182.72 ,OP,182.72,457.52,,,,,,
Humana MCR ADV,CPT,74240,X-ray xm upr gi trc 1cntrst,APC 5571,RVU Per Case,$182.72 ,OP,182.72,552.84,,,,,,
Humana MCR ADV,CPT,74246,X-ray xm upr gi trc 2cntrst,APC 5571,RVU Per Case,$182.72 ,OP,182.72,632.91,,,,,,
Humana MCR ADV,CPT,74250,X-ray xm sm int 1cntrst std,APC 5571,RVU Per Case,$182.72 ,OP,182.72,518.52,,,,,,
Humana MCR ADV,CPT,74251,X-ray xm sm int 2cntrst std,APC 5571,RVU Per Case,$182.72 ,OP,182.72,"1,593.72",,,,,,
Humana MCR ADV,CPT,74261,Ct colonography dx,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Humana MCR ADV,CPT,74262,Ct colonography dx w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,182.72,,,,,,
Humana MCR ADV,CPT,74270,X-ray xm colon 1cntrst std,APC 5571,RVU Per Case,$182.72 ,OP,182.72,747.28,,,,,,
Humana MCR ADV,CPT,74280,X-ray xm colon 2cntrst std,APC 5571,RVU Per Case,$182.72 ,OP,182.72,"1,029.43",,,,,,
Humana MCR ADV,CPT,74283,Ther nma rdctj intus/obstrcj,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,182.72,,,,,,
Humana MCR ADV,CPT,74290,Contrast x-ray gallbladder,APC 5571,RVU Per Case,$182.72 ,OP,182.72,331.7,,,,,,
Humana MCR ADV,CPT,74400,Urography iv +-kub tomog,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,568.09,,,,,,
Humana MCR ADV,CPT,74410,Urography nfs drip&/bolus,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,598.59,,,,,,
Humana MCR ADV,CPT,74415,Urography nfs drip&/bls w/nf,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,682.47,,,,,,
Humana MCR ADV,CPT,74420,Urography rtrgr +-kub,APC 5572,RVU Per Unit,$376.70 ,OP,376.7,659.6,,,,,,
Humana MCR ADV,CPT,74425,Urography antegrade rs&i,APC 5572,RVU Per Case,$376.70 ,OP,366.02,376.7,,,,,,
Humana MCR ADV,CPT,74430,Contrast x-ray bladder,APC 5572,RVU Per Case,$376.70 ,OP,376.7,404.14,,,,,,
Humana MCR ADV,CPT,74440,X-ray male genital tract,APC 5523,RVU Per Case,$235.49 ,OP,235.49,434.65,,,,,,
Humana MCR ADV,CPT,74445,X-ray exam of penis,APC 5522,RVU Per Case,$111.51 ,OP,111.51,545.21,,,,,,
Humana MCR ADV,CPT,74450,X-ray urethra/bladder,APC 5523,RVU Per Case,$235.49 ,OP,235.49,396.52,,,,,,
Humana MCR ADV,CPT,74455,X-ray urethra/bladder,APC 5523,RVU Per Case,$235.49 ,OP,235.49,472.78,,,,,,
Humana MCR ADV,CPT,74470,X-ray exam of kidney lesion,APC 5524,RVU Per Case,$494.15 ,OP,400.34,494.15,,,,,,
Humana MCR ADV,CPT,74485,Dilation urtr/urt rs&i,APC 5373,RVU Per Case,"$1,834.80 ",OP,629.1,"1,834.80",,,,,,
Humana MCR ADV,CPT,74710,X-ray measurement of pelvis,APC 5521,RVU Per Case,$82.79 ,OP,82.79,232.58,,,,,,
Humana MCR ADV,CPT,74712,Mri fetal sngl/1st gestation,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,507.00",,,,,,
Humana MCR ADV,CPT,74740,X-ray female genital tract,APC 5523,RVU Per Case,$235.49 ,OP,235.49,404.14,,,,,,
Humana MCR ADV,CPT,74775,X-ray exam of perineum,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,457.52,,,,,,
Humana MCR ADV,CPT,75557,Cardiac mri for morph,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Humana MCR ADV,CPT,75559,Cardiac mri w/stress img,APC 5524,RVU Per Case,$494.15 ,OP,494.15,"1,507.00",,,,,,
Humana MCR ADV,CPT,75561,Cardiac mri for morph w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Humana MCR ADV,CPT,75563,Card mri w/stress img & dye,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"1,609.22",,,,,,
Humana MCR ADV,CPT,75571,Ct hrt w/o dye w/ca test,APC 5521,RVU Per Case,$82.79 ,OP,82.79,927,,,,,,
Humana MCR ADV,CPT,75572,Ct hrt w/3d image,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,927,,,,,,
Humana MCR ADV,CPT,75573,Ct hrt w/3d image congen,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,927,,,,,,
Humana MCR ADV,CPT,75574,Ct angio hrt w/3d image,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,927,,,,,,
Humana MCR ADV,CPT,75600,Contrast exam thoracic aorta,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,742.41","2,928.39",,,,,,
Humana MCR ADV,CPT,75605,Contrast exam thoracic aorta,APC 5184,RVU Per Case,"$4,881.61 ",OP,"1,506.03","4,881.61",,,,,,
Humana MCR ADV,CPT,75625,Contrast exam abdominl aorta,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,486.95","2,928.39",,,,,,
Humana MCR ADV,CPT,75630,X-ray aorta leg arteries,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","2,928.39",,,,,,
Humana MCR ADV,CPT,75635,Ct angio abdominal arteries,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Humana MCR ADV,CPT,75705,Artery x-rays spine,APC 5184,RVU Per Case,"$4,881.61 ",OP,"1,826.28","4,881.61",,,,,,
Humana MCR ADV,CPT,75710,Artery x-rays arm/leg,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,567.02","2,928.39",,,,,,
Humana MCR ADV,CPT,75716,Artery x-rays arms/legs,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,730.97","2,928.39",,,,,,
Humana MCR ADV,CPT,75726,Artery x-rays abdomen,APC 5184,RVU Per Case,"$4,881.61 ",OP,"1,547.95","4,881.61",,,,,,
Humana MCR ADV,CPT,75731,Artery x-rays adrenal gland,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,601.33","2,928.39",,,,,,
Humana MCR ADV,CPT,75733,Artery x-rays adrenals,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,795.78","2,928.39",,,,,,
Humana MCR ADV,CPT,75736,Artery x-rays pelvis,APC 5184,RVU Per Case,"$4,881.61 ",OP,"1,563.20","4,881.61",,,,,,
Humana MCR ADV,CPT,75741,Artery x-rays lung,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,506.03","2,928.39",,,,,,
Humana MCR ADV,CPT,75743,Artery x-rays lungs,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,635.64","2,928.39",,,,,,
Humana MCR ADV,CPT,75746,Artery x-rays lung,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,517.46","2,928.39",,,,,,
Humana MCR ADV,CPT,75756,Artery x-rays chest,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,601.33","2,928.39",,,,,,
Humana MCR ADV,CPT,75801,Lymph vessel x-ray arm/leg,APC 5181,RVU Per Case,$554.25 ,OP,554.25,"1,281.07",,,,,,
Humana MCR ADV,CPT,75803,Lymph vessel x-ray arms/legs,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,437.39","1,438.93",,,,,,
Humana MCR ADV,CPT,75805,Lymph vessel x-ray trunk,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,483.14","2,928.39",,,,,,
Humana MCR ADV,CPT,75807,Lymph vessel x-ray trunk,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,582.28","2,928.39",,,,,,
Humana MCR ADV,CPT,75809,Nonvascular shunt x-ray,APC 5522,RVU Per Case,$111.51 ,OP,111.51,446.08,,,,,,
Humana MCR ADV,CPT,75810,Vein x-ray spleen/liver,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,836.65","2,928.39",,,,,,
Humana MCR ADV,CPT,75820,Vein x-ray arm/leg,APC 5182,RVU Per Case,"$1,438.93 ",OP,610.03,"1,438.93",,,,,,
Humana MCR ADV,CPT,75822,Vein x-ray arms/legs,APC 5182,RVU Per Case,"$1,438.93 ",OP,747.28,"1,438.93",,,,,,
Humana MCR ADV,CPT,75825,Vein x-ray trunk,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,441.20","2,928.39",,,,,,
Humana MCR ADV,CPT,75827,Vein x-ray chest,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,433.58","1,438.93",,,,,,
Humana MCR ADV,CPT,75831,Vein x-ray kidney,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,456.44","2,928.39",,,,,,
Humana MCR ADV,CPT,75833,Vein x-ray kidneys,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,608.95","2,928.39",,,,,,
Humana MCR ADV,CPT,75840,Vein x-ray adrenal gland,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,445.01","2,928.39",,,,,,
Humana MCR ADV,CPT,75842,Vein x-ray adrenal glands,APC 5184,RVU Per Case,"$4,881.61 ",OP,"1,616.58","4,881.61",,,,,,
Humana MCR ADV,CPT,75860,Vein x-ray neck,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,479.33","2,928.39",,,,,,
Humana MCR ADV,CPT,75870,Vein x-ray skull,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,467.89","2,928.39",,,,,,
Humana MCR ADV,CPT,75872,Vein x-ray skull epidural,APC 5181,RVU Per Case,$554.25 ,OP,554.25,"1,608.95",,,,,,
Humana MCR ADV,CPT,75880,Vein x-ray eye socket,APC 5181,RVU Per Case,$554.25 ,OP,554.25,613.85,,,,,,
Humana MCR ADV,CPT,75885,Vein x-ray liver w/hemodynam,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,536.51","2,928.39",,,,,,
Humana MCR ADV,CPT,75887,Vein x-ray liver w/o hemodyn,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,547.95","2,928.39",,,,,,
Humana MCR ADV,CPT,75889,Vein x-ray liver w/hemodynam,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,456.44","2,928.39",,,,,,
Humana MCR ADV,CPT,75891,Vein x-ray liver,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,456.44","2,928.39",,,,,,
Humana MCR ADV,CPT,75893,Venous sampling by catheter,APC 5184,RVU Per Case,"$4,881.61 ",OP,"1,296.32","4,881.61",,,,,,
Humana MCR ADV,CPT,75898,Follow-up angiography,APC 5183,RVU Per Case,"$2,928.39 ",OP,655.78,"2,928.39",,,,,,
Humana MCR ADV,CPT,75956,Xray endovasc thor ao repr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,75957,Xray endovasc thor ao repr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,597.52","8,948.83",,,,,,
Humana MCR ADV,CPT,75958,Xray place prox ext thor ao,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,052.29","8,948.83",,,,,,
Humana MCR ADV,CPT,75959,Xray place dist ext thor ao,APC 5881,RVU Per Case,"$8,948.83 ",OP,926.48,"8,948.83",,,,,,
Humana MCR ADV,CPT,76000,Fluoroscopy <1 hr phys/qhp,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,495.65,,,,,,
Humana MCR ADV,CPT,76010,X-ray nose to rectum,APC 5521,RVU Per Case,$82.79 ,OP,82.79,144.88,,,,,,
Humana MCR ADV,CPT,76080,X-ray exam of fistula,APC 5524,RVU Per Case,$494.15 ,OP,331.7,494.15,,,,,,
Humana MCR ADV,CPT,76098,X-ray exam surgical specimen,APC 5524,RVU Per Case,$494.15 ,OP,102.95,494.15,,,,,,
Humana MCR ADV,CPT,76100,X-ray exam of body section,APC 5522,RVU Per Case,$111.51 ,OP,111.51,690.1,,,,,,
Humana MCR ADV,CPT,76101,Complex body section x-ray,APC 5522,RVU Per Case,$111.51 ,OP,111.51,949.36,,,,,,
Humana MCR ADV,CPT,76102,Complex body section x-rays,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,111.51,,,,,,
Humana MCR ADV,CPT,76120,Cine/video x-rays,APC 5522,RVU Per Case,$111.51 ,OP,111.51,392.7,,,,,,
Humana MCR ADV,CPT,76145,Med physic dos eval rad exps,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,129.83,,,,,,
Humana MCR ADV,CPT,76380,Cat scan follow-up study,APC 5521,RVU Per Case,$82.79 ,OP,82.79,689.66,,,,,,
Humana MCR ADV,CPT,76390,Mr spectroscopy,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,"1,507.00",,,,,,
Humana MCR ADV,CPT,76391,Mr elastography,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Humana MCR ADV,CPT,76496,Fluoroscopic procedure,APC 5521,RVU Per Case,$82.79 ,OP,82.79,82.79,,,,,,
Humana MCR ADV,CPT,76497,Ct procedure,APC 5521,RVU Per Case,$82.79 ,OP,82.79,927,,,,,,
Humana MCR ADV,CPT,76498,Mri procedure,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,"1,507.00",,,,,,
Humana MCR ADV,CPT,76499,Radiographic procedure,APC 5521,RVU Per Case,$82.79 ,OP,82.79,82.79,,,,,,
Humana MCR ADV,CPT,76506,Echo exam of head,APC 5522,RVU Per Case,$111.51 ,OP,111.51,602.41,,,,,,
Humana MCR ADV,CPT,76510,Oph us dx b-scan&quan a-scan,APC 5734,RVU Per Case,$114.56 ,OP,114.56,751.1,,,,,,
Humana MCR ADV,CPT,76511,Oph us dx quan a-scan only,APC 5522,RVU Per Case,$111.51 ,OP,111.51,495.65,,,,,,
Humana MCR ADV,CPT,76512,Oph us dx b-scan,APC 5522,RVU Per Case,$111.51 ,OP,111.51,468.96,,,,,,
Humana MCR ADV,CPT,76513,Oph us dx ant sgm us uni/bi,APC 5522,RVU Per Case,$111.51 ,OP,111.51,438.47,,,,,,
Humana MCR ADV,CPT,76514,Echo exam of eye thickness,APC 5731,RVU Per Case,$25.25 ,OP,25.25,64.82,,,,,,
Humana MCR ADV,CPT,76516,Echo exam of eye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,346.96,,,,,,
Humana MCR ADV,CPT,76519,Echo exam of eye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,369.83,,,,,,
Humana MCR ADV,CPT,76529,Echo exam of eye,APC 5521,RVU Per Case,$82.79 ,OP,82.79,354.58,,,,,,
Humana MCR ADV,CPT,76536,Us exam of head and neck,APC 5522,RVU Per Case,$111.51 ,OP,111.51,594.77,,,,,,
Humana MCR ADV,CPT,76604,Us exam chest,APC 5522,RVU Per Case,$111.51 ,OP,111.51,446.08,,,,,,
Humana MCR ADV,CPT,76641,Ultrasound breast complete,APC 5522,RVU Per Case,$111.51 ,OP,111.51,174.71,,,,,,
Humana MCR ADV,CPT,76642,Ultrasound breast limited,APC 5521,RVU Per Case,$82.79 ,OP,82.79,174.71,,,,,,
Humana MCR ADV,CPT,76700,Us exam abdom complete,APC 5522,RVU Per Case,$111.51 ,OP,111.51,739.67,,,,,,
Humana MCR ADV,CPT,76705,Echo exam of abdomen,APC 5522,RVU Per Case,$111.51 ,OP,111.51,537.6,,,,,,
Humana MCR ADV,CPT,76706,Us abdl aorta screen aaa,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,575.73,,,,,,
Humana MCR ADV,CPT,76770,Us exam abdo back wall comp,APC 5522,RVU Per Case,$111.51 ,OP,111.51,678.66,,,,,,
Humana MCR ADV,CPT,76775,Us exam abdo back wall lim,APC 5522,RVU Per Case,$111.51 ,OP,111.51,602.41,,,,,,
Humana MCR ADV,CPT,76776,Us exam k transpl w/doppler,APC 5522,RVU Per Case,$111.51 ,OP,111.51,751.1,,,,,,
Humana MCR ADV,CPT,76800,Us exam spinal canal,APC 5522,RVU Per Case,$111.51 ,OP,111.51,632.91,,,,,,
Humana MCR ADV,CPT,76801,Ob us < 14 wks single fetus,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,712.98,,,,,,
Humana MCR ADV,CPT,76805,Ob us >= 14 wks sngl fetus,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,789.23,,,,,,
Humana MCR ADV,CPT,76811,Ob us detailed sngl fetus,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,204.81",,,,,,
Humana MCR ADV,CPT,76813,Ob us nuchal meas 1 gest,APC 5522,RVU Per Case,$111.51 ,OP,111.51,667.22,,,,,,
Humana MCR ADV,CPT,76815,Ob us limited fetus(s),APC 5522,RVU Per Case,$111.51 ,OP,111.51,472.78,,,,,,
Humana MCR ADV,CPT,76816,Ob us follow-up per fetus,APC 5522,RVU Per Case,$111.51 ,OP,111.51,571.91,,,,,,
Humana MCR ADV,CPT,76817,Transvaginal us obstetric,APC 5522,RVU Per Case,$111.51 ,OP,111.51,560.47,,,,,,
Humana MCR ADV,CPT,76818,Fetal biophys profile w/nst,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,625.29,,,,,,
Humana MCR ADV,CPT,76819,Fetal biophys profil w/o nst,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,526.16,,,,,,
Humana MCR ADV,CPT,76820,Umbilical artery echo,APC 5522,RVU Per Case,$111.51 ,OP,111.51,297.39,,,,,,
Humana MCR ADV,CPT,76821,Middle cerebral artery echo,APC 5522,RVU Per Case,$111.51 ,OP,111.51,510.9,,,,,,
Humana MCR ADV,CPT,76825,Echo exam of fetal heart,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,067.55",,,,,,
Humana MCR ADV,CPT,76826,Echo exam of fetal heart,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,587.16,,,,,,
Humana MCR ADV,CPT,76827,Echo exam of fetal heart,APC 5522,RVU Per Case,$111.51 ,OP,111.51,381.27,,,,,,
Humana MCR ADV,CPT,76828,Echo exam of fetal heart,APC 5522,RVU Per Case,$111.51 ,OP,111.51,282.14,,,,,,
Humana MCR ADV,CPT,76830,Transvaginal us non-ob,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,651.97,,,,,,
Humana MCR ADV,CPT,76831,Echo exam uterus,APC 5523,RVU Per Case,$235.49 ,OP,235.49,621.47,,,,,,
Humana MCR ADV,CPT,76856,Us exam pelvic complete,APC 5522,RVU Per Case,$111.51 ,OP,111.51,655.78,,,,,,
Humana MCR ADV,CPT,76857,Us exam pelvic limited,APC 5522,RVU Per Case,$111.51 ,OP,111.51,518.52,,,,,,
Humana MCR ADV,CPT,76870,Us exam scrotum,APC 5522,RVU Per Case,$111.51 ,OP,111.51,621.47,,,,,,
Humana MCR ADV,CPT,76872,Us transrectal,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,735.85,,,,,,
Humana MCR ADV,CPT,76873,Echograp trans r pros study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,934.12,,,,,,
Humana MCR ADV,CPT,76881,Us compl joint r-t w/img,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,644.34,,,,,,
Humana MCR ADV,CPT,76882,Us lmtd jt/nonvasc xtr strux,APC 5522,RVU Per Case,$111.51 ,OP,111.51,644.34,,,,,,
Humana MCR ADV,CPT,76885,Us exam infant hips dynamic,APC 5521,RVU Per Case,$82.79 ,OP,82.79,701.54,,,,,,
Humana MCR ADV,CPT,76886,Us exam infant hips static,APC 5521,RVU Per Case,$82.79 ,OP,82.79,518.52,,,,,,
Humana MCR ADV,CPT,76936,Echo guide for artery repair,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,654.72",,,,,,
Humana MCR ADV,CPT,76975,Gi endoscopic ultrasound,APC 5523,RVU Per Case,$235.49 ,OP,235.49,529.96,,,,,,
Humana MCR ADV,CPT,76977,Us bone density measure,APC 5522,RVU Per Unit,$111.51 ,OP,80.07,111.51,,,,,,
Humana MCR ADV,CPT,76978,Us trgt dyn mbubb 1st les,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,182.72,,,,,,
Humana MCR ADV,CPT,76981,Use parenchyma,APC 5522,RVU Per Case,$111.51 ,OP,111.51,111.51,,,,,,
Humana MCR ADV,CPT,76982,Use 1st target lesion,APC 5522,RVU Per Case,$111.51 ,OP,111.51,111.51,,,,,,
Humana MCR ADV,CPT,76999,Echo examination procedure,APC 5521,RVU Per Case,$82.79 ,OP,82.79,82.79,,,,,,
Humana MCR ADV,CPT,77046,Mri breast c- unilateral,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Humana MCR ADV,CPT,77047,Mri breast c- bilateral,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Humana MCR ADV,CPT,77053,X-ray of mammary duct,APC 5523,RVU Per Case,$235.49 ,OP,235.49,411.78,,,,,,
Humana MCR ADV,CPT,77054,X-ray of mammary ducts,APC 5523,RVU Per Case,$235.49 ,OP,235.49,235.49,,,,,,
Humana MCR ADV,CPT,77063,Breast tomosynthesis bi,Physician,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Humana MCR ADV,CPT,77065,Dx mammo incl cad uni,Physician,Per Unit,$83.47 ,OP,83.47,275.87,,,,,,
Humana MCR ADV,CPT,77066,Dx mammo incl cad bi,Physician,Per Unit,$106.70 ,OP,106.7,275.87,,,,,,
Humana MCR ADV,CPT,77067,Scr mammo bi incl cad,Physician,Per Unit,$88.24 ,OP,88.24,275.87,,,,,,
Humana MCR ADV,CPT,77071,X-ray stress view,APC 5521,RVU Per Case,$82.79 ,OP,82.79,205.88,,,,,,
Humana MCR ADV,CPT,77072,X-rays for bone age,APC 5522,RVU Per Case,$111.51 ,OP,111.51,122,,,,,,
Humana MCR ADV,CPT,77073,X-rays bone length studies,APC 5522,RVU Per Case,$111.51 ,OP,111.51,198.25,,,,,,
Humana MCR ADV,CPT,77074,X-rays bone survey limited,APC 5522,RVU Per Case,$111.51 ,OP,111.51,358.39,,,,,,
Humana MCR ADV,CPT,77075,X-rays bone survey complete,APC 5522,RVU Per Case,$111.51 ,OP,111.51,514.72,,,,,,
Humana MCR ADV,CPT,77076,X-rays bone survey infant,APC 5522,RVU Per Case,$111.51 ,OP,111.51,476.6,,,,,,
Humana MCR ADV,CPT,77077,Joint survey single view,APC 5522,RVU Per Case,$111.51 ,OP,111.51,224.95,,,,,,
Humana MCR ADV,CPT,77078,Ct bone density axial,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,927,,,,,,
Humana MCR ADV,CPT,77080,Dxa bone density axial,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,537.6,,,,,,
Humana MCR ADV,CPT,77081,Dxa bone density/peripheral,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,167.76,,,,,,
Humana MCR ADV,CPT,77084,Magnetic image bone marrow,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,507.00",,,,,,
Humana MCR ADV,CPT,77085,Dxa bone density study,APC 5522,RVU Per Case,$111.51 ,OP,111.51,111.51,,,,,,
Humana MCR ADV,CPT,77086,Fracture assessment via dxa,APC 5521,RVU Per Case,$82.79 ,OP,82.79,213.51,,,,,,
Humana MCR ADV,CPT,77280,Set radiation therapy field,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,964.61,,,,,,
Humana MCR ADV,CPT,77285,Set radiation therapy field,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,"1,662.33",,,,,,
Humana MCR ADV,CPT,77290,Set radiation therapy field,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,"2,558.32",,,,,,
Humana MCR ADV,CPT,77295,3-d radiotherapy plan,APC 5613,RVU Per Unit,"$1,291.62 ",OP,"1,291.62","3,736.44",,,,,,
Humana MCR ADV,CPT,77299,Radiation therapy planning,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,129.83,,,,,,
Humana MCR ADV,CPT,77300,Radiation therapy dose plan,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,388.89,,,,,,
Humana MCR ADV,CPT,77301,Radiotherapy dose plan imrt,APC 5613,RVU Per Unit,"$1,291.62 ",OP,"1,291.62","11,205.50",,,,,,
Humana MCR ADV,CPT,77306,Telethx isodose plan simple,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,392.7,,,,,,
Humana MCR ADV,CPT,77307,Telethx isodose plan cplx,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,777.79,,,,,,
Humana MCR ADV,CPT,77316,Brachytx isodose plan simple,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,747.28,,,,,,
Humana MCR ADV,CPT,77317,Brachytx isodose intermed,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,"1,059.93",,,,,,
Humana MCR ADV,CPT,77318,Brachytx isodose complex,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,"1,456.44",,,,,,
Humana MCR ADV,CPT,77321,Special teletx port plan,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,659.6,,,,,,
Humana MCR ADV,CPT,77331,Special radiation dosimetry,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,320.27,,,,,,
Humana MCR ADV,CPT,77332,Radiation treatment aid(s),APC 5611,RVU Per Unit,$129.83 ,OP,129.83,407.96,,,,,,
Humana MCR ADV,CPT,77333,Radiation treatment aid(s),APC 5611,RVU Per Unit,$129.83 ,OP,129.83,369.83,,,,,,
Humana MCR ADV,CPT,77334,Radiation treatment aid(s),APC 5612,RVU Per Unit,$346.58 ,OP,346.58,869.3,,,,,,
Humana MCR ADV,CPT,77336,Radiation physics consult,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,343.14,,,,,,
Humana MCR ADV,CPT,77338,Design mlc device for imrt,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,346.58,,,,,,
Humana MCR ADV,CPT,77370,Radiation physics consult,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,629.1,,,,,,
Humana MCR ADV,CPT,77371,Srs multisource,APC 5627,RVU Per Case,"$7,954.01 ",OP,"6,969.60","7,954.01",,,,,,
Humana MCR ADV,CPT,77372,Srs linear based,APC 5627,RVU Per Case,"$7,954.01 ",OP,"4,148.22","7,954.01",,,,,,
Humana MCR ADV,CPT,77373,Sbrt delivery,APC 5626,RVU Per Unit,"$1,774.17 ",OP,"1,774.17","13,221.44",,,,,,
Humana MCR ADV,CPT,77385,Ntsty modul rad tx dlvr smpl,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"1,379.33",,,,,,
Humana MCR ADV,CPT,77386,Ntsty modul rad tx dlvr cplx,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"1,379.33",,,,,,
Humana MCR ADV,CPT,77399,External radiation dosimetry,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,129.83,,,,,,
Humana MCR ADV,CPT,77401,Radiation treatment delivery,APC 5621,RVU Per Unit,$123.36 ,OP,123.36,183.02,,,,,,
Humana MCR ADV,CPT,77402,Radiation treatment delivery,APC 5621,RVU Per Unit,$123.36 ,OP,123.36,123.36,,,,,,
Humana MCR ADV,CPT,77407,Radiation treatment delivery,APC 5622,RVU Per Unit,$247.32 ,OP,247.32,247.32,,,,,,
Humana MCR ADV,CPT,77412,Radiation treatment delivery,APC 5622,RVU Per Unit,$247.32 ,OP,247.32,"1,067.55",,,,,,
Humana MCR ADV,CPT,77423,Neutron beam tx complex,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"1,235.32",,,,,,
Humana MCR ADV,CPT,77424,Io rad tx delivery by x-ray,APC 5627,RVU Per Case,"$7,954.01 ",OP,"7,954.01","7,954.01",,,,,,
Humana MCR ADV,CPT,77425,Io rad tx deliver by elctrns,APC 5627,RVU Per Case,"$7,954.01 ",OP,"7,954.01","7,954.01",,,,,,
Humana MCR ADV,CPT,77470,Special radiation treatment,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"1,509.83",,,,,,
Humana MCR ADV,CPT,77520,Proton trmt simple w/o comp,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,555.2,,,,,,
Humana MCR ADV,CPT,77522,Proton trmt simple w/comp,APC 5625,RVU Per Unit,"$1,328.18 ",OP,"1,328.18","1,328.18",,,,,,
Humana MCR ADV,CPT,77523,Proton trmt intermediate,APC 5625,RVU Per Unit,"$1,328.18 ",OP,"1,328.18","1,328.18",,,,,,
Humana MCR ADV,CPT,77525,Proton treatment complex,APC 5625,RVU Per Unit,"$1,328.18 ",OP,"1,328.18","1,328.18",,,,,,
Humana MCR ADV,CPT,77600,Hyperthermia treatment,APC 5622,RVU Per Unit,$247.32 ,OP,247.32,"1,902.54",,,,,,
Humana MCR ADV,CPT,77605,Hyperthermia treatment,APC 5624,RVU Per Unit,$724.98 ,OP,724.98,"3,397.11",,,,,,
Humana MCR ADV,CPT,77610,Hyperthermia treatment,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"3,156.91",,,,,,
Humana MCR ADV,CPT,77615,Hyperthermia treatment,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"4,464.67",,,,,,
Humana MCR ADV,CPT,77620,Hyperthermia treatment,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"2,013.11",,,,,,
Humana MCR ADV,CPT,77750,Infuse radioactive materials,APC 5622,RVU Per Unit,$247.32 ,OP,247.32,"1,730.97",,,,,,
Humana MCR ADV,CPT,77761,Apply intrcav radiat simple,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"1,803.41",,,,,,
Humana MCR ADV,CPT,77762,Apply intrcav radiat interm,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"2,463.00",,,,,,
Humana MCR ADV,CPT,77763,Apply intrcav radiat compl,APC 5624,RVU Per Unit,$724.98 ,OP,724.98,724.98,,,,,,
Humana MCR ADV,CPT,77767,Hdr rdncl skn surf brachytx,APC 5622,RVU Per Unit,$247.32 ,OP,247.32,247.32,,,,,,
Humana MCR ADV,CPT,77768,Hdr rdncl skn surf brachytx,APC 5622,RVU Per Unit,$247.32 ,OP,247.32,247.32,,,,,,
Humana MCR ADV,CPT,77770,Hdr rdncl ntrstl/icav brchtx,APC 5624,RVU Per Unit,$724.98 ,OP,724.98,964.61,,,,,,
Humana MCR ADV,CPT,77771,Hdr rdncl ntrstl/icav brchtx,APC 5624,RVU Per Unit,$724.98 ,OP,724.98,"2,882.39",,,,,,
Humana MCR ADV,CPT,77772,Hdr rdncl ntrstl/icav brchtx,APC 5624,RVU Per Unit,$724.98 ,OP,724.98,"4,285.47",,,,,,
Humana MCR ADV,CPT,77778,Apply interstit radiat compl,APC 5624,RVU Per Unit,$724.98 ,OP,724.98,"4,209.21",,,,,,
Humana MCR ADV,CPT,77789,Apply surf ldr radionuclide,APC 5621,RVU Per Unit,$123.36 ,OP,123.36,533.78,,,,,,
Humana MCR ADV,CPT,77799,Radium/radioisotope therapy,APC 5621,RVU Per Unit,$123.36 ,OP,123.36,123.36,,,,,,
Humana MCR ADV,CPT,78012,Thyroid uptake measurement,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,453.71,,,,,,
Humana MCR ADV,CPT,78013,Thyroid imaging w/blood flow,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,884.55,,,,,,
Humana MCR ADV,CPT,78014,Thyroid imaging w/blood flow,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,105.68",,,,,,
Humana MCR ADV,CPT,78015,Thyroid met imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,044.69",,,,,,
Humana MCR ADV,CPT,78016,Thyroid met imaging/studies,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,578.46",,,,,,
Humana MCR ADV,CPT,78018,Thyroid met imaging body,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,616.58",,,,,,
Humana MCR ADV,CPT,78070,Parathyroid planar imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,884.55,,,,,,
Humana MCR ADV,CPT,78071,Parathyrd planar w/wo subtrj,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,884.55,,,,,,
Humana MCR ADV,CPT,78072,Parathyrd planar w/spect&ct,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,884.55,,,,,,
Humana MCR ADV,CPT,78075,Adrenal cortex & medulla img,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","2,085.54",,,,,,
Humana MCR ADV,CPT,78099,Endocrine nuclear procedure,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Humana MCR ADV,CPT,78102,Bone marrow imaging ltd,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Humana MCR ADV,CPT,78103,Bone marrow imaging mult,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,109.50",,,,,,
Humana MCR ADV,CPT,78104,Bone marrow imaging body,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,273.44",,,,,,
Humana MCR ADV,CPT,78110,Plasma volume single,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,336.39",,,,,,
Humana MCR ADV,CPT,78111,Plasma volume multiple,APC 5593,RVU Per Unit,"$1,336.39 ",OP,518.52,"1,336.39",,,,,,
Humana MCR ADV,CPT,78120,Red cell mass single,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Humana MCR ADV,CPT,78121,Red cell mass multiple,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,552.84,,,,,,
Humana MCR ADV,CPT,78122,Blood volume,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,701.54,,,,,,
Humana MCR ADV,CPT,78130,Red cell survival study,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,793.05,,,,,,
Humana MCR ADV,CPT,78140,Red cell sequestration,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,781.61,,,,,,
Humana MCR ADV,CPT,78185,Spleen imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Humana MCR ADV,CPT,78191,Platelet survival,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,067.55",,,,,,
Humana MCR ADV,CPT,78195,Lymph system imaging,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,704.28",,,,,,
Humana MCR ADV,CPT,78199,Blood/lymph nuclear exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Humana MCR ADV,CPT,78201,Liver imaging,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,884.55,,,,,,
Humana MCR ADV,CPT,78202,Liver imaging with flow,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,014.17",,,,,,
Humana MCR ADV,CPT,78215,Liver and spleen imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,941.74,,,,,,
Humana MCR ADV,CPT,78216,Liver & spleen image/flow,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,728.23,,,,,,
Humana MCR ADV,CPT,78226,Hepatobiliary system imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,570.83",,,,,,
Humana MCR ADV,CPT,78227,Hepatobil syst image w/drug,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,570.83",,,,,,
Humana MCR ADV,CPT,78230,Salivary gland imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,804.48,,,,,,
Humana MCR ADV,CPT,78231,Serial salivary imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,697.72,,,,,,
Humana MCR ADV,CPT,78232,Salivary gland function exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,712.98,,,,,,
Humana MCR ADV,CPT,78258,Esophageal motility study,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,113.30",,,,,,
Humana MCR ADV,CPT,78261,Gastric mucosa imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,242.94",,,,,,
Humana MCR ADV,CPT,78262,Gastroesophageal reflux exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,227.68",,,,,,
Humana MCR ADV,CPT,78264,Gastric emptying imag study,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,403.08",,,,,,
Humana MCR ADV,CPT,78265,Gastric emptying imag study,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,403.08",,,,,,
Humana MCR ADV,CPT,78266,Gastric emptying imag study,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,403.08",,,,,,
Humana MCR ADV,CPT,78267,Breath tst attain/anal c-14,Lab Services,Per Unit,$11.06 ,OP,11.06,11.06,,,,,,
Humana MCR ADV,CPT,78268,Breath test analysis c-14,Lab Services,Per Unit,$94.41 ,OP,94.41,301.2,,,,,,
Humana MCR ADV,CPT,78278,Acute gi blood loss imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Humana MCR ADV,CPT,78282,Gi protein loss exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,407.96,,,,,,
Humana MCR ADV,CPT,78290,Meckels divert exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,498.39",,,,,,
Humana MCR ADV,CPT,78291,Leveen/shunt patency exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,227.68",,,,,,
Humana MCR ADV,CPT,78299,Gi nuclear procedure,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Humana MCR ADV,CPT,78300,Bone imaging limited area,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,869.3,,,,,,
Humana MCR ADV,CPT,78305,Bone imaging multiple areas,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,155.24",,,,,,
Humana MCR ADV,CPT,78306,Bone imaging whole body,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,281.07",,,,,,
Humana MCR ADV,CPT,78315,Bone imaging 3 phase,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,692.84",,,,,,
Humana MCR ADV,CPT,78399,Musculoskeletal nuclear exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Humana MCR ADV,CPT,78414,Non-imaging heart function,APC 5592,RVU Per Unit,$500.81 ,OP,377.46,500.81,,,,,,
Humana MCR ADV,CPT,78428,Cardiac shunt imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,998.92,,,,,,
Humana MCR ADV,CPT,78429,Myocrd img pet 1 std w/ct,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,240.30",,,,,,
Humana MCR ADV,CPT,78430,Myocrd img pet rst/strs w/ct,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,217.42",,,,,,
Humana MCR ADV,CPT,78431,Myocrd img pet rst&strs ct,APC 1522,RVU Per Unit,"$2,302.98 ",OP,"2,150.30","7,339.44",,,,,,
Humana MCR ADV,CPT,78432,Myocrd img pet 2rtracer,APC 1523,RVU Per Unit,"$2,814.64 ",OP,"2,628.05","8,030.21",,,,,,
Humana MCR ADV,CPT,78433,Myocrd img pet 2rtracer ct,APC 1523,RVU Per Unit,"$2,814.64 ",OP,"2,628.05","8,778.55",,,,,,
Humana MCR ADV,CPT,78445,Vascular flow imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,838.79,,,,,,
Humana MCR ADV,CPT,78451,Ht muscle image spect sing,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","2,116.06",,,,,,
Humana MCR ADV,CPT,78452,Ht muscle image spect mult,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","3,343.73",,,,,,
Humana MCR ADV,CPT,78453,Ht muscle image planar sing,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,631.84",,,,,,
Humana MCR ADV,CPT,78454,Ht musc image planar mult,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,772.90",,,,,,
Humana MCR ADV,CPT,78456,Acute venous thrombus image,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,784.34",,,,,,
Humana MCR ADV,CPT,78457,Venous thrombosis imaging,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,964.61,,,,,,
Humana MCR ADV,CPT,78458,Ven thrombosis images bilat,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,078.99",,,,,,
Humana MCR ADV,CPT,78459,Myocrd img pet single study,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","7,240.30",,,,,,
Humana MCR ADV,CPT,78466,Heart infarct image,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,922.67,,,,,,
Humana MCR ADV,CPT,78468,Heart infarct image (ef),APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,166.68",,,,,,
Humana MCR ADV,CPT,78469,Heart infarct image (3d),APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,338.26",,,,,,
Humana MCR ADV,CPT,78472,Gated heart planar single,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,368.75",,,,,,
Humana MCR ADV,CPT,78473,Gated heart multiple,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,872.03",,,,,,
Humana MCR ADV,CPT,78481,Heart first pass single,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,201.00",,,,,,
Humana MCR ADV,CPT,78483,Heart first pass multiple,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,700.46",,,,,,
Humana MCR ADV,CPT,78491,Myocrd img pet 1std rst/strs,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,217.42",,,,,,
Humana MCR ADV,CPT,78492,Myocrd img pet mlt rst&strs,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,339.44",,,,,,
Humana MCR ADV,CPT,78494,Heart image spect,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,486.95",,,,,,
Humana MCR ADV,CPT,78499,Cardiovascular nuclear exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Humana MCR ADV,CPT,78579,Lung ventilation imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,155.24",,,,,,
Humana MCR ADV,CPT,78580,Lung perfusion imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,071.37",,,,,,
Humana MCR ADV,CPT,78582,Lung ventilat&perfus imaging,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,769.09",,,,,,
Humana MCR ADV,CPT,78597,Lung perfusion differential,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,906.36",,,,,,
Humana MCR ADV,CPT,78598,Lung perf&ventilat diferentl,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,906.36",,,,,,
Humana MCR ADV,CPT,78599,Respiratory nuclear exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Humana MCR ADV,CPT,78600,Brain image < 4 views,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,888.36,,,,,,
Humana MCR ADV,CPT,78601,Brain image w/flow < 4 views,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,059.93",,,,,,
Humana MCR ADV,CPT,78605,Brain image 4+ views,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,991.29,,,,,,
Humana MCR ADV,CPT,78606,Brain image w/flow 4 + views,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,540.33",,,,,,
Humana MCR ADV,CPT,78608,Brain imaging (pet),APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,209.80",,,,,,
Humana MCR ADV,CPT,78610,Brain flow imaging only,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,888.36,,,,,,
Humana MCR ADV,CPT,78630,Cerebrospinal fluid scan,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,647.08",,,,,,
Humana MCR ADV,CPT,78635,Csf ventriculography,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,475.51",,,,,,
Humana MCR ADV,CPT,78645,Csf shunt evaluation,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,502.21",,,,,,
Humana MCR ADV,CPT,78650,Csf leakage imaging,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,601.33",,,,,,
Humana MCR ADV,CPT,78660,Nuclear exam of tear flow,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,831.17,,,,,,
Humana MCR ADV,CPT,78699,Nervous system nuclear exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Humana MCR ADV,CPT,78700,Kidney imaging morphol,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,884.55,,,,,,
Humana MCR ADV,CPT,78701,Kidney imaging with flow,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,056.11",,,,,,
Humana MCR ADV,CPT,78707,K flow/funct image w/o drug,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,235.32",,,,,,
Humana MCR ADV,CPT,78708,K flow/funct image w/drug,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,014.17",,,,,,
Humana MCR ADV,CPT,78709,K flow/funct image multiple,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,795.78",,,,,,
Humana MCR ADV,CPT,78725,Kidney function study,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,518.52,,,,,,
Humana MCR ADV,CPT,78740,Ureteral reflux study,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,040.87",,,,,,
Humana MCR ADV,CPT,78761,Testicular imaging w/flow,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,052.29",,,,,,
Humana MCR ADV,CPT,78799,Genitourinary nuclear exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Humana MCR ADV,CPT,78800,Rp loclzj tum 1 area 1 d img,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,949.36,,,,,,
Humana MCR ADV,CPT,78801,Rp loclzj tum 2+area 1+d img,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,265.81",,,,,,
Humana MCR ADV,CPT,78802,Rp loclzj tum whbdy 1 d img,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,654.72",,,,,,
Humana MCR ADV,CPT,78803,Rp loclzj tum spect 1 area,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,826.28",,,,,,
Humana MCR ADV,CPT,78804,Rp loclzj tum whbdy 2+d img,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","2,870.96",,,,,,
Humana MCR ADV,CPT,78808,Iv inj ra drug dx study,APC 5591,RVU Per Case,$385.91 ,OP,385.91,385.91,,,,,,
Humana MCR ADV,CPT,78811,Pet image ltd area,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,336.39",,,,,,
Humana MCR ADV,CPT,78812,Pet image skull-thigh,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,347.07",,,,,,
Humana MCR ADV,CPT,78813,Pet image full body,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,354.67",,,,,,
Humana MCR ADV,CPT,78814,Pet image w/ct lmtd,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,404.24",,,,,,
Humana MCR ADV,CPT,78815,Pet image w/ct skull-thigh,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,446.19",,,,,,
Humana MCR ADV,CPT,78816,Pet image w/ct full body,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,461.44",,,,,,
Humana MCR ADV,CPT,78830,Rp loclzj tum spect w/ct 1,APC 5593,RVU Per Unit,"$1,336.39 ",OP,927,"2,600.43",,,,,,
Humana MCR ADV,CPT,78831,Rp loclzj tum spect 2 areas,APC 5593,RVU Per Unit,"$1,336.39 ",OP,927,"3,860.65",,,,,,
Humana MCR ADV,CPT,78832,Rp loclzj tum spect w/ct 2,APC 5594,RVU Per Unit,"$1,514.86 ",OP,927,"5,097.10",,,,,,
Humana MCR ADV,CPT,78999,Nuclear diagnostic exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Humana MCR ADV,CPT,79005,Nuclear rx oral admin,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,800.67,,,,,,
Humana MCR ADV,CPT,79101,Nuclear rx iv admin,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,896,,,,,,
Humana MCR ADV,CPT,79200,Nuclear rx intracav admin,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,911.23,,,,,,
Humana MCR ADV,CPT,79300,Nuclr rx interstit colloid,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,724.42,,,,,,
Humana MCR ADV,CPT,79403,Hematopoietic nuclear tx,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,"1,132.37",,,,,,
Humana MCR ADV,CPT,79440,Nuclear rx intra-articular,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,838.79,,,,,,
Humana MCR ADV,CPT,79445,Nuclear rx intra-arterial,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,"1,162.87",,,,,,
Humana MCR ADV,CPT,79999,Nuclear medicine therapy,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,255.45,,,,,,
Humana MCR ADV,CPT,80047,Metabolic panel ionized ca,Lab Services,Per Unit,$13.73 ,OP,13.73,41.94,,,,,,
Humana MCR ADV,CPT,80048,Metabolic panel total ca,Lab Services,Per Unit,$8.46 ,OP,8.46,132.19,,,,,,
Humana MCR ADV,CPT,80051,Electrolyte panel,Lab Services,Per Unit,$7.01 ,OP,7.01,34.31,,,,,,
Humana MCR ADV,CPT,80053,Comprehen metabolic panel,Lab Services,Per Unit,$10.56 ,OP,10.56,172.42,,,,,,
Humana MCR ADV,CPT,80055,Obstetric panel,Lab Services,Per Unit,$47.81 ,OP,47.81,301.2,,,,,,
Humana MCR ADV,CPT,80061,Lipid panel,Lab Services,Per Unit,$13.39 ,OP,13.39,68.63,,,,,,
Humana MCR ADV,CPT,80069,Renal function panel,Lab Services,Per Unit,$8.68 ,OP,8.68,38.13,,,,,,
Humana MCR ADV,CPT,80074,Acute hepatitis panel,Lab Services,Per Unit,$47.63 ,OP,47.63,213.51,,,,,,
Humana MCR ADV,CPT,80076,Hepatic function panel,Lab Services,Per Unit,$8.17 ,OP,8.17,126.44,,,,,,
Humana MCR ADV,CPT,80081,Obstetric panel,Lab Services,Per Unit,$74.86 ,OP,74.86,74.86,,,,,,
Humana MCR ADV,CPT,80143,Drug assay acetaminophen,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,
Humana MCR ADV,CPT,80145,Drug assay adalimumab,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,
Humana MCR ADV,CPT,80150,Assay of amikacin,Lab Services,Per Unit,$15.08 ,OP,15.08,49.56,,,,,,
Humana MCR ADV,CPT,80151,Drug assay amiodarone,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,
Humana MCR ADV,CPT,80155,Drug assay caffeine,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,
Humana MCR ADV,CPT,80156,Assay carbamazepine total,Lab Services,Per Unit,$14.57 ,OP,14.57,64.82,,,,,,
Humana MCR ADV,CPT,80157,Assay carbamazepine free,Lab Services,Per Unit,$13.25 ,OP,13.25,57.19,,,,,,
Humana MCR ADV,CPT,80158,Drug assay cyclosporine,Lab Services,Per Unit,$18.05 ,OP,18.05,80.07,,,,,,
Humana MCR ADV,CPT,80159,Drug assay clozapine,Lab Services,Per Unit,$20.15 ,OP,20.15,20.15,,,,,,
Humana MCR ADV,CPT,80161,Asy carbamazepin 10-11-epxid,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,
Humana MCR ADV,CPT,80162,Assay of digoxin total,Lab Services,Per Unit,$13.28 ,OP,13.28,61,,,,,,
Humana MCR ADV,CPT,80163,Assay of digoxin free,Lab Services,Per Unit,$13.28 ,OP,13.28,61,,,,,,
Humana MCR ADV,CPT,80164,Assay dipropylacetic acd tot,Lab Services,Per Unit,$13.54 ,OP,13.54,61,,,,,,
Humana MCR ADV,CPT,80165,Dipropylacetic acid free,Lab Services,Per Unit,$13.54 ,OP,13.54,61,,,,,,
Humana MCR ADV,CPT,80167,Drug assay felbamate,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,
Humana MCR ADV,CPT,80168,Assay of ethosuximide,Lab Services,Per Unit,$16.34 ,OP,16.34,72.44,,,,,,
Humana MCR ADV,CPT,80169,Drug assay everolimus,Lab Services,Per Unit,$13.73 ,OP,13.73,13.73,,,,,,
Humana MCR ADV,CPT,80170,Assay of gentamicin,Lab Services,Per Unit,$16.38 ,OP,16.38,72.44,,,,,,
Humana MCR ADV,CPT,80171,Drug screen quant gabapentin,Lab Services,Per Unit,$21.67 ,OP,21.67,21.67,,,,,,
Humana MCR ADV,CPT,80173,Assay of haloperidol,Lab Services,Per Unit,$15.78 ,OP,15.78,15.78,,,,,,
Humana MCR ADV,CPT,80175,Drug screen quan lamotrigine,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,
Humana MCR ADV,CPT,80176,Assay of lidocaine,Lab Services,Per Unit,$14.69 ,OP,14.69,64.82,,,,,,
Humana MCR ADV,CPT,80177,Drug scrn quan levetiracetam,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,
Humana MCR ADV,CPT,80178,Assay of lithium,Lab Services,Per Unit,$6.61 ,OP,6.61,30.51,,,,,,
Humana MCR ADV,CPT,80179,Drug assay salicylate,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,
Humana MCR ADV,CPT,80180,Drug scrn quan mycophenolate,Lab Services,Per Unit,$18.05 ,OP,18.05,18.05,,,,,,
Humana MCR ADV,CPT,80181,Drug assay flecainide,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,
Humana MCR ADV,CPT,80183,Drug scrn quant oxcarbazepin,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,
Humana MCR ADV,CPT,80184,Assay of phenobarbital,Lab Services,Per Unit,$15.30 ,OP,15.3,49.56,,,,,,
Humana MCR ADV,CPT,80185,Assay of phenytoin total,Lab Services,Per Unit,$13.25 ,OP,13.25,57.19,,,,,,
Humana MCR ADV,CPT,80186,Assay of phenytoin free,Lab Services,Per Unit,$13.76 ,OP,13.76,61,,,,,,
Humana MCR ADV,CPT,80187,Drug assay posaconazole,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,
Humana MCR ADV,CPT,80188,Assay of primidone,Lab Services,Per Unit,$16.59 ,OP,16.59,72.44,,,,,,
Humana MCR ADV,CPT,80189,Drug assay itraconzaole,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,
Humana MCR ADV,CPT,80190,Assay of procainamide,Lab Services,Per Unit,$60.00 ,OP,60,76.26,,,,,,
Humana MCR ADV,CPT,80192,Assay of procainamide,Lab Services,Per Unit,$16.75 ,OP,16.75,76.26,,,,,,
Humana MCR ADV,CPT,80193,Drug assay leflunomide,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,
Humana MCR ADV,CPT,80194,Assay of quinidine,Lab Services,Per Unit,$14.60 ,OP,14.6,64.82,,,,,,
Humana MCR ADV,CPT,80195,Assay of sirolimus,Lab Services,Per Unit,$13.73 ,OP,13.73,61,,,,,,
Humana MCR ADV,CPT,80197,Assay of tacrolimus,Lab Services,Per Unit,$13.73 ,OP,13.73,61,,,,,,
Humana MCR ADV,CPT,80198,Assay of theophylline,Lab Services,Per Unit,$14.14 ,OP,14.14,64.82,,,,,,
Humana MCR ADV,CPT,80199,Drug screen quant tiagabine,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,
Humana MCR ADV,CPT,80200,Assay of tobramycin,Lab Services,Per Unit,$16.13 ,OP,16.13,49.56,,,,,,
Humana MCR ADV,CPT,80201,Assay of topiramate,Lab Services,Per Unit,$11.92 ,OP,11.92,53.38,,,,,,
Humana MCR ADV,CPT,80202,Assay of vancomycin,Lab Services,Per Unit,$13.54 ,OP,13.54,61,,,,,,
Humana MCR ADV,CPT,80203,Drug screen quant zonisamide,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,
Humana MCR ADV,CPT,80204,Drug assay methotrexate,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,
Humana MCR ADV,CPT,80210,Drug assay rufinamide,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,
Humana MCR ADV,CPT,80230,Drug assay infliximab,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,
Humana MCR ADV,CPT,80235,Drug assay lacosamide,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,
Humana MCR ADV,CPT,80280,Drug assay vedolizumab,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,
Humana MCR ADV,CPT,80285,Drug assay voriconazole,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,
Humana MCR ADV,CPT,80299,Quantitative assay drug,Lab Services,Per Unit,$18.64 ,OP,18.64,61,,,,,,
Humana MCR ADV,CPT,80305,Drug test prsmv dir opt obs,Lab Services,Per Unit,$12.60 ,OP,12.6,64.82,,,,,,
Humana MCR ADV,CPT,80306,Drug test prsmv instrmnt,Lab Services,Per Unit,$17.14 ,OP,17.14,64.82,,,,,,
Humana MCR ADV,CPT,80307,Drug test prsmv chem anlyzr,Lab Services,Per Unit,$62.14 ,OP,62.14,62.14,,,,,,
Humana MCR ADV,CPT,80400,Acth stimulation panel,Lab Services,Per Unit,$32.62 ,OP,32.62,144.88,,,,,,
Humana MCR ADV,CPT,80402,Acth stimulation panel,Lab Services,Per Unit,$86.96 ,OP,86.96,388.89,,,,,,
Humana MCR ADV,CPT,80406,Acth stimulation panel,Lab Services,Per Unit,$78.26 ,OP,78.26,346.96,,,,,,
Humana MCR ADV,CPT,80408,Aldosterone suppression eval,Lab Services,Per Unit,$125.50 ,OP,125.5,560.47,,,,,,
Humana MCR ADV,CPT,80410,Calcitonin stimul panel,Lab Services,Per Unit,$80.37 ,OP,80.37,358.39,,,,,,
Humana MCR ADV,CPT,80412,Crh stimulation panel,Lab Services,Per Unit,$801.62 ,OP,801.62,"1,467.89",,,,,,
Humana MCR ADV,CPT,80414,Testosterone response panel,Lab Services,Per Unit,$51.64 ,OP,51.64,228.77,,,,,,
Humana MCR ADV,CPT,80415,Tot estradiol response panel,Lab Services,Per Unit,$55.89 ,OP,55.89,99.13,,,,,,
Humana MCR ADV,CPT,80416,Renin stimulation panel,Lab Services,Per Unit,$209.32 ,OP,209.32,587.16,,,,,,
Humana MCR ADV,CPT,80417,Renin stimulation panel,Lab Services,Per Unit,$43.99 ,OP,43.99,194.45,,,,,,
Humana MCR ADV,CPT,80418,Pituitary evaluation panel,Lab Services,Per Unit,$579.48 ,OP,579.48,"2,573.58",,,,,,
Humana MCR ADV,CPT,80420,Dexamethasone panel,Lab Services,Per Unit,$161.88 ,OP,161.88,320.27,,,,,,
Humana MCR ADV,CPT,80422,Glucagon tolerance panel,Lab Services,Per Unit,$46.07 ,OP,46.07,205.88,,,,,,
Humana MCR ADV,CPT,80424,Glucagon tolerance panel,Lab Services,Per Unit,$50.50 ,OP,50.5,224.95,,,,,,
Humana MCR ADV,CPT,80426,Gonadotropin hormone panel,Lab Services,Per Unit,$148.41 ,OP,148.41,659.6,,,,,,
Humana MCR ADV,CPT,80428,Growth hormone panel,Lab Services,Per Unit,$66.70 ,OP,66.7,289.76,,,,,,
Humana MCR ADV,CPT,80430,Growth hormone panel,Lab Services,Per Unit,$129.33 ,OP,129.33,343.14,,,,,,
Humana MCR ADV,CPT,80432,Insulin suppression panel,Lab Services,Per Unit,$165.61 ,OP,165.61,602.41,,,,,,
Humana MCR ADV,CPT,80434,Insulin tolerance panel,Lab Services,Per Unit,$285.03 ,OP,285.03,449.9,,,,,,
Humana MCR ADV,CPT,80435,Insulin tolerance panel,Lab Services,Per Unit,$103.00 ,OP,103,449.9,,,,,,
Humana MCR ADV,CPT,80436,Metyrapone panel,Lab Services,Per Unit,$91.16 ,OP,91.16,301.2,,,,,,
Humana MCR ADV,CPT,80438,Trh stimulation panel,Lab Services,Per Unit,$50.41 ,OP,50.41,224.95,,,,,,
Humana MCR ADV,CPT,80439,Trh stimulation panel,Lab Services,Per Unit,$67.21 ,OP,67.21,297.39,,,,,,
Humana MCR ADV,CPT,80500,Lab pathology consultation,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Humana MCR ADV,CPT,80502,Lab pathology consultation,APC 5672,RVU Per Case,$152.64 ,OP,152.64,320.27,,,,,,
Humana MCR ADV,CPT,81000,Urinalysis nonauto w/scope,Lab Services,Per Unit,$4.02 ,OP,4.02,15.26,,,,,,
Humana MCR ADV,CPT,81001,Urinalysis auto w/scope,Lab Services,Per Unit,$3.17 ,OP,3.17,15.26,,,,,,
Humana MCR ADV,CPT,81002,Urinalysis nonauto w/o scope,Lab Services,Per Unit,$3.48 ,OP,3.48,11.44,,,,,,
Humana MCR ADV,CPT,81003,Urinalysis auto w/o scope,Lab Services,Per Unit,$2.25 ,OP,2.25,11.44,,,,,,
Humana MCR ADV,CPT,81005,Urinalysis,Lab Services,Per Unit,$2.17 ,OP,2.17,11.44,,,,,,
Humana MCR ADV,CPT,81007,Urine screen for bacteria,Lab Services,Per Unit,$29.98 ,OP,11.44,29.98,,,,,,
Humana MCR ADV,CPT,81015,Microscopic exam of urine,Lab Services,Per Unit,$3.05 ,OP,3.05,15.26,,,,,,
Humana MCR ADV,CPT,81020,Urinalysis glass test,Lab Services,Per Unit,$4.70 ,OP,4.7,15.26,,,,,,
Humana MCR ADV,CPT,81025,Urine pregnancy test,Lab Services,Per Unit,$8.61 ,OP,8.61,30.51,,,,,,
Humana MCR ADV,CPT,81050,Urinalysis volume measure,Lab Services,Per Unit,$3.64 ,OP,3.64,11.44,,,,,,
Humana MCR ADV,CPT,81105,Hpa-1 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
Humana MCR ADV,CPT,81106,Hpa-2 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
Humana MCR ADV,CPT,81107,Hpa-3 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
Humana MCR ADV,CPT,81108,Hpa-4 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
Humana MCR ADV,CPT,81109,Hpa-5 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
Humana MCR ADV,CPT,81110,Hpa-6 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
Humana MCR ADV,CPT,81111,Hpa-9 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
Humana MCR ADV,CPT,81112,Hpa-15 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
Humana MCR ADV,CPT,81120,Idh1 common variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,
Humana MCR ADV,CPT,81121,Idh2 common variants,Lab Services,Per Unit,$295.79 ,OP,295.79,295.79,,,,,,
Humana MCR ADV,CPT,81161,Dmd dup/delet analysis,Lab Services,Per Unit,$279.00 ,OP,279,279,,,,,,
Humana MCR ADV,CPT,81162,Brca1&2 gen full seq dup/del,Lab Services,Per Unit,"$1,824.88 ",OP,"1,824.88","1,824.88",,,,,,
Humana MCR ADV,CPT,81163,Brca1&2 gene full seq alys,Lab Services,Per Unit,$468.00 ,OP,468,468,,,,,,
Humana MCR ADV,CPT,81164,Brca1&2 gen ful dup/del alys,Lab Services,Per Unit,$584.23 ,OP,584.23,584.23,,,,,,
Humana MCR ADV,CPT,81165,Brca1 gene full seq alys,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,
Humana MCR ADV,CPT,81166,Brca1 gene full dup/del alys,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,
Humana MCR ADV,CPT,81167,Brca2 gene full dup/del alys,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,
Humana MCR ADV,CPT,81168,Ccnd1/igh translocation alys,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,
Humana MCR ADV,CPT,81170,Abl1 gene,Lab Services,Per Unit,$300.00 ,OP,300,300,,,,,,
Humana MCR ADV,CPT,81171,Aff2 gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Humana MCR ADV,CPT,81172,Aff2 gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Humana MCR ADV,CPT,81173,Ar gene full gene sequence,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,
Humana MCR ADV,CPT,81174,Ar gene known famil variant,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Humana MCR ADV,CPT,81175,Asxl1 full gene sequence,Lab Services,Per Unit,$676.50 ,OP,676.5,676.5,,,,,,
Humana MCR ADV,CPT,81176,Asxl1 gene target seq alys,Lab Services,Per Unit,$241.90 ,OP,241.9,241.9,,,,,,
Humana MCR ADV,CPT,81177,Atn1 gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Humana MCR ADV,CPT,81178,Atxn1 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Humana MCR ADV,CPT,81179,Atxn2 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Humana MCR ADV,CPT,81180,Atxn3 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Humana MCR ADV,CPT,81181,Atxn7 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Humana MCR ADV,CPT,81182,Atxn8os gen detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Humana MCR ADV,CPT,81183,Atxn10 gene detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Humana MCR ADV,CPT,81184,Cacna1a gen detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Humana MCR ADV,CPT,81185,Cacna1a gene full gene seq,Lab Services,Per Unit,$846.27 ,OP,846.27,846.27,,,,,,
Humana MCR ADV,CPT,81186,Cacna1a gen known famil vrnt,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Humana MCR ADV,CPT,81187,Cnbp gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Humana MCR ADV,CPT,81188,Cstb gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Humana MCR ADV,CPT,81189,Cstb gene full gene sequence,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Humana MCR ADV,CPT,81190,Cstb gene known famil vrnt,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Humana MCR ADV,CPT,81191,Ntrk1 translocation analysis,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,
Humana MCR ADV,CPT,81192,Ntrk2 translocation analysis,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,
Humana MCR ADV,CPT,81193,Ntrk3 translocation analysis,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,
Humana MCR ADV,CPT,81194,Ntrk translocation analysis,Lab Services,Per Unit,$518.28 ,OP,518.28,518.28,,,,,,
Humana MCR ADV,CPT,81200,Aspa gene,Lab Services,Per Unit,$47.25 ,OP,47.25,47.25,,,,,,
Humana MCR ADV,CPT,81201,Apc gene full sequence,Lab Services,Per Unit,$780.00 ,OP,780,780,,,,,,
Humana MCR ADV,CPT,81202,Apc gene known fam variants,Lab Services,Per Unit,$280.00 ,OP,280,280,,,,,,
Humana MCR ADV,CPT,81203,Apc gene dup/delet variants,Lab Services,Per Unit,$200.00 ,OP,200,200,,,,,,
Humana MCR ADV,CPT,81204,Ar gene charac alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Humana MCR ADV,CPT,81205,Bckdhb gene,Lab Services,Per Unit,$94.99 ,OP,94.99,94.99,,,,,,
Humana MCR ADV,CPT,81206,Bcr/abl1 gene major bp,Lab Services,Per Unit,$163.96 ,OP,163.96,163.96,,,,,,
Humana MCR ADV,CPT,81207,Bcr/abl1 gene minor bp,Lab Services,Per Unit,$144.84 ,OP,144.84,144.84,,,,,,
Humana MCR ADV,CPT,81208,Bcr/abl1 gene other bp,Lab Services,Per Unit,$214.62 ,OP,214.62,214.62,,,,,,
Humana MCR ADV,CPT,81209,Blm gene,Lab Services,Per Unit,$39.31 ,OP,39.31,39.31,,,,,,
Humana MCR ADV,CPT,81210,Braf gene,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,
Humana MCR ADV,CPT,81212,Brca1&2 185&5385&6174 vrnt,Lab Services,Per Unit,$440.00 ,OP,440,440,,,,,,
Humana MCR ADV,CPT,81215,Brca1 gene known famil vrnt,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,
Humana MCR ADV,CPT,81216,Brca2 gene full seq alys,Lab Services,Per Unit,$185.12 ,OP,185.12,185.12,,,,,,
Humana MCR ADV,CPT,81217,Brca2 gene known famil vrnt,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,
Humana MCR ADV,CPT,81218,Cebpa gene full sequence,Lab Services,Per Unit,$241.90 ,OP,241.9,241.9,,,,,,
Humana MCR ADV,CPT,81219,Calr gene com variants,Lab Services,Per Unit,$121.63 ,OP,121.63,121.63,,,,,,
Humana MCR ADV,CPT,81220,Cftr gene com variants,Lab Services,Per Unit,$556.60 ,OP,556.6,556.6,,,,,,
Humana MCR ADV,CPT,81221,Cftr gene known fam variants,Lab Services,Per Unit,$97.22 ,OP,97.22,97.22,,,,,,
Humana MCR ADV,CPT,81222,Cftr gene dup/delet variants,Lab Services,Per Unit,$435.07 ,OP,435.07,435.07,,,,,,
Humana MCR ADV,CPT,81223,Cftr gene full sequence,Lab Services,Per Unit,$499.00 ,OP,499,499,,,,,,
Humana MCR ADV,CPT,81224,Cftr gene intron poly t,Lab Services,Per Unit,$168.75 ,OP,168.75,168.75,,,,,,
Humana MCR ADV,CPT,81225,Cyp2c19 gene com variants,Lab Services,Per Unit,$291.36 ,OP,291.36,291.36,,,,,,
Humana MCR ADV,CPT,81226,Cyp2d6 gene com variants,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,
Humana MCR ADV,CPT,81227,Cyp2c9 gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Humana MCR ADV,CPT,81228,Cytogen micrarray copy nmbr,Lab Services,Per Unit,$900.00 ,OP,900,900,,,,,,
Humana MCR ADV,CPT,81229,Cytogen m array copy no&snp,Lab Services,Per Unit,"$1,160.00 ",OP,"1,160.00","1,160.00",,,,,,
Humana MCR ADV,CPT,81230,Cyp3a4 gene common variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Humana MCR ADV,CPT,81231,Cyp3a5 gene common variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Humana MCR ADV,CPT,81232,Dpyd gene common variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Humana MCR ADV,CPT,81233,Btk gene common variants,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,
Humana MCR ADV,CPT,81234,Dmpk gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Humana MCR ADV,CPT,81235,Egfr gene com variants,Lab Services,Per Unit,$324.58 ,OP,324.58,324.58,,,,,,
Humana MCR ADV,CPT,81236,Ezh2 gene full gene sequence,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,
Humana MCR ADV,CPT,81237,Ezh2 gene common variants,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,
Humana MCR ADV,CPT,81238,F9 full gene sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,
Humana MCR ADV,CPT,81239,Dmpk gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Humana MCR ADV,CPT,81240,F2 gene,Lab Services,Per Unit,$65.69 ,OP,65.69,65.69,,,,,,
Humana MCR ADV,CPT,81241,F5 gene,Lab Services,Per Unit,$73.37 ,OP,73.37,73.37,,,,,,
Humana MCR ADV,CPT,81242,Fancc gene,Lab Services,Per Unit,$36.62 ,OP,36.62,36.62,,,,,,
Humana MCR ADV,CPT,81243,Fmr1 gene detection,Lab Services,Per Unit,$57.04 ,OP,57.04,57.04,,,,,,
Humana MCR ADV,CPT,81244,Fmr1 gene charac alleles,Lab Services,Per Unit,$44.89 ,OP,44.89,44.89,,,,,,
Humana MCR ADV,CPT,81245,Flt3 gene,Lab Services,Per Unit,$165.51 ,OP,165.51,165.51,,,,,,
Humana MCR ADV,CPT,81246,Flt3 gene analysis,Lab Services,Per Unit,$83.00 ,OP,83,83,,,,,,
Humana MCR ADV,CPT,81247,G6pd gene alys cmn variant,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Humana MCR ADV,CPT,81248,G6pd known familial variant,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,
Humana MCR ADV,CPT,81249,G6pd full gene sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,
Humana MCR ADV,CPT,81250,G6pc gene,Lab Services,Per Unit,$58.49 ,OP,58.49,58.49,,,,,,
Humana MCR ADV,CPT,81251,Gba gene,Lab Services,Per Unit,$47.25 ,OP,47.25,47.25,,,,,,
Humana MCR ADV,CPT,81252,Gjb2 gene full sequence,Lab Services,Per Unit,$101.12 ,OP,101.12,101.12,,,,,,
Humana MCR ADV,CPT,81253,Gjb2 gene known fam variants,Lab Services,Per Unit,$61.52 ,OP,61.52,61.52,,,,,,
Humana MCR ADV,CPT,81254,Gjb6 gene com variants,Lab Services,Per Unit,$35.00 ,OP,35,35,,,,,,
Humana MCR ADV,CPT,81255,Hexa gene,Lab Services,Per Unit,$51.45 ,OP,51.45,51.45,,,,,,
Humana MCR ADV,CPT,81256,Hfe gene,Lab Services,Per Unit,$65.36 ,OP,65.36,65.36,,,,,,
Humana MCR ADV,CPT,81257,Hba1/hba2 gene,Lab Services,Per Unit,$102.26 ,OP,102.26,102.26,,,,,,
Humana MCR ADV,CPT,81258,Hba1/hba2 gene fam vrnt,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,
Humana MCR ADV,CPT,81259,Hba1/hba2 full gene sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,
Humana MCR ADV,CPT,81260,Ikbkap gene,Lab Services,Per Unit,$39.31 ,OP,39.31,39.31,,,,,,
Humana MCR ADV,CPT,81261,Igh gene rearrange amp meth,Lab Services,Per Unit,$197.99 ,OP,197.99,197.99,,,,,,
Humana MCR ADV,CPT,81262,Igh gene rearrang dir probe,Lab Services,Per Unit,$68.55 ,OP,68.55,68.55,,,,,,
Humana MCR ADV,CPT,81263,Igh vari regional mutation,Lab Services,Per Unit,$294.52 ,OP,294.52,294.52,,,,,,
Humana MCR ADV,CPT,81264,Igk rearrangeabn clonal pop,Lab Services,Per Unit,$172.73 ,OP,172.73,172.73,,,,,,
Humana MCR ADV,CPT,81265,Str markers specimen anal,Lab Services,Per Unit,$233.07 ,OP,233.07,233.07,,,,,,
Humana MCR ADV,CPT,81266,Str markers spec anal addl,Lab Services,Per Unit,$304.81 ,OP,304.81,304.81,,,,,,
Humana MCR ADV,CPT,81267,Chimerism anal no cell selec,Lab Services,Per Unit,$207.46 ,OP,207.46,207.46,,,,,,
Humana MCR ADV,CPT,81268,Chimerism anal w/cell select,Lab Services,Per Unit,$260.79 ,OP,260.79,260.79,,,,,,
Humana MCR ADV,CPT,81269,Hba1/hba2 gene dup/del vrnts,Lab Services,Per Unit,$202.40 ,OP,202.4,202.4,,,,,,
Humana MCR ADV,CPT,81270,Jak2 gene,Lab Services,Per Unit,$91.66 ,OP,91.66,91.66,,,,,,
Humana MCR ADV,CPT,81271,Htt gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Humana MCR ADV,CPT,81272,Kit gene targeted seq analys,Lab Services,Per Unit,$329.51 ,OP,329.51,329.51,,,,,,
Humana MCR ADV,CPT,81273,Kit gene analys d816 variant,Lab Services,Per Unit,$124.87 ,OP,124.87,124.87,,,,,,
Humana MCR ADV,CPT,81274,Htt gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Humana MCR ADV,CPT,81275,Kras gene variants exon 2,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,
Humana MCR ADV,CPT,81276,Kras gene addl variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,
Humana MCR ADV,CPT,81277,Cytogenomic neo microra alys,Lab Services,Per Unit,"$1,160.00 ",OP,"1,160.00","1,160.00",,,,,,
Humana MCR ADV,CPT,81278,Igh@/bcl2 translocation alys,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,
Humana MCR ADV,CPT,81279,Jak2 gene trgt sequence alys,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Humana MCR ADV,CPT,81283,Ifnl3 gene,Lab Services,Per Unit,$73.37 ,OP,73.37,73.37,,,,,,
Humana MCR ADV,CPT,81284,Fxn gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Humana MCR ADV,CPT,81285,Fxn gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Humana MCR ADV,CPT,81286,Fxn gene full gene sequence,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Humana MCR ADV,CPT,81287,Mgmt gene prmtr mthyltn alys,Lab Services,Per Unit,$124.64 ,OP,124.64,124.64,,,,,,
Humana MCR ADV,CPT,81288,Mlh1 gene,Lab Services,Per Unit,$192.32 ,OP,192.32,192.32,,,,,,
Humana MCR ADV,CPT,81289,Fxn gene known famil variant,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Humana MCR ADV,CPT,81290,Mcoln1 gene,Lab Services,Per Unit,$39.31 ,OP,39.31,39.31,,,,,,
Humana MCR ADV,CPT,81291,Mthfr gene,Lab Services,Per Unit,$65.34 ,OP,65.34,65.34,,,,,,
Humana MCR ADV,CPT,81292,Mlh1 gene full seq,Lab Services,Per Unit,$675.40 ,OP,675.4,675.4,,,,,,
Humana MCR ADV,CPT,81293,Mlh1 gene known variants,Lab Services,Per Unit,$331.00 ,OP,331,331,,,,,,
Humana MCR ADV,CPT,81294,Mlh1 gene dup/delete variant,Lab Services,Per Unit,$202.40 ,OP,202.4,202.4,,,,,,
Humana MCR ADV,CPT,81295,Msh2 gene full seq,Lab Services,Per Unit,$381.70 ,OP,381.7,381.7,,,,,,
Humana MCR ADV,CPT,81296,Msh2 gene known variants,Lab Services,Per Unit,$337.73 ,OP,337.73,337.73,,,,,,
Humana MCR ADV,CPT,81297,Msh2 gene dup/delete variant,Lab Services,Per Unit,$213.30 ,OP,213.3,213.3,,,,,,
Humana MCR ADV,CPT,81298,Msh6 gene full seq,Lab Services,Per Unit,$641.85 ,OP,641.85,641.85,,,,,,
Humana MCR ADV,CPT,81299,Msh6 gene known variants,Lab Services,Per Unit,$308.00 ,OP,308,308,,,,,,
Humana MCR ADV,CPT,81300,Msh6 gene dup/delete variant,Lab Services,Per Unit,$238.00 ,OP,238,238,,,,,,
Humana MCR ADV,CPT,81301,Microsatellite instability,Lab Services,Per Unit,$348.56 ,OP,348.56,348.56,,,,,,
Humana MCR ADV,CPT,81302,Mecp2 gene full seq,Lab Services,Per Unit,$527.87 ,OP,527.87,527.87,,,,,,
Humana MCR ADV,CPT,81303,Mecp2 gene known variant,Lab Services,Per Unit,$120.00 ,OP,120,120,,,,,,
Humana MCR ADV,CPT,81304,Mecp2 gene dup/delet variant,Lab Services,Per Unit,$150.00 ,OP,150,150,,,,,,
Humana MCR ADV,CPT,81305,Myd88 gene p.leu265pro vrnt,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,
Humana MCR ADV,CPT,81306,Nudt15 gene common variants,Lab Services,Per Unit,$291.36 ,OP,291.36,291.36,,,,,,
Humana MCR ADV,CPT,81307,Palb2 gene full gene seq,Lab Services,Per Unit,$676.50 ,OP,676.5,676.5,,,,,,
Humana MCR ADV,CPT,81308,Palb2 gene known famil vrnt,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,
Humana MCR ADV,CPT,81309,Pik3ca gene trgt seq alys,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Humana MCR ADV,CPT,81310,Npm1 gene,Lab Services,Per Unit,$246.52 ,OP,246.52,246.52,,,,,,
Humana MCR ADV,CPT,81311,Nras gene variants exon 2&3,Lab Services,Per Unit,$295.79 ,OP,295.79,295.79,,,,,,
Humana MCR ADV,CPT,81312,Pabpn1 gene detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Humana MCR ADV,CPT,81313,Pca3/klk3 antigen,Lab Services,Per Unit,$255.05 ,OP,255.05,255.05,,,,,,
Humana MCR ADV,CPT,81314,Pdgfra gene,Lab Services,Per Unit,$329.51 ,OP,329.51,329.51,,,,,,
Humana MCR ADV,CPT,81315,Pml/raralpha com breakpoints,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,
Humana MCR ADV,CPT,81316,Pml/raralpha 1 breakpoint,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,
Humana MCR ADV,CPT,81317,Pms2 gene full seq analysis,Lab Services,Per Unit,$676.50 ,OP,676.5,676.5,,,,,,
Humana MCR ADV,CPT,81318,Pms2 known familial variants,Lab Services,Per Unit,$331.00 ,OP,331,331,,,,,,
Humana MCR ADV,CPT,81319,Pms2 gene dup/delet variants,Lab Services,Per Unit,$203.50 ,OP,203.5,203.5,,,,,,
Humana MCR ADV,CPT,81320,Plcg2 gene common variants,Lab Services,Per Unit,$291.36 ,OP,291.36,291.36,,,,,,
Humana MCR ADV,CPT,81321,Pten gene full sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,
Humana MCR ADV,CPT,81322,Pten gene known fam variant,Lab Services,Per Unit,$46.60 ,OP,46.6,46.6,,,,,,
Humana MCR ADV,CPT,81323,Pten gene dup/delet variant,Lab Services,Per Unit,$300.00 ,OP,300,300,,,,,,
Humana MCR ADV,CPT,81324,Pmp22 gene dup/delet,Lab Services,Per Unit,$758.36 ,OP,758.36,758.36,,,,,,
Humana MCR ADV,CPT,81325,Pmp22 gene full sequence,Lab Services,Per Unit,$769.58 ,OP,769.58,769.58,,,,,,
Humana MCR ADV,CPT,81326,Pmp22 gene known fam variant,Lab Services,Per Unit,$46.60 ,OP,46.6,46.6,,,,,,
Humana MCR ADV,CPT,81327,Sept9 gen prmtr mthyltn alys,Lab Services,Per Unit,$192.00 ,OP,192,192,,,,,,
Humana MCR ADV,CPT,81328,Slco1b1 gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Humana MCR ADV,CPT,81329,Smn1 gene dos/deletion alys,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Humana MCR ADV,CPT,81330,Smpd1 gene common variants,Lab Services,Per Unit,$47.00 ,OP,47,47,,,,,,
Humana MCR ADV,CPT,81331,Snrpn/ube3a gene,Lab Services,Per Unit,$51.07 ,OP,51.07,51.07,,,,,,
Humana MCR ADV,CPT,81332,Serpina1 gene,Lab Services,Per Unit,$43.65 ,OP,43.65,43.65,,,,,,
Humana MCR ADV,CPT,81333,Tgfbi gene common variants,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Humana MCR ADV,CPT,81334,Runx1 gene targeted seq alys,Lab Services,Per Unit,$329.51 ,OP,329.51,329.51,,,,,,
Humana MCR ADV,CPT,81335,Tpmt gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Humana MCR ADV,CPT,81336,Smn1 gene full gene sequence,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,
Humana MCR ADV,CPT,81337,Smn1 gen nown famil seq vrnt,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Humana MCR ADV,CPT,81338,Mpl gene common variants,Lab Services,Per Unit,$150.33 ,OP,150.33,150.33,,,,,,
Humana MCR ADV,CPT,81339,Mpl gene seq alys exon 10,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Humana MCR ADV,CPT,81340,Trb@ gene rearrange amplify,Lab Services,Per Unit,$208.92 ,OP,208.92,208.92,,,,,,
Humana MCR ADV,CPT,81341,Trb@ gene rearrange dirprobe,Lab Services,Per Unit,$49.59 ,OP,49.59,49.59,,,,,,
Humana MCR ADV,CPT,81342,Trg gene rearrangement anal,Lab Services,Per Unit,$201.50 ,OP,201.5,201.5,,,,,,
Humana MCR ADV,CPT,81343,Ppp2r2b gen detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Humana MCR ADV,CPT,81344,Tbp gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Humana MCR ADV,CPT,81345,Tert gene targeted seq alys,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Humana MCR ADV,CPT,81346,Tyms gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Humana MCR ADV,CPT,81347,Sf3b1 gene common variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,
Humana MCR ADV,CPT,81348,Srsf2 gene common variants,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,
Humana MCR ADV,CPT,81350,Ugt1a1 gene common variants,Lab Services,Per Unit,$234.00 ,OP,234,234,,,,,,
Humana MCR ADV,CPT,81351,Tp53 gene full gene sequence,Lab Services,Per Unit,$641.85 ,OP,641.85,641.85,,,,,,
Humana MCR ADV,CPT,81352,Tp53 gene trgt sequence alys,Lab Services,Per Unit,$329.51 ,OP,329.51,329.51,,,,,,
Humana MCR ADV,CPT,81353,Tp53 gene known famil vrnt,Lab Services,Per Unit,$308.00 ,OP,308,308,,,,,,
Humana MCR ADV,CPT,81355,Vkorc1 gene,Lab Services,Per Unit,$88.20 ,OP,88.2,88.2,,,,,,
Humana MCR ADV,CPT,81357,U2af1 gene common variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,
Humana MCR ADV,CPT,81360,Zrsr2 gene common variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,
Humana MCR ADV,CPT,81361,Hbb gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Humana MCR ADV,CPT,81362,Hbb gene known fam variant,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,
Humana MCR ADV,CPT,81363,Hbb gene dup/del variants,Lab Services,Per Unit,$202.40 ,OP,202.4,202.4,,,,,,
Humana MCR ADV,CPT,81364,Hbb full gene sequence,Lab Services,Per Unit,$324.58 ,OP,324.58,324.58,,,,,,
Humana MCR ADV,CPT,81370,Hla i & ii typing lr,Lab Services,Per Unit,$402.12 ,OP,402.12,402.12,,,,,,
Humana MCR ADV,CPT,81371,Hla i & ii type verify lr,Lab Services,Per Unit,$404.52 ,OP,404.52,404.52,,,,,,
Humana MCR ADV,CPT,81372,Hla i typing complete lr,Lab Services,Per Unit,$403.59 ,OP,403.59,403.59,,,,,,
Humana MCR ADV,CPT,81373,Hla i typing 1 locus lr,Lab Services,Per Unit,$127.43 ,OP,127.43,127.43,,,,,,
Humana MCR ADV,CPT,81374,Hla i typing 1 antigen lr,Lab Services,Per Unit,$74.33 ,OP,74.33,74.33,,,,,,
Humana MCR ADV,CPT,81375,Hla ii typing ag equiv lr,Lab Services,Per Unit,$220.74 ,OP,220.74,220.74,,,,,,
Humana MCR ADV,CPT,81376,Hla ii typing 1 locus lr,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
Humana MCR ADV,CPT,81377,Hla ii type 1 ag equiv lr,Lab Services,Per Unit,$94.74 ,OP,94.74,94.74,,,,,,
Humana MCR ADV,CPT,81378,Hla i & ii typing hr,Lab Services,Per Unit,$345.57 ,OP,345.57,345.57,,,,,,
Humana MCR ADV,CPT,81379,Hla i typing complete hr,Lab Services,Per Unit,$335.38 ,OP,335.38,335.38,,,,,,
Humana MCR ADV,CPT,81380,Hla i typing 1 locus hr,Lab Services,Per Unit,$177.25 ,OP,177.25,177.25,,,,,,
Humana MCR ADV,CPT,81381,Hla i typing 1 allele hr,Lab Services,Per Unit,$169.90 ,OP,169.9,169.9,,,,,,
Humana MCR ADV,CPT,81382,Hla ii typing 1 loc hr,Lab Services,Per Unit,$123.68 ,OP,123.68,123.68,,,,,,
Humana MCR ADV,CPT,81383,Hla ii typing 1 allele hr,Lab Services,Per Unit,$109.13 ,OP,109.13,109.13,,,,,,
Humana MCR ADV,CPT,81400,Mopath procedure level 1,Lab Services,Per Unit,$63.96 ,OP,63.96,63.96,,,,,,
Humana MCR ADV,CPT,81401,Mopath procedure level 2,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Humana MCR ADV,CPT,81402,Mopath procedure level 3,Lab Services,Per Unit,$150.33 ,OP,150.33,150.33,,,,,,
Humana MCR ADV,CPT,81403,Mopath procedure level 4,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Humana MCR ADV,CPT,81404,Mopath procedure level 5,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Humana MCR ADV,CPT,81405,Mopath procedure level 6,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,
Humana MCR ADV,CPT,81406,Mopath procedure level 7,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,
Humana MCR ADV,CPT,81407,Mopath procedure level 8,Lab Services,Per Unit,$846.27 ,OP,846.27,846.27,,,,,,
Humana MCR ADV,CPT,81408,Mopath procedure level 9,Lab Services,Per Unit,"$2,000.00 ",OP,"2,000.00","2,000.00",,,,,,
Humana MCR ADV,CPT,81410,Aortic dysfunction/dilation,Lab Services,Per Unit,$504.00 ,OP,504,504,,,,,,
Humana MCR ADV,CPT,81411,Aortic dysfunction/dilation,Lab Services,Per Unit,"$1,350.19 ",OP,"1,350.19","1,350.19",,,,,,
Humana MCR ADV,CPT,81412,Ashkenazi jewish assoc dis,Lab Services,Per Unit,"$2,448.56 ",OP,"2,448.56","2,448.56",,,,,,
Humana MCR ADV,CPT,81413,Car ion chnnlpath inc 10 gns,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,
Humana MCR ADV,CPT,81414,Car ion chnnlpath inc 2 gns,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,
Humana MCR ADV,CPT,81415,Exome sequence analysis,Lab Services,Per Unit,"$4,780.00 ",OP,"4,780.00","4,780.00",,,,,,
Humana MCR ADV,CPT,81416,Exome sequence analysis,Lab Services,Per Unit,"$12,000.00 ",OP,"12,000.00","12,000.00",,,,,,
Humana MCR ADV,CPT,81417,Exome re-evaluation,Lab Services,Per Unit,$320.00 ,OP,320,320,,,,,,
Humana MCR ADV,CPT,81419,Epilepsy gen seq alys panel,Lab Services,Per Unit,"$2,448.56 ",OP,"2,448.56","2,448.56",,,,,,
Humana MCR ADV,CPT,81420,Fetal chrmoml aneuploidy,Lab Services,Per Unit,$759.05 ,OP,759.05,759.05,,,,,,
Humana MCR ADV,CPT,81422,Fetal chrmoml microdeltj,Lab Services,Per Unit,$759.05 ,OP,759.05,759.05,,,,,,
Humana MCR ADV,CPT,81425,Genome sequence analysis,Lab Services,Per Unit,"$5,031.20 ",OP,"5,031.20","5,031.20",,,,,,
Humana MCR ADV,CPT,81426,Genome sequence analysis,Lab Services,Per Unit,"$2,709.95 ",OP,"2,709.95","2,709.95",,,,,,
Humana MCR ADV,CPT,81427,Genome re-evaluation,Lab Services,Per Unit,"$2,337.65 ",OP,"2,337.65","2,337.65",,,,,,
Humana MCR ADV,CPT,81430,Hearing loss sequence analys,Lab Services,Per Unit,"$1,625.00 ",OP,"1,625.00","1,625.00",,,,,,
Humana MCR ADV,CPT,81431,Hearing loss dup/del analys,Lab Services,Per Unit,$679.57 ,OP,679.57,679.57,,,,,,
Humana MCR ADV,CPT,81432,Hrdtry brst ca-rlatd dsordrs,Lab Services,Per Unit,$679.05 ,OP,679.05,679.05,,,,,,
Humana MCR ADV,CPT,81433,Hrdtry brst ca-rlatd dsordrs,Lab Services,Per Unit,$438.93 ,OP,438.93,438.93,,,,,,
Humana MCR ADV,CPT,81434,Hereditary retinal disorders,Lab Services,Per Unit,$597.91 ,OP,597.91,597.91,,,,,,
Humana MCR ADV,CPT,81435,Hereditary colon ca dsordrs,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,
Humana MCR ADV,CPT,81436,Hereditary colon ca dsordrs,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,
Humana MCR ADV,CPT,81437,Heredtry nurondcrn tum dsrdr,Lab Services,Per Unit,$438.93 ,OP,438.93,438.93,,,,,,
Humana MCR ADV,CPT,81438,Heredtry nurondcrn tum dsrdr,Lab Services,Per Unit,$438.93 ,OP,438.93,438.93,,,,,,
Humana MCR ADV,CPT,81439,Hrdtry cardmypy gene panel,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,
Humana MCR ADV,CPT,81440,Mitochondrial gene,Lab Services,Per Unit,"$3,324.00 ",OP,"3,324.00","3,324.00",,,,,,
Humana MCR ADV,CPT,81442,Noonan spectrum disorders,Lab Services,Per Unit,"$2,143.60 ",OP,"2,143.60","2,143.60",,,,,,
Humana MCR ADV,CPT,81443,Genetic tstg severe inh cond,Lab Services,Per Unit,"$2,448.56 ",OP,"2,448.56","2,448.56",,,,,,
Humana MCR ADV,CPT,81445,Targeted genomic seq analys,Lab Services,Per Unit,$597.91 ,OP,597.91,597.91,,,,,,
Humana MCR ADV,CPT,81448,Hrdtry perph neurphy panel,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,
Humana MCR ADV,CPT,81450,Targeted genomic seq analys,Lab Services,Per Unit,$759.53 ,OP,759.53,759.53,,,,,,
Humana MCR ADV,CPT,81455,Targeted genomic seq analys,Lab Services,Per Unit,"$2,919.60 ",OP,"2,919.60","2,919.60",,,,,,
Humana MCR ADV,CPT,81460,Whole mitochondrial genome,Lab Services,Per Unit,"$1,287.00 ",OP,"1,287.00","1,287.00",,,,,,
Humana MCR ADV,CPT,81465,Whole mitochondrial genome,Lab Services,Per Unit,$936.00 ,OP,936,936,,,,,,
Humana MCR ADV,CPT,81470,X-linked intellectual dblt,Lab Services,Per Unit,$914.00 ,OP,914,914,,,,,,
Humana MCR ADV,CPT,81471,X-linked intellectual dblt,Lab Services,Per Unit,$914.00 ,OP,914,914,,,,,,
Humana MCR ADV,CPT,81490,Autoimmune rheumatoid arthr,Lab Services,Per Unit,$840.65 ,OP,840.65,840.65,,,,,,
Humana MCR ADV,CPT,81493,Cor artery disease mrna,Lab Services,Per Unit,"$1,050.00 ",OP,"1,050.00","1,050.00",,,,,,
Humana MCR ADV,CPT,81500,Onco (ovar) two proteins,Lab Services,Per Unit,$260.50 ,OP,91.51,260.5,,,,,,
Humana MCR ADV,CPT,81503,Onco (ovar) five proteins,Lab Services,Per Unit,$897.00 ,OP,91.51,897,,,,,,
Humana MCR ADV,CPT,81504,Oncology tissue of origin,Lab Services,Per Unit,$520.00 ,OP,520,520,,,,,,
Humana MCR ADV,CPT,81506,Endo assay seven anal,Lab Services,Per Unit,$68.92 ,OP,57.19,68.92,,,,,,
Humana MCR ADV,CPT,81507,Fetal aneuploidy trisom risk,Lab Services,Per Unit,$795.00 ,OP,795,795,,,,,,
Humana MCR ADV,CPT,81508,Ftl cgen abnor two proteins,Lab Services,Per Unit,$54.30 ,OP,54.3,144.88,,,,,,
Humana MCR ADV,CPT,81509,Ftl cgen abnor 3 proteins,Lab Services,Per Unit,"$1,487.37 ",OP,213.51,"1,487.37",,,,,,
Humana MCR ADV,CPT,81510,Ftl cgen abnor three anal,Lab Services,Per Unit,$55.54 ,OP,55.54,202.07,,,,,,
Humana MCR ADV,CPT,81511,Ftl cgen abnor four anal,Lab Services,Per Unit,$153.50 ,OP,153.5,270.71,,,,,,
Humana MCR ADV,CPT,81512,Ftl cgen abnor five anal,Lab Services,Per Unit,$69.52 ,OP,69.52,270.71,,,,,,
Humana MCR ADV,CPT,81513,Nfct ds bv rna vag flu alg,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
Humana MCR ADV,CPT,81514,Nfct ds bv&vaginitis dna alg,Lab Services,Per Unit,$262.99 ,OP,262.99,262.99,,,,,,
Humana MCR ADV,CPT,81518,Onc brst mrna 11 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
Humana MCR ADV,CPT,81519,Oncology breast mrna,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
Humana MCR ADV,CPT,81520,Onc breast mrna 58 genes,Lab Services,Per Unit,"$2,510.21 ",OP,"2,510.21","2,510.21",,,,,,
Humana MCR ADV,CPT,81521,Onc breast mrna 70 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
Humana MCR ADV,CPT,81522,Onc breast mrna 12 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
Humana MCR ADV,CPT,81525,Oncology colon mrna,Lab Services,Per Unit,"$3,116.00 ",OP,"3,116.00","3,116.00",,,,,,
Humana MCR ADV,CPT,81528,Oncology colorectal scr,Lab Services,Per Unit,$508.87 ,OP,508.87,508.87,,,,,,
Humana MCR ADV,CPT,81529,Onc cutan mlnma mrna 31 gene,Lab Services,Per Unit,"$7,193.00 ",OP,"7,193.00","7,193.00",,,,,,
Humana MCR ADV,CPT,81535,Oncology gynecologic,Lab Services,Per Unit,$579.46 ,OP,579.46,579.46,,,,,,
Humana MCR ADV,CPT,81536,Oncology gynecologic,Lab Services,Per Unit,$177.56 ,OP,177.56,177.56,,,,,,
Humana MCR ADV,CPT,81538,Oncology lung,Lab Services,Per Unit,"$2,871.00 ",OP,"2,871.00","2,871.00",,,,,,
Humana MCR ADV,CPT,81539,Oncology prostate prob score,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
Humana MCR ADV,CPT,81540,Oncology tum unknown origin,Lab Services,Per Unit,"$3,750.00 ",OP,"3,750.00","3,750.00",,,,,,
Humana MCR ADV,CPT,81541,Onc prostate mrna 46 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
Humana MCR ADV,CPT,81542,Onc prostate mrna 22 cnt gen,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
Humana MCR ADV,CPT,81546,Onc thyr mrna 10-196 gen alg,Lab Services,Per Unit,"$3,600.00 ",OP,"3,600.00","3,600.00",,,,,,
Humana MCR ADV,CPT,81551,Onc prostate 3 genes,Lab Services,Per Unit,"$2,030.00 ",OP,"2,030.00","2,030.00",,,,,,
Humana MCR ADV,CPT,81552,Onc uveal mlnma mrna 15 gene,Lab Services,Per Unit,"$7,776.00 ",OP,"7,776.00","7,776.00",,,,,,
Humana MCR ADV,CPT,81554,Pulm ds ipf mrna 190 gen alg,Lab Services,Per Unit,"$5,500.00 ",OP,"5,500.00","5,500.00",,,,,,
Humana MCR ADV,CPT,81595,Cardiology hrt trnspl mrna,Lab Services,Per Unit,"$3,240.00 ",OP,"3,240.00","3,240.00",,,,,,
Humana MCR ADV,CPT,81596,Nfct ds chrnc hcv 6 assays,Lab Services,Per Unit,$72.19 ,OP,72.19,72.19,,,,,,
Humana MCR ADV,CPT,82009,Test for acetone/ketones,Lab Services,Per Unit,$4.52 ,OP,4.52,19.07,,,,,,
Humana MCR ADV,CPT,82010,Acetone assay,Lab Services,Per Unit,$8.17 ,OP,8.17,41.94,,,,,,
Humana MCR ADV,CPT,82013,Acetylcholinesterase assay,Lab Services,Per Unit,$12.29 ,OP,12.29,12.29,,,,,,
Humana MCR ADV,CPT,82016,Acylcarnitines qual,Lab Services,Per Unit,$16.49 ,OP,16.49,61,,,,,,
Humana MCR ADV,CPT,82017,Acylcarnitines quant,Lab Services,Per Unit,$16.87 ,OP,16.87,76.26,,,,,,
Humana MCR ADV,CPT,82024,Assay of acth,Lab Services,Per Unit,$38.62 ,OP,38.62,171.58,,,,,,
Humana MCR ADV,CPT,82030,Assay of adp & amp,Lab Services,Per Unit,$25.80 ,OP,25.8,99.13,,,,,,
Humana MCR ADV,CPT,82040,Assay of serum albumin,Lab Services,Per Unit,$4.95 ,OP,4.95,22.88,,,,,,
Humana MCR ADV,CPT,82042,Other source albumin quan ea,Lab Services,Per Unit,$7.78 ,OP,7.78,26.7,,,,,,
Humana MCR ADV,CPT,82043,Ur albumin quantitative,Lab Services,Per Unit,$5.78 ,OP,5.78,26.7,,,,,,
Humana MCR ADV,CPT,82044,Ur albumin semiquantitative,Lab Services,Per Unit,$6.23 ,OP,6.23,22.88,,,,,,
Humana MCR ADV,CPT,82045,Albumin ischemia modified,Lab Services,Per Unit,$33.94 ,OP,33.94,125.82,,,,,,
Humana MCR ADV,CPT,82075,Assay of breath ethanol,Lab Services,Per Unit,$30.00 ,OP,30,45.74,,,,,,
Humana MCR ADV,CPT,82077,Assay spec xcp ur&breath ia,Lab Services,Per Unit,$17.27 ,OP,17.27,17.27,,,,,,
Humana MCR ADV,CPT,82085,Assay of aldolase,Lab Services,Per Unit,$9.71 ,OP,9.71,41.94,,,,,,
Humana MCR ADV,CPT,82088,Assay of aldosterone,Lab Services,Per Unit,$40.75 ,OP,40.75,183.02,,,,,,
Humana MCR ADV,CPT,82103,Alpha-1-antitrypsin total,Lab Services,Per Unit,$13.44 ,OP,13.44,61,,,,,,
Humana MCR ADV,CPT,82104,Alpha-1-antitrypsin pheno,Lab Services,Per Unit,$14.46 ,OP,14.46,64.82,,,,,,
Humana MCR ADV,CPT,82105,Alpha-fetoprotein serum,Lab Services,Per Unit,$16.77 ,OP,16.77,76.26,,,,,,
Humana MCR ADV,CPT,82106,Alpha-fetoprotein amniotic,Lab Services,Per Unit,$17.00 ,OP,17,76.26,,,,,,
Humana MCR ADV,CPT,82107,Alpha-fetoprotein l3,Lab Services,Per Unit,$64.41 ,OP,64.41,209.7,,,,,,
Humana MCR ADV,CPT,82108,Assay of aluminum,Lab Services,Per Unit,$25.48 ,OP,25.48,114.39,,,,,,
Humana MCR ADV,CPT,82120,Amines vaginal fluid qual,Lab Services,Per Unit,$5.99 ,OP,5.99,19.07,,,,,,
Humana MCR ADV,CPT,82127,Amino acid single qual,Lab Services,Per Unit,$14.18 ,OP,14.18,61,,,,,,
Humana MCR ADV,CPT,82128,Amino acids mult qual,Lab Services,Per Unit,$13.87 ,OP,13.87,61,,,,,,
Humana MCR ADV,CPT,82131,Amino acids single quant,Lab Services,Per Unit,$22.98 ,OP,22.98,76.26,,,,,,
Humana MCR ADV,CPT,82135,Assay aminolevulinic acid,Lab Services,Per Unit,$16.45 ,OP,16.45,64.82,,,,,,
Humana MCR ADV,CPT,82136,Amino acids quant 2-5,Lab Services,Per Unit,$19.61 ,OP,19.61,76.26,,,,,,
Humana MCR ADV,CPT,82139,Amino acids quan 6 or more,Lab Services,Per Unit,$16.87 ,OP,16.87,16.87,,,,,,
Humana MCR ADV,CPT,82140,Assay of ammonia,Lab Services,Per Unit,$14.57 ,OP,14.57,64.82,,,,,,
Humana MCR ADV,CPT,82143,Amniotic fluid scan,Lab Services,Per Unit,$9.35 ,OP,9.35,30.51,,,,,,
Humana MCR ADV,CPT,82150,Assay of amylase,Lab Services,Per Unit,$6.48 ,OP,6.48,34.31,,,,,,
Humana MCR ADV,CPT,82154,Androstanediol glucuronide,Lab Services,Per Unit,$28.83 ,OP,28.83,28.83,,,,,,
Humana MCR ADV,CPT,82157,Assay of androstenedione,Lab Services,Per Unit,$29.28 ,OP,29.28,129.64,,,,,,
Humana MCR ADV,CPT,82160,Assay of androsterone,Lab Services,Per Unit,$25.55 ,OP,25.55,110.57,,,,,,
Humana MCR ADV,CPT,82163,Assay of angiotensin ii,Lab Services,Per Unit,$20.52 ,OP,20.52,91.51,,,,,,
Humana MCR ADV,CPT,82164,Angiotensin i enzyme test,Lab Services,Per Unit,$14.60 ,OP,14.6,64.82,,,,,,
Humana MCR ADV,CPT,82172,Assay of apolipoprotein,Lab Services,Per Unit,$21.09 ,OP,21.09,68.63,,,,,,
Humana MCR ADV,CPT,82175,Assay of arsenic,Lab Services,Per Unit,$18.97 ,OP,18.97,83.87,,,,,,
Humana MCR ADV,CPT,82180,Assay of ascorbic acid,Lab Services,Per Unit,$9.89 ,OP,9.89,9.89,,,,,,
Humana MCR ADV,CPT,82190,Atomic absorption,Lab Services,Per Unit,$15.90 ,OP,15.9,64.82,,,,,,
Humana MCR ADV,CPT,82232,Assay of beta-2 protein,Lab Services,Per Unit,$16.18 ,OP,16.18,72.44,,,,,,
Humana MCR ADV,CPT,82239,Bile acids total,Lab Services,Per Unit,$17.12 ,OP,17.12,76.26,,,,,,
Humana MCR ADV,CPT,82240,Bile acids cholylglycine,Lab Services,Per Unit,$26.58 ,OP,26.58,64.82,,,,,,
Humana MCR ADV,CPT,82247,Bilirubin total,Lab Services,Per Unit,$5.02 ,OP,5.02,26.7,,,,,,
Humana MCR ADV,CPT,82248,Bilirubin direct,Lab Services,Per Unit,$5.02 ,OP,5.02,26.7,,,,,,
Humana MCR ADV,CPT,82252,Fecal bilirubin test,Lab Services,Per Unit,$4.56 ,OP,4.56,19.07,,,,,,
Humana MCR ADV,CPT,82261,Assay of biotinidase,Lab Services,Per Unit,$16.87 ,OP,16.87,76.26,,,,,,
Humana MCR ADV,CPT,82270,Occult blood feces,Lab Services,Per Unit,$4.38 ,OP,4.38,15.26,,,,,,
Humana MCR ADV,CPT,82271,Occult blood other sources,Lab Services,Per Unit,$5.32 ,OP,5.32,15.26,,,,,,
Humana MCR ADV,CPT,82272,Occult bld feces 1-3 tests,Lab Services,Per Unit,$4.23 ,OP,4.23,15.26,,,,,,
Humana MCR ADV,CPT,82274,Assay test for blood fecal,Lab Services,Per Unit,$15.92 ,OP,15.92,80.07,,,,,,
Humana MCR ADV,CPT,82286,Assay of bradykinin,Lab Services,Per Unit,$5.16 ,OP,5.16,30.51,,,,,,
Humana MCR ADV,CPT,82300,Assay of cadmium,Lab Services,Per Unit,$23.64 ,OP,23.64,102.95,,,,,,
Humana MCR ADV,CPT,82306,Vitamin d 25 hydroxy,Lab Services,Per Unit,$29.60 ,OP,29.6,356.68,,,,,,
Humana MCR ADV,CPT,82308,Assay of calcitonin,Lab Services,Per Unit,$26.79 ,OP,26.79,118.19,,,,,,
Humana MCR ADV,CPT,82310,Assay of calcium,Lab Services,Per Unit,$5.16 ,OP,5.16,22.88,,,,,,
Humana MCR ADV,CPT,82330,Assay of calcium,Lab Services,Per Unit,$13.68 ,OP,13.68,61,,,,,,
Humana MCR ADV,CPT,82331,Calcium infusion test,Lab Services,Per Unit,$13.34 ,OP,13.34,22.88,,,,,,
Humana MCR ADV,CPT,82340,Assay of calcium in urine,Lab Services,Per Unit,$6.03 ,OP,6.03,26.7,,,,,,
Humana MCR ADV,CPT,82355,Calculus analysis qual,Lab Services,Per Unit,$11.58 ,OP,11.58,53.38,,,,,,
Humana MCR ADV,CPT,82360,Calculus assay quant,Lab Services,Per Unit,$12.87 ,OP,12.87,45.74,,,,,,
Humana MCR ADV,CPT,82365,Calculus spectroscopy,Lab Services,Per Unit,$12.90 ,OP,12.9,45.74,,,,,,
Humana MCR ADV,CPT,82370,X-ray assay calculus,Lab Services,Per Unit,$12.52 ,OP,12.52,45.74,,,,,,
Humana MCR ADV,CPT,82373,Assay c-d transfer measure,Lab Services,Per Unit,$18.06 ,OP,18.06,80.07,,,,,,
Humana MCR ADV,CPT,82374,Assay blood carbon dioxide,Lab Services,Per Unit,$4.88 ,OP,4.88,22.88,,,,,,
Humana MCR ADV,CPT,82375,Assay carboxyhb quant,Lab Services,Per Unit,$12.32 ,OP,12.32,26.7,,,,,,
Humana MCR ADV,CPT,82376,Assay carboxyhb qual,Lab Services,Per Unit,$14.07 ,OP,14.07,26.7,,,,,,
Humana MCR ADV,CPT,82378,Carcinoembryonic antigen,Lab Services,Per Unit,$18.96 ,OP,18.96,83.87,,,,,,
Humana MCR ADV,CPT,82379,Assay of carnitine,Lab Services,Per Unit,$16.87 ,OP,16.87,76.26,,,,,,
Humana MCR ADV,CPT,82380,Assay of carotene,Lab Services,Per Unit,$9.22 ,OP,9.22,41.94,,,,,,
Humana MCR ADV,CPT,82382,Assay urine catecholamines,Lab Services,Per Unit,$27.30 ,OP,27.3,76.26,,,,,,
Humana MCR ADV,CPT,82383,Assay blood catecholamines,Lab Services,Per Unit,$29.08 ,OP,29.08,110.57,,,,,,
Humana MCR ADV,CPT,82384,Assay three catecholamines,Lab Services,Per Unit,$25.25 ,OP,25.25,110.57,,,,,,
Humana MCR ADV,CPT,82387,Assay of cathepsin-d,Lab Services,Per Unit,$18.06 ,OP,18.06,91.51,,,,,,
Humana MCR ADV,CPT,82390,Assay of ceruloplasmin,Lab Services,Per Unit,$10.74 ,OP,10.74,49.56,,,,,,
Humana MCR ADV,CPT,82397,Chemiluminescent assay,Lab Services,Per Unit,$14.12 ,OP,14.12,64.82,,,,,,
Humana MCR ADV,CPT,82415,Assay of chloramphenicol,Lab Services,Per Unit,$12.67 ,OP,12.67,57.19,,,,,,
Humana MCR ADV,CPT,82435,Assay of blood chloride,Lab Services,Per Unit,$4.60 ,OP,4.6,19.07,,,,,,
Humana MCR ADV,CPT,82436,Assay of urine chloride,Lab Services,Per Unit,$5.75 ,OP,5.75,22.88,,,,,,
Humana MCR ADV,CPT,82438,Assay other fluid chlorides,Lab Services,Per Unit,$5.00 ,OP,5,5,,,,,,
Humana MCR ADV,CPT,82441,Test for chlorohydrocarbons,Lab Services,Per Unit,$6.01 ,OP,6.01,26.7,,,,,,
Humana MCR ADV,CPT,82465,Assay bld/serum cholesterol,Lab Services,Per Unit,$4.35 ,OP,4.35,22.88,,,,,,
Humana MCR ADV,CPT,82480,Assay serum cholinesterase,Lab Services,Per Unit,$7.87 ,OP,7.87,34.31,,,,,,
Humana MCR ADV,CPT,82482,Assay rbc cholinesterase,Lab Services,Per Unit,$9.81 ,OP,9.81,34.31,,,,,,
Humana MCR ADV,CPT,82485,Assay chondroitin sulfate,Lab Services,Per Unit,$20.65 ,OP,20.65,91.51,,,,,,
Humana MCR ADV,CPT,82495,Assay of chromium,Lab Services,Per Unit,$20.28 ,OP,20.28,91.51,,,,,,
Humana MCR ADV,CPT,82507,Assay of citrate,Lab Services,Per Unit,$27.80 ,OP,27.8,57.19,,,,,,
Humana MCR ADV,CPT,82523,Collagen crosslinks,Lab Services,Per Unit,$18.68 ,OP,18.68,95.32,,,,,,
Humana MCR ADV,CPT,82525,Assay of copper,Lab Services,Per Unit,$12.41 ,OP,12.41,53.38,,,,,,
Humana MCR ADV,CPT,82528,Assay of corticosterone,Lab Services,Per Unit,$22.52 ,OP,22.52,99.13,,,,,,
Humana MCR ADV,CPT,82530,Cortisol free,Lab Services,Per Unit,$16.71 ,OP,16.71,76.26,,,,,,
Humana MCR ADV,CPT,82533,Total cortisol,Lab Services,Per Unit,$16.30 ,OP,16.3,72.44,,,,,,
Humana MCR ADV,CPT,82540,Assay of creatine,Lab Services,Per Unit,$4.64 ,OP,4.64,19.07,,,,,,
Humana MCR ADV,CPT,82542,Col chromotography qual/quan,Lab Services,Per Unit,$24.09 ,OP,24.09,80.07,,,,,,
Humana MCR ADV,CPT,82550,Assay of ck (cpk),Lab Services,Per Unit,$6.51 ,OP,6.51,30.51,,,,,,
Humana MCR ADV,CPT,82552,Assay of cpk in blood,Lab Services,Per Unit,$13.39 ,OP,13.39,61,,,,,,
Humana MCR ADV,CPT,82553,Creatine mb fraction,Lab Services,Per Unit,$11.55 ,OP,11.55,49.56,,,,,,
Humana MCR ADV,CPT,82554,Creatine isoforms,Lab Services,Per Unit,$11.87 ,OP,11.87,53.38,,,,,,
Humana MCR ADV,CPT,82565,Assay of creatinine,Lab Services,Per Unit,$5.12 ,OP,5.12,22.88,,,,,,
Humana MCR ADV,CPT,82570,Assay of urine creatinine,Lab Services,Per Unit,$5.18 ,OP,5.18,26.7,,,,,,
Humana MCR ADV,CPT,82575,Creatinine clearance test,Lab Services,Per Unit,$9.46 ,OP,9.46,41.94,,,,,,
Humana MCR ADV,CPT,82585,Assay of cryofibrinogen,Lab Services,Per Unit,$14.14 ,OP,14.14,38.13,,,,,,
Humana MCR ADV,CPT,82595,Assay of cryoglobulin,Lab Services,Per Unit,$6.47 ,OP,6.47,30.51,,,,,,
Humana MCR ADV,CPT,82600,Assay of cyanide,Lab Services,Per Unit,$19.40 ,OP,19.4,19.4,,,,,,
Humana MCR ADV,CPT,82607,Vitamin b-12,Lab Services,Per Unit,$15.08 ,OP,15.08,68.63,,,,,,
Humana MCR ADV,CPT,82608,B-12 binding capacity,Lab Services,Per Unit,$14.32 ,OP,14.32,14.32,,,,,,
Humana MCR ADV,CPT,82610,Cystatin c,Lab Services,Per Unit,$18.52 ,OP,18.52,61,,,,,,
Humana MCR ADV,CPT,82615,Test for urine cystines,Lab Services,Per Unit,$9.55 ,OP,9.55,38.13,,,,,,
Humana MCR ADV,CPT,82626,Dehydroepiandrosterone,Lab Services,Per Unit,$25.27 ,OP,25.27,114.39,,,,,,
Humana MCR ADV,CPT,82627,Dehydroepiandrosterone,Lab Services,Per Unit,$22.23 ,OP,22.23,99.13,,,,,,
Humana MCR ADV,CPT,82633,Desoxycorticosterone,Lab Services,Per Unit,$30.98 ,OP,30.98,122,,,,,,
Humana MCR ADV,CPT,82634,Deoxycortisol,Lab Services,Per Unit,$29.28 ,OP,29.28,76.26,,,,,,
Humana MCR ADV,CPT,82638,Assay of dibucaine number,Lab Services,Per Unit,$12.25 ,OP,12.25,53.38,,,,,,
Humana MCR ADV,CPT,82642,Dihydrotestosterone,Lab Services,Per Unit,$29.28 ,OP,29.28,114.39,,,,,,
Humana MCR ADV,CPT,82652,Vit d 1 25-dihydroxy,Lab Services,Per Unit,$38.50 ,OP,38.5,171.58,,,,,,
Humana MCR ADV,CPT,82656,Pancreatic elastase fecal,Lab Services,Per Unit,$11.53 ,OP,11.53,11.53,,,,,,
Humana MCR ADV,CPT,82657,Enzyme cell activity,Lab Services,Per Unit,$22.17 ,OP,22.17,80.07,,,,,,
Humana MCR ADV,CPT,82658,Enzyme cell activity ra,Lab Services,Per Unit,$44.03 ,OP,44.03,44.03,,,,,,
Humana MCR ADV,CPT,82664,Electrophoretic test,Lab Services,Per Unit,$61.50 ,OP,61.5,122,,,,,,
Humana MCR ADV,CPT,82668,Assay of erythropoietin,Lab Services,Per Unit,$18.79 ,OP,18.79,83.87,,,,,,
Humana MCR ADV,CPT,82670,Assay of total estradiol,Lab Services,Per Unit,$27.94 ,OP,27.94,49.56,,,,,,
Humana MCR ADV,CPT,82671,Assay of estrogens,Lab Services,Per Unit,$32.30 ,OP,32.3,114.39,,,,,,
Humana MCR ADV,CPT,82672,Assay of estrogen,Lab Services,Per Unit,$21.70 ,OP,21.7,95.32,,,,,,
Humana MCR ADV,CPT,82677,Assay of estriol,Lab Services,Per Unit,$24.18 ,OP,24.18,49.56,,,,,,
Humana MCR ADV,CPT,82679,Assay of estrone,Lab Services,Per Unit,$24.95 ,OP,24.95,57.19,,,,,,
Humana MCR ADV,CPT,82681,Assay dir meas fr estradiol,Lab Services,Per Unit,$27.94 ,OP,27.94,27.94,,,,,,
Humana MCR ADV,CPT,82693,Assay of ethylene glycol,Lab Services,Per Unit,$14.90 ,OP,14.9,64.82,,,,,,
Humana MCR ADV,CPT,82696,Assay of etiocholanolone,Lab Services,Per Unit,$26.24 ,OP,26.24,64.82,,,,,,
Humana MCR ADV,CPT,82705,Fats/lipids feces qual,Lab Services,Per Unit,$5.10 ,OP,5.1,5.1,,,,,,
Humana MCR ADV,CPT,82710,Fats/lipids feces quant,Lab Services,Per Unit,$16.80 ,OP,16.8,16.8,,,,,,
Humana MCR ADV,CPT,82715,Assay of fecal fat,Lab Services,Per Unit,$22.97 ,OP,15.26,22.97,,,,,,
Humana MCR ADV,CPT,82725,Assay of blood fatty acids,Lab Services,Per Unit,$18.77 ,OP,18.77,18.77,,,,,,
Humana MCR ADV,CPT,82726,Long chain fatty acids,Lab Services,Per Unit,$19.75 ,OP,19.75,80.07,,,,,,
Humana MCR ADV,CPT,82728,Assay of ferritin,Lab Services,Per Unit,$13.63 ,OP,13.63,61,,,,,,
Humana MCR ADV,CPT,82731,Assay of fetal fibronectin,Lab Services,Per Unit,$64.41 ,OP,64.41,236.38,,,,,,
Humana MCR ADV,CPT,82735,Assay of fluoride,Lab Services,Per Unit,$18.54 ,OP,18.54,83.87,,,,,,
Humana MCR ADV,CPT,82746,Assay of folic acid serum,Lab Services,Per Unit,$14.70 ,OP,14.7,64.82,,,,,,
Humana MCR ADV,CPT,82747,Assay of folic acid rbc,Lab Services,Per Unit,$17.65 ,OP,17.65,76.26,,,,,,
Humana MCR ADV,CPT,82757,Assay of semen fructose,Lab Services,Per Unit,$17.34 ,OP,17.34,76.26,,,,,,
Humana MCR ADV,CPT,82759,Assay of rbc galactokinase,Lab Services,Per Unit,$21.48 ,OP,21.48,95.32,,,,,,
Humana MCR ADV,CPT,82760,Assay of galactose,Lab Services,Per Unit,$11.20 ,OP,11.2,49.56,,,,,,
Humana MCR ADV,CPT,82775,Assay galactose transferase,Lab Services,Per Unit,$21.07 ,OP,21.07,80.07,,,,,,
Humana MCR ADV,CPT,82776,Galactose transferase test,Lab Services,Per Unit,$11.74 ,OP,11.74,26.7,,,,,,
Humana MCR ADV,CPT,82777,Galectin-3,Lab Services,Per Unit,$44.25 ,OP,44.25,44.25,,,,,,
Humana MCR ADV,CPT,82784,Assay iga/igd/igg/igm each,Lab Services,Per Unit,$9.30 ,OP,9.3,41.94,,,,,,
Humana MCR ADV,CPT,82785,Assay of ige,Lab Services,Per Unit,$16.46 ,OP,16.46,72.44,,,,,,
Humana MCR ADV,CPT,82787,Igg 1 2 3 or 4 each,Lab Services,Per Unit,$8.02 ,OP,8.02,34.31,,,,,,
Humana MCR ADV,CPT,82800,Blood ph,Lab Services,Per Unit,$11.00 ,OP,11,30.51,,,,,,
Humana MCR ADV,CPT,82803,Blood gases any combination,Lab Services,Per Unit,$26.07 ,OP,26.07,61,,,,,,
Humana MCR ADV,CPT,82805,Blood gases w/o2 saturation,Lab Services,Per Unit,$78.77 ,OP,78.77,141.07,,,,,,
Humana MCR ADV,CPT,82810,Blood gases o2 sat only,Lab Services,Per Unit,$9.77 ,OP,9.77,9.77,,,,,,
Humana MCR ADV,CPT,82820,Hemoglobin-oxygen affinity,Lab Services,Per Unit,$13.34 ,OP,13.34,49.56,,,,,,
Humana MCR ADV,CPT,82930,Gastric analy w/ph ea spec,Lab Services,Per Unit,$6.71 ,OP,6.71,6.71,,,,,,
Humana MCR ADV,CPT,82938,Gastrin test,Lab Services,Per Unit,$17.69 ,OP,17.69,80.07,,,,,,
Humana MCR ADV,CPT,82941,Assay of gastrin,Lab Services,Per Unit,$17.63 ,OP,17.63,80.07,,,,,,
Humana MCR ADV,CPT,82943,Assay of glucagon,Lab Services,Per Unit,$14.29 ,OP,14.29,34.31,,,,,,
Humana MCR ADV,CPT,82945,Glucose other fluid,Lab Services,Per Unit,$3.93 ,OP,3.93,19.07,,,,,,
Humana MCR ADV,CPT,82946,Glucagon tolerance test,Lab Services,Per Unit,$17.77 ,OP,17.77,68.63,,,,,,
Humana MCR ADV,CPT,82947,Assay glucose blood quant,Lab Services,Per Unit,$3.93 ,OP,3.93,19.07,,,,,,
Humana MCR ADV,CPT,82948,Reagent strip/blood glucose,Lab Services,Per Unit,$5.04 ,OP,5.04,15.26,,,,,,
Humana MCR ADV,CPT,82950,Glucose test,Lab Services,Per Unit,$4.75 ,OP,4.75,22.88,,,,,,
Humana MCR ADV,CPT,82951,Glucose tolerance test (gtt),Lab Services,Per Unit,$12.87 ,OP,12.87,64.82,,,,,,
Humana MCR ADV,CPT,82952,Gtt-added samples,Lab Services,Per Unit,$3.92 ,OP,3.92,19.07,,,,,,
Humana MCR ADV,CPT,82955,Assay of g6pd enzyme,Lab Services,Per Unit,$9.70 ,OP,9.7,41.94,,,,,,
Humana MCR ADV,CPT,82960,Test for g6pd enzyme,Lab Services,Per Unit,$6.05 ,OP,6.05,6.05,,,,,,
Humana MCR ADV,CPT,82962,Glucose blood test,Lab Services,Per Unit,$3.28 ,OP,3.28,11.44,,,,,,
Humana MCR ADV,CPT,82963,Assay of glucosidase,Lab Services,Per Unit,$21.48 ,OP,21.48,80.07,,,,,,
Humana MCR ADV,CPT,82965,Assay of gdh enzyme,Lab Services,Per Unit,$13.15 ,OP,13.15,34.31,,,,,,
Humana MCR ADV,CPT,82977,Assay of ggt,Lab Services,Per Unit,$7.20 ,OP,7.2,34.31,,,,,,
Humana MCR ADV,CPT,82978,Assay of glutathione,Lab Services,Per Unit,$15.45 ,OP,15.45,64.82,,,,,,
Humana MCR ADV,CPT,82979,Assay rbc glutathione,Lab Services,Per Unit,$9.44 ,OP,9.44,30.51,,,,,,
Humana MCR ADV,CPT,82985,Assay of glycated protein,Lab Services,Per Unit,$16.76 ,OP,16.76,76.26,,,,,,
Humana MCR ADV,CPT,83001,Assay of gonadotropin (fsh),Lab Services,Per Unit,$18.58 ,OP,18.58,91.51,,,,,,
Humana MCR ADV,CPT,83002,Assay of gonadotropin (lh),Lab Services,Per Unit,$18.52 ,OP,18.52,91.51,,,,,,
Humana MCR ADV,CPT,83003,Assay growth hormone (hgh),Lab Services,Per Unit,$16.67 ,OP,16.67,72.44,,,,,,
Humana MCR ADV,CPT,83006,Growth stimulation gene 2,Lab Services,Per Unit,$75.60 ,OP,75.6,75.6,,,,,,
Humana MCR ADV,CPT,83009,H pylori (c-13) blood,Lab Services,Per Unit,$67.36 ,OP,67.36,301.2,,,,,,
Humana MCR ADV,CPT,83010,Assay of haptoglobin quant,Lab Services,Per Unit,$12.58 ,OP,12.58,57.19,,,,,,
Humana MCR ADV,CPT,83012,Assay of haptoglobins,Lab Services,Per Unit,$26.89 ,OP,26.89,72.44,,,,,,
Humana MCR ADV,CPT,83013,H pylori (c-13) breath,Lab Services,Per Unit,$67.36 ,OP,67.36,301.2,,,,,,
Humana MCR ADV,CPT,83014,H pylori drug admin,Lab Services,Per Unit,$7.86 ,OP,7.86,34.31,,,,,,
Humana MCR ADV,CPT,83015,Heavy metal qual any anal,Lab Services,Per Unit,$20.94 ,OP,20.94,83.87,,,,,,
Humana MCR ADV,CPT,83018,Heavy metal quant each nes,Lab Services,Per Unit,$21.96 ,OP,21.96,99.13,,,,,,
Humana MCR ADV,CPT,83020,Hemoglobin electrophoresis,Lab Services,Per Unit,$12.87 ,OP,12.87,45.74,,,,,,
Humana MCR ADV,CPT,83021,Hemoglobin chromotography,Lab Services,Per Unit,$18.06 ,OP,18.06,80.07,,,,,,
Humana MCR ADV,CPT,83026,Hemoglobin copper sulfate,Lab Services,Per Unit,$4.01 ,OP,4.01,4.01,,,,,,
Humana MCR ADV,CPT,83030,Fetal hemoglobin chemical,Lab Services,Per Unit,$10.74 ,OP,10.74,10.74,,,,,,
Humana MCR ADV,CPT,83033,Fetal hemoglobin assay qual,Lab Services,Per Unit,$8.00 ,OP,8,8,,,,,,
Humana MCR ADV,CPT,83036,Glycosylated hemoglobin test,Lab Services,Per Unit,$9.71 ,OP,9.71,49.56,,,,,,
Humana MCR ADV,CPT,83037,Glycosylated hb home device,Lab Services,Per Unit,$9.71 ,OP,9.71,41.94,,,,,,
Humana MCR ADV,CPT,83045,Blood methemoglobin test,Lab Services,Per Unit,$6.49 ,OP,6.49,22.88,,,,,,
Humana MCR ADV,CPT,83050,Blood methemoglobin assay,Lab Services,Per Unit,$8.20 ,OP,8.2,15.26,,,,,,
Humana MCR ADV,CPT,83051,Assay of plasma hemoglobin,Lab Services,Per Unit,$7.31 ,OP,7.31,7.31,,,,,,
Humana MCR ADV,CPT,83060,Blood sulfhemoglobin assay,Lab Services,Per Unit,$8.80 ,OP,8.8,15.26,,,,,,
Humana MCR ADV,CPT,83065,Assay of hemoglobin heat,Lab Services,Per Unit,$9.00 ,OP,9,15.26,,,,,,
Humana MCR ADV,CPT,83068,Hemoglobin stability screen,Lab Services,Per Unit,$9.47 ,OP,9.47,9.47,,,,,,
Humana MCR ADV,CPT,83069,Assay of urine hemoglobin,Lab Services,Per Unit,$3.95 ,OP,3.95,7.62,,,,,,
Humana MCR ADV,CPT,83070,Assay of hemosiderin qual,Lab Services,Per Unit,$4.75 ,OP,4.75,15.26,,,,,,
Humana MCR ADV,CPT,83080,Assay of b hexosaminidase,Lab Services,Per Unit,$16.87 ,OP,16.87,76.26,,,,,,
Humana MCR ADV,CPT,83088,Assay of histamine,Lab Services,Per Unit,$29.53 ,OP,29.53,129.64,,,,,,
Humana MCR ADV,CPT,83090,Assay of homocystine,Lab Services,Per Unit,$17.92 ,OP,17.92,76.26,,,,,,
Humana MCR ADV,CPT,83150,Assay of homovanillic acid,Lab Services,Per Unit,$22.41 ,OP,22.41,87.69,,,,,,
Humana MCR ADV,CPT,83491,Assay of corticosteroids 17,Lab Services,Per Unit,$17.90 ,OP,17.9,76.26,,,,,,
Humana MCR ADV,CPT,83497,Assay of 5-hiaa,Lab Services,Per Unit,$12.90 ,OP,12.9,57.19,,,,,,
Humana MCR ADV,CPT,83498,Assay of progesterone 17-d,Lab Services,Per Unit,$27.17 ,OP,27.17,122,,,,,,
Humana MCR ADV,CPT,83500,Assay free hydroxyproline,Lab Services,Per Unit,$22.65 ,OP,22.65,99.13,,,,,,
Humana MCR ADV,CPT,83505,Assay total hydroxyproline,Lab Services,Per Unit,$24.30 ,OP,24.3,106.76,,,,,,
Humana MCR ADV,CPT,83516,Immunoassay nonantibody,Lab Services,Per Unit,$11.53 ,OP,11.53,49.56,,,,,,
Humana MCR ADV,CPT,83518,Immunoassay dipstick,Lab Services,Per Unit,$9.64 ,OP,9.64,9.64,,,,,,
Humana MCR ADV,CPT,83519,Ria nonantibody,Lab Services,Per Unit,$18.40 ,OP,18.4,61,,,,,,
Humana MCR ADV,CPT,83520,Immunoassay quant nos nonab,Lab Services,Per Unit,$17.27 ,OP,17.27,57.19,,,,,,
Humana MCR ADV,CPT,83525,Assay of insulin,Lab Services,Per Unit,$11.43 ,OP,11.43,49.56,,,,,,
Humana MCR ADV,CPT,83527,Assay of insulin,Lab Services,Per Unit,$12.95 ,OP,12.95,57.19,,,,,,
Humana MCR ADV,CPT,83528,Assay of intrinsic factor,Lab Services,Per Unit,$19.82 ,OP,19.82,72.44,,,,,,
Humana MCR ADV,CPT,83540,Assay of iron,Lab Services,Per Unit,$6.47 ,OP,6.47,30.51,,,,,,
Humana MCR ADV,CPT,83550,Iron binding test,Lab Services,Per Unit,$8.74 ,OP,8.74,38.13,,,,,,
Humana MCR ADV,CPT,83570,Assay of idh enzyme,Lab Services,Per Unit,$8.85 ,OP,8.85,38.13,,,,,,
Humana MCR ADV,CPT,83582,Assay of ketogenic steroids,Lab Services,Per Unit,$15.47 ,OP,15.47,15.47,,,,,,
Humana MCR ADV,CPT,83586,Assay 17- ketosteroids,Lab Services,Per Unit,$12.80 ,OP,12.8,57.19,,,,,,
Humana MCR ADV,CPT,83593,Fractionation ketosteroids,Lab Services,Per Unit,$28.50 ,OP,28.5,118.19,,,,,,
Humana MCR ADV,CPT,83605,Assay of lactic acid,Lab Services,Per Unit,$11.57 ,OP,11.57,53.38,,,,,,
Humana MCR ADV,CPT,83615,Lactate (ld) (ldh) enzyme,Lab Services,Per Unit,$6.04 ,OP,6.04,26.7,,,,,,
Humana MCR ADV,CPT,83625,Assay of ldh enzymes,Lab Services,Per Unit,$12.79 ,OP,12.79,49.56,,,,,,
Humana MCR ADV,CPT,83630,Lactoferrin fecal (qual),Lab Services,Per Unit,$19.70 ,OP,19.7,87.69,,,,,,
Humana MCR ADV,CPT,83631,Lactoferrin fecal (quant),Lab Services,Per Unit,$19.63 ,OP,19.63,87.69,,,,,,
Humana MCR ADV,CPT,83632,Placental lactogen,Lab Services,Per Unit,$20.22 ,OP,20.22,91.51,,,,,,
Humana MCR ADV,CPT,83633,Test urine for lactose,Lab Services,Per Unit,$11.25 ,OP,11.25,22.88,,,,,,
Humana MCR ADV,CPT,83655,Assay of lead,Lab Services,Per Unit,$12.11 ,OP,12.11,53.38,,,,,,
Humana MCR ADV,CPT,83661,L/s ratio fetal lung,Lab Services,Per Unit,$21.99 ,OP,21.99,99.13,,,,,,
Humana MCR ADV,CPT,83662,Foam stability fetal lung,Lab Services,Per Unit,$18.91 ,OP,18.91,83.87,,,,,,
Humana MCR ADV,CPT,83663,Fluoro polarize fetal lung,Lab Services,Per Unit,$18.91 ,OP,18.91,83.87,,,,,,
Humana MCR ADV,CPT,83664,Lamellar bdy fetal lung,Lab Services,Per Unit,$19.32 ,OP,19.32,83.87,,,,,,
Humana MCR ADV,CPT,83670,Assay of lap enzyme,Lab Services,Per Unit,$9.81 ,OP,9.81,41.94,,,,,,
Humana MCR ADV,CPT,83690,Assay of lipase,Lab Services,Per Unit,$6.89 ,OP,6.89,61.5,,,,,,
Humana MCR ADV,CPT,83695,Assay of lipoprotein(a),Lab Services,Per Unit,$14.32 ,OP,14.32,57.19,,,,,,
Humana MCR ADV,CPT,83698,Assay lipoprotein pla2,Lab Services,Per Unit,$46.31 ,OP,46.31,125.82,,,,,,
Humana MCR ADV,CPT,83700,Lipopro bld electrophoretic,Lab Services,Per Unit,$11.26 ,OP,11.26,49.56,,,,,,
Humana MCR ADV,CPT,83701,Lipoprotein bld hr fraction,Lab Services,Per Unit,$33.86 ,OP,33.86,110.57,,,,,,
Humana MCR ADV,CPT,83704,Lipoprotein bld quan part,Lab Services,Per Unit,$34.19 ,OP,34.19,141.07,,,,,,
Humana MCR ADV,CPT,83718,Assay of lipoprotein,Lab Services,Per Unit,$8.19 ,OP,8.19,41.94,,,,,,
Humana MCR ADV,CPT,83719,Assay of blood lipoprotein,Lab Services,Per Unit,$12.75 ,OP,12.75,53.38,,,,,,
Humana MCR ADV,CPT,83721,Assay of blood lipoprotein,Lab Services,Per Unit,$10.50 ,OP,10.5,41.94,,,,,,
Humana MCR ADV,CPT,83722,Lipoprtn dir meas sd ldl chl,Lab Services,Per Unit,$34.19 ,OP,34.19,141.07,,,,,,
Humana MCR ADV,CPT,83727,Assay of lrh hormone,Lab Services,Per Unit,$17.19 ,OP,17.19,76.26,,,,,,
Humana MCR ADV,CPT,83735,Assay of magnesium,Lab Services,Per Unit,$6.70 ,OP,6.7,34.31,,,,,,
Humana MCR ADV,CPT,83775,Assay malate dehydrogenase,Lab Services,Per Unit,$7.37 ,OP,7.37,34.31,,,,,,
Humana MCR ADV,CPT,83785,Assay of manganese,Lab Services,Per Unit,$26.65 ,OP,26.65,110.57,,,,,,
Humana MCR ADV,CPT,83789,Mass spectrometry qual/quan,Lab Services,Per Unit,$24.11 ,OP,24.11,80.07,,,,,,
Humana MCR ADV,CPT,83825,Assay of mercury,Lab Services,Per Unit,$16.26 ,OP,16.26,72.44,,,,,,
Humana MCR ADV,CPT,83835,Assay of metanephrines,Lab Services,Per Unit,$16.94 ,OP,16.94,76.26,,,,,,
Humana MCR ADV,CPT,83857,Assay of methemalbumin,Lab Services,Per Unit,$10.74 ,OP,10.74,49.56,,,,,,
Humana MCR ADV,CPT,83861,Microfluid analy tears,Lab Services,Per Unit,$22.48 ,OP,22.48,22.48,,,,,,
Humana MCR ADV,CPT,83864,Mucopolysaccharides,Lab Services,Per Unit,$28.50 ,OP,28.5,87.69,,,,,,
Humana MCR ADV,CPT,83872,Assay synovial fluid mucin,Lab Services,Per Unit,$5.86 ,OP,5.86,26.7,,,,,,
Humana MCR ADV,CPT,83873,Assay of csf protein,Lab Services,Per Unit,$17.20 ,OP,17.2,72.44,,,,,,
Humana MCR ADV,CPT,83874,Assay of myoglobin,Lab Services,Per Unit,$12.92 ,OP,12.92,57.19,,,,,,
Humana MCR ADV,CPT,83876,Assay myeloperoxidase,Lab Services,Per Unit,$50.86 ,OP,50.86,57.19,,,,,,
Humana MCR ADV,CPT,83880,Assay of natriuretic peptide,Lab Services,Per Unit,$39.26 ,OP,39.26,245.98,,,,,,
Humana MCR ADV,CPT,83883,Assay nephelometry not spec,Lab Services,Per Unit,$13.60 ,OP,13.6,61,,,,,,
Humana MCR ADV,CPT,83885,Assay of nickel,Lab Services,Per Unit,$24.51 ,OP,24.51,45.74,,,,,,
Humana MCR ADV,CPT,83915,Assay of nucleotidase,Lab Services,Per Unit,$11.15 ,OP,11.15,11.15,,,,,,
Humana MCR ADV,CPT,83916,Oligoclonal bands,Lab Services,Per Unit,$27.39 ,OP,27.39,87.69,,,,,,
Humana MCR ADV,CPT,83918,Organic acids total quant,Lab Services,Per Unit,$23.60 ,OP,23.6,72.44,,,,,,
Humana MCR ADV,CPT,83919,Organic acids qual each,Lab Services,Per Unit,$16.45 ,OP,16.45,16.45,,,,,,
Humana MCR ADV,CPT,83921,Organic acid single quant,Lab Services,Per Unit,$21.21 ,OP,21.21,72.44,,,,,,
Humana MCR ADV,CPT,83930,Assay of blood osmolality,Lab Services,Per Unit,$6.61 ,OP,6.61,26.7,,,,,,
Humana MCR ADV,CPT,83935,Assay of urine osmolality,Lab Services,Per Unit,$6.82 ,OP,6.82,30.51,,,,,,
Humana MCR ADV,CPT,83937,Assay of osteocalcin,Lab Services,Per Unit,$29.85 ,OP,29.85,133.45,,,,,,
Humana MCR ADV,CPT,83945,Assay of oxalate,Lab Services,Per Unit,$14.45 ,OP,14.45,57.19,,,,,,
Humana MCR ADV,CPT,83950,Oncoprotein her-2/neu,Lab Services,Per Unit,$64.41 ,OP,64.41,209.7,,,,,,
Humana MCR ADV,CPT,83951,Oncoprotein dcp,Lab Services,Per Unit,$64.41 ,OP,64.41,209.7,,,,,,
Humana MCR ADV,CPT,83970,Assay of parathormone,Lab Services,Per Unit,$41.28 ,OP,41.28,183.02,,,,,,
Humana MCR ADV,CPT,83986,Assay ph body fluid nos,Lab Services,Per Unit,$3.58 ,OP,3.58,19.07,,,,,,
Humana MCR ADV,CPT,83987,Exhaled breath condensate,Lab Services,Per Unit,$3.58 ,OP,3.58,3.58,,,,,,
Humana MCR ADV,CPT,83993,Assay for calprotectin fecal,Lab Services,Per Unit,$19.63 ,OP,19.63,87.69,,,,,,
Humana MCR ADV,CPT,84030,Assay of blood pku,Lab Services,Per Unit,$5.50 ,OP,5.5,26.7,,,,,,
Humana MCR ADV,CPT,84035,Assay of phenylketones,Lab Services,Per Unit,$3.98 ,OP,3.98,15.26,,,,,,
Humana MCR ADV,CPT,84060,Assay acid phosphatase,Lab Services,Per Unit,$7.64 ,OP,7.64,34.31,,,,,,
Humana MCR ADV,CPT,84066,Assay prostate phosphatase,Lab Services,Per Unit,$9.66 ,OP,9.66,41.94,,,,,,
Humana MCR ADV,CPT,84075,Assay alkaline phosphatase,Lab Services,Per Unit,$5.18 ,OP,5.18,26.7,,,,,,
Humana MCR ADV,CPT,84078,Assay alkaline phosphatase,Lab Services,Per Unit,$8.26 ,OP,8.26,34.31,,,,,,
Humana MCR ADV,CPT,84080,Assay alkaline phosphatases,Lab Services,Per Unit,$14.78 ,OP,14.78,64.82,,,,,,
Humana MCR ADV,CPT,84081,Assay phosphatidylglycerol,Lab Services,Per Unit,$16.52 ,OP,16.52,72.44,,,,,,
Humana MCR ADV,CPT,84085,Assay of rbc pg6d enzyme,Lab Services,Per Unit,$9.44 ,OP,9.44,30.51,,,,,,
Humana MCR ADV,CPT,84087,Assay phosphohexose enzymes,Lab Services,Per Unit,$10.73 ,OP,10.73,45.74,,,,,,
Humana MCR ADV,CPT,84100,Assay of phosphorus,Lab Services,Per Unit,$4.74 ,OP,4.74,22.88,,,,,,
Humana MCR ADV,CPT,84105,Assay of urine phosphorus,Lab Services,Per Unit,$5.78 ,OP,5.78,22.88,,,,,,
Humana MCR ADV,CPT,84106,Test for porphobilinogen,Lab Services,Per Unit,$5.82 ,OP,5.82,19.07,,,,,,
Humana MCR ADV,CPT,84110,Assay of porphobilinogen,Lab Services,Per Unit,$8.44 ,OP,8.44,38.13,,,,,,
Humana MCR ADV,CPT,84112,Eval amniotic fluid protein,Lab Services,Per Unit,$98.11 ,OP,98.11,98.11,,,,,,
Humana MCR ADV,CPT,84119,Test urine for porphyrins,Lab Services,Per Unit,$13.36 ,OP,13.36,13.36,,,,,,
Humana MCR ADV,CPT,84120,Assay of urine porphyrins,Lab Services,Per Unit,$14.71 ,OP,14.71,64.82,,,,,,
Humana MCR ADV,CPT,84126,Assay of feces porphyrins,Lab Services,Per Unit,$39.11 ,OP,39.11,114.39,,,,,,
Humana MCR ADV,CPT,84132,Assay of serum potassium,Lab Services,Per Unit,$4.76 ,OP,4.76,22.88,,,,,,
Humana MCR ADV,CPT,84133,Assay of urine potassium,Lab Services,Per Unit,$4.73 ,OP,4.73,19.07,,,,,,
Humana MCR ADV,CPT,84134,Assay of prealbumin,Lab Services,Per Unit,$14.59 ,OP,14.59,64.82,,,,,,
Humana MCR ADV,CPT,84135,Assay of pregnanediol,Lab Services,Per Unit,$21.27 ,OP,21.27,57.19,,,,,,
Humana MCR ADV,CPT,84138,Assay of pregnanetriol,Lab Services,Per Unit,$21.05 ,OP,21.05,83.87,,,,,,
Humana MCR ADV,CPT,84140,Assay of pregnenolone,Lab Services,Per Unit,$20.67 ,OP,20.67,91.51,,,,,,
Humana MCR ADV,CPT,84143,Assay of 17-hydroxypregneno,Lab Services,Per Unit,$22.81 ,OP,22.81,102.95,,,,,,
Humana MCR ADV,CPT,84144,Assay of progesterone,Lab Services,Per Unit,$20.86 ,OP,20.86,91.51,,,,,,
Humana MCR ADV,CPT,84145,Procalcitonin (pct),Lab Services,Per Unit,$27.22 ,OP,27.22,27.22,,,,,,
Humana MCR ADV,CPT,84146,Assay of prolactin,Lab Services,Per Unit,$19.38 ,OP,19.38,87.69,,,,,,
Humana MCR ADV,CPT,84150,Assay of prostaglandin,Lab Services,Per Unit,$41.77 ,OP,41.77,41.77,,,,,,
Humana MCR ADV,CPT,84152,Assay of psa complexed,Lab Services,Per Unit,$18.39 ,OP,18.39,80.07,,,,,,
Humana MCR ADV,CPT,84153,Assay of psa total,Lab Services,Per Unit,$18.39 ,OP,18.39,80.07,,,,,,
Humana MCR ADV,CPT,84154,Assay of psa free,Lab Services,Per Unit,$18.39 ,OP,18.39,80.07,,,,,,
Humana MCR ADV,CPT,84155,Assay of protein serum,Lab Services,Per Unit,$3.67 ,OP,3.67,15.26,,,,,,
Humana MCR ADV,CPT,84156,Assay of protein urine,Lab Services,Per Unit,$3.67 ,OP,3.67,15.26,,,,,,
Humana MCR ADV,CPT,84157,Assay of protein other,Lab Services,Per Unit,$4.00 ,OP,4,19.07,,,,,,
Humana MCR ADV,CPT,84160,Assay of protein any source,Lab Services,Per Unit,$5.61 ,OP,5.61,22.88,,,,,,
Humana MCR ADV,CPT,84163,Pappa serum,Lab Services,Per Unit,$15.05 ,OP,15.05,68.63,,,,,,
Humana MCR ADV,CPT,84165,Protein e-phoresis serum,Lab Services,Per Unit,$10.74 ,OP,10.74,49.56,,,,,,
Humana MCR ADV,CPT,84166,Protein e-phoresis/urine/csf,Lab Services,Per Unit,$17.83 ,OP,17.83,80.07,,,,,,
Humana MCR ADV,CPT,84181,Western blot test,Lab Services,Per Unit,$17.03 ,OP,17.03,118.19,,,,,,
Humana MCR ADV,CPT,84182,Protein western blot test,Lab Services,Per Unit,$29.21 ,OP,29.21,129.64,,,,,,
Humana MCR ADV,CPT,84202,Assay rbc protoporphyrin,Lab Services,Per Unit,$14.35 ,OP,14.35,64.82,,,,,,
Humana MCR ADV,CPT,84203,Test rbc protoporphyrin,Lab Services,Per Unit,$9.74 ,OP,9.74,38.13,,,,,,
Humana MCR ADV,CPT,84206,Assay of proinsulin,Lab Services,Per Unit,$26.69 ,OP,26.69,80.07,,,,,,
Humana MCR ADV,CPT,84207,Assay of vitamin b-6,Lab Services,Per Unit,$28.10 ,OP,28.1,125.82,,,,,,
Humana MCR ADV,CPT,84210,Assay of pyruvate,Lab Services,Per Unit,$14.48 ,OP,14.48,49.56,,,,,,
Humana MCR ADV,CPT,84220,Assay of pyruvate kinase,Lab Services,Per Unit,$9.44 ,OP,9.44,41.94,,,,,,
Humana MCR ADV,CPT,84228,Assay of quinine,Lab Services,Per Unit,$11.63 ,OP,11.63,53.38,,,,,,
Humana MCR ADV,CPT,84233,Assay of estrogen,Lab Services,Per Unit,$87.88 ,OP,87.88,209.7,,,,,,
Humana MCR ADV,CPT,84234,Assay of progesterone,Lab Services,Per Unit,$64.88 ,OP,64.88,183.02,,,,,,
Humana MCR ADV,CPT,84235,Assay of endocrine hormone,Lab Services,Per Unit,$71.23 ,OP,71.23,163.95,,,,,,
Humana MCR ADV,CPT,84238,Assay nonendocrine receptor,Lab Services,Per Unit,$36.57 ,OP,36.57,163.95,,,,,,
Humana MCR ADV,CPT,84244,Assay of renin,Lab Services,Per Unit,$21.99 ,OP,21.99,99.13,,,,,,
Humana MCR ADV,CPT,84252,Assay of vitamin b-2,Lab Services,Per Unit,$20.24 ,OP,20.24,20.24,,,,,,
Humana MCR ADV,CPT,84255,Assay of selenium,Lab Services,Per Unit,$25.53 ,OP,25.53,114.39,,,,,,
Humana MCR ADV,CPT,84260,Assay of serotonin,Lab Services,Per Unit,$30.98 ,OP,30.98,30.98,,,,,,
Humana MCR ADV,CPT,84270,Assay of sex hormone globul,Lab Services,Per Unit,$21.73 ,OP,21.73,95.32,,,,,,
Humana MCR ADV,CPT,84275,Assay of sialic acid,Lab Services,Per Unit,$13.44 ,OP,13.44,13.44,,,,,,
Humana MCR ADV,CPT,84285,Assay of silica,Lab Services,Per Unit,$25.21 ,OP,25.21,38.13,,,,,,
Humana MCR ADV,CPT,84295,Assay of serum sodium,Lab Services,Per Unit,$4.81 ,OP,4.81,22.88,,,,,,
Humana MCR ADV,CPT,84300,Assay of urine sodium,Lab Services,Per Unit,$5.06 ,OP,5.06,22.88,,,,,,
Humana MCR ADV,CPT,84302,Assay of sweat sodium,Lab Services,Per Unit,$4.86 ,OP,4.86,22.88,,,,,,
Humana MCR ADV,CPT,84305,Assay of somatomedin,Lab Services,Per Unit,$21.26 ,OP,21.26,95.32,,,,,,
Humana MCR ADV,CPT,84307,Assay of somatostatin,Lab Services,Per Unit,$18.28 ,OP,18.28,80.07,,,,,,
Humana MCR ADV,CPT,84311,Spectrophotometry,Lab Services,Per Unit,$8.10 ,OP,8.1,30.51,,,,,,
Humana MCR ADV,CPT,84315,Body fluid specific gravity,Lab Services,Per Unit,$3.28 ,OP,3.28,11.44,,,,,,
Humana MCR ADV,CPT,84375,Chromatogram assay sugars,Lab Services,Per Unit,$39.00 ,OP,39,39,,,,,,
Humana MCR ADV,CPT,84376,Sugars single qual,Lab Services,Per Unit,$5.50 ,OP,5.5,22.88,,,,,,
Humana MCR ADV,CPT,84377,Sugars multiple qual,Lab Services,Per Unit,$5.50 ,OP,5.5,22.88,,,,,,
Humana MCR ADV,CPT,84378,Sugars single quant,Lab Services,Per Unit,$11.53 ,OP,11.53,49.56,,,,,,
Humana MCR ADV,CPT,84379,Sugars multiple quant,Lab Services,Per Unit,$11.53 ,OP,11.53,49.56,,,,,,
Humana MCR ADV,CPT,84392,Assay of urine sulfate,Lab Services,Per Unit,$5.49 ,OP,5.49,22.88,,,,,,
Humana MCR ADV,CPT,84402,Assay of free testosterone,Lab Services,Per Unit,$25.47 ,OP,25.47,114.39,,,,,,
Humana MCR ADV,CPT,84403,Assay of total testosterone,Lab Services,Per Unit,$25.81 ,OP,25.81,114.39,,,,,,
Humana MCR ADV,CPT,84410,Testosterone bioavailable,Lab Services,Per Unit,$51.28 ,OP,51.28,51.28,,,,,,
Humana MCR ADV,CPT,84425,Assay of vitamin b-1,Lab Services,Per Unit,$21.23 ,OP,21.23,95.32,,,,,,
Humana MCR ADV,CPT,84430,Assay of thiocyanate,Lab Services,Per Unit,$11.63 ,OP,11.63,53.38,,,,,,
Humana MCR ADV,CPT,84431,Thromboxane urine,Lab Services,Per Unit,$35.11 ,OP,35.11,35.11,,,,,,
Humana MCR ADV,CPT,84432,Assay of thyroglobulin,Lab Services,Per Unit,$16.06 ,OP,16.06,72.44,,,,,,
Humana MCR ADV,CPT,84436,Assay of total thyroxine,Lab Services,Per Unit,$6.87 ,OP,6.87,30.51,,,,,,
Humana MCR ADV,CPT,84437,Assay of neonatal thyroxine,Lab Services,Per Unit,$6.47 ,OP,6.47,30.51,,,,,,
Humana MCR ADV,CPT,84439,Assay of free thyroxine,Lab Services,Per Unit,$9.02 ,OP,9.02,41.94,,,,,,
Humana MCR ADV,CPT,84442,Assay of thyroid activity,Lab Services,Per Unit,$14.78 ,OP,14.78,64.82,,,,,,
Humana MCR ADV,CPT,84443,Assay thyroid stim hormone,Lab Services,Per Unit,$16.80 ,OP,16.8,76.26,,,,,,
Humana MCR ADV,CPT,84445,Assay of tsi globulin,Lab Services,Per Unit,$50.86 ,OP,50.86,224.95,,,,,,
Humana MCR ADV,CPT,84446,Assay of vitamin e,Lab Services,Per Unit,$14.18 ,OP,14.18,64.82,,,,,,
Humana MCR ADV,CPT,84449,Assay of transcortin,Lab Services,Per Unit,$18.00 ,OP,18,80.07,,,,,,
Humana MCR ADV,CPT,84450,Transferase (ast) (sgot),Lab Services,Per Unit,$5.18 ,OP,5.18,22.88,,,,,,
Humana MCR ADV,CPT,84460,Alanine amino (alt) (sgpt),Lab Services,Per Unit,$5.30 ,OP,5.3,26.7,,,,,,
Humana MCR ADV,CPT,84466,Assay of transferrin,Lab Services,Per Unit,$12.76 ,OP,12.76,57.19,,,,,,
Humana MCR ADV,CPT,84478,Assay of triglycerides,Lab Services,Per Unit,$5.74 ,OP,5.74,30.51,,,,,,
Humana MCR ADV,CPT,84479,Assay of thyroid (t3 or t4),Lab Services,Per Unit,$6.47 ,OP,6.47,30.51,,,,,,
Humana MCR ADV,CPT,84480,Assay triiodothyronine (t3),Lab Services,Per Unit,$14.18 ,OP,14.18,49.56,,,,,,
Humana MCR ADV,CPT,84481,Free assay (ft-3),Lab Services,Per Unit,$16.94 ,OP,16.94,49.56,,,,,,
Humana MCR ADV,CPT,84482,T3 reverse,Lab Services,Per Unit,$15.76 ,OP,15.76,68.63,,,,,,
Humana MCR ADV,CPT,84484,Assay of troponin quant,Lab Services,Per Unit,$12.47 ,OP,12.47,92.24,,,,,,
Humana MCR ADV,CPT,84485,Assay duodenal fluid trypsin,Lab Services,Per Unit,$7.20 ,OP,7.2,7.2,,,,,,
Humana MCR ADV,CPT,84488,Test feces for trypsin,Lab Services,Per Unit,$7.30 ,OP,7.3,34.31,,,,,,
Humana MCR ADV,CPT,84490,Assay of feces for trypsin,Lab Services,Per Unit,$9.93 ,OP,9.93,26.7,,,,,,
Humana MCR ADV,CPT,84510,Assay of tyrosine,Lab Services,Per Unit,$10.63 ,OP,10.63,45.74,,,,,,
Humana MCR ADV,CPT,84512,Assay of troponin qual,Lab Services,Per Unit,$10.09 ,OP,10.09,34.31,,,,,,
Humana MCR ADV,CPT,84520,Assay of urea nitrogen,Lab Services,Per Unit,$3.95 ,OP,3.95,19.07,,,,,,
Humana MCR ADV,CPT,84525,Urea nitrogen semi-quant,Lab Services,Per Unit,$5.13 ,OP,5.13,15.26,,,,,,
Humana MCR ADV,CPT,84540,Assay of urine/urea-n,Lab Services,Per Unit,$5.56 ,OP,5.56,22.88,,,,,,
Humana MCR ADV,CPT,84545,Urea-n clearance test,Lab Services,Per Unit,$7.20 ,OP,7.2,19.07,,,,,,
Humana MCR ADV,CPT,84550,Assay of blood/uric acid,Lab Services,Per Unit,$4.52 ,OP,4.52,19.07,,,,,,
Humana MCR ADV,CPT,84560,Assay of urine/uric acid,Lab Services,Per Unit,$5.08 ,OP,5.08,22.88,,,,,,
Humana MCR ADV,CPT,84577,Assay of feces/urobilinogen,Lab Services,Per Unit,$16.80 ,OP,16.8,57.19,,,,,,
Humana MCR ADV,CPT,84578,Test urine urobilinogen,Lab Services,Per Unit,$4.47 ,OP,4.47,15.26,,,,,,
Humana MCR ADV,CPT,84580,Assay of urine urobilinogen,Lab Services,Per Unit,$9.55 ,OP,9.55,19.07,,,,,,
Humana MCR ADV,CPT,84583,Assay of urine urobilinogen,Lab Services,Per Unit,$6.05 ,OP,6.05,22.88,,,,,,
Humana MCR ADV,CPT,84585,Assay of urine vma,Lab Services,Per Unit,$15.50 ,OP,15.5,68.63,,,,,,
Humana MCR ADV,CPT,84586,Assay of vip,Lab Services,Per Unit,$35.33 ,OP,35.33,156.32,,,,,,
Humana MCR ADV,CPT,84588,Assay of vasopressin,Lab Services,Per Unit,$33.94 ,OP,33.94,125.82,,,,,,
Humana MCR ADV,CPT,84590,Assay of vitamin a,Lab Services,Per Unit,$11.61 ,OP,11.61,53.38,,,,,,
Humana MCR ADV,CPT,84591,Assay of nos vitamin,Lab Services,Per Unit,$17.06 ,OP,17.06,53.38,,,,,,
Humana MCR ADV,CPT,84597,Assay of vitamin k,Lab Services,Per Unit,$13.72 ,OP,13.72,49.56,,,,,,
Humana MCR ADV,CPT,84600,Assay of volatiles,Lab Services,Per Unit,$17.11 ,OP,17.11,72.44,,,,,,
Humana MCR ADV,CPT,84620,Xylose tolerance test,Lab Services,Per Unit,$12.91 ,OP,12.91,38.13,,,,,,
Humana MCR ADV,CPT,84630,Assay of zinc,Lab Services,Per Unit,$11.39 ,OP,11.39,49.56,,,,,,
Humana MCR ADV,CPT,84681,Assay of c-peptide,Lab Services,Per Unit,$20.81 ,OP,20.81,91.51,,,,,,
Humana MCR ADV,CPT,84702,Chorionic gonadotropin test,Lab Services,Per Unit,$15.05 ,OP,15.05,76.26,,,,,,
Humana MCR ADV,CPT,84703,Chorionic gonadotropin assay,Lab Services,Per Unit,$7.52 ,OP,7.52,38.13,,,,,,
Humana MCR ADV,CPT,84704,Hcg free betachain test,Lab Services,Per Unit,$15.29 ,OP,15.29,68.63,,,,,,
Humana MCR ADV,CPT,84830,Ovulation tests,Lab Services,Per Unit,$12.70 ,OP,12.7,49.56,,,,,,
Humana MCR ADV,CPT,85002,Bleeding time test,Lab Services,Per Unit,$4.82 ,OP,4.82,22.88,,,,,,
Humana MCR ADV,CPT,85004,Automated diff wbc count,Lab Services,Per Unit,$6.47 ,OP,6.47,34.31,,,,,,
Humana MCR ADV,CPT,85007,Bl smear w/diff wbc count,Lab Services,Per Unit,$3.80 ,OP,3.8,19.07,,,,,,
Humana MCR ADV,CPT,85008,Bl smear w/o diff wbc count,Lab Services,Per Unit,$3.43 ,OP,3.43,19.07,,,,,,
Humana MCR ADV,CPT,85009,Manual diff wbc count b-coat,Lab Services,Per Unit,$5.07 ,OP,5.07,19.07,,,,,,
Humana MCR ADV,CPT,85013,Spun microhematocrit,Lab Services,Per Unit,$7.00 ,OP,7,7,,,,,,
Humana MCR ADV,CPT,85014,Hematocrit,Lab Services,Per Unit,$2.37 ,OP,2.37,11.44,,,,,,
Humana MCR ADV,CPT,85018,Hemoglobin,Lab Services,Per Unit,$2.37 ,OP,2.37,11.44,,,,,,
Humana MCR ADV,CPT,85025,Complete cbc w/auto diff wbc,Lab Services,Per Unit,$7.77 ,OP,7.77,67.65,,,,,,
Humana MCR ADV,CPT,85027,Complete cbc automated,Lab Services,Per Unit,$6.47 ,OP,6.47,34.31,,,,,,
Humana MCR ADV,CPT,85032,Manual cell count each,Lab Services,Per Unit,$4.31 ,OP,4.31,22.88,,,,,,
Humana MCR ADV,CPT,85041,Automated rbc count,Lab Services,Per Unit,$3.02 ,OP,3.02,11.44,,,,,,
Humana MCR ADV,CPT,85044,Manual reticulocyte count,Lab Services,Per Unit,$4.31 ,OP,4.31,4.31,,,,,,
Humana MCR ADV,CPT,85045,Automated reticulocyte count,Lab Services,Per Unit,$3.99 ,OP,3.99,19.07,,,,,,
Humana MCR ADV,CPT,85046,Reticyte/hgb concentrate,Lab Services,Per Unit,$5.57 ,OP,5.57,26.7,,,,,,
Humana MCR ADV,CPT,85048,Automated leukocyte count,Lab Services,Per Unit,$2.54 ,OP,2.54,11.44,,,,,,
Humana MCR ADV,CPT,85049,Automated platelet count,Lab Services,Per Unit,$4.48 ,OP,4.48,22.88,,,,,,
Humana MCR ADV,CPT,85055,Reticulated platelet assay,Lab Services,Per Unit,$35.74 ,OP,35.74,61,,,,,,
Humana MCR ADV,CPT,85097,Bone marrow interpretation,APC 5674,RVU Per Case,$671.45 ,OP,438.47,671.45,,,,,,
Humana MCR ADV,CPT,85130,Chromogenic substrate assay,Lab Services,Per Unit,$11.89 ,OP,11.89,53.38,,,,,,
Humana MCR ADV,CPT,85170,Blood clot retraction,Lab Services,Per Unit,$16.30 ,OP,16.3,16.3,,,,,,
Humana MCR ADV,CPT,85175,Blood clot lysis time,Lab Services,Per Unit,$20.37 ,OP,19.07,20.37,,,,,,
Humana MCR ADV,CPT,85210,Clot factor ii prothrom spec,Lab Services,Per Unit,$12.98 ,OP,12.98,64.82,,,,,,
Humana MCR ADV,CPT,85220,Blooc clot factor v test,Lab Services,Per Unit,$17.65 ,OP,17.65,80.07,,,,,,
Humana MCR ADV,CPT,85230,Clot factor vii proconvertin,Lab Services,Per Unit,$17.90 ,OP,17.9,80.07,,,,,,
Humana MCR ADV,CPT,85240,Clot factor viii ahg 1 stage,Lab Services,Per Unit,$17.90 ,OP,17.9,80.07,,,,,,
Humana MCR ADV,CPT,85244,Clot factor viii reltd antgn,Lab Services,Per Unit,$20.42 ,OP,20.42,91.51,,,,,,
Humana MCR ADV,CPT,85245,Clot factor viii vw ristoctn,Lab Services,Per Unit,$22.94 ,OP,22.94,64.82,,,,,,
Humana MCR ADV,CPT,85246,Clot factor viii vw antigen,Lab Services,Per Unit,$22.94 ,OP,22.94,64.82,,,,,,
Humana MCR ADV,CPT,85247,Clot factor viii multimetric,Lab Services,Per Unit,$22.94 ,OP,22.94,22.94,,,,,,
Humana MCR ADV,CPT,85250,Clot factor ix ptc/chrstmas,Lab Services,Per Unit,$19.04 ,OP,19.04,83.87,,,,,,
Humana MCR ADV,CPT,85260,Clot factor x stuart-power,Lab Services,Per Unit,$17.90 ,OP,17.9,80.07,,,,,,
Humana MCR ADV,CPT,85270,Clot factor xi pta,Lab Services,Per Unit,$17.90 ,OP,17.9,80.07,,,,,,
Humana MCR ADV,CPT,85280,Clot factor xii hageman,Lab Services,Per Unit,$19.35 ,OP,19.35,87.69,,,,,,
Humana MCR ADV,CPT,85290,Clot factor xiii fibrin stab,Lab Services,Per Unit,$16.34 ,OP,16.34,72.44,,,,,,
Humana MCR ADV,CPT,85291,Clot factor xiii fibrin scrn,Lab Services,Per Unit,$9.11 ,OP,9.11,38.13,,,,,,
Humana MCR ADV,CPT,85292,Clot factor fletcher fact,Lab Services,Per Unit,$18.93 ,OP,18.93,83.87,,,,,,
Humana MCR ADV,CPT,85293,Clot factor wght kininogen,Lab Services,Per Unit,$18.93 ,OP,18.93,83.87,,,,,,
Humana MCR ADV,CPT,85300,Antithrombin iii activity,Lab Services,Per Unit,$11.85 ,OP,11.85,53.38,,,,,,
Humana MCR ADV,CPT,85301,Antithrombin iii antigen,Lab Services,Per Unit,$10.81 ,OP,10.81,49.56,,,,,,
Humana MCR ADV,CPT,85302,Clot inhibit prot c antigen,Lab Services,Per Unit,$12.01 ,OP,12.01,53.38,,,,,,
Humana MCR ADV,CPT,85303,Clot inhibit prot c activity,Lab Services,Per Unit,$13.84 ,OP,13.84,61,,,,,,
Humana MCR ADV,CPT,85305,Clot inhibit prot s total,Lab Services,Per Unit,$11.61 ,OP,11.61,53.38,,,,,,
Humana MCR ADV,CPT,85306,Clot inhibit prot s free,Lab Services,Per Unit,$15.32 ,OP,15.32,68.63,,,,,,
Humana MCR ADV,CPT,85307,Assay activated protein c,Lab Services,Per Unit,$15.32 ,OP,15.32,68.63,,,,,,
Humana MCR ADV,CPT,85335,Factor inhibitor test,Lab Services,Per Unit,$12.87 ,OP,12.87,12.87,,,,,,
Humana MCR ADV,CPT,85337,Thrombomodulin,Lab Services,Per Unit,$17.27 ,OP,17.27,45.74,,,,,,
Humana MCR ADV,CPT,85345,Coagulation time lee & white,Lab Services,Per Unit,$4.69 ,OP,4.69,4.69,,,,,,
Humana MCR ADV,CPT,85347,Coagulation time activated,Lab Services,Per Unit,$4.28 ,OP,4.28,15.26,,,,,,
Humana MCR ADV,CPT,85348,Coagulation time otr method,Lab Services,Per Unit,$4.49 ,OP,4.49,15.26,,,,,,
Humana MCR ADV,CPT,85360,Euglobulin lysis,Lab Services,Per Unit,$8.41 ,OP,8.41,38.13,,,,,,
Humana MCR ADV,CPT,85362,Fibrin degradation products,Lab Services,Per Unit,$6.89 ,OP,6.89,30.51,,,,,,
Humana MCR ADV,CPT,85366,Fibrinogen test,Lab Services,Per Unit,$80.46 ,OP,30.51,80.46,,,,,,
Humana MCR ADV,CPT,85370,Fibrinogen test,Lab Services,Per Unit,$12.43 ,OP,12.43,49.56,,,,,,
Humana MCR ADV,CPT,85378,Fibrin degrade semiquant,Lab Services,Per Unit,$9.72 ,OP,9.72,30.51,,,,,,
Humana MCR ADV,CPT,85379,Fibrin degradation quant,Lab Services,Per Unit,$10.18 ,OP,10.18,135.29,,,,,,
Humana MCR ADV,CPT,85380,Fibrin degradj d-dimer,Lab Services,Per Unit,$10.18 ,OP,10.18,45.74,,,,,,
Humana MCR ADV,CPT,85384,Fibrinogen activity,Lab Services,Per Unit,$9.72 ,OP,9.72,38.13,,,,,,
Humana MCR ADV,CPT,85385,Fibrinogen antigen,Lab Services,Per Unit,$14.46 ,OP,14.46,38.13,,,,,,
Humana MCR ADV,CPT,85390,Fibrinolysins screen i&r,Lab Services,Per Unit,$15.48 ,OP,15.48,38.13,,,,,,
Humana MCR ADV,CPT,85397,Clotting funct activity,Lab Services,Per Unit,$30.86 ,OP,30.86,30.86,,,,,,
Humana MCR ADV,CPT,85400,Fibrinolytic plasmin,Lab Services,Per Unit,$7.71 ,OP,7.71,38.13,,,,,,
Humana MCR ADV,CPT,85410,Fibrinolytic antiplasmin,Lab Services,Per Unit,$7.71 ,OP,7.71,34.31,,,,,,
Humana MCR ADV,CPT,85415,Fibrinolytic plasminogen,Lab Services,Per Unit,$17.19 ,OP,17.19,76.26,,,,,,
Humana MCR ADV,CPT,85420,Fibrinolytic plasminogen,Lab Services,Per Unit,$6.53 ,OP,6.53,6.53,,,,,,
Humana MCR ADV,CPT,85421,Fibrinolytic plasminogen,Lab Services,Per Unit,$10.18 ,OP,10.18,45.74,,,,,,
Humana MCR ADV,CPT,85441,Heinz bodies direct,Lab Services,Per Unit,$4.20 ,OP,4.2,19.07,,,,,,
Humana MCR ADV,CPT,85445,Heinz bodies induced,Lab Services,Per Unit,$6.82 ,OP,6.82,30.51,,,,,,
Humana MCR ADV,CPT,85460,Hemoglobin fetal,Lab Services,Per Unit,$7.73 ,OP,7.73,7.73,,,,,,
Humana MCR ADV,CPT,85461,Hemoglobin fetal,Lab Services,Per Unit,$9.36 ,OP,9.36,30.51,,,,,,
Humana MCR ADV,CPT,85475,Hemolysin acid,Lab Services,Per Unit,$8.87 ,OP,8.87,38.13,,,,,,
Humana MCR ADV,CPT,85520,Heparin assay,Lab Services,Per Unit,$13.09 ,OP,13.09,57.19,,,,,,
Humana MCR ADV,CPT,85525,Heparin neutralization,Lab Services,Per Unit,$11.84 ,OP,11.84,53.38,,,,,,
Humana MCR ADV,CPT,85530,Heparin-protamine tolerance,Lab Services,Per Unit,$13.09 ,OP,13.09,48.46,,,,,,
Humana MCR ADV,CPT,85536,Iron stain peripheral blood,Lab Services,Per Unit,$6.88 ,OP,6.88,30.51,,,,,,
Humana MCR ADV,CPT,85540,Wbc alkaline phosphatase,Lab Services,Per Unit,$8.60 ,OP,8.6,38.13,,,,,,
Humana MCR ADV,CPT,85547,Rbc mechanical fragility,Lab Services,Per Unit,$8.60 ,OP,8.6,11.44,,,,,,
Humana MCR ADV,CPT,85549,Muramidase,Lab Services,Per Unit,$18.75 ,OP,18.75,83.87,,,,,,
Humana MCR ADV,CPT,85555,Rbc osmotic fragility,Lab Services,Per Unit,$7.47 ,OP,7.47,30.51,,,,,,
Humana MCR ADV,CPT,85557,Rbc osmotic fragility,Lab Services,Per Unit,$13.36 ,OP,13.36,13.36,,,,,,
Humana MCR ADV,CPT,85576,Blood platelet aggregation,Lab Services,Per Unit,$24.91 ,OP,24.91,95.32,,,,,,
Humana MCR ADV,CPT,85597,Phospholipid pltlt neutraliz,Lab Services,Per Unit,$17.98 ,OP,17.98,80.07,,,,,,
Humana MCR ADV,CPT,85598,Hexagnal phosph pltlt neutrl,Lab Services,Per Unit,$17.98 ,OP,17.98,17.98,,,,,,
Humana MCR ADV,CPT,85610,Prothrombin time,Lab Services,Per Unit,$4.29 ,OP,4.29,19.07,,,,,,
Humana MCR ADV,CPT,85611,Prothrombin test,Lab Services,Per Unit,$3.94 ,OP,3.94,19.07,,,,,,
Humana MCR ADV,CPT,85612,Viper venom prothrombin time,Lab Services,Per Unit,$17.49 ,OP,17.49,17.49,,,,,,
Humana MCR ADV,CPT,85613,Russell viper venom diluted,Lab Services,Per Unit,$9.58 ,OP,9.58,41.94,,,,,,
Humana MCR ADV,CPT,85635,Reptilase test,Lab Services,Per Unit,$9.85 ,OP,9.85,19.07,,,,,,
Humana MCR ADV,CPT,85651,Rbc sed rate nonautomated,Lab Services,Per Unit,$4.27 ,OP,4.27,19.07,,,,,,
Humana MCR ADV,CPT,85652,Rbc sed rate automated,Lab Services,Per Unit,$2.70 ,OP,2.7,15.26,,,,,,
Humana MCR ADV,CPT,85660,Rbc sickle cell test,Lab Services,Per Unit,$5.51 ,OP,5.51,22.88,,,,,,
Humana MCR ADV,CPT,85670,Thrombin time plasma,Lab Services,Per Unit,$5.77 ,OP,5.77,26.7,,,,,,
Humana MCR ADV,CPT,85675,Thrombin time titer,Lab Services,Per Unit,$6.85 ,OP,6.85,30.51,,,,,,
Humana MCR ADV,CPT,85705,Thromboplastin inhibition,Lab Services,Per Unit,$9.63 ,OP,9.63,41.94,,,,,,
Humana MCR ADV,CPT,85730,Thromboplastin time partial,Lab Services,Per Unit,$6.01 ,OP,6.01,30.51,,,,,,
Humana MCR ADV,CPT,85732,Thromboplastin time partial,Lab Services,Per Unit,$6.47 ,OP,6.47,30.51,,,,,,
Humana MCR ADV,CPT,85810,Blood viscosity examination,Lab Services,Per Unit,$11.67 ,OP,11.67,53.38,,,,,,
Humana MCR ADV,CPT,86000,Agglutinins febrile antigen,Lab Services,Per Unit,$6.98 ,OP,6.98,6.98,,,,,,
Humana MCR ADV,CPT,86001,Allergen specific igg,Lab Services,Per Unit,$7.82 ,OP,7.82,22.88,,,,,,
Humana MCR ADV,CPT,86003,Allg spec ige crude xtrc ea,Lab Services,Per Unit,$5.22 ,OP,5.22,22.88,,,,,,
Humana MCR ADV,CPT,86005,Allg spec ige multiallg scr,Lab Services,Per Unit,$7.97 ,OP,7.97,7.97,,,,,,
Humana MCR ADV,CPT,86008,Allg spec ige recomb ea,Lab Services,Per Unit,$17.93 ,OP,17.93,80.07,,,,,,
Humana MCR ADV,CPT,86021,Wbc antibody identification,Lab Services,Per Unit,$15.05 ,OP,15.05,68.63,,,,,,
Humana MCR ADV,CPT,86022,Platelet antibodies,Lab Services,Per Unit,$18.37 ,OP,18.37,64.82,,,,,,
Humana MCR ADV,CPT,86023,Immunoglobulin assay,Lab Services,Per Unit,$12.46 ,OP,12.46,57.19,,,,,,
Humana MCR ADV,CPT,86038,Antinuclear antibodies,Lab Services,Per Unit,$12.09 ,OP,12.09,53.38,,,,,,
Humana MCR ADV,CPT,86039,Antinuclear antibodies (ana),Lab Services,Per Unit,$11.16 ,OP,11.16,49.56,,,,,,
Humana MCR ADV,CPT,86060,Antistreptolysin o titer,Lab Services,Per Unit,$7.30 ,OP,7.3,34.31,,,,,,
Humana MCR ADV,CPT,86063,Antistreptolysin o screen,Lab Services,Per Unit,$5.77 ,OP,5.77,26.7,,,,,,
Humana MCR ADV,CPT,86077,Phys blood bank serv xmatch,APC 5731,RVU Per Case,$25.25 ,OP,25.25,244.01,,,,,,
Humana MCR ADV,CPT,86078,Phys blood bank serv reactj,APC 5672,RVU Per Case,$152.64 ,OP,152.64,247.83,,,,,,
Humana MCR ADV,CPT,86079,Phys blood bank serv authrj,APC 5671,RVU Per Case,$50.92 ,OP,50.92,251.64,,,,,,
Humana MCR ADV,CPT,86140,C-reactive protein,Lab Services,Per Unit,$5.18 ,OP,5.18,22.88,,,,,,
Humana MCR ADV,CPT,86141,C-reactive protein hs,Lab Services,Per Unit,$12.95 ,OP,12.95,57.19,,,,,,
Humana MCR ADV,CPT,86146,Beta-2 glycoprotein antibody,Lab Services,Per Unit,$25.45 ,OP,25.45,114.39,,,,,,
Humana MCR ADV,CPT,86147,Cardiolipin antibody ea ig,Lab Services,Per Unit,$25.45 ,OP,25.45,114.39,,,,,,
Humana MCR ADV,CPT,86148,Anti-phospholipid antibody,Lab Services,Per Unit,$16.07 ,OP,16.07,72.44,,,,,,
Humana MCR ADV,CPT,86152,Cell enumeration & id,Lab Services,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Humana MCR ADV,CPT,86155,Chemotaxis assay,Lab Services,Per Unit,$15.99 ,OP,15.99,72.44,,,,,,
Humana MCR ADV,CPT,86156,Cold agglutinin screen,Lab Services,Per Unit,$8.07 ,OP,8.07,30.51,,,,,,
Humana MCR ADV,CPT,86157,Cold agglutinin titer,Lab Services,Per Unit,$8.06 ,OP,8.06,34.31,,,,,,
Humana MCR ADV,CPT,86160,Complement antigen,Lab Services,Per Unit,$12.00 ,OP,12,53.38,,,,,,
Humana MCR ADV,CPT,86161,Complement/function activity,Lab Services,Per Unit,$12.00 ,OP,12,53.38,,,,,,
Humana MCR ADV,CPT,86162,Complement total (ch50),Lab Services,Per Unit,$20.32 ,OP,20.32,91.51,,,,,,
Humana MCR ADV,CPT,86171,Complement fixation each,Lab Services,Per Unit,$10.01 ,OP,10.01,45.74,,,,,,
Humana MCR ADV,CPT,86200,Ccp antibody,Lab Services,Per Unit,$12.95 ,OP,12.95,57.19,,,,,,
Humana MCR ADV,CPT,86215,Deoxyribonuclease antibody,Lab Services,Per Unit,$13.25 ,OP,13.25,57.19,,,,,,
Humana MCR ADV,CPT,86225,Dna antibody native,Lab Services,Per Unit,$13.74 ,OP,13.74,61,,,,,,
Humana MCR ADV,CPT,86226,Dna antibody single strand,Lab Services,Per Unit,$12.11 ,OP,12.11,53.38,,,,,,
Humana MCR ADV,CPT,86235,Nuclear antigen antibody,Lab Services,Per Unit,$17.93 ,OP,17.93,80.07,,,,,,
Humana MCR ADV,CPT,86255,Fluorescent antibody screen,Lab Services,Per Unit,$12.05 ,OP,12.05,53.38,,,,,,
Humana MCR ADV,CPT,86256,Fluorescent antibody titer,Lab Services,Per Unit,$12.05 ,OP,12.05,53.38,,,,,,
Humana MCR ADV,CPT,86277,Growth hormone antibody,Lab Services,Per Unit,$15.74 ,OP,15.74,68.63,,,,,,
Humana MCR ADV,CPT,86280,Hemagglutination inhibition,Lab Services,Per Unit,$8.19 ,OP,8.19,8.19,,,,,,
Humana MCR ADV,CPT,86294,Immunoassay tumor qual,Lab Services,Per Unit,$25.57 ,OP,25.57,80.07,,,,,,
Humana MCR ADV,CPT,86300,Immunoassay tumor ca 15-3,Lab Services,Per Unit,$20.81 ,OP,20.81,91.51,,,,,,
Humana MCR ADV,CPT,86301,Immunoassay tumor ca 19-9,Lab Services,Per Unit,$20.81 ,OP,20.81,91.51,,,,,,
Humana MCR ADV,CPT,86304,Immunoassay tumor ca 125,Lab Services,Per Unit,$20.81 ,OP,20.81,91.51,,,,,,
Humana MCR ADV,CPT,86305,Human epididymis protein 4,Lab Services,Per Unit,$20.81 ,OP,20.81,20.81,,,,,,
Humana MCR ADV,CPT,86308,Heterophile antibody screen,Lab Services,Per Unit,$5.18 ,OP,5.18,26.7,,,,,,
Humana MCR ADV,CPT,86309,Heterophile antibody titer,Lab Services,Per Unit,$6.47 ,OP,6.47,30.51,,,,,,
Humana MCR ADV,CPT,86310,Heterophile antibody absrbj,Lab Services,Per Unit,$7.37 ,OP,7.37,7.37,,,,,,
Humana MCR ADV,CPT,86316,Immunoassay tumor other,Lab Services,Per Unit,$20.81 ,OP,20.81,91.51,,,,,,
Humana MCR ADV,CPT,86317,Immunoassay infectious agent,Lab Services,Per Unit,$14.99 ,OP,14.99,68.63,,,,,,
Humana MCR ADV,CPT,86318,Ia infectious agent antibody,Lab Services,Per Unit,$18.09 ,OP,18.09,64.82,,,,,,
Humana MCR ADV,CPT,86320,Serum immunoelectrophoresis,Lab Services,Per Unit,$29.92 ,OP,29.92,99.13,,,,,,
Humana MCR ADV,CPT,86325,Other immunoelectrophoresis,Lab Services,Per Unit,$23.13 ,OP,23.13,99.13,,,,,,
Humana MCR ADV,CPT,86327,Immunoelectrophoresis assay,Lab Services,Per Unit,$29.92 ,OP,29.92,72.44,,,,,,
Humana MCR ADV,CPT,86328,Ia nfct ab sarscov2 covid19,Lab Services,Per Unit,$45.23 ,OP,45.23,64.82,,,,,,
Humana MCR ADV,CPT,86329,Immunodiffusion nes,Lab Services,Per Unit,$14.05 ,OP,14.05,14.05,,,,,,
Humana MCR ADV,CPT,86331,Immunodiffusion ouchterlony,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Humana MCR ADV,CPT,86332,Immune complex assay,Lab Services,Per Unit,$24.37 ,OP,24.37,106.76,,,,,,
Humana MCR ADV,CPT,86334,Immunofix e-phoresis serum,Lab Services,Per Unit,$22.34 ,OP,22.34,99.13,,,,,,
Humana MCR ADV,CPT,86335,Immunfix e-phorsis/urine/csf,Lab Services,Per Unit,$29.35 ,OP,29.35,129.64,,,,,,
Humana MCR ADV,CPT,86336,Inhibin a,Lab Services,Per Unit,$15.59 ,OP,15.59,68.63,,,,,,
Humana MCR ADV,CPT,86337,Insulin antibodies,Lab Services,Per Unit,$21.41 ,OP,21.41,95.32,,,,,,
Humana MCR ADV,CPT,86340,Intrinsic factor antibody,Lab Services,Per Unit,$15.08 ,OP,15.08,68.63,,,,,,
Humana MCR ADV,CPT,86341,Islet cell antibody,Lab Services,Per Unit,$23.57 ,OP,23.57,87.69,,,,,,
Humana MCR ADV,CPT,86343,Leukocyte histamine release,Lab Services,Per Unit,$12.46 ,OP,12.46,57.19,,,,,,
Humana MCR ADV,CPT,86344,Leukocyte phagocytosis,Lab Services,Per Unit,$10.39 ,OP,10.39,34.31,,,,,,
Humana MCR ADV,CPT,86352,Cell function assay w/stim,Lab Services,Per Unit,$135.86 ,OP,135.86,135.86,,,,,,
Humana MCR ADV,CPT,86353,Lymphocyte transformation,Lab Services,Per Unit,$49.03 ,OP,49.03,217.32,,,,,,
Humana MCR ADV,CPT,86355,B cells total count,Lab Services,Per Unit,$37.73 ,OP,37.73,167.76,,,,,,
Humana MCR ADV,CPT,86356,Mononuclear cell antigen,Lab Services,Per Unit,$26.78 ,OP,26.78,61,,,,,,
Humana MCR ADV,CPT,86357,Nk cells total count,Lab Services,Per Unit,$37.73 ,OP,37.73,167.76,,,,,,
Humana MCR ADV,CPT,86359,T cells total count,Lab Services,Per Unit,$37.73 ,OP,37.73,167.76,,,,,,
Humana MCR ADV,CPT,86360,T cell absolute count/ratio,Lab Services,Per Unit,$46.98 ,OP,46.98,209.7,,,,,,
Humana MCR ADV,CPT,86361,T cell absolute count,Lab Services,Per Unit,$26.78 ,OP,26.78,61,,,,,,
Humana MCR ADV,CPT,86367,Stem cells total count,Lab Services,Per Unit,$77.78 ,OP,77.78,167.76,,,,,,
Humana MCR ADV,CPT,86376,Microsomal antibody each,Lab Services,Per Unit,$14.55 ,OP,14.55,64.82,,,,,,
Humana MCR ADV,CPT,86382,Neutralization test viral,Lab Services,Per Unit,$16.91 ,OP,16.91,76.26,,,,,,
Humana MCR ADV,CPT,86384,Nitroblue tetrazolium dye,Lab Services,Per Unit,$13.61 ,OP,13.61,13.61,,,,,,
Humana MCR ADV,CPT,86386,Nuclear matrix protein 22,Lab Services,Per Unit,$21.78 ,OP,21.78,21.78,,,,,,
Humana MCR ADV,CPT,86403,Particle agglut antbdy scrn,Lab Services,Per Unit,$11.54 ,OP,11.54,26.7,,,,,,
Humana MCR ADV,CPT,86406,Particle agglut antbdy titr,Lab Services,Per Unit,$10.64 ,OP,10.64,45.74,,,,,,
Humana MCR ADV,CPT,86408,Neutrlzg antb sarscov2 scr,Lab Services,Per Unit,$42.13 ,OP,42.13,42.13,,,,,,
Humana MCR ADV,CPT,86409,Neutrlzg antb sarscov2 titer,Lab Services,Per Unit,$105.33 ,OP,105.33,105.33,,,,,,
Humana MCR ADV,CPT,86413,Sars-cov-2 antb quantitative,Lab Services,Per Unit,$51.43 ,OP,51.43,51.43,,,,,,
Humana MCR ADV,CPT,86430,Rheumatoid factor test qual,Lab Services,Per Unit,$6.14 ,OP,6.14,26.7,,,,,,
Humana MCR ADV,CPT,86431,Rheumatoid factor quant,Lab Services,Per Unit,$5.67 ,OP,5.67,26.7,,,,,,
Humana MCR ADV,CPT,86480,Tb test cell immun measure,Lab Services,Per Unit,$61.98 ,OP,61.98,274.51,,,,,,
Humana MCR ADV,CPT,86481,Tb ag response t-cell susp,Lab Services,Per Unit,$100.00 ,OP,100,100,,,,,,
Humana MCR ADV,CPT,86485,Skin test candida,APC 5731,RVU Per Case,$25.25 ,OP,25.25,61,,,,,,
Humana MCR ADV,CPT,86486,Skin test nos antigen,APC 5731,RVU Per Case,$25.25 ,OP,25.25,30.51,,,,,,
Humana MCR ADV,CPT,86490,Coccidioidomycosis skin test,APC 5733,RVU Per Case,$56.95 ,OP,38.13,56.95,,,,,,
Humana MCR ADV,CPT,86510,Histoplasmosis skin test,APC 5733,RVU Per Case,$56.95 ,OP,38.13,56.95,,,,,,
Humana MCR ADV,CPT,86580,Tb intradermal test,APC 5731,RVU Per Case,$25.25 ,OP,25.25,38.13,,,,,,
Humana MCR ADV,CPT,86590,Streptokinase antibody,Lab Services,Per Unit,$12.66 ,OP,12.66,49.56,,,,,,
Humana MCR ADV,CPT,86592,Syphilis test non-trep qual,Lab Services,Per Unit,$4.27 ,OP,4.27,19.07,,,,,,
Humana MCR ADV,CPT,86593,Syphilis test non-trep quant,Lab Services,Per Unit,$4.40 ,OP,4.4,19.07,,,,,,
Humana MCR ADV,CPT,86602,Antinomyces antibody,Lab Services,Per Unit,$10.18 ,OP,10.18,45.74,,,,,,
Humana MCR ADV,CPT,86603,Adenovirus antibody,Lab Services,Per Unit,$12.87 ,OP,12.87,12.87,,,,,,
Humana MCR ADV,CPT,86606,Aspergillus antibody,Lab Services,Per Unit,$15.05 ,OP,15.05,68.63,,,,,,
Humana MCR ADV,CPT,86609,Bacterium antibody,Lab Services,Per Unit,$12.88 ,OP,12.88,57.19,,,,,,
Humana MCR ADV,CPT,86611,Bartonella antibody,Lab Services,Per Unit,$10.18 ,OP,10.18,45.74,,,,,,
Humana MCR ADV,CPT,86612,Blastomyces antibody,Lab Services,Per Unit,$12.90 ,OP,12.9,57.19,,,,,,
Humana MCR ADV,CPT,86615,Bordetella antibody,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
Humana MCR ADV,CPT,86617,Lyme disease antibody,Lab Services,Per Unit,$15.49 ,OP,15.49,68.63,,,,,,
Humana MCR ADV,CPT,86618,Lyme disease antibody,Lab Services,Per Unit,$17.03 ,OP,17.03,83.87,,,,,,
Humana MCR ADV,CPT,86619,Borrelia antibody,Lab Services,Per Unit,$13.38 ,OP,13.38,61,,,,,,
Humana MCR ADV,CPT,86622,Brucella antibody,Lab Services,Per Unit,$8.93 ,OP,8.93,38.13,,,,,,
Humana MCR ADV,CPT,86625,Campylobacter antibody,Lab Services,Per Unit,$13.12 ,OP,13.12,57.19,,,,,,
Humana MCR ADV,CPT,86628,Candida antibody,Lab Services,Per Unit,$12.01 ,OP,12.01,53.38,,,,,,
Humana MCR ADV,CPT,86631,Chlamydia antibody,Lab Services,Per Unit,$11.82 ,OP,11.82,53.38,,,,,,
Humana MCR ADV,CPT,86632,Chlamydia igm antibody,Lab Services,Per Unit,$12.68 ,OP,12.68,57.19,,,,,,
Humana MCR ADV,CPT,86635,Coccidioides antibody,Lab Services,Per Unit,$11.47 ,OP,11.47,49.56,,,,,,
Humana MCR ADV,CPT,86638,Q fever antibody,Lab Services,Per Unit,$12.12 ,OP,12.12,53.38,,,,,,
Humana MCR ADV,CPT,86641,Cryptococcus antibody,Lab Services,Per Unit,$14.41 ,OP,14.41,64.82,,,,,,
Humana MCR ADV,CPT,86644,Cmv antibody,Lab Services,Per Unit,$14.39 ,OP,14.39,64.82,,,,,,
Humana MCR ADV,CPT,86645,Cmv antibody igm,Lab Services,Per Unit,$16.85 ,OP,16.85,76.26,,,,,,
Humana MCR ADV,CPT,86648,Diphtheria antibody,Lab Services,Per Unit,$15.21 ,OP,15.21,68.63,,,,,,
Humana MCR ADV,CPT,86651,Encephalitis californ antbdy,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
Humana MCR ADV,CPT,86652,Encephaltis east eqne anbdy,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
Humana MCR ADV,CPT,86653,Encephaltis st louis antbody,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
Humana MCR ADV,CPT,86654,Encephaltis west eqne antbdy,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
Humana MCR ADV,CPT,86658,Enterovirus antibody,Lab Services,Per Unit,$13.03 ,OP,13.03,57.19,,,,,,
Humana MCR ADV,CPT,86663,Epstein-barr antibody,Lab Services,Per Unit,$13.12 ,OP,13.12,57.19,,,,,,
Humana MCR ADV,CPT,86664,Epstein-barr nuclear antigen,Lab Services,Per Unit,$15.29 ,OP,15.29,68.63,,,,,,
Humana MCR ADV,CPT,86665,Epstein-barr capsid vca,Lab Services,Per Unit,$18.14 ,OP,18.14,80.07,,,,,,
Humana MCR ADV,CPT,86666,Ehrlichia antibody,Lab Services,Per Unit,$10.18 ,OP,10.18,45.74,,,,,,
Humana MCR ADV,CPT,86668,Francisella tularensis,Lab Services,Per Unit,$14.16 ,OP,14.16,45.74,,,,,,
Humana MCR ADV,CPT,86671,Fungus nes antibody,Lab Services,Per Unit,$12.25 ,OP,12.25,53.38,,,,,,
Humana MCR ADV,CPT,86674,Giardia lamblia antibody,Lab Services,Per Unit,$14.72 ,OP,14.72,14.72,,,,,,
Humana MCR ADV,CPT,86677,Helicobacter pylori antibody,Lab Services,Per Unit,$16.85 ,OP,16.85,64.82,,,,,,
Humana MCR ADV,CPT,86682,Helminth antibody,Lab Services,Per Unit,$13.01 ,OP,13.01,57.19,,,,,,
Humana MCR ADV,CPT,86684,Hemophilus influenza antibdy,Lab Services,Per Unit,$15.84 ,OP,15.84,72.44,,,,,,
Humana MCR ADV,CPT,86687,Htlv-i antibody,Lab Services,Per Unit,$9.09 ,OP,9.09,38.13,,,,,,
Humana MCR ADV,CPT,86688,Htlv-ii antibody,Lab Services,Per Unit,$14.00 ,OP,14,61,,,,,,
Humana MCR ADV,CPT,86689,Htlv/hiv confirmj antibody,Lab Services,Per Unit,$19.35 ,OP,19.35,87.69,,,,,,
Humana MCR ADV,CPT,86692,Hepatitis delta agent antbdy,Lab Services,Per Unit,$17.16 ,OP,17.16,76.26,,,,,,
Humana MCR ADV,CPT,86694,Herpes simplex nes antbdy,Lab Services,Per Unit,$14.39 ,OP,14.39,64.82,,,,,,
Humana MCR ADV,CPT,86695,Herpes simplex type 1 test,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
Humana MCR ADV,CPT,86696,Herpes simplex type 2 test,Lab Services,Per Unit,$19.35 ,OP,19.35,87.69,,,,,,
Humana MCR ADV,CPT,86698,Histoplasma antibody,Lab Services,Per Unit,$13.79 ,OP,13.79,57.19,,,,,,
Humana MCR ADV,CPT,86701,Hiv-1antibody,Lab Services,Per Unit,$8.89 ,OP,8.89,38.13,,,,,,
Humana MCR ADV,CPT,86702,Hiv-2 antibody,Lab Services,Per Unit,$13.52 ,OP,13.52,61,,,,,,
Humana MCR ADV,CPT,86703,Hiv-1/hiv-2 1 result antbdy,Lab Services,Per Unit,$13.71 ,OP,13.71,61,,,,,,
Humana MCR ADV,CPT,86704,Hep b core antibody total,Lab Services,Per Unit,$12.05 ,OP,12.05,53.38,,,,,,
Humana MCR ADV,CPT,86705,Hep b core antibody igm,Lab Services,Per Unit,$11.77 ,OP,11.77,53.38,,,,,,
Humana MCR ADV,CPT,86706,Hep b surface antibody,Lab Services,Per Unit,$10.74 ,OP,10.74,49.56,,,,,,
Humana MCR ADV,CPT,86707,Hepatitis be antibody,Lab Services,Per Unit,$11.57 ,OP,11.57,53.38,,,,,,
Humana MCR ADV,CPT,86708,Hepatitis a antibody,Lab Services,Per Unit,$12.39 ,OP,12.39,53.38,,,,,,
Humana MCR ADV,CPT,86709,Hepatitis a igm antibody,Lab Services,Per Unit,$11.26 ,OP,11.26,49.56,,,,,,
Humana MCR ADV,CPT,86710,Influenza virus antibody,Lab Services,Per Unit,$13.55 ,OP,13.55,68.63,,,,,,
Humana MCR ADV,CPT,86711,John cunningham antibody,Lab Services,Per Unit,$16.89 ,OP,16.89,16.89,,,,,,
Humana MCR ADV,CPT,86713,Legionella antibody,Lab Services,Per Unit,$15.30 ,OP,15.3,68.63,,,,,,
Humana MCR ADV,CPT,86717,Leishmania antibody,Lab Services,Per Unit,$12.25 ,OP,12.25,53.38,,,,,,
Humana MCR ADV,CPT,86720,Leptospira antibody,Lab Services,Per Unit,$16.20 ,OP,16.2,57.19,,,,,,
Humana MCR ADV,CPT,86723,Listeria monocytogenes,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,
Humana MCR ADV,CPT,86727,Lymph choriomeningitis ab,Lab Services,Per Unit,$12.87 ,OP,12.87,57.19,,,,,,
Humana MCR ADV,CPT,86732,Mucormycosis antibody,Lab Services,Per Unit,$15.00 ,OP,15,57.19,,,,,,
Humana MCR ADV,CPT,86735,Mumps antibody,Lab Services,Per Unit,$13.05 ,OP,13.05,57.19,,,,,,
Humana MCR ADV,CPT,86738,Mycoplasma antibody,Lab Services,Per Unit,$13.24 ,OP,13.24,57.19,,,,,,
Humana MCR ADV,CPT,86741,Neisseria meningitidis,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
Humana MCR ADV,CPT,86744,Nocardia antibody,Lab Services,Per Unit,$15.99 ,OP,15.99,57.19,,,,,,
Humana MCR ADV,CPT,86747,Parvovirus antibody,Lab Services,Per Unit,$15.03 ,OP,15.03,68.63,,,,,,
Humana MCR ADV,CPT,86750,Malaria antibody,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
Humana MCR ADV,CPT,86753,Protozoa antibody nos,Lab Services,Per Unit,$12.39 ,OP,12.39,53.38,,,,,,
Humana MCR ADV,CPT,86756,Respiratory virus antibody,Lab Services,Per Unit,$15.89 ,OP,15.89,57.19,,,,,,
Humana MCR ADV,CPT,86757,Rickettsia antibody,Lab Services,Per Unit,$19.35 ,OP,19.35,87.69,,,,,,
Humana MCR ADV,CPT,86759,Rotavirus antibody,Lab Services,Per Unit,$18.23 ,OP,18.23,57.19,,,,,,
Humana MCR ADV,CPT,86762,Rubella antibody,Lab Services,Per Unit,$14.39 ,OP,14.39,64.82,,,,,,
Humana MCR ADV,CPT,86765,Rubeola antibody,Lab Services,Per Unit,$12.88 ,OP,12.88,57.19,,,,,,
Humana MCR ADV,CPT,86768,Salmonella antibody,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,
Humana MCR ADV,CPT,86769,Sars-cov-2 covid-19 antibody,Lab Services,Per Unit,$42.13 ,OP,42.13,57.19,,,,,,
Humana MCR ADV,CPT,86771,Shigella antibody,Lab Services,Per Unit,$24.48 ,OP,24.48,57.19,,,,,,
Humana MCR ADV,CPT,86774,Tetanus antibody,Lab Services,Per Unit,$14.80 ,OP,14.8,64.82,,,,,,
Humana MCR ADV,CPT,86777,Toxoplasma antibody,Lab Services,Per Unit,$14.39 ,OP,14.39,64.82,,,,,,
Humana MCR ADV,CPT,86778,Toxoplasma antibody igm,Lab Services,Per Unit,$14.41 ,OP,14.41,64.82,,,,,,
Humana MCR ADV,CPT,86780,Treponema pallidum,Lab Services,Per Unit,$13.24 ,OP,13.24,13.24,,,,,,
Humana MCR ADV,CPT,86784,Trichinella antibody,Lab Services,Per Unit,$12.56 ,OP,12.56,12.56,,,,,,
Humana MCR ADV,CPT,86787,Varicella-zoster antibody,Lab Services,Per Unit,$12.88 ,OP,12.88,57.19,,,,,,
Humana MCR ADV,CPT,86788,West nile virus ab igm,Lab Services,Per Unit,$16.85 ,OP,16.85,76.26,,,,,,
Humana MCR ADV,CPT,86789,West nile virus antibody,Lab Services,Per Unit,$14.39 ,OP,14.39,64.82,,,,,,
Humana MCR ADV,CPT,86790,Virus antibody nos,Lab Services,Per Unit,$12.88 ,OP,12.88,57.19,,,,,,
Humana MCR ADV,CPT,86793,Yersinia antibody,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
Humana MCR ADV,CPT,86794,Zika virus igm antibody,Lab Services,Per Unit,$16.85 ,OP,16.85,16.85,,,,,,
Humana MCR ADV,CPT,86800,Thyroglobulin antibody,Lab Services,Per Unit,$15.91 ,OP,15.91,72.44,,,,,,
Humana MCR ADV,CPT,86803,Hepatitis c ab test,Lab Services,Per Unit,$14.27 ,OP,14.27,64.82,,,,,,
Humana MCR ADV,CPT,86804,Hep c ab test confirm,Lab Services,Per Unit,$15.49 ,OP,15.49,68.63,,,,,,
Humana MCR ADV,CPT,86805,Lymphocytotoxicity assay,Lab Services,Per Unit,$189.51 ,OP,189.51,232.58,,,,,,
Humana MCR ADV,CPT,86806,Lymphocytotoxicity assay,Lab Services,Per Unit,$47.59 ,OP,47.59,213.51,,,,,,
Humana MCR ADV,CPT,86807,Cytotoxic antibody screening,Lab Services,Per Unit,$78.65 ,OP,78.65,175.39,,,,,,
Humana MCR ADV,CPT,86808,Cytotoxic antibody screening,Lab Services,Per Unit,$29.68 ,OP,29.68,133.45,,,,,,
Humana MCR ADV,CPT,86812,Hla typing a b or c,Lab Services,Per Unit,$25.81 ,OP,25.81,114.39,,,,,,
Humana MCR ADV,CPT,86813,Hla typing a b or c,Lab Services,Per Unit,$58.00 ,OP,58,247.83,,,,,,
Humana MCR ADV,CPT,86816,Hla typing dr/dq,Lab Services,Per Unit,$30.17 ,OP,30.17,102.95,,,,,,
Humana MCR ADV,CPT,86817,Hla typing dr/dq,Lab Services,Per Unit,$106.14 ,OP,106.14,247.83,,,,,,
Humana MCR ADV,CPT,86821,Lymphocyte culture mixed,Lab Services,Per Unit,$36.56 ,OP,36.56,251.64,,,,,,
Humana MCR ADV,CPT,86825,Hla x-math non-cytotoxic,Lab Services,Per Unit,$109.49 ,OP,109.49,109.49,,,,,,
Humana MCR ADV,CPT,86826,Hla x-match noncytotoxc addl,Lab Services,Per Unit,$36.53 ,OP,36.53,36.53,,,,,,
Humana MCR ADV,CPT,86828,Hla class i&ii antibody qual,Lab Services,Per Unit,$64.19 ,OP,64.19,64.19,,,,,,
Humana MCR ADV,CPT,86829,Hla class i/ii antibody qual,Lab Services,Per Unit,$64.19 ,OP,64.19,64.19,,,,,,
Humana MCR ADV,CPT,86830,Hla class i phenotype qual,Lab Services,Per Unit,$95.52 ,OP,95.52,95.52,,,,,,
Humana MCR ADV,CPT,86831,Hla class ii phenotype qual,Lab Services,Per Unit,$81.88 ,OP,81.88,81.88,,,,,,
Humana MCR ADV,CPT,86832,Hla class i high defin qual,Lab Services,Per Unit,$323.75 ,OP,323.75,323.75,,,,,,
Humana MCR ADV,CPT,86833,Hla class ii high defin qual,Lab Services,Per Unit,$325.80 ,OP,325.8,325.8,,,,,,
Humana MCR ADV,CPT,86834,Hla class i semiquant panel,Lab Services,Per Unit,$357.56 ,OP,357.56,357.56,,,,,,
Humana MCR ADV,CPT,86835,Hla class ii semiquant panel,Lab Services,Per Unit,$322.96 ,OP,322.96,322.96,,,,,,
Humana MCR ADV,CPT,86850,Rbc antibody screen,APC 5671,RVU Per Case,$50.92 ,OP,50.92,76.26,,,,,,
Humana MCR ADV,CPT,86860,Rbc antibody elution,APC 5672,RVU Per Case,$152.64 ,OP,91.51,152.64,,,,,,
Humana MCR ADV,CPT,86870,Rbc antibody identification,APC 5673,RVU Per Case,$298.05 ,OP,141.07,298.05,,,,,,
Humana MCR ADV,CPT,86880,Coombs test direct,APC 5733,RVU Per Case,$56.95 ,OP,22.88,56.95,,,,,,
Humana MCR ADV,CPT,86885,Coombs test indirect qual,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Humana MCR ADV,CPT,86886,Coombs test indirect titer,APC 5672,RVU Per Case,$152.64 ,OP,22.88,152.64,,,,,,
Humana MCR ADV,CPT,86890,Autologous blood process,APC 5672,RVU Per Case,$152.64 ,OP,152.64,308.83,,,,,,
Humana MCR ADV,CPT,86891,Autologous blood op salvage,APC 5674,RVU Per Case,$671.45 ,OP,480.4,671.45,,,,,,
Humana MCR ADV,CPT,86900,Blood typing serologic abo,APC 5734,RVU Per Case,$114.56 ,OP,11.44,114.56,,,,,,
Humana MCR ADV,CPT,86901,Blood typing serologic rh(d),APC 5732,RVU Per Case,$34.63 ,OP,22.88,34.63,,,,,,
Humana MCR ADV,CPT,86902,Blood type antigen donor ea,APC 5673,RVU Per Case,$298.05 ,OP,41.94,298.05,,,,,,
Humana MCR ADV,CPT,86904,Blood typing patient serum,APC 5732,RVU Per Case,$34.63 ,OP,34.63,41.94,,,,,,
Humana MCR ADV,CPT,86905,Blood typing rbc antigens,APC 5673,RVU Per Case,$298.05 ,OP,15.26,298.05,,,,,,
Humana MCR ADV,CPT,86906,Bld typing serologic rh phnt,APC 5732,RVU Per Case,$34.63 ,OP,34.31,34.63,,,,,,
Humana MCR ADV,CPT,86920,Compatibility test spin,APC 5672,RVU Per Case,$152.64 ,OP,125.82,152.64,,,,,,
Humana MCR ADV,CPT,86921,Compatibility test incubate,APC 5672,RVU Per Case,$152.64 ,OP,102.95,152.64,,,,,,
Humana MCR ADV,CPT,86922,Compatibility test antiglob,APC 5672,RVU Per Case,$152.64 ,OP,118.19,152.64,,,,,,
Humana MCR ADV,CPT,86923,Compatibility test electric,APC 5672,RVU Per Case,$152.64 ,OP,91.51,152.64,,,,,,
Humana MCR ADV,CPT,86927,Plasma fresh frozen,APC 5672,RVU Per Unit,$152.64 ,OP,49.56,152.64,,,,,,
Humana MCR ADV,CPT,86930,Frozen blood prep,APC 5673,RVU Per Case,$298.05 ,OP,298.05,385.09,,,,,,
Humana MCR ADV,CPT,86931,Frozen blood thaw,APC 5673,RVU Per Case,$298.05 ,OP,289.76,298.05,,,,,,
Humana MCR ADV,CPT,86932,Frozen blood freeze/thaw,APC 5732,RVU Per Case,$34.63 ,OP,34.63,385.09,,,,,,
Humana MCR ADV,CPT,86940,Hemolysins/agglutinins auto,Lab Services,Per Unit,$8.77 ,OP,8.77,38.13,,,,,,
Humana MCR ADV,CPT,86941,Hemolysins/agglutinins,Lab Services,Per Unit,$12.11 ,OP,12.11,53.38,,,,,,
Humana MCR ADV,CPT,86945,Blood product/irradiation,APC 5732,RVU Per Case,$34.63 ,OP,34.63,110.57,,,,,,
Humana MCR ADV,CPT,86950,Leukacyte transfusion,APC 5672,RVU Per Case,$152.64 ,OP,152.64,240.2,,,,,,
Humana MCR ADV,CPT,86960,Vol reduction of blood/prod,APC 5672,RVU Per Case,$152.64 ,OP,110.57,152.64,,,,,,
Humana MCR ADV,CPT,86965,Pooling blood platelets,APC 5672,RVU Per Case,$152.64 ,OP,95.32,152.64,,,,,,
Humana MCR ADV,CPT,86970,Rbc pretx incubatj w/chemicl,APC 5732,RVU Per Case,$34.63 ,OP,34.63,76.26,,,,,,
Humana MCR ADV,CPT,86971,Rbc pretx incubatj w/enzymes,APC 5673,RVU Per Case,$298.05 ,OP,298.05,298.05,,,,,,
Humana MCR ADV,CPT,86972,Rbc pretx incubatj w/density,APC 5672,RVU Per Case,$152.64 ,OP,122,152.64,,,,,,
Humana MCR ADV,CPT,86975,Rbc serum pretx incubj drugs,APC 5735,RVU Per Case,$276.53 ,OP,102.95,276.53,,,,,,
Humana MCR ADV,CPT,86976,Rbc serum pretx id dilution,APC 5731,RVU Per Case,$25.25 ,OP,25.25,118.19,,,,,,
Humana MCR ADV,CPT,86977,Rbc serum pretx incubj/inhib,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Humana MCR ADV,CPT,86978,Rbc pretreatment serum,APC 5732,RVU Per Case,$34.63 ,OP,34.63,102.95,,,,,,
Humana MCR ADV,CPT,86985,Split blood or products,APC 5672,RVU Per Case,$152.64 ,OP,76.26,152.64,,,,,,
Humana MCR ADV,CPT,86999,Transfusion procedure,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Humana MCR ADV,CPT,87003,Small animal inoculation,Lab Services,Per Unit,$16.84 ,OP,16.84,76.26,,,,,,
Humana MCR ADV,CPT,87015,Specimen infect agnt concntj,Lab Services,Per Unit,$6.68 ,OP,6.68,30.51,,,,,,
Humana MCR ADV,CPT,87040,Blood culture for bacteria,Lab Services,Per Unit,$10.32 ,OP,10.32,45.74,,,,,,
Humana MCR ADV,CPT,87045,Feces culture aerobic bact,Lab Services,Per Unit,$9.44 ,OP,9.44,41.94,,,,,,
Humana MCR ADV,CPT,87046,Stool cultr aerobic bact ea,Lab Services,Per Unit,$9.44 ,OP,9.44,41.94,,,,,,
Humana MCR ADV,CPT,87070,Culture othr specimn aerobic,Lab Services,Per Unit,$8.62 ,OP,8.62,41.94,,,,,,
Humana MCR ADV,CPT,87071,Culture aerobic quant other,Lab Services,Per Unit,$9.89 ,OP,9.89,41.94,,,,,,
Humana MCR ADV,CPT,87073,Culture bacteria anaerobic,Lab Services,Per Unit,$9.66 ,OP,9.66,41.94,,,,,,
Humana MCR ADV,CPT,87075,Cultr bacteria except blood,Lab Services,Per Unit,$9.47 ,OP,9.47,41.94,,,,,,
Humana MCR ADV,CPT,87076,Culture anaerobe ident each,Lab Services,Per Unit,$8.08 ,OP,8.08,19.07,,,,,,
Humana MCR ADV,CPT,87077,Culture aerobic identify,Lab Services,Per Unit,$8.08 ,OP,8.08,22.88,,,,,,
Humana MCR ADV,CPT,87081,Culture screen only,Lab Services,Per Unit,$6.63 ,OP,6.63,34.31,,,,,,
Humana MCR ADV,CPT,87084,Culture of specimen by kit,Lab Services,Per Unit,$27.07 ,OP,22.88,27.07,,,,,,
Humana MCR ADV,CPT,87086,Urine culture/colony count,Lab Services,Per Unit,$8.07 ,OP,8.07,41.94,,,,,,
Humana MCR ADV,CPT,87088,Urine bacteria culture,Lab Services,Per Unit,$8.09 ,OP,8.09,41.94,,,,,,
Humana MCR ADV,CPT,87101,Skin fungi culture,Lab Services,Per Unit,$7.71 ,OP,7.71,34.31,,,,,,
Humana MCR ADV,CPT,87102,Fungus isolation culture,Lab Services,Per Unit,$8.41 ,OP,8.41,38.13,,,,,,
Humana MCR ADV,CPT,87103,Blood fungus culture,Lab Services,Per Unit,$20.46 ,OP,20.46,41.94,,,,,,
Humana MCR ADV,CPT,87106,Fungi identification yeast,Lab Services,Per Unit,$10.32 ,OP,10.32,45.74,,,,,,
Humana MCR ADV,CPT,87107,Fungi identification mold,Lab Services,Per Unit,$10.32 ,OP,10.32,45.74,,,,,,
Humana MCR ADV,CPT,87109,Mycoplasma,Lab Services,Per Unit,$15.39 ,OP,15.39,68.63,,,,,,
Humana MCR ADV,CPT,87110,Chlamydia culture,Lab Services,Per Unit,$19.60 ,OP,19.6,87.69,,,,,,
Humana MCR ADV,CPT,87116,Mycobacteria culture,Lab Services,Per Unit,$10.80 ,OP,10.8,49.56,,,,,,
Humana MCR ADV,CPT,87118,Mycobacteric identification,Lab Services,Per Unit,$14.61 ,OP,14.61,49.56,,,,,,
Humana MCR ADV,CPT,87140,Culture type immunofluoresc,Lab Services,Per Unit,$5.57 ,OP,5.57,26.7,,,,,,
Humana MCR ADV,CPT,87143,Culture typing glc/hplc,Lab Services,Per Unit,$12.52 ,OP,12.52,57.19,,,,,,
Humana MCR ADV,CPT,87147,Culture type immunologic,Lab Services,Per Unit,$5.18 ,OP,5.18,22.88,,,,,,
Humana MCR ADV,CPT,87149,Dna/rna direct probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
Humana MCR ADV,CPT,87150,Dna/rna amplified probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,
Humana MCR ADV,CPT,87152,Culture type pulse field gel,Lab Services,Per Unit,$7.74 ,OP,7.74,22.88,,,,,,
Humana MCR ADV,CPT,87153,Dna/rna sequencing,Lab Services,Per Unit,$115.36 ,OP,115.36,115.36,,,,,,
Humana MCR ADV,CPT,87158,Culture typing added method,Lab Services,Per Unit,$7.74 ,OP,7.74,7.74,,,,,,
Humana MCR ADV,CPT,87164,Dark field examination,Lab Services,Per Unit,$10.74 ,OP,10.74,49.56,,,,,,
Humana MCR ADV,CPT,87166,Dark field examination,Lab Services,Per Unit,$11.30 ,OP,11.3,49.56,,,,,,
Humana MCR ADV,CPT,87168,Macroscopic exam arthropod,Lab Services,Per Unit,$4.27 ,OP,4.27,19.07,,,,,,
Humana MCR ADV,CPT,87169,Macroscopic exam parasite,Lab Services,Per Unit,$4.31 ,OP,4.31,19.07,,,,,,
Humana MCR ADV,CPT,87172,Pinworm exam,Lab Services,Per Unit,$4.27 ,OP,4.27,22.88,,,,,,
Humana MCR ADV,CPT,87176,Tissue homogenization cultr,Lab Services,Per Unit,$5.88 ,OP,5.88,26.7,,,,,,
Humana MCR ADV,CPT,87177,Ova and parasites smears,Lab Services,Per Unit,$8.90 ,OP,8.9,41.94,,,,,,
Humana MCR ADV,CPT,87181,Microbe susceptible diffuse,Lab Services,Per Unit,$4.75 ,OP,4.75,22.88,,,,,,
Humana MCR ADV,CPT,87184,Microbe susceptible disk,Lab Services,Per Unit,$7.48 ,OP,7.48,34.31,,,,,,
Humana MCR ADV,CPT,87185,Microbe susceptible enzyme,Lab Services,Per Unit,$4.75 ,OP,4.75,22.88,,,,,,
Humana MCR ADV,CPT,87186,Microbe susceptible mic,Lab Services,Per Unit,$8.65 ,OP,8.65,38.13,,,,,,
Humana MCR ADV,CPT,87187,Microbe susceptible mlc,Lab Services,Per Unit,$40.17 ,OP,40.17,45.74,,,,,,
Humana MCR ADV,CPT,87188,Microbe suscept macrobroth,Lab Services,Per Unit,$6.64 ,OP,6.64,30.51,,,,,,
Humana MCR ADV,CPT,87190,Microbe suscept mycobacteri,Lab Services,Per Unit,$7.31 ,OP,7.31,26.7,,,,,,
Humana MCR ADV,CPT,87197,Bactericidal level serum,Lab Services,Per Unit,$15.02 ,OP,15.02,68.63,,,,,,
Humana MCR ADV,CPT,87205,Smear gram stain,Lab Services,Per Unit,$4.27 ,OP,4.27,22.88,,,,,,
Humana MCR ADV,CPT,87206,Smear fluorescent/acid stai,Lab Services,Per Unit,$5.39 ,OP,5.39,26.7,,,,,,
Humana MCR ADV,CPT,87207,Smear special stain,Lab Services,Per Unit,$5.99 ,OP,5.99,41.94,,,,,,
Humana MCR ADV,CPT,87209,Smear complex stain,Lab Services,Per Unit,$17.98 ,OP,17.98,80.07,,,,,,
Humana MCR ADV,CPT,87210,Smear wet mount saline/ink,Lab Services,Per Unit,$5.82 ,OP,5.82,22.88,,,,,,
Humana MCR ADV,CPT,87220,Tissue exam for fungi,Lab Services,Per Unit,$4.27 ,OP,4.27,22.88,,,,,,
Humana MCR ADV,CPT,87230,Assay toxin or antitoxin,Lab Services,Per Unit,$19.74 ,OP,19.74,87.69,,,,,,
Humana MCR ADV,CPT,87250,Virus inoculate eggs/animal,Lab Services,Per Unit,$19.56 ,OP,19.56,87.69,,,,,,
Humana MCR ADV,CPT,87252,Virus inoculation tissue,Lab Services,Per Unit,$26.07 ,OP,26.07,102.95,,,,,,
Humana MCR ADV,CPT,87253,Virus inoculate tissue addl,Lab Services,Per Unit,$20.20 ,OP,20.2,91.51,,,,,,
Humana MCR ADV,CPT,87254,Virus inoculation shell via,Lab Services,Per Unit,$19.56 ,OP,19.56,87.69,,,,,,
Humana MCR ADV,CPT,87255,Genet virus isolate hsv,Lab Services,Per Unit,$33.86 ,OP,33.86,152.51,,,,,,
Humana MCR ADV,CPT,87260,Adenovirus ag if,Lab Services,Per Unit,$14.43 ,OP,14.43,14.43,,,,,,
Humana MCR ADV,CPT,87265,Pertussis ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Humana MCR ADV,CPT,87267,Enterovirus antibody dfa,Lab Services,Per Unit,$13.42 ,OP,13.42,53.38,,,,,,
Humana MCR ADV,CPT,87269,Giardia ag if,Lab Services,Per Unit,$13.61 ,OP,13.61,53.38,,,,,,
Humana MCR ADV,CPT,87270,Chlamydia trachomatis ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Humana MCR ADV,CPT,87271,Cytomegalovirus dfa,Lab Services,Per Unit,$13.42 ,OP,13.42,53.38,,,,,,
Humana MCR ADV,CPT,87272,Cryptosporidium ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Humana MCR ADV,CPT,87273,Herpes simplex 2 ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,
Humana MCR ADV,CPT,87274,Herpes simplex 1 ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,
Humana MCR ADV,CPT,87275,Influenza b ag if,Lab Services,Per Unit,$12.25 ,OP,12.25,53.38,,,,,,
Humana MCR ADV,CPT,87276,Influenza a ag if,Lab Services,Per Unit,$16.07 ,OP,16.07,53.38,,,,,,
Humana MCR ADV,CPT,87278,Legion pneumophilia ag if,Lab Services,Per Unit,$15.60 ,OP,15.6,53.38,,,,,,
Humana MCR ADV,CPT,87279,Parainfluenza ag if,Lab Services,Per Unit,$16.43 ,OP,16.43,53.38,,,,,,
Humana MCR ADV,CPT,87280,Respiratory syncytial ag if,Lab Services,Per Unit,$13.42 ,OP,13.42,53.38,,,,,,
Humana MCR ADV,CPT,87281,Pneumocystis carinii ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Humana MCR ADV,CPT,87283,Rubeola ag if,Lab Services,Per Unit,$60.80 ,OP,53.38,60.8,,,,,,
Humana MCR ADV,CPT,87285,Treponema pallidum ag if,Lab Services,Per Unit,$12.18 ,OP,12.18,53.38,,,,,,
Humana MCR ADV,CPT,87290,Varicella zoster ag if,Lab Services,Per Unit,$13.42 ,OP,13.42,53.38,,,,,,
Humana MCR ADV,CPT,87299,Antibody detection nos if,Lab Services,Per Unit,$16.10 ,OP,16.1,53.38,,,,,,
Humana MCR ADV,CPT,87300,Ag detection polyval if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,
Humana MCR ADV,CPT,87301,Adenovirus ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Humana MCR ADV,CPT,87305,Aspergillus ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Humana MCR ADV,CPT,87320,Chylmd trach ag ia,Lab Services,Per Unit,$15.00 ,OP,15,53.38,,,,,,
Humana MCR ADV,CPT,87324,Clostridium ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Humana MCR ADV,CPT,87327,Cryptococcus neoform ag ia,Lab Services,Per Unit,$13.42 ,OP,13.42,53.38,,,,,,
Humana MCR ADV,CPT,87328,Cryptosporidium ag ia,Lab Services,Per Unit,$13.82 ,OP,13.82,53.38,,,,,,
Humana MCR ADV,CPT,87329,Giardia ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Humana MCR ADV,CPT,87332,Cytomegalovirus ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Humana MCR ADV,CPT,87335,E coli 0157 ag ia,Lab Services,Per Unit,$12.66 ,OP,12.66,53.38,,,,,,
Humana MCR ADV,CPT,87336,Entamoeb hist dispr ag ia,Lab Services,Per Unit,$16.00 ,OP,16,53.38,,,,,,
Humana MCR ADV,CPT,87337,Entamoeb hist group ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Humana MCR ADV,CPT,87338,Hpylori stool ag ia,Lab Services,Per Unit,$14.38 ,OP,14.38,64.82,,,,,,
Humana MCR ADV,CPT,87339,H pylori ag ia,Lab Services,Per Unit,$16.00 ,OP,16,53.38,,,,,,
Humana MCR ADV,CPT,87340,Hepatitis b surface ag ia,Lab Services,Per Unit,$10.33 ,OP,10.33,45.74,,,,,,
Humana MCR ADV,CPT,87341,Hepatitis b surface ag ia,Lab Services,Per Unit,$10.33 ,OP,10.33,45.74,,,,,,
Humana MCR ADV,CPT,87350,Hepatitis be ag ia,Lab Services,Per Unit,$11.53 ,OP,11.53,49.56,,,,,,
Humana MCR ADV,CPT,87380,Hepatitis delta agent ag ia,Lab Services,Per Unit,$18.36 ,OP,18.36,72.44,,,,,,
Humana MCR ADV,CPT,87385,Histoplasma capsul ag ia,Lab Services,Per Unit,$13.25 ,OP,13.25,53.38,,,,,,
Humana MCR ADV,CPT,87389,Hiv-1 ag w/hiv-1&2 ab ag ia,Lab Services,Per Unit,$24.08 ,OP,24.08,24.08,,,,,,
Humana MCR ADV,CPT,87390,Hiv-1 ag ia,Lab Services,Per Unit,$24.06 ,OP,24.06,24.06,,,,,,
Humana MCR ADV,CPT,87391,Hiv-2 ag ia,Lab Services,Per Unit,$21.90 ,OP,21.9,80.07,,,,,,
Humana MCR ADV,CPT,87400,Influenza a/b each ag ia,Lab Services,Per Unit,$14.13 ,OP,14.13,61,,,,,,
Humana MCR ADV,CPT,87420,Resp syncytial virus ag ia,Lab Services,Per Unit,$13.91 ,OP,13.91,53.38,,,,,,
Humana MCR ADV,CPT,87425,Rotavirus ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Humana MCR ADV,CPT,87426,Sarscov coronavirus ag ia,Lab Services,Per Unit,$35.33 ,OP,35.33,35.33,,,,,,
Humana MCR ADV,CPT,87427,Shiga-like toxin ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Humana MCR ADV,CPT,87428,Sarscov & inf vir a&b ag ia,Lab Services,Per Unit,$63.59 ,OP,63.59,63.59,,,,,,
Humana MCR ADV,CPT,87430,Strep a ag ia,Lab Services,Per Unit,$16.81 ,OP,16.81,61,,,,,,
Humana MCR ADV,CPT,87449,Nos each organism ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,61,,,,,,
Humana MCR ADV,CPT,87451,Polyvalent mult org ea ag ia,Lab Services,Per Unit,$10.51 ,OP,10.51,41.94,,,,,,
Humana MCR ADV,CPT,87471,Bartonella dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,
Humana MCR ADV,CPT,87472,Bartonella dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Humana MCR ADV,CPT,87475,Lyme dis dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
Humana MCR ADV,CPT,87476,Lyme dis dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Humana MCR ADV,CPT,87480,Candida dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,99.13,,,,,,
Humana MCR ADV,CPT,87481,Candida dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Humana MCR ADV,CPT,87482,Candida dna quant,Lab Services,Per Unit,$55.74 ,OP,55.74,186.82,,,,,,
Humana MCR ADV,CPT,87483,Cns dna amp probe type 12-25,Lab Services,Per Unit,$416.78 ,OP,416.78,416.78,,,,,,
Humana MCR ADV,CPT,87485,Chylmd pneum dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
Humana MCR ADV,CPT,87486,Chylmd pneum dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Humana MCR ADV,CPT,87487,Chylmd pneum dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Humana MCR ADV,CPT,87490,Chylmd trach dna dir probe,Lab Services,Per Unit,$22.75 ,OP,22.75,99.13,,,,,,
Humana MCR ADV,CPT,87491,Chylmd trach dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Humana MCR ADV,CPT,87492,Chylmd trach dna quant,Lab Services,Per Unit,$53.47 ,OP,53.47,156.32,,,,,,
Humana MCR ADV,CPT,87493,C diff amplified probe,Lab Services,Per Unit,$37.27 ,OP,37.27,37.27,,,,,,
Humana MCR ADV,CPT,87495,Cytomeg dna dir probe,Lab Services,Per Unit,$30.03 ,OP,30.03,30.03,,,,,,
Humana MCR ADV,CPT,87496,Cytomeg dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Humana MCR ADV,CPT,87497,Cytomeg dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Humana MCR ADV,CPT,87498,Enterovirus probe&revrs trns,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Humana MCR ADV,CPT,87500,Vanomycin dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Humana MCR ADV,CPT,87501,Influenza dna amp prob 1+,Lab Services,Per Unit,$51.31 ,OP,51.31,51.31,,,,,,
Humana MCR ADV,CPT,87502,Influenza dna amp probe,Lab Services,Per Unit,$95.80 ,OP,95.8,95.8,,,,,,
Humana MCR ADV,CPT,87503,Influenza dna amp prob addl,Lab Services,Per Unit,$29.22 ,OP,29.22,29.22,,,,,,
Humana MCR ADV,CPT,87505,Nfct agent detection gi,Lab Services,Per Unit,$128.29 ,OP,128.29,128.29,,,,,,
Humana MCR ADV,CPT,87506,Iadna-dna/rna probe tq 6-11,Lab Services,Per Unit,$262.99 ,OP,262.99,262.99,,,,,,
Humana MCR ADV,CPT,87507,Iadna-dna/rna probe tq 12-25,Lab Services,Per Unit,$416.78 ,OP,416.78,416.78,,,,,,
Humana MCR ADV,CPT,87510,Gardner vag dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,99.13,,,,,,
Humana MCR ADV,CPT,87511,Gardner vag dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Humana MCR ADV,CPT,87512,Gardner vag dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,186.82,,,,,,
Humana MCR ADV,CPT,87516,Hepatitis b dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Humana MCR ADV,CPT,87517,Hepatitis b dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Humana MCR ADV,CPT,87520,Hepatitis c rna dir probe,Lab Services,Per Unit,$31.22 ,OP,31.22,87.69,,,,,,
Humana MCR ADV,CPT,87521,Hepatitis c probe&rvrs trnsc,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Humana MCR ADV,CPT,87522,Hepatitis c revrs trnscrpj,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Humana MCR ADV,CPT,87525,Hepatitis g dna dir probe,Lab Services,Per Unit,$29.80 ,OP,29.8,87.69,,,,,,
Humana MCR ADV,CPT,87526,Hepatitis g dna amp probe,Lab Services,Per Unit,$39.26 ,OP,39.26,156.32,,,,,,
Humana MCR ADV,CPT,87527,Hepatitis g dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,186.82,,,,,,
Humana MCR ADV,CPT,87528,Hsv dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
Humana MCR ADV,CPT,87529,Hsv dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Humana MCR ADV,CPT,87530,Hsv dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Humana MCR ADV,CPT,87531,Hhv-6 dna dir probe,Lab Services,Per Unit,$58.00 ,OP,58,87.69,,,,,,
Humana MCR ADV,CPT,87532,Hhv-6 dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,
Humana MCR ADV,CPT,87533,Hhv-6 dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,186.82,,,,,,
Humana MCR ADV,CPT,87534,Hiv-1 dna dir probe,Lab Services,Per Unit,$21.92 ,OP,21.92,87.69,,,,,,
Humana MCR ADV,CPT,87535,Hiv-1 probe&reverse trnscrpj,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Humana MCR ADV,CPT,87536,Hiv-1 quant&revrse trnscrpj,Lab Services,Per Unit,$85.10 ,OP,85.1,377.46,,,,,,
Humana MCR ADV,CPT,87537,Hiv-2 dna dir probe,Lab Services,Per Unit,$21.92 ,OP,21.92,87.69,,,,,,
Humana MCR ADV,CPT,87538,Hiv-2 probe&revrse trnscripj,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Humana MCR ADV,CPT,87539,Hiv-2 quant&revrse trnscripj,Lab Services,Per Unit,$58.62 ,OP,58.62,190.64,,,,,,
Humana MCR ADV,CPT,87540,Legion pneumo dna dir prob,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
Humana MCR ADV,CPT,87541,Legion pneumo dna amp prob,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Humana MCR ADV,CPT,87542,Legion pneumo dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,186.82,,,,,,
Humana MCR ADV,CPT,87550,Mycobacteria dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
Humana MCR ADV,CPT,87551,Mycobacteria dna amp probe,Lab Services,Per Unit,$48.24 ,OP,48.24,156.32,,,,,,
Humana MCR ADV,CPT,87552,Mycobacteria dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Humana MCR ADV,CPT,87555,M.tuberculo dna dir probe,Lab Services,Per Unit,$26.88 ,OP,26.88,87.69,,,,,,
Humana MCR ADV,CPT,87556,M.tuberculo dna amp probe,Lab Services,Per Unit,$41.68 ,OP,41.68,156.32,,,,,,
Humana MCR ADV,CPT,87557,M.tuberculo dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Humana MCR ADV,CPT,87560,M.avium-intra dna dir prob,Lab Services,Per Unit,$27.29 ,OP,27.29,87.69,,,,,,
Humana MCR ADV,CPT,87561,M.avium-intra dna amp prob,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Humana MCR ADV,CPT,87562,M.avium-intra dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Humana MCR ADV,CPT,87563,M. genitalium amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Humana MCR ADV,CPT,87580,M.pneumon dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
Humana MCR ADV,CPT,87581,M.pneumon dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Humana MCR ADV,CPT,87582,M.pneumon dna quant,Lab Services,Per Unit,$302.62 ,OP,186.82,302.62,,,,,,
Humana MCR ADV,CPT,87590,N.gonorrhoeae dna dir prob,Lab Services,Per Unit,$26.88 ,OP,26.88,99.13,,,,,,
Humana MCR ADV,CPT,87591,N.gonorrhoeae dna amp prob,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Humana MCR ADV,CPT,87592,N.gonorrhoeae dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,
Humana MCR ADV,CPT,87623,Hpv low-risk types,Lab Services,Per Unit,$35.09 ,OP,35.09,93.87,,,,,,
Humana MCR ADV,CPT,87624,Hpv high-risk types,Lab Services,Per Unit,$35.09 ,OP,35.09,93.87,,,,,,
Humana MCR ADV,CPT,87625,Hpv types 16 & 18 only,Lab Services,Per Unit,$40.55 ,OP,40.55,93.87,,,,,,
Humana MCR ADV,CPT,87631,Resp virus 3-5 targets,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
Humana MCR ADV,CPT,87632,Resp virus 6-11 targets,Lab Services,Per Unit,$218.06 ,OP,218.06,218.06,,,,,,
Humana MCR ADV,CPT,87633,Resp virus 12-25 targets,Lab Services,Per Unit,$416.78 ,OP,416.78,416.78,,,,,,
Humana MCR ADV,CPT,87634,Rsv dna/rna amp probe,Lab Services,Per Unit,$70.20 ,OP,70.2,70.2,,,,,,
Humana MCR ADV,CPT,87635,Sars-cov-2 covid-19 amp prb,Lab Services,Per Unit,$51.31 ,OP,51.31,51.31,,,,,,
Humana MCR ADV,CPT,87636,Sarscov2 & inf a&b amp prb,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
Humana MCR ADV,CPT,87637,Sarscov2&inf a&b&rsv amp prb,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
Humana MCR ADV,CPT,87640,Staph a dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Humana MCR ADV,CPT,87641,Mr-staph dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Humana MCR ADV,CPT,87650,Strep a dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
Humana MCR ADV,CPT,87651,Strep a dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Humana MCR ADV,CPT,87652,Strep a dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,186.82,,,,,,
Humana MCR ADV,CPT,87653,Strep b dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,
Humana MCR ADV,CPT,87660,Trichomonas vagin dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
Humana MCR ADV,CPT,87661,Trichomonas vaginalis amplif,Lab Services,Per Unit,$35.09 ,OP,35.09,87.69,,,,,,
Humana MCR ADV,CPT,87662,Zika virus dna/rna amp probe,Lab Services,Per Unit,$51.31 ,OP,51.31,51.31,,,,,,
Humana MCR ADV,CPT,87797,Detect agent nos dna dir,Lab Services,Per Unit,$30.03 ,OP,30.03,99.13,,,,,,
Humana MCR ADV,CPT,87798,Detect agent nos dna amp,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Humana MCR ADV,CPT,87799,Detect agent nos dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Humana MCR ADV,CPT,87800,Detect agnt mult dna direc,Lab Services,Per Unit,$43.67 ,OP,43.67,179.2,,,,,,
Humana MCR ADV,CPT,87801,Detect agnt mult dna ampli,Lab Services,Per Unit,$70.20 ,OP,70.2,312.64,,,,,,
Humana MCR ADV,CPT,87802,Strep b assay w/optic,Lab Services,Per Unit,$12.73 ,OP,12.73,61,,,,,,
Humana MCR ADV,CPT,87803,Clostridium toxin a w/optic,Lab Services,Per Unit,$16.00 ,OP,16,61,,,,,,
Humana MCR ADV,CPT,87804,Influenza assay w/optic,Lab Services,Per Unit,$16.55 ,OP,16.55,61,,,,,,
Humana MCR ADV,CPT,87806,Hiv w/hiv1&2 antb w/optic,Lab Services,Per Unit,$32.77 ,OP,32.77,61,,,,,,
Humana MCR ADV,CPT,87807,Rsv assay w/optic,Lab Services,Per Unit,$13.10 ,OP,13.1,53.38,,,,,,
Humana MCR ADV,CPT,87808,Trichomonas assay w/optic,Lab Services,Per Unit,$15.29 ,OP,15.29,61,,,,,,
Humana MCR ADV,CPT,87809,Adenovirus assay w/optic,Lab Services,Per Unit,$21.76 ,OP,21.76,53.38,,,,,,
Humana MCR ADV,CPT,87810,Chylmd trach assay w/optic,Lab Services,Per Unit,$35.29 ,OP,35.29,53.38,,,,,,
Humana MCR ADV,CPT,87811,Sars-cov-2 covid19 w/optic,Lab Services,Per Unit,$41.38 ,OP,41.38,41.38,,,,,,
Humana MCR ADV,CPT,87850,N. gonorrhoeae assay w/optic,Lab Services,Per Unit,$24.56 ,OP,24.56,53.38,,,,,,
Humana MCR ADV,CPT,87880,Strep a assay w/optic,Lab Services,Per Unit,$16.53 ,OP,16.53,61,,,,,,
Humana MCR ADV,CPT,87899,Agent nos assay w/optic,Lab Services,Per Unit,$16.07 ,OP,16.07,61,,,,,,
Humana MCR ADV,CPT,87900,Phenotype infect agent drug,Lab Services,Per Unit,$130.35 ,OP,130.35,518.52,,,,,,
Humana MCR ADV,CPT,87901,Genotype dna hiv reverse t,Lab Services,Per Unit,$257.45 ,OP,257.45,"1,147.62",,,,,,
Humana MCR ADV,CPT,87902,Genotype dna/rna hep c,Lab Services,Per Unit,$257.45 ,OP,257.45,"1,147.62",,,,,,
Humana MCR ADV,CPT,87903,Phenotype dna hiv w/culture,Lab Services,Per Unit,$488.66 ,OP,488.66,488.66,,,,,,
Humana MCR ADV,CPT,87904,Phenotype dna hiv w/clt add,Lab Services,Per Unit,$26.07 ,OP,26.07,26.07,,,,,,
Humana MCR ADV,CPT,87905,Sialidase enzyme assay,Lab Services,Per Unit,$12.22 ,OP,12.22,53.38,,,,,,
Humana MCR ADV,CPT,87906,Genotype dna/rna hiv,Lab Services,Per Unit,$128.73 ,OP,128.73,128.73,,,,,,
Humana MCR ADV,CPT,87910,Genotype cytomegalovirus,Lab Services,Per Unit,$257.45 ,OP,257.45,257.45,,,,,,
Humana MCR ADV,CPT,87912,Genotype dna hepatitis b,Lab Services,Per Unit,$257.45 ,OP,257.45,257.45,,,,,,
Humana MCR ADV,CPT,88104,Cytopath fl nongyn smears,APC 5732,RVU Per Case,$34.63 ,OP,34.63,175.39,,,,,,
Humana MCR ADV,CPT,88106,Cytopath fl nongyn filter,APC 5731,RVU Per Case,$25.25 ,OP,25.25,247.83,,,,,,
Humana MCR ADV,CPT,88108,Cytopath concentrate tech,APC 5732,RVU Per Case,$34.63 ,OP,34.63,228.77,,,,,,
Humana MCR ADV,CPT,88112,Cytopath cell enhance tech,APC 5671,RVU Per Case,$50.92 ,OP,50.92,232.58,,,,,,
Humana MCR ADV,CPT,88120,Cytp urne 3-5 probes ea spec,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Humana MCR ADV,CPT,88121,Cytp urine 3-5 probes cmptr,APC 5673,RVU Per Case,$298.05 ,OP,298.05,298.05,,,,,,
Humana MCR ADV,CPT,88125,Forensic cytopathology,APC 5671,RVU Per Case,$50.92 ,OP,45.74,50.92,,,,,,
Humana MCR ADV,CPT,88130,Sex chromatin identification,Lab Services,Per Unit,$17.98 ,OP,17.98,68.63,,,,,,
Humana MCR ADV,CPT,88140,Sex chromatin identification,Lab Services,Per Unit,$7.99 ,OP,7.99,34.31,,,,,,
Humana MCR ADV,CPT,88142,Cytopath c/v thin layer,Lab Services,Per Unit,$20.26 ,OP,20.26,91.51,,,,,,
Humana MCR ADV,CPT,88143,Cytopath c/v thin layer redo,Lab Services,Per Unit,$23.04 ,OP,23.04,91.51,,,,,,
Humana MCR ADV,CPT,88147,Cytopath c/v automated,Lab Services,Per Unit,$50.56 ,OP,45.74,50.56,,,,,,
Humana MCR ADV,CPT,88148,Cytopath c/v auto rescreen,Lab Services,Per Unit,$16.00 ,OP,16,45.74,,,,,,
Humana MCR ADV,CPT,88150,Cytopath c/v manual,Lab Services,Per Unit,$15.15 ,OP,15.15,45.74,,,,,,
Humana MCR ADV,CPT,88152,Cytopath c/v auto redo,Lab Services,Per Unit,$27.64 ,OP,27.64,45.74,,,,,,
Humana MCR ADV,CPT,88153,Cytopath c/v redo,Lab Services,Per Unit,$24.03 ,OP,24.03,45.74,,,,,,
Humana MCR ADV,CPT,88155,Cytopath c/v index add-on,Lab Services,Per Unit,$14.65 ,OP,14.65,26.7,,,,,,
Humana MCR ADV,CPT,88160,Cytopath smear other source,APC 5731,RVU Per Case,$25.25 ,OP,25.25,141.07,,,,,,
Humana MCR ADV,CPT,88161,Cytopath smear other source,APC 5731,RVU Per Case,$25.25 ,OP,25.25,152.51,,,,,,
Humana MCR ADV,CPT,88162,Cytopath smear other source,APC 5671,RVU Per Case,$50.92 ,OP,50.92,205.88,,,,,,
Humana MCR ADV,CPT,88164,Cytopath tbs c/v manual,Lab Services,Per Unit,$15.15 ,OP,15.15,45.74,,,,,,
Humana MCR ADV,CPT,88165,Cytopath tbs c/v redo,Lab Services,Per Unit,$42.22 ,OP,42.22,45.74,,,,,,
Humana MCR ADV,CPT,88166,Cytopath tbs c/v auto redo,Lab Services,Per Unit,$15.15 ,OP,15.15,45.74,,,,,,
Humana MCR ADV,CPT,88167,Cytopath tbs c/v select,Lab Services,Per Unit,$15.15 ,OP,15.15,45.74,,,,,,
Humana MCR ADV,CPT,88172,Cytp dx eval fna 1st ea site,APC 5672,RVU Per Case,$152.64 ,OP,118.19,152.64,,,,,,
Humana MCR ADV,CPT,88173,Cytopath eval fna report,APC 5671,RVU Per Case,$50.92 ,OP,50.92,327.9,,,,,,
Humana MCR ADV,CPT,88174,Cytopath c/v auto in fluid,Lab Services,Per Unit,$25.37 ,OP,25.37,95.32,,,,,,
Humana MCR ADV,CPT,88175,Cytopath c/v auto fluid redo,Lab Services,Per Unit,$26.61 ,OP,26.61,118.19,,,,,,
Humana MCR ADV,CPT,88182,Cell marker study,APC 5671,RVU Per Case,$50.92 ,OP,50.92,339.33,,,,,,
Humana MCR ADV,CPT,88184,Flowcytometry/ tc 1 marker,APC 5673,RVU Per Case,$298.05 ,OP,298.05,404.14,,,,,,
Humana MCR ADV,CPT,88199,Cytopathology procedure,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Humana MCR ADV,CPT,88230,Tissue culture lymphocyte,Lab Services,Per Unit,$116.49 ,OP,116.49,518.52,,,,,,
Humana MCR ADV,CPT,88233,Tissue culture skin/biopsy,Lab Services,Per Unit,$140.73 ,OP,140.73,625.29,,,,,,
Humana MCR ADV,CPT,88235,Tissue culture placenta,Lab Services,Per Unit,$150.30 ,OP,150.3,655.78,,,,,,
Humana MCR ADV,CPT,88237,Tissue culture bone marrow,Lab Services,Per Unit,$143.75 ,OP,143.75,564.29,,,,,,
Humana MCR ADV,CPT,88239,Tissue culture tumor,Lab Services,Per Unit,$147.52 ,OP,147.52,655.78,,,,,,
Humana MCR ADV,CPT,88240,Cell cryopreserve/storage,Lab Services,Per Unit,$13.07 ,OP,13.07,45.74,,,,,,
Humana MCR ADV,CPT,88241,Frozen cell preparation,Lab Services,Per Unit,$12.09 ,OP,12.09,45.74,,,,,,
Humana MCR ADV,CPT,88245,Chromosome analysis 20-25,Lab Services,Per Unit,$173.17 ,OP,173.17,648.16,,,,,,
Humana MCR ADV,CPT,88248,Chromosome analysis 50-100,Lab Services,Per Unit,$173.17 ,OP,173.17,770.16,,,,,,
Humana MCR ADV,CPT,88249,Chromosome analysis 100,Lab Services,Per Unit,$173.17 ,OP,173.17,770.16,,,,,,
Humana MCR ADV,CPT,88261,Chromosome analysis 5,Lab Services,Per Unit,$264.34 ,OP,264.34,785.42,,,,,,
Humana MCR ADV,CPT,88262,Chromosome analysis 15-20,Lab Services,Per Unit,$125.49 ,OP,125.49,556.65,,,,,,
Humana MCR ADV,CPT,88263,Chromosome analysis 45,Lab Services,Per Unit,$150.29 ,OP,150.29,671.03,,,,,,
Humana MCR ADV,CPT,88264,Chromosome analysis 20-25,Lab Services,Per Unit,$144.61 ,OP,144.61,556.65,,,,,,
Humana MCR ADV,CPT,88267,Chromosome analys placenta,Lab Services,Per Unit,$188.57 ,OP,188.57,800.67,,,,,,
Humana MCR ADV,CPT,88269,Chromosome analys amniotic,Lab Services,Per Unit,$173.66 ,OP,173.66,739.67,,,,,,
Humana MCR ADV,CPT,88271,Cytogenetics dna probe,Lab Services,Per Unit,$21.42 ,OP,21.42,64.82,,,,,,
Humana MCR ADV,CPT,88272,Cytogenetics 3-5,Lab Services,Per Unit,$40.70 ,OP,40.7,114.39,,,,,,
Humana MCR ADV,CPT,88273,Cytogenetics 10-30,Lab Services,Per Unit,$34.81 ,OP,34.81,144.88,,,,,,
Humana MCR ADV,CPT,88274,Cytogenetics 25-99,Lab Services,Per Unit,$42.38 ,OP,42.38,156.32,,,,,,
Humana MCR ADV,CPT,88275,Cytogenetics 100-300,Lab Services,Per Unit,$51.19 ,OP,51.19,179.2,,,,,,
Humana MCR ADV,CPT,88280,Chromosome karyotype study,Lab Services,Per Unit,$33.47 ,OP,33.47,110.57,,,,,,
Humana MCR ADV,CPT,88283,Chromosome banding study,Lab Services,Per Unit,$68.60 ,OP,68.6,68.6,,,,,,
Humana MCR ADV,CPT,88285,Chromosome count additional,Lab Services,Per Unit,$26.91 ,OP,26.91,83.87,,,,,,
Humana MCR ADV,CPT,88289,Chromosome study additional,Lab Services,Per Unit,$34.43 ,OP,34.43,129.64,,,,,,
Humana MCR ADV,CPT,88299,Cytogenetic study,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Humana MCR ADV,CPT,88300,Surgical path gross,APC 5731,RVU Per Case,$25.25 ,OP,25.25,99.13,,,,,,
Humana MCR ADV,CPT,88302,Tissue exam by pathologist,APC 5731,RVU Per Case,$25.25 ,OP,25.25,217.32,,,,,,
Humana MCR ADV,CPT,88304,Tissue exam by pathologist,APC 5671,RVU Per Case,$50.92 ,OP,50.92,263.08,,,,,,
Humana MCR ADV,CPT,88305,Tissue exam by pathologist,APC 5671,RVU Per Case,$50.92 ,OP,50.92,362.21,,,,,,
Humana MCR ADV,CPT,88307,Tissue exam by pathologist,APC 5673,RVU Per Case,$298.05 ,OP,298.05,671.03,,,,,,
Humana MCR ADV,CPT,88309,Tissue exam by pathologist,APC 5674,RVU Per Case,$671.45 ,OP,671.45,911.23,,,,,,
Humana MCR ADV,CPT,88312,Special stains group 1,APC 5671,RVU Per Case,$50.92 ,OP,50.92,366.02,,,,,,
Humana MCR ADV,CPT,88313,Special stains group 2,APC 5732,RVU Per Case,$34.63 ,OP,34.63,308.83,,,,,,
Humana MCR ADV,CPT,88319,Enzyme histochemistry,APC 5674,RVU Per Case,$671.45 ,OP,568.09,671.45,,,,,,
Humana MCR ADV,CPT,88321,Microslide consultation,APC 5732,RVU Per Case,$34.63 ,OP,34.63,438.47,,,,,,
Humana MCR ADV,CPT,88323,Microslide consultation,APC 5671,RVU Per Case,$50.92 ,OP,50.92,289.76,,,,,,
Humana MCR ADV,CPT,88325,Comprehensive review of data,APC 5672,RVU Per Case,$152.64 ,OP,152.64,949.36,,,,,,
Humana MCR ADV,CPT,88329,Path consult introp,APC 5732,RVU Per Case,$34.63 ,OP,34.63,247.83,,,,,,
Humana MCR ADV,CPT,88331,Path consult intraop 1 bloc,APC 5672,RVU Per Case,$152.64 ,OP,152.51,152.64,,,,,,
Humana MCR ADV,CPT,88333,Intraop cyto path consult 1,APC 5674,RVU Per Case,$671.45 ,OP,163.95,671.45,,,,,,
Humana MCR ADV,CPT,88342,Immunohisto antb 1st stain,APC 5672,RVU Per Case,$152.64 ,OP,152.64,297.39,,,,,,
Humana MCR ADV,CPT,88344,Immunohisto antibody slide,APC 5673,RVU Per Case,$298.05 ,OP,297.39,298.05,,,,,,
Humana MCR ADV,CPT,88346,Immunofluor antb 1st stain,APC 5673,RVU Per Case,$298.05 ,OP,293.57,298.05,,,,,,
Humana MCR ADV,CPT,88348,Electron microscopy,APC 5674,RVU Per Case,$671.45 ,OP,671.45,"2,794.70",,,,,,
Humana MCR ADV,CPT,88355,Analysis skeletal muscle,APC 5672,RVU Per Case,$152.64 ,OP,152.64,777.79,,,,,,
Humana MCR ADV,CPT,88356,Analysis nerve,APC 5671,RVU Per Case,$50.92 ,OP,50.92,766.35,,,,,,
Humana MCR ADV,CPT,88358,Analysis tumor,APC 5672,RVU Per Case,$152.64 ,OP,152.64,171.58,,,,,,
Humana MCR ADV,CPT,88360,Tumor immunohistochem/manual,APC 5672,RVU Per Case,$152.64 ,OP,152.64,335.53,,,,,,
Humana MCR ADV,CPT,88361,Tumor immunohistochem/comput,APC 5673,RVU Per Case,$298.05 ,OP,298.05,484.22,,,,,,
Humana MCR ADV,CPT,88362,Nerve teasing preparations,APC 5674,RVU Per Case,$671.45 ,OP,671.45,793.05,,,,,,
Humana MCR ADV,CPT,88363,Xm archive tissue molec anal,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Humana MCR ADV,CPT,88365,Insitu hybridization (fish),APC 5672,RVU Per Case,$152.64 ,OP,152.64,499.47,,,,,,
Humana MCR ADV,CPT,88366,Insitu hybridization (fish),APC 5673,RVU Per Case,$298.05 ,OP,298.05,499.47,,,,,,
Humana MCR ADV,CPT,88367,Insitu hybridization auto,APC 5673,RVU Per Case,$298.05 ,OP,298.05,907.42,,,,,,
Humana MCR ADV,CPT,88368,Insitu hybridization manual,APC 5673,RVU Per Case,$298.05 ,OP,298.05,747.28,,,,,,
Humana MCR ADV,CPT,88374,M/phmtrc alys ishquant/semiq,APC 5672,RVU Per Case,$152.64 ,OP,152.64,907.42,,,,,,
Humana MCR ADV,CPT,88377,M/phmtrc alys ishquant/semiq,APC 5672,RVU Per Case,$152.64 ,OP,152.64,747.28,,,,,,
Humana MCR ADV,CPT,88399,Surgical pathology procedure,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Humana MCR ADV,CPT,88720,Bilirubin total transcut,Lab Services,Per Unit,$5.02 ,OP,5.02,22.88,,,,,,
Humana MCR ADV,CPT,88738,Hgb quant transcutaneous,Lab Services,Per Unit,$5.02 ,OP,5.02,5.02,,,,,,
Humana MCR ADV,CPT,88740,Transcutaneous carboxyhb,Lab Services,Per Unit,$9.37 ,OP,9.37,22.88,,,,,,
Humana MCR ADV,CPT,88741,Transcutaneous methb,Lab Services,Per Unit,$9.37 ,OP,9.37,22.88,,,,,,
Humana MCR ADV,CPT,89049,Chct for mal hyperthermia,APC 5672,RVU Per Case,$152.64 ,OP,152.64,"1,201.00",,,,,,
Humana MCR ADV,CPT,89050,Body fluid cell count,Lab Services,Per Unit,$4.72 ,OP,4.72,22.88,,,,,,
Humana MCR ADV,CPT,89051,Body fluid cell count,Lab Services,Per Unit,$5.60 ,OP,5.6,26.7,,,,,,
Humana MCR ADV,CPT,89055,Leukocyte assessment fecal,Lab Services,Per Unit,$4.27 ,OP,4.27,22.88,,,,,,
Humana MCR ADV,CPT,89060,Exam synovial fluid crystals,Lab Services,Per Unit,$7.33 ,OP,7.33,30.51,,,,,,
Humana MCR ADV,CPT,89125,Specimen fat stain,Lab Services,Per Unit,$5.88 ,OP,5.88,11.44,,,,,,
Humana MCR ADV,CPT,89160,Exam feces for meat fibers,Lab Services,Per Unit,$4.85 ,OP,4.85,15.26,,,,,,
Humana MCR ADV,CPT,89190,Nasal smear for eosinophils,Lab Services,Per Unit,$5.79 ,OP,5.79,22.88,,,,,,
Humana MCR ADV,CPT,89220,Sputum specimen collection,APC 5672,RVU Per Case,$152.64 ,OP,80.07,152.64,,,,,,
Humana MCR ADV,CPT,89230,Collect sweat for test,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Humana MCR ADV,CPT,89240,Pathology lab procedure,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Humana MCR ADV,CPT,89250,Cultr oocyte/embryo <4 days,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Humana MCR ADV,CPT,89251,Cultr oocyte/embryo <4 days,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Humana MCR ADV,CPT,89253,Embryo hatching,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Humana MCR ADV,CPT,89254,Oocyte identification,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Humana MCR ADV,CPT,89255,Prepare embryo for transfer,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Humana MCR ADV,CPT,89257,Sperm identification,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Humana MCR ADV,CPT,89258,Cryopreservation embryo(s),APC 5674,RVU Per Case,$671.45 ,OP,671.45,671.45,,,,,,
Humana MCR ADV,CPT,89259,Cryopreservation sperm,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Humana MCR ADV,CPT,89260,Sperm isolation simple,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Humana MCR ADV,CPT,89261,Sperm isolation complex,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Humana MCR ADV,CPT,89264,Identify sperm tissue,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Humana MCR ADV,CPT,89268,Insemination of oocytes,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Humana MCR ADV,CPT,89272,Extended culture of oocytes,APC 5674,RVU Per Case,$671.45 ,OP,671.45,671.45,,,,,,
Humana MCR ADV,CPT,89280,Assist oocyte fertilization,APC 5674,RVU Per Case,$671.45 ,OP,671.45,671.45,,,,,,
Humana MCR ADV,CPT,89281,Assist oocyte fertilization,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Humana MCR ADV,CPT,89290,Biopsy oocyte polar body,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Humana MCR ADV,CPT,89291,Biopsy oocyte polar body,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Humana MCR ADV,CPT,89300,Semen analysis w/huhner,Lab Services,Per Unit,$9.84 ,OP,9.84,45.74,,,,,,
Humana MCR ADV,CPT,89310,Semen analysis w/count,Lab Services,Per Unit,$8.61 ,OP,8.61,30.51,,,,,,
Humana MCR ADV,CPT,89320,Semen anal vol/count/mot,Lab Services,Per Unit,$12.31 ,OP,12.31,49.56,,,,,,
Humana MCR ADV,CPT,89321,Semen anal sperm detection,Lab Services,Per Unit,$12.05 ,OP,12.05,49.56,,,,,,
Humana MCR ADV,CPT,89322,Semen anal strict criteria,Lab Services,Per Unit,$15.50 ,OP,15.5,61,,,,,,
Humana MCR ADV,CPT,89325,Sperm antibody test,Lab Services,Per Unit,$10.67 ,OP,10.67,10.67,,,,,,
Humana MCR ADV,CPT,89329,Sperm evaluation test,Lab Services,Per Unit,$19.59 ,OP,19.59,91.51,,,,,,
Humana MCR ADV,CPT,89330,Evaluation cervical mucus,Lab Services,Per Unit,$10.38 ,OP,10.38,45.74,,,,,,
Humana MCR ADV,CPT,89331,Retrograde ejaculation anal,Lab Services,Per Unit,$19.59 ,OP,19.59,83.87,,,,,,
Humana MCR ADV,CPT,89335,Cryopreserve testicular tiss,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Humana MCR ADV,CPT,89337,Cryopreservation oocyte(s),APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Humana MCR ADV,CPT,89342,Storage/year embryo(s),APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Humana MCR ADV,CPT,89343,Storage/year sperm/semen,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Humana MCR ADV,CPT,89344,Storage/year reprod tissue,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Humana MCR ADV,CPT,89346,Storage/year oocyte(s),APC 5673,RVU Per Case,$298.05 ,OP,298.05,298.05,,,,,,
Humana MCR ADV,CPT,89352,Thawing cryopresrved embryo,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Humana MCR ADV,CPT,89353,Thawing cryopresrved sperm,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Humana MCR ADV,CPT,89354,Thaw cryoprsvrd reprod tiss,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Humana MCR ADV,CPT,89356,Thawing cryopresrved oocyte,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Humana MCR ADV,CPT,89398,Unlisted reprod med lab proc,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Humana MCR ADV,CPT,90371,Hep b ig im,APC 1630,Per Unit,$130.31 ,OP,130.31,735.85,,,,,,
Humana MCR ADV,CPT,90375,Rabies ig im/sc,APC 9133,Per Unit,$267.30 ,OP,267.3,617.65,,,,,,
Humana MCR ADV,CPT,90376,Rabies ig heat treated,APC 9134,Per Unit,$287.38 ,OP,287.38,617.65,,,,,,
Humana MCR ADV,CPT,90378,Rsv mab im 50mg,APC 9003,Per Unit,"$1,185.67 ",OP,"1,185.67","3,154.20",,,,,,
Humana MCR ADV,CPT,90385,Rh ig minidose im,APC 9063,Per Unit,$151.41 ,OP,151.41,202.07,,,,,,
Humana MCR ADV,CPT,90396,Varicella-zoster ig im,APC 9135,Per Unit,"$1,965.97 ",OP,495.65,"1,965.97",,,,,,
Humana MCR ADV,CPT,90471,Immunization admin,APC 5692,RVU Per Case,$63.42 ,OP,57.19,63.42,,,,,,
Humana MCR ADV,CPT,90473,Immune admin oral/nasal,APC 5692,RVU Per Case,$63.42 ,OP,57.19,63.42,,,,,,
Humana MCR ADV,CPT,90630,Flu vacc iiv4 no preserv id,Other,Straight Discount,29.70%,OP,,,,,,,,
Humana MCR ADV,CPT,90653,Iiv adjuvant vaccine im,Other,Straight Discount,29.70%,OP,,,,,,,,
Humana MCR ADV,CPT,90654,Flu vacc iiv3 no preserv id,Other,Straight Discount,29.70%,OP,,,,,,,,
Humana MCR ADV,CPT,90655,Iiv3 vacc no prsv 0.25 ml im,Other,Straight Discount,29.70%,OP,68.63,68.63,,,,,,
Humana MCR ADV,CPT,90656,Iiv3 vacc no prsv 0.5 ml im,Other,Straight Discount,29.70%,OP,76.26,76.26,,,,,,
Humana MCR ADV,CPT,90657,Iiv3 vaccine splt 0.25 ml im,Other,Straight Discount,29.70%,OP,110.57,110.57,,,,,,
Humana MCR ADV,CPT,90660,Laiv3 vaccine intranasal,Other,Straight Discount,29.70%,OP,122,122,,,,,,
Humana MCR ADV,CPT,90661,Cciiv3 vac no prsv 0.5 ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Humana MCR ADV,CPT,90662,Iiv no prsv increased ag im,Other,Straight Discount,29.70%,OP,,,,,,,,
Humana MCR ADV,CPT,90670,Pcv13 vaccine im,Other,Straight Discount,29.70%,OP,,,,,,,,
Humana MCR ADV,CPT,90672,Laiv4 vaccine intranasal,Other,Straight Discount,29.70%,OP,,,,,,,,
Humana MCR ADV,CPT,90673,Riv3 vaccine no preserv im,Other,Straight Discount,29.70%,OP,,,,,,,,
Humana MCR ADV,CPT,90674,Cciiv4 vac no prsv 0.5 ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Humana MCR ADV,CPT,90675,Rabies vaccine im,APC 9139,Per Unit,$327.53 ,OP,327.53,945.56,,,,,,
Humana MCR ADV,CPT,90676,Rabies vaccine id,APC 9140,Per Unit,$189.63 ,OP,189.63,945.56,,,,,,
Humana MCR ADV,CPT,90677,Pcv20 vaccine im,Other,Straight Discount,29.70%,OP,,,,,,,,
Humana MCR ADV,CPT,90682,Riv4 vacc recombinant dna im,Other,Straight Discount,29.70%,OP,,,,,,,,
Humana MCR ADV,CPT,90685,Iiv4 vacc no prsv 0.25 ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Humana MCR ADV,CPT,90686,Iiv4 vacc no prsv 0.5 ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Humana MCR ADV,CPT,90687,Iiv4 vaccine splt 0.25 ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Humana MCR ADV,CPT,90688,Iiv4 vaccine splt 0.5 ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Humana MCR ADV,CPT,90689,Vacc iiv4 no prsrv 0.25ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Humana MCR ADV,CPT,90694,Vacc aiiv4 no prsrv 0.5ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Humana MCR ADV,CPT,90732,Ppsv23 vacc 2 yrs+ subq/im,Other,Straight Discount,29.70%,OP,228.77,228.77,,,,,,
Humana MCR ADV,CPT,90739,Hepb vacc 2 dose adult im,Other,Straight Discount,29.70%,OP,,,,,,,,
Humana MCR ADV,CPT,90740,Hepb vacc 3 dose immunsup im,Other,Straight Discount,29.70%,OP,"1,029.43","1,029.43",,,,,,
Humana MCR ADV,CPT,90743,Hepb vacc 2 dose adolesc im,Other,Straight Discount,29.70%,OP,141.07,141.07,,,,,,
Humana MCR ADV,CPT,90744,Hepb vacc 3 dose ped/adol im,Other,Straight Discount,29.70%,OP,141.07,141.07,,,,,,
Humana MCR ADV,CPT,90746,Hepb vaccine 3 dose adult im,Other,Straight Discount,29.70%,OP,369.83,369.83,,,,,,
Humana MCR ADV,CPT,90747,Hepb vacc 4 dose immunsup im,Other,Straight Discount,29.70%,OP,"1,029.43","1,029.43",,,,,,
Humana MCR ADV,CPT,90756,Cciiv4 vacc abx free im,Other,Straight Discount,29.70%,OP,,,,,,,,
Humana MCR ADV,CPT,90791,Psych diagnostic evaluation,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,789.23,,,,,,
Humana MCR ADV,CPT,90792,Psych diag eval w/med srvcs,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,789.23,,,,,,
Humana MCR ADV,CPT,90832,Psytx w pt 30 minutes,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,331.7,,,,,,
Humana MCR ADV,CPT,90834,Psytx w pt 45 minutes,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,480.4,,,,,,
Humana MCR ADV,CPT,90837,Psytx w pt 60 minutes,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,705.35,,,,,,
Humana MCR ADV,CPT,90839,Psytx crisis initial 60 min,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,136.74,,,,,,
Humana MCR ADV,CPT,90845,Psychoanalysis,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,423.22,,,,,,
Humana MCR ADV,CPT,90846,Family psytx w/o pt 50 min,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,449.9,,,,,,
Humana MCR ADV,CPT,90847,Family psytx w/pt 50 min,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,583.35,,,,,,
Humana MCR ADV,CPT,90849,Multiple family group psytx,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,171.58,,,,,,
Humana MCR ADV,CPT,90853,Group psychotherapy,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,368.97,,,,,,
Humana MCR ADV,CPT,90865,Narcosynthesis,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,808.29,,,,,,
Humana MCR ADV,CPT,90867,Tcranial magn stim tx plan,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Humana MCR ADV,CPT,90868,Tcranial magn stim tx deli,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Humana MCR ADV,CPT,90869,Tcran magn stim redetemine,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Humana MCR ADV,CPT,90870,Electroconvulsive therapy,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,709.16,,,,,,
Humana MCR ADV,CPT,90880,Hypnotherapy,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,545.21,,,,,,
Humana MCR ADV,CPT,90899,Psychiatric service/therapy,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Humana MCR ADV,CPT,90901,Biofeedback train any meth,Physician,Per Unit,$19.59 ,OP,19.59,19.59,,,,,,
Humana MCR ADV,CPT,90912,Bfb training 1st 15 min,Physician,Per Unit,$43.33 ,OP,43.33,476.6,,,,,,
Humana MCR ADV,CPT,90913,Bfb training ea addl 15 min,Physician,Per Unit,$24.51 ,OP,24.51,264.78,,,,,,
Humana MCR ADV,CPT,90935,Hemodialysis one evaluation,APC 5401,RVU Per Unit,$669.60 ,OP,373.65,669.6,,,,,,
Humana MCR ADV,CPT,90945,Dialysis one evaluation,APC 5024,RVU Per Unit,$372.22 ,OP,372.22,388.89,,,,,,
Humana MCR ADV,CPT,91010,Esophagus motility study,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Humana MCR ADV,CPT,91020,Gastric motility studies,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,"1,265.81",,,,,,
Humana MCR ADV,CPT,91022,Duodenal motility study,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,"1,044.69",,,,,,
Humana MCR ADV,CPT,91030,Acid perfusion of esophagus,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,754.91,,,,,,
Humana MCR ADV,CPT,91034,Gastroesophageal reflux test,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Humana MCR ADV,CPT,91035,G-esoph reflx tst w/electrod,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Humana MCR ADV,CPT,91037,Esoph imped function test,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Humana MCR ADV,CPT,91038,Esoph imped funct test > 1hr,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Humana MCR ADV,CPT,91040,Esoph balloon distension tst,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Humana MCR ADV,CPT,91065,Breath hydrogen/methane test,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Humana MCR ADV,CPT,91110,Gi tract capsule endoscopy,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,828.48,,,,,,
Humana MCR ADV,CPT,91111,Esophageal capsule endoscopy,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,828.48,,,,,,
Humana MCR ADV,CPT,91112,Gi wireless capsule measure,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,828.48,,,,,,
Humana MCR ADV,CPT,91117,Colon motility 6 hr study,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,272.35,,,,,,
Humana MCR ADV,CPT,91120,Rectal sensation test,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Humana MCR ADV,CPT,91122,Anal pressure record,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,272.35,,,,,,
Humana MCR ADV,CPT,91132,Electrogastrography,APC 5722,RVU Per Unit,$270.61 ,OP,244.01,270.61,,,,,,
Humana MCR ADV,CPT,91133,Electrogastrography w/test,APC 5734,RVU Per Case,$114.56 ,OP,114.56,312.64,,,,,,
Humana MCR ADV,CPT,91200,Liver elastography,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
Humana MCR ADV,CPT,91299,Gastroenterology procedure,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Humana MCR ADV,CPT,91300,Sarscov2 vac 30mcg/0.3ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Humana MCR ADV,CPT,91301,Sarscov2 vac 100mcg/0.5ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Humana MCR ADV,CPT,91303,Sarscov2 vac ad26 .5ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Humana MCR ADV,CPT,92002,Eye exam new patient,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,354.58,,,,,,
Humana MCR ADV,CPT,92004,Eye exam new patient,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,663.41,,,,,,
Humana MCR ADV,CPT,92012,Eye exam establish patient,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,373.65,,,,,,
Humana MCR ADV,CPT,92014,Eye exam&tx estab pt 1/>vst,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,545.21,,,,,,
Humana MCR ADV,CPT,92018,New eye exam & treatment,APC 5503,RVU Per Case,"$2,049.05 ",OP,671.03,"2,049.05",,,,,,
Humana MCR ADV,CPT,92019,Eye exam & treatment,APC 5503,RVU Per Case,"$2,049.05 ",OP,331.7,"2,049.05",,,,,,
Humana MCR ADV,CPT,92020,Special eye evaluation,APC 5734,RVU Per Case,$114.56 ,OP,114.56,125.82,,,,,,
Humana MCR ADV,CPT,92025,Corneal topography,APC 5733,RVU Per Case,$56.95 ,OP,56.95,167.76,,,,,,
Humana MCR ADV,CPT,92060,Special eye evaluation,APC 5733,RVU Per Case,$56.95 ,OP,56.95,285.96,,,,,,
Humana MCR ADV,CPT,92065,Orthoptic/pleoptic training,APC 5733,RVU Per Case,$56.95 ,OP,56.95,224.95,,,,,,
Humana MCR ADV,CPT,92081,Visual field examination(s),APC 5733,RVU Per Case,$56.95 ,OP,56.95,255.45,,,,,,
Humana MCR ADV,CPT,92082,Visual field examination(s),APC 5733,RVU Per Case,$56.95 ,OP,56.95,339.33,,,,,,
Humana MCR ADV,CPT,92083,Visual field examination(s),APC 5734,RVU Per Case,$114.56 ,OP,114.56,385.09,,,,,,
Humana MCR ADV,CPT,92132,Cmptr ophth dx img ant segmt,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Humana MCR ADV,CPT,92133,Cmptr ophth img optic nerve,APC 5733,RVU Per Case,$56.95 ,OP,56.95,224.95,,,,,,
Humana MCR ADV,CPT,92134,Cptr ophth dx img post segmt,APC 5733,RVU Per Case,$56.95 ,OP,56.95,224.95,,,,,,
Humana MCR ADV,CPT,92136,Ophthalmic biometry,APC 5734,RVU Per Case,$114.56 ,OP,114.56,411.78,,,,,,
Humana MCR ADV,CPT,92145,Corneal hysteresis deter,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Humana MCR ADV,CPT,92201,Opscpy extnd rta draw uni/bi,APC 5733,RVU Per Case,$56.95 ,OP,56.95,118.19,,,,,,
Humana MCR ADV,CPT,92202,Opscpy extnd on/mac draw,APC 5733,RVU Per Case,$56.95 ,OP,56.95,76.37,,,,,,
Humana MCR ADV,CPT,92227,Img rta detcj/mntr ds staff,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Humana MCR ADV,CPT,92228,Img rta detc/mntr ds phy/qhp,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Humana MCR ADV,CPT,92229,Img rta detc/mntr ds poc aly,APC 5733,RVU Per Unit,$56.95 ,OP,56.95,56.95,,,,,,
Humana MCR ADV,CPT,92230,Eye exam with photos,APC 5723,RVU Per Case,$499.16 ,OP,289.76,499.16,,,,,,
Humana MCR ADV,CPT,92235,Fluorescein angrph uni/bi,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,629.1,,,,,,
Humana MCR ADV,CPT,92240,Icg angiography uni/bi,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,162.87",,,,,,
Humana MCR ADV,CPT,92242,Fluorescein icg angiography,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,791.98",,,,,,
Humana MCR ADV,CPT,92250,Eye exam with photos,APC 5734,RVU Per Case,$114.56 ,OP,114.56,346.96,,,,,,
Humana MCR ADV,CPT,92260,Ophthalmoscopy/dynamometry,APC 5732,RVU Per Case,$34.63 ,OP,34.63,87.69,,,,,,
Humana MCR ADV,CPT,92265,Eye muscle evaluation,APC 5733,RVU Per Case,$56.95 ,OP,56.95,381.27,,,,,,
Humana MCR ADV,CPT,92270,Electro-oculography,APC 5734,RVU Per Case,$114.56 ,OP,114.56,438.47,,,,,,
Humana MCR ADV,CPT,92273,Full field erg w/i&r,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,648.16,,,,,,
Humana MCR ADV,CPT,92274,Multifocal erg w/i&r,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,386.03,,,,,,
Humana MCR ADV,CPT,92283,Color vision examination,APC 5733,RVU Per Case,$56.95 ,OP,56.95,224.95,,,,,,
Humana MCR ADV,CPT,92284,Dark adaptation eye exam,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
Humana MCR ADV,CPT,92285,Eye photography,APC 5733,RVU Per Case,$56.95 ,OP,56.95,205.88,,,,,,
Humana MCR ADV,CPT,92286,Internal eye photography,APC 5734,RVU Per Case,$114.56 ,OP,114.56,583.35,,,,,,
Humana MCR ADV,CPT,92287,Internal eye photography,APC 5734,RVU Per Case,$114.56 ,OP,114.56,549.03,,,,,,
Humana MCR ADV,CPT,92311,Contact lens fitting,APC 5735,RVU Per Case,$276.53 ,OP,276.53,449.9,,,,,,
Humana MCR ADV,CPT,92312,Contact lens fitting,APC 5734,RVU Per Case,$114.56 ,OP,114.56,510.9,,,,,,
Humana MCR ADV,CPT,92313,Contact lens fitting,APC 5734,RVU Per Case,$114.56 ,OP,114.56,434.65,,,,,,
Humana MCR ADV,CPT,92315,Rx cntact lens aphakia 1 eye,APC 5734,RVU Per Case,$114.56 ,OP,114.56,312.64,,,,,,
Humana MCR ADV,CPT,92316,Rx cntact lens aphakia 2 eye,APC 5734,RVU Per Case,$114.56 ,OP,114.56,411.78,,,,,,
Humana MCR ADV,CPT,92317,Rx corneoscleral cntact lens,APC 5732,RVU Per Case,$34.63 ,OP,34.63,324.09,,,,,,
Humana MCR ADV,CPT,92325,Modification of contact lens,APC 5734,RVU Per Case,$114.56 ,OP,114.56,141.07,,,,,,
Humana MCR ADV,CPT,92326,Replacement of contact lens,APC 5733,RVU Per Case,$56.95 ,OP,56.95,205.88,,,,,,
Humana MCR ADV,CPT,92352,Fit aphakia spectcl monofocl,APC 5733,RVU Per Case,$56.95 ,OP,56.95,198.25,,,,,,
Humana MCR ADV,CPT,92353,Fit aphakia spectcl multifoc,APC 5733,RVU Per Case,$56.95 ,OP,56.95,232.58,,,,,,
Humana MCR ADV,CPT,92354,Fit spectacles single system,APC 5732,RVU Per Case,$34.63 ,OP,34.63,510.9,,,,,,
Humana MCR ADV,CPT,92355,Fit spectacles compound lens,APC 5732,RVU Per Case,$34.63 ,OP,34.63,285.96,,,,,,
Humana MCR ADV,CPT,92358,Aphakia prosth service temp,APC 5733,RVU Per Case,$56.95 ,OP,56.95,102.95,,,,,,
Humana MCR ADV,CPT,92371,Repair & adjust spectacles,APC 5733,RVU Per Case,$56.95 ,OP,56.95,76.26,,,,,,
Humana MCR ADV,CPT,92499,Eye service or procedure,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Humana MCR ADV,CPT,92502,Ear and throat examination,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,526.16,,,,,,
Humana MCR ADV,CPT,92507,Speech/hearing therapy,Physician,Per Unit,$75.75 ,OP,75.75,354.58,,,,,,
Humana MCR ADV,CPT,92508,Speech/hearing therapy,Physician,Per Unit,$23.07 ,OP,23.07,171.58,,,,,,
Humana MCR ADV,CPT,92511,Nasopharyngoscopy,APC 5151,RVU Per Unit,$168.23 ,OP,168.23,842.61,,,,,,
Humana MCR ADV,CPT,92512,Nasal function studies,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,331.7,,,,,,
Humana MCR ADV,CPT,92516,Facial nerve function test,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Humana MCR ADV,CPT,92517,Vemp test i&r cervical,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Humana MCR ADV,CPT,92518,Vemp test i&r ocular,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Humana MCR ADV,CPT,92519,Vemp tst i&r cervical&ocular,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Humana MCR ADV,CPT,92520,Laryngeal function studies,APC 5734,RVU Per Case,$114.56 ,OP,114.56,339.33,,,,,,
Humana MCR ADV,CPT,92521,Evaluation of speech fluency,Physician,Per Unit,$132.47 ,OP,132.47,857.86,,,,,,
Humana MCR ADV,CPT,92522,Evaluate speech production,Physician,Per Unit,$111.22 ,OP,111.22,857.86,,,,,,
Humana MCR ADV,CPT,92523,Speech sound lang comprehen,Physician,Per Unit,$227.69 ,OP,227.69,857.86,,,,,,
Humana MCR ADV,CPT,92524,Behavral qualit analys voice,Physician,Per Unit,$108.89 ,OP,108.89,857.86,,,,,,
Humana MCR ADV,CPT,92526,Oral function therapy,Physician,Per Unit,$83.51 ,OP,83.51,453.71,,,,,,
Humana MCR ADV,CPT,92537,Caloric vstblr test w/rec,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,163.95,,,,,,
Humana MCR ADV,CPT,92538,Caloric vstblr test w/rec,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,163.95,,,,,,
Humana MCR ADV,CPT,92540,Basic vestibular evaluation,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Humana MCR ADV,CPT,92541,Spontaneous nystagmus test,APC 5734,RVU Per Case,$114.56 ,OP,114.56,335.53,,,,,,
Humana MCR ADV,CPT,92542,Positional nystagmus test,APC 5734,RVU Per Case,$114.56 ,OP,114.56,346.96,,,,,,
Humana MCR ADV,CPT,92544,Optokinetic nystagmus test,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,282.14,,,,,,
Humana MCR ADV,CPT,92545,Oscillating tracking test,APC 5722,RVU Per Unit,$270.61 ,OP,263.08,270.61,,,,,,
Humana MCR ADV,CPT,92546,Sinusoidal rotational test,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,468.96,,,,,,
Humana MCR ADV,CPT,92548,Cdp-sot 6 cond w/i&r,APC 5734,RVU Per Case,$114.56 ,OP,114.56,556.65,,,,,,
Humana MCR ADV,CPT,92549,Cdp-sot 6 cond w/i&r mct&adt,APC 5734,RVU Per Case,$114.56 ,OP,114.56,556.65,,,,,,
Humana MCR ADV,CPT,92550,Tympanometry & reflex thresh,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
Humana MCR ADV,CPT,92552,Pure tone audiometry air,APC 5734,RVU Per Case,$114.56 ,OP,114.56,129.64,,,,,,
Humana MCR ADV,CPT,92553,Audiometry air & bone,APC 5721,RVU Per Case,$142.80 ,OP,142.8,175.39,,,,,,
Humana MCR ADV,CPT,92555,Speech threshold audiometry,APC 5732,RVU Per Case,$34.63 ,OP,34.63,99.13,,,,,,
Humana MCR ADV,CPT,92556,Speech audiometry complete,APC 5733,RVU Per Case,$56.95 ,OP,56.95,152.51,,,,,,
Humana MCR ADV,CPT,92557,Comprehensive hearing test,APC 5721,RVU Per Case,$142.80 ,OP,142.8,278.32,,,,,,
Humana MCR ADV,CPT,92561,Bekesy audiometry diagnosis,APC 5734,RVU Per Case,$114.56 ,OP,114.56,171.58,,,,,,
Humana MCR ADV,CPT,92562,Loudness balance test,APC 5721,RVU Per Case,$142.80 ,OP,137.25,142.8,,,,,,
Humana MCR ADV,CPT,92563,Tone decay hearing test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,125.82,,,,,,
Humana MCR ADV,CPT,92564,Sisi hearing test,APC 5731,RVU Per Case,$25.25 ,OP,25.25,122,,,,,,
Humana MCR ADV,CPT,92565,Stenger test pure tone,APC 5732,RVU Per Case,$34.63 ,OP,34.63,80.07,,,,,,
Humana MCR ADV,CPT,92567,Tympanometry,APC 5732,RVU Per Case,$34.63 ,OP,34.63,110.57,,,,,,
Humana MCR ADV,CPT,92568,Acoustic refl threshold tst,APC 5732,RVU Per Case,$34.63 ,OP,34.63,110.57,,,,,,
Humana MCR ADV,CPT,92570,Acoustic immitance testing,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
Humana MCR ADV,CPT,92571,Filtered speech hearing test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,102.95,,,,,,
Humana MCR ADV,CPT,92572,Staggered spondaic word test,APC 5721,RVU Per Case,$142.80 ,OP,99.13,142.8,,,,,,
Humana MCR ADV,CPT,92575,Sensorineural acuity test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,202.07,,,,,,
Humana MCR ADV,CPT,92576,Synthetic sentence test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,129.64,,,,,,
Humana MCR ADV,CPT,92577,Stenger test speech,APC 5723,RVU Per Case,$499.16 ,OP,114.39,499.16,,,,,,
Humana MCR ADV,CPT,92579,Visual audiometry (vra),APC 5721,RVU Per Case,$142.80 ,OP,142.8,259.27,,,,,,
Humana MCR ADV,CPT,92582,Conditioning play audiometry,APC 5721,RVU Per Case,$142.80 ,OP,142.8,247.83,,,,,,
Humana MCR ADV,CPT,92583,Select picture audiometry,APC 5733,RVU Per Case,$56.95 ,OP,56.95,205.88,,,,,,
Humana MCR ADV,CPT,92584,Electrocochleography,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,427.03,,,,,,
Humana MCR ADV,CPT,92587,Evoked auditory test limited,APC 5722,RVU Per Unit,$270.61 ,OP,244.01,270.61,,,,,,
Humana MCR ADV,CPT,92588,Evoked auditory tst complete,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,385.09,,,,,,
Humana MCR ADV,CPT,92596,Ear protector evaluation,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Humana MCR ADV,CPT,92597,Oral speech device eval,Physician,Per Unit,$70.53 ,OP,70.53,583.35,,,,,,
Humana MCR ADV,CPT,92601,Cochlear implt f/up exam <7,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Humana MCR ADV,CPT,92602,Reprogram cochlear implt <7,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Humana MCR ADV,CPT,92603,Cochlear implt f/up exam 7/>,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Humana MCR ADV,CPT,92604,Reprogram cochlear implt 7/>,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Humana MCR ADV,CPT,92607,Ex for speech device rx 1hr,Physician,Per Unit,$122.72 ,OP,122.72,804.48,,,,,,
Humana MCR ADV,CPT,92608,Ex for speech device rx addl,Physician,Per Unit,$49.31 ,OP,49.31,163.95,,,,,,
Humana MCR ADV,CPT,92609,Use of speech device service,Physician,Per Unit,$102.45 ,OP,102.45,430.83,,,,,,
Humana MCR ADV,CPT,92610,Evaluate swallowing function,Physician,Per Unit,$69.06 ,OP,69.06,423.22,,,,,,
Humana MCR ADV,CPT,92611,Motion fluoroscopy/swallow,Physician,Per Unit,$90.57 ,OP,90.57,461.34,,,,,,
Humana MCR ADV,CPT,92612,Endoscopy swallow (fees) vid,Physician,Per Unit,$65.56 ,OP,65.56,796.85,,,,,,
Humana MCR ADV,CPT,92614,Laryngoscopic sensory vid,Physician,Per Unit,$64.93 ,OP,64.93,709.16,,,,,,
Humana MCR ADV,CPT,92616,Fees w/laryngeal sense test,Physician,Per Unit,$97.82 ,OP,97.82,972.25,,,,,,
Humana MCR ADV,CPT,92620,Auditory function 60 min,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
Humana MCR ADV,CPT,92625,Tinnitus assessment,APC 5721,RVU Per Case,$142.80 ,OP,142.8,293.57,,,,,,
Humana MCR ADV,CPT,92626,Eval aud funcj 1st hour,APC 5721,RVU Per Case,$142.80 ,OP,142.8,407.96,,,,,,
Humana MCR ADV,CPT,92640,Aud brainstem implt programg,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,385.09,,,,,,
Humana MCR ADV,CPT,92651,Aep hearing status deter i&r,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Humana MCR ADV,CPT,92652,Aep thrshld est mlt freq i&r,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Humana MCR ADV,CPT,92653,Aep neurodiagnostic i&r,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Humana MCR ADV,CPT,92700,Ent procedure/service,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Humana MCR ADV,CPT,92920,Prq cardiac angioplast 1 art,APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,92924,Prq card angio/athrect 1 art,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
Humana MCR ADV,CPT,92928,Prq card stent w/angio 1 vsl,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Humana MCR ADV,CPT,92933,Prq card stent/ath/angio,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Humana MCR ADV,CPT,92937,Prq revasc byp graft 1 vsl,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Humana MCR ADV,CPT,92941,Prq card revasc mi 1 vsl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,92943,Prq card revasc chronic 1vsl,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Humana MCR ADV,CPT,92950,Heart/lung resuscitation cpr,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,567.02",,,,,,
Humana MCR ADV,CPT,92953,Temporary external pacing,APC 5781,RVU Per Unit,$575.01 ,OP,575.01,575.01,,,,,,
Humana MCR ADV,CPT,92960,Cardioversion electric ext,APC 5781,RVU Per Unit,$575.01 ,OP,575.01,"1,460.26",,,,,,
Humana MCR ADV,CPT,92961,Cardioversion electric int,APC 5781,RVU Per Unit,$575.01 ,OP,575.01,"1,513.64",,,,,,
Humana MCR ADV,CPT,92970,Cardioassist internal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,040.87","8,948.83",,,,,,
Humana MCR ADV,CPT,92971,Cardioassist external,APC 5881,RVU Per Case,"$8,948.83 ",OP,590.97,"8,948.83",,,,,,
Humana MCR ADV,CPT,92975,Dissolve clot heart vessel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"2,367.69","8,948.83",,,,,,
Humana MCR ADV,CPT,92977,Dissolve clot heart vessel,APC 5694,RVU Per Unit,$318.00 ,OP,318,850.23,,,,,,
Humana MCR ADV,CPT,92986,Revision of aortic valve,APC 5192,RVU Per Case,"$5,072.43 ",OP,"5,072.43","8,048.60",,,,,,
Humana MCR ADV,CPT,92987,Revision of mitral valve,APC 5193,RVU Per Case,"$10,277.14 ",OP,"8,338.36","10,277.14",,,,,,
Humana MCR ADV,CPT,92990,Revision of pulmonary valve,APC 5193,RVU Per Case,"$10,277.14 ",OP,"6,409.14","10,277.14",,,,,,
Humana MCR ADV,CPT,92997,Pul art balloon repr percut,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
Humana MCR ADV,CPT,93005,Electrocardiogram tracing,APC 5733,RVU Per Case,$56.95 ,OP,56.95,72.44,,,,,,
Humana MCR ADV,CPT,93017,Cardiovascular stress test,APC 5722,RVU Per Case,$270.61 ,OP,270.61,362.21,,,,,,
Humana MCR ADV,CPT,93024,Cardiac drug stress test,APC 5735,RVU Per Case,$276.53 ,OP,276.53,712.98,,,,,,
Humana MCR ADV,CPT,93025,Microvolt t-wave assess,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,"1,246.76",,,,,,
Humana MCR ADV,CPT,93041,Rhythm ecg tracing,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Humana MCR ADV,CPT,93050,Art pressure waveform analys,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Humana MCR ADV,CPT,93225,Ecg monit/reprt up to 48 hrs,APC 5734,RVU Per Case,$114.56 ,OP,114.56,224.95,,,,,,
Humana MCR ADV,CPT,93226,Ecg monit/reprt up to 48 hrs,APC 5734,RVU Per Case,$114.56 ,OP,114.56,926.48,,,,,,
Humana MCR ADV,CPT,93229,Remote 30 day ecg tech supp,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Humana MCR ADV,CPT,93242,Ext ecg>48hr<7d recording,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Humana MCR ADV,CPT,93243,Ext ecg>48hr<7d scan a/r,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Humana MCR ADV,CPT,93246,Ext ecg>7d<15d recording,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Humana MCR ADV,CPT,93247,Ext ecg>7d<15d scan a/r,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Humana MCR ADV,CPT,93260,Prgrmg dev eval impltbl sys,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Humana MCR ADV,CPT,93261,Interrogate subq defib,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Humana MCR ADV,CPT,93270,Remote 30 day ecg rev/report,APC 5741,RVU Per Case,$38.02 ,OP,38.02,137.25,,,,,,
Humana MCR ADV,CPT,93271,Ecg/monitoring and analysis,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,"1,281.07",,,,,,
Humana MCR ADV,CPT,93278,Ecg/signal-averaged,APC 5733,RVU Per Case,$56.95 ,OP,56.95,251.64,,,,,,
Humana MCR ADV,CPT,93279,Prgrmg dev eval pm/ldls pm,APC 5741,RVU Per Case,$38.02 ,OP,38.02,327.9,,,,,,
Humana MCR ADV,CPT,93280,Pm device progr eval dual,APC 5741,RVU Per Case,$38.02 ,OP,38.02,381.27,,,,,,
Humana MCR ADV,CPT,93281,Pm device progr eval multi,APC 5741,RVU Per Case,$38.02 ,OP,38.02,446.08,,,,,,
Humana MCR ADV,CPT,93282,Prgrmg eval implantable dfb,APC 5741,RVU Per Case,$38.02 ,OP,38.02,415.59,,,,,,
Humana MCR ADV,CPT,93283,Prgrmg eval implantable dfb,APC 5741,RVU Per Case,$38.02 ,OP,38.02,503.28,,,,,,
Humana MCR ADV,CPT,93284,Prgrmg eval implantable dfb,APC 5741,RVU Per Case,$38.02 ,OP,38.02,587.16,,,,,,
Humana MCR ADV,CPT,93285,Prgrmg dev eval scrms ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,282.14,,,,,,
Humana MCR ADV,CPT,93288,Interrog evl pm/ldls pm ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,255.45,,,,,,
Humana MCR ADV,CPT,93289,Interrog device eval heart,APC 5741,RVU Per Case,$38.02 ,OP,38.02,385.09,,,,,,
Humana MCR ADV,CPT,93290,Interrog dev eval icpms ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,190.64,,,,,,
Humana MCR ADV,CPT,93291,Interrog dev eval scrms ip,APC 5731,RVU Per Case,$25.25 ,OP,25.25,244.01,,,,,,
Humana MCR ADV,CPT,93292,Wcd device interrogate,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Humana MCR ADV,CPT,93293,Pm phone r-strip device eval,APC 5741,RVU Per Case,$38.02 ,OP,38.02,366.02,,,,,,
Humana MCR ADV,CPT,93296,Rem interrog evl pm/ids,APC 5741,RVU Per Case,$38.02 ,OP,38.02,213.51,,,,,,
Humana MCR ADV,CPT,93303,Echo transthoracic,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,292.50",,,,,,
Humana MCR ADV,CPT,93304,Echo transthoracic,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,796.85,,,,,,
Humana MCR ADV,CPT,93306,Tte w/doppler complete,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,593.72",,,,,,
Humana MCR ADV,CPT,93307,Tte w/o doppler complete,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,056.11",,,,,,
Humana MCR ADV,CPT,93308,Tte f-up or lmtd,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,667.22,,,,,,
Humana MCR ADV,CPT,93312,Echo transesophageal,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,921.59",,,,,,
Humana MCR ADV,CPT,93313,Echo transesophageal,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,494.15,,,,,,
Humana MCR ADV,CPT,93315,Echo transesophageal,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,738.59",,,,,,
Humana MCR ADV,CPT,93316,Echo transesophageal,APC 5524,RVU Per Unit,$494.15 ,OP,259.27,494.15,,,,,,
Humana MCR ADV,CPT,93318,Echo transesophageal intraop,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,330.63",,,,,,
Humana MCR ADV,CPT,93350,Stress tte only,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,239.13",,,,,,
Humana MCR ADV,CPT,93351,Stress tte complete,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,635.64",,,,,,
Humana MCR ADV,CPT,93451,Right heart cath,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Humana MCR ADV,CPT,93452,Left hrt cath w/ventrclgrphy,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Humana MCR ADV,CPT,93453,R&l hrt cath w/ventriclgrphy,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Humana MCR ADV,CPT,93454,Coronary artery angio s&i,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","2,966.62",,,,,,
Humana MCR ADV,CPT,93455,Coronary art/grft angio s&i,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","2,966.62",,,,,,
Humana MCR ADV,CPT,93456,R hrt coronary artery angio,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Humana MCR ADV,CPT,93457,R hrt art/grft angio,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Humana MCR ADV,CPT,93458,L hrt artery/ventricle angio,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Humana MCR ADV,CPT,93459,L hrt art/grft angio,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Humana MCR ADV,CPT,93460,R&l hrt art/ventricle angio,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Humana MCR ADV,CPT,93461,R&l hrt art/ventricle angio,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Humana MCR ADV,CPT,93503,Insert/place heart catheter,APC 5182,RVU Per Case,"$1,438.93 ",OP,651.97,"1,438.93",,,,,,
Humana MCR ADV,CPT,93505,Biopsy of heart lining,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,346.47",,,,,,
Humana MCR ADV,CPT,93530,Rt heart cath congenital,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Humana MCR ADV,CPT,93531,R & l heart cath congenital,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","16,124.56",,,,,,
Humana MCR ADV,CPT,93532,R & l heart cath congenital,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","16,600.26",,,,,,
Humana MCR ADV,CPT,93533,R & l heart cath congenital,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","16,111.09",,,,,,
Humana MCR ADV,CPT,93580,Transcath closure of asd,APC 5194,RVU Per Case,"$16,438.60 ",OP,"5,905.86","16,438.60",,,,,,
Humana MCR ADV,CPT,93581,Transcath closure of vsd,APC 5194,RVU Per Case,"$16,438.60 ",OP,"7,739.77","16,438.60",,,,,,
Humana MCR ADV,CPT,93582,Perq transcath closure pda,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Humana MCR ADV,CPT,93583,Perq transcath septal reduxn,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,93590,Perq transcath cls mitral,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Humana MCR ADV,CPT,93591,Perq transcath cls aortic,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Humana MCR ADV,CPT,93600,Bundle of his recording,APC 5212,RVU Per Case,"$6,220.22 ",OP,"6,220.22","6,220.22",,,,,,
Humana MCR ADV,CPT,93602,Intra-atrial recording,APC 5212,RVU Per Case,"$6,220.22 ",OP,968.43,"6,220.22",,,,,,
Humana MCR ADV,CPT,93603,Right ventricular recording,APC 5211,RVU Per Case,"$1,138.72 ",OP,"1,117.12","1,138.72",,,,,,
Humana MCR ADV,CPT,93610,Intra-atrial pacing,APC 5212,RVU Per Case,"$6,220.22 ",OP,"1,323.01","6,220.22",,,,,,
Humana MCR ADV,CPT,93612,Intraventricular pacing,APC 5212,RVU Per Case,"$6,220.22 ",OP,"1,376.38","6,220.22",,,,,,
Humana MCR ADV,CPT,93615,Esophageal recording,APC 5211,RVU Per Case,"$1,138.72 ",OP,392.7,"1,138.72",,,,,,
Humana MCR ADV,CPT,93616,Esophageal recording,APC 5211,RVU Per Case,"$1,138.72 ",OP,"1,138.72","1,138.72",,,,,,
Humana MCR ADV,CPT,93618,Heart rhythm pacing,APC 5211,RVU Per Case,"$1,138.72 ",OP,"1,138.72","2,367.69",,,,,,
Humana MCR ADV,CPT,93619,Electrophysiology evaluation,APC 5212,RVU Per Case,"$6,220.22 ",OP,"4,312.16","6,220.22",,,,,,
Humana MCR ADV,CPT,93620,Electrophysiology evaluation,APC 5212,RVU Per Case,"$6,220.22 ",OP,"5,112.83","6,220.22",,,,,,
Humana MCR ADV,CPT,93624,Electrophysiologic study,APC 5212,RVU Per Case,"$6,220.22 ",OP,"2,051.24","6,220.22",,,,,,
Humana MCR ADV,CPT,93642,Electrophysiology evaluation,APC 5211,RVU Per Case,"$1,138.72 ",OP,"1,138.72","2,775.65",,,,,,
Humana MCR ADV,CPT,93650,Ablate heart dysrhythm focus,APC 5212,RVU Per Case,"$6,220.22 ",OP,"3,488.62","6,220.22",,,,,,
Humana MCR ADV,CPT,93653,Ep & ablate supravent arrhyt,APC 5213,RVU Per Case,"$21,964.94 ",OP,"10,420.09","21,964.94",,,,,,
Humana MCR ADV,CPT,93654,Ep & ablate ventric tachy,APC 5213,RVU Per Case,"$21,964.94 ",OP,"10,889.05","21,964.94",,,,,,
Humana MCR ADV,CPT,93656,Tx atrial fib pulm vein isol,APC 5213,RVU Per Case,"$21,964.94 ",OP,"10,420.09","21,964.94",,,,,,
Humana MCR ADV,CPT,93660,Tilt table evaluation,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,983.68,,,,,,
Humana MCR ADV,CPT,93668,Peripheral vascular rehab,APC 5733,RVU Per Unit,$56.95 ,OP,56.95,99.13,,,,,,
Humana MCR ADV,CPT,93701,Bioimpedance cv analysis,APC 5734,RVU Per Case,$114.56 ,OP,114.56,198.25,,,,,,
Humana MCR ADV,CPT,93702,Bis xtracell fluid analysis,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Humana MCR ADV,CPT,93724,Analyze pacemaker system,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,"1,948.29",,,,,,
Humana MCR ADV,CPT,93740,Temperature gradient studies,APC 5721,RVU Per Case,$142.80 ,OP,57.19,142.8,,,,,,
Humana MCR ADV,CPT,93745,Set-up cardiovert-defibrill,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,278.82,,,,,,
Humana MCR ADV,CPT,93750,Interrogation vad in person,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,102.65,,,,,,
Humana MCR ADV,CPT,93786,Ambl bp mntr w/sw rec only,APC 5734,RVU Per Case,$114.56 ,OP,114.56,171.58,,,,,,
Humana MCR ADV,CPT,93788,Ambl bp mntr w/sw a/r,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Humana MCR ADV,CPT,93797,Cardiac rehab,APC 5771,RVU Per Unit,$118.77 ,OP,102.95,118.77,,,,,,
Humana MCR ADV,CPT,93798,Cardiac rehab/monitor,APC 5771,RVU Per Unit,$118.77 ,OP,118.77,148.69,,,,,,
Humana MCR ADV,CPT,93799,Cardiovascular procedure,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Humana MCR ADV,CPT,93880,Extracranial bilat study,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,239.13",,,,,,
Humana MCR ADV,CPT,93882,Extracranial uni/ltd study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,815.92,,,,,,
Humana MCR ADV,CPT,93886,Intracranial complete study,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,483.14",,,,,,
Humana MCR ADV,CPT,93888,Intracranial limited study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,"1,010.37",,,,,,
Humana MCR ADV,CPT,93890,Tcd vasoreactivity study,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,307.75",,,,,,
Humana MCR ADV,CPT,93892,Tcd emboli detect w/o inj,APC 5522,RVU Per Case,$111.51 ,OP,111.51,"1,425.95",,,,,,
Humana MCR ADV,CPT,93893,Tcd emboli detect w/inj,APC 5522,RVU Per Case,$111.51 ,OP,111.51,"1,422.14",,,,,,
Humana MCR ADV,CPT,93922,Upr/l xtremity art 2 levels,APC 5734,RVU Per Case,$114.56 ,OP,114.56,594.77,,,,,,
Humana MCR ADV,CPT,93923,Upr/lxtr art stdy 3+ lvls,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,922.67,,,,,,
Humana MCR ADV,CPT,93924,Lwr xtr vasc stdy bilat,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,136.19",,,,,,
Humana MCR ADV,CPT,93925,Lower extremity study,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,525.07",,,,,,
Humana MCR ADV,CPT,93926,Lower extremity study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,976.05,,,,,,
Humana MCR ADV,CPT,93930,Upper extremity study,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,223.88",,,,,,
Humana MCR ADV,CPT,93931,Upper extremity study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,815.92,,,,,,
Humana MCR ADV,CPT,93970,Extremity study,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,273.44",,,,,,
Humana MCR ADV,CPT,93971,Extremity study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,842.61,,,,,,
Humana MCR ADV,CPT,93975,Vascular study,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,367.82,,,,,,
Humana MCR ADV,CPT,93976,Vascular study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,"1,082.81",,,,,,
Humana MCR ADV,CPT,93978,Vascular study,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,197.20",,,,,,
Humana MCR ADV,CPT,93979,Vascular study,APC 5522,RVU Per Case,$111.51 ,OP,111.51,823.54,,,,,,
Humana MCR ADV,CPT,93980,Penile vascular study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,934.12,,,,,,
Humana MCR ADV,CPT,93981,Penile vascular study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,667.22,,,,,,
Humana MCR ADV,CPT,93985,Dup-scan hemo compl bi std,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,136.19",,,,,,
Humana MCR ADV,CPT,93986,Dup-scan hemo compl uni std,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,646.72,,,,,,
Humana MCR ADV,CPT,93990,Doppler flow testing,APC 5522,RVU Per Case,$111.51 ,OP,111.51,956.99,,,,,,
Humana MCR ADV,CPT,93998,Noninvas vasc dx study proc,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Humana MCR ADV,CPT,94002,Vent mgmt inpat init day,APC 5801,RVU Per Unit,$496.58 ,OP,496.58,541.4,,,,,,
Humana MCR ADV,CPT,94003,Vent mgmt inpat subq day,APC 5801,RVU Per Unit,$496.58 ,OP,496.58,496.58,,,,,,
Humana MCR ADV,CPT,94010,Breathing capacity test,APC 5721,RVU Per Case,$142.80 ,OP,142.8,209.7,,,,,,
Humana MCR ADV,CPT,94011,Spirometry up to 2 yrs old,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
Humana MCR ADV,CPT,94012,Spirmtry w/brnchdil inf-2 yr,APC 5722,RVU Per Case,$270.61 ,OP,270.61,270.61,,,,,,
Humana MCR ADV,CPT,94013,Meas lung vol thru 2 yrs,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Humana MCR ADV,CPT,94014,Patient recorded spirometry,APC 5735,RVU Per Case,$276.53 ,OP,276.53,301.2,,,,,,
Humana MCR ADV,CPT,94015,Patient recorded spirometry,APC 5722,RVU Per Case,$270.61 ,OP,148.69,270.61,,,,,,
Humana MCR ADV,CPT,94016,Review patient spirometry,Physician,Per Unit,$24.70 ,OP,24.7,152.51,,,,,,
Humana MCR ADV,CPT,94060,Evaluation of wheezing,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,369.83,,,,,,
Humana MCR ADV,CPT,94070,Evaluation of wheezing,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,392.7,,,,,,
Humana MCR ADV,CPT,94150,Vital capacity test,APC 5721,RVU Per Case,$142.80 ,OP,141.07,142.8,,,,,,
Humana MCR ADV,CPT,94200,Lung function test (mbc/mvv),APC 5733,RVU Per Case,$56.95 ,OP,56.95,144.88,,,,,,
Humana MCR ADV,CPT,94375,Respiratory flow volume loop,APC 5722,RVU Per Case,$270.61 ,OP,232.58,270.61,,,,,,
Humana MCR ADV,CPT,94450,Hypoxia response curve,APC 5722,RVU Per Case,$270.61 ,OP,270.61,316.46,,,,,,
Humana MCR ADV,CPT,94452,Hast w/report,APC 5734,RVU Per Case,$114.56 ,OP,114.56,346.96,,,,,,
Humana MCR ADV,CPT,94453,Hast w/oxygen titrate,APC 5734,RVU Per Case,$114.56 ,OP,114.56,461.34,,,,,,
Humana MCR ADV,CPT,94610,Surfactant admin thru tube,APC 5791,RVU Per Case,$192.26 ,OP,192.26,438.47,,,,,,
Humana MCR ADV,CPT,94617,Exercise tst brncspsm w/ecg,APC 5734,RVU Per Case,$114.56 ,OP,114.56,465.15,,,,,,
Humana MCR ADV,CPT,94618,Pulmonary stress testing,APC 5734,RVU Per Case,$114.56 ,OP,114.56,465.15,,,,,,
Humana MCR ADV,CPT,94619,Exercise tst brncspsm wo ecg,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Humana MCR ADV,CPT,94621,Cardiopulm exercise testing,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,017.99",,,,,,
Humana MCR ADV,CPT,94640,Airway inhalation treatment,APC 5791,RVU Per Case,$192.26 ,OP,87.69,192.26,,,,,,
Humana MCR ADV,CPT,94642,Aerosol inhalation treatment,APC 5791,RVU Per Case,$192.26 ,OP,192.26,255.45,,,,,,
Humana MCR ADV,CPT,94644,Cbt 1st hour,APC 5734,RVU Per Case,$114.56 ,OP,114.56,217.32,,,,,,
Humana MCR ADV,CPT,94660,Pos airway pressure cpap,APC 5791,RVU Per Case,$192.26 ,OP,192.26,346.96,,,,,,
Humana MCR ADV,CPT,94662,Neg press ventilation cnp,APC 5801,RVU Per Unit,$496.58 ,OP,221.14,496.58,,,,,,
Humana MCR ADV,CPT,94664,Evaluate pt use of inhaler,APC 5791,RVU Per Case,$192.26 ,OP,99.13,192.26,,,,,,
Humana MCR ADV,CPT,94667,Chest wall manipulation,APC 5734,RVU Per Case,$114.56 ,OP,114.56,137.25,,,,,,
Humana MCR ADV,CPT,94668,Chest wall manipulation,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Humana MCR ADV,CPT,94669,Mechanical chest wall oscill,APC 5791,RVU Per Case,$192.26 ,OP,192.26,192.26,,,,,,
Humana MCR ADV,CPT,94680,Exhaled air analysis o2,APC 5721,RVU Per Case,$142.80 ,OP,142.8,369.83,,,,,,
Humana MCR ADV,CPT,94681,Exhaled air analysis o2/co2,APC 5722,RVU Per Case,$270.61 ,OP,270.61,270.61,,,,,,
Humana MCR ADV,CPT,94690,Exhaled air analysis,APC 5733,RVU Per Case,$56.95 ,OP,56.95,320.27,,,,,,
Humana MCR ADV,CPT,94726,Pulm funct tst plethysmograp,APC 5722,RVU Per Case,$270.61 ,OP,270.61,282.14,,,,,,
Humana MCR ADV,CPT,94727,Pulm function test by gas,APC 5721,RVU Per Case,$142.80 ,OP,142.8,221.14,,,,,,
Humana MCR ADV,CPT,94728,Airwy resist by oscillometry,APC 5722,RVU Per Case,$270.61 ,OP,270.61,282.14,,,,,,
Humana MCR ADV,CPT,94762,Measure blood oxygen level,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,202.07,,,,,,
Humana MCR ADV,CPT,94772,Breath recording infant,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Humana MCR ADV,CPT,94775,Ped home apnea rec hk-up,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Humana MCR ADV,CPT,94776,Ped home apnea rec downld,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Humana MCR ADV,CPT,94780,Cars/bd tst inft-12mo 60 min,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Humana MCR ADV,CPT,94799,Pulmonary service/procedure,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
Humana MCR ADV,CPT,95004,Percut allergy skin tests,APC 5724,RVU Per Case,$941.27 ,OP,30.51,941.27,,,,,,
Humana MCR ADV,CPT,95012,Exhaled nitric oxide meas,APC 5732,RVU Per Case,$34.63 ,OP,34.63,102.95,,,,,,
Humana MCR ADV,CPT,95017,Perq & icut allg test venoms,APC 5731,RVU Per Case,$25.25 ,OP,25.25,87.69,,,,,,
Humana MCR ADV,CPT,95018,Perq&ic allg test drugs/biol,APC 5732,RVU Per Case,$34.63 ,OP,34.63,87.69,,,,,,
Humana MCR ADV,CPT,95024,Icut allergy test drug/bug,APC 5733,RVU Per Case,$56.95 ,OP,38.13,56.95,,,,,,
Humana MCR ADV,CPT,95027,Icut allergy titrate-airborn,APC 5731,RVU Per Case,$25.25 ,OP,25.25,26.7,,,,,,
Humana MCR ADV,CPT,95028,Icut allergy test-delayed,APC 5732,RVU Per Case,$34.63 ,OP,34.63,57.19,,,,,,
Humana MCR ADV,CPT,95044,Allergy patch tests,APC 5724,RVU Per Case,$941.27 ,OP,34.31,941.27,,,,,,
Humana MCR ADV,CPT,95052,Photo patch test,APC 5733,RVU Per Case,$56.95 ,OP,38.13,56.95,,,,,,
Humana MCR ADV,CPT,95056,Photosensitivity tests,APC 5734,RVU Per Case,$114.56 ,OP,114.56,179.2,,,,,,
Humana MCR ADV,CPT,95060,Eye allergy tests,APC 5734,RVU Per Case,$114.56 ,OP,114.56,122,,,,,,
Humana MCR ADV,CPT,95065,Nose allergy test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,110.57,,,,,,
Humana MCR ADV,CPT,95070,Bronchial allergy tests,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Humana MCR ADV,CPT,95076,Ingest challenge ini 120 min,APC 5723,RVU Per Unit,$499.16 ,OP,320.27,499.16,,,,,,
Humana MCR ADV,CPT,95115,Immunotherapy one injection,APC 5691,RVU Per Case,$40.93 ,OP,40.93,57.19,,,,,,
Humana MCR ADV,CPT,95117,Immunotherapy injections,APC 5691,RVU Per Case,$40.93 ,OP,40.93,68.63,,,,,,
Humana MCR ADV,CPT,95144,Antigen therapy services,APC 5691,RVU Per Case,$40.93 ,OP,40.93,61,,,,,,
Humana MCR ADV,CPT,95145,Antigen therapy services,APC 5691,RVU Per Case,$40.93 ,OP,40.93,80.07,,,,,,
Humana MCR ADV,CPT,95146,Antigen therapy services,APC 5691,RVU Per Case,$40.93 ,OP,40.93,129.64,,,,,,
Humana MCR ADV,CPT,95147,Antigen therapy services,APC 5692,RVU Per Case,$63.42 ,OP,63.42,125.82,,,,,,
Humana MCR ADV,CPT,95148,Antigen therapy services,APC 5692,RVU Per Case,$63.42 ,OP,63.42,179.2,,,,,,
Humana MCR ADV,CPT,95149,Antigen therapy services,APC 5692,RVU Per Case,$63.42 ,OP,63.42,232.58,,,,,,
Humana MCR ADV,CPT,95165,Antigen therapy services,APC 5691,RVU Per Case,$40.93 ,OP,40.93,61,,,,,,
Humana MCR ADV,CPT,95170,Antigen therapy services,APC 5691,RVU Per Case,$40.93 ,OP,40.93,49.56,,,,,,
Humana MCR ADV,CPT,95180,Rapid desensitization,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
Humana MCR ADV,CPT,95199,Allergy immunology services,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Humana MCR ADV,CPT,95249,Cont gluc mntr pt prov eqp,APC 5733,RVU Per Unit,$56.95 ,OP,56.95,686.28,,,,,,
Humana MCR ADV,CPT,95250,Cont gluc mntr phys/qhp eqp,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,686.28,,,,,,
Humana MCR ADV,CPT,95700,Eeg cont rec w/vid eeg tech,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Humana MCR ADV,CPT,95705,Eeg w/o vid 2-12 hr unmntr,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Humana MCR ADV,CPT,95706,Eeg wo vid 2-12hr intmt mntr,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Humana MCR ADV,CPT,95707,Eeg w/o vid 2-12hr cont mntr,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Humana MCR ADV,CPT,95708,Eeg wo vid ea 12-26hr unmntr,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Humana MCR ADV,CPT,95709,Eeg w/o vid ea 12-26hr intmt,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Humana MCR ADV,CPT,95710,Eeg w/o vid ea 12-26hr cont,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Humana MCR ADV,CPT,95711,Veeg 2-12 hr unmonitored,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Humana MCR ADV,CPT,95712,Veeg 2-12 hr intmt mntr,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Humana MCR ADV,CPT,95713,Veeg 2-12 hr cont mntr,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Humana MCR ADV,CPT,95714,Veeg ea 12-26 hr unmntr,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Humana MCR ADV,CPT,95715,Veeg ea 12-26hr intmt mntr,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Humana MCR ADV,CPT,95716,Veeg ea 12-26hr cont mntr,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,941.27,,,,,,
Humana MCR ADV,CPT,95782,Polysom <6 yrs 4/> paramtrs,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"4,472.29",,,,,,
Humana MCR ADV,CPT,95783,Polysom <6 yrs cpap/bilvl,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"4,472.29",,,,,,
Humana MCR ADV,CPT,95800,Slp stdy unattended,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Humana MCR ADV,CPT,95801,Slp stdy unatnd w/anal,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Humana MCR ADV,CPT,95803,Actigraphy testing,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Humana MCR ADV,CPT,95805,Multiple sleep latency test,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,"2,249.49",,,,,,
Humana MCR ADV,CPT,95806,Sleep study unatt&resp efft,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,413.8,,,,,,
Humana MCR ADV,CPT,95807,Sleep study attended,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,"2,638.38",,,,,,
Humana MCR ADV,CPT,95808,Polysom any age 1-3> param,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,941.27,,,,,,
Humana MCR ADV,CPT,95810,Polysom 6/> yrs 4/> param,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"1,103.46",,,,,,
Humana MCR ADV,CPT,95811,Polysom 6/>yrs cpap 4/> parm,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"1,103.46",,,,,,
Humana MCR ADV,CPT,95812,Eeg 41-60 minutes,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,242.94",,,,,,
Humana MCR ADV,CPT,95813,Eeg extnd mntr 61-119 min,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,521.26",,,,,,
Humana MCR ADV,CPT,95816,Eeg awake and drowsy,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,139.99",,,,,,
Humana MCR ADV,CPT,95819,Eeg awake and asleep,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,223.88",,,,,,
Humana MCR ADV,CPT,95822,Eeg coma or sleep only,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,223.88",,,,,,
Humana MCR ADV,CPT,95824,Eeg cerebral death only,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,503.28,,,,,,
Humana MCR ADV,CPT,95836,Ecog impltd brn npgt <30 d,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Humana MCR ADV,CPT,95851,Range of motion measurements,Physician,Per Unit,$7.59 ,OP,7.59,83.87,,,,,,
Humana MCR ADV,CPT,95852,Range of motion measurements,Physician,Per Unit,$5.52 ,OP,5.52,64.82,,,,,,
Humana MCR ADV,CPT,95857,Cholinesterase challenge,APC 5722,RVU Per Unit,$270.61 ,OP,209.7,270.61,,,,,,
Humana MCR ADV,CPT,95860,Muscle test one limb,APC 5734,RVU Per Case,$114.56 ,OP,114.56,423.22,,,,,,
Humana MCR ADV,CPT,95861,Muscle test 2 limbs,APC 5734,RVU Per Case,$114.56 ,OP,114.56,613.85,,,,,,
Humana MCR ADV,CPT,95863,Muscle test 3 limbs,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,732.04,,,,,,
Humana MCR ADV,CPT,95864,Muscle test 4 limbs,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,850.23,,,,,,
Humana MCR ADV,CPT,95865,Muscle test larynx,APC 5734,RVU Per Case,$114.56 ,OP,114.56,439,,,,,,
Humana MCR ADV,CPT,95866,Muscle test hemidiaphragm,APC 5721,RVU Per Case,$142.80 ,OP,142.8,480.4,,,,,,
Humana MCR ADV,CPT,95867,Muscle test cran nerv unilat,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,369.83,,,,,,
Humana MCR ADV,CPT,95868,Muscle test cran nerve bilat,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,503.28,,,,,,
Humana MCR ADV,CPT,95869,Muscle test thor paraspinal,APC 5721,RVU Per Case,$142.80 ,OP,142.8,236.38,,,,,,
Humana MCR ADV,CPT,95870,Muscle test nonparaspinal,APC 5734,RVU Per Case,$114.56 ,OP,114.56,228.77,,,,,,
Humana MCR ADV,CPT,95872,Muscle test one fiber,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,635.69,,,,,,
Humana MCR ADV,CPT,95875,Limb exercise test,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,364.88,,,,,,
Humana MCR ADV,CPT,95905,Motor &/ sens nrve cndj test,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
Humana MCR ADV,CPT,95907,Nvr cndj tst 1-2 studies,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Humana MCR ADV,CPT,95908,Nrv cndj tst 3-4 studies,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Humana MCR ADV,CPT,95909,Nrv cndj tst 5-6 studies,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Humana MCR ADV,CPT,95910,Nrv cndj test 7-8 studies,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Humana MCR ADV,CPT,95911,Nrv cndj test 9-10 studies,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Humana MCR ADV,CPT,95912,Nrv cndj test 11-12 studies,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Humana MCR ADV,CPT,95913,Nrv cndj test 13/> studies,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Humana MCR ADV,CPT,95921,Autonomic nrv parasym inervj,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,282.21,,,,,,
Humana MCR ADV,CPT,95922,Autonomic nrv adrenrg inervj,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Humana MCR ADV,CPT,95923,Autonomic nrv syst funj test,APC 5734,RVU Per Case,$114.56 ,OP,114.56,447.55,,,,,,
Humana MCR ADV,CPT,95924,Ans parasymp & symp w/tilt,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Humana MCR ADV,CPT,95925,Somatosensory testing,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,461.8,,,,,,
Humana MCR ADV,CPT,95926,Somatosensory testing,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,602.41,,,,,,
Humana MCR ADV,CPT,95927,Somatosensory testing,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,621.47,,,,,,
Humana MCR ADV,CPT,95928,C motor evoked uppr limbs,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,964.61,,,,,,
Humana MCR ADV,CPT,95929,C motor evoked lwr limbs,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,"1,017.99",,,,,,
Humana MCR ADV,CPT,95930,Visual ep test cns w/i&r,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,537.6,,,,,,
Humana MCR ADV,CPT,95933,Blink reflex test,APC 5733,RVU Per Case,$56.95 ,OP,56.95,339.33,,,,,,
Humana MCR ADV,CPT,95937,Neuromuscular junction test,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,305.01,,,,,,
Humana MCR ADV,CPT,95938,Somatosensory testing,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Humana MCR ADV,CPT,95939,C motor evoked upr&lwr limbs,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,941.27,,,,,,
Humana MCR ADV,CPT,95943,Parasymp&symp hrt rate test,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Humana MCR ADV,CPT,95954,Eeg monitoring/giving drugs,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,"1,277.26",,,,,,
Humana MCR ADV,CPT,95958,Eeg monitoring/function test,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"1,982.60",,,,,,
Humana MCR ADV,CPT,95961,Electrode stimulation brain,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"1,265.81",,,,,,
Humana MCR ADV,CPT,95965,Meg spontaneous,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"10,992.00",,,,,,
Humana MCR ADV,CPT,95966,Meg evoked single,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"5,455.97",,,,,,
Humana MCR ADV,CPT,95970,Alys npgt w/o prgrmg,APC 5734,RVU Per Case,$114.56 ,OP,114.56,255.45,,,,,,
Humana MCR ADV,CPT,95971,Alys smpl sp/pn npgt w/prgrm,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,297.39,,,,,,
Humana MCR ADV,CPT,95972,Alys cplx sp/pn npgt w/prgrm,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,533.78,,,,,,
Humana MCR ADV,CPT,95976,Alys smpl cn npgt prgrmg,APC 5741,RVU Per Unit,$38.02 ,OP,38.02,657.7,,,,,,
Humana MCR ADV,CPT,95977,Alys cplx cn npgt prgrmg,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,876.92,,,,,,
Humana MCR ADV,CPT,95981,Io anal gast n-stim subsq,APC 5734,RVU Per Case,$114.56 ,OP,114.56,144.88,,,,,,
Humana MCR ADV,CPT,95982,Io ga n-stim subsq w/reprog,APC 5741,RVU Per Case,$38.02 ,OP,38.02,224.95,,,,,,
Humana MCR ADV,CPT,95983,Alys brn npgt prgrmg 15 min,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,260.22,,,,,,
Humana MCR ADV,CPT,95990,Spin/brain pump refil & main,APC 5694,RVU Per Unit,$318.00 ,OP,312.64,318,,,,,,
Humana MCR ADV,CPT,95991,Spin/brain pump refil & main,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,453.71,,,,,,
Humana MCR ADV,CPT,95992,Canalith repositioning proc,Physician,Per Unit,$36.73 ,OP,36.73,36.73,,,,,,
Humana MCR ADV,CPT,95999,Neurological procedure,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
Humana MCR ADV,CPT,96000,Motion analysis video/3d,APC 5723,RVU Per Unit,$499.16 ,OP,449.9,499.16,,,,,,
Humana MCR ADV,CPT,96001,Motion test w/ft press meas,APC 5724,RVU Per Unit,$941.27 ,OP,526.16,941.27,,,,,,
Humana MCR ADV,CPT,96002,Dynamic surface emg,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Humana MCR ADV,CPT,96003,Dynamic fine wire emg,APC 5722,RVU Per Case,$270.61 ,OP,91.51,270.61,,,,,,
Humana MCR ADV,CPT,96105,Assessment of aphasia,Physician,Per Unit,$98.92 ,OP,98.92,419.4,,,,,,
Humana MCR ADV,CPT,96112,Devel tst phys/qhp 1st hr,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,693.9,,,,,,
Humana MCR ADV,CPT,96116,Nubhvl xm phys/qhp 1st hr,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,518.52,,,,,,
Humana MCR ADV,CPT,96125,Cognitive test by hc pro,Physician,Per Unit,$103.76 ,OP,103.76,510.9,,,,,,
Humana MCR ADV,CPT,96127,Brief emotional/behav assmt,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Humana MCR ADV,CPT,96130,Psycl tst eval phys/qhp 1st,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,438.47,,,,,,
Humana MCR ADV,CPT,96132,Nrpsyc tst eval phys/qhp 1st,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,583.35,,,,,,
Humana MCR ADV,CPT,96136,Psycl/nrpsyc tst phy/qhp 1st,APC 5734,RVU Per Unit,$114.56 ,OP,114.56,219.24,,,,,,
Humana MCR ADV,CPT,96138,Psycl/nrpsyc tech 1st,APC 5735,RVU Per Unit,$276.53 ,OP,133.45,276.53,,,,,,
Humana MCR ADV,CPT,96146,Psycl/nrpsyc tst auto result,APC 5731,RVU Per Unit,$25.25 ,OP,18.8,25.25,,,,,,
Humana MCR ADV,CPT,96156,Hlth bhv assmt/reassessment,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,526.34,,,,,,
Humana MCR ADV,CPT,96158,Hlth bhv ivntj indiv 1st 30,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,236.39,,,,,,
Humana MCR ADV,CPT,96160,Pt-focused hlth risk assmt,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Humana MCR ADV,CPT,96161,Caregiver health risk assmt,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Humana MCR ADV,CPT,96164,Hlth bhv ivntj grp 1st 30,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,61.03,,,,,,
Humana MCR ADV,CPT,96167,Hlth bhv ivntj fam 1st 30,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,236.39,,,,,,
Humana MCR ADV,CPT,96360,Hydration iv infusion init,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,293.57,,,,,,
Humana MCR ADV,CPT,96361,Hydrate iv infusion add-on,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,122.99,,,,,,
Humana MCR ADV,CPT,96365,Ther/proph/diag iv inf init,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,354.58,,,,,,
Humana MCR ADV,CPT,96366,Ther/proph/diag iv inf addon,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,114.39,,,,,,
Humana MCR ADV,CPT,96367,Tx/proph/dg addl seq iv inf,APC 5692,RVU Per Unit,$63.42 ,OP,63.42,179.2,,,,,,
Humana MCR ADV,CPT,96369,Sc ther infusion up to 1 hr,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,758.72,,,,,,
Humana MCR ADV,CPT,96370,Sc ther infusion addl hr,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,83.87,,,,,,
Humana MCR ADV,CPT,96371,Sc ther infusion reset pump,APC 5692,RVU Per Case,$63.42 ,OP,63.42,366.02,,,,,,
Humana MCR ADV,CPT,96372,Ther/proph/diag inj sc/im,APC 5692,RVU Per Case,$63.42 ,OP,63.42,106.76,,,,,,
Humana MCR ADV,CPT,96373,Ther/proph/diag inj ia,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,208.24,,,,,,
Humana MCR ADV,CPT,96374,Ther/proph/diag inj iv push,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,278.32,,,,,,
Humana MCR ADV,CPT,96375,Tx/pro/dx inj new drug addon,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,202.94,,,,,,
Humana MCR ADV,CPT,96377,Applicaton on-body injector,APC 5691,RVU Per Case,$40.93 ,OP,40.93,40.93,,,,,,
Humana MCR ADV,CPT,96379,Ther/prop/diag inj/inf proc,APC 5691,RVU Per Case,$40.93 ,OP,40.93,40.93,,,,,,
Humana MCR ADV,CPT,96401,Chemo anti-neopl sq/im,APC 5692,RVU Per Case,$63.42 ,OP,63.42,377.46,,,,,,
Humana MCR ADV,CPT,96402,Chemo hormon antineopl sq/im,APC 5692,RVU Per Case,$63.42 ,OP,63.42,205.88,,,,,,
Humana MCR ADV,CPT,96405,Chemo intralesional up to 7,APC 5692,RVU Per Case,$63.42 ,OP,63.42,468.96,,,,,,
Humana MCR ADV,CPT,96406,Chemo intralesional over 7,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,648.16,,,,,,
Humana MCR ADV,CPT,96409,Chemo iv push sngl drug,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,629.1,,,,,,
Humana MCR ADV,CPT,96411,Chemo iv push addl drug,APC 5692,RVU Per Unit,$63.42 ,OP,63.42,362.21,,,,,,
Humana MCR ADV,CPT,96413,Chemo iv infusion 1 hr,APC 5694,RVU Per Unit,$318.00 ,OP,133.34,318,,,,,,
Humana MCR ADV,CPT,96415,Chemo iv infusion addl hr,APC 5692,RVU Per Unit,$63.42 ,OP,63.42,202.07,,,,,,
Humana MCR ADV,CPT,96416,Chemo prolong infuse w/pump,APC 5694,RVU Per Unit,$318.00 ,OP,318,926.48,,,,,,
Humana MCR ADV,CPT,96417,Chemo iv infus each addl seq,APC 5692,RVU Per Unit,$63.42 ,OP,63.42,427.03,,,,,,
Humana MCR ADV,CPT,96420,Chemo ia push tecnique,APC 5694,RVU Per Unit,$318.00 ,OP,318,613.85,,,,,,
Humana MCR ADV,CPT,96422,Chemo ia infusion up to 1 hr,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,979.86,,,,,,
Humana MCR ADV,CPT,96423,Chemo ia infuse each addl hr,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,434.65,,,,,,
Humana MCR ADV,CPT,96425,Chemotherapy infusion method,APC 5694,RVU Per Unit,$318.00 ,OP,318,968.43,,,,,,
Humana MCR ADV,CPT,96440,Chemotherapy intracavitary,APC 5694,RVU Per Unit,$318.00 ,OP,318,"3,339.91",,,,,,
Humana MCR ADV,CPT,96446,Chemotx admn prtl cavity,APC 5694,RVU Per Unit,$318.00 ,OP,318,318,,,,,,
Humana MCR ADV,CPT,96450,Chemotherapy into cns,APC 5694,RVU Per Unit,$318.00 ,OP,318,"1,159.06",,,,,,
Humana MCR ADV,CPT,96521,Refill/maint portable pump,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,716.79,,,,,,
Humana MCR ADV,CPT,96522,Refill/maint pump/resvr syst,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,610.03,,,,,,
Humana MCR ADV,CPT,96523,Irrig drug delivery device,APC 5733,RVU Per Case,$56.95 ,OP,56.95,141.07,,,,,,
Humana MCR ADV,CPT,96542,Chemotherapy injection,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,751.1,,,,,,
Humana MCR ADV,CPT,96549,Chemotherapy unspecified,APC 5691,RVU Per Case,$40.93 ,OP,40.93,40.93,,,,,,
Humana MCR ADV,CPT,96567,Pdt dstr prmlg les skn,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
Humana MCR ADV,CPT,96573,Pdt dstr prmlg les phys/qhp,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
Humana MCR ADV,CPT,96574,Dbrdmt prmlg les w/pdt,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
Humana MCR ADV,CPT,96900,Ultraviolet light therapy,APC 5732,RVU Per Case,$34.63 ,OP,34.63,114.39,,,,,,
Humana MCR ADV,CPT,96910,Photochemotherapy with uv-b,APC 5733,RVU Per Case,$56.95 ,OP,56.95,335.53,,,,,,
Humana MCR ADV,CPT,96912,Photochemotherapy with uv-a,APC 5733,RVU Per Case,$56.95 ,OP,56.95,430.83,,,,,,
Humana MCR ADV,CPT,96913,Photochemotherapy uv-a or b,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,651.97,,,,,,
Humana MCR ADV,CPT,96920,Laser tx skin < 250 sq cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
Humana MCR ADV,CPT,96921,Laser tx skin 250-500 sq cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
Humana MCR ADV,CPT,96922,Laser tx skin >500 sq cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"1,307.75",,,,,,
Humana MCR ADV,CPT,96999,Dermatological procedure,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
Humana MCR ADV,CPT,97012,Mechanical traction therapy,Physician,Per Unit,$14.55 ,OP,14.55,68.63,,,,,,
Humana MCR ADV,CPT,97016,Vasopneumatic device therapy,Physician,Per Unit,$11.78 ,OP,11.78,72.44,,,,,,
Humana MCR ADV,CPT,97018,Paraffin bath therapy,Physician,Per Unit,$5.69 ,OP,5.69,5.69,,,,,,
Humana MCR ADV,CPT,97022,Whirlpool therapy,Physician,Per Unit,$17.16 ,OP,17.16,83.87,,,,,,
Humana MCR ADV,CPT,97024,Diathermy eg microwave,Physician,Per Unit,$6.96 ,OP,6.96,26.7,,,,,,
Humana MCR ADV,CPT,97026,Infrared therapy,Physician,Per Unit,$6.32 ,OP,6.32,26.7,,,,,,
Humana MCR ADV,CPT,97028,Ultraviolet therapy,Physician,Per Unit,$7.98 ,OP,7.98,7.98,,,,,,
Humana MCR ADV,CPT,97032,Electrical stimulation,Physician,Per Unit,$14.55 ,OP,14.55,76.26,,,,,,
Humana MCR ADV,CPT,97033,Electric current therapy,Physician,Per Unit,$19.67 ,OP,19.67,114.39,,,,,,
Humana MCR ADV,CPT,97034,Contrast bath therapy,Physician,Per Unit,$14.42 ,OP,14.42,68.63,,,,,,
Humana MCR ADV,CPT,97035,Ultrasound therapy,Physician,Per Unit,$14.10 ,OP,14.1,53.38,,,,,,
Humana MCR ADV,CPT,97036,Hydrotherapy,Physician,Per Unit,$33.09 ,OP,33.09,118.19,,,,,,
Humana MCR ADV,CPT,97110,Therapeutic exercises,Physician,Per Unit,$29.26 ,OP,29.26,133.45,,,,,,
Humana MCR ADV,CPT,97112,Neuromuscular reeducation,Physician,Per Unit,$33.86 ,OP,33.86,137.25,,,,,,
Humana MCR ADV,CPT,97113,Aquatic therapy/exercises,Physician,Per Unit,$36.67 ,OP,36.67,160.13,,,,,,
Humana MCR ADV,CPT,97116,Gait training therapy,Physician,Per Unit,$29.26 ,OP,29.26,114.39,,,,,,
Humana MCR ADV,CPT,97124,Massage therapy,Physician,Per Unit,$28.22 ,OP,28.22,106.76,,,,,,
Humana MCR ADV,CPT,97129,Ther ivntj 1st 15 min,Physician,Per Unit,$23.04 ,OP,23.04,114.39,,,,,,
Humana MCR ADV,CPT,97130,Ther ivntj ea addl 15 min,Physician,Per Unit,$22.35 ,OP,22.35,110.97,,,,,,
Humana MCR ADV,CPT,97140,Manual therapy 1/> regions,Physician,Per Unit,$26.97 ,OP,26.97,122,,,,,,
Humana MCR ADV,CPT,97150,Group therapeutic procedures,Physician,Per Unit,$17.53 ,OP,17.53,83.87,,,,,,
Humana MCR ADV,CPT,97151,Bhv id assmt by phys/qhp,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Humana MCR ADV,CPT,97152,Bhv id suprt assmt by 1 tech,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Humana MCR ADV,CPT,97153,Adaptive behavior tx by tech,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Humana MCR ADV,CPT,97154,Grp adapt bhv tx by tech,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Humana MCR ADV,CPT,97155,Adapt behavior tx phys/qhp,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Humana MCR ADV,CPT,97156,Fam adapt bhv tx gdn phy/qhp,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Humana MCR ADV,CPT,97157,Mult fam adapt bhv tx gdn,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Humana MCR ADV,CPT,97158,Grp adapt bhv tx by phy/qhp,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Humana MCR ADV,CPT,97161,Pt eval low complex 20 min,Physician,Per Unit,$98.12 ,OP,98.12,330.81,,,,,,
Humana MCR ADV,CPT,97162,Pt eval mod complex 30 min,Physician,Per Unit,$98.12 ,OP,98.12,331.7,,,,,,
Humana MCR ADV,CPT,97163,Pt eval high complex 45 min,Physician,Per Unit,$98.12 ,OP,98.12,331.7,,,,,,
Humana MCR ADV,CPT,97164,Pt re-eval est plan care,Physician,Per Unit,$66.97 ,OP,66.97,175.39,,,,,,
Humana MCR ADV,CPT,97165,Ot eval low complex 30 min,Physician,Per Unit,$95.26 ,OP,95.26,354.58,,,,,,
Humana MCR ADV,CPT,97166,Ot eval mod complex 45 min,Physician,Per Unit,$95.26 ,OP,95.26,354.58,,,,,,
Humana MCR ADV,CPT,97167,Ot eval high complex 60 min,Physician,Per Unit,$95.26 ,OP,95.26,354.58,,,,,,
Humana MCR ADV,CPT,97168,Ot re-eval est plan care,Physician,Per Unit,$64.11 ,OP,64.11,202.07,,,,,,
Humana MCR ADV,CPT,97530,Therapeutic activities,Physician,Per Unit,$37.50 ,OP,37.5,137.25,,,,,,
Humana MCR ADV,CPT,97533,Sensory integration,Physician,Per Unit,$57.03 ,OP,57.03,122,,,,,,
Humana MCR ADV,CPT,97535,Self care mngment training,Physician,Per Unit,$32.44 ,OP,32.44,137.25,,,,,,
Humana MCR ADV,CPT,97537,Community/work reintegration,Physician,Per Unit,$31.26 ,OP,31.26,125.82,,,,,,
Humana MCR ADV,CPT,97542,Wheelchair mngment training,Physician,Per Unit,$31.58 ,OP,31.58,125.82,,,,,,
Humana MCR ADV,CPT,97597,Rmvl devital tis 20 cm/<,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,282.14,,,,,,
Humana MCR ADV,CPT,97602,Wound(s) care non-selective,APC 5051,RVU Per Case,$183.73 ,OP,171.58,183.73,,,,,,
Humana MCR ADV,CPT,97605,Neg press wound tx <=50 cm,APC 5051,RVU Per Case,$183.73 ,OP,163.95,183.73,,,,,,
Humana MCR ADV,CPT,97606,Neg press wound tx >50 cm,APC 5052,RVU Per Case,$353.91 ,OP,175.39,353.91,,,,,,
Humana MCR ADV,CPT,97607,Neg press wnd tx <=50 sq cm,APC 5052,RVU Per Unit,$353.91 ,OP,163.95,353.91,,,,,,
Humana MCR ADV,CPT,97608,Neg press wound tx >50 cm,APC 5052,RVU Per Unit,$353.91 ,OP,175.39,353.91,,,,,,
Humana MCR ADV,CPT,97610,Low frequency non-thermal us,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
Humana MCR ADV,CPT,97750,Physical performance test,Physician,Per Unit,$33.07 ,OP,33.07,137.25,,,,,,
Humana MCR ADV,CPT,97755,Assistive technology assess,Physician,Per Unit,$37.42 ,OP,37.42,156.32,,,,,,
Humana MCR ADV,CPT,97760,Orthotic mgmt&traing 1st enc,Physician,Per Unit,$47.55 ,OP,47.55,152.51,,,,,,
Humana MCR ADV,CPT,97761,Prosthetic traing 1st enc,Physician,Per Unit,$40.55 ,OP,40.55,133.45,,,,,,
Humana MCR ADV,CPT,97763,Orthc/prostc mgmt sbsq enc,Physician,Per Unit,$51.94 ,OP,51.94,160.13,,,,,,
Humana MCR ADV,CPT,97802,Medical nutrition indiv in,Physician,Per Unit,$30.75 ,OP,30.75,148.69,,,,,,
Humana MCR ADV,CPT,97803,Med nutrition indiv subseq,Physician,Per Unit,$31.17 ,OP,31.17,129.64,,,,,,
Humana MCR ADV,CPT,97804,Medical nutrition group,Physician,Per Unit,$16.45 ,OP,16.45,64.82,,,,,,
Humana MCR ADV,CPT,97810,Acupunct w/o stimul 15 min,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,186.82,,,,,,
Humana MCR ADV,CPT,97813,Acupunct w/stimul 15 min,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,198.25,,,,,,
Humana MCR ADV,CPT,98925,Osteopath manj 1-2 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,141.07,,,,,,
Humana MCR ADV,CPT,98926,Osteopath manj 3-4 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,27.17,,,,,,
Humana MCR ADV,CPT,98927,Osteopath manj 5-6 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,251.64,,,,,,
Humana MCR ADV,CPT,98928,Osteopath manj 7-8 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,297.39,,,,,,
Humana MCR ADV,CPT,98929,Osteopath manj 9-10 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,343.14,,,,,,
Humana MCR ADV,CPT,98940,Chiropract manj 1-2 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,125.82,,,,,,
Humana MCR ADV,CPT,98941,Chiropract manj 3-4 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,171.58,,,,,,
Humana MCR ADV,CPT,98942,Chiropractic manj 5 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,224.95,,,,,,
Humana MCR ADV,CPT,98966,Hc pro phone call 5-10 min,Physician,Per Unit,$12.73 ,OP,12.73,61,,,,,,
Humana MCR ADV,CPT,98967,Hc pro phone call 11-20 min,Physician,Per Unit,$25.14 ,OP,25.14,118.19,,,,,,
Humana MCR ADV,CPT,98968,Hc pro phone call 21-30 min,Physician,Per Unit,$37.46 ,OP,37.46,171.58,,,,,,
Humana MCR ADV,CPT,98970,Qnhp ol dig assmt&mgmt 5-10,Physician,Per Unit,$11.36 ,OP,11.36,11.36,,,,,,
Humana MCR ADV,CPT,98971,Qnhp ol dig assmt&mgmt 11-20,Physician,Per Unit,$20.31 ,OP,20.31,20.31,,,,,,
Humana MCR ADV,CPT,98972,Qnhp ol dig assmt&mgmt 21+,Physician,Per Unit,$32.41 ,OP,32.41,32.41,,,,,,
Humana MCR ADV,CPT,99170,Anogenital exam child w imag,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,663.41,,,,,,
Humana MCR ADV,CPT,99184,Hypothermia ill neonate,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,99190,Special pump services,APC 5881,RVU Per Case,"$8,948.83 ",OP,"2,299.05","8,948.83",,,,,,
Humana MCR ADV,CPT,99191,Special pump services,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,612.76","8,948.83",,,,,,
Humana MCR ADV,CPT,99192,Special pump services,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,151.42","8,948.83",,,,,,
Humana MCR ADV,CPT,99195,Phlebotomy,APC 5734,RVU Per Case,$114.56 ,OP,114.56,331.7,,,,,,
Humana MCR ADV,CPT,99281,Emergency dept visit,APC 5021,RVU Per Case,$74.29 ,OP,74.29,245.98,,,,,,
Humana MCR ADV,CPT,99282,Emergency dept visit,APC 5022,RVU Per Case,$134.66 ,OP,134.66,368.97,,,,,,
Humana MCR ADV,CPT,99283,Emergency dept visit,APC 5023,RVU Per Case,$237.00 ,OP,237,737.94,,,,,,
Humana MCR ADV,CPT,99284,Emergency dept visit,APC 5024,RVU Per Case,$372.22 ,OP,372.22,"1,291.40",,,,,,
Humana MCR ADV,CPT,99285,Emergency dept visit,APC 5025,RVU Per Case,$534.29 ,OP,534.29,"1,967.84",,,,,,
Humana MCR ADV,CPT,99291,Critical care first hour,APC 5041,RVU Per Case,$708.83 ,OP,708.83,"1,197.20",,,,,,
Humana MCR ADV,CPT,99356,Prolng svc i/p/obs 1st hour,APC 5881,RVU Per Case,"$8,948.83 ",OP,499.47,"8,948.83",,,,,,
Humana MCR ADV,CPT,99357,Prolng svc i/p/obs ea addl,APC 5881,RVU Per Case,"$8,948.83 ",OP,507.08,"8,948.83",,,,,,
Humana MCR ADV,CPT,99406,Behav chng smoking 3-10 min,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,64.82,,,,,,
Humana MCR ADV,CPT,99407,Behav chng smoking > 10 min,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,125.82,,,,,,
Humana MCR ADV,CPT,99453,Rem mntr physiol param setup,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,121.51,,,,,,
Humana MCR ADV,CPT,99454,Rem mntr physiol param dev,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Humana MCR ADV,CPT,99460,Init nb em per day hosp,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,305.01,,,,,,
Humana MCR ADV,CPT,99462,Sbsq nb em per day hosp,APC 5881,RVU Per Case,"$8,948.83 ",OP,160.13,"8,948.83",,,,,,
Humana MCR ADV,CPT,99463,Same day nb discharge,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,404.14,,,,,,
Humana MCR ADV,CPT,99465,Nb resuscitation,APC 5781,RVU Per Unit,$575.01 ,OP,575.01,781.61,,,,,,
Humana MCR ADV,CPT,99468,Neonate crit care initial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,510.41","8,948.83",,,,,,
Humana MCR ADV,CPT,99469,Neonate crit care subsq,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,936.85","8,948.83",,,,,,
Humana MCR ADV,CPT,99471,Ped critical care initial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,049.07","8,948.83",,,,,,
Humana MCR ADV,CPT,99472,Ped critical care subsq,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,982.60","8,948.83",,,,,,
Humana MCR ADV,CPT,99473,Self-meas bp pt educaj/train,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Humana MCR ADV,CPT,99475,Ped crit care age 2-5 init,APC 5881,RVU Per Case,"$8,948.83 ",OP,"2,790.89","8,948.83",,,,,,
Humana MCR ADV,CPT,99476,Ped crit care age 2-5 subsq,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,643.28","8,948.83",,,,,,
Humana MCR ADV,CPT,99477,Init day hosp neonate care,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,734.78","8,948.83",,,,,,
Humana MCR ADV,CPT,99478,Ic lbw inf < 1500 gm subsq,APC 5881,RVU Per Case,"$8,948.83 ",OP,716.79,"8,948.83",,,,,,
Humana MCR ADV,CPT,99479,Ic lbw inf 1500-2500 g subsq,APC 5881,RVU Per Case,"$8,948.83 ",OP,629.1,"8,948.83",,,,,,
Humana MCR ADV,CPT,99480,Ic inf pbw 2501-5000 g subsq,APC 5881,RVU Per Case,"$8,948.83 ",OP,606.21,"8,948.83",,,,,,
Humana MCR ADV,CPT,99483,Assmt & care pln pt cog imp,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Humana MCR ADV,CPT,99484,Care mgmt svc bhvl hlth cond,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Humana MCR ADV,CPT,99487,Cplx chrnc care 1st 60 min,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,136.74,,,,,,
Humana MCR ADV,CPT,99490,Chrnc care mgmt svc 1st 20,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Humana MCR ADV,CPT,99492,1st psyc collab care mgmt,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Humana MCR ADV,CPT,99493,Sbsq psyc collab care mgmt,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Humana MCR ADV,CPT,99495,Trans care mgmt 14 day disch,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,121.51,,,,,,
Humana MCR ADV,CPT,99496,Trans care mgmt 7 day disch,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,121.51,,,,,,
Humana MCR ADV,CPT,99497,Advncd care plan 30 min,APC 5822,RVU Per Case,$76.62 ,OP,76.62,76.62,,,,,,
Humana MCR ADV,CPT,0001A,Adm sarscov2 30mcg/0.3ml 1st,APC 9397,RVU Per Unit,$40.93 ,OP,40.93,40.93,,,,,,
Humana MCR ADV,CPT,0001U,Rbc dna hea 35 ag 11 bld grp,Lab Services,Per Unit,$720.00 ,OP,720,720,,,,,,
Humana MCR ADV,CPT,0002A,Adm sarscov2 30mcg/0.3ml 2nd,APC 9398,RVU Per Unit,$40.93 ,OP,40.93,40.93,,,,,,
Humana MCR ADV,CPT,0002M,Liver dis 10 assays w/ash,Lab Services,Per Unit,$503.40 ,OP,503.4,503.4,,,,,,
Humana MCR ADV,CPT,0002U,Onc clrct 3 ur metab alg plp,Lab Services,Per Unit,$25.00 ,OP,25,25,,,,,,
Humana MCR ADV,CPT,0003A,Adm sarscov2 30mcg/0.3ml 3rd,APC 9398,RVU Per Unit,$40.93 ,OP,40.93,40.93,,,,,,
Humana MCR ADV,CPT,0003M,Liver dis 10 assays w/nash,Lab Services,Per Unit,$503.40 ,OP,503.4,503.4,,,,,,
Humana MCR ADV,CPT,0003U,Onc ovar 5 prtn ser alg scor,Lab Services,Per Unit,$950.00 ,OP,950,950,,,,,,
Humana MCR ADV,CPT,0004M,Scoliosis dna alys,Lab Services,Per Unit,$79.00 ,OP,79,79,,,,,,
Humana MCR ADV,CPT,0005U,Onco prst8 3 gene ur alg,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
Humana MCR ADV,CPT,0006M,Onc hep gene risk classifier,Lab Services,Per Unit,$150.00 ,OP,150,150,,,,,,
Humana MCR ADV,CPT,0007M,Onc gastro 51 gene nomogram,Lab Services,Per Unit,$375.00 ,OP,375,375,,,,,,
Humana MCR ADV,CPT,0007U,Rx test prsmv ur w/def conf,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
Humana MCR ADV,CPT,0008U,Hpylori detcj abx rstnc dna,Lab Services,Per Unit,$597.91 ,OP,597.91,597.91,,,,,,
Humana MCR ADV,CPT,0009U,Onc brst ca erbb2 amp/nonamp,Lab Services,Per Unit,$107.00 ,OP,107,107,,,,,,
Humana MCR ADV,CPT,0010U,Nfct ds strn typ whl gen seq,Lab Services,Per Unit,$427.26 ,OP,427.26,427.26,,,,,,
Humana MCR ADV,CPT,0011A,Adm sarscov2 100mcg/0.5ml1st,APC 9397,RVU Per Unit,$40.93 ,OP,40.93,40.93,,,,,,
Humana MCR ADV,CPT,0011M,Onc prst8 ca mrna 12 gen alg,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
Humana MCR ADV,CPT,0011U,Rx mntr lc-ms/ms oral fluid,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
Humana MCR ADV,CPT,0012A,Adm sarscov2 100mcg/0.5ml2nd,APC 9398,RVU Per Unit,$40.93 ,OP,40.93,40.93,,,,,,
Humana MCR ADV,CPT,0012M,Onc mrna 5 gen rsk urthl ca,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
Humana MCR ADV,CPT,0012U,Germln do gene reargmt detcj,Lab Services,Per Unit,"$2,515.60 ",OP,"2,515.60","2,515.60",,,,,,
Humana MCR ADV,CPT,0013A,Adm sarscov2 100mcg/0.5ml3rd,APC 9398,RVU Per Unit,$40.93 ,OP,40.93,40.93,,,,,,
Humana MCR ADV,CPT,0013M,Onc mrna 5 gen recr urthl ca,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
Humana MCR ADV,CPT,0013U,Onc sld org neo gene reargmt,Lab Services,Per Unit,"$2,515.60 ",OP,"2,515.60","2,515.60",,,,,,
Humana MCR ADV,CPT,0014M,Liver ds alys 3 bmrk srm alg,Lab Services,Per Unit,$176.19 ,OP,176.19,176.19,,,,,,
Humana MCR ADV,CPT,0014U,Hem hmtlmf neo gene reargmt,Lab Services,Per Unit,"$2,515.60 ",OP,"2,515.60","2,515.60",,,,,,
Humana MCR ADV,CPT,0016U,Onc hmtlmf neo rna bcr/abl1,Lab Services,Per Unit,$163.96 ,OP,163.96,163.96,,,,,,
Humana MCR ADV,CPT,0017U,Onc hmtlmf neo jak2 mut dna,Lab Services,Per Unit,$91.66 ,OP,91.66,91.66,,,,,,
Humana MCR ADV,CPT,0018U,Onc thyr 10 microrna seq alg,Lab Services,Per Unit,"$3,002.09 ",OP,"3,002.09","3,002.09",,,,,,
Humana MCR ADV,CPT,0019U,Onc rna tiss predict alg,Lab Services,Per Unit,"$3,675.00 ",OP,"3,675.00","3,675.00",,,,,,
Humana MCR ADV,CPT,0021U,Onc prst8 detcj 8 autoantb,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
Humana MCR ADV,CPT,0022U,Trgt gen seq dna&rna 23 gene,Lab Services,Per Unit,"$1,950.00 ",OP,"1,950.00","1,950.00",,,,,,
Humana MCR ADV,CPT,0023U,Onc aml dna detcj/nondetcj,Lab Services,Per Unit,$248.51 ,OP,248.51,248.51,,,,,,
Humana MCR ADV,CPT,0024U,Glyca nuc mr spectrsc quan,Lab Services,Per Unit,$34.19 ,OP,34.19,34.19,,,,,,
Humana MCR ADV,CPT,0025U,Tenofovir liq chrom ur quan,Lab Services,Per Unit,$85.77 ,OP,85.77,85.77,,,,,,
Humana MCR ADV,CPT,0026U,Onc thyr dna&mrna 112 genes,Lab Services,Per Unit,"$3,600.00 ",OP,"3,600.00","3,600.00",,,,,,
Humana MCR ADV,CPT,0027U,Jak2 gene trgt seq alys,Lab Services,Per Unit,$121.91 ,OP,121.91,121.91,,,,,,
Humana MCR ADV,CPT,0029U,Rx metab advrs trgt seq alys,Lab Services,Per Unit,$742.27 ,OP,742.27,742.27,,,,,,
Humana MCR ADV,CPT,0030U,Rx metab warf trgt seq alys,Lab Services,Per Unit,$134.13 ,OP,134.13,134.13,,,,,,
Humana MCR ADV,CPT,0031A,Adm sarscov2 vac ad26 .5ml,APC 9398,RVU Per Unit,$40.93 ,OP,40.93,40.93,,,,,,
Humana MCR ADV,CPT,0031U,Cyp1a2 gene,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Humana MCR ADV,CPT,0032U,Comt gene,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Humana MCR ADV,CPT,0033U,Htr2a htr2c genes,Lab Services,Per Unit,$349.62 ,OP,349.62,349.62,,,,,,
Humana MCR ADV,CPT,0034U,Tpmt nudt15 genes,Lab Services,Per Unit,$466.17 ,OP,466.17,466.17,,,,,,
Humana MCR ADV,CPT,0035U,Neuro csf prion prtn qual,Lab Services,Per Unit,$540.99 ,OP,540.99,540.99,,,,,,
Humana MCR ADV,CPT,0036U,Xome tum & nml spec seq alys,Lab Services,Per Unit,"$4,780.00 ",OP,"4,780.00","4,780.00",,,,,,
Humana MCR ADV,CPT,0037U,Trgt gen seq dna 324 genes,Lab Services,Per Unit,"$3,500.00 ",OP,"3,500.00","3,500.00",,,,,,
Humana MCR ADV,CPT,0038U,Vitamin d srm microsamp quan,Lab Services,Per Unit,$29.60 ,OP,29.6,29.6,,,,,,
Humana MCR ADV,CPT,0039U,Dna antb 2strand hi avidity,Lab Services,Per Unit,$13.74 ,OP,13.74,13.74,,,,,,
Humana MCR ADV,CPT,0040U,Bcr/abl1 gene major bp quan,Lab Services,Per Unit,$409.90 ,OP,409.9,409.9,,,,,,
Humana MCR ADV,CPT,0041U,B brgdrferi antb 5 prtn igm,Lab Services,Per Unit,$17.21 ,OP,17.21,17.21,,,,,,
Humana MCR ADV,CPT,0042U,B brgdrferi antb 12 prtn igg,Lab Services,Per Unit,$17.21 ,OP,17.21,17.21,,,,,,
Humana MCR ADV,CPT,0043U,Tbrf b grp antb 4 prtn igm,Lab Services,Per Unit,$14.86 ,OP,14.86,14.86,,,,,,
Humana MCR ADV,CPT,0044U,Tbrf b grp antb 4 prtn igg,Lab Services,Per Unit,$14.86 ,OP,14.86,14.86,,,,,,
Humana MCR ADV,CPT,0045U,Onc brst dux carc is 12 gene,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
Humana MCR ADV,CPT,0046U,Flt3 gene itd variants quan,Lab Services,Per Unit,$407.43 ,OP,407.43,407.43,,,,,,
Humana MCR ADV,CPT,0047U,Onc prst8 mrna 17 gene alg,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
Humana MCR ADV,CPT,0048U,Onc sld org neo dna 468 gene,Lab Services,Per Unit,"$2,919.60 ",OP,"2,919.60","2,919.60",,,,,,
Humana MCR ADV,CPT,0049U,Npm1 gene analysis quan,Lab Services,Per Unit,$407.43 ,OP,407.43,407.43,,,,,,
Humana MCR ADV,CPT,0050U,Trgt gen seq dna 194 genes,Lab Services,Per Unit,"$2,916.60 ",OP,"2,916.60","2,916.60",,,,,,
Humana MCR ADV,CPT,0051U,Rx mntr lc-ms/ms ur 31 pnl,Lab Services,Per Unit,$193.71 ,OP,193.71,193.71,,,,,,
Humana MCR ADV,CPT,0052U,Lpoprtn bld w/5 maj classes,Lab Services,Per Unit,$33.86 ,OP,33.86,33.86,,,,,,
Humana MCR ADV,CPT,0053U,Onc prst8 ca fish alys 4 gen,Lab Services,Per Unit,"$2,030.00 ",OP,"2,030.00","2,030.00",,,,,,
Humana MCR ADV,CPT,0054U,Rx mntr 14+ drugs & sbsts,Lab Services,Per Unit,$148.96 ,OP,148.96,148.96,,,,,,
Humana MCR ADV,CPT,0055U,Card hrt trnspl 96 dna seq,Lab Services,Per Unit,"$3,240.00 ",OP,"3,240.00","3,240.00",,,,,,
Humana MCR ADV,CPT,0056U,Hem aml dna gene reargmt,Lab Services,Per Unit,"$2,515.60 ",OP,"2,515.60","2,515.60",,,,,,
Humana MCR ADV,CPT,0058U,Onc merkel cll carc srm quan,Lab Services,Per Unit,$322.96 ,OP,322.96,322.96,,,,,,
Humana MCR ADV,CPT,0059U,Onc merkel cll carc srm +/-,Lab Services,Per Unit,$322.96 ,OP,322.96,322.96,,,,,,
Humana MCR ADV,CPT,0060U,Twn zyg gen seq alys chrms2,Lab Services,Per Unit,$759.05 ,OP,759.05,759.05,,,,,,
Humana MCR ADV,CPT,0061U,Tc meas 5 bmrk sfdi m-s alys,Lab Services,Per Unit,$25.10 ,OP,25.1,25.1,,,,,,
Humana MCR ADV,CPT,0062U,Ai sle igg&igm alys 80 bmrk,Lab Services,Per Unit,$380.72 ,OP,380.72,380.72,,,,,,
Humana MCR ADV,CPT,0063U,Neuro autism 32 amines alg,Lab Services,Per Unit,$750.00 ,OP,750,750,,,,,,
Humana MCR ADV,CPT,0064U,Antb tp total&rpr ia qual,Lab Services,Per Unit,$31.33 ,OP,31.33,31.33,,,,,,
Humana MCR ADV,CPT,0065U,Syfls tst nontreponemal antb,Lab Services,Per Unit,$18.09 ,OP,18.09,18.09,,,,,,
Humana MCR ADV,CPT,0066U,Pamg-1 ia cervico-vag fluid,Lab Services,Per Unit,$15.29 ,OP,15.29,15.29,,,,,,
Humana MCR ADV,CPT,0067U,Onc brst imhchem prfl 4 bmrk,Lab Services,Per Unit,"$1,897.00 ",OP,"1,897.00","1,897.00",,,,,,
Humana MCR ADV,CPT,0068U,Candida species pnl amp prb,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
Humana MCR ADV,CPT,0069U,Onc clrct microrna mir-31-3p,Lab Services,Per Unit,$380.00 ,OP,380,380,,,,,,
Humana MCR ADV,CPT,0070U,Cyp2d6 gen com&slct rar vrnt,Lab Services,Per Unit,$676.37 ,OP,676.37,676.37,,,,,,
Humana MCR ADV,CPT,0071T,Us leiomyomata ablate <200,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","2,684.38",,,,,,
Humana MCR ADV,CPT,0071U,Cyp2d6 full gene sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,
Humana MCR ADV,CPT,0072T,Us leiomyomata ablate >200,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","2,684.38",,,,,,
Humana MCR ADV,CPT,0072U,Cyp2d6 gen cyp2d6-2d7 hybrid,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,
Humana MCR ADV,CPT,0073U,Cyp2d6 gen cyp2d7-2d6 hybrid,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,
Humana MCR ADV,CPT,0074U,Cyp2d6 nonduplicated gene,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,
Humana MCR ADV,CPT,0075T,Perq stent/chest vert art,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,0075U,Cyp2d6 5' gene dup/mlt,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,
Humana MCR ADV,CPT,0076T,S&i stent/chest vert art,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,0076U,Cyp2d6 3' gene dup/mlt,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,
Humana MCR ADV,CPT,0077U,Ig paraprotein qual bld/ur,Lab Services,Per Unit,$43.43 ,OP,43.43,43.43,,,,,,
Humana MCR ADV,CPT,0078U,Pain mgt opi use gnotyp pnl,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,
Humana MCR ADV,CPT,0080U,Onc lng 5 clin rsk factr alg,Lab Services,Per Unit,"$3,520.00 ",OP,"3,520.00","3,520.00",,,,,,
Humana MCR ADV,CPT,0082U,Rx test def 90+ rx/sbsts ur,Lab Services,Per Unit,$246.92 ,OP,246.92,246.92,,,,,,
Humana MCR ADV,CPT,0083U,Onc rspse chemo cntrst tomog,Lab Services,Per Unit,$167.35 ,OP,167.35,167.35,,,,,,
Humana MCR ADV,CPT,0084U,Rbc dna gnotyp 10 bld groups,Lab Services,Per Unit,$720.00 ,OP,720,720,,,,,,
Humana MCR ADV,CPT,0086U,Nfct ds bact&fng org id 6+,Lab Services,Per Unit,$200.00 ,OP,200,200,,,,,,
Humana MCR ADV,CPT,0087U,Crd hrt trnspl mrna 1283 gen,Lab Services,Per Unit,"$3,159.42 ",OP,"3,159.42","3,159.42",,,,,,
Humana MCR ADV,CPT,0088U,Trnsplj kdn algrft rej 1494,Lab Services,Per Unit,"$3,159.42 ",OP,"3,159.42","3,159.42",,,,,,
Humana MCR ADV,CPT,0089U,Onc mlnma prame & linc00518,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
Humana MCR ADV,CPT,0090U,Onc cutan mlnma mrna 23 gene,Lab Services,Per Unit,"$1,755.00 ",OP,"1,755.00","1,755.00",,,,,,
Humana MCR ADV,CPT,0092U,Onc lng 3 prtn bmrk plsm alg,Lab Services,Per Unit,"$2,488.00 ",OP,"2,488.00","2,488.00",,,,,,
Humana MCR ADV,CPT,0093U,Rx mntr 65 com drugs urine,Lab Services,Per Unit,$62.14 ,OP,62.14,62.14,,,,,,
Humana MCR ADV,CPT,0094U,Genome rapid sequence alys,Lab Services,Per Unit,"$7,582.20 ",OP,"7,582.20","7,582.20",,,,,,
Humana MCR ADV,CPT,0095U,Inflm ee elisa alys alg,Lab Services,Per Unit,$771.98 ,OP,771.98,771.98,,,,,,
Humana MCR ADV,CPT,0096U,Hpv hi risk types male urine,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,
Humana MCR ADV,CPT,0097U,Gi pathogen 22 targets,Lab Services,Per Unit,$363.04 ,OP,363.04,363.04,,,,,,
Humana MCR ADV,CPT,0101T,Extracorp shockwv tx hi enrg,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","2,896.40",,,,,,
Humana MCR ADV,CPT,0102T,Extracorp shockwv tx anesth,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","2,896.40",,,,,,
Humana MCR ADV,CPT,0105U,Neph ckd mult eclia tum nec,Lab Services,Per Unit,$950.00 ,OP,950,950,,,,,,
Humana MCR ADV,CPT,0106T,Touch quant sensory test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Humana MCR ADV,CPT,0106U,Gstr emptg 7 timed brth spec,Lab Services,Per Unit,$874.49 ,OP,874.49,874.49,,,,,,
Humana MCR ADV,CPT,0107T,Vibrate quant sensory test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Humana MCR ADV,CPT,0107U,C diff tox ag detcj ia stool,Lab Services,Per Unit,$16.00 ,OP,16,16,,,,,,
Humana MCR ADV,CPT,0108T,Cool quant sensory test,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Humana MCR ADV,CPT,0108U,Gi barrett esoph 9 prtn bmrk,Lab Services,Per Unit,"$2,513.25 ",OP,"2,513.25","2,513.25",,,,,,
Humana MCR ADV,CPT,0109T,Heat quant sensory test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Humana MCR ADV,CPT,0109U,Id aspergillus dna 4 species,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
Humana MCR ADV,CPT,0110T,Nos quant sensory test,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Humana MCR ADV,CPT,0110U,Rx mntr 1+oral onc rx&sbsts,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,
Humana MCR ADV,CPT,0111U,Onc colon ca kras&nras alys,Lab Services,Per Unit,$682.29 ,OP,682.29,682.29,,,,,,
Humana MCR ADV,CPT,0112U,Iadi 16s&18s rrna genes,Lab Services,Per Unit,$356.13 ,OP,356.13,356.13,,,,,,
Humana MCR ADV,CPT,0113U,Onc prst8 pca3&tmprss2-erg,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
Humana MCR ADV,CPT,0114U,Gi barretts esoph vim&ccna1,Lab Services,Per Unit,"$1,938.01 ",OP,"1,938.01","1,938.01",,,,,,
Humana MCR ADV,CPT,0115U,Respir iadna 18 viral&2 bact,Lab Services,Per Unit,$275.35 ,OP,275.35,275.35,,,,,,
Humana MCR ADV,CPT,0116U,Rx mntr nzm ia 35+oral flu,Lab Services,Per Unit,$246.92 ,OP,246.92,246.92,,,,,,
Humana MCR ADV,CPT,0117U,Pain mgmt 11 endogenous anal,Lab Services,Per Unit,$840.65 ,OP,840.65,840.65,,,,,,
Humana MCR ADV,CPT,0118U,Trnsplj don-drv cll-fr dna,Lab Services,Per Unit,"$2,753.25 ",OP,"2,753.25","2,753.25",,,,,,
Humana MCR ADV,CPT,0119U,Crd ceramides liq chrom plsm,Lab Services,Per Unit,$83.76 ,OP,83.76,83.76,,,,,,
Humana MCR ADV,CPT,0120U,Onc b cll lymphm mrna 58 gen,Lab Services,Per Unit,"$2,510.21 ",OP,"2,510.21","2,510.21",,,,,,
Humana MCR ADV,CPT,0121U,Sc dis vcam-1 whole blood,Lab Services,Per Unit,$509.20 ,OP,509.2,509.2,,,,,,
Humana MCR ADV,CPT,0122U,Sc dis p-selectin whl blood,Lab Services,Per Unit,$526.23 ,OP,526.23,526.23,,,,,,
Humana MCR ADV,CPT,0123U,Mchnl fragility rbc prflg,Lab Services,Per Unit,$357.63 ,OP,357.63,357.63,,,,,,
Humana MCR ADV,CPT,0130U,Hered colon ca do mrna pnl,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,
Humana MCR ADV,CPT,0131U,Hered brst ca rltd do pnl 13,Lab Services,Per Unit,$710.00 ,OP,710,710,,,,,,
Humana MCR ADV,CPT,0132U,Hered ova ca rltd do pnl 17,Lab Services,Per Unit,$741.64 ,OP,741.64,741.64,,,,,,
Humana MCR ADV,CPT,0133U,Hered prst8 ca rltd do 11,Lab Services,Per Unit,$690.29 ,OP,690.29,690.29,,,,,,
Humana MCR ADV,CPT,0134U,Hered pan ca mrna pnl 18 gen,Lab Services,Per Unit,$748.39 ,OP,748.39,748.39,,,,,,
Humana MCR ADV,CPT,0135U,Hered gyn ca mrna pnl 12 gen,Lab Services,Per Unit,$700.56 ,OP,700.56,700.56,,,,,,
Humana MCR ADV,CPT,0136U,Atm mrna seq alys,Lab Services,Per Unit,$407.43 ,OP,407.43,407.43,,,,,,
Humana MCR ADV,CPT,0137U,Palb2 mrna seq alys,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,
Humana MCR ADV,CPT,0138U,Brca1 brca2 mrna seq alys,Lab Services,Per Unit,$468.33 ,OP,468.33,468.33,,,,,,
Humana MCR ADV,CPT,0145U,Drug assay 65+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
Humana MCR ADV,CPT,0146U,Drug assay 80+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
Humana MCR ADV,CPT,0147U,Drug assay 85+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
Humana MCR ADV,CPT,0148U,Drug assay 100+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
Humana MCR ADV,CPT,0149U,Drug assay 60+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
Humana MCR ADV,CPT,0150U,Drug assay 120+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
Humana MCR ADV,CPT,0154U,Onc urthl ca rna fgfr3 gene,Lab Services,Per Unit,$482.14 ,OP,482.14,482.14,,,,,,
Humana MCR ADV,CPT,0155U,Onc brst ca dna pik3ca gene,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Humana MCR ADV,CPT,0166U,Liver ds 10 biochem asy srm,Lab Services,Per Unit,$503.40 ,OP,503.4,503.4,,,,,,
Humana MCR ADV,CPT,0167U,Chornc gonadotropin hcg ia,Lab Services,Per Unit,$7.52 ,OP,7.52,7.52,,,,,,
Humana MCR ADV,CPT,0169U,Nudt15&tpmt gene com vrnt,Lab Services,Per Unit,$466.17 ,OP,466.17,466.17,,,,,,
Humana MCR ADV,CPT,0170U,Neuro asd rna next gen seq,Lab Services,Per Unit,"$1,755.00 ",OP,"1,755.00","1,755.00",,,,,,
Humana MCR ADV,CPT,0172U,Onc sld tum alys brca1 brca2,Lab Services,Per Unit,"$3,030.00 ",OP,"3,030.00","3,030.00",,,,,,
Humana MCR ADV,CPT,0176U,Cdtb&vinculin igg antb ia,Lab Services,Per Unit,$64.19 ,OP,64.19,64.19,,,,,,
Humana MCR ADV,CPT,0177U,Onc brst ca dna pik3ca 11,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Humana MCR ADV,CPT,0181U,Co gnotyp aqp1 exon 1,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Humana MCR ADV,CPT,0182U,Crom gnotyp cd55 exons 1-10,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,
Humana MCR ADV,CPT,0183U,Di gnotyp slc4a1 exon 19,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Humana MCR ADV,CPT,0184T,Exc rectal tumor endoscopic,APC 5331,RVU Per Case,"$5,145.78 ",OP,"5,145.78","5,145.78",,,,,,
Humana MCR ADV,CPT,0184U,Do gnotyp art4 exon 2,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Humana MCR ADV,CPT,0185U,Fut1 gnotyp fut1 exon 4,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Humana MCR ADV,CPT,0186U,Fut2 gnotyp fut2 exon 2,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Humana MCR ADV,CPT,0187U,Fy gnotyp ackr1 exons 1-2,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Humana MCR ADV,CPT,0188U,Ge gnotyp gypc exons 1-4,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Humana MCR ADV,CPT,0189U,Gypa gnotyp ntrns 1 5 exon 2,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Humana MCR ADV,CPT,0190U,Gypb gnotyp ntrns 1 5 seux 3,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Humana MCR ADV,CPT,0191T,Insert ant segment drain int,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,009.10",,,,,,
Humana MCR ADV,CPT,0191U,In gnotyp cd44 exons 2 3 6,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Humana MCR ADV,CPT,0192U,Jk gnotyp slc14a1 exon 9,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Humana MCR ADV,CPT,0193U,Jr gnotyp abcg2 exons 2-26,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,
Humana MCR ADV,CPT,0194U,Kel gnotyp kel exon 8,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Humana MCR ADV,CPT,0195U,Klf1 targeted sequencing,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,
Humana MCR ADV,CPT,0196U,Lu gnotyp bcam exon 3,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Humana MCR ADV,CPT,0197U,Lw gnotyp icam4 exon 1,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Humana MCR ADV,CPT,0198T,Ocular blood flow measure,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Humana MCR ADV,CPT,0198U,Rhd&rhce gntyp rhd1-10&rhce5,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,
Humana MCR ADV,CPT,0199U,Sc gnotyp ermap exons 4 12,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Humana MCR ADV,CPT,0200T,Perq sacral augmt unilat inj,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
Humana MCR ADV,CPT,0200U,Xk gnotyp xk exons 1-3,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Humana MCR ADV,CPT,0201T,Perq sacral augmt bilat inj,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
Humana MCR ADV,CPT,0201U,Yt gnotyp ache exon 2,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Humana MCR ADV,CPT,0202T,Post vert arthrplst 1 lumbar,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
Humana MCR ADV,CPT,0202U,Nfct ds 22 trgt sars-cov-2,Lab Services,Per Unit,$416.78 ,OP,416.78,416.78,,,,,,
Humana MCR ADV,CPT,0203U,Ai ibd mrna xprsn prfl 17,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
Humana MCR ADV,CPT,0204U,Onc thyr mrna xprsn alys 593,Lab Services,Per Unit,"$2,919.60 ",OP,"2,919.60","2,919.60",,,,,,
Humana MCR ADV,CPT,0205U,Oph amd alys 3 gene variants,Lab Services,Per Unit,$47.00 ,OP,47,47,,,,,,
Humana MCR ADV,CPT,0207T,Clear eyelid gland w/heat,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Humana MCR ADV,CPT,0208T,Audiometry air only,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Humana MCR ADV,CPT,0209T,Audiometry air & bone,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Humana MCR ADV,CPT,0210T,Speech audiometry threshold,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Humana MCR ADV,CPT,0210U,Syphilis tst antb ia quan,Lab Services,Per Unit,$18.63 ,OP,18.63,18.63,,,,,,
Humana MCR ADV,CPT,0211T,Speech audiom thresh & recog,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Humana MCR ADV,CPT,0212T,Compre audiometry evaluation,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
Humana MCR ADV,CPT,0213T,Njx paravert w/us cer/thor,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,841.63,,,,,,
Humana MCR ADV,CPT,0216T,Njx paravert w/us lumb/sac,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,841.63,,,,,,
Humana MCR ADV,CPT,0218U,Neuro musc dys dmd seq alys,Lab Services,Per Unit,"$2,279.00 ",OP,"2,279.00","2,279.00",,,,,,
Humana MCR ADV,CPT,0219T,Plmt post facet implt cerv,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
Humana MCR ADV,CPT,0220T,Plmt post facet implt thor,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
Humana MCR ADV,CPT,0221T,Plmt post facet implt lumb,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
Humana MCR ADV,CPT,0224U,Antibody sars-cov-2 titer(s),Lab Services,Per Unit,$42.13 ,OP,42.13,42.13,,,,,,
Humana MCR ADV,CPT,0226U,Svnt sarscov2 elisa plsm srm,Lab Services,Per Unit,$42.28 ,OP,42.28,42.28,,,,,,
Humana MCR ADV,CPT,0232T,Njx platelet plasma,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
Humana MCR ADV,CPT,0234T,Trluml perip athrc renal art,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Humana MCR ADV,CPT,0235T,Trluml perip athrc visceral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,0236T,Trluml perip athrc abd aorta,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Humana MCR ADV,CPT,0237T,Trluml perip athrc brchiocph,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Humana MCR ADV,CPT,0238T,Trluml perip athrc iliac art,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Humana MCR ADV,CPT,0239U,Trgt gen seq alys pnl 311+,Lab Services,Per Unit,"$3,500.00 ",OP,"3,500.00","3,500.00",,,,,,
Humana MCR ADV,CPT,0240U,Nfct ds vir resp rna 3 trgt,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
Humana MCR ADV,CPT,0241U,Nfct ds vir resp rna 4 trgt,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
Humana MCR ADV,CPT,0242U,Trgt gen seq alys pnl 55-74,Lab Services,Per Unit,"$5,000.00 ",OP,"5,000.00","5,000.00",,,,,,
Humana MCR ADV,CPT,0253T,Insert aqueous drain device,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,009.10",,,,,,
Humana MCR ADV,CPT,0263T,Im b1 mrw cel ther cmpl,APC 5243,RVU Per Unit,"$4,131.87 ",OP,"4,131.87","4,131.87",,,,,,
Humana MCR ADV,CPT,0264T,Im b1 mrw cel ther xcl hrvst,APC 5243,RVU Per Unit,"$4,131.87 ",OP,"4,131.87","4,131.87",,,,,,
Humana MCR ADV,CPT,0265T,Im b1 mrw cel ther hrvst onl,APC 5243,RVU Per Unit,"$4,131.87 ",OP,"4,131.87","4,131.87",,,,,,
Humana MCR ADV,CPT,0266T,Implt/rpl crtd sns dev total,APC 5465,RVU Per Case,"$30,131.14 ",OP,"30,131.14","30,131.14",,,,,,
Humana MCR ADV,CPT,0267T,Implt/rpl crtd sns dev lead,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Humana MCR ADV,CPT,0268T,Implt/rpl crtd sns dev gen,APC 5465,RVU Per Case,"$30,131.14 ",OP,"30,131.14","30,131.14",,,,,,
Humana MCR ADV,CPT,0269T,Rev/remvl crtd sns dev total,APC 5432,RVU Per Case,"$5,833.22 ",OP,"5,833.22","5,833.22",,,,,,
Humana MCR ADV,CPT,0270T,Rev/remvl crtd sns dev lead,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Humana MCR ADV,CPT,0271T,Rev/remvl crtd sns dev gen,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Humana MCR ADV,CPT,0272T,Interrogate crtd sns dev,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Humana MCR ADV,CPT,0273T,Interrogate crtd sns w/pgrmg,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Humana MCR ADV,CPT,0274T,Perq lamot/lam crv/thrc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
Humana MCR ADV,CPT,0275T,Perq lamot/lam lumbar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
Humana MCR ADV,CPT,0278T,Tempr,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
Humana MCR ADV,CPT,0308T,Insj ocular telescope prosth,APC 5495,RVU Per Case,"$21,250.81 ",OP,"21,250.81","21,250.81",,,,,,
Humana MCR ADV,CPT,0312T,Laps impltj nstim vagus,APC 5465,RVU Per Case,"$30,131.14 ",OP,"30,131.14","30,131.14",,,,,,
Humana MCR ADV,CPT,0313T,Laps rmvl nstim array vagus,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Humana MCR ADV,CPT,0314T,Laps rmvl vgl arry&pls gen,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Humana MCR ADV,CPT,0315T,Rmvl vagus nerve pls gen,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Humana MCR ADV,CPT,0316T,Replc vagus nerve pls gen,APC 5465,RVU Per Case,"$30,131.14 ",OP,"30,131.14","30,131.14",,,,,,
Humana MCR ADV,CPT,0317T,Elec alys vagus nrv pls gen,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Humana MCR ADV,CPT,0330T,Tear film img uni/bi w/i&r,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Humana MCR ADV,CPT,0331T,Heart symp image plnr,APC 5593,RVU Per Unit,"$1,336.39 ",OP,922.67,"1,336.39",,,,,,
Humana MCR ADV,CPT,0332T,Heart symp image plnr spect,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,338.26",,,,,,
Humana MCR ADV,CPT,0335T,Insj sinus tarsi implant,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
Humana MCR ADV,CPT,0338T,Trnscth renal symp denrv unl,APC 5192,RVU Per Case,"$5,072.43 ",OP,"5,072.43","5,072.43",,,,,,
Humana MCR ADV,CPT,0339T,Trnscth renal symp denrv bil,APC 5192,RVU Per Case,"$5,072.43 ",OP,"5,072.43","5,072.43",,,,,,
Humana MCR ADV,CPT,0342T,Thxp apheresis w/hdl delip,APC 5243,RVU Per Unit,"$4,131.87 ",OP,"4,131.87","4,131.87",,,,,,
Humana MCR ADV,CPT,0345T,Transcath mtral vlve repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,0347T,Ins bone device for rsa,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Humana MCR ADV,CPT,0348T,Rsa spine exam,APC 5522,RVU Per Case,$111.51 ,OP,111.51,111.51,,,,,,
Humana MCR ADV,CPT,0349T,Rsa upper extr exam,APC 5522,RVU Per Case,$111.51 ,OP,111.51,111.51,,,,,,
Humana MCR ADV,CPT,0350T,Rsa lower extr exam,APC 5521,RVU Per Case,$82.79 ,OP,82.79,82.79,,,,,,
Humana MCR ADV,CPT,0355T,Gi tract capsule endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","1,662.91",,,,,,
Humana MCR ADV,CPT,0356T,Insrt drug device for iop,APC 5692,RVU Per Case,$63.42 ,OP,63.42,63.42,,,,,,
Humana MCR ADV,CPT,0358T,Bia whole body,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Humana MCR ADV,CPT,0362T,Bhv id suprt assmt ea 15 min,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Humana MCR ADV,CPT,0373T,Adapt bhv tx ea 15 min,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Humana MCR ADV,CPT,0379T,Vis field assmnt tech suppt,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Humana MCR ADV,CPT,0394T,Hdr elctrnc skn surf brchytx,APC 5622,RVU Per Unit,$247.32 ,OP,247.32,247.32,,,,,,
Humana MCR ADV,CPT,0395T,Hdr elctr ntrst/ntrcv brchtx,APC 5624,RVU Per Unit,$724.98 ,OP,724.98,724.98,,,,,,
Humana MCR ADV,CPT,0398T,Mrgfus strtctc les abltj,APC 5463,RVU Per Case,"$11,498.23 ",OP,"11,498.23","11,498.23",,,,,,
Humana MCR ADV,CPT,0402T,Colgn cross-link crn med sep,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","2,049.05",,,,,,
Humana MCR ADV,CPT,0404T,Trnscrv uterin fibroid abltj,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,140.35","9,201.00",,,,,,
Humana MCR ADV,CPT,0408T,Insj/rplc cardiac modulj sys,APC 5231,RVU Per Case,"$23,577.44 ",OP,"23,577.44","23,577.44",,,,,,
Humana MCR ADV,CPT,0409T,Insj/rplc car modulj pls gn,APC 5231,RVU Per Case,"$23,577.44 ",OP,"23,577.44","23,577.44",,,,,,
Humana MCR ADV,CPT,0410T,Insj/rplc car modulj atr elt,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
Humana MCR ADV,CPT,0411T,Insj/rplc car modulj vnt elt,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
Humana MCR ADV,CPT,0412T,Rmvl cardiac modulj pls gen,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Humana MCR ADV,CPT,0413T,Rmvl car modulj tranvns elt,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Humana MCR ADV,CPT,0414T,Rmvl & rpl car modulj pls gn,APC 5231,RVU Per Case,"$23,577.44 ",OP,"23,577.44","23,577.44",,,,,,
Humana MCR ADV,CPT,0415T,Repos car modulj tranvns elt,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,554.25,,,,,,
Humana MCR ADV,CPT,0416T,Reloc skin pocket pls gen,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","1,755.36",,,,,,
Humana MCR ADV,CPT,0417T,Prgrmg eval cardiac modulj,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Humana MCR ADV,CPT,0418T,Interro eval cardiac modulj,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Humana MCR ADV,CPT,0419T,Dstrj neurofibroma xtnsv,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,536.39,,,,,,
Humana MCR ADV,CPT,0420T,Dstrj neurofibroma xtnsv,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,536.39,,,,,,
Humana MCR ADV,CPT,0421T,Waterjet prostate abltj cmpl,APC 5376,RVU Per Case,"$8,450.70 ",OP,"8,450.70","8,450.70",,,,,,
Humana MCR ADV,CPT,0422T,Tactile breast img uni/bi,APC 5521,RVU Per Case,$82.79 ,OP,82.79,82.79,,,,,,
Humana MCR ADV,CPT,0424T,Insj/rplc nstim apnea compl,APC 5465,RVU Per Case,"$30,131.14 ",OP,"30,131.14","30,131.14",,,,,,
Humana MCR ADV,CPT,0425T,Insj/rplc nstim apnea sen ld,APC 5463,RVU Per Case,"$11,498.23 ",OP,"11,498.23","11,498.23",,,,,,
Humana MCR ADV,CPT,0426T,Insj/rplc nstim apnea stm ld,APC 5463,RVU Per Case,"$11,498.23 ",OP,"11,498.23","11,498.23",,,,,,
Humana MCR ADV,CPT,0427T,Insj/rplc nstim apnea pls gn,APC 5465,RVU Per Case,"$30,131.14 ",OP,"30,131.14","30,131.14",,,,,,
Humana MCR ADV,CPT,0428T,Rmvl nstim apnea pls gen,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Humana MCR ADV,CPT,0429T,Rmvl nstim apnea sen ld,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Humana MCR ADV,CPT,0430T,Rmvl nstim apnea stimj ld,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Humana MCR ADV,CPT,0431T,Rmvl/rplc nstim apnea pls gn,APC 5465,RVU Per Case,"$30,131.14 ",OP,"30,131.14","30,131.14",,,,,,
Humana MCR ADV,CPT,0432T,Repos nstim apnea stimj ld,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Humana MCR ADV,CPT,0433T,Repos nstim apnea sensing ld,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Humana MCR ADV,CPT,0434T,Interro eval npgs apnea,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,102.65,,,,,,
Humana MCR ADV,CPT,0435T,Prgrmg eval npgs apnea 1 ses,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,102.65,,,,,,
Humana MCR ADV,CPT,0436T,Prgrmg eval npgs apnea study,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,941.27,,,,,,
Humana MCR ADV,CPT,0440T,Abltj perc uxtr/perph nrv,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","1,795.30",,,,,,
Humana MCR ADV,CPT,0441T,Abltj perc lxtr/perph nrv,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","1,795.30",,,,,,
Humana MCR ADV,CPT,0442T,Abltj perc plex/trncl nrv,APC 5432,RVU Per Case,"$5,833.22 ",OP,"5,833.22","5,833.22",,,,,,
Humana MCR ADV,CPT,0446T,Insj impltbl glucose sensor,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","1,755.36",,,,,,
Humana MCR ADV,CPT,0447T,Rmvl impltbl glucose sensor,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
Humana MCR ADV,CPT,0448T,Remvl insj impltbl gluc sens,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","1,755.36",,,,,,
Humana MCR ADV,CPT,0449T,Insj aqueous drain dev 1st,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,009.10",,,,,,
Humana MCR ADV,CPT,0451T,Insj/rplcmt aortic ventr sys,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,0452T,Insj/rplcmt dev vasc seal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,0453T,Insj/rplcmt mech-elec ntrfce,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
Humana MCR ADV,CPT,0454T,Insj/rplcmt subq electrode,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
Humana MCR ADV,CPT,0455T,Remvl aortic ventr cmpl sys,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,0456T,Remvl aortic dev vasc seal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,0457T,Remvl mech-elec skin ntrfce,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Humana MCR ADV,CPT,0458T,Remvl subq electrode,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Humana MCR ADV,CPT,0459T,Relocaj rplcmt aortic ventr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,0460T,Repos aortic ventr dev eltrd,APC 5221,RVU Per Unit,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Humana MCR ADV,CPT,0461T,Repos aortic contrpulsj dev,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,0462T,Prgrmg eval aortic ventr sys,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,278.82,,,,,,
Humana MCR ADV,CPT,0463T,Interrog aortic ventr sys,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,278.82,,,,,,
Humana MCR ADV,CPT,0464T,Visual ep test for glaucoma,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Humana MCR ADV,CPT,0465T,Supchrdl njx rx w/o supply,APC 5694,RVU Per Unit,$318.00 ,OP,318,318,,,,,,
Humana MCR ADV,CPT,0467T,Revj/rplmnt ch respir eltrd,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Humana MCR ADV,CPT,0468T,Rmvl ch wal respir eltrd/ra,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Humana MCR ADV,CPT,0472T,Prgrmg io rta eltrd ra,APC 5743,RVU Per Case,$278.82 ,OP,278.82,278.82,,,,,,
Humana MCR ADV,CPT,0473T,Reprgrmg io rta eltrd ra,APC 5742,RVU Per Case,$102.65 ,OP,102.65,102.65,,,,,,
Humana MCR ADV,CPT,0476T,Rec ftl car sgl elec tr data,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Humana MCR ADV,CPT,0477T,Rec ftl car sgl xrtj alys,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Humana MCR ADV,CPT,0479T,Fxjl abl lsr 1st 100 sq cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,536.39,,,,,,
Humana MCR ADV,CPT,0481T,Njx autol wbc concentrate,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
Humana MCR ADV,CPT,0483T,Tmvi percutaneous approach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,0484T,Tmvi transthoracic exposure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,0485T,Oct mid ear i&r unilateral,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Humana MCR ADV,CPT,0486T,Oct mid ear i&r bilateral,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Humana MCR ADV,CPT,0487T,Trvg biomchn mapg w/reprt,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Humana MCR ADV,CPT,0491T,Abl lsr opn wnd 1st 20 sqcm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,353.91,,,,,,
Humana MCR ADV,CPT,0494T,Prep & cannulj cdvr don lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,0495T,Mntr cdvr don lng 1st 2 hrs,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,0496T,Mntr cdvr don lng ea addl hr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,0497T,Xtrnl pt act ecg in-off conn,APC 5741,RVU Per Case,$38.02 ,OP,38.02,"1,574.64",,,,,,
Humana MCR ADV,CPT,0499T,Cysto f/urtl strix/stenosis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","3,148.08",,,,,,
Humana MCR ADV,CPT,0503T,Cor ffr alys gnrj ffr mdl,APC 1511,RVU Per Unit,$972.67 ,OP,908.19,972.67,,,,,,
Humana MCR ADV,CPT,0505T,Ev fempop artl revsc,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Humana MCR ADV,CPT,0506T,Mac pgmt opt dns meas hfp,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Humana MCR ADV,CPT,0507T,Near ifr 2img mibmn glnd i&r,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Humana MCR ADV,CPT,0508T,Pls echo us b1 dns meas tib,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,111.51,,,,,,
Humana MCR ADV,CPT,0509T,Pattern erg w/i&r,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,386.03,,,,,,
Humana MCR ADV,CPT,0510T,Rmvl sinus tarsi implant,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","2,896.40",,,,,,
Humana MCR ADV,CPT,0511T,Rmvl&rinsj sinus tarsi implt,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
Humana MCR ADV,CPT,0512T,Esw integ wnd hlg 1st wnd,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,183.73,,,,,,
Humana MCR ADV,CPT,0515T,Insj wcs lv compl sys,APC 5231,RVU Per Case,"$23,577.44 ",OP,"23,577.44","23,577.44",,,,,,
Humana MCR ADV,CPT,0516T,Insj wcs lv eltrd only,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
Humana MCR ADV,CPT,0517T,Insj wcs lv pg compnt,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
Humana MCR ADV,CPT,0518T,Rmvl pg compnt wcs,APC 5221,RVU Per Unit,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Humana MCR ADV,CPT,0519T,Rmvl & rplcmt pg compnt wcs,APC 5221,RVU Per Unit,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Humana MCR ADV,CPT,0520T,Rmvl&rplcmt pg wcs new eltrd,APC 5231,RVU Per Case,"$23,577.44 ",OP,"23,577.44","23,577.44",,,,,,
Humana MCR ADV,CPT,0521T,Interrog dev eval wcs ip,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Humana MCR ADV,CPT,0522T,Prgrmg dev eval wcs ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Humana MCR ADV,CPT,0524T,Ev cath dir chem abltj w/img,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","2,928.39",,,,,,
Humana MCR ADV,CPT,0525T,Insj/rplcmt compl iims,APC 5223,RVU Per Case,"$10,642.67 ",OP,"10,642.67","10,642.67",,,,,,
Humana MCR ADV,CPT,0526T,Insj/rplcmt iims eltrd only,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
Humana MCR ADV,CPT,0527T,Insj/rplcmt iims implt mntr,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
Humana MCR ADV,CPT,0528T,Prgrmg dev eval iims ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Humana MCR ADV,CPT,0529T,Interrog dev eval iims ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Humana MCR ADV,CPT,0530T,Removal complete iims,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Humana MCR ADV,CPT,0531T,Removal iims electrode only,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Humana MCR ADV,CPT,0532T,Removal iims implt mntr only,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Humana MCR ADV,CPT,0534T,Cont rec mvmt do setup&train,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Humana MCR ADV,CPT,0535T,Cont rec mvmt do reprt cnfig,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Humana MCR ADV,CPT,0540T,Car-t cll admn autologous,APC 5694,RVU Per Unit,$318.00 ,OP,318,318,,,,,,
Humana MCR ADV,CPT,0541T,Myocardial imaging mcg,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Humana MCR ADV,CPT,0543T,Ta mv rpr w/artif chord tend,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,0544T,Tcat mv annulus rcnstj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,0545T,Tcat tv annulus rcnstj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,0548T,Tprnl balo cntnc dev bi,APC 5377,RVU Per Case,"$11,755.91 ",OP,"11,755.91","11,755.91",,,,,,
Humana MCR ADV,CPT,0549T,Tprnl balo cntnc dev uni,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,516.83","4,516.83",,,,,,
Humana MCR ADV,CPT,0550T,Tprnl balo cntnc dev rmvl ea,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","3,148.08",,,,,,
Humana MCR ADV,CPT,0551T,Tprnl balo cntnc dev adjmt,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,272.35,,,,,,
Humana MCR ADV,CPT,0555T,B1 str&fx rsk transmis data,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,25.25,,,,,,
Humana MCR ADV,CPT,0556T,B1 str & fx rsk assessment,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,235.49,,,,,,
Humana MCR ADV,CPT,0558T,Ct scan f/biomchn ct alys,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,927,,,,,,
Humana MCR ADV,CPT,0559T,Antmc mdl 3d print 1st cmpnt,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Humana MCR ADV,CPT,0561T,Antmc guide 3d print 1st gd,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Humana MCR ADV,CPT,0563T,Evac meibomian glnd heat bi,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Humana MCR ADV,CPT,0564T,Onc chemo rx cytotox csc 14,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Humana MCR ADV,CPT,0565T,Autol cell implt adps hrvg,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Humana MCR ADV,CPT,0566T,Autol cell implt adps njx,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,267.26,,,,,,
Humana MCR ADV,CPT,0569T,Ttvr perq appr 1st prosth,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,0570T,Ttvr perq ea addl prosth,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,0571T,Insj/rplcmt icds ss eltrd,APC 5232,RVU Per Case,"$33,604.66 ",OP,"33,604.66","33,604.66",,,,,,
Humana MCR ADV,CPT,0572T,Insertion ss dfb electrode,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
Humana MCR ADV,CPT,0573T,Removal ss dfb electrode,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Humana MCR ADV,CPT,0574T,Repos prev ss impl dfb eltrd,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Humana MCR ADV,CPT,0575T,Prgrmg dev eval icds ss ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Humana MCR ADV,CPT,0576T,Interrog dev eval icds ss ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Humana MCR ADV,CPT,0577T,Ephys eval icds ss,APC 5211,RVU Per Case,"$1,138.72 ",OP,"1,138.72","2,775.65",,,,,,
Humana MCR ADV,CPT,0579T,Rem interrog dev icds tech,APC 5741,RVU Per Case,$38.02 ,OP,38.02,213.51,,,,,,
Humana MCR ADV,CPT,0580T,Rmvl ss impl dfb pg only,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Humana MCR ADV,CPT,0583T,Tmpst auto tube dlvr sys,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","1,384.33",,,,,,
Humana MCR ADV,CPT,0584T,Perq islet cell transplant,APC 5881,RVU Per Case,"$8,948.83 ",OP,"2,508.76","8,948.83",,,,,,
Humana MCR ADV,CPT,0585T,Laps islet cell transplant,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,254.96","8,948.83",,,,,,
Humana MCR ADV,CPT,0586T,Open islet cell transplant,APC 5881,RVU Per Case,"$8,948.83 ",OP,"6,965.79","8,948.83",,,,,,
Humana MCR ADV,CPT,0587T,Perq impltj/rplcmt isdns ptn,APC 5462,RVU Per Case,"$6,304.35 ",OP,"6,304.35","6,304.35",,,,,,
Humana MCR ADV,CPT,0588T,Revision/removal isdns ptn,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Humana MCR ADV,CPT,0589T,Elec alys smpl prgrmg iins,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,255.45,,,,,,
Humana MCR ADV,CPT,0590T,Elec alys cplx prgrmg iins,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,255.45,,,,,,
Humana MCR ADV,CPT,0594T,Osteot hum xtrnl lngth dev,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
Humana MCR ADV,CPT,0596T,Temp fml iu vlv-pmp 1st insj,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,588.17,,,,,,
Humana MCR ADV,CPT,0597T,Temp fml iu valve-pmp rplcmt,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,588.17,,,,,,
Humana MCR ADV,CPT,0598T,Ncntc r-t fluor wnd img 1st,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Humana MCR ADV,CPT,0600T,Ire abltj 1+tum organ perq,APC 5362,RVU Per Case,"$9,115.38 ",OP,"9,115.38","9,115.38",,,,,,
Humana MCR ADV,CPT,0601T,Ire abltj 1+tumors open,APC 5362,RVU Per Case,"$9,115.38 ",OP,"9,115.38","9,115.38",,,,,,
Humana MCR ADV,CPT,0604T,Rem oct rta dev setup&educaj,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,121.51,,,,,,
Humana MCR ADV,CPT,0605T,Rem oct rta techl sprt min 8,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Humana MCR ADV,CPT,0607T,Rem mntr pulm flu mntr setup,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,121.51,,,,,,
Humana MCR ADV,CPT,0608T,Rem mntr pulm flu mntr alys,APC 5741,RVU Per Unit,$38.02 ,OP,38.02,38.02,,,,,,
Humana MCR ADV,CPT,0609T,Mrs disc pain acquisj data,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Humana MCR ADV,CPT,0611T,Mrs disc pain alg alys data,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,507.00",,,,,,
Humana MCR ADV,CPT,0614T,Rmvl&rplcmt ss impl dfb pg,APC 5231,RVU Per Case,"$23,577.44 ",OP,"23,577.44","23,577.44",,,,,,
Humana MCR ADV,CPT,0615T,Eye mvmt alys w/o calbrj i&r,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Humana MCR ADV,CPT,0616T,Insertion of iris prosthesis,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","2,127.64",,,,,,
Humana MCR ADV,CPT,0617T,Insj iris prosth w/rmvl&insj,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,009.10",,,,,,
Humana MCR ADV,CPT,0618T,Insj iris prosth sec io lens,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,009.10",,,,,,
Humana MCR ADV,CPT,0619T,Cysto w/prst8 commissurotomy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,516.83","4,516.83",,,,,,
Humana MCR ADV,CPT,0620T,Evasc ven artlz tibl/prnl vn,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Humana MCR ADV,CPT,0627T,Perq njx algc fluor lmbr 1st,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
Humana MCR ADV,CPT,0629T,Perq njx algc ct lmbr 1st,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
Humana MCR ADV,CPT,0631T,Tc vis lit hyperspectral img,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Humana MCR ADV,CPT,0632T,Perq tcat us abltj nrv p-art,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Humana MCR ADV,CPT,0633T,Ct breast w/3d uni c-,APC 5522,RVU Per Case,$111.51 ,OP,111.51,111.51,,,,,,
Humana MCR ADV,CPT,0634T,Ct breast w/3d uni c+,APC 5571,RVU Per Case,$182.72 ,OP,182.72,182.72,,,,,,
Humana MCR ADV,CPT,0635T,Ct breast w/3d uni c-/c+,APC 5571,RVU Per Case,$182.72 ,OP,182.72,182.72,,,,,,
Humana MCR ADV,CPT,0636T,Ct breast w/3d bi c-,APC 5523,RVU Per Case,$235.49 ,OP,235.49,235.49,,,,,,
Humana MCR ADV,CPT,0637T,Ct breast w/3d bi c+,APC 5572,RVU Per Case,$376.70 ,OP,376.7,376.7,,,,,,
Humana MCR ADV,CPT,0638T,Ct breast w/3d bi c-/c+,APC 5572,RVU Per Case,$376.70 ,OP,376.7,376.7,,,,,,
Humana MCR ADV,CPT,0641T,Ncntc nr ifr spctrsc wnd img,APC 5732,RVU Per Unit,$34.63 ,OP,34.63,34.63,,,,,,
Humana MCR ADV,CPT,0644T,Tcat rmvl/dblk icar mas perq,APC 5192,RVU Per Case,"$5,072.43 ",OP,"5,072.43","5,072.43",,,,,,
Humana MCR ADV,CPT,0647T,Insj gtube perq mag gastrpxy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","1,662.91",,,,,,
Humana MCR ADV,CPT,0648T,Quan mr alys tiss w/o mri,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,235.49,,,,,,
Humana MCR ADV,CPT,0650T,Prgrmg dev eval scrms remote,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Humana MCR ADV,CPT,0651T,Mag ctrld capsule endoscopy,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,828.48,,,,,,
Humana MCR ADV,CPT,0652T,Egd flx transnasal dx br/wa,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,828.48,,,,,,
Humana MCR ADV,CPT,0653T,Egd flx transnasal bx 1/ml,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,828.48,,,,,,
Humana MCR ADV,CPT,0654T,Egd flx transnasal tube/cath,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","1,662.91",,,,,,
Humana MCR ADV,CPT,0655T,Tprnl focal abltj mal prst8,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","3,148.08",,,,,,
Humana MCR ADV,CPT,0656T,Vrt bdy tethering ant,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,0657T,Vrt bdy tethering ant 8+ seg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,0658T,Elec impd spectrsc 1+skn les,APC 5733,RVU Per Unit,$56.95 ,OP,56.95,56.95,,,,,,
Humana MCR ADV,CPT,0659T,Tcat intra-c nfs supersat o2,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,0662T,Scalp cool 1st meas&calbrj,APC 5732,RVU Per Unit,$34.63 ,OP,34.63,34.63,,,,,,
Humana MCR ADV,CPT,A0425,Ground mileage,Ambulance,Per Unit,$7.47 ,OP,7.47,7.47,,,,,,
Humana MCR ADV,CPT,A0426,Als 1,Ambulance,Per Case,$231.98 ,OP,231.98,"2,249.49",,,,,,
Humana MCR ADV,CPT,A0427,Als1-emergency,Ambulance,Per Case,$231.98 ,OP,231.98,"2,287.62",,,,,,
Humana MCR ADV,CPT,A0428,Bls,Ambulance,Per Case,$231.98 ,OP,231.98,231.98,,,,,,
Humana MCR ADV,CPT,A0429,Bls-emergency,Ambulance,Per Case,$231.98 ,OP,231.98,"1,883.47",,,,,,
Humana MCR ADV,CPT,A0430,Fixed wing air transport,Ambulance,Per Case,"$3,147.91 ",OP,"3,147.91","3,147.91",,,,,,
Humana MCR ADV,CPT,A0431,Rotary wing air transport,Ambulance,Per Case,"$3,659.92 ",OP,"3,659.92","3,659.92",,,,,,
Humana MCR ADV,CPT,A0432,Pi volunteer ambulance co,Ambulance,Per Case,$231.98 ,OP,231.98,231.98,,,,,,
Humana MCR ADV,CPT,A0433,Als 2,Ambulance,Per Case,$231.98 ,OP,231.98,"2,859.52",,,,,,
Humana MCR ADV,CPT,A0434,Specialty care transport,Ambulance,Per Case,$231.98 ,OP,231.98,"6,100.31",,,,,,
Humana MCR ADV,CPT,A0435,Fixed wing air mileage,Ambulance,Per Unit,$8.93 ,OP,8.93,8.93,,,,,,
Humana MCR ADV,CPT,A0436,Rotary wing air mileage,Ambulance,Per Unit,$23.83 ,OP,23.83,23.83,,,,,,
Humana MCR ADV,CPT,A4563,Vag inser rectal control sys,Durable Medical Equipment,Per Unit,"$1,372.71 ",OP,"1,372.71","1,372.71",,,,,,
Humana MCR ADV,CPT,A9513,Lutetium lu 177 dotatat ther,APC 9067,Per Unit,$274.33 ,OP,274.33,274.33,,,,,,
Humana MCR ADV,CPT,A9517,I131 iodide cap- rx,APC 1064,Per Unit,$20.12 ,OP,20.12,32.18,,,,,,
Humana MCR ADV,CPT,A9527,Iodine i-125 sodium iodide,APC 2632,Per Unit,$30.66 ,OP,30.66,30.66,,,,,,
Humana MCR ADV,CPT,A9530,I131 iodide sol- rx,APC 1150,Per Unit,$13.34 ,OP,13.34,13.34,,,,,,
Humana MCR ADV,CPT,A9543,Y90 ibritumomab- rx,APC 1643,Per Unit,"$59,793.85 ",OP,"59,793.85","59,793.85",,,,,,
Humana MCR ADV,CPT,A9563,P32 na phosphate,APC 1675,Per Unit,$458.34 ,OP,458.34,458.34,,,,,,
Humana MCR ADV,CPT,A9590,Iodine i-131 iobenguane 1mci,APC 9339,Per Unit,$320.12 ,OP,320.12,320.12,,,,,,
Humana MCR ADV,CPT,A9591,Fluoroestradiol f 18,APC 9370,Per Unit,$644.83 ,OP,644.83,644.83,,,,,,
Humana MCR ADV,CPT,A9592,Copper cu 64 dotatate diag,APC 9383,Per Unit,$918.21 ,OP,918.21,918.21,,,,,,
Humana MCR ADV,CPT,A9593,Gallium ga-68 psma-11 ucsf,APC 9409,Per Unit,$732.86 ,OP,732.86,732.86,,,,,,
Humana MCR ADV,CPT,A9594,Gallium ga-68 psma-11- ucla,APC 9410,Per Unit,$717.55 ,OP,717.55,717.55,,,,,,
Humana MCR ADV,CPT,A9600,Sr89 strontium,APC 0701,Per Unit,"$3,975.00 ",OP,"3,975.00","4,407.46",,,,,,
Humana MCR ADV,CPT,A9604,Sm 153 lexidronam,APC 1295,Per Unit,"$17,259.85 ",OP,"17,259.85","17,259.85",,,,,,
Humana MCR ADV,CPT,A9606,Radium ra223 dichloride ther,APC 1745,Per Unit,$145.65 ,OP,145.65,145.65,,,,,,
Humana MCR ADV,CPT,C1052,Hemostatic agent- gi- topic,APC 2031,Straight Discount,29.70%,OP,,,,,,,,
Humana MCR ADV,CPT,C1062,Intravertebral fx aug impl,APC 2032,Straight Discount,29.70%,OP,,,,,,,,
Humana MCR ADV,CPT,C1716,Brachytx- non-str- gold-198,APC 2645,Per Unit,$330.76 ,OP,330.76,330.76,,,,,,
Humana MCR ADV,CPT,C1717,Brachytx- non-str-hdr ir-192,APC 2646,Per Unit,$383.90 ,OP,383.9,383.9,,,,,,
Humana MCR ADV,CPT,C1719,Brachytx- ns- non-hdrir-192,APC 2647,Per Unit,$323.97 ,OP,323.97,323.97,,,,,,
Humana MCR ADV,CPT,C1734,Orth/devic/drug bn/bn-tis/bn,APC 2026,Straight Discount,29.70%,OP,,,,,,,,
Humana MCR ADV,CPT,C1748,Endoscope- single- ugi,APC 2029,Straight Discount,29.70%,OP,,,,,,,,
Humana MCR ADV,CPT,C1761,Cath- trans intra litho/coro,APC 2033,Straight Discount,29.70%,OP,,,,,,,,
Humana MCR ADV,CPT,C1823,Gen- neuro- trans sen/stim,APC 2993,Straight Discount,29.70%,OP,,,,,,,,
Humana MCR ADV,CPT,C1824,Generator- ccm- implant,APC 2024,Straight Discount,29.70%,OP,,,,,,,,
Humana MCR ADV,CPT,C1825,Gen- neuro- carot sinus baro,APC 2030,Straight Discount,29.70%,OP,,,,,,,,
Humana MCR ADV,CPT,C1831,Personalized interbody cage,APC 2034,Straight Discount,29.70%,OP,,,,,,,,
Humana MCR ADV,CPT,C1839,Iris prosthesis,APC 2028,Straight Discount,29.70%,OP,,,,,,,,
Humana MCR ADV,CPT,C1982,Cath- pressure-valve-occlu,APC 2025,Straight Discount,29.70%,OP,,,,,,,,
Humana MCR ADV,CPT,C2596,Probe- robotic- water-jet,APC 2027,Straight Discount,29.70%,OP,,,,,,,,
Humana MCR ADV,CPT,C2616,Brachytx- non-str-yttrium-90,APC 2616,Per Unit,"$19,955.81 ",OP,"19,955.81","19,955.81",,,,,,
Humana MCR ADV,CPT,C2634,Brachytx- non-str- ha- i-125,APC 2634,Per Unit,$169.87 ,OP,169.87,169.87,,,,,,
Humana MCR ADV,CPT,C2635,Brachytx- non-str- ha- p-103,APC 2635,Per Unit,$52.25 ,OP,52.25,52.25,,,,,,
Humana MCR ADV,CPT,C2636,Brachy linear- non-str-p-103,APC 2636,Per Unit,$36.02 ,OP,36.02,36.02,,,,,,
Humana MCR ADV,CPT,C2638,Brachytx- stranded- i-125,APC 2638,Per Unit,$42.90 ,OP,42.9,42.9,,,,,,
Humana MCR ADV,CPT,C2639,Brachytx- non-stranded-i-125,APC 2639,Per Unit,$39.11 ,OP,39.11,39.11,,,,,,
Humana MCR ADV,CPT,C2640,Brachytx- stranded- p-103,APC 2640,Per Unit,$100.65 ,OP,100.65,100.65,,,,,,
Humana MCR ADV,CPT,C2641,Brachytx- non-stranded-p-103,APC 2641,Per Unit,$79.72 ,OP,79.72,79.72,,,,,,
Humana MCR ADV,CPT,C2642,Brachytx- stranded- c-131,APC 2642,Per Unit,$82.43 ,OP,82.43,82.43,,,,,,
Humana MCR ADV,CPT,C2643,Brachytx- non-stranded-c-131,APC 2643,Per Unit,$92.16 ,OP,92.16,92.16,,,,,,
Humana MCR ADV,CPT,C2645,Brachytx planar- p-103,APC 2648,Per Unit,$5.38 ,OP,5.38,5.38,,,,,,
Humana MCR ADV,CPT,C2698,Brachytx- stranded- nos,APC 2698,Per Unit,$42.90 ,OP,42.9,42.9,,,,,,
Humana MCR ADV,CPT,C2699,Brachytx- non-stranded- nos,APC 2699,Per Unit,$36.02 ,OP,36.02,36.02,,,,,,
Humana MCR ADV,CPT,C5271,Low cost skin substitute app,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,536.39,,,,,,
Humana MCR ADV,CPT,C5273,Low cost skin substitute app,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","1,755.36",,,,,,
Humana MCR ADV,CPT,C5275,Low cost skin substitute app,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,536.39,,,,,,
Humana MCR ADV,CPT,C5277,Low cost skin substitute app,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,536.39,,,,,,
Humana MCR ADV,CPT,C8900,Mra w/cont- abd,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Humana MCR ADV,CPT,C8901,Mra w/o cont- abd,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Humana MCR ADV,CPT,C8902,Mra w/o fol w/cont- abd,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Humana MCR ADV,CPT,C8903,Mri w/cont- breast-  uni,APC 5571,RVU Per Case,$182.72 ,OP,182.72,"1,507.00",,,,,,
Humana MCR ADV,CPT,C8905,Mri w/o fol w/cont- brst- un,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Humana MCR ADV,CPT,C8906,Mri w/cont- breast-  bi,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Humana MCR ADV,CPT,C8908,Mri w/o fol w/cont- breast-,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Humana MCR ADV,CPT,C8909,Mra w/cont- chest,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Humana MCR ADV,CPT,C8910,Mra w/o cont- chest,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Humana MCR ADV,CPT,C8911,Mra w/o fol w/cont- chest,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Humana MCR ADV,CPT,C8912,Mra w/cont- lwr ext,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Humana MCR ADV,CPT,C8913,Mra w/o cont- lwr ext,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Humana MCR ADV,CPT,C8914,Mra w/o fol w/cont- lwr ext,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Humana MCR ADV,CPT,C8918,Mra w/cont- pelvis,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Humana MCR ADV,CPT,C8919,Mra w/o cont- pelvis,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Humana MCR ADV,CPT,C8920,Mra w/o fol w/cont- pelvis,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Humana MCR ADV,CPT,C8921,Tte w or w/o fol w/cont- com,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
Humana MCR ADV,CPT,C8922,Tte w or w/o fol w/cont- f/u,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
Humana MCR ADV,CPT,C8923,2d tte w or w/o fol w/con-co,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
Humana MCR ADV,CPT,C8924,2d tte w or w/o fol w/con-fu,APC 5572,RVU Per Unit,$376.70 ,OP,376.7,376.7,,,,,,
Humana MCR ADV,CPT,C8925,2d tee w or w/o fol w/con-in,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
Humana MCR ADV,CPT,C8926,Tee w or w/o fol w/cont-cong,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
Humana MCR ADV,CPT,C8927,Tee w or w/o fol w/cont- mon,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
Humana MCR ADV,CPT,C8928,Tte w or w/o fol w/con-stres,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
Humana MCR ADV,CPT,C8929,Tte w or wo fol wcon-doppler,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
Humana MCR ADV,CPT,C8930,Tte w or w/o contr- cont ecg,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
Humana MCR ADV,CPT,C8931,Mra- w/dye- spinal canal,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Humana MCR ADV,CPT,C8932,Mra- w/o dye- spinal canal,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Humana MCR ADV,CPT,C8933,Mra- w/o&w/dye- spinal canal,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Humana MCR ADV,CPT,C8934,Mra- w/dye- upper extremity,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Humana MCR ADV,CPT,C8935,Mra- w/o dye- upper extr,APC 5523,RVU Per Case,$235.49 ,OP,235.49,235.49,,,,,,
Humana MCR ADV,CPT,C8936,Mra- w/o&w/dye- upper extr,APC 5572,RVU Per Case,$376.70 ,OP,376.7,376.7,,,,,,
Humana MCR ADV,CPT,C8957,Prolonged iv inf- req pump,APC 5694,RVU Per Unit,$318.00 ,OP,318,318,,,,,,
Humana MCR ADV,CPT,C9046,Cocaine hcl nasal solution,APC 9307,Per Unit,$1.33 ,OP,1.33,1.33,,,,,,
Humana MCR ADV,CPT,C9047,Injection- caplacizumab-yhdp,APC 9199,Per Unit,$691.29 ,OP,691.29,691.29,,,,,,
Humana MCR ADV,CPT,C9067,Gallium ga-68 dotatoc,APC 9323,Per Unit,$8.64 ,OP,8.64,8.64,,,,,,
Humana MCR ADV,CPT,C9081,Idecabtagene car pos t,APC 9422,Per Unit,"$432,085.00 ",OP,"432,085.00","432,085.00",,,,,,
Humana MCR ADV,CPT,C9082,Inj dostarlimab-gxly- 100 mg,APC 9423,Per Unit,"$2,136.09 ",OP,"2,136.09","2,136.09",,,,,,
Humana MCR ADV,CPT,C9083,Inj- amivantamab-vmjw- 10 mg,APC 9424,Per Unit,$87.89 ,OP,87.89,87.89,,,,,,
Humana MCR ADV,CPT,C9084,loncastuximab-lpyl- 0.1 mg,APC 9425,Per Unit,$242.05 ,OP,242.05,242.05,,,,,,
Humana MCR ADV,CPT,C9248,Inj- clevidipine butyrate,APC 9087,Per Unit,$2.91 ,OP,2.91,2.91,,,,,,
Humana MCR ADV,CPT,C9250,Artiss fibrin sealant,APC 1848,Per Unit,$156.84 ,OP,156.84,156.84,,,,,,
Humana MCR ADV,CPT,C9257,Bevacizumab injection,APC 1281,Per Unit,$1.76 ,OP,1.76,1.76,,,,,,
Humana MCR ADV,CPT,C9460,Injection- cangrelor,APC 9460,Per Unit,$16.32 ,OP,16.32,16.32,,,,,,
Humana MCR ADV,CPT,C9462,Injection- delafloxacin,APC 9462,Per Unit,$0.37 ,OP,0.37,0.37,,,,,,
Humana MCR ADV,CPT,C9482,Sotalol hydrochloride iv,APC 9482,Per Unit,$17.58 ,OP,17.58,17.58,,,,,,
Humana MCR ADV,CPT,C9488,Conivaptan hcl,APC 9488,Per Unit,$43.94 ,OP,43.94,43.94,,,,,,
Humana MCR ADV,CPT,C9600,Perc drug-el cor stent sing,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Humana MCR ADV,CPT,C9602,Perc d-e cor stent ather s,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Humana MCR ADV,CPT,C9604,Perc d-e cor revasc t cabg s,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Humana MCR ADV,CPT,C9606,Perc d-e cor revasc w ami s,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Humana MCR ADV,CPT,C9607,Perc d-e cor revasc chro sin,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Humana MCR ADV,CPT,C9725,Place endorectal app,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,812.16,,,,,,
Humana MCR ADV,CPT,C9727,Insert palate implants,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","1,384.33",,,,,,
Humana MCR ADV,CPT,C9728,Place device/marker- non pro,APC 5613,RVU Per Unit,"$1,291.62 ",OP,"1,291.62","1,291.62",,,,,,
Humana MCR ADV,CPT,C9733,Non-ophthalmic fva,APC 5572,RVU Per Case,$376.70 ,OP,376.7,376.7,,,,,,
Humana MCR ADV,CPT,C9734,U/s trtmt- not leiomyomata,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
Humana MCR ADV,CPT,C9739,Cystoscopy prostatic imp 1-3,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,516.83","4,516.83",,,,,,
Humana MCR ADV,CPT,C9740,Cysto impl 4 or more,APC 5376,RVU Per Case,"$8,450.70 ",OP,"8,450.70","8,450.70",,,,,,
Humana MCR ADV,CPT,C9752,Intraosseous des lumb/sacrum,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
Humana MCR ADV,CPT,C9757,Spine/lumbar disk surgery,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
Humana MCR ADV,CPT,C9761,Cysto- litho- vacuum kidney,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,516.83","4,516.83",,,,,,
Humana MCR ADV,CPT,C9762,Cardiac mri seg dys strain,APC 5524,RVU Per Case,$494.15 ,OP,494.15,494.15,,,,,,
Humana MCR ADV,CPT,C9763,Cardiac mri seg dys stress,APC 5524,RVU Per Case,$494.15 ,OP,494.15,494.15,,,,,,
Humana MCR ADV,CPT,C9764,Revasc intravasc lithotripsy,APC 5192,RVU Per Case,"$5,072.43 ",OP,"5,072.43","5,072.43",,,,,,
Humana MCR ADV,CPT,C9765,Revasc intra lithotrip-stent,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Humana MCR ADV,CPT,C9766,Revasc intra lithotrip-ather,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Humana MCR ADV,CPT,C9767,Revasc lithotrip-stent-ather,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Humana MCR ADV,CPT,C9769,Cysto w/temp pros implant,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,516.83","4,516.83",,,,,,
Humana MCR ADV,CPT,C9771,Nsl/sins cryo post nasal tis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","2,800.20",,,,,,
Humana MCR ADV,CPT,C9772,Revasc lithotrip tibi/perone,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Humana MCR ADV,CPT,C9773,Revasc lithotr-stent tib/per,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Humana MCR ADV,CPT,C9774,Revasc lithotr-ather tib/per,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Humana MCR ADV,CPT,C9775,Revasc lith-sten-ath tib/per,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Humana MCR ADV,CPT,C9778,Colpopexy- min/inv- ex-perit,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","2,684.38",,,,,,
Humana MCR ADV,CPT,C9779,ESD endoscopy or colonoscopy,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","2,500.37",,,,,,
Humana MCR ADV,CPT,C9780,Insert cv cath inf & sup app,APC 1534,RVU Per Unit,"$8,442.89 ",OP,"7,883.19","8,442.89",,,,,,
Humana MCR ADV,CPT,C9803,Hopd covid-19 spec collect,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Humana MCR ADV,CPT,D0150,Comprehensve oral evaluation,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D0240,Intraoral occlusal film,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D0250,Extraoral 2d project image,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D0251,Extraoral posterior image,APC 5521,RVU Per Case,$82.79 ,OP,82.79,82.79,,,,,,
Humana MCR ADV,CPT,D0270,Dental bitewing single image,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D0272,Dental bitewings two images,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D0274,Bitewings four images,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D0277,Vert bitewings 7 to 8 images,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D0460,Pulp vitality test,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D0600,Non-ionizing diag proc,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D1510,Space maintainer fxd unilat,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D1516,Fixed bilat space maint- max,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D1517,Fixed bilat space maint- man,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D1520,Remove unilat space maintain,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D1526,Remove bilat space main- max,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D1527,Remove bilat space main- man,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D1551,Recement space maint - max,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D1552,Recement space maint - man,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D1553,Recement unilat space maint,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D1575,Dist space maint- fixed unil,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D2999,Dental unspec restorative pr,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D3460,Endodontic endosseous implan,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D3999,Endodontic procedure,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D4260,Osseous surgery 4 or more,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D4263,Bone replce graft first site,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D4264,Bone replce graft each add,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D4268,Surgical revision procedure,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D4270,Pedicle soft tissue graft pr,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D4273,Auto tissue graft 1st tooth,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D4355,Full mouth debridement,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D4381,Localized delivery antimicro,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D5911,Facial moulage sectional,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D5912,Facial moulage complete,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D5983,Radiation applicator,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D5984,Radiation shield,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D5985,Radiation cone locator,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D5987,Commissure splint,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D6920,Dental connector bar,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D7111,Extraction coronal remnants,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D7140,Extraction erupted tooth/exr,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D7210,Rem imp tooth w mucoper flp,APC 5871,RVU Per Unit,"$1,426.03 ",OP,953.17,"1,426.03",,,,,,
Humana MCR ADV,CPT,D7220,Impact tooth remov soft tiss,APC 5871,RVU Per Unit,"$1,426.03 ",OP,953.17,"1,426.03",,,,,,
Humana MCR ADV,CPT,D7230,Impact tooth remov part bony,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,391.64","1,426.03",,,,,,
Humana MCR ADV,CPT,D7240,Impact tooth remov comp bony,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,715.71",,,,,,
Humana MCR ADV,CPT,D7241,Impact tooth rem bony w/comp,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","2,001.67",,,,,,
Humana MCR ADV,CPT,D7250,Tooth root removal,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D7260,Oral antral fistula closure,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D7261,Primary closure sinus perf,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D7291,Transseptal fiberotomy,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D7940,Reshaping bone orthognathic,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D9930,Treatment of complications,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D9944,Occ guard- hard- full arch,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D9945,Occ guard- soft- full arch,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D9946,Occ guard- hard- part arch,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D9950,Occlusion analysis,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D9951,Limited occlusal adjustment,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,D9952,Complete occlusal adjustment,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Humana MCR ADV,CPT,G0008,Admin influenza virus vac,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,57.19,,,,,,
Humana MCR ADV,CPT,G0009,Admin pneumococcal vaccine,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,57.19,,,,,,
Humana MCR ADV,CPT,G0010,Admin hepatitis b vaccine,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,57.19,,,,,,
Humana MCR ADV,CPT,G0027,Semen analysis,Lab Services,Per Unit,$6.50 ,OP,6.5,34.31,,,,,,
Humana MCR ADV,CPT,G0101,Ca screen-pelvic/breast exam,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,186.82,,,,,,
Humana MCR ADV,CPT,G0103,Psa screening,Lab Services,Per Unit,$19.31 ,OP,19.31,80.07,,,,,,
Humana MCR ADV,CPT,G0104,Ca screen-flexi sigmoidscope,APC 5311,RVU Per Unit,$812.16 ,OP,678.66,812.16,,,,,,
Humana MCR ADV,CPT,G0105,Colorectal scrn- hi risk ind,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,812.16,,,,,,
Humana MCR ADV,CPT,G0106,Colon ca screen-barium enema,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,"1,090.43",,,,,,
Humana MCR ADV,CPT,G0108,Diab manage trn  per indiv,Physician,Per Unit,$54.47 ,OP,54.47,125.82,,,,,,
Humana MCR ADV,CPT,G0109,Diab manage trn ind/group,Physician,Per Unit,$15.18 ,OP,15.18,72.44,,,,,,
Humana MCR ADV,CPT,G0117,Glaucoma scrn hgh risk direc,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,232.58,,,,,,
Humana MCR ADV,CPT,G0118,Glaucoma scrn hgh risk direc,APC 5732,RVU Per Unit,$34.63 ,OP,34.63,160.13,,,,,,
Humana MCR ADV,CPT,G0120,Colon ca scrn- barium enema,APC 5572,RVU Per Unit,$376.70 ,OP,376.7,"1,090.43",,,,,,
Humana MCR ADV,CPT,G0121,Colon ca scrn not hi rsk ind,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,812.16,,,,,,
Humana MCR ADV,CPT,G0123,Screen cerv/vag thin layer,Lab Services,Per Unit,$20.26 ,OP,20.26,91.51,,,,,,
Humana MCR ADV,CPT,G0127,Trim nail(s),APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Humana MCR ADV,CPT,G0129,Partial hosp prog service,APC 5853,RVU Per Case,$266.56 ,OP,266.56,266.56,,,,,,
Humana MCR ADV,CPT,G0130,Single energy x-ray study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,171.58,,,,,,
Humana MCR ADV,CPT,G0143,Scr c/v cyto-thinlayer-rescr,Lab Services,Per Unit,$27.05 ,OP,27.05,91.51,,,,,,
Humana MCR ADV,CPT,G0144,Scr c/v cyto-thinlayer-rescr,Lab Services,Per Unit,$43.97 ,OP,43.97,95.32,,,,,,
Humana MCR ADV,CPT,G0145,Scr c/v cyto-thinlayer-rescr,Lab Services,Per Unit,$26.49 ,OP,26.49,118.19,,,,,,
Humana MCR ADV,CPT,G0147,Scr c/v cyto- automated sys,Lab Services,Per Unit,$15.15 ,OP,15.15,45.74,,,,,,
Humana MCR ADV,CPT,G0148,Scr c/v cyto- autosys- rescr,Lab Services,Per Unit,$31.94 ,OP,31.94,45.74,,,,,,
Humana MCR ADV,CPT,G0166,Extrnl counterpulse- per tx,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Humana MCR ADV,CPT,G0175,Opps service-sched team conf,APC 5024,RVU Per Unit,$372.22 ,OP,372.22,392.7,,,,,,
Humana MCR ADV,CPT,G0176,Opps/php-activity therapy,APC 5853,RVU Per Case,$266.56 ,OP,266.56,266.56,,,,,,
Humana MCR ADV,CPT,G0186,Dstry eye lesn-fdr vssl tech,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,515.61,,,,,,
Humana MCR ADV,CPT,G0235,Pet not otherwise specified,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"7,236.50",,,,,,
Humana MCR ADV,CPT,G0237,Therapeutic procd strg endur,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,61,,,,,,
Humana MCR ADV,CPT,G0238,Oth resp proc- indiv,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,64.82,,,,,,
Humana MCR ADV,CPT,G0239,Oth resp proc- group,APC 5732,RVU Per Unit,$34.63 ,OP,34.63,64.82,,,,,,
Humana MCR ADV,CPT,G0245,Initial foot exam pt lops,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,339.33,,,,,,
Humana MCR ADV,CPT,G0246,Followup eval of foot pt lop,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,198.25,,,,,,
Humana MCR ADV,CPT,G0247,Routine footcare pt w lops,APC 5051,RVU Per Case,$183.73 ,OP,183.73,232.58,,,,,,
Humana MCR ADV,CPT,G0248,Demonstrate use home inr mon,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,804.48,,,,,,
Humana MCR ADV,CPT,G0249,Provide inr test mater/equip,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,686.28,,,,,,
Humana MCR ADV,CPT,G0257,Unsched dialysis esrd pt hos,APC 5401,RVU Per Unit,$669.60 ,OP,669.6,669.6,,,,,,
Humana MCR ADV,CPT,G0260,Inj for sacroiliac jt anesth,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,649.39,,,,,,
Humana MCR ADV,CPT,G0270,Mnt subs tx for change dx,Physician,Per Unit,$26.49 ,OP,26.49,122,,,,,,
Humana MCR ADV,CPT,G0271,Group mnt 2 or more 30 mins,Physician,Per Unit,$13.98 ,OP,13.98,68.63,,,,,,
Humana MCR ADV,CPT,G0276,Pild/placebo control clin tr,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
Humana MCR ADV,CPT,G0277,Hbot- full body chamber- 30m,APC 5061,RVU Per Unit,$122.06 ,OP,122.06,122.06,,,,,,
Humana MCR ADV,CPT,G0279,Tomosynthesis- mammo,Physician,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Humana MCR ADV,CPT,G0281,Elec stim unattend for press,Physician,Per Unit,$12.74 ,OP,12.74,61,,,,,,
Humana MCR ADV,CPT,G0283,Elec stim other than wound,Physician,Per Unit,$12.74 ,OP,12.74,61,,,,,,
Humana MCR ADV,CPT,G0293,Non-cov surg proc-clin trial,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Humana MCR ADV,CPT,G0294,Non-cov proc- clinical trial,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Humana MCR ADV,CPT,G0296,Visit to determ ldct elig,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Humana MCR ADV,CPT,G0302,Pre-op service lvrs complete,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Humana MCR ADV,CPT,G0303,Pre-op service lvrs 10-15dos,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Humana MCR ADV,CPT,G0304,Pre-op service lvrs 1-9 dos,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Humana MCR ADV,CPT,G0305,Post op service lvrs min 6,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Humana MCR ADV,CPT,G0306,Cbc/diffwbc w/o platelet,Lab Services,Per Unit,$7.77 ,OP,7.77,34.31,,,,,,
Humana MCR ADV,CPT,G0307,Cbc without platelet,Lab Services,Per Unit,$6.47 ,OP,6.47,30.51,,,,,,
Humana MCR ADV,CPT,G0328,Fecal blood scrn immunoassay,Lab Services,Per Unit,$18.05 ,OP,18.05,72.44,,,,,,
Humana MCR ADV,CPT,G0329,Electromagntic tx for ulcers,Physician,Per Unit,$10.46 ,OP,10.46,45.74,,,,,,
Humana MCR ADV,CPT,G0341,Percutaneous islet celltrans,APC 5881,RVU Per Case,"$8,948.83 ",OP,"2,508.76","8,948.83",,,,,,
Humana MCR ADV,CPT,G0342,Laparoscopy islet cell trans,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,254.96","8,948.83",,,,,,
Humana MCR ADV,CPT,G0343,Laparotomy islet cell transp,APC 5881,RVU Per Case,"$8,948.83 ",OP,"6,965.79","8,948.83",,,,,,
Humana MCR ADV,CPT,G0379,Direct refer hospital observ,APC 5025,RVU Per Case,$534.29 ,OP,534.29,534.29,,,,,,
Humana MCR ADV,CPT,G0380,Lev 1 hosp type b ed visit,APC 5031,RVU Per Case,$72.19 ,OP,72.19,72.19,,,,,,
Humana MCR ADV,CPT,G0381,Lev 2 hosp type b ed visit,APC 5032,RVU Per Case,$97.63 ,OP,97.63,97.63,,,,,,
Humana MCR ADV,CPT,G0382,Lev 3 hosp type b ed visit,APC 5033,RVU Per Case,$185.19 ,OP,185.19,185.19,,,,,,
Humana MCR ADV,CPT,G0383,Lev 4 hosp type b ed visit,APC 5034,RVU Per Case,$233.92 ,OP,233.92,233.92,,,,,,
Humana MCR ADV,CPT,G0384,Lev 5 hosp type b ed visit,APC 5035,RVU Per Case,$325.81 ,OP,325.81,325.81,,,,,,
Humana MCR ADV,CPT,G0390,Trauma respons w/hosp criti,APC 5045,RVU Per Unit,$964.64 ,OP,964.64,964.64,,,,,,
Humana MCR ADV,CPT,G0396,Alcohol/subs interv 15-30mn,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,163.95,,,,,,
Humana MCR ADV,CPT,G0397,Alcohol/subs interv >30 min,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,136.74,,,,,,
Humana MCR ADV,CPT,G0398,Home sleep test/type 2 porta,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,367.82,,,,,,
Humana MCR ADV,CPT,G0399,Home sleep test/type 3 porta,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Humana MCR ADV,CPT,G0400,Home sleep test/type 4 porta,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,367.82,,,,,,
Humana MCR ADV,CPT,G0402,Initial preventive exam,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,491.83,,,,,,
Humana MCR ADV,CPT,G0404,Ekg tracing for initial prev,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,25.25,,,,,,
Humana MCR ADV,CPT,G0410,Grp psych partial hosp 45-50,APC 5853,RVU Per Case,$266.56 ,OP,266.56,266.56,,,,,,
Humana MCR ADV,CPT,G0411,Inter active grp psych parti,APC 5853,RVU Per Case,$266.56 ,OP,266.56,266.56,,,,,,
Humana MCR ADV,CPT,G0412,Open tx iliac spine uni/bil,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,510.41","6,411.04",,,,,,
Humana MCR ADV,CPT,G0413,Pelvic ring fracture uni/bil,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,527.33",,,,,,
Humana MCR ADV,CPT,G0414,Pelvic ring fx treat int fix,APC 5115,RVU Per Case,"$12,601.93 ",OP,"6,161.31","12,601.93",,,,,,
Humana MCR ADV,CPT,G0415,Open tx post pelvic fxcture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"8,452.74","12,601.93",,,,,,
Humana MCR ADV,CPT,G0416,Prostate biopsy- any mthd,APC 5673,RVU Per Case,$298.05 ,OP,298.05,"3,297.99",,,,,,
Humana MCR ADV,CPT,G0420,Ed svc ckd ind per session,Physician,Per Unit,$111.79 ,OP,111.79,111.79,,,,,,
Humana MCR ADV,CPT,G0421,Ed svc ckd grp per session,Physician,Per Unit,$26.73 ,OP,26.73,26.73,,,,,,
Humana MCR ADV,CPT,G0422,Intens cardiac rehab w/exerc,APC 5771,RVU Per Unit,$118.77 ,OP,118.77,118.77,,,,,,
Humana MCR ADV,CPT,G0423,Intens cardiac rehab no exer,APC 5771,RVU Per Unit,$118.77 ,OP,118.77,118.77,,,,,,
Humana MCR ADV,CPT,G0424,Pulmonary rehab w exer,APC 5733,RVU Per Unit,$56.95 ,OP,56.95,56.95,,,,,,
Humana MCR ADV,CPT,G0429,Dermal filler injection(s),APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","1,755.36",,,,,,
Humana MCR ADV,CPT,G0432,Eia hiv-1/hiv-2 screen,Lab Services,Per Unit,$19.57 ,OP,19.57,19.57,,,,,,
Humana MCR ADV,CPT,G0433,Elisa hiv-1/hiv-2 screen,Lab Services,Per Unit,$18.29 ,OP,18.29,18.29,,,,,,
Humana MCR ADV,CPT,G0435,Oral hiv-1/hiv-2 screen,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,
Humana MCR ADV,CPT,G0438,Ppps- initial visit,Physician,Per Unit,$163.74 ,OP,163.74,163.74,,,,,,
Humana MCR ADV,CPT,G0439,Ppps- subseq visit,Physician,Per Unit,$129.00 ,OP,129,129,,,,,,
Humana MCR ADV,CPT,G0442,Annual alcohol screen 15 min,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Humana MCR ADV,CPT,G0443,Brief alcohol misuse counsel,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Humana MCR ADV,CPT,G0444,Depression screen annual,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Humana MCR ADV,CPT,G0445,High inten beh couns std 30m,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Humana MCR ADV,CPT,G0446,Intens behave ther cardio dx,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Humana MCR ADV,CPT,G0447,Behavior counsel obesity 15m,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Humana MCR ADV,CPT,G0451,Devlopment test interpt&rep,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Humana MCR ADV,CPT,G0455,Fecal microbiota prep instil,APC 5301,RVU Per Case,$828.48 ,OP,828.48,828.48,,,,,,
Humana MCR ADV,CPT,G0460,Autologous prp for ulcers,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","1,755.36",,,,,,
Humana MCR ADV,CPT,G0463,Hospital outpt clinic visit,APC 5012,RVU Per Case,$121.51 ,OP,95.32,121.51,,,,,,
Humana MCR ADV,CPT,G0471,Ven blood coll snf/hha,Lab Services,Per Unit,$5.00 ,OP,5,5,,,,,,
Humana MCR ADV,CPT,G0472,Hep c screen high risk/other,Lab Services,Per Unit,$46.35 ,OP,46.35,46.35,,,,,,
Humana MCR ADV,CPT,G0473,Group behave couns 2-10,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Humana MCR ADV,CPT,G0475,Hiv combination assay,Lab Services,Per Unit,$24.08 ,OP,24.08,24.08,,,,,,
Humana MCR ADV,CPT,G0476,Hpv combo assay ca screen,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,
Humana MCR ADV,CPT,G0480,Drug test def 1-7 classes,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
Humana MCR ADV,CPT,G0481,Drug test def 8-14 classes,Lab Services,Per Unit,$156.59 ,OP,156.59,156.59,,,,,,
Humana MCR ADV,CPT,G0482,Drug test def 15-21 classes,Lab Services,Per Unit,$198.74 ,OP,198.74,198.74,,,,,,
Humana MCR ADV,CPT,G0483,Drug test def 22+ classes,Lab Services,Per Unit,$246.92 ,OP,246.92,246.92,,,,,,
Humana MCR ADV,CPT,G0498,Chemo extend iv infus w/pump,APC 5694,RVU Per Unit,$318.00 ,OP,318,318,,,,,,
Humana MCR ADV,CPT,G0499,Hepb screen high risk indiv,Lab Services,Per Unit,$28.27 ,OP,28.27,28.27,,,,,,
Humana MCR ADV,CPT,G0516,Insert drug del implant- >=4,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
Humana MCR ADV,CPT,G0517,Remove drug implant,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
Humana MCR ADV,CPT,G0518,Remove w insert drug implant,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
Humana MCR ADV,CPT,G0659,Drug test def simple all cl,Lab Services,Per Unit,$62.14 ,OP,62.14,62.14,,,,,,
Humana MCR ADV,CPT,G2000,Blinded conv. tx mdd clin tr,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Humana MCR ADV,CPT,G2011,Alcohol/sub misuse assess,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,25.25,,,,,,
Humana MCR ADV,CPT,G2065,Clin mang h risk dx 30,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Humana MCR ADV,CPT,G2066,Inter devc remote 30d,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Humana MCR ADV,CPT,G2082,Visit esketamine 56m or less,APC 1508,RVU Per Unit,$665.67 ,OP,621.54,665.67,,,,,,
Humana MCR ADV,CPT,G2083,Visit esketamine- > 56m,APC 1511,RVU Per Unit,$972.67 ,OP,972.67,972.67,,,,,,
Humana MCR ADV,CPT,G2086,Off base opioid tx 70min,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,136.74,,,,,,
Humana MCR ADV,CPT,G2087,Off base opioid tx- 60 m,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,136.74,,,,,,
Humana MCR ADV,CPT,G2170,Avf by tissue w thermal e,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Humana MCR ADV,CPT,G2171,Avf use magnetic/art/ven,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Humana MCR ADV,CPT,G2214,Init/sub psych care m 1st 30,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Humana MCR ADV,CPT,G2250,Remot img sub by pt- non e/m,Physician,Per Unit,$9.24 ,OP,9.24,9.24,,,,,,
Humana MCR ADV,CPT,G2251,Brief chkin- 5-10- non-e/m,Physician,Per Unit,$13.05 ,OP,13.05,13.05,,,,,,
Humana MCR ADV,CPT,G2252,Brief chkin by md/qhp- 11-20,Physician,Per Unit,$25.14 ,OP,25.14,25.14,,,,,,
Humana MCR ADV,CPT,J0121,Inj.- omadacycline- 1 mg,APC 9311,Per Unit,$3.30 ,OP,3.3,3.3,,,,,,
Humana MCR ADV,CPT,J0129,Abatacept injection,APC 9230,Per Unit,$45.27 ,OP,45.27,73.44,,,,,,
Humana MCR ADV,CPT,J0135,Adalimumab injection,APC 1083,Per Unit,"$1,581.57 ",OP,"1,581.57","1,581.57",,,,,,
Humana MCR ADV,CPT,J0178,Aflibercept injection,APC 1420,Per Unit,$917.94 ,OP,917.94,917.94,,,,,,
Humana MCR ADV,CPT,J0179,Inj- brolucizumab-dbll- 1 mg,APC 9340,Per Unit,$312.01 ,OP,312.01,312.01,,,,,,
Humana MCR ADV,CPT,J0180,Agalsidase beta injection,APC 9208,Per Unit,$198.14 ,OP,198.14,508.92,,,,,,
Humana MCR ADV,CPT,J0185,Inj.- aprepitant- 1 mg,APC 9463,Per Unit,$1.69 ,OP,1.69,1.69,,,,,,
Humana MCR ADV,CPT,J0202,Injection- alemtuzumab,APC 1809,Per Unit,"$2,086.32 ",OP,277.19,"2,086.32",,,,,,
Humana MCR ADV,CPT,J0207,Amifostine,APC 7000,Per Unit,"$1,135.69 ",OP,"1,135.69","1,985.16",,,,,,
Humana MCR ADV,CPT,J0220,Alglucosidase alfa injection,APC 9234,Per Unit,$117.07 ,OP,117.07,474.68,,,,,,
Humana MCR ADV,CPT,J0221,Lumizyme injection,APC 1413,Per Unit,$180.35 ,OP,180.35,180.35,,,,,,
Humana MCR ADV,CPT,J0222,Inj.- patisiran- 0.1 mg,APC 9180,Per Unit,$97.75 ,OP,97.75,97.75,,,,,,
Humana MCR ADV,CPT,J0223,Inj givosiran 0.5 mg,APC 9343,Per Unit,$106.76 ,OP,106.76,106.76,,,,,,
Humana MCR ADV,CPT,J0224,Inj. lumasiran- 0.5 mg,APC 9407,Per Unit,$302.30 ,OP,302.3,302.3,,,,,,
Humana MCR ADV,CPT,J0256,Alpha 1 proteinase inhibitor,APC 0901,Per Unit,$4.54 ,OP,4.54,7.9,,,,,,
Humana MCR ADV,CPT,J0257,Glassia injection,APC 1415,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,
Humana MCR ADV,CPT,J0287,Amphotericin b lipid complex,APC 9024,Per Unit,$9.50 ,OP,9.5,49.56,,,,,,
Humana MCR ADV,CPT,J0289,Amphotericin b liposome inj,APC 0736,Per Unit,$28.75 ,OP,28.75,118.19,,,,,,
Humana MCR ADV,CPT,J0291,Inj.- plazomicin- 5 mg,APC 9183,Per Unit,$3.05 ,OP,3.05,3.05,,,,,,
Humana MCR ADV,CPT,J0300,Amobarbital 125 mg inj,APC 1341,Per Unit,$125.22 ,OP,30.51,125.22,,,,,,
Humana MCR ADV,CPT,J0390,Chloroquine injection,APC 9352,Per Unit,$165.22 ,OP,83.87,165.22,,,,,,
Humana MCR ADV,CPT,J0401,Inj aripiprazole ext rel 1mg,APC 1468,Per Unit,$6.01 ,OP,6.01,7.62,,,,,,
Humana MCR ADV,CPT,J0475,Baclofen 10 mg injection,APC 9032,Per Unit,$177.43 ,OP,177.43,826.29,,,,,,
Humana MCR ADV,CPT,J0480,Basiliximab,APC 1683,Per Unit,"$4,013.08 ",OP,"4,013.08","7,724.52",,,,,,
Humana MCR ADV,CPT,J0485,Belatacept injection,APC 9286,Per Unit,$3.80 ,OP,3.8,3.8,,,,,,
Humana MCR ADV,CPT,J0490,Belimumab injection,APC 1353,Per Unit,$47.57 ,OP,47.57,47.57,,,,,,
Humana MCR ADV,CPT,J0517,Inj.- benralizumab- 1 mg,APC 9466,Per Unit,$170.80 ,OP,170.8,170.8,,,,,,
Humana MCR ADV,CPT,J0558,Peng benzathine/procaine inj,APC 9088,Per Unit,$11.79 ,OP,11.79,11.79,,,,,,
Humana MCR ADV,CPT,J0561,Penicillin g benzathine inj,APC 1829,Per Unit,$14.95 ,OP,14.95,14.95,,,,,,
Humana MCR ADV,CPT,J0565,Inj- bezlotoxumab- 10 mg,APC 9490,Per Unit,$39.77 ,OP,39.77,39.77,,,,,,
Humana MCR ADV,CPT,J0570,Buprenorphine implant 74.2mg,APC 9058,Per Unit,"$1,311.75 ",OP,209.7,"1,311.75",,,,,,
Humana MCR ADV,CPT,J0584,Injection- burosumab-twza 1m,APC 9187,Per Unit,$369.11 ,OP,369.11,369.11,,,,,,
Humana MCR ADV,CPT,J0585,Injection-onabotulinumtoxina,APC 0902,Per Unit,$6.09 ,OP,6.09,6.09,,,,,,
Humana MCR ADV,CPT,J0586,Abobotulinumtoxina,APC 1289,Per Unit,$8.41 ,OP,8.41,8.41,,,,,,
Humana MCR ADV,CPT,J0587,Inj- rimabotulinumtoxinb,APC 9018,Per Unit,$12.05 ,OP,12.05,39.5,,,,,,
Humana MCR ADV,CPT,J0588,Incobotulinumtoxin a,APC 9278,Per Unit,$5.05 ,OP,5.05,5.05,,,,,,
Humana MCR ADV,CPT,J0594,Busulfan injection,APC 1178,Per Unit,$1.71 ,OP,1.71,61,,,,,,
Humana MCR ADV,CPT,J0596,Injection- ruconest,APC 9445,Per Unit,$29.97 ,OP,29.97,29.97,,,,,,
Humana MCR ADV,CPT,J0597,C-1 esterase- berinert,APC 9269,Per Unit,$57.39 ,OP,57.39,57.39,,,,,,
Humana MCR ADV,CPT,J0598,C-1 esterase- cinryze,APC 9251,Per Unit,$58.93 ,OP,58.93,58.93,,,,,,
Humana MCR ADV,CPT,J0599,Inj.- haegarda 10 units,APC 9015,Per Unit,$10.25 ,OP,10.25,10.25,,,,,,
Humana MCR ADV,CPT,J0600,Edetate calcium disodium inj,APC 1274,Per Unit,"$5,708.59 ",OP,362.21,"5,708.59",,,,,,
Humana MCR ADV,CPT,J0630,Calcitonin salmon injection,APC 1433,Per Unit,"$3,100.79 ",OP,191.13,"3,100.79",,,,,,
Humana MCR ADV,CPT,J0638,Canakinumab injection,APC 1311,Per Unit,$115.61 ,OP,115.61,115.61,,,,,,
Humana MCR ADV,CPT,J0641,Inj levoleucovorin nos 0.5mg,APC 1236,Per Unit,$0.09 ,OP,0.09,0.09,,,,,,
Humana MCR ADV,CPT,J0642,Injection- khapzory- 0.5 mg,APC 9334,Per Unit,$1.86 ,OP,1.86,1.86,,,,,,
Humana MCR ADV,CPT,J0691,Inj lefamulin 1 mg,APC 9332,Per Unit,$0.72 ,OP,0.72,0.72,,,,,,
Humana MCR ADV,CPT,J0695,Inj ceftolozane tazobactam,APC 9452,Per Unit,$6.64 ,OP,6.64,6.64,,,,,,
Humana MCR ADV,CPT,J0699,Inj- cefiderocol- 10 mg,APC 9426,Per Unit,$2.01 ,OP,2.01,2.01,,,,,,
Humana MCR ADV,CPT,J0712,Ceftaroline fosamil inj,APC 1824,Per Unit,$3.51 ,OP,3.51,3.51,,,,,,
Humana MCR ADV,CPT,J0714,Ceftazidime and avibactam,APC 1825,Per Unit,$92.39 ,OP,92.39,92.39,,,,,,
Humana MCR ADV,CPT,J0716,Centruroides immune f(ab),APC 1431,Per Unit,"$5,190.15 ",OP,"5,190.15","5,190.15",,,,,,
Humana MCR ADV,CPT,J0717,Certolizumab pegol inj 1mg,APC 1474,Per Unit,$6.27 ,OP,6.27,6.27,,,,,,
Humana MCR ADV,CPT,J0740,Cidofovir injection,APC 9033,Per Unit,$563.76 ,OP,563.76,"3,694.50",,,,,,
Humana MCR ADV,CPT,J0741,Inj- cabote rilpivir 2mg 3mg,APC 9414,Per Unit,$20.56 ,OP,20.56,20.56,,,,,,
Humana MCR ADV,CPT,J0742,Inj imip 4 cilas 4 releb 2mg,APC 9362,Per Unit,$2.32 ,OP,2.32,2.32,,,,,,
Humana MCR ADV,CPT,J0745,Inj codeine phosphate /30 mg,APC 9393,Per Unit,$135.64 ,OP,7.62,135.64,,,,,,
Humana MCR ADV,CPT,J0775,Collagenase- clost hist inj,APC 1340,Per Unit,$56.66 ,OP,56.66,56.66,,,,,,
Humana MCR ADV,CPT,J0791,Inj crizanlizumab-tmca 5mg,APC 9359,Per Unit,$123.29 ,OP,123.29,123.29,,,,,,
Humana MCR ADV,CPT,J0795,Corticorelin ovine triflutal,APC 1684,Per Unit,$9.67 ,OP,9.67,22.88,,,,,,
Humana MCR ADV,CPT,J0840,Crotalidae poly immune fab,APC 9274,Per Unit,"$2,743.36 ",OP,"2,743.36","2,743.36",,,,,,
Humana MCR ADV,CPT,J0841,Inj crotalidae im f(ab)2 eq,APC 9188,Per Unit,"$1,189.81 ",OP,"1,189.81","1,189.81",,,,,,
Humana MCR ADV,CPT,J0850,Cytomegalovirus imm iv /vial,APC 0903,Per Unit,"$1,538.70 ",OP,"1,538.70","4,266.40",,,,,,
Humana MCR ADV,CPT,J0875,Injection- dalbavancin,APC 1823,Per Unit,$15.89 ,OP,15.89,15.89,,,,,,
Humana MCR ADV,CPT,J0881,Darbepoetin alfa- non-esrd,APC 1685,Per Unit,$3.15 ,OP,3.15,15.26,,,,,,
Humana MCR ADV,CPT,J0882,Darbepoetin alfa- esrd use,APC 1482,Per Unit,$3.15 ,OP,3.15,15.26,,,,,,
Humana MCR ADV,CPT,J0883,Argatroban nonesrd use 1mg,APC 1859,Per Unit,$1.20 ,OP,1.2,1.2,,,,,,
Humana MCR ADV,CPT,J0884,Argatroban esrd dialysis 1mg,APC 9065,Per Unit,$1.20 ,OP,1.2,1.2,,,,,,
Humana MCR ADV,CPT,J0885,Epoetin alfa- non-esrd,APC 1686,Per Unit,$8.15 ,OP,8.15,45.74,,,,,,
Humana MCR ADV,CPT,J0888,Epoetin beta non esrd,APC 9077,Per Unit,$1.51 ,OP,1.51,1.51,,,,,,
Humana MCR ADV,CPT,J0894,Decitabine injection,APC 9231,Per Unit,$3.45 ,OP,3.45,3.45,,,,,,
Humana MCR ADV,CPT,J0896,Inj luspatercept-aamt 0.25mg,APC 9347,Per Unit,$36.85 ,OP,36.85,36.85,,,,,,
Humana MCR ADV,CPT,J0897,Denosumab injection,APC 9272,Per Unit,$21.19 ,OP,21.19,21.19,,,,,,
Humana MCR ADV,CPT,J1095,Injection- dexamethasone 9%,APC 9172,Per Unit,$1.04 ,OP,1.04,1.04,,,,,,
Humana MCR ADV,CPT,J1096,Dexametha opth insert 0.1 mg,APC 9308,Per Unit,$133.30 ,OP,133.3,133.3,,,,,,
Humana MCR ADV,CPT,J1162,Digoxin immune fab (ovine),APC 1687,Per Unit,"$4,128.19 ",OP,"2,344.81","4,128.19",,,,,,
Humana MCR ADV,CPT,J1190,Dexrazoxane hcl injection,APC 0726,Per Unit,$192.33 ,OP,192.33,"1,849.16",,,,,,
Humana MCR ADV,CPT,J1201,Inj. cetirizine hcl 0.5mg,APC 9361,Per Unit,$15.38 ,OP,15.38,15.38,,,,,,
Humana MCR ADV,CPT,J1212,Dimethyl sulfoxide 50% 50 ml,APC 1832,Per Unit,$637.11 ,OP,339.33,637.11,,,,,,
Humana MCR ADV,CPT,J1290,Ecallantide injection,APC 9263,Per Unit,$503.88 ,OP,503.88,503.88,,,,,,
Humana MCR ADV,CPT,J1300,Eculizumab injection,APC 9236,Per Unit,$229.23 ,OP,229.23,679.45,,,,,,
Humana MCR ADV,CPT,J1301,Injection- edaravone- 1 mg,APC 9493,Per Unit,$20.51 ,OP,20.51,20.51,,,,,,
Humana MCR ADV,CPT,J1303,Inj.- ravulizumab-cwvz 10 mg,APC 9312,Per Unit,$224.68 ,OP,224.68,224.68,,,,,,
Humana MCR ADV,CPT,J1305,Inj- evinacumab-dgnb- 5mg,APC 9416,Per Unit,$165.63 ,OP,165.63,165.63,,,,,,
Humana MCR ADV,CPT,J1322,Elosulfase alfa- injection,APC 1480,Per Unit,$250.33 ,OP,250.33,250.33,,,,,,
Humana MCR ADV,CPT,J1364,Erythro lactobionate /500 mg,APC 1669,Per Unit,$77.75 ,OP,38.13,77.75,,,,,,
Humana MCR ADV,CPT,J1410,Inj estrogen conjugate 25 mg,APC 9038,Per Unit,$341.46 ,OP,341.46,381.27,,,,,,
Humana MCR ADV,CPT,J1426,Injection- casimersen- 10 mg,APC 9412,Per Unit,$166.47 ,OP,166.47,166.47,,,,,,
Humana MCR ADV,CPT,J1427,Inj. viltolarsen,APC 9386,Per Unit,$59.05 ,OP,59.05,59.05,,,,,,
Humana MCR ADV,CPT,J1429,Inj golodirsen 10 mg,APC 9356,Per Unit,$166.21 ,OP,166.21,166.21,,,,,,
Humana MCR ADV,CPT,J1430,Ethanolamine oleate 100 mg,APC 1688,Per Unit,$444.10 ,OP,444.1,728.23,,,,,,
Humana MCR ADV,CPT,J1437,Inj. fe derisomaltose 10 mg,APC 9388,Per Unit,$24.87 ,OP,24.87,24.87,,,,,,
Humana MCR ADV,CPT,J1438,Etanercept injection,APC 1608,Per Unit,$790.78 ,OP,714.31,790.78,,,,,,
Humana MCR ADV,CPT,J1439,Inj ferric carboxymaltos 1mg,APC 9441,Per Unit,$1.12 ,OP,1.12,1.12,,,,,,
Humana MCR ADV,CPT,J1442,Inj filgrastim excl biosimil,APC 1469,Per Unit,$0.97 ,OP,0.97,3.09,,,,,,
Humana MCR ADV,CPT,J1447,Inj tbo filgrastim 1 microg,APC 1748,Per Unit,$0.46 ,OP,0.46,3.1,,,,,,
Humana MCR ADV,CPT,J1448,Injection- trilaciclib- 1mg,APC 9415,Per Unit,$4.97 ,OP,4.97,4.97,,,,,,
Humana MCR ADV,CPT,J1451,Fomepizole- 15 mg,APC 1689,Per Unit,$5.98 ,OP,5.98,49.56,,,,,,
Humana MCR ADV,CPT,J1453,Fosaprepitant injection,APC 9242,Per Unit,$0.24 ,OP,0.24,7.62,,,,,,
Humana MCR ADV,CPT,J1454,Inj fosnetupitant- palonoset,APC 9099,Per Unit,$571.22 ,OP,571.22,571.22,,,,,,
Humana MCR ADV,CPT,J1455,Foscarnet sodium injection,APC 1849,Per Unit,$72.86 ,OP,49.56,72.86,,,,,,
Humana MCR ADV,CPT,J1458,Galsulfase injection,APC 9224,Per Unit,$411.92 ,OP,411.92,"1,289.57",,,,,,
Humana MCR ADV,CPT,J1459,Inj ivig privigen 500 mg,APC 1214,Per Unit,$44.48 ,OP,44.48,143.18,,,,,,
Humana MCR ADV,CPT,J1460,Gamma globulin 1 cc inj,APC 1850,Per Unit,$44.13 ,OP,44.13,61,,,,,,
Humana MCR ADV,CPT,J1554,Inj. asceniv,APC 9392,Per Unit,$481.77 ,OP,481.77,481.77,,,,,,
Humana MCR ADV,CPT,J1555,Inj cuvitru- 100 mg,APC 9034,Per Unit,$14.50 ,OP,14.5,14.5,,,,,,
Humana MCR ADV,CPT,J1556,Inj- imm glob bivigam- 500mg,APC 9130,Per Unit,$70.49 ,OP,70.49,70.49,,,,,,
Humana MCR ADV,CPT,J1557,Gammaplex injection,APC 9270,Per Unit,$48.53 ,OP,48.53,48.53,,,,,,
Humana MCR ADV,CPT,J1558,Inj. xembify- 100 mg,APC 9372,Per Unit,$13.61 ,OP,13.61,13.61,,,,,,
Humana MCR ADV,CPT,J1559,Hizentra injection,APC 1312,Per Unit,$11.58 ,OP,11.58,11.58,,,,,,
Humana MCR ADV,CPT,J1560,Gamma globulin > 10 cc inj,APC 1851,Per Unit,$441.31 ,OP,441.31,621.47,,,,,,
Humana MCR ADV,CPT,J1561,Gamunex-c/gammaked,APC 0948,Per Unit,$48.22 ,OP,48.22,158.91,,,,,,
Humana MCR ADV,CPT,J1566,Immune globulin- powder,APC 2731,Per Unit,$65.49 ,OP,65.49,152.51,,,,,,
Humana MCR ADV,CPT,J1568,Octagam injection,APC 0943,Per Unit,$41.63 ,OP,41.63,41.63,,,,,,
Humana MCR ADV,CPT,J1569,Gammagard liquid injection,APC 0944,Per Unit,$44.49 ,OP,44.49,171.58,,,,,,
Humana MCR ADV,CPT,J1571,Hepagam b im injection,APC 0946,Per Unit,$70.94 ,OP,70.94,213.51,,,,,,
Humana MCR ADV,CPT,J1572,Flebogamma injection,APC 0947,Per Unit,$36.80 ,OP,36.8,171.58,,,,,,
Humana MCR ADV,CPT,J1573,Hepagam b intravenous- inj,APC 1138,Per Unit,$71.24 ,OP,71.24,213.51,,,,,,
Humana MCR ADV,CPT,J1575,Hyqvia 100mg immuneglobulin,APC 1826,Per Unit,$15.16 ,OP,15.16,15.16,,,,,,
Humana MCR ADV,CPT,J1595,Injection glatiramer acetate,APC 1015,Per Unit,$141.29 ,OP,141.29,298.68,,,,,,
Humana MCR ADV,CPT,J1602,Golimumab for iv use 1mg,APC 1475,Per Unit,$16.82 ,OP,16.82,16.82,,,,,,
Humana MCR ADV,CPT,J1610,Glucagon hydrochloride/1 mg,APC 9042,Per Unit,$171.74 ,OP,171.74,343.14,,,,,,
Humana MCR ADV,CPT,J1628,Inj.- guselkumab- 1 mg,APC 9029,Per Unit,$82.56 ,OP,82.56,82.56,,,,,,
Humana MCR ADV,CPT,J1632,Inj.- brexanolone- 1 mg,APC 9333,Per Unit,$74.65 ,OP,74.65,74.65,,,,,,
Humana MCR ADV,CPT,J1640,Hemin- 1 mg,APC 1690,Per Unit,$26.64 ,OP,26.64,38.13,,,,,,
Humana MCR ADV,CPT,J1670,Tetanus immune globulin inj,APC 1670,Per Unit,$441.70 ,OP,441.7,"1,040.87",,,,,,
Humana MCR ADV,CPT,J1726,Makena- 10 mg,APC 9074,Per Unit,$16.82 ,OP,16.82,16.82,,,,,,
Humana MCR ADV,CPT,J1729,Inj hydroxyprogst capoat nos,APC 9318,Per Unit,$21.54 ,OP,21.54,21.54,,,,,,
Humana MCR ADV,CPT,J1738,Inj. meloxicam 1 mg,APC 9371,Per Unit,$3.18 ,OP,3.18,3.18,,,,,,
Humana MCR ADV,CPT,J1740,Ibandronate sodium injection,APC 9229,Per Unit,$37.09 ,OP,37.09,674.85,,,,,,
Humana MCR ADV,CPT,J1742,Ibutilide fumarate injection,APC 9044,Per Unit,$205.06 ,OP,205.06,"1,898.73",,,,,,
Humana MCR ADV,CPT,J1744,Icatibant injection,APC 1443,Per Unit,$204.96 ,OP,204.96,204.96,,,,,,
Humana MCR ADV,CPT,J1745,Infliximab not biosimil 10mg,APC 7043,Per Unit,$39.53 ,OP,39.53,301.32,,,,,,
Humana MCR ADV,CPT,J1746,Inj.- ibalizumab-uiyk- 10 mg,APC 9189,Per Unit,$66.39 ,OP,66.39,66.39,,,,,,
Humana MCR ADV,CPT,J1750,Inj iron dextran,APC 1237,Per Unit,$15.84 ,OP,15.84,15.84,,,,,,
Humana MCR ADV,CPT,J1786,Imuglucerase injection,APC 1327,Per Unit,$44.05 ,OP,44.05,44.05,,,,,,
Humana MCR ADV,CPT,J1823,Inj. inebilizumab-cdon- 1 mg,APC 9394,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Humana MCR ADV,CPT,J1826,Interferon beta-1a inj,APC 1852,Per Unit,"$2,293.85 ",OP,"2,293.85","2,293.85",,,,,,
Humana MCR ADV,CPT,J1830,Interferon beta-1b / .25 mg,APC 0910,Per Unit,$406.24 ,OP,406.24,538.7,,,,,,
Humana MCR ADV,CPT,J1833,Injection- isavuconazonium,APC 9456,Per Unit,$0.83 ,OP,0.83,0.83,,,,,,
Humana MCR ADV,CPT,J1930,Lanreotide injection,APC 9237,Per Unit,$67.64 ,OP,67.64,129.64,,,,,,
Humana MCR ADV,CPT,J1931,Laronidase injection,APC 9209,Per Unit,$34.75 ,OP,34.75,95.46,,,,,,
Humana MCR ADV,CPT,J1943,Inj.- aristada initio- 1 mg,APC 9179,Per Unit,$3.05 ,OP,3.05,3.05,,,,,,
Humana MCR ADV,CPT,J1944,Aripirazole lauroxil 1 mg,APC 9470,Per Unit,$2.99 ,OP,2.99,2.99,,,,,,
Humana MCR ADV,CPT,J1950,Leuprolide acetate /3.75 mg,APC 0800,Per Unit,"$1,406.37 ",OP,"1,406.37","1,525.07",,,,,,
Humana MCR ADV,CPT,J1951,Inj fensolvi 0.25 mg,APC 9419,Per Unit,$126.28 ,OP,126.28,126.28,,,,,,
Humana MCR ADV,CPT,J2182,Injection- mepolizumab- 1mg,APC 9473,Per Unit,$28.29 ,OP,28.29,28.29,,,,,,
Humana MCR ADV,CPT,J2186,Inj.- meropenem- vaborbactam,APC 9178,Per Unit,$1.76 ,OP,1.76,1.76,,,,,,
Humana MCR ADV,CPT,J2248,Micafungin sodium injection,APC 9227,Per Unit,$0.97 ,OP,0.97,0.97,,,,,,
Humana MCR ADV,CPT,J2265,Minocycline hydrochloride,APC 1853,Per Unit,$2.00 ,OP,2,2,,,,,,
Humana MCR ADV,CPT,J2278,Ziconotide injection,APC 1694,Per Unit,$8.69 ,OP,8.69,30.51,,,,,,
Humana MCR ADV,CPT,J2315,Naltrexone- depot form,APC 0759,Per Unit,$3.53 ,OP,3.53,3.53,,,,,,
Humana MCR ADV,CPT,J2323,Natalizumab injection,APC 9126,Per Unit,$23.24 ,OP,23.24,103.45,,,,,,
Humana MCR ADV,CPT,J2326,Inj- nusinersen- 0.1mg,APC 9489,Per Unit,"$1,122.13 ",OP,"1,122.13","1,122.13",,,,,,
Humana MCR ADV,CPT,J2350,Injection- ocrelizumab- 1 mg,APC 9494,Per Unit,$58.29 ,OP,58.29,58.29,,,,,,
Humana MCR ADV,CPT,J2353,Octreotide injection- depot,APC 1207,Per Unit,$205.37 ,OP,205.37,408.99,,,,,,
Humana MCR ADV,CPT,J2357,Omalizumab injection,APC 9300,Per Unit,$37.67 ,OP,37.67,70.74,,,,,,
Humana MCR ADV,CPT,J2358,Olanzapine long-acting inj,APC 1331,Per Unit,$2.91 ,OP,2.91,2.91,,,,,,
Humana MCR ADV,CPT,J2406,Injection- oritavancin 10 mg,APC 9427,Per Unit,$41.92 ,OP,41.92,41.92,,,,,,
Humana MCR ADV,CPT,J2407,Injection- oritavancin,APC 1660,Per Unit,$23.63 ,OP,23.63,23.63,,,,,,
Humana MCR ADV,CPT,J2425,Palifermin injection,APC 1696,Per Unit,$23.93 ,OP,23.93,23.93,,,,,,
Humana MCR ADV,CPT,J2426,Paliperidone palmitate inj,APC 9255,Per Unit,$12.66 ,OP,12.66,12.66,,,,,,
Humana MCR ADV,CPT,J2502,Inj- pasireotide long acting,APC 9454,Per Unit,$359.03 ,OP,359.03,359.03,,,,,,
Humana MCR ADV,CPT,J2504,Pegademase bovine- 25 iu,APC 1739,Per Unit,$4.06 ,OP,4.06,"1,098.07",,,,,,
Humana MCR ADV,CPT,J2505,Injection- pegfilgrastim 6mg,APC 9119,Per Unit,"$2,221.63 ",OP,"2,221.63","10,481.09",,,,,,
Humana MCR ADV,CPT,J2507,Pegloticase injection,APC 9281,Per Unit,"$2,960.91 ",OP,"2,960.91","2,960.91",,,,,,
Humana MCR ADV,CPT,J2515,Pentobarbital sodium inj,APC 1854,Per Unit,$26.41 ,OP,26.41,26.41,,,,,,
Humana MCR ADV,CPT,J2547,Injection- peramivir,APC 9451,Per Unit,$1.68 ,OP,1.68,1.68,,,,,,
Humana MCR ADV,CPT,J2560,Phenobarbital sodium inj,APC 9069,Per Unit,$40.22 ,OP,40.22,40.22,,,,,,
Humana MCR ADV,CPT,J2562,Plerixafor injection,APC 9252,Per Unit,$382.85 ,OP,382.85,382.85,,,,,,
Humana MCR ADV,CPT,J2597,Inj desmopressin acetate,APC 1440,Per Unit,$9.40 ,OP,9.4,9.4,,,,,,
Humana MCR ADV,CPT,J2724,Protein c concentrate,APC 1139,Per Unit,$15.13 ,OP,15.13,61,,,,,,
Humana MCR ADV,CPT,J2760,Phentolaine mesylate inj,APC 1458,Per Unit,$416.00 ,OP,255.45,416,,,,,,
Humana MCR ADV,CPT,J2770,Quinupristin/dalfopristin,APC 2770,Per Unit,$444.67 ,OP,444.67,712.98,,,,,,
Humana MCR ADV,CPT,J2778,Ranibizumab injection,APC 9233,Per Unit,$318.47 ,OP,318.47,318.47,,,,,,
Humana MCR ADV,CPT,J2783,Rasburicase,APC 0738,Per Unit,$315.06 ,OP,315.06,804.48,,,,,,
Humana MCR ADV,CPT,J2786,Injection- reslizumab- 1mg,APC 9481,Per Unit,$10.11 ,OP,10.11,10.11,,,,,,
Humana MCR ADV,CPT,J2792,Rho(d) immune globulin h- sd,APC 1609,Per Unit,$31.42 ,OP,31.42,80.07,,,,,,
Humana MCR ADV,CPT,J2794,Inj risperdal consta- 0.5 mg,APC 9125,Per Unit,$11.04 ,OP,11.04,19.71,,,,,,
Humana MCR ADV,CPT,J2796,Romiplostim injection,APC 9245,Per Unit,$83.47 ,OP,83.47,83.47,,,,,,
Humana MCR ADV,CPT,J2798,Inj.- perseris- 0.5 mg,APC 9181,Per Unit,$10.69 ,OP,10.69,10.69,,,,,,
Humana MCR ADV,CPT,J2820,Sargramostim injection,APC 0731,Per Unit,$51.55 ,OP,51.55,122,,,,,,
Humana MCR ADV,CPT,J2840,Inj sebelipase alfa 1 mg,APC 9478,Per Unit,$539.91 ,OP,539.91,539.91,,,,,,
Humana MCR ADV,CPT,J2850,Inj secretin synthetic human,APC 1700,Per Unit,$34.78 ,OP,34.78,129.64,,,,,,
Humana MCR ADV,CPT,J2860,Injection- siltuximab,APC 9455,Per Unit,$124.09 ,OP,124.09,124.09,,,,,,
Humana MCR ADV,CPT,J2941,Somatropin injection,APC 9319,Per Unit,$36.54 ,OP,36.54,226.93,,,,,,
Humana MCR ADV,CPT,J2993,Reteplase injection,APC 9005,Per Unit,"$2,506.51 ",OP,"2,506.51","4,712.48",,,,,,
Humana MCR ADV,CPT,J2997,Alteplase recombinant,APC 7048,Per Unit,$87.75 ,OP,87.75,163.95,,,,,,
Humana MCR ADV,CPT,J3031,Inj.- fremanezumab-vfrm 1 mg,APC 9197,Per Unit,$2.34 ,OP,2.34,2.34,,,,,,
Humana MCR ADV,CPT,J3032,Inj. eptinezumab-jjmr 1 mg,APC 9357,Per Unit,$15.64 ,OP,15.64,15.64,,,,,,
Humana MCR ADV,CPT,J3060,Inj- taliglucerase alfa 10 u,APC 9294,Per Unit,$41.32 ,OP,41.32,41.32,,,,,,
Humana MCR ADV,CPT,J3090,Inj tedizolid phosphate,APC 1662,Per Unit,$1.60 ,OP,1.6,1.6,,,,,,
Humana MCR ADV,CPT,J3095,Telavancin injection,APC 9258,Per Unit,$6.16 ,OP,6.16,6.16,,,,,,
Humana MCR ADV,CPT,J3101,Tenecteplase injection,APC 9002,Per Unit,$134.74 ,OP,134.74,202.07,,,,,,
Humana MCR ADV,CPT,J3111,Inj. romosozumab-aqqg 1 mg,APC 9327,Per Unit,$9.34 ,OP,9.34,9.34,,,,,,
Humana MCR ADV,CPT,J3145,Testosterone undecanoate 1mg,APC 9078,Per Unit,$1.63 ,OP,1.63,1.63,,,,,,
Humana MCR ADV,CPT,J3240,Thyrotropin injection,APC 9108,Per Unit,"$1,837.25 ",OP,"1,837.25","3,617.49",,,,,,
Humana MCR ADV,CPT,J3241,Inj. teprotumumab-trbw 10 mg,APC 9355,Per Unit,$315.88 ,OP,315.88,315.88,,,,,,
Humana MCR ADV,CPT,J3243,Tigecycline injection,APC 9228,Per Unit,$1.12 ,OP,1.12,3.82,,,,,,
Humana MCR ADV,CPT,J3245,Inj.- tildrakizumab- 1 mg,APC 9306,Per Unit,$134.08 ,OP,134.08,134.08,,,,,,
Humana MCR ADV,CPT,J3246,Tirofiban hcl,APC 7041,Per Unit,$3.83 ,OP,3.83,3.83,,,,,,
Humana MCR ADV,CPT,J3262,Tocilizumab injection,APC 9264,Per Unit,$5.55 ,OP,5.55,5.55,,,,,,
Humana MCR ADV,CPT,J3285,Treprostinil injection,APC 1701,Per Unit,$59.68 ,OP,59.68,238.44,,,,,,
Humana MCR ADV,CPT,J3304,Inj triamcinolone ace xr 1mg,APC 9469,Per Unit,$17.75 ,OP,17.75,17.75,,,,,,
Humana MCR ADV,CPT,J3315,Triptorelin pamoate,APC 9122,Per Unit,$379.90 ,OP,379.9,379.9,,,,,,
Humana MCR ADV,CPT,J3316,Inj.- triptorelin xr 3.75 mg,APC 9016,Per Unit,"$3,120.11 ",OP,"3,120.11","3,120.11",,,,,,
Humana MCR ADV,CPT,J3357,Ustekinumab sub cu inj- 1 mg,APC 9261,Per Unit,$176.65 ,OP,176.65,176.65,,,,,,
Humana MCR ADV,CPT,J3358,Ustekinumab- iv inject- 1 mg,APC 9487,Per Unit,$11.68 ,OP,11.68,11.68,,,,,,
Humana MCR ADV,CPT,J3380,Injection- vedolizumab,APC 1489,Per Unit,$21.28 ,OP,21.28,21.28,,,,,,
Humana MCR ADV,CPT,J3385,Velaglucerase alfa,APC 9271,Per Unit,$359.29 ,OP,359.29,359.29,,,,,,
Humana MCR ADV,CPT,J3396,Verteporfin injection,APC 1203,Per Unit,$11.25 ,OP,11.25,37.64,,,,,,
Humana MCR ADV,CPT,J3398,Inj luxturna 1 billion vec g,APC 9070,Per Unit,"$2,953.71 ",OP,"2,953.71","2,953.71",,,,,,
Humana MCR ADV,CPT,J7168,Prothrombin complex kcentra,APC 9132,Per Unit,$1.99 ,OP,1.99,1.99,,,,,,
Humana MCR ADV,CPT,J7169,Inj andexxa- 10 mg,APC 9198,Per Unit,$289.93 ,OP,289.93,289.93,,,,,,
Humana MCR ADV,CPT,J7170,Inj.- emicizumab-kxwh 0.5 mg,APC 9257,Per Unit,$48.88 ,OP,48.88,48.88,,,,,,
Humana MCR ADV,CPT,J7175,Inj- factor x- (human)- 1iu,APC 1857,Per Unit,$8.20 ,OP,8.2,8.2,,,,,,
Humana MCR ADV,CPT,J7178,Inj human fibrinogen con nos,APC 1478,Per Unit,$1.30 ,OP,1.3,1.3,,,,,,
Humana MCR ADV,CPT,J7179,Vonvendi inj 1 iu vwf:rco,APC 9059,Per Unit,$1.85 ,OP,1.85,1.85,,,,,,
Humana MCR ADV,CPT,J7180,Factor xiii anti-hem factor,APC 1416,Per Unit,$9.14 ,OP,9.14,9.14,,,,,,
Humana MCR ADV,CPT,J7181,Factor xiii recomb a-subunit,APC 1746,Per Unit,$15.87 ,OP,15.87,15.87,,,,,,
Humana MCR ADV,CPT,J7182,Factor viii recomb novoeight,APC 1856,Per Unit,$1.51 ,OP,1.51,1.51,,,,,,
Humana MCR ADV,CPT,J7183,Wilate injection,APC 1352,Per Unit,$1.16 ,OP,1.16,1.16,,,,,,
Humana MCR ADV,CPT,J7185,Xyntha inj,APC 1268,Per Unit,$1.33 ,OP,1.33,1.33,,,,,,
Humana MCR ADV,CPT,J7186,Antihemophilic viii/vwf comp,APC 1213,Per Unit,$1.14 ,OP,1.14,3.82,,,,,,
Humana MCR ADV,CPT,J7187,Humate-p- inj,APC 1704,Per Unit,$1.26 ,OP,1.26,2.98,,,,,,
Humana MCR ADV,CPT,J7188,Factor viii recomb obizur,APC 1827,Per Unit,$3.19 ,OP,3.19,3.19,,,,,,
Humana MCR ADV,CPT,J7189,Factor viia recomb novoseven,APC 1705,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Humana MCR ADV,CPT,J7190,Factor viii,APC 0925,Per Unit,$1.12 ,OP,1.12,3.02,,,,,,
Humana MCR ADV,CPT,J7192,Factor viii recombinant nos,APC 0927,Per Unit,$1.43 ,OP,1.43,3.85,,,,,,
Humana MCR ADV,CPT,J7193,Factor ix non-recombinant,APC 0931,Per Unit,$1.17 ,OP,1.17,3.36,,,,,,
Humana MCR ADV,CPT,J7194,Factor ix complex,APC 0928,Per Unit,$1.54 ,OP,1.54,2.52,,,,,,
Humana MCR ADV,CPT,J7195,Factor ix recombinant nos,APC 0932,Per Unit,$1.61 ,OP,1.61,3.57,,,,,,
Humana MCR ADV,CPT,J7197,Antithrombin iii injection,APC 1263,Per Unit,$3.20 ,OP,3.2,10.61,,,,,,
Humana MCR ADV,CPT,J7198,Anti-inhibitor,APC 0929,Per Unit,$2.21 ,OP,2.21,5.2,,,,,,
Humana MCR ADV,CPT,J7200,Factor ix recombinan rixubis,APC 1467,Per Unit,$1.54 ,OP,1.54,1.54,,,,,,
Humana MCR ADV,CPT,J7201,Factor ix alprolix recomb,APC 1486,Per Unit,$3.28 ,OP,3.28,3.28,,,,,,
Humana MCR ADV,CPT,J7202,Factor ix idelvion inj,APC 9171,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana MCR ADV,CPT,J7203,Factor ix recomb gly rebinyn,APC 9468,Per Unit,$4.23 ,OP,4.23,4.23,,,,,,
Humana MCR ADV,CPT,J7204,Inj recombin esperoct per iu,APC 9354,Per Unit,$2.23 ,OP,2.23,2.23,,,,,,
Humana MCR ADV,CPT,J7205,Factor viii fc fusion recomb,APC 1656,Per Unit,$2.15 ,OP,2.15,2.15,,,,,,
Humana MCR ADV,CPT,J7207,Factor viii pegylated recomb,APC 1844,Per Unit,$1.92 ,OP,1.92,1.92,,,,,,
Humana MCR ADV,CPT,J7208,Inj. jivi 1 iu,APC 9299,Per Unit,$2.10 ,OP,2.1,2.1,,,,,,
Humana MCR ADV,CPT,J7209,Factor viii nuwiq recomb 1iu,APC 1846,Per Unit,$1.24 ,OP,1.24,1.24,,,,,,
Humana MCR ADV,CPT,J7210,Inj- afstyla- 1 i.u.,APC 9043,Per Unit,$1.36 ,OP,1.36,1.36,,,,,,
Humana MCR ADV,CPT,J7211,Inj- kovaltry- 1 i.u.,APC 9075,Per Unit,$1.24 ,OP,1.24,1.24,,,,,,
Humana MCR ADV,CPT,J7212,Factor viia recomb sevenfact,APC 9395,Per Unit,$2.27 ,OP,2.27,2.27,,,,,,
Humana MCR ADV,CPT,J7308,Aminolevulinic acid hcl top,APC 7308,Per Unit,$392.48 ,OP,392.48,392.48,,,,,,
Humana MCR ADV,CPT,J7311,Inj.- retisert- 0.01 mg,APC 9225,Per Unit,$339.00 ,OP,339,"93,937.12",,,,,,
Humana MCR ADV,CPT,J7312,Dexamethasone intra implant,APC 9256,Per Unit,$199.69 ,OP,199.69,199.69,,,,,,
Humana MCR ADV,CPT,J7313,Inj.- iluvien- 0.01 mg,APC 9450,Per Unit,$490.95 ,OP,490.95,490.95,,,,,,
Humana MCR ADV,CPT,J7314,Inj.- yutiq- 0.01 mg,APC 9328,Per Unit,$513.16 ,OP,513.16,513.16,,,,,,
Humana MCR ADV,CPT,J7316,Inj- ocriplasmin- 0.125 mg,APC 9298,Per Unit,"$1,046.93 ",OP,"1,046.93","1,046.93",,,,,,
Humana MCR ADV,CPT,J7318,Inj- durolane 1 mg,APC 9174,Per Unit,$17.23 ,OP,17.23,17.23,,,,,,
Humana MCR ADV,CPT,J7320,Genvisc 850- inj- 1mg,APC 9079,Per Unit,$16.92 ,OP,16.92,16.92,,,,,,
Humana MCR ADV,CPT,J7322,Hymovis injection 1 mg,APC 9471,Per Unit,$31.67 ,OP,31.67,903.6,,,,,,
Humana MCR ADV,CPT,J7323,Euflexxa inj per dose,APC 0875,Per Unit,$138.82 ,OP,138.82,590.67,,,,,,
Humana MCR ADV,CPT,J7324,Orthovisc inj per dose,APC 0877,Per Unit,$148.74 ,OP,148.74,880.74,,,,,,
Humana MCR ADV,CPT,J7325,Synvisc or synvisc-one,APC 0874,Per Unit,$11.24 ,OP,11.24,11.24,,,,,,
Humana MCR ADV,CPT,J7326,Gel-one,APC 1417,Per Unit,"$1,219.00 ",OP,"1,219.00","1,219.00",,,,,,
Humana MCR ADV,CPT,J7327,Monovisc inj per dose,APC 1747,Per Unit,$762.80 ,OP,762.8,762.8,,,,,,
Humana MCR ADV,CPT,J7328,Gelsyn-3 injection 0.1 mg,APC 1862,Per Unit,$2.18 ,OP,2.18,2.18,,,,,,
Humana MCR ADV,CPT,J7329,Inj- trivisc 1 mg,APC 9196,Per Unit,$19.12 ,OP,19.12,19.12,,,,,,
Humana MCR ADV,CPT,J7331,Synojoynt- inj.- 1 mg,APC 9337,Per Unit,$18.02 ,OP,18.02,18.02,,,,,,
Humana MCR ADV,CPT,J7336,Capsaicin 8% patch,APC 9071,Per Unit,$3.23 ,OP,3.23,3.23,,,,,,
Humana MCR ADV,CPT,J7340,Carbidopa levodopa ent 100ml,APC 9320,Per Unit,$211.70 ,OP,211.7,211.7,,,,,,
Humana MCR ADV,CPT,J7342,Ciprofloxacin otic susp 6 mg,APC 9479,Per Unit,$29.98 ,OP,29.98,29.98,,,,,,
Humana MCR ADV,CPT,J7345,Aminolevulinic acid- 10% gel,APC 9301,Per Unit,$1.59 ,OP,1.59,1.59,,,,,,
Humana MCR ADV,CPT,J7351,Inj bimatoprost itc imp1mcg,APC 9351,Per Unit,$205.63 ,OP,205.63,205.63,,,,,,
Humana MCR ADV,CPT,J7352,Afamelanotide implant- 1 mg,APC 9396,Per Unit,"$3,218.90 ",OP,"3,218.90","3,218.90",,,,,,
Humana MCR ADV,CPT,J7402,Mometasone sinus sinuva,APC 9346,Per Unit,$10.56 ,OP,10.56,10.56,,,,,,
Humana MCR ADV,CPT,J7501,Azathioprine parenteral,APC 0887,Per Unit,$245.02 ,OP,245.02,442.27,,,,,,
Humana MCR ADV,CPT,J7504,Lymphocyte immune globulin,APC 0890,Per Unit,"$2,355.53 ",OP,"2,245.67","2,355.53",,,,,,
Humana MCR ADV,CPT,J7511,Antithymocyte globuln rabbit,APC 9104,Per Unit,$837.42 ,OP,837.42,"1,807.23",,,,,,
Humana MCR ADV,CPT,J7525,Tacrolimus injection,APC 9006,Per Unit,$219.33 ,OP,219.33,540.46,,,,,,
Humana MCR ADV,CPT,J8560,Etoposide oral 50 mg,APC 0802,Per Unit,$75.63 ,OP,75.63,75.63,,,,,,
Humana MCR ADV,CPT,J8655,Oral netupitant- palonosetro,APC 9448,Per Unit,$315.59 ,OP,315.59,315.59,,,,,,
Humana MCR ADV,CPT,J8670,Rolapitant- oral- 1mg,APC 1761,Per Unit,$1.75 ,OP,1.75,1.75,,,,,,
Humana MCR ADV,CPT,J9015,Aldesleukin injection,APC 0807,Per Unit,"$3,795.26 ",OP,"3,795.26","3,795.26",,,,,,
Humana MCR ADV,CPT,J9017,Arsenic trioxide injection,APC 9012,Per Unit,$13.11 ,OP,13.11,179.2,,,,,,
Humana MCR ADV,CPT,J9019,Erwinaze injection,APC 9289,Per Unit,$427.27 ,OP,427.27,427.27,,,,,,
Humana MCR ADV,CPT,J9022,Inj- atezolizumab-10 mg,APC 9483,Per Unit,$79.75 ,OP,79.75,79.75,,,,,,
Humana MCR ADV,CPT,J9023,Injection- avelumab- 10 mg,APC 9491,Per Unit,$86.19 ,OP,86.19,86.19,,,,,,
Humana MCR ADV,CPT,J9025,Azacitidine injection,APC 1709,Per Unit,$0.93 ,OP,0.93,22.88,,,,,,
Humana MCR ADV,CPT,J9027,Clofarabine injection,APC 1710,Per Unit,$53.15 ,OP,53.15,564.29,,,,,,
Humana MCR ADV,CPT,J9032,Injection- belinostat- 10mg,APC 1658,Per Unit,$42.77 ,OP,42.77,42.77,,,,,,
Humana MCR ADV,CPT,J9033,Inj.- treanda 1 mg,APC 9243,Per Unit,$22.01 ,OP,22.01,91.51,,,,,,
Humana MCR ADV,CPT,J9034,Inj.- bendeka 1 mg,APC 1861,Per Unit,$19.65 ,OP,19.65,19.65,,,,,,
Humana MCR ADV,CPT,J9035,Bevacizumab injection,APC 9214,Per Unit,$70.41 ,OP,70.41,278.32,,,,,,
Humana MCR ADV,CPT,J9036,Inj. belrapzo/bendamustine,APC 9313,Per Unit,$21.47 ,OP,21.47,21.47,,,,,,
Humana MCR ADV,CPT,J9037,Inj belantamab mafodont blmf,APC 9384,Per Unit,$42.78 ,OP,42.78,42.78,,,,,,
Humana MCR ADV,CPT,J9039,Injection- blinatumomab,APC 9449,Per Unit,$123.88 ,OP,123.88,123.88,,,,,,
Humana MCR ADV,CPT,J9041,Inj.- velcade 0.1 mg,APC 9207,Per Unit,$45.16 ,OP,45.16,175.39,,,,,,
Humana MCR ADV,CPT,J9042,Brentuximab vedotin inj,APC 9287,Per Unit,$189.34 ,OP,189.34,189.34,,,,,,
Humana MCR ADV,CPT,J9043,Cabazitaxel injection,APC 9276,Per Unit,$189.00 ,OP,189,189,,,,,,
Humana MCR ADV,CPT,J9044,Inj- bortezomib- nos- 0.1 mg,APC 9192,Per Unit,$18.31 ,OP,18.31,18.31,,,,,,
Humana MCR ADV,CPT,J9047,Injection- carfilzomib- 1 mg,APC 9295,Per Unit,$41.10 ,OP,41.1,41.1,,,,,,
Humana MCR ADV,CPT,J9050,Carmustine injection,APC 0812,Per Unit,"$1,234.46 ",OP,"1,234.46","1,234.46",,,,,,
Humana MCR ADV,CPT,J9055,Cetuximab injection,APC 9215,Per Unit,$66.71 ,OP,66.71,240.2,,,,,,
Humana MCR ADV,CPT,J9057,Inj.- copanlisib- 1 mg,APC 9030,Per Unit,$80.96 ,OP,80.96,80.96,,,,,,
Humana MCR ADV,CPT,J9065,Inj cladribine per 1 mg,APC 0858,Per Unit,$18.02 ,OP,18.02,144.88,,,,,,
Humana MCR ADV,CPT,J9070,Cyclophosphamide 100 mg inj,APC 1408,Per Unit,$29.15 ,OP,19.07,29.15,,,,,,
Humana MCR ADV,CPT,J9119,Inj.- cemiplimab-rwlc- 1 mg,APC 9304,Per Unit,$27.54 ,OP,27.54,27.54,,,,,,
Humana MCR ADV,CPT,J9120,Dactinomycin injection,APC 0752,Per Unit,$890.64 ,OP,890.64,"2,634.57",,,,,,
Humana MCR ADV,CPT,J9144,Daratumumab- hyaluronidase,APC 9378,Per Unit,$45.10 ,OP,45.1,45.1,,,,,,
Humana MCR ADV,CPT,J9145,Injection- daratumumab 10 mg,APC 9476,Per Unit,$57.55 ,OP,57.55,57.55,,,,,,
Humana MCR ADV,CPT,J9150,Daunorubicin injection,APC 0820,Per Unit,$40.36 ,OP,40.36,80.07,,,,,,
Humana MCR ADV,CPT,J9153,Inj daunorubicin- cytarabine,APC 9302,Per Unit,$202.60 ,OP,202.6,202.6,,,,,,
Humana MCR ADV,CPT,J9155,Degarelix injection,APC 1296,Per Unit,$4.12 ,OP,4.12,4.12,,,,,,
Humana MCR ADV,CPT,J9173,Inj.- durvalumab- 10 mg,APC 9492,Per Unit,$76.86 ,OP,76.86,76.86,,,,,,
Humana MCR ADV,CPT,J9176,Injection- elotuzumab- 1mg,APC 9477,Per Unit,$6.77 ,OP,6.77,6.77,,,,,,
Humana MCR ADV,CPT,J9177,Inj enfort vedo-ejfv 0.25mg,APC 9364,Per Unit,$30.17 ,OP,30.17,30.17,,,,,,
Humana MCR ADV,CPT,J9179,Eribulin mesylate injection,APC 1426,Per Unit,$123.93 ,OP,123.93,123.93,,,,,,
Humana MCR ADV,CPT,J9198,Inj. infugem- 100 mg,APC 9387,Per Unit,$34.00 ,OP,34,34,,,,,,
Humana MCR ADV,CPT,J9202,Goserelin acetate implant,APC 0810,Per Unit,$525.21 ,OP,525.21,915.04,,,,,,
Humana MCR ADV,CPT,J9203,Gemtuzumab ozogamicin 0.1 mg,APC 9495,Per Unit,$207.99 ,OP,207.99,207.99,,,,,,
Humana MCR ADV,CPT,J9204,Inj mogamulizumab-kpkc- 1 mg,APC 9182,Per Unit,$210.05 ,OP,210.05,210.05,,,,,,
Humana MCR ADV,CPT,J9205,Inj irinotecan liposome 1 mg,APC 9474,Per Unit,$57.20 ,OP,57.2,57.2,,,,,,
Humana MCR ADV,CPT,J9207,Ixabepilone injection,APC 9240,Per Unit,$112.12 ,OP,112.12,308.83,,,,,,
Humana MCR ADV,CPT,J9210,Inj.- emapalumab-lzsg- 1 mg,APC 9310,Per Unit,$376.03 ,OP,376.03,376.03,,,,,,
Humana MCR ADV,CPT,J9214,Interferon alfa-2b inj,APC 0836,Per Unit,$33.24 ,OP,33.24,72.44,,,,,,
Humana MCR ADV,CPT,J9217,Leuprolide acetate suspnsion,APC 9217,Per Unit,$139.09 ,OP,139.09,987.49,,,,,,
Humana MCR ADV,CPT,J9223,Inj. lurbinectedin- 0.1 mg,APC 9389,Per Unit,$174.03 ,OP,174.03,174.03,,,,,,
Humana MCR ADV,CPT,J9225,Vantas implant,APC 1711,Per Unit,"$5,166.29 ",OP,"5,166.29","7,613.94",,,,,,
Humana MCR ADV,CPT,J9226,Supprelin la implant,APC 1142,Per Unit,"$43,467.03 ",OP,"43,467.03","71,949.32",,,,,,
Humana MCR ADV,CPT,J9227,Inj. isatuximab-irfc 10 mg,APC 9377,Per Unit,$67.60 ,OP,67.6,67.6,,,,,,
Humana MCR ADV,CPT,J9228,Ipilimumab injection,APC 9284,Per Unit,$158.65 ,OP,158.65,158.65,,,,,,
Humana MCR ADV,CPT,J9229,Inj inotuzumab ozogam 0.1 mg,APC 9028,Per Unit,"$2,371.62 ",OP,"2,371.62","2,371.62",,,,,,
Humana MCR ADV,CPT,J9230,Mechlorethamine hcl inj,APC 0751,Per Unit,$11.74 ,OP,11.74,712.98,,,,,,
Humana MCR ADV,CPT,J9245,Inj melpha hydroch nos 50 mg,APC 0840,Per Unit,$208.41 ,OP,208.41,"7,888.46",,,,,,
Humana MCR ADV,CPT,J9246,Inj.- evomela- 1 mg,APC 9375,Per Unit,$18.20 ,OP,18.2,18.2,,,,,,
Humana MCR ADV,CPT,J9247,Inj- melphalan flufenami 1mg,APC 9417,Per Unit,$499.86 ,OP,499.86,499.86,,,,,,
Humana MCR ADV,CPT,J9261,Nelarabine injection,APC 0825,Per Unit,$155.90 ,OP,155.9,488.04,,,,,,
Humana MCR ADV,CPT,J9262,Inj- omacetaxine mep- 0.01mg,APC 9297,Per Unit,$3.30 ,OP,3.3,3.3,,,,,,
Humana MCR ADV,CPT,J9264,Paclitaxel protein bound,APC 1712,Per Unit,$14.08 ,OP,14.08,45.74,,,,,,
Humana MCR ADV,CPT,J9266,Pegaspargase injection,APC 0843,Per Unit,"$21,561.05 ",OP,"12,715.34","21,561.05",,,,,,
Humana MCR ADV,CPT,J9268,Pentostatin injection,APC 0844,Per Unit,"$1,880.67 ",OP,"1,880.67","7,030.61",,,,,,
Humana MCR ADV,CPT,J9269,Inj. tagraxofusp-erzs 10 mcg,APC 9309,Per Unit,$290.37 ,OP,290.37,290.37,,,,,,
Humana MCR ADV,CPT,J9270,Plicamycin (mithramycin) inj,APC 9093,Per Unit,$115.40 ,OP,115.4,385.09,,,,,,
Humana MCR ADV,CPT,J9271,Inj pembrolizumab,APC 1490,Per Unit,$52.75 ,OP,52.75,52.75,,,,,,
Humana MCR ADV,CPT,J9280,Mitomycin injection,APC 1232,Per Unit,$38.63 ,OP,38.63,76.26,,,,,,
Humana MCR ADV,CPT,J9281,Mitomycin instillation,APC 9374,Per Unit,$281.88 ,OP,281.88,281.88,,,,,,
Humana MCR ADV,CPT,J9285,Inj- olaratumab- 10 mg,APC 9485,Per Unit,$52.07 ,OP,52.07,52.07,,,,,,
Humana MCR ADV,CPT,J9293,Mitoxantrone hydrochl / 5 mg,APC 0864,Per Unit,$26.29 ,OP,26.29,392.7,,,,,,
Humana MCR ADV,CPT,J9295,Injection- necitumumab- 1 mg,APC 9475,Per Unit,$5.74 ,OP,5.74,5.74,,,,,,
Humana MCR ADV,CPT,J9299,Injection- nivolumab,APC 9453,Per Unit,$28.86 ,OP,28.86,28.86,,,,,,
Humana MCR ADV,CPT,J9301,Obinutuzumab inj,APC 1476,Per Unit,$64.54 ,OP,64.54,64.54,,,,,,
Humana MCR ADV,CPT,J9302,Ofatumumab injection,APC 9260,Per Unit,$63.96 ,OP,63.96,63.96,,,,,,
Humana MCR ADV,CPT,J9303,Panitumumab injection,APC 9235,Per Unit,$130.38 ,OP,130.38,130.38,,,,,,
Humana MCR ADV,CPT,J9305,Inj. pemetrexed nos 10mg,APC 9213,Per Unit,$74.93 ,OP,74.93,232.58,,,,,,
Humana MCR ADV,CPT,J9306,Injection- pertuzumab- 1 mg,APC 1471,Per Unit,$13.56 ,OP,13.56,13.56,,,,,,
Humana MCR ADV,CPT,J9307,Pralatrexate injection,APC 9259,Per Unit,$314.84 ,OP,314.84,314.84,,,,,,
Humana MCR ADV,CPT,J9308,Injection- ramucirumab,APC 1488,Per Unit,$62.69 ,OP,62.69,62.69,,,,,,
Humana MCR ADV,CPT,J9309,Inj- polatuzumab vedotin 1mg,APC 9331,Per Unit,$113.57 ,OP,113.57,113.57,,,,,,
Humana MCR ADV,CPT,J9311,Inj rituximab- hyaluronidase,APC 9467,Per Unit,$37.94 ,OP,37.94,37.94,,,,,,
Humana MCR ADV,CPT,J9312,Inj.- rituximab- 10 mg,APC 9186,Per Unit,$86.94 ,OP,86.94,86.94,,,,,,
Humana MCR ADV,CPT,J9313,Inj.- lumoxiti- 0.01 mg,APC 9305,Per Unit,$23.39 ,OP,23.39,23.39,,,,,,
Humana MCR ADV,CPT,J9316,Pertuzu- trastuzu- 10 mg,APC 9390,Per Unit,$72.15 ,OP,72.15,72.15,,,,,,
Humana MCR ADV,CPT,J9317,Sacituzumab govitecan-hziy,APC 9376,Per Unit,$30.35 ,OP,30.35,30.35,,,,,,
Humana MCR ADV,CPT,J9318,Inj romidepsin non-lyo 0.1mg,APC 9428,Per Unit,$33.91 ,OP,33.91,33.91,,,,,,
Humana MCR ADV,CPT,J9319,Inj romidepsin lyophil 0.1mg,APC 9429,Per Unit,$33.68 ,OP,33.68,33.68,,,,,,
Humana MCR ADV,CPT,J9320,Streptozocin injection,APC 0850,Per Unit,$348.51 ,OP,348.51,"1,372.57",,,,,,
Humana MCR ADV,CPT,J9325,Inj talimogene laherparepvec,APC 9472,Per Unit,$57.26 ,OP,57.26,57.26,,,,,,
Humana MCR ADV,CPT,J9328,Temozolomide injection,APC 9253,Per Unit,$10.41 ,OP,10.41,10.41,,,,,,
Humana MCR ADV,CPT,J9330,Temsirolimus injection,APC 1168,Per Unit,$38.25 ,OP,38.25,38.25,,,,,,
Humana MCR ADV,CPT,J9340,Thiotepa injection,APC 0851,Per Unit,$305.84 ,OP,305.84,446.08,,,,,,
Humana MCR ADV,CPT,J9348,Inj. naxitamab-gqgk- 1 mg,APC 9408,Per Unit,$539.07 ,OP,539.07,539.07,,,,,,
Humana MCR ADV,CPT,J9349,Inj.- tafasitamab-cxix,APC 9385,Per Unit,$12.62 ,OP,12.62,12.62,,,,,,
Humana MCR ADV,CPT,J9352,Injection trabectedin 0.1mg,APC 9480,Per Unit,$325.03 ,OP,325.03,325.03,,,,,,
Humana MCR ADV,CPT,J9353,Inj. margetuximab-cmkb- 5 mg,APC 9418,Per Unit,$42.99 ,OP,42.99,42.99,,,,,,
Humana MCR ADV,CPT,J9354,Inj- ado-trastuzumab emt 1mg,APC 9131,Per Unit,$34.18 ,OP,34.18,34.18,,,,,,
Humana MCR ADV,CPT,J9355,Inj trastuzumab excl biosimi,APC 1613,Per Unit,$89.81 ,OP,89.81,238.1,,,,,,
Humana MCR ADV,CPT,J9356,Inj. herceptin hylecta- 10mg,APC 9314,Per Unit,$71.85 ,OP,71.85,71.85,,,,,,
Humana MCR ADV,CPT,J9357,Valrubicin injection,APC 1235,Per Unit,"$1,425.37 ",OP,"1,425.37","1,795.78",,,,,,
Humana MCR ADV,CPT,J9358,Inj fam-trastu deru-nxki 1mg,APC 9353,Per Unit,$24.27 ,OP,24.27,24.27,,,,,,
Humana MCR ADV,CPT,J9371,Inj- vincristine sul lip 1mg,APC 1466,Per Unit,"$3,370.23 ",OP,28.22,"3,370.23",,,,,,
Humana MCR ADV,CPT,J9395,Injection- fulvestrant,APC 9120,Per Unit,$15.98 ,OP,15.98,396.52,,,,,,
Humana MCR ADV,CPT,J9400,Inj- ziv-aflibercept- 1mg,APC 9296,Per Unit,$8.42 ,OP,8.42,8.42,,,,,,
Humana MCR ADV,CPT,J9600,Porfimer sodium injection,APC 0856,Per Unit,"$21,856.35 ",OP,"13,169.04","21,856.35",,,,,,
Humana MCR ADV,CPT,K0672,Removable soft interface le,Durable Medical Equipment,Per Unit,$85.14 ,OP,85.14,85.14,,,,,,
Humana MCR ADV,CPT,L0112,Cranial cervical orthosis,Durable Medical Equipment,Per Unit,"$1,404.96 ",OP,"1,404.96","4,830.68",,,,,,
Humana MCR ADV,CPT,L0113,Cranial cervical torticollis,Durable Medical Equipment,Per Unit,$286.27 ,OP,286.27,286.27,,,,,,
Humana MCR ADV,CPT,L0120,Cerv flex n/adj foam pre ots,Durable Medical Equipment,Per Unit,$26.55 ,OP,26.55,91.51,,,,,,
Humana MCR ADV,CPT,L0130,Flex thermoplastic collar mo,Durable Medical Equipment,Per Unit,$153.23 ,OP,153.23,526.16,,,,,,
Humana MCR ADV,CPT,L0140,Cervical semi-rigid adjustab,Durable Medical Equipment,Per Unit,$60.09 ,OP,60.09,205.88,,,,,,
Humana MCR ADV,CPT,L0150,Cerv semi-rig adj molded chn,Durable Medical Equipment,Per Unit,$107.45 ,OP,107.45,369.83,,,,,,
Humana MCR ADV,CPT,L0160,Cerv sr wire occ/man pre ots,Durable Medical Equipment,Per Unit,$156.89 ,OP,156.89,541.4,,,,,,
Humana MCR ADV,CPT,L0170,Cervical collar molded to pt,Durable Medical Equipment,Per Unit,$807.10 ,OP,807.1,"2,775.65",,,,,,
Humana MCR ADV,CPT,L0172,Cerv col sr foam 2pc pre ots,Durable Medical Equipment,Per Unit,$142.17 ,OP,142.17,488.04,,,,,,
Humana MCR ADV,CPT,L0174,Cerv sr 2pc thor ext pre ots,Durable Medical Equipment,Per Unit,$279.55 ,OP,279.55,960.8,,,,,,
Humana MCR ADV,CPT,L0180,Cer post col occ/man sup adj,Durable Medical Equipment,Per Unit,$452.88 ,OP,452.88,"1,559.39",,,,,,
Humana MCR ADV,CPT,L0190,Cerv collar supp adj cerv ba,Durable Medical Equipment,Per Unit,$534.12 ,OP,534.12,"1,837.71",,,,,,
Humana MCR ADV,CPT,L0200,Cerv col supp adj bar & thor,Durable Medical Equipment,Per Unit,$619.54 ,OP,619.54,"2,131.30",,,,,,
Humana MCR ADV,CPT,L0220,Thor rib belt custom fabrica,Durable Medical Equipment,Per Unit,$129.68 ,OP,129.68,446.08,,,,,,
Humana MCR ADV,CPT,L0450,Tlso flex trunk/thor pre ots,Durable Medical Equipment,Per Unit,$128.11 ,OP,128.11,560.47,,,,,,
Humana MCR ADV,CPT,L0454,Tlso trnk sj-t9 pre cst,Durable Medical Equipment,Per Unit,$348.14 ,OP,348.14,"1,197.20",,,,,,
Humana MCR ADV,CPT,L0455,Tlso flex trnk sj-t9 pre ots,Durable Medical Equipment,Per Unit,$249.16 ,OP,249.16,249.16,,,,,,
Humana MCR ADV,CPT,L0456,Tlso flex trnk sj-ss pre cst,Durable Medical Equipment,Per Unit,$998.38 ,OP,998.38,"3,435.25",,,,,,
Humana MCR ADV,CPT,L0457,Tlso flex trnk sj-ss pre ots,Durable Medical Equipment,Per Unit,$714.52 ,OP,714.52,714.52,,,,,,
Humana MCR ADV,CPT,L0458,Tlso 2mod symphis-xipho pre,Durable Medical Equipment,Per Unit,$895.27 ,OP,895.27,"3,080.66",,,,,,
Humana MCR ADV,CPT,L0460,Tlso 2 shl symphys-stern cst,Durable Medical Equipment,Per Unit,"$1,007.68 ",OP,"1,007.68","3,465.73",,,,,,
Humana MCR ADV,CPT,L0462,Tlso 3mod sacro-scap pre,Durable Medical Equipment,Per Unit,"$1,253.37 ",OP,"1,253.37","4,312.16",,,,,,
Humana MCR ADV,CPT,L0464,Tlso 4mod sacro-scap pre,Durable Medical Equipment,Per Unit,"$1,492.13 ",OP,"1,492.13","5,131.88",,,,,,
Humana MCR ADV,CPT,L0466,Tlso r fram soft ant pre cst,Durable Medical Equipment,Per Unit,$380.86 ,OP,380.86,"1,311.56",,,,,,
Humana MCR ADV,CPT,L0467,Tlso r fram soft pre ots,Durable Medical Equipment,Per Unit,$277.04 ,OP,277.04,277.04,,,,,,
Humana MCR ADV,CPT,L0468,Tlso rig fram pelvic pre cst,Durable Medical Equipment,Per Unit,$477.29 ,OP,477.29,"1,643.28",,,,,,
Humana MCR ADV,CPT,L0469,Tlso rig fram pelvic pre ots,Durable Medical Equipment,Per Unit,$351.00 ,OP,351,351,,,,,,
Humana MCR ADV,CPT,L0470,Tlso rigid frame pre subclav,Durable Medical Equipment,Per Unit,$660.47 ,OP,660.47,"2,272.36",,,,,,
Humana MCR ADV,CPT,L0472,Tlso rigid frame hyperex pre,Durable Medical Equipment,Per Unit,$406.41 ,OP,406.41,"1,399.26",,,,,,
Humana MCR ADV,CPT,L0480,Tlso rigid plastic custom fa,Durable Medical Equipment,Per Unit,"$1,516.23 ",OP,"1,516.23","5,215.77",,,,,,
Humana MCR ADV,CPT,L0482,Tlso rigid lined custom fab,Durable Medical Equipment,Per Unit,"$1,693.64 ",OP,"1,693.64","5,825.80",,,,,,
Humana MCR ADV,CPT,L0484,Tlso rigid plastic cust fab,Durable Medical Equipment,Per Unit,"$1,829.06 ",OP,"1,829.06","6,290.94",,,,,,
Humana MCR ADV,CPT,L0486,Tlso rigidlined cust fab two,Durable Medical Equipment,Per Unit,"$2,054.11 ",OP,"2,054.11","7,064.92",,,,,,
Humana MCR ADV,CPT,L0488,Tlso rigid lined pre one pie,Durable Medical Equipment,Per Unit,"$1,007.68 ",OP,"1,007.68","3,465.73",,,,,,
Humana MCR ADV,CPT,L0490,Tlso rigid plastic pre one,Durable Medical Equipment,Per Unit,$283.96 ,OP,283.96,976.05,,,,,,
Humana MCR ADV,CPT,L0491,Tlso 2 piece rigid shell,Durable Medical Equipment,Per Unit,$770.93 ,OP,770.93,"2,649.83",,,,,,
Humana MCR ADV,CPT,L0492,Tlso 3 piece rigid shell,Durable Medical Equipment,Per Unit,$502.01 ,OP,502.01,"1,727.15",,,,,,
Humana MCR ADV,CPT,L0621,Sio flex pelvic/sacr pre ots,Durable Medical Equipment,Per Unit,$67.68 ,OP,67.68,446.08,,,,,,
Humana MCR ADV,CPT,L0622,Sio flex pelvisacral custom,Durable Medical Equipment,Per Unit,$268.31 ,OP,268.31,"1,384.01",,,,,,
Humana MCR ADV,CPT,L0623,Sio rig pnl pelv/sac pre ots,Durable Medical Equipment,Per Unit,$126.95 ,OP,126.95,126.95,,,,,,
Humana MCR ADV,CPT,L0625,Lo flex l1-below l5 pre ots,Durable Medical Equipment,Per Unit,$39.58 ,OP,39.58,285.96,,,,,,
Humana MCR ADV,CPT,L0626,Lo sag rig pnl stays pre cst,Durable Medical Equipment,Per Unit,$78.25 ,OP,78.25,404.14,,,,,,
Humana MCR ADV,CPT,L0627,Lo sag ri an/pos pnl pre cst,Durable Medical Equipment,Per Unit,$412.59 ,OP,412.59,"2,127.49",,,,,,
Humana MCR ADV,CPT,L0628,Lso flex no ri stays pre ots,Durable Medical Equipment,Per Unit,$60.27 ,OP,60.27,434.65,,,,,,
Humana MCR ADV,CPT,L0630,Lso r post pnl sj-t9 pre cst,Durable Medical Equipment,Per Unit,$162.59 ,OP,162.59,838.79,,,,,,
Humana MCR ADV,CPT,L0631,Lso sag r an/pos pnl pre cst,Durable Medical Equipment,Per Unit,"$1,030.49 ",OP,"1,030.49","5,314.90",,,,,,
Humana MCR ADV,CPT,L0633,Lso sc r pos/lat pnl pre cst,Durable Medical Equipment,Per Unit,$287.85 ,OP,287.85,"1,483.14",,,,,,
Humana MCR ADV,CPT,L0635,Lso sagit rigid panel prefab,Durable Medical Equipment,Per Unit,"$1,003.05 ",OP,"1,003.05","5,173.83",,,,,,
Humana MCR ADV,CPT,L0636,Lso sagittal rigid panel cus,Durable Medical Equipment,Per Unit,"$1,360.98 ",OP,"1,360.98","7,019.17",,,,,,
Humana MCR ADV,CPT,L0637,Lso sc r ant/pos pnl pre cst,Durable Medical Equipment,Per Unit,"$1,300.47 ",OP,"1,300.47","6,710.34",,,,,,
Humana MCR ADV,CPT,L0638,Lso sag-coronal panel custom,Durable Medical Equipment,Per Unit,"$1,323.97 ",OP,"1,323.97","6,828.54",,,,,,
Humana MCR ADV,CPT,L0639,Lso s/c shell/panel prefab,Durable Medical Equipment,Per Unit,"$1,300.47 ",OP,"1,300.47","6,710.34",,,,,,
Humana MCR ADV,CPT,L0640,Lso s/c shell/panel custom,Durable Medical Equipment,Per Unit,"$1,050.39 ",OP,"1,050.39","5,417.84",,,,,,
Humana MCR ADV,CPT,L0641,Lo rig pos pnl l1-l5 pre ots,Durable Medical Equipment,Per Unit,$56.00 ,OP,56,56,,,,,,
Humana MCR ADV,CPT,L0642,Lo sag ri an/pos pnl pre ots,Durable Medical Equipment,Per Unit,$295.35 ,OP,295.35,295.35,,,,,,
Humana MCR ADV,CPT,L0643,Lso sag ctr rigi pos pre ots,Durable Medical Equipment,Per Unit,$116.37 ,OP,116.37,116.37,,,,,,
Humana MCR ADV,CPT,L0648,Lso sag r an/pos pnl pre ots,Durable Medical Equipment,Per Unit,$737.61 ,OP,737.61,737.61,,,,,,
Humana MCR ADV,CPT,L0649,Lso sc r pos/lat pnl pre ots,Durable Medical Equipment,Per Unit,$206.04 ,OP,206.04,206.04,,,,,,
Humana MCR ADV,CPT,L0650,Lso sc r ant/pos pnl pre ots,Durable Medical Equipment,Per Unit,$880.49 ,OP,880.49,880.49,,,,,,
Humana MCR ADV,CPT,L0651,Lso sag-co shell pnl pre ots,Durable Medical Equipment,Per Unit,$880.49 ,OP,880.49,880.49,,,,,,
Humana MCR ADV,CPT,L0700,Ctlso a-p-l control molded,Durable Medical Equipment,Per Unit,"$1,998.37 ",OP,"1,998.37","6,874.29",,,,,,
Humana MCR ADV,CPT,L0710,Ctlso a-p-l control w/ inter,Durable Medical Equipment,Per Unit,"$2,196.75 ",OP,"2,196.75","7,552.94",,,,,,
Humana MCR ADV,CPT,L0810,Halo cervical into jckt vest,Durable Medical Equipment,Per Unit,"$2,683.14 ",OP,"2,683.14","9,226.72",,,,,,
Humana MCR ADV,CPT,L0820,Halo cervical into body jack,Durable Medical Equipment,Per Unit,"$2,110.65 ",OP,"2,110.65","7,259.37",,,,,,
Humana MCR ADV,CPT,L0830,Halo cerv into milwaukee typ,Durable Medical Equipment,Per Unit,"$3,229.60 ",OP,"3,229.60","11,106.37",,,,,,
Humana MCR ADV,CPT,L0859,Mri compatible system,Durable Medical Equipment,Per Unit,"$1,143.45 ",OP,"1,143.45","3,930.89",,,,,,
Humana MCR ADV,CPT,L0861,Halo repl liner/interface,Durable Medical Equipment,Per Unit,$216.37 ,OP,216.37,743.48,,,,,,
Humana MCR ADV,CPT,L0970,Tlso corset front,Durable Medical Equipment,Per Unit,$107.27 ,OP,107.27,369.83,,,,,,
Humana MCR ADV,CPT,L0972,Lso corset front,Durable Medical Equipment,Per Unit,$97.64 ,OP,97.64,335.53,,,,,,
Humana MCR ADV,CPT,L0974,Tlso full corset,Durable Medical Equipment,Per Unit,$175.42 ,OP,175.42,602.41,,,,,,
Humana MCR ADV,CPT,L0976,Lso full corset,Durable Medical Equipment,Per Unit,$150.09 ,OP,150.09,150.09,,,,,,
Humana MCR ADV,CPT,L0978,Axillary crutch extension,Durable Medical Equipment,Per Unit,$188.90 ,OP,188.9,648.16,,,,,,
Humana MCR ADV,CPT,L0980,Peroneal straps pair pre ots,Durable Medical Equipment,Per Unit,$17.15 ,OP,17.15,57.19,,,,,,
Humana MCR ADV,CPT,L0982,Stocking sup grips 4 pre ots,Durable Medical Equipment,Per Unit,$15.70 ,OP,15.7,53.38,,,,,,
Humana MCR ADV,CPT,L0984,Protect body sock ea pre ots,Durable Medical Equipment,Per Unit,$67.93 ,OP,67.93,232.58,,,,,,
Humana MCR ADV,CPT,L1000,Ctlso milwauke initial model,Durable Medical Equipment,Per Unit,"$2,035.53 ",OP,"2,035.53","7,000.10",,,,,,
Humana MCR ADV,CPT,L1005,Tension based scoliosis orth,Durable Medical Equipment,Per Unit,"$3,212.88 ",OP,"3,212.88","11,049.19",,,,,,
Humana MCR ADV,CPT,L1010,Ctlso axilla sling,Durable Medical Equipment,Per Unit,$83.99 ,OP,83.99,289.76,,,,,,
Humana MCR ADV,CPT,L1020,Kyphosis pad,Durable Medical Equipment,Per Unit,$108.17 ,OP,108.17,373.65,,,,,,
Humana MCR ADV,CPT,L1025,Kyphosis pad floating,Durable Medical Equipment,Per Unit,$156.06 ,OP,156.06,537.6,,,,,,
Humana MCR ADV,CPT,L1030,Lumbar bolster pad,Durable Medical Equipment,Per Unit,$78.60 ,OP,78.6,270.71,,,,,,
Humana MCR ADV,CPT,L1040,Lumbar or lumbar rib pad,Durable Medical Equipment,Per Unit,$89.00 ,OP,89,305.01,,,,,,
Humana MCR ADV,CPT,L1050,Sternal pad,Durable Medical Equipment,Per Unit,$100.72 ,OP,100.72,346.96,,,,,,
Humana MCR ADV,CPT,L1060,Thoracic pad,Durable Medical Equipment,Per Unit,$108.72 ,OP,108.72,373.65,,,,,,
Humana MCR ADV,CPT,L1070,Trapezius sling,Durable Medical Equipment,Per Unit,$112.62 ,OP,112.62,388.89,,,,,,
Humana MCR ADV,CPT,L1080,Outrigger,Durable Medical Equipment,Per Unit,$52.52 ,OP,52.52,179.2,,,,,,
Humana MCR ADV,CPT,L1085,Outrigger bil w/ vert extens,Durable Medical Equipment,Per Unit,$175.83 ,OP,175.83,606.21,,,,,,
Humana MCR ADV,CPT,L1090,Lumbar sling,Durable Medical Equipment,Per Unit,$101.01 ,OP,101.01,346.96,,,,,,
Humana MCR ADV,CPT,L1100,Ring flange plastic/leather,Durable Medical Equipment,Per Unit,$190.64 ,OP,190.64,655.78,,,,,,
Humana MCR ADV,CPT,L1110,Ring flange plas/leather mol,Durable Medical Equipment,Per Unit,$319.63 ,OP,319.63,"1,098.07",,,,,,
Humana MCR ADV,CPT,L1120,Covers for upright each,Durable Medical Equipment,Per Unit,$38.18 ,OP,38.18,129.64,,,,,,
Humana MCR ADV,CPT,L1200,Furnsh initial orthosis only,Durable Medical Equipment,Per Unit,"$1,796.37 ",OP,"1,796.37","6,176.57",,,,,,
Humana MCR ADV,CPT,L1210,Lateral thoracic extension,Durable Medical Equipment,Per Unit,$245.60 ,OP,245.6,846.41,,,,,,
Humana MCR ADV,CPT,L1220,Anterior thoracic extension,Durable Medical Equipment,Per Unit,$239.05 ,OP,239.05,823.54,,,,,,
Humana MCR ADV,CPT,L1230,Milwaukee type superstructur,Durable Medical Equipment,Per Unit,$669.67 ,OP,669.67,"2,302.87",,,,,,
Humana MCR ADV,CPT,L1240,Lumbar derotation pad,Durable Medical Equipment,Per Unit,$91.29 ,OP,91.29,312.64,,,,,,
Humana MCR ADV,CPT,L1250,Anterior asis pad,Durable Medical Equipment,Per Unit,$79.39 ,OP,79.39,274.51,,,,,,
Humana MCR ADV,CPT,L1260,Anterior thoracic derotation,Durable Medical Equipment,Per Unit,$94.68 ,OP,94.68,324.09,,,,,,
Humana MCR ADV,CPT,L1270,Abdominal pad,Durable Medical Equipment,Per Unit,$83.20 ,OP,83.2,285.96,,,,,,
Humana MCR ADV,CPT,L1280,Rib gusset (elastic) each,Durable Medical Equipment,Per Unit,$87.71 ,OP,87.71,301.2,,,,,,
Humana MCR ADV,CPT,L1290,Lateral trochanteric pad,Durable Medical Equipment,Per Unit,$78.00 ,OP,78,266.89,,,,,,
Humana MCR ADV,CPT,L1300,Body jacket mold to patient,Durable Medical Equipment,Per Unit,"$1,730.06 ",OP,"1,730.06","5,951.62",,,,,,
Humana MCR ADV,CPT,L1310,Post-operative body jacket,Durable Medical Equipment,Per Unit,"$1,802.00 ",OP,"1,802.00","6,195.63",,,,,,
Humana MCR ADV,CPT,L1600,Ho flex frejka w/cov pre cst,Durable Medical Equipment,Per Unit,$129.35 ,OP,129.35,446.08,,,,,,
Humana MCR ADV,CPT,L1610,Ho frejka cov only pre cst,Durable Medical Equipment,Per Unit,$54.94 ,OP,54.94,190.64,,,,,,
Humana MCR ADV,CPT,L1620,Ho flex pavlik harns pre cst,Durable Medical Equipment,Per Unit,$157.73 ,OP,157.73,541.4,,,,,,
Humana MCR ADV,CPT,L1630,Abduct control hip semi-flex,Durable Medical Equipment,Per Unit,$212.06 ,OP,212.06,728.23,,,,,,
Humana MCR ADV,CPT,L1640,Pelv band/spread bar thigh c,Durable Medical Equipment,Per Unit,$475.20 ,OP,475.2,"1,635.64",,,,,,
Humana MCR ADV,CPT,L1650,Ho abduction hip adjustable,Durable Medical Equipment,Per Unit,$247.55 ,OP,247.55,850.23,,,,,,
Humana MCR ADV,CPT,L1652,Ho bi thighcuffs w sprdr bar,Durable Medical Equipment,Per Unit,$357.83 ,OP,357.83,"1,231.50",,,,,,
Humana MCR ADV,CPT,L1660,Ho abduction static plastic,Durable Medical Equipment,Per Unit,$181.40 ,OP,181.4,625.29,,,,,,
Humana MCR ADV,CPT,L1680,Pelvic & hip control thigh c,Durable Medical Equipment,Per Unit,"$1,143.62 ",OP,"1,143.62","3,934.69",,,,,,
Humana MCR ADV,CPT,L1685,Post-op hip abduct custom fa,Durable Medical Equipment,Per Unit,"$1,116.47 ",OP,"1,116.47","3,839.39",,,,,,
Humana MCR ADV,CPT,L1686,Ho post-op hip abduction,Durable Medical Equipment,Per Unit,$940.60 ,OP,940.6,"3,233.17",,,,,,
Humana MCR ADV,CPT,L1690,Combination bilateral ho,Durable Medical Equipment,Per Unit,"$1,941.15 ",OP,"1,941.15","6,676.03",,,,,,
Humana MCR ADV,CPT,L1700,Leg perthes orth toronto typ,Durable Medical Equipment,Per Unit,"$1,561.78 ",OP,"1,561.78","5,372.08",,,,,,
Humana MCR ADV,CPT,L1710,Legg perthes orth newington,Durable Medical Equipment,Per Unit,"$1,988.75 ",OP,"1,988.75","6,839.98",,,,,,
Humana MCR ADV,CPT,L1720,Legg perthes orthosis trilat,Durable Medical Equipment,Per Unit,"$1,480.82 ",OP,"1,480.82","5,093.76",,,,,,
Humana MCR ADV,CPT,L1730,Legg perthes orth scottish r,Durable Medical Equipment,Per Unit,"$1,250.14 ",OP,"1,250.14","4,300.73",,,,,,
Humana MCR ADV,CPT,L1755,Legg perthes patten bottom t,Durable Medical Equipment,Per Unit,"$1,797.35 ",OP,"1,797.35","6,180.39",,,,,,
Humana MCR ADV,CPT,L1810,Ko elastic with joints,Durable Medical Equipment,Per Unit,$103.34 ,OP,103.34,103.34,,,,,,
Humana MCR ADV,CPT,L1812,Ko elastic w/joints pre ots,Durable Medical Equipment,Per Unit,$81.50 ,OP,81.5,81.5,,,,,,
Humana MCR ADV,CPT,L1820,Ko elas w/ condyle pads & jo,Durable Medical Equipment,Per Unit,$142.66 ,OP,142.66,142.66,,,,,,
Humana MCR ADV,CPT,L1830,Ko immob canvas long pre ots,Durable Medical Equipment,Per Unit,$71.04 ,OP,71.04,285.96,,,,,,
Humana MCR ADV,CPT,L1831,Knee orth pos locking joint,Durable Medical Equipment,Per Unit,$295.44 ,OP,295.44,"1,017.99",,,,,,
Humana MCR ADV,CPT,L1832,Ko adj jnt pos r sup pre cst,Durable Medical Equipment,Per Unit,$691.44 ,OP,691.44,"2,379.12",,,,,,
Humana MCR ADV,CPT,L1833,Ko adj jnt pos r sup pre ots,Durable Medical Equipment,Per Unit,$534.19 ,OP,534.19,534.19,,,,,,
Humana MCR ADV,CPT,L1834,Ko w/0 joint rigid molded to,Durable Medical Equipment,Per Unit,$728.61 ,OP,728.61,"2,504.94",,,,,,
Humana MCR ADV,CPT,L1836,Ko rigid w/o joints pre ots,Durable Medical Equipment,Per Unit,$104.41 ,OP,104.41,104.41,,,,,,
Humana MCR ADV,CPT,L1840,Ko derot ant cruciate custom,Durable Medical Equipment,Per Unit,$944.00 ,OP,944,"3,248.41",,,,,,
Humana MCR ADV,CPT,L1843,Ko single upright pre cst,Durable Medical Equipment,Per Unit,$900.70 ,OP,900.7,"3,095.90",,,,,,
Humana MCR ADV,CPT,L1844,Ko w/adj jt rot cntrl molded,Durable Medical Equipment,Per Unit,"$1,528.66 ",OP,"1,528.66","5,257.70",,,,,,
Humana MCR ADV,CPT,L1845,Ko double upright pre cst,Durable Medical Equipment,Per Unit,$840.88 ,OP,840.88,840.88,,,,,,
Humana MCR ADV,CPT,L1846,Ko w adj flex/ext rotat mold,Durable Medical Equipment,Per Unit,"$1,174.51 ",OP,"1,174.51","1,174.51",,,,,,
Humana MCR ADV,CPT,L1847,Ko dbl upright w/air pre cst,Durable Medical Equipment,Per Unit,$577.37 ,OP,577.37,"1,986.41",,,,,,
Humana MCR ADV,CPT,L1848,Ko dbl upright w/air pre ots,Durable Medical Equipment,Per Unit,$577.37 ,OP,577.37,577.37,,,,,,
Humana MCR ADV,CPT,L1850,Ko swedish type pre ots,Durable Medical Equipment,Per Unit,$234.85 ,OP,234.85,983.68,,,,,,
Humana MCR ADV,CPT,L1851,Ko single upright prefab ots,Durable Medical Equipment,Per Unit,$702.11 ,OP,702.11,702.11,,,,,,
Humana MCR ADV,CPT,L1852,Ko double upright prefab ots,Durable Medical Equipment,Per Unit,$665.20 ,OP,665.2,665.2,,,,,,
Humana MCR ADV,CPT,L1860,Ko supracondylar socket mold,Durable Medical Equipment,Per Unit,"$1,251.75 ",OP,"1,251.75","4,304.53",,,,,,
Humana MCR ADV,CPT,L1900,Afo sprng wir drsflx calf bd,Durable Medical Equipment,Per Unit,$286.39 ,OP,286.39,983.68,,,,,,
Humana MCR ADV,CPT,L1902,Afo ankle gauntlet pre ots,Durable Medical Equipment,Per Unit,$74.93 ,OP,74.93,259.27,,,,,,
Humana MCR ADV,CPT,L1904,Afo molded ankle gauntlet,Durable Medical Equipment,Per Unit,$453.09 ,OP,453.09,"1,559.39",,,,,,
Humana MCR ADV,CPT,L1906,Afo multilig ank sup pre ots,Durable Medical Equipment,Per Unit,$112.88 ,OP,112.88,388.89,,,,,,
Humana MCR ADV,CPT,L1907,Afo supramalleolar custom,Durable Medical Equipment,Per Unit,$564.86 ,OP,564.86,"1,944.48",,,,,,
Humana MCR ADV,CPT,L1910,Afo sing bar clasp attach sh,Durable Medical Equipment,Per Unit,$281.51 ,OP,281.51,968.43,,,,,,
Humana MCR ADV,CPT,L1920,Afo sing upright w/ adjust s,Durable Medical Equipment,Per Unit,$412.37 ,OP,412.37,"1,418.32",,,,,,
Humana MCR ADV,CPT,L1930,Afo plastic,Durable Medical Equipment,Per Unit,$252.89 ,OP,252.89,869.3,,,,,,
Humana MCR ADV,CPT,L1932,Afo rig ant tib prefab tcf/=,Durable Medical Equipment,Per Unit,$895.75 ,OP,895.75,"3,080.66",,,,,,
Humana MCR ADV,CPT,L1940,Afo molded to patient plasti,Durable Medical Equipment,Per Unit,$488.84 ,OP,488.84,"1,681.40",,,,,,
Humana MCR ADV,CPT,L1945,Afo molded plas rig ant tib,Durable Medical Equipment,Per Unit,"$1,126.77 ",OP,"1,126.77","3,873.69",,,,,,
Humana MCR ADV,CPT,L1950,Afo spiral molded to pt plas,Durable Medical Equipment,Per Unit,$772.00 ,OP,772,"2,653.63",,,,,,
Humana MCR ADV,CPT,L1951,Afo spiral prefabricated,Durable Medical Equipment,Per Unit,$843.02 ,OP,843.02,"2,897.65",,,,,,
Humana MCR ADV,CPT,L1960,Afo pos solid ank plastic mo,Durable Medical Equipment,Per Unit,$622.25 ,OP,622.25,"2,138.93",,,,,,
Humana MCR ADV,CPT,L1970,Afo plastic molded w/ankle j,Durable Medical Equipment,Per Unit,$694.78 ,OP,694.78,"2,390.56",,,,,,
Humana MCR ADV,CPT,L1971,Afo w/ankle joint- prefab,Durable Medical Equipment,Per Unit,$470.55 ,OP,470.55,"1,616.58",,,,,,
Humana MCR ADV,CPT,L1980,Afo sing solid stirrup calf,Durable Medical Equipment,Per Unit,$405.31 ,OP,405.31,"1,395.45",,,,,,
Humana MCR ADV,CPT,L1990,Afo doub solid stirrup calf,Durable Medical Equipment,Per Unit,$469.10 ,OP,469.1,"1,612.76",,,,,,
Humana MCR ADV,CPT,L2000,Kafo sing fre stirr thi/calf,Durable Medical Equipment,Per Unit,"$1,122.95 ",OP,"1,122.95","3,862.25",,,,,,
Humana MCR ADV,CPT,L2005,Kafo sng/dbl mechanical act,Durable Medical Equipment,Per Unit,"$4,113.39 ",OP,"4,113.39","14,145.09",,,,,,
Humana MCR ADV,CPT,L2010,Kafo sng solid stirrup w/o j,Durable Medical Equipment,Per Unit,$875.89 ,OP,875.89,"3,012.03",,,,,,
Humana MCR ADV,CPT,L2020,Kafo dbl solid stirrup band/,Durable Medical Equipment,Per Unit,"$1,106.22 ",OP,"1,106.22","3,805.07",,,,,,
Humana MCR ADV,CPT,L2030,Kafo dbl solid stirrup w/o j,Durable Medical Equipment,Per Unit,"$1,087.33 ",OP,"1,087.33","3,740.26",,,,,,
Humana MCR ADV,CPT,L2034,Kafo pla sin up w/wo k/a cus,Durable Medical Equipment,Per Unit,"$2,039.24 ",OP,"2,039.24","7,011.54",,,,,,
Humana MCR ADV,CPT,L2035,Kafo plastic pediatric size,Durable Medical Equipment,Per Unit,$173.91 ,OP,173.91,598.59,,,,,,
Humana MCR ADV,CPT,L2036,Kafo plas doub free knee mol,Durable Medical Equipment,Per Unit,"$1,861.04 ",OP,"1,861.04","6,401.51",,,,,,
Humana MCR ADV,CPT,L2037,Kafo plas sing free knee mol,Durable Medical Equipment,Per Unit,"$1,664.67 ",OP,"1,664.67","5,726.65",,,,,,
Humana MCR ADV,CPT,L2038,Kafo w/o joint multi-axis an,Durable Medical Equipment,Per Unit,"$1,341.97 ",OP,"1,341.97","4,613.36",,,,,,
Humana MCR ADV,CPT,L2040,Hkafo torsion bil rot straps,Durable Medical Equipment,Per Unit,$203.08 ,OP,203.08,697.72,,,,,,
Humana MCR ADV,CPT,L2050,Hkafo torsion cable hip pelv,Durable Medical Equipment,Per Unit,$489.17 ,OP,489.17,"1,681.40",,,,,,
Humana MCR ADV,CPT,L2060,Hkafo torsion ball bearing j,Durable Medical Equipment,Per Unit,$611.86 ,OP,611.86,"2,104.61",,,,,,
Humana MCR ADV,CPT,L2070,Hkafo torsion unilat rot str,Durable Medical Equipment,Per Unit,$155.80 ,OP,155.8,537.6,,,,,,
Humana MCR ADV,CPT,L2080,Hkafo unilat torsion cable,Durable Medical Equipment,Per Unit,$374.61 ,OP,374.61,"1,288.69",,,,,,
Humana MCR ADV,CPT,L2090,Hkafo unilat torsion ball br,Durable Medical Equipment,Per Unit,$499.12 ,OP,499.12,"1,715.71",,,,,,
Humana MCR ADV,CPT,L2106,Afo tib fx cast plaster mold,Durable Medical Equipment,Per Unit,$791.23 ,OP,791.23,"2,722.27",,,,,,
Humana MCR ADV,CPT,L2108,Afo tib fx cast molded to pt,Durable Medical Equipment,Per Unit,"$1,154.03 ",OP,"1,154.03","3,969.02",,,,,,
Humana MCR ADV,CPT,L2112,Afo tibial fracture soft,Durable Medical Equipment,Per Unit,$506.43 ,OP,506.43,"1,742.41",,,,,,
Humana MCR ADV,CPT,L2114,Afo tib fx semi-rigid,Durable Medical Equipment,Per Unit,$634.33 ,OP,634.33,634.33,,,,,,
Humana MCR ADV,CPT,L2116,Afo tibial fracture rigid,Durable Medical Equipment,Per Unit,$773.69 ,OP,773.69,773.69,,,,,,
Humana MCR ADV,CPT,L2126,Kafo fem fx cast thermoplas,Durable Medical Equipment,Per Unit,"$1,281.77 ",OP,"1,281.77","4,407.46",,,,,,
Humana MCR ADV,CPT,L2128,Kafo fem fx cast molded to p,Durable Medical Equipment,Per Unit,"$1,609.47 ",OP,"1,609.47","5,536.03",,,,,,
Humana MCR ADV,CPT,L2132,Kafo femoral fx cast soft,Durable Medical Equipment,Per Unit,$976.92 ,OP,976.92,"3,358.99",,,,,,
Humana MCR ADV,CPT,L2134,Kafo fem fx cast semi-rigid,Durable Medical Equipment,Per Unit,"$1,156.80 ",OP,"1,156.80","3,976.64",,,,,,
Humana MCR ADV,CPT,L2136,Kafo femoral fx cast rigid,Durable Medical Equipment,Per Unit,"$1,265.95 ",OP,"1,265.95","4,354.09",,,,,,
Humana MCR ADV,CPT,L2180,Plas shoe insert w ank joint,Durable Medical Equipment,Per Unit,$133.08 ,OP,133.08,457.52,,,,,,
Humana MCR ADV,CPT,L2182,Drop lock knee,Durable Medical Equipment,Per Unit,$114.71 ,OP,114.71,392.7,,,,,,
Humana MCR ADV,CPT,L2184,Limited motion knee joint,Durable Medical Equipment,Per Unit,$116.27 ,OP,116.27,400.34,,,,,,
Humana MCR ADV,CPT,L2186,Adj motion knee jnt lerman t,Durable Medical Equipment,Per Unit,$154.63 ,OP,154.63,529.96,,,,,,
Humana MCR ADV,CPT,L2188,Quadrilateral brim,Durable Medical Equipment,Per Unit,$281.10 ,OP,281.1,968.43,,,,,,
Humana MCR ADV,CPT,L2190,Waist belt,Durable Medical Equipment,Per Unit,$85.62 ,OP,85.62,293.57,,,,,,
Humana MCR ADV,CPT,L2192,Pelvic band & belt thigh fla,Durable Medical Equipment,Per Unit,$334.67 ,OP,334.67,"1,151.42",,,,,,
Humana MCR ADV,CPT,L2200,Limited ankle motion ea jnt,Durable Medical Equipment,Per Unit,$50.44 ,OP,50.44,175.39,,,,,,
Humana MCR ADV,CPT,L2210,Dorsiflexion assist each joi,Durable Medical Equipment,Per Unit,$63.09 ,OP,63.09,217.32,,,,,,
Humana MCR ADV,CPT,L2220,Dorsi & plantar flex ass/res,Durable Medical Equipment,Per Unit,$81.22 ,OP,81.22,278.32,,,,,,
Humana MCR ADV,CPT,L2230,Split flat caliper stirr & p,Durable Medical Equipment,Per Unit,$96.02 ,OP,96.02,331.7,,,,,,
Humana MCR ADV,CPT,L2232,Rocker bottom- contact afo,Durable Medical Equipment,Per Unit,$97.51 ,OP,97.51,335.53,,,,,,
Humana MCR ADV,CPT,L2240,Round caliper and plate atta,Durable Medical Equipment,Per Unit,$95.58 ,OP,95.58,327.9,,,,,,
Humana MCR ADV,CPT,L2250,Foot plate molded stirrup at,Durable Medical Equipment,Per Unit,$335.30 ,OP,335.3,"1,151.42",,,,,,
Humana MCR ADV,CPT,L2260,Reinforced solid stirrup,Durable Medical Equipment,Per Unit,$188.16 ,OP,188.16,648.16,,,,,,
Humana MCR ADV,CPT,L2265,Long tongue stirrup,Durable Medical Equipment,Per Unit,$134.94 ,OP,134.94,465.15,,,,,,
Humana MCR ADV,CPT,L2270,Varus/valgus strap padded/li,Durable Medical Equipment,Per Unit,$61.87 ,OP,61.87,213.51,,,,,,
Humana MCR ADV,CPT,L2275,Plastic mod low ext pad/line,Durable Medical Equipment,Per Unit,$130.85 ,OP,130.85,449.9,,,,,,
Humana MCR ADV,CPT,L2280,Molded inner boot,Durable Medical Equipment,Per Unit,$566.69 ,OP,566.69,"1,948.29",,,,,,
Humana MCR ADV,CPT,L2300,Abduction bar jointed adjust,Durable Medical Equipment,Per Unit,$252.72 ,OP,252.72,869.3,,,,,,
Humana MCR ADV,CPT,L2310,Abduction bar-straight,Durable Medical Equipment,Per Unit,$115.47 ,OP,115.47,396.52,,,,,,
Humana MCR ADV,CPT,L2320,Non-molded lacer,Durable Medical Equipment,Per Unit,$193.64 ,OP,193.64,667.22,,,,,,
Humana MCR ADV,CPT,L2330,Lacer molded to patient mode,Durable Medical Equipment,Per Unit,$368.55 ,OP,368.55,"1,265.81",,,,,,
Humana MCR ADV,CPT,L2335,Anterior swing band,Durable Medical Equipment,Per Unit,$282.18 ,OP,282.18,972.25,,,,,,
Humana MCR ADV,CPT,L2340,Pre-tibial shell molded to p,Durable Medical Equipment,Per Unit,$419.50 ,OP,419.5,"1,441.20",,,,,,
Humana MCR ADV,CPT,L2350,Prosthetic type socket molde,Durable Medical Equipment,Per Unit,$836.35 ,OP,836.35,"2,874.78",,,,,,
Humana MCR ADV,CPT,L2360,Extended steel shank,Durable Medical Equipment,Per Unit,$51.76 ,OP,51.76,179.2,,,,,,
Humana MCR ADV,CPT,L2370,Patten bottom,Durable Medical Equipment,Per Unit,$321.26 ,OP,321.26,"1,105.68",,,,,,
Humana MCR ADV,CPT,L2375,Torsion ank & half solid sti,Durable Medical Equipment,Per Unit,$123.52 ,OP,123.52,423.22,,,,,,
Humana MCR ADV,CPT,L2380,Torsion straight knee joint,Durable Medical Equipment,Per Unit,$129.54 ,OP,129.54,446.08,,,,,,
Humana MCR ADV,CPT,L2385,Straight knee joint heavy du,Durable Medical Equipment,Per Unit,$147.50 ,OP,147.5,507.08,,,,,,
Humana MCR ADV,CPT,L2387,Add le poly knee custom kafo,Durable Medical Equipment,Per Unit,$191.63 ,OP,191.63,659.6,,,,,,
Humana MCR ADV,CPT,L2390,Offset knee joint each,Durable Medical Equipment,Per Unit,$102.75 ,OP,102.75,354.58,,,,,,
Humana MCR ADV,CPT,L2395,Offset knee joint heavy duty,Durable Medical Equipment,Per Unit,$146.86 ,OP,146.86,503.28,,,,,,
Humana MCR ADV,CPT,L2397,Suspension sleeve lower ext,Durable Medical Equipment,Per Unit,$122.52 ,OP,122.52,423.22,,,,,,
Humana MCR ADV,CPT,L2405,Knee joint drop lock ea jnt,Durable Medical Equipment,Per Unit,$87.52 ,OP,87.52,301.2,,,,,,
Humana MCR ADV,CPT,L2415,Knee joint cam lock each joi,Durable Medical Equipment,Per Unit,$121.95 ,OP,121.95,419.4,,,,,,
Humana MCR ADV,CPT,L2425,Knee disc/dial lock/adj flex,Durable Medical Equipment,Per Unit,$143.90 ,OP,143.9,495.65,,,,,,
Humana MCR ADV,CPT,L2430,Knee jnt ratchet lock ea jnt,Durable Medical Equipment,Per Unit,$143.90 ,OP,143.9,495.65,,,,,,
Humana MCR ADV,CPT,L2492,Knee lift loop drop lock rin,Durable Medical Equipment,Per Unit,$117.74 ,OP,117.74,404.14,,,,,,
Humana MCR ADV,CPT,L2500,Thi/glut/ischia wgt bearing,Durable Medical Equipment,Per Unit,$314.13 ,OP,314.13,"1,078.99",,,,,,
Humana MCR ADV,CPT,L2510,Th/wght bear quad-lat brim m,Durable Medical Equipment,Per Unit,$809.60 ,OP,809.6,"2,783.26",,,,,,
Humana MCR ADV,CPT,L2520,Th/wght bear quad-lat brim c,Durable Medical Equipment,Per Unit,$539.56 ,OP,539.56,"1,856.79",,,,,,
Humana MCR ADV,CPT,L2525,Th/wght bear nar m-l brim mo,Durable Medical Equipment,Per Unit,"$1,144.16 ",OP,"1,144.16","3,934.69",,,,,,
Humana MCR ADV,CPT,L2526,Th/wght bear nar m-l brim cu,Durable Medical Equipment,Per Unit,$642.90 ,OP,642.9,"2,211.37",,,,,,
Humana MCR ADV,CPT,L2530,Thigh/wght bear lacer non-mo,Durable Medical Equipment,Per Unit,$240.74 ,OP,240.74,827.35,,,,,,
Humana MCR ADV,CPT,L2540,Thigh/wght bear lacer molded,Durable Medical Equipment,Per Unit,$455.54 ,OP,455.54,"1,567.02",,,,,,
Humana MCR ADV,CPT,L2550,Thigh/wght bear high roll cu,Durable Medical Equipment,Per Unit,$341.55 ,OP,341.55,"1,174.31",,,,,,
Humana MCR ADV,CPT,L2570,Hip clevis type 2 posit jnt,Durable Medical Equipment,Per Unit,$447.07 ,OP,447.07,"1,536.51",,,,,,
Humana MCR ADV,CPT,L2580,Pelvic control pelvic sling,Durable Medical Equipment,Per Unit,$435.62 ,OP,435.62,"1,498.39",,,,,,
Humana MCR ADV,CPT,L2600,Hip clevis/thrust bearing fr,Durable Medical Equipment,Per Unit,$214.10 ,OP,214.1,735.85,,,,,,
Humana MCR ADV,CPT,L2610,Hip clevis/thrust bearing lo,Durable Medical Equipment,Per Unit,$236.58 ,OP,236.58,812.11,,,,,,
Humana MCR ADV,CPT,L2620,Pelvic control hip heavy dut,Durable Medical Equipment,Per Unit,$250.96 ,OP,250.96,861.67,,,,,,
Humana MCR ADV,CPT,L2622,Hip joint adjustable flexion,Durable Medical Equipment,Per Unit,$319.42 ,OP,319.42,"1,098.07",,,,,,
Humana MCR ADV,CPT,L2624,Hip adj flex ext abduct cont,Durable Medical Equipment,Per Unit,$391.68 ,OP,391.68,"1,345.89",,,,,,
Humana MCR ADV,CPT,L2627,Plastic mold recipro hip & c,Durable Medical Equipment,Per Unit,"$2,145.41 ",OP,"2,145.41","7,377.56",,,,,,
Humana MCR ADV,CPT,L2628,Metal frame recipro hip & ca,Durable Medical Equipment,Per Unit,"$1,572.54 ",OP,"1,572.54","5,406.41",,,,,,
Humana MCR ADV,CPT,L2630,Pelvic control band & belt u,Durable Medical Equipment,Per Unit,$232.43 ,OP,232.43,800.67,,,,,,
Humana MCR ADV,CPT,L2640,Pelvic control band & belt b,Durable Medical Equipment,Per Unit,$315.42 ,OP,315.42,"1,086.62",,,,,,
Humana MCR ADV,CPT,L2650,Pelv & thor control gluteal,Durable Medical Equipment,Per Unit,$138.91 ,OP,138.91,476.6,,,,,,
Humana MCR ADV,CPT,L2660,Thoracic control thoracic ba,Durable Medical Equipment,Per Unit,$179.86 ,OP,179.86,617.65,,,,,,
Humana MCR ADV,CPT,L2670,Thorac cont paraspinal uprig,Durable Medical Equipment,Per Unit,$160.11 ,OP,160.11,549.03,,,,,,
Humana MCR ADV,CPT,L2680,Thorac cont lat support upri,Durable Medical Equipment,Per Unit,$146.88 ,OP,146.88,503.28,,,,,,
Humana MCR ADV,CPT,L2750,Plating chrome/nickel pr bar,Durable Medical Equipment,Per Unit,$78.45 ,OP,78.45,270.71,,,,,,
Humana MCR ADV,CPT,L2755,Carbon graphite lamination,Durable Medical Equipment,Per Unit,$131.16 ,OP,131.16,449.9,,,,,,
Humana MCR ADV,CPT,L2760,Extension per extension per,Durable Medical Equipment,Per Unit,$57.03 ,OP,57.03,194.45,,,,,,
Humana MCR ADV,CPT,L2768,Ortho sidebar disconnect,Durable Medical Equipment,Per Unit,$130.78 ,OP,130.78,449.9,,,,,,
Humana MCR ADV,CPT,L2780,Non-corrosive finish,Durable Medical Equipment,Per Unit,$63.53 ,OP,63.53,217.32,,,,,,
Humana MCR ADV,CPT,L2785,Drop lock retainer each,Durable Medical Equipment,Per Unit,$29.75 ,OP,29.75,102.95,,,,,,
Humana MCR ADV,CPT,L2795,Knee control full kneecap,Durable Medical Equipment,Per Unit,$82.32 ,OP,82.32,282.14,,,,,,
Humana MCR ADV,CPT,L2800,Knee cap medial or lateral p,Durable Medical Equipment,Per Unit,$101.09 ,OP,101.09,101.09,,,,,,
Humana MCR ADV,CPT,L2810,Knee control condylar pad,Durable Medical Equipment,Per Unit,$81.98 ,OP,81.98,282.14,,,,,,
Humana MCR ADV,CPT,L2820,Soft interface below knee se,Durable Medical Equipment,Per Unit,$81.51 ,OP,81.51,282.14,,,,,,
Humana MCR ADV,CPT,L2830,Soft interface above knee se,Durable Medical Equipment,Per Unit,$88.18 ,OP,88.18,305.01,,,,,,
Humana MCR ADV,CPT,L2840,Tibial length sock fx or equ,Durable Medical Equipment,Per Unit,$43.30 ,OP,43.3,148.69,,,,,,
Humana MCR ADV,CPT,L2850,Femoral lgth sock fx or equa,Durable Medical Equipment,Per Unit,$60.72 ,OP,60.72,209.7,,,,,,
Humana MCR ADV,CPT,L3000,Ft insert ucb berkeley shell,Durable Medical Equipment,Per Unit,$315.34 ,OP,315.34,"1,082.81",,,,,,
Humana MCR ADV,CPT,L3001,Foot insert remov molded spe,Durable Medical Equipment,Per Unit,$132.78 ,OP,132.78,686.28,,,,,,
Humana MCR ADV,CPT,L3002,Foot insert plastazote or eq,Durable Medical Equipment,Per Unit,$162.12 ,OP,162.12,834.98,,,,,,
Humana MCR ADV,CPT,L3003,Foot insert silicone gel eac,Durable Medical Equipment,Per Unit,$174.89 ,OP,174.89,903.6,,,,,,
Humana MCR ADV,CPT,L3010,Foot longitudinal arch suppo,Durable Medical Equipment,Per Unit,$174.89 ,OP,174.89,903.6,,,,,,
Humana MCR ADV,CPT,L3020,Foot longitud/metatarsal sup,Durable Medical Equipment,Per Unit,$199.16 ,OP,199.16,"1,025.61",,,,,,
Humana MCR ADV,CPT,L3030,Foot arch support remov prem,Durable Medical Equipment,Per Unit,$76.59 ,OP,76.59,"1,239.13",,,,,,
Humana MCR ADV,CPT,L3031,Foot lamin/prepreg composite,Durable Medical Equipment,Per Unit,$122.94 ,OP,122.94,"1,334.45",,,,,,
Humana MCR ADV,CPT,L3040,Ft arch suprt premold longit,Durable Medical Equipment,Per Unit,$47.25 ,OP,47.25,163.95,,,,,,
Humana MCR ADV,CPT,L3050,Foot arch supp premold metat,Durable Medical Equipment,Per Unit,$47.25 ,OP,47.25,163.95,,,,,,
Humana MCR ADV,CPT,L3060,Foot arch supp longitud/meta,Durable Medical Equipment,Per Unit,$74.04 ,OP,74.04,255.45,,,,,,
Humana MCR ADV,CPT,L3070,Arch suprt att to sho longit,Durable Medical Equipment,Per Unit,$31.91 ,OP,31.91,110.57,,,,,,
Humana MCR ADV,CPT,L3080,Arch supp att to shoe metata,Durable Medical Equipment,Per Unit,$31.91 ,OP,31.91,110.57,,,,,,
Humana MCR ADV,CPT,L3090,Arch supp att to shoe long/m,Durable Medical Equipment,Per Unit,$40.86 ,OP,40.86,141.07,,,,,,
Humana MCR ADV,CPT,L3100,Hallus-valgus nt dyn pre ots,Durable Medical Equipment,Per Unit,$43.43 ,OP,43.43,148.69,,,,,,
Humana MCR ADV,CPT,L3140,Abduction rotation bar shoe,Durable Medical Equipment,Per Unit,$89.37 ,OP,89.37,308.83,,,,,,
Humana MCR ADV,CPT,L3150,Abduct rotation bar w/o shoe,Durable Medical Equipment,Per Unit,$81.72 ,OP,81.72,282.14,,,,,,
Humana MCR ADV,CPT,L3170,Foot plas heel stabi pre ots,Durable Medical Equipment,Per Unit,$51.06 ,OP,51.06,175.39,,,,,,
Humana MCR ADV,CPT,L3224,Woman's shoe oxford brace,Durable Medical Equipment,Per Unit,$67.83 ,OP,67.83,232.58,,,,,,
Humana MCR ADV,CPT,L3225,Man's shoe oxford brace,Durable Medical Equipment,Per Unit,$74.09 ,OP,74.09,255.45,,,,,,
Humana MCR ADV,CPT,L3300,Sho lift taper to metatarsal,Durable Medical Equipment,Per Unit,$52.35 ,OP,52.35,179.2,,,,,,
Humana MCR ADV,CPT,L3310,Shoe lift elev heel/sole neo,Durable Medical Equipment,Per Unit,$81.72 ,OP,81.72,282.14,,,,,,
Humana MCR ADV,CPT,L3330,Lifts elevation metal extens,Durable Medical Equipment,Per Unit,$568.10 ,OP,568.1,"1,952.10",,,,,,
Humana MCR ADV,CPT,L3332,Shoe lifts tapered to one-ha,Durable Medical Equipment,Per Unit,$74.04 ,OP,74.04,255.45,,,,,,
Humana MCR ADV,CPT,L3334,Shoe lifts elevation heel /i,Durable Medical Equipment,Per Unit,$38.28 ,OP,38.28,133.45,,,,,,
Humana MCR ADV,CPT,L3340,Shoe wedge sach,Durable Medical Equipment,Per Unit,$85.56 ,OP,85.56,293.57,,,,,,
Humana MCR ADV,CPT,L3350,Shoe heel wedge,Durable Medical Equipment,Per Unit,$22.96 ,OP,22.96,80.07,,,,,,
Humana MCR ADV,CPT,L3360,Shoe sole wedge outside sole,Durable Medical Equipment,Per Unit,$35.74 ,OP,35.74,122,,,,,,
Humana MCR ADV,CPT,L3370,Shoe sole wedge between sole,Durable Medical Equipment,Per Unit,$49.79 ,OP,49.79,171.58,,,,,,
Humana MCR ADV,CPT,L3380,Shoe clubfoot wedge,Durable Medical Equipment,Per Unit,$49.79 ,OP,49.79,171.58,,,,,,
Humana MCR ADV,CPT,L3390,Shoe outflare wedge,Durable Medical Equipment,Per Unit,$49.79 ,OP,49.79,171.58,,,,,,
Humana MCR ADV,CPT,L3400,Shoe metatarsal bar wedge ro,Durable Medical Equipment,Per Unit,$40.86 ,OP,40.86,141.07,,,,,,
Humana MCR ADV,CPT,L3410,Shoe metatarsal bar between,Durable Medical Equipment,Per Unit,$93.19 ,OP,93.19,320.27,,,,,,
Humana MCR ADV,CPT,L3420,Full sole/heel wedge btween,Durable Medical Equipment,Per Unit,$54.90 ,OP,54.9,190.64,,,,,,
Humana MCR ADV,CPT,L3430,Sho heel count plast reinfor,Durable Medical Equipment,Per Unit,$160.86 ,OP,160.86,552.84,,,,,,
Humana MCR ADV,CPT,L3440,Heel leather reinforced,Durable Medical Equipment,Per Unit,$76.59 ,OP,76.59,263.08,,,,,,
Humana MCR ADV,CPT,L3450,Shoe heel sach cushion type,Durable Medical Equipment,Per Unit,$105.93 ,OP,105.93,105.93,,,,,,
Humana MCR ADV,CPT,L3455,Shoe heel new leather standa,Durable Medical Equipment,Per Unit,$40.86 ,OP,40.86,141.07,,,,,,
Humana MCR ADV,CPT,L3460,Shoe heel new rubber standar,Durable Medical Equipment,Per Unit,$34.49 ,OP,34.49,118.19,,,,,,
Humana MCR ADV,CPT,L3465,Shoe heel thomas with wedge,Durable Medical Equipment,Per Unit,$58.76 ,OP,58.76,202.07,,,,,,
Humana MCR ADV,CPT,L3470,Shoe heel thomas extend to b,Durable Medical Equipment,Per Unit,$62.54 ,OP,62.54,213.51,,,,,,
Humana MCR ADV,CPT,L3480,Shoe heel pad & depress for,Durable Medical Equipment,Per Unit,$62.54 ,OP,62.54,213.51,,,,,,
Humana MCR ADV,CPT,L3500,Ortho shoe add leather insol,Durable Medical Equipment,Per Unit,$29.35 ,OP,29.35,99.13,,,,,,
Humana MCR ADV,CPT,L3510,Orthopedic shoe add rub insl,Durable Medical Equipment,Per Unit,$29.35 ,OP,29.35,99.13,,,,,,
Humana MCR ADV,CPT,L3520,O shoe add felt w leath insl,Durable Medical Equipment,Per Unit,$31.91 ,OP,31.91,110.57,,,,,,
Humana MCR ADV,CPT,L3530,Ortho shoe add half sole,Durable Medical Equipment,Per Unit,$31.91 ,OP,31.91,110.57,,,,,,
Humana MCR ADV,CPT,L3540,Ortho shoe add full sole,Durable Medical Equipment,Per Unit,$51.06 ,OP,51.06,175.39,,,,,,
Humana MCR ADV,CPT,L3550,O shoe add standard toe tap,Durable Medical Equipment,Per Unit,$8.97 ,OP,8.97,30.51,,,,,,
Humana MCR ADV,CPT,L3560,O shoe add horseshoe toe tap,Durable Medical Equipment,Per Unit,$22.96 ,OP,22.96,80.07,,,,,,
Humana MCR ADV,CPT,L3570,O shoe add instep extension,Durable Medical Equipment,Per Unit,$85.56 ,OP,85.56,293.57,,,,,,
Humana MCR ADV,CPT,L3580,O shoe add instep velcro clo,Durable Medical Equipment,Per Unit,$65.11 ,OP,65.11,224.95,,,,,,
Humana MCR ADV,CPT,L3590,O shoe convert to sof counte,Durable Medical Equipment,Per Unit,$53.63 ,OP,53.63,183.02,,,,,,
Humana MCR ADV,CPT,L3595,Ortho shoe add march bar,Durable Medical Equipment,Per Unit,$42.10 ,OP,42.1,144.88,,,,,,
Humana MCR ADV,CPT,L3600,Trans shoe calip plate exist,Durable Medical Equipment,Per Unit,$76.59 ,OP,76.59,263.08,,,,,,
Humana MCR ADV,CPT,L3610,Trans shoe caliper plate new,Durable Medical Equipment,Per Unit,$100.86 ,OP,100.86,346.96,,,,,,
Humana MCR ADV,CPT,L3620,Trans shoe solid stirrup exi,Durable Medical Equipment,Per Unit,$76.59 ,OP,76.59,263.08,,,,,,
Humana MCR ADV,CPT,L3630,Trans shoe solid stirrup new,Durable Medical Equipment,Per Unit,$100.86 ,OP,100.86,346.96,,,,,,
Humana MCR ADV,CPT,L3640,Shoe dennis browne splint bo,Durable Medical Equipment,Per Unit,$43.43 ,OP,43.43,148.69,,,,,,
Humana MCR ADV,CPT,L3650,So 8 abd restraint pre ots,Durable Medical Equipment,Per Unit,$65.83 ,OP,65.83,224.95,,,,,,
Humana MCR ADV,CPT,L3660,So 8 ab rstr can/web pre ots,Durable Medical Equipment,Per Unit,$94.40 ,OP,94.4,324.09,,,,,,
Humana MCR ADV,CPT,L3670,So acro/clav can web pre ots,Durable Medical Equipment,Per Unit,$103.86 ,OP,103.86,358.39,,,,,,
Humana MCR ADV,CPT,L3671,So cap design w/o jnts cf,Durable Medical Equipment,Per Unit,$823.17 ,OP,823.17,"2,832.83",,,,,,
Humana MCR ADV,CPT,L3674,So airplane w/wo joint cf,Durable Medical Equipment,Per Unit,"$1,079.87 ",OP,"1,079.87","1,079.87",,,,,,
Humana MCR ADV,CPT,L3675,So vest canvas/web pre ots,Durable Medical Equipment,Per Unit,$160.35 ,OP,160.35,552.84,,,,,,
Humana MCR ADV,CPT,L3702,Eo w/o joints cf,Durable Medical Equipment,Per Unit,$263.81 ,OP,263.81,907.42,,,,,,
Humana MCR ADV,CPT,L3710,Eo elas w/metal jnts pre ots,Durable Medical Equipment,Per Unit,$130.45 ,OP,130.45,449.9,,,,,,
Humana MCR ADV,CPT,L3720,Forearm/arm cuffs free motio,Durable Medical Equipment,Per Unit,$624.22 ,OP,624.22,"2,146.54",,,,,,
Humana MCR ADV,CPT,L3730,Forearm/arm cuffs ext/flex a,Durable Medical Equipment,Per Unit,$827.96 ,OP,827.96,"2,848.08",,,,,,
Humana MCR ADV,CPT,L3740,Cuffs adj lock w/ active con,Durable Medical Equipment,Per Unit,$981.62 ,OP,981.62,"3,374.24",,,,,,
Humana MCR ADV,CPT,L3760,Eo adj jt prefab custom fit,Durable Medical Equipment,Per Unit,$456.89 ,OP,456.89,"1,570.83",,,,,,
Humana MCR ADV,CPT,L3761,Eo- adj lock joint prefab ot,Durable Medical Equipment,Per Unit,$456.89 ,OP,456.89,456.89,,,,,,
Humana MCR ADV,CPT,L3762,Eo rigid w/o joints pre ots,Durable Medical Equipment,Per Unit,$98.22 ,OP,98.22,339.33,,,,,,
Humana MCR ADV,CPT,L3763,Ewho rigid w/o jnts cf,Durable Medical Equipment,Per Unit,$683.66 ,OP,683.66,"2,352.44",,,,,,
Humana MCR ADV,CPT,L3764,Ewho w/joint(s) cf,Durable Medical Equipment,Per Unit,$715.47 ,OP,715.47,"2,459.19",,,,,,
Humana MCR ADV,CPT,L3765,Ewhfo rigid w/o jnts cf,Durable Medical Equipment,Per Unit,"$1,171.43 ",OP,"1,171.43","4,030.02",,,,,,
Humana MCR ADV,CPT,L3766,Ewhfo w/joint(s) cf,Durable Medical Equipment,Per Unit,"$1,240.47 ",OP,"1,240.47","4,266.40",,,,,,
Humana MCR ADV,CPT,L3806,Whfo w/joint(s) custom fab,Durable Medical Equipment,Per Unit,$414.97 ,OP,414.97,"1,425.95",,,,,,
Humana MCR ADV,CPT,L3807,Whfo w/o joints pre cst,Durable Medical Equipment,Per Unit,$228.43 ,OP,228.43,785.42,,,,,,
Humana MCR ADV,CPT,L3808,Whfo- rigid w/o joints,Durable Medical Equipment,Per Unit,$325.43 ,OP,325.43,"1,120.94",,,,,,
Humana MCR ADV,CPT,L3809,Whfo w/o joints pre ots,Durable Medical Equipment,Per Unit,$228.43 ,OP,228.43,228.43,,,,,,
Humana MCR ADV,CPT,L3900,Hinge extension/flex wrist/f,Durable Medical Equipment,Per Unit,"$1,479.93 ",OP,"1,479.93","5,089.95",,,,,,
Humana MCR ADV,CPT,L3901,Hinge ext/flex wrist finger,Durable Medical Equipment,Per Unit,"$1,939.53 ",OP,"1,939.53","6,668.40",,,,,,
Humana MCR ADV,CPT,L3904,Whfo electric custom fitted,Durable Medical Equipment,Per Unit,"$3,083.64 ",OP,"3,083.64","10,603.11",,,,,,
Humana MCR ADV,CPT,L3905,Who w/nontorsion jnt(s) cf,Durable Medical Equipment,Per Unit,$905.97 ,OP,905.97,"3,114.97",,,,,,
Humana MCR ADV,CPT,L3906,Who w/o joints cf,Durable Medical Equipment,Per Unit,$462.97 ,OP,462.97,"1,593.72",,,,,,
Humana MCR ADV,CPT,L3908,Who cock-up nonmolde pre ots,Durable Medical Equipment,Per Unit,$66.98 ,OP,66.98,228.77,,,,,,
Humana MCR ADV,CPT,L3912,Hfo flexion glove pre ots,Durable Medical Equipment,Per Unit,$96.25 ,OP,96.25,331.7,,,,,,
Humana MCR ADV,CPT,L3913,Hfo w/o joints cf,Durable Medical Equipment,Per Unit,$247.41 ,OP,247.41,850.23,,,,,,
Humana MCR ADV,CPT,L3915,Who nontorsion jnts pre cst,Durable Medical Equipment,Per Unit,$485.63 ,OP,485.63,"1,669.97",,,,,,
Humana MCR ADV,CPT,L3916,Who nontorsion jnts pre ots,Durable Medical Equipment,Per Unit,$485.63 ,OP,485.63,485.63,,,,,,
Humana MCR ADV,CPT,L3917,Metacarp fx orthosis pre cst,Durable Medical Equipment,Per Unit,$96.47 ,OP,96.47,331.7,,,,,,
Humana MCR ADV,CPT,L3918,Metacarp fx orthosis pre ots,Durable Medical Equipment,Per Unit,$96.47 ,OP,96.47,96.47,,,,,,
Humana MCR ADV,CPT,L3919,Ho w/o joints cf,Durable Medical Equipment,Per Unit,$247.41 ,OP,247.41,850.23,,,,,,
Humana MCR ADV,CPT,L3921,Hfo w/joint(s) cf,Durable Medical Equipment,Per Unit,$293.46 ,OP,293.46,"1,010.37",,,,,,
Humana MCR ADV,CPT,L3923,Hfo without joints pre cst,Durable Medical Equipment,Per Unit,$88.25 ,OP,88.25,305.01,,,,,,
Humana MCR ADV,CPT,L3924,Hfo without joints pre ots,Durable Medical Equipment,Per Unit,$88.25 ,OP,88.25,88.25,,,,,,
Humana MCR ADV,CPT,L3925,Fo pip dip jnt/sprng pre ots,Durable Medical Equipment,Per Unit,$60.01 ,OP,60.01,205.88,,,,,,
Humana MCR ADV,CPT,L3927,Fo pip dip no jt spr pre ots,Durable Medical Equipment,Per Unit,$31.98 ,OP,31.98,110.57,,,,,,
Humana MCR ADV,CPT,L3929,Hfo nontorsion jnts pre cst,Durable Medical Equipment,Per Unit,$83.44 ,OP,83.44,285.96,,,,,,
Humana MCR ADV,CPT,L3930,Hfo nontorsion jnts pre ots,Durable Medical Equipment,Per Unit,$83.44 ,OP,83.44,83.44,,,,,,
Humana MCR ADV,CPT,L3931,Whfo nontorsion joint prefab,Durable Medical Equipment,Per Unit,$190.48 ,OP,190.48,655.78,,,,,,
Humana MCR ADV,CPT,L3933,Fo w/o joints cf,Durable Medical Equipment,Per Unit,$194.93 ,OP,194.93,671.03,,,,,,
Humana MCR ADV,CPT,L3935,Fo nontorsion joint cf,Durable Medical Equipment,Per Unit,$201.82 ,OP,201.82,693.9,,,,,,
Humana MCR ADV,CPT,L3960,Sewho airplan desig abdu pos,Durable Medical Equipment,Per Unit,$728.64 ,OP,728.64,"2,504.94",,,,,,
Humana MCR ADV,CPT,L3961,Sewho cap design w/o jnts cf,Durable Medical Equipment,Per Unit,"$1,534.92 ",OP,"1,534.92","5,280.58",,,,,,
Humana MCR ADV,CPT,L3962,Sewho erbs palsey design abd,Durable Medical Equipment,Per Unit,$659.00 ,OP,659,"2,264.75",,,,,,
Humana MCR ADV,CPT,L3967,Sewho airplane w/o jnts cf,Durable Medical Equipment,Per Unit,"$1,812.20 ",OP,"1,812.20","6,233.76",,,,,,
Humana MCR ADV,CPT,L3971,Sewho cap design w/jnt(s) cf,Durable Medical Equipment,Per Unit,"$1,720.20 ",OP,"1,720.20","5,917.29",,,,,,
Humana MCR ADV,CPT,L3973,Sewho airplane w/jnt(s) cf,Durable Medical Equipment,Per Unit,"$1,812.20 ",OP,"1,812.20","6,233.76",,,,,,
Humana MCR ADV,CPT,L3975,Sewhfo cap design w/o jnt cf,Durable Medical Equipment,Per Unit,"$1,534.92 ",OP,"1,534.92","5,280.58",,,,,,
Humana MCR ADV,CPT,L3976,Sewhfo airplane w/o jnts cf,Durable Medical Equipment,Per Unit,"$1,534.92 ",OP,"1,534.92","5,280.58",,,,,,
Humana MCR ADV,CPT,L3977,Sewhfo cap desgn w/jnt(s) cf,Durable Medical Equipment,Per Unit,"$1,720.20 ",OP,"1,720.20","5,917.29",,,,,,
Humana MCR ADV,CPT,L3978,Sewhfo airplane w/jnt(s) cf,Durable Medical Equipment,Per Unit,"$1,812.20 ",OP,"1,812.20","6,233.76",,,,,,
Humana MCR ADV,CPT,L3980,Up ext fx orthos humeral nos,Durable Medical Equipment,Per Unit,$353.43 ,OP,353.43,"1,216.24",,,,,,
Humana MCR ADV,CPT,L3981,Ue fx orth shoul cap forearm,Durable Medical Equipment,Per Unit,$919.57 ,OP,919.57,919.57,,,,,,
Humana MCR ADV,CPT,L3982,Upper ext fx orthosis rad/ul,Durable Medical Equipment,Per Unit,$358.87 ,OP,358.87,"1,235.32",,,,,,
Humana MCR ADV,CPT,L3984,Upper ext fx orthosis wrist,Durable Medical Equipment,Per Unit,$316.13 ,OP,316.13,"1,086.62",,,,,,
Humana MCR ADV,CPT,L3995,Sock fracture or equal each,Durable Medical Equipment,Per Unit,$37.51 ,OP,37.51,129.64,,,,,,
Humana MCR ADV,CPT,L4000,Repl girdle milwaukee orth,Durable Medical Equipment,Per Unit,"$1,326.47 ",OP,"1,326.47","4,559.97",,,,,,
Humana MCR ADV,CPT,L4010,Replace trilateral socket br,Durable Medical Equipment,Per Unit,$806.25 ,OP,806.25,"2,771.83",,,,,,
Humana MCR ADV,CPT,L4020,Replace quadlat socket brim,Durable Medical Equipment,Per Unit,$968.52 ,OP,968.52,"3,332.30",,,,,,
Humana MCR ADV,CPT,L4030,Replace socket brim cust fit,Durable Medical Equipment,Per Unit,$615.47 ,OP,615.47,"2,116.06",,,,,,
Humana MCR ADV,CPT,L4040,Replace molded thigh lacer,Durable Medical Equipment,Per Unit,$416.80 ,OP,416.8,"1,433.58",,,,,,
Humana MCR ADV,CPT,L4045,Replace non-molded thigh lac,Durable Medical Equipment,Per Unit,$307.89 ,OP,307.89,"1,059.93",,,,,,
Humana MCR ADV,CPT,L4050,Replace molded calf lacer,Durable Medical Equipment,Per Unit,$412.80 ,OP,412.8,"1,418.32",,,,,,
Humana MCR ADV,CPT,L4055,Replace non-molded calf lace,Durable Medical Equipment,Per Unit,$250.92 ,OP,250.92,861.67,,,,,,
Humana MCR ADV,CPT,L4060,Replace high roll cuff,Durable Medical Equipment,Per Unit,$326.17 ,OP,326.17,"1,120.94",,,,,,
Humana MCR ADV,CPT,L4070,Replace prox & dist upright,Durable Medical Equipment,Per Unit,$264.15 ,OP,264.15,907.42,,,,,,
Humana MCR ADV,CPT,L4080,Repl met band kafo-afo prox,Durable Medical Equipment,Per Unit,$99.72 ,OP,99.72,343.14,,,,,,
Humana MCR ADV,CPT,L4090,Repl met band kafo-afo calf/,Durable Medical Equipment,Per Unit,$84.84 ,OP,84.84,293.57,,,,,,
Humana MCR ADV,CPT,L4100,Repl leath cuff kafo prox th,Durable Medical Equipment,Per Unit,$101.94 ,OP,101.94,350.76,,,,,,
Humana MCR ADV,CPT,L4110,Repl leath cuff kafo-afo cal,Durable Medical Equipment,Per Unit,$79.60 ,OP,79.6,274.51,,,,,,
Humana MCR ADV,CPT,L4130,Replace pretibial shell,Durable Medical Equipment,Per Unit,$481.14 ,OP,481.14,"1,654.72",,,,,,
Humana MCR ADV,CPT,L4350,Ankle control ortho pre ots,Durable Medical Equipment,Per Unit,$97.13 ,OP,97.13,335.53,,,,,,
Humana MCR ADV,CPT,L4360,Pneumat walking boot pre cst,Durable Medical Equipment,Per Unit,$259.89 ,OP,259.89,892.18,,,,,,
Humana MCR ADV,CPT,L4361,Pneuma/vac walk boot pre ots,Durable Medical Equipment,Per Unit,$259.89 ,OP,259.89,259.89,,,,,,
Humana MCR ADV,CPT,L4370,Pneum full leg splnt pre ots,Durable Medical Equipment,Per Unit,$236.26 ,OP,236.26,812.11,,,,,,
Humana MCR ADV,CPT,L4386,Non-pneum walk boot pre cst,Durable Medical Equipment,Per Unit,$159.16 ,OP,159.16,549.03,,,,,,
Humana MCR ADV,CPT,L4387,Non-pneum walk boot pre ots,Durable Medical Equipment,Per Unit,$159.16 ,OP,159.16,159.16,,,,,,
Humana MCR ADV,CPT,L4392,Replace afo soft interface,Durable Medical Equipment,Per Unit,$23.62 ,OP,23.62,80.07,,,,,,
Humana MCR ADV,CPT,L4394,Replace foot drop spint,Durable Medical Equipment,Per Unit,$17.23 ,OP,17.23,61,,,,,,
Humana MCR ADV,CPT,L4396,Static or dynami afo pre cst,Durable Medical Equipment,Per Unit,$168.46 ,OP,168.46,579.53,,,,,,
Humana MCR ADV,CPT,L4397,Static or dynami afo pre ots,Durable Medical Equipment,Per Unit,$168.46 ,OP,168.46,168.46,,,,,,
Humana MCR ADV,CPT,L4398,Foot drop splint pre ots,Durable Medical Equipment,Per Unit,$77.54 ,OP,77.54,266.89,,,,,,
Humana MCR ADV,CPT,L4631,Afo- walk boot type- cus fab,Durable Medical Equipment,Per Unit,"$1,479.79 ",OP,"1,479.79","1,479.79",,,,,,
Humana MCR ADV,CPT,L5000,Sho insert w arch toe filler,Durable Medical Equipment,Per Unit,$576.42 ,OP,576.42,"1,982.60",,,,,,
Humana MCR ADV,CPT,L5010,Mold socket ank hgt w/ toe f,Durable Medical Equipment,Per Unit,"$1,610.60 ",OP,"1,610.60","5,539.84",,,,,,
Humana MCR ADV,CPT,L5020,Tibial tubercle hgt w/ toe f,Durable Medical Equipment,Per Unit,"$2,523.29 ",OP,"2,523.29","8,677.68",,,,,,
Humana MCR ADV,CPT,L5050,Ank symes mold sckt sach ft,Durable Medical Equipment,Per Unit,"$2,755.91 ",OP,"2,755.91","9,478.35",,,,,,
Humana MCR ADV,CPT,L5060,Symes met fr leath socket ar,Durable Medical Equipment,Per Unit,"$3,397.24 ",OP,"3,397.24","11,682.09",,,,,,
Humana MCR ADV,CPT,L5100,Molded socket shin sach foot,Durable Medical Equipment,Per Unit,"$2,744.12 ",OP,"2,744.12","9,436.43",,,,,,
Humana MCR ADV,CPT,L5105,Plast socket jts/thgh lacer,Durable Medical Equipment,Per Unit,"$3,872.55 ",OP,"3,872.55","13,317.74",,,,,,
Humana MCR ADV,CPT,L5150,Mold sckt ext knee shin sach,Durable Medical Equipment,Per Unit,"$4,305.35 ",OP,"4,305.35","14,804.69",,,,,,
Humana MCR ADV,CPT,L5160,Mold socket bent knee shin s,Durable Medical Equipment,Per Unit,"$4,727.07 ",OP,"4,727.07","16,257.32",,,,,,
Humana MCR ADV,CPT,L5200,Kne sing axis fric shin sach,Durable Medical Equipment,Per Unit,"$3,656.04 ",OP,"3,656.04","12,574.26",,,,,,
Humana MCR ADV,CPT,L5210,No knee/ankle joints w/ ft b,Durable Medical Equipment,Per Unit,"$2,902.89 ",OP,"2,902.89","9,981.64",,,,,,
Humana MCR ADV,CPT,L5220,No knee joint with artic ali,Durable Medical Equipment,Per Unit,"$3,197.74 ",OP,"3,197.74","10,995.81",,,,,,
Humana MCR ADV,CPT,L5230,Fem focal defic constant fri,Durable Medical Equipment,Per Unit,"$4,796.11 ",OP,"4,796.11","16,493.71",,,,,,
Humana MCR ADV,CPT,L5250,Hip canad sing axi cons fric,Durable Medical Equipment,Per Unit,"$5,623.57 ",OP,"5,623.57","19,341.79",,,,,,
Humana MCR ADV,CPT,L5270,Tilt table locking hip sing,Durable Medical Equipment,Per Unit,"$6,265.76 ",OP,"6,265.76","21,549.33",,,,,,
Humana MCR ADV,CPT,L5280,Hemipelvect canad sing axis,Durable Medical Equipment,Per Unit,"$6,090.55 ",OP,"6,090.55","20,946.94",,,,,,
Humana MCR ADV,CPT,L5301,Bk mold socket sach ft endo,Durable Medical Equipment,Per Unit,"$2,694.66 ",OP,"2,694.66","9,268.66",,,,,,
Humana MCR ADV,CPT,L5312,Knee disart- sach ft- endo,Durable Medical Equipment,Per Unit,"$4,245.62 ",OP,"4,245.62","4,245.62",,,,,,
Humana MCR ADV,CPT,L5321,Ak open end sach,Durable Medical Equipment,Per Unit,"$3,593.24 ",OP,"3,593.24","12,356.94",,,,,,
Humana MCR ADV,CPT,L5331,Hip disart canadian sach ft,Durable Medical Equipment,Per Unit,"$5,262.80 ",OP,"5,262.80","18,098.85",,,,,,
Humana MCR ADV,CPT,L5341,Hemipelvectomy canadian sach,Durable Medical Equipment,Per Unit,"$5,594.28 ",OP,"5,594.28","19,238.85",,,,,,
Humana MCR ADV,CPT,L5400,Postop dress & 1 cast chg bk,Durable Medical Equipment,Per Unit,"$1,604.68 ",OP,"1,604.68","5,516.97",,,,,,
Humana MCR ADV,CPT,L5410,Postop dsg bk ea add cast ch,Durable Medical Equipment,Per Unit,$443.32 ,OP,443.32,"1,525.07",,,,,,
Humana MCR ADV,CPT,L5420,Postop dsg & 1 cast chg ak/d,Durable Medical Equipment,Per Unit,"$2,026.64 ",OP,"2,026.64","6,969.60",,,,,,
Humana MCR ADV,CPT,L5430,Postop dsg ak ea add cast ch,Durable Medical Equipment,Per Unit,$550.12 ,OP,550.12,"1,891.10",,,,,,
Humana MCR ADV,CPT,L5450,Postop app non-wgt bear dsg,Durable Medical Equipment,Per Unit,$475.67 ,OP,475.67,"1,635.64",,,,,,
Humana MCR ADV,CPT,L5460,Postop app non-wgt bear dsg,Durable Medical Equipment,Per Unit,$623.89 ,OP,623.89,"2,146.54",,,,,,
Humana MCR ADV,CPT,L5500,Init bk ptb plaster direct,Durable Medical Equipment,Per Unit,"$1,483.19 ",OP,"1,483.19","5,101.39",,,,,,
Humana MCR ADV,CPT,L5505,Init ak ischal plstr direct,Durable Medical Equipment,Per Unit,"$2,086.44 ",OP,"2,086.44","7,175.49",,,,,,
Humana MCR ADV,CPT,L5510,Prep bk ptb plaster molded,Durable Medical Equipment,Per Unit,"$1,771.18 ",OP,"1,771.18","6,092.69",,,,,,
Humana MCR ADV,CPT,L5520,Perp bk ptb thermopls direct,Durable Medical Equipment,Per Unit,"$1,587.65 ",OP,"1,587.65","5,459.77",,,,,,
Humana MCR ADV,CPT,L5530,Prep bk ptb thermopls molded,Durable Medical Equipment,Per Unit,"$2,087.07 ",OP,"2,087.07","7,179.30",,,,,,
Humana MCR ADV,CPT,L5535,Prep bk ptb open end socket,Durable Medical Equipment,Per Unit,"$1,945.59 ",OP,"1,945.59","6,691.29",,,,,,
Humana MCR ADV,CPT,L5540,Prep bk ptb laminated socket,Durable Medical Equipment,Per Unit,"$2,060.66 ",OP,"2,060.66","7,087.80",,,,,,
Humana MCR ADV,CPT,L5560,Prep ak ischial plast molded,Durable Medical Equipment,Per Unit,"$2,348.01 ",OP,"2,348.01","8,075.28",,,,,,
Humana MCR ADV,CPT,L5570,Prep ak ischial direct form,Durable Medical Equipment,Per Unit,"$2,278.83 ",OP,"2,278.83","7,838.89",,,,,,
Humana MCR ADV,CPT,L5580,Prep ak ischial thermo mold,Durable Medical Equipment,Per Unit,"$2,828.36 ",OP,"2,828.36","9,726.18",,,,,,
Humana MCR ADV,CPT,L5585,Prep ak ischial open end,Durable Medical Equipment,Per Unit,"$3,312.24 ",OP,"3,312.24","11,392.33",,,,,,
Humana MCR ADV,CPT,L5590,Prep ak ischial laminated,Durable Medical Equipment,Per Unit,"$2,948.85 ",OP,"2,948.85","10,141.77",,,,,,
Humana MCR ADV,CPT,L5595,Hip disartic sach thermopls,Durable Medical Equipment,Per Unit,"$4,608.29 ",OP,"4,608.29","15,849.36",,,,,,
Humana MCR ADV,CPT,L5600,Hip disart sach laminat mold,Durable Medical Equipment,Per Unit,"$5,244.91 ",OP,"5,244.91","18,037.85",,,,,,
Humana MCR ADV,CPT,L5610,Above knee hydracadence,Durable Medical Equipment,Per Unit,"$2,529.59 ",OP,"2,529.59","8,700.56",,,,,,
Humana MCR ADV,CPT,L5611,Ak 4 bar link w/fric swing,Durable Medical Equipment,Per Unit,"$1,611.13 ",OP,"1,611.13","5,539.84",,,,,,
Humana MCR ADV,CPT,L5613,Ak 4 bar ling w/hydraul swig,Durable Medical Equipment,Per Unit,"$2,450.64 ",OP,"2,450.64","8,429.87",,,,,,
Humana MCR ADV,CPT,L5614,4-bar link above knee w/swng,Durable Medical Equipment,Per Unit,"$1,697.23 ",OP,"1,697.23","5,837.23",,,,,,
Humana MCR ADV,CPT,L5616,Ak univ multiplex sys frict,Durable Medical Equipment,Per Unit,"$1,477.66 ",OP,"1,477.66","5,082.32",,,,,,
Humana MCR ADV,CPT,L5617,Ak/bk self-aligning unit ea,Durable Medical Equipment,Per Unit,$562.74 ,OP,562.74,"1,936.85",,,,,,
Humana MCR ADV,CPT,L5618,Test socket symes,Durable Medical Equipment,Per Unit,$336.06 ,OP,336.06,"1,155.24",,,,,,
Humana MCR ADV,CPT,L5620,Test socket below knee,Durable Medical Equipment,Per Unit,$298.16 ,OP,298.16,"1,025.61",,,,,,
Humana MCR ADV,CPT,L5622,Test socket knee disarticula,Durable Medical Equipment,Per Unit,$401.70 ,OP,401.7,"1,380.19",,,,,,
Humana MCR ADV,CPT,L5624,Test socket above knee,Durable Medical Equipment,Per Unit,$401.54 ,OP,401.54,"1,380.19",,,,,,
Humana MCR ADV,CPT,L5626,Test socket hip disarticulat,Durable Medical Equipment,Per Unit,$635.70 ,OP,635.7,"2,184.67",,,,,,
Humana MCR ADV,CPT,L5628,Test socket hemipelvectomy,Durable Medical Equipment,Per Unit,$643.74 ,OP,643.74,"2,215.19",,,,,,
Humana MCR ADV,CPT,L5629,Below knee acrylic socket,Durable Medical Equipment,Per Unit,$317.79 ,OP,317.79,"1,094.25",,,,,,
Humana MCR ADV,CPT,L5630,Syme typ expandabl wall sckt,Durable Medical Equipment,Per Unit,$552.17 ,OP,552.17,"1,898.73",,,,,,
Humana MCR ADV,CPT,L5631,Ak/knee disartic acrylic soc,Durable Medical Equipment,Per Unit,$439.37 ,OP,439.37,"1,509.83",,,,,,
Humana MCR ADV,CPT,L5632,Symes type ptb brim design s,Durable Medical Equipment,Per Unit,$270.81 ,OP,270.81,930.3,,,,,,
Humana MCR ADV,CPT,L5634,Symes type poster opening so,Durable Medical Equipment,Per Unit,$338.66 ,OP,338.66,"1,162.87",,,,,,
Humana MCR ADV,CPT,L5636,Symes type medial opening so,Durable Medical Equipment,Per Unit,$258.86 ,OP,258.86,888.36,,,,,,
Humana MCR ADV,CPT,L5637,Below knee total contact,Durable Medical Equipment,Per Unit,$385.17 ,OP,385.17,"1,323.01",,,,,,
Humana MCR ADV,CPT,L5638,Below knee leather socket,Durable Medical Equipment,Per Unit,$648.87 ,OP,648.87,"2,230.43",,,,,,
Humana MCR ADV,CPT,L5639,Below knee wood socket,Durable Medical Equipment,Per Unit,"$1,121.15 ",OP,"1,121.15","3,854.63",,,,,,
Humana MCR ADV,CPT,L5640,Knee disarticulat leather so,Durable Medical Equipment,Per Unit,$736.94 ,OP,736.94,"2,535.44",,,,,,
Humana MCR ADV,CPT,L5642,Above knee leather socket,Durable Medical Equipment,Per Unit,$683.11 ,OP,683.11,"2,348.62",,,,,,
Humana MCR ADV,CPT,L5643,Hip flex inner socket ext fr,Durable Medical Equipment,Per Unit,"$2,014.84 ",OP,"2,014.84","6,927.67",,,,,,
Humana MCR ADV,CPT,L5644,Above knee wood socket,Durable Medical Equipment,Per Unit,$590.63 ,OP,590.63,"2,032.17",,,,,,
Humana MCR ADV,CPT,L5645,Bk flex inner socket ext fra,Durable Medical Equipment,Per Unit,$979.82 ,OP,979.82,"3,370.43",,,,,,
Humana MCR ADV,CPT,L5646,Below knee cushion socket,Durable Medical Equipment,Per Unit,$620.93 ,OP,620.93,"2,135.11",,,,,,
Humana MCR ADV,CPT,L5647,Below knee suction socket,Durable Medical Equipment,Per Unit,$795.44 ,OP,795.44,"2,733.70",,,,,,
Humana MCR ADV,CPT,L5648,Above knee cushion socket,Durable Medical Equipment,Per Unit,$733.68 ,OP,733.68,"2,524.00",,,,,,
Humana MCR ADV,CPT,L5649,Isch containmt/narrow m-l so,Durable Medical Equipment,Per Unit,"$2,465.24 ",OP,"2,465.24","8,479.43",,,,,,
Humana MCR ADV,CPT,L5650,Tot contact ak/knee disart s,Durable Medical Equipment,Per Unit,$488.17 ,OP,488.17,"1,677.58",,,,,,
Humana MCR ADV,CPT,L5651,Ak flex inner socket ext fra,Durable Medical Equipment,Per Unit,"$1,430.29 ",OP,"1,430.29","4,918.37",,,,,,
Humana MCR ADV,CPT,L5652,Suction susp ak/knee disart,Durable Medical Equipment,Per Unit,$435.97 ,OP,435.97,"1,498.39",,,,,,
Humana MCR ADV,CPT,L5653,Knee disart expand wall sock,Durable Medical Equipment,Per Unit,$680.24 ,OP,680.24,"2,341.00",,,,,,
Humana MCR ADV,CPT,L5654,Socket insert symes,Durable Medical Equipment,Per Unit,$394.33 ,OP,394.33,"1,357.32",,,,,,
Humana MCR ADV,CPT,L5655,Socket insert below knee,Durable Medical Equipment,Per Unit,$284.71 ,OP,284.71,979.86,,,,,,
Humana MCR ADV,CPT,L5656,Socket insert knee articulat,Durable Medical Equipment,Per Unit,$432.53 ,OP,432.53,"1,486.95",,,,,,
Humana MCR ADV,CPT,L5658,Socket insert above knee,Durable Medical Equipment,Per Unit,$456.55 ,OP,456.55,"1,570.83",,,,,,
Humana MCR ADV,CPT,L5661,Multi-durometer symes,Durable Medical Equipment,Per Unit,$655.04 ,OP,655.04,"2,253.31",,,,,,
Humana MCR ADV,CPT,L5665,Multi-durometer below knee,Durable Medical Equipment,Per Unit,$582.36 ,OP,582.36,"2,001.67",,,,,,
Humana MCR ADV,CPT,L5666,Below knee cuff suspension,Durable Medical Equipment,Per Unit,$77.11 ,OP,77.11,266.89,,,,,,
Humana MCR ADV,CPT,L5668,Bk molded distal cushion,Durable Medical Equipment,Per Unit,$114.86 ,OP,114.86,396.52,,,,,,
Humana MCR ADV,CPT,L5670,Bk molded supracondylar susp,Durable Medical Equipment,Per Unit,$271.35 ,OP,271.35,934.12,,,,,,
Humana MCR ADV,CPT,L5671,Bk/ak locking mechanism,Durable Medical Equipment,Per Unit,$497.40 ,OP,497.4,"1,711.89",,,,,,
Humana MCR ADV,CPT,L5672,Bk removable medial brim sus,Durable Medical Equipment,Per Unit,$359.07 ,OP,359.07,"1,235.32",,,,,,
Humana MCR ADV,CPT,L5673,Socket insert w lock mech,Durable Medical Equipment,Per Unit,$790.52 ,OP,790.52,"2,718.45",,,,,,
Humana MCR ADV,CPT,L5676,Bk knee joints single axis p,Durable Medical Equipment,Per Unit,$362.36 ,OP,362.36,"1,246.76",,,,,,
Humana MCR ADV,CPT,L5677,Bk knee joints polycentric p,Durable Medical Equipment,Per Unit,$554.97 ,OP,554.97,"1,910.16",,,,,,
Humana MCR ADV,CPT,L5678,Bk joint covers pair,Durable Medical Equipment,Per Unit,$39.70 ,OP,39.7,137.25,,,,,,
Humana MCR ADV,CPT,L5679,Socket insert w/o lock mech,Durable Medical Equipment,Per Unit,$658.75 ,OP,658.75,"2,264.75",,,,,,
Humana MCR ADV,CPT,L5680,Bk thigh lacer non-molded,Durable Medical Equipment,Per Unit,$304.37 ,OP,304.37,"1,048.50",,,,,,
Humana MCR ADV,CPT,L5681,Intl custm cong/latyp insert,Durable Medical Equipment,Per Unit,"$1,323.02 ",OP,"1,323.02","4,548.54",,,,,,
Humana MCR ADV,CPT,L5682,Bk thigh lacer glut/ischia m,Durable Medical Equipment,Per Unit,$625.37 ,OP,625.37,"2,150.36",,,,,,
Humana MCR ADV,CPT,L5683,Initial custom socket insert,Durable Medical Equipment,Per Unit,"$1,323.02 ",OP,"1,323.02","4,548.54",,,,,,
Humana MCR ADV,CPT,L5684,Bk fork strap,Durable Medical Equipment,Per Unit,$48.13 ,OP,48.13,163.95,,,,,,
Humana MCR ADV,CPT,L5685,Below knee sus/seal sleeve,Durable Medical Equipment,Per Unit,$128.85 ,OP,128.85,442.27,,,,,,
Humana MCR ADV,CPT,L5686,Bk back check,Durable Medical Equipment,Per Unit,$57.89 ,OP,57.89,198.25,,,,,,
Humana MCR ADV,CPT,L5688,Bk waist belt webbing,Durable Medical Equipment,Per Unit,$61.48 ,OP,61.48,209.7,,,,,,
Humana MCR ADV,CPT,L5690,Bk waist belt padded and lin,Durable Medical Equipment,Per Unit,$125.50 ,OP,125.5,430.83,,,,,,
Humana MCR ADV,CPT,L5692,Ak pelvic control belt light,Durable Medical Equipment,Per Unit,$132.88 ,OP,132.88,457.52,,,,,,
Humana MCR ADV,CPT,L5694,Ak pelvic control belt pad/l,Durable Medical Equipment,Per Unit,$181.41 ,OP,181.41,625.29,,,,,,
Humana MCR ADV,CPT,L5695,Ak sleeve susp neoprene/equa,Durable Medical Equipment,Per Unit,$163.08 ,OP,163.08,560.47,,,,,,
Humana MCR ADV,CPT,L5696,Ak/knee disartic pelvic join,Durable Medical Equipment,Per Unit,$196.99 ,OP,196.99,678.66,,,,,,
Humana MCR ADV,CPT,L5697,Ak/knee disartic pelvic band,Durable Medical Equipment,Per Unit,$93.55 ,OP,93.55,320.27,,,,,,
Humana MCR ADV,CPT,L5698,Ak/knee disartic silesian ba,Durable Medical Equipment,Per Unit,$120.01 ,OP,120.01,411.78,,,,,,
Humana MCR ADV,CPT,L5699,Shoulder harness,Durable Medical Equipment,Per Unit,$205.11 ,OP,205.11,705.35,,,,,,
Humana MCR ADV,CPT,L5700,Replace socket below knee,Durable Medical Equipment,Per Unit,"$3,085.07 ",OP,"3,085.07","10,610.72",,,,,,
Humana MCR ADV,CPT,L5701,Replace socket above knee,Durable Medical Equipment,Per Unit,"$3,827.32 ",OP,"3,827.32","13,161.41",,,,,,
Humana MCR ADV,CPT,L5702,Replace socket hip,Durable Medical Equipment,Per Unit,"$4,823.75 ",OP,"4,823.75","16,589.03",,,,,,
Humana MCR ADV,CPT,L5703,Symes ankle w/o (sach) foot,Durable Medical Equipment,Per Unit,"$2,537.43 ",OP,"2,537.43","8,727.25",,,,,,
Humana MCR ADV,CPT,L5704,Custom shape cover bk,Durable Medical Equipment,Per Unit,$629.03 ,OP,629.03,"2,161.80",,,,,,
Humana MCR ADV,CPT,L5705,Custom shape cover ak,Durable Medical Equipment,Per Unit,"$1,153.25 ",OP,"1,153.25","3,965.20",,,,,,
Humana MCR ADV,CPT,L5706,Custom shape cvr knee disart,Durable Medical Equipment,Per Unit,"$1,124.85 ",OP,"1,124.85","3,869.89",,,,,,
Humana MCR ADV,CPT,L5707,Custom shape cvr hip disart,Durable Medical Equipment,Per Unit,"$1,511.27 ",OP,"1,511.27","5,196.70",,,,,,
Humana MCR ADV,CPT,L5710,Kne-shin exo sng axi mnl loc,Durable Medical Equipment,Per Unit,$359.65 ,OP,359.65,"1,235.32",,,,,,
Humana MCR ADV,CPT,L5711,Knee-shin exo mnl lock ultra,Durable Medical Equipment,Per Unit,$603.60 ,OP,603.6,"2,074.10",,,,,,
Humana MCR ADV,CPT,L5712,Knee-shin exo frict swg & st,Durable Medical Equipment,Per Unit,$430.88 ,OP,430.88,"1,483.14",,,,,,
Humana MCR ADV,CPT,L5714,Knee-shin exo variable frict,Durable Medical Equipment,Per Unit,$438.43 ,OP,438.43,"1,506.03",,,,,,
Humana MCR ADV,CPT,L5716,Knee-shin exo mech stance ph,Durable Medical Equipment,Per Unit,$866.93 ,OP,866.93,"2,981.52",,,,,,
Humana MCR ADV,CPT,L5718,Knee-shin exo frct swg & sta,Durable Medical Equipment,Per Unit,$927.01 ,OP,927.01,"3,187.41",,,,,,
Humana MCR ADV,CPT,L5722,Knee-shin pneum swg frct exo,Durable Medical Equipment,Per Unit,"$1,127.32 ",OP,"1,127.32","3,877.51",,,,,,
Humana MCR ADV,CPT,L5724,Knee-shin exo fluid swing ph,Durable Medical Equipment,Per Unit,"$1,737.57 ",OP,"1,737.57","5,974.48",,,,,,
Humana MCR ADV,CPT,L5726,Knee-shin ext jnts fld swg e,Durable Medical Equipment,Per Unit,"$2,068.65 ",OP,"2,068.65","7,114.49",,,,,,
Humana MCR ADV,CPT,L5728,Knee-shin fluid swg & stance,Durable Medical Equipment,Per Unit,"$2,424.23 ",OP,"2,424.23","8,338.36",,,,,,
Humana MCR ADV,CPT,L5780,Knee-shin pneum/hydra pneum,Durable Medical Equipment,Per Unit,"$1,334.72 ",OP,"1,334.72","4,590.49",,,,,,
Humana MCR ADV,CPT,L5781,Lower limb pros vacuum pump,Durable Medical Equipment,Per Unit,"$4,024.33 ",OP,"4,024.33","13,840.07",,,,,,
Humana MCR ADV,CPT,L5782,Hd low limb pros vacuum pump,Durable Medical Equipment,Per Unit,"$4,242.55 ",OP,"4,242.55","14,591.17",,,,,,
Humana MCR ADV,CPT,L5785,Exoskeletal bk ultralt mater,Durable Medical Equipment,Per Unit,$519.54 ,OP,519.54,"1,788.15",,,,,,
Humana MCR ADV,CPT,L5790,Exoskeletal ak ultra-light m,Durable Medical Equipment,Per Unit,$749.83 ,OP,749.83,"2,577.38",,,,,,
Humana MCR ADV,CPT,L5795,Exoskel hip ultra-light mate,Durable Medical Equipment,Per Unit,"$1,073.66 ",OP,"1,073.66","3,690.70",,,,,,
Humana MCR ADV,CPT,L5810,Endoskel knee-shin mnl lock,Durable Medical Equipment,Per Unit,$572.04 ,OP,572.04,"1,967.35",,,,,,
Humana MCR ADV,CPT,L5811,Endo knee-shin mnl lck ultra,Durable Medical Equipment,Per Unit,$789.42 ,OP,789.42,"2,714.64",,,,,,
Humana MCR ADV,CPT,L5812,Endo knee-shin frct swg & st,Durable Medical Equipment,Per Unit,$594.07 ,OP,594.07,"2,043.61",,,,,,
Humana MCR ADV,CPT,L5814,Endo knee-shin hydral swg ph,Durable Medical Equipment,Per Unit,"$3,735.37 ",OP,"3,735.37","12,844.96",,,,,,
Humana MCR ADV,CPT,L5816,Endo knee-shin polyc mch sta,Durable Medical Equipment,Per Unit,$850.43 ,OP,850.43,"2,924.33",,,,,,
Humana MCR ADV,CPT,L5818,Endo knee-shin frct swg & st,Durable Medical Equipment,Per Unit,$960.30 ,OP,960.3,"3,301.79",,,,,,
Humana MCR ADV,CPT,L5822,Endo knee-shin pneum swg frc,Durable Medical Equipment,Per Unit,"$1,761.65 ",OP,"1,761.65","6,058.37",,,,,,
Humana MCR ADV,CPT,L5824,Endo knee-shin fluid swing p,Durable Medical Equipment,Per Unit,"$1,665.27 ",OP,"1,665.27","5,726.65",,,,,,
Humana MCR ADV,CPT,L5826,Miniature knee joint,Durable Medical Equipment,Per Unit,"$3,140.97 ",OP,"3,140.97","10,801.35",,,,,,
Humana MCR ADV,CPT,L5828,Endo knee-shin fluid swg/sta,Durable Medical Equipment,Per Unit,"$2,963.78 ",OP,"2,963.78","10,191.33",,,,,,
Humana MCR ADV,CPT,L5830,Endo knee-shin pneum/swg pha,Durable Medical Equipment,Per Unit,"$1,998.37 ",OP,"1,998.37","6,874.29",,,,,,
Humana MCR ADV,CPT,L5840,Multi-axial knee/shin system,Durable Medical Equipment,Per Unit,"$3,922.28 ",OP,"3,922.28","13,489.32",,,,,,
Humana MCR ADV,CPT,L5845,Knee-shin sys stance flexion,Durable Medical Equipment,Per Unit,"$1,802.73 ",OP,"1,802.73","6,199.43",,,,,,
Humana MCR ADV,CPT,L5848,Knee-shin sys hydraul stance,Durable Medical Equipment,Per Unit,"$1,081.55 ",OP,"1,081.55","3,721.19",,,,,,
Humana MCR ADV,CPT,L5850,Endo ak/hip knee extens assi,Durable Medical Equipment,Per Unit,$127.92 ,OP,127.92,438.47,,,,,,
Humana MCR ADV,CPT,L5855,Mech hip extension assist,Durable Medical Equipment,Per Unit,$308.82 ,OP,308.82,"1,063.73",,,,,,
Humana MCR ADV,CPT,L5856,Elec knee-shin swing/stance,Durable Medical Equipment,Per Unit,"$24,144.68 ",OP,"24,144.68","83,036.63",,,,,,
Humana MCR ADV,CPT,L5857,Elec knee-shin swing only,Durable Medical Equipment,Per Unit,"$8,567.44 ",OP,"8,567.44","29,464.49",,,,,,
Humana MCR ADV,CPT,L5858,Stance phase only,Durable Medical Equipment,Per Unit,"$18,692.70 ",OP,"18,692.70","64,285.82",,,,,,
Humana MCR ADV,CPT,L5859,Knee-shin pro flex/ext cont,Durable Medical Equipment,Per Unit,"$14,593.21 ",OP,"14,593.21","14,593.21",,,,,,
Humana MCR ADV,CPT,L5910,Endo below knee alignable sy,Durable Medical Equipment,Per Unit,$362.17 ,OP,362.17,"1,246.76",,,,,,
Humana MCR ADV,CPT,L5920,Endo ak/hip alignable system,Durable Medical Equipment,Per Unit,$530.58 ,OP,530.58,"1,826.28",,,,,,
Humana MCR ADV,CPT,L5925,Above knee manual lock,Durable Medical Equipment,Per Unit,$336.00 ,OP,336,"1,155.24",,,,,,
Humana MCR ADV,CPT,L5930,High activity knee frame,Durable Medical Equipment,Per Unit,"$3,385.39 ",OP,"3,385.39","11,643.96",,,,,,
Humana MCR ADV,CPT,L5940,Endo bk ultra-light material,Durable Medical Equipment,Per Unit,$501.60 ,OP,501.6,"1,723.33",,,,,,
Humana MCR ADV,CPT,L5950,Endo ak ultra-light material,Durable Medical Equipment,Per Unit,$777.99 ,OP,777.99,"2,676.51",,,,,,
Humana MCR ADV,CPT,L5960,Endo hip ultra-light materia,Durable Medical Equipment,Per Unit,"$1,163.29 ",OP,"1,163.29","3,999.51",,,,,,
Humana MCR ADV,CPT,L5961,Endo poly hip- pneu/hyd/rot,Durable Medical Equipment,Per Unit,"$4,800.88 ",OP,"4,800.88","4,800.88",,,,,,
Humana MCR ADV,CPT,L5962,Below knee flex cover system,Durable Medical Equipment,Per Unit,$587.78 ,OP,587.78,"2,020.72",,,,,,
Humana MCR ADV,CPT,L5964,Above knee flex cover system,Durable Medical Equipment,Per Unit,"$1,127.47 ",OP,"1,127.47","3,877.51",,,,,,
Humana MCR ADV,CPT,L5966,Hip flexible cover system,Durable Medical Equipment,Per Unit,"$1,452.38 ",OP,"1,452.38","4,994.63",,,,,,
Humana MCR ADV,CPT,L5968,Multiaxial ankle w dorsiflex,Durable Medical Equipment,Per Unit,"$3,654.91 ",OP,"3,654.91","12,570.45",,,,,,
Humana MCR ADV,CPT,L5970,Foot external keel sach foot,Durable Medical Equipment,Per Unit,$218.47 ,OP,218.47,751.1,,,,,,
Humana MCR ADV,CPT,L5971,Sach foot- replacement,Durable Medical Equipment,Per Unit,$218.47 ,OP,218.47,751.1,,,,,,
Humana MCR ADV,CPT,L5972,Flexible keel foot,Durable Medical Equipment,Per Unit,$397.97 ,OP,397.97,"1,368.75",,,,,,
Humana MCR ADV,CPT,L5973,Ank-foot sys dors-plant flex,Durable Medical Equipment,Per Unit,"$17,757.02 ",OP,"17,757.02","17,757.02",,,,,,
Humana MCR ADV,CPT,L5974,Foot single axis ankle/foot,Durable Medical Equipment,Per Unit,$233.03 ,OP,233.03,800.67,,,,,,
Humana MCR ADV,CPT,L5975,Combo ankle/foot prosthesis,Durable Medical Equipment,Per Unit,$466.28 ,OP,466.28,"1,605.15",,,,,,
Humana MCR ADV,CPT,L5976,Energy storing foot,Durable Medical Equipment,Per Unit,$591.07 ,OP,591.07,"2,032.17",,,,,,
Humana MCR ADV,CPT,L5978,Ft prosth multiaxial ankl/ft,Durable Medical Equipment,Per Unit,$313.20 ,OP,313.2,"1,078.99",,,,,,
Humana MCR ADV,CPT,L5979,Multi-axial ankle/ft prosth,Durable Medical Equipment,Per Unit,"$2,507.69 ",OP,"2,507.69","8,624.30",,,,,,
Humana MCR ADV,CPT,L5980,Flex foot system,Durable Medical Equipment,Per Unit,"$3,820.69 ",OP,"3,820.69","13,138.54",,,,,,
Humana MCR ADV,CPT,L5981,Flex-walk sys low ext prosth,Durable Medical Equipment,Per Unit,"$3,431.91 ",OP,"3,431.91","11,804.09",,,,,,
Humana MCR ADV,CPT,L5982,Exoskeletal axial rotation u,Durable Medical Equipment,Per Unit,$644.71 ,OP,644.71,"2,218.98",,,,,,
Humana MCR ADV,CPT,L5984,Endoskeletal axial rotation,Durable Medical Equipment,Per Unit,$646.71 ,OP,646.71,"2,222.79",,,,,,
Humana MCR ADV,CPT,L5985,Lwr ext dynamic prosth pylon,Durable Medical Equipment,Per Unit,$284.02 ,OP,284.02,976.05,,,,,,
Humana MCR ADV,CPT,L5986,Multi-axial rotation unit,Durable Medical Equipment,Per Unit,$780.11 ,OP,780.11,"2,684.14",,,,,,
Humana MCR ADV,CPT,L5987,Shank ft w vert load pylon,Durable Medical Equipment,Per Unit,"$7,235.38 ",OP,"7,235.38","24,881.63",,,,,,
Humana MCR ADV,CPT,L5988,Vertical shock reducing pylo,Durable Medical Equipment,Per Unit,"$2,009.25 ",OP,"2,009.25","6,908.59",,,,,,
Humana MCR ADV,CPT,L5990,User adjustable heel height,Durable Medical Equipment,Per Unit,"$1,824.64 ",OP,"1,824.64","6,275.69",,,,,,
Humana MCR ADV,CPT,L6000,Part hand thumb rem,Durable Medical Equipment,Per Unit,"$1,771.55 ",OP,"1,771.55","6,092.69",,,,,,
Humana MCR ADV,CPT,L6010,Part hand little/ring,Durable Medical Equipment,Per Unit,"$1,971.44 ",OP,"1,971.44","6,778.98",,,,,,
Humana MCR ADV,CPT,L6020,Part hand no fingers,Durable Medical Equipment,Per Unit,"$1,838.05 ",OP,"1,838.05","6,321.45",,,,,,
Humana MCR ADV,CPT,L6026,Part hand myo exclu term dev,Durable Medical Equipment,Per Unit,"$4,375.03 ",OP,"4,375.03","4,375.03",,,,,,
Humana MCR ADV,CPT,L6050,Wrst mld sck flx hng tri pad,Durable Medical Equipment,Per Unit,"$2,500.12 ",OP,"2,500.12","8,597.63",,,,,,
Humana MCR ADV,CPT,L6055,Wrst mold sock w/exp interfa,Durable Medical Equipment,Per Unit,"$3,189.04 ",OP,"3,189.04","10,969.11",,,,,,
Humana MCR ADV,CPT,L6100,Elb mold sock flex hinge pad,Durable Medical Equipment,Per Unit,"$2,530.04 ",OP,"2,530.04","8,700.56",,,,,,
Humana MCR ADV,CPT,L6110,Elbow mold sock suspension t,Durable Medical Equipment,Per Unit,"$2,676.61 ",OP,"2,676.61","9,203.84",,,,,,
Humana MCR ADV,CPT,L6120,Elbow mold doub splt soc ste,Durable Medical Equipment,Per Unit,"$3,027.26 ",OP,"3,027.26","10,412.46",,,,,,
Humana MCR ADV,CPT,L6130,Elbow stump activated lock h,Durable Medical Equipment,Per Unit,"$3,193.82 ",OP,"3,193.82","10,984.37",,,,,,
Humana MCR ADV,CPT,L6200,Elbow mold outsid lock hinge,Durable Medical Equipment,Per Unit,"$3,290.01 ",OP,"3,290.01","11,316.08",,,,,,
Humana MCR ADV,CPT,L6205,Elbow molded w/ expand inter,Durable Medical Equipment,Per Unit,"$4,538.50 ",OP,"4,538.50","15,609.16",,,,,,
Humana MCR ADV,CPT,L6250,Elbow inter loc elbow forarm,Durable Medical Equipment,Per Unit,"$3,236.79 ",OP,"3,236.79","11,133.06",,,,,,
Humana MCR ADV,CPT,L6300,Shlder disart int lock elbow,Durable Medical Equipment,Per Unit,"$4,464.43 ",OP,"4,464.43","15,353.72",,,,,,
Humana MCR ADV,CPT,L6310,Shoulder passive restor comp,Durable Medical Equipment,Per Unit,"$4,046.04 ",OP,"4,046.04","13,916.32",,,,,,
Humana MCR ADV,CPT,L6320,Shoulder passive restor cap,Durable Medical Equipment,Per Unit,"$2,108.67 ",OP,"2,108.67","7,251.74",,,,,,
Humana MCR ADV,CPT,L6350,Thoracic intern lock elbow,Durable Medical Equipment,Per Unit,"$4,891.63 ",OP,"4,891.63","16,821.60",,,,,,
Humana MCR ADV,CPT,L6360,Thoracic passive restor comp,Durable Medical Equipment,Per Unit,"$4,246.80 ",OP,"4,246.80","14,606.43",,,,,,
Humana MCR ADV,CPT,L6370,Thoracic passive restor cap,Durable Medical Equipment,Per Unit,"$2,462.85 ",OP,"2,462.85","8,471.79",,,,,,
Humana MCR ADV,CPT,L6380,Postop dsg cast chg wrst/elb,Durable Medical Equipment,Per Unit,"$1,424.44 ",OP,"1,424.44","4,899.32",,,,,,
Humana MCR ADV,CPT,L6382,Postop dsg cast chg elb dis/,Durable Medical Equipment,Per Unit,"$1,695.74 ",OP,"1,695.74","5,833.42",,,,,,
Humana MCR ADV,CPT,L6384,Postop dsg cast chg shlder/t,Durable Medical Equipment,Per Unit,"$2,145.20 ",OP,"2,145.20","7,377.56",,,,,,
Humana MCR ADV,CPT,L6386,Postop ea cast chg & realign,Durable Medical Equipment,Per Unit,$470.24 ,OP,470.24,"1,616.58",,,,,,
Humana MCR ADV,CPT,L6388,Postop applicat rigid dsg on,Durable Medical Equipment,Per Unit,$517.85 ,OP,517.85,"1,780.53",,,,,,
Humana MCR ADV,CPT,L6400,Below elbow prosth tiss shap,Durable Medical Equipment,Per Unit,"$2,736.86 ",OP,"2,736.86","9,413.54",,,,,,
Humana MCR ADV,CPT,L6450,Elb disart prosth tiss shap,Durable Medical Equipment,Per Unit,"$3,576.94 ",OP,"3,576.94","12,299.74",,,,,,
Humana MCR ADV,CPT,L6500,Above elbow prosth tiss shap,Durable Medical Equipment,Per Unit,"$3,512.48 ",OP,"3,512.48","12,078.62",,,,,,
Humana MCR ADV,CPT,L6550,Shldr disar prosth tiss shap,Durable Medical Equipment,Per Unit,"$4,549.39 ",OP,"4,549.39","15,647.29",,,,,,
Humana MCR ADV,CPT,L6570,Scap thorac prosth tiss shap,Durable Medical Equipment,Per Unit,"$5,078.79 ",OP,"5,078.79","17,465.96",,,,,,
Humana MCR ADV,CPT,L6580,Wrist/elbow bowden cable mol,Durable Medical Equipment,Per Unit,"$2,030.62 ",OP,"2,030.62","6,984.85",,,,,,
Humana MCR ADV,CPT,L6582,Wrist/elbow bowden cbl dir f,Durable Medical Equipment,Per Unit,"$1,705.44 ",OP,"1,705.44","5,863.93",,,,,,
Humana MCR ADV,CPT,L6584,Elbow fair lead cable molded,Durable Medical Equipment,Per Unit,"$2,525.30 ",OP,"2,525.30","8,685.31",,,,,,
Humana MCR ADV,CPT,L6586,Elbow fair lead cable dir fo,Durable Medical Equipment,Per Unit,"$2,250.20 ",OP,"2,250.20","7,739.77",,,,,,
Humana MCR ADV,CPT,L6588,Shdr fair lead cable molded,Durable Medical Equipment,Per Unit,"$3,583.73 ",OP,"3,583.73","12,326.44",,,,,,
Humana MCR ADV,CPT,L6590,Shdr fair lead cable direct,Durable Medical Equipment,Per Unit,"$3,123.36 ",OP,"3,123.36","10,740.36",,,,,,
Humana MCR ADV,CPT,L6600,Polycentric hinge pair,Durable Medical Equipment,Per Unit,$228.13 ,OP,228.13,785.42,,,,,,
Humana MCR ADV,CPT,L6605,Single pivot hinge pair,Durable Medical Equipment,Per Unit,$234.81 ,OP,234.81,808.29,,,,,,
Humana MCR ADV,CPT,L6610,Flexible metal hinge pair,Durable Medical Equipment,Per Unit,$221.98 ,OP,221.98,762.54,,,,,,
Humana MCR ADV,CPT,L6611,Additional switch- ext power,Durable Medical Equipment,Per Unit,$414.10 ,OP,414.1,"1,425.95",,,,,,
Humana MCR ADV,CPT,L6615,Disconnect locking wrist uni,Durable Medical Equipment,Per Unit,$215.48 ,OP,215.48,739.67,,,,,,
Humana MCR ADV,CPT,L6616,Disconnect insert locking wr,Durable Medical Equipment,Per Unit,$64.86 ,OP,64.86,224.95,,,,,,
Humana MCR ADV,CPT,L6620,Flexion/extension wrist unit,Durable Medical Equipment,Per Unit,$376.69 ,OP,376.69,"1,296.32",,,,,,
Humana MCR ADV,CPT,L6621,Flex/ext wrist w/wo friction,Durable Medical Equipment,Per Unit,"$2,300.54 ",OP,"2,300.54","7,911.34",,,,,,
Humana MCR ADV,CPT,L6623,Spring-ass rot wrst w/ latch,Durable Medical Equipment,Per Unit,$717.59 ,OP,717.59,"2,466.81",,,,,,
Humana MCR ADV,CPT,L6624,Flex/ext/rotation wrist unit,Durable Medical Equipment,Per Unit,"$3,787.86 ",OP,"3,787.86","13,027.98",,,,,,
Humana MCR ADV,CPT,L6625,Rotation wrst w/ cable lock,Durable Medical Equipment,Per Unit,$531.84 ,OP,531.84,"1,830.09",,,,,,
Humana MCR ADV,CPT,L6628,Quick disconn hook adapter o,Durable Medical Equipment,Per Unit,$572.47 ,OP,572.47,"1,967.35",,,,,,
Humana MCR ADV,CPT,L6629,Lamination collar w/ couplin,Durable Medical Equipment,Per Unit,$195.07 ,OP,195.07,671.03,,,,,,
Humana MCR ADV,CPT,L6630,Stainless steel any wrist,Durable Medical Equipment,Per Unit,$287.35 ,OP,287.35,987.49,,,,,,
Humana MCR ADV,CPT,L6632,Latex suspension sleeve each,Durable Medical Equipment,Per Unit,$64.97 ,OP,64.97,224.95,,,,,,
Humana MCR ADV,CPT,L6635,Lift assist for elbow,Durable Medical Equipment,Per Unit,$207.68 ,OP,207.68,712.98,,,,,,
Humana MCR ADV,CPT,L6637,Nudge control elbow lock,Durable Medical Equipment,Per Unit,$406.60 ,OP,406.6,"1,399.26",,,,,,
Humana MCR ADV,CPT,L6638,Elec lock on manual pw elbow,Durable Medical Equipment,Per Unit,"$2,515.20 ",OP,"2,515.20","8,651.00",,,,,,
Humana MCR ADV,CPT,L6640,Shoulder abduction joint pai,Durable Medical Equipment,Per Unit,$338.63 ,OP,338.63,"1,162.87",,,,,,
Humana MCR ADV,CPT,L6641,Excursion amplifier pulley t,Durable Medical Equipment,Per Unit,$197.18 ,OP,197.18,678.66,,,,,,
Humana MCR ADV,CPT,L6642,Excursion amplifier lever ty,Durable Medical Equipment,Per Unit,$289.92 ,OP,289.92,998.92,,,,,,
Humana MCR ADV,CPT,L6645,Shoulder flexion-abduction j,Durable Medical Equipment,Per Unit,$366.21 ,OP,366.21,"1,258.19",,,,,,
Humana MCR ADV,CPT,L6646,Multipo locking shoulder jnt,Durable Medical Equipment,Per Unit,"$3,172.24 ",OP,"3,172.24","10,908.12",,,,,,
Humana MCR ADV,CPT,L6647,Shoulder lock actuator,Durable Medical Equipment,Per Unit,$522.26 ,OP,522.26,"1,795.78",,,,,,
Humana MCR ADV,CPT,L6648,Ext pwrd shlder lock/unlock,Durable Medical Equipment,Per Unit,"$3,271.71 ",OP,"3,271.71","11,251.26",,,,,,
Humana MCR ADV,CPT,L6650,Shoulder universal joint,Durable Medical Equipment,Per Unit,$397.20 ,OP,397.2,"1,364.94",,,,,,
Humana MCR ADV,CPT,L6655,Standard control cable extra,Durable Medical Equipment,Per Unit,$77.05 ,OP,77.05,263.08,,,,,,
Humana MCR ADV,CPT,L6660,Heavy duty control cable,Durable Medical Equipment,Per Unit,$103.11 ,OP,103.11,354.58,,,,,,
Humana MCR ADV,CPT,L6665,Teflon or equal cable lining,Durable Medical Equipment,Per Unit,$46.05 ,OP,46.05,160.13,,,,,,
Humana MCR ADV,CPT,L6670,Hook to hand cable adapter,Durable Medical Equipment,Per Unit,$47.96 ,OP,47.96,163.95,,,,,,
Humana MCR ADV,CPT,L6672,Harness chest/shlder saddle,Durable Medical Equipment,Per Unit,$220.08 ,OP,220.08,758.72,,,,,,
Humana MCR ADV,CPT,L6675,Harness figure of 8 sing con,Durable Medical Equipment,Per Unit,$120.09 ,OP,120.09,411.78,,,,,,
Humana MCR ADV,CPT,L6676,Harness figure of 8 dual con,Durable Medical Equipment,Per Unit,$125.64 ,OP,125.64,430.83,,,,,,
Humana MCR ADV,CPT,L6677,Ue triple control harness,Durable Medical Equipment,Per Unit,$298.35 ,OP,298.35,"1,025.61",,,,,,
Humana MCR ADV,CPT,L6680,Test sock wrist disart/bel e,Durable Medical Equipment,Per Unit,$309.33 ,OP,309.33,"1,063.73",,,,,,
Humana MCR ADV,CPT,L6682,Test sock elbw disart/above,Durable Medical Equipment,Per Unit,$342.01 ,OP,342.01,"1,178.12",,,,,,
Humana MCR ADV,CPT,L6684,Test socket shldr disart/tho,Durable Medical Equipment,Per Unit,$464.75 ,OP,464.75,"1,597.52",,,,,,
Humana MCR ADV,CPT,L6686,Suction socket,Durable Medical Equipment,Per Unit,$689.63 ,OP,689.63,"2,371.49",,,,,,
Humana MCR ADV,CPT,L6687,Frame typ socket bel elbow/w,Durable Medical Equipment,Per Unit,$576.80 ,OP,576.8,"1,982.60",,,,,,
Humana MCR ADV,CPT,L6688,Frame typ sock above elb/dis,Durable Medical Equipment,Per Unit,$638.36 ,OP,638.36,"2,196.11",,,,,,
Humana MCR ADV,CPT,L6689,Frame typ socket shoulder di,Durable Medical Equipment,Per Unit,$760.81 ,OP,760.81,"2,615.51",,,,,,
Humana MCR ADV,CPT,L6690,Frame typ sock interscap-tho,Durable Medical Equipment,Per Unit,$895.74 ,OP,895.74,"3,080.66",,,,,,
Humana MCR ADV,CPT,L6691,Removable insert each,Durable Medical Equipment,Per Unit,$353.58 ,OP,353.58,"1,216.24",,,,,,
Humana MCR ADV,CPT,L6692,Silicone gel insert or equal,Durable Medical Equipment,Per Unit,$643.25 ,OP,643.25,"2,211.37",,,,,,
Humana MCR ADV,CPT,L6693,Lockingelbow forearm cntrbal,Durable Medical Equipment,Per Unit,"$2,855.43 ",OP,"2,855.43","9,821.50",,,,,,
Humana MCR ADV,CPT,L6694,Elbow socket ins use w/lock,Durable Medical Equipment,Per Unit,$790.52 ,OP,790.52,"2,718.45",,,,,,
Humana MCR ADV,CPT,L6695,Elbow socket ins use w/o lck,Durable Medical Equipment,Per Unit,$658.75 ,OP,658.75,"2,264.75",,,,,,
Humana MCR ADV,CPT,L6696,Cus elbo skt in for con/atyp,Durable Medical Equipment,Per Unit,"$1,323.02 ",OP,"1,323.02","4,548.54",,,,,,
Humana MCR ADV,CPT,L6697,Cus elbo skt in not con/atyp,Durable Medical Equipment,Per Unit,"$1,323.02 ",OP,"1,323.02","4,548.54",,,,,,
Humana MCR ADV,CPT,L6698,Below/above elbow lock mech,Durable Medical Equipment,Per Unit,$497.40 ,OP,497.4,"1,711.89",,,,,,
Humana MCR ADV,CPT,L6703,Term dev- passive hand mitt,Durable Medical Equipment,Per Unit,$351.79 ,OP,351.79,"1,208.62",,,,,,
Humana MCR ADV,CPT,L6704,Term dev- sport/rec/work att,Durable Medical Equipment,Per Unit,$679.06 ,OP,679.06,"2,337.18",,,,,,
Humana MCR ADV,CPT,L6706,Term dev mech hook vol open,Durable Medical Equipment,Per Unit,$421.40 ,OP,421.4,"1,448.82",,,,,,
Humana MCR ADV,CPT,L6707,Term dev mech hook vol close,Durable Medical Equipment,Per Unit,"$1,490.70 ",OP,"1,490.70","5,128.07",,,,,,
Humana MCR ADV,CPT,L6708,Term dev mech hand vol open,Durable Medical Equipment,Per Unit,$985.41 ,OP,985.41,"3,389.47",,,,,,
Humana MCR ADV,CPT,L6709,Term dev mech hand vol close,Durable Medical Equipment,Per Unit,"$1,398.55 ",OP,"1,398.55","4,811.61",,,,,,
Humana MCR ADV,CPT,L6711,Ped term dev- hook- vol open,Durable Medical Equipment,Per Unit,$676.19 ,OP,676.19,"2,325.74",,,,,,
Humana MCR ADV,CPT,L6712,Ped term dev- hook- vol clos,Durable Medical Equipment,Per Unit,"$1,245.05 ",OP,"1,245.05","4,281.66",,,,,,
Humana MCR ADV,CPT,L6713,Ped term dev- hand- vol open,Durable Medical Equipment,Per Unit,"$1,571.33 ",OP,"1,571.33","5,402.59",,,,,,
Humana MCR ADV,CPT,L6714,Ped term dev- hand- vol clos,Durable Medical Equipment,Per Unit,"$1,330.91 ",OP,"1,330.91","4,579.05",,,,,,
Humana MCR ADV,CPT,L6715,Term device- multi art digit,Durable Medical Equipment,Per Unit,"$3,175.42 ",OP,"3,175.42","3,175.42",,,,,,
Humana MCR ADV,CPT,L6721,Hook/hand- hvy dty- vol open,Durable Medical Equipment,Per Unit,"$2,365.59 ",OP,"2,365.59","8,136.28",,,,,,
Humana MCR ADV,CPT,L6722,Hook/hand- hvy dty- vol clos,Durable Medical Equipment,Per Unit,"$2,039.28 ",OP,"2,039.28","7,011.54",,,,,,
Humana MCR ADV,CPT,L6805,Term dev modifier wrist unit,Durable Medical Equipment,Per Unit,$385.75 ,OP,385.75,"1,326.82",,,,,,
Humana MCR ADV,CPT,L6810,Term dev precision pinch dev,Durable Medical Equipment,Per Unit,$205.07 ,OP,205.07,705.35,,,,,,
Humana MCR ADV,CPT,L6880,Elec hand ind art digits,Durable Medical Equipment,Per Unit,"$24,030.68 ",OP,"24,030.68","24,030.68",,,,,,
Humana MCR ADV,CPT,L6881,Term dev auto grasp feature,Durable Medical Equipment,Per Unit,"$4,111.91 ",OP,"4,111.91","14,141.27",,,,,,
Humana MCR ADV,CPT,L6882,Microprocessor control uplmb,Durable Medical Equipment,Per Unit,"$3,119.08 ",OP,"3,119.08","10,725.10",,,,,,
Humana MCR ADV,CPT,L6883,Replc sockt below e/w disa,Durable Medical Equipment,Per Unit,"$1,997.96 ",OP,"1,997.96","6,870.47",,,,,,
Humana MCR ADV,CPT,L6884,Replc sockt above elbow disa,Durable Medical Equipment,Per Unit,"$2,733.67 ",OP,"2,733.67","9,402.10",,,,,,
Humana MCR ADV,CPT,L6885,Replc sockt shldr dis/interc,Durable Medical Equipment,Per Unit,"$4,246.80 ",OP,"4,246.80","14,606.43",,,,,,
Humana MCR ADV,CPT,L6890,Prefab glove for term device,Durable Medical Equipment,Per Unit,$200.88 ,OP,200.88,690.1,,,,,,
Humana MCR ADV,CPT,L6895,Custom glove for term device,Durable Medical Equipment,Per Unit,$671.68 ,OP,671.68,"2,310.49",,,,,,
Humana MCR ADV,CPT,L6900,Hand restorat thumb/1 finger,Durable Medical Equipment,Per Unit,"$1,950.52 ",OP,"1,950.52","6,706.52",,,,,,
Humana MCR ADV,CPT,L6905,Hand restoration multiple fi,Durable Medical Equipment,Per Unit,"$1,930.47 ",OP,"1,930.47","6,637.91",,,,,,
Humana MCR ADV,CPT,L6910,Hand restoration no fingers,Durable Medical Equipment,Per Unit,"$1,897.78 ",OP,"1,897.78","6,527.33",,,,,,
Humana MCR ADV,CPT,L6915,Hand restoration replacmnt g,Durable Medical Equipment,Per Unit,$815.40 ,OP,815.4,"2,806.14",,,,,,
Humana MCR ADV,CPT,L6920,Wrist disarticul switch ctrl,Durable Medical Equipment,Per Unit,"$8,425.39 ",OP,"8,425.39","28,976.47",,,,,,
Humana MCR ADV,CPT,L6925,Wrist disart myoelectronic c,Durable Medical Equipment,Per Unit,"$9,001.12 ",OP,"9,001.12","30,955.25",,,,,,
Humana MCR ADV,CPT,L6930,Below elbow switch control,Durable Medical Equipment,Per Unit,"$8,114.82 ",OP,"8,114.82","27,908.91",,,,,,
Humana MCR ADV,CPT,L6935,Below elbow myoelectronic ct,Durable Medical Equipment,Per Unit,"$8,958.82 ",OP,"8,958.82","30,810.37",,,,,,
Humana MCR ADV,CPT,L6940,Elbow disarticulation switch,Durable Medical Equipment,Per Unit,"$10,478.90 ",OP,"10,478.90","36,037.57",,,,,,
Humana MCR ADV,CPT,L6945,Elbow disart myoelectronic c,Durable Medical Equipment,Per Unit,"$11,690.57 ",OP,"11,690.57","40,204.84",,,,,,
Humana MCR ADV,CPT,L6950,Above elbow switch control,Durable Medical Equipment,Per Unit,"$10,459.47 ",OP,"10,459.47","35,972.77",,,,,,
Humana MCR ADV,CPT,L6955,Above elbow myoelectronic ct,Durable Medical Equipment,Per Unit,"$12,129.70 ",OP,"12,129.70","41,714.68",,,,,,
Humana MCR ADV,CPT,L6960,Shldr disartic switch contro,Durable Medical Equipment,Per Unit,"$12,759.97 ",OP,"12,759.97","43,884.09",,,,,,
Humana MCR ADV,CPT,L6965,Shldr disartic myoelectronic,Durable Medical Equipment,Per Unit,"$15,116.16 ",OP,"15,116.16","51,986.07",,,,,,
Humana MCR ADV,CPT,L6970,Interscapular-thor switch ct,Durable Medical Equipment,Per Unit,"$16,180.17 ",OP,"16,180.17","55,646.26",,,,,,
Humana MCR ADV,CPT,L6975,Interscap-thor myoelectronic,Durable Medical Equipment,Per Unit,"$17,834.37 ",OP,"17,834.37","61,334.79",,,,,,
Humana MCR ADV,CPT,L7007,Adult electric hand,Durable Medical Equipment,Per Unit,"$3,673.63 ",OP,"3,673.63","12,635.27",,,,,,
Humana MCR ADV,CPT,L7008,Pediatric electric hand,Durable Medical Equipment,Per Unit,"$5,696.71 ",OP,"5,696.71","19,593.43",,,,,,
Humana MCR ADV,CPT,L7009,Adult electric hook,Durable Medical Equipment,Per Unit,"$3,758.57 ",OP,"3,758.57","12,925.03",,,,,,
Humana MCR ADV,CPT,L7040,Prehensile actuator,Durable Medical Equipment,Per Unit,"$3,059.23 ",OP,"3,059.23","10,519.22",,,,,,
Humana MCR ADV,CPT,L7045,Pediatric electric hook,Durable Medical Equipment,Per Unit,"$1,616.29 ",OP,"1,616.29","5,558.92",,,,,,
Humana MCR ADV,CPT,L7170,Electronic elbow hosmer swit,Durable Medical Equipment,Per Unit,"$6,050.00 ",OP,"6,050.00","20,805.87",,,,,,
Humana MCR ADV,CPT,L7180,Electronic elbow sequential,Durable Medical Equipment,Per Unit,"$39,141.46 ",OP,"39,141.46","134,610.92",,,,,,
Humana MCR ADV,CPT,L7181,Electronic elbo simultaneous,Durable Medical Equipment,Per Unit,"$40,299.84 ",OP,"40,299.84","138,595.19",,,,,,
Humana MCR ADV,CPT,L7185,Electron elbow adolescent sw,Durable Medical Equipment,Per Unit,"$6,360.51 ",OP,"6,360.51","21,873.42",,,,,,
Humana MCR ADV,CPT,L7186,Electron elbow child switch,Durable Medical Equipment,Per Unit,"$10,692.92 ",OP,"10,692.92","36,773.42",,,,,,
Humana MCR ADV,CPT,L7190,Elbow adolescent myoelectron,Durable Medical Equipment,Per Unit,"$8,439.80 ",OP,"8,439.80","29,026.03",,,,,,
Humana MCR ADV,CPT,L7191,Elbow child myoelectronic ct,Durable Medical Equipment,Per Unit,"$11,247.26 ",OP,"11,247.26","38,679.77",,,,,,
Humana MCR ADV,CPT,L7259,Electronic wrist rotator any,Durable Medical Equipment,Per Unit,"$4,121.94 ",OP,"4,121.94","4,121.94",,,,,,
Humana MCR ADV,CPT,L7360,Six volt bat otto bock/eq ea,Durable Medical Equipment,Per Unit,$266.08 ,OP,266.08,915.04,,,,,,
Humana MCR ADV,CPT,L7362,Battery chrgr six volt otto,Durable Medical Equipment,Per Unit,$290.68 ,OP,290.68,998.92,,,,,,
Humana MCR ADV,CPT,L7364,Twelve volt battery utah/equ,Durable Medical Equipment,Per Unit,$514.33 ,OP,514.33,"1,769.09",,,,,,
Humana MCR ADV,CPT,L7366,Battery chrgr 12 volt utah/e,Durable Medical Equipment,Per Unit,$707.34 ,OP,707.34,"2,432.50",,,,,,
Humana MCR ADV,CPT,L7367,Replacemnt lithium ionbatter,Durable Medical Equipment,Per Unit,$391.59 ,OP,391.59,"1,345.89",,,,,,
Humana MCR ADV,CPT,L7368,Lithium ion battery charger,Durable Medical Equipment,Per Unit,$507.61 ,OP,507.61,"1,746.22",,,,,,
Humana MCR ADV,CPT,L7400,Add ue prost be/wd- ultlite,Durable Medical Equipment,Per Unit,$308.25 ,OP,308.25,"1,059.93",,,,,,
Humana MCR ADV,CPT,L7401,Add ue prost a/e ultlite mat,Durable Medical Equipment,Per Unit,$345.06 ,OP,345.06,"1,185.76",,,,,,
Humana MCR ADV,CPT,L7402,Add ue prost s/d ultlite mat,Durable Medical Equipment,Per Unit,$372.68 ,OP,372.68,"1,281.07",,,,,,
Humana MCR ADV,CPT,L7403,Add ue prost b/e acrylic,Durable Medical Equipment,Per Unit,$370.41 ,OP,370.41,"1,273.44",,,,,,
Humana MCR ADV,CPT,L7404,Add ue prost a/e acrylic,Durable Medical Equipment,Per Unit,$559.06 ,OP,559.06,"1,921.59",,,,,,
Humana MCR ADV,CPT,L7405,Add ue prost s/d acrylic,Durable Medical Equipment,Per Unit,$731.10 ,OP,731.1,"2,512.57",,,,,,
Humana MCR ADV,CPT,L7700,Pros soc insert gasket/seal,Durable Medical Equipment,Per Unit,$150.48 ,OP,150.48,150.48,,,,,,
Humana MCR ADV,CPT,L8000,Mastectomy bra,Durable Medical Equipment,Per Unit,$42.59 ,OP,42.59,144.88,,,,,,
Humana MCR ADV,CPT,L8001,Breast prosthesis bra & form,Durable Medical Equipment,Per Unit,$126.18 ,OP,126.18,434.65,,,,,,
Humana MCR ADV,CPT,L8002,Brst prsth bra & bilat form,Durable Medical Equipment,Per Unit,$165.94 ,OP,165.94,571.91,,,,,,
Humana MCR ADV,CPT,L8015,Ext breastprosthesis garment,Durable Medical Equipment,Per Unit,$60.29 ,OP,60.29,205.88,,,,,,
Humana MCR ADV,CPT,L8020,Mastectomy form,Durable Medical Equipment,Per Unit,$227.40 ,OP,227.4,781.61,,,,,,
Humana MCR ADV,CPT,L8030,Breast prosthes w/o adhesive,Durable Medical Equipment,Per Unit,$351.55 ,OP,351.55,"1,208.62",,,,,,
Humana MCR ADV,CPT,L8031,Breast prosthesis w adhesive,Durable Medical Equipment,Per Unit,$351.55 ,OP,351.55,351.55,,,,,,
Humana MCR ADV,CPT,L8032,Reusable nipple prosthesis,Durable Medical Equipment,Per Unit,$39.39 ,OP,39.39,39.39,,,,,,
Humana MCR ADV,CPT,L8035,Custom breast prosthesis,Durable Medical Equipment,Per Unit,"$3,684.79 ",OP,"3,684.79","12,673.39",,,,,,
Humana MCR ADV,CPT,L8040,Nasal prosthesis,Durable Medical Equipment,Per Unit,"$2,493.50 ",OP,"2,493.50","8,574.74",,,,,,
Humana MCR ADV,CPT,L8041,Midfacial prosthesis,Durable Medical Equipment,Per Unit,"$3,005.20 ",OP,"3,005.20","10,336.21",,,,,,
Humana MCR ADV,CPT,L8042,Orbital prosthesis,Durable Medical Equipment,Per Unit,"$3,376.62 ",OP,"3,376.62","11,613.47",,,,,,
Humana MCR ADV,CPT,L8043,Upper facial prosthesis,Durable Medical Equipment,Per Unit,"$3,781.84 ",OP,"3,781.84","13,005.10",,,,,,
Humana MCR ADV,CPT,L8044,Hemi-facial prosthesis,Durable Medical Equipment,Per Unit,"$4,187.02 ",OP,"4,187.02","14,400.54",,,,,,
Humana MCR ADV,CPT,L8045,Auricular prosthesis,Durable Medical Equipment,Per Unit,"$3,278.72 ",OP,"3,278.72","11,274.13",,,,,,
Humana MCR ADV,CPT,L8046,Partial facial prosthesis,Durable Medical Equipment,Per Unit,"$2,701.33 ",OP,"2,701.33","9,291.53",,,,,,
Humana MCR ADV,CPT,L8047,Nasal septal prosthesis,Durable Medical Equipment,Per Unit,"$1,384.42 ",OP,"1,384.42","4,762.05",,,,,,
Humana MCR ADV,CPT,L8300,Truss single w/ standard pad,Durable Medical Equipment,Per Unit,$84.35 ,OP,84.35,289.76,,,,,,
Humana MCR ADV,CPT,L8310,Truss double w/ standard pad,Durable Medical Equipment,Per Unit,$149.44 ,OP,149.44,514.72,,,,,,
Humana MCR ADV,CPT,L8320,Truss addition to std pad wa,Durable Medical Equipment,Per Unit,$62.00 ,OP,62,213.51,,,,,,
Humana MCR ADV,CPT,L8330,Truss add to std pad scrotal,Durable Medical Equipment,Per Unit,$49.37 ,OP,49.37,171.58,,,,,,
Humana MCR ADV,CPT,L8400,Sheath below knee,Durable Medical Equipment,Per Unit,$15.74 ,OP,15.74,53.38,,,,,,
Humana MCR ADV,CPT,L8410,Sheath above knee,Durable Medical Equipment,Per Unit,$20.72 ,OP,20.72,72.44,,,,,,
Humana MCR ADV,CPT,L8415,Sheath upper limb,Durable Medical Equipment,Per Unit,$21.44 ,OP,21.44,72.44,,,,,,
Humana MCR ADV,CPT,L8417,Pros sheath/sock w gel cushn,Durable Medical Equipment,Per Unit,$75.64 ,OP,75.64,259.27,,,,,,
Humana MCR ADV,CPT,L8420,Prosthetic sock multi ply bk,Durable Medical Equipment,Per Unit,$20.98 ,OP,20.98,72.44,,,,,,
Humana MCR ADV,CPT,L8430,Prosthetic sock multi ply ak,Durable Medical Equipment,Per Unit,$23.76 ,OP,23.76,80.07,,,,,,
Humana MCR ADV,CPT,L8435,Pros sock multi ply upper lm,Durable Medical Equipment,Per Unit,$22.58 ,OP,22.58,76.26,,,,,,
Humana MCR ADV,CPT,L8440,Shrinker below knee,Durable Medical Equipment,Per Unit,$46.88 ,OP,46.88,160.13,,,,,,
Humana MCR ADV,CPT,L8460,Shrinker above knee,Durable Medical Equipment,Per Unit,$66.65 ,OP,66.65,228.77,,,,,,
Humana MCR ADV,CPT,L8465,Shrinker upper limb,Durable Medical Equipment,Per Unit,$61.60 ,OP,61.6,213.51,,,,,,
Humana MCR ADV,CPT,L8470,Pros sock single ply bk,Durable Medical Equipment,Per Unit,$6.67 ,OP,6.67,22.88,,,,,,
Humana MCR ADV,CPT,L8480,Pros sock single ply ak,Durable Medical Equipment,Per Unit,$9.20 ,OP,9.2,30.51,,,,,,
Humana MCR ADV,CPT,L8485,Pros sock single ply upper l,Durable Medical Equipment,Per Unit,$12.39 ,OP,12.39,41.94,,,,,,
Humana MCR ADV,CPT,L8500,Artificial larynx,Durable Medical Equipment,Per Unit,$661.87 ,OP,661.87,"2,276.18",,,,,,
Humana MCR ADV,CPT,L8501,Tracheostomy speaking valve,Durable Medical Equipment,Per Unit,$120.80 ,OP,120.8,415.59,,,,,,
Humana MCR ADV,CPT,L8507,Trach-esoph voice pros pt in,Durable Medical Equipment,Per Unit,$42.11 ,OP,42.11,144.88,,,,,,
Humana MCR ADV,CPT,L8509,Trach-esoph voice pros md in,Durable Medical Equipment,Per Unit,$109.85 ,OP,109.85,377.46,,,,,,
Humana MCR ADV,CPT,L8510,Voice amplifier,Durable Medical Equipment,Per Unit,$254.17 ,OP,254.17,873.11,,,,,,
Humana MCR ADV,CPT,L8511,Indwelling trach insert,Durable Medical Equipment,Per Unit,$73.14 ,OP,73.14,251.64,,,,,,
Humana MCR ADV,CPT,L8512,Gel cap for trach voice pros,Durable Medical Equipment,Per Unit,$2.19 ,OP,2.19,7.62,,,,,,
Humana MCR ADV,CPT,L8513,Trach pros cleaning device,Durable Medical Equipment,Per Unit,$5.22 ,OP,5.22,19.07,,,,,,
Humana MCR ADV,CPT,L8514,Repl trach puncture dilator,Durable Medical Equipment,Per Unit,$94.85 ,OP,94.85,327.9,,,,,,
Humana MCR ADV,CPT,L8515,Gel cap app device for trach,Durable Medical Equipment,Per Unit,$63.49 ,OP,63.49,217.32,,,,,,
Humana MCR ADV,CPT,L8615,Coch implant headset replace,Durable Medical Equipment,Per Unit,$453.62 ,OP,453.62,"1,559.39",,,,,,
Humana MCR ADV,CPT,L8616,Coch implant microphone repl,Durable Medical Equipment,Per Unit,$105.64 ,OP,105.64,362.21,,,,,,
Humana MCR ADV,CPT,L8617,Coch implant trans coil repl,Durable Medical Equipment,Per Unit,$92.27 ,OP,92.27,92.27,,,,,,
Humana MCR ADV,CPT,L8618,Coch implant tran cable repl,Durable Medical Equipment,Per Unit,$26.38 ,OP,26.38,91.51,,,,,,
Humana MCR ADV,CPT,L8619,Coch imp ext proc/contr rplc,Durable Medical Equipment,Per Unit,"$8,454.02 ",OP,"8,454.02","29,075.59",,,,,,
Humana MCR ADV,CPT,L8621,Repl zinc air battery,Durable Medical Equipment,Per Unit,$0.62 ,OP,0.62,3.82,,,,,,
Humana MCR ADV,CPT,L8622,Repl alkaline battery,Durable Medical Equipment,Per Unit,$0.32 ,OP,0.32,1.9,,,,,,
Humana MCR ADV,CPT,L8623,Lith ion batt cid-non-earlvl,Durable Medical Equipment,Per Unit,$65.06 ,OP,65.06,65.06,,,,,,
Humana MCR ADV,CPT,L8624,Lith ion batt cid- ear level,Durable Medical Equipment,Per Unit,$162.20 ,OP,162.2,556.65,,,,,,
Humana MCR ADV,CPT,L8625,Charger coch impl/aoi battry,Durable Medical Equipment,Per Unit,$189.97 ,OP,189.97,189.97,,,,,,
Humana MCR ADV,CPT,L8627,Cid ext speech process repl,Durable Medical Equipment,Per Unit,"$7,175.59 ",OP,"7,175.59","7,175.59",,,,,,
Humana MCR ADV,CPT,L8628,Cid ext controller repl,Durable Medical Equipment,Per Unit,"$1,278.42 ",OP,"1,278.42","1,278.42",,,,,,
Humana MCR ADV,CPT,L8629,Cid transmit coil and cable,Durable Medical Equipment,Per Unit,$180.09 ,OP,180.09,180.09,,,,,,
Humana MCR ADV,CPT,L8681,Pt prgrm for implt neurostim,Durable Medical Equipment,Per Unit,"$1,147.11 ",OP,"1,147.11","3,946.14",,,,,,
Humana MCR ADV,CPT,L8683,Radiofq trsmtr for implt neu,Durable Medical Equipment,Per Unit,"$5,420.03 ",OP,"5,420.03","18,640.24",,,,,,
Humana MCR ADV,CPT,L8684,Radiof trsmtr implt scrl neu,Durable Medical Equipment,Per Unit,$850.48 ,OP,850.48,"2,924.33",,,,,,
Humana MCR ADV,CPT,L8689,External recharg sys intern,Durable Medical Equipment,Per Unit,"$1,734.92 ",OP,"1,734.92","5,966.87",,,,,,
Humana MCR ADV,CPT,L8691,Aoi snd proc repl excl actua,Durable Medical Equipment,Per Unit,"$1,732.10 ",OP,"1,732.10","9,222.90",,,,,,
Humana MCR ADV,CPT,L8693,Aud osseo dev- abutment,Durable Medical Equipment,Per Unit,"$1,525.09 ",OP,"1,525.09","1,525.09",,,,,,
Humana MCR ADV,CPT,L8694,Aoi transducer/actuator repl,Durable Medical Equipment,Per Unit,$949.85 ,OP,949.85,949.85,,,,,,
Humana MCR ADV,CPT,L8695,External recharg sys extern,Durable Medical Equipment,Per Unit,$16.77 ,OP,16.77,57.19,,,,,,
Humana MCR ADV,CPT,L8696,Ext antenna phren nerve stim,Durable Medical Equipment,Per Unit,$217.98 ,OP,217.98,217.98,,,,,,
Humana MCR ADV,CPT,M0201,Covid-19 vaccine home admin,APC 1494,RVU Per Unit,$36.33 ,OP,36.33,36.33,,,,,,
Humana MCR ADV,CPT,M0240,Casiri and imdev repeat,APC 1506,RVU Per Unit,$461.00 ,OP,430.44,461,,,,,,
Humana MCR ADV,CPT,M0241,Casiri and imdev repeat hm,APC 1509,RVU Per Unit,$768.00 ,OP,768,768,,,,,,
Humana MCR ADV,CPT,M0243,Casirivi and imdevi inj,APC 1506,RVU Per Unit,$461.00 ,OP,461,461,,,,,,
Humana MCR ADV,CPT,M0244,Casirivi and imdevi inj hm,APC 1509,RVU Per Unit,$768.00 ,OP,717.08,768,,,,,,
Humana MCR ADV,CPT,M0245,Bamlan and etesev infusion,APC 1506,RVU Per Unit,$461.00 ,OP,430.44,461,,,,,,
Humana MCR ADV,CPT,M0246,Bamlan and etesev infus home,APC 1509,RVU Per Unit,$768.00 ,OP,717.08,768,,,,,,
Humana MCR ADV,CPT,M0247,Sotrovimab infusion,APC 1506,RVU Per Unit,$461.00 ,OP,430.44,461,,,,,,
Humana MCR ADV,CPT,M0248,Sotrovimab inf- home admin,APC 1509,RVU Per Unit,$768.00 ,OP,717.08,768,,,,,,
Humana MCR ADV,CPT,M0249,Adm tocilizu covid-19 1st,APC 1506,RVU Per Unit,$461.00 ,OP,430.44,461,,,,,,
Humana MCR ADV,CPT,M0250,Adm tocilizu covid-19 2nd,APC 1506,RVU Per Unit,$461.00 ,OP,430.44,461,,,,,,
Humana MCR ADV,CPT,P2028,Cephalin floculation test,Lab Services,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,
Humana MCR ADV,CPT,P2029,Congo red blood test,Lab Services,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,
Humana MCR ADV,CPT,P2033,Blood thymol turbidity,Lab Services,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,
Humana MCR ADV,CPT,P2038,Blood mucoprotein,Lab Services,Per Unit,$4.95 ,OP,4.95,22.88,,,,,,
Humana MCR ADV,CPT,P3000,Screen pap by tech w md supv,Lab Services,Per Unit,$15.15 ,OP,15.15,45.74,,,,,,
Humana MCR ADV,CPT,P9010,Whole blood for transfusion,APC 9510,Per Unit,$172.22 ,OP,172.22,172.22,,,,,,
Humana MCR ADV,CPT,P9011,Blood split unit,APC 9520,Per Unit,$169.28 ,OP,169.28,169.28,,,,,,
Humana MCR ADV,CPT,P9012,Cryoprecipitate each unit,APC 9511,Per Unit,$91.59 ,OP,91.59,91.59,,,,,,
Humana MCR ADV,CPT,P9016,Rbc leukocytes reduced,APC 9512,Per Unit,$216.23 ,OP,216.23,216.23,,,,,,
Humana MCR ADV,CPT,P9017,Plasma 1 donor frz w/in 8 hr,APC 9508,Per Unit,$94.81 ,OP,94.81,94.81,,,,,,
Humana MCR ADV,CPT,P9019,Platelets- each unit,APC 9515,Per Unit,$81.77 ,OP,81.77,81.77,,,,,,
Humana MCR ADV,CPT,P9020,Plaelet rich plasma unit,APC 9516,Per Unit,$229.41 ,OP,229.41,229.41,,,,,,
Humana MCR ADV,CPT,P9021,Red blood cells unit,APC 9517,Per Unit,$157.87 ,OP,157.87,157.87,,,,,,
Humana MCR ADV,CPT,P9022,Washed red blood cells unit,APC 9518,Per Unit,$435.72 ,OP,435.72,435.72,,,,,,
Humana MCR ADV,CPT,P9023,Frozen plasma- pooled- sd,APC 9509,Per Unit,$102.26 ,OP,102.26,102.26,,,,,,
Humana MCR ADV,CPT,P9025,Plasma cryo redu path each,APC 9538,Per Unit,$75.36 ,OP,75.36,75.36,,,,,,
Humana MCR ADV,CPT,P9026,Cryo fib comp path redu each,APC 9539,Per Unit,$91.59 ,OP,91.59,91.59,,,,,,
Humana MCR ADV,CPT,P9031,Platelets leukocytes reduced,APC 9526,Per Unit,$171.96 ,OP,171.96,171.96,,,,,,
Humana MCR ADV,CPT,P9032,Platelets- irradiated,APC 9500,Per Unit,$162.52 ,OP,162.52,162.52,,,,,,
Humana MCR ADV,CPT,P9033,Platelets leukoreduced irrad,APC 9521,Per Unit,$244.54 ,OP,244.54,244.54,,,,,,
Humana MCR ADV,CPT,P9034,Platelets- pheresis,APC 9507,Per Unit,$371.63 ,OP,371.63,371.63,,,,,,
Humana MCR ADV,CPT,P9035,Platelet pheres leukoreduced,APC 9501,Per Unit,$558.38 ,OP,558.38,558.38,,,,,,
Humana MCR ADV,CPT,P9036,Platelet pheresis irradiated,APC 9502,Per Unit,$693.83 ,OP,693.83,693.83,,,,,,
Humana MCR ADV,CPT,P9037,Plate pheres leukoredu irrad,APC 9530,Per Unit,$708.10 ,OP,708.1,708.1,,,,,,
Humana MCR ADV,CPT,P9038,Rbc irradiated,APC 9505,Per Unit,$194.21 ,OP,194.21,194.21,,,,,,
Humana MCR ADV,CPT,P9039,Rbc deglycerolized,APC 9504,Per Unit,$500.86 ,OP,500.86,500.86,,,,,,
Humana MCR ADV,CPT,P9040,Rbc leukoreduced irradiated,APC 9522,Per Unit,$298.86 ,OP,298.86,298.86,,,,,,
Humana MCR ADV,CPT,P9041,Albumin (human)-5%- 50ml,APC 0961,Per Unit,$10.49 ,OP,10.49,10.49,,,,,,
Humana MCR ADV,CPT,P9043,Plasma protein fract-5%-50ml,APC 9514,Per Unit,$9.16 ,OP,9.16,106.76,,,,,,
Humana MCR ADV,CPT,P9044,Cryoprecipitatereducedplasma,APC 9523,Per Unit,$75.36 ,OP,75.36,75.36,,,,,,
Humana MCR ADV,CPT,P9045,Albumin (human)- 5%- 250 ml,APC 0963,Per Unit,$52.45 ,OP,52.45,274.51,,,,,,
Humana MCR ADV,CPT,P9046,Albumin (human)- 25%- 20 ml,APC 0964,Per Unit,$20.98 ,OP,20.98,129.64,,,,,,
Humana MCR ADV,CPT,P9047,Albumin (human)- 25%- 50ml,APC 0965,Per Unit,$52.45 ,OP,52.45,255.45,,,,,,
Humana MCR ADV,CPT,P9048,Plasmaprotein fract-5%-250ml,APC 9519,Per Unit,$183.92 ,OP,183.92,198.25,,,,,,
Humana MCR ADV,CPT,P9051,Blood- l/r- cmv-neg,APC 9524,Per Unit,$243.44 ,OP,243.44,243.44,,,,,,
Humana MCR ADV,CPT,P9052,Platelets- hla-m- l/r- unit,APC 9525,Per Unit,$923.57 ,OP,923.57,923.57,,,,,,
Humana MCR ADV,CPT,P9053,Plt- pher- l/r cmv-neg- irr,APC 9531,Per Unit,$513.08 ,OP,513.08,513.08,,,,,,
Humana MCR ADV,CPT,P9054,Blood- l/r- froz/degly/wash,APC 9527,Per Unit,$356.39 ,OP,356.39,356.39,,,,,,
Humana MCR ADV,CPT,P9055,Plt- aph/pher- l/r- cmv-neg,APC 9528,Per Unit,$550.63 ,OP,550.63,550.63,,,,,,
Humana MCR ADV,CPT,P9056,Blood- l/r- irradiated,APC 9529,Per Unit,$176.83 ,OP,176.83,176.83,,,,,,
Humana MCR ADV,CPT,P9057,Rbc- frz/deg/wsh- l/r- irrad,APC 9532,Per Unit,$298.91 ,OP,298.91,298.91,,,,,,
Humana MCR ADV,CPT,P9058,Rbc- l/r- cmv-neg- irrad,APC 9533,Per Unit,$279.73 ,OP,279.73,279.73,,,,,,
Humana MCR ADV,CPT,P9059,Plasma- frz between 8-24hour,APC 9513,Per Unit,$81.61 ,OP,81.61,81.61,,,,,,
Humana MCR ADV,CPT,P9060,Fr frz plasma donor retested,APC 9503,Per Unit,$74.65 ,OP,74.65,74.65,,,,,,
Humana MCR ADV,CPT,P9070,Pathogen reduced plasma pool,APC 9534,Per Unit,$60.91 ,OP,60.91,60.91,,,,,,
Humana MCR ADV,CPT,P9071,Pathogen reduced plasma sing,APC 9535,Per Unit,$140.88 ,OP,140.88,140.88,,,,,,
Humana MCR ADV,CPT,P9073,Platelets pheresis path redu,APC 9536,Per Unit,$669.72 ,OP,669.72,669.72,,,,,,
Humana MCR ADV,CPT,P9099,Blood component/product noc,APC 9537,Per Unit,$9.16 ,OP,9.16,9.16,,,,,,
Humana MCR ADV,CPT,P9100,Pathogen test for platelets,APC 5732,RVU Per Unit,$34.63 ,OP,34.63,34.63,,,,,,
Humana MCR ADV,CPT,P9612,Catheterize for urine spec,Lab Services,Per Unit,$3.00 ,OP,3,3,,,,,,
Humana MCR ADV,CPT,Q0035,Cardiokymography,APC 5732,RVU Per Case,$34.63 ,OP,34.63,106.76,,,,,,
Humana MCR ADV,CPT,Q0091,Obtaining screen pap smear,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,205.88,,,,,,
Humana MCR ADV,CPT,Q0111,Wet mounts/ w preparations,Lab Services,Per Unit,$15.15 ,OP,15.15,15.15,,,,,,
Humana MCR ADV,CPT,Q0112,Potassium hydroxide preps,Lab Services,Per Unit,$5.83 ,OP,5.83,22.88,,,,,,
Humana MCR ADV,CPT,Q0113,Pinworm examinations,Lab Services,Per Unit,$4.27 ,OP,4.27,26.7,,,,,,
Humana MCR ADV,CPT,Q0114,Fern test,Lab Services,Per Unit,$9.74 ,OP,9.74,34.31,,,,,,
Humana MCR ADV,CPT,Q0115,Post-coital mucous exam,Lab Services,Per Unit,$25.00 ,OP,25,49.56,,,,,,
Humana MCR ADV,CPT,Q0138,Ferumoxytol- non-esrd,APC 1297,Per Unit,$1.00 ,OP,1,1,,,,,,
Humana MCR ADV,CPT,Q0139,Ferumoxytol- esrd use,APC 1485,Per Unit,$1.00 ,OP,1,1,,,,,,
Humana MCR ADV,CPT,Q0240,Casirivi and imdevi 600 mg,Other,Straight Discount,29.70%,OP,,,,,,,,
Humana MCR ADV,CPT,Q0243,Casirivimab and imdevimab,Other,Straight Discount,29.70%,OP,,,,,,,,
Humana MCR ADV,CPT,Q0244,Casirivi and imdevi 1200 mg,Other,Straight Discount,29.70%,OP,,,,,,,,
Humana MCR ADV,CPT,Q0245,Bamlanivimab and etesevima,Other,Straight Discount,29.70%,OP,,,,,,,,
Humana MCR ADV,CPT,Q0247,Sotrovimab,Other,Straight Discount,29.70%,OP,,,,,,,,
Humana MCR ADV,CPT,Q0249,Tocilizumab for covid-19,Other,Straight Discount,29.70%,OP,,,,,,,,
Humana MCR ADV,CPT,Q0477,Pwr module pt cable lvad rpl,Durable Medical Equipment,Per Unit,$780.34 ,OP,780.34,780.34,,,,,,
Humana MCR ADV,CPT,Q0478,Power adapter- combo vad,Durable Medical Equipment,Per Unit,$184.82 ,OP,184.82,184.82,,,,,,
Humana MCR ADV,CPT,Q0479,Power module combo vad- rep,Durable Medical Equipment,Per Unit,"$12,073.17 ",OP,"12,073.17","12,073.17",,,,,,
Humana MCR ADV,CPT,Q0480,Driver pneumatic vad- rep,Durable Medical Equipment,Per Unit,"$90,585.51 ",OP,"90,585.51","311,531.29",,,,,,
Humana MCR ADV,CPT,Q0481,Microprcsr cu elec vad- rep,Durable Medical Equipment,Per Unit,"$14,614.95 ",OP,"14,614.95","50,262.72",,,,,,
Humana MCR ADV,CPT,Q0482,Microprcsr cu combo vad- rep,Durable Medical Equipment,Per Unit,"$4,577.67 ",OP,"4,577.67","15,742.60",,,,,,
Humana MCR ADV,CPT,Q0483,Monitor elec vad- rep,Durable Medical Equipment,Per Unit,"$18,857.93 ",OP,"18,857.93","64,853.90",,,,,,
Humana MCR ADV,CPT,Q0484,Monitor elec or comb vad rep,Durable Medical Equipment,Per Unit,"$3,662.14 ",OP,"3,662.14","12,593.32",,,,,,
Humana MCR ADV,CPT,Q0485,Monitor cable elec vad- rep,Durable Medical Equipment,Per Unit,$353.60 ,OP,353.6,"1,216.24",,,,,,
Humana MCR ADV,CPT,Q0486,Mon cable elec/pneum vad rep,Durable Medical Equipment,Per Unit,$294.28 ,OP,294.28,"1,010.37",,,,,,
Humana MCR ADV,CPT,Q0487,Leads any type vad- rep only,Durable Medical Equipment,Per Unit,$343.31 ,OP,343.31,"1,181.94",,,,,,
Humana MCR ADV,CPT,Q0489,Pwr pck base combo vad- rep,Durable Medical Equipment,Per Unit,"$16,348.80 ",OP,"16,348.80","56,225.77",,,,,,
Humana MCR ADV,CPT,Q0490,Emr pwr source elec vad- rep,Durable Medical Equipment,Per Unit,$707.17 ,OP,707.17,"2,432.50",,,,,,
Humana MCR ADV,CPT,Q0491,Emr pwr source combo vad rep,Durable Medical Equipment,Per Unit,"$1,111.75 ",OP,"1,111.75","3,824.13",,,,,,
Humana MCR ADV,CPT,Q0492,Emr pwr cbl elec vad- rep,Durable Medical Equipment,Per Unit,$89.58 ,OP,89.58,308.83,,,,,,
Humana MCR ADV,CPT,Q0493,Emr pwr cbl combo vad- rep,Durable Medical Equipment,Per Unit,$255.02 ,OP,255.02,876.92,,,,,,
Humana MCR ADV,CPT,Q0494,Emr hd pmp elec/combo- rep,Durable Medical Equipment,Per Unit,$215.79 ,OP,215.79,743.48,,,,,,
Humana MCR ADV,CPT,Q0495,Charger elec/combo vad- rep,Durable Medical Equipment,Per Unit,"$4,201.23 ",OP,"4,201.23","14,450.10",,,,,,
Humana MCR ADV,CPT,Q0496,Battery elec/combo vad- rep,Durable Medical Equipment,Per Unit,"$1,507.90 ",OP,"1,507.90","5,185.26",,,,,,
Humana MCR ADV,CPT,Q0497,Bat clps elec/comb vad- rep,Durable Medical Equipment,Per Unit,$470.84 ,OP,470.84,"1,620.40",,,,,,
Humana MCR ADV,CPT,Q0498,Holster elec/combo vad- rep,Durable Medical Equipment,Per Unit,$516.61 ,OP,516.61,"1,776.71",,,,,,
Humana MCR ADV,CPT,Q0499,Belt/vest elec/combo vad rep,Durable Medical Equipment,Per Unit,$167.86 ,OP,167.86,575.73,,,,,,
Humana MCR ADV,CPT,Q0500,Filters elec/combo vad- rep,Durable Medical Equipment,Per Unit,$30.69 ,OP,30.69,106.76,,,,,,
Humana MCR ADV,CPT,Q0501,Shwr cov elec/combo vad- rep,Durable Medical Equipment,Per Unit,$513.63 ,OP,513.63,"1,765.27",,,,,,
Humana MCR ADV,CPT,Q0502,Mobility cart pneum vad- rep,Durable Medical Equipment,Per Unit,$653.97 ,OP,653.97,"2,249.49",,,,,,
Humana MCR ADV,CPT,Q0503,Battery pneum vad replacemnt,Durable Medical Equipment,Per Unit,"$1,307.87 ",OP,"1,307.87","4,498.98",,,,,,
Humana MCR ADV,CPT,Q0504,Pwr adpt pneum vad- rep veh,Durable Medical Equipment,Per Unit,$690.16 ,OP,690.16,"2,375.30",,,,,,
Humana MCR ADV,CPT,Q0506,Lith-ion batt elec/pneum vad,Durable Medical Equipment,Per Unit,$859.04 ,OP,859.04,859.04,,,,,,
Humana MCR ADV,CPT,Q2017,Teniposide- 50 mg,APC 7035,Per Unit,"$2,645.71 ",OP,"1,582.28","2,645.71",,,,,,
Humana MCR ADV,CPT,Q2026,Radiesse injection,APC 9094,Per Unit,$257.37 ,OP,257.37,257.37,,,,,,
Humana MCR ADV,CPT,Q2028,Inj- sculptra- 0.5mg,APC 9095,Per Unit,$2.49 ,OP,2.49,2.49,,,,,,
Humana MCR ADV,CPT,Q2034,Agriflu vaccine,Other,Straight Discount,29.70%,OP,,,,,,,,
Humana MCR ADV,CPT,Q2035,Afluria vacc- 3 yrs & >- im,Other,Straight Discount,29.70%,OP,,,,,,,,
Humana MCR ADV,CPT,Q2036,Flulaval vacc- 3 yrs & >- im,Other,Straight Discount,29.70%,OP,,,,,,,,
Humana MCR ADV,CPT,Q2037,Fluvirin vacc- 3 yrs & >- im,Other,Straight Discount,29.70%,OP,,,,,,,,
Humana MCR ADV,CPT,Q2038,Fluzone vacc- 3 yrs & >- im,Other,Straight Discount,29.70%,OP,,,,,,,,
Humana MCR ADV,CPT,Q2039,Influenza virus vaccine- nos,Other,Straight Discount,29.70%,OP,,,,,,,,
Humana MCR ADV,CPT,Q2041,Axicabtagene ciloleucel car+,APC 9035,Per Unit,"$395,380.00 ",OP,"395,380.00","395,380.00",,,,,,
Humana MCR ADV,CPT,Q2042,Tisagenlecleucel car-pos t,APC 9194,Per Unit,"$434,337.60 ",OP,"434,337.60","434,337.60",,,,,,
Humana MCR ADV,CPT,Q2043,Sipuleucel-t auto cd54+,APC 9273,Per Unit,"$53,017.58 ",OP,"53,017.58","53,017.58",,,,,,
Humana MCR ADV,CPT,Q2049,Imported lipodox inj,APC 1421,Per Unit,$311.04 ,OP,311.04,311.04,,,,,,
Humana MCR ADV,CPT,Q2050,Doxorubicin inj 10mg,APC 7046,Per Unit,$234.03 ,OP,234.03,"1,719.01",,,,,,
Humana MCR ADV,CPT,Q2053,Brexucabtagene car pos t,APC 9391,Per Unit,"$395,380.00 ",OP,"395,380.00","395,380.00",,,,,,
Humana MCR ADV,CPT,Q2054,Lisocabtagene mara car pos t,APC 9413,Per Unit,"$422,609.00 ",OP,"422,609.00","422,609.00",,,,,,
Humana MCR ADV,CPT,Q3027,Inj beta interferon im 1 mcg,APC 1472,Per Unit,$55.29 ,OP,55.29,74.17,,,,,,
Humana MCR ADV,CPT,Q5101,Injection- zarxio,APC 1822,Per Unit,$0.32 ,OP,0.32,0.32,,,,,,
Humana MCR ADV,CPT,Q5103,Injection- inflectra,APC 1847,Per Unit,$41.19 ,OP,41.19,41.19,,,,,,
Humana MCR ADV,CPT,Q5104,Injection- renflexis,APC 9036,Per Unit,$38.79 ,OP,38.79,38.79,,,,,,
Humana MCR ADV,CPT,Q5106,Inj retacrit non-esrd use,APC 9097,Per Unit,$8.66 ,OP,8.66,8.66,,,,,,
Humana MCR ADV,CPT,Q5107,Inj mvasi 10 mg,APC 9329,Per Unit,$44.56 ,OP,44.56,44.56,,,,,,
Humana MCR ADV,CPT,Q5108,Injection- fulphila,APC 9173,Per Unit,$211.19 ,OP,211.19,211.19,,,,,,
Humana MCR ADV,CPT,Q5110,Nivestym,APC 9193,Per Unit,$0.33 ,OP,0.33,0.33,,,,,,
Humana MCR ADV,CPT,Q5111,Injection- udenyca 0.5 mg,APC 9195,Per Unit,$222.38 ,OP,222.38,222.38,,,,,,
Humana MCR ADV,CPT,Q5112,Inj ontruzant 10 mg,APC 9382,Per Unit,$66.55 ,OP,66.55,66.55,,,,,,
Humana MCR ADV,CPT,Q5113,Inj herzuma 10 mg,APC 9349,Per Unit,$57.30 ,OP,57.3,57.3,,,,,,
Humana MCR ADV,CPT,Q5114,Inj ogivri 10 mg,APC 9341,Per Unit,$59.91 ,OP,59.91,59.91,,,,,,
Humana MCR ADV,CPT,Q5115,Inj truxima 10 mg,APC 9336,Per Unit,$60.58 ,OP,60.58,60.58,,,,,,
Humana MCR ADV,CPT,Q5116,Inj.- trazimera- 10 mg,APC 9350,Per Unit,$59.93 ,OP,59.93,59.93,,,,,,
Humana MCR ADV,CPT,Q5117,Inj.- kanjinti- 10 mg,APC 9330,Per Unit,$53.18 ,OP,53.18,53.18,,,,,,
Humana MCR ADV,CPT,Q5118,Inj.- zirabev- 10 mg,APC 9348,Per Unit,$52.37 ,OP,52.37,52.37,,,,,,
Humana MCR ADV,CPT,Q5119,Inj ruxience- 10 mg,APC 9367,Per Unit,$58.80 ,OP,58.8,58.8,,,,,,
Humana MCR ADV,CPT,Q5120,Inj pegfilgrastim-bmez 0.5mg,APC 9345,Per Unit,$245.43 ,OP,245.43,245.43,,,,,,
Humana MCR ADV,CPT,Q5121,Inj. avsola- 10 mg,APC 9381,Per Unit,$47.12 ,OP,47.12,47.12,,,,,,
Humana MCR ADV,CPT,Q5122,Inj- nyvepria,APC 9406,Per Unit,$284.69 ,OP,284.69,284.69,,,,,,
Humana MCR ADV,CPT,Q5123,Inj. riabni- 10 mg,APC 9411,Per Unit,$72.23 ,OP,72.23,72.23,,,,,,
Humana MCR ADV,CPT,Q9968,Visualization adjunct,APC 1446,Per Unit,$6.73 ,OP,6.73,6.73,,,,,,
Humana MCR ADV,CPT,Q9969,Non-heu tc-99m add-on/dose,APC 1442,Per Unit,$10.00 ,OP,10,10,,,,,,
Humana MCR ADV,CPT,Q9991,Buprenorph xr 100 mg or less,APC 9073,Per Unit,"$1,796.80 ",OP,"1,796.80","1,796.80",,,,,,
Humana MCR ADV,CPT,Q9992,Buprenorphine xr over 100 mg,APC 9239,Per Unit,"$1,796.80 ",OP,"1,796.80","1,796.80",,,,,,
Humana MCR ADV,CPT,U0001,2019-ncov diagnostic p,Lab Services,Per Unit,$35.91 ,OP,35.91,35.91,,,,,,
Humana MCR ADV,CPT,U0002,Covid-19 lab test non-cdc,Lab Services,Per Unit,$51.31 ,OP,51.31,51.31,,,,,,
Humana MCR ADV,CPT,U0003,Cov-19 amp prb hgh thruput,Lab Services,Per Unit,$75.00 ,OP,75,75,,,,,,
Humana MCR ADV,CPT,U0004,Cov-19 test non-cdc hgh thru,Lab Services,Per Unit,$75.00 ,OP,75,75,,,,,,
Humana MCR ADV,CPT,U0005,Infec agen detec ampli probe,Lab Services,Per Unit,$25.00 ,OP,25,25,,,,,,
Humana MCR ADV,CPT,V2020,Vision svcs frames purchases,Durable Medical Equipment,Per Unit,$75.22 ,OP,75.22,388.89,,,,,,
Humana MCR ADV,CPT,V2100,Lens spher single plano 4.00,Durable Medical Equipment,Per Unit,$46.49 ,OP,46.49,240.2,,,,,,
Humana MCR ADV,CPT,V2101,Single visn sphere 4.12-7.00,Durable Medical Equipment,Per Unit,$44.67 ,OP,44.67,228.77,,,,,,
Humana MCR ADV,CPT,V2102,Singl visn sphere 7.12-20.00,Durable Medical Equipment,Per Unit,$77.24 ,OP,77.24,400.34,,,,,,
Humana MCR ADV,CPT,V2103,Spherocylindr 4.00d/12-2.00d,Durable Medical Equipment,Per Unit,$39.13 ,OP,39.13,202.07,,,,,,
Humana MCR ADV,CPT,V2104,Spherocylindr 4.00d/2.12-4d,Durable Medical Equipment,Per Unit,$40.34 ,OP,40.34,209.7,,,,,,
Humana MCR ADV,CPT,V2105,Spherocylinder 4.00d/4.25-6d,Durable Medical Equipment,Per Unit,$47.98 ,OP,47.98,247.83,,,,,,
Humana MCR ADV,CPT,V2106,Spherocylinder 4.00d/>6.00d,Durable Medical Equipment,Per Unit,$53.15 ,OP,53.15,274.51,,,,,,
Humana MCR ADV,CPT,V2107,Spherocylinder 4.25d/12-2d,Durable Medical Equipment,Per Unit,$47.33 ,OP,47.33,244.01,,,,,,
Humana MCR ADV,CPT,V2108,Spherocylinder 4.25d/2.12-4d,Durable Medical Equipment,Per Unit,$47.46 ,OP,47.46,244.01,,,,,,
Humana MCR ADV,CPT,V2109,Spherocylinder 4.25d/4.25-6d,Durable Medical Equipment,Per Unit,$66.10 ,OP,66.1,339.33,,,,,,
Humana MCR ADV,CPT,V2110,Spherocylinder 4.25d/over 6d,Durable Medical Equipment,Per Unit,$53.39 ,OP,53.39,274.51,,,,,,
Humana MCR ADV,CPT,V2111,Spherocylindr 7.25d/.25-2.25,Durable Medical Equipment,Per Unit,$64.70 ,OP,64.7,335.53,,,,,,
Humana MCR ADV,CPT,V2112,Spherocylindr 7.25d/2.25-4d,Durable Medical Equipment,Per Unit,$73.09 ,OP,73.09,377.46,,,,,,
Humana MCR ADV,CPT,V2113,Spherocylindr 7.25d/4.25-6d,Durable Medical Equipment,Per Unit,$73.91 ,OP,73.91,381.27,,,,,,
Humana MCR ADV,CPT,V2114,Spherocylinder over 12.00d,Durable Medical Equipment,Per Unit,$87.57 ,OP,87.57,453.71,,,,,,
Humana MCR ADV,CPT,V2115,Lens lenticular bifocal,Durable Medical Equipment,Per Unit,$88.27 ,OP,88.27,453.71,,,,,,
Humana MCR ADV,CPT,V2118,Lens aniseikonic single,Durable Medical Equipment,Per Unit,$96.05 ,OP,96.05,495.65,,,,,,
Humana MCR ADV,CPT,V2121,Lenticular lens- single,Durable Medical Equipment,Per Unit,$86.61 ,OP,86.61,446.08,,,,,,
Humana MCR ADV,CPT,V2200,Lens spher bifoc plano 4.00d,Durable Medical Equipment,Per Unit,$52.35 ,OP,52.35,270.71,,,,,,
Humana MCR ADV,CPT,V2201,Lens sphere bifocal 4.12-7.0,Durable Medical Equipment,Per Unit,$56.09 ,OP,56.09,289.76,,,,,,
Humana MCR ADV,CPT,V2202,Lens sphere bifocal 7.12-20.,Durable Medical Equipment,Per Unit,$69.53 ,OP,69.53,358.39,,,,,,
Humana MCR ADV,CPT,V2203,Lens sphcyl bifocal 4.00d/.1,Durable Medical Equipment,Per Unit,$53.92 ,OP,53.92,278.32,,,,,,
Humana MCR ADV,CPT,V2204,Lens sphcy bifocal 4.00d/2.1,Durable Medical Equipment,Per Unit,$55.48 ,OP,55.48,285.96,,,,,,
Humana MCR ADV,CPT,V2205,Lens sphcy bifocal 4.00d/4.2,Durable Medical Equipment,Per Unit,$61.51 ,OP,61.51,316.46,,,,,,
Humana MCR ADV,CPT,V2206,Lens sphcy bifocal 4.00d/ove,Durable Medical Equipment,Per Unit,$72.21 ,OP,72.21,373.65,,,,,,
Humana MCR ADV,CPT,V2207,Lens sphcy bifocal 4.25-7d/.,Durable Medical Equipment,Per Unit,$61.03 ,OP,61.03,316.46,,,,,,
Humana MCR ADV,CPT,V2208,Lens sphcy bifocal 4.25-7/2.,Durable Medical Equipment,Per Unit,$59.97 ,OP,59.97,308.83,,,,,,
Humana MCR ADV,CPT,V2209,Lens sphcy bifocal 4.25-7/4.,Durable Medical Equipment,Per Unit,$70.40 ,OP,70.4,362.21,,,,,,
Humana MCR ADV,CPT,V2210,Lens sphcy bifocal 4.25-7/ov,Durable Medical Equipment,Per Unit,$75.86 ,OP,75.86,392.7,,,,,,
Humana MCR ADV,CPT,V2211,Lens sphcy bifo 7.25-12/.25-,Durable Medical Equipment,Per Unit,$73.85 ,OP,73.85,381.27,,,,,,
Humana MCR ADV,CPT,V2212,Lens sphcyl bifo 7.25-12/2.2,Durable Medical Equipment,Per Unit,$77.30 ,OP,77.3,400.34,,,,,,
Humana MCR ADV,CPT,V2213,Lens sphcyl bifo 7.25-12/4.2,Durable Medical Equipment,Per Unit,$81.28 ,OP,81.28,419.4,,,,,,
Humana MCR ADV,CPT,V2214,Lens sphcyl bifocal over 12.,Durable Medical Equipment,Per Unit,$84.95 ,OP,84.95,438.47,,,,,,
Humana MCR ADV,CPT,V2215,Lens lenticular bifocal,Durable Medical Equipment,Per Unit,$106.06 ,OP,106.06,549.03,,,,,,
Humana MCR ADV,CPT,V2218,Lens aniseikonic bifocal,Durable Medical Equipment,Per Unit,$108.09 ,OP,108.09,556.65,,,,,,
Humana MCR ADV,CPT,V2219,Lens bifocal seg width over,Durable Medical Equipment,Per Unit,$49.86 ,OP,49.86,255.45,,,,,,
Humana MCR ADV,CPT,V2220,Lens bifocal add over 3.25d,Durable Medical Equipment,Per Unit,$44.28 ,OP,44.28,228.77,,,,,,
Humana MCR ADV,CPT,V2221,Lenticular lens- bifocal,Durable Medical Equipment,Per Unit,$88.33 ,OP,88.33,457.52,,,,,,
Humana MCR ADV,CPT,V2300,Lens sphere trifocal 4.00d,Durable Medical Equipment,Per Unit,$71.57 ,OP,71.57,369.83,,,,,,
Humana MCR ADV,CPT,V2301,Lens sphere trifocal 4.12-7.,Durable Medical Equipment,Per Unit,$87.77 ,OP,87.77,453.71,,,,,,
Humana MCR ADV,CPT,V2302,Lens sphere trifocal 7.12-20,Durable Medical Equipment,Per Unit,$82.00 ,OP,82,423.22,,,,,,
Humana MCR ADV,CPT,V2303,Lens sphcy trifocal 4.0/.12-,Durable Medical Equipment,Per Unit,$68.89 ,OP,68.89,354.58,,,,,,
Humana MCR ADV,CPT,V2304,Lens sphcy trifocal 4.0/2.25,Durable Medical Equipment,Per Unit,$69.70 ,OP,69.7,358.39,,,,,,
Humana MCR ADV,CPT,V2305,Lens sphcy trifocal 4.0/4.25,Durable Medical Equipment,Per Unit,$77.86 ,OP,77.86,400.34,,,,,,
Humana MCR ADV,CPT,V2306,Lens sphcyl trifocal 4.00/>6,Durable Medical Equipment,Per Unit,$80.17 ,OP,80.17,411.78,,,,,,
Humana MCR ADV,CPT,V2307,Lens sphcy trifocal 4.25-7/.,Durable Medical Equipment,Per Unit,$76.33 ,OP,76.33,392.7,,,,,,
Humana MCR ADV,CPT,V2308,Lens sphc trifocal 4.25-7/2.,Durable Medical Equipment,Per Unit,$83.26 ,OP,83.26,430.83,,,,,,
Humana MCR ADV,CPT,V2309,Lens sphc trifocal 4.25-7/4.,Durable Medical Equipment,Per Unit,$87.13 ,OP,87.13,449.9,,,,,,
Humana MCR ADV,CPT,V2310,Lens sphc trifocal 4.25-7/>6,Durable Medical Equipment,Per Unit,$91.01 ,OP,91.01,468.96,,,,,,
Humana MCR ADV,CPT,V2311,Lens sphc trifo 7.25-12/.25-,Durable Medical Equipment,Per Unit,$105.08 ,OP,105.08,541.4,,,,,,
Humana MCR ADV,CPT,V2312,Lens sphc trifo 7.25-12/2.25,Durable Medical Equipment,Per Unit,$96.32 ,OP,96.32,495.65,,,,,,
Humana MCR ADV,CPT,V2313,Lens sphc trifo 7.25-12/4.25,Durable Medical Equipment,Per Unit,$105.15 ,OP,105.15,541.4,,,,,,
Humana MCR ADV,CPT,V2314,Lens sphcyl trifocal over 12,Durable Medical Equipment,Per Unit,$107.48 ,OP,107.48,552.84,,,,,,
Humana MCR ADV,CPT,V2315,Lens lenticular trifocal,Durable Medical Equipment,Per Unit,$119.32 ,OP,119.32,613.85,,,,,,
Humana MCR ADV,CPT,V2318,Lens aniseikonic trifocal,Durable Medical Equipment,Per Unit,$146.68 ,OP,146.68,754.91,,,,,,
Humana MCR ADV,CPT,V2319,Lens trifocal seg width > 28,Durable Medical Equipment,Per Unit,$66.22 ,OP,66.22,343.14,,,,,,
Humana MCR ADV,CPT,V2320,Lens trifocal add over 3.25d,Durable Medical Equipment,Per Unit,$69.85 ,OP,69.85,362.21,,,,,,
Humana MCR ADV,CPT,V2321,Lenticular lens- trifocal,Durable Medical Equipment,Per Unit,$117.61 ,OP,117.61,606.21,,,,,,
Humana MCR ADV,CPT,V2410,Lens variab asphericity sing,Durable Medical Equipment,Per Unit,$102.83 ,OP,102.83,529.96,,,,,,
Humana MCR ADV,CPT,V2430,Lens variable asphericity bi,Durable Medical Equipment,Per Unit,$108.84 ,OP,108.84,560.47,,,,,,
Humana MCR ADV,CPT,V2500,Contact lens pmma spherical,Durable Medical Equipment,Per Unit,$92.01 ,OP,92.01,92.01,,,,,,
Humana MCR ADV,CPT,V2501,Cntct lens pmma-toric/prism,Durable Medical Equipment,Per Unit,$130.56 ,OP,130.56,674.85,,,,,,
Humana MCR ADV,CPT,V2502,Contact lens pmma bifocal,Durable Medical Equipment,Per Unit,$176.91 ,OP,176.91,911.23,,,,,,
Humana MCR ADV,CPT,V2503,Cntct lens pmma color vision,Durable Medical Equipment,Per Unit,$170.87 ,OP,170.87,880.74,,,,,,
Humana MCR ADV,CPT,V2510,Cntct gas permeable sphericl,Durable Medical Equipment,Per Unit,$122.68 ,OP,122.68,632.91,,,,,,
Humana MCR ADV,CPT,V2511,Cntct toric prism ballast,Durable Medical Equipment,Per Unit,$181.84 ,OP,181.84,937.93,,,,,,
Humana MCR ADV,CPT,V2512,Cntct lens gas permbl bifocl,Durable Medical Equipment,Per Unit,$209.31 ,OP,209.31,"1,078.99",,,,,,
Humana MCR ADV,CPT,V2513,Contact lens extended wear,Durable Medical Equipment,Per Unit,$210.87 ,OP,210.87,"1,086.62",,,,,,
Humana MCR ADV,CPT,V2520,Contact lens hydrophilic,Durable Medical Equipment,Per Unit,$122.25 ,OP,122.25,629.1,,,,,,
Humana MCR ADV,CPT,V2521,Cntct lens hydrophilic toric,Durable Medical Equipment,Per Unit,$242.09 ,OP,242.09,"1,250.57",,,,,,
Humana MCR ADV,CPT,V2522,Cntct lens hydrophil bifocl,Durable Medical Equipment,Per Unit,$177.16 ,OP,177.16,915.04,,,,,,
Humana MCR ADV,CPT,V2523,Cntct lens hydrophil extend,Durable Medical Equipment,Per Unit,$186.00 ,OP,186,960.8,,,,,,
Humana MCR ADV,CPT,V2530,Contact lens gas impermeable,Durable Medical Equipment,Per Unit,$297.37 ,OP,297.37,"1,532.70",,,,,,
Humana MCR ADV,CPT,V2531,Contact lens gas permeable,Durable Medical Equipment,Per Unit,$544.58 ,OP,544.58,"2,809.96",,,,,,
Humana MCR ADV,CPT,V2623,Plastic eye prosth custom,Durable Medical Equipment,Per Unit,$942.94 ,OP,942.94,"4,864.99",,,,,,
Humana MCR ADV,CPT,V2624,Polishing artifical eye,Durable Medical Equipment,Per Unit,$60.88 ,OP,60.88,312.64,,,,,,
Humana MCR ADV,CPT,V2625,Enlargemnt of eye prosthesis,Durable Medical Equipment,Per Unit,$482.12 ,OP,482.12,"2,485.87",,,,,,
Humana MCR ADV,CPT,V2626,Reduction of eye prosthesis,Durable Medical Equipment,Per Unit,$199.51 ,OP,199.51,"1,029.43",,,,,,
Humana MCR ADV,CPT,V2627,Scleral cover shell,Durable Medical Equipment,Per Unit,"$1,430.28 ",OP,"1,430.28","7,377.56",,,,,,
Humana MCR ADV,CPT,V2628,Fabrication & fitting,Durable Medical Equipment,Per Unit,$304.24 ,OP,304.24,"1,570.83",,,,,,
Humana MCR ADV,CPT,V2700,Balance lens,Durable Medical Equipment,Per Unit,$44.84 ,OP,44.84,232.58,,,,,,
Humana MCR ADV,CPT,V2710,Glass/plastic slab off prism,Durable Medical Equipment,Per Unit,$73.51 ,OP,73.51,377.46,,,,,,
Humana MCR ADV,CPT,V2715,Prism lens/es,Durable Medical Equipment,Per Unit,$14.41 ,OP,14.41,72.44,,,,,,
Humana MCR ADV,CPT,V2718,Fresnell prism press-on lens,Durable Medical Equipment,Per Unit,$31.12 ,OP,31.12,160.13,,,,,,
Humana MCR ADV,CPT,V2730,Special base curve,Durable Medical Equipment,Per Unit,$26.06 ,OP,26.06,133.45,,,,,,
Humana MCR ADV,CPT,V2744,Tint photochromatic lens/es,Durable Medical Equipment,Per Unit,$17.83 ,OP,17.83,91.51,,,,,,
Humana MCR ADV,CPT,V2745,Tint- any color/solid/grad,Durable Medical Equipment,Per Unit,$10.27 ,OP,10.27,53.38,,,,,,
Humana MCR ADV,CPT,V2750,Anti-reflective coating,Durable Medical Equipment,Per Unit,$20.02 ,OP,20.02,102.95,,,,,,
Humana MCR ADV,CPT,V2755,Uv lens/es,Durable Medical Equipment,Per Unit,$16.76 ,OP,16.76,87.69,,,,,,
Humana MCR ADV,CPT,V2770,Occluder lens/es,Durable Medical Equipment,Per Unit,$19.52 ,OP,19.52,99.13,,,,,,
Humana MCR ADV,CPT,V2780,Oversize lens/es,Durable Medical Equipment,Per Unit,$12.53 ,OP,12.53,64.82,,,,,,
Humana MCR ADV,CPT,V2782,Lens- 1.54-1.65 p/1.60-1.79g,Durable Medical Equipment,Per Unit,$64.75 ,OP,64.75,335.53,,,,,,
Humana MCR ADV,CPT,V2783,Lens- >= 1.66 p/>=1.80 g,Durable Medical Equipment,Per Unit,$73.02 ,OP,73.02,377.46,,,,,,
Humana MCR ADV,CPT,V2784,Lens polycarb or equal,Durable Medical Equipment,Per Unit,$47.48 ,OP,47.48,244.01,,,,,,
Humana MCR ADV,CPT,V2785,Corneal tissue processing,Other,Straight Discount,29.70%,OP,,,,,,,,
Humana Medicaid,DRG,11,LIVER TRANSPLANT andOR INTESTINAL TRANSPLANT,,Relative Weights,"$38,043.18 ",IP,"38,043.18","38,043.18",,,,,,
Humana Medicaid,DRG,12,LIVER TRANSPLANT andOR INTESTINAL TRANSPLANT,,Relative Weights,"$40,281.56 ",IP,"40,281.56","40,281.56",,,,,,
Humana Medicaid,DRG,13,LIVER TRANSPLANT andOR INTESTINAL TRANSPLANT,,Relative Weights,"$42,053.29 ",IP,"42,053.29","42,053.29",,,,,,
Humana Medicaid,DRG,14,LIVER TRANSPLANT andOR INTESTINAL TRANSPLANT,,Relative Weights,"$78,175.26 ",IP,"78,175.26","78,175.26",,,,,,
Humana Medicaid,DRG,21,HEART andOR LUNG TRANSPLANT,,Relative Weights,"$45,599.51 ",IP,"45,599.51","45,599.51",,,,,,
Humana Medicaid,DRG,22,HEART &/OR LUNG TRANSPLANT,,Relative Weights,"$58,026.75 ",IP,"58,026.75","58,026.75",,,,,,
Humana Medicaid,DRG,23,HEART andOR LUNG TRANSPLANT,,Relative Weights,"$74,400.53 ",IP,"74,400.53","74,400.53",,,,,,
Humana Medicaid,DRG,24,HEART andOR LUNG TRANSPLANT,,Relative Weights,"$107,953.54 ",IP,"107,953.54","107,953.54",,,,,,
Humana Medicaid,DRG,41,TRACHEOSTOMY W MV 96+ HOURS W EXTENSIVE PROCEDURE,,Relative Weights,"$33,014.21 ",IP,"33,014.21","33,014.21",,,,,,
Humana Medicaid,DRG,42,TRACHEOSTOMY W MV 96+ HOURS W EXTENSIVE PROCEDURE,,Relative Weights,"$37,820.51 ",IP,"37,820.51","37,820.51",,,,,,
Humana Medicaid,DRG,43,TRACHEOSTOMY W MV 96 HOURS W EXTENSIVE PROCEDURE,,Relative Weights,"$49,052.96 ",IP,"49,052.96","49,052.96",,,,,,
Humana Medicaid,DRG,44,TRACHEOSTOMY W MV 96 HOURS W EXTENSIVE PROCEDURE,,Relative Weights,"$72,921.22 ",IP,"72,921.22","72,921.22",,,,,,
Humana Medicaid,DRG,51,TRACHEOSTOMY W MV 96 HOURS WO EXTENSIVE PROCEDURE,,Relative Weights,"$23,684.08 ",IP,"23,684.08","23,684.08",,,,,,
Humana Medicaid,DRG,52,TRACHEOSTOMY W MV 96+ HOURS W/O EXTENSIVE PROCEDURE,,Relative Weights,"$26,315.91 ",IP,"26,315.91","26,315.91",,,,,,
Humana Medicaid,DRG,53,TRACHEOSTOMY W MV 96 HOURS WO EXTENSIVE PROCEDURE,,Relative Weights,"$36,197.91 ",IP,"36,197.91","36,197.91",,,,,,
Humana Medicaid,DRG,54,TRACHEOSTOMY W MV 96 HOURS WO EXTENSIVE PROCEDURE,,Relative Weights,"$48,934.75 ",IP,"48,934.75","48,934.75",,,,,,
Humana Medicaid,DRG,61,PANCREAS TRANSPLANT,,Relative Weights,"$40,520.03 ",IP,"40,520.03","40,520.03",,,,,,
Humana Medicaid,DRG,62,PANCREAS TRANSPLANT,,Relative Weights,"$45,022.22 ",IP,"45,022.22","45,022.22",,,,,,
Humana Medicaid,DRG,63,PANCREAS TRANSPLANT,,Relative Weights,"$47,794.94 ",IP,"47,794.94","47,794.94",,,,,,
Humana Medicaid,DRG,64,PANCREAS TRANSPLANT,,Relative Weights,"$66,459.33 ",IP,"66,459.33","66,459.33",,,,,,
Humana Medicaid,DRG,71,ALLOGENEIC BONE MARROW TRANSPLANT,,Relative Weights,"$38,434.91 ",IP,"38,434.91","38,434.91",,,,,,
Humana Medicaid,DRG,72,ALLOGENEIC BONE MARROW TRANSPLANT,,Relative Weights,"$48,059.19 ",IP,"48,059.19","48,059.19",,,,,,
Humana Medicaid,DRG,73,ALLOGENEIC BONE MARROW TRANSPLANT,,Relative Weights,"$59,827.69 ",IP,"59,827.69","59,827.69",,,,,,
Humana Medicaid,DRG,74,ALLOGENEIC BONE MARROW TRANSPLANT,,Relative Weights,"$99,672.84 ",IP,"99,672.84","99,672.84",,,,,,
Humana Medicaid,DRG,81,AUTOLOGOUS BONE MARROW TRANSPLANT,,Relative Weights,"$22,091.37 ",IP,"22,091.37","22,091.37",,,,,,
Humana Medicaid,DRG,82,AUTOLOGOUS BONE MARROW TRANSPLANT,,Relative Weights,"$27,118.96 ",IP,"27,118.96","27,118.96",,,,,,
Humana Medicaid,DRG,83,AUTOLOGOUS BONE MARROW TRANSPLANT,,Relative Weights,"$32,175.76 ",IP,"32,175.76","32,175.76",,,,,,
Humana Medicaid,DRG,84,AUTOLOGOUS BONE MARROW TRANSPLANT,,Relative Weights,"$51,576.54 ",IP,"51,576.54","51,576.54",,,,,,
Humana Medicaid,DRG,91,EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO),,Relative Weights,"$27,699.69 ",IP,"27,699.69","27,699.69",,,,,,
Humana Medicaid,DRG,92,EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO),,Relative Weights,"$30,776.86 ",IP,"30,776.86","30,776.86",,,,,,
Humana Medicaid,DRG,93,EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO),,Relative Weights,"$36,358.72 ",IP,"36,358.72","36,358.72",,,,,,
Humana Medicaid,DRG,94,EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO),,Relative Weights,"$79,300.63 ",IP,"79,300.63","79,300.63",,,,,,
Humana Medicaid,DRG,101,HEAD TRAUMA WITH DEEP COMA,,Relative Weights,"$4,104.27 ",IP,"4,104.27","4,104.27",,,,,,
Humana Medicaid,DRG,102,HEAD TRAUMA WITH DEEP COMA,,Relative Weights,"$7,527.81 ",IP,"7,527.81","7,527.81",,,,,,
Humana Medicaid,DRG,103,HEAD TRAUMA WITH DEEP COMA,,Relative Weights,"$12,592.86 ",IP,"12,592.86","12,592.86",,,,,,
Humana Medicaid,DRG,104,HEAD TRAUMA WITH DEEP COMA,,Relative Weights,"$37,584.09 ",IP,"37,584.09","37,584.09",,,,,,
Humana Medicaid,DRG,201,CRANIOTOMY FOR TRAUMA,,Relative Weights,"$9,991.61 ",IP,"9,991.61","9,991.61",,,,,,
Humana Medicaid,DRG,202,CRANIOTOMY FOR TRAUMA,,Relative Weights,"$11,868.15 ",IP,"11,868.15","11,868.15",,,,,,
Humana Medicaid,DRG,203,CRANIOTOMY FOR TRAUMA,,Relative Weights,"$16,002.32 ",IP,"16,002.32","16,002.32",,,,,,
Humana Medicaid,DRG,204,CRANIOTOMY FOR TRAUMA,,Relative Weights,"$28,673.87 ",IP,"28,673.87","28,673.87",,,,,,
Humana Medicaid,DRG,211,CRANIOTOMY EXCEPT FOR TRAUMA,,Relative Weights,"$9,882.68 ",IP,"9,882.68","9,882.68",,,,,,
Humana Medicaid,DRG,212,CRANIOTOMY EXCEPT FOR TRAUMA,,Relative Weights,"$13,243.69 ",IP,"13,243.69","13,243.69",,,,,,
Humana Medicaid,DRG,213,CRANIOTOMY EXCEPT FOR TRAUMA,,Relative Weights,"$18,834.48 ",IP,"18,834.48","18,834.48",,,,,,
Humana Medicaid,DRG,214,CRANIOTOMY EXCEPT FOR TRAUMA,,Relative Weights,"$27,671.86 ",IP,"27,671.86","27,671.86",,,,,,
Humana Medicaid,DRG,221,VENTRICULAR SHUNT PROCEDURES,,Relative Weights,"$6,449.86 ",IP,"6,449.86","6,449.86",,,,,,
Humana Medicaid,DRG,222,VENTRICULAR SHUNT PROCEDURES,,Relative Weights,"$7,492.76 ",IP,"7,492.76","7,492.76",,,,,,
Humana Medicaid,DRG,223,VENTRICULAR SHUNT PROCEDURES,,Relative Weights,"$10,628.01 ",IP,"10,628.01","10,628.01",,,,,,
Humana Medicaid,DRG,224,VENTRICULAR SHUNT PROCEDURES,,Relative Weights,"$25,450.32 ",IP,"25,450.32","25,450.32",,,,,,
Humana Medicaid,DRG,231,SPINAL PROCEDURES,,Relative Weights,"$7,646.71 ",IP,"7,646.71","7,646.71",,,,,,
Humana Medicaid,DRG,232,SPINAL PROCEDURES,,Relative Weights,"$9,630.12 ",IP,"9,630.12","9,630.12",,,,,,
Humana Medicaid,DRG,233,SPINAL PROCEDURES,,Relative Weights,"$16,000.26 ",IP,"16,000.26","16,000.26",,,,,,
Humana Medicaid,DRG,234,SPINAL PROCEDURES,,Relative Weights,"$29,075.91 ",IP,"29,075.91","29,075.91",,,,,,
Humana Medicaid,DRG,241,EXTRACRANIAL VASCULAR PROCEDURES,,Relative Weights,"$5,741.65 ",IP,"5,741.65","5,741.65",,,,,,
Humana Medicaid,DRG,242,EXTRACRANIAL VASCULAR PROCEDURES,,Relative Weights,"$6,726.14 ",IP,"6,726.14","6,726.14",,,,,,
Humana Medicaid,DRG,243,EXTRACRANIAL VASCULAR PROCEDURES,,Relative Weights,"$13,747.79 ",IP,"13,747.79","13,747.79",,,,,,
Humana Medicaid,DRG,244,EXTRACRANIAL VASCULAR PROCEDURES,,Relative Weights,"$24,782.31 ",IP,"24,782.31","24,782.31",,,,,,
Humana Medicaid,DRG,261,OTHER NERVOUS SYSTEM and RELATED PROCEDURES,,Relative Weights,"$7,157.39 ",IP,"7,157.39","7,157.39",,,,,,
Humana Medicaid,DRG,262,OTHER NERVOUS SYSTEM and RELATED PROCEDURES,,Relative Weights,"$8,935.31 ",IP,"8,935.31","8,935.31",,,,,,
Humana Medicaid,DRG,263,OTHER NERVOUS SYSTEM and RELATED PROCEDURES,,Relative Weights,"$12,455.76 ",IP,"12,455.76","12,455.76",,,,,,
Humana Medicaid,DRG,264,OTHER NERVOUS SYSTEM & RELATED PROCEDURES,,Relative Weights,"$22,781.03 ",IP,"22,781.03","22,781.03",,,,,,
Humana Medicaid,DRG,401,SPINAL DISORDERS and INJURIES,,Relative Weights,"$5,482.55 ",IP,"5,482.55","5,482.55",,,,,,
Humana Medicaid,DRG,402,SPINAL DISORDERS and INJURIES,,Relative Weights,"$5,877.72 ",IP,"5,877.72","5,877.72",,,,,,
Humana Medicaid,DRG,403,SPINAL DISORDERS and INJURIES,,Relative Weights,"$8,545.98 ",IP,"8,545.98","8,545.98",,,,,,
Humana Medicaid,DRG,404,SPINAL DISORDERS and INJURIES,,Relative Weights,"$17,945.87 ",IP,"17,945.87","17,945.87",,,,,,
Humana Medicaid,DRG,411,NERVOUS SYSTEM MALIGNANCY,,Relative Weights,"$4,340.00 ",IP,"4,340.00","4,340.00",,,,,,
Humana Medicaid,DRG,412,NERVOUS SYSTEM MALIGNANCY,,Relative Weights,"$4,441.02 ",IP,"4,441.02","4,441.02",,,,,,
Humana Medicaid,DRG,413,NERVOUS SYSTEM MALIGNANCY,,Relative Weights,"$5,802.81 ",IP,"5,802.81","5,802.81",,,,,,
Humana Medicaid,DRG,414,NERVOUS SYSTEM MALIGNANCY,,Relative Weights,"$8,029.51 ",IP,"8,029.51","8,029.51",,,,,,
Humana Medicaid,DRG,421,DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS,,Relative Weights,"$3,328.02 ",IP,"3,328.02","3,328.02",,,,,,
Humana Medicaid,DRG,422,DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS,,Relative Weights,"$3,814.25 ",IP,"3,814.25","3,814.25",,,,,,
Humana Medicaid,DRG,423,DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS,,Relative Weights,"$5,381.53 ",IP,"5,381.53","5,381.53",,,,,,
Humana Medicaid,DRG,424,DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS,,Relative Weights,"$12,544.07 ",IP,"12,544.07","12,544.07",,,,,,
Humana Medicaid,DRG,431,MULTIPLE SCLEROSIS and OTHER DEMYELINATING DISEASES,,Relative Weights,"$4,040.70 ",IP,"4,040.70","4,040.70",,,,,,
Humana Medicaid,DRG,432,MULTIPLE SCLEROSIS and OTHER DEMYELINATING DISEASES,,Relative Weights,"$5,014.88 ",IP,"5,014.88","5,014.88",,,,,,
Humana Medicaid,DRG,433,MULTIPLE SCLEROSIS and OTHER DEMYELINATING DISEASES,,Relative Weights,"$7,268.72 ",IP,"7,268.72","7,268.72",,,,,,
Humana Medicaid,DRG,434,MULTIPLE SCLEROSIS & OTHER DEMYELINATING DISEASES,,Relative Weights,"$15,032.61 ",IP,"15,032.61","15,032.61",,,,,,
Humana Medicaid,DRG,441,INTRACRANIAL HEMORRHAGE,,Relative Weights,"$3,968.19 ",IP,"3,968.19","3,968.19",,,,,,
Humana Medicaid,DRG,442,INTRACRANIAL HEMORRHAGE,,Relative Weights,"$4,927.25 ",IP,"4,927.25","4,927.25",,,,,,
Humana Medicaid,DRG,443,INTRACRANIAL HEMORRHAGE,,Relative Weights,"$6,702.77 ",IP,"6,702.77","6,702.77",,,,,,
Humana Medicaid,DRG,444,INTRACRANIAL HEMORRHAGE,,Relative Weights,"$9,326.01 ",IP,"9,326.01","9,326.01",,,,,,
Humana Medicaid,DRG,451,CVA and PRECEREBRAL OCCLUSION W INFARCT,,Relative Weights,"$3,612.20 ",IP,"3,612.20","3,612.20",,,,,,
Humana Medicaid,DRG,452,CVA and PRECEREBRAL OCCLUSION W INFARCT,,Relative Weights,"$4,429.34 ",IP,"4,429.34","4,429.34",,,,,,
Humana Medicaid,DRG,453,CVA and PRECEREBRAL OCCLUSION W INFARCT,,Relative Weights,"$5,951.60 ",IP,"5,951.60","5,951.60",,,,,,
Humana Medicaid,DRG,454,CVA and PRECEREBRAL OCCLUSION W INFARCT,,Relative Weights,"$10,976.10 ",IP,"10,976.10","10,976.10",,,,,,
Humana Medicaid,DRG,461,NONSPECIFIC CVA and PRECEREBRAL OCCLUSION WO INFARCT,,Relative Weights,"$3,784.70 ",IP,"3,784.70","3,784.70",,,,,,
Humana Medicaid,DRG,462,NONSPECIFIC CVA and PRECEREBRAL OCCLUSION WO INFARCT,,Relative Weights,"$4,264.40 ",IP,"4,264.40","4,264.40",,,,,,
Humana Medicaid,DRG,463,NONSPECIFIC CVA and PRECEREBRAL OCCLUSION WO INFARCT,,Relative Weights,"$5,292.53 ",IP,"5,292.53","5,292.53",,,,,,
Humana Medicaid,DRG,464,NONSPECIFIC CVA and PRECEREBRAL OCCLUSION WO INFARCT,,Relative Weights,"$10,621.82 ",IP,"10,621.82","10,621.82",,,,,,
Humana Medicaid,DRG,471,TRANSIENT ISCHEMIA,,Relative Weights,"$3,321.15 ",IP,"3,321.15","3,321.15",,,,,,
Humana Medicaid,DRG,472,TRANSIENT ISCHEMIA,,Relative Weights,"$3,597.42 ",IP,"3,597.42","3,597.42",,,,,,
Humana Medicaid,DRG,473,TRANSIENT ISCHEMIA,,Relative Weights,"$4,242.41 ",IP,"4,242.41","4,242.41",,,,,,
Humana Medicaid,DRG,474,TRANSIENT ISCHEMIA,,Relative Weights,"$7,719.21 ",IP,"7,719.21","7,719.21",,,,,,
Humana Medicaid,DRG,481,PERIPHERAL CRANIAL and AUTONOMIC NERVE DISORDERS,,Relative Weights,"$3,400.87 ",IP,"3,400.87","3,400.87",,,,,,
Humana Medicaid,DRG,482,PERIPHERAL CRANIAL and AUTONOMIC NERVE DISORDERS,,Relative Weights,"$3,627.32 ",IP,"3,627.32","3,627.32",,,,,,
Humana Medicaid,DRG,483,PERIPHERAL CRANIAL and AUTONOMIC NERVE DISORDERS,,Relative Weights,"$4,545.48 ",IP,"4,545.48","4,545.48",,,,,,
Humana Medicaid,DRG,484,"PERIPHERAL, CRANIAL & AUTONOMIC NERVE DISORDERS",,Relative Weights,"$10,429.39 ",IP,"10,429.39","10,429.39",,,,,,
Humana Medicaid,DRG,491,BACTERIAL and TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,,Relative Weights,"$5,943.01 ",IP,"5,943.01","5,943.01",,,,,,
Humana Medicaid,DRG,492,BACTERIAL and TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,,Relative Weights,"$9,716.03 ",IP,"9,716.03","9,716.03",,,,,,
Humana Medicaid,DRG,493,BACTERIAL and TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,,Relative Weights,"$11,066.13 ",IP,"11,066.13","11,066.13",,,,,,
Humana Medicaid,DRG,494,BACTERIAL and TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,,Relative Weights,"$20,732.33 ",IP,"20,732.33","20,732.33",,,,,,
Humana Medicaid,DRG,501,NONBACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS,,Relative Weights,"$3,211.53 ",IP,"3,211.53","3,211.53",,,,,,
Humana Medicaid,DRG,502,NONBACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS,,Relative Weights,"$6,688.34 ",IP,"6,688.34","6,688.34",,,,,,
Humana Medicaid,DRG,503,NONBACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS,,Relative Weights,"$10,165.49 ",IP,"10,165.49","10,165.49",,,,,,
Humana Medicaid,DRG,504,NONBACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS,,Relative Weights,"$22,308.54 ",IP,"22,308.54","22,308.54",,,,,,
Humana Medicaid,DRG,511,VIRAL MENINGITIS,,Relative Weights,"$2,048.35 ",IP,"2,048.35","2,048.35",,,,,,
Humana Medicaid,DRG,512,VIRAL MENINGITIS,,Relative Weights,"$3,205.00 ",IP,"3,205.00","3,205.00",,,,,,
Humana Medicaid,DRG,513,VIRAL MENINGITIS,,Relative Weights,"$5,993.52 ",IP,"5,993.52","5,993.52",,,,,,
Humana Medicaid,DRG,514,VIRAL MENINGITIS,,Relative Weights,"$12,441.32 ",IP,"12,441.32","12,441.32",,,,,,
Humana Medicaid,DRG,521,ALTERATION IN CONSCIOUSNESS,,Relative Weights,"$3,101.91 ",IP,"3,101.91","3,101.91",,,,,,
Humana Medicaid,DRG,522,ALTERATION IN CONSCIOUSNESS,,Relative Weights,"$3,492.61 ",IP,"3,492.61","3,492.61",,,,,,
Humana Medicaid,DRG,523,ALTERATION IN CONSCIOUSNESS,,Relative Weights,"$4,423.15 ",IP,"4,423.15","4,423.15",,,,,,
Humana Medicaid,DRG,524,ALTERATION IN CONSCIOUSNESS,,Relative Weights,"$9,303.33 ",IP,"9,303.33","9,303.33",,,,,,
Humana Medicaid,DRG,531,SEIZURE,,Relative Weights,"$2,710.87 ",IP,"2,710.87","2,710.87",,,,,,
Humana Medicaid,DRG,532,SEIZURE,,Relative Weights,"$3,311.87 ",IP,"3,311.87","3,311.87",,,,,,
Humana Medicaid,DRG,533,SEIZURE,,Relative Weights,"$4,410.44 ",IP,"4,410.44","4,410.44",,,,,,
Humana Medicaid,DRG,534,SEIZURE,,Relative Weights,"$10,918.03 ",IP,"10,918.03","10,918.03",,,,,,
Humana Medicaid,DRG,541,MIGRAINE and OTHER HEADACHES,,Relative Weights,"$2,681.66 ",IP,"2,681.66","2,681.66",,,,,,
Humana Medicaid,DRG,542,MIGRAINE and OTHER HEADACHES,,Relative Weights,"$3,180.26 ",IP,"3,180.26","3,180.26",,,,,,
Humana Medicaid,DRG,543,MIGRAINE and OTHER HEADACHES,,Relative Weights,"$3,960.98 ",IP,"3,960.98","3,960.98",,,,,,
Humana Medicaid,DRG,544,MIGRAINE and OTHER HEADACHES,,Relative Weights,"$6,681.46 ",IP,"6,681.46","6,681.46",,,,,,
Humana Medicaid,DRG,551,HEAD TRAUMA W COMA 1 HR OR HEMORRHAGE,,Relative Weights,"$3,376.47 ",IP,"3,376.47","3,376.47",,,,,,
Humana Medicaid,DRG,552,HEAD TRAUMA W COMA 1 HR OR HEMORRHAGE,,Relative Weights,"$4,570.57 ",IP,"4,570.57","4,570.57",,,,,,
Humana Medicaid,DRG,553,HEAD TRAUMA W COMA 1 HR OR HEMORRHAGE,,Relative Weights,"$6,561.54 ",IP,"6,561.54","6,561.54",,,,,,
Humana Medicaid,DRG,554,HEAD TRAUMA W COMA 1 HR OR HEMORRHAGE,,Relative Weights,"$13,008.65 ",IP,"13,008.65","13,008.65",,,,,,
Humana Medicaid,DRG,561,BRAIN CONTUSIONLACERATION and COMPLICATED SKULL FX COMA  1 HR OR NO COMA,,Relative Weights,"$3,264.10 ",IP,"3,264.10","3,264.10",,,,,,
Humana Medicaid,DRG,562,BRAIN CONTUSIONLACERATION and COMPLICATED SKULL FX COMA  1 HR OR NO COMA,,Relative Weights,"$4,370.58 ",IP,"4,370.58","4,370.58",,,,,,
Humana Medicaid,DRG,563,BRAIN CONTUSIONLACERATION and COMPLICATED SKULL FX COMA  1 HR OR NO COMA,,Relative Weights,"$6,249.87 ",IP,"6,249.87","6,249.87",,,,,,
Humana Medicaid,DRG,564,BRAIN CONTUSIONLACERATION and COMPLICATED SKULL FX COMA  1 HR OR NO COMA,,Relative Weights,"$13,974.93 ",IP,"13,974.93","13,974.93",,,,,,
Humana Medicaid,DRG,571,CONCUSSION CLOSED SKULL FX NOSUNCOMPLICATED INTRACRANIAL INJURY COMA  1 HR OR NO COMA,,Relative Weights,"$2,653.48 ",IP,"2,653.48","2,653.48",,,,,,
Humana Medicaid,DRG,572,CONCUSSION CLOSED SKULL FX NOSUNCOMPLICATED INTRACRANIAL INJURY COMA  1 HR OR NO COMA,,Relative Weights,"$3,996.71 ",IP,"3,996.71","3,996.71",,,,,,
Humana Medicaid,DRG,573,CONCUSSION CLOSED SKULL FX NOSUNCOMPLICATED INTRACRANIAL INJURY COMA  1 HR OR NO COMA,,Relative Weights,"$5,550.25 ",IP,"5,550.25","5,550.25",,,,,,
Humana Medicaid,DRG,574,CONCUSSION CLOSED SKULL FX NOSUNCOMPLICATED INTRACRANIAL INJURY COMA  1 HR OR NO COMA,,Relative Weights,"$10,437.98 ",IP,"10,437.98","10,437.98",,,,,,
Humana Medicaid,DRG,581,OTHER DISORDERS OF NERVOUS SYSTEM,,Relative Weights,"$3,385.75 ",IP,"3,385.75","3,385.75",,,,,,
Humana Medicaid,DRG,582,OTHER DISORDERS OF NERVOUS SYSTEM,,Relative Weights,"$4,062.35 ",IP,"4,062.35","4,062.35",,,,,,
Humana Medicaid,DRG,583,OTHER DISORDERS OF NERVOUS SYSTEM,,Relative Weights,"$5,313.15 ",IP,"5,313.15","5,313.15",,,,,,
Humana Medicaid,DRG,584,OTHER DISORDERS OF NERVOUS SYSTEM,,Relative Weights,"$10,386.78 ",IP,"10,386.78","10,386.78",,,,,,
Humana Medicaid,DRG,591,ANOXIC and OTHER SEVERE BRAIN DAMAGE,,Relative Weights,"$3,746.90 ",IP,"3,746.90","3,746.90",,,,,,
Humana Medicaid,DRG,592,ANOXIC and OTHER SEVERE BRAIN DAMAGE,,Relative Weights,"$4,463.01 ",IP,"4,463.01","4,463.01",,,,,,
Humana Medicaid,DRG,593,ANOXIC and OTHER SEVERE BRAIN DAMAGE,,Relative Weights,"$6,809.98 ",IP,"6,809.98","6,809.98",,,,,,
Humana Medicaid,DRG,594,ANOXIC & OTHER SEVERE BRAIN DAMAGE,,Relative Weights,"$11,699.43 ",IP,"11,699.43","11,699.43",,,,,,
Humana Medicaid,DRG,731,ORBIT AND EYE PROCEDURES,,Relative Weights,"$5,014.53 ",IP,"5,014.53","5,014.53",,,,,,
Humana Medicaid,DRG,732,ORBIT AND EYE PROCEDURES,,Relative Weights,"$6,421.34 ",IP,"6,421.34","6,421.34",,,,,,
Humana Medicaid,DRG,733,ORBIT AND EYE PROCEDURES,,Relative Weights,"$9,718.43 ",IP,"9,718.43","9,718.43",,,,,,
Humana Medicaid,DRG,734,ORBIT AND EYE PROCEDURES,,Relative Weights,"$22,403.73 ",IP,"22,403.73","22,403.73",,,,,,
Humana Medicaid,DRG,821,EYE INFECTIONS AND OTHER EYE DISORDERS,,Relative Weights,"$2,633.21 ",IP,"2,633.21","2,633.21",,,,,,
Humana Medicaid,DRG,822,EYE INFECTIONS AND OTHER EYE DISORDERS,,Relative Weights,"$3,410.83 ",IP,"3,410.83","3,410.83",,,,,,
Humana Medicaid,DRG,823,EYE INFECTIONS AND OTHER EYE DISORDERS,,Relative Weights,"$4,809.73 ",IP,"4,809.73","4,809.73",,,,,,
Humana Medicaid,DRG,824,EYE INFECTIONS AND OTHER EYE DISORDERS,,Relative Weights,"$13,027.89 ",IP,"13,027.89","13,027.89",,,,,,
Humana Medicaid,DRG,891,MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$9,059.01 ",IP,"9,059.01","9,059.01",,,,,,
Humana Medicaid,DRG,892,MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$11,457.52 ",IP,"11,457.52","11,457.52",,,,,,
Humana Medicaid,DRG,893,MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$17,804.98 ",IP,"17,804.98","17,804.98",,,,,,
Humana Medicaid,DRG,894,MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$32,041.75 ",IP,"32,041.75","32,041.75",,,,,,
Humana Medicaid,DRG,911,OTHER MAJOR HEAD and NECK PROCEDURES,,Relative Weights,"$6,729.57 ",IP,"6,729.57","6,729.57",,,,,,
Humana Medicaid,DRG,912,OTHER MAJOR HEAD and NECK PROCEDURES,,Relative Weights,"$9,964.47 ",IP,"9,964.47","9,964.47",,,,,,
Humana Medicaid,DRG,913,OTHER MAJOR HEAD and NECK PROCEDURES,,Relative Weights,"$16,613.29 ",IP,"16,613.29","16,613.29",,,,,,
Humana Medicaid,DRG,914,OTHER MAJOR HEAD and NECK PROCEDURES,,Relative Weights,"$32,825.56 ",IP,"32,825.56","32,825.56",,,,,,
Humana Medicaid,DRG,921,FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$6,039.23 ",IP,"6,039.23","6,039.23",,,,,,
Humana Medicaid,DRG,922,FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$8,191.36 ",IP,"8,191.36","8,191.36",,,,,,
Humana Medicaid,DRG,923,FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$13,246.44 ",IP,"13,246.44","13,246.44",,,,,,
Humana Medicaid,DRG,924,FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$30,839.40 ",IP,"30,839.40","30,839.40",,,,,,
Humana Medicaid,DRG,951,CLEFT LIP and PALATE REPAIR,,Relative Weights,"$4,246.53 ",IP,"4,246.53","4,246.53",,,,,,
Humana Medicaid,DRG,952,CLEFT LIP and PALATE REPAIR,,Relative Weights,"$4,867.46 ",IP,"4,867.46","4,867.46",,,,,,
Humana Medicaid,DRG,953,CLEFT LIP & PALATE REPAIR,,Relative Weights,"$7,436.75 ",IP,"7,436.75","7,436.75",,,,,,
Humana Medicaid,DRG,954,CLEFT LIP and PALATE REPAIR,,Relative Weights,"$14,987.25 ",IP,"14,987.25","14,987.25",,,,,,
Humana Medicaid,DRG,971,TONSIL and ADENOID PROCEDURES,,Relative Weights,"$2,853.47 ",IP,"2,853.47","2,853.47",,,,,,
Humana Medicaid,DRG,972,TONSIL & ADENOID PROCEDURES,,Relative Weights,"$3,981.59 ",IP,"3,981.59","3,981.59",,,,,,
Humana Medicaid,DRG,973,TONSIL & ADENOID PROCEDURES,,Relative Weights,"$6,406.56 ",IP,"6,406.56","6,406.56",,,,,,
Humana Medicaid,DRG,974,TONSIL and ADENOID PROCEDURES,,Relative Weights,"$15,100.30 ",IP,"15,100.30","15,100.30",,,,,,
Humana Medicaid,DRG,981,OTHER EAR NOSE MOUTH and THROAT PROCEDURES,,Relative Weights,"$4,806.30 ",IP,"4,806.30","4,806.30",,,,,,
Humana Medicaid,DRG,982,OTHER EAR NOSE MOUTH and THROAT PROCEDURES,,Relative Weights,"$6,289.73 ",IP,"6,289.73","6,289.73",,,,,,
Humana Medicaid,DRG,983,"OTHER EAR, NOSE, MOUTH & THROAT PROCEDURES",,Relative Weights,"$10,153.46 ",IP,"10,153.46","10,153.46",,,,,,
Humana Medicaid,DRG,984,OTHER EAR NOSE MOUTH and THROAT PROCEDURES,,Relative Weights,"$19,630.32 ",IP,"19,630.32","19,630.32",,,,,,
Humana Medicaid,DRG,1101,EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES,,Relative Weights,"$4,539.30 ",IP,"4,539.30","4,539.30",,,,,,
Humana Medicaid,DRG,1102,EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES,,Relative Weights,"$4,571.26 ",IP,"4,571.26","4,571.26",,,,,,
Humana Medicaid,DRG,1103,EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES,,Relative Weights,"$6,424.43 ",IP,"6,424.43","6,424.43",,,,,,
Humana Medicaid,DRG,1104,EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES,,Relative Weights,"$10,388.84 ",IP,"10,388.84","10,388.84",,,,,,
Humana Medicaid,DRG,1111,VERTIGO and OTHER LABYRINTH DISORDERS,,Relative Weights,"$3,014.97 ",IP,"3,014.97","3,014.97",,,,,,
Humana Medicaid,DRG,1112,VERTIGO and OTHER LABYRINTH DISORDERS,,Relative Weights,"$3,232.83 ",IP,"3,232.83","3,232.83",,,,,,
Humana Medicaid,DRG,1113,VERTIGO and OTHER LABYRINTH DISORDERS,,Relative Weights,"$3,830.06 ",IP,"3,830.06","3,830.06",,,,,,
Humana Medicaid,DRG,1114,VERTIGO and OTHER LABYRINTH DISORDERS,,Relative Weights,"$5,856.07 ",IP,"5,856.07","5,856.07",,,,,,
Humana Medicaid,DRG,1131,INFECTIONS OF UPPER RESPIRATORY TRACT,,Relative Weights,"$1,710.57 ",IP,"1,710.57","1,710.57",,,,,,
Humana Medicaid,DRG,1132,INFECTIONS OF UPPER RESPIRATORY TRACT,,Relative Weights,"$2,449.71 ",IP,"2,449.71","2,449.71",,,,,,
Humana Medicaid,DRG,1133,INFECTIONS OF UPPER RESPIRATORY TRACT,,Relative Weights,"$3,709.10 ",IP,"3,709.10","3,709.10",,,,,,
Humana Medicaid,DRG,1134,INFECTIONS OF UPPER RESPIRATORY TRACT,,Relative Weights,"$7,363.91 ",IP,"7,363.91","7,363.91",,,,,,
Humana Medicaid,DRG,1141,DENTAL DISEASES AND DISORDERS,,Relative Weights,"$2,233.23 ",IP,"2,233.23","2,233.23",,,,,,
Humana Medicaid,DRG,1142,DENTAL DISEASES AND DISORDERS,,Relative Weights,"$3,024.94 ",IP,"3,024.94","3,024.94",,,,,,
Humana Medicaid,DRG,1143,DENTAL DISEASES AND DISORDERS,,Relative Weights,"$4,392.57 ",IP,"4,392.57","4,392.57",,,,,,
Humana Medicaid,DRG,1144,DENTAL DISEASES AND DISORDERS,,Relative Weights,"$11,476.08 ",IP,"11,476.08","11,476.08",,,,,,
Humana Medicaid,DRG,1151,OTHER EAR NOSE MOUTHTHROAT and CRANIALFACIAL DIAGNOSES,,Relative Weights,"$2,472.39 ",IP,"2,472.39","2,472.39",,,,,,
Humana Medicaid,DRG,1152,OTHER EAR NOSE MOUTHTHROAT and CRANIALFACIAL DIAGNOSES,,Relative Weights,"$3,380.25 ",IP,"3,380.25","3,380.25",,,,,,
Humana Medicaid,DRG,1153,"OTHER EAR, NOSE, MOUTH,THROAT & CRANIAL/FACIAL DIAGNOSES",,Relative Weights,"$4,829.66 ",IP,"4,829.66","4,829.66",,,,,,
Humana Medicaid,DRG,1154,"OTHER EAR, NOSE, MOUTH,THROAT & CRANIAL/FACIAL DIAGNOSES",,Relative Weights,"$10,560.66 ",IP,"10,560.66","10,560.66",,,,,,
Humana Medicaid,DRG,1201,MAJOR RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$8,978.60 ",IP,"8,978.60","8,978.60",,,,,,
Humana Medicaid,DRG,1202,MAJOR RESPIRATORY & CHEST PROCEDURES,,Relative Weights,"$10,724.22 ",IP,"10,724.22","10,724.22",,,,,,
Humana Medicaid,DRG,1203,MAJOR RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$15,096.86 ",IP,"15,096.86","15,096.86",,,,,,
Humana Medicaid,DRG,1204,MAJOR RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$30,187.20 ",IP,"30,187.20","30,187.20",,,,,,
Humana Medicaid,DRG,1211,OTHER RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$6,647.79 ",IP,"6,647.79","6,647.79",,,,,,
Humana Medicaid,DRG,1212,OTHER RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$8,066.62 ",IP,"8,066.62","8,066.62",,,,,,
Humana Medicaid,DRG,1213,OTHER RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$12,267.10 ",IP,"12,267.10","12,267.10",,,,,,
Humana Medicaid,DRG,1214,OTHER RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$23,708.13 ",IP,"23,708.13","23,708.13",,,,,,
Humana Medicaid,DRG,1301,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96 HOURS,,Relative Weights,"$15,152.88 ",IP,"15,152.88","15,152.88",,,,,,
Humana Medicaid,DRG,1302,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS,,Relative Weights,"$17,209.82 ",IP,"17,209.82","17,209.82",,,,,,
Humana Medicaid,DRG,1303,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96 HOURS,,Relative Weights,"$20,315.17 ",IP,"20,315.17","20,315.17",,,,,,
Humana Medicaid,DRG,1304,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96 HOURS,,Relative Weights,"$28,326.47 ",IP,"28,326.47","28,326.47",,,,,,
Humana Medicaid,DRG,1311,CYSTIC FIBROSIS  PULMONARY DISEASE,,Relative Weights,"$6,540.23 ",IP,"6,540.23","6,540.23",,,,,,
Humana Medicaid,DRG,1312,CYSTIC FIBROSIS - PULMONARY DISEASE,,Relative Weights,"$9,797.46 ",IP,"9,797.46","9,797.46",,,,,,
Humana Medicaid,DRG,1313,CYSTIC FIBROSIS - PULMONARY DISEASE,,Relative Weights,"$13,253.65 ",IP,"13,253.65","13,253.65",,,,,,
Humana Medicaid,DRG,1314,CYSTIC FIBROSIS  PULMONARY DISEASE,,Relative Weights,"$17,241.78 ",IP,"17,241.78","17,241.78",,,,,,
Humana Medicaid,DRG,1321,BPD and OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,,Relative Weights,"$2,377.20 ",IP,"2,377.20","2,377.20",,,,,,
Humana Medicaid,DRG,1322,BPD and OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,,Relative Weights,"$3,157.24 ",IP,"3,157.24","3,157.24",,,,,,
Humana Medicaid,DRG,1323,BPD & OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,,Relative Weights,"$5,204.90 ",IP,"5,204.90","5,204.90",,,,,,
Humana Medicaid,DRG,1324,BPD and OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,,Relative Weights,"$9,706.75 ",IP,"9,706.75","9,706.75",,,,,,
Humana Medicaid,DRG,1331,RESPIRATORY FAILURE,,Relative Weights,"$2,072.41 ",IP,"2,072.41","2,072.41",,,,,,
Humana Medicaid,DRG,1332,RESPIRATORY FAILURE,,Relative Weights,"$3,703.26 ",IP,"3,703.26","3,703.26",,,,,,
Humana Medicaid,DRG,1333,RESPIRATORY FAILURE,,Relative Weights,"$5,064.70 ",IP,"5,064.70","5,064.70",,,,,,
Humana Medicaid,DRG,1334,RESPIRATORY FAILURE,,Relative Weights,"$9,349.38 ",IP,"9,349.38","9,349.38",,,,,,
Humana Medicaid,DRG,1341,PULMONARY EMBOLISM,,Relative Weights,"$2,977.18 ",IP,"2,977.18","2,977.18",,,,,,
Humana Medicaid,DRG,1342,PULMONARY EMBOLISM,,Relative Weights,"$3,832.12 ",IP,"3,832.12","3,832.12",,,,,,
Humana Medicaid,DRG,1343,PULMONARY EMBOLISM,,Relative Weights,"$5,276.03 ",IP,"5,276.03","5,276.03",,,,,,
Humana Medicaid,DRG,1344,PULMONARY EMBOLISM,,Relative Weights,"$8,166.27 ",IP,"8,166.27","8,166.27",,,,,,
Humana Medicaid,DRG,1351,MAJOR CHEST and RESPIRAZORY TRAUMA,,Relative Weights,"$3,792.26 ",IP,"3,792.26","3,792.26",,,,,,
Humana Medicaid,DRG,1352,MAJOR CHEST & RESPIRATORY TRAUMA,,Relative Weights,"$3,955.48 ",IP,"3,955.48","3,955.48",,,,,,
Humana Medicaid,DRG,1353,MAJOR CHEST and RESPIRATORY TRAUMA,,Relative Weights,"$5,683.92 ",IP,"5,683.92","5,683.92",,,,,,
Humana Medicaid,DRG,1354,MAJOR CHEST and RESPIRATORY TRAUMA,,Relative Weights,"$10,178.89 ",IP,"10,178.89","10,178.89",,,,,,
Humana Medicaid,DRG,1361,RESPIRATORY MALIGNANCY,,Relative Weights,"$4,244.47 ",IP,"4,244.47","4,244.47",,,,,,
Humana Medicaid,DRG,1362,RESPIRATORY MALIGNANCY,,Relative Weights,"$4,742.73 ",IP,"4,742.73","4,742.73",,,,,,
Humana Medicaid,DRG,1363,RESPIRATORY MALIGNANCY,,Relative Weights,"$6,049.19 ",IP,"6,049.19","6,049.19",,,,,,
Humana Medicaid,DRG,1364,RESPIRATORY MALIGNANCY,,Relative Weights,"$9,049.05 ",IP,"9,049.05","9,049.05",,,,,,
Humana Medicaid,DRG,1371,MAJOR RESPIRATORY INFECTIONS and INFLAMMATIONS,,Relative Weights,"$3,151.74 ",IP,"3,151.74","3,151.74",,,,,,
Humana Medicaid,DRG,1372,MAJOR RESPIRATORY INFECTIONS and INFLAMMATIONS,,Relative Weights,"$3,930.39 ",IP,"3,930.39","3,930.39",,,,,,
Humana Medicaid,DRG,1373,MAJOR RESPIRATORY INFECTIONS & INFLAMMATIONS,,Relative Weights,"$5,471.90 ",IP,"5,471.90","5,471.90",,,,,,
Humana Medicaid,DRG,1374,MAJOR RESPIRATORY INFECTIONS and INFLAMMATIONS,,Relative Weights,"$8,758.68 ",IP,"8,758.68","8,758.68",,,,,,
Humana Medicaid,DRG,1381,BRONCHIOLITIS and RSV PNEUMONIA,,Relative Weights,"$1,796.82 ",IP,"1,796.82","1,796.82",,,,,,
Humana Medicaid,DRG,1382,BRONCHIOLITIS and RSV PNEUMONIA,,Relative Weights,"$2,575.82 ",IP,"2,575.82","2,575.82",,,,,,
Humana Medicaid,DRG,1383,BRONCHIOLITIS and RSV PNEUMONIA,,Relative Weights,"$4,712.83 ",IP,"4,712.83","4,712.83",,,,,,
Humana Medicaid,DRG,1384,BRONCHIOLITIS and RSV PNEUMONIA,,Relative Weights,"$9,865.85 ",IP,"9,865.85","9,865.85",,,,,,
Humana Medicaid,DRG,1391,OTHER PNEUMONIA,,Relative Weights,"$2,182.71 ",IP,"2,182.71","2,182.71",,,,,,
Humana Medicaid,DRG,1392,OTHER PNEUMONIA,,Relative Weights,"$3,016.35 ",IP,"3,016.35","3,016.35",,,,,,
Humana Medicaid,DRG,1393,OTHER PNEUMONIA,,Relative Weights,"$4,342.75 ",IP,"4,342.75","4,342.75",,,,,,
Humana Medicaid,DRG,1394,OTHER PNEUMONIA,,Relative Weights,"$7,186.59 ",IP,"7,186.59","7,186.59",,,,,,
Humana Medicaid,DRG,1401,CHRONIC OBSTRUCTIVE PULMONARY DISEASE,,Relative Weights,"$2,639.05 ",IP,"2,639.05","2,639.05",,,,,,
Humana Medicaid,DRG,1402,CHRONIC OBSTRUCTIVE PULMONARY DISEASE,,Relative Weights,"$3,167.20 ",IP,"3,167.20","3,167.20",,,,,,
Humana Medicaid,DRG,1403,CHRONIC OBSTRUCTIVE PULMONARY DISEASE,,Relative Weights,"$3,958.92 ",IP,"3,958.92","3,958.92",,,,,,
Humana Medicaid,DRG,1404,CHRONIC OBSTRUCTIVE PULMONARY DISEASE,,Relative Weights,"$5,969.47 ",IP,"5,969.47","5,969.47",,,,,,
Humana Medicaid,DRG,1411,ASTHMA,,Relative Weights,"$2,018.80 ",IP,"2,018.80","2,018.80",,,,,,
Humana Medicaid,DRG,1412,ASTHMA,,Relative Weights,"$2,763.78 ",IP,"2,763.78","2,763.78",,,,,,
Humana Medicaid,DRG,1413,ASTHMA,,Relative Weights,"$4,049.98 ",IP,"4,049.98","4,049.98",,,,,,
Humana Medicaid,DRG,1414,ASTHMA,,Relative Weights,"$6,508.28 ",IP,"6,508.28","6,508.28",,,,,,
Humana Medicaid,DRG,1421,INTERSTITIAL and ALVEOLAR LUNG DISEASES,,Relative Weights,"$3,358.26 ",IP,"3,358.26","3,358.26",,,,,,
Humana Medicaid,DRG,1422,INTERSTITIAL and ALVEOLAR LUNG DISEASES,,Relative Weights,"$3,679.89 ",IP,"3,679.89","3,679.89",,,,,,
Humana Medicaid,DRG,1423,INTERSTITIAL and ALVEOLAR LUNG DISEASES,,Relative Weights,"$4,888.08 ",IP,"4,888.08","4,888.08",,,,,,
Humana Medicaid,DRG,1424,INTERSTITIAL and ALVEOLAR LUNG DISEASES,,Relative Weights,"$7,901.68 ",IP,"7,901.68","7,901.68",,,,,,
Humana Medicaid,DRG,1431,OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$2,504.69 ",IP,"2,504.69","2,504.69",,,,,,
Humana Medicaid,DRG,1432,OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$3,509.11 ",IP,"3,509.11","3,509.11",,,,,,
Humana Medicaid,DRG,1433,OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$5,145.11 ",IP,"5,145.11","5,145.11",,,,,,
Humana Medicaid,DRG,1434,OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$8,358.70 ",IP,"8,358.70","8,358.70",,,,,,
Humana Medicaid,DRG,1441,"RESPIRATORY SIGNS, SYMPTOMS & MINOR DIAGNOSES",,Relative Weights,"$2,636.99 ",IP,"2,636.99","2,636.99",,,,,,
Humana Medicaid,DRG,1442,RESPIRATORY SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$3,405.68 ",IP,"3,405.68","3,405.68",,,,,,
Humana Medicaid,DRG,1443,RESPIRATORY SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$4,454.42 ",IP,"4,454.42","4,454.42",,,,,,
Humana Medicaid,DRG,1444,RESPIRATORY SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$7,998.24 ",IP,"7,998.24","7,998.24",,,,,,
Humana Medicaid,DRG,1451,ACUTE BRONCHITIS AND RELATED SYMPTOMS,,Relative Weights,"$2,478.23 ",IP,"2,478.23","2,478.23",,,,,,
Humana Medicaid,DRG,1452,ACUTE BRONCHITIS AND RELATED SYMPTOMS,,Relative Weights,"$2,974.43 ",IP,"2,974.43","2,974.43",,,,,,
Humana Medicaid,DRG,1453,ACUTE BRONCHITIS AND RELATED SYMPTOMS,,Relative Weights,"$3,820.09 ",IP,"3,820.09","3,820.09",,,,,,
Humana Medicaid,DRG,1454,ACUTE BRONCHITIS AND RELATED SYMPTOMS,,Relative Weights,"$6,746.07 ",IP,"6,746.07","6,746.07",,,,,,
Humana Medicaid,DRG,1601,MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,,Relative Weights,"$19,007.33 ",IP,"19,007.33","19,007.33",,,,,,
Humana Medicaid,DRG,1602,MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,,Relative Weights,"$21,418.55 ",IP,"21,418.55","21,418.55",,,,,,
Humana Medicaid,DRG,1603,MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,,Relative Weights,"$29,897.52 ",IP,"29,897.52","29,897.52",,,,,,
Humana Medicaid,DRG,1604,MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,,Relative Weights,"$58,616.75 ",IP,"58,616.75","58,616.75",,,,,,
Humana Medicaid,DRG,1611,CARDIAC DEFIBRILLATOR and HEART ASSIST IMPLANT,,Relative Weights,"$21,623.70 ",IP,"21,623.70","21,623.70",,,,,,
Humana Medicaid,DRG,1612,CARDIAC DEFIBRILLATOR and HEART ASSIST IMPLANT,,Relative Weights,"$25,324.21 ",IP,"25,324.21","25,324.21",,,,,,
Humana Medicaid,DRG,1613,CARDIAC DEFIBRILLATOR and HEART ASSIST IMPLANT,,Relative Weights,"$37,168.99 ",IP,"37,168.99","37,168.99",,,,,,
Humana Medicaid,DRG,1614,CARDIAC DEFIBRILLATOR and HEART ASSIST IMPLANT,,Relative Weights,"$84,952.59 ",IP,"84,952.59","84,952.59",,,,,,
Humana Medicaid,DRG,1621,CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX,,Relative Weights,"$21,734.00 ",IP,"21,734.00","21,734.00",,,,,,
Humana Medicaid,DRG,1622,CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX,,Relative Weights,"$25,647.21 ",IP,"25,647.21","25,647.21",,,,,,
Humana Medicaid,DRG,1623,CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX,,Relative Weights,"$32,557.19 ",IP,"32,557.19","32,557.19",,,,,,
Humana Medicaid,DRG,1624,CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX,,Relative Weights,"$51,493.39 ",IP,"51,493.39","51,493.39",,,,,,
Humana Medicaid,DRG,1631,CARDIAC VALVE PROCEDURES WO AMI OR COMPLEX PDX,,Relative Weights,"$18,870.57 ",IP,"18,870.57","18,870.57",,,,,,
Humana Medicaid,DRG,1632,CARDIAC VALVE PROCEDURES WO AMI OR COMPLEX PDX,,Relative Weights,"$20,678.38 ",IP,"20,678.38","20,678.38",,,,,,
Humana Medicaid,DRG,1633,CARDIAC VALVE PROCEDURES WO AMI OR COMPLEX PDX,,Relative Weights,"$25,441.73 ",IP,"25,441.73","25,441.73",,,,,,
Humana Medicaid,DRG,1634,CARDIAC VALVE PROCEDURES WO AMI OR COMPLEX PDX,,Relative Weights,"$42,290.40 ",IP,"42,290.40","42,290.40",,,,,,
Humana Medicaid,DRG,1651,CORONARY BYPASS W AMI OR COMPLEX PDX,,Relative Weights,"$17,424.93 ",IP,"17,424.93","17,424.93",,,,,,
Humana Medicaid,DRG,1652,CORONARY BYPASS W AMI OR COMPLEX PDX,,Relative Weights,"$20,592.13 ",IP,"20,592.13","20,592.13",,,,,,
Humana Medicaid,DRG,1653,CORONARY BYPASS W AMI OR COMPLEX PDX,,Relative Weights,"$24,876.46 ",IP,"24,876.46","24,876.46",,,,,,
Humana Medicaid,DRG,1654,CORONARY BYPASS W AMI OR COMPLEX PDX,,Relative Weights,"$37,414.00 ",IP,"37,414.00","37,414.00",,,,,,
Humana Medicaid,DRG,1661,CORONARY BYPASS W/O AMI OR COMPLEX PDX,,Relative Weights,"$16,087.19 ",IP,"16,087.19","16,087.19",,,,,,
Humana Medicaid,DRG,1662,CORONARY BYPASS WO AMI OR COMPLEX PDX,,Relative Weights,"$17,173.40 ",IP,"17,173.40","17,173.40",,,,,,
Humana Medicaid,DRG,1663,CORONARY BYPASS WO AMI OR COMPLEX PDX,,Relative Weights,"$20,743.67 ",IP,"20,743.67","20,743.67",,,,,,
Humana Medicaid,DRG,1664,CORONARY BYPASS WO AMI OR COMPLEX PDX,,Relative Weights,"$33,503.88 ",IP,"33,503.88","33,503.88",,,,,,
Humana Medicaid,DRG,1671,OTHER CARDIOTHORACIC and THORACIC VASCULAR PROCEDURES,,Relative Weights,"$15,753.88 ",IP,"15,753.88","15,753.88",,,,,,
Humana Medicaid,DRG,1672,OTHER CARDIOTHORACIC & THORACIC VASCULAR PROCEDURES,,Relative Weights,"$16,654.52 ",IP,"16,654.52","16,654.52",,,,,,
Humana Medicaid,DRG,1673,OTHER CARDIOTHORACIC & THORACIC VASCULAR PROCEDURES,,Relative Weights,"$20,943.66 ",IP,"20,943.66","20,943.66",,,,,,
Humana Medicaid,DRG,1674,OTHER CARDIOTHORACIC and THORACIC VASCULAR PROCEDURES,,Relative Weights,"$39,564.41 ",IP,"39,564.41","39,564.41",,,,,,
Humana Medicaid,DRG,1691,MAJOR ABDOMINAL VASCULAR PROCEDURES,,Relative Weights,"$9,314.67 ",IP,"9,314.67","9,314.67",,,,,,
Humana Medicaid,DRG,1692,MAJOR ABDOMINAL VASCULAR PROCEDURES,,Relative Weights,"$12,244.08 ",IP,"12,244.08","12,244.08",,,,,,
Humana Medicaid,DRG,1693,MAJOR ABDOMINAL VASCULAR PROCEDURES,,Relative Weights,"$19,456.45 ",IP,"19,456.45","19,456.45",,,,,,
Humana Medicaid,DRG,1694,MAJOR ABDOMINAL VASCULAR PROCEDURES,,Relative Weights,"$33,906.95 ",IP,"33,906.95","33,906.95",,,,,,
Humana Medicaid,DRG,1701,PERMANENT CARDIAC PACEMAKER IMPLANT W AMI HEART FAILURE OR SHOCK,,Relative Weights,"$10,265.14 ",IP,"10,265.14","10,265.14",,,,,,
Humana Medicaid,DRG,1702,PERMANENT CARDIAC PACEMAKER IMPLANT W AMI HEART FAILURE OR SHOCK,,Relative Weights,"$10,949.99 ",IP,"10,949.99","10,949.99",,,,,,
Humana Medicaid,DRG,1703,PERMANENT CARDIAC PACEMAKER IMPLANT W AMI HEART FAILURE OR SHOCK,,Relative Weights,"$13,975.61 ",IP,"13,975.61","13,975.61",,,,,,
Humana Medicaid,DRG,1704,"PERMANENT CARDIAC PACEMAKER IMPLANT W AMI, HEART FAILURE OR SHOCK",,Relative Weights,"$19,895.26 ",IP,"19,895.26","19,895.26",,,,,,
Humana Medicaid,DRG,1711,PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK,,Relative Weights,"$8,272.45 ",IP,"8,272.45","8,272.45",,,,,,
Humana Medicaid,DRG,1712,PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK,,Relative Weights,"$9,180.66 ",IP,"9,180.66","9,180.66",,,,,,
Humana Medicaid,DRG,1713,PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK,,Relative Weights,"$10,971.29 ",IP,"10,971.29","10,971.29",,,,,,
Humana Medicaid,DRG,1714,PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK,,Relative Weights,"$17,965.80 ",IP,"17,965.80","17,965.80",,,,,,
Humana Medicaid,DRG,1741,PERCUTANEOUS CORONARY INTERVENTION W AMI,,Relative Weights,"$9,597.47 ",IP,"9,597.47","9,597.47",,,,,,
Humana Medicaid,DRG,1742,PERCUTANEOUS CORONARY INTERVENTION W AMI,,Relative Weights,"$10,364.10 ",IP,"10,364.10","10,364.10",,,,,,
Humana Medicaid,DRG,1743,PERCUTANEOUS CORONARY INTERVENTION W AMI,,Relative Weights,"$12,874.29 ",IP,"12,874.29","12,874.29",,,,,,
Humana Medicaid,DRG,1744,PERCUTANEOUS CORONARY INTERVENTION W AMI,,Relative Weights,"$19,364.01 ",IP,"19,364.01","19,364.01",,,,,,
Humana Medicaid,DRG,1751,PERCUTANEOUS CORONARY INTERVENTION WO AMI,,Relative Weights,"$11,256.84 ",IP,"11,256.84","11,256.84",,,,,,
Humana Medicaid,DRG,1752,PERCUTANEOUS CORONARY INTERVENTION WO AMI,,Relative Weights,"$12,009.39 ",IP,"12,009.39","12,009.39",,,,,,
Humana Medicaid,DRG,1753,PERCUTANEOUS CORONARY INTERVENTION WO AMI,,Relative Weights,"$14,253.95 ",IP,"14,253.95","14,253.95",,,,,,
Humana Medicaid,DRG,1754,PERCUTANEOUS CORONARY INTERVENTION WO AMI,,Relative Weights,"$25,147.58 ",IP,"25,147.58","25,147.58",,,,,,
Humana Medicaid,DRG,1761,CARDIAC PACEMAKER and DEFIBRILLATOR DEVICE REPLACEMENT,,Relative Weights,"$9,268.97 ",IP,"9,268.97","9,268.97",,,,,,
Humana Medicaid,DRG,1762,CARDIAC PACEMAKER and DEFIBRILLATOR DEVICE REPLACEMENT,,Relative Weights,"$10,537.63 ",IP,"10,537.63","10,537.63",,,,,,
Humana Medicaid,DRG,1763,CARDIAC PACEMAKER & DEFIBRILLATOR DEVICE REPLACEMENT,,Relative Weights,"$15,961.08 ",IP,"15,961.08","15,961.08",,,,,,
Humana Medicaid,DRG,1764,CARDIAC PACEMAKER and DEFIBRILLATOR DEVICE REPLACEMENT,,Relative Weights,"$25,961.29 ",IP,"25,961.29","25,961.29",,,,,,
Humana Medicaid,DRG,1771,CARDIAC PACEMAKER and DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,,Relative Weights,"$6,530.96 ",IP,"6,530.96","6,530.96",,,,,,
Humana Medicaid,DRG,1772,CARDIAC PACEMAKER and DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,,Relative Weights,"$9,029.80 ",IP,"9,029.80","9,029.80",,,,,,
Humana Medicaid,DRG,1773,CARDIAC PACEMAKER & DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,,Relative Weights,"$11,280.21 ",IP,"11,280.21","11,280.21",,,,,,
Humana Medicaid,DRG,1774,CARDIAC PACEMAKER & DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,,Relative Weights,"$17,033.20 ",IP,"17,033.20","17,033.20",,,,,,
Humana Medicaid,DRG,1801,OTHER CIRCULATORY SYSTEM PROCEDURES,,Relative Weights,"$6,351.58 ",IP,"6,351.58","6,351.58",,,,,,
Humana Medicaid,DRG,1802,OTHER CIRCULATORY SYSTEM PROCEDURES,,Relative Weights,"$7,715.78 ",IP,"7,715.78","7,715.78",,,,,,
Humana Medicaid,DRG,1803,OTHER CIRCULATORY SYSTEM PROCEDURES,,Relative Weights,"$10,872.33 ",IP,"10,872.33","10,872.33",,,,,,
Humana Medicaid,DRG,1804,OTHER CIRCULATORY SYSTEM PROCEDURES,,Relative Weights,"$20,062.95 ",IP,"20,062.95","20,062.95",,,,,,
Humana Medicaid,DRG,1811,LOWER EXTREMITY ARTERIAL PROCEDURES,,Relative Weights,"$9,268.28 ",IP,"9,268.28","9,268.28",,,,,,
Humana Medicaid,DRG,1812,LOWER EXTREMITY ARTERIAL PROCEDURES,,Relative Weights,"$11,438.97 ",IP,"11,438.97","11,438.97",,,,,,
Humana Medicaid,DRG,1813,LOWER EXTREMITY ARTERIAL PROCEDURES,,Relative Weights,"$16,303.68 ",IP,"16,303.68","16,303.68",,,,,,
Humana Medicaid,DRG,1814,LOWER EXTREMITY ARTERIAL PROCEDURES,,Relative Weights,"$27,105.22 ",IP,"27,105.22","27,105.22",,,,,,
Humana Medicaid,DRG,1821,OTHER PERIPHERAL VASCULAR PROCEDURES,,Relative Weights,"$9,585.79 ",IP,"9,585.79","9,585.79",,,,,,
Humana Medicaid,DRG,1822,OTHER PERIPHERAL VASCULAR PROCEDURES,,Relative Weights,"$11,451.68 ",IP,"11,451.68","11,451.68",,,,,,
Humana Medicaid,DRG,1823,OTHER PERIPHERAL VASCULAR PROCEDURES,,Relative Weights,"$12,966.73 ",IP,"12,966.73","12,966.73",,,,,,
Humana Medicaid,DRG,1824,OTHER PERIPHERAL VASCULAR PROCEDURES,,Relative Weights,"$25,526.94 ",IP,"25,526.94","25,526.94",,,,,,
Humana Medicaid,DRG,1901,ACUTE MYOCARDIAL INFARCTION,,Relative Weights,"$3,454.82 ",IP,"3,454.82","3,454.82",,,,,,
Humana Medicaid,DRG,1902,ACUTE MYOCARDIAL INFARCTION,,Relative Weights,"$4,023.17 ",IP,"4,023.17","4,023.17",,,,,,
Humana Medicaid,DRG,1903,ACUTE MYOCARDIAL INFARCTION,,Relative Weights,"$5,278.78 ",IP,"5,278.78","5,278.78",,,,,,
Humana Medicaid,DRG,1904,ACUTE MYOCARDIAL INFARCTION,,Relative Weights,"$8,568.66 ",IP,"8,568.66","8,568.66",,,,,,
Humana Medicaid,DRG,1911,CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,,Relative Weights,"$4,795.99 ",IP,"4,795.99","4,795.99",,,,,,
Humana Medicaid,DRG,1912,CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,,Relative Weights,"$5,349.23 ",IP,"5,349.23","5,349.23",,,,,,
Humana Medicaid,DRG,1913,CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,,Relative Weights,"$6,652.26 ",IP,"6,652.26","6,652.26",,,,,,
Humana Medicaid,DRG,1914,CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,,Relative Weights,"$10,568.22 ",IP,"10,568.22","10,568.22",,,,,,
Humana Medicaid,DRG,1921,CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS,,Relative Weights,"$5,126.56 ",IP,"5,126.56","5,126.56",,,,,,
Humana Medicaid,DRG,1922,CARDIAC CATHETERIZATION FOR OTHER NONCORONARY CONDITIONS,,Relative Weights,"$5,995.59 ",IP,"5,995.59","5,995.59",,,,,,
Humana Medicaid,DRG,1923,CARDIAC CATHETERIZATION FOR OTHER NONCORONARY CONDITIONS,,Relative Weights,"$8,192.04 ",IP,"8,192.04","8,192.04",,,,,,
Humana Medicaid,DRG,1924,CARDIAC CATHETERIZATION FOR OTHER NONCORONARY CONDITIONS,,Relative Weights,"$14,030.25 ",IP,"14,030.25","14,030.25",,,,,,
Humana Medicaid,DRG,1931,ACUTE & SUBACUTE ENDOCARDITIS,,Relative Weights,"$4,156.16 ",IP,"4,156.16","4,156.16",,,,,,
Humana Medicaid,DRG,1932,ACUTE & SUBACUTE ENDOCARDITIS,,Relative Weights,"$5,201.81 ",IP,"5,201.81","5,201.81",,,,,,
Humana Medicaid,DRG,1933,ACUTE and SUBACUTE ENDOCARDITIS,,Relative Weights,"$7,472.15 ",IP,"7,472.15","7,472.15",,,,,,
Humana Medicaid,DRG,1934,ACUTE and SUBACUTE ENDOCARDITIS,,Relative Weights,"$12,655.75 ",IP,"12,655.75","12,655.75",,,,,,
Humana Medicaid,DRG,1941,HEART FAILURE,,Relative Weights,"$2,590.60 ",IP,"2,590.60","2,590.60",,,,,,
Humana Medicaid,DRG,1942,HEART FAILURE,,Relative Weights,"$3,135.24 ",IP,"3,135.24","3,135.24",,,,,,
Humana Medicaid,DRG,1943,HEART FAILURE,,Relative Weights,"$4,368.86 ",IP,"4,368.86","4,368.86",,,,,,
Humana Medicaid,DRG,1944,HEART FAILURE,,Relative Weights,"$7,070.79 ",IP,"7,070.79","7,070.79",,,,,,
Humana Medicaid,DRG,1961,CARDIAC ARREST and SHOCK,,Relative Weights,"$2,365.52 ",IP,"2,365.52","2,365.52",,,,,,
Humana Medicaid,DRG,1962,CARDIAC ARREST and SHOCK,,Relative Weights,"$2,596.44 ",IP,"2,596.44","2,596.44",,,,,,
Humana Medicaid,DRG,1963,CARDIAC ARREST & SHOCK,,Relative Weights,"$4,010.12 ",IP,"4,010.12","4,010.12",,,,,,
Humana Medicaid,DRG,1964,CARDIAC ARREST & SHOCK,,Relative Weights,"$8,325.03 ",IP,"8,325.03","8,325.03",,,,,,
Humana Medicaid,DRG,1971,PERIPHERAL and OTHER VASCULAR DISORDERS,,Relative Weights,"$2,758.63 ",IP,"2,758.63","2,758.63",,,,,,
Humana Medicaid,DRG,1972,PERIPHERAL and OTHER VASCULAR DISORDERS,,Relative Weights,"$3,488.49 ",IP,"3,488.49","3,488.49",,,,,,
Humana Medicaid,DRG,1973,PERIPHERAL and OTHER VASCULAR DISORDERS,,Relative Weights,"$4,794.61 ",IP,"4,794.61","4,794.61",,,,,,
Humana Medicaid,DRG,1974,PERIPHERAL & OTHER VASCULAR DISORDERS,,Relative Weights,"$9,053.51 ",IP,"9,053.51","9,053.51",,,,,,
Humana Medicaid,DRG,1981,ANGINA PECTORIS & CORONARY ATHEROSCLEROSIS,,Relative Weights,"$2,680.28 ",IP,"2,680.28","2,680.28",,,,,,
Humana Medicaid,DRG,1982,ANGINA PECTORIS and CORONARY ATHEROSCLEROSIS,,Relative Weights,"$2,985.77 ",IP,"2,985.77","2,985.77",,,,,,
Humana Medicaid,DRG,1983,ANGINA PECTORIS and CORONARY ATHEROSCLEROSIS,,Relative Weights,"$3,628.00 ",IP,"3,628.00","3,628.00",,,,,,
Humana Medicaid,DRG,1984,ANGINA PECTORIS and CORONARY ATHEROSCLEROSIS,,Relative Weights,"$6,763.25 ",IP,"6,763.25","6,763.25",,,,,,
Humana Medicaid,DRG,1991,HYPERTENSION,,Relative Weights,"$2,662.41 ",IP,"2,662.41","2,662.41",,,,,,
Humana Medicaid,DRG,1992,HYPERTENSION,,Relative Weights,"$2,956.56 ",IP,"2,956.56","2,956.56",,,,,,
Humana Medicaid,DRG,1993,HYPERTENSION,,Relative Weights,"$3,736.93 ",IP,"3,736.93","3,736.93",,,,,,
Humana Medicaid,DRG,1994,HYPERTENSION,,Relative Weights,"$6,634.39 ",IP,"6,634.39","6,634.39",,,,,,
Humana Medicaid,DRG,2001,CARDIAC STRUCTURAL and VALVULAR DISORDERS,,Relative Weights,"$2,919.45 ",IP,"2,919.45","2,919.45",,,,,,
Humana Medicaid,DRG,2002,CARDIAC STRUCTURAL and VALVULAR DISORDERS,,Relative Weights,"$3,565.12 ",IP,"3,565.12","3,565.12",,,,,,
Humana Medicaid,DRG,2003,CARDIAC STRUCTURAL & VALVULAR DISORDERS,,Relative Weights,"$4,853.03 ",IP,"4,853.03","4,853.03",,,,,,
Humana Medicaid,DRG,2004,CARDIAC STRUCTURAL and VALVULAR DISORDERS,,Relative Weights,"$10,524.92 ",IP,"10,524.92","10,524.92",,,,,,
Humana Medicaid,DRG,2011,CARDIAC ARRHYTHMIA and CONDUCTION DISORDERS,,Relative Weights,"$2,322.91 ",IP,"2,322.91","2,322.91",,,,,,
Humana Medicaid,DRG,2012,CARDIAC ARRHYTHMIA and CONDUCTION DISORDERS,,Relative Weights,"$2,865.50 ",IP,"2,865.50","2,865.50",,,,,,
Humana Medicaid,DRG,2013,CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS,,Relative Weights,"$3,988.81 ",IP,"3,988.81","3,988.81",,,,,,
Humana Medicaid,DRG,2014,CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS,,Relative Weights,"$7,490.70 ",IP,"7,490.70","7,490.70",,,,,,
Humana Medicaid,DRG,2031,CHEST PAIN,,Relative Weights,"$2,896.08 ",IP,"2,896.08","2,896.08",,,,,,
Humana Medicaid,DRG,2032,CHEST PAIN,,Relative Weights,"$3,156.55 ",IP,"3,156.55","3,156.55",,,,,,
Humana Medicaid,DRG,2033,CHEST PAIN,,Relative Weights,"$3,647.25 ",IP,"3,647.25","3,647.25",,,,,,
Humana Medicaid,DRG,2034,CHEST PAIN,,Relative Weights,"$5,656.08 ",IP,"5,656.08","5,656.08",,,,,,
Humana Medicaid,DRG,2041,SYNCOPE and COLLAPSE,,Relative Weights,"$3,210.15 ",IP,"3,210.15","3,210.15",,,,,,
Humana Medicaid,DRG,2042,SYNCOPE and COLLAPSE,,Relative Weights,"$3,469.25 ",IP,"3,469.25","3,469.25",,,,,,
Humana Medicaid,DRG,2043,SYNCOPE and COLLAPSE,,Relative Weights,"$3,913.56 ",IP,"3,913.56","3,913.56",,,,,,
Humana Medicaid,DRG,2044,SYNCOPE and COLLAPSE,,Relative Weights,"$6,621.67 ",IP,"6,621.67","6,621.67",,,,,,
Humana Medicaid,DRG,2051,CARDIOMYOPATHY,,Relative Weights,"$3,094.70 ",IP,"3,094.70","3,094.70",,,,,,
Humana Medicaid,DRG,2052,CARDIOMYOPATHY,,Relative Weights,"$3,108.78 ",IP,"3,108.78","3,108.78",,,,,,
Humana Medicaid,DRG,2053,CARDIOMYOPATHY,,Relative Weights,"$4,834.47 ",IP,"4,834.47","4,834.47",,,,,,
Humana Medicaid,DRG,2054,CARDIOMYOPATHY,,Relative Weights,"$12,099.76 ",IP,"12,099.76","12,099.76",,,,,,
Humana Medicaid,DRG,2061,MALFUNCTIONREACTIONCOMPLICATION OF CARDIACVASC DEVICE OR PROCEDURE,,Relative Weights,"$3,915.62 ",IP,"3,915.62","3,915.62",,,,,,
Humana Medicaid,DRG,2062,MALFUNCTIONREACTIONCOMPLICATION OF CARDIACVASC DEVICE OR PROCEDURE,,Relative Weights,"$4,064.41 ",IP,"4,064.41","4,064.41",,,,,,
Humana Medicaid,DRG,2063,"MALFUNCTION,REACTION,COMPLICATION OF CARDIAC/VASC DEVICE OR PROCEDURE",,Relative Weights,"$5,616.22 ",IP,"5,616.22","5,616.22",,,,,,
Humana Medicaid,DRG,2064,MALFUNCTIONREACTIONCOMPLICATION OF CARDIACVASC DEVICE OR PROCEDURE,,Relative Weights,"$11,629.68 ",IP,"11,629.68","11,629.68",,,,,,
Humana Medicaid,DRG,2071,OTHER CIRCULATORY SYSTEM DIAGNOSES,,Relative Weights,"$2,947.97 ",IP,"2,947.97","2,947.97",,,,,,
Humana Medicaid,DRG,2072,OTHER CIRCULATORY SYSTEM DIAGNOSES,,Relative Weights,"$3,511.17 ",IP,"3,511.17","3,511.17",,,,,,
Humana Medicaid,DRG,2073,OTHER CIRCULATORY SYSTEM DIAGNOSES,,Relative Weights,"$4,590.50 ",IP,"4,590.50","4,590.50",,,,,,
Humana Medicaid,DRG,2074,OTHER CIRCULATORY SYSTEM DIAGNOSES,,Relative Weights,"$8,837.72 ",IP,"8,837.72","8,837.72",,,,,,
Humana Medicaid,DRG,2201,MAJOR STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$7,004.47 ",IP,"7,004.47","7,004.47",,,,,,
Humana Medicaid,DRG,2202,MAJOR STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$10,124.94 ",IP,"10,124.94","10,124.94",,,,,,
Humana Medicaid,DRG,2203,MAJOR STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$15,446.33 ",IP,"15,446.33","15,446.33",,,,,,
Humana Medicaid,DRG,2204,MAJOR STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$29,728.80 ",IP,"29,728.80","29,728.80",,,,,,
Humana Medicaid,DRG,2221,OTHER STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$3,629.38 ",IP,"3,629.38","3,629.38",,,,,,
Humana Medicaid,DRG,2222,OTHER STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$5,962.94 ",IP,"5,962.94","5,962.94",,,,,,
Humana Medicaid,DRG,2223,OTHER STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$9,116.74 ",IP,"9,116.74","9,116.74",,,,,,
Humana Medicaid,DRG,2224,"OTHER STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES",,Relative Weights,"$19,946.46 ",IP,"19,946.46","19,946.46",,,,,,
Humana Medicaid,DRG,2231,OTHER SMALL & LARGE BOWEL PROCEDURES,,Relative Weights,"$5,180.51 ",IP,"5,180.51","5,180.51",,,,,,
Humana Medicaid,DRG,2232,OTHER SMALL and LARGE BOWEL PROCEDURES,,Relative Weights,"$7,107.90 ",IP,"7,107.90","7,107.90",,,,,,
Humana Medicaid,DRG,2233,OTHER SMALL and LARGE BOWEL PROCEDURES,,Relative Weights,"$10,759.27 ",IP,"10,759.27","10,759.27",,,,,,
Humana Medicaid,DRG,2234,OTHER SMALL and LARGE BOWEL PROCEDURES,,Relative Weights,"$20,449.53 ",IP,"20,449.53","20,449.53",,,,,,
Humana Medicaid,DRG,2241,PERITONEAL ADHESIOLYSIS,,Relative Weights,"$6,143.69 ",IP,"6,143.69","6,143.69",,,,,,
Humana Medicaid,DRG,2242,PERITONEAL ADHESIOLYSIS,,Relative Weights,"$7,746.36 ",IP,"7,746.36","7,746.36",,,,,,
Humana Medicaid,DRG,2243,PERITONEAL ADHESIOLYSIS,,Relative Weights,"$11,242.41 ",IP,"11,242.41","11,242.41",,,,,,
Humana Medicaid,DRG,2244,PERITONEAL ADHESIOLYSIS,,Relative Weights,"$20,422.04 ",IP,"20,422.04","20,422.04",,,,,,
Humana Medicaid,DRG,2261,ANAL PROCEDURES,,Relative Weights,"$4,263.71 ",IP,"4,263.71","4,263.71",,,,,,
Humana Medicaid,DRG,2262,ANAL PROCEDURES,,Relative Weights,"$5,861.92 ",IP,"5,861.92","5,861.92",,,,,,
Humana Medicaid,DRG,2263,ANAL PROCEDURES,,Relative Weights,"$7,950.47 ",IP,"7,950.47","7,950.47",,,,,,
Humana Medicaid,DRG,2264,ANAL PROCEDURES,,Relative Weights,"$17,017.73 ",IP,"17,017.73","17,017.73",,,,,,
Humana Medicaid,DRG,2271,HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL and UMBILICAL,,Relative Weights,"$5,689.07 ",IP,"5,689.07","5,689.07",,,,,,
Humana Medicaid,DRG,2272,HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL and UMBILICAL,,Relative Weights,"$6,795.89 ",IP,"6,795.89","6,795.89",,,,,,
Humana Medicaid,DRG,2273,"HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL & UMBILICAL",,Relative Weights,"$10,114.97 ",IP,"10,114.97","10,114.97",,,,,,
Humana Medicaid,DRG,2274,"HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL & UMBILICAL",,Relative Weights,"$20,038.21 ",IP,"20,038.21","20,038.21",,,,,,
Humana Medicaid,DRG,2281,INGUINAL FEMORAL and UMBILICAL HERNIA PROCEDURES,,Relative Weights,"$4,335.53 ",IP,"4,335.53","4,335.53",,,,,,
Humana Medicaid,DRG,2282,INGUINAL FEMORAL and UMBILICAL HERNIA PROCEDURES,,Relative Weights,"$5,502.48 ",IP,"5,502.48","5,502.48",,,,,,
Humana Medicaid,DRG,2283,INGUINAL FEMORAL and UMBILICAL HERNIA PROCEDURES,,Relative Weights,"$7,788.28 ",IP,"7,788.28","7,788.28",,,,,,
Humana Medicaid,DRG,2284,"INGUINAL, FEMORAL & UMBILICAL HERNIA PROCEDURES",,Relative Weights,"$16,501.95 ",IP,"16,501.95","16,501.95",,,,,,
Humana Medicaid,DRG,2291,OTHER DIGESTIVE SYSTEM & ABDOMINAL PROCEDURES,,Relative Weights,"$5,564.34 ",IP,"5,564.34","5,564.34",,,,,,
Humana Medicaid,DRG,2292,OTHER DIGESTIVE SYSTEM and ABDOMINAL PROCEDURES,,Relative Weights,"$7,117.87 ",IP,"7,117.87","7,117.87",,,,,,
Humana Medicaid,DRG,2293,OTHER DIGESTIVE SYSTEM and ABDOMINAL PROCEDURES,,Relative Weights,"$10,259.30 ",IP,"10,259.30","10,259.30",,,,,,
Humana Medicaid,DRG,2294,OTHER DIGESTIVE SYSTEM and ABDOMINAL PROCEDURES,,Relative Weights,"$20,018.28 ",IP,"20,018.28","20,018.28",,,,,,
Humana Medicaid,DRG,2301,MAJOR SMALL BOWEL PROCEDURES,,Relative Weights,"$6,770.12 ",IP,"6,770.12","6,770.12",,,,,,
Humana Medicaid,DRG,2302,MAJOR SMALL BOWEL PROCEDURES,,Relative Weights,"$8,787.20 ",IP,"8,787.20","8,787.20",,,,,,
Humana Medicaid,DRG,2303,MAJOR SMALL BOWEL PROCEDURES,,Relative Weights,"$13,506.56 ",IP,"13,506.56","13,506.56",,,,,,
Humana Medicaid,DRG,2304,MAJOR SMALL BOWEL PROCEDURES,,Relative Weights,"$27,168.10 ",IP,"27,168.10","27,168.10",,,,,,
Humana Medicaid,DRG,2311,MAJOR LARGE BOWEL PROCEDURES,,Relative Weights,"$6,900.01 ",IP,"6,900.01","6,900.01",,,,,,
Humana Medicaid,DRG,2312,MAJOR LARGE BOWEL PROCEDURES,,Relative Weights,"$8,451.83 ",IP,"8,451.83","8,451.83",,,,,,
Humana Medicaid,DRG,2313,MAJOR LARGE BOWEL PROCEDURES,,Relative Weights,"$12,656.43 ",IP,"12,656.43","12,656.43",,,,,,
Humana Medicaid,DRG,2314,MAJOR LARGE BOWEL PROCEDURES,,Relative Weights,"$23,212.62 ",IP,"23,212.62","23,212.62",,,,,,
Humana Medicaid,DRG,2321,GASTRIC FUNDOPLICATION,,Relative Weights,"$5,317.96 ",IP,"5,317.96","5,317.96",,,,,,
Humana Medicaid,DRG,2322,GASTRIC FUNDOPLICATION,,Relative Weights,"$6,619.27 ",IP,"6,619.27","6,619.27",,,,,,
Humana Medicaid,DRG,2323,GASTRIC FUNDOPLICATION,,Relative Weights,"$9,668.60 ",IP,"9,668.60","9,668.60",,,,,,
Humana Medicaid,DRG,2324,GASTRIC FUNDOPLICATION,,Relative Weights,"$26,510.06 ",IP,"26,510.06","26,510.06",,,,,,
Humana Medicaid,DRG,2331,APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$5,328.61 ",IP,"5,328.61","5,328.61",,,,,,
Humana Medicaid,DRG,2332,APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$6,525.46 ",IP,"6,525.46","6,525.46",,,,,,
Humana Medicaid,DRG,2333,APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$9,426.35 ",IP,"9,426.35","9,426.35",,,,,,
Humana Medicaid,DRG,2334,APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$16,969.28 ",IP,"16,969.28","16,969.28",,,,,,
Humana Medicaid,DRG,2341,APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$3,837.96 ",IP,"3,837.96","3,837.96",,,,,,
Humana Medicaid,DRG,2342,APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$4,853.72 ",IP,"4,853.72","4,853.72",,,,,,
Humana Medicaid,DRG,2343,APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$7,767.67 ",IP,"7,767.67","7,767.67",,,,,,
Humana Medicaid,DRG,2344,APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$15,153.91 ",IP,"15,153.91","15,153.91",,,,,,
Humana Medicaid,DRG,2401,DIGESTIVE MALIGNANCY,,Relative Weights,"$4,130.38 ",IP,"4,130.38","4,130.38",,,,,,
Humana Medicaid,DRG,2402,DIGESTIVE MALIGNANCY,,Relative Weights,"$4,471.61 ",IP,"4,471.61","4,471.61",,,,,,
Humana Medicaid,DRG,2403,DIGESTIVE MALIGNANCY,,Relative Weights,"$5,940.95 ",IP,"5,940.95","5,940.95",,,,,,
Humana Medicaid,DRG,2404,DIGESTIVE MALIGNANCY,,Relative Weights,"$10,480.94 ",IP,"10,480.94","10,480.94",,,,,,
Humana Medicaid,DRG,2411,PEPTIC ULCER & GASTRITIS,,Relative Weights,"$3,142.46 ",IP,"3,142.46","3,142.46",,,,,,
Humana Medicaid,DRG,2412,PEPTIC ULCER and GASTRITIS,,Relative Weights,"$3,833.49 ",IP,"3,833.49","3,833.49",,,,,,
Humana Medicaid,DRG,2413,PEPTIC ULCER and GASTRITIS,,Relative Weights,"$5,293.90 ",IP,"5,293.90","5,293.90",,,,,,
Humana Medicaid,DRG,2414,PEPTIC ULCER and GASTRITIS,,Relative Weights,"$11,497.38 ",IP,"11,497.38","11,497.38",,,,,,
Humana Medicaid,DRG,2421,MAJOR ESOPHAGEAL DISORDERS,,Relative Weights,"$2,834.23 ",IP,"2,834.23","2,834.23",,,,,,
Humana Medicaid,DRG,2422,MAJOR ESOPHAGEAL DISORDERS,,Relative Weights,"$3,630.75 ",IP,"3,630.75","3,630.75",,,,,,
Humana Medicaid,DRG,2423,MAJOR ESOPHAGEAL DISORDERS,,Relative Weights,"$5,095.29 ",IP,"5,095.29","5,095.29",,,,,,
Humana Medicaid,DRG,2424,MAJOR ESOPHAGEAL DISORDERS,,Relative Weights,"$11,235.54 ",IP,"11,235.54","11,235.54",,,,,,
Humana Medicaid,DRG,2431,OTHER ESOPHAGEAL DISORDERS,,Relative Weights,"$2,619.12 ",IP,"2,619.12","2,619.12",,,,,,
Humana Medicaid,DRG,2432,OTHER ESOPHAGEAL DISORDERS,,Relative Weights,"$3,394.34 ",IP,"3,394.34","3,394.34",,,,,,
Humana Medicaid,DRG,2433,OTHER ESOPHAGEAL DISORDERS,,Relative Weights,"$4,672.28 ",IP,"4,672.28","4,672.28",,,,,,
Humana Medicaid,DRG,2434,OTHER ESOPHAGEAL DISORDERS,,Relative Weights,"$10,028.72 ",IP,"10,028.72","10,028.72",,,,,,
Humana Medicaid,DRG,2441,DIVERTICULITIS and DIVERTICULOSIS,,Relative Weights,"$2,541.46 ",IP,"2,541.46","2,541.46",,,,,,
Humana Medicaid,DRG,2442,DIVERTICULITIS and DIVERTICULOSIS,,Relative Weights,"$3,268.57 ",IP,"3,268.57","3,268.57",,,,,,
Humana Medicaid,DRG,2443,DIVERTICULITIS & DIVERTICULOSIS,,Relative Weights,"$4,670.91 ",IP,"4,670.91","4,670.91",,,,,,
Humana Medicaid,DRG,2444,DIVERTICULITIS & DIVERTICULOSIS,,Relative Weights,"$10,075.80 ",IP,"10,075.80","10,075.80",,,,,,
Humana Medicaid,DRG,2451,INFLAMMATORY BOWEL DISEASE,,Relative Weights,"$3,109.82 ",IP,"3,109.82","3,109.82",,,,,,
Humana Medicaid,DRG,2452,INFLAMMATORY BOWEL DISEASE,,Relative Weights,"$3,884.35 ",IP,"3,884.35","3,884.35",,,,,,
Humana Medicaid,DRG,2453,INFLAMMATORY BOWEL DISEASE,,Relative Weights,"$5,370.53 ",IP,"5,370.53","5,370.53",,,,,,
Humana Medicaid,DRG,2454,INFLAMMATORY BOWEL DISEASE,,Relative Weights,"$12,127.25 ",IP,"12,127.25","12,127.25",,,,,,
Humana Medicaid,DRG,2461,GASTROINTESTINAL VASCULAR INSUFFICIENCY,,Relative Weights,"$3,009.82 ",IP,"3,009.82","3,009.82",,,,,,
Humana Medicaid,DRG,2462,GASTROINTESTINAL VASCULAR INSUFFICIENCY,,Relative Weights,"$3,644.84 ",IP,"3,644.84","3,644.84",,,,,,
Humana Medicaid,DRG,2463,GASTROINTESTINAL VASCULAR INSUFFICIENCY,,Relative Weights,"$5,068.14 ",IP,"5,068.14","5,068.14",,,,,,
Humana Medicaid,DRG,2464,GASTROINTESTINAL VASCULAR INSUFFICIENCY,,Relative Weights,"$9,550.40 ",IP,"9,550.40","9,550.40",,,,,,
Humana Medicaid,DRG,2471,INTESTINAL OBSTRUCTION,,Relative Weights,"$2,323.60 ",IP,"2,323.60","2,323.60",,,,,,
Humana Medicaid,DRG,2472,INTESTINAL OBSTRUCTION,,Relative Weights,"$2,999.17 ",IP,"2,999.17","2,999.17",,,,,,
Humana Medicaid,DRG,2473,INTESTINAL OBSTRUCTION,,Relative Weights,"$4,431.74 ",IP,"4,431.74","4,431.74",,,,,,
Humana Medicaid,DRG,2474,INTESTINAL OBSTRUCTION,,Relative Weights,"$9,108.15 ",IP,"9,108.15","9,108.15",,,,,,
Humana Medicaid,DRG,2481,MAJOR GASTROINTESTINAL and PERITONEAL INFECTIONS,,Relative Weights,"$2,573.42 ",IP,"2,573.42","2,573.42",,,,,,
Humana Medicaid,DRG,2482,MAJOR GASTROINTESTINAL and PERITONEAL INFECTIONS,,Relative Weights,"$3,590.89 ",IP,"3,590.89","3,590.89",,,,,,
Humana Medicaid,DRG,2483,MAJOR GASTROINTESTINAL & PERITONEAL INFECTIONS,,Relative Weights,"$4,839.63 ",IP,"4,839.63","4,839.63",,,,,,
Humana Medicaid,DRG,2484,MAJOR GASTROINTESTINAL and PERITONEAL INFECTIONS,,Relative Weights,"$10,133.19 ",IP,"10,133.19","10,133.19",,,,,,
Humana Medicaid,DRG,2491,OTHER GASTROENTERITIS NAUSEA and VOMITING,,Relative Weights,"$2,187.52 ",IP,"2,187.52","2,187.52",,,,,,
Humana Medicaid,DRG,2492,OTHER GASTROENTERITIS NAUSEA and VOMITING,,Relative Weights,"$2,797.80 ",IP,"2,797.80","2,797.80",,,,,,
Humana Medicaid,DRG,2493,"OTHER GASTROENTERITIS, NAUSEA & VOMITING",,Relative Weights,"$3,754.80 ",IP,"3,754.80","3,754.80",,,,,,
Humana Medicaid,DRG,2494,"OTHER GASTROENTERITIS, NAUSEA & VOMITING",,Relative Weights,"$8,298.22 ",IP,"8,298.22","8,298.22",,,,,,
Humana Medicaid,DRG,2511,ABDOMINAL PAIN,,Relative Weights,"$2,520.84 ",IP,"2,520.84","2,520.84",,,,,,
Humana Medicaid,DRG,2512,ABDOMINAL PAIN,,Relative Weights,"$3,175.79 ",IP,"3,175.79","3,175.79",,,,,,
Humana Medicaid,DRG,2513,ABDOMINAL PAIN,,Relative Weights,"$4,112.86 ",IP,"4,112.86","4,112.86",,,,,,
Humana Medicaid,DRG,2514,ABDOMINAL PAIN,,Relative Weights,"$7,334.01 ",IP,"7,334.01","7,334.01",,,,,,
Humana Medicaid,DRG,2521,MALFUNCTION REACTION and COMPLICATION OF GI DEVICE OR PROCEDURE,,Relative Weights,"$2,913.26 ",IP,"2,913.26","2,913.26",,,,,,
Humana Medicaid,DRG,2522,MALFUNCTION REACTION and COMPLICATION OF GI DEVICE OR PROCEDURE,,Relative Weights,"$3,639.34 ",IP,"3,639.34","3,639.34",,,,,,
Humana Medicaid,DRG,2523,MALFUNCTION REACTION and COMPLICATION OF GI DEVICE OR PROCEDURE,,Relative Weights,"$5,172.60 ",IP,"5,172.60","5,172.60",,,,,,
Humana Medicaid,DRG,2524,MALFUNCTION REACTION and COMPLICATION OF GI DEVICE OR PROCEDURE,,Relative Weights,"$11,168.53 ",IP,"11,168.53","11,168.53",,,,,,
Humana Medicaid,DRG,2531,OTHER and UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,,Relative Weights,"$2,890.24 ",IP,"2,890.24","2,890.24",,,,,,
Humana Medicaid,DRG,2532,OTHER and UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,,Relative Weights,"$3,602.23 ",IP,"3,602.23","3,602.23",,,,,,
Humana Medicaid,DRG,2533,OTHER and UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,,Relative Weights,"$5,054.39 ",IP,"5,054.39","5,054.39",,,,,,
Humana Medicaid,DRG,2534,OTHER and UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,,Relative Weights,"$9,586.48 ",IP,"9,586.48","9,586.48",,,,,,
Humana Medicaid,DRG,2541,OTHER DIGESTIVE SYSTEM DIAGNOSES,,Relative Weights,"$2,614.99 ",IP,"2,614.99","2,614.99",,,,,,
Humana Medicaid,DRG,2542,OTHER DIGESTIVE SYSTEM DIAGNOSES,,Relative Weights,"$3,386.43 ",IP,"3,386.43","3,386.43",,,,,,
Humana Medicaid,DRG,2543,OTHER DIGESTIVE SYSTEM DIAGNOSES,,Relative Weights,"$4,771.93 ",IP,"4,771.93","4,771.93",,,,,,
Humana Medicaid,DRG,2544,OTHER DIGESTIVE SYSTEM DIAGNOSES,,Relative Weights,"$9,778.91 ",IP,"9,778.91","9,778.91",,,,,,
Humana Medicaid,DRG,2601,MAJOR PANCREAS LIVER and SHUNT PROCEDURES,,Relative Weights,"$9,438.72 ",IP,"9,438.72","9,438.72",,,,,,
Humana Medicaid,DRG,2602,MAJOR PANCREAS LIVER and SHUNT PROCEDURES,,Relative Weights,"$11,500.13 ",IP,"11,500.13","11,500.13",,,,,,
Humana Medicaid,DRG,2603,MAJOR PANCREAS LIVER and SHUNT PROCEDURES,,Relative Weights,"$16,312.61 ",IP,"16,312.61","16,312.61",,,,,,
Humana Medicaid,DRG,2604,MAJOR PANCREAS LIVER and SHUNT PROCEDURES,,Relative Weights,"$34,324.11 ",IP,"34,324.11","34,324.11",,,,,,
Humana Medicaid,DRG,2611,MAJOR BILIARY TRACT PROCEDURES,,Relative Weights,"$6,801.05 ",IP,"6,801.05","6,801.05",,,,,,
Humana Medicaid,DRG,2612,MAJOR BILIARY TRACT PROCEDURES,,Relative Weights,"$10,119.10 ",IP,"10,119.10","10,119.10",,,,,,
Humana Medicaid,DRG,2613,MAJOR BILIARY TRACT PROCEDURES,,Relative Weights,"$14,491.05 ",IP,"14,491.05","14,491.05",,,,,,
Humana Medicaid,DRG,2614,MAJOR BILIARY TRACT PROCEDURES,,Relative Weights,"$28,576.97 ",IP,"28,576.97","28,576.97",,,,,,
Humana Medicaid,DRG,2631,CHOLECYSTECTOMY,,Relative Weights,"$5,153.36 ",IP,"5,153.36","5,153.36",,,,,,
Humana Medicaid,DRG,2632,CHOLECYSTECTOMY,,Relative Weights,"$6,574.60 ",IP,"6,574.60","6,574.60",,,,,,
Humana Medicaid,DRG,2633,CHOLECYSTECTOMY,,Relative Weights,"$8,823.28 ",IP,"8,823.28","8,823.28",,,,,,
Humana Medicaid,DRG,2634,CHOLECYSTECTOMY,,Relative Weights,"$16,983.37 ",IP,"16,983.37","16,983.37",,,,,,
Humana Medicaid,DRG,2641,OTHER HEPATOBILIARY PANCREAS and ABDOMINAL PROCEDURES,,Relative Weights,"$6,826.47 ",IP,"6,826.47","6,826.47",,,,,,
Humana Medicaid,DRG,2642,OTHER HEPATOBILIARY PANCREAS and ABDOMINAL PROCEDURES,,Relative Weights,"$7,584.86 ",IP,"7,584.86","7,584.86",,,,,,
Humana Medicaid,DRG,2643,"OTHER HEPATOBILIARY, PANCREAS & ABDOMINAL PROCEDURES",,Relative Weights,"$11,612.15 ",IP,"11,612.15","11,612.15",,,,,,
Humana Medicaid,DRG,2644,OTHER HEPATOBILIARY PANCREAS and ABDOMINAL PROCEDURES,,Relative Weights,"$29,218.86 ",IP,"29,218.86","29,218.86",,,,,,
Humana Medicaid,DRG,2791,HEPATIC COMA and OTHER MAJOR ACUTE LIVER DISORDERS,,Relative Weights,"$2,567.92 ",IP,"2,567.92","2,567.92",,,,,,
Humana Medicaid,DRG,2792,HEPATIC COMA and OTHER MAJOR ACUTE LIVER DISORDERS,,Relative Weights,"$3,323.89 ",IP,"3,323.89","3,323.89",,,,,,
Humana Medicaid,DRG,2793,HEPATIC COMA & OTHER MAJOR ACUTE LIVER DISORDERS,,Relative Weights,"$4,704.93 ",IP,"4,704.93","4,704.93",,,,,,
Humana Medicaid,DRG,2794,HEPATIC COMA and OTHER MAJOR ACUTE LIVER DISORDERS,,Relative Weights,"$11,290.86 ",IP,"11,290.86","11,290.86",,,,,,
Humana Medicaid,DRG,2801,ALCOHOLIC LIVER DISEASE,,Relative Weights,"$2,499.54 ",IP,"2,499.54","2,499.54",,,,,,
Humana Medicaid,DRG,2802,ALCOHOLIC LIVER DISEASE,,Relative Weights,"$3,093.32 ",IP,"3,093.32","3,093.32",,,,,,
Humana Medicaid,DRG,2803,ALCOHOLIC LIVER DISEASE,,Relative Weights,"$4,638.26 ",IP,"4,638.26","4,638.26",,,,,,
Humana Medicaid,DRG,2804,ALCOHOLIC LIVER DISEASE,,Relative Weights,"$10,324.24 ",IP,"10,324.24","10,324.24",,,,,,
Humana Medicaid,DRG,2811,MALIGNANCY OF HEPATOBILIARY SYSTEM & PANCREAS,,Relative Weights,"$3,619.41 ",IP,"3,619.41","3,619.41",,,,,,
Humana Medicaid,DRG,2812,MALIGNANCY OF HEPATOBILIARY SYSTEM and PANCREAS,,Relative Weights,"$4,564.04 ",IP,"4,564.04","4,564.04",,,,,,
Humana Medicaid,DRG,2813,MALIGNANCY OF HEPATOBILIARY SYSTEM and PANCREAS,,Relative Weights,"$5,844.73 ",IP,"5,844.73","5,844.73",,,,,,
Humana Medicaid,DRG,2814,MALIGNANCY OF HEPATOBILIARY SYSTEM and PANCREAS,,Relative Weights,"$9,186.50 ",IP,"9,186.50","9,186.50",,,,,,
Humana Medicaid,DRG,2821,DISORDERS OF PANCREAS EXCEPT MALIGNANCY,,Relative Weights,"$2,462.42 ",IP,"2,462.42","2,462.42",,,,,,
Humana Medicaid,DRG,2822,DISORDERS OF PANCREAS EXCEPT MALIGNANCY,,Relative Weights,"$3,135.24 ",IP,"3,135.24","3,135.24",,,,,,
Humana Medicaid,DRG,2823,DISORDERS OF PANCREAS EXCEPT MALIGNANCY,,Relative Weights,"$4,746.16 ",IP,"4,746.16","4,746.16",,,,,,
Humana Medicaid,DRG,2824,DISORDERS OF PANCREAS EXCEPT MALIGNANCY,,Relative Weights,"$12,503.18 ",IP,"12,503.18","12,503.18",,,,,,
Humana Medicaid,DRG,2831,OTHER DISORDERS OF THE LIVER,,Relative Weights,"$2,720.83 ",IP,"2,720.83","2,720.83",,,,,,
Humana Medicaid,DRG,2832,OTHER DISORDERS OF THE LIVER,,Relative Weights,"$3,349.67 ",IP,"3,349.67","3,349.67",,,,,,
Humana Medicaid,DRG,2833,OTHER DISORDERS OF THE LIVER,,Relative Weights,"$4,885.67 ",IP,"4,885.67","4,885.67",,,,,,
Humana Medicaid,DRG,2834,OTHER DISORDERS OF THE LIVER,,Relative Weights,"$10,248.65 ",IP,"10,248.65","10,248.65",,,,,,
Humana Medicaid,DRG,2841,DISORDERS OF GALLBLADDER and BILIARY TRACT,,Relative Weights,"$3,351.73 ",IP,"3,351.73","3,351.73",,,,,,
Humana Medicaid,DRG,2842,DISORDERS OF GALLBLADDER and BILIARY TRACT,,Relative Weights,"$4,147.57 ",IP,"4,147.57","4,147.57",,,,,,
Humana Medicaid,DRG,2843,DISORDERS OF GALLBLADDER and BILIARY TRACT,,Relative Weights,"$5,552.31 ",IP,"5,552.31","5,552.31",,,,,,
Humana Medicaid,DRG,2844,DISORDERS OF GALLBLADDER and BILIARY TRACT,,Relative Weights,"$10,788.48 ",IP,"10,788.48","10,788.48",,,,,,
Humana Medicaid,DRG,3011,HIP JOINT REPLACEMENT,,Relative Weights,"$7,771.10 ",IP,"7,771.10","7,771.10",,,,,,
Humana Medicaid,DRG,3012,HIP JOINT REPLACEMENT,,Relative Weights,"$8,122.29 ",IP,"8,122.29","8,122.29",,,,,,
Humana Medicaid,DRG,3013,HIP JOINT REPLACEMENT,,Relative Weights,"$10,480.59 ",IP,"10,480.59","10,480.59",,,,,,
Humana Medicaid,DRG,3014,HIP JOINT REPLACEMENT,,Relative Weights,"$16,617.41 ",IP,"16,617.41","16,617.41",,,,,,
Humana Medicaid,DRG,3021,KNEE JOINT REPLACEMENT,,Relative Weights,"$7,208.24 ",IP,"7,208.24","7,208.24",,,,,,
Humana Medicaid,DRG,3022,KNEE JOINT REPLACEMENT,,Relative Weights,"$7,702.03 ",IP,"7,702.03","7,702.03",,,,,,
Humana Medicaid,DRG,3023,KNEE JOINT REPLACEMENT,,Relative Weights,"$9,864.13 ",IP,"9,864.13","9,864.13",,,,,,
Humana Medicaid,DRG,3024,KNEE JOINT REPLACEMENT,,Relative Weights,"$17,075.12 ",IP,"17,075.12","17,075.12",,,,,,
Humana Medicaid,DRG,3031,DORSAL and LUMBAR FUSION PROC FOR CURVATURE OF BACK,,Relative Weights,"$22,622.27 ",IP,"22,622.27","22,622.27",,,,,,
Humana Medicaid,DRG,3032,DORSAL and LUMBAR FUSION PROC FOR CURVATURE OF BACK,,Relative Weights,"$26,401.82 ",IP,"26,401.82","26,401.82",,,,,,
Humana Medicaid,DRG,3033,DORSAL and LUMBAR FUSION PROC FOR CURVATURE OF BACK,,Relative Weights,"$36,462.15 ",IP,"36,462.15","36,462.15",,,,,,
Humana Medicaid,DRG,3034,DORSAL and LUMBAR FUSION PROC FOR CURVATURE OF BACK,,Relative Weights,"$46,680.22 ",IP,"46,680.22","46,680.22",,,,,,
Humana Medicaid,DRG,3041,DORSAL and LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK,,Relative Weights,"$13,662.91 ",IP,"13,662.91","13,662.91",,,,,,
Humana Medicaid,DRG,3042,DORSAL and LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK,,Relative Weights,"$15,568.66 ",IP,"15,568.66","15,568.66",,,,,,
Humana Medicaid,DRG,3043,DORSAL and LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK,,Relative Weights,"$23,409.86 ",IP,"23,409.86","23,409.86",,,,,,
Humana Medicaid,DRG,3044,DORSAL and LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK,,Relative Weights,"$37,522.24 ",IP,"37,522.24","37,522.24",,,,,,
Humana Medicaid,DRG,3051,AMPUTATION OF LOWER LIMB EXCEPT TOES,,Relative Weights,"$4,866.09 ",IP,"4,866.09","4,866.09",,,,,,
Humana Medicaid,DRG,3052,AMPUTATION OF LOWER LIMB EXCEPT TOES,,Relative Weights,"$6,637.82 ",IP,"6,637.82","6,637.82",,,,,,
Humana Medicaid,DRG,3053,AMPUTATION OF LOWER LIMB EXCEPT TOES,,Relative Weights,"$10,080.61 ",IP,"10,080.61","10,080.61",,,,,,
Humana Medicaid,DRG,3054,AMPUTATION OF LOWER LIMB EXCEPT TOES,,Relative Weights,"$19,786.33 ",IP,"19,786.33","19,786.33",,,,,,
Humana Medicaid,DRG,3081,HIP and FEMUR FRACTURE REPAIR,,Relative Weights,"$6,633.70 ",IP,"6,633.70","6,633.70",,,,,,
Humana Medicaid,DRG,3082,HIP and FEMUR FRACTURE REPAIR,,Relative Weights,"$7,529.88 ",IP,"7,529.88","7,529.88",,,,,,
Humana Medicaid,DRG,3083,HIP & FEMUR FRACTURE REPAIR,,Relative Weights,"$9,249.72 ",IP,"9,249.72","9,249.72",,,,,,
Humana Medicaid,DRG,3084,HIP and FEMUR FRACTURE REPAIR,,Relative Weights,"$14,744.30 ",IP,"14,744.30","14,744.30",,,,,,
Humana Medicaid,DRG,3091,OTHER SIGNIFICANT HIP and FEMUR SURGERY,,Relative Weights,"$7,238.83 ",IP,"7,238.83","7,238.83",,,,,,
Humana Medicaid,DRG,3092,OTHER SIGNIFICANT HIP and FEMUR SURGERY,,Relative Weights,"$9,130.83 ",IP,"9,130.83","9,130.83",,,,,,
Humana Medicaid,DRG,3093,OTHER SIGNIFICANT HIP & FEMUR SURGERY,,Relative Weights,"$12,063.33 ",IP,"12,063.33","12,063.33",,,,,,
Humana Medicaid,DRG,3094,OTHER SIGNIFICANT HIP & FEMUR SURGERY,,Relative Weights,"$21,019.95 ",IP,"21,019.95","21,019.95",,,,,,
Humana Medicaid,DRG,3101,INTERVERTEBRAL DISC EXCISION and DECOMPRESSION,,Relative Weights,"$5,634.78 ",IP,"5,634.78","5,634.78",,,,,,
Humana Medicaid,DRG,3102,INTERVERTEBRAL DISC EXCISION and DECOMPRESSION,,Relative Weights,"$6,775.27 ",IP,"6,775.27","6,775.27",,,,,,
Humana Medicaid,DRG,3103,INTERVERTEBRAL DISC EXCISION and DECOMPRESSION,,Relative Weights,"$9,328.07 ",IP,"9,328.07","9,328.07",,,,,,
Humana Medicaid,DRG,3104,INTERVERTEBRAL DISC EXCISION & DECOMPRESSION,,Relative Weights,"$18,301.18 ",IP,"18,301.18","18,301.18",,,,,,
Humana Medicaid,DRG,3121,SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$6,515.49 ",IP,"6,515.49","6,515.49",,,,,,
Humana Medicaid,DRG,3122,SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$8,587.21 ",IP,"8,587.21","8,587.21",,,,,,
Humana Medicaid,DRG,3123,SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$12,636.50 ",IP,"12,636.50","12,636.50",,,,,,
Humana Medicaid,DRG,3124,SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$31,602.60 ",IP,"31,602.60","31,602.60",,,,,,
Humana Medicaid,DRG,3131,KNEE & LOWER LEG PROCEDURES EXCEPT FOOT,,Relative Weights,"$5,906.59 ",IP,"5,906.59","5,906.59",,,,,,
Humana Medicaid,DRG,3132,KNEE and LOWER LEG PROCEDURES EXCEPT FOOT,,Relative Weights,"$7,791.03 ",IP,"7,791.03","7,791.03",,,,,,
Humana Medicaid,DRG,3133,KNEE and LOWER LEG PROCEDURES EXCEPT FOOT,,Relative Weights,"$10,674.40 ",IP,"10,674.40","10,674.40",,,,,,
Humana Medicaid,DRG,3134,KNEE and LOWER LEG PROCEDURES EXCEPT FOOT,,Relative Weights,"$18,704.94 ",IP,"18,704.94","18,704.94",,,,,,
Humana Medicaid,DRG,3141,FOOT & TOE PROCEDURES,,Relative Weights,"$5,184.29 ",IP,"5,184.29","5,184.29",,,,,,
Humana Medicaid,DRG,3142,FOOT and TOE PROCEDURES,,Relative Weights,"$5,760.89 ",IP,"5,760.89","5,760.89",,,,,,
Humana Medicaid,DRG,3143,FOOT and TOE PROCEDURES,,Relative Weights,"$7,587.61 ",IP,"7,587.61","7,587.61",,,,,,
Humana Medicaid,DRG,3144,FOOT and TOE PROCEDURES,,Relative Weights,"$15,541.86 ",IP,"15,541.86","15,541.86",,,,,,
Humana Medicaid,DRG,3151,SHOULDER UPPER ARM and FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT,,Relative Weights,"$4,407.35 ",IP,"4,407.35","4,407.35",,,,,,
Humana Medicaid,DRG,3152,SHOULDER UPPER ARM and FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT,,Relative Weights,"$7,204.46 ",IP,"7,204.46","7,204.46",,,,,,
Humana Medicaid,DRG,3153,SHOULDER UPPER ARM and FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT,,Relative Weights,"$9,814.99 ",IP,"9,814.99","9,814.99",,,,,,
Humana Medicaid,DRG,3154,SHOULDER UPPER ARM and FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT,,Relative Weights,"$17,630.42 ",IP,"17,630.42","17,630.42",,,,,,
Humana Medicaid,DRG,3161,HAND and WRIST PROCEDURES,,Relative Weights,"$4,228.66 ",IP,"4,228.66","4,228.66",,,,,,
Humana Medicaid,DRG,3162,HAND and WRIST PROCEDURES,,Relative Weights,"$5,513.82 ",IP,"5,513.82","5,513.82",,,,,,
Humana Medicaid,DRG,3163,HAND and WRIST PROCEDURES,,Relative Weights,"$8,327.78 ",IP,"8,327.78","8,327.78",,,,,,
Humana Medicaid,DRG,3164,HAND and WRIST PROCEDURES,,Relative Weights,"$17,742.44 ",IP,"17,742.44","17,742.44",,,,,,
Humana Medicaid,DRG,3171,TENDON MUSCLE and OTHER SOFT TISSUE PROCEDURES,,Relative Weights,"$4,914.20 ",IP,"4,914.20","4,914.20",,,,,,
Humana Medicaid,DRG,3172,TENDON MUSCLE and OTHER SOFT TISSUE PROCEDURES,,Relative Weights,"$6,410.69 ",IP,"6,410.69","6,410.69",,,,,,
Humana Medicaid,DRG,3173,TENDON MUSCLE and OTHER SOFT TISSUE PROCEDURES,,Relative Weights,"$9,611.56 ",IP,"9,611.56","9,611.56",,,,,,
Humana Medicaid,DRG,3174,TENDON MUSCLE and OTHER SOFT TISSUE PROCEDURES,,Relative Weights,"$20,290.08 ",IP,"20,290.08","20,290.08",,,,,,
Humana Medicaid,DRG,3201,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE PROCEDURES,,Relative Weights,"$5,415.55 ",IP,"5,415.55","5,415.55",,,,,,
Humana Medicaid,DRG,3202,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE PROCEDURES,,Relative Weights,"$6,995.19 ",IP,"6,995.19","6,995.19",,,,,,
Humana Medicaid,DRG,3203,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE PROCEDURES,,Relative Weights,"$10,390.22 ",IP,"10,390.22","10,390.22",,,,,,
Humana Medicaid,DRG,3204,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE PROCEDURES,,Relative Weights,"$19,965.01 ",IP,"19,965.01","19,965.01",,,,,,
Humana Medicaid,DRG,3211,CERVICAL SPINAL FUSION and OTHER BACKNECK PROC EXC DISC EXCISDECOMP,,Relative Weights,"$8,441.17 ",IP,"8,441.17","8,441.17",,,,,,
Humana Medicaid,DRG,3212,CERVICAL SPINAL FUSION and OTHER BACKNECK PROC EXC DISC EXCISDECOMP,,Relative Weights,"$10,023.57 ",IP,"10,023.57","10,023.57",,,,,,
Humana Medicaid,DRG,3213,CERVICAL SPINAL FUSION and OTHER BACKNECK PROC EXC DISC EXCISDECOMP,,Relative Weights,"$14,027.50 ",IP,"14,027.50","14,027.50",,,,,,
Humana Medicaid,DRG,3214,CERVICAL SPINAL FUSION and OTHER BACKNECK PROC EXC DISC EXCISDECOMP,,Relative Weights,"$25,569.90 ",IP,"25,569.90","25,569.90",,,,,,
Humana Medicaid,DRG,3221,SHOULDER and ELBOW JOINT REPLACEMENT,,Relative Weights,"$8,466.60 ",IP,"8,466.60","8,466.60",,,,,,
Humana Medicaid,DRG,3222,SHOULDER and ELBOW JOINT REPLACEMENT,,Relative Weights,"$8,949.40 ",IP,"8,949.40","8,949.40",,,,,,
Humana Medicaid,DRG,3223,SHOULDER and ELBOW JOINT REPLACEMENT,,Relative Weights,"$11,526.59 ",IP,"11,526.59","11,526.59",,,,,,
Humana Medicaid,DRG,3224,SHOULDER and ELBOW JOINT REPLACEMENT,,Relative Weights,"$17,494.69 ",IP,"17,494.69","17,494.69",,,,,,
Humana Medicaid,DRG,3401,FRACTURE OF FEMUR,,Relative Weights,"$2,284.43 ",IP,"2,284.43","2,284.43",,,,,,
Humana Medicaid,DRG,3402,FRACTURE OF FEMUR,,Relative Weights,"$2,649.70 ",IP,"2,649.70","2,649.70",,,,,,
Humana Medicaid,DRG,3403,FRACTURE OF FEMUR,,Relative Weights,"$3,664.08 ",IP,"3,664.08","3,664.08",,,,,,
Humana Medicaid,DRG,3404,FRACTURE OF FEMUR,,Relative Weights,"$6,893.48 ",IP,"6,893.48","6,893.48",,,,,,
Humana Medicaid,DRG,3411,FRACTURE OF PELVIS OR DISLOCATION OF HIP,,Relative Weights,"$2,584.41 ",IP,"2,584.41","2,584.41",,,,,,
Humana Medicaid,DRG,3412,FRACTURE OF PELVIS OR DISLOCATION OF HIP,,Relative Weights,"$2,958.62 ",IP,"2,958.62","2,958.62",,,,,,
Humana Medicaid,DRG,3413,FRACTURE OF PELVIS OR DISLOCATION OF HIP,,Relative Weights,"$3,751.71 ",IP,"3,751.71","3,751.71",,,,,,
Humana Medicaid,DRG,3414,FRACTURE OF PELVIS OR DISLOCATION OF HIP,,Relative Weights,"$8,259.05 ",IP,"8,259.05","8,259.05",,,,,,
Humana Medicaid,DRG,3421,FRACTURES and DISLOCATIONS EXCEPT FEMUR PELVIS and BACK,,Relative Weights,"$2,677.53 ",IP,"2,677.53","2,677.53",,,,,,
Humana Medicaid,DRG,3422,"FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK",,Relative Weights,"$3,262.04 ",IP,"3,262.04","3,262.04",,,,,,
Humana Medicaid,DRG,3423,"FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK",,Relative Weights,"$4,236.57 ",IP,"4,236.57","4,236.57",,,,,,
Humana Medicaid,DRG,3424,FRACTURES and DISLOCATIONS EXCEPT FEMUR PELVIS and BACK,,Relative Weights,"$8,410.59 ",IP,"8,410.59","8,410.59",,,,,,
Humana Medicaid,DRG,3431,MUSCULOSKELETAL MALIGNANCY and PATHOL FRACTURE DT MUSCSKEL MALIG,,Relative Weights,"$4,528.30 ",IP,"4,528.30","4,528.30",,,,,,
Humana Medicaid,DRG,3432,MUSCULOSKELETAL MALIGNANCY and PATHOL FRACTURE DT MUSCSKEL MALIG,,Relative Weights,"$4,916.60 ",IP,"4,916.60","4,916.60",,,,,,
Humana Medicaid,DRG,3433,MUSCULOSKELETAL MALIGNANCY & PATHOL FRACTURE D/T MUSCSKEL MALIG,,Relative Weights,"$6,907.57 ",IP,"6,907.57","6,907.57",,,,,,
Humana Medicaid,DRG,3434,MUSCULOSKELETAL MALIGNANCY and PATHOL FRACTURE DT MUSCSKEL MALIG,,Relative Weights,"$11,710.09 ",IP,"11,710.09","11,710.09",,,,,,
Humana Medicaid,DRG,3441,OSTEOMYELITIS SEPTIC ARTHRITIS and OTHER MUSCULOSKELETAL INFECTIONS,,Relative Weights,"$3,603.61 ",IP,"3,603.61","3,603.61",,,,,,
Humana Medicaid,DRG,3442,OSTEOMYELITIS SEPTIC ARTHRITIS and OTHER MUSCULOSKELETAL INFECTIONS,,Relative Weights,"$4,272.99 ",IP,"4,272.99","4,272.99",,,,,,
Humana Medicaid,DRG,3443,OSTEOMYELITIS SEPTIC ARTHRITIS and OTHER MUSCULOSKELETAL INFECTIONS,,Relative Weights,"$5,859.85 ",IP,"5,859.85","5,859.85",,,,,,
Humana Medicaid,DRG,3444,OSTEOMYELITIS SEPTIC ARTHRITIS and OTHER MUSCULOSKELETAL INFECTIONS,,Relative Weights,"$10,885.73 ",IP,"10,885.73","10,885.73",,,,,,
Humana Medicaid,DRG,3461,CONNECTIVE TISSUE DISORDERS,,Relative Weights,"$3,601.54 ",IP,"3,601.54","3,601.54",,,,,,
Humana Medicaid,DRG,3462,CONNECTIVE TISSUE DISORDERS,,Relative Weights,"$4,539.99 ",IP,"4,539.99","4,539.99",,,,,,
Humana Medicaid,DRG,3463,CONNECTIVE TISSUE DISORDERS,,Relative Weights,"$6,445.74 ",IP,"6,445.74","6,445.74",,,,,,
Humana Medicaid,DRG,3464,CONNECTIVE TISSUE DISORDERS,,Relative Weights,"$15,116.11 ",IP,"15,116.11","15,116.11",,,,,,
Humana Medicaid,DRG,3471,OTHER BACK and NECK DISORDERS FRACTURES and INJURIES,,Relative Weights,"$3,279.91 ",IP,"3,279.91","3,279.91",,,,,,
Humana Medicaid,DRG,3472,"OTHER BACK & NECK DISORDERS, FRACTURES & INJURIES",,Relative Weights,"$3,772.33 ",IP,"3,772.33","3,772.33",,,,,,
Humana Medicaid,DRG,3473,OTHER BACK and NECK DISORDERS FRACTURES and INJURIES,,Relative Weights,"$4,894.95 ",IP,"4,894.95","4,894.95",,,,,,
Humana Medicaid,DRG,3474,OTHER BACK and NECK DISORDERS FRACTURES and INJURIES,,Relative Weights,"$9,864.13 ",IP,"9,864.13","9,864.13",,,,,,
Humana Medicaid,DRG,3491,MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE,,Relative Weights,"$2,603.31 ",IP,"2,603.31","2,603.31",,,,,,
Humana Medicaid,DRG,3492,MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE,,Relative Weights,"$3,535.91 ",IP,"3,535.91","3,535.91",,,,,,
Humana Medicaid,DRG,3493,MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE,,Relative Weights,"$5,006.97 ",IP,"5,006.97","5,006.97",,,,,,
Humana Medicaid,DRG,3494,MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE,,Relative Weights,"$9,666.89 ",IP,"9,666.89","9,666.89",,,,,,
Humana Medicaid,DRG,3511,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$2,708.80 ",IP,"2,708.80","2,708.80",,,,,,
Humana Medicaid,DRG,3512,OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$3,066.17 ",IP,"3,066.17","3,066.17",,,,,,
Humana Medicaid,DRG,3513,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$4,449.61 ",IP,"4,449.61","4,449.61",,,,,,
Humana Medicaid,DRG,3514,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$8,785.14 ",IP,"8,785.14","8,785.14",,,,,,
Humana Medicaid,DRG,3611,SKIN GRAFT FOR SKIN and SUBCUTANEOUS TISSUE DIAGNOSES,,Relative Weights,"$5,861.92 ",IP,"5,861.92","5,861.92",,,,,,
Humana Medicaid,DRG,3612,SKIN GRAFT FOR SKIN and SUBCUTANEOUS TISSUE DIAGNOSES,,Relative Weights,"$6,759.47 ",IP,"6,759.47","6,759.47",,,,,,
Humana Medicaid,DRG,3613,SKIN GRAFT FOR SKIN and SUBCUTANEOUS TISSUE DIAGNOSES,,Relative Weights,"$10,411.18 ",IP,"10,411.18","10,411.18",,,,,,
Humana Medicaid,DRG,3614,SKIN GRAFT FOR SKIN & SUBCUTANEOUS TISSUE DIAGNOSES,,Relative Weights,"$23,051.12 ",IP,"23,051.12","23,051.12",,,,,,
Humana Medicaid,DRG,3621,MASTECTOMY PROCEDURES,,Relative Weights,"$5,733.06 ",IP,"5,733.06","5,733.06",,,,,,
Humana Medicaid,DRG,3622,MASTECTOMY PROCEDURES,,Relative Weights,"$6,783.86 ",IP,"6,783.86","6,783.86",,,,,,
Humana Medicaid,DRG,3623,MASTECTOMY PROCEDURES,,Relative Weights,"$8,730.85 ",IP,"8,730.85","8,730.85",,,,,,
Humana Medicaid,DRG,3624,MASTECTOMY PROCEDURES,,Relative Weights,"$15,662.13 ",IP,"15,662.13","15,662.13",,,,,,
Humana Medicaid,DRG,3631,BREAST PROCEDURES EXCEPT MASTECTOMY,,Relative Weights,"$5,772.23 ",IP,"5,772.23","5,772.23",,,,,,
Humana Medicaid,DRG,3632,BREAST PROCEDURES EXCEPT MASTECTOMY,,Relative Weights,"$7,919.20 ",IP,"7,919.20","7,919.20",,,,,,
Humana Medicaid,DRG,3633,BREAST PROCEDURES EXCEPT MASTECTOMY,,Relative Weights,"$10,641.07 ",IP,"10,641.07","10,641.07",,,,,,
Humana Medicaid,DRG,3634,BREAST PROCEDURES EXCEPT MASTECTOMY,,Relative Weights,"$13,007.96 ",IP,"13,007.96","13,007.96",,,,,,
Humana Medicaid,DRG,3641,OTHER SKIN SUBCUTANEOUS TISSUE and RELATED PROCEDURES,,Relative Weights,"$3,659.27 ",IP,"3,659.27","3,659.27",,,,,,
Humana Medicaid,DRG,3642,"OTHER SKIN, SUBCUTANEOUS TISSUE & RELATED PROCEDURES",,Relative Weights,"$5,232.39 ",IP,"5,232.39","5,232.39",,,,,,
Humana Medicaid,DRG,3643,OTHER SKIN SUBCUTANEOUS TISSUE and RELATED PROCEDURES,,Relative Weights,"$8,152.18 ",IP,"8,152.18","8,152.18",,,,,,
Humana Medicaid,DRG,3644,OTHER SKIN SUBCUTANEOUS TISSUE and RELATED PROCEDURES,,Relative Weights,"$16,685.79 ",IP,"16,685.79","16,685.79",,,,,,
Humana Medicaid,DRG,3801,SKIN ULCERS,,Relative Weights,"$2,950.72 ",IP,"2,950.72","2,950.72",,,,,,
Humana Medicaid,DRG,3802,SKIN ULCERS,,Relative Weights,"$3,415.64 ",IP,"3,415.64","3,415.64",,,,,,
Humana Medicaid,DRG,3803,SKIN ULCERS,,Relative Weights,"$4,667.13 ",IP,"4,667.13","4,667.13",,,,,,
Humana Medicaid,DRG,3804,SKIN ULCERS,,Relative Weights,"$9,197.15 ",IP,"9,197.15","9,197.15",,,,,,
Humana Medicaid,DRG,3811,MAJOR SKIN DISORDERS,,Relative Weights,"$2,135.64 ",IP,"2,135.64","2,135.64",,,,,,
Humana Medicaid,DRG,3812,MAJOR SKIN DISORDERS,,Relative Weights,"$3,426.98 ",IP,"3,426.98","3,426.98",,,,,,
Humana Medicaid,DRG,3813,MAJOR SKIN DISORDERS,,Relative Weights,"$6,058.47 ",IP,"6,058.47","6,058.47",,,,,,
Humana Medicaid,DRG,3814,MAJOR SKIN DISORDERS,,Relative Weights,"$15,997.51 ",IP,"15,997.51","15,997.51",,,,,,
Humana Medicaid,DRG,3821,MALIGNANT BREAST DISORDERS,,Relative Weights,"$3,708.41 ",IP,"3,708.41","3,708.41",,,,,,
Humana Medicaid,DRG,3822,MALIGNANT BREAST DISORDERS,,Relative Weights,"$3,837.96 ",IP,"3,837.96","3,837.96",,,,,,
Humana Medicaid,DRG,3823,MALIGNANT BREAST DISORDERS,,Relative Weights,"$5,221.05 ",IP,"5,221.05","5,221.05",,,,,,
Humana Medicaid,DRG,3824,MALIGNANT BREAST DISORDERS,,Relative Weights,"$8,582.75 ",IP,"8,582.75","8,582.75",,,,,,
Humana Medicaid,DRG,3831,CELLULITIS & OTHER SKIN INFECTIONS,,Relative Weights,"$2,128.08 ",IP,"2,128.08","2,128.08",,,,,,
Humana Medicaid,DRG,3832,CELLULITIS and OTHER SKIN INFECTIONS,,Relative Weights,"$2,886.11 ",IP,"2,886.11","2,886.11",,,,,,
Humana Medicaid,DRG,3833,CELLULITIS and OTHER SKIN INFECTIONS,,Relative Weights,"$4,151.00 ",IP,"4,151.00","4,151.00",,,,,,
Humana Medicaid,DRG,3834,CELLULITIS and OTHER SKIN INFECTIONS,,Relative Weights,"$8,552.16 ",IP,"8,552.16","8,552.16",,,,,,
Humana Medicaid,DRG,3841,CONTUSION OPEN WOUND and OTHER TRAUMA TO SKIN and SUBCUTANEOUS TISSUE,,Relative Weights,"$2,690.94 ",IP,"2,690.94","2,690.94",,,,,,
Humana Medicaid,DRG,3842,CONTUSION OPEN WOUND and OTHER TRAUMA TO SKIN and SUBCUTANEOUS TISSUE,,Relative Weights,"$3,464.09 ",IP,"3,464.09","3,464.09",,,,,,
Humana Medicaid,DRG,3843,CONTUSION OPEN WOUND and OTHER TRAUMA TO SKIN and SUBCUTANEOUS TISSUE,,Relative Weights,"$4,737.92 ",IP,"4,737.92","4,737.92",,,,,,
Humana Medicaid,DRG,3844,CONTUSION OPEN WOUND and OTHER TRAUMA TO SKIN and SUBCUTANEOUS TISSUE,,Relative Weights,"$9,439.41 ",IP,"9,439.41","9,439.41",,,,,,
Humana Medicaid,DRG,3851,OTHER SKIN SUBCUTANEOUS TISSUE and BREAST DISORDERS,,Relative Weights,"$2,189.24 ",IP,"2,189.24","2,189.24",,,,,,
Humana Medicaid,DRG,3852,OTHER SKIN SUBCUTANEOUS TISSUE and BREAST DISORDERS,,Relative Weights,"$2,880.96 ",IP,"2,880.96","2,880.96",,,,,,
Humana Medicaid,DRG,3853,"OTHER SKIN, SUBCUTANEOUS TISSUE & BREAST DISORDERS",,Relative Weights,"$4,186.05 ",IP,"4,186.05","4,186.05",,,,,,
Humana Medicaid,DRG,3854,OTHER SKIN SUBCUTANEOUS TISSUE and BREAST DISORDERS,,Relative Weights,"$8,871.05 ",IP,"8,871.05","8,871.05",,,,,,
Humana Medicaid,DRG,4011,ADRENAL PROCEDURES,,Relative Weights,"$6,855.68 ",IP,"6,855.68","6,855.68",,,,,,
Humana Medicaid,DRG,4012,ADRENAL PROCEDURES,,Relative Weights,"$10,778.52 ",IP,"10,778.52","10,778.52",,,,,,
Humana Medicaid,DRG,4013,ADRENAL PROCEDURES,,Relative Weights,"$13,300.04 ",IP,"13,300.04","13,300.04",,,,,,
Humana Medicaid,DRG,4014,ADRENAL PROCEDURES,,Relative Weights,"$24,027.70 ",IP,"24,027.70","24,027.70",,,,,,
Humana Medicaid,DRG,4031,PROCEDURES FOR OBESITY,,Relative Weights,"$5,110.06 ",IP,"5,110.06","5,110.06",,,,,,
Humana Medicaid,DRG,4032,PROCEDURES FOR OBESITY,,Relative Weights,"$6,108.30 ",IP,"6,108.30","6,108.30",,,,,,
Humana Medicaid,DRG,4033,PROCEDURES FOR OBESITY,,Relative Weights,"$9,074.13 ",IP,"9,074.13","9,074.13",,,,,,
Humana Medicaid,DRG,4034,PROCEDURES FOR OBESITY,,Relative Weights,"$26,392.19 ",IP,"26,392.19","26,392.19",,,,,,
Humana Medicaid,DRG,4041,"THYROID, PARATHYROID & THYROGLOSSAL PROCEDURES",,Relative Weights,"$4,728.64 ",IP,"4,728.64","4,728.64",,,,,,
Humana Medicaid,DRG,4042,THYROID PARATHYROID and THYROGLOSSAL PROCEDURES,,Relative Weights,"$6,537.48 ",IP,"6,537.48","6,537.48",,,,,,
Humana Medicaid,DRG,4043,THYROID PARATHYROID and THYROGLOSSAL PROCEDURES,,Relative Weights,"$10,989.85 ",IP,"10,989.85","10,989.85",,,,,,
Humana Medicaid,DRG,4044,THYROID PARATHYROID and THYROGLOSSAL PROCEDURES,,Relative Weights,"$24,206.39 ",IP,"24,206.39","24,206.39",,,,,,
Humana Medicaid,DRG,4051,OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL and METABOLIC DISORDERS,,Relative Weights,"$7,505.82 ",IP,"7,505.82","7,505.82",,,,,,
Humana Medicaid,DRG,4052,OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL and METABOLIC DISORDERS,,Relative Weights,"$8,475.19 ",IP,"8,475.19","8,475.19",,,,,,
Humana Medicaid,DRG,4053,OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL and METABOLIC DISORDERS,,Relative Weights,"$12,612.79 ",IP,"12,612.79","12,612.79",,,,,,
Humana Medicaid,DRG,4054,OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL and METABOLIC DISORDERS,,Relative Weights,"$26,164.03 ",IP,"26,164.03","26,164.03",,,,,,
Humana Medicaid,DRG,4201,DIABETES,,Relative Weights,"$2,259.68 ",IP,"2,259.68","2,259.68",,,,,,
Humana Medicaid,DRG,4202,DIABETES,,Relative Weights,"$2,723.24 ",IP,"2,723.24","2,723.24",,,,,,
Humana Medicaid,DRG,4203,DIABETES,,Relative Weights,"$3,776.79 ",IP,"3,776.79","3,776.79",,,,,,
Humana Medicaid,DRG,4204,DIABETES,,Relative Weights,"$8,028.82 ",IP,"8,028.82","8,028.82",,,,,,
Humana Medicaid,DRG,4211,MALNUTRITION FAILURE TO THRIVE and OTHER NUTRITIONAL DISORDERS,,Relative Weights,"$2,343.53 ",IP,"2,343.53","2,343.53",,,,,,
Humana Medicaid,DRG,4212,MALNUTRITION FAILURE TO THRIVE and OTHER NUTRITIONAL DISORDERS,,Relative Weights,"$3,329.74 ",IP,"3,329.74","3,329.74",,,,,,
Humana Medicaid,DRG,4213,"MALNUTRITION, FAILURE TO THRIVE & OTHER NUTRITIONAL DISORDERS",,Relative Weights,"$5,181.88 ",IP,"5,181.88","5,181.88",,,,,,
Humana Medicaid,DRG,4214,MALNUTRITION FAILURE TO THRIVE and OTHER NUTRITIONAL DISORDERS,,Relative Weights,"$10,295.72 ",IP,"10,295.72","10,295.72",,,,,,
Humana Medicaid,DRG,4221,HYPOVOLEMIA and RELATED ELECTROLYTE DISORDERS,,Relative Weights,"$1,870.01 ",IP,"1,870.01","1,870.01",,,,,,
Humana Medicaid,DRG,4222,HYPOVOLEMIA and RELATED ELECTROLYTE DISORDERS,,Relative Weights,"$2,609.84 ",IP,"2,609.84","2,609.84",,,,,,
Humana Medicaid,DRG,4223,HYPOVOLEMIA and RELATED ELECTROLYTE DISORDERS,,Relative Weights,"$3,459.28 ",IP,"3,459.28","3,459.28",,,,,,
Humana Medicaid,DRG,4224,HYPOVOLEMIA and RELATED ELECTROLYTE DISORDERS,,Relative Weights,"$7,038.84 ",IP,"7,038.84","7,038.84",,,,,,
Humana Medicaid,DRG,4231,INBORN ERRORS OF METABOLISM,,Relative Weights,"$5,529.29 ",IP,"5,529.29","5,529.29",,,,,,
Humana Medicaid,DRG,4232,INBORN ERRORS OF METABOLISM,,Relative Weights,"$5,948.85 ",IP,"5,948.85","5,948.85",,,,,,
Humana Medicaid,DRG,4233,INBORN ERRORS OF METABOLISM,,Relative Weights,"$8,447.01 ",IP,"8,447.01","8,447.01",,,,,,
Humana Medicaid,DRG,4234,INBORN ERRORS OF METABOLISM,,Relative Weights,"$27,194.91 ",IP,"27,194.91","27,194.91",,,,,,
Humana Medicaid,DRG,4241,OTHER ENDOCRINE DISORDERS,,Relative Weights,"$2,869.62 ",IP,"2,869.62","2,869.62",,,,,,
Humana Medicaid,DRG,4242,OTHER ENDOCRINE DISORDERS,,Relative Weights,"$3,662.02 ",IP,"3,662.02","3,662.02",,,,,,
Humana Medicaid,DRG,4243,OTHER ENDOCRINE DISORDERS,,Relative Weights,"$5,028.28 ",IP,"5,028.28","5,028.28",,,,,,
Humana Medicaid,DRG,4244,OTHER ENDOCRINE DISORDERS,,Relative Weights,"$10,807.73 ",IP,"10,807.73","10,807.73",,,,,,
Humana Medicaid,DRG,4251,OTHER NONHYPOVOLEMIC ELECTROLYTE DISORDERS,,Relative Weights,"$2,221.89 ",IP,"2,221.89","2,221.89",,,,,,
Humana Medicaid,DRG,4252,OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS,,Relative Weights,"$2,908.79 ",IP,"2,908.79","2,908.79",,,,,,
Humana Medicaid,DRG,4253,OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS,,Relative Weights,"$3,943.11 ",IP,"3,943.11","3,943.11",,,,,,
Humana Medicaid,DRG,4254,OTHER NONHYPOVOLEMIC ELECTROLYTE DISORDERS,,Relative Weights,"$7,662.17 ",IP,"7,662.17","7,662.17",,,,,,
Humana Medicaid,DRG,4261,NONHYPOVOLEMIC SODIUM DISORDERS,,Relative Weights,"$2,409.16 ",IP,"2,409.16","2,409.16",,,,,,
Humana Medicaid,DRG,4262,NONHYPOVOLEMIC SODIUM DISORDERS,,Relative Weights,"$2,941.78 ",IP,"2,941.78","2,941.78",,,,,,
Humana Medicaid,DRG,4263,NON-HYPOVOLEMIC SODIUM DISORDERS,,Relative Weights,"$4,191.21 ",IP,"4,191.21","4,191.21",,,,,,
Humana Medicaid,DRG,4264,NONHYPOVOLEMIC SODIUM DISORDERS,,Relative Weights,"$8,224.69 ",IP,"8,224.69","8,224.69",,,,,,
Humana Medicaid,DRG,4271,THYROID DISORDERS,,Relative Weights,"$2,411.91 ",IP,"2,411.91","2,411.91",,,,,,
Humana Medicaid,DRG,4272,THYROID DISORDERS,,Relative Weights,"$3,208.44 ",IP,"3,208.44","3,208.44",,,,,,
Humana Medicaid,DRG,4273,THYROID DISORDERS,,Relative Weights,"$4,621.77 ",IP,"4,621.77","4,621.77",,,,,,
Humana Medicaid,DRG,4274,THYROID DISORDERS,,Relative Weights,"$9,834.92 ",IP,"9,834.92","9,834.92",,,,,,
Humana Medicaid,DRG,4401,KIDNEY TRANSPLANT,,Relative Weights,"$26,376.39 ",IP,"26,376.39","26,376.39",,,,,,
Humana Medicaid,DRG,4402,KIDNEY TRANSPLANT,,Relative Weights,"$28,441.58 ",IP,"28,441.58","28,441.58",,,,,,
Humana Medicaid,DRG,4403,KIDNEY TRANSPLANT,,Relative Weights,"$31,863.75 ",IP,"31,863.75","31,863.75",,,,,,
Humana Medicaid,DRG,4404,KIDNEY TRANSPLANT,,Relative Weights,"$48,433.40 ",IP,"48,433.40","48,433.40",,,,,,
Humana Medicaid,DRG,4411,MAJOR BLADDER PROCEDURES,,Relative Weights,"$7,124.74 ",IP,"7,124.74","7,124.74",,,,,,
Humana Medicaid,DRG,4412,MAJOR BLADDER PROCEDURES,,Relative Weights,"$11,337.94 ",IP,"11,337.94","11,337.94",,,,,,
Humana Medicaid,DRG,4413,MAJOR BLADDER PROCEDURES,,Relative Weights,"$14,853.23 ",IP,"14,853.23","14,853.23",,,,,,
Humana Medicaid,DRG,4414,MAJOR BLADDER PROCEDURES,,Relative Weights,"$32,299.47 ",IP,"32,299.47","32,299.47",,,,,,
Humana Medicaid,DRG,4421,KIDNEY and URINARY TRACT PROCEDURES FOR MALIGNANCY,,Relative Weights,"$7,007.22 ",IP,"7,007.22","7,007.22",,,,,,
Humana Medicaid,DRG,4422,KIDNEY and URINARY TRACT PROCEDURES FOR MALIGNANCY,,Relative Weights,"$7,784.16 ",IP,"7,784.16","7,784.16",,,,,,
Humana Medicaid,DRG,4423,KIDNEY & URINARY TRACT PROCEDURES FOR MALIGNANCY,,Relative Weights,"$11,551.33 ",IP,"11,551.33","11,551.33",,,,,,
Humana Medicaid,DRG,4424,KIDNEY and URINARY TRACT PROCEDURES FOR MALIGNANCY,,Relative Weights,"$20,973.56 ",IP,"20,973.56","20,973.56",,,,,,
Humana Medicaid,DRG,4431,KIDNEY and URINARY TRACT PROCEDURES FOR NONMALIGNANCY,,Relative Weights,"$5,745.77 ",IP,"5,745.77","5,745.77",,,,,,
Humana Medicaid,DRG,4432,KIDNEY and URINARY TRACT PROCEDURES FOR NONMALIGNANCY,,Relative Weights,"$6,928.19 ",IP,"6,928.19","6,928.19",,,,,,
Humana Medicaid,DRG,4433,KIDNEY & URINARY TRACT PROCEDURES FOR NONMALIGNANCY,,Relative Weights,"$10,300.53 ",IP,"10,300.53","10,300.53",,,,,,
Humana Medicaid,DRG,4434,KIDNEY & URINARY TRACT PROCEDURES FOR NONMALIGNANCY,,Relative Weights,"$21,259.80 ",IP,"21,259.80","21,259.80",,,,,,
Humana Medicaid,DRG,4441,RENAL DIALYSIS ACCESS DEVICE AND VESSEL REPAIR,,Relative Weights,"$6,643.67 ",IP,"6,643.67","6,643.67",,,,,,
Humana Medicaid,DRG,4442,RENAL DIALYSIS ACCESS DEVICE AND VESSEL REPAIR,,Relative Weights,"$8,351.49 ",IP,"8,351.49","8,351.49",,,,,,
Humana Medicaid,DRG,4443,RENAL DIALYSIS ACCESS DEVICE AND VESSEL REPAIR,,Relative Weights,"$12,840.62 ",IP,"12,840.62","12,840.62",,,,,,
Humana Medicaid,DRG,4444,RENAL DIALYSIS ACCESS DEVICE AND VESSEL REPAIR,,Relative Weights,"$25,251.70 ",IP,"25,251.70","25,251.70",,,,,,
Humana Medicaid,DRG,4451,OTHER BLADDER PROCEDURES,,Relative Weights,"$4,867.46 ",IP,"4,867.46","4,867.46",,,,,,
Humana Medicaid,DRG,4452,OTHER BLADDER PROCEDURES,,Relative Weights,"$6,607.93 ",IP,"6,607.93","6,607.93",,,,,,
Humana Medicaid,DRG,4453,OTHER BLADDER PROCEDURES,,Relative Weights,"$8,634.63 ",IP,"8,634.63","8,634.63",,,,,,
Humana Medicaid,DRG,4454,OTHER BLADDER PROCEDURES,,Relative Weights,"$17,913.22 ",IP,"17,913.22","17,913.22",,,,,,
Humana Medicaid,DRG,4461,URETHRAL & TRANSURETHRAL PROCEDURES,,Relative Weights,"$4,096.37 ",IP,"4,096.37","4,096.37",,,,,,
Humana Medicaid,DRG,4462,URETHRAL & TRANSURETHRAL PROCEDURES,,Relative Weights,"$5,093.91 ",IP,"5,093.91","5,093.91",,,,,,
Humana Medicaid,DRG,4463,URETHRAL and TRANSURETHRAL PROCEDURES,,Relative Weights,"$7,454.97 ",IP,"7,454.97","7,454.97",,,,,,
Humana Medicaid,DRG,4464,URETHRAL and TRANSURETHRAL PROCEDURES,,Relative Weights,"$15,279.67 ",IP,"15,279.67","15,279.67",,,,,,
Humana Medicaid,DRG,4471,OTHER KIDNEY URINARY TRACT and RELATED PROCEDURES,,Relative Weights,"$6,383.54 ",IP,"6,383.54","6,383.54",,,,,,
Humana Medicaid,DRG,4472,"OTHER KIDNEY, URINARY TRACT & RELATED PROCEDURES",,Relative Weights,"$7,988.27 ",IP,"7,988.27","7,988.27",,,,,,
Humana Medicaid,DRG,4473,OTHER KIDNEY URINARY TRACT and RELATED PROCEDURES,,Relative Weights,"$11,578.48 ",IP,"11,578.48","11,578.48",,,,,,
Humana Medicaid,DRG,4474,OTHER KIDNEY URINARY TRACT and RELATED PROCEDURES,,Relative Weights,"$26,335.15 ",IP,"26,335.15","26,335.15",,,,,,
Humana Medicaid,DRG,4611,KIDNEY and URINARY TRACT MALIGNANCY,,Relative Weights,"$4,213.89 ",IP,"4,213.89","4,213.89",,,,,,
Humana Medicaid,DRG,4612,KIDNEY and URINARY TRACT MALIGNANCY,,Relative Weights,"$4,354.09 ",IP,"4,354.09","4,354.09",,,,,,
Humana Medicaid,DRG,4613,KIDNEY and URINARY TRACT MALIGNANCY,,Relative Weights,"$5,833.40 ",IP,"5,833.40","5,833.40",,,,,,
Humana Medicaid,DRG,4614,KIDNEY & URINARY TRACT MALIGNANCY,,Relative Weights,"$10,495.71 ",IP,"10,495.71","10,495.71",,,,,,
Humana Medicaid,DRG,4621,NEPHRITIS and NEPHROSIS,,Relative Weights,"$2,361.40 ",IP,"2,361.40","2,361.40",,,,,,
Humana Medicaid,DRG,4622,NEPHRITIS and NEPHROSIS,,Relative Weights,"$3,007.07 ",IP,"3,007.07","3,007.07",,,,,,
Humana Medicaid,DRG,4623,NEPHRITIS and NEPHROSIS,,Relative Weights,"$5,343.04 ",IP,"5,343.04","5,343.04",,,,,,
Humana Medicaid,DRG,4624,NEPHRITIS and NEPHROSIS,,Relative Weights,"$14,645.34 ",IP,"14,645.34","14,645.34",,,,,,
Humana Medicaid,DRG,4631,KIDNEY and URINARY TRACT INFECTIONS,,Relative Weights,"$2,386.48 ",IP,"2,386.48","2,386.48",,,,,,
Humana Medicaid,DRG,4632,KIDNEY and URINARY TRACT INFECTIONS,,Relative Weights,"$2,925.29 ",IP,"2,925.29","2,925.29",,,,,,
Humana Medicaid,DRG,4633,KIDNEY and URINARY TRACT INFECTIONS,,Relative Weights,"$3,755.49 ",IP,"3,755.49","3,755.49",,,,,,
Humana Medicaid,DRG,4634,KIDNEY and URINARY TRACT INFECTIONS,,Relative Weights,"$6,746.75 ",IP,"6,746.75","6,746.75",,,,,,
Humana Medicaid,DRG,4651,URINARY STONES & ACQUIRED UPPER URINARY TRACT OBSTRUCTION,,Relative Weights,"$2,676.16 ",IP,"2,676.16","2,676.16",,,,,,
Humana Medicaid,DRG,4652,URINARY STONES and ACQUIRED UPPER URINARY TRACT OBSTRUCTION,,Relative Weights,"$3,212.22 ",IP,"3,212.22","3,212.22",,,,,,
Humana Medicaid,DRG,4653,URINARY STONES and ACQUIRED UPPER URINARY TRACT OBSTRUCTION,,Relative Weights,"$4,385.36 ",IP,"4,385.36","4,385.36",,,,,,
Humana Medicaid,DRG,4654,URINARY STONES and ACQUIRED UPPER URINARY TRACT OBSTRUCTION,,Relative Weights,"$8,949.40 ",IP,"8,949.40","8,949.40",,,,,,
Humana Medicaid,DRG,4661,"MALFUNCTION, REACTION, COMPLIC OF GENITOURINARY DEVICE OR PROC",,Relative Weights,"$2,602.62 ",IP,"2,602.62","2,602.62",,,,,,
Humana Medicaid,DRG,4662,"MALFUNCTION, REACTION, COMPLIC OF GENITOURINARY DEVICE OR PROC",,Relative Weights,"$3,336.61 ",IP,"3,336.61","3,336.61",,,,,,
Humana Medicaid,DRG,4663,MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC,,Relative Weights,"$4,821.07 ",IP,"4,821.07","4,821.07",,,,,,
Humana Medicaid,DRG,4664,MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC,,Relative Weights,"$8,281.73 ",IP,"8,281.73","8,281.73",,,,,,
Humana Medicaid,DRG,4681,OTHER KIDNEY and URINARY TRACT DIAGNOSES SIGNS and SYMPTOMS,,Relative Weights,"$2,645.58 ",IP,"2,645.58","2,645.58",,,,,,
Humana Medicaid,DRG,4682,OTHER KIDNEY and URINARY TRACT DIAGNOSES SIGNS and SYMPTOMS,,Relative Weights,"$3,341.08 ",IP,"3,341.08","3,341.08",,,,,,
Humana Medicaid,DRG,4683,"OTHER KIDNEY & URINARY TRACT DIAGNOSES, SIGNS & SYMPTOMS",,Relative Weights,"$4,559.92 ",IP,"4,559.92","4,559.92",,,,,,
Humana Medicaid,DRG,4684,OTHER KIDNEY and URINARY TRACT DIAGNOSES SIGNS and SYMPTOMS,,Relative Weights,"$9,588.20 ",IP,"9,588.20","9,588.20",,,,,,
Humana Medicaid,DRG,4691,ACUTE KIDNEY INJURY,,Relative Weights,"$2,379.95 ",IP,"2,379.95","2,379.95",,,,,,
Humana Medicaid,DRG,4692,ACUTE KIDNEY INJURY,,Relative Weights,"$3,050.71 ",IP,"3,050.71","3,050.71",,,,,,
Humana Medicaid,DRG,4693,ACUTE KIDNEY INJURY,,Relative Weights,"$4,563.35 ",IP,"4,563.35","4,563.35",,,,,,
Humana Medicaid,DRG,4694,ACUTE KIDNEY INJURY,,Relative Weights,"$9,568.95 ",IP,"9,568.95","9,568.95",,,,,,
Humana Medicaid,DRG,4701,CHRONIC KIDNEY DISEASE,,Relative Weights,"$2,503.66 ",IP,"2,503.66","2,503.66",,,,,,
Humana Medicaid,DRG,4702,CHRONIC KIDNEY DISEASE,,Relative Weights,"$3,283.35 ",IP,"3,283.35","3,283.35",,,,,,
Humana Medicaid,DRG,4703,CHRONIC KIDNEY DISEASE,,Relative Weights,"$4,530.02 ",IP,"4,530.02","4,530.02",,,,,,
Humana Medicaid,DRG,4704,CHRONIC KIDNEY DISEASE,,Relative Weights,"$8,193.42 ",IP,"8,193.42","8,193.42",,,,,,
Humana Medicaid,DRG,4801,MAJOR MALE PELVIC PROCEDURES,,Relative Weights,"$6,131.66 ",IP,"6,131.66","6,131.66",,,,,,
Humana Medicaid,DRG,4802,MAJOR MALE PELVIC PROCEDURES,,Relative Weights,"$6,485.60 ",IP,"6,485.60","6,485.60",,,,,,
Humana Medicaid,DRG,4803,MAJOR MALE PELVIC PROCEDURES,,Relative Weights,"$10,188.85 ",IP,"10,188.85","10,188.85",,,,,,
Humana Medicaid,DRG,4804,MAJOR MALE PELVIC PROCEDURES,,Relative Weights,"$21,900.66 ",IP,"21,900.66","21,900.66",,,,,,
Humana Medicaid,DRG,4821,TRANSURETHRAL PROSTATECTOMY,,Relative Weights,"$4,027.30 ",IP,"4,027.30","4,027.30",,,,,,
Humana Medicaid,DRG,4822,TRANSURETHRAL PROSTATECTOMY,,Relative Weights,"$4,459.58 ",IP,"4,459.58","4,459.58",,,,,,
Humana Medicaid,DRG,4823,TRANSURETHRAL PROSTATECTOMY,,Relative Weights,"$7,759.08 ",IP,"7,759.08","7,759.08",,,,,,
Humana Medicaid,DRG,4824,TRANSURETHRAL PROSTATECTOMY,,Relative Weights,"$15,069.03 ",IP,"15,069.03","15,069.03",,,,,,
Humana Medicaid,DRG,4831,PENIS TESTES and SCROTAL PROCEDURES,,Relative Weights,"$5,523.10 ",IP,"5,523.10","5,523.10",,,,,,
Humana Medicaid,DRG,4832,PENIS TESTES and SCROTAL PROCEDURES,,Relative Weights,"$6,593.84 ",IP,"6,593.84","6,593.84",,,,,,
Humana Medicaid,DRG,4833,PENIS TESTES and SCROTAL PROCEDURES,,Relative Weights,"$8,503.71 ",IP,"8,503.71","8,503.71",,,,,,
Humana Medicaid,DRG,4834,PENIS TESTES and SCROTAL PROCEDURES,,Relative Weights,"$16,764.14 ",IP,"16,764.14","16,764.14",,,,,,
Humana Medicaid,DRG,4841,OTHER MALE REPRODUCTIVE SYSTEM and RELATED PROCEDURES,,Relative Weights,"$6,414.47 ",IP,"6,414.47","6,414.47",,,,,,
Humana Medicaid,DRG,4842,OTHER MALE REPRODUCTIVE SYSTEM and RELATED PROCEDURES,,Relative Weights,"$6,893.48 ",IP,"6,893.48","6,893.48",,,,,,
Humana Medicaid,DRG,4843,OTHER MALE REPRODUCTIVE SYSTEM and RELATED PROCEDURES,,Relative Weights,"$7,922.98 ",IP,"7,922.98","7,922.98",,,,,,
Humana Medicaid,DRG,4844,OTHER MALE REPRODUCTIVE SYSTEM and RELATED PROCEDURES,,Relative Weights,"$22,148.41 ",IP,"22,148.41","22,148.41",,,,,,
Humana Medicaid,DRG,5001,MALIGNANCY MALE REPRODUCTIVE SYSTEM,,Relative Weights,"$3,471.31 ",IP,"3,471.31","3,471.31",,,,,,
Humana Medicaid,DRG,5002,MALIGNANCY MALE REPRODUCTIVE SYSTEM,,Relative Weights,"$3,960.98 ",IP,"3,960.98","3,960.98",,,,,,
Humana Medicaid,DRG,5003,"MALIGNANCY, MALE REPRODUCTIVE SYSTEM",,Relative Weights,"$5,381.18 ",IP,"5,381.18","5,381.18",,,,,,
Humana Medicaid,DRG,5004,MALIGNANCY MALE REPRODUCTIVE SYSTEM,,Relative Weights,"$8,653.88 ",IP,"8,653.88","8,653.88",,,,,,
Humana Medicaid,DRG,5011,MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,,Relative Weights,"$2,269.65 ",IP,"2,269.65","2,269.65",,,,,,
Humana Medicaid,DRG,5012,MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,,Relative Weights,"$2,988.52 ",IP,"2,988.52","2,988.52",,,,,,
Humana Medicaid,DRG,5013,MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,,Relative Weights,"$4,126.95 ",IP,"4,126.95","4,126.95",,,,,,
Humana Medicaid,DRG,5014,MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,,Relative Weights,"$8,519.52 ",IP,"8,519.52","8,519.52",,,,,,
Humana Medicaid,DRG,5101,PELVIC EVISCERATION RADICAL HYSTERECTOMY and OTHER RADICAL GYN PROCS,,Relative Weights,"$6,667.03 ",IP,"6,667.03","6,667.03",,,,,,
Humana Medicaid,DRG,5102,PELVIC EVISCERATION RADICAL HYSTERECTOMY and OTHER RADICAL GYN PROCS,,Relative Weights,"$7,636.06 ",IP,"7,636.06","7,636.06",,,,,,
Humana Medicaid,DRG,5103,"PELVIC EVISCERATION, RADICAL HYSTERECTOMY & OTHER RADICAL GYN PROCS",,Relative Weights,"$12,159.55 ",IP,"12,159.55","12,159.55",,,,,,
Humana Medicaid,DRG,5104,PELVIC EVISCERATION RADICAL HYSTERECTOMY and OTHER RADICAL GYN PROCS,,Relative Weights,"$22,308.54 ",IP,"22,308.54","22,308.54",,,,,,
Humana Medicaid,DRG,5111,UTERINE and ADNEXA PROCEDURES FOR OVARIAN and ADNEXAL MALIGNANCY,,Relative Weights,"$6,477.69 ",IP,"6,477.69","6,477.69",,,,,,
Humana Medicaid,DRG,5112,UTERINE and ADNEXA PROCEDURES FOR OVARIAN and ADNEXAL MALIGNANCY,,Relative Weights,"$7,830.89 ",IP,"7,830.89","7,830.89",,,,,,
Humana Medicaid,DRG,5113,UTERINE & ADNEXA PROCEDURES FOR OVARIAN & ADNEXAL MALIGNANCY,,Relative Weights,"$10,746.90 ",IP,"10,746.90","10,746.90",,,,,,
Humana Medicaid,DRG,5114,UTERINE & ADNEXA PROCEDURES FOR OVARIAN & ADNEXAL MALIGNANCY,,Relative Weights,"$23,120.88 ",IP,"23,120.88","23,120.88",,,,,,
Humana Medicaid,DRG,5121,UTERINE and ADNEXA PROCEDURES FOR NONOVARIAN and NONADNEXAL MALIG,,Relative Weights,"$6,341.62 ",IP,"6,341.62","6,341.62",,,,,,
Humana Medicaid,DRG,5122,UTERINE and ADNEXA PROCEDURES FOR NONOVARIAN and NONADNEXAL MALIG,,Relative Weights,"$7,038.84 ",IP,"7,038.84","7,038.84",,,,,,
Humana Medicaid,DRG,5123,UTERINE and ADNEXA PROCEDURES FOR NONOVARIAN and NONADNEXAL MALIG,,Relative Weights,"$9,937.66 ",IP,"9,937.66","9,937.66",,,,,,
Humana Medicaid,DRG,5124,UTERINE & ADNEXA PROCEDURES FOR NON-OVARIAN & NON-ADNEXAL MALIG,,Relative Weights,"$20,453.99 ",IP,"20,453.99","20,453.99",,,,,,
Humana Medicaid,DRG,5131,UTERINE & ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA,,Relative Weights,"$4,384.67 ",IP,"4,384.67","4,384.67",,,,,,
Humana Medicaid,DRG,5132,UTERINE and ADNEXA PROCEDURES FOR NONMALIGNANCY EXCEPT LEIOMYOMA,,Relative Weights,"$5,107.31 ",IP,"5,107.31","5,107.31",,,,,,
Humana Medicaid,DRG,5133,UTERINE and ADNEXA PROCEDURES FOR NONMALIGNANCY EXCEPT LEIOMYOMA,,Relative Weights,"$8,107.86 ",IP,"8,107.86","8,107.86",,,,,,
Humana Medicaid,DRG,5134,UTERINE and ADNEXA PROCEDURES FOR NONMALIGNANCY EXCEPT LEIOMYOMA,,Relative Weights,"$16,632.53 ",IP,"16,632.53","16,632.53",,,,,,
Humana Medicaid,DRG,5141,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,,Relative Weights,"$3,945.51 ",IP,"3,945.51","3,945.51",,,,,,
Humana Medicaid,DRG,5142,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,,Relative Weights,"$5,893.19 ",IP,"5,893.19","5,893.19",,,,,,
Humana Medicaid,DRG,5143,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,,Relative Weights,"$10,581.96 ",IP,"10,581.96","10,581.96",,,,,,
Humana Medicaid,DRG,5144,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,,Relative Weights,"$22,849.41 ",IP,"22,849.41","22,849.41",,,,,,
Humana Medicaid,DRG,5171,DILATION and CURETTAGE FOR NONOBSTETRIC DIAGNOSES,,Relative Weights,"$3,258.61 ",IP,"3,258.61","3,258.61",,,,,,
Humana Medicaid,DRG,5172,DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES,,Relative Weights,"$4,494.28 ",IP,"4,494.28","4,494.28",,,,,,
Humana Medicaid,DRG,5173,DILATION and CURETTAGE FOR NONOBSTETRIC DIAGNOSES,,Relative Weights,"$6,942.62 ",IP,"6,942.62","6,942.62",,,,,,
Humana Medicaid,DRG,5174,DILATION and CURETTAGE FOR NONOBSTETRIC DIAGNOSES,,Relative Weights,"$14,767.33 ",IP,"14,767.33","14,767.33",,,,,,
Humana Medicaid,DRG,5181,OTHER FEMALE REPRODUCTIVE SYSTEM and RELATED PROCEDURES,,Relative Weights,"$4,123.51 ",IP,"4,123.51","4,123.51",,,,,,
Humana Medicaid,DRG,5182,OTHER FEMALE REPRODUCTIVE SYSTEM & RELATED PROCEDURES,,Relative Weights,"$5,436.16 ",IP,"5,436.16","5,436.16",,,,,,
Humana Medicaid,DRG,5183,OTHER FEMALE REPRODUCTIVE SYSTEM & RELATED PROCEDURES,,Relative Weights,"$9,420.16 ",IP,"9,420.16","9,420.16",,,,,,
Humana Medicaid,DRG,5184,OTHER FEMALE REPRODUCTIVE SYSTEM and RELATED PROCEDURES,,Relative Weights,"$21,115.47 ",IP,"21,115.47","21,115.47",,,,,,
Humana Medicaid,DRG,5191,UTERINE and ADNEXA PROCEDURES FOR LEIOMYOMA,,Relative Weights,"$3,160.33 ",IP,"3,160.33","3,160.33",,,,,,
Humana Medicaid,DRG,5192,UTERINE and ADNEXA PROCEDURES FOR LEIOMYOMA,,Relative Weights,"$3,849.30 ",IP,"3,849.30","3,849.30",,,,,,
Humana Medicaid,DRG,5193,UTERINE & ADNEXA PROCEDURES FOR LEIOMYOMA,,Relative Weights,"$7,527.81 ",IP,"7,527.81","7,527.81",,,,,,
Humana Medicaid,DRG,5194,UTERINE and ADNEXA PROCEDURES FOR LEIOMYOMA,,Relative Weights,"$15,622.96 ",IP,"15,622.96","15,622.96",,,,,,
Humana Medicaid,DRG,5301,FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,,Relative Weights,"$3,382.31 ",IP,"3,382.31","3,382.31",,,,,,
Humana Medicaid,DRG,5302,FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,,Relative Weights,"$3,815.97 ",IP,"3,815.97","3,815.97",,,,,,
Humana Medicaid,DRG,5303,FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,,Relative Weights,"$5,327.23 ",IP,"5,327.23","5,327.23",,,,,,
Humana Medicaid,DRG,5304,FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,,Relative Weights,"$9,039.08 ",IP,"9,039.08","9,039.08",,,,,,
Humana Medicaid,DRG,5311,FEMALE REPRODUCTIVE SYSTEM INFECTIONS,,Relative Weights,"$2,096.46 ",IP,"2,096.46","2,096.46",,,,,,
Humana Medicaid,DRG,5312,FEMALE REPRODUCTIVE SYSTEM INFECTIONS,,Relative Weights,"$2,868.93 ",IP,"2,868.93","2,868.93",,,,,,
Humana Medicaid,DRG,5313,FEMALE REPRODUCTIVE SYSTEM INFECTIONS,,Relative Weights,"$4,503.56 ",IP,"4,503.56","4,503.56",,,,,,
Humana Medicaid,DRG,5314,FEMALE REPRODUCTIVE SYSTEM INFECTIONS,,Relative Weights,"$9,958.97 ",IP,"9,958.97","9,958.97",,,,,,
Humana Medicaid,DRG,5321,MENSTRUAL and OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,,Relative Weights,"$2,302.29 ",IP,"2,302.29","2,302.29",,,,,,
Humana Medicaid,DRG,5322,MENSTRUAL and OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,,Relative Weights,"$2,696.78 ",IP,"2,696.78","2,696.78",,,,,,
Humana Medicaid,DRG,5323,MENSTRUAL and OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,,Relative Weights,"$4,143.44 ",IP,"4,143.44","4,143.44",,,,,,
Humana Medicaid,DRG,5324,MENSTRUAL and OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,,Relative Weights,"$9,044.24 ",IP,"9,044.24","9,044.24",,,,,,
Humana Medicaid,DRG,5401,CESAREAN DELIVERY,,Relative Weights,"$2,493.69 ",IP,"2,493.69","2,493.69",,,,,,
Humana Medicaid,DRG,5402,CESAREAN DELIVERY,,Relative Weights,"$2,909.48 ",IP,"2,909.48","2,909.48",,,,,,
Humana Medicaid,DRG,5403,CESAREAN DELIVERY,,Relative Weights,"$4,140.35 ",IP,"4,140.35","4,140.35",,,,,,
Humana Medicaid,DRG,5404,CESAREAN DELIVERY,,Relative Weights,"$8,525.02 ",IP,"8,525.02","8,525.02",,,,,,
Humana Medicaid,DRG,5411,VAGINAL DELIVERY W STERILIZATION &/OR D&C,,Relative Weights,"$2,683.03 ",IP,"2,683.03","2,683.03",,,,,,
Humana Medicaid,DRG,5412,VAGINAL DELIVERY W STERILIZATION andOR DandC,,Relative Weights,"$2,694.03 ",IP,"2,694.03","2,694.03",,,,,,
Humana Medicaid,DRG,5413,VAGINAL DELIVERY W STERILIZATION andOR DandC,,Relative Weights,"$3,800.85 ",IP,"3,800.85","3,800.85",,,,,,
Humana Medicaid,DRG,5414,VAGINAL DELIVERY W STERILIZATION andOR DandC,,Relative Weights,"$9,356.59 ",IP,"9,356.59","9,356.59",,,,,,
Humana Medicaid,DRG,5421,VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION &/OR D&C,,Relative Weights,"$1,729.81 ",IP,"1,729.81","1,729.81",,,,,,
Humana Medicaid,DRG,5422,VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION andOR DandC,,Relative Weights,"$1,962.10 ",IP,"1,962.10","1,962.10",,,,,,
Humana Medicaid,DRG,5423,VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION andOR DandC,,Relative Weights,"$2,979.24 ",IP,"2,979.24","2,979.24",,,,,,
Humana Medicaid,DRG,5424,VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION andOR DandC,,Relative Weights,"$11,346.53 ",IP,"11,346.53","11,346.53",,,,,,
Humana Medicaid,DRG,5441,DandC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES,,Relative Weights,"$1,946.30 ",IP,"1,946.30","1,946.30",,,,,,
Humana Medicaid,DRG,5442,"D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES",,Relative Weights,"$2,595.06 ",IP,"2,595.06","2,595.06",,,,,,
Humana Medicaid,DRG,5443,"D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES",,Relative Weights,"$3,856.51 ",IP,"3,856.51","3,856.51",,,,,,
Humana Medicaid,DRG,5444,DandC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES,,Relative Weights,"$14,310.30 ",IP,"14,310.30","14,310.30",,,,,,
Humana Medicaid,DRG,5451,ECTOPIC PREGNANCY PROCEDURE,,Relative Weights,"$2,785.09 ",IP,"2,785.09","2,785.09",,,,,,
Humana Medicaid,DRG,5452,ECTOPIC PREGNANCY PROCEDURE,,Relative Weights,"$3,114.63 ",IP,"3,114.63","3,114.63",,,,,,
Humana Medicaid,DRG,5453,ECTOPIC PREGNANCY PROCEDURE,,Relative Weights,"$3,214.96 ",IP,"3,214.96","3,214.96",,,,,,
Humana Medicaid,DRG,5454,ECTOPIC PREGNANCY PROCEDURE,,Relative Weights,"$4,812.48 ",IP,"4,812.48","4,812.48",,,,,,
Humana Medicaid,DRG,5461,OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES,,Relative Weights,"$2,385.45 ",IP,"2,385.45","2,385.45",,,,,,
Humana Medicaid,DRG,5462,OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES,,Relative Weights,"$4,587.41 ",IP,"4,587.41","4,587.41",,,,,,
Humana Medicaid,DRG,5463,OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES,,Relative Weights,"$5,857.79 ",IP,"5,857.79","5,857.79",,,,,,
Humana Medicaid,DRG,5464,OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES,,Relative Weights,"$11,895.30 ",IP,"11,895.30","11,895.30",,,,,,
Humana Medicaid,DRG,5601,VAGINAL DELIVERY,VAGINAL DELIVERY,Relative Weights,"$1,539.10 ",IP,"1,539.10","1,539.10",,,,,,
Humana Medicaid,DRG,5602,VAGINAL DELIVERY,VAGINAL DELIVERY,Relative Weights,"$1,659.37 ",IP,"1,659.37","1,659.37",,,,,,
Humana Medicaid,DRG,5603,VAGINAL DELIVERY,VAGINAL DELIVERY,Relative Weights,"$2,337.34 ",IP,"2,337.34","2,337.34",,,,,,
Humana Medicaid,DRG,5604,VAGINAL DELIVERY,VAGINAL DELIVERY,Relative Weights,"$4,292.23 ",IP,"4,292.23","4,292.23",,,,,,
Humana Medicaid,DRG,5611,POSTPARTUM and POST ABORTION DIAGNOSES WO PROCEDURE,,Relative Weights,"$1,236.71 ",IP,"1,236.71","1,236.71",,,,,,
Humana Medicaid,DRG,5612,POSTPARTUM and POST ABORTION DIAGNOSES WO PROCEDURE,,Relative Weights,"$1,778.26 ",IP,"1,778.26","1,778.26",,,,,,
Humana Medicaid,DRG,5613,POSTPARTUM and POST ABORTION DIAGNOSES WO PROCEDURE,,Relative Weights,"$2,747.29 ",IP,"2,747.29","2,747.29",,,,,,
Humana Medicaid,DRG,5614,POSTPARTUM and POST ABORTION DIAGNOSES WO PROCEDURE,,Relative Weights,"$5,898.34 ",IP,"5,898.34","5,898.34",,,,,,
Humana Medicaid,DRG,5631,PRETERM LABOR,,Relative Weights,"$1,387.56 ",IP,"1,387.56","1,387.56",,,,,,
Humana Medicaid,DRG,5632,PRETERM LABOR,,Relative Weights,"$1,719.85 ",IP,"1,719.85","1,719.85",,,,,,
Humana Medicaid,DRG,5633,PRETERM LABOR,,Relative Weights,"$2,634.92 ",IP,"2,634.92","2,634.92",,,,,,
Humana Medicaid,DRG,5634,PRETERM LABOR,,Relative Weights,"$4,637.23 ",IP,"4,637.23","4,637.23",,,,,,
Humana Medicaid,DRG,5641,ABORTION WO DandC ASPIRATION CURETTAGE OR HYSTEROTOMY,,Relative Weights,"$1,463.85 ",IP,"1,463.85","1,463.85",,,,,,
Humana Medicaid,DRG,5642,"ABORTION W/O D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",,Relative Weights,"$1,520.55 ",IP,"1,520.55","1,520.55",,,,,,
Humana Medicaid,DRG,5643,"ABORTION W/O D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",,Relative Weights,"$2,435.62 ",IP,"2,435.62","2,435.62",,,,,,
Humana Medicaid,DRG,5644,ABORTION WO DandC ASPIRATION CURETTAGE OR HYSTEROTOMY,,Relative Weights,"$3,935.55 ",IP,"3,935.55","3,935.55",,,,,,
Humana Medicaid,DRG,5651,FALSE LABOR,FALSE LABOR,Relative Weights,$992.39 ,IP,992.39,992.39,,,,,,
Humana Medicaid,DRG,5652,FALSE LABOR,FALSE LABOR,Relative Weights,"$1,254.23 ",IP,"1,254.23","1,254.23",,,,,,
Humana Medicaid,DRG,5653,FALSE LABOR,FALSE LABOR,Relative Weights,"$2,123.61 ",IP,"2,123.61","2,123.61",,,,,,
Humana Medicaid,DRG,5654,FALSE LABOR,FALSE LABOR,Relative Weights,"$2,123.61 ",IP,"2,123.61","2,123.61",,,,,,
Humana Medicaid,DRG,5661,OTHER ANTEPARTUM DIAGNOSES,,Relative Weights,"$1,462.82 ",IP,"1,462.82","1,462.82",,,,,,
Humana Medicaid,DRG,5662,OTHER ANTEPARTUM DIAGNOSES,,Relative Weights,"$1,906.44 ",IP,"1,906.44","1,906.44",,,,,,
Humana Medicaid,DRG,5663,OTHER ANTEPARTUM DIAGNOSES,,Relative Weights,"$2,718.08 ",IP,"2,718.08","2,718.08",,,,,,
Humana Medicaid,DRG,5664,OTHER ANTEPARTUM DIAGNOSES,,Relative Weights,"$5,715.19 ",IP,"5,715.19","5,715.19",,,,,,
Humana Medicaid,DRG,5801,NEONATE TRANSFERRED 5 DAYS OLD NOT BORN HERE,,Relative Weights,"$1,625.35 ",IP,"1,625.35","1,625.35",,,,,,
Humana Medicaid,DRG,5802,NEONATE TRANSFERRED 5 DAYS OLD NOT BORN HERE,,Relative Weights,"$2,301.61 ",IP,"2,301.61","2,301.61",,,,,,
Humana Medicaid,DRG,5803,NEONATE TRANSFERRED 5 DAYS OLD NOT BORN HERE,,Relative Weights,"$3,477.84 ",IP,"3,477.84","3,477.84",,,,,,
Humana Medicaid,DRG,5804,NEONATE TRANSFERRED 5 DAYS OLD NOT BORN HERE,,Relative Weights,"$6,537.48 ",IP,"6,537.48","6,537.48",,,,,,
Humana Medicaid,DRG,5811,NEONATE TRANSFERRED  5 DAYS OLD BORN HERE,,Relative Weights,$559.42 ,IP,559.42,559.42,,,,,,
Humana Medicaid,DRG,5812,NEONATE TRANSFERRED  5 DAYS OLD BORN HERE,,Relative Weights,$716.80 ,IP,716.8,716.8,,,,,,
Humana Medicaid,DRG,5813,NEONATE TRANSFERRED  5 DAYS OLD BORN HERE,,Relative Weights,"$1,204.41 ",IP,"1,204.41","1,204.41",,,,,,
Humana Medicaid,DRG,5814,NEONATE TRANSFERRED  5 DAYS OLD BORN HERE,,Relative Weights,"$2,109.52 ",IP,"2,109.52","2,109.52",,,,,,
Humana Medicaid,DRG,5831,NEONATE W ECMO,,Relative Weights,"$87,271.04 ",IP,"87,271.04","87,271.04",,,,,,
Humana Medicaid,DRG,5832,NEONATE W ECMO,,Relative Weights,"$87,459.00 ",IP,"87,459.00","87,459.00",,,,,,
Humana Medicaid,DRG,5833,NEONATE W ECMO,,Relative Weights,"$148,358.12 ",IP,"148,358.12","148,358.12",,,,,,
Humana Medicaid,DRG,5834,NEONATE W ECMO,,Relative Weights,"$163,193.83 ",IP,"163,193.83","163,193.83",,,,,,
Humana Medicaid,DRG,5881,NEONATE BWT <1500G W MAJOR PROCEDURE,,Relative Weights,"$67,852.39 ",IP,"67,852.39","67,852.39",,,,,,
Humana Medicaid,DRG,5882,NEONATE BWT <1500G W MAJOR PROCEDURE,,Relative Weights,"$75,391.54 ",IP,"75,391.54","75,391.54",,,,,,
Humana Medicaid,DRG,5883,NEONATE BWT 1500G W MAJOR PROCEDURE,,Relative Weights,"$83,636.16 ",IP,"83,636.16","83,636.16",,,,,,
Humana Medicaid,DRG,5884,NEONATE BWT 1500G W MAJOR PROCEDURE,,Relative Weights,"$133,619.66 ",IP,"133,619.66","133,619.66",,,,,,
Humana Medicaid,DRG,5891,NEONATE BWT 500G OR GA 24 WEEKS,,Relative Weights,"$98,896.59 ",IP,"98,896.59","98,896.59",,,,,,
Humana Medicaid,DRG,5892,NEONATE BWT 500G OR GA 24 WEEKS,,Relative Weights,"$69,370.87 ",IP,"69,370.87","69,370.87",,,,,,
Humana Medicaid,DRG,5893,NEONATE BWT 500G OR GA 24 WEEKS,,Relative Weights,"$63,064.65 ",IP,"63,064.65","63,064.65",,,,,,
Humana Medicaid,DRG,5894,NEONATE BWT <500G OR GA <24 WEEKS,,Relative Weights,"$11,889.12 ",IP,"11,889.12","11,889.12",,,,,,
Humana Medicaid,DRG,5911,NEONATE BIRTHWT 500749G WO MAJOR PROCEDURE,,Relative Weights,"$57,344.65 ",IP,"57,344.65","57,344.65",,,,,,
Humana Medicaid,DRG,5912,NEONATE BIRTHWT 500749G WO MAJOR PROCEDURE,,Relative Weights,"$79,559.04 ",IP,"79,559.04","79,559.04",,,,,,
Humana Medicaid,DRG,5913,NEONATE BIRTHWT 500749G WO MAJOR PROCEDURE,,Relative Weights,"$85,488.65 ",IP,"85,488.65","85,488.65",,,,,,
Humana Medicaid,DRG,5914,NEONATE BIRTHWT 500-749G W/O MAJOR PROCEDURE,,Relative Weights,"$110,417.00 ",IP,"110,417.00","110,417.00",,,,,,
Humana Medicaid,DRG,5931,NEONATE BIRTHWT 750-999G W/O MAJOR PROCEDURE,,Relative Weights,"$37,781.34 ",IP,"37,781.34","37,781.34",,,,,,
Humana Medicaid,DRG,5932,NEONATE BIRTHWT 750999G WO MAJOR PROCEDURE,,Relative Weights,"$59,330.12 ",IP,"59,330.12","59,330.12",,,,,,
Humana Medicaid,DRG,5933,NEONATE BIRTHWT 750999G WO MAJOR PROCEDURE,,Relative Weights,"$71,323.01 ",IP,"71,323.01","71,323.01",,,,,,
Humana Medicaid,DRG,5934,NEONATE BIRTHWT 750999G WO MAJOR PROCEDURE,,Relative Weights,"$96,423.52 ",IP,"96,423.52","96,423.52",,,,,,
Humana Medicaid,DRG,6021,NEONATE BWT 10001249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$36,367.31 ",IP,"36,367.31","36,367.31",,,,,,
Humana Medicaid,DRG,6022,NEONATE BWT 10001249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$43,081.42 ",IP,"43,081.42","43,081.42",,,,,,
Humana Medicaid,DRG,6023,NEONATE BWT 10001249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$56,708.94 ",IP,"56,708.94","56,708.94",,,,,,
Humana Medicaid,DRG,6024,NEONATE BWT 10001249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$82,218.02 ",IP,"82,218.02","82,218.02",,,,,,
Humana Medicaid,DRG,6031,NEONATE BIRTHWT 10001249G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$21,131.62 ",IP,"21,131.62","21,131.62",,,,,,
Humana Medicaid,DRG,6032,NEONATE BIRTHWT 10001249G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$31,760.66 ",IP,"31,760.66","31,760.66",,,,,,
Humana Medicaid,DRG,6033,NEONATE BIRTHWT 10001249G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$45,733.18 ",IP,"45,733.18","45,733.18",,,,,,
Humana Medicaid,DRG,6034,NEONATE BIRTHWT 10001249G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$71,521.63 ",IP,"71,521.63","71,521.63",,,,,,
Humana Medicaid,DRG,6071,NEONATE BWT 1250-1499G W RESP DIST SYND/OTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$24,973.02 ",IP,"24,973.02","24,973.02",,,,,,
Humana Medicaid,DRG,6072,NEONATE BWT 12501499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$31,699.15 ",IP,"31,699.15","31,699.15",,,,,,
Humana Medicaid,DRG,6073,NEONATE BWT 12501499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$41,632.01 ",IP,"41,632.01","41,632.01",,,,,,
Humana Medicaid,DRG,6074,NEONATE BWT 12501499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$64,492.07 ",IP,"64,492.07","64,492.07",,,,,,
Humana Medicaid,DRG,6081,NEONATE BWT 12501499G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$16,607.44 ",IP,"16,607.44","16,607.44",,,,,,
Humana Medicaid,DRG,6082,NEONATE BWT 12501499G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$23,967.23 ",IP,"23,967.23","23,967.23",,,,,,
Humana Medicaid,DRG,6083,NEONATE BWT 12501499G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$34,646.09 ",IP,"34,646.09","34,646.09",,,,,,
Humana Medicaid,DRG,6084,NEONATE BWT 12501499G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$60,788.81 ",IP,"60,788.81","60,788.81",,,,,,
Humana Medicaid,DRG,6091,NEONATE BWT 15002499G W MAJOR PROCEDURE,,Relative Weights,"$25,499.11 ",IP,"25,499.11","25,499.11",,,,,,
Humana Medicaid,DRG,6092,NEONATE BWT 15002499G W MAJOR PROCEDURE,,Relative Weights,"$27,431.32 ",IP,"27,431.32","27,431.32",,,,,,
Humana Medicaid,DRG,6093,NEONATE BWT 15002499G W MAJOR PROCEDURE,,Relative Weights,"$47,002.54 ",IP,"47,002.54","47,002.54",,,,,,
Humana Medicaid,DRG,6094,NEONATE BWT 15002499G W MAJOR PROCEDURE,,Relative Weights,"$99,687.62 ",IP,"99,687.62","99,687.62",,,,,,
Humana Medicaid,DRG,6111,NEONATE BIRTHWT 15001999G W MAJOR ANOMALY,,Relative Weights,"$12,585.30 ",IP,"12,585.30","12,585.30",,,,,,
Humana Medicaid,DRG,6112,NEONATE BIRTHWT 15001999G W MAJOR ANOMALY,,Relative Weights,"$19,393.91 ",IP,"19,393.91","19,393.91",,,,,,
Humana Medicaid,DRG,6113,NEONATE BIRTHWT 15001999G W MAJOR ANOMALY,,Relative Weights,"$32,347.92 ",IP,"32,347.92","32,347.92",,,,,,
Humana Medicaid,DRG,6114,NEONATE BIRTHWT 15001999G W MAJOR ANOMALY,,Relative Weights,"$58,174.51 ",IP,"58,174.51","58,174.51",,,,,,
Humana Medicaid,DRG,6121,NEONATE BWT 1500-1999G W RESP DIST SYND/OTH MAJ RESP COND,,Relative Weights,"$16,224.65 ",IP,"16,224.65","16,224.65",,,,,,
Humana Medicaid,DRG,6122,NEONATE BWT 15001999G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$21,637.79 ",IP,"21,637.79","21,637.79",,,,,,
Humana Medicaid,DRG,6123,NEONATE BWT 15001999G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$29,186.22 ",IP,"29,186.22","29,186.22",,,,,,
Humana Medicaid,DRG,6124,NEONATE BWT 15001999G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$42,407.23 ",IP,"42,407.23","42,407.23",,,,,,
Humana Medicaid,DRG,6131,NEONATE BIRTHWT 1500-1999G W CONGENITAL/PERINATAL INFECTION,,Relative Weights,"$13,196.61 ",IP,"13,196.61","13,196.61",,,,,,
Humana Medicaid,DRG,6132,NEONATE BIRTHWT 15001999G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$21,189.35 ",IP,"21,189.35","21,189.35",,,,,,
Humana Medicaid,DRG,6133,NEONATE BIRTHWT 15001999G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$27,656.40 ",IP,"27,656.40","27,656.40",,,,,,
Humana Medicaid,DRG,6134,NEONATE BIRTHWT 15001999G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$47,731.03 ",IP,"47,731.03","47,731.03",,,,,,
Humana Medicaid,DRG,6141,NEONATE BWT 15001999G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$8,925.34 ",IP,"8,925.34","8,925.34",,,,,,
Humana Medicaid,DRG,6142,NEONATE BWT 1500-1999G W OR W/O OTHER SIGNIFICANT CONDITION,,Relative Weights,"$15,030.54 ",IP,"15,030.54","15,030.54",,,,,,
Humana Medicaid,DRG,6143,NEONATE BWT 1500-1999G W OR W/O OTHER SIGNIFICANT CONDITION,,Relative Weights,"$25,580.55 ",IP,"25,580.55","25,580.55",,,,,,
Humana Medicaid,DRG,6144,NEONATE BWT 15001999G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$45,341.79 ",IP,"45,341.79","45,341.79",,,,,,
Humana Medicaid,DRG,6211,NEONATE BWT 20002499G W MAJOR ANOMALY,,Relative Weights,"$6,929.91 ",IP,"6,929.91","6,929.91",,,,,,
Humana Medicaid,DRG,6212,NEONATE BWT 20002499G W MAJOR ANOMALY,,Relative Weights,"$14,367.69 ",IP,"14,367.69","14,367.69",,,,,,
Humana Medicaid,DRG,6213,NEONATE BWT 20002499G W MAJOR ANOMALY,,Relative Weights,"$26,320.72 ",IP,"26,320.72","26,320.72",,,,,,
Humana Medicaid,DRG,6214,NEONATE BWT 20002499G W MAJOR ANOMALY,,Relative Weights,"$49,514.79 ",IP,"49,514.79","49,514.79",,,,,,
Humana Medicaid,DRG,6221,NEONATE BWT 20002499G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$10,129.06 ",IP,"10,129.06","10,129.06",,,,,,
Humana Medicaid,DRG,6222,NEONATE BWT 20002499G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$13,681.47 ",IP,"13,681.47","13,681.47",,,,,,
Humana Medicaid,DRG,6223,NEONATE BWT 20002499G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$17,417.03 ",IP,"17,417.03","17,417.03",,,,,,
Humana Medicaid,DRG,6224,NEONATE BWT 20002499G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$32,501.52 ",IP,"32,501.52","32,501.52",,,,,,
Humana Medicaid,DRG,6231,NEONATE BWT 20002499G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$7,947.73 ",IP,"7,947.73","7,947.73",,,,,,
Humana Medicaid,DRG,6232,NEONATE BWT 20002499G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$11,704.59 ",IP,"11,704.59","11,704.59",,,,,,
Humana Medicaid,DRG,6233,NEONATE BWT 20002499G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$18,604.26 ",IP,"18,604.26","18,604.26",,,,,,
Humana Medicaid,DRG,6234,NEONATE BWT 2000-2499G W CONGENITAL/PERINATAL INFECTION,,Relative Weights,"$29,470.40 ",IP,"29,470.40","29,470.40",,,,,,
Humana Medicaid,DRG,6251,NEONATE BWT 20002499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$8,481.72 ",IP,"8,481.72","8,481.72",,,,,,
Humana Medicaid,DRG,6252,NEONATE BWT 20002499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$12,056.81 ",IP,"12,056.81","12,056.81",,,,,,
Humana Medicaid,DRG,6253,NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$17,253.12 ",IP,"17,253.12","17,253.12",,,,,,
Humana Medicaid,DRG,6254,NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$25,500.83 ",IP,"25,500.83","25,500.83",,,,,,
Humana Medicaid,DRG,6261,NEONATE BWT 20002499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM,,Relative Weights,"$1,026.75 ",IP,"1,026.75","1,026.75",,,,,,
Humana Medicaid,DRG,6262,NEONATE BWT 20002499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM,,Relative Weights,"$1,832.56 ",IP,"1,832.56","1,832.56",,,,,,
Humana Medicaid,DRG,6263,NEONATE BWT 20002499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM,,Relative Weights,"$5,129.99 ",IP,"5,129.99","5,129.99",,,,,,
Humana Medicaid,DRG,6264,"NEONATE BWT 2000-2499G, NORMAL NEWBORN OR NEONATE W OTHER PROBLEM",,Relative Weights,"$14,511.67 ",IP,"14,511.67","14,511.67",,,,,,
Humana Medicaid,DRG,6301,NEONATE BIRTHWT 2499G W MAJOR CARDIOVASCULAR PROCEDURE,,Relative Weights,"$14,642.59 ",IP,"14,642.59","14,642.59",,,,,,
Humana Medicaid,DRG,6302,NEONATE BIRTHWT 2499G W MAJOR CARDIOVASCULAR PROCEDURE,,Relative Weights,"$26,499.41 ",IP,"26,499.41","26,499.41",,,,,,
Humana Medicaid,DRG,6303,NEONATE BIRTHWT 2499G W MAJOR CARDIOVASCULAR PROCEDURE,,Relative Weights,"$44,508.84 ",IP,"44,508.84","44,508.84",,,,,,
Humana Medicaid,DRG,6304,NEONATE BIRTHWT >2499G W MAJOR CARDIOVASCULAR PROCEDURE,,Relative Weights,"$79,154.59 ",IP,"79,154.59","79,154.59",,,,,,
Humana Medicaid,DRG,6311,NEONATE BIRTHWT 2499G W OTHER MAJOR PROCEDURE,,Relative Weights,"$11,884.65 ",IP,"11,884.65","11,884.65",,,,,,
Humana Medicaid,DRG,6312,NEONATE BIRTHWT 2499G W OTHER MAJOR PROCEDURE,,Relative Weights,"$19,077.77 ",IP,"19,077.77","19,077.77",,,,,,
Humana Medicaid,DRG,6313,NEONATE BIRTHWT 2499G W OTHER MAJOR PROCEDURE,,Relative Weights,"$33,764.00 ",IP,"33,764.00","33,764.00",,,,,,
Humana Medicaid,DRG,6314,NEONATE BIRTHWT 2499G W OTHER MAJOR PROCEDURE,,Relative Weights,"$74,464.79 ",IP,"74,464.79","74,464.79",,,,,,
Humana Medicaid,DRG,6331,NEONATE BIRTHWT 2499G W MAJOR ANOMALY,,Relative Weights,"$2,688.87 ",IP,"2,688.87","2,688.87",,,,,,
Humana Medicaid,DRG,6332,NEONATE BIRTHWT 2499G W MAJOR ANOMALY,,Relative Weights,"$7,851.51 ",IP,"7,851.51","7,851.51",,,,,,
Humana Medicaid,DRG,6333,NEONATE BIRTHWT 2499G W MAJOR ANOMALY,,Relative Weights,"$17,713.92 ",IP,"17,713.92","17,713.92",,,,,,
Humana Medicaid,DRG,6334,NEONATE BIRTHWT 2499G W MAJOR ANOMALY,,Relative Weights,"$44,843.19 ",IP,"44,843.19","44,843.19",,,,,,
Humana Medicaid,DRG,6341,"NEONATE, BIRTHWT >2499G W RESP DIST SYND/OTH MAJ RESP COND",,Relative Weights,"$4,461.64 ",IP,"4,461.64","4,461.64",,,,,,
Humana Medicaid,DRG,6342,"NEONATE, BIRTHWT >2499G W RESP DIST SYND/OTH MAJ RESP COND",,Relative Weights,"$7,881.41 ",IP,"7,881.41","7,881.41",,,,,,
Humana Medicaid,DRG,6343,NEONATE BIRTHWT 2499G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$11,444.81 ",IP,"11,444.81","11,444.81",,,,,,
Humana Medicaid,DRG,6344,NEONATE BIRTHWT 2499G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$28,806.17 ",IP,"28,806.17","28,806.17",,,,,,
Humana Medicaid,DRG,6361,NEONATE BIRTHWT 2499G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$4,375.39 ",IP,"4,375.39","4,375.39",,,,,,
Humana Medicaid,DRG,6362,NEONATE BIRTHWT 2499G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$6,615.83 ",IP,"6,615.83","6,615.83",,,,,,
Humana Medicaid,DRG,6363,NEONATE BIRTHWT >2499G W CONGENITAL/PERINATAL INFECTION,,Relative Weights,"$13,140.60 ",IP,"13,140.60","13,140.60",,,,,,
Humana Medicaid,DRG,6364,NEONATE BIRTHWT 2499G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$22,289.30 ",IP,"22,289.30","22,289.30",,,,,,
Humana Medicaid,DRG,6391,NEONATE BIRTHWT 2499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$4,122.14 ",IP,"4,122.14","4,122.14",,,,,,
Humana Medicaid,DRG,6392,NEONATE BIRTHWT >2499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$7,440.19 ",IP,"7,440.19","7,440.19",,,,,,
Humana Medicaid,DRG,6393,NEONATE BIRTHWT >2499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$11,681.22 ",IP,"11,681.22","11,681.22",,,,,,
Humana Medicaid,DRG,6394,NEONATE BIRTHWT 2499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$20,735.08 ",IP,"20,735.08","20,735.08",,,,,,
Humana Medicaid,DRG,6401,NEONATE BIRTHWT 2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM,,Relative Weights,$571.11 ,IP,571.11,571.11,,,,,,
Humana Medicaid,DRG,6402,NEONATE BIRTHWT 2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM,,Relative Weights,$900.64 ,IP,900.64,900.64,,,,,,
Humana Medicaid,DRG,6403,"NEONATE BIRTHWT >2499G, NORMAL NEWBORN OR NEONATE W OTHER PROBLEM",,Relative Weights,"$2,228.41 ",IP,"2,228.41","2,228.41",,,,,,
Humana Medicaid,DRG,6404,NEONATE BIRTHWT 2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM,,Relative Weights,"$13,890.74 ",IP,"13,890.74","13,890.74",,,,,,
Humana Medicaid,DRG,6501,SPLENECTOMY,,Relative Weights,"$6,304.16 ",IP,"6,304.16","6,304.16",,,,,,
Humana Medicaid,DRG,6502,SPLENECTOMY,,Relative Weights,"$8,491.69 ",IP,"8,491.69","8,491.69",,,,,,
Humana Medicaid,DRG,6503,SPLENECTOMY,,Relative Weights,"$13,332.00 ",IP,"13,332.00","13,332.00",,,,,,
Humana Medicaid,DRG,6504,SPLENECTOMY,,Relative Weights,"$23,483.06 ",IP,"23,483.06","23,483.06",,,,,,
Humana Medicaid,DRG,6511,OTHER PROCEDURES OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$5,293.90 ",IP,"5,293.90","5,293.90",,,,,,
Humana Medicaid,DRG,6512,OTHER PROCEDURES OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$7,236.76 ",IP,"7,236.76","7,236.76",,,,,,
Humana Medicaid,DRG,6513,OTHER PROCEDURES OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$10,916.31 ",IP,"10,916.31","10,916.31",,,,,,
Humana Medicaid,DRG,6514,OTHER PROCEDURES OF BLOOD & BLOOD-FORMING ORGANS,,Relative Weights,"$33,538.24 ",IP,"33,538.24","33,538.24",,,,,,
Humana Medicaid,DRG,6601,MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS and COAGUL,,Relative Weights,"$3,747.59 ",IP,"3,747.59","3,747.59",,,,,,
Humana Medicaid,DRG,6602,MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS and COAGUL,,Relative Weights,"$4,287.77 ",IP,"4,287.77","4,287.77",,,,,,
Humana Medicaid,DRG,6603,MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS and COAGUL,,Relative Weights,"$6,366.70 ",IP,"6,366.70","6,366.70",,,,,,
Humana Medicaid,DRG,6604,MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS and COAGUL,,Relative Weights,"$16,194.41 ",IP,"16,194.41","16,194.41",,,,,,
Humana Medicaid,DRG,6611,COAGULATION and PLATELET DISORDERS,,Relative Weights,"$3,902.56 ",IP,"3,902.56","3,902.56",,,,,,
Humana Medicaid,DRG,6612,COAGULATION and PLATELET DISORDERS,,Relative Weights,"$5,668.11 ",IP,"5,668.11","5,668.11",,,,,,
Humana Medicaid,DRG,6613,COAGULATION and PLATELET DISORDERS,,Relative Weights,"$9,739.74 ",IP,"9,739.74","9,739.74",,,,,,
Humana Medicaid,DRG,6614,COAGULATION and PLATELET DISORDERS,,Relative Weights,"$15,545.30 ",IP,"15,545.30","15,545.30",,,,,,
Humana Medicaid,DRG,6621,SICKLE CELL ANEMIA CRISIS,,Relative Weights,"$2,821.17 ",IP,"2,821.17","2,821.17",,,,,,
Humana Medicaid,DRG,6622,SICKLE CELL ANEMIA CRISIS,,Relative Weights,"$3,681.27 ",IP,"3,681.27","3,681.27",,,,,,
Humana Medicaid,DRG,6623,SICKLE CELL ANEMIA CRISIS,,Relative Weights,"$5,206.96 ",IP,"5,206.96","5,206.96",,,,,,
Humana Medicaid,DRG,6624,SICKLE CELL ANEMIA CRISIS,,Relative Weights,"$10,694.33 ",IP,"10,694.33","10,694.33",,,,,,
Humana Medicaid,DRG,6631,OTHER ANEMIA and DISORDERS OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$2,701.59 ",IP,"2,701.59","2,701.59",,,,,,
Humana Medicaid,DRG,6632,OTHER ANEMIA and DISORDERS OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$3,327.33 ",IP,"3,327.33","3,327.33",,,,,,
Humana Medicaid,DRG,6633,OTHER ANEMIA and DISORDERS OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$4,391.20 ",IP,"4,391.20","4,391.20",,,,,,
Humana Medicaid,DRG,6634,OTHER ANEMIA and DISORDERS OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$8,007.52 ",IP,"8,007.52","8,007.52",,,,,,
Humana Medicaid,DRG,6801,MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$7,740.52 ",IP,"7,740.52","7,740.52",,,,,,
Humana Medicaid,DRG,6802,MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$10,236.62 ",IP,"10,236.62","10,236.62",,,,,,
Humana Medicaid,DRG,6803,MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$16,199.56 ",IP,"16,199.56","16,199.56",,,,,,
Humana Medicaid,DRG,6804,MAJOR O.R. PROCEDURES FOR LYMPHATIC/HEMATOPOIETIC/OTHER NEOPLASMS,,Relative Weights,"$34,974.94 ",IP,"34,974.94","34,974.94",,,,,,
Humana Medicaid,DRG,6811,OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$6,220.66 ",IP,"6,220.66","6,220.66",,,,,,
Humana Medicaid,DRG,6812,OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$7,805.46 ",IP,"7,805.46","7,805.46",,,,,,
Humana Medicaid,DRG,6813,OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$13,731.30 ",IP,"13,731.30","13,731.30",,,,,,
Humana Medicaid,DRG,6814,OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$32,311.50 ",IP,"32,311.50","32,311.50",,,,,,
Humana Medicaid,DRG,6901,ACUTE LEUKEMIA,,Relative Weights,"$8,376.23 ",IP,"8,376.23","8,376.23",,,,,,
Humana Medicaid,DRG,6902,ACUTE LEUKEMIA,,Relative Weights,"$11,965.06 ",IP,"11,965.06","11,965.06",,,,,,
Humana Medicaid,DRG,6903,ACUTE LEUKEMIA,,Relative Weights,"$18,264.07 ",IP,"18,264.07","18,264.07",,,,,,
Humana Medicaid,DRG,6904,ACUTE LEUKEMIA,,Relative Weights,"$33,495.63 ",IP,"33,495.63","33,495.63",,,,,,
Humana Medicaid,DRG,6911,LYMPHOMA MYELOMA and NONACUTE LEUKEMIA,,Relative Weights,"$6,184.92 ",IP,"6,184.92","6,184.92",,,,,,
Humana Medicaid,DRG,6912,"LYMPHOMA, MYELOMA & NON-ACUTE LEUKEMIA",,Relative Weights,"$6,251.93 ",IP,"6,251.93","6,251.93",,,,,,
Humana Medicaid,DRG,6913,LYMPHOMA MYELOMA and NONACUTE LEUKEMIA,,Relative Weights,"$9,090.97 ",IP,"9,090.97","9,090.97",,,,,,
Humana Medicaid,DRG,6914,LYMPHOMA MYELOMA and NONACUTE LEUKEMIA,,Relative Weights,"$18,806.65 ",IP,"18,806.65","18,806.65",,,,,,
Humana Medicaid,DRG,6921,RADIOTHERAPY,,Relative Weights,"$5,028.28 ",IP,"5,028.28","5,028.28",,,,,,
Humana Medicaid,DRG,6922,RADIOTHERAPY,,Relative Weights,"$8,603.36 ",IP,"8,603.36","8,603.36",,,,,,
Humana Medicaid,DRG,6923,RADIOTHERAPY,,Relative Weights,"$11,232.45 ",IP,"11,232.45","11,232.45",,,,,,
Humana Medicaid,DRG,6924,RADIOTHERAPY,,Relative Weights,"$22,232.95 ",IP,"22,232.95","22,232.95",,,,,,
Humana Medicaid,DRG,6941,LYMPHATIC & OTHER MALIGNANCIES & NEOPLASMS OF UNCERTAIN BEHAVIOR,,Relative Weights,"$3,669.93 ",IP,"3,669.93","3,669.93",,,,,,
Humana Medicaid,DRG,6942,LYMPHATIC and OTHER MALIGNANCIES and NEOPLASMS OF UNCERTAIN BEHAVIOR,,Relative Weights,"$4,230.04 ",IP,"4,230.04","4,230.04",,,,,,
Humana Medicaid,DRG,6943,LYMPHATIC and OTHER MALIGNANCIES and NEOPLASMS OF UNCERTAIN BEHAVIOR,,Relative Weights,"$5,867.41 ",IP,"5,867.41","5,867.41",,,,,,
Humana Medicaid,DRG,6944,LYMPHATIC and OTHER MALIGNANCIES and NEOPLASMS OF UNCERTAIN BEHAVIOR,,Relative Weights,"$11,092.25 ",IP,"11,092.25","11,092.25",,,,,,
Humana Medicaid,DRG,6951,CHEMOTHERAPY FOR ACUTE LEUKEMIA,,Relative Weights,"$3,844.14 ",IP,"3,844.14","3,844.14",,,,,,
Humana Medicaid,DRG,6952,CHEMOTHERAPY FOR ACUTE LEUKEMIA,,Relative Weights,"$4,908.70 ",IP,"4,908.70","4,908.70",,,,,,
Humana Medicaid,DRG,6953,CHEMOTHERAPY FOR ACUTE LEUKEMIA,,Relative Weights,"$11,375.74 ",IP,"11,375.74","11,375.74",,,,,,
Humana Medicaid,DRG,6954,CHEMOTHERAPY FOR ACUTE LEUKEMIA,,Relative Weights,"$32,868.17 ",IP,"32,868.17","32,868.17",,,,,,
Humana Medicaid,DRG,6961,OTHER CHEMOTHERAPY,,Relative Weights,"$4,174.03 ",IP,"4,174.03","4,174.03",,,,,,
Humana Medicaid,DRG,6962,OTHER CHEMOTHERAPY,,Relative Weights,"$5,397.68 ",IP,"5,397.68","5,397.68",,,,,,
Humana Medicaid,DRG,6963,OTHER CHEMOTHERAPY,,Relative Weights,"$7,757.01 ",IP,"7,757.01","7,757.01",,,,,,
Humana Medicaid,DRG,6964,OTHER CHEMOTHERAPY,,Relative Weights,"$17,845.53 ",IP,"17,845.53","17,845.53",,,,,,
Humana Medicaid,DRG,7101,INFECTIOUS & PARASITIC DISEASES INCLUDING HIV W O.R. PROCEDURE,,Relative Weights,"$5,318.64 ",IP,"5,318.64","5,318.64",,,,,,
Humana Medicaid,DRG,7102,INFECTIOUS and PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE,,Relative Weights,"$7,922.30 ",IP,"7,922.30","7,922.30",,,,,,
Humana Medicaid,DRG,7103,INFECTIOUS and PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE,,Relative Weights,"$12,117.63 ",IP,"12,117.63","12,117.63",,,,,,
Humana Medicaid,DRG,7104,INFECTIOUS and PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE,,Relative Weights,"$24,582.32 ",IP,"24,582.32","24,582.32",,,,,,
Humana Medicaid,DRG,7111,POSTOP POSTTRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE,,Relative Weights,"$5,432.73 ",IP,"5,432.73","5,432.73",,,,,,
Humana Medicaid,DRG,7112,POSTOP POSTTRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE,,Relative Weights,"$7,124.05 ",IP,"7,124.05","7,124.05",,,,,,
Humana Medicaid,DRG,7113,POSTOP POSTTRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE,,Relative Weights,"$12,166.42 ",IP,"12,166.42","12,166.42",,,,,,
Humana Medicaid,DRG,7114,POSTOP POSTTRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE,,Relative Weights,"$25,010.82 ",IP,"25,010.82","25,010.82",,,,,,
Humana Medicaid,DRG,7201,SEPTICEMIA and DISSEMINATED INFECTIONS,,Relative Weights,"$2,801.24 ",IP,"2,801.24","2,801.24",,,,,,
Humana Medicaid,DRG,7202,SEPTICEMIA and DISSEMINATED INFECTIONS,,Relative Weights,"$3,678.52 ",IP,"3,678.52","3,678.52",,,,,,
Humana Medicaid,DRG,7203,SEPTICEMIA and DISSEMINATED INFECTIONS,,Relative Weights,"$5,399.74 ",IP,"5,399.74","5,399.74",,,,,,
Humana Medicaid,DRG,7204,SEPTICEMIA and DISSEMINATED INFECTIONS,,Relative Weights,"$10,740.72 ",IP,"10,740.72","10,740.72",,,,,,
Humana Medicaid,DRG,7211,"POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS",,Relative Weights,"$2,917.38 ",IP,"2,917.38","2,917.38",,,,,,
Humana Medicaid,DRG,7212,POSTOPERATIVE POSTTRAUMATIC OTHER DEVICE INFECTIONS,,Relative Weights,"$3,837.27 ",IP,"3,837.27","3,837.27",,,,,,
Humana Medicaid,DRG,7213,POSTOPERATIVE POSTTRAUMATIC OTHER DEVICE INFECTIONS,,Relative Weights,"$6,182.18 ",IP,"6,182.18","6,182.18",,,,,,
Humana Medicaid,DRG,7214,POSTOPERATIVE POSTTRAUMATIC OTHER DEVICE INFECTIONS,,Relative Weights,"$12,158.86 ",IP,"12,158.86","12,158.86",,,,,,
Humana Medicaid,DRG,7221,FEVER,,Relative Weights,"$1,952.14 ",IP,"1,952.14","1,952.14",,,,,,
Humana Medicaid,DRG,7222,FEVER,,Relative Weights,"$2,920.13 ",IP,"2,920.13","2,920.13",,,,,,
Humana Medicaid,DRG,7223,FEVER,,Relative Weights,"$3,952.39 ",IP,"3,952.39","3,952.39",,,,,,
Humana Medicaid,DRG,7224,FEVER,,Relative Weights,"$6,941.25 ",IP,"6,941.25","6,941.25",,,,,,
Humana Medicaid,DRG,7231,VIRAL ILLNESS,,Relative Weights,"$1,908.50 ",IP,"1,908.50","1,908.50",,,,,,
Humana Medicaid,DRG,7232,VIRAL ILLNESS,,Relative Weights,"$2,685.44 ",IP,"2,685.44","2,685.44",,,,,,
Humana Medicaid,DRG,7233,VIRAL ILLNESS,,Relative Weights,"$4,131.07 ",IP,"4,131.07","4,131.07",,,,,,
Humana Medicaid,DRG,7234,VIRAL ILLNESS,,Relative Weights,"$10,429.39 ",IP,"10,429.39","10,429.39",,,,,,
Humana Medicaid,DRG,7241,OTHER INFECTIOUS and PARASITIC DISEASES,,Relative Weights,"$3,048.31 ",IP,"3,048.31","3,048.31",,,,,,
Humana Medicaid,DRG,7242,OTHER INFECTIOUS and PARASITIC DISEASES,,Relative Weights,"$3,655.49 ",IP,"3,655.49","3,655.49",,,,,,
Humana Medicaid,DRG,7243,OTHER INFECTIOUS and PARASITIC DISEASES,,Relative Weights,"$5,820.68 ",IP,"5,820.68","5,820.68",,,,,,
Humana Medicaid,DRG,7244,OTHER INFECTIOUS and PARASITIC DISEASES,,Relative Weights,"$13,099.02 ",IP,"13,099.02","13,099.02",,,,,,
Humana Medicaid,DRG,7401,MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE,,Relative Weights,"$6,032.70 ",IP,"6,032.70","6,032.70",,,,,,
Humana Medicaid,DRG,7402,MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE,,Relative Weights,"$6,703.46 ",IP,"6,703.46","6,703.46",,,,,,
Humana Medicaid,DRG,7403,MENTAL ILLNESS DIAGNOSIS W O.R. PROCEDURE,,Relative Weights,"$13,324.79 ",IP,"13,324.79","13,324.79",,,,,,
Humana Medicaid,DRG,7404,MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE,,Relative Weights,"$26,668.81 ",IP,"26,668.81","26,668.81",,,,,,
Humana Medicaid,DRG,7501,SCHIZOPHRENIA,,Relative Weights,"$2,530.12 ",IP,"2,530.12","2,530.12",,,,,,
Humana Medicaid,DRG,7502,SCHIZOPHRENIA,,Relative Weights,"$2,708.80 ",IP,"2,708.80","2,708.80",,,,,,
Humana Medicaid,DRG,7503,SCHIZOPHRENIA,,Relative Weights,"$4,799.08 ",IP,"4,799.08","4,799.08",,,,,,
Humana Medicaid,DRG,7504,SCHIZOPHRENIA,,Relative Weights,"$13,473.58 ",IP,"13,473.58","13,473.58",,,,,,
Humana Medicaid,DRG,7511,MAJOR DEPRESSIVE DISORDERS and OTHERUNSPECIFIED PSYCHOSES,,Relative Weights,"$1,760.40 ",IP,"1,760.40","1,760.40",,,,,,
Humana Medicaid,DRG,7512,MAJOR DEPRESSIVE DISORDERS & OTHER/UNSPECIFIED PSYCHOSES,,Relative Weights,"$2,237.01 ",IP,"2,237.01","2,237.01",,,,,,
Humana Medicaid,DRG,7513,MAJOR DEPRESSIVE DISORDERS and OTHERUNSPECIFIED PSYCHOSES,,Relative Weights,"$3,773.70 ",IP,"3,773.70","3,773.70",,,,,,
Humana Medicaid,DRG,7514,MAJOR DEPRESSIVE DISORDERS and OTHERUNSPECIFIED PSYCHOSES,,Relative Weights,"$8,518.14 ",IP,"8,518.14","8,518.14",,,,,,
Humana Medicaid,DRG,7521,DISORDERS OF PERSONALITY and IMPULSE CONTROL,,Relative Weights,"$1,687.20 ",IP,"1,687.20","1,687.20",,,,,,
Humana Medicaid,DRG,7522,DISORDERS OF PERSONALITY & IMPULSE CONTROL,,Relative Weights,"$2,102.30 ",IP,"2,102.30","2,102.30",,,,,,
Humana Medicaid,DRG,7523,DISORDERS OF PERSONALITY & IMPULSE CONTROL,,Relative Weights,"$3,885.72 ",IP,"3,885.72","3,885.72",,,,,,
Humana Medicaid,DRG,7524,DISORDERS OF PERSONALITY and IMPULSE CONTROL,,Relative Weights,"$13,737.14 ",IP,"13,737.14","13,737.14",,,,,,
Humana Medicaid,DRG,7531,BIPOLAR DISORDERS,,Relative Weights,"$1,873.11 ",IP,"1,873.11","1,873.11",,,,,,
Humana Medicaid,DRG,7532,BIPOLAR DISORDERS,,Relative Weights,"$2,183.40 ",IP,"2,183.40","2,183.40",,,,,,
Humana Medicaid,DRG,7533,BIPOLAR DISORDERS,,Relative Weights,"$3,541.07 ",IP,"3,541.07","3,541.07",,,,,,
Humana Medicaid,DRG,7534,BIPOLAR DISORDERS,,Relative Weights,"$10,043.84 ",IP,"10,043.84","10,043.84",,,,,,
Humana Medicaid,DRG,7541,DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,,Relative Weights,"$1,523.64 ",IP,"1,523.64","1,523.64",,,,,,
Humana Medicaid,DRG,7542,DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,,Relative Weights,"$2,007.46 ",IP,"2,007.46","2,007.46",,,,,,
Humana Medicaid,DRG,7543,DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,,Relative Weights,"$3,012.23 ",IP,"3,012.23","3,012.23",,,,,,
Humana Medicaid,DRG,7544,DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,,Relative Weights,"$7,979.68 ",IP,"7,979.68","7,979.68",,,,,,
Humana Medicaid,DRG,7551,ADJUSTMENT DISORDERS and NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,,Relative Weights,"$1,532.57 ",IP,"1,532.57","1,532.57",,,,,,
Humana Medicaid,DRG,7552,ADJUSTMENT DISORDERS and NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,,Relative Weights,"$2,506.06 ",IP,"2,506.06","2,506.06",,,,,,
Humana Medicaid,DRG,7553,ADJUSTMENT DISORDERS and NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,,Relative Weights,"$3,538.32 ",IP,"3,538.32","3,538.32",,,,,,
Humana Medicaid,DRG,7554,ADJUSTMENT DISORDERS and NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,,Relative Weights,"$6,118.26 ",IP,"6,118.26","6,118.26",,,,,,
Humana Medicaid,DRG,7561,ACUTE ANXIETY and DELIRIUM STATES,,Relative Weights,"$2,496.79 ",IP,"2,496.79","2,496.79",,,,,,
Humana Medicaid,DRG,7562,ACUTE ANXIETY & DELIRIUM STATES,,Relative Weights,"$3,057.58 ",IP,"3,057.58","3,057.58",,,,,,
Humana Medicaid,DRG,7563,ACUTE ANXIETY and DELIRIUM STATES,,Relative Weights,"$3,397.43 ",IP,"3,397.43","3,397.43",,,,,,
Humana Medicaid,DRG,7564,ACUTE ANXIETY and DELIRIUM STATES,,Relative Weights,"$7,384.52 ",IP,"7,384.52","7,384.52",,,,,,
Humana Medicaid,DRG,7571,ORGANIC MENTAL HEALTH DISTURBANCES,,Relative Weights,"$2,504.35 ",IP,"2,504.35","2,504.35",,,,,,
Humana Medicaid,DRG,7572,ORGANIC MENTAL HEALTH DISTURBANCES,,Relative Weights,"$3,161.02 ",IP,"3,161.02","3,161.02",,,,,,
Humana Medicaid,DRG,7573,ORGANIC MENTAL HEALTH DISTURBANCES,,Relative Weights,"$5,750.24 ",IP,"5,750.24","5,750.24",,,,,,
Humana Medicaid,DRG,7574,ORGANIC MENTAL HEALTH DISTURBANCES,,Relative Weights,"$15,933.94 ",IP,"15,933.94","15,933.94",,,,,,
Humana Medicaid,DRG,7581,BEHAVIORAL DISORDERS,,Relative Weights,"$2,326.35 ",IP,"2,326.35","2,326.35",,,,,,
Humana Medicaid,DRG,7582,BEHAVIORAL DISORDERS,,Relative Weights,"$2,881.65 ",IP,"2,881.65","2,881.65",,,,,,
Humana Medicaid,DRG,7583,BEHAVIORAL DISORDERS,,Relative Weights,"$4,037.26 ",IP,"4,037.26","4,037.26",,,,,,
Humana Medicaid,DRG,7584,BEHAVIORAL DISORDERS,,Relative Weights,"$5,464.00 ",IP,"5,464.00","5,464.00",,,,,,
Humana Medicaid,DRG,7591,EATING DISORDERS,,Relative Weights,"$4,564.04 ",IP,"4,564.04","4,564.04",,,,,,
Humana Medicaid,DRG,7592,EATING DISORDERS,,Relative Weights,"$5,955.04 ",IP,"5,955.04","5,955.04",,,,,,
Humana Medicaid,DRG,7593,EATING DISORDERS,,Relative Weights,"$9,440.78 ",IP,"9,440.78","9,440.78",,,,,,
Humana Medicaid,DRG,7594,EATING DISORDERS,,Relative Weights,"$12,954.01 ",IP,"12,954.01","12,954.01",,,,,,
Humana Medicaid,DRG,7601,OTHER MENTAL HEALTH DISORDERS,,Relative Weights,"$2,553.48 ",IP,"2,553.48","2,553.48",,,,,,
Humana Medicaid,DRG,7602,OTHER MENTAL HEALTH DISORDERS,,Relative Weights,"$3,467.19 ",IP,"3,467.19","3,467.19",,,,,,
Humana Medicaid,DRG,7603,OTHER MENTAL HEALTH DISORDERS,,Relative Weights,"$6,902.07 ",IP,"6,902.07","6,902.07",,,,,,
Humana Medicaid,DRG,7604,OTHER MENTAL HEALTH DISORDERS,,Relative Weights,"$12,546.82 ",IP,"12,546.82","12,546.82",,,,,,
Humana Medicaid,DRG,7701,DRUG and ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE,,Relative Weights,"$1,041.53 ",IP,"1,041.53","1,041.53",,,,,,
Humana Medicaid,DRG,7702,"DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE",,Relative Weights,"$1,522.95 ",IP,"1,522.95","1,522.95",,,,,,
Humana Medicaid,DRG,7703,"DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE",,Relative Weights,"$2,633.89 ",IP,"2,633.89","2,633.89",,,,,,
Humana Medicaid,DRG,7704,DRUG and ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE,,Relative Weights,"$6,153.65 ",IP,"6,153.65","6,153.65",,,,,,
Humana Medicaid,DRG,7721,ALCOHOL and DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY,,Relative Weights,"$2,743.85 ",IP,"2,743.85","2,743.85",,,,,,
Humana Medicaid,DRG,7722,ALCOHOL and DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY,,Relative Weights,"$3,502.58 ",IP,"3,502.58","3,502.58",,,,,,
Humana Medicaid,DRG,7723,ALCOHOL and DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY,,Relative Weights,"$4,241.72 ",IP,"4,241.72","4,241.72",,,,,,
Humana Medicaid,DRG,7724,ALCOHOL & DRUG DEPENDENCE W REHAB OR REHAB/DETOX THERAPY,,Relative Weights,"$9,550.40 ",IP,"9,550.40","9,550.40",,,,,,
Humana Medicaid,DRG,7731,OPIOID ABUSE and DEPENDENCE,,Relative Weights,"$1,275.88 ",IP,"1,275.88","1,275.88",,,,,,
Humana Medicaid,DRG,7732,OPIOID ABUSE and DEPENDENCE,,Relative Weights,"$1,881.01 ",IP,"1,881.01","1,881.01",,,,,,
Humana Medicaid,DRG,7733,OPIOID ABUSE and DEPENDENCE,,Relative Weights,"$3,476.12 ",IP,"3,476.12","3,476.12",,,,,,
Humana Medicaid,DRG,7734,OPIOID ABUSE & DEPENDENCE,,Relative Weights,"$9,565.86 ",IP,"9,565.86","9,565.86",,,,,,
Humana Medicaid,DRG,7741,COCAINE ABUSE and DEPENDENCE,,Relative Weights,"$1,761.43 ",IP,"1,761.43","1,761.43",,,,,,
Humana Medicaid,DRG,7742,COCAINE ABUSE and DEPENDENCE,,Relative Weights,"$1,956.95 ",IP,"1,956.95","1,956.95",,,,,,
Humana Medicaid,DRG,7743,COCAINE ABUSE and DEPENDENCE,,Relative Weights,"$3,314.62 ",IP,"3,314.62","3,314.62",,,,,,
Humana Medicaid,DRG,7744,COCAINE ABUSE and DEPENDENCE,,Relative Weights,"$9,105.40 ",IP,"9,105.40","9,105.40",,,,,,
Humana Medicaid,DRG,7751,ALCOHOL ABUSE and DEPENDENCE,,Relative Weights,"$1,741.50 ",IP,"1,741.50","1,741.50",,,,,,
Humana Medicaid,DRG,7752,ALCOHOL ABUSE & DEPENDENCE,,Relative Weights,"$2,441.81 ",IP,"2,441.81","2,441.81",,,,,,
Humana Medicaid,DRG,7753,ALCOHOL ABUSE and DEPENDENCE,,Relative Weights,"$3,986.06 ",IP,"3,986.06","3,986.06",,,,,,
Humana Medicaid,DRG,7754,ALCOHOL ABUSE and DEPENDENCE,,Relative Weights,"$10,751.37 ",IP,"10,751.37","10,751.37",,,,,,
Humana Medicaid,DRG,7761,OTHER DRUG ABUSE and DEPENDENCE,,Relative Weights,"$2,414.66 ",IP,"2,414.66","2,414.66",,,,,,
Humana Medicaid,DRG,7762,OTHER DRUG ABUSE & DEPENDENCE,,Relative Weights,"$2,653.48 ",IP,"2,653.48","2,653.48",,,,,,
Humana Medicaid,DRG,7763,OTHER DRUG ABUSE & DEPENDENCE,,Relative Weights,"$4,175.40 ",IP,"4,175.40","4,175.40",,,,,,
Humana Medicaid,DRG,7764,OTHER DRUG ABUSE and DEPENDENCE,,Relative Weights,"$7,699.28 ",IP,"7,699.28","7,699.28",,,,,,
Humana Medicaid,DRG,7921,EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$7,773.51 ",IP,"7,773.51","7,773.51",,,,,,
Humana Medicaid,DRG,7922,EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$8,931.53 ",IP,"8,931.53","8,931.53",,,,,,
Humana Medicaid,DRG,7923,EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$13,005.21 ",IP,"13,005.21","13,005.21",,,,,,
Humana Medicaid,DRG,7924,EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$27,591.45 ",IP,"27,591.45","27,591.45",,,,,,
Humana Medicaid,DRG,7931,MODERATELY EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$4,608.37 ",IP,"4,608.37","4,608.37",,,,,,
Humana Medicaid,DRG,7932,MODERATELY EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$6,350.90 ",IP,"6,350.90","6,350.90",,,,,,
Humana Medicaid,DRG,7933,MODERATELY EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$9,808.12 ",IP,"9,808.12","9,808.12",,,,,,
Humana Medicaid,DRG,7934,MODERATELY EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$20,177.03 ",IP,"20,177.03","20,177.03",,,,,,
Humana Medicaid,DRG,7941,NONEXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$3,990.87 ",IP,"3,990.87","3,990.87",,,,,,
Humana Medicaid,DRG,7942,NONEXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$5,327.92 ",IP,"5,327.92","5,327.92",,,,,,
Humana Medicaid,DRG,7943,NONEXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$7,911.30 ",IP,"7,911.30","7,911.30",,,,,,
Humana Medicaid,DRG,7944,NON-EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$16,457.28 ",IP,"16,457.28","16,457.28",,,,,,
Humana Medicaid,DRG,8101,HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION,,Relative Weights,"$2,594.03 ",IP,"2,594.03","2,594.03",,,,,,
Humana Medicaid,DRG,8102,HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION,,Relative Weights,"$3,420.11 ",IP,"3,420.11","3,420.11",,,,,,
Humana Medicaid,DRG,8103,HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION,,Relative Weights,"$5,351.98 ",IP,"5,351.98","5,351.98",,,,,,
Humana Medicaid,DRG,8104,HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION,,Relative Weights,"$10,772.68 ",IP,"10,772.68","10,772.68",,,,,,
Humana Medicaid,DRG,8111,ALLERGIC REACTIONS,,Relative Weights,"$1,582.40 ",IP,"1,582.40","1,582.40",,,,,,
Humana Medicaid,DRG,8112,ALLERGIC REACTIONS,,Relative Weights,"$2,325.66 ",IP,"2,325.66","2,325.66",,,,,,
Humana Medicaid,DRG,8113,ALLERGIC REACTIONS,,Relative Weights,"$4,003.24 ",IP,"4,003.24","4,003.24",,,,,,
Humana Medicaid,DRG,8114,ALLERGIC REACTIONS,,Relative Weights,"$9,358.65 ",IP,"9,358.65","9,358.65",,,,,,
Humana Medicaid,DRG,8121,POISONING OF MEDICINAL AGENTS,,Relative Weights,"$1,778.95 ",IP,"1,778.95","1,778.95",,,,,,
Humana Medicaid,DRG,8122,POISONING OF MEDICINAL AGENTS,,Relative Weights,"$2,471.70 ",IP,"2,471.70","2,471.70",,,,,,
Humana Medicaid,DRG,8123,POISONING OF MEDICINAL AGENTS,,Relative Weights,"$3,713.91 ",IP,"3,713.91","3,713.91",,,,,,
Humana Medicaid,DRG,8124,POISONING OF MEDICINAL AGENTS,,Relative Weights,"$7,487.95 ",IP,"7,487.95","7,487.95",,,,,,
Humana Medicaid,DRG,8131,OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$2,963.09 ",IP,"2,963.09","2,963.09",,,,,,
Humana Medicaid,DRG,8132,OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$3,546.91 ",IP,"3,546.91","3,546.91",,,,,,
Humana Medicaid,DRG,8133,OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$5,048.90 ",IP,"5,048.90","5,048.90",,,,,,
Humana Medicaid,DRG,8134,OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$10,108.45 ",IP,"10,108.45","10,108.45",,,,,,
Humana Medicaid,DRG,8151,OTHER INJURY POISONING and TOXIC EFFECT DIAGNOSES,,Relative Weights,"$2,225.32 ",IP,"2,225.32","2,225.32",,,,,,
Humana Medicaid,DRG,8152,"OTHER INJURY, POISONING & TOXIC EFFECT DIAGNOSES",,Relative Weights,"$3,062.74 ",IP,"3,062.74","3,062.74",,,,,,
Humana Medicaid,DRG,8153,OTHER INJURY POISONING and TOXIC EFFECT DIAGNOSES,,Relative Weights,"$5,006.29 ",IP,"5,006.29","5,006.29",,,,,,
Humana Medicaid,DRG,8154,OTHER INJURY POISONING and TOXIC EFFECT DIAGNOSES,,Relative Weights,"$14,243.99 ",IP,"14,243.99","14,243.99",,,,,,
Humana Medicaid,DRG,8161,TOXIC EFFECTS OF NONMEDICINAL SUBSTANCES,,Relative Weights,"$2,832.85 ",IP,"2,832.85","2,832.85",,,,,,
Humana Medicaid,DRG,8162,TOXIC EFFECTS OF NONMEDICINAL SUBSTANCES,,Relative Weights,"$3,147.27 ",IP,"3,147.27","3,147.27",,,,,,
Humana Medicaid,DRG,8163,TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES,,Relative Weights,"$3,543.13 ",IP,"3,543.13","3,543.13",,,,,,
Humana Medicaid,DRG,8164,TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES,,Relative Weights,"$7,485.21 ",IP,"7,485.21","7,485.21",,,,,,
Humana Medicaid,DRG,8171,OVERDOSE,,Relative Weights,"$1,970.70 ",IP,"1,970.70","1,970.70",,,,,,
Humana Medicaid,DRG,8172,OVERDOSE,,Relative Weights,"$2,320.16 ",IP,"2,320.16","2,320.16",,,,,,
Humana Medicaid,DRG,8173,OVERDOSE,,Relative Weights,"$3,714.94 ",IP,"3,714.94","3,714.94",,,,,,
Humana Medicaid,DRG,8174,OVERDOSE,,Relative Weights,"$7,902.37 ",IP,"7,902.37","7,902.37",,,,,,
Humana Medicaid,DRG,8411,EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT,,Relative Weights,"$22,662.13 ",IP,"22,662.13","22,662.13",,,,,,
Humana Medicaid,DRG,8412,EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT,,Relative Weights,"$23,053.18 ",IP,"23,053.18","23,053.18",,,,,,
Humana Medicaid,DRG,8413,EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT,,Relative Weights,"$35,475.26 ",IP,"35,475.26","35,475.26",,,,,,
Humana Medicaid,DRG,8414,EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT,,Relative Weights,"$76,935.80 ",IP,"76,935.80","76,935.80",,,,,,
Humana Medicaid,DRG,8421,BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS,,Relative Weights,"$7,378.34 ",IP,"7,378.34","7,378.34",,,,,,
Humana Medicaid,DRG,8422,BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS,,Relative Weights,"$11,298.08 ",IP,"11,298.08","11,298.08",,,,,,
Humana Medicaid,DRG,8423,BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS,,Relative Weights,"$20,251.94 ",IP,"20,251.94","20,251.94",,,,,,
Humana Medicaid,DRG,8424,BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS,,Relative Weights,"$47,998.02 ",IP,"47,998.02","47,998.02",,,,,,
Humana Medicaid,DRG,8431,EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT,,Relative Weights,"$3,499.14 ",IP,"3,499.14","3,499.14",,,,,,
Humana Medicaid,DRG,8432,EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT,,Relative Weights,"$3,888.47 ",IP,"3,888.47","3,888.47",,,,,,
Humana Medicaid,DRG,8433,EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT,,Relative Weights,"$4,320.07 ",IP,"4,320.07","4,320.07",,,,,,
Humana Medicaid,DRG,8434,EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS W/O SKIN GRAFT,,Relative Weights,"$12,575.34 ",IP,"12,575.34","12,575.34",,,,,,
Humana Medicaid,DRG,8441,PARTIAL THICKNESS BURNS WO SKIN GRAFT,,Relative Weights,"$2,201.96 ",IP,"2,201.96","2,201.96",,,,,,
Humana Medicaid,DRG,8442,PARTIAL THICKNESS BURNS WO SKIN GRAFT,,Relative Weights,"$3,652.06 ",IP,"3,652.06","3,652.06",,,,,,
Humana Medicaid,DRG,8443,PARTIAL THICKNESS BURNS WO SKIN GRAFT,,Relative Weights,"$7,050.86 ",IP,"7,050.86","7,050.86",,,,,,
Humana Medicaid,DRG,8444,PARTIAL THICKNESS BURNS W/O SKIN GRAFT,,Relative Weights,"$19,183.95 ",IP,"19,183.95","19,183.95",,,,,,
Humana Medicaid,DRG,8501,PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE,,Relative Weights,"$9,879.93 ",IP,"9,879.93","9,879.93",,,,,,
Humana Medicaid,DRG,8502,PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE,,Relative Weights,"$12,498.36 ",IP,"12,498.36","12,498.36",,,,,,
Humana Medicaid,DRG,8503,PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE,,Relative Weights,"$15,265.59 ",IP,"15,265.59","15,265.59",,,,,,
Humana Medicaid,DRG,8504,"PROCEDURE W DIAG OF REHAB, AFTERCARE OR OTH CONTACT W HEALTH SERVICE",,Relative Weights,"$33,306.29 ",IP,"33,306.29","33,306.29",,,,,,
Humana Medicaid,DRG,8601,REHABILITATION,REHABILITATION,Relative Weights,"$2,725.99 ",IP,"2,725.99","2,725.99",,,,,,
Humana Medicaid,DRG,8602,REHABILITATION,REHABILITATION,Relative Weights,"$2,784.40 ",IP,"2,784.40","2,784.40",,,,,,
Humana Medicaid,DRG,8603,REHABILITATION,REHABILITATION,Relative Weights,"$4,569.88 ",IP,"4,569.88","4,569.88",,,,,,
Humana Medicaid,DRG,8604,REHABILITATION,REHABILITATION,Relative Weights,"$7,353.25 ",IP,"7,353.25","7,353.25",,,,,,
Humana Medicaid,DRG,8611,"SIGNS, SYMPTOMS & OTHER FACTORS INFLUENCING HEALTH STATUS",,Relative Weights,"$2,528.74 ",IP,"2,528.74","2,528.74",,,,,,
Humana Medicaid,DRG,8612,SIGNS SYMPTOMS and OTHER FACTORS INFLUENCING HEALTH STATUS,,Relative Weights,"$3,061.36 ",IP,"3,061.36","3,061.36",,,,,,
Humana Medicaid,DRG,8613,SIGNS SYMPTOMS and OTHER FACTORS INFLUENCING HEALTH STATUS,,Relative Weights,"$4,043.10 ",IP,"4,043.10","4,043.10",,,,,,
Humana Medicaid,DRG,8614,SIGNS SYMPTOMS and OTHER FACTORS INFLUENCING HEALTH STATUS,,Relative Weights,"$7,783.47 ",IP,"7,783.47","7,783.47",,,,,,
Humana Medicaid,DRG,8621,OTHER AFTERCARE and CONVALESCENCE,,Relative Weights,"$2,738.70 ",IP,"2,738.70","2,738.70",,,,,,
Humana Medicaid,DRG,8622,OTHER AFTERCARE and CONVALESCENCE,,Relative Weights,"$3,392.96 ",IP,"3,392.96","3,392.96",,,,,,
Humana Medicaid,DRG,8623,OTHER AFTERCARE and CONVALESCENCE,,Relative Weights,"$4,971.92 ",IP,"4,971.92","4,971.92",,,,,,
Humana Medicaid,DRG,8624,OTHER AFTERCARE and CONVALESCENCE,,Relative Weights,"$9,845.92 ",IP,"9,845.92","9,845.92",,,,,,
Humana Medicaid,DRG,8631,NEONATAL AFTERCARE,,Relative Weights,"$4,260.96 ",IP,"4,260.96","4,260.96",,,,,,
Humana Medicaid,DRG,8632,NEONATAL AFTERCARE,,Relative Weights,"$10,340.39 ",IP,"10,340.39","10,340.39",,,,,,
Humana Medicaid,DRG,8633,NEONATAL AFTERCARE,,Relative Weights,"$23,505.05 ",IP,"23,505.05","23,505.05",,,,,,
Humana Medicaid,DRG,8634,NEONATAL AFTERCARE,,Relative Weights,"$48,982.51 ",IP,"48,982.51","48,982.51",,,,,,
Humana Medicaid,DRG,8901,HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS,,Relative Weights,"$3,464.78 ",IP,"3,464.78","3,464.78",,,,,,
Humana Medicaid,DRG,8902,HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS,,Relative Weights,"$4,475.73 ",IP,"4,475.73","4,475.73",,,,,,
Humana Medicaid,DRG,8903,HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS,,Relative Weights,"$6,306.22 ",IP,"6,306.22","6,306.22",,,,,,
Humana Medicaid,DRG,8904,HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS,,Relative Weights,"$13,523.40 ",IP,"13,523.40","13,523.40",,,,,,
Humana Medicaid,DRG,8921,HIV W MAJOR HIV RELATED CONDITION,,Relative Weights,"$3,450.69 ",IP,"3,450.69","3,450.69",,,,,,
Humana Medicaid,DRG,8922,HIV W MAJOR HIV RELATED CONDITION,,Relative Weights,"$4,178.15 ",IP,"4,178.15","4,178.15",,,,,,
Humana Medicaid,DRG,8923,HIV W MAJOR HIV RELATED CONDITION,,Relative Weights,"$4,816.26 ",IP,"4,816.26","4,816.26",,,,,,
Humana Medicaid,DRG,8924,HIV W MAJOR HIV RELATED CONDITION,,Relative Weights,"$8,453.20 ",IP,"8,453.20","8,453.20",,,,,,
Humana Medicaid,DRG,8931,HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,,Relative Weights,"$2,817.73 ",IP,"2,817.73","2,817.73",,,,,,
Humana Medicaid,DRG,8932,HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,,Relative Weights,"$4,010.80 ",IP,"4,010.80","4,010.80",,,,,,
Humana Medicaid,DRG,8933,HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,,Relative Weights,"$5,201.12 ",IP,"5,201.12","5,201.12",,,,,,
Humana Medicaid,DRG,8934,HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,,Relative Weights,"$9,134.61 ",IP,"9,134.61","9,134.61",,,,,,
Humana Medicaid,DRG,8941,HIV W ONE SIGNIF HIV COND OR W/O SIGNIF RELATED COND,,Relative Weights,"$2,969.96 ",IP,"2,969.96","2,969.96",,,,,,
Humana Medicaid,DRG,8942,HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND,,Relative Weights,"$3,496.05 ",IP,"3,496.05","3,496.05",,,,,,
Humana Medicaid,DRG,8943,HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND,,Relative Weights,"$4,518.34 ",IP,"4,518.34","4,518.34",,,,,,
Humana Medicaid,DRG,8944,HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND,,Relative Weights,"$6,751.91 ",IP,"6,751.91","6,751.91",,,,,,
Humana Medicaid,DRG,9101,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$13,920.63 ",IP,"13,920.63","13,920.63",,,,,,
Humana Medicaid,DRG,9102,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$15,317.47 ",IP,"15,317.47","15,317.47",,,,,,
Humana Medicaid,DRG,9103,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$18,619.37 ",IP,"18,619.37","18,619.37",,,,,,
Humana Medicaid,DRG,9104,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$36,457.00 ",IP,"36,457.00","36,457.00",,,,,,
Humana Medicaid,DRG,9111,EXTENSIVE ABDOMINAL/THORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA,,Relative Weights,"$7,838.80 ",IP,"7,838.80","7,838.80",,,,,,
Humana Medicaid,DRG,9112,EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA,,Relative Weights,"$10,303.63 ",IP,"10,303.63","10,303.63",,,,,,
Humana Medicaid,DRG,9113,EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA,,Relative Weights,"$13,414.47 ",IP,"13,414.47","13,414.47",,,,,,
Humana Medicaid,DRG,9114,EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA,,Relative Weights,"$32,085.73 ",IP,"32,085.73","32,085.73",,,,,,
Humana Medicaid,DRG,9121,MUSCULOSKELETAL and OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$8,688.93 ",IP,"8,688.93","8,688.93",,,,,,
Humana Medicaid,DRG,9122,MUSCULOSKELETAL and OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$9,567.24 ",IP,"9,567.24","9,567.24",,,,,,
Humana Medicaid,DRG,9123,MUSCULOSKELETAL & OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$14,948.76 ",IP,"14,948.76","14,948.76",,,,,,
Humana Medicaid,DRG,9124,MUSCULOSKELETAL & OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$30,211.60 ",IP,"30,211.60","30,211.60",,,,,,
Humana Medicaid,DRG,9301,MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE,,Relative Weights,"$3,875.76 ",IP,"3,875.76","3,875.76",,,,,,
Humana Medicaid,DRG,9302,MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE,,Relative Weights,"$4,609.06 ",IP,"4,609.06","4,609.06",,,,,,
Humana Medicaid,DRG,9303,MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE,,Relative Weights,"$7,139.17 ",IP,"7,139.17","7,139.17",,,,,,
Humana Medicaid,DRG,9304,MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE,,Relative Weights,"$15,709.89 ",IP,"15,709.89","15,709.89",,,,,,
Humana Medicaid,DRG,9501,EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$7,265.63 ",IP,"7,265.63","7,265.63",,,,,,
Humana Medicaid,DRG,9502,EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$9,410.20 ",IP,"9,410.20","9,410.20",,,,,,
Humana Medicaid,DRG,9503,EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$12,679.80 ",IP,"12,679.80","12,679.80",,,,,,
Humana Medicaid,DRG,9504,EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$27,388.02 ",IP,"27,388.02","27,388.02",,,,,,
Humana Medicaid,DRG,9511,MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$5,641.31 ",IP,"5,641.31","5,641.31",,,,,,
Humana Medicaid,DRG,9512,MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$7,394.49 ",IP,"7,394.49","7,394.49",,,,,,
Humana Medicaid,DRG,9513,MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$11,184.68 ",IP,"11,184.68","11,184.68",,,,,,
Humana Medicaid,DRG,9514,MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$22,584.13 ",IP,"22,584.13","22,584.13",,,,,,
Humana Medicaid,DRG,9521,NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$4,663.69 ",IP,"4,663.69","4,663.69",,,,,,
Humana Medicaid,DRG,9522,NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$6,212.76 ",IP,"6,212.76","6,212.76",,,,,,
Humana Medicaid,DRG,9523,NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$9,852.10 ",IP,"9,852.10","9,852.10",,,,,,
Humana Medicaid,DRG,9524,NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$20,519.28 ",IP,"20,519.28","20,519.28",,,,,,
Humana Medicaid,CPT,100,Anesth salivary gland,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,102,Anesth repair of cleft lip,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,103,Anesth blepharoplasty,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,104,Anesth electroshock,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,120,Anesth ear surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,124,Anesth ear exam,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,126,Anesth tympanotomy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,140,Anesth procedures on eye,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,142,Anesth lens surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,144,Anesth corneal transplant,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,145,Anesth vitreoretinal surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,147,Anesth iridectomy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,148,Anesth eye exam,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,160,Anesth nose/sinus surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,162,Anesth nose/sinus surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,164,Anesth biopsy of nose,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,170,Anesth procedure on mouth,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,172,Anesth cleft palate repair,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,174,Anesth pharyngeal surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,176,Anesth pharyngeal surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,190,Anesth face/skull bone surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,192,Anesth facial bone surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,210,Anesth cranial surg nos,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,211,Anesth cran surg hemotoma,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,212,Anesth skull drainage,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,214,Anesth skull drainage,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,215,Anesth skull repair/fract,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,216,Anesth head vessel surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,218,Anesth special head surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,220,Anesth intrcrn nerve,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,222,Anesth head nerve surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,300,Anesth head/neck/ptrunk,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,320,Anesth neck organ 1yr/>,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,322,Anesth biopsy of thyroid,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,326,Anesth larynx/trach < 1 yr,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,350,Anesth neck vessel surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,352,Anesth neck vessel surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,400,Anesth skin ext/per/atrunk,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,402,Anesth surgery of breast,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,404,Anesth surgery of breast,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,406,Anesth surgery of breast,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,410,Anesth correct heart rhythm,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,450,Anesth surgery of shoulder,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,454,Anesth collar bone biopsy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,470,Anesth removal of rib,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,472,Anesth chest wall repair,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,474,Anesth surgery of rib,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,500,Anesth esophageal surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,520,Anesth chest procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,522,Anesth chest lining biopsy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,524,Anesth chest drainage,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,528,Anes mediascpy & dx thorscpy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,529,Anes medscpy&thorscpy 1 lung,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,530,Anesth pacemaker insertion,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,532,Anesth vascular access,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,534,Anesth cardioverter/defib,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,537,Anesth cardiac electrophys,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,539,Anesth trach-bronch reconst,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,540,Anesth chest surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,541,Anesth one lung ventilation,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,542,Anesthesia removal pleura,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,546,Anesth lung chest wall surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,548,Anesth trachea bronchi surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,550,Anesth sternal debridement,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,560,Anesth heart surg w/o pump,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,561,Anesth heart surg <1 yr,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,562,Anesth hrt surg w/pmp age 1+,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,563,Anesth heart surg w/arrest,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,566,Anesth cabg w/o pump,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,567,Anesth cabg w/pump,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,580,Anesth heart/lung transplnt,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,600,Anesth spine cord surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,604,Anesth sitting procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,620,Anesth spine cord surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,625,Anes spine tranthor w/o vent,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,626,Anes spine transthor w/vent,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,630,Anesth spine cord surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,632,Anesth removal of nerves,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,635,Anesth lumbar puncture,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,640,Anesth spine manipulation,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,670,Anesth spine cord surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,700,Anesth abdominal wall surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,702,Anesth for liver biopsy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,730,Anesth abdominal wall surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,731,Anes upr gi ndsc px nos,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,732,Anes upr gi ndsc px ercp,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,740,Anesth upper gi visualize,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,750,Anesth repair of hernia,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,752,Anesth repair of hernia,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,754,Anesth repair of hernia,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,756,Anesth repair of hernia,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,770,Anesth blood vessel repair,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,790,Anesth surg upper abdomen,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,792,Anesth hemorr/excise liver,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,794,Anesth pancreas removal,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,796,Anesth for liver transplant,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,797,Anesth surgery for obesity,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,800,Anesth abdominal wall surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,802,Anesth fat layer removal,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,810,Anesth low intestine scope,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,811,Anes lwr intst ndsc nos,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,812,Anes lwr intst scr colsc,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,813,Anes upr lwr gi ndsc px,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,820,Anesth abdominal wall surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,830,Anesth repair of hernia,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,832,Anesth repair of hernia,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,834,Anesth hernia repair < 1 yr,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,836,Anesth hernia repair preemie,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,840,Anesth surg lower abdomen,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,842,Anesth amniocentesis,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,844,Anesth pelvis surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,846,Anesth hysterectomy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,848,Anesth pelvic organ surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,851,Anesth tubal ligation,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,860,Anesth surgery of abdomen,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,862,Anesth kidney/ureter surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,864,Anesth removal of bladder,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,865,Anesth removal of prostate,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,866,Anesth removal of adrenal,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,868,Anesth kidney transplant,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,870,Anesth bladder stone surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,872,Anesth kidney stone destruct,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,873,Anesth kidney stone destruct,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,880,Anesth abdomen vessel surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,882,Anesth major vein ligation,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,902,Anesth anorectal surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,904,Anesth perineal surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,906,Anesth removal of vulva,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,908,Anesth removal of prostate,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,910,Anesth bladder surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,912,Anesth bladder tumor surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,914,Anesth removal of prostate,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,916,Anesth bleeding control,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,918,Anesth stone removal,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,920,Anesth genitalia surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,921,Anesth vasectomy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,922,Anesth sperm duct surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,924,Anesth testis exploration,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,926,Anesth removal of testis,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,928,Anesth removal of testis,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,930,Anesth testis suspension,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,932,Anesth amputation of penis,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,934,Anesth penis nodes removal,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,936,Anesth penis nodes removal,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,938,Anesth insert penis device,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,940,Anesth vaginal procedures,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,942,Anesth surg on vag/urethral,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,944,Anesth vaginal hysterectomy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,948,Anesth repair of cervix,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,950,Anesth vaginal endoscopy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,952,Anesth hysteroscope/graph,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1112,Anesth bone aspirate/bx,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1120,Anesth pelvis surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1130,Anesth body cast procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1140,Anesth amputation at pelvis,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1150,Anesth pelvic tumor surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1160,Anesth pelvis procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1170,Anesth pelvis surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1173,Anesth fx repair pelvis,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1180,Anesth pelvis nerve removal,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1190,Anesth pelvis nerve removal,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1200,Anesth hip joint procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1202,Anesth arthroscopy of hip,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1210,Anesth hip joint surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1212,Anesth hip disarticulation,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1214,Anesth hip arthroplasty,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1215,Anesth revise hip repair,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1220,Anesth procedure on femur,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1230,Anesth surgery of femur,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1232,Anesth amputation of femur,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1234,Anesth radical femur surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1250,Anesth upper leg surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1260,Anesth upper leg veins surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1270,Anesth thigh arteries surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1272,Anesth femoral artery surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1274,Anesth femoral embolectomy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1320,Anesth knee area surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1340,Anesth knee area procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1360,Anesth knee area surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1380,Anesth knee joint procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1382,Anesth dx knee arthroscopy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1390,Anesth knee area procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1392,Anesth knee area surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1400,Anesth knee joint surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1402,Anesth knee arthroplasty,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1404,Anesth amputation at knee,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1420,Anesth knee joint casting,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1430,Anesth knee veins surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1432,Anesth knee vessel surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1440,Anesth knee arteries surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1442,Anesth knee artery surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1444,Anesth knee artery repair,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1462,Anesth lower leg procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1464,Anesth ankle/ft arthroscopy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1470,Anesth lower leg surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1472,Anesth achilles tendon surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1474,Anesth lower leg surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1480,Anesth lower leg bone surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1482,Anesth radical leg surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1484,Anesth lower leg revision,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1486,Anesth ankle replacement,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1490,Anesth lower leg casting,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1500,Anesth leg arteries surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1502,Anesth lwr leg embolectomy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1520,Anesth lower leg vein surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1522,Anesth lower leg vein surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1610,Anesth surgery of shoulder,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1620,Anesth shoulder procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1622,Anes dx shoulder arthroscopy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1630,Anesth surgery of shoulder,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1634,Anesth shoulder joint amput,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1636,Anesth forequarter amput,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1638,Anesth shoulder replacement,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1650,Anesth shoulder artery surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1652,Anesth shoulder vessel surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1654,Anesth shoulder vessel surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1656,Anesth arm-leg vessel surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1670,Anesth shoulder vein surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1680,Anesth shoulder casting,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1682,Anesth airplane cast,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1710,Anesth elbow area surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1712,Anesth uppr arm tendon surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1714,Anesth uppr arm tendon surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1716,Anesth biceps tendon repair,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1730,Anesth uppr arm procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1732,Anesth dx elbow arthroscopy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1740,Anesth upper arm surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1742,Anesth humerus surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1744,Anesth humerus repair,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1756,Anesth radical humerus surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1758,Anesth humeral lesion surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1760,Anesth elbow replacement,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1770,Anesth uppr arm artery surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1772,Anesth uppr arm embolectomy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1780,Anesth upper arm vein surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1782,Anesth uppr arm vein repair,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1810,Anesth lower arm surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1820,Anesth lower arm procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1829,Anesth dx wrist arthroscopy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1830,Anesth lower arm surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1832,Anesth wrist replacement,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1840,Anesth lwr arm artery surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1842,Anesth lwr arm embolectomy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1844,Anesth vascular shunt surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1850,Anesth lower arm vein surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1852,Anesth lwr arm vein repair,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1860,Anesth lower arm casting,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1916,Anesth dx arteriography,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1920,Anesth catheterize heart,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1922,Anesth cat or mri scan,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1924,Anes ther interven rad artrl,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1925,Anes ther interven rad card,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1926,Anes tx interv rad hrt/cran,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1930,Anes ther interven rad vein,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1931,Anes ther interven rad tips,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1932,Anes tx interv rad th vein,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1933,Anes tx interv rad cran vein,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1935,Anesth perc img dx sp proc,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1936,Anesth perc img tx sp proc,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1951,Anesth burn less 4 percent,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1952,Anesth burn 4-9 percent,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1953,Anesth burn each 9 percent,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1958,Anesth antepartum manipul,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1960,Anesth vaginal delivery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1961,Anesth cs delivery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1962,Anesth emer hysterectomy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1963,Anesth cs hysterectomy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1965,Anesth inc/missed ab proc,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1966,Anesth induced ab procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1967,Anesth/analg vag delivery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1968,Anes/analg cs deliver add-on,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1969,Anesth/analg cs hyst add-on,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1991,Anesth nerve block/inj,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1992,Anesth n block/inj prone,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1996,Hosp manage cont drug admin,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,1999,Unlisted anesth procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,10004,Fna bx w/o img gdn ea addl,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
Humana Medicaid,CPT,10005,Fna bx w/us gdn 1st les,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
Humana Medicaid,CPT,10006,Fna bx w/us gdn ea addl,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
Humana Medicaid,CPT,10007,Fna bx w/fluor gdn 1st les,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
Humana Medicaid,CPT,10008,Fna bx w/fluor gdn ea addl,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
Humana Medicaid,CPT,10009,Fna bx w/ct gdn 1st les,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
Humana Medicaid,CPT,10010,Fna bx w/ct gdn ea addl,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
Humana Medicaid,CPT,10011,Fna bx w/mr gdn 1st les,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
Humana Medicaid,CPT,10012,Fna bx w/mr gdn ea addl,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
Humana Medicaid,CPT,10021,Fna bx w/o img gdn 1st les,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
Humana Medicaid,CPT,10022,Fna w/image,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
Humana Medicaid,CPT,10030,Guide cathet fluid drainage,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
Humana Medicaid,CPT,10040,Acne surgery,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,10060,Drainage of skin abscess,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,10061,Drainage of skin abscess,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,10080,Drainage of pilonidal cyst,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,10081,Drainage of pilonidal cyst,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
Humana Medicaid,CPT,10120,Remove foreign body,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,10121,Remove foreign body,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Humana Medicaid,CPT,10140,Drainage of hematoma/fluid,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
Humana Medicaid,CPT,10160,Puncture drainage of lesion,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,11055,Trim skin lesion,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,11056,Trim skin lesions 2 to 4,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,11057,Trim skin lesions over 4,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,11100,Biopsy skin lesion,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,11101,Biopsy skin add-on,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,11102,Tangntl bx skin single les,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,11103,Tangntl bx skin ea sep/addl,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,11104,Punch bx skin single lesion,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,11105,Punch bx skin ea sep/addl,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,11106,Incal bx skn single les,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,11107,Incal bx skn ea sep/addl,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,11200,Removal of skin tags <w/15,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,11201,Remove skin tags add-on,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,11300,Shave skin lesion 0.5 cm/<,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,11301,Shave skin lesion 0.6-1.0 cm,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,11302,Shave skin lesion 1.1-2.0 cm,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,11303,Shave skin lesion >2.0 cm,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,11305,Shave skin lesion 0.5 cm/<,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,11306,Shave skin lesion 0.6-1.0 cm,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,11307,Shave skin lesion 1.1-2.0 cm,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,11308,Shave skin lesion >2.0 cm,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,11310,Shave skin lesion 0.5 cm/<,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,11311,Shave skin lesion 0.6-1.0 cm,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,11312,Shave skin lesion 1.1-2.0 cm,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,11313,Shave skin lesion >2.0 cm,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,11400,Exc tr-ext b9+marg 0.5 cm<,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,11401,Exc tr-ext b9+marg 0.6-1 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,11402,Exc tr-ext b9+marg 1.1-2 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,11403,Exc tr-ext b9+marg 2.1-3cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,11404,Exc tr-ext b9+marg 3.1-4 cm,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Humana Medicaid,CPT,11406,Exc tr-ext b9+marg >4.0 cm,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Humana Medicaid,CPT,11420,Exc h-f-nk-sp b9+marg 0.5/<,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Humana Medicaid,CPT,11421,Exc h-f-nk-sp b9+marg 0.6-1,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,11422,Exc h-f-nk-sp b9+marg 1.1-2,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Humana Medicaid,CPT,11423,Exc h-f-nk-sp b9+marg 2.1-3,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Humana Medicaid,CPT,11424,Exc h-f-nk-sp b9+marg 3.1-4,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Humana Medicaid,CPT,11426,Exc h-f-nk-sp b9+marg >4 cm,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Humana Medicaid,CPT,11440,Exc face-mm b9+marg 0.5 cm/<,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,11441,Exc face-mm b9+marg 0.6-1 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,11442,Exc face-mm b9+marg 1.1-2 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,11443,Exc face-mm b9+marg 2.1-3 cm,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Humana Medicaid,CPT,11444,Exc face-mm b9+marg 3.1-4 cm,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Humana Medicaid,CPT,11446,Exc face-mm b9+marg >4 cm,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Humana Medicaid,CPT,11450,Removal sweat gland lesion,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Humana Medicaid,CPT,11451,Removal sweat gland lesion,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Humana Medicaid,CPT,11462,Removal sweat gland lesion,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Humana Medicaid,CPT,11463,Removal sweat gland lesion,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Humana Medicaid,CPT,11470,Removal sweat gland lesion,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Humana Medicaid,CPT,11471,Removal sweat gland lesion,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Humana Medicaid,CPT,11600,Exc tr-ext mal+marg 0.5 cm/<,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,11601,Exc tr-ext mal+marg 0.6-1 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,11602,Exc tr-ext mal+marg 1.1-2 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,11603,Exc tr-ext mal+marg 2.1-3 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,11604,Exc tr-ext mal+marg 3.1-4 cm,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Humana Medicaid,CPT,11606,Exc tr-ext mal+marg >4 cm,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Humana Medicaid,CPT,11620,Exc h-f-nk-sp mal+marg 0.5/<,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Humana Medicaid,CPT,11621,Exc s/n/h/f/g mal+mrg 0.6-1,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,11622,Exc s/n/h/f/g mal+mrg 1.1-2,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,11623,Exc s/n/h/f/g mal+mrg 2.1-3,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Humana Medicaid,CPT,11624,Exc s/n/h/f/g mal+mrg 3.1-4,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Humana Medicaid,CPT,11626,Exc s/n/h/f/g mal+mrg >4 cm,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Humana Medicaid,CPT,11640,Exc f/e/e/n/l mal+mrg 0.5cm<,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,11641,Exc f/e/e/n/l mal+mrg 0.6-1,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,11642,Exc f/e/e/n/l mal+mrg 1.1-2,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,11643,Exc f/e/e/n/l mal+mrg 2.1-3,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Humana Medicaid,CPT,11644,Exc f/e/e/n/l mal+mrg 3.1-4,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Humana Medicaid,CPT,11646,Exc f/e/e/n/l mal+mrg >4 cm,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Humana Medicaid,CPT,11719,Trim nail(s) any number,General Surgery,Per Unit,$46.77 ,OP,46.77,46.77,,,,,,
Humana Medicaid,CPT,11720,Debride nail 1-5,General Surgery,Per Unit,$46.77 ,OP,46.77,46.77,,,,,,
Humana Medicaid,CPT,11721,Debride nail 6 or more,General Surgery,Per Unit,$46.77 ,OP,46.77,46.77,,,,,,
Humana Medicaid,CPT,11730,Removal of nail plate,General Surgery,Per Unit,$46.77 ,OP,46.77,46.77,,,,,,
Humana Medicaid,CPT,11732,Remove nail plate add-on,General Surgery,Per Unit,$46.77 ,OP,46.77,46.77,,,,,,
Humana Medicaid,CPT,11740,Drain blood from under nail,General Surgery,Per Unit,$46.77 ,OP,46.77,46.77,,,,,,
Humana Medicaid,CPT,11750,Removal of nail bed,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,11752,Remove nail bed/tip,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Humana Medicaid,CPT,11755,Biopsy nail unit,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,11760,Repair of nail bed,General Surgery,Per Unit,$46.77 ,OP,46.77,46.77,,,,,,
Humana Medicaid,CPT,11762,Reconstruction of nail bed,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Humana Medicaid,CPT,11765,Excision of nail fold toe,General Surgery,Per Unit,$46.77 ,OP,46.77,46.77,,,,,,
Humana Medicaid,CPT,11770,Remove pilonidal cyst simple,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Humana Medicaid,CPT,11771,Remove pilonidal cyst exten,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Humana Medicaid,CPT,11772,Remove pilonidal cyst compl,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Humana Medicaid,CPT,11900,Inject skin lesions </w 7,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,11901,Inject skin lesions >7,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,11920,Correct skin color 6.0 cm/<,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,11921,Correct skn color 6.1-20.0cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,11922,Correct skin color ea 20.0cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,11950,Tx contour defects 1 cc/<,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,11951,Tx contour defects 1.1-5.0cc,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,11952,Tx contour defects 5.1-10cc,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,11954,Tx contour defects >10.0 cc,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Humana Medicaid,CPT,11960,Insert tissue expander(s),General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Humana Medicaid,CPT,11971,Rmvl tis xpndr wo insj implt,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Humana Medicaid,CPT,11976,Remove contraceptive capsule,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,11980,Implant hormone pellet(s),General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,11981,Insert drug implant device,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,11982,Remove drug implant device,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,11983,Remove/insert drug implant,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
Humana Medicaid,CPT,13100,Cmplx rpr trunk 1.1-2.5 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,13101,Cmplx rpr trunk 2.6-7.5 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,13102,Cmplx rpr trunk addl 5cm/<,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,13120,Cmplx rpr s/a/l 1.1-2.5 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,13121,Cmplx rpr s/a/l 2.6-7.5 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,13122,Cmplx rpr s/a/l addl 5 cm/>,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,13131,Cmplx rpr f/c/c/m/n/ax/g/h/f,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,13132,Cmplx rpr f/c/c/m/n/ax/g/h/f,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,13133,Cmplx rpr f/c/c/m/n/ax/g/h/f,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,13151,Cmplx rpr e/n/e/l 1.1-2.5 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,13152,Cmplx rpr e/n/e/l 2.6-7.5 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,13153,Cmplx rpr e/n/e/l addl 5cm/<,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Humana Medicaid,CPT,15050,Skin pinch graft,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,15775,Hair trnspl 1-15 punch grfts,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,15776,Hair trnspl >15 punch grafts,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,15780,Dermabrasion total face,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
Humana Medicaid,CPT,15781,Dermabrasion segmental face,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
Humana Medicaid,CPT,15782,Dermabrasion other than face,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
Humana Medicaid,CPT,15783,Dermabrasion suprfl any site,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
Humana Medicaid,CPT,15786,Abrasion lesion single,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,15787,Abrasion lesions add-on,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,15788,Chemical peel face epiderm,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,15789,Chemical peel face dermal,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,15792,Chemical peel nonfacial,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,15793,Chemical peel nonfacial,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
Humana Medicaid,CPT,15819,Plastic surgery neck,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Humana Medicaid,CPT,15820,Revision of lower eyelid,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Humana Medicaid,CPT,15821,Revision of lower eyelid,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Humana Medicaid,CPT,15822,Revision of upper eyelid,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Humana Medicaid,CPT,15823,Revision of upper eyelid,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Humana Medicaid,CPT,15824,Removal of forehead wrinkles,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Humana Medicaid,CPT,15825,Removal of neck wrinkles,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Humana Medicaid,CPT,15826,Removal of brow wrinkles,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Humana Medicaid,CPT,15828,Removal of face wrinkles,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Humana Medicaid,CPT,15829,Removal of skin wrinkles,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Humana Medicaid,CPT,15830,Exc skin abd,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Humana Medicaid,CPT,15832,Excise excessive skin thigh,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Humana Medicaid,CPT,15833,Excise excessive skin leg,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Humana Medicaid,CPT,15834,Excise excessive skin hip,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Humana Medicaid,CPT,15835,Excise excessive skin buttck,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Humana Medicaid,CPT,15836,Excise excessive skin arm,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Humana Medicaid,CPT,15837,Excise excess skin arm/hand,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Humana Medicaid,CPT,15838,Excise excess skin fat pad,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Humana Medicaid,CPT,15839,Excise excess skin & tissue,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Humana Medicaid,CPT,15847,Exc skin abd add-on,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Humana Medicaid,CPT,15850,Remove sutures same surgeon,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Humana Medicaid,CPT,15851,Remove sutures diff surgeon,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Humana Medicaid,CPT,15876,Suction lipectomy head&neck,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Humana Medicaid,CPT,15877,Suction lipectomy trunk,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Humana Medicaid,CPT,15878,Suction lipectomy upr extrem,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Humana Medicaid,CPT,15879,Suction lipectomy lwr extrem,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Humana Medicaid,CPT,17000,Destruct premalg lesion,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,17003,Destruct premalg les 2-14,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,17004,Destroy premal lesions 15/>,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,17106,Destruction of skin lesions,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
Humana Medicaid,CPT,17107,Destruction of skin lesions,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
Humana Medicaid,CPT,17108,Destruction of skin lesions,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
Humana Medicaid,CPT,17110,Destruct b9 lesion 1-14,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,17111,Destruct lesion 15 or more,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,17250,Chem caut of granltj tissue,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,17260,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,17261,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,17262,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,17263,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,17264,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,17266,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,17270,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,17271,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,17272,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,17273,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,17274,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,17276,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,17280,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,17281,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,17282,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,17283,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,17284,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,17286,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,17340,Cryotherapy of skin,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,17360,Skin peel therapy,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,17380,Hair removal by electrolysis,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,17999,Skin tissue procedure,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,19000,Drainage of breast lesion,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
Humana Medicaid,CPT,19001,Drain breast lesion add-on,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
Humana Medicaid,CPT,19020,Incision of breast lesion,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Humana Medicaid,CPT,19081,Bx breast 1st lesion strtctc,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Humana Medicaid,CPT,19082,Bx breast add lesion strtctc,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Humana Medicaid,CPT,19083,Bx breast 1st lesion us imag,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Humana Medicaid,CPT,19084,Bx breast add lesion us imag,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Humana Medicaid,CPT,19085,Bx breast 1st lesion mr imag,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Humana Medicaid,CPT,19086,Bx breast add lesion mr imag,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Humana Medicaid,CPT,19100,Bx breast percut w/o image,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Humana Medicaid,CPT,19101,Biopsy of breast open,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Humana Medicaid,CPT,19105,Cryosurg ablate fa each,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Humana Medicaid,CPT,19110,Nipple exploration,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Humana Medicaid,CPT,19112,Excise breast duct fistula,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Humana Medicaid,CPT,19120,Removal of breast lesion,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Humana Medicaid,CPT,19125,Excision breast lesion,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Humana Medicaid,CPT,19126,Excision addl breast lesion,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Humana Medicaid,CPT,19294,Prep tum cav iort prtl mast,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
Humana Medicaid,CPT,19297,Place breast cath for rad,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Humana Medicaid,CPT,19298,Place breast rad tube/caths,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Humana Medicaid,CPT,19300,Removal of breast tissue,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Humana Medicaid,CPT,19301,Partial mastectomy,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Humana Medicaid,CPT,19302,P-mastectomy w/ln removal,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Humana Medicaid,CPT,19303,Mast simple complete,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Humana Medicaid,CPT,19304,Mast subq,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Humana Medicaid,CPT,19305,Mast radical,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
Humana Medicaid,CPT,19306,Mast rad urban type,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
Humana Medicaid,CPT,19307,Mast mod rad,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
Humana Medicaid,CPT,19316,Suspension of breast,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Humana Medicaid,CPT,19318,Breast reduction,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
Humana Medicaid,CPT,19324,Enlarge breast,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Humana Medicaid,CPT,19325,Breast augmentation w/implt,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Humana Medicaid,CPT,19328,Rmvl intact breast implant,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Humana Medicaid,CPT,19330,Rmvl ruptured breast implant,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Humana Medicaid,CPT,19340,Insj breast implt sm d mast,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Humana Medicaid,CPT,19342,Insj/rplcmt brst implt sep d,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Humana Medicaid,CPT,19350,Breast reconstruction,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Humana Medicaid,CPT,19355,Correct inverted nipple(s),General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Humana Medicaid,CPT,19357,Tiss xpndr plmt brst rcnstj,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
Humana Medicaid,CPT,19361,Brst rcnstj latsms drsi flap,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
Humana Medicaid,CPT,19364,Brst rcnstj free flap,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
Humana Medicaid,CPT,19366,Breast reconstruction,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
Humana Medicaid,CPT,19367,Brst rcnstj 1 pdcl tram flap,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Humana Medicaid,CPT,19368,Brst rcnstj 1pdcl tram anast,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
Humana Medicaid,CPT,19369,Brst rcnstj 2 pdcl tram flap,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Humana Medicaid,CPT,19370,Revj peri-implt capsule brst,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Humana Medicaid,CPT,19371,Peri-implt capslc brst compl,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Humana Medicaid,CPT,19380,Revj reconstructed breast,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Humana Medicaid,CPT,19396,Design custom breast implant,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Humana Medicaid,CPT,19499,Breast surgery procedure,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Humana Medicaid,CPT,20206,Needle biopsy muscle,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
Humana Medicaid,CPT,20220,Bone biopsy trocar/needle,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
Humana Medicaid,CPT,20500,Injection of sinus tract,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,20526,Ther injection carp tunnel,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
Humana Medicaid,CPT,20527,Inj dupuytren cord w/enzyme,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
Humana Medicaid,CPT,20550,Inj tendon sheath/ligament,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
Humana Medicaid,CPT,20551,Inj tendon origin/insertion,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
Humana Medicaid,CPT,20552,Inj trigger point 1/2 muscl,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
Humana Medicaid,CPT,20553,Inject trigger points 3/>,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
Humana Medicaid,CPT,20560,Ndl insj w/o njx 1 or 2 musc,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,20561,Ndl insj w/o njx 3+ musc,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,20600,Drain/inj joint/bursa w/o us,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
Humana Medicaid,CPT,20605,Drain/inj joint/bursa w/o us,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
Humana Medicaid,CPT,20610,Drain/inj joint/bursa w/o us,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
Humana Medicaid,CPT,20612,Aspirate/inj ganglion cyst,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
Humana Medicaid,CPT,20822,Replantation digit complete,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,20824,Replantation thumb complete,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,20827,Replantation thumb complete,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,20957,Mt bone graft microvasc,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,20972,Bone/skin graft metatarsal,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,20973,Bone/skin graft great toe,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,20999,Musculoskeletal surgery,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,21010,Incision of jaw joint,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,21025,Excision of bone lower jaw,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,21030,Excise max/zygoma b9 tumor,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Humana Medicaid,CPT,21031,Remove exostosis mandible,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Humana Medicaid,CPT,21032,Remove exostosis maxilla,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,21034,Excise max/zygoma mal tumor,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,21040,Excise mandible lesion,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,21044,Removal of jaw bone lesion,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,21045,Extensive jaw surgery,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,21046,Remove mandible cyst complex,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Humana Medicaid,CPT,21047,Excise lwr jaw cyst w/repair,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,21048,Remove maxilla cyst complex,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,21049,Excis uppr jaw cyst w/repair,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,21050,Removal of jaw joint,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,21060,Remove jaw joint cartilage,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,21070,Remove coronoid process,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,21073,Mnpj of tmj w/anesth,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,21076,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Humana Medicaid,CPT,21077,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Humana Medicaid,CPT,21079,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Humana Medicaid,CPT,21080,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Humana Medicaid,CPT,21081,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Humana Medicaid,CPT,21082,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Humana Medicaid,CPT,21083,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Humana Medicaid,CPT,21084,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Humana Medicaid,CPT,21085,Prepare face/oral prosthesis,Dental,Per Unit,$30.61 ,OP,30.61,30.61,,,,,,
Humana Medicaid,CPT,21086,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Humana Medicaid,CPT,21087,Prepare face/oral prosthesis,Dental,Per Unit,$30.61 ,OP,30.61,30.61,,,,,,
Humana Medicaid,CPT,21088,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Humana Medicaid,CPT,21089,Prepare face/oral prosthesis,Dental,Per Unit,$30.61 ,OP,30.61,30.61,,,,,,
Humana Medicaid,CPT,21100,Maxillofacial fixation,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Humana Medicaid,CPT,21110,Interdental fixation,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,21120,Reconstruction of chin,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,21121,Reconstruction of chin,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,21122,Reconstruction of chin,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Humana Medicaid,CPT,21123,Reconstruction of chin,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,21125,Augmentation lower jaw bone,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,21127,Augmentation lower jaw bone,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,21138,Reduction of forehead,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,21172,Reconstruct orbit/forehead,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,21175,Reconstruct orbit/forehead,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,21193,Reconst lwr jaw w/o graft,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,21195,Reconst lwr jaw w/o fixation,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,21196,Reconst lwr jaw w/fixation,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,21198,Reconstr lwr jaw segment,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,21199,Reconstr lwr jaw w/advance,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,21206,Reconstruct upper jaw bone,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,21215,Lower jaw bone graft,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,21235,Ear cartilage graft,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,21240,Reconstruction of jaw joint,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,21242,Reconstruction of jaw joint,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,21243,Reconstruction of jaw joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Humana Medicaid,CPT,21244,Reconstruction of lower jaw,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,21245,Reconstruction of jaw,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,21246,Reconstruction of jaw,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,21248,Reconstruction of jaw,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,21249,Reconstruction of jaw,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,21270,Augmentation cheek bone,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,21280,Revision of eyelid,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,21282,Revision of eyelid,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,21295,Revision of jaw muscle/bone,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,21296,Revision of jaw muscle/bone,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,21315,Closed tx nose fx w/o stablj,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,21320,Closed tx nose fx w/ stablj,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,21336,Open tx septal fx w/wo stabj,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,21337,Closed tx septal&nose fx,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,21345,Closed tx nose/jaw fx,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,21346,Opn tx nasomax fx w/fixj,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,21400,Closed tx orbit w/o manipulj,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,21401,Closed tx orbit w/manipulj,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,21421,Treat mouth roof fracture,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Humana Medicaid,CPT,21422,Treat mouth roof fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,21440,Treat dental ridge fracture,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Humana Medicaid,CPT,21445,Treat dental ridge fracture,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Humana Medicaid,CPT,21450,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,21451,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,21452,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Humana Medicaid,CPT,21453,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,21454,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,21461,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,21462,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,21465,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,21470,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,21485,Reset dislocated jaw,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,21490,Repair dislocated jaw,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,21495,Treat hyoid bone fracture,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,21497,Interdental wiring,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,21685,Hyoid myotomy & suspension,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,21805,Treatment of rib fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,21811,Optx of rib fx w/fixj scope,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,21812,Treatment of rib fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,21813,Treatment of rib fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,21820,Treat sternum fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,21825,Treat sternum fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,22305,Closed tx spine process fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,22310,Closed tx vert fx w/o manj,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,22315,Closed tx vert fx w/manj,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,22505,Manipulation of spine,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Humana Medicaid,CPT,22515,Perq vertebral augmentation,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"7,098.75","7,098.75",,,,,,
Humana Medicaid,CPT,22999,Abdomen surgery procedure,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,23470,Reconstruct shoulder joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Humana Medicaid,CPT,23472,Reconstruct shoulder joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Humana Medicaid,CPT,23473,Revis reconst shoulder joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Humana Medicaid,CPT,23474,Revis reconst shoulder joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Humana Medicaid,CPT,23500,Treat clavicle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,23505,Treat clavicle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,23515,Treat clavicle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,23520,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,23525,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,23530,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,23532,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,23540,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,23545,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,23550,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,23552,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,23570,Treat shoulder blade fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,23575,Treat shoulder blade fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,23585,Treat scapula fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,23600,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,23605,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,23615,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,23616,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,23620,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,23625,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,23630,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,23650,Treat shoulder dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,23655,Treat shoulder dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Humana Medicaid,CPT,23660,Treat shoulder dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,23665,Treat dislocation/fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,23670,Treat dislocation/fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,23675,Treat dislocation/fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,23680,Treat dislocation/fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,23700,Fixation of shoulder,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Humana Medicaid,CPT,23929,Shoulder surgery procedure,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,24300,Manipulate elbow w/anesth,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Humana Medicaid,CPT,24360,Reconstruct elbow joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
Humana Medicaid,CPT,24361,Reconstruct elbow joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Humana Medicaid,CPT,24362,Reconstruct elbow joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Humana Medicaid,CPT,24363,Replace elbow joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Humana Medicaid,CPT,24365,Reconstruct head of radius,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Humana Medicaid,CPT,24366,Reconstruct head of radius,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Humana Medicaid,CPT,24370,Revise reconst elbow joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Humana Medicaid,CPT,24371,Revise reconst elbow joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Humana Medicaid,CPT,24500,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,24505,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,24515,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,24516,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,24530,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,24535,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,24538,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,24545,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,24546,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,24560,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,24565,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,24566,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,24575,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,24576,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,24577,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,24579,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,24582,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,24586,Treat elbow fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,24587,Treat elbow fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,24600,Treat elbow dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,24605,Treat elbow dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Humana Medicaid,CPT,24615,Treat elbow dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,24620,Treat elbow fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,24635,Treat elbow fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,24640,Treat elbow dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,24650,Treat radius fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,24655,Treat radius fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,24665,Treat radius fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,24666,Treat radius fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,24670,Treat ulnar fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,24675,Treat ulnar fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,24685,Treat ulnar fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,24999,Upper arm/elbow surgery,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,25001,Incise flexor carpi radialis,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,25111,Remove wrist tendon lesion,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,25112,Reremove wrist tendon lesion,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,25136,Remove & graft wrist lesion,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,25210,Removal of wrist bone,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,25215,Removal of wrist bones,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,25259,Manipulate wrist w/anesthes,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Humana Medicaid,CPT,25315,Revise palsy hand tendon(s),Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,25316,Revise palsy hand tendon(s),Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,25332,Revise wrist joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
Humana Medicaid,CPT,25394,Repair carpal bone shorten,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,25430,Vasc graft into carpal bone,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,25431,Repair nonunion carpal bone,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,25441,Reconstruct wrist joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Humana Medicaid,CPT,25442,Reconstruct wrist joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Humana Medicaid,CPT,25443,Reconstruct wrist joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
Humana Medicaid,CPT,25444,Reconstruct wrist joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Humana Medicaid,CPT,25445,Reconstruct wrist joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
Humana Medicaid,CPT,25446,Wrist replacement,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Humana Medicaid,CPT,25447,Repair wrist joints,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
Humana Medicaid,CPT,25449,Remove wrist joint implant,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
Humana Medicaid,CPT,25500,Treat fracture of radius,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,25505,Treat fracture of radius,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,25515,Treat fracture of radius,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,25520,Treat fracture of radius,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,25525,Treat fracture of radius,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,25526,Treat fracture of radius,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,25530,Treat fracture of ulna,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,25535,Treat fracture of ulna,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,25545,Treat fracture of ulna,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,25560,Treat fracture radius & ulna,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,25565,Treat fracture radius & ulna,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,25574,Treat fracture radius & ulna,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,25575,Treat fracture radius/ulna,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,25600,Treat fracture radius/ulna,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,25605,Treat fracture radius/ulna,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,25606,Treat fx distal radial,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,25607,Treat fx rad extra-articul,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,25608,Treat fx rad intra-articul,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,25609,Treat fx radial 3+ frag,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,25622,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,25624,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,25628,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,25630,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,25635,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,25645,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,25650,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,25651,Pin ulnar styloid fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,25652,Treat fracture ulnar styloid,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,25660,Treat wrist dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,25670,Treat wrist dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,25671,Pin radioulnar dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,25675,Treat wrist dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,25676,Treat wrist dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,25680,Treat wrist fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,25685,Treat wrist fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,25690,Treat wrist dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,25695,Treat wrist dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,25820,Fusion of hand bones,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,25825,Fuse hand bones with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,25929,Amputation follow-up surgery,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,25999,Forearm or wrist surgery,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,26010,Drainage of finger abscess,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,26011,Drainage of finger abscess,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
Humana Medicaid,CPT,26020,Drain hand tendon sheath,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26025,Drainage of palm bursa,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26030,Drainage of palm bursas,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26034,Treat hand bone lesion,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26035,Decompress fingers/hand,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26037,Decompress fingers/hand,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26040,Release palm contracture,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26045,Release palm contracture,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26055,Incise finger tendon sheath,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26060,Incision of finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26070,Explore/treat hand joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26075,Explore/treat finger joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26080,Explore/treat finger joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26100,Biopsy hand joint lining,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26105,Biopsy finger joint lining,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26110,Biopsy finger joint lining,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26111,Exc hand les sc 1.5 cm/>,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26113,Exc hand tum deep 1.5 cm/>,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26115,Exc hand les sc < 1.5 cm,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26116,Exc hand tum deep < 1.5 cm,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26117,Rad resect hand tumor < 3 cm,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26118,Rad resect hand tumor 3 cm/>,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26121,Release palm contracture,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26123,Release palm contracture,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26125,Release palm contracture,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26130,Remove wrist joint lining,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26135,Revise finger joint each,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26140,Revise finger joint each,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26145,Tendon excision palm/finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26160,Remove tendon sheath lesion,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26170,Removal of palm tendon each,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26180,Removal of finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26185,Remove finger bone,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26200,Remove hand bone lesion,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26205,Remove/graft bone lesion,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26210,Removal of finger lesion,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26215,Remove/graft finger lesion,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26230,Partial removal of hand bone,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26235,Partial removal finger bone,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26236,Partial removal finger bone,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26250,Extensive hand surgery,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26260,Resect prox finger tumor,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26262,Resect distal finger tumor,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26320,Removal of implant from hand,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26340,Manipulate finger w/anesth,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Humana Medicaid,CPT,26341,Manipulat palm cord post inj,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,26350,Repair finger/hand tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26352,Repair/graft hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26356,Repair finger/hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26357,Repair finger/hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26358,Repair/graft hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26370,Repair finger/hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26372,Repair/graft hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26373,Repair finger/hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26390,Revise hand/finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26392,Repair/graft hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26410,Repair hand tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26412,Repair/graft hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26415,Excision hand/finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26416,Graft hand or finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26418,Repair finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26420,Repair/graft finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26426,Repair finger/hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26428,Repair/graft finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26432,Repair finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26433,Repair finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26434,Repair/graft finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26437,Realignment of tendons,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26440,Release palm/finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26442,Release palm & finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26445,Release hand/finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26449,Release forearm/hand tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26450,Incision of palm tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26455,Incision of finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26460,Incise hand/finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26471,Fusion of finger tendons,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26474,Fusion of finger tendons,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26476,Tendon lengthening,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26477,Tendon shortening,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26478,Lengthening of hand tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26479,Shortening of hand tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26480,Transplant hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26483,Transplant/graft hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26485,Transplant palm tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26489,Transplant/graft palm tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26490,Revise thumb tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26492,Tendon transfer with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26494,Hand tendon/muscle transfer,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26496,Revise thumb tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26497,Finger tendon transfer,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26498,Finger tendon transfer,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26499,Revision of finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26500,Hand tendon reconstruction,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26502,Hand tendon reconstruction,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26508,Release thumb contracture,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26510,Thumb tendon transfer,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26516,Fusion of knuckle joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26517,Fusion of knuckle joints,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26518,Fusion of knuckle joints,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26520,Release knuckle contracture,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26525,Release finger contracture,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26530,Revise knuckle joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
Humana Medicaid,CPT,26531,Revise knuckle with implant,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
Humana Medicaid,CPT,26535,Revise finger joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
Humana Medicaid,CPT,26536,Revise/implant finger joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
Humana Medicaid,CPT,26540,Repair hand joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26541,Repair hand joint with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26542,Repair hand joint with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26545,Reconstruct finger joint,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26546,Repair nonunion hand,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26548,Reconstruct finger joint,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26550,Construct thumb replacement,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26555,Positional change of finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26560,Repair of web finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26561,Repair of web finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26562,Repair of web finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26565,Correct metacarpal flaw,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26567,Correct finger deformity,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26568,Lengthen metacarpal/finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26580,Repair hand deformity,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26587,Reconstruct extra finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26590,Repair finger deformity,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26591,Repair muscles of hand,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26593,Release muscles of hand,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26596,Excision constricting tissue,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26600,Treat metacarpal fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,26605,Treat metacarpal fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,26607,Treat metacarpal fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,26608,Treat metacarpal fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,26615,Treat metacarpal fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,26641,Treat thumb dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,26645,Treat thumb fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,26650,Treat thumb fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,26665,Treat thumb fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,26670,Treat hand dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,26675,Treat hand dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Humana Medicaid,CPT,26676,Pin hand dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,26685,Treat hand dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,26686,Treat hand dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,26700,Treat knuckle dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,26705,Treat knuckle dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Humana Medicaid,CPT,26706,Pin knuckle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,26715,Treat knuckle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,26720,Treat finger fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,26725,Treat finger fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,26727,Treat finger fracture each,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,26735,Treat finger fracture each,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,26740,Treat finger fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,26742,Treat finger fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,26746,Treat finger fracture each,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,26750,Treat finger fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,26755,Treat finger fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,26756,Pin finger fracture each,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,26765,Treat finger fracture each,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,26770,Treat finger dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,26775,Treat finger dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Humana Medicaid,CPT,26776,Pin finger dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,26785,Treat finger dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,26820,Thumb fusion with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26841,Fusion of thumb,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26842,Thumb fusion with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26843,Fusion of hand joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26844,Fusion/graft of hand joint,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26850,Fusion of knuckle,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26852,Fusion of knuckle with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26860,Fusion of finger joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26861,Fusion of finger jnt add-on,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26862,Fusion/graft of finger joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26863,Fuse/graft added joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26910,Amputate metacarpal bone,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26951,Amputation of finger/thumb,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Humana Medicaid,CPT,26952,Amputation of finger/thumb,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Humana Medicaid,CPT,26989,Hand/finger surgery,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27125,Partial hip replacement,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
Humana Medicaid,CPT,27130,Total hip arthroplasty,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Humana Medicaid,CPT,27132,Total hip arthroplasty,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Humana Medicaid,CPT,27134,Revise hip joint replacement,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Humana Medicaid,CPT,27137,Revise hip joint replacement,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Humana Medicaid,CPT,27138,Revise hip joint replacement,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Humana Medicaid,CPT,27175,Treat slipped epiphysis,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,27178,Treat slipped epiphysis,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,27181,Treat slipped epiphysis,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,27193,Treat pelvic ring fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27194,Treat pelvic ring fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27197,Clsd tx pelvic ring fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27198,Clsd tx pelvic ring fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27200,Treat tail bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27202,Treat tail bone fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,27215,Treat pelvic fracture(s),Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,27216,Treat pelvic ring fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,27217,Treat pelvic ring fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,27218,Treat pelvic ring fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,27220,Treat hip socket fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27222,Treat hip socket fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27226,Treat hip wall fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,27227,Treat hip fracture(s),Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,27230,Treat thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27232,Treat thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27235,Treat thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,27236,Treat thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,27238,Treat thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27240,Treat thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27246,Treat thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27248,Treat thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,27250,Treat hip dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27252,Treat hip dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Humana Medicaid,CPT,27253,Treat hip dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,27256,Treat hip dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27257,Treat hip dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Humana Medicaid,CPT,27265,Treat hip dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27266,Treat hip dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Humana Medicaid,CPT,27267,Cltx thigh fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27268,Cltx thigh fx w/mnpj,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27269,Optx thigh fx,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,27275,Manipulation of hip joint,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Humana Medicaid,CPT,27299,Pelvis/hip joint surgery,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27412,Autochondrocyte implant knee,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Humana Medicaid,CPT,27415,Osteochondral knee allograft,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Humana Medicaid,CPT,27437,Revise kneecap,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
Humana Medicaid,CPT,27438,Revise kneecap with implant,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Humana Medicaid,CPT,27440,Revision of knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Humana Medicaid,CPT,27441,Revision of knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Humana Medicaid,CPT,27442,Revision of knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Humana Medicaid,CPT,27443,Revision of knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Humana Medicaid,CPT,27445,Revision of knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Humana Medicaid,CPT,27446,Revision of knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Humana Medicaid,CPT,27447,Total knee arthroplasty,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Humana Medicaid,CPT,27486,Revise/replace knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Humana Medicaid,CPT,27487,Revise/replace knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Humana Medicaid,CPT,27500,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27501,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27502,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27503,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27507,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,27508,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27509,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,27510,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27511,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,27513,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,27514,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,27516,Treat thigh fx growth plate,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27517,Treat thigh fx growth plate,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27520,Treat kneecap fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27524,Treat kneecap fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,27530,Treat knee fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27532,Treat knee fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27535,Treat knee fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,27536,Treat knee fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,27538,Treat knee fracture(s),Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27540,Treat knee fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,27550,Treat knee dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27552,Treat knee dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Humana Medicaid,CPT,27560,Treat kneecap dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27562,Treat kneecap dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Humana Medicaid,CPT,27566,Treat kneecap dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,27570,Fixation of knee joint,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Humana Medicaid,CPT,27599,Leg surgery procedure,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27605,Incision of achilles tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,27700,Revision of ankle joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
Humana Medicaid,CPT,27702,Reconstruct ankle joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Humana Medicaid,CPT,27703,Reconstruction ankle joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Humana Medicaid,CPT,27720,Repair of tibia,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,27722,Repair/graft of tibia,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,27724,Repair/graft of tibia,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,27726,Repair fibula nonunion,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,27750,Treatment of tibia fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27752,Treatment of tibia fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27756,Treatment of tibia fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,27758,Treatment of tibia fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,27759,Treatment of tibia fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,27760,Cltx medial ankle fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27762,Cltx med ankle fx w/mnpj,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27766,Optx medial ankle fx,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,27767,Cltx post ankle fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27768,Cltx post ankle fx w/mnpj,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27769,Optx post ankle fx,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,27780,Treatment of fibula fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27781,Treatment of fibula fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27784,Treatment of fibula fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,27786,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27788,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27792,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,27808,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27810,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27814,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,27816,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27818,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27822,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,27823,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,27824,Treat lower leg fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27825,Treat lower leg fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27826,Treat lower leg fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,27827,Treat lower leg fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,27828,Treat lower leg fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,27829,Treat lower leg joint,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,27830,Treat lower leg dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27831,Treat lower leg dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27832,Treat lower leg dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,27840,Treat ankle dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,27842,Treat ankle dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Humana Medicaid,CPT,27846,Treat ankle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,27848,Treat ankle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,27860,Fixation of ankle joint,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Humana Medicaid,CPT,27899,Leg/ankle surgery procedure,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,28001,Drainage of bursa of foot,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28002,Treatment of foot infection,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28005,Treat foot bone lesion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28008,Incision of foot fascia,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28010,Incision of toe tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28011,Incision of toe tendons,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28020,Exploration of foot joint,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28022,Exploration of foot joint,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28024,Exploration of toe joint,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28039,Exc foot/toe tum sc 1.5 cm/>,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28041,Exc foot/toe tum dep 1.5cm/>,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28045,Exc foot/toe tum deep <1.5cm,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28046,Resect foot/toe tumor < 3 cm,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28047,Resect foot/toe tumor 3 cm/>,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28050,Biopsy of foot joint lining,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28052,Biopsy of foot joint lining,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28054,Biopsy of toe joint lining,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28055,Neurectomy foot,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28060,Partial removal foot fascia,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28062,Removal of foot fascia,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28070,Removal of foot joint lining,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28072,Removal of foot joint lining,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28080,Removal of foot lesion,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28086,Excise foot tendon sheath,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28088,Excise foot tendon sheath,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28090,Removal of foot lesion,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28092,Removal of toe lesions,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28100,Removal of ankle/heel lesion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28102,Remove/graft foot lesion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28103,Remove/graft foot lesion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28104,Removal of foot lesion,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28106,Remove/graft foot lesion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28107,Remove/graft foot lesion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28108,Removal of toe lesions,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28110,Part removal of metatarsal,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28111,Part removal of metatarsal,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28112,Part removal of metatarsal,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28113,Part removal of metatarsal,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28114,Removal of metatarsal heads,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28116,Revision of foot,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28118,Removal of heel bone,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28119,Removal of heel spur,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28120,Part removal of ankle/heel,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28122,Partial removal of foot bone,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28124,Partial removal of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28126,Partial removal of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28130,Removal of ankle bone,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28140,Removal of metatarsal,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28150,Removal of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28153,Partial removal of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28160,Partial removal of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28171,Resect tarsal tumor,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28173,Resect metatarsal tumor,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28175,Resect phalanx of toe tumor,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28190,Removal of foot foreign body,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,28193,Removal of foot foreign body,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28200,Repair of foot tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28202,Repair/graft of foot tendon,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28208,Repair of foot tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28210,Repair/graft of foot tendon,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28220,Release of foot tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28222,Release of foot tendons,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28225,Release of foot tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28226,Release of foot tendons,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28230,Incision of foot tendon(s),Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28232,Incision of toe tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28234,Incision of foot tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28238,Revision of foot tendon,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28240,Release of big toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28250,Revision of foot fascia,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28260,Release of midfoot joint,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28261,Revision of foot tendon,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28262,Revision of foot and ankle,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28264,Release of midfoot joint,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28270,Release of foot contracture,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28272,Release of toe joint each,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28280,Fusion of toes,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28285,Repair of hammertoe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28286,Repair of hammertoe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28288,Partial removal of foot bone,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28289,Corrj halux rigdus w/o implt,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28290,Correction of bunion,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28291,Corrj halux rigdus w/implt,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28292,Correction hallux valgus,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28293,Correction of bunion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28294,Correction of bunion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28295,Correction hallux valgus,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28296,Correction hallux valgus,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28297,Correction hallux valgus,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28298,Correction hallux valgus,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28299,Correction hallux valgus,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28300,Incision of heel bone,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28302,Incision of ankle bone,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28304,Incision of midfoot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28305,Incise/graft midfoot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28306,Incision of metatarsal,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28307,Incision of metatarsal,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28308,Incision of metatarsal,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28309,Incision of metatarsals,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28310,Revision of big toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28312,Revision of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28313,Repair deformity of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28315,Removal of sesamoid bone,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28320,Repair of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28322,Repair of metatarsals,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28340,Resect enlarged toe tissue,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28341,Resect enlarged toe,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28344,Repair extra toe(s),Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28345,Repair webbed toe(s),Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28360,Reconstruct cleft foot,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28400,Treatment of heel fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,28405,Treatment of heel fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,28406,Treatment of heel fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,28415,Treat heel fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,28420,Treat/graft heel fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,28430,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,28435,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,28436,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,28445,Treat ankle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,28446,Osteochondral talus autogrft,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28450,Treat midfoot fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,28455,Treat midfoot fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,28456,Treat midfoot fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,28465,Treat midfoot fracture each,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,28470,Treat metatarsal fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,28475,Treat metatarsal fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,28476,Treat metatarsal fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,28485,Treat metatarsal fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,28490,Treat big toe fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,28495,Treat big toe fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,28496,Treat big toe fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,28505,Treat big toe fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,28510,Treatment of toe fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,28515,Treatment of toe fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,28525,Treat toe fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,28530,Treat sesamoid bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,28531,Treat sesamoid bone fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,28540,Treat foot dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,28545,Treat foot dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Humana Medicaid,CPT,28546,Treat foot dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,28555,Repair foot dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,28570,Treat foot dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,28575,Treat foot dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Humana Medicaid,CPT,28576,Treat foot dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,28585,Repair foot dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,28600,Treat foot dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,28605,Treat foot dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Humana Medicaid,CPT,28606,Treat foot dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,28615,Repair foot dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,28630,Treat toe dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,28635,Treat toe dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Humana Medicaid,CPT,28636,Treat toe dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,28645,Repair toe dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,28660,Treat toe dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,28665,Treat toe dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Humana Medicaid,CPT,28666,Treat toe dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,28675,Repair of toe dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,28705,Fusion of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28715,Fusion of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28725,Fusion of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28730,Fusion of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28735,Fusion of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28737,Revision of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28740,Fusion of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28750,Fusion of big toe joint,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28755,Fusion of big toe joint,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28760,Fusion of big toe joint,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28805,Amputation thru metatarsal,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28810,Amputation toe & metatarsal,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,28820,Amputation of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28825,Partial amputation of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28890,Hi enrgy eswt plantar fascia,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,28899,Foot/toes surgery procedure,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,29000,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Humana Medicaid,CPT,29010,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Humana Medicaid,CPT,29015,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Humana Medicaid,CPT,29035,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Humana Medicaid,CPT,29040,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Humana Medicaid,CPT,29044,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Humana Medicaid,CPT,29046,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Humana Medicaid,CPT,29049,Application of figure eight,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Humana Medicaid,CPT,29055,Application of shoulder cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Humana Medicaid,CPT,29058,Application of shoulder cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Humana Medicaid,CPT,29065,Application of long arm cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Humana Medicaid,CPT,29075,Application of forearm cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Humana Medicaid,CPT,29085,Apply hand/wrist cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Humana Medicaid,CPT,29086,Apply finger cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Humana Medicaid,CPT,29105,Apply long arm splint,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Humana Medicaid,CPT,29125,Apply forearm splint,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Humana Medicaid,CPT,29126,Apply forearm splint,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Humana Medicaid,CPT,29130,Application of finger splint,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Humana Medicaid,CPT,29131,Application of finger splint,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Humana Medicaid,CPT,29200,Strapping of chest,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Humana Medicaid,CPT,29240,Strapping of shoulder,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Humana Medicaid,CPT,29260,Strapping of elbow or wrist,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Humana Medicaid,CPT,29280,Strapping of hand or finger,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Humana Medicaid,CPT,29305,Application of hip cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Humana Medicaid,CPT,29325,Application of hip casts,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Humana Medicaid,CPT,29345,Application of long leg cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Humana Medicaid,CPT,29355,Application of long leg cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Humana Medicaid,CPT,29358,Apply long leg cast brace,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Humana Medicaid,CPT,29365,Application of long leg cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Humana Medicaid,CPT,29405,Apply short leg cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Humana Medicaid,CPT,29425,Apply short leg cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Humana Medicaid,CPT,29435,Apply short leg cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Humana Medicaid,CPT,29440,Addition of walker to cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Humana Medicaid,CPT,29445,Apply rigid leg cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Humana Medicaid,CPT,29450,Application of leg cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Humana Medicaid,CPT,29505,Application long leg splint,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Humana Medicaid,CPT,29515,Application lower leg splint,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Humana Medicaid,CPT,29520,Strapping of hip,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Humana Medicaid,CPT,29530,Strapping of knee,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Humana Medicaid,CPT,29540,Strapping of ankle and/or ft,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Humana Medicaid,CPT,29550,Strapping of toes,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Humana Medicaid,CPT,29580,Application of paste boot,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Humana Medicaid,CPT,29581,Apply multlay comprs lwr leg,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Humana Medicaid,CPT,29582,Apply multlay comprs upr leg,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Humana Medicaid,CPT,29583,Apply multlay comprs upr arm,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Humana Medicaid,CPT,29584,Appl multlay comprs arm/hand,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Humana Medicaid,CPT,29700,Removal/revision of cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Humana Medicaid,CPT,29705,Removal/revision of cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Humana Medicaid,CPT,29710,Removal/revision of cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Humana Medicaid,CPT,29720,Repair of body cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Humana Medicaid,CPT,29730,Windowing of cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Humana Medicaid,CPT,29740,Wedging of cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Humana Medicaid,CPT,29750,Wedging of clubfoot cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Humana Medicaid,CPT,29799,Casting/strapping procedure,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Humana Medicaid,CPT,29800,Jaw arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29804,Jaw arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29805,Sho arthrs dx +- synovial bx,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29806,Sho arthrs srg capsulorpaphy,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Humana Medicaid,CPT,29807,Sho arthrs srg rpr slap les,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Humana Medicaid,CPT,29819,Sho arthrs srg rmvl loose/fb,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29820,Sho arthrs srg prtl synvct,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29821,Sho arthrs srg compl synvct,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Humana Medicaid,CPT,29822,Sho arthrs srg lmtd dbrdmt,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29823,Sho arthrs srg xtnsv dbrdmt,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29824,Sho arthrs srg dstl claviclc,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29825,Sho arthrs srg lss&rescj ads,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29826,Sho arthrs srg decompression,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29827,Sho arthrs srg rt8tr cuf rpr,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Humana Medicaid,CPT,29828,Sho arthrs srg bicp tenodsis,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Humana Medicaid,CPT,29830,Elbow arthroscopy,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29834,Elbow arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29835,Elbow arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29836,Elbow arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Humana Medicaid,CPT,29837,Elbow arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29838,Elbow arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29840,Wrist arthroscopy,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29843,Wrist arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29844,Wrist arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29845,Wrist arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29846,Wrist arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29847,Wrist arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Humana Medicaid,CPT,29848,Wrist endoscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29850,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29851,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29855,Tibial arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Humana Medicaid,CPT,29856,Tibial arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Humana Medicaid,CPT,29860,Hip arthroscopy dx,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Humana Medicaid,CPT,29861,Hip arthro w/fb removal,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29862,Hip arthr0 w/debridement,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Humana Medicaid,CPT,29863,Hip arthr0 w/synovectomy,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29866,Autgrft implnt knee w/scope,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Humana Medicaid,CPT,29867,Allgrft implnt knee w/scope,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Humana Medicaid,CPT,29868,Meniscal trnspl knee w/scpe,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Humana Medicaid,CPT,29870,Knee arthroscopy dx,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29871,Knee arthroscopy/drainage,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29873,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29874,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29875,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29876,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29877,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29879,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29880,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29881,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29882,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29883,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29884,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29885,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Humana Medicaid,CPT,29886,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29887,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Humana Medicaid,CPT,29888,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Humana Medicaid,CPT,29889,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Humana Medicaid,CPT,29891,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29892,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Humana Medicaid,CPT,29893,Scope plantar fasciotomy,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,29894,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29895,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29897,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29898,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29899,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Humana Medicaid,CPT,29900,Mcp joint arthroscopy dx,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29901,Mcp joint arthroscopy surg,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29902,Mcp joint arthroscopy surg,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29904,Subtalar arthro w/fb rmvl,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29905,Subtalar arthro w/exc,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29906,Subtalar arthro w/deb,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,29907,Subtalar arthro w/fusion,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Humana Medicaid,CPT,29914,Hip arthro w/femoroplasty,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Humana Medicaid,CPT,29915,Hip arthro acetabuloplasty,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Humana Medicaid,CPT,29916,Hip arthro w/labral repair,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Humana Medicaid,CPT,29999,Arthroscopy of joint,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,30020,Drainage of nose lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,30100,Intranasal biopsy,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,30110,Removal of nose polyp(s),Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,30115,Removal of nose polyp(s),Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,30117,Removal of intranasal lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,30118,Removal of intranasal lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,30120,Revision of nose,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,30124,Removal of nose lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,30125,Removal of nose lesion,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,30130,Excise inferior turbinate,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,30140,Resect inferior turbinate,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,30150,Partial removal of nose,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,30160,Removal of nose,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,30200,Injection treatment of nose,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,30220,Insert nasal septal button,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,30310,Remove nasal foreign body,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,30320,Remove nasal foreign body,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,30400,Reconstruction of nose,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,30410,Reconstruction of nose,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,30420,Reconstruction of nose,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,30430,Revision of nose,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,30435,Revision of nose,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,30450,Revision of nose,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,30460,Revision of nose,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,30462,Revision of nose,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,30465,Repair nasal stenosis,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,30468,Rpr nsl vlv collapse w/implt,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,30520,Repair of nasal septum,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,30540,Repair nasal defect,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,30560,Release of nasal adhesions,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,30580,Repair upper jaw fistula,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,30600,Repair mouth/nose fistula,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,30620,Intranasal reconstruction,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,30630,Repair nasal septum defect,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,30801,Ablate inf turbinate superf,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,30802,Ablate inf turbinate submuc,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,30915,Ligation nasal sinus artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Humana Medicaid,CPT,30920,Ligation upper jaw artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Humana Medicaid,CPT,30930,Ther fx nasal inf turbinate,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,30999,Nasal surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,31000,Irrigation maxillary sinus,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,31002,Irrigation sphenoid sinus,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,31020,Exploration maxillary sinus,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,31030,Exploration maxillary sinus,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,31032,Explore sinus remove polyps,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,31050,Exploration sphenoid sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,31051,Sphenoid sinus surgery,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,31070,Exploration of frontal sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,31075,Exploration of frontal sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,31080,Removal of frontal sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,31081,Removal of frontal sinus,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,31084,Removal of frontal sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,31085,Removal of frontal sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,31086,Removal of frontal sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,31087,Removal of frontal sinus,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,31090,Exploration of sinuses,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,31200,Removal of ethmoid sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,31201,Removal of ethmoid sinus,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,31205,Removal of ethmoid sinus,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,31225,Removal of upper jaw,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Humana Medicaid,CPT,31233,Nsl/sins ndsc dx max sinusc,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Humana Medicaid,CPT,31235,Nsl/sins ndsc dx sphn sinusc,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Humana Medicaid,CPT,31237,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Humana Medicaid,CPT,31238,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Humana Medicaid,CPT,31239,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Humana Medicaid,CPT,31240,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Humana Medicaid,CPT,31241,Nsl/sins ndsc w/artery lig,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Humana Medicaid,CPT,31253,Nsl/sins ndsc total,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,31254,Nsl/sins ndsc w/prtl ethmdct,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Humana Medicaid,CPT,31255,Nsl/sins ndsc w/tot ethmdct,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Humana Medicaid,CPT,31256,Exploration maxillary sinus,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Humana Medicaid,CPT,31257,Nsl/sins ndsc tot w/sphendt,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,31259,Nsl/sins ndsc sphn tiss rmvl,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,31267,Endoscopy maxillary sinus,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Humana Medicaid,CPT,31276,Nsl/sins ndsc frnt tiss rmvl,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Humana Medicaid,CPT,31287,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Humana Medicaid,CPT,31288,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Humana Medicaid,CPT,31290,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Humana Medicaid,CPT,31291,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Humana Medicaid,CPT,31292,Nsl/sins ndsc med/inf dcmprn,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Humana Medicaid,CPT,31293,Nsl/sins ndsc med&inf dcmprn,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Humana Medicaid,CPT,31294,Nsl/sins ndsc surg on dcmprn,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Humana Medicaid,CPT,31295,Nsl/sins ndsc surg max sins,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Humana Medicaid,CPT,31296,Nsl/sins ndsc surg frnt sins,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Humana Medicaid,CPT,31297,Nsl/sins ndsc surg sphn sins,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Humana Medicaid,CPT,31298,Nsl/sins ndsc surg frnt&sphn,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Humana Medicaid,CPT,31299,Sinus surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,31300,Removal of larynx lesion,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,31320,Diagnostic incision larynx,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,31375,Partial removal of larynx,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,31400,Revision of larynx,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,31420,Removal of epiglottis,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,31500,Insert emergency airway,General Medicine,Per Unit,$385.17 ,OP,385.17,385.17,,,,,,
Humana Medicaid,CPT,31510,Laryngoscopy with biopsy,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Humana Medicaid,CPT,31512,Removal of larynx lesion,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Humana Medicaid,CPT,31513,Injection into vocal cord,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Humana Medicaid,CPT,31515,Laryngoscopy for aspiration,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Humana Medicaid,CPT,31520,Dx laryngoscopy newborn,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Humana Medicaid,CPT,31525,Dx laryngoscopy excl nb,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Humana Medicaid,CPT,31526,Dx laryngoscopy w/oper scope,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Humana Medicaid,CPT,31527,Laryngoscopy for treatment,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Humana Medicaid,CPT,31528,Laryngoscopy and dilation,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Humana Medicaid,CPT,31529,Laryngoscopy and dilation,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Humana Medicaid,CPT,31530,Laryngoscopy w/fb removal,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Humana Medicaid,CPT,31531,Laryngoscopy w/fb & op scope,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Humana Medicaid,CPT,31535,Laryngoscopy w/biopsy,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Humana Medicaid,CPT,31536,Laryngoscopy w/bx & op scope,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Humana Medicaid,CPT,31540,Laryngoscopy w/exc of tumor,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Humana Medicaid,CPT,31541,Larynscop w/tumr exc + scope,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Humana Medicaid,CPT,31545,Remove vc lesion w/scope,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Humana Medicaid,CPT,31546,Remove vc lesion scope/graft,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Humana Medicaid,CPT,31551,Laryngoplasty laryngeal sten,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,31552,Laryngoplasty laryngeal sten,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,31553,Laryngoplasty laryngeal sten,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,31554,Laryngoplasty laryngeal sten,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,31560,Laryngoscop w/arytenoidectom,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Humana Medicaid,CPT,31561,Larynscop remve cart + scop,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Humana Medicaid,CPT,31570,Laryngoscope w/vc inj,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Humana Medicaid,CPT,31571,Laryngoscop w/vc inj + scope,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Humana Medicaid,CPT,31572,Largsc w/laser dstrj les,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Humana Medicaid,CPT,31573,Largsc w/ther injection,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Humana Medicaid,CPT,31574,Largsc w/njx augmentation,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Humana Medicaid,CPT,31576,Laryngoscopy with biopsy,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Humana Medicaid,CPT,31577,Largsc w/rmvl foreign bdy(s),Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Humana Medicaid,CPT,31578,Largsc w/removal lesion,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Humana Medicaid,CPT,31579,Laryngoscopy telescopic,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Humana Medicaid,CPT,31580,Laryngoplasty laryngeal web,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,31582,Revision of larynx,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,31584,Laryngoplasty fx rdctj fixj,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,31587,Laryngoplasty cricoid split,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,31588,Revision of larynx,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,31590,Reinnervate larynx,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,31591,Laryngoplasty medialization,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,31595,Larynx nerve surgery,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,31599,Larynx surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,31615,Visualization of windpipe,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
Humana Medicaid,CPT,31622,Dx bronchoscope/wash,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
Humana Medicaid,CPT,31623,Dx bronchoscope/brush,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
Humana Medicaid,CPT,31624,Dx bronchoscope/lavage,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
Humana Medicaid,CPT,31625,Bronchoscopy w/biopsy(s),Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
Humana Medicaid,CPT,31626,Bronchoscopy w/markers,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
Humana Medicaid,CPT,31627,Navigational bronchoscopy,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,31628,Bronchoscopy/lung bx each,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
Humana Medicaid,CPT,31629,Bronchoscopy/needle bx each,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
Humana Medicaid,CPT,31632,Bronchoscopy/lung bx addl,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
Humana Medicaid,CPT,31633,Bronchoscopy/needle bx addl,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
Humana Medicaid,CPT,31635,Bronchoscopy w/fb removal,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
Humana Medicaid,CPT,31643,Diag bronchoscope/catheter,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
Humana Medicaid,CPT,31645,Brnchsc w/ther aspir 1st,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
Humana Medicaid,CPT,31646,Brnchsc w/ther aspir sbsq,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
Humana Medicaid,CPT,31720,Clearance of airways,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
Humana Medicaid,CPT,31725,Clearance of airways,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Humana Medicaid,CPT,31899,Airways surgical procedure,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
Humana Medicaid,CPT,33206,Insert heart pm atrial,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Humana Medicaid,CPT,33207,Insert heart pm ventricular,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Humana Medicaid,CPT,33208,Insrt heart pm atrial & vent,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Humana Medicaid,CPT,33212,Insert pulse gen sngl lead,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Humana Medicaid,CPT,33213,Insert pulse gen dual leads,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Humana Medicaid,CPT,33214,Upgrade of pacemaker system,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Humana Medicaid,CPT,33221,Insert pulse gen mult leads,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Humana Medicaid,CPT,33224,Insert pacing lead & connect,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Humana Medicaid,CPT,33225,L ventric pacing lead add-on,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Humana Medicaid,CPT,33226,Reposition l ventric lead,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
Humana Medicaid,CPT,33227,Remove&replace pm gen singl,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Humana Medicaid,CPT,33228,Remv&replc pm gen dual lead,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Humana Medicaid,CPT,33229,Remv&replc pm gen mult leads,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Humana Medicaid,CPT,33230,Insrt pulse gen w/dual leads,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Humana Medicaid,CPT,33231,Insrt pulse gen w/mult leads,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Humana Medicaid,CPT,33233,Removal of pm generator,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
Humana Medicaid,CPT,33240,Insrt pulse gen w/singl lead,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Humana Medicaid,CPT,33241,Remove pulse generator,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
Humana Medicaid,CPT,33249,Insj/rplcmt defib w/lead(s),Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Humana Medicaid,CPT,33262,Rmvl& replc pulse gen 1 lead,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Humana Medicaid,CPT,33263,Rmvl & rplcmt dfb gen 2 lead,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Humana Medicaid,CPT,33264,Rmvl & rplcmt dfb gen mlt ld,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Humana Medicaid,CPT,33270,Ins/rep subq defibrillator,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Humana Medicaid,CPT,33274,Tcat insj/rpl perm ldls pm,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Humana Medicaid,CPT,33275,Tcat rmvl perm ldls pm w/img,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
Humana Medicaid,CPT,33282,Implant pat-active ht record,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Humana Medicaid,CPT,33285,Insj subq car rhythm mntr,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Humana Medicaid,CPT,33289,Tcat impl wrls p-art prs snr,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Humana Medicaid,CPT,33889,Artery transpose/endovas taa,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,33967,Insert i-aort percut device,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Humana Medicaid,CPT,33968,Remove aortic assist device,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
Humana Medicaid,CPT,33990,Insj perq vad l hrt arterial,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Humana Medicaid,CPT,33991,Insj perq vad l hrt artl&ven,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Humana Medicaid,CPT,33992,Rmvl perq left heart vad,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
Humana Medicaid,CPT,33993,Reposg perq r/l hrt vad,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
Humana Medicaid,CPT,33995,Insj perq vad r hrt venous,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Humana Medicaid,CPT,33997,Rmvl perq right heart vad,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
Humana Medicaid,CPT,33999,Cardiac surgery procedure,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Humana Medicaid,CPT,34001,Removal of artery clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,34101,Removal of artery clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,34111,Removal of arm artery clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,34201,Removal of artery clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,34203,Removal of leg artery clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,34421,Removal of vein clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,34471,Removal of vein clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,34490,Removal of vein clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,34501,Repair valve femoral vein,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,34510,Transposition of vein valve,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,34520,Cross-over vein graft,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,34530,Leg vein fusion,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,34714,Opn fem art expos cndt crtj,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,34715,Opn ax/subcla art expos,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,34716,Opn ax/subcla art expos cndt,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,34812,Opn fem art expos,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,34834,Opn brach art expos,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,35011,Repair defect of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,35013,Repair artery rupture arm,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,35045,Repair defect of arm artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,35180,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Humana Medicaid,CPT,35184,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Humana Medicaid,CPT,35188,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Humana Medicaid,CPT,35190,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Humana Medicaid,CPT,35201,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Humana Medicaid,CPT,35206,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Humana Medicaid,CPT,35207,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Humana Medicaid,CPT,35226,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Humana Medicaid,CPT,35231,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Humana Medicaid,CPT,35236,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Humana Medicaid,CPT,35256,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,35261,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,35266,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Humana Medicaid,CPT,35301,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,35302,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,35303,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,35304,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,35305,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,35306,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,35321,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,35355,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,35371,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,35372,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,35390,Reoperation carotid add-on,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,35400,Angioscopy,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,35452,Repair arterial blockage,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Humana Medicaid,CPT,35472,Repair arterial blockage,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Humana Medicaid,CPT,35694,Art trnsposj subclav carotid,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,35697,Reimplant artery each,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,35700,Reoperation bypass graft,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,35701,Expl n/flwd surg neck art,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,35702,Expl n/flwd surg uxtr art,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,35703,Expl n/flwd surg lxtr art,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,35721,Exploration femoral artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,35741,Exploration popliteal artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,35761,Exploration of artery/vein,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,35800,Explore neck vessels,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,35820,Explore chest vessels,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,35860,Explore limb vessels,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,35875,Removal of clot in graft,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,35876,Removal of clot in graft,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,35901,Excision graft neck,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,35903,Excision graft extremity,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Humana Medicaid,CPT,36005,Injection ext venography,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Humana Medicaid,CPT,36010,Place catheter in vein,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Humana Medicaid,CPT,36011,Place catheter in vein,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Humana Medicaid,CPT,36012,Place catheter in vein,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Humana Medicaid,CPT,36013,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Humana Medicaid,CPT,36014,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Humana Medicaid,CPT,36015,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Humana Medicaid,CPT,36100,Establish access to artery,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Humana Medicaid,CPT,36120,Establish access to artery,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Humana Medicaid,CPT,36140,Intro ndl icath upr/lxtr art,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Humana Medicaid,CPT,36160,Establish access to aorta,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Humana Medicaid,CPT,36200,Place catheter in aorta,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Humana Medicaid,CPT,36215,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Humana Medicaid,CPT,36216,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Humana Medicaid,CPT,36217,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Humana Medicaid,CPT,36218,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Humana Medicaid,CPT,36221,Place cath thoracic aorta,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Humana Medicaid,CPT,36222,Place cath carotid/inom art,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Humana Medicaid,CPT,36223,Place cath carotid/inom art,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Humana Medicaid,CPT,36224,Place cath carotd art,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Humana Medicaid,CPT,36225,Place cath subclavian art,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Humana Medicaid,CPT,36226,Place cath vertebral art,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Humana Medicaid,CPT,36227,Place cath xtrnl carotid,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Humana Medicaid,CPT,36228,Place cath intracranial art,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Humana Medicaid,CPT,36245,Ins cath abd/l-ext art 1st,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Humana Medicaid,CPT,36246,Ins cath abd/l-ext art 2nd,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Humana Medicaid,CPT,36247,Ins cath abd/l-ext art 3rd,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Humana Medicaid,CPT,36248,Ins cath abd/l-ext art addl,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Humana Medicaid,CPT,36251,Ins cath ren art 1st unilat,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Humana Medicaid,CPT,36252,Ins cath ren art 1st bilat,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Humana Medicaid,CPT,36253,Ins cath ren art 2nd+ unilat,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Humana Medicaid,CPT,36254,Ins cath ren art 2nd+ bilat,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Humana Medicaid,CPT,36260,Insertion of infusion pump,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Humana Medicaid,CPT,36299,Vessel injection procedure,Vascular Surgery,Per Unit,$500.46 ,OP,500.46,500.46,,,,,,
Humana Medicaid,CPT,36430,Blood transfusion service,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,36440,Bl push transfuse 2 yr/<,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,36450,Bl exchange/transfuse nb,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,36455,Bl exchange/transfuse non-nb,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,36456,Prtl exchange transfuse nb,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,36460,Transfusion service fetal,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,36465,Njx noncmpnd sclrsnt 1 vein,Vascular Surgery,Per Unit,$500.46 ,OP,500.46,500.46,,,,,,
Humana Medicaid,CPT,36466,Njx noncmpnd sclrsnt mlt vn,Vascular Surgery,Per Unit,$500.46 ,OP,500.46,500.46,,,,,,
Humana Medicaid,CPT,36468,Njx sclrsnt spider veins,Vascular Surgery,Per Unit,$500.46 ,OP,500.46,500.46,,,,,,
Humana Medicaid,CPT,36470,Njx sclrsnt 1 incmptnt vein,Vascular Surgery,Per Unit,$500.46 ,OP,500.46,500.46,,,,,,
Humana Medicaid,CPT,36471,Njx sclrsnt mlt incmptnt vn,Vascular Surgery,Per Unit,$500.46 ,OP,500.46,500.46,,,,,,
Humana Medicaid,CPT,36481,Insertion of catheter vein,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Humana Medicaid,CPT,36500,Insertion of catheter vein,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Humana Medicaid,CPT,36511,Apheresis wbc,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Humana Medicaid,CPT,36512,Apheresis rbc,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Humana Medicaid,CPT,36513,Apheresis platelets,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,36514,Apheresis plasma,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Humana Medicaid,CPT,36515,Apheresis adsorp/reinfuse,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Humana Medicaid,CPT,36516,Apheresis immunoads slctv,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Humana Medicaid,CPT,36522,Photopheresis,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Humana Medicaid,CPT,36557,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
Humana Medicaid,CPT,36558,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
Humana Medicaid,CPT,36560,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
Humana Medicaid,CPT,36561,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
Humana Medicaid,CPT,36563,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
Humana Medicaid,CPT,36565,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
Humana Medicaid,CPT,36566,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
Humana Medicaid,CPT,36581,Replace tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
Humana Medicaid,CPT,36582,Replace tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
Humana Medicaid,CPT,36583,Replace tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
Humana Medicaid,CPT,36593,Declot vascular device,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Humana Medicaid,CPT,36620,Insertion catheter artery,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Humana Medicaid,CPT,36625,Insertion catheter artery,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Humana Medicaid,CPT,36640,Insertion catheter artery,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Humana Medicaid,CPT,36680,Insert needle bone cavity,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
Humana Medicaid,CPT,36800,Insertion of cannula,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
Humana Medicaid,CPT,36810,Insertion of cannula,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
Humana Medicaid,CPT,36815,Insertion of cannula,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
Humana Medicaid,CPT,36823,Insertion of cannula(s),Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,36838,Dist revas ligation hemo,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,36860,External cannula declotting,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Humana Medicaid,CPT,36903,Intro cath dialysis circuit,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,36905,Thrmbc/nfs dialysis circuit,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,36906,Thrmbc/nfs dialysis circuit,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,36907,Balo angiop ctr dialysis seg,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,36908,Stent plmt ctr dialysis seg,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,36909,Dialysis circuit embolj,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,37145,Revision of circulation,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,37182,Insert hepatic shunt (tips),Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,37183,Remove hepatic shunt (tips),Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,37184,Prim art m-thrmbc 1st vsl,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,37185,Prim art m-thrmbc sbsq vsl,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,37186,Sec art thrombectomy add-on,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,37195,Thrombolytic therapy stroke,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Humana Medicaid,CPT,37202,Transcatheter therapy infuse,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Humana Medicaid,CPT,37215,Transcath stent cca w/eps,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,37216,Transcath stent cca w/o eps,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,37217,Stent placemt retro carotid,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,37218,Stent placemt ante carotid,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,37220,Iliac revasc,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,37221,Iliac revasc w/stent,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,37222,Iliac revasc add-on,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,37223,Iliac revasc w/stent add-on,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,37224,Fem/popl revas w/tla,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,37225,Fem/popl revas w/ather,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,37226,Fem/popl revasc w/stent,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,37227,Fem/popl revasc stnt & ather,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,37228,Tib/per revasc w/tla,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,37229,Tib/per revasc w/ather,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,37230,Tib/per revasc w/stent,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,37231,Tib/per revasc stent & ather,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,37232,Tib/per revasc add-on,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,37233,Tibper revasc w/ather add-on,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,37234,Revsc opn/prq tib/pero stent,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,37235,Tib/per revasc stnt & ather,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,37236,Open/perq place stent 1st,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,37237,Open/perq place stent ea add,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,37238,Open/perq place stent same,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,37239,Open/perq place stent ea add,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,37241,Vasc embolize/occlude venous,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,37242,Vasc embolize/occlude artery,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,37243,Vasc embolize/occlude organ,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,37244,Vasc embolize/occlude bleed,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,37247,Trluml balo angiop addl art,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,37249,Trluml balo angiop addl vein,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,37250,Iv us first vessel add-on,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Humana Medicaid,CPT,37251,Iv us each add vessel add-on,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Humana Medicaid,CPT,37500,Endoscopy ligate perf veins,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,37501,Vascular endoscopy procedure,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,37565,Ligation of neck vein,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Humana Medicaid,CPT,37600,Ligation of neck artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Humana Medicaid,CPT,37605,Ligation of neck artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Humana Medicaid,CPT,37606,Ligation of neck artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Humana Medicaid,CPT,37607,Ligation of a-v fistula,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Humana Medicaid,CPT,37609,Temporal artery procedure,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Humana Medicaid,CPT,37615,Ligation of neck artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Humana Medicaid,CPT,37618,Ligation of extremity artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Humana Medicaid,CPT,37619,Ligation of inf vena cava,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,37650,Revision of major vein,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Humana Medicaid,CPT,37790,Penile venous occlusion,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,37799,Vascular surgery procedure,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Humana Medicaid,CPT,38102,Removal of spleen total,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,38120,Laparoscopy splenectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Humana Medicaid,CPT,38129,Laparoscope proc spleen,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Humana Medicaid,CPT,38205,Harvest allogeneic stem cell,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Humana Medicaid,CPT,38206,Harvest auto stem cells,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Humana Medicaid,CPT,38207,Cryopreserve stem cells,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Humana Medicaid,CPT,38208,Thaw preserved stem cells,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,38209,Wash harvest stem cells,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Humana Medicaid,CPT,38210,T-cell depletion of harvest,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,38211,Tumor cell deplete of harvst,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,38212,Rbc depletion of harvest,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,38213,Platelet deplete of harvest,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,38214,Volume deplete of harvest,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Humana Medicaid,CPT,38215,Harvest stem cell concentrte,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Humana Medicaid,CPT,38230,Bone marrow harvest allogen,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Humana Medicaid,CPT,38232,Bone marrow harvest autolog,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Humana Medicaid,CPT,38240,Transplt allo hct/donor,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Humana Medicaid,CPT,38241,Transplt autol hct/donor,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Humana Medicaid,CPT,38242,Transplt allo lymphocytes,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Humana Medicaid,CPT,38243,Transplj hematopoietic boost,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Humana Medicaid,CPT,38300,Drainage lymph node lesion,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
Humana Medicaid,CPT,38305,Drainage lymph node lesion,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
Humana Medicaid,CPT,38308,Incision of lymph channels,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
Humana Medicaid,CPT,38380,Thoracic duct procedure,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,38500,Biopsy/removal lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
Humana Medicaid,CPT,38505,Needle biopsy lymph nodes,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Humana Medicaid,CPT,38510,Biopsy/removal lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
Humana Medicaid,CPT,38520,Biopsy/removal lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
Humana Medicaid,CPT,38525,Biopsy/removal lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
Humana Medicaid,CPT,38530,Biopsy/removal lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
Humana Medicaid,CPT,38531,Open bx/exc inguinofem nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
Humana Medicaid,CPT,38542,Explore deep node(s) neck,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,38550,Removal neck/armpit lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,38555,Removal neck/armpit lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,38562,Removal pelvic lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
Humana Medicaid,CPT,38570,Laparoscopy lymph node biop,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Humana Medicaid,CPT,38571,Laparoscopy lymphadenectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Humana Medicaid,CPT,38572,Laparoscopy lymphadenectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Humana Medicaid,CPT,38573,Laps pelvic lymphadec,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Humana Medicaid,CPT,38589,Laparoscope proc lymphatic,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Humana Medicaid,CPT,38700,Removal of lymph nodes neck,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,38720,Removal of lymph nodes neck,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,38724,Removal of lymph nodes neck,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
Humana Medicaid,CPT,38740,Remove armpit lymph nodes,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Humana Medicaid,CPT,38745,Remove armpit lymph nodes,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Humana Medicaid,CPT,38747,Remove abdominal lymph nodes,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,38760,Remove groin lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
Humana Medicaid,CPT,38792,Ra tracer id of sentinl node,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,38794,Access thoracic lymph duct,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Humana Medicaid,CPT,38999,Blood/lymph system procedure,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
Humana Medicaid,CPT,39545,Revision of diaphragm,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,39599,Diaphragm surgery procedure,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Humana Medicaid,CPT,40490,Biopsy of lip,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,40500,Partial excision of lip,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,40510,Partial excision of lip,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,40520,Partial excision of lip,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,40525,Reconstruct lip with flap,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,40527,Reconstruct lip with flap,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,40530,Partial removal of lip,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,40650,Repair lip,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,40652,Repair lip,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,40654,Repair lip,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,40799,Lip surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,40801,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,40805,Removal foreign body mouth,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,40806,Incision of lip fold,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,40808,Biopsy of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,40810,Excision of mouth lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,40812,Excise/repair mouth lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,40814,Excise/repair mouth lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,40816,Excision of mouth lesion,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,40818,Excise oral mucosa for graft,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,40819,Excise lip or cheek fold,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,40820,Treatment of mouth lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,40830,Repair mouth laceration,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,40831,Repair mouth laceration,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,40840,Reconstruction of mouth,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,40842,Reconstruction of mouth,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,40843,Reconstruction of mouth,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,40844,Reconstruction of mouth,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,40845,Reconstruction of mouth,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,40899,Mouth surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,41000,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,41005,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,41006,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,41007,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,41008,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,41009,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,41010,Incision of tongue fold,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,41015,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,41016,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,41017,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,41018,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,41100,Biopsy of tongue,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,41105,Biopsy of tongue,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,41108,Biopsy of floor of mouth,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,41110,Excision of tongue lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,41112,Excision of tongue lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,41113,Excision of tongue lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,41114,Excision of tongue lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,41115,Excision of tongue fold,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,41116,Excision of mouth lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,41120,Partial removal of tongue,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,41130,Partial removal of tongue,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,41135,Tongue and neck surgery,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,41150,Tongue mouth jaw surgery,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,41500,Fixation of tongue,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,41510,Tongue to lip surgery,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,41512,Tongue suspension,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,41520,Reconstruction tongue fold,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,41530,Tongue base vol reduction,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,41599,Tongue and mouth surgery,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,41805,Removal foreign body gum,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,41806,Removal foreign body jawbone,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Humana Medicaid,CPT,41820,Excision gum each quadrant,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Humana Medicaid,CPT,41821,Excision of gum flap,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,41822,Excision of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,41823,Excision of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,41825,Excision of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Humana Medicaid,CPT,41826,Excision of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Humana Medicaid,CPT,41827,Excision of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Humana Medicaid,CPT,41828,Excision of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Humana Medicaid,CPT,41830,Removal of gum tissue,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Humana Medicaid,CPT,41850,Treatment of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Humana Medicaid,CPT,41870,Gum graft,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,41872,Repair gum,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Humana Medicaid,CPT,41874,Repair tooth socket,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,41899,Dental surgery procedure,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,42100,Biopsy roof of mouth,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,42104,Excision lesion mouth roof,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,42106,Excision lesion mouth roof,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,42107,Excision lesion mouth roof,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,42120,Remove palate/lesion,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,42140,Excision of uvula,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,42160,Treatment mouth roof lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,42180,Repair palate,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,42182,Repair palate,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,42260,Repair nose to lip fistula,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,42280,Preparation palate mold,Dental,Per Unit,$30.61 ,OP,30.61,30.61,,,,,,
Humana Medicaid,CPT,42281,Insertion palate prosthesis,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,42299,Palate/uvula surgery,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,42300,Drainage of salivary gland,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,42305,Drainage of salivary gland,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,42310,Drainage of salivary gland,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,42320,Drainage of salivary gland,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,42330,Removal of salivary stone,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,42335,Removal of salivary stone,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,42340,Removal of salivary stone,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,42400,Biopsy of salivary gland,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,42405,Biopsy of salivary gland,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,42408,Excision of salivary cyst,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,42409,Drainage of salivary cyst,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,42410,Excise parotid gland/lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,42415,Excise parotid gland/lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,42420,Excise parotid gland/lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,42425,Excise parotid gland/lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,42426,Excise parotid gland/lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,42440,Excise submaxillary gland,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,42450,Excise sublingual gland,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,42500,Repair salivary duct,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,42505,Repair salivary duct,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,42507,Parotid duct diversion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,42509,Parotid duct diversion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,42510,Parotid duct diversion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,42600,Closure of salivary fistula,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,42650,Dilation of salivary duct,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,42660,Dilation of salivary duct,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,42665,Ligation of salivary duct,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,42699,Salivary surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,42720,Drainage of throat abscess,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,42725,Drainage of throat abscess,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,42800,Biopsy of throat,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,42804,Biopsy of upper nose/throat,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,42806,Biopsy of upper nose/throat,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,42808,Excise pharynx lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,42810,Excision of neck cyst,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,42815,Excision of neck cyst,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,42820,Remove tonsils and adenoids,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
Humana Medicaid,CPT,42821,Remove tonsils and adenoids,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
Humana Medicaid,CPT,42825,Removal of tonsils,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
Humana Medicaid,CPT,42826,Removal of tonsils,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
Humana Medicaid,CPT,42830,Removal of adenoids,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
Humana Medicaid,CPT,42831,Removal of adenoids,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
Humana Medicaid,CPT,42835,Removal of adenoids,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
Humana Medicaid,CPT,42836,Removal of adenoids,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
Humana Medicaid,CPT,42842,Extensive surgery of throat,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
Humana Medicaid,CPT,42844,Extensive surgery of throat,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
Humana Medicaid,CPT,42860,Excision of tonsil tags,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
Humana Medicaid,CPT,42870,Excision of lingual tonsil,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
Humana Medicaid,CPT,42890,Partial removal of pharynx,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,42892,Revision of pharyngeal walls,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,42900,Repair throat wound,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,42950,Reconstruction of throat,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,42953,Repair throat esophagus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,42955,Surgical opening of throat,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,42960,Control throat bleeding,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,42962,Control throat bleeding,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,42970,Control nose/throat bleeding,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,42972,Control nose/throat bleeding,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,42999,Throat surgery procedure,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
Humana Medicaid,CPT,43020,Incision of esophagus,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,43030,Throat muscle surgery,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,43100,Excision of esophagus lesion,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,43130,Removal of esophagus pouch,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,43191,Esophagoscopy rigid trnso dx,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Humana Medicaid,CPT,43192,Esophagoscp rig trnso inject,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Humana Medicaid,CPT,43193,Esophagoscp rig trnso biopsy,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Humana Medicaid,CPT,43194,Esophagoscp rig trnso rem fb,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Humana Medicaid,CPT,43196,Esophagoscp guide wire dilat,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Humana Medicaid,CPT,43197,Esophagoscopy flex dx brush,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Humana Medicaid,CPT,43198,Esophagosc flex trnsn biopsy,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Humana Medicaid,CPT,43200,Esophagoscopy flexible brush,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Humana Medicaid,CPT,43201,Esoph scope w/submucous inj,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Humana Medicaid,CPT,43202,Esophagoscopy flex biopsy,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Humana Medicaid,CPT,43204,Esoph scope w/sclerosis inj,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Humana Medicaid,CPT,43205,Esophagus endoscopy/ligation,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Humana Medicaid,CPT,43206,Esoph optical endomicroscopy,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Humana Medicaid,CPT,43211,Esophagoscop mucosal resect,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Humana Medicaid,CPT,43213,Esophagoscopy retro balloon,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Humana Medicaid,CPT,43214,Esophagosc dilate balloon 30,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Humana Medicaid,CPT,43215,Esophagoscopy flex remove fb,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Humana Medicaid,CPT,43216,Esophagoscopy lesion removal,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Humana Medicaid,CPT,43217,Esophagoscopy snare les remv,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Humana Medicaid,CPT,43220,Esophagoscopy balloon <30mm,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Humana Medicaid,CPT,43226,Esoph endoscopy dilation,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Humana Medicaid,CPT,43227,Esophagoscopy control bleed,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Humana Medicaid,CPT,43229,Esophagoscopy lesion ablate,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Humana Medicaid,CPT,43231,Esophagoscop ultrasound exam,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Humana Medicaid,CPT,43232,Esophagoscopy w/us needle bx,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Humana Medicaid,CPT,43233,Egd balloon dil esoph30 mm/>,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Humana Medicaid,CPT,43235,Egd diagnostic brush wash,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Humana Medicaid,CPT,43236,Uppr gi scope w/submuc inj,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Humana Medicaid,CPT,43237,Endoscopic us exam esoph,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Humana Medicaid,CPT,43238,Egd us fine needle bx/aspir,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Humana Medicaid,CPT,43239,Egd biopsy single/multiple,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Humana Medicaid,CPT,43241,Egd tube/cath insertion,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Humana Medicaid,CPT,43242,Egd us fine needle bx/aspir,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Humana Medicaid,CPT,43243,Egd injection varices,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Humana Medicaid,CPT,43244,Egd varices ligation,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Humana Medicaid,CPT,43245,Egd dilate stricture,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Humana Medicaid,CPT,43246,Egd place gastrostomy tube,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Humana Medicaid,CPT,43247,Egd remove foreign body,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Humana Medicaid,CPT,43248,Egd guide wire insertion,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Humana Medicaid,CPT,43249,Esoph egd dilation <30 mm,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Humana Medicaid,CPT,43250,Egd cautery tumor polyp,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Humana Medicaid,CPT,43251,Egd remove lesion snare,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Humana Medicaid,CPT,43253,Egd us transmural injxn/mark,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Humana Medicaid,CPT,43254,Egd endo mucosal resection,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Humana Medicaid,CPT,43255,Egd control bleeding any,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Humana Medicaid,CPT,43257,Egd w/thrml txmnt gerd,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Humana Medicaid,CPT,43259,Egd us exam duodenum/jejunum,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Humana Medicaid,CPT,43260,Ercp w/specimen collection,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
Humana Medicaid,CPT,43261,Endo cholangiopancreatograph,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
Humana Medicaid,CPT,43262,Endo cholangiopancreatograph,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
Humana Medicaid,CPT,43263,Ercp sphincter pressure meas,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
Humana Medicaid,CPT,43270,Egd lesion ablation,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Humana Medicaid,CPT,43275,Ercp remove forgn body duct,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
Humana Medicaid,CPT,43276,Ercp stent exchange w/dilate,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
Humana Medicaid,CPT,43277,Ercp ea duct/ampulla dilate,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
Humana Medicaid,CPT,43279,Lap myotomy heller,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Humana Medicaid,CPT,43280,Laparoscopy fundoplasty,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Humana Medicaid,CPT,43281,Lap paraesophag hern repair,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Humana Medicaid,CPT,43282,Lap paraesoph her rpr w/mesh,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Humana Medicaid,CPT,43283,Lap esoph lengthening,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Humana Medicaid,CPT,43284,Laps esophgl sphnctr agmntj,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Humana Medicaid,CPT,43285,Rmvl esophgl sphnctr dev,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Humana Medicaid,CPT,43289,Laparoscope proc esoph,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Humana Medicaid,CPT,43300,Repair of esophagus,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,43305,Repair esophagus and fistula,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,43320,Fuse esophagus & stomach,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,43332,Transab esoph hiat hern rpr,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Humana Medicaid,CPT,43333,Transab esoph hiat hern rpr,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Humana Medicaid,CPT,43334,Transthor diaphrag hern rpr,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Humana Medicaid,CPT,43335,Transthor diaphrag hern rpr,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Humana Medicaid,CPT,43336,Thorabd diaphr hern repair,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Humana Medicaid,CPT,43337,Thorabd diaphr hern repair,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Humana Medicaid,CPT,43338,Esoph lengthening,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Humana Medicaid,CPT,43401,Esophagus surgery for veins,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,43410,Repair esophagus wound,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,43420,Repair esophagus opening,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,43450,Dilate esophagus 1/mult pass,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Humana Medicaid,CPT,43453,Dilate esophagus,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Humana Medicaid,CPT,43499,Esophagus surgery procedure,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Humana Medicaid,CPT,43500,Surgical opening of stomach,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,43510,Surgical opening of stomach,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Humana Medicaid,CPT,43520,Incision of pyloric muscle,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Humana Medicaid,CPT,43610,Excision of stomach lesion,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,43644,Lap gastric bypass/roux-en-y,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Humana Medicaid,CPT,43645,Lap gastr bypass incl smll i,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Humana Medicaid,CPT,43647,Lap impl electrode antrum,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Humana Medicaid,CPT,43648,Lap revise/remv eltrd antrum,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Humana Medicaid,CPT,43651,Laparoscopy vagus nerve,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Humana Medicaid,CPT,43652,Laparoscopy vagus nerve,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Humana Medicaid,CPT,43653,Laparoscopy gastrostomy,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Humana Medicaid,CPT,43659,Laparoscope proc stom,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Humana Medicaid,CPT,43752,Nasal/orogastric w/tube plmt,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Humana Medicaid,CPT,43753,Tx gastro intub w/asp,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Humana Medicaid,CPT,43754,Dx gastr intub w/asp spec,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Humana Medicaid,CPT,43755,Dx gastr intub w/asp specs,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Humana Medicaid,CPT,43756,Dx duod intub w/asp spec,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Humana Medicaid,CPT,43757,Dx duod intub w/asp specs,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Humana Medicaid,CPT,43760,Change gastrostomy tube,Gastroenterology,Per Unit,$119.18 ,OP,119.18,119.18,,,,,,
Humana Medicaid,CPT,43761,Reposition gastrostomy tube,Gastroenterology,Per Unit,$119.18 ,OP,119.18,119.18,,,,,,
Humana Medicaid,CPT,43762,Rplc gtube no revj trc,Gastroenterology,Per Unit,$119.18 ,OP,119.18,119.18,,,,,,
Humana Medicaid,CPT,43763,Rplc gtube revj gstrst trc,Gastroenterology,Per Unit,$119.18 ,OP,119.18,119.18,,,,,,
Humana Medicaid,CPT,43770,Lap place gastr adj device,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Humana Medicaid,CPT,43771,Lap revise gastr adj device,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Humana Medicaid,CPT,43772,Lap rmvl gastr adj device,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Humana Medicaid,CPT,43773,Lap replace gastr adj device,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Humana Medicaid,CPT,43774,Lap rmvl gastr adj all parts,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Humana Medicaid,CPT,43775,Lap sleeve gastrectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Humana Medicaid,CPT,43830,Place gastrostomy tube,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Humana Medicaid,CPT,43831,Place gastrostomy tube,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Humana Medicaid,CPT,43832,Place gastrostomy tube,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,43842,V-band gastroplasty,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Humana Medicaid,CPT,43843,Gastroplasty w/o v-band,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,43848,Revision gastroplasty,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,43860,Revise stomach-bowel fusion,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,43870,Repair stomach opening,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Humana Medicaid,CPT,43880,Repair stomach-bowel fistula,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,43881,Impl/redo electrd antrum,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,43882,Revise/remove electrd antrum,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,43886,Revise gastric port open,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Humana Medicaid,CPT,43887,Remove gastric port open,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Humana Medicaid,CPT,43888,Change gastric port open,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Humana Medicaid,CPT,43999,Stomach surgery procedure,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Humana Medicaid,CPT,44005,Freeing of bowel adhesion,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,44015,Insert needle cath bowel,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
Humana Medicaid,CPT,44020,Explore small intestine,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,44050,Reduce bowel obstruction,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,44055,Correct malrotation of bowel,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,44100,Biopsy of bowel,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,44110,Excise intestine lesion(s),General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,44111,Excision of bowel lesion(s),General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,44125,Removal of small intestine,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,44130,Bowel to bowel fusion,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,44139,Mobilization of colon,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,44141,Partial removal of colon,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,44143,Partial removal of colon,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,44180,Lap enterolysis,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Humana Medicaid,CPT,44186,Lap jejunostomy,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Humana Medicaid,CPT,44187,Lap ileo/jejuno-stomy,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Humana Medicaid,CPT,44188,Lap colostomy,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Humana Medicaid,CPT,44204,Laparo partial colectomy,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Humana Medicaid,CPT,44206,Lap part colectomy w/stoma,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Humana Medicaid,CPT,44207,L colectomy/coloproctostomy,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Humana Medicaid,CPT,44208,L colectomy/coloproctostomy,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Humana Medicaid,CPT,44213,Lap mobil splenic fl add-on,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Humana Medicaid,CPT,44238,Laparoscope proc intestine,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Humana Medicaid,CPT,44300,Open bowel to skin,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,44312,Revision of ileostomy,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,44320,Colostomy,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,44340,Revision of colostomy,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,44346,Revision of colostomy,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,44360,Small bowel endoscopy,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Humana Medicaid,CPT,44361,Small bowel endoscopy/biopsy,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Humana Medicaid,CPT,44363,Small bowel endoscopy,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Humana Medicaid,CPT,44364,Small bowel endoscopy,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Humana Medicaid,CPT,44365,Small bowel endoscopy,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Humana Medicaid,CPT,44366,Small bowel endoscopy,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Humana Medicaid,CPT,44369,Small bowel endoscopy,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Humana Medicaid,CPT,44370,Small bowel endoscopy/stent,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Humana Medicaid,CPT,44372,Small bowel endoscopy,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Humana Medicaid,CPT,44373,Small bowel endoscopy,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Humana Medicaid,CPT,44376,Small bowel endoscopy,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Humana Medicaid,CPT,44377,Small bowel endoscopy/biopsy,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Humana Medicaid,CPT,44378,Small bowel endoscopy,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Humana Medicaid,CPT,44379,S bowel endoscope w/stent,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Humana Medicaid,CPT,44380,Small bowel endoscopy br/wa,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,44381,Small bowel endoscopy br/wa,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,44382,Small bowel endoscopy,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,44384,Small bowel endoscopy,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Humana Medicaid,CPT,44385,Endoscopy of bowel pouch,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,44386,Endoscopy bowel pouch/biop,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,44388,Colonoscopy thru stoma spx,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,44389,Colonoscopy with biopsy,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,44390,Colonoscopy for foreign body,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,44391,Colonoscopy for bleeding,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,44392,Colonoscopy & polypectomy,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,44394,Colonoscopy w/snare,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,44401,Colonoscopy with ablation,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,44402,Colonoscopy w/stent plcmt,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Humana Medicaid,CPT,44403,Colonoscopy w/resection,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,44404,Colonoscopy w/injection,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,44405,Colonoscopy w/dilation,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,44406,Colonoscopy w/ultrasound,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,44407,Colonoscopy w/ndl aspir/bx,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,44408,Colonoscopy w/decompression,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,44500,Intro gastrointestinal tube,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Humana Medicaid,CPT,44602,Suture small intestine,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,44603,Suture small intestine,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,44615,Intestinal stricturoplasty,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,44620,Repair bowel opening,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,44640,Repair bowel-skin fistula,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,44650,Repair bowel fistula,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,44799,Unlisted px small intestine,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Humana Medicaid,CPT,44800,Excision of bowel pouch,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,44820,Excision of mesentery lesion,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,44850,Repair of mesentery,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,44899,Bowel surgery procedure,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Humana Medicaid,CPT,44900,Drain appendix abscess open,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,44950,Appendectomy,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,44955,Appendectomy add-on,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,44960,Appendectomy,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,44970,Laparoscopy appendectomy,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Humana Medicaid,CPT,44979,Laparoscope proc app,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Humana Medicaid,CPT,45000,Drainage of pelvic abscess,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,45005,Drainage of rectal abscess,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Humana Medicaid,CPT,45020,Drainage of rectal abscess,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,45100,Biopsy of rectum,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Humana Medicaid,CPT,45108,Removal of anorectal lesion,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,45113,Partial proctectomy,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,45123,Partial proctectomy,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,45130,Excision of rectal prolapse,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,45136,Excise ileoanal reservior,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,45150,Excision of rectal stricture,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,45160,Excision of rectal lesion,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,45171,Exc rect tum transanal part,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,45172,Exc rect tum transanal full,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,45190,Destruction rectal tumor,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,45300,Proctosigmoidoscopy dx,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,45303,Proctosigmoidoscopy dilate,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Humana Medicaid,CPT,45305,Proctosigmoidoscopy w/bx,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,45307,Proctosigmoidoscopy fb,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,45308,Proctosigmoidoscopy removal,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Humana Medicaid,CPT,45309,Proctosigmoidoscopy removal,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,45315,Proctosigmoidoscopy removal,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,45317,Proctosigmoidoscopy bleed,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Humana Medicaid,CPT,45320,Proctosigmoidoscopy ablate,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Humana Medicaid,CPT,45321,Proctosigmoidoscopy volvul,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Humana Medicaid,CPT,45327,Proctosigmoidoscopy w/stent,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Humana Medicaid,CPT,45330,Diagnostic sigmoidoscopy,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,45331,Sigmoidoscopy and biopsy,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,45332,Sigmoidoscopy w/fb removal,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,45333,Sigmoidoscopy & polypectomy,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,45334,Sigmoidoscopy for bleeding,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,45335,Sigmoidoscopy w/submuc inj,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,45337,Sigmoidoscopy & decompress,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,45338,Sigmoidoscopy w/tumr remove,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,45340,Sig w/tndsc balloon dilation,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,45341,Sigmoidoscopy w/ultrasound,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,45342,Sigmoidoscopy w/us guide bx,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,45346,Sigmoidoscopy w/ablation,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,45347,Sigmoidoscopy w/plcmt stent,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Humana Medicaid,CPT,45349,Sigmoidoscopy w/resection,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Humana Medicaid,CPT,45350,Sgmdsc w/band ligation,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,45378,Diagnostic colonoscopy,Preventive Care,Per Unit,$387.00 ,OP,387,387,,,,,,
Humana Medicaid,CPT,45379,Colonoscopy w/fb removal,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,45380,Colonoscopy and biopsy,Preventive Care,Per Unit,$387.00 ,OP,387,387,,,,,,
Humana Medicaid,CPT,45381,Colonoscopy submucous njx,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,45382,Colonoscopy w/control bleed,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,45384,Colonoscopy w/lesion removal,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,45385,Colonoscopy w/lesion removal,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,45386,Colonoscopy w/balloon dilat,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,45388,Colonoscopy w/ablation,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,45389,Colonoscopy w/stent plcmt,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Humana Medicaid,CPT,45390,Colonoscopy w/resection,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Humana Medicaid,CPT,45391,Colonoscopy w/endoscope us,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,45392,Colonoscopy w/endoscopic fnb,Preventive Care,Per Unit,$387.00 ,OP,387,387,,,,,,
Humana Medicaid,CPT,45393,Colonoscopy w/decompression,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,45398,Colonoscopy w/band ligation,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,45399,Unlisted procedure colon,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,45400,Laparoscopic proc,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Humana Medicaid,CPT,45402,Lap proctopexy w/sig resect,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Humana Medicaid,CPT,45499,Laparoscope proc rectum,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Humana Medicaid,CPT,45500,Repair of rectum,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,45505,Repair of rectum,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,45520,Treatment of rectal prolapse,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Humana Medicaid,CPT,45541,Correct rectal prolapse,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,45560,Repair of rectocele,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,45562,Exploration/repair of rectum,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,45800,Repair rect/bladder fistula,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,45820,Repair rectourethral fistula,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,45900,Reduction of rectal prolapse,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Humana Medicaid,CPT,45905,Dilation of anal sphincter,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Humana Medicaid,CPT,45910,Dilation of rectal narrowing,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Humana Medicaid,CPT,45915,Remove rectal obstruction,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Humana Medicaid,CPT,45990,Surg dx exam anorectal,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Humana Medicaid,CPT,45999,Rectum surgery procedure,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Humana Medicaid,CPT,46020,Placement of seton,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Humana Medicaid,CPT,46030,Removal of rectal marker,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Humana Medicaid,CPT,46040,Incision of rectal abscess,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Humana Medicaid,CPT,46045,Incision of rectal abscess,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,46050,Incision of anal abscess,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Humana Medicaid,CPT,46060,Incision of rectal abscess,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,46070,Incision of anal septum,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Humana Medicaid,CPT,46080,Incision of anal sphincter,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Humana Medicaid,CPT,46083,Incise external hemorrhoid,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Humana Medicaid,CPT,46200,Removal of anal fissure,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Humana Medicaid,CPT,46220,Excise anal ext tag/papilla,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Humana Medicaid,CPT,46221,Ligation of hemorrhoid(s),General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Humana Medicaid,CPT,46230,Removal of anal tags,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Humana Medicaid,CPT,46250,Remove ext hem groups 2+,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,46255,Remove int/ext hem 1 group,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,46257,Remove in/ex hem grp & fiss,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,46258,Remove in/ex hem grp w/fistu,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,46260,Remove in/ex hem groups 2+,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,46261,Remove in/ex hem grps & fiss,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,46262,Remove in/ex hem grps w/fist,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,46270,Remove anal fist subq,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,46275,Remove anal fist inter,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,46280,Remove anal fist complex,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,46285,Remove anal fist 2 stage,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Humana Medicaid,CPT,46288,Repair anal fistula,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,46320,Removal of hemorrhoid clot,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Humana Medicaid,CPT,46500,Injection into hemorrhoid(s),General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Humana Medicaid,CPT,46505,Chemodenervation anal musc,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Humana Medicaid,CPT,46600,Diagnostic anoscopy spx,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,46601,Diagnostic anoscopy,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,46604,Anoscopy and dilation,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,46606,Anoscopy and biopsy,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,46607,Diagnostic anoscopy & biopsy,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Humana Medicaid,CPT,46608,Anoscopy remove for body,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,46610,Anoscopy remove lesion,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Humana Medicaid,CPT,46611,Anoscopy,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,46612,Anoscopy remove lesions,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Humana Medicaid,CPT,46614,Anoscopy control bleeding,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,46615,Anoscopy,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Humana Medicaid,CPT,46700,Repair of anal stricture,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,46705,Repair of anal stricture,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,46706,Repr of anal fistula w/glue,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Humana Medicaid,CPT,46707,Repair anorectal fist w/plug,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Humana Medicaid,CPT,46710,Repr per/vag pouch sngl proc,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,46712,Repr per/vag pouch dbl proc,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,46715,Rep perf anoper fistu,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,46716,Rep perf anoper/vestib fistu,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,46740,Construction of absent anus,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,46750,Repair of anal sphincter,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,46751,Repair of anal sphincter,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,46753,Reconstruction of anus,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,46754,Removal of suture from anus,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Humana Medicaid,CPT,46760,Repair of anal sphincter,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,46761,Repair of anal sphincter,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,46762,Implant artificial sphincter,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,46900,Destruction anal lesion(s),General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Humana Medicaid,CPT,46910,Destruction anal lesion(s),General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Humana Medicaid,CPT,46916,Cryosurgery anal lesion(s),General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Humana Medicaid,CPT,46917,Laser surgery anal lesions,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Humana Medicaid,CPT,46922,Excision of anal lesion(s),General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Humana Medicaid,CPT,46924,Destruction anal lesion(s),General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Humana Medicaid,CPT,46930,Destroy internal hemorrhoids,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Humana Medicaid,CPT,46940,Treatment of anal fissure,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Humana Medicaid,CPT,46942,Treatment of anal fissure,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Humana Medicaid,CPT,46945,Int hrhc lig 1 hroid w/o img,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Humana Medicaid,CPT,46946,Int hrhc lig 2+hroid w/o img,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Humana Medicaid,CPT,46947,Hemorrhoidopexy by stapling,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,46948,Int hrhc tranal dartlzj 2+,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,46999,Anus surgery procedure,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Humana Medicaid,CPT,47370,Laparo ablate liver tumor rf,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Humana Medicaid,CPT,47371,Laparo ablate liver cryosurg,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Humana Medicaid,CPT,47379,Laparoscope procedure liver,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Humana Medicaid,CPT,47510,Insert catheter bile duct,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
Humana Medicaid,CPT,47511,Insert bile duct drain,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
Humana Medicaid,CPT,47525,Change bile duct catheter,Gastroenterology,Per Unit,$119.18 ,OP,119.18,119.18,,,,,,
Humana Medicaid,CPT,47530,Revise/reinsert bile tube,Gastroenterology,Per Unit,$119.18 ,OP,119.18,119.18,,,,,,
Humana Medicaid,CPT,47537,Removal biliary drg cath,Gastroenterology,Per Unit,$119.18 ,OP,119.18,119.18,,,,,,
Humana Medicaid,CPT,47560,Laparoscopy w/cholangio,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Humana Medicaid,CPT,47561,Laparo w/cholangio/biopsy,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Humana Medicaid,CPT,47562,Laparoscopic cholecystectomy,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Humana Medicaid,CPT,47563,Laparo cholecystectomy/graph,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Humana Medicaid,CPT,47564,Laparo cholecystectomy/explr,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Humana Medicaid,CPT,47570,Laparo cholecystoenterostomy,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Humana Medicaid,CPT,47579,Laparoscope proc biliary,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Humana Medicaid,CPT,47630,Remove bile duct stone,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
Humana Medicaid,CPT,48550,Donor pancreatectomy,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,49000,Exploration of abdomen,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,49002,Reopening of abdomen,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,49010,Exploration behind abdomen,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,49203,Exc abd tum 5 cm or less,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,49204,Exc abd tum over 5 cm,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,49205,Exc abd tum over 10 cm,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,49215,Excise sacral spine tumor,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,49220,Multiple surgery abdomen,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,49250,Excision of umbilicus,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Humana Medicaid,CPT,49255,Removal of omentum,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,49320,Diag laparo separate proc,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Humana Medicaid,CPT,49321,Laparoscopy biopsy,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Humana Medicaid,CPT,49322,Laparoscopy aspiration,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Humana Medicaid,CPT,49323,Laparo drain lymphocele,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Humana Medicaid,CPT,49324,Lap insert tunnel ip cath,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Humana Medicaid,CPT,49325,Lap revision perm ip cath,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Humana Medicaid,CPT,49326,Lap w/omentopexy add-on,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Humana Medicaid,CPT,49329,Laparo proc abdm/per/oment,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Humana Medicaid,CPT,49402,Remove foreign body adbomen,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Humana Medicaid,CPT,49425,Insert abdomen-venous drain,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,49426,Revise abdomen-venous shunt,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Humana Medicaid,CPT,49428,Ligation of shunt,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,49429,Removal of shunt,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Humana Medicaid,CPT,49440,Place gastrostomy tube perc,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Humana Medicaid,CPT,49441,Place duod/jej tube perc,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Humana Medicaid,CPT,49442,Place cecostomy tube perc,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,49446,Change g-tube to g-j perc,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Humana Medicaid,CPT,49450,Replace g/c tube perc,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Humana Medicaid,CPT,49451,Replace duod/jej tube perc,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Humana Medicaid,CPT,49452,Replace g-j tube perc,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Humana Medicaid,CPT,49460,Fix g/colon tube w/device,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Humana Medicaid,CPT,49491,Rpr hern preemie reduc,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Humana Medicaid,CPT,49492,Rpr ing hern premie blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Humana Medicaid,CPT,49495,Rpr ing hernia baby reduc,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Humana Medicaid,CPT,49496,Rpr ing hernia baby blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Humana Medicaid,CPT,49500,Rpr ing hernia init reduce,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Humana Medicaid,CPT,49501,Rpr ing hernia init blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Humana Medicaid,CPT,49505,Prp i/hern init reduc >5 yr,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Humana Medicaid,CPT,49507,Prp i/hern init block >5 yr,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Humana Medicaid,CPT,49520,Rerepair ing hernia reduce,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Humana Medicaid,CPT,49521,Rerepair ing hernia blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Humana Medicaid,CPT,49525,Repair ing hernia sliding,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Humana Medicaid,CPT,49540,Repair lumbar hernia,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Humana Medicaid,CPT,49550,Rpr rem hernia init reduce,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Humana Medicaid,CPT,49553,Rpr fem hernia init blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Humana Medicaid,CPT,49555,Rerepair fem hernia reduce,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Humana Medicaid,CPT,49557,Rerepair fem hernia blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Humana Medicaid,CPT,49560,Rpr ventral hern init reduc,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Humana Medicaid,CPT,49561,Rpr ventral hern init block,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Humana Medicaid,CPT,49565,Rerepair ventrl hern reduce,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Humana Medicaid,CPT,49566,Rerepair ventrl hern block,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Humana Medicaid,CPT,49568,Hernia repair w/mesh,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Humana Medicaid,CPT,49570,Rpr epigastric hern reduce,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Humana Medicaid,CPT,49572,Rpr epigastric hern blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Humana Medicaid,CPT,49580,Rpr umbil hern reduc < 5 yr,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Humana Medicaid,CPT,49582,Rpr umbil hern block < 5 yr,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Humana Medicaid,CPT,49585,Rpr umbil hern reduc > 5 yr,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Humana Medicaid,CPT,49587,Rpr umbil hern block > 5 yr,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Humana Medicaid,CPT,49590,Repair spigelian hernia,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Humana Medicaid,CPT,49600,Repair umbilical lesion,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Humana Medicaid,CPT,49606,Repair umbilical lesion,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Humana Medicaid,CPT,49610,Repair umbilical lesion,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Humana Medicaid,CPT,49650,Lap ing hernia repair init,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Humana Medicaid,CPT,49651,Lap ing hernia repair recur,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Humana Medicaid,CPT,49652,Lap vent/abd hernia repair,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Humana Medicaid,CPT,49653,Lap vent/abd hern proc comp,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Humana Medicaid,CPT,49654,Lap inc hernia repair,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Humana Medicaid,CPT,49655,Lap inc hern repair comp,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Humana Medicaid,CPT,49656,Lap inc hernia repair recur,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Humana Medicaid,CPT,49657,Lap inc hern recur comp,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Humana Medicaid,CPT,49659,Laparo proc hernia repair,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Humana Medicaid,CPT,49900,Repair of abdominal wall,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,49904,Omental flap extra-abdom,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Humana Medicaid,CPT,49905,Omental flap intra-abdom,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Humana Medicaid,CPT,49906,Free omental flap microvasc,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Humana Medicaid,CPT,49999,Abdomen surgery procedure,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Humana Medicaid,CPT,50389,Remove renal tube w/fluoro,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Humana Medicaid,CPT,50390,Drainage of kidney lesion,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Humana Medicaid,CPT,50391,Instll rx agnt into rnal tub,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Humana Medicaid,CPT,50396,Measure kidney pressure,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Humana Medicaid,CPT,50398,Change kidney tube,Gastroenterology,Per Unit,$119.18 ,OP,119.18,119.18,,,,,,
Humana Medicaid,CPT,50430,Njx px nfrosgrm &/urtrgrm,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Humana Medicaid,CPT,50431,Njx px nfrosgrm &/urtrgrm,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Humana Medicaid,CPT,50541,Laparo ablate renal cyst,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Humana Medicaid,CPT,50542,Laparo ablate renal mass,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Humana Medicaid,CPT,50543,Laparo partial nephrectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Humana Medicaid,CPT,50544,Laparoscopy pyeloplasty,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Humana Medicaid,CPT,50549,Laparoscope proc renal,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Humana Medicaid,CPT,50945,Laparoscopy ureterolithotomy,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Humana Medicaid,CPT,50947,Laparo new ureter/bladder,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Humana Medicaid,CPT,50948,Laparo new ureter/bladder,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Humana Medicaid,CPT,50949,Laparoscope proc ureter,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Humana Medicaid,CPT,51100,Drain bladder by needle,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Humana Medicaid,CPT,51500,Removal of bladder cyst,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Humana Medicaid,CPT,51705,Change of bladder tube,Gastroenterology,Per Unit,$119.18 ,OP,119.18,119.18,,,,,,
Humana Medicaid,CPT,51710,Change of bladder tube,Gastroenterology,Per Unit,$119.18 ,OP,119.18,119.18,,,,,,
Humana Medicaid,CPT,51715,Endoscopic injection/implant,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Humana Medicaid,CPT,51720,Treatment of bladder lesion,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Humana Medicaid,CPT,51725,Simple cystometrogram,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Humana Medicaid,CPT,51726,Complex cystometrogram,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Humana Medicaid,CPT,51727,Cystometrogram w/up,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Humana Medicaid,CPT,51728,Cystometrogram w/vp,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Humana Medicaid,CPT,51729,Cystometrogram w/vp&up,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Humana Medicaid,CPT,51741,Electro-uroflowmetry first,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Humana Medicaid,CPT,51784,Anal/urinary muscle study,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,51785,Anal/urinary muscle study,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,51792,Urinary reflex study,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Humana Medicaid,CPT,51990,Laparo urethral suspension,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Humana Medicaid,CPT,51992,Laparo sling operation,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Humana Medicaid,CPT,51999,Laparoscope proc bla,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Humana Medicaid,CPT,52010,Cystoscopy & duct catheter,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Humana Medicaid,CPT,52270,Cystoscopy & revise urethra,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Humana Medicaid,CPT,52275,Cystoscopy & revise urethra,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Humana Medicaid,CPT,52276,Cystoscopy and treatment,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Humana Medicaid,CPT,52277,Cystoscopy and treatment,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Humana Medicaid,CPT,52282,Cystoscopy implant stent,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Humana Medicaid,CPT,52283,Cystoscopy and treatment,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Humana Medicaid,CPT,52285,Cystoscopy and treatment,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Humana Medicaid,CPT,52400,Cystouretero w/congen repr,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Humana Medicaid,CPT,52402,Cystourethro cut ejacul duct,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Humana Medicaid,CPT,52442,Cystourethro w/addl implant,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Humana Medicaid,CPT,52601,Prostatectomy (turp),Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Humana Medicaid,CPT,52630,Remove prostate regrowth,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Humana Medicaid,CPT,52647,Laser surgery of prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Humana Medicaid,CPT,52648,Laser surgery of prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Humana Medicaid,CPT,52649,Prostate laser enucleation,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Humana Medicaid,CPT,53000,Incision of urethra,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Humana Medicaid,CPT,53010,Incision of urethra,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Humana Medicaid,CPT,53020,Incision of urethra,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Humana Medicaid,CPT,53025,Incision of urethra,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Humana Medicaid,CPT,53040,Drainage of urethra abscess,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Humana Medicaid,CPT,53060,Drainage of urethra abscess,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Humana Medicaid,CPT,53080,Drainage of urinary leakage,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Humana Medicaid,CPT,53085,Drainage of urinary leakage,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Humana Medicaid,CPT,53200,Biopsy of urethra,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Humana Medicaid,CPT,53210,Removal of urethra,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Humana Medicaid,CPT,53215,Removal of urethra,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Humana Medicaid,CPT,53220,Treatment of urethra lesion,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Humana Medicaid,CPT,53230,Removal of urethra lesion,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Humana Medicaid,CPT,53235,Removal of urethra lesion,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Humana Medicaid,CPT,53240,Surgery for urethra pouch,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Humana Medicaid,CPT,53250,Removal of urethra gland,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Humana Medicaid,CPT,53260,Treatment of urethra lesion,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Humana Medicaid,CPT,53265,Treatment of urethra lesion,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Humana Medicaid,CPT,53270,Removal of urethra gland,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Humana Medicaid,CPT,53275,Repair of urethra defect,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Humana Medicaid,CPT,53400,Revise urethra stage 1,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Humana Medicaid,CPT,53405,Revise urethra stage 2,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Humana Medicaid,CPT,53410,Reconstruction of urethra,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Humana Medicaid,CPT,53415,Reconstruction of urethra,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Humana Medicaid,CPT,53420,Reconstruct urethra stage 1,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Humana Medicaid,CPT,53425,Reconstruct urethra stage 2,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Humana Medicaid,CPT,53430,Reconstruction of urethra,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Humana Medicaid,CPT,53431,Reconstruct urethra/bladder,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Humana Medicaid,CPT,53440,Male sling procedure,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Humana Medicaid,CPT,53442,Remove/revise male sling,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Humana Medicaid,CPT,53444,Insert tandem cuff,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Humana Medicaid,CPT,53446,Remove uro sphincter,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Humana Medicaid,CPT,53448,Remov/replc ur sphinctr comp,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Humana Medicaid,CPT,53449,Repair uro sphincter,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Humana Medicaid,CPT,53450,Revision of urethra,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Humana Medicaid,CPT,53460,Revision of urethra,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Humana Medicaid,CPT,53500,Urethrlys transvag w/ scope,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Humana Medicaid,CPT,53502,Repair of urethra injury,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Humana Medicaid,CPT,53505,Repair of urethra injury,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Humana Medicaid,CPT,53510,Repair of urethra injury,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Humana Medicaid,CPT,53515,Repair of urethra injury,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Humana Medicaid,CPT,53520,Repair of urethra defect,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Humana Medicaid,CPT,53605,Dilate urethra stricture,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Humana Medicaid,CPT,53620,Dilate urethra stricture,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Humana Medicaid,CPT,53621,Dilate urethra stricture,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Humana Medicaid,CPT,53665,Dilation of urethra,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Humana Medicaid,CPT,53855,Insert prost urethral stent,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Humana Medicaid,CPT,53860,Transurethral rf treatment,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Humana Medicaid,CPT,54000,Slitting of prepuce,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Humana Medicaid,CPT,54001,Slitting of prepuce,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,54015,Drain penis lesion,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,54050,Destruction penis lesion(s),Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Humana Medicaid,CPT,54055,Destruction penis lesion(s),Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,54056,Cryosurgery penis lesion(s),Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Humana Medicaid,CPT,54057,Laser surg penis lesion(s),Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,54060,Excision of penis lesion(s),Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,54065,Destruction penis lesion(s),Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,54100,Biopsy of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,54105,Biopsy of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,54110,Treatment of penis lesion,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,54115,Treatment of penis lesion,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,54150,Circumcision w/regionl block,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,54160,Circumcision neonate,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,54161,Circum 28 days or older,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,54162,Lysis penil circumic lesion,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,54163,Repair of circumcision,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,54164,Frenulotomy of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,54230,Prepare penis study,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,54231,Dynamic cavernosometry,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,54300,Revision of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,54304,Revision of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,54340,Secondary urethral surgery,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,54360,Penis plastic surgery,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,54380,Repair penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,54385,Repair penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,54400,Insert semi-rigid prosthesis,Urological Surgery,Per Unit,"$6,916.67 ",OP,"6,916.67","6,916.67",,,,,,
Humana Medicaid,CPT,54401,Insert self-contd prosthesis,Urological Surgery,Per Unit,"$6,916.67 ",OP,"6,916.67","6,916.67",,,,,,
Humana Medicaid,CPT,54405,Insert multi-comp penis pros,Urological Surgery,Per Unit,"$6,916.67 ",OP,"6,916.67","6,916.67",,,,,,
Humana Medicaid,CPT,54406,Remove muti-comp penis pros,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,54408,Repair multi-comp penis pros,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,54410,Remove/replace penis prosth,Urological Surgery,Per Unit,"$6,916.67 ",OP,"6,916.67","6,916.67",,,,,,
Humana Medicaid,CPT,54411,Remov/replc penis pros comp,Urological Surgery,Per Unit,"$6,916.67 ",OP,"6,916.67","6,916.67",,,,,,
Humana Medicaid,CPT,54415,Remove self-contd penis pros,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,54416,Remv/repl penis contain pros,Urological Surgery,Per Unit,"$6,916.67 ",OP,"6,916.67","6,916.67",,,,,,
Humana Medicaid,CPT,54417,Remv/replc penis pros compl,Urological Surgery,Per Unit,"$6,916.67 ",OP,"6,916.67","6,916.67",,,,,,
Humana Medicaid,CPT,54420,Revision of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,54430,Revision of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,54435,Revision of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,54440,Repair of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,54450,Preputial stretching,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Humana Medicaid,CPT,54500,Biopsy of testis,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Humana Medicaid,CPT,54505,Biopsy of testis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,54512,Excise lesion testis,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Humana Medicaid,CPT,54520,Removal of testis,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Humana Medicaid,CPT,54522,Orchiectomy partial,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,54530,Removal of testis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,54535,Extensive testis surgery,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,54550,Exploration for testis,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Humana Medicaid,CPT,54560,Exploration for testis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,54600,Reduce testis torsion,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Humana Medicaid,CPT,54620,Suspension of testis,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Humana Medicaid,CPT,54640,Orchiopexy ingun/scrot appr,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Humana Medicaid,CPT,54650,Orchiopexy (fowler-stephens),Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,54660,Revision of testis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,54670,Repair testis injury,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Humana Medicaid,CPT,54680,Relocation of testis(es),Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,54690,Laparoscopy orchiectomy,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,54692,Laparoscopy orchiopexy,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,54699,Laparoscope proc testis,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Humana Medicaid,CPT,54700,Drainage of scrotum,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Humana Medicaid,CPT,54800,Biopsy of epididymis,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Humana Medicaid,CPT,54830,Remove epididymis lesion,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Humana Medicaid,CPT,54840,Remove epididymis lesion,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Humana Medicaid,CPT,54860,Removal of epididymis,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Humana Medicaid,CPT,54861,Removal of epididymis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,54865,Explore epididymis,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Humana Medicaid,CPT,54900,Fusion of spermatic ducts,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Humana Medicaid,CPT,54901,Fusion of spermatic ducts,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,55040,Removal of hydrocele,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,55041,Removal of hydroceles,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,55060,Repair of hydrocele,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Humana Medicaid,CPT,55100,Drainage of scrotum abscess,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Humana Medicaid,CPT,55110,Explore scrotum,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,55120,Removal of scrotum lesion,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Humana Medicaid,CPT,55150,Removal of scrotum,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Humana Medicaid,CPT,55175,Revision of scrotum,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Humana Medicaid,CPT,55180,Revision of scrotum,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,55200,Incision of sperm duct,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Humana Medicaid,CPT,55250,Removal of sperm duct(s),Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Humana Medicaid,CPT,55400,Repair of sperm duct,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,55450,Ligation of sperm duct,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Humana Medicaid,CPT,55500,Removal of hydrocele,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Humana Medicaid,CPT,55520,Removal of sperm cord lesion,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Humana Medicaid,CPT,55530,Revise spermatic cord veins,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,55535,Revise spermatic cord veins,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Humana Medicaid,CPT,55540,Revise hernia & sperm veins,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,55550,Laparo ligate spermatic vein,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,55559,Laparo proc spermatic cord,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Humana Medicaid,CPT,55600,Incise sperm duct pouch,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Humana Medicaid,CPT,55605,Incise sperm duct pouch,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,55650,Remove sperm duct pouch,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,55680,Remove sperm pouch lesion,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Humana Medicaid,CPT,55801,Removal of prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Humana Medicaid,CPT,55810,Extensive prostate surgery,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Humana Medicaid,CPT,55815,Extensive prostate surgery,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Humana Medicaid,CPT,55821,Removal of prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Humana Medicaid,CPT,55831,Removal of prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Humana Medicaid,CPT,55840,Extensive prostate surgery,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Humana Medicaid,CPT,55842,Extensive prostate surgery,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Humana Medicaid,CPT,55845,Extensive prostate surgery,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Humana Medicaid,CPT,55860,Surgical exposure prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Humana Medicaid,CPT,55866,Laparo radical prostatectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Humana Medicaid,CPT,55870,Electroejaculation,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Humana Medicaid,CPT,55873,Cryoablate prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Humana Medicaid,CPT,55874,Tprnl plmt biodegrdabl matrl,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Humana Medicaid,CPT,55880,Abltj mal prst8 tiss hifu,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Humana Medicaid,CPT,55899,Genital surgery procedure,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Humana Medicaid,CPT,56405,I & d of vulva/perineum,Gynecology,Per Unit,$102.34 ,OP,102.34,102.34,,,,,,
Humana Medicaid,CPT,56420,Drainage of gland abscess,Gynecology,Per Unit,$102.34 ,OP,102.34,102.34,,,,,,
Humana Medicaid,CPT,56820,Exam of vulva w/scope,Gynecology,Per Unit,$102.34 ,OP,102.34,102.34,,,,,,
Humana Medicaid,CPT,57150,Treat vagina infection,Gynecology,Per Unit,$102.34 ,OP,102.34,102.34,,,,,,
Humana Medicaid,CPT,57160,Insert pessary/other device,Gynecology,Per Unit,$102.34 ,OP,102.34,102.34,,,,,,
Humana Medicaid,CPT,57170,Fitting of diaphragm/cap,Gynecology,Per Unit,$102.34 ,OP,102.34,102.34,,,,,,
Humana Medicaid,CPT,57220,Revision of urethra,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Humana Medicaid,CPT,57230,Repair of urethral lesion,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Humana Medicaid,CPT,57240,Anterior colporrhaphy,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Humana Medicaid,CPT,57250,Repair rectum & vagina,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Humana Medicaid,CPT,57260,Cmbn ant pst colprhy,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Humana Medicaid,CPT,57265,Cmbn ap colprhy w/ntrcl rpr,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Humana Medicaid,CPT,57267,Insert mesh/pelvic flr addon,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Humana Medicaid,CPT,57268,Repair of bowel bulge,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Humana Medicaid,CPT,57270,Repair of bowel pouch,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Humana Medicaid,CPT,57287,Revise/remove sling repair,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Humana Medicaid,CPT,57288,Repair bladder defect,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Humana Medicaid,CPT,57289,Repair bladder & vagina,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Humana Medicaid,CPT,57410,Pelvic examination,Gynecology,Per Unit,$102.34 ,OP,102.34,102.34,,,,,,
Humana Medicaid,CPT,58300,Insert intrauterine device,Gynecology,Per Unit,$102.34 ,OP,102.34,102.34,,,,,,
Humana Medicaid,CPT,58301,Remove intrauterine device,Gynecology,Per Unit,$102.34 ,OP,102.34,102.34,,,,,,
Humana Medicaid,CPT,58321,Artificial insemination,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Humana Medicaid,CPT,58322,Artificial insemination,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Humana Medicaid,CPT,58323,Sperm washing,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Humana Medicaid,CPT,58970,Retrieval of oocyte,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Humana Medicaid,CPT,58974,Transfer of embryo,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Humana Medicaid,CPT,58976,Transfer of embryo,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Humana Medicaid,CPT,59020,Fetal contract stress test,Obstetrics,Per Unit,$139.58 ,OP,139.58,139.58,,,,,,
Humana Medicaid,CPT,59025,Fetal non-stress test,Obstetrics,Per Unit,$139.58 ,OP,139.58,139.58,,,,,,
Humana Medicaid,CPT,59030,Fetal scalp blood sample,Obstetrics,Per Unit,$139.58 ,OP,139.58,139.58,,,,,,
Humana Medicaid,CPT,59050,Fetal monitor w/report,Obstetrics,Per Unit,$139.58 ,OP,139.58,139.58,,,,,,
Humana Medicaid,CPT,59072,Umbilical cord occlud w/us,Obstetrics,Per Unit,$482.07 ,OP,482.07,482.07,,,,,,
Humana Medicaid,CPT,59074,Fetal fluid drainage w/us,Obstetrics,Per Unit,$139.58 ,OP,139.58,139.58,,,,,,
Humana Medicaid,CPT,59076,Fetal shunt placement w/us,Obstetrics,Per Unit,$482.07 ,OP,482.07,482.07,,,,,,
Humana Medicaid,CPT,59400,Obstetrical care,Obstetrics,Per Unit,"$1,075.20 ",OP,"1,075.20","1,075.20",,,,,,
Humana Medicaid,CPT,59409,Obstetrical care,Obstetrics,Per Unit,"$1,075.20 ",OP,"1,075.20","1,075.20",,,,,,
Humana Medicaid,CPT,59410,Obstetrical care,Obstetrics,Per Unit,"$1,075.20 ",OP,"1,075.20","1,075.20",,,,,,
Humana Medicaid,CPT,59610,Vbac delivery,Obstetrics,Per Unit,"$1,075.20 ",OP,"1,075.20","1,075.20",,,,,,
Humana Medicaid,CPT,59612,Vbac delivery only,Obstetrics,Per Unit,"$1,075.20 ",OP,"1,075.20","1,075.20",,,,,,
Humana Medicaid,CPT,59614,Vbac care after delivery,Obstetrics,Per Unit,"$1,075.20 ",OP,"1,075.20","1,075.20",,,,,,
Humana Medicaid,CPT,59812,Treatment of miscarriage,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Humana Medicaid,CPT,59820,Care of miscarriage,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Humana Medicaid,CPT,59821,Treatment of miscarriage,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Humana Medicaid,CPT,59830,Treat uterus infection,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Humana Medicaid,CPT,59840,Abortion,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Humana Medicaid,CPT,59841,Abortion,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Humana Medicaid,CPT,59850,Abortion,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Humana Medicaid,CPT,59851,Abortion,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Humana Medicaid,CPT,59852,Abortion,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Humana Medicaid,CPT,59855,Abortion,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Humana Medicaid,CPT,59856,Abortion,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Humana Medicaid,CPT,59857,Abortion,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Humana Medicaid,CPT,59866,Abortion (mpr),Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Humana Medicaid,CPT,59897,Fetal invas px w/us,Obstetrics,Per Unit,$139.58 ,OP,139.58,139.58,,,,,,
Humana Medicaid,CPT,60000,Drain thyroid/tongue cyst,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,60100,Biopsy of thyroid,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,60300,Aspir/inj thyroid cyst,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,60650,Laparoscopy adrenalectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Humana Medicaid,CPT,60659,Laparo proc endocrine,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Humana Medicaid,CPT,60699,Endocrine surgery procedure,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
Humana Medicaid,CPT,61000,Remove cranial cavity fluid,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Humana Medicaid,CPT,61001,Remove cranial cavity fluid,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Humana Medicaid,CPT,61020,Remove brain cavity fluid,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Humana Medicaid,CPT,61026,Injection into brain canal,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Humana Medicaid,CPT,61070,Brain canal shunt procedure,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Humana Medicaid,CPT,61215,Insert brain-fluid device,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,61623,Endovasc tempory vessel occl,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,61624,Transcath occlusion cns,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,61626,Transcath occlusion non-cns,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,61630,Intracranial angioplasty,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,61635,Intracran angioplsty w/stent,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,61640,Dilate ic vasospasm init,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,61641,Dilat ic vspsm ea vsl sm ter,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,61642,Dilat ic vspsm ea diff ter,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,61645,Perq art m-thrombect &/nfs,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,61651,Evasc prlng admn rx agnt add,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,61720,Incise skull/brain surgery,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,61770,Incise skull for treatment,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,61790,Treat trigeminal nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,61791,Treat trigeminal tract,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,61796,Srs cranial lesion simple,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"2,592.65","2,592.65",,,,,,
Humana Medicaid,CPT,61797,Srs cran les simple addl,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"2,592.65","2,592.65",,,,,,
Humana Medicaid,CPT,61798,Srs cranial lesion complex,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"2,592.65","2,592.65",,,,,,
Humana Medicaid,CPT,61799,Srs cran les complex addl,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"2,592.65","2,592.65",,,,,,
Humana Medicaid,CPT,61800,Apply srs headframe add-on,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"2,592.65","2,592.65",,,,,,
Humana Medicaid,CPT,61850,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Humana Medicaid,CPT,61880,Revise/remove neuroelectrode,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,61885,Insrt/redo neurostim 1 array,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Humana Medicaid,CPT,61886,Implant neurostim arrays,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Humana Medicaid,CPT,61888,Revise/remove neuroreceiver,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,62000,Treat skull fracture,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,62194,Replace/irrigate catheter,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,62225,Replace/irrigate catheter,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,62230,Replace/revise brain shunt,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,62252,Csf shunt reprogram,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,62292,Njx chemonucleolysis lmbr,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,62302,Myelography lumbar injection,Diagnostic Radiology,Per Unit,$345.35 ,OP,345.35,345.35,,,,,,
Humana Medicaid,CPT,62303,Myelography lumbar injection,Diagnostic Radiology,Per Unit,$345.35 ,OP,345.35,345.35,,,,,,
Humana Medicaid,CPT,62304,Myelography lumbar injection,Diagnostic Radiology,Per Unit,$345.35 ,OP,345.35,345.35,,,,,,
Humana Medicaid,CPT,62305,Myelography lumbar injection,Diagnostic Radiology,Per Unit,$345.35 ,OP,345.35,345.35,,,,,,
Humana Medicaid,CPT,62310,Inject spine cerv/thoracic,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Humana Medicaid,CPT,62311,Inject spine lumbar/sacral,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Humana Medicaid,CPT,62318,Inject spine w/cath crv/thrc,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Humana Medicaid,CPT,62319,Inject spine w/cath lmb/scrl,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Humana Medicaid,CPT,62350,Implant spinal canal cath,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,62355,Remove spinal canal catheter,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,62360,Insert spine infusion device,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"7,098.75","7,098.75",,,,,,
Humana Medicaid,CPT,62361,Implant spine infusion pump,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"7,098.75","7,098.75",,,,,,
Humana Medicaid,CPT,62362,Implant spine infusion pump,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"7,098.75","7,098.75",,,,,,
Humana Medicaid,CPT,62365,Remove spine infusion device,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,62367,Analyze spine infus pump,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Humana Medicaid,CPT,62368,Analyze sp inf pump w/reprog,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Humana Medicaid,CPT,62369,Anal sp inf pmp w/reprg&fill,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Humana Medicaid,CPT,62370,Anl sp inf pmp w/mdreprg&fil,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Humana Medicaid,CPT,63600,Remove spinal cord lesion,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,63610,Stimulation of spinal cord,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,63615,Remove lesion of spinal cord,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,63620,Srs spinal lesion,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"2,592.65","2,592.65",,,,,,
Humana Medicaid,CPT,63621,Srs spinal lesion addl,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"2,592.65","2,592.65",,,,,,
Humana Medicaid,CPT,63650,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,63661,Remove spine eltrd perq aray,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,63662,Remove spine eltrd plate,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,63663,Revise spine eltrd perq aray,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,63664,Revise spine eltrd plate,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Humana Medicaid,CPT,63685,Insrt/redo spine n generator,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Humana Medicaid,CPT,63688,Revise/remove neuroreceiver,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,63707,Repair spinal fluid leakage,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,63741,Install spinal shunt,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,63744,Revision of spinal shunt,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,63746,Removal of spinal shunt,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64400,Njx aa&/strd trigeminal nrv,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Humana Medicaid,CPT,64402,N block inj facial,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Humana Medicaid,CPT,64405,Njx aa&/strd gr ocpl nrv,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Humana Medicaid,CPT,64408,Njx aa&/strd vagus nrv,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Humana Medicaid,CPT,64410,N block inj phrenic,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Humana Medicaid,CPT,64412,N block inj spinal accessor,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Humana Medicaid,CPT,64413,N block inj cervical plexus,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Humana Medicaid,CPT,64415,Njx aa&/strd brach plexus,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Humana Medicaid,CPT,64416,Njx aa&/strd brach plex nfs,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Humana Medicaid,CPT,64417,Njx aa&/strd axillary nrv,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Humana Medicaid,CPT,64418,Njx aa&/strd sprscap nrv,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Humana Medicaid,CPT,64420,Njx aa&/strd ntrcost nrv 1,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Humana Medicaid,CPT,64421,Njx aa&/strd ntrcost nrv ea,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Humana Medicaid,CPT,64425,Njx aa&/strd ii ih nerves,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Humana Medicaid,CPT,64430,Njx aa&/strd pudendal nerve,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Humana Medicaid,CPT,64435,Njx aa&/strd paracrv nrv,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Humana Medicaid,CPT,64445,Njx aa&/strd sciatic nerve,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Humana Medicaid,CPT,64446,Njx aa&/strd sciatic nrv nfs,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Humana Medicaid,CPT,64447,Njx aa&/strd femoral nerve,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Humana Medicaid,CPT,64448,Njx aa&/strd fem nerve nfs,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Humana Medicaid,CPT,64449,Njx aa&/strd lmbr plex nfs,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Humana Medicaid,CPT,64450,Njx aa&/strd other pn/branch,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Humana Medicaid,CPT,64454,Njx aa&/strd gnclr nrv brnch,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Humana Medicaid,CPT,64455,Njx aa&/strd pltr com dg nrv,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Humana Medicaid,CPT,64486,Tap block unil by injection,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Humana Medicaid,CPT,64487,Tap block uni by infusion,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Humana Medicaid,CPT,64488,Tap block bi injection,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Humana Medicaid,CPT,64489,Tap block bi by infusion,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Humana Medicaid,CPT,64505,N block spenopalatine gangl,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Humana Medicaid,CPT,64508,N block carotid sinus s/p,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Humana Medicaid,CPT,64510,N block stellate ganglion,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Humana Medicaid,CPT,64517,N block inj hypogas plxs,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Humana Medicaid,CPT,64530,N block inj celiac pelus,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Humana Medicaid,CPT,64550,Appl surface neurostimulator,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,64553,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,64555,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,64561,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,64565,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,64566,Neuroeltrd stim post tibial,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Humana Medicaid,CPT,64568,Inc for vagus n elect impl,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Humana Medicaid,CPT,64569,Revise/repl vagus n eltrd,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Humana Medicaid,CPT,64570,Remove vagus n eltrd,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64575,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Humana Medicaid,CPT,64580,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"7,098.75","7,098.75",,,,,,
Humana Medicaid,CPT,64581,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"7,098.75","7,098.75",,,,,,
Humana Medicaid,CPT,64585,Revise/remove neuroelectrode,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64590,Insrt/redo pn/gastr stimul,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"7,098.75","7,098.75",,,,,,
Humana Medicaid,CPT,64595,Revise/rmv pn/gastr stimul,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,64600,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Humana Medicaid,CPT,64605,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Humana Medicaid,CPT,64610,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Humana Medicaid,CPT,64611,Chemodenerv saliv glands,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Humana Medicaid,CPT,64612,Destroy nerve face muscle,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Humana Medicaid,CPT,64615,Chemodenerv musc migraine,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Humana Medicaid,CPT,64616,Chemodenerv musc neck dyston,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Humana Medicaid,CPT,64617,Chemodener muscle larynx emg,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Humana Medicaid,CPT,64620,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Humana Medicaid,CPT,64624,Dstrj nulyt agt gnclr nrv,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Humana Medicaid,CPT,64625,Rf abltj nrv nrvtg si jt,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64630,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Humana Medicaid,CPT,64632,N block inj common digit,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Humana Medicaid,CPT,64640,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Humana Medicaid,CPT,64642,Chemodenerv 1 extremity 1-4,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Humana Medicaid,CPT,64643,Chemodenerv 1 extrem 1-4 ea,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Humana Medicaid,CPT,64644,Chemodenerv 1 extrem 5/> mus,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Humana Medicaid,CPT,64645,Chemodenerv 1 extrem 5/> ea,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Humana Medicaid,CPT,64646,Chemodenerv trunk musc 1-5,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Humana Medicaid,CPT,64647,Chemodenerv trunk musc 6/>,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Humana Medicaid,CPT,64650,Chemodenerv eccrine glands,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Humana Medicaid,CPT,64653,Chemodenerv eccrine glands,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Humana Medicaid,CPT,64680,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Humana Medicaid,CPT,64681,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Humana Medicaid,CPT,64702,Revise finger/toe nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64704,Revise hand/foot nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64708,Revise arm/leg nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64712,Revision of sciatic nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64713,Revision of arm nerve(s),Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,64714,Revise low back nerve(s),Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,64716,Revision of cranial nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,64718,Revise ulnar nerve at elbow,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64719,Revise ulnar nerve at wrist,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64721,Carpal tunnel surgery,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64722,Relieve pressure on nerve(s),Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64726,Release foot/toe nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64727,Internal nerve revision,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,64732,Incision of brow nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64734,Incision of cheek nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,64736,Incision of chin nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64738,Incision of jaw nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64740,Incision of tongue nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64742,Incision of facial nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,64744,Incise nerve back of head,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64746,Incise diaphragm nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,64763,Incise hip/thigh nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64766,Incise hip/thigh nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64771,Sever cranial nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64772,Incision of spinal nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64774,Remove skin nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64776,Remove digit nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64778,Digit nerve surgery add-on,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64782,Remove limb nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64783,Limb nerve surgery add-on,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64784,Remove nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64786,Remove sciatic nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64787,Implant nerve end,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64788,Remove skin nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64790,Removal of nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64792,Removal of nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64795,Biopsy of nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64802,Sympathectomy cervical,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64804,Remove sympathetic nerves,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64818,Remove sympathetic nerves,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64820,Sympathectomy digital artery,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64821,Remove sympathetic nerves,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,64822,Remove sympathetic nerves,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,64823,Sympathectomy supfc palmar,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,64831,Repair of digit nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64832,Repair nerve add-on,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64834,Repair of hand or foot nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64835,Repair of hand or foot nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64836,Repair of hand or foot nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64837,Repair nerve add-on,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64840,Repair of leg nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,64856,Repair/transpose nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64857,Repair arm/leg nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64858,Repair sciatic nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,64859,Nerve surgery,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,64861,Repair of arm nerves,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64862,Repair of low back nerves,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,64864,Repair of facial nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,64865,Repair of facial nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,64866,Fusion of facial/other nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,64868,Fusion of facial/other nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,64872,Subsequent repair of nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64874,Repair & revise nerve add-on,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64876,Repair nerve/shorten bone,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64885,Nerve graft head/neck </4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,64886,Nerve graft head/neck >4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,64890,Nerve graft hand/foot </4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,64891,Nerve graft hand/foot >4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,64892,Nerve graft arm/leg <4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,64893,Nerve graft arm/leg >4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,64895,Nerve graft hand/foot </4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,64896,Nerve graft hand/foot >4 cm,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"7,098.75","7,098.75",,,,,,
Humana Medicaid,CPT,64897,Nerve graft arm/leg </4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,64898,Nerve graft arm/leg >4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,64901,Nerve graft add-on,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,64902,Nerve graft add-on,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,64905,Nerve pedicle transfer,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,64907,Nerve pedicle transfer,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,64910,Nerve repair w/allograft,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,64911,Neurorraphy w/vein autograft,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,64912,Nrv rpr w/nrv algrft 1st,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,64913,Nrv rpr w/nrv algrft ea addl,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,64999,Nervous system surgery,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Humana Medicaid,CPT,65091,Revise eye,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,65093,Revise eye with implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,65101,Removal of eye,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,65103,Remove eye/insert implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,65105,Remove eye/attach implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,65110,Removal of eye,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,65112,Remove eye/revise socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,65114,Remove eye/revise socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,65125,Revise ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,65130,Insert ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,65135,Insert ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,65140,Attach ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,65150,Revise ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,65155,Reinsert ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,65175,Removal of ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,65205,Remove foreign body from eye,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,65210,Remove foreign body from eye,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,65220,Remove foreign body from eye,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,65222,Remove foreign body from eye,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,65235,Remove foreign body from eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Humana Medicaid,CPT,65260,Remove foreign body from eye,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Humana Medicaid,CPT,65265,Remove foreign body from eye,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Humana Medicaid,CPT,65270,Repair of eye wound,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Humana Medicaid,CPT,65272,Repair of eye wound,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Humana Medicaid,CPT,65275,Repair of eye wound,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Humana Medicaid,CPT,65280,Repair of eye wound,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Humana Medicaid,CPT,65285,Repair of eye wound,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Humana Medicaid,CPT,65286,Repair of eye wound,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Humana Medicaid,CPT,65290,Repair of eye socket wound,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
Humana Medicaid,CPT,65400,Removal of eye lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Humana Medicaid,CPT,65410,Biopsy of cornea,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Humana Medicaid,CPT,65420,Removal of eye lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Humana Medicaid,CPT,65426,Removal of eye lesion,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Humana Medicaid,CPT,65430,Corneal smear,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Humana Medicaid,CPT,65435,Curette/treat cornea,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Humana Medicaid,CPT,65436,Curette/treat cornea,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Humana Medicaid,CPT,65450,Treatment of corneal lesion,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Humana Medicaid,CPT,65600,Revision of cornea,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Humana Medicaid,CPT,65710,Corneal transplant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Humana Medicaid,CPT,65730,Corneal transplant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Humana Medicaid,CPT,65750,Corneal transplant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Humana Medicaid,CPT,65755,Corneal transplant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Humana Medicaid,CPT,65756,Corneal trnspl endothelial,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Humana Medicaid,CPT,65757,Prep corneal endo allograft,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Humana Medicaid,CPT,65760,Revision of cornea,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Humana Medicaid,CPT,65765,Revision of cornea,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Humana Medicaid,CPT,65767,Corneal tissue transplant,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Humana Medicaid,CPT,65770,Revise cornea with implant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Humana Medicaid,CPT,65771,Radial keratotomy,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Humana Medicaid,CPT,65772,Correction of astigmatism,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Humana Medicaid,CPT,65775,Correction of astigmatism,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Humana Medicaid,CPT,65778,Cover eye w/membrane,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Humana Medicaid,CPT,65779,Cover eye w/membrane suture,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Humana Medicaid,CPT,65780,Ocular reconst transplant,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Humana Medicaid,CPT,65781,Ocular reconst transplant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Humana Medicaid,CPT,65782,Ocular reconst transplant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Humana Medicaid,CPT,65785,Impltj ntrstrml crnl rng seg,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Humana Medicaid,CPT,65800,Drainage of eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Humana Medicaid,CPT,65810,Drainage of eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Humana Medicaid,CPT,65815,Drainage of eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Humana Medicaid,CPT,65820,Relieve inner eye pressure,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Humana Medicaid,CPT,65850,Incision of eye,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Humana Medicaid,CPT,65855,Trabeculoplasty laser surg,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Humana Medicaid,CPT,65860,Incise inner eye adhesions,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Humana Medicaid,CPT,65865,Incise inner eye adhesions,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Humana Medicaid,CPT,65870,Incise inner eye adhesions,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Humana Medicaid,CPT,65875,Incise inner eye adhesions,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Humana Medicaid,CPT,65880,Incise inner eye adhesions,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Humana Medicaid,CPT,65900,Remove eye lesion,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Humana Medicaid,CPT,65920,Remove implant of eye,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Humana Medicaid,CPT,65930,Remove blood clot from eye,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Humana Medicaid,CPT,66020,Injection treatment of eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Humana Medicaid,CPT,66030,Injection treatment of eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Humana Medicaid,CPT,66130,Remove eye lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Humana Medicaid,CPT,66150,Glaucoma surgery,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Humana Medicaid,CPT,66155,Glaucoma surgery,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Humana Medicaid,CPT,66160,Glaucoma surgery,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Humana Medicaid,CPT,66170,Glaucoma surgery,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Humana Medicaid,CPT,66172,Incision of eye,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Humana Medicaid,CPT,66174,Translum dil eye canal,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Humana Medicaid,CPT,66175,Trnslum dil eye canal w/stnt,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Humana Medicaid,CPT,66179,Aqueous shunt eye w/o graft,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Humana Medicaid,CPT,66180,Aqueous shunt eye w/graft,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Humana Medicaid,CPT,66183,Insert ant drainage device,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Humana Medicaid,CPT,66184,Revision of aqueous shunt,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Humana Medicaid,CPT,66185,Revise aqueous shunt eye,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Humana Medicaid,CPT,66220,Repair eye lesion,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Humana Medicaid,CPT,66225,Repair/graft eye lesion,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Humana Medicaid,CPT,66250,Follow-up surgery of eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Humana Medicaid,CPT,66500,Incision of iris,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Humana Medicaid,CPT,66505,Incision of iris,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Humana Medicaid,CPT,66600,Remove iris and lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Humana Medicaid,CPT,66605,Removal of iris,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Humana Medicaid,CPT,66625,Removal of iris,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Humana Medicaid,CPT,66630,Removal of iris,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Humana Medicaid,CPT,66635,Removal of iris,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Humana Medicaid,CPT,66680,Repair iris & ciliary body,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Humana Medicaid,CPT,66682,Repair iris & ciliary body,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Humana Medicaid,CPT,66700,Destruction ciliary body,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Humana Medicaid,CPT,66710,Ciliary transsleral therapy,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Humana Medicaid,CPT,66711,Ecp ciliary body destruction,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Humana Medicaid,CPT,66720,Destruction ciliary body,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Humana Medicaid,CPT,66740,Destruction ciliary body,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Humana Medicaid,CPT,66761,Revision of iris,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Humana Medicaid,CPT,66762,Revision of iris,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Humana Medicaid,CPT,66770,Removal of inner eye lesion,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Humana Medicaid,CPT,66820,Incision secondary cataract,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
Humana Medicaid,CPT,66821,After cataract laser surgery,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Humana Medicaid,CPT,66825,Reposition intraocular lens,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
Humana Medicaid,CPT,66830,Removal of lens lesion,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
Humana Medicaid,CPT,66840,Removal of lens material,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
Humana Medicaid,CPT,66850,Removal of lens material,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
Humana Medicaid,CPT,66852,Removal of lens material,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Humana Medicaid,CPT,66920,Extraction of lens,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
Humana Medicaid,CPT,66930,Extraction of lens,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
Humana Medicaid,CPT,66940,Extraction of lens,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
Humana Medicaid,CPT,66982,Xcapsl ctrc rmvl cplx wo ecp,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
Humana Medicaid,CPT,66983,Cataract surg w/iol 1 stage,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
Humana Medicaid,CPT,66984,Xcapsl ctrc rmvl w/o ecp,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
Humana Medicaid,CPT,66985,Insert lens prosthesis,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
Humana Medicaid,CPT,66986,Exchange lens prosthesis,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
Humana Medicaid,CPT,66987,Xcapsl ctrc rmvl cplx w/ecp,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
Humana Medicaid,CPT,66988,Xcapsl ctrc rmvl w/ecp,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
Humana Medicaid,CPT,66999,Eye surgery procedure,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Humana Medicaid,CPT,67005,Partial removal of eye fluid,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Humana Medicaid,CPT,67010,Partial removal of eye fluid,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Humana Medicaid,CPT,67015,Release of eye fluid,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Humana Medicaid,CPT,67025,Replace eye fluid,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Humana Medicaid,CPT,67027,Implant eye drug system,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Humana Medicaid,CPT,67028,Injection eye drug,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Humana Medicaid,CPT,67030,Incise inner eye strands,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Humana Medicaid,CPT,67031,Laser surgery eye strands,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Humana Medicaid,CPT,67036,Removal of inner eye fluid,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Humana Medicaid,CPT,67039,Laser treatment of retina,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Humana Medicaid,CPT,67040,Laser treatment of retina,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Humana Medicaid,CPT,67041,Vit for macular pucker,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Humana Medicaid,CPT,67042,Vit for macular hole,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Humana Medicaid,CPT,67043,Vit for membrane dissect,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Humana Medicaid,CPT,67101,Repair detached retina crtx,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Humana Medicaid,CPT,67105,Repair detached retina pc,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Humana Medicaid,CPT,67107,Repair detached retina,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Humana Medicaid,CPT,67108,Repair detached retina,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Humana Medicaid,CPT,67110,Repair detached retina,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Humana Medicaid,CPT,67112,Rerepair detached retina,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Humana Medicaid,CPT,67113,Repair retinal detach cplx,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Humana Medicaid,CPT,67115,Release encircling material,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Humana Medicaid,CPT,67120,Remove eye implant material,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Humana Medicaid,CPT,67121,Remove eye implant material,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Humana Medicaid,CPT,67141,Treatment of retina,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Humana Medicaid,CPT,67145,Treatment of retina,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Humana Medicaid,CPT,67208,Treatment of retinal lesion,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Humana Medicaid,CPT,67210,Treatment of retinal lesion,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Humana Medicaid,CPT,67218,Treatment of retinal lesion,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Humana Medicaid,CPT,67220,Treatment of choroid lesion,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Humana Medicaid,CPT,67221,Ocular photodynamic ther,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Humana Medicaid,CPT,67225,Eye photodynamic ther add-on,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Humana Medicaid,CPT,67227,Dstrj extensive retinopathy,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Humana Medicaid,CPT,67228,Treatment x10sv retinopathy,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Humana Medicaid,CPT,67229,Tr retinal les preterm inf,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Humana Medicaid,CPT,67250,Reinforce eye wall,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Humana Medicaid,CPT,67255,Reinforce/graft eye wall,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Humana Medicaid,CPT,67299,Eye surgery procedure,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Humana Medicaid,CPT,67311,Revise eye muscle,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
Humana Medicaid,CPT,67312,Revise two eye muscles,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
Humana Medicaid,CPT,67314,Revise eye muscle,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
Humana Medicaid,CPT,67316,Revise two eye muscles,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
Humana Medicaid,CPT,67318,Revise eye muscle(s),Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
Humana Medicaid,CPT,67320,Revise eye muscle(s) add-on,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
Humana Medicaid,CPT,67331,Eye surgery follow-up add-on,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
Humana Medicaid,CPT,67332,Rerevise eye muscles add-on,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
Humana Medicaid,CPT,67334,Revise eye muscle w/suture,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
Humana Medicaid,CPT,67335,Eye suture during surgery,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
Humana Medicaid,CPT,67340,Revise eye muscle add-on,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
Humana Medicaid,CPT,67343,Release eye tissue,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
Humana Medicaid,CPT,67345,Destroy nerve of eye muscle,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
Humana Medicaid,CPT,67346,Biopsy eye muscle,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Humana Medicaid,CPT,67399,Unlisted px extraocular musc,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
Humana Medicaid,CPT,67400,Explore/biopsy eye socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,67405,Explore/drain eye socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,67412,Explore/treat eye socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,67413,Explore/treat eye socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,67414,Explr/decompress eye socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,67415,Aspiration orbital contents,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Humana Medicaid,CPT,67445,Explr/decompress eye socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,67500,Inject/treat eye socket,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Humana Medicaid,CPT,67505,Inject/treat eye socket,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Humana Medicaid,CPT,67515,Inject/treat eye socket,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Humana Medicaid,CPT,67550,Insert eye socket implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,67560,Revise eye socket implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,67570,Decompress optic nerve,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,67599,Orbit surgery procedure,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Humana Medicaid,CPT,67700,Drainage of eyelid abscess,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Humana Medicaid,CPT,67710,Incision of eyelid,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Humana Medicaid,CPT,67715,Incision of eyelid fold,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Humana Medicaid,CPT,67800,Remove eyelid lesion,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Humana Medicaid,CPT,67801,Remove eyelid lesions,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Humana Medicaid,CPT,67805,Remove eyelid lesions,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Humana Medicaid,CPT,67808,Remove eyelid lesion(s),Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Humana Medicaid,CPT,67810,Biopsy eyelid & lid margin,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Humana Medicaid,CPT,67820,Revise eyelashes,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Humana Medicaid,CPT,67825,Revise eyelashes,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Humana Medicaid,CPT,67830,Revise eyelashes,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Humana Medicaid,CPT,67835,Revise eyelashes,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,67840,Remove eyelid lesion,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Humana Medicaid,CPT,67850,Treat eyelid lesion,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Humana Medicaid,CPT,67875,Closure of eyelid by suture,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Humana Medicaid,CPT,67880,Revision of eyelid,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Humana Medicaid,CPT,67882,Revision of eyelid,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Humana Medicaid,CPT,67900,Repair brow defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,67901,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,67902,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,67903,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,67904,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,67906,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,67908,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,67909,Revise eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,67911,Revise eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,67912,Correction eyelid w/implant,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Humana Medicaid,CPT,67914,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Humana Medicaid,CPT,67915,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Humana Medicaid,CPT,67916,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Humana Medicaid,CPT,67917,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,67921,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Humana Medicaid,CPT,67922,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Humana Medicaid,CPT,67923,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Humana Medicaid,CPT,67924,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,67930,Repair eyelid wound,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Humana Medicaid,CPT,67935,Repair eyelid wound,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Humana Medicaid,CPT,67938,Remove eyelid foreign body,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Humana Medicaid,CPT,67950,Revision of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,67961,Revision of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,67966,Revision of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,67971,Reconstruction of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,67973,Reconstruction of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,67974,Reconstruction of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,67975,Reconstruction of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,67999,Revision of eyelid,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Humana Medicaid,CPT,68020,Incise/drain eyelid lining,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Humana Medicaid,CPT,68040,Treatment of eyelid lesions,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Humana Medicaid,CPT,68100,Biopsy of eyelid lining,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Humana Medicaid,CPT,68110,Remove eyelid lining lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Humana Medicaid,CPT,68115,Remove eyelid lining lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Humana Medicaid,CPT,68130,Remove eyelid lining lesion,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Humana Medicaid,CPT,68135,Remove eyelid lining lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Humana Medicaid,CPT,68200,Treat eyelid by injection,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Humana Medicaid,CPT,68320,Revise/graft eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Humana Medicaid,CPT,68325,Revise/graft eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Humana Medicaid,CPT,68326,Revise/graft eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Humana Medicaid,CPT,68328,Revise/graft eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Humana Medicaid,CPT,68330,Revise eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Humana Medicaid,CPT,68335,Revise/graft eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Humana Medicaid,CPT,68340,Separate eyelid adhesions,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Humana Medicaid,CPT,68360,Revise eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Humana Medicaid,CPT,68362,Revise eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Humana Medicaid,CPT,68371,Harvest eye tissue alograft,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Humana Medicaid,CPT,68399,Eyelid lining surgery,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Humana Medicaid,CPT,68400,Incise/drain tear gland,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Humana Medicaid,CPT,68420,Incise/drain tear sac,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Humana Medicaid,CPT,68440,Incise tear duct opening,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Humana Medicaid,CPT,68500,Removal of tear gland,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,68505,Partial removal tear gland,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,68510,Biopsy of tear gland,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Humana Medicaid,CPT,68520,Removal of tear sac,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,68525,Biopsy of tear sac,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Humana Medicaid,CPT,68530,Clearance of tear duct,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Humana Medicaid,CPT,68540,Remove tear gland lesion,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,68550,Remove tear gland lesion,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,68700,Repair tear ducts,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,68705,Revise tear duct opening,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Humana Medicaid,CPT,68720,Create tear sac drain,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,68745,Create tear duct drain,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,68750,Create tear duct drain,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,68760,Close tear duct opening,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Humana Medicaid,CPT,68761,Close tear duct opening,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Humana Medicaid,CPT,68770,Close tear system fistula,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Humana Medicaid,CPT,68801,Dilate tear duct opening,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Humana Medicaid,CPT,68810,Probe nasolacrimal duct,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Humana Medicaid,CPT,68811,Probe nasolacrimal duct,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Humana Medicaid,CPT,68815,Probe nasolacrimal duct,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Humana Medicaid,CPT,68816,Probe nl duct w/balloon,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Humana Medicaid,CPT,68840,Explore/irrigate tear ducts,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Humana Medicaid,CPT,68899,Tear duct system surgery,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Humana Medicaid,CPT,69005,Drain external ear lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,69100,Biopsy of external ear,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,69105,Biopsy of external ear canal,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,69110,Remove external ear partial,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,69120,Removal of external ear,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,69140,Remove ear canal lesion(s),Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,69145,Remove ear canal lesion(s),Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,69150,Extensive ear canal surgery,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,69155,Extensive ear/neck surgery,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,69205,Clear outer ear canal,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,69222,Clean out mastoid cavity,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,69300,Revise external ear,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,69310,Rebuild outer ear canal,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,69320,Rebuild outer ear canal,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,69399,Outer ear surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,69421,Incision of eardrum,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,69424,Remove ventilating tube,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,69433,Create eardrum opening,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,69436,Create eardrum opening,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,69440,Exploration of middle ear,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,69450,Eardrum revision,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,69501,Mastoidectomy,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,69502,Mastoidectomy,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,69505,Remove mastoid structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,69511,Extensive mastoid surgery,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,69530,Extensive mastoid surgery,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,69540,Remove ear lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,69550,Remove ear lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,69552,Remove ear lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,69601,Mastoid surgery revision,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,69602,Mastoid surgery revision,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,69603,Mastoid surgery revision,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,69604,Mastoid surgery revision,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,69605,Mastoid surgery revision,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,69610,Repair of eardrum,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,69620,Repair of eardrum,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,69631,Repair eardrum structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,69632,Rebuild eardrum structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,69633,Rebuild eardrum structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,69635,Repair eardrum structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,69636,Rebuild eardrum structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,69637,Rebuild eardrum structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,69641,Revise middle ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,69642,Revise middle ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,69643,Revise middle ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,69644,Revise middle ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,69645,Revise middle ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,69646,Revise middle ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,69650,Release middle ear bone,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,69660,Revise middle ear bone,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,69661,Revise middle ear bone,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,69662,Revise middle ear bone,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,69666,Repair middle ear structures,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,69667,Repair middle ear structures,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,69670,Remove mastoid air cells,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,69676,Remove middle ear nerve,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,69700,Close mastoid fistula,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,69705,Nps surg dilat eust tube uni,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Humana Medicaid,CPT,69706,Nps surg dilat eust tube bi,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Humana Medicaid,CPT,69710,Implant/replace hearing aid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,69711,Remove/repair hearing aid,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,69714,Implant temple bone w/stimul,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,69715,Temple bne implnt w/stimulat,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,69717,Temple bone implant revision,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,69718,Revise temple bone implant,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,69720,Release facial nerve,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,69725,Release facial nerve,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,69740,Repair facial nerve,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,69745,Repair facial nerve,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,69799,Middle ear surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,69801,Incise inner ear,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,69805,Explore inner ear,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,69806,Explore inner ear,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,69820,Establish inner ear window,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,69840,Revise inner ear window,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,69905,Remove inner ear,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Humana Medicaid,CPT,69910,Remove inner ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,69915,Incise inner ear nerve,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,69930,Implant cochlear device,Otolaryngology Surgery,Per Unit,"$15,529.51 ",OP,"15,529.51","15,529.51",,,,,,
Humana Medicaid,CPT,69949,Inner ear surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,69955,Release facial nerve,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,69960,Release inner ear canal,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Humana Medicaid,CPT,70010,Contrast x-ray of brain,Diagnostic Radiology,Per Unit,$345.35 ,OP,345.35,345.35,,,,,,
Humana Medicaid,CPT,70015,Contrast x-ray of brain,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Humana Medicaid,CPT,70030,X-ray eye for foreign body,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,70100,X-ray exam of jaw <4views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,70110,X-ray exam of jaw 4/> views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,70120,X-ray exam of mastoids,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,70130,X-ray exam of mastoids,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,70134,X-ray exam of middle ear,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,70140,X-ray exam of facial bones,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,70150,X-ray exam of facial bones,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,70160,X-ray exam of nasal bones,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,70190,X-ray exam of eye sockets,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,70200,X-ray exam of eye sockets,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,70210,X-ray exam of sinuses,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,70220,X-ray exam of sinuses,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,70240,X-ray exam pituitary saddle,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,70250,X-ray exam of skull,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,70260,X-ray exam of skull,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,70300,X-ray exam of teeth,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,70310,X-ray exam of teeth,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,70320,Full mouth x-ray of teeth,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,70328,X-ray exam of jaw joint,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,70330,X-ray exam of jaw joints,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,70336,Magnetic image jaw joint,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Humana Medicaid,CPT,70350,X-ray head for orthodontia,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,70355,Panoramic x-ray of jaws,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,70360,X-ray exam of neck,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,70370,Throat x-ray & fluoroscopy,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,70373,Contrast x-ray of larynx,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,70380,X-ray exam of salivary gland,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,70450,Ct head/brain w/o dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Humana Medicaid,CPT,70460,Ct head/brain w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Humana Medicaid,CPT,70470,Ct head/brain w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Humana Medicaid,CPT,70480,Ct orbit/ear/fossa w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Humana Medicaid,CPT,70481,Ct orbit/ear/fossa w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Humana Medicaid,CPT,70482,Ct orbit/ear/fossa w/o&w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Humana Medicaid,CPT,70486,Ct maxillofacial w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Humana Medicaid,CPT,70487,Ct maxillofacial w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Humana Medicaid,CPT,70488,Ct maxillofacial w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Humana Medicaid,CPT,70490,Ct soft tissue neck w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Humana Medicaid,CPT,70491,Ct soft tissue neck w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Humana Medicaid,CPT,70492,Ct sft tsue nck w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Humana Medicaid,CPT,70496,Ct angiography head,Interventional Radiology,Per Unit,$178.94 ,OP,178.94,178.94,,,,,,
Humana Medicaid,CPT,70498,Ct angiography neck,Interventional Radiology,Per Unit,$178.94 ,OP,178.94,178.94,,,,,,
Humana Medicaid,CPT,70540,Mri orbit/face/neck w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Humana Medicaid,CPT,70542,Mri orbit/face/neck w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Humana Medicaid,CPT,70543,Mri orbt/fac/nck w/o &w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Humana Medicaid,CPT,70544,Mr angiography head w/o dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Humana Medicaid,CPT,70545,Mr angiography head w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Humana Medicaid,CPT,70546,Mr angiograph head w/o&w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Humana Medicaid,CPT,70547,Mr angiography neck w/o dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Humana Medicaid,CPT,70548,Mr angiography neck w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Humana Medicaid,CPT,70549,Mr angiograph neck w/o&w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Humana Medicaid,CPT,70551,Mri brain stem w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Humana Medicaid,CPT,70552,Mri brain stem w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Humana Medicaid,CPT,70553,Mri brain stem w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Humana Medicaid,CPT,70554,Fmri brain by tech,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Humana Medicaid,CPT,70555,Fmri brain by phys/psych,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Humana Medicaid,CPT,70557,Mri brain w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Humana Medicaid,CPT,70558,Mri brain w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Humana Medicaid,CPT,70559,Mri brain w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Humana Medicaid,CPT,71010,Chest x-ray 1 view frontal,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,71015,Chest x-ray stereo frontal,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,71020,Chest x-ray 2vw frontal&latl,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,71021,Chest x-ray frnt lat lordotc,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,71022,Chest x-ray frnt lat oblique,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,71023,Chest x-ray and fluoroscopy,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,71030,Chest x-ray 4/> views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,71034,Chest x-ray&fluoro 4/> views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,71035,Chest x-ray special views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,71045,X-ray exam chest 1 view,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,71046,X-ray exam chest 2 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,71047,X-ray exam chest 3 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,71048,X-ray exam chest 4+ views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,71100,X-ray exam ribs uni 2 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,71101,X-ray exam unilat ribs/chest,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,71110,X-ray exam ribs bil 3 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,71111,X-ray exam ribs/chest4/> vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,71120,X-ray exam breastbone 2/>vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,71130,X-ray strenoclavic jt 3/>vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,71250,Ct thorax dx c-,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Humana Medicaid,CPT,71260,Ct thorax dx c+,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Humana Medicaid,CPT,71270,Ct thorax dx c-/c+,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Humana Medicaid,CPT,71271,Ct thorax lung cancer scr c-,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Humana Medicaid,CPT,71275,Ct angiography chest,Interventional Radiology,Per Unit,$178.94 ,OP,178.94,178.94,,,,,,
Humana Medicaid,CPT,71550,Mri chest w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Humana Medicaid,CPT,71551,Mri chest w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Humana Medicaid,CPT,71552,Mri chest w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Humana Medicaid,CPT,71555,Mri angio chest w or w/o dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Humana Medicaid,CPT,72010,X-ray exam spine ap&lat,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,72020,X-ray exam of spine 1 view,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,72040,X-ray exam neck spine 2-3 vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,72050,X-ray exam neck spine 4/5vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,72052,X-ray exam neck spine 6/>vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,72069,X-ray exam trunk spine stand,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,72070,X-ray exam thorac spine 2vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,72072,X-ray exam thorac spine 3vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,72074,X-ray exam thorac spine4/>vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,72080,X-ray exam thoracolmb 2/> vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,72081,X-ray exam entire spi 1 vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,72082,X-ray exam entire spi 2/3 vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,72083,X-ray exam entire spi 4/5 vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,72084,X-ray exam entire spi 6/> vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,72090,X-ray exam scloiosis erect,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,72100,X-ray exam l-s spine 2/3 vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,72110,X-ray exam l-2 spine 4/>vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,72114,X-ray exam l-s spine bending,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,72120,X-ray bend only l-s spine,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,72125,Ct neck spine w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Humana Medicaid,CPT,72126,Ct neck spine w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Humana Medicaid,CPT,72127,Ct neck spine w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Humana Medicaid,CPT,72128,Ct chest spine w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Humana Medicaid,CPT,72129,Ct chest spine w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Humana Medicaid,CPT,72130,Ct chest spine w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Humana Medicaid,CPT,72131,Ct lumbar spine w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Humana Medicaid,CPT,72132,Ct lumbar spine w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Humana Medicaid,CPT,72133,Ct lumbar spine w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Humana Medicaid,CPT,72141,Mri neck spine w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Humana Medicaid,CPT,72142,Mri neck spine w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Humana Medicaid,CPT,72146,Mri chest spine w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Humana Medicaid,CPT,72147,Mri chest spine w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Humana Medicaid,CPT,72148,Mri lumbar spine w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Humana Medicaid,CPT,72149,Mri lumbar spine w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Humana Medicaid,CPT,72156,Mri neck spine w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Humana Medicaid,CPT,72157,Mri chest spine w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Humana Medicaid,CPT,72158,Mri lumbar spine w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Humana Medicaid,CPT,72159,Mr angio spine w/o&w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Humana Medicaid,CPT,72170,X-ray exam of pelvis,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,72190,X-ray exam of pelvis,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,72191,Ct angiograph pelv w/o&w/dye,Interventional Radiology,Per Unit,$178.94 ,OP,178.94,178.94,,,,,,
Humana Medicaid,CPT,72192,Ct pelvis w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Humana Medicaid,CPT,72193,Ct pelvis w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Humana Medicaid,CPT,72194,Ct pelvis w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Humana Medicaid,CPT,72195,Mri pelvis w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Humana Medicaid,CPT,72196,Mri pelvis w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Humana Medicaid,CPT,72197,Mri pelvis w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Humana Medicaid,CPT,72198,Mr angio pelvis w/o & w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Humana Medicaid,CPT,72200,X-ray exam si joints,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,72202,X-ray exam si joints 3/> vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,72220,X-ray exam sacrum tailbone,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,72240,Myelography neck spine,Diagnostic Radiology,Per Unit,$345.35 ,OP,345.35,345.35,,,,,,
Humana Medicaid,CPT,72255,Myelography thoracic spine,Diagnostic Radiology,Per Unit,$345.35 ,OP,345.35,345.35,,,,,,
Humana Medicaid,CPT,72265,Myelography l-s spine,Diagnostic Radiology,Per Unit,$345.35 ,OP,345.35,345.35,,,,,,
Humana Medicaid,CPT,72270,Myelogphy 2/> spine regions,Diagnostic Radiology,Per Unit,$345.35 ,OP,345.35,345.35,,,,,,
Humana Medicaid,CPT,72275,Epidurography,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,72285,Discography cerv/thor spine,Diagnostic Radiology,Per Unit,$345.35 ,OP,345.35,345.35,,,,,,
Humana Medicaid,CPT,72295,X-ray of lower spine disk,Diagnostic Radiology,Per Unit,$345.35 ,OP,345.35,345.35,,,,,,
Humana Medicaid,CPT,73000,X-ray exam of collar bone,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,73010,X-ray exam of shoulder blade,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,73020,X-ray exam of shoulder,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,73030,X-ray exam of shoulder,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,73050,X-ray exam of shoulders,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,73060,X-ray exam of humerus,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,73070,X-ray exam of elbow,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,73080,X-ray exam of elbow,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,73090,X-ray exam of forearm,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,73092,X-ray exam of arm infant,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,73100,X-ray exam of wrist,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,73110,X-ray exam of wrist,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,73120,X-ray exam of hand,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,73130,X-ray exam of hand,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,73140,X-ray exam of finger(s),Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,73200,Ct upper extremity w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Humana Medicaid,CPT,73201,Ct upper extremity w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Humana Medicaid,CPT,73202,Ct uppr extremity w/o&w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Humana Medicaid,CPT,73206,Ct angio upr extrm w/o&w/dye,Interventional Radiology,Per Unit,$178.94 ,OP,178.94,178.94,,,,,,
Humana Medicaid,CPT,73218,Mri upper extremity w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Humana Medicaid,CPT,73219,Mri upper extremity w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Humana Medicaid,CPT,73220,Mri uppr extremity w/o&w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Humana Medicaid,CPT,73221,Mri joint upr extrem w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Humana Medicaid,CPT,73222,Mri joint upr extrem w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Humana Medicaid,CPT,73223,Mri joint upr extr w/o&w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Humana Medicaid,CPT,73225,Mr angio upr extr w/o&w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Humana Medicaid,CPT,73500,X-ray exam of hip,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,73501,X-ray exam hip uni 1 view,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,73502,X-ray exam hip uni 2-3 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,73503,X-ray exam hip uni 4/> views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,73510,X-ray exam of hip,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,73520,X-ray exam of hips,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,73521,X-ray exam hips bi 2 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,73522,X-ray exam hips bi 3-4 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,73523,X-ray exam hips bi 5/> views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,73530,X-ray exam of hip,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,73540,X-ray exam of pelvis & hips,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,73550,X-ray exam of thigh,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,73551,X-ray exam of femur 1,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,73552,X-ray exam of femur 2/>,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,73560,X-ray exam of knee 1 or 2,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,73562,X-ray exam of knee 3,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,73564,X-ray exam knee 4 or more,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,73565,X-ray exam of knees,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,73590,X-ray exam of lower leg,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,73592,X-ray exam of leg infant,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,73600,X-ray exam of ankle,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,73610,X-ray exam of ankle,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,73620,X-ray exam of foot,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,73630,X-ray exam of foot,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,73650,X-ray exam of heel,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,73660,X-ray exam of toe(s),Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,73700,Ct lower extremity w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Humana Medicaid,CPT,73701,Ct lower extremity w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Humana Medicaid,CPT,73702,Ct lwr extremity w/o&w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Humana Medicaid,CPT,73706,Ct angio lwr extr w/o&w/dye,Interventional Radiology,Per Unit,$178.94 ,OP,178.94,178.94,,,,,,
Humana Medicaid,CPT,73718,Mri lower extremity w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Humana Medicaid,CPT,73719,Mri lower extremity w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Humana Medicaid,CPT,73720,Mri lwr extremity w/o&w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Humana Medicaid,CPT,73721,Mri jnt of lwr extre w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Humana Medicaid,CPT,73722,Mri joint of lwr extr w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Humana Medicaid,CPT,73723,Mri joint lwr extr w/o&w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Humana Medicaid,CPT,73725,Mr ang lwr ext w or w/o dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Humana Medicaid,CPT,74000,X-ray exam of abdomen,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,74010,X-ray exam of abdomen,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,74018,X-ray exam abdomen 1 view,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,74019,X-ray exam abdomen 2 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,74020,X-ray exam of abdomen,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,74021,X-ray exam abdomen 3+ views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,74022,X-ray exam complete abdomen,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,74150,Ct abdomen w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Humana Medicaid,CPT,74160,Ct abdomen w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Humana Medicaid,CPT,74170,Ct abdomen w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Humana Medicaid,CPT,74174,Ct angio abd&pelv w/o&w/dye,Interventional Radiology,Per Unit,$178.94 ,OP,178.94,178.94,,,,,,
Humana Medicaid,CPT,74175,Ct angio abdom w/o & w/dye,Interventional Radiology,Per Unit,$178.94 ,OP,178.94,178.94,,,,,,
Humana Medicaid,CPT,74176,Ct abd & pelvis w/o contrast,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Humana Medicaid,CPT,74177,Ct abd & pelv w/contrast,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Humana Medicaid,CPT,74178,Ct abd & pelv 1/> regns,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Humana Medicaid,CPT,74181,Mri abdomen w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Humana Medicaid,CPT,74182,Mri abdomen w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Humana Medicaid,CPT,74183,Mri abdomen w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Humana Medicaid,CPT,74185,Mri angio abdom w orw/o dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Humana Medicaid,CPT,74210,X-ray xm phrnx&/crv esoph c+,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,74220,X-ray xm esophagus 1cntrst,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,74235,Remove esophagus obstruction,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,74261,Ct colonography dx,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Humana Medicaid,CPT,74262,Ct colonography dx w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Humana Medicaid,CPT,74263,Ct colonography screening,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Humana Medicaid,CPT,74300,X-ray bile ducts/pancreas,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,74301,X-rays at surgery add-on,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,74305,X-ray bile ducts/pancreas,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,74320,Contrast x-ray of bile ducts,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,74327,X-ray bile stone removal,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,74328,X-ray bile duct endoscopy,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,74329,X-ray for pancreas endoscopy,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,74330,X-ray bile/panc endoscopy,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,74340,X-ray guide for gi tube,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,74355,X-ray guide intestinal tube,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,74360,X-ray guide gi dilation,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,74363,X-ray bile duct dilation,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,74475,X-ray control cath insert,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,74480,X-ray control cath insert,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,74485,Dilation urtr/urt rs&i,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,74710,X-ray measurement of pelvis,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,74712,Mri fetal sngl/1st gestation,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Humana Medicaid,CPT,74713,Mri fetal ea addl gestation,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Humana Medicaid,CPT,74742,X-ray fallopian tube,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,75557,Cardiac mri for morph,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Humana Medicaid,CPT,75559,Cardiac mri w/stress img,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Humana Medicaid,CPT,75561,Cardiac mri for morph w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Humana Medicaid,CPT,75563,Card mri w/stress img & dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Humana Medicaid,CPT,75565,Card mri veloc flow mapping,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Humana Medicaid,CPT,75571,Ct hrt w/o dye w/ca test,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Humana Medicaid,CPT,75572,Ct hrt w/3d image,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Humana Medicaid,CPT,75573,Ct hrt w/3d image congen,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Humana Medicaid,CPT,75574,Ct angio hrt w/3d image,Interventional Radiology,Per Unit,$178.94 ,OP,178.94,178.94,,,,,,
Humana Medicaid,CPT,75605,Contrast exam thoracic aorta,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Humana Medicaid,CPT,75635,Ct angio abdominal arteries,Interventional Radiology,Per Unit,$178.94 ,OP,178.94,178.94,,,,,,
Humana Medicaid,CPT,75705,Artery x-rays spine,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Humana Medicaid,CPT,75726,Artery x-rays abdomen,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Humana Medicaid,CPT,75736,Artery x-rays pelvis,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Humana Medicaid,CPT,75774,Artery x-ray each vessel,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Humana Medicaid,CPT,75791,Av dialysis shunt imaging,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,75842,Vein x-ray adrenal glands,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Humana Medicaid,CPT,75893,Venous sampling by catheter,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Humana Medicaid,CPT,75894,X-rays transcath therapy,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,75896,X-rays transcath therapy,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,75901,Remove cva device obstruct,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,75902,Remove cva lumen obstruct,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,75945,Intravascular us,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Humana Medicaid,CPT,75946,Intravascular us add-on,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Humana Medicaid,CPT,75952,Endovasc repair abdom aorta,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,75953,Abdom aneurysm endovas rpr,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,75954,Iliac aneurysm endovas rpr,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,75956,Xray endovasc thor ao repr,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,75957,Xray endovasc thor ao repr,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,75958,Xray place prox ext thor ao,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,75959,Xray place dist ext thor ao,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,75962,Repair arterial blockage,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,75964,Repair artery blockage each,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,75966,Repair arterial blockage,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,75968,Repair artery blockage each,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,75970,Vascular biopsy,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,75980,Contrast xray exam bile duct,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,75982,Contrast xray exam bile duct,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,75984,Xray control catheter change,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,75989,Abscess drainage under x-ray,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,76010,X-ray nose to rectum,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,76100,X-ray exam of body section,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,76101,Complex body section x-ray,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,76102,Complex body section x-rays,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,76120,Cine/video x-rays,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,76125,Cine/video x-rays add-on,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,76145,Med physic dos eval rad exps,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Humana Medicaid,CPT,76380,Cat scan follow-up study,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Humana Medicaid,CPT,76390,Mr spectroscopy,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Humana Medicaid,CPT,76391,Mr elastography,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Humana Medicaid,CPT,76496,Fluoroscopic procedure,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,76497,Ct procedure,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Humana Medicaid,CPT,76498,Mri procedure,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Humana Medicaid,CPT,76499,Radiographic procedure,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,76506,Echo exam of head,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,76510,Oph us dx b-scan&quan a-scan,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,76511,Oph us dx quan a-scan only,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,76512,Oph us dx b-scan,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,76513,Oph us dx ant sgm us uni/bi,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,76514,Echo exam of eye thickness,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,76516,Echo exam of eye,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,76519,Echo exam of eye,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,76529,Echo exam of eye,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,76536,Us exam of head and neck,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,76604,Us exam chest,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,76641,Ultrasound breast complete,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,76642,Ultrasound breast limited,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,76700,Us exam abdom complete,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Humana Medicaid,CPT,76705,Echo exam of abdomen,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,76706,Us abdl aorta screen aaa,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,76770,Us exam abdo back wall comp,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Humana Medicaid,CPT,76775,Us exam abdo back wall lim,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,76776,Us exam k transpl w/doppler,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,76800,Us exam spinal canal,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,76801,Ob us < 14 wks single fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Humana Medicaid,CPT,76802,Ob us < 14 wks addl fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Humana Medicaid,CPT,76805,Ob us >= 14 wks sngl fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Humana Medicaid,CPT,76810,Ob us >= 14 wks addl fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Humana Medicaid,CPT,76811,Ob us detailed sngl fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Humana Medicaid,CPT,76812,Ob us detailed addl fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Humana Medicaid,CPT,76813,Ob us nuchal meas 1 gest,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Humana Medicaid,CPT,76814,Ob us nuchal meas add-on,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Humana Medicaid,CPT,76815,Ob us limited fetus(s),Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Humana Medicaid,CPT,76816,Ob us follow-up per fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Humana Medicaid,CPT,76817,Transvaginal us obstetric,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Humana Medicaid,CPT,76818,Fetal biophys profile w/nst,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Humana Medicaid,CPT,76819,Fetal biophys profil w/o nst,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Humana Medicaid,CPT,76820,Umbilical artery echo,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Humana Medicaid,CPT,76821,Middle cerebral artery echo,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Humana Medicaid,CPT,76825,Echo exam of fetal heart,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Humana Medicaid,CPT,76826,Echo exam of fetal heart,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Humana Medicaid,CPT,76827,Echo exam of fetal heart,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Humana Medicaid,CPT,76828,Echo exam of fetal heart,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Humana Medicaid,CPT,76830,Transvaginal us non-ob,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,76831,Echo exam uterus,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Humana Medicaid,CPT,76856,Us exam pelvic complete,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Humana Medicaid,CPT,76857,Us exam pelvic limited,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,76870,Us exam scrotum,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,76872,Us transrectal,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,76873,Echograp trans r pros study,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Humana Medicaid,CPT,76881,Us compl joint r-t w/img,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,76882,Us lmtd jt/nonvasc xtr strux,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,76885,Us exam infant hips dynamic,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,76886,Us exam infant hips static,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,76930,Echo guide cardiocentesis,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Humana Medicaid,CPT,76932,Echo guide for heart biopsy,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Humana Medicaid,CPT,76936,Echo guide for artery repair,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,76937,Us guide vascular access,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Humana Medicaid,CPT,76940,Us guide tissue ablation,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Humana Medicaid,CPT,76941,Echo guide for transfusion,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Humana Medicaid,CPT,76942,Echo guide for biopsy,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Humana Medicaid,CPT,76945,Echo guide villus sampling,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Humana Medicaid,CPT,76946,Echo guide for amniocentesis,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Humana Medicaid,CPT,76948,Echo guide ova aspiration,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Humana Medicaid,CPT,76965,Echo guidance radiotherapy,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Humana Medicaid,CPT,76970,Ultrasound exam follow-up,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,76975,Gi endoscopic ultrasound,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Humana Medicaid,CPT,76977,Us bone density measure,Diagnostic Radiology,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
Humana Medicaid,CPT,76978,Us trgt dyn mbubb 1st les,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Humana Medicaid,CPT,76979,Us trgt dyn mbubb ea addl,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Humana Medicaid,CPT,76981,Use parenchyma,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,76982,Use 1st target lesion,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,76983,Use ea addl target lesion,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,76998,Us guide intraop,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Humana Medicaid,CPT,76999,Echo examination procedure,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,77001,Fluoroguide for vein device,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,77002,Needle localization by xray,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,77003,Fluoroguide for spine inject,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,77011,Ct scan for localization,Interventional Radiology,Per Unit,$61.07 ,OP,61.07,61.07,,,,,,
Humana Medicaid,CPT,77012,Ct scan for needle biopsy,Interventional Radiology,Per Unit,$61.07 ,OP,61.07,61.07,,,,,,
Humana Medicaid,CPT,77013,Ct guide for tissue ablation,Interventional Radiology,Per Unit,$61.07 ,OP,61.07,61.07,,,,,,
Humana Medicaid,CPT,77014,Ct scan for therapy guide,Interventional Radiology,Per Unit,$61.07 ,OP,61.07,61.07,,,,,,
Humana Medicaid,CPT,77021,Mri guidance ndl plmt rs&i,Interventional Radiology,Per Unit,$108.13 ,OP,108.13,108.13,,,,,,
Humana Medicaid,CPT,77022,Mri gdn parnchyma tiss abltj,Interventional Radiology,Per Unit,$108.13 ,OP,108.13,108.13,,,,,,
Humana Medicaid,CPT,77046,Mri breast c- unilateral,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Humana Medicaid,CPT,77047,Mri breast c- bilateral,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Humana Medicaid,CPT,77048,Mri breast c-+ w/cad uni,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Humana Medicaid,CPT,77049,Mri breast c-+ w/cad bi,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Humana Medicaid,CPT,77055,Mammogram one breast,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
Humana Medicaid,CPT,77056,Mammogram both breasts,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
Humana Medicaid,CPT,77057,Mammogram screening,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
Humana Medicaid,CPT,77058,Mri one breast,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Humana Medicaid,CPT,77059,Mri both breasts,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Humana Medicaid,CPT,77061,Breast tomosynthesis uni,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
Humana Medicaid,CPT,77062,Breast tomosynthesis bi,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
Humana Medicaid,CPT,77063,Breast tomosynthesis bi,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
Humana Medicaid,CPT,77065,Dx mammo incl cad uni,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
Humana Medicaid,CPT,77066,Dx mammo incl cad bi,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
Humana Medicaid,CPT,77067,Scr mammo bi incl cad,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
Humana Medicaid,CPT,77072,X-rays for bone age,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,77073,X-rays bone length studies,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,77074,X-rays bone survey limited,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,77076,X-rays bone survey infant,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,77077,Joint survey single view,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,77078,Ct bone density axial,Diagnostic Radiology,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
Humana Medicaid,CPT,77080,Dxa bone density axial,Diagnostic Radiology,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
Humana Medicaid,CPT,77081,Dxa bone density/peripheral,Diagnostic Radiology,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
Humana Medicaid,CPT,77084,Magnetic image bone marrow,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Humana Medicaid,CPT,77085,Dxa bone density study,Diagnostic Radiology,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
Humana Medicaid,CPT,77086,Fracture assessment via dxa,Diagnostic Radiology,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
Humana Medicaid,CPT,77261,Radiation therapy planning,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Humana Medicaid,CPT,77262,Radiation therapy planning,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Humana Medicaid,CPT,77263,Radiation therapy planning,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Humana Medicaid,CPT,77280,Set radiation therapy field,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Humana Medicaid,CPT,77285,Set radiation therapy field,Therapeutic Radiology,Per Unit,$434.17 ,OP,434.17,434.17,,,,,,
Humana Medicaid,CPT,77290,Set radiation therapy field,Therapeutic Radiology,Per Unit,$434.17 ,OP,434.17,434.17,,,,,,
Humana Medicaid,CPT,77293,Respirator motion mgmt simul,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Humana Medicaid,CPT,77295,3-d radiotherapy plan,Therapeutic Radiology,Per Unit,$68.45 ,OP,68.45,68.45,,,,,,
Humana Medicaid,CPT,77299,Radiation therapy planning,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Humana Medicaid,CPT,77300,Radiation therapy dose plan,Therapeutic Radiology,Per Unit,$434.17 ,OP,434.17,434.17,,,,,,
Humana Medicaid,CPT,77301,Radiotherapy dose plan imrt,Therapeutic Radiology,Per Unit,$68.45 ,OP,68.45,68.45,,,,,,
Humana Medicaid,CPT,77306,Telethx isodose plan simple,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Humana Medicaid,CPT,77307,Telethx isodose plan cplx,Therapeutic Radiology,Per Unit,$434.17 ,OP,434.17,434.17,,,,,,
Humana Medicaid,CPT,77316,Brachytx isodose plan simple,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Humana Medicaid,CPT,77317,Brachytx isodose intermed,Therapeutic Radiology,Per Unit,$434.17 ,OP,434.17,434.17,,,,,,
Humana Medicaid,CPT,77318,Brachytx isodose complex,Therapeutic Radiology,Per Unit,$434.17 ,OP,434.17,434.17,,,,,,
Humana Medicaid,CPT,77321,Special teletx port plan,Therapeutic Radiology,Per Unit,$434.17 ,OP,434.17,434.17,,,,,,
Humana Medicaid,CPT,77331,Special radiation dosimetry,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Humana Medicaid,CPT,77332,Radiation treatment aid(s),Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Humana Medicaid,CPT,77333,Radiation treatment aid(s),Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Humana Medicaid,CPT,77334,Radiation treatment aid(s),Therapeutic Radiology,Per Unit,$434.17 ,OP,434.17,434.17,,,,,,
Humana Medicaid,CPT,77336,Radiation physics consult,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Humana Medicaid,CPT,77338,Design mlc device for imrt,Therapeutic Radiology,Per Unit,$434.17 ,OP,434.17,434.17,,,,,,
Humana Medicaid,CPT,77370,Radiation physics consult,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Humana Medicaid,CPT,77371,Srs multisource,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"2,592.65","2,592.65",,,,,,
Humana Medicaid,CPT,77372,Srs linear based,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"2,592.65","2,592.65",,,,,,
Humana Medicaid,CPT,77373,Sbrt delivery,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
Humana Medicaid,CPT,77385,Ntsty modul rad tx dlvr smpl,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Humana Medicaid,CPT,77386,Ntsty modul rad tx dlvr cplx,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Humana Medicaid,CPT,77387,Guidance for radj tx dlvr,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Humana Medicaid,CPT,77399,External radiation dosimetry,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Humana Medicaid,CPT,77401,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Humana Medicaid,CPT,77402,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Humana Medicaid,CPT,77407,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Humana Medicaid,CPT,77412,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Humana Medicaid,CPT,77417,Radiology port images(s),Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,77422,Neutron beam tx simple,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Humana Medicaid,CPT,77423,Neutron beam tx complex,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Humana Medicaid,CPT,77424,Io rad tx delivery by x-ray,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
Humana Medicaid,CPT,77425,Io rad tx deliver by elctrns,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
Humana Medicaid,CPT,77427,Radiation tx management x5,Therapeutic Radiology,Per Unit,$70.25 ,OP,70.25,70.25,,,,,,
Humana Medicaid,CPT,77431,Radiation therapy management,Therapeutic Radiology,Per Unit,$70.25 ,OP,70.25,70.25,,,,,,
Humana Medicaid,CPT,77432,Stereotactic radiation trmt,Therapeutic Radiology,Per Unit,$70.25 ,OP,70.25,70.25,,,,,,
Humana Medicaid,CPT,77435,Sbrt management,Therapeutic Radiology,Per Unit,$70.25 ,OP,70.25,70.25,,,,,,
Humana Medicaid,CPT,77469,Io radiation tx management,Therapeutic Radiology,Per Unit,$70.25 ,OP,70.25,70.25,,,,,,
Humana Medicaid,CPT,77470,Special radiation treatment,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Humana Medicaid,CPT,77499,Radiation therapy management,Therapeutic Radiology,Per Unit,$70.25 ,OP,70.25,70.25,,,,,,
Humana Medicaid,CPT,77520,Proton trmt simple w/o comp,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Humana Medicaid,CPT,77522,Proton trmt simple w/comp,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
Humana Medicaid,CPT,77523,Proton trmt intermediate,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
Humana Medicaid,CPT,77525,Proton treatment complex,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
Humana Medicaid,CPT,77600,Hyperthermia treatment,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Humana Medicaid,CPT,77605,Hyperthermia treatment,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Humana Medicaid,CPT,77610,Hyperthermia treatment,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Humana Medicaid,CPT,77615,Hyperthermia treatment,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Humana Medicaid,CPT,77620,Hyperthermia treatment,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Humana Medicaid,CPT,77750,Infuse radioactive materials,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Humana Medicaid,CPT,77761,Apply intrcav radiat simple,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Humana Medicaid,CPT,77762,Apply intrcav radiat interm,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
Humana Medicaid,CPT,77763,Apply intrcav radiat compl,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
Humana Medicaid,CPT,77767,Hdr rdncl skn surf brachytx,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Humana Medicaid,CPT,77768,Hdr rdncl skn surf brachytx,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Humana Medicaid,CPT,77770,Hdr rdncl ntrstl/icav brchtx,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Humana Medicaid,CPT,77771,Hdr rdncl ntrstl/icav brchtx,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
Humana Medicaid,CPT,77772,Hdr rdncl ntrstl/icav brchtx,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
Humana Medicaid,CPT,77776,Apply interstit radiat simpl,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Humana Medicaid,CPT,77777,Apply interstit radiat inter,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Humana Medicaid,CPT,77778,Apply interstit radiat compl,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
Humana Medicaid,CPT,77785,Hdr brachytx 1 channel,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Humana Medicaid,CPT,77786,Hdr brachytx 2-12 channel,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
Humana Medicaid,CPT,77787,Hdr brachytx over 12 chan,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
Humana Medicaid,CPT,77789,Apply surf ldr radionuclide,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Humana Medicaid,CPT,77790,Radiation handling,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Humana Medicaid,CPT,77799,Radium/radioisotope therapy,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Humana Medicaid,CPT,78012,Thyroid uptake measurement,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78013,Thyroid imaging w/blood flow,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78014,Thyroid imaging w/blood flow,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78015,Thyroid met imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78016,Thyroid met imaging/studies,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78018,Thyroid met imaging body,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78020,Thyroid met uptake,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78070,Parathyroid planar imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Humana Medicaid,CPT,78071,Parathyrd planar w/wo subtrj,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78072,Parathyrd planar w/spect&ct,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78075,Adrenal cortex & medulla img,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Humana Medicaid,CPT,78099,Endocrine nuclear procedure,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78102,Bone marrow imaging ltd,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78103,Bone marrow imaging mult,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78104,Bone marrow imaging body,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78110,Plasma volume single,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Humana Medicaid,CPT,78111,Plasma volume multiple,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Humana Medicaid,CPT,78120,Red cell mass single,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78121,Red cell mass multiple,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78122,Blood volume,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Humana Medicaid,CPT,78130,Red cell survival study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78135,Red cell survival kinetics,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78140,Red cell sequestration,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78185,Spleen imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78190,Platelet survival kinetics,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78191,Platelet survival,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78195,Lymph system imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Humana Medicaid,CPT,78199,Blood/lymph nuclear exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78201,Liver imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Humana Medicaid,CPT,78202,Liver imaging with flow,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Humana Medicaid,CPT,78205,Liver imaging (3d),Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Humana Medicaid,CPT,78206,Liver image (3d) with flow,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Humana Medicaid,CPT,78215,Liver and spleen imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Humana Medicaid,CPT,78216,Liver & spleen image/flow,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Humana Medicaid,CPT,78226,Hepatobiliary system imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78227,Hepatobil syst image w/drug,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78230,Salivary gland imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78231,Serial salivary imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78232,Salivary gland function exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78258,Esophageal motility study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78261,Gastric mucosa imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78262,Gastroesophageal reflux exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78264,Gastric emptying imag study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78265,Gastric emptying imag study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78266,Gastric emptying imag study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78267,Breath tst attain/anal c-14,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,78270,Vit b-12 absorption exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78271,Vit b-12 absrp exam int fac,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78272,Vit b-12 absorp combined,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78278,Acute gi blood loss imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Humana Medicaid,CPT,78282,Gi protein loss exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78290,Meckels divert exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78291,Leveen/shunt patency exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78299,Gi nuclear procedure,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78300,Bone imaging limited area,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78305,Bone imaging multiple areas,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78306,Bone imaging whole body,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78315,Bone imaging 3 phase,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78320,Bone imaging (3d),Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78350,Bone mineral single photon,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78351,Bone mineral dual photon,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78399,Musculoskeletal nuclear exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78414,Non-imaging heart function,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78428,Cardiac shunt imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78429,Myocrd img pet 1 std w/ct,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Humana Medicaid,CPT,78430,Myocrd img pet rst/strs w/ct,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Humana Medicaid,CPT,78431,Myocrd img pet rst&strs ct,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Humana Medicaid,CPT,78432,Myocrd img pet 2rtracer,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Humana Medicaid,CPT,78433,Myocrd img pet 2rtracer ct,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Humana Medicaid,CPT,78434,Aqmbf pet rest & rx stress,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Humana Medicaid,CPT,78445,Vascular flow imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78451,Ht muscle image spect sing,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Humana Medicaid,CPT,78452,Ht muscle image spect mult,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Humana Medicaid,CPT,78453,Ht muscle image planar sing,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Humana Medicaid,CPT,78454,Ht musc image planar mult,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Humana Medicaid,CPT,78456,Acute venous thrombus image,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78457,Venous thrombosis imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Humana Medicaid,CPT,78458,Ven thrombosis images bilat,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78459,Myocrd img pet single study,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Humana Medicaid,CPT,78466,Heart infarct image,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78468,Heart infarct image (ef),Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78469,Heart infarct image (3d),Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Humana Medicaid,CPT,78472,Gated heart planar single,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78473,Gated heart multiple,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78481,Heart first pass single,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78483,Heart first pass multiple,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Humana Medicaid,CPT,78491,Myocrd img pet 1std rst/strs,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Humana Medicaid,CPT,78492,Myocrd img pet mlt rst&strs,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Humana Medicaid,CPT,78494,Heart image spect,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78496,Heart first pass add-on,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78499,Cardiovascular nuclear exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78579,Lung ventilation imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Humana Medicaid,CPT,78580,Lung perfusion imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Humana Medicaid,CPT,78582,Lung ventilat&perfus imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Humana Medicaid,CPT,78597,Lung perfusion differential,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Humana Medicaid,CPT,78598,Lung perf&ventilat diferentl,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Humana Medicaid,CPT,78599,Respiratory nuclear exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78600,Brain image < 4 views,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78601,Brain image w/flow < 4 views,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78605,Brain image 4+ views,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78606,Brain image w/flow 4 + views,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78607,Brain imaging (3d),Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Humana Medicaid,CPT,78608,Brain imaging (pet),Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Humana Medicaid,CPT,78609,Brain imaging (pet),Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Humana Medicaid,CPT,78610,Brain flow imaging only,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78630,Cerebrospinal fluid scan,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Humana Medicaid,CPT,78635,Csf ventriculography,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78645,Csf shunt evaluation,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Humana Medicaid,CPT,78647,Cerebrospinal fluid scan,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Humana Medicaid,CPT,78650,Csf leakage imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Humana Medicaid,CPT,78660,Nuclear exam of tear flow,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78699,Nervous system nuclear exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78700,Kidney imaging morphol,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78701,Kidney imaging with flow,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78707,K flow/funct image w/o drug,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78708,K flow/funct image w/drug,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78709,K flow/funct image multiple,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78710,Kidney imaging (3d),Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78725,Kidney function study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78730,Urinary bladder retention,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78740,Ureteral reflux study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78761,Testicular imaging w/flow,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78799,Genitourinary nuclear exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78800,Rp loclzj tum 1 area 1 d img,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Humana Medicaid,CPT,78801,Rp loclzj tum 2+area 1+d img,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Humana Medicaid,CPT,78802,Rp loclzj tum whbdy 1 d img,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Humana Medicaid,CPT,78803,Rp loclzj tum spect 1 area,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Humana Medicaid,CPT,78804,Rp loclzj tum whbdy 2+d img,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Humana Medicaid,CPT,78805,Abscess imaging ltd area,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Humana Medicaid,CPT,78806,Abscess imaging whole body,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Humana Medicaid,CPT,78807,Nuclear localization/abscess,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Humana Medicaid,CPT,78811,Pet image ltd area,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Humana Medicaid,CPT,78812,Pet image skull-thigh,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Humana Medicaid,CPT,78813,Pet image full body,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Humana Medicaid,CPT,78814,Pet image w/ct lmtd,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Humana Medicaid,CPT,78815,Pet image w/ct skull-thigh,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Humana Medicaid,CPT,78816,Pet image w/ct full body,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Humana Medicaid,CPT,78830,Rp loclzj tum spect w/ct 1,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Humana Medicaid,CPT,78831,Rp loclzj tum spect 2 areas,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Humana Medicaid,CPT,78832,Rp loclzj tum spect w/ct 2,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Humana Medicaid,CPT,78835,Rp quan meas single area,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,78999,Nuclear diagnostic exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,79005,Nuclear rx oral admin,Therapeutic Radiology,Per Unit,$174.28 ,OP,174.28,174.28,,,,,,
Humana Medicaid,CPT,79101,Nuclear rx iv admin,Therapeutic Radiology,Per Unit,$174.28 ,OP,174.28,174.28,,,,,,
Humana Medicaid,CPT,79200,Nuclear rx intracav admin,Therapeutic Radiology,Per Unit,$174.28 ,OP,174.28,174.28,,,,,,
Humana Medicaid,CPT,79300,Nuclr rx interstit colloid,Therapeutic Radiology,Per Unit,$174.28 ,OP,174.28,174.28,,,,,,
Humana Medicaid,CPT,79403,Hematopoietic nuclear tx,Therapeutic Radiology,Per Unit,$174.28 ,OP,174.28,174.28,,,,,,
Humana Medicaid,CPT,79440,Nuclear rx intra-articular,Therapeutic Radiology,Per Unit,$174.28 ,OP,174.28,174.28,,,,,,
Humana Medicaid,CPT,79445,Nuclear rx intra-arterial,Therapeutic Radiology,Per Unit,$174.28 ,OP,174.28,174.28,,,,,,
Humana Medicaid,CPT,79999,Nuclear medicine therapy,Therapeutic Radiology,Per Unit,$174.28 ,OP,174.28,174.28,,,,,,
Humana Medicaid,CPT,80047,Metabolic panel ionized ca,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
Humana Medicaid,CPT,80048,Metabolic panel total ca,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
Humana Medicaid,CPT,80050,General health panel,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
Humana Medicaid,CPT,80051,Electrolyte panel,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
Humana Medicaid,CPT,80053,Comprehen metabolic panel,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
Humana Medicaid,CPT,80055,Obstetric panel,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
Humana Medicaid,CPT,80061,Lipid panel,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
Humana Medicaid,CPT,80069,Renal function panel,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
Humana Medicaid,CPT,80074,Acute hepatitis panel,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
Humana Medicaid,CPT,80076,Hepatic function panel,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
Humana Medicaid,CPT,80081,Obstetric panel,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
Humana Medicaid,CPT,80143,Drug assay acetaminophen,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80145,Drug assay adalimumab,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80150,Assay of amikacin,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80151,Drug assay amiodarone,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80155,Drug assay caffeine,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80156,Assay carbamazepine total,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80157,Assay carbamazepine free,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80158,Drug assay cyclosporine,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80159,Drug assay clozapine,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80161,"Asy carbamazepin 10,11-epxid",Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80162,Assay of digoxin total,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80163,Assay of digoxin free,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80164,Assay dipropylacetic acd tot,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80165,Dipropylacetic acid free,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80167,Drug assay felbamate,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80168,Assay of ethosuximide,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80169,Drug assay everolimus,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80170,Assay of gentamicin,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80171,Drug screen quant gabapentin,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80173,Assay of haloperidol,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80175,Drug screen quan lamotrigine,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80176,Assay of lidocaine,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80177,Drug scrn quan levetiracetam,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80178,Assay of lithium,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80179,Drug assay salicylate,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80180,Drug scrn quan mycophenolate,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80181,Drug assay flecainide,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80183,Drug scrn quant oxcarbazepin,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80184,Assay of phenobarbital,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80185,Assay of phenytoin total,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80186,Assay of phenytoin free,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80187,Drug assay posaconazole,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80188,Assay of primidone,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80189,Drug assay itraconzaole,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80190,Assay of procainamide,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80192,Assay of procainamide,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80193,Drug assay leflunomide,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80194,Assay of quinidine,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80195,Assay of sirolimus,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80197,Assay of tacrolimus,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80198,Assay of theophylline,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80199,Drug screen quant tiagabine,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80200,Assay of tobramycin,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80201,Assay of topiramate,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80202,Assay of vancomycin,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80203,Drug screen quant zonisamide,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80204,Drug assay methotrexate,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80210,Drug assay rufinamide,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80230,Drug assay infliximab,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80235,Drug assay lacosamide,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80280,Drug assay vedolizumab,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80285,Drug assay voriconazole,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80299,Quantitative assay drug,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80300,Drug screen non tlc devices,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Humana Medicaid,CPT,80301,Drug screen class list a,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Humana Medicaid,CPT,80302,Drug screen prsmptv 1 class,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,80303,Drug screen one/mult class,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Humana Medicaid,CPT,80304,Drug screen one/mult class,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Humana Medicaid,CPT,80305,Drug test prsmv dir opt obs,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,80306,Drug test prsmv instrmnt,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,80307,Drug test prsmv chem anlyzr,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,80320,Drug screen quantalcohols,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,80321,Alcohols biomarkers 1or 2,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,80322,Alcohols biomarkers 3/more,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,80323,Alkaloids nos,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,80324,Drug screen amphetamines 1/2,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,80325,Amphetamines 3or 4,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,80326,Amphetamines 5 or more,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,80327,Anabolic steroid 1 or 2,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,80328,Anabolic steroid 3 or more,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,80329,Analgesics non-opioid 1 or 2,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,80330,Analgesics non-opioid 3-5,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,80331,Analgesics non-opioid 6/more,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,80332,Antidepressants class 1 or 2,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,80333,Antidepressants class 3-5,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,80334,Antidepressants class 6/more,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,80335,Antidepressant tricyclic 1/2,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,80336,Antidepressant tricyclic 3-5,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,80337,Tricyclic & cyclicals 6/more,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,80338,Antidepressant not specified,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,80339,Antiepileptics nos 1-3,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,80340,Antiepileptics nos 4-6,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,80341,Antiepileptics nos 7/more,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,80342,Antipsychotics nos 1-3,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,80343,Antipsychotics nos 4-6,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,80344,Antipsychotics nos 7/more,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,80345,Drug screening barbiturates,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,80346,Benzodiazepines1-12,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,80347,Benzodiazepines 13 or more,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,80348,Drug screening buprenorphine,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,80349,Cannabinoids natural,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,80350,Cannabinoids synthetic 1-3,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,80351,Cannabinoids synthetic 4-6,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,80352,Cannabinoid synthetic 7/more,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,80353,Drug screening cocaine,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,80354,Drug screening fentanyl,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,80355,Gabapentin non-blood,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,80356,Heroin metabolite,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,80357,Ketamine and norketamine,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,80358,Drug screening methadone,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,80359,Methylenedioxyamphetamines,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,80360,Methylphenidate,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,80361,Opiates 1 or more,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,80362,Opioids & opiate analogs 1/2,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,80363,Opioids & opiate analogs 3/4,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,80364,Opioid &opiate analog 5/more,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,80365,Drug screening oxycodone,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,80366,Drug screening pregabalin,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,80367,Drug screening propoxyphene,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,80368,Sedative hypnotics,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,80369,Skeletal muscle relaxant 1/2,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,80370,Skel musc relaxant 3 or more,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,80371,Stimulants synthetic,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,80372,Drug screening tapentadol,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,80373,Drug screening tramadol,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,80374,Stereoisomer analysis,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,80375,Drug/substance nos 1-3,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,80376,Drug/substance nos 4-6,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,80377,Drug/substance nos 7/more,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,80400,Acth stimulation panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Humana Medicaid,CPT,80402,Acth stimulation panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Humana Medicaid,CPT,80406,Acth stimulation panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Humana Medicaid,CPT,80408,Aldosterone suppression eval,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Humana Medicaid,CPT,80410,Calcitonin stimul panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Humana Medicaid,CPT,80412,Crh stimulation panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Humana Medicaid,CPT,80414,Testosterone response panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Humana Medicaid,CPT,80415,Tot estradiol response panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Humana Medicaid,CPT,80416,Renin stimulation panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Humana Medicaid,CPT,80417,Renin stimulation panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Humana Medicaid,CPT,80418,Pituitary evaluation panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Humana Medicaid,CPT,80420,Dexamethasone panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Humana Medicaid,CPT,80422,Glucagon tolerance panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Humana Medicaid,CPT,80424,Glucagon tolerance panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Humana Medicaid,CPT,80426,Gonadotropin hormone panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Humana Medicaid,CPT,80428,Growth hormone panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Humana Medicaid,CPT,80430,Growth hormone panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Humana Medicaid,CPT,80432,Insulin suppression panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Humana Medicaid,CPT,80434,Insulin tolerance panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Humana Medicaid,CPT,80435,Insulin tolerance panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Humana Medicaid,CPT,80436,Metyrapone panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Humana Medicaid,CPT,80438,Trh stimulation panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Humana Medicaid,CPT,80439,Trh stimulation panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Humana Medicaid,CPT,80500,Lab pathology consultation,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,80502,Lab pathology consultation,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,81000,Urinalysis nonauto w/scope,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
Humana Medicaid,CPT,81001,Urinalysis auto w/scope,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
Humana Medicaid,CPT,81002,Urinalysis nonauto w/o scope,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
Humana Medicaid,CPT,81003,Urinalysis auto w/o scope,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
Humana Medicaid,CPT,81005,Urinalysis,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
Humana Medicaid,CPT,81007,Urine screen for bacteria,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
Humana Medicaid,CPT,81015,Microscopic exam of urine,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
Humana Medicaid,CPT,81020,Urinalysis glass test,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
Humana Medicaid,CPT,81025,Urine pregnancy test,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
Humana Medicaid,CPT,81050,Urinalysis volume measure,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
Humana Medicaid,CPT,81099,Urinalysis test procedure,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
Humana Medicaid,CPT,81105,Hpa-1 genotyping,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81106,Hpa-2 genotyping,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81107,Hpa-3 genotyping,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81108,Hpa-4 genotyping,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81109,Hpa-5 genotyping,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81110,Hpa-6 genotyping,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81111,Hpa-9 genotyping,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81112,Hpa-15 genotyping,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81120,Idh1 common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81121,Idh2 common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81161,Dmd dup/delet analysis,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81162,Brca1&2 gen full seq dup/del,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81163,Brca1&2 gene full seq alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81164,Brca1&2 gen ful dup/del alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81165,Brca1 gene full seq alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81166,Brca1 gene full dup/del alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81167,Brca2 gene full dup/del alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81168,Ccnd1/igh translocation alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81170,Abl1 gene,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81171,Aff2 gene detc abnor alleles,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81172,Aff2 gene charac alleles,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81173,Ar gene full gene sequence,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81174,Ar gene known famil variant,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81175,Asxl1 full gene sequence,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81176,Asxl1 gene target seq alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81177,Atn1 gene detc abnor alleles,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81178,Atxn1 gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81179,Atxn2 gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81180,Atxn3 gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81181,Atxn7 gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81182,Atxn8os gen detc abnor allel,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81183,Atxn10 gene detc abnor allel,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81184,Cacna1a gen detc abnor allel,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81185,Cacna1a gene full gene seq,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81186,Cacna1a gen known famil vrnt,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81187,Cnbp gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81188,Cstb gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81189,Cstb gene full gene sequence,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81190,Cstb gene known famil vrnt,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81191,Ntrk1 translocation analysis,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81192,Ntrk2 translocation analysis,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81193,Ntrk3 translocation analysis,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81194,Ntrk translocation analysis,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81200,Aspa gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81201,Apc gene full sequence,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81202,Apc gene known fam variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81203,Apc gene dup/delet variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81204,Ar gene charac alleles,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81205,Bckdhb gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81206,Bcr/abl1 gene major bp,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81207,Bcr/abl1 gene minor bp,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81208,Bcr/abl1 gene other bp,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81209,Blm gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81210,Braf gene,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81211,Brca1&2 seq & com dup/del,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81212,Brca1&2 185&5385&6174 vrnt,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81213,Brca1&2 uncom dup/del var,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81214,Brca1 full seq & com dup/del,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81215,Brca1 gene known famil vrnt,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81216,Brca2 gene full seq alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81217,Brca2 gene known famil vrnt,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81218,Cebpa gene full sequence,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81219,Calr gene com variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81220,Cftr gene com variants,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81221,Cftr gene known fam variants,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81222,Cftr gene dup/delet variants,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81223,Cftr gene full sequence,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81224,Cftr gene intron poly t,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81225,Cyp2c19 gene com variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81226,Cyp2d6 gene com variants,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81227,Cyp2c9 gene com variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81228,Cytogen micrarray copy nmbr,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81229,Cytogen m array copy no&snp,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81230,Cyp3a4 gene common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81231,Cyp3a5 gene common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81232,Dpyd gene common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81233,Btk gene common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81234,Dmpk gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81235,Egfr gene com variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81236,Ezh2 gene full gene sequence,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81237,Ezh2 gene common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81238,F9 full gene sequence,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81239,Dmpk gene charac alleles,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81240,F2 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81241,F5 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81242,Fancc gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81243,Fmr1 gene detection,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81244,Fmr1 gene charac alleles,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81245,Flt3 gene,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81246,Flt3 gene analysis,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81247,G6pd gene alys cmn variant,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81248,G6pd known familial variant,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81249,G6pd full gene sequence,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81250,G6pc gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81251,Gba gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81252,Gjb2 gene full sequence,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81253,Gjb2 gene known fam variants,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81254,Gjb6 gene com variants,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81255,Hexa gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81256,Hfe gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81257,Hba1/hba2 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81258,Hba1/hba2 gene fam vrnt,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81259,Hba1/hba2 full gene sequence,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81260,Ikbkap gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81261,Igh gene rearrange amp meth,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81262,Igh gene rearrang dir probe,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81263,Igh vari regional mutation,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81264,Igk rearrangeabn clonal pop,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81265,Str markers specimen anal,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81266,Str markers spec anal addl,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81267,Chimerism anal no cell selec,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81268,Chimerism anal w/cell select,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81269,Hba1/hba2 gene dup/del vrnts,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81270,Jak2 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81271,Htt gene detc abnor alleles,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81272,Kit gene targeted seq analys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81273,Kit gene analys d816 variant,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81274,Htt gene charac alleles,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81275,Kras gene variants exon 2,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81276,Kras gene addl variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81277,Cytogenomic neo microra alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81278,Igh/bcl2 translocation alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81279,Jak2 gene trgt sequence alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81280,Long qt synd gene full seq,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81281,Long qt synd known fam var,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81282,Long qt syn gene dup/dlt var,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81283,Ifnl3 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81284,Fxn gene detc abnor alleles,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81285,Fxn gene charac alleles,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81286,Fxn gene full gene sequence,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81287,Mgmt gene prmtr mthyltn alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81288,Mlh1 gene,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81289,Fxn gene known famil variant,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81290,Mcoln1 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81291,Mthfr gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81292,Mlh1 gene full seq,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81293,Mlh1 gene known variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81294,Mlh1 gene dup/delete variant,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81295,Msh2 gene full seq,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81296,Msh2 gene known variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81297,Msh2 gene dup/delete variant,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81298,Msh6 gene full seq,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81299,Msh6 gene known variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81300,Msh6 gene dup/delete variant,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81301,Microsatellite instability,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81302,Mecp2 gene full seq,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81303,Mecp2 gene known variant,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81304,Mecp2 gene dup/delet variant,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81305,Myd88 gene p.leu265pro vrnt,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81306,Nudt15 gene common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81307,Palb2 gene full gene seq,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81308,Palb2 gene known famil vrnt,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81309,Pik3ca gene trgt seq alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81310,Npm1 gene,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81311,Nras gene variants exon 2&3,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81312,Pabpn1 gene detc abnor allel,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81313,Pca3/klk3 antigen,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81314,Pdgfra gene,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81315,Pml/raralpha com breakpoints,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81316,Pml/raralpha 1 breakpoint,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81317,Pms2 gene full seq analysis,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81318,Pms2 known familial variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81319,Pms2 gene dup/delet variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81320,Plcg2 gene common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81321,Pten gene full sequence,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81322,Pten gene known fam variant,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81323,Pten gene dup/delet variant,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81324,Pmp22 gene dup/delet,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81325,Pmp22 gene full sequence,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81326,Pmp22 gene known fam variant,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81327,Sept9 gen prmtr mthyltn alys,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81328,Slco1b1 gene com variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81329,Smn1 gene dos/deletion alys,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81330,Smpd1 gene common variants,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81331,Snrpn/ube3a gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81332,Serpina1 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81333,Tgfbi gene common variants,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81334,Runx1 gene targeted seq alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81335,Tpmt gene com variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81336,Smn1 gene full gene sequence,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81337,Smn1 gen nown famil seq vrnt,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81338,Mpl gene common variants,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81339,Mpl gene seq alys exon 10,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81340,Trb@ gene rearrange amplify,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81341,Trb@ gene rearrange dirprobe,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81342,Trg gene rearrangement anal,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81343,Ppp2r2b gen detc abnor allel,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81344,Tbp gene detc abnor alleles,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81345,Tert gene targeted seq alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81346,Tyms gene com variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81347,Sf3b1 gene common variants,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81348,Srsf2 gene common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81350,Ugt1a1 gene common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81351,Tp53 gene full gene sequence,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81352,Tp53 gene trgt sequence alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81353,Tp53 gene known famil vrnt,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81355,Vkorc1 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81357,U2af1 gene common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81360,Zrsr2 gene common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81361,Hbb gene com variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81362,Hbb gene known fam variant,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81363,Hbb gene dup/del variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81364,Hbb full gene sequence,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81370,Hla i & ii typing lr,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81371,Hla i & ii type verify lr,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81372,Hla i typing complete lr,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81373,Hla i typing 1 locus lr,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81374,Hla i typing 1 antigen lr,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81375,Hla ii typing ag equiv lr,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81376,Hla ii typing 1 locus lr,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81377,Hla ii type 1 ag equiv lr,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81378,Hla i & ii typing hr,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81379,Hla i typing complete hr,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81380,Hla i typing 1 locus hr,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81381,Hla i typing 1 allele hr,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81382,Hla ii typing 1 loc hr,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81383,Hla ii typing 1 allele hr,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81400,Mopath procedure level 1,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81401,Mopath procedure level 2,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81402,Mopath procedure level 3,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81403,Mopath procedure level 4,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81404,Mopath procedure level 5,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81405,Mopath procedure level 6,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81406,Mopath procedure level 7,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81407,Mopath procedure level 8,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81408,Mopath procedure level 9,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81410,Aortic dysfunction/dilation,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81411,Aortic dysfunction/dilation,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81412,Ashkenazi jewish assoc dis,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81413,Car ion chnnlpath inc 10 gns,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81414,Car ion chnnlpath inc 2 gns,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81415,Exome sequence analysis,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81416,Exome sequence analysis,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81417,Exome re-evaluation,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81419,Epilepsy gen seq alys panel,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81420,Fetal chrmoml aneuploidy,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81422,Fetal chrmoml microdeltj,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81425,Genome sequence analysis,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81426,Genome sequence analysis,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81427,Genome re-evaluation,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81430,Hearing loss sequence analys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81431,Hearing loss dup/del analys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81432,Hrdtry brst ca-rlatd dsordrs,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81433,Hrdtry brst ca-rlatd dsordrs,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81434,Hereditary retinal disorders,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81435,Hereditary colon ca dsordrs,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81436,Hereditary colon ca dsordrs,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81437,Heredtry nurondcrn tum dsrdr,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81438,Heredtry nurondcrn tum dsrdr,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81439,Hrdtry cardmypy gene panel,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81440,Mitochondrial gene,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81442,Noonan spectrum disorders,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81443,Genetic tstg severe inh cond,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81445,Targeted genomic seq analys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81448,Hrdtry perph neurphy panel,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81450,Targeted genomic seq analys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81455,Targeted genomic seq analys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81460,Whole mitochondrial genome,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81465,Whole mitochondrial genome,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81470,X-linked intellectual dblt,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81471,X-linked intellectual dblt,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81479,Unlisted molecular pathology,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81490,Autoimmune rheumatoid arthr,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81493,Cor artery disease mrna,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81500,Onco (ovar) two proteins,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81503,Onco (ovar) five proteins,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81504,Oncology tissue of origin,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81506,Endo assay seven anal,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81507,Fetal aneuploidy trisom risk,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81508,Ftl cgen abnor two proteins,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81509,Ftl cgen abnor 3 proteins,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81510,Ftl cgen abnor three anal,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81511,Ftl cgen abnor four anal,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81512,Ftl cgen abnor five anal,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81513,Nfct ds bv rna vag flu alg,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81514,Nfct ds bv&vaginitis dna alg,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81518,Onc brst mrna 11 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81519,Oncology breast mrna,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81520,Onc breast mrna 58 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81521,Onc breast mrna 70 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81522,Onc breast mrna 12 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81525,Oncology colon mrna,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81528,Oncology colorectal scr,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81529,Onc cutan mlnma mrna 31 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81535,Oncology gynecologic,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81536,Oncology gynecologic,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81538,Oncology lung,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81539,Oncology prostate prob score,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81540,Oncology tum unknown origin,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81541,Onc prostate mrna 46 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81542,Onc prostate mrna 22 cnt gen,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81545,Oncology thyroid,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81546,"Onc thyr mrna 10,196 gen alg",Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81551,Onc prostate 3 genes,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81552,Onc uveal mlnma mrna 15 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81554,Pulm ds ipf mrna 190 gen alg,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,81595,Cardiology hrt trnspl mrna,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,81596,Nfct ds chrnc hcv 6 assays,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,81599,Unlisted maaa,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,82009,Test for acetone/ketones,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,82010,Acetone assay,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82013,Acetylcholinesterase assay,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82016,Acylcarnitines qual,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82017,Acylcarnitines quant,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82024,Assay of acth,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Humana Medicaid,CPT,82030,Assay of adp & amp,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,82040,Assay of serum albumin,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,82042,Other source albumin quan ea,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,82043,Ur albumin quantitative,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
Humana Medicaid,CPT,82044,Ur albumin semiquantitative,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
Humana Medicaid,CPT,82045,Albumin ischemia modified,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,82075,Assay of breath ethanol,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82077,Assay spec xcp ur&breath ia,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82085,Assay of aldolase,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82088,Assay of aldosterone,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Humana Medicaid,CPT,82103,Alpha-1-antitrypsin total,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82104,Alpha-1-antitrypsin pheno,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82105,Alpha-fetoprotein serum,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82106,Alpha-fetoprotein amniotic,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82107,Alpha-fetoprotein l3,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,82108,Assay of aluminum,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Humana Medicaid,CPT,82120,Amines vaginal fluid qual,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,82127,Amino acid single qual,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82128,Amino acids mult qual,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82131,Amino acids single quant,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82135,Assay aminolevulinic acid,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82136,Amino acids quant 2-5,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82139,Amino acids quan 6 or more,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82140,Assay of ammonia,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82143,Amniotic fluid scan,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,82150,Assay of amylase,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,82154,Androstanediol glucuronide,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,82157,Assay of androstenedione,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,82160,Assay of androsterone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,82163,Assay of angiotensin ii,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,82164,Angiotensin i enzyme test,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82172,Assay of apolipoprotein,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82175,Assay of arsenic,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Humana Medicaid,CPT,82180,Assay of ascorbic acid,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82190,Atomic absorption,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82232,Assay of beta-2 protein,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,82239,Bile acids total,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82240,Bile acids cholylglycine,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82247,Bilirubin total,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,82248,Bilirubin direct,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,82252,Fecal bilirubin test,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,82261,Assay of biotinidase,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82270,Occult blood feces,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,82271,Occult blood other sources,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,82272,Occult bld feces 1-3 tests,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,82274,Assay test for blood fecal,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82286,Assay of bradykinin,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,82300,Assay of cadmium,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Humana Medicaid,CPT,82306,Vitamin d 25 hydroxy,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,82308,Assay of calcitonin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,82310,Assay of calcium,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,82330,Assay of calcium,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82331,Calcium infusion test,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82340,Assay of calcium in urine,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,82355,Calculus analysis qual,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82360,Calculus assay quant,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82365,Calculus spectroscopy,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82370,X-ray assay calculus,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82373,Assay c-d transfer measure,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82374,Assay blood carbon dioxide,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,82375,Assay carboxyhb quant,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82376,Assay carboxyhb qual,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82378,Carcinoembryonic antigen,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82379,Assay of carnitine,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82380,Assay of carotene,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82382,Assay urine catecholamines,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,82383,Assay blood catecholamines,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,82384,Assay three catecholamines,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,82387,Assay of cathepsin-d,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82390,Assay of ceruloplasmin,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82397,Chemiluminescent assay,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82415,Assay of chloramphenicol,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,82435,Assay of blood chloride,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,82436,Assay of urine chloride,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,82438,Assay other fluid chlorides,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,82441,Test for chlorohydrocarbons,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Humana Medicaid,CPT,82465,Assay bld/serum cholesterol,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,82480,Assay serum cholinesterase,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,82482,Assay rbc cholinesterase,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,82485,Assay chondroitin sulfate,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,82486,Gas/liquid chromatography,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,82487,Paper chromatography,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,82488,Paper chromatography,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,82489,Thin layer chromatography,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,82491,Chromotography quant sing,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82492,Chromotography quant mult,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,82495,Assay of chromium,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Humana Medicaid,CPT,82507,Assay of citrate,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82523,Collagen crosslinks,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82525,Assay of copper,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Humana Medicaid,CPT,82528,Assay of corticosterone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,82530,Cortisol free,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82533,Total cortisol,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,82540,Assay of creatine,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,82541,Column chromotography qual,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,82542,Col chromotography qual/quan,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82543,Column chromotograph/isotope,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,82544,Column chromotograph/isotope,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,82550,Assay of ck (cpk),Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,82552,Assay of cpk in blood,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82553,Creatine mb fraction,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82554,Creatine isoforms,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82565,Assay of creatinine,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,82570,Assay of urine creatinine,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,82575,Creatinine clearance test,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82585,Assay of cryofibrinogen,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82595,Assay of cryoglobulin,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,82600,Assay of cyanide,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Humana Medicaid,CPT,82607,Vitamin b-12,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,82608,B-12 binding capacity,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82610,Cystatin c,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82615,Test for urine cystines,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82626,Dehydroepiandrosterone,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82627,Dehydroepiandrosterone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,82633,Desoxycorticosterone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,82634,Deoxycortisol,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,82638,Assay of dibucaine number,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82642,Dihydrotestosterone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,82652,Vit d 1 25-dihydroxy,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,82656,Pancreatic elastase fecal,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82657,Enzyme cell activity,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82658,Enzyme cell activity ra,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,82664,Electrophoretic test,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,82668,Assay of erythropoietin,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82670,Assay of total estradiol,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,82671,Assay of estrogens,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,82672,Assay of estrogen,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,82677,Assay of estriol,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,82679,Assay of estrone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,82681,Assay dir meas fr estradiol,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,82693,Assay of ethylene glycol,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Humana Medicaid,CPT,82696,Assay of etiocholanolone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,82705,Fats/lipids feces qual,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,82710,Fats/lipids feces quant,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82715,Assay of fecal fat,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82725,Assay of blood fatty acids,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82726,Long chain fatty acids,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82728,Assay of ferritin,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82731,Assay of fetal fibronectin,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,82735,Assay of fluoride,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Humana Medicaid,CPT,82746,Assay of folic acid serum,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82747,Assay of folic acid rbc,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
Humana Medicaid,CPT,82757,Assay of semen fructose,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82759,Assay of rbc galactokinase,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82760,Assay of galactose,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82775,Assay galactose transferase,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82776,Galactose transferase test,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82777,Galectin-3,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,82784,Assay iga/igd/igg/igm each,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82785,Assay of ige,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82787,Igg 1 2 3 or 4 each,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82800,Blood ph,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82803,Blood gases any combination,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82805,Blood gases w/o2 saturation,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,82810,Blood gases o2 sat only,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82820,Hemoglobin-oxygen affinity,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Humana Medicaid,CPT,82930,Gastric analy w/ph ea spec,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,82938,Gastrin test,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,82941,Assay of gastrin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,82943,Assay of glucagon,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,82945,Glucose other fluid,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,82946,Glucagon tolerance test,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82947,Assay glucose blood quant,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,82948,Reagent strip/blood glucose,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,82950,Glucose test,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,82951,Glucose tolerance test (gtt),Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82952,Gtt-added samples,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,82955,Assay of g6pd enzyme,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82960,Test for g6pd enzyme,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,82962,Glucose blood test,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,82963,Assay of glucosidase,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82965,Assay of gdh enzyme,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82977,Assay of ggt,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,82978,Assay of glutathione,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82979,Assay rbc glutathione,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,82985,Assay of glycated protein,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,83001,Assay of gonadotropin (fsh),Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,83002,Assay of gonadotropin (lh),Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,83003,Assay growth hormone (hgh),Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,83006,Growth stimulation gene 2,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Humana Medicaid,CPT,83009,H pylori (c-13) blood,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,83010,Assay of haptoglobin quant,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,83012,Assay of haptoglobins,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,83013,H pylori (c-13) breath,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,83014,H pylori drug admin,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,83015,Heavy metal qual any anal,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Humana Medicaid,CPT,83018,Heavy metal quant each nes,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Humana Medicaid,CPT,83020,Hemoglobin electrophoresis,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,83021,Hemoglobin chromotography,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
Humana Medicaid,CPT,83026,Hemoglobin copper sulfate,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Humana Medicaid,CPT,83030,Fetal hemoglobin chemical,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,83033,Fetal hemoglobin assay qual,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,83036,Glycosylated hemoglobin test,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,83037,Glycosylated hb home device,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,83045,Blood methemoglobin test,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,83050,Blood methemoglobin assay,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,83051,Assay of plasma hemoglobin,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,83060,Blood sulfhemoglobin assay,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,83065,Assay of hemoglobin heat,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,83068,Hemoglobin stability screen,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,83069,Assay of urine hemoglobin,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,83070,Assay of hemosiderin qual,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,83080,Assay of b hexosaminidase,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,83088,Assay of histamine,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,83090,Assay of homocystine,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,83150,Assay of homovanillic acid,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,83491,Assay of corticosteroids 17,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,83497,Assay of 5-hiaa,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,83498,Assay of progesterone 17-d,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,83499,Assay of progesterone 20-,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Humana Medicaid,CPT,83500,Assay free hydroxyproline,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,83505,Assay total hydroxyproline,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,83516,Immunoassay nonantibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,83518,Immunoassay dipstick,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,83519,Ria nonantibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,83520,Immunoassay quant nos nonab,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,83525,Assay of insulin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,83527,Assay of insulin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,83528,Assay of intrinsic factor,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,83540,Assay of iron,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,83550,Iron binding test,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,83570,Assay of idh enzyme,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,83582,Assay of ketogenic steroids,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,83586,Assay 17- ketosteroids,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,83593,Fractionation ketosteroids,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,83605,Assay of lactic acid,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,83615,Lactate (ld) (ldh) enzyme,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,83625,Assay of ldh enzymes,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,83630,Lactoferrin fecal (qual),Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,83631,Lactoferrin fecal (quant),Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,83632,Placental lactogen,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,83633,Test urine for lactose,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,83655,Assay of lead,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Humana Medicaid,CPT,83661,L/s ratio fetal lung,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,83662,Foam stability fetal lung,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,83663,Fluoro polarize fetal lung,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,83664,Lamellar bdy fetal lung,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,83670,Assay of lap enzyme,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,83690,Assay of lipase,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,83695,Assay of lipoprotein(a),Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,83698,Assay lipoprotein pla2,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,83700,Lipopro bld electrophoretic,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,83701,Lipoprotein bld hr fraction,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,83704,Lipoprotein bld quan part,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,83718,Assay of lipoprotein,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,83719,Assay of blood lipoprotein,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,83721,Assay of blood lipoprotein,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,83722,Lipoprtn dir meas sd ldl chl,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,83727,Assay of lrh hormone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,83735,Assay of magnesium,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,83775,Assay malate dehydrogenase,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,83785,Assay of manganese,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Humana Medicaid,CPT,83788,Mass spectrometry qual,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,83789,Mass spectrometry qual/quan,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,83825,Assay of mercury,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Humana Medicaid,CPT,83835,Assay of metanephrines,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,83857,Assay of methemalbumin,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,83861,Microfluid analy tears,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,83864,Mucopolysaccharides,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,83872,Assay synovial fluid mucin,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,83873,Assay of csf protein,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,83874,Assay of myoglobin,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,83876,Assay myeloperoxidase,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,83880,Assay of natriuretic peptide,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,83883,Assay nephelometry not spec,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,83885,Assay of nickel,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Humana Medicaid,CPT,83915,Assay of nucleotidase,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,83916,Oligoclonal bands,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,83918,Organic acids total quant,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Humana Medicaid,CPT,83919,Organic acids qual each,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,83921,Organic acid single quant,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,83930,Assay of blood osmolality,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,83935,Assay of urine osmolality,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,83937,Assay of osteocalcin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,83945,Assay of oxalate,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,83950,Oncoprotein her-2/neu,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,83951,Oncoprotein dcp,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,83970,Assay of parathormone,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Humana Medicaid,CPT,83986,Assay ph body fluid nos,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,83987,Exhaled breath condensate,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,83992,Assay for phencyclidine,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Humana Medicaid,CPT,83993,Assay for calprotectin fecal,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,84030,Assay of blood pku,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,84035,Assay of phenylketones,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,84060,Assay acid phosphatase,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,84061,Phosphatase forensic exam,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,84066,Assay prostate phosphatase,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,84075,Assay alkaline phosphatase,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,84078,Assay alkaline phosphatase,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,84080,Assay alkaline phosphatases,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,84081,Assay phosphatidylglycerol,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,84085,Assay of rbc pg6d enzyme,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,84087,Assay phosphohexose enzymes,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,84100,Assay of phosphorus,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,84105,Assay of urine phosphorus,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,84106,Test for porphobilinogen,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,84110,Assay of porphobilinogen,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,84112,Eval amniotic fluid protein,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,84119,Test urine for porphyrins,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,84120,Assay of urine porphyrins,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,84126,Assay of feces porphyrins,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,84132,Assay of serum potassium,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,84133,Assay of urine potassium,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,84134,Assay of prealbumin,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,84135,Assay of pregnanediol,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,84138,Assay of pregnanetriol,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,84140,Assay of pregnenolone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,84143,Assay of 17-hydroxypregneno,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,84144,Assay of progesterone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,84145,Procalcitonin (pct),Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,84146,Assay of prolactin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,84150,Assay of prostaglandin,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Humana Medicaid,CPT,84152,Assay of psa complexed,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,84153,Assay of psa total,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,84154,Assay of psa free,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,84155,Assay of protein serum,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,84156,Assay of protein urine,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,84157,Assay of protein other,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,84160,Assay of protein any source,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,84163,Pappa serum,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,84165,Protein e-phoresis serum,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,84166,Protein e-phoresis/urine/csf,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,84181,Western blot test,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,84182,Protein western blot test,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,84202,Assay rbc protoporphyrin,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,84203,Test rbc protoporphyrin,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,84206,Assay of proinsulin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,84207,Assay of vitamin b-6,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,84210,Assay of pyruvate,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,84220,Assay of pyruvate kinase,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,84228,Assay of quinine,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,84233,Assay of estrogen,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Humana Medicaid,CPT,84234,Assay of progesterone,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Humana Medicaid,CPT,84235,Assay of endocrine hormone,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Humana Medicaid,CPT,84238,Assay nonendocrine receptor,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,84244,Assay of renin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,84252,Assay of vitamin b-2,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,84255,Assay of selenium,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,84260,Assay of serotonin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,84270,Assay of sex hormone globul,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,84275,Assay of sialic acid,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,84285,Assay of silica,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Humana Medicaid,CPT,84295,Assay of serum sodium,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,84300,Assay of urine sodium,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,84302,Assay of sweat sodium,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,84305,Assay of somatomedin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,84307,Assay of somatostatin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,84311,Spectrophotometry,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,84315,Body fluid specific gravity,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,84375,Chromatogram assay sugars,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,84376,Sugars single qual,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,84377,Sugars multiple qual,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,84378,Sugars single quant,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,84379,Sugars multiple quant,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,84392,Assay of urine sulfate,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
Humana Medicaid,CPT,84402,Assay of free testosterone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,84403,Assay of total testosterone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,84410,Testosterone bioavailable,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Humana Medicaid,CPT,84425,Assay of vitamin b-1,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,84430,Assay of thiocyanate,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Humana Medicaid,CPT,84431,Thromboxane urine,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,84432,Assay of thyroglobulin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,84436,Assay of total thyroxine,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,84437,Assay of neonatal thyroxine,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,84439,Assay of free thyroxine,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,84442,Assay of thyroid activity,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,84443,Assay thyroid stim hormone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,84445,Assay of tsi globulin,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Humana Medicaid,CPT,84446,Assay of vitamin e,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,84449,Assay of transcortin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,84450,Transferase (ast) (sgot),Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,84460,Alanine amino (alt) (sgpt),Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,84466,Assay of transferrin,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,84478,Assay of triglycerides,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,84479,Assay of thyroid (t3 or t4),Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,84480,Assay triiodothyronine (t3),Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,84481,Free assay (ft-3),Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,84482,T3 reverse,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,84484,Assay of troponin quant,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,84485,Assay duodenal fluid trypsin,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,84488,Test feces for trypsin,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,84490,Assay of feces for trypsin,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,84510,Assay of tyrosine,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,84512,Assay of troponin qual,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,84520,Assay of urea nitrogen,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,84525,Urea nitrogen semi-quant,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,84540,Assay of urine/urea-n,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,84545,Urea-n clearance test,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,84550,Assay of blood/uric acid,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,84560,Assay of urine/uric acid,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,84577,Assay of feces/urobilinogen,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,84578,Test urine urobilinogen,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,84580,Assay of urine urobilinogen,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,84583,Assay of urine urobilinogen,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,84585,Assay of urine vma,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,84586,Assay of vip,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Humana Medicaid,CPT,84588,Assay of vasopressin,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Humana Medicaid,CPT,84590,Assay of vitamin a,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,84591,Assay of nos vitamin,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,84597,Assay of vitamin k,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,84600,Assay of volatiles,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,84620,Xylose tolerance test,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,84630,Assay of zinc,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Humana Medicaid,CPT,84681,Assay of c-peptide,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,84702,Chorionic gonadotropin test,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,84703,Chorionic gonadotropin assay,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,84704,Hcg free betachain test,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,84830,Ovulation tests,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,84999,Clinical chemistry test,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,85002,Bleeding time test,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Humana Medicaid,CPT,85004,Automated diff wbc count,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Humana Medicaid,CPT,85007,Bl smear w/diff wbc count,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Humana Medicaid,CPT,85008,Bl smear w/o diff wbc count,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Humana Medicaid,CPT,85009,Manual diff wbc count b-coat,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Humana Medicaid,CPT,85013,Spun microhematocrit,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Humana Medicaid,CPT,85014,Hematocrit,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Humana Medicaid,CPT,85018,Hemoglobin,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Humana Medicaid,CPT,85025,Complete cbc w/auto diff wbc,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Humana Medicaid,CPT,85027,Complete cbc automated,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Humana Medicaid,CPT,85032,Manual cell count each,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Humana Medicaid,CPT,85041,Automated rbc count,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Humana Medicaid,CPT,85044,Manual reticulocyte count,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Humana Medicaid,CPT,85045,Automated reticulocyte count,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Humana Medicaid,CPT,85046,Reticyte/hgb concentrate,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Humana Medicaid,CPT,85048,Automated leukocyte count,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Humana Medicaid,CPT,85049,Automated platelet count,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Humana Medicaid,CPT,85055,Reticulated platelet assay,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Humana Medicaid,CPT,85060,Blood smear interpretation,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,85097,Bone marrow interpretation,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,85130,Chromogenic substrate assay,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
Humana Medicaid,CPT,85170,Blood clot retraction,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Humana Medicaid,CPT,85175,Blood clot lysis time,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Humana Medicaid,CPT,85210,Clot factor ii prothrom spec,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Humana Medicaid,CPT,85220,Blooc clot factor v test,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Humana Medicaid,CPT,85230,Clot factor vii proconvertin,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Humana Medicaid,CPT,85240,Clot factor viii ahg 1 stage,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Humana Medicaid,CPT,85244,Clot factor viii reltd antgn,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Humana Medicaid,CPT,85245,Clot factor viii vw ristoctn,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Humana Medicaid,CPT,85246,Clot factor viii vw antigen,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Humana Medicaid,CPT,85247,Clot factor viii multimetric,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Humana Medicaid,CPT,85250,Clot factor ix ptc/chrstmas,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Humana Medicaid,CPT,85260,Clot factor x stuart-power,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Humana Medicaid,CPT,85270,Clot factor xi pta,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Humana Medicaid,CPT,85280,Clot factor xii hageman,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Humana Medicaid,CPT,85290,Clot factor xiii fibrin stab,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Humana Medicaid,CPT,85291,Clot factor xiii fibrin scrn,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Humana Medicaid,CPT,85292,Clot factor fletcher fact,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Humana Medicaid,CPT,85293,Clot factor wght kininogen,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Humana Medicaid,CPT,85300,Antithrombin iii activity,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Humana Medicaid,CPT,85301,Antithrombin iii antigen,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Humana Medicaid,CPT,85302,Clot inhibit prot c antigen,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Humana Medicaid,CPT,85303,Clot inhibit prot c activity,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Humana Medicaid,CPT,85305,Clot inhibit prot s total,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Humana Medicaid,CPT,85306,Clot inhibit prot s free,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Humana Medicaid,CPT,85307,Assay activated protein c,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,85335,Factor inhibitor test,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Humana Medicaid,CPT,85337,Thrombomodulin,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Humana Medicaid,CPT,85345,Coagulation time lee & white,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Humana Medicaid,CPT,85347,Coagulation time activated,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Humana Medicaid,CPT,85348,Coagulation time otr method,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Humana Medicaid,CPT,85360,Euglobulin lysis,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
Humana Medicaid,CPT,85362,Fibrin degradation products,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Humana Medicaid,CPT,85366,Fibrinogen test,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Humana Medicaid,CPT,85370,Fibrinogen test,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Humana Medicaid,CPT,85378,Fibrin degrade semiquant,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Humana Medicaid,CPT,85379,Fibrin degradation quant,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Humana Medicaid,CPT,85380,Fibrin degradj d-dimer,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
Humana Medicaid,CPT,85384,Fibrinogen activity,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Humana Medicaid,CPT,85385,Fibrinogen antigen,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Humana Medicaid,CPT,85390,Fibrinolysins screen i&r,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Humana Medicaid,CPT,85396,Clotting assay whole blood,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Humana Medicaid,CPT,85397,Clotting funct activity,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Humana Medicaid,CPT,85400,Fibrinolytic plasmin,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Humana Medicaid,CPT,85410,Fibrinolytic antiplasmin,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Humana Medicaid,CPT,85415,Fibrinolytic plasminogen,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Humana Medicaid,CPT,85420,Fibrinolytic plasminogen,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Humana Medicaid,CPT,85421,Fibrinolytic plasminogen,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Humana Medicaid,CPT,85441,Heinz bodies direct,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Humana Medicaid,CPT,85445,Heinz bodies induced,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Humana Medicaid,CPT,85460,Hemoglobin fetal,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
Humana Medicaid,CPT,85461,Hemoglobin fetal,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Humana Medicaid,CPT,85475,Hemolysin acid,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Humana Medicaid,CPT,85520,Heparin assay,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Humana Medicaid,CPT,85525,Heparin neutralization,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Humana Medicaid,CPT,85530,Heparin-protamine tolerance,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Humana Medicaid,CPT,85536,Iron stain peripheral blood,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Humana Medicaid,CPT,85540,Wbc alkaline phosphatase,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
Humana Medicaid,CPT,85547,Rbc mechanical fragility,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
Humana Medicaid,CPT,85549,Muramidase,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,85555,Rbc osmotic fragility,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
Humana Medicaid,CPT,85557,Rbc osmotic fragility,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
Humana Medicaid,CPT,85576,Blood platelet aggregation,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Humana Medicaid,CPT,85597,Phospholipid pltlt neutraliz,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Humana Medicaid,CPT,85598,Hexagnal phosph pltlt neutrl,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Humana Medicaid,CPT,85610,Prothrombin time,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Humana Medicaid,CPT,85611,Prothrombin test,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Humana Medicaid,CPT,85612,Viper venom prothrombin time,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Humana Medicaid,CPT,85613,Russell viper venom diluted,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Humana Medicaid,CPT,85635,Reptilase test,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
Humana Medicaid,CPT,85651,Rbc sed rate nonautomated,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Humana Medicaid,CPT,85652,Rbc sed rate automated,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Humana Medicaid,CPT,85660,Rbc sickle cell test,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Humana Medicaid,CPT,85670,Thrombin time plasma,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Humana Medicaid,CPT,85675,Thrombin time titer,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Humana Medicaid,CPT,85705,Thromboplastin inhibition,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Humana Medicaid,CPT,85730,Thromboplastin time partial,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Humana Medicaid,CPT,85732,Thromboplastin time partial,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Humana Medicaid,CPT,85810,Blood viscosity examination,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
Humana Medicaid,CPT,85999,Hematology procedure,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Humana Medicaid,CPT,86000,Agglutinins febrile antigen,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86001,Allergen specific igg,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86003,Allg spec ige crude xtrc ea,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86005,Allg spec ige multiallg scr,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86008,Allg spec ige recomb ea,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86021,Wbc antibody identification,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86022,Platelet antibodies,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86023,Immunoglobulin assay,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86038,Antinuclear antibodies,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86039,Antinuclear antibodies (ana),Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86060,Antistreptolysin o titer,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86063,Antistreptolysin o screen,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86140,C-reactive protein,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86141,C-reactive protein hs,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86146,Beta-2 glycoprotein antibody,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,86147,Cardiolipin antibody ea ig,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Humana Medicaid,CPT,86148,Anti-phospholipid antibody,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,86152,Cell enumeration & id,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Humana Medicaid,CPT,86153,Cell enumeration phys interp,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86155,Chemotaxis assay,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86156,Cold agglutinin screen,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86157,Cold agglutinin titer,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86160,Complement antigen,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86161,Complement/function activity,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86162,Complement total (ch50),Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86171,Complement fixation each,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86185,Counterimmunoelectrophoresis,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86200,Ccp antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86215,Deoxyribonuclease antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86225,Dna antibody native,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86226,Dna antibody single strand,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86235,Nuclear antigen antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86243,Fc receptor,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Humana Medicaid,CPT,86255,Fluorescent antibody screen,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86256,Fluorescent antibody titer,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86277,Growth hormone antibody,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,86280,Hemagglutination inhibition,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86294,Immunoassay tumor qual,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,86300,Immunoassay tumor ca 15-3,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,86301,Immunoassay tumor ca 19-9,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,86304,Immunoassay tumor ca 125,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,86305,Human epididymis protein 4,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,86308,Heterophile antibody screen,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86309,Heterophile antibody titer,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86310,Heterophile antibody absrbj,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86316,Immunoassay tumor other,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,86317,Immunoassay infectious agent,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86318,Ia infectious agent antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86320,Serum immunoelectrophoresis,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,86325,Other immunoelectrophoresis,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,86327,Immunoelectrophoresis assay,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,86328,Ia nfct ab sarscov2 covid19,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86329,Immunodiffusion nes,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86331,Immunodiffusion ouchterlony,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86332,Immune complex assay,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Humana Medicaid,CPT,86334,Immunofix e-phoresis serum,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86335,Immunfix e-phorsis/urine/csf,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Humana Medicaid,CPT,86336,Inhibin a,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,86337,Insulin antibodies,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,86340,Intrinsic factor antibody,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,86341,Islet cell antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86343,Leukocyte histamine release,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86344,Leukocyte phagocytosis,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86352,Cell function assay w/stim,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Humana Medicaid,CPT,86353,Lymphocyte transformation,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Humana Medicaid,CPT,86355,B cells total count,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Humana Medicaid,CPT,86356,Mononuclear cell antigen,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Humana Medicaid,CPT,86357,Nk cells total count,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Humana Medicaid,CPT,86359,T cells total count,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Humana Medicaid,CPT,86360,T cell absolute count/ratio,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Humana Medicaid,CPT,86361,T cell absolute count,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Humana Medicaid,CPT,86367,Stem cells total count,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Humana Medicaid,CPT,86376,Microsomal antibody each,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,86378,Migration inhibitory factor,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Humana Medicaid,CPT,86382,Neutralization test viral,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86384,Nitroblue tetrazolium dye,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86386,Nuclear matrix protein 22,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86403,Particle agglut antbdy scrn,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86406,Particle agglut antbdy titr,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86408,Neutrlzg antb sarscov2 scr,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86409,Neutrlzg antb sarscov2 titer,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86413,Sars-cov-2 antb quantitative,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86430,Rheumatoid factor test qual,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86431,Rheumatoid factor quant,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86480,Tb test cell immun measure,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Humana Medicaid,CPT,86481,Tb ag response t-cell susp,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Humana Medicaid,CPT,86485,Skin test candida,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Humana Medicaid,CPT,86486,Skin test nos antigen,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86490,Coccidioidomycosis skin test,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Humana Medicaid,CPT,86510,Histoplasmosis skin test,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Humana Medicaid,CPT,86580,Tb intradermal test,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86590,Streptokinase antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86592,Syphilis test non-trep qual,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86593,Syphilis test non-trep quant,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86602,Antinomyces antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86603,Adenovirus antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86606,Aspergillus antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86609,Bacterium antibody,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,86611,Bartonella antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86612,Blastomyces antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86615,Bordetella antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86617,Lyme disease antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86618,Lyme disease antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86619,Borrelia antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86622,Brucella antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86625,Campylobacter antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86628,Candida antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86631,Chlamydia antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86632,Chlamydia igm antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86635,Coccidioides antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86638,Q fever antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86641,Cryptococcus antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86644,Cmv antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86645,Cmv antibody igm,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86648,Diphtheria antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86651,Encephalitis californ antbdy,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86652,Encephaltis east eqne anbdy,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86653,Encephaltis st louis antbody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86654,Encephaltis west eqne antbdy,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86658,Enterovirus antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86663,Epstein-barr antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86664,Epstein-barr nuclear antigen,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86665,Epstein-barr capsid vca,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86666,Ehrlichia antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86668,Francisella tularensis,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86671,Fungus nes antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86674,Giardia lamblia antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86677,Helicobacter pylori antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86682,Helminth antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86684,Hemophilus influenza antibdy,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86687,Htlv-i antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86688,Htlv-ii antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86689,Htlv/hiv confirmj antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86692,Hepatitis delta agent antbdy,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86694,Herpes simplex nes antbdy,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86695,Herpes simplex type 1 test,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86696,Herpes simplex type 2 test,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86698,Histoplasma antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86701,Hiv-1antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86702,Hiv-2 antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86703,Hiv-1/hiv-2 1 result antbdy,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86704,Hep b core antibody total,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86705,Hep b core antibody igm,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86706,Hep b surface antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86707,Hepatitis be antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86708,Hepatitis a antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86709,Hepatitis a igm antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86710,Influenza virus antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86711,John cunningham antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86713,Legionella antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86717,Leishmania antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86720,Leptospira antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86723,Listeria monocytogenes,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86727,Lymph choriomeningitis ab,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86729,Lympho venereum antibody,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Humana Medicaid,CPT,86732,Mucormycosis antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86735,Mumps antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86738,Mycoplasma antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86741,Neisseria meningitidis,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86744,Nocardia antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86747,Parvovirus antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86750,Malaria antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86753,Protozoa antibody nos,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86756,Respiratory virus antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86757,Rickettsia antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86759,Rotavirus antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86762,Rubella antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86765,Rubeola antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86768,Salmonella antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86769,Sars-cov-2 covid-19 antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86771,Shigella antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86774,Tetanus antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86777,Toxoplasma antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86778,Toxoplasma antibody igm,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86780,Treponema pallidum,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86784,Trichinella antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86787,Varicella-zoster antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86788,West nile virus ab igm,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86789,West nile virus antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86790,Virus antibody nos,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86793,Yersinia antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86794,Zika virus igm antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86800,Thyroglobulin antibody,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Humana Medicaid,CPT,86803,Hepatitis c ab test,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86804,Hep c ab test confirm,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,86805,Lymphocytotoxicity assay,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Humana Medicaid,CPT,86806,Lymphocytotoxicity assay,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
Humana Medicaid,CPT,86807,Cytotoxic antibody screening,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Humana Medicaid,CPT,86808,Cytotoxic antibody screening,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
Humana Medicaid,CPT,86812,Hla typing a b or c,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
Humana Medicaid,CPT,86813,Hla typing a b or c,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Humana Medicaid,CPT,86816,Hla typing dr/dq,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
Humana Medicaid,CPT,86817,Hla typing dr/dq,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Humana Medicaid,CPT,86821,Lymphocyte culture mixed,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
Humana Medicaid,CPT,86822,Lymphocyte culture primed,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Humana Medicaid,CPT,86825,Hla x-math non-cytotoxic,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Humana Medicaid,CPT,86826,Hla x-match noncytotoxc addl,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
Humana Medicaid,CPT,86828,Hla class i&ii antibody qual,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
Humana Medicaid,CPT,86829,Hla class i/ii antibody qual,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
Humana Medicaid,CPT,86830,Hla class i phenotype qual,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Humana Medicaid,CPT,86831,Hla class ii phenotype qual,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Humana Medicaid,CPT,86832,Hla class i high defin qual,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Humana Medicaid,CPT,86833,Hla class ii high defin qual,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Humana Medicaid,CPT,86834,Hla class i semiquant panel,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Humana Medicaid,CPT,86835,Hla class ii semiquant panel,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Humana Medicaid,CPT,86849,Immunology procedure,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86850,Rbc antibody screen,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Humana Medicaid,CPT,86860,Rbc antibody elution,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Humana Medicaid,CPT,86870,Rbc antibody identification,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Humana Medicaid,CPT,86880,Coombs test direct,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Humana Medicaid,CPT,86885,Coombs test indirect qual,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Humana Medicaid,CPT,86886,Coombs test indirect titer,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Humana Medicaid,CPT,86900,Blood typing serologic abo,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Humana Medicaid,CPT,86901,Blood typing serologic rh(d),Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
Humana Medicaid,CPT,86902,Blood type antigen donor ea,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Humana Medicaid,CPT,86904,Blood typing patient serum,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
Humana Medicaid,CPT,86905,Blood typing rbc antigens,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Humana Medicaid,CPT,86906,Bld typing serologic rh phnt,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
Humana Medicaid,CPT,86910,Blood typing paternity test,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
Humana Medicaid,CPT,86911,Blood typing antigen system,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
Humana Medicaid,CPT,86920,Compatibility test spin,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Humana Medicaid,CPT,86921,Compatibility test incubate,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Humana Medicaid,CPT,86922,Compatibility test antiglob,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Humana Medicaid,CPT,86923,Compatibility test electric,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Humana Medicaid,CPT,86940,Hemolysins/agglutinins auto,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86941,Hemolysins/agglutinins,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,86999,Transfusion procedure,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
Humana Medicaid,CPT,87003,Small animal inoculation,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87015,Specimen infect agnt concntj,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87040,Blood culture for bacteria,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87045,Feces culture aerobic bact,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87046,Stool cultr aerobic bact ea,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87070,Culture othr specimn aerobic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87071,Culture aerobic quant other,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87073,Culture bacteria anaerobic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87075,Cultr bacteria except blood,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87076,Culture anaerobe ident each,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87077,Culture aerobic identify,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87081,Culture screen only,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87084,Culture of specimen by kit,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87086,Urine culture/colony count,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87088,Urine bacteria culture,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87101,Skin fungi culture,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87102,Fungus isolation culture,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87103,Blood fungus culture,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87106,Fungi identification yeast,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87107,Fungi identification mold,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87109,Mycoplasma,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87110,Chlamydia culture,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87116,Mycobacteria culture,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87118,Mycobacteric identification,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87140,Culture type immunofluoresc,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87143,Culture typing glc/hplc,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87147,Culture type immunologic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87149,Dna/rna direct probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87150,Dna/rna amplified probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87152,Culture type pulse field gel,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87158,Culture typing added method,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87164,Dark field examination,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87166,Dark field examination,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87168,Macroscopic exam arthropod,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87169,Macroscopic exam parasite,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87172,Pinworm exam,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87176,Tissue homogenization cultr,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87177,Ova and parasites smears,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87181,Microbe susceptible diffuse,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87184,Microbe susceptible disk,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87185,Microbe susceptible enzyme,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87186,Microbe susceptible mic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87187,Microbe susceptible mlc,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87188,Microbe suscept macrobroth,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87190,Microbe suscept mycobacteri,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87197,Bactericidal level serum,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87205,Smear gram stain,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87206,Smear fluorescent/acid stai,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87207,Smear special stain,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87209,Smear complex stain,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87210,Smear wet mount saline/ink,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87220,Tissue exam for fungi,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87230,Assay toxin or antitoxin,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87250,Virus inoculate eggs/animal,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87252,Virus inoculation tissue,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87253,Virus inoculate tissue addl,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87254,Virus inoculation shell via,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87255,Genet virus isolate hsv,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87260,Adenovirus ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87265,Pertussis ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87267,Enterovirus antibody dfa,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87269,Giardia ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87270,Chlamydia trachomatis ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87271,Cytomegalovirus dfa,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87272,Cryptosporidium ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87273,Herpes simplex 2 ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87274,Herpes simplex 1 ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87275,Influenza b ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87276,Influenza a ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87277,Legionella micdadei ag if,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,87278,Legion pneumophilia ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87279,Parainfluenza ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87280,Respiratory syncytial ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87281,Pneumocystis carinii ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87283,Rubeola ag if,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87285,Treponema pallidum ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87290,Varicella zoster ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87299,Antibody detection nos if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87300,Ag detection polyval if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87301,Adenovirus ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87305,Aspergillus ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87320,Chylmd trach ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87324,Clostridium ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87327,Cryptococcus neoform ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87328,Cryptosporidium ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87329,Giardia ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87332,Cytomegalovirus ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87335,E coli 0157 ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87336,Entamoeb hist dispr ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87337,Entamoeb hist group ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87338,Hpylori stool ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87339,H pylori ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87340,Hepatitis b surface ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87341,Hepatitis b surface ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87350,Hepatitis be ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87380,Hepatitis delta agent ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87385,Histoplasma capsul ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87389,Hiv-1 ag w/hiv-1&2 ab ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87390,Hiv-1 ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87391,Hiv-2 ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87400,Influenza a/b each ag ia,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,87420,Resp syncytial virus ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87425,Rotavirus ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87426,Sarscov coronavirus ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87427,Shiga-like toxin ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87428,Sarscov & inf vir a&b ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87430,Strep a ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87449,Nos each organism ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87450,Ag detect nos ia single,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87451,Polyvalent mult org ea ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87470,Bartonella dna dir probe,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,87471,Bartonella dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87472,Bartonella dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87475,Lyme dis dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87476,Lyme dis dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87477,Lyme dis dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87480,Candida dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87481,Candida dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87482,Candida dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87485,Chylmd pneum dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87486,Chylmd pneum dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87487,Chylmd pneum dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87490,Chylmd trach dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87491,Chylmd trach dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87492,Chylmd trach dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87493,C diff amplified probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87495,Cytomeg dna dir probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87496,Cytomeg dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87497,Cytomeg dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87498,Enterovirus probe&revrs trns,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87500,Vanomycin dna amp probe,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Humana Medicaid,CPT,87501,Influenza dna amp prob 1+,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87502,Influenza dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87503,Influenza dna amp prob addl,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Humana Medicaid,CPT,87510,Gardner vag dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87511,Gardner vag dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87512,Gardner vag dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87515,Hepatitis b dna dir probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87516,Hepatitis b dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87517,Hepatitis b dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87520,Hepatitis c rna dir probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87521,Hepatitis c probe&rvrs trnsc,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87522,Hepatitis c revrs trnscrpj,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87525,Hepatitis g dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87526,Hepatitis g dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87527,Hepatitis g dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87528,Hsv dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87529,Hsv dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87530,Hsv dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87531,Hhv-6 dna dir probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87532,Hhv-6 dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87533,Hhv-6 dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87534,Hiv-1 dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87535,Hiv-1 probe&reverse trnscrpj,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87536,Hiv-1 quant&revrse trnscrpj,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87537,Hiv-2 dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87538,Hiv-2 probe&revrse trnscripj,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87539,Hiv-2 quant&revrse trnscripj,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87540,Legion pneumo dna dir prob,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87541,Legion pneumo dna amp prob,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87542,Legion pneumo dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87550,Mycobacteria dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87551,Mycobacteria dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87552,Mycobacteria dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87555,M.tuberculo dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87556,M.tuberculo dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87557,M.tuberculo dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87560,M.avium-intra dna dir prob,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87561,M.avium-intra dna amp prob,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87562,M.avium-intra dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87563,M. genitalium amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87580,M.pneumon dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87581,M.pneumon dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87590,N.gonorrhoeae dna dir prob,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87591,N.gonorrhoeae dna amp prob,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87592,N.gonorrhoeae dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87623,Hpv low-risk types,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87624,Hpv high-risk types,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87625,Hpv types 16 & 18 only,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87634,Rsv dna/rna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87635,Sars-cov-2 covid-19 amp prb,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87636,Sarscov2 & inf a&b amp prb,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87637,Sarscov2&inf a&b&rsv amp prb,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87640,Staph a dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87641,Mr-staph dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87650,Strep a dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87651,Strep a dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87652,Strep a dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87653,Strep b dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87660,Trichomonas vagin dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87661,Trichomonas vaginalis amplif,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87662,Zika virus dna/rna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87797,Detect agent nos dna dir,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87798,Detect agent nos dna amp,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87799,Detect agent nos dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87800,Detect agnt mult dna direc,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87801,Detect agnt mult dna ampli,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87802,Strep b assay w/optic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87803,Clostridium toxin a w/optic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87804,Influenza assay w/optic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87806,Hiv w/hiv1&2 antb w/optic,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87807,Rsv assay w/optic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87808,Trichomonas assay w/optic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87809,Adenovirus assay w/optic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87810,Chylmd trach assay w/optic,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87811,Sars-cov-2 covid19 w/optic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87850,N. gonorrhoeae assay w/optic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87880,Strep a assay w/optic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87899,Agent nos assay w/optic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87904,Phenotype dna hiv w/clt add,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,87905,Sialidase enzyme assay,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,87999,Microbiology procedure,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,88104,Cytopath fl nongyn smears,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,88106,Cytopath fl nongyn filter,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,88108,Cytopath concentrate tech,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,88112,Cytopath cell enhance tech,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,88120,Cytp urne 3-5 probes ea spec,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,88125,Forensic cytopathology,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,88130,Sex chromatin identification,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,88140,Sex chromatin identification,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,88141,Cytopath c/v interpret,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Humana Medicaid,CPT,88142,Cytopath c/v thin layer,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Humana Medicaid,CPT,88143,Cytopath c/v thin layer redo,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Humana Medicaid,CPT,88147,Cytopath c/v automated,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Humana Medicaid,CPT,88148,Cytopath c/v auto rescreen,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Humana Medicaid,CPT,88150,Cytopath c/v manual,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Humana Medicaid,CPT,88152,Cytopath c/v auto redo,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Humana Medicaid,CPT,88153,Cytopath c/v redo,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Humana Medicaid,CPT,88154,Cytopath c/v select,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Humana Medicaid,CPT,88155,Cytopath c/v index add-on,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Humana Medicaid,CPT,88160,Cytopath smear other source,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,88161,Cytopath smear other source,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,88162,Cytopath smear other source,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,88164,Cytopath tbs c/v manual,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Humana Medicaid,CPT,88165,Cytopath tbs c/v redo,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Humana Medicaid,CPT,88166,Cytopath tbs c/v auto redo,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Humana Medicaid,CPT,88167,Cytopath tbs c/v select,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Humana Medicaid,CPT,88172,Cytp dx eval fna 1st ea site,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,88173,Cytopath eval fna report,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,88174,Cytopath c/v auto in fluid,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Humana Medicaid,CPT,88175,Cytopath c/v auto fluid redo,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Humana Medicaid,CPT,88177,Cytp fna eval ea addl,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,88182,Cell marker study,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,88184,Flowcytometry/ tc 1 marker,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,88187,Flowcytometry/read 2-8,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,88188,Flowcytometry/read 9-15,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,88189,Flowcytometry/read 16 & >,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,88199,Cytopathology procedure,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,88240,Cell cryopreserve/storage,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,88241,Frozen cell preparation,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,88245,Chromosome analysis 20-25,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,88248,Chromosome analysis 50-100,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,88249,Chromosome analysis 100,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,88261,Chromosome analysis 5,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,88262,Chromosome analysis 15-20,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,88263,Chromosome analysis 45,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,88264,Chromosome analysis 20-25,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,88267,Chromosome analys placenta,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,88269,Chromosome analys amniotic,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,88271,Cytogenetics dna probe,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,88272,Cytogenetics 3-5,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,88273,Cytogenetics 10-30,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,88274,Cytogenetics 25-99,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,88275,Cytogenetics 100-300,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,88280,Chromosome karyotype study,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,88283,Chromosome banding study,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,88285,Chromosome count additional,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,88289,Chromosome study additional,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,88291,Cyto/molecular report,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,88299,Cytogenetic study,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,88300,Surgical path gross,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,88302,Tissue exam by pathologist,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,88304,Tissue exam by pathologist,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,88305,Tissue exam by pathologist,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,88311,Decalcify tissue,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,88312,Special stains group 1,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,88313,Special stains group 2,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,88314,Histochemical stains add-on,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,88321,Microslide consultation,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,88323,Microslide consultation,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,88325,Comprehensive review of data,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,88329,Path consult introp,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,88331,Path consult intraop 1 bloc,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,88332,Path consult intraop addl,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,88333,Intraop cyto path consult 1,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,88334,Intraop cyto path consult 2,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,88342,Immunohisto antb 1st stain,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,88346,Immunofluor antb 1st stain,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,88347,Immunofluorescent study,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,88355,Analysis skeletal muscle,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,88356,Analysis nerve,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,88358,Analysis tumor,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,88363,Xm archive tissue molec anal,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,88364,Insitu hybridization (fish),Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,88369,M/phmtrc alysishquant/semiq,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,88371,Protein western blot tissue,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,88372,Protein analysis w/probe,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,88373,M/phmtrc alys ishquant/semiq,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,88374,M/phmtrc alys ishquant/semiq,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,88375,Optical endomicroscpy interp,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,88377,M/phmtrc alys ishquant/semiq,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,88380,Microdissection laser,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,88381,Microdissection manual,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,88387,Tiss exam molecular study,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,88388,Tiss ex molecul study add-on,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,88399,Surgical pathology procedure,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,88720,Bilirubin total transcut,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,88738,Hgb quant transcutaneous,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Humana Medicaid,CPT,88740,Transcutaneous carboxyhb,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Humana Medicaid,CPT,88741,Transcutaneous methb,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Humana Medicaid,CPT,88749,In vivo lab service,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,89050,Body fluid cell count,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,89051,Body fluid cell count,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,89055,Leukocyte assessment fecal,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Humana Medicaid,CPT,89060,Exam synovial fluid crystals,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,89125,Specimen fat stain,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,89160,Exam feces for meat fibers,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,89190,Nasal smear for eosinophils,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,89220,Sputum specimen collection,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,89230,Collect sweat for test,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,89240,Pathology lab procedure,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,89250,Cultr oocyte/embryo <4 days,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,89253,Embryo hatching,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,89254,Oocyte identification,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,89255,Prepare embryo for transfer,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,89257,Sperm identification,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,89260,Sperm isolation simple,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,89261,Sperm isolation complex,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,89264,Identify sperm tissue,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,89281,Assist oocyte fertilization,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,89290,Biopsy oocyte polar body,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,89291,Biopsy oocyte polar body,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,89300,Semen analysis w/huhner,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,89310,Semen analysis w/count,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,89320,Semen anal vol/count/mot,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,89321,Semen anal sperm detection,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,89322,Semen anal strict criteria,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,89325,Sperm antibody test,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,89329,Sperm evaluation test,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,89330,Evaluation cervical mucus,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,89331,Retrograde ejaculation anal,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,89335,Cryopreserve testicular tiss,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,89353,Thawing cryopresrved sperm,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,89398,Unlisted reprod med lab proc,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,90287,Botulinum antitoxin,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,90288,Botulism ig iv,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,90291,Cmv ig iv,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,90371,Hep b ig im,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Humana Medicaid,CPT,90375,Rabies ig im/sc,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Humana Medicaid,CPT,90376,Rabies ig heat treated,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Humana Medicaid,CPT,90377,Rabies ig ht&sol human im/sc,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Humana Medicaid,CPT,90378,Rsv mab im 50mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Humana Medicaid,CPT,90384,Rh ig full-dose im,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,90386,Rh ig iv,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Humana Medicaid,CPT,90389,Tetanus ig im,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,90393,Vaccina ig im,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,90396,Varicella-zoster ig im,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,90460,Im admin 1st/only component,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,90461,Im admin each addl component,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,90471,Immunization admin,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,90472,Immunization admin each add,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,90473,Immune admin oral/nasal,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,90474,Immune admin oral/nasal addl,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,90476,Adenovirus vaccine type 4,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90477,Adenovirus vaccine type 7,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90581,Anthrax vaccine sc or im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Humana Medicaid,CPT,90585,Bcg vaccine percut,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90586,Bcg vaccine intravesical,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Humana Medicaid,CPT,90587,Dengue vacc quad 3 dose subq,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Humana Medicaid,CPT,90619,Menacwy-tt vaccine im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Humana Medicaid,CPT,90620,Menb-4c vacc 2 dose im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Humana Medicaid,CPT,90621,Menb-fhbp vacc 2/3 dose im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Humana Medicaid,CPT,90625,Cholera vaccine live oral,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90630,Flu vacc iiv4 no preserv id,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90632,Hepa vaccine adult im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90633,Hepa vacc ped/adol 2 dose im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90634,Hepa vacc ped/adol 3 dose,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90636,Hep a/hep b vacc adult im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Humana Medicaid,CPT,90644,Hib-mency vacc 6wk-18m0 im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Humana Medicaid,CPT,90645,Hib vaccine hboc im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Humana Medicaid,CPT,90646,Hib vaccine prp-d im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Humana Medicaid,CPT,90647,Hib prp-omp vacc 3 dose im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90648,Hib prp-t vaccine 4 dose im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90649,4vhpv vaccine 3 dose im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Humana Medicaid,CPT,90650,2vhpv vaccine 3 dose im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90651,9vhpv vaccine 2/3 dose im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Humana Medicaid,CPT,90653,Iiv adjuvant vaccine im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90654,Flu vacc iiv3 no preserv id,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90655,Iiv3 vacc no prsv 0.25 ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90656,Iiv3 vacc no prsv 0.5 ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90657,Iiv3 vaccine splt 0.25 ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90658,Iiv3 vaccine splt 0.5 ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90660,Laiv3 vaccine intranasal,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90661,Cciiv3 vac no prsv 0.5 ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90662,Iiv no prsv increased ag im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90664,Laiv vacc pandemic intranasl,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90666,Flu vac pandem prsrv free im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90667,Iiv vacc pandemic adjuvt im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90668,Iiv vaccine pandemic im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90669,Pneumococcal vacc 7 val im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Humana Medicaid,CPT,90670,Pcv13 vaccine im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Humana Medicaid,CPT,90672,Laiv4 vaccine intranasal,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90673,Riv3 vaccine no preserv im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90674,Cciiv4 vac no prsv 0.5 ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90675,Rabies vaccine im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Humana Medicaid,CPT,90676,Rabies vaccine id,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Humana Medicaid,CPT,90680,Rv5 vacc 3 dose live oral,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Humana Medicaid,CPT,90681,Rv1 vacc 2 dose live oral,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90682,Riv4 vacc recombinant dna im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90685,Iiv4 vacc no prsv 0.25 ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90686,Iiv4 vacc no prsv 0.5 ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90687,Iiv4 vaccine splt 0.25 ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90688,Iiv4 vaccine splt 0.5 ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90689,Vacc iiv4 no prsrv 0.25ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90690,Typhoid vaccine oral,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90691,Typhoid vaccine im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90692,Typhoid vaccine h-p sc/id,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90693,Typhoid vaccine akd sc,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90694,Vacc aiiv4 no prsrv 0.5ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90696,Dtap-ipv vaccine 4-6 yrs im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90697,Dtap-ipv-hib-hepb vaccine im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90698,Dtap-ipv/hib vaccine im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90700,Dtap vaccine < 7 yrs im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90702,Dt vaccine under 7 yrs im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90703,Tetanus vaccine im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90704,Mumps vaccine sc,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90705,Measles vaccine sc,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90706,Rubella vaccine sc,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90707,Mmr vaccine sc,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90708,Measles-rubella vaccine sc,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90710,Mmrv vaccine sc,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90712,Oral poliovirus vaccine,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Humana Medicaid,CPT,90713,Poliovirus ipv sc/im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90714,Td vacc no presv 7 yrs+ im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90715,Tdap vaccine 7 yrs/> im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90716,Var vaccine live subq,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Humana Medicaid,CPT,90717,Yellow fever vaccine subq,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Humana Medicaid,CPT,90719,Diphtheria vaccine im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90720,Dtp/hib vaccine im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Humana Medicaid,CPT,90721,Dtap/hib vaccine im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Humana Medicaid,CPT,90723,Dtap-hep b-ipv vaccine im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90725,Cholera vaccine injectable,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90727,Plague vaccine im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Humana Medicaid,CPT,90732,Ppsv23 vacc 2 yrs+ subq/im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90733,Mpsv4 vaccine subq,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Humana Medicaid,CPT,90734,Menacwyd/menacwycrm vacc im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Humana Medicaid,CPT,90735,Encephalitis vaccine sc,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Humana Medicaid,CPT,90736,Hzv vaccine live subq,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Humana Medicaid,CPT,90738,Inactivated je vacc im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Humana Medicaid,CPT,90739,Hepb vacc 2 dose adult im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90740,Hepb vacc 3 dose immunsup im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Humana Medicaid,CPT,90743,Hepb vacc 2 dose adolesc im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90744,Hepb vacc 3 dose ped/adol im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90746,Hepb vaccine 3 dose adult im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90747,Hepb vacc 4 dose immunsup im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Humana Medicaid,CPT,90748,Hib-hepb vaccine im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90749,Vaccine toxoid,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90750,Hzv vacc recombinant im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Humana Medicaid,CPT,90756,Cciiv4 vacc abx free im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,90785,Psytx complex interactive,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Humana Medicaid,CPT,90791,Psych diagnostic evaluation,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
Humana Medicaid,CPT,90792,Psych diag eval w/med srvcs,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
Humana Medicaid,CPT,90832,Psytx w pt 30 minutes,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Humana Medicaid,CPT,90833,Psytx w pt w e/m 30 min,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Humana Medicaid,CPT,90834,Psytx w pt 45 minutes,Behavioral Health,Per Unit,$84.55 ,OP,84.55,84.55,,,,,,
Humana Medicaid,CPT,90836,Psytx w pt w e/m 45 min,Behavioral Health,Per Unit,$84.55 ,OP,84.55,84.55,,,,,,
Humana Medicaid,CPT,90837,Psytx w pt 60 minutes,Behavioral Health,Per Unit,$84.55 ,OP,84.55,84.55,,,,,,
Humana Medicaid,CPT,90838,Psytx w pt w e/m 60 min,Behavioral Health,Per Unit,$84.55 ,OP,84.55,84.55,,,,,,
Humana Medicaid,CPT,90839,Psytx crisis initial 60 min,Behavioral Health,Per Unit,$84.55 ,OP,84.55,84.55,,,,,,
Humana Medicaid,CPT,90840,Psytx crisis ea addl 30 min,Behavioral Health,Per Unit,$84.55 ,OP,84.55,84.55,,,,,,
Humana Medicaid,CPT,90845,Psychoanalysis,Behavioral Health,Per Unit,$84.55 ,OP,84.55,84.55,,,,,,
Humana Medicaid,CPT,90846,Family psytx w/o pt 50 min,Behavioral Health,Per Unit,$89.14 ,OP,89.14,89.14,,,,,,
Humana Medicaid,CPT,90847,Family psytx w/pt 50 min,Behavioral Health,Per Unit,$89.14 ,OP,89.14,89.14,,,,,,
Humana Medicaid,CPT,90849,Multiple family group psytx,Behavioral Health,Per Unit,$119.88 ,OP,119.88,119.88,,,,,,
Humana Medicaid,CPT,90853,Group psychotherapy,Behavioral Health,Per Unit,$119.88 ,OP,119.88,119.88,,,,,,
Humana Medicaid,CPT,90863,Pharmacologic mgmt w/psytx,Behavioral Health,Per Unit,$80.13 ,OP,80.13,80.13,,,,,,
Humana Medicaid,CPT,90865,Narcosynthesis,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
Humana Medicaid,CPT,90867,Tcranial magn stim tx plan,Behavioral Health,Per Unit,$276.44 ,OP,276.44,276.44,,,,,,
Humana Medicaid,CPT,90868,Tcranial magn stim tx deli,Behavioral Health,Per Unit,$276.44 ,OP,276.44,276.44,,,,,,
Humana Medicaid,CPT,90869,Tcran magn stim redetemine,Behavioral Health,Per Unit,$276.44 ,OP,276.44,276.44,,,,,,
Humana Medicaid,CPT,90870,Electroconvulsive therapy,Behavioral Health,Per Unit,$276.44 ,OP,276.44,276.44,,,,,,
Humana Medicaid,CPT,90875,Psychophysiological therapy,Ancillary Services,Per Unit,$123.52 ,OP,123.52,123.52,,,,,,
Humana Medicaid,CPT,90876,Psychophysiological therapy,Ancillary Services,Per Unit,$123.52 ,OP,123.52,123.52,,,,,,
Humana Medicaid,CPT,90880,Hypnotherapy,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Humana Medicaid,CPT,90882,Environmental manipulation,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Humana Medicaid,CPT,90885,Psy evaluation of records,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Humana Medicaid,CPT,90887,Consultation with family,Behavioral Health,Per Unit,$89.14 ,OP,89.14,89.14,,,,,,
Humana Medicaid,CPT,90889,Preparation of report,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Humana Medicaid,CPT,90899,Psychiatric service/therapy,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Humana Medicaid,CPT,90901,Biofeedback train any meth,Ancillary Services,Per Unit,$123.52 ,OP,123.52,123.52,,,,,,
Humana Medicaid,CPT,90911,Biofeedback peri/uro/rectal,Ancillary Services,Per Unit,$123.52 ,OP,123.52,123.52,,,,,,
Humana Medicaid,CPT,90912,Bfb training 1st 15 min,Ancillary Services,Per Unit,$123.52 ,OP,123.52,123.52,,,,,,
Humana Medicaid,CPT,90913,Bfb training ea addl 15 min,Ancillary Services,Per Unit,$123.52 ,OP,123.52,123.52,,,,,,
Humana Medicaid,CPT,90935,Hemodialysis one evaluation,Nephrology,Per Unit,$540.95 ,OP,540.95,540.95,,,,,,
Humana Medicaid,CPT,90937,Hemodialysis repeated eval,Nephrology,Per Unit,$540.95 ,OP,540.95,540.95,,,,,,
Humana Medicaid,CPT,90940,Hemodialysis access study,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Humana Medicaid,CPT,90945,Dialysis one evaluation,Nephrology,Per Unit,$540.95 ,OP,540.95,540.95,,,,,,
Humana Medicaid,CPT,90947,Dialysis repeated eval,Nephrology,Per Unit,$540.95 ,OP,540.95,540.95,,,,,,
Humana Medicaid,CPT,90989,Dialysis training complete,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Humana Medicaid,CPT,90993,Dialysis training incompl,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Humana Medicaid,CPT,90997,Hemoperfusion,Nephrology,Per Unit,$540.95 ,OP,540.95,540.95,,,,,,
Humana Medicaid,CPT,90999,Dialysis procedure,Nephrology,Per Unit,$540.95 ,OP,540.95,540.95,,,,,,
Humana Medicaid,CPT,91010,Esophagus motility study,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Humana Medicaid,CPT,91013,Esophgl motil w/stim/perfus,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Humana Medicaid,CPT,91020,Gastric motility studies,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Humana Medicaid,CPT,91022,Duodenal motility study,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Humana Medicaid,CPT,91030,Acid perfusion of esophagus,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Humana Medicaid,CPT,91034,Gastroesophageal reflux test,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Humana Medicaid,CPT,91035,G-esoph reflx tst w/electrod,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Humana Medicaid,CPT,91037,Esoph imped function test,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Humana Medicaid,CPT,91038,Esoph imped funct test > 1hr,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Humana Medicaid,CPT,91040,Esoph balloon distension tst,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Humana Medicaid,CPT,91110,Gi tract capsule endoscopy,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
Humana Medicaid,CPT,91111,Esophageal capsule endoscopy,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Humana Medicaid,CPT,91112,Gi wireless capsule measure,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Humana Medicaid,CPT,91117,Colon motility 6 hr study,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Humana Medicaid,CPT,91120,Rectal sensation test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,91122,Anal pressure record,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,91132,Electrogastrography,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,91133,Electrogastrography w/test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,91200,Liver elastography,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,91299,Gastroenterology procedure,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Humana Medicaid,CPT,91300,Sarscov2 vac 30mcg/0.3ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,91301,Sarscov2 vac 100mcg/0.5ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,91302,Coronavirus vaccine 3,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,91303,Coronavirus vaccine 4,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,91304,Coronavirus vaccine 5,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,91305,Coronavirus vaccine 6,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,91306,Coronavirus vaccine 7,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,91307,Coronavirus vaccine 8,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,91308,Coronavirus vaccine 9,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,91309,Coronavirus vaccine 10,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,91310,Coronavirus vaccine 11,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,92015,Determine refractive state,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92018,New eye exam & treatment,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Humana Medicaid,CPT,92019,Eye exam & treatment,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Humana Medicaid,CPT,92020,Special eye evaluation,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92025,Corneal topography,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92060,Special eye evaluation,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92065,Orthoptic/pleoptic training,Ancillary Services,Per Unit,$123.52 ,OP,123.52,123.52,,,,,,
Humana Medicaid,CPT,92071,Contact lens fitting for tx,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92072,Fit contac lens for managmnt,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92081,Visual field examination(s),Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92082,Visual field examination(s),Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92083,Visual field examination(s),Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92100,Serial tonometry exam(s),Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92132,Cmptr ophth dx img ant segmt,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92133,Cmptr ophth img optic nerve,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92134,Cptr ophth dx img post segmt,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92136,Ophthalmic biometry,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92140,Glaucoma provocative tests,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92145,Corneal hysteresis deter,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92201,Opscpy extnd rta draw uni/bi,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92202,Opscpy extnd on/mac draw,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92225,Special eye exam initial,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92226,Special eye exam subsequent,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92227,Img rta detcj/mntr ds staff,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92228,Img rta detc/mntr ds phy/qhp,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Humana Medicaid,CPT,92229,Img rta detc/mntr ds poc aly,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92230,Eye exam with photos,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Humana Medicaid,CPT,92235,Fluorescein angrph uni/bi,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Humana Medicaid,CPT,92240,Icg angiography uni/bi,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Humana Medicaid,CPT,92242,Fluorescein icg angiography,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Humana Medicaid,CPT,92250,Eye exam with photos,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92260,Ophthalmoscopy/dynamometry,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92265,Eye muscle evaluation,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92270,Electro-oculography,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Humana Medicaid,CPT,92273,Full field erg w/i&r,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Humana Medicaid,CPT,92274,Multifocal erg w/i&r,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Humana Medicaid,CPT,92275,Electroretinography,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Humana Medicaid,CPT,92283,Color vision examination,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92284,Dark adaptation eye exam,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92285,Eye photography,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92286,Internal eye photography,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92287,Internal eye photography,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92310,Contact lens fitting,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92311,Contact lens fitting,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92312,Contact lens fitting,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92313,Contact lens fitting,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92314,Prescription of contact lens,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92315,Rx cntact lens aphakia 1 eye,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92316,Rx cntact lens aphakia 2 eye,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92317,Rx corneoscleral cntact lens,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92325,Modification of contact lens,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92326,Replacement of contact lens,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92340,Fit spectacles monofocal,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92341,Fit spectacles bifocal,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92342,Fit spectacles multifocal,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92352,Fit aphakia spectcl monofocl,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92353,Fit aphakia spectcl multifoc,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92354,Fit spectacles single system,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92355,Fit spectacles compound lens,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92358,Aphakia prosth service temp,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92370,Repair & adjust spectacles,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92371,Repair & adjust spectacles,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92499,Eye service or procedure,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,92507,Speech/hearing therapy,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Humana Medicaid,CPT,92516,Facial nerve function test,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
Humana Medicaid,CPT,92517,Vemp test i&r cervical,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
Humana Medicaid,CPT,92518,Vemp test i&r ocular,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
Humana Medicaid,CPT,92519,Vemp tst i&r cervical&ocular,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
Humana Medicaid,CPT,92520,Laryngeal function studies,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
Humana Medicaid,CPT,92521,Evaluation of speech fluency,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Humana Medicaid,CPT,92522,Evaluate speech production,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Humana Medicaid,CPT,92523,Speech sound lang comprehen,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Humana Medicaid,CPT,92524,Behavral qualit analys voice,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Humana Medicaid,CPT,92534,Optokinetic nystagmus test,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
Humana Medicaid,CPT,92537,Caloric vstblr test w/rec,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
Humana Medicaid,CPT,92538,Caloric vstblr test w/rec,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
Humana Medicaid,CPT,92540,Basic vestibular evaluation,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
Humana Medicaid,CPT,92543,Caloric vestibular test,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
Humana Medicaid,CPT,92546,Sinusoidal rotational test,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
Humana Medicaid,CPT,92547,Supplemental electrical test,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
Humana Medicaid,CPT,92548,Cdp-sot 6 cond w/i&r,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
Humana Medicaid,CPT,92549,Cdp-sot 6 cond w/i&r mct&adt,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
Humana Medicaid,CPT,92550,Tympanometry & reflex thresh,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Humana Medicaid,CPT,92553,Audiometry air & bone,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Humana Medicaid,CPT,92557,Comprehensive hearing test,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Humana Medicaid,CPT,92558,Evoked auditory test qual,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Humana Medicaid,CPT,92570,Acoustic immitance testing,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Humana Medicaid,CPT,92572,Staggered spondaic word test,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Humana Medicaid,CPT,92577,Stenger test speech,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Humana Medicaid,CPT,92579,Visual audiometry (vra),Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Humana Medicaid,CPT,92582,Conditioning play audiometry,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Humana Medicaid,CPT,92584,Electrocochleography,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Humana Medicaid,CPT,92585,Auditor evoke potent compre,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Humana Medicaid,CPT,92586,Auditor evoke potent limit,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Humana Medicaid,CPT,92587,Evoked auditory test limited,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Humana Medicaid,CPT,92588,Evoked auditory tst complete,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Humana Medicaid,CPT,92597,Oral speech device eval,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Humana Medicaid,CPT,92601,Cochlear implt f/up exam <7,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,92602,Reprogram cochlear implt <7,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,92603,Cochlear implt f/up exam 7/>,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,92604,Reprogram cochlear implt 7/>,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,92605,Ex for nonspeech device rx,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Humana Medicaid,CPT,92606,Non-speech device service,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,92607,Ex for speech device rx 1hr,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Humana Medicaid,CPT,92608,Ex for speech device rx addl,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Humana Medicaid,CPT,92610,Evaluate swallowing function,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Humana Medicaid,CPT,92618,Ex for nonspeech dev rx add,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Humana Medicaid,CPT,92620,Auditory function 60 min,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Humana Medicaid,CPT,92621,Auditory function + 15 min,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Humana Medicaid,CPT,92625,Tinnitus assessment,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Humana Medicaid,CPT,92626,Eval aud funcj 1st hour,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Humana Medicaid,CPT,92627,Eval aud funcj ea addl 15,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Humana Medicaid,CPT,92630,Aud rehab pre-ling hear loss,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,92633,Aud rehab postling hear loss,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,92651,Aep hearing status deter i&r,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Humana Medicaid,CPT,92652,Aep thrshld est mlt freq i&r,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Humana Medicaid,CPT,92653,Aep neurodiagnostic i&r,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Humana Medicaid,CPT,92920,Prq cardiac angioplast 1 art,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Humana Medicaid,CPT,92921,Prq cardiac angio addl art,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Humana Medicaid,CPT,92924,Prq card angio/athrect 1 art,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Humana Medicaid,CPT,92925,Prq card angio/athrect addl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Humana Medicaid,CPT,92928,Prq card stent w/angio 1 vsl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Humana Medicaid,CPT,92929,Prq card stent w/angio addl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Humana Medicaid,CPT,92933,Prq card stent/ath/angio,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Humana Medicaid,CPT,92934,Prq card stent/ath/angio,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Humana Medicaid,CPT,92937,Prq revasc byp graft 1 vsl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Humana Medicaid,CPT,92938,Prq revasc byp graft addl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Humana Medicaid,CPT,92941,Prq card revasc mi 1 vsl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Humana Medicaid,CPT,92943,Prq card revasc chronic 1vsl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Humana Medicaid,CPT,92944,Prq card revasc chronic addl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Humana Medicaid,CPT,92950,Heart/lung resuscitation cpr,General Medicine,Per Unit,$385.17 ,OP,385.17,385.17,,,,,,
Humana Medicaid,CPT,92953,Temporary external pacing,Cardiology,Per Unit,$347.43 ,OP,347.43,347.43,,,,,,
Humana Medicaid,CPT,92960,Cardioversion electric ext,Cardiology,Per Unit,$347.43 ,OP,347.43,347.43,,,,,,
Humana Medicaid,CPT,92961,Cardioversion electric int,Cardiology,Per Unit,$347.43 ,OP,347.43,347.43,,,,,,
Humana Medicaid,CPT,92971,Cardioassist external,Cardiology,Per Unit,$347.43 ,OP,347.43,347.43,,,,,,
Humana Medicaid,CPT,92973,Prq coronary mech thrombect,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Humana Medicaid,CPT,92975,Dissolve clot heart vessel,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Humana Medicaid,CPT,92977,Dissolve clot heart vessel,General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
Humana Medicaid,CPT,92978,Endoluminl ivus oct c 1st,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,92979,Endoluminl ivus oct c ea,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,92986,Revision of aortic valve,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Humana Medicaid,CPT,92987,Revision of mitral valve,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Humana Medicaid,CPT,92990,Revision of pulmonary valve,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Humana Medicaid,CPT,92997,Pul art balloon repr percut,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Humana Medicaid,CPT,92998,Pul art balloon repr percut,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Humana Medicaid,CPT,93000,Electrocardiogram complete,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Humana Medicaid,CPT,93005,Electrocardiogram tracing,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Humana Medicaid,CPT,93010,Electrocardiogram report,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Humana Medicaid,CPT,93015,Cardiovascular stress test,Cardiology,Per Unit,$174.07 ,OP,174.07,174.07,,,,,,
Humana Medicaid,CPT,93016,Cardiovascular stress test,Cardiology,Per Unit,$174.07 ,OP,174.07,174.07,,,,,,
Humana Medicaid,CPT,93017,Cardiovascular stress test,Cardiology,Per Unit,$174.07 ,OP,174.07,174.07,,,,,,
Humana Medicaid,CPT,93018,Cardiovascular stress test,Cardiology,Per Unit,$174.07 ,OP,174.07,174.07,,,,,,
Humana Medicaid,CPT,93024,Cardiac drug stress test,Cardiology,Per Unit,$174.07 ,OP,174.07,174.07,,,,,,
Humana Medicaid,CPT,93025,Microvolt t-wave assess,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,93040,Rhythm ecg with report,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Humana Medicaid,CPT,93041,Rhythm ecg tracing,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Humana Medicaid,CPT,93042,Rhythm ecg report,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Humana Medicaid,CPT,93050,Art pressure waveform analys,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,93224,Ecg monit/reprt up to 48 hrs,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,93225,Ecg monit/reprt up to 48 hrs,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,93226,Ecg monit/reprt up to 48 hrs,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,93227,Ecg monit/reprt up to 48 hrs,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,93228,Remote 30 day ecg rev/report,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,93229,Remote 30 day ecg tech supp,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,93241,Ext ecg>48hr<7d rec scan a/r,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,93242,Ext ecg>48hr<7d recording,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,93243,Ext ecg>48hr<7d scan a/r,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,93244,Ext ecg>48hr<7d rev&interpj,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,93245,Ext ecg>7d<15d rec scan a/r,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,93246,Ext ecg>7d<15d recording,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,93247,Ext ecg>7d<15d scan a/r,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,93248,Ext ecg>7d<15d rev&interpj,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,93260,Prgrmg dev eval impltbl sys,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,93261,Interrogate subq defib,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,93264,Rem mntr wrls p-art prs snr,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,93268,Ecg record/review,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,93270,Remote 30 day ecg rev/report,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,93271,Ecg/monitoring and analysis,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,93272,Ecg/review interpret only,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,93278,Ecg/signal-averaged,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Humana Medicaid,CPT,93279,Prgrmg dev eval pm/ldls pm,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,93280,Pm device progr eval dual,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,93281,Pm device progr eval multi,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,93282,Prgrmg eval implantable dfb,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,93283,Prgrmg eval implantable dfb,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,93284,Prgrmg eval implantable dfb,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,93285,Prgrmg dev eval scrms ip,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,93286,Peri-px eval pm/ldls pm ip,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,93287,Peri-px device eval & prgr,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,93288,Interrog evl pm/ldls pm ip,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,93289,Interrog device eval heart,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,93290,Interrog dev eval icpms ip,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,93291,Interrog dev eval scrms ip,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,93292,Wcd device interrogate,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,93293,Pm phone r-strip device eval,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,93294,Rem interrog evl pm/ldls pm,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,93295,Dev interrog remote 1/2/mlt,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,93296,Rem interrog evl pm/ids,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,93297,Rem interrog dev eval icpms,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,93298,Rem interrog dev eval scrms,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,93299,Interrog eval icpms/scrms,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,93303,Echo transthoracic,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Humana Medicaid,CPT,93304,Echo transthoracic,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Humana Medicaid,CPT,93306,Tte w/doppler complete,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Humana Medicaid,CPT,93307,Tte w/o doppler complete,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Humana Medicaid,CPT,93308,Tte f-up or lmtd,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Humana Medicaid,CPT,93312,Echo transesophageal,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Humana Medicaid,CPT,93313,Echo transesophageal,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Humana Medicaid,CPT,93314,Echo transesophageal,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Humana Medicaid,CPT,93315,Echo transesophageal,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Humana Medicaid,CPT,93316,Echo transesophageal,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Humana Medicaid,CPT,93317,Echo transesophageal,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Humana Medicaid,CPT,93318,Echo transesophageal intraop,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Humana Medicaid,CPT,93320,Doppler echo exam heart,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Humana Medicaid,CPT,93321,Doppler echo exam heart,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Humana Medicaid,CPT,93325,Doppler color flow add-on,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,93350,Stress tte only,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Humana Medicaid,CPT,93351,Stress tte complete,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Humana Medicaid,CPT,93352,Admin ecg contrast agent,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Humana Medicaid,CPT,93355,Echo transesophageal (tee),Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Humana Medicaid,CPT,93356,Myocrd strain img spckl trck,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Humana Medicaid,CPT,93451,Right heart cath,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Humana Medicaid,CPT,93452,Left hrt cath w/ventrclgrphy,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Humana Medicaid,CPT,93453,R&l hrt cath w/ventriclgrphy,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Humana Medicaid,CPT,93454,Coronary artery angio s&i,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Humana Medicaid,CPT,93455,Coronary art/grft angio s&i,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Humana Medicaid,CPT,93456,R hrt coronary artery angio,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Humana Medicaid,CPT,93457,R hrt art/grft angio,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Humana Medicaid,CPT,93458,L hrt artery/ventricle angio,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Humana Medicaid,CPT,93459,L hrt art/grft angio,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Humana Medicaid,CPT,93460,R&l hrt art/ventricle angio,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Humana Medicaid,CPT,93461,R&l hrt art/ventricle angio,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Humana Medicaid,CPT,93462,L hrt cath trnsptl puncture,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Humana Medicaid,CPT,93464,Exercise w/hemodynamic meas,Cardiology,Per Unit,$174.07 ,OP,174.07,174.07,,,,,,
Humana Medicaid,CPT,93505,Biopsy of heart lining,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Humana Medicaid,CPT,93530,Rt heart cath congenital,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Humana Medicaid,CPT,93531,R & l heart cath congenital,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Humana Medicaid,CPT,93532,R & l heart cath congenital,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Humana Medicaid,CPT,93533,R & l heart cath congenital,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Humana Medicaid,CPT,93600,Bundle of his recording,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
Humana Medicaid,CPT,93602,Intra-atrial recording,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
Humana Medicaid,CPT,93603,Right ventricular recording,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
Humana Medicaid,CPT,93609,Map tachycardia add-on,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
Humana Medicaid,CPT,93610,Intra-atrial pacing,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
Humana Medicaid,CPT,93612,Intraventricular pacing,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
Humana Medicaid,CPT,93613,Electrophys map 3d add-on,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
Humana Medicaid,CPT,93615,Esophageal recording,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
Humana Medicaid,CPT,93616,Esophageal recording,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
Humana Medicaid,CPT,93618,Heart rhythm pacing,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
Humana Medicaid,CPT,93619,Electrophysiology evaluation,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
Humana Medicaid,CPT,93620,Electrophysiology evaluation,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
Humana Medicaid,CPT,93621,Electrophysiology evaluation,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
Humana Medicaid,CPT,93622,Electrophysiology evaluation,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
Humana Medicaid,CPT,93623,Stimulation pacing heart,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
Humana Medicaid,CPT,93624,Electrophysiologic study,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
Humana Medicaid,CPT,93631,Heart pacing mapping,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
Humana Medicaid,CPT,93640,Evaluation heart device,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
Humana Medicaid,CPT,93641,Electrophysiology evaluation,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
Humana Medicaid,CPT,93642,Electrophysiology evaluation,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
Humana Medicaid,CPT,93644,Electrophysiology evaluation,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
Humana Medicaid,CPT,93650,Ablate heart dysrhythm focus,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
Humana Medicaid,CPT,93653,Ep & ablate supravent arrhyt,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
Humana Medicaid,CPT,93654,Ep & ablate ventric tachy,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
Humana Medicaid,CPT,93655,Ablate arrhythmia add on,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
Humana Medicaid,CPT,93656,Tx atrial fib pulm vein isol,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
Humana Medicaid,CPT,93657,Tx l/r atrial fib addl,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
Humana Medicaid,CPT,93660,Tilt table evaluation,Cardiology,Per Unit,$174.07 ,OP,174.07,174.07,,,,,,
Humana Medicaid,CPT,93662,Intracardiac ecg (ice),Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
Humana Medicaid,CPT,93668,Peripheral vascular rehab,Cardiology,Per Unit,$174.07 ,OP,174.07,174.07,,,,,,
Humana Medicaid,CPT,93701,Bioimpedance cv analysis,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,93702,Bis xtracell fluid analysis,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,93724,Analyze pacemaker system,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Humana Medicaid,CPT,93745,Set-up cardiovert-defibrill,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,93750,Interrogation vad in person,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,93770,Measure venous pressure,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,93784,Ambl bp mntr w/software,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,93786,Ambl bp mntr w/sw rec only,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,93788,Ambl bp mntr w/sw a/r,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,93790,Ambl bp mntr w/sw i&r,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,93792,Pt/caregiver traing home inr,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Humana Medicaid,CPT,93793,Anticoag mgmt pt warfarin,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,93797,Cardiac rehab,Rehabilitation,Per Unit,$274.82 ,OP,274.82,274.82,,,,,,
Humana Medicaid,CPT,93798,Cardiac rehab/monitor,Rehabilitation,Per Unit,$274.82 ,OP,274.82,274.82,,,,,,
Humana Medicaid,CPT,93799,Cardiovascular procedure,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Humana Medicaid,CPT,93880,Extracranial bilat study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,93882,Extracranial uni/ltd study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,93886,Intracranial complete study,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Humana Medicaid,CPT,93888,Intracranial limited study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,93890,Tcd vasoreactivity study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,93892,Tcd emboli detect w/o inj,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Humana Medicaid,CPT,93893,Tcd emboli detect w/inj,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,93895,Carotid intima atheroma eval,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,93922,Upr/l xtremity art 2 levels,Cardiology,Per Unit,$174.07 ,OP,174.07,174.07,,,,,,
Humana Medicaid,CPT,93923,Upr/lxtr art stdy 3+ lvls,Cardiology,Per Unit,$174.07 ,OP,174.07,174.07,,,,,,
Humana Medicaid,CPT,93924,Lwr xtr vasc stdy bilat,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,93925,Lower extremity study,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Humana Medicaid,CPT,93926,Lower extremity study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,93930,Upper extremity study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,93931,Upper extremity study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,93965,Extremity study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,93970,Extremity study,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Humana Medicaid,CPT,93971,Extremity study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,93975,Vascular study,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Humana Medicaid,CPT,93976,Vascular study,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Humana Medicaid,CPT,93978,Vascular study,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Humana Medicaid,CPT,93979,Vascular study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,93980,Penile vascular study,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Humana Medicaid,CPT,93981,Penile vascular study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,93982,Aneurysm pressure sens study,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,93985,Dup-scan hemo compl bi std,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,93986,Dup-scan hemo compl uni std,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,93990,Doppler flow testing,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,93998,Noninvas vasc dx study proc,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,94002,Vent mgmt inpat init day,Pulmonary,Per Unit,$417.61 ,OP,417.61,417.61,,,,,,
Humana Medicaid,CPT,94003,Vent mgmt inpat subq day,Pulmonary,Per Unit,$417.61 ,OP,417.61,417.61,,,,,,
Humana Medicaid,CPT,94004,Vent mgmt nf per day,Pulmonary,Per Unit,$417.61 ,OP,417.61,417.61,,,,,,
Humana Medicaid,CPT,94005,Home vent mgmt supervision,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,94010,Breathing capacity test,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Humana Medicaid,CPT,94011,Spirometry up to 2 yrs old,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Humana Medicaid,CPT,94012,Spirmtry w/brnchdil inf-2 yr,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Humana Medicaid,CPT,94013,Meas lung vol thru 2 yrs,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Humana Medicaid,CPT,94014,Patient recorded spirometry,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Humana Medicaid,CPT,94015,Patient recorded spirometry,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Humana Medicaid,CPT,94016,Review patient spirometry,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Humana Medicaid,CPT,94060,Evaluation of wheezing,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Humana Medicaid,CPT,94070,Evaluation of wheezing,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Humana Medicaid,CPT,94150,Vital capacity test,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Humana Medicaid,CPT,94200,Lung function test (mbc/mvv),Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Humana Medicaid,CPT,94250,Expired gas collection,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Humana Medicaid,CPT,94375,Respiratory flow volume loop,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Humana Medicaid,CPT,94400,Co2 breathing response curve,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Humana Medicaid,CPT,94450,Hypoxia response curve,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Humana Medicaid,CPT,94452,Hast w/report,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Humana Medicaid,CPT,94453,Hast w/oxygen titrate,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Humana Medicaid,CPT,94610,Surfactant admin thru tube,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
Humana Medicaid,CPT,94617,Exercise tst brncspsm w/ecg,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Humana Medicaid,CPT,94618,Pulmonary stress testing,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Humana Medicaid,CPT,94619,Exercise tst brncspsm wo ecg,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Humana Medicaid,CPT,94620,Pulmonary stress test/simple,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Humana Medicaid,CPT,94621,Cardiopulm exercise testing,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Humana Medicaid,CPT,94640,Airway inhalation treatment,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
Humana Medicaid,CPT,94642,Aerosol inhalation treatment,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
Humana Medicaid,CPT,94644,Cbt 1st hour,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
Humana Medicaid,CPT,94645,Cbt each addl hour,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
Humana Medicaid,CPT,94660,Pos airway pressure cpap,Pulmonary,Per Unit,$417.61 ,OP,417.61,417.61,,,,,,
Humana Medicaid,CPT,94662,Neg press ventilation cnp,Pulmonary,Per Unit,$417.61 ,OP,417.61,417.61,,,,,,
Humana Medicaid,CPT,94664,Evaluate pt use of inhaler,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
Humana Medicaid,CPT,94667,Chest wall manipulation,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
Humana Medicaid,CPT,94668,Chest wall manipulation,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
Humana Medicaid,CPT,94669,Mechanical chest wall oscill,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
Humana Medicaid,CPT,94680,Exhaled air analysis o2,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Humana Medicaid,CPT,94681,Exhaled air analysis o2/co2,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Humana Medicaid,CPT,94690,Exhaled air analysis,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Humana Medicaid,CPT,94726,Pulm funct tst plethysmograp,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Humana Medicaid,CPT,94727,Pulm function test by gas,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Humana Medicaid,CPT,94728,Airwy resist by oscillometry,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Humana Medicaid,CPT,94729,Co/membane diffuse capacity,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Humana Medicaid,CPT,94750,Pulmonary compliance study,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Humana Medicaid,CPT,94762,Measure blood oxygen level,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Humana Medicaid,CPT,94770,Exhaled carbon dioxide test,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Humana Medicaid,CPT,94772,Breath recording infant,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Humana Medicaid,CPT,94774,Ped home apnea rec compl,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Humana Medicaid,CPT,94775,Ped home apnea rec hk-up,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Humana Medicaid,CPT,94776,Ped home apnea rec downld,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Humana Medicaid,CPT,94777,Ped home apnea rec report,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Humana Medicaid,CPT,94780,Cars/bd tst inft-12mo 60 min,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Humana Medicaid,CPT,94781,Cars/bd tst inft-12mo +30min,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Humana Medicaid,CPT,94799,Pulmonary service/procedure,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Humana Medicaid,CPT,95004,Percut allergy skin tests,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
Humana Medicaid,CPT,95012,Exhaled nitric oxide meas,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Humana Medicaid,CPT,95017,Perq & icut allg test venoms,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
Humana Medicaid,CPT,95018,Perq&ic allg test drugs/biol,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
Humana Medicaid,CPT,95024,Icut allergy test drug/bug,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
Humana Medicaid,CPT,95027,Icut allergy titrate-airborn,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
Humana Medicaid,CPT,95028,Icut allergy test-delayed,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
Humana Medicaid,CPT,95044,Allergy patch tests,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
Humana Medicaid,CPT,95052,Photo patch test,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
Humana Medicaid,CPT,95056,Photosensitivity tests,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
Humana Medicaid,CPT,95060,Eye allergy tests,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
Humana Medicaid,CPT,95065,Nose allergy test,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
Humana Medicaid,CPT,95070,Bronchial allergy tests,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
Humana Medicaid,CPT,95071,Bronchial allergy tests,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
Humana Medicaid,CPT,95076,Ingest challenge ini 120 min,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Humana Medicaid,CPT,95079,Ingest challenge addl 60 min,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Humana Medicaid,CPT,95115,Immunotherapy one injection,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Humana Medicaid,CPT,95117,Immunotherapy injections,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Humana Medicaid,CPT,95120,Immunotherapy one injection,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Humana Medicaid,CPT,95125,Immunotherapy 2/> injections,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Humana Medicaid,CPT,95130,Immntx 1 sting insect,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Humana Medicaid,CPT,95131,Immntx 2 sting insects,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Humana Medicaid,CPT,95132,Immntx 3 sting insects,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Humana Medicaid,CPT,95133,Immntx 4 sting insects,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Humana Medicaid,CPT,95134,Immntx 5 sting insects,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Humana Medicaid,CPT,95144,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Humana Medicaid,CPT,95145,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Humana Medicaid,CPT,95146,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Humana Medicaid,CPT,95147,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Humana Medicaid,CPT,95148,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Humana Medicaid,CPT,95149,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Humana Medicaid,CPT,95165,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Humana Medicaid,CPT,95170,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Humana Medicaid,CPT,95180,Rapid desensitization,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
Humana Medicaid,CPT,95199,Allergy immunology services,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
Humana Medicaid,CPT,95249,Cont gluc mntr pt prov eqp,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,95250,Cont gluc mntr phys/qhp eqp,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,95251,Cont gluc mntr analysis i&r,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,95700,Eeg cont rec w/vid eeg tech,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Humana Medicaid,CPT,95705,Eeg w/o vid 2-12 hr unmntr,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Humana Medicaid,CPT,95706,Eeg wo vid 2-12hr intmt mntr,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Humana Medicaid,CPT,95707,Eeg w/o vid 2-12hr cont mntr,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Humana Medicaid,CPT,95708,Eeg wo vid ea 12-26hr unmntr,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Humana Medicaid,CPT,95709,Eeg w/o vid ea 12-26hr intmt,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Humana Medicaid,CPT,95710,Eeg w/o vid ea 12-26hr cont,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Humana Medicaid,CPT,95711,Veeg 2-12 hr unmonitored,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Humana Medicaid,CPT,95712,Veeg 2-12 hr intmt mntr,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Humana Medicaid,CPT,95713,Veeg 2-12 hr cont mntr,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Humana Medicaid,CPT,95714,Veeg ea 12-26 hr unmntr,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Humana Medicaid,CPT,95715,Veeg ea 12-26hr intmt mntr,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Humana Medicaid,CPT,95716,Veeg ea 12-26hr cont mntr,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Humana Medicaid,CPT,95717,Eeg phys/qhp 2-12 hr w/o vid,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Humana Medicaid,CPT,95718,Eeg phys/qhp 2-12 hr w/veeg,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Humana Medicaid,CPT,95719,Eeg phys/qhp ea incr w/o vid,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Humana Medicaid,CPT,95720,Eeg phy/qhp ea incr w/veeg,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Humana Medicaid,CPT,95721,Eeg phy/qhp>36<60 hr w/o vid,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Humana Medicaid,CPT,95722,Eeg phy/qhp>36<60 hr w/veeg,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Humana Medicaid,CPT,95723,Eeg phy/qhp>60<84 hr w/o vid,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Humana Medicaid,CPT,95724,Eeg phy/qhp>60<84 hr w/veeg,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Humana Medicaid,CPT,95725,Eeg phy/qhp>84 hr w/o vid,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Humana Medicaid,CPT,95726,Eeg phy/qhp>84 hr w/veeg,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Humana Medicaid,CPT,95782,Polysom <6 yrs 4/> paramtrs,Pulmonary,Per Unit,$437.56 ,OP,437.56,437.56,,,,,,
Humana Medicaid,CPT,95783,Polysom <6 yrs cpap/bilvl,Pulmonary,Per Unit,$437.56 ,OP,437.56,437.56,,,,,,
Humana Medicaid,CPT,95803,Actigraphy testing,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,95805,Multiple sleep latency test,Pulmonary,Per Unit,$437.56 ,OP,437.56,437.56,,,,,,
Humana Medicaid,CPT,95807,Sleep study attended,Pulmonary,Per Unit,$437.56 ,OP,437.56,437.56,,,,,,
Humana Medicaid,CPT,95808,Polysom any age 1-3> param,Pulmonary,Per Unit,$437.56 ,OP,437.56,437.56,,,,,,
Humana Medicaid,CPT,95810,Polysom 6/> yrs 4/> param,Pulmonary,Per Unit,$437.56 ,OP,437.56,437.56,,,,,,
Humana Medicaid,CPT,95811,Polysom 6/>yrs cpap 4/> parm,Pulmonary,Per Unit,$437.56 ,OP,437.56,437.56,,,,,,
Humana Medicaid,CPT,95812,Eeg 41-60 minutes,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Humana Medicaid,CPT,95813,Eeg extnd mntr 61-119 min,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Humana Medicaid,CPT,95816,Eeg awake and drowsy,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Humana Medicaid,CPT,95819,Eeg awake and asleep,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Humana Medicaid,CPT,95822,Eeg coma or sleep only,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Humana Medicaid,CPT,95824,Eeg cerebral death only,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Humana Medicaid,CPT,95827,Eeg all night recording,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Humana Medicaid,CPT,95829,Surgery electrocorticogram,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Humana Medicaid,CPT,95836,Ecog impltd brn npgt <30 d,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Humana Medicaid,CPT,95857,Cholinesterase challenge,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,95860,Muscle test one limb,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,95861,Muscle test 2 limbs,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,95863,Muscle test 3 limbs,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,95864,Muscle test 4 limbs,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,95865,Muscle test larynx,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,95866,Muscle test hemidiaphragm,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,95867,Muscle test cran nerv unilat,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,95868,Muscle test cran nerve bilat,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,95869,Muscle test thor paraspinal,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,95870,Muscle test nonparaspinal,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,95872,Muscle test one fiber,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,95873,Guide nerv destr elec stim,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Humana Medicaid,CPT,95874,Guide nerv destr needle emg,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Humana Medicaid,CPT,95875,Limb exercise test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,95885,Musc tst done w/nerv tst lim,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,95886,Musc test done w/n test comp,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,95887,Musc tst done w/n tst nonext,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,95905,Motor &/ sens nrve cndj test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,95907,Nvr cndj tst 1-2 studies,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,95908,Nrv cndj tst 3-4 studies,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,95909,Nrv cndj tst 5-6 studies,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,95910,Nrv cndj test 7-8 studies,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,95911,Nrv cndj test 9-10 studies,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,95912,Nrv cndj test 11-12 studies,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,95913,Nrv cndj test 13/> studies,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,95921,Autonomic nrv parasym inervj,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,95922,Autonomic nrv adrenrg inervj,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,95923,Autonomic nrv syst funj test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,95924,Ans parasymp & symp w/tilt,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,95925,Somatosensory testing,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,95926,Somatosensory testing,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,95927,Somatosensory testing,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,95928,C motor evoked uppr limbs,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,95929,C motor evoked lwr limbs,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,95930,Visual ep test cns w/i&r,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,95933,Blink reflex test,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,95937,Neuromuscular junction test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,95938,Somatosensory testing,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,95939,C motor evoked upr&lwr limbs,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,95943,Parasymp&symp hrt rate test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,95950,Ambulatory eeg monitoring,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Humana Medicaid,CPT,95951,Eeg monitoring/videorecord,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Humana Medicaid,CPT,95953,Eeg monitoring/computer,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Humana Medicaid,CPT,95954,Eeg monitoring/giving drugs,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Humana Medicaid,CPT,95955,Eeg during surgery,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Humana Medicaid,CPT,95956,Eeg monitor technol attended,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Humana Medicaid,CPT,95957,Eeg digital analysis,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,95958,Eeg monitoring/function test,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Humana Medicaid,CPT,95965,Meg spontaneous,Diagnostic Radiology,Per Unit,$221.34 ,OP,221.34,221.34,,,,,,
Humana Medicaid,CPT,95966,Meg evoked single,Diagnostic Radiology,Per Unit,$221.34 ,OP,221.34,221.34,,,,,,
Humana Medicaid,CPT,95967,Meg evoked each addl,Diagnostic Radiology,Per Unit,$221.34 ,OP,221.34,221.34,,,,,,
Humana Medicaid,CPT,95970,Alys npgt w/o prgrmg,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Humana Medicaid,CPT,95971,Alys smpl sp/pn npgt w/prgrm,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Humana Medicaid,CPT,95972,Alys cplx sp/pn npgt w/prgrm,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Humana Medicaid,CPT,95973,Analyze neurostim complex,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Humana Medicaid,CPT,95974,Cranial neurostim complex,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Humana Medicaid,CPT,95975,Cranial neurostim complex,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Humana Medicaid,CPT,95976,Alys smpl cn npgt prgrmg,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Humana Medicaid,CPT,95977,Alys cplx cn npgt prgrmg,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Humana Medicaid,CPT,95978,Analyze neurostim brain/1h,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Humana Medicaid,CPT,95979,Analyz neurostim brain addon,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Humana Medicaid,CPT,95980,Io anal gast n-stim init,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Humana Medicaid,CPT,95981,Io anal gast n-stim subsq,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,95982,Io ga n-stim subsq w/reprog,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,95983,Alys brn npgt prgrmg 15 min,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Humana Medicaid,CPT,95984,Alys brn npgt prgrmg addl 15,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Humana Medicaid,CPT,95999,Neurological procedure,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Humana Medicaid,CPT,96000,Motion analysis video/3d,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,96001,Motion test w/ft press meas,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,96002,Dynamic surface emg,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,96003,Dynamic fine wire emg,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,96020,Functional brain mapping,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Humana Medicaid,CPT,96101,Psycho testing by psych/phys,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Humana Medicaid,CPT,96102,Psycho testing by technician,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Humana Medicaid,CPT,96103,Psycho testing admin by comp,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Humana Medicaid,CPT,96105,Assessment of aphasia,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Humana Medicaid,CPT,96110,Developmental screen w/score,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Humana Medicaid,CPT,96111,Developmental test extend,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Humana Medicaid,CPT,96112,Devel tst phys/qhp 1st hr,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Humana Medicaid,CPT,96113,Devel tst phys/qhp ea addl,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Humana Medicaid,CPT,96116,Nubhvl xm phys/qhp 1st hr,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Humana Medicaid,CPT,96118,Neuropsych tst by psych/phys,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Humana Medicaid,CPT,96119,Neuropsych testing by tec,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Humana Medicaid,CPT,96120,Neuropsych tst admin w/comp,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Humana Medicaid,CPT,96121,Nubhvl xm phy/qhp ea addl hr,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Humana Medicaid,CPT,96125,Cognitive test by hc pro,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Humana Medicaid,CPT,96127,Brief emotional/behav assmt,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Humana Medicaid,CPT,96130,Psycl tst eval phys/qhp 1st,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Humana Medicaid,CPT,96131,Psycl tst eval phys/qhp ea,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Humana Medicaid,CPT,96132,Nrpsyc tst eval phys/qhp 1st,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Humana Medicaid,CPT,96133,Nrpsyc tst eval phys/qhp ea,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Humana Medicaid,CPT,96136,Psycl/nrpsyc tst phy/qhp 1st,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Humana Medicaid,CPT,96137,Psycl/nrpsyc tst phy/qhp ea,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Humana Medicaid,CPT,96138,Psycl/nrpsyc tech 1st,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Humana Medicaid,CPT,96139,Psycl/nrpsyc tst tech ea,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Humana Medicaid,CPT,96146,Psycl/nrpsyc tst auto result,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Humana Medicaid,CPT,96150,Assess hlth/behave init,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
Humana Medicaid,CPT,96151,Assess hlth/behave subseq,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
Humana Medicaid,CPT,96153,Intervene hlth/behave group,Behavioral Health,Per Unit,$119.88 ,OP,119.88,119.88,,,,,,
Humana Medicaid,CPT,96154,Interv hlth/behav fam w/pt,Behavioral Health,Per Unit,$89.14 ,OP,89.14,89.14,,,,,,
Humana Medicaid,CPT,96155,Interv hlth/behav fam no pt,Behavioral Health,Per Unit,$89.14 ,OP,89.14,89.14,,,,,,
Humana Medicaid,CPT,96156,Hlth bhv assmt/reassessment,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
Humana Medicaid,CPT,96160,Pt-focused hlth risk assmt,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Humana Medicaid,CPT,96161,Caregiver health risk assmt,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Humana Medicaid,CPT,96360,Hydration iv infusion init,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Humana Medicaid,CPT,96361,Hydrate iv infusion add-on,General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
Humana Medicaid,CPT,96365,Ther/proph/diag iv inf init,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Humana Medicaid,CPT,96366,Ther/proph/diag iv inf addon,General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
Humana Medicaid,CPT,96367,Tx/proph/dg addl seq iv inf,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Humana Medicaid,CPT,96368,Ther/diag concurrent inf,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Humana Medicaid,CPT,96369,Sc ther infusion up to 1 hr,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Humana Medicaid,CPT,96370,Sc ther infusion addl hr,General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
Humana Medicaid,CPT,96371,Sc ther infusion reset pump,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Humana Medicaid,CPT,96413,Chemo iv infusion 1 hr,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Humana Medicaid,CPT,96415,Chemo iv infusion addl hr,General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
Humana Medicaid,CPT,96416,Chemo prolong infuse w/pump,General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
Humana Medicaid,CPT,96417,Chemo iv infus each addl seq,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Humana Medicaid,CPT,96422,Chemo ia infusion up to 1 hr,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Humana Medicaid,CPT,96423,Chemo ia infuse each addl hr,General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
Humana Medicaid,CPT,96425,Chemotherapy infusion method,General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
Humana Medicaid,CPT,96446,Chemotx admn prtl cavity,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Humana Medicaid,CPT,96450,Chemotherapy into cns,General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
Humana Medicaid,CPT,96549,Chemotherapy unspecified,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Humana Medicaid,CPT,96567,Pdt dstr prmlg les skn,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,96570,Photodynmc tx 30 min add-on,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,96571,Photodynamic tx addl 15 min,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,96573,Pdt dstr prmlg les phys/qhp,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,96574,Dbrdmt prmlg les w/pdt,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,96900,Ultraviolet light therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,96902,Trichogram,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,96913,Photochemotherapy uv-a or b,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,96920,Laser tx skin < 250 sq cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,96921,Laser tx skin 250-500 sq cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,96922,Laser tx skin >500 sq cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,96931,Rcm celulr subcelulr img skn,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,96932,Rcm celulr subcelulr img skn,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,96933,Rcm celulr subcelulr img skn,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,96934,Rcm celulr subcelulr img skn,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,96935,Rcm celulr subcelulr img skn,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,96936,Rcm celulr subcelulr img skn,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,96999,Dermatological procedure,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,97001,Pt evaluation,Rehabilitation,Per Unit,$192.71 ,OP,192.71,192.71,,,,,,
Humana Medicaid,CPT,97002,Pt re-evaluation,Rehabilitation,Per Unit,$192.71 ,OP,192.71,192.71,,,,,,
Humana Medicaid,CPT,97003,Ot evaluation,Rehabilitation,Per Unit,$306.55 ,OP,306.55,306.55,,,,,,
Humana Medicaid,CPT,97004,Ot re-evaluation,Rehabilitation,Per Unit,$306.55 ,OP,306.55,306.55,,,,,,
Humana Medicaid,CPT,97010,Hot or cold packs therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,97012,Mechanical traction therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,97014,Electric stimulation therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,97016,Vasopneumatic device therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,97018,Paraffin bath therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,97022,Whirlpool therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,97024,Diathermy eg microwave,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,97026,Infrared therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,97028,Ultraviolet therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,97032,Electrical stimulation,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,97033,Electric current therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,97034,Contrast bath therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,97035,Ultrasound therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,97039,Physical therapy treatment,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,97116,Gait training therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,97124,Massage therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,97139,Physical medicine procedure,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,97161,Pt eval low complex 20 min,Rehabilitation,Per Unit,$192.71 ,OP,192.71,192.71,,,,,,
Humana Medicaid,CPT,97162,Pt eval mod complex 30 min,Rehabilitation,Per Unit,$192.71 ,OP,192.71,192.71,,,,,,
Humana Medicaid,CPT,97163,Pt eval high complex 45 min,Rehabilitation,Per Unit,$192.71 ,OP,192.71,192.71,,,,,,
Humana Medicaid,CPT,97164,Pt re-eval est plan care,Rehabilitation,Per Unit,$192.71 ,OP,192.71,192.71,,,,,,
Humana Medicaid,CPT,97165,Ot eval low complex 30 min,Rehabilitation,Per Unit,$306.55 ,OP,306.55,306.55,,,,,,
Humana Medicaid,CPT,97166,Ot eval mod complex 45 min,Rehabilitation,Per Unit,$306.55 ,OP,306.55,306.55,,,,,,
Humana Medicaid,CPT,97167,Ot eval high complex 60 min,Rehabilitation,Per Unit,$306.55 ,OP,306.55,306.55,,,,,,
Humana Medicaid,CPT,97168,Ot re-eval est plan care,Rehabilitation,Per Unit,$306.55 ,OP,306.55,306.55,,,,,,
Humana Medicaid,CPT,97535,Self care mngment training,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,97545,Work hardening,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,97546,Work hardening add-on,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,97755,Assistive technology assess,Rehabilitation,Per Unit,$192.71 ,OP,192.71,192.71,,,,,,
Humana Medicaid,CPT,97762,C/o for orthotic/prosth use,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,97799,Physical medicine procedure,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,97802,Medical nutrition indiv in,Ancillary Services,Per Unit,$100.15 ,OP,100.15,100.15,,,,,,
Humana Medicaid,CPT,97803,Med nutrition indiv subseq,Ancillary Services,Per Unit,$100.15 ,OP,100.15,100.15,,,,,,
Humana Medicaid,CPT,97804,Medical nutrition group,Ancillary Services,Per Unit,$100.15 ,OP,100.15,100.15,,,,,,
Humana Medicaid,CPT,97810,Acupunct w/o stimul 15 min,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,97811,Acupunct w/o stimul addl 15m,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,97813,Acupunct w/stimul 15 min,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,97814,Acupunct w/stimul addl 15m,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,98925,Osteopath manj 1-2 regions,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,98926,Osteopath manj 3-4 regions,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,98927,Osteopath manj 5-6 regions,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,98928,Osteopath manj 7-8 regions,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,98929,Osteopath manj 9-10 regions,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,98940,Chiropract manj 1-2 regions,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,98941,Chiropract manj 3-4 regions,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,98942,Chiropractic manj 5 regions,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,98943,Chiropract manj xtrspinl 1/>,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,98960,Self-mgmt educ & train 1 pt,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Humana Medicaid,CPT,98961,Self-mgmt educ/train 2-4 pt,Preventive Care,Per Unit,$26.23 ,OP,26.23,26.23,,,,,,
Humana Medicaid,CPT,98962,Self-mgmt educ/train 5-8 pt,Preventive Care,Per Unit,$26.23 ,OP,26.23,26.23,,,,,,
Humana Medicaid,CPT,99050,Medical services after hrs,Ancillary Services,Per Unit,$26.19 ,OP,26.19,26.19,,,,,,
Humana Medicaid,CPT,99051,Med serv eve/wkend/holiday,Ancillary Services,Per Unit,$26.19 ,OP,26.19,26.19,,,,,,
Humana Medicaid,CPT,99053,Med serv 10pm-8am 24 hr fac,Ancillary Services,Per Unit,$26.19 ,OP,26.19,26.19,,,,,,
Humana Medicaid,CPT,99058,Office emergency care,Ancillary Services,Per Unit,$26.19 ,OP,26.19,26.19,,,,,,
Humana Medicaid,CPT,99060,Out of office emerg med serv,Ancillary Services,Per Unit,$26.19 ,OP,26.19,26.19,,,,,,
Humana Medicaid,CPT,99078,Group health education,Preventive Care,Per Unit,$26.23 ,OP,26.23,26.23,,,,,,
Humana Medicaid,CPT,99091,Collj & interpj data ea 30 d,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,99100,Special anesthesia service,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,99116,Anesthesia with hypothermia,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,99135,Special anesthesia procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,99140,Emergency anesthesia,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,99143,Mod sedat phys/qhp <5 yrs,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,99144,Mod sedat phys/qhp 5yrs/>,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,99145,Mod sedat phys/qhp ea 15 min,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,99148,Mod sed diff phys/qhp<5 yrs,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,99149,Mod sed diff phys/qhp 5/>yrs,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,99150,Mod sed diff phys/qhp add on,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,99151,Mod sed same phys/qhp <5 yrs,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,99152,Mod sed same phys/qhp 5/>yrs,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,99153,Mod sed same phys/qhp ea,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,99155,Mod sed oth phys/qhp <5 yrs,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,99156,Mod sed oth phys/qhp 5/>yrs,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,99157,Mod sed other phys/qhp ea,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,99172,Ocular function screen,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,99173,Visual acuity screen,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,99174,Ocular instrumnt screen bil,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,99175,Induction of vomiting,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Humana Medicaid,CPT,99177,Ocular instrumnt screen bil,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,99188,App topical fluoride varnish,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Humana Medicaid,CPT,99238,Hospital discharge day,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,99239,Hospital discharge day,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,99363,Anticoagulant mgmt initial,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,99364,Anticoagulant mgmt subseq,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,99366,Team conf w/pat by hc prof,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,99367,Team conf w/o pat by phys,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,99368,Team conf w/o pat by hc pro,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,99374,Home health care supervision,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,99375,Home health care supervision,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,99377,Hospice care supervision,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,99378,Hospice care supervision,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,99379,Nursing fac care supervision,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,99380,Nursing fac care supervision,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,99406,Behav chng smoking 3-10 min,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Humana Medicaid,CPT,99407,Behav chng smoking > 10 min,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Humana Medicaid,CPT,99408,Audit/dast 15-30 min,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Humana Medicaid,CPT,99409,Audit/dast over 30 min,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Humana Medicaid,CPT,99439,Chrnc care mgmt svc ea addl,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,99453,Rem mntr physiol param setup,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Humana Medicaid,CPT,99454,Rem mntr physiol param dev,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,99457,Rem physiol mntr 1st 20 min,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,99458,Rem physiol mntr ea addl 20,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,99465,Nb resuscitation,General Medicine,Per Unit,$385.17 ,OP,385.17,385.17,,,,,,
Humana Medicaid,CPT,99473,Self-meas bp pt educaj/train,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,99474,Self-meas bp 2 readg bid 30d,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,99483,Assmt & care pln pt cog imp,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Humana Medicaid,CPT,99484,Care mgmt svc bhvl hlth cond,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Humana Medicaid,CPT,99487,Cplx chrnc care 1st 60 min,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,99489,Cplx chrnc care ea addl 30,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,99490,Chrnc care mgmt svc 1st 20,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,99491,Chrnc care mgmt svc 30 min,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,99492,1st psyc collab care mgmt,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Humana Medicaid,CPT,99493,Sbsq psyc collab care mgmt,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Humana Medicaid,CPT,99494,1st/sbsq psyc collab care,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Humana Medicaid,CPT,99495,Trans care mgmt 14 day disch,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,99496,Trans care mgmt 7 day disch,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,99497,Advncd care plan 30 min,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,99498,Advncd care plan addl 30 min,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,99503,Home visit resp therapy,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
Humana Medicaid,CPT,99504,Home visit mech ventilator,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
Humana Medicaid,CPT,0001A,Adm sarscov2 30mcg/0.3ml 1st,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,0001M,Nfct ds chrnc hcv 6 assays,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,0001U,Rbc dna hea 35 ag 11 bld grp,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0002A,Adm sarscov2 30mcg/0.3ml 2nd,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,0002M,Liver dis 10 assays w/ash,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0002U,Onc clrct 3 ur metab alg plp,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0003A,Fee covid-19 vac 1 booster,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,0003M,Liver dis 10 assays w/nash,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0003U,Onc ovar 5 prtn ser alg scor,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0004A,Fee covid-19 vac 1 res,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,0004M,Scoliosis dna alys,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0004U,Nfct ds dna 27 resist genes,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0005U,Onco prst8 3 gene ur alg,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0006M,Onc hep gene risk classifier,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0006U,Detc ia meds 120+ analytes,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,0007M,Onc gastro 51 gene nomogram,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,0008M,Onc breast risk score,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0008U,Hpylori detcj abx rstnc dna,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Humana Medicaid,CPT,0009M,Fetal aneuploidy trisom risk,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0009U,Onc brst ca erbb2 amp/nonamp,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0010M,Onc prostate prob score,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0010U,Nfct ds strn typ whl gen seq,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0011A,Adm sarscov2 100mcg/0.5ml1st,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,0011M,Onc prst8 ca mrna 12 gen alg,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0011U,Rx mntr lc-ms/ms oral fluid,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,0012A,Adm sarscov2 100mcg/0.5ml2nd,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,0012M,Onc mrna 5 gen rsk urthl ca,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0012U,Germln do gene reargmt detcj,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0013A,Fee covid-19 vac 2 booster,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,0013M,Onc mrna 5 gen recr urthl ca,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0013U,Onc sld org neo gene reargmt,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0014A,Fee covid-19 vac 2 res,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,0014M,Liver ds alys 3 bmrk srm alg,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0014U,Hem hmtlmf neo gene reargmt,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0015M,Adrnl cortcl tum bchm asy 25,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0015U,Rx metab advrs rx rxn dna,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0016M,Onc bladder mrna 209 gen alg,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0016U,Onc hmtlmf neo rna bcr/abl1,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,0017M,Onc dlbcl mrna 20 genes alg,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0017U,Onc hmtlmf neo jak2 mut dna,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0018U,Onc thyr 10 microrna seq alg,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0019T,Extracorp shock wv tx ms nos,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,0019U,Onc rna tiss predict alg,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0020U,Rx test prsmv ur w/def conf,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,0021A,Fee covid-19 vac 3 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,0021U,Onc prst8 detcj 8 autoantb,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0022A,Fee covid-19 vac 3 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,0022U,Trgt gen seq dna&rna 23 gene,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0023A,Fee covid-19 vac 3 booster,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,0023U,Onc aml dna detcj/nondetcj,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,0024A,Fee covid-19 vac 3 res,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,0024U,Glyca nuc mr spectrsc quan,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,0025U,Tenofovir liq chrom ur quan,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,0026U,Onc thyr dna&mrna 112 genes,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0027U,Jak2 gene trgt seq alys,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0028U,Cyp2d6 gene cpy nmr cmn vrnt,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0029U,Rx metab advrs trgt seq alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0030U,Rx metab warf trgt seq alys,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0031A,Fee covid-19 vac 4 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,0031U,Cyp1a2 gene,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,0032A,Fee covid-19 vac 4 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,0032U,Comt gene,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,0033A,Fee covid-19 vac 4 booster,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,0033U,Htr2a htr2c genes,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0034A,Fee covid-19 vac 4 res,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,0034U,Tpmt nudt15 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0035U,Neuro csf prion prtn qual,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0036U,Xome tum & nml spec seq alys,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0037U,Trgt gen seq dna 324 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0038U,Vitamin d srm microsamp quan,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,0039U,Dna antb 2strand hi avidity,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,0040U,Bcr/abl1 gene major bp quan,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0041A,Fee covid-19 vac 5 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,0041U,B brgdrferi antb 5 prtn igm,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Humana Medicaid,CPT,0042A,Fee covid-19 vac 5 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,0042T,Ct perfusion w/contrast cbf,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Humana Medicaid,CPT,0042U,B brgdrferi antb 12 prtn igg,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Humana Medicaid,CPT,0043A,Fee covid-19 vac 5 booster,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,0043U,Tbrf b grp antb 4 prtn igm,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,0044A,Fee covid-19 vac 5 res,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,0044U,Tbrf b grp antb 4 prtn igg,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,0045U,Onc brst dux carc is 12 gene,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,0046U,Flt3 gene itd variants quan,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,0047U,Onc prst8 mrna 17 gene alg,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0048U,Onc sld org neo dna 468 gene,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0049U,Npm1 gene analysis quan,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,0050U,Trgt gen seq dna 194 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0051A,Fee covid-19 vac 6 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,0051U,Rx mntr lc-ms/ms ur 31 pnl,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,0052A,Fee covid-19 vac 6 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,0052U,Lpoprtn bld w/5 maj classes,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,0053A,Fee covid-19 vac 6 booster,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,0053U,Onc prst8 ca fish alys 4 gen,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0054A,Fee covid-19 vac 6 res,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,0054U,Rx mntr 14+ drugs & sbsts,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,0055U,Card hrt trnspl 96 dna seq,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0056U,Hem aml dna gene reargmt,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0057U,Onc sld org neo mrna 51 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0058T,Cryopreservation ovary tiss,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,0058U,Onc merkel cll carc srm quan,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Humana Medicaid,CPT,0059U,Onc merkel cll carc srm +/-,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Humana Medicaid,CPT,0060U,Twn zyg gen seq alys chrms2,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0061A,Fee covid-19 vac 7 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,0061U,Tc meas 5 bmrk sfdi m-s alys,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
Humana Medicaid,CPT,0062A,Fee covid-19 vac 7 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,0062U,Ai sle igg&igm alys 80 bmrk,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,0063A,Fee covid-19 vac 7 booster,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,0063U,Neuro autism 32 amines alg,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0064A,Fee covid-19 vac 7 res,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,0064U,Antb tp total&rpr ia qual,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,0065U,Syfls tst nontreponemal antb,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,0066U,Pamg-1 ia cervico-vag fluid,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,0067U,Onc brst imhchem prfl 4 bmrk,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,0069U,Onc clrct microrna mir-31-3p,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,0070U,Cyp2d6 gen com&slct rar vrnt,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0071A,Fee covid-19 vac 8 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,0071U,Cyp2d6 full gene sequence,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,0072A,Fee covid-19 vac 8 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,0072U,Cyp2d6 gen cyp2d6-2d7 hybrid,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0073A,Fee covid-19 vac 8 booster,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,0073U,Cyp2d6 gen cyp2d7-2d6 hybrid,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0074A,Fee covid-19 vac 8 res,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,0074U,Cyp2d6 nonduplicated gene,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0075T,Perq stent/chest vert art,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,0075U,Cyp2d6 5' gene dup/mlt,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0076T,S&i stent/chest vert art,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,0076U,Cyp2d6 3' gene dup/mlt,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0077U,Ig paraprotein qual bld/ur,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Humana Medicaid,CPT,0078U,Pain mgt opi use gnotyp pnl,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,0079U,Cmprtv dna alys mlt snps,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0080U,Onc lng 5 clin rsk factr alg,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0081A,Fee covid-19 vac 9 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,0081U,Onc uveal mlnma mrna 15 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0082A,Fee covid-19 vac 9 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,0083A,Fee covid-19 vac 9 booster,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,0083U,Onc rspse chemo cntrst tomog,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,0084A,Fee covid-19 vac 9 res,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,0084U,Rbc dna gnotyp 10 bld groups,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0085T,Breath test heart reject,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,0085U,Cdtb&vinculin igg antb ia,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Humana Medicaid,CPT,0086U,Nfct ds bact&fng org id 6+,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,0087U,Crd hrt trnspl mrna 1283 gen,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0088U,Trnsplj kdn algrft rej 1494,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0089U,Onc mlnma prame & linc00518,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0090U,Onc cutan mlnma mrna 23 gene,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0091A,Fee covid-19 vac 10 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,0091U,Onc clrct scr whl bld alg,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Humana Medicaid,CPT,0092A,Fee covid-19 vac 10 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,0092U,Onc lng 3 prtn bmrk plsm alg,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0093A,Fee covid-19 vac 10 booster,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,0093U,Rx mntr 65 com drugs urine,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,0094A,Fee covid-19 vac 10 res,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,0094U,Genome rapid sequence alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0095U,Inflm ee elisa alys alg,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0096U,Hpv hi risk types male urine,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,0099T,Implant corneal ring,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Humana Medicaid,CPT,0100T,Prosth retina receive&gen,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Humana Medicaid,CPT,0101A,Fee covid-19 vac 11 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,0101T,Extracorp shockwv tx hi enrg,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Humana Medicaid,CPT,0101U,Hered colon ca do 15 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0102A,Fee covid-19 vac 11 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,0102U,Hered brst ca rltd do 17 gen,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0103A,Fee covid-19 vac 11 booster,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,0103T,Holotranscobalamin,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,0103U,Hered ova ca pnl 24 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0104A,Fee covid-19 vac 11 res,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,0104U,Hered pan ca pnl 32 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0105U,Neph ckd mult eclia tum nec,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0106T,Touch quant sensory test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,0107T,Vibrate quant sensory test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,0107U,C diff tox ag detcj ia stool,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,0108T,Cool quant sensory test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,0108U,Gi barrett esoph 9 prtn bmrk,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0109T,Heat quant sensory test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,0109U,Id aspergillus dna 4 species,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,0110T,Nos quant sensory test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,0110U,Rx mntr 1+oral onc rx&sbsts,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,0111T,Rbc membranes fatty acids,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Humana Medicaid,CPT,0111U,Onc colon ca kras&nras alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0112U,Iadi 16s&18s rrna genes,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,0113U,Onc prst8 pca3&tmprss2-erg,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0114U,Gi barretts esoph vim&ccna1,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0115U,Respir iadna 18 viral&2 bact,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,0116U,Rx mntr nzm ia 35+oral flu,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,0117U,Pain mgmt 11 endogenous anal,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0118U,Trnsplj don-drv cll-fr dna,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0119U,Crd ceramides liq chrom plsm,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,0120U,Onc b cll lymphm mrna 58 gen,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0121U,Sc dis vcam-1 whole blood,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
Humana Medicaid,CPT,0122U,Sc dis p-selectin whl blood,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
Humana Medicaid,CPT,0123T,Scleral fistulization,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Humana Medicaid,CPT,0123U,Mchnl fragility rbc prflg,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Humana Medicaid,CPT,0124U,Ftl cgen abnor 3 analytes,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0125U,Ftl cgen abnor prnt comp 5,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0126T,Chd risk imt study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,0126U,Ftl cgen abnor prnt comp 5 y,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0127U,Ob pe 3 analytes,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0128U,Ob pe 3 analytes y chrmsm,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0129U,Hered brst ca rltd do panel,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0130U,Hered colon ca do mrna pnl,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0131U,Hered brst ca rltd do pnl 13,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0132U,Hered ova ca rltd do pnl 17,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0133U,Hered prst8 ca rltd do 11,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0134U,Hered pan ca mrna pnl 18 gen,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0135U,Hered gyn ca mrna pnl 12 gen,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0136U,Atm mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0137U,Palb2 mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0138U,Brca1 brca2 mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0139U,Neuro austm meas 6 c metablt,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0140U,Nfct ds fungi dna 15 trgt,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,0141U,Nfct ds bact&fng gram pos,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,0142U,Nfct ds bact&fng gram neg,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,0145U,Drug assay 65+ rx/metablt,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,0146U,Drug assay 80+ rx/metablt,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,0147U,Drug assay 85+ rx/metablt,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,0148U,Drug assay 100+ rx/metablt,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,0149U,Drug assay 60+ rx/metablt,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,0151U,Nfct bct/vir resp nfctj 33,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,0152U,Nfct ds dna untrgt ngnrj seq,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,0153U,Onc breast mrna 101 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0154U,Onc urthl ca rna fgfr3 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0155U,Onc brst ca dna pik3ca gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0156U,Copy number sequence alys,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0157U,Apc mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0158U,Mlh1 mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0159U,Msh2 mrna seq alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,0160U,Msh6 mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0161U,Pms2 mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0162U,Hered colon ca trgt mrna pnl,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0163U,Onc clrct scr 3 prtn alg,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0164U,Gi ibs ia anti-cdtb&vinculin,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,0165U,Peanut allg asmt epi,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Humana Medicaid,CPT,0166U,Liver ds 10 biochem asy srm,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0167U,Chornc gonadotropin hcg ia,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Humana Medicaid,CPT,0168U,Ftl aneuploidy dna seq alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0169U,Nudt15&tpmt gene com vrnt,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,0170U,Neuro asd rna next gen seq,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0171U,Trgt gen seq alys pnl dna 23,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0172T,Lumbar spine process addl,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"7,098.75","7,098.75",,,,,,
Humana Medicaid,CPT,0172U,Onc sld tum alys brca1 brca2,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0173U,Psyc gen alys panel 14 genes,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0174U,Onc solid tumor 30 prtn trgt,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0175U,Psyc gen alys panel 15 genes,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0176U,Cdtb&vinculin igg antb ia,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0177U,Onc brst ca dna pik3ca 11,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0178T,64 lead ecg w/i&r,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Humana Medicaid,CPT,0178U,Peanut allg asmt epi clin rx,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Humana Medicaid,CPT,0179T,64 lead ecg w/tracing,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Humana Medicaid,CPT,0179U,Onc nonsm cll lng ca alys 23,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0180U,Abo gnotyp abo 7 exons,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0181U,Co gnotyp aqp1 exon 1,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0182T,Hdr elect brachytherapy,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Humana Medicaid,CPT,0182U,Crom gnotyp cd55 exons 1-10,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0183U,Di gnotyp slc4a1 exon 19,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0184T,Exc rectal tumor endoscopic,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Humana Medicaid,CPT,0184U,Do gnotyp art4 exon 2,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0185U,Fut1 gnotyp fut1 exon 4,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0186U,Fut2 gnotyp fut2 exon 2,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0187U,Fy gnotyp ackr1 exons 1-2,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0188U,Ge gnotyp gypc exons 1-4,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0189U,Gypa gnotyp ntrns 1 5 exon 2,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0190U,Gypb gnotyp ntrns 1 5 seux 3,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0191T,Insert ant segment drain int,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Humana Medicaid,CPT,0191U,In gnotyp cd44 exons 2 3 6,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0192U,Jk gnotyp slc14a1 exon 9,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0193U,Jr gnotyp abcg2 exons 2-26,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0194U,Kel gnotyp kel exon 8,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0195U,Klf1 targeted sequencing,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0196U,Lu gnotyp bcam exon 3,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0197U,Lw gnotyp icam4 exon 1,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0198T,Ocular blood flow measure,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,0198U,Rhd&rhce gntyp rhd1-10&rhce5,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0199U,Sc gnotyp ermap exons 4 12,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0200U,Xk gnotyp xk exons 1-3,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0201U,Yt gnotyp ache exon 2,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0203U,Ai ibd mrna xprsn prfl 17,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0204U,Onc thyr mrna xprsn alys 593,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0205T,Inirs each vessel add-on,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,0205U,Oph amd alys 3 gene variants,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0206T,Cptr dbs alys car elec dta,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,0206U,Neuro alzheimer cell aggregj,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0207T,Clear eyelid gland w/heat,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,0207U,Neuro alzheimer quan imaging,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,0208U,Onc mtc mrna xprsn alys 108,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0209U,Cytog const alys interrog,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0210U,Syphilis tst antb ia quan,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,0211U,Onc pan-tum dna&rna gnrj seq,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0212T,Compre audiometry evaluation,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Humana Medicaid,CPT,0212U,Rare ds gen dna alys proband,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0213U,Rare ds gen dna alys ea comp,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0214U,Rare ds xom dna alys proband,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0215T,Njx paravert w/us cer/thor,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Humana Medicaid,CPT,0215U,Rare ds xom dna alys ea comp,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0216U,Neuro inh ataxia dna 12 com,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0217U,Neuro inh ataxia dna 51 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0218U,Neuro musc dys dmd seq alys,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0219U,Nfct agt hiv gnrj seq alys,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Humana Medicaid,CPT,0220U,Onc brst ca ai assmt 12 feat,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,0221U,Abo gnotyp next gnrj seq abo,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0222U,Rhd&rhce gntyp next gnrj seq,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0223T,Acoustic ecg w/i&r,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Humana Medicaid,CPT,0224T,Acoustic ecg 1+ analysis,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,0224U,Antibody sars-cov-2 titer(s),Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,0225T,Acoustic ecg analy & reprog,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,0226U,Svnt sarscov2 elisa plsm srm,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Humana Medicaid,CPT,0227U,Rx asy prsmv30+rx/metablt,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,0228T,Njx tfrml eprl w/us cer/thor,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Humana Medicaid,CPT,0228U,Onc prst8 ma molec prfl alg,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0229T,Njx tfrml eprl w/us cer/thor,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Humana Medicaid,CPT,0229U,Bcat1 promoter mthyltn alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,0230U,Ar full sequence analysis,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0231U,Cacna1a full gene analysis,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0232T,Njx platelet plasma,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,0232U,Cstb full gene analysis,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0233T,Skin glycation spectroscopy,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,0233U,Fxn gene analysis,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,0234U,Mecp2 full gene analysis,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0235T,Trluml perip athrc visceral,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,0235U,Pten full gene analysis,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0236T,Trluml perip athrc abd aorta,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,0236U,Smn1&smn2 full gene analysis,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Humana Medicaid,CPT,0237T,Trluml perip athrc brchiocph,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,0237U,Car ion chnlpthy gen seq pnl,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0238T,Trluml perip athrc iliac art,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,0238U,Onc lnch syn gen dna seq aly,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0239U,Trgt gen seq alys pnl 311+,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,0240T,Esoph motility 3d topography,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Humana Medicaid,CPT,0241T,Esoph motility w/stim/perf,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Humana Medicaid,CPT,0243T,Intm msr bronchodil wheeze,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Humana Medicaid,CPT,0244T,Cont msr bronchodil wheeze,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Humana Medicaid,CPT,0249T,Ligation hemorrhoid w/us,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Humana Medicaid,CPT,0253T,Insert aqueous drain device,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Humana Medicaid,CPT,0255T,Evasc rpr iliac art bifr s&i,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Humana Medicaid,CPT,0263T,Im b1 mrw cel ther cmpl,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Humana Medicaid,CPT,0264T,Im b1 mrw cel ther xcl hrvst,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Humana Medicaid,CPT,0265T,Im b1 mrw cel ther hrvst onl,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Humana Medicaid,CPT,0266T,Implt/rpl crtd sns dev total,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Humana Medicaid,CPT,0267T,Implt/rpl crtd sns dev lead,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,0268T,Implt/rpl crtd sns dev gen,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Humana Medicaid,CPT,0269T,Rev/remvl crtd sns dev total,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,0270T,Rev/remvl crtd sns dev lead,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,0271T,Rev/remvl crtd sns dev gen,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,0272T,Interrogate crtd sns dev,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,0273T,Interrogate crtd sns w/pgrmg,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,0278T,Tempr,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,0282T,Periph field stimul trial,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,0283T,Periph field stimul perm,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Humana Medicaid,CPT,0284T,Periph field stimul revise,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,0285T,Periph field stimul analys,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,0286T,Near ifr spectrsc of wounds,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,0288T,Anoscopy w/rf delivery,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Humana Medicaid,CPT,0289T,Laser inc for pkp/lkp donor,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Humana Medicaid,CPT,0290T,Laser inc for pkp/lkp recip,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Humana Medicaid,CPT,0294T,Ins lt atrl mont pres lead,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Humana Medicaid,CPT,0295T,Ext ecg complete,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,0296T,Ext ecg recording,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,0297T,Ext ecg scan w/report,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,0298T,Ext ecg review and interp,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,0301T,Mw therapy for breast tumor,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Humana Medicaid,CPT,0302T,Icar ischm mntrng sys compl,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Humana Medicaid,CPT,0303T,Icar ischm mntrng sys eltrd,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Humana Medicaid,CPT,0304T,Icar ischm mntrng sys device,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Humana Medicaid,CPT,0305T,Icar ischm mntrng prgrm eval,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,0306T,Icar ischm mntr interr eval,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,0307T,Rmvl icar ischm mntrng dvce,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
Humana Medicaid,CPT,0308T,Insj ocular telescope prosth,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Humana Medicaid,CPT,0310T,Motor function mapping ntms,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,0311T,Cal & alys cntrl artl press,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,0312T,Laps impltj nstim vagus,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Humana Medicaid,CPT,0313T,Laps rmvl nstim array vagus,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,0314T,Laps rmvl vgl arry&pls gen,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,0315T,Rmvl vagus nerve pls gen,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,0316T,Replc vagus nerve pls gen,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Humana Medicaid,CPT,0317T,Elec alys vagus nrv pls gen,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,0329T,Mntr io press 24hrs/> uni/bi,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Humana Medicaid,CPT,0330T,Tear film img uni/bi w/i&r,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Humana Medicaid,CPT,0331T,Heart symp image plnr,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Humana Medicaid,CPT,0332T,Heart symp image plnr spect,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Humana Medicaid,CPT,0333T,Visual ep scr acuity auto,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,0335T,Insj sinus tarsi implant,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,0337T,Endothel fxnassmnt non-invas,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,0341T,Quant pupillometry w/ rprt,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,0342T,Thxp apheresis w/hdl delip,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Humana Medicaid,CPT,0346T,Ultrasound elastography,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,0348T,Rsa spine exam,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,0349T,Rsa upper extr exam,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,0350T,Rsa lower extr exam,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,0352T,Oct brst/node i&r per spec,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,0354T,Oct breast surg cavity i&r,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,0355T,Gi tract capsule endoscopy,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,0356T,Insrt drug device for iop,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Humana Medicaid,CPT,0357T,Cryopreservation oocyte(s),Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,0358T,Bia whole body,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,0362T,Bhv id suprt assmt ea 15 min,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
Humana Medicaid,CPT,0373T,Adapt bhv tx ea 15 min,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
Humana Medicaid,CPT,0376T,Insert ant segment drain int,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Humana Medicaid,CPT,0377T,Anoscpy inj agent for incont,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Humana Medicaid,CPT,0378T,Visual field assmnt rev/rprt,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,0379T,Vis field assmnt tech suppt,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,0380T,Comp animat ret imag series,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,0381T,Ext h rate epi sz 14 days,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,0382T,Ext h rate sz 14 day ri only,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,0383T,Ext h rate sz up to 30 days,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,0384T,Ex h rate sz 30 day ri only,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,0385T,Ex h rate for sz ovr 30 day,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,0386T,Ex h rate sz 30+ day ri only,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,0387T,Leadless c pm ins/rpl ventr,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Humana Medicaid,CPT,0388T,Leadless c pm remove ventr,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
Humana Medicaid,CPT,0389T,Prog eval inper leadls pm,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,0390T,Periproc eval inper ledls pm,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,0391T,Intergt eval inper leadls pm,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,0392T,Lap es sph augment dev place,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Humana Medicaid,CPT,0393T,Es sph augmnt device removal,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Humana Medicaid,CPT,0394T,Hdr elctrnc skn surf brchytx,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Humana Medicaid,CPT,0395T,Hdr elctr ntrst/ntrcv brchtx,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Humana Medicaid,CPT,0398T,Mrgfus strtctc les abltj,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Humana Medicaid,CPT,0399T,Myocardial strain imaging,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Humana Medicaid,CPT,0400T,Mltispectrl digital les alys,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,0401T,Mltispectrl digital les alys,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,0402T,Colgn cross-link crn med sep,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Humana Medicaid,CPT,0403T,Diabetes prev standard curr,Preventive Care,Per Unit,$26.23 ,OP,26.23,26.23,,,,,,
Humana Medicaid,CPT,0406T,Sin ndsc plmt drg elut mplnt,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Humana Medicaid,CPT,0407T,Sin ndsc plmt drg elut mplnt,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Humana Medicaid,CPT,0408T,Insj/rplc cardiac modulj sys,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Humana Medicaid,CPT,0409T,Insj/rplc car modulj pls gn,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Humana Medicaid,CPT,0412T,Rmvl cardiac modulj pls gen,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
Humana Medicaid,CPT,0414T,Rmvl & rpl car modulj pls gn,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Humana Medicaid,CPT,0417T,Prgrmg eval cardiac modulj,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,0418T,Interro eval cardiac modulj,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,0419T,Dstrj neurofibroma xtnsv,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,0420T,Dstrj neurofibroma xtnsv,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,0421T,Waterjet prostate abltj cmpl,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Humana Medicaid,CPT,0422T,Tactile breast img uni/bi,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
Humana Medicaid,CPT,0423T,Assay secretory type ii pla2,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,0424T,Insj/rplc nstim apnea compl,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Humana Medicaid,CPT,0425T,Insj/rplc nstim apnea sen ld,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,0426T,Insj/rplc nstim apnea stm ld,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Humana Medicaid,CPT,0427T,Insj/rplc nstim apnea pls gn,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"7,098.75","7,098.75",,,,,,
Humana Medicaid,CPT,0428T,Rmvl nstim apnea pls gen,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,0429T,Rmvl nstim apnea sen ld,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,0430T,Rmvl nstim apnea stimj ld,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,0431T,Rmvl/rplc nstim apnea pls gn,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"7,098.75","7,098.75",,,,,,
Humana Medicaid,CPT,0432T,Repos nstim apnea stimj ld,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,0433T,Repos nstim apnea sensing ld,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,0434T,Interro eval npgs apnea,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,0435T,Prgrmg eval npgs apnea 1 ses,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,0436T,Prgrmg eval npgs apnea study,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,0437T,Impltj synth rnfcmt abdl wal,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Humana Medicaid,CPT,0438T,Tprnl plmt biodegrdabl matrl,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Humana Medicaid,CPT,0439T,Myocrd contrast prfuj echo,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Humana Medicaid,CPT,0440T,Abltj perc uxtr/perph nrv,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,0441T,Abltj perc lxtr/perph nrv,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,0442T,Abltj perc plex/trncl nrv,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,0443T,R-t spctrl alys prst8 tiss,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,0446T,Insj impltbl glucose sensor,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,0447T,Rmvl impltbl glucose sensor,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,0448T,Remvl insj impltbl gluc sens,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Humana Medicaid,CPT,0449T,Insj aqueous drain dev 1st,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Humana Medicaid,CPT,0450T,Insj aqueous drain dev each,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Humana Medicaid,CPT,0453T,Insj/rplcmt mech-elec ntrfce,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Humana Medicaid,CPT,0457T,Remvl mech-elec skin ntrfce,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
Humana Medicaid,CPT,0462T,Prgrmg eval aortic ventr sys,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,0463T,Interrog aortic ventr sys,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,0464T,Visual ep test for glaucoma,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Humana Medicaid,CPT,0466T,Insj ch wal respir eltrd/ra,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Humana Medicaid,CPT,0467T,Revj/rplmnt ch respir eltrd,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,0468T,Rmvl ch wal respir eltrd/ra,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Humana Medicaid,CPT,0469T,Rta polarize scan oc scr bi,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Humana Medicaid,CPT,0470T,Oct skn img acquisj i&r 1st,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Humana Medicaid,CPT,0471T,Oct skn img acquisj i&r addl,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Humana Medicaid,CPT,0472T,Prgrmg io rta eltrd ra,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,0473T,Reprgrmg io rta eltrd ra,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,0474T,Insj aqueous drg dev io rsvr,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Humana Medicaid,CPT,0475T,Rec ftl car sgl 3 ch i&r,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Humana Medicaid,CPT,0476T,Rec ftl car sgl elec tr data,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Humana Medicaid,CPT,0477T,Rec ftl car sgl xrtj alys,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Humana Medicaid,CPT,0478T,Rec ftl car 3 ch rev i&r,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Humana Medicaid,CPT,0481T,Njx autol wbc concentrate,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,0482T,Absl quan myocrd bld flo pet,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Humana Medicaid,CPT,0485T,Oct mid ear i&r unilateral,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,0486T,Oct mid ear i&r bilateral,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,0487T,Trvg biomchn mapg w/reprt,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,0488T,Diabetes prev online/elec,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Humana Medicaid,CPT,0489T,Regn cell tx scldr hands,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,0490T,Regn cell tx scldr h mlt inj,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,0497T,Xtrnl pt act ecg in-off conn,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Humana Medicaid,CPT,0498T,Xtrnl pt act ecg r&i pr 30 d,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Humana Medicaid,CPT,0499T,Cysto f/urtl strix/stenosis,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Humana Medicaid,CPT,0500T,Hpv 5+ hi risk hpv types,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,0501T,Cor ffr derived cor cta data,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Humana Medicaid,CPT,0502T,Cor ffr data prep & transmis,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Humana Medicaid,CPT,0503T,Cor ffr alys gnrj ffr mdl,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Humana Medicaid,CPT,0504T,Cor ffr data review i&r,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Humana Medicaid,CPT,0505T,Ev fempop artl revsc,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,0506T,Mac pgmt opt dns meas hfp,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,0507T,Near ifr 2img mibmn glnd i&r,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,0508T,Pls echo us b1 dns meas tib,Diagnostic Radiology,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
Humana Medicaid,CPT,0509T,Pattern erg w/i&r,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Humana Medicaid,CPT,0510T,Rmvl sinus tarsi implant,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Humana Medicaid,CPT,0511T,Rmvl&rinsj sinus tarsi implt,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Humana Medicaid,CPT,0514T,Intraop vis axis id pt fixj,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,0515T,Insj wcs lv compl sys,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Humana Medicaid,CPT,0517T,Insj wcs lv pg compnt,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Humana Medicaid,CPT,0518T,Rmvl pg compnt wcs,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
Humana Medicaid,CPT,0519T,Rmvl & rplcmt pg compnt wcs,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Humana Medicaid,CPT,0520T,Rmvl&rplcmt pg wcs new eltrd,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Humana Medicaid,CPT,0521T,Interrog dev eval wcs ip,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,0522T,Prgrmg dev eval wcs ip,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,0525T,Insj/rplcmt compl iims,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Humana Medicaid,CPT,0527T,Insj/rplcmt iims implt mntr,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Humana Medicaid,CPT,0528T,Prgrmg dev eval iims ip,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,0529T,Interrog dev eval iims ip,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,0530T,Removal complete iims,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
Humana Medicaid,CPT,0532T,Removal iims implt mntr only,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
Humana Medicaid,CPT,0533T,Cont rec mvmt do 6-10 days,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,0534T,Cont rec mvmt do setup&train,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,0535T,Cont rec mvmt do reprt cnfig,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,0536T,Cont rec mvmt do dl w/i&r,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,0541T,Myocardial imaging mcg,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Humana Medicaid,CPT,0542T,Myocardial imaging mcg i&r,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Humana Medicaid,CPT,0546T,Rf spectrsc ntraop mrgn asmt,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,0547T,B1 matrl qual tst mcrind tib,Diagnostic Radiology,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
Humana Medicaid,CPT,0548T,Tprnl balo cntnc dev bi,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Humana Medicaid,CPT,0549T,Tprnl balo cntnc dev uni,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Humana Medicaid,CPT,0550T,Tprnl balo cntnc dev rmvl ea,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Humana Medicaid,CPT,0551T,Tprnl balo cntnc dev adjmt,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Humana Medicaid,CPT,0552T,Low-level laser therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,0553T,Perq tcat iliac anast implt,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,0554T,B1 str & fx rsk analysis,Diagnostic Radiology,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
Humana Medicaid,CPT,0556T,B1 str & fx rsk assessment,Diagnostic Radiology,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
Humana Medicaid,CPT,0558T,Ct scan f/biomchn ct alys,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Humana Medicaid,CPT,0563T,Evac meibomian glnd heat bi,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,0564T,Onc chemo rx cytotox csc 14,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,0566T,Autol cell implt adps njx,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
Humana Medicaid,CPT,0568T,Intro mix saline&air f/ssg,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,0571T,Insj/rplcmt icds ss eltrd,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Humana Medicaid,CPT,0575T,Prgrmg dev eval icds ss ip,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,0576T,Interrog dev eval icds ss ip,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,0577T,Ephys eval icds ss,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Humana Medicaid,CPT,0578T,Rem interrog dev icds phys,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,0579T,Rem interrog dev icds tech,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,0581T,Abltj mal brst tum perq crtx,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Humana Medicaid,CPT,0582T,Trurl abltj mal prst8 tiss,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Humana Medicaid,CPT,0583T,Tmpst auto tube dlvr sys,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,0587T,Perq impltj/rplcmt isdns ptn,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Humana Medicaid,CPT,0588T,Revision/removal isdns ptn,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Humana Medicaid,CPT,0589T,Elec alys smpl prgrmg iins,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Humana Medicaid,CPT,0590T,Elec alys cplx prgrmg iins,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Humana Medicaid,CPT,0591T,Hlth&wb coaching indiv 1st,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Humana Medicaid,CPT,0592T,Hlth&wb coaching indiv f-up,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Humana Medicaid,CPT,0593T,Hlth&wb coaching group,Preventive Care,Per Unit,$26.23 ,OP,26.23,26.23,,,,,,
Humana Medicaid,CPT,0596T,Temp fml iu vlv-pmp 1st insj,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Humana Medicaid,CPT,0597T,Temp fml iu valve-pmp rplcmt,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Humana Medicaid,CPT,0602T,Transdermal gfr measurements,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,0603T,Transdermal gfr monitoring,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,0604T,Rem oct rta dev setup&educaj,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,0605T,Rem oct rta techl sprt min 8,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,0607T,Rem mntr pulm flu mntr setup,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,0608T,Rem mntr pulm flu mntr alys,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,0609T,Mrs disc pain acquisj data,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Humana Medicaid,CPT,0610T,Mrs disc pain transmis data,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,0611T,Mrs disc pain alg alys data,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,0614T,Rmvl&rplcmt ss impl dfb pg,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Humana Medicaid,CPT,0615T,Eye mvmt alys w/o calbrj i&r,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,0616T,Insertion of iris prosthesis,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Humana Medicaid,CPT,0617T,Insj iris prosth w/rmvl&insj,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Humana Medicaid,CPT,0618T,Insj iris prosth sec io lens,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Humana Medicaid,CPT,0619T,Cysto w/prst8 commissurotomy,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Humana Medicaid,CPT,0620T,Evasc ven artlz tibl/prnl vn,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,0621T,Trabeculostomy interno laser,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Humana Medicaid,CPT,0622T,Trabeculostomy int lsr w/scp,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Humana Medicaid,CPT,0623T,Auto quantification c plaque,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Humana Medicaid,CPT,0632T,Perq tcat us abltj nrv p-art,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Humana Medicaid,CPT,0633T,Ct breast w/3d uni c-,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Humana Medicaid,CPT,0634T,Ct breast w/3d uni c+,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Humana Medicaid,CPT,0635T,Ct breast w/3d uni c-/c+,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Humana Medicaid,CPT,0636T,Ct breast w/3d bi c-,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Humana Medicaid,CPT,0637T,Ct breast w/3d bi c+,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Humana Medicaid,CPT,0638T,Ct breast w/3d bi c-/c+,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Humana Medicaid,CPT,0639T,Wrls skn snr anisotropy meas,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,C1762,"Conn tiss, human(inc fascia)",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,C1763,"Conn tiss, non-human",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,C1849,"Skin substitute, synthetic",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,C1878,Matrl for vocal cord,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,C2615,"Sealant, pulmonary, liquid",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,C8900,"Mra w/cont, abd",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Humana Medicaid,CPT,C8901,"Mra w/o cont, abd",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Humana Medicaid,CPT,C8902,"Mra w/o fol w/cont, abd",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Humana Medicaid,CPT,C8903,"Mri w/cont, breast, uni",Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Humana Medicaid,CPT,C8904,"Mri w/o cont, breast, uni",Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Humana Medicaid,CPT,C8905,"Mri w/o fol w/cont, brst, un",Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Humana Medicaid,CPT,C8906,"Mri w/cont, breast, bi",Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Humana Medicaid,CPT,C8907,"Mri w/o cont, breast, bi",Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Humana Medicaid,CPT,C8908,"Mri w/o fol w/cont, breast,",Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Humana Medicaid,CPT,C8909,"Mra w/cont, chest",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Humana Medicaid,CPT,C8910,"Mra w/o cont, chest",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Humana Medicaid,CPT,C8911,"Mra w/o fol w/cont, chest",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Humana Medicaid,CPT,C8912,"Mra w/cont, lwr ext",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Humana Medicaid,CPT,C8913,"Mra w/o cont, lwr ext",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Humana Medicaid,CPT,C8914,"Mra w/o fol w/cont, lwr ext",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Humana Medicaid,CPT,C8918,"Mra w/cont, pelvis",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Humana Medicaid,CPT,C8919,"Mra w/o cont, pelvis",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Humana Medicaid,CPT,C8920,"Mra w/o fol w/cont, pelvis",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Humana Medicaid,CPT,C8921,"Tte w or w/o fol w/cont, com",Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Humana Medicaid,CPT,C8922,"Tte w or w/o fol w/cont, f/u",Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Humana Medicaid,CPT,C8923,"2d tte w or w/o fol w/con,co",Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Humana Medicaid,CPT,C8924,"2d tte w or w/o fol w/con,fu",Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Humana Medicaid,CPT,C8925,"2d tee w or w/o fol w/con,in",Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Humana Medicaid,CPT,C8926,"Tee w or w/o fol w/cont,cong",Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Humana Medicaid,CPT,C8927,"Tee w or w/o fol w/cont, mon",Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Humana Medicaid,CPT,C8928,"Tte w or w/o fol w/con,stres",Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Humana Medicaid,CPT,C8929,"Tte w or wo fol wcon,doppler",Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Humana Medicaid,CPT,C8930,"Tte w or w/o contr, cont ecg",Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Humana Medicaid,CPT,C8931,"Mra, w/dye, spinal canal",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Humana Medicaid,CPT,C8932,"Mra, w/o dye, spinal canal",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Humana Medicaid,CPT,C8933,"Mra, w/o&w/dye, spinal canal",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Humana Medicaid,CPT,C8934,"Mra, w/dye, upper extremity",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Humana Medicaid,CPT,C8935,"Mra, w/o dye, upper extr",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Humana Medicaid,CPT,C8936,"Mra, w/o&w/dye, upper extr",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Humana Medicaid,CPT,C8957,"Prolonged iv inf, req pump",General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
Humana Medicaid,CPT,C9014,"Injection, cerliponase alfa",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,C9015,"C-1 esterase, haegarda",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,C9016,"Inj, triptorelin ext rel",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,C9024,"Inj, daunorubicin-cytarabine",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Humana Medicaid,CPT,C9025,"Injection, ramucirumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,C9026,"Injection, vedolizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,C9027,"Injection, pembrolizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Humana Medicaid,CPT,C9028,Inj. inotuzumab ozogamicin,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Humana Medicaid,CPT,C9029,"Injection, guselkumab",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Humana Medicaid,CPT,C9030,Inj copanlisib,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,C9031,"Lutetium Lu 177 dotatate, tx",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,C9032,Voretigene neparvovec-rzyl,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,C9033,"Inj, akynzeo",Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,189.67,189.67,,,,,,
Humana Medicaid,CPT,C9034,"Injection, dexamethasone 9%",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,C9035,"Injection, Aristada Initio",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Humana Medicaid,CPT,C9036,"Injection, patisiran",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,C9037,"Injection, risperidone",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,C9038,Inj mogamulizumab-kpkc,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,C9040,"Injection, fremanezumab-vfrm",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,C9041,"Inj, coagulation factor xa",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,C9042,"Inj., belrapzo 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,C9043,"Injection, levoleucovorin",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Humana Medicaid,CPT,C9044,"Injection, cemiplimab-rwlc",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,C9045,Moxetumomab pasudotox-tdfk,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,C9047,"Injection, caplacizumab-yhdp",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,C9048,Dexamethasone ophth insert,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,C9049,"Injection, tagraxofusp-erzs",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,C9050,"Injection, emapalumab-lzsg",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Humana Medicaid,CPT,C9051,"Injection, omadacycline",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Humana Medicaid,CPT,C9052,"Injection, ravulizumab-cwv",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,C9053,"Inj, crizanlizumab-tmca",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Humana Medicaid,CPT,C9054,"Injection, lefamulin",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,C9055,"Inj, brexanolone",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,C9056,"Injection, givosiran",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,C9057,Inj cetirizine hydrochloride,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,C9058,"Injection,pegfilgrastim-bmez",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,C9059,"Injection, meloxicam",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,C9061,"Injection, teprotumumab-trbw",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,C9062,Daratumumab hyaluronidase,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,C9063,"Injection, eptinezumab-jjmr",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,C9064,Mitomycin pyelocalyceal inst,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,C9065,Romidepsin non-lyophilized,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,C9066,Sacituzumab govitecan-hziy,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,C9069,Belantamab mafodontin-blmf,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Humana Medicaid,CPT,C9070,"Injection, tafasitamab-cxix",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,C9071,"Injection, viltolarsen",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,C9072,"Inj, imm glob asceniv",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Humana Medicaid,CPT,C9121,"Injection, argatroban",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Humana Medicaid,CPT,C9122,Mometasone furoate (sinuva),Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Humana Medicaid,CPT,C9132,"Kcentra, per i.u.",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,C9137,Adynovate Factor VIII recom,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,C9138,Nuwiq Factor VIII recomb,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,C9139,"Idelvion, 1 i.u.",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,C9140,Afstyla factor viii recomb,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,C9141,Factor viii pegylated-aucl,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,C9248,"Inj, clevidipine butyrate",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,C9250,Artiss fibrin sealant,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,C9257,Bevacizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Humana Medicaid,CPT,C9293,"Injection, glucarpidase",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,C9349,"Puraply, puraply antimic",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,C9352,"Neuragen nerve guide, per cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,C9353,"Neurawrap nerve protector,cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,C9354,"Veritas collagen matrix, cm2",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,C9355,"Neuromatrix nerve cuff, cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,C9356,"Tenoglide tendon prot, cm2",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,C9358,"Surgimend, fetal",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,C9359,"Implnt,bon void filler-putty",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,C9360,"Surgimend, neonatal",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,C9361,Neuromend nerve wrap,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,C9362,"Implnt,bon void filler-strip",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,C9363,Integra meshed bil wound mat,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,C9364,"Porcine implant, permacol",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,C9408,"Iodine i-131 iobenguane, tx",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,C9442,"Injection, belinostat",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,C9443,"Injection, dalbavancin",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Humana Medicaid,CPT,C9444,"Injection, oritavancin",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Humana Medicaid,CPT,C9445,"C-1 esterase, Ruconest",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,C9446,"Inj, tedizolid phosphate",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,C9447,"Inj, phenylephrine ketorolac",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,C9448,Oral netupitant palonosetron,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
Humana Medicaid,CPT,C9449,"Inj, blinatumomab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,C9450,Fluocinolone acetonide implt,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,C9451,"Injection, peramivir",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Humana Medicaid,CPT,C9452,"Inj, ceftolozane/tazobactam",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,C9453,"Injection, nivolumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,C9454,"Inj, pasireotide long acting",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,C9455,"Injection, siltuximab",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Humana Medicaid,CPT,C9456,"Inj, isavuconazonium sulfate",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,C9460,"Injection, cangrelor",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,C9465,"Injection, Durolane",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,C9466,"Injection, benralizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,C9467,Inj rituximab hyaluronidase,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,C9468,"Inj, factor ix, Rebinyn",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,C9469,Inj triamcinolone acetonide,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,C9470,Aripiprazole lauroxil im,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,C9471,"Hymovis, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Humana Medicaid,CPT,C9472,Inj talimogene laherparepvec,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,C9473,"Injection, mepolizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Humana Medicaid,CPT,C9474,"Inj, irinotecan liposome",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,C9475,"Injection, necitumumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,C9476,"Injection, daratumumab",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Humana Medicaid,CPT,C9477,"Injection, elotuzumab",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Humana Medicaid,CPT,C9478,"Injection, sebelipase alfa",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,C9480,"Injection, trabectedin",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,C9481,"Injection, reslizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Humana Medicaid,CPT,C9482,Sotalol hydrochloride iv,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,C9483,"Injection, atezolizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,C9484,"Injection, eteplirsen",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,C9485,"Injection, olaratumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,C9487,"Ustekinumab IV inj, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Humana Medicaid,CPT,C9488,Conivaptan hcl,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,C9489,"Injection, nusinersen",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,C9490,"Injection, bezlotoxumab",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Humana Medicaid,CPT,C9491,"Injection, avelumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,C9492,"Injection, durvalumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,C9493,"Injection, edaravone",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Humana Medicaid,CPT,C9494,"Injection, ocrelizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,C9497,"Loxapine, inhalation powder",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,C9600,Perc drug-el cor stent sing,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Humana Medicaid,CPT,C9601,Perc drug-el cor stent bran,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Humana Medicaid,CPT,C9602,Perc d-e cor stent ather s,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Humana Medicaid,CPT,C9603,Perc d-e cor stent ather br,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Humana Medicaid,CPT,C9604,Perc d-e cor revasc t cabg s,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Humana Medicaid,CPT,C9605,Perc d-e cor revasc t cabg b,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Humana Medicaid,CPT,C9606,Perc d-e cor revasc w ami s,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Humana Medicaid,CPT,C9607,Perc d-e cor revasc chro sin,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Humana Medicaid,CPT,C9608,Perc d-e cor revasc chro add,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Humana Medicaid,CPT,C9724,Eps stomach plic,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Humana Medicaid,CPT,C9726,Rxt breast appl place/remov,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Humana Medicaid,CPT,C9728,"Place device/marker, non pro",Therapeutic Radiology,Per Unit,$68.45 ,OP,68.45,68.45,,,,,,
Humana Medicaid,CPT,C9734,"U/s trtmt, not leiomyomata",General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Humana Medicaid,CPT,C9737,Lap esoph augmentation,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Humana Medicaid,CPT,C9739,Cystoscopy prostatic imp 1-3,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Humana Medicaid,CPT,C9740,Cysto impl 4 or more,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Humana Medicaid,CPT,C9741,Impl pressure sensor w/angio,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Humana Medicaid,CPT,C9742,Laryngoscopy with injection,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Humana Medicaid,CPT,C9743,Bulking/spacer material impl,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,C9744,Abd us w/contrast,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Humana Medicaid,CPT,C9745,Nasal endo eustachian tube,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Humana Medicaid,CPT,C9747,"Ablation, hifu, prostate",Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Humana Medicaid,CPT,C9749,Repair nasal stenosis w/imp,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,C9750,Ins/rem-replace compl iims,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Humana Medicaid,CPT,C9762,Cardiac mri seg dys strain,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Humana Medicaid,CPT,C9763,Cardiac mri seg dys stress,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Humana Medicaid,CPT,C9765,Revasc intra lithotrip-stent,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,C9767,Revasc lithotrip-stent-ather,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,C9768,Endo us-guide hep porto grad,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Humana Medicaid,CPT,C9769,Cysto w/temp pros implant,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Humana Medicaid,CPT,C9770,"Vitrec/mech pars, subret inj",Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Humana Medicaid,CPT,C9771,Nsl/sins cryo post nasal tis,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Humana Medicaid,CPT,C9772,Revasc lithotrip tibi/perone,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,C9773,Revasc lithotr-stent tib/per,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,C9774,Revasc lithotr-ather tib/per,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,C9775,Revasc lith-sten-ath tib/per,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Humana Medicaid,CPT,C9803,Hopd covid-19 spec collect,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,D0120,Periodic oral evaluation,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Humana Medicaid,CPT,D0140,Limit oral eval problm focus,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Humana Medicaid,CPT,D0145,"Oral evaluation, pt < 3yrs",Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Humana Medicaid,CPT,D0150,Comprehensve oral evaluation,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Humana Medicaid,CPT,D0160,Extensv oral eval prob focus,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Humana Medicaid,CPT,D0170,"Re-eval,est pt,problem focus",Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Humana Medicaid,CPT,D0171,Re-eval post-op visit,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Humana Medicaid,CPT,D0180,Comp periodontal evaluation,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Humana Medicaid,CPT,D0190,Screening of a patient,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Humana Medicaid,CPT,D0191,Assessment of a patient,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Humana Medicaid,CPT,D0210,Intraor complete film series,Dental,Per Unit,$87.62 ,OP,87.62,87.62,,,,,,
Humana Medicaid,CPT,D0220,Intraoral periapical first,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Humana Medicaid,CPT,D0230,Intraoral periapical ea add,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Humana Medicaid,CPT,D0240,Intraoral occlusal film,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Humana Medicaid,CPT,D0250,Extraoral 2d project image,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Humana Medicaid,CPT,D0251,Extraoral posterior image,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Humana Medicaid,CPT,D0260,Extraoral ea additional film,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Humana Medicaid,CPT,D0270,Dental bitewing single image,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Humana Medicaid,CPT,D0272,Dental bitewings two images,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Humana Medicaid,CPT,D0273,Bitewings - three images,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Humana Medicaid,CPT,D0274,Bitewings four images,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Humana Medicaid,CPT,D0277,Vert bitewings 7 to 8 images,Dental,Per Unit,$87.62 ,OP,87.62,87.62,,,,,,
Humana Medicaid,CPT,D0290,Skull/facial bone image,Dental,Per Unit,$87.62 ,OP,87.62,87.62,,,,,,
Humana Medicaid,CPT,D0310,Dental saliography,Dental,Per Unit,$87.62 ,OP,87.62,87.62,,,,,,
Humana Medicaid,CPT,D0320,Dental tmj arthrogram incl i,Dental,Per Unit,$87.62 ,OP,87.62,87.62,,,,,,
Humana Medicaid,CPT,D0321,Other tmj images by report,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Humana Medicaid,CPT,D0322,Dental tomographic survey,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Humana Medicaid,CPT,D0330,Panoramic image,Dental,Per Unit,$87.62 ,OP,87.62,87.62,,,,,,
Humana Medicaid,CPT,D0340,2d cephalometric image,Dental,Per Unit,$87.62 ,OP,87.62,87.62,,,,,,
Humana Medicaid,CPT,D0350,Oral/facial photo images,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Humana Medicaid,CPT,D0351,3d photographic image,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Humana Medicaid,CPT,D0364,Cone beam ct capt & interp,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Humana Medicaid,CPT,D0365,Cone beam ct interprete man,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Humana Medicaid,CPT,D0366,Cone beam ct interprete max,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Humana Medicaid,CPT,D0367,Cone beam ct interp both jaw,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Humana Medicaid,CPT,D0368,Cone beam ct interprete tmj,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Humana Medicaid,CPT,D0369,Max mri capture & interprete,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Humana Medicaid,CPT,D0370,Max ultrasound capt & interp,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,D0371,Sialoendoscopy capt & interp,Dental,Per Unit,$87.62 ,OP,87.62,87.62,,,,,,
Humana Medicaid,CPT,D0380,Cone beam ct capture limited,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Humana Medicaid,CPT,D0381,Cone beam ct capt mandible,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Humana Medicaid,CPT,D0382,Cone beam ct capt maxilla,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Humana Medicaid,CPT,D0383,Cone beam ct both jaws,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Humana Medicaid,CPT,D0384,Cone beam ct capture tmj,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Humana Medicaid,CPT,D0385,Max mri image capture,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Humana Medicaid,CPT,D0386,Max ultrasound image capture,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,D0391,Imterprete diagnostic image,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Humana Medicaid,CPT,D0393,Trtmnt simulation 3d image,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Humana Medicaid,CPT,D0394,Digital sub 2 or more images,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Humana Medicaid,CPT,D0395,Fusion 2 or more 3d images,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Humana Medicaid,CPT,D0411,Hba1c in office testing,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,D0412,Blood glucose level test,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,D0414,Lab process microbial spec,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,D0415,Collection of microorganisms,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,D0416,Viral culture,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,D0418,Analysis of saliva sample,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,D0419,Assess of salivary flow,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Humana Medicaid,CPT,D0421,Gen tst suscept oral disease,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,D0422,Collect & prep genetic samp,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,D0423,Genetic test spec analysis,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,D0425,Caries susceptibility test,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,D0431,Diag tst detect mucos abnorm,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Humana Medicaid,CPT,D0460,Pulp vitality test,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Humana Medicaid,CPT,D0470,Diagnostic casts,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Humana Medicaid,CPT,D0472,"Gross exam, prep & report",Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,D0473,"Micro exam, prep & report",Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,D0474,Micro w exam of surg margins,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D0475,Decalcification procedure,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,D0476,Spec stains for microorganis,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,D0477,Spec stains not for microorg,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,D0478,Immunohistochemical stains,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,D0479,Tissue in-situ hybridization,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,D0480,Cytopath smear prep & report,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,D0481,Electron microscopy,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,D0482,Direct immunofluorescence,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,D0483,Indirect immunofluorescence,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,D0484,Consult slides prep elsewher,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Humana Medicaid,CPT,D0485,Consult inc prep of slides,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D0486,Access of transep cytol samp,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,D0502,Other oral pathology procedu,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Humana Medicaid,CPT,D0600,Non-ionizing diag proc,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Humana Medicaid,CPT,D0601,Caries risk assess low risk,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Humana Medicaid,CPT,D0602,Caries risk assess mod risk,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Humana Medicaid,CPT,D0603,Caries risk assess high risk,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Humana Medicaid,CPT,D0604,Antigen test pub hlth pathog,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,D0605,Antibody test pub hlth path,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,D0701,Pano radio image,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Humana Medicaid,CPT,D0702,2d cephal radio image,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Humana Medicaid,CPT,D0703,2d oral/facial photo image,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Humana Medicaid,CPT,D0704,3d photo image capture only,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Humana Medicaid,CPT,D0705,Extra oral post radio image,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Humana Medicaid,CPT,D0706,Intraoral occlus radio image,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Humana Medicaid,CPT,D0707,Intraoral periap radio image,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Humana Medicaid,CPT,D0708,Intraoral bite radio image,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Humana Medicaid,CPT,D0709,Intraoral cmplt radio images,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Humana Medicaid,CPT,D0999,Unspecified diagnostic proce,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Humana Medicaid,CPT,D1110,Dental prophylaxis adult,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Humana Medicaid,CPT,D1120,Dental prophylaxis child,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Humana Medicaid,CPT,D1206,Topical fluoride varnish,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Humana Medicaid,CPT,D1208,Topical app fluorid ex vrnsh,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Humana Medicaid,CPT,D1310,Nutri counsel-control caries,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Humana Medicaid,CPT,D1320,Tobacco counseling,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Humana Medicaid,CPT,D1321,Couns for high risk sub use,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Humana Medicaid,CPT,D1330,Oral hygiene instruction,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Humana Medicaid,CPT,D1351,Dental sealant per tooth,Dental,Per Unit,$24.50 ,OP,24.5,24.5,,,,,,
Humana Medicaid,CPT,D1352,"Prev resin rest, perm tooth",Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Humana Medicaid,CPT,D1353,Sealant repair per tooth,Dental,Per Unit,$24.50 ,OP,24.5,24.5,,,,,,
Humana Medicaid,CPT,D1354,Int caries med app per tooth,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Humana Medicaid,CPT,D1355,Caries med app per tooth,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Humana Medicaid,CPT,D1510,Space maintainer fxd unilat,Dental,Per Unit,$156.21 ,OP,156.21,156.21,,,,,,
Humana Medicaid,CPT,D1515,Fixed bilat space maintainer,Dental,Per Unit,$156.21 ,OP,156.21,156.21,,,,,,
Humana Medicaid,CPT,D1516,"Fixed bilat space maint, max",Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Humana Medicaid,CPT,D1517,"Fixed bilat space maint, man",Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Humana Medicaid,CPT,D1520,Remove unilat space maintain,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Humana Medicaid,CPT,D1525,Remove bilat space maintain,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Humana Medicaid,CPT,D1526,"Remove bilat space main, max",Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Humana Medicaid,CPT,D1527,"Remove bilat space main, man",Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Humana Medicaid,CPT,D1550,Recement space maintainer,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D1551,Recement space maint - max,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Humana Medicaid,CPT,D1552,Recement space maint - man,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Humana Medicaid,CPT,D1553,Recement unilat space maint,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Humana Medicaid,CPT,D1555,Remove fix space maintainer,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Humana Medicaid,CPT,D1556,Rem fixed unilat space maint,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Humana Medicaid,CPT,D1557,Remove fixed bilat maint max,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Humana Medicaid,CPT,D1558,Remove fixed bilat man,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Humana Medicaid,CPT,D1575,"Dist space maint, fixed unil",Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Humana Medicaid,CPT,D1999,Unspecified preventive proc,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Humana Medicaid,CPT,D2140,Amalgam one surface permanen,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2150,Amalgam two surfaces permane,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2160,Amalgam three surfaces perma,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Humana Medicaid,CPT,D2161,Amalgam 4 or > surfaces perm,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Humana Medicaid,CPT,D2330,Resin one surface-anterior,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2331,Resin two surfaces-anterior,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2332,Resin three surfaces-anterio,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2335,Resin 4/> surf or w incis an,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Humana Medicaid,CPT,D2390,Ant resin-based cmpst crown,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2391,Post 1 srfc resinbased cmpst,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2392,Post 2 srfc resinbased cmpst,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2393,Post 3 srfc resinbased cmpst,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2394,Post >=4srfc resinbase cmpst,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2410,Dental gold foil one surface,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2420,Dental gold foil two surface,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2430,Dental gold foil three surfa,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2510,Dental inlay metalic 1 surf,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2520,Dental inlay metallic 2 surf,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2530,Dental inlay metl 3/more sur,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2542,Dental onlay metallic 2 surf,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2543,Dental onlay metallic 3 surf,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2544,Dental onlay metl 4/more sur,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2610,Inlay porcelain/ceramic 1 su,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2620,Inlay porcelain/ceramic 2 su,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2630,Dental onlay porc 3/more sur,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Humana Medicaid,CPT,D2642,Dental onlay porcelin 2 surf,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2643,Dental onlay porcelin 3 surf,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2644,Dental onlay porc 4/more sur,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2650,Inlay composite/resin one su,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2651,Inlay composite/resin two su,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2652,Dental inlay resin 3/mre sur,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2662,Dental onlay resin 2 surface,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2663,Dental onlay resin 3 surface,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2664,Dental onlay resin 4/mre sur,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2710,Crown resin-based indirect,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Humana Medicaid,CPT,D2712,Crown 3/4 resin-based compos,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Humana Medicaid,CPT,D2720,Crown resin w/ high noble me,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Humana Medicaid,CPT,D2721,Crown resin w/ base metal,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Humana Medicaid,CPT,D2722,Crown resin w/ noble metal,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Humana Medicaid,CPT,D2740,Crown porcelain/ceramic,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Humana Medicaid,CPT,D2750,Crown porcelain w/ h noble m,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Humana Medicaid,CPT,D2751,Crown porcelain fused base m,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Humana Medicaid,CPT,D2752,Crown porcelain w/ noble met,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Humana Medicaid,CPT,D2753,Crown porc fused to titanium,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Humana Medicaid,CPT,D2780,Crown 3/4 cast hi noble met,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Humana Medicaid,CPT,D2781,Crown 3/4 cast base metal,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Humana Medicaid,CPT,D2782,Crown 3/4 cast noble metal,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Humana Medicaid,CPT,D2783,Crown 3/4 porcelain/ceramic,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Humana Medicaid,CPT,D2790,Crown full cast high noble m,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Humana Medicaid,CPT,D2791,Crown full cast base metal,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Humana Medicaid,CPT,D2792,Crown full cast noble metal,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Humana Medicaid,CPT,D2794,Crown-titanium,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Humana Medicaid,CPT,D2799,Provisional crown,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2910,Recement inlay onlay or part,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2915,Recement cast or prefab post,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2920,Re-cement or re-bond crown,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2921,Reattach tooth fragment,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2928,Prefab porc/cer crown perm,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Humana Medicaid,CPT,D2929,Prefab porc/ceram crown pri,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Humana Medicaid,CPT,D2930,Prefab stnlss steel crwn pri,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Humana Medicaid,CPT,D2931,Prefab stnlss steel crown pe,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Humana Medicaid,CPT,D2932,Prefabricated resin crown,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Humana Medicaid,CPT,D2933,Prefab stainless steel crown,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Humana Medicaid,CPT,D2934,Prefab steel crown primary,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Humana Medicaid,CPT,D2941,Int therapeutic restoration,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Humana Medicaid,CPT,D2950,Core build-up incl any pins,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Humana Medicaid,CPT,D2951,Tooth pin retention,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Humana Medicaid,CPT,D2952,Post and core cast + crown,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Humana Medicaid,CPT,D2953,Each addtnl cast post,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Humana Medicaid,CPT,D2954,Prefab post/core + crown,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Humana Medicaid,CPT,D2955,Post removal,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2957,Each addtnl prefab post,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Humana Medicaid,CPT,D2960,Labial veneer resin direct,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2961,Labial veneer resin indirect,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2962,Labial veneer porc indirect,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2970,Temp crown (fractured tooth),Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2971,Add proc construct new crown,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2975,Coping,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2980,Crown repair,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2981,Inlay repair,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2982,Onlay repair,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2983,Veneer repair,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2990,Resin infiltration of lesion,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D2999,Dental unspec restorative pr,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Humana Medicaid,CPT,D3110,Pulp cap direct,Dental,Per Unit,$74.70 ,OP,74.7,74.7,,,,,,
Humana Medicaid,CPT,D3120,Pulp cap indirect,Dental,Per Unit,$74.70 ,OP,74.7,74.7,,,,,,
Humana Medicaid,CPT,D3220,Therapeutic pulpotomy,Dental,Per Unit,$74.70 ,OP,74.7,74.7,,,,,,
Humana Medicaid,CPT,D3221,Gross pulpal debridement,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Humana Medicaid,CPT,D3222,Part pulp for apexogenesis,Dental,Per Unit,$74.70 ,OP,74.7,74.7,,,,,,
Humana Medicaid,CPT,D3230,Pulpal therapy anterior prim,Dental,Per Unit,$74.70 ,OP,74.7,74.7,,,,,,
Humana Medicaid,CPT,D3240,Pulpal therapy posterior pri,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Humana Medicaid,CPT,D3310,"End thxpy, anterior tooth",Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Humana Medicaid,CPT,D3320,"End thxpy, premolar tooth",Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Humana Medicaid,CPT,D3330,"End thxpy, molar tooth",Dental,Per Unit,$135.31 ,OP,135.31,135.31,,,,,,
Humana Medicaid,CPT,D3331,Non-surg tx root canal obs,Dental,Per Unit,$135.31 ,OP,135.31,135.31,,,,,,
Humana Medicaid,CPT,D3332,Incomplete endodontic tx,Dental,Per Unit,$135.31 ,OP,135.31,135.31,,,,,,
Humana Medicaid,CPT,D3333,Internal root repair,Dental,Per Unit,$135.31 ,OP,135.31,135.31,,,,,,
Humana Medicaid,CPT,D3346,Retreat root canal anterior,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Humana Medicaid,CPT,D3347,Retreat root canal premolar,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Humana Medicaid,CPT,D3348,Retreat root canal molar,Dental,Per Unit,$135.31 ,OP,135.31,135.31,,,,,,
Humana Medicaid,CPT,D3351,Apexification/recalc initial,Dental,Per Unit,$74.70 ,OP,74.7,74.7,,,,,,
Humana Medicaid,CPT,D3352,Apexification/recalc interim,Dental,Per Unit,$74.70 ,OP,74.7,74.7,,,,,,
Humana Medicaid,CPT,D3353,Apexification/recalc final,Dental,Per Unit,$74.70 ,OP,74.7,74.7,,,,,,
Humana Medicaid,CPT,D3355,Pulpal regeneration initial,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Humana Medicaid,CPT,D3356,Pulpal regeneration interim,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Humana Medicaid,CPT,D3357,Pulpal regeneration complete,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Humana Medicaid,CPT,D3410,Apicoectomy - anterior,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Humana Medicaid,CPT,D3421,Root surgery premolar,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Humana Medicaid,CPT,D3425,Root surgery molar,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Humana Medicaid,CPT,D3426,Root surgery ea add root,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Humana Medicaid,CPT,D3427,Periradicular surgery,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Humana Medicaid,CPT,D3428,Bone graft peri per tooth,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Humana Medicaid,CPT,D3429,Bone graft peri each addl,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Humana Medicaid,CPT,D3430,Retrograde filling,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Humana Medicaid,CPT,D3431,Biological materials,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Humana Medicaid,CPT,D3432,Guided tissue regeneration,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Humana Medicaid,CPT,D3450,Root amputation,Dental,Per Unit,$135.31 ,OP,135.31,135.31,,,,,,
Humana Medicaid,CPT,D3460,Endodontic endosseous implan,Dental,Per Unit,$135.31 ,OP,135.31,135.31,,,,,,
Humana Medicaid,CPT,D3470,Intentional replantation,Dental,Per Unit,$135.31 ,OP,135.31,135.31,,,,,,
Humana Medicaid,CPT,D3471,Surg rep root res anterior,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Humana Medicaid,CPT,D3472,Surg rep root res premolar,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Humana Medicaid,CPT,D3473,Surg rep root res molar,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Humana Medicaid,CPT,D3501,Surg exp root surf anterior,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Humana Medicaid,CPT,D3502,Surg exp root surf premolar,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Humana Medicaid,CPT,D3503,Surg exp root surf molar,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Humana Medicaid,CPT,D3910,Isolation- tooth w rubb dam,Dental,Per Unit,$135.31 ,OP,135.31,135.31,,,,,,
Humana Medicaid,CPT,D3920,Tooth splitting,Dental,Per Unit,$135.31 ,OP,135.31,135.31,,,,,,
Humana Medicaid,CPT,D3950,Canal prep/fitting of dowel,Dental,Per Unit,$135.31 ,OP,135.31,135.31,,,,,,
Humana Medicaid,CPT,D3999,Endodontic procedure,Dental,Per Unit,$74.70 ,OP,74.7,74.7,,,,,,
Humana Medicaid,CPT,D4210,Gingivectomy/plasty 4 or mor,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Humana Medicaid,CPT,D4211,Gingivectomy/plasty 1 to 3,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Humana Medicaid,CPT,D4212,Gingivectomy/plasty rest,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Humana Medicaid,CPT,D4230,Ana crown exp 4 or> per quad,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Humana Medicaid,CPT,D4231,Ana crown exp 1-3 per quad,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Humana Medicaid,CPT,D4240,Gingival flap proc w/ planin,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Humana Medicaid,CPT,D4241,Gngvl flap w rootplan 1-3 th,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Humana Medicaid,CPT,D4245,Apically positioned flap,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Humana Medicaid,CPT,D4249,Crown lengthen hard tissue,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Humana Medicaid,CPT,D4260,Osseous surgery 4 or more,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Humana Medicaid,CPT,D4261,Osseous surg 1 to 3 teeth,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Humana Medicaid,CPT,D4263,Bone replce graft first site,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Humana Medicaid,CPT,D4264,Bone replce graft each add,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Humana Medicaid,CPT,D4265,Bio mtrls to aid soft/os reg,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Humana Medicaid,CPT,D4266,Guided tiss regen resorble,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Humana Medicaid,CPT,D4267,Guided tiss regen nonresorb,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Humana Medicaid,CPT,D4268,Surgical revision procedure,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Humana Medicaid,CPT,D4270,Pedicle soft tissue graft pr,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Humana Medicaid,CPT,D4273,Auto tissue graft 1st tooth,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Humana Medicaid,CPT,D4274,Mesial/distal wedge proc,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Humana Medicaid,CPT,D4275,Non-auto graft 1st tooth,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Humana Medicaid,CPT,D4276,Con tissue w dble ped graft,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Humana Medicaid,CPT,D4277,Soft tissue graft firsttooth,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Humana Medicaid,CPT,D4278,Soft tissue graft addl tooth,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Humana Medicaid,CPT,D4283,Auto tissue graft addl tooth,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Humana Medicaid,CPT,D4285,Non-auto graft addl tooth,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Humana Medicaid,CPT,D4320,Provision splnt intracoronal,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Humana Medicaid,CPT,D4321,Provisional splint extracoro,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Humana Medicaid,CPT,D4341,Periodontal scaling & root,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Humana Medicaid,CPT,D4342,Periodontal scaling 1-3teeth,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Humana Medicaid,CPT,D4346,Scaling gingiv inflammation,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Humana Medicaid,CPT,D4355,Full mouth debridement,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Humana Medicaid,CPT,D4381,Localized delivery antimicro,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Humana Medicaid,CPT,D4910,Periodontal maint procedures,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Humana Medicaid,CPT,D4920,Unscheduled dressing change,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Humana Medicaid,CPT,D4921,Gingival irrigation per quad,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Humana Medicaid,CPT,D4999,Unspecified periodontal proc,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Humana Medicaid,CPT,D5110,Dentures complete maxillary,Dental,Per Unit,$162.24 ,OP,162.24,162.24,,,,,,
Humana Medicaid,CPT,D5120,Dentures complete mandible,Dental,Per Unit,$162.24 ,OP,162.24,162.24,,,,,,
Humana Medicaid,CPT,D5130,Dentures immediat maxillary,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
Humana Medicaid,CPT,D5140,Dentures immediat mandible,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
Humana Medicaid,CPT,D5211,Dentures maxill part resin,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
Humana Medicaid,CPT,D5212,Dentures mand part resin,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
Humana Medicaid,CPT,D5213,Dentures maxill part metal,Dental,Per Unit,$162.24 ,OP,162.24,162.24,,,,,,
Humana Medicaid,CPT,D5214,Dentures mandibl part metal,Dental,Per Unit,$162.24 ,OP,162.24,162.24,,,,,,
Humana Medicaid,CPT,D5221,Immed max part denture resin,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
Humana Medicaid,CPT,D5222,Immed man part denture resin,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
Humana Medicaid,CPT,D5223,Immed max part dent metal,Dental,Per Unit,$162.24 ,OP,162.24,162.24,,,,,,
Humana Medicaid,CPT,D5224,Immed mand part dent metal,Dental,Per Unit,$162.24 ,OP,162.24,162.24,,,,,,
Humana Medicaid,CPT,D5225,Maxillary part denture flex,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
Humana Medicaid,CPT,D5226,Mandibular part denture flex,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
Humana Medicaid,CPT,D5281,Removable partial denture,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
Humana Medicaid,CPT,D5282,"Remove unil part denture,max",Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
Humana Medicaid,CPT,D5283,"Remove unil part denture,man",Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
Humana Medicaid,CPT,D5284,Rem unilat dent flex base,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
Humana Medicaid,CPT,D5286,Rem unilat dent 1 pc resin,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
Humana Medicaid,CPT,D5410,Dentures adjust cmplt maxil,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D5411,Dentures adjust cmplt mand,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D5421,Dentures adjust part maxill,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D5422,Dentures adjust part mandbl,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D5510,Dentur repr broken compl bas,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Humana Medicaid,CPT,D5511,Rep broke comp dent base man,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Humana Medicaid,CPT,D5512,Rep broke comp dent base max,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Humana Medicaid,CPT,D5520,Replace denture teeth complt,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Humana Medicaid,CPT,D5610,Dentures repair resin base,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Humana Medicaid,CPT,D5611,Rep resin part dent base man,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Humana Medicaid,CPT,D5612,Rep resin part dent base max,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Humana Medicaid,CPT,D5620,Rep part denture cast frame,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Humana Medicaid,CPT,D5621,Rep cast part frame man,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Humana Medicaid,CPT,D5622,Rep cast part frame max,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Humana Medicaid,CPT,D5630,Rep partial denture clasp,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Humana Medicaid,CPT,D5640,Replace part denture teeth,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Humana Medicaid,CPT,D5650,Add tooth to partial denture,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Humana Medicaid,CPT,D5660,Add clasp to partial denture,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Humana Medicaid,CPT,D5670,Replc tth&acrlc on mtl frmwk,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
Humana Medicaid,CPT,D5671,Replc tth&acrlc mandibular,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
Humana Medicaid,CPT,D5710,Dentures rebase cmplt maxil,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Humana Medicaid,CPT,D5711,Dentures rebase cmplt mand,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Humana Medicaid,CPT,D5720,Dentures rebase part maxill,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Humana Medicaid,CPT,D5721,Dentures rebase part mandbl,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Humana Medicaid,CPT,D5730,Denture reln cmplt max dir,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Humana Medicaid,CPT,D5731,Denture reln cmplt mand dir,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Humana Medicaid,CPT,D5740,Denture reln part max dir,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Humana Medicaid,CPT,D5741,Denture reln part mand dir,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Humana Medicaid,CPT,D5750,Denture reln cmplt max indir,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Humana Medicaid,CPT,D5751,Denture reln cmplt mand ind,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Humana Medicaid,CPT,D5760,Denture reln part max indir,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Humana Medicaid,CPT,D5761,Denture reln part mand indir,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Humana Medicaid,CPT,D5810,Denture interm cmplt maxill,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Humana Medicaid,CPT,D5811,Denture interm cmplt mandbl,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Humana Medicaid,CPT,D5820,Denture interm part maxill,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Humana Medicaid,CPT,D5821,Denture interm part mandbl,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Humana Medicaid,CPT,D5850,Denture tiss conditn maxill,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Humana Medicaid,CPT,D5851,Denture tiss condtin mandbl,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Humana Medicaid,CPT,D5862,Precision attachment,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Humana Medicaid,CPT,D5863,Overdenture complete max,Dental,Per Unit,$162.24 ,OP,162.24,162.24,,,,,,
Humana Medicaid,CPT,D5864,Overdenture partial max,Dental,Per Unit,$162.24 ,OP,162.24,162.24,,,,,,
Humana Medicaid,CPT,D5865,Overdenture complete mandib,Dental,Per Unit,$162.24 ,OP,162.24,162.24,,,,,,
Humana Medicaid,CPT,D5866,Overdenture partial mandib,Dental,Per Unit,$162.24 ,OP,162.24,162.24,,,,,,
Humana Medicaid,CPT,D5867,Replacement of precision att,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Humana Medicaid,CPT,D5875,Prosthesis modification,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Humana Medicaid,CPT,D5876,Add metal sub to acrylc dent,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Humana Medicaid,CPT,D5899,Removable prosthodontic proc,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Humana Medicaid,CPT,D5911,Facial moulage sectional,Dental,Per Unit,$30.61 ,OP,30.61,30.61,,,,,,
Humana Medicaid,CPT,D5912,Facial moulage complete,Dental,Per Unit,$30.61 ,OP,30.61,30.61,,,,,,
Humana Medicaid,CPT,D5913,Nasal prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Humana Medicaid,CPT,D5914,Auricular prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Humana Medicaid,CPT,D5915,Orbital prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Humana Medicaid,CPT,D5916,Ocular prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Humana Medicaid,CPT,D5919,Facial prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Humana Medicaid,CPT,D5922,Nasal septal prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Humana Medicaid,CPT,D5923,Ocular prosthesis interim,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Humana Medicaid,CPT,D5924,Cranial prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Humana Medicaid,CPT,D5925,Facial augmentation implant,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Humana Medicaid,CPT,D5926,Replacement nasal prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Humana Medicaid,CPT,D5927,Auricular replacement,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Humana Medicaid,CPT,D5928,Orbital replacement,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Humana Medicaid,CPT,D5929,Facial replacement,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Humana Medicaid,CPT,D5931,Surgical obturator,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Humana Medicaid,CPT,D5932,Postsurgical obturator,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Humana Medicaid,CPT,D5933,Refitting of obturator,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Humana Medicaid,CPT,D5934,Mandibular flange prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Humana Medicaid,CPT,D5935,Mandibular denture prosth,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Humana Medicaid,CPT,D5936,Temp obturator prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Humana Medicaid,CPT,D5937,Trismus appliance,Dental,Per Unit,$30.61 ,OP,30.61,30.61,,,,,,
Humana Medicaid,CPT,D5951,Feeding aid,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Humana Medicaid,CPT,D5952,Pediatric speech aid,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Humana Medicaid,CPT,D5953,Adult speech aid,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Humana Medicaid,CPT,D5954,Superimposed prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Humana Medicaid,CPT,D5955,Palatal lift prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Humana Medicaid,CPT,D5958,Intraoral con def inter plt,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Humana Medicaid,CPT,D5959,Intraoral con def mod palat,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Humana Medicaid,CPT,D5960,Modify speech aid prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Humana Medicaid,CPT,D5982,Surgical stent,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Humana Medicaid,CPT,D5983,Radiation applicator,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Humana Medicaid,CPT,D5984,Radiation shield,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Humana Medicaid,CPT,D5985,Radiation cone locator,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Humana Medicaid,CPT,D5986,Fluoride applicator,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D5987,Commissure splint,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Humana Medicaid,CPT,D5988,Surgical splint,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Humana Medicaid,CPT,D5991,Vesiculobullous disease carr,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D5992,Adjust max prost appliance,Dental,Per Unit,$30.61 ,OP,30.61,30.61,,,,,,
Humana Medicaid,CPT,D5993,Main/clean max prosthesis,Dental,Per Unit,$30.61 ,OP,30.61,30.61,,,,,,
Humana Medicaid,CPT,D5994,Peridontal medicament,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Humana Medicaid,CPT,D5995,"Peri medicament w/seal, max",Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Humana Medicaid,CPT,D5996,"Peri medicament w/seal, mand",Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Humana Medicaid,CPT,D5999,Maxillofacial prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Humana Medicaid,CPT,D6010,Odontics endosteal implant,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Humana Medicaid,CPT,D6011,Second stage implant surgery,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Humana Medicaid,CPT,D6012,Endosteal implant,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Humana Medicaid,CPT,D6013,Surgical place mini implant,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Humana Medicaid,CPT,D6040,Odontics eposteal implant,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Humana Medicaid,CPT,D6050,Odontics transosteal implnt,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Humana Medicaid,CPT,D6051,Interim abutment,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6055,Implant connecting bar,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6056,Prefabricated abutment,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6057,Custom abutment,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6058,Abutment supported crown,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6059,Abutment supported mtl crown,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6060,Abutment supported mtl crown,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6061,Abutment supported mtl crown,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6062,Abutment supported mtl crown,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6063,Abutment supported mtl crown,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6064,Abutment supported mtl crown,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6065,Implant supported crown,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6066,Implant supported mtl crown,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6067,Implant supported mtl crown,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6068,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6069,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6070,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6071,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6072,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6073,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6074,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6075,Implant supported retainer,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6076,Implant supported retainer,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6077,Implant supported retainer,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6080,Implant maintenance,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Humana Medicaid,CPT,D6081,"Scale & debride, single imp",Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Humana Medicaid,CPT,D6082,Imp crown porc to base alloy,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6083,Imp crown porc to noble allo,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6084,Imp crown porc to titanium,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6085,Provisional implant crown,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Humana Medicaid,CPT,D6086,Imp crown base alloys,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6087,Implant crown noble alloys,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6088,Imp crown titanium alloys,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6090,Repair implant,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Humana Medicaid,CPT,D6091,Repl semi/precision attach,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Humana Medicaid,CPT,D6092,Recement supp crown,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Humana Medicaid,CPT,D6093,Recement supp part denture,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Humana Medicaid,CPT,D6094,Abut support crown titanium,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6095,Odontics repr abutment,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Humana Medicaid,CPT,D6096,Remove broken imp ret screw,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Humana Medicaid,CPT,D6097,Abut crown porc to titanium,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6098,Imp retain porc to base allo,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6099,Imp retainer for fpd,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6100,Removal of implant,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Humana Medicaid,CPT,D6101,Debridement of a periimplant,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Humana Medicaid,CPT,D6102,Debridement & contouring,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Humana Medicaid,CPT,D6103,Bone graft repair perimplant,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Humana Medicaid,CPT,D6104,Bone graft time of implant,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Humana Medicaid,CPT,D6110,Implnt/abut remov dent max,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6111,Implnt/abut remov dent mand,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6112,Imp/abut rem dent part max,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6113,Imp/abut rem dent part mand,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6114,Implnt/abut fixed dent max,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6115,Implnt/abut fixed dent mand,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6116,Imp/abut fixed dent part max,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6117,Imp/abut fixed dent part man,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6118,Imp/abut int fixed dent man,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6119,Int/abut int fixed dent max,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6120,Imp retain porc to titanium,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6121,Retain metal fpd base alloys,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6122,Retain metal fpd noble alloy,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6123,Retain metal fpd titanium,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6190,Radio/surgical implant index,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Humana Medicaid,CPT,D6191,Semi precision abutment,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Humana Medicaid,CPT,D6192,Semi precision attachment,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Humana Medicaid,CPT,D6194,Abut support retainer titani,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6195,Abut retain porc to titanium,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Humana Medicaid,CPT,D6199,Implant procedure,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Humana Medicaid,CPT,D6205,Pontic-indirect resin based,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
Humana Medicaid,CPT,D6210,Prosthodont high noble metal,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
Humana Medicaid,CPT,D6211,Bridge base metal cast,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
Humana Medicaid,CPT,D6212,Bridge noble metal cast,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
Humana Medicaid,CPT,D6214,Pontic titanium,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
Humana Medicaid,CPT,D6240,Bridge porcelain high noble,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
Humana Medicaid,CPT,D6241,Bridge porcelain base metal,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
Humana Medicaid,CPT,D6242,Bridge porcelain nobel metal,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
Humana Medicaid,CPT,D6243,Pontic porcelain to titanium,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
Humana Medicaid,CPT,D6245,Bridge porcelain/ceramic,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
Humana Medicaid,CPT,D6250,Bridge resin w/high noble,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
Humana Medicaid,CPT,D6251,Bridge resin base metal,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
Humana Medicaid,CPT,D6252,Bridge resin w/noble metal,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
Humana Medicaid,CPT,D6253,Provisional pontic,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
Humana Medicaid,CPT,D6545,Dental retainr cast metl,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Humana Medicaid,CPT,D6548,Porcelain/ceramic retainer,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Humana Medicaid,CPT,D6549,Resin retainer,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Humana Medicaid,CPT,D6600,Porcelain/ceramic inlay 2srf,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Humana Medicaid,CPT,D6601,Porc/ceram inlay >= 3 surfac,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Humana Medicaid,CPT,D6602,Cst hgh nble mtl inlay 2 srf,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Humana Medicaid,CPT,D6603,Cst hgh nble mtl inlay >=3sr,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Humana Medicaid,CPT,D6604,Cst bse mtl inlay 2 surfaces,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Humana Medicaid,CPT,D6605,Cst bse mtl inlay >= 3 surfa,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Humana Medicaid,CPT,D6606,Cast noble metal inlay 2 sur,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Humana Medicaid,CPT,D6607,Cst noble mtl inlay >=3 surf,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Humana Medicaid,CPT,D6608,Onlay porc/crmc 2 surfaces,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Humana Medicaid,CPT,D6609,Onlay porc/crmc >=3 surfaces,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Humana Medicaid,CPT,D6610,Onlay cst hgh nbl mtl 2 srfc,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Humana Medicaid,CPT,D6611,Onlay cst hgh nbl mtl >=3srf,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Humana Medicaid,CPT,D6612,Onlay cst base mtl 2 surface,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Humana Medicaid,CPT,D6613,Onlay cst base mtl >=3 surfa,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Humana Medicaid,CPT,D6614,Onlay cst nbl mtl 2 surfaces,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Humana Medicaid,CPT,D6615,Onlay cst nbl mtl >=3 surfac,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Humana Medicaid,CPT,D6624,Inlay titanium,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Humana Medicaid,CPT,D6634,Onlay titanium,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Humana Medicaid,CPT,D6710,Crown-indirect resin based,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Humana Medicaid,CPT,D6720,Retain crown resin w hi nble,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Humana Medicaid,CPT,D6721,Crown resin w/base metal,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Humana Medicaid,CPT,D6722,Crown resin w/noble metal,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Humana Medicaid,CPT,D6740,Crown porcelain/ceramic,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Humana Medicaid,CPT,D6750,Crown porcelain high noble,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Humana Medicaid,CPT,D6751,Crown porcelain base metal,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Humana Medicaid,CPT,D6752,Crown porcelain noble metal,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Humana Medicaid,CPT,D6753,Retain crown porc to titaniu,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Humana Medicaid,CPT,D6780,Crown 3/4 high noble metal,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Humana Medicaid,CPT,D6781,Crown 3/4 cast based metal,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Humana Medicaid,CPT,D6782,Crown 3/4 cast noble metal,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Humana Medicaid,CPT,D6783,Crown 3/4 porcelain/ceramic,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Humana Medicaid,CPT,D6784,Retainer crown 3/4 titanium,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Humana Medicaid,CPT,D6790,Crown full high noble metal,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Humana Medicaid,CPT,D6791,Crown full base metal cast,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Humana Medicaid,CPT,D6792,Crown full noble metal cast,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Humana Medicaid,CPT,D6793,Provisional retainer crown,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Humana Medicaid,CPT,D6794,Crown titanium,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Humana Medicaid,CPT,D6920,Dental connector bar,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Humana Medicaid,CPT,D6930,Recement/bond part denture,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Humana Medicaid,CPT,D6940,Stress breaker,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Humana Medicaid,CPT,D6950,Precision attachment,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Humana Medicaid,CPT,D6980,Fixed partial repair,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Humana Medicaid,CPT,D6985,Pediatric partial denture fx,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
Humana Medicaid,CPT,D6999,Fixed prosthodontic proc,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Humana Medicaid,CPT,D7111,Extraction coronal remnants,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7140,Extraction erupted tooth/exr,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7210,Rem imp tooth w mucoper flp,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7220,Impact tooth remov soft tiss,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7230,Impact tooth remov part bony,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7240,Impact tooth remov comp bony,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7241,Impact tooth rem bony w/comp,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Humana Medicaid,CPT,D7250,Tooth root removal,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7251,Coronectomy,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Humana Medicaid,CPT,D7260,Oral antral fistula closure,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7261,Primary closure sinus perf,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Humana Medicaid,CPT,D7270,Tooth reimplantation,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7272,Tooth transplantation,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7280,Exposure of unerupted tooth,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Humana Medicaid,CPT,D7282,Mobilize erupted/malpos toot,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7283,Place device impacted tooth,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7285,Biopsy of oral tissue hard,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7286,Biopsy of oral tissue soft,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D7287,Exfoliative cytolog collect,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7288,Brush biopsy,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7290,Repositioning of teeth,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D7291,Transseptal fiberotomy,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7292,Screw retained plate,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7293,Temp anchorage dev w flap,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7294,Temp anchorage dev w/o flap,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7295,"Bone harvest,auto graft proc",Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7296,"Corticotomy, 1-3 teeth",Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Humana Medicaid,CPT,D7297,"Corticotomy, 4 or more teeth",Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Humana Medicaid,CPT,D7310,Alveoplasty w/ extraction,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7311,Alveoloplasty w/extract 1-3,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7320,Alveoplasty w/o extraction,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7321,Alveoloplasty not w/extracts,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7340,Vestibuloplasty ridge extens,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Humana Medicaid,CPT,D7350,Vestibuloplasty exten graft,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,D7410,Rad exc lesion up to 1.25 cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7411,Excision benign lesion>1.25c,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7412,Excision benign lesion compl,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7413,Excision malig lesion<=1.25c,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7414,Excision malig lesion>1.25cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7415,Excision malig les complicat,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7440,Malig tumor exc to 1.25 cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7441,Malig tumor > 1.25 cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7450,Rem odontogen cyst to 1.25cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7451,Rem odontogen cyst > 1.25 cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7460,Rem nonodonto cyst to 1.25cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7461,Rem nonodonto cyst > 1.25 cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7465,Lesion destruction,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7471,Rem exostosis any site,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7472,Removal of torus palatinus,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Humana Medicaid,CPT,D7473,Remove torus mandibularis,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7485,Surg reduct osseoustuberosit,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7490,Maxilla or mandible resectio,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Humana Medicaid,CPT,D7510,I&d absc intraoral soft tiss,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D7511,Incision/drain abscess intra,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7520,I&d abscess extraoral,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7521,Incision/drain abscess extra,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7530,Removal fb skin/areolar tiss,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7540,Removal of fb reaction,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Humana Medicaid,CPT,D7550,Removal of sloughed off bone,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7560,Maxillary sinusotomy,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Humana Medicaid,CPT,D7610,Maxilla open reduct simple,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,D7620,Clsd reduct simpl maxilla fx,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Humana Medicaid,CPT,D7630,Open red simpl mandible fx,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,D7640,Clsd red simpl mandible fx,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Humana Medicaid,CPT,D7650,Open red simp malar/zygom fx,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Humana Medicaid,CPT,D7660,Clsd red simp malar/zygom fx,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7670,Closd rductn splint alveolus,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7671,Alveolus open reduction,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7680,Reduct simple facial bone fx,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Humana Medicaid,CPT,D7710,Maxilla open reduct compound,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,D7720,Clsd reduct compd maxilla fx,Dental,Per Unit,$156.21 ,OP,156.21,156.21,,,,,,
Humana Medicaid,CPT,D7730,Open reduct compd mandble fx,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,D7740,Clsd reduct compd mandble fx,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Humana Medicaid,CPT,D7750,Open red comp malar/zygma fx,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Humana Medicaid,CPT,D7760,Clsd red comp malar/zygma fx,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7770,Open reduc compd alveolus fx,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7771,Alveolus clsd reduc stblz te,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7780,Reduct compnd facial bone fx,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7810,Tmj open reduct-dislocation,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,D7820,Closed tmp manipulation,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7830,Tmj manipulation under anest,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7840,Removal of tmj condyle,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,D7850,Tmj meniscectomy,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,D7852,Tmj repair of joint disc,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,D7854,Tmj excisn of joint membrane,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,D7856,Tmj cutting of a muscle,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,D7858,Tmj reconstruction,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,D7860,Tmj cutting into joint,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,D7865,Tmj reshaping components,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,D7870,Tmj aspiration joint fluid,Dental,Per Unit,$156.21 ,OP,156.21,156.21,,,,,,
Humana Medicaid,CPT,D7871,Lysis + lavage w catheters,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7872,Tmj diagnostic arthroscopy,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D7873,Tmj arthroscopy lysis adhesn,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,D7874,Tmj arthroscopy disc reposit,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,D7875,Tmj arthroscopy synovectomy,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,D7876,Tmj arthroscopy discectomy,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,D7877,Tmj arthroscopy debridement,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,D7880,Occlusal orthotic appliance,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7881,Occ orthotic device adjust,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D7899,Tmj unspecified therapy,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7910,Dent sutur recent wnd to 5cm,Dental,Per Unit,$156.21 ,OP,156.21,156.21,,,,,,
Humana Medicaid,CPT,D7911,Dental suture wound to 5 cm,Dental,Per Unit,$156.21 ,OP,156.21,156.21,,,,,,
Humana Medicaid,CPT,D7912,Suture complicate wnd > 5 cm,Dental,Per Unit,$156.21 ,OP,156.21,156.21,,,,,,
Humana Medicaid,CPT,D7920,Dental skin graft,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7921,Collect & appl blood product,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7922,Place intra-socket bio dress,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7940,Reshaping bone orthognathic,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7941,Bone cutting ramus closed,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,D7943,Cutting ramus open w/graft,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,D7944,Bone cutting segmented,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,D7945,Bone cutting body mandible,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,D7946,Reconstruction maxilla total,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,D7947,Reconstruct maxilla segment,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,D7948,Reconstruct midface no graft,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,D7949,Reconstruct midface w/graft,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,D7950,Mandible graft,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Humana Medicaid,CPT,D7951,Sinus aug w bone or bone sub,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Humana Medicaid,CPT,D7952,Sinus augmentation vertical,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Humana Medicaid,CPT,D7953,Bone replacement graft,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Humana Medicaid,CPT,D7955,Repair maxillofacial defects,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Humana Medicaid,CPT,D7960,Frenulectomy/frenectomy,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D7961,Buccal/labial frenectomy,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7962,Lingual frenectomy,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7963,Frenuloplasty,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7970,Excision hyperplastic tissue,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Humana Medicaid,CPT,D7971,Excision pericoronal gingiva,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7972,Surg redct fibrous tuberosit,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7979,Non-surgical sialolithotomy,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7980,Surgical sialolithotomy,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Humana Medicaid,CPT,D7981,Excision of salivary gland,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7982,Sialodochoplasty,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,D7983,Closure of salivary fistula,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7990,Emergency tracheotomy,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,D7991,Dental coronoidectomy,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Humana Medicaid,CPT,D7993,Surg place craniofacial impl,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Humana Medicaid,CPT,D7994,Surg place zygomatic impl,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Humana Medicaid,CPT,D7995,Synthetic graft facial bones,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7996,Implant mandible for augment,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Humana Medicaid,CPT,D7997,Appliance removal,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7998,Intraoral place of fix dev,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D7999,Oral surgery procedure,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Humana Medicaid,CPT,D8010,Limited dental tx primary,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Humana Medicaid,CPT,D8020,Limited dental tx transition,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Humana Medicaid,CPT,D8030,Limited dental tx adolescent,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Humana Medicaid,CPT,D8040,Limited dental tx adult,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Humana Medicaid,CPT,D8050,Intercep dental tx primary,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Humana Medicaid,CPT,D8060,Intercep dental tx transitn,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Humana Medicaid,CPT,D8070,Compre dental tx transition,Dental,Per Unit,$195.04 ,OP,195.04,195.04,,,,,,
Humana Medicaid,CPT,D8080,Compre dental tx adolescent,Dental,Per Unit,$195.04 ,OP,195.04,195.04,,,,,,
Humana Medicaid,CPT,D8090,Compre dental tx adult,Dental,Per Unit,$195.04 ,OP,195.04,195.04,,,,,,
Humana Medicaid,CPT,D8210,Orthodontic rem appliance tx,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Humana Medicaid,CPT,D8220,Fixed appliance therapy habt,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Humana Medicaid,CPT,D8660,Preorthodontic tx visit,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Humana Medicaid,CPT,D8670,Periodic orthodontc tx visit,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Humana Medicaid,CPT,D8680,Orthodontic retention,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Humana Medicaid,CPT,D8681,Removable retainer adjust,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D8690,Orthodontic treatment,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Humana Medicaid,CPT,D8691,Repair ortho appliance,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Humana Medicaid,CPT,D8692,Replacement retainer,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Humana Medicaid,CPT,D8693,Rebond/recement retainers,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Humana Medicaid,CPT,D8694,Repair fixed retainers,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Humana Medicaid,CPT,D8695,Remove fixed ortho appliance,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Humana Medicaid,CPT,D8696,Rep of ortho appliance max,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Humana Medicaid,CPT,D8697,Rep of ortho appliance man,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Humana Medicaid,CPT,D8698,Recement fixed retainer max,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Humana Medicaid,CPT,D8699,Recement fixed retainer man,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Humana Medicaid,CPT,D8701,Repair fixed retainer max,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Humana Medicaid,CPT,D8702,Repair of fixed retainer man,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Humana Medicaid,CPT,D8703,Replace broken retainer max,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Humana Medicaid,CPT,D8704,Replace broken retainer man,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Humana Medicaid,CPT,D8999,Orthodontic procedure,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Humana Medicaid,CPT,D9110,Tx dental pain minor proc,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D9120,Fix partial denture section,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Humana Medicaid,CPT,D9130,Temporomandibular joint dysf,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,D9210,Dent anesthesia w/o surgery,Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
Humana Medicaid,CPT,D9211,Regional block anesthesia,Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
Humana Medicaid,CPT,D9212,Trigeminal block anesthesia,Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
Humana Medicaid,CPT,D9215,Local anesthesia,Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
Humana Medicaid,CPT,D9219,Eval mod/deep sed/gen anest,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Humana Medicaid,CPT,D9220,General anesthesia,Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
Humana Medicaid,CPT,D9221,General anesthesia ea ad 15m,Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
Humana Medicaid,CPT,D9222,"Deep anest, 1st 15 min",Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
Humana Medicaid,CPT,D9223,General anesth ea addl 15 mi,Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
Humana Medicaid,CPT,D9230,Analgesia,Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
Humana Medicaid,CPT,D9239,"Iv mod sedation, 1st 15 min",Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
Humana Medicaid,CPT,D9241,Intravenous sedation,Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
Humana Medicaid,CPT,D9242,Iv sedation ea ad 15 m,Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
Humana Medicaid,CPT,D9243,Iv sedation ea addl 15m,Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
Humana Medicaid,CPT,D9248,Sedation (non-iv),Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
Humana Medicaid,CPT,D9310,Dental consultation,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D9311,Consult w/med hlth care prof,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D9410,Dental house call,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D9420,Hospital/asc call,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D9430,Office visit during hours,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D9440,Office visit after hours,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D9450,Case presentation tx plan,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,D9610,Dent therapeutic drug inject,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D9612,Thera par drugs 2 or > admin,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D9613,Infiltration thera drug,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D9630,Drugs/meds disp for home use,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D9910,Dent appl desensitizing med,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D9911,Appl desensitizing resin,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D9920,Behavior management,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D9930,Treatment of complications,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D9931,Clean/inspect rem appliance,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D9932,Clean & inspect rem dent max,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D9933,Clean & inspect rem dent man,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D9934,Clean rem part denture max,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D9935,Clean rem part denture mand,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D9940,Dental occlusal guard,Dental,Per Unit,$156.21 ,OP,156.21,156.21,,,,,,
Humana Medicaid,CPT,D9941,Fabrication athletic guard,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D9942,Repair/reline occlusal guard,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D9943,Occlusal guard adjustment,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D9944,"Occ guard, hard, full arch",Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D9945,"Occ guard, soft, full arch",Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D9946,"Occ guard, hard, part arch",Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D9950,Occlusion analysis,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D9951,Limited occlusal adjustment,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D9952,Complete occlusal adjustment,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D9970,Enamel microabrasion,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D9971,Odontoplasty per tooth,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D9972,Extrnl bleaching per arch,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D9973,Extrnl bleaching per tooth,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D9974,Intrnl bleaching per tooth,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D9975,External bleaching home app,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D9991,"Case mgmt, appt barriers",Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,D9992,"Case mgmt, care coordination",Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,D9993,"Case mgmt, interviewing",Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,D9994,"Case mgmt, pt education",Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Humana Medicaid,CPT,D9995,Teledentistry real-time,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D9996,Teledentistry dent review,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,D9997,Dent case mgmt special needs,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,D9999,Adjunctive procedure,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Humana Medicaid,CPT,G0008,Admin influenza virus vac,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,G0009,Admin pneumococcal vaccine,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,G0010,Admin hepatitis b vaccine,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Humana Medicaid,CPT,G0027,Semen analysis,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,G0068,Adm iv infusion drug in home,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Humana Medicaid,CPT,G0069,Adm sq infusion drug in home,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Humana Medicaid,CPT,G0070,Adm of chemo drug in home,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Humana Medicaid,CPT,G0071,Comm svcs by rhc/fqhc 5 min,Ancillary Services,Per Unit,$26.19 ,OP,26.19,26.19,,,,,,
Humana Medicaid,CPT,G0076,Care manag h vst new pt 20 m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,G0077,Care manag h vst new pt 30 m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,G0078,Care manag h vst new pt 45 m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,G0079,Care manag h vst new pt 60 m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,G0080,Care manag h vst new pt 75 m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,G0081,Care man h v ext pt 20 mi,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,G0082,Care man h v ext pt 30 m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,G0083,Care man h v ext pt 45 m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,G0084,Care man h v ext pt 60 m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,G0085,Care man h v ext pt 75 m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,G0086,Care man home care plan 30 m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,G0087,Care man home care plan 60 m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,G0088,Adm iv drug 1st home visit,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Humana Medicaid,CPT,G0089,Adm subq drug 1st home visit,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Humana Medicaid,CPT,G0090,Adm iv chemo 1st home visit,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Humana Medicaid,CPT,G0103,Psa screening,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,G0104,Ca screen;flexi sigmoidscope,Preventive Care,Per Unit,$387.00 ,OP,387,387,,,,,,
Humana Medicaid,CPT,G0105,Colorectal scrn; hi risk ind,Preventive Care,Per Unit,$387.00 ,OP,387,387,,,,,,
Humana Medicaid,CPT,G0108,Diab manage trn per indiv,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Humana Medicaid,CPT,G0109,Diab manage trn ind/group,Preventive Care,Per Unit,$26.23 ,OP,26.23,26.23,,,,,,
Humana Medicaid,CPT,G0117,Glaucoma scrn hgh risk direc,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,G0118,Glaucoma scrn hgh risk direc,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,G0121,Colon ca scrn not hi rsk ind,Preventive Care,Per Unit,$387.00 ,OP,387,387,,,,,,
Humana Medicaid,CPT,G0122,Colon ca scrn; barium enema,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Humana Medicaid,CPT,G0123,Screen cerv/vag thin layer,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Humana Medicaid,CPT,G0124,Screen c/v thin layer by md,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Humana Medicaid,CPT,G0127,Trim nail(s),General Surgery,Per Unit,$46.77 ,OP,46.77,46.77,,,,,,
Humana Medicaid,CPT,G0128,Corf skilled nursing service,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,G0130,Single energy x-ray study,Diagnostic Radiology,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
Humana Medicaid,CPT,G0141,"Scr c/v cyto,autosys and md",Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Humana Medicaid,CPT,G0143,"Scr c/v cyto,thinlayer,rescr",Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Humana Medicaid,CPT,G0144,"Scr c/v cyto,thinlayer,rescr",Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Humana Medicaid,CPT,G0145,"Scr c/v cyto,thinlayer,rescr",Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Humana Medicaid,CPT,G0147,"Scr c/v cyto, automated sys",Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Humana Medicaid,CPT,G0148,"Scr c/v cyto, autosys, rescr",Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Humana Medicaid,CPT,G0151,"Hhcp-serv of pt,ea 15 min",Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,G0152,"Hhcp-serv of ot,ea 15 min",Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,G0153,"Hhcp-svs of s/l path,ea 15mn",Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,G0155,"Hhcp-svs of csw,ea 15 min",Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,G0157,Hhc pt assistant ea 15,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,G0158,Hhc ot assistant ea 15,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,G0159,Hhc pt maint ea 15 min,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,G0160,Hhc occup therapy ea 15,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,G0161,Hhc slp ea 15 min,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,G0162,"Hhc rn e&m plan svs, 15 min",Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,G0166,"Extrnl counterpulse, per tx",Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,G0175,"Opps service,sched team conf",Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,G0176,Opps/php;activity therapy,Behavioral Health,Per Unit,$48.15 ,OP,48.15,48.15,,,,,,
Humana Medicaid,CPT,G0177,Opps/php; train & educ serv,Behavioral Health,Per Unit,$48.15 ,OP,48.15,48.15,,,,,,
Humana Medicaid,CPT,G0179,Md recertification hha pt,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,G0180,Md certification hha patient,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,G0181,Home health care supervision,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,G0182,Hospice care supervision,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,G0186,"Dstry eye lesn,fdr vssl tech",Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Humana Medicaid,CPT,G0202,Scr mammo bi incl cad,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
Humana Medicaid,CPT,G0204,Dx mammo incl cad bi,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
Humana Medicaid,CPT,G0206,Dx mammo incl cad uni,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
Humana Medicaid,CPT,G0219,Pet img wholbod melano nonco,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Humana Medicaid,CPT,G0235,Pet not otherwise specified,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Humana Medicaid,CPT,G0237,Therapeutic procd strg endur,Rehabilitation,Per Unit,$73.11 ,OP,73.11,73.11,,,,,,
Humana Medicaid,CPT,G0238,"Oth resp proc, indiv",Rehabilitation,Per Unit,$73.11 ,OP,73.11,73.11,,,,,,
Humana Medicaid,CPT,G0239,"Oth resp proc, group",Rehabilitation,Per Unit,$73.11 ,OP,73.11,73.11,,,,,,
Humana Medicaid,CPT,G0248,Demonstrate use home inr mon,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Humana Medicaid,CPT,G0252,Pet imaging initial dx,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Humana Medicaid,CPT,G0255,Current percep threshold tst,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,G0257,Unsched dialysis esrd pt hos,Nephrology,Per Unit,$540.95 ,OP,540.95,540.95,,,,,,
Humana Medicaid,CPT,G0270,Mnt subs tx for change dx,Ancillary Services,Per Unit,$100.15 ,OP,100.15,100.15,,,,,,
Humana Medicaid,CPT,G0271,Group mnt 2 or more 30 mins,Ancillary Services,Per Unit,$100.15 ,OP,100.15,100.15,,,,,,
Humana Medicaid,CPT,G0278,"Iliac art angio,cardiac cath",Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Humana Medicaid,CPT,G0279,"Tomosynthesis, mammo",Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
Humana Medicaid,CPT,G0283,Elec stim other than wound,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,G0289,"Arthro, loose body + chondro",Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,G0293,"Non-cov surg proc,clin trial",Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,G0297,Ldct for lung ca screen,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Humana Medicaid,CPT,G0306,Cbc/diffwbc w/o platelet,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Humana Medicaid,CPT,G0307,Cbc without platelet,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Humana Medicaid,CPT,G0328,Fecal blood scrn immunoassay,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,G0339,"Robot lin-radsurg com, first",Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"2,592.65","2,592.65",,,,,,
Humana Medicaid,CPT,G0340,Robt lin-radsurg fractx 2-5,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"2,592.65","2,592.65",,,,,,
Humana Medicaid,CPT,G0365,Vessel mapping hemo access,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Humana Medicaid,CPT,G0378,Hospital observation per hr,Ancillary Services,Per Unit,$651.20 ,OP,651.2,651.2,,,,,,
Humana Medicaid,CPT,G0389,Ultrasound exam aaa screen,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,G0396,Alcohol/subs interv 15-30mn,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Humana Medicaid,CPT,G0397,Alcohol/subs interv >30 min,Behavioral Health,Per Unit,$84.55 ,OP,84.55,84.55,,,,,,
Humana Medicaid,CPT,G0403,Ekg for initial prevent exam,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Humana Medicaid,CPT,G0404,Ekg tracing for initial prev,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Humana Medicaid,CPT,G0405,Ekg interpret & report preve,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Humana Medicaid,CPT,G0409,Corf related serv 15 mins ea,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Humana Medicaid,CPT,G0410,Grp psych partial hosp 45-50,Behavioral Health,Per Unit,$119.88 ,OP,119.88,119.88,,,,,,
Humana Medicaid,CPT,G0411,Inter active grp psych parti,Behavioral Health,Per Unit,$119.88 ,OP,119.88,119.88,,,,,,
Humana Medicaid,CPT,G0412,Open tx iliac spine uni/bil,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,G0413,Pelvic ring fracture uni/bil,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,G0414,Pelvic ring fx treat int fix,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,G0415,Open tx post pelvic fxcture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Humana Medicaid,CPT,G0420,Ed svc ckd ind per session,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Humana Medicaid,CPT,G0421,Ed svc ckd grp per session,Preventive Care,Per Unit,$26.23 ,OP,26.23,26.23,,,,,,
Humana Medicaid,CPT,G0422,Intens cardiac rehab w/exerc,Rehabilitation,Per Unit,$274.82 ,OP,274.82,274.82,,,,,,
Humana Medicaid,CPT,G0423,Intens cardiac rehab no exer,Rehabilitation,Per Unit,$274.82 ,OP,274.82,274.82,,,,,,
Humana Medicaid,CPT,G0424,Pulmonary rehab w exer,Rehabilitation,Per Unit,$73.11 ,OP,73.11,73.11,,,,,,
Humana Medicaid,CPT,G0431,Drug screen multiple class,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,G0432,Eia hiv-1/hiv-2 screen,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,G0433,Elisa hiv-1/hiv-2 screen,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,G0434,Drug screen multi drug class,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,G0435,Oral hiv-1/hiv-2 screen,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,G0436,Tobacco-use counsel 3-10 min,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Humana Medicaid,CPT,G0437,Tobacco-use counsel>10min,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Humana Medicaid,CPT,G0442,Annual alcohol screen 15 min,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Humana Medicaid,CPT,G0443,Brief alcohol misuse counsel,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Humana Medicaid,CPT,G0444,Depression screen annual,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Humana Medicaid,CPT,G0445,High inten beh couns std 30m,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Humana Medicaid,CPT,G0446,Intens behave ther cardio dx,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Humana Medicaid,CPT,G0447,Behavior counsel obesity 15m,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Humana Medicaid,CPT,G0448,Place perm pacing cardiovert,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Humana Medicaid,CPT,G0451,Devlopment test interpt&rep,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Humana Medicaid,CPT,G0452,Molecular pathology interpr,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Humana Medicaid,CPT,G0459,Telehealth inpt pharm mgmt,Behavioral Health,Per Unit,$80.13 ,OP,80.13,80.13,,,,,,
Humana Medicaid,CPT,G0464,"Colorec CA scr, sto bas DNA",Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Humana Medicaid,CPT,G0472,Hep c screen high risk/other,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,G0473,Group behave couns 2-10,Behavioral Health,Per Unit,$119.88 ,OP,119.88,119.88,,,,,,
Humana Medicaid,CPT,G0475,Hiv combination assay,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,G0476,Hpv combo assay ca screen,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,G0477,Drug test presump optical,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,G0478,Drug test presump opt inst,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,G0479,Drug test presump not opt,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,G0480,Drug test def 1-7 classes,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,G0491,Dialysis acu kidney no esrd,Nephrology,Per Unit,$540.95 ,OP,540.95,540.95,,,,,,
Humana Medicaid,CPT,G0492,Md/oth eval acut kid no esrd,Nephrology,Per Unit,$540.95 ,OP,540.95,540.95,,,,,,
Humana Medicaid,CPT,G0495,Rn care train/edu in hh,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Humana Medicaid,CPT,G0496,Lpn care train/edu in hh,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Humana Medicaid,CPT,G0498,Chemo extend iv infus w/pump,General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
Humana Medicaid,CPT,G0499,Hepb screen high risk indiv,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,G0500,Mod sedat endo service >5yrs,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Humana Medicaid,CPT,G0502,"Init psych care manag, 70min",Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Humana Medicaid,CPT,G0503,"Subseq  psych care man,60mi",Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Humana Medicaid,CPT,G0504,Init/sub psych care add 30 m,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Humana Medicaid,CPT,G0506,Comp asses care plan ccm svc,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,G0507,Care manage serv minimum 20,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Humana Medicaid,CPT,G0511,Ccm/bhi by rhc/fqhc 20min mo,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,G0512,Cocm by rhc/fqhc 60 min mo,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Humana Medicaid,CPT,G0515,Cognitive skills development,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,G0516,"Insert drug del implant, >=4",General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,G0517,Remove drug implant,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Humana Medicaid,CPT,G0518,Remove w insert drug implant,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
Humana Medicaid,CPT,G0659,Drug test def simple all cl,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Humana Medicaid,CPT,G2000,Blinded conv. tx mdd clin tr,Behavioral Health,Per Unit,$276.44 ,OP,276.44,276.44,,,,,,
Humana Medicaid,CPT,G2010,Remot image submit by pt,Ancillary Services,Per Unit,$26.19 ,OP,26.19,26.19,,,,,,
Humana Medicaid,CPT,G2011,Alcohol/sub misuse assess,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Humana Medicaid,CPT,G2012,Brief check in by md/qhp,Ancillary Services,Per Unit,$26.19 ,OP,26.19,26.19,,,,,,
Humana Medicaid,CPT,G2014,Post-d/c care plan overs 30m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,G2015,Post-d/c care plan overs 60m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,G2058,Ccm add 20min,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,G2064,Md mang high risk dx 30,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,G2065,Clin mang h risk dx 30,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,G2066,Inter devc remote 30d,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Humana Medicaid,CPT,G2082,Visit esketamine 56m or less,Behavioral Health,Per Unit,$80.13 ,OP,80.13,80.13,,,,,,
Humana Medicaid,CPT,G2083,"Visit esketamine, > 56m",Behavioral Health,Per Unit,$80.13 ,OP,80.13,80.13,,,,,,
Humana Medicaid,CPT,G2168,Svs by pt in home health,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,G2169,Svs by ot in home health,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,G2213,Initiat med assist tx in er,Behavioral Health,Per Unit,$80.13 ,OP,80.13,80.13,,,,,,
Humana Medicaid,CPT,G2214,Init/sub psych care m 1st 30,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Humana Medicaid,CPT,G2250,"Remot img sub by pt, non e/m",Ancillary Services,Per Unit,$26.19 ,OP,26.19,26.19,,,,,,
Humana Medicaid,CPT,G2251,"Brief chkin, 5-10, non-e/m",Ancillary Services,Per Unit,$26.19 ,OP,26.19,26.19,,,,,,
Humana Medicaid,CPT,G2252,"Brief chkin by md/qhp, 11-20",Ancillary Services,Per Unit,$26.19 ,OP,26.19,26.19,,,,,,
Humana Medicaid,CPT,G3001,"Admin + supply, tositumomab",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Humana Medicaid,CPT,G6001,Echo guidance radiotherapy,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Humana Medicaid,CPT,G6002,Stereoscopic x-ray guidance,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Humana Medicaid,CPT,G6003,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Humana Medicaid,CPT,G6004,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Humana Medicaid,CPT,G6005,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Humana Medicaid,CPT,G6006,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Humana Medicaid,CPT,G6007,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Humana Medicaid,CPT,G6008,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Humana Medicaid,CPT,G6009,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Humana Medicaid,CPT,G6010,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Humana Medicaid,CPT,G6011,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Humana Medicaid,CPT,G6012,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Humana Medicaid,CPT,G6013,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Humana Medicaid,CPT,G6014,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Humana Medicaid,CPT,G6015,Radiation tx delivery imrt,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Humana Medicaid,CPT,G6016,Delivery comp imrt,Therapeutic Radiology,Per Unit,$434.17 ,OP,434.17,434.17,,,,,,
Humana Medicaid,CPT,G6018,Ileoscopy w/stent,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
Humana Medicaid,CPT,G6019,Colonoscopy lesion removal,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Humana Medicaid,CPT,G6020,Colonoscopy w/stent,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Humana Medicaid,CPT,G6021,Unlisted px small intestine,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Humana Medicaid,CPT,G6022,Sigmoidoscopy w/ablate tumr,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,G6023,Sigmoidoscopy w/stent,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Humana Medicaid,CPT,G6024,Lesion removal colonoscopy,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,G6025,Colonoscopy w/stent,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Humana Medicaid,CPT,G6027,Anoscopy hra w/spec collect,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,G6028,Anoscopy hra w/biopsy,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Humana Medicaid,CPT,G6030,Assay of amitriptyline,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,G6031,Assay of benzodiazepines,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,G6032,Assay of desipramine,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,G6034,Assay of doxepin,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,G6035,Assay of  gold,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,G6036,Assay of Imipramine,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,G6037,Assay of nortiptyline,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,G6038,Assay of salicylate,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Humana Medicaid,CPT,G6039,Assay of acetaminophen,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Humana Medicaid,CPT,G6040,Assay of ethanol,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Humana Medicaid,CPT,G6041,Assay of urine alkaloids,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Humana Medicaid,CPT,G6042,Assay of amphetamines,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Humana Medicaid,CPT,G6043,Assay of barbiturates,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Humana Medicaid,CPT,G6044,Assay of cocaine,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Humana Medicaid,CPT,G6045,Assay of dihydrocodeinone,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Humana Medicaid,CPT,G6046,Assay of dihydromorphinone,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Humana Medicaid,CPT,G6047,Assay of dihydrotestosterone,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Humana Medicaid,CPT,G6048,Assay of dimethadione,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Humana Medicaid,CPT,G6049,Assay of Epiandrosterone,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Humana Medicaid,CPT,G6050,Assay of Ethchlorvynol,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Humana Medicaid,CPT,G6051,Assay of flurazepam,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Humana Medicaid,CPT,G6052,Assay of meprobamate,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Humana Medicaid,CPT,G6053,Assay of methadone,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Humana Medicaid,CPT,G6054,Assay of methsuximide,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Humana Medicaid,CPT,G6055,Assay of nicotine,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Humana Medicaid,CPT,G6056,Assay of opiates,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Humana Medicaid,CPT,G6057,Assay of phenothiazine,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Humana Medicaid,CPT,G6058,Drug confirmation,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Humana Medicaid,CPT,G9012,Other specified case mgmt,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,G9016,Demo-smoking cessation coun,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Humana Medicaid,CPT,G9020,Rimantadine hcl 100mg oral,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,G9034,"Zanamivir, inh pwdr, brand",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Humana Medicaid,CPT,G9035,"Oseltamivir phosp, brand",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Humana Medicaid,CPT,G9143,Warfarin respon genetic test,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,G9147,Outpt iv insulin tx any mea,General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
Humana Medicaid,CPT,G9157,Transesoph doppl cardiac mon,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Humana Medicaid,CPT,G9187,Bpci home visit,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,G9477,Care coord at hospice,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,G9686,Nursing facility conference,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,G9873,1 em core session,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Humana Medicaid,CPT,G9874,4 em core sessions,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Humana Medicaid,CPT,G9875,9 em core sessions,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Humana Medicaid,CPT,G9876,2 em core ms mo 7-9 no wl,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Humana Medicaid,CPT,G9877,2 em core ms mo 10-12 no wl,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Humana Medicaid,CPT,G9878,2 em core ms mo 7-9 wl,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Humana Medicaid,CPT,G9879,2 em core ms mo 10-12 wl,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Humana Medicaid,CPT,G9880,Em 5 percent wl,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Humana Medicaid,CPT,G9881,Em 9 percent wl,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Humana Medicaid,CPT,G9882,2 em ongoing ms mo 13-15 wl,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Humana Medicaid,CPT,G9883,2 em ongoing ms mo 16-18 wl,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Humana Medicaid,CPT,G9884,2 em ongoing ms mo 19-21 wl,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Humana Medicaid,CPT,G9885,2 em ongoing ms mo 22-24 wl,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Humana Medicaid,CPT,G9890,Em bridge payment,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Humana Medicaid,CPT,G9987,Bpci advanced in home visit,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,H0001,Alcohol and/or drug assess,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
Humana Medicaid,CPT,H0002,Alcohol and/or drug screenin,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
Humana Medicaid,CPT,H0003,Alcohol and/or drug screenin,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,H0004,Alcohol and/or drug services,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Humana Medicaid,CPT,H0005,Alcohol and/or drug services,Behavioral Health,Per Unit,$119.88 ,OP,119.88,119.88,,,,,,
Humana Medicaid,CPT,H0006,Alcohol and/or drug services,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Humana Medicaid,CPT,H0007,Alcohol and/or drug services,Behavioral Health,Per Unit,$135.70 ,OP,135.7,135.7,,,,,,
Humana Medicaid,CPT,H0014,Alcohol and/or drug services,Behavioral Health,Per Unit,$80.13 ,OP,80.13,80.13,,,,,,
Humana Medicaid,CPT,H0015,Alcohol and/or drug services,Behavioral Health,Per Unit,$339.88 ,OP,339.88,339.88,,,,,,
Humana Medicaid,CPT,H0020,Alcohol and/or drug services,Behavioral Health,Per Unit,$80.13 ,OP,80.13,80.13,,,,,,
Humana Medicaid,CPT,H0022,Alcohol and/or drug interven,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Humana Medicaid,CPT,H0031,Mh health assess by non-md,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
Humana Medicaid,CPT,H0032,Mh svc plan dev by non-md,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Humana Medicaid,CPT,H0033,Oral med adm direct observe,Behavioral Health,Per Unit,$80.13 ,OP,80.13,80.13,,,,,,
Humana Medicaid,CPT,H0034,Med trng & support per 15min,Behavioral Health,Per Unit,$80.13 ,OP,80.13,80.13,,,,,,
Humana Medicaid,CPT,H0035,Mh partial hosp tx under 24h,Behavioral Health,Per Unit,$220.60 ,OP,220.6,220.6,,,,,,
Humana Medicaid,CPT,H0037,Comm psy sup tx pgm per diem,Behavioral Health,Per Unit,$220.60 ,OP,220.6,220.6,,,,,,
Humana Medicaid,CPT,H0046,"Mental health service, nos",Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Humana Medicaid,CPT,H0047,Alcohol/drug abuse svc nos,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Humana Medicaid,CPT,H0049,Alcohol/drug screening,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Humana Medicaid,CPT,H0050,Alcohol/drug service 15 min,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Humana Medicaid,CPT,H1002,Carecoordination prenatal,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,H1003,Prenatal at risk education,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Humana Medicaid,CPT,H1011,Family assessment,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
Humana Medicaid,CPT,H2000,Comp multidisipln evaluation,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Humana Medicaid,CPT,H2001,Rehabilitation program 1/2 d,Behavioral Health,Per Unit,$166.94 ,OP,166.94,166.94,,,,,,
Humana Medicaid,CPT,H2010,Comprehensive med svc 15 min,Behavioral Health,Per Unit,$80.13 ,OP,80.13,80.13,,,,,,
Humana Medicaid,CPT,H2011,"Crisis interven svc, 15 min",Behavioral Health,Per Unit,$135.70 ,OP,135.7,135.7,,,,,,
Humana Medicaid,CPT,H2012,"Behav hlth day treat, per hr",Behavioral Health,Per Unit,$276.34 ,OP,276.34,276.34,,,,,,
Humana Medicaid,CPT,H2014,"Skills train and dev, 15 min",Behavioral Health,Per Unit,$48.15 ,OP,48.15,48.15,,,,,,
Humana Medicaid,CPT,H2017,"Psysoc rehab svc, per 15 min",Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Humana Medicaid,CPT,H2018,"Psysoc rehab svc, per diem",Behavioral Health,Per Unit,$220.60 ,OP,220.6,220.6,,,,,,
Humana Medicaid,CPT,H2019,"Ther behav svc, per 15 min",Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Humana Medicaid,CPT,H2020,"Ther behav svc, per diem",Behavioral Health,Per Unit,$220.60 ,OP,220.6,220.6,,,,,,
Humana Medicaid,CPT,H2027,"Psychoed svc, per 15 min",Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Humana Medicaid,CPT,H2028,"Sex offend tx svc, 15 min",Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Humana Medicaid,CPT,H2029,"Sex offend tx svc, per diem",Behavioral Health,Per Unit,$220.60 ,OP,220.6,220.6,,,,,,
Humana Medicaid,CPT,H2032,"Activity therapy, per 15 min",Behavioral Health,Per Unit,$48.15 ,OP,48.15,48.15,,,,,,
Humana Medicaid,CPT,H2033,Multisys ther/juvenile 15min,Behavioral Health,Per Unit,$48.15 ,OP,48.15,48.15,,,,,,
Humana Medicaid,CPT,H2035,"A/d tx program, per hour",Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Humana Medicaid,CPT,H2036,"A/d tx program, per diem",Behavioral Health,Per Unit,$220.60 ,OP,220.6,220.6,,,,,,
Humana Medicaid,CPT,J0121,"Inj., omadacycline, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Humana Medicaid,CPT,J0122,"Inj., eravacycline, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,J0129,Abatacept injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Humana Medicaid,CPT,J0130,Abciximab injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Humana Medicaid,CPT,J0135,Adalimumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,518.96,518.96,,,,,,
Humana Medicaid,CPT,J0178,Aflibercept injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Humana Medicaid,CPT,J0179,"Inj, brolucizumab-dbll, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Humana Medicaid,CPT,J0180,Agalsidase beta injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Humana Medicaid,CPT,J0185,"Inj., aprepitant, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Humana Medicaid,CPT,J0202,"Injection, alemtuzumab",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,J0205,Alglucerase injection,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Humana Medicaid,CPT,J0207,Amifostine,Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,244.88,244.88,,,,,,
Humana Medicaid,CPT,J0210,Methyldopate hcl injection,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Humana Medicaid,CPT,J0215,Alefacept,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Humana Medicaid,CPT,J0220,Alglucosidase alfa injection,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,J0221,Lumizyme injection,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,J0222,"Inj., patisiran, 0.1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,J0223,Inj givosiran 0.5 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,J0256,Alpha 1 proteinase inhibitor,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Humana Medicaid,CPT,J0257,Glassia injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Humana Medicaid,CPT,J0287,Amphotericin b lipid complex,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,J0288,Ampho b cholesteryl sulfate,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,J0289,Amphotericin b liposome inj,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,J0291,"Inj., plazomicin, 5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,J0348,Anidulafungin injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,J0350,Injection anistreplase 30 u,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,J0364,Apomorphine hydrochloride,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,J0365,"Aprotonin, 10,000 kiu",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Humana Medicaid,CPT,J0401,Inj aripiprazole ext rel 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Humana Medicaid,CPT,J0475,Baclofen 10 mg injection,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,384.11,384.11,,,,,,
Humana Medicaid,CPT,J0480,Basiliximab,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Humana Medicaid,CPT,J0485,Belatacept injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Humana Medicaid,CPT,J0490,Belimumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Humana Medicaid,CPT,J0517,"Inj., benralizumab, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,J0558,Peng benzathine/procaine inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,J0561,Penicillin g benzathine inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,J0565,"Inj, bezlotoxumab, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Humana Medicaid,CPT,J0567,"Inj., cerliponase alfa 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,J0570,Buprenorphine implant 74.2mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Humana Medicaid,CPT,J0583,Bivalirudin,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,J0584,"Injection, burosumab-twza 1m",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,J0585,"Injection,onabotulinumtoxina",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,J0586,Abobotulinumtoxina,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,384.11,384.11,,,,,,
Humana Medicaid,CPT,J0587,"Inj, rimabotulinumtoxinb",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,J0588,Incobotulinumtoxin a,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,J0591,"Inj deoxycholic acid, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,J0593,"Inj., lanadelumab-flyo, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,J0594,Busulfan injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Humana Medicaid,CPT,J0596,"Injection, ruconest",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J0597,"C-1 esterase, berinert",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,J0598,"C-1 esterase, cinryze",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,J0599,"Inj., haegarda 10 units",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,J0600,Edetate calcium disodium inj,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J0604,"Cinacalcet, esrd on dialysis",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,J0606,"Inj, etelcalcetide, 0.1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,J0630,Calcitonin salmon injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Humana Medicaid,CPT,J0637,Caspofungin acetate,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,J0638,Canakinumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Humana Medicaid,CPT,J0641,Inj levoleucovorin nos 0.5mg,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
Humana Medicaid,CPT,J0642,"Injection, khapzory, 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,J0691,Inj lefamulin 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Humana Medicaid,CPT,J0693,"Inj., cefiderocol, 5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Humana Medicaid,CPT,J0695,Inj ceftolozane tazobactam,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Humana Medicaid,CPT,J0712,Ceftaroline fosamil inj,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
Humana Medicaid,CPT,J0714,Ceftazidime and avibactam,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,J0716,Centruroides immune f(ab),Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Humana Medicaid,CPT,J0717,Certolizumab pegol inj 1mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Humana Medicaid,CPT,J0740,Cidofovir injection,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Humana Medicaid,CPT,J0742,Inj imip 4 cilas 4 releb 2mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Humana Medicaid,CPT,J0775,"Collagenase, clost hist inj",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Humana Medicaid,CPT,J0791,Inj crizanlizumab-tmca 5mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Humana Medicaid,CPT,J0795,Corticorelin ovine triflutal,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Humana Medicaid,CPT,J0800,Corticotropin injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,J0833,Cosyntropin injection nos,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,J0840,Crotalidae poly immune fab,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Humana Medicaid,CPT,J0841,Inj crotalidae im f(ab')2 eq,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Humana Medicaid,CPT,J0850,Cytomegalovirus imm iv /vial,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Humana Medicaid,CPT,J0875,"Injection, dalbavancin",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,J0878,Daptomycin injection,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,189.67,189.67,,,,,,
Humana Medicaid,CPT,J0881,"Darbepoetin alfa, non-esrd",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,J0882,"Darbepoetin alfa, esrd use",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Humana Medicaid,CPT,J0883,Argatroban nonesrd use 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,J0884,Argatroban esrd dialysis 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,J0885,"Epoetin alfa, non-esrd",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,J0886,Epoetin alfa 1000 units esrd,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,J0890,Peginesatide injection,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Humana Medicaid,CPT,J0894,Decitabine injection,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Humana Medicaid,CPT,J0896,Inj luspatercept-aamt 0.25mg,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Humana Medicaid,CPT,J0897,Denosumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,518.96,518.96,,,,,,
Humana Medicaid,CPT,J1095,"Injection, dexamethasone 9%",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,J1096,Dexametha opth insert 0.1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,J1097,Phenylep ketorolac opth soln,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,J1162,Digoxin immune fab (ovine),Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J1190,Dexrazoxane hcl injection,Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,244.88,244.88,,,,,,
Humana Medicaid,CPT,J1201,Inj. cetirizine hcl 0.5mg,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,J1205,Chlorothiazide sodium inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,J1212,Dimethyl sulfoxide 50% 50 ml,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,J1267,Doripenem injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,J1290,Ecallantide injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Humana Medicaid,CPT,J1300,Eculizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,J1301,"Injection, edaravone, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Humana Medicaid,CPT,J1303,"Inj., ravulizumab-cwvz 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,J1322,"Elosulfase alfa, injection",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,J1327,Eptifibatide injection,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Humana Medicaid,CPT,J1410,Inj estrogen conjugate 25 mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Humana Medicaid,CPT,J1428,"Inj, eteplirsen, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,J1429,Inj golodirsen 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,J1430,Ethanolamine oleate 100 mg,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,384.11,384.11,,,,,,
Humana Medicaid,CPT,J1436,Etidronate disodium inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,J1437,Inj. fe derisomaltose 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,J1438,Etanercept injection,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,J1439,Inj ferric carboxymaltos 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,J1442,Inj filgrastim excl biosimil,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,J1446,"Inj, tbo-filgrastim, 5 mcg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,J1447,Inj tbo filgrastim 1 microg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,J1451,"Fomepizole, 15 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,J1452,Intraocular fomivirsen na,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,J1453,Fosaprepitant injection,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Humana Medicaid,CPT,J1454,"Inj fosnetupitant, palonoset",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,J1455,Foscarnet sodium injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,J1457,Gallium nitrate injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,J1458,Galsulfase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,J1459,Inj ivig privigen 500 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Humana Medicaid,CPT,J1460,Gamma globulin 1 cc inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,J1555,"Inj cuvitru, 100 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Humana Medicaid,CPT,J1556,"Inj, imm glob bivigam, 500mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,J1557,Gammaplex injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,J1558,"Inj. xembify, 100 mg",Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,384.11,384.11,,,,,,
Humana Medicaid,CPT,J1559,Hizentra injection,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,384.11,384.11,,,,,,
Humana Medicaid,CPT,J1560,Gamma globulin > 10 cc inj,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,J1561,Gamunex-c/gammaked,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Humana Medicaid,CPT,J1562,"Vivaglobin, inj",Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,384.11,384.11,,,,,,
Humana Medicaid,CPT,J1566,"Immune globulin, powder",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Humana Medicaid,CPT,J1568,Octagam injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Humana Medicaid,CPT,J1569,Gammagard liquid injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Humana Medicaid,CPT,J1570,Ganciclovir sodium injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,J1571,Hepagam b im injection,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,J1572,Flebogamma injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Humana Medicaid,CPT,J1573,"Hepagam b intravenous, inj",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,J1575,Hyqvia 100mg immuneglobulin,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,J1595,Injection glatiramer acetate,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,J1599,"Ivig non-lyophilized, nos",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Humana Medicaid,CPT,J1602,Golimumab for iv use 1mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Humana Medicaid,CPT,J1610,Glucagon hydrochloride/1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Humana Medicaid,CPT,J1628,"Inj., guselkumab, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Humana Medicaid,CPT,J1632,"Inj., brexanolone, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J1640,"Hemin, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J1670,Tetanus immune globulin inj,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,J1675,Histrelin acetate,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Humana Medicaid,CPT,J1738,Inj. meloxicam 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,J1740,Ibandronate sodium injection,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Humana Medicaid,CPT,J1742,Ibutilide fumarate injection,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
Humana Medicaid,CPT,J1743,Idursulfase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Humana Medicaid,CPT,J1744,Icatibant injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J1745,Infliximab not biosimil 10mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Humana Medicaid,CPT,J1746,"Inj., ibalizumab-uiyk, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J1750,Inj iron dextran,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,J1756,Iron sucrose injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,J1786,Imuglucerase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Humana Medicaid,CPT,J1823,"Inj. inebilizumab-cdon, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,J1826,Interferon beta-1a inj,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
Humana Medicaid,CPT,J1830,Interferon beta-1b / .25 mg,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,J1833,"Injection, isavuconazonium",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,J1930,Lanreotide injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,J1931,Laronidase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Humana Medicaid,CPT,J1942,Aripiprazole lauroxil 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Humana Medicaid,CPT,J1943,"Inj., aristada initio, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Humana Medicaid,CPT,J1944,Aripirazole lauroxil 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Humana Medicaid,CPT,J1945,Lepirudin,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Humana Medicaid,CPT,J1950,Leuprolide acetate /3.75 mg,Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,244.88,244.88,,,,,,
Humana Medicaid,CPT,J2062,Loxapine for inhalation 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,J2170,Mecasermin injection,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,J2182,"Injection, mepolizumab, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Humana Medicaid,CPT,J2186,"Inj., meropenem, vaborbactam",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Humana Medicaid,CPT,J2248,Micafungin sodium injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,J2278,Ziconotide injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Humana Medicaid,CPT,J2315,"Naltrexone, depot form",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Humana Medicaid,CPT,J2323,Natalizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,J2325,Nesiritide injection,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,384.11,384.11,,,,,,
Humana Medicaid,CPT,J2326,"Inj, nusinersen, 0.1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,J2350,"Injection, ocrelizumab, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,J2353,"Octreotide injection, depot",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,J2355,Oprelvekin injection,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,J2357,Omalizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Humana Medicaid,CPT,J2407,"Injection, oritavancin",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Humana Medicaid,CPT,J2425,Palifermin injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Humana Medicaid,CPT,J2426,Paliperidone palmitate inj,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Humana Medicaid,CPT,J2469,Palonosetron hcl,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
Humana Medicaid,CPT,J2502,"Inj, pasireotide long acting",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,J2503,Pegaptanib sodium injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Humana Medicaid,CPT,J2504,"Pegademase bovine, 25 iu",Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,518.96,518.96,,,,,,
Humana Medicaid,CPT,J2505,"Injection, pegfilgrastim 6mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,J2507,Pegloticase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Humana Medicaid,CPT,J2513,Pentastarch 10% solution,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
Humana Medicaid,CPT,J2515,Pentobarbital sodium inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,J2545,Pentamidine non-comp unit,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,J2547,"Injection, peramivir",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Humana Medicaid,CPT,J2562,Plerixafor injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J2597,Inj desmopressin acetate,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Humana Medicaid,CPT,J2724,Protein c concentrate,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Humana Medicaid,CPT,J2730,Pralidoxime chloride inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,J2770,Quinupristin/dalfopristin,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,189.67,189.67,,,,,,
Humana Medicaid,CPT,J2778,Ranibizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Humana Medicaid,CPT,J2783,Rasburicase,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Humana Medicaid,CPT,J2786,"Injection, reslizumab, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Humana Medicaid,CPT,J2790,Rho d immune globulin inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,J2791,Rhophylac injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,J2792,"Rho(d) immune globulin h, sd",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,J2793,Rilonacept injection,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,J2794,"Inj risperdal consta, 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,J2796,Romiplostim injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Humana Medicaid,CPT,J2797,"Inj., rolapitant, 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Humana Medicaid,CPT,J2798,"Inj., perseris, 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,J2805,Sincalide injection,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
Humana Medicaid,CPT,J2820,Sargramostim injection,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,J2840,Inj sebelipase alfa 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,J2850,Inj secretin synthetic human,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,J2860,"Injection, siltuximab",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Humana Medicaid,CPT,J2993,Reteplase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,J2997,Alteplase recombinant,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,J3031,"Inj., fremanezumab-vfrm 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,J3032,Inj. eptinezumab-jjmr 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,J3060,"Inj, taliglucerase alfa 10 u",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Humana Medicaid,CPT,J3090,Inj tedizolid phosphate,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Humana Medicaid,CPT,J3095,Telavancin injection,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,J3101,Tenecteplase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J3110,Teriparatide injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Humana Medicaid,CPT,J3111,Inj. romosozumab-aqqg 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Humana Medicaid,CPT,J3145,Testosterone undecanoate 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,J3240,Thyrotropin injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Humana Medicaid,CPT,J3241,Inj. teprotumumab-trbw 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,J3243,Tigecycline injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,J3245,"Inj., tildrakizumab, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Humana Medicaid,CPT,J3246,Tirofiban hcl,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Humana Medicaid,CPT,J3262,Tocilizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Humana Medicaid,CPT,J3285,Treprostinil injection,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,J3300,Triamcinolone a inj prs-free,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,J3304,Inj triamcinolone ace xr 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,J3315,Triptorelin pamoate,Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,244.88,244.88,,,,,,
Humana Medicaid,CPT,J3316,"Inj., triptorelin xr 3.75 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,J3355,"Urofollitropin, 75 iu",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Humana Medicaid,CPT,J3357,"Ustekinumab sub cu inj, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Humana Medicaid,CPT,J3358,"Ustekinumab, iv inject, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J3365,"Urokinase 250,000 iu inj",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,J3380,"Injection, vedolizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,J3385,Velaglucerase alfa,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Humana Medicaid,CPT,J3396,Verteporfin injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Humana Medicaid,CPT,J3397,"Inj., vestronidase alfa-vjbk",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,J3398,Inj luxturna 1 billion vec g,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,J3399,Inj onase abepar-xioi treat,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,J3470,Hyaluronidase injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,J3471,"Ovine, up to 999 usp units",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,J3472,"Ovine, 1000 usp units",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,J3473,Hyaluronidase recombinant,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,J7169,"Inj andexxa, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,J7170,"Inj., emicizumab-kxwh 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,J7175,"Inj, factor x, (human), 1iu",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,J7177,"Inj., fibryga, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Humana Medicaid,CPT,J7178,Inj human fibrinogen con nos,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Humana Medicaid,CPT,J7179,Vonvendi inj 1 iu vwf:rco,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J7180,Factor xiii anti-hem factor,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,J7181,Factor xiii recomb a-subunit,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,J7182,Factor viii recomb novoeight,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J7183,Wilate injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J7185,Xyntha inj,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J7186,Antihemophilic viii/vwf comp,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J7187,"Humate-p, inj",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J7188,Factor viii recomb obizur,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J7189,Factor viia recomb novoseven,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J7190,Factor viii,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J7191,Factor viii (porcine),Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J7192,Factor viii recombinant nos,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J7193,Factor ix non-recombinant,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J7194,Factor ix complex,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J7195,Factor ix recombinant nos,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J7196,Antithrombin recombinant,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,J7197,Antithrombin iii injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J7198,Anti-inhibitor,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Humana Medicaid,CPT,J7199,Hemophilia clot factor noc,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Humana Medicaid,CPT,J7200,Factor ix recombinan rixubis,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J7201,Factor ix alprolix recomb,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J7202,Factor ix idelvion inj,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J7203,Factor ix recomb gly rebinyn,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J7204,Inj recombin esperoct per iu,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J7205,Factor viii fc fusion recomb,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J7207,Factor viii pegylated recomb,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J7208,Inj. jivi 1 iu,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J7209,Factor viii nuwiq recomb 1iu,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J7210,"Inj, afstyla, 1 i.u.",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J7211,"Inj, kovaltry, 1 i.u.",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J7212,Factor viia recomb sevenfact,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J7296,"Kyleena, 19.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,J7297,"Liletta, 52 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,J7298,"Mirena, 52 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,J7300,Intraut copper contraceptive,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,J7301,"Skyla, 13.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,J7302,Levonorgestrel iu 52 mg,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,J7303,Contraceptive vaginal ring,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,J7304,Contraceptive hormone patch,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,J7306,Levonorgestrel implant sys,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Humana Medicaid,CPT,J7307,Etonogestrel implant system,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,J7308,Aminolevulinic acid hcl top,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,J7309,"Methyl aminolevulinate, top",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,J7310,Ganciclovir long act implant,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,J7311,"Inj., retisert, 0.01 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,J7312,Dexamethasone intra implant,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Humana Medicaid,CPT,J7313,"Inj., iluvien, 0.01 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J7314,"Inj., yutiq, 0.01 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J7315,Ophthalmic mitomycin,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,J7316,"Inj, ocriplasmin, 0.125 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,J7318,"Inj, durolane 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,J7320,"Genvisc 850, inj, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Humana Medicaid,CPT,J7321,Hyalgan or supartz inj dose,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,J7322,Hymovis injection 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Humana Medicaid,CPT,J7323,Euflexxa inj per dose,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Humana Medicaid,CPT,J7324,Orthovisc inj per dose,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Humana Medicaid,CPT,J7325,Synvisc or synvisc-one,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,J7326,Gel-one,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,J7327,Monovisc inj per dose,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,384.11,384.11,,,,,,
Humana Medicaid,CPT,J7328,Gelsyn-3 injection 0.1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Humana Medicaid,CPT,J7329,"Inj, trivisc 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,J7330,Cultured chondrocytes implnt,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,J7331,"Synojoynt, inj., 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,J7332,"Inj., triluron, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,J7333,Visco-3 inj dose,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,J7336,Capsaicin 8% patch,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,J7340,Carbidopa levodopa ent 100ml,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,J7345,"Aminolevulinic acid, 10% gel",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,J7351,Inj bimatoprost itc imp1mcg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Humana Medicaid,CPT,J7352,"Afamelanotide implant, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,J7401,Mometasone furoate sinus imp,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,384.11,384.11,,,,,,
Humana Medicaid,CPT,J7501,Azathioprine parenteral,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
Humana Medicaid,CPT,J7504,Lymphocyte immune globulin,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J7505,Monoclonal antibodies,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,518.96,518.96,,,,,,
Humana Medicaid,CPT,J7511,Antithymocyte globuln rabbit,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Humana Medicaid,CPT,J7513,"Daclizumab, parenteral",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Humana Medicaid,CPT,J7525,Tacrolimus injection,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Humana Medicaid,CPT,J7639,Dornase alfa non-comp unit,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,J7685,Tobramycin comp unit,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,J7686,"Treprostinil, non-comp unit",Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Humana Medicaid,CPT,J8501,Oral aprepitant,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
Humana Medicaid,CPT,J8560,Etoposide oral 50 mg,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
Humana Medicaid,CPT,J8562,Oral fludarabine phosphate,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Humana Medicaid,CPT,J8565,Gefitinib oral,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Humana Medicaid,CPT,J8655,"Oral netupitant, palonosetro",Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,189.67,189.67,,,,,,
Humana Medicaid,CPT,J8670,"Rolapitant, oral, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
Humana Medicaid,CPT,J8705,Topotecan oral,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,J9010,Alemtuzumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Humana Medicaid,CPT,J9015,Aldesleukin injection,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,518.96,518.96,,,,,,
Humana Medicaid,CPT,J9017,Arsenic trioxide injection,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Humana Medicaid,CPT,J9019,Erwinaze injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Humana Medicaid,CPT,J9020,"Asparaginase, nos",Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
Humana Medicaid,CPT,J9022,"Inj, atezolizumab,10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Humana Medicaid,CPT,J9023,"Injection, avelumab, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J9025,Azacitidine injection,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
Humana Medicaid,CPT,J9027,Clofarabine injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,J9030,Bcg live intravesical 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
Humana Medicaid,CPT,J9031,Bcg live intravesical vac,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
Humana Medicaid,CPT,J9032,"Injection, belinostat, 10mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,J9033,"Inj., treanda 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,J9034,"Inj., bendeka 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,J9035,Bevacizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,J9036,Inj. belrapzo/bendamustine,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,J9039,"Injection, blinatumomab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,J9040,Bleomycin sulfate injection,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
Humana Medicaid,CPT,J9041,"Inj., velcade 0.1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,244.88,244.88,,,,,,
Humana Medicaid,CPT,J9042,Brentuximab vedotin inj,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Humana Medicaid,CPT,J9043,Cabazitaxel injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J9044,"Inj, bortezomib, nos, 0.1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Humana Medicaid,CPT,J9047,"Injection, carfilzomib, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Humana Medicaid,CPT,J9050,Carmustine injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J9055,Cetuximab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Humana Medicaid,CPT,J9057,"Inj., copanlisib, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,J9065,Inj cladribine per 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,189.67,189.67,,,,,,
Humana Medicaid,CPT,J9070,Cyclophosphamide 100 mg inj,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
Humana Medicaid,CPT,J9098,Cytarabine liposome inj,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Humana Medicaid,CPT,J9118,Inj. calaspargase pegol-mknl,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Humana Medicaid,CPT,J9119,"Inj., cemiplimab-rwlc, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J9120,Dactinomycin injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Humana Medicaid,CPT,J9144,"Daratumumab, hyaluronidase",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,J9145,"Injection, daratumumab 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,J9150,Daunorubicin injection,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,189.67,189.67,,,,,,
Humana Medicaid,CPT,J9151,Daunorubicin citrate inj,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
Humana Medicaid,CPT,J9153,"Inj daunorubicin, cytarabine",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Humana Medicaid,CPT,J9155,Degarelix injection,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,189.67,189.67,,,,,,
Humana Medicaid,CPT,J9160,Denileukin diftitox inj,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J9171,Docetaxel injection,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
Humana Medicaid,CPT,J9173,"Inj., durvalumab, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J9176,"Injection, elotuzumab, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,J9177,Inj enfort vedo-ejfv 0.25mg,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J9179,Eribulin mesylate injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Humana Medicaid,CPT,J9185,Fludarabine phosphate inj,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
Humana Medicaid,CPT,J9198,"Inj. infugem, 100 mg",Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,189.67,189.67,,,,,,
Humana Medicaid,CPT,J9199,"Injection, infugem, 200 mg",Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,189.67,189.67,,,,,,
Humana Medicaid,CPT,J9200,Floxuridine injection,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
Humana Medicaid,CPT,J9202,Goserelin acetate implant,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Humana Medicaid,CPT,J9203,Gemtuzumab ozogamicin 0.1 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J9204,"Inj mogamulizumab-kpkc, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Humana Medicaid,CPT,J9205,Inj irinotecan liposome 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,J9207,Ixabepilone injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Humana Medicaid,CPT,J9208,Ifosfamide injection,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
Humana Medicaid,CPT,J9210,"Inj., emapalumab-lzsg, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,J9211,Idarubicin hcl injection,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
Humana Medicaid,CPT,J9213,Interferon alfa-2a inj,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Humana Medicaid,CPT,J9214,Interferon alfa-2b inj,Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,244.88,244.88,,,,,,
Humana Medicaid,CPT,J9216,Interferon gamma 1-b inj,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Humana Medicaid,CPT,J9217,Leuprolide acetate suspnsion,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Humana Medicaid,CPT,J9219,Leuprolide acetate implant,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J9223,"Inj. lurbinectedin, 0.1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,J9225,Vantas implant,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,J9226,Supprelin la implant,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,J9227,Inj. isatuximab-irfc 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,J9228,Ipilimumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,J9229,Inj inotuzumab ozogam 0.1 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Humana Medicaid,CPT,J9230,Mechlorethamine hcl inj,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
Humana Medicaid,CPT,J9245,Inj melpha hydroch nos 50 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J9246,"Inj., evomela, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J9261,Nelarabine injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J9262,"Inj, omacetaxine mep, 0.01mg",Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Humana Medicaid,CPT,J9264,Paclitaxel protein bound,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Humana Medicaid,CPT,J9266,Pegaspargase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Humana Medicaid,CPT,J9268,Pentostatin injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Humana Medicaid,CPT,J9269,Inj. tagraxofusp-erzs 10 mcg,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,J9270,Plicamycin (mithramycin) inj,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Humana Medicaid,CPT,J9271,Inj pembrolizumab,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Humana Medicaid,CPT,J9280,Mitomycin injection,Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,244.88,244.88,,,,,,
Humana Medicaid,CPT,J9281,Mitomycin instillation,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,J9285,"Inj, olaratumab, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J9293,Mitoxantrone hydrochl / 5 mg,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
Humana Medicaid,CPT,J9295,"Injection, necitumumab, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J9299,"Injection, nivolumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J9300,Gemtuzumab ozogamicin inj,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J9301,Obinutuzumab inj,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J9302,Ofatumumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Humana Medicaid,CPT,J9303,Panitumumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,J9304,"Inj. pemetrexed, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J9305,Inj. pemetrexed nos 10mg,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J9306,"Injection, pertuzumab, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,J9307,Pralatrexate injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J9308,"Injection, ramucirumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,J9309,"Inj, polatuzumab vedotin 1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Humana Medicaid,CPT,J9310,Rituximab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,J9311,"Inj rituximab, hyaluronidase",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J9312,"Inj., rituximab, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J9313,"Inj., lumoxiti, 0.01 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J9315,Romidepsin injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J9316,"Pertuzu, trastuzu, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,J9317,Sacituzumab govitecan-hziy,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,518.96,518.96,,,,,,
Humana Medicaid,CPT,J9320,Streptozocin injection,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,189.67,189.67,,,,,,
Humana Medicaid,CPT,J9325,Inj talimogene laherparepvec,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J9328,Temozolomide injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Humana Medicaid,CPT,J9330,Temsirolimus injection,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,518.96,518.96,,,,,,
Humana Medicaid,CPT,J9340,Thiotepa injection,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,189.67,189.67,,,,,,
Humana Medicaid,CPT,J9352,Injection trabectedin 0.1mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,J9354,"Inj, ado-trastuzumab emt 1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J9355,Inj trastuzumab excl biosimi,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,J9356,"Inj. herceptin hylecta, 10mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,J9357,Valrubicin injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,J9358,Inj fam-trastu deru-nxki 1mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,J9371,"Inj, vincristine sul lip 1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,J9395,"Injection, fulvestrant",Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,518.96,518.96,,,,,,
Humana Medicaid,CPT,J9400,"Inj, ziv-aflibercept, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Humana Medicaid,CPT,J9600,Porfimer sodium injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,L8604,Dextranomer/hyaluronic acid,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,L8605,Inj bulking agent anal canal,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,L8607,Inj vocal cord bulking agent,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,M0239,Bamlanivimab-xxxx infusion,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Humana Medicaid,CPT,M0243,Casirivi and imdevi infusion,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Humana Medicaid,CPT,P2028,Cephalin floculation test,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,P2029,Congo red blood test,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,P2031,Hair analysis,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,P2033,Blood thymol turbidity,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,P2038,Blood mucoprotein,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,P3000,Screen pap by tech w md supv,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Humana Medicaid,CPT,P3001,Screening pap smear by phys,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Humana Medicaid,CPT,P7001,Culture bacterial urine,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,P9010,Whole blood for transfusion,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,P9011,Blood split unit,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,P9012,Cryoprecipitate each unit,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,P9016,Rbc leukocytes reduced,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,P9017,Plasma 1 donor frz w/in 8 hr,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,P9019,"Platelets, each unit",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,P9020,Plaelet rich plasma unit,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,P9021,Red blood cells unit,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,P9022,Washed red blood cells unit,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,P9023,"Frozen plasma, pooled, sd",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,P9031,Platelets leukocytes reduced,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,P9032,"Platelets, irradiated",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,P9033,Platelets leukoreduced irrad,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,P9034,"Platelets, pheresis",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,P9035,Platelet pheres leukoreduced,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,P9036,Platelet pheresis irradiated,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,P9037,Plate pheres leukoredu irrad,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,P9038,Rbc irradiated,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,P9039,Rbc deglycerolized,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,P9040,Rbc leukoreduced irradiated,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,P9041,"Albumin (human),5%, 50ml",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,P9043,"Plasma protein fract,5%,50ml",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,P9044,Cryoprecipitatereducedplasma,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,P9045,"Albumin (human), 5%, 250 ml",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,P9046,"Albumin (human), 25%, 20 ml",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,P9047,"Albumin (human), 25%, 50ml",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,P9048,"Plasmaprotein fract,5%,250ml",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,P9050,"Granulocytes, pheresis unit",Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Humana Medicaid,CPT,P9051,"Blood, l/r, cmv-neg",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,P9052,"Platelets, hla-m, l/r, unit",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,P9053,"Plt, pher, l/r cmv-neg, irr",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,P9054,"Blood, l/r, froz/degly/wash",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,P9055,"Plt, aph/pher, l/r, cmv-neg",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,P9056,"Blood, l/r, irradiated",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,P9057,"Rbc, frz/deg/wsh, l/r, irrad",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,P9058,"Rbc, l/r, cmv-neg, irrad",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,P9059,"Plasma, frz between 8-24hour",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,P9060,Fr frz plasma donor retested,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,P9070,Pathogen reduced plasma pool,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,P9071,Pathogen reduced plasma sing,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,P9072,Plate path red/rapid bac tes,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,P9073,Platelets pheresis path redu,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,P9099,Blood component/product noc,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,P9100,Pathogen test for platelets,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,Q0035,Cardiokymography,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Humana Medicaid,CPT,Q0081,Infusion ther other than che,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Humana Medicaid,CPT,Q0084,Chemotherapy by infusion,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Humana Medicaid,CPT,Q0085,Chemo by both infusion and o,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Humana Medicaid,CPT,Q0091,Obtaining screen pap smear,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Humana Medicaid,CPT,Q0111,Wet mounts/ w preparations,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,Q0112,Potassium hydroxide preps,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,Q0113,Pinworm examinations,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,Q0114,Fern test,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Humana Medicaid,CPT,Q0115,Post-coital mucous exam,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,Q0138,"Ferumoxytol, non-esrd",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,Q0139,"Ferumoxytol, esrd use",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,Q0239,Bamlanivimab-xxxx,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Humana Medicaid,CPT,Q0243,Casirivimab and imdevimab,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Humana Medicaid,CPT,Q0515,Sermorelin acetate injection,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,518.96,518.96,,,,,,
Humana Medicaid,CPT,Q2017,"Teniposide, 50 mg",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Humana Medicaid,CPT,Q2028,"Inj, sculptra, 0.5mg",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q2034,Agriflu vaccine,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,Q2035,"Afluria vacc, 3 yrs & >, im",Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,Q2036,"Flulaval vacc, 3 yrs & >, im",Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,Q2037,"Fluvirin vacc, 3 yrs & >, im",Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,Q2038,"Fluzone vacc, 3 yrs & >, im",Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,Q2039,"Influenza virus vaccine, nos",Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Humana Medicaid,CPT,Q2040,Tisagenlecleucel car-pos t,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,Q2043,Sipuleucel-t auto cd54+,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,Q2049,Imported lipodox inj,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,Q2050,Doxorubicin inj 10mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Humana Medicaid,CPT,Q3014,Telehealth facility fee,Ancillary Services,Per Unit,$8.33 ,OP,8.33,8.33,,,,,,
Humana Medicaid,CPT,Q3027,Inj beta interferon im 1 mcg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Humana Medicaid,CPT,Q3028,Inj beta interferon sq 1 mcg,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,Q4074,Iloprost non-comp unit dose,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,Q4081,"Epoetin alfa, 100 units esrd",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,Q4100,"Skin substitute, nos",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4101,Apligraf,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4102,Oasis wound matrix,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4103,Oasis burn matrix,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4104,Integra bmwd,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4105,Integra drt or omnigraft,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4106,Dermagraft,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4107,Graftjacket,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4108,Integra matrix,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4110,Primatrix,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4111,Gammagraft,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4112,Cymetra injectable,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4113,Graftjacket xpress,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4114,Integra flowable wound matri,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4115,Alloskin,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4116,Alloderm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4117,Hyalomatrix,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4118,Matristem micromatrix,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4119,Matristem wound matrix,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4120,Matristem burn matrix,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4121,Theraskin,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4122,"Dermacell, awm, porous sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4123,Alloskin,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4124,Oasis tri-layer wound matrix,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4125,Arthroflex,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4126,Memoderm/derma/tranz/integup,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4127,Talymed,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4128,Flexhd/allopatchhd/matrixhd,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4129,Unite biomatrix,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4130,Strattice tm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4131,Epifix or epicord,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4132,"Grafix core, grafixpl core",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4133,Grafix stravix prime pl sqcm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4134,Hmatrix,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4135,Mediskin,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4136,Ezderm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4137,Amnioexcel biodexcel 1sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4138,"Biodfence dryflex, 1cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4139,"Amnio or biodmatrix, inj 1cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4140,Biodfence 1cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4141,"Alloskin ac, 1 cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4142,Xcm biologic tiss matrix 1cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4143,"Repriza, 1cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4145,"Epifix, inj, 1mg",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4146,"Tensix, 1cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4147,Architect ecm px fx 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4148,Neox neox rt or clarix cord,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4149,"Excellagen, 0.1 cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4150,Allowrap ds or dry 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4151,"Amnioband, guardian 1 sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4152,Dermapure 1 square cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4153,"Dermavest, plurivest sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4154,Biovance 1 square cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4155,Neoxflo or clarixflo 1 mg,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4156,Neox 100 or clarix 100,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4157,Revitalon 1 square cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4158,"Kerecis omega3, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4159,Affinity1 square cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4160,Nushield 1 square cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4161,Bio-connekt per square cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4162,"Wndex flw, bioskn flw, 0.5cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4163,"Woundex, bioskin, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4164,"Helicoll, per square cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4165,"Keramatrix, kerasorb sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4166,"Cytal, per square centimeter",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4167,"Truskin, per sq centimeter",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4168,"Amnioband, 1 mg",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4169,"Artacent wound, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4170,"Cygnus, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4171,"Interfyl, 1 mg",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4172,Puraply or puraply am,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4173,Palingen or palingen xplus,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4174,Palingen or promatrx,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4175,Miroderm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4176,"Neopatch or therion, 1 sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4177,"Floweramnioflo, 0.1 cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4178,"Floweramniopatch, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4179,"Flowerderm, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4180,"Revita, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4181,"Amnio wound, per square cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4182,"Transcyte, per sq centimeter",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4183,"Surgigraft, 1 sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4184,Cellesta or duo per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4185,Cellesta flowab amnion 0.5cc,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4186,Epifix 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4187,Epicord 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4188,Amnioarmor 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4189,"Artacent ac, 1 mg",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4190,Artacent ac 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4191,Restorigin 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4192,"Restorigin, 1 cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4193,Coll-e-derm 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4194,Novachor 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4195,Puraply 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4196,Puraply am 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4197,Puraply xt 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4198,Genesis amnio membrane 1sqcm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4200,Skin te 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4201,Matrion 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4202,"Keroxx (2.5g/cc), 1cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4203,"Derma-gide, 1 sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4204,Xwrap 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4205,Membrane graft or wrap sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4206,Fluid flow or fluid gf 1 cc,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4208,Novafix per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4209,Surgraft per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4210,Axolotl graf dualgraf sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4211,Amnion bio or axobio sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4212,"Allogen, per cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4213,"Ascent, 0.5 mg",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4214,Cellesta cord per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4215,"Axolotl ambient, cryo 0.1 mg",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4216,Artacent cord per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4217,Woundfix biowound plus xplus,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4218,Surgicord per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4219,Surgigraft dual per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4220,"Bellacell hd, surederm sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4221,Amniowrap2 per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4222,"Progenamatrix, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4226,Myown harv prep proc sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4227,Amniocore per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4228,"Bionextpatch, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4229,Cogenex amnio memb per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4230,Cogenex flow amnion 0.5 cc,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4231,"Corplex p, per cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4232,"Corplex, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4233,Surfactor /nudyn per 0.5 cc,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4234,"Xcellerate, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4235,Amniorepair or altiply sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4236,Carepatch per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4237,"Cryo-cord, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4238,"Derm-maxx, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4239,Amnio-maxx or lite per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4240,Corecyte topical only 0.5 cc,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4241,"Polycyte, topical only 0.5cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4242,"Amniocyte plus, per 0.5 cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4244,"Procenta, per 200 mg",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4245,"Amniotext, per cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4246,"Coretext or protext, per cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4247,"Amniotext patch, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4248,Dermacyte amn mem allo sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4249,"Amniply, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4250,Amnioamp-mp per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4254,Novafix dl per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q4255,"Reguard, topical use per sq",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,Q5101,"Injection, zarxio",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,Q5102,"Inj., infliximab biosimilar",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Humana Medicaid,CPT,Q5103,"Injection, inflectra",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Humana Medicaid,CPT,Q5104,"Injection, renflexis",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Humana Medicaid,CPT,Q5105,Inj retacrit esrd on dialysi,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,Q5106,Inj retacrit non-esrd use,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,Q5107,Inj mvasi 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,Q5108,"Injection, fulphila",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,Q5109,"Injection, ixifi, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,Q5110,Nivestym,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Humana Medicaid,CPT,Q5111,"Injection, udenyca 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,Q5112,Inj ontruzant 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,Q5113,Inj herzuma 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,Q5114,Inj ogivri 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,Q5115,Inj truxima 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,Q5116,"Inj., trazimera, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,Q5117,"Inj., kanjinti, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,Q5118,"Inj., zirabev, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,Q5119,"Inj ruxience, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,Q5120,Inj pegfilgrastim-bmez 0.5mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,Q5121,"Inj. avsola, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Humana Medicaid,CPT,Q5122,"Inj, nyvepria",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Humana Medicaid,CPT,Q9975,Factor VIII FC Fusion Recomb,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Humana Medicaid,CPT,Q9979,"Injection, Alemtuzumab",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Humana Medicaid,CPT,Q9980,"Genvisc, inj, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Humana Medicaid,CPT,Q9984,Kyleena,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,Q9987,Pathogen test for platelets,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,Q9988,Platelet pheresis path reduc,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,Q9989,"Ustekinumab IV Inj, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Humana Medicaid,CPT,Q9991,Buprenorph xr 100 mg or less,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,Q9992,Buprenorphine xr over 100 mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Humana Medicaid,CPT,Q9993,"Inj., triamcinolone ext rel",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,Q9995,"inj. emicizumab-kxwh, 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Humana Medicaid,CPT,S0013,"Esketamine, nasal spray",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Humana Medicaid,CPT,S0040,"Injection, ticarcillin disod",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Humana Medicaid,CPT,S0088,Imatinib 100 mg,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Humana Medicaid,CPT,S0126,Inj follitropin alfa 75 iu,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,S0132,Inj ganirelix acetat 250 mcg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Humana Medicaid,CPT,S0140,"Saquinavir, 200 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Humana Medicaid,CPT,S0142,Colistimethate inh sol mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Humana Medicaid,CPT,S0145,Peg interferon alfa-2a/180,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,S0148,Peg interferon alfa-2b/10,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Humana Medicaid,CPT,S0155,Epoprostenol dilutant,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Humana Medicaid,CPT,S0166,Inj olanzapine 2.5mg,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,S0175,Flutamide 125 mg,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
Humana Medicaid,CPT,S0178,Lomustine 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Humana Medicaid,CPT,S0190,"Mifepristone, oral, 200 mg",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Humana Medicaid,CPT,S0195,Pneumo vaccine 5-9 yrs,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Humana Medicaid,CPT,S0199,Med abortion inc all ex drug,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Humana Medicaid,CPT,S0201,Partial hospitalization serv,Behavioral Health,Per Unit,$220.60 ,OP,220.6,220.6,,,,,,
Humana Medicaid,CPT,S0220,Medical conference by physic,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,S0221,"Medical conference, 60 min",Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,S0250,Comp geriatr assmt team,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,S0257,End of life counseling,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,S0271,Home hospice case 30 days,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,S0280,"Medical home, initial plan",Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,S0281,"Medical home, maintenance",Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,S0311,Comp mgmt care coord adv ill,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,S0315,Disease management program,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,S0316,Follow-up/reassessment,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,S0340,Lifestyle mod 1st stage,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,S0353,Cancer treatmentplan initial,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,S0354,Cancer treatment plan change,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,S0390,Rout foot care per visit,General Surgery,Per Unit,$46.77 ,OP,46.77,46.77,,,,,,
Humana Medicaid,CPT,S0395,Impression casting ft,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Humana Medicaid,CPT,S0592,Comp cont lens eval,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Humana Medicaid,CPT,S0601,Screening proctoscopy,Preventive Care,Per Unit,$387.00 ,OP,387,387,,,,,,
Humana Medicaid,CPT,S0618,Audiometry for hearing aid,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Humana Medicaid,CPT,S0800,Laser in situ keratomileusis,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Humana Medicaid,CPT,S0810,Photorefractive keratectomy,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Humana Medicaid,CPT,S0812,Phototherap keratect,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Humana Medicaid,CPT,S2066,Breast gap flap reconst,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
Humana Medicaid,CPT,S2067,"Breast ""stacked"" diep/gap",General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
Humana Medicaid,CPT,S2068,Breast diep or siea flap,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
Humana Medicaid,CPT,S2083,Adjustment gastric band,Gastroenterology,Per Unit,$119.18 ,OP,119.18,119.18,,,,,,
Humana Medicaid,CPT,S2112,Knee arthroscp harv,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,S2202,Echosclerotherapy,Vascular Surgery,Per Unit,$500.46 ,OP,500.46,500.46,,,,,,
Humana Medicaid,CPT,S2225,Myringotomy laser-assist,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Humana Medicaid,CPT,S2230,Implant semi-imp hear,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,S2235,Implant auditory brain imp,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,S2260,Induced abortion 17-24 weeks,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Humana Medicaid,CPT,S2265,Induced abortion 25-28 wks,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Humana Medicaid,CPT,S2266,Induced abortion 29-31 wks,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Humana Medicaid,CPT,S2267,Induced abortion 32 or more,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Humana Medicaid,CPT,S2300,"Arthroscopy, shoulder, surgi",Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Humana Medicaid,CPT,S2340,Chemodenervation of abductor,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,S2341,Chemodenerv adduct vocal,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Humana Medicaid,CPT,S2342,Nasal endoscop po debrid,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Humana Medicaid,CPT,S2400,Fetal surg congen hernia,Obstetrics,Per Unit,$139.58 ,OP,139.58,139.58,,,,,,
Humana Medicaid,CPT,S2401,Fetal surg urin trac obstr,Obstetrics,Per Unit,$482.07 ,OP,482.07,482.07,,,,,,
Humana Medicaid,CPT,S2402,Fetal surg cong cyst malf,Obstetrics,Per Unit,$482.07 ,OP,482.07,482.07,,,,,,
Humana Medicaid,CPT,S2403,Fetal surg pulmon sequest,Obstetrics,Per Unit,$482.07 ,OP,482.07,482.07,,,,,,
Humana Medicaid,CPT,S2404,Fetal surg myelomeningo,Obstetrics,Per Unit,$482.07 ,OP,482.07,482.07,,,,,,
Humana Medicaid,CPT,S2405,Fetal surg sacrococ teratoma,Obstetrics,Per Unit,$139.58 ,OP,139.58,139.58,,,,,,
Humana Medicaid,CPT,S2409,Fetal surg noc,Obstetrics,Per Unit,$139.58 ,OP,139.58,139.58,,,,,,
Humana Medicaid,CPT,S2411,Fetoscop laser ther ttts,Obstetrics,Per Unit,$139.58 ,OP,139.58,139.58,,,,,,
Humana Medicaid,CPT,S3620,Newborn metabolic screening,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
Humana Medicaid,CPT,S3630,Eosinophil blood count,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Humana Medicaid,CPT,S3645,Hiv-1 antibody testing of or,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,S3650,"Saliva test, hormone level;",Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,S3652,"Saliva test, hormone level;",Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,S3655,Antisperm antibodies test,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Humana Medicaid,CPT,S3708,Gastrointestinal fat absorpt,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,S3721,Pca3 testing,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Humana Medicaid,CPT,S3722,Dose optimization auc - 5fu,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Humana Medicaid,CPT,S3800,Genetic testing als,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,S3840,Dna analysis ret-oncogene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,S3841,Gene test retinoblastoma,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,S3842,Gene test hippel-lindau,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,S3844,Dna analysis deafness,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,S3845,Gene test alpha-thalassemia,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,S3846,Gene test beta-thalassemia,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,S3849,Gene test niemann-pick,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,S3850,Gene test sickle cell,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,S3852,Dna analysis apoe alzheimer,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,S3853,Gene test myo musclr dyst,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,S3854,Gene profile panel breast,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,S3861,Genetic test brugada,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,S3865,Comp genet test hyp cardiomy,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,S3866,Spec gene test hyp cardiomy,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,S3870,Cgh test developmental delay,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,S3890,Fecal dna analysis,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Humana Medicaid,CPT,S3900,Surface emg,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,S3902,Ballistocardiogram,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,S3904,Masters two step,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Humana Medicaid,CPT,S4011,Ivf package,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Humana Medicaid,CPT,S4013,Compl gift case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Humana Medicaid,CPT,S4014,Compl zift case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Humana Medicaid,CPT,S4015,Complete ivf nos case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Humana Medicaid,CPT,S4016,Frozen ivf case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Humana Medicaid,CPT,S4017,Ivf canc a stim case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Humana Medicaid,CPT,S4018,F emb trns canc case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Humana Medicaid,CPT,S4020,Ivf canc a aspir case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Humana Medicaid,CPT,S4021,Ivf canc p aspir case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Humana Medicaid,CPT,S4022,Asst oocyte fert case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Humana Medicaid,CPT,S4023,Incompl donor egg case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Humana Medicaid,CPT,S4025,Donor serv ivf case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Humana Medicaid,CPT,S4026,Procure donor sperm,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Humana Medicaid,CPT,S4027,Store prev froz embryos,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Humana Medicaid,CPT,S4028,Microsurg epi sperm asp,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Humana Medicaid,CPT,S4030,Sperm procure init visit,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Humana Medicaid,CPT,S4031,Sperm procure subs visit,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Humana Medicaid,CPT,S4035,Stimulated iui case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Humana Medicaid,CPT,S4037,Cryo embryo transf case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Humana Medicaid,CPT,S4040,Monit store cryo embryo 30 d,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Humana Medicaid,CPT,S4042,Ovulation mgmt per cycle,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,S4981,Insert levonorgestrel ius,Gynecology,Per Unit,$102.34 ,OP,102.34,102.34,,,,,,
Humana Medicaid,CPT,S4989,Contracept iud,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Humana Medicaid,CPT,S5180,Hh respiratory thrpy in eval,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
Humana Medicaid,CPT,S5181,Hh respiratory thrpy nos/day,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
Humana Medicaid,CPT,S8032,Low dose CT lung screening,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Humana Medicaid,CPT,S8035,Magnetic source imaging,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Humana Medicaid,CPT,S8037,Mrcp,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Humana Medicaid,CPT,S8055,Us guidance fetal reduct,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Humana Medicaid,CPT,S8080,Scintimammography,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Humana Medicaid,CPT,S8092,Electron beam computed tomog,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Humana Medicaid,CPT,S8110,Peak expiratory flow rate (p,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Humana Medicaid,CPT,S8930,Auricular electrostimulation,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Humana Medicaid,CPT,S8940,Hippotherapy per session,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,S8948,Low-level laser trmt 15 min,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,S8950,"Complex lymphedema therapy,",Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,S8990,Pt or manip for maint,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,S9015,Automated eeg monitoring,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Humana Medicaid,CPT,S9024,Paranasal sinus ultrasound,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Humana Medicaid,CPT,S9061,Medical supplies and equipme,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,S9090,Vertebral axial decompressio,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,S9098,Home phototherapy visit,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,S9128,"Speech therapy, in the home,",Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Humana Medicaid,CPT,S9129,"Occupational therapy, in the",Rehabilitation,Per Unit,$306.55 ,OP,306.55,306.55,,,,,,
Humana Medicaid,CPT,S9131,Pt in the home per diem,Rehabilitation,Per Unit,$192.71 ,OP,192.71,192.71,,,,,,
Humana Medicaid,CPT,S9140,"Diabetic management program,",Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Humana Medicaid,CPT,S9141,"Diabetic management program,",Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Humana Medicaid,CPT,S9145,Insulin pump initiation,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Humana Medicaid,CPT,S9152,"Speech therapy, re-eval",Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Humana Medicaid,CPT,S9211,Home mgmt gest hypertension,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,S9213,Hm preeclamp per diem,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,S9214,Hm gest dm per diem,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,S9335,Ht hemodialysis diem,Nephrology,Per Unit,$540.95 ,OP,540.95,540.95,,,,,,
Humana Medicaid,CPT,S9339,Hit periton dialysis diem,Nephrology,Per Unit,$540.95 ,OP,540.95,540.95,,,,,,
Humana Medicaid,CPT,S9370,Ht inj antiemetic diem,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,S9372,Ht inj anticoag diem,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,S9445,Pt education noc individ,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Humana Medicaid,CPT,S9446,Pt education noc group,Preventive Care,Per Unit,$26.23 ,OP,26.23,26.23,,,,,,
Humana Medicaid,CPT,S9452,Nutrition class,Preventive Care,Per Unit,$26.23 ,OP,26.23,26.23,,,,,,
Humana Medicaid,CPT,S9453,Smoking cessation class,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Humana Medicaid,CPT,S9455,"Diabetic management program,",Preventive Care,Per Unit,$26.23 ,OP,26.23,26.23,,,,,,
Humana Medicaid,CPT,S9465,"Diabetic management program,",Ancillary Services,Per Unit,$100.15 ,OP,100.15,100.15,,,,,,
Humana Medicaid,CPT,S9470,"Nutritional counseling, diet",Ancillary Services,Per Unit,$100.15 ,OP,100.15,100.15,,,,,,
Humana Medicaid,CPT,S9472,Cardiac rehabilitation progr,Rehabilitation,Per Unit,$274.82 ,OP,274.82,274.82,,,,,,
Humana Medicaid,CPT,S9473,Pulmonary rehabilitation pro,Rehabilitation,Per Unit,$73.11 ,OP,73.11,73.11,,,,,,
Humana Medicaid,CPT,S9475,Ambulatory setting substance,Behavioral Health,Per Unit,$220.60 ,OP,220.6,220.6,,,,,,
Humana Medicaid,CPT,S9476,Vestibular rehab per diem,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Humana Medicaid,CPT,S9480,Intensive outpatient psychia,Behavioral Health,Per Unit,$339.88 ,OP,339.88,339.88,,,,,,
Humana Medicaid,CPT,S9482,Family stabilization 15 min,Behavioral Health,Per Unit,$89.14 ,OP,89.14,89.14,,,,,,
Humana Medicaid,CPT,S9484,Crisis intervention per hour,Behavioral Health,Per Unit,$135.70 ,OP,135.7,135.7,,,,,,
Humana Medicaid,CPT,S9485,Crisis intervention mental h,Behavioral Health,Per Unit,$220.60 ,OP,220.6,220.6,,,,,,
Humana Medicaid,CPT,S9537,Ht hem horm inj diem,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,S9538,Hit blood products diem,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Humana Medicaid,CPT,S9558,Ht inj growth horm diem,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,S9559,Hit inj interferon diem,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,S9560,Ht inj hormone diem,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,S9562,Ht inj palivizumab diem,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,T1006,Family/couple counseling,Behavioral Health,Per Unit,$89.14 ,OP,89.14,89.14,,,,,,
Humana Medicaid,CPT,T1007,Treatment plan development,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Humana Medicaid,CPT,T1012,Alcohol/substance abuse skil,Behavioral Health,Per Unit,$48.15 ,OP,48.15,48.15,,,,,,
Humana Medicaid,CPT,T1016,Case management,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,T1017,Targeted case management,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,T1023,Program intake assessment,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Humana Medicaid,CPT,T1040,Comm bh clinic svc per diem,Behavioral Health,Per Unit,$220.60 ,OP,220.6,220.6,,,,,,
Humana Medicaid,CPT,T2022,"Case management, per month",Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,T2023,Targeted case mgmt per month,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Humana Medicaid,CPT,U0001,2019-ncov diagnostic p,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Humana Medicaid,CPT,U0002,Covid-19 lab test non-cdc,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,U0005,Infec agen detec ampli probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Humana Medicaid,CPT,V2785,Corneal tissue processing,Ophthalmology,Per Unit,"$1,390.89 ",OP,"1,390.89","1,390.89",,,,,,
Humana Medicaid,CPT,V2790,Amniotic membrane,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Humana Medicaid,CPT,V5362,Speech screening,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,V5363,Language screening,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Humana Medicaid,CPT,V5364,Dysphagia screening,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Duals,DRG,MS-001,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W MCC,Surgical,Relative Weights,"$168,855.33 ",IP,"17,718.00","557,099.42",,,,,,
Meridian Duals,DRG,MS-002,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W/O MCC,Surgical,Relative Weights,"$87,426.55 ",IP,"17,718.00","282,516.19",,,,,,
Meridian Duals,DRG,MS-003,ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITH MAJOR O.R. PROCEDURES,Surgical,Relative Weights,"$111,577.60 ",IP,"111,577.60","382,110.62",,,,,,
Meridian Duals,DRG,MS-004,TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES,Surgical,Relative Weights,"$69,628.33 ",IP,"69,628.33","232,723.01",,,,,,
Meridian Duals,DRG,MS-005,LIVER TRANSPLANT W MCC OR INTESTINAL TRANSPLANT,Surgical,Relative Weights,"$59,773.19 ",IP,"59,773.19","207,904.03",,,,,,
Meridian Duals,DRG,MS-006,LIVER TRANSPLANT W/O MCC,Surgical,Relative Weights,"$27,427.34 ",IP,"27,427.34","98,217.50",,,,,,
Meridian Duals,DRG,MS-007,LUNG TRANSPLANT,Surgical,Relative Weights,"$67,628.10 ",IP,"67,628.10","217,451.81",,,,,,
Meridian Duals,DRG,MS-008,SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,Surgical,Relative Weights,"$31,730.89 ",IP,"31,730.89","113,220.58",,,,,,
Meridian Duals,DRG,MS-010,PANCREAS TRANSPLANT,Surgical,Relative Weights,"$21,141.08 ",IP,"2,420.00","80,158.18",,,,,,
Meridian Duals,DRG,MS-011,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC,Surgical,Relative Weights,"$29,325.37 ",IP,"2,420.00","99,667.01",,,,,,
Meridian Duals,DRG,MS-012,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC,Surgical,Relative Weights,"$22,383.85 ",IP,"2,420.00","76,083.84",,,,,,
Meridian Duals,DRG,MS-013,TRACHEOSTOMY FOR FACE -  MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC,Surgical,Relative Weights,"$15,907.20 ",IP,"2,420.00","48,894.05",,,,,,
Meridian Duals,DRG,MS-014,ALLOGENEIC BONE MARROW TRANSPLANT,Surgical,Relative Weights,"$62,354.51 ",IP,"2,420.00","257,136.77",,,,,,
Meridian Duals,DRG,MS-016,AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,Surgical,Relative Weights,"$39,340.51 ",IP,"2,420.00","138,805.63",,,,,,
Meridian Duals,DRG,MS-017,AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,Surgical,Relative Weights,"$28,357.66 ",IP,"2,420.00","89,659.58",,,,,,
Meridian Duals,DRG,MS-018,CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,Medical,Relative Weights,"$218,711.49 ",IP,"2,420.00","218,711.49",,,,,,
Meridian Duals,DRG,MS-019,SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,Surgical,Relative Weights,"$39,009.97 ",IP,"2,420.00","39,009.97",,,,,,
Meridian Duals,DRG,MS-020,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,Surgical,Relative Weights,"$60,368.88 ",IP,"2,420.00","218,151.36",,,,,,
Meridian Duals,DRG,MS-021,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,Surgical,Relative Weights,"$44,054.63 ",IP,"2,420.00","166,797.79",,,,,,
Meridian Duals,DRG,MS-022,INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W/O CC/MCC,Surgical,Relative Weights,"$28,282.33 ",IP,"2,420.00","99,425.09",,,,,,
Meridian Duals,DRG,MS-023,CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX CNS PDX W MCC OR CHEMO IMPLANT,Surgical,Relative Weights,"$33,124.34 ",IP,"2,420.00","113,240.74",,,,,,
Meridian Duals,DRG,MS-024,CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,Surgical,Relative Weights,"$23,004.07 ",IP,"2,420.00","80,972.64",,,,,,
Meridian Duals,DRG,MS-025,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$26,265.17 ",IP,"2,420.00","88,593.12",,,,,,
Meridian Duals,DRG,MS-026,CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC,Surgical,Relative Weights,"$17,882.32 ",IP,"2,420.00","61,403.33",,,,,,
Meridian Duals,DRG,MS-027,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$14,683.71 ",IP,"2,420.00","48,317.47",,,,,,
Meridian Duals,DRG,MS-028,SPINAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$34,007.36 ",IP,"2,420.00","112,702.46",,,,,,
Meridian Duals,DRG,MS-029,SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,Surgical,Relative Weights,"$19,253.57 ",IP,"2,420.00","64,653.12",,,,,,
Meridian Duals,DRG,MS-030,SPINAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$13,763.89 ",IP,"2,420.00","45,805.54",,,,,,
Meridian Duals,DRG,MS-031,VENTRICULAR SHUNT PROCEDURES WITH MCC,Surgical,Relative Weights,"$25,531.07 ",IP,"2,420.00","88,189.92",,,,,,
Meridian Duals,DRG,MS-032,VENTRICULAR SHUNT PROCEDURES WITH CC,Surgical,Relative Weights,"$12,944.53 ",IP,"2,420.00","44,192.74",,,,,,
Meridian Duals,DRG,MS-033,VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,057.78 ",IP,"2,420.00","34,290.14",,,,,,
Meridian Duals,DRG,MS-034,CAROTID ARTERY STENT PROCEDURE W MCC,Surgical,Relative Weights,"$23,232.41 ",IP,"2,420.00","75,674.59",,,,,,
Meridian Duals,DRG,MS-035,CAROTID ARTERY STENT PROCEDURES WITH CC,Surgical,Relative Weights,"$13,664.03 ",IP,"2,420.00","46,412.35",,,,,,
Meridian Duals,DRG,MS-036,CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,817.58 ",IP,"2,420.00","35,300.16",,,,,,
Meridian Duals,DRG,MS-037,EXTRACRANIAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$19,141.44 ",IP,"2,420.00","65,384.93",,,,,,
Meridian Duals,DRG,MS-038,EXTRACRANIAL PROCEDURES WITH CC,Surgical,Relative Weights,"$9,687.52 ",IP,"2,420.00","33,772.03",,,,,,
Meridian Duals,DRG,MS-039,EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,652.43 ",IP,"2,420.00","22,807.01",,,,,,
Meridian Duals,DRG,MS-040,PERIPHERAL- CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC,Surgical,Relative Weights,"$22,570.73 ",IP,"2,420.00","79,438.46",,,,,,
Meridian Duals,DRG,MS-041,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W CC OR PERIPH NEUROSTIM,Surgical,Relative Weights,"$13,722.43 ",IP,"2,420.00","47,809.44",,,,,,
Meridian Duals,DRG,MS-042,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W/O CC/MCC,Surgical,Relative Weights,"$11,103.16 ",IP,"2,420.00","37,261.73",,,,,,
Meridian Duals,DRG,MS-052,SPINAL DISORDERS AND INJURIES WITH CC/MCC,Medical,Relative Weights,"$10,824.58 ",IP,"2,420.00","32,838.62",,,,,,
Meridian Duals,DRG,MS-053,SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,Medical,Relative Weights,"$6,636.66 ",IP,"2,420.00","19,476.58",,,,,,
Meridian Duals,DRG,MS-054,NERVOUS SYSTEM NEOPLASMS WITH MCC,Medical,Relative Weights,"$7,990.98 ",IP,"2,420.00","27,016.42",,,,,,
Meridian Duals,DRG,MS-055,NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,Medical,Relative Weights,"$6,100.55 ",IP,"2,420.00","19,877.76",,,,,,
Meridian Duals,DRG,MS-056,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,Medical,Relative Weights,"$12,820.72 ",IP,"2,420.00","44,198.78",,,,,,
Meridian Duals,DRG,MS-057,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,Medical,Relative Weights,"$7,402.30 ",IP,"2,420.00","24,409.73",,,,,,
Meridian Duals,DRG,MS-058,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,Medical,Relative Weights,"$10,148.89 ",IP,"2,420.00","39,406.75",,,,,,
Meridian Duals,DRG,MS-059,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,Medical,Relative Weights,"$6,583.52 ",IP,"2,420.00","21,984.48",,,,,,
Meridian Duals,DRG,MS-060,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,Medical,Relative Weights,"$5,359.44 ",IP,"2,420.00","17,775.07",,,,,,
Meridian Duals,DRG,MS-061,ISCHEMIC STROKE -  PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC,Medical,Relative Weights,"$16,884.83 ",IP,"2,420.00","56,316.96",,,,,,
Meridian Duals,DRG,MS-062,ISCHEMIC STROKE -  PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC,Medical,Relative Weights,"$11,611.83 ",IP,"2,420.00","40,545.79",,,,,,
Meridian Duals,DRG,MS-063,ISCHEMIC STROKE- PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC,Medical,Relative Weights,"$9,984.78 ",IP,"2,420.00","33,884.93",,,,,,
Meridian Duals,DRG,MS-064,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,Medical,Relative Weights,"$11,206.52 ",IP,"2,420.00","37,795.97",,,,,,
Meridian Duals,DRG,MS-065,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC,Medical,Relative Weights,"$5,956.88 ",IP,"2,420.00","20,718.43",,,,,,
Meridian Duals,DRG,MS-066,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,Medical,Relative Weights,"$4,155.80 ",IP,"2,420.00","14,454.72",,,,,,
Meridian Duals,DRG,MS-067,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,Medical,Relative Weights,"$8,326.78 ",IP,"2,420.00","29,524.32",,,,,,
Meridian Duals,DRG,MS-068,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,Medical,Relative Weights,"$5,191.24 ",IP,"2,420.00","18,212.54",,,,,,
Meridian Duals,DRG,MS-069,TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,Medical,Relative Weights,"$4,596.73 ",IP,"2,420.00","15,730.85",,,,,,
Meridian Duals,DRG,MS-070,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC,Medical,Relative Weights,"$9,808.99 ",IP,"2,420.00","33,725.66",,,,,,
Meridian Duals,DRG,MS-071,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC,Medical,Relative Weights,"$5,908.99 ",IP,"2,420.00","20,053.15",,,,,,
Meridian Duals,DRG,MS-072,NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$4,506.79 ",IP,"2,420.00","14,888.16",,,,,,
Meridian Duals,DRG,MS-073,CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,Medical,Relative Weights,"$8,485.05 ",IP,"2,420.00","28,538.50",,,,,,
Meridian Duals,DRG,MS-074,CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,Medical,Relative Weights,"$5,951.04 ",IP,"2,420.00","19,920.10",,,,,,
Meridian Duals,DRG,MS-075,VIRAL MENINGITIS WITH CC/MCC,Medical,Relative Weights,"$9,501.81 ",IP,"2,420.00","32,421.31",,,,,,
Meridian Duals,DRG,MS-076,VIRAL MENINGITIS WITHOUT CC/MCC,Medical,Relative Weights,"$5,751.89 ",IP,"2,420.00","18,194.40",,,,,,
Meridian Duals,DRG,MS-077,HYPERTENSIVE ENCEPHALOPATHY WITH MCC,Medical,Relative Weights,"$8,952.25 ",IP,"2,420.00","31,096.80",,,,,,
Meridian Duals,DRG,MS-078,HYPERTENSIVE ENCEPHALOPATHY WITH CC,Medical,Relative Weights,"$5,547.49 ",IP,"2,420.00","19,393.92",,,,,,
Meridian Duals,DRG,MS-079,HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC,Medical,Relative Weights,"$4,256.25 ",IP,"2,420.00","14,940.58",,,,,,
Meridian Duals,DRG,MS-080,NONTRAUMATIC STUPOR & COMA W MCC,Medical,Relative Weights,"$12,237.30 ",IP,"2,420.00","38,632.61",,,,,,
Meridian Duals,DRG,MS-081,NONTRAUMATIC STUPOR & COMA W/O MCC,Medical,Relative Weights,"$4,515.55 ",IP,"2,420.00","17,722.66",,,,,,
Meridian Duals,DRG,MS-082,TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,Medical,Relative Weights,"$13,221.35 ",IP,"2,420.00","45,396.29",,,,,,
Meridian Duals,DRG,MS-083,TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,Medical,Relative Weights,"$7,849.06 ",IP,"2,420.00","26,423.71",,,,,,
Meridian Duals,DRG,MS-084,TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,Medical,Relative Weights,"$5,288.77 ",IP,"2,420.00","18,089.57",,,,,,
Meridian Duals,DRG,MS-085,TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,Medical,Relative Weights,"$13,500.51 ",IP,"2,420.00","45,275.33",,,,,,
Meridian Duals,DRG,MS-086,TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,Medical,Relative Weights,"$7,443.18 ",IP,"2,420.00","24,954.05",,,,,,
Meridian Duals,DRG,MS-087,TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,Medical,Relative Weights,"$5,043.49 ",IP,"2,420.00","16,918.27",,,,,,
Meridian Duals,DRG,MS-088,CONCUSSION WITH MCC,Medical,Relative Weights,"$8,498.48 ",IP,"2,420.00","28,004.26",,,,,,
Meridian Duals,DRG,MS-089,CONCUSSION WITH CC,Medical,Relative Weights,"$6,210.92 ",IP,"2,420.00","19,883.81",,,,,,
Meridian Duals,DRG,MS-090,CONCUSSION WITHOUT CC/MCC,Medical,Relative Weights,"$4,990.93 ",IP,"2,420.00","17,101.73",,,,,,
Meridian Duals,DRG,MS-091,OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,Medical,Relative Weights,"$9,640.80 ",IP,"2,420.00","31,552.42",,,,,,
Meridian Duals,DRG,MS-092,OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,Medical,Relative Weights,"$5,775.25 ",IP,"2,420.00","19,476.58",,,,,,
Meridian Duals,DRG,MS-093,OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,Medical,Relative Weights,"$4,568.11 ",IP,"2,420.00","15,345.79",,,,,,
Meridian Duals,DRG,MS-094,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,Medical,Relative Weights,"$21,245.62 ",IP,"2,420.00","72,269.57",,,,,,
Meridian Duals,DRG,MS-095,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,Medical,Relative Weights,"$14,642.83 ",IP,"2,420.00","48,527.14",,,,,,
Meridian Duals,DRG,MS-096,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,Medical,Relative Weights,"$13,623.15 ",IP,"2,420.00","45,603.94",,,,,,
Meridian Duals,DRG,MS-097,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,Medical,Relative Weights,"$21,961.03 ",IP,"2,420.00","72,090.14",,,,,,
Meridian Duals,DRG,MS-098,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,Medical,Relative Weights,"$12,337.16 ",IP,"2,420.00","39,412.80",,,,,,
Meridian Duals,DRG,MS-099,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,Medical,Relative Weights,"$8,187.20 ",IP,"2,420.00","25,853.18",,,,,,
Meridian Duals,DRG,MS-100,SEIZURES WITH MCC,Medical,Relative Weights,"$10,958.32 ",IP,"2,420.00","36,695.23",,,,,,
Meridian Duals,DRG,MS-101,SEIZURES WITHOUT MCC,Medical,Relative Weights,"$5,188.32 ",IP,"2,420.00","17,799.26",,,,,,
Meridian Duals,DRG,MS-102,HEADACHES WITH MCC,Medical,Relative Weights,"$6,734.19 ",IP,"2,420.00","24,042.82",,,,,,
Meridian Duals,DRG,MS-103,HEADACHES W/O MCC,Medical,Relative Weights,"$4,844.34 ",IP,"2,420.00","16,117.92",,,,,,
Meridian Duals,DRG,MS-113,ORBITAL PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$12,815.47 ",IP,"2,420.00","42,983.14",,,,,,
Meridian Duals,DRG,MS-114,ORBITAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,454.10 ",IP,"2,420.00","24,006.53",,,,,,
Meridian Duals,DRG,MS-115,EXTRAOCULAR PROCEDURES EXCEPT ORBIT,Surgical,Relative Weights,"$8,506.66 ",IP,"2,420.00","29,957.76",,,,,,
Meridian Duals,DRG,MS-116,INTRAOCULAR PROCEDURES W CC/MCC,Surgical,Relative Weights,"$10,995.11 ",IP,"2,420.00","38,122.56",,,,,,
Meridian Duals,DRG,MS-117,INTRAOCULAR PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$6,080.69 ",IP,"2,420.00","22,109.47",,,,,,
Meridian Duals,DRG,MS-121,ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,Medical,Relative Weights,"$6,953.20 ",IP,"2,420.00","25,558.85",,,,,,
Meridian Duals,DRG,MS-122,ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,Medical,Relative Weights,"$3,769.77 ",IP,"2,420.00","15,575.62",,,,,,
Meridian Duals,DRG,MS-123,NEUROLOGICAL EYE DISORDERS,Medical,Relative Weights,"$4,478.17 ",IP,"2,420.00","15,740.93",,,,,,
Meridian Duals,DRG,MS-124,OTHER DISORDERS OF THE EYE WITH MCC,Medical,Relative Weights,"$8,187.79 ",IP,"2,420.00","28,010.30",,,,,,
Meridian Duals,DRG,MS-125,OTHER DISORDERS OF THE EYE WITHOUT MCC,Medical,Relative Weights,"$4,888.14 ",IP,"2,420.00","15,914.30",,,,,,
Meridian Duals,DRG,MS-135,SINUS AND MASTOID PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$12,518.21 ",IP,"2,420.00","46,057.54",,,,,,
Meridian Duals,DRG,MS-136,SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,332.22 ",IP,"2,420.00","23,990.40",,,,,,
Meridian Duals,DRG,MS-137,MOUTH PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$8,816.77 ",IP,"2,420.00","26,879.33",,,,,,
Meridian Duals,DRG,MS-138,MOUTH PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$5,002.03 ",IP,"2,420.00","17,365.82",,,,,,
Meridian Duals,DRG,MS-139,SALIVARY GLAND PROCEDURES,Surgical,Relative Weights,"$7,207.24 ",IP,"2,420.00","24,883.49",,,,,,
Meridian Duals,DRG,MS-140,MAJOR HEAD AND NECK PROCEDURES WITH MCC,Medical,Relative Weights,"$23,231.24 ",IP,"2,420.00","23,231.24",,,,,,
Meridian Duals,DRG,MS-141,MAJOR HEAD AND NECK PROCEDURES WITH CC,Medical,Relative Weights,"$12,883.80 ",IP,"2,420.00","12,883.80",,,,,,
Meridian Duals,DRG,MS-142,MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,Medical,Relative Weights,"$9,373.91 ",IP,"2,420.00","9,373.91",,,,,,
Meridian Duals,DRG,MS-143,OTHER EAR- NOSE- MOUTH AND THROAT O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$17,402.26 ",IP,"2,420.00","17,402.26",,,,,,
Meridian Duals,DRG,MS-144,HERNIA PROCEDURES AGE 0-17,Surgical,Relative Weights,"$10,287.30 ",IP,"2,420.00","10,287.30",,,,,,
Meridian Duals,DRG,MS-145,OTHER EAR -  NOSE -  MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC,Medical,Relative Weights,"$7,151.76 ",IP,"2,420.00","7,151.76",,,,,,
Meridian Duals,DRG,MS-146,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH MCC,Medical,Relative Weights,"$11,920.18 ",IP,"2,420.00","38,880.58",,,,,,
Meridian Duals,DRG,MS-147,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH CC,Medical,Relative Weights,"$7,598.52 ",IP,"2,420.00","25,016.54",,,,,,
Meridian Duals,DRG,MS-148,EAR - NOSE - MOUTH & THROAT MALIGNANCY W/O CC/MCC,Medical,Relative Weights,"$4,596.14 ",IP,"2,420.00","15,329.66",,,,,,
Meridian Duals,DRG,MS-149,DYSEQUILIBRIUM,Medical,Relative Weights,"$4,304.14 ",IP,"2,420.00","14,726.88",,,,,,
Meridian Duals,DRG,MS-150,EPISTAXIS WITH MCC,Medical,Relative Weights,"$7,752.70 ",IP,"2,420.00","26,036.64",,,,,,
Meridian Duals,DRG,MS-151,EPISTAXIS WITHOUT MCC,Medical,Relative Weights,"$4,312.31 ",IP,"2,420.00","14,093.86",,,,,,
Meridian Duals,DRG,MS-152,OTITIS MEDIA AND URI WITH MCC,Medical,Relative Weights,"$6,310.20 ",IP,"2,420.00","20,946.24",,,,,,
Meridian Duals,DRG,MS-153,OTITIS MEDIA AND URI WITHOUT MCC,Medical,Relative Weights,"$4,165.14 ",IP,"2,420.00","14,241.02",,,,,,
Meridian Duals,DRG,MS-154,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH MCC,Medical,Relative Weights,"$9,033.43 ",IP,"2,420.00","28,969.92",,,,,,
Meridian Duals,DRG,MS-155,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH CC,Medical,Relative Weights,"$5,311.55 ",IP,"2,420.00","18,166.18",,,,,,
Meridian Duals,DRG,MS-156,OTHER EAR -  NOSE -  MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$3,845.11 ",IP,"2,420.00","13,194.72",,,,,,
Meridian Duals,DRG,MS-157,DENTAL AND ORAL DISEASES WITH MCC,Medical,Relative Weights,"$9,205.13 ",IP,"2,420.00","31,508.06",,,,,,
Meridian Duals,DRG,MS-158,DENTAL AND ORAL DISEASES WITH CC,Medical,Relative Weights,"$5,257.24 ",IP,"2,420.00","17,470.66",,,,,,
Meridian Duals,DRG,MS-159,DENTAL AND ORAL DISEASES WITHOUT CC/MCC,Medical,Relative Weights,"$3,872.56 ",IP,"2,420.00","13,565.66",,,,,,
Meridian Duals,DRG,MS-163,MAJOR CHEST PROCEDURES WITH MCC,Surgical,Relative Weights,"$29,240.10 ",IP,"2,420.00","98,253.79",,,,,,
Meridian Duals,DRG,MS-164,MAJOR CHEST PROCEDURES WITH CC,Surgical,Relative Weights,"$15,508.91 ",IP,"2,420.00","51,037.06",,,,,,
Meridian Duals,DRG,MS-165,MAJOR CHEST PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$11,193.09 ",IP,"2,420.00","37,279.87",,,,,,
Meridian Duals,DRG,MS-166,OTHER RESP SYSTEM O.R. PROCEDURES W MCC,Surgical,Relative Weights,"$21,745.53 ",IP,"2,420.00","75,210.91",,,,,,
Meridian Duals,DRG,MS-167,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$10,621.35 ",IP,"2,420.00","38,594.30",,,,,,
Meridian Duals,DRG,MS-168,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,909.80 ",IP,"2,420.00","26,746.27",,,,,,
Meridian Duals,DRG,MS-175,PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,Medical,Relative Weights,"$9,028.76 ",IP,"2,420.00","29,119.10",,,,,,
Meridian Duals,DRG,MS-176,PULMONARY EMBOLISM WITHOUT MCC,Medical,Relative Weights,"$5,184.82 ",IP,"2,420.00","17,103.74",,,,,,
Meridian Duals,DRG,MS-177,RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC,Medical,Relative Weights,"$10,798.89 ",IP,"2,420.00","38,126.59",,,,,,
Meridian Duals,DRG,MS-178,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,Medical,Relative Weights,"$7,053.65 ",IP,"2,420.00","25,064.93",,,,,,
Meridian Duals,DRG,MS-179,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,Medical,Relative Weights,"$5,096.64 ",IP,"2,420.00","17,460.58",,,,,,
Meridian Duals,DRG,MS-180,RESPIRATORY NEOPLASMS WITH MCC,Medical,Relative Weights,"$10,161.15 ",IP,"2,420.00","34,773.98",,,,,,
Meridian Duals,DRG,MS-181,RESPIRATORY NEOPLASMS WITH CC,Medical,Relative Weights,"$6,541.47 ",IP,"2,420.00","23,224.32",,,,,,
Meridian Duals,DRG,MS-182,RESPIRATORY NEOPLASMS WITHOUT CC/MCC,Medical,Relative Weights,"$4,625.34 ",IP,"2,420.00","16,990.85",,,,,,
Meridian Duals,DRG,MS-183,MAJOR CHEST TRAUMA WITH MCC,Medical,Relative Weights,"$9,104.10 ",IP,"2,420.00","30,425.47",,,,,,
Meridian Duals,DRG,MS-184,MAJOR CHEST TRAUMA WITH CC,Medical,Relative Weights,"$6,078.94 ",IP,"2,420.00","20,526.91",,,,,,
Meridian Duals,DRG,MS-185,MAJOR CHEST TRAUMA W/O CC/MCC,Medical,Relative Weights,"$4,525.48 ",IP,"2,420.00","14,797.44",,,,,,
Meridian Duals,DRG,MS-186,PLEURAL EFFUSION WITH MCC,Medical,Relative Weights,"$9,015.91 ",IP,"2,420.00","31,104.86",,,,,,
Meridian Duals,DRG,MS-187,PLEURAL EFFUSION WITH CC,Medical,Relative Weights,"$6,032.22 ",IP,"2,420.00","20,722.46",,,,,,
Meridian Duals,DRG,MS-188,PLEURAL EFFUSION WITHOUT CC/MCC,Medical,Relative Weights,"$4,260.34 ",IP,"2,420.00","14,734.94",,,,,,
Meridian Duals,DRG,MS-189,PULMONARY EDEMA AND RESPIRATORY FAILURE,Medical,Relative Weights,"$7,160.52 ",IP,"2,420.00","24,508.51",,,,,,
Meridian Duals,DRG,MS-190,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,Medical,Relative Weights,"$6,570.67 ",IP,"2,420.00","23,063.04",,,,,,
Meridian Duals,DRG,MS-191,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,Medical,Relative Weights,"$5,164.38 ",IP,"2,420.00","17,998.85",,,,,,
Meridian Duals,DRG,MS-192,CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC,Medical,Relative Weights,"$4,062.36 ",IP,"2,420.00","14,297.47",,,,,,
Meridian Duals,DRG,MS-193,SIMPLE PNEUMONIA & PLEURISY W MCC,Medical,Relative Weights,"$7,662.18 ",IP,"2,420.00","26,883.36",,,,,,
Meridian Duals,DRG,MS-194,SIMPLE PNEUMONIA AND PLEURISY WITH CC,Medical,Relative Weights,"$5,045.24 ",IP,"2,420.00","17,914.18",,,,,,
Meridian Duals,DRG,MS-195,SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,Medical,Relative Weights,"$3,888.32 ",IP,"2,420.00","13,751.14",,,,,,
Meridian Duals,DRG,MS-196,INTERSTITIAL LUNG DISEASE WITH MCC,Medical,Relative Weights,"$10,153.56 ",IP,"2,420.00","33,776.06",,,,,,
Meridian Duals,DRG,MS-197,INTERSTITIAL LUNG DISEASE WITH CC,Medical,Relative Weights,"$5,880.96 ",IP,"2,420.00","20,593.44",,,,,,
Meridian Duals,DRG,MS-198,INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,Medical,Relative Weights,"$4,341.51 ",IP,"2,420.00","15,220.80",,,,,,
Meridian Duals,DRG,MS-199,PNEUMOTHORAX WITH MCC,Medical,Relative Weights,"$10,453.74 ",IP,"2,420.00","36,169.06",,,,,,
Meridian Duals,DRG,MS-200,PNEUMOTHORAX WITH CC,Medical,Relative Weights,"$6,286.84 ",IP,"2,420.00","21,815.14",,,,,,
Meridian Duals,DRG,MS-201,PNEUMOTHORAX WITHOUT CC/MCC,Medical,Relative Weights,"$4,144.12 ",IP,"2,420.00","14,474.88",,,,,,
Meridian Duals,DRG,MS-202,BRONCHITIS AND ASTHMA WITH CC/MCC,Medical,Relative Weights,"$5,647.36 ",IP,"2,420.00","19,111.68",,,,,,
Meridian Duals,DRG,MS-203,BRONCHITIS AND ASTHMA WITHOUT CC/MCC,Medical,Relative Weights,"$4,128.93 ",IP,"2,420.00","13,987.01",,,,,,
Meridian Duals,DRG,MS-204,RESPIRATORY SIGNS AND SYMPTOMS,Medical,Relative Weights,"$4,634.69 ",IP,"2,420.00","16,380.00",,,,,,
Meridian Duals,DRG,MS-205,OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,Medical,Relative Weights,"$9,839.36 ",IP,"2,420.00","32,945.47",,,,,,
Meridian Duals,DRG,MS-206,OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,Medical,Relative Weights,"$5,174.31 ",IP,"2,420.00","17,589.60",,,,,,
Meridian Duals,DRG,MS-207,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS,Medical,Relative Weights,"$33,499.27 ",IP,"2,420.00","115,629.70",,,,,,
Meridian Duals,DRG,MS-208,RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,Medical,Relative Weights,"$14,861.83 ",IP,"2,420.00","50,079.46",,,,,,
Meridian Duals,DRG,MS-215,OTHER HEART ASSIST SYSTEM IMPLANT,Surgical,Relative Weights,"$61,661.88 ",IP,"61,661.88","259,783.78",,,,,,
Meridian Duals,DRG,MS-216,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$58,630.29 ",IP,"58,630.29","202,454.78",,,,,,
Meridian Duals,DRG,MS-217,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,Surgical,Relative Weights,"$37,864.14 ",IP,"37,864.14","134,096.26",,,,,,
Meridian Duals,DRG,MS-218,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,Surgical,Relative Weights,"$35,678.79 ",IP,"35,678.79","108,892.22",,,,,,
Meridian Duals,DRG,MS-219,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$47,057.01 ",IP,"47,057.01","158,056.42",,,,,,
Meridian Duals,DRG,MS-220,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,Surgical,Relative Weights,"$31,567.37 ",IP,"31,567.37","106,966.94",,,,,,
Meridian Duals,DRG,MS-221,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,Surgical,Relative Weights,"$26,746.97 ",IP,"26,746.97","92,659.39",,,,,,
Meridian Duals,DRG,MS-222,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITH MCC,Surgical,Relative Weights,"$46,434.46 ",IP,"46,434.46","168,227.14",,,,,,
Meridian Duals,DRG,MS-223,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITHOUT MCC,Surgical,Relative Weights,"$33,864.27 ",IP,"33,864.27","121,018.46",,,,,,
Meridian Duals,DRG,MS-224,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITH MCC,Surgical,Relative Weights,"$43,912.13 ",IP,"43,912.13","149,107.39",,,,,,
Meridian Duals,DRG,MS-225,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITHOUT MCC,Surgical,Relative Weights,"$32,808.39 ",IP,"32,808.39","113,879.81",,,,,,
Meridian Duals,DRG,MS-226,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$38,340.11 ",IP,"25,420.00","134,824.03",,,,,,
Meridian Duals,DRG,MS-227,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Surgical,Relative Weights,"$30,439.07 ",IP,"25,420.00","105,420.67",,,,,,
Meridian Duals,DRG,MS-228,OTHER CARDIOTHORACIC PROCEDURES WITH MCC,Surgical,Relative Weights,"$31,129.37 ",IP,"31,129.37","126,731.81",,,,,,
Meridian Duals,DRG,MS-229,OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$20,096.88 ",IP,"20,096.88","82,754.78",,,,,,
Meridian Duals,DRG,MS-231,CORONARY BYPASS W PTCA W MCC,Surgical,Relative Weights,"$50,901.53 ",IP,"50,901.53","165,543.84",,,,,,
Meridian Duals,DRG,MS-232,CORONARY BYPASS W PTCA W/O MCC,Surgical,Relative Weights,"$34,770.65 ",IP,"34,770.65","120,687.84",,,,,,
Meridian Duals,DRG,MS-233,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,Surgical,Relative Weights,"$46,266.85 ",IP,"42,365.00","156,621.02",,,,,,
Meridian Duals,DRG,MS-234,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,Surgical,Relative Weights,"$31,162.65 ",IP,"31,162.65","104,959.01",,,,,,
Meridian Duals,DRG,MS-235,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$35,648.42 ",IP,"32,351.00","118,633.54",,,,,,
Meridian Duals,DRG,MS-236,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Surgical,Relative Weights,"$23,926.80 ",IP,"23,926.80","81,226.66",,,,,,
Meridian Duals,DRG,MS-239,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,Surgical,Relative Weights,"$28,125.81 ",IP,"2,420.00","94,141.15",,,,,,
Meridian Duals,DRG,MS-240,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,Surgical,Relative Weights,"$16,286.81 ",IP,"2,420.00","55,641.60",,,,,,
Meridian Duals,DRG,MS-241,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,Surgical,Relative Weights,"$9,299.74 ",IP,"2,420.00","30,568.61",,,,,,
Meridian Duals,DRG,MS-242,PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,Surgical,Relative Weights,"$21,769.47 ",IP,"15,407.00","74,815.78",,,,,,
Meridian Duals,DRG,MS-243,PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,Surgical,Relative Weights,"$14,708.24 ",IP,"14,708.24","50,992.70",,,,,,
Meridian Duals,DRG,MS-244,PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,Surgical,Relative Weights,"$12,049.83 ",IP,"12,049.83","41,840.06",,,,,,
Meridian Duals,DRG,MS-245,AICD GENERATOR PROCEDURES,Surgical,Relative Weights,"$31,640.37 ",IP,"15,407.00","104,989.25",,,,,,
Meridian Duals,DRG,MS-246,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Surgical,Relative Weights,"$18,246.15 ",IP,"18,246.15","63,963.65",,,,,,
Meridian Duals,DRG,MS-247,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITHOUT MCC,Surgical,Relative Weights,"$11,523.64 ",IP,"11,523.64","41,019.55",,,,,,
Meridian Duals,DRG,MS-248,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Surgical,Relative Weights,"$18,467.49 ",IP,"18,467.49","62,425.44",,,,,,
Meridian Duals,DRG,MS-249,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITHOUT MCC,Surgical,Relative Weights,"$10,942.55 ",IP,"10,942.55","38,638.66",,,,,,
Meridian Duals,DRG,MS-250,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT CORONARY ARTERY STENT WITH MCC,Surgical,Relative Weights,"$14,727.51 ",IP,"14,727.51","51,410.02",,,,,,
Meridian Duals,DRG,MS-251,PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W/O MCC,Surgical,Relative Weights,"$9,685.18 ",IP,"2,420.00","33,929.28",,,,,,
Meridian Duals,DRG,MS-252,OTHER VASCULAR PROCEDURES W MCC,Surgical,Relative Weights,"$19,422.35 ",IP,"2,420.00","66,132.86",,,,,,
Meridian Duals,DRG,MS-253,OTHER VASCULAR PROCEDURES WITH CC,Surgical,Relative Weights,"$15,497.23 ",IP,"2,420.00","52,549.06",,,,,,
Meridian Duals,DRG,MS-254,OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,605.00 ",IP,"2,420.00","36,693.22",,,,,,
Meridian Duals,DRG,MS-255,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,Surgical,Relative Weights,"$14,806.35 ",IP,"2,420.00","53,415.94",,,,,,
Meridian Duals,DRG,MS-256,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,Surgical,Relative Weights,"$9,602.26 ",IP,"2,420.00","34,604.64",,,,,,
Meridian Duals,DRG,MS-257,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$6,804.86 ",IP,"2,420.00","22,869.50",,,,,,
Meridian Duals,DRG,MS-258,CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,Surgical,Relative Weights,"$18,501.95 ",IP,"11,861.00","61,663.39",,,,,,
Meridian Duals,DRG,MS-259,CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,Surgical,Relative Weights,"$12,201.09 ",IP,"11,861.00","41,985.22",,,,,,
Meridian Duals,DRG,MS-260,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,Surgical,Relative Weights,"$20,833.31 ",IP,"10,167.00","74,583.94",,,,,,
Meridian Duals,DRG,MS-261,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,Surgical,Relative Weights,"$11,644.53 ",IP,"10,167.00","39,281.76",,,,,,
Meridian Duals,DRG,MS-262,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,Surgical,Relative Weights,"$9,964.34 ",IP,"9,964.34","33,820.42",,,,,,
Meridian Duals,DRG,MS-263,VEIN LIGATION AND STRIPPING,Surgical,Relative Weights,"$13,509.27 ",IP,"2,420.00","47,559.46",,,,,,
Meridian Duals,DRG,MS-264,OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,Surgical,Relative Weights,"$19,001.28 ",IP,"2,420.00","65,278.08",,,,,,
Meridian Duals,DRG,MS-265,AICD LEAD PROCEDURES,Surgical,Relative Weights,"$19,654.78 ",IP,"2,420.00","62,925.41",,,,,,
Meridian Duals,DRG,MS-266,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,Surgical,Relative Weights,"$41,160.28 ",IP,"41,160.28","143,567.42",,,,,,
Meridian Duals,DRG,MS-267,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$32,692.75 ",IP,"32,692.75","114,420.10",,,,,,
Meridian Duals,DRG,MS-268,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,Surgical,Relative Weights,"$40,666.21 ",IP,"32,968.00","136,737.22",,,,,,
Meridian Duals,DRG,MS-269,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,Surgical,Relative Weights,"$25,200.52 ",IP,"25,200.52","86,010.62",,,,,,
Meridian Duals,DRG,MS-270,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,Surgical,Relative Weights,"$30,292.48 ",IP,"30,292.48","103,021.63",,,,,,
Meridian Duals,DRG,MS-271,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,Surgical,Relative Weights,"$20,822.21 ",IP,"20,822.21","71,527.68",,,,,,
Meridian Duals,DRG,MS-272,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$15,699.88 ",IP,"15,699.88","52,442.21",,,,,,
Meridian Duals,DRG,MS-273,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,Surgical,Relative Weights,"$22,348.22 ",IP,"16,176.00","74,799.65",,,,,,
Meridian Duals,DRG,MS-274,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$19,194.00 ",IP,"16,176.00","63,701.57",,,,,,
Meridian Duals,DRG,MS-280,ACUTE MYOCARDIAL INFARCTION - DISCHARGED ALIVE W MCC,Medical,Relative Weights,"$9,384.42 ",IP,"2,420.00","32,878.94",,,,,,
Meridian Duals,DRG,MS-281,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITH CC,Medical,Relative Weights,"$5,434.78 ",IP,"2,420.00","19,528.99",,,,,,
Meridian Duals,DRG,MS-282,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITHOUT CC/MCC,Medical,Relative Weights,"$4,240.48 ",IP,"2,420.00","14,876.06",,,,,,
Meridian Duals,DRG,MS-283,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH MCC,Medical,Relative Weights,"$10,889.99 ",IP,"2,420.00","36,281.95",,,,,,
Meridian Duals,DRG,MS-284,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH CC,Medical,Relative Weights,"$4,224.71 ",IP,"2,420.00","14,622.05",,,,,,
Meridian Duals,DRG,MS-285,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITHOUT CC/MCC,Medical,Relative Weights,"$2,889.09 ",IP,"2,420.00","10,438.85",,,,,,
Meridian Duals,DRG,MS-286,CIRCULATORY DISORDERS EXCEPT AMI- WITH CARDIAC CATHETERIZATION WITH MCC,Medical,Relative Weights,"$12,476.16 ",IP,"2,420.00","44,299.58",,,,,,
Meridian Duals,DRG,MS-287,CIRCULATORY DISORDERS EXCEPT AMI -  WITH CARDIAC CATHETERIZATION WITHOUT MCC,Medical,Relative Weights,"$6,512.27 ",IP,"6,512.27","23,228.35",,,,,,
Meridian Duals,DRG,MS-288,ACUTE & SUBACUTE ENDOCARDITIS W MCC,Medical,Relative Weights,"$15,682.94 ",IP,"2,420.00","53,573.18",,,,,,
Meridian Duals,DRG,MS-289,ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,Medical,Relative Weights,"$9,598.75 ",IP,"9,181.00","33,542.21",,,,,,
Meridian Duals,DRG,MS-290,ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,Medical,Relative Weights,"$5,997.18 ",IP,"2,420.00","20,172.10",,,,,,
Meridian Duals,DRG,MS-291,HEART FAILURE AND SHOCK WITH MCC,Medical,Relative Weights,"$7,406.97 ",IP,"2,420.00","27,131.33",,,,,,
Meridian Duals,DRG,MS-292,HEART FAILURE AND SHOCK WITH CC,Medical,Relative Weights,"$5,042.91 ",IP,"2,420.00","18,254.88",,,,,,
Meridian Duals,DRG,MS-293,HEART FAILURE AND SHOCK WITHOUT CC/MCC,Medical,Relative Weights,"$3,445.06 ",IP,"2,420.00","13,210.85",,,,,,
Meridian Duals,DRG,MS-294,DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC,Medical,Relative Weights,"$7,491.65 ",IP,"2,420.00","25,641.50",,,,,,
Meridian Duals,DRG,MS-295,DEEP VEIN THROMBOPHLEBITIS W/O CC/MCC,Medical,Relative Weights,"$5,747.22 ",IP,"2,420.00","11,632.32",,,,,,
Meridian Duals,DRG,MS-296,CARDIAC ARREST - UNEXPLAINED W MCC,Medical,Relative Weights,"$9,316.09 ",IP,"2,420.00","31,659.26",,,,,,
Meridian Duals,DRG,MS-297,CARDIAC ARREST- UNEXPLAINED WITH CC,Medical,Relative Weights,"$4,128.93 ",IP,"2,420.00","14,575.68",,,,,,
Meridian Duals,DRG,MS-298,CARDIAC ARREST- UNEXPLAINED WITHOUT CC/MCC,Medical,Relative Weights,"$2,854.63 ",IP,"2,420.00","10,144.51",,,,,,
Meridian Duals,DRG,MS-299,PERIPHERAL VASCULAR DISORDERS WITH MCC,Medical,Relative Weights,"$8,950.50 ",IP,"2,420.00","29,225.95",,,,,,
Meridian Duals,DRG,MS-300,PERIPHERAL VASCULAR DISORDERS WITH CC,Medical,Relative Weights,"$6,095.87 ",IP,"2,420.00","20,716.42",,,,,,
Meridian Duals,DRG,MS-301,PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$4,339.76 ",IP,"2,420.00","14,632.13",,,,,,
Meridian Duals,DRG,MS-302,ATHEROSCLEROSIS WITH MCC,Medical,Relative Weights,"$6,393.72 ",IP,"2,420.00","22,222.37",,,,,,
Meridian Duals,DRG,MS-303,ATHEROSCLEROSIS WITHOUT MCC,Medical,Relative Weights,"$3,957.24 ",IP,"2,420.00","13,622.11",,,,,,
Meridian Duals,DRG,MS-304,HYPERTENSION WITH MCC,Medical,Relative Weights,"$6,406.57 ",IP,"2,420.00","22,004.64",,,,,,
Meridian Duals,DRG,MS-305,HYPERTENSION WITHOUT MCC,Medical,Relative Weights,"$4,321.07 ",IP,"2,420.00","14,747.04",,,,,,
Meridian Duals,DRG,MS-306,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,Medical,Relative Weights,"$8,803.33 ",IP,"2,420.00","28,516.32",,,,,,
Meridian Duals,DRG,MS-307,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,Medical,Relative Weights,"$5,083.20 ",IP,"2,420.00","17,785.15",,,,,,
Meridian Duals,DRG,MS-308,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,Medical,Relative Weights,"$7,013.35 ",IP,"2,420.00","23,944.03",,,,,,
Meridian Duals,DRG,MS-309,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,Medical,Relative Weights,"$4,382.98 ",IP,"2,420.00","15,247.01",,,,,,
Meridian Duals,DRG,MS-310,CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC,Medical,Relative Weights,"$3,265.77 ",IP,"2,420.00","11,275.49",,,,,,
Meridian Duals,DRG,MS-311,ANGINA PECTORIS,Medical,Relative Weights,"$4,079.29 ",IP,"2,420.00","13,809.60",,,,,,
Meridian Duals,DRG,MS-312,SYNCOPE AND COLLAPSE,Medical,Relative Weights,"$4,898.07 ",IP,"2,420.00","16,462.66",,,,,,
Meridian Duals,DRG,MS-313,CHEST PAIN,Medical,Relative Weights,"$4,213.03 ",IP,"2,420.00","14,420.45",,,,,,
Meridian Duals,DRG,MS-314,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,Medical,Relative Weights,"$12,174.81 ",IP,"2,420.00","40,914.72",,,,,,
Meridian Duals,DRG,MS-315,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,Medical,Relative Weights,"$5,684.73 ",IP,"2,420.00","19,563.26",,,,,,
Meridian Duals,DRG,MS-316,OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$4,224.71 ",IP,"2,420.00","14,962.75",,,,,,
Meridian Duals,DRG,MS-319,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,Surgical,Relative Weights,"$25,216.87 ",IP,"2,420.00","82,670.11",,,,,,
Meridian Duals,DRG,MS-320,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$14,048.89 ",IP,"2,420.00","47,329.63",,,,,,
Meridian Duals,DRG,MS-326,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$31,047.60 ",IP,"2,420.00","106,253.28",,,,,,
Meridian Duals,DRG,MS-327,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC,Surgical,Relative Weights,"$14,978.05 ",IP,"2,420.00","51,869.66",,,,,,
Meridian Duals,DRG,MS-328,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$9,734.83 ",IP,"2,420.00","31,752.00",,,,,,
Meridian Duals,DRG,MS-329,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Surgical,Relative Weights,"$28,535.79 ",IP,"2,420.00","98,929.15",,,,,,
Meridian Duals,DRG,MS-330,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Surgical,Relative Weights,"$14,888.11 ",IP,"2,420.00","50,940.29",,,,,,
Meridian Duals,DRG,MS-331,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$9,989.45 ",IP,"2,420.00","34,054.27",,,,,,
Meridian Duals,DRG,MS-332,RECTAL RESECTION WITH MCC,Surgical,Relative Weights,"$24,303.48 ",IP,"2,420.00","70,396.70",,,,,,
Meridian Duals,DRG,MS-333,RECTAL RESECTION WITH CC,Surgical,Relative Weights,"$12,505.36 ",IP,"2,420.00","45,626.11",,,,,,
Meridian Duals,DRG,MS-334,RECTAL RESECTION WITHOUT CC/MCC,Surgical,Relative Weights,"$9,394.35 ",IP,"2,420.00","31,052.45",,,,,,
Meridian Duals,DRG,MS-335,PERITONEAL ADHESIOLYSIS WITH MCC,Surgical,Relative Weights,"$22,855.14 ",IP,"2,420.00","81,549.22",,,,,,
Meridian Duals,DRG,MS-336,PERITONEAL ADHESIOLYSIS WITH CC,Surgical,Relative Weights,"$13,381.37 ",IP,"2,420.00","45,686.59",,,,,,
Meridian Duals,DRG,MS-337,PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$9,561.96 ",IP,"2,420.00","33,056.35",,,,,,
Meridian Duals,DRG,MS-338,APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$16,336.45 ",IP,"2,420.00","58,667.62",,,,,,
Meridian Duals,DRG,MS-339,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W CC,Surgical,Relative Weights,"$9,912.95 ",IP,"2,420.00","34,596.58",,,,,,
Meridian Duals,DRG,MS-340,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC/MCC,Surgical,Relative Weights,"$7,173.37 ",IP,"2,420.00","24,948.00",,,,,,
Meridian Duals,DRG,MS-341,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$13,563.00 ",IP,"2,420.00","51,571.30",,,,,,
Meridian Duals,DRG,MS-342,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH CC,Surgical,Relative Weights,"$8,368.25 ",IP,"2,420.00","32,463.65",,,,,,
Meridian Duals,DRG,MS-343,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$6,474.31 ",IP,"2,420.00","23,216.26",,,,,,
Meridian Duals,DRG,MS-344,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Surgical,Relative Weights,"$16,459.67 ",IP,"2,420.00","60,381.22",,,,,,
Meridian Duals,DRG,MS-345,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Surgical,Relative Weights,"$9,220.31 ",IP,"2,420.00","32,927.33",,,,,,
Meridian Duals,DRG,MS-346,MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,448.43 ",IP,"2,420.00","25,859.23",,,,,,
Meridian Duals,DRG,MS-347,ANAL AND STOMAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$14,394.04 ",IP,"2,420.00","53,149.82",,,,,,
Meridian Duals,DRG,MS-348,ANAL AND STOMAL PROCEDURES WITH CC,Surgical,Relative Weights,"$7,873.01 ",IP,"2,420.00","28,411.49",,,,,,
Meridian Duals,DRG,MS-349,ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$5,719.19 ",IP,"2,420.00","19,774.94",,,,,,
Meridian Duals,DRG,MS-350,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,Surgical,Relative Weights,"$14,336.22 ",IP,"2,420.00","49,176.29",,,,,,
Meridian Duals,DRG,MS-351,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,Surgical,Relative Weights,"$8,717.48 ",IP,"2,420.00","29,399.33",,,,,,
Meridian Duals,DRG,MS-352,INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,449.78 ",IP,"2,420.00","21,708.29",,,,,,
Meridian Duals,DRG,MS-353,HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,Surgical,Relative Weights,"$17,665.65 ",IP,"2,420.00","59,812.70",,,,,,
Meridian Duals,DRG,MS-354,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W CC,Surgical,Relative Weights,"$10,423.37 ",IP,"2,420.00","34,717.54",,,,,,
Meridian Duals,DRG,MS-355,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W/O CC/MCC,Surgical,Relative Weights,"$7,943.67 ",IP,"2,420.00","27,667.58",,,,,,
Meridian Duals,DRG,MS-356,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$25,157.89 ",IP,"2,420.00","82,196.35",,,,,,
Meridian Duals,DRG,MS-357,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$13,248.22 ",IP,"2,420.00","45,368.06",,,,,,
Meridian Duals,DRG,MS-358,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,878.85 ",IP,"2,420.00","27,653.47",,,,,,
Meridian Duals,DRG,MS-368,MAJOR ESOPHAGEAL DISORDERS WITH MCC,Medical,Relative Weights,"$11,382.90 ",IP,"2,420.00","38,376.58",,,,,,
Meridian Duals,DRG,MS-369,MAJOR ESOPHAGEAL DISORDERS WITH CC,Medical,Relative Weights,"$6,290.93 ",IP,"2,420.00","21,432.10",,,,,,
Meridian Duals,DRG,MS-370,MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$4,368.96 ",IP,"2,420.00","15,065.57",,,,,,
Meridian Duals,DRG,MS-371,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,Medical,Relative Weights,"$10,110.34 ",IP,"2,420.00","34,786.08",,,,,,
Meridian Duals,DRG,MS-372,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,Medical,Relative Weights,"$6,011.19 ",IP,"2,420.00","20,613.60",,,,,,
Meridian Duals,DRG,MS-373,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,Medical,Relative Weights,"$4,348.52 ",IP,"2,420.00","14,954.69",,,,,,
Meridian Duals,DRG,MS-374,DIGESTIVE MALIGNANCY WITH MCC,Medical,Relative Weights,"$12,110.57 ",IP,"2,420.00","40,269.60",,,,,,
Meridian Duals,DRG,MS-375,DIGESTIVE MALIGNANCY WITH CC,Medical,Relative Weights,"$7,052.48 ",IP,"2,420.00","24,339.17",,,,,,
Meridian Duals,DRG,MS-376,DIGESTIVE MALIGNANCY WITHOUT CC/MCC,Medical,Relative Weights,"$5,249.65 ",IP,"2,420.00","20,186.21",,,,,,
Meridian Duals,DRG,MS-377,GASTROINTESTINAL HEMORRHAGE WITH MCC,Medical,Relative Weights,"$10,519.15 ",IP,"2,420.00","35,681.18",,,,,,
Meridian Duals,DRG,MS-378,GASTROINTESTINAL HEMORRHAGE WITH CC,Medical,Relative Weights,"$5,802.12 ",IP,"2,420.00","19,920.10",,,,,,
Meridian Duals,DRG,MS-379,GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,Medical,Relative Weights,"$3,721.30 ",IP,"2,420.00","13,017.31",,,,,,
Meridian Duals,DRG,MS-380,COMPLICATED PEPTIC ULCER WITH MCC,Medical,Relative Weights,"$11,017.89 ",IP,"2,420.00","38,054.02",,,,,,
Meridian Duals,DRG,MS-381,COMPLICATED PEPTIC ULCER WITH CC,Medical,Relative Weights,"$6,186.39 ",IP,"2,420.00","21,706.27",,,,,,
Meridian Duals,DRG,MS-382,COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,Medical,Relative Weights,"$4,488.68 ",IP,"2,420.00","15,954.62",,,,,,
Meridian Duals,DRG,MS-383,UNCOMPLICATED PEPTIC ULCER WITH MCC,Medical,Relative Weights,"$7,665.69 ",IP,"2,420.00","26,738.21",,,,,,
Meridian Duals,DRG,MS-384,UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,Medical,Relative Weights,"$5,214.02 ",IP,"2,420.00","17,543.23",,,,,,
Meridian Duals,DRG,MS-385,INFLAMMATORY BOWEL DISEASE WITH MCC,Medical,Relative Weights,"$9,474.36 ",IP,"2,420.00","32,463.65",,,,,,
Meridian Duals,DRG,MS-386,INFLAMMATORY BOWEL DISEASE W CC,Medical,Relative Weights,"$5,811.46 ",IP,"2,420.00","19,861.63",,,,,,
Meridian Duals,DRG,MS-387,INFLAMMATORY BOWEL DISEASE W/O CC/MCC,Medical,Relative Weights,"$4,173.90 ",IP,"2,420.00","14,126.11",,,,,,
Meridian Duals,DRG,MS-388,GASTROINTESTINAL OBSTRUCTION WITH MCC,Medical,Relative Weights,"$8,845.38 ",IP,"2,420.00","30,746.02",,,,,,
Meridian Duals,DRG,MS-389,GASTROINTESTINAL OBSTRUCTION WITH CC,Medical,Relative Weights,"$4,807.55 ",IP,"2,420.00","16,928.35",,,,,,
Meridian Duals,DRG,MS-390,GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,Medical,Relative Weights,"$3,405.35 ",IP,"2,420.00","11,684.74",,,,,,
Meridian Duals,DRG,MS-391,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC,Medical,Relative Weights,"$7,295.42 ",IP,"2,420.00","24,897.60",,,,,,
Meridian Duals,DRG,MS-392,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC,Medical,Relative Weights,"$4,472.33 ",IP,"2,420.00","15,351.84",,,,,,
Meridian Duals,DRG,MS-393,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,Medical,Relative Weights,"$9,701.54 ",IP,"2,420.00","32,749.92",,,,,,
Meridian Duals,DRG,MS-394,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,Medical,Relative Weights,"$5,494.93 ",IP,"2,420.00","18,912.10",,,,,,
Meridian Duals,DRG,MS-395,OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$3,804.81 ",IP,"2,420.00","13,192.70",,,,,,
Meridian Duals,DRG,MS-405,PANCREAS- LIVER AND SHUNT PROCEDURES WITH MCC,Surgical,Relative Weights,"$33,508.03 ",IP,"2,420.00","109,412.35",,,,,,
Meridian Duals,DRG,MS-406,PANCREAS -  LIVER AND SHUNT PROCEDURES WITH CC,Surgical,Relative Weights,"$16,824.68 ",IP,"2,420.00","56,264.54",,,,,,
Meridian Duals,DRG,MS-407,PANCREAS -  LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$12,369.28 ",IP,"2,420.00","42,059.81",,,,,,
Meridian Duals,DRG,MS-408,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,Surgical,Relative Weights,"$21,917.23 ",IP,"2,420.00","71,842.18",,,,,,
Meridian Duals,DRG,MS-409,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,Surgical,Relative Weights,"$12,359.94 ",IP,"2,420.00","48,259.01",,,,,,
Meridian Duals,DRG,MS-410,BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W/O CC/MCC,Surgical,Relative Weights,"$9,158.99 ",IP,"2,420.00","33,465.60",,,,,,
Meridian Duals,DRG,MS-411,CHOLECYSTECTOMY W C.D.E. W MCC,Surgical,Relative Weights,"$21,920.73 ",IP,"2,420.00","77,220.86",,,,,,
Meridian Duals,DRG,MS-412,CHOLECYSTECTOMY WITH C.D.E. WITH CC,Surgical,Relative Weights,"$13,300.78 ",IP,"2,420.00","47,920.32",,,,,,
Meridian Duals,DRG,MS-413,CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,Surgical,Relative Weights,"$10,108.59 ",IP,"2,420.00","32,604.77",,,,,,
Meridian Duals,DRG,MS-414,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,Surgical,Relative Weights,"$21,189.55 ",IP,"2,420.00","68,874.62",,,,,,
Meridian Duals,DRG,MS-415,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,Surgical,Relative Weights,"$11,865.29 ",IP,"2,420.00","41,362.27",,,,,,
Meridian Duals,DRG,MS-416,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,Surgical,Relative Weights,"$8,306.34 ",IP,"2,420.00","27,222.05",,,,,,
Meridian Duals,DRG,MS-417,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,Surgical,Relative Weights,"$14,158.10 ",IP,"2,420.00","48,599.71",,,,,,
Meridian Duals,DRG,MS-418,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,Surgical,Relative Weights,"$9,863.89 ",IP,"2,420.00","33,645.02",,,,,,
Meridian Duals,DRG,MS-419,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,Surgical,Relative Weights,"$7,681.45 ",IP,"2,420.00","26,345.09",,,,,,
Meridian Duals,DRG,MS-420,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,Surgical,Relative Weights,"$20,536.63 ",IP,"2,420.00","69,245.57",,,,,,
Meridian Duals,DRG,MS-421,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,Surgical,Relative Weights,"$11,139.95 ",IP,"2,420.00","37,118.59",,,,,,
Meridian Duals,DRG,MS-422,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,489.14 ",IP,"2,420.00","28,314.72",,,,,,
Meridian Duals,DRG,MS-423,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$24,445.98 ",IP,"2,420.00","85,442.11",,,,,,
Meridian Duals,DRG,MS-424,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$13,339.32 ",IP,"2,420.00","45,388.22",,,,,,
Meridian Duals,DRG,MS-425,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$9,009.49 ",IP,"2,420.00","29,463.84",,,,,,
Meridian Duals,DRG,MS-432,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,Medical,Relative Weights,"$10,984.02 ",IP,"2,420.00","36,759.74",,,,,,
Meridian Duals,DRG,MS-433,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,Medical,Relative Weights,"$6,014.70 ",IP,"2,420.00","20,805.12",,,,,,
Meridian Duals,DRG,MS-434,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Medical,Relative Weights,"$3,624.94 ",IP,"2,420.00","12,900.38",,,,,,
Meridian Duals,DRG,MS-435,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,Medical,Relative Weights,"$10,239.99 ",IP,"2,420.00","34,213.54",,,,,,
Meridian Duals,DRG,MS-436,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,Medical,Relative Weights,"$6,549.65 ",IP,"2,420.00","22,694.11",,,,,,
Meridian Duals,DRG,MS-437,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,Medical,Relative Weights,"$5,232.13 ",IP,"2,420.00","17,698.46",,,,,,
Meridian Duals,DRG,MS-438,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,Medical,Relative Weights,"$9,331.28 ",IP,"2,420.00","33,028.13",,,,,,
Meridian Duals,DRG,MS-439,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,Medical,Relative Weights,"$4,936.03 ",IP,"2,420.00","17,079.55",,,,,,
Meridian Duals,DRG,MS-440,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,Medical,Relative Weights,"$3,540.84 ",IP,"2,420.00","12,410.50",,,,,,
Meridian Duals,DRG,MS-441,DISORDERS OF LIVER EXCEPT MALIGNANCY- CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC,Medical,Relative Weights,"$10,976.43 ",IP,"2,420.00","37,306.08",,,,,,
Meridian Duals,DRG,MS-442,DISORDERS OF LIVER EXCEPT MALIGNANCY -  CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC,Medical,Relative Weights,"$5,431.27 ",IP,"2,420.00","18,817.34",,,,,,
Meridian Duals,DRG,MS-443,DISORDERS OF LIVER EXCEPT MALIGNANCY -  CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Medical,Relative Weights,"$3,873.14 ",IP,"2,420.00","13,714.85",,,,,,
Meridian Duals,DRG,MS-444,DISORDERS OF THE BILIARY TRACT WITH MCC,Medical,Relative Weights,"$9,762.27 ",IP,"2,420.00","32,782.18",,,,,,
Meridian Duals,DRG,MS-445,DISORDERS OF THE BILIARY TRACT WITH CC,Medical,Relative Weights,"$6,292.68 ",IP,"2,420.00","21,661.92",,,,,,
Meridian Duals,DRG,MS-446,DISORDERS OF THE BILIARY TRACT W/O CC/MCC,Medical,Relative Weights,"$4,769.01 ",IP,"2,420.00","16,384.03",,,,,,
Meridian Duals,DRG,MS-453,COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W MCC,Surgical,Relative Weights,"$53,658.63 ",IP,"2,420.00","189,645.12",,,,,,
Meridian Duals,DRG,MS-454,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC,Surgical,Relative Weights,"$35,584.18 ",IP,"2,420.00","123,480.00",,,,,,
Meridian Duals,DRG,MS-455,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CC/MCC,Surgical,Relative Weights,"$27,923.16 ",IP,"2,420.00","97,036.13",,,,,,
Meridian Duals,DRG,MS-456,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH MCC,Surgical,Relative Weights,"$50,224.67 ",IP,"2,420.00","183,076.99",,,,,,
Meridian Duals,DRG,MS-457,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH CC,Surgical,Relative Weights,"$37,936.56 ",IP,"2,420.00","131,308.13",,,,,,
Meridian Duals,DRG,MS-458,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC,Surgical,Relative Weights,"$29,244.77 ",IP,"2,420.00","94,629.02",,,,,,
Meridian Duals,DRG,MS-459,SPINAL FUSION EXCEPT CERVICAL WITH MCC,Surgical,Relative Weights,"$39,324.16 ",IP,"21,658.00","138,136.32",,,,,,
Meridian Duals,DRG,MS-460,SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,Surgical,Relative Weights,"$22,955.59 ",IP,"21,658.00","79,841.66",,,,,,
Meridian Duals,DRG,MS-461,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,Surgical,Relative Weights,"$35,517.60 ",IP,"2,420.00","108,436.61",,,,,,
Meridian Duals,DRG,MS-462,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,Surgical,Relative Weights,"$18,346.02 ",IP,"2,420.00","63,229.82",,,,,,
Meridian Duals,DRG,MS-463,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,Surgical,Relative Weights,"$31,362.97 ",IP,"2,420.00","105,392.45",,,,,,
Meridian Duals,DRG,MS-464,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,Surgical,Relative Weights,"$17,379.49 ",IP,"2,420.00","59,526.43",,,,,,
Meridian Duals,DRG,MS-465,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$10,769.69 ",IP,"2,420.00","38,610.43",,,,,,
Meridian Duals,DRG,MS-466,REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,Surgical,Relative Weights,"$31,219.30 ",IP,"2,420.00","102,797.86",,,,,,
Meridian Duals,DRG,MS-467,REVISION OF HIP OR KNEE REPLACEMENT W CC,Surgical,Relative Weights,"$20,892.88 ",IP,"2,420.00","70,803.94",,,,,,
Meridian Duals,DRG,MS-468,REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,Surgical,Relative Weights,"$16,366.23 ",IP,"2,420.00","56,691.94",,,,,,
Meridian Duals,DRG,MS-469,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,Surgical,Relative Weights,"$18,021.90 ",IP,"2,420.00","63,300.38",,,,,,
Meridian Duals,DRG,MS-470,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,Surgical,Relative Weights,"$11,097.90 ",IP,"2,420.00","39,682.94",,,,,,
Meridian Duals,DRG,MS-471,CERVICAL SPINAL FUSION WITH MCC,Surgical,Relative Weights,"$29,315.44 ",IP,"15,407.00","100,687.10",,,,,,
Meridian Duals,DRG,MS-472,CERVICAL SPINAL FUSION WITH CC,Surgical,Relative Weights,"$17,833.84 ",IP,"15,407.00","61,316.64",,,,,,
Meridian Duals,DRG,MS-473,CERVICAL SPINAL FUSION WITHOUT CC/MCC,Surgical,Relative Weights,"$14,827.96 ",IP,"14,827.96","50,649.98",,,,,,
Meridian Duals,DRG,MS-474,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,Surgical,Relative Weights,"$23,804.74 ",IP,"2,420.00","78,117.98",,,,,,
Meridian Duals,DRG,MS-475,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,Surgical,Relative Weights,"$12,826.56 ",IP,"2,420.00","42,356.16",,,,,,
Meridian Duals,DRG,MS-476,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$6,776.24 ",IP,"2,420.00","23,480.35",,,,,,
Meridian Duals,DRG,MS-477,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Surgical,Relative Weights,"$19,616.24 ",IP,"2,420.00","65,626.85",,,,,,
Meridian Duals,DRG,MS-478,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Surgical,Relative Weights,"$13,773.24 ",IP,"2,420.00","46,712.74",,,,,,
Meridian Duals,DRG,MS-479,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Surgical,Relative Weights,"$10,567.62 ",IP,"2,420.00","35,929.15",,,,,,
Meridian Duals,DRG,MS-480,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,Surgical,Relative Weights,"$17,670.91 ",IP,"2,420.00","60,852.96",,,,,,
Meridian Duals,DRG,MS-481,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,Surgical,Relative Weights,"$12,241.39 ",IP,"2,420.00","42,090.05",,,,,,
Meridian Duals,DRG,MS-482,HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC,Surgical,Relative Weights,"$9,611.60 ",IP,"2,420.00","33,169.25",,,,,,
Meridian Duals,DRG,MS-483,MAJOR JOINT & LIMB REATTACHMENT PROC OF UPPER EXTREMITY W CC/MCC,Surgical,Relative Weights,"$13,932.67 ",IP,"2,420.00","48,224.74",,,,,,
Meridian Duals,DRG,MS-485,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,Surgical,Relative Weights,"$19,912.33 ",IP,"2,420.00","66,104.64",,,,,,
Meridian Duals,DRG,MS-486,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,Surgical,Relative Weights,"$12,552.66 ",IP,"2,420.00","43,356.10",,,,,,
Meridian Duals,DRG,MS-487,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Surgical,Relative Weights,"$9,578.90 ",IP,"2,420.00","32,401.15",,,,,,
Meridian Duals,DRG,MS-488,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,Surgical,Relative Weights,"$11,538.24 ",IP,"2,420.00","39,699.07",,,,,,
Meridian Duals,DRG,MS-489,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Surgical,Relative Weights,"$7,581.59 ",IP,"2,420.00","25,381.44",,,,,,
Meridian Duals,DRG,MS-492,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH MCC,Surgical,Relative Weights,"$20,265.07 ",IP,"2,420.00","69,457.25",,,,,,
Meridian Duals,DRG,MS-493,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH CC,Surgical,Relative Weights,"$13,582.85 ",IP,"2,420.00","46,408.32",,,,,,
Meridian Duals,DRG,MS-494,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITHOUT CC/MCC,Surgical,Relative Weights,"$10,814.07 ",IP,"2,420.00","36,517.82",,,,,,
Meridian Duals,DRG,MS-495,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,Surgical,Relative Weights,"$21,268.98 ",IP,"2,420.00","69,201.22",,,,,,
Meridian Duals,DRG,MS-496,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,Surgical,Relative Weights,"$11,600.73 ",IP,"2,420.00","41,136.48",,,,,,
Meridian Duals,DRG,MS-497,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,Surgical,Relative Weights,"$8,476.87 ",IP,"2,420.00","29,621.09",,,,,,
Meridian Duals,DRG,MS-498,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,Surgical,Relative Weights,"$15,089.01 ",IP,"2,420.00","49,353.70",,,,,,
Meridian Duals,DRG,MS-499,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,Surgical,Relative Weights,"$7,002.25 ",IP,"2,420.00","23,202.14",,,,,,
Meridian Duals,DRG,MS-500,SOFT TISSUE PROCEDURES WITH MCC,Surgical,Relative Weights,"$18,626.93 ",IP,"2,420.00","60,786.43",,,,,,
Meridian Duals,DRG,MS-501,SOFT TISSUE PROCEDURES WITH CC,Surgical,Relative Weights,"$10,244.08 ",IP,"2,420.00","33,828.48",,,,,,
Meridian Duals,DRG,MS-502,SOFT TISSUE PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,783.66 ",IP,"2,420.00","26,625.31",,,,,,
Meridian Duals,DRG,MS-503,FOOT PROCEDURES WITH MCC,Surgical,Relative Weights,"$15,421.31 ",IP,"2,420.00","54,766.66",,,,,,
Meridian Duals,DRG,MS-504,FOOT PROCEDURES WITH CC,Surgical,Relative Weights,"$10,366.14 ",IP,"2,420.00","35,007.84",,,,,,
Meridian Duals,DRG,MS-505,FOOT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,366.14 ",IP,"2,420.00","33,899.04",,,,,,
Meridian Duals,DRG,MS-506,MAJOR THUMB OR JOINT PROCEDURES,Surgical,Relative Weights,"$8,664.34 ",IP,"2,420.00","26,986.18",,,,,,
Meridian Duals,DRG,MS-507,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W CC/MCC,Surgical,Relative Weights,"$12,035.82 ",IP,"2,420.00","42,336.00",,,,,,
Meridian Duals,DRG,MS-508,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$8,232.76 ",IP,"2,420.00","31,417.34",,,,,,
Meridian Duals,DRG,MS-509,ARTHROSCOPY,Surgical,Relative Weights,"$9,849.29 ",IP,"2,420.00","28,056.67",,,,,,
Meridian Duals,DRG,MS-510,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH MCC,Surgical,Relative Weights,"$16,023.42 ",IP,"2,420.00","56,206.08",,,,,,
Meridian Duals,DRG,MS-511,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH CC,Surgical,Relative Weights,"$11,489.77 ",IP,"2,420.00","37,985.47",,,,,,
Meridian Duals,DRG,MS-512,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$9,078.40 ",IP,"2,420.00","30,518.21",,,,,,
Meridian Duals,DRG,MS-513,HAND OR WRIST PROCEDURES- EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$9,180.60 ",IP,"2,420.00","31,794.34",,,,,,
Meridian Duals,DRG,MS-514,HAND OR WRIST PROCEDURES -  EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$5,834.82 ",IP,"2,420.00","21,506.69",,,,,,
Meridian Duals,DRG,MS-515,OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W MCC,Surgical,Relative Weights,"$18,341.35 ",IP,"2,420.00","63,584.64",,,,,,
Meridian Duals,DRG,MS-516,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$11,462.90 ",IP,"2,420.00","39,092.26",,,,,,
Meridian Duals,DRG,MS-517,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,165.60 ",IP,"2,420.00","28,532.45",,,,,,
Meridian Duals,DRG,MS-518,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,Surgical,Relative Weights,"$20,947.77 ",IP,"10,289.00","68,717.38",,,,,,
Meridian Duals,DRG,MS-519,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,Surgical,Relative Weights,"$11,446.55 ",IP,"10,289.00","38,479.39",,,,,,
Meridian Duals,DRG,MS-520,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,Surgical,Relative Weights,"$8,282.98 ",IP,"8,282.98","26,974.08",,,,,,
Meridian Duals,DRG,MS-521,HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,Surgical,Relative Weights,"$17,906.85 ",IP,"2,420.00","17,906.85",,,,,,
Meridian Duals,DRG,MS-522,HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,Surgical,Relative Weights,"$12,786.27 ",IP,"2,420.00","12,786.27",,,,,,
Meridian Duals,DRG,MS-533,FRACTURES OF FEMUR WITH MCC,Medical,Relative Weights,"$8,270.72 ",IP,"2,420.00","29,421.50",,,,,,
Meridian Duals,DRG,MS-534,FRACTURES OF FEMUR WITHOUT MCC,Medical,Relative Weights,"$4,614.83 ",IP,"2,420.00","15,680.45",,,,,,
Meridian Duals,DRG,MS-535,FRACTURES OF HIP AND PELVIS WITH MCC,Medical,Relative Weights,"$7,199.65 ",IP,"2,420.00","24,738.34",,,,,,
Meridian Duals,DRG,MS-536,FRACTURES OF HIP AND PELVIS WITHOUT MCC,Medical,Relative Weights,"$4,506.79 ",IP,"2,420.00","15,291.36",,,,,,
Meridian Duals,DRG,MS-537,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITH CC/MCC,Medical,Relative Weights,"$5,462.81 ",IP,"2,420.00","18,363.74",,,,,,
Meridian Duals,DRG,MS-538,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITHOUT CC/MCC,Medical,Relative Weights,"$4,223.54 ",IP,"2,420.00","14,535.36",,,,,,
Meridian Duals,DRG,MS-539,OSTEOMYELITIS WITH MCC,Medical,Relative Weights,"$11,374.72 ",IP,"2,420.00","38,005.63",,,,,,
Meridian Duals,DRG,MS-540,OSTEOMYELITIS WITH CC,Medical,Relative Weights,"$7,601.45 ",IP,"2,420.00","26,208.00",,,,,,
Meridian Duals,DRG,MS-541,OSTEOMYELITIS WITHOUT CC/MCC,Medical,Relative Weights,"$4,924.35 ",IP,"2,420.00","18,279.07",,,,,,
Meridian Duals,DRG,MS-542,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,Medical,Relative Weights,"$10,565.87 ",IP,"2,420.00","36,787.97",,,,,,
Meridian Duals,DRG,MS-543,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,Medical,Relative Weights,"$6,104.05 ",IP,"2,420.00","21,295.01",,,,,,
Meridian Duals,DRG,MS-544,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,Medical,Relative Weights,"$4,541.83 ",IP,"2,420.00","15,289.34",,,,,,
Meridian Duals,DRG,MS-545,CONNECTIVE TISSUE DISORDERS WITH MCC,Medical,Relative Weights,"$14,618.30 ",IP,"2,420.00","50,964.48",,,,,,
Meridian Duals,DRG,MS-546,CONNECTIVE TISSUE DISORDERS WITH CC,Medical,Relative Weights,"$7,054.81 ",IP,"2,420.00","24,260.54",,,,,,
Meridian Duals,DRG,MS-547,CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$4,868.29 ",IP,"2,420.00","16,331.62",,,,,,
Meridian Duals,DRG,MS-548,SEPTIC ARTHRITIS WITH MCC,Medical,Relative Weights,"$11,976.83 ",IP,"2,420.00","39,983.33",,,,,,
Meridian Duals,DRG,MS-549,SEPTIC ARTHRITIS W CC,Medical,Relative Weights,"$7,299.51 ",IP,"2,420.00","24,052.90",,,,,,
Meridian Duals,DRG,MS-550,SEPTIC ARTHRITIS W/O CC/MCC,Medical,Relative Weights,"$5,132.84 ",IP,"2,420.00","17,418.24",,,,,,
Meridian Duals,DRG,MS-551,MEDICAL BACK PROBLEMS WITH MCC,Medical,Relative Weights,"$9,504.14 ",IP,"2,420.00","32,042.30",,,,,,
Meridian Duals,DRG,MS-552,MEDICAL BACK PROBLEMS WITHOUT MCC,Medical,Relative Weights,"$5,509.53 ",IP,"2,420.00","18,383.90",,,,,,
Meridian Duals,DRG,MS-553,BONE DISEASES AND ARTHROPATHIES WITH MCC,Medical,Relative Weights,"$7,425.66 ",IP,"2,420.00","25,915.68",,,,,,
Meridian Duals,DRG,MS-554,BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,Medical,Relative Weights,"$4,628.26 ",IP,"2,420.00","15,869.95",,,,,,
Meridian Duals,DRG,MS-555,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Medical,Relative Weights,"$7,992.15 ",IP,"2,420.00","26,516.45",,,,,,
Meridian Duals,DRG,MS-556,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,Medical,Relative Weights,"$4,722.87 ",IP,"2,420.00","15,962.69",,,,,,
Meridian Duals,DRG,MS-557,TENDONITIS -  MYOSITIS AND BURSITIS WITH MCC,Medical,Relative Weights,"$8,170.85 ",IP,"2,420.00","29,397.31",,,,,,
Meridian Duals,DRG,MS-558,TENDONITIS- MYOSITIS AND BURSITIS WITHOUT MCC,Medical,Relative Weights,"$5,030.64 ",IP,"2,420.00","17,365.82",,,,,,
Meridian Duals,DRG,MS-559,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Medical,Relative Weights,"$10,893.50 ",IP,"2,420.00","36,324.29",,,,,,
Meridian Duals,DRG,MS-560,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Medical,Relative Weights,"$6,283.92 ",IP,"2,420.00","21,036.96",,,,,,
Meridian Duals,DRG,MS-561,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Medical,Relative Weights,"$4,627.68 ",IP,"2,420.00","15,067.58",,,,,,
Meridian Duals,DRG,MS-562,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITH MCC,Medical,Relative Weights,"$8,245.02 ",IP,"2,420.00","27,157.54",,,,,,
Meridian Duals,DRG,MS-563,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITHOUT MCC,Medical,Relative Weights,"$5,093.72 ",IP,"2,420.00","17,216.64",,,,,,
Meridian Duals,DRG,MS-564,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,Medical,Relative Weights,"$8,897.94 ",IP,"2,420.00","30,481.92",,,,,,
Meridian Duals,DRG,MS-565,OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W CC,Medical,Relative Weights,"$5,894.39 ",IP,"2,420.00","19,766.88",,,,,,
Meridian Duals,DRG,MS-566,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$4,391.15 ",IP,"2,420.00","15,275.23",,,,,,
Meridian Duals,DRG,MS-570,SKIN DEBRIDEMENT WITH MCC,Surgical,Relative Weights,"$16,595.75 ",IP,"2,420.00","57,923.71",,,,,,
Meridian Duals,DRG,MS-571,SKIN DEBRIDEMENT WITH CC,Surgical,Relative Weights,"$9,550.86 ",IP,"2,420.00","33,713.57",,,,,,
Meridian Duals,DRG,MS-572,SKIN DEBRIDEMENT WITHOUT CC/MCC,Surgical,Relative Weights,"$6,449.78 ",IP,"2,420.00","22,613.47",,,,,,
Meridian Duals,DRG,MS-573,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,Surgical,Relative Weights,"$32,348.77 ",IP,"2,420.00","107,156.45",,,,,,
Meridian Duals,DRG,MS-574,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,Surgical,Relative Weights,"$18,959.81 ",IP,"2,420.00","62,935.49",,,,,,
Meridian Duals,DRG,MS-575,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS W/O CC/MCC,Surgical,Relative Weights,"$10,297.22 ",IP,"2,420.00","35,421.12",,,,,,
Meridian Duals,DRG,MS-576,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,Surgical,Relative Weights,"$29,572.40 ",IP,"2,420.00","97,759.87",,,,,,
Meridian Duals,DRG,MS-577,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,Surgical,Relative Weights,"$14,889.86 ",IP,"2,420.00","48,698.50",,,,,,
Meridian Duals,DRG,MS-578,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,Surgical,Relative Weights,"$9,316.09 ",IP,"2,420.00","32,808.38",,,,,,
Meridian Duals,DRG,MS-579,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC,Surgical,Relative Weights,"$18,366.46 ",IP,"2,420.00","60,199.78",,,,,,
Meridian Duals,DRG,MS-580,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC,Surgical,Relative Weights,"$10,096.33 ",IP,"2,420.00","32,431.39",,,,,,
Meridian Duals,DRG,MS-581,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,040.62 ",IP,"2,420.00","25,296.77",,,,,,
Meridian Duals,DRG,MS-582,MASTECTOMY FOR MALIGNANCY WITH CC/MCC,Surgical,Relative Weights,"$9,595.83 ",IP,"2,420.00","31,826.59",,,,,,
Meridian Duals,DRG,MS-583,MASTECTOMY FOR MALIGNANCY W/O CC/MCC,Surgical,Relative Weights,"$9,002.48 ",IP,"2,420.00","29,461.82",,,,,,
Meridian Duals,DRG,MS-584,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$10,726.47 ",IP,"2,420.00","36,860.54",,,,,,
Meridian Duals,DRG,MS-585,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,159.40 ",IP,"2,420.00","34,217.57",,,,,,
Meridian Duals,DRG,MS-592,SKIN ULCERS WITH MCC,Medical,Relative Weights,"$9,894.84 ",IP,"2,420.00","35,971.49",,,,,,
Meridian Duals,DRG,MS-593,SKIN ULCERS WITH CC,Medical,Relative Weights,"$6,661.19 ",IP,"2,420.00","23,139.65",,,,,,
Meridian Duals,DRG,MS-594,SKIN ULCERS WITHOUT CC/MCC,Medical,Relative Weights,"$4,765.50 ",IP,"2,420.00","16,323.55",,,,,,
Meridian Duals,DRG,MS-595,MAJOR SKIN DISORDERS WITH MCC,Medical,Relative Weights,"$11,776.52 ",IP,"2,420.00","40,977.22",,,,,,
Meridian Duals,DRG,MS-596,MAJOR SKIN DISORDERS W/O MCC,Medical,Relative Weights,"$5,809.13 ",IP,"2,420.00","19,637.86",,,,,,
Meridian Duals,DRG,MS-597,MALIGNANT BREAST DISORDERS W MCC,Medical,Relative Weights,"$9,601.09 ",IP,"2,420.00","34,128.86",,,,,,
Meridian Duals,DRG,MS-598,MALIGNANT BREAST DISORDERS WITH CC,Medical,Relative Weights,"$6,499.42 ",IP,"2,420.00","21,946.18",,,,,,
Meridian Duals,DRG,MS-599,MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$3,921.03 ",IP,"2,420.00","14,019.26",,,,,,
Meridian Duals,DRG,MS-600,NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,Medical,Relative Weights,"$5,821.97 ",IP,"2,420.00","19,337.47",,,,,,
Meridian Duals,DRG,MS-601,NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$4,010.97 ",IP,"2,420.00","12,475.01",,,,,,
Meridian Duals,DRG,MS-602,CELLULITIS WITH MCC,Medical,Relative Weights,"$8,468.11 ",IP,"2,420.00","28,824.77",,,,,,
Meridian Duals,DRG,MS-603,CELLULITIS WITHOUT MCC,Medical,Relative Weights,"$4,985.09 ",IP,"2,420.00","17,004.96",,,,,,
Meridian Duals,DRG,MS-604,TRAUMA TO THE SKIN -  SUBCUTANEOUS TISSUE AND BREAST WITH MCC,Medical,Relative Weights,"$8,631.05 ",IP,"2,420.00","29,524.32",,,,,,
Meridian Duals,DRG,MS-605,TRAUMA TO THE SKIN- SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC,Medical,Relative Weights,"$5,278.85 ",IP,"2,420.00","17,654.11",,,,,,
Meridian Duals,DRG,MS-606,MINOR SKIN DISORDERS WITH MCC,Medical,Relative Weights,"$8,830.78 ",IP,"2,420.00","30,149.28",,,,,,
Meridian Duals,DRG,MS-607,MINOR SKIN DISORDERS WITHOUT MCC,Medical,Relative Weights,"$4,836.75 ",IP,"2,420.00","16,654.18",,,,,,
Meridian Duals,DRG,MS-614,ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$13,956.03 ",IP,"2,420.00","49,055.33",,,,,,
Meridian Duals,DRG,MS-615,ADRENAL & PITUITARY PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$9,198.12 ",IP,"2,420.00","29,919.46",,,,,,
Meridian Duals,DRG,MS-616,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Surgical,Relative Weights,"$23,162.92 ",IP,"2,420.00","80,656.13",,,,,,
Meridian Duals,DRG,MS-617,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Surgical,Relative Weights,"$11,854.19 ",IP,"2,420.00","41,354.21",,,,,,
Meridian Duals,DRG,MS-618,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$7,610.79 ",IP,"2,420.00","25,290.72",,,,,,
Meridian Duals,DRG,MS-619,O.R. PROCEDURES FOR OBESITY WITH MCC,Surgical,Relative Weights,"$17,880.57 ",IP,"2,420.00","62,062.56",,,,,,
Meridian Duals,DRG,MS-620,O.R. PROCEDURES FOR OBESITY WITH CC,Surgical,Relative Weights,"$10,294.30 ",IP,"2,420.00","36,179.14",,,,,,
Meridian Duals,DRG,MS-621,O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,Surgical,Relative Weights,"$9,327.19 ",IP,"2,420.00","31,691.52",,,,,,
Meridian Duals,DRG,MS-622,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Surgical,Relative Weights,"$21,111.30 ",IP,"2,420.00","76,114.08",,,,,,
Meridian Duals,DRG,MS-623,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE -  NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Surgical,Relative Weights,"$10,929.71 ",IP,"2,420.00","39,364.42",,,,,,
Meridian Duals,DRG,MS-624,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$6,417.66 ",IP,"2,420.00","22,216.32",,,,,,
Meridian Duals,DRG,MS-625,THYROID- PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$16,586.99 ",IP,"2,420.00","58,970.02",,,,,,
Meridian Duals,DRG,MS-626,THYROID -  PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC,Surgical,Relative Weights,"$9,653.06 ",IP,"2,420.00","33,925.25",,,,,,
Meridian Duals,DRG,MS-627,THYROID -  PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,907.64 ",IP,"2,420.00","23,016.67",,,,,,
Meridian Duals,DRG,MS-628,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$21,487.98 ",IP,"2,420.00","74,376.29",,,,,,
Meridian Duals,DRG,MS-629,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$13,696.73 ",IP,"2,420.00","46,827.65",,,,,,
Meridian Duals,DRG,MS-630,OTHER ENDOCRINE - NUTRIT & METAB O.R. PROC W/O CC/MCC,Surgical,Relative Weights,"$8,230.42 ",IP,"2,420.00","29,207.81",,,,,,
Meridian Duals,DRG,MS-637,DIABETES WITH MCC,Medical,Relative Weights,"$8,039.45 ",IP,"2,420.00","27,935.71",,,,,,
Meridian Duals,DRG,MS-638,DIABETES WITH CC,Medical,Relative Weights,"$5,135.76 ",IP,"2,420.00","17,823.46",,,,,,
Meridian Duals,DRG,MS-639,DIABETES WITHOUT CC/MCC,Medical,Relative Weights,"$3,560.11 ",IP,"2,420.00","12,362.11",,,,,,
Meridian Duals,DRG,MS-640,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITH MCC,Medical,Relative Weights,"$7,187.97 ",IP,"2,420.00","24,478.27",,,,,,
Meridian Duals,DRG,MS-641,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITHOUT MCC,Medical,Relative Weights,"$4,404.59 ",IP,"2,420.00","15,253.06",,,,,,
Meridian Duals,DRG,MS-642,INBORN AND OTHER DISORDERS OF METABOLISM,Medical,Relative Weights,"$7,532.53 ",IP,"2,420.00","24,510.53",,,,,,
Meridian Duals,DRG,MS-643,ENDOCRINE DISORDERS WITH MCC,Medical,Relative Weights,"$9,739.50 ",IP,"2,420.00","32,770.08",,,,,,
Meridian Duals,DRG,MS-644,ENDOCRINE DISORDERS WITH CC,Medical,Relative Weights,"$5,955.71 ",IP,"2,420.00","20,726.50",,,,,,
Meridian Duals,DRG,MS-645,ENDOCRINE DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$4,488.68 ",IP,"2,420.00","15,426.43",,,,,,
Meridian Duals,DRG,MS-650,KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,Neonate,Relative Weights,"$26,401.24 ",IP,"2,420.00","26,401.24",,,,,,
Meridian Duals,DRG,MS-651,KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,Neonate,Relative Weights,"$21,598.94 ",IP,"2,420.00","21,598.94",,,,,,
Meridian Duals,DRG,MS-652,KIDNEY TRANSPLANT,Surgical,Relative Weights,"$18,601.23 ",IP,"2,420.00","68,239.58",,,,,,
Meridian Duals,DRG,MS-653,MAJOR BLADDER PROCEDURES WITH MCC,Surgical,Relative Weights,"$31,882.15 ",IP,"2,420.00","111,615.84",,,,,,
Meridian Duals,DRG,MS-654,MAJOR BLADDER PROCEDURES WITH CC,Surgical,Relative Weights,"$16,952.58 ",IP,"2,420.00","56,693.95",,,,,,
Meridian Duals,DRG,MS-655,MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$12,149.11 ",IP,"2,420.00","41,577.98",,,,,,
Meridian Duals,DRG,MS-656,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,Surgical,Relative Weights,"$19,184.65 ",IP,"2,420.00","65,733.70",,,,,,
Meridian Duals,DRG,MS-657,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,Surgical,Relative Weights,"$11,298.80 ",IP,"2,420.00","38,993.47",,,,,,
Meridian Duals,DRG,MS-658,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,Surgical,Relative Weights,"$9,215.06 ",IP,"2,420.00","31,649.18",,,,,,
Meridian Duals,DRG,MS-659,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,Surgical,Relative Weights,"$15,571.98 ",IP,"2,420.00","54,024.77",,,,,,
Meridian Duals,DRG,MS-660,KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC,Surgical,Relative Weights,"$8,427.82 ",IP,"2,420.00","28,641.31",,,,,,
Meridian Duals,DRG,MS-661,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,Surgical,Relative Weights,"$6,212.09 ",IP,"2,420.00","21,976.42",,,,,,
Meridian Duals,DRG,MS-662,MINOR BLADDER PROCEDURES WITH MCC,Surgical,Relative Weights,"$17,154.06 ",IP,"2,420.00","63,800.35",,,,,,
Meridian Duals,DRG,MS-663,MINOR BLADDER PROCEDURES WITH CC,Surgical,Relative Weights,"$9,341.20 ",IP,"2,420.00","30,711.74",,,,,,
Meridian Duals,DRG,MS-664,MINOR BLADDER PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,913.48 ",IP,"2,420.00","22,309.06",,,,,,
Meridian Duals,DRG,MS-665,PROSTATECTOMY WITH MCC,Surgical,Relative Weights,"$17,763.76 ",IP,"2,420.00","59,844.96",,,,,,
Meridian Duals,DRG,MS-666,PROSTATECTOMY WITH CC,Surgical,Relative Weights,"$10,159.98 ",IP,"2,420.00","35,665.06",,,,,,
Meridian Duals,DRG,MS-667,PROSTATECTOMY W/O CC/MCC,Surgical,Relative Weights,"$5,825.48 ",IP,"2,420.00","18,924.19",,,,,,
Meridian Duals,DRG,MS-668,TRANSURETHRAL PROCEDURES W MCC,Surgical,Relative Weights,"$16,389.01 ",IP,"2,420.00","56,212.13",,,,,,
Meridian Duals,DRG,MS-669,TRANSURETHRAL PROCEDURES WITH CC,Surgical,Relative Weights,"$9,130.96 ",IP,"2,420.00","31,161.31",,,,,,
Meridian Duals,DRG,MS-670,TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$5,714.52 ",IP,"2,420.00","19,730.59",,,,,,
Meridian Duals,DRG,MS-671,URETHRAL PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$10,402.93 ",IP,"2,420.00","36,844.42",,,,,,
Meridian Duals,DRG,MS-672,URETHRAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,718.43 ",IP,"2,420.00","20,829.31",,,,,,
Meridian Duals,DRG,MS-673,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,Surgical,Relative Weights,"$20,255.14 ",IP,"2,420.00","72,063.94",,,,,,
Meridian Duals,DRG,MS-674,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,Surgical,Relative Weights,"$13,918.07 ",IP,"2,420.00","49,275.07",,,,,,
Meridian Duals,DRG,MS-675,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,247.58 ",IP,"2,420.00","32,901.12",,,,,,
Meridian Duals,DRG,MS-682,RENAL FAILURE WITH MCC,Medical,Relative Weights,"$8,600.68 ",IP,"2,420.00","29,796.48",,,,,,
Meridian Duals,DRG,MS-683,RENAL FAILURE WITH CC,Medical,Relative Weights,"$5,135.18 ",IP,"2,420.00","18,089.57",,,,,,
Meridian Duals,DRG,MS-684,RENAL FAILURE WITHOUT CC/MCC,Medical,Relative Weights,"$3,550.18 ",IP,"2,420.00","12,404.45",,,,,,
Meridian Duals,DRG,MS-686,KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,Medical,Relative Weights,"$10,951.90 ",IP,"2,420.00","35,402.98",,,,,,
Meridian Duals,DRG,MS-687,KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,Medical,Relative Weights,"$6,132.67 ",IP,"2,420.00","21,220.42",,,,,,
Meridian Duals,DRG,MS-688,KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,Medical,Relative Weights,"$4,005.13 ",IP,"2,420.00","15,549.41",,,,,,
Meridian Duals,DRG,MS-689,KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,Medical,Relative Weights,"$6,507.01 ",IP,"2,420.00","22,550.98",,,,,,
Meridian Duals,DRG,MS-690,KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,Medical,Relative Weights,"$4,637.02 ",IP,"2,420.00","15,942.53",,,,,,
Meridian Duals,DRG,MS-693,URINARY STONES WITH MCC,Medical,Relative Weights,"$7,799.42 ",IP,"2,420.00","27,282.53",,,,,,
Meridian Duals,DRG,MS-694,URINARY STONES WITHOUT MCC,Medical,Relative Weights,"$4,503.87 ",IP,"2,420.00","14,926.46",,,,,,
Meridian Duals,DRG,MS-695,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,Medical,Relative Weights,"$6,644.26 ",IP,"2,420.00","23,633.57",,,,,,
Meridian Duals,DRG,MS-696,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,Medical,Relative Weights,"$4,040.75 ",IP,"2,420.00","13,696.70",,,,,,
Meridian Duals,DRG,MS-697,URETHRAL STRICTURE,Medical,Relative Weights,"$5,835.99 ",IP,"2,420.00","19,633.82",,,,,,
Meridian Duals,DRG,MS-698,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,Medical,Relative Weights,"$9,406.03 ",IP,"2,420.00","32,630.98",,,,,,
Meridian Duals,DRG,MS-699,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,Medical,Relative Weights,"$5,997.76 ",IP,"2,420.00","20,819.23",,,,,,
Meridian Duals,DRG,MS-700,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$4,359.62 ",IP,"2,420.00","14,952.67",,,,,,
Meridian Duals,DRG,MS-707,MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$11,225.80 ",IP,"2,420.00","37,697.18",,,,,,
Meridian Duals,DRG,MS-708,MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,708.72 ",IP,"2,420.00","29,272.32",,,,,,
Meridian Duals,DRG,MS-709,PENIS PROCEDURES W CC/MCC,Surgical,Relative Weights,"$13,525.04 ",IP,"2,420.00","48,496.90",,,,,,
Meridian Duals,DRG,MS-710,PENIS PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$9,353.47 ",IP,"2,420.00","30,961.73",,,,,,
Meridian Duals,DRG,MS-711,TESTES PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$12,448.71 ",IP,"2,420.00","43,206.91",,,,,,
Meridian Duals,DRG,MS-712,TESTES PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,190.48 ",IP,"2,420.00","20,567.23",,,,,,
Meridian Duals,DRG,MS-713,TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,Surgical,Relative Weights,"$8,721.57 ",IP,"2,420.00","29,473.92",,,,,,
Meridian Duals,DRG,MS-714,TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,Surgical,Relative Weights,"$5,424.26 ",IP,"2,420.00","18,454.46",,,,,,
Meridian Duals,DRG,MS-715,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,Surgical,Relative Weights,"$11,806.30 ",IP,"2,420.00","43,071.84",,,,,,
Meridian Duals,DRG,MS-716,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$7,450.77 ",IP,"2,420.00","29,544.48",,,,,,
Meridian Duals,DRG,MS-717,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,Surgical,Relative Weights,"$10,515.64 ",IP,"2,420.00","35,568.29",,,,,,
Meridian Duals,DRG,MS-718,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$7,210.16 ",IP,"2,420.00","24,583.10",,,,,,
Meridian Duals,DRG,MS-722,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH MCC,Medical,Relative Weights,"$10,001.72 ",IP,"2,420.00","36,386.78",,,,,,
Meridian Duals,DRG,MS-723,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH CC,Medical,Relative Weights,"$6,376.78 ",IP,"2,420.00","22,325.18",,,,,,
Meridian Duals,DRG,MS-724,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Medical,Relative Weights,"$3,784.95 ",IP,"2,420.00","11,902.46",,,,,,
Meridian Duals,DRG,MS-725,BENIGN PROSTATIC HYPERTROPHY WITH MCC,Medical,Relative Weights,"$7,507.42 ",IP,"2,420.00","25,308.86",,,,,,
Meridian Duals,DRG,MS-726,BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,Medical,Relative Weights,"$4,349.11 ",IP,"2,420.00","15,416.35",,,,,,
Meridian Duals,DRG,MS-727,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,Medical,Relative Weights,"$8,298.75 ",IP,"2,420.00","28,774.37",,,,,,
Meridian Duals,DRG,MS-728,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,Medical,Relative Weights,"$4,705.35 ",IP,"2,420.00","16,178.40",,,,,,
Meridian Duals,DRG,MS-729,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,Medical,Relative Weights,"$5,883.88 ",IP,"2,420.00","21,649.82",,,,,,
Meridian Duals,DRG,MS-730,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$3,322.42 ",IP,"2,420.00","12,733.06",,,,,,
Meridian Duals,DRG,MS-734,PELVIC EVISCERATION -  RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC,Surgical,Relative Weights,"$12,990.08 ",IP,"2,420.00","44,188.70",,,,,,
Meridian Duals,DRG,MS-735,PELVIC EVISCERATION -  RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC,Surgical,Relative Weights,"$8,255.53 ",IP,"2,420.00","27,703.87",,,,,,
Meridian Duals,DRG,MS-736,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,Surgical,Relative Weights,"$24,882.82 ",IP,"2,420.00","87,109.34",,,,,,
Meridian Duals,DRG,MS-737,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,Surgical,Relative Weights,"$12,019.46 ",IP,"2,420.00","40,059.94",,,,,,
Meridian Duals,DRG,MS-738,UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY W/O CC/MCC,Surgical,Relative Weights,"$8,619.37 ",IP,"2,420.00","27,798.62",,,,,,
Meridian Duals,DRG,MS-739,UTERINE -ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W MCC,Surgical,Relative Weights,"$22,332.46 ",IP,"2,420.00","75,489.12",,,,,,
Meridian Duals,DRG,MS-740,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,Surgical,Relative Weights,"$10,521.48 ",IP,"2,420.00","35,983.58",,,,,,
Meridian Duals,DRG,MS-741,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$7,474.72 ",IP,"2,420.00","26,802.72",,,,,,
Meridian Duals,DRG,MS-742,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,Surgical,Relative Weights,"$10,033.84 ",IP,"2,420.00","34,060.32",,,,,,
Meridian Duals,DRG,MS-743,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$6,615.64 ",IP,"2,420.00","23,153.76",,,,,,
Meridian Duals,DRG,MS-744,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC,Surgical,Relative Weights,"$10,485.28 ",IP,"2,420.00","35,088.48",,,,,,
Meridian Duals,DRG,MS-745,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC,Surgical,Relative Weights,"$6,832.89 ",IP,"2,420.00","21,476.45",,,,,,
Meridian Duals,DRG,MS-746,VAGINA -  CERVIX AND VULVA PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$9,411.29 ",IP,"2,420.00","32,880.96",,,,,,
Meridian Duals,DRG,MS-747,VAGINA- CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$5,484.42 ",IP,"2,420.00","18,793.15",,,,,,
Meridian Duals,DRG,MS-748,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,Surgical,Relative Weights,"$7,870.09 ",IP,"2,420.00","26,645.47",,,,,,
Meridian Duals,DRG,MS-749,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$15,848.80 ",IP,"2,420.00","52,258.75",,,,,,
Meridian Duals,DRG,MS-750,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,548.71 ",IP,"2,420.00","26,836.99",,,,,,
Meridian Duals,DRG,MS-754,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH MCC,Medical,Relative Weights,"$10,665.15 ",IP,"2,420.00","35,519.90",,,,,,
Meridian Duals,DRG,MS-755,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH CC,Medical,Relative Weights,"$6,595.20 ",IP,"2,420.00","20,639.81",,,,,,
Meridian Duals,DRG,MS-756,MALIGNANCY - FEMALE REPRODUCTIVE SYSTEM W/O CC/MCC,Medical,Relative Weights,"$5,363.53 ",IP,"2,420.00","17,676.29",,,,,,
Meridian Duals,DRG,MS-757,INFECTIONS - FEMALE REPRODUCTIVE SYSTEM W MCC,Medical,Relative Weights,"$8,904.37 ",IP,"2,420.00","28,633.25",,,,,,
Meridian Duals,DRG,MS-758,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITH CC,Medical,Relative Weights,"$5,663.12 ",IP,"2,420.00","19,462.46",,,,,,
Meridian Duals,DRG,MS-759,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Medical,Relative Weights,"$3,991.11 ",IP,"2,420.00","13,311.65",,,,,,
Meridian Duals,DRG,MS-760,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,Medical,Relative Weights,"$5,373.46 ",IP,"2,420.00","18,194.40",,,,,,
Meridian Duals,DRG,MS-761,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$3,450.32 ",IP,"2,420.00","11,398.46",,,,,,
Meridian Duals,DRG,MS-768,VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C,Surgical,Relative Weights,"$6,830.55 ",IP,"2,420.00","20,311.20",,,,,,
Meridian Duals,DRG,MS-769,POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,Surgical,Relative Weights,"$9,446.91 ",IP,"2,420.00","29,090.88",,,,,,
Meridian Duals,DRG,MS-770,ABORTION WITH D&C- ASPIRATION CURETTAGE OR HYSTEROTOMY,Surgical,Relative Weights,"$5,196.50 ",IP,"2,420.00","15,851.81",,,,,,
Meridian Duals,DRG,MS-776,POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,Medical,Relative Weights,"$4,523.14 ",IP,"2,420.00","14,311.58",,,,,,
Meridian Duals,DRG,MS-779,ABORTION WITHOUT D&C,Medical,Relative Weights,"$6,184.64 ",IP,"2,420.00","23,018.69",,,,,,
Meridian Duals,DRG,MS-783,CESAREAN SECTION WITH STERILIZATION WITH MCC,C-Section,Relative Weights,"$10,949.56 ",IP,"2,420.00","43,239.17",,,,,,
Meridian Duals,DRG,MS-784,CESAREAN SECTION WITH STERILIZATION WITH CC,C-Section,Relative Weights,"$6,400.14 ",IP,"2,420.00","21,071.23",,,,,,
Meridian Duals,DRG,MS-785,CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,C-Section,Relative Weights,"$5,354.18 ",IP,"2,420.00","17,305.34",,,,,,
Meridian Duals,DRG,MS-786,CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,C-Section,Relative Weights,"$9,311.42 ",IP,"2,420.00","34,564.32",,,,,,
Meridian Duals,DRG,MS-787,CESAREAN SECTION WITHOUT STERILIZATION WITH CC,C-Section,Relative Weights,"$6,216.18 ",IP,"2,420.00","21,077.28",,,,,,
Meridian Duals,DRG,MS-788,CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,C-Section,Relative Weights,"$5,182.48 ",IP,"2,420.00","18,268.99",,,,,,
Meridian Duals,DRG,MS-789,NEONATES- DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY,Medical,Relative Weights,"$10,044.93 ",IP,"2,420.00","34,070.40",,,,,,
Meridian Duals,DRG,MS-790,EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME- NEONATE,Medical,Relative Weights,"$33,125.50 ",IP,"2,420.00","112,351.68",,,,,,
Meridian Duals,DRG,MS-791,PREMATURITY W MAJOR PROBLEMS,Medical,Relative Weights,"$22,623.29 ",IP,"2,420.00","76,732.99",,,,,,
Meridian Duals,DRG,MS-792,PREMATURITY W/O MAJOR PROBLEMS,Medical,Relative Weights,"$13,650.60 ",IP,"2,420.00","46,297.44",,,,,,
Meridian Duals,DRG,MS-793,FULL TERM NEONATE WITH MAJOR PROBLEMS,Medical,Relative Weights,"$23,238.84 ",IP,"2,420.00","78,819.55",,,,,,
Meridian Duals,DRG,MS-794,NEONATE WITH OTHER SIGNIFICANT PROBLEMS,Medical,Relative Weights,"$8,225.17 ",IP,"2,420.00","27,897.41",,,,,,
Meridian Duals,DRG,MS-795,NORMAL NEWBORN,Medical,Relative Weights,"$1,113.70 ",IP,"1,113.70","3,775.97",,,,,,
Meridian Duals,DRG,MS-796,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,Vaginal Delivery,Relative Weights,"$6,253.56 ",IP,"2,420.00","39,761.57",,,,,,
Meridian Duals,DRG,MS-797,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,Vaginal Delivery,Relative Weights,"$5,369.37 ",IP,"2,420.00","17,394.05",,,,,,
Meridian Duals,DRG,MS-798,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,Vaginal Delivery,Relative Weights,"$4,832.66 ",IP,"2,420.00","17,394.05",,,,,,
Meridian Duals,DRG,MS-799,SPLENECTOMY WITH MCC,Surgical,Relative Weights,"$30,061.22 ",IP,"2,420.00","99,677.09",,,,,,
Meridian Duals,DRG,MS-800,SPLENECTOMY WITH CC,Surgical,Relative Weights,"$17,251.01 ",IP,"2,420.00","57,294.72",,,,,,
Meridian Duals,DRG,MS-801,SPLENECTOMY WITHOUT CC/MCC,Surgical,Relative Weights,"$9,834.69 ",IP,"2,420.00","37,763.71",,,,,,
Meridian Duals,DRG,MS-802,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,Surgical,Relative Weights,"$21,676.62 ",IP,"2,420.00","63,552.38",,,,,,
Meridian Duals,DRG,MS-803,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,Surgical,Relative Weights,"$11,017.31 ",IP,"2,420.00","35,917.06",,,,,,
Meridian Duals,DRG,MS-804,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,Surgical,Relative Weights,"$7,976.96 ",IP,"2,420.00","27,470.02",,,,,,
Meridian Duals,DRG,MS-805,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,Vaginal Delivery,Relative Weights,"$6,014.70 ",IP,"2,420.00","20,980.51",,,,,,
Meridian Duals,DRG,MS-806,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,Vaginal Delivery,Relative Weights,"$4,290.12 ",IP,"2,420.00","14,297.47",,,,,,
Meridian Duals,DRG,MS-807,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,Vaginal Delivery,Relative Weights,"$3,751.08 ",IP,"2,420.00","12,636.29",,,,,,
Meridian Duals,DRG,MS-808,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,Medical,Relative Weights,"$12,765.24 ",IP,"2,420.00","42,932.74",,,,,,
Meridian Duals,DRG,MS-809,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,Medical,Relative Weights,"$7,144.75 ",IP,"2,420.00","24,512.54",,,,,,
Meridian Duals,DRG,MS-810,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$5,616.40 ",IP,"2,420.00","18,857.66",,,,,,
Meridian Duals,DRG,MS-811,RED BLOOD CELL DISORDERS WITH MCC,Medical,Relative Weights,"$8,055.22 ",IP,"2,420.00","27,020.45",,,,,,
Meridian Duals,DRG,MS-812,RED BLOOD CELL DISORDERS WITHOUT MCC,Medical,Relative Weights,"$5,141.02 ",IP,"2,420.00","17,553.31",,,,,,
Meridian Duals,DRG,MS-813,COAGULATION DISORDERS,Medical,Relative Weights,"$9,023.50 ",IP,"2,420.00","31,957.63",,,,,,
Meridian Duals,DRG,MS-814,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,Medical,Relative Weights,"$11,047.67 ",IP,"2,420.00","35,261.86",,,,,,
Meridian Duals,DRG,MS-815,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,Medical,Relative Weights,"$5,801.53 ",IP,"2,420.00","20,418.05",,,,,,
Meridian Duals,DRG,MS-816,RETICULOENDOTHELIAL & IMMUNITY DISORDERS W/O CC/MCC,Medical,Relative Weights,"$3,860.88 ",IP,"2,420.00","14,432.54",,,,,,
Meridian Duals,DRG,MS-817,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$13,471.89 ",IP,"2,420.00","50,726.59",,,,,,
Meridian Duals,DRG,MS-818,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$7,941.34 ",IP,"2,420.00","25,681.82",,,,,,
Meridian Duals,DRG,MS-819,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$5,765.32 ",IP,"2,420.00","16,085.66",,,,,,
Meridian Duals,DRG,MS-820,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$33,239.97 ",IP,"2,420.00","115,248.67",,,,,,
Meridian Duals,DRG,MS-821,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$12,586.54 ",IP,"2,420.00","45,003.17",,,,,,
Meridian Duals,DRG,MS-822,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,308.86 ",IP,"2,420.00","25,490.30",,,,,,
Meridian Duals,DRG,MS-823,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,Surgical,Relative Weights,"$26,290.86 ",IP,"2,420.00","85,280.83",,,,,,
Meridian Duals,DRG,MS-824,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,Surgical,Relative Weights,"$13,808.28 ",IP,"2,420.00","46,874.02",,,,,,
Meridian Duals,DRG,MS-825,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,184.87 ",IP,"2,420.00","27,306.72",,,,,,
Meridian Duals,DRG,MS-826,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$29,460.27 ",IP,"2,420.00","101,102.40",,,,,,
Meridian Duals,DRG,MS-827,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$14,603.70 ",IP,"2,420.00","46,694.59",,,,,,
Meridian Duals,DRG,MS-828,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$9,776.29 ",IP,"2,420.00","33,288.19",,,,,,
Meridian Duals,DRG,MS-829,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$18,737.31 ",IP,"2,420.00","63,300.38",,,,,,
Meridian Duals,DRG,MS-830,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,655.00 ",IP,"2,420.00","27,796.61",,,,,,
Meridian Duals,DRG,MS-831,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,Medical,Relative Weights,"$6,551.40 ",IP,"2,420.00","21,742.56",,,,,,
Meridian Duals,DRG,MS-832,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,Medical,Relative Weights,"$4,545.33 ",IP,"2,420.00","14,424.48",,,,,,
Meridian Duals,DRG,MS-833,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,Medical,Relative Weights,"$3,136.12 ",IP,"2,420.00","10,727.14",,,,,,
Meridian Duals,DRG,MS-834,ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W MCC,Medical,Relative Weights,"$35,345.32 ",IP,"2,420.00","117,784.80",,,,,,
Meridian Duals,DRG,MS-835,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC,Medical,Relative Weights,"$12,344.17 ",IP,"2,420.00","40,888.51",,,,,,
Meridian Duals,DRG,MS-836,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Medical,Relative Weights,"$6,853.33 ",IP,"2,420.00","26,562.82",,,,,,
Meridian Duals,DRG,MS-837,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,Medical,Relative Weights,"$33,284.35 ",IP,"2,420.00","120,774.53",,,,,,
Meridian Duals,DRG,MS-838,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,Medical,Relative Weights,"$13,199.74 ",IP,"2,420.00","44,108.06",,,,,,
Meridian Duals,DRG,MS-839,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Medical,Relative Weights,"$8,685.36 ",IP,"2,420.00","25,728.19",,,,,,
Meridian Duals,DRG,MS-840,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,Medical,Relative Weights,"$18,807.97 ",IP,"2,420.00","64,415.23",,,,,,
Meridian Duals,DRG,MS-841,LYMPHOMA & NON-ACUTE LEUKEMIA W CC,Medical,Relative Weights,"$9,470.27 ",IP,"2,420.00","32,491.87",,,,,,
Meridian Duals,DRG,MS-842,LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,Medical,Relative Weights,"$6,406.57 ",IP,"2,420.00","23,115.46",,,,,,
Meridian Duals,DRG,MS-843,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,Medical,Relative Weights,"$11,140.53 ",IP,"2,420.00","38,461.25",,,,,,
Meridian Duals,DRG,MS-844,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,Medical,Relative Weights,"$6,915.82 ",IP,"2,420.00","24,353.28",,,,,,
Meridian Duals,DRG,MS-845,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$4,957.64 ",IP,"2,420.00","17,456.54",,,,,,
Meridian Duals,DRG,MS-846,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,Medical,Relative Weights,"$15,609.94 ",IP,"2,420.00","52,952.26",,,,,,
Meridian Duals,DRG,MS-847,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,Medical,Relative Weights,"$7,802.93 ",IP,"2,420.00","26,528.54",,,,,,
Meridian Duals,DRG,MS-848,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Medical,Relative Weights,"$6,028.71 ",IP,"2,420.00","19,785.02",,,,,,
Meridian Duals,DRG,MS-849,RADIOTHERAPY,Medical,Relative Weights,"$14,562.82 ",IP,"2,420.00","42,856.13",,,,,,
Meridian Duals,DRG,MS-853,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$29,012.34 ",IP,"2,420.00","102,787.78",,,,,,
Meridian Duals,DRG,MS-854,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$12,393.81 ",IP,"2,420.00","43,569.79",,,,,,
Meridian Duals,DRG,MS-855,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,875.75 ",IP,"2,420.00","32,322.53",,,,,,
Meridian Duals,DRG,MS-856,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$27,237.54 ",IP,"2,420.00","89,222.11",,,,,,
Meridian Duals,DRG,MS-857,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$12,278.18 ",IP,"2,420.00","40,991.33",,,,,,
Meridian Duals,DRG,MS-858,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,940.17 ",IP,"2,420.00","27,748.22",,,,,,
Meridian Duals,DRG,MS-862,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W MCC,Medical,Relative Weights,"$11,076.88 ",IP,"2,420.00","37,308.10",,,,,,
Meridian Duals,DRG,MS-863,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W/O MCC,Medical,Relative Weights,"$5,906.65 ",IP,"2,420.00","19,918.08",,,,,,
Meridian Duals,DRG,MS-864,FEVER AND INFLAMMATORY CONDITIONS,Medical,Relative Weights,"$5,118.83 ",IP,"2,420.00","17,083.58",,,,,,
Meridian Duals,DRG,MS-865,VIRAL ILLNESS WITH MCC,Medical,Relative Weights,"$8,630.47 ",IP,"2,420.00","28,088.93",,,,,,
Meridian Duals,DRG,MS-866,VIRAL ILLNESS WITHOUT MCC,Medical,Relative Weights,"$4,899.83 ",IP,"2,420.00","16,504.99",,,,,,
Meridian Duals,DRG,MS-867,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,Medical,Relative Weights,"$13,064.84 ",IP,"2,420.00","44,053.63",,,,,,
Meridian Duals,DRG,MS-868,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,Medical,Relative Weights,"$6,225.52 ",IP,"2,420.00","22,115.52",,,,,,
Meridian Duals,DRG,MS-869,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$4,254.50 ",IP,"2,420.00","14,968.80",,,,,,
Meridian Duals,DRG,MS-870,SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,Medical,Relative Weights,"$37,604.26 ",IP,"2,420.00","127,497.89",,,,,,
Meridian Duals,DRG,MS-871,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,Medical,Relative Weights,"$10,933.79 ",IP,"2,420.00","37,624.61",,,,,,
Meridian Duals,DRG,MS-872,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,Medical,Relative Weights,"$5,993.67 ",IP,"2,420.00","20,952.29",,,,,,
Meridian Duals,DRG,MS-876,O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,Surgical,Relative Weights,"$19,085.37 ",IP,"2,420.00","73,382.40",,,,,,
Meridian Duals,DRG,MS-880,ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,Medical,Relative Weights,"$5,048.75 ",IP,"2,420.00","17,275.10",,,,,,
Meridian Duals,DRG,MS-881,DEPRESSIVE NEUROSES,Medical,Relative Weights,"$4,683.74 ",IP,"2,420.00","16,517.09",,,,,,
Meridian Duals,DRG,MS-882,NEUROSES EXCEPT DEPRESSIVE,Medical,Relative Weights,"$4,809.89 ",IP,"2,420.00","15,922.37",,,,,,
Meridian Duals,DRG,MS-883,DISORDERS OF PERSONALITY & IMPULSE CONTROL,Medical,Relative Weights,"$9,237.83 ",IP,"2,420.00","26,945.86",,,,,,
Meridian Duals,DRG,MS-884,ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,Medical,Relative Weights,"$8,452.34 ",IP,"2,420.00","28,990.08",,,,,,
Meridian Duals,DRG,MS-885,PSYCHOSES,Medical,Relative Weights,"$7,238.19 ",IP,"2,420.00","24,502.46",,,,,,
Meridian Duals,DRG,MS-886,BEHAVIORAL AND DEVELOPMENTAL DISORDERS,Medical,Relative Weights,"$7,146.50 ",IP,"2,420.00","27,127.30",,,,,,
Meridian Duals,DRG,MS-887,OTHER MENTAL DISORDER DIAGNOSES,Medical,Relative Weights,"$6,306.12 ",IP,"2,420.00","21,936.10",,,,,,
Meridian Duals,DRG,MS-894,ALCOHOL- DRUG ABUSE OR DEPENDENCE- LEFT AMA,Medical,Relative Weights,"$3,206.20 ",IP,"2,420.00","11,700.86",,,,,,
Meridian Duals,DRG,MS-895,ALCOHOL- DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY,Medical,Relative Weights,"$9,339.45 ",IP,"2,420.00","32,798.30",,,,,,
Meridian Duals,DRG,MS-896,ALCOHOL -  DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC,Medical,Relative Weights,"$10,397.09 ",IP,"2,420.00","34,669.15",,,,,,
Meridian Duals,DRG,MS-897,ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC,Medical,Relative Weights,"$4,829.74 ",IP,"2,420.00","16,567.49",,,,,,
Meridian Duals,DRG,MS-901,WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,Surgical,Relative Weights,"$24,929.54 ",IP,"2,420.00","87,236.35",,,,,,
Meridian Duals,DRG,MS-902,WOUND DEBRIDEMENTS FOR INJURIES WITH CC,Surgical,Relative Weights,"$11,471.66 ",IP,"2,420.00","39,652.70",,,,,,
Meridian Duals,DRG,MS-903,WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,630.24 ",IP,"2,420.00","23,063.04",,,,,,
Meridian Duals,DRG,MS-904,SKIN GRAFTS FOR INJURIES WITH CC/MCC,Surgical,Relative Weights,"$21,765.97 ",IP,"2,420.00","71,313.98",,,,,,
Meridian Duals,DRG,MS-905,SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,Surgical,Relative Weights,"$9,636.13 ",IP,"2,420.00","33,554.30",,,,,,
Meridian Duals,DRG,MS-906,HAND PROCEDURES FOR INJURIES,Surgical,Relative Weights,"$10,534.33 ",IP,"2,420.00","35,096.54",,,,,,
Meridian Duals,DRG,MS-907,OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,Surgical,Relative Weights,"$23,057.79 ",IP,"2,420.00","80,430.34",,,,,,
Meridian Duals,DRG,MS-908,OTHER O.R. PROCEDURES FOR INJURIES WITH CC,Surgical,Relative Weights,"$11,974.50 ",IP,"2,420.00","41,592.10",,,,,,
Meridian Duals,DRG,MS-909,OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,006.75 ",IP,"2,420.00","26,584.99",,,,,,
Meridian Duals,DRG,MS-913,TRAUMATIC INJURY WITH MCC,Medical,Relative Weights,"$9,569.55 ",IP,"2,420.00","29,762.21",,,,,,
Meridian Duals,DRG,MS-914,TRAUMATIC INJURY WITHOUT MCC,Medical,Relative Weights,"$5,179.56 ",IP,"2,420.00","17,371.87",,,,,,
Meridian Duals,DRG,MS-915,ALLERGIC REACTIONS WITH MCC,Medical,Relative Weights,"$9,925.21 ",IP,"2,420.00","34,253.86",,,,,,
Meridian Duals,DRG,MS-916,ALLERGIC REACTIONS WITHOUT MCC,Medical,Relative Weights,"$3,845.11 ",IP,"2,420.00","12,765.31",,,,,,
Meridian Duals,DRG,MS-917,POISONING & TOXIC EFFECTS OF DRUGS W MCC,Medical,Relative Weights,"$8,634.55 ",IP,"2,420.00","29,498.11",,,,,,
Meridian Duals,DRG,MS-918,POISONING & TOXIC EFFECTS OF DRUGS W/O MCC,Medical,Relative Weights,"$4,623.01 ",IP,"2,420.00","15,805.44",,,,,,
Meridian Duals,DRG,MS-919,COMPLICATIONS OF TREATMENT WITH MCC,Medical,Relative Weights,"$10,769.69 ",IP,"2,420.00","36,798.05",,,,,,
Meridian Duals,DRG,MS-920,COMPLICATIONS OF TREATMENT WITH CC,Medical,Relative Weights,"$5,983.74 ",IP,"2,420.00","20,311.20",,,,,,
Meridian Duals,DRG,MS-921,COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,Medical,Relative Weights,"$4,075.79 ",IP,"2,420.00","13,922.50",,,,,,
Meridian Duals,DRG,MS-922,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC,Medical,Relative Weights,"$9,275.21 ",IP,"2,420.00","32,328.58",,,,,,
Meridian Duals,DRG,MS-923,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC,Medical,Relative Weights,"$5,488.50 ",IP,"2,420.00","17,448.48",,,,,,
Meridian Duals,DRG,MS-927,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,Surgical,Relative Weights,"$123,174.83 ",IP,"2,420.00","402,060.96",,,,,,
Meridian Duals,DRG,MS-928,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,Surgical,Relative Weights,"$38,145.05 ",IP,"2,420.00","124,889.18",,,,,,
Meridian Duals,DRG,MS-929,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,Surgical,Relative Weights,"$17,601.41 ",IP,"2,420.00","59,300.64",,,,,,
Meridian Duals,DRG,MS-933,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,Medical,Relative Weights,"$13,215.51 ",IP,"2,420.00","63,306.43",,,,,,
Meridian Duals,DRG,MS-934,FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,Medical,Relative Weights,"$11,335.01 ",IP,"2,420.00","36,485.57",,,,,,
Meridian Duals,DRG,MS-935,NON-EXTENSIVE BURNS,Medical,Relative Weights,"$11,288.29 ",IP,"2,420.00","38,955.17",,,,,,
Meridian Duals,DRG,MS-939,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,Surgical,Relative Weights,"$19,707.93 ",IP,"2,420.00","73,672.70",,,,,,
Meridian Duals,DRG,MS-940,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,Surgical,Relative Weights,"$12,970.23 ",IP,"2,420.00","45,799.49",,,,,,
Meridian Duals,DRG,MS-941,O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W/O CC/MCC,Surgical,Relative Weights,"$11,231.05 ",IP,"2,420.00","38,922.91",,,,,,
Meridian Duals,DRG,MS-945,REHABILITATION WITH CC/MCC,Medical,Relative Weights,"$8,654.41 ",IP,"2,420.00","29,338.85",,,,,,
Meridian Duals,DRG,MS-946,REHABILITATION WITHOUT CC/MCC,Medical,Relative Weights,"$6,577.10 ",IP,"2,420.00","21,913.92",,,,,,
Meridian Duals,DRG,MS-947,SIGNS AND SYMPTOMS WITH MCC,Medical,Relative Weights,"$6,973.05 ",IP,"2,420.00","24,137.57",,,,,,
Meridian Duals,DRG,MS-948,SIGNS AND SYMPTOMS WITHOUT MCC,Medical,Relative Weights,"$4,596.73 ",IP,"2,420.00","15,716.74",,,,,,
Meridian Duals,DRG,MS-949,AFTERCARE WITH CC/MCC,Medical,Relative Weights,"$6,481.90 ",IP,"2,420.00","21,952.22",,,,,,
Meridian Duals,DRG,MS-950,AFTERCARE WITHOUT CC/MCC,Medical,Relative Weights,"$4,322.83 ",IP,"2,420.00","14,936.54",,,,,,
Meridian Duals,DRG,MS-951,OTHER FACTORS INFLUENCING HEALTH STATUS,Medical,Relative Weights,"$3,268.11 ",IP,"2,420.00","11,823.84",,,,,,
Meridian Duals,DRG,MS-955,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,Surgical,Relative Weights,"$36,730.00 ",IP,"2,420.00","122,582.88",,,,,,
Meridian Duals,DRG,MS-956,LIMB REATTACHMENT- HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,Surgical,Relative Weights,"$22,484.30 ",IP,"2,420.00","79,093.73",,,,,,
Meridian Duals,DRG,MS-957,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Surgical,Relative Weights,"$43,338.63 ",IP,"2,420.00","151,879.39",,,,,,
Meridian Duals,DRG,MS-958,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,Surgical,Relative Weights,"$24,561.61 ",IP,"2,420.00","84,488.54",,,,,,
Meridian Duals,DRG,MS-959,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,Surgical,Relative Weights,"$15,979.04 ",IP,"2,420.00","56,458.08",,,,,,
Meridian Duals,DRG,MS-963,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Medical,Relative Weights,"$15,942.83 ",IP,"2,420.00","54,938.02",,,,,,
Meridian Duals,DRG,MS-964,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,Medical,Relative Weights,"$8,712.23 ",IP,"2,420.00","30,108.96",,,,,,
Meridian Duals,DRG,MS-965,OTHER MULTIPLE SIGNIFICANT TRAUMA W/O CC/MCC,Medical,Relative Weights,"$5,329.07 ",IP,"2,420.00","18,488.74",,,,,,
Meridian Duals,DRG,MS-969,HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$34,175.55 ",IP,"2,420.00","116,982.43",,,,,,
Meridian Duals,DRG,MS-970,HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$17,454.24 ",IP,"2,420.00","58,806.72",,,,,,
Meridian Duals,DRG,MS-974,HIV WITH MAJOR RELATED CONDITION WITH MCC,Medical,Relative Weights,"$15,712.73 ",IP,"2,420.00","53,905.82",,,,,,
Meridian Duals,DRG,MS-975,HIV WITH MAJOR RELATED CONDITION WITH CC,Medical,Relative Weights,"$7,487.56 ",IP,"2,420.00","27,054.72",,,,,,
Meridian Duals,DRG,MS-976,HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,Medical,Relative Weights,"$5,545.74 ",IP,"2,420.00","18,430.27",,,,,,
Meridian Duals,DRG,MS-977,HIV WITH OR WITHOUT OTHER RELATED CONDITION,Medical,Relative Weights,"$7,734.01 ",IP,"2,420.00","26,218.08",,,,,,
Meridian Duals,DRG,MS-981,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$26,949.04 ",IP,"2,420.00","90,532.51",,,,,,
Meridian Duals,DRG,MS-982,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Surgical,Relative Weights,"$14,813.94 ",IP,"2,420.00","49,152.10",,,,,,
Meridian Duals,DRG,MS-983,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$9,649.56 ",IP,"2,420.00","33,003.94",,,,,,
Meridian Duals,DRG,MS-987,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$19,131.51 ",IP,"2,420.00","67,207.39",,,,,,
Meridian Duals,DRG,MS-988,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Surgical,Relative Weights,"$9,965.51 ",IP,"2,420.00","34,640.93",,,,,,
Meridian Duals,DRG,MS-989,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$6,561.91 ",IP,"2,420.00","23,232.38",,,,,,
Meridian Duals,CPT,176,Anesth pharyngeal surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,211,Anesth cran surg hemotoma,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,214,Anesth skull drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,215,Anesth skull repair/fract,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,524,Anesth chest drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,540,Anesth chest surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,542,Anesthesia removal pleura,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,546,Anesth lung chest wall surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,560,Anesth heart surg w/o pump,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,561,Anesth heart surg <1 yr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,562,Anesth hrt surg w/pmp age 1+,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,567,Anesth cabg w/pump,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,580,Anesth heart/lung transplnt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,632,Anesth removal of nerves,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,792,Anesth hemorr/excise liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,794,Anesth pancreas removal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,796,Anesth for liver transplant,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,844,Anesth pelvis surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,846,Anesth hysterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,848,Anesth pelvic organ surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,864,Anesth removal of bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,866,Anesth removal of adrenal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,868,Anesth kidney transplant,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,882,Anesth major vein ligation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,908,Anesth removal of prostate,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,932,Anesth amputation of penis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,934,Anesth penis nodes removal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,936,Anesth penis nodes removal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,1272,Anesth femoral artery surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,1442,Anesth knee artery surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,1444,Anesth knee artery repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,1502,Anesth lwr leg embolectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,1652,Anesth shoulder vessel surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,1654,Anesth shoulder vessel surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,1656,Anesth arm-leg vessel surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,1990,Support for organ donor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,10005,Fna bx w/us gdn 1st les,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,10007,Fna bx w/fluor gdn 1st les,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,10009,Fna bx w/ct gdn 1st les,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,10011,Fna bx w/mr gdn 1st les,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,10021,Fna bx w/o img gdn 1st les,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,10030,Guide cathet fluid drainage,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,10035,Perq dev soft tiss 1st imag,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,10040,Acne surgery,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,10060,Drainage of skin abscess,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,10061,Drainage of skin abscess,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,10080,Drainage of pilonidal cyst,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,10081,Drainage of pilonidal cyst,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,10120,Remove foreign body,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,10121,Remove foreign body,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,10140,Drainage of hematoma/fluid,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,10160,Puncture drainage of lesion,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,10180,Complex drainage wound,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,11000,Debride infected skin,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Meridian Duals,CPT,11004,Debride genitalia & perineum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,11005,Debride abdom wall,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,11006,Debride genit/per/abdom wall,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,11008,Remove mesh from abd wall,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,11010,Debride skin at fx site,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,11011,Debride skin musc at fx site,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,11012,Deb skin bone at fx site,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,11042,Deb subq tissue 20 sq cm/<,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,11043,Deb musc/fascia 20 sq cm/<,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Meridian Duals,CPT,11044,Deb bone 20 sq cm/<,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,11055,Trim skin lesion,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,11056,Trim skin lesions 2 to 4,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,11057,Trim skin lesions over 4,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,11102,Tangntl bx skin single les,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,11104,Punch bx skin single lesion,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,11106,Incal bx skn single les,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Meridian Duals,CPT,11200,Removal of skin tags <w/15,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,11300,Shave skin lesion 0.5 cm/<,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,11301,Shave skin lesion 0.6-1.0 cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,11302,Shave skin lesion 1.1-2.0 cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,11303,Shave skin lesion >2.0 cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,11305,Shave skin lesion 0.5 cm/<,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,11306,Shave skin lesion 0.6-1.0 cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,11307,Shave skin lesion 1.1-2.0 cm,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,11308,Shave skin lesion >2.0 cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,11310,Shave skin lesion 0.5 cm/<,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,11311,Shave skin lesion 0.6-1.0 cm,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,11312,Shave skin lesion 1.1-2.0 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,11313,Shave skin lesion >2.0 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,11400,Exc tr-ext b9+marg 0.5 cm<,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,11401,Exc tr-ext b9+marg 0.6-1 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,11402,Exc tr-ext b9+marg 1.1-2 cm,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,11403,Exc tr-ext b9+marg 2.1-3cm,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,11404,Exc tr-ext b9+marg 3.1-4 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,11406,Exc tr-ext b9+marg >4.0 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,11420,Exc h-f-nk-sp b9+marg 0.5/<,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,11421,Exc h-f-nk-sp b9+marg 0.6-1,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,11422,Exc h-f-nk-sp b9+marg 1.1-2,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,11423,Exc h-f-nk-sp b9+marg 2.1-3,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,11424,Exc h-f-nk-sp b9+marg 3.1-4,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,11426,Exc h-f-nk-sp b9+marg >4 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,11440,Exc face-mm b9+marg 0.5 cm/<,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,11441,Exc face-mm b9+marg 0.6-1 cm,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,11442,Exc face-mm b9+marg 1.1-2 cm,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,11443,Exc face-mm b9+marg 2.1-3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,11444,Exc face-mm b9+marg 3.1-4 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,11446,Exc face-mm b9+marg >4 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,11450,Removal sweat gland lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,11451,Removal sweat gland lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,11462,Removal sweat gland lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,11463,Removal sweat gland lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,11470,Removal sweat gland lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,11471,Removal sweat gland lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,11600,Exc tr-ext mal+marg 0.5 cm/<,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,11601,Exc tr-ext mal+marg 0.6-1 cm,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,11602,Exc tr-ext mal+marg 1.1-2 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,11603,Exc tr-ext mal+marg 2.1-3 cm,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,11604,Exc tr-ext mal+marg 3.1-4 cm,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,11606,Exc tr-ext mal+marg >4 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,11620,Exc h-f-nk-sp mal+marg 0.5/<,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,11621,Exc s/n/h/f/g mal+mrg 0.6-1,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,11622,Exc s/n/h/f/g mal+mrg 1.1-2,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,11623,Exc s/n/h/f/g mal+mrg 2.1-3,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,11624,Exc s/n/h/f/g mal+mrg 3.1-4,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,11626,Exc s/n/h/f/g mal+mrg >4 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,11640,Exc f/e/e/n/l mal+mrg 0.5cm<,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,11641,Exc f/e/e/n/l mal+mrg 0.6-1,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,11642,Exc f/e/e/n/l mal+mrg 1.1-2,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,11643,Exc f/e/e/n/l mal+mrg 2.1-3,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,11644,Exc f/e/e/n/l mal+mrg 3.1-4,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,11646,Exc f/e/e/n/l mal+mrg >4 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,11719,Trim nail(s) any number,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Meridian Duals,CPT,11720,Debride nail 1-5,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Meridian Duals,CPT,11721,Debride nail 6 or more,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Meridian Duals,CPT,11730,Removal of nail plate,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,11740,Drain blood from under nail,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Meridian Duals,CPT,11750,Removal of nail bed,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,11755,Biopsy nail unit,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,11760,Repair of nail bed,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Meridian Duals,CPT,11762,Reconstruction of nail bed,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,11765,Excision of nail fold toe,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,11770,Remove pilonidal cyst simple,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,11771,Remove pilonidal cyst exten,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,11772,Remove pilonidal cyst compl,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,11900,Inject skin lesions </w 7,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,11901,Inject skin lesions >7,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,11920,Correct skin color 6.0 cm/<,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Meridian Duals,CPT,11921,Correct skn color 6.1-20.0cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Meridian Duals,CPT,11950,Tx contour defects 1 cc/<,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,11951,Tx contour defects 1.1-5.0cc,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Meridian Duals,CPT,11952,Tx contour defects 5.1-10cc,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Meridian Duals,CPT,11954,Tx contour defects >10.0 cc,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Meridian Duals,CPT,11960,Insert tissue expander(s),APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Meridian Duals,CPT,11970,Rplcmt tiss xpndr perm implt,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,11971,Rmvl tis xpndr wo insj implt,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,11976,Remove contraceptive capsule,APC 5071,RVU Per Case,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,11980,Implant hormone pellet(s),APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Meridian Duals,CPT,11981,Insert drug implant device,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Meridian Duals,CPT,11982,Remove drug implant device,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Meridian Duals,CPT,11983,Remove/insert drug implant,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Meridian Duals,CPT,12001,Rpr s/n/ax/gen/trnk 2.5cm/<,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,12002,Rpr s/n/ax/gen/trnk2.6-7.5cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,12004,Rpr s/n/ax/gen/trk7.6-12.5cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,12005,Rpr s/n/a/gen/trk12.6-20.0cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,12006,Rpr s/n/a/gen/trk20.1-30.0cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,12007,Rpr s/n/ax/gen/trnk >30.0 cm,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,12011,Rpr f/e/e/n/l/m 2.5 cm/<,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,12013,Rpr f/e/e/n/l/m 2.6-5.0 cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,12014,Rpr f/e/e/n/l/m 5.1-7.5 cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,12015,Rpr f/e/e/n/l/m 7.6-12.5 cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,12016,Rpr fe/e/en/l/m 12.6-20.0 cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,12017,Rpr fe/e/en/l/m 20.1-30.0 cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,12018,Rpr f/e/e/n/l/m >30.0 cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,12020,Closure of split wound,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Meridian Duals,CPT,12021,Closure of split wound,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,12031,Intmd rpr s/a/t/ext 2.5 cm/<,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,12032,Intmd rpr s/a/t/ext 2.6-7.5,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,12034,Intmd rpr s/tr/ext 7.6-12.5,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,12035,Intmd rpr s/a/t/ext 12.6-20,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,12036,Intmd rpr s/a/t/ext 20.1-30,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Meridian Duals,CPT,12037,Intmd rpr s/tr/ext >30.0 cm,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,12041,Intmd rpr n-hf/genit 2.5cm/<,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,12042,Intmd rpr n-hf/genit2.6-7.5,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,12044,Intmd rpr n-hf/genit7.6-12.5,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Meridian Duals,CPT,12045,Intmd rpr n-hf/genit12.6-20,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Meridian Duals,CPT,12046,Intmd rpr n-hf/genit20.1-30,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Meridian Duals,CPT,12047,Intmd rpr n-hf/genit >30.0cm,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,12051,Intmd rpr face/mm 2.5 cm/<,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,12052,Intmd rpr face/mm 2.6-5.0 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,12053,Intmd rpr face/mm 5.1-7.5 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,12054,Intmd rpr face/mm 7.6-12.5cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,12055,Intmd rpr face/mm 12.6-20 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,12056,Intmd rpr face/mm 20.1-30.0,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,12057,Intmd rpr face/mm >30.0 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,13100,Cmplx rpr trunk 1.1-2.5 cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Meridian Duals,CPT,13101,Cmplx rpr trunk 2.6-7.5 cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Meridian Duals,CPT,13120,Cmplx rpr s/a/l 1.1-2.5 cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Meridian Duals,CPT,13121,Cmplx rpr s/a/l 2.6-7.5 cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Meridian Duals,CPT,13131,Cmplx rpr f/c/c/m/n/ax/g/h/f,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,13132,Cmplx rpr f/c/c/m/n/ax/g/h/f,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Meridian Duals,CPT,13151,Cmplx rpr e/n/e/l 1.1-2.5 cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Meridian Duals,CPT,13152,Cmplx rpr e/n/e/l 2.6-7.5 cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Meridian Duals,CPT,13160,Late closure of wound,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,14000,Tis trnfr trunk 10 sq cm/<,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,14001,Tis trnfr trunk 10.1-30sqcm,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,14020,Tis trnfr s/a/l 10 sq cm/<,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,14021,Tis trnfr s/a/l 10.1-30 sqcm,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,14040,Tis trnfr f/c/c/m/n/a/g/h/f,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,14041,Tis trnfr f/c/c/m/n/a/g/h/f,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,14060,Tis trnfr e/n/e/l 10 sq cm/<,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,14061,Tis trnfr e/n/e/l10.1-30sqcm,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,14301,Tis trnfr any 30.1-60 sq cm,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Meridian Duals,CPT,14350,Filleted finger/toe flap,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,15002,Wound prep trk/arm/leg,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,15004,Wound prep f/n/hf/g,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Meridian Duals,CPT,15040,Harvest cultured skin graft,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,15050,Skin pinch graft,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Meridian Duals,CPT,15100,Skin splt grft trnk/arm/leg,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,15110,Epidrm autogrft trnk/arm/leg,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,15115,Epidrm a-grft face/nck/hf/g,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,15120,Skn splt a-grft fac/nck/hf/g,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Meridian Duals,CPT,15130,Derm autograft trnk/arm/leg,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,15135,Derm autograft face/nck/hf/g,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Meridian Duals,CPT,15150,Cult skin grft t/arm/leg,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,15155,Cult skin graft f/n/hf/g,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Meridian Duals,CPT,15200,Skin full graft trunk,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,15220,Skin full graft sclp/arm/leg,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,15240,Skin full grft face/genit/hf,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,15260,Skin full graft een & lips,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,15271,Skin sub graft trnk/arm/leg,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,15273,Skin sub grft t/arm/lg child,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Meridian Duals,CPT,15275,Skin sub graft face/nk/hf/g,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,15277,Skn sub grft f/n/hf/g child,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,15570,Skin pedicle flap trunk,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,15572,Skin pedicle flap arms/legs,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Meridian Duals,CPT,15574,Pedcle fh/ch/ch/m/n/ax/g/h/f,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,15576,Pedicle e/n/e/l/ntroral,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,15600,Delay flap trunk,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Meridian Duals,CPT,15610,Delay flap arms/legs,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,15620,Delay flap f/c/c/n/ax/g/h/f,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,15630,Delay flap eye/nos/ear/lip,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,15650,Transfer skin pedicle flap,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,15730,Mdfc flap w/prsrv vasc pedcl,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Meridian Duals,CPT,15731,Forehead flap w/vasc pedicle,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Meridian Duals,CPT,15733,Musc myoq/fscq flp h&n pedcl,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","9,201.00",,,,,,
Meridian Duals,CPT,15734,Muscle-skin graft trunk,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Meridian Duals,CPT,15736,Muscle-skin graft arm,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,15738,Muscle-skin graft leg,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Meridian Duals,CPT,15740,Island pedicle flap graft,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,15750,Neurovascular pedicle flap,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Meridian Duals,CPT,15756,Free myo/skin flap microvasc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,15757,Free skin flap microvasc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,15758,Free fascial flap microvasc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,15760,Composite skin graft,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,15769,Grfg autol soft tiss dir exc,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Meridian Duals,CPT,15770,Derma-fat-fascia graft,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Meridian Duals,CPT,15771,Grfg autol fat lipo 50 cc/<,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Meridian Duals,CPT,15773,Grfg autol fat lipo 25 cc/<,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,15775,Hair trnspl 1-15 punch grfts,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,15776,Hair trnspl >15 punch grafts,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,15780,Dermabrasion total face,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,15781,Dermabrasion segmental face,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,15782,Dermabrasion other than face,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,15783,Dermabrasion suprfl any site,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,15786,Abrasion lesion single,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,15788,Chemical peel face epiderm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,15789,Chemical peel face dermal,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Meridian Duals,CPT,15792,Chemical peel nonfacial,APC 5053,RVU Per Case,$536.39 ,OP,536.39,"4,314.00",,,,,,
Meridian Duals,CPT,15793,Chemical peel nonfacial,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,15819,Plastic surgery neck,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,15820,Revision of lower eyelid,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,15821,Revision of lower eyelid,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,15822,Revision of upper eyelid,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,15823,Revision of upper eyelid,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,15824,Removal of forehead wrinkles,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,15825,Removal of neck wrinkles,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Meridian Duals,CPT,15826,Removal of brow wrinkles,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Meridian Duals,CPT,15828,Removal of face wrinkles,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Meridian Duals,CPT,15829,Removal of skin wrinkles,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Meridian Duals,CPT,15830,Exc skin abd,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,15832,Excise excessive skin thigh,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,15833,Excise excessive skin leg,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,15834,Excise excessive skin hip,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,15835,Excise excessive skin buttck,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,15836,Excise excessive skin arm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,15837,Excise excess skin arm/hand,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,15838,Excise excess skin fat pad,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,15839,Excise excess skin & tissue,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,15840,Nerve palsy fascial graft,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Meridian Duals,CPT,15841,Nerve palsy muscle graft,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Meridian Duals,CPT,15842,Nerve palsy microsurg graft,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,15845,Skin and muscle repair face,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Meridian Duals,CPT,15850,Remove sutures same surgeon,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Meridian Duals,CPT,15851,Remove sutures diff surgeon,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,15852,Dressing change not for burn,APC 5053,RVU Per Case,$536.39 ,OP,536.39,"4,314.00",,,,,,
Meridian Duals,CPT,15860,Test for blood flow in graft,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Meridian Duals,CPT,15876,Suction lipectomy head&neck,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Meridian Duals,CPT,15877,Suction lipectomy trunk,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Meridian Duals,CPT,15878,Suction lipectomy upr extrem,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,15879,Suction lipectomy lwr extrem,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Meridian Duals,CPT,15920,Removal of tail bone ulcer,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,15922,Removal of tail bone ulcer,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Meridian Duals,CPT,15931,Remove sacrum pressure sore,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,15933,Remove sacrum pressure sore,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,15934,Remove sacrum pressure sore,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Meridian Duals,CPT,15935,Remove sacrum pressure sore,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Meridian Duals,CPT,15936,Remove sacrum pressure sore,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,15937,Remove sacrum pressure sore,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,15940,Remove hip pressure sore,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,15941,Remove hip pressure sore,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,15944,Remove hip pressure sore,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Meridian Duals,CPT,15945,Remove hip pressure sore,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,15946,Remove hip pressure sore,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,15950,Remove thigh pressure sore,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,15951,Remove thigh pressure sore,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,15952,Remove thigh pressure sore,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,15953,Remove thigh pressure sore,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Meridian Duals,CPT,15956,Remove thigh pressure sore,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,15958,Remove thigh pressure sore,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Meridian Duals,CPT,15999,Removal of pressure sore,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,16000,Initial treatment of burn(s),APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,16020,Dress/debrid p-thick burn s,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,16025,Dress/debrid p-thick burn m,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,16030,Dress/debrid p-thick burn l,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,16035,Incision of burn scab initi,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,16036,Escharotomy addl incision,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,17000,Destruct premalg lesion,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,17004,Destroy premal lesions 15/>,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,17106,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,17107,Destruction of skin lesions,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Meridian Duals,CPT,17108,Destruction of skin lesions,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,17110,Destruct b9 lesion 1-14,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,17111,Destruct lesion 15 or more,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,17250,Chem caut of granltj tissue,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,17260,Destruction of skin lesions,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,17261,Destruction of skin lesions,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,17262,Destruction of skin lesions,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,17263,Destruction of skin lesions,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,17264,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,17266,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,17270,Destruction of skin lesions,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,17271,Destruction of skin lesions,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,17272,Destruction of skin lesions,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,17273,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,17274,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,17276,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,17280,Destruction of skin lesions,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,17281,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,17282,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,17283,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,17284,Destruction of skin lesions,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Meridian Duals,CPT,17286,Destruction of skin lesions,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Meridian Duals,CPT,17311,Mohs 1 stage h/n/hf/g,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Meridian Duals,CPT,17313,Mohs 1 stage t/a/l,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Meridian Duals,CPT,17340,Cryotherapy of skin,APC 5732,RVU Per Case,$34.63 ,OP,34.63,"4,314.00",,,,,,
Meridian Duals,CPT,17360,Skin peel therapy,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,17380,Hair removal by electrolysis,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Meridian Duals,CPT,17999,Skin tissue procedure,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,19000,Drainage of breast lesion,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,19020,Incision of breast lesion,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,19081,Bx breast 1st lesion strtctc,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,19083,Bx breast 1st lesion us imag,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,19085,Bx breast 1st lesion mr imag,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,19100,Bx breast percut w/o image,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,19101,Biopsy of breast open,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Meridian Duals,CPT,19105,Cryosurg ablate fa each,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Meridian Duals,CPT,19110,Nipple exploration,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Meridian Duals,CPT,19112,Excise breast duct fistula,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Meridian Duals,CPT,19120,Removal of breast lesion,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Meridian Duals,CPT,19125,Excision breast lesion,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Meridian Duals,CPT,19281,Perq device breast 1st imag,APC 5071,RVU Per Case,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,19283,Perq dev breast 1st strtctc,APC 5071,RVU Per Case,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,19285,Perq dev breast 1st us imag,APC 5071,RVU Per Case,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,19287,Perq dev breast 1st mr guide,APC 5071,RVU Per Case,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,19296,Place po breast cath for rad,APC 5093,RVU Per Case,"$9,128.05 ",OP,"4,314.00","9,128.05",,,,,,
Meridian Duals,CPT,19298,Place breast rad tube/caths,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
Meridian Duals,CPT,19300,Removal of breast tissue,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","9,201.00",,,,,,
Meridian Duals,CPT,19301,Partial mastectomy,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Meridian Duals,CPT,19302,P-mastectomy w/ln removal,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
Meridian Duals,CPT,19303,Mast simple complete,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
Meridian Duals,CPT,19305,Mast radical,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,19306,Mast rad urban type,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,19307,Mast mod rad,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,19316,Suspension of breast,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
Meridian Duals,CPT,19318,Breast reduction,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,19325,Breast augmentation w/implt,APC 5093,RVU Per Case,"$9,128.05 ",OP,"4,314.00","9,128.05",,,,,,
Meridian Duals,CPT,19328,Rmvl intact breast implant,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Meridian Duals,CPT,19330,Rmvl ruptured breast implant,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Meridian Duals,CPT,19340,Insj breast implt sm d mast,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,19342,Insj/rplcmt brst implt sep d,APC 5093,RVU Per Case,"$9,128.05 ",OP,"4,314.00","9,128.05",,,,,,
Meridian Duals,CPT,19350,Breast reconstruction,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Meridian Duals,CPT,19355,Correct inverted nipple(s),APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Meridian Duals,CPT,19357,Tiss xpndr plmt brst rcnstj,APC 5094,RVU Per Case,"$15,276.83 ",OP,"4,140.35","15,276.83",,,,,,
Meridian Duals,CPT,19361,Brst rcnstj latsms drsi flap,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,19364,Brst rcnstj free flap,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,19367,Brst rcnstj 1 pdcl tram flap,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,19368,Brst rcnstj 1pdcl tram anast,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,19369,Brst rcnstj 2 pdcl tram flap,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,19370,Revj peri-implt capsule brst,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Meridian Duals,CPT,19371,Peri-implt capslc brst compl,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Meridian Duals,CPT,19380,Revj reconstructed breast,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
Meridian Duals,CPT,19396,Design custom breast implant,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Meridian Duals,CPT,19499,Breast surgery procedure,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Meridian Duals,CPT,20100,Explore wound neck,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Meridian Duals,CPT,20101,Explore wound chest,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,20102,Explore wound abdomen,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,20103,Explore wound extremity,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,20150,Excise epiphyseal bar,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,20200,Muscle biopsy,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,20205,Deep muscle biopsy,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,20206,Needle biopsy muscle,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,20220,Bone biopsy trocar/needle,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,20225,Bone biopsy trocar/needle,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,20240,Bone biopsy open superficial,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,20245,Bone biopsy open deep,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,20250,Open bone biopsy,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,20251,Open bone biopsy,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,20500,Injection of sinus tract,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,20520,Removal of foreign body,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,20525,Removal of foreign body,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,20526,Ther injection carp tunnel,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Meridian Duals,CPT,20527,Inj dupuytren cord w/enzyme,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Meridian Duals,CPT,20550,Inj tendon sheath/ligament,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Meridian Duals,CPT,20551,Inj tendon origin/insertion,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Meridian Duals,CPT,20552,Inj trigger point 1/2 muscl,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Meridian Duals,CPT,20553,Inject trigger points 3/>,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Meridian Duals,CPT,20555,Place ndl musc/tis for rt,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,20560,Ndl insj w/o njx 1 or 2 musc,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,"4,314.00",,,,,,
Meridian Duals,CPT,20561,Ndl insj w/o njx 3+ musc,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,"4,314.00",,,,,,
Meridian Duals,CPT,20600,Drain/inj joint/bursa w/o us,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Meridian Duals,CPT,20604,Drain/inj joint/bursa w/us,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Meridian Duals,CPT,20605,Drain/inj joint/bursa w/o us,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Meridian Duals,CPT,20606,Drain/inj joint/bursa w/us,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Meridian Duals,CPT,20610,Drain/inj joint/bursa w/o us,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Meridian Duals,CPT,20611,Drain/inj joint/bursa w/us,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Meridian Duals,CPT,20612,Aspirate/inj ganglion cyst,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Meridian Duals,CPT,20615,Treatment of bone cyst,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,20650,Insert and remove bone pin,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,20660,Apply rem fixation device,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,20661,Application of head brace,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,20662,Application of pelvis brace,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,20663,Application of thigh brace,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,20664,Application of halo,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,20665,Removal of fixation device,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Meridian Duals,CPT,20670,Removal of support implant,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,20680,Removal of support implant,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,20690,Apply bone fixation device,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,20692,Apply bone fixation device,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,20693,Adjust bone fixation device,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,20694,Remove bone fixation device,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,20696,Comp multiplane ext fixation,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,20697,Comp ext fixate strut change,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,20802,Replantation arm complete,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,20805,Replant forearm complete,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,20808,Replantation hand complete,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,20816,Replantation digit complete,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,20822,Replantation digit complete,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,20824,Replantation thumb complete,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,20827,Replantation thumb complete,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,20838,Replantation foot complete,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,20900,Removal of bone for graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,20902,Removal of bone for graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,20910,Remove cartilage for graft,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Meridian Duals,CPT,20912,Remove cartilage for graft,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Meridian Duals,CPT,20920,Removal of fascia for graft,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,20922,Removal of fascia for graft,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,20924,Removal of tendon for graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,20950,Fluid pressure muscle,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,20955,Fibula bone graft microvasc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,20956,Iliac bone graft microvasc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,20957,Mt bone graft microvasc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,20962,Other bone graft microvasc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,20969,Bone/skin graft microvasc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,20970,Bone/skin graft iliac crest,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,20972,Bone/skin graft metatarsal,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,20973,Bone/skin graft great toe,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,20974,Electrical bone stimulation,Physician,Per Unit,$50.41 ,OP,50.41,"4,314.00",,,,,,
Meridian Duals,CPT,20979,Us bone stimulation,APC 5731,RVU Per Case,$25.25 ,OP,25.25,"4,314.00",,,,,,
Meridian Duals,CPT,20982,Ablate bone tumor(s) perq,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,20983,Ablate bone tumor(s) perq,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,20999,Musculoskeletal surgery,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,21010,Incision of jaw joint,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,21011,Exc face les sc <2 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,21012,Exc face les sbq 2 cm/>,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,21013,Exc face tum deep < 2 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,21014,Exc face tum deep 2 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,21015,Resect face/scalp tum < 2 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,21016,Resect face/scalp tum 2 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,21025,Excision of bone lower jaw,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21026,Excision of facial bone(s),APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21029,Contour of face bone lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,21030,Excise max/zygoma b9 tumor,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21031,Remove exostosis mandible,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,21032,Remove exostosis maxilla,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,21034,Excise max/zygoma mal tumor,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21040,Excise mandible lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,21044,Removal of jaw bone lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21045,Extensive jaw surgery,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21046,Remove mandible cyst complex,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21047,Excise lwr jaw cyst w/repair,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21048,Remove maxilla cyst complex,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21049,Excis uppr jaw cyst w/repair,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21050,Removal of jaw joint,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21060,Remove jaw joint cartilage,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21070,Remove coronoid process,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21073,Mnpj of tmj w/anesth,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,21076,Prepare face/oral prosthesis,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,21077,Prepare face/oral prosthesis,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21079,Prepare face/oral prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,21080,Prepare face/oral prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,21081,Prepare face/oral prosthesis,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21082,Prepare face/oral prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,21083,Prepare face/oral prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,21084,Prepare face/oral prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,21085,Prepare face/oral prosthesis,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Meridian Duals,CPT,21086,Prepare face/oral prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,21087,Prepare face/oral prosthesis,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21088,Prepare face/oral prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,21089,Prepare face/oral prosthesis,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Meridian Duals,CPT,21100,Maxillofacial fixation,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21110,Interdental fixation,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,21120,Reconstruction of chin,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21121,Reconstruction of chin,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,21122,Reconstruction of chin,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21123,Reconstruction of chin,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,21125,Augmentation lower jaw bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21127,Augmentation lower jaw bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21137,Reduction of forehead,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,21138,Reduction of forehead,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21139,Reduction of forehead,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21141,Lefort i-1 piece w/o graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21142,Lefort i-2 piece w/o graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21143,Lefort i-3/> piece w/o graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21145,Lefort i-1 piece w/ graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21146,Lefort i-2 piece w/ graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21147,Lefort i-3/> piece w/ graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21150,Lefort ii anterior intrusion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21151,Lefort ii w/bone grafts,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21154,Lefort iii w/o lefort i,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21155,Lefort iii w/ lefort i,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21159,Lefort iii w/fhdw/o lefort i,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21160,Lefort iii w/fhd w/ lefort i,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21172,Reconstruct orbit/forehead,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21175,Reconstruct orbit/forehead,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21179,Reconstruct entire forehead,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21180,Reconstruct entire forehead,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21181,Contour cranial bone lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21182,Reconstruct cranial bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21183,Reconstruct cranial bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21184,Reconstruct cranial bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21188,Reconstruction of midface,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21193,Reconst lwr jaw w/o graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,21194,Reconst lwr jaw w/graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21195,Reconst lwr jaw w/o fixation,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21196,Reconst lwr jaw w/fixation,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21198,Reconstr lwr jaw segment,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21199,Reconstr lwr jaw w/advance,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21206,Reconstruct upper jaw bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21208,Augmentation of facial bones,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21209,Reduction of facial bones,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21210,Face bone graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21215,Lower jaw bone graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21230,Rib cartilage graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21235,Ear cartilage graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21240,Reconstruction of jaw joint,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21242,Reconstruction of jaw joint,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21243,Reconstruction of jaw joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,21244,Reconstruction of lower jaw,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21245,Reconstruction of jaw,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21246,Reconstruction of jaw,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21247,Reconstruct lower jaw bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21248,Reconstruction of jaw,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21249,Reconstruction of jaw,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21255,Reconstruct lower jaw bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21256,Reconstruction of orbit,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21260,Revise eye sockets,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21261,Revise eye sockets,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21263,Revise eye sockets,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21267,Revise eye sockets,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21268,Revise eye sockets,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21270,Augmentation cheek bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21275,Revision orbitofacial bones,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21280,Revision of eyelid,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,21282,Revision of eyelid,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,21295,Revision of jaw muscle/bone,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,21296,Revision of jaw muscle/bone,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,21299,Cranio/maxillofacial surgery,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Meridian Duals,CPT,21310,Closed tx nose fx w/o manj,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,21315,Closed tx nose fx w/o stablj,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,21320,Closed tx nose fx w/ stablj,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,21325,Open tx nose fx uncomplicatd,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,21330,Open tx nose fx w/skele fixj,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21335,Open tx nose & septal fx,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,21336,Open tx septal fx w/wo stabj,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,21337,Closed tx septal&nose fx,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,21338,Open nasoethmoid fx w/o fixj,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21339,Open nasoethmoid fx w/ fixj,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21340,Perq tx nasoethmoid fx,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,21343,Open tx dprsd front sinus fx,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21344,Open tx compl front sinus fx,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21345,Closed tx nose/jaw fx,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,21346,Opn tx nasomax fx w/fixj,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21347,Opn tx nasomax fx multple,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21348,Opn tx nasomax fx w/graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21355,Perq tx malar fracture,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,21356,Opn tx dprsd zygomatic arch,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21360,Opn tx dprsd malar fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21365,Opn tx complx malar fx,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21366,Opn tx complx malar w/grft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21385,Opn tx orbit fx transantral,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21386,Opn tx orbit fx periorbital,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21387,Opn tx orbit fx combined,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21390,Opn tx orbit periorbtl implt,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21395,Opn tx orbit periorbt w/grft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21400,Closed tx orbit w/o manipulj,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Meridian Duals,CPT,21401,Closed tx orbit w/manipulj,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,21406,Opn tx orbit fx w/o implant,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21407,Opn tx orbit fx w/implant,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21408,Opn tx orbit fx w/bone grft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21421,Treat mouth roof fracture,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,21422,Treat mouth roof fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21423,Treat mouth roof fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21431,Treat craniofacial fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21432,Treat craniofacial fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21433,Treat craniofacial fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21435,Treat craniofacial fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21436,Treat craniofacial fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21440,Treat dental ridge fracture,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,21445,Treat dental ridge fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21450,Treat lower jaw fracture,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Meridian Duals,CPT,21451,Treat lower jaw fracture,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,21452,Treat lower jaw fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21453,Treat lower jaw fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21454,Treat lower jaw fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21461,Treat lower jaw fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21462,Treat lower jaw fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,21465,Treat lower jaw fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21470,Treat lower jaw fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21480,Reset dislocated jaw,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,21485,Reset dislocated jaw,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,21490,Repair dislocated jaw,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,21497,Interdental wiring,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,21499,Head surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Meridian Duals,CPT,21501,Drain neck/chest lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,21502,Drain chest lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,21510,Drainage of bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,21550,Biopsy of neck/chest,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,21552,Exc neck les sc 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,21554,Exc neck tum deep 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,21555,Exc neck les sc < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,21556,Exc neck tum deep < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,21557,Resect neck thorax tumor<5cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,21558,Resect neck tumor 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,21600,Partial removal of rib,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,21601,Exc chest wall tumor w/ribs,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,21602,Exc ch wal tum w/o lymphadec,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,21603,Exc ch wal tum w/lymphadec,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,21610,Partial removal of rib,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,21615,Removal of rib,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,21616,Removal of rib and nerves,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,21620,Partial removal of sternum,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,21627,Sternal debridement,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,21630,Extensive sternum surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,21632,Extensive sternum surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,21685,Hyoid myotomy & suspension,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,21700,Revision of neck muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,21705,Revision of neck muscle/rib,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,21720,Revision of neck muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,21725,Revision of neck muscle,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,21740,Reconstruction of sternum,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,21742,Repair stern/nuss w/o scope,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,21743,Repair sternum/nuss w/scope,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,21750,Repair of sternum separation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,21811,Optx of rib fx w/fixj scope,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,21812,Treatment of rib fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,21813,Treatment of rib fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,21820,Treat sternum fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,21825,Treat sternum fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,21899,Neck/chest surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Meridian Duals,CPT,21920,Biopsy soft tissue of back,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,21925,Biopsy soft tissue of back,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,21930,Exc back les sc < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,21931,Exc back les sc 3 cm/>,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,21932,Exc back tum deep < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,21933,Exc back tum deep 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,21935,Resect back tum < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,21936,Resect back tum 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,22010,I&d p-spine c/t/cerv-thor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,22015,I&d abscess p-spine l/s/ls,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,22100,Remove part of neck vertebra,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,22101,Remove part thorax vertebra,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,22102,Remove part lumbar vertebra,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,22110,Remove part of neck vertebra,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,22112,Remove part thorax vertebra,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,22114,Remove part lumbar vertebra,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,22206,Incis spine 3 column thorac,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,22207,Incis spine 3 column lumbar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,22210,Incis 1 vertebral seg cerv,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,22212,Incis 1 vertebral seg thorac,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,22214,Incis 1 vertebral seg lumbar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,22220,Incis w/discectomy cervical,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,22222,Incis w/discectomy thoracic,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,22224,Incis w/discectomy lumbar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,22310,Closed tx vert fx w/o manj,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,22315,Closed tx vert fx w/manj,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,22318,Treat odontoid fx w/o graft,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,22319,Treat odontoid fx w/graft,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,22325,Treat spine fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,22326,Treat neck spine fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,22327,Treat thorax spine fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,22505,Manipulation of spine,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,22510,Perq cervicothoracic inject,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","15,496.26",,,,,,
Meridian Duals,CPT,22511,Perq lumbosacral injection,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","9,201.00",,,,,,
Meridian Duals,CPT,22513,Perq vertebral augmentation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,22514,Perq vertebral augmentation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,22532,Lat thorax spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,22533,Lat lumbar spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,22548,Neck spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,22551,Neck spine fuse&remov bel c2,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Meridian Duals,CPT,22554,Neck spine fusion,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,22556,Thorax spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,22558,Lumbar spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,22586,Prescrl fuse w/ instr l5-s1,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,22590,Spine & skull spinal fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,22595,Neck spinal fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,22600,Neck spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,22610,Thorax spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,22612,Lumbar spine fusion,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,22630,Lumbar spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,22633,Lumbar spine fusion combined,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,22800,Post fusion </6 vert seg,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,22802,Post fusion 7-12 vert seg,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,22804,Post fusion 13/> vert seg,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,22808,Ant fusion 2-3 vert seg,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,22810,Ant fusion 4-7 vert seg,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,22812,Ant fusion 8/> vert seg,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,22818,Kyphectomy 1-2 segments,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,22819,Kyphectomy 3 or more,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,22830,Exploration of spinal fusion,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,22849,Reinsert spinal fixation,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,22850,Remove spine fixation device,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,22852,Remove spine fixation device,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,22855,Remove spine fixation device,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,22856,Cerv artific diskectomy,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,140.35","16,238.16",,,,,,
Meridian Duals,CPT,22857,Lumbar artif diskectomy,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,22861,Revise cerv artific disc,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,22862,Revise lumbar artif disc,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,22864,Remove cerv artif disc,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,22865,Remove lumb artif disc,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,22867,Insj stablj dev w/dcmprn,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,22869,Insj stablj dev w/o dcmprn,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,22899,Spine surgery procedure,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,22900,Exc abdl tum deep < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,22901,Exc abdl tum deep 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,22902,Exc abd les sc < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,22903,Exc abd les sc 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,22904,Radical resect abd tumor<5cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,22905,Rad resect abd tumor 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,22999,Abdomen surgery procedure,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,23000,Removal of calcium deposits,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,23020,Release shoulder joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,23030,Drain shoulder lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,23031,Drain shoulder bursa,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,23035,Drain shoulder bone lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,23040,Exploratory shoulder surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,23044,Exploratory shoulder surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,23065,Biopsy shoulder tissues,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,23066,Biopsy shoulder tissues,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,23071,Exc shoulder les sc 3 cm/>,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,23073,Exc shoulder tum deep 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,23075,Exc shoulder les sc < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,23076,Exc shoulder tum deep < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,23077,Resect shoulder tumor < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,23078,Resect shoulder tumor 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,23100,Biopsy of shoulder joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,23101,Shoulder joint surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,23105,Remove shoulder joint lining,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,23106,Incision of collarbone joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,23107,Explore treat shoulder joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,23120,Partial removal collar bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,23125,Removal of collar bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,23130,Remove shoulder bone part,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,23140,Removal of bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,23145,Removal of bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,23146,Removal of bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,23150,Removal of humerus lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,23155,Removal of humerus lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,23156,Removal of humerus lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,23170,Remove collar bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,23172,Remove shoulder blade lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,23174,Remove humerus lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,23180,Remove collar bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,23182,Remove shoulder blade lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,23184,Remove humerus lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,23190,Partial removal of scapula,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,23195,Removal of head of humerus,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,23200,Resect clavicle tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,23210,Resect scapula tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,23220,Resect prox humerus tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,23330,Remove shoulder foreign body,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,23333,Remove shoulder fb deep,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,23334,Shoulder prosthesis removal,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,23335,Shoulder prosthesis removal,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,23395,Muscle transfer shoulder/arm,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,23397,Muscle transfers,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,23400,Fixation of shoulder blade,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,23405,Incision of tendon & muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,23406,Incise tendon(s) & muscle(s),APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,23410,Repair rotator cuff acute,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,23412,Repair rotator cuff chronic,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,23415,Release of shoulder ligament,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,23420,Repair of shoulder,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,23430,Repair biceps tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,23440,Remove/transplant tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,23450,Repair shoulder capsule,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,23455,Repair shoulder capsule,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,23460,Repair shoulder capsule,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,23462,Repair shoulder capsule,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,23465,Repair shoulder capsule,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,23466,Repair shoulder capsule,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,23470,Reconstruct shoulder joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,23472,Reconstruct shoulder joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,23473,Revis reconst shoulder joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,23474,Revis reconst shoulder joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,23480,Revision of collar bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,23485,Revision of collar bone,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,23490,Reinforce clavicle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,23491,Reinforce shoulder bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,23500,Treat clavicle fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,23505,Treat clavicle fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,23515,Treat clavicle fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,23520,Treat clavicle dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,23525,Treat clavicle dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,23530,Treat clavicle dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,23532,Treat clavicle dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,23540,Treat clavicle dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,23545,Treat clavicle dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,23550,Treat clavicle dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,23552,Treat clavicle dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,23570,Treat shoulder blade fx,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,23575,Treat shoulder blade fx,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,23585,Treat scapula fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,23600,Treat humerus fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,23605,Treat humerus fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,23615,Treat humerus fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Meridian Duals,CPT,23616,Treat humerus fracture,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,23620,Treat humerus fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,23625,Treat humerus fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,23630,Treat humerus fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,23650,Treat shoulder dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,23655,Treat shoulder dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,23660,Treat shoulder dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,23665,Treat dislocation/fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,23670,Treat dislocation/fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,23675,Treat dislocation/fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,23680,Treat dislocation/fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,23700,Fixation of shoulder,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,23800,Fusion of shoulder joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,23802,Fusion of shoulder joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,23900,Amputation of arm & girdle,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,23920,Amputation at shoulder joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,23921,Amputation follow-up surgery,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,23929,Shoulder surgery procedure,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,23930,Drainage of arm lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,23931,Drainage of arm bursa,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,23935,Drain arm/elbow bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,24000,Exploratory elbow surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,24006,Release elbow joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,24065,Biopsy arm/elbow soft tissue,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,24066,Biopsy arm/elbow soft tissue,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,24071,Exc arm/elbow les sc 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,24073,Ex arm/elbow tum deep 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,24075,Exc arm/elbow les sc < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,24076,Ex arm/elbow tum deep < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,24077,Resect arm/elbow tum < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,24079,Resect arm/elbow tum 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,24100,Biopsy elbow joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,24101,Explore/treat elbow joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,24102,Remove elbow joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,24105,Removal of elbow bursa,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,24110,Remove humerus lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,24115,Remove/graft bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,24116,Remove/graft bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,24120,Remove elbow lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,24125,Remove/graft bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,24126,Remove/graft bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,24130,Removal of head of radius,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,24134,Removal of arm bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,24136,Remove radius bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,24138,Remove elbow bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,24140,Partial removal of arm bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,24145,Partial removal of radius,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,24147,Partial removal of elbow,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,24149,Radical resection of elbow,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,24150,Resect distal humerus tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,24152,Resect radius tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,24155,Removal of elbow joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,24160,Remove elbow joint implant,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,24164,Remove radius head implant,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,24200,Removal of arm foreign body,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,24201,Removal of arm foreign body,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,24300,Manipulate elbow w/anesth,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,24301,Muscle/tendon transfer,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,24305,Arm tendon lengthening,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,24310,Revision of arm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,24320,Repair of arm tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,24330,Revision of arm muscles,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,24331,Revision of arm muscles,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,24332,Tenolysis triceps,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,24340,Repair of biceps tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,24341,Repair arm tendon/muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,24342,Repair of ruptured tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,24343,Repr elbow lat ligmnt w/tiss,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,24344,Reconstruct elbow lat ligmnt,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,24345,Repr elbw med ligmnt w/tissu,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,24346,Reconstruct elbow med ligmnt,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,24357,Repair elbow perc,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,24358,Repair elbow w/deb open,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,24359,Repair elbow deb/attch open,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,24360,Reconstruct elbow joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,24361,Reconstruct elbow joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,24362,Reconstruct elbow joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,24363,Replace elbow joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,24365,Reconstruct head of radius,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,24366,Reconstruct head of radius,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,24370,Revise reconst elbow joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,24371,Revise reconst elbow joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,24400,Revision of humerus,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,24410,Revision of humerus,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,24420,Revision of humerus,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,24430,Repair of humerus,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,24435,Repair humerus with graft,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,24470,Revision of elbow joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,24495,Decompression of forearm,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,24498,Reinforce humerus,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,24500,Treat humerus fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,24505,Treat humerus fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,24515,Treat humerus fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Meridian Duals,CPT,24516,Treat humerus fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,24530,Treat humerus fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,24535,Treat humerus fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,24538,Treat humerus fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,24545,Treat humerus fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Meridian Duals,CPT,24546,Treat humerus fracture,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,24560,Treat humerus fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,24565,Treat humerus fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,24566,Treat humerus fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,24575,Treat humerus fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,24576,Treat humerus fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,24577,Treat humerus fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,24579,Treat humerus fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,24582,Treat humerus fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,24586,Treat elbow fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,24587,Treat elbow fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,24600,Treat elbow dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,24605,Treat elbow dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,24615,Treat elbow dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,24620,Treat elbow fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,24635,Treat elbow fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,24640,Treat elbow dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,24650,Treat radius fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,24655,Treat radius fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,24665,Treat radius fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,24666,Treat radius fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Meridian Duals,CPT,24670,Treat ulnar fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,24675,Treat ulnar fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,24685,Treat ulnar fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,24800,Fusion of elbow joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,24802,Fusion/graft of elbow joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,24900,Amputation of upper arm,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,24920,Amputation of upper arm,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,24925,Amputation follow-up surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,24930,Amputation follow-up surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,24931,Amputate upper arm & implant,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,24935,Revision of amputation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,24940,Revision of upper arm,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,24999,Upper arm/elbow surgery,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,25000,Incision of tendon sheath,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,25001,Incise flexor carpi radialis,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25020,Decompress forearm 1 space,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,25023,Decompress forearm 1 space,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25024,Decompress forearm 2 spaces,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25025,Decompress forearm 2 spaces,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,25028,Drainage of forearm lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25031,Drainage of forearm bursa,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,25035,Treat forearm bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,25040,Explore/treat wrist joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25065,Biopsy forearm soft tissues,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,25066,Biopsy forearm soft tissues,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,25071,Exc forearm les sc 3 cm/>,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,25073,Exc forearm tum deep 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,25075,Exc forearm les sc < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,25076,Exc forearm tum deep < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,25077,Resect forearm/wrist tum<3cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,25078,Resect forarm/wrist tum 3cm>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,25085,Incision of wrist capsule,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25100,Biopsy of wrist joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25101,Explore/treat wrist joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25105,Remove wrist joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25107,Remove wrist joint cartilage,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25109,Excise tendon forearm/wrist,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25110,Remove wrist tendon lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,25111,Remove wrist tendon lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,25112,Reremove wrist tendon lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,25115,Remove wrist/forearm lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,25116,Remove wrist/forearm lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25118,Excise wrist tendon sheath,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,25119,Partial removal of ulna,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25120,Removal of forearm lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25125,Remove/graft forearm lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,25126,Remove/graft forearm lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25130,Removal of wrist lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25135,Remove & graft wrist lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,25136,Remove & graft wrist lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,25145,Remove forearm bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25150,Partial removal of ulna,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25151,Partial removal of radius,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","9,201.00",,,,,,
Meridian Duals,CPT,25170,Resect radius/ulnar tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,25210,Removal of wrist bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25215,Removal of wrist bones,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25230,Partial removal of radius,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25240,Partial removal of ulna,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25248,Remove forearm foreign body,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,25250,Removal of wrist prosthesis,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,25251,Removal of wrist prosthesis,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25259,Manipulate wrist w/anesthes,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,25260,Repair forearm tendon/muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25263,Repair forearm tendon/muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,25265,Repair forearm tendon/muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25270,Repair forearm tendon/muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25272,Repair forearm tendon/muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25274,Repair forearm tendon/muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25275,Repair forearm tendon sheath,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25280,Revise wrist/forearm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25290,Incise wrist/forearm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25295,Release wrist/forearm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25300,Fusion of tendons at wrist,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25301,Fusion of tendons at wrist,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25310,Transplant forearm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25312,Transplant forearm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25315,Revise palsy hand tendon(s),APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,25316,Revise palsy hand tendon(s),APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,25320,Repair/revise wrist joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,25332,Revise wrist joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25335,Realignment of hand,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25337,Reconstruct ulna/radioulnar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,25350,Revision of radius,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,25355,Revision of radius,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25360,Revision of ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,25365,Revise radius & ulna,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,25370,Revise radius or ulna,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25375,Revise radius & ulna,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25390,Shorten radius or ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,25391,Lengthen radius or ulna,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,25392,Shorten radius & ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,25393,Lengthen radius & ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,25394,Repair carpal bone shorten,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25400,Repair radius or ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,25405,Repair/graft radius or ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,25415,Repair radius & ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,25420,Repair/graft radius & ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,25425,Repair/graft radius or ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,25426,Repair/graft radius & ulna,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25430,Vasc graft into carpal bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25431,Repair nonunion carpal bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,25440,Repair/graft wrist bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,25441,Reconstruct wrist joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,25442,Reconstruct wrist joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,25443,Reconstruct wrist joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,25444,Reconstruct wrist joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,25445,Reconstruct wrist joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,25446,Wrist replacement,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,25447,Repair wrist joints,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25449,Remove wrist joint implant,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,25450,Revision of wrist joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25455,Revision of wrist joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25490,Reinforce radius,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,25491,Reinforce ulna,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,25492,Reinforce radius and ulna,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25500,Treat fracture of radius,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,25505,Treat fracture of radius,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,25515,Treat fracture of radius,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,25520,Treat fracture of radius,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,25525,Treat fracture of radius,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,25526,Treat fracture of radius,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,25530,Treat fracture of ulna,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,25535,Treat fracture of ulna,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,25545,Treat fracture of ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,25560,Treat fracture radius & ulna,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,25565,Treat fracture radius & ulna,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,25574,Treat fracture radius & ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,25575,Treat fracture radius/ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,25600,Treat fracture radius/ulna,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,25605,Treat fracture radius/ulna,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,25606,Treat fx distal radial,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25607,Treat fx rad extra-articul,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,25608,Treat fx rad intra-articul,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,25609,Treat fx radial 3+ frag,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,25622,Treat wrist bone fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,25624,Treat wrist bone fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,25628,Treat wrist bone fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,25630,Treat wrist bone fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,25635,Treat wrist bone fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,25645,Treat wrist bone fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25650,Treat wrist bone fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,25651,Pin ulnar styloid fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25652,Treat fracture ulnar styloid,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,25660,Treat wrist dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,25670,Treat wrist dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,25671,Pin radioulnar dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25675,Treat wrist dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,25676,Treat wrist dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,25680,Treat wrist fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,25685,Treat wrist fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,25690,Treat wrist dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,25695,Treat wrist dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,25800,Fusion of wrist joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,25805,Fusion/graft of wrist joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,25810,Fusion/graft of wrist joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,25820,Fusion of hand bones,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,25825,Fuse hand bones with graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,25830,Fusion radioulnar jnt/ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,25900,Amputation of forearm,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,25905,Amputation of forearm,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,25907,Amputation follow-up surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25909,Amputation follow-up surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,25915,Amputation of forearm,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,25920,Amputate hand at wrist,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,25922,Amputate hand at wrist,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,25924,Amputation follow-up surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,25927,Amputation of hand,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25929,Amputation follow-up surgery,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,25931,Amputation follow-up surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,25999,Forearm or wrist surgery,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,26010,Drainage of finger abscess,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,26011,Drainage of finger abscess,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,26020,Drain hand tendon sheath,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26025,Drainage of palm bursa,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26030,Drainage of palm bursas,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26034,Treat hand bone lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,26035,Decompress fingers/hand,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26037,Decompress fingers/hand,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26040,Release palm contracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,26045,Release palm contracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26055,Incise finger tendon sheath,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,26060,Incision of finger tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,26070,Explore/treat hand joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,26075,Explore/treat finger joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26080,Explore/treat finger joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,26100,Biopsy hand joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26105,Biopsy finger joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26110,Biopsy finger joint lining,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,26111,Exc hand les sc 1.5 cm/>,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,26113,Exc hand tum deep 1.5 cm/>,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,26115,Exc hand les sc < 1.5 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,26116,Exc hand tum deep < 1.5 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,26117,Rad resect hand tumor < 3 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,26118,Rad resect hand tumor 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,26121,Release palm contracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26123,Release palm contracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26130,Remove wrist joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26135,Revise finger joint each,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26140,Revise finger joint each,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,26145,Tendon excision palm/finger,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,26160,Remove tendon sheath lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,26170,Removal of palm tendon each,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,26180,Removal of finger tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,26185,Remove finger bone,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,26200,Remove hand bone lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,26205,Remove/graft bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,26210,Removal of finger lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,26215,Remove/graft finger lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26230,Partial removal of hand bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26235,Partial removal finger bone,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,26236,Partial removal finger bone,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,26250,Extensive hand surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26260,Resect prox finger tumor,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26262,Resect distal finger tumor,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,26320,Removal of implant from hand,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,26340,Manipulate finger w/anesth,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,26341,Manipulat palm cord post inj,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,26350,Repair finger/hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26352,Repair/graft hand tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,26356,Repair finger/hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26357,Repair finger/hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26358,Repair/graft hand tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,26370,Repair finger/hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","9,201.00",,,,,,
Meridian Duals,CPT,26372,Repair/graft hand tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,26373,Repair finger/hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26390,Revise hand/finger tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,26392,Repair/graft hand tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,26410,Repair hand tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,26412,Repair/graft hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26415,Excision hand/finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26416,Graft hand or finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26418,Repair finger tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,26420,Repair/graft finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26426,Repair finger/hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26428,Repair/graft finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26432,Repair finger tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,26433,Repair finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26434,Repair/graft finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26437,Realignment of tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26440,Release palm/finger tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,26442,Release palm & finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26445,Release hand/finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26449,Release forearm/hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26450,Incision of palm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26455,Incision of finger tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,26460,Incise hand/finger tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,26471,Fusion of finger tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26474,Fusion of finger tendons,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,26476,Tendon lengthening,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26477,Tendon shortening,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26478,Lengthening of hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26479,Shortening of hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26480,Transplant hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26483,Transplant/graft hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26485,Transplant palm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26489,Transplant/graft palm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26490,Revise thumb tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26492,Tendon transfer with graft,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26494,Hand tendon/muscle transfer,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26496,Revise thumb tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26497,Finger tendon transfer,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26498,Finger tendon transfer,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26499,Revision of finger,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26500,Hand tendon reconstruction,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,26502,Hand tendon reconstruction,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26508,Release thumb contracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26510,Thumb tendon transfer,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26516,Fusion of knuckle joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26517,Fusion of knuckle joints,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26518,Fusion of knuckle joints,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,26520,Release knuckle contracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26525,Release finger contracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,26530,Revise knuckle joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,26531,Revise knuckle with implant,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,26535,Revise finger joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26536,Revise/implant finger joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,26540,Repair hand joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26541,Repair hand joint with graft,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26542,Repair hand joint with graft,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26545,Reconstruct finger joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26546,Repair nonunion hand,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,26548,Reconstruct finger joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26550,Construct thumb replacement,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26551,Great toe-hand transfer,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,26553,Single transfer toe-hand,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,26554,Double transfer toe-hand,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,26555,Positional change of finger,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,26556,Toe joint transfer,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,26560,Repair of web finger,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,26561,Repair of web finger,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26562,Repair of web finger,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26565,Correct metacarpal flaw,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26567,Correct finger deformity,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26568,Lengthen metacarpal/finger,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,26580,Repair hand deformity,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26587,Reconstruct extra finger,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26590,Repair finger deformity,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,26591,Repair muscles of hand,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26593,Release muscles of hand,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26596,Excision constricting tissue,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26600,Treat metacarpal fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,26605,Treat metacarpal fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,26607,Treat metacarpal fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26608,Treat metacarpal fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26615,Treat metacarpal fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26641,Treat thumb dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,26645,Treat thumb fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,26650,Treat thumb fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26665,Treat thumb fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26670,Treat hand dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,26675,Treat hand dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,26676,Pin hand dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26685,Treat hand dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26686,Treat hand dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26700,Treat knuckle dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,26705,Treat knuckle dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,26706,Pin knuckle dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26715,Treat knuckle dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26720,Treat finger fracture each,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,26725,Treat finger fracture each,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,26727,Treat finger fracture each,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26735,Treat finger fracture each,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26740,Treat finger fracture each,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,26742,Treat finger fracture each,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,26746,Treat finger fracture each,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26750,Treat finger fracture each,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,26755,Treat finger fracture each,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,26756,Pin finger fracture each,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26765,Treat finger fracture each,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26770,Treat finger dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,26775,Treat finger dislocation,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Meridian Duals,CPT,26776,Pin finger dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26785,Treat finger dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26820,Thumb fusion with graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,26841,Fusion of thumb,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,26842,Thumb fusion with graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,26843,Fusion of hand joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,26844,Fusion/graft of hand joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,26850,Fusion of knuckle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,26852,Fusion of knuckle with graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,26860,Fusion of finger joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26862,Fusion/graft of finger joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26910,Amputate metacarpal bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26951,Amputation of finger/thumb,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26952,Amputation of finger/thumb,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26989,Hand/finger surgery,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,26990,Drainage of pelvis lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,26991,Drainage of pelvis bursa,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,26992,Drainage of bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27000,Incision of hip tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,27001,Incision of hip tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27003,Incision of hip tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27005,Incision of hip tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27006,Incision of hip tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27025,Incision of hip/thigh fascia,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27027,Buttock fasciotomy,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27030,Drainage of hip joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27033,Exploration of hip joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27035,Denervation of hip joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27036,Excision of hip joint/muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27040,Biopsy of soft tissues,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,27041,Biopsy of soft tissues,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,27043,Exc hip pelvis les sc 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,27045,Exc hip/pelv tum deep 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,27047,Exc hip/pelvis les sc < 3 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,27048,Exc hip/pelv tum deep < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,27049,Resect hip/pelv tum < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,27050,Biopsy of sacroiliac joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,27052,Biopsy of hip joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,27054,Removal of hip joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27057,Buttock fasciotomy w/dbrdmt,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,27059,Resect hip/pelv tum 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,27060,Removal of ischial bursa,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27062,Remove femur lesion/bursa,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27065,Remove hip bone les super,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27066,Remove hip bone les deep,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27067,Remove/graft hip bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27070,Part remove hip bone super,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27071,Part removal hip bone deep,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27075,Resect hip tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27076,Resect hip tum incl acetabul,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27077,Resect hip tum w/innom bone,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,27078,Rsect hip tum incl femur,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,27080,Removal of tail bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27086,Remove hip foreign body,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,27087,Remove hip foreign body,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27090,Removal of hip prosthesis,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,27091,Removal of hip prosthesis,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,27097,Revision of hip tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27098,Transfer tendon to pelvis,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27100,Transfer of abdominal muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27105,Transfer of spinal muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27110,Transfer of iliopsoas muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27111,Transfer of iliopsoas muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27120,Reconstruction of hip socket,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,27122,Reconstruction of hip socket,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,27125,Partial hip replacement,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,27130,Total hip arthroplasty,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,27132,Total hip arthroplasty,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,27134,Revise hip joint replacement,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,27137,Revise hip joint replacement,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,27138,Revise hip joint replacement,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,27140,Transplant femur ridge,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,27146,Incision of hip bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27147,Revision of hip bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27151,Incision of hip bones,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27156,Revision of hip bones,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27158,Revision of pelvis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27161,Incision of neck of femur,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27165,Incision/fixation of femur,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27170,Repair/graft femur head/neck,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27175,Treat slipped epiphysis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27176,Treat slipped epiphysis,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,27177,Treat slipped epiphysis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27178,Treat slipped epiphysis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27179,Revise head/neck of femur,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27181,Treat slipped epiphysis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27185,Revision of femur epiphysis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27187,Reinforce hip bones,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27197,Clsd tx pelvic ring fx,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,27198,Clsd tx pelvic ring fx,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,27200,Treat tail bone fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,27202,Treat tail bone fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27220,Treat hip socket fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,27222,Treat hip socket fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,27226,Treat hip wall fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27227,Treat hip fracture(s),APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27228,Treat hip fracture(s),APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27230,Treat thigh fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,27232,Treat thigh fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,27235,Treat thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27236,Treat thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27238,Treat thigh fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,27240,Treat thigh fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,27244,Treat thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27245,Treat thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27246,Treat thigh fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,27248,Treat thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27250,Treat hip dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,27252,Treat hip dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,27253,Treat hip dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27254,Treat hip dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27256,Treat hip dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,27257,Treat hip dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,27258,Treat hip dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27259,Treat hip dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27265,Treat hip dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,27266,Treat hip dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,27267,Cltx thigh fx,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27268,Cltx thigh fx w/mnpj,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27269,Optx thigh fx,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,27275,Manipulation of hip joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,27279,Arthrodesis sacroiliac joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,27280,Fusion of sacroiliac joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,27282,Fusion of pubic bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,27284,Fusion of hip joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,27286,Fusion of hip joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,27290,Amputation of leg at hip,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,27295,Amputation of leg at hip,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,27299,Pelvis/hip joint surgery,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,27301,Drain thigh/knee lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,27303,Drainage of bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27305,Incise thigh tendon & fascia,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27306,Incision of thigh tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27307,Incision of thigh tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27310,Exploration of knee joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27323,Biopsy thigh soft tissues,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,27324,Biopsy thigh soft tissues,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,27325,Neurectomy hamstring,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,27326,Neurectomy popliteal,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,27327,Exc thigh/knee les sc < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,27328,Exc thigh/knee tum deep <5cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,27329,Resect thigh/knee tum < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,27330,Biopsy knee joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27331,Explore/treat knee joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27332,Removal of knee cartilage,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27333,Removal of knee cartilage,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27334,Remove knee joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27335,Remove knee joint lining,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27337,Exc thigh/knee les sc 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,27339,Exc thigh/knee tum dep 5cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,27340,Removal of kneecap bursa,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27345,Removal of knee cyst,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27347,Remove knee cyst,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27350,Removal of kneecap,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27355,Remove femur lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27356,Remove femur lesion/graft,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,27357,Remove femur lesion/graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27360,Partial removal leg bone(s),APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27364,Resect thigh/knee tum 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,27365,Resect femur/knee tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27372,Removal of foreign body,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,27380,Repair of kneecap tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27381,Repair/graft kneecap tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27385,Repair of thigh muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27386,Repair/graft of thigh muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27390,Incision of thigh tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27391,Incision of thigh tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27392,Incision of thigh tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27393,Lengthening of thigh tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27394,Lengthening of thigh tendons,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27395,Lengthening of thigh tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27396,Transplant of thigh tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27397,Transplants of thigh tendons,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27400,Revise thigh muscles/tendons,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27403,Repair of knee cartilage,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27405,Repair of knee ligament,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,27407,Repair of knee ligament,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,27409,Repair of knee ligaments,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,27412,Autochondrocyte implant knee,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27415,Osteochondral knee allograft,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,27416,Osteochondral knee autograft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27418,Repair degenerated kneecap,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27420,Revision of unstable kneecap,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27422,Revision of unstable kneecap,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27424,Revision/removal of kneecap,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27425,Lat retinacular release open,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27427,Reconstruction knee,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,27428,Reconstruction knee,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Meridian Duals,CPT,27429,Reconstruction knee,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Meridian Duals,CPT,27430,Revision of thigh muscles,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27435,Incision of knee joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27437,Revise kneecap,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27438,Revise kneecap with implant,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,27440,Revision of knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,27441,Revision of knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,27442,Revision of knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,27443,Revision of knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,27445,Revision of knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,27446,Revision of knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Meridian Duals,CPT,27447,Total knee arthroplasty,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,27448,Incision of thigh,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27450,Incision of thigh,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27454,Realignment of thigh bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27455,Realignment of knee,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27457,Realignment of knee,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27465,Shortening of thigh bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27466,Lengthening of thigh bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27468,Shorten/lengthen thighs,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27470,Repair of thigh,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27472,Repair/graft of thigh,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27475,Surgery to stop leg growth,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27477,Surgery to stop leg growth,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27479,Surgery to stop leg growth,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27485,Surgery to stop leg growth,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27486,Revise/replace knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,27487,Revise/replace knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,27488,Removal of knee prosthesis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27495,Reinforce thigh,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27496,Decompression of thigh/knee,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27497,Decompression of thigh/knee,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27498,Decompression of thigh/knee,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,27499,Decompression of thigh/knee,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27500,Treatment of thigh fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,27501,Treatment of thigh fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,27502,Treatment of thigh fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,27503,Treatment of thigh fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,27506,Treatment of thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27507,Treatment of thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27508,Treatment of thigh fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,27509,Treatment of thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27510,Treatment of thigh fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,27511,Treatment of thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27513,Treatment of thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27514,Treatment of thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27516,Treat thigh fx growth plate,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,27517,Treat thigh fx growth plate,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,27519,Treat thigh fx growth plate,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27520,Treat kneecap fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,27524,Treat kneecap fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27530,Treat knee fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,27532,Treat knee fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27535,Treat knee fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27536,Treat knee fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27538,Treat knee fracture(s),APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,27540,Treat knee fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27550,Treat knee dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,27552,Treat knee dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,27556,Treat knee dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27557,Treat knee dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27558,Treat knee dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27560,Treat kneecap dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,27562,Treat kneecap dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,27566,Treat kneecap dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27570,Fixation of knee joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,27580,Fusion of knee,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,27590,Amputate leg at thigh,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,27591,Amputate leg at thigh,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,27592,Amputate leg at thigh,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,27594,Amputation follow-up surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27596,Amputation follow-up surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27598,Amputate lower leg at knee,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,27599,Leg surgery procedure,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,27600,Decompression of lower leg,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27601,Decompression of lower leg,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27602,Decompression of lower leg,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27603,Drain lower leg lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,27604,Drain lower leg bursa,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27605,Incision of achilles tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,27606,Incision of achilles tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27607,Treat lower leg bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27610,Explore/treat ankle joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27612,Exploration of ankle joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27613,Biopsy lower leg soft tissue,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,27614,Biopsy lower leg soft tissue,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,27615,Resect leg/ankle tum < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,27616,Resect leg/ankle tum 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,27618,Exc leg/ankle tum < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,27619,Exc leg/ankle tum deep <5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,27620,Explore/treat ankle joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27625,Remove ankle joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27626,Remove ankle joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27630,Removal of tendon lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27632,Exc leg/ankle les sc 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,27634,Exc leg/ankle tum dep 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,27635,Remove lower leg bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27637,Remove/graft leg bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27638,Remove/graft leg bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27640,Partial removal of tibia,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27641,Partial removal of fibula,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27645,Resect tibia tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27646,Resect fibula tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27647,Resect talus/calcaneus tum,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27650,Repair achilles tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27652,Repair/graft achilles tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,27654,Repair of achilles tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,27656,Repair leg fascia defect,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27658,Repair of leg tendon each,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27659,Repair of leg tendon each,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27664,Repair of leg tendon each,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27665,Repair of leg tendon each,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27675,Repair lower leg tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27676,Repair lower leg tendons,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27680,Release of lower leg tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27681,Release of lower leg tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27685,Revision of lower leg tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27686,Revise lower leg tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27687,Revision of calf tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27690,Revise lower leg tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27691,Revise lower leg tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,27695,Repair of ankle ligament,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27696,Repair of ankle ligaments,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27698,Repair of ankle ligament,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27700,Revision of ankle joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27702,Reconstruct ankle joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,27703,Reconstruction ankle joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,27704,Removal of ankle implant,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27705,Incision of tibia,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27707,Incision of fibula,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27709,Incision of tibia & fibula,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,27712,Realignment of lower leg,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,27715,Revision of lower leg,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,27720,Repair of tibia,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27722,Repair/graft of tibia,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27724,Repair/graft of tibia,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,27725,Repair of lower leg,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27726,Repair fibula nonunion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,27727,Repair of lower leg,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27730,Repair of tibia epiphysis,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27732,Repair of fibula epiphysis,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27734,Repair lower leg epiphyses,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27740,Repair of leg epiphyses,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27742,Repair of leg epiphyses,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27745,Reinforce tibia,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27750,Treatment of tibia fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,27752,Treatment of tibia fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,27756,Treatment of tibia fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27758,Treatment of tibia fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Meridian Duals,CPT,27759,Treatment of tibia fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,27760,Cltx medial ankle fx,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,27762,Cltx med ankle fx w/mnpj,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,27766,Optx medial ankle fx,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27767,Cltx post ankle fx,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,27768,Cltx post ankle fx w/mnpj,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,27769,Optx post ankle fx,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27780,Treatment of fibula fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,27781,Treatment of fibula fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,27784,Treatment of fibula fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27786,Treatment of ankle fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,27788,Treatment of ankle fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,27792,Treatment of ankle fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27808,Treatment of ankle fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,27810,Treatment of ankle fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,27814,Treatment of ankle fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,27816,Treatment of ankle fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,27818,Treatment of ankle fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,27822,Treatment of ankle fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27823,Treatment of ankle fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27824,Treat lower leg fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,27825,Treat lower leg fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,27826,Treat lower leg fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27827,Treat lower leg fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,27828,Treat lower leg fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Meridian Duals,CPT,27829,Treat lower leg joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27830,Treat lower leg dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,27831,Treat lower leg dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27832,Treat lower leg dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27840,Treat ankle dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,27842,Treat ankle dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,27846,Treat ankle dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27848,Treat ankle dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27860,Fixation of ankle joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27870,Fusion of ankle joint open,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Meridian Duals,CPT,27871,Fusion of tibiofibular joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Meridian Duals,CPT,27880,Amputation of lower leg,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,27881,Amputation of lower leg,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27882,Amputation of lower leg,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27884,Amputation follow-up surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27886,Amputation follow-up surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27888,Amputation of foot at ankle,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,27889,Amputation of foot at ankle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27892,Decompression of leg,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27893,Decompression of leg,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,27894,Decompression of leg,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,27899,Leg/ankle surgery procedure,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,28001,Drainage of bursa of foot,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,28002,Treatment of foot infection,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,28003,Treatment of foot infection,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28005,Treat foot bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28008,Incision of foot fascia,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28010,Incision of toe tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,28011,Incision of toe tendons,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,28020,Exploration of foot joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28022,Exploration of foot joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28024,Exploration of toe joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,28035,Decompression of tibia nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,28039,Exc foot/toe tum sc 1.5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,28041,Exc foot/toe tum dep 1.5cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,28043,Exc foot/toe tum sc < 1.5 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,28045,Exc foot/toe tum deep <1.5cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,28046,Resect foot/toe tumor < 3 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,28047,Resect foot/toe tumor 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,28050,Biopsy of foot joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28052,Biopsy of foot joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28054,Biopsy of toe joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28055,Neurectomy foot,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,28060,Partial removal foot fascia,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28062,Removal of foot fascia,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28070,Removal of foot joint lining,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,28072,Removal of foot joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28080,Removal of foot lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,28086,Excise foot tendon sheath,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28088,Excise foot tendon sheath,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28090,Removal of foot lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,28092,Removal of toe lesions,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,28100,Removal of ankle/heel lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28102,Remove/graft foot lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,28103,Remove/graft foot lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,28104,Removal of foot lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28106,Remove/graft foot lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,28107,Remove/graft foot lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,28108,Removal of toe lesions,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,28110,Part removal of metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28111,Part removal of metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28112,Part removal of metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28113,Part removal of metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28114,Removal of metatarsal heads,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28116,Revision of foot,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28118,Removal of heel bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28119,Removal of heel spur,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28120,Part removal of ankle/heel,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28122,Partial removal of foot bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28124,Partial removal of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28126,Partial removal of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28130,Removal of ankle bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,28140,Removal of metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28150,Removal of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28153,Partial removal of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28160,Partial removal of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28171,Resect tarsal tumor,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28173,Resect metatarsal tumor,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28175,Resect phalanx of toe tumor,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,28190,Removal of foot foreign body,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,28192,Removal of foot foreign body,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,28193,Removal of foot foreign body,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,28200,Repair of foot tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28202,Repair/graft of foot tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,28208,Repair of foot tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28210,Repair/graft of foot tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,28220,Release of foot tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,28222,Release of foot tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28225,Release of foot tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28226,Release of foot tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28230,Incision of foot tendon(s),APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,28232,Incision of toe tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,28234,Incision of foot tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,28238,Revision of foot tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,28240,Release of big toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28250,Revision of foot fascia,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28260,Release of midfoot joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28261,Revision of foot tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,28262,Revision of foot and ankle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,28264,Release of midfoot joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,28270,Release of foot contracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28272,Release of toe joint each,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,28280,Fusion of toes,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28285,Repair of hammertoe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28286,Repair of hammertoe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28288,Partial removal of foot bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28289,Corrj halux rigdus w/o implt,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28291,Corrj halux rigdus w/implt,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,28292,Correction hallux valgus,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28295,Correction hallux valgus,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28296,Correction hallux valgus,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28297,Correction hallux valgus,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,28298,Correction hallux valgus,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,28299,Correction hallux valgus,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,28300,Incision of heel bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,28302,Incision of ankle bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,28304,Incision of midfoot bones,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,28305,Incise/graft midfoot bones,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,28306,Incision of metatarsal,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,28307,Incision of metatarsal,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,28308,Incision of metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28309,Incision of metatarsals,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,28310,Revision of big toe,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,28312,Revision of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28313,Repair deformity of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28315,Removal of sesamoid bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28320,Repair of foot bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,28322,Repair of metatarsals,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,28340,Resect enlarged toe tissue,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28341,Resect enlarged toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28344,Repair extra toe(s),APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28345,Repair webbed toe(s),APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,28360,Reconstruct cleft foot,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,28400,Treatment of heel fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,28405,Treatment of heel fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,28406,Treatment of heel fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,28415,Treat heel fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,28420,Treat/graft heel fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,28430,Treatment of ankle fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,28435,Treatment of ankle fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,28436,Treatment of ankle fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,28445,Treat ankle fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,28446,Osteochondral talus autogrft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,28450,Treat midfoot fracture each,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,28455,Treat midfoot fracture each,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,28456,Treat midfoot fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,28465,Treat midfoot fracture each,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,28470,Treat metatarsal fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,28475,Treat metatarsal fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,28476,Treat metatarsal fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28485,Treat metatarsal fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,28490,Treat big toe fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,28495,Treat big toe fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,28496,Treat big toe fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28505,Treat big toe fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28510,Treatment of toe fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,28515,Treatment of toe fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,28525,Treat toe fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28530,Treat sesamoid bone fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,28531,Treat sesamoid bone fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,28540,Treat foot dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,28545,Treat foot dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28546,Treat foot dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,28555,Repair foot dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,28570,Treat foot dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,28575,Treat foot dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28576,Treat foot dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,28585,Repair foot dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,28600,Treat foot dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,28605,Treat foot dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,28606,Treat foot dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28615,Repair foot dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,28630,Treat toe dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,28635,Treat toe dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,28636,Treat toe dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28645,Repair toe dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28660,Treat toe dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,28665,Treat toe dislocation,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Meridian Duals,CPT,28666,Treat toe dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28675,Repair of toe dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28705,Fusion of foot bones,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,28715,Fusion of foot bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Meridian Duals,CPT,28725,Fusion of foot bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Meridian Duals,CPT,28730,Fusion of foot bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Meridian Duals,CPT,28735,Fusion of foot bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,28737,Revision of foot bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,28740,Fusion of foot bones,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,28750,Fusion of big toe joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,28755,Fusion of big toe joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,28760,Fusion of big toe joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,28800,Amputation of midfoot,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28805,Amputation thru metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28810,Amputation toe & metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28820,Amputation of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28825,Partial amputation of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,28890,Hi enrgy eswt plantar fascia,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,28899,Foot/toes surgery procedure,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,29000,Application of body cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Meridian Duals,CPT,29010,Application of body cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Meridian Duals,CPT,29015,Application of body cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Meridian Duals,CPT,29035,Application of body cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Meridian Duals,CPT,29040,Application of body cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Meridian Duals,CPT,29044,Application of body cast,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Meridian Duals,CPT,29046,Application of body cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Meridian Duals,CPT,29049,Application of figure eight,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Meridian Duals,CPT,29055,Application of shoulder cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Meridian Duals,CPT,29058,Application of shoulder cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Meridian Duals,CPT,29065,Application of long arm cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Meridian Duals,CPT,29075,Application of forearm cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Meridian Duals,CPT,29085,Apply hand/wrist cast,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Meridian Duals,CPT,29086,Apply finger cast,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Meridian Duals,CPT,29105,Apply long arm splint,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Meridian Duals,CPT,29125,Apply forearm splint,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Meridian Duals,CPT,29126,Apply forearm splint,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Meridian Duals,CPT,29130,Application of finger splint,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Meridian Duals,CPT,29131,Application of finger splint,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Meridian Duals,CPT,29200,Strapping of chest,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Meridian Duals,CPT,29240,Strapping of shoulder,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Meridian Duals,CPT,29260,Strapping of elbow or wrist,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Meridian Duals,CPT,29280,Strapping of hand or finger,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Meridian Duals,CPT,29305,Application of hip cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Meridian Duals,CPT,29325,Application of hip casts,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Meridian Duals,CPT,29345,Application of long leg cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Meridian Duals,CPT,29355,Application of long leg cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Meridian Duals,CPT,29358,Apply long leg cast brace,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Meridian Duals,CPT,29365,Application of long leg cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Meridian Duals,CPT,29405,Apply short leg cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Meridian Duals,CPT,29425,Apply short leg cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Meridian Duals,CPT,29435,Apply short leg cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Meridian Duals,CPT,29440,Addition of walker to cast,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Meridian Duals,CPT,29445,Apply rigid leg cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Meridian Duals,CPT,29450,Application of leg cast,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Meridian Duals,CPT,29505,Application long leg splint,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Meridian Duals,CPT,29515,Application lower leg splint,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Meridian Duals,CPT,29520,Strapping of hip,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Meridian Duals,CPT,29530,Strapping of knee,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Meridian Duals,CPT,29540,Strapping of ankle and/or ft,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Meridian Duals,CPT,29550,Strapping of toes,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Meridian Duals,CPT,29580,Application of paste boot,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Meridian Duals,CPT,29581,Apply multlay comprs lwr leg,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Meridian Duals,CPT,29584,Appl multlay comprs arm/hand,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Meridian Duals,CPT,29700,Removal/revision of cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Meridian Duals,CPT,29705,Removal/revision of cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Meridian Duals,CPT,29710,Removal/revision of cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Meridian Duals,CPT,29720,Repair of body cast,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Meridian Duals,CPT,29730,Windowing of cast,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Meridian Duals,CPT,29740,Wedging of cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Meridian Duals,CPT,29750,Wedging of clubfoot cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Meridian Duals,CPT,29799,Casting/strapping procedure,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Meridian Duals,CPT,29800,Jaw arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,29804,Jaw arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,29805,Sho arthrs dx +- synovial bx,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,29806,Sho arthrs srg capsulorpaphy,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,29807,Sho arthrs srg rpr slap les,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,29819,Sho arthrs srg rmvl loose/fb,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,29820,Sho arthrs srg prtl synvct,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,29821,Sho arthrs srg compl synvct,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,29822,Sho arthrs srg lmtd dbrdmt,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,29823,Sho arthrs srg xtnsv dbrdmt,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,29824,Sho arthrs srg dstl claviclc,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,29825,Sho arthrs srg lss&rescj ads,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,29827,Sho arthrs srg rt8tr cuf rpr,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,29828,Sho arthrs srg bicp tenodsis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,29830,Elbow arthroscopy,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,29834,Elbow arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,29835,Elbow arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,29836,Elbow arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,29837,Elbow arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,29838,Elbow arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,29840,Wrist arthroscopy,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,29843,Wrist arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,29844,Wrist arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,29845,Wrist arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,29846,Wrist arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,29847,Wrist arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,29848,Wrist endoscopy/surgery,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,29850,Knee arthroscopy/surgery,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,29851,Knee arthroscopy/surgery,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,29855,Tibial arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,29856,Tibial arthroscopy/surgery,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,29860,Hip arthroscopy dx,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,29861,Hip arthro w/fb removal,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,29862,Hip arthr0 w/debridement,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,29863,Hip arthr0 w/synovectomy,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,29866,Autgrft implnt knee w/scope,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,29867,Allgrft implnt knee w/scope,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,29868,Meniscal trnspl knee w/scpe,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,29870,Knee arthroscopy dx,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,29871,Knee arthroscopy/drainage,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,29873,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,29874,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,29875,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,29876,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,29877,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,29879,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,29880,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,29881,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,29882,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,29883,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,29884,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,29885,Knee arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,29886,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,29887,Knee arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,29888,Knee arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,29889,Knee arthroscopy/surgery,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Meridian Duals,CPT,29891,Ankle arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,29892,Ankle arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,29893,Scope plantar fasciotomy,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,29894,Ankle arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,29895,Ankle arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,29897,Ankle arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,29898,Ankle arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,29899,Ankle arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,29900,Mcp joint arthroscopy dx,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,29901,Mcp joint arthroscopy surg,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,29902,Mcp joint arthroscopy surg,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Meridian Duals,CPT,29904,Subtalar arthro w/fb rmvl,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,29905,Subtalar arthro w/exc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,29906,Subtalar arthro w/deb,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,29907,Subtalar arthro w/fusion,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,29914,Hip arthro w/femoroplasty,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,29915,Hip arthro acetabuloplasty,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,29916,Hip arthro w/labral repair,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,29999,Arthroscopy of joint,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Meridian Duals,CPT,30000,Drainage of nose lesion,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Meridian Duals,CPT,30020,Drainage of nose lesion,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Meridian Duals,CPT,30100,Intranasal biopsy,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,30110,Removal of nose polyp(s),APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,30115,Removal of nose polyp(s),APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,30117,Removal of intranasal lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,30118,Removal of intranasal lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,30120,Revision of nose,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,30124,Removal of nose lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,30125,Removal of nose lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,30130,Excise inferior turbinate,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,30140,Resect inferior turbinate,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,30150,Partial removal of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,30160,Removal of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,30200,Injection treatment of nose,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Meridian Duals,CPT,30210,Nasal sinus therapy,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,30220,Insert nasal septal button,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,30300,Remove nasal foreign body,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Meridian Duals,CPT,30310,Remove nasal foreign body,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,30320,Remove nasal foreign body,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,30400,Reconstruction of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,30410,Reconstruction of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,30420,Reconstruction of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,30430,Revision of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,30435,Revision of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,30450,Revision of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,30460,Revision of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,30462,Revision of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,30465,Repair nasal stenosis,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,30468,Rpr nsl vlv collapse w/implt,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,30520,Repair of nasal septum,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,30540,Repair nasal defect,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,30545,Repair nasal defect,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,30560,Release of nasal adhesions,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Meridian Duals,CPT,30580,Repair upper jaw fistula,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,30600,Repair mouth/nose fistula,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,30620,Intranasal reconstruction,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,30630,Repair nasal septum defect,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,30801,Ablate inf turbinate superf,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,30802,Ablate inf turbinate submuc,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,30901,Control of nosebleed,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Meridian Duals,CPT,30903,Control of nosebleed,APC 5734,RVU Per Unit,$114.56 ,OP,114.56,"4,314.00",,,,,,
Meridian Duals,CPT,30905,Control of nosebleed,APC 5734,RVU Per Unit,$114.56 ,OP,114.56,"4,314.00",,,,,,
Meridian Duals,CPT,30906,Repeat control of nosebleed,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Meridian Duals,CPT,30915,Ligation nasal sinus artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,30920,Ligation upper jaw artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,30930,Ther fx nasal inf turbinate,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,30999,Nasal surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Meridian Duals,CPT,31000,Irrigation maxillary sinus,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Meridian Duals,CPT,31002,Irrigation sphenoid sinus,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,31020,Exploration maxillary sinus,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,31030,Exploration maxillary sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,31032,Explore sinus remove polyps,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,31040,Exploration behind upper jaw,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,31050,Exploration sphenoid sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,31051,Sphenoid sinus surgery,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,31070,Exploration of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,31075,Exploration of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,31080,Removal of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,31081,Removal of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,31084,Removal of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,31085,Removal of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,31086,Removal of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,31087,Removal of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,31090,Exploration of sinuses,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,31200,Removal of ethmoid sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,31201,Removal of ethmoid sinus,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,31205,Removal of ethmoid sinus,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,31225,Removal of upper jaw,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,31230,Removal of upper jaw,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,31231,Nasal endoscopy dx,APC 5151,RVU Per Unit,$168.23 ,OP,168.23,"4,314.00",,,,,,
Meridian Duals,CPT,31233,Nsl/sins ndsc dx max sinusc,APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
Meridian Duals,CPT,31235,Nsl/sins ndsc dx sphn sinusc,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Meridian Duals,CPT,31237,Nasal/sinus endoscopy surg,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Meridian Duals,CPT,31238,Nasal/sinus endoscopy surg,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Meridian Duals,CPT,31239,Nasal/sinus endoscopy surg,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Meridian Duals,CPT,31240,Nasal/sinus endoscopy surg,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Meridian Duals,CPT,31241,Nsl/sins ndsc w/artery lig,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Meridian Duals,CPT,31253,Nsl/sins ndsc total,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,31254,Nsl/sins ndsc w/prtl ethmdct,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Meridian Duals,CPT,31255,Nsl/sins ndsc w/tot ethmdct,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,31256,Exploration maxillary sinus,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Meridian Duals,CPT,31257,Nsl/sins ndsc tot w/sphendt,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,31259,Nsl/sins ndsc sphn tiss rmvl,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,31267,Endoscopy maxillary sinus,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Meridian Duals,CPT,31276,Nsl/sins ndsc frnt tiss rmvl,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,31287,Nasal/sinus endoscopy surg,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,31288,Nasal/sinus endoscopy surg,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,31290,Nasal/sinus endoscopy surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,31291,Nasal/sinus endoscopy surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,31292,Nsl/sins ndsc med/inf dcmprn,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Meridian Duals,CPT,31293,Nsl/sins ndsc med&inf dcmprn,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Meridian Duals,CPT,31294,Nsl/sins ndsc surg on dcmprn,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Meridian Duals,CPT,31295,Nsl/sins ndsc surg max sins,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Meridian Duals,CPT,31296,Nsl/sins ndsc surg frnt sins,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,31297,Nsl/sins ndsc surg sphn sins,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Meridian Duals,CPT,31298,Nsl/sins ndsc surg frnt&sphn,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,31299,Sinus surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Meridian Duals,CPT,31300,Removal of larynx lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,31360,Removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,31365,Removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,31367,Partial removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,31368,Partial removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,31370,Partial removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,31375,Partial removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,31380,Partial removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,31382,Partial removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,31390,Removal of larynx & pharynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,31395,Reconstruct larynx & pharynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,31400,Revision of larynx,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,31420,Removal of epiglottis,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,31500,Insert emergency airway,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Meridian Duals,CPT,31502,Change of windpipe airway,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Meridian Duals,CPT,31505,Diagnostic laryngoscopy,APC 5151,RVU Per Unit,$168.23 ,OP,168.23,"4,314.00",,,,,,
Meridian Duals,CPT,31510,Laryngoscopy with biopsy,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Meridian Duals,CPT,31511,Remove foreign body larynx,APC 5151,RVU Per Unit,$168.23 ,OP,168.23,"4,314.00",,,,,,
Meridian Duals,CPT,31512,Removal of larynx lesion,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Meridian Duals,CPT,31513,Injection into vocal cord,APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
Meridian Duals,CPT,31515,Laryngoscopy for aspiration,APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
Meridian Duals,CPT,31520,Dx laryngoscopy newborn,APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
Meridian Duals,CPT,31525,Dx laryngoscopy excl nb,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Meridian Duals,CPT,31526,Dx laryngoscopy w/oper scope,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Meridian Duals,CPT,31527,Laryngoscopy for treatment,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Meridian Duals,CPT,31528,Laryngoscopy and dilation,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Meridian Duals,CPT,31529,Laryngoscopy and dilation,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Meridian Duals,CPT,31530,Laryngoscopy w/fb removal,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Meridian Duals,CPT,31531,Laryngoscopy w/fb & op scope,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Meridian Duals,CPT,31535,Laryngoscopy w/biopsy,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Meridian Duals,CPT,31536,Laryngoscopy w/bx & op scope,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Meridian Duals,CPT,31540,Laryngoscopy w/exc of tumor,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Meridian Duals,CPT,31541,Larynscop w/tumr exc + scope,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Meridian Duals,CPT,31545,Remove vc lesion w/scope,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Meridian Duals,CPT,31546,Remove vc lesion scope/graft,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Meridian Duals,CPT,31551,Laryngoplasty laryngeal sten,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,31552,Laryngoplasty laryngeal sten,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,31553,Laryngoplasty laryngeal sten,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,31554,Laryngoplasty laryngeal sten,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,31560,Laryngoscop w/arytenoidectom,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Meridian Duals,CPT,31561,Larynscop remve cart + scop,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Meridian Duals,CPT,31570,Laryngoscope w/vc inj,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Meridian Duals,CPT,31571,Laryngoscop w/vc inj + scope,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Meridian Duals,CPT,31572,Largsc w/laser dstrj les,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Meridian Duals,CPT,31573,Largsc w/ther injection,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Meridian Duals,CPT,31574,Largsc w/njx augmentation,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Meridian Duals,CPT,31575,Diagnostic laryngoscopy,APC 5151,RVU Per Unit,$168.23 ,OP,168.23,"4,314.00",,,,,,
Meridian Duals,CPT,31576,Laryngoscopy with biopsy,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Meridian Duals,CPT,31577,Largsc w/rmvl foreign bdy(s),APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
Meridian Duals,CPT,31578,Largsc w/removal lesion,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Meridian Duals,CPT,31579,Laryngoscopy telescopic,APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
Meridian Duals,CPT,31580,Laryngoplasty laryngeal web,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,31584,Laryngoplasty fx rdctj fixj,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,31587,Laryngoplasty cricoid split,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,31590,Reinnervate larynx,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,31591,Laryngoplasty medialization,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,31592,Cricotracheal resection,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,31599,Larynx surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Meridian Duals,CPT,31600,Incision of windpipe,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,31601,Incision of windpipe,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,31603,Incision of windpipe,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,31605,Incision of windpipe,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Meridian Duals,CPT,31610,Incision of windpipe,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,31611,Surgery/speech prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,31612,Puncture/clear windpipe,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,31613,Repair windpipe opening,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,31614,Repair windpipe opening,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,31615,Visualization of windpipe,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Meridian Duals,CPT,31622,Dx bronchoscope/wash,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Meridian Duals,CPT,31623,Dx bronchoscope/brush,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Meridian Duals,CPT,31624,Dx bronchoscope/lavage,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Meridian Duals,CPT,31625,Bronchoscopy w/biopsy(s),APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Meridian Duals,CPT,31626,Bronchoscopy w/markers,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Meridian Duals,CPT,31628,Bronchoscopy/lung bx each,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Meridian Duals,CPT,31629,Bronchoscopy/needle bx each,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Meridian Duals,CPT,31630,Bronchoscopy dilate/fx repr,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Meridian Duals,CPT,31631,Bronchoscopy dilate w/stent,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Meridian Duals,CPT,31634,Bronch w/balloon occlusion,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Meridian Duals,CPT,31635,Bronchoscopy w/fb removal,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Meridian Duals,CPT,31636,Bronchoscopy bronch stents,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Meridian Duals,CPT,31638,Bronchoscopy revise stent,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Meridian Duals,CPT,31640,Bronchoscopy w/tumor excise,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Meridian Duals,CPT,31641,Bronchoscopy treat blockage,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Meridian Duals,CPT,31643,Diag bronchoscope/catheter,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Meridian Duals,CPT,31645,Brnchsc w/ther aspir 1st,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Meridian Duals,CPT,31646,Brnchsc w/ther aspir sbsq,APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
Meridian Duals,CPT,31647,Bronchial valve init insert,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Meridian Duals,CPT,31648,Bronchial valve remov init,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Meridian Duals,CPT,31649,Bronchial valve remov addl,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Meridian Duals,CPT,31652,Bronch ebus samplng 1/2 node,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Meridian Duals,CPT,31653,Bronch ebus samplng 3/> node,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Meridian Duals,CPT,31660,Bronch thermoplsty 1 lobe,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Meridian Duals,CPT,31661,Bronch thermoplsty 2/> lobes,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Meridian Duals,CPT,31717,Bronchial brush biopsy,APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
Meridian Duals,CPT,31720,Clearance of airways,APC 5791,RVU Per Case,$192.26 ,OP,192.26,"4,314.00",,,,,,
Meridian Duals,CPT,31725,Clearance of airways,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,31730,Intro windpipe wire/tube,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Meridian Duals,CPT,31750,Repair of windpipe,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,31755,Repair of windpipe,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,31760,Repair of windpipe,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,31766,Reconstruction of windpipe,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,31770,Repair/graft of bronchus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,31775,Reconstruct bronchus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,31780,Reconstruct windpipe,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,31781,Reconstruct windpipe,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,31785,Remove windpipe lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,31786,Remove windpipe lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,31800,Repair of windpipe injury,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,31805,Repair of windpipe injury,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,31820,Closure of windpipe lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,31825,Repair of windpipe defect,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,31830,Revise windpipe scar,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,31899,Airways surgical procedure,APC 5151,RVU Per Unit,$168.23 ,OP,168.23,"4,314.00",,,,,,
Meridian Duals,CPT,32035,Thoracostomy w/rib resection,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32036,Thoracostomy w/flap drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32096,Open wedge/bx lung infiltr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32097,Open wedge/bx lung nodule,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32098,Open biopsy of lung pleura,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32100,Exploration of chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32110,Explore/repair chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32120,Re-exploration of chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32124,Explore chest free adhesions,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32140,Removal of lung lesion(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32141,Remove/treat lung lesions,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32150,Removal of lung lesion(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32151,Remove lung foreign body,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32160,Open chest heart massage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32200,Drain open lung lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32215,Treat chest lining,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32220,Release of lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32225,Partial release of lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32310,Removal of chest lining,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32320,Free/remove chest lining,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32400,Needle biopsy chest lining,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,32408,Core ndl bx lng/med perq,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,32440,Remove lung pneumonectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32442,Sleeve pneumonectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32445,Removal of lung extrapleural,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32480,Partial removal of lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32482,Bilobectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32484,Segmentectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32486,Sleeve lobectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32488,Completion pneumonectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32491,Lung volume reduction,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32501,Repair bronchus add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32503,Resect apical lung tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32504,Resect apical lung tum/chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32505,Wedge resect of lung initial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32506,Wedge resect of lung add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32507,Wedge resect of lung diag,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32540,Removal of lung lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32550,Insert pleural cath,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Meridian Duals,CPT,32551,Insertion of chest tube,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Meridian Duals,CPT,32552,Remove lung catheter,APC 5181,RVU Per Case,$554.25 ,OP,554.25,"4,314.00",,,,,,
Meridian Duals,CPT,32553,Ins mark thor for rt perq,APC 5613,RVU Per Unit,"$1,291.62 ",OP,"1,291.62","4,314.00",,,,,,
Meridian Duals,CPT,32554,Aspirate pleura w/o imaging,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Meridian Duals,CPT,32555,Aspirate pleura w/ imaging,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Meridian Duals,CPT,32556,Insert cath pleura w/o image,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,32557,Insert cath pleura w/ image,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Meridian Duals,CPT,32560,Treat pleurodesis w/agent,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Meridian Duals,CPT,32561,Lyse chest fibrin init day,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Meridian Duals,CPT,32562,Lyse chest fibrin subq day,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Meridian Duals,CPT,32601,Thoracoscopy diagnostic,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,32604,Thoracoscopy wbx sac,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,32606,Thoracoscopy w/bx med space,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,32607,Thoracoscopy w/bx infiltrate,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,32608,Thoracoscopy w/bx nodule,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,32609,Thoracoscopy w/bx pleura,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,32650,Thoracoscopy w/pleurodesis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32651,Thoracoscopy remove cortex,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32652,Thoracoscopy rem totl cortex,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32653,Thoracoscopy remov fb/fibrin,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32654,Thoracoscopy contrl bleeding,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32655,Thoracoscopy resect bullae,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32656,Thoracoscopy w/pleurectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32658,Thoracoscopy w/sac fb remove,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32659,Thoracoscopy w/sac drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32661,Thoracoscopy w/pericard exc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32662,Thoracoscopy w/mediast exc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32663,Thoracoscopy w/lobectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32664,Thoracoscopy w/ th nrv exc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32665,Thoracoscop w/esoph musc exc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32666,Thoracoscopy w/wedge resect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32667,Thoracoscopy w/w resect addl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32668,Thoracoscopy w/w resect diag,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32669,Thoracoscopy remove segment,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32670,Thoracoscopy bilobectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32671,Thoracoscopy pneumonectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32672,Thoracoscopy for lvrs,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32673,Thoracoscopy w/thymus resect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32674,Thoracoscopy lymph node exc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32800,Repair lung hernia,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32810,Close chest after drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32815,Close bronchial fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32820,Reconstruct injured chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32850,Donor pneumonectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32851,Lung transplant single,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32852,Lung transplant with bypass,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32853,Lung transplant double,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32854,Lung transplant with bypass,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32855,Prepare donor lung single,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32856,Prepare donor lung double,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32900,Removal of rib(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32905,Revise & repair chest wall,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32906,Revise & repair chest wall,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32940,Revision of lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32960,Therapeutic pneumothorax,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Meridian Duals,CPT,32994,Ablate pulm tumor perq crybl,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,32997,Total lung lavage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,32998,Ablate pulm tumor perq rf,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,32999,Chest surgery procedure,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Meridian Duals,CPT,33016,Pericardiocentesis w/imaging,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Meridian Duals,CPT,33017,Prcrd drg 6yr+ w/o cgen car,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33018,Prcrd drg 0-5yr or w/anomly,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33019,Perq prcrd drg insj cath ct,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33020,Incision of heart sac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33025,Incision of heart sac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33030,Partial removal of heart sac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33031,Partial removal of heart sac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33050,Resect heart sac lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33120,Removal of heart lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33130,Removal of heart lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33140,Heart revascularize (tmr),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33141,Heart tmr w/other procedure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33202,Insert epicard eltrd open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33203,Insert epicard eltrd endo,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33206,Insert heart pm atrial,APC 5223,RVU Per Case,"$10,642.67 ",OP,"4,314.00","10,642.67",,,,,,
Meridian Duals,CPT,33207,Insert heart pm ventricular,APC 5223,RVU Per Case,"$10,642.67 ",OP,"4,314.00","10,642.67",,,,,,
Meridian Duals,CPT,33208,Insrt heart pm atrial & vent,APC 5223,RVU Per Case,"$10,642.67 ",OP,"4,314.00","10,642.67",,,,,,
Meridian Duals,CPT,33210,Insert electrd/pm cath sngl,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
Meridian Duals,CPT,33211,Insert card electrodes dual,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
Meridian Duals,CPT,33212,Insert pulse gen sngl lead,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
Meridian Duals,CPT,33213,Insert pulse gen dual leads,APC 5223,RVU Per Case,"$10,642.67 ",OP,"4,314.00","10,642.67",,,,,,
Meridian Duals,CPT,33214,Upgrade of pacemaker system,APC 5223,RVU Per Case,"$10,642.67 ",OP,"4,314.00","10,642.67",,,,,,
Meridian Duals,CPT,33215,Reposition pacing-defib lead,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,33216,Insert 1 electrode pm-defib,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
Meridian Duals,CPT,33217,Insert 2 electrode pm-defib,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
Meridian Duals,CPT,33218,Repair lead pace-defib one,APC 5221,RVU Per Unit,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Meridian Duals,CPT,33220,Repair lead pace-defib dual,APC 5221,RVU Per Unit,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Meridian Duals,CPT,33221,Insert pulse gen mult leads,APC 5224,RVU Per Case,"$19,045.26 ",OP,"4,314.00","19,045.26",,,,,,
Meridian Duals,CPT,33222,Relocation pocket pacemaker,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,33223,Relocate pocket for defib,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,33224,Insert pacing lead & connect,APC 5223,RVU Per Case,"$10,642.67 ",OP,"4,314.00","10,642.67",,,,,,
Meridian Duals,CPT,33226,Reposition l ventric lead,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,33227,Remove&replace pm gen singl,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
Meridian Duals,CPT,33228,Remv&replc pm gen dual lead,APC 5223,RVU Per Case,"$10,642.67 ",OP,"4,140.35","10,642.67",,,,,,
Meridian Duals,CPT,33229,Remv&replc pm gen mult leads,APC 5224,RVU Per Case,"$19,045.26 ",OP,"4,314.00","19,045.26",,,,,,
Meridian Duals,CPT,33230,Insrt pulse gen w/dual leads,APC 5231,RVU Per Case,"$23,577.44 ",OP,"4,314.00","23,577.44",,,,,,
Meridian Duals,CPT,33231,Insrt pulse gen w/mult leads,APC 5232,RVU Per Case,"$33,604.66 ",OP,"4,314.00","33,604.66",,,,,,
Meridian Duals,CPT,33233,Removal of pm generator,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
Meridian Duals,CPT,33234,Removal of pacemaker system,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Meridian Duals,CPT,33235,Removal pacemaker electrode,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Meridian Duals,CPT,33236,Remove electrode/thoracotomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33237,Remove electrode/thoracotomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33238,Remove electrode/thoracotomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33240,Insrt pulse gen w/singl lead,APC 5231,RVU Per Case,"$23,577.44 ",OP,"4,140.35","23,577.44",,,,,,
Meridian Duals,CPT,33241,Remove pulse generator,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Meridian Duals,CPT,33243,Remove eltrd/thoracotomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33244,Remove elctrd transvenously,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Meridian Duals,CPT,33249,Insj/rplcmt defib w/lead(s),APC 5232,RVU Per Case,"$33,604.66 ",OP,"4,140.35","33,604.66",,,,,,
Meridian Duals,CPT,33250,Ablate heart dysrhythm focus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33251,Ablate heart dysrhythm focus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33254,Ablate atria lmtd,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33255,Ablate atria w/o bypass ext,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33256,Ablate atria w/bypass exten,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33257,Ablate atria lmtd add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33258,Ablate atria x10sv add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33259,Ablate atria w/bypass add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33261,Ablate heart dysrhythm focus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33262,Rmvl& replc pulse gen 1 lead,APC 5231,RVU Per Case,"$23,577.44 ",OP,"4,314.00","23,577.44",,,,,,
Meridian Duals,CPT,33263,Rmvl & rplcmt dfb gen 2 lead,APC 5231,RVU Per Case,"$23,577.44 ",OP,"4,140.35","23,577.44",,,,,,
Meridian Duals,CPT,33264,Rmvl & rplcmt dfb gen mlt ld,APC 5232,RVU Per Case,"$33,604.66 ",OP,"4,314.00","33,604.66",,,,,,
Meridian Duals,CPT,33265,Ablate atria lmtd endo,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33266,Ablate atria x10sv endo,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33270,Ins/rep subq defibrillator,APC 5232,RVU Per Case,"$33,604.66 ",OP,"4,314.00","33,604.66",,,,,,
Meridian Duals,CPT,33271,Insj subq impltbl dfb elctrd,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
Meridian Duals,CPT,33272,Rmvl of subq defibrillator,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Meridian Duals,CPT,33273,Repos prev impltbl subq dfb,APC 5221,RVU Per Unit,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Meridian Duals,CPT,33274,Tcat insj/rpl perm ldls pm,APC 5194,RVU Per Case,"$16,438.60 ",OP,"4,314.00","16,438.60",,,,,,
Meridian Duals,CPT,33275,Tcat rmvl perm ldls pm w/img,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,33285,Insj subq car rhythm mntr,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
Meridian Duals,CPT,33286,Rmvl subq car rhythm mntr,APC 5071,RVU Per Case,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,33289,Tcat impl wrls p-art prs snr,APC 5200,RVU Per Case,"$29,487.35 ",OP,"4,314.00","29,487.35",,,,,,
Meridian Duals,CPT,33300,Repair of heart wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33305,Repair of heart wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33310,Exploratory heart surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33315,Exploratory heart surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33320,Repair major blood vessel(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33321,Repair major vessel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33322,Repair major blood vessel(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33330,Insert major vessel graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33335,Insert major vessel graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33340,Perq clsr tcat l atr apndge,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33361,Replace aortic valve perq,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33362,Replace aortic valve open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33363,Replace aortic valve open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33364,Replace aortic valve open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33365,Replace aortic valve open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33366,Trcath replace aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33367,Replace aortic valve w/byp,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33368,Replace aortic valve w/byp,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33369,Replace aortic valve w/byp,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33390,Valvuloplasty aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33391,Valvuloplasty aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33404,Prepare heart-aorta conduit,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33405,Replacement aortic valve opn,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33406,Replacement aortic valve opn,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33410,Replacement aortic valve opn,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33411,Replacement of aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33412,Replacement of aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33413,Replacement of aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33414,Repair of aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33415,Revision subvalvular tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33416,Revise ventricle muscle,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33417,Repair of aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33418,Repair tcat mitral valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33420,Revision of mitral valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33422,Revision of mitral valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33425,Repair of mitral valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33426,Repair of mitral valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33427,Repair of mitral valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33430,Replacement of mitral valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33440,Rplcmt a-valve tlcj autol pv,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33460,Revision of tricuspid valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33463,Valvuloplasty tricuspid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33464,Valvuloplasty tricuspid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33465,Replace tricuspid valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33468,Revision of tricuspid valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33470,Revision of pulmonary valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33471,Valvotomy pulmonary valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33474,Revision of pulmonary valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33475,Replacement pulmonary valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33476,Revision of heart chamber,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33477,Implant tcat pulm vlv perq,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33478,Revision of heart chamber,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33496,Repair prosth valve clot,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33500,Repair heart vessel fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33501,Repair heart vessel fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33502,Coronary artery correction,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33503,Coronary artery graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33504,Coronary artery graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33505,Repair artery w/tunnel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33506,Repair artery translocation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33507,Repair art intramural,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33510,Cabg vein single,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33511,Cabg vein two,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33512,Cabg vein three,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33513,Cabg vein four,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33514,Cabg vein five,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33516,Cabg vein six or more,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33517,Cabg artery-vein single,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33518,Cabg artery-vein two,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33519,Cabg artery-vein three,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33521,Cabg artery-vein four,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33522,Cabg artery-vein five,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33523,Cabg art-vein six or more,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33530,Coronary artery bypass/reop,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33533,Cabg arterial single,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33534,Cabg arterial two,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33535,Cabg arterial three,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33536,Cabg arterial four or more,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33542,Removal of heart lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33545,Repair of heart damage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33548,Restore/remodel ventricle,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33572,Open coronary endarterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33600,Closure of valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33602,Closure of valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33606,Anastomosis/artery-aorta,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33608,Repair anomaly w/conduit,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33610,Repair by enlargement,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33611,Repair double ventricle,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33612,Repair double ventricle,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33615,Repair modified fontan,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33617,Repair single ventricle,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33619,Repair single ventricle,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33620,Apply r&l pulm art bands,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33621,Transthor cath for stent,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33622,Redo compl cardiac anomaly,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33641,Repair heart septum defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33645,Revision of heart veins,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33647,Repair heart septum defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33660,Repair of heart defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33665,Repair of heart defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33670,Repair of heart chambers,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33675,Close mult vsd,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33676,Close mult vsd w/resection,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33677,Cl mult vsd w/rem pul band,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33681,Repair heart septum defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33684,Repair heart septum defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33688,Repair heart septum defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33690,Reinforce pulmonary artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33692,Repair of heart defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33694,Repair of heart defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33697,Repair of heart defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33702,Repair of heart defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33710,Repair of heart defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33720,Repair of heart defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33722,Repair of heart defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33724,Repair venous anomaly,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33726,Repair pul venous stenosis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33730,Repair heart-vein defect(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33732,Repair heart-vein defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33735,Revision of heart chamber,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33736,Revision of heart chamber,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33737,Revision of heart chamber,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33741,Tas congenital car anomal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33745,Tis cgen car anomal 1st shnt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33746,Tis cgen car anomal ea addl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33750,Major vessel shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33755,Major vessel shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33762,Major vessel shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33764,Major vessel shunt & graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33766,Major vessel shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33767,Major vessel shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33768,Cavopulmonary shunting,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33770,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33771,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33774,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33775,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33776,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33777,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33778,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33779,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33780,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33781,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33782,Nikaidoh proc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33783,Nikaidoh proc w/ostia implt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33786,Repair arterial trunk,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33788,Revision of pulmonary artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33800,Aortic suspension,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33802,Repair vessel defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33803,Repair vessel defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33813,Repair septal defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33814,Repair septal defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33820,Revise major vessel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33822,Revise major vessel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33824,Revise major vessel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33840,Remove aorta constriction,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33845,Remove aorta constriction,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33851,Remove aorta constriction,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33852,Repair septal defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33853,Repair septal defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33858,As-aort grf f/aortic dsj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33859,As-aort grf f/ds oth/thn dsj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33863,Ascending aortic graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33864,Ascending aortic graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33871,Transvrs a-arch grf hypthrm,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33875,Thoracic aortic graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33877,Thoracoabdominal graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33880,Endovasc taa repr incl subcl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33881,Endovasc taa repr w/o subcl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33883,Insert endovasc prosth taa,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33884,Endovasc prosth taa add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33886,Endovasc prosth delayed,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33889,Artery transpose/endovas taa,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33891,Car-car bp grft/endovas taa,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33910,Remove lung artery emboli,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33915,Remove lung artery emboli,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33916,Surgery of great vessel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33917,Repair pulmonary artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33920,Repair pulmonary atresia,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33922,Transect pulmonary artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33924,Remove pulmonary shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33925,Rpr pul art unifocal w/o cpb,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33926,Repr pul art unifocal w/cpb,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33927,Impltj tot rplcmt hrt sys,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33928,Rmvl & rplcmt tot hrt sys,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33929,Rmvl rplcmt hrt sys f/trnspl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33930,Removal of donor heart/lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33933,Prepare donor heart/lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33935,Transplantation heart/lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33940,Removal of donor heart,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33944,Prepare donor heart,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33945,Transplantation of heart,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33946,Ecmo/ecls initiation venous,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33947,Ecmo/ecls initiation artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33948,Ecmo/ecls daily mgmt-venous,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33949,Ecmo/ecls daily mgmt artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33951,Ecmo/ecls insj prph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33952,Ecmo/ecls insj prph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33953,Ecmo/ecls insj prph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33954,Ecmo/ecls insj prph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33955,Ecmo/ecls insj ctr cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33956,Ecmo/ecls insj ctr cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33957,Ecmo/ecls repos perph cnula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33958,Ecmo/ecls repos perph cnula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33959,Ecmo/ecls repos perph cnula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33962,Ecmo/ecls repos perph cnula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33963,Ecmo/ecls repos perph cnula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33964,Ecmo/ecls repos perph cnula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33965,Ecmo/ecls rmvl perph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33966,Ecmo/ecls rmvl prph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33967,Insert i-aort percut device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33968,Remove aortic assist device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33969,Ecmo/ecls rmvl perph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33970,Aortic circulation assist,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33971,Aortic circulation assist,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33973,Insert balloon device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33974,Remove intra-aortic balloon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33975,Implant ventricular device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33976,Implant ventricular device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33977,Remove ventricular device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33978,Remove ventricular device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33979,Insert intracorporeal device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33980,Remove intracorporeal device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33981,Replace vad pump ext,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33982,Replace vad intra w/o bp,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33983,Replace vad intra w/bp,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33984,Ecmo/ecls rmvl prph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33985,Ecmo/ecls rmvl ctr cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33986,Ecmo/ecls rmvl ctr cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33987,Artery expos/graft artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33988,Insertion of left heart vent,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33989,Removal of left heart vent,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33990,Insj perq vad l hrt arterial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33991,Insj perq vad l hrt artl&ven,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33992,Rmvl perq left heart vad,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33993,Reposg perq r/l hrt vad,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33995,Insj perq vad r hrt venous,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33997,Rmvl perq right heart vad,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,33999,Cardiac surgery procedure,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Meridian Duals,CPT,34001,Removal of artery clot,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,34051,Removal of artery clot,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,34101,Removal of artery clot,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,34111,Removal of arm artery clot,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,34151,Removal of artery clot,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,34201,Removal of artery clot,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,34203,Removal of leg artery clot,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,34401,Removal of vein clot,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,34421,Removal of vein clot,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,34451,Removal of vein clot,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,34471,Removal of vein clot,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Meridian Duals,CPT,34490,Removal of vein clot,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,34501,Repair valve femoral vein,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,34502,Reconstruct vena cava,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,34510,Transposition of vein valve,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,34520,Cross-over vein graft,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,34530,Leg vein fusion,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,34701,Evasc rpr a-ao ndgft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,34702,Evasc rpr a-ao ndgft rpt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,34703,Evasc rpr a-unilac ndgft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,34704,Evasc rpr a-unilac ndgft rpt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,34705,Evac rpr a-biiliac ndgft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,34706,Evasc rpr a-biiliac rpt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,34707,Evasc rpr ilio-iliac ndgft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,34708,Evasc rpr ilio-iliac rpt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,34709,Plmt xtn prosth evasc rpr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,34710,Dlyd plmt xtn prosth 1st vsl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,34711,Dlyd plmt xtn prosth ea addl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,34712,Tcat dlvr enhncd fixj dev,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,34717,Evasc rpr a-iliac ndgft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,34718,Evasc rpr n/a a-iliac ndgft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,34808,Endovas iliac a device addon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,34812,Opn fem art expos,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,34813,Femoral endovas graft add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,34820,Opn iliac art expos,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,34830,Open aortic tube prosth repr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,34831,Open aortoiliac prosth repr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,34832,Open aortofemor prosth repr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,34833,Opn ilac art expos cndt crtj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,34834,Opn brach art expos,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,34841,Endovasc visc aorta 1 graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,34842,Endovasc visc aorta 2 graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,34843,Endovasc visc aorta 3 graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,34844,Endovasc visc aorta 4 graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,34845,Visc & infraren abd 1 prosth,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,34846,Visc & infraren abd 2 prosth,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,34847,Visc & infraren abd 3 prosth,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,34848,Visc & infraren abd 4+ prost,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35001,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35002,Repair artery rupture neck,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35005,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35011,Repair defect of artery,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,35013,Repair artery rupture arm,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35021,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35022,Repair artery rupture chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35045,Repair defect of arm artery,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,35081,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35082,Repair artery rupture aorta,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35091,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35092,Repair artery rupture aorta,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35102,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35103,Repair artery rupture aorta,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35111,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35112,Repair artery rupture spleen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35121,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35122,Repair artery rupture belly,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35131,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35132,Repair artery rupture groin,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35141,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35142,Repair artery rupture thigh,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35151,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35152,Repair ruptd popliteal art,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35180,Repair blood vessel lesion,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Meridian Duals,CPT,35182,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35184,Repair blood vessel lesion,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,35188,Repair blood vessel lesion,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,35189,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35190,Repair blood vessel lesion,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,35201,Repair blood vessel lesion,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,35206,Repair blood vessel lesion,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,35207,Repair blood vessel lesion,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,35211,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35216,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35221,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35226,Repair blood vessel lesion,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,35231,Repair blood vessel lesion,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,35236,Repair blood vessel lesion,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,35241,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35246,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35251,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35256,Repair blood vessel lesion,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,35261,Repair blood vessel lesion,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,35266,Repair blood vessel lesion,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,35271,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35276,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35281,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35286,Repair blood vessel lesion,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,35301,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35302,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35303,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35304,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35305,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35306,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35311,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35321,Rechanneling of artery,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,35331,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35341,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35351,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35355,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35361,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35363,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35371,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35372,Rechanneling of artery,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,35390,Reoperation carotid add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35400,Angioscopy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35501,Art byp grft ipsilat carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35506,Art byp grft subclav-carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35508,Art byp grft carotid-vertbrl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35509,Art byp grft contral carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35510,Art byp grft carotid-brchial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35511,Art byp grft subclav-subclav,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35512,Art byp grft subclav-brchial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35515,Art byp grft subclav-vertbrl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35516,Art byp grft subclav-axilary,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35518,Art byp grft axillary-axilry,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35521,Art byp grft axill-femoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35522,Art byp grft axill-brachial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35523,Art byp grft brchl-ulnr-rdl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35525,Art byp grft brachial-brchl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35526,Art byp grft aor/carot/innom,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35531,Art byp grft aorcel/aormesen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35533,Art byp grft axill/fem/fem,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35535,Art byp grft hepatorenal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35536,Art byp grft splenorenal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35537,Art byp grft aortoiliac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35538,Art byp grft aortobi-iliac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35539,Art byp grft aortofemoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35540,Art byp grft aortbifemoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35556,Art byp grft fem-popliteal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35558,Art byp grft fem-femoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35560,Art byp grft aortorenal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35563,Art byp grft ilioiliac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35565,Art byp grft iliofemoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35566,Art byp fem-ant-post tib/prl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35570,Art byp tibial-tib/peroneal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35571,Art byp pop-tibl-prl-other,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35583,Vein byp grft fem-popliteal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35585,Vein byp fem-tibial peroneal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35587,Vein byp pop-tibl peroneal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35600,Harvest art for cabg add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35601,Art byp common ipsi carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35606,Art byp carotid-subclavian,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35612,Art byp subclav-subclavian,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35616,Art byp subclav-axillary,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35621,Art byp axillary-femoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35623,Art byp axillary-pop-tibial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35626,Art byp aorsubcl/carot/innom,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35631,Art byp aor-celiac-msn-renal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35632,Art byp ilio-celiac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35633,Art byp ilio-mesenteric,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35634,Art byp iliorenal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35636,Art byp spenorenal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35637,Art byp aortoiliac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35638,Art byp aortobi-iliac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35642,Art byp carotid-vertebral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35645,Art byp subclav-vertebrl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35646,Art byp aortobifemoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35647,Art byp aortofemoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35650,Art byp axillary-axillary,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35654,Art byp axill-fem-femoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35656,Art byp femoral-popliteal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35661,Art byp femoral-femoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35663,Art byp ilioiliac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35665,Art byp iliofemoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35666,Art byp fem-ant-post tib/prl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35671,Art byp pop-tibl-prl-other,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35681,Composite byp grft pros&vein,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35682,Composite byp grft 2 veins,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35683,Composite byp grft 3/> segmt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35691,Art trnsposj vertbrl carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35693,Art trnsposj subclavian,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35694,Art trnsposj subclav carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35695,Art trnsposj carotid subclav,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35697,Reimplant artery each,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35700,Reoperation bypass graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35701,Expl n/flwd surg neck art,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35702,Expl n/flwd surg uxtr art,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35703,Expl n/flwd surg lxtr art,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35800,Explore neck vessels,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,35820,Explore chest vessels,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35840,Explore abdominal vessels,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35860,Explore limb vessels,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,35870,Repair vessel graft defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35875,Removal of clot in graft,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,35876,Removal of clot in graft,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,35879,Revise graft w/vein,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,35881,Revise graft w/vein,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,35883,Revise graft w/nonauto graft,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,35884,Revise graft w/vein,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,35901,Excision graft neck,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35903,Excision graft extremity,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,35905,Excision graft thorax,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,35907,Excision graft abdomen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,36002,Pseudoaneurysm injection trt,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Meridian Duals,CPT,36221,Place cath thoracic aorta,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,36222,Place cath carotid/inom art,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,36223,Place cath carotid/inom art,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,36224,Place cath carotd art,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,36225,Place cath subclavian art,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,36226,Place cath vertebral art,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,36251,Ins cath ren art 1st unilat,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,36252,Ins cath ren art 1st bilat,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,36253,Ins cath ren art 2nd+ unilat,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,36254,Ins cath ren art 2nd+ bilat,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,36260,Insertion of infusion pump,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,36261,Revision of infusion pump,APC 5221,RVU Per Unit,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Meridian Duals,CPT,36262,Removal of infusion pump,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Meridian Duals,CPT,36415,Routine venipuncture,Lab Services,Per Unit,$3.00 ,OP,3,"4,314.00",,,,,,
Meridian Duals,CPT,36420,Vein access cutdown < 1 yr,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Meridian Duals,CPT,36425,Vein access cutdown > 1 yr,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Meridian Duals,CPT,36430,Blood transfusion service,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Meridian Duals,CPT,36440,Bl push transfuse 2 yr/<,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Meridian Duals,CPT,36450,Bl exchange/transfuse nb,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Meridian Duals,CPT,36455,Bl exchange/transfuse non-nb,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Meridian Duals,CPT,36456,Prtl exchange transfuse nb,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Meridian Duals,CPT,36460,Transfusion service fetal,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Meridian Duals,CPT,36465,Njx noncmpnd sclrsnt 1 vein,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,36466,Njx noncmpnd sclrsnt mlt vn,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,36468,Njx sclrsnt spider veins,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,36470,Njx sclrsnt 1 incmptnt vein,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,36471,Njx sclrsnt mlt incmptnt vn,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,36473,Endovenous mchnchem 1st vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,36475,Endovenous rf 1st vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,36478,Endovenous laser 1st vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,36482,Endoven ther chem adhes 1st,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,36511,Apheresis wbc,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
Meridian Duals,CPT,36512,Apheresis rbc,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
Meridian Duals,CPT,36513,Apheresis platelets,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Meridian Duals,CPT,36514,Apheresis plasma,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
Meridian Duals,CPT,36516,Apheresis immunoads slctv,APC 5243,RVU Per Unit,"$4,131.87 ",OP,"4,131.87","4,314.00",,,,,,
Meridian Duals,CPT,36522,Photopheresis,APC 5243,RVU Per Unit,"$4,131.87 ",OP,"4,131.87","4,314.00",,,,,,
Meridian Duals,CPT,36555,Insert non-tunnel cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,36556,Insert non-tunnel cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,36557,Insert tunneled cv cath,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,36558,Insert tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,36560,Insert tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,36561,Insert tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,36563,Insert tunneled cv cath,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,36565,Insert tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,36566,Insert tunneled cv cath,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,36568,Insj picc <5 yr w/o imaging,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Meridian Duals,CPT,36569,Insj picc 5 yr+ w/o imaging,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Meridian Duals,CPT,36570,Insert picvad cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,36571,Insert picvad cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,36572,Insj picc rs&i <5 yr,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Meridian Duals,CPT,36573,Insj picc rs&i 5 yr+,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Meridian Duals,CPT,36575,Repair tunneled cv cath,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Meridian Duals,CPT,36576,Repair tunneled cv cath,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Meridian Duals,CPT,36578,Replace tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,36580,Replace cvad cath,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Meridian Duals,CPT,36581,Replace tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,36582,Replace tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,36583,Replace tunneled cv cath,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,36584,Compl rplcmt picc rs&i,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Meridian Duals,CPT,36585,Replace picvad cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,36589,Removal tunneled cv cath,APC 5181,RVU Per Case,$554.25 ,OP,554.25,"4,314.00",,,,,,
Meridian Duals,CPT,36590,Removal tunneled cv cath,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Meridian Duals,CPT,36591,Draw blood off venous device,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Meridian Duals,CPT,36592,Collect blood from picc,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Meridian Duals,CPT,36593,Declot vascular device,APC 5694,RVU Per Unit,$318.00 ,OP,318,"4,314.00",,,,,,
Meridian Duals,CPT,36595,Mech remov tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,36596,Mech remov tunneled cv cath,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Meridian Duals,CPT,36597,Reposition venous catheter,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Meridian Duals,CPT,36598,Inj w/fluor eval cv device,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,"4,314.00",,,,,,
Meridian Duals,CPT,36600,Withdrawal of arterial blood,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Meridian Duals,CPT,36640,Insertion catheter artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,36660,Insertion catheter artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,36680,Insert needle bone cavity,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Meridian Duals,CPT,36800,Insertion of cannula,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,36810,Insertion of cannula,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,36815,Insertion of cannula,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,36818,Av fuse uppr arm cephalic,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,36819,Av fuse uppr arm basilic,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,36820,Av fusion/forearm vein,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,36821,Av fusion direct any site,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","9,201.00",,,,,,
Meridian Duals,CPT,36823,Insertion of cannula(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,36825,Artery-vein autograft,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,36830,Artery-vein nonautograft,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,36831,Open thrombect av fistula,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,36832,Av fistula revision open,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,36833,Av fistula revision,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,36835,Artery to vein shunt,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,36838,Dist revas ligation hemo,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,36860,External cannula declotting,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Meridian Duals,CPT,36861,Cannula declotting,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,36901,Intro cath dialysis circuit,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Meridian Duals,CPT,36902,Intro cath dialysis circuit,APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,314.00","5,072.43",,,,,,
Meridian Duals,CPT,36903,Intro cath dialysis circuit,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Meridian Duals,CPT,36904,Thrmbc/nfs dialysis circuit,APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,314.00","5,072.43",,,,,,
Meridian Duals,CPT,36905,Thrmbc/nfs dialysis circuit,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Meridian Duals,CPT,36906,Thrmbc/nfs dialysis circuit,APC 5194,RVU Per Case,"$16,438.60 ",OP,"4,140.35","16,438.60",,,,,,
Meridian Duals,CPT,37140,Revision of circulation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,37145,Revision of circulation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,37160,Revision of circulation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,37180,Revision of circulation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,37181,Splice spleen/kidney veins,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,37182,Insert hepatic shunt (tips),APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Meridian Duals,CPT,37183,Remove hepatic shunt (tips),APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,314.00","5,072.43",,,,,,
Meridian Duals,CPT,37184,Prim art m-thrmbc 1st vsl,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Meridian Duals,CPT,37187,Venous mech thrombectomy,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
Meridian Duals,CPT,37188,Ven mechnl thrmbc repeat tx,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,37191,Ins endovas vena cava filtr,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,37192,Redo endovas vena cava filtr,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,37193,Rem endovas vena cava filter,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,37195,Thrombolytic therapy stroke,APC 5694,RVU Per Unit,$318.00 ,OP,318,"4,314.00",,,,,,
Meridian Duals,CPT,37197,Remove intrvas foreign body,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,37200,Transcatheter biopsy,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,37211,Thrombolytic art therapy,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,37212,Thrombolytic venous therapy,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,37213,Thromblytic art/ven therapy,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,37214,Cessj therapy cath removal,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,37215,Transcath stent cca w/eps,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,37217,Stent placemt retro carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,37218,Stent placemt ante carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,37220,Iliac revasc,APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,314.00","5,072.43",,,,,,
Meridian Duals,CPT,37221,Iliac revasc w/stent,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
Meridian Duals,CPT,37224,Fem/popl revas w/tla,APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,314.00","5,072.43",,,,,,
Meridian Duals,CPT,37225,Fem/popl revas w/ather,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Meridian Duals,CPT,37226,Fem/popl revasc w/stent,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
Meridian Duals,CPT,37227,Fem/popl revasc stnt & ather,APC 5194,RVU Per Case,"$16,438.60 ",OP,"4,314.00","16,438.60",,,,,,
Meridian Duals,CPT,37228,Tib/per revasc w/tla,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Meridian Duals,CPT,37229,Tib/per revasc w/ather,APC 5194,RVU Per Case,"$16,438.60 ",OP,"4,314.00","16,438.60",,,,,,
Meridian Duals,CPT,37230,Tib/per revasc w/stent,APC 5194,RVU Per Case,"$16,438.60 ",OP,"4,314.00","16,438.60",,,,,,
Meridian Duals,CPT,37231,Tib/per revasc stent & ather,APC 5194,RVU Per Case,"$16,438.60 ",OP,"4,314.00","16,438.60",,,,,,
Meridian Duals,CPT,37236,Open/perq place stent 1st,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Meridian Duals,CPT,37238,Open/perq place stent same,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
Meridian Duals,CPT,37241,Vasc embolize/occlude venous,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Meridian Duals,CPT,37242,Vasc embolize/occlude artery,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
Meridian Duals,CPT,37243,Vasc embolize/occlude organ,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Meridian Duals,CPT,37244,Vasc embolize/occlude bleed,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
Meridian Duals,CPT,37246,Trluml balo angiop 1st art,APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,314.00","5,072.43",,,,,,
Meridian Duals,CPT,37248,Trluml balo angiop 1st vein,APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,314.00","5,072.43",,,,,,
Meridian Duals,CPT,37500,Endoscopy ligate perf veins,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,37501,Vascular endoscopy procedure,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Meridian Duals,CPT,37565,Ligation of neck vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,37600,Ligation of neck artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,37605,Ligation of neck artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,37606,Ligation of neck artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,37607,Ligation of a-v fistula,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,37609,Temporal artery procedure,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,37615,Ligation of neck artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,37616,Ligation of chest artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,37617,Ligation of abdomen artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,37618,Ligation of extremity artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,37619,Ligation of inf vena cava,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,37650,Revision of major vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,37660,Revision of major vein,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,37700,Revise leg vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,37718,Ligate/strip short leg vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,37722,Ligate/strip long leg vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,37735,Removal of leg veins/lesion,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,37760,Ligate leg veins radical,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,37761,Ligate leg veins open,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,37765,Stab phleb veins xtr 10-20,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,37766,Phleb veins - extrem 20+,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,37780,Revision of leg vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,37785,Ligate/divide/excise vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,37788,Revascularization penis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,37790,Penile venous occlusion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,37799,Vascular surgery procedure,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Meridian Duals,CPT,38100,Removal of spleen total,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,38101,Removal of spleen partial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,38102,Removal of spleen total,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,38115,Repair of ruptured spleen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,38120,Laparoscopy splenectomy,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Meridian Duals,CPT,38129,Laparoscope proc spleen,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,38206,Harvest auto stem cells,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
Meridian Duals,CPT,38207,Cryopreserve stem cells,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Meridian Duals,CPT,38208,Thaw preserved stem cells,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Meridian Duals,CPT,38209,Wash harvest stem cells,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Meridian Duals,CPT,38210,T-cell depletion of harvest,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Meridian Duals,CPT,38211,Tumor cell deplete of harvst,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Meridian Duals,CPT,38212,Rbc depletion of harvest,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Meridian Duals,CPT,38213,Platelet deplete of harvest,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Meridian Duals,CPT,38214,Volume deplete of harvest,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Meridian Duals,CPT,38215,Harvest stem cell concentrte,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Meridian Duals,CPT,38220,Dx bone marrow aspirations,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,38221,Dx bone marrow biopsies,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,38222,Dx bone marrow bx & aspir,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,38230,Bone marrow harvest allogen,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
Meridian Duals,CPT,38232,Bone marrow harvest autolog,APC 5243,RVU Per Unit,"$4,131.87 ",OP,"4,131.87","4,314.00",,,,,,
Meridian Duals,CPT,38240,Transplt allo hct/donor,APC 5244,RVU Per Case,"$32,580.57 ",OP,"4,314.00","32,580.57",,,,,,
Meridian Duals,CPT,38241,Transplt autol hct/donor,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
Meridian Duals,CPT,38242,Transplt allo lymphocytes,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
Meridian Duals,CPT,38243,Transplj hematopoietic boost,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
Meridian Duals,CPT,38300,Drainage lymph node lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,38305,Drainage lymph node lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,38308,Incision of lymph channels,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Meridian Duals,CPT,38380,Thoracic duct procedure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,38381,Thoracic duct procedure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,38382,Thoracic duct procedure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,38500,Biopsy/removal lymph nodes,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Meridian Duals,CPT,38505,Needle biopsy lymph nodes,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,38510,Biopsy/removal lymph nodes,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Meridian Duals,CPT,38520,Biopsy/removal lymph nodes,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Meridian Duals,CPT,38525,Biopsy/removal lymph nodes,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Meridian Duals,CPT,38530,Biopsy/removal lymph nodes,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Meridian Duals,CPT,38531,Open bx/exc inguinofem nodes,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Meridian Duals,CPT,38542,Explore deep node(s) neck,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,38550,Removal neck/armpit lesion,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Meridian Duals,CPT,38555,Removal neck/armpit lesion,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
Meridian Duals,CPT,38562,Removal pelvic lymph nodes,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Meridian Duals,CPT,38564,Removal abdomen lymph nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,38570,Laparoscopy lymph node biop,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,38571,Laparoscopy lymphadenectomy,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,38572,Laparoscopy lymphadenectomy,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,38573,Laps pelvic lymphadec,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,38589,Laparoscope proc lymphatic,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,38700,Removal of lymph nodes neck,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
Meridian Duals,CPT,38720,Removal of lymph nodes neck,APC 5093,RVU Per Case,"$9,128.05 ",OP,"4,314.00","9,128.05",,,,,,
Meridian Duals,CPT,38724,Removal of lymph nodes neck,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,38740,Remove armpit lymph nodes,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,38745,Remove armpit lymph nodes,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,38746,Remove thoracic lymph nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,38747,Remove abdominal lymph nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,38760,Remove groin lymph nodes,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
Meridian Duals,CPT,38765,Remove groin lymph nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,38770,Remove pelvis lymph nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,38780,Remove abdomen lymph nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,38792,Ra tracer id of sentinl node,APC 5591,RVU Per Case,$385.91 ,OP,385.91,"4,314.00",,,,,,
Meridian Duals,CPT,38999,Blood/lymph system procedure,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Meridian Duals,CPT,39000,Exploration of chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,39010,Exploration of chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,39200,Resect mediastinal cyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,39220,Resect mediastinal tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,39401,Mediastinoscpy w/medstnl bx,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,39402,Mediastinoscpy w/lmph nod bx,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,39499,Chest procedure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,39501,Repair diaphragm laceration,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,39503,Repair of diaphragm hernia,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,39540,Repair of diaphragm hernia,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,39541,Repair of diaphragm hernia,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,39545,Revision of diaphragm,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,39560,Resect diaphragm simple,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,39561,Resect diaphragm complex,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,39599,Diaphragm surgery procedure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,40490,Biopsy of lip,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Meridian Duals,CPT,40500,Partial excision of lip,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,40510,Partial excision of lip,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,40520,Partial excision of lip,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,40525,Reconstruct lip with flap,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,40527,Reconstruct lip with flap,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,40530,Partial removal of lip,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,40650,Repair lip,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Meridian Duals,CPT,40652,Repair lip,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Meridian Duals,CPT,40654,Repair lip,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,40700,Repair cleft lip/nasal,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,40701,Repair cleft lip/nasal,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,40702,Repair cleft lip/nasal,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,40720,Repair cleft lip/nasal,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,40761,Repair cleft lip/nasal,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,40799,Lip surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Meridian Duals,CPT,40800,Drainage of mouth lesion,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,40801,Drainage of mouth lesion,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Meridian Duals,CPT,40804,Removal foreign body mouth,APC 5301,RVU Per Case,$828.48 ,OP,828.48,"4,314.00",,,,,,
Meridian Duals,CPT,40805,Removal foreign body mouth,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Meridian Duals,CPT,40806,Incision of lip fold,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Meridian Duals,CPT,40808,Biopsy of mouth lesion,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Meridian Duals,CPT,40810,Excision of mouth lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,40812,Excise/repair mouth lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,40814,Excise/repair mouth lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,40816,Excision of mouth lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,40818,Excise oral mucosa for graft,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Meridian Duals,CPT,40819,Excise lip or cheek fold,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,40820,Treatment of mouth lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,40830,Repair mouth laceration,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Meridian Duals,CPT,40831,Repair mouth laceration,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Meridian Duals,CPT,40840,Reconstruction of mouth,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,40842,Reconstruction of mouth,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,40843,Reconstruction of mouth,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,40844,Reconstruction of mouth,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,40845,Reconstruction of mouth,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,40899,Mouth surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Meridian Duals,CPT,41000,Drainage of mouth lesion,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Meridian Duals,CPT,41005,Drainage of mouth lesion,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Meridian Duals,CPT,41006,Drainage of mouth lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,41007,Drainage of mouth lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,41008,Drainage of mouth lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,41009,Drainage of mouth lesion,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Meridian Duals,CPT,41010,Incision of tongue fold,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,41015,Drainage of mouth lesion,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Meridian Duals,CPT,41016,Drainage of mouth lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,41017,Drainage of mouth lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,41018,Drainage of mouth lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,41019,Place needles h&n for rt,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,41100,Biopsy of tongue,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Meridian Duals,CPT,41105,Biopsy of tongue,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,41108,Biopsy of floor of mouth,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,41110,Excision of tongue lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,41112,Excision of tongue lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,41113,Excision of tongue lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,41114,Excision of tongue lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,41115,Excision of tongue fold,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,41116,Excision of mouth lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,41120,Partial removal of tongue,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,41130,Partial removal of tongue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,41135,Tongue and neck surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,41140,Removal of tongue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,41145,Tongue removal neck surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,41150,Tongue mouth jaw surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,41153,Tongue mouth neck surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,41155,Tongue jaw & neck surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,41250,Repair tongue laceration,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Meridian Duals,CPT,41251,Repair tongue laceration,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Meridian Duals,CPT,41252,Repair tongue laceration,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Meridian Duals,CPT,41510,Tongue to lip surgery,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,41512,Tongue suspension,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,41520,Reconstruction tongue fold,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,41530,Tongue base vol reduction,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,41599,Tongue and mouth surgery,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Meridian Duals,CPT,41800,Drainage of gum lesion,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Meridian Duals,CPT,41805,Removal foreign body gum,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,41806,Removal foreign body jawbone,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,41820,Excision gum each quadrant,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,41821,Excision of gum flap,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,41822,Excision of gum lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,41823,Excision of gum lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,41825,Excision of gum lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,41826,Excision of gum lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,41827,Excision of gum lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,41828,Excision of gum lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,41830,Removal of gum tissue,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,41850,Treatment of gum lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,41870,Gum graft,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,41872,Repair gum,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,41874,Repair tooth socket,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,41899,Dental surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Meridian Duals,CPT,42000,Drainage mouth roof lesion,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Meridian Duals,CPT,42100,Biopsy roof of mouth,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,42104,Excision lesion mouth roof,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,42106,Excision lesion mouth roof,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,42107,Excision lesion mouth roof,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,42120,Remove palate/lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,42140,Excision of uvula,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,42145,Repair palate pharynx/uvula,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,42160,Treatment mouth roof lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,42180,Repair palate,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Meridian Duals,CPT,42182,Repair palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,42200,Reconstruct cleft palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,42205,Reconstruct cleft palate,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,42210,Reconstruct cleft palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,42215,Reconstruct cleft palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,42220,Reconstruct cleft palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,42225,Reconstruct cleft palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,42226,Lengthening of palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,42227,Lengthening of palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,42235,Repair palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,42260,Repair nose to lip fistula,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,42280,Preparation palate mold,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Meridian Duals,CPT,42281,Insertion palate prosthesis,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,42299,Palate/uvula surgery,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Meridian Duals,CPT,42300,Drainage of salivary gland,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,42305,Drainage of salivary gland,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,42310,Drainage of salivary gland,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Meridian Duals,CPT,42320,Drainage of salivary gland,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Meridian Duals,CPT,42330,Removal of salivary stone,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,42335,Removal of salivary stone,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,42340,Removal of salivary stone,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,42400,Biopsy of salivary gland,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,42405,Biopsy of salivary gland,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,42408,Excision of salivary cyst,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,42409,Drainage of salivary cyst,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,42410,Excise parotid gland/lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,42415,Excise parotid gland/lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,42420,Excise parotid gland/lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,42425,Excise parotid gland/lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,42426,Excise parotid gland/lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,42440,Excise submaxillary gland,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,42450,Excise sublingual gland,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,42500,Repair salivary duct,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,42505,Repair salivary duct,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,42507,Parotid duct diversion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,42509,Parotid duct diversion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,42510,Parotid duct diversion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,42600,Closure of salivary fistula,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,42650,Dilation of salivary duct,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,42660,Dilation of salivary duct,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Meridian Duals,CPT,42665,Ligation of salivary duct,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,42699,Salivary surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Meridian Duals,CPT,42700,Drainage of tonsil abscess,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Meridian Duals,CPT,42720,Drainage of throat abscess,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,42725,Drainage of throat abscess,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,42800,Biopsy of throat,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,42804,Biopsy of upper nose/throat,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,42806,Biopsy of upper nose/throat,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,42808,Excise pharynx lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,42809,Remove pharynx foreign body,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Meridian Duals,CPT,42810,Excision of neck cyst,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,42815,Excision of neck cyst,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,42820,Remove tonsils and adenoids,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,42821,Remove tonsils and adenoids,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,42825,Removal of tonsils,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,42826,Removal of tonsils,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,42830,Removal of adenoids,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,42831,Removal of adenoids,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,42835,Removal of adenoids,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,42836,Removal of adenoids,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,42842,Extensive surgery of throat,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,42844,Extensive surgery of throat,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,42845,Extensive surgery of throat,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,42860,Excision of tonsil tags,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,42870,Excision of lingual tonsil,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,42890,Partial removal of pharynx,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,42892,Revision of pharyngeal walls,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,42894,Revision of pharyngeal walls,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,42900,Repair throat wound,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,42950,Reconstruction of throat,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,42953,Repair throat esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,42955,Surgical opening of throat,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,42960,Control throat bleeding,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Meridian Duals,CPT,42961,Control throat bleeding,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,42962,Control throat bleeding,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,42970,Control nose/throat bleeding,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Meridian Duals,CPT,42971,Control nose/throat bleeding,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,42972,Control nose/throat bleeding,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,42999,Throat surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Meridian Duals,CPT,43020,Incision of esophagus,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,43030,Throat muscle surgery,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,43045,Incision of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43100,Excision of esophagus lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43101,Excision of esophagus lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43107,Removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43108,Removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43112,Esphg tot w/thrcm,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43113,Removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43116,Partial removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43117,Partial removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43118,Partial removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43121,Partial removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43122,Partial removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43123,Partial removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43124,Removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43130,Removal of esophagus pouch,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,43135,Removal of esophagus pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43180,Esophagoscopy rigid trnso,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,43191,Esophagoscopy rigid trnso dx,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,43192,Esophagoscp rig trnso inject,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,43193,Esophagoscp rig trnso biopsy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,43194,Esophagoscp rig trnso rem fb,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,43195,Esophagoscopy rigid balloon,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Meridian Duals,CPT,43196,Esophagoscp guide wire dilat,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Meridian Duals,CPT,43197,Esophagoscopy flex dx brush,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Meridian Duals,CPT,43198,Esophagosc flex trnsn biopsy,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Meridian Duals,CPT,43200,Esophagoscopy flexible brush,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Meridian Duals,CPT,43201,Esoph scope w/submucous inj,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,43202,Esophagoscopy flex biopsy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,43204,Esoph scope w/sclerosis inj,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,43205,Esophagus endoscopy/ligation,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,43206,Esoph optical endomicroscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,43210,Egd esophagogastrc fndoplsty,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Meridian Duals,CPT,43211,Esophagoscop mucosal resect,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,43212,Esophagoscop stent placement,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Meridian Duals,CPT,43213,Esophagoscopy retro balloon,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,43214,Esophagosc dilate balloon 30,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,43215,Esophagoscopy flex remove fb,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,43216,Esophagoscopy lesion removal,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,43217,Esophagoscopy snare les remv,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,43220,Esophagoscopy balloon <30mm,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,43226,Esoph endoscopy dilation,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,43227,Esophagoscopy control bleed,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,43229,Esophagoscopy lesion ablate,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Meridian Duals,CPT,43231,Esophagoscop ultrasound exam,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,43232,Esophagoscopy w/us needle bx,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,43233,Egd balloon dil esoph30 mm/>,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,43235,Egd diagnostic brush wash,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Meridian Duals,CPT,43236,Uppr gi scope w/submuc inj,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Meridian Duals,CPT,43237,Endoscopic us exam esoph,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,43238,Egd us fine needle bx/aspir,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,43239,Egd biopsy single/multiple,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Meridian Duals,CPT,43240,Egd w/transmural drain cyst,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Meridian Duals,CPT,43241,Egd tube/cath insertion,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,43242,Egd us fine needle bx/aspir,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,43243,Egd injection varices,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,43244,Egd varices ligation,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,43245,Egd dilate stricture,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,43246,Egd place gastrostomy tube,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,43247,Egd remove foreign body,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Meridian Duals,CPT,43248,Egd guide wire insertion,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Meridian Duals,CPT,43249,Esoph egd dilation <30 mm,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,43250,Egd cautery tumor polyp,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,43251,Egd remove lesion snare,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,43252,Egd optical endomicroscopy,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Meridian Duals,CPT,43253,Egd us transmural injxn/mark,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,43254,Egd endo mucosal resection,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,43255,Egd control bleeding any,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,43257,Egd w/thrml txmnt gerd,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Meridian Duals,CPT,43259,Egd us exam duodenum/jejunum,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,43260,Ercp w/specimen collection,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Meridian Duals,CPT,43261,Endo cholangiopancreatograph,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Meridian Duals,CPT,43262,Endo cholangiopancreatograph,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Meridian Duals,CPT,43263,Ercp sphincter pressure meas,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Meridian Duals,CPT,43264,Ercp remove duct calculi,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Meridian Duals,CPT,43265,Ercp lithotripsy calculi,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Meridian Duals,CPT,43266,Egd endoscopic stent place,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Meridian Duals,CPT,43270,Egd lesion ablation,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,43274,Ercp duct stent placement,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Meridian Duals,CPT,43275,Ercp remove forgn body duct,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Meridian Duals,CPT,43276,Ercp stent exchange w/dilate,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Meridian Duals,CPT,43277,Ercp ea duct/ampulla dilate,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Meridian Duals,CPT,43278,Ercp lesion ablate w/dilate,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Meridian Duals,CPT,43279,Lap myotomy heller,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43280,Laparoscopy fundoplasty,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Meridian Duals,CPT,43281,Lap paraesophag hern repair,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Meridian Duals,CPT,43282,Lap paraesoph her rpr w/mesh,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Meridian Duals,CPT,43283,Lap esoph lengthening,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43284,Laps esophgl sphnctr agmntj,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Meridian Duals,CPT,43285,Rmvl esophgl sphnctr dev,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,43286,Esphg tot w/laps moblj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43287,Esphg dstl 2/3 w/laps moblj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43288,Esphg thrsc moblj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43289,Laparoscope proc esoph,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,43300,Repair of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43305,Repair esophagus and fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43310,Repair of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43312,Repair esophagus and fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43313,Esophagoplasty congenital,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43314,Tracheo-esophagoplasty cong,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43320,Fuse esophagus & stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43325,Revise esophagus & stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43327,Esoph fundoplasty lap,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43328,Esoph fundoplasty thor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43330,Esophagomyotomy abdominal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43331,Esophagomyotomy thoracic,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43332,Transab esoph hiat hern rpr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43333,Transab esoph hiat hern rpr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43334,Transthor diaphrag hern rpr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43335,Transthor diaphrag hern rpr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43336,Thorabd diaphr hern repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43337,Thorabd diaphr hern repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43338,Esoph lengthening,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43340,Fuse esophagus & intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43341,Fuse esophagus & intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43351,Surgical opening esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43352,Surgical opening esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43360,Gastrointestinal repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43361,Gastrointestinal repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43400,Ligate esophagus veins,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43405,Ligate/staple esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43410,Repair esophagus wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43415,Repair esophagus wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43420,Repair esophagus opening,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,43425,Repair esophagus opening,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43450,Dilate esophagus 1/mult pass,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Meridian Duals,CPT,43453,Dilate esophagus,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,43460,Pressure treatment esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43496,Free jejunum flap microvasc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43499,Esophagus surgery procedure,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Meridian Duals,CPT,43500,Surgical opening of stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43501,Surgical repair of stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43502,Surgical repair of stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43510,Surgical opening of stomach,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Meridian Duals,CPT,43520,Incision of pyloric muscle,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43605,Biopsy of stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43610,Excision of stomach lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43611,Excision of stomach lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43620,Removal of stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43621,Removal of stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43622,Removal of stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43631,Removal of stomach partial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43632,Removal of stomach partial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43633,Removal of stomach partial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43634,Removal of stomach partial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43635,Removal of stomach partial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43640,Vagotomy & pylorus repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43641,Vagotomy & pylorus repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43644,Lap gastric bypass/roux-en-y,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43645,Lap gastr bypass incl smll i,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43647,Lap impl electrode antrum,APC 5463,RVU Per Case,"$11,498.23 ",OP,"4,314.00","11,498.23",,,,,,
Meridian Duals,CPT,43648,Lap revise/remv eltrd antrum,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,43651,Laparoscopy vagus nerve,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,43652,Laparoscopy vagus nerve,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,43653,Laparoscopy gastrostomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,43659,Laparoscope proc stom,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,43752,Nasal/orogastric w/tube plmt,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Meridian Duals,CPT,43753,Tx gastro intub w/asp,APC 5722,RVU Per Case,$270.61 ,OP,270.61,"4,314.00",,,,,,
Meridian Duals,CPT,43754,Dx gastr intub w/asp spec,APC 5722,RVU Per Case,$270.61 ,OP,270.61,"4,314.00",,,,,,
Meridian Duals,CPT,43755,Dx gastr intub w/asp specs,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,"4,314.00",,,,,,
Meridian Duals,CPT,43756,Dx duod intub w/asp spec,APC 5301,RVU Per Case,$828.48 ,OP,828.48,"4,314.00",,,,,,
Meridian Duals,CPT,43757,Dx duod intub w/asp specs,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Meridian Duals,CPT,43761,Reposition gastrostomy tube,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Meridian Duals,CPT,43762,Rplc gtube no revj trc,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Meridian Duals,CPT,43763,Rplc gtube revj gstrst trc,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Meridian Duals,CPT,43770,Lap place gastr adj device,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,43771,Lap revise gastr adj device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43772,Lap rmvl gastr adj device,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Meridian Duals,CPT,43773,Lap replace gastr adj device,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,43774,Lap rmvl gastr adj all parts,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Meridian Duals,CPT,43775,Lap sleeve gastrectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43800,Reconstruction of pylorus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43810,Fusion of stomach and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43820,Fusion of stomach and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43825,Fusion of stomach and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43830,Place gastrostomy tube,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,43831,Place gastrostomy tube,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Meridian Duals,CPT,43832,Place gastrostomy tube,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43840,Repair of stomach lesion,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Meridian Duals,CPT,43843,Gastroplasty w/o v-band,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43845,Gastroplasty duodenal switch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43846,Gastric bypass for obesity,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43847,Gastric bypass incl small i,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43848,Revision gastroplasty,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43850,Revise stomach-bowel fusion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43855,Revise stomach-bowel fusion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43860,Revise stomach-bowel fusion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43865,Revise stomach-bowel fusion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43870,Repair stomach opening,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Meridian Duals,CPT,43880,Repair stomach-bowel fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43881,Impl/redo electrd antrum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43882,Revise/remove electrd antrum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,43886,Revise gastric port open,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Meridian Duals,CPT,43887,Remove gastric port open,APC 5054,RVU Per Case,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,43888,Change gastric port open,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Meridian Duals,CPT,43999,Stomach surgery procedure,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Meridian Duals,CPT,44005,Freeing of bowel adhesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44010,Incision of small bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44015,Insert needle cath bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44020,Explore small intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44021,Decompress small bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44025,Incision of large bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44050,Reduce bowel obstruction,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44055,Correct malrotation of bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44100,Biopsy of bowel,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Meridian Duals,CPT,44110,Excise intestine lesion(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44111,Excision of bowel lesion(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44120,Removal of small intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44121,Removal of small intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44125,Removal of small intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44126,Enterectomy w/o taper cong,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44127,Enterectomy w/taper cong,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44128,Enterectomy cong add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44130,Bowel to bowel fusion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44132,Enterectomy cadaver donor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44133,Enterectomy live donor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44135,Intestine transplnt cadaver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44136,Intestine transplant live,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44137,Remove intestinal allograft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44139,Mobilization of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44140,Partial removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44141,Partial removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44143,Partial removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44144,Partial removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44145,Partial removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44146,Partial removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44147,Partial removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44150,Removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44151,Removal of colon/ileostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44155,Removal of colon/ileostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44156,Removal of colon/ileostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44157,Colectomy w/ileoanal anast,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44158,Colectomy w/neo-rectum pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44160,Removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44180,Lap enterolysis,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,44186,Lap jejunostomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,44187,Lap ileo/jejuno-stomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44188,Lap colostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44202,Lap enterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44203,Lap resect s/intestine addl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44204,Laparo partial colectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44205,Lap colectomy part w/ileum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44206,Lap part colectomy w/stoma,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44207,L colectomy/coloproctostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44208,L colectomy/coloproctostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44210,Laparo total proctocolectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44211,Lap colectomy w/proctectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44212,Laparo total proctocolectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44213,Lap mobil splenic fl add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44227,Lap close enterostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44238,Laparoscope proc intestine,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,44300,Open bowel to skin,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,44310,Ileostomy/jejunostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44312,Revision of ileostomy,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Meridian Duals,CPT,44314,Revision of ileostomy,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Meridian Duals,CPT,44316,Devise bowel pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44320,Colostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44322,Colostomy with biopsies,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44340,Revision of colostomy,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Meridian Duals,CPT,44345,Revision of colostomy,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Meridian Duals,CPT,44346,Revision of colostomy,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Meridian Duals,CPT,44360,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,44361,Small bowel endoscopy/biopsy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,44363,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,44364,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,44365,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,44366,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,44369,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,44370,Small bowel endoscopy/stent,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Meridian Duals,CPT,44372,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,44373,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,44376,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,44377,Small bowel endoscopy/biopsy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,44378,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,44379,S bowel endoscope w/stent,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Meridian Duals,CPT,44380,Small bowel endoscopy br/wa,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Meridian Duals,CPT,44381,Small bowel endoscopy br/wa,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,44382,Small bowel endoscopy,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Meridian Duals,CPT,44384,Small bowel endoscopy,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Meridian Duals,CPT,44385,Endoscopy of bowel pouch,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Meridian Duals,CPT,44386,Endoscopy bowel pouch/biop,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Meridian Duals,CPT,44388,Colonoscopy thru stoma spx,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Meridian Duals,CPT,44389,Colonoscopy with biopsy,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,44390,Colonoscopy for foreign body,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Meridian Duals,CPT,44391,Colonoscopy for bleeding,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,44392,Colonoscopy & polypectomy,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,44394,Colonoscopy w/snare,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,44401,Colonoscopy with ablation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,44402,Colonoscopy w/stent plcmt,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Meridian Duals,CPT,44403,Colonoscopy w/resection,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,44404,Colonoscopy w/injection,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,44405,Colonoscopy w/dilation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,44406,Colonoscopy w/ultrasound,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,44407,Colonoscopy w/ndl aspir/bx,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,44408,Colonoscopy w/decompression,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Meridian Duals,CPT,44500,Intro gastrointestinal tube,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Meridian Duals,CPT,44602,Suture small intestine,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Meridian Duals,CPT,44603,Suture small intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44604,Suture large intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44605,Repair of bowel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44615,Intestinal stricturoplasty,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44620,Repair bowel opening,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44625,Repair bowel opening,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44626,Repair bowel opening,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44640,Repair bowel-skin fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44650,Repair bowel fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44660,Repair bowel-bladder fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44661,Repair bowel-bladder fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44680,Surgical revision intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44700,Suspend bowel w/prosthesis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44715,Prepare donor intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44720,Prep donor intestine/venous,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44721,Prep donor intestine/artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44799,Unlisted px small intestine,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Meridian Duals,CPT,44800,Excision of bowel pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44820,Excision of mesentery lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44850,Repair of mesentery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44899,Bowel surgery procedure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44900,Drain appendix abscess open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44950,Appendectomy,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Meridian Duals,CPT,44960,Appendectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,44970,Laparoscopy appendectomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,44979,Laparoscope proc app,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,45000,Drainage of pelvic abscess,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,45005,Drainage of rectal abscess,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,45020,Drainage of rectal abscess,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,45100,Biopsy of rectum,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,45108,Removal of anorectal lesion,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,45110,Removal of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,45111,Partial removal of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,45112,Removal of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,45113,Partial proctectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,45114,Partial removal of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,45116,Partial removal of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,45119,Remove rectum w/reservoir,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,45120,Removal of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,45121,Removal of rectum and colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,45123,Partial proctectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,45126,Pelvic exenteration,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,45130,Excision of rectal prolapse,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,45135,Excision of rectal prolapse,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,45136,Excise ileoanal reservior,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,45150,Excision of rectal stricture,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,45160,Excision of rectal lesion,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,45171,Exc rect tum transanal part,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,45172,Exc rect tum transanal full,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,45190,Destruction rectal tumor,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,45300,Proctosigmoidoscopy dx,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Meridian Duals,CPT,45303,Proctosigmoidoscopy dilate,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,45305,Proctosigmoidoscopy w/bx,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,45307,Proctosigmoidoscopy fb,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,45308,Proctosigmoidoscopy removal,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,45309,Proctosigmoidoscopy removal,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,45315,Proctosigmoidoscopy removal,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,45317,Proctosigmoidoscopy bleed,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,45320,Proctosigmoidoscopy ablate,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,45321,Proctosigmoidoscopy volvul,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,45327,Proctosigmoidoscopy w/stent,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Meridian Duals,CPT,45330,Diagnostic sigmoidoscopy,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Meridian Duals,CPT,45331,Sigmoidoscopy and biopsy,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Meridian Duals,CPT,45332,Sigmoidoscopy w/fb removal,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,45333,Sigmoidoscopy & polypectomy,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Meridian Duals,CPT,45334,Sigmoidoscopy for bleeding,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,45335,Sigmoidoscopy w/submuc inj,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Meridian Duals,CPT,45337,Sigmoidoscopy & decompress,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Meridian Duals,CPT,45338,Sigmoidoscopy w/tumr remove,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,45340,Sig w/tndsc balloon dilation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,45341,Sigmoidoscopy w/ultrasound,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Meridian Duals,CPT,45342,Sigmoidoscopy w/us guide bx,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,45346,Sigmoidoscopy w/ablation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,45347,Sigmoidoscopy w/plcmt stent,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Meridian Duals,CPT,45349,Sigmoidoscopy w/resection,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,45350,Sgmdsc w/band ligation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,45378,Diagnostic colonoscopy,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Meridian Duals,CPT,45379,Colonoscopy w/fb removal,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,45380,Colonoscopy and biopsy,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,45381,Colonoscopy submucous njx,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,45382,Colonoscopy w/control bleed,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,45384,Colonoscopy w/lesion removal,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,45385,Colonoscopy w/lesion removal,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,45386,Colonoscopy w/balloon dilat,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,45388,Colonoscopy w/ablation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,45389,Colonoscopy w/stent plcmt,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Meridian Duals,CPT,45390,Colonoscopy w/resection,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,45391,Colonoscopy w/endoscope us,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,45392,Colonoscopy w/endoscopic fnb,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,45393,Colonoscopy w/decompression,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,45395,Lap removal of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,45397,Lap remove rectum w/pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,45398,Colonoscopy w/band ligation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,45399,Unlisted procedure colon,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Meridian Duals,CPT,45400,Laparoscopic proc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,45402,Lap proctopexy w/sig resect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,45499,Laparoscope proc rectum,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,45500,Repair of rectum,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,45505,Repair of rectum,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,45520,Treatment of rectal prolapse,APC 5311,RVU Per Case,$812.16 ,OP,812.16,"4,314.00",,,,,,
Meridian Duals,CPT,45540,Correct rectal prolapse,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,45541,Correct rectal prolapse,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,45550,Repair rectum/remove sigmoid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,45560,Repair of rectocele,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,45562,Exploration/repair of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,45563,Exploration/repair of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,45800,Repair rect/bladder fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,45805,Repair fistula w/colostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,45820,Repair rectourethral fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,45825,Repair fistula w/colostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,45900,Reduction of rectal prolapse,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Meridian Duals,CPT,45905,Dilation of anal sphincter,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,45910,Dilation of rectal narrowing,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,45915,Remove rectal obstruction,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,45990,Surg dx exam anorectal,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,45999,Rectum surgery procedure,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Meridian Duals,CPT,46020,Placement of seton,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,46030,Removal of rectal marker,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,46040,Incision of rectal abscess,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,46045,Incision of rectal abscess,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,46050,Incision of anal abscess,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Meridian Duals,CPT,46060,Incision of rectal abscess,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,46070,Incision of anal septum,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,46080,Incision of anal sphincter,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,46083,Incise external hemorrhoid,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Meridian Duals,CPT,46200,Removal of anal fissure,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,46220,Excise anal ext tag/papilla,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,46221,Ligation of hemorrhoid(s),APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Meridian Duals,CPT,46230,Removal of anal tags,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,46250,Remove ext hem groups 2+,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,46255,Remove int/ext hem 1 group,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,46257,Remove in/ex hem grp & fiss,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,46258,Remove in/ex hem grp w/fistu,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,46260,Remove in/ex hem groups 2+,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,46261,Remove in/ex hem grps & fiss,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,46262,Remove in/ex hem grps w/fist,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,46270,Remove anal fist subq,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,46275,Remove anal fist inter,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,46280,Remove anal fist complex,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,46285,Remove anal fist 2 stage,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,46288,Repair anal fistula,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,46320,Removal of hemorrhoid clot,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,46500,Injection into hemorrhoid(s),APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Meridian Duals,CPT,46505,Chemodenervation anal musc,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,46600,Diagnostic anoscopy spx,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Meridian Duals,CPT,46601,Diagnostic anoscopy,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Meridian Duals,CPT,46604,Anoscopy and dilation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,46606,Anoscopy and biopsy,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,46607,Diagnostic anoscopy & biopsy,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,46608,Anoscopy remove for body,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Meridian Duals,CPT,46610,Anoscopy remove lesion,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,46611,Anoscopy,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Meridian Duals,CPT,46612,Anoscopy remove lesions,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,46614,Anoscopy control bleeding,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,46615,Anoscopy,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,46700,Repair of anal stricture,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,46705,Repair of anal stricture,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,46706,Repr of anal fistula w/glue,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,46707,Repair anorectal fist w/plug,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,46710,Repr per/vag pouch sngl proc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,46712,Repr per/vag pouch dbl proc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,46715,Rep perf anoper fistu,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,46716,Rep perf anoper/vestib fistu,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,46730,Construction of absent anus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,46735,Construction of absent anus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,46740,Construction of absent anus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,46742,Repair of imperforated anus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,46744,Repair of cloacal anomaly,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,46746,Repair of cloacal anomaly,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,46748,Repair of cloacal anomaly,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,46750,Repair of anal sphincter,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,46751,Repair of anal sphincter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,46753,Reconstruction of anus,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,46754,Removal of suture from anus,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,46760,Repair of anal sphincter,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,46761,Repair of anal sphincter,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,46900,Destruction anal lesion(s),APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,46910,Destruction anal lesion(s),APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,46916,Cryosurgery anal lesion(s),APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,46917,Laser surgery anal lesions,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,46922,Excision of anal lesion(s),APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,46924,Destruction anal lesion(s),APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,46930,Destroy internal hemorrhoids,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,46940,Treatment of anal fissure,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,46942,Treatment of anal fissure,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Meridian Duals,CPT,46945,Int hrhc lig 1 hroid w/o img,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,46946,Int hrhc lig 2+hroid w/o img,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,46947,Hemorrhoidopexy by stapling,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,46948,Int hrhc tranal dartlzj 2+,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Meridian Duals,CPT,46999,Anus surgery procedure,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Meridian Duals,CPT,47000,Needle biopsy of liver,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,47010,Open drainage liver lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47015,Inject/aspirate liver cyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47100,Wedge biopsy of liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47120,Partial removal of liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47122,Extensive removal of liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47125,Partial removal of liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47130,Partial removal of liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47133,Removal of donor liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47135,Transplantation of liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47140,Partial removal donor liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47141,Partial removal donor liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47142,Partial removal donor liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47143,Prep donor liver whole,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47144,Prep donor liver 3-segment,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47145,Prep donor liver lobe split,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47146,Prep donor liver/venous,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47147,Prep donor liver/arterial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47300,Surgery for liver lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47350,Repair liver wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47360,Repair liver wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47361,Repair liver wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47362,Repair liver wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47370,Laparo ablate liver tumor rf,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Meridian Duals,CPT,47371,Laparo ablate liver cryosurg,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Meridian Duals,CPT,47379,Laparoscope procedure liver,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,47380,Open ablate liver tumor rf,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47381,Open ablate liver tumor cryo,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47382,Percut ablate liver rf,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,47383,Perq abltj lvr cryoablation,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,47399,Liver surgery procedure,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,47400,Incision of liver duct,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47420,Incision of bile duct,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47425,Incision of bile duct,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47460,Incise bile duct sphincter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47480,Incision of gallbladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47490,Incision of gallbladder,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Meridian Duals,CPT,47531,Injection for cholangiogram,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Meridian Duals,CPT,47532,Injection for cholangiogram,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Meridian Duals,CPT,47533,Plmt biliary drainage cath,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Meridian Duals,CPT,47534,Plmt biliary drainage cath,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Meridian Duals,CPT,47535,Conversion ext bil drg cath,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Meridian Duals,CPT,47536,Exchange biliary drg cath,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Meridian Duals,CPT,47537,Removal biliary drg cath,APC 5301,RVU Per Case,$828.48 ,OP,828.48,"4,314.00",,,,,,
Meridian Duals,CPT,47538,Perq plmt bile duct stent,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,47539,Perq plmt bile duct stent,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,47540,Perq plmt bile duct stent,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,47541,Plmt access bil tree sm bwl,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Meridian Duals,CPT,47550,Bile duct endoscopy add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47552,Biliary endo perq dx w/speci,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Meridian Duals,CPT,47553,Biliary endoscopy thru skin,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Meridian Duals,CPT,47554,Biliary endoscopy thru skin,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,47555,Biliary endoscopy thru skin,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Meridian Duals,CPT,47556,Biliary endoscopy thru skin,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,47562,Laparoscopic cholecystectomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,47563,Laparo cholecystectomy/graph,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,47564,Laparo cholecystectomy/explr,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,47570,Laparo cholecystoenterostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47579,Laparoscope proc biliary,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,47600,Removal of gallbladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,47605,Removal of gallbladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,47610,Removal of gallbladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,47612,Removal of gallbladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,47620,Removal of gallbladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,47700,Exploration of bile ducts,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47701,Bile duct revision,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47711,Excision of bile duct tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47712,Excision of bile duct tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47715,Excision of bile duct cyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47720,Fuse gallbladder & bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47721,Fuse upper gi structures,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47740,Fuse gallbladder & bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47741,Fuse gallbladder & bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47760,Fuse bile ducts and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47765,Fuse liver ducts & bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47780,Fuse bile ducts and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47785,Fuse bile ducts and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47800,Reconstruction of bile ducts,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47801,Placement bile duct support,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47802,Fuse liver duct & intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47900,Suture bile duct injury,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,47999,Bile tract surgery procedure,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Meridian Duals,CPT,48000,Drainage of abdomen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,48001,Placement of drain pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,48020,Removal of pancreatic stone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,48100,Biopsy of pancreas open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,48102,Needle biopsy pancreas,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,48105,Resect/debride pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,48120,Removal of pancreas lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,48140,Partial removal of pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,48145,Partial removal of pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,48146,Pancreatectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,48148,Removal of pancreatic duct,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,48150,Partial removal of pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,48152,Pancreatectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,48153,Pancreatectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,48154,Pancreatectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,48155,Removal of pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,48400,Injection intraop add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,48500,Surgery of pancreatic cyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,48510,Drain pancreatic pseudocyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,48520,Fuse pancreas cyst and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,48540,Fuse pancreas cyst and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,48545,Pancreatorrhaphy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,48547,Duodenal exclusion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,48548,Fuse pancreas and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,48551,Prep donor pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,48552,Prep donor pancreas/venous,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,48554,Transpl allograft pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,48556,Removal allograft pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,48999,Pancreas surgery procedure,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,49000,Exploration of abdomen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,49002,Reopening of abdomen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,49010,Exploration behind abdomen,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Meridian Duals,CPT,49013,Prpertl pel pack hemrrg trma,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,49014,Reexploration pelvic wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,49020,Drainage abdom abscess open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,49040,Drain open abdom abscess,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,49060,Drain open retroperi abscess,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,49062,Drain to peritoneal cavity,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,49082,Abd paracentesis,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Meridian Duals,CPT,49083,Abd paracentesis w/imaging,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Meridian Duals,CPT,49084,Peritoneal lavage,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Meridian Duals,CPT,49180,Biopsy abdominal mass,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,49185,Sclerotx fluid collection,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,49203,Exc abd tum 5 cm or less,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,49204,Exc abd tum over 5 cm,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,49205,Exc abd tum over 10 cm,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,49215,Excise sacral spine tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,49250,Excision of umbilicus,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Meridian Duals,CPT,49255,Removal of omentum,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Meridian Duals,CPT,49320,Diag laparo separate proc,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,49321,Laparoscopy biopsy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,49322,Laparoscopy aspiration,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,49323,Laparo drain lymphocele,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,49324,Lap insert tunnel ip cath,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,49325,Lap revision perm ip cath,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,49329,Laparo proc abdm/per/oment,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,49402,Remove foreign body adbomen,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Meridian Duals,CPT,49405,Image cath fluid colxn visc,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,49406,Image cath fluid peri/retro,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,49407,Image cath fluid trns/vgnl,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,49411,Ins mark abd/pel for rt perq,APC 5613,RVU Per Unit,"$1,291.62 ",OP,"1,291.62","4,314.00",,,,,,
Meridian Duals,CPT,49412,Ins device for rt guide open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,49418,Insert tun ip cath perc,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Meridian Duals,CPT,49419,Insert tun ip cath w/port,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Meridian Duals,CPT,49421,Ins tun ip cath for dial opn,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Meridian Duals,CPT,49422,Remove tunneled ip cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,49423,Exchange drainage catheter,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,49425,Insert abdomen-venous drain,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,49426,Revise abdomen-venous shunt,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Meridian Duals,CPT,49428,Ligation of shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,49429,Removal of shunt,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Meridian Duals,CPT,49436,Embedded ip cath exit-site,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,49440,Place gastrostomy tube perc,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,49441,Place duod/jej tube perc,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,49442,Place cecostomy tube perc,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Meridian Duals,CPT,49446,Change g-tube to g-j perc,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Meridian Duals,CPT,49450,Replace g/c tube perc,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Meridian Duals,CPT,49451,Replace duod/jej tube perc,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Meridian Duals,CPT,49452,Replace g-j tube perc,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Meridian Duals,CPT,49460,Fix g/colon tube w/device,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Meridian Duals,CPT,49465,Fluoro exam of g/colon tube,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"4,314.00",,,,,,
Meridian Duals,CPT,49491,Rpr hern preemie reduc,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,49492,Rpr ing hern premie blocked,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Meridian Duals,CPT,49495,Rpr ing hernia baby reduc,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Meridian Duals,CPT,49496,Rpr ing hernia baby blocked,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Meridian Duals,CPT,49500,Rpr ing hernia init reduce,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Meridian Duals,CPT,49501,Rpr ing hernia init blocked,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Meridian Duals,CPT,49505,Prp i/hern init reduc >5 yr,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Meridian Duals,CPT,49507,Prp i/hern init block >5 yr,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Meridian Duals,CPT,49520,Rerepair ing hernia reduce,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Meridian Duals,CPT,49521,Rerepair ing hernia blocked,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Meridian Duals,CPT,49525,Repair ing hernia sliding,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Meridian Duals,CPT,49540,Repair lumbar hernia,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,49550,Rpr rem hernia init reduce,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Meridian Duals,CPT,49553,Rpr fem hernia init blocked,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Meridian Duals,CPT,49555,Rerepair fem hernia reduce,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Meridian Duals,CPT,49557,Rerepair fem hernia blocked,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Meridian Duals,CPT,49560,Rpr ventral hern init reduc,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Meridian Duals,CPT,49561,Rpr ventral hern init block,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Meridian Duals,CPT,49565,Rerepair ventrl hern reduce,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,49566,Rerepair ventrl hern block,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,49570,Rpr epigastric hern reduce,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Meridian Duals,CPT,49572,Rpr epigastric hern blocked,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Meridian Duals,CPT,49580,Rpr umbil hern reduc < 5 yr,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Meridian Duals,CPT,49582,Rpr umbil hern block < 5 yr,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Meridian Duals,CPT,49585,Rpr umbil hern reduc > 5 yr,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Meridian Duals,CPT,49587,Rpr umbil hern block > 5 yr,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Meridian Duals,CPT,49590,Repair spigelian hernia,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Meridian Duals,CPT,49600,Repair umbilical lesion,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Meridian Duals,CPT,49605,Repair umbilical lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,49606,Repair umbilical lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,49610,Repair umbilical lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,49611,Repair umbilical lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,49650,Lap ing hernia repair init,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,49651,Lap ing hernia repair recur,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,49652,Lap vent/abd hernia repair,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,49653,Lap vent/abd hern proc comp,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,49654,Lap inc hernia repair,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,49655,Lap inc hern repair comp,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Meridian Duals,CPT,49656,Lap inc hernia repair recur,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Meridian Duals,CPT,49657,Lap inc hern recur comp,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Meridian Duals,CPT,49659,Laparo proc hernia repair,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,49900,Repair of abdominal wall,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,49904,Omental flap extra-abdom,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,49905,Omental flap intra-abdom,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,49906,Free omental flap microvasc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,49999,Abdomen surgery procedure,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Meridian Duals,CPT,50010,Exploration of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50020,Renal abscess open drain,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,50040,Drainage of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50045,Exploration of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50060,Removal of kidney stone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50065,Incision of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50070,Incision of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50075,Removal of kidney stone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50080,Removal of kidney stone,APC 5376,RVU Per Case,"$8,450.70 ",OP,"4,314.00","8,450.70",,,,,,
Meridian Duals,CPT,50081,Removal of kidney stone,APC 5376,RVU Per Case,"$8,450.70 ",OP,"4,314.00","8,450.70",,,,,,
Meridian Duals,CPT,50100,Revise kidney blood vessels,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50120,Exploration of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50125,Explore and drain kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50130,Removal of kidney stone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50135,Exploration of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50200,Renal biopsy perq,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,50205,Renal biopsy open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50220,Remove kidney open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50225,Removal kidney open complex,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50230,Removal kidney open radical,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50234,Removal of kidney & ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50236,Removal of kidney & ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50240,Partial removal of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50250,Cryoablate renal mass open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50280,Removal of kidney lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50290,Removal of kidney lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50300,Remove cadaver donor kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50320,Remove kidney living donor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50323,Prep cadaver renal allograft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50325,Prep donor renal graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50327,Prep renal graft/venous,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50328,Prep renal graft/arterial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50329,Prep renal graft/ureteral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50340,Removal of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50360,Transplantation of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50365,Transplantation of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50370,Remove transplanted kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50380,Reimplantation of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50382,Change ureter stent percut,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,50384,Remove ureter stent percut,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,50385,Change stent via transureth,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,50386,Remove stent via transureth,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,50387,Change nephroureteral cath,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,50389,Remove renal tube w/fluoro,APC 5372,RVU Per Case,$588.17 ,OP,588.17,"4,314.00",,,,,,
Meridian Duals,CPT,50390,Drainage of kidney lesion,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,50391,Instll rx agnt into rnal tub,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Meridian Duals,CPT,50396,Measure kidney pressure,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Meridian Duals,CPT,50400,Revision of kidney/ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50405,Revision of kidney/ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50430,Njx px nfrosgrm &/urtrgrm,APC 5372,RVU Per Case,$588.17 ,OP,588.17,"4,314.00",,,,,,
Meridian Duals,CPT,50431,Njx px nfrosgrm &/urtrgrm,APC 5372,RVU Per Case,$588.17 ,OP,588.17,"4,314.00",,,,,,
Meridian Duals,CPT,50432,Plmt nephrostomy catheter,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,50433,Plmt nephroureteral catheter,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,50434,Convert nephrostomy catheter,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,50435,Exchange nephrostomy cath,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,50436,Dilat xst trc ndurlgc px,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,50437,Dilat xst trc new access rcs,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,50500,Repair of kidney wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50520,Close kidney-skin fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50525,Close nephrovisceral fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50526,Close nephrovisceral fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50540,Revision of horseshoe kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50541,Laparo ablate renal cyst,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,50542,Laparo ablate renal mass,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Meridian Duals,CPT,50543,Laparo partial nephrectomy,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Meridian Duals,CPT,50544,Laparoscopy pyeloplasty,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,50545,Laparo radical nephrectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50546,Laparoscopic nephrectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50547,Laparo removal donor kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50548,Laparo remove w/ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50549,Laparoscope proc renal,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,50551,Kidney endoscopy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,50553,Kidney endoscopy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,50555,Kidney endoscopy & biopsy,APC 5376,RVU Per Case,"$8,450.70 ",OP,"4,314.00","8,450.70",,,,,,
Meridian Duals,CPT,50557,Kidney endoscopy & treatment,APC 5376,RVU Per Case,"$8,450.70 ",OP,"4,314.00","8,450.70",,,,,,
Meridian Duals,CPT,50561,Kidney endoscopy & treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,50562,Renal scope w/tumor resect,APC 5376,RVU Per Case,"$8,450.70 ",OP,"4,314.00","8,450.70",,,,,,
Meridian Duals,CPT,50570,Kidney endoscopy,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,50572,Kidney endoscopy,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Meridian Duals,CPT,50574,Kidney endoscopy & biopsy,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,50575,Kidney endoscopy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,50576,Kidney endoscopy & treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,50580,Kidney endoscopy & treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,50590,Fragmenting of kidney stone,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,50592,Perc rf ablate renal tumor,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,50593,Perc cryo ablate renal tum,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Meridian Duals,CPT,50600,Exploration of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50605,Insert ureteral support,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50610,Removal of ureter stone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50620,Removal of ureter stone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50630,Removal of ureter stone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50650,Removal of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50660,Removal of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50686,Measure ureter pressure,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,"4,314.00",,,,,,
Meridian Duals,CPT,50688,Change of ureter tube/stent,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,50693,Plmt ureteral stent prq,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,50694,Plmt ureteral stent prq,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,50695,Plmt ureteral stent prq,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,50700,Revision of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50715,Release of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50722,Release of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50725,Release/revise ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50727,Revise ureter,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,50728,Revise ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50740,Fusion of ureter & kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50750,Fusion of ureter & kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50760,Fusion of ureters,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50770,Splicing of ureters,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50780,Reimplant ureter in bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50782,Reimplant ureter in bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50783,Reimplant ureter in bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50785,Reimplant ureter in bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50800,Implant ureter in bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50810,Fusion of ureter & bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50815,Urine shunt to intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50820,Construct bowel bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50825,Construct bowel bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50830,Revise urine flow,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50840,Replace ureter by bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50845,Appendico-vesicostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50860,Transplant ureter to skin,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50900,Repair of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50920,Closure ureter/skin fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50930,Closure ureter/bowel fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50940,Release of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,50945,Laparoscopy ureterolithotomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,50947,Laparo new ureter/bladder,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,50948,Laparo new ureter/bladder,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Meridian Duals,CPT,50949,Laparoscope proc ureter,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,50951,Endoscopy of ureter,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,50953,Endoscopy of ureter,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,50955,Ureter endoscopy & biopsy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,50957,Ureter endoscopy & treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,50961,Ureter endoscopy & treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,50970,Ureter endoscopy,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,50972,Ureter endoscopy & catheter,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,50974,Ureter endoscopy & biopsy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,50976,Ureter endoscopy & treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,50980,Ureter endoscopy & treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,51020,Incise & treat bladder,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,51030,Incise & treat bladder,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,51040,Incise & drain bladder,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,51045,Incise bladder/drain ureter,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,51050,Removal of bladder stone,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,51060,Removal of ureter stone,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,51065,Remove ureter calculus,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,51080,Drainage of bladder abscess,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,51100,Drain bladder by needle,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Meridian Duals,CPT,51101,Drain bladder by trocar/cath,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"4,314.00",,,,,,
Meridian Duals,CPT,51102,Drain bl w/cath insertion,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,51500,Removal of bladder cyst,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,51520,Removal of bladder lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,51525,Removal of bladder lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,51530,Removal of bladder lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,51535,Repair of ureter lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,51550,Partial removal of bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,51555,Partial removal of bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,51565,Revise bladder & ureter(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,51570,Removal of bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,51575,Removal of bladder & nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,51580,Remove bladder/revise tract,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,51585,Removal of bladder & nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,51590,Remove bladder/revise tract,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,51595,Remove bladder/revise tract,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,51596,Remove bladder/create pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,51597,Removal of pelvic structures,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,51700,Irrigation of bladder,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Meridian Duals,CPT,51701,Insert bladder catheter,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Meridian Duals,CPT,51702,Insert temp bladder cath,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Meridian Duals,CPT,51703,Insert bladder cath complex,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,"4,314.00",,,,,,
Meridian Duals,CPT,51705,Change of bladder tube,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Meridian Duals,CPT,51710,Change of bladder tube,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Meridian Duals,CPT,51715,Endoscopic injection/implant,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,51720,Treatment of bladder lesion,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Meridian Duals,CPT,51725,Simple cystometrogram,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Meridian Duals,CPT,51726,Complex cystometrogram,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Meridian Duals,CPT,51727,Cystometrogram w/up,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Meridian Duals,CPT,51728,Cystometrogram w/vp,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Meridian Duals,CPT,51729,Cystometrogram w/vp&up,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Meridian Duals,CPT,51736,Urine flow measurement,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Meridian Duals,CPT,51741,Electro-uroflowmetry first,APC 5721,RVU Per Case,$142.80 ,OP,142.8,"4,314.00",,,,,,
Meridian Duals,CPT,51784,Anal/urinary muscle study,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,"4,314.00",,,,,,
Meridian Duals,CPT,51785,Anal/urinary muscle study,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Meridian Duals,CPT,51792,Urinary reflex study,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Meridian Duals,CPT,51798,Us urine capacity measure,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Meridian Duals,CPT,51800,Revision of bladder/urethra,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,51820,Revision of urinary tract,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,51840,Attach bladder/urethra,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Meridian Duals,CPT,51841,Attach bladder/urethra,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,51845,Repair bladder neck,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Meridian Duals,CPT,51860,Repair of bladder wound,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,51865,Repair of bladder wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,51880,Repair of bladder opening,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,51900,Repair bladder/vagina lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,51920,Close bladder-uterus fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,51925,Hysterectomy/bladder repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,51940,Correction of bladder defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,51960,Revision of bladder & bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,51980,Construct bladder opening,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,51990,Laparo urethral suspension,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,51992,Laparo sling operation,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,51999,Laparoscope proc bla,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,52000,Cystoscopy,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Meridian Duals,CPT,52001,Cystoscopy removal of clots,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,52005,Cystoscopy & ureter catheter,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,52007,Cystoscopy and biopsy,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,52010,Cystoscopy & duct catheter,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Meridian Duals,CPT,52204,Cystoscopy w/biopsy(s),APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,52214,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,52224,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,52234,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,52235,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,52240,Cystoscopy and treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,52250,Cystoscopy and radiotracer,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,52260,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,52265,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,52270,Cystoscopy & revise urethra,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,52275,Cystoscopy & revise urethra,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,52276,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,52277,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,52281,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,52282,Cystoscopy implant stent,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,52283,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,52285,Cystoscopy and treatment,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Meridian Duals,CPT,52287,Cystoscopy chemodenervation,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,52290,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,52300,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,52301,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,52305,Cystoscopy and treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,52310,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,52315,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,52317,Remove bladder stone,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,52318,Remove bladder stone,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,52320,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,52325,Cystoscopy stone removal,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,52327,Cystoscopy inject material,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,52330,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,52332,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,52334,Create passage to kidney,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,52341,Cysto w/ureter stricture tx,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,52342,Cysto w/up stricture tx,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,52343,Cysto w/renal stricture tx,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,52344,Cysto/uretero stricture tx,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,52345,Cysto/uretero w/up stricture,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,52346,Cystouretero w/renal strict,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,52351,Cystouretero & or pyeloscope,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,52352,Cystouretero w/stone remove,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,52353,Cystouretero w/lithotripsy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,52354,Cystouretero w/biopsy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,52355,Cystouretero w/excise tumor,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,52356,Cysto/uretero w/lithotripsy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,52400,Cystouretero w/congen repr,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,52402,Cystourethro cut ejacul duct,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,52450,Incision of prostate,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,52500,Revision of bladder neck,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,52601,Prostatectomy (turp),APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,52630,Remove prostate regrowth,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,52640,Relieve bladder contracture,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,52647,Laser surgery of prostate,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,52648,Laser surgery of prostate,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,52649,Prostate laser enucleation,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,52700,Drainage of prostate abscess,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,53000,Incision of urethra,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,53010,Incision of urethra,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,53020,Incision of urethra,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,53025,Incision of urethra,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,53040,Drainage of urethra abscess,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,53060,Drainage of urethra abscess,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,53080,Drainage of urinary leakage,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Meridian Duals,CPT,53085,Drainage of urinary leakage,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,53200,Biopsy of urethra,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,53210,Removal of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,53215,Removal of urethra,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,53220,Treatment of urethra lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,53230,Removal of urethra lesion,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,53235,Removal of urethra lesion,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,53240,Surgery for urethra pouch,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,53250,Removal of urethra gland,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,53260,Treatment of urethra lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,53265,Treatment of urethra lesion,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,53270,Removal of urethra gland,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,53275,Repair of urethra defect,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,53400,Revise urethra stage 1,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,53405,Revise urethra stage 2,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,53410,Reconstruction of urethra,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,53415,Reconstruction of urethra,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,53420,Reconstruct urethra stage 1,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,53425,Reconstruct urethra stage 2,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,53430,Reconstruction of urethra,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,53431,Reconstruct urethra/bladder,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,53440,Male sling procedure,APC 5377,RVU Per Case,"$11,755.91 ",OP,"4,140.35","11,755.91",,,,,,
Meridian Duals,CPT,53442,Remove/revise male sling,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,53444,Insert tandem cuff,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,314.00","18,684.12",,,,,,
Meridian Duals,CPT,53445,Insert uro/ves nck sphincter,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,140.35","18,684.12",,,,,,
Meridian Duals,CPT,53446,Remove uro sphincter,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,53447,Remove/replace ur sphincter,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,314.00","18,684.12",,,,,,
Meridian Duals,CPT,53448,Remov/replc ur sphinctr comp,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,53449,Repair uro sphincter,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,53450,Revision of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,53460,Revision of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,53500,Urethrlys transvag w/ scope,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,53502,Repair of urethra injury,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,53505,Repair of urethra injury,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,53510,Repair of urethra injury,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,53515,Repair of urethra injury,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,53520,Repair of urethra defect,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,53600,Dilate urethra stricture,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Meridian Duals,CPT,53601,Dilate urethra stricture,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Meridian Duals,CPT,53605,Dilate urethra stricture,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,53620,Dilate urethra stricture,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Meridian Duals,CPT,53621,Dilate urethra stricture,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Meridian Duals,CPT,53660,Dilation of urethra,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,"4,314.00",,,,,,
Meridian Duals,CPT,53661,Dilation of urethra,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Meridian Duals,CPT,53665,Dilation of urethra,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,53850,Prostatic microwave thermotx,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,53852,Prostatic rf thermotx,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,53854,Trurl dstrj prst8 tiss rf wv,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,53855,Insert prost urethral stent,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,53860,Transurethral rf treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,53899,Urology surgery procedure,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Meridian Duals,CPT,54000,Slitting of prepuce,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,54001,Slitting of prepuce,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,54015,Drain penis lesion,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,54050,Destruction penis lesion(s),APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Meridian Duals,CPT,54055,Destruction penis lesion(s),APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,54056,Cryosurgery penis lesion(s),APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,54057,Laser surg penis lesion(s),APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,54060,Excision of penis lesion(s),APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,54065,Destruction penis lesion(s),APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,54100,Biopsy of penis,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,54105,Biopsy of penis,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,54110,Treatment of penis lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,54111,Treat penis lesion graft,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,54112,Treat penis lesion graft,APC 5376,RVU Per Case,"$8,450.70 ",OP,"4,314.00","8,450.70",,,,,,
Meridian Duals,CPT,54115,Treatment of penis lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,54120,Partial removal of penis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,54125,Removal of penis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,54130,Remove penis & nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,54135,Remove penis & nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,54150,Circumcision w/regionl block,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,54160,Circumcision neonate,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Meridian Duals,CPT,54161,Circum 28 days or older,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,54162,Lysis penil circumic lesion,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,54163,Repair of circumcision,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,54164,Frenulotomy of penis,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,54200,Treatment of penis lesion,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Meridian Duals,CPT,54205,Treatment of penis lesion,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,54220,Treatment of penis lesion,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Meridian Duals,CPT,54231,Dynamic cavernosometry,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Meridian Duals,CPT,54235,Penile injection,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Meridian Duals,CPT,54240,Penis study,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"4,314.00",,,,,,
Meridian Duals,CPT,54250,Penis study,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Meridian Duals,CPT,54300,Revision of penis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,54304,Revision of penis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,54308,Reconstruction of urethra,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,54312,Reconstruction of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,54316,Reconstruction of urethra,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,54318,Reconstruction of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,54322,Reconstruction of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,54324,Reconstruction of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,54326,Reconstruction of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,54328,Revise penis/urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,54332,Revise penis/urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,54336,Revise penis/urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,54340,Secondary urethral surgery,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,54344,Secondary urethral surgery,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,54348,Secondary urethral surgery,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,54352,Reconstruct urethra/penis,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,54360,Penis plastic surgery,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,54380,Repair penis,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,54385,Repair penis,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,54390,Repair penis and bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,54400,Insert semi-rigid prosthesis,APC 5377,RVU Per Case,"$11,755.91 ",OP,"4,314.00","11,755.91",,,,,,
Meridian Duals,CPT,54401,Insert self-contd prosthesis,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,314.00","18,684.12",,,,,,
Meridian Duals,CPT,54405,Insert multi-comp penis pros,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,140.35","18,684.12",,,,,,
Meridian Duals,CPT,54406,Remove muti-comp penis pros,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,54408,Repair multi-comp penis pros,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,54410,Remove/replace penis prosth,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,140.35","18,684.12",,,,,,
Meridian Duals,CPT,54411,Remov/replc penis pros comp,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,314.00","18,684.12",,,,,,
Meridian Duals,CPT,54415,Remove self-contd penis pros,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,54416,Remv/repl penis contain pros,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,314.00","18,684.12",,,,,,
Meridian Duals,CPT,54417,Remv/replc penis pros compl,APC 5377,RVU Per Case,"$11,755.91 ",OP,"4,314.00","11,755.91",,,,,,
Meridian Duals,CPT,54420,Revision of penis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,54430,Revision of penis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,54435,Revision of penis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,54437,Repair corporeal tear,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,54438,Replantation of penis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,54440,Repair of penis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,54450,Preputial stretching,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Meridian Duals,CPT,54500,Biopsy of testis,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,54505,Biopsy of testis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,54512,Excise lesion testis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,54520,Removal of testis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,54522,Orchiectomy partial,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,54530,Removal of testis,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Meridian Duals,CPT,54535,Extensive testis surgery,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,54550,Exploration for testis,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Meridian Duals,CPT,54560,Exploration for testis,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,54600,Reduce testis torsion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,54620,Suspension of testis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,54640,Orchiopexy ingun/scrot appr,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Meridian Duals,CPT,54650,Orchiopexy (fowler-stephens),APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Meridian Duals,CPT,54660,Revision of testis,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,54670,Repair testis injury,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,54680,Relocation of testis(es),APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,54690,Laparoscopy orchiectomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,54692,Laparoscopy orchiopexy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,54699,Laparoscope proc testis,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,54700,Drainage of scrotum,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,54800,Biopsy of epididymis,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,54830,Remove epididymis lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,54840,Remove epididymis lesion,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,54860,Removal of epididymis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,54861,Removal of epididymis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,54865,Explore epididymis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,54900,Fusion of spermatic ducts,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,54901,Fusion of spermatic ducts,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,55000,Drainage of hydrocele,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,55040,Removal of hydrocele,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Meridian Duals,CPT,55041,Removal of hydroceles,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Meridian Duals,CPT,55060,Repair of hydrocele,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,55100,Drainage of scrotum abscess,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,55110,Explore scrotum,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,55120,Removal of scrotum lesion,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,55150,Removal of scrotum,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,55175,Revision of scrotum,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,55180,Revision of scrotum,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,55200,Incision of sperm duct,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,55250,Removal of sperm duct(s),APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,55400,Repair of sperm duct,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,55500,Removal of hydrocele,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,55520,Removal of sperm cord lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,55530,Revise spermatic cord veins,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,55535,Revise spermatic cord veins,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Meridian Duals,CPT,55540,Revise hernia & sperm veins,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Meridian Duals,CPT,55550,Laparo ligate spermatic vein,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,55559,Laparo proc spermatic cord,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,55600,Incise sperm duct pouch,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,55605,Incise sperm duct pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,55650,Remove sperm duct pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,55680,Remove sperm pouch lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,55700,Biopsy of prostate,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Meridian Duals,CPT,55705,Biopsy of prostate,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,55706,Prostate saturation sampling,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,55720,Drainage of prostate abscess,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,55725,Drainage of prostate abscess,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,55801,Removal of prostate,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,55810,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,55812,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,55815,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,55821,Removal of prostate,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,55831,Removal of prostate,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,55840,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,55842,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,55845,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,55860,Surgical exposure prostate,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,55862,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,55865,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,55866,Laparo radical prostatectomy,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Meridian Duals,CPT,55870,Electroejaculation,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Meridian Duals,CPT,55873,Cryoablate prostate,APC 5376,RVU Per Case,"$8,450.70 ",OP,"4,314.00","8,450.70",,,,,,
Meridian Duals,CPT,55874,Tprnl plmt biodegrdabl matrl,APC 5375,RVU Per Unit,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,55875,Transperi needle place pros,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,55876,Place rt device/marker pros,APC 5613,RVU Per Unit,"$1,291.62 ",OP,"1,291.62","4,314.00",,,,,,
Meridian Duals,CPT,55880,Abltj mal prst8 tiss hifu,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Meridian Duals,CPT,55899,Genital surgery procedure,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Meridian Duals,CPT,55920,Place needles pelvic for rt,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Meridian Duals,CPT,55970,Sex transformation m to f,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Meridian Duals,CPT,55980,Sex transformation f to m,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Meridian Duals,CPT,56405,I & d of vulva/perineum,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Meridian Duals,CPT,56420,Drainage of gland abscess,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Meridian Duals,CPT,56440,Surgery for vulva lesion,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,56441,Lysis of labial lesion(s),APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,56442,Hymenotomy,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,56501,Destroy vulva lesions sim,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,56515,Destroy vulva lesion/s compl,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Meridian Duals,CPT,56605,Biopsy of vulva/perineum,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Meridian Duals,CPT,56620,Partial removal of vulva,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,56625,Complete removal of vulva,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,56630,Extensive vulva surgery,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Meridian Duals,CPT,56631,Extensive vulva surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,56632,Extensive vulva surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,56633,Extensive vulva surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,56634,Extensive vulva surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,56637,Extensive vulva surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,56640,Extensive vulva surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,56700,Partial removal of hymen,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,56740,Remove vagina gland lesion,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,56800,Repair of vagina,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,56805,Repair clitoris,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,56810,Repair of perineum,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,56820,Exam of vulva w/scope,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Meridian Duals,CPT,56821,Exam/biopsy of vulva w/scope,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Meridian Duals,CPT,57000,Exploration of vagina,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,57010,Drainage of pelvic abscess,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,57020,Drainage of pelvic fluid,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Meridian Duals,CPT,57022,I & d vaginal hematoma pp,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,57023,I & d vag hematoma non-ob,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,57061,Destroy vag lesions simple,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,57065,Destroy vag lesions complex,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,57100,Biopsy of vagina,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Meridian Duals,CPT,57105,Biopsy of vagina,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,57106,Remove vagina wall partial,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,57107,Remove vagina tissue part,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,57109,Vaginectomy partial w/nodes,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,57110,Remove vagina wall complete,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,57111,Remove vagina tissue compl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,57120,Closure of vagina,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Meridian Duals,CPT,57130,Remove vagina lesion,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,57135,Remove vagina lesion,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,57150,Treat vagina infection,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Meridian Duals,CPT,57155,Insert uteri tandem/ovoids,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Meridian Duals,CPT,57156,Ins vag brachytx device,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Meridian Duals,CPT,57160,Insert pessary/other device,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Meridian Duals,CPT,57170,Fitting of diaphragm/cap,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Meridian Duals,CPT,57180,Treat vaginal bleeding,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Meridian Duals,CPT,57200,Repair of vagina,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,57210,Repair vagina/perineum,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,57220,Revision of urethra,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Meridian Duals,CPT,57230,Repair of urethral lesion,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,57240,Anterior colporrhaphy,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Meridian Duals,CPT,57250,Repair rectum & vagina,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Meridian Duals,CPT,57260,Cmbn ant pst colprhy,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Meridian Duals,CPT,57265,Cmbn ap colprhy w/ntrcl rpr,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Meridian Duals,CPT,57268,Repair of bowel bulge,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Meridian Duals,CPT,57270,Repair of bowel pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,57280,Suspension of vagina,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,57282,Colpopexy extraperitoneal,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,57283,Colpopexy intraperitoneal,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,57284,Repair paravag defect open,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Meridian Duals,CPT,57285,Repair paravag defect vag,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,57287,Revise/remove sling repair,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,57288,Repair bladder defect,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,57289,Repair bladder & vagina,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,314.00","6,952.74",,,,,,
Meridian Duals,CPT,57291,Construction of vagina,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Meridian Duals,CPT,57292,Construct vagina with graft,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Meridian Duals,CPT,57295,Revise vag graft via vagina,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,57296,Revise vag graft open abd,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,57300,Repair rectum-vagina fistula,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,57305,Repair rectum-vagina fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,57307,Fistula repair & colostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,57308,Fistula repair transperine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,57310,Repair urethrovaginal lesion,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,314.00","6,952.74",,,,,,
Meridian Duals,CPT,57311,Repair urethrovaginal lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,57320,Repair bladder-vagina lesion,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Meridian Duals,CPT,57330,Repair bladder-vagina lesion,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,314.00","6,952.74",,,,,,
Meridian Duals,CPT,57335,Repair vagina,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Meridian Duals,CPT,57400,Dilation of vagina,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,57410,Pelvic examination,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,57415,Remove vaginal foreign body,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,57420,Exam of vagina w/scope,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Meridian Duals,CPT,57421,Exam/biopsy of vag w/scope,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Meridian Duals,CPT,57423,Repair paravag defect lap,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Meridian Duals,CPT,57425,Laparoscopy surg colpopexy,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,57426,Revise prosth vag graft lap,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,314.00","6,952.74",,,,,,
Meridian Duals,CPT,57452,Exam of cervix w/scope,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Meridian Duals,CPT,57454,Bx/curett of cervix w/scope,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Meridian Duals,CPT,57455,Biopsy of cervix w/scope,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Meridian Duals,CPT,57456,Endocerv curettage w/scope,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Meridian Duals,CPT,57460,Bx of cervix w/scope leep,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,57461,Conz of cervix w/scope leep,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,57500,Biopsy of cervix,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Meridian Duals,CPT,57505,Endocervical curettage,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Meridian Duals,CPT,57510,Cauterization of cervix,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,57511,Cryocautery of cervix,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Meridian Duals,CPT,57513,Laser surgery of cervix,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,57520,Conization of cervix,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,57522,Conization of cervix,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,57530,Removal of cervix,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Meridian Duals,CPT,57531,Removal of cervix radical,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,57540,Removal of residual cervix,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,57545,Remove cervix/repair pelvis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,57550,Removal of residual cervix,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Meridian Duals,CPT,57555,Remove cervix/repair vagina,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Meridian Duals,CPT,57556,Remove cervix repair bowel,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Meridian Duals,CPT,57558,D&c of cervical stump,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,57700,Revision of cervix,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,57720,Revision of cervix,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,57800,Dilation of cervical canal,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,58100,Biopsy of uterus lining,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Meridian Duals,CPT,58120,Dilation and curettage,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,58140,Myomectomy abdom method,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,58145,Myomectomy vag method,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","9,201.00",,,,,,
Meridian Duals,CPT,58146,Myomectomy abdom complex,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,58150,Total hysterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,58152,Total hysterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,58180,Partial hysterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,58200,Extensive hysterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,58210,Extensive hysterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,58240,Removal of pelvis contents,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,58260,Vaginal hysterectomy,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Meridian Duals,CPT,58262,Vag hyst including t/o,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Meridian Duals,CPT,58263,Vag hyst w/t/o & vag repair,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Meridian Duals,CPT,58267,Vag hyst w/urinary repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,58270,Vag hyst w/enterocele repair,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Meridian Duals,CPT,58275,Hysterectomy/revise vagina,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,58280,Hysterectomy/revise vagina,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,58285,Extensive hysterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,58290,Vag hyst complex,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,314.00","6,952.74",,,,,,
Meridian Duals,CPT,58291,Vag hyst incl t/o complex,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Meridian Duals,CPT,58292,Vag hyst t/o & repair compl,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,314.00","6,952.74",,,,,,
Meridian Duals,CPT,58294,Vag hyst w/enterocele compl,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Meridian Duals,CPT,58301,Remove intrauterine device,APC 5412,RVU Per Case,$288.05 ,OP,288.05,"4,314.00",,,,,,
Meridian Duals,CPT,58321,Artificial insemination,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Meridian Duals,CPT,58322,Artificial insemination,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Meridian Duals,CPT,58323,Sperm washing,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Meridian Duals,CPT,58345,Reopen fallopian tube,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,58346,Insert heyman uteri capsule,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Meridian Duals,CPT,58350,Reopen fallopian tube,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Meridian Duals,CPT,58353,Endometr ablate thermal,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Meridian Duals,CPT,58356,Endometrial cryoablation,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Meridian Duals,CPT,58400,Suspension of uterus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,58410,Suspension of uterus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,58520,Repair of ruptured uterus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,58540,Revision of uterus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,58541,Lsh uterus 250 g or less,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,58542,Lsh w/t/o ut 250 g or less,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,58543,Lsh uterus above 250 g,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,58544,Lsh w/t/o uterus above 250 g,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,58545,Laparoscopic myomectomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,58546,Laparo-myomectomy complex,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,58548,Lap radical hyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,58550,Laparo-asst vag hysterectomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,58552,Laparo-vag hyst incl t/o,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,58553,Laparo-vag hyst complex,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,58554,Laparo-vag hyst w/t/o compl,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,58555,Hysteroscopy dx sep proc,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,58558,Hysteroscopy biopsy,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","9,201.00",,,,,,
Meridian Duals,CPT,58559,Hysteroscopy lysis,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,58560,Hysteroscopy resect septum,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,58561,Hysteroscopy remove myoma,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,58562,Hysteroscopy remove fb,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,58563,Hysteroscopy ablation,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Meridian Duals,CPT,58565,Hysteroscopy sterilization,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,58570,Tlh uterus 250 g or less,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,58571,Tlh w/t/o 250 g or less,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,58572,Tlh uterus over 250 g,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,58573,Tlh w/t/o uterus over 250 g,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,58575,Laps tot hyst resj mal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,58578,Laparo proc uterus,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,58579,Hysteroscope procedure,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Meridian Duals,CPT,58600,Division of fallopian tube,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,58605,Division of fallopian tube,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,58611,Ligate oviduct(s) add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,58615,Occlude fallopian tube(s),APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,58660,Laparoscopy lysis,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,58661,Laparoscopy remove adnexa,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,58662,Laparoscopy excise lesions,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,58670,Laparoscopy tubal cautery,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,58671,Laparoscopy tubal block,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,58672,Laparoscopy fimbrioplasty,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,58673,Laparoscopy salpingostomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,58674,Laps abltj uterine fibroids,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,58679,Laparo proc oviduct-ovary,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,58700,Removal of fallopian tube,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,58720,Removal of ovary/tube(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,58740,Adhesiolysis tube ovary,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,58750,Repair oviduct,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,58752,Revise ovarian tube(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,58760,Fimbrioplasty,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,58770,Create new tubal opening,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,58800,Drainage of ovarian cyst(s),APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,58805,Drainage of ovarian cyst(s),APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,58820,Drain ovary abscess open,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,58822,Drain ovary abscess percut,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,58825,Transposition ovary(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,58900,Biopsy of ovary(s),APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,58920,Partial removal of ovary(s),APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,314.00","6,952.74",,,,,,
Meridian Duals,CPT,58925,Removal of ovarian cyst(s),APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Meridian Duals,CPT,58940,Removal of ovary(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,58943,Removal of ovary(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,58950,Resect ovarian malignancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,58951,Resect ovarian malignancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,58952,Resect ovarian malignancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,58953,Tah rad dissect for debulk,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,58954,Tah rad debulk/lymph remove,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,58956,Bso omentectomy w/tah,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,58957,Resect recurrent gyn mal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,58958,Resect recur gyn mal w/lym,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,58960,Exploration of abdomen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,58970,Retrieval of oocyte,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Meridian Duals,CPT,58974,Transfer of embryo,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Meridian Duals,CPT,58976,Transfer of embryo,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Meridian Duals,CPT,58999,Genital surgery procedure,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Meridian Duals,CPT,59000,Amniocentesis diagnostic,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Meridian Duals,CPT,59001,Amniocentesis therapeutic,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Meridian Duals,CPT,59012,Fetal cord puncture prenatal,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Meridian Duals,CPT,59015,Chorion biopsy,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Meridian Duals,CPT,59020,Fetal contract stress test,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Meridian Duals,CPT,59025,Fetal non-stress test,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Meridian Duals,CPT,59030,Fetal scalp blood sample,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Meridian Duals,CPT,59070,Transabdom amnioinfus w/us,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Meridian Duals,CPT,59072,Umbilical cord occlud w/us,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Meridian Duals,CPT,59074,Fetal fluid drainage w/us,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Meridian Duals,CPT,59076,Fetal shunt placement w/us,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Meridian Duals,CPT,59100,Remove uterus lesion,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Meridian Duals,CPT,59120,Treat ectopic pregnancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,59121,Treat ectopic pregnancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,59130,Treat ectopic pregnancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,59135,Treat ectopic pregnancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,59136,Treat ectopic pregnancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,59140,Treat ectopic pregnancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,59150,Treat ectopic pregnancy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,59151,Treat ectopic pregnancy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,59160,D & c after delivery,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,59200,Insert cervical dilator,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Meridian Duals,CPT,59300,Episiotomy or vaginal repair,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,59320,Revision of cervix,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,59325,Revision of cervix,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,59350,Repair of uterus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,59409,Obstetrical care,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,59412,Antepartum manipulation,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,59414,Deliver placenta,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,59514,Cesarean delivery only,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,59525,Remove uterus after cesarean,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,59612,Vbac delivery only,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,59620,Attempted vbac delivery only,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,59812,Treatment of miscarriage,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,59820,Care of miscarriage,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,59821,Treatment of miscarriage,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,59830,Treat uterus infection,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,59840,Abortion,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,59841,Abortion,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,59850,Abortion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,59851,Abortion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,59852,Abortion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,59855,Abortion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,59856,Abortion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,59857,Abortion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,59866,Abortion (mpr),APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Meridian Duals,CPT,59870,Evacuate mole of uterus,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,59871,Remove cerclage suture,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Meridian Duals,CPT,59897,Fetal invas px w/us,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Meridian Duals,CPT,59898,Laparo proc ob care/deliver,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,59899,Maternity care procedure,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Meridian Duals,CPT,60000,Drain thyroid/tongue cyst,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,60100,Biopsy of thyroid,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,60200,Remove thyroid lesion,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,60210,Partial thyroid excision,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,60212,Partial thyroid excision,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,60220,Partial removal of thyroid,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,60225,Partial removal of thyroid,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,60240,Removal of thyroid,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,60252,Removal of thyroid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,60254,Extensive thyroid surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,60260,Repeat thyroid surgery,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,60270,Removal of thyroid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,60271,Removal of thyroid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,60280,Remove thyroid duct lesion,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,60281,Remove thyroid duct lesion,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,60300,Aspir/inj thyroid cyst,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,60500,Explore parathyroid glands,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,60502,Re-explore parathyroids,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,60505,Explore parathyroid glands,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,60520,Removal of thymus gland,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,60521,Removal of thymus gland,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,60522,Removal of thymus gland,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,60540,Explore adrenal gland,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,60545,Explore adrenal gland,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,60600,Remove carotid body lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,60605,Remove carotid body lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,60650,Laparoscopy adrenalectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,60659,Laparo proc endocrine,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,60699,Endocrine surgery procedure,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Meridian Duals,CPT,61000,Remove cranial cavity fluid,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Meridian Duals,CPT,61001,Remove cranial cavity fluid,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Meridian Duals,CPT,61020,Remove brain cavity fluid,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Meridian Duals,CPT,61026,Injection into brain canal,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Meridian Duals,CPT,61050,Remove brain canal fluid,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Meridian Duals,CPT,61055,Injection into brain canal,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Meridian Duals,CPT,61070,Brain canal shunt procedure,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Meridian Duals,CPT,61105,Twist drill hole,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61107,Drill skull for implantation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61108,Drill skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61120,Burr hole for puncture,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61140,Pierce skull for biopsy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61150,Pierce skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61151,Pierce skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61154,Pierce skull & remove clot,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61156,Pierce skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61210,Pierce skull implant device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61215,Insert brain-fluid device,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Meridian Duals,CPT,61250,Pierce skull & explore,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61253,Pierce skull & explore,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61304,Open skull for exploration,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61305,Open skull for exploration,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61312,Open skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61313,Open skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61314,Open skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61315,Open skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61316,Implt cran bone flap to abdo,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61320,Open skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61321,Open skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61322,Decompressive craniotomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61323,Decompressive lobectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61330,Decompress eye socket,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,61333,Explore orbit/remove lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61340,Subtemporal decompression,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61343,Incise skull (press relief),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61345,Relieve cranial pressure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61450,Incise skull for surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61458,Incise skull for brain wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61460,Incise skull for surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61500,Removal of skull lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61501,Remove infected skull bone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61510,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61512,Remove brain lining lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61514,Removal of brain abscess,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61516,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61517,Implt brain chemotx add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61518,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61519,Remove brain lining lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61520,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61521,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61522,Removal of brain abscess,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61524,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61526,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61530,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61531,Implant brain electrodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61533,Implant brain electrodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61534,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61535,Remove brain electrodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61536,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61537,Removal of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61538,Removal of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61539,Removal of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61540,Removal of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61541,Incision of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61543,Removal of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61544,Remove & treat brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61545,Excision of brain tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61546,Removal of pituitary gland,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61548,Removal of pituitary gland,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61550,Release of skull seams,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61552,Release of skull seams,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61556,Incise skull/sutures,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61557,Incise skull/sutures,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61558,Excision of skull/sutures,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61559,Excision of skull/sutures,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61563,Excision of skull tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61564,Excision of skull tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61566,Removal of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61567,Incision of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61570,Remove foreign body brain,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61571,Incise skull for brain wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61575,Skull base/brainstem surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61576,Skull base/brainstem surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61580,Craniofacial approach skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61581,Craniofacial approach skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61582,Craniofacial approach skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61583,Craniofacial approach skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61584,Orbitocranial approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61585,Orbitocranial approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61586,Resect nasopharynx skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61590,Infratemporal approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61591,Infratemporal approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61592,Orbitocranial approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61595,Transtemporal approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61596,Transcochlear approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61597,Transcondylar approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61598,Transpetrosal approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61600,Resect/excise cranial lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61601,Resect/excise cranial lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61605,Resect/excise cranial lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61606,Resect/excise cranial lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61607,Resect/excise cranial lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61608,Resect/excise cranial lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61611,Transect artery sinus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61613,Remove aneurysm sinus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61615,Resect/excise lesion skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61616,Resect/excise lesion skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61618,Repair dura,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61619,Repair dura,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61623,Endovasc tempory vessel occl,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Meridian Duals,CPT,61624,Transcath occlusion cns,APC 5194,RVU Per Case,"$16,438.60 ",OP,"4,314.00","16,438.60",,,,,,
Meridian Duals,CPT,61626,Transcath occlusion non-cns,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Meridian Duals,CPT,61630,Intracranial angioplasty,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61635,Intracran angioplsty w/stent,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61645,Perq art m-thrombect &/nfs,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61650,Evasc prlng admn rx agnt 1st,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61651,Evasc prlng admn rx agnt add,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61680,Intracranial vessel surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61682,Intracranial vessel surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61684,Intracranial vessel surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61686,Intracranial vessel surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61690,Intracranial vessel surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61692,Intracranial vessel surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61697,Brain aneurysm repr complx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61698,Brain aneurysm repr complx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61700,Brain aneurysm repr simple,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61702,Inner skull vessel surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61703,Clamp neck artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61705,Revise circulation to head,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61708,Revise circulation to head,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61710,Revise circulation to head,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61711,Fusion of skull arteries,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61720,Incise skull/brain surgery,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Meridian Duals,CPT,61735,Incise skull/brain surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61750,Incise skull/brain biopsy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61751,Brain biopsy w/ct/mr guide,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61760,Implant brain electrodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61770,Incise skull for treatment,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Meridian Duals,CPT,61790,Treat trigeminal nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,61791,Treat trigeminal tract,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,61850,Implant neuroelectrodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61860,Implant neuroelectrodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61863,Implant neuroelectrode,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61864,Implant neuroelectrde addl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61867,Implant neuroelectrode,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61868,Implant neuroelectrde addl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,61880,Revise/remove neuroelectrode,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","4,314.00",,,,,,
Meridian Duals,CPT,61885,Insrt/redo neurostim 1 array,APC 5464,RVU Per Case,"$20,957.35 ",OP,"4,140.35","20,957.35",,,,,,
Meridian Duals,CPT,61886,Implant neurostim arrays,APC 5465,RVU Per Case,"$30,131.14 ",OP,"4,314.00","30,131.14",,,,,,
Meridian Duals,CPT,61888,Revise/remove neuroreceiver,APC 5463,RVU Per Case,"$11,498.23 ",OP,"4,314.00","11,498.23",,,,,,
Meridian Duals,CPT,62000,Treat skull fracture,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,62005,Treat skull fracture,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,62010,Treatment of head injury,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,62100,Repair brain fluid leakage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,62115,Reduction of skull defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,62117,Reduction of skull defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,62120,Repair skull cavity lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,62121,Incise skull repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,62140,Repair of skull defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,62141,Repair of skull defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,62142,Remove skull plate/flap,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,62143,Replace skull plate/flap,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,62145,Repair of skull & brain,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,62146,Repair of skull with graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,62147,Repair of skull with graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,62148,Retr bone flap to fix skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,62161,Dissect brain w/scope,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,62162,Remove colloid cyst w/scope,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,62164,Remove brain tumor w/scope,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,62165,Remove pituit tumor w/scope,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,62180,Establish brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,62190,Establish brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,62192,Establish brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,62194,Replace/irrigate catheter,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,62200,Establish brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,62201,Brain cavity shunt w/scope,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,62220,Establish brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,62223,Establish brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,62225,Replace/irrigate catheter,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Meridian Duals,CPT,62230,Replace/revise brain shunt,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Meridian Duals,CPT,62252,Csf shunt reprogram,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,"4,314.00",,,,,,
Meridian Duals,CPT,62256,Remove brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,62258,Replace brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,62263,Epidural lysis mult sessions,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Meridian Duals,CPT,62264,Epidural lysis on single day,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Meridian Duals,CPT,62267,Interdiscal perq aspir dx,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,62268,Drain spinal cord cyst,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Meridian Duals,CPT,62269,Needle biopsy spinal cord,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,62270,Dx lmbr spi pnxr,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Meridian Duals,CPT,62272,Ther spi pnxr drg csf,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Meridian Duals,CPT,62273,Inject epidural patch,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Meridian Duals,CPT,62280,Treat spinal cord lesion,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Meridian Duals,CPT,62281,Treat spinal cord lesion,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Meridian Duals,CPT,62282,Treat spinal canal lesion,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Meridian Duals,CPT,62287,Percutaneous diskectomy,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,62292,Njx chemonucleolysis lmbr,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,62294,Injection into spinal artery,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Meridian Duals,CPT,62302,Myelography lumbar injection,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"4,314.00",,,,,,
Meridian Duals,CPT,62303,Myelography lumbar injection,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"4,314.00",,,,,,
Meridian Duals,CPT,62304,Myelography lumbar injection,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"4,314.00",,,,,,
Meridian Duals,CPT,62305,Myelography lumbar injection,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"4,314.00",,,,,,
Meridian Duals,CPT,62320,Njx interlaminar crv/thrc,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Meridian Duals,CPT,62321,Njx interlaminar crv/thrc,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Meridian Duals,CPT,62322,Njx interlaminar lmbr/sac,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Meridian Duals,CPT,62323,Njx interlaminar lmbr/sac,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Meridian Duals,CPT,62324,Njx interlaminar crv/thrc,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Meridian Duals,CPT,62325,Njx interlaminar crv/thrc,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Meridian Duals,CPT,62326,Njx interlaminar lmbr/sac,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Meridian Duals,CPT,62327,Njx interlaminar lmbr/sac,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Meridian Duals,CPT,62328,Dx lmbr spi pnxr w/fluor/ct,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Meridian Duals,CPT,62329,Ther spi pnxr csf fluor/ct,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Meridian Duals,CPT,62350,Implant spinal canal cath,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Meridian Duals,CPT,62351,Implant spinal canal cath,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,62355,Remove spinal canal catheter,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,62360,Insert spine infusion device,APC 5471,RVU Per Case,"$17,429.07 ",OP,"4,314.00","17,429.07",,,,,,
Meridian Duals,CPT,62361,Implant spine infusion pump,APC 5471,RVU Per Case,"$17,429.07 ",OP,"4,314.00","17,429.07",,,,,,
Meridian Duals,CPT,62362,Implant spine infusion pump,APC 5471,RVU Per Case,"$17,429.07 ",OP,"4,140.35","17,429.07",,,,,,
Meridian Duals,CPT,62365,Remove spine infusion device,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Meridian Duals,CPT,62367,Analyze spine infus pump,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,"4,314.00",,,,,,
Meridian Duals,CPT,62368,Analyze sp inf pump w/reprog,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,"4,314.00",,,,,,
Meridian Duals,CPT,62369,Anal sp inf pmp w/reprg&fill,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,"4,314.00",,,,,,
Meridian Duals,CPT,62370,Anl sp inf pmp w/mdreprg&fil,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,"4,314.00",,,,,,
Meridian Duals,CPT,62380,Ndsc dcmprn 1 ntrspc lumbar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,63001,Remove spine lamina 1/2 crvl,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,63003,Remove spine lamina 1/2 thrc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,63005,Remove spine lamina 1/2 lmbr,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,63011,Remove spine lamina 1/2 scrl,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,63012,Remove lamina/facets lumbar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,63015,Remove spine lamina >2 crvcl,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,63016,Remove spine lamina >2 thrc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,63017,Remove spine lamina >2 lmbr,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,63020,Neck spine disk surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,63030,Low back disk surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,63040,Laminotomy single cervical,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,63042,Laminotomy single lumbar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,63045,Remove spine lamina 1 crvl,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,63046,Remove spine lamina 1 thrc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,63047,Remove spine lamina 1 lmbr,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,63050,Cervical laminoplsty 2/> seg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63051,C-laminoplasty w/graft/plate,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63055,Decompress spinal cord thrc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,63056,Decompress spinal cord lmbr,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,63064,Decompress spinal cord thrc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,63075,Neck spine disk surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,63077,Spine disk surgery thorax,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63078,Spine disk surgery thorax,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63081,Remove vert body dcmprn crvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63082,Remove vertebral body add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63085,Remove vert body dcmprn thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63086,Remove vertebral body add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63087,Remov vertbr dcmprn thrclmbr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63088,Remove vertebral body add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63090,Remove vert body dcmprn lmbr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63091,Remove vertebral body add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63101,Remove vert body dcmprn thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63102,Remove vert body dcmprn lmbr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63103,Remove vertebral body add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63170,Incise spinal cord tract(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63172,Drainage of spinal cyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63173,Drainage of spinal cyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63185,Incise spine nrv half segmnt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63190,Incise spine nrv >2 segmnts,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63191,Incise spine accessory nerve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63194,Incise spine & cord cervical,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63195,Incise spine & cord thoracic,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63196,Incise spine&cord 2 trx crvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63197,Incise spine&cord 2 trx thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63198,Incise spin&cord 2 stgs crvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63199,Incise spin&cord 2 stgs thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63200,Release spinal cord lumbar,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63250,Revise spinal cord vsls crvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63251,Revise spinal cord vsls thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63252,Revise spine cord vsl thrlmb,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63265,Excise intraspinl lesion crv,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,63266,Excise intrspinl lesion thrc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,63267,Excise intrspinl lesion lmbr,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,63268,Excise intrspinl lesion scrl,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,63270,Excise intrspinl lesion crvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63271,Excise intrspinl lesion thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63272,Excise intrspinl lesion lmbr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63273,Excise intrspinl lesion scrl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63275,Bx/exc xdrl spine lesn crvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63276,Bx/exc xdrl spine lesn thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63277,Bx/exc xdrl spine lesn lmbr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63278,Bx/exc xdrl spine lesn scrl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63280,Bx/exc idrl spine lesn crvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63281,Bx/exc idrl spine lesn thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63282,Bx/exc idrl spine lesn lmbr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63283,Bx/exc idrl spine lesn scrl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63285,Bx/exc idrl imed lesn cervl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63286,Bx/exc idrl imed lesn thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63287,Bx/exc idrl imed lesn thrlmb,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63290,Bx/exc xdrl/idrl lsn any lvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63295,Repair laminectomy defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63300,Remove vert xdrl body crvcl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63301,Remove vert xdrl body thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63302,Remove vert xdrl body thrlmb,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63303,Remov vert xdrl bdy lmbr/sac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63304,Remove vert idrl body crvcl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63305,Remove vert idrl body thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63306,Remov vert idrl bdy thrclmbr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63307,Remov vert idrl bdy lmbr/sac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63308,Remove vertebral body add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63600,Remove spinal cord lesion,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,63610,Stimulation of spinal cord,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,63650,Implant neuroelectrodes,APC 5462,RVU Per Case,"$6,304.35 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,63655,Implant neuroelectrodes,APC 5464,RVU Per Case,"$20,957.35 ",OP,"4,140.35","20,957.35",,,,,,
Meridian Duals,CPT,63661,Remove spine eltrd perq aray,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,63662,Remove spine eltrd plate,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","4,314.00",,,,,,
Meridian Duals,CPT,63663,Revise spine eltrd perq aray,APC 5462,RVU Per Case,"$6,304.35 ",OP,"4,314.00","6,304.35",,,,,,
Meridian Duals,CPT,63664,Revise spine eltrd plate,APC 5463,RVU Per Case,"$11,498.23 ",OP,"4,314.00","11,498.23",,,,,,
Meridian Duals,CPT,63685,Insrt/redo spine n generator,APC 5465,RVU Per Case,"$30,131.14 ",OP,"4,140.35","30,131.14",,,,,,
Meridian Duals,CPT,63688,Revise/remove neuroreceiver,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","4,314.00",,,,,,
Meridian Duals,CPT,63700,Repair of spinal herniation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63702,Repair of spinal herniation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63704,Repair of spinal herniation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63706,Repair of spinal herniation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63707,Repair spinal fluid leakage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63709,Repair spinal fluid leakage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63710,Graft repair of spine defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63740,Install spinal shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,63741,Install spinal shunt,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Meridian Duals,CPT,63744,Revision of spinal shunt,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Meridian Duals,CPT,63746,Removal of spinal shunt,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,64400,Njx aa&/strd trigeminal nrv,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Meridian Duals,CPT,64405,Njx aa&/strd gr ocpl nrv,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Meridian Duals,CPT,64408,Njx aa&/strd vagus nrv,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Meridian Duals,CPT,64415,Njx aa&/strd brach plexus,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Meridian Duals,CPT,64416,Njx aa&/strd brach plex nfs,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Meridian Duals,CPT,64417,Njx aa&/strd axillary nrv,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Meridian Duals,CPT,64418,Njx aa&/strd sprscap nrv,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Meridian Duals,CPT,64420,Njx aa&/strd ntrcost nrv 1,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Meridian Duals,CPT,64421,Njx aa&/strd ntrcost nrv ea,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Meridian Duals,CPT,64425,Njx aa&/strd ii ih nerves,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Meridian Duals,CPT,64430,Njx aa&/strd pudendal nerve,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Meridian Duals,CPT,64435,Njx aa&/strd paracrv nrv,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Meridian Duals,CPT,64445,Njx aa&/strd sciatic nerve,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Meridian Duals,CPT,64446,Njx aa&/strd sciatic nrv nfs,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Meridian Duals,CPT,64447,Njx aa&/strd femoral nerve,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Meridian Duals,CPT,64448,Njx aa&/strd fem nerve nfs,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Meridian Duals,CPT,64449,Njx aa&/strd lmbr plex nfs,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Meridian Duals,CPT,64450,Njx aa&/strd other pn/branch,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Meridian Duals,CPT,64451,Njx aa&/strd nrv nrvtg si jt,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Meridian Duals,CPT,64454,Njx aa&/strd gnclr nrv brnch,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Meridian Duals,CPT,64455,Njx aa&/strd pltr com dg nrv,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Meridian Duals,CPT,64461,Pvb thoracic single inj site,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Meridian Duals,CPT,64463,Pvb thoracic cont infusion,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Meridian Duals,CPT,64479,Njx aa&/strd tfrm epi c/t 1,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Meridian Duals,CPT,64483,Njx aa&/strd tfrm epi l/s 1,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Meridian Duals,CPT,64490,Inj paravert f jnt c/t 1 lev,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Meridian Duals,CPT,64493,Inj paravert f jnt l/s 1 lev,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Meridian Duals,CPT,64505,N block spenopalatine gangl,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Meridian Duals,CPT,64510,N block stellate ganglion,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Meridian Duals,CPT,64517,N block inj hypogas plxs,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Meridian Duals,CPT,64520,N block lumbar/thoracic,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Meridian Duals,CPT,64530,N block inj celiac pelus,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Meridian Duals,CPT,64553,Implant neuroelectrodes,APC 5463,RVU Per Case,"$11,498.23 ",OP,"4,314.00","11,498.23",,,,,,
Meridian Duals,CPT,64555,Implant neuroelectrodes,APC 5462,RVU Per Case,"$6,304.35 ",OP,"4,314.00","6,304.35",,,,,,
Meridian Duals,CPT,64561,Implant neuroelectrodes,APC 5462,RVU Per Case,"$6,304.35 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,64566,Neuroeltrd stim post tibial,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Meridian Duals,CPT,64568,Inc for vagus n elect impl,APC 5465,RVU Per Case,"$30,131.14 ",OP,"4,140.35","30,131.14",,,,,,
Meridian Duals,CPT,64569,Revise/repl vagus n eltrd,APC 5463,RVU Per Case,"$11,498.23 ",OP,"4,314.00","11,498.23",,,,,,
Meridian Duals,CPT,64570,Remove vagus n eltrd,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Meridian Duals,CPT,64575,Implant neuroelectrodes,APC 5463,RVU Per Case,"$11,498.23 ",OP,"4,314.00","11,498.23",,,,,,
Meridian Duals,CPT,64580,Implant neuroelectrodes,APC 5464,RVU Per Case,"$20,957.35 ",OP,"4,314.00","20,957.35",,,,,,
Meridian Duals,CPT,64581,Implant neuroelectrodes,APC 5462,RVU Per Case,"$6,304.35 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,64585,Revise/remove neuroelectrode,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","4,314.00",,,,,,
Meridian Duals,CPT,64590,Insrt/redo pn/gastr stimul,APC 5464,RVU Per Case,"$20,957.35 ",OP,"4,140.35","20,957.35",,,,,,
Meridian Duals,CPT,64595,Revise/rmv pn/gastr stimul,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","4,314.00",,,,,,
Meridian Duals,CPT,64600,Injection treatment of nerve,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Meridian Duals,CPT,64605,Injection treatment of nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,64610,Injection treatment of nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,64611,Chemodenerv saliv glands,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Meridian Duals,CPT,64612,Destroy nerve face muscle,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Meridian Duals,CPT,64615,Chemodenerv musc migraine,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Meridian Duals,CPT,64616,Chemodenerv musc neck dyston,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Meridian Duals,CPT,64617,Chemodener muscle larynx emg,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Meridian Duals,CPT,64620,Injection treatment of nerve,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Meridian Duals,CPT,64624,Dstrj nulyt agt gnclr nrv,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,64625,Rf abltj nrv nrvtg si jt,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,64630,Injection treatment of nerve,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Meridian Duals,CPT,64632,N block inj common digit,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Meridian Duals,CPT,64633,Destroy cerv/thor facet jnt,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,64635,Destroy lumb/sac facet jnt,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,64640,Injection treatment of nerve,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Meridian Duals,CPT,64642,Chemodenerv 1 extremity 1-4,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Meridian Duals,CPT,64644,Chemodenerv 1 extrem 5/> mus,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Meridian Duals,CPT,64646,Chemodenerv trunk musc 1-5,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Meridian Duals,CPT,64647,Chemodenerv trunk musc 6/>,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Meridian Duals,CPT,64650,Chemodenerv eccrine glands,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Meridian Duals,CPT,64653,Chemodenerv eccrine glands,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Meridian Duals,CPT,64680,Injection treatment of nerve,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Meridian Duals,CPT,64681,Injection treatment of nerve,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Meridian Duals,CPT,64702,Revise finger/toe nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,64704,Revise hand/foot nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,64708,Revise arm/leg nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,64712,Revision of sciatic nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,64713,Revision of arm nerve(s),APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,64714,Revise low back nerve(s),APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,64716,Revision of cranial nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,64718,Revise ulnar nerve at elbow,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,64719,Revise ulnar nerve at wrist,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,64721,Carpal tunnel surgery,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,64722,Relieve pressure on nerve(s),APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,64726,Release foot/toe nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,64732,Incision of brow nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,64734,Incision of cheek nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,64736,Incision of chin nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,64738,Incision of jaw nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,64740,Incision of tongue nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,64742,Incision of facial nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,64744,Incise nerve back of head,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,64746,Incise diaphragm nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,64755,Incision of stomach nerves,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,64760,Incision of vagus nerve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,64763,Incise hip/thigh nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,64766,Incise hip/thigh nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,64771,Sever cranial nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,64772,Incision of spinal nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,64774,Remove skin nerve lesion,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,64776,Remove digit nerve lesion,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,64782,Remove limb nerve lesion,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,64784,Remove nerve lesion,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,64786,Remove sciatic nerve lesion,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Meridian Duals,CPT,64788,Remove skin nerve lesion,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,64790,Removal of nerve lesion,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,64792,Removal of nerve lesion,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Meridian Duals,CPT,64795,Biopsy of nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,64802,Sympathectomy cervical,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,64804,Remove sympathetic nerves,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,64809,Remove sympathetic nerves,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,64818,Remove sympathetic nerves,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,64820,Sympathectomy digital artery,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,64821,Remove sympathetic nerves,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,64822,Remove sympathetic nerves,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,64823,Sympathectomy supfc palmar,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Meridian Duals,CPT,64831,Repair of digit nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,64834,Repair of hand or foot nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Meridian Duals,CPT,64835,Repair of hand or foot nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Meridian Duals,CPT,64836,Repair of hand or foot nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Meridian Duals,CPT,64840,Repair of leg nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Meridian Duals,CPT,64856,Repair/transpose nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Meridian Duals,CPT,64857,Repair arm/leg nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Meridian Duals,CPT,64858,Repair sciatic nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,64861,Repair of arm nerves,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Meridian Duals,CPT,64862,Repair of low back nerves,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Meridian Duals,CPT,64864,Repair of facial nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Meridian Duals,CPT,64865,Repair of facial nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Meridian Duals,CPT,64866,Fusion of facial/other nerve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,64868,Fusion of facial/other nerve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,64885,Nerve graft head/neck </4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Meridian Duals,CPT,64886,Nerve graft head/neck >4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Meridian Duals,CPT,64890,Nerve graft hand/foot </4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Meridian Duals,CPT,64891,Nerve graft hand/foot >4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Meridian Duals,CPT,64892,Nerve graft arm/leg <4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Meridian Duals,CPT,64893,Nerve graft arm/leg >4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Meridian Duals,CPT,64895,Nerve graft hand/foot </4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Meridian Duals,CPT,64896,Nerve graft hand/foot >4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Meridian Duals,CPT,64897,Nerve graft arm/leg </4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Meridian Duals,CPT,64898,Nerve graft arm/leg >4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Meridian Duals,CPT,64905,Nerve pedicle transfer,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Meridian Duals,CPT,64907,Nerve pedicle transfer,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Meridian Duals,CPT,64910,Nerve repair w/allograft,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Meridian Duals,CPT,64911,Neurorraphy w/vein autograft,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Meridian Duals,CPT,64912,Nrv rpr w/nrv algrft 1st,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Meridian Duals,CPT,64999,Nervous system surgery,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Meridian Duals,CPT,65091,Revise eye,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,65093,Revise eye with implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,65101,Removal of eye,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,65103,Remove eye/insert implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,65105,Remove eye/attach implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,65110,Removal of eye,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,65112,Remove eye/revise socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,65114,Remove eye/revise socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,65125,Revise ocular implant,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,65130,Insert ocular implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,65135,Insert ocular implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,65140,Attach ocular implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,65150,Revise ocular implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,65155,Reinsert ocular implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,65175,Removal of ocular implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,65205,Remove foreign body from eye,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Meridian Duals,CPT,65210,Remove foreign body from eye,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Meridian Duals,CPT,65220,Remove foreign body from eye,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Meridian Duals,CPT,65222,Remove foreign body from eye,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Meridian Duals,CPT,65235,Remove foreign body from eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,65260,Remove foreign body from eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,65265,Remove foreign body from eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,65270,Repair of eye wound,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,65272,Repair of eye wound,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,65273,Repair of eye wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,65275,Repair of eye wound,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,65280,Repair of eye wound,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Meridian Duals,CPT,65285,Repair of eye wound,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Meridian Duals,CPT,65286,Repair of eye wound,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,65290,Repair of eye socket wound,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,65400,Removal of eye lesion,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Meridian Duals,CPT,65410,Biopsy of cornea,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,65420,Removal of eye lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,65426,Removal of eye lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,65430,Corneal smear,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Meridian Duals,CPT,65435,Curette/treat cornea,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Meridian Duals,CPT,65436,Curette/treat cornea,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,65450,Treatment of corneal lesion,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Meridian Duals,CPT,65600,Revision of cornea,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,65710,Corneal transplant,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Meridian Duals,CPT,65730,Corneal transplant,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","9,201.00",,,,,,
Meridian Duals,CPT,65750,Corneal transplant,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Meridian Duals,CPT,65755,Corneal transplant,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Meridian Duals,CPT,65756,Corneal trnspl endothelial,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","9,201.00",,,,,,
Meridian Duals,CPT,65770,Revise cornea with implant,APC 5493,RVU Per Case,"$7,506.93 ",OP,"4,314.00","7,506.93",,,,,,
Meridian Duals,CPT,65772,Correction of astigmatism,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Meridian Duals,CPT,65775,Correction of astigmatism,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,65778,Cover eye w/membrane,APC 5502,RVU Per Case,$828.42 ,OP,828.42,"4,314.00",,,,,,
Meridian Duals,CPT,65779,Cover eye w/membrane suture,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,65780,Ocular reconst transplant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,65781,Ocular reconst transplant,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Meridian Duals,CPT,65782,Ocular reconst transplant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,65785,Impltj ntrstrml crnl rng seg,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Meridian Duals,CPT,65800,Drainage of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,65810,Drainage of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,65815,Drainage of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,65820,Relieve inner eye pressure,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Meridian Duals,CPT,65850,Incision of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,65855,Trabeculoplasty laser surg,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Meridian Duals,CPT,65860,Incise inner eye adhesions,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Meridian Duals,CPT,65865,Incise inner eye adhesions,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,65870,Incise inner eye adhesions,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,65875,Incise inner eye adhesions,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,65880,Incise inner eye adhesions,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Meridian Duals,CPT,65900,Remove eye lesion,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,65920,Remove implant of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,65930,Remove blood clot from eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,66020,Injection treatment of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,66030,Injection treatment of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,66130,Remove eye lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,66150,Glaucoma surgery,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Meridian Duals,CPT,66155,Glaucoma surgery,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Meridian Duals,CPT,66160,Glaucoma surgery,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,66170,Glaucoma surgery,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,66172,Incision of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,66174,Translum dil eye canal,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Meridian Duals,CPT,66175,Trnslum dil eye canal w/stnt,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Meridian Duals,CPT,66179,Aqueous shunt eye w/o graft,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Meridian Duals,CPT,66180,Aqueous shunt eye w/graft,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","9,201.00",,,,,,
Meridian Duals,CPT,66183,Insert ant drainage device,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Meridian Duals,CPT,66184,Revision of aqueous shunt,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,66185,Revise aqueous shunt eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,66225,Repair/graft eye lesion,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Meridian Duals,CPT,66250,Follow-up surgery of eye,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,66500,Incision of iris,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,66505,Incision of iris,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,66600,Remove iris and lesion,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Meridian Duals,CPT,66605,Removal of iris,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,66625,Removal of iris,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,66630,Removal of iris,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,66635,Removal of iris,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,66680,Repair iris & ciliary body,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,66682,Repair iris & ciliary body,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,66700,Destruction ciliary body,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,66710,Ciliary transsleral therapy,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,66711,Ecp ciliary body destruction,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,66720,Destruction ciliary body,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,66740,Destruction ciliary body,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,66761,Revision of iris,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Meridian Duals,CPT,66762,Revision of iris,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Meridian Duals,CPT,66770,Removal of inner eye lesion,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Meridian Duals,CPT,66820,Incision secondary cataract,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,66821,After cataract laser surgery,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Meridian Duals,CPT,66825,Reposition intraocular lens,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,66830,Removal of lens lesion,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,66840,Removal of lens material,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,66850,Removal of lens material,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,66852,Removal of lens material,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Meridian Duals,CPT,66920,Extraction of lens,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,66930,Extraction of lens,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Meridian Duals,CPT,66940,Extraction of lens,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,66982,Xcapsl ctrc rmvl cplx wo ecp,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,66983,Cataract surg w/iol 1 stage,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,66984,Xcapsl ctrc rmvl w/o ecp,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,66985,Insert lens prosthesis,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,66986,Exchange lens prosthesis,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,66987,Xcapsl ctrc rmvl cplx w/ecp,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Meridian Duals,CPT,66988,Xcapsl ctrc rmvl w/ecp,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Meridian Duals,CPT,66999,Eye surgery procedure,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,67005,Partial removal of eye fluid,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,67010,Partial removal of eye fluid,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,67015,Release of eye fluid,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,67025,Replace eye fluid,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,67027,Implant eye drug system,APC 5494,RVU Per Case,"$15,359.39 ",OP,"4,314.00","15,359.39",,,,,,
Meridian Duals,CPT,67028,Injection eye drug,APC 5694,RVU Per Unit,$318.00 ,OP,318,"4,314.00",,,,,,
Meridian Duals,CPT,67030,Incise inner eye strands,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,67031,Laser surgery eye strands,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Meridian Duals,CPT,67036,Removal of inner eye fluid,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Meridian Duals,CPT,67039,Laser treatment of retina,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Meridian Duals,CPT,67040,Laser treatment of retina,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Meridian Duals,CPT,67041,Vit for macular pucker,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Meridian Duals,CPT,67042,Vit for macular hole,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Meridian Duals,CPT,67043,Vit for membrane dissect,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Meridian Duals,CPT,67101,Repair detached retina crtx,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,67105,Repair detached retina pc,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Meridian Duals,CPT,67107,Repair detached retina,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Meridian Duals,CPT,67108,Repair detached retina,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","9,201.00",,,,,,
Meridian Duals,CPT,67110,Repair detached retina,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,67113,Repair retinal detach cplx,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","9,201.00",,,,,,
Meridian Duals,CPT,67115,Release encircling material,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Meridian Duals,CPT,67120,Remove eye implant material,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,67121,Remove eye implant material,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,67141,Treatment of retina,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Meridian Duals,CPT,67145,Treatment of retina,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Meridian Duals,CPT,67208,Treatment of retinal lesion,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Meridian Duals,CPT,67210,Treatment of retinal lesion,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Meridian Duals,CPT,67218,Treatment of retinal lesion,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,67220,Treatment of choroid lesion,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Meridian Duals,CPT,67221,Ocular photodynamic ther,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Meridian Duals,CPT,67227,Dstrj extensive retinopathy,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,67228,Treatment x10sv retinopathy,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Meridian Duals,CPT,67229,Tr retinal les preterm inf,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Meridian Duals,CPT,67250,Reinforce eye wall,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,67255,Reinforce/graft eye wall,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,67299,Eye surgery procedure,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,67311,Revise eye muscle,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,67312,Revise two eye muscles,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,67314,Revise eye muscle,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,67316,Revise two eye muscles,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,67318,Revise eye muscle(s),APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,67343,Release eye tissue,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,67345,Destroy nerve of eye muscle,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Meridian Duals,CPT,67346,Biopsy eye muscle,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,67399,Unlisted px extraocular musc,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Meridian Duals,CPT,67400,Explore/biopsy eye socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,67405,Explore/drain eye socket,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,67412,Explore/treat eye socket,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,67413,Explore/treat eye socket,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,67414,Explr/decompress eye socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,67415,Aspiration orbital contents,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,67420,Explore/treat eye socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,67430,Explore/treat eye socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,67440,Explore/drain eye socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,67445,Explr/decompress eye socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,67450,Explore/biopsy eye socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,67500,Inject/treat eye socket,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Meridian Duals,CPT,67505,Inject/treat eye socket,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Meridian Duals,CPT,67515,Inject/treat eye socket,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Meridian Duals,CPT,67550,Insert eye socket implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,67560,Revise eye socket implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,67570,Decompress optic nerve,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,67599,Orbit surgery procedure,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Meridian Duals,CPT,67700,Drainage of eyelid abscess,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Meridian Duals,CPT,67710,Incision of eyelid,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Meridian Duals,CPT,67715,Incision of eyelid fold,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,67800,Remove eyelid lesion,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Meridian Duals,CPT,67801,Remove eyelid lesions,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Meridian Duals,CPT,67805,Remove eyelid lesions,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Meridian Duals,CPT,67808,Remove eyelid lesion(s),APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,67810,Biopsy eyelid & lid margin,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Meridian Duals,CPT,67820,Revise eyelashes,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Meridian Duals,CPT,67825,Revise eyelashes,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Meridian Duals,CPT,67830,Revise eyelashes,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Meridian Duals,CPT,67835,Revise eyelashes,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,67840,Remove eyelid lesion,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Meridian Duals,CPT,67850,Treat eyelid lesion,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Meridian Duals,CPT,67875,Closure of eyelid by suture,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Meridian Duals,CPT,67880,Revision of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,67882,Revision of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,67900,Repair brow defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,67901,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,67902,Repair eyelid defect,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,67903,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,67904,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,67906,Repair eyelid defect,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,67908,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,67909,Revise eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,67911,Revise eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,67912,Correction eyelid w/implant,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,67914,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,67915,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,67916,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,67917,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,67921,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,67922,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,67923,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,67924,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,67930,Repair eyelid wound,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,67935,Repair eyelid wound,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,67938,Remove eyelid foreign body,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Meridian Duals,CPT,67950,Revision of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,67961,Revision of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,67966,Revision of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,67971,Reconstruction of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,67973,Reconstruction of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,67974,Reconstruction of eyelid,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,67975,Reconstruction of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,67999,Revision of eyelid,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Meridian Duals,CPT,68020,Incise/drain eyelid lining,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Meridian Duals,CPT,68040,Treatment of eyelid lesions,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Meridian Duals,CPT,68100,Biopsy of eyelid lining,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,68110,Remove eyelid lining lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,68115,Remove eyelid lining lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,68130,Remove eyelid lining lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,68135,Remove eyelid lining lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,68200,Treat eyelid by injection,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Meridian Duals,CPT,68320,Revise/graft eyelid lining,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,68325,Revise/graft eyelid lining,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,68326,Revise/graft eyelid lining,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,68328,Revise/graft eyelid lining,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,68330,Revise eyelid lining,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Meridian Duals,CPT,68335,Revise/graft eyelid lining,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,68340,Separate eyelid adhesions,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,68360,Revise eyelid lining,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,68362,Revise eyelid lining,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,68371,Harvest eye tissue alograft,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,68399,Eyelid lining surgery,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Meridian Duals,CPT,68400,Incise/drain tear gland,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Meridian Duals,CPT,68420,Incise/drain tear sac,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,68440,Incise tear duct opening,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Meridian Duals,CPT,68500,Removal of tear gland,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,68505,Partial removal tear gland,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,68510,Biopsy of tear gland,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,68520,Removal of tear sac,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,68525,Biopsy of tear sac,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,68530,Clearance of tear duct,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Meridian Duals,CPT,68540,Remove tear gland lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,68550,Remove tear gland lesion,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,68700,Repair tear ducts,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,68705,Revise tear duct opening,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Meridian Duals,CPT,68720,Create tear sac drain,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,68745,Create tear duct drain,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,68750,Create tear duct drain,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Meridian Duals,CPT,68760,Close tear duct opening,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Meridian Duals,CPT,68761,Close tear duct opening,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Meridian Duals,CPT,68770,Close tear system fistula,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,68801,Dilate tear duct opening,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Meridian Duals,CPT,68810,Probe nasolacrimal duct,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Meridian Duals,CPT,68811,Probe nasolacrimal duct,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,68815,Probe nasolacrimal duct,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,68816,Probe nl duct w/balloon,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Meridian Duals,CPT,68840,Explore/irrigate tear ducts,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Meridian Duals,CPT,68899,Tear duct system surgery,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Meridian Duals,CPT,69000,Drain external ear lesion,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,69005,Drain external ear lesion,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,69020,Drain outer ear canal lesion,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Meridian Duals,CPT,69100,Biopsy of external ear,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Meridian Duals,CPT,69105,Biopsy of external ear canal,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,69110,Remove external ear partial,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,69120,Removal of external ear,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,69140,Remove ear canal lesion(s),APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,69145,Remove ear canal lesion(s),APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Meridian Duals,CPT,69150,Extensive ear canal surgery,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,69155,Extensive ear/neck surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,69200,Clear outer ear canal,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Meridian Duals,CPT,69205,Clear outer ear canal,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Meridian Duals,CPT,69209,Remove impacted ear wax uni,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Meridian Duals,CPT,69210,Remove impacted ear wax uni,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Meridian Duals,CPT,69220,Clean out mastoid cavity,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Meridian Duals,CPT,69222,Clean out mastoid cavity,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Meridian Duals,CPT,69300,Revise external ear,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,69310,Rebuild outer ear canal,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,69320,Rebuild outer ear canal,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,69399,Outer ear surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Meridian Duals,CPT,69420,Incision of eardrum,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Meridian Duals,CPT,69421,Incision of eardrum,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,69424,Remove ventilating tube,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,69433,Create eardrum opening,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Meridian Duals,CPT,69436,Create eardrum opening,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,69440,Exploration of middle ear,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,69450,Eardrum revision,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,69501,Mastoidectomy,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,69502,Mastoidectomy,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,69505,Remove mastoid structures,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,69511,Extensive mastoid surgery,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,69530,Extensive mastoid surgery,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,69535,Remove part of temporal bone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,69540,Remove ear lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,69550,Remove ear lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,69552,Remove ear lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,69554,Remove ear lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,69601,Mastoid surgery revision,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,69602,Mastoid surgery revision,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,69603,Mastoid surgery revision,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,69604,Mastoid surgery revision,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,69610,Repair of eardrum,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,69620,Repair of eardrum,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,69631,Repair eardrum structures,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,69632,Rebuild eardrum structures,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,69633,Rebuild eardrum structures,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,69635,Repair eardrum structures,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,69636,Rebuild eardrum structures,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,69637,Rebuild eardrum structures,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,69641,Revise middle ear & mastoid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,69642,Revise middle ear & mastoid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,69643,Revise middle ear & mastoid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,69644,Revise middle ear & mastoid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,69645,Revise middle ear & mastoid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,69646,Revise middle ear & mastoid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,69650,Release middle ear bone,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,69660,Revise middle ear bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,69661,Revise middle ear bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,69662,Revise middle ear bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,69666,Repair middle ear structures,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,69667,Repair middle ear structures,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,69670,Remove mastoid air cells,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,69676,Remove middle ear nerve,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,69700,Close mastoid fistula,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,69705,Nps surg dilat eust tube uni,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,69706,Nps surg dilat eust tube bi,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,69711,Remove/repair hearing aid,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,69714,Implant temple bone w/stimul,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,69715,Temple bne implnt w/stimulat,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Meridian Duals,CPT,69717,Temple bone implant revision,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Meridian Duals,CPT,69718,Revise temple bone implant,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Meridian Duals,CPT,69720,Release facial nerve,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,69725,Release facial nerve,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,69740,Repair facial nerve,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,69745,Repair facial nerve,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,69799,Middle ear surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Meridian Duals,CPT,69801,Incise inner ear,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Meridian Duals,CPT,69805,Explore inner ear,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,69806,Explore inner ear,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,69905,Remove inner ear,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,69910,Remove inner ear & mastoid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,69915,Incise inner ear nerve,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Meridian Duals,CPT,69930,Implant cochlear device,APC 5166,RVU Per Case,"$35,230.37 ",OP,"4,140.35","35,230.37",,,,,,
Meridian Duals,CPT,69949,Inner ear surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Meridian Duals,CPT,69950,Incise inner ear nerve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Meridian Duals,CPT,69955,Release facial nerve,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,69960,Release inner ear canal,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,69970,Remove inner ear lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Meridian Duals,CPT,69979,Temporal bone surgery,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Meridian Duals,CPT,70010,Contrast x-ray of brain,APC 5572,RVU Per Case,$376.70 ,OP,376.7,899.79,,,,,,
Meridian Duals,CPT,70015,Contrast x-ray of brain,APC 5573,RVU Per Case,$731.85 ,OP,731.85,735.85,,,,,,
Meridian Duals,CPT,70030,X-ray eye for foreign body,APC 5521,RVU Per Case,$82.79 ,OP,82.79,144.88,,,,,,
Meridian Duals,CPT,70100,X-ray exam of jaw <4views,APC 5521,RVU Per Case,$82.79 ,OP,82.79,156.32,,,,,,
Meridian Duals,CPT,70110,X-ray exam of jaw 4/> views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,202.07,,,,,,
Meridian Duals,CPT,70120,X-ray exam of mastoids,APC 5522,RVU Per Case,$111.51 ,OP,111.51,171.58,,,,,,
Meridian Duals,CPT,70130,X-ray exam of mastoids,APC 5522,RVU Per Case,$111.51 ,OP,111.51,282.14,,,,,,
Meridian Duals,CPT,70134,X-ray exam of middle ear,APC 5524,RVU Per Case,$494.15 ,OP,244.01,494.15,,,,,,
Meridian Duals,CPT,70140,X-ray exam of facial bones,APC 5521,RVU Per Case,$82.79 ,OP,82.79,156.32,,,,,,
Meridian Duals,CPT,70150,X-ray exam of facial bones,APC 5522,RVU Per Case,$111.51 ,OP,111.51,221.14,,,,,,
Meridian Duals,CPT,70160,X-ray exam of nasal bones,APC 5521,RVU Per Case,$82.79 ,OP,82.79,163.95,,,,,,
Meridian Duals,CPT,70170,X-ray exam of tear duct,APC 5523,RVU Per Case,$235.49 ,OP,235.49,274.51,,,,,,
Meridian Duals,CPT,70190,X-ray exam of eye sockets,APC 5521,RVU Per Case,$82.79 ,OP,82.79,183.02,,,,,,
Meridian Duals,CPT,70200,X-ray exam of eye sockets,APC 5522,RVU Per Case,$111.51 ,OP,111.51,228.77,,,,,,
Meridian Duals,CPT,70210,X-ray exam of sinuses,APC 5521,RVU Per Case,$82.79 ,OP,82.79,156.32,,,,,,
Meridian Duals,CPT,70220,X-ray exam of sinuses,APC 5521,RVU Per Case,$82.79 ,OP,82.79,202.07,,,,,,
Meridian Duals,CPT,70240,X-ray exam pituitary saddle,APC 5521,RVU Per Case,$82.79 ,OP,82.79,148.69,,,,,,
Meridian Duals,CPT,70250,X-ray exam of skull,APC 5522,RVU Per Case,$111.51 ,OP,111.51,186.82,,,,,,
Meridian Duals,CPT,70260,X-ray exam of skull,APC 5522,RVU Per Case,$111.51 ,OP,111.51,251.64,,,,,,
Meridian Duals,CPT,70300,X-ray exam of teeth,APC 5521,RVU Per Case,$82.79 ,OP,76.26,82.79,,,,,,
Meridian Duals,CPT,70310,X-ray exam of teeth,APC 5523,RVU Per Case,$235.49 ,OP,235.49,235.49,,,,,,
Meridian Duals,CPT,70320,Full mouth x-ray of teeth,APC 5523,RVU Per Case,$235.49 ,OP,235.49,247.83,,,,,,
Meridian Duals,CPT,70328,X-ray exam of jaw joint,APC 5521,RVU Per Case,$82.79 ,OP,82.79,152.51,,,,,,
Meridian Duals,CPT,70330,X-ray exam of jaw joints,APC 5521,RVU Per Case,$82.79 ,OP,82.79,244.01,,,,,,
Meridian Duals,CPT,70332,X-ray exam of jaw joint,APC 5523,RVU Per Case,$235.49 ,OP,235.49,446.08,,,,,,
Meridian Duals,CPT,70336,Magnetic image jaw joint,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Meridian Duals,CPT,70350,X-ray head for orthodontia,APC 5521,RVU Per Case,$82.79 ,OP,82.79,106.76,,,,,,
Meridian Duals,CPT,70355,Panoramic x-ray of jaws,APC 5521,RVU Per Case,$82.79 ,OP,82.79,122,,,,,,
Meridian Duals,CPT,70360,X-ray exam of neck,APC 5521,RVU Per Case,$82.79 ,OP,82.79,137.25,,,,,,
Meridian Duals,CPT,70370,Throat x-ray & fluoroscopy,APC 5521,RVU Per Case,$82.79 ,OP,82.79,381.27,,,,,,
Meridian Duals,CPT,70371,Speech evaluation complex,APC 5523,RVU Per Case,$235.49 ,OP,235.49,510.9,,,,,,
Meridian Duals,CPT,70380,X-ray exam of salivary gland,APC 5521,RVU Per Case,$82.79 ,OP,82.79,190.64,,,,,,
Meridian Duals,CPT,70390,X-ray exam of salivary duct,APC 5523,RVU Per Case,$235.49 ,OP,235.49,235.49,,,,,,
Meridian Duals,CPT,70450,Ct head/brain w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Meridian Duals,CPT,70460,Ct head/brain w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Meridian Duals,CPT,70470,Ct head/brain w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Meridian Duals,CPT,70480,Ct orbit/ear/fossa w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Meridian Duals,CPT,70481,Ct orbit/ear/fossa w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Meridian Duals,CPT,70482,Ct orbit/ear/fossa w/o&w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Meridian Duals,CPT,70486,Ct maxillofacial w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Meridian Duals,CPT,70487,Ct maxillofacial w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Meridian Duals,CPT,70488,Ct maxillofacial w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Meridian Duals,CPT,70490,Ct soft tissue neck w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Meridian Duals,CPT,70491,Ct soft tissue neck w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Meridian Duals,CPT,70492,Ct sft tsue nck w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Meridian Duals,CPT,70496,Ct angiography head,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Meridian Duals,CPT,70498,Ct angiography neck,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Meridian Duals,CPT,70540,Mri orbit/face/neck w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Meridian Duals,CPT,70542,Mri orbit/face/neck w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Meridian Duals,CPT,70543,Mri orbt/fac/nck w/o &w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Meridian Duals,CPT,70544,Mr angiography head w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Meridian Duals,CPT,70545,Mr angiography head w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Meridian Duals,CPT,70546,Mr angiograph head w/o&w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Meridian Duals,CPT,70547,Mr angiography neck w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Meridian Duals,CPT,70548,Mr angiography neck w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Meridian Duals,CPT,70549,Mr angiograph neck w/o&w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Meridian Duals,CPT,70551,Mri brain stem w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Meridian Duals,CPT,70552,Mri brain stem w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Meridian Duals,CPT,70553,Mri brain stem w/o & w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Meridian Duals,CPT,70554,Fmri brain by tech,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Meridian Duals,CPT,70555,Fmri brain by phys/psych,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,507.00",,,,,,
Meridian Duals,CPT,70557,Mri brain w/o dye,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,149.44",,,,,,
Meridian Duals,CPT,70558,Mri brain w/dye,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,"1,609.22",,,,,,
Meridian Duals,CPT,70559,Mri brain w/o & w/dye,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,"1,609.22",,,,,,
Meridian Duals,CPT,71045,X-ray exam chest 1 view,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,152.51,,,,,,
Meridian Duals,CPT,71046,X-ray exam chest 2 views,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,167.76,,,,,,
Meridian Duals,CPT,71047,X-ray exam chest 3 views,APC 5521,RVU Per Case,$82.79 ,OP,82.79,240.2,,,,,,
Meridian Duals,CPT,71048,X-ray exam chest 4+ views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,240.2,,,,,,
Meridian Duals,CPT,71100,X-ray exam ribs uni 2 views,APC 5521,RVU Per Case,$82.79 ,OP,82.79,171.58,,,,,,
Meridian Duals,CPT,71101,X-ray exam unilat ribs/chest,APC 5522,RVU Per Case,$111.51 ,OP,111.51,202.07,,,,,,
Meridian Duals,CPT,71110,X-ray exam ribs bil 3 views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,213.51,,,,,,
Meridian Duals,CPT,71111,X-ray exam ribs/chest4/> vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,270.71,,,,,,
Meridian Duals,CPT,71120,X-ray exam breastbone 2/>vws,APC 5521,RVU Per Case,$82.79 ,OP,82.79,171.58,,,,,,
Meridian Duals,CPT,71130,X-ray strenoclavic jt 3/>vws,APC 5521,RVU Per Case,$82.79 ,OP,82.79,194.45,,,,,,
Meridian Duals,CPT,71250,Ct thorax dx c-,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Meridian Duals,CPT,71260,Ct thorax dx c+,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Meridian Duals,CPT,71270,Ct thorax dx c-/c+,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Meridian Duals,CPT,71271,Ct thorax lung cancer scr c-,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,927,,,,,,
Meridian Duals,CPT,71275,Ct angiography chest,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Meridian Duals,CPT,71550,Mri chest w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Meridian Duals,CPT,71551,Mri chest w/dye,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"1,609.22",,,,,,
Meridian Duals,CPT,71552,Mri chest w/o & w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Meridian Duals,CPT,72020,X-ray exam of spine 1 view,APC 5521,RVU Per Case,$82.79 ,OP,82.79,122,,,,,,
Meridian Duals,CPT,72040,X-ray exam neck spine 2-3 vw,APC 5521,RVU Per Case,$82.79 ,OP,82.79,190.64,,,,,,
Meridian Duals,CPT,72050,X-ray exam neck spine 4/5vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,293.57,,,,,,
Meridian Duals,CPT,72052,X-ray exam neck spine 6/>vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,339.33,,,,,,
Meridian Duals,CPT,72070,X-ray exam thorac spine 2vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,175.39,,,,,,
Meridian Duals,CPT,72072,X-ray exam thorac spine 3vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,202.07,,,,,,
Meridian Duals,CPT,72074,X-ray exam thorac spine4/>vw,APC 5522,RVU Per Case,$111.51 ,OP,111.51,236.38,,,,,,
Meridian Duals,CPT,72080,X-ray exam thoracolmb 2/> vw,APC 5521,RVU Per Case,$82.79 ,OP,82.79,183.02,,,,,,
Meridian Duals,CPT,72081,X-ray exam entire spi 1 vw,APC 5521,RVU Per Case,$82.79 ,OP,82.79,354.58,,,,,,
Meridian Duals,CPT,72082,X-ray exam entire spi 2/3 vw,APC 5522,RVU Per Case,$111.51 ,OP,111.51,354.58,,,,,,
Meridian Duals,CPT,72083,X-ray exam entire spi 4/5 vw,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,354.58,,,,,,
Meridian Duals,CPT,72084,X-ray exam entire spi 6/> vw,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,354.58,,,,,,
Meridian Duals,CPT,72100,X-ray exam l-s spine 2/3 vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,202.07,,,,,,
Meridian Duals,CPT,72110,X-ray exam l-2 spine 4/>vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,301.2,,,,,,
Meridian Duals,CPT,72114,X-ray exam l-s spine bending,APC 5522,RVU Per Case,$111.51 ,OP,111.51,362.21,,,,,,
Meridian Duals,CPT,72120,X-ray bend only l-s spine,APC 5522,RVU Per Case,$111.51 ,OP,111.51,251.64,,,,,,
Meridian Duals,CPT,72125,Ct neck spine w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Meridian Duals,CPT,72126,Ct neck spine w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,965.53,,,,,,
Meridian Duals,CPT,72127,Ct neck spine w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Meridian Duals,CPT,72128,Ct chest spine w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Meridian Duals,CPT,72129,Ct chest spine w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Meridian Duals,CPT,72130,Ct chest spine w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Meridian Duals,CPT,72131,Ct lumbar spine w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Meridian Duals,CPT,72132,Ct lumbar spine w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,965.53,,,,,,
Meridian Duals,CPT,72133,Ct lumbar spine w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Meridian Duals,CPT,72141,Mri neck spine w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Meridian Duals,CPT,72142,Mri neck spine w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Meridian Duals,CPT,72146,Mri chest spine w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Meridian Duals,CPT,72147,Mri chest spine w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Meridian Duals,CPT,72148,Mri lumbar spine w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Meridian Duals,CPT,72149,Mri lumbar spine w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Meridian Duals,CPT,72156,Mri neck spine w/o & w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Meridian Duals,CPT,72157,Mri chest spine w/o & w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Meridian Duals,CPT,72158,Mri lumbar spine w/o & w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Meridian Duals,CPT,72170,X-ray exam of pelvis,APC 5522,RVU Per Case,$111.51 ,OP,111.51,133.45,,,,,,
Meridian Duals,CPT,72190,X-ray exam of pelvis,APC 5522,RVU Per Case,$111.51 ,OP,111.51,205.88,,,,,,
Meridian Duals,CPT,72191,Ct angiograph pelv w/o&w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Meridian Duals,CPT,72192,Ct pelvis w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Meridian Duals,CPT,72193,Ct pelvis w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Meridian Duals,CPT,72194,Ct pelvis w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Meridian Duals,CPT,72195,Mri pelvis w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Meridian Duals,CPT,72196,Mri pelvis w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Meridian Duals,CPT,72197,Mri pelvis w/o & w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Meridian Duals,CPT,72200,X-ray exam si joints,APC 5522,RVU Per Case,$111.51 ,OP,111.51,148.69,,,,,,
Meridian Duals,CPT,72202,X-ray exam si joints 3/> vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,183.02,,,,,,
Meridian Duals,CPT,72220,X-ray exam sacrum tailbone,APC 5521,RVU Per Case,$82.79 ,OP,82.79,156.32,,,,,,
Meridian Duals,CPT,72240,Myelography neck spine,APC 5573,RVU Per Case,$731.85 ,OP,731.85,842.61,,,,,,
Meridian Duals,CPT,72255,Myelography thoracic spine,APC 5573,RVU Per Case,$731.85 ,OP,731.85,766.35,,,,,,
Meridian Duals,CPT,72265,Myelography l-s spine,APC 5573,RVU Per Case,$731.85 ,OP,731.85,781.61,,,,,,
Meridian Duals,CPT,72270,Myelogphy 2/> spine regions,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"1,216.24",,,,,,
Meridian Duals,CPT,72285,Discography cerv/thor spine,APC 5431,RVU Per Case,"$1,795.30 ",OP,976.05,"1,795.30",,,,,,
Meridian Duals,CPT,72295,X-ray of lower spine disk,APC 5431,RVU Per Case,"$1,795.30 ",OP,873.11,"1,795.30",,,,,,
Meridian Duals,CPT,73000,X-ray exam of collar bone,APC 5521,RVU Per Case,$82.79 ,OP,82.79,141.07,,,,,,
Meridian Duals,CPT,73010,X-ray exam of shoulder blade,APC 5522,RVU Per Case,$111.51 ,OP,111.51,144.88,,,,,,
Meridian Duals,CPT,73020,X-ray exam of shoulder,APC 5521,RVU Per Case,$82.79 ,OP,82.79,122,,,,,,
Meridian Duals,CPT,73030,X-ray exam of shoulder,APC 5521,RVU Per Case,$82.79 ,OP,82.79,163.95,,,,,,
Meridian Duals,CPT,73040,Contrast x-ray of shoulder,APC 5572,RVU Per Case,$376.70 ,OP,376.7,552.84,,,,,,
Meridian Duals,CPT,73050,X-ray exam of shoulders,APC 5521,RVU Per Case,$82.79 ,OP,82.79,186.82,,,,,,
Meridian Duals,CPT,73060,X-ray exam of humerus,APC 5521,RVU Per Case,$82.79 ,OP,82.79,152.51,,,,,,
Meridian Duals,CPT,73070,X-ray exam of elbow,APC 5521,RVU Per Case,$82.79 ,OP,82.79,137.25,,,,,,
Meridian Duals,CPT,73080,X-ray exam of elbow,APC 5521,RVU Per Case,$82.79 ,OP,82.79,179.2,,,,,,
Meridian Duals,CPT,73085,Contrast x-ray of elbow,APC 5572,RVU Per Case,$376.70 ,OP,376.7,503.28,,,,,,
Meridian Duals,CPT,73090,X-ray exam of forearm,APC 5521,RVU Per Case,$82.79 ,OP,82.79,137.25,,,,,,
Meridian Duals,CPT,73092,X-ray exam of arm infant,APC 5522,RVU Per Case,$111.51 ,OP,111.51,141.07,,,,,,
Meridian Duals,CPT,73100,X-ray exam of wrist,APC 5521,RVU Per Case,$82.79 ,OP,82.79,144.88,,,,,,
Meridian Duals,CPT,73110,X-ray exam of wrist,APC 5521,RVU Per Case,$82.79 ,OP,82.79,171.58,,,,,,
Meridian Duals,CPT,73115,Contrast x-ray of wrist,APC 5572,RVU Per Case,$376.70 ,OP,376.7,526.16,,,,,,
Meridian Duals,CPT,73120,X-ray exam of hand,APC 5522,RVU Per Case,$111.51 ,OP,111.51,137.25,,,,,,
Meridian Duals,CPT,73130,X-ray exam of hand,APC 5521,RVU Per Case,$82.79 ,OP,82.79,156.32,,,,,,
Meridian Duals,CPT,73140,X-ray exam of finger(s),APC 5521,RVU Per Case,$82.79 ,OP,82.79,160.13,,,,,,
Meridian Duals,CPT,73200,Ct upper extremity w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Meridian Duals,CPT,73201,Ct upper extremity w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,965.53,,,,,,
Meridian Duals,CPT,73202,Ct uppr extremity w/o&w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Meridian Duals,CPT,73206,Ct angio upr extrm w/o&w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Meridian Duals,CPT,73218,Mri upper extremity w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Meridian Duals,CPT,73219,Mri upper extremity w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Meridian Duals,CPT,73220,Mri uppr extremity w/o&w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Meridian Duals,CPT,73221,Mri joint upr extrem w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Meridian Duals,CPT,73222,Mri joint upr extrem w/dye,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"1,609.22",,,,,,
Meridian Duals,CPT,73223,Mri joint upr extr w/o&w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Meridian Duals,CPT,73501,X-ray exam hip uni 1 view,APC 5521,RVU Per Case,$82.79 ,OP,82.79,129.64,,,,,,
Meridian Duals,CPT,73502,X-ray exam hip uni 2-3 views,APC 5521,RVU Per Case,$82.79 ,OP,82.79,198.25,,,,,,
Meridian Duals,CPT,73503,X-ray exam hip uni 4/> views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,198.25,,,,,,
Meridian Duals,CPT,73521,X-ray exam hips bi 2 views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,202.07,,,,,,
Meridian Duals,CPT,73522,X-ray exam hips bi 3-4 views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,202.07,,,,,,
Meridian Duals,CPT,73523,X-ray exam hips bi 5/> views,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,202.07,,,,,,
Meridian Duals,CPT,73525,Contrast x-ray of hip,APC 5572,RVU Per Case,$376.70 ,OP,376.7,503.28,,,,,,
Meridian Duals,CPT,73551,X-ray exam of femur 1,APC 5521,RVU Per Case,$82.79 ,OP,82.79,148.69,,,,,,
Meridian Duals,CPT,73552,X-ray exam of femur 2/>,APC 5521,RVU Per Case,$82.79 ,OP,82.79,148.69,,,,,,
Meridian Duals,CPT,73560,X-ray exam of knee 1 or 2,APC 5521,RVU Per Case,$82.79 ,OP,82.79,144.88,,,,,,
Meridian Duals,CPT,73562,X-ray exam of knee 3,APC 5521,RVU Per Case,$82.79 ,OP,82.79,186.82,,,,,,
Meridian Duals,CPT,73564,X-ray exam knee 4 or more,APC 5522,RVU Per Case,$111.51 ,OP,111.51,205.88,,,,,,
Meridian Duals,CPT,73565,X-ray exam of knees,APC 5521,RVU Per Case,$82.79 ,OP,82.79,152.51,,,,,,
Meridian Duals,CPT,73580,Contrast x-ray of knee joint,APC 5572,RVU Per Case,$376.70 ,OP,376.7,625.29,,,,,,
Meridian Duals,CPT,73590,X-ray exam of lower leg,APC 5521,RVU Per Case,$82.79 ,OP,82.79,137.25,,,,,,
Meridian Duals,CPT,73592,X-ray exam of leg infant,APC 5521,RVU Per Case,$82.79 ,OP,82.79,141.07,,,,,,
Meridian Duals,CPT,73600,X-ray exam of ankle,APC 5521,RVU Per Case,$82.79 ,OP,82.79,137.25,,,,,,
Meridian Duals,CPT,73610,X-ray exam of ankle,APC 5521,RVU Per Case,$82.79 ,OP,82.79,156.32,,,,,,
Meridian Duals,CPT,73615,Contrast x-ray of ankle,APC 5572,RVU Per Case,$376.70 ,OP,376.7,376.7,,,,,,
Meridian Duals,CPT,73620,X-ray exam of foot,APC 5521,RVU Per Case,$82.79 ,OP,82.79,133.45,,,,,,
Meridian Duals,CPT,73630,X-ray exam of foot,APC 5521,RVU Per Case,$82.79 ,OP,82.79,156.32,,,,,,
Meridian Duals,CPT,73650,X-ray exam of heel,APC 5521,RVU Per Case,$82.79 ,OP,82.79,137.25,,,,,,
Meridian Duals,CPT,73660,X-ray exam of toe(s),APC 5521,RVU Per Case,$82.79 ,OP,82.79,141.07,,,,,,
Meridian Duals,CPT,73700,Ct lower extremity w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Meridian Duals,CPT,73701,Ct lower extremity w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Meridian Duals,CPT,73702,Ct lwr extremity w/o&w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Meridian Duals,CPT,73706,Ct angio lwr extr w/o&w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Meridian Duals,CPT,73718,Mri lower extremity w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Meridian Duals,CPT,73719,Mri lower extremity w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Meridian Duals,CPT,73720,Mri lwr extremity w/o&w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Meridian Duals,CPT,73721,Mri jnt of lwr extre w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Meridian Duals,CPT,73722,Mri joint of lwr extr w/dye,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"1,609.22",,,,,,
Meridian Duals,CPT,73723,Mri joint lwr extr w/o&w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Meridian Duals,CPT,74018,X-ray exam abdomen 1 view,APC 5521,RVU Per Case,$82.79 ,OP,82.79,137.25,,,,,,
Meridian Duals,CPT,74019,X-ray exam abdomen 2 views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,194.45,,,,,,
Meridian Duals,CPT,74021,X-ray exam abdomen 3+ views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,205.88,,,,,,
Meridian Duals,CPT,74022,X-ray exam complete abdomen,APC 5522,RVU Per Case,$111.51 ,OP,111.51,251.64,,,,,,
Meridian Duals,CPT,74150,Ct abdomen w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Meridian Duals,CPT,74160,Ct abdomen w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Meridian Duals,CPT,74170,Ct abdomen w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Meridian Duals,CPT,74174,Ct angio abd&pelv w/o&w/dye,APC 5572,RVU Per Unit,$376.70 ,OP,376.7,965.53,,,,,,
Meridian Duals,CPT,74175,Ct angio abdom w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Meridian Duals,CPT,74176,Ct abd & pelvis w/o contrast,APC 5523,RVU Per Case,$235.49 ,OP,235.49,927,,,,,,
Meridian Duals,CPT,74177,Ct abd & pelv w/contrast,APC 5572,RVU Per Case,$376.70 ,OP,376.7,965.53,,,,,,
Meridian Duals,CPT,74178,Ct abd & pelv 1/> regns,APC 5572,RVU Per Case,$376.70 ,OP,376.7,927,,,,,,
Meridian Duals,CPT,74181,Mri abdomen w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Meridian Duals,CPT,74182,Mri abdomen w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Meridian Duals,CPT,74183,Mri abdomen w/o & w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Meridian Duals,CPT,74190,X-ray exam of peritoneum,APC 5524,RVU Per Case,$494.15 ,OP,400.34,494.15,,,,,,
Meridian Duals,CPT,74210,X-ray xm phrnx&/crv esoph c+,APC 5571,RVU Per Case,$182.72 ,OP,182.72,182.72,,,,,,
Meridian Duals,CPT,74220,X-ray xm esophagus 1cntrst,APC 5571,RVU Per Case,$182.72 ,OP,182.72,446.08,,,,,,
Meridian Duals,CPT,74221,X-ray xm esophagus 2cntrst,APC 5571,RVU Per Case,$182.72 ,OP,182.72,446.08,,,,,,
Meridian Duals,CPT,74230,X-ray xm swlng funcj c+,APC 5571,RVU Per Case,$182.72 ,OP,182.72,457.52,,,,,,
Meridian Duals,CPT,74240,X-ray xm upr gi trc 1cntrst,APC 5571,RVU Per Case,$182.72 ,OP,182.72,552.84,,,,,,
Meridian Duals,CPT,74246,X-ray xm upr gi trc 2cntrst,APC 5571,RVU Per Case,$182.72 ,OP,182.72,632.91,,,,,,
Meridian Duals,CPT,74250,X-ray xm sm int 1cntrst std,APC 5571,RVU Per Case,$182.72 ,OP,182.72,518.52,,,,,,
Meridian Duals,CPT,74251,X-ray xm sm int 2cntrst std,APC 5571,RVU Per Case,$182.72 ,OP,182.72,"1,593.72",,,,,,
Meridian Duals,CPT,74261,Ct colonography dx,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Meridian Duals,CPT,74262,Ct colonography dx w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,182.72,,,,,,
Meridian Duals,CPT,74270,X-ray xm colon 1cntrst std,APC 5571,RVU Per Case,$182.72 ,OP,182.72,747.28,,,,,,
Meridian Duals,CPT,74280,X-ray xm colon 2cntrst std,APC 5571,RVU Per Case,$182.72 ,OP,182.72,"1,029.43",,,,,,
Meridian Duals,CPT,74283,Ther nma rdctj intus/obstrcj,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,182.72,,,,,,
Meridian Duals,CPT,74290,Contrast x-ray gallbladder,APC 5571,RVU Per Case,$182.72 ,OP,182.72,331.7,,,,,,
Meridian Duals,CPT,74400,Urography iv +-kub tomog,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,568.09,,,,,,
Meridian Duals,CPT,74410,Urography nfs drip&/bolus,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,598.59,,,,,,
Meridian Duals,CPT,74415,Urography nfs drip&/bls w/nf,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,682.47,,,,,,
Meridian Duals,CPT,74420,Urography rtrgr +-kub,APC 5572,RVU Per Unit,$376.70 ,OP,376.7,659.6,,,,,,
Meridian Duals,CPT,74425,Urography antegrade rs&i,APC 5572,RVU Per Case,$376.70 ,OP,366.02,376.7,,,,,,
Meridian Duals,CPT,74430,Contrast x-ray bladder,APC 5572,RVU Per Case,$376.70 ,OP,376.7,404.14,,,,,,
Meridian Duals,CPT,74440,X-ray male genital tract,APC 5523,RVU Per Case,$235.49 ,OP,235.49,434.65,,,,,,
Meridian Duals,CPT,74445,X-ray exam of penis,APC 5522,RVU Per Case,$111.51 ,OP,111.51,545.21,,,,,,
Meridian Duals,CPT,74450,X-ray urethra/bladder,APC 5523,RVU Per Case,$235.49 ,OP,235.49,396.52,,,,,,
Meridian Duals,CPT,74455,X-ray urethra/bladder,APC 5523,RVU Per Case,$235.49 ,OP,235.49,472.78,,,,,,
Meridian Duals,CPT,74470,X-ray exam of kidney lesion,APC 5524,RVU Per Case,$494.15 ,OP,400.34,494.15,,,,,,
Meridian Duals,CPT,74485,Dilation urtr/urt rs&i,APC 5373,RVU Per Case,"$1,834.80 ",OP,629.1,"1,834.80",,,,,,
Meridian Duals,CPT,74710,X-ray measurement of pelvis,APC 5521,RVU Per Case,$82.79 ,OP,82.79,232.58,,,,,,
Meridian Duals,CPT,74712,Mri fetal sngl/1st gestation,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,507.00",,,,,,
Meridian Duals,CPT,74740,X-ray female genital tract,APC 5523,RVU Per Case,$235.49 ,OP,235.49,404.14,,,,,,
Meridian Duals,CPT,74775,X-ray exam of perineum,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,457.52,,,,,,
Meridian Duals,CPT,75557,Cardiac mri for morph,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Meridian Duals,CPT,75559,Cardiac mri w/stress img,APC 5524,RVU Per Case,$494.15 ,OP,494.15,"1,507.00",,,,,,
Meridian Duals,CPT,75561,Cardiac mri for morph w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Meridian Duals,CPT,75563,Card mri w/stress img & dye,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"1,609.22",,,,,,
Meridian Duals,CPT,75571,Ct hrt w/o dye w/ca test,APC 5521,RVU Per Case,$82.79 ,OP,82.79,927,,,,,,
Meridian Duals,CPT,75572,Ct hrt w/3d image,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,927,,,,,,
Meridian Duals,CPT,75573,Ct hrt w/3d image congen,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,927,,,,,,
Meridian Duals,CPT,75574,Ct angio hrt w/3d image,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,927,,,,,,
Meridian Duals,CPT,75600,Contrast exam thoracic aorta,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,742.41","2,928.39",,,,,,
Meridian Duals,CPT,75605,Contrast exam thoracic aorta,APC 5184,RVU Per Case,"$4,881.61 ",OP,"1,506.03","4,881.61",,,,,,
Meridian Duals,CPT,75625,Contrast exam abdominl aorta,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,486.95","2,928.39",,,,,,
Meridian Duals,CPT,75630,X-ray aorta leg arteries,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","2,928.39",,,,,,
Meridian Duals,CPT,75635,Ct angio abdominal arteries,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Meridian Duals,CPT,75705,Artery x-rays spine,APC 5184,RVU Per Case,"$4,881.61 ",OP,"1,826.28","4,881.61",,,,,,
Meridian Duals,CPT,75710,Artery x-rays arm/leg,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,567.02","2,928.39",,,,,,
Meridian Duals,CPT,75716,Artery x-rays arms/legs,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,730.97","2,928.39",,,,,,
Meridian Duals,CPT,75726,Artery x-rays abdomen,APC 5184,RVU Per Case,"$4,881.61 ",OP,"1,547.95","4,881.61",,,,,,
Meridian Duals,CPT,75731,Artery x-rays adrenal gland,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,601.33","2,928.39",,,,,,
Meridian Duals,CPT,75733,Artery x-rays adrenals,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,795.78","2,928.39",,,,,,
Meridian Duals,CPT,75736,Artery x-rays pelvis,APC 5184,RVU Per Case,"$4,881.61 ",OP,"1,563.20","4,881.61",,,,,,
Meridian Duals,CPT,75741,Artery x-rays lung,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,506.03","2,928.39",,,,,,
Meridian Duals,CPT,75743,Artery x-rays lungs,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,635.64","2,928.39",,,,,,
Meridian Duals,CPT,75746,Artery x-rays lung,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,517.46","2,928.39",,,,,,
Meridian Duals,CPT,75756,Artery x-rays chest,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,601.33","2,928.39",,,,,,
Meridian Duals,CPT,75801,Lymph vessel x-ray arm/leg,APC 5181,RVU Per Case,$554.25 ,OP,554.25,"1,281.07",,,,,,
Meridian Duals,CPT,75803,Lymph vessel x-ray arms/legs,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,437.39","1,438.93",,,,,,
Meridian Duals,CPT,75805,Lymph vessel x-ray trunk,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,483.14","2,928.39",,,,,,
Meridian Duals,CPT,75807,Lymph vessel x-ray trunk,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,582.28","2,928.39",,,,,,
Meridian Duals,CPT,75809,Nonvascular shunt x-ray,APC 5522,RVU Per Case,$111.51 ,OP,111.51,446.08,,,,,,
Meridian Duals,CPT,75810,Vein x-ray spleen/liver,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,836.65","2,928.39",,,,,,
Meridian Duals,CPT,75820,Vein x-ray arm/leg,APC 5182,RVU Per Case,"$1,438.93 ",OP,610.03,"1,438.93",,,,,,
Meridian Duals,CPT,75822,Vein x-ray arms/legs,APC 5182,RVU Per Case,"$1,438.93 ",OP,747.28,"1,438.93",,,,,,
Meridian Duals,CPT,75825,Vein x-ray trunk,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,441.20","2,928.39",,,,,,
Meridian Duals,CPT,75827,Vein x-ray chest,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,433.58","1,438.93",,,,,,
Meridian Duals,CPT,75831,Vein x-ray kidney,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,456.44","2,928.39",,,,,,
Meridian Duals,CPT,75833,Vein x-ray kidneys,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,608.95","2,928.39",,,,,,
Meridian Duals,CPT,75840,Vein x-ray adrenal gland,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,445.01","2,928.39",,,,,,
Meridian Duals,CPT,75842,Vein x-ray adrenal glands,APC 5184,RVU Per Case,"$4,881.61 ",OP,"1,616.58","4,881.61",,,,,,
Meridian Duals,CPT,75860,Vein x-ray neck,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,479.33","2,928.39",,,,,,
Meridian Duals,CPT,75870,Vein x-ray skull,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,467.89","2,928.39",,,,,,
Meridian Duals,CPT,75872,Vein x-ray skull epidural,APC 5181,RVU Per Case,$554.25 ,OP,554.25,"1,608.95",,,,,,
Meridian Duals,CPT,75880,Vein x-ray eye socket,APC 5181,RVU Per Case,$554.25 ,OP,554.25,613.85,,,,,,
Meridian Duals,CPT,75885,Vein x-ray liver w/hemodynam,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,536.51","2,928.39",,,,,,
Meridian Duals,CPT,75887,Vein x-ray liver w/o hemodyn,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,547.95","2,928.39",,,,,,
Meridian Duals,CPT,75889,Vein x-ray liver w/hemodynam,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,456.44","2,928.39",,,,,,
Meridian Duals,CPT,75891,Vein x-ray liver,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,456.44","2,928.39",,,,,,
Meridian Duals,CPT,75893,Venous sampling by catheter,APC 5184,RVU Per Case,"$4,881.61 ",OP,"1,296.32","4,881.61",,,,,,
Meridian Duals,CPT,75898,Follow-up angiography,APC 5183,RVU Per Case,"$2,928.39 ",OP,655.78,"2,928.39",,,,,,
Meridian Duals,CPT,75956,Xray endovasc thor ao repr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,75957,Xray endovasc thor ao repr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,597.52","8,948.83",,,,,,
Meridian Duals,CPT,75958,Xray place prox ext thor ao,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,052.29","8,948.83",,,,,,
Meridian Duals,CPT,75959,Xray place dist ext thor ao,APC 5881,RVU Per Case,"$8,948.83 ",OP,926.48,"8,948.83",,,,,,
Meridian Duals,CPT,76000,Fluoroscopy <1 hr phys/qhp,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,495.65,,,,,,
Meridian Duals,CPT,76010,X-ray nose to rectum,APC 5521,RVU Per Case,$82.79 ,OP,82.79,144.88,,,,,,
Meridian Duals,CPT,76080,X-ray exam of fistula,APC 5524,RVU Per Case,$494.15 ,OP,331.7,494.15,,,,,,
Meridian Duals,CPT,76098,X-ray exam surgical specimen,APC 5524,RVU Per Case,$494.15 ,OP,102.95,494.15,,,,,,
Meridian Duals,CPT,76100,X-ray exam of body section,APC 5522,RVU Per Case,$111.51 ,OP,111.51,690.1,,,,,,
Meridian Duals,CPT,76101,Complex body section x-ray,APC 5522,RVU Per Case,$111.51 ,OP,111.51,949.36,,,,,,
Meridian Duals,CPT,76102,Complex body section x-rays,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,111.51,,,,,,
Meridian Duals,CPT,76120,Cine/video x-rays,APC 5522,RVU Per Case,$111.51 ,OP,111.51,392.7,,,,,,
Meridian Duals,CPT,76145,Med physic dos eval rad exps,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,129.83,,,,,,
Meridian Duals,CPT,76380,Cat scan follow-up study,APC 5521,RVU Per Case,$82.79 ,OP,82.79,689.66,,,,,,
Meridian Duals,CPT,76390,Mr spectroscopy,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,"1,507.00",,,,,,
Meridian Duals,CPT,76391,Mr elastography,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Meridian Duals,CPT,76496,Fluoroscopic procedure,APC 5521,RVU Per Case,$82.79 ,OP,82.79,82.79,,,,,,
Meridian Duals,CPT,76497,Ct procedure,APC 5521,RVU Per Case,$82.79 ,OP,82.79,927,,,,,,
Meridian Duals,CPT,76498,Mri procedure,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,"1,507.00",,,,,,
Meridian Duals,CPT,76499,Radiographic procedure,APC 5521,RVU Per Case,$82.79 ,OP,82.79,82.79,,,,,,
Meridian Duals,CPT,76506,Echo exam of head,APC 5522,RVU Per Case,$111.51 ,OP,111.51,602.41,,,,,,
Meridian Duals,CPT,76510,Oph us dx b-scan&quan a-scan,APC 5734,RVU Per Case,$114.56 ,OP,114.56,751.1,,,,,,
Meridian Duals,CPT,76511,Oph us dx quan a-scan only,APC 5522,RVU Per Case,$111.51 ,OP,111.51,495.65,,,,,,
Meridian Duals,CPT,76512,Oph us dx b-scan,APC 5522,RVU Per Case,$111.51 ,OP,111.51,468.96,,,,,,
Meridian Duals,CPT,76513,Oph us dx ant sgm us uni/bi,APC 5522,RVU Per Case,$111.51 ,OP,111.51,438.47,,,,,,
Meridian Duals,CPT,76514,Echo exam of eye thickness,APC 5731,RVU Per Case,$25.25 ,OP,25.25,64.82,,,,,,
Meridian Duals,CPT,76516,Echo exam of eye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,346.96,,,,,,
Meridian Duals,CPT,76519,Echo exam of eye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,369.83,,,,,,
Meridian Duals,CPT,76529,Echo exam of eye,APC 5521,RVU Per Case,$82.79 ,OP,82.79,354.58,,,,,,
Meridian Duals,CPT,76536,Us exam of head and neck,APC 5522,RVU Per Case,$111.51 ,OP,111.51,594.77,,,,,,
Meridian Duals,CPT,76604,Us exam chest,APC 5522,RVU Per Case,$111.51 ,OP,111.51,446.08,,,,,,
Meridian Duals,CPT,76641,Ultrasound breast complete,APC 5522,RVU Per Case,$111.51 ,OP,111.51,174.71,,,,,,
Meridian Duals,CPT,76642,Ultrasound breast limited,APC 5521,RVU Per Case,$82.79 ,OP,82.79,174.71,,,,,,
Meridian Duals,CPT,76700,Us exam abdom complete,APC 5522,RVU Per Case,$111.51 ,OP,111.51,739.67,,,,,,
Meridian Duals,CPT,76705,Echo exam of abdomen,APC 5522,RVU Per Case,$111.51 ,OP,111.51,537.6,,,,,,
Meridian Duals,CPT,76706,Us abdl aorta screen aaa,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,575.73,,,,,,
Meridian Duals,CPT,76770,Us exam abdo back wall comp,APC 5522,RVU Per Case,$111.51 ,OP,111.51,678.66,,,,,,
Meridian Duals,CPT,76775,Us exam abdo back wall lim,APC 5522,RVU Per Case,$111.51 ,OP,111.51,602.41,,,,,,
Meridian Duals,CPT,76776,Us exam k transpl w/doppler,APC 5522,RVU Per Case,$111.51 ,OP,111.51,751.1,,,,,,
Meridian Duals,CPT,76800,Us exam spinal canal,APC 5522,RVU Per Case,$111.51 ,OP,111.51,632.91,,,,,,
Meridian Duals,CPT,76801,Ob us < 14 wks single fetus,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,712.98,,,,,,
Meridian Duals,CPT,76805,Ob us >= 14 wks sngl fetus,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,789.23,,,,,,
Meridian Duals,CPT,76811,Ob us detailed sngl fetus,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,204.81",,,,,,
Meridian Duals,CPT,76813,Ob us nuchal meas 1 gest,APC 5522,RVU Per Case,$111.51 ,OP,111.51,667.22,,,,,,
Meridian Duals,CPT,76815,Ob us limited fetus(s),APC 5522,RVU Per Case,$111.51 ,OP,111.51,472.78,,,,,,
Meridian Duals,CPT,76816,Ob us follow-up per fetus,APC 5522,RVU Per Case,$111.51 ,OP,111.51,571.91,,,,,,
Meridian Duals,CPT,76817,Transvaginal us obstetric,APC 5522,RVU Per Case,$111.51 ,OP,111.51,560.47,,,,,,
Meridian Duals,CPT,76818,Fetal biophys profile w/nst,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,625.29,,,,,,
Meridian Duals,CPT,76819,Fetal biophys profil w/o nst,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,526.16,,,,,,
Meridian Duals,CPT,76820,Umbilical artery echo,APC 5522,RVU Per Case,$111.51 ,OP,111.51,297.39,,,,,,
Meridian Duals,CPT,76821,Middle cerebral artery echo,APC 5522,RVU Per Case,$111.51 ,OP,111.51,510.9,,,,,,
Meridian Duals,CPT,76825,Echo exam of fetal heart,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,067.55",,,,,,
Meridian Duals,CPT,76826,Echo exam of fetal heart,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,587.16,,,,,,
Meridian Duals,CPT,76827,Echo exam of fetal heart,APC 5522,RVU Per Case,$111.51 ,OP,111.51,381.27,,,,,,
Meridian Duals,CPT,76828,Echo exam of fetal heart,APC 5522,RVU Per Case,$111.51 ,OP,111.51,282.14,,,,,,
Meridian Duals,CPT,76830,Transvaginal us non-ob,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,651.97,,,,,,
Meridian Duals,CPT,76831,Echo exam uterus,APC 5523,RVU Per Case,$235.49 ,OP,235.49,621.47,,,,,,
Meridian Duals,CPT,76856,Us exam pelvic complete,APC 5522,RVU Per Case,$111.51 ,OP,111.51,655.78,,,,,,
Meridian Duals,CPT,76857,Us exam pelvic limited,APC 5522,RVU Per Case,$111.51 ,OP,111.51,518.52,,,,,,
Meridian Duals,CPT,76870,Us exam scrotum,APC 5522,RVU Per Case,$111.51 ,OP,111.51,621.47,,,,,,
Meridian Duals,CPT,76872,Us transrectal,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,735.85,,,,,,
Meridian Duals,CPT,76873,Echograp trans r pros study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,934.12,,,,,,
Meridian Duals,CPT,76881,Us compl joint r-t w/img,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,644.34,,,,,,
Meridian Duals,CPT,76882,Us lmtd jt/nonvasc xtr strux,APC 5522,RVU Per Case,$111.51 ,OP,111.51,644.34,,,,,,
Meridian Duals,CPT,76885,Us exam infant hips dynamic,APC 5521,RVU Per Case,$82.79 ,OP,82.79,701.54,,,,,,
Meridian Duals,CPT,76886,Us exam infant hips static,APC 5521,RVU Per Case,$82.79 ,OP,82.79,518.52,,,,,,
Meridian Duals,CPT,76936,Echo guide for artery repair,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,654.72",,,,,,
Meridian Duals,CPT,76975,Gi endoscopic ultrasound,APC 5523,RVU Per Case,$235.49 ,OP,235.49,529.96,,,,,,
Meridian Duals,CPT,76977,Us bone density measure,APC 5522,RVU Per Unit,$111.51 ,OP,80.07,111.51,,,,,,
Meridian Duals,CPT,76978,Us trgt dyn mbubb 1st les,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,182.72,,,,,,
Meridian Duals,CPT,76981,Use parenchyma,APC 5522,RVU Per Case,$111.51 ,OP,111.51,111.51,,,,,,
Meridian Duals,CPT,76982,Use 1st target lesion,APC 5522,RVU Per Case,$111.51 ,OP,111.51,111.51,,,,,,
Meridian Duals,CPT,76999,Echo examination procedure,APC 5521,RVU Per Case,$82.79 ,OP,82.79,82.79,,,,,,
Meridian Duals,CPT,77046,Mri breast c- unilateral,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Meridian Duals,CPT,77047,Mri breast c- bilateral,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Meridian Duals,CPT,77053,X-ray of mammary duct,APC 5523,RVU Per Case,$235.49 ,OP,235.49,411.78,,,,,,
Meridian Duals,CPT,77054,X-ray of mammary ducts,APC 5523,RVU Per Case,$235.49 ,OP,235.49,235.49,,,,,,
Meridian Duals,CPT,77063,Breast tomosynthesis bi,Physician,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Meridian Duals,CPT,77065,Dx mammo incl cad uni,Physician,Per Unit,$83.47 ,OP,83.47,275.87,,,,,,
Meridian Duals,CPT,77066,Dx mammo incl cad bi,Physician,Per Unit,$106.70 ,OP,106.7,275.87,,,,,,
Meridian Duals,CPT,77067,Scr mammo bi incl cad,Physician,Per Unit,$88.24 ,OP,88.24,275.87,,,,,,
Meridian Duals,CPT,77071,X-ray stress view,APC 5521,RVU Per Case,$82.79 ,OP,82.79,205.88,,,,,,
Meridian Duals,CPT,77072,X-rays for bone age,APC 5522,RVU Per Case,$111.51 ,OP,111.51,122,,,,,,
Meridian Duals,CPT,77073,X-rays bone length studies,APC 5522,RVU Per Case,$111.51 ,OP,111.51,198.25,,,,,,
Meridian Duals,CPT,77074,X-rays bone survey limited,APC 5522,RVU Per Case,$111.51 ,OP,111.51,358.39,,,,,,
Meridian Duals,CPT,77075,X-rays bone survey complete,APC 5522,RVU Per Case,$111.51 ,OP,111.51,514.72,,,,,,
Meridian Duals,CPT,77076,X-rays bone survey infant,APC 5522,RVU Per Case,$111.51 ,OP,111.51,476.6,,,,,,
Meridian Duals,CPT,77077,Joint survey single view,APC 5522,RVU Per Case,$111.51 ,OP,111.51,224.95,,,,,,
Meridian Duals,CPT,77078,Ct bone density axial,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,927,,,,,,
Meridian Duals,CPT,77080,Dxa bone density axial,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,537.6,,,,,,
Meridian Duals,CPT,77081,Dxa bone density/peripheral,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,167.76,,,,,,
Meridian Duals,CPT,77084,Magnetic image bone marrow,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,507.00",,,,,,
Meridian Duals,CPT,77085,Dxa bone density study,APC 5522,RVU Per Case,$111.51 ,OP,111.51,111.51,,,,,,
Meridian Duals,CPT,77086,Fracture assessment via dxa,APC 5521,RVU Per Case,$82.79 ,OP,82.79,213.51,,,,,,
Meridian Duals,CPT,77280,Set radiation therapy field,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,964.61,,,,,,
Meridian Duals,CPT,77285,Set radiation therapy field,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,"1,662.33",,,,,,
Meridian Duals,CPT,77290,Set radiation therapy field,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,"2,558.32",,,,,,
Meridian Duals,CPT,77295,3-d radiotherapy plan,APC 5613,RVU Per Unit,"$1,291.62 ",OP,"1,291.62","3,736.44",,,,,,
Meridian Duals,CPT,77299,Radiation therapy planning,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,129.83,,,,,,
Meridian Duals,CPT,77300,Radiation therapy dose plan,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,388.89,,,,,,
Meridian Duals,CPT,77301,Radiotherapy dose plan imrt,APC 5613,RVU Per Unit,"$1,291.62 ",OP,"1,291.62","11,205.50",,,,,,
Meridian Duals,CPT,77306,Telethx isodose plan simple,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,392.7,,,,,,
Meridian Duals,CPT,77307,Telethx isodose plan cplx,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,777.79,,,,,,
Meridian Duals,CPT,77316,Brachytx isodose plan simple,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,747.28,,,,,,
Meridian Duals,CPT,77317,Brachytx isodose intermed,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,"1,059.93",,,,,,
Meridian Duals,CPT,77318,Brachytx isodose complex,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,"1,456.44",,,,,,
Meridian Duals,CPT,77321,Special teletx port plan,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,659.6,,,,,,
Meridian Duals,CPT,77331,Special radiation dosimetry,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,320.27,,,,,,
Meridian Duals,CPT,77332,Radiation treatment aid(s),APC 5611,RVU Per Unit,$129.83 ,OP,129.83,407.96,,,,,,
Meridian Duals,CPT,77333,Radiation treatment aid(s),APC 5611,RVU Per Unit,$129.83 ,OP,129.83,369.83,,,,,,
Meridian Duals,CPT,77334,Radiation treatment aid(s),APC 5612,RVU Per Unit,$346.58 ,OP,346.58,869.3,,,,,,
Meridian Duals,CPT,77336,Radiation physics consult,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,343.14,,,,,,
Meridian Duals,CPT,77338,Design mlc device for imrt,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,346.58,,,,,,
Meridian Duals,CPT,77370,Radiation physics consult,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,629.1,,,,,,
Meridian Duals,CPT,77371,Srs multisource,APC 5627,RVU Per Case,"$7,954.01 ",OP,"6,969.60","7,954.01",,,,,,
Meridian Duals,CPT,77372,Srs linear based,APC 5627,RVU Per Case,"$7,954.01 ",OP,"4,148.22","7,954.01",,,,,,
Meridian Duals,CPT,77373,Sbrt delivery,APC 5626,RVU Per Unit,"$1,774.17 ",OP,"1,774.17","13,221.44",,,,,,
Meridian Duals,CPT,77385,Ntsty modul rad tx dlvr smpl,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"1,379.33",,,,,,
Meridian Duals,CPT,77386,Ntsty modul rad tx dlvr cplx,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"1,379.33",,,,,,
Meridian Duals,CPT,77399,External radiation dosimetry,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,129.83,,,,,,
Meridian Duals,CPT,77401,Radiation treatment delivery,APC 5621,RVU Per Unit,$123.36 ,OP,123.36,183.02,,,,,,
Meridian Duals,CPT,77402,Radiation treatment delivery,APC 5621,RVU Per Unit,$123.36 ,OP,123.36,123.36,,,,,,
Meridian Duals,CPT,77407,Radiation treatment delivery,APC 5622,RVU Per Unit,$247.32 ,OP,247.32,247.32,,,,,,
Meridian Duals,CPT,77412,Radiation treatment delivery,APC 5622,RVU Per Unit,$247.32 ,OP,247.32,"1,067.55",,,,,,
Meridian Duals,CPT,77423,Neutron beam tx complex,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"1,235.32",,,,,,
Meridian Duals,CPT,77424,Io rad tx delivery by x-ray,APC 5627,RVU Per Case,"$7,954.01 ",OP,"7,954.01","7,954.01",,,,,,
Meridian Duals,CPT,77425,Io rad tx deliver by elctrns,APC 5627,RVU Per Case,"$7,954.01 ",OP,"7,954.01","7,954.01",,,,,,
Meridian Duals,CPT,77470,Special radiation treatment,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"1,509.83",,,,,,
Meridian Duals,CPT,77520,Proton trmt simple w/o comp,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,555.2,,,,,,
Meridian Duals,CPT,77522,Proton trmt simple w/comp,APC 5625,RVU Per Unit,"$1,328.18 ",OP,"1,328.18","1,328.18",,,,,,
Meridian Duals,CPT,77523,Proton trmt intermediate,APC 5625,RVU Per Unit,"$1,328.18 ",OP,"1,328.18","1,328.18",,,,,,
Meridian Duals,CPT,77525,Proton treatment complex,APC 5625,RVU Per Unit,"$1,328.18 ",OP,"1,328.18","1,328.18",,,,,,
Meridian Duals,CPT,77600,Hyperthermia treatment,APC 5622,RVU Per Unit,$247.32 ,OP,247.32,"1,902.54",,,,,,
Meridian Duals,CPT,77605,Hyperthermia treatment,APC 5624,RVU Per Unit,$724.98 ,OP,724.98,"3,397.11",,,,,,
Meridian Duals,CPT,77610,Hyperthermia treatment,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"3,156.91",,,,,,
Meridian Duals,CPT,77615,Hyperthermia treatment,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"4,464.67",,,,,,
Meridian Duals,CPT,77620,Hyperthermia treatment,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"2,013.11",,,,,,
Meridian Duals,CPT,77750,Infuse radioactive materials,APC 5622,RVU Per Unit,$247.32 ,OP,247.32,"1,730.97",,,,,,
Meridian Duals,CPT,77761,Apply intrcav radiat simple,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"1,803.41",,,,,,
Meridian Duals,CPT,77762,Apply intrcav radiat interm,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"2,463.00",,,,,,
Meridian Duals,CPT,77763,Apply intrcav radiat compl,APC 5624,RVU Per Unit,$724.98 ,OP,724.98,724.98,,,,,,
Meridian Duals,CPT,77767,Hdr rdncl skn surf brachytx,APC 5622,RVU Per Unit,$247.32 ,OP,247.32,247.32,,,,,,
Meridian Duals,CPT,77768,Hdr rdncl skn surf brachytx,APC 5622,RVU Per Unit,$247.32 ,OP,247.32,247.32,,,,,,
Meridian Duals,CPT,77770,Hdr rdncl ntrstl/icav brchtx,APC 5624,RVU Per Unit,$724.98 ,OP,724.98,964.61,,,,,,
Meridian Duals,CPT,77771,Hdr rdncl ntrstl/icav brchtx,APC 5624,RVU Per Unit,$724.98 ,OP,724.98,"2,882.39",,,,,,
Meridian Duals,CPT,77772,Hdr rdncl ntrstl/icav brchtx,APC 5624,RVU Per Unit,$724.98 ,OP,724.98,"4,285.47",,,,,,
Meridian Duals,CPT,77778,Apply interstit radiat compl,APC 5624,RVU Per Unit,$724.98 ,OP,724.98,"4,209.21",,,,,,
Meridian Duals,CPT,77789,Apply surf ldr radionuclide,APC 5621,RVU Per Unit,$123.36 ,OP,123.36,533.78,,,,,,
Meridian Duals,CPT,77799,Radium/radioisotope therapy,APC 5621,RVU Per Unit,$123.36 ,OP,123.36,123.36,,,,,,
Meridian Duals,CPT,78012,Thyroid uptake measurement,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,453.71,,,,,,
Meridian Duals,CPT,78013,Thyroid imaging w/blood flow,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,884.55,,,,,,
Meridian Duals,CPT,78014,Thyroid imaging w/blood flow,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,105.68",,,,,,
Meridian Duals,CPT,78015,Thyroid met imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,044.69",,,,,,
Meridian Duals,CPT,78016,Thyroid met imaging/studies,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,578.46",,,,,,
Meridian Duals,CPT,78018,Thyroid met imaging body,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,616.58",,,,,,
Meridian Duals,CPT,78070,Parathyroid planar imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,884.55,,,,,,
Meridian Duals,CPT,78071,Parathyrd planar w/wo subtrj,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,884.55,,,,,,
Meridian Duals,CPT,78072,Parathyrd planar w/spect&ct,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,884.55,,,,,,
Meridian Duals,CPT,78075,Adrenal cortex & medulla img,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","2,085.54",,,,,,
Meridian Duals,CPT,78099,Endocrine nuclear procedure,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Meridian Duals,CPT,78102,Bone marrow imaging ltd,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Meridian Duals,CPT,78103,Bone marrow imaging mult,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,109.50",,,,,,
Meridian Duals,CPT,78104,Bone marrow imaging body,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,273.44",,,,,,
Meridian Duals,CPT,78110,Plasma volume single,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,336.39",,,,,,
Meridian Duals,CPT,78111,Plasma volume multiple,APC 5593,RVU Per Unit,"$1,336.39 ",OP,518.52,"1,336.39",,,,,,
Meridian Duals,CPT,78120,Red cell mass single,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Meridian Duals,CPT,78121,Red cell mass multiple,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,552.84,,,,,,
Meridian Duals,CPT,78122,Blood volume,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,701.54,,,,,,
Meridian Duals,CPT,78130,Red cell survival study,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,793.05,,,,,,
Meridian Duals,CPT,78140,Red cell sequestration,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,781.61,,,,,,
Meridian Duals,CPT,78185,Spleen imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Meridian Duals,CPT,78191,Platelet survival,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,067.55",,,,,,
Meridian Duals,CPT,78195,Lymph system imaging,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,704.28",,,,,,
Meridian Duals,CPT,78199,Blood/lymph nuclear exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Meridian Duals,CPT,78201,Liver imaging,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,884.55,,,,,,
Meridian Duals,CPT,78202,Liver imaging with flow,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,014.17",,,,,,
Meridian Duals,CPT,78215,Liver and spleen imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,941.74,,,,,,
Meridian Duals,CPT,78216,Liver & spleen image/flow,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,728.23,,,,,,
Meridian Duals,CPT,78226,Hepatobiliary system imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,570.83",,,,,,
Meridian Duals,CPT,78227,Hepatobil syst image w/drug,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,570.83",,,,,,
Meridian Duals,CPT,78230,Salivary gland imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,804.48,,,,,,
Meridian Duals,CPT,78231,Serial salivary imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,697.72,,,,,,
Meridian Duals,CPT,78232,Salivary gland function exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,712.98,,,,,,
Meridian Duals,CPT,78258,Esophageal motility study,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,113.30",,,,,,
Meridian Duals,CPT,78261,Gastric mucosa imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,242.94",,,,,,
Meridian Duals,CPT,78262,Gastroesophageal reflux exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,227.68",,,,,,
Meridian Duals,CPT,78264,Gastric emptying imag study,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,403.08",,,,,,
Meridian Duals,CPT,78265,Gastric emptying imag study,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,403.08",,,,,,
Meridian Duals,CPT,78266,Gastric emptying imag study,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,403.08",,,,,,
Meridian Duals,CPT,78267,Breath tst attain/anal c-14,Lab Services,Per Unit,$11.06 ,OP,11.06,11.06,,,,,,
Meridian Duals,CPT,78268,Breath test analysis c-14,Lab Services,Per Unit,$94.41 ,OP,94.41,301.2,,,,,,
Meridian Duals,CPT,78278,Acute gi blood loss imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Meridian Duals,CPT,78282,Gi protein loss exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,407.96,,,,,,
Meridian Duals,CPT,78290,Meckels divert exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,498.39",,,,,,
Meridian Duals,CPT,78291,Leveen/shunt patency exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,227.68",,,,,,
Meridian Duals,CPT,78299,Gi nuclear procedure,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Meridian Duals,CPT,78300,Bone imaging limited area,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,869.3,,,,,,
Meridian Duals,CPT,78305,Bone imaging multiple areas,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,155.24",,,,,,
Meridian Duals,CPT,78306,Bone imaging whole body,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,281.07",,,,,,
Meridian Duals,CPT,78315,Bone imaging 3 phase,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,692.84",,,,,,
Meridian Duals,CPT,78399,Musculoskeletal nuclear exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Meridian Duals,CPT,78414,Non-imaging heart function,APC 5592,RVU Per Unit,$500.81 ,OP,377.46,500.81,,,,,,
Meridian Duals,CPT,78428,Cardiac shunt imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,998.92,,,,,,
Meridian Duals,CPT,78429,Myocrd img pet 1 std w/ct,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,240.30",,,,,,
Meridian Duals,CPT,78430,Myocrd img pet rst/strs w/ct,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,217.42",,,,,,
Meridian Duals,CPT,78431,Myocrd img pet rst&strs ct,APC 1522,RVU Per Unit,"$2,302.98 ",OP,"2,150.30","7,339.44",,,,,,
Meridian Duals,CPT,78432,Myocrd img pet 2rtracer,APC 1523,RVU Per Unit,"$2,814.64 ",OP,"2,628.05","8,030.21",,,,,,
Meridian Duals,CPT,78433,Myocrd img pet 2rtracer ct,APC 1523,RVU Per Unit,"$2,814.64 ",OP,"2,628.05","8,778.55",,,,,,
Meridian Duals,CPT,78445,Vascular flow imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,838.79,,,,,,
Meridian Duals,CPT,78451,Ht muscle image spect sing,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","2,116.06",,,,,,
Meridian Duals,CPT,78452,Ht muscle image spect mult,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","3,343.73",,,,,,
Meridian Duals,CPT,78453,Ht muscle image planar sing,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,631.84",,,,,,
Meridian Duals,CPT,78454,Ht musc image planar mult,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,772.90",,,,,,
Meridian Duals,CPT,78456,Acute venous thrombus image,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,784.34",,,,,,
Meridian Duals,CPT,78457,Venous thrombosis imaging,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,964.61,,,,,,
Meridian Duals,CPT,78458,Ven thrombosis images bilat,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,078.99",,,,,,
Meridian Duals,CPT,78459,Myocrd img pet single study,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","7,240.30",,,,,,
Meridian Duals,CPT,78466,Heart infarct image,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,922.67,,,,,,
Meridian Duals,CPT,78468,Heart infarct image (ef),APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,166.68",,,,,,
Meridian Duals,CPT,78469,Heart infarct image (3d),APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,338.26",,,,,,
Meridian Duals,CPT,78472,Gated heart planar single,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,368.75",,,,,,
Meridian Duals,CPT,78473,Gated heart multiple,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,872.03",,,,,,
Meridian Duals,CPT,78481,Heart first pass single,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,201.00",,,,,,
Meridian Duals,CPT,78483,Heart first pass multiple,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,700.46",,,,,,
Meridian Duals,CPT,78491,Myocrd img pet 1std rst/strs,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,217.42",,,,,,
Meridian Duals,CPT,78492,Myocrd img pet mlt rst&strs,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,339.44",,,,,,
Meridian Duals,CPT,78494,Heart image spect,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,486.95",,,,,,
Meridian Duals,CPT,78499,Cardiovascular nuclear exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Meridian Duals,CPT,78579,Lung ventilation imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,155.24",,,,,,
Meridian Duals,CPT,78580,Lung perfusion imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,071.37",,,,,,
Meridian Duals,CPT,78582,Lung ventilat&perfus imaging,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,769.09",,,,,,
Meridian Duals,CPT,78597,Lung perfusion differential,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,906.36",,,,,,
Meridian Duals,CPT,78598,Lung perf&ventilat diferentl,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,906.36",,,,,,
Meridian Duals,CPT,78599,Respiratory nuclear exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Meridian Duals,CPT,78600,Brain image < 4 views,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,888.36,,,,,,
Meridian Duals,CPT,78601,Brain image w/flow < 4 views,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,059.93",,,,,,
Meridian Duals,CPT,78605,Brain image 4+ views,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,991.29,,,,,,
Meridian Duals,CPT,78606,Brain image w/flow 4 + views,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,540.33",,,,,,
Meridian Duals,CPT,78608,Brain imaging (pet),APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,209.80",,,,,,
Meridian Duals,CPT,78610,Brain flow imaging only,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,888.36,,,,,,
Meridian Duals,CPT,78630,Cerebrospinal fluid scan,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,647.08",,,,,,
Meridian Duals,CPT,78635,Csf ventriculography,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,475.51",,,,,,
Meridian Duals,CPT,78645,Csf shunt evaluation,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,502.21",,,,,,
Meridian Duals,CPT,78650,Csf leakage imaging,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,601.33",,,,,,
Meridian Duals,CPT,78660,Nuclear exam of tear flow,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,831.17,,,,,,
Meridian Duals,CPT,78699,Nervous system nuclear exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Meridian Duals,CPT,78700,Kidney imaging morphol,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,884.55,,,,,,
Meridian Duals,CPT,78701,Kidney imaging with flow,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,056.11",,,,,,
Meridian Duals,CPT,78707,K flow/funct image w/o drug,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,235.32",,,,,,
Meridian Duals,CPT,78708,K flow/funct image w/drug,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,014.17",,,,,,
Meridian Duals,CPT,78709,K flow/funct image multiple,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,795.78",,,,,,
Meridian Duals,CPT,78725,Kidney function study,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,518.52,,,,,,
Meridian Duals,CPT,78740,Ureteral reflux study,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,040.87",,,,,,
Meridian Duals,CPT,78761,Testicular imaging w/flow,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,052.29",,,,,,
Meridian Duals,CPT,78799,Genitourinary nuclear exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Meridian Duals,CPT,78800,Rp loclzj tum 1 area 1 d img,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,949.36,,,,,,
Meridian Duals,CPT,78801,Rp loclzj tum 2+area 1+d img,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,265.81",,,,,,
Meridian Duals,CPT,78802,Rp loclzj tum whbdy 1 d img,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,654.72",,,,,,
Meridian Duals,CPT,78803,Rp loclzj tum spect 1 area,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,826.28",,,,,,
Meridian Duals,CPT,78804,Rp loclzj tum whbdy 2+d img,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","2,870.96",,,,,,
Meridian Duals,CPT,78808,Iv inj ra drug dx study,APC 5591,RVU Per Case,$385.91 ,OP,385.91,385.91,,,,,,
Meridian Duals,CPT,78811,Pet image ltd area,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,336.39",,,,,,
Meridian Duals,CPT,78812,Pet image skull-thigh,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,347.07",,,,,,
Meridian Duals,CPT,78813,Pet image full body,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,354.67",,,,,,
Meridian Duals,CPT,78814,Pet image w/ct lmtd,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,404.24",,,,,,
Meridian Duals,CPT,78815,Pet image w/ct skull-thigh,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,446.19",,,,,,
Meridian Duals,CPT,78816,Pet image w/ct full body,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,461.44",,,,,,
Meridian Duals,CPT,78830,Rp loclzj tum spect w/ct 1,APC 5593,RVU Per Unit,"$1,336.39 ",OP,927,"2,600.43",,,,,,
Meridian Duals,CPT,78831,Rp loclzj tum spect 2 areas,APC 5593,RVU Per Unit,"$1,336.39 ",OP,927,"3,860.65",,,,,,
Meridian Duals,CPT,78832,Rp loclzj tum spect w/ct 2,APC 5594,RVU Per Unit,"$1,514.86 ",OP,927,"5,097.10",,,,,,
Meridian Duals,CPT,78999,Nuclear diagnostic exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Meridian Duals,CPT,79005,Nuclear rx oral admin,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,800.67,,,,,,
Meridian Duals,CPT,79101,Nuclear rx iv admin,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,896,,,,,,
Meridian Duals,CPT,79200,Nuclear rx intracav admin,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,911.23,,,,,,
Meridian Duals,CPT,79300,Nuclr rx interstit colloid,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,724.42,,,,,,
Meridian Duals,CPT,79403,Hematopoietic nuclear tx,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,"1,132.37",,,,,,
Meridian Duals,CPT,79440,Nuclear rx intra-articular,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,838.79,,,,,,
Meridian Duals,CPT,79445,Nuclear rx intra-arterial,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,"1,162.87",,,,,,
Meridian Duals,CPT,79999,Nuclear medicine therapy,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,255.45,,,,,,
Meridian Duals,CPT,80047,Metabolic panel ionized ca,Lab Services,Per Unit,$13.73 ,OP,13.73,41.94,,,,,,
Meridian Duals,CPT,80048,Metabolic panel total ca,Lab Services,Per Unit,$8.46 ,OP,8.46,132.19,,,,,,
Meridian Duals,CPT,80051,Electrolyte panel,Lab Services,Per Unit,$7.01 ,OP,7.01,34.31,,,,,,
Meridian Duals,CPT,80053,Comprehen metabolic panel,Lab Services,Per Unit,$10.56 ,OP,10.56,172.42,,,,,,
Meridian Duals,CPT,80055,Obstetric panel,Lab Services,Per Unit,$47.81 ,OP,47.81,301.2,,,,,,
Meridian Duals,CPT,80061,Lipid panel,Lab Services,Per Unit,$13.39 ,OP,13.39,68.63,,,,,,
Meridian Duals,CPT,80069,Renal function panel,Lab Services,Per Unit,$8.68 ,OP,8.68,38.13,,,,,,
Meridian Duals,CPT,80074,Acute hepatitis panel,Lab Services,Per Unit,$47.63 ,OP,47.63,213.51,,,,,,
Meridian Duals,CPT,80076,Hepatic function panel,Lab Services,Per Unit,$8.17 ,OP,8.17,126.44,,,,,,
Meridian Duals,CPT,80081,Obstetric panel,Lab Services,Per Unit,$74.86 ,OP,74.86,74.86,,,,,,
Meridian Duals,CPT,80143,Drug assay acetaminophen,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,
Meridian Duals,CPT,80145,Drug assay adalimumab,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,
Meridian Duals,CPT,80150,Assay of amikacin,Lab Services,Per Unit,$15.08 ,OP,15.08,49.56,,,,,,
Meridian Duals,CPT,80151,Drug assay amiodarone,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,
Meridian Duals,CPT,80155,Drug assay caffeine,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,
Meridian Duals,CPT,80156,Assay carbamazepine total,Lab Services,Per Unit,$14.57 ,OP,14.57,64.82,,,,,,
Meridian Duals,CPT,80157,Assay carbamazepine free,Lab Services,Per Unit,$13.25 ,OP,13.25,57.19,,,,,,
Meridian Duals,CPT,80158,Drug assay cyclosporine,Lab Services,Per Unit,$18.05 ,OP,18.05,80.07,,,,,,
Meridian Duals,CPT,80159,Drug assay clozapine,Lab Services,Per Unit,$20.15 ,OP,20.15,20.15,,,,,,
Meridian Duals,CPT,80161,Asy carbamazepin 10-11-epxid,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,
Meridian Duals,CPT,80162,Assay of digoxin total,Lab Services,Per Unit,$13.28 ,OP,13.28,61,,,,,,
Meridian Duals,CPT,80163,Assay of digoxin free,Lab Services,Per Unit,$13.28 ,OP,13.28,61,,,,,,
Meridian Duals,CPT,80164,Assay dipropylacetic acd tot,Lab Services,Per Unit,$13.54 ,OP,13.54,61,,,,,,
Meridian Duals,CPT,80165,Dipropylacetic acid free,Lab Services,Per Unit,$13.54 ,OP,13.54,61,,,,,,
Meridian Duals,CPT,80167,Drug assay felbamate,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,
Meridian Duals,CPT,80168,Assay of ethosuximide,Lab Services,Per Unit,$16.34 ,OP,16.34,72.44,,,,,,
Meridian Duals,CPT,80169,Drug assay everolimus,Lab Services,Per Unit,$13.73 ,OP,13.73,13.73,,,,,,
Meridian Duals,CPT,80170,Assay of gentamicin,Lab Services,Per Unit,$16.38 ,OP,16.38,72.44,,,,,,
Meridian Duals,CPT,80171,Drug screen quant gabapentin,Lab Services,Per Unit,$21.67 ,OP,21.67,21.67,,,,,,
Meridian Duals,CPT,80173,Assay of haloperidol,Lab Services,Per Unit,$15.78 ,OP,15.78,15.78,,,,,,
Meridian Duals,CPT,80175,Drug screen quan lamotrigine,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,
Meridian Duals,CPT,80176,Assay of lidocaine,Lab Services,Per Unit,$14.69 ,OP,14.69,64.82,,,,,,
Meridian Duals,CPT,80177,Drug scrn quan levetiracetam,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,
Meridian Duals,CPT,80178,Assay of lithium,Lab Services,Per Unit,$6.61 ,OP,6.61,30.51,,,,,,
Meridian Duals,CPT,80179,Drug assay salicylate,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,
Meridian Duals,CPT,80180,Drug scrn quan mycophenolate,Lab Services,Per Unit,$18.05 ,OP,18.05,18.05,,,,,,
Meridian Duals,CPT,80181,Drug assay flecainide,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,
Meridian Duals,CPT,80183,Drug scrn quant oxcarbazepin,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,
Meridian Duals,CPT,80184,Assay of phenobarbital,Lab Services,Per Unit,$15.30 ,OP,15.3,49.56,,,,,,
Meridian Duals,CPT,80185,Assay of phenytoin total,Lab Services,Per Unit,$13.25 ,OP,13.25,57.19,,,,,,
Meridian Duals,CPT,80186,Assay of phenytoin free,Lab Services,Per Unit,$13.76 ,OP,13.76,61,,,,,,
Meridian Duals,CPT,80187,Drug assay posaconazole,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,
Meridian Duals,CPT,80188,Assay of primidone,Lab Services,Per Unit,$16.59 ,OP,16.59,72.44,,,,,,
Meridian Duals,CPT,80189,Drug assay itraconzaole,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,
Meridian Duals,CPT,80190,Assay of procainamide,Lab Services,Per Unit,$60.00 ,OP,60,76.26,,,,,,
Meridian Duals,CPT,80192,Assay of procainamide,Lab Services,Per Unit,$16.75 ,OP,16.75,76.26,,,,,,
Meridian Duals,CPT,80193,Drug assay leflunomide,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,
Meridian Duals,CPT,80194,Assay of quinidine,Lab Services,Per Unit,$14.60 ,OP,14.6,64.82,,,,,,
Meridian Duals,CPT,80195,Assay of sirolimus,Lab Services,Per Unit,$13.73 ,OP,13.73,61,,,,,,
Meridian Duals,CPT,80197,Assay of tacrolimus,Lab Services,Per Unit,$13.73 ,OP,13.73,61,,,,,,
Meridian Duals,CPT,80198,Assay of theophylline,Lab Services,Per Unit,$14.14 ,OP,14.14,64.82,,,,,,
Meridian Duals,CPT,80199,Drug screen quant tiagabine,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,
Meridian Duals,CPT,80200,Assay of tobramycin,Lab Services,Per Unit,$16.13 ,OP,16.13,49.56,,,,,,
Meridian Duals,CPT,80201,Assay of topiramate,Lab Services,Per Unit,$11.92 ,OP,11.92,53.38,,,,,,
Meridian Duals,CPT,80202,Assay of vancomycin,Lab Services,Per Unit,$13.54 ,OP,13.54,61,,,,,,
Meridian Duals,CPT,80203,Drug screen quant zonisamide,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,
Meridian Duals,CPT,80204,Drug assay methotrexate,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,
Meridian Duals,CPT,80210,Drug assay rufinamide,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,
Meridian Duals,CPT,80230,Drug assay infliximab,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,
Meridian Duals,CPT,80235,Drug assay lacosamide,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,
Meridian Duals,CPT,80280,Drug assay vedolizumab,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,
Meridian Duals,CPT,80285,Drug assay voriconazole,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,
Meridian Duals,CPT,80299,Quantitative assay drug,Lab Services,Per Unit,$18.64 ,OP,18.64,61,,,,,,
Meridian Duals,CPT,80305,Drug test prsmv dir opt obs,Lab Services,Per Unit,$12.60 ,OP,12.6,64.82,,,,,,
Meridian Duals,CPT,80306,Drug test prsmv instrmnt,Lab Services,Per Unit,$17.14 ,OP,17.14,64.82,,,,,,
Meridian Duals,CPT,80307,Drug test prsmv chem anlyzr,Lab Services,Per Unit,$62.14 ,OP,62.14,62.14,,,,,,
Meridian Duals,CPT,80400,Acth stimulation panel,Lab Services,Per Unit,$32.62 ,OP,32.62,144.88,,,,,,
Meridian Duals,CPT,80402,Acth stimulation panel,Lab Services,Per Unit,$86.96 ,OP,86.96,388.89,,,,,,
Meridian Duals,CPT,80406,Acth stimulation panel,Lab Services,Per Unit,$78.26 ,OP,78.26,346.96,,,,,,
Meridian Duals,CPT,80408,Aldosterone suppression eval,Lab Services,Per Unit,$125.50 ,OP,125.5,560.47,,,,,,
Meridian Duals,CPT,80410,Calcitonin stimul panel,Lab Services,Per Unit,$80.37 ,OP,80.37,358.39,,,,,,
Meridian Duals,CPT,80412,Crh stimulation panel,Lab Services,Per Unit,$801.62 ,OP,801.62,"1,467.89",,,,,,
Meridian Duals,CPT,80414,Testosterone response panel,Lab Services,Per Unit,$51.64 ,OP,51.64,228.77,,,,,,
Meridian Duals,CPT,80415,Tot estradiol response panel,Lab Services,Per Unit,$55.89 ,OP,55.89,99.13,,,,,,
Meridian Duals,CPT,80416,Renin stimulation panel,Lab Services,Per Unit,$209.32 ,OP,209.32,587.16,,,,,,
Meridian Duals,CPT,80417,Renin stimulation panel,Lab Services,Per Unit,$43.99 ,OP,43.99,194.45,,,,,,
Meridian Duals,CPT,80418,Pituitary evaluation panel,Lab Services,Per Unit,$579.48 ,OP,579.48,"2,573.58",,,,,,
Meridian Duals,CPT,80420,Dexamethasone panel,Lab Services,Per Unit,$161.88 ,OP,161.88,320.27,,,,,,
Meridian Duals,CPT,80422,Glucagon tolerance panel,Lab Services,Per Unit,$46.07 ,OP,46.07,205.88,,,,,,
Meridian Duals,CPT,80424,Glucagon tolerance panel,Lab Services,Per Unit,$50.50 ,OP,50.5,224.95,,,,,,
Meridian Duals,CPT,80426,Gonadotropin hormone panel,Lab Services,Per Unit,$148.41 ,OP,148.41,659.6,,,,,,
Meridian Duals,CPT,80428,Growth hormone panel,Lab Services,Per Unit,$66.70 ,OP,66.7,289.76,,,,,,
Meridian Duals,CPT,80430,Growth hormone panel,Lab Services,Per Unit,$129.33 ,OP,129.33,343.14,,,,,,
Meridian Duals,CPT,80432,Insulin suppression panel,Lab Services,Per Unit,$165.61 ,OP,165.61,602.41,,,,,,
Meridian Duals,CPT,80434,Insulin tolerance panel,Lab Services,Per Unit,$285.03 ,OP,285.03,449.9,,,,,,
Meridian Duals,CPT,80435,Insulin tolerance panel,Lab Services,Per Unit,$103.00 ,OP,103,449.9,,,,,,
Meridian Duals,CPT,80436,Metyrapone panel,Lab Services,Per Unit,$91.16 ,OP,91.16,301.2,,,,,,
Meridian Duals,CPT,80438,Trh stimulation panel,Lab Services,Per Unit,$50.41 ,OP,50.41,224.95,,,,,,
Meridian Duals,CPT,80439,Trh stimulation panel,Lab Services,Per Unit,$67.21 ,OP,67.21,297.39,,,,,,
Meridian Duals,CPT,80500,Lab pathology consultation,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Meridian Duals,CPT,80502,Lab pathology consultation,APC 5672,RVU Per Case,$152.64 ,OP,152.64,320.27,,,,,,
Meridian Duals,CPT,81000,Urinalysis nonauto w/scope,Lab Services,Per Unit,$4.02 ,OP,4.02,15.26,,,,,,
Meridian Duals,CPT,81001,Urinalysis auto w/scope,Lab Services,Per Unit,$3.17 ,OP,3.17,15.26,,,,,,
Meridian Duals,CPT,81002,Urinalysis nonauto w/o scope,Lab Services,Per Unit,$3.48 ,OP,3.48,11.44,,,,,,
Meridian Duals,CPT,81003,Urinalysis auto w/o scope,Lab Services,Per Unit,$2.25 ,OP,2.25,11.44,,,,,,
Meridian Duals,CPT,81005,Urinalysis,Lab Services,Per Unit,$2.17 ,OP,2.17,11.44,,,,,,
Meridian Duals,CPT,81007,Urine screen for bacteria,Lab Services,Per Unit,$29.98 ,OP,11.44,29.98,,,,,,
Meridian Duals,CPT,81015,Microscopic exam of urine,Lab Services,Per Unit,$3.05 ,OP,3.05,15.26,,,,,,
Meridian Duals,CPT,81020,Urinalysis glass test,Lab Services,Per Unit,$4.70 ,OP,4.7,15.26,,,,,,
Meridian Duals,CPT,81025,Urine pregnancy test,Lab Services,Per Unit,$8.61 ,OP,8.61,30.51,,,,,,
Meridian Duals,CPT,81050,Urinalysis volume measure,Lab Services,Per Unit,$3.64 ,OP,3.64,11.44,,,,,,
Meridian Duals,CPT,81105,Hpa-1 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
Meridian Duals,CPT,81106,Hpa-2 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
Meridian Duals,CPT,81107,Hpa-3 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
Meridian Duals,CPT,81108,Hpa-4 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
Meridian Duals,CPT,81109,Hpa-5 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
Meridian Duals,CPT,81110,Hpa-6 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
Meridian Duals,CPT,81111,Hpa-9 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
Meridian Duals,CPT,81112,Hpa-15 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
Meridian Duals,CPT,81120,Idh1 common variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,
Meridian Duals,CPT,81121,Idh2 common variants,Lab Services,Per Unit,$295.79 ,OP,295.79,295.79,,,,,,
Meridian Duals,CPT,81161,Dmd dup/delet analysis,Lab Services,Per Unit,$279.00 ,OP,279,279,,,,,,
Meridian Duals,CPT,81162,Brca1&2 gen full seq dup/del,Lab Services,Per Unit,"$1,824.88 ",OP,"1,824.88","1,824.88",,,,,,
Meridian Duals,CPT,81163,Brca1&2 gene full seq alys,Lab Services,Per Unit,$468.00 ,OP,468,468,,,,,,
Meridian Duals,CPT,81164,Brca1&2 gen ful dup/del alys,Lab Services,Per Unit,$584.23 ,OP,584.23,584.23,,,,,,
Meridian Duals,CPT,81165,Brca1 gene full seq alys,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,
Meridian Duals,CPT,81166,Brca1 gene full dup/del alys,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,
Meridian Duals,CPT,81167,Brca2 gene full dup/del alys,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,
Meridian Duals,CPT,81168,Ccnd1/igh translocation alys,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,
Meridian Duals,CPT,81170,Abl1 gene,Lab Services,Per Unit,$300.00 ,OP,300,300,,,,,,
Meridian Duals,CPT,81171,Aff2 gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Meridian Duals,CPT,81172,Aff2 gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Meridian Duals,CPT,81173,Ar gene full gene sequence,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,
Meridian Duals,CPT,81174,Ar gene known famil variant,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Meridian Duals,CPT,81175,Asxl1 full gene sequence,Lab Services,Per Unit,$676.50 ,OP,676.5,676.5,,,,,,
Meridian Duals,CPT,81176,Asxl1 gene target seq alys,Lab Services,Per Unit,$241.90 ,OP,241.9,241.9,,,,,,
Meridian Duals,CPT,81177,Atn1 gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Meridian Duals,CPT,81178,Atxn1 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Meridian Duals,CPT,81179,Atxn2 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Meridian Duals,CPT,81180,Atxn3 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Meridian Duals,CPT,81181,Atxn7 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Meridian Duals,CPT,81182,Atxn8os gen detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Meridian Duals,CPT,81183,Atxn10 gene detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Meridian Duals,CPT,81184,Cacna1a gen detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Meridian Duals,CPT,81185,Cacna1a gene full gene seq,Lab Services,Per Unit,$846.27 ,OP,846.27,846.27,,,,,,
Meridian Duals,CPT,81186,Cacna1a gen known famil vrnt,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Meridian Duals,CPT,81187,Cnbp gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Meridian Duals,CPT,81188,Cstb gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Meridian Duals,CPT,81189,Cstb gene full gene sequence,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Meridian Duals,CPT,81190,Cstb gene known famil vrnt,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Meridian Duals,CPT,81191,Ntrk1 translocation analysis,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,
Meridian Duals,CPT,81192,Ntrk2 translocation analysis,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,
Meridian Duals,CPT,81193,Ntrk3 translocation analysis,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,
Meridian Duals,CPT,81194,Ntrk translocation analysis,Lab Services,Per Unit,$518.28 ,OP,518.28,518.28,,,,,,
Meridian Duals,CPT,81200,Aspa gene,Lab Services,Per Unit,$47.25 ,OP,47.25,47.25,,,,,,
Meridian Duals,CPT,81201,Apc gene full sequence,Lab Services,Per Unit,$780.00 ,OP,780,780,,,,,,
Meridian Duals,CPT,81202,Apc gene known fam variants,Lab Services,Per Unit,$280.00 ,OP,280,280,,,,,,
Meridian Duals,CPT,81203,Apc gene dup/delet variants,Lab Services,Per Unit,$200.00 ,OP,200,200,,,,,,
Meridian Duals,CPT,81204,Ar gene charac alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Meridian Duals,CPT,81205,Bckdhb gene,Lab Services,Per Unit,$94.99 ,OP,94.99,94.99,,,,,,
Meridian Duals,CPT,81206,Bcr/abl1 gene major bp,Lab Services,Per Unit,$163.96 ,OP,163.96,163.96,,,,,,
Meridian Duals,CPT,81207,Bcr/abl1 gene minor bp,Lab Services,Per Unit,$144.84 ,OP,144.84,144.84,,,,,,
Meridian Duals,CPT,81208,Bcr/abl1 gene other bp,Lab Services,Per Unit,$214.62 ,OP,214.62,214.62,,,,,,
Meridian Duals,CPT,81209,Blm gene,Lab Services,Per Unit,$39.31 ,OP,39.31,39.31,,,,,,
Meridian Duals,CPT,81210,Braf gene,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,
Meridian Duals,CPT,81212,Brca1&2 185&5385&6174 vrnt,Lab Services,Per Unit,$440.00 ,OP,440,440,,,,,,
Meridian Duals,CPT,81215,Brca1 gene known famil vrnt,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,
Meridian Duals,CPT,81216,Brca2 gene full seq alys,Lab Services,Per Unit,$185.12 ,OP,185.12,185.12,,,,,,
Meridian Duals,CPT,81217,Brca2 gene known famil vrnt,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,
Meridian Duals,CPT,81218,Cebpa gene full sequence,Lab Services,Per Unit,$241.90 ,OP,241.9,241.9,,,,,,
Meridian Duals,CPT,81219,Calr gene com variants,Lab Services,Per Unit,$121.63 ,OP,121.63,121.63,,,,,,
Meridian Duals,CPT,81220,Cftr gene com variants,Lab Services,Per Unit,$556.60 ,OP,556.6,556.6,,,,,,
Meridian Duals,CPT,81221,Cftr gene known fam variants,Lab Services,Per Unit,$97.22 ,OP,97.22,97.22,,,,,,
Meridian Duals,CPT,81222,Cftr gene dup/delet variants,Lab Services,Per Unit,$435.07 ,OP,435.07,435.07,,,,,,
Meridian Duals,CPT,81223,Cftr gene full sequence,Lab Services,Per Unit,$499.00 ,OP,499,499,,,,,,
Meridian Duals,CPT,81224,Cftr gene intron poly t,Lab Services,Per Unit,$168.75 ,OP,168.75,168.75,,,,,,
Meridian Duals,CPT,81225,Cyp2c19 gene com variants,Lab Services,Per Unit,$291.36 ,OP,291.36,291.36,,,,,,
Meridian Duals,CPT,81226,Cyp2d6 gene com variants,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,
Meridian Duals,CPT,81227,Cyp2c9 gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Meridian Duals,CPT,81228,Cytogen micrarray copy nmbr,Lab Services,Per Unit,$900.00 ,OP,900,900,,,,,,
Meridian Duals,CPT,81229,Cytogen m array copy no&snp,Lab Services,Per Unit,"$1,160.00 ",OP,"1,160.00","1,160.00",,,,,,
Meridian Duals,CPT,81230,Cyp3a4 gene common variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Meridian Duals,CPT,81231,Cyp3a5 gene common variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Meridian Duals,CPT,81232,Dpyd gene common variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Meridian Duals,CPT,81233,Btk gene common variants,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,
Meridian Duals,CPT,81234,Dmpk gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Meridian Duals,CPT,81235,Egfr gene com variants,Lab Services,Per Unit,$324.58 ,OP,324.58,324.58,,,,,,
Meridian Duals,CPT,81236,Ezh2 gene full gene sequence,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,
Meridian Duals,CPT,81237,Ezh2 gene common variants,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,
Meridian Duals,CPT,81238,F9 full gene sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,
Meridian Duals,CPT,81239,Dmpk gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Meridian Duals,CPT,81240,F2 gene,Lab Services,Per Unit,$65.69 ,OP,65.69,65.69,,,,,,
Meridian Duals,CPT,81241,F5 gene,Lab Services,Per Unit,$73.37 ,OP,73.37,73.37,,,,,,
Meridian Duals,CPT,81242,Fancc gene,Lab Services,Per Unit,$36.62 ,OP,36.62,36.62,,,,,,
Meridian Duals,CPT,81243,Fmr1 gene detection,Lab Services,Per Unit,$57.04 ,OP,57.04,57.04,,,,,,
Meridian Duals,CPT,81244,Fmr1 gene charac alleles,Lab Services,Per Unit,$44.89 ,OP,44.89,44.89,,,,,,
Meridian Duals,CPT,81245,Flt3 gene,Lab Services,Per Unit,$165.51 ,OP,165.51,165.51,,,,,,
Meridian Duals,CPT,81246,Flt3 gene analysis,Lab Services,Per Unit,$83.00 ,OP,83,83,,,,,,
Meridian Duals,CPT,81247,G6pd gene alys cmn variant,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Meridian Duals,CPT,81248,G6pd known familial variant,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,
Meridian Duals,CPT,81249,G6pd full gene sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,
Meridian Duals,CPT,81250,G6pc gene,Lab Services,Per Unit,$58.49 ,OP,58.49,58.49,,,,,,
Meridian Duals,CPT,81251,Gba gene,Lab Services,Per Unit,$47.25 ,OP,47.25,47.25,,,,,,
Meridian Duals,CPT,81252,Gjb2 gene full sequence,Lab Services,Per Unit,$101.12 ,OP,101.12,101.12,,,,,,
Meridian Duals,CPT,81253,Gjb2 gene known fam variants,Lab Services,Per Unit,$61.52 ,OP,61.52,61.52,,,,,,
Meridian Duals,CPT,81254,Gjb6 gene com variants,Lab Services,Per Unit,$35.00 ,OP,35,35,,,,,,
Meridian Duals,CPT,81255,Hexa gene,Lab Services,Per Unit,$51.45 ,OP,51.45,51.45,,,,,,
Meridian Duals,CPT,81256,Hfe gene,Lab Services,Per Unit,$65.36 ,OP,65.36,65.36,,,,,,
Meridian Duals,CPT,81257,Hba1/hba2 gene,Lab Services,Per Unit,$102.26 ,OP,102.26,102.26,,,,,,
Meridian Duals,CPT,81258,Hba1/hba2 gene fam vrnt,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,
Meridian Duals,CPT,81259,Hba1/hba2 full gene sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,
Meridian Duals,CPT,81260,Ikbkap gene,Lab Services,Per Unit,$39.31 ,OP,39.31,39.31,,,,,,
Meridian Duals,CPT,81261,Igh gene rearrange amp meth,Lab Services,Per Unit,$197.99 ,OP,197.99,197.99,,,,,,
Meridian Duals,CPT,81262,Igh gene rearrang dir probe,Lab Services,Per Unit,$68.55 ,OP,68.55,68.55,,,,,,
Meridian Duals,CPT,81263,Igh vari regional mutation,Lab Services,Per Unit,$294.52 ,OP,294.52,294.52,,,,,,
Meridian Duals,CPT,81264,Igk rearrangeabn clonal pop,Lab Services,Per Unit,$172.73 ,OP,172.73,172.73,,,,,,
Meridian Duals,CPT,81265,Str markers specimen anal,Lab Services,Per Unit,$233.07 ,OP,233.07,233.07,,,,,,
Meridian Duals,CPT,81266,Str markers spec anal addl,Lab Services,Per Unit,$304.81 ,OP,304.81,304.81,,,,,,
Meridian Duals,CPT,81267,Chimerism anal no cell selec,Lab Services,Per Unit,$207.46 ,OP,207.46,207.46,,,,,,
Meridian Duals,CPT,81268,Chimerism anal w/cell select,Lab Services,Per Unit,$260.79 ,OP,260.79,260.79,,,,,,
Meridian Duals,CPT,81269,Hba1/hba2 gene dup/del vrnts,Lab Services,Per Unit,$202.40 ,OP,202.4,202.4,,,,,,
Meridian Duals,CPT,81270,Jak2 gene,Lab Services,Per Unit,$91.66 ,OP,91.66,91.66,,,,,,
Meridian Duals,CPT,81271,Htt gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Meridian Duals,CPT,81272,Kit gene targeted seq analys,Lab Services,Per Unit,$329.51 ,OP,329.51,329.51,,,,,,
Meridian Duals,CPT,81273,Kit gene analys d816 variant,Lab Services,Per Unit,$124.87 ,OP,124.87,124.87,,,,,,
Meridian Duals,CPT,81274,Htt gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Meridian Duals,CPT,81275,Kras gene variants exon 2,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,
Meridian Duals,CPT,81276,Kras gene addl variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,
Meridian Duals,CPT,81277,Cytogenomic neo microra alys,Lab Services,Per Unit,"$1,160.00 ",OP,"1,160.00","1,160.00",,,,,,
Meridian Duals,CPT,81278,Igh@/bcl2 translocation alys,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,
Meridian Duals,CPT,81279,Jak2 gene trgt sequence alys,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Meridian Duals,CPT,81283,Ifnl3 gene,Lab Services,Per Unit,$73.37 ,OP,73.37,73.37,,,,,,
Meridian Duals,CPT,81284,Fxn gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Meridian Duals,CPT,81285,Fxn gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Meridian Duals,CPT,81286,Fxn gene full gene sequence,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Meridian Duals,CPT,81287,Mgmt gene prmtr mthyltn alys,Lab Services,Per Unit,$124.64 ,OP,124.64,124.64,,,,,,
Meridian Duals,CPT,81288,Mlh1 gene,Lab Services,Per Unit,$192.32 ,OP,192.32,192.32,,,,,,
Meridian Duals,CPT,81289,Fxn gene known famil variant,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Meridian Duals,CPT,81290,Mcoln1 gene,Lab Services,Per Unit,$39.31 ,OP,39.31,39.31,,,,,,
Meridian Duals,CPT,81291,Mthfr gene,Lab Services,Per Unit,$65.34 ,OP,65.34,65.34,,,,,,
Meridian Duals,CPT,81292,Mlh1 gene full seq,Lab Services,Per Unit,$675.40 ,OP,675.4,675.4,,,,,,
Meridian Duals,CPT,81293,Mlh1 gene known variants,Lab Services,Per Unit,$331.00 ,OP,331,331,,,,,,
Meridian Duals,CPT,81294,Mlh1 gene dup/delete variant,Lab Services,Per Unit,$202.40 ,OP,202.4,202.4,,,,,,
Meridian Duals,CPT,81295,Msh2 gene full seq,Lab Services,Per Unit,$381.70 ,OP,381.7,381.7,,,,,,
Meridian Duals,CPT,81296,Msh2 gene known variants,Lab Services,Per Unit,$337.73 ,OP,337.73,337.73,,,,,,
Meridian Duals,CPT,81297,Msh2 gene dup/delete variant,Lab Services,Per Unit,$213.30 ,OP,213.3,213.3,,,,,,
Meridian Duals,CPT,81298,Msh6 gene full seq,Lab Services,Per Unit,$641.85 ,OP,641.85,641.85,,,,,,
Meridian Duals,CPT,81299,Msh6 gene known variants,Lab Services,Per Unit,$308.00 ,OP,308,308,,,,,,
Meridian Duals,CPT,81300,Msh6 gene dup/delete variant,Lab Services,Per Unit,$238.00 ,OP,238,238,,,,,,
Meridian Duals,CPT,81301,Microsatellite instability,Lab Services,Per Unit,$348.56 ,OP,348.56,348.56,,,,,,
Meridian Duals,CPT,81302,Mecp2 gene full seq,Lab Services,Per Unit,$527.87 ,OP,527.87,527.87,,,,,,
Meridian Duals,CPT,81303,Mecp2 gene known variant,Lab Services,Per Unit,$120.00 ,OP,120,120,,,,,,
Meridian Duals,CPT,81304,Mecp2 gene dup/delet variant,Lab Services,Per Unit,$150.00 ,OP,150,150,,,,,,
Meridian Duals,CPT,81305,Myd88 gene p.leu265pro vrnt,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,
Meridian Duals,CPT,81306,Nudt15 gene common variants,Lab Services,Per Unit,$291.36 ,OP,291.36,291.36,,,,,,
Meridian Duals,CPT,81307,Palb2 gene full gene seq,Lab Services,Per Unit,$676.50 ,OP,676.5,676.5,,,,,,
Meridian Duals,CPT,81308,Palb2 gene known famil vrnt,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,
Meridian Duals,CPT,81309,Pik3ca gene trgt seq alys,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Meridian Duals,CPT,81310,Npm1 gene,Lab Services,Per Unit,$246.52 ,OP,246.52,246.52,,,,,,
Meridian Duals,CPT,81311,Nras gene variants exon 2&3,Lab Services,Per Unit,$295.79 ,OP,295.79,295.79,,,,,,
Meridian Duals,CPT,81312,Pabpn1 gene detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Meridian Duals,CPT,81313,Pca3/klk3 antigen,Lab Services,Per Unit,$255.05 ,OP,255.05,255.05,,,,,,
Meridian Duals,CPT,81314,Pdgfra gene,Lab Services,Per Unit,$329.51 ,OP,329.51,329.51,,,,,,
Meridian Duals,CPT,81315,Pml/raralpha com breakpoints,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,
Meridian Duals,CPT,81316,Pml/raralpha 1 breakpoint,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,
Meridian Duals,CPT,81317,Pms2 gene full seq analysis,Lab Services,Per Unit,$676.50 ,OP,676.5,676.5,,,,,,
Meridian Duals,CPT,81318,Pms2 known familial variants,Lab Services,Per Unit,$331.00 ,OP,331,331,,,,,,
Meridian Duals,CPT,81319,Pms2 gene dup/delet variants,Lab Services,Per Unit,$203.50 ,OP,203.5,203.5,,,,,,
Meridian Duals,CPT,81320,Plcg2 gene common variants,Lab Services,Per Unit,$291.36 ,OP,291.36,291.36,,,,,,
Meridian Duals,CPT,81321,Pten gene full sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,
Meridian Duals,CPT,81322,Pten gene known fam variant,Lab Services,Per Unit,$46.60 ,OP,46.6,46.6,,,,,,
Meridian Duals,CPT,81323,Pten gene dup/delet variant,Lab Services,Per Unit,$300.00 ,OP,300,300,,,,,,
Meridian Duals,CPT,81324,Pmp22 gene dup/delet,Lab Services,Per Unit,$758.36 ,OP,758.36,758.36,,,,,,
Meridian Duals,CPT,81325,Pmp22 gene full sequence,Lab Services,Per Unit,$769.58 ,OP,769.58,769.58,,,,,,
Meridian Duals,CPT,81326,Pmp22 gene known fam variant,Lab Services,Per Unit,$46.60 ,OP,46.6,46.6,,,,,,
Meridian Duals,CPT,81327,Sept9 gen prmtr mthyltn alys,Lab Services,Per Unit,$192.00 ,OP,192,192,,,,,,
Meridian Duals,CPT,81328,Slco1b1 gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Meridian Duals,CPT,81329,Smn1 gene dos/deletion alys,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Meridian Duals,CPT,81330,Smpd1 gene common variants,Lab Services,Per Unit,$47.00 ,OP,47,47,,,,,,
Meridian Duals,CPT,81331,Snrpn/ube3a gene,Lab Services,Per Unit,$51.07 ,OP,51.07,51.07,,,,,,
Meridian Duals,CPT,81332,Serpina1 gene,Lab Services,Per Unit,$43.65 ,OP,43.65,43.65,,,,,,
Meridian Duals,CPT,81333,Tgfbi gene common variants,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Meridian Duals,CPT,81334,Runx1 gene targeted seq alys,Lab Services,Per Unit,$329.51 ,OP,329.51,329.51,,,,,,
Meridian Duals,CPT,81335,Tpmt gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Meridian Duals,CPT,81336,Smn1 gene full gene sequence,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,
Meridian Duals,CPT,81337,Smn1 gen nown famil seq vrnt,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Meridian Duals,CPT,81338,Mpl gene common variants,Lab Services,Per Unit,$150.33 ,OP,150.33,150.33,,,,,,
Meridian Duals,CPT,81339,Mpl gene seq alys exon 10,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Meridian Duals,CPT,81340,Trb@ gene rearrange amplify,Lab Services,Per Unit,$208.92 ,OP,208.92,208.92,,,,,,
Meridian Duals,CPT,81341,Trb@ gene rearrange dirprobe,Lab Services,Per Unit,$49.59 ,OP,49.59,49.59,,,,,,
Meridian Duals,CPT,81342,Trg gene rearrangement anal,Lab Services,Per Unit,$201.50 ,OP,201.5,201.5,,,,,,
Meridian Duals,CPT,81343,Ppp2r2b gen detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Meridian Duals,CPT,81344,Tbp gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Meridian Duals,CPT,81345,Tert gene targeted seq alys,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Meridian Duals,CPT,81346,Tyms gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Meridian Duals,CPT,81347,Sf3b1 gene common variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,
Meridian Duals,CPT,81348,Srsf2 gene common variants,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,
Meridian Duals,CPT,81350,Ugt1a1 gene common variants,Lab Services,Per Unit,$234.00 ,OP,234,234,,,,,,
Meridian Duals,CPT,81351,Tp53 gene full gene sequence,Lab Services,Per Unit,$641.85 ,OP,641.85,641.85,,,,,,
Meridian Duals,CPT,81352,Tp53 gene trgt sequence alys,Lab Services,Per Unit,$329.51 ,OP,329.51,329.51,,,,,,
Meridian Duals,CPT,81353,Tp53 gene known famil vrnt,Lab Services,Per Unit,$308.00 ,OP,308,308,,,,,,
Meridian Duals,CPT,81355,Vkorc1 gene,Lab Services,Per Unit,$88.20 ,OP,88.2,88.2,,,,,,
Meridian Duals,CPT,81357,U2af1 gene common variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,
Meridian Duals,CPT,81360,Zrsr2 gene common variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,
Meridian Duals,CPT,81361,Hbb gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Meridian Duals,CPT,81362,Hbb gene known fam variant,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,
Meridian Duals,CPT,81363,Hbb gene dup/del variants,Lab Services,Per Unit,$202.40 ,OP,202.4,202.4,,,,,,
Meridian Duals,CPT,81364,Hbb full gene sequence,Lab Services,Per Unit,$324.58 ,OP,324.58,324.58,,,,,,
Meridian Duals,CPT,81370,Hla i & ii typing lr,Lab Services,Per Unit,$402.12 ,OP,402.12,402.12,,,,,,
Meridian Duals,CPT,81371,Hla i & ii type verify lr,Lab Services,Per Unit,$404.52 ,OP,404.52,404.52,,,,,,
Meridian Duals,CPT,81372,Hla i typing complete lr,Lab Services,Per Unit,$403.59 ,OP,403.59,403.59,,,,,,
Meridian Duals,CPT,81373,Hla i typing 1 locus lr,Lab Services,Per Unit,$127.43 ,OP,127.43,127.43,,,,,,
Meridian Duals,CPT,81374,Hla i typing 1 antigen lr,Lab Services,Per Unit,$74.33 ,OP,74.33,74.33,,,,,,
Meridian Duals,CPT,81375,Hla ii typing ag equiv lr,Lab Services,Per Unit,$220.74 ,OP,220.74,220.74,,,,,,
Meridian Duals,CPT,81376,Hla ii typing 1 locus lr,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
Meridian Duals,CPT,81377,Hla ii type 1 ag equiv lr,Lab Services,Per Unit,$94.74 ,OP,94.74,94.74,,,,,,
Meridian Duals,CPT,81378,Hla i & ii typing hr,Lab Services,Per Unit,$345.57 ,OP,345.57,345.57,,,,,,
Meridian Duals,CPT,81379,Hla i typing complete hr,Lab Services,Per Unit,$335.38 ,OP,335.38,335.38,,,,,,
Meridian Duals,CPT,81380,Hla i typing 1 locus hr,Lab Services,Per Unit,$177.25 ,OP,177.25,177.25,,,,,,
Meridian Duals,CPT,81381,Hla i typing 1 allele hr,Lab Services,Per Unit,$169.90 ,OP,169.9,169.9,,,,,,
Meridian Duals,CPT,81382,Hla ii typing 1 loc hr,Lab Services,Per Unit,$123.68 ,OP,123.68,123.68,,,,,,
Meridian Duals,CPT,81383,Hla ii typing 1 allele hr,Lab Services,Per Unit,$109.13 ,OP,109.13,109.13,,,,,,
Meridian Duals,CPT,81400,Mopath procedure level 1,Lab Services,Per Unit,$63.96 ,OP,63.96,63.96,,,,,,
Meridian Duals,CPT,81401,Mopath procedure level 2,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Meridian Duals,CPT,81402,Mopath procedure level 3,Lab Services,Per Unit,$150.33 ,OP,150.33,150.33,,,,,,
Meridian Duals,CPT,81403,Mopath procedure level 4,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Meridian Duals,CPT,81404,Mopath procedure level 5,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Meridian Duals,CPT,81405,Mopath procedure level 6,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,
Meridian Duals,CPT,81406,Mopath procedure level 7,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,
Meridian Duals,CPT,81407,Mopath procedure level 8,Lab Services,Per Unit,$846.27 ,OP,846.27,846.27,,,,,,
Meridian Duals,CPT,81408,Mopath procedure level 9,Lab Services,Per Unit,"$2,000.00 ",OP,"2,000.00","2,000.00",,,,,,
Meridian Duals,CPT,81410,Aortic dysfunction/dilation,Lab Services,Per Unit,$504.00 ,OP,504,504,,,,,,
Meridian Duals,CPT,81411,Aortic dysfunction/dilation,Lab Services,Per Unit,"$1,350.19 ",OP,"1,350.19","1,350.19",,,,,,
Meridian Duals,CPT,81412,Ashkenazi jewish assoc dis,Lab Services,Per Unit,"$2,448.56 ",OP,"2,448.56","2,448.56",,,,,,
Meridian Duals,CPT,81413,Car ion chnnlpath inc 10 gns,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,
Meridian Duals,CPT,81414,Car ion chnnlpath inc 2 gns,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,
Meridian Duals,CPT,81415,Exome sequence analysis,Lab Services,Per Unit,"$4,780.00 ",OP,"4,780.00","4,780.00",,,,,,
Meridian Duals,CPT,81416,Exome sequence analysis,Lab Services,Per Unit,"$12,000.00 ",OP,"12,000.00","12,000.00",,,,,,
Meridian Duals,CPT,81417,Exome re-evaluation,Lab Services,Per Unit,$320.00 ,OP,320,320,,,,,,
Meridian Duals,CPT,81419,Epilepsy gen seq alys panel,Lab Services,Per Unit,"$2,448.56 ",OP,"2,448.56","2,448.56",,,,,,
Meridian Duals,CPT,81420,Fetal chrmoml aneuploidy,Lab Services,Per Unit,$759.05 ,OP,759.05,759.05,,,,,,
Meridian Duals,CPT,81422,Fetal chrmoml microdeltj,Lab Services,Per Unit,$759.05 ,OP,759.05,759.05,,,,,,
Meridian Duals,CPT,81425,Genome sequence analysis,Lab Services,Per Unit,"$5,031.20 ",OP,"5,031.20","5,031.20",,,,,,
Meridian Duals,CPT,81426,Genome sequence analysis,Lab Services,Per Unit,"$2,709.95 ",OP,"2,709.95","2,709.95",,,,,,
Meridian Duals,CPT,81427,Genome re-evaluation,Lab Services,Per Unit,"$2,337.65 ",OP,"2,337.65","2,337.65",,,,,,
Meridian Duals,CPT,81430,Hearing loss sequence analys,Lab Services,Per Unit,"$1,625.00 ",OP,"1,625.00","1,625.00",,,,,,
Meridian Duals,CPT,81431,Hearing loss dup/del analys,Lab Services,Per Unit,$679.57 ,OP,679.57,679.57,,,,,,
Meridian Duals,CPT,81432,Hrdtry brst ca-rlatd dsordrs,Lab Services,Per Unit,$679.05 ,OP,679.05,679.05,,,,,,
Meridian Duals,CPT,81433,Hrdtry brst ca-rlatd dsordrs,Lab Services,Per Unit,$438.93 ,OP,438.93,438.93,,,,,,
Meridian Duals,CPT,81434,Hereditary retinal disorders,Lab Services,Per Unit,$597.91 ,OP,597.91,597.91,,,,,,
Meridian Duals,CPT,81435,Hereditary colon ca dsordrs,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,
Meridian Duals,CPT,81436,Hereditary colon ca dsordrs,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,
Meridian Duals,CPT,81437,Heredtry nurondcrn tum dsrdr,Lab Services,Per Unit,$438.93 ,OP,438.93,438.93,,,,,,
Meridian Duals,CPT,81438,Heredtry nurondcrn tum dsrdr,Lab Services,Per Unit,$438.93 ,OP,438.93,438.93,,,,,,
Meridian Duals,CPT,81439,Hrdtry cardmypy gene panel,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,
Meridian Duals,CPT,81440,Mitochondrial gene,Lab Services,Per Unit,"$3,324.00 ",OP,"3,324.00","3,324.00",,,,,,
Meridian Duals,CPT,81442,Noonan spectrum disorders,Lab Services,Per Unit,"$2,143.60 ",OP,"2,143.60","2,143.60",,,,,,
Meridian Duals,CPT,81443,Genetic tstg severe inh cond,Lab Services,Per Unit,"$2,448.56 ",OP,"2,448.56","2,448.56",,,,,,
Meridian Duals,CPT,81445,Targeted genomic seq analys,Lab Services,Per Unit,$597.91 ,OP,597.91,597.91,,,,,,
Meridian Duals,CPT,81448,Hrdtry perph neurphy panel,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,
Meridian Duals,CPT,81450,Targeted genomic seq analys,Lab Services,Per Unit,$759.53 ,OP,759.53,759.53,,,,,,
Meridian Duals,CPT,81455,Targeted genomic seq analys,Lab Services,Per Unit,"$2,919.60 ",OP,"2,919.60","2,919.60",,,,,,
Meridian Duals,CPT,81460,Whole mitochondrial genome,Lab Services,Per Unit,"$1,287.00 ",OP,"1,287.00","1,287.00",,,,,,
Meridian Duals,CPT,81465,Whole mitochondrial genome,Lab Services,Per Unit,$936.00 ,OP,936,936,,,,,,
Meridian Duals,CPT,81470,X-linked intellectual dblt,Lab Services,Per Unit,$914.00 ,OP,914,914,,,,,,
Meridian Duals,CPT,81471,X-linked intellectual dblt,Lab Services,Per Unit,$914.00 ,OP,914,914,,,,,,
Meridian Duals,CPT,81490,Autoimmune rheumatoid arthr,Lab Services,Per Unit,$840.65 ,OP,840.65,840.65,,,,,,
Meridian Duals,CPT,81493,Cor artery disease mrna,Lab Services,Per Unit,"$1,050.00 ",OP,"1,050.00","1,050.00",,,,,,
Meridian Duals,CPT,81500,Onco (ovar) two proteins,Lab Services,Per Unit,$260.50 ,OP,91.51,260.5,,,,,,
Meridian Duals,CPT,81503,Onco (ovar) five proteins,Lab Services,Per Unit,$897.00 ,OP,91.51,897,,,,,,
Meridian Duals,CPT,81504,Oncology tissue of origin,Lab Services,Per Unit,$520.00 ,OP,520,520,,,,,,
Meridian Duals,CPT,81506,Endo assay seven anal,Lab Services,Per Unit,$68.92 ,OP,57.19,68.92,,,,,,
Meridian Duals,CPT,81507,Fetal aneuploidy trisom risk,Lab Services,Per Unit,$795.00 ,OP,795,795,,,,,,
Meridian Duals,CPT,81508,Ftl cgen abnor two proteins,Lab Services,Per Unit,$54.30 ,OP,54.3,144.88,,,,,,
Meridian Duals,CPT,81509,Ftl cgen abnor 3 proteins,Lab Services,Per Unit,"$1,487.37 ",OP,213.51,"1,487.37",,,,,,
Meridian Duals,CPT,81510,Ftl cgen abnor three anal,Lab Services,Per Unit,$55.54 ,OP,55.54,202.07,,,,,,
Meridian Duals,CPT,81511,Ftl cgen abnor four anal,Lab Services,Per Unit,$153.50 ,OP,153.5,270.71,,,,,,
Meridian Duals,CPT,81512,Ftl cgen abnor five anal,Lab Services,Per Unit,$69.52 ,OP,69.52,270.71,,,,,,
Meridian Duals,CPT,81513,Nfct ds bv rna vag flu alg,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
Meridian Duals,CPT,81514,Nfct ds bv&vaginitis dna alg,Lab Services,Per Unit,$262.99 ,OP,262.99,262.99,,,,,,
Meridian Duals,CPT,81518,Onc brst mrna 11 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
Meridian Duals,CPT,81519,Oncology breast mrna,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
Meridian Duals,CPT,81520,Onc breast mrna 58 genes,Lab Services,Per Unit,"$2,510.21 ",OP,"2,510.21","2,510.21",,,,,,
Meridian Duals,CPT,81521,Onc breast mrna 70 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
Meridian Duals,CPT,81522,Onc breast mrna 12 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
Meridian Duals,CPT,81525,Oncology colon mrna,Lab Services,Per Unit,"$3,116.00 ",OP,"3,116.00","3,116.00",,,,,,
Meridian Duals,CPT,81528,Oncology colorectal scr,Lab Services,Per Unit,$508.87 ,OP,508.87,508.87,,,,,,
Meridian Duals,CPT,81529,Onc cutan mlnma mrna 31 gene,Lab Services,Per Unit,"$7,193.00 ",OP,"7,193.00","7,193.00",,,,,,
Meridian Duals,CPT,81535,Oncology gynecologic,Lab Services,Per Unit,$579.46 ,OP,579.46,579.46,,,,,,
Meridian Duals,CPT,81536,Oncology gynecologic,Lab Services,Per Unit,$177.56 ,OP,177.56,177.56,,,,,,
Meridian Duals,CPT,81538,Oncology lung,Lab Services,Per Unit,"$2,871.00 ",OP,"2,871.00","2,871.00",,,,,,
Meridian Duals,CPT,81539,Oncology prostate prob score,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
Meridian Duals,CPT,81540,Oncology tum unknown origin,Lab Services,Per Unit,"$3,750.00 ",OP,"3,750.00","3,750.00",,,,,,
Meridian Duals,CPT,81541,Onc prostate mrna 46 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
Meridian Duals,CPT,81542,Onc prostate mrna 22 cnt gen,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
Meridian Duals,CPT,81546,Onc thyr mrna 10-196 gen alg,Lab Services,Per Unit,"$3,600.00 ",OP,"3,600.00","3,600.00",,,,,,
Meridian Duals,CPT,81551,Onc prostate 3 genes,Lab Services,Per Unit,"$2,030.00 ",OP,"2,030.00","2,030.00",,,,,,
Meridian Duals,CPT,81552,Onc uveal mlnma mrna 15 gene,Lab Services,Per Unit,"$7,776.00 ",OP,"7,776.00","7,776.00",,,,,,
Meridian Duals,CPT,81554,Pulm ds ipf mrna 190 gen alg,Lab Services,Per Unit,"$5,500.00 ",OP,"5,500.00","5,500.00",,,,,,
Meridian Duals,CPT,81595,Cardiology hrt trnspl mrna,Lab Services,Per Unit,"$3,240.00 ",OP,"3,240.00","3,240.00",,,,,,
Meridian Duals,CPT,81596,Nfct ds chrnc hcv 6 assays,Lab Services,Per Unit,$72.19 ,OP,72.19,72.19,,,,,,
Meridian Duals,CPT,82009,Test for acetone/ketones,Lab Services,Per Unit,$4.52 ,OP,4.52,19.07,,,,,,
Meridian Duals,CPT,82010,Acetone assay,Lab Services,Per Unit,$8.17 ,OP,8.17,41.94,,,,,,
Meridian Duals,CPT,82013,Acetylcholinesterase assay,Lab Services,Per Unit,$12.29 ,OP,12.29,12.29,,,,,,
Meridian Duals,CPT,82016,Acylcarnitines qual,Lab Services,Per Unit,$16.49 ,OP,16.49,61,,,,,,
Meridian Duals,CPT,82017,Acylcarnitines quant,Lab Services,Per Unit,$16.87 ,OP,16.87,76.26,,,,,,
Meridian Duals,CPT,82024,Assay of acth,Lab Services,Per Unit,$38.62 ,OP,38.62,171.58,,,,,,
Meridian Duals,CPT,82030,Assay of adp & amp,Lab Services,Per Unit,$25.80 ,OP,25.8,99.13,,,,,,
Meridian Duals,CPT,82040,Assay of serum albumin,Lab Services,Per Unit,$4.95 ,OP,4.95,22.88,,,,,,
Meridian Duals,CPT,82042,Other source albumin quan ea,Lab Services,Per Unit,$7.78 ,OP,7.78,26.7,,,,,,
Meridian Duals,CPT,82043,Ur albumin quantitative,Lab Services,Per Unit,$5.78 ,OP,5.78,26.7,,,,,,
Meridian Duals,CPT,82044,Ur albumin semiquantitative,Lab Services,Per Unit,$6.23 ,OP,6.23,22.88,,,,,,
Meridian Duals,CPT,82045,Albumin ischemia modified,Lab Services,Per Unit,$33.94 ,OP,33.94,125.82,,,,,,
Meridian Duals,CPT,82075,Assay of breath ethanol,Lab Services,Per Unit,$30.00 ,OP,30,45.74,,,,,,
Meridian Duals,CPT,82077,Assay spec xcp ur&breath ia,Lab Services,Per Unit,$17.27 ,OP,17.27,17.27,,,,,,
Meridian Duals,CPT,82085,Assay of aldolase,Lab Services,Per Unit,$9.71 ,OP,9.71,41.94,,,,,,
Meridian Duals,CPT,82088,Assay of aldosterone,Lab Services,Per Unit,$40.75 ,OP,40.75,183.02,,,,,,
Meridian Duals,CPT,82103,Alpha-1-antitrypsin total,Lab Services,Per Unit,$13.44 ,OP,13.44,61,,,,,,
Meridian Duals,CPT,82104,Alpha-1-antitrypsin pheno,Lab Services,Per Unit,$14.46 ,OP,14.46,64.82,,,,,,
Meridian Duals,CPT,82105,Alpha-fetoprotein serum,Lab Services,Per Unit,$16.77 ,OP,16.77,76.26,,,,,,
Meridian Duals,CPT,82106,Alpha-fetoprotein amniotic,Lab Services,Per Unit,$17.00 ,OP,17,76.26,,,,,,
Meridian Duals,CPT,82107,Alpha-fetoprotein l3,Lab Services,Per Unit,$64.41 ,OP,64.41,209.7,,,,,,
Meridian Duals,CPT,82108,Assay of aluminum,Lab Services,Per Unit,$25.48 ,OP,25.48,114.39,,,,,,
Meridian Duals,CPT,82120,Amines vaginal fluid qual,Lab Services,Per Unit,$5.99 ,OP,5.99,19.07,,,,,,
Meridian Duals,CPT,82127,Amino acid single qual,Lab Services,Per Unit,$14.18 ,OP,14.18,61,,,,,,
Meridian Duals,CPT,82128,Amino acids mult qual,Lab Services,Per Unit,$13.87 ,OP,13.87,61,,,,,,
Meridian Duals,CPT,82131,Amino acids single quant,Lab Services,Per Unit,$22.98 ,OP,22.98,76.26,,,,,,
Meridian Duals,CPT,82135,Assay aminolevulinic acid,Lab Services,Per Unit,$16.45 ,OP,16.45,64.82,,,,,,
Meridian Duals,CPT,82136,Amino acids quant 2-5,Lab Services,Per Unit,$19.61 ,OP,19.61,76.26,,,,,,
Meridian Duals,CPT,82139,Amino acids quan 6 or more,Lab Services,Per Unit,$16.87 ,OP,16.87,16.87,,,,,,
Meridian Duals,CPT,82140,Assay of ammonia,Lab Services,Per Unit,$14.57 ,OP,14.57,64.82,,,,,,
Meridian Duals,CPT,82143,Amniotic fluid scan,Lab Services,Per Unit,$9.35 ,OP,9.35,30.51,,,,,,
Meridian Duals,CPT,82150,Assay of amylase,Lab Services,Per Unit,$6.48 ,OP,6.48,34.31,,,,,,
Meridian Duals,CPT,82154,Androstanediol glucuronide,Lab Services,Per Unit,$28.83 ,OP,28.83,28.83,,,,,,
Meridian Duals,CPT,82157,Assay of androstenedione,Lab Services,Per Unit,$29.28 ,OP,29.28,129.64,,,,,,
Meridian Duals,CPT,82160,Assay of androsterone,Lab Services,Per Unit,$25.55 ,OP,25.55,110.57,,,,,,
Meridian Duals,CPT,82163,Assay of angiotensin ii,Lab Services,Per Unit,$20.52 ,OP,20.52,91.51,,,,,,
Meridian Duals,CPT,82164,Angiotensin i enzyme test,Lab Services,Per Unit,$14.60 ,OP,14.6,64.82,,,,,,
Meridian Duals,CPT,82172,Assay of apolipoprotein,Lab Services,Per Unit,$21.09 ,OP,21.09,68.63,,,,,,
Meridian Duals,CPT,82175,Assay of arsenic,Lab Services,Per Unit,$18.97 ,OP,18.97,83.87,,,,,,
Meridian Duals,CPT,82180,Assay of ascorbic acid,Lab Services,Per Unit,$9.89 ,OP,9.89,9.89,,,,,,
Meridian Duals,CPT,82190,Atomic absorption,Lab Services,Per Unit,$15.90 ,OP,15.9,64.82,,,,,,
Meridian Duals,CPT,82232,Assay of beta-2 protein,Lab Services,Per Unit,$16.18 ,OP,16.18,72.44,,,,,,
Meridian Duals,CPT,82239,Bile acids total,Lab Services,Per Unit,$17.12 ,OP,17.12,76.26,,,,,,
Meridian Duals,CPT,82240,Bile acids cholylglycine,Lab Services,Per Unit,$26.58 ,OP,26.58,64.82,,,,,,
Meridian Duals,CPT,82247,Bilirubin total,Lab Services,Per Unit,$5.02 ,OP,5.02,26.7,,,,,,
Meridian Duals,CPT,82248,Bilirubin direct,Lab Services,Per Unit,$5.02 ,OP,5.02,26.7,,,,,,
Meridian Duals,CPT,82252,Fecal bilirubin test,Lab Services,Per Unit,$4.56 ,OP,4.56,19.07,,,,,,
Meridian Duals,CPT,82261,Assay of biotinidase,Lab Services,Per Unit,$16.87 ,OP,16.87,76.26,,,,,,
Meridian Duals,CPT,82270,Occult blood feces,Lab Services,Per Unit,$4.38 ,OP,4.38,15.26,,,,,,
Meridian Duals,CPT,82271,Occult blood other sources,Lab Services,Per Unit,$5.32 ,OP,5.32,15.26,,,,,,
Meridian Duals,CPT,82272,Occult bld feces 1-3 tests,Lab Services,Per Unit,$4.23 ,OP,4.23,15.26,,,,,,
Meridian Duals,CPT,82274,Assay test for blood fecal,Lab Services,Per Unit,$15.92 ,OP,15.92,80.07,,,,,,
Meridian Duals,CPT,82286,Assay of bradykinin,Lab Services,Per Unit,$5.16 ,OP,5.16,30.51,,,,,,
Meridian Duals,CPT,82300,Assay of cadmium,Lab Services,Per Unit,$23.64 ,OP,23.64,102.95,,,,,,
Meridian Duals,CPT,82306,Vitamin d 25 hydroxy,Lab Services,Per Unit,$29.60 ,OP,29.6,356.68,,,,,,
Meridian Duals,CPT,82308,Assay of calcitonin,Lab Services,Per Unit,$26.79 ,OP,26.79,118.19,,,,,,
Meridian Duals,CPT,82310,Assay of calcium,Lab Services,Per Unit,$5.16 ,OP,5.16,22.88,,,,,,
Meridian Duals,CPT,82330,Assay of calcium,Lab Services,Per Unit,$13.68 ,OP,13.68,61,,,,,,
Meridian Duals,CPT,82331,Calcium infusion test,Lab Services,Per Unit,$13.34 ,OP,13.34,22.88,,,,,,
Meridian Duals,CPT,82340,Assay of calcium in urine,Lab Services,Per Unit,$6.03 ,OP,6.03,26.7,,,,,,
Meridian Duals,CPT,82355,Calculus analysis qual,Lab Services,Per Unit,$11.58 ,OP,11.58,53.38,,,,,,
Meridian Duals,CPT,82360,Calculus assay quant,Lab Services,Per Unit,$12.87 ,OP,12.87,45.74,,,,,,
Meridian Duals,CPT,82365,Calculus spectroscopy,Lab Services,Per Unit,$12.90 ,OP,12.9,45.74,,,,,,
Meridian Duals,CPT,82370,X-ray assay calculus,Lab Services,Per Unit,$12.52 ,OP,12.52,45.74,,,,,,
Meridian Duals,CPT,82373,Assay c-d transfer measure,Lab Services,Per Unit,$18.06 ,OP,18.06,80.07,,,,,,
Meridian Duals,CPT,82374,Assay blood carbon dioxide,Lab Services,Per Unit,$4.88 ,OP,4.88,22.88,,,,,,
Meridian Duals,CPT,82375,Assay carboxyhb quant,Lab Services,Per Unit,$12.32 ,OP,12.32,26.7,,,,,,
Meridian Duals,CPT,82376,Assay carboxyhb qual,Lab Services,Per Unit,$14.07 ,OP,14.07,26.7,,,,,,
Meridian Duals,CPT,82378,Carcinoembryonic antigen,Lab Services,Per Unit,$18.96 ,OP,18.96,83.87,,,,,,
Meridian Duals,CPT,82379,Assay of carnitine,Lab Services,Per Unit,$16.87 ,OP,16.87,76.26,,,,,,
Meridian Duals,CPT,82380,Assay of carotene,Lab Services,Per Unit,$9.22 ,OP,9.22,41.94,,,,,,
Meridian Duals,CPT,82382,Assay urine catecholamines,Lab Services,Per Unit,$27.30 ,OP,27.3,76.26,,,,,,
Meridian Duals,CPT,82383,Assay blood catecholamines,Lab Services,Per Unit,$29.08 ,OP,29.08,110.57,,,,,,
Meridian Duals,CPT,82384,Assay three catecholamines,Lab Services,Per Unit,$25.25 ,OP,25.25,110.57,,,,,,
Meridian Duals,CPT,82387,Assay of cathepsin-d,Lab Services,Per Unit,$18.06 ,OP,18.06,91.51,,,,,,
Meridian Duals,CPT,82390,Assay of ceruloplasmin,Lab Services,Per Unit,$10.74 ,OP,10.74,49.56,,,,,,
Meridian Duals,CPT,82397,Chemiluminescent assay,Lab Services,Per Unit,$14.12 ,OP,14.12,64.82,,,,,,
Meridian Duals,CPT,82415,Assay of chloramphenicol,Lab Services,Per Unit,$12.67 ,OP,12.67,57.19,,,,,,
Meridian Duals,CPT,82435,Assay of blood chloride,Lab Services,Per Unit,$4.60 ,OP,4.6,19.07,,,,,,
Meridian Duals,CPT,82436,Assay of urine chloride,Lab Services,Per Unit,$5.75 ,OP,5.75,22.88,,,,,,
Meridian Duals,CPT,82438,Assay other fluid chlorides,Lab Services,Per Unit,$5.00 ,OP,5,5,,,,,,
Meridian Duals,CPT,82441,Test for chlorohydrocarbons,Lab Services,Per Unit,$6.01 ,OP,6.01,26.7,,,,,,
Meridian Duals,CPT,82465,Assay bld/serum cholesterol,Lab Services,Per Unit,$4.35 ,OP,4.35,22.88,,,,,,
Meridian Duals,CPT,82480,Assay serum cholinesterase,Lab Services,Per Unit,$7.87 ,OP,7.87,34.31,,,,,,
Meridian Duals,CPT,82482,Assay rbc cholinesterase,Lab Services,Per Unit,$9.81 ,OP,9.81,34.31,,,,,,
Meridian Duals,CPT,82485,Assay chondroitin sulfate,Lab Services,Per Unit,$20.65 ,OP,20.65,91.51,,,,,,
Meridian Duals,CPT,82495,Assay of chromium,Lab Services,Per Unit,$20.28 ,OP,20.28,91.51,,,,,,
Meridian Duals,CPT,82507,Assay of citrate,Lab Services,Per Unit,$27.80 ,OP,27.8,57.19,,,,,,
Meridian Duals,CPT,82523,Collagen crosslinks,Lab Services,Per Unit,$18.68 ,OP,18.68,95.32,,,,,,
Meridian Duals,CPT,82525,Assay of copper,Lab Services,Per Unit,$12.41 ,OP,12.41,53.38,,,,,,
Meridian Duals,CPT,82528,Assay of corticosterone,Lab Services,Per Unit,$22.52 ,OP,22.52,99.13,,,,,,
Meridian Duals,CPT,82530,Cortisol free,Lab Services,Per Unit,$16.71 ,OP,16.71,76.26,,,,,,
Meridian Duals,CPT,82533,Total cortisol,Lab Services,Per Unit,$16.30 ,OP,16.3,72.44,,,,,,
Meridian Duals,CPT,82540,Assay of creatine,Lab Services,Per Unit,$4.64 ,OP,4.64,19.07,,,,,,
Meridian Duals,CPT,82542,Col chromotography qual/quan,Lab Services,Per Unit,$24.09 ,OP,24.09,80.07,,,,,,
Meridian Duals,CPT,82550,Assay of ck (cpk),Lab Services,Per Unit,$6.51 ,OP,6.51,30.51,,,,,,
Meridian Duals,CPT,82552,Assay of cpk in blood,Lab Services,Per Unit,$13.39 ,OP,13.39,61,,,,,,
Meridian Duals,CPT,82553,Creatine mb fraction,Lab Services,Per Unit,$11.55 ,OP,11.55,49.56,,,,,,
Meridian Duals,CPT,82554,Creatine isoforms,Lab Services,Per Unit,$11.87 ,OP,11.87,53.38,,,,,,
Meridian Duals,CPT,82565,Assay of creatinine,Lab Services,Per Unit,$5.12 ,OP,5.12,22.88,,,,,,
Meridian Duals,CPT,82570,Assay of urine creatinine,Lab Services,Per Unit,$5.18 ,OP,5.18,26.7,,,,,,
Meridian Duals,CPT,82575,Creatinine clearance test,Lab Services,Per Unit,$9.46 ,OP,9.46,41.94,,,,,,
Meridian Duals,CPT,82585,Assay of cryofibrinogen,Lab Services,Per Unit,$14.14 ,OP,14.14,38.13,,,,,,
Meridian Duals,CPT,82595,Assay of cryoglobulin,Lab Services,Per Unit,$6.47 ,OP,6.47,30.51,,,,,,
Meridian Duals,CPT,82600,Assay of cyanide,Lab Services,Per Unit,$19.40 ,OP,19.4,19.4,,,,,,
Meridian Duals,CPT,82607,Vitamin b-12,Lab Services,Per Unit,$15.08 ,OP,15.08,68.63,,,,,,
Meridian Duals,CPT,82608,B-12 binding capacity,Lab Services,Per Unit,$14.32 ,OP,14.32,14.32,,,,,,
Meridian Duals,CPT,82610,Cystatin c,Lab Services,Per Unit,$18.52 ,OP,18.52,61,,,,,,
Meridian Duals,CPT,82615,Test for urine cystines,Lab Services,Per Unit,$9.55 ,OP,9.55,38.13,,,,,,
Meridian Duals,CPT,82626,Dehydroepiandrosterone,Lab Services,Per Unit,$25.27 ,OP,25.27,114.39,,,,,,
Meridian Duals,CPT,82627,Dehydroepiandrosterone,Lab Services,Per Unit,$22.23 ,OP,22.23,99.13,,,,,,
Meridian Duals,CPT,82633,Desoxycorticosterone,Lab Services,Per Unit,$30.98 ,OP,30.98,122,,,,,,
Meridian Duals,CPT,82634,Deoxycortisol,Lab Services,Per Unit,$29.28 ,OP,29.28,76.26,,,,,,
Meridian Duals,CPT,82638,Assay of dibucaine number,Lab Services,Per Unit,$12.25 ,OP,12.25,53.38,,,,,,
Meridian Duals,CPT,82642,Dihydrotestosterone,Lab Services,Per Unit,$29.28 ,OP,29.28,114.39,,,,,,
Meridian Duals,CPT,82652,Vit d 1 25-dihydroxy,Lab Services,Per Unit,$38.50 ,OP,38.5,171.58,,,,,,
Meridian Duals,CPT,82656,Pancreatic elastase fecal,Lab Services,Per Unit,$11.53 ,OP,11.53,11.53,,,,,,
Meridian Duals,CPT,82657,Enzyme cell activity,Lab Services,Per Unit,$22.17 ,OP,22.17,80.07,,,,,,
Meridian Duals,CPT,82658,Enzyme cell activity ra,Lab Services,Per Unit,$44.03 ,OP,44.03,44.03,,,,,,
Meridian Duals,CPT,82664,Electrophoretic test,Lab Services,Per Unit,$61.50 ,OP,61.5,122,,,,,,
Meridian Duals,CPT,82668,Assay of erythropoietin,Lab Services,Per Unit,$18.79 ,OP,18.79,83.87,,,,,,
Meridian Duals,CPT,82670,Assay of total estradiol,Lab Services,Per Unit,$27.94 ,OP,27.94,49.56,,,,,,
Meridian Duals,CPT,82671,Assay of estrogens,Lab Services,Per Unit,$32.30 ,OP,32.3,114.39,,,,,,
Meridian Duals,CPT,82672,Assay of estrogen,Lab Services,Per Unit,$21.70 ,OP,21.7,95.32,,,,,,
Meridian Duals,CPT,82677,Assay of estriol,Lab Services,Per Unit,$24.18 ,OP,24.18,49.56,,,,,,
Meridian Duals,CPT,82679,Assay of estrone,Lab Services,Per Unit,$24.95 ,OP,24.95,57.19,,,,,,
Meridian Duals,CPT,82681,Assay dir meas fr estradiol,Lab Services,Per Unit,$27.94 ,OP,27.94,27.94,,,,,,
Meridian Duals,CPT,82693,Assay of ethylene glycol,Lab Services,Per Unit,$14.90 ,OP,14.9,64.82,,,,,,
Meridian Duals,CPT,82696,Assay of etiocholanolone,Lab Services,Per Unit,$26.24 ,OP,26.24,64.82,,,,,,
Meridian Duals,CPT,82705,Fats/lipids feces qual,Lab Services,Per Unit,$5.10 ,OP,5.1,5.1,,,,,,
Meridian Duals,CPT,82710,Fats/lipids feces quant,Lab Services,Per Unit,$16.80 ,OP,16.8,16.8,,,,,,
Meridian Duals,CPT,82715,Assay of fecal fat,Lab Services,Per Unit,$22.97 ,OP,15.26,22.97,,,,,,
Meridian Duals,CPT,82725,Assay of blood fatty acids,Lab Services,Per Unit,$18.77 ,OP,18.77,18.77,,,,,,
Meridian Duals,CPT,82726,Long chain fatty acids,Lab Services,Per Unit,$19.75 ,OP,19.75,80.07,,,,,,
Meridian Duals,CPT,82728,Assay of ferritin,Lab Services,Per Unit,$13.63 ,OP,13.63,61,,,,,,
Meridian Duals,CPT,82731,Assay of fetal fibronectin,Lab Services,Per Unit,$64.41 ,OP,64.41,236.38,,,,,,
Meridian Duals,CPT,82735,Assay of fluoride,Lab Services,Per Unit,$18.54 ,OP,18.54,83.87,,,,,,
Meridian Duals,CPT,82746,Assay of folic acid serum,Lab Services,Per Unit,$14.70 ,OP,14.7,64.82,,,,,,
Meridian Duals,CPT,82747,Assay of folic acid rbc,Lab Services,Per Unit,$17.65 ,OP,17.65,76.26,,,,,,
Meridian Duals,CPT,82757,Assay of semen fructose,Lab Services,Per Unit,$17.34 ,OP,17.34,76.26,,,,,,
Meridian Duals,CPT,82759,Assay of rbc galactokinase,Lab Services,Per Unit,$21.48 ,OP,21.48,95.32,,,,,,
Meridian Duals,CPT,82760,Assay of galactose,Lab Services,Per Unit,$11.20 ,OP,11.2,49.56,,,,,,
Meridian Duals,CPT,82775,Assay galactose transferase,Lab Services,Per Unit,$21.07 ,OP,21.07,80.07,,,,,,
Meridian Duals,CPT,82776,Galactose transferase test,Lab Services,Per Unit,$11.74 ,OP,11.74,26.7,,,,,,
Meridian Duals,CPT,82777,Galectin-3,Lab Services,Per Unit,$44.25 ,OP,44.25,44.25,,,,,,
Meridian Duals,CPT,82784,Assay iga/igd/igg/igm each,Lab Services,Per Unit,$9.30 ,OP,9.3,41.94,,,,,,
Meridian Duals,CPT,82785,Assay of ige,Lab Services,Per Unit,$16.46 ,OP,16.46,72.44,,,,,,
Meridian Duals,CPT,82787,Igg 1 2 3 or 4 each,Lab Services,Per Unit,$8.02 ,OP,8.02,34.31,,,,,,
Meridian Duals,CPT,82800,Blood ph,Lab Services,Per Unit,$11.00 ,OP,11,30.51,,,,,,
Meridian Duals,CPT,82803,Blood gases any combination,Lab Services,Per Unit,$26.07 ,OP,26.07,61,,,,,,
Meridian Duals,CPT,82805,Blood gases w/o2 saturation,Lab Services,Per Unit,$78.77 ,OP,78.77,141.07,,,,,,
Meridian Duals,CPT,82810,Blood gases o2 sat only,Lab Services,Per Unit,$9.77 ,OP,9.77,9.77,,,,,,
Meridian Duals,CPT,82820,Hemoglobin-oxygen affinity,Lab Services,Per Unit,$13.34 ,OP,13.34,49.56,,,,,,
Meridian Duals,CPT,82930,Gastric analy w/ph ea spec,Lab Services,Per Unit,$6.71 ,OP,6.71,6.71,,,,,,
Meridian Duals,CPT,82938,Gastrin test,Lab Services,Per Unit,$17.69 ,OP,17.69,80.07,,,,,,
Meridian Duals,CPT,82941,Assay of gastrin,Lab Services,Per Unit,$17.63 ,OP,17.63,80.07,,,,,,
Meridian Duals,CPT,82943,Assay of glucagon,Lab Services,Per Unit,$14.29 ,OP,14.29,34.31,,,,,,
Meridian Duals,CPT,82945,Glucose other fluid,Lab Services,Per Unit,$3.93 ,OP,3.93,19.07,,,,,,
Meridian Duals,CPT,82946,Glucagon tolerance test,Lab Services,Per Unit,$17.77 ,OP,17.77,68.63,,,,,,
Meridian Duals,CPT,82947,Assay glucose blood quant,Lab Services,Per Unit,$3.93 ,OP,3.93,19.07,,,,,,
Meridian Duals,CPT,82948,Reagent strip/blood glucose,Lab Services,Per Unit,$5.04 ,OP,5.04,15.26,,,,,,
Meridian Duals,CPT,82950,Glucose test,Lab Services,Per Unit,$4.75 ,OP,4.75,22.88,,,,,,
Meridian Duals,CPT,82951,Glucose tolerance test (gtt),Lab Services,Per Unit,$12.87 ,OP,12.87,64.82,,,,,,
Meridian Duals,CPT,82952,Gtt-added samples,Lab Services,Per Unit,$3.92 ,OP,3.92,19.07,,,,,,
Meridian Duals,CPT,82955,Assay of g6pd enzyme,Lab Services,Per Unit,$9.70 ,OP,9.7,41.94,,,,,,
Meridian Duals,CPT,82960,Test for g6pd enzyme,Lab Services,Per Unit,$6.05 ,OP,6.05,6.05,,,,,,
Meridian Duals,CPT,82962,Glucose blood test,Lab Services,Per Unit,$3.28 ,OP,3.28,11.44,,,,,,
Meridian Duals,CPT,82963,Assay of glucosidase,Lab Services,Per Unit,$21.48 ,OP,21.48,80.07,,,,,,
Meridian Duals,CPT,82965,Assay of gdh enzyme,Lab Services,Per Unit,$13.15 ,OP,13.15,34.31,,,,,,
Meridian Duals,CPT,82977,Assay of ggt,Lab Services,Per Unit,$7.20 ,OP,7.2,34.31,,,,,,
Meridian Duals,CPT,82978,Assay of glutathione,Lab Services,Per Unit,$15.45 ,OP,15.45,64.82,,,,,,
Meridian Duals,CPT,82979,Assay rbc glutathione,Lab Services,Per Unit,$9.44 ,OP,9.44,30.51,,,,,,
Meridian Duals,CPT,82985,Assay of glycated protein,Lab Services,Per Unit,$16.76 ,OP,16.76,76.26,,,,,,
Meridian Duals,CPT,83001,Assay of gonadotropin (fsh),Lab Services,Per Unit,$18.58 ,OP,18.58,91.51,,,,,,
Meridian Duals,CPT,83002,Assay of gonadotropin (lh),Lab Services,Per Unit,$18.52 ,OP,18.52,91.51,,,,,,
Meridian Duals,CPT,83003,Assay growth hormone (hgh),Lab Services,Per Unit,$16.67 ,OP,16.67,72.44,,,,,,
Meridian Duals,CPT,83006,Growth stimulation gene 2,Lab Services,Per Unit,$75.60 ,OP,75.6,75.6,,,,,,
Meridian Duals,CPT,83009,H pylori (c-13) blood,Lab Services,Per Unit,$67.36 ,OP,67.36,301.2,,,,,,
Meridian Duals,CPT,83010,Assay of haptoglobin quant,Lab Services,Per Unit,$12.58 ,OP,12.58,57.19,,,,,,
Meridian Duals,CPT,83012,Assay of haptoglobins,Lab Services,Per Unit,$26.89 ,OP,26.89,72.44,,,,,,
Meridian Duals,CPT,83013,H pylori (c-13) breath,Lab Services,Per Unit,$67.36 ,OP,67.36,301.2,,,,,,
Meridian Duals,CPT,83014,H pylori drug admin,Lab Services,Per Unit,$7.86 ,OP,7.86,34.31,,,,,,
Meridian Duals,CPT,83015,Heavy metal qual any anal,Lab Services,Per Unit,$20.94 ,OP,20.94,83.87,,,,,,
Meridian Duals,CPT,83018,Heavy metal quant each nes,Lab Services,Per Unit,$21.96 ,OP,21.96,99.13,,,,,,
Meridian Duals,CPT,83020,Hemoglobin electrophoresis,Lab Services,Per Unit,$12.87 ,OP,12.87,45.74,,,,,,
Meridian Duals,CPT,83021,Hemoglobin chromotography,Lab Services,Per Unit,$18.06 ,OP,18.06,80.07,,,,,,
Meridian Duals,CPT,83026,Hemoglobin copper sulfate,Lab Services,Per Unit,$4.01 ,OP,4.01,4.01,,,,,,
Meridian Duals,CPT,83030,Fetal hemoglobin chemical,Lab Services,Per Unit,$10.74 ,OP,10.74,10.74,,,,,,
Meridian Duals,CPT,83033,Fetal hemoglobin assay qual,Lab Services,Per Unit,$8.00 ,OP,8,8,,,,,,
Meridian Duals,CPT,83036,Glycosylated hemoglobin test,Lab Services,Per Unit,$9.71 ,OP,9.71,49.56,,,,,,
Meridian Duals,CPT,83037,Glycosylated hb home device,Lab Services,Per Unit,$9.71 ,OP,9.71,41.94,,,,,,
Meridian Duals,CPT,83045,Blood methemoglobin test,Lab Services,Per Unit,$6.49 ,OP,6.49,22.88,,,,,,
Meridian Duals,CPT,83050,Blood methemoglobin assay,Lab Services,Per Unit,$8.20 ,OP,8.2,15.26,,,,,,
Meridian Duals,CPT,83051,Assay of plasma hemoglobin,Lab Services,Per Unit,$7.31 ,OP,7.31,7.31,,,,,,
Meridian Duals,CPT,83060,Blood sulfhemoglobin assay,Lab Services,Per Unit,$8.80 ,OP,8.8,15.26,,,,,,
Meridian Duals,CPT,83065,Assay of hemoglobin heat,Lab Services,Per Unit,$9.00 ,OP,9,15.26,,,,,,
Meridian Duals,CPT,83068,Hemoglobin stability screen,Lab Services,Per Unit,$9.47 ,OP,9.47,9.47,,,,,,
Meridian Duals,CPT,83069,Assay of urine hemoglobin,Lab Services,Per Unit,$3.95 ,OP,3.95,7.62,,,,,,
Meridian Duals,CPT,83070,Assay of hemosiderin qual,Lab Services,Per Unit,$4.75 ,OP,4.75,15.26,,,,,,
Meridian Duals,CPT,83080,Assay of b hexosaminidase,Lab Services,Per Unit,$16.87 ,OP,16.87,76.26,,,,,,
Meridian Duals,CPT,83088,Assay of histamine,Lab Services,Per Unit,$29.53 ,OP,29.53,129.64,,,,,,
Meridian Duals,CPT,83090,Assay of homocystine,Lab Services,Per Unit,$17.92 ,OP,17.92,76.26,,,,,,
Meridian Duals,CPT,83150,Assay of homovanillic acid,Lab Services,Per Unit,$22.41 ,OP,22.41,87.69,,,,,,
Meridian Duals,CPT,83491,Assay of corticosteroids 17,Lab Services,Per Unit,$17.90 ,OP,17.9,76.26,,,,,,
Meridian Duals,CPT,83497,Assay of 5-hiaa,Lab Services,Per Unit,$12.90 ,OP,12.9,57.19,,,,,,
Meridian Duals,CPT,83498,Assay of progesterone 17-d,Lab Services,Per Unit,$27.17 ,OP,27.17,122,,,,,,
Meridian Duals,CPT,83500,Assay free hydroxyproline,Lab Services,Per Unit,$22.65 ,OP,22.65,99.13,,,,,,
Meridian Duals,CPT,83505,Assay total hydroxyproline,Lab Services,Per Unit,$24.30 ,OP,24.3,106.76,,,,,,
Meridian Duals,CPT,83516,Immunoassay nonantibody,Lab Services,Per Unit,$11.53 ,OP,11.53,49.56,,,,,,
Meridian Duals,CPT,83518,Immunoassay dipstick,Lab Services,Per Unit,$9.64 ,OP,9.64,9.64,,,,,,
Meridian Duals,CPT,83519,Ria nonantibody,Lab Services,Per Unit,$18.40 ,OP,18.4,61,,,,,,
Meridian Duals,CPT,83520,Immunoassay quant nos nonab,Lab Services,Per Unit,$17.27 ,OP,17.27,57.19,,,,,,
Meridian Duals,CPT,83525,Assay of insulin,Lab Services,Per Unit,$11.43 ,OP,11.43,49.56,,,,,,
Meridian Duals,CPT,83527,Assay of insulin,Lab Services,Per Unit,$12.95 ,OP,12.95,57.19,,,,,,
Meridian Duals,CPT,83528,Assay of intrinsic factor,Lab Services,Per Unit,$19.82 ,OP,19.82,72.44,,,,,,
Meridian Duals,CPT,83540,Assay of iron,Lab Services,Per Unit,$6.47 ,OP,6.47,30.51,,,,,,
Meridian Duals,CPT,83550,Iron binding test,Lab Services,Per Unit,$8.74 ,OP,8.74,38.13,,,,,,
Meridian Duals,CPT,83570,Assay of idh enzyme,Lab Services,Per Unit,$8.85 ,OP,8.85,38.13,,,,,,
Meridian Duals,CPT,83582,Assay of ketogenic steroids,Lab Services,Per Unit,$15.47 ,OP,15.47,15.47,,,,,,
Meridian Duals,CPT,83586,Assay 17- ketosteroids,Lab Services,Per Unit,$12.80 ,OP,12.8,57.19,,,,,,
Meridian Duals,CPT,83593,Fractionation ketosteroids,Lab Services,Per Unit,$28.50 ,OP,28.5,118.19,,,,,,
Meridian Duals,CPT,83605,Assay of lactic acid,Lab Services,Per Unit,$11.57 ,OP,11.57,53.38,,,,,,
Meridian Duals,CPT,83615,Lactate (ld) (ldh) enzyme,Lab Services,Per Unit,$6.04 ,OP,6.04,26.7,,,,,,
Meridian Duals,CPT,83625,Assay of ldh enzymes,Lab Services,Per Unit,$12.79 ,OP,12.79,49.56,,,,,,
Meridian Duals,CPT,83630,Lactoferrin fecal (qual),Lab Services,Per Unit,$19.70 ,OP,19.7,87.69,,,,,,
Meridian Duals,CPT,83631,Lactoferrin fecal (quant),Lab Services,Per Unit,$19.63 ,OP,19.63,87.69,,,,,,
Meridian Duals,CPT,83632,Placental lactogen,Lab Services,Per Unit,$20.22 ,OP,20.22,91.51,,,,,,
Meridian Duals,CPT,83633,Test urine for lactose,Lab Services,Per Unit,$11.25 ,OP,11.25,22.88,,,,,,
Meridian Duals,CPT,83655,Assay of lead,Lab Services,Per Unit,$12.11 ,OP,12.11,53.38,,,,,,
Meridian Duals,CPT,83661,L/s ratio fetal lung,Lab Services,Per Unit,$21.99 ,OP,21.99,99.13,,,,,,
Meridian Duals,CPT,83662,Foam stability fetal lung,Lab Services,Per Unit,$18.91 ,OP,18.91,83.87,,,,,,
Meridian Duals,CPT,83663,Fluoro polarize fetal lung,Lab Services,Per Unit,$18.91 ,OP,18.91,83.87,,,,,,
Meridian Duals,CPT,83664,Lamellar bdy fetal lung,Lab Services,Per Unit,$19.32 ,OP,19.32,83.87,,,,,,
Meridian Duals,CPT,83670,Assay of lap enzyme,Lab Services,Per Unit,$9.81 ,OP,9.81,41.94,,,,,,
Meridian Duals,CPT,83690,Assay of lipase,Lab Services,Per Unit,$6.89 ,OP,6.89,61.5,,,,,,
Meridian Duals,CPT,83695,Assay of lipoprotein(a),Lab Services,Per Unit,$14.32 ,OP,14.32,57.19,,,,,,
Meridian Duals,CPT,83698,Assay lipoprotein pla2,Lab Services,Per Unit,$46.31 ,OP,46.31,125.82,,,,,,
Meridian Duals,CPT,83700,Lipopro bld electrophoretic,Lab Services,Per Unit,$11.26 ,OP,11.26,49.56,,,,,,
Meridian Duals,CPT,83701,Lipoprotein bld hr fraction,Lab Services,Per Unit,$33.86 ,OP,33.86,110.57,,,,,,
Meridian Duals,CPT,83704,Lipoprotein bld quan part,Lab Services,Per Unit,$34.19 ,OP,34.19,141.07,,,,,,
Meridian Duals,CPT,83718,Assay of lipoprotein,Lab Services,Per Unit,$8.19 ,OP,8.19,41.94,,,,,,
Meridian Duals,CPT,83719,Assay of blood lipoprotein,Lab Services,Per Unit,$12.75 ,OP,12.75,53.38,,,,,,
Meridian Duals,CPT,83721,Assay of blood lipoprotein,Lab Services,Per Unit,$10.50 ,OP,10.5,41.94,,,,,,
Meridian Duals,CPT,83722,Lipoprtn dir meas sd ldl chl,Lab Services,Per Unit,$34.19 ,OP,34.19,141.07,,,,,,
Meridian Duals,CPT,83727,Assay of lrh hormone,Lab Services,Per Unit,$17.19 ,OP,17.19,76.26,,,,,,
Meridian Duals,CPT,83735,Assay of magnesium,Lab Services,Per Unit,$6.70 ,OP,6.7,34.31,,,,,,
Meridian Duals,CPT,83775,Assay malate dehydrogenase,Lab Services,Per Unit,$7.37 ,OP,7.37,34.31,,,,,,
Meridian Duals,CPT,83785,Assay of manganese,Lab Services,Per Unit,$26.65 ,OP,26.65,110.57,,,,,,
Meridian Duals,CPT,83789,Mass spectrometry qual/quan,Lab Services,Per Unit,$24.11 ,OP,24.11,80.07,,,,,,
Meridian Duals,CPT,83825,Assay of mercury,Lab Services,Per Unit,$16.26 ,OP,16.26,72.44,,,,,,
Meridian Duals,CPT,83835,Assay of metanephrines,Lab Services,Per Unit,$16.94 ,OP,16.94,76.26,,,,,,
Meridian Duals,CPT,83857,Assay of methemalbumin,Lab Services,Per Unit,$10.74 ,OP,10.74,49.56,,,,,,
Meridian Duals,CPT,83861,Microfluid analy tears,Lab Services,Per Unit,$22.48 ,OP,22.48,22.48,,,,,,
Meridian Duals,CPT,83864,Mucopolysaccharides,Lab Services,Per Unit,$28.50 ,OP,28.5,87.69,,,,,,
Meridian Duals,CPT,83872,Assay synovial fluid mucin,Lab Services,Per Unit,$5.86 ,OP,5.86,26.7,,,,,,
Meridian Duals,CPT,83873,Assay of csf protein,Lab Services,Per Unit,$17.20 ,OP,17.2,72.44,,,,,,
Meridian Duals,CPT,83874,Assay of myoglobin,Lab Services,Per Unit,$12.92 ,OP,12.92,57.19,,,,,,
Meridian Duals,CPT,83876,Assay myeloperoxidase,Lab Services,Per Unit,$50.86 ,OP,50.86,57.19,,,,,,
Meridian Duals,CPT,83880,Assay of natriuretic peptide,Lab Services,Per Unit,$39.26 ,OP,39.26,245.98,,,,,,
Meridian Duals,CPT,83883,Assay nephelometry not spec,Lab Services,Per Unit,$13.60 ,OP,13.6,61,,,,,,
Meridian Duals,CPT,83885,Assay of nickel,Lab Services,Per Unit,$24.51 ,OP,24.51,45.74,,,,,,
Meridian Duals,CPT,83915,Assay of nucleotidase,Lab Services,Per Unit,$11.15 ,OP,11.15,11.15,,,,,,
Meridian Duals,CPT,83916,Oligoclonal bands,Lab Services,Per Unit,$27.39 ,OP,27.39,87.69,,,,,,
Meridian Duals,CPT,83918,Organic acids total quant,Lab Services,Per Unit,$23.60 ,OP,23.6,72.44,,,,,,
Meridian Duals,CPT,83919,Organic acids qual each,Lab Services,Per Unit,$16.45 ,OP,16.45,16.45,,,,,,
Meridian Duals,CPT,83921,Organic acid single quant,Lab Services,Per Unit,$21.21 ,OP,21.21,72.44,,,,,,
Meridian Duals,CPT,83930,Assay of blood osmolality,Lab Services,Per Unit,$6.61 ,OP,6.61,26.7,,,,,,
Meridian Duals,CPT,83935,Assay of urine osmolality,Lab Services,Per Unit,$6.82 ,OP,6.82,30.51,,,,,,
Meridian Duals,CPT,83937,Assay of osteocalcin,Lab Services,Per Unit,$29.85 ,OP,29.85,133.45,,,,,,
Meridian Duals,CPT,83945,Assay of oxalate,Lab Services,Per Unit,$14.45 ,OP,14.45,57.19,,,,,,
Meridian Duals,CPT,83950,Oncoprotein her-2/neu,Lab Services,Per Unit,$64.41 ,OP,64.41,209.7,,,,,,
Meridian Duals,CPT,83951,Oncoprotein dcp,Lab Services,Per Unit,$64.41 ,OP,64.41,209.7,,,,,,
Meridian Duals,CPT,83970,Assay of parathormone,Lab Services,Per Unit,$41.28 ,OP,41.28,183.02,,,,,,
Meridian Duals,CPT,83986,Assay ph body fluid nos,Lab Services,Per Unit,$3.58 ,OP,3.58,19.07,,,,,,
Meridian Duals,CPT,83987,Exhaled breath condensate,Lab Services,Per Unit,$3.58 ,OP,3.58,3.58,,,,,,
Meridian Duals,CPT,83993,Assay for calprotectin fecal,Lab Services,Per Unit,$19.63 ,OP,19.63,87.69,,,,,,
Meridian Duals,CPT,84030,Assay of blood pku,Lab Services,Per Unit,$5.50 ,OP,5.5,26.7,,,,,,
Meridian Duals,CPT,84035,Assay of phenylketones,Lab Services,Per Unit,$3.98 ,OP,3.98,15.26,,,,,,
Meridian Duals,CPT,84060,Assay acid phosphatase,Lab Services,Per Unit,$7.64 ,OP,7.64,34.31,,,,,,
Meridian Duals,CPT,84066,Assay prostate phosphatase,Lab Services,Per Unit,$9.66 ,OP,9.66,41.94,,,,,,
Meridian Duals,CPT,84075,Assay alkaline phosphatase,Lab Services,Per Unit,$5.18 ,OP,5.18,26.7,,,,,,
Meridian Duals,CPT,84078,Assay alkaline phosphatase,Lab Services,Per Unit,$8.26 ,OP,8.26,34.31,,,,,,
Meridian Duals,CPT,84080,Assay alkaline phosphatases,Lab Services,Per Unit,$14.78 ,OP,14.78,64.82,,,,,,
Meridian Duals,CPT,84081,Assay phosphatidylglycerol,Lab Services,Per Unit,$16.52 ,OP,16.52,72.44,,,,,,
Meridian Duals,CPT,84085,Assay of rbc pg6d enzyme,Lab Services,Per Unit,$9.44 ,OP,9.44,30.51,,,,,,
Meridian Duals,CPT,84087,Assay phosphohexose enzymes,Lab Services,Per Unit,$10.73 ,OP,10.73,45.74,,,,,,
Meridian Duals,CPT,84100,Assay of phosphorus,Lab Services,Per Unit,$4.74 ,OP,4.74,22.88,,,,,,
Meridian Duals,CPT,84105,Assay of urine phosphorus,Lab Services,Per Unit,$5.78 ,OP,5.78,22.88,,,,,,
Meridian Duals,CPT,84106,Test for porphobilinogen,Lab Services,Per Unit,$5.82 ,OP,5.82,19.07,,,,,,
Meridian Duals,CPT,84110,Assay of porphobilinogen,Lab Services,Per Unit,$8.44 ,OP,8.44,38.13,,,,,,
Meridian Duals,CPT,84112,Eval amniotic fluid protein,Lab Services,Per Unit,$98.11 ,OP,98.11,98.11,,,,,,
Meridian Duals,CPT,84119,Test urine for porphyrins,Lab Services,Per Unit,$13.36 ,OP,13.36,13.36,,,,,,
Meridian Duals,CPT,84120,Assay of urine porphyrins,Lab Services,Per Unit,$14.71 ,OP,14.71,64.82,,,,,,
Meridian Duals,CPT,84126,Assay of feces porphyrins,Lab Services,Per Unit,$39.11 ,OP,39.11,114.39,,,,,,
Meridian Duals,CPT,84132,Assay of serum potassium,Lab Services,Per Unit,$4.76 ,OP,4.76,22.88,,,,,,
Meridian Duals,CPT,84133,Assay of urine potassium,Lab Services,Per Unit,$4.73 ,OP,4.73,19.07,,,,,,
Meridian Duals,CPT,84134,Assay of prealbumin,Lab Services,Per Unit,$14.59 ,OP,14.59,64.82,,,,,,
Meridian Duals,CPT,84135,Assay of pregnanediol,Lab Services,Per Unit,$21.27 ,OP,21.27,57.19,,,,,,
Meridian Duals,CPT,84138,Assay of pregnanetriol,Lab Services,Per Unit,$21.05 ,OP,21.05,83.87,,,,,,
Meridian Duals,CPT,84140,Assay of pregnenolone,Lab Services,Per Unit,$20.67 ,OP,20.67,91.51,,,,,,
Meridian Duals,CPT,84143,Assay of 17-hydroxypregneno,Lab Services,Per Unit,$22.81 ,OP,22.81,102.95,,,,,,
Meridian Duals,CPT,84144,Assay of progesterone,Lab Services,Per Unit,$20.86 ,OP,20.86,91.51,,,,,,
Meridian Duals,CPT,84145,Procalcitonin (pct),Lab Services,Per Unit,$27.22 ,OP,27.22,27.22,,,,,,
Meridian Duals,CPT,84146,Assay of prolactin,Lab Services,Per Unit,$19.38 ,OP,19.38,87.69,,,,,,
Meridian Duals,CPT,84150,Assay of prostaglandin,Lab Services,Per Unit,$41.77 ,OP,41.77,41.77,,,,,,
Meridian Duals,CPT,84152,Assay of psa complexed,Lab Services,Per Unit,$18.39 ,OP,18.39,80.07,,,,,,
Meridian Duals,CPT,84153,Assay of psa total,Lab Services,Per Unit,$18.39 ,OP,18.39,80.07,,,,,,
Meridian Duals,CPT,84154,Assay of psa free,Lab Services,Per Unit,$18.39 ,OP,18.39,80.07,,,,,,
Meridian Duals,CPT,84155,Assay of protein serum,Lab Services,Per Unit,$3.67 ,OP,3.67,15.26,,,,,,
Meridian Duals,CPT,84156,Assay of protein urine,Lab Services,Per Unit,$3.67 ,OP,3.67,15.26,,,,,,
Meridian Duals,CPT,84157,Assay of protein other,Lab Services,Per Unit,$4.00 ,OP,4,19.07,,,,,,
Meridian Duals,CPT,84160,Assay of protein any source,Lab Services,Per Unit,$5.61 ,OP,5.61,22.88,,,,,,
Meridian Duals,CPT,84163,Pappa serum,Lab Services,Per Unit,$15.05 ,OP,15.05,68.63,,,,,,
Meridian Duals,CPT,84165,Protein e-phoresis serum,Lab Services,Per Unit,$10.74 ,OP,10.74,49.56,,,,,,
Meridian Duals,CPT,84166,Protein e-phoresis/urine/csf,Lab Services,Per Unit,$17.83 ,OP,17.83,80.07,,,,,,
Meridian Duals,CPT,84181,Western blot test,Lab Services,Per Unit,$17.03 ,OP,17.03,118.19,,,,,,
Meridian Duals,CPT,84182,Protein western blot test,Lab Services,Per Unit,$29.21 ,OP,29.21,129.64,,,,,,
Meridian Duals,CPT,84202,Assay rbc protoporphyrin,Lab Services,Per Unit,$14.35 ,OP,14.35,64.82,,,,,,
Meridian Duals,CPT,84203,Test rbc protoporphyrin,Lab Services,Per Unit,$9.74 ,OP,9.74,38.13,,,,,,
Meridian Duals,CPT,84206,Assay of proinsulin,Lab Services,Per Unit,$26.69 ,OP,26.69,80.07,,,,,,
Meridian Duals,CPT,84207,Assay of vitamin b-6,Lab Services,Per Unit,$28.10 ,OP,28.1,125.82,,,,,,
Meridian Duals,CPT,84210,Assay of pyruvate,Lab Services,Per Unit,$14.48 ,OP,14.48,49.56,,,,,,
Meridian Duals,CPT,84220,Assay of pyruvate kinase,Lab Services,Per Unit,$9.44 ,OP,9.44,41.94,,,,,,
Meridian Duals,CPT,84228,Assay of quinine,Lab Services,Per Unit,$11.63 ,OP,11.63,53.38,,,,,,
Meridian Duals,CPT,84233,Assay of estrogen,Lab Services,Per Unit,$87.88 ,OP,87.88,209.7,,,,,,
Meridian Duals,CPT,84234,Assay of progesterone,Lab Services,Per Unit,$64.88 ,OP,64.88,183.02,,,,,,
Meridian Duals,CPT,84235,Assay of endocrine hormone,Lab Services,Per Unit,$71.23 ,OP,71.23,163.95,,,,,,
Meridian Duals,CPT,84238,Assay nonendocrine receptor,Lab Services,Per Unit,$36.57 ,OP,36.57,163.95,,,,,,
Meridian Duals,CPT,84244,Assay of renin,Lab Services,Per Unit,$21.99 ,OP,21.99,99.13,,,,,,
Meridian Duals,CPT,84252,Assay of vitamin b-2,Lab Services,Per Unit,$20.24 ,OP,20.24,20.24,,,,,,
Meridian Duals,CPT,84255,Assay of selenium,Lab Services,Per Unit,$25.53 ,OP,25.53,114.39,,,,,,
Meridian Duals,CPT,84260,Assay of serotonin,Lab Services,Per Unit,$30.98 ,OP,30.98,30.98,,,,,,
Meridian Duals,CPT,84270,Assay of sex hormone globul,Lab Services,Per Unit,$21.73 ,OP,21.73,95.32,,,,,,
Meridian Duals,CPT,84275,Assay of sialic acid,Lab Services,Per Unit,$13.44 ,OP,13.44,13.44,,,,,,
Meridian Duals,CPT,84285,Assay of silica,Lab Services,Per Unit,$25.21 ,OP,25.21,38.13,,,,,,
Meridian Duals,CPT,84295,Assay of serum sodium,Lab Services,Per Unit,$4.81 ,OP,4.81,22.88,,,,,,
Meridian Duals,CPT,84300,Assay of urine sodium,Lab Services,Per Unit,$5.06 ,OP,5.06,22.88,,,,,,
Meridian Duals,CPT,84302,Assay of sweat sodium,Lab Services,Per Unit,$4.86 ,OP,4.86,22.88,,,,,,
Meridian Duals,CPT,84305,Assay of somatomedin,Lab Services,Per Unit,$21.26 ,OP,21.26,95.32,,,,,,
Meridian Duals,CPT,84307,Assay of somatostatin,Lab Services,Per Unit,$18.28 ,OP,18.28,80.07,,,,,,
Meridian Duals,CPT,84311,Spectrophotometry,Lab Services,Per Unit,$8.10 ,OP,8.1,30.51,,,,,,
Meridian Duals,CPT,84315,Body fluid specific gravity,Lab Services,Per Unit,$3.28 ,OP,3.28,11.44,,,,,,
Meridian Duals,CPT,84375,Chromatogram assay sugars,Lab Services,Per Unit,$39.00 ,OP,39,39,,,,,,
Meridian Duals,CPT,84376,Sugars single qual,Lab Services,Per Unit,$5.50 ,OP,5.5,22.88,,,,,,
Meridian Duals,CPT,84377,Sugars multiple qual,Lab Services,Per Unit,$5.50 ,OP,5.5,22.88,,,,,,
Meridian Duals,CPT,84378,Sugars single quant,Lab Services,Per Unit,$11.53 ,OP,11.53,49.56,,,,,,
Meridian Duals,CPT,84379,Sugars multiple quant,Lab Services,Per Unit,$11.53 ,OP,11.53,49.56,,,,,,
Meridian Duals,CPT,84392,Assay of urine sulfate,Lab Services,Per Unit,$5.49 ,OP,5.49,22.88,,,,,,
Meridian Duals,CPT,84402,Assay of free testosterone,Lab Services,Per Unit,$25.47 ,OP,25.47,114.39,,,,,,
Meridian Duals,CPT,84403,Assay of total testosterone,Lab Services,Per Unit,$25.81 ,OP,25.81,114.39,,,,,,
Meridian Duals,CPT,84410,Testosterone bioavailable,Lab Services,Per Unit,$51.28 ,OP,51.28,51.28,,,,,,
Meridian Duals,CPT,84425,Assay of vitamin b-1,Lab Services,Per Unit,$21.23 ,OP,21.23,95.32,,,,,,
Meridian Duals,CPT,84430,Assay of thiocyanate,Lab Services,Per Unit,$11.63 ,OP,11.63,53.38,,,,,,
Meridian Duals,CPT,84431,Thromboxane urine,Lab Services,Per Unit,$35.11 ,OP,35.11,35.11,,,,,,
Meridian Duals,CPT,84432,Assay of thyroglobulin,Lab Services,Per Unit,$16.06 ,OP,16.06,72.44,,,,,,
Meridian Duals,CPT,84436,Assay of total thyroxine,Lab Services,Per Unit,$6.87 ,OP,6.87,30.51,,,,,,
Meridian Duals,CPT,84437,Assay of neonatal thyroxine,Lab Services,Per Unit,$6.47 ,OP,6.47,30.51,,,,,,
Meridian Duals,CPT,84439,Assay of free thyroxine,Lab Services,Per Unit,$9.02 ,OP,9.02,41.94,,,,,,
Meridian Duals,CPT,84442,Assay of thyroid activity,Lab Services,Per Unit,$14.78 ,OP,14.78,64.82,,,,,,
Meridian Duals,CPT,84443,Assay thyroid stim hormone,Lab Services,Per Unit,$16.80 ,OP,16.8,76.26,,,,,,
Meridian Duals,CPT,84445,Assay of tsi globulin,Lab Services,Per Unit,$50.86 ,OP,50.86,224.95,,,,,,
Meridian Duals,CPT,84446,Assay of vitamin e,Lab Services,Per Unit,$14.18 ,OP,14.18,64.82,,,,,,
Meridian Duals,CPT,84449,Assay of transcortin,Lab Services,Per Unit,$18.00 ,OP,18,80.07,,,,,,
Meridian Duals,CPT,84450,Transferase (ast) (sgot),Lab Services,Per Unit,$5.18 ,OP,5.18,22.88,,,,,,
Meridian Duals,CPT,84460,Alanine amino (alt) (sgpt),Lab Services,Per Unit,$5.30 ,OP,5.3,26.7,,,,,,
Meridian Duals,CPT,84466,Assay of transferrin,Lab Services,Per Unit,$12.76 ,OP,12.76,57.19,,,,,,
Meridian Duals,CPT,84478,Assay of triglycerides,Lab Services,Per Unit,$5.74 ,OP,5.74,30.51,,,,,,
Meridian Duals,CPT,84479,Assay of thyroid (t3 or t4),Lab Services,Per Unit,$6.47 ,OP,6.47,30.51,,,,,,
Meridian Duals,CPT,84480,Assay triiodothyronine (t3),Lab Services,Per Unit,$14.18 ,OP,14.18,49.56,,,,,,
Meridian Duals,CPT,84481,Free assay (ft-3),Lab Services,Per Unit,$16.94 ,OP,16.94,49.56,,,,,,
Meridian Duals,CPT,84482,T3 reverse,Lab Services,Per Unit,$15.76 ,OP,15.76,68.63,,,,,,
Meridian Duals,CPT,84484,Assay of troponin quant,Lab Services,Per Unit,$12.47 ,OP,12.47,92.24,,,,,,
Meridian Duals,CPT,84485,Assay duodenal fluid trypsin,Lab Services,Per Unit,$7.20 ,OP,7.2,7.2,,,,,,
Meridian Duals,CPT,84488,Test feces for trypsin,Lab Services,Per Unit,$7.30 ,OP,7.3,34.31,,,,,,
Meridian Duals,CPT,84490,Assay of feces for trypsin,Lab Services,Per Unit,$9.93 ,OP,9.93,26.7,,,,,,
Meridian Duals,CPT,84510,Assay of tyrosine,Lab Services,Per Unit,$10.63 ,OP,10.63,45.74,,,,,,
Meridian Duals,CPT,84512,Assay of troponin qual,Lab Services,Per Unit,$10.09 ,OP,10.09,34.31,,,,,,
Meridian Duals,CPT,84520,Assay of urea nitrogen,Lab Services,Per Unit,$3.95 ,OP,3.95,19.07,,,,,,
Meridian Duals,CPT,84525,Urea nitrogen semi-quant,Lab Services,Per Unit,$5.13 ,OP,5.13,15.26,,,,,,
Meridian Duals,CPT,84540,Assay of urine/urea-n,Lab Services,Per Unit,$5.56 ,OP,5.56,22.88,,,,,,
Meridian Duals,CPT,84545,Urea-n clearance test,Lab Services,Per Unit,$7.20 ,OP,7.2,19.07,,,,,,
Meridian Duals,CPT,84550,Assay of blood/uric acid,Lab Services,Per Unit,$4.52 ,OP,4.52,19.07,,,,,,
Meridian Duals,CPT,84560,Assay of urine/uric acid,Lab Services,Per Unit,$5.08 ,OP,5.08,22.88,,,,,,
Meridian Duals,CPT,84577,Assay of feces/urobilinogen,Lab Services,Per Unit,$16.80 ,OP,16.8,57.19,,,,,,
Meridian Duals,CPT,84578,Test urine urobilinogen,Lab Services,Per Unit,$4.47 ,OP,4.47,15.26,,,,,,
Meridian Duals,CPT,84580,Assay of urine urobilinogen,Lab Services,Per Unit,$9.55 ,OP,9.55,19.07,,,,,,
Meridian Duals,CPT,84583,Assay of urine urobilinogen,Lab Services,Per Unit,$6.05 ,OP,6.05,22.88,,,,,,
Meridian Duals,CPT,84585,Assay of urine vma,Lab Services,Per Unit,$15.50 ,OP,15.5,68.63,,,,,,
Meridian Duals,CPT,84586,Assay of vip,Lab Services,Per Unit,$35.33 ,OP,35.33,156.32,,,,,,
Meridian Duals,CPT,84588,Assay of vasopressin,Lab Services,Per Unit,$33.94 ,OP,33.94,125.82,,,,,,
Meridian Duals,CPT,84590,Assay of vitamin a,Lab Services,Per Unit,$11.61 ,OP,11.61,53.38,,,,,,
Meridian Duals,CPT,84591,Assay of nos vitamin,Lab Services,Per Unit,$17.06 ,OP,17.06,53.38,,,,,,
Meridian Duals,CPT,84597,Assay of vitamin k,Lab Services,Per Unit,$13.72 ,OP,13.72,49.56,,,,,,
Meridian Duals,CPT,84600,Assay of volatiles,Lab Services,Per Unit,$17.11 ,OP,17.11,72.44,,,,,,
Meridian Duals,CPT,84620,Xylose tolerance test,Lab Services,Per Unit,$12.91 ,OP,12.91,38.13,,,,,,
Meridian Duals,CPT,84630,Assay of zinc,Lab Services,Per Unit,$11.39 ,OP,11.39,49.56,,,,,,
Meridian Duals,CPT,84681,Assay of c-peptide,Lab Services,Per Unit,$20.81 ,OP,20.81,91.51,,,,,,
Meridian Duals,CPT,84702,Chorionic gonadotropin test,Lab Services,Per Unit,$15.05 ,OP,15.05,76.26,,,,,,
Meridian Duals,CPT,84703,Chorionic gonadotropin assay,Lab Services,Per Unit,$7.52 ,OP,7.52,38.13,,,,,,
Meridian Duals,CPT,84704,Hcg free betachain test,Lab Services,Per Unit,$15.29 ,OP,15.29,68.63,,,,,,
Meridian Duals,CPT,84830,Ovulation tests,Lab Services,Per Unit,$12.70 ,OP,12.7,49.56,,,,,,
Meridian Duals,CPT,85002,Bleeding time test,Lab Services,Per Unit,$4.82 ,OP,4.82,22.88,,,,,,
Meridian Duals,CPT,85004,Automated diff wbc count,Lab Services,Per Unit,$6.47 ,OP,6.47,34.31,,,,,,
Meridian Duals,CPT,85007,Bl smear w/diff wbc count,Lab Services,Per Unit,$3.80 ,OP,3.8,19.07,,,,,,
Meridian Duals,CPT,85008,Bl smear w/o diff wbc count,Lab Services,Per Unit,$3.43 ,OP,3.43,19.07,,,,,,
Meridian Duals,CPT,85009,Manual diff wbc count b-coat,Lab Services,Per Unit,$5.07 ,OP,5.07,19.07,,,,,,
Meridian Duals,CPT,85013,Spun microhematocrit,Lab Services,Per Unit,$7.00 ,OP,7,7,,,,,,
Meridian Duals,CPT,85014,Hematocrit,Lab Services,Per Unit,$2.37 ,OP,2.37,11.44,,,,,,
Meridian Duals,CPT,85018,Hemoglobin,Lab Services,Per Unit,$2.37 ,OP,2.37,11.44,,,,,,
Meridian Duals,CPT,85025,Complete cbc w/auto diff wbc,Lab Services,Per Unit,$7.77 ,OP,7.77,67.65,,,,,,
Meridian Duals,CPT,85027,Complete cbc automated,Lab Services,Per Unit,$6.47 ,OP,6.47,34.31,,,,,,
Meridian Duals,CPT,85032,Manual cell count each,Lab Services,Per Unit,$4.31 ,OP,4.31,22.88,,,,,,
Meridian Duals,CPT,85041,Automated rbc count,Lab Services,Per Unit,$3.02 ,OP,3.02,11.44,,,,,,
Meridian Duals,CPT,85044,Manual reticulocyte count,Lab Services,Per Unit,$4.31 ,OP,4.31,4.31,,,,,,
Meridian Duals,CPT,85045,Automated reticulocyte count,Lab Services,Per Unit,$3.99 ,OP,3.99,19.07,,,,,,
Meridian Duals,CPT,85046,Reticyte/hgb concentrate,Lab Services,Per Unit,$5.57 ,OP,5.57,26.7,,,,,,
Meridian Duals,CPT,85048,Automated leukocyte count,Lab Services,Per Unit,$2.54 ,OP,2.54,11.44,,,,,,
Meridian Duals,CPT,85049,Automated platelet count,Lab Services,Per Unit,$4.48 ,OP,4.48,22.88,,,,,,
Meridian Duals,CPT,85055,Reticulated platelet assay,Lab Services,Per Unit,$35.74 ,OP,35.74,61,,,,,,
Meridian Duals,CPT,85097,Bone marrow interpretation,APC 5674,RVU Per Case,$671.45 ,OP,438.47,671.45,,,,,,
Meridian Duals,CPT,85130,Chromogenic substrate assay,Lab Services,Per Unit,$11.89 ,OP,11.89,53.38,,,,,,
Meridian Duals,CPT,85170,Blood clot retraction,Lab Services,Per Unit,$16.30 ,OP,16.3,16.3,,,,,,
Meridian Duals,CPT,85175,Blood clot lysis time,Lab Services,Per Unit,$20.37 ,OP,19.07,20.37,,,,,,
Meridian Duals,CPT,85210,Clot factor ii prothrom spec,Lab Services,Per Unit,$12.98 ,OP,12.98,64.82,,,,,,
Meridian Duals,CPT,85220,Blooc clot factor v test,Lab Services,Per Unit,$17.65 ,OP,17.65,80.07,,,,,,
Meridian Duals,CPT,85230,Clot factor vii proconvertin,Lab Services,Per Unit,$17.90 ,OP,17.9,80.07,,,,,,
Meridian Duals,CPT,85240,Clot factor viii ahg 1 stage,Lab Services,Per Unit,$17.90 ,OP,17.9,80.07,,,,,,
Meridian Duals,CPT,85244,Clot factor viii reltd antgn,Lab Services,Per Unit,$20.42 ,OP,20.42,91.51,,,,,,
Meridian Duals,CPT,85245,Clot factor viii vw ristoctn,Lab Services,Per Unit,$22.94 ,OP,22.94,64.82,,,,,,
Meridian Duals,CPT,85246,Clot factor viii vw antigen,Lab Services,Per Unit,$22.94 ,OP,22.94,64.82,,,,,,
Meridian Duals,CPT,85247,Clot factor viii multimetric,Lab Services,Per Unit,$22.94 ,OP,22.94,22.94,,,,,,
Meridian Duals,CPT,85250,Clot factor ix ptc/chrstmas,Lab Services,Per Unit,$19.04 ,OP,19.04,83.87,,,,,,
Meridian Duals,CPT,85260,Clot factor x stuart-power,Lab Services,Per Unit,$17.90 ,OP,17.9,80.07,,,,,,
Meridian Duals,CPT,85270,Clot factor xi pta,Lab Services,Per Unit,$17.90 ,OP,17.9,80.07,,,,,,
Meridian Duals,CPT,85280,Clot factor xii hageman,Lab Services,Per Unit,$19.35 ,OP,19.35,87.69,,,,,,
Meridian Duals,CPT,85290,Clot factor xiii fibrin stab,Lab Services,Per Unit,$16.34 ,OP,16.34,72.44,,,,,,
Meridian Duals,CPT,85291,Clot factor xiii fibrin scrn,Lab Services,Per Unit,$9.11 ,OP,9.11,38.13,,,,,,
Meridian Duals,CPT,85292,Clot factor fletcher fact,Lab Services,Per Unit,$18.93 ,OP,18.93,83.87,,,,,,
Meridian Duals,CPT,85293,Clot factor wght kininogen,Lab Services,Per Unit,$18.93 ,OP,18.93,83.87,,,,,,
Meridian Duals,CPT,85300,Antithrombin iii activity,Lab Services,Per Unit,$11.85 ,OP,11.85,53.38,,,,,,
Meridian Duals,CPT,85301,Antithrombin iii antigen,Lab Services,Per Unit,$10.81 ,OP,10.81,49.56,,,,,,
Meridian Duals,CPT,85302,Clot inhibit prot c antigen,Lab Services,Per Unit,$12.01 ,OP,12.01,53.38,,,,,,
Meridian Duals,CPT,85303,Clot inhibit prot c activity,Lab Services,Per Unit,$13.84 ,OP,13.84,61,,,,,,
Meridian Duals,CPT,85305,Clot inhibit prot s total,Lab Services,Per Unit,$11.61 ,OP,11.61,53.38,,,,,,
Meridian Duals,CPT,85306,Clot inhibit prot s free,Lab Services,Per Unit,$15.32 ,OP,15.32,68.63,,,,,,
Meridian Duals,CPT,85307,Assay activated protein c,Lab Services,Per Unit,$15.32 ,OP,15.32,68.63,,,,,,
Meridian Duals,CPT,85335,Factor inhibitor test,Lab Services,Per Unit,$12.87 ,OP,12.87,12.87,,,,,,
Meridian Duals,CPT,85337,Thrombomodulin,Lab Services,Per Unit,$17.27 ,OP,17.27,45.74,,,,,,
Meridian Duals,CPT,85345,Coagulation time lee & white,Lab Services,Per Unit,$4.69 ,OP,4.69,4.69,,,,,,
Meridian Duals,CPT,85347,Coagulation time activated,Lab Services,Per Unit,$4.28 ,OP,4.28,15.26,,,,,,
Meridian Duals,CPT,85348,Coagulation time otr method,Lab Services,Per Unit,$4.49 ,OP,4.49,15.26,,,,,,
Meridian Duals,CPT,85360,Euglobulin lysis,Lab Services,Per Unit,$8.41 ,OP,8.41,38.13,,,,,,
Meridian Duals,CPT,85362,Fibrin degradation products,Lab Services,Per Unit,$6.89 ,OP,6.89,30.51,,,,,,
Meridian Duals,CPT,85366,Fibrinogen test,Lab Services,Per Unit,$80.46 ,OP,30.51,80.46,,,,,,
Meridian Duals,CPT,85370,Fibrinogen test,Lab Services,Per Unit,$12.43 ,OP,12.43,49.56,,,,,,
Meridian Duals,CPT,85378,Fibrin degrade semiquant,Lab Services,Per Unit,$9.72 ,OP,9.72,30.51,,,,,,
Meridian Duals,CPT,85379,Fibrin degradation quant,Lab Services,Per Unit,$10.18 ,OP,10.18,135.29,,,,,,
Meridian Duals,CPT,85380,Fibrin degradj d-dimer,Lab Services,Per Unit,$10.18 ,OP,10.18,45.74,,,,,,
Meridian Duals,CPT,85384,Fibrinogen activity,Lab Services,Per Unit,$9.72 ,OP,9.72,38.13,,,,,,
Meridian Duals,CPT,85385,Fibrinogen antigen,Lab Services,Per Unit,$14.46 ,OP,14.46,38.13,,,,,,
Meridian Duals,CPT,85390,Fibrinolysins screen i&r,Lab Services,Per Unit,$15.48 ,OP,15.48,38.13,,,,,,
Meridian Duals,CPT,85397,Clotting funct activity,Lab Services,Per Unit,$30.86 ,OP,30.86,30.86,,,,,,
Meridian Duals,CPT,85400,Fibrinolytic plasmin,Lab Services,Per Unit,$7.71 ,OP,7.71,38.13,,,,,,
Meridian Duals,CPT,85410,Fibrinolytic antiplasmin,Lab Services,Per Unit,$7.71 ,OP,7.71,34.31,,,,,,
Meridian Duals,CPT,85415,Fibrinolytic plasminogen,Lab Services,Per Unit,$17.19 ,OP,17.19,76.26,,,,,,
Meridian Duals,CPT,85420,Fibrinolytic plasminogen,Lab Services,Per Unit,$6.53 ,OP,6.53,6.53,,,,,,
Meridian Duals,CPT,85421,Fibrinolytic plasminogen,Lab Services,Per Unit,$10.18 ,OP,10.18,45.74,,,,,,
Meridian Duals,CPT,85441,Heinz bodies direct,Lab Services,Per Unit,$4.20 ,OP,4.2,19.07,,,,,,
Meridian Duals,CPT,85445,Heinz bodies induced,Lab Services,Per Unit,$6.82 ,OP,6.82,30.51,,,,,,
Meridian Duals,CPT,85460,Hemoglobin fetal,Lab Services,Per Unit,$7.73 ,OP,7.73,7.73,,,,,,
Meridian Duals,CPT,85461,Hemoglobin fetal,Lab Services,Per Unit,$9.36 ,OP,9.36,30.51,,,,,,
Meridian Duals,CPT,85475,Hemolysin acid,Lab Services,Per Unit,$8.87 ,OP,8.87,38.13,,,,,,
Meridian Duals,CPT,85520,Heparin assay,Lab Services,Per Unit,$13.09 ,OP,13.09,57.19,,,,,,
Meridian Duals,CPT,85525,Heparin neutralization,Lab Services,Per Unit,$11.84 ,OP,11.84,53.38,,,,,,
Meridian Duals,CPT,85530,Heparin-protamine tolerance,Lab Services,Per Unit,$13.09 ,OP,13.09,48.46,,,,,,
Meridian Duals,CPT,85536,Iron stain peripheral blood,Lab Services,Per Unit,$6.88 ,OP,6.88,30.51,,,,,,
Meridian Duals,CPT,85540,Wbc alkaline phosphatase,Lab Services,Per Unit,$8.60 ,OP,8.6,38.13,,,,,,
Meridian Duals,CPT,85547,Rbc mechanical fragility,Lab Services,Per Unit,$8.60 ,OP,8.6,11.44,,,,,,
Meridian Duals,CPT,85549,Muramidase,Lab Services,Per Unit,$18.75 ,OP,18.75,83.87,,,,,,
Meridian Duals,CPT,85555,Rbc osmotic fragility,Lab Services,Per Unit,$7.47 ,OP,7.47,30.51,,,,,,
Meridian Duals,CPT,85557,Rbc osmotic fragility,Lab Services,Per Unit,$13.36 ,OP,13.36,13.36,,,,,,
Meridian Duals,CPT,85576,Blood platelet aggregation,Lab Services,Per Unit,$24.91 ,OP,24.91,95.32,,,,,,
Meridian Duals,CPT,85597,Phospholipid pltlt neutraliz,Lab Services,Per Unit,$17.98 ,OP,17.98,80.07,,,,,,
Meridian Duals,CPT,85598,Hexagnal phosph pltlt neutrl,Lab Services,Per Unit,$17.98 ,OP,17.98,17.98,,,,,,
Meridian Duals,CPT,85610,Prothrombin time,Lab Services,Per Unit,$4.29 ,OP,4.29,19.07,,,,,,
Meridian Duals,CPT,85611,Prothrombin test,Lab Services,Per Unit,$3.94 ,OP,3.94,19.07,,,,,,
Meridian Duals,CPT,85612,Viper venom prothrombin time,Lab Services,Per Unit,$17.49 ,OP,17.49,17.49,,,,,,
Meridian Duals,CPT,85613,Russell viper venom diluted,Lab Services,Per Unit,$9.58 ,OP,9.58,41.94,,,,,,
Meridian Duals,CPT,85635,Reptilase test,Lab Services,Per Unit,$9.85 ,OP,9.85,19.07,,,,,,
Meridian Duals,CPT,85651,Rbc sed rate nonautomated,Lab Services,Per Unit,$4.27 ,OP,4.27,19.07,,,,,,
Meridian Duals,CPT,85652,Rbc sed rate automated,Lab Services,Per Unit,$2.70 ,OP,2.7,15.26,,,,,,
Meridian Duals,CPT,85660,Rbc sickle cell test,Lab Services,Per Unit,$5.51 ,OP,5.51,22.88,,,,,,
Meridian Duals,CPT,85670,Thrombin time plasma,Lab Services,Per Unit,$5.77 ,OP,5.77,26.7,,,,,,
Meridian Duals,CPT,85675,Thrombin time titer,Lab Services,Per Unit,$6.85 ,OP,6.85,30.51,,,,,,
Meridian Duals,CPT,85705,Thromboplastin inhibition,Lab Services,Per Unit,$9.63 ,OP,9.63,41.94,,,,,,
Meridian Duals,CPT,85730,Thromboplastin time partial,Lab Services,Per Unit,$6.01 ,OP,6.01,30.51,,,,,,
Meridian Duals,CPT,85732,Thromboplastin time partial,Lab Services,Per Unit,$6.47 ,OP,6.47,30.51,,,,,,
Meridian Duals,CPT,85810,Blood viscosity examination,Lab Services,Per Unit,$11.67 ,OP,11.67,53.38,,,,,,
Meridian Duals,CPT,86000,Agglutinins febrile antigen,Lab Services,Per Unit,$6.98 ,OP,6.98,6.98,,,,,,
Meridian Duals,CPT,86001,Allergen specific igg,Lab Services,Per Unit,$7.82 ,OP,7.82,22.88,,,,,,
Meridian Duals,CPT,86003,Allg spec ige crude xtrc ea,Lab Services,Per Unit,$5.22 ,OP,5.22,22.88,,,,,,
Meridian Duals,CPT,86005,Allg spec ige multiallg scr,Lab Services,Per Unit,$7.97 ,OP,7.97,7.97,,,,,,
Meridian Duals,CPT,86008,Allg spec ige recomb ea,Lab Services,Per Unit,$17.93 ,OP,17.93,80.07,,,,,,
Meridian Duals,CPT,86021,Wbc antibody identification,Lab Services,Per Unit,$15.05 ,OP,15.05,68.63,,,,,,
Meridian Duals,CPT,86022,Platelet antibodies,Lab Services,Per Unit,$18.37 ,OP,18.37,64.82,,,,,,
Meridian Duals,CPT,86023,Immunoglobulin assay,Lab Services,Per Unit,$12.46 ,OP,12.46,57.19,,,,,,
Meridian Duals,CPT,86038,Antinuclear antibodies,Lab Services,Per Unit,$12.09 ,OP,12.09,53.38,,,,,,
Meridian Duals,CPT,86039,Antinuclear antibodies (ana),Lab Services,Per Unit,$11.16 ,OP,11.16,49.56,,,,,,
Meridian Duals,CPT,86060,Antistreptolysin o titer,Lab Services,Per Unit,$7.30 ,OP,7.3,34.31,,,,,,
Meridian Duals,CPT,86063,Antistreptolysin o screen,Lab Services,Per Unit,$5.77 ,OP,5.77,26.7,,,,,,
Meridian Duals,CPT,86077,Phys blood bank serv xmatch,APC 5731,RVU Per Case,$25.25 ,OP,25.25,244.01,,,,,,
Meridian Duals,CPT,86078,Phys blood bank serv reactj,APC 5672,RVU Per Case,$152.64 ,OP,152.64,247.83,,,,,,
Meridian Duals,CPT,86079,Phys blood bank serv authrj,APC 5671,RVU Per Case,$50.92 ,OP,50.92,251.64,,,,,,
Meridian Duals,CPT,86140,C-reactive protein,Lab Services,Per Unit,$5.18 ,OP,5.18,22.88,,,,,,
Meridian Duals,CPT,86141,C-reactive protein hs,Lab Services,Per Unit,$12.95 ,OP,12.95,57.19,,,,,,
Meridian Duals,CPT,86146,Beta-2 glycoprotein antibody,Lab Services,Per Unit,$25.45 ,OP,25.45,114.39,,,,,,
Meridian Duals,CPT,86147,Cardiolipin antibody ea ig,Lab Services,Per Unit,$25.45 ,OP,25.45,114.39,,,,,,
Meridian Duals,CPT,86148,Anti-phospholipid antibody,Lab Services,Per Unit,$16.07 ,OP,16.07,72.44,,,,,,
Meridian Duals,CPT,86152,Cell enumeration & id,Lab Services,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Meridian Duals,CPT,86155,Chemotaxis assay,Lab Services,Per Unit,$15.99 ,OP,15.99,72.44,,,,,,
Meridian Duals,CPT,86156,Cold agglutinin screen,Lab Services,Per Unit,$8.07 ,OP,8.07,30.51,,,,,,
Meridian Duals,CPT,86157,Cold agglutinin titer,Lab Services,Per Unit,$8.06 ,OP,8.06,34.31,,,,,,
Meridian Duals,CPT,86160,Complement antigen,Lab Services,Per Unit,$12.00 ,OP,12,53.38,,,,,,
Meridian Duals,CPT,86161,Complement/function activity,Lab Services,Per Unit,$12.00 ,OP,12,53.38,,,,,,
Meridian Duals,CPT,86162,Complement total (ch50),Lab Services,Per Unit,$20.32 ,OP,20.32,91.51,,,,,,
Meridian Duals,CPT,86171,Complement fixation each,Lab Services,Per Unit,$10.01 ,OP,10.01,45.74,,,,,,
Meridian Duals,CPT,86200,Ccp antibody,Lab Services,Per Unit,$12.95 ,OP,12.95,57.19,,,,,,
Meridian Duals,CPT,86215,Deoxyribonuclease antibody,Lab Services,Per Unit,$13.25 ,OP,13.25,57.19,,,,,,
Meridian Duals,CPT,86225,Dna antibody native,Lab Services,Per Unit,$13.74 ,OP,13.74,61,,,,,,
Meridian Duals,CPT,86226,Dna antibody single strand,Lab Services,Per Unit,$12.11 ,OP,12.11,53.38,,,,,,
Meridian Duals,CPT,86235,Nuclear antigen antibody,Lab Services,Per Unit,$17.93 ,OP,17.93,80.07,,,,,,
Meridian Duals,CPT,86255,Fluorescent antibody screen,Lab Services,Per Unit,$12.05 ,OP,12.05,53.38,,,,,,
Meridian Duals,CPT,86256,Fluorescent antibody titer,Lab Services,Per Unit,$12.05 ,OP,12.05,53.38,,,,,,
Meridian Duals,CPT,86277,Growth hormone antibody,Lab Services,Per Unit,$15.74 ,OP,15.74,68.63,,,,,,
Meridian Duals,CPT,86280,Hemagglutination inhibition,Lab Services,Per Unit,$8.19 ,OP,8.19,8.19,,,,,,
Meridian Duals,CPT,86294,Immunoassay tumor qual,Lab Services,Per Unit,$25.57 ,OP,25.57,80.07,,,,,,
Meridian Duals,CPT,86300,Immunoassay tumor ca 15-3,Lab Services,Per Unit,$20.81 ,OP,20.81,91.51,,,,,,
Meridian Duals,CPT,86301,Immunoassay tumor ca 19-9,Lab Services,Per Unit,$20.81 ,OP,20.81,91.51,,,,,,
Meridian Duals,CPT,86304,Immunoassay tumor ca 125,Lab Services,Per Unit,$20.81 ,OP,20.81,91.51,,,,,,
Meridian Duals,CPT,86305,Human epididymis protein 4,Lab Services,Per Unit,$20.81 ,OP,20.81,20.81,,,,,,
Meridian Duals,CPT,86308,Heterophile antibody screen,Lab Services,Per Unit,$5.18 ,OP,5.18,26.7,,,,,,
Meridian Duals,CPT,86309,Heterophile antibody titer,Lab Services,Per Unit,$6.47 ,OP,6.47,30.51,,,,,,
Meridian Duals,CPT,86310,Heterophile antibody absrbj,Lab Services,Per Unit,$7.37 ,OP,7.37,7.37,,,,,,
Meridian Duals,CPT,86316,Immunoassay tumor other,Lab Services,Per Unit,$20.81 ,OP,20.81,91.51,,,,,,
Meridian Duals,CPT,86317,Immunoassay infectious agent,Lab Services,Per Unit,$14.99 ,OP,14.99,68.63,,,,,,
Meridian Duals,CPT,86318,Ia infectious agent antibody,Lab Services,Per Unit,$18.09 ,OP,18.09,64.82,,,,,,
Meridian Duals,CPT,86320,Serum immunoelectrophoresis,Lab Services,Per Unit,$29.92 ,OP,29.92,99.13,,,,,,
Meridian Duals,CPT,86325,Other immunoelectrophoresis,Lab Services,Per Unit,$23.13 ,OP,23.13,99.13,,,,,,
Meridian Duals,CPT,86327,Immunoelectrophoresis assay,Lab Services,Per Unit,$29.92 ,OP,29.92,72.44,,,,,,
Meridian Duals,CPT,86328,Ia nfct ab sarscov2 covid19,Lab Services,Per Unit,$45.23 ,OP,45.23,64.82,,,,,,
Meridian Duals,CPT,86329,Immunodiffusion nes,Lab Services,Per Unit,$14.05 ,OP,14.05,14.05,,,,,,
Meridian Duals,CPT,86331,Immunodiffusion ouchterlony,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Meridian Duals,CPT,86332,Immune complex assay,Lab Services,Per Unit,$24.37 ,OP,24.37,106.76,,,,,,
Meridian Duals,CPT,86334,Immunofix e-phoresis serum,Lab Services,Per Unit,$22.34 ,OP,22.34,99.13,,,,,,
Meridian Duals,CPT,86335,Immunfix e-phorsis/urine/csf,Lab Services,Per Unit,$29.35 ,OP,29.35,129.64,,,,,,
Meridian Duals,CPT,86336,Inhibin a,Lab Services,Per Unit,$15.59 ,OP,15.59,68.63,,,,,,
Meridian Duals,CPT,86337,Insulin antibodies,Lab Services,Per Unit,$21.41 ,OP,21.41,95.32,,,,,,
Meridian Duals,CPT,86340,Intrinsic factor antibody,Lab Services,Per Unit,$15.08 ,OP,15.08,68.63,,,,,,
Meridian Duals,CPT,86341,Islet cell antibody,Lab Services,Per Unit,$23.57 ,OP,23.57,87.69,,,,,,
Meridian Duals,CPT,86343,Leukocyte histamine release,Lab Services,Per Unit,$12.46 ,OP,12.46,57.19,,,,,,
Meridian Duals,CPT,86344,Leukocyte phagocytosis,Lab Services,Per Unit,$10.39 ,OP,10.39,34.31,,,,,,
Meridian Duals,CPT,86352,Cell function assay w/stim,Lab Services,Per Unit,$135.86 ,OP,135.86,135.86,,,,,,
Meridian Duals,CPT,86353,Lymphocyte transformation,Lab Services,Per Unit,$49.03 ,OP,49.03,217.32,,,,,,
Meridian Duals,CPT,86355,B cells total count,Lab Services,Per Unit,$37.73 ,OP,37.73,167.76,,,,,,
Meridian Duals,CPT,86356,Mononuclear cell antigen,Lab Services,Per Unit,$26.78 ,OP,26.78,61,,,,,,
Meridian Duals,CPT,86357,Nk cells total count,Lab Services,Per Unit,$37.73 ,OP,37.73,167.76,,,,,,
Meridian Duals,CPT,86359,T cells total count,Lab Services,Per Unit,$37.73 ,OP,37.73,167.76,,,,,,
Meridian Duals,CPT,86360,T cell absolute count/ratio,Lab Services,Per Unit,$46.98 ,OP,46.98,209.7,,,,,,
Meridian Duals,CPT,86361,T cell absolute count,Lab Services,Per Unit,$26.78 ,OP,26.78,61,,,,,,
Meridian Duals,CPT,86367,Stem cells total count,Lab Services,Per Unit,$77.78 ,OP,77.78,167.76,,,,,,
Meridian Duals,CPT,86376,Microsomal antibody each,Lab Services,Per Unit,$14.55 ,OP,14.55,64.82,,,,,,
Meridian Duals,CPT,86382,Neutralization test viral,Lab Services,Per Unit,$16.91 ,OP,16.91,76.26,,,,,,
Meridian Duals,CPT,86384,Nitroblue tetrazolium dye,Lab Services,Per Unit,$13.61 ,OP,13.61,13.61,,,,,,
Meridian Duals,CPT,86386,Nuclear matrix protein 22,Lab Services,Per Unit,$21.78 ,OP,21.78,21.78,,,,,,
Meridian Duals,CPT,86403,Particle agglut antbdy scrn,Lab Services,Per Unit,$11.54 ,OP,11.54,26.7,,,,,,
Meridian Duals,CPT,86406,Particle agglut antbdy titr,Lab Services,Per Unit,$10.64 ,OP,10.64,45.74,,,,,,
Meridian Duals,CPT,86408,Neutrlzg antb sarscov2 scr,Lab Services,Per Unit,$42.13 ,OP,42.13,42.13,,,,,,
Meridian Duals,CPT,86409,Neutrlzg antb sarscov2 titer,Lab Services,Per Unit,$105.33 ,OP,105.33,105.33,,,,,,
Meridian Duals,CPT,86413,Sars-cov-2 antb quantitative,Lab Services,Per Unit,$51.43 ,OP,51.43,51.43,,,,,,
Meridian Duals,CPT,86430,Rheumatoid factor test qual,Lab Services,Per Unit,$6.14 ,OP,6.14,26.7,,,,,,
Meridian Duals,CPT,86431,Rheumatoid factor quant,Lab Services,Per Unit,$5.67 ,OP,5.67,26.7,,,,,,
Meridian Duals,CPT,86480,Tb test cell immun measure,Lab Services,Per Unit,$61.98 ,OP,61.98,274.51,,,,,,
Meridian Duals,CPT,86481,Tb ag response t-cell susp,Lab Services,Per Unit,$100.00 ,OP,100,100,,,,,,
Meridian Duals,CPT,86485,Skin test candida,APC 5731,RVU Per Case,$25.25 ,OP,25.25,61,,,,,,
Meridian Duals,CPT,86486,Skin test nos antigen,APC 5731,RVU Per Case,$25.25 ,OP,25.25,30.51,,,,,,
Meridian Duals,CPT,86490,Coccidioidomycosis skin test,APC 5733,RVU Per Case,$56.95 ,OP,38.13,56.95,,,,,,
Meridian Duals,CPT,86510,Histoplasmosis skin test,APC 5733,RVU Per Case,$56.95 ,OP,38.13,56.95,,,,,,
Meridian Duals,CPT,86580,Tb intradermal test,APC 5731,RVU Per Case,$25.25 ,OP,25.25,38.13,,,,,,
Meridian Duals,CPT,86590,Streptokinase antibody,Lab Services,Per Unit,$12.66 ,OP,12.66,49.56,,,,,,
Meridian Duals,CPT,86592,Syphilis test non-trep qual,Lab Services,Per Unit,$4.27 ,OP,4.27,19.07,,,,,,
Meridian Duals,CPT,86593,Syphilis test non-trep quant,Lab Services,Per Unit,$4.40 ,OP,4.4,19.07,,,,,,
Meridian Duals,CPT,86602,Antinomyces antibody,Lab Services,Per Unit,$10.18 ,OP,10.18,45.74,,,,,,
Meridian Duals,CPT,86603,Adenovirus antibody,Lab Services,Per Unit,$12.87 ,OP,12.87,12.87,,,,,,
Meridian Duals,CPT,86606,Aspergillus antibody,Lab Services,Per Unit,$15.05 ,OP,15.05,68.63,,,,,,
Meridian Duals,CPT,86609,Bacterium antibody,Lab Services,Per Unit,$12.88 ,OP,12.88,57.19,,,,,,
Meridian Duals,CPT,86611,Bartonella antibody,Lab Services,Per Unit,$10.18 ,OP,10.18,45.74,,,,,,
Meridian Duals,CPT,86612,Blastomyces antibody,Lab Services,Per Unit,$12.90 ,OP,12.9,57.19,,,,,,
Meridian Duals,CPT,86615,Bordetella antibody,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
Meridian Duals,CPT,86617,Lyme disease antibody,Lab Services,Per Unit,$15.49 ,OP,15.49,68.63,,,,,,
Meridian Duals,CPT,86618,Lyme disease antibody,Lab Services,Per Unit,$17.03 ,OP,17.03,83.87,,,,,,
Meridian Duals,CPT,86619,Borrelia antibody,Lab Services,Per Unit,$13.38 ,OP,13.38,61,,,,,,
Meridian Duals,CPT,86622,Brucella antibody,Lab Services,Per Unit,$8.93 ,OP,8.93,38.13,,,,,,
Meridian Duals,CPT,86625,Campylobacter antibody,Lab Services,Per Unit,$13.12 ,OP,13.12,57.19,,,,,,
Meridian Duals,CPT,86628,Candida antibody,Lab Services,Per Unit,$12.01 ,OP,12.01,53.38,,,,,,
Meridian Duals,CPT,86631,Chlamydia antibody,Lab Services,Per Unit,$11.82 ,OP,11.82,53.38,,,,,,
Meridian Duals,CPT,86632,Chlamydia igm antibody,Lab Services,Per Unit,$12.68 ,OP,12.68,57.19,,,,,,
Meridian Duals,CPT,86635,Coccidioides antibody,Lab Services,Per Unit,$11.47 ,OP,11.47,49.56,,,,,,
Meridian Duals,CPT,86638,Q fever antibody,Lab Services,Per Unit,$12.12 ,OP,12.12,53.38,,,,,,
Meridian Duals,CPT,86641,Cryptococcus antibody,Lab Services,Per Unit,$14.41 ,OP,14.41,64.82,,,,,,
Meridian Duals,CPT,86644,Cmv antibody,Lab Services,Per Unit,$14.39 ,OP,14.39,64.82,,,,,,
Meridian Duals,CPT,86645,Cmv antibody igm,Lab Services,Per Unit,$16.85 ,OP,16.85,76.26,,,,,,
Meridian Duals,CPT,86648,Diphtheria antibody,Lab Services,Per Unit,$15.21 ,OP,15.21,68.63,,,,,,
Meridian Duals,CPT,86651,Encephalitis californ antbdy,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
Meridian Duals,CPT,86652,Encephaltis east eqne anbdy,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
Meridian Duals,CPT,86653,Encephaltis st louis antbody,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
Meridian Duals,CPT,86654,Encephaltis west eqne antbdy,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
Meridian Duals,CPT,86658,Enterovirus antibody,Lab Services,Per Unit,$13.03 ,OP,13.03,57.19,,,,,,
Meridian Duals,CPT,86663,Epstein-barr antibody,Lab Services,Per Unit,$13.12 ,OP,13.12,57.19,,,,,,
Meridian Duals,CPT,86664,Epstein-barr nuclear antigen,Lab Services,Per Unit,$15.29 ,OP,15.29,68.63,,,,,,
Meridian Duals,CPT,86665,Epstein-barr capsid vca,Lab Services,Per Unit,$18.14 ,OP,18.14,80.07,,,,,,
Meridian Duals,CPT,86666,Ehrlichia antibody,Lab Services,Per Unit,$10.18 ,OP,10.18,45.74,,,,,,
Meridian Duals,CPT,86668,Francisella tularensis,Lab Services,Per Unit,$14.16 ,OP,14.16,45.74,,,,,,
Meridian Duals,CPT,86671,Fungus nes antibody,Lab Services,Per Unit,$12.25 ,OP,12.25,53.38,,,,,,
Meridian Duals,CPT,86674,Giardia lamblia antibody,Lab Services,Per Unit,$14.72 ,OP,14.72,14.72,,,,,,
Meridian Duals,CPT,86677,Helicobacter pylori antibody,Lab Services,Per Unit,$16.85 ,OP,16.85,64.82,,,,,,
Meridian Duals,CPT,86682,Helminth antibody,Lab Services,Per Unit,$13.01 ,OP,13.01,57.19,,,,,,
Meridian Duals,CPT,86684,Hemophilus influenza antibdy,Lab Services,Per Unit,$15.84 ,OP,15.84,72.44,,,,,,
Meridian Duals,CPT,86687,Htlv-i antibody,Lab Services,Per Unit,$9.09 ,OP,9.09,38.13,,,,,,
Meridian Duals,CPT,86688,Htlv-ii antibody,Lab Services,Per Unit,$14.00 ,OP,14,61,,,,,,
Meridian Duals,CPT,86689,Htlv/hiv confirmj antibody,Lab Services,Per Unit,$19.35 ,OP,19.35,87.69,,,,,,
Meridian Duals,CPT,86692,Hepatitis delta agent antbdy,Lab Services,Per Unit,$17.16 ,OP,17.16,76.26,,,,,,
Meridian Duals,CPT,86694,Herpes simplex nes antbdy,Lab Services,Per Unit,$14.39 ,OP,14.39,64.82,,,,,,
Meridian Duals,CPT,86695,Herpes simplex type 1 test,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
Meridian Duals,CPT,86696,Herpes simplex type 2 test,Lab Services,Per Unit,$19.35 ,OP,19.35,87.69,,,,,,
Meridian Duals,CPT,86698,Histoplasma antibody,Lab Services,Per Unit,$13.79 ,OP,13.79,57.19,,,,,,
Meridian Duals,CPT,86701,Hiv-1antibody,Lab Services,Per Unit,$8.89 ,OP,8.89,38.13,,,,,,
Meridian Duals,CPT,86702,Hiv-2 antibody,Lab Services,Per Unit,$13.52 ,OP,13.52,61,,,,,,
Meridian Duals,CPT,86703,Hiv-1/hiv-2 1 result antbdy,Lab Services,Per Unit,$13.71 ,OP,13.71,61,,,,,,
Meridian Duals,CPT,86704,Hep b core antibody total,Lab Services,Per Unit,$12.05 ,OP,12.05,53.38,,,,,,
Meridian Duals,CPT,86705,Hep b core antibody igm,Lab Services,Per Unit,$11.77 ,OP,11.77,53.38,,,,,,
Meridian Duals,CPT,86706,Hep b surface antibody,Lab Services,Per Unit,$10.74 ,OP,10.74,49.56,,,,,,
Meridian Duals,CPT,86707,Hepatitis be antibody,Lab Services,Per Unit,$11.57 ,OP,11.57,53.38,,,,,,
Meridian Duals,CPT,86708,Hepatitis a antibody,Lab Services,Per Unit,$12.39 ,OP,12.39,53.38,,,,,,
Meridian Duals,CPT,86709,Hepatitis a igm antibody,Lab Services,Per Unit,$11.26 ,OP,11.26,49.56,,,,,,
Meridian Duals,CPT,86710,Influenza virus antibody,Lab Services,Per Unit,$13.55 ,OP,13.55,68.63,,,,,,
Meridian Duals,CPT,86711,John cunningham antibody,Lab Services,Per Unit,$16.89 ,OP,16.89,16.89,,,,,,
Meridian Duals,CPT,86713,Legionella antibody,Lab Services,Per Unit,$15.30 ,OP,15.3,68.63,,,,,,
Meridian Duals,CPT,86717,Leishmania antibody,Lab Services,Per Unit,$12.25 ,OP,12.25,53.38,,,,,,
Meridian Duals,CPT,86720,Leptospira antibody,Lab Services,Per Unit,$16.20 ,OP,16.2,57.19,,,,,,
Meridian Duals,CPT,86723,Listeria monocytogenes,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,
Meridian Duals,CPT,86727,Lymph choriomeningitis ab,Lab Services,Per Unit,$12.87 ,OP,12.87,57.19,,,,,,
Meridian Duals,CPT,86732,Mucormycosis antibody,Lab Services,Per Unit,$15.00 ,OP,15,57.19,,,,,,
Meridian Duals,CPT,86735,Mumps antibody,Lab Services,Per Unit,$13.05 ,OP,13.05,57.19,,,,,,
Meridian Duals,CPT,86738,Mycoplasma antibody,Lab Services,Per Unit,$13.24 ,OP,13.24,57.19,,,,,,
Meridian Duals,CPT,86741,Neisseria meningitidis,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
Meridian Duals,CPT,86744,Nocardia antibody,Lab Services,Per Unit,$15.99 ,OP,15.99,57.19,,,,,,
Meridian Duals,CPT,86747,Parvovirus antibody,Lab Services,Per Unit,$15.03 ,OP,15.03,68.63,,,,,,
Meridian Duals,CPT,86750,Malaria antibody,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
Meridian Duals,CPT,86753,Protozoa antibody nos,Lab Services,Per Unit,$12.39 ,OP,12.39,53.38,,,,,,
Meridian Duals,CPT,86756,Respiratory virus antibody,Lab Services,Per Unit,$15.89 ,OP,15.89,57.19,,,,,,
Meridian Duals,CPT,86757,Rickettsia antibody,Lab Services,Per Unit,$19.35 ,OP,19.35,87.69,,,,,,
Meridian Duals,CPT,86759,Rotavirus antibody,Lab Services,Per Unit,$18.23 ,OP,18.23,57.19,,,,,,
Meridian Duals,CPT,86762,Rubella antibody,Lab Services,Per Unit,$14.39 ,OP,14.39,64.82,,,,,,
Meridian Duals,CPT,86765,Rubeola antibody,Lab Services,Per Unit,$12.88 ,OP,12.88,57.19,,,,,,
Meridian Duals,CPT,86768,Salmonella antibody,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,
Meridian Duals,CPT,86769,Sars-cov-2 covid-19 antibody,Lab Services,Per Unit,$42.13 ,OP,42.13,57.19,,,,,,
Meridian Duals,CPT,86771,Shigella antibody,Lab Services,Per Unit,$24.48 ,OP,24.48,57.19,,,,,,
Meridian Duals,CPT,86774,Tetanus antibody,Lab Services,Per Unit,$14.80 ,OP,14.8,64.82,,,,,,
Meridian Duals,CPT,86777,Toxoplasma antibody,Lab Services,Per Unit,$14.39 ,OP,14.39,64.82,,,,,,
Meridian Duals,CPT,86778,Toxoplasma antibody igm,Lab Services,Per Unit,$14.41 ,OP,14.41,64.82,,,,,,
Meridian Duals,CPT,86780,Treponema pallidum,Lab Services,Per Unit,$13.24 ,OP,13.24,13.24,,,,,,
Meridian Duals,CPT,86784,Trichinella antibody,Lab Services,Per Unit,$12.56 ,OP,12.56,12.56,,,,,,
Meridian Duals,CPT,86787,Varicella-zoster antibody,Lab Services,Per Unit,$12.88 ,OP,12.88,57.19,,,,,,
Meridian Duals,CPT,86788,West nile virus ab igm,Lab Services,Per Unit,$16.85 ,OP,16.85,76.26,,,,,,
Meridian Duals,CPT,86789,West nile virus antibody,Lab Services,Per Unit,$14.39 ,OP,14.39,64.82,,,,,,
Meridian Duals,CPT,86790,Virus antibody nos,Lab Services,Per Unit,$12.88 ,OP,12.88,57.19,,,,,,
Meridian Duals,CPT,86793,Yersinia antibody,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
Meridian Duals,CPT,86794,Zika virus igm antibody,Lab Services,Per Unit,$16.85 ,OP,16.85,16.85,,,,,,
Meridian Duals,CPT,86800,Thyroglobulin antibody,Lab Services,Per Unit,$15.91 ,OP,15.91,72.44,,,,,,
Meridian Duals,CPT,86803,Hepatitis c ab test,Lab Services,Per Unit,$14.27 ,OP,14.27,64.82,,,,,,
Meridian Duals,CPT,86804,Hep c ab test confirm,Lab Services,Per Unit,$15.49 ,OP,15.49,68.63,,,,,,
Meridian Duals,CPT,86805,Lymphocytotoxicity assay,Lab Services,Per Unit,$189.51 ,OP,189.51,232.58,,,,,,
Meridian Duals,CPT,86806,Lymphocytotoxicity assay,Lab Services,Per Unit,$47.59 ,OP,47.59,213.51,,,,,,
Meridian Duals,CPT,86807,Cytotoxic antibody screening,Lab Services,Per Unit,$78.65 ,OP,78.65,175.39,,,,,,
Meridian Duals,CPT,86808,Cytotoxic antibody screening,Lab Services,Per Unit,$29.68 ,OP,29.68,133.45,,,,,,
Meridian Duals,CPT,86812,Hla typing a b or c,Lab Services,Per Unit,$25.81 ,OP,25.81,114.39,,,,,,
Meridian Duals,CPT,86813,Hla typing a b or c,Lab Services,Per Unit,$58.00 ,OP,58,247.83,,,,,,
Meridian Duals,CPT,86816,Hla typing dr/dq,Lab Services,Per Unit,$30.17 ,OP,30.17,102.95,,,,,,
Meridian Duals,CPT,86817,Hla typing dr/dq,Lab Services,Per Unit,$106.14 ,OP,106.14,247.83,,,,,,
Meridian Duals,CPT,86821,Lymphocyte culture mixed,Lab Services,Per Unit,$36.56 ,OP,36.56,251.64,,,,,,
Meridian Duals,CPT,86825,Hla x-math non-cytotoxic,Lab Services,Per Unit,$109.49 ,OP,109.49,109.49,,,,,,
Meridian Duals,CPT,86826,Hla x-match noncytotoxc addl,Lab Services,Per Unit,$36.53 ,OP,36.53,36.53,,,,,,
Meridian Duals,CPT,86828,Hla class i&ii antibody qual,Lab Services,Per Unit,$64.19 ,OP,64.19,64.19,,,,,,
Meridian Duals,CPT,86829,Hla class i/ii antibody qual,Lab Services,Per Unit,$64.19 ,OP,64.19,64.19,,,,,,
Meridian Duals,CPT,86830,Hla class i phenotype qual,Lab Services,Per Unit,$95.52 ,OP,95.52,95.52,,,,,,
Meridian Duals,CPT,86831,Hla class ii phenotype qual,Lab Services,Per Unit,$81.88 ,OP,81.88,81.88,,,,,,
Meridian Duals,CPT,86832,Hla class i high defin qual,Lab Services,Per Unit,$323.75 ,OP,323.75,323.75,,,,,,
Meridian Duals,CPT,86833,Hla class ii high defin qual,Lab Services,Per Unit,$325.80 ,OP,325.8,325.8,,,,,,
Meridian Duals,CPT,86834,Hla class i semiquant panel,Lab Services,Per Unit,$357.56 ,OP,357.56,357.56,,,,,,
Meridian Duals,CPT,86835,Hla class ii semiquant panel,Lab Services,Per Unit,$322.96 ,OP,322.96,322.96,,,,,,
Meridian Duals,CPT,86850,Rbc antibody screen,APC 5671,RVU Per Case,$50.92 ,OP,50.92,76.26,,,,,,
Meridian Duals,CPT,86860,Rbc antibody elution,APC 5672,RVU Per Case,$152.64 ,OP,91.51,152.64,,,,,,
Meridian Duals,CPT,86870,Rbc antibody identification,APC 5673,RVU Per Case,$298.05 ,OP,141.07,298.05,,,,,,
Meridian Duals,CPT,86880,Coombs test direct,APC 5733,RVU Per Case,$56.95 ,OP,22.88,56.95,,,,,,
Meridian Duals,CPT,86885,Coombs test indirect qual,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Meridian Duals,CPT,86886,Coombs test indirect titer,APC 5672,RVU Per Case,$152.64 ,OP,22.88,152.64,,,,,,
Meridian Duals,CPT,86890,Autologous blood process,APC 5672,RVU Per Case,$152.64 ,OP,152.64,308.83,,,,,,
Meridian Duals,CPT,86891,Autologous blood op salvage,APC 5674,RVU Per Case,$671.45 ,OP,480.4,671.45,,,,,,
Meridian Duals,CPT,86900,Blood typing serologic abo,APC 5734,RVU Per Case,$114.56 ,OP,11.44,114.56,,,,,,
Meridian Duals,CPT,86901,Blood typing serologic rh(d),APC 5732,RVU Per Case,$34.63 ,OP,22.88,34.63,,,,,,
Meridian Duals,CPT,86902,Blood type antigen donor ea,APC 5673,RVU Per Case,$298.05 ,OP,41.94,298.05,,,,,,
Meridian Duals,CPT,86904,Blood typing patient serum,APC 5732,RVU Per Case,$34.63 ,OP,34.63,41.94,,,,,,
Meridian Duals,CPT,86905,Blood typing rbc antigens,APC 5673,RVU Per Case,$298.05 ,OP,15.26,298.05,,,,,,
Meridian Duals,CPT,86906,Bld typing serologic rh phnt,APC 5732,RVU Per Case,$34.63 ,OP,34.31,34.63,,,,,,
Meridian Duals,CPT,86920,Compatibility test spin,APC 5672,RVU Per Case,$152.64 ,OP,125.82,152.64,,,,,,
Meridian Duals,CPT,86921,Compatibility test incubate,APC 5672,RVU Per Case,$152.64 ,OP,102.95,152.64,,,,,,
Meridian Duals,CPT,86922,Compatibility test antiglob,APC 5672,RVU Per Case,$152.64 ,OP,118.19,152.64,,,,,,
Meridian Duals,CPT,86923,Compatibility test electric,APC 5672,RVU Per Case,$152.64 ,OP,91.51,152.64,,,,,,
Meridian Duals,CPT,86927,Plasma fresh frozen,APC 5672,RVU Per Unit,$152.64 ,OP,49.56,152.64,,,,,,
Meridian Duals,CPT,86930,Frozen blood prep,APC 5673,RVU Per Case,$298.05 ,OP,298.05,385.09,,,,,,
Meridian Duals,CPT,86931,Frozen blood thaw,APC 5673,RVU Per Case,$298.05 ,OP,289.76,298.05,,,,,,
Meridian Duals,CPT,86932,Frozen blood freeze/thaw,APC 5732,RVU Per Case,$34.63 ,OP,34.63,385.09,,,,,,
Meridian Duals,CPT,86940,Hemolysins/agglutinins auto,Lab Services,Per Unit,$8.77 ,OP,8.77,38.13,,,,,,
Meridian Duals,CPT,86941,Hemolysins/agglutinins,Lab Services,Per Unit,$12.11 ,OP,12.11,53.38,,,,,,
Meridian Duals,CPT,86945,Blood product/irradiation,APC 5732,RVU Per Case,$34.63 ,OP,34.63,110.57,,,,,,
Meridian Duals,CPT,86950,Leukacyte transfusion,APC 5672,RVU Per Case,$152.64 ,OP,152.64,240.2,,,,,,
Meridian Duals,CPT,86960,Vol reduction of blood/prod,APC 5672,RVU Per Case,$152.64 ,OP,110.57,152.64,,,,,,
Meridian Duals,CPT,86965,Pooling blood platelets,APC 5672,RVU Per Case,$152.64 ,OP,95.32,152.64,,,,,,
Meridian Duals,CPT,86970,Rbc pretx incubatj w/chemicl,APC 5732,RVU Per Case,$34.63 ,OP,34.63,76.26,,,,,,
Meridian Duals,CPT,86971,Rbc pretx incubatj w/enzymes,APC 5673,RVU Per Case,$298.05 ,OP,298.05,298.05,,,,,,
Meridian Duals,CPT,86972,Rbc pretx incubatj w/density,APC 5672,RVU Per Case,$152.64 ,OP,122,152.64,,,,,,
Meridian Duals,CPT,86975,Rbc serum pretx incubj drugs,APC 5735,RVU Per Case,$276.53 ,OP,102.95,276.53,,,,,,
Meridian Duals,CPT,86976,Rbc serum pretx id dilution,APC 5731,RVU Per Case,$25.25 ,OP,25.25,118.19,,,,,,
Meridian Duals,CPT,86977,Rbc serum pretx incubj/inhib,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Meridian Duals,CPT,86978,Rbc pretreatment serum,APC 5732,RVU Per Case,$34.63 ,OP,34.63,102.95,,,,,,
Meridian Duals,CPT,86985,Split blood or products,APC 5672,RVU Per Case,$152.64 ,OP,76.26,152.64,,,,,,
Meridian Duals,CPT,86999,Transfusion procedure,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Meridian Duals,CPT,87003,Small animal inoculation,Lab Services,Per Unit,$16.84 ,OP,16.84,76.26,,,,,,
Meridian Duals,CPT,87015,Specimen infect agnt concntj,Lab Services,Per Unit,$6.68 ,OP,6.68,30.51,,,,,,
Meridian Duals,CPT,87040,Blood culture for bacteria,Lab Services,Per Unit,$10.32 ,OP,10.32,45.74,,,,,,
Meridian Duals,CPT,87045,Feces culture aerobic bact,Lab Services,Per Unit,$9.44 ,OP,9.44,41.94,,,,,,
Meridian Duals,CPT,87046,Stool cultr aerobic bact ea,Lab Services,Per Unit,$9.44 ,OP,9.44,41.94,,,,,,
Meridian Duals,CPT,87070,Culture othr specimn aerobic,Lab Services,Per Unit,$8.62 ,OP,8.62,41.94,,,,,,
Meridian Duals,CPT,87071,Culture aerobic quant other,Lab Services,Per Unit,$9.89 ,OP,9.89,41.94,,,,,,
Meridian Duals,CPT,87073,Culture bacteria anaerobic,Lab Services,Per Unit,$9.66 ,OP,9.66,41.94,,,,,,
Meridian Duals,CPT,87075,Cultr bacteria except blood,Lab Services,Per Unit,$9.47 ,OP,9.47,41.94,,,,,,
Meridian Duals,CPT,87076,Culture anaerobe ident each,Lab Services,Per Unit,$8.08 ,OP,8.08,19.07,,,,,,
Meridian Duals,CPT,87077,Culture aerobic identify,Lab Services,Per Unit,$8.08 ,OP,8.08,22.88,,,,,,
Meridian Duals,CPT,87081,Culture screen only,Lab Services,Per Unit,$6.63 ,OP,6.63,34.31,,,,,,
Meridian Duals,CPT,87084,Culture of specimen by kit,Lab Services,Per Unit,$27.07 ,OP,22.88,27.07,,,,,,
Meridian Duals,CPT,87086,Urine culture/colony count,Lab Services,Per Unit,$8.07 ,OP,8.07,41.94,,,,,,
Meridian Duals,CPT,87088,Urine bacteria culture,Lab Services,Per Unit,$8.09 ,OP,8.09,41.94,,,,,,
Meridian Duals,CPT,87101,Skin fungi culture,Lab Services,Per Unit,$7.71 ,OP,7.71,34.31,,,,,,
Meridian Duals,CPT,87102,Fungus isolation culture,Lab Services,Per Unit,$8.41 ,OP,8.41,38.13,,,,,,
Meridian Duals,CPT,87103,Blood fungus culture,Lab Services,Per Unit,$20.46 ,OP,20.46,41.94,,,,,,
Meridian Duals,CPT,87106,Fungi identification yeast,Lab Services,Per Unit,$10.32 ,OP,10.32,45.74,,,,,,
Meridian Duals,CPT,87107,Fungi identification mold,Lab Services,Per Unit,$10.32 ,OP,10.32,45.74,,,,,,
Meridian Duals,CPT,87109,Mycoplasma,Lab Services,Per Unit,$15.39 ,OP,15.39,68.63,,,,,,
Meridian Duals,CPT,87110,Chlamydia culture,Lab Services,Per Unit,$19.60 ,OP,19.6,87.69,,,,,,
Meridian Duals,CPT,87116,Mycobacteria culture,Lab Services,Per Unit,$10.80 ,OP,10.8,49.56,,,,,,
Meridian Duals,CPT,87118,Mycobacteric identification,Lab Services,Per Unit,$14.61 ,OP,14.61,49.56,,,,,,
Meridian Duals,CPT,87140,Culture type immunofluoresc,Lab Services,Per Unit,$5.57 ,OP,5.57,26.7,,,,,,
Meridian Duals,CPT,87143,Culture typing glc/hplc,Lab Services,Per Unit,$12.52 ,OP,12.52,57.19,,,,,,
Meridian Duals,CPT,87147,Culture type immunologic,Lab Services,Per Unit,$5.18 ,OP,5.18,22.88,,,,,,
Meridian Duals,CPT,87149,Dna/rna direct probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
Meridian Duals,CPT,87150,Dna/rna amplified probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,
Meridian Duals,CPT,87152,Culture type pulse field gel,Lab Services,Per Unit,$7.74 ,OP,7.74,22.88,,,,,,
Meridian Duals,CPT,87153,Dna/rna sequencing,Lab Services,Per Unit,$115.36 ,OP,115.36,115.36,,,,,,
Meridian Duals,CPT,87158,Culture typing added method,Lab Services,Per Unit,$7.74 ,OP,7.74,7.74,,,,,,
Meridian Duals,CPT,87164,Dark field examination,Lab Services,Per Unit,$10.74 ,OP,10.74,49.56,,,,,,
Meridian Duals,CPT,87166,Dark field examination,Lab Services,Per Unit,$11.30 ,OP,11.3,49.56,,,,,,
Meridian Duals,CPT,87168,Macroscopic exam arthropod,Lab Services,Per Unit,$4.27 ,OP,4.27,19.07,,,,,,
Meridian Duals,CPT,87169,Macroscopic exam parasite,Lab Services,Per Unit,$4.31 ,OP,4.31,19.07,,,,,,
Meridian Duals,CPT,87172,Pinworm exam,Lab Services,Per Unit,$4.27 ,OP,4.27,22.88,,,,,,
Meridian Duals,CPT,87176,Tissue homogenization cultr,Lab Services,Per Unit,$5.88 ,OP,5.88,26.7,,,,,,
Meridian Duals,CPT,87177,Ova and parasites smears,Lab Services,Per Unit,$8.90 ,OP,8.9,41.94,,,,,,
Meridian Duals,CPT,87181,Microbe susceptible diffuse,Lab Services,Per Unit,$4.75 ,OP,4.75,22.88,,,,,,
Meridian Duals,CPT,87184,Microbe susceptible disk,Lab Services,Per Unit,$7.48 ,OP,7.48,34.31,,,,,,
Meridian Duals,CPT,87185,Microbe susceptible enzyme,Lab Services,Per Unit,$4.75 ,OP,4.75,22.88,,,,,,
Meridian Duals,CPT,87186,Microbe susceptible mic,Lab Services,Per Unit,$8.65 ,OP,8.65,38.13,,,,,,
Meridian Duals,CPT,87187,Microbe susceptible mlc,Lab Services,Per Unit,$40.17 ,OP,40.17,45.74,,,,,,
Meridian Duals,CPT,87188,Microbe suscept macrobroth,Lab Services,Per Unit,$6.64 ,OP,6.64,30.51,,,,,,
Meridian Duals,CPT,87190,Microbe suscept mycobacteri,Lab Services,Per Unit,$7.31 ,OP,7.31,26.7,,,,,,
Meridian Duals,CPT,87197,Bactericidal level serum,Lab Services,Per Unit,$15.02 ,OP,15.02,68.63,,,,,,
Meridian Duals,CPT,87205,Smear gram stain,Lab Services,Per Unit,$4.27 ,OP,4.27,22.88,,,,,,
Meridian Duals,CPT,87206,Smear fluorescent/acid stai,Lab Services,Per Unit,$5.39 ,OP,5.39,26.7,,,,,,
Meridian Duals,CPT,87207,Smear special stain,Lab Services,Per Unit,$5.99 ,OP,5.99,41.94,,,,,,
Meridian Duals,CPT,87209,Smear complex stain,Lab Services,Per Unit,$17.98 ,OP,17.98,80.07,,,,,,
Meridian Duals,CPT,87210,Smear wet mount saline/ink,Lab Services,Per Unit,$5.82 ,OP,5.82,22.88,,,,,,
Meridian Duals,CPT,87220,Tissue exam for fungi,Lab Services,Per Unit,$4.27 ,OP,4.27,22.88,,,,,,
Meridian Duals,CPT,87230,Assay toxin or antitoxin,Lab Services,Per Unit,$19.74 ,OP,19.74,87.69,,,,,,
Meridian Duals,CPT,87250,Virus inoculate eggs/animal,Lab Services,Per Unit,$19.56 ,OP,19.56,87.69,,,,,,
Meridian Duals,CPT,87252,Virus inoculation tissue,Lab Services,Per Unit,$26.07 ,OP,26.07,102.95,,,,,,
Meridian Duals,CPT,87253,Virus inoculate tissue addl,Lab Services,Per Unit,$20.20 ,OP,20.2,91.51,,,,,,
Meridian Duals,CPT,87254,Virus inoculation shell via,Lab Services,Per Unit,$19.56 ,OP,19.56,87.69,,,,,,
Meridian Duals,CPT,87255,Genet virus isolate hsv,Lab Services,Per Unit,$33.86 ,OP,33.86,152.51,,,,,,
Meridian Duals,CPT,87260,Adenovirus ag if,Lab Services,Per Unit,$14.43 ,OP,14.43,14.43,,,,,,
Meridian Duals,CPT,87265,Pertussis ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Meridian Duals,CPT,87267,Enterovirus antibody dfa,Lab Services,Per Unit,$13.42 ,OP,13.42,53.38,,,,,,
Meridian Duals,CPT,87269,Giardia ag if,Lab Services,Per Unit,$13.61 ,OP,13.61,53.38,,,,,,
Meridian Duals,CPT,87270,Chlamydia trachomatis ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Meridian Duals,CPT,87271,Cytomegalovirus dfa,Lab Services,Per Unit,$13.42 ,OP,13.42,53.38,,,,,,
Meridian Duals,CPT,87272,Cryptosporidium ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Meridian Duals,CPT,87273,Herpes simplex 2 ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,
Meridian Duals,CPT,87274,Herpes simplex 1 ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,
Meridian Duals,CPT,87275,Influenza b ag if,Lab Services,Per Unit,$12.25 ,OP,12.25,53.38,,,,,,
Meridian Duals,CPT,87276,Influenza a ag if,Lab Services,Per Unit,$16.07 ,OP,16.07,53.38,,,,,,
Meridian Duals,CPT,87278,Legion pneumophilia ag if,Lab Services,Per Unit,$15.60 ,OP,15.6,53.38,,,,,,
Meridian Duals,CPT,87279,Parainfluenza ag if,Lab Services,Per Unit,$16.43 ,OP,16.43,53.38,,,,,,
Meridian Duals,CPT,87280,Respiratory syncytial ag if,Lab Services,Per Unit,$13.42 ,OP,13.42,53.38,,,,,,
Meridian Duals,CPT,87281,Pneumocystis carinii ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Meridian Duals,CPT,87283,Rubeola ag if,Lab Services,Per Unit,$60.80 ,OP,53.38,60.8,,,,,,
Meridian Duals,CPT,87285,Treponema pallidum ag if,Lab Services,Per Unit,$12.18 ,OP,12.18,53.38,,,,,,
Meridian Duals,CPT,87290,Varicella zoster ag if,Lab Services,Per Unit,$13.42 ,OP,13.42,53.38,,,,,,
Meridian Duals,CPT,87299,Antibody detection nos if,Lab Services,Per Unit,$16.10 ,OP,16.1,53.38,,,,,,
Meridian Duals,CPT,87300,Ag detection polyval if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,
Meridian Duals,CPT,87301,Adenovirus ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Meridian Duals,CPT,87305,Aspergillus ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Meridian Duals,CPT,87320,Chylmd trach ag ia,Lab Services,Per Unit,$15.00 ,OP,15,53.38,,,,,,
Meridian Duals,CPT,87324,Clostridium ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Meridian Duals,CPT,87327,Cryptococcus neoform ag ia,Lab Services,Per Unit,$13.42 ,OP,13.42,53.38,,,,,,
Meridian Duals,CPT,87328,Cryptosporidium ag ia,Lab Services,Per Unit,$13.82 ,OP,13.82,53.38,,,,,,
Meridian Duals,CPT,87329,Giardia ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Meridian Duals,CPT,87332,Cytomegalovirus ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Meridian Duals,CPT,87335,E coli 0157 ag ia,Lab Services,Per Unit,$12.66 ,OP,12.66,53.38,,,,,,
Meridian Duals,CPT,87336,Entamoeb hist dispr ag ia,Lab Services,Per Unit,$16.00 ,OP,16,53.38,,,,,,
Meridian Duals,CPT,87337,Entamoeb hist group ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Meridian Duals,CPT,87338,Hpylori stool ag ia,Lab Services,Per Unit,$14.38 ,OP,14.38,64.82,,,,,,
Meridian Duals,CPT,87339,H pylori ag ia,Lab Services,Per Unit,$16.00 ,OP,16,53.38,,,,,,
Meridian Duals,CPT,87340,Hepatitis b surface ag ia,Lab Services,Per Unit,$10.33 ,OP,10.33,45.74,,,,,,
Meridian Duals,CPT,87341,Hepatitis b surface ag ia,Lab Services,Per Unit,$10.33 ,OP,10.33,45.74,,,,,,
Meridian Duals,CPT,87350,Hepatitis be ag ia,Lab Services,Per Unit,$11.53 ,OP,11.53,49.56,,,,,,
Meridian Duals,CPT,87380,Hepatitis delta agent ag ia,Lab Services,Per Unit,$18.36 ,OP,18.36,72.44,,,,,,
Meridian Duals,CPT,87385,Histoplasma capsul ag ia,Lab Services,Per Unit,$13.25 ,OP,13.25,53.38,,,,,,
Meridian Duals,CPT,87389,Hiv-1 ag w/hiv-1&2 ab ag ia,Lab Services,Per Unit,$24.08 ,OP,24.08,24.08,,,,,,
Meridian Duals,CPT,87390,Hiv-1 ag ia,Lab Services,Per Unit,$24.06 ,OP,24.06,24.06,,,,,,
Meridian Duals,CPT,87391,Hiv-2 ag ia,Lab Services,Per Unit,$21.90 ,OP,21.9,80.07,,,,,,
Meridian Duals,CPT,87400,Influenza a/b each ag ia,Lab Services,Per Unit,$14.13 ,OP,14.13,61,,,,,,
Meridian Duals,CPT,87420,Resp syncytial virus ag ia,Lab Services,Per Unit,$13.91 ,OP,13.91,53.38,,,,,,
Meridian Duals,CPT,87425,Rotavirus ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Meridian Duals,CPT,87426,Sarscov coronavirus ag ia,Lab Services,Per Unit,$35.33 ,OP,35.33,35.33,,,,,,
Meridian Duals,CPT,87427,Shiga-like toxin ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Meridian Duals,CPT,87428,Sarscov & inf vir a&b ag ia,Lab Services,Per Unit,$63.59 ,OP,63.59,63.59,,,,,,
Meridian Duals,CPT,87430,Strep a ag ia,Lab Services,Per Unit,$16.81 ,OP,16.81,61,,,,,,
Meridian Duals,CPT,87449,Nos each organism ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,61,,,,,,
Meridian Duals,CPT,87451,Polyvalent mult org ea ag ia,Lab Services,Per Unit,$10.51 ,OP,10.51,41.94,,,,,,
Meridian Duals,CPT,87471,Bartonella dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,
Meridian Duals,CPT,87472,Bartonella dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Meridian Duals,CPT,87475,Lyme dis dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
Meridian Duals,CPT,87476,Lyme dis dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Meridian Duals,CPT,87480,Candida dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,99.13,,,,,,
Meridian Duals,CPT,87481,Candida dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Meridian Duals,CPT,87482,Candida dna quant,Lab Services,Per Unit,$55.74 ,OP,55.74,186.82,,,,,,
Meridian Duals,CPT,87483,Cns dna amp probe type 12-25,Lab Services,Per Unit,$416.78 ,OP,416.78,416.78,,,,,,
Meridian Duals,CPT,87485,Chylmd pneum dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
Meridian Duals,CPT,87486,Chylmd pneum dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Meridian Duals,CPT,87487,Chylmd pneum dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Meridian Duals,CPT,87490,Chylmd trach dna dir probe,Lab Services,Per Unit,$22.75 ,OP,22.75,99.13,,,,,,
Meridian Duals,CPT,87491,Chylmd trach dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Meridian Duals,CPT,87492,Chylmd trach dna quant,Lab Services,Per Unit,$53.47 ,OP,53.47,156.32,,,,,,
Meridian Duals,CPT,87493,C diff amplified probe,Lab Services,Per Unit,$37.27 ,OP,37.27,37.27,,,,,,
Meridian Duals,CPT,87495,Cytomeg dna dir probe,Lab Services,Per Unit,$30.03 ,OP,30.03,30.03,,,,,,
Meridian Duals,CPT,87496,Cytomeg dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Meridian Duals,CPT,87497,Cytomeg dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Meridian Duals,CPT,87498,Enterovirus probe&revrs trns,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Meridian Duals,CPT,87500,Vanomycin dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Meridian Duals,CPT,87501,Influenza dna amp prob 1+,Lab Services,Per Unit,$51.31 ,OP,51.31,51.31,,,,,,
Meridian Duals,CPT,87502,Influenza dna amp probe,Lab Services,Per Unit,$95.80 ,OP,95.8,95.8,,,,,,
Meridian Duals,CPT,87503,Influenza dna amp prob addl,Lab Services,Per Unit,$29.22 ,OP,29.22,29.22,,,,,,
Meridian Duals,CPT,87505,Nfct agent detection gi,Lab Services,Per Unit,$128.29 ,OP,128.29,128.29,,,,,,
Meridian Duals,CPT,87506,Iadna-dna/rna probe tq 6-11,Lab Services,Per Unit,$262.99 ,OP,262.99,262.99,,,,,,
Meridian Duals,CPT,87507,Iadna-dna/rna probe tq 12-25,Lab Services,Per Unit,$416.78 ,OP,416.78,416.78,,,,,,
Meridian Duals,CPT,87510,Gardner vag dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,99.13,,,,,,
Meridian Duals,CPT,87511,Gardner vag dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Meridian Duals,CPT,87512,Gardner vag dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,186.82,,,,,,
Meridian Duals,CPT,87516,Hepatitis b dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Meridian Duals,CPT,87517,Hepatitis b dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Meridian Duals,CPT,87520,Hepatitis c rna dir probe,Lab Services,Per Unit,$31.22 ,OP,31.22,87.69,,,,,,
Meridian Duals,CPT,87521,Hepatitis c probe&rvrs trnsc,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Meridian Duals,CPT,87522,Hepatitis c revrs trnscrpj,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Meridian Duals,CPT,87525,Hepatitis g dna dir probe,Lab Services,Per Unit,$29.80 ,OP,29.8,87.69,,,,,,
Meridian Duals,CPT,87526,Hepatitis g dna amp probe,Lab Services,Per Unit,$39.26 ,OP,39.26,156.32,,,,,,
Meridian Duals,CPT,87527,Hepatitis g dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,186.82,,,,,,
Meridian Duals,CPT,87528,Hsv dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
Meridian Duals,CPT,87529,Hsv dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Meridian Duals,CPT,87530,Hsv dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Meridian Duals,CPT,87531,Hhv-6 dna dir probe,Lab Services,Per Unit,$58.00 ,OP,58,87.69,,,,,,
Meridian Duals,CPT,87532,Hhv-6 dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,
Meridian Duals,CPT,87533,Hhv-6 dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,186.82,,,,,,
Meridian Duals,CPT,87534,Hiv-1 dna dir probe,Lab Services,Per Unit,$21.92 ,OP,21.92,87.69,,,,,,
Meridian Duals,CPT,87535,Hiv-1 probe&reverse trnscrpj,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Meridian Duals,CPT,87536,Hiv-1 quant&revrse trnscrpj,Lab Services,Per Unit,$85.10 ,OP,85.1,377.46,,,,,,
Meridian Duals,CPT,87537,Hiv-2 dna dir probe,Lab Services,Per Unit,$21.92 ,OP,21.92,87.69,,,,,,
Meridian Duals,CPT,87538,Hiv-2 probe&revrse trnscripj,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Meridian Duals,CPT,87539,Hiv-2 quant&revrse trnscripj,Lab Services,Per Unit,$58.62 ,OP,58.62,190.64,,,,,,
Meridian Duals,CPT,87540,Legion pneumo dna dir prob,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
Meridian Duals,CPT,87541,Legion pneumo dna amp prob,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Meridian Duals,CPT,87542,Legion pneumo dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,186.82,,,,,,
Meridian Duals,CPT,87550,Mycobacteria dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
Meridian Duals,CPT,87551,Mycobacteria dna amp probe,Lab Services,Per Unit,$48.24 ,OP,48.24,156.32,,,,,,
Meridian Duals,CPT,87552,Mycobacteria dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Meridian Duals,CPT,87555,M.tuberculo dna dir probe,Lab Services,Per Unit,$26.88 ,OP,26.88,87.69,,,,,,
Meridian Duals,CPT,87556,M.tuberculo dna amp probe,Lab Services,Per Unit,$41.68 ,OP,41.68,156.32,,,,,,
Meridian Duals,CPT,87557,M.tuberculo dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Meridian Duals,CPT,87560,M.avium-intra dna dir prob,Lab Services,Per Unit,$27.29 ,OP,27.29,87.69,,,,,,
Meridian Duals,CPT,87561,M.avium-intra dna amp prob,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Meridian Duals,CPT,87562,M.avium-intra dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Meridian Duals,CPT,87563,M. genitalium amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Meridian Duals,CPT,87580,M.pneumon dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
Meridian Duals,CPT,87581,M.pneumon dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Meridian Duals,CPT,87582,M.pneumon dna quant,Lab Services,Per Unit,$302.62 ,OP,186.82,302.62,,,,,,
Meridian Duals,CPT,87590,N.gonorrhoeae dna dir prob,Lab Services,Per Unit,$26.88 ,OP,26.88,99.13,,,,,,
Meridian Duals,CPT,87591,N.gonorrhoeae dna amp prob,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Meridian Duals,CPT,87592,N.gonorrhoeae dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,
Meridian Duals,CPT,87623,Hpv low-risk types,Lab Services,Per Unit,$35.09 ,OP,35.09,93.87,,,,,,
Meridian Duals,CPT,87624,Hpv high-risk types,Lab Services,Per Unit,$35.09 ,OP,35.09,93.87,,,,,,
Meridian Duals,CPT,87625,Hpv types 16 & 18 only,Lab Services,Per Unit,$40.55 ,OP,40.55,93.87,,,,,,
Meridian Duals,CPT,87631,Resp virus 3-5 targets,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
Meridian Duals,CPT,87632,Resp virus 6-11 targets,Lab Services,Per Unit,$218.06 ,OP,218.06,218.06,,,,,,
Meridian Duals,CPT,87633,Resp virus 12-25 targets,Lab Services,Per Unit,$416.78 ,OP,416.78,416.78,,,,,,
Meridian Duals,CPT,87634,Rsv dna/rna amp probe,Lab Services,Per Unit,$70.20 ,OP,70.2,70.2,,,,,,
Meridian Duals,CPT,87635,Sars-cov-2 covid-19 amp prb,Lab Services,Per Unit,$51.31 ,OP,51.31,51.31,,,,,,
Meridian Duals,CPT,87636,Sarscov2 & inf a&b amp prb,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
Meridian Duals,CPT,87637,Sarscov2&inf a&b&rsv amp prb,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
Meridian Duals,CPT,87640,Staph a dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Meridian Duals,CPT,87641,Mr-staph dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Meridian Duals,CPT,87650,Strep a dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
Meridian Duals,CPT,87651,Strep a dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Meridian Duals,CPT,87652,Strep a dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,186.82,,,,,,
Meridian Duals,CPT,87653,Strep b dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,
Meridian Duals,CPT,87660,Trichomonas vagin dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
Meridian Duals,CPT,87661,Trichomonas vaginalis amplif,Lab Services,Per Unit,$35.09 ,OP,35.09,87.69,,,,,,
Meridian Duals,CPT,87662,Zika virus dna/rna amp probe,Lab Services,Per Unit,$51.31 ,OP,51.31,51.31,,,,,,
Meridian Duals,CPT,87797,Detect agent nos dna dir,Lab Services,Per Unit,$30.03 ,OP,30.03,99.13,,,,,,
Meridian Duals,CPT,87798,Detect agent nos dna amp,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Meridian Duals,CPT,87799,Detect agent nos dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Meridian Duals,CPT,87800,Detect agnt mult dna direc,Lab Services,Per Unit,$43.67 ,OP,43.67,179.2,,,,,,
Meridian Duals,CPT,87801,Detect agnt mult dna ampli,Lab Services,Per Unit,$70.20 ,OP,70.2,312.64,,,,,,
Meridian Duals,CPT,87802,Strep b assay w/optic,Lab Services,Per Unit,$12.73 ,OP,12.73,61,,,,,,
Meridian Duals,CPT,87803,Clostridium toxin a w/optic,Lab Services,Per Unit,$16.00 ,OP,16,61,,,,,,
Meridian Duals,CPT,87804,Influenza assay w/optic,Lab Services,Per Unit,$16.55 ,OP,16.55,61,,,,,,
Meridian Duals,CPT,87806,Hiv w/hiv1&2 antb w/optic,Lab Services,Per Unit,$32.77 ,OP,32.77,61,,,,,,
Meridian Duals,CPT,87807,Rsv assay w/optic,Lab Services,Per Unit,$13.10 ,OP,13.1,53.38,,,,,,
Meridian Duals,CPT,87808,Trichomonas assay w/optic,Lab Services,Per Unit,$15.29 ,OP,15.29,61,,,,,,
Meridian Duals,CPT,87809,Adenovirus assay w/optic,Lab Services,Per Unit,$21.76 ,OP,21.76,53.38,,,,,,
Meridian Duals,CPT,87810,Chylmd trach assay w/optic,Lab Services,Per Unit,$35.29 ,OP,35.29,53.38,,,,,,
Meridian Duals,CPT,87811,Sars-cov-2 covid19 w/optic,Lab Services,Per Unit,$41.38 ,OP,41.38,41.38,,,,,,
Meridian Duals,CPT,87850,N. gonorrhoeae assay w/optic,Lab Services,Per Unit,$24.56 ,OP,24.56,53.38,,,,,,
Meridian Duals,CPT,87880,Strep a assay w/optic,Lab Services,Per Unit,$16.53 ,OP,16.53,61,,,,,,
Meridian Duals,CPT,87899,Agent nos assay w/optic,Lab Services,Per Unit,$16.07 ,OP,16.07,61,,,,,,
Meridian Duals,CPT,87900,Phenotype infect agent drug,Lab Services,Per Unit,$130.35 ,OP,130.35,518.52,,,,,,
Meridian Duals,CPT,87901,Genotype dna hiv reverse t,Lab Services,Per Unit,$257.45 ,OP,257.45,"1,147.62",,,,,,
Meridian Duals,CPT,87902,Genotype dna/rna hep c,Lab Services,Per Unit,$257.45 ,OP,257.45,"1,147.62",,,,,,
Meridian Duals,CPT,87903,Phenotype dna hiv w/culture,Lab Services,Per Unit,$488.66 ,OP,488.66,488.66,,,,,,
Meridian Duals,CPT,87904,Phenotype dna hiv w/clt add,Lab Services,Per Unit,$26.07 ,OP,26.07,26.07,,,,,,
Meridian Duals,CPT,87905,Sialidase enzyme assay,Lab Services,Per Unit,$12.22 ,OP,12.22,53.38,,,,,,
Meridian Duals,CPT,87906,Genotype dna/rna hiv,Lab Services,Per Unit,$128.73 ,OP,128.73,128.73,,,,,,
Meridian Duals,CPT,87910,Genotype cytomegalovirus,Lab Services,Per Unit,$257.45 ,OP,257.45,257.45,,,,,,
Meridian Duals,CPT,87912,Genotype dna hepatitis b,Lab Services,Per Unit,$257.45 ,OP,257.45,257.45,,,,,,
Meridian Duals,CPT,88104,Cytopath fl nongyn smears,APC 5732,RVU Per Case,$34.63 ,OP,34.63,175.39,,,,,,
Meridian Duals,CPT,88106,Cytopath fl nongyn filter,APC 5731,RVU Per Case,$25.25 ,OP,25.25,247.83,,,,,,
Meridian Duals,CPT,88108,Cytopath concentrate tech,APC 5732,RVU Per Case,$34.63 ,OP,34.63,228.77,,,,,,
Meridian Duals,CPT,88112,Cytopath cell enhance tech,APC 5671,RVU Per Case,$50.92 ,OP,50.92,232.58,,,,,,
Meridian Duals,CPT,88120,Cytp urne 3-5 probes ea spec,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Meridian Duals,CPT,88121,Cytp urine 3-5 probes cmptr,APC 5673,RVU Per Case,$298.05 ,OP,298.05,298.05,,,,,,
Meridian Duals,CPT,88125,Forensic cytopathology,APC 5671,RVU Per Case,$50.92 ,OP,45.74,50.92,,,,,,
Meridian Duals,CPT,88130,Sex chromatin identification,Lab Services,Per Unit,$17.98 ,OP,17.98,68.63,,,,,,
Meridian Duals,CPT,88140,Sex chromatin identification,Lab Services,Per Unit,$7.99 ,OP,7.99,34.31,,,,,,
Meridian Duals,CPT,88142,Cytopath c/v thin layer,Lab Services,Per Unit,$20.26 ,OP,20.26,91.51,,,,,,
Meridian Duals,CPT,88143,Cytopath c/v thin layer redo,Lab Services,Per Unit,$23.04 ,OP,23.04,91.51,,,,,,
Meridian Duals,CPT,88147,Cytopath c/v automated,Lab Services,Per Unit,$50.56 ,OP,45.74,50.56,,,,,,
Meridian Duals,CPT,88148,Cytopath c/v auto rescreen,Lab Services,Per Unit,$16.00 ,OP,16,45.74,,,,,,
Meridian Duals,CPT,88150,Cytopath c/v manual,Lab Services,Per Unit,$15.15 ,OP,15.15,45.74,,,,,,
Meridian Duals,CPT,88152,Cytopath c/v auto redo,Lab Services,Per Unit,$27.64 ,OP,27.64,45.74,,,,,,
Meridian Duals,CPT,88153,Cytopath c/v redo,Lab Services,Per Unit,$24.03 ,OP,24.03,45.74,,,,,,
Meridian Duals,CPT,88155,Cytopath c/v index add-on,Lab Services,Per Unit,$14.65 ,OP,14.65,26.7,,,,,,
Meridian Duals,CPT,88160,Cytopath smear other source,APC 5731,RVU Per Case,$25.25 ,OP,25.25,141.07,,,,,,
Meridian Duals,CPT,88161,Cytopath smear other source,APC 5731,RVU Per Case,$25.25 ,OP,25.25,152.51,,,,,,
Meridian Duals,CPT,88162,Cytopath smear other source,APC 5671,RVU Per Case,$50.92 ,OP,50.92,205.88,,,,,,
Meridian Duals,CPT,88164,Cytopath tbs c/v manual,Lab Services,Per Unit,$15.15 ,OP,15.15,45.74,,,,,,
Meridian Duals,CPT,88165,Cytopath tbs c/v redo,Lab Services,Per Unit,$42.22 ,OP,42.22,45.74,,,,,,
Meridian Duals,CPT,88166,Cytopath tbs c/v auto redo,Lab Services,Per Unit,$15.15 ,OP,15.15,45.74,,,,,,
Meridian Duals,CPT,88167,Cytopath tbs c/v select,Lab Services,Per Unit,$15.15 ,OP,15.15,45.74,,,,,,
Meridian Duals,CPT,88172,Cytp dx eval fna 1st ea site,APC 5672,RVU Per Case,$152.64 ,OP,118.19,152.64,,,,,,
Meridian Duals,CPT,88173,Cytopath eval fna report,APC 5671,RVU Per Case,$50.92 ,OP,50.92,327.9,,,,,,
Meridian Duals,CPT,88174,Cytopath c/v auto in fluid,Lab Services,Per Unit,$25.37 ,OP,25.37,95.32,,,,,,
Meridian Duals,CPT,88175,Cytopath c/v auto fluid redo,Lab Services,Per Unit,$26.61 ,OP,26.61,118.19,,,,,,
Meridian Duals,CPT,88182,Cell marker study,APC 5671,RVU Per Case,$50.92 ,OP,50.92,339.33,,,,,,
Meridian Duals,CPT,88184,Flowcytometry/ tc 1 marker,APC 5673,RVU Per Case,$298.05 ,OP,298.05,404.14,,,,,,
Meridian Duals,CPT,88199,Cytopathology procedure,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Meridian Duals,CPT,88230,Tissue culture lymphocyte,Lab Services,Per Unit,$116.49 ,OP,116.49,518.52,,,,,,
Meridian Duals,CPT,88233,Tissue culture skin/biopsy,Lab Services,Per Unit,$140.73 ,OP,140.73,625.29,,,,,,
Meridian Duals,CPT,88235,Tissue culture placenta,Lab Services,Per Unit,$150.30 ,OP,150.3,655.78,,,,,,
Meridian Duals,CPT,88237,Tissue culture bone marrow,Lab Services,Per Unit,$143.75 ,OP,143.75,564.29,,,,,,
Meridian Duals,CPT,88239,Tissue culture tumor,Lab Services,Per Unit,$147.52 ,OP,147.52,655.78,,,,,,
Meridian Duals,CPT,88240,Cell cryopreserve/storage,Lab Services,Per Unit,$13.07 ,OP,13.07,45.74,,,,,,
Meridian Duals,CPT,88241,Frozen cell preparation,Lab Services,Per Unit,$12.09 ,OP,12.09,45.74,,,,,,
Meridian Duals,CPT,88245,Chromosome analysis 20-25,Lab Services,Per Unit,$173.17 ,OP,173.17,648.16,,,,,,
Meridian Duals,CPT,88248,Chromosome analysis 50-100,Lab Services,Per Unit,$173.17 ,OP,173.17,770.16,,,,,,
Meridian Duals,CPT,88249,Chromosome analysis 100,Lab Services,Per Unit,$173.17 ,OP,173.17,770.16,,,,,,
Meridian Duals,CPT,88261,Chromosome analysis 5,Lab Services,Per Unit,$264.34 ,OP,264.34,785.42,,,,,,
Meridian Duals,CPT,88262,Chromosome analysis 15-20,Lab Services,Per Unit,$125.49 ,OP,125.49,556.65,,,,,,
Meridian Duals,CPT,88263,Chromosome analysis 45,Lab Services,Per Unit,$150.29 ,OP,150.29,671.03,,,,,,
Meridian Duals,CPT,88264,Chromosome analysis 20-25,Lab Services,Per Unit,$144.61 ,OP,144.61,556.65,,,,,,
Meridian Duals,CPT,88267,Chromosome analys placenta,Lab Services,Per Unit,$188.57 ,OP,188.57,800.67,,,,,,
Meridian Duals,CPT,88269,Chromosome analys amniotic,Lab Services,Per Unit,$173.66 ,OP,173.66,739.67,,,,,,
Meridian Duals,CPT,88271,Cytogenetics dna probe,Lab Services,Per Unit,$21.42 ,OP,21.42,64.82,,,,,,
Meridian Duals,CPT,88272,Cytogenetics 3-5,Lab Services,Per Unit,$40.70 ,OP,40.7,114.39,,,,,,
Meridian Duals,CPT,88273,Cytogenetics 10-30,Lab Services,Per Unit,$34.81 ,OP,34.81,144.88,,,,,,
Meridian Duals,CPT,88274,Cytogenetics 25-99,Lab Services,Per Unit,$42.38 ,OP,42.38,156.32,,,,,,
Meridian Duals,CPT,88275,Cytogenetics 100-300,Lab Services,Per Unit,$51.19 ,OP,51.19,179.2,,,,,,
Meridian Duals,CPT,88280,Chromosome karyotype study,Lab Services,Per Unit,$33.47 ,OP,33.47,110.57,,,,,,
Meridian Duals,CPT,88283,Chromosome banding study,Lab Services,Per Unit,$68.60 ,OP,68.6,68.6,,,,,,
Meridian Duals,CPT,88285,Chromosome count additional,Lab Services,Per Unit,$26.91 ,OP,26.91,83.87,,,,,,
Meridian Duals,CPT,88289,Chromosome study additional,Lab Services,Per Unit,$34.43 ,OP,34.43,129.64,,,,,,
Meridian Duals,CPT,88299,Cytogenetic study,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Meridian Duals,CPT,88300,Surgical path gross,APC 5731,RVU Per Case,$25.25 ,OP,25.25,99.13,,,,,,
Meridian Duals,CPT,88302,Tissue exam by pathologist,APC 5731,RVU Per Case,$25.25 ,OP,25.25,217.32,,,,,,
Meridian Duals,CPT,88304,Tissue exam by pathologist,APC 5671,RVU Per Case,$50.92 ,OP,50.92,263.08,,,,,,
Meridian Duals,CPT,88305,Tissue exam by pathologist,APC 5671,RVU Per Case,$50.92 ,OP,50.92,362.21,,,,,,
Meridian Duals,CPT,88307,Tissue exam by pathologist,APC 5673,RVU Per Case,$298.05 ,OP,298.05,671.03,,,,,,
Meridian Duals,CPT,88309,Tissue exam by pathologist,APC 5674,RVU Per Case,$671.45 ,OP,671.45,911.23,,,,,,
Meridian Duals,CPT,88312,Special stains group 1,APC 5671,RVU Per Case,$50.92 ,OP,50.92,366.02,,,,,,
Meridian Duals,CPT,88313,Special stains group 2,APC 5732,RVU Per Case,$34.63 ,OP,34.63,308.83,,,,,,
Meridian Duals,CPT,88319,Enzyme histochemistry,APC 5674,RVU Per Case,$671.45 ,OP,568.09,671.45,,,,,,
Meridian Duals,CPT,88321,Microslide consultation,APC 5732,RVU Per Case,$34.63 ,OP,34.63,438.47,,,,,,
Meridian Duals,CPT,88323,Microslide consultation,APC 5671,RVU Per Case,$50.92 ,OP,50.92,289.76,,,,,,
Meridian Duals,CPT,88325,Comprehensive review of data,APC 5672,RVU Per Case,$152.64 ,OP,152.64,949.36,,,,,,
Meridian Duals,CPT,88329,Path consult introp,APC 5732,RVU Per Case,$34.63 ,OP,34.63,247.83,,,,,,
Meridian Duals,CPT,88331,Path consult intraop 1 bloc,APC 5672,RVU Per Case,$152.64 ,OP,152.51,152.64,,,,,,
Meridian Duals,CPT,88333,Intraop cyto path consult 1,APC 5674,RVU Per Case,$671.45 ,OP,163.95,671.45,,,,,,
Meridian Duals,CPT,88342,Immunohisto antb 1st stain,APC 5672,RVU Per Case,$152.64 ,OP,152.64,297.39,,,,,,
Meridian Duals,CPT,88344,Immunohisto antibody slide,APC 5673,RVU Per Case,$298.05 ,OP,297.39,298.05,,,,,,
Meridian Duals,CPT,88346,Immunofluor antb 1st stain,APC 5673,RVU Per Case,$298.05 ,OP,293.57,298.05,,,,,,
Meridian Duals,CPT,88348,Electron microscopy,APC 5674,RVU Per Case,$671.45 ,OP,671.45,"2,794.70",,,,,,
Meridian Duals,CPT,88355,Analysis skeletal muscle,APC 5672,RVU Per Case,$152.64 ,OP,152.64,777.79,,,,,,
Meridian Duals,CPT,88356,Analysis nerve,APC 5671,RVU Per Case,$50.92 ,OP,50.92,766.35,,,,,,
Meridian Duals,CPT,88358,Analysis tumor,APC 5672,RVU Per Case,$152.64 ,OP,152.64,171.58,,,,,,
Meridian Duals,CPT,88360,Tumor immunohistochem/manual,APC 5672,RVU Per Case,$152.64 ,OP,152.64,335.53,,,,,,
Meridian Duals,CPT,88361,Tumor immunohistochem/comput,APC 5673,RVU Per Case,$298.05 ,OP,298.05,484.22,,,,,,
Meridian Duals,CPT,88362,Nerve teasing preparations,APC 5674,RVU Per Case,$671.45 ,OP,671.45,793.05,,,,,,
Meridian Duals,CPT,88363,Xm archive tissue molec anal,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Meridian Duals,CPT,88365,Insitu hybridization (fish),APC 5672,RVU Per Case,$152.64 ,OP,152.64,499.47,,,,,,
Meridian Duals,CPT,88366,Insitu hybridization (fish),APC 5673,RVU Per Case,$298.05 ,OP,298.05,499.47,,,,,,
Meridian Duals,CPT,88367,Insitu hybridization auto,APC 5673,RVU Per Case,$298.05 ,OP,298.05,907.42,,,,,,
Meridian Duals,CPT,88368,Insitu hybridization manual,APC 5673,RVU Per Case,$298.05 ,OP,298.05,747.28,,,,,,
Meridian Duals,CPT,88374,M/phmtrc alys ishquant/semiq,APC 5672,RVU Per Case,$152.64 ,OP,152.64,907.42,,,,,,
Meridian Duals,CPT,88377,M/phmtrc alys ishquant/semiq,APC 5672,RVU Per Case,$152.64 ,OP,152.64,747.28,,,,,,
Meridian Duals,CPT,88399,Surgical pathology procedure,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Meridian Duals,CPT,88720,Bilirubin total transcut,Lab Services,Per Unit,$5.02 ,OP,5.02,22.88,,,,,,
Meridian Duals,CPT,88738,Hgb quant transcutaneous,Lab Services,Per Unit,$5.02 ,OP,5.02,5.02,,,,,,
Meridian Duals,CPT,88740,Transcutaneous carboxyhb,Lab Services,Per Unit,$9.37 ,OP,9.37,22.88,,,,,,
Meridian Duals,CPT,88741,Transcutaneous methb,Lab Services,Per Unit,$9.37 ,OP,9.37,22.88,,,,,,
Meridian Duals,CPT,89049,Chct for mal hyperthermia,APC 5672,RVU Per Case,$152.64 ,OP,152.64,"1,201.00",,,,,,
Meridian Duals,CPT,89050,Body fluid cell count,Lab Services,Per Unit,$4.72 ,OP,4.72,22.88,,,,,,
Meridian Duals,CPT,89051,Body fluid cell count,Lab Services,Per Unit,$5.60 ,OP,5.6,26.7,,,,,,
Meridian Duals,CPT,89055,Leukocyte assessment fecal,Lab Services,Per Unit,$4.27 ,OP,4.27,22.88,,,,,,
Meridian Duals,CPT,89060,Exam synovial fluid crystals,Lab Services,Per Unit,$7.33 ,OP,7.33,30.51,,,,,,
Meridian Duals,CPT,89125,Specimen fat stain,Lab Services,Per Unit,$5.88 ,OP,5.88,11.44,,,,,,
Meridian Duals,CPT,89160,Exam feces for meat fibers,Lab Services,Per Unit,$4.85 ,OP,4.85,15.26,,,,,,
Meridian Duals,CPT,89190,Nasal smear for eosinophils,Lab Services,Per Unit,$5.79 ,OP,5.79,22.88,,,,,,
Meridian Duals,CPT,89220,Sputum specimen collection,APC 5672,RVU Per Case,$152.64 ,OP,80.07,152.64,,,,,,
Meridian Duals,CPT,89230,Collect sweat for test,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Meridian Duals,CPT,89240,Pathology lab procedure,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Meridian Duals,CPT,89250,Cultr oocyte/embryo <4 days,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Meridian Duals,CPT,89251,Cultr oocyte/embryo <4 days,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Meridian Duals,CPT,89253,Embryo hatching,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Meridian Duals,CPT,89254,Oocyte identification,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Meridian Duals,CPT,89255,Prepare embryo for transfer,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Meridian Duals,CPT,89257,Sperm identification,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Meridian Duals,CPT,89258,Cryopreservation embryo(s),APC 5674,RVU Per Case,$671.45 ,OP,671.45,671.45,,,,,,
Meridian Duals,CPT,89259,Cryopreservation sperm,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Meridian Duals,CPT,89260,Sperm isolation simple,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Meridian Duals,CPT,89261,Sperm isolation complex,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Meridian Duals,CPT,89264,Identify sperm tissue,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Meridian Duals,CPT,89268,Insemination of oocytes,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Meridian Duals,CPT,89272,Extended culture of oocytes,APC 5674,RVU Per Case,$671.45 ,OP,671.45,671.45,,,,,,
Meridian Duals,CPT,89280,Assist oocyte fertilization,APC 5674,RVU Per Case,$671.45 ,OP,671.45,671.45,,,,,,
Meridian Duals,CPT,89281,Assist oocyte fertilization,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Meridian Duals,CPT,89290,Biopsy oocyte polar body,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Meridian Duals,CPT,89291,Biopsy oocyte polar body,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Meridian Duals,CPT,89300,Semen analysis w/huhner,Lab Services,Per Unit,$9.84 ,OP,9.84,45.74,,,,,,
Meridian Duals,CPT,89310,Semen analysis w/count,Lab Services,Per Unit,$8.61 ,OP,8.61,30.51,,,,,,
Meridian Duals,CPT,89320,Semen anal vol/count/mot,Lab Services,Per Unit,$12.31 ,OP,12.31,49.56,,,,,,
Meridian Duals,CPT,89321,Semen anal sperm detection,Lab Services,Per Unit,$12.05 ,OP,12.05,49.56,,,,,,
Meridian Duals,CPT,89322,Semen anal strict criteria,Lab Services,Per Unit,$15.50 ,OP,15.5,61,,,,,,
Meridian Duals,CPT,89325,Sperm antibody test,Lab Services,Per Unit,$10.67 ,OP,10.67,10.67,,,,,,
Meridian Duals,CPT,89329,Sperm evaluation test,Lab Services,Per Unit,$19.59 ,OP,19.59,91.51,,,,,,
Meridian Duals,CPT,89330,Evaluation cervical mucus,Lab Services,Per Unit,$10.38 ,OP,10.38,45.74,,,,,,
Meridian Duals,CPT,89331,Retrograde ejaculation anal,Lab Services,Per Unit,$19.59 ,OP,19.59,83.87,,,,,,
Meridian Duals,CPT,89335,Cryopreserve testicular tiss,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Meridian Duals,CPT,89337,Cryopreservation oocyte(s),APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Meridian Duals,CPT,89342,Storage/year embryo(s),APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Meridian Duals,CPT,89343,Storage/year sperm/semen,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Meridian Duals,CPT,89344,Storage/year reprod tissue,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Meridian Duals,CPT,89346,Storage/year oocyte(s),APC 5673,RVU Per Case,$298.05 ,OP,298.05,298.05,,,,,,
Meridian Duals,CPT,89352,Thawing cryopresrved embryo,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Meridian Duals,CPT,89353,Thawing cryopresrved sperm,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Meridian Duals,CPT,89354,Thaw cryoprsvrd reprod tiss,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Meridian Duals,CPT,89356,Thawing cryopresrved oocyte,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Meridian Duals,CPT,89398,Unlisted reprod med lab proc,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Meridian Duals,CPT,90371,Hep b ig im,APC 1630,Per Unit,$130.31 ,OP,130.31,735.85,,,,,,
Meridian Duals,CPT,90375,Rabies ig im/sc,APC 9133,Per Unit,$267.30 ,OP,267.3,617.65,,,,,,
Meridian Duals,CPT,90376,Rabies ig heat treated,APC 9134,Per Unit,$287.38 ,OP,287.38,617.65,,,,,,
Meridian Duals,CPT,90378,Rsv mab im 50mg,APC 9003,Per Unit,"$1,185.67 ",OP,"1,185.67","3,154.20",,,,,,
Meridian Duals,CPT,90385,Rh ig minidose im,APC 9063,Per Unit,$151.41 ,OP,151.41,202.07,,,,,,
Meridian Duals,CPT,90396,Varicella-zoster ig im,APC 9135,Per Unit,"$1,965.97 ",OP,495.65,"1,965.97",,,,,,
Meridian Duals,CPT,90471,Immunization admin,APC 5692,RVU Per Case,$63.42 ,OP,57.19,63.42,,,,,,
Meridian Duals,CPT,90473,Immune admin oral/nasal,APC 5692,RVU Per Case,$63.42 ,OP,57.19,63.42,,,,,,
Meridian Duals,CPT,90630,Flu vacc iiv4 no preserv id,Other,Straight Discount,29.70%,OP,,,,,,,,
Meridian Duals,CPT,90653,Iiv adjuvant vaccine im,Other,Straight Discount,29.70%,OP,,,,,,,,
Meridian Duals,CPT,90654,Flu vacc iiv3 no preserv id,Other,Straight Discount,29.70%,OP,,,,,,,,
Meridian Duals,CPT,90655,Iiv3 vacc no prsv 0.25 ml im,Other,Straight Discount,29.70%,OP,68.63,68.63,,,,,,
Meridian Duals,CPT,90656,Iiv3 vacc no prsv 0.5 ml im,Other,Straight Discount,29.70%,OP,76.26,76.26,,,,,,
Meridian Duals,CPT,90657,Iiv3 vaccine splt 0.25 ml im,Other,Straight Discount,29.70%,OP,110.57,110.57,,,,,,
Meridian Duals,CPT,90660,Laiv3 vaccine intranasal,Other,Straight Discount,29.70%,OP,122,122,,,,,,
Meridian Duals,CPT,90661,Cciiv3 vac no prsv 0.5 ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Meridian Duals,CPT,90662,Iiv no prsv increased ag im,Other,Straight Discount,29.70%,OP,,,,,,,,
Meridian Duals,CPT,90670,Pcv13 vaccine im,Other,Straight Discount,29.70%,OP,,,,,,,,
Meridian Duals,CPT,90672,Laiv4 vaccine intranasal,Other,Straight Discount,29.70%,OP,,,,,,,,
Meridian Duals,CPT,90673,Riv3 vaccine no preserv im,Other,Straight Discount,29.70%,OP,,,,,,,,
Meridian Duals,CPT,90674,Cciiv4 vac no prsv 0.5 ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Meridian Duals,CPT,90675,Rabies vaccine im,APC 9139,Per Unit,$327.53 ,OP,327.53,945.56,,,,,,
Meridian Duals,CPT,90676,Rabies vaccine id,APC 9140,Per Unit,$189.63 ,OP,189.63,945.56,,,,,,
Meridian Duals,CPT,90677,Pcv20 vaccine im,Other,Straight Discount,29.70%,OP,,,,,,,,
Meridian Duals,CPT,90682,Riv4 vacc recombinant dna im,Other,Straight Discount,29.70%,OP,,,,,,,,
Meridian Duals,CPT,90685,Iiv4 vacc no prsv 0.25 ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Meridian Duals,CPT,90686,Iiv4 vacc no prsv 0.5 ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Meridian Duals,CPT,90687,Iiv4 vaccine splt 0.25 ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Meridian Duals,CPT,90688,Iiv4 vaccine splt 0.5 ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Meridian Duals,CPT,90689,Vacc iiv4 no prsrv 0.25ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Meridian Duals,CPT,90694,Vacc aiiv4 no prsrv 0.5ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Meridian Duals,CPT,90732,Ppsv23 vacc 2 yrs+ subq/im,Other,Straight Discount,29.70%,OP,228.77,228.77,,,,,,
Meridian Duals,CPT,90739,Hepb vacc 2 dose adult im,Other,Straight Discount,29.70%,OP,,,,,,,,
Meridian Duals,CPT,90740,Hepb vacc 3 dose immunsup im,Other,Straight Discount,29.70%,OP,"1,029.43","1,029.43",,,,,,
Meridian Duals,CPT,90743,Hepb vacc 2 dose adolesc im,Other,Straight Discount,29.70%,OP,141.07,141.07,,,,,,
Meridian Duals,CPT,90744,Hepb vacc 3 dose ped/adol im,Other,Straight Discount,29.70%,OP,141.07,141.07,,,,,,
Meridian Duals,CPT,90746,Hepb vaccine 3 dose adult im,Other,Straight Discount,29.70%,OP,369.83,369.83,,,,,,
Meridian Duals,CPT,90747,Hepb vacc 4 dose immunsup im,Other,Straight Discount,29.70%,OP,"1,029.43","1,029.43",,,,,,
Meridian Duals,CPT,90756,Cciiv4 vacc abx free im,Other,Straight Discount,29.70%,OP,,,,,,,,
Meridian Duals,CPT,90791,Psych diagnostic evaluation,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,789.23,,,,,,
Meridian Duals,CPT,90792,Psych diag eval w/med srvcs,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,789.23,,,,,,
Meridian Duals,CPT,90832,Psytx w pt 30 minutes,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,331.7,,,,,,
Meridian Duals,CPT,90834,Psytx w pt 45 minutes,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,480.4,,,,,,
Meridian Duals,CPT,90837,Psytx w pt 60 minutes,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,705.35,,,,,,
Meridian Duals,CPT,90839,Psytx crisis initial 60 min,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,136.74,,,,,,
Meridian Duals,CPT,90845,Psychoanalysis,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,423.22,,,,,,
Meridian Duals,CPT,90846,Family psytx w/o pt 50 min,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,449.9,,,,,,
Meridian Duals,CPT,90847,Family psytx w/pt 50 min,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,583.35,,,,,,
Meridian Duals,CPT,90849,Multiple family group psytx,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,171.58,,,,,,
Meridian Duals,CPT,90853,Group psychotherapy,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,368.97,,,,,,
Meridian Duals,CPT,90865,Narcosynthesis,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,808.29,,,,,,
Meridian Duals,CPT,90867,Tcranial magn stim tx plan,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Meridian Duals,CPT,90868,Tcranial magn stim tx deli,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Meridian Duals,CPT,90869,Tcran magn stim redetemine,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Meridian Duals,CPT,90870,Electroconvulsive therapy,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,709.16,,,,,,
Meridian Duals,CPT,90880,Hypnotherapy,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,545.21,,,,,,
Meridian Duals,CPT,90899,Psychiatric service/therapy,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Meridian Duals,CPT,90901,Biofeedback train any meth,Physician,Per Unit,$19.59 ,OP,19.59,19.59,,,,,,
Meridian Duals,CPT,90912,Bfb training 1st 15 min,Physician,Per Unit,$43.33 ,OP,43.33,476.6,,,,,,
Meridian Duals,CPT,90913,Bfb training ea addl 15 min,Physician,Per Unit,$24.51 ,OP,24.51,264.78,,,,,,
Meridian Duals,CPT,90935,Hemodialysis one evaluation,APC 5401,RVU Per Unit,$669.60 ,OP,373.65,669.6,,,,,,
Meridian Duals,CPT,90945,Dialysis one evaluation,APC 5024,RVU Per Unit,$372.22 ,OP,372.22,388.89,,,,,,
Meridian Duals,CPT,91010,Esophagus motility study,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Meridian Duals,CPT,91020,Gastric motility studies,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,"1,265.81",,,,,,
Meridian Duals,CPT,91022,Duodenal motility study,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,"1,044.69",,,,,,
Meridian Duals,CPT,91030,Acid perfusion of esophagus,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,754.91,,,,,,
Meridian Duals,CPT,91034,Gastroesophageal reflux test,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Meridian Duals,CPT,91035,G-esoph reflx tst w/electrod,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Meridian Duals,CPT,91037,Esoph imped function test,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Meridian Duals,CPT,91038,Esoph imped funct test > 1hr,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Meridian Duals,CPT,91040,Esoph balloon distension tst,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Meridian Duals,CPT,91065,Breath hydrogen/methane test,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Meridian Duals,CPT,91110,Gi tract capsule endoscopy,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,828.48,,,,,,
Meridian Duals,CPT,91111,Esophageal capsule endoscopy,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,828.48,,,,,,
Meridian Duals,CPT,91112,Gi wireless capsule measure,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,828.48,,,,,,
Meridian Duals,CPT,91117,Colon motility 6 hr study,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,272.35,,,,,,
Meridian Duals,CPT,91120,Rectal sensation test,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Meridian Duals,CPT,91122,Anal pressure record,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,272.35,,,,,,
Meridian Duals,CPT,91132,Electrogastrography,APC 5722,RVU Per Unit,$270.61 ,OP,244.01,270.61,,,,,,
Meridian Duals,CPT,91133,Electrogastrography w/test,APC 5734,RVU Per Case,$114.56 ,OP,114.56,312.64,,,,,,
Meridian Duals,CPT,91200,Liver elastography,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
Meridian Duals,CPT,91299,Gastroenterology procedure,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Meridian Duals,CPT,91300,Sarscov2 vac 30mcg/0.3ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Meridian Duals,CPT,91301,Sarscov2 vac 100mcg/0.5ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Meridian Duals,CPT,91303,Sarscov2 vac ad26 .5ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Meridian Duals,CPT,92002,Eye exam new patient,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,354.58,,,,,,
Meridian Duals,CPT,92004,Eye exam new patient,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,663.41,,,,,,
Meridian Duals,CPT,92012,Eye exam establish patient,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,373.65,,,,,,
Meridian Duals,CPT,92014,Eye exam&tx estab pt 1/>vst,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,545.21,,,,,,
Meridian Duals,CPT,92018,New eye exam & treatment,APC 5503,RVU Per Case,"$2,049.05 ",OP,671.03,"2,049.05",,,,,,
Meridian Duals,CPT,92019,Eye exam & treatment,APC 5503,RVU Per Case,"$2,049.05 ",OP,331.7,"2,049.05",,,,,,
Meridian Duals,CPT,92020,Special eye evaluation,APC 5734,RVU Per Case,$114.56 ,OP,114.56,125.82,,,,,,
Meridian Duals,CPT,92025,Corneal topography,APC 5733,RVU Per Case,$56.95 ,OP,56.95,167.76,,,,,,
Meridian Duals,CPT,92060,Special eye evaluation,APC 5733,RVU Per Case,$56.95 ,OP,56.95,285.96,,,,,,
Meridian Duals,CPT,92065,Orthoptic/pleoptic training,APC 5733,RVU Per Case,$56.95 ,OP,56.95,224.95,,,,,,
Meridian Duals,CPT,92081,Visual field examination(s),APC 5733,RVU Per Case,$56.95 ,OP,56.95,255.45,,,,,,
Meridian Duals,CPT,92082,Visual field examination(s),APC 5733,RVU Per Case,$56.95 ,OP,56.95,339.33,,,,,,
Meridian Duals,CPT,92083,Visual field examination(s),APC 5734,RVU Per Case,$114.56 ,OP,114.56,385.09,,,,,,
Meridian Duals,CPT,92132,Cmptr ophth dx img ant segmt,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Meridian Duals,CPT,92133,Cmptr ophth img optic nerve,APC 5733,RVU Per Case,$56.95 ,OP,56.95,224.95,,,,,,
Meridian Duals,CPT,92134,Cptr ophth dx img post segmt,APC 5733,RVU Per Case,$56.95 ,OP,56.95,224.95,,,,,,
Meridian Duals,CPT,92136,Ophthalmic biometry,APC 5734,RVU Per Case,$114.56 ,OP,114.56,411.78,,,,,,
Meridian Duals,CPT,92145,Corneal hysteresis deter,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Meridian Duals,CPT,92201,Opscpy extnd rta draw uni/bi,APC 5733,RVU Per Case,$56.95 ,OP,56.95,118.19,,,,,,
Meridian Duals,CPT,92202,Opscpy extnd on/mac draw,APC 5733,RVU Per Case,$56.95 ,OP,56.95,76.37,,,,,,
Meridian Duals,CPT,92227,Img rta detcj/mntr ds staff,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Meridian Duals,CPT,92228,Img rta detc/mntr ds phy/qhp,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Meridian Duals,CPT,92229,Img rta detc/mntr ds poc aly,APC 5733,RVU Per Unit,$56.95 ,OP,56.95,56.95,,,,,,
Meridian Duals,CPT,92230,Eye exam with photos,APC 5723,RVU Per Case,$499.16 ,OP,289.76,499.16,,,,,,
Meridian Duals,CPT,92235,Fluorescein angrph uni/bi,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,629.1,,,,,,
Meridian Duals,CPT,92240,Icg angiography uni/bi,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,162.87",,,,,,
Meridian Duals,CPT,92242,Fluorescein icg angiography,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,791.98",,,,,,
Meridian Duals,CPT,92250,Eye exam with photos,APC 5734,RVU Per Case,$114.56 ,OP,114.56,346.96,,,,,,
Meridian Duals,CPT,92260,Ophthalmoscopy/dynamometry,APC 5732,RVU Per Case,$34.63 ,OP,34.63,87.69,,,,,,
Meridian Duals,CPT,92265,Eye muscle evaluation,APC 5733,RVU Per Case,$56.95 ,OP,56.95,381.27,,,,,,
Meridian Duals,CPT,92270,Electro-oculography,APC 5734,RVU Per Case,$114.56 ,OP,114.56,438.47,,,,,,
Meridian Duals,CPT,92273,Full field erg w/i&r,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,648.16,,,,,,
Meridian Duals,CPT,92274,Multifocal erg w/i&r,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,386.03,,,,,,
Meridian Duals,CPT,92283,Color vision examination,APC 5733,RVU Per Case,$56.95 ,OP,56.95,224.95,,,,,,
Meridian Duals,CPT,92284,Dark adaptation eye exam,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
Meridian Duals,CPT,92285,Eye photography,APC 5733,RVU Per Case,$56.95 ,OP,56.95,205.88,,,,,,
Meridian Duals,CPT,92286,Internal eye photography,APC 5734,RVU Per Case,$114.56 ,OP,114.56,583.35,,,,,,
Meridian Duals,CPT,92287,Internal eye photography,APC 5734,RVU Per Case,$114.56 ,OP,114.56,549.03,,,,,,
Meridian Duals,CPT,92311,Contact lens fitting,APC 5735,RVU Per Case,$276.53 ,OP,276.53,449.9,,,,,,
Meridian Duals,CPT,92312,Contact lens fitting,APC 5734,RVU Per Case,$114.56 ,OP,114.56,510.9,,,,,,
Meridian Duals,CPT,92313,Contact lens fitting,APC 5734,RVU Per Case,$114.56 ,OP,114.56,434.65,,,,,,
Meridian Duals,CPT,92315,Rx cntact lens aphakia 1 eye,APC 5734,RVU Per Case,$114.56 ,OP,114.56,312.64,,,,,,
Meridian Duals,CPT,92316,Rx cntact lens aphakia 2 eye,APC 5734,RVU Per Case,$114.56 ,OP,114.56,411.78,,,,,,
Meridian Duals,CPT,92317,Rx corneoscleral cntact lens,APC 5732,RVU Per Case,$34.63 ,OP,34.63,324.09,,,,,,
Meridian Duals,CPT,92325,Modification of contact lens,APC 5734,RVU Per Case,$114.56 ,OP,114.56,141.07,,,,,,
Meridian Duals,CPT,92326,Replacement of contact lens,APC 5733,RVU Per Case,$56.95 ,OP,56.95,205.88,,,,,,
Meridian Duals,CPT,92352,Fit aphakia spectcl monofocl,APC 5733,RVU Per Case,$56.95 ,OP,56.95,198.25,,,,,,
Meridian Duals,CPT,92353,Fit aphakia spectcl multifoc,APC 5733,RVU Per Case,$56.95 ,OP,56.95,232.58,,,,,,
Meridian Duals,CPT,92354,Fit spectacles single system,APC 5732,RVU Per Case,$34.63 ,OP,34.63,510.9,,,,,,
Meridian Duals,CPT,92355,Fit spectacles compound lens,APC 5732,RVU Per Case,$34.63 ,OP,34.63,285.96,,,,,,
Meridian Duals,CPT,92358,Aphakia prosth service temp,APC 5733,RVU Per Case,$56.95 ,OP,56.95,102.95,,,,,,
Meridian Duals,CPT,92371,Repair & adjust spectacles,APC 5733,RVU Per Case,$56.95 ,OP,56.95,76.26,,,,,,
Meridian Duals,CPT,92499,Eye service or procedure,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Meridian Duals,CPT,92502,Ear and throat examination,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,526.16,,,,,,
Meridian Duals,CPT,92507,Speech/hearing therapy,Physician,Per Unit,$75.75 ,OP,75.75,354.58,,,,,,
Meridian Duals,CPT,92508,Speech/hearing therapy,Physician,Per Unit,$23.07 ,OP,23.07,171.58,,,,,,
Meridian Duals,CPT,92511,Nasopharyngoscopy,APC 5151,RVU Per Unit,$168.23 ,OP,168.23,842.61,,,,,,
Meridian Duals,CPT,92512,Nasal function studies,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,331.7,,,,,,
Meridian Duals,CPT,92516,Facial nerve function test,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Meridian Duals,CPT,92517,Vemp test i&r cervical,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Meridian Duals,CPT,92518,Vemp test i&r ocular,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Meridian Duals,CPT,92519,Vemp tst i&r cervical&ocular,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Meridian Duals,CPT,92520,Laryngeal function studies,APC 5734,RVU Per Case,$114.56 ,OP,114.56,339.33,,,,,,
Meridian Duals,CPT,92521,Evaluation of speech fluency,Physician,Per Unit,$132.47 ,OP,132.47,857.86,,,,,,
Meridian Duals,CPT,92522,Evaluate speech production,Physician,Per Unit,$111.22 ,OP,111.22,857.86,,,,,,
Meridian Duals,CPT,92523,Speech sound lang comprehen,Physician,Per Unit,$227.69 ,OP,227.69,857.86,,,,,,
Meridian Duals,CPT,92524,Behavral qualit analys voice,Physician,Per Unit,$108.89 ,OP,108.89,857.86,,,,,,
Meridian Duals,CPT,92526,Oral function therapy,Physician,Per Unit,$83.51 ,OP,83.51,453.71,,,,,,
Meridian Duals,CPT,92537,Caloric vstblr test w/rec,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,163.95,,,,,,
Meridian Duals,CPT,92538,Caloric vstblr test w/rec,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,163.95,,,,,,
Meridian Duals,CPT,92540,Basic vestibular evaluation,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Meridian Duals,CPT,92541,Spontaneous nystagmus test,APC 5734,RVU Per Case,$114.56 ,OP,114.56,335.53,,,,,,
Meridian Duals,CPT,92542,Positional nystagmus test,APC 5734,RVU Per Case,$114.56 ,OP,114.56,346.96,,,,,,
Meridian Duals,CPT,92544,Optokinetic nystagmus test,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,282.14,,,,,,
Meridian Duals,CPT,92545,Oscillating tracking test,APC 5722,RVU Per Unit,$270.61 ,OP,263.08,270.61,,,,,,
Meridian Duals,CPT,92546,Sinusoidal rotational test,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,468.96,,,,,,
Meridian Duals,CPT,92548,Cdp-sot 6 cond w/i&r,APC 5734,RVU Per Case,$114.56 ,OP,114.56,556.65,,,,,,
Meridian Duals,CPT,92549,Cdp-sot 6 cond w/i&r mct&adt,APC 5734,RVU Per Case,$114.56 ,OP,114.56,556.65,,,,,,
Meridian Duals,CPT,92550,Tympanometry & reflex thresh,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
Meridian Duals,CPT,92552,Pure tone audiometry air,APC 5734,RVU Per Case,$114.56 ,OP,114.56,129.64,,,,,,
Meridian Duals,CPT,92553,Audiometry air & bone,APC 5721,RVU Per Case,$142.80 ,OP,142.8,175.39,,,,,,
Meridian Duals,CPT,92555,Speech threshold audiometry,APC 5732,RVU Per Case,$34.63 ,OP,34.63,99.13,,,,,,
Meridian Duals,CPT,92556,Speech audiometry complete,APC 5733,RVU Per Case,$56.95 ,OP,56.95,152.51,,,,,,
Meridian Duals,CPT,92557,Comprehensive hearing test,APC 5721,RVU Per Case,$142.80 ,OP,142.8,278.32,,,,,,
Meridian Duals,CPT,92561,Bekesy audiometry diagnosis,APC 5734,RVU Per Case,$114.56 ,OP,114.56,171.58,,,,,,
Meridian Duals,CPT,92562,Loudness balance test,APC 5721,RVU Per Case,$142.80 ,OP,137.25,142.8,,,,,,
Meridian Duals,CPT,92563,Tone decay hearing test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,125.82,,,,,,
Meridian Duals,CPT,92564,Sisi hearing test,APC 5731,RVU Per Case,$25.25 ,OP,25.25,122,,,,,,
Meridian Duals,CPT,92565,Stenger test pure tone,APC 5732,RVU Per Case,$34.63 ,OP,34.63,80.07,,,,,,
Meridian Duals,CPT,92567,Tympanometry,APC 5732,RVU Per Case,$34.63 ,OP,34.63,110.57,,,,,,
Meridian Duals,CPT,92568,Acoustic refl threshold tst,APC 5732,RVU Per Case,$34.63 ,OP,34.63,110.57,,,,,,
Meridian Duals,CPT,92570,Acoustic immitance testing,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
Meridian Duals,CPT,92571,Filtered speech hearing test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,102.95,,,,,,
Meridian Duals,CPT,92572,Staggered spondaic word test,APC 5721,RVU Per Case,$142.80 ,OP,99.13,142.8,,,,,,
Meridian Duals,CPT,92575,Sensorineural acuity test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,202.07,,,,,,
Meridian Duals,CPT,92576,Synthetic sentence test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,129.64,,,,,,
Meridian Duals,CPT,92577,Stenger test speech,APC 5723,RVU Per Case,$499.16 ,OP,114.39,499.16,,,,,,
Meridian Duals,CPT,92579,Visual audiometry (vra),APC 5721,RVU Per Case,$142.80 ,OP,142.8,259.27,,,,,,
Meridian Duals,CPT,92582,Conditioning play audiometry,APC 5721,RVU Per Case,$142.80 ,OP,142.8,247.83,,,,,,
Meridian Duals,CPT,92583,Select picture audiometry,APC 5733,RVU Per Case,$56.95 ,OP,56.95,205.88,,,,,,
Meridian Duals,CPT,92584,Electrocochleography,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,427.03,,,,,,
Meridian Duals,CPT,92587,Evoked auditory test limited,APC 5722,RVU Per Unit,$270.61 ,OP,244.01,270.61,,,,,,
Meridian Duals,CPT,92588,Evoked auditory tst complete,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,385.09,,,,,,
Meridian Duals,CPT,92596,Ear protector evaluation,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Meridian Duals,CPT,92597,Oral speech device eval,Physician,Per Unit,$70.53 ,OP,70.53,583.35,,,,,,
Meridian Duals,CPT,92601,Cochlear implt f/up exam <7,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Meridian Duals,CPT,92602,Reprogram cochlear implt <7,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Meridian Duals,CPT,92603,Cochlear implt f/up exam 7/>,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Meridian Duals,CPT,92604,Reprogram cochlear implt 7/>,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Meridian Duals,CPT,92607,Ex for speech device rx 1hr,Physician,Per Unit,$122.72 ,OP,122.72,804.48,,,,,,
Meridian Duals,CPT,92608,Ex for speech device rx addl,Physician,Per Unit,$49.31 ,OP,49.31,163.95,,,,,,
Meridian Duals,CPT,92609,Use of speech device service,Physician,Per Unit,$102.45 ,OP,102.45,430.83,,,,,,
Meridian Duals,CPT,92610,Evaluate swallowing function,Physician,Per Unit,$69.06 ,OP,69.06,423.22,,,,,,
Meridian Duals,CPT,92611,Motion fluoroscopy/swallow,Physician,Per Unit,$90.57 ,OP,90.57,461.34,,,,,,
Meridian Duals,CPT,92612,Endoscopy swallow (fees) vid,Physician,Per Unit,$65.56 ,OP,65.56,796.85,,,,,,
Meridian Duals,CPT,92614,Laryngoscopic sensory vid,Physician,Per Unit,$64.93 ,OP,64.93,709.16,,,,,,
Meridian Duals,CPT,92616,Fees w/laryngeal sense test,Physician,Per Unit,$97.82 ,OP,97.82,972.25,,,,,,
Meridian Duals,CPT,92620,Auditory function 60 min,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
Meridian Duals,CPT,92625,Tinnitus assessment,APC 5721,RVU Per Case,$142.80 ,OP,142.8,293.57,,,,,,
Meridian Duals,CPT,92626,Eval aud funcj 1st hour,APC 5721,RVU Per Case,$142.80 ,OP,142.8,407.96,,,,,,
Meridian Duals,CPT,92640,Aud brainstem implt programg,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,385.09,,,,,,
Meridian Duals,CPT,92651,Aep hearing status deter i&r,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Meridian Duals,CPT,92652,Aep thrshld est mlt freq i&r,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Meridian Duals,CPT,92653,Aep neurodiagnostic i&r,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Meridian Duals,CPT,92700,Ent procedure/service,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Meridian Duals,CPT,92920,Prq cardiac angioplast 1 art,APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,92924,Prq card angio/athrect 1 art,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
Meridian Duals,CPT,92928,Prq card stent w/angio 1 vsl,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Meridian Duals,CPT,92933,Prq card stent/ath/angio,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Meridian Duals,CPT,92937,Prq revasc byp graft 1 vsl,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Meridian Duals,CPT,92941,Prq card revasc mi 1 vsl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,92943,Prq card revasc chronic 1vsl,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Meridian Duals,CPT,92950,Heart/lung resuscitation cpr,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,567.02",,,,,,
Meridian Duals,CPT,92953,Temporary external pacing,APC 5781,RVU Per Unit,$575.01 ,OP,575.01,575.01,,,,,,
Meridian Duals,CPT,92960,Cardioversion electric ext,APC 5781,RVU Per Unit,$575.01 ,OP,575.01,"1,460.26",,,,,,
Meridian Duals,CPT,92961,Cardioversion electric int,APC 5781,RVU Per Unit,$575.01 ,OP,575.01,"1,513.64",,,,,,
Meridian Duals,CPT,92970,Cardioassist internal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,040.87","8,948.83",,,,,,
Meridian Duals,CPT,92971,Cardioassist external,APC 5881,RVU Per Case,"$8,948.83 ",OP,590.97,"8,948.83",,,,,,
Meridian Duals,CPT,92975,Dissolve clot heart vessel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"2,367.69","8,948.83",,,,,,
Meridian Duals,CPT,92977,Dissolve clot heart vessel,APC 5694,RVU Per Unit,$318.00 ,OP,318,850.23,,,,,,
Meridian Duals,CPT,92986,Revision of aortic valve,APC 5192,RVU Per Case,"$5,072.43 ",OP,"5,072.43","8,048.60",,,,,,
Meridian Duals,CPT,92987,Revision of mitral valve,APC 5193,RVU Per Case,"$10,277.14 ",OP,"8,338.36","10,277.14",,,,,,
Meridian Duals,CPT,92990,Revision of pulmonary valve,APC 5193,RVU Per Case,"$10,277.14 ",OP,"6,409.14","10,277.14",,,,,,
Meridian Duals,CPT,92997,Pul art balloon repr percut,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
Meridian Duals,CPT,93005,Electrocardiogram tracing,APC 5733,RVU Per Case,$56.95 ,OP,56.95,72.44,,,,,,
Meridian Duals,CPT,93017,Cardiovascular stress test,APC 5722,RVU Per Case,$270.61 ,OP,270.61,362.21,,,,,,
Meridian Duals,CPT,93024,Cardiac drug stress test,APC 5735,RVU Per Case,$276.53 ,OP,276.53,712.98,,,,,,
Meridian Duals,CPT,93025,Microvolt t-wave assess,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,"1,246.76",,,,,,
Meridian Duals,CPT,93041,Rhythm ecg tracing,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Meridian Duals,CPT,93050,Art pressure waveform analys,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Meridian Duals,CPT,93225,Ecg monit/reprt up to 48 hrs,APC 5734,RVU Per Case,$114.56 ,OP,114.56,224.95,,,,,,
Meridian Duals,CPT,93226,Ecg monit/reprt up to 48 hrs,APC 5734,RVU Per Case,$114.56 ,OP,114.56,926.48,,,,,,
Meridian Duals,CPT,93229,Remote 30 day ecg tech supp,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Meridian Duals,CPT,93242,Ext ecg>48hr<7d recording,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Meridian Duals,CPT,93243,Ext ecg>48hr<7d scan a/r,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Meridian Duals,CPT,93246,Ext ecg>7d<15d recording,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Meridian Duals,CPT,93247,Ext ecg>7d<15d scan a/r,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Meridian Duals,CPT,93260,Prgrmg dev eval impltbl sys,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Meridian Duals,CPT,93261,Interrogate subq defib,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Meridian Duals,CPT,93270,Remote 30 day ecg rev/report,APC 5741,RVU Per Case,$38.02 ,OP,38.02,137.25,,,,,,
Meridian Duals,CPT,93271,Ecg/monitoring and analysis,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,"1,281.07",,,,,,
Meridian Duals,CPT,93278,Ecg/signal-averaged,APC 5733,RVU Per Case,$56.95 ,OP,56.95,251.64,,,,,,
Meridian Duals,CPT,93279,Prgrmg dev eval pm/ldls pm,APC 5741,RVU Per Case,$38.02 ,OP,38.02,327.9,,,,,,
Meridian Duals,CPT,93280,Pm device progr eval dual,APC 5741,RVU Per Case,$38.02 ,OP,38.02,381.27,,,,,,
Meridian Duals,CPT,93281,Pm device progr eval multi,APC 5741,RVU Per Case,$38.02 ,OP,38.02,446.08,,,,,,
Meridian Duals,CPT,93282,Prgrmg eval implantable dfb,APC 5741,RVU Per Case,$38.02 ,OP,38.02,415.59,,,,,,
Meridian Duals,CPT,93283,Prgrmg eval implantable dfb,APC 5741,RVU Per Case,$38.02 ,OP,38.02,503.28,,,,,,
Meridian Duals,CPT,93284,Prgrmg eval implantable dfb,APC 5741,RVU Per Case,$38.02 ,OP,38.02,587.16,,,,,,
Meridian Duals,CPT,93285,Prgrmg dev eval scrms ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,282.14,,,,,,
Meridian Duals,CPT,93288,Interrog evl pm/ldls pm ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,255.45,,,,,,
Meridian Duals,CPT,93289,Interrog device eval heart,APC 5741,RVU Per Case,$38.02 ,OP,38.02,385.09,,,,,,
Meridian Duals,CPT,93290,Interrog dev eval icpms ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,190.64,,,,,,
Meridian Duals,CPT,93291,Interrog dev eval scrms ip,APC 5731,RVU Per Case,$25.25 ,OP,25.25,244.01,,,,,,
Meridian Duals,CPT,93292,Wcd device interrogate,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Meridian Duals,CPT,93293,Pm phone r-strip device eval,APC 5741,RVU Per Case,$38.02 ,OP,38.02,366.02,,,,,,
Meridian Duals,CPT,93296,Rem interrog evl pm/ids,APC 5741,RVU Per Case,$38.02 ,OP,38.02,213.51,,,,,,
Meridian Duals,CPT,93303,Echo transthoracic,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,292.50",,,,,,
Meridian Duals,CPT,93304,Echo transthoracic,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,796.85,,,,,,
Meridian Duals,CPT,93306,Tte w/doppler complete,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,593.72",,,,,,
Meridian Duals,CPT,93307,Tte w/o doppler complete,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,056.11",,,,,,
Meridian Duals,CPT,93308,Tte f-up or lmtd,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,667.22,,,,,,
Meridian Duals,CPT,93312,Echo transesophageal,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,921.59",,,,,,
Meridian Duals,CPT,93313,Echo transesophageal,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,494.15,,,,,,
Meridian Duals,CPT,93315,Echo transesophageal,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,738.59",,,,,,
Meridian Duals,CPT,93316,Echo transesophageal,APC 5524,RVU Per Unit,$494.15 ,OP,259.27,494.15,,,,,,
Meridian Duals,CPT,93318,Echo transesophageal intraop,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,330.63",,,,,,
Meridian Duals,CPT,93350,Stress tte only,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,239.13",,,,,,
Meridian Duals,CPT,93351,Stress tte complete,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,635.64",,,,,,
Meridian Duals,CPT,93451,Right heart cath,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Meridian Duals,CPT,93452,Left hrt cath w/ventrclgrphy,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Meridian Duals,CPT,93453,R&l hrt cath w/ventriclgrphy,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Meridian Duals,CPT,93454,Coronary artery angio s&i,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","2,966.62",,,,,,
Meridian Duals,CPT,93455,Coronary art/grft angio s&i,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","2,966.62",,,,,,
Meridian Duals,CPT,93456,R hrt coronary artery angio,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Meridian Duals,CPT,93457,R hrt art/grft angio,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Meridian Duals,CPT,93458,L hrt artery/ventricle angio,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Meridian Duals,CPT,93459,L hrt art/grft angio,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Meridian Duals,CPT,93460,R&l hrt art/ventricle angio,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Meridian Duals,CPT,93461,R&l hrt art/ventricle angio,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Meridian Duals,CPT,93503,Insert/place heart catheter,APC 5182,RVU Per Case,"$1,438.93 ",OP,651.97,"1,438.93",,,,,,
Meridian Duals,CPT,93505,Biopsy of heart lining,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,346.47",,,,,,
Meridian Duals,CPT,93530,Rt heart cath congenital,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Meridian Duals,CPT,93531,R & l heart cath congenital,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","16,124.56",,,,,,
Meridian Duals,CPT,93532,R & l heart cath congenital,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","16,600.26",,,,,,
Meridian Duals,CPT,93533,R & l heart cath congenital,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","16,111.09",,,,,,
Meridian Duals,CPT,93580,Transcath closure of asd,APC 5194,RVU Per Case,"$16,438.60 ",OP,"5,905.86","16,438.60",,,,,,
Meridian Duals,CPT,93581,Transcath closure of vsd,APC 5194,RVU Per Case,"$16,438.60 ",OP,"7,739.77","16,438.60",,,,,,
Meridian Duals,CPT,93582,Perq transcath closure pda,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Meridian Duals,CPT,93583,Perq transcath septal reduxn,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,93590,Perq transcath cls mitral,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Meridian Duals,CPT,93591,Perq transcath cls aortic,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Meridian Duals,CPT,93600,Bundle of his recording,APC 5212,RVU Per Case,"$6,220.22 ",OP,"6,220.22","6,220.22",,,,,,
Meridian Duals,CPT,93602,Intra-atrial recording,APC 5212,RVU Per Case,"$6,220.22 ",OP,968.43,"6,220.22",,,,,,
Meridian Duals,CPT,93603,Right ventricular recording,APC 5211,RVU Per Case,"$1,138.72 ",OP,"1,117.12","1,138.72",,,,,,
Meridian Duals,CPT,93610,Intra-atrial pacing,APC 5212,RVU Per Case,"$6,220.22 ",OP,"1,323.01","6,220.22",,,,,,
Meridian Duals,CPT,93612,Intraventricular pacing,APC 5212,RVU Per Case,"$6,220.22 ",OP,"1,376.38","6,220.22",,,,,,
Meridian Duals,CPT,93615,Esophageal recording,APC 5211,RVU Per Case,"$1,138.72 ",OP,392.7,"1,138.72",,,,,,
Meridian Duals,CPT,93616,Esophageal recording,APC 5211,RVU Per Case,"$1,138.72 ",OP,"1,138.72","1,138.72",,,,,,
Meridian Duals,CPT,93618,Heart rhythm pacing,APC 5211,RVU Per Case,"$1,138.72 ",OP,"1,138.72","2,367.69",,,,,,
Meridian Duals,CPT,93619,Electrophysiology evaluation,APC 5212,RVU Per Case,"$6,220.22 ",OP,"4,312.16","6,220.22",,,,,,
Meridian Duals,CPT,93620,Electrophysiology evaluation,APC 5212,RVU Per Case,"$6,220.22 ",OP,"5,112.83","6,220.22",,,,,,
Meridian Duals,CPT,93624,Electrophysiologic study,APC 5212,RVU Per Case,"$6,220.22 ",OP,"2,051.24","6,220.22",,,,,,
Meridian Duals,CPT,93642,Electrophysiology evaluation,APC 5211,RVU Per Case,"$1,138.72 ",OP,"1,138.72","2,775.65",,,,,,
Meridian Duals,CPT,93650,Ablate heart dysrhythm focus,APC 5212,RVU Per Case,"$6,220.22 ",OP,"3,488.62","6,220.22",,,,,,
Meridian Duals,CPT,93653,Ep & ablate supravent arrhyt,APC 5213,RVU Per Case,"$21,964.94 ",OP,"10,420.09","21,964.94",,,,,,
Meridian Duals,CPT,93654,Ep & ablate ventric tachy,APC 5213,RVU Per Case,"$21,964.94 ",OP,"10,889.05","21,964.94",,,,,,
Meridian Duals,CPT,93656,Tx atrial fib pulm vein isol,APC 5213,RVU Per Case,"$21,964.94 ",OP,"10,420.09","21,964.94",,,,,,
Meridian Duals,CPT,93660,Tilt table evaluation,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,983.68,,,,,,
Meridian Duals,CPT,93668,Peripheral vascular rehab,APC 5733,RVU Per Unit,$56.95 ,OP,56.95,99.13,,,,,,
Meridian Duals,CPT,93701,Bioimpedance cv analysis,APC 5734,RVU Per Case,$114.56 ,OP,114.56,198.25,,,,,,
Meridian Duals,CPT,93702,Bis xtracell fluid analysis,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Meridian Duals,CPT,93724,Analyze pacemaker system,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,"1,948.29",,,,,,
Meridian Duals,CPT,93740,Temperature gradient studies,APC 5721,RVU Per Case,$142.80 ,OP,57.19,142.8,,,,,,
Meridian Duals,CPT,93745,Set-up cardiovert-defibrill,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,278.82,,,,,,
Meridian Duals,CPT,93750,Interrogation vad in person,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,102.65,,,,,,
Meridian Duals,CPT,93786,Ambl bp mntr w/sw rec only,APC 5734,RVU Per Case,$114.56 ,OP,114.56,171.58,,,,,,
Meridian Duals,CPT,93788,Ambl bp mntr w/sw a/r,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Meridian Duals,CPT,93797,Cardiac rehab,APC 5771,RVU Per Unit,$118.77 ,OP,102.95,118.77,,,,,,
Meridian Duals,CPT,93798,Cardiac rehab/monitor,APC 5771,RVU Per Unit,$118.77 ,OP,118.77,148.69,,,,,,
Meridian Duals,CPT,93799,Cardiovascular procedure,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Meridian Duals,CPT,93880,Extracranial bilat study,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,239.13",,,,,,
Meridian Duals,CPT,93882,Extracranial uni/ltd study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,815.92,,,,,,
Meridian Duals,CPT,93886,Intracranial complete study,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,483.14",,,,,,
Meridian Duals,CPT,93888,Intracranial limited study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,"1,010.37",,,,,,
Meridian Duals,CPT,93890,Tcd vasoreactivity study,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,307.75",,,,,,
Meridian Duals,CPT,93892,Tcd emboli detect w/o inj,APC 5522,RVU Per Case,$111.51 ,OP,111.51,"1,425.95",,,,,,
Meridian Duals,CPT,93893,Tcd emboli detect w/inj,APC 5522,RVU Per Case,$111.51 ,OP,111.51,"1,422.14",,,,,,
Meridian Duals,CPT,93922,Upr/l xtremity art 2 levels,APC 5734,RVU Per Case,$114.56 ,OP,114.56,594.77,,,,,,
Meridian Duals,CPT,93923,Upr/lxtr art stdy 3+ lvls,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,922.67,,,,,,
Meridian Duals,CPT,93924,Lwr xtr vasc stdy bilat,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,136.19",,,,,,
Meridian Duals,CPT,93925,Lower extremity study,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,525.07",,,,,,
Meridian Duals,CPT,93926,Lower extremity study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,976.05,,,,,,
Meridian Duals,CPT,93930,Upper extremity study,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,223.88",,,,,,
Meridian Duals,CPT,93931,Upper extremity study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,815.92,,,,,,
Meridian Duals,CPT,93970,Extremity study,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,273.44",,,,,,
Meridian Duals,CPT,93971,Extremity study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,842.61,,,,,,
Meridian Duals,CPT,93975,Vascular study,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,367.82,,,,,,
Meridian Duals,CPT,93976,Vascular study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,"1,082.81",,,,,,
Meridian Duals,CPT,93978,Vascular study,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,197.20",,,,,,
Meridian Duals,CPT,93979,Vascular study,APC 5522,RVU Per Case,$111.51 ,OP,111.51,823.54,,,,,,
Meridian Duals,CPT,93980,Penile vascular study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,934.12,,,,,,
Meridian Duals,CPT,93981,Penile vascular study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,667.22,,,,,,
Meridian Duals,CPT,93985,Dup-scan hemo compl bi std,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,136.19",,,,,,
Meridian Duals,CPT,93986,Dup-scan hemo compl uni std,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,646.72,,,,,,
Meridian Duals,CPT,93990,Doppler flow testing,APC 5522,RVU Per Case,$111.51 ,OP,111.51,956.99,,,,,,
Meridian Duals,CPT,93998,Noninvas vasc dx study proc,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Meridian Duals,CPT,94002,Vent mgmt inpat init day,APC 5801,RVU Per Unit,$496.58 ,OP,496.58,541.4,,,,,,
Meridian Duals,CPT,94003,Vent mgmt inpat subq day,APC 5801,RVU Per Unit,$496.58 ,OP,496.58,496.58,,,,,,
Meridian Duals,CPT,94010,Breathing capacity test,APC 5721,RVU Per Case,$142.80 ,OP,142.8,209.7,,,,,,
Meridian Duals,CPT,94011,Spirometry up to 2 yrs old,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
Meridian Duals,CPT,94012,Spirmtry w/brnchdil inf-2 yr,APC 5722,RVU Per Case,$270.61 ,OP,270.61,270.61,,,,,,
Meridian Duals,CPT,94013,Meas lung vol thru 2 yrs,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Meridian Duals,CPT,94014,Patient recorded spirometry,APC 5735,RVU Per Case,$276.53 ,OP,276.53,301.2,,,,,,
Meridian Duals,CPT,94015,Patient recorded spirometry,APC 5722,RVU Per Case,$270.61 ,OP,148.69,270.61,,,,,,
Meridian Duals,CPT,94016,Review patient spirometry,Physician,Per Unit,$24.70 ,OP,24.7,152.51,,,,,,
Meridian Duals,CPT,94060,Evaluation of wheezing,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,369.83,,,,,,
Meridian Duals,CPT,94070,Evaluation of wheezing,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,392.7,,,,,,
Meridian Duals,CPT,94150,Vital capacity test,APC 5721,RVU Per Case,$142.80 ,OP,141.07,142.8,,,,,,
Meridian Duals,CPT,94200,Lung function test (mbc/mvv),APC 5733,RVU Per Case,$56.95 ,OP,56.95,144.88,,,,,,
Meridian Duals,CPT,94375,Respiratory flow volume loop,APC 5722,RVU Per Case,$270.61 ,OP,232.58,270.61,,,,,,
Meridian Duals,CPT,94450,Hypoxia response curve,APC 5722,RVU Per Case,$270.61 ,OP,270.61,316.46,,,,,,
Meridian Duals,CPT,94452,Hast w/report,APC 5734,RVU Per Case,$114.56 ,OP,114.56,346.96,,,,,,
Meridian Duals,CPT,94453,Hast w/oxygen titrate,APC 5734,RVU Per Case,$114.56 ,OP,114.56,461.34,,,,,,
Meridian Duals,CPT,94610,Surfactant admin thru tube,APC 5791,RVU Per Case,$192.26 ,OP,192.26,438.47,,,,,,
Meridian Duals,CPT,94617,Exercise tst brncspsm w/ecg,APC 5734,RVU Per Case,$114.56 ,OP,114.56,465.15,,,,,,
Meridian Duals,CPT,94618,Pulmonary stress testing,APC 5734,RVU Per Case,$114.56 ,OP,114.56,465.15,,,,,,
Meridian Duals,CPT,94619,Exercise tst brncspsm wo ecg,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Meridian Duals,CPT,94621,Cardiopulm exercise testing,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,017.99",,,,,,
Meridian Duals,CPT,94640,Airway inhalation treatment,APC 5791,RVU Per Case,$192.26 ,OP,87.69,192.26,,,,,,
Meridian Duals,CPT,94642,Aerosol inhalation treatment,APC 5791,RVU Per Case,$192.26 ,OP,192.26,255.45,,,,,,
Meridian Duals,CPT,94644,Cbt 1st hour,APC 5734,RVU Per Case,$114.56 ,OP,114.56,217.32,,,,,,
Meridian Duals,CPT,94660,Pos airway pressure cpap,APC 5791,RVU Per Case,$192.26 ,OP,192.26,346.96,,,,,,
Meridian Duals,CPT,94662,Neg press ventilation cnp,APC 5801,RVU Per Unit,$496.58 ,OP,221.14,496.58,,,,,,
Meridian Duals,CPT,94664,Evaluate pt use of inhaler,APC 5791,RVU Per Case,$192.26 ,OP,99.13,192.26,,,,,,
Meridian Duals,CPT,94667,Chest wall manipulation,APC 5734,RVU Per Case,$114.56 ,OP,114.56,137.25,,,,,,
Meridian Duals,CPT,94668,Chest wall manipulation,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Meridian Duals,CPT,94669,Mechanical chest wall oscill,APC 5791,RVU Per Case,$192.26 ,OP,192.26,192.26,,,,,,
Meridian Duals,CPT,94680,Exhaled air analysis o2,APC 5721,RVU Per Case,$142.80 ,OP,142.8,369.83,,,,,,
Meridian Duals,CPT,94681,Exhaled air analysis o2/co2,APC 5722,RVU Per Case,$270.61 ,OP,270.61,270.61,,,,,,
Meridian Duals,CPT,94690,Exhaled air analysis,APC 5733,RVU Per Case,$56.95 ,OP,56.95,320.27,,,,,,
Meridian Duals,CPT,94726,Pulm funct tst plethysmograp,APC 5722,RVU Per Case,$270.61 ,OP,270.61,282.14,,,,,,
Meridian Duals,CPT,94727,Pulm function test by gas,APC 5721,RVU Per Case,$142.80 ,OP,142.8,221.14,,,,,,
Meridian Duals,CPT,94728,Airwy resist by oscillometry,APC 5722,RVU Per Case,$270.61 ,OP,270.61,282.14,,,,,,
Meridian Duals,CPT,94762,Measure blood oxygen level,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,202.07,,,,,,
Meridian Duals,CPT,94772,Breath recording infant,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Meridian Duals,CPT,94775,Ped home apnea rec hk-up,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Meridian Duals,CPT,94776,Ped home apnea rec downld,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Meridian Duals,CPT,94780,Cars/bd tst inft-12mo 60 min,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Meridian Duals,CPT,94799,Pulmonary service/procedure,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
Meridian Duals,CPT,95004,Percut allergy skin tests,APC 5724,RVU Per Case,$941.27 ,OP,30.51,941.27,,,,,,
Meridian Duals,CPT,95012,Exhaled nitric oxide meas,APC 5732,RVU Per Case,$34.63 ,OP,34.63,102.95,,,,,,
Meridian Duals,CPT,95017,Perq & icut allg test venoms,APC 5731,RVU Per Case,$25.25 ,OP,25.25,87.69,,,,,,
Meridian Duals,CPT,95018,Perq&ic allg test drugs/biol,APC 5732,RVU Per Case,$34.63 ,OP,34.63,87.69,,,,,,
Meridian Duals,CPT,95024,Icut allergy test drug/bug,APC 5733,RVU Per Case,$56.95 ,OP,38.13,56.95,,,,,,
Meridian Duals,CPT,95027,Icut allergy titrate-airborn,APC 5731,RVU Per Case,$25.25 ,OP,25.25,26.7,,,,,,
Meridian Duals,CPT,95028,Icut allergy test-delayed,APC 5732,RVU Per Case,$34.63 ,OP,34.63,57.19,,,,,,
Meridian Duals,CPT,95044,Allergy patch tests,APC 5724,RVU Per Case,$941.27 ,OP,34.31,941.27,,,,,,
Meridian Duals,CPT,95052,Photo patch test,APC 5733,RVU Per Case,$56.95 ,OP,38.13,56.95,,,,,,
Meridian Duals,CPT,95056,Photosensitivity tests,APC 5734,RVU Per Case,$114.56 ,OP,114.56,179.2,,,,,,
Meridian Duals,CPT,95060,Eye allergy tests,APC 5734,RVU Per Case,$114.56 ,OP,114.56,122,,,,,,
Meridian Duals,CPT,95065,Nose allergy test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,110.57,,,,,,
Meridian Duals,CPT,95070,Bronchial allergy tests,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Meridian Duals,CPT,95076,Ingest challenge ini 120 min,APC 5723,RVU Per Unit,$499.16 ,OP,320.27,499.16,,,,,,
Meridian Duals,CPT,95115,Immunotherapy one injection,APC 5691,RVU Per Case,$40.93 ,OP,40.93,57.19,,,,,,
Meridian Duals,CPT,95117,Immunotherapy injections,APC 5691,RVU Per Case,$40.93 ,OP,40.93,68.63,,,,,,
Meridian Duals,CPT,95144,Antigen therapy services,APC 5691,RVU Per Case,$40.93 ,OP,40.93,61,,,,,,
Meridian Duals,CPT,95145,Antigen therapy services,APC 5691,RVU Per Case,$40.93 ,OP,40.93,80.07,,,,,,
Meridian Duals,CPT,95146,Antigen therapy services,APC 5691,RVU Per Case,$40.93 ,OP,40.93,129.64,,,,,,
Meridian Duals,CPT,95147,Antigen therapy services,APC 5692,RVU Per Case,$63.42 ,OP,63.42,125.82,,,,,,
Meridian Duals,CPT,95148,Antigen therapy services,APC 5692,RVU Per Case,$63.42 ,OP,63.42,179.2,,,,,,
Meridian Duals,CPT,95149,Antigen therapy services,APC 5692,RVU Per Case,$63.42 ,OP,63.42,232.58,,,,,,
Meridian Duals,CPT,95165,Antigen therapy services,APC 5691,RVU Per Case,$40.93 ,OP,40.93,61,,,,,,
Meridian Duals,CPT,95170,Antigen therapy services,APC 5691,RVU Per Case,$40.93 ,OP,40.93,49.56,,,,,,
Meridian Duals,CPT,95180,Rapid desensitization,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
Meridian Duals,CPT,95199,Allergy immunology services,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Meridian Duals,CPT,95249,Cont gluc mntr pt prov eqp,APC 5733,RVU Per Unit,$56.95 ,OP,56.95,686.28,,,,,,
Meridian Duals,CPT,95250,Cont gluc mntr phys/qhp eqp,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,686.28,,,,,,
Meridian Duals,CPT,95700,Eeg cont rec w/vid eeg tech,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Meridian Duals,CPT,95705,Eeg w/o vid 2-12 hr unmntr,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Meridian Duals,CPT,95706,Eeg wo vid 2-12hr intmt mntr,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Meridian Duals,CPT,95707,Eeg w/o vid 2-12hr cont mntr,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Meridian Duals,CPT,95708,Eeg wo vid ea 12-26hr unmntr,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Meridian Duals,CPT,95709,Eeg w/o vid ea 12-26hr intmt,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Meridian Duals,CPT,95710,Eeg w/o vid ea 12-26hr cont,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Meridian Duals,CPT,95711,Veeg 2-12 hr unmonitored,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Meridian Duals,CPT,95712,Veeg 2-12 hr intmt mntr,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Meridian Duals,CPT,95713,Veeg 2-12 hr cont mntr,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Meridian Duals,CPT,95714,Veeg ea 12-26 hr unmntr,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Meridian Duals,CPT,95715,Veeg ea 12-26hr intmt mntr,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Meridian Duals,CPT,95716,Veeg ea 12-26hr cont mntr,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,941.27,,,,,,
Meridian Duals,CPT,95782,Polysom <6 yrs 4/> paramtrs,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"4,472.29",,,,,,
Meridian Duals,CPT,95783,Polysom <6 yrs cpap/bilvl,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"4,472.29",,,,,,
Meridian Duals,CPT,95800,Slp stdy unattended,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Meridian Duals,CPT,95801,Slp stdy unatnd w/anal,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Meridian Duals,CPT,95803,Actigraphy testing,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Meridian Duals,CPT,95805,Multiple sleep latency test,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,"2,249.49",,,,,,
Meridian Duals,CPT,95806,Sleep study unatt&resp efft,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,413.8,,,,,,
Meridian Duals,CPT,95807,Sleep study attended,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,"2,638.38",,,,,,
Meridian Duals,CPT,95808,Polysom any age 1-3> param,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,941.27,,,,,,
Meridian Duals,CPT,95810,Polysom 6/> yrs 4/> param,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"1,103.46",,,,,,
Meridian Duals,CPT,95811,Polysom 6/>yrs cpap 4/> parm,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"1,103.46",,,,,,
Meridian Duals,CPT,95812,Eeg 41-60 minutes,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,242.94",,,,,,
Meridian Duals,CPT,95813,Eeg extnd mntr 61-119 min,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,521.26",,,,,,
Meridian Duals,CPT,95816,Eeg awake and drowsy,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,139.99",,,,,,
Meridian Duals,CPT,95819,Eeg awake and asleep,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,223.88",,,,,,
Meridian Duals,CPT,95822,Eeg coma or sleep only,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,223.88",,,,,,
Meridian Duals,CPT,95824,Eeg cerebral death only,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,503.28,,,,,,
Meridian Duals,CPT,95836,Ecog impltd brn npgt <30 d,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Meridian Duals,CPT,95851,Range of motion measurements,Physician,Per Unit,$7.59 ,OP,7.59,83.87,,,,,,
Meridian Duals,CPT,95852,Range of motion measurements,Physician,Per Unit,$5.52 ,OP,5.52,64.82,,,,,,
Meridian Duals,CPT,95857,Cholinesterase challenge,APC 5722,RVU Per Unit,$270.61 ,OP,209.7,270.61,,,,,,
Meridian Duals,CPT,95860,Muscle test one limb,APC 5734,RVU Per Case,$114.56 ,OP,114.56,423.22,,,,,,
Meridian Duals,CPT,95861,Muscle test 2 limbs,APC 5734,RVU Per Case,$114.56 ,OP,114.56,613.85,,,,,,
Meridian Duals,CPT,95863,Muscle test 3 limbs,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,732.04,,,,,,
Meridian Duals,CPT,95864,Muscle test 4 limbs,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,850.23,,,,,,
Meridian Duals,CPT,95865,Muscle test larynx,APC 5734,RVU Per Case,$114.56 ,OP,114.56,439,,,,,,
Meridian Duals,CPT,95866,Muscle test hemidiaphragm,APC 5721,RVU Per Case,$142.80 ,OP,142.8,480.4,,,,,,
Meridian Duals,CPT,95867,Muscle test cran nerv unilat,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,369.83,,,,,,
Meridian Duals,CPT,95868,Muscle test cran nerve bilat,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,503.28,,,,,,
Meridian Duals,CPT,95869,Muscle test thor paraspinal,APC 5721,RVU Per Case,$142.80 ,OP,142.8,236.38,,,,,,
Meridian Duals,CPT,95870,Muscle test nonparaspinal,APC 5734,RVU Per Case,$114.56 ,OP,114.56,228.77,,,,,,
Meridian Duals,CPT,95872,Muscle test one fiber,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,635.69,,,,,,
Meridian Duals,CPT,95875,Limb exercise test,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,364.88,,,,,,
Meridian Duals,CPT,95905,Motor &/ sens nrve cndj test,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
Meridian Duals,CPT,95907,Nvr cndj tst 1-2 studies,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Meridian Duals,CPT,95908,Nrv cndj tst 3-4 studies,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Meridian Duals,CPT,95909,Nrv cndj tst 5-6 studies,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Meridian Duals,CPT,95910,Nrv cndj test 7-8 studies,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Meridian Duals,CPT,95911,Nrv cndj test 9-10 studies,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Meridian Duals,CPT,95912,Nrv cndj test 11-12 studies,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Meridian Duals,CPT,95913,Nrv cndj test 13/> studies,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Meridian Duals,CPT,95921,Autonomic nrv parasym inervj,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,282.21,,,,,,
Meridian Duals,CPT,95922,Autonomic nrv adrenrg inervj,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Meridian Duals,CPT,95923,Autonomic nrv syst funj test,APC 5734,RVU Per Case,$114.56 ,OP,114.56,447.55,,,,,,
Meridian Duals,CPT,95924,Ans parasymp & symp w/tilt,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Meridian Duals,CPT,95925,Somatosensory testing,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,461.8,,,,,,
Meridian Duals,CPT,95926,Somatosensory testing,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,602.41,,,,,,
Meridian Duals,CPT,95927,Somatosensory testing,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,621.47,,,,,,
Meridian Duals,CPT,95928,C motor evoked uppr limbs,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,964.61,,,,,,
Meridian Duals,CPT,95929,C motor evoked lwr limbs,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,"1,017.99",,,,,,
Meridian Duals,CPT,95930,Visual ep test cns w/i&r,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,537.6,,,,,,
Meridian Duals,CPT,95933,Blink reflex test,APC 5733,RVU Per Case,$56.95 ,OP,56.95,339.33,,,,,,
Meridian Duals,CPT,95937,Neuromuscular junction test,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,305.01,,,,,,
Meridian Duals,CPT,95938,Somatosensory testing,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Meridian Duals,CPT,95939,C motor evoked upr&lwr limbs,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,941.27,,,,,,
Meridian Duals,CPT,95943,Parasymp&symp hrt rate test,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Meridian Duals,CPT,95954,Eeg monitoring/giving drugs,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,"1,277.26",,,,,,
Meridian Duals,CPT,95958,Eeg monitoring/function test,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"1,982.60",,,,,,
Meridian Duals,CPT,95961,Electrode stimulation brain,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"1,265.81",,,,,,
Meridian Duals,CPT,95965,Meg spontaneous,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"10,992.00",,,,,,
Meridian Duals,CPT,95966,Meg evoked single,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"5,455.97",,,,,,
Meridian Duals,CPT,95970,Alys npgt w/o prgrmg,APC 5734,RVU Per Case,$114.56 ,OP,114.56,255.45,,,,,,
Meridian Duals,CPT,95971,Alys smpl sp/pn npgt w/prgrm,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,297.39,,,,,,
Meridian Duals,CPT,95972,Alys cplx sp/pn npgt w/prgrm,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,533.78,,,,,,
Meridian Duals,CPT,95976,Alys smpl cn npgt prgrmg,APC 5741,RVU Per Unit,$38.02 ,OP,38.02,657.7,,,,,,
Meridian Duals,CPT,95977,Alys cplx cn npgt prgrmg,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,876.92,,,,,,
Meridian Duals,CPT,95981,Io anal gast n-stim subsq,APC 5734,RVU Per Case,$114.56 ,OP,114.56,144.88,,,,,,
Meridian Duals,CPT,95982,Io ga n-stim subsq w/reprog,APC 5741,RVU Per Case,$38.02 ,OP,38.02,224.95,,,,,,
Meridian Duals,CPT,95983,Alys brn npgt prgrmg 15 min,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,260.22,,,,,,
Meridian Duals,CPT,95990,Spin/brain pump refil & main,APC 5694,RVU Per Unit,$318.00 ,OP,312.64,318,,,,,,
Meridian Duals,CPT,95991,Spin/brain pump refil & main,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,453.71,,,,,,
Meridian Duals,CPT,95992,Canalith repositioning proc,Physician,Per Unit,$36.73 ,OP,36.73,36.73,,,,,,
Meridian Duals,CPT,95999,Neurological procedure,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
Meridian Duals,CPT,96000,Motion analysis video/3d,APC 5723,RVU Per Unit,$499.16 ,OP,449.9,499.16,,,,,,
Meridian Duals,CPT,96001,Motion test w/ft press meas,APC 5724,RVU Per Unit,$941.27 ,OP,526.16,941.27,,,,,,
Meridian Duals,CPT,96002,Dynamic surface emg,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Meridian Duals,CPT,96003,Dynamic fine wire emg,APC 5722,RVU Per Case,$270.61 ,OP,91.51,270.61,,,,,,
Meridian Duals,CPT,96105,Assessment of aphasia,Physician,Per Unit,$98.92 ,OP,98.92,419.4,,,,,,
Meridian Duals,CPT,96112,Devel tst phys/qhp 1st hr,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,693.9,,,,,,
Meridian Duals,CPT,96116,Nubhvl xm phys/qhp 1st hr,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,518.52,,,,,,
Meridian Duals,CPT,96125,Cognitive test by hc pro,Physician,Per Unit,$103.76 ,OP,103.76,510.9,,,,,,
Meridian Duals,CPT,96127,Brief emotional/behav assmt,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Meridian Duals,CPT,96130,Psycl tst eval phys/qhp 1st,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,438.47,,,,,,
Meridian Duals,CPT,96132,Nrpsyc tst eval phys/qhp 1st,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,583.35,,,,,,
Meridian Duals,CPT,96136,Psycl/nrpsyc tst phy/qhp 1st,APC 5734,RVU Per Unit,$114.56 ,OP,114.56,219.24,,,,,,
Meridian Duals,CPT,96138,Psycl/nrpsyc tech 1st,APC 5735,RVU Per Unit,$276.53 ,OP,133.45,276.53,,,,,,
Meridian Duals,CPT,96146,Psycl/nrpsyc tst auto result,APC 5731,RVU Per Unit,$25.25 ,OP,18.8,25.25,,,,,,
Meridian Duals,CPT,96156,Hlth bhv assmt/reassessment,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,526.34,,,,,,
Meridian Duals,CPT,96158,Hlth bhv ivntj indiv 1st 30,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,236.39,,,,,,
Meridian Duals,CPT,96160,Pt-focused hlth risk assmt,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Meridian Duals,CPT,96161,Caregiver health risk assmt,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Meridian Duals,CPT,96164,Hlth bhv ivntj grp 1st 30,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,61.03,,,,,,
Meridian Duals,CPT,96167,Hlth bhv ivntj fam 1st 30,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,236.39,,,,,,
Meridian Duals,CPT,96360,Hydration iv infusion init,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,293.57,,,,,,
Meridian Duals,CPT,96361,Hydrate iv infusion add-on,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,122.99,,,,,,
Meridian Duals,CPT,96365,Ther/proph/diag iv inf init,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,354.58,,,,,,
Meridian Duals,CPT,96366,Ther/proph/diag iv inf addon,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,114.39,,,,,,
Meridian Duals,CPT,96367,Tx/proph/dg addl seq iv inf,APC 5692,RVU Per Unit,$63.42 ,OP,63.42,179.2,,,,,,
Meridian Duals,CPT,96369,Sc ther infusion up to 1 hr,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,758.72,,,,,,
Meridian Duals,CPT,96370,Sc ther infusion addl hr,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,83.87,,,,,,
Meridian Duals,CPT,96371,Sc ther infusion reset pump,APC 5692,RVU Per Case,$63.42 ,OP,63.42,366.02,,,,,,
Meridian Duals,CPT,96372,Ther/proph/diag inj sc/im,APC 5692,RVU Per Case,$63.42 ,OP,63.42,106.76,,,,,,
Meridian Duals,CPT,96373,Ther/proph/diag inj ia,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,208.24,,,,,,
Meridian Duals,CPT,96374,Ther/proph/diag inj iv push,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,278.32,,,,,,
Meridian Duals,CPT,96375,Tx/pro/dx inj new drug addon,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,202.94,,,,,,
Meridian Duals,CPT,96377,Applicaton on-body injector,APC 5691,RVU Per Case,$40.93 ,OP,40.93,40.93,,,,,,
Meridian Duals,CPT,96379,Ther/prop/diag inj/inf proc,APC 5691,RVU Per Case,$40.93 ,OP,40.93,40.93,,,,,,
Meridian Duals,CPT,96401,Chemo anti-neopl sq/im,APC 5692,RVU Per Case,$63.42 ,OP,63.42,377.46,,,,,,
Meridian Duals,CPT,96402,Chemo hormon antineopl sq/im,APC 5692,RVU Per Case,$63.42 ,OP,63.42,205.88,,,,,,
Meridian Duals,CPT,96405,Chemo intralesional up to 7,APC 5692,RVU Per Case,$63.42 ,OP,63.42,468.96,,,,,,
Meridian Duals,CPT,96406,Chemo intralesional over 7,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,648.16,,,,,,
Meridian Duals,CPT,96409,Chemo iv push sngl drug,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,629.1,,,,,,
Meridian Duals,CPT,96411,Chemo iv push addl drug,APC 5692,RVU Per Unit,$63.42 ,OP,63.42,362.21,,,,,,
Meridian Duals,CPT,96413,Chemo iv infusion 1 hr,APC 5694,RVU Per Unit,$318.00 ,OP,133.34,318,,,,,,
Meridian Duals,CPT,96415,Chemo iv infusion addl hr,APC 5692,RVU Per Unit,$63.42 ,OP,63.42,202.07,,,,,,
Meridian Duals,CPT,96416,Chemo prolong infuse w/pump,APC 5694,RVU Per Unit,$318.00 ,OP,318,926.48,,,,,,
Meridian Duals,CPT,96417,Chemo iv infus each addl seq,APC 5692,RVU Per Unit,$63.42 ,OP,63.42,427.03,,,,,,
Meridian Duals,CPT,96420,Chemo ia push tecnique,APC 5694,RVU Per Unit,$318.00 ,OP,318,613.85,,,,,,
Meridian Duals,CPT,96422,Chemo ia infusion up to 1 hr,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,979.86,,,,,,
Meridian Duals,CPT,96423,Chemo ia infuse each addl hr,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,434.65,,,,,,
Meridian Duals,CPT,96425,Chemotherapy infusion method,APC 5694,RVU Per Unit,$318.00 ,OP,318,968.43,,,,,,
Meridian Duals,CPT,96440,Chemotherapy intracavitary,APC 5694,RVU Per Unit,$318.00 ,OP,318,"3,339.91",,,,,,
Meridian Duals,CPT,96446,Chemotx admn prtl cavity,APC 5694,RVU Per Unit,$318.00 ,OP,318,318,,,,,,
Meridian Duals,CPT,96450,Chemotherapy into cns,APC 5694,RVU Per Unit,$318.00 ,OP,318,"1,159.06",,,,,,
Meridian Duals,CPT,96521,Refill/maint portable pump,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,716.79,,,,,,
Meridian Duals,CPT,96522,Refill/maint pump/resvr syst,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,610.03,,,,,,
Meridian Duals,CPT,96523,Irrig drug delivery device,APC 5733,RVU Per Case,$56.95 ,OP,56.95,141.07,,,,,,
Meridian Duals,CPT,96542,Chemotherapy injection,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,751.1,,,,,,
Meridian Duals,CPT,96549,Chemotherapy unspecified,APC 5691,RVU Per Case,$40.93 ,OP,40.93,40.93,,,,,,
Meridian Duals,CPT,96567,Pdt dstr prmlg les skn,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
Meridian Duals,CPT,96573,Pdt dstr prmlg les phys/qhp,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
Meridian Duals,CPT,96574,Dbrdmt prmlg les w/pdt,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
Meridian Duals,CPT,96900,Ultraviolet light therapy,APC 5732,RVU Per Case,$34.63 ,OP,34.63,114.39,,,,,,
Meridian Duals,CPT,96910,Photochemotherapy with uv-b,APC 5733,RVU Per Case,$56.95 ,OP,56.95,335.53,,,,,,
Meridian Duals,CPT,96912,Photochemotherapy with uv-a,APC 5733,RVU Per Case,$56.95 ,OP,56.95,430.83,,,,,,
Meridian Duals,CPT,96913,Photochemotherapy uv-a or b,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,651.97,,,,,,
Meridian Duals,CPT,96920,Laser tx skin < 250 sq cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
Meridian Duals,CPT,96921,Laser tx skin 250-500 sq cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
Meridian Duals,CPT,96922,Laser tx skin >500 sq cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"1,307.75",,,,,,
Meridian Duals,CPT,96999,Dermatological procedure,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
Meridian Duals,CPT,97012,Mechanical traction therapy,Physician,Per Unit,$14.55 ,OP,14.55,68.63,,,,,,
Meridian Duals,CPT,97016,Vasopneumatic device therapy,Physician,Per Unit,$11.78 ,OP,11.78,72.44,,,,,,
Meridian Duals,CPT,97018,Paraffin bath therapy,Physician,Per Unit,$5.69 ,OP,5.69,5.69,,,,,,
Meridian Duals,CPT,97022,Whirlpool therapy,Physician,Per Unit,$17.16 ,OP,17.16,83.87,,,,,,
Meridian Duals,CPT,97024,Diathermy eg microwave,Physician,Per Unit,$6.96 ,OP,6.96,26.7,,,,,,
Meridian Duals,CPT,97026,Infrared therapy,Physician,Per Unit,$6.32 ,OP,6.32,26.7,,,,,,
Meridian Duals,CPT,97028,Ultraviolet therapy,Physician,Per Unit,$7.98 ,OP,7.98,7.98,,,,,,
Meridian Duals,CPT,97032,Electrical stimulation,Physician,Per Unit,$14.55 ,OP,14.55,76.26,,,,,,
Meridian Duals,CPT,97033,Electric current therapy,Physician,Per Unit,$19.67 ,OP,19.67,114.39,,,,,,
Meridian Duals,CPT,97034,Contrast bath therapy,Physician,Per Unit,$14.42 ,OP,14.42,68.63,,,,,,
Meridian Duals,CPT,97035,Ultrasound therapy,Physician,Per Unit,$14.10 ,OP,14.1,53.38,,,,,,
Meridian Duals,CPT,97036,Hydrotherapy,Physician,Per Unit,$33.09 ,OP,33.09,118.19,,,,,,
Meridian Duals,CPT,97110,Therapeutic exercises,Physician,Per Unit,$29.26 ,OP,29.26,133.45,,,,,,
Meridian Duals,CPT,97112,Neuromuscular reeducation,Physician,Per Unit,$33.86 ,OP,33.86,137.25,,,,,,
Meridian Duals,CPT,97113,Aquatic therapy/exercises,Physician,Per Unit,$36.67 ,OP,36.67,160.13,,,,,,
Meridian Duals,CPT,97116,Gait training therapy,Physician,Per Unit,$29.26 ,OP,29.26,114.39,,,,,,
Meridian Duals,CPT,97124,Massage therapy,Physician,Per Unit,$28.22 ,OP,28.22,106.76,,,,,,
Meridian Duals,CPT,97129,Ther ivntj 1st 15 min,Physician,Per Unit,$23.04 ,OP,23.04,114.39,,,,,,
Meridian Duals,CPT,97130,Ther ivntj ea addl 15 min,Physician,Per Unit,$22.35 ,OP,22.35,110.97,,,,,,
Meridian Duals,CPT,97140,Manual therapy 1/> regions,Physician,Per Unit,$26.97 ,OP,26.97,122,,,,,,
Meridian Duals,CPT,97150,Group therapeutic procedures,Physician,Per Unit,$17.53 ,OP,17.53,83.87,,,,,,
Meridian Duals,CPT,97151,Bhv id assmt by phys/qhp,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Meridian Duals,CPT,97152,Bhv id suprt assmt by 1 tech,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Meridian Duals,CPT,97153,Adaptive behavior tx by tech,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Meridian Duals,CPT,97154,Grp adapt bhv tx by tech,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Meridian Duals,CPT,97155,Adapt behavior tx phys/qhp,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Meridian Duals,CPT,97156,Fam adapt bhv tx gdn phy/qhp,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Meridian Duals,CPT,97157,Mult fam adapt bhv tx gdn,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Meridian Duals,CPT,97158,Grp adapt bhv tx by phy/qhp,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Meridian Duals,CPT,97161,Pt eval low complex 20 min,Physician,Per Unit,$98.12 ,OP,98.12,330.81,,,,,,
Meridian Duals,CPT,97162,Pt eval mod complex 30 min,Physician,Per Unit,$98.12 ,OP,98.12,331.7,,,,,,
Meridian Duals,CPT,97163,Pt eval high complex 45 min,Physician,Per Unit,$98.12 ,OP,98.12,331.7,,,,,,
Meridian Duals,CPT,97164,Pt re-eval est plan care,Physician,Per Unit,$66.97 ,OP,66.97,175.39,,,,,,
Meridian Duals,CPT,97165,Ot eval low complex 30 min,Physician,Per Unit,$95.26 ,OP,95.26,354.58,,,,,,
Meridian Duals,CPT,97166,Ot eval mod complex 45 min,Physician,Per Unit,$95.26 ,OP,95.26,354.58,,,,,,
Meridian Duals,CPT,97167,Ot eval high complex 60 min,Physician,Per Unit,$95.26 ,OP,95.26,354.58,,,,,,
Meridian Duals,CPT,97168,Ot re-eval est plan care,Physician,Per Unit,$64.11 ,OP,64.11,202.07,,,,,,
Meridian Duals,CPT,97530,Therapeutic activities,Physician,Per Unit,$37.50 ,OP,37.5,137.25,,,,,,
Meridian Duals,CPT,97533,Sensory integration,Physician,Per Unit,$57.03 ,OP,57.03,122,,,,,,
Meridian Duals,CPT,97535,Self care mngment training,Physician,Per Unit,$32.44 ,OP,32.44,137.25,,,,,,
Meridian Duals,CPT,97537,Community/work reintegration,Physician,Per Unit,$31.26 ,OP,31.26,125.82,,,,,,
Meridian Duals,CPT,97542,Wheelchair mngment training,Physician,Per Unit,$31.58 ,OP,31.58,125.82,,,,,,
Meridian Duals,CPT,97597,Rmvl devital tis 20 cm/<,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,282.14,,,,,,
Meridian Duals,CPT,97602,Wound(s) care non-selective,APC 5051,RVU Per Case,$183.73 ,OP,171.58,183.73,,,,,,
Meridian Duals,CPT,97605,Neg press wound tx <=50 cm,APC 5051,RVU Per Case,$183.73 ,OP,163.95,183.73,,,,,,
Meridian Duals,CPT,97606,Neg press wound tx >50 cm,APC 5052,RVU Per Case,$353.91 ,OP,175.39,353.91,,,,,,
Meridian Duals,CPT,97607,Neg press wnd tx <=50 sq cm,APC 5052,RVU Per Unit,$353.91 ,OP,163.95,353.91,,,,,,
Meridian Duals,CPT,97608,Neg press wound tx >50 cm,APC 5052,RVU Per Unit,$353.91 ,OP,175.39,353.91,,,,,,
Meridian Duals,CPT,97610,Low frequency non-thermal us,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
Meridian Duals,CPT,97750,Physical performance test,Physician,Per Unit,$33.07 ,OP,33.07,137.25,,,,,,
Meridian Duals,CPT,97755,Assistive technology assess,Physician,Per Unit,$37.42 ,OP,37.42,156.32,,,,,,
Meridian Duals,CPT,97760,Orthotic mgmt&traing 1st enc,Physician,Per Unit,$47.55 ,OP,47.55,152.51,,,,,,
Meridian Duals,CPT,97761,Prosthetic traing 1st enc,Physician,Per Unit,$40.55 ,OP,40.55,133.45,,,,,,
Meridian Duals,CPT,97763,Orthc/prostc mgmt sbsq enc,Physician,Per Unit,$51.94 ,OP,51.94,160.13,,,,,,
Meridian Duals,CPT,97802,Medical nutrition indiv in,Physician,Per Unit,$30.75 ,OP,30.75,148.69,,,,,,
Meridian Duals,CPT,97803,Med nutrition indiv subseq,Physician,Per Unit,$31.17 ,OP,31.17,129.64,,,,,,
Meridian Duals,CPT,97804,Medical nutrition group,Physician,Per Unit,$16.45 ,OP,16.45,64.82,,,,,,
Meridian Duals,CPT,97810,Acupunct w/o stimul 15 min,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,186.82,,,,,,
Meridian Duals,CPT,97813,Acupunct w/stimul 15 min,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,198.25,,,,,,
Meridian Duals,CPT,98925,Osteopath manj 1-2 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,141.07,,,,,,
Meridian Duals,CPT,98926,Osteopath manj 3-4 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,27.17,,,,,,
Meridian Duals,CPT,98927,Osteopath manj 5-6 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,251.64,,,,,,
Meridian Duals,CPT,98928,Osteopath manj 7-8 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,297.39,,,,,,
Meridian Duals,CPT,98929,Osteopath manj 9-10 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,343.14,,,,,,
Meridian Duals,CPT,98940,Chiropract manj 1-2 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,125.82,,,,,,
Meridian Duals,CPT,98941,Chiropract manj 3-4 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,171.58,,,,,,
Meridian Duals,CPT,98942,Chiropractic manj 5 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,224.95,,,,,,
Meridian Duals,CPT,98966,Hc pro phone call 5-10 min,Physician,Per Unit,$12.73 ,OP,12.73,61,,,,,,
Meridian Duals,CPT,98967,Hc pro phone call 11-20 min,Physician,Per Unit,$25.14 ,OP,25.14,118.19,,,,,,
Meridian Duals,CPT,98968,Hc pro phone call 21-30 min,Physician,Per Unit,$37.46 ,OP,37.46,171.58,,,,,,
Meridian Duals,CPT,98970,Qnhp ol dig assmt&mgmt 5-10,Physician,Per Unit,$11.36 ,OP,11.36,11.36,,,,,,
Meridian Duals,CPT,98971,Qnhp ol dig assmt&mgmt 11-20,Physician,Per Unit,$20.31 ,OP,20.31,20.31,,,,,,
Meridian Duals,CPT,98972,Qnhp ol dig assmt&mgmt 21+,Physician,Per Unit,$32.41 ,OP,32.41,32.41,,,,,,
Meridian Duals,CPT,99170,Anogenital exam child w imag,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,663.41,,,,,,
Meridian Duals,CPT,99184,Hypothermia ill neonate,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,99190,Special pump services,APC 5881,RVU Per Case,"$8,948.83 ",OP,"2,299.05","8,948.83",,,,,,
Meridian Duals,CPT,99191,Special pump services,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,612.76","8,948.83",,,,,,
Meridian Duals,CPT,99192,Special pump services,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,151.42","8,948.83",,,,,,
Meridian Duals,CPT,99195,Phlebotomy,APC 5734,RVU Per Case,$114.56 ,OP,114.56,331.7,,,,,,
Meridian Duals,CPT,99281,Emergency dept visit,APC 5021,RVU Per Case,$74.29 ,OP,74.29,245.98,,,,,,
Meridian Duals,CPT,99282,Emergency dept visit,APC 5022,RVU Per Case,$134.66 ,OP,134.66,368.97,,,,,,
Meridian Duals,CPT,99283,Emergency dept visit,APC 5023,RVU Per Case,$237.00 ,OP,237,737.94,,,,,,
Meridian Duals,CPT,99284,Emergency dept visit,APC 5024,RVU Per Case,$372.22 ,OP,372.22,"1,291.40",,,,,,
Meridian Duals,CPT,99285,Emergency dept visit,APC 5025,RVU Per Case,$534.29 ,OP,534.29,"1,967.84",,,,,,
Meridian Duals,CPT,99291,Critical care first hour,APC 5041,RVU Per Case,$708.83 ,OP,708.83,"1,197.20",,,,,,
Meridian Duals,CPT,99356,Prolng svc i/p/obs 1st hour,APC 5881,RVU Per Case,"$8,948.83 ",OP,499.47,"8,948.83",,,,,,
Meridian Duals,CPT,99357,Prolng svc i/p/obs ea addl,APC 5881,RVU Per Case,"$8,948.83 ",OP,507.08,"8,948.83",,,,,,
Meridian Duals,CPT,99406,Behav chng smoking 3-10 min,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,64.82,,,,,,
Meridian Duals,CPT,99407,Behav chng smoking > 10 min,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,125.82,,,,,,
Meridian Duals,CPT,99453,Rem mntr physiol param setup,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,121.51,,,,,,
Meridian Duals,CPT,99454,Rem mntr physiol param dev,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Meridian Duals,CPT,99460,Init nb em per day hosp,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,305.01,,,,,,
Meridian Duals,CPT,99462,Sbsq nb em per day hosp,APC 5881,RVU Per Case,"$8,948.83 ",OP,160.13,"8,948.83",,,,,,
Meridian Duals,CPT,99463,Same day nb discharge,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,404.14,,,,,,
Meridian Duals,CPT,99465,Nb resuscitation,APC 5781,RVU Per Unit,$575.01 ,OP,575.01,781.61,,,,,,
Meridian Duals,CPT,99468,Neonate crit care initial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,510.41","8,948.83",,,,,,
Meridian Duals,CPT,99469,Neonate crit care subsq,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,936.85","8,948.83",,,,,,
Meridian Duals,CPT,99471,Ped critical care initial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,049.07","8,948.83",,,,,,
Meridian Duals,CPT,99472,Ped critical care subsq,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,982.60","8,948.83",,,,,,
Meridian Duals,CPT,99473,Self-meas bp pt educaj/train,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Meridian Duals,CPT,99475,Ped crit care age 2-5 init,APC 5881,RVU Per Case,"$8,948.83 ",OP,"2,790.89","8,948.83",,,,,,
Meridian Duals,CPT,99476,Ped crit care age 2-5 subsq,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,643.28","8,948.83",,,,,,
Meridian Duals,CPT,99477,Init day hosp neonate care,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,734.78","8,948.83",,,,,,
Meridian Duals,CPT,99478,Ic lbw inf < 1500 gm subsq,APC 5881,RVU Per Case,"$8,948.83 ",OP,716.79,"8,948.83",,,,,,
Meridian Duals,CPT,99479,Ic lbw inf 1500-2500 g subsq,APC 5881,RVU Per Case,"$8,948.83 ",OP,629.1,"8,948.83",,,,,,
Meridian Duals,CPT,99480,Ic inf pbw 2501-5000 g subsq,APC 5881,RVU Per Case,"$8,948.83 ",OP,606.21,"8,948.83",,,,,,
Meridian Duals,CPT,99483,Assmt & care pln pt cog imp,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Meridian Duals,CPT,99484,Care mgmt svc bhvl hlth cond,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Meridian Duals,CPT,99487,Cplx chrnc care 1st 60 min,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,136.74,,,,,,
Meridian Duals,CPT,99490,Chrnc care mgmt svc 1st 20,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Meridian Duals,CPT,99492,1st psyc collab care mgmt,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Meridian Duals,CPT,99493,Sbsq psyc collab care mgmt,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Meridian Duals,CPT,99495,Trans care mgmt 14 day disch,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,121.51,,,,,,
Meridian Duals,CPT,99496,Trans care mgmt 7 day disch,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,121.51,,,,,,
Meridian Duals,CPT,99497,Advncd care plan 30 min,APC 5822,RVU Per Case,$76.62 ,OP,76.62,76.62,,,,,,
Meridian Duals,CPT,0001A,Adm sarscov2 30mcg/0.3ml 1st,APC 9397,RVU Per Unit,$40.93 ,OP,40.93,40.93,,,,,,
Meridian Duals,CPT,0001U,Rbc dna hea 35 ag 11 bld grp,Lab Services,Per Unit,$720.00 ,OP,720,720,,,,,,
Meridian Duals,CPT,0002A,Adm sarscov2 30mcg/0.3ml 2nd,APC 9398,RVU Per Unit,$40.93 ,OP,40.93,40.93,,,,,,
Meridian Duals,CPT,0002M,Liver dis 10 assays w/ash,Lab Services,Per Unit,$503.40 ,OP,503.4,503.4,,,,,,
Meridian Duals,CPT,0002U,Onc clrct 3 ur metab alg plp,Lab Services,Per Unit,$25.00 ,OP,25,25,,,,,,
Meridian Duals,CPT,0003A,Adm sarscov2 30mcg/0.3ml 3rd,APC 9398,RVU Per Unit,$40.93 ,OP,40.93,40.93,,,,,,
Meridian Duals,CPT,0003M,Liver dis 10 assays w/nash,Lab Services,Per Unit,$503.40 ,OP,503.4,503.4,,,,,,
Meridian Duals,CPT,0003U,Onc ovar 5 prtn ser alg scor,Lab Services,Per Unit,$950.00 ,OP,950,950,,,,,,
Meridian Duals,CPT,0004M,Scoliosis dna alys,Lab Services,Per Unit,$79.00 ,OP,79,79,,,,,,
Meridian Duals,CPT,0005U,Onco prst8 3 gene ur alg,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
Meridian Duals,CPT,0006M,Onc hep gene risk classifier,Lab Services,Per Unit,$150.00 ,OP,150,150,,,,,,
Meridian Duals,CPT,0007M,Onc gastro 51 gene nomogram,Lab Services,Per Unit,$375.00 ,OP,375,375,,,,,,
Meridian Duals,CPT,0007U,Rx test prsmv ur w/def conf,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
Meridian Duals,CPT,0008U,Hpylori detcj abx rstnc dna,Lab Services,Per Unit,$597.91 ,OP,597.91,597.91,,,,,,
Meridian Duals,CPT,0009U,Onc brst ca erbb2 amp/nonamp,Lab Services,Per Unit,$107.00 ,OP,107,107,,,,,,
Meridian Duals,CPT,0010U,Nfct ds strn typ whl gen seq,Lab Services,Per Unit,$427.26 ,OP,427.26,427.26,,,,,,
Meridian Duals,CPT,0011A,Adm sarscov2 100mcg/0.5ml1st,APC 9397,RVU Per Unit,$40.93 ,OP,40.93,40.93,,,,,,
Meridian Duals,CPT,0011M,Onc prst8 ca mrna 12 gen alg,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
Meridian Duals,CPT,0011U,Rx mntr lc-ms/ms oral fluid,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
Meridian Duals,CPT,0012A,Adm sarscov2 100mcg/0.5ml2nd,APC 9398,RVU Per Unit,$40.93 ,OP,40.93,40.93,,,,,,
Meridian Duals,CPT,0012M,Onc mrna 5 gen rsk urthl ca,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
Meridian Duals,CPT,0012U,Germln do gene reargmt detcj,Lab Services,Per Unit,"$2,515.60 ",OP,"2,515.60","2,515.60",,,,,,
Meridian Duals,CPT,0013A,Adm sarscov2 100mcg/0.5ml3rd,APC 9398,RVU Per Unit,$40.93 ,OP,40.93,40.93,,,,,,
Meridian Duals,CPT,0013M,Onc mrna 5 gen recr urthl ca,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
Meridian Duals,CPT,0013U,Onc sld org neo gene reargmt,Lab Services,Per Unit,"$2,515.60 ",OP,"2,515.60","2,515.60",,,,,,
Meridian Duals,CPT,0014M,Liver ds alys 3 bmrk srm alg,Lab Services,Per Unit,$176.19 ,OP,176.19,176.19,,,,,,
Meridian Duals,CPT,0014U,Hem hmtlmf neo gene reargmt,Lab Services,Per Unit,"$2,515.60 ",OP,"2,515.60","2,515.60",,,,,,
Meridian Duals,CPT,0016U,Onc hmtlmf neo rna bcr/abl1,Lab Services,Per Unit,$163.96 ,OP,163.96,163.96,,,,,,
Meridian Duals,CPT,0017U,Onc hmtlmf neo jak2 mut dna,Lab Services,Per Unit,$91.66 ,OP,91.66,91.66,,,,,,
Meridian Duals,CPT,0018U,Onc thyr 10 microrna seq alg,Lab Services,Per Unit,"$3,002.09 ",OP,"3,002.09","3,002.09",,,,,,
Meridian Duals,CPT,0019U,Onc rna tiss predict alg,Lab Services,Per Unit,"$3,675.00 ",OP,"3,675.00","3,675.00",,,,,,
Meridian Duals,CPT,0021U,Onc prst8 detcj 8 autoantb,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
Meridian Duals,CPT,0022U,Trgt gen seq dna&rna 23 gene,Lab Services,Per Unit,"$1,950.00 ",OP,"1,950.00","1,950.00",,,,,,
Meridian Duals,CPT,0023U,Onc aml dna detcj/nondetcj,Lab Services,Per Unit,$248.51 ,OP,248.51,248.51,,,,,,
Meridian Duals,CPT,0024U,Glyca nuc mr spectrsc quan,Lab Services,Per Unit,$34.19 ,OP,34.19,34.19,,,,,,
Meridian Duals,CPT,0025U,Tenofovir liq chrom ur quan,Lab Services,Per Unit,$85.77 ,OP,85.77,85.77,,,,,,
Meridian Duals,CPT,0026U,Onc thyr dna&mrna 112 genes,Lab Services,Per Unit,"$3,600.00 ",OP,"3,600.00","3,600.00",,,,,,
Meridian Duals,CPT,0027U,Jak2 gene trgt seq alys,Lab Services,Per Unit,$121.91 ,OP,121.91,121.91,,,,,,
Meridian Duals,CPT,0029U,Rx metab advrs trgt seq alys,Lab Services,Per Unit,$742.27 ,OP,742.27,742.27,,,,,,
Meridian Duals,CPT,0030U,Rx metab warf trgt seq alys,Lab Services,Per Unit,$134.13 ,OP,134.13,134.13,,,,,,
Meridian Duals,CPT,0031A,Adm sarscov2 vac ad26 .5ml,APC 9398,RVU Per Unit,$40.93 ,OP,40.93,40.93,,,,,,
Meridian Duals,CPT,0031U,Cyp1a2 gene,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Meridian Duals,CPT,0032U,Comt gene,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Meridian Duals,CPT,0033U,Htr2a htr2c genes,Lab Services,Per Unit,$349.62 ,OP,349.62,349.62,,,,,,
Meridian Duals,CPT,0034U,Tpmt nudt15 genes,Lab Services,Per Unit,$466.17 ,OP,466.17,466.17,,,,,,
Meridian Duals,CPT,0035U,Neuro csf prion prtn qual,Lab Services,Per Unit,$540.99 ,OP,540.99,540.99,,,,,,
Meridian Duals,CPT,0036U,Xome tum & nml spec seq alys,Lab Services,Per Unit,"$4,780.00 ",OP,"4,780.00","4,780.00",,,,,,
Meridian Duals,CPT,0037U,Trgt gen seq dna 324 genes,Lab Services,Per Unit,"$3,500.00 ",OP,"3,500.00","3,500.00",,,,,,
Meridian Duals,CPT,0038U,Vitamin d srm microsamp quan,Lab Services,Per Unit,$29.60 ,OP,29.6,29.6,,,,,,
Meridian Duals,CPT,0039U,Dna antb 2strand hi avidity,Lab Services,Per Unit,$13.74 ,OP,13.74,13.74,,,,,,
Meridian Duals,CPT,0040U,Bcr/abl1 gene major bp quan,Lab Services,Per Unit,$409.90 ,OP,409.9,409.9,,,,,,
Meridian Duals,CPT,0041U,B brgdrferi antb 5 prtn igm,Lab Services,Per Unit,$17.21 ,OP,17.21,17.21,,,,,,
Meridian Duals,CPT,0042U,B brgdrferi antb 12 prtn igg,Lab Services,Per Unit,$17.21 ,OP,17.21,17.21,,,,,,
Meridian Duals,CPT,0043U,Tbrf b grp antb 4 prtn igm,Lab Services,Per Unit,$14.86 ,OP,14.86,14.86,,,,,,
Meridian Duals,CPT,0044U,Tbrf b grp antb 4 prtn igg,Lab Services,Per Unit,$14.86 ,OP,14.86,14.86,,,,,,
Meridian Duals,CPT,0045U,Onc brst dux carc is 12 gene,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
Meridian Duals,CPT,0046U,Flt3 gene itd variants quan,Lab Services,Per Unit,$407.43 ,OP,407.43,407.43,,,,,,
Meridian Duals,CPT,0047U,Onc prst8 mrna 17 gene alg,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
Meridian Duals,CPT,0048U,Onc sld org neo dna 468 gene,Lab Services,Per Unit,"$2,919.60 ",OP,"2,919.60","2,919.60",,,,,,
Meridian Duals,CPT,0049U,Npm1 gene analysis quan,Lab Services,Per Unit,$407.43 ,OP,407.43,407.43,,,,,,
Meridian Duals,CPT,0050U,Trgt gen seq dna 194 genes,Lab Services,Per Unit,"$2,916.60 ",OP,"2,916.60","2,916.60",,,,,,
Meridian Duals,CPT,0051U,Rx mntr lc-ms/ms ur 31 pnl,Lab Services,Per Unit,$193.71 ,OP,193.71,193.71,,,,,,
Meridian Duals,CPT,0052U,Lpoprtn bld w/5 maj classes,Lab Services,Per Unit,$33.86 ,OP,33.86,33.86,,,,,,
Meridian Duals,CPT,0053U,Onc prst8 ca fish alys 4 gen,Lab Services,Per Unit,"$2,030.00 ",OP,"2,030.00","2,030.00",,,,,,
Meridian Duals,CPT,0054U,Rx mntr 14+ drugs & sbsts,Lab Services,Per Unit,$148.96 ,OP,148.96,148.96,,,,,,
Meridian Duals,CPT,0055U,Card hrt trnspl 96 dna seq,Lab Services,Per Unit,"$3,240.00 ",OP,"3,240.00","3,240.00",,,,,,
Meridian Duals,CPT,0056U,Hem aml dna gene reargmt,Lab Services,Per Unit,"$2,515.60 ",OP,"2,515.60","2,515.60",,,,,,
Meridian Duals,CPT,0058U,Onc merkel cll carc srm quan,Lab Services,Per Unit,$322.96 ,OP,322.96,322.96,,,,,,
Meridian Duals,CPT,0059U,Onc merkel cll carc srm +/-,Lab Services,Per Unit,$322.96 ,OP,322.96,322.96,,,,,,
Meridian Duals,CPT,0060U,Twn zyg gen seq alys chrms2,Lab Services,Per Unit,$759.05 ,OP,759.05,759.05,,,,,,
Meridian Duals,CPT,0061U,Tc meas 5 bmrk sfdi m-s alys,Lab Services,Per Unit,$25.10 ,OP,25.1,25.1,,,,,,
Meridian Duals,CPT,0062U,Ai sle igg&igm alys 80 bmrk,Lab Services,Per Unit,$380.72 ,OP,380.72,380.72,,,,,,
Meridian Duals,CPT,0063U,Neuro autism 32 amines alg,Lab Services,Per Unit,$750.00 ,OP,750,750,,,,,,
Meridian Duals,CPT,0064U,Antb tp total&rpr ia qual,Lab Services,Per Unit,$31.33 ,OP,31.33,31.33,,,,,,
Meridian Duals,CPT,0065U,Syfls tst nontreponemal antb,Lab Services,Per Unit,$18.09 ,OP,18.09,18.09,,,,,,
Meridian Duals,CPT,0066U,Pamg-1 ia cervico-vag fluid,Lab Services,Per Unit,$15.29 ,OP,15.29,15.29,,,,,,
Meridian Duals,CPT,0067U,Onc brst imhchem prfl 4 bmrk,Lab Services,Per Unit,"$1,897.00 ",OP,"1,897.00","1,897.00",,,,,,
Meridian Duals,CPT,0068U,Candida species pnl amp prb,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
Meridian Duals,CPT,0069U,Onc clrct microrna mir-31-3p,Lab Services,Per Unit,$380.00 ,OP,380,380,,,,,,
Meridian Duals,CPT,0070U,Cyp2d6 gen com&slct rar vrnt,Lab Services,Per Unit,$676.37 ,OP,676.37,676.37,,,,,,
Meridian Duals,CPT,0071T,Us leiomyomata ablate <200,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","2,684.38",,,,,,
Meridian Duals,CPT,0071U,Cyp2d6 full gene sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,
Meridian Duals,CPT,0072T,Us leiomyomata ablate >200,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","2,684.38",,,,,,
Meridian Duals,CPT,0072U,Cyp2d6 gen cyp2d6-2d7 hybrid,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,
Meridian Duals,CPT,0073U,Cyp2d6 gen cyp2d7-2d6 hybrid,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,
Meridian Duals,CPT,0074U,Cyp2d6 nonduplicated gene,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,
Meridian Duals,CPT,0075T,Perq stent/chest vert art,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,0075U,Cyp2d6 5' gene dup/mlt,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,
Meridian Duals,CPT,0076T,S&i stent/chest vert art,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,0076U,Cyp2d6 3' gene dup/mlt,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,
Meridian Duals,CPT,0077U,Ig paraprotein qual bld/ur,Lab Services,Per Unit,$43.43 ,OP,43.43,43.43,,,,,,
Meridian Duals,CPT,0078U,Pain mgt opi use gnotyp pnl,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,
Meridian Duals,CPT,0080U,Onc lng 5 clin rsk factr alg,Lab Services,Per Unit,"$3,520.00 ",OP,"3,520.00","3,520.00",,,,,,
Meridian Duals,CPT,0082U,Rx test def 90+ rx/sbsts ur,Lab Services,Per Unit,$246.92 ,OP,246.92,246.92,,,,,,
Meridian Duals,CPT,0083U,Onc rspse chemo cntrst tomog,Lab Services,Per Unit,$167.35 ,OP,167.35,167.35,,,,,,
Meridian Duals,CPT,0084U,Rbc dna gnotyp 10 bld groups,Lab Services,Per Unit,$720.00 ,OP,720,720,,,,,,
Meridian Duals,CPT,0086U,Nfct ds bact&fng org id 6+,Lab Services,Per Unit,$200.00 ,OP,200,200,,,,,,
Meridian Duals,CPT,0087U,Crd hrt trnspl mrna 1283 gen,Lab Services,Per Unit,"$3,159.42 ",OP,"3,159.42","3,159.42",,,,,,
Meridian Duals,CPT,0088U,Trnsplj kdn algrft rej 1494,Lab Services,Per Unit,"$3,159.42 ",OP,"3,159.42","3,159.42",,,,,,
Meridian Duals,CPT,0089U,Onc mlnma prame & linc00518,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
Meridian Duals,CPT,0090U,Onc cutan mlnma mrna 23 gene,Lab Services,Per Unit,"$1,755.00 ",OP,"1,755.00","1,755.00",,,,,,
Meridian Duals,CPT,0092U,Onc lng 3 prtn bmrk plsm alg,Lab Services,Per Unit,"$2,488.00 ",OP,"2,488.00","2,488.00",,,,,,
Meridian Duals,CPT,0093U,Rx mntr 65 com drugs urine,Lab Services,Per Unit,$62.14 ,OP,62.14,62.14,,,,,,
Meridian Duals,CPT,0094U,Genome rapid sequence alys,Lab Services,Per Unit,"$7,582.20 ",OP,"7,582.20","7,582.20",,,,,,
Meridian Duals,CPT,0095U,Inflm ee elisa alys alg,Lab Services,Per Unit,$771.98 ,OP,771.98,771.98,,,,,,
Meridian Duals,CPT,0096U,Hpv hi risk types male urine,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,
Meridian Duals,CPT,0097U,Gi pathogen 22 targets,Lab Services,Per Unit,$363.04 ,OP,363.04,363.04,,,,,,
Meridian Duals,CPT,0101T,Extracorp shockwv tx hi enrg,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","2,896.40",,,,,,
Meridian Duals,CPT,0102T,Extracorp shockwv tx anesth,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","2,896.40",,,,,,
Meridian Duals,CPT,0105U,Neph ckd mult eclia tum nec,Lab Services,Per Unit,$950.00 ,OP,950,950,,,,,,
Meridian Duals,CPT,0106T,Touch quant sensory test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Meridian Duals,CPT,0106U,Gstr emptg 7 timed brth spec,Lab Services,Per Unit,$874.49 ,OP,874.49,874.49,,,,,,
Meridian Duals,CPT,0107T,Vibrate quant sensory test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Meridian Duals,CPT,0107U,C diff tox ag detcj ia stool,Lab Services,Per Unit,$16.00 ,OP,16,16,,,,,,
Meridian Duals,CPT,0108T,Cool quant sensory test,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Meridian Duals,CPT,0108U,Gi barrett esoph 9 prtn bmrk,Lab Services,Per Unit,"$2,513.25 ",OP,"2,513.25","2,513.25",,,,,,
Meridian Duals,CPT,0109T,Heat quant sensory test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Meridian Duals,CPT,0109U,Id aspergillus dna 4 species,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
Meridian Duals,CPT,0110T,Nos quant sensory test,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Meridian Duals,CPT,0110U,Rx mntr 1+oral onc rx&sbsts,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,
Meridian Duals,CPT,0111U,Onc colon ca kras&nras alys,Lab Services,Per Unit,$682.29 ,OP,682.29,682.29,,,,,,
Meridian Duals,CPT,0112U,Iadi 16s&18s rrna genes,Lab Services,Per Unit,$356.13 ,OP,356.13,356.13,,,,,,
Meridian Duals,CPT,0113U,Onc prst8 pca3&tmprss2-erg,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
Meridian Duals,CPT,0114U,Gi barretts esoph vim&ccna1,Lab Services,Per Unit,"$1,938.01 ",OP,"1,938.01","1,938.01",,,,,,
Meridian Duals,CPT,0115U,Respir iadna 18 viral&2 bact,Lab Services,Per Unit,$275.35 ,OP,275.35,275.35,,,,,,
Meridian Duals,CPT,0116U,Rx mntr nzm ia 35+oral flu,Lab Services,Per Unit,$246.92 ,OP,246.92,246.92,,,,,,
Meridian Duals,CPT,0117U,Pain mgmt 11 endogenous anal,Lab Services,Per Unit,$840.65 ,OP,840.65,840.65,,,,,,
Meridian Duals,CPT,0118U,Trnsplj don-drv cll-fr dna,Lab Services,Per Unit,"$2,753.25 ",OP,"2,753.25","2,753.25",,,,,,
Meridian Duals,CPT,0119U,Crd ceramides liq chrom plsm,Lab Services,Per Unit,$83.76 ,OP,83.76,83.76,,,,,,
Meridian Duals,CPT,0120U,Onc b cll lymphm mrna 58 gen,Lab Services,Per Unit,"$2,510.21 ",OP,"2,510.21","2,510.21",,,,,,
Meridian Duals,CPT,0121U,Sc dis vcam-1 whole blood,Lab Services,Per Unit,$509.20 ,OP,509.2,509.2,,,,,,
Meridian Duals,CPT,0122U,Sc dis p-selectin whl blood,Lab Services,Per Unit,$526.23 ,OP,526.23,526.23,,,,,,
Meridian Duals,CPT,0123U,Mchnl fragility rbc prflg,Lab Services,Per Unit,$357.63 ,OP,357.63,357.63,,,,,,
Meridian Duals,CPT,0130U,Hered colon ca do mrna pnl,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,
Meridian Duals,CPT,0131U,Hered brst ca rltd do pnl 13,Lab Services,Per Unit,$710.00 ,OP,710,710,,,,,,
Meridian Duals,CPT,0132U,Hered ova ca rltd do pnl 17,Lab Services,Per Unit,$741.64 ,OP,741.64,741.64,,,,,,
Meridian Duals,CPT,0133U,Hered prst8 ca rltd do 11,Lab Services,Per Unit,$690.29 ,OP,690.29,690.29,,,,,,
Meridian Duals,CPT,0134U,Hered pan ca mrna pnl 18 gen,Lab Services,Per Unit,$748.39 ,OP,748.39,748.39,,,,,,
Meridian Duals,CPT,0135U,Hered gyn ca mrna pnl 12 gen,Lab Services,Per Unit,$700.56 ,OP,700.56,700.56,,,,,,
Meridian Duals,CPT,0136U,Atm mrna seq alys,Lab Services,Per Unit,$407.43 ,OP,407.43,407.43,,,,,,
Meridian Duals,CPT,0137U,Palb2 mrna seq alys,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,
Meridian Duals,CPT,0138U,Brca1 brca2 mrna seq alys,Lab Services,Per Unit,$468.33 ,OP,468.33,468.33,,,,,,
Meridian Duals,CPT,0145U,Drug assay 65+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
Meridian Duals,CPT,0146U,Drug assay 80+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
Meridian Duals,CPT,0147U,Drug assay 85+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
Meridian Duals,CPT,0148U,Drug assay 100+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
Meridian Duals,CPT,0149U,Drug assay 60+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
Meridian Duals,CPT,0150U,Drug assay 120+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
Meridian Duals,CPT,0154U,Onc urthl ca rna fgfr3 gene,Lab Services,Per Unit,$482.14 ,OP,482.14,482.14,,,,,,
Meridian Duals,CPT,0155U,Onc brst ca dna pik3ca gene,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Meridian Duals,CPT,0166U,Liver ds 10 biochem asy srm,Lab Services,Per Unit,$503.40 ,OP,503.4,503.4,,,,,,
Meridian Duals,CPT,0167U,Chornc gonadotropin hcg ia,Lab Services,Per Unit,$7.52 ,OP,7.52,7.52,,,,,,
Meridian Duals,CPT,0169U,Nudt15&tpmt gene com vrnt,Lab Services,Per Unit,$466.17 ,OP,466.17,466.17,,,,,,
Meridian Duals,CPT,0170U,Neuro asd rna next gen seq,Lab Services,Per Unit,"$1,755.00 ",OP,"1,755.00","1,755.00",,,,,,
Meridian Duals,CPT,0172U,Onc sld tum alys brca1 brca2,Lab Services,Per Unit,"$3,030.00 ",OP,"3,030.00","3,030.00",,,,,,
Meridian Duals,CPT,0176U,Cdtb&vinculin igg antb ia,Lab Services,Per Unit,$64.19 ,OP,64.19,64.19,,,,,,
Meridian Duals,CPT,0177U,Onc brst ca dna pik3ca 11,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Meridian Duals,CPT,0181U,Co gnotyp aqp1 exon 1,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Meridian Duals,CPT,0182U,Crom gnotyp cd55 exons 1-10,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,
Meridian Duals,CPT,0183U,Di gnotyp slc4a1 exon 19,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Meridian Duals,CPT,0184T,Exc rectal tumor endoscopic,APC 5331,RVU Per Case,"$5,145.78 ",OP,"5,145.78","5,145.78",,,,,,
Meridian Duals,CPT,0184U,Do gnotyp art4 exon 2,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Meridian Duals,CPT,0185U,Fut1 gnotyp fut1 exon 4,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Meridian Duals,CPT,0186U,Fut2 gnotyp fut2 exon 2,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Meridian Duals,CPT,0187U,Fy gnotyp ackr1 exons 1-2,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Meridian Duals,CPT,0188U,Ge gnotyp gypc exons 1-4,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Meridian Duals,CPT,0189U,Gypa gnotyp ntrns 1 5 exon 2,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Meridian Duals,CPT,0190U,Gypb gnotyp ntrns 1 5 seux 3,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Meridian Duals,CPT,0191T,Insert ant segment drain int,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,009.10",,,,,,
Meridian Duals,CPT,0191U,In gnotyp cd44 exons 2 3 6,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Meridian Duals,CPT,0192U,Jk gnotyp slc14a1 exon 9,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Meridian Duals,CPT,0193U,Jr gnotyp abcg2 exons 2-26,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,
Meridian Duals,CPT,0194U,Kel gnotyp kel exon 8,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Meridian Duals,CPT,0195U,Klf1 targeted sequencing,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,
Meridian Duals,CPT,0196U,Lu gnotyp bcam exon 3,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Meridian Duals,CPT,0197U,Lw gnotyp icam4 exon 1,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Meridian Duals,CPT,0198T,Ocular blood flow measure,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Meridian Duals,CPT,0198U,Rhd&rhce gntyp rhd1-10&rhce5,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,
Meridian Duals,CPT,0199U,Sc gnotyp ermap exons 4 12,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Meridian Duals,CPT,0200T,Perq sacral augmt unilat inj,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
Meridian Duals,CPT,0200U,Xk gnotyp xk exons 1-3,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Meridian Duals,CPT,0201T,Perq sacral augmt bilat inj,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
Meridian Duals,CPT,0201U,Yt gnotyp ache exon 2,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Meridian Duals,CPT,0202T,Post vert arthrplst 1 lumbar,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
Meridian Duals,CPT,0202U,Nfct ds 22 trgt sars-cov-2,Lab Services,Per Unit,$416.78 ,OP,416.78,416.78,,,,,,
Meridian Duals,CPT,0203U,Ai ibd mrna xprsn prfl 17,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
Meridian Duals,CPT,0204U,Onc thyr mrna xprsn alys 593,Lab Services,Per Unit,"$2,919.60 ",OP,"2,919.60","2,919.60",,,,,,
Meridian Duals,CPT,0205U,Oph amd alys 3 gene variants,Lab Services,Per Unit,$47.00 ,OP,47,47,,,,,,
Meridian Duals,CPT,0207T,Clear eyelid gland w/heat,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Meridian Duals,CPT,0208T,Audiometry air only,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Meridian Duals,CPT,0209T,Audiometry air & bone,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Meridian Duals,CPT,0210T,Speech audiometry threshold,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Meridian Duals,CPT,0210U,Syphilis tst antb ia quan,Lab Services,Per Unit,$18.63 ,OP,18.63,18.63,,,,,,
Meridian Duals,CPT,0211T,Speech audiom thresh & recog,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Meridian Duals,CPT,0212T,Compre audiometry evaluation,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
Meridian Duals,CPT,0213T,Njx paravert w/us cer/thor,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,841.63,,,,,,
Meridian Duals,CPT,0216T,Njx paravert w/us lumb/sac,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,841.63,,,,,,
Meridian Duals,CPT,0218U,Neuro musc dys dmd seq alys,Lab Services,Per Unit,"$2,279.00 ",OP,"2,279.00","2,279.00",,,,,,
Meridian Duals,CPT,0219T,Plmt post facet implt cerv,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
Meridian Duals,CPT,0220T,Plmt post facet implt thor,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
Meridian Duals,CPT,0221T,Plmt post facet implt lumb,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
Meridian Duals,CPT,0224U,Antibody sars-cov-2 titer(s),Lab Services,Per Unit,$42.13 ,OP,42.13,42.13,,,,,,
Meridian Duals,CPT,0226U,Svnt sarscov2 elisa plsm srm,Lab Services,Per Unit,$42.28 ,OP,42.28,42.28,,,,,,
Meridian Duals,CPT,0232T,Njx platelet plasma,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
Meridian Duals,CPT,0234T,Trluml perip athrc renal art,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Meridian Duals,CPT,0235T,Trluml perip athrc visceral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,0236T,Trluml perip athrc abd aorta,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Meridian Duals,CPT,0237T,Trluml perip athrc brchiocph,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Meridian Duals,CPT,0238T,Trluml perip athrc iliac art,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Meridian Duals,CPT,0239U,Trgt gen seq alys pnl 311+,Lab Services,Per Unit,"$3,500.00 ",OP,"3,500.00","3,500.00",,,,,,
Meridian Duals,CPT,0240U,Nfct ds vir resp rna 3 trgt,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
Meridian Duals,CPT,0241U,Nfct ds vir resp rna 4 trgt,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
Meridian Duals,CPT,0242U,Trgt gen seq alys pnl 55-74,Lab Services,Per Unit,"$5,000.00 ",OP,"5,000.00","5,000.00",,,,,,
Meridian Duals,CPT,0253T,Insert aqueous drain device,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,009.10",,,,,,
Meridian Duals,CPT,0263T,Im b1 mrw cel ther cmpl,APC 5243,RVU Per Unit,"$4,131.87 ",OP,"4,131.87","4,131.87",,,,,,
Meridian Duals,CPT,0264T,Im b1 mrw cel ther xcl hrvst,APC 5243,RVU Per Unit,"$4,131.87 ",OP,"4,131.87","4,131.87",,,,,,
Meridian Duals,CPT,0265T,Im b1 mrw cel ther hrvst onl,APC 5243,RVU Per Unit,"$4,131.87 ",OP,"4,131.87","4,131.87",,,,,,
Meridian Duals,CPT,0266T,Implt/rpl crtd sns dev total,APC 5465,RVU Per Case,"$30,131.14 ",OP,"30,131.14","30,131.14",,,,,,
Meridian Duals,CPT,0267T,Implt/rpl crtd sns dev lead,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Meridian Duals,CPT,0268T,Implt/rpl crtd sns dev gen,APC 5465,RVU Per Case,"$30,131.14 ",OP,"30,131.14","30,131.14",,,,,,
Meridian Duals,CPT,0269T,Rev/remvl crtd sns dev total,APC 5432,RVU Per Case,"$5,833.22 ",OP,"5,833.22","5,833.22",,,,,,
Meridian Duals,CPT,0270T,Rev/remvl crtd sns dev lead,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Meridian Duals,CPT,0271T,Rev/remvl crtd sns dev gen,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Meridian Duals,CPT,0272T,Interrogate crtd sns dev,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Meridian Duals,CPT,0273T,Interrogate crtd sns w/pgrmg,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Meridian Duals,CPT,0274T,Perq lamot/lam crv/thrc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
Meridian Duals,CPT,0275T,Perq lamot/lam lumbar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
Meridian Duals,CPT,0278T,Tempr,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
Meridian Duals,CPT,0308T,Insj ocular telescope prosth,APC 5495,RVU Per Case,"$21,250.81 ",OP,"21,250.81","21,250.81",,,,,,
Meridian Duals,CPT,0312T,Laps impltj nstim vagus,APC 5465,RVU Per Case,"$30,131.14 ",OP,"30,131.14","30,131.14",,,,,,
Meridian Duals,CPT,0313T,Laps rmvl nstim array vagus,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Meridian Duals,CPT,0314T,Laps rmvl vgl arry&pls gen,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Meridian Duals,CPT,0315T,Rmvl vagus nerve pls gen,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Meridian Duals,CPT,0316T,Replc vagus nerve pls gen,APC 5465,RVU Per Case,"$30,131.14 ",OP,"30,131.14","30,131.14",,,,,,
Meridian Duals,CPT,0317T,Elec alys vagus nrv pls gen,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Meridian Duals,CPT,0330T,Tear film img uni/bi w/i&r,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Meridian Duals,CPT,0331T,Heart symp image plnr,APC 5593,RVU Per Unit,"$1,336.39 ",OP,922.67,"1,336.39",,,,,,
Meridian Duals,CPT,0332T,Heart symp image plnr spect,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,338.26",,,,,,
Meridian Duals,CPT,0335T,Insj sinus tarsi implant,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
Meridian Duals,CPT,0338T,Trnscth renal symp denrv unl,APC 5192,RVU Per Case,"$5,072.43 ",OP,"5,072.43","5,072.43",,,,,,
Meridian Duals,CPT,0339T,Trnscth renal symp denrv bil,APC 5192,RVU Per Case,"$5,072.43 ",OP,"5,072.43","5,072.43",,,,,,
Meridian Duals,CPT,0342T,Thxp apheresis w/hdl delip,APC 5243,RVU Per Unit,"$4,131.87 ",OP,"4,131.87","4,131.87",,,,,,
Meridian Duals,CPT,0345T,Transcath mtral vlve repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,0347T,Ins bone device for rsa,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Meridian Duals,CPT,0348T,Rsa spine exam,APC 5522,RVU Per Case,$111.51 ,OP,111.51,111.51,,,,,,
Meridian Duals,CPT,0349T,Rsa upper extr exam,APC 5522,RVU Per Case,$111.51 ,OP,111.51,111.51,,,,,,
Meridian Duals,CPT,0350T,Rsa lower extr exam,APC 5521,RVU Per Case,$82.79 ,OP,82.79,82.79,,,,,,
Meridian Duals,CPT,0355T,Gi tract capsule endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","1,662.91",,,,,,
Meridian Duals,CPT,0356T,Insrt drug device for iop,APC 5692,RVU Per Case,$63.42 ,OP,63.42,63.42,,,,,,
Meridian Duals,CPT,0358T,Bia whole body,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Meridian Duals,CPT,0362T,Bhv id suprt assmt ea 15 min,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Meridian Duals,CPT,0373T,Adapt bhv tx ea 15 min,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Meridian Duals,CPT,0379T,Vis field assmnt tech suppt,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Meridian Duals,CPT,0394T,Hdr elctrnc skn surf brchytx,APC 5622,RVU Per Unit,$247.32 ,OP,247.32,247.32,,,,,,
Meridian Duals,CPT,0395T,Hdr elctr ntrst/ntrcv brchtx,APC 5624,RVU Per Unit,$724.98 ,OP,724.98,724.98,,,,,,
Meridian Duals,CPT,0398T,Mrgfus strtctc les abltj,APC 5463,RVU Per Case,"$11,498.23 ",OP,"11,498.23","11,498.23",,,,,,
Meridian Duals,CPT,0402T,Colgn cross-link crn med sep,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","2,049.05",,,,,,
Meridian Duals,CPT,0404T,Trnscrv uterin fibroid abltj,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,140.35","9,201.00",,,,,,
Meridian Duals,CPT,0408T,Insj/rplc cardiac modulj sys,APC 5231,RVU Per Case,"$23,577.44 ",OP,"23,577.44","23,577.44",,,,,,
Meridian Duals,CPT,0409T,Insj/rplc car modulj pls gn,APC 5231,RVU Per Case,"$23,577.44 ",OP,"23,577.44","23,577.44",,,,,,
Meridian Duals,CPT,0410T,Insj/rplc car modulj atr elt,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
Meridian Duals,CPT,0411T,Insj/rplc car modulj vnt elt,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
Meridian Duals,CPT,0412T,Rmvl cardiac modulj pls gen,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Meridian Duals,CPT,0413T,Rmvl car modulj tranvns elt,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Meridian Duals,CPT,0414T,Rmvl & rpl car modulj pls gn,APC 5231,RVU Per Case,"$23,577.44 ",OP,"23,577.44","23,577.44",,,,,,
Meridian Duals,CPT,0415T,Repos car modulj tranvns elt,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,554.25,,,,,,
Meridian Duals,CPT,0416T,Reloc skin pocket pls gen,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","1,755.36",,,,,,
Meridian Duals,CPT,0417T,Prgrmg eval cardiac modulj,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Meridian Duals,CPT,0418T,Interro eval cardiac modulj,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Meridian Duals,CPT,0419T,Dstrj neurofibroma xtnsv,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,536.39,,,,,,
Meridian Duals,CPT,0420T,Dstrj neurofibroma xtnsv,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,536.39,,,,,,
Meridian Duals,CPT,0421T,Waterjet prostate abltj cmpl,APC 5376,RVU Per Case,"$8,450.70 ",OP,"8,450.70","8,450.70",,,,,,
Meridian Duals,CPT,0422T,Tactile breast img uni/bi,APC 5521,RVU Per Case,$82.79 ,OP,82.79,82.79,,,,,,
Meridian Duals,CPT,0424T,Insj/rplc nstim apnea compl,APC 5465,RVU Per Case,"$30,131.14 ",OP,"30,131.14","30,131.14",,,,,,
Meridian Duals,CPT,0425T,Insj/rplc nstim apnea sen ld,APC 5463,RVU Per Case,"$11,498.23 ",OP,"11,498.23","11,498.23",,,,,,
Meridian Duals,CPT,0426T,Insj/rplc nstim apnea stm ld,APC 5463,RVU Per Case,"$11,498.23 ",OP,"11,498.23","11,498.23",,,,,,
Meridian Duals,CPT,0427T,Insj/rplc nstim apnea pls gn,APC 5465,RVU Per Case,"$30,131.14 ",OP,"30,131.14","30,131.14",,,,,,
Meridian Duals,CPT,0428T,Rmvl nstim apnea pls gen,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Meridian Duals,CPT,0429T,Rmvl nstim apnea sen ld,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Meridian Duals,CPT,0430T,Rmvl nstim apnea stimj ld,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Meridian Duals,CPT,0431T,Rmvl/rplc nstim apnea pls gn,APC 5465,RVU Per Case,"$30,131.14 ",OP,"30,131.14","30,131.14",,,,,,
Meridian Duals,CPT,0432T,Repos nstim apnea stimj ld,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Meridian Duals,CPT,0433T,Repos nstim apnea sensing ld,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Meridian Duals,CPT,0434T,Interro eval npgs apnea,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,102.65,,,,,,
Meridian Duals,CPT,0435T,Prgrmg eval npgs apnea 1 ses,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,102.65,,,,,,
Meridian Duals,CPT,0436T,Prgrmg eval npgs apnea study,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,941.27,,,,,,
Meridian Duals,CPT,0440T,Abltj perc uxtr/perph nrv,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","1,795.30",,,,,,
Meridian Duals,CPT,0441T,Abltj perc lxtr/perph nrv,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","1,795.30",,,,,,
Meridian Duals,CPT,0442T,Abltj perc plex/trncl nrv,APC 5432,RVU Per Case,"$5,833.22 ",OP,"5,833.22","5,833.22",,,,,,
Meridian Duals,CPT,0446T,Insj impltbl glucose sensor,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","1,755.36",,,,,,
Meridian Duals,CPT,0447T,Rmvl impltbl glucose sensor,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
Meridian Duals,CPT,0448T,Remvl insj impltbl gluc sens,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","1,755.36",,,,,,
Meridian Duals,CPT,0449T,Insj aqueous drain dev 1st,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,009.10",,,,,,
Meridian Duals,CPT,0451T,Insj/rplcmt aortic ventr sys,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,0452T,Insj/rplcmt dev vasc seal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,0453T,Insj/rplcmt mech-elec ntrfce,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
Meridian Duals,CPT,0454T,Insj/rplcmt subq electrode,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
Meridian Duals,CPT,0455T,Remvl aortic ventr cmpl sys,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,0456T,Remvl aortic dev vasc seal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,0457T,Remvl mech-elec skin ntrfce,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Meridian Duals,CPT,0458T,Remvl subq electrode,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Meridian Duals,CPT,0459T,Relocaj rplcmt aortic ventr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,0460T,Repos aortic ventr dev eltrd,APC 5221,RVU Per Unit,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Meridian Duals,CPT,0461T,Repos aortic contrpulsj dev,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,0462T,Prgrmg eval aortic ventr sys,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,278.82,,,,,,
Meridian Duals,CPT,0463T,Interrog aortic ventr sys,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,278.82,,,,,,
Meridian Duals,CPT,0464T,Visual ep test for glaucoma,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Meridian Duals,CPT,0465T,Supchrdl njx rx w/o supply,APC 5694,RVU Per Unit,$318.00 ,OP,318,318,,,,,,
Meridian Duals,CPT,0467T,Revj/rplmnt ch respir eltrd,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Meridian Duals,CPT,0468T,Rmvl ch wal respir eltrd/ra,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Meridian Duals,CPT,0472T,Prgrmg io rta eltrd ra,APC 5743,RVU Per Case,$278.82 ,OP,278.82,278.82,,,,,,
Meridian Duals,CPT,0473T,Reprgrmg io rta eltrd ra,APC 5742,RVU Per Case,$102.65 ,OP,102.65,102.65,,,,,,
Meridian Duals,CPT,0476T,Rec ftl car sgl elec tr data,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Meridian Duals,CPT,0477T,Rec ftl car sgl xrtj alys,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Meridian Duals,CPT,0479T,Fxjl abl lsr 1st 100 sq cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,536.39,,,,,,
Meridian Duals,CPT,0481T,Njx autol wbc concentrate,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
Meridian Duals,CPT,0483T,Tmvi percutaneous approach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,0484T,Tmvi transthoracic exposure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,0485T,Oct mid ear i&r unilateral,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Meridian Duals,CPT,0486T,Oct mid ear i&r bilateral,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Meridian Duals,CPT,0487T,Trvg biomchn mapg w/reprt,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Meridian Duals,CPT,0491T,Abl lsr opn wnd 1st 20 sqcm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,353.91,,,,,,
Meridian Duals,CPT,0494T,Prep & cannulj cdvr don lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,0495T,Mntr cdvr don lng 1st 2 hrs,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,0496T,Mntr cdvr don lng ea addl hr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,0497T,Xtrnl pt act ecg in-off conn,APC 5741,RVU Per Case,$38.02 ,OP,38.02,"1,574.64",,,,,,
Meridian Duals,CPT,0499T,Cysto f/urtl strix/stenosis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","3,148.08",,,,,,
Meridian Duals,CPT,0503T,Cor ffr alys gnrj ffr mdl,APC 1511,RVU Per Unit,$972.67 ,OP,908.19,972.67,,,,,,
Meridian Duals,CPT,0505T,Ev fempop artl revsc,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Meridian Duals,CPT,0506T,Mac pgmt opt dns meas hfp,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Meridian Duals,CPT,0507T,Near ifr 2img mibmn glnd i&r,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Meridian Duals,CPT,0508T,Pls echo us b1 dns meas tib,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,111.51,,,,,,
Meridian Duals,CPT,0509T,Pattern erg w/i&r,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,386.03,,,,,,
Meridian Duals,CPT,0510T,Rmvl sinus tarsi implant,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","2,896.40",,,,,,
Meridian Duals,CPT,0511T,Rmvl&rinsj sinus tarsi implt,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
Meridian Duals,CPT,0512T,Esw integ wnd hlg 1st wnd,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,183.73,,,,,,
Meridian Duals,CPT,0515T,Insj wcs lv compl sys,APC 5231,RVU Per Case,"$23,577.44 ",OP,"23,577.44","23,577.44",,,,,,
Meridian Duals,CPT,0516T,Insj wcs lv eltrd only,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
Meridian Duals,CPT,0517T,Insj wcs lv pg compnt,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
Meridian Duals,CPT,0518T,Rmvl pg compnt wcs,APC 5221,RVU Per Unit,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Meridian Duals,CPT,0519T,Rmvl & rplcmt pg compnt wcs,APC 5221,RVU Per Unit,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Meridian Duals,CPT,0520T,Rmvl&rplcmt pg wcs new eltrd,APC 5231,RVU Per Case,"$23,577.44 ",OP,"23,577.44","23,577.44",,,,,,
Meridian Duals,CPT,0521T,Interrog dev eval wcs ip,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Meridian Duals,CPT,0522T,Prgrmg dev eval wcs ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Meridian Duals,CPT,0524T,Ev cath dir chem abltj w/img,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","2,928.39",,,,,,
Meridian Duals,CPT,0525T,Insj/rplcmt compl iims,APC 5223,RVU Per Case,"$10,642.67 ",OP,"10,642.67","10,642.67",,,,,,
Meridian Duals,CPT,0526T,Insj/rplcmt iims eltrd only,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
Meridian Duals,CPT,0527T,Insj/rplcmt iims implt mntr,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
Meridian Duals,CPT,0528T,Prgrmg dev eval iims ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Meridian Duals,CPT,0529T,Interrog dev eval iims ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Meridian Duals,CPT,0530T,Removal complete iims,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Meridian Duals,CPT,0531T,Removal iims electrode only,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Meridian Duals,CPT,0532T,Removal iims implt mntr only,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Meridian Duals,CPT,0534T,Cont rec mvmt do setup&train,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Meridian Duals,CPT,0535T,Cont rec mvmt do reprt cnfig,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Meridian Duals,CPT,0540T,Car-t cll admn autologous,APC 5694,RVU Per Unit,$318.00 ,OP,318,318,,,,,,
Meridian Duals,CPT,0541T,Myocardial imaging mcg,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Meridian Duals,CPT,0543T,Ta mv rpr w/artif chord tend,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,0544T,Tcat mv annulus rcnstj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,0545T,Tcat tv annulus rcnstj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,0548T,Tprnl balo cntnc dev bi,APC 5377,RVU Per Case,"$11,755.91 ",OP,"11,755.91","11,755.91",,,,,,
Meridian Duals,CPT,0549T,Tprnl balo cntnc dev uni,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,516.83","4,516.83",,,,,,
Meridian Duals,CPT,0550T,Tprnl balo cntnc dev rmvl ea,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","3,148.08",,,,,,
Meridian Duals,CPT,0551T,Tprnl balo cntnc dev adjmt,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,272.35,,,,,,
Meridian Duals,CPT,0555T,B1 str&fx rsk transmis data,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,25.25,,,,,,
Meridian Duals,CPT,0556T,B1 str & fx rsk assessment,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,235.49,,,,,,
Meridian Duals,CPT,0558T,Ct scan f/biomchn ct alys,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,927,,,,,,
Meridian Duals,CPT,0559T,Antmc mdl 3d print 1st cmpnt,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Meridian Duals,CPT,0561T,Antmc guide 3d print 1st gd,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Meridian Duals,CPT,0563T,Evac meibomian glnd heat bi,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Meridian Duals,CPT,0564T,Onc chemo rx cytotox csc 14,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Meridian Duals,CPT,0565T,Autol cell implt adps hrvg,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Meridian Duals,CPT,0566T,Autol cell implt adps njx,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,267.26,,,,,,
Meridian Duals,CPT,0569T,Ttvr perq appr 1st prosth,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,0570T,Ttvr perq ea addl prosth,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,0571T,Insj/rplcmt icds ss eltrd,APC 5232,RVU Per Case,"$33,604.66 ",OP,"33,604.66","33,604.66",,,,,,
Meridian Duals,CPT,0572T,Insertion ss dfb electrode,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
Meridian Duals,CPT,0573T,Removal ss dfb electrode,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Meridian Duals,CPT,0574T,Repos prev ss impl dfb eltrd,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Meridian Duals,CPT,0575T,Prgrmg dev eval icds ss ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Meridian Duals,CPT,0576T,Interrog dev eval icds ss ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Meridian Duals,CPT,0577T,Ephys eval icds ss,APC 5211,RVU Per Case,"$1,138.72 ",OP,"1,138.72","2,775.65",,,,,,
Meridian Duals,CPT,0579T,Rem interrog dev icds tech,APC 5741,RVU Per Case,$38.02 ,OP,38.02,213.51,,,,,,
Meridian Duals,CPT,0580T,Rmvl ss impl dfb pg only,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Meridian Duals,CPT,0583T,Tmpst auto tube dlvr sys,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","1,384.33",,,,,,
Meridian Duals,CPT,0584T,Perq islet cell transplant,APC 5881,RVU Per Case,"$8,948.83 ",OP,"2,508.76","8,948.83",,,,,,
Meridian Duals,CPT,0585T,Laps islet cell transplant,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,254.96","8,948.83",,,,,,
Meridian Duals,CPT,0586T,Open islet cell transplant,APC 5881,RVU Per Case,"$8,948.83 ",OP,"6,965.79","8,948.83",,,,,,
Meridian Duals,CPT,0587T,Perq impltj/rplcmt isdns ptn,APC 5462,RVU Per Case,"$6,304.35 ",OP,"6,304.35","6,304.35",,,,,,
Meridian Duals,CPT,0588T,Revision/removal isdns ptn,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Meridian Duals,CPT,0589T,Elec alys smpl prgrmg iins,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,255.45,,,,,,
Meridian Duals,CPT,0590T,Elec alys cplx prgrmg iins,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,255.45,,,,,,
Meridian Duals,CPT,0594T,Osteot hum xtrnl lngth dev,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
Meridian Duals,CPT,0596T,Temp fml iu vlv-pmp 1st insj,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,588.17,,,,,,
Meridian Duals,CPT,0597T,Temp fml iu valve-pmp rplcmt,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,588.17,,,,,,
Meridian Duals,CPT,0598T,Ncntc r-t fluor wnd img 1st,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Meridian Duals,CPT,0600T,Ire abltj 1+tum organ perq,APC 5362,RVU Per Case,"$9,115.38 ",OP,"9,115.38","9,115.38",,,,,,
Meridian Duals,CPT,0601T,Ire abltj 1+tumors open,APC 5362,RVU Per Case,"$9,115.38 ",OP,"9,115.38","9,115.38",,,,,,
Meridian Duals,CPT,0604T,Rem oct rta dev setup&educaj,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,121.51,,,,,,
Meridian Duals,CPT,0605T,Rem oct rta techl sprt min 8,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Meridian Duals,CPT,0607T,Rem mntr pulm flu mntr setup,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,121.51,,,,,,
Meridian Duals,CPT,0608T,Rem mntr pulm flu mntr alys,APC 5741,RVU Per Unit,$38.02 ,OP,38.02,38.02,,,,,,
Meridian Duals,CPT,0609T,Mrs disc pain acquisj data,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Meridian Duals,CPT,0611T,Mrs disc pain alg alys data,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,507.00",,,,,,
Meridian Duals,CPT,0614T,Rmvl&rplcmt ss impl dfb pg,APC 5231,RVU Per Case,"$23,577.44 ",OP,"23,577.44","23,577.44",,,,,,
Meridian Duals,CPT,0615T,Eye mvmt alys w/o calbrj i&r,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Meridian Duals,CPT,0616T,Insertion of iris prosthesis,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","2,127.64",,,,,,
Meridian Duals,CPT,0617T,Insj iris prosth w/rmvl&insj,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,009.10",,,,,,
Meridian Duals,CPT,0618T,Insj iris prosth sec io lens,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,009.10",,,,,,
Meridian Duals,CPT,0619T,Cysto w/prst8 commissurotomy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,516.83","4,516.83",,,,,,
Meridian Duals,CPT,0620T,Evasc ven artlz tibl/prnl vn,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Meridian Duals,CPT,0627T,Perq njx algc fluor lmbr 1st,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
Meridian Duals,CPT,0629T,Perq njx algc ct lmbr 1st,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
Meridian Duals,CPT,0631T,Tc vis lit hyperspectral img,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Meridian Duals,CPT,0632T,Perq tcat us abltj nrv p-art,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Meridian Duals,CPT,0633T,Ct breast w/3d uni c-,APC 5522,RVU Per Case,$111.51 ,OP,111.51,111.51,,,,,,
Meridian Duals,CPT,0634T,Ct breast w/3d uni c+,APC 5571,RVU Per Case,$182.72 ,OP,182.72,182.72,,,,,,
Meridian Duals,CPT,0635T,Ct breast w/3d uni c-/c+,APC 5571,RVU Per Case,$182.72 ,OP,182.72,182.72,,,,,,
Meridian Duals,CPT,0636T,Ct breast w/3d bi c-,APC 5523,RVU Per Case,$235.49 ,OP,235.49,235.49,,,,,,
Meridian Duals,CPT,0637T,Ct breast w/3d bi c+,APC 5572,RVU Per Case,$376.70 ,OP,376.7,376.7,,,,,,
Meridian Duals,CPT,0638T,Ct breast w/3d bi c-/c+,APC 5572,RVU Per Case,$376.70 ,OP,376.7,376.7,,,,,,
Meridian Duals,CPT,0641T,Ncntc nr ifr spctrsc wnd img,APC 5732,RVU Per Unit,$34.63 ,OP,34.63,34.63,,,,,,
Meridian Duals,CPT,0644T,Tcat rmvl/dblk icar mas perq,APC 5192,RVU Per Case,"$5,072.43 ",OP,"5,072.43","5,072.43",,,,,,
Meridian Duals,CPT,0647T,Insj gtube perq mag gastrpxy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","1,662.91",,,,,,
Meridian Duals,CPT,0648T,Quan mr alys tiss w/o mri,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,235.49,,,,,,
Meridian Duals,CPT,0650T,Prgrmg dev eval scrms remote,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Meridian Duals,CPT,0651T,Mag ctrld capsule endoscopy,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,828.48,,,,,,
Meridian Duals,CPT,0652T,Egd flx transnasal dx br/wa,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,828.48,,,,,,
Meridian Duals,CPT,0653T,Egd flx transnasal bx 1/ml,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,828.48,,,,,,
Meridian Duals,CPT,0654T,Egd flx transnasal tube/cath,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","1,662.91",,,,,,
Meridian Duals,CPT,0655T,Tprnl focal abltj mal prst8,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","3,148.08",,,,,,
Meridian Duals,CPT,0656T,Vrt bdy tethering ant,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,0657T,Vrt bdy tethering ant 8+ seg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,0658T,Elec impd spectrsc 1+skn les,APC 5733,RVU Per Unit,$56.95 ,OP,56.95,56.95,,,,,,
Meridian Duals,CPT,0659T,Tcat intra-c nfs supersat o2,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,0662T,Scalp cool 1st meas&calbrj,APC 5732,RVU Per Unit,$34.63 ,OP,34.63,34.63,,,,,,
Meridian Duals,CPT,A0425,Ground mileage,Ambulance,Per Unit,$7.47 ,OP,7.47,7.47,,,,,,
Meridian Duals,CPT,A0426,Als 1,Ambulance,Per Case,$231.98 ,OP,231.98,"2,249.49",,,,,,
Meridian Duals,CPT,A0427,Als1-emergency,Ambulance,Per Case,$231.98 ,OP,231.98,"2,287.62",,,,,,
Meridian Duals,CPT,A0428,Bls,Ambulance,Per Case,$231.98 ,OP,231.98,231.98,,,,,,
Meridian Duals,CPT,A0429,Bls-emergency,Ambulance,Per Case,$231.98 ,OP,231.98,"1,883.47",,,,,,
Meridian Duals,CPT,A0430,Fixed wing air transport,Ambulance,Per Case,"$3,147.91 ",OP,"3,147.91","3,147.91",,,,,,
Meridian Duals,CPT,A0431,Rotary wing air transport,Ambulance,Per Case,"$3,659.92 ",OP,"3,659.92","3,659.92",,,,,,
Meridian Duals,CPT,A0432,Pi volunteer ambulance co,Ambulance,Per Case,$231.98 ,OP,231.98,231.98,,,,,,
Meridian Duals,CPT,A0433,Als 2,Ambulance,Per Case,$231.98 ,OP,231.98,"2,859.52",,,,,,
Meridian Duals,CPT,A0434,Specialty care transport,Ambulance,Per Case,$231.98 ,OP,231.98,"6,100.31",,,,,,
Meridian Duals,CPT,A0435,Fixed wing air mileage,Ambulance,Per Unit,$8.93 ,OP,8.93,8.93,,,,,,
Meridian Duals,CPT,A0436,Rotary wing air mileage,Ambulance,Per Unit,$23.83 ,OP,23.83,23.83,,,,,,
Meridian Duals,CPT,A4563,Vag inser rectal control sys,Durable Medical Equipment,Per Unit,"$1,372.71 ",OP,"1,372.71","1,372.71",,,,,,
Meridian Duals,CPT,A9513,Lutetium lu 177 dotatat ther,APC 9067,Per Unit,$274.33 ,OP,274.33,274.33,,,,,,
Meridian Duals,CPT,A9517,I131 iodide cap- rx,APC 1064,Per Unit,$20.12 ,OP,20.12,32.18,,,,,,
Meridian Duals,CPT,A9527,Iodine i-125 sodium iodide,APC 2632,Per Unit,$30.66 ,OP,30.66,30.66,,,,,,
Meridian Duals,CPT,A9530,I131 iodide sol- rx,APC 1150,Per Unit,$13.34 ,OP,13.34,13.34,,,,,,
Meridian Duals,CPT,A9543,Y90 ibritumomab- rx,APC 1643,Per Unit,"$59,793.85 ",OP,"59,793.85","59,793.85",,,,,,
Meridian Duals,CPT,A9563,P32 na phosphate,APC 1675,Per Unit,$458.34 ,OP,458.34,458.34,,,,,,
Meridian Duals,CPT,A9590,Iodine i-131 iobenguane 1mci,APC 9339,Per Unit,$320.12 ,OP,320.12,320.12,,,,,,
Meridian Duals,CPT,A9591,Fluoroestradiol f 18,APC 9370,Per Unit,$644.83 ,OP,644.83,644.83,,,,,,
Meridian Duals,CPT,A9592,Copper cu 64 dotatate diag,APC 9383,Per Unit,$918.21 ,OP,918.21,918.21,,,,,,
Meridian Duals,CPT,A9593,Gallium ga-68 psma-11 ucsf,APC 9409,Per Unit,$732.86 ,OP,732.86,732.86,,,,,,
Meridian Duals,CPT,A9594,Gallium ga-68 psma-11- ucla,APC 9410,Per Unit,$717.55 ,OP,717.55,717.55,,,,,,
Meridian Duals,CPT,A9600,Sr89 strontium,APC 0701,Per Unit,"$3,975.00 ",OP,"3,975.00","4,407.46",,,,,,
Meridian Duals,CPT,A9604,Sm 153 lexidronam,APC 1295,Per Unit,"$17,259.85 ",OP,"17,259.85","17,259.85",,,,,,
Meridian Duals,CPT,A9606,Radium ra223 dichloride ther,APC 1745,Per Unit,$145.65 ,OP,145.65,145.65,,,,,,
Meridian Duals,CPT,C1052,Hemostatic agent- gi- topic,APC 2031,Straight Discount,29.70%,OP,,,,,,,,
Meridian Duals,CPT,C1062,Intravertebral fx aug impl,APC 2032,Straight Discount,29.70%,OP,,,,,,,,
Meridian Duals,CPT,C1716,Brachytx- non-str- gold-198,APC 2645,Per Unit,$330.76 ,OP,330.76,330.76,,,,,,
Meridian Duals,CPT,C1717,Brachytx- non-str-hdr ir-192,APC 2646,Per Unit,$383.90 ,OP,383.9,383.9,,,,,,
Meridian Duals,CPT,C1719,Brachytx- ns- non-hdrir-192,APC 2647,Per Unit,$323.97 ,OP,323.97,323.97,,,,,,
Meridian Duals,CPT,C1734,Orth/devic/drug bn/bn-tis/bn,APC 2026,Straight Discount,29.70%,OP,,,,,,,,
Meridian Duals,CPT,C1748,Endoscope- single- ugi,APC 2029,Straight Discount,29.70%,OP,,,,,,,,
Meridian Duals,CPT,C1761,Cath- trans intra litho/coro,APC 2033,Straight Discount,29.70%,OP,,,,,,,,
Meridian Duals,CPT,C1823,Gen- neuro- trans sen/stim,APC 2993,Straight Discount,29.70%,OP,,,,,,,,
Meridian Duals,CPT,C1824,Generator- ccm- implant,APC 2024,Straight Discount,29.70%,OP,,,,,,,,
Meridian Duals,CPT,C1825,Gen- neuro- carot sinus baro,APC 2030,Straight Discount,29.70%,OP,,,,,,,,
Meridian Duals,CPT,C1831,Personalized interbody cage,APC 2034,Straight Discount,29.70%,OP,,,,,,,,
Meridian Duals,CPT,C1839,Iris prosthesis,APC 2028,Straight Discount,29.70%,OP,,,,,,,,
Meridian Duals,CPT,C1982,Cath- pressure-valve-occlu,APC 2025,Straight Discount,29.70%,OP,,,,,,,,
Meridian Duals,CPT,C2596,Probe- robotic- water-jet,APC 2027,Straight Discount,29.70%,OP,,,,,,,,
Meridian Duals,CPT,C2616,Brachytx- non-str-yttrium-90,APC 2616,Per Unit,"$19,955.81 ",OP,"19,955.81","19,955.81",,,,,,
Meridian Duals,CPT,C2634,Brachytx- non-str- ha- i-125,APC 2634,Per Unit,$169.87 ,OP,169.87,169.87,,,,,,
Meridian Duals,CPT,C2635,Brachytx- non-str- ha- p-103,APC 2635,Per Unit,$52.25 ,OP,52.25,52.25,,,,,,
Meridian Duals,CPT,C2636,Brachy linear- non-str-p-103,APC 2636,Per Unit,$36.02 ,OP,36.02,36.02,,,,,,
Meridian Duals,CPT,C2638,Brachytx- stranded- i-125,APC 2638,Per Unit,$42.90 ,OP,42.9,42.9,,,,,,
Meridian Duals,CPT,C2639,Brachytx- non-stranded-i-125,APC 2639,Per Unit,$39.11 ,OP,39.11,39.11,,,,,,
Meridian Duals,CPT,C2640,Brachytx- stranded- p-103,APC 2640,Per Unit,$100.65 ,OP,100.65,100.65,,,,,,
Meridian Duals,CPT,C2641,Brachytx- non-stranded-p-103,APC 2641,Per Unit,$79.72 ,OP,79.72,79.72,,,,,,
Meridian Duals,CPT,C2642,Brachytx- stranded- c-131,APC 2642,Per Unit,$82.43 ,OP,82.43,82.43,,,,,,
Meridian Duals,CPT,C2643,Brachytx- non-stranded-c-131,APC 2643,Per Unit,$92.16 ,OP,92.16,92.16,,,,,,
Meridian Duals,CPT,C2645,Brachytx planar- p-103,APC 2648,Per Unit,$5.38 ,OP,5.38,5.38,,,,,,
Meridian Duals,CPT,C2698,Brachytx- stranded- nos,APC 2698,Per Unit,$42.90 ,OP,42.9,42.9,,,,,,
Meridian Duals,CPT,C2699,Brachytx- non-stranded- nos,APC 2699,Per Unit,$36.02 ,OP,36.02,36.02,,,,,,
Meridian Duals,CPT,C5271,Low cost skin substitute app,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,536.39,,,,,,
Meridian Duals,CPT,C5273,Low cost skin substitute app,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","1,755.36",,,,,,
Meridian Duals,CPT,C5275,Low cost skin substitute app,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,536.39,,,,,,
Meridian Duals,CPT,C5277,Low cost skin substitute app,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,536.39,,,,,,
Meridian Duals,CPT,C8900,Mra w/cont- abd,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Meridian Duals,CPT,C8901,Mra w/o cont- abd,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Meridian Duals,CPT,C8902,Mra w/o fol w/cont- abd,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Meridian Duals,CPT,C8903,Mri w/cont- breast-  uni,APC 5571,RVU Per Case,$182.72 ,OP,182.72,"1,507.00",,,,,,
Meridian Duals,CPT,C8905,Mri w/o fol w/cont- brst- un,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Meridian Duals,CPT,C8906,Mri w/cont- breast-  bi,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Meridian Duals,CPT,C8908,Mri w/o fol w/cont- breast-,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Meridian Duals,CPT,C8909,Mra w/cont- chest,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Meridian Duals,CPT,C8910,Mra w/o cont- chest,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Meridian Duals,CPT,C8911,Mra w/o fol w/cont- chest,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Meridian Duals,CPT,C8912,Mra w/cont- lwr ext,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Meridian Duals,CPT,C8913,Mra w/o cont- lwr ext,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Meridian Duals,CPT,C8914,Mra w/o fol w/cont- lwr ext,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Meridian Duals,CPT,C8918,Mra w/cont- pelvis,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Meridian Duals,CPT,C8919,Mra w/o cont- pelvis,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Meridian Duals,CPT,C8920,Mra w/o fol w/cont- pelvis,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Meridian Duals,CPT,C8921,Tte w or w/o fol w/cont- com,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
Meridian Duals,CPT,C8922,Tte w or w/o fol w/cont- f/u,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
Meridian Duals,CPT,C8923,2d tte w or w/o fol w/con-co,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
Meridian Duals,CPT,C8924,2d tte w or w/o fol w/con-fu,APC 5572,RVU Per Unit,$376.70 ,OP,376.7,376.7,,,,,,
Meridian Duals,CPT,C8925,2d tee w or w/o fol w/con-in,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
Meridian Duals,CPT,C8926,Tee w or w/o fol w/cont-cong,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
Meridian Duals,CPT,C8927,Tee w or w/o fol w/cont- mon,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
Meridian Duals,CPT,C8928,Tte w or w/o fol w/con-stres,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
Meridian Duals,CPT,C8929,Tte w or wo fol wcon-doppler,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
Meridian Duals,CPT,C8930,Tte w or w/o contr- cont ecg,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
Meridian Duals,CPT,C8931,Mra- w/dye- spinal canal,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Meridian Duals,CPT,C8932,Mra- w/o dye- spinal canal,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Meridian Duals,CPT,C8933,Mra- w/o&w/dye- spinal canal,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Meridian Duals,CPT,C8934,Mra- w/dye- upper extremity,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Meridian Duals,CPT,C8935,Mra- w/o dye- upper extr,APC 5523,RVU Per Case,$235.49 ,OP,235.49,235.49,,,,,,
Meridian Duals,CPT,C8936,Mra- w/o&w/dye- upper extr,APC 5572,RVU Per Case,$376.70 ,OP,376.7,376.7,,,,,,
Meridian Duals,CPT,C8957,Prolonged iv inf- req pump,APC 5694,RVU Per Unit,$318.00 ,OP,318,318,,,,,,
Meridian Duals,CPT,C9046,Cocaine hcl nasal solution,APC 9307,Per Unit,$1.33 ,OP,1.33,1.33,,,,,,
Meridian Duals,CPT,C9047,Injection- caplacizumab-yhdp,APC 9199,Per Unit,$691.29 ,OP,691.29,691.29,,,,,,
Meridian Duals,CPT,C9067,Gallium ga-68 dotatoc,APC 9323,Per Unit,$8.64 ,OP,8.64,8.64,,,,,,
Meridian Duals,CPT,C9081,Idecabtagene car pos t,APC 9422,Per Unit,"$432,085.00 ",OP,"432,085.00","432,085.00",,,,,,
Meridian Duals,CPT,C9082,Inj dostarlimab-gxly- 100 mg,APC 9423,Per Unit,"$2,136.09 ",OP,"2,136.09","2,136.09",,,,,,
Meridian Duals,CPT,C9083,Inj- amivantamab-vmjw- 10 mg,APC 9424,Per Unit,$87.89 ,OP,87.89,87.89,,,,,,
Meridian Duals,CPT,C9084,loncastuximab-lpyl- 0.1 mg,APC 9425,Per Unit,$242.05 ,OP,242.05,242.05,,,,,,
Meridian Duals,CPT,C9248,Inj- clevidipine butyrate,APC 9087,Per Unit,$2.91 ,OP,2.91,2.91,,,,,,
Meridian Duals,CPT,C9250,Artiss fibrin sealant,APC 1848,Per Unit,$156.84 ,OP,156.84,156.84,,,,,,
Meridian Duals,CPT,C9257,Bevacizumab injection,APC 1281,Per Unit,$1.76 ,OP,1.76,1.76,,,,,,
Meridian Duals,CPT,C9460,Injection- cangrelor,APC 9460,Per Unit,$16.32 ,OP,16.32,16.32,,,,,,
Meridian Duals,CPT,C9462,Injection- delafloxacin,APC 9462,Per Unit,$0.37 ,OP,0.37,0.37,,,,,,
Meridian Duals,CPT,C9482,Sotalol hydrochloride iv,APC 9482,Per Unit,$17.58 ,OP,17.58,17.58,,,,,,
Meridian Duals,CPT,C9488,Conivaptan hcl,APC 9488,Per Unit,$43.94 ,OP,43.94,43.94,,,,,,
Meridian Duals,CPT,C9600,Perc drug-el cor stent sing,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Meridian Duals,CPT,C9602,Perc d-e cor stent ather s,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Meridian Duals,CPT,C9604,Perc d-e cor revasc t cabg s,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Meridian Duals,CPT,C9606,Perc d-e cor revasc w ami s,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Meridian Duals,CPT,C9607,Perc d-e cor revasc chro sin,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Meridian Duals,CPT,C9725,Place endorectal app,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,812.16,,,,,,
Meridian Duals,CPT,C9727,Insert palate implants,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","1,384.33",,,,,,
Meridian Duals,CPT,C9728,Place device/marker- non pro,APC 5613,RVU Per Unit,"$1,291.62 ",OP,"1,291.62","1,291.62",,,,,,
Meridian Duals,CPT,C9733,Non-ophthalmic fva,APC 5572,RVU Per Case,$376.70 ,OP,376.7,376.7,,,,,,
Meridian Duals,CPT,C9734,U/s trtmt- not leiomyomata,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
Meridian Duals,CPT,C9739,Cystoscopy prostatic imp 1-3,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,516.83","4,516.83",,,,,,
Meridian Duals,CPT,C9740,Cysto impl 4 or more,APC 5376,RVU Per Case,"$8,450.70 ",OP,"8,450.70","8,450.70",,,,,,
Meridian Duals,CPT,C9752,Intraosseous des lumb/sacrum,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
Meridian Duals,CPT,C9757,Spine/lumbar disk surgery,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
Meridian Duals,CPT,C9761,Cysto- litho- vacuum kidney,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,516.83","4,516.83",,,,,,
Meridian Duals,CPT,C9762,Cardiac mri seg dys strain,APC 5524,RVU Per Case,$494.15 ,OP,494.15,494.15,,,,,,
Meridian Duals,CPT,C9763,Cardiac mri seg dys stress,APC 5524,RVU Per Case,$494.15 ,OP,494.15,494.15,,,,,,
Meridian Duals,CPT,C9764,Revasc intravasc lithotripsy,APC 5192,RVU Per Case,"$5,072.43 ",OP,"5,072.43","5,072.43",,,,,,
Meridian Duals,CPT,C9765,Revasc intra lithotrip-stent,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Meridian Duals,CPT,C9766,Revasc intra lithotrip-ather,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Meridian Duals,CPT,C9767,Revasc lithotrip-stent-ather,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Meridian Duals,CPT,C9769,Cysto w/temp pros implant,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,516.83","4,516.83",,,,,,
Meridian Duals,CPT,C9771,Nsl/sins cryo post nasal tis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","2,800.20",,,,,,
Meridian Duals,CPT,C9772,Revasc lithotrip tibi/perone,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Meridian Duals,CPT,C9773,Revasc lithotr-stent tib/per,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Meridian Duals,CPT,C9774,Revasc lithotr-ather tib/per,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Meridian Duals,CPT,C9775,Revasc lith-sten-ath tib/per,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Meridian Duals,CPT,C9778,Colpopexy- min/inv- ex-perit,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","2,684.38",,,,,,
Meridian Duals,CPT,C9779,ESD endoscopy or colonoscopy,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","2,500.37",,,,,,
Meridian Duals,CPT,C9780,Insert cv cath inf & sup app,APC 1534,RVU Per Unit,"$8,442.89 ",OP,"7,883.19","8,442.89",,,,,,
Meridian Duals,CPT,C9803,Hopd covid-19 spec collect,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Meridian Duals,CPT,D0150,Comprehensve oral evaluation,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D0240,Intraoral occlusal film,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D0250,Extraoral 2d project image,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D0251,Extraoral posterior image,APC 5521,RVU Per Case,$82.79 ,OP,82.79,82.79,,,,,,
Meridian Duals,CPT,D0270,Dental bitewing single image,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D0272,Dental bitewings two images,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D0274,Bitewings four images,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D0277,Vert bitewings 7 to 8 images,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D0460,Pulp vitality test,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D0600,Non-ionizing diag proc,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D1510,Space maintainer fxd unilat,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D1516,Fixed bilat space maint- max,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D1517,Fixed bilat space maint- man,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D1520,Remove unilat space maintain,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D1526,Remove bilat space main- max,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D1527,Remove bilat space main- man,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D1551,Recement space maint - max,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D1552,Recement space maint - man,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D1553,Recement unilat space maint,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D1575,Dist space maint- fixed unil,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D2999,Dental unspec restorative pr,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D3460,Endodontic endosseous implan,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D3999,Endodontic procedure,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D4260,Osseous surgery 4 or more,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D4263,Bone replce graft first site,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D4264,Bone replce graft each add,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D4268,Surgical revision procedure,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D4270,Pedicle soft tissue graft pr,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D4273,Auto tissue graft 1st tooth,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D4355,Full mouth debridement,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D4381,Localized delivery antimicro,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D5911,Facial moulage sectional,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D5912,Facial moulage complete,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D5983,Radiation applicator,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D5984,Radiation shield,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D5985,Radiation cone locator,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D5987,Commissure splint,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D6920,Dental connector bar,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D7111,Extraction coronal remnants,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D7140,Extraction erupted tooth/exr,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D7210,Rem imp tooth w mucoper flp,APC 5871,RVU Per Unit,"$1,426.03 ",OP,953.17,"1,426.03",,,,,,
Meridian Duals,CPT,D7220,Impact tooth remov soft tiss,APC 5871,RVU Per Unit,"$1,426.03 ",OP,953.17,"1,426.03",,,,,,
Meridian Duals,CPT,D7230,Impact tooth remov part bony,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,391.64","1,426.03",,,,,,
Meridian Duals,CPT,D7240,Impact tooth remov comp bony,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,715.71",,,,,,
Meridian Duals,CPT,D7241,Impact tooth rem bony w/comp,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","2,001.67",,,,,,
Meridian Duals,CPT,D7250,Tooth root removal,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D7260,Oral antral fistula closure,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D7261,Primary closure sinus perf,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D7291,Transseptal fiberotomy,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D7940,Reshaping bone orthognathic,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D9930,Treatment of complications,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D9944,Occ guard- hard- full arch,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D9945,Occ guard- soft- full arch,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D9946,Occ guard- hard- part arch,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D9950,Occlusion analysis,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D9951,Limited occlusal adjustment,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,D9952,Complete occlusal adjustment,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Meridian Duals,CPT,G0008,Admin influenza virus vac,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,57.19,,,,,,
Meridian Duals,CPT,G0009,Admin pneumococcal vaccine,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,57.19,,,,,,
Meridian Duals,CPT,G0010,Admin hepatitis b vaccine,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,57.19,,,,,,
Meridian Duals,CPT,G0027,Semen analysis,Lab Services,Per Unit,$6.50 ,OP,6.5,34.31,,,,,,
Meridian Duals,CPT,G0101,Ca screen-pelvic/breast exam,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,186.82,,,,,,
Meridian Duals,CPT,G0103,Psa screening,Lab Services,Per Unit,$19.31 ,OP,19.31,80.07,,,,,,
Meridian Duals,CPT,G0104,Ca screen-flexi sigmoidscope,APC 5311,RVU Per Unit,$812.16 ,OP,678.66,812.16,,,,,,
Meridian Duals,CPT,G0105,Colorectal scrn- hi risk ind,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,812.16,,,,,,
Meridian Duals,CPT,G0106,Colon ca screen-barium enema,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,"1,090.43",,,,,,
Meridian Duals,CPT,G0108,Diab manage trn  per indiv,Physician,Per Unit,$54.47 ,OP,54.47,125.82,,,,,,
Meridian Duals,CPT,G0109,Diab manage trn ind/group,Physician,Per Unit,$15.18 ,OP,15.18,72.44,,,,,,
Meridian Duals,CPT,G0117,Glaucoma scrn hgh risk direc,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,232.58,,,,,,
Meridian Duals,CPT,G0118,Glaucoma scrn hgh risk direc,APC 5732,RVU Per Unit,$34.63 ,OP,34.63,160.13,,,,,,
Meridian Duals,CPT,G0120,Colon ca scrn- barium enema,APC 5572,RVU Per Unit,$376.70 ,OP,376.7,"1,090.43",,,,,,
Meridian Duals,CPT,G0121,Colon ca scrn not hi rsk ind,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,812.16,,,,,,
Meridian Duals,CPT,G0123,Screen cerv/vag thin layer,Lab Services,Per Unit,$20.26 ,OP,20.26,91.51,,,,,,
Meridian Duals,CPT,G0127,Trim nail(s),APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Meridian Duals,CPT,G0129,Partial hosp prog service,APC 5853,RVU Per Case,$266.56 ,OP,266.56,266.56,,,,,,
Meridian Duals,CPT,G0130,Single energy x-ray study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,171.58,,,,,,
Meridian Duals,CPT,G0143,Scr c/v cyto-thinlayer-rescr,Lab Services,Per Unit,$27.05 ,OP,27.05,91.51,,,,,,
Meridian Duals,CPT,G0144,Scr c/v cyto-thinlayer-rescr,Lab Services,Per Unit,$43.97 ,OP,43.97,95.32,,,,,,
Meridian Duals,CPT,G0145,Scr c/v cyto-thinlayer-rescr,Lab Services,Per Unit,$26.49 ,OP,26.49,118.19,,,,,,
Meridian Duals,CPT,G0147,Scr c/v cyto- automated sys,Lab Services,Per Unit,$15.15 ,OP,15.15,45.74,,,,,,
Meridian Duals,CPT,G0148,Scr c/v cyto- autosys- rescr,Lab Services,Per Unit,$31.94 ,OP,31.94,45.74,,,,,,
Meridian Duals,CPT,G0166,Extrnl counterpulse- per tx,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Meridian Duals,CPT,G0175,Opps service-sched team conf,APC 5024,RVU Per Unit,$372.22 ,OP,372.22,392.7,,,,,,
Meridian Duals,CPT,G0176,Opps/php-activity therapy,APC 5853,RVU Per Case,$266.56 ,OP,266.56,266.56,,,,,,
Meridian Duals,CPT,G0186,Dstry eye lesn-fdr vssl tech,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,515.61,,,,,,
Meridian Duals,CPT,G0235,Pet not otherwise specified,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"7,236.50",,,,,,
Meridian Duals,CPT,G0237,Therapeutic procd strg endur,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,61,,,,,,
Meridian Duals,CPT,G0238,Oth resp proc- indiv,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,64.82,,,,,,
Meridian Duals,CPT,G0239,Oth resp proc- group,APC 5732,RVU Per Unit,$34.63 ,OP,34.63,64.82,,,,,,
Meridian Duals,CPT,G0245,Initial foot exam pt lops,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,339.33,,,,,,
Meridian Duals,CPT,G0246,Followup eval of foot pt lop,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,198.25,,,,,,
Meridian Duals,CPT,G0247,Routine footcare pt w lops,APC 5051,RVU Per Case,$183.73 ,OP,183.73,232.58,,,,,,
Meridian Duals,CPT,G0248,Demonstrate use home inr mon,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,804.48,,,,,,
Meridian Duals,CPT,G0249,Provide inr test mater/equip,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,686.28,,,,,,
Meridian Duals,CPT,G0257,Unsched dialysis esrd pt hos,APC 5401,RVU Per Unit,$669.60 ,OP,669.6,669.6,,,,,,
Meridian Duals,CPT,G0260,Inj for sacroiliac jt anesth,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,649.39,,,,,,
Meridian Duals,CPT,G0270,Mnt subs tx for change dx,Physician,Per Unit,$26.49 ,OP,26.49,122,,,,,,
Meridian Duals,CPT,G0271,Group mnt 2 or more 30 mins,Physician,Per Unit,$13.98 ,OP,13.98,68.63,,,,,,
Meridian Duals,CPT,G0276,Pild/placebo control clin tr,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
Meridian Duals,CPT,G0277,Hbot- full body chamber- 30m,APC 5061,RVU Per Unit,$122.06 ,OP,122.06,122.06,,,,,,
Meridian Duals,CPT,G0279,Tomosynthesis- mammo,Physician,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Meridian Duals,CPT,G0281,Elec stim unattend for press,Physician,Per Unit,$12.74 ,OP,12.74,61,,,,,,
Meridian Duals,CPT,G0283,Elec stim other than wound,Physician,Per Unit,$12.74 ,OP,12.74,61,,,,,,
Meridian Duals,CPT,G0293,Non-cov surg proc-clin trial,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Meridian Duals,CPT,G0294,Non-cov proc- clinical trial,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Meridian Duals,CPT,G0296,Visit to determ ldct elig,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Meridian Duals,CPT,G0302,Pre-op service lvrs complete,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Meridian Duals,CPT,G0303,Pre-op service lvrs 10-15dos,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Meridian Duals,CPT,G0304,Pre-op service lvrs 1-9 dos,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Meridian Duals,CPT,G0305,Post op service lvrs min 6,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Meridian Duals,CPT,G0306,Cbc/diffwbc w/o platelet,Lab Services,Per Unit,$7.77 ,OP,7.77,34.31,,,,,,
Meridian Duals,CPT,G0307,Cbc without platelet,Lab Services,Per Unit,$6.47 ,OP,6.47,30.51,,,,,,
Meridian Duals,CPT,G0328,Fecal blood scrn immunoassay,Lab Services,Per Unit,$18.05 ,OP,18.05,72.44,,,,,,
Meridian Duals,CPT,G0329,Electromagntic tx for ulcers,Physician,Per Unit,$10.46 ,OP,10.46,45.74,,,,,,
Meridian Duals,CPT,G0341,Percutaneous islet celltrans,APC 5881,RVU Per Case,"$8,948.83 ",OP,"2,508.76","8,948.83",,,,,,
Meridian Duals,CPT,G0342,Laparoscopy islet cell trans,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,254.96","8,948.83",,,,,,
Meridian Duals,CPT,G0343,Laparotomy islet cell transp,APC 5881,RVU Per Case,"$8,948.83 ",OP,"6,965.79","8,948.83",,,,,,
Meridian Duals,CPT,G0379,Direct refer hospital observ,APC 5025,RVU Per Case,$534.29 ,OP,534.29,534.29,,,,,,
Meridian Duals,CPT,G0380,Lev 1 hosp type b ed visit,APC 5031,RVU Per Case,$72.19 ,OP,72.19,72.19,,,,,,
Meridian Duals,CPT,G0381,Lev 2 hosp type b ed visit,APC 5032,RVU Per Case,$97.63 ,OP,97.63,97.63,,,,,,
Meridian Duals,CPT,G0382,Lev 3 hosp type b ed visit,APC 5033,RVU Per Case,$185.19 ,OP,185.19,185.19,,,,,,
Meridian Duals,CPT,G0383,Lev 4 hosp type b ed visit,APC 5034,RVU Per Case,$233.92 ,OP,233.92,233.92,,,,,,
Meridian Duals,CPT,G0384,Lev 5 hosp type b ed visit,APC 5035,RVU Per Case,$325.81 ,OP,325.81,325.81,,,,,,
Meridian Duals,CPT,G0390,Trauma respons w/hosp criti,APC 5045,RVU Per Unit,$964.64 ,OP,964.64,964.64,,,,,,
Meridian Duals,CPT,G0396,Alcohol/subs interv 15-30mn,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,163.95,,,,,,
Meridian Duals,CPT,G0397,Alcohol/subs interv >30 min,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,136.74,,,,,,
Meridian Duals,CPT,G0398,Home sleep test/type 2 porta,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,367.82,,,,,,
Meridian Duals,CPT,G0399,Home sleep test/type 3 porta,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Meridian Duals,CPT,G0400,Home sleep test/type 4 porta,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,367.82,,,,,,
Meridian Duals,CPT,G0402,Initial preventive exam,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,491.83,,,,,,
Meridian Duals,CPT,G0404,Ekg tracing for initial prev,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,25.25,,,,,,
Meridian Duals,CPT,G0410,Grp psych partial hosp 45-50,APC 5853,RVU Per Case,$266.56 ,OP,266.56,266.56,,,,,,
Meridian Duals,CPT,G0411,Inter active grp psych parti,APC 5853,RVU Per Case,$266.56 ,OP,266.56,266.56,,,,,,
Meridian Duals,CPT,G0412,Open tx iliac spine uni/bil,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,510.41","6,411.04",,,,,,
Meridian Duals,CPT,G0413,Pelvic ring fracture uni/bil,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,527.33",,,,,,
Meridian Duals,CPT,G0414,Pelvic ring fx treat int fix,APC 5115,RVU Per Case,"$12,601.93 ",OP,"6,161.31","12,601.93",,,,,,
Meridian Duals,CPT,G0415,Open tx post pelvic fxcture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"8,452.74","12,601.93",,,,,,
Meridian Duals,CPT,G0416,Prostate biopsy- any mthd,APC 5673,RVU Per Case,$298.05 ,OP,298.05,"3,297.99",,,,,,
Meridian Duals,CPT,G0420,Ed svc ckd ind per session,Physician,Per Unit,$111.79 ,OP,111.79,111.79,,,,,,
Meridian Duals,CPT,G0421,Ed svc ckd grp per session,Physician,Per Unit,$26.73 ,OP,26.73,26.73,,,,,,
Meridian Duals,CPT,G0422,Intens cardiac rehab w/exerc,APC 5771,RVU Per Unit,$118.77 ,OP,118.77,118.77,,,,,,
Meridian Duals,CPT,G0423,Intens cardiac rehab no exer,APC 5771,RVU Per Unit,$118.77 ,OP,118.77,118.77,,,,,,
Meridian Duals,CPT,G0424,Pulmonary rehab w exer,APC 5733,RVU Per Unit,$56.95 ,OP,56.95,56.95,,,,,,
Meridian Duals,CPT,G0429,Dermal filler injection(s),APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","1,755.36",,,,,,
Meridian Duals,CPT,G0432,Eia hiv-1/hiv-2 screen,Lab Services,Per Unit,$19.57 ,OP,19.57,19.57,,,,,,
Meridian Duals,CPT,G0433,Elisa hiv-1/hiv-2 screen,Lab Services,Per Unit,$18.29 ,OP,18.29,18.29,,,,,,
Meridian Duals,CPT,G0435,Oral hiv-1/hiv-2 screen,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,
Meridian Duals,CPT,G0438,Ppps- initial visit,Physician,Per Unit,$163.74 ,OP,163.74,163.74,,,,,,
Meridian Duals,CPT,G0439,Ppps- subseq visit,Physician,Per Unit,$129.00 ,OP,129,129,,,,,,
Meridian Duals,CPT,G0442,Annual alcohol screen 15 min,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Meridian Duals,CPT,G0443,Brief alcohol misuse counsel,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Meridian Duals,CPT,G0444,Depression screen annual,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Meridian Duals,CPT,G0445,High inten beh couns std 30m,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Meridian Duals,CPT,G0446,Intens behave ther cardio dx,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Meridian Duals,CPT,G0447,Behavior counsel obesity 15m,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Meridian Duals,CPT,G0451,Devlopment test interpt&rep,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Meridian Duals,CPT,G0455,Fecal microbiota prep instil,APC 5301,RVU Per Case,$828.48 ,OP,828.48,828.48,,,,,,
Meridian Duals,CPT,G0460,Autologous prp for ulcers,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","1,755.36",,,,,,
Meridian Duals,CPT,G0463,Hospital outpt clinic visit,APC 5012,RVU Per Case,$121.51 ,OP,95.32,121.51,,,,,,
Meridian Duals,CPT,G0471,Ven blood coll snf/hha,Lab Services,Per Unit,$5.00 ,OP,5,5,,,,,,
Meridian Duals,CPT,G0472,Hep c screen high risk/other,Lab Services,Per Unit,$46.35 ,OP,46.35,46.35,,,,,,
Meridian Duals,CPT,G0473,Group behave couns 2-10,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Meridian Duals,CPT,G0475,Hiv combination assay,Lab Services,Per Unit,$24.08 ,OP,24.08,24.08,,,,,,
Meridian Duals,CPT,G0476,Hpv combo assay ca screen,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,
Meridian Duals,CPT,G0480,Drug test def 1-7 classes,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
Meridian Duals,CPT,G0481,Drug test def 8-14 classes,Lab Services,Per Unit,$156.59 ,OP,156.59,156.59,,,,,,
Meridian Duals,CPT,G0482,Drug test def 15-21 classes,Lab Services,Per Unit,$198.74 ,OP,198.74,198.74,,,,,,
Meridian Duals,CPT,G0483,Drug test def 22+ classes,Lab Services,Per Unit,$246.92 ,OP,246.92,246.92,,,,,,
Meridian Duals,CPT,G0498,Chemo extend iv infus w/pump,APC 5694,RVU Per Unit,$318.00 ,OP,318,318,,,,,,
Meridian Duals,CPT,G0499,Hepb screen high risk indiv,Lab Services,Per Unit,$28.27 ,OP,28.27,28.27,,,,,,
Meridian Duals,CPT,G0516,Insert drug del implant- >=4,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
Meridian Duals,CPT,G0517,Remove drug implant,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
Meridian Duals,CPT,G0518,Remove w insert drug implant,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
Meridian Duals,CPT,G0659,Drug test def simple all cl,Lab Services,Per Unit,$62.14 ,OP,62.14,62.14,,,,,,
Meridian Duals,CPT,G2000,Blinded conv. tx mdd clin tr,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Meridian Duals,CPT,G2011,Alcohol/sub misuse assess,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,25.25,,,,,,
Meridian Duals,CPT,G2065,Clin mang h risk dx 30,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Meridian Duals,CPT,G2066,Inter devc remote 30d,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Meridian Duals,CPT,G2082,Visit esketamine 56m or less,APC 1508,RVU Per Unit,$665.67 ,OP,621.54,665.67,,,,,,
Meridian Duals,CPT,G2083,Visit esketamine- > 56m,APC 1511,RVU Per Unit,$972.67 ,OP,972.67,972.67,,,,,,
Meridian Duals,CPT,G2086,Off base opioid tx 70min,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,136.74,,,,,,
Meridian Duals,CPT,G2087,Off base opioid tx- 60 m,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,136.74,,,,,,
Meridian Duals,CPT,G2170,Avf by tissue w thermal e,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Meridian Duals,CPT,G2171,Avf use magnetic/art/ven,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Meridian Duals,CPT,G2214,Init/sub psych care m 1st 30,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Meridian Duals,CPT,G2250,Remot img sub by pt- non e/m,Physician,Per Unit,$9.24 ,OP,9.24,9.24,,,,,,
Meridian Duals,CPT,G2251,Brief chkin- 5-10- non-e/m,Physician,Per Unit,$13.05 ,OP,13.05,13.05,,,,,,
Meridian Duals,CPT,G2252,Brief chkin by md/qhp- 11-20,Physician,Per Unit,$25.14 ,OP,25.14,25.14,,,,,,
Meridian Duals,CPT,J0121,Inj.- omadacycline- 1 mg,APC 9311,Per Unit,$3.30 ,OP,3.3,3.3,,,,,,
Meridian Duals,CPT,J0129,Abatacept injection,APC 9230,Per Unit,$45.27 ,OP,45.27,73.44,,,,,,
Meridian Duals,CPT,J0135,Adalimumab injection,APC 1083,Per Unit,"$1,581.57 ",OP,"1,581.57","1,581.57",,,,,,
Meridian Duals,CPT,J0178,Aflibercept injection,APC 1420,Per Unit,$917.94 ,OP,917.94,917.94,,,,,,
Meridian Duals,CPT,J0179,Inj- brolucizumab-dbll- 1 mg,APC 9340,Per Unit,$312.01 ,OP,312.01,312.01,,,,,,
Meridian Duals,CPT,J0180,Agalsidase beta injection,APC 9208,Per Unit,$198.14 ,OP,198.14,508.92,,,,,,
Meridian Duals,CPT,J0185,Inj.- aprepitant- 1 mg,APC 9463,Per Unit,$1.69 ,OP,1.69,1.69,,,,,,
Meridian Duals,CPT,J0202,Injection- alemtuzumab,APC 1809,Per Unit,"$2,086.32 ",OP,277.19,"2,086.32",,,,,,
Meridian Duals,CPT,J0207,Amifostine,APC 7000,Per Unit,"$1,135.69 ",OP,"1,135.69","1,985.16",,,,,,
Meridian Duals,CPT,J0220,Alglucosidase alfa injection,APC 9234,Per Unit,$117.07 ,OP,117.07,474.68,,,,,,
Meridian Duals,CPT,J0221,Lumizyme injection,APC 1413,Per Unit,$180.35 ,OP,180.35,180.35,,,,,,
Meridian Duals,CPT,J0222,Inj.- patisiran- 0.1 mg,APC 9180,Per Unit,$97.75 ,OP,97.75,97.75,,,,,,
Meridian Duals,CPT,J0223,Inj givosiran 0.5 mg,APC 9343,Per Unit,$106.76 ,OP,106.76,106.76,,,,,,
Meridian Duals,CPT,J0224,Inj. lumasiran- 0.5 mg,APC 9407,Per Unit,$302.30 ,OP,302.3,302.3,,,,,,
Meridian Duals,CPT,J0256,Alpha 1 proteinase inhibitor,APC 0901,Per Unit,$4.54 ,OP,4.54,7.9,,,,,,
Meridian Duals,CPT,J0257,Glassia injection,APC 1415,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,
Meridian Duals,CPT,J0287,Amphotericin b lipid complex,APC 9024,Per Unit,$9.50 ,OP,9.5,49.56,,,,,,
Meridian Duals,CPT,J0289,Amphotericin b liposome inj,APC 0736,Per Unit,$28.75 ,OP,28.75,118.19,,,,,,
Meridian Duals,CPT,J0291,Inj.- plazomicin- 5 mg,APC 9183,Per Unit,$3.05 ,OP,3.05,3.05,,,,,,
Meridian Duals,CPT,J0300,Amobarbital 125 mg inj,APC 1341,Per Unit,$125.22 ,OP,30.51,125.22,,,,,,
Meridian Duals,CPT,J0390,Chloroquine injection,APC 9352,Per Unit,$165.22 ,OP,83.87,165.22,,,,,,
Meridian Duals,CPT,J0401,Inj aripiprazole ext rel 1mg,APC 1468,Per Unit,$6.01 ,OP,6.01,7.62,,,,,,
Meridian Duals,CPT,J0475,Baclofen 10 mg injection,APC 9032,Per Unit,$177.43 ,OP,177.43,826.29,,,,,,
Meridian Duals,CPT,J0480,Basiliximab,APC 1683,Per Unit,"$4,013.08 ",OP,"4,013.08","7,724.52",,,,,,
Meridian Duals,CPT,J0485,Belatacept injection,APC 9286,Per Unit,$3.80 ,OP,3.8,3.8,,,,,,
Meridian Duals,CPT,J0490,Belimumab injection,APC 1353,Per Unit,$47.57 ,OP,47.57,47.57,,,,,,
Meridian Duals,CPT,J0517,Inj.- benralizumab- 1 mg,APC 9466,Per Unit,$170.80 ,OP,170.8,170.8,,,,,,
Meridian Duals,CPT,J0558,Peng benzathine/procaine inj,APC 9088,Per Unit,$11.79 ,OP,11.79,11.79,,,,,,
Meridian Duals,CPT,J0561,Penicillin g benzathine inj,APC 1829,Per Unit,$14.95 ,OP,14.95,14.95,,,,,,
Meridian Duals,CPT,J0565,Inj- bezlotoxumab- 10 mg,APC 9490,Per Unit,$39.77 ,OP,39.77,39.77,,,,,,
Meridian Duals,CPT,J0570,Buprenorphine implant 74.2mg,APC 9058,Per Unit,"$1,311.75 ",OP,209.7,"1,311.75",,,,,,
Meridian Duals,CPT,J0584,Injection- burosumab-twza 1m,APC 9187,Per Unit,$369.11 ,OP,369.11,369.11,,,,,,
Meridian Duals,CPT,J0585,Injection-onabotulinumtoxina,APC 0902,Per Unit,$6.09 ,OP,6.09,6.09,,,,,,
Meridian Duals,CPT,J0586,Abobotulinumtoxina,APC 1289,Per Unit,$8.41 ,OP,8.41,8.41,,,,,,
Meridian Duals,CPT,J0587,Inj- rimabotulinumtoxinb,APC 9018,Per Unit,$12.05 ,OP,12.05,39.5,,,,,,
Meridian Duals,CPT,J0588,Incobotulinumtoxin a,APC 9278,Per Unit,$5.05 ,OP,5.05,5.05,,,,,,
Meridian Duals,CPT,J0594,Busulfan injection,APC 1178,Per Unit,$1.71 ,OP,1.71,61,,,,,,
Meridian Duals,CPT,J0596,Injection- ruconest,APC 9445,Per Unit,$29.97 ,OP,29.97,29.97,,,,,,
Meridian Duals,CPT,J0597,C-1 esterase- berinert,APC 9269,Per Unit,$57.39 ,OP,57.39,57.39,,,,,,
Meridian Duals,CPT,J0598,C-1 esterase- cinryze,APC 9251,Per Unit,$58.93 ,OP,58.93,58.93,,,,,,
Meridian Duals,CPT,J0599,Inj.- haegarda 10 units,APC 9015,Per Unit,$10.25 ,OP,10.25,10.25,,,,,,
Meridian Duals,CPT,J0600,Edetate calcium disodium inj,APC 1274,Per Unit,"$5,708.59 ",OP,362.21,"5,708.59",,,,,,
Meridian Duals,CPT,J0630,Calcitonin salmon injection,APC 1433,Per Unit,"$3,100.79 ",OP,191.13,"3,100.79",,,,,,
Meridian Duals,CPT,J0638,Canakinumab injection,APC 1311,Per Unit,$115.61 ,OP,115.61,115.61,,,,,,
Meridian Duals,CPT,J0641,Inj levoleucovorin nos 0.5mg,APC 1236,Per Unit,$0.09 ,OP,0.09,0.09,,,,,,
Meridian Duals,CPT,J0642,Injection- khapzory- 0.5 mg,APC 9334,Per Unit,$1.86 ,OP,1.86,1.86,,,,,,
Meridian Duals,CPT,J0691,Inj lefamulin 1 mg,APC 9332,Per Unit,$0.72 ,OP,0.72,0.72,,,,,,
Meridian Duals,CPT,J0695,Inj ceftolozane tazobactam,APC 9452,Per Unit,$6.64 ,OP,6.64,6.64,,,,,,
Meridian Duals,CPT,J0699,Inj- cefiderocol- 10 mg,APC 9426,Per Unit,$2.01 ,OP,2.01,2.01,,,,,,
Meridian Duals,CPT,J0712,Ceftaroline fosamil inj,APC 1824,Per Unit,$3.51 ,OP,3.51,3.51,,,,,,
Meridian Duals,CPT,J0714,Ceftazidime and avibactam,APC 1825,Per Unit,$92.39 ,OP,92.39,92.39,,,,,,
Meridian Duals,CPT,J0716,Centruroides immune f(ab),APC 1431,Per Unit,"$5,190.15 ",OP,"5,190.15","5,190.15",,,,,,
Meridian Duals,CPT,J0717,Certolizumab pegol inj 1mg,APC 1474,Per Unit,$6.27 ,OP,6.27,6.27,,,,,,
Meridian Duals,CPT,J0740,Cidofovir injection,APC 9033,Per Unit,$563.76 ,OP,563.76,"3,694.50",,,,,,
Meridian Duals,CPT,J0741,Inj- cabote rilpivir 2mg 3mg,APC 9414,Per Unit,$20.56 ,OP,20.56,20.56,,,,,,
Meridian Duals,CPT,J0742,Inj imip 4 cilas 4 releb 2mg,APC 9362,Per Unit,$2.32 ,OP,2.32,2.32,,,,,,
Meridian Duals,CPT,J0745,Inj codeine phosphate /30 mg,APC 9393,Per Unit,$135.64 ,OP,7.62,135.64,,,,,,
Meridian Duals,CPT,J0775,Collagenase- clost hist inj,APC 1340,Per Unit,$56.66 ,OP,56.66,56.66,,,,,,
Meridian Duals,CPT,J0791,Inj crizanlizumab-tmca 5mg,APC 9359,Per Unit,$123.29 ,OP,123.29,123.29,,,,,,
Meridian Duals,CPT,J0795,Corticorelin ovine triflutal,APC 1684,Per Unit,$9.67 ,OP,9.67,22.88,,,,,,
Meridian Duals,CPT,J0840,Crotalidae poly immune fab,APC 9274,Per Unit,"$2,743.36 ",OP,"2,743.36","2,743.36",,,,,,
Meridian Duals,CPT,J0841,Inj crotalidae im f(ab)2 eq,APC 9188,Per Unit,"$1,189.81 ",OP,"1,189.81","1,189.81",,,,,,
Meridian Duals,CPT,J0850,Cytomegalovirus imm iv /vial,APC 0903,Per Unit,"$1,538.70 ",OP,"1,538.70","4,266.40",,,,,,
Meridian Duals,CPT,J0875,Injection- dalbavancin,APC 1823,Per Unit,$15.89 ,OP,15.89,15.89,,,,,,
Meridian Duals,CPT,J0881,Darbepoetin alfa- non-esrd,APC 1685,Per Unit,$3.15 ,OP,3.15,15.26,,,,,,
Meridian Duals,CPT,J0882,Darbepoetin alfa- esrd use,APC 1482,Per Unit,$3.15 ,OP,3.15,15.26,,,,,,
Meridian Duals,CPT,J0883,Argatroban nonesrd use 1mg,APC 1859,Per Unit,$1.20 ,OP,1.2,1.2,,,,,,
Meridian Duals,CPT,J0884,Argatroban esrd dialysis 1mg,APC 9065,Per Unit,$1.20 ,OP,1.2,1.2,,,,,,
Meridian Duals,CPT,J0885,Epoetin alfa- non-esrd,APC 1686,Per Unit,$8.15 ,OP,8.15,45.74,,,,,,
Meridian Duals,CPT,J0888,Epoetin beta non esrd,APC 9077,Per Unit,$1.51 ,OP,1.51,1.51,,,,,,
Meridian Duals,CPT,J0894,Decitabine injection,APC 9231,Per Unit,$3.45 ,OP,3.45,3.45,,,,,,
Meridian Duals,CPT,J0896,Inj luspatercept-aamt 0.25mg,APC 9347,Per Unit,$36.85 ,OP,36.85,36.85,,,,,,
Meridian Duals,CPT,J0897,Denosumab injection,APC 9272,Per Unit,$21.19 ,OP,21.19,21.19,,,,,,
Meridian Duals,CPT,J1095,Injection- dexamethasone 9%,APC 9172,Per Unit,$1.04 ,OP,1.04,1.04,,,,,,
Meridian Duals,CPT,J1096,Dexametha opth insert 0.1 mg,APC 9308,Per Unit,$133.30 ,OP,133.3,133.3,,,,,,
Meridian Duals,CPT,J1162,Digoxin immune fab (ovine),APC 1687,Per Unit,"$4,128.19 ",OP,"2,344.81","4,128.19",,,,,,
Meridian Duals,CPT,J1190,Dexrazoxane hcl injection,APC 0726,Per Unit,$192.33 ,OP,192.33,"1,849.16",,,,,,
Meridian Duals,CPT,J1201,Inj. cetirizine hcl 0.5mg,APC 9361,Per Unit,$15.38 ,OP,15.38,15.38,,,,,,
Meridian Duals,CPT,J1212,Dimethyl sulfoxide 50% 50 ml,APC 1832,Per Unit,$637.11 ,OP,339.33,637.11,,,,,,
Meridian Duals,CPT,J1290,Ecallantide injection,APC 9263,Per Unit,$503.88 ,OP,503.88,503.88,,,,,,
Meridian Duals,CPT,J1300,Eculizumab injection,APC 9236,Per Unit,$229.23 ,OP,229.23,679.45,,,,,,
Meridian Duals,CPT,J1301,Injection- edaravone- 1 mg,APC 9493,Per Unit,$20.51 ,OP,20.51,20.51,,,,,,
Meridian Duals,CPT,J1303,Inj.- ravulizumab-cwvz 10 mg,APC 9312,Per Unit,$224.68 ,OP,224.68,224.68,,,,,,
Meridian Duals,CPT,J1305,Inj- evinacumab-dgnb- 5mg,APC 9416,Per Unit,$165.63 ,OP,165.63,165.63,,,,,,
Meridian Duals,CPT,J1322,Elosulfase alfa- injection,APC 1480,Per Unit,$250.33 ,OP,250.33,250.33,,,,,,
Meridian Duals,CPT,J1364,Erythro lactobionate /500 mg,APC 1669,Per Unit,$77.75 ,OP,38.13,77.75,,,,,,
Meridian Duals,CPT,J1410,Inj estrogen conjugate 25 mg,APC 9038,Per Unit,$341.46 ,OP,341.46,381.27,,,,,,
Meridian Duals,CPT,J1426,Injection- casimersen- 10 mg,APC 9412,Per Unit,$166.47 ,OP,166.47,166.47,,,,,,
Meridian Duals,CPT,J1427,Inj. viltolarsen,APC 9386,Per Unit,$59.05 ,OP,59.05,59.05,,,,,,
Meridian Duals,CPT,J1429,Inj golodirsen 10 mg,APC 9356,Per Unit,$166.21 ,OP,166.21,166.21,,,,,,
Meridian Duals,CPT,J1430,Ethanolamine oleate 100 mg,APC 1688,Per Unit,$444.10 ,OP,444.1,728.23,,,,,,
Meridian Duals,CPT,J1437,Inj. fe derisomaltose 10 mg,APC 9388,Per Unit,$24.87 ,OP,24.87,24.87,,,,,,
Meridian Duals,CPT,J1438,Etanercept injection,APC 1608,Per Unit,$790.78 ,OP,714.31,790.78,,,,,,
Meridian Duals,CPT,J1439,Inj ferric carboxymaltos 1mg,APC 9441,Per Unit,$1.12 ,OP,1.12,1.12,,,,,,
Meridian Duals,CPT,J1442,Inj filgrastim excl biosimil,APC 1469,Per Unit,$0.97 ,OP,0.97,3.09,,,,,,
Meridian Duals,CPT,J1447,Inj tbo filgrastim 1 microg,APC 1748,Per Unit,$0.46 ,OP,0.46,3.1,,,,,,
Meridian Duals,CPT,J1448,Injection- trilaciclib- 1mg,APC 9415,Per Unit,$4.97 ,OP,4.97,4.97,,,,,,
Meridian Duals,CPT,J1451,Fomepizole- 15 mg,APC 1689,Per Unit,$5.98 ,OP,5.98,49.56,,,,,,
Meridian Duals,CPT,J1453,Fosaprepitant injection,APC 9242,Per Unit,$0.24 ,OP,0.24,7.62,,,,,,
Meridian Duals,CPT,J1454,Inj fosnetupitant- palonoset,APC 9099,Per Unit,$571.22 ,OP,571.22,571.22,,,,,,
Meridian Duals,CPT,J1455,Foscarnet sodium injection,APC 1849,Per Unit,$72.86 ,OP,49.56,72.86,,,,,,
Meridian Duals,CPT,J1458,Galsulfase injection,APC 9224,Per Unit,$411.92 ,OP,411.92,"1,289.57",,,,,,
Meridian Duals,CPT,J1459,Inj ivig privigen 500 mg,APC 1214,Per Unit,$44.48 ,OP,44.48,143.18,,,,,,
Meridian Duals,CPT,J1460,Gamma globulin 1 cc inj,APC 1850,Per Unit,$44.13 ,OP,44.13,61,,,,,,
Meridian Duals,CPT,J1554,Inj. asceniv,APC 9392,Per Unit,$481.77 ,OP,481.77,481.77,,,,,,
Meridian Duals,CPT,J1555,Inj cuvitru- 100 mg,APC 9034,Per Unit,$14.50 ,OP,14.5,14.5,,,,,,
Meridian Duals,CPT,J1556,Inj- imm glob bivigam- 500mg,APC 9130,Per Unit,$70.49 ,OP,70.49,70.49,,,,,,
Meridian Duals,CPT,J1557,Gammaplex injection,APC 9270,Per Unit,$48.53 ,OP,48.53,48.53,,,,,,
Meridian Duals,CPT,J1558,Inj. xembify- 100 mg,APC 9372,Per Unit,$13.61 ,OP,13.61,13.61,,,,,,
Meridian Duals,CPT,J1559,Hizentra injection,APC 1312,Per Unit,$11.58 ,OP,11.58,11.58,,,,,,
Meridian Duals,CPT,J1560,Gamma globulin > 10 cc inj,APC 1851,Per Unit,$441.31 ,OP,441.31,621.47,,,,,,
Meridian Duals,CPT,J1561,Gamunex-c/gammaked,APC 0948,Per Unit,$48.22 ,OP,48.22,158.91,,,,,,
Meridian Duals,CPT,J1566,Immune globulin- powder,APC 2731,Per Unit,$65.49 ,OP,65.49,152.51,,,,,,
Meridian Duals,CPT,J1568,Octagam injection,APC 0943,Per Unit,$41.63 ,OP,41.63,41.63,,,,,,
Meridian Duals,CPT,J1569,Gammagard liquid injection,APC 0944,Per Unit,$44.49 ,OP,44.49,171.58,,,,,,
Meridian Duals,CPT,J1571,Hepagam b im injection,APC 0946,Per Unit,$70.94 ,OP,70.94,213.51,,,,,,
Meridian Duals,CPT,J1572,Flebogamma injection,APC 0947,Per Unit,$36.80 ,OP,36.8,171.58,,,,,,
Meridian Duals,CPT,J1573,Hepagam b intravenous- inj,APC 1138,Per Unit,$71.24 ,OP,71.24,213.51,,,,,,
Meridian Duals,CPT,J1575,Hyqvia 100mg immuneglobulin,APC 1826,Per Unit,$15.16 ,OP,15.16,15.16,,,,,,
Meridian Duals,CPT,J1595,Injection glatiramer acetate,APC 1015,Per Unit,$141.29 ,OP,141.29,298.68,,,,,,
Meridian Duals,CPT,J1602,Golimumab for iv use 1mg,APC 1475,Per Unit,$16.82 ,OP,16.82,16.82,,,,,,
Meridian Duals,CPT,J1610,Glucagon hydrochloride/1 mg,APC 9042,Per Unit,$171.74 ,OP,171.74,343.14,,,,,,
Meridian Duals,CPT,J1628,Inj.- guselkumab- 1 mg,APC 9029,Per Unit,$82.56 ,OP,82.56,82.56,,,,,,
Meridian Duals,CPT,J1632,Inj.- brexanolone- 1 mg,APC 9333,Per Unit,$74.65 ,OP,74.65,74.65,,,,,,
Meridian Duals,CPT,J1640,Hemin- 1 mg,APC 1690,Per Unit,$26.64 ,OP,26.64,38.13,,,,,,
Meridian Duals,CPT,J1670,Tetanus immune globulin inj,APC 1670,Per Unit,$441.70 ,OP,441.7,"1,040.87",,,,,,
Meridian Duals,CPT,J1726,Makena- 10 mg,APC 9074,Per Unit,$16.82 ,OP,16.82,16.82,,,,,,
Meridian Duals,CPT,J1729,Inj hydroxyprogst capoat nos,APC 9318,Per Unit,$21.54 ,OP,21.54,21.54,,,,,,
Meridian Duals,CPT,J1738,Inj. meloxicam 1 mg,APC 9371,Per Unit,$3.18 ,OP,3.18,3.18,,,,,,
Meridian Duals,CPT,J1740,Ibandronate sodium injection,APC 9229,Per Unit,$37.09 ,OP,37.09,674.85,,,,,,
Meridian Duals,CPT,J1742,Ibutilide fumarate injection,APC 9044,Per Unit,$205.06 ,OP,205.06,"1,898.73",,,,,,
Meridian Duals,CPT,J1744,Icatibant injection,APC 1443,Per Unit,$204.96 ,OP,204.96,204.96,,,,,,
Meridian Duals,CPT,J1745,Infliximab not biosimil 10mg,APC 7043,Per Unit,$39.53 ,OP,39.53,301.32,,,,,,
Meridian Duals,CPT,J1746,Inj.- ibalizumab-uiyk- 10 mg,APC 9189,Per Unit,$66.39 ,OP,66.39,66.39,,,,,,
Meridian Duals,CPT,J1750,Inj iron dextran,APC 1237,Per Unit,$15.84 ,OP,15.84,15.84,,,,,,
Meridian Duals,CPT,J1786,Imuglucerase injection,APC 1327,Per Unit,$44.05 ,OP,44.05,44.05,,,,,,
Meridian Duals,CPT,J1823,Inj. inebilizumab-cdon- 1 mg,APC 9394,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Meridian Duals,CPT,J1826,Interferon beta-1a inj,APC 1852,Per Unit,"$2,293.85 ",OP,"2,293.85","2,293.85",,,,,,
Meridian Duals,CPT,J1830,Interferon beta-1b / .25 mg,APC 0910,Per Unit,$406.24 ,OP,406.24,538.7,,,,,,
Meridian Duals,CPT,J1833,Injection- isavuconazonium,APC 9456,Per Unit,$0.83 ,OP,0.83,0.83,,,,,,
Meridian Duals,CPT,J1930,Lanreotide injection,APC 9237,Per Unit,$67.64 ,OP,67.64,129.64,,,,,,
Meridian Duals,CPT,J1931,Laronidase injection,APC 9209,Per Unit,$34.75 ,OP,34.75,95.46,,,,,,
Meridian Duals,CPT,J1943,Inj.- aristada initio- 1 mg,APC 9179,Per Unit,$3.05 ,OP,3.05,3.05,,,,,,
Meridian Duals,CPT,J1944,Aripirazole lauroxil 1 mg,APC 9470,Per Unit,$2.99 ,OP,2.99,2.99,,,,,,
Meridian Duals,CPT,J1950,Leuprolide acetate /3.75 mg,APC 0800,Per Unit,"$1,406.37 ",OP,"1,406.37","1,525.07",,,,,,
Meridian Duals,CPT,J1951,Inj fensolvi 0.25 mg,APC 9419,Per Unit,$126.28 ,OP,126.28,126.28,,,,,,
Meridian Duals,CPT,J2182,Injection- mepolizumab- 1mg,APC 9473,Per Unit,$28.29 ,OP,28.29,28.29,,,,,,
Meridian Duals,CPT,J2186,Inj.- meropenem- vaborbactam,APC 9178,Per Unit,$1.76 ,OP,1.76,1.76,,,,,,
Meridian Duals,CPT,J2248,Micafungin sodium injection,APC 9227,Per Unit,$0.97 ,OP,0.97,0.97,,,,,,
Meridian Duals,CPT,J2265,Minocycline hydrochloride,APC 1853,Per Unit,$2.00 ,OP,2,2,,,,,,
Meridian Duals,CPT,J2278,Ziconotide injection,APC 1694,Per Unit,$8.69 ,OP,8.69,30.51,,,,,,
Meridian Duals,CPT,J2315,Naltrexone- depot form,APC 0759,Per Unit,$3.53 ,OP,3.53,3.53,,,,,,
Meridian Duals,CPT,J2323,Natalizumab injection,APC 9126,Per Unit,$23.24 ,OP,23.24,103.45,,,,,,
Meridian Duals,CPT,J2326,Inj- nusinersen- 0.1mg,APC 9489,Per Unit,"$1,122.13 ",OP,"1,122.13","1,122.13",,,,,,
Meridian Duals,CPT,J2350,Injection- ocrelizumab- 1 mg,APC 9494,Per Unit,$58.29 ,OP,58.29,58.29,,,,,,
Meridian Duals,CPT,J2353,Octreotide injection- depot,APC 1207,Per Unit,$205.37 ,OP,205.37,408.99,,,,,,
Meridian Duals,CPT,J2357,Omalizumab injection,APC 9300,Per Unit,$37.67 ,OP,37.67,70.74,,,,,,
Meridian Duals,CPT,J2358,Olanzapine long-acting inj,APC 1331,Per Unit,$2.91 ,OP,2.91,2.91,,,,,,
Meridian Duals,CPT,J2406,Injection- oritavancin 10 mg,APC 9427,Per Unit,$41.92 ,OP,41.92,41.92,,,,,,
Meridian Duals,CPT,J2407,Injection- oritavancin,APC 1660,Per Unit,$23.63 ,OP,23.63,23.63,,,,,,
Meridian Duals,CPT,J2425,Palifermin injection,APC 1696,Per Unit,$23.93 ,OP,23.93,23.93,,,,,,
Meridian Duals,CPT,J2426,Paliperidone palmitate inj,APC 9255,Per Unit,$12.66 ,OP,12.66,12.66,,,,,,
Meridian Duals,CPT,J2502,Inj- pasireotide long acting,APC 9454,Per Unit,$359.03 ,OP,359.03,359.03,,,,,,
Meridian Duals,CPT,J2504,Pegademase bovine- 25 iu,APC 1739,Per Unit,$4.06 ,OP,4.06,"1,098.07",,,,,,
Meridian Duals,CPT,J2505,Injection- pegfilgrastim 6mg,APC 9119,Per Unit,"$2,221.63 ",OP,"2,221.63","10,481.09",,,,,,
Meridian Duals,CPT,J2507,Pegloticase injection,APC 9281,Per Unit,"$2,960.91 ",OP,"2,960.91","2,960.91",,,,,,
Meridian Duals,CPT,J2515,Pentobarbital sodium inj,APC 1854,Per Unit,$26.41 ,OP,26.41,26.41,,,,,,
Meridian Duals,CPT,J2547,Injection- peramivir,APC 9451,Per Unit,$1.68 ,OP,1.68,1.68,,,,,,
Meridian Duals,CPT,J2560,Phenobarbital sodium inj,APC 9069,Per Unit,$40.22 ,OP,40.22,40.22,,,,,,
Meridian Duals,CPT,J2562,Plerixafor injection,APC 9252,Per Unit,$382.85 ,OP,382.85,382.85,,,,,,
Meridian Duals,CPT,J2597,Inj desmopressin acetate,APC 1440,Per Unit,$9.40 ,OP,9.4,9.4,,,,,,
Meridian Duals,CPT,J2724,Protein c concentrate,APC 1139,Per Unit,$15.13 ,OP,15.13,61,,,,,,
Meridian Duals,CPT,J2760,Phentolaine mesylate inj,APC 1458,Per Unit,$416.00 ,OP,255.45,416,,,,,,
Meridian Duals,CPT,J2770,Quinupristin/dalfopristin,APC 2770,Per Unit,$444.67 ,OP,444.67,712.98,,,,,,
Meridian Duals,CPT,J2778,Ranibizumab injection,APC 9233,Per Unit,$318.47 ,OP,318.47,318.47,,,,,,
Meridian Duals,CPT,J2783,Rasburicase,APC 0738,Per Unit,$315.06 ,OP,315.06,804.48,,,,,,
Meridian Duals,CPT,J2786,Injection- reslizumab- 1mg,APC 9481,Per Unit,$10.11 ,OP,10.11,10.11,,,,,,
Meridian Duals,CPT,J2792,Rho(d) immune globulin h- sd,APC 1609,Per Unit,$31.42 ,OP,31.42,80.07,,,,,,
Meridian Duals,CPT,J2794,Inj risperdal consta- 0.5 mg,APC 9125,Per Unit,$11.04 ,OP,11.04,19.71,,,,,,
Meridian Duals,CPT,J2796,Romiplostim injection,APC 9245,Per Unit,$83.47 ,OP,83.47,83.47,,,,,,
Meridian Duals,CPT,J2798,Inj.- perseris- 0.5 mg,APC 9181,Per Unit,$10.69 ,OP,10.69,10.69,,,,,,
Meridian Duals,CPT,J2820,Sargramostim injection,APC 0731,Per Unit,$51.55 ,OP,51.55,122,,,,,,
Meridian Duals,CPT,J2840,Inj sebelipase alfa 1 mg,APC 9478,Per Unit,$539.91 ,OP,539.91,539.91,,,,,,
Meridian Duals,CPT,J2850,Inj secretin synthetic human,APC 1700,Per Unit,$34.78 ,OP,34.78,129.64,,,,,,
Meridian Duals,CPT,J2860,Injection- siltuximab,APC 9455,Per Unit,$124.09 ,OP,124.09,124.09,,,,,,
Meridian Duals,CPT,J2941,Somatropin injection,APC 9319,Per Unit,$36.54 ,OP,36.54,226.93,,,,,,
Meridian Duals,CPT,J2993,Reteplase injection,APC 9005,Per Unit,"$2,506.51 ",OP,"2,506.51","4,712.48",,,,,,
Meridian Duals,CPT,J2997,Alteplase recombinant,APC 7048,Per Unit,$87.75 ,OP,87.75,163.95,,,,,,
Meridian Duals,CPT,J3031,Inj.- fremanezumab-vfrm 1 mg,APC 9197,Per Unit,$2.34 ,OP,2.34,2.34,,,,,,
Meridian Duals,CPT,J3032,Inj. eptinezumab-jjmr 1 mg,APC 9357,Per Unit,$15.64 ,OP,15.64,15.64,,,,,,
Meridian Duals,CPT,J3060,Inj- taliglucerase alfa 10 u,APC 9294,Per Unit,$41.32 ,OP,41.32,41.32,,,,,,
Meridian Duals,CPT,J3090,Inj tedizolid phosphate,APC 1662,Per Unit,$1.60 ,OP,1.6,1.6,,,,,,
Meridian Duals,CPT,J3095,Telavancin injection,APC 9258,Per Unit,$6.16 ,OP,6.16,6.16,,,,,,
Meridian Duals,CPT,J3101,Tenecteplase injection,APC 9002,Per Unit,$134.74 ,OP,134.74,202.07,,,,,,
Meridian Duals,CPT,J3111,Inj. romosozumab-aqqg 1 mg,APC 9327,Per Unit,$9.34 ,OP,9.34,9.34,,,,,,
Meridian Duals,CPT,J3145,Testosterone undecanoate 1mg,APC 9078,Per Unit,$1.63 ,OP,1.63,1.63,,,,,,
Meridian Duals,CPT,J3240,Thyrotropin injection,APC 9108,Per Unit,"$1,837.25 ",OP,"1,837.25","3,617.49",,,,,,
Meridian Duals,CPT,J3241,Inj. teprotumumab-trbw 10 mg,APC 9355,Per Unit,$315.88 ,OP,315.88,315.88,,,,,,
Meridian Duals,CPT,J3243,Tigecycline injection,APC 9228,Per Unit,$1.12 ,OP,1.12,3.82,,,,,,
Meridian Duals,CPT,J3245,Inj.- tildrakizumab- 1 mg,APC 9306,Per Unit,$134.08 ,OP,134.08,134.08,,,,,,
Meridian Duals,CPT,J3246,Tirofiban hcl,APC 7041,Per Unit,$3.83 ,OP,3.83,3.83,,,,,,
Meridian Duals,CPT,J3262,Tocilizumab injection,APC 9264,Per Unit,$5.55 ,OP,5.55,5.55,,,,,,
Meridian Duals,CPT,J3285,Treprostinil injection,APC 1701,Per Unit,$59.68 ,OP,59.68,238.44,,,,,,
Meridian Duals,CPT,J3304,Inj triamcinolone ace xr 1mg,APC 9469,Per Unit,$17.75 ,OP,17.75,17.75,,,,,,
Meridian Duals,CPT,J3315,Triptorelin pamoate,APC 9122,Per Unit,$379.90 ,OP,379.9,379.9,,,,,,
Meridian Duals,CPT,J3316,Inj.- triptorelin xr 3.75 mg,APC 9016,Per Unit,"$3,120.11 ",OP,"3,120.11","3,120.11",,,,,,
Meridian Duals,CPT,J3357,Ustekinumab sub cu inj- 1 mg,APC 9261,Per Unit,$176.65 ,OP,176.65,176.65,,,,,,
Meridian Duals,CPT,J3358,Ustekinumab- iv inject- 1 mg,APC 9487,Per Unit,$11.68 ,OP,11.68,11.68,,,,,,
Meridian Duals,CPT,J3380,Injection- vedolizumab,APC 1489,Per Unit,$21.28 ,OP,21.28,21.28,,,,,,
Meridian Duals,CPT,J3385,Velaglucerase alfa,APC 9271,Per Unit,$359.29 ,OP,359.29,359.29,,,,,,
Meridian Duals,CPT,J3396,Verteporfin injection,APC 1203,Per Unit,$11.25 ,OP,11.25,37.64,,,,,,
Meridian Duals,CPT,J3398,Inj luxturna 1 billion vec g,APC 9070,Per Unit,"$2,953.71 ",OP,"2,953.71","2,953.71",,,,,,
Meridian Duals,CPT,J7168,Prothrombin complex kcentra,APC 9132,Per Unit,$1.99 ,OP,1.99,1.99,,,,,,
Meridian Duals,CPT,J7169,Inj andexxa- 10 mg,APC 9198,Per Unit,$289.93 ,OP,289.93,289.93,,,,,,
Meridian Duals,CPT,J7170,Inj.- emicizumab-kxwh 0.5 mg,APC 9257,Per Unit,$48.88 ,OP,48.88,48.88,,,,,,
Meridian Duals,CPT,J7175,Inj- factor x- (human)- 1iu,APC 1857,Per Unit,$8.20 ,OP,8.2,8.2,,,,,,
Meridian Duals,CPT,J7178,Inj human fibrinogen con nos,APC 1478,Per Unit,$1.30 ,OP,1.3,1.3,,,,,,
Meridian Duals,CPT,J7179,Vonvendi inj 1 iu vwf:rco,APC 9059,Per Unit,$1.85 ,OP,1.85,1.85,,,,,,
Meridian Duals,CPT,J7180,Factor xiii anti-hem factor,APC 1416,Per Unit,$9.14 ,OP,9.14,9.14,,,,,,
Meridian Duals,CPT,J7181,Factor xiii recomb a-subunit,APC 1746,Per Unit,$15.87 ,OP,15.87,15.87,,,,,,
Meridian Duals,CPT,J7182,Factor viii recomb novoeight,APC 1856,Per Unit,$1.51 ,OP,1.51,1.51,,,,,,
Meridian Duals,CPT,J7183,Wilate injection,APC 1352,Per Unit,$1.16 ,OP,1.16,1.16,,,,,,
Meridian Duals,CPT,J7185,Xyntha inj,APC 1268,Per Unit,$1.33 ,OP,1.33,1.33,,,,,,
Meridian Duals,CPT,J7186,Antihemophilic viii/vwf comp,APC 1213,Per Unit,$1.14 ,OP,1.14,3.82,,,,,,
Meridian Duals,CPT,J7187,Humate-p- inj,APC 1704,Per Unit,$1.26 ,OP,1.26,2.98,,,,,,
Meridian Duals,CPT,J7188,Factor viii recomb obizur,APC 1827,Per Unit,$3.19 ,OP,3.19,3.19,,,,,,
Meridian Duals,CPT,J7189,Factor viia recomb novoseven,APC 1705,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Meridian Duals,CPT,J7190,Factor viii,APC 0925,Per Unit,$1.12 ,OP,1.12,3.02,,,,,,
Meridian Duals,CPT,J7192,Factor viii recombinant nos,APC 0927,Per Unit,$1.43 ,OP,1.43,3.85,,,,,,
Meridian Duals,CPT,J7193,Factor ix non-recombinant,APC 0931,Per Unit,$1.17 ,OP,1.17,3.36,,,,,,
Meridian Duals,CPT,J7194,Factor ix complex,APC 0928,Per Unit,$1.54 ,OP,1.54,2.52,,,,,,
Meridian Duals,CPT,J7195,Factor ix recombinant nos,APC 0932,Per Unit,$1.61 ,OP,1.61,3.57,,,,,,
Meridian Duals,CPT,J7197,Antithrombin iii injection,APC 1263,Per Unit,$3.20 ,OP,3.2,10.61,,,,,,
Meridian Duals,CPT,J7198,Anti-inhibitor,APC 0929,Per Unit,$2.21 ,OP,2.21,5.2,,,,,,
Meridian Duals,CPT,J7200,Factor ix recombinan rixubis,APC 1467,Per Unit,$1.54 ,OP,1.54,1.54,,,,,,
Meridian Duals,CPT,J7201,Factor ix alprolix recomb,APC 1486,Per Unit,$3.28 ,OP,3.28,3.28,,,,,,
Meridian Duals,CPT,J7202,Factor ix idelvion inj,APC 9171,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Duals,CPT,J7203,Factor ix recomb gly rebinyn,APC 9468,Per Unit,$4.23 ,OP,4.23,4.23,,,,,,
Meridian Duals,CPT,J7204,Inj recombin esperoct per iu,APC 9354,Per Unit,$2.23 ,OP,2.23,2.23,,,,,,
Meridian Duals,CPT,J7205,Factor viii fc fusion recomb,APC 1656,Per Unit,$2.15 ,OP,2.15,2.15,,,,,,
Meridian Duals,CPT,J7207,Factor viii pegylated recomb,APC 1844,Per Unit,$1.92 ,OP,1.92,1.92,,,,,,
Meridian Duals,CPT,J7208,Inj. jivi 1 iu,APC 9299,Per Unit,$2.10 ,OP,2.1,2.1,,,,,,
Meridian Duals,CPT,J7209,Factor viii nuwiq recomb 1iu,APC 1846,Per Unit,$1.24 ,OP,1.24,1.24,,,,,,
Meridian Duals,CPT,J7210,Inj- afstyla- 1 i.u.,APC 9043,Per Unit,$1.36 ,OP,1.36,1.36,,,,,,
Meridian Duals,CPT,J7211,Inj- kovaltry- 1 i.u.,APC 9075,Per Unit,$1.24 ,OP,1.24,1.24,,,,,,
Meridian Duals,CPT,J7212,Factor viia recomb sevenfact,APC 9395,Per Unit,$2.27 ,OP,2.27,2.27,,,,,,
Meridian Duals,CPT,J7308,Aminolevulinic acid hcl top,APC 7308,Per Unit,$392.48 ,OP,392.48,392.48,,,,,,
Meridian Duals,CPT,J7311,Inj.- retisert- 0.01 mg,APC 9225,Per Unit,$339.00 ,OP,339,"93,937.12",,,,,,
Meridian Duals,CPT,J7312,Dexamethasone intra implant,APC 9256,Per Unit,$199.69 ,OP,199.69,199.69,,,,,,
Meridian Duals,CPT,J7313,Inj.- iluvien- 0.01 mg,APC 9450,Per Unit,$490.95 ,OP,490.95,490.95,,,,,,
Meridian Duals,CPT,J7314,Inj.- yutiq- 0.01 mg,APC 9328,Per Unit,$513.16 ,OP,513.16,513.16,,,,,,
Meridian Duals,CPT,J7316,Inj- ocriplasmin- 0.125 mg,APC 9298,Per Unit,"$1,046.93 ",OP,"1,046.93","1,046.93",,,,,,
Meridian Duals,CPT,J7318,Inj- durolane 1 mg,APC 9174,Per Unit,$17.23 ,OP,17.23,17.23,,,,,,
Meridian Duals,CPT,J7320,Genvisc 850- inj- 1mg,APC 9079,Per Unit,$16.92 ,OP,16.92,16.92,,,,,,
Meridian Duals,CPT,J7322,Hymovis injection 1 mg,APC 9471,Per Unit,$31.67 ,OP,31.67,903.6,,,,,,
Meridian Duals,CPT,J7323,Euflexxa inj per dose,APC 0875,Per Unit,$138.82 ,OP,138.82,590.67,,,,,,
Meridian Duals,CPT,J7324,Orthovisc inj per dose,APC 0877,Per Unit,$148.74 ,OP,148.74,880.74,,,,,,
Meridian Duals,CPT,J7325,Synvisc or synvisc-one,APC 0874,Per Unit,$11.24 ,OP,11.24,11.24,,,,,,
Meridian Duals,CPT,J7326,Gel-one,APC 1417,Per Unit,"$1,219.00 ",OP,"1,219.00","1,219.00",,,,,,
Meridian Duals,CPT,J7327,Monovisc inj per dose,APC 1747,Per Unit,$762.80 ,OP,762.8,762.8,,,,,,
Meridian Duals,CPT,J7328,Gelsyn-3 injection 0.1 mg,APC 1862,Per Unit,$2.18 ,OP,2.18,2.18,,,,,,
Meridian Duals,CPT,J7329,Inj- trivisc 1 mg,APC 9196,Per Unit,$19.12 ,OP,19.12,19.12,,,,,,
Meridian Duals,CPT,J7331,Synojoynt- inj.- 1 mg,APC 9337,Per Unit,$18.02 ,OP,18.02,18.02,,,,,,
Meridian Duals,CPT,J7336,Capsaicin 8% patch,APC 9071,Per Unit,$3.23 ,OP,3.23,3.23,,,,,,
Meridian Duals,CPT,J7340,Carbidopa levodopa ent 100ml,APC 9320,Per Unit,$211.70 ,OP,211.7,211.7,,,,,,
Meridian Duals,CPT,J7342,Ciprofloxacin otic susp 6 mg,APC 9479,Per Unit,$29.98 ,OP,29.98,29.98,,,,,,
Meridian Duals,CPT,J7345,Aminolevulinic acid- 10% gel,APC 9301,Per Unit,$1.59 ,OP,1.59,1.59,,,,,,
Meridian Duals,CPT,J7351,Inj bimatoprost itc imp1mcg,APC 9351,Per Unit,$205.63 ,OP,205.63,205.63,,,,,,
Meridian Duals,CPT,J7352,Afamelanotide implant- 1 mg,APC 9396,Per Unit,"$3,218.90 ",OP,"3,218.90","3,218.90",,,,,,
Meridian Duals,CPT,J7402,Mometasone sinus sinuva,APC 9346,Per Unit,$10.56 ,OP,10.56,10.56,,,,,,
Meridian Duals,CPT,J7501,Azathioprine parenteral,APC 0887,Per Unit,$245.02 ,OP,245.02,442.27,,,,,,
Meridian Duals,CPT,J7504,Lymphocyte immune globulin,APC 0890,Per Unit,"$2,355.53 ",OP,"2,245.67","2,355.53",,,,,,
Meridian Duals,CPT,J7511,Antithymocyte globuln rabbit,APC 9104,Per Unit,$837.42 ,OP,837.42,"1,807.23",,,,,,
Meridian Duals,CPT,J7525,Tacrolimus injection,APC 9006,Per Unit,$219.33 ,OP,219.33,540.46,,,,,,
Meridian Duals,CPT,J8560,Etoposide oral 50 mg,APC 0802,Per Unit,$75.63 ,OP,75.63,75.63,,,,,,
Meridian Duals,CPT,J8655,Oral netupitant- palonosetro,APC 9448,Per Unit,$315.59 ,OP,315.59,315.59,,,,,,
Meridian Duals,CPT,J8670,Rolapitant- oral- 1mg,APC 1761,Per Unit,$1.75 ,OP,1.75,1.75,,,,,,
Meridian Duals,CPT,J9015,Aldesleukin injection,APC 0807,Per Unit,"$3,795.26 ",OP,"3,795.26","3,795.26",,,,,,
Meridian Duals,CPT,J9017,Arsenic trioxide injection,APC 9012,Per Unit,$13.11 ,OP,13.11,179.2,,,,,,
Meridian Duals,CPT,J9019,Erwinaze injection,APC 9289,Per Unit,$427.27 ,OP,427.27,427.27,,,,,,
Meridian Duals,CPT,J9022,Inj- atezolizumab-10 mg,APC 9483,Per Unit,$79.75 ,OP,79.75,79.75,,,,,,
Meridian Duals,CPT,J9023,Injection- avelumab- 10 mg,APC 9491,Per Unit,$86.19 ,OP,86.19,86.19,,,,,,
Meridian Duals,CPT,J9025,Azacitidine injection,APC 1709,Per Unit,$0.93 ,OP,0.93,22.88,,,,,,
Meridian Duals,CPT,J9027,Clofarabine injection,APC 1710,Per Unit,$53.15 ,OP,53.15,564.29,,,,,,
Meridian Duals,CPT,J9032,Injection- belinostat- 10mg,APC 1658,Per Unit,$42.77 ,OP,42.77,42.77,,,,,,
Meridian Duals,CPT,J9033,Inj.- treanda 1 mg,APC 9243,Per Unit,$22.01 ,OP,22.01,91.51,,,,,,
Meridian Duals,CPT,J9034,Inj.- bendeka 1 mg,APC 1861,Per Unit,$19.65 ,OP,19.65,19.65,,,,,,
Meridian Duals,CPT,J9035,Bevacizumab injection,APC 9214,Per Unit,$70.41 ,OP,70.41,278.32,,,,,,
Meridian Duals,CPT,J9036,Inj. belrapzo/bendamustine,APC 9313,Per Unit,$21.47 ,OP,21.47,21.47,,,,,,
Meridian Duals,CPT,J9037,Inj belantamab mafodont blmf,APC 9384,Per Unit,$42.78 ,OP,42.78,42.78,,,,,,
Meridian Duals,CPT,J9039,Injection- blinatumomab,APC 9449,Per Unit,$123.88 ,OP,123.88,123.88,,,,,,
Meridian Duals,CPT,J9041,Inj.- velcade 0.1 mg,APC 9207,Per Unit,$45.16 ,OP,45.16,175.39,,,,,,
Meridian Duals,CPT,J9042,Brentuximab vedotin inj,APC 9287,Per Unit,$189.34 ,OP,189.34,189.34,,,,,,
Meridian Duals,CPT,J9043,Cabazitaxel injection,APC 9276,Per Unit,$189.00 ,OP,189,189,,,,,,
Meridian Duals,CPT,J9044,Inj- bortezomib- nos- 0.1 mg,APC 9192,Per Unit,$18.31 ,OP,18.31,18.31,,,,,,
Meridian Duals,CPT,J9047,Injection- carfilzomib- 1 mg,APC 9295,Per Unit,$41.10 ,OP,41.1,41.1,,,,,,
Meridian Duals,CPT,J9050,Carmustine injection,APC 0812,Per Unit,"$1,234.46 ",OP,"1,234.46","1,234.46",,,,,,
Meridian Duals,CPT,J9055,Cetuximab injection,APC 9215,Per Unit,$66.71 ,OP,66.71,240.2,,,,,,
Meridian Duals,CPT,J9057,Inj.- copanlisib- 1 mg,APC 9030,Per Unit,$80.96 ,OP,80.96,80.96,,,,,,
Meridian Duals,CPT,J9065,Inj cladribine per 1 mg,APC 0858,Per Unit,$18.02 ,OP,18.02,144.88,,,,,,
Meridian Duals,CPT,J9070,Cyclophosphamide 100 mg inj,APC 1408,Per Unit,$29.15 ,OP,19.07,29.15,,,,,,
Meridian Duals,CPT,J9119,Inj.- cemiplimab-rwlc- 1 mg,APC 9304,Per Unit,$27.54 ,OP,27.54,27.54,,,,,,
Meridian Duals,CPT,J9120,Dactinomycin injection,APC 0752,Per Unit,$890.64 ,OP,890.64,"2,634.57",,,,,,
Meridian Duals,CPT,J9144,Daratumumab- hyaluronidase,APC 9378,Per Unit,$45.10 ,OP,45.1,45.1,,,,,,
Meridian Duals,CPT,J9145,Injection- daratumumab 10 mg,APC 9476,Per Unit,$57.55 ,OP,57.55,57.55,,,,,,
Meridian Duals,CPT,J9150,Daunorubicin injection,APC 0820,Per Unit,$40.36 ,OP,40.36,80.07,,,,,,
Meridian Duals,CPT,J9153,Inj daunorubicin- cytarabine,APC 9302,Per Unit,$202.60 ,OP,202.6,202.6,,,,,,
Meridian Duals,CPT,J9155,Degarelix injection,APC 1296,Per Unit,$4.12 ,OP,4.12,4.12,,,,,,
Meridian Duals,CPT,J9173,Inj.- durvalumab- 10 mg,APC 9492,Per Unit,$76.86 ,OP,76.86,76.86,,,,,,
Meridian Duals,CPT,J9176,Injection- elotuzumab- 1mg,APC 9477,Per Unit,$6.77 ,OP,6.77,6.77,,,,,,
Meridian Duals,CPT,J9177,Inj enfort vedo-ejfv 0.25mg,APC 9364,Per Unit,$30.17 ,OP,30.17,30.17,,,,,,
Meridian Duals,CPT,J9179,Eribulin mesylate injection,APC 1426,Per Unit,$123.93 ,OP,123.93,123.93,,,,,,
Meridian Duals,CPT,J9198,Inj. infugem- 100 mg,APC 9387,Per Unit,$34.00 ,OP,34,34,,,,,,
Meridian Duals,CPT,J9202,Goserelin acetate implant,APC 0810,Per Unit,$525.21 ,OP,525.21,915.04,,,,,,
Meridian Duals,CPT,J9203,Gemtuzumab ozogamicin 0.1 mg,APC 9495,Per Unit,$207.99 ,OP,207.99,207.99,,,,,,
Meridian Duals,CPT,J9204,Inj mogamulizumab-kpkc- 1 mg,APC 9182,Per Unit,$210.05 ,OP,210.05,210.05,,,,,,
Meridian Duals,CPT,J9205,Inj irinotecan liposome 1 mg,APC 9474,Per Unit,$57.20 ,OP,57.2,57.2,,,,,,
Meridian Duals,CPT,J9207,Ixabepilone injection,APC 9240,Per Unit,$112.12 ,OP,112.12,308.83,,,,,,
Meridian Duals,CPT,J9210,Inj.- emapalumab-lzsg- 1 mg,APC 9310,Per Unit,$376.03 ,OP,376.03,376.03,,,,,,
Meridian Duals,CPT,J9214,Interferon alfa-2b inj,APC 0836,Per Unit,$33.24 ,OP,33.24,72.44,,,,,,
Meridian Duals,CPT,J9217,Leuprolide acetate suspnsion,APC 9217,Per Unit,$139.09 ,OP,139.09,987.49,,,,,,
Meridian Duals,CPT,J9223,Inj. lurbinectedin- 0.1 mg,APC 9389,Per Unit,$174.03 ,OP,174.03,174.03,,,,,,
Meridian Duals,CPT,J9225,Vantas implant,APC 1711,Per Unit,"$5,166.29 ",OP,"5,166.29","7,613.94",,,,,,
Meridian Duals,CPT,J9226,Supprelin la implant,APC 1142,Per Unit,"$43,467.03 ",OP,"43,467.03","71,949.32",,,,,,
Meridian Duals,CPT,J9227,Inj. isatuximab-irfc 10 mg,APC 9377,Per Unit,$67.60 ,OP,67.6,67.6,,,,,,
Meridian Duals,CPT,J9228,Ipilimumab injection,APC 9284,Per Unit,$158.65 ,OP,158.65,158.65,,,,,,
Meridian Duals,CPT,J9229,Inj inotuzumab ozogam 0.1 mg,APC 9028,Per Unit,"$2,371.62 ",OP,"2,371.62","2,371.62",,,,,,
Meridian Duals,CPT,J9230,Mechlorethamine hcl inj,APC 0751,Per Unit,$11.74 ,OP,11.74,712.98,,,,,,
Meridian Duals,CPT,J9245,Inj melpha hydroch nos 50 mg,APC 0840,Per Unit,$208.41 ,OP,208.41,"7,888.46",,,,,,
Meridian Duals,CPT,J9246,Inj.- evomela- 1 mg,APC 9375,Per Unit,$18.20 ,OP,18.2,18.2,,,,,,
Meridian Duals,CPT,J9247,Inj- melphalan flufenami 1mg,APC 9417,Per Unit,$499.86 ,OP,499.86,499.86,,,,,,
Meridian Duals,CPT,J9261,Nelarabine injection,APC 0825,Per Unit,$155.90 ,OP,155.9,488.04,,,,,,
Meridian Duals,CPT,J9262,Inj- omacetaxine mep- 0.01mg,APC 9297,Per Unit,$3.30 ,OP,3.3,3.3,,,,,,
Meridian Duals,CPT,J9264,Paclitaxel protein bound,APC 1712,Per Unit,$14.08 ,OP,14.08,45.74,,,,,,
Meridian Duals,CPT,J9266,Pegaspargase injection,APC 0843,Per Unit,"$21,561.05 ",OP,"12,715.34","21,561.05",,,,,,
Meridian Duals,CPT,J9268,Pentostatin injection,APC 0844,Per Unit,"$1,880.67 ",OP,"1,880.67","7,030.61",,,,,,
Meridian Duals,CPT,J9269,Inj. tagraxofusp-erzs 10 mcg,APC 9309,Per Unit,$290.37 ,OP,290.37,290.37,,,,,,
Meridian Duals,CPT,J9270,Plicamycin (mithramycin) inj,APC 9093,Per Unit,$115.40 ,OP,115.4,385.09,,,,,,
Meridian Duals,CPT,J9271,Inj pembrolizumab,APC 1490,Per Unit,$52.75 ,OP,52.75,52.75,,,,,,
Meridian Duals,CPT,J9280,Mitomycin injection,APC 1232,Per Unit,$38.63 ,OP,38.63,76.26,,,,,,
Meridian Duals,CPT,J9281,Mitomycin instillation,APC 9374,Per Unit,$281.88 ,OP,281.88,281.88,,,,,,
Meridian Duals,CPT,J9285,Inj- olaratumab- 10 mg,APC 9485,Per Unit,$52.07 ,OP,52.07,52.07,,,,,,
Meridian Duals,CPT,J9293,Mitoxantrone hydrochl / 5 mg,APC 0864,Per Unit,$26.29 ,OP,26.29,392.7,,,,,,
Meridian Duals,CPT,J9295,Injection- necitumumab- 1 mg,APC 9475,Per Unit,$5.74 ,OP,5.74,5.74,,,,,,
Meridian Duals,CPT,J9299,Injection- nivolumab,APC 9453,Per Unit,$28.86 ,OP,28.86,28.86,,,,,,
Meridian Duals,CPT,J9301,Obinutuzumab inj,APC 1476,Per Unit,$64.54 ,OP,64.54,64.54,,,,,,
Meridian Duals,CPT,J9302,Ofatumumab injection,APC 9260,Per Unit,$63.96 ,OP,63.96,63.96,,,,,,
Meridian Duals,CPT,J9303,Panitumumab injection,APC 9235,Per Unit,$130.38 ,OP,130.38,130.38,,,,,,
Meridian Duals,CPT,J9305,Inj. pemetrexed nos 10mg,APC 9213,Per Unit,$74.93 ,OP,74.93,232.58,,,,,,
Meridian Duals,CPT,J9306,Injection- pertuzumab- 1 mg,APC 1471,Per Unit,$13.56 ,OP,13.56,13.56,,,,,,
Meridian Duals,CPT,J9307,Pralatrexate injection,APC 9259,Per Unit,$314.84 ,OP,314.84,314.84,,,,,,
Meridian Duals,CPT,J9308,Injection- ramucirumab,APC 1488,Per Unit,$62.69 ,OP,62.69,62.69,,,,,,
Meridian Duals,CPT,J9309,Inj- polatuzumab vedotin 1mg,APC 9331,Per Unit,$113.57 ,OP,113.57,113.57,,,,,,
Meridian Duals,CPT,J9311,Inj rituximab- hyaluronidase,APC 9467,Per Unit,$37.94 ,OP,37.94,37.94,,,,,,
Meridian Duals,CPT,J9312,Inj.- rituximab- 10 mg,APC 9186,Per Unit,$86.94 ,OP,86.94,86.94,,,,,,
Meridian Duals,CPT,J9313,Inj.- lumoxiti- 0.01 mg,APC 9305,Per Unit,$23.39 ,OP,23.39,23.39,,,,,,
Meridian Duals,CPT,J9316,Pertuzu- trastuzu- 10 mg,APC 9390,Per Unit,$72.15 ,OP,72.15,72.15,,,,,,
Meridian Duals,CPT,J9317,Sacituzumab govitecan-hziy,APC 9376,Per Unit,$30.35 ,OP,30.35,30.35,,,,,,
Meridian Duals,CPT,J9318,Inj romidepsin non-lyo 0.1mg,APC 9428,Per Unit,$33.91 ,OP,33.91,33.91,,,,,,
Meridian Duals,CPT,J9319,Inj romidepsin lyophil 0.1mg,APC 9429,Per Unit,$33.68 ,OP,33.68,33.68,,,,,,
Meridian Duals,CPT,J9320,Streptozocin injection,APC 0850,Per Unit,$348.51 ,OP,348.51,"1,372.57",,,,,,
Meridian Duals,CPT,J9325,Inj talimogene laherparepvec,APC 9472,Per Unit,$57.26 ,OP,57.26,57.26,,,,,,
Meridian Duals,CPT,J9328,Temozolomide injection,APC 9253,Per Unit,$10.41 ,OP,10.41,10.41,,,,,,
Meridian Duals,CPT,J9330,Temsirolimus injection,APC 1168,Per Unit,$38.25 ,OP,38.25,38.25,,,,,,
Meridian Duals,CPT,J9340,Thiotepa injection,APC 0851,Per Unit,$305.84 ,OP,305.84,446.08,,,,,,
Meridian Duals,CPT,J9348,Inj. naxitamab-gqgk- 1 mg,APC 9408,Per Unit,$539.07 ,OP,539.07,539.07,,,,,,
Meridian Duals,CPT,J9349,Inj.- tafasitamab-cxix,APC 9385,Per Unit,$12.62 ,OP,12.62,12.62,,,,,,
Meridian Duals,CPT,J9352,Injection trabectedin 0.1mg,APC 9480,Per Unit,$325.03 ,OP,325.03,325.03,,,,,,
Meridian Duals,CPT,J9353,Inj. margetuximab-cmkb- 5 mg,APC 9418,Per Unit,$42.99 ,OP,42.99,42.99,,,,,,
Meridian Duals,CPT,J9354,Inj- ado-trastuzumab emt 1mg,APC 9131,Per Unit,$34.18 ,OP,34.18,34.18,,,,,,
Meridian Duals,CPT,J9355,Inj trastuzumab excl biosimi,APC 1613,Per Unit,$89.81 ,OP,89.81,238.1,,,,,,
Meridian Duals,CPT,J9356,Inj. herceptin hylecta- 10mg,APC 9314,Per Unit,$71.85 ,OP,71.85,71.85,,,,,,
Meridian Duals,CPT,J9357,Valrubicin injection,APC 1235,Per Unit,"$1,425.37 ",OP,"1,425.37","1,795.78",,,,,,
Meridian Duals,CPT,J9358,Inj fam-trastu deru-nxki 1mg,APC 9353,Per Unit,$24.27 ,OP,24.27,24.27,,,,,,
Meridian Duals,CPT,J9371,Inj- vincristine sul lip 1mg,APC 1466,Per Unit,"$3,370.23 ",OP,28.22,"3,370.23",,,,,,
Meridian Duals,CPT,J9395,Injection- fulvestrant,APC 9120,Per Unit,$15.98 ,OP,15.98,396.52,,,,,,
Meridian Duals,CPT,J9400,Inj- ziv-aflibercept- 1mg,APC 9296,Per Unit,$8.42 ,OP,8.42,8.42,,,,,,
Meridian Duals,CPT,J9600,Porfimer sodium injection,APC 0856,Per Unit,"$21,856.35 ",OP,"13,169.04","21,856.35",,,,,,
Meridian Duals,CPT,K0672,Removable soft interface le,Durable Medical Equipment,Per Unit,$85.14 ,OP,85.14,85.14,,,,,,
Meridian Duals,CPT,L0112,Cranial cervical orthosis,Durable Medical Equipment,Per Unit,"$1,404.96 ",OP,"1,404.96","4,830.68",,,,,,
Meridian Duals,CPT,L0113,Cranial cervical torticollis,Durable Medical Equipment,Per Unit,$286.27 ,OP,286.27,286.27,,,,,,
Meridian Duals,CPT,L0120,Cerv flex n/adj foam pre ots,Durable Medical Equipment,Per Unit,$26.55 ,OP,26.55,91.51,,,,,,
Meridian Duals,CPT,L0130,Flex thermoplastic collar mo,Durable Medical Equipment,Per Unit,$153.23 ,OP,153.23,526.16,,,,,,
Meridian Duals,CPT,L0140,Cervical semi-rigid adjustab,Durable Medical Equipment,Per Unit,$60.09 ,OP,60.09,205.88,,,,,,
Meridian Duals,CPT,L0150,Cerv semi-rig adj molded chn,Durable Medical Equipment,Per Unit,$107.45 ,OP,107.45,369.83,,,,,,
Meridian Duals,CPT,L0160,Cerv sr wire occ/man pre ots,Durable Medical Equipment,Per Unit,$156.89 ,OP,156.89,541.4,,,,,,
Meridian Duals,CPT,L0170,Cervical collar molded to pt,Durable Medical Equipment,Per Unit,$807.10 ,OP,807.1,"2,775.65",,,,,,
Meridian Duals,CPT,L0172,Cerv col sr foam 2pc pre ots,Durable Medical Equipment,Per Unit,$142.17 ,OP,142.17,488.04,,,,,,
Meridian Duals,CPT,L0174,Cerv sr 2pc thor ext pre ots,Durable Medical Equipment,Per Unit,$279.55 ,OP,279.55,960.8,,,,,,
Meridian Duals,CPT,L0180,Cer post col occ/man sup adj,Durable Medical Equipment,Per Unit,$452.88 ,OP,452.88,"1,559.39",,,,,,
Meridian Duals,CPT,L0190,Cerv collar supp adj cerv ba,Durable Medical Equipment,Per Unit,$534.12 ,OP,534.12,"1,837.71",,,,,,
Meridian Duals,CPT,L0200,Cerv col supp adj bar & thor,Durable Medical Equipment,Per Unit,$619.54 ,OP,619.54,"2,131.30",,,,,,
Meridian Duals,CPT,L0220,Thor rib belt custom fabrica,Durable Medical Equipment,Per Unit,$129.68 ,OP,129.68,446.08,,,,,,
Meridian Duals,CPT,L0450,Tlso flex trunk/thor pre ots,Durable Medical Equipment,Per Unit,$128.11 ,OP,128.11,560.47,,,,,,
Meridian Duals,CPT,L0454,Tlso trnk sj-t9 pre cst,Durable Medical Equipment,Per Unit,$348.14 ,OP,348.14,"1,197.20",,,,,,
Meridian Duals,CPT,L0455,Tlso flex trnk sj-t9 pre ots,Durable Medical Equipment,Per Unit,$249.16 ,OP,249.16,249.16,,,,,,
Meridian Duals,CPT,L0456,Tlso flex trnk sj-ss pre cst,Durable Medical Equipment,Per Unit,$998.38 ,OP,998.38,"3,435.25",,,,,,
Meridian Duals,CPT,L0457,Tlso flex trnk sj-ss pre ots,Durable Medical Equipment,Per Unit,$714.52 ,OP,714.52,714.52,,,,,,
Meridian Duals,CPT,L0458,Tlso 2mod symphis-xipho pre,Durable Medical Equipment,Per Unit,$895.27 ,OP,895.27,"3,080.66",,,,,,
Meridian Duals,CPT,L0460,Tlso 2 shl symphys-stern cst,Durable Medical Equipment,Per Unit,"$1,007.68 ",OP,"1,007.68","3,465.73",,,,,,
Meridian Duals,CPT,L0462,Tlso 3mod sacro-scap pre,Durable Medical Equipment,Per Unit,"$1,253.37 ",OP,"1,253.37","4,312.16",,,,,,
Meridian Duals,CPT,L0464,Tlso 4mod sacro-scap pre,Durable Medical Equipment,Per Unit,"$1,492.13 ",OP,"1,492.13","5,131.88",,,,,,
Meridian Duals,CPT,L0466,Tlso r fram soft ant pre cst,Durable Medical Equipment,Per Unit,$380.86 ,OP,380.86,"1,311.56",,,,,,
Meridian Duals,CPT,L0467,Tlso r fram soft pre ots,Durable Medical Equipment,Per Unit,$277.04 ,OP,277.04,277.04,,,,,,
Meridian Duals,CPT,L0468,Tlso rig fram pelvic pre cst,Durable Medical Equipment,Per Unit,$477.29 ,OP,477.29,"1,643.28",,,,,,
Meridian Duals,CPT,L0469,Tlso rig fram pelvic pre ots,Durable Medical Equipment,Per Unit,$351.00 ,OP,351,351,,,,,,
Meridian Duals,CPT,L0470,Tlso rigid frame pre subclav,Durable Medical Equipment,Per Unit,$660.47 ,OP,660.47,"2,272.36",,,,,,
Meridian Duals,CPT,L0472,Tlso rigid frame hyperex pre,Durable Medical Equipment,Per Unit,$406.41 ,OP,406.41,"1,399.26",,,,,,
Meridian Duals,CPT,L0480,Tlso rigid plastic custom fa,Durable Medical Equipment,Per Unit,"$1,516.23 ",OP,"1,516.23","5,215.77",,,,,,
Meridian Duals,CPT,L0482,Tlso rigid lined custom fab,Durable Medical Equipment,Per Unit,"$1,693.64 ",OP,"1,693.64","5,825.80",,,,,,
Meridian Duals,CPT,L0484,Tlso rigid plastic cust fab,Durable Medical Equipment,Per Unit,"$1,829.06 ",OP,"1,829.06","6,290.94",,,,,,
Meridian Duals,CPT,L0486,Tlso rigidlined cust fab two,Durable Medical Equipment,Per Unit,"$2,054.11 ",OP,"2,054.11","7,064.92",,,,,,
Meridian Duals,CPT,L0488,Tlso rigid lined pre one pie,Durable Medical Equipment,Per Unit,"$1,007.68 ",OP,"1,007.68","3,465.73",,,,,,
Meridian Duals,CPT,L0490,Tlso rigid plastic pre one,Durable Medical Equipment,Per Unit,$283.96 ,OP,283.96,976.05,,,,,,
Meridian Duals,CPT,L0491,Tlso 2 piece rigid shell,Durable Medical Equipment,Per Unit,$770.93 ,OP,770.93,"2,649.83",,,,,,
Meridian Duals,CPT,L0492,Tlso 3 piece rigid shell,Durable Medical Equipment,Per Unit,$502.01 ,OP,502.01,"1,727.15",,,,,,
Meridian Duals,CPT,L0621,Sio flex pelvic/sacr pre ots,Durable Medical Equipment,Per Unit,$67.68 ,OP,67.68,446.08,,,,,,
Meridian Duals,CPT,L0622,Sio flex pelvisacral custom,Durable Medical Equipment,Per Unit,$268.31 ,OP,268.31,"1,384.01",,,,,,
Meridian Duals,CPT,L0623,Sio rig pnl pelv/sac pre ots,Durable Medical Equipment,Per Unit,$126.95 ,OP,126.95,126.95,,,,,,
Meridian Duals,CPT,L0625,Lo flex l1-below l5 pre ots,Durable Medical Equipment,Per Unit,$39.58 ,OP,39.58,285.96,,,,,,
Meridian Duals,CPT,L0626,Lo sag rig pnl stays pre cst,Durable Medical Equipment,Per Unit,$78.25 ,OP,78.25,404.14,,,,,,
Meridian Duals,CPT,L0627,Lo sag ri an/pos pnl pre cst,Durable Medical Equipment,Per Unit,$412.59 ,OP,412.59,"2,127.49",,,,,,
Meridian Duals,CPT,L0628,Lso flex no ri stays pre ots,Durable Medical Equipment,Per Unit,$60.27 ,OP,60.27,434.65,,,,,,
Meridian Duals,CPT,L0630,Lso r post pnl sj-t9 pre cst,Durable Medical Equipment,Per Unit,$162.59 ,OP,162.59,838.79,,,,,,
Meridian Duals,CPT,L0631,Lso sag r an/pos pnl pre cst,Durable Medical Equipment,Per Unit,"$1,030.49 ",OP,"1,030.49","5,314.90",,,,,,
Meridian Duals,CPT,L0633,Lso sc r pos/lat pnl pre cst,Durable Medical Equipment,Per Unit,$287.85 ,OP,287.85,"1,483.14",,,,,,
Meridian Duals,CPT,L0635,Lso sagit rigid panel prefab,Durable Medical Equipment,Per Unit,"$1,003.05 ",OP,"1,003.05","5,173.83",,,,,,
Meridian Duals,CPT,L0636,Lso sagittal rigid panel cus,Durable Medical Equipment,Per Unit,"$1,360.98 ",OP,"1,360.98","7,019.17",,,,,,
Meridian Duals,CPT,L0637,Lso sc r ant/pos pnl pre cst,Durable Medical Equipment,Per Unit,"$1,300.47 ",OP,"1,300.47","6,710.34",,,,,,
Meridian Duals,CPT,L0638,Lso sag-coronal panel custom,Durable Medical Equipment,Per Unit,"$1,323.97 ",OP,"1,323.97","6,828.54",,,,,,
Meridian Duals,CPT,L0639,Lso s/c shell/panel prefab,Durable Medical Equipment,Per Unit,"$1,300.47 ",OP,"1,300.47","6,710.34",,,,,,
Meridian Duals,CPT,L0640,Lso s/c shell/panel custom,Durable Medical Equipment,Per Unit,"$1,050.39 ",OP,"1,050.39","5,417.84",,,,,,
Meridian Duals,CPT,L0641,Lo rig pos pnl l1-l5 pre ots,Durable Medical Equipment,Per Unit,$56.00 ,OP,56,56,,,,,,
Meridian Duals,CPT,L0642,Lo sag ri an/pos pnl pre ots,Durable Medical Equipment,Per Unit,$295.35 ,OP,295.35,295.35,,,,,,
Meridian Duals,CPT,L0643,Lso sag ctr rigi pos pre ots,Durable Medical Equipment,Per Unit,$116.37 ,OP,116.37,116.37,,,,,,
Meridian Duals,CPT,L0648,Lso sag r an/pos pnl pre ots,Durable Medical Equipment,Per Unit,$737.61 ,OP,737.61,737.61,,,,,,
Meridian Duals,CPT,L0649,Lso sc r pos/lat pnl pre ots,Durable Medical Equipment,Per Unit,$206.04 ,OP,206.04,206.04,,,,,,
Meridian Duals,CPT,L0650,Lso sc r ant/pos pnl pre ots,Durable Medical Equipment,Per Unit,$880.49 ,OP,880.49,880.49,,,,,,
Meridian Duals,CPT,L0651,Lso sag-co shell pnl pre ots,Durable Medical Equipment,Per Unit,$880.49 ,OP,880.49,880.49,,,,,,
Meridian Duals,CPT,L0700,Ctlso a-p-l control molded,Durable Medical Equipment,Per Unit,"$1,998.37 ",OP,"1,998.37","6,874.29",,,,,,
Meridian Duals,CPT,L0710,Ctlso a-p-l control w/ inter,Durable Medical Equipment,Per Unit,"$2,196.75 ",OP,"2,196.75","7,552.94",,,,,,
Meridian Duals,CPT,L0810,Halo cervical into jckt vest,Durable Medical Equipment,Per Unit,"$2,683.14 ",OP,"2,683.14","9,226.72",,,,,,
Meridian Duals,CPT,L0820,Halo cervical into body jack,Durable Medical Equipment,Per Unit,"$2,110.65 ",OP,"2,110.65","7,259.37",,,,,,
Meridian Duals,CPT,L0830,Halo cerv into milwaukee typ,Durable Medical Equipment,Per Unit,"$3,229.60 ",OP,"3,229.60","11,106.37",,,,,,
Meridian Duals,CPT,L0859,Mri compatible system,Durable Medical Equipment,Per Unit,"$1,143.45 ",OP,"1,143.45","3,930.89",,,,,,
Meridian Duals,CPT,L0861,Halo repl liner/interface,Durable Medical Equipment,Per Unit,$216.37 ,OP,216.37,743.48,,,,,,
Meridian Duals,CPT,L0970,Tlso corset front,Durable Medical Equipment,Per Unit,$107.27 ,OP,107.27,369.83,,,,,,
Meridian Duals,CPT,L0972,Lso corset front,Durable Medical Equipment,Per Unit,$97.64 ,OP,97.64,335.53,,,,,,
Meridian Duals,CPT,L0974,Tlso full corset,Durable Medical Equipment,Per Unit,$175.42 ,OP,175.42,602.41,,,,,,
Meridian Duals,CPT,L0976,Lso full corset,Durable Medical Equipment,Per Unit,$150.09 ,OP,150.09,150.09,,,,,,
Meridian Duals,CPT,L0978,Axillary crutch extension,Durable Medical Equipment,Per Unit,$188.90 ,OP,188.9,648.16,,,,,,
Meridian Duals,CPT,L0980,Peroneal straps pair pre ots,Durable Medical Equipment,Per Unit,$17.15 ,OP,17.15,57.19,,,,,,
Meridian Duals,CPT,L0982,Stocking sup grips 4 pre ots,Durable Medical Equipment,Per Unit,$15.70 ,OP,15.7,53.38,,,,,,
Meridian Duals,CPT,L0984,Protect body sock ea pre ots,Durable Medical Equipment,Per Unit,$67.93 ,OP,67.93,232.58,,,,,,
Meridian Duals,CPT,L1000,Ctlso milwauke initial model,Durable Medical Equipment,Per Unit,"$2,035.53 ",OP,"2,035.53","7,000.10",,,,,,
Meridian Duals,CPT,L1005,Tension based scoliosis orth,Durable Medical Equipment,Per Unit,"$3,212.88 ",OP,"3,212.88","11,049.19",,,,,,
Meridian Duals,CPT,L1010,Ctlso axilla sling,Durable Medical Equipment,Per Unit,$83.99 ,OP,83.99,289.76,,,,,,
Meridian Duals,CPT,L1020,Kyphosis pad,Durable Medical Equipment,Per Unit,$108.17 ,OP,108.17,373.65,,,,,,
Meridian Duals,CPT,L1025,Kyphosis pad floating,Durable Medical Equipment,Per Unit,$156.06 ,OP,156.06,537.6,,,,,,
Meridian Duals,CPT,L1030,Lumbar bolster pad,Durable Medical Equipment,Per Unit,$78.60 ,OP,78.6,270.71,,,,,,
Meridian Duals,CPT,L1040,Lumbar or lumbar rib pad,Durable Medical Equipment,Per Unit,$89.00 ,OP,89,305.01,,,,,,
Meridian Duals,CPT,L1050,Sternal pad,Durable Medical Equipment,Per Unit,$100.72 ,OP,100.72,346.96,,,,,,
Meridian Duals,CPT,L1060,Thoracic pad,Durable Medical Equipment,Per Unit,$108.72 ,OP,108.72,373.65,,,,,,
Meridian Duals,CPT,L1070,Trapezius sling,Durable Medical Equipment,Per Unit,$112.62 ,OP,112.62,388.89,,,,,,
Meridian Duals,CPT,L1080,Outrigger,Durable Medical Equipment,Per Unit,$52.52 ,OP,52.52,179.2,,,,,,
Meridian Duals,CPT,L1085,Outrigger bil w/ vert extens,Durable Medical Equipment,Per Unit,$175.83 ,OP,175.83,606.21,,,,,,
Meridian Duals,CPT,L1090,Lumbar sling,Durable Medical Equipment,Per Unit,$101.01 ,OP,101.01,346.96,,,,,,
Meridian Duals,CPT,L1100,Ring flange plastic/leather,Durable Medical Equipment,Per Unit,$190.64 ,OP,190.64,655.78,,,,,,
Meridian Duals,CPT,L1110,Ring flange plas/leather mol,Durable Medical Equipment,Per Unit,$319.63 ,OP,319.63,"1,098.07",,,,,,
Meridian Duals,CPT,L1120,Covers for upright each,Durable Medical Equipment,Per Unit,$38.18 ,OP,38.18,129.64,,,,,,
Meridian Duals,CPT,L1200,Furnsh initial orthosis only,Durable Medical Equipment,Per Unit,"$1,796.37 ",OP,"1,796.37","6,176.57",,,,,,
Meridian Duals,CPT,L1210,Lateral thoracic extension,Durable Medical Equipment,Per Unit,$245.60 ,OP,245.6,846.41,,,,,,
Meridian Duals,CPT,L1220,Anterior thoracic extension,Durable Medical Equipment,Per Unit,$239.05 ,OP,239.05,823.54,,,,,,
Meridian Duals,CPT,L1230,Milwaukee type superstructur,Durable Medical Equipment,Per Unit,$669.67 ,OP,669.67,"2,302.87",,,,,,
Meridian Duals,CPT,L1240,Lumbar derotation pad,Durable Medical Equipment,Per Unit,$91.29 ,OP,91.29,312.64,,,,,,
Meridian Duals,CPT,L1250,Anterior asis pad,Durable Medical Equipment,Per Unit,$79.39 ,OP,79.39,274.51,,,,,,
Meridian Duals,CPT,L1260,Anterior thoracic derotation,Durable Medical Equipment,Per Unit,$94.68 ,OP,94.68,324.09,,,,,,
Meridian Duals,CPT,L1270,Abdominal pad,Durable Medical Equipment,Per Unit,$83.20 ,OP,83.2,285.96,,,,,,
Meridian Duals,CPT,L1280,Rib gusset (elastic) each,Durable Medical Equipment,Per Unit,$87.71 ,OP,87.71,301.2,,,,,,
Meridian Duals,CPT,L1290,Lateral trochanteric pad,Durable Medical Equipment,Per Unit,$78.00 ,OP,78,266.89,,,,,,
Meridian Duals,CPT,L1300,Body jacket mold to patient,Durable Medical Equipment,Per Unit,"$1,730.06 ",OP,"1,730.06","5,951.62",,,,,,
Meridian Duals,CPT,L1310,Post-operative body jacket,Durable Medical Equipment,Per Unit,"$1,802.00 ",OP,"1,802.00","6,195.63",,,,,,
Meridian Duals,CPT,L1600,Ho flex frejka w/cov pre cst,Durable Medical Equipment,Per Unit,$129.35 ,OP,129.35,446.08,,,,,,
Meridian Duals,CPT,L1610,Ho frejka cov only pre cst,Durable Medical Equipment,Per Unit,$54.94 ,OP,54.94,190.64,,,,,,
Meridian Duals,CPT,L1620,Ho flex pavlik harns pre cst,Durable Medical Equipment,Per Unit,$157.73 ,OP,157.73,541.4,,,,,,
Meridian Duals,CPT,L1630,Abduct control hip semi-flex,Durable Medical Equipment,Per Unit,$212.06 ,OP,212.06,728.23,,,,,,
Meridian Duals,CPT,L1640,Pelv band/spread bar thigh c,Durable Medical Equipment,Per Unit,$475.20 ,OP,475.2,"1,635.64",,,,,,
Meridian Duals,CPT,L1650,Ho abduction hip adjustable,Durable Medical Equipment,Per Unit,$247.55 ,OP,247.55,850.23,,,,,,
Meridian Duals,CPT,L1652,Ho bi thighcuffs w sprdr bar,Durable Medical Equipment,Per Unit,$357.83 ,OP,357.83,"1,231.50",,,,,,
Meridian Duals,CPT,L1660,Ho abduction static plastic,Durable Medical Equipment,Per Unit,$181.40 ,OP,181.4,625.29,,,,,,
Meridian Duals,CPT,L1680,Pelvic & hip control thigh c,Durable Medical Equipment,Per Unit,"$1,143.62 ",OP,"1,143.62","3,934.69",,,,,,
Meridian Duals,CPT,L1685,Post-op hip abduct custom fa,Durable Medical Equipment,Per Unit,"$1,116.47 ",OP,"1,116.47","3,839.39",,,,,,
Meridian Duals,CPT,L1686,Ho post-op hip abduction,Durable Medical Equipment,Per Unit,$940.60 ,OP,940.6,"3,233.17",,,,,,
Meridian Duals,CPT,L1690,Combination bilateral ho,Durable Medical Equipment,Per Unit,"$1,941.15 ",OP,"1,941.15","6,676.03",,,,,,
Meridian Duals,CPT,L1700,Leg perthes orth toronto typ,Durable Medical Equipment,Per Unit,"$1,561.78 ",OP,"1,561.78","5,372.08",,,,,,
Meridian Duals,CPT,L1710,Legg perthes orth newington,Durable Medical Equipment,Per Unit,"$1,988.75 ",OP,"1,988.75","6,839.98",,,,,,
Meridian Duals,CPT,L1720,Legg perthes orthosis trilat,Durable Medical Equipment,Per Unit,"$1,480.82 ",OP,"1,480.82","5,093.76",,,,,,
Meridian Duals,CPT,L1730,Legg perthes orth scottish r,Durable Medical Equipment,Per Unit,"$1,250.14 ",OP,"1,250.14","4,300.73",,,,,,
Meridian Duals,CPT,L1755,Legg perthes patten bottom t,Durable Medical Equipment,Per Unit,"$1,797.35 ",OP,"1,797.35","6,180.39",,,,,,
Meridian Duals,CPT,L1810,Ko elastic with joints,Durable Medical Equipment,Per Unit,$103.34 ,OP,103.34,103.34,,,,,,
Meridian Duals,CPT,L1812,Ko elastic w/joints pre ots,Durable Medical Equipment,Per Unit,$81.50 ,OP,81.5,81.5,,,,,,
Meridian Duals,CPT,L1820,Ko elas w/ condyle pads & jo,Durable Medical Equipment,Per Unit,$142.66 ,OP,142.66,142.66,,,,,,
Meridian Duals,CPT,L1830,Ko immob canvas long pre ots,Durable Medical Equipment,Per Unit,$71.04 ,OP,71.04,285.96,,,,,,
Meridian Duals,CPT,L1831,Knee orth pos locking joint,Durable Medical Equipment,Per Unit,$295.44 ,OP,295.44,"1,017.99",,,,,,
Meridian Duals,CPT,L1832,Ko adj jnt pos r sup pre cst,Durable Medical Equipment,Per Unit,$691.44 ,OP,691.44,"2,379.12",,,,,,
Meridian Duals,CPT,L1833,Ko adj jnt pos r sup pre ots,Durable Medical Equipment,Per Unit,$534.19 ,OP,534.19,534.19,,,,,,
Meridian Duals,CPT,L1834,Ko w/0 joint rigid molded to,Durable Medical Equipment,Per Unit,$728.61 ,OP,728.61,"2,504.94",,,,,,
Meridian Duals,CPT,L1836,Ko rigid w/o joints pre ots,Durable Medical Equipment,Per Unit,$104.41 ,OP,104.41,104.41,,,,,,
Meridian Duals,CPT,L1840,Ko derot ant cruciate custom,Durable Medical Equipment,Per Unit,$944.00 ,OP,944,"3,248.41",,,,,,
Meridian Duals,CPT,L1843,Ko single upright pre cst,Durable Medical Equipment,Per Unit,$900.70 ,OP,900.7,"3,095.90",,,,,,
Meridian Duals,CPT,L1844,Ko w/adj jt rot cntrl molded,Durable Medical Equipment,Per Unit,"$1,528.66 ",OP,"1,528.66","5,257.70",,,,,,
Meridian Duals,CPT,L1845,Ko double upright pre cst,Durable Medical Equipment,Per Unit,$840.88 ,OP,840.88,840.88,,,,,,
Meridian Duals,CPT,L1846,Ko w adj flex/ext rotat mold,Durable Medical Equipment,Per Unit,"$1,174.51 ",OP,"1,174.51","1,174.51",,,,,,
Meridian Duals,CPT,L1847,Ko dbl upright w/air pre cst,Durable Medical Equipment,Per Unit,$577.37 ,OP,577.37,"1,986.41",,,,,,
Meridian Duals,CPT,L1848,Ko dbl upright w/air pre ots,Durable Medical Equipment,Per Unit,$577.37 ,OP,577.37,577.37,,,,,,
Meridian Duals,CPT,L1850,Ko swedish type pre ots,Durable Medical Equipment,Per Unit,$234.85 ,OP,234.85,983.68,,,,,,
Meridian Duals,CPT,L1851,Ko single upright prefab ots,Durable Medical Equipment,Per Unit,$702.11 ,OP,702.11,702.11,,,,,,
Meridian Duals,CPT,L1852,Ko double upright prefab ots,Durable Medical Equipment,Per Unit,$665.20 ,OP,665.2,665.2,,,,,,
Meridian Duals,CPT,L1860,Ko supracondylar socket mold,Durable Medical Equipment,Per Unit,"$1,251.75 ",OP,"1,251.75","4,304.53",,,,,,
Meridian Duals,CPT,L1900,Afo sprng wir drsflx calf bd,Durable Medical Equipment,Per Unit,$286.39 ,OP,286.39,983.68,,,,,,
Meridian Duals,CPT,L1902,Afo ankle gauntlet pre ots,Durable Medical Equipment,Per Unit,$74.93 ,OP,74.93,259.27,,,,,,
Meridian Duals,CPT,L1904,Afo molded ankle gauntlet,Durable Medical Equipment,Per Unit,$453.09 ,OP,453.09,"1,559.39",,,,,,
Meridian Duals,CPT,L1906,Afo multilig ank sup pre ots,Durable Medical Equipment,Per Unit,$112.88 ,OP,112.88,388.89,,,,,,
Meridian Duals,CPT,L1907,Afo supramalleolar custom,Durable Medical Equipment,Per Unit,$564.86 ,OP,564.86,"1,944.48",,,,,,
Meridian Duals,CPT,L1910,Afo sing bar clasp attach sh,Durable Medical Equipment,Per Unit,$281.51 ,OP,281.51,968.43,,,,,,
Meridian Duals,CPT,L1920,Afo sing upright w/ adjust s,Durable Medical Equipment,Per Unit,$412.37 ,OP,412.37,"1,418.32",,,,,,
Meridian Duals,CPT,L1930,Afo plastic,Durable Medical Equipment,Per Unit,$252.89 ,OP,252.89,869.3,,,,,,
Meridian Duals,CPT,L1932,Afo rig ant tib prefab tcf/=,Durable Medical Equipment,Per Unit,$895.75 ,OP,895.75,"3,080.66",,,,,,
Meridian Duals,CPT,L1940,Afo molded to patient plasti,Durable Medical Equipment,Per Unit,$488.84 ,OP,488.84,"1,681.40",,,,,,
Meridian Duals,CPT,L1945,Afo molded plas rig ant tib,Durable Medical Equipment,Per Unit,"$1,126.77 ",OP,"1,126.77","3,873.69",,,,,,
Meridian Duals,CPT,L1950,Afo spiral molded to pt plas,Durable Medical Equipment,Per Unit,$772.00 ,OP,772,"2,653.63",,,,,,
Meridian Duals,CPT,L1951,Afo spiral prefabricated,Durable Medical Equipment,Per Unit,$843.02 ,OP,843.02,"2,897.65",,,,,,
Meridian Duals,CPT,L1960,Afo pos solid ank plastic mo,Durable Medical Equipment,Per Unit,$622.25 ,OP,622.25,"2,138.93",,,,,,
Meridian Duals,CPT,L1970,Afo plastic molded w/ankle j,Durable Medical Equipment,Per Unit,$694.78 ,OP,694.78,"2,390.56",,,,,,
Meridian Duals,CPT,L1971,Afo w/ankle joint- prefab,Durable Medical Equipment,Per Unit,$470.55 ,OP,470.55,"1,616.58",,,,,,
Meridian Duals,CPT,L1980,Afo sing solid stirrup calf,Durable Medical Equipment,Per Unit,$405.31 ,OP,405.31,"1,395.45",,,,,,
Meridian Duals,CPT,L1990,Afo doub solid stirrup calf,Durable Medical Equipment,Per Unit,$469.10 ,OP,469.1,"1,612.76",,,,,,
Meridian Duals,CPT,L2000,Kafo sing fre stirr thi/calf,Durable Medical Equipment,Per Unit,"$1,122.95 ",OP,"1,122.95","3,862.25",,,,,,
Meridian Duals,CPT,L2005,Kafo sng/dbl mechanical act,Durable Medical Equipment,Per Unit,"$4,113.39 ",OP,"4,113.39","14,145.09",,,,,,
Meridian Duals,CPT,L2010,Kafo sng solid stirrup w/o j,Durable Medical Equipment,Per Unit,$875.89 ,OP,875.89,"3,012.03",,,,,,
Meridian Duals,CPT,L2020,Kafo dbl solid stirrup band/,Durable Medical Equipment,Per Unit,"$1,106.22 ",OP,"1,106.22","3,805.07",,,,,,
Meridian Duals,CPT,L2030,Kafo dbl solid stirrup w/o j,Durable Medical Equipment,Per Unit,"$1,087.33 ",OP,"1,087.33","3,740.26",,,,,,
Meridian Duals,CPT,L2034,Kafo pla sin up w/wo k/a cus,Durable Medical Equipment,Per Unit,"$2,039.24 ",OP,"2,039.24","7,011.54",,,,,,
Meridian Duals,CPT,L2035,Kafo plastic pediatric size,Durable Medical Equipment,Per Unit,$173.91 ,OP,173.91,598.59,,,,,,
Meridian Duals,CPT,L2036,Kafo plas doub free knee mol,Durable Medical Equipment,Per Unit,"$1,861.04 ",OP,"1,861.04","6,401.51",,,,,,
Meridian Duals,CPT,L2037,Kafo plas sing free knee mol,Durable Medical Equipment,Per Unit,"$1,664.67 ",OP,"1,664.67","5,726.65",,,,,,
Meridian Duals,CPT,L2038,Kafo w/o joint multi-axis an,Durable Medical Equipment,Per Unit,"$1,341.97 ",OP,"1,341.97","4,613.36",,,,,,
Meridian Duals,CPT,L2040,Hkafo torsion bil rot straps,Durable Medical Equipment,Per Unit,$203.08 ,OP,203.08,697.72,,,,,,
Meridian Duals,CPT,L2050,Hkafo torsion cable hip pelv,Durable Medical Equipment,Per Unit,$489.17 ,OP,489.17,"1,681.40",,,,,,
Meridian Duals,CPT,L2060,Hkafo torsion ball bearing j,Durable Medical Equipment,Per Unit,$611.86 ,OP,611.86,"2,104.61",,,,,,
Meridian Duals,CPT,L2070,Hkafo torsion unilat rot str,Durable Medical Equipment,Per Unit,$155.80 ,OP,155.8,537.6,,,,,,
Meridian Duals,CPT,L2080,Hkafo unilat torsion cable,Durable Medical Equipment,Per Unit,$374.61 ,OP,374.61,"1,288.69",,,,,,
Meridian Duals,CPT,L2090,Hkafo unilat torsion ball br,Durable Medical Equipment,Per Unit,$499.12 ,OP,499.12,"1,715.71",,,,,,
Meridian Duals,CPT,L2106,Afo tib fx cast plaster mold,Durable Medical Equipment,Per Unit,$791.23 ,OP,791.23,"2,722.27",,,,,,
Meridian Duals,CPT,L2108,Afo tib fx cast molded to pt,Durable Medical Equipment,Per Unit,"$1,154.03 ",OP,"1,154.03","3,969.02",,,,,,
Meridian Duals,CPT,L2112,Afo tibial fracture soft,Durable Medical Equipment,Per Unit,$506.43 ,OP,506.43,"1,742.41",,,,,,
Meridian Duals,CPT,L2114,Afo tib fx semi-rigid,Durable Medical Equipment,Per Unit,$634.33 ,OP,634.33,634.33,,,,,,
Meridian Duals,CPT,L2116,Afo tibial fracture rigid,Durable Medical Equipment,Per Unit,$773.69 ,OP,773.69,773.69,,,,,,
Meridian Duals,CPT,L2126,Kafo fem fx cast thermoplas,Durable Medical Equipment,Per Unit,"$1,281.77 ",OP,"1,281.77","4,407.46",,,,,,
Meridian Duals,CPT,L2128,Kafo fem fx cast molded to p,Durable Medical Equipment,Per Unit,"$1,609.47 ",OP,"1,609.47","5,536.03",,,,,,
Meridian Duals,CPT,L2132,Kafo femoral fx cast soft,Durable Medical Equipment,Per Unit,$976.92 ,OP,976.92,"3,358.99",,,,,,
Meridian Duals,CPT,L2134,Kafo fem fx cast semi-rigid,Durable Medical Equipment,Per Unit,"$1,156.80 ",OP,"1,156.80","3,976.64",,,,,,
Meridian Duals,CPT,L2136,Kafo femoral fx cast rigid,Durable Medical Equipment,Per Unit,"$1,265.95 ",OP,"1,265.95","4,354.09",,,,,,
Meridian Duals,CPT,L2180,Plas shoe insert w ank joint,Durable Medical Equipment,Per Unit,$133.08 ,OP,133.08,457.52,,,,,,
Meridian Duals,CPT,L2182,Drop lock knee,Durable Medical Equipment,Per Unit,$114.71 ,OP,114.71,392.7,,,,,,
Meridian Duals,CPT,L2184,Limited motion knee joint,Durable Medical Equipment,Per Unit,$116.27 ,OP,116.27,400.34,,,,,,
Meridian Duals,CPT,L2186,Adj motion knee jnt lerman t,Durable Medical Equipment,Per Unit,$154.63 ,OP,154.63,529.96,,,,,,
Meridian Duals,CPT,L2188,Quadrilateral brim,Durable Medical Equipment,Per Unit,$281.10 ,OP,281.1,968.43,,,,,,
Meridian Duals,CPT,L2190,Waist belt,Durable Medical Equipment,Per Unit,$85.62 ,OP,85.62,293.57,,,,,,
Meridian Duals,CPT,L2192,Pelvic band & belt thigh fla,Durable Medical Equipment,Per Unit,$334.67 ,OP,334.67,"1,151.42",,,,,,
Meridian Duals,CPT,L2200,Limited ankle motion ea jnt,Durable Medical Equipment,Per Unit,$50.44 ,OP,50.44,175.39,,,,,,
Meridian Duals,CPT,L2210,Dorsiflexion assist each joi,Durable Medical Equipment,Per Unit,$63.09 ,OP,63.09,217.32,,,,,,
Meridian Duals,CPT,L2220,Dorsi & plantar flex ass/res,Durable Medical Equipment,Per Unit,$81.22 ,OP,81.22,278.32,,,,,,
Meridian Duals,CPT,L2230,Split flat caliper stirr & p,Durable Medical Equipment,Per Unit,$96.02 ,OP,96.02,331.7,,,,,,
Meridian Duals,CPT,L2232,Rocker bottom- contact afo,Durable Medical Equipment,Per Unit,$97.51 ,OP,97.51,335.53,,,,,,
Meridian Duals,CPT,L2240,Round caliper and plate atta,Durable Medical Equipment,Per Unit,$95.58 ,OP,95.58,327.9,,,,,,
Meridian Duals,CPT,L2250,Foot plate molded stirrup at,Durable Medical Equipment,Per Unit,$335.30 ,OP,335.3,"1,151.42",,,,,,
Meridian Duals,CPT,L2260,Reinforced solid stirrup,Durable Medical Equipment,Per Unit,$188.16 ,OP,188.16,648.16,,,,,,
Meridian Duals,CPT,L2265,Long tongue stirrup,Durable Medical Equipment,Per Unit,$134.94 ,OP,134.94,465.15,,,,,,
Meridian Duals,CPT,L2270,Varus/valgus strap padded/li,Durable Medical Equipment,Per Unit,$61.87 ,OP,61.87,213.51,,,,,,
Meridian Duals,CPT,L2275,Plastic mod low ext pad/line,Durable Medical Equipment,Per Unit,$130.85 ,OP,130.85,449.9,,,,,,
Meridian Duals,CPT,L2280,Molded inner boot,Durable Medical Equipment,Per Unit,$566.69 ,OP,566.69,"1,948.29",,,,,,
Meridian Duals,CPT,L2300,Abduction bar jointed adjust,Durable Medical Equipment,Per Unit,$252.72 ,OP,252.72,869.3,,,,,,
Meridian Duals,CPT,L2310,Abduction bar-straight,Durable Medical Equipment,Per Unit,$115.47 ,OP,115.47,396.52,,,,,,
Meridian Duals,CPT,L2320,Non-molded lacer,Durable Medical Equipment,Per Unit,$193.64 ,OP,193.64,667.22,,,,,,
Meridian Duals,CPT,L2330,Lacer molded to patient mode,Durable Medical Equipment,Per Unit,$368.55 ,OP,368.55,"1,265.81",,,,,,
Meridian Duals,CPT,L2335,Anterior swing band,Durable Medical Equipment,Per Unit,$282.18 ,OP,282.18,972.25,,,,,,
Meridian Duals,CPT,L2340,Pre-tibial shell molded to p,Durable Medical Equipment,Per Unit,$419.50 ,OP,419.5,"1,441.20",,,,,,
Meridian Duals,CPT,L2350,Prosthetic type socket molde,Durable Medical Equipment,Per Unit,$836.35 ,OP,836.35,"2,874.78",,,,,,
Meridian Duals,CPT,L2360,Extended steel shank,Durable Medical Equipment,Per Unit,$51.76 ,OP,51.76,179.2,,,,,,
Meridian Duals,CPT,L2370,Patten bottom,Durable Medical Equipment,Per Unit,$321.26 ,OP,321.26,"1,105.68",,,,,,
Meridian Duals,CPT,L2375,Torsion ank & half solid sti,Durable Medical Equipment,Per Unit,$123.52 ,OP,123.52,423.22,,,,,,
Meridian Duals,CPT,L2380,Torsion straight knee joint,Durable Medical Equipment,Per Unit,$129.54 ,OP,129.54,446.08,,,,,,
Meridian Duals,CPT,L2385,Straight knee joint heavy du,Durable Medical Equipment,Per Unit,$147.50 ,OP,147.5,507.08,,,,,,
Meridian Duals,CPT,L2387,Add le poly knee custom kafo,Durable Medical Equipment,Per Unit,$191.63 ,OP,191.63,659.6,,,,,,
Meridian Duals,CPT,L2390,Offset knee joint each,Durable Medical Equipment,Per Unit,$102.75 ,OP,102.75,354.58,,,,,,
Meridian Duals,CPT,L2395,Offset knee joint heavy duty,Durable Medical Equipment,Per Unit,$146.86 ,OP,146.86,503.28,,,,,,
Meridian Duals,CPT,L2397,Suspension sleeve lower ext,Durable Medical Equipment,Per Unit,$122.52 ,OP,122.52,423.22,,,,,,
Meridian Duals,CPT,L2405,Knee joint drop lock ea jnt,Durable Medical Equipment,Per Unit,$87.52 ,OP,87.52,301.2,,,,,,
Meridian Duals,CPT,L2415,Knee joint cam lock each joi,Durable Medical Equipment,Per Unit,$121.95 ,OP,121.95,419.4,,,,,,
Meridian Duals,CPT,L2425,Knee disc/dial lock/adj flex,Durable Medical Equipment,Per Unit,$143.90 ,OP,143.9,495.65,,,,,,
Meridian Duals,CPT,L2430,Knee jnt ratchet lock ea jnt,Durable Medical Equipment,Per Unit,$143.90 ,OP,143.9,495.65,,,,,,
Meridian Duals,CPT,L2492,Knee lift loop drop lock rin,Durable Medical Equipment,Per Unit,$117.74 ,OP,117.74,404.14,,,,,,
Meridian Duals,CPT,L2500,Thi/glut/ischia wgt bearing,Durable Medical Equipment,Per Unit,$314.13 ,OP,314.13,"1,078.99",,,,,,
Meridian Duals,CPT,L2510,Th/wght bear quad-lat brim m,Durable Medical Equipment,Per Unit,$809.60 ,OP,809.6,"2,783.26",,,,,,
Meridian Duals,CPT,L2520,Th/wght bear quad-lat brim c,Durable Medical Equipment,Per Unit,$539.56 ,OP,539.56,"1,856.79",,,,,,
Meridian Duals,CPT,L2525,Th/wght bear nar m-l brim mo,Durable Medical Equipment,Per Unit,"$1,144.16 ",OP,"1,144.16","3,934.69",,,,,,
Meridian Duals,CPT,L2526,Th/wght bear nar m-l brim cu,Durable Medical Equipment,Per Unit,$642.90 ,OP,642.9,"2,211.37",,,,,,
Meridian Duals,CPT,L2530,Thigh/wght bear lacer non-mo,Durable Medical Equipment,Per Unit,$240.74 ,OP,240.74,827.35,,,,,,
Meridian Duals,CPT,L2540,Thigh/wght bear lacer molded,Durable Medical Equipment,Per Unit,$455.54 ,OP,455.54,"1,567.02",,,,,,
Meridian Duals,CPT,L2550,Thigh/wght bear high roll cu,Durable Medical Equipment,Per Unit,$341.55 ,OP,341.55,"1,174.31",,,,,,
Meridian Duals,CPT,L2570,Hip clevis type 2 posit jnt,Durable Medical Equipment,Per Unit,$447.07 ,OP,447.07,"1,536.51",,,,,,
Meridian Duals,CPT,L2580,Pelvic control pelvic sling,Durable Medical Equipment,Per Unit,$435.62 ,OP,435.62,"1,498.39",,,,,,
Meridian Duals,CPT,L2600,Hip clevis/thrust bearing fr,Durable Medical Equipment,Per Unit,$214.10 ,OP,214.1,735.85,,,,,,
Meridian Duals,CPT,L2610,Hip clevis/thrust bearing lo,Durable Medical Equipment,Per Unit,$236.58 ,OP,236.58,812.11,,,,,,
Meridian Duals,CPT,L2620,Pelvic control hip heavy dut,Durable Medical Equipment,Per Unit,$250.96 ,OP,250.96,861.67,,,,,,
Meridian Duals,CPT,L2622,Hip joint adjustable flexion,Durable Medical Equipment,Per Unit,$319.42 ,OP,319.42,"1,098.07",,,,,,
Meridian Duals,CPT,L2624,Hip adj flex ext abduct cont,Durable Medical Equipment,Per Unit,$391.68 ,OP,391.68,"1,345.89",,,,,,
Meridian Duals,CPT,L2627,Plastic mold recipro hip & c,Durable Medical Equipment,Per Unit,"$2,145.41 ",OP,"2,145.41","7,377.56",,,,,,
Meridian Duals,CPT,L2628,Metal frame recipro hip & ca,Durable Medical Equipment,Per Unit,"$1,572.54 ",OP,"1,572.54","5,406.41",,,,,,
Meridian Duals,CPT,L2630,Pelvic control band & belt u,Durable Medical Equipment,Per Unit,$232.43 ,OP,232.43,800.67,,,,,,
Meridian Duals,CPT,L2640,Pelvic control band & belt b,Durable Medical Equipment,Per Unit,$315.42 ,OP,315.42,"1,086.62",,,,,,
Meridian Duals,CPT,L2650,Pelv & thor control gluteal,Durable Medical Equipment,Per Unit,$138.91 ,OP,138.91,476.6,,,,,,
Meridian Duals,CPT,L2660,Thoracic control thoracic ba,Durable Medical Equipment,Per Unit,$179.86 ,OP,179.86,617.65,,,,,,
Meridian Duals,CPT,L2670,Thorac cont paraspinal uprig,Durable Medical Equipment,Per Unit,$160.11 ,OP,160.11,549.03,,,,,,
Meridian Duals,CPT,L2680,Thorac cont lat support upri,Durable Medical Equipment,Per Unit,$146.88 ,OP,146.88,503.28,,,,,,
Meridian Duals,CPT,L2750,Plating chrome/nickel pr bar,Durable Medical Equipment,Per Unit,$78.45 ,OP,78.45,270.71,,,,,,
Meridian Duals,CPT,L2755,Carbon graphite lamination,Durable Medical Equipment,Per Unit,$131.16 ,OP,131.16,449.9,,,,,,
Meridian Duals,CPT,L2760,Extension per extension per,Durable Medical Equipment,Per Unit,$57.03 ,OP,57.03,194.45,,,,,,
Meridian Duals,CPT,L2768,Ortho sidebar disconnect,Durable Medical Equipment,Per Unit,$130.78 ,OP,130.78,449.9,,,,,,
Meridian Duals,CPT,L2780,Non-corrosive finish,Durable Medical Equipment,Per Unit,$63.53 ,OP,63.53,217.32,,,,,,
Meridian Duals,CPT,L2785,Drop lock retainer each,Durable Medical Equipment,Per Unit,$29.75 ,OP,29.75,102.95,,,,,,
Meridian Duals,CPT,L2795,Knee control full kneecap,Durable Medical Equipment,Per Unit,$82.32 ,OP,82.32,282.14,,,,,,
Meridian Duals,CPT,L2800,Knee cap medial or lateral p,Durable Medical Equipment,Per Unit,$101.09 ,OP,101.09,101.09,,,,,,
Meridian Duals,CPT,L2810,Knee control condylar pad,Durable Medical Equipment,Per Unit,$81.98 ,OP,81.98,282.14,,,,,,
Meridian Duals,CPT,L2820,Soft interface below knee se,Durable Medical Equipment,Per Unit,$81.51 ,OP,81.51,282.14,,,,,,
Meridian Duals,CPT,L2830,Soft interface above knee se,Durable Medical Equipment,Per Unit,$88.18 ,OP,88.18,305.01,,,,,,
Meridian Duals,CPT,L2840,Tibial length sock fx or equ,Durable Medical Equipment,Per Unit,$43.30 ,OP,43.3,148.69,,,,,,
Meridian Duals,CPT,L2850,Femoral lgth sock fx or equa,Durable Medical Equipment,Per Unit,$60.72 ,OP,60.72,209.7,,,,,,
Meridian Duals,CPT,L3000,Ft insert ucb berkeley shell,Durable Medical Equipment,Per Unit,$315.34 ,OP,315.34,"1,082.81",,,,,,
Meridian Duals,CPT,L3001,Foot insert remov molded spe,Durable Medical Equipment,Per Unit,$132.78 ,OP,132.78,686.28,,,,,,
Meridian Duals,CPT,L3002,Foot insert plastazote or eq,Durable Medical Equipment,Per Unit,$162.12 ,OP,162.12,834.98,,,,,,
Meridian Duals,CPT,L3003,Foot insert silicone gel eac,Durable Medical Equipment,Per Unit,$174.89 ,OP,174.89,903.6,,,,,,
Meridian Duals,CPT,L3010,Foot longitudinal arch suppo,Durable Medical Equipment,Per Unit,$174.89 ,OP,174.89,903.6,,,,,,
Meridian Duals,CPT,L3020,Foot longitud/metatarsal sup,Durable Medical Equipment,Per Unit,$199.16 ,OP,199.16,"1,025.61",,,,,,
Meridian Duals,CPT,L3030,Foot arch support remov prem,Durable Medical Equipment,Per Unit,$76.59 ,OP,76.59,"1,239.13",,,,,,
Meridian Duals,CPT,L3031,Foot lamin/prepreg composite,Durable Medical Equipment,Per Unit,$122.94 ,OP,122.94,"1,334.45",,,,,,
Meridian Duals,CPT,L3040,Ft arch suprt premold longit,Durable Medical Equipment,Per Unit,$47.25 ,OP,47.25,163.95,,,,,,
Meridian Duals,CPT,L3050,Foot arch supp premold metat,Durable Medical Equipment,Per Unit,$47.25 ,OP,47.25,163.95,,,,,,
Meridian Duals,CPT,L3060,Foot arch supp longitud/meta,Durable Medical Equipment,Per Unit,$74.04 ,OP,74.04,255.45,,,,,,
Meridian Duals,CPT,L3070,Arch suprt att to sho longit,Durable Medical Equipment,Per Unit,$31.91 ,OP,31.91,110.57,,,,,,
Meridian Duals,CPT,L3080,Arch supp att to shoe metata,Durable Medical Equipment,Per Unit,$31.91 ,OP,31.91,110.57,,,,,,
Meridian Duals,CPT,L3090,Arch supp att to shoe long/m,Durable Medical Equipment,Per Unit,$40.86 ,OP,40.86,141.07,,,,,,
Meridian Duals,CPT,L3100,Hallus-valgus nt dyn pre ots,Durable Medical Equipment,Per Unit,$43.43 ,OP,43.43,148.69,,,,,,
Meridian Duals,CPT,L3140,Abduction rotation bar shoe,Durable Medical Equipment,Per Unit,$89.37 ,OP,89.37,308.83,,,,,,
Meridian Duals,CPT,L3150,Abduct rotation bar w/o shoe,Durable Medical Equipment,Per Unit,$81.72 ,OP,81.72,282.14,,,,,,
Meridian Duals,CPT,L3170,Foot plas heel stabi pre ots,Durable Medical Equipment,Per Unit,$51.06 ,OP,51.06,175.39,,,,,,
Meridian Duals,CPT,L3224,Woman's shoe oxford brace,Durable Medical Equipment,Per Unit,$67.83 ,OP,67.83,232.58,,,,,,
Meridian Duals,CPT,L3225,Man's shoe oxford brace,Durable Medical Equipment,Per Unit,$74.09 ,OP,74.09,255.45,,,,,,
Meridian Duals,CPT,L3300,Sho lift taper to metatarsal,Durable Medical Equipment,Per Unit,$52.35 ,OP,52.35,179.2,,,,,,
Meridian Duals,CPT,L3310,Shoe lift elev heel/sole neo,Durable Medical Equipment,Per Unit,$81.72 ,OP,81.72,282.14,,,,,,
Meridian Duals,CPT,L3330,Lifts elevation metal extens,Durable Medical Equipment,Per Unit,$568.10 ,OP,568.1,"1,952.10",,,,,,
Meridian Duals,CPT,L3332,Shoe lifts tapered to one-ha,Durable Medical Equipment,Per Unit,$74.04 ,OP,74.04,255.45,,,,,,
Meridian Duals,CPT,L3334,Shoe lifts elevation heel /i,Durable Medical Equipment,Per Unit,$38.28 ,OP,38.28,133.45,,,,,,
Meridian Duals,CPT,L3340,Shoe wedge sach,Durable Medical Equipment,Per Unit,$85.56 ,OP,85.56,293.57,,,,,,
Meridian Duals,CPT,L3350,Shoe heel wedge,Durable Medical Equipment,Per Unit,$22.96 ,OP,22.96,80.07,,,,,,
Meridian Duals,CPT,L3360,Shoe sole wedge outside sole,Durable Medical Equipment,Per Unit,$35.74 ,OP,35.74,122,,,,,,
Meridian Duals,CPT,L3370,Shoe sole wedge between sole,Durable Medical Equipment,Per Unit,$49.79 ,OP,49.79,171.58,,,,,,
Meridian Duals,CPT,L3380,Shoe clubfoot wedge,Durable Medical Equipment,Per Unit,$49.79 ,OP,49.79,171.58,,,,,,
Meridian Duals,CPT,L3390,Shoe outflare wedge,Durable Medical Equipment,Per Unit,$49.79 ,OP,49.79,171.58,,,,,,
Meridian Duals,CPT,L3400,Shoe metatarsal bar wedge ro,Durable Medical Equipment,Per Unit,$40.86 ,OP,40.86,141.07,,,,,,
Meridian Duals,CPT,L3410,Shoe metatarsal bar between,Durable Medical Equipment,Per Unit,$93.19 ,OP,93.19,320.27,,,,,,
Meridian Duals,CPT,L3420,Full sole/heel wedge btween,Durable Medical Equipment,Per Unit,$54.90 ,OP,54.9,190.64,,,,,,
Meridian Duals,CPT,L3430,Sho heel count plast reinfor,Durable Medical Equipment,Per Unit,$160.86 ,OP,160.86,552.84,,,,,,
Meridian Duals,CPT,L3440,Heel leather reinforced,Durable Medical Equipment,Per Unit,$76.59 ,OP,76.59,263.08,,,,,,
Meridian Duals,CPT,L3450,Shoe heel sach cushion type,Durable Medical Equipment,Per Unit,$105.93 ,OP,105.93,105.93,,,,,,
Meridian Duals,CPT,L3455,Shoe heel new leather standa,Durable Medical Equipment,Per Unit,$40.86 ,OP,40.86,141.07,,,,,,
Meridian Duals,CPT,L3460,Shoe heel new rubber standar,Durable Medical Equipment,Per Unit,$34.49 ,OP,34.49,118.19,,,,,,
Meridian Duals,CPT,L3465,Shoe heel thomas with wedge,Durable Medical Equipment,Per Unit,$58.76 ,OP,58.76,202.07,,,,,,
Meridian Duals,CPT,L3470,Shoe heel thomas extend to b,Durable Medical Equipment,Per Unit,$62.54 ,OP,62.54,213.51,,,,,,
Meridian Duals,CPT,L3480,Shoe heel pad & depress for,Durable Medical Equipment,Per Unit,$62.54 ,OP,62.54,213.51,,,,,,
Meridian Duals,CPT,L3500,Ortho shoe add leather insol,Durable Medical Equipment,Per Unit,$29.35 ,OP,29.35,99.13,,,,,,
Meridian Duals,CPT,L3510,Orthopedic shoe add rub insl,Durable Medical Equipment,Per Unit,$29.35 ,OP,29.35,99.13,,,,,,
Meridian Duals,CPT,L3520,O shoe add felt w leath insl,Durable Medical Equipment,Per Unit,$31.91 ,OP,31.91,110.57,,,,,,
Meridian Duals,CPT,L3530,Ortho shoe add half sole,Durable Medical Equipment,Per Unit,$31.91 ,OP,31.91,110.57,,,,,,
Meridian Duals,CPT,L3540,Ortho shoe add full sole,Durable Medical Equipment,Per Unit,$51.06 ,OP,51.06,175.39,,,,,,
Meridian Duals,CPT,L3550,O shoe add standard toe tap,Durable Medical Equipment,Per Unit,$8.97 ,OP,8.97,30.51,,,,,,
Meridian Duals,CPT,L3560,O shoe add horseshoe toe tap,Durable Medical Equipment,Per Unit,$22.96 ,OP,22.96,80.07,,,,,,
Meridian Duals,CPT,L3570,O shoe add instep extension,Durable Medical Equipment,Per Unit,$85.56 ,OP,85.56,293.57,,,,,,
Meridian Duals,CPT,L3580,O shoe add instep velcro clo,Durable Medical Equipment,Per Unit,$65.11 ,OP,65.11,224.95,,,,,,
Meridian Duals,CPT,L3590,O shoe convert to sof counte,Durable Medical Equipment,Per Unit,$53.63 ,OP,53.63,183.02,,,,,,
Meridian Duals,CPT,L3595,Ortho shoe add march bar,Durable Medical Equipment,Per Unit,$42.10 ,OP,42.1,144.88,,,,,,
Meridian Duals,CPT,L3600,Trans shoe calip plate exist,Durable Medical Equipment,Per Unit,$76.59 ,OP,76.59,263.08,,,,,,
Meridian Duals,CPT,L3610,Trans shoe caliper plate new,Durable Medical Equipment,Per Unit,$100.86 ,OP,100.86,346.96,,,,,,
Meridian Duals,CPT,L3620,Trans shoe solid stirrup exi,Durable Medical Equipment,Per Unit,$76.59 ,OP,76.59,263.08,,,,,,
Meridian Duals,CPT,L3630,Trans shoe solid stirrup new,Durable Medical Equipment,Per Unit,$100.86 ,OP,100.86,346.96,,,,,,
Meridian Duals,CPT,L3640,Shoe dennis browne splint bo,Durable Medical Equipment,Per Unit,$43.43 ,OP,43.43,148.69,,,,,,
Meridian Duals,CPT,L3650,So 8 abd restraint pre ots,Durable Medical Equipment,Per Unit,$65.83 ,OP,65.83,224.95,,,,,,
Meridian Duals,CPT,L3660,So 8 ab rstr can/web pre ots,Durable Medical Equipment,Per Unit,$94.40 ,OP,94.4,324.09,,,,,,
Meridian Duals,CPT,L3670,So acro/clav can web pre ots,Durable Medical Equipment,Per Unit,$103.86 ,OP,103.86,358.39,,,,,,
Meridian Duals,CPT,L3671,So cap design w/o jnts cf,Durable Medical Equipment,Per Unit,$823.17 ,OP,823.17,"2,832.83",,,,,,
Meridian Duals,CPT,L3674,So airplane w/wo joint cf,Durable Medical Equipment,Per Unit,"$1,079.87 ",OP,"1,079.87","1,079.87",,,,,,
Meridian Duals,CPT,L3675,So vest canvas/web pre ots,Durable Medical Equipment,Per Unit,$160.35 ,OP,160.35,552.84,,,,,,
Meridian Duals,CPT,L3702,Eo w/o joints cf,Durable Medical Equipment,Per Unit,$263.81 ,OP,263.81,907.42,,,,,,
Meridian Duals,CPT,L3710,Eo elas w/metal jnts pre ots,Durable Medical Equipment,Per Unit,$130.45 ,OP,130.45,449.9,,,,,,
Meridian Duals,CPT,L3720,Forearm/arm cuffs free motio,Durable Medical Equipment,Per Unit,$624.22 ,OP,624.22,"2,146.54",,,,,,
Meridian Duals,CPT,L3730,Forearm/arm cuffs ext/flex a,Durable Medical Equipment,Per Unit,$827.96 ,OP,827.96,"2,848.08",,,,,,
Meridian Duals,CPT,L3740,Cuffs adj lock w/ active con,Durable Medical Equipment,Per Unit,$981.62 ,OP,981.62,"3,374.24",,,,,,
Meridian Duals,CPT,L3760,Eo adj jt prefab custom fit,Durable Medical Equipment,Per Unit,$456.89 ,OP,456.89,"1,570.83",,,,,,
Meridian Duals,CPT,L3761,Eo- adj lock joint prefab ot,Durable Medical Equipment,Per Unit,$456.89 ,OP,456.89,456.89,,,,,,
Meridian Duals,CPT,L3762,Eo rigid w/o joints pre ots,Durable Medical Equipment,Per Unit,$98.22 ,OP,98.22,339.33,,,,,,
Meridian Duals,CPT,L3763,Ewho rigid w/o jnts cf,Durable Medical Equipment,Per Unit,$683.66 ,OP,683.66,"2,352.44",,,,,,
Meridian Duals,CPT,L3764,Ewho w/joint(s) cf,Durable Medical Equipment,Per Unit,$715.47 ,OP,715.47,"2,459.19",,,,,,
Meridian Duals,CPT,L3765,Ewhfo rigid w/o jnts cf,Durable Medical Equipment,Per Unit,"$1,171.43 ",OP,"1,171.43","4,030.02",,,,,,
Meridian Duals,CPT,L3766,Ewhfo w/joint(s) cf,Durable Medical Equipment,Per Unit,"$1,240.47 ",OP,"1,240.47","4,266.40",,,,,,
Meridian Duals,CPT,L3806,Whfo w/joint(s) custom fab,Durable Medical Equipment,Per Unit,$414.97 ,OP,414.97,"1,425.95",,,,,,
Meridian Duals,CPT,L3807,Whfo w/o joints pre cst,Durable Medical Equipment,Per Unit,$228.43 ,OP,228.43,785.42,,,,,,
Meridian Duals,CPT,L3808,Whfo- rigid w/o joints,Durable Medical Equipment,Per Unit,$325.43 ,OP,325.43,"1,120.94",,,,,,
Meridian Duals,CPT,L3809,Whfo w/o joints pre ots,Durable Medical Equipment,Per Unit,$228.43 ,OP,228.43,228.43,,,,,,
Meridian Duals,CPT,L3900,Hinge extension/flex wrist/f,Durable Medical Equipment,Per Unit,"$1,479.93 ",OP,"1,479.93","5,089.95",,,,,,
Meridian Duals,CPT,L3901,Hinge ext/flex wrist finger,Durable Medical Equipment,Per Unit,"$1,939.53 ",OP,"1,939.53","6,668.40",,,,,,
Meridian Duals,CPT,L3904,Whfo electric custom fitted,Durable Medical Equipment,Per Unit,"$3,083.64 ",OP,"3,083.64","10,603.11",,,,,,
Meridian Duals,CPT,L3905,Who w/nontorsion jnt(s) cf,Durable Medical Equipment,Per Unit,$905.97 ,OP,905.97,"3,114.97",,,,,,
Meridian Duals,CPT,L3906,Who w/o joints cf,Durable Medical Equipment,Per Unit,$462.97 ,OP,462.97,"1,593.72",,,,,,
Meridian Duals,CPT,L3908,Who cock-up nonmolde pre ots,Durable Medical Equipment,Per Unit,$66.98 ,OP,66.98,228.77,,,,,,
Meridian Duals,CPT,L3912,Hfo flexion glove pre ots,Durable Medical Equipment,Per Unit,$96.25 ,OP,96.25,331.7,,,,,,
Meridian Duals,CPT,L3913,Hfo w/o joints cf,Durable Medical Equipment,Per Unit,$247.41 ,OP,247.41,850.23,,,,,,
Meridian Duals,CPT,L3915,Who nontorsion jnts pre cst,Durable Medical Equipment,Per Unit,$485.63 ,OP,485.63,"1,669.97",,,,,,
Meridian Duals,CPT,L3916,Who nontorsion jnts pre ots,Durable Medical Equipment,Per Unit,$485.63 ,OP,485.63,485.63,,,,,,
Meridian Duals,CPT,L3917,Metacarp fx orthosis pre cst,Durable Medical Equipment,Per Unit,$96.47 ,OP,96.47,331.7,,,,,,
Meridian Duals,CPT,L3918,Metacarp fx orthosis pre ots,Durable Medical Equipment,Per Unit,$96.47 ,OP,96.47,96.47,,,,,,
Meridian Duals,CPT,L3919,Ho w/o joints cf,Durable Medical Equipment,Per Unit,$247.41 ,OP,247.41,850.23,,,,,,
Meridian Duals,CPT,L3921,Hfo w/joint(s) cf,Durable Medical Equipment,Per Unit,$293.46 ,OP,293.46,"1,010.37",,,,,,
Meridian Duals,CPT,L3923,Hfo without joints pre cst,Durable Medical Equipment,Per Unit,$88.25 ,OP,88.25,305.01,,,,,,
Meridian Duals,CPT,L3924,Hfo without joints pre ots,Durable Medical Equipment,Per Unit,$88.25 ,OP,88.25,88.25,,,,,,
Meridian Duals,CPT,L3925,Fo pip dip jnt/sprng pre ots,Durable Medical Equipment,Per Unit,$60.01 ,OP,60.01,205.88,,,,,,
Meridian Duals,CPT,L3927,Fo pip dip no jt spr pre ots,Durable Medical Equipment,Per Unit,$31.98 ,OP,31.98,110.57,,,,,,
Meridian Duals,CPT,L3929,Hfo nontorsion jnts pre cst,Durable Medical Equipment,Per Unit,$83.44 ,OP,83.44,285.96,,,,,,
Meridian Duals,CPT,L3930,Hfo nontorsion jnts pre ots,Durable Medical Equipment,Per Unit,$83.44 ,OP,83.44,83.44,,,,,,
Meridian Duals,CPT,L3931,Whfo nontorsion joint prefab,Durable Medical Equipment,Per Unit,$190.48 ,OP,190.48,655.78,,,,,,
Meridian Duals,CPT,L3933,Fo w/o joints cf,Durable Medical Equipment,Per Unit,$194.93 ,OP,194.93,671.03,,,,,,
Meridian Duals,CPT,L3935,Fo nontorsion joint cf,Durable Medical Equipment,Per Unit,$201.82 ,OP,201.82,693.9,,,,,,
Meridian Duals,CPT,L3960,Sewho airplan desig abdu pos,Durable Medical Equipment,Per Unit,$728.64 ,OP,728.64,"2,504.94",,,,,,
Meridian Duals,CPT,L3961,Sewho cap design w/o jnts cf,Durable Medical Equipment,Per Unit,"$1,534.92 ",OP,"1,534.92","5,280.58",,,,,,
Meridian Duals,CPT,L3962,Sewho erbs palsey design abd,Durable Medical Equipment,Per Unit,$659.00 ,OP,659,"2,264.75",,,,,,
Meridian Duals,CPT,L3967,Sewho airplane w/o jnts cf,Durable Medical Equipment,Per Unit,"$1,812.20 ",OP,"1,812.20","6,233.76",,,,,,
Meridian Duals,CPT,L3971,Sewho cap design w/jnt(s) cf,Durable Medical Equipment,Per Unit,"$1,720.20 ",OP,"1,720.20","5,917.29",,,,,,
Meridian Duals,CPT,L3973,Sewho airplane w/jnt(s) cf,Durable Medical Equipment,Per Unit,"$1,812.20 ",OP,"1,812.20","6,233.76",,,,,,
Meridian Duals,CPT,L3975,Sewhfo cap design w/o jnt cf,Durable Medical Equipment,Per Unit,"$1,534.92 ",OP,"1,534.92","5,280.58",,,,,,
Meridian Duals,CPT,L3976,Sewhfo airplane w/o jnts cf,Durable Medical Equipment,Per Unit,"$1,534.92 ",OP,"1,534.92","5,280.58",,,,,,
Meridian Duals,CPT,L3977,Sewhfo cap desgn w/jnt(s) cf,Durable Medical Equipment,Per Unit,"$1,720.20 ",OP,"1,720.20","5,917.29",,,,,,
Meridian Duals,CPT,L3978,Sewhfo airplane w/jnt(s) cf,Durable Medical Equipment,Per Unit,"$1,812.20 ",OP,"1,812.20","6,233.76",,,,,,
Meridian Duals,CPT,L3980,Up ext fx orthos humeral nos,Durable Medical Equipment,Per Unit,$353.43 ,OP,353.43,"1,216.24",,,,,,
Meridian Duals,CPT,L3981,Ue fx orth shoul cap forearm,Durable Medical Equipment,Per Unit,$919.57 ,OP,919.57,919.57,,,,,,
Meridian Duals,CPT,L3982,Upper ext fx orthosis rad/ul,Durable Medical Equipment,Per Unit,$358.87 ,OP,358.87,"1,235.32",,,,,,
Meridian Duals,CPT,L3984,Upper ext fx orthosis wrist,Durable Medical Equipment,Per Unit,$316.13 ,OP,316.13,"1,086.62",,,,,,
Meridian Duals,CPT,L3995,Sock fracture or equal each,Durable Medical Equipment,Per Unit,$37.51 ,OP,37.51,129.64,,,,,,
Meridian Duals,CPT,L4000,Repl girdle milwaukee orth,Durable Medical Equipment,Per Unit,"$1,326.47 ",OP,"1,326.47","4,559.97",,,,,,
Meridian Duals,CPT,L4010,Replace trilateral socket br,Durable Medical Equipment,Per Unit,$806.25 ,OP,806.25,"2,771.83",,,,,,
Meridian Duals,CPT,L4020,Replace quadlat socket brim,Durable Medical Equipment,Per Unit,$968.52 ,OP,968.52,"3,332.30",,,,,,
Meridian Duals,CPT,L4030,Replace socket brim cust fit,Durable Medical Equipment,Per Unit,$615.47 ,OP,615.47,"2,116.06",,,,,,
Meridian Duals,CPT,L4040,Replace molded thigh lacer,Durable Medical Equipment,Per Unit,$416.80 ,OP,416.8,"1,433.58",,,,,,
Meridian Duals,CPT,L4045,Replace non-molded thigh lac,Durable Medical Equipment,Per Unit,$307.89 ,OP,307.89,"1,059.93",,,,,,
Meridian Duals,CPT,L4050,Replace molded calf lacer,Durable Medical Equipment,Per Unit,$412.80 ,OP,412.8,"1,418.32",,,,,,
Meridian Duals,CPT,L4055,Replace non-molded calf lace,Durable Medical Equipment,Per Unit,$250.92 ,OP,250.92,861.67,,,,,,
Meridian Duals,CPT,L4060,Replace high roll cuff,Durable Medical Equipment,Per Unit,$326.17 ,OP,326.17,"1,120.94",,,,,,
Meridian Duals,CPT,L4070,Replace prox & dist upright,Durable Medical Equipment,Per Unit,$264.15 ,OP,264.15,907.42,,,,,,
Meridian Duals,CPT,L4080,Repl met band kafo-afo prox,Durable Medical Equipment,Per Unit,$99.72 ,OP,99.72,343.14,,,,,,
Meridian Duals,CPT,L4090,Repl met band kafo-afo calf/,Durable Medical Equipment,Per Unit,$84.84 ,OP,84.84,293.57,,,,,,
Meridian Duals,CPT,L4100,Repl leath cuff kafo prox th,Durable Medical Equipment,Per Unit,$101.94 ,OP,101.94,350.76,,,,,,
Meridian Duals,CPT,L4110,Repl leath cuff kafo-afo cal,Durable Medical Equipment,Per Unit,$79.60 ,OP,79.6,274.51,,,,,,
Meridian Duals,CPT,L4130,Replace pretibial shell,Durable Medical Equipment,Per Unit,$481.14 ,OP,481.14,"1,654.72",,,,,,
Meridian Duals,CPT,L4350,Ankle control ortho pre ots,Durable Medical Equipment,Per Unit,$97.13 ,OP,97.13,335.53,,,,,,
Meridian Duals,CPT,L4360,Pneumat walking boot pre cst,Durable Medical Equipment,Per Unit,$259.89 ,OP,259.89,892.18,,,,,,
Meridian Duals,CPT,L4361,Pneuma/vac walk boot pre ots,Durable Medical Equipment,Per Unit,$259.89 ,OP,259.89,259.89,,,,,,
Meridian Duals,CPT,L4370,Pneum full leg splnt pre ots,Durable Medical Equipment,Per Unit,$236.26 ,OP,236.26,812.11,,,,,,
Meridian Duals,CPT,L4386,Non-pneum walk boot pre cst,Durable Medical Equipment,Per Unit,$159.16 ,OP,159.16,549.03,,,,,,
Meridian Duals,CPT,L4387,Non-pneum walk boot pre ots,Durable Medical Equipment,Per Unit,$159.16 ,OP,159.16,159.16,,,,,,
Meridian Duals,CPT,L4392,Replace afo soft interface,Durable Medical Equipment,Per Unit,$23.62 ,OP,23.62,80.07,,,,,,
Meridian Duals,CPT,L4394,Replace foot drop spint,Durable Medical Equipment,Per Unit,$17.23 ,OP,17.23,61,,,,,,
Meridian Duals,CPT,L4396,Static or dynami afo pre cst,Durable Medical Equipment,Per Unit,$168.46 ,OP,168.46,579.53,,,,,,
Meridian Duals,CPT,L4397,Static or dynami afo pre ots,Durable Medical Equipment,Per Unit,$168.46 ,OP,168.46,168.46,,,,,,
Meridian Duals,CPT,L4398,Foot drop splint pre ots,Durable Medical Equipment,Per Unit,$77.54 ,OP,77.54,266.89,,,,,,
Meridian Duals,CPT,L4631,Afo- walk boot type- cus fab,Durable Medical Equipment,Per Unit,"$1,479.79 ",OP,"1,479.79","1,479.79",,,,,,
Meridian Duals,CPT,L5000,Sho insert w arch toe filler,Durable Medical Equipment,Per Unit,$576.42 ,OP,576.42,"1,982.60",,,,,,
Meridian Duals,CPT,L5010,Mold socket ank hgt w/ toe f,Durable Medical Equipment,Per Unit,"$1,610.60 ",OP,"1,610.60","5,539.84",,,,,,
Meridian Duals,CPT,L5020,Tibial tubercle hgt w/ toe f,Durable Medical Equipment,Per Unit,"$2,523.29 ",OP,"2,523.29","8,677.68",,,,,,
Meridian Duals,CPT,L5050,Ank symes mold sckt sach ft,Durable Medical Equipment,Per Unit,"$2,755.91 ",OP,"2,755.91","9,478.35",,,,,,
Meridian Duals,CPT,L5060,Symes met fr leath socket ar,Durable Medical Equipment,Per Unit,"$3,397.24 ",OP,"3,397.24","11,682.09",,,,,,
Meridian Duals,CPT,L5100,Molded socket shin sach foot,Durable Medical Equipment,Per Unit,"$2,744.12 ",OP,"2,744.12","9,436.43",,,,,,
Meridian Duals,CPT,L5105,Plast socket jts/thgh lacer,Durable Medical Equipment,Per Unit,"$3,872.55 ",OP,"3,872.55","13,317.74",,,,,,
Meridian Duals,CPT,L5150,Mold sckt ext knee shin sach,Durable Medical Equipment,Per Unit,"$4,305.35 ",OP,"4,305.35","14,804.69",,,,,,
Meridian Duals,CPT,L5160,Mold socket bent knee shin s,Durable Medical Equipment,Per Unit,"$4,727.07 ",OP,"4,727.07","16,257.32",,,,,,
Meridian Duals,CPT,L5200,Kne sing axis fric shin sach,Durable Medical Equipment,Per Unit,"$3,656.04 ",OP,"3,656.04","12,574.26",,,,,,
Meridian Duals,CPT,L5210,No knee/ankle joints w/ ft b,Durable Medical Equipment,Per Unit,"$2,902.89 ",OP,"2,902.89","9,981.64",,,,,,
Meridian Duals,CPT,L5220,No knee joint with artic ali,Durable Medical Equipment,Per Unit,"$3,197.74 ",OP,"3,197.74","10,995.81",,,,,,
Meridian Duals,CPT,L5230,Fem focal defic constant fri,Durable Medical Equipment,Per Unit,"$4,796.11 ",OP,"4,796.11","16,493.71",,,,,,
Meridian Duals,CPT,L5250,Hip canad sing axi cons fric,Durable Medical Equipment,Per Unit,"$5,623.57 ",OP,"5,623.57","19,341.79",,,,,,
Meridian Duals,CPT,L5270,Tilt table locking hip sing,Durable Medical Equipment,Per Unit,"$6,265.76 ",OP,"6,265.76","21,549.33",,,,,,
Meridian Duals,CPT,L5280,Hemipelvect canad sing axis,Durable Medical Equipment,Per Unit,"$6,090.55 ",OP,"6,090.55","20,946.94",,,,,,
Meridian Duals,CPT,L5301,Bk mold socket sach ft endo,Durable Medical Equipment,Per Unit,"$2,694.66 ",OP,"2,694.66","9,268.66",,,,,,
Meridian Duals,CPT,L5312,Knee disart- sach ft- endo,Durable Medical Equipment,Per Unit,"$4,245.62 ",OP,"4,245.62","4,245.62",,,,,,
Meridian Duals,CPT,L5321,Ak open end sach,Durable Medical Equipment,Per Unit,"$3,593.24 ",OP,"3,593.24","12,356.94",,,,,,
Meridian Duals,CPT,L5331,Hip disart canadian sach ft,Durable Medical Equipment,Per Unit,"$5,262.80 ",OP,"5,262.80","18,098.85",,,,,,
Meridian Duals,CPT,L5341,Hemipelvectomy canadian sach,Durable Medical Equipment,Per Unit,"$5,594.28 ",OP,"5,594.28","19,238.85",,,,,,
Meridian Duals,CPT,L5400,Postop dress & 1 cast chg bk,Durable Medical Equipment,Per Unit,"$1,604.68 ",OP,"1,604.68","5,516.97",,,,,,
Meridian Duals,CPT,L5410,Postop dsg bk ea add cast ch,Durable Medical Equipment,Per Unit,$443.32 ,OP,443.32,"1,525.07",,,,,,
Meridian Duals,CPT,L5420,Postop dsg & 1 cast chg ak/d,Durable Medical Equipment,Per Unit,"$2,026.64 ",OP,"2,026.64","6,969.60",,,,,,
Meridian Duals,CPT,L5430,Postop dsg ak ea add cast ch,Durable Medical Equipment,Per Unit,$550.12 ,OP,550.12,"1,891.10",,,,,,
Meridian Duals,CPT,L5450,Postop app non-wgt bear dsg,Durable Medical Equipment,Per Unit,$475.67 ,OP,475.67,"1,635.64",,,,,,
Meridian Duals,CPT,L5460,Postop app non-wgt bear dsg,Durable Medical Equipment,Per Unit,$623.89 ,OP,623.89,"2,146.54",,,,,,
Meridian Duals,CPT,L5500,Init bk ptb plaster direct,Durable Medical Equipment,Per Unit,"$1,483.19 ",OP,"1,483.19","5,101.39",,,,,,
Meridian Duals,CPT,L5505,Init ak ischal plstr direct,Durable Medical Equipment,Per Unit,"$2,086.44 ",OP,"2,086.44","7,175.49",,,,,,
Meridian Duals,CPT,L5510,Prep bk ptb plaster molded,Durable Medical Equipment,Per Unit,"$1,771.18 ",OP,"1,771.18","6,092.69",,,,,,
Meridian Duals,CPT,L5520,Perp bk ptb thermopls direct,Durable Medical Equipment,Per Unit,"$1,587.65 ",OP,"1,587.65","5,459.77",,,,,,
Meridian Duals,CPT,L5530,Prep bk ptb thermopls molded,Durable Medical Equipment,Per Unit,"$2,087.07 ",OP,"2,087.07","7,179.30",,,,,,
Meridian Duals,CPT,L5535,Prep bk ptb open end socket,Durable Medical Equipment,Per Unit,"$1,945.59 ",OP,"1,945.59","6,691.29",,,,,,
Meridian Duals,CPT,L5540,Prep bk ptb laminated socket,Durable Medical Equipment,Per Unit,"$2,060.66 ",OP,"2,060.66","7,087.80",,,,,,
Meridian Duals,CPT,L5560,Prep ak ischial plast molded,Durable Medical Equipment,Per Unit,"$2,348.01 ",OP,"2,348.01","8,075.28",,,,,,
Meridian Duals,CPT,L5570,Prep ak ischial direct form,Durable Medical Equipment,Per Unit,"$2,278.83 ",OP,"2,278.83","7,838.89",,,,,,
Meridian Duals,CPT,L5580,Prep ak ischial thermo mold,Durable Medical Equipment,Per Unit,"$2,828.36 ",OP,"2,828.36","9,726.18",,,,,,
Meridian Duals,CPT,L5585,Prep ak ischial open end,Durable Medical Equipment,Per Unit,"$3,312.24 ",OP,"3,312.24","11,392.33",,,,,,
Meridian Duals,CPT,L5590,Prep ak ischial laminated,Durable Medical Equipment,Per Unit,"$2,948.85 ",OP,"2,948.85","10,141.77",,,,,,
Meridian Duals,CPT,L5595,Hip disartic sach thermopls,Durable Medical Equipment,Per Unit,"$4,608.29 ",OP,"4,608.29","15,849.36",,,,,,
Meridian Duals,CPT,L5600,Hip disart sach laminat mold,Durable Medical Equipment,Per Unit,"$5,244.91 ",OP,"5,244.91","18,037.85",,,,,,
Meridian Duals,CPT,L5610,Above knee hydracadence,Durable Medical Equipment,Per Unit,"$2,529.59 ",OP,"2,529.59","8,700.56",,,,,,
Meridian Duals,CPT,L5611,Ak 4 bar link w/fric swing,Durable Medical Equipment,Per Unit,"$1,611.13 ",OP,"1,611.13","5,539.84",,,,,,
Meridian Duals,CPT,L5613,Ak 4 bar ling w/hydraul swig,Durable Medical Equipment,Per Unit,"$2,450.64 ",OP,"2,450.64","8,429.87",,,,,,
Meridian Duals,CPT,L5614,4-bar link above knee w/swng,Durable Medical Equipment,Per Unit,"$1,697.23 ",OP,"1,697.23","5,837.23",,,,,,
Meridian Duals,CPT,L5616,Ak univ multiplex sys frict,Durable Medical Equipment,Per Unit,"$1,477.66 ",OP,"1,477.66","5,082.32",,,,,,
Meridian Duals,CPT,L5617,Ak/bk self-aligning unit ea,Durable Medical Equipment,Per Unit,$562.74 ,OP,562.74,"1,936.85",,,,,,
Meridian Duals,CPT,L5618,Test socket symes,Durable Medical Equipment,Per Unit,$336.06 ,OP,336.06,"1,155.24",,,,,,
Meridian Duals,CPT,L5620,Test socket below knee,Durable Medical Equipment,Per Unit,$298.16 ,OP,298.16,"1,025.61",,,,,,
Meridian Duals,CPT,L5622,Test socket knee disarticula,Durable Medical Equipment,Per Unit,$401.70 ,OP,401.7,"1,380.19",,,,,,
Meridian Duals,CPT,L5624,Test socket above knee,Durable Medical Equipment,Per Unit,$401.54 ,OP,401.54,"1,380.19",,,,,,
Meridian Duals,CPT,L5626,Test socket hip disarticulat,Durable Medical Equipment,Per Unit,$635.70 ,OP,635.7,"2,184.67",,,,,,
Meridian Duals,CPT,L5628,Test socket hemipelvectomy,Durable Medical Equipment,Per Unit,$643.74 ,OP,643.74,"2,215.19",,,,,,
Meridian Duals,CPT,L5629,Below knee acrylic socket,Durable Medical Equipment,Per Unit,$317.79 ,OP,317.79,"1,094.25",,,,,,
Meridian Duals,CPT,L5630,Syme typ expandabl wall sckt,Durable Medical Equipment,Per Unit,$552.17 ,OP,552.17,"1,898.73",,,,,,
Meridian Duals,CPT,L5631,Ak/knee disartic acrylic soc,Durable Medical Equipment,Per Unit,$439.37 ,OP,439.37,"1,509.83",,,,,,
Meridian Duals,CPT,L5632,Symes type ptb brim design s,Durable Medical Equipment,Per Unit,$270.81 ,OP,270.81,930.3,,,,,,
Meridian Duals,CPT,L5634,Symes type poster opening so,Durable Medical Equipment,Per Unit,$338.66 ,OP,338.66,"1,162.87",,,,,,
Meridian Duals,CPT,L5636,Symes type medial opening so,Durable Medical Equipment,Per Unit,$258.86 ,OP,258.86,888.36,,,,,,
Meridian Duals,CPT,L5637,Below knee total contact,Durable Medical Equipment,Per Unit,$385.17 ,OP,385.17,"1,323.01",,,,,,
Meridian Duals,CPT,L5638,Below knee leather socket,Durable Medical Equipment,Per Unit,$648.87 ,OP,648.87,"2,230.43",,,,,,
Meridian Duals,CPT,L5639,Below knee wood socket,Durable Medical Equipment,Per Unit,"$1,121.15 ",OP,"1,121.15","3,854.63",,,,,,
Meridian Duals,CPT,L5640,Knee disarticulat leather so,Durable Medical Equipment,Per Unit,$736.94 ,OP,736.94,"2,535.44",,,,,,
Meridian Duals,CPT,L5642,Above knee leather socket,Durable Medical Equipment,Per Unit,$683.11 ,OP,683.11,"2,348.62",,,,,,
Meridian Duals,CPT,L5643,Hip flex inner socket ext fr,Durable Medical Equipment,Per Unit,"$2,014.84 ",OP,"2,014.84","6,927.67",,,,,,
Meridian Duals,CPT,L5644,Above knee wood socket,Durable Medical Equipment,Per Unit,$590.63 ,OP,590.63,"2,032.17",,,,,,
Meridian Duals,CPT,L5645,Bk flex inner socket ext fra,Durable Medical Equipment,Per Unit,$979.82 ,OP,979.82,"3,370.43",,,,,,
Meridian Duals,CPT,L5646,Below knee cushion socket,Durable Medical Equipment,Per Unit,$620.93 ,OP,620.93,"2,135.11",,,,,,
Meridian Duals,CPT,L5647,Below knee suction socket,Durable Medical Equipment,Per Unit,$795.44 ,OP,795.44,"2,733.70",,,,,,
Meridian Duals,CPT,L5648,Above knee cushion socket,Durable Medical Equipment,Per Unit,$733.68 ,OP,733.68,"2,524.00",,,,,,
Meridian Duals,CPT,L5649,Isch containmt/narrow m-l so,Durable Medical Equipment,Per Unit,"$2,465.24 ",OP,"2,465.24","8,479.43",,,,,,
Meridian Duals,CPT,L5650,Tot contact ak/knee disart s,Durable Medical Equipment,Per Unit,$488.17 ,OP,488.17,"1,677.58",,,,,,
Meridian Duals,CPT,L5651,Ak flex inner socket ext fra,Durable Medical Equipment,Per Unit,"$1,430.29 ",OP,"1,430.29","4,918.37",,,,,,
Meridian Duals,CPT,L5652,Suction susp ak/knee disart,Durable Medical Equipment,Per Unit,$435.97 ,OP,435.97,"1,498.39",,,,,,
Meridian Duals,CPT,L5653,Knee disart expand wall sock,Durable Medical Equipment,Per Unit,$680.24 ,OP,680.24,"2,341.00",,,,,,
Meridian Duals,CPT,L5654,Socket insert symes,Durable Medical Equipment,Per Unit,$394.33 ,OP,394.33,"1,357.32",,,,,,
Meridian Duals,CPT,L5655,Socket insert below knee,Durable Medical Equipment,Per Unit,$284.71 ,OP,284.71,979.86,,,,,,
Meridian Duals,CPT,L5656,Socket insert knee articulat,Durable Medical Equipment,Per Unit,$432.53 ,OP,432.53,"1,486.95",,,,,,
Meridian Duals,CPT,L5658,Socket insert above knee,Durable Medical Equipment,Per Unit,$456.55 ,OP,456.55,"1,570.83",,,,,,
Meridian Duals,CPT,L5661,Multi-durometer symes,Durable Medical Equipment,Per Unit,$655.04 ,OP,655.04,"2,253.31",,,,,,
Meridian Duals,CPT,L5665,Multi-durometer below knee,Durable Medical Equipment,Per Unit,$582.36 ,OP,582.36,"2,001.67",,,,,,
Meridian Duals,CPT,L5666,Below knee cuff suspension,Durable Medical Equipment,Per Unit,$77.11 ,OP,77.11,266.89,,,,,,
Meridian Duals,CPT,L5668,Bk molded distal cushion,Durable Medical Equipment,Per Unit,$114.86 ,OP,114.86,396.52,,,,,,
Meridian Duals,CPT,L5670,Bk molded supracondylar susp,Durable Medical Equipment,Per Unit,$271.35 ,OP,271.35,934.12,,,,,,
Meridian Duals,CPT,L5671,Bk/ak locking mechanism,Durable Medical Equipment,Per Unit,$497.40 ,OP,497.4,"1,711.89",,,,,,
Meridian Duals,CPT,L5672,Bk removable medial brim sus,Durable Medical Equipment,Per Unit,$359.07 ,OP,359.07,"1,235.32",,,,,,
Meridian Duals,CPT,L5673,Socket insert w lock mech,Durable Medical Equipment,Per Unit,$790.52 ,OP,790.52,"2,718.45",,,,,,
Meridian Duals,CPT,L5676,Bk knee joints single axis p,Durable Medical Equipment,Per Unit,$362.36 ,OP,362.36,"1,246.76",,,,,,
Meridian Duals,CPT,L5677,Bk knee joints polycentric p,Durable Medical Equipment,Per Unit,$554.97 ,OP,554.97,"1,910.16",,,,,,
Meridian Duals,CPT,L5678,Bk joint covers pair,Durable Medical Equipment,Per Unit,$39.70 ,OP,39.7,137.25,,,,,,
Meridian Duals,CPT,L5679,Socket insert w/o lock mech,Durable Medical Equipment,Per Unit,$658.75 ,OP,658.75,"2,264.75",,,,,,
Meridian Duals,CPT,L5680,Bk thigh lacer non-molded,Durable Medical Equipment,Per Unit,$304.37 ,OP,304.37,"1,048.50",,,,,,
Meridian Duals,CPT,L5681,Intl custm cong/latyp insert,Durable Medical Equipment,Per Unit,"$1,323.02 ",OP,"1,323.02","4,548.54",,,,,,
Meridian Duals,CPT,L5682,Bk thigh lacer glut/ischia m,Durable Medical Equipment,Per Unit,$625.37 ,OP,625.37,"2,150.36",,,,,,
Meridian Duals,CPT,L5683,Initial custom socket insert,Durable Medical Equipment,Per Unit,"$1,323.02 ",OP,"1,323.02","4,548.54",,,,,,
Meridian Duals,CPT,L5684,Bk fork strap,Durable Medical Equipment,Per Unit,$48.13 ,OP,48.13,163.95,,,,,,
Meridian Duals,CPT,L5685,Below knee sus/seal sleeve,Durable Medical Equipment,Per Unit,$128.85 ,OP,128.85,442.27,,,,,,
Meridian Duals,CPT,L5686,Bk back check,Durable Medical Equipment,Per Unit,$57.89 ,OP,57.89,198.25,,,,,,
Meridian Duals,CPT,L5688,Bk waist belt webbing,Durable Medical Equipment,Per Unit,$61.48 ,OP,61.48,209.7,,,,,,
Meridian Duals,CPT,L5690,Bk waist belt padded and lin,Durable Medical Equipment,Per Unit,$125.50 ,OP,125.5,430.83,,,,,,
Meridian Duals,CPT,L5692,Ak pelvic control belt light,Durable Medical Equipment,Per Unit,$132.88 ,OP,132.88,457.52,,,,,,
Meridian Duals,CPT,L5694,Ak pelvic control belt pad/l,Durable Medical Equipment,Per Unit,$181.41 ,OP,181.41,625.29,,,,,,
Meridian Duals,CPT,L5695,Ak sleeve susp neoprene/equa,Durable Medical Equipment,Per Unit,$163.08 ,OP,163.08,560.47,,,,,,
Meridian Duals,CPT,L5696,Ak/knee disartic pelvic join,Durable Medical Equipment,Per Unit,$196.99 ,OP,196.99,678.66,,,,,,
Meridian Duals,CPT,L5697,Ak/knee disartic pelvic band,Durable Medical Equipment,Per Unit,$93.55 ,OP,93.55,320.27,,,,,,
Meridian Duals,CPT,L5698,Ak/knee disartic silesian ba,Durable Medical Equipment,Per Unit,$120.01 ,OP,120.01,411.78,,,,,,
Meridian Duals,CPT,L5699,Shoulder harness,Durable Medical Equipment,Per Unit,$205.11 ,OP,205.11,705.35,,,,,,
Meridian Duals,CPT,L5700,Replace socket below knee,Durable Medical Equipment,Per Unit,"$3,085.07 ",OP,"3,085.07","10,610.72",,,,,,
Meridian Duals,CPT,L5701,Replace socket above knee,Durable Medical Equipment,Per Unit,"$3,827.32 ",OP,"3,827.32","13,161.41",,,,,,
Meridian Duals,CPT,L5702,Replace socket hip,Durable Medical Equipment,Per Unit,"$4,823.75 ",OP,"4,823.75","16,589.03",,,,,,
Meridian Duals,CPT,L5703,Symes ankle w/o (sach) foot,Durable Medical Equipment,Per Unit,"$2,537.43 ",OP,"2,537.43","8,727.25",,,,,,
Meridian Duals,CPT,L5704,Custom shape cover bk,Durable Medical Equipment,Per Unit,$629.03 ,OP,629.03,"2,161.80",,,,,,
Meridian Duals,CPT,L5705,Custom shape cover ak,Durable Medical Equipment,Per Unit,"$1,153.25 ",OP,"1,153.25","3,965.20",,,,,,
Meridian Duals,CPT,L5706,Custom shape cvr knee disart,Durable Medical Equipment,Per Unit,"$1,124.85 ",OP,"1,124.85","3,869.89",,,,,,
Meridian Duals,CPT,L5707,Custom shape cvr hip disart,Durable Medical Equipment,Per Unit,"$1,511.27 ",OP,"1,511.27","5,196.70",,,,,,
Meridian Duals,CPT,L5710,Kne-shin exo sng axi mnl loc,Durable Medical Equipment,Per Unit,$359.65 ,OP,359.65,"1,235.32",,,,,,
Meridian Duals,CPT,L5711,Knee-shin exo mnl lock ultra,Durable Medical Equipment,Per Unit,$603.60 ,OP,603.6,"2,074.10",,,,,,
Meridian Duals,CPT,L5712,Knee-shin exo frict swg & st,Durable Medical Equipment,Per Unit,$430.88 ,OP,430.88,"1,483.14",,,,,,
Meridian Duals,CPT,L5714,Knee-shin exo variable frict,Durable Medical Equipment,Per Unit,$438.43 ,OP,438.43,"1,506.03",,,,,,
Meridian Duals,CPT,L5716,Knee-shin exo mech stance ph,Durable Medical Equipment,Per Unit,$866.93 ,OP,866.93,"2,981.52",,,,,,
Meridian Duals,CPT,L5718,Knee-shin exo frct swg & sta,Durable Medical Equipment,Per Unit,$927.01 ,OP,927.01,"3,187.41",,,,,,
Meridian Duals,CPT,L5722,Knee-shin pneum swg frct exo,Durable Medical Equipment,Per Unit,"$1,127.32 ",OP,"1,127.32","3,877.51",,,,,,
Meridian Duals,CPT,L5724,Knee-shin exo fluid swing ph,Durable Medical Equipment,Per Unit,"$1,737.57 ",OP,"1,737.57","5,974.48",,,,,,
Meridian Duals,CPT,L5726,Knee-shin ext jnts fld swg e,Durable Medical Equipment,Per Unit,"$2,068.65 ",OP,"2,068.65","7,114.49",,,,,,
Meridian Duals,CPT,L5728,Knee-shin fluid swg & stance,Durable Medical Equipment,Per Unit,"$2,424.23 ",OP,"2,424.23","8,338.36",,,,,,
Meridian Duals,CPT,L5780,Knee-shin pneum/hydra pneum,Durable Medical Equipment,Per Unit,"$1,334.72 ",OP,"1,334.72","4,590.49",,,,,,
Meridian Duals,CPT,L5781,Lower limb pros vacuum pump,Durable Medical Equipment,Per Unit,"$4,024.33 ",OP,"4,024.33","13,840.07",,,,,,
Meridian Duals,CPT,L5782,Hd low limb pros vacuum pump,Durable Medical Equipment,Per Unit,"$4,242.55 ",OP,"4,242.55","14,591.17",,,,,,
Meridian Duals,CPT,L5785,Exoskeletal bk ultralt mater,Durable Medical Equipment,Per Unit,$519.54 ,OP,519.54,"1,788.15",,,,,,
Meridian Duals,CPT,L5790,Exoskeletal ak ultra-light m,Durable Medical Equipment,Per Unit,$749.83 ,OP,749.83,"2,577.38",,,,,,
Meridian Duals,CPT,L5795,Exoskel hip ultra-light mate,Durable Medical Equipment,Per Unit,"$1,073.66 ",OP,"1,073.66","3,690.70",,,,,,
Meridian Duals,CPT,L5810,Endoskel knee-shin mnl lock,Durable Medical Equipment,Per Unit,$572.04 ,OP,572.04,"1,967.35",,,,,,
Meridian Duals,CPT,L5811,Endo knee-shin mnl lck ultra,Durable Medical Equipment,Per Unit,$789.42 ,OP,789.42,"2,714.64",,,,,,
Meridian Duals,CPT,L5812,Endo knee-shin frct swg & st,Durable Medical Equipment,Per Unit,$594.07 ,OP,594.07,"2,043.61",,,,,,
Meridian Duals,CPT,L5814,Endo knee-shin hydral swg ph,Durable Medical Equipment,Per Unit,"$3,735.37 ",OP,"3,735.37","12,844.96",,,,,,
Meridian Duals,CPT,L5816,Endo knee-shin polyc mch sta,Durable Medical Equipment,Per Unit,$850.43 ,OP,850.43,"2,924.33",,,,,,
Meridian Duals,CPT,L5818,Endo knee-shin frct swg & st,Durable Medical Equipment,Per Unit,$960.30 ,OP,960.3,"3,301.79",,,,,,
Meridian Duals,CPT,L5822,Endo knee-shin pneum swg frc,Durable Medical Equipment,Per Unit,"$1,761.65 ",OP,"1,761.65","6,058.37",,,,,,
Meridian Duals,CPT,L5824,Endo knee-shin fluid swing p,Durable Medical Equipment,Per Unit,"$1,665.27 ",OP,"1,665.27","5,726.65",,,,,,
Meridian Duals,CPT,L5826,Miniature knee joint,Durable Medical Equipment,Per Unit,"$3,140.97 ",OP,"3,140.97","10,801.35",,,,,,
Meridian Duals,CPT,L5828,Endo knee-shin fluid swg/sta,Durable Medical Equipment,Per Unit,"$2,963.78 ",OP,"2,963.78","10,191.33",,,,,,
Meridian Duals,CPT,L5830,Endo knee-shin pneum/swg pha,Durable Medical Equipment,Per Unit,"$1,998.37 ",OP,"1,998.37","6,874.29",,,,,,
Meridian Duals,CPT,L5840,Multi-axial knee/shin system,Durable Medical Equipment,Per Unit,"$3,922.28 ",OP,"3,922.28","13,489.32",,,,,,
Meridian Duals,CPT,L5845,Knee-shin sys stance flexion,Durable Medical Equipment,Per Unit,"$1,802.73 ",OP,"1,802.73","6,199.43",,,,,,
Meridian Duals,CPT,L5848,Knee-shin sys hydraul stance,Durable Medical Equipment,Per Unit,"$1,081.55 ",OP,"1,081.55","3,721.19",,,,,,
Meridian Duals,CPT,L5850,Endo ak/hip knee extens assi,Durable Medical Equipment,Per Unit,$127.92 ,OP,127.92,438.47,,,,,,
Meridian Duals,CPT,L5855,Mech hip extension assist,Durable Medical Equipment,Per Unit,$308.82 ,OP,308.82,"1,063.73",,,,,,
Meridian Duals,CPT,L5856,Elec knee-shin swing/stance,Durable Medical Equipment,Per Unit,"$24,144.68 ",OP,"24,144.68","83,036.63",,,,,,
Meridian Duals,CPT,L5857,Elec knee-shin swing only,Durable Medical Equipment,Per Unit,"$8,567.44 ",OP,"8,567.44","29,464.49",,,,,,
Meridian Duals,CPT,L5858,Stance phase only,Durable Medical Equipment,Per Unit,"$18,692.70 ",OP,"18,692.70","64,285.82",,,,,,
Meridian Duals,CPT,L5859,Knee-shin pro flex/ext cont,Durable Medical Equipment,Per Unit,"$14,593.21 ",OP,"14,593.21","14,593.21",,,,,,
Meridian Duals,CPT,L5910,Endo below knee alignable sy,Durable Medical Equipment,Per Unit,$362.17 ,OP,362.17,"1,246.76",,,,,,
Meridian Duals,CPT,L5920,Endo ak/hip alignable system,Durable Medical Equipment,Per Unit,$530.58 ,OP,530.58,"1,826.28",,,,,,
Meridian Duals,CPT,L5925,Above knee manual lock,Durable Medical Equipment,Per Unit,$336.00 ,OP,336,"1,155.24",,,,,,
Meridian Duals,CPT,L5930,High activity knee frame,Durable Medical Equipment,Per Unit,"$3,385.39 ",OP,"3,385.39","11,643.96",,,,,,
Meridian Duals,CPT,L5940,Endo bk ultra-light material,Durable Medical Equipment,Per Unit,$501.60 ,OP,501.6,"1,723.33",,,,,,
Meridian Duals,CPT,L5950,Endo ak ultra-light material,Durable Medical Equipment,Per Unit,$777.99 ,OP,777.99,"2,676.51",,,,,,
Meridian Duals,CPT,L5960,Endo hip ultra-light materia,Durable Medical Equipment,Per Unit,"$1,163.29 ",OP,"1,163.29","3,999.51",,,,,,
Meridian Duals,CPT,L5961,Endo poly hip- pneu/hyd/rot,Durable Medical Equipment,Per Unit,"$4,800.88 ",OP,"4,800.88","4,800.88",,,,,,
Meridian Duals,CPT,L5962,Below knee flex cover system,Durable Medical Equipment,Per Unit,$587.78 ,OP,587.78,"2,020.72",,,,,,
Meridian Duals,CPT,L5964,Above knee flex cover system,Durable Medical Equipment,Per Unit,"$1,127.47 ",OP,"1,127.47","3,877.51",,,,,,
Meridian Duals,CPT,L5966,Hip flexible cover system,Durable Medical Equipment,Per Unit,"$1,452.38 ",OP,"1,452.38","4,994.63",,,,,,
Meridian Duals,CPT,L5968,Multiaxial ankle w dorsiflex,Durable Medical Equipment,Per Unit,"$3,654.91 ",OP,"3,654.91","12,570.45",,,,,,
Meridian Duals,CPT,L5970,Foot external keel sach foot,Durable Medical Equipment,Per Unit,$218.47 ,OP,218.47,751.1,,,,,,
Meridian Duals,CPT,L5971,Sach foot- replacement,Durable Medical Equipment,Per Unit,$218.47 ,OP,218.47,751.1,,,,,,
Meridian Duals,CPT,L5972,Flexible keel foot,Durable Medical Equipment,Per Unit,$397.97 ,OP,397.97,"1,368.75",,,,,,
Meridian Duals,CPT,L5973,Ank-foot sys dors-plant flex,Durable Medical Equipment,Per Unit,"$17,757.02 ",OP,"17,757.02","17,757.02",,,,,,
Meridian Duals,CPT,L5974,Foot single axis ankle/foot,Durable Medical Equipment,Per Unit,$233.03 ,OP,233.03,800.67,,,,,,
Meridian Duals,CPT,L5975,Combo ankle/foot prosthesis,Durable Medical Equipment,Per Unit,$466.28 ,OP,466.28,"1,605.15",,,,,,
Meridian Duals,CPT,L5976,Energy storing foot,Durable Medical Equipment,Per Unit,$591.07 ,OP,591.07,"2,032.17",,,,,,
Meridian Duals,CPT,L5978,Ft prosth multiaxial ankl/ft,Durable Medical Equipment,Per Unit,$313.20 ,OP,313.2,"1,078.99",,,,,,
Meridian Duals,CPT,L5979,Multi-axial ankle/ft prosth,Durable Medical Equipment,Per Unit,"$2,507.69 ",OP,"2,507.69","8,624.30",,,,,,
Meridian Duals,CPT,L5980,Flex foot system,Durable Medical Equipment,Per Unit,"$3,820.69 ",OP,"3,820.69","13,138.54",,,,,,
Meridian Duals,CPT,L5981,Flex-walk sys low ext prosth,Durable Medical Equipment,Per Unit,"$3,431.91 ",OP,"3,431.91","11,804.09",,,,,,
Meridian Duals,CPT,L5982,Exoskeletal axial rotation u,Durable Medical Equipment,Per Unit,$644.71 ,OP,644.71,"2,218.98",,,,,,
Meridian Duals,CPT,L5984,Endoskeletal axial rotation,Durable Medical Equipment,Per Unit,$646.71 ,OP,646.71,"2,222.79",,,,,,
Meridian Duals,CPT,L5985,Lwr ext dynamic prosth pylon,Durable Medical Equipment,Per Unit,$284.02 ,OP,284.02,976.05,,,,,,
Meridian Duals,CPT,L5986,Multi-axial rotation unit,Durable Medical Equipment,Per Unit,$780.11 ,OP,780.11,"2,684.14",,,,,,
Meridian Duals,CPT,L5987,Shank ft w vert load pylon,Durable Medical Equipment,Per Unit,"$7,235.38 ",OP,"7,235.38","24,881.63",,,,,,
Meridian Duals,CPT,L5988,Vertical shock reducing pylo,Durable Medical Equipment,Per Unit,"$2,009.25 ",OP,"2,009.25","6,908.59",,,,,,
Meridian Duals,CPT,L5990,User adjustable heel height,Durable Medical Equipment,Per Unit,"$1,824.64 ",OP,"1,824.64","6,275.69",,,,,,
Meridian Duals,CPT,L6000,Part hand thumb rem,Durable Medical Equipment,Per Unit,"$1,771.55 ",OP,"1,771.55","6,092.69",,,,,,
Meridian Duals,CPT,L6010,Part hand little/ring,Durable Medical Equipment,Per Unit,"$1,971.44 ",OP,"1,971.44","6,778.98",,,,,,
Meridian Duals,CPT,L6020,Part hand no fingers,Durable Medical Equipment,Per Unit,"$1,838.05 ",OP,"1,838.05","6,321.45",,,,,,
Meridian Duals,CPT,L6026,Part hand myo exclu term dev,Durable Medical Equipment,Per Unit,"$4,375.03 ",OP,"4,375.03","4,375.03",,,,,,
Meridian Duals,CPT,L6050,Wrst mld sck flx hng tri pad,Durable Medical Equipment,Per Unit,"$2,500.12 ",OP,"2,500.12","8,597.63",,,,,,
Meridian Duals,CPT,L6055,Wrst mold sock w/exp interfa,Durable Medical Equipment,Per Unit,"$3,189.04 ",OP,"3,189.04","10,969.11",,,,,,
Meridian Duals,CPT,L6100,Elb mold sock flex hinge pad,Durable Medical Equipment,Per Unit,"$2,530.04 ",OP,"2,530.04","8,700.56",,,,,,
Meridian Duals,CPT,L6110,Elbow mold sock suspension t,Durable Medical Equipment,Per Unit,"$2,676.61 ",OP,"2,676.61","9,203.84",,,,,,
Meridian Duals,CPT,L6120,Elbow mold doub splt soc ste,Durable Medical Equipment,Per Unit,"$3,027.26 ",OP,"3,027.26","10,412.46",,,,,,
Meridian Duals,CPT,L6130,Elbow stump activated lock h,Durable Medical Equipment,Per Unit,"$3,193.82 ",OP,"3,193.82","10,984.37",,,,,,
Meridian Duals,CPT,L6200,Elbow mold outsid lock hinge,Durable Medical Equipment,Per Unit,"$3,290.01 ",OP,"3,290.01","11,316.08",,,,,,
Meridian Duals,CPT,L6205,Elbow molded w/ expand inter,Durable Medical Equipment,Per Unit,"$4,538.50 ",OP,"4,538.50","15,609.16",,,,,,
Meridian Duals,CPT,L6250,Elbow inter loc elbow forarm,Durable Medical Equipment,Per Unit,"$3,236.79 ",OP,"3,236.79","11,133.06",,,,,,
Meridian Duals,CPT,L6300,Shlder disart int lock elbow,Durable Medical Equipment,Per Unit,"$4,464.43 ",OP,"4,464.43","15,353.72",,,,,,
Meridian Duals,CPT,L6310,Shoulder passive restor comp,Durable Medical Equipment,Per Unit,"$4,046.04 ",OP,"4,046.04","13,916.32",,,,,,
Meridian Duals,CPT,L6320,Shoulder passive restor cap,Durable Medical Equipment,Per Unit,"$2,108.67 ",OP,"2,108.67","7,251.74",,,,,,
Meridian Duals,CPT,L6350,Thoracic intern lock elbow,Durable Medical Equipment,Per Unit,"$4,891.63 ",OP,"4,891.63","16,821.60",,,,,,
Meridian Duals,CPT,L6360,Thoracic passive restor comp,Durable Medical Equipment,Per Unit,"$4,246.80 ",OP,"4,246.80","14,606.43",,,,,,
Meridian Duals,CPT,L6370,Thoracic passive restor cap,Durable Medical Equipment,Per Unit,"$2,462.85 ",OP,"2,462.85","8,471.79",,,,,,
Meridian Duals,CPT,L6380,Postop dsg cast chg wrst/elb,Durable Medical Equipment,Per Unit,"$1,424.44 ",OP,"1,424.44","4,899.32",,,,,,
Meridian Duals,CPT,L6382,Postop dsg cast chg elb dis/,Durable Medical Equipment,Per Unit,"$1,695.74 ",OP,"1,695.74","5,833.42",,,,,,
Meridian Duals,CPT,L6384,Postop dsg cast chg shlder/t,Durable Medical Equipment,Per Unit,"$2,145.20 ",OP,"2,145.20","7,377.56",,,,,,
Meridian Duals,CPT,L6386,Postop ea cast chg & realign,Durable Medical Equipment,Per Unit,$470.24 ,OP,470.24,"1,616.58",,,,,,
Meridian Duals,CPT,L6388,Postop applicat rigid dsg on,Durable Medical Equipment,Per Unit,$517.85 ,OP,517.85,"1,780.53",,,,,,
Meridian Duals,CPT,L6400,Below elbow prosth tiss shap,Durable Medical Equipment,Per Unit,"$2,736.86 ",OP,"2,736.86","9,413.54",,,,,,
Meridian Duals,CPT,L6450,Elb disart prosth tiss shap,Durable Medical Equipment,Per Unit,"$3,576.94 ",OP,"3,576.94","12,299.74",,,,,,
Meridian Duals,CPT,L6500,Above elbow prosth tiss shap,Durable Medical Equipment,Per Unit,"$3,512.48 ",OP,"3,512.48","12,078.62",,,,,,
Meridian Duals,CPT,L6550,Shldr disar prosth tiss shap,Durable Medical Equipment,Per Unit,"$4,549.39 ",OP,"4,549.39","15,647.29",,,,,,
Meridian Duals,CPT,L6570,Scap thorac prosth tiss shap,Durable Medical Equipment,Per Unit,"$5,078.79 ",OP,"5,078.79","17,465.96",,,,,,
Meridian Duals,CPT,L6580,Wrist/elbow bowden cable mol,Durable Medical Equipment,Per Unit,"$2,030.62 ",OP,"2,030.62","6,984.85",,,,,,
Meridian Duals,CPT,L6582,Wrist/elbow bowden cbl dir f,Durable Medical Equipment,Per Unit,"$1,705.44 ",OP,"1,705.44","5,863.93",,,,,,
Meridian Duals,CPT,L6584,Elbow fair lead cable molded,Durable Medical Equipment,Per Unit,"$2,525.30 ",OP,"2,525.30","8,685.31",,,,,,
Meridian Duals,CPT,L6586,Elbow fair lead cable dir fo,Durable Medical Equipment,Per Unit,"$2,250.20 ",OP,"2,250.20","7,739.77",,,,,,
Meridian Duals,CPT,L6588,Shdr fair lead cable molded,Durable Medical Equipment,Per Unit,"$3,583.73 ",OP,"3,583.73","12,326.44",,,,,,
Meridian Duals,CPT,L6590,Shdr fair lead cable direct,Durable Medical Equipment,Per Unit,"$3,123.36 ",OP,"3,123.36","10,740.36",,,,,,
Meridian Duals,CPT,L6600,Polycentric hinge pair,Durable Medical Equipment,Per Unit,$228.13 ,OP,228.13,785.42,,,,,,
Meridian Duals,CPT,L6605,Single pivot hinge pair,Durable Medical Equipment,Per Unit,$234.81 ,OP,234.81,808.29,,,,,,
Meridian Duals,CPT,L6610,Flexible metal hinge pair,Durable Medical Equipment,Per Unit,$221.98 ,OP,221.98,762.54,,,,,,
Meridian Duals,CPT,L6611,Additional switch- ext power,Durable Medical Equipment,Per Unit,$414.10 ,OP,414.1,"1,425.95",,,,,,
Meridian Duals,CPT,L6615,Disconnect locking wrist uni,Durable Medical Equipment,Per Unit,$215.48 ,OP,215.48,739.67,,,,,,
Meridian Duals,CPT,L6616,Disconnect insert locking wr,Durable Medical Equipment,Per Unit,$64.86 ,OP,64.86,224.95,,,,,,
Meridian Duals,CPT,L6620,Flexion/extension wrist unit,Durable Medical Equipment,Per Unit,$376.69 ,OP,376.69,"1,296.32",,,,,,
Meridian Duals,CPT,L6621,Flex/ext wrist w/wo friction,Durable Medical Equipment,Per Unit,"$2,300.54 ",OP,"2,300.54","7,911.34",,,,,,
Meridian Duals,CPT,L6623,Spring-ass rot wrst w/ latch,Durable Medical Equipment,Per Unit,$717.59 ,OP,717.59,"2,466.81",,,,,,
Meridian Duals,CPT,L6624,Flex/ext/rotation wrist unit,Durable Medical Equipment,Per Unit,"$3,787.86 ",OP,"3,787.86","13,027.98",,,,,,
Meridian Duals,CPT,L6625,Rotation wrst w/ cable lock,Durable Medical Equipment,Per Unit,$531.84 ,OP,531.84,"1,830.09",,,,,,
Meridian Duals,CPT,L6628,Quick disconn hook adapter o,Durable Medical Equipment,Per Unit,$572.47 ,OP,572.47,"1,967.35",,,,,,
Meridian Duals,CPT,L6629,Lamination collar w/ couplin,Durable Medical Equipment,Per Unit,$195.07 ,OP,195.07,671.03,,,,,,
Meridian Duals,CPT,L6630,Stainless steel any wrist,Durable Medical Equipment,Per Unit,$287.35 ,OP,287.35,987.49,,,,,,
Meridian Duals,CPT,L6632,Latex suspension sleeve each,Durable Medical Equipment,Per Unit,$64.97 ,OP,64.97,224.95,,,,,,
Meridian Duals,CPT,L6635,Lift assist for elbow,Durable Medical Equipment,Per Unit,$207.68 ,OP,207.68,712.98,,,,,,
Meridian Duals,CPT,L6637,Nudge control elbow lock,Durable Medical Equipment,Per Unit,$406.60 ,OP,406.6,"1,399.26",,,,,,
Meridian Duals,CPT,L6638,Elec lock on manual pw elbow,Durable Medical Equipment,Per Unit,"$2,515.20 ",OP,"2,515.20","8,651.00",,,,,,
Meridian Duals,CPT,L6640,Shoulder abduction joint pai,Durable Medical Equipment,Per Unit,$338.63 ,OP,338.63,"1,162.87",,,,,,
Meridian Duals,CPT,L6641,Excursion amplifier pulley t,Durable Medical Equipment,Per Unit,$197.18 ,OP,197.18,678.66,,,,,,
Meridian Duals,CPT,L6642,Excursion amplifier lever ty,Durable Medical Equipment,Per Unit,$289.92 ,OP,289.92,998.92,,,,,,
Meridian Duals,CPT,L6645,Shoulder flexion-abduction j,Durable Medical Equipment,Per Unit,$366.21 ,OP,366.21,"1,258.19",,,,,,
Meridian Duals,CPT,L6646,Multipo locking shoulder jnt,Durable Medical Equipment,Per Unit,"$3,172.24 ",OP,"3,172.24","10,908.12",,,,,,
Meridian Duals,CPT,L6647,Shoulder lock actuator,Durable Medical Equipment,Per Unit,$522.26 ,OP,522.26,"1,795.78",,,,,,
Meridian Duals,CPT,L6648,Ext pwrd shlder lock/unlock,Durable Medical Equipment,Per Unit,"$3,271.71 ",OP,"3,271.71","11,251.26",,,,,,
Meridian Duals,CPT,L6650,Shoulder universal joint,Durable Medical Equipment,Per Unit,$397.20 ,OP,397.2,"1,364.94",,,,,,
Meridian Duals,CPT,L6655,Standard control cable extra,Durable Medical Equipment,Per Unit,$77.05 ,OP,77.05,263.08,,,,,,
Meridian Duals,CPT,L6660,Heavy duty control cable,Durable Medical Equipment,Per Unit,$103.11 ,OP,103.11,354.58,,,,,,
Meridian Duals,CPT,L6665,Teflon or equal cable lining,Durable Medical Equipment,Per Unit,$46.05 ,OP,46.05,160.13,,,,,,
Meridian Duals,CPT,L6670,Hook to hand cable adapter,Durable Medical Equipment,Per Unit,$47.96 ,OP,47.96,163.95,,,,,,
Meridian Duals,CPT,L6672,Harness chest/shlder saddle,Durable Medical Equipment,Per Unit,$220.08 ,OP,220.08,758.72,,,,,,
Meridian Duals,CPT,L6675,Harness figure of 8 sing con,Durable Medical Equipment,Per Unit,$120.09 ,OP,120.09,411.78,,,,,,
Meridian Duals,CPT,L6676,Harness figure of 8 dual con,Durable Medical Equipment,Per Unit,$125.64 ,OP,125.64,430.83,,,,,,
Meridian Duals,CPT,L6677,Ue triple control harness,Durable Medical Equipment,Per Unit,$298.35 ,OP,298.35,"1,025.61",,,,,,
Meridian Duals,CPT,L6680,Test sock wrist disart/bel e,Durable Medical Equipment,Per Unit,$309.33 ,OP,309.33,"1,063.73",,,,,,
Meridian Duals,CPT,L6682,Test sock elbw disart/above,Durable Medical Equipment,Per Unit,$342.01 ,OP,342.01,"1,178.12",,,,,,
Meridian Duals,CPT,L6684,Test socket shldr disart/tho,Durable Medical Equipment,Per Unit,$464.75 ,OP,464.75,"1,597.52",,,,,,
Meridian Duals,CPT,L6686,Suction socket,Durable Medical Equipment,Per Unit,$689.63 ,OP,689.63,"2,371.49",,,,,,
Meridian Duals,CPT,L6687,Frame typ socket bel elbow/w,Durable Medical Equipment,Per Unit,$576.80 ,OP,576.8,"1,982.60",,,,,,
Meridian Duals,CPT,L6688,Frame typ sock above elb/dis,Durable Medical Equipment,Per Unit,$638.36 ,OP,638.36,"2,196.11",,,,,,
Meridian Duals,CPT,L6689,Frame typ socket shoulder di,Durable Medical Equipment,Per Unit,$760.81 ,OP,760.81,"2,615.51",,,,,,
Meridian Duals,CPT,L6690,Frame typ sock interscap-tho,Durable Medical Equipment,Per Unit,$895.74 ,OP,895.74,"3,080.66",,,,,,
Meridian Duals,CPT,L6691,Removable insert each,Durable Medical Equipment,Per Unit,$353.58 ,OP,353.58,"1,216.24",,,,,,
Meridian Duals,CPT,L6692,Silicone gel insert or equal,Durable Medical Equipment,Per Unit,$643.25 ,OP,643.25,"2,211.37",,,,,,
Meridian Duals,CPT,L6693,Lockingelbow forearm cntrbal,Durable Medical Equipment,Per Unit,"$2,855.43 ",OP,"2,855.43","9,821.50",,,,,,
Meridian Duals,CPT,L6694,Elbow socket ins use w/lock,Durable Medical Equipment,Per Unit,$790.52 ,OP,790.52,"2,718.45",,,,,,
Meridian Duals,CPT,L6695,Elbow socket ins use w/o lck,Durable Medical Equipment,Per Unit,$658.75 ,OP,658.75,"2,264.75",,,,,,
Meridian Duals,CPT,L6696,Cus elbo skt in for con/atyp,Durable Medical Equipment,Per Unit,"$1,323.02 ",OP,"1,323.02","4,548.54",,,,,,
Meridian Duals,CPT,L6697,Cus elbo skt in not con/atyp,Durable Medical Equipment,Per Unit,"$1,323.02 ",OP,"1,323.02","4,548.54",,,,,,
Meridian Duals,CPT,L6698,Below/above elbow lock mech,Durable Medical Equipment,Per Unit,$497.40 ,OP,497.4,"1,711.89",,,,,,
Meridian Duals,CPT,L6703,Term dev- passive hand mitt,Durable Medical Equipment,Per Unit,$351.79 ,OP,351.79,"1,208.62",,,,,,
Meridian Duals,CPT,L6704,Term dev- sport/rec/work att,Durable Medical Equipment,Per Unit,$679.06 ,OP,679.06,"2,337.18",,,,,,
Meridian Duals,CPT,L6706,Term dev mech hook vol open,Durable Medical Equipment,Per Unit,$421.40 ,OP,421.4,"1,448.82",,,,,,
Meridian Duals,CPT,L6707,Term dev mech hook vol close,Durable Medical Equipment,Per Unit,"$1,490.70 ",OP,"1,490.70","5,128.07",,,,,,
Meridian Duals,CPT,L6708,Term dev mech hand vol open,Durable Medical Equipment,Per Unit,$985.41 ,OP,985.41,"3,389.47",,,,,,
Meridian Duals,CPT,L6709,Term dev mech hand vol close,Durable Medical Equipment,Per Unit,"$1,398.55 ",OP,"1,398.55","4,811.61",,,,,,
Meridian Duals,CPT,L6711,Ped term dev- hook- vol open,Durable Medical Equipment,Per Unit,$676.19 ,OP,676.19,"2,325.74",,,,,,
Meridian Duals,CPT,L6712,Ped term dev- hook- vol clos,Durable Medical Equipment,Per Unit,"$1,245.05 ",OP,"1,245.05","4,281.66",,,,,,
Meridian Duals,CPT,L6713,Ped term dev- hand- vol open,Durable Medical Equipment,Per Unit,"$1,571.33 ",OP,"1,571.33","5,402.59",,,,,,
Meridian Duals,CPT,L6714,Ped term dev- hand- vol clos,Durable Medical Equipment,Per Unit,"$1,330.91 ",OP,"1,330.91","4,579.05",,,,,,
Meridian Duals,CPT,L6715,Term device- multi art digit,Durable Medical Equipment,Per Unit,"$3,175.42 ",OP,"3,175.42","3,175.42",,,,,,
Meridian Duals,CPT,L6721,Hook/hand- hvy dty- vol open,Durable Medical Equipment,Per Unit,"$2,365.59 ",OP,"2,365.59","8,136.28",,,,,,
Meridian Duals,CPT,L6722,Hook/hand- hvy dty- vol clos,Durable Medical Equipment,Per Unit,"$2,039.28 ",OP,"2,039.28","7,011.54",,,,,,
Meridian Duals,CPT,L6805,Term dev modifier wrist unit,Durable Medical Equipment,Per Unit,$385.75 ,OP,385.75,"1,326.82",,,,,,
Meridian Duals,CPT,L6810,Term dev precision pinch dev,Durable Medical Equipment,Per Unit,$205.07 ,OP,205.07,705.35,,,,,,
Meridian Duals,CPT,L6880,Elec hand ind art digits,Durable Medical Equipment,Per Unit,"$24,030.68 ",OP,"24,030.68","24,030.68",,,,,,
Meridian Duals,CPT,L6881,Term dev auto grasp feature,Durable Medical Equipment,Per Unit,"$4,111.91 ",OP,"4,111.91","14,141.27",,,,,,
Meridian Duals,CPT,L6882,Microprocessor control uplmb,Durable Medical Equipment,Per Unit,"$3,119.08 ",OP,"3,119.08","10,725.10",,,,,,
Meridian Duals,CPT,L6883,Replc sockt below e/w disa,Durable Medical Equipment,Per Unit,"$1,997.96 ",OP,"1,997.96","6,870.47",,,,,,
Meridian Duals,CPT,L6884,Replc sockt above elbow disa,Durable Medical Equipment,Per Unit,"$2,733.67 ",OP,"2,733.67","9,402.10",,,,,,
Meridian Duals,CPT,L6885,Replc sockt shldr dis/interc,Durable Medical Equipment,Per Unit,"$4,246.80 ",OP,"4,246.80","14,606.43",,,,,,
Meridian Duals,CPT,L6890,Prefab glove for term device,Durable Medical Equipment,Per Unit,$200.88 ,OP,200.88,690.1,,,,,,
Meridian Duals,CPT,L6895,Custom glove for term device,Durable Medical Equipment,Per Unit,$671.68 ,OP,671.68,"2,310.49",,,,,,
Meridian Duals,CPT,L6900,Hand restorat thumb/1 finger,Durable Medical Equipment,Per Unit,"$1,950.52 ",OP,"1,950.52","6,706.52",,,,,,
Meridian Duals,CPT,L6905,Hand restoration multiple fi,Durable Medical Equipment,Per Unit,"$1,930.47 ",OP,"1,930.47","6,637.91",,,,,,
Meridian Duals,CPT,L6910,Hand restoration no fingers,Durable Medical Equipment,Per Unit,"$1,897.78 ",OP,"1,897.78","6,527.33",,,,,,
Meridian Duals,CPT,L6915,Hand restoration replacmnt g,Durable Medical Equipment,Per Unit,$815.40 ,OP,815.4,"2,806.14",,,,,,
Meridian Duals,CPT,L6920,Wrist disarticul switch ctrl,Durable Medical Equipment,Per Unit,"$8,425.39 ",OP,"8,425.39","28,976.47",,,,,,
Meridian Duals,CPT,L6925,Wrist disart myoelectronic c,Durable Medical Equipment,Per Unit,"$9,001.12 ",OP,"9,001.12","30,955.25",,,,,,
Meridian Duals,CPT,L6930,Below elbow switch control,Durable Medical Equipment,Per Unit,"$8,114.82 ",OP,"8,114.82","27,908.91",,,,,,
Meridian Duals,CPT,L6935,Below elbow myoelectronic ct,Durable Medical Equipment,Per Unit,"$8,958.82 ",OP,"8,958.82","30,810.37",,,,,,
Meridian Duals,CPT,L6940,Elbow disarticulation switch,Durable Medical Equipment,Per Unit,"$10,478.90 ",OP,"10,478.90","36,037.57",,,,,,
Meridian Duals,CPT,L6945,Elbow disart myoelectronic c,Durable Medical Equipment,Per Unit,"$11,690.57 ",OP,"11,690.57","40,204.84",,,,,,
Meridian Duals,CPT,L6950,Above elbow switch control,Durable Medical Equipment,Per Unit,"$10,459.47 ",OP,"10,459.47","35,972.77",,,,,,
Meridian Duals,CPT,L6955,Above elbow myoelectronic ct,Durable Medical Equipment,Per Unit,"$12,129.70 ",OP,"12,129.70","41,714.68",,,,,,
Meridian Duals,CPT,L6960,Shldr disartic switch contro,Durable Medical Equipment,Per Unit,"$12,759.97 ",OP,"12,759.97","43,884.09",,,,,,
Meridian Duals,CPT,L6965,Shldr disartic myoelectronic,Durable Medical Equipment,Per Unit,"$15,116.16 ",OP,"15,116.16","51,986.07",,,,,,
Meridian Duals,CPT,L6970,Interscapular-thor switch ct,Durable Medical Equipment,Per Unit,"$16,180.17 ",OP,"16,180.17","55,646.26",,,,,,
Meridian Duals,CPT,L6975,Interscap-thor myoelectronic,Durable Medical Equipment,Per Unit,"$17,834.37 ",OP,"17,834.37","61,334.79",,,,,,
Meridian Duals,CPT,L7007,Adult electric hand,Durable Medical Equipment,Per Unit,"$3,673.63 ",OP,"3,673.63","12,635.27",,,,,,
Meridian Duals,CPT,L7008,Pediatric electric hand,Durable Medical Equipment,Per Unit,"$5,696.71 ",OP,"5,696.71","19,593.43",,,,,,
Meridian Duals,CPT,L7009,Adult electric hook,Durable Medical Equipment,Per Unit,"$3,758.57 ",OP,"3,758.57","12,925.03",,,,,,
Meridian Duals,CPT,L7040,Prehensile actuator,Durable Medical Equipment,Per Unit,"$3,059.23 ",OP,"3,059.23","10,519.22",,,,,,
Meridian Duals,CPT,L7045,Pediatric electric hook,Durable Medical Equipment,Per Unit,"$1,616.29 ",OP,"1,616.29","5,558.92",,,,,,
Meridian Duals,CPT,L7170,Electronic elbow hosmer swit,Durable Medical Equipment,Per Unit,"$6,050.00 ",OP,"6,050.00","20,805.87",,,,,,
Meridian Duals,CPT,L7180,Electronic elbow sequential,Durable Medical Equipment,Per Unit,"$39,141.46 ",OP,"39,141.46","134,610.92",,,,,,
Meridian Duals,CPT,L7181,Electronic elbo simultaneous,Durable Medical Equipment,Per Unit,"$40,299.84 ",OP,"40,299.84","138,595.19",,,,,,
Meridian Duals,CPT,L7185,Electron elbow adolescent sw,Durable Medical Equipment,Per Unit,"$6,360.51 ",OP,"6,360.51","21,873.42",,,,,,
Meridian Duals,CPT,L7186,Electron elbow child switch,Durable Medical Equipment,Per Unit,"$10,692.92 ",OP,"10,692.92","36,773.42",,,,,,
Meridian Duals,CPT,L7190,Elbow adolescent myoelectron,Durable Medical Equipment,Per Unit,"$8,439.80 ",OP,"8,439.80","29,026.03",,,,,,
Meridian Duals,CPT,L7191,Elbow child myoelectronic ct,Durable Medical Equipment,Per Unit,"$11,247.26 ",OP,"11,247.26","38,679.77",,,,,,
Meridian Duals,CPT,L7259,Electronic wrist rotator any,Durable Medical Equipment,Per Unit,"$4,121.94 ",OP,"4,121.94","4,121.94",,,,,,
Meridian Duals,CPT,L7360,Six volt bat otto bock/eq ea,Durable Medical Equipment,Per Unit,$266.08 ,OP,266.08,915.04,,,,,,
Meridian Duals,CPT,L7362,Battery chrgr six volt otto,Durable Medical Equipment,Per Unit,$290.68 ,OP,290.68,998.92,,,,,,
Meridian Duals,CPT,L7364,Twelve volt battery utah/equ,Durable Medical Equipment,Per Unit,$514.33 ,OP,514.33,"1,769.09",,,,,,
Meridian Duals,CPT,L7366,Battery chrgr 12 volt utah/e,Durable Medical Equipment,Per Unit,$707.34 ,OP,707.34,"2,432.50",,,,,,
Meridian Duals,CPT,L7367,Replacemnt lithium ionbatter,Durable Medical Equipment,Per Unit,$391.59 ,OP,391.59,"1,345.89",,,,,,
Meridian Duals,CPT,L7368,Lithium ion battery charger,Durable Medical Equipment,Per Unit,$507.61 ,OP,507.61,"1,746.22",,,,,,
Meridian Duals,CPT,L7400,Add ue prost be/wd- ultlite,Durable Medical Equipment,Per Unit,$308.25 ,OP,308.25,"1,059.93",,,,,,
Meridian Duals,CPT,L7401,Add ue prost a/e ultlite mat,Durable Medical Equipment,Per Unit,$345.06 ,OP,345.06,"1,185.76",,,,,,
Meridian Duals,CPT,L7402,Add ue prost s/d ultlite mat,Durable Medical Equipment,Per Unit,$372.68 ,OP,372.68,"1,281.07",,,,,,
Meridian Duals,CPT,L7403,Add ue prost b/e acrylic,Durable Medical Equipment,Per Unit,$370.41 ,OP,370.41,"1,273.44",,,,,,
Meridian Duals,CPT,L7404,Add ue prost a/e acrylic,Durable Medical Equipment,Per Unit,$559.06 ,OP,559.06,"1,921.59",,,,,,
Meridian Duals,CPT,L7405,Add ue prost s/d acrylic,Durable Medical Equipment,Per Unit,$731.10 ,OP,731.1,"2,512.57",,,,,,
Meridian Duals,CPT,L7700,Pros soc insert gasket/seal,Durable Medical Equipment,Per Unit,$150.48 ,OP,150.48,150.48,,,,,,
Meridian Duals,CPT,L8000,Mastectomy bra,Durable Medical Equipment,Per Unit,$42.59 ,OP,42.59,144.88,,,,,,
Meridian Duals,CPT,L8001,Breast prosthesis bra & form,Durable Medical Equipment,Per Unit,$126.18 ,OP,126.18,434.65,,,,,,
Meridian Duals,CPT,L8002,Brst prsth bra & bilat form,Durable Medical Equipment,Per Unit,$165.94 ,OP,165.94,571.91,,,,,,
Meridian Duals,CPT,L8015,Ext breastprosthesis garment,Durable Medical Equipment,Per Unit,$60.29 ,OP,60.29,205.88,,,,,,
Meridian Duals,CPT,L8020,Mastectomy form,Durable Medical Equipment,Per Unit,$227.40 ,OP,227.4,781.61,,,,,,
Meridian Duals,CPT,L8030,Breast prosthes w/o adhesive,Durable Medical Equipment,Per Unit,$351.55 ,OP,351.55,"1,208.62",,,,,,
Meridian Duals,CPT,L8031,Breast prosthesis w adhesive,Durable Medical Equipment,Per Unit,$351.55 ,OP,351.55,351.55,,,,,,
Meridian Duals,CPT,L8032,Reusable nipple prosthesis,Durable Medical Equipment,Per Unit,$39.39 ,OP,39.39,39.39,,,,,,
Meridian Duals,CPT,L8035,Custom breast prosthesis,Durable Medical Equipment,Per Unit,"$3,684.79 ",OP,"3,684.79","12,673.39",,,,,,
Meridian Duals,CPT,L8040,Nasal prosthesis,Durable Medical Equipment,Per Unit,"$2,493.50 ",OP,"2,493.50","8,574.74",,,,,,
Meridian Duals,CPT,L8041,Midfacial prosthesis,Durable Medical Equipment,Per Unit,"$3,005.20 ",OP,"3,005.20","10,336.21",,,,,,
Meridian Duals,CPT,L8042,Orbital prosthesis,Durable Medical Equipment,Per Unit,"$3,376.62 ",OP,"3,376.62","11,613.47",,,,,,
Meridian Duals,CPT,L8043,Upper facial prosthesis,Durable Medical Equipment,Per Unit,"$3,781.84 ",OP,"3,781.84","13,005.10",,,,,,
Meridian Duals,CPT,L8044,Hemi-facial prosthesis,Durable Medical Equipment,Per Unit,"$4,187.02 ",OP,"4,187.02","14,400.54",,,,,,
Meridian Duals,CPT,L8045,Auricular prosthesis,Durable Medical Equipment,Per Unit,"$3,278.72 ",OP,"3,278.72","11,274.13",,,,,,
Meridian Duals,CPT,L8046,Partial facial prosthesis,Durable Medical Equipment,Per Unit,"$2,701.33 ",OP,"2,701.33","9,291.53",,,,,,
Meridian Duals,CPT,L8047,Nasal septal prosthesis,Durable Medical Equipment,Per Unit,"$1,384.42 ",OP,"1,384.42","4,762.05",,,,,,
Meridian Duals,CPT,L8300,Truss single w/ standard pad,Durable Medical Equipment,Per Unit,$84.35 ,OP,84.35,289.76,,,,,,
Meridian Duals,CPT,L8310,Truss double w/ standard pad,Durable Medical Equipment,Per Unit,$149.44 ,OP,149.44,514.72,,,,,,
Meridian Duals,CPT,L8320,Truss addition to std pad wa,Durable Medical Equipment,Per Unit,$62.00 ,OP,62,213.51,,,,,,
Meridian Duals,CPT,L8330,Truss add to std pad scrotal,Durable Medical Equipment,Per Unit,$49.37 ,OP,49.37,171.58,,,,,,
Meridian Duals,CPT,L8400,Sheath below knee,Durable Medical Equipment,Per Unit,$15.74 ,OP,15.74,53.38,,,,,,
Meridian Duals,CPT,L8410,Sheath above knee,Durable Medical Equipment,Per Unit,$20.72 ,OP,20.72,72.44,,,,,,
Meridian Duals,CPT,L8415,Sheath upper limb,Durable Medical Equipment,Per Unit,$21.44 ,OP,21.44,72.44,,,,,,
Meridian Duals,CPT,L8417,Pros sheath/sock w gel cushn,Durable Medical Equipment,Per Unit,$75.64 ,OP,75.64,259.27,,,,,,
Meridian Duals,CPT,L8420,Prosthetic sock multi ply bk,Durable Medical Equipment,Per Unit,$20.98 ,OP,20.98,72.44,,,,,,
Meridian Duals,CPT,L8430,Prosthetic sock multi ply ak,Durable Medical Equipment,Per Unit,$23.76 ,OP,23.76,80.07,,,,,,
Meridian Duals,CPT,L8435,Pros sock multi ply upper lm,Durable Medical Equipment,Per Unit,$22.58 ,OP,22.58,76.26,,,,,,
Meridian Duals,CPT,L8440,Shrinker below knee,Durable Medical Equipment,Per Unit,$46.88 ,OP,46.88,160.13,,,,,,
Meridian Duals,CPT,L8460,Shrinker above knee,Durable Medical Equipment,Per Unit,$66.65 ,OP,66.65,228.77,,,,,,
Meridian Duals,CPT,L8465,Shrinker upper limb,Durable Medical Equipment,Per Unit,$61.60 ,OP,61.6,213.51,,,,,,
Meridian Duals,CPT,L8470,Pros sock single ply bk,Durable Medical Equipment,Per Unit,$6.67 ,OP,6.67,22.88,,,,,,
Meridian Duals,CPT,L8480,Pros sock single ply ak,Durable Medical Equipment,Per Unit,$9.20 ,OP,9.2,30.51,,,,,,
Meridian Duals,CPT,L8485,Pros sock single ply upper l,Durable Medical Equipment,Per Unit,$12.39 ,OP,12.39,41.94,,,,,,
Meridian Duals,CPT,L8500,Artificial larynx,Durable Medical Equipment,Per Unit,$661.87 ,OP,661.87,"2,276.18",,,,,,
Meridian Duals,CPT,L8501,Tracheostomy speaking valve,Durable Medical Equipment,Per Unit,$120.80 ,OP,120.8,415.59,,,,,,
Meridian Duals,CPT,L8507,Trach-esoph voice pros pt in,Durable Medical Equipment,Per Unit,$42.11 ,OP,42.11,144.88,,,,,,
Meridian Duals,CPT,L8509,Trach-esoph voice pros md in,Durable Medical Equipment,Per Unit,$109.85 ,OP,109.85,377.46,,,,,,
Meridian Duals,CPT,L8510,Voice amplifier,Durable Medical Equipment,Per Unit,$254.17 ,OP,254.17,873.11,,,,,,
Meridian Duals,CPT,L8511,Indwelling trach insert,Durable Medical Equipment,Per Unit,$73.14 ,OP,73.14,251.64,,,,,,
Meridian Duals,CPT,L8512,Gel cap for trach voice pros,Durable Medical Equipment,Per Unit,$2.19 ,OP,2.19,7.62,,,,,,
Meridian Duals,CPT,L8513,Trach pros cleaning device,Durable Medical Equipment,Per Unit,$5.22 ,OP,5.22,19.07,,,,,,
Meridian Duals,CPT,L8514,Repl trach puncture dilator,Durable Medical Equipment,Per Unit,$94.85 ,OP,94.85,327.9,,,,,,
Meridian Duals,CPT,L8515,Gel cap app device for trach,Durable Medical Equipment,Per Unit,$63.49 ,OP,63.49,217.32,,,,,,
Meridian Duals,CPT,L8615,Coch implant headset replace,Durable Medical Equipment,Per Unit,$453.62 ,OP,453.62,"1,559.39",,,,,,
Meridian Duals,CPT,L8616,Coch implant microphone repl,Durable Medical Equipment,Per Unit,$105.64 ,OP,105.64,362.21,,,,,,
Meridian Duals,CPT,L8617,Coch implant trans coil repl,Durable Medical Equipment,Per Unit,$92.27 ,OP,92.27,92.27,,,,,,
Meridian Duals,CPT,L8618,Coch implant tran cable repl,Durable Medical Equipment,Per Unit,$26.38 ,OP,26.38,91.51,,,,,,
Meridian Duals,CPT,L8619,Coch imp ext proc/contr rplc,Durable Medical Equipment,Per Unit,"$8,454.02 ",OP,"8,454.02","29,075.59",,,,,,
Meridian Duals,CPT,L8621,Repl zinc air battery,Durable Medical Equipment,Per Unit,$0.62 ,OP,0.62,3.82,,,,,,
Meridian Duals,CPT,L8622,Repl alkaline battery,Durable Medical Equipment,Per Unit,$0.32 ,OP,0.32,1.9,,,,,,
Meridian Duals,CPT,L8623,Lith ion batt cid-non-earlvl,Durable Medical Equipment,Per Unit,$65.06 ,OP,65.06,65.06,,,,,,
Meridian Duals,CPT,L8624,Lith ion batt cid- ear level,Durable Medical Equipment,Per Unit,$162.20 ,OP,162.2,556.65,,,,,,
Meridian Duals,CPT,L8625,Charger coch impl/aoi battry,Durable Medical Equipment,Per Unit,$189.97 ,OP,189.97,189.97,,,,,,
Meridian Duals,CPT,L8627,Cid ext speech process repl,Durable Medical Equipment,Per Unit,"$7,175.59 ",OP,"7,175.59","7,175.59",,,,,,
Meridian Duals,CPT,L8628,Cid ext controller repl,Durable Medical Equipment,Per Unit,"$1,278.42 ",OP,"1,278.42","1,278.42",,,,,,
Meridian Duals,CPT,L8629,Cid transmit coil and cable,Durable Medical Equipment,Per Unit,$180.09 ,OP,180.09,180.09,,,,,,
Meridian Duals,CPT,L8681,Pt prgrm for implt neurostim,Durable Medical Equipment,Per Unit,"$1,147.11 ",OP,"1,147.11","3,946.14",,,,,,
Meridian Duals,CPT,L8683,Radiofq trsmtr for implt neu,Durable Medical Equipment,Per Unit,"$5,420.03 ",OP,"5,420.03","18,640.24",,,,,,
Meridian Duals,CPT,L8684,Radiof trsmtr implt scrl neu,Durable Medical Equipment,Per Unit,$850.48 ,OP,850.48,"2,924.33",,,,,,
Meridian Duals,CPT,L8689,External recharg sys intern,Durable Medical Equipment,Per Unit,"$1,734.92 ",OP,"1,734.92","5,966.87",,,,,,
Meridian Duals,CPT,L8691,Aoi snd proc repl excl actua,Durable Medical Equipment,Per Unit,"$1,732.10 ",OP,"1,732.10","9,222.90",,,,,,
Meridian Duals,CPT,L8693,Aud osseo dev- abutment,Durable Medical Equipment,Per Unit,"$1,525.09 ",OP,"1,525.09","1,525.09",,,,,,
Meridian Duals,CPT,L8694,Aoi transducer/actuator repl,Durable Medical Equipment,Per Unit,$949.85 ,OP,949.85,949.85,,,,,,
Meridian Duals,CPT,L8695,External recharg sys extern,Durable Medical Equipment,Per Unit,$16.77 ,OP,16.77,57.19,,,,,,
Meridian Duals,CPT,L8696,Ext antenna phren nerve stim,Durable Medical Equipment,Per Unit,$217.98 ,OP,217.98,217.98,,,,,,
Meridian Duals,CPT,M0201,Covid-19 vaccine home admin,APC 1494,RVU Per Unit,$36.33 ,OP,36.33,36.33,,,,,,
Meridian Duals,CPT,M0240,Casiri and imdev repeat,APC 1506,RVU Per Unit,$461.00 ,OP,430.44,461,,,,,,
Meridian Duals,CPT,M0241,Casiri and imdev repeat hm,APC 1509,RVU Per Unit,$768.00 ,OP,768,768,,,,,,
Meridian Duals,CPT,M0243,Casirivi and imdevi inj,APC 1506,RVU Per Unit,$461.00 ,OP,461,461,,,,,,
Meridian Duals,CPT,M0244,Casirivi and imdevi inj hm,APC 1509,RVU Per Unit,$768.00 ,OP,717.08,768,,,,,,
Meridian Duals,CPT,M0245,Bamlan and etesev infusion,APC 1506,RVU Per Unit,$461.00 ,OP,430.44,461,,,,,,
Meridian Duals,CPT,M0246,Bamlan and etesev infus home,APC 1509,RVU Per Unit,$768.00 ,OP,717.08,768,,,,,,
Meridian Duals,CPT,M0247,Sotrovimab infusion,APC 1506,RVU Per Unit,$461.00 ,OP,430.44,461,,,,,,
Meridian Duals,CPT,M0248,Sotrovimab inf- home admin,APC 1509,RVU Per Unit,$768.00 ,OP,717.08,768,,,,,,
Meridian Duals,CPT,M0249,Adm tocilizu covid-19 1st,APC 1506,RVU Per Unit,$461.00 ,OP,430.44,461,,,,,,
Meridian Duals,CPT,M0250,Adm tocilizu covid-19 2nd,APC 1506,RVU Per Unit,$461.00 ,OP,430.44,461,,,,,,
Meridian Duals,CPT,P2028,Cephalin floculation test,Lab Services,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,
Meridian Duals,CPT,P2029,Congo red blood test,Lab Services,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,
Meridian Duals,CPT,P2033,Blood thymol turbidity,Lab Services,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,
Meridian Duals,CPT,P2038,Blood mucoprotein,Lab Services,Per Unit,$4.95 ,OP,4.95,22.88,,,,,,
Meridian Duals,CPT,P3000,Screen pap by tech w md supv,Lab Services,Per Unit,$15.15 ,OP,15.15,45.74,,,,,,
Meridian Duals,CPT,P9010,Whole blood for transfusion,APC 9510,Per Unit,$172.22 ,OP,172.22,172.22,,,,,,
Meridian Duals,CPT,P9011,Blood split unit,APC 9520,Per Unit,$169.28 ,OP,169.28,169.28,,,,,,
Meridian Duals,CPT,P9012,Cryoprecipitate each unit,APC 9511,Per Unit,$91.59 ,OP,91.59,91.59,,,,,,
Meridian Duals,CPT,P9016,Rbc leukocytes reduced,APC 9512,Per Unit,$216.23 ,OP,216.23,216.23,,,,,,
Meridian Duals,CPT,P9017,Plasma 1 donor frz w/in 8 hr,APC 9508,Per Unit,$94.81 ,OP,94.81,94.81,,,,,,
Meridian Duals,CPT,P9019,Platelets- each unit,APC 9515,Per Unit,$81.77 ,OP,81.77,81.77,,,,,,
Meridian Duals,CPT,P9020,Plaelet rich plasma unit,APC 9516,Per Unit,$229.41 ,OP,229.41,229.41,,,,,,
Meridian Duals,CPT,P9021,Red blood cells unit,APC 9517,Per Unit,$157.87 ,OP,157.87,157.87,,,,,,
Meridian Duals,CPT,P9022,Washed red blood cells unit,APC 9518,Per Unit,$435.72 ,OP,435.72,435.72,,,,,,
Meridian Duals,CPT,P9023,Frozen plasma- pooled- sd,APC 9509,Per Unit,$102.26 ,OP,102.26,102.26,,,,,,
Meridian Duals,CPT,P9025,Plasma cryo redu path each,APC 9538,Per Unit,$75.36 ,OP,75.36,75.36,,,,,,
Meridian Duals,CPT,P9026,Cryo fib comp path redu each,APC 9539,Per Unit,$91.59 ,OP,91.59,91.59,,,,,,
Meridian Duals,CPT,P9031,Platelets leukocytes reduced,APC 9526,Per Unit,$171.96 ,OP,171.96,171.96,,,,,,
Meridian Duals,CPT,P9032,Platelets- irradiated,APC 9500,Per Unit,$162.52 ,OP,162.52,162.52,,,,,,
Meridian Duals,CPT,P9033,Platelets leukoreduced irrad,APC 9521,Per Unit,$244.54 ,OP,244.54,244.54,,,,,,
Meridian Duals,CPT,P9034,Platelets- pheresis,APC 9507,Per Unit,$371.63 ,OP,371.63,371.63,,,,,,
Meridian Duals,CPT,P9035,Platelet pheres leukoreduced,APC 9501,Per Unit,$558.38 ,OP,558.38,558.38,,,,,,
Meridian Duals,CPT,P9036,Platelet pheresis irradiated,APC 9502,Per Unit,$693.83 ,OP,693.83,693.83,,,,,,
Meridian Duals,CPT,P9037,Plate pheres leukoredu irrad,APC 9530,Per Unit,$708.10 ,OP,708.1,708.1,,,,,,
Meridian Duals,CPT,P9038,Rbc irradiated,APC 9505,Per Unit,$194.21 ,OP,194.21,194.21,,,,,,
Meridian Duals,CPT,P9039,Rbc deglycerolized,APC 9504,Per Unit,$500.86 ,OP,500.86,500.86,,,,,,
Meridian Duals,CPT,P9040,Rbc leukoreduced irradiated,APC 9522,Per Unit,$298.86 ,OP,298.86,298.86,,,,,,
Meridian Duals,CPT,P9041,Albumin (human)-5%- 50ml,APC 0961,Per Unit,$10.49 ,OP,10.49,10.49,,,,,,
Meridian Duals,CPT,P9043,Plasma protein fract-5%-50ml,APC 9514,Per Unit,$9.16 ,OP,9.16,106.76,,,,,,
Meridian Duals,CPT,P9044,Cryoprecipitatereducedplasma,APC 9523,Per Unit,$75.36 ,OP,75.36,75.36,,,,,,
Meridian Duals,CPT,P9045,Albumin (human)- 5%- 250 ml,APC 0963,Per Unit,$52.45 ,OP,52.45,274.51,,,,,,
Meridian Duals,CPT,P9046,Albumin (human)- 25%- 20 ml,APC 0964,Per Unit,$20.98 ,OP,20.98,129.64,,,,,,
Meridian Duals,CPT,P9047,Albumin (human)- 25%- 50ml,APC 0965,Per Unit,$52.45 ,OP,52.45,255.45,,,,,,
Meridian Duals,CPT,P9048,Plasmaprotein fract-5%-250ml,APC 9519,Per Unit,$183.92 ,OP,183.92,198.25,,,,,,
Meridian Duals,CPT,P9051,Blood- l/r- cmv-neg,APC 9524,Per Unit,$243.44 ,OP,243.44,243.44,,,,,,
Meridian Duals,CPT,P9052,Platelets- hla-m- l/r- unit,APC 9525,Per Unit,$923.57 ,OP,923.57,923.57,,,,,,
Meridian Duals,CPT,P9053,Plt- pher- l/r cmv-neg- irr,APC 9531,Per Unit,$513.08 ,OP,513.08,513.08,,,,,,
Meridian Duals,CPT,P9054,Blood- l/r- froz/degly/wash,APC 9527,Per Unit,$356.39 ,OP,356.39,356.39,,,,,,
Meridian Duals,CPT,P9055,Plt- aph/pher- l/r- cmv-neg,APC 9528,Per Unit,$550.63 ,OP,550.63,550.63,,,,,,
Meridian Duals,CPT,P9056,Blood- l/r- irradiated,APC 9529,Per Unit,$176.83 ,OP,176.83,176.83,,,,,,
Meridian Duals,CPT,P9057,Rbc- frz/deg/wsh- l/r- irrad,APC 9532,Per Unit,$298.91 ,OP,298.91,298.91,,,,,,
Meridian Duals,CPT,P9058,Rbc- l/r- cmv-neg- irrad,APC 9533,Per Unit,$279.73 ,OP,279.73,279.73,,,,,,
Meridian Duals,CPT,P9059,Plasma- frz between 8-24hour,APC 9513,Per Unit,$81.61 ,OP,81.61,81.61,,,,,,
Meridian Duals,CPT,P9060,Fr frz plasma donor retested,APC 9503,Per Unit,$74.65 ,OP,74.65,74.65,,,,,,
Meridian Duals,CPT,P9070,Pathogen reduced plasma pool,APC 9534,Per Unit,$60.91 ,OP,60.91,60.91,,,,,,
Meridian Duals,CPT,P9071,Pathogen reduced plasma sing,APC 9535,Per Unit,$140.88 ,OP,140.88,140.88,,,,,,
Meridian Duals,CPT,P9073,Platelets pheresis path redu,APC 9536,Per Unit,$669.72 ,OP,669.72,669.72,,,,,,
Meridian Duals,CPT,P9099,Blood component/product noc,APC 9537,Per Unit,$9.16 ,OP,9.16,9.16,,,,,,
Meridian Duals,CPT,P9100,Pathogen test for platelets,APC 5732,RVU Per Unit,$34.63 ,OP,34.63,34.63,,,,,,
Meridian Duals,CPT,P9612,Catheterize for urine spec,Lab Services,Per Unit,$3.00 ,OP,3,3,,,,,,
Meridian Duals,CPT,Q0035,Cardiokymography,APC 5732,RVU Per Case,$34.63 ,OP,34.63,106.76,,,,,,
Meridian Duals,CPT,Q0091,Obtaining screen pap smear,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,205.88,,,,,,
Meridian Duals,CPT,Q0111,Wet mounts/ w preparations,Lab Services,Per Unit,$15.15 ,OP,15.15,15.15,,,,,,
Meridian Duals,CPT,Q0112,Potassium hydroxide preps,Lab Services,Per Unit,$5.83 ,OP,5.83,22.88,,,,,,
Meridian Duals,CPT,Q0113,Pinworm examinations,Lab Services,Per Unit,$4.27 ,OP,4.27,26.7,,,,,,
Meridian Duals,CPT,Q0114,Fern test,Lab Services,Per Unit,$9.74 ,OP,9.74,34.31,,,,,,
Meridian Duals,CPT,Q0115,Post-coital mucous exam,Lab Services,Per Unit,$25.00 ,OP,25,49.56,,,,,,
Meridian Duals,CPT,Q0138,Ferumoxytol- non-esrd,APC 1297,Per Unit,$1.00 ,OP,1,1,,,,,,
Meridian Duals,CPT,Q0139,Ferumoxytol- esrd use,APC 1485,Per Unit,$1.00 ,OP,1,1,,,,,,
Meridian Duals,CPT,Q0240,Casirivi and imdevi 600 mg,Other,Straight Discount,29.70%,OP,,,,,,,,
Meridian Duals,CPT,Q0243,Casirivimab and imdevimab,Other,Straight Discount,29.70%,OP,,,,,,,,
Meridian Duals,CPT,Q0244,Casirivi and imdevi 1200 mg,Other,Straight Discount,29.70%,OP,,,,,,,,
Meridian Duals,CPT,Q0245,Bamlanivimab and etesevima,Other,Straight Discount,29.70%,OP,,,,,,,,
Meridian Duals,CPT,Q0247,Sotrovimab,Other,Straight Discount,29.70%,OP,,,,,,,,
Meridian Duals,CPT,Q0249,Tocilizumab for covid-19,Other,Straight Discount,29.70%,OP,,,,,,,,
Meridian Duals,CPT,Q0477,Pwr module pt cable lvad rpl,Durable Medical Equipment,Per Unit,$780.34 ,OP,780.34,780.34,,,,,,
Meridian Duals,CPT,Q0478,Power adapter- combo vad,Durable Medical Equipment,Per Unit,$184.82 ,OP,184.82,184.82,,,,,,
Meridian Duals,CPT,Q0479,Power module combo vad- rep,Durable Medical Equipment,Per Unit,"$12,073.17 ",OP,"12,073.17","12,073.17",,,,,,
Meridian Duals,CPT,Q0480,Driver pneumatic vad- rep,Durable Medical Equipment,Per Unit,"$90,585.51 ",OP,"90,585.51","311,531.29",,,,,,
Meridian Duals,CPT,Q0481,Microprcsr cu elec vad- rep,Durable Medical Equipment,Per Unit,"$14,614.95 ",OP,"14,614.95","50,262.72",,,,,,
Meridian Duals,CPT,Q0482,Microprcsr cu combo vad- rep,Durable Medical Equipment,Per Unit,"$4,577.67 ",OP,"4,577.67","15,742.60",,,,,,
Meridian Duals,CPT,Q0483,Monitor elec vad- rep,Durable Medical Equipment,Per Unit,"$18,857.93 ",OP,"18,857.93","64,853.90",,,,,,
Meridian Duals,CPT,Q0484,Monitor elec or comb vad rep,Durable Medical Equipment,Per Unit,"$3,662.14 ",OP,"3,662.14","12,593.32",,,,,,
Meridian Duals,CPT,Q0485,Monitor cable elec vad- rep,Durable Medical Equipment,Per Unit,$353.60 ,OP,353.6,"1,216.24",,,,,,
Meridian Duals,CPT,Q0486,Mon cable elec/pneum vad rep,Durable Medical Equipment,Per Unit,$294.28 ,OP,294.28,"1,010.37",,,,,,
Meridian Duals,CPT,Q0487,Leads any type vad- rep only,Durable Medical Equipment,Per Unit,$343.31 ,OP,343.31,"1,181.94",,,,,,
Meridian Duals,CPT,Q0489,Pwr pck base combo vad- rep,Durable Medical Equipment,Per Unit,"$16,348.80 ",OP,"16,348.80","56,225.77",,,,,,
Meridian Duals,CPT,Q0490,Emr pwr source elec vad- rep,Durable Medical Equipment,Per Unit,$707.17 ,OP,707.17,"2,432.50",,,,,,
Meridian Duals,CPT,Q0491,Emr pwr source combo vad rep,Durable Medical Equipment,Per Unit,"$1,111.75 ",OP,"1,111.75","3,824.13",,,,,,
Meridian Duals,CPT,Q0492,Emr pwr cbl elec vad- rep,Durable Medical Equipment,Per Unit,$89.58 ,OP,89.58,308.83,,,,,,
Meridian Duals,CPT,Q0493,Emr pwr cbl combo vad- rep,Durable Medical Equipment,Per Unit,$255.02 ,OP,255.02,876.92,,,,,,
Meridian Duals,CPT,Q0494,Emr hd pmp elec/combo- rep,Durable Medical Equipment,Per Unit,$215.79 ,OP,215.79,743.48,,,,,,
Meridian Duals,CPT,Q0495,Charger elec/combo vad- rep,Durable Medical Equipment,Per Unit,"$4,201.23 ",OP,"4,201.23","14,450.10",,,,,,
Meridian Duals,CPT,Q0496,Battery elec/combo vad- rep,Durable Medical Equipment,Per Unit,"$1,507.90 ",OP,"1,507.90","5,185.26",,,,,,
Meridian Duals,CPT,Q0497,Bat clps elec/comb vad- rep,Durable Medical Equipment,Per Unit,$470.84 ,OP,470.84,"1,620.40",,,,,,
Meridian Duals,CPT,Q0498,Holster elec/combo vad- rep,Durable Medical Equipment,Per Unit,$516.61 ,OP,516.61,"1,776.71",,,,,,
Meridian Duals,CPT,Q0499,Belt/vest elec/combo vad rep,Durable Medical Equipment,Per Unit,$167.86 ,OP,167.86,575.73,,,,,,
Meridian Duals,CPT,Q0500,Filters elec/combo vad- rep,Durable Medical Equipment,Per Unit,$30.69 ,OP,30.69,106.76,,,,,,
Meridian Duals,CPT,Q0501,Shwr cov elec/combo vad- rep,Durable Medical Equipment,Per Unit,$513.63 ,OP,513.63,"1,765.27",,,,,,
Meridian Duals,CPT,Q0502,Mobility cart pneum vad- rep,Durable Medical Equipment,Per Unit,$653.97 ,OP,653.97,"2,249.49",,,,,,
Meridian Duals,CPT,Q0503,Battery pneum vad replacemnt,Durable Medical Equipment,Per Unit,"$1,307.87 ",OP,"1,307.87","4,498.98",,,,,,
Meridian Duals,CPT,Q0504,Pwr adpt pneum vad- rep veh,Durable Medical Equipment,Per Unit,$690.16 ,OP,690.16,"2,375.30",,,,,,
Meridian Duals,CPT,Q0506,Lith-ion batt elec/pneum vad,Durable Medical Equipment,Per Unit,$859.04 ,OP,859.04,859.04,,,,,,
Meridian Duals,CPT,Q2017,Teniposide- 50 mg,APC 7035,Per Unit,"$2,645.71 ",OP,"1,582.28","2,645.71",,,,,,
Meridian Duals,CPT,Q2026,Radiesse injection,APC 9094,Per Unit,$257.37 ,OP,257.37,257.37,,,,,,
Meridian Duals,CPT,Q2028,Inj- sculptra- 0.5mg,APC 9095,Per Unit,$2.49 ,OP,2.49,2.49,,,,,,
Meridian Duals,CPT,Q2034,Agriflu vaccine,Other,Straight Discount,29.70%,OP,,,,,,,,
Meridian Duals,CPT,Q2035,Afluria vacc- 3 yrs & >- im,Other,Straight Discount,29.70%,OP,,,,,,,,
Meridian Duals,CPT,Q2036,Flulaval vacc- 3 yrs & >- im,Other,Straight Discount,29.70%,OP,,,,,,,,
Meridian Duals,CPT,Q2037,Fluvirin vacc- 3 yrs & >- im,Other,Straight Discount,29.70%,OP,,,,,,,,
Meridian Duals,CPT,Q2038,Fluzone vacc- 3 yrs & >- im,Other,Straight Discount,29.70%,OP,,,,,,,,
Meridian Duals,CPT,Q2039,Influenza virus vaccine- nos,Other,Straight Discount,29.70%,OP,,,,,,,,
Meridian Duals,CPT,Q2041,Axicabtagene ciloleucel car+,APC 9035,Per Unit,"$395,380.00 ",OP,"395,380.00","395,380.00",,,,,,
Meridian Duals,CPT,Q2042,Tisagenlecleucel car-pos t,APC 9194,Per Unit,"$434,337.60 ",OP,"434,337.60","434,337.60",,,,,,
Meridian Duals,CPT,Q2043,Sipuleucel-t auto cd54+,APC 9273,Per Unit,"$53,017.58 ",OP,"53,017.58","53,017.58",,,,,,
Meridian Duals,CPT,Q2049,Imported lipodox inj,APC 1421,Per Unit,$311.04 ,OP,311.04,311.04,,,,,,
Meridian Duals,CPT,Q2050,Doxorubicin inj 10mg,APC 7046,Per Unit,$234.03 ,OP,234.03,"1,719.01",,,,,,
Meridian Duals,CPT,Q2053,Brexucabtagene car pos t,APC 9391,Per Unit,"$395,380.00 ",OP,"395,380.00","395,380.00",,,,,,
Meridian Duals,CPT,Q2054,Lisocabtagene mara car pos t,APC 9413,Per Unit,"$422,609.00 ",OP,"422,609.00","422,609.00",,,,,,
Meridian Duals,CPT,Q3027,Inj beta interferon im 1 mcg,APC 1472,Per Unit,$55.29 ,OP,55.29,74.17,,,,,,
Meridian Duals,CPT,Q5101,Injection- zarxio,APC 1822,Per Unit,$0.32 ,OP,0.32,0.32,,,,,,
Meridian Duals,CPT,Q5103,Injection- inflectra,APC 1847,Per Unit,$41.19 ,OP,41.19,41.19,,,,,,
Meridian Duals,CPT,Q5104,Injection- renflexis,APC 9036,Per Unit,$38.79 ,OP,38.79,38.79,,,,,,
Meridian Duals,CPT,Q5106,Inj retacrit non-esrd use,APC 9097,Per Unit,$8.66 ,OP,8.66,8.66,,,,,,
Meridian Duals,CPT,Q5107,Inj mvasi 10 mg,APC 9329,Per Unit,$44.56 ,OP,44.56,44.56,,,,,,
Meridian Duals,CPT,Q5108,Injection- fulphila,APC 9173,Per Unit,$211.19 ,OP,211.19,211.19,,,,,,
Meridian Duals,CPT,Q5110,Nivestym,APC 9193,Per Unit,$0.33 ,OP,0.33,0.33,,,,,,
Meridian Duals,CPT,Q5111,Injection- udenyca 0.5 mg,APC 9195,Per Unit,$222.38 ,OP,222.38,222.38,,,,,,
Meridian Duals,CPT,Q5112,Inj ontruzant 10 mg,APC 9382,Per Unit,$66.55 ,OP,66.55,66.55,,,,,,
Meridian Duals,CPT,Q5113,Inj herzuma 10 mg,APC 9349,Per Unit,$57.30 ,OP,57.3,57.3,,,,,,
Meridian Duals,CPT,Q5114,Inj ogivri 10 mg,APC 9341,Per Unit,$59.91 ,OP,59.91,59.91,,,,,,
Meridian Duals,CPT,Q5115,Inj truxima 10 mg,APC 9336,Per Unit,$60.58 ,OP,60.58,60.58,,,,,,
Meridian Duals,CPT,Q5116,Inj.- trazimera- 10 mg,APC 9350,Per Unit,$59.93 ,OP,59.93,59.93,,,,,,
Meridian Duals,CPT,Q5117,Inj.- kanjinti- 10 mg,APC 9330,Per Unit,$53.18 ,OP,53.18,53.18,,,,,,
Meridian Duals,CPT,Q5118,Inj.- zirabev- 10 mg,APC 9348,Per Unit,$52.37 ,OP,52.37,52.37,,,,,,
Meridian Duals,CPT,Q5119,Inj ruxience- 10 mg,APC 9367,Per Unit,$58.80 ,OP,58.8,58.8,,,,,,
Meridian Duals,CPT,Q5120,Inj pegfilgrastim-bmez 0.5mg,APC 9345,Per Unit,$245.43 ,OP,245.43,245.43,,,,,,
Meridian Duals,CPT,Q5121,Inj. avsola- 10 mg,APC 9381,Per Unit,$47.12 ,OP,47.12,47.12,,,,,,
Meridian Duals,CPT,Q5122,Inj- nyvepria,APC 9406,Per Unit,$284.69 ,OP,284.69,284.69,,,,,,
Meridian Duals,CPT,Q5123,Inj. riabni- 10 mg,APC 9411,Per Unit,$72.23 ,OP,72.23,72.23,,,,,,
Meridian Duals,CPT,Q9968,Visualization adjunct,APC 1446,Per Unit,$6.73 ,OP,6.73,6.73,,,,,,
Meridian Duals,CPT,Q9969,Non-heu tc-99m add-on/dose,APC 1442,Per Unit,$10.00 ,OP,10,10,,,,,,
Meridian Duals,CPT,Q9991,Buprenorph xr 100 mg or less,APC 9073,Per Unit,"$1,796.80 ",OP,"1,796.80","1,796.80",,,,,,
Meridian Duals,CPT,Q9992,Buprenorphine xr over 100 mg,APC 9239,Per Unit,"$1,796.80 ",OP,"1,796.80","1,796.80",,,,,,
Meridian Duals,CPT,U0001,2019-ncov diagnostic p,Lab Services,Per Unit,$35.91 ,OP,35.91,35.91,,,,,,
Meridian Duals,CPT,U0002,Covid-19 lab test non-cdc,Lab Services,Per Unit,$51.31 ,OP,51.31,51.31,,,,,,
Meridian Duals,CPT,U0003,Cov-19 amp prb hgh thruput,Lab Services,Per Unit,$75.00 ,OP,75,75,,,,,,
Meridian Duals,CPT,U0004,Cov-19 test non-cdc hgh thru,Lab Services,Per Unit,$75.00 ,OP,75,75,,,,,,
Meridian Duals,CPT,U0005,Infec agen detec ampli probe,Lab Services,Per Unit,$25.00 ,OP,25,25,,,,,,
Meridian Duals,CPT,V2020,Vision svcs frames purchases,Durable Medical Equipment,Per Unit,$75.22 ,OP,75.22,388.89,,,,,,
Meridian Duals,CPT,V2100,Lens spher single plano 4.00,Durable Medical Equipment,Per Unit,$46.49 ,OP,46.49,240.2,,,,,,
Meridian Duals,CPT,V2101,Single visn sphere 4.12-7.00,Durable Medical Equipment,Per Unit,$44.67 ,OP,44.67,228.77,,,,,,
Meridian Duals,CPT,V2102,Singl visn sphere 7.12-20.00,Durable Medical Equipment,Per Unit,$77.24 ,OP,77.24,400.34,,,,,,
Meridian Duals,CPT,V2103,Spherocylindr 4.00d/12-2.00d,Durable Medical Equipment,Per Unit,$39.13 ,OP,39.13,202.07,,,,,,
Meridian Duals,CPT,V2104,Spherocylindr 4.00d/2.12-4d,Durable Medical Equipment,Per Unit,$40.34 ,OP,40.34,209.7,,,,,,
Meridian Duals,CPT,V2105,Spherocylinder 4.00d/4.25-6d,Durable Medical Equipment,Per Unit,$47.98 ,OP,47.98,247.83,,,,,,
Meridian Duals,CPT,V2106,Spherocylinder 4.00d/>6.00d,Durable Medical Equipment,Per Unit,$53.15 ,OP,53.15,274.51,,,,,,
Meridian Duals,CPT,V2107,Spherocylinder 4.25d/12-2d,Durable Medical Equipment,Per Unit,$47.33 ,OP,47.33,244.01,,,,,,
Meridian Duals,CPT,V2108,Spherocylinder 4.25d/2.12-4d,Durable Medical Equipment,Per Unit,$47.46 ,OP,47.46,244.01,,,,,,
Meridian Duals,CPT,V2109,Spherocylinder 4.25d/4.25-6d,Durable Medical Equipment,Per Unit,$66.10 ,OP,66.1,339.33,,,,,,
Meridian Duals,CPT,V2110,Spherocylinder 4.25d/over 6d,Durable Medical Equipment,Per Unit,$53.39 ,OP,53.39,274.51,,,,,,
Meridian Duals,CPT,V2111,Spherocylindr 7.25d/.25-2.25,Durable Medical Equipment,Per Unit,$64.70 ,OP,64.7,335.53,,,,,,
Meridian Duals,CPT,V2112,Spherocylindr 7.25d/2.25-4d,Durable Medical Equipment,Per Unit,$73.09 ,OP,73.09,377.46,,,,,,
Meridian Duals,CPT,V2113,Spherocylindr 7.25d/4.25-6d,Durable Medical Equipment,Per Unit,$73.91 ,OP,73.91,381.27,,,,,,
Meridian Duals,CPT,V2114,Spherocylinder over 12.00d,Durable Medical Equipment,Per Unit,$87.57 ,OP,87.57,453.71,,,,,,
Meridian Duals,CPT,V2115,Lens lenticular bifocal,Durable Medical Equipment,Per Unit,$88.27 ,OP,88.27,453.71,,,,,,
Meridian Duals,CPT,V2118,Lens aniseikonic single,Durable Medical Equipment,Per Unit,$96.05 ,OP,96.05,495.65,,,,,,
Meridian Duals,CPT,V2121,Lenticular lens- single,Durable Medical Equipment,Per Unit,$86.61 ,OP,86.61,446.08,,,,,,
Meridian Duals,CPT,V2200,Lens spher bifoc plano 4.00d,Durable Medical Equipment,Per Unit,$52.35 ,OP,52.35,270.71,,,,,,
Meridian Duals,CPT,V2201,Lens sphere bifocal 4.12-7.0,Durable Medical Equipment,Per Unit,$56.09 ,OP,56.09,289.76,,,,,,
Meridian Duals,CPT,V2202,Lens sphere bifocal 7.12-20.,Durable Medical Equipment,Per Unit,$69.53 ,OP,69.53,358.39,,,,,,
Meridian Duals,CPT,V2203,Lens sphcyl bifocal 4.00d/.1,Durable Medical Equipment,Per Unit,$53.92 ,OP,53.92,278.32,,,,,,
Meridian Duals,CPT,V2204,Lens sphcy bifocal 4.00d/2.1,Durable Medical Equipment,Per Unit,$55.48 ,OP,55.48,285.96,,,,,,
Meridian Duals,CPT,V2205,Lens sphcy bifocal 4.00d/4.2,Durable Medical Equipment,Per Unit,$61.51 ,OP,61.51,316.46,,,,,,
Meridian Duals,CPT,V2206,Lens sphcy bifocal 4.00d/ove,Durable Medical Equipment,Per Unit,$72.21 ,OP,72.21,373.65,,,,,,
Meridian Duals,CPT,V2207,Lens sphcy bifocal 4.25-7d/.,Durable Medical Equipment,Per Unit,$61.03 ,OP,61.03,316.46,,,,,,
Meridian Duals,CPT,V2208,Lens sphcy bifocal 4.25-7/2.,Durable Medical Equipment,Per Unit,$59.97 ,OP,59.97,308.83,,,,,,
Meridian Duals,CPT,V2209,Lens sphcy bifocal 4.25-7/4.,Durable Medical Equipment,Per Unit,$70.40 ,OP,70.4,362.21,,,,,,
Meridian Duals,CPT,V2210,Lens sphcy bifocal 4.25-7/ov,Durable Medical Equipment,Per Unit,$75.86 ,OP,75.86,392.7,,,,,,
Meridian Duals,CPT,V2211,Lens sphcy bifo 7.25-12/.25-,Durable Medical Equipment,Per Unit,$73.85 ,OP,73.85,381.27,,,,,,
Meridian Duals,CPT,V2212,Lens sphcyl bifo 7.25-12/2.2,Durable Medical Equipment,Per Unit,$77.30 ,OP,77.3,400.34,,,,,,
Meridian Duals,CPT,V2213,Lens sphcyl bifo 7.25-12/4.2,Durable Medical Equipment,Per Unit,$81.28 ,OP,81.28,419.4,,,,,,
Meridian Duals,CPT,V2214,Lens sphcyl bifocal over 12.,Durable Medical Equipment,Per Unit,$84.95 ,OP,84.95,438.47,,,,,,
Meridian Duals,CPT,V2215,Lens lenticular bifocal,Durable Medical Equipment,Per Unit,$106.06 ,OP,106.06,549.03,,,,,,
Meridian Duals,CPT,V2218,Lens aniseikonic bifocal,Durable Medical Equipment,Per Unit,$108.09 ,OP,108.09,556.65,,,,,,
Meridian Duals,CPT,V2219,Lens bifocal seg width over,Durable Medical Equipment,Per Unit,$49.86 ,OP,49.86,255.45,,,,,,
Meridian Duals,CPT,V2220,Lens bifocal add over 3.25d,Durable Medical Equipment,Per Unit,$44.28 ,OP,44.28,228.77,,,,,,
Meridian Duals,CPT,V2221,Lenticular lens- bifocal,Durable Medical Equipment,Per Unit,$88.33 ,OP,88.33,457.52,,,,,,
Meridian Duals,CPT,V2300,Lens sphere trifocal 4.00d,Durable Medical Equipment,Per Unit,$71.57 ,OP,71.57,369.83,,,,,,
Meridian Duals,CPT,V2301,Lens sphere trifocal 4.12-7.,Durable Medical Equipment,Per Unit,$87.77 ,OP,87.77,453.71,,,,,,
Meridian Duals,CPT,V2302,Lens sphere trifocal 7.12-20,Durable Medical Equipment,Per Unit,$82.00 ,OP,82,423.22,,,,,,
Meridian Duals,CPT,V2303,Lens sphcy trifocal 4.0/.12-,Durable Medical Equipment,Per Unit,$68.89 ,OP,68.89,354.58,,,,,,
Meridian Duals,CPT,V2304,Lens sphcy trifocal 4.0/2.25,Durable Medical Equipment,Per Unit,$69.70 ,OP,69.7,358.39,,,,,,
Meridian Duals,CPT,V2305,Lens sphcy trifocal 4.0/4.25,Durable Medical Equipment,Per Unit,$77.86 ,OP,77.86,400.34,,,,,,
Meridian Duals,CPT,V2306,Lens sphcyl trifocal 4.00/>6,Durable Medical Equipment,Per Unit,$80.17 ,OP,80.17,411.78,,,,,,
Meridian Duals,CPT,V2307,Lens sphcy trifocal 4.25-7/.,Durable Medical Equipment,Per Unit,$76.33 ,OP,76.33,392.7,,,,,,
Meridian Duals,CPT,V2308,Lens sphc trifocal 4.25-7/2.,Durable Medical Equipment,Per Unit,$83.26 ,OP,83.26,430.83,,,,,,
Meridian Duals,CPT,V2309,Lens sphc trifocal 4.25-7/4.,Durable Medical Equipment,Per Unit,$87.13 ,OP,87.13,449.9,,,,,,
Meridian Duals,CPT,V2310,Lens sphc trifocal 4.25-7/>6,Durable Medical Equipment,Per Unit,$91.01 ,OP,91.01,468.96,,,,,,
Meridian Duals,CPT,V2311,Lens sphc trifo 7.25-12/.25-,Durable Medical Equipment,Per Unit,$105.08 ,OP,105.08,541.4,,,,,,
Meridian Duals,CPT,V2312,Lens sphc trifo 7.25-12/2.25,Durable Medical Equipment,Per Unit,$96.32 ,OP,96.32,495.65,,,,,,
Meridian Duals,CPT,V2313,Lens sphc trifo 7.25-12/4.25,Durable Medical Equipment,Per Unit,$105.15 ,OP,105.15,541.4,,,,,,
Meridian Duals,CPT,V2314,Lens sphcyl trifocal over 12,Durable Medical Equipment,Per Unit,$107.48 ,OP,107.48,552.84,,,,,,
Meridian Duals,CPT,V2315,Lens lenticular trifocal,Durable Medical Equipment,Per Unit,$119.32 ,OP,119.32,613.85,,,,,,
Meridian Duals,CPT,V2318,Lens aniseikonic trifocal,Durable Medical Equipment,Per Unit,$146.68 ,OP,146.68,754.91,,,,,,
Meridian Duals,CPT,V2319,Lens trifocal seg width > 28,Durable Medical Equipment,Per Unit,$66.22 ,OP,66.22,343.14,,,,,,
Meridian Duals,CPT,V2320,Lens trifocal add over 3.25d,Durable Medical Equipment,Per Unit,$69.85 ,OP,69.85,362.21,,,,,,
Meridian Duals,CPT,V2321,Lenticular lens- trifocal,Durable Medical Equipment,Per Unit,$117.61 ,OP,117.61,606.21,,,,,,
Meridian Duals,CPT,V2410,Lens variab asphericity sing,Durable Medical Equipment,Per Unit,$102.83 ,OP,102.83,529.96,,,,,,
Meridian Duals,CPT,V2430,Lens variable asphericity bi,Durable Medical Equipment,Per Unit,$108.84 ,OP,108.84,560.47,,,,,,
Meridian Duals,CPT,V2500,Contact lens pmma spherical,Durable Medical Equipment,Per Unit,$92.01 ,OP,92.01,92.01,,,,,,
Meridian Duals,CPT,V2501,Cntct lens pmma-toric/prism,Durable Medical Equipment,Per Unit,$130.56 ,OP,130.56,674.85,,,,,,
Meridian Duals,CPT,V2502,Contact lens pmma bifocal,Durable Medical Equipment,Per Unit,$176.91 ,OP,176.91,911.23,,,,,,
Meridian Duals,CPT,V2503,Cntct lens pmma color vision,Durable Medical Equipment,Per Unit,$170.87 ,OP,170.87,880.74,,,,,,
Meridian Duals,CPT,V2510,Cntct gas permeable sphericl,Durable Medical Equipment,Per Unit,$122.68 ,OP,122.68,632.91,,,,,,
Meridian Duals,CPT,V2511,Cntct toric prism ballast,Durable Medical Equipment,Per Unit,$181.84 ,OP,181.84,937.93,,,,,,
Meridian Duals,CPT,V2512,Cntct lens gas permbl bifocl,Durable Medical Equipment,Per Unit,$209.31 ,OP,209.31,"1,078.99",,,,,,
Meridian Duals,CPT,V2513,Contact lens extended wear,Durable Medical Equipment,Per Unit,$210.87 ,OP,210.87,"1,086.62",,,,,,
Meridian Duals,CPT,V2520,Contact lens hydrophilic,Durable Medical Equipment,Per Unit,$122.25 ,OP,122.25,629.1,,,,,,
Meridian Duals,CPT,V2521,Cntct lens hydrophilic toric,Durable Medical Equipment,Per Unit,$242.09 ,OP,242.09,"1,250.57",,,,,,
Meridian Duals,CPT,V2522,Cntct lens hydrophil bifocl,Durable Medical Equipment,Per Unit,$177.16 ,OP,177.16,915.04,,,,,,
Meridian Duals,CPT,V2523,Cntct lens hydrophil extend,Durable Medical Equipment,Per Unit,$186.00 ,OP,186,960.8,,,,,,
Meridian Duals,CPT,V2530,Contact lens gas impermeable,Durable Medical Equipment,Per Unit,$297.37 ,OP,297.37,"1,532.70",,,,,,
Meridian Duals,CPT,V2531,Contact lens gas permeable,Durable Medical Equipment,Per Unit,$544.58 ,OP,544.58,"2,809.96",,,,,,
Meridian Duals,CPT,V2623,Plastic eye prosth custom,Durable Medical Equipment,Per Unit,$942.94 ,OP,942.94,"4,864.99",,,,,,
Meridian Duals,CPT,V2624,Polishing artifical eye,Durable Medical Equipment,Per Unit,$60.88 ,OP,60.88,312.64,,,,,,
Meridian Duals,CPT,V2625,Enlargemnt of eye prosthesis,Durable Medical Equipment,Per Unit,$482.12 ,OP,482.12,"2,485.87",,,,,,
Meridian Duals,CPT,V2626,Reduction of eye prosthesis,Durable Medical Equipment,Per Unit,$199.51 ,OP,199.51,"1,029.43",,,,,,
Meridian Duals,CPT,V2627,Scleral cover shell,Durable Medical Equipment,Per Unit,"$1,430.28 ",OP,"1,430.28","7,377.56",,,,,,
Meridian Duals,CPT,V2628,Fabrication & fitting,Durable Medical Equipment,Per Unit,$304.24 ,OP,304.24,"1,570.83",,,,,,
Meridian Duals,CPT,V2700,Balance lens,Durable Medical Equipment,Per Unit,$44.84 ,OP,44.84,232.58,,,,,,
Meridian Duals,CPT,V2710,Glass/plastic slab off prism,Durable Medical Equipment,Per Unit,$73.51 ,OP,73.51,377.46,,,,,,
Meridian Duals,CPT,V2715,Prism lens/es,Durable Medical Equipment,Per Unit,$14.41 ,OP,14.41,72.44,,,,,,
Meridian Duals,CPT,V2718,Fresnell prism press-on lens,Durable Medical Equipment,Per Unit,$31.12 ,OP,31.12,160.13,,,,,,
Meridian Duals,CPT,V2730,Special base curve,Durable Medical Equipment,Per Unit,$26.06 ,OP,26.06,133.45,,,,,,
Meridian Duals,CPT,V2744,Tint photochromatic lens/es,Durable Medical Equipment,Per Unit,$17.83 ,OP,17.83,91.51,,,,,,
Meridian Duals,CPT,V2745,Tint- any color/solid/grad,Durable Medical Equipment,Per Unit,$10.27 ,OP,10.27,53.38,,,,,,
Meridian Duals,CPT,V2750,Anti-reflective coating,Durable Medical Equipment,Per Unit,$20.02 ,OP,20.02,102.95,,,,,,
Meridian Duals,CPT,V2755,Uv lens/es,Durable Medical Equipment,Per Unit,$16.76 ,OP,16.76,87.69,,,,,,
Meridian Duals,CPT,V2770,Occluder lens/es,Durable Medical Equipment,Per Unit,$19.52 ,OP,19.52,99.13,,,,,,
Meridian Duals,CPT,V2780,Oversize lens/es,Durable Medical Equipment,Per Unit,$12.53 ,OP,12.53,64.82,,,,,,
Meridian Duals,CPT,V2782,Lens- 1.54-1.65 p/1.60-1.79g,Durable Medical Equipment,Per Unit,$64.75 ,OP,64.75,335.53,,,,,,
Meridian Duals,CPT,V2783,Lens- >= 1.66 p/>=1.80 g,Durable Medical Equipment,Per Unit,$73.02 ,OP,73.02,377.46,,,,,,
Meridian Duals,CPT,V2784,Lens polycarb or equal,Durable Medical Equipment,Per Unit,$47.48 ,OP,47.48,244.01,,,,,,
Meridian Duals,CPT,V2785,Corneal tissue processing,Other,Straight Discount,29.70%,OP,,,,,,,,
Meridian Medicaid,DRG,11,LIVER TRANSPLANT andOR INTESTINAL TRANSPLANT,,Relative Weights,"$38,043.18 ",IP,"38,043.18","38,043.18",,,,,,
Meridian Medicaid,DRG,12,LIVER TRANSPLANT andOR INTESTINAL TRANSPLANT,,Relative Weights,"$40,281.56 ",IP,"40,281.56","40,281.56",,,,,,
Meridian Medicaid,DRG,13,LIVER TRANSPLANT andOR INTESTINAL TRANSPLANT,,Relative Weights,"$42,053.29 ",IP,"42,053.29","42,053.29",,,,,,
Meridian Medicaid,DRG,14,LIVER TRANSPLANT andOR INTESTINAL TRANSPLANT,,Relative Weights,"$78,175.26 ",IP,"78,175.26","78,175.26",,,,,,
Meridian Medicaid,DRG,21,HEART andOR LUNG TRANSPLANT,,Relative Weights,"$45,599.51 ",IP,"45,599.51","45,599.51",,,,,,
Meridian Medicaid,DRG,22,HEART &/OR LUNG TRANSPLANT,,Relative Weights,"$58,026.75 ",IP,"58,026.75","58,026.75",,,,,,
Meridian Medicaid,DRG,23,HEART andOR LUNG TRANSPLANT,,Relative Weights,"$74,400.53 ",IP,"74,400.53","74,400.53",,,,,,
Meridian Medicaid,DRG,24,HEART andOR LUNG TRANSPLANT,,Relative Weights,"$107,953.54 ",IP,"107,953.54","107,953.54",,,,,,
Meridian Medicaid,DRG,41,TRACHEOSTOMY W MV 96+ HOURS W EXTENSIVE PROCEDURE,,Relative Weights,"$33,014.21 ",IP,"33,014.21","33,014.21",,,,,,
Meridian Medicaid,DRG,42,TRACHEOSTOMY W MV 96+ HOURS W EXTENSIVE PROCEDURE,,Relative Weights,"$37,820.51 ",IP,"37,820.51","37,820.51",,,,,,
Meridian Medicaid,DRG,43,TRACHEOSTOMY W MV 96 HOURS W EXTENSIVE PROCEDURE,,Relative Weights,"$49,052.96 ",IP,"49,052.96","49,052.96",,,,,,
Meridian Medicaid,DRG,44,TRACHEOSTOMY W MV 96 HOURS W EXTENSIVE PROCEDURE,,Relative Weights,"$72,921.22 ",IP,"72,921.22","72,921.22",,,,,,
Meridian Medicaid,DRG,51,TRACHEOSTOMY W MV 96 HOURS WO EXTENSIVE PROCEDURE,,Relative Weights,"$23,684.08 ",IP,"23,684.08","23,684.08",,,,,,
Meridian Medicaid,DRG,52,TRACHEOSTOMY W MV 96+ HOURS W/O EXTENSIVE PROCEDURE,,Relative Weights,"$26,315.91 ",IP,"26,315.91","26,315.91",,,,,,
Meridian Medicaid,DRG,53,TRACHEOSTOMY W MV 96 HOURS WO EXTENSIVE PROCEDURE,,Relative Weights,"$36,197.91 ",IP,"36,197.91","36,197.91",,,,,,
Meridian Medicaid,DRG,54,TRACHEOSTOMY W MV 96 HOURS WO EXTENSIVE PROCEDURE,,Relative Weights,"$48,934.75 ",IP,"48,934.75","48,934.75",,,,,,
Meridian Medicaid,DRG,61,PANCREAS TRANSPLANT,,Relative Weights,"$40,520.03 ",IP,"40,520.03","40,520.03",,,,,,
Meridian Medicaid,DRG,62,PANCREAS TRANSPLANT,,Relative Weights,"$45,022.22 ",IP,"45,022.22","45,022.22",,,,,,
Meridian Medicaid,DRG,63,PANCREAS TRANSPLANT,,Relative Weights,"$47,794.94 ",IP,"47,794.94","47,794.94",,,,,,
Meridian Medicaid,DRG,64,PANCREAS TRANSPLANT,,Relative Weights,"$66,459.33 ",IP,"66,459.33","66,459.33",,,,,,
Meridian Medicaid,DRG,71,ALLOGENEIC BONE MARROW TRANSPLANT,,Relative Weights,"$38,434.91 ",IP,"38,434.91","38,434.91",,,,,,
Meridian Medicaid,DRG,72,ALLOGENEIC BONE MARROW TRANSPLANT,,Relative Weights,"$48,059.19 ",IP,"48,059.19","48,059.19",,,,,,
Meridian Medicaid,DRG,73,ALLOGENEIC BONE MARROW TRANSPLANT,,Relative Weights,"$59,827.69 ",IP,"59,827.69","59,827.69",,,,,,
Meridian Medicaid,DRG,74,ALLOGENEIC BONE MARROW TRANSPLANT,,Relative Weights,"$99,672.84 ",IP,"99,672.84","99,672.84",,,,,,
Meridian Medicaid,DRG,81,AUTOLOGOUS BONE MARROW TRANSPLANT,,Relative Weights,"$22,091.37 ",IP,"22,091.37","22,091.37",,,,,,
Meridian Medicaid,DRG,82,AUTOLOGOUS BONE MARROW TRANSPLANT,,Relative Weights,"$27,118.96 ",IP,"27,118.96","27,118.96",,,,,,
Meridian Medicaid,DRG,83,AUTOLOGOUS BONE MARROW TRANSPLANT,,Relative Weights,"$32,175.76 ",IP,"32,175.76","32,175.76",,,,,,
Meridian Medicaid,DRG,84,AUTOLOGOUS BONE MARROW TRANSPLANT,,Relative Weights,"$51,576.54 ",IP,"51,576.54","51,576.54",,,,,,
Meridian Medicaid,DRG,91,EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO),,Relative Weights,"$27,699.69 ",IP,"27,699.69","27,699.69",,,,,,
Meridian Medicaid,DRG,92,EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO),,Relative Weights,"$30,776.86 ",IP,"30,776.86","30,776.86",,,,,,
Meridian Medicaid,DRG,93,EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO),,Relative Weights,"$36,358.72 ",IP,"36,358.72","36,358.72",,,,,,
Meridian Medicaid,DRG,94,EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO),,Relative Weights,"$79,300.63 ",IP,"79,300.63","79,300.63",,,,,,
Meridian Medicaid,DRG,101,HEAD TRAUMA WITH DEEP COMA,,Relative Weights,"$4,104.27 ",IP,"4,104.27","4,104.27",,,,,,
Meridian Medicaid,DRG,102,HEAD TRAUMA WITH DEEP COMA,,Relative Weights,"$7,527.81 ",IP,"7,527.81","7,527.81",,,,,,
Meridian Medicaid,DRG,103,HEAD TRAUMA WITH DEEP COMA,,Relative Weights,"$12,592.86 ",IP,"12,592.86","12,592.86",,,,,,
Meridian Medicaid,DRG,104,HEAD TRAUMA WITH DEEP COMA,,Relative Weights,"$37,584.09 ",IP,"37,584.09","37,584.09",,,,,,
Meridian Medicaid,DRG,201,CRANIOTOMY FOR TRAUMA,,Relative Weights,"$9,991.61 ",IP,"9,991.61","9,991.61",,,,,,
Meridian Medicaid,DRG,202,CRANIOTOMY FOR TRAUMA,,Relative Weights,"$11,868.15 ",IP,"11,868.15","11,868.15",,,,,,
Meridian Medicaid,DRG,203,CRANIOTOMY FOR TRAUMA,,Relative Weights,"$16,002.32 ",IP,"16,002.32","16,002.32",,,,,,
Meridian Medicaid,DRG,204,CRANIOTOMY FOR TRAUMA,,Relative Weights,"$28,673.87 ",IP,"28,673.87","28,673.87",,,,,,
Meridian Medicaid,DRG,211,CRANIOTOMY EXCEPT FOR TRAUMA,,Relative Weights,"$9,882.68 ",IP,"9,882.68","9,882.68",,,,,,
Meridian Medicaid,DRG,212,CRANIOTOMY EXCEPT FOR TRAUMA,,Relative Weights,"$13,243.69 ",IP,"13,243.69","13,243.69",,,,,,
Meridian Medicaid,DRG,213,CRANIOTOMY EXCEPT FOR TRAUMA,,Relative Weights,"$18,834.48 ",IP,"18,834.48","18,834.48",,,,,,
Meridian Medicaid,DRG,214,CRANIOTOMY EXCEPT FOR TRAUMA,,Relative Weights,"$27,671.86 ",IP,"27,671.86","27,671.86",,,,,,
Meridian Medicaid,DRG,221,VENTRICULAR SHUNT PROCEDURES,,Relative Weights,"$6,449.86 ",IP,"6,449.86","6,449.86",,,,,,
Meridian Medicaid,DRG,222,VENTRICULAR SHUNT PROCEDURES,,Relative Weights,"$7,492.76 ",IP,"7,492.76","7,492.76",,,,,,
Meridian Medicaid,DRG,223,VENTRICULAR SHUNT PROCEDURES,,Relative Weights,"$10,628.01 ",IP,"10,628.01","10,628.01",,,,,,
Meridian Medicaid,DRG,224,VENTRICULAR SHUNT PROCEDURES,,Relative Weights,"$25,450.32 ",IP,"25,450.32","25,450.32",,,,,,
Meridian Medicaid,DRG,231,SPINAL PROCEDURES,,Relative Weights,"$7,646.71 ",IP,"7,646.71","7,646.71",,,,,,
Meridian Medicaid,DRG,232,SPINAL PROCEDURES,,Relative Weights,"$9,630.12 ",IP,"9,630.12","9,630.12",,,,,,
Meridian Medicaid,DRG,233,SPINAL PROCEDURES,,Relative Weights,"$16,000.26 ",IP,"16,000.26","16,000.26",,,,,,
Meridian Medicaid,DRG,234,SPINAL PROCEDURES,,Relative Weights,"$29,075.91 ",IP,"29,075.91","29,075.91",,,,,,
Meridian Medicaid,DRG,241,EXTRACRANIAL VASCULAR PROCEDURES,,Relative Weights,"$5,741.65 ",IP,"5,741.65","5,741.65",,,,,,
Meridian Medicaid,DRG,242,EXTRACRANIAL VASCULAR PROCEDURES,,Relative Weights,"$6,726.14 ",IP,"6,726.14","6,726.14",,,,,,
Meridian Medicaid,DRG,243,EXTRACRANIAL VASCULAR PROCEDURES,,Relative Weights,"$13,747.79 ",IP,"13,747.79","13,747.79",,,,,,
Meridian Medicaid,DRG,244,EXTRACRANIAL VASCULAR PROCEDURES,,Relative Weights,"$24,782.31 ",IP,"24,782.31","24,782.31",,,,,,
Meridian Medicaid,DRG,261,OTHER NERVOUS SYSTEM and RELATED PROCEDURES,,Relative Weights,"$7,157.39 ",IP,"7,157.39","7,157.39",,,,,,
Meridian Medicaid,DRG,262,OTHER NERVOUS SYSTEM and RELATED PROCEDURES,,Relative Weights,"$8,935.31 ",IP,"8,935.31","8,935.31",,,,,,
Meridian Medicaid,DRG,263,OTHER NERVOUS SYSTEM and RELATED PROCEDURES,,Relative Weights,"$12,455.76 ",IP,"12,455.76","12,455.76",,,,,,
Meridian Medicaid,DRG,264,OTHER NERVOUS SYSTEM & RELATED PROCEDURES,,Relative Weights,"$22,781.03 ",IP,"22,781.03","22,781.03",,,,,,
Meridian Medicaid,DRG,401,SPINAL DISORDERS and INJURIES,,Relative Weights,"$5,482.55 ",IP,"5,482.55","5,482.55",,,,,,
Meridian Medicaid,DRG,402,SPINAL DISORDERS and INJURIES,,Relative Weights,"$5,877.72 ",IP,"5,877.72","5,877.72",,,,,,
Meridian Medicaid,DRG,403,SPINAL DISORDERS and INJURIES,,Relative Weights,"$8,545.98 ",IP,"8,545.98","8,545.98",,,,,,
Meridian Medicaid,DRG,404,SPINAL DISORDERS and INJURIES,,Relative Weights,"$17,945.87 ",IP,"17,945.87","17,945.87",,,,,,
Meridian Medicaid,DRG,411,NERVOUS SYSTEM MALIGNANCY,,Relative Weights,"$4,340.00 ",IP,"4,340.00","4,340.00",,,,,,
Meridian Medicaid,DRG,412,NERVOUS SYSTEM MALIGNANCY,,Relative Weights,"$4,441.02 ",IP,"4,441.02","4,441.02",,,,,,
Meridian Medicaid,DRG,413,NERVOUS SYSTEM MALIGNANCY,,Relative Weights,"$5,802.81 ",IP,"5,802.81","5,802.81",,,,,,
Meridian Medicaid,DRG,414,NERVOUS SYSTEM MALIGNANCY,,Relative Weights,"$8,029.51 ",IP,"8,029.51","8,029.51",,,,,,
Meridian Medicaid,DRG,421,DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS,,Relative Weights,"$3,328.02 ",IP,"3,328.02","3,328.02",,,,,,
Meridian Medicaid,DRG,422,DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS,,Relative Weights,"$3,814.25 ",IP,"3,814.25","3,814.25",,,,,,
Meridian Medicaid,DRG,423,DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS,,Relative Weights,"$5,381.53 ",IP,"5,381.53","5,381.53",,,,,,
Meridian Medicaid,DRG,424,DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS,,Relative Weights,"$12,544.07 ",IP,"12,544.07","12,544.07",,,,,,
Meridian Medicaid,DRG,431,MULTIPLE SCLEROSIS and OTHER DEMYELINATING DISEASES,,Relative Weights,"$4,040.70 ",IP,"4,040.70","4,040.70",,,,,,
Meridian Medicaid,DRG,432,MULTIPLE SCLEROSIS and OTHER DEMYELINATING DISEASES,,Relative Weights,"$5,014.88 ",IP,"5,014.88","5,014.88",,,,,,
Meridian Medicaid,DRG,433,MULTIPLE SCLEROSIS and OTHER DEMYELINATING DISEASES,,Relative Weights,"$7,268.72 ",IP,"7,268.72","7,268.72",,,,,,
Meridian Medicaid,DRG,434,MULTIPLE SCLEROSIS & OTHER DEMYELINATING DISEASES,,Relative Weights,"$15,032.61 ",IP,"15,032.61","15,032.61",,,,,,
Meridian Medicaid,DRG,441,INTRACRANIAL HEMORRHAGE,,Relative Weights,"$3,968.19 ",IP,"3,968.19","3,968.19",,,,,,
Meridian Medicaid,DRG,442,INTRACRANIAL HEMORRHAGE,,Relative Weights,"$4,927.25 ",IP,"4,927.25","4,927.25",,,,,,
Meridian Medicaid,DRG,443,INTRACRANIAL HEMORRHAGE,,Relative Weights,"$6,702.77 ",IP,"6,702.77","6,702.77",,,,,,
Meridian Medicaid,DRG,444,INTRACRANIAL HEMORRHAGE,,Relative Weights,"$9,326.01 ",IP,"9,326.01","9,326.01",,,,,,
Meridian Medicaid,DRG,451,CVA and PRECEREBRAL OCCLUSION W INFARCT,,Relative Weights,"$3,612.20 ",IP,"3,612.20","3,612.20",,,,,,
Meridian Medicaid,DRG,452,CVA and PRECEREBRAL OCCLUSION W INFARCT,,Relative Weights,"$4,429.34 ",IP,"4,429.34","4,429.34",,,,,,
Meridian Medicaid,DRG,453,CVA and PRECEREBRAL OCCLUSION W INFARCT,,Relative Weights,"$5,951.60 ",IP,"5,951.60","5,951.60",,,,,,
Meridian Medicaid,DRG,454,CVA and PRECEREBRAL OCCLUSION W INFARCT,,Relative Weights,"$10,976.10 ",IP,"10,976.10","10,976.10",,,,,,
Meridian Medicaid,DRG,461,NONSPECIFIC CVA and PRECEREBRAL OCCLUSION WO INFARCT,,Relative Weights,"$3,784.70 ",IP,"3,784.70","3,784.70",,,,,,
Meridian Medicaid,DRG,462,NONSPECIFIC CVA and PRECEREBRAL OCCLUSION WO INFARCT,,Relative Weights,"$4,264.40 ",IP,"4,264.40","4,264.40",,,,,,
Meridian Medicaid,DRG,463,NONSPECIFIC CVA and PRECEREBRAL OCCLUSION WO INFARCT,,Relative Weights,"$5,292.53 ",IP,"5,292.53","5,292.53",,,,,,
Meridian Medicaid,DRG,464,NONSPECIFIC CVA and PRECEREBRAL OCCLUSION WO INFARCT,,Relative Weights,"$10,621.82 ",IP,"10,621.82","10,621.82",,,,,,
Meridian Medicaid,DRG,471,TRANSIENT ISCHEMIA,,Relative Weights,"$3,321.15 ",IP,"3,321.15","3,321.15",,,,,,
Meridian Medicaid,DRG,472,TRANSIENT ISCHEMIA,,Relative Weights,"$3,597.42 ",IP,"3,597.42","3,597.42",,,,,,
Meridian Medicaid,DRG,473,TRANSIENT ISCHEMIA,,Relative Weights,"$4,242.41 ",IP,"4,242.41","4,242.41",,,,,,
Meridian Medicaid,DRG,474,TRANSIENT ISCHEMIA,,Relative Weights,"$7,719.21 ",IP,"7,719.21","7,719.21",,,,,,
Meridian Medicaid,DRG,481,PERIPHERAL CRANIAL and AUTONOMIC NERVE DISORDERS,,Relative Weights,"$3,400.87 ",IP,"3,400.87","3,400.87",,,,,,
Meridian Medicaid,DRG,482,PERIPHERAL CRANIAL and AUTONOMIC NERVE DISORDERS,,Relative Weights,"$3,627.32 ",IP,"3,627.32","3,627.32",,,,,,
Meridian Medicaid,DRG,483,PERIPHERAL CRANIAL and AUTONOMIC NERVE DISORDERS,,Relative Weights,"$4,545.48 ",IP,"4,545.48","4,545.48",,,,,,
Meridian Medicaid,DRG,484,"PERIPHERAL, CRANIAL & AUTONOMIC NERVE DISORDERS",,Relative Weights,"$10,429.39 ",IP,"10,429.39","10,429.39",,,,,,
Meridian Medicaid,DRG,491,BACTERIAL and TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,,Relative Weights,"$5,943.01 ",IP,"5,943.01","5,943.01",,,,,,
Meridian Medicaid,DRG,492,BACTERIAL and TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,,Relative Weights,"$9,716.03 ",IP,"9,716.03","9,716.03",,,,,,
Meridian Medicaid,DRG,493,BACTERIAL and TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,,Relative Weights,"$11,066.13 ",IP,"11,066.13","11,066.13",,,,,,
Meridian Medicaid,DRG,494,BACTERIAL and TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,,Relative Weights,"$20,732.33 ",IP,"20,732.33","20,732.33",,,,,,
Meridian Medicaid,DRG,501,NONBACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS,,Relative Weights,"$3,211.53 ",IP,"3,211.53","3,211.53",,,,,,
Meridian Medicaid,DRG,502,NONBACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS,,Relative Weights,"$6,688.34 ",IP,"6,688.34","6,688.34",,,,,,
Meridian Medicaid,DRG,503,NONBACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS,,Relative Weights,"$10,165.49 ",IP,"10,165.49","10,165.49",,,,,,
Meridian Medicaid,DRG,504,NONBACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS,,Relative Weights,"$22,308.54 ",IP,"22,308.54","22,308.54",,,,,,
Meridian Medicaid,DRG,511,VIRAL MENINGITIS,,Relative Weights,"$2,048.35 ",IP,"2,048.35","2,048.35",,,,,,
Meridian Medicaid,DRG,512,VIRAL MENINGITIS,,Relative Weights,"$3,205.00 ",IP,"3,205.00","3,205.00",,,,,,
Meridian Medicaid,DRG,513,VIRAL MENINGITIS,,Relative Weights,"$5,993.52 ",IP,"5,993.52","5,993.52",,,,,,
Meridian Medicaid,DRG,514,VIRAL MENINGITIS,,Relative Weights,"$12,441.32 ",IP,"12,441.32","12,441.32",,,,,,
Meridian Medicaid,DRG,521,ALTERATION IN CONSCIOUSNESS,,Relative Weights,"$3,101.91 ",IP,"3,101.91","3,101.91",,,,,,
Meridian Medicaid,DRG,522,ALTERATION IN CONSCIOUSNESS,,Relative Weights,"$3,492.61 ",IP,"3,492.61","3,492.61",,,,,,
Meridian Medicaid,DRG,523,ALTERATION IN CONSCIOUSNESS,,Relative Weights,"$4,423.15 ",IP,"4,423.15","4,423.15",,,,,,
Meridian Medicaid,DRG,524,ALTERATION IN CONSCIOUSNESS,,Relative Weights,"$9,303.33 ",IP,"9,303.33","9,303.33",,,,,,
Meridian Medicaid,DRG,531,SEIZURE,,Relative Weights,"$2,710.87 ",IP,"2,710.87","2,710.87",,,,,,
Meridian Medicaid,DRG,532,SEIZURE,,Relative Weights,"$3,311.87 ",IP,"3,311.87","3,311.87",,,,,,
Meridian Medicaid,DRG,533,SEIZURE,,Relative Weights,"$4,410.44 ",IP,"4,410.44","4,410.44",,,,,,
Meridian Medicaid,DRG,534,SEIZURE,,Relative Weights,"$10,918.03 ",IP,"10,918.03","10,918.03",,,,,,
Meridian Medicaid,DRG,541,MIGRAINE and OTHER HEADACHES,,Relative Weights,"$2,681.66 ",IP,"2,681.66","2,681.66",,,,,,
Meridian Medicaid,DRG,542,MIGRAINE and OTHER HEADACHES,,Relative Weights,"$3,180.26 ",IP,"3,180.26","3,180.26",,,,,,
Meridian Medicaid,DRG,543,MIGRAINE and OTHER HEADACHES,,Relative Weights,"$3,960.98 ",IP,"3,960.98","3,960.98",,,,,,
Meridian Medicaid,DRG,544,MIGRAINE and OTHER HEADACHES,,Relative Weights,"$6,681.46 ",IP,"6,681.46","6,681.46",,,,,,
Meridian Medicaid,DRG,551,HEAD TRAUMA W COMA 1 HR OR HEMORRHAGE,,Relative Weights,"$3,376.47 ",IP,"3,376.47","3,376.47",,,,,,
Meridian Medicaid,DRG,552,HEAD TRAUMA W COMA 1 HR OR HEMORRHAGE,,Relative Weights,"$4,570.57 ",IP,"4,570.57","4,570.57",,,,,,
Meridian Medicaid,DRG,553,HEAD TRAUMA W COMA 1 HR OR HEMORRHAGE,,Relative Weights,"$6,561.54 ",IP,"6,561.54","6,561.54",,,,,,
Meridian Medicaid,DRG,554,HEAD TRAUMA W COMA 1 HR OR HEMORRHAGE,,Relative Weights,"$13,008.65 ",IP,"13,008.65","13,008.65",,,,,,
Meridian Medicaid,DRG,561,BRAIN CONTUSIONLACERATION and COMPLICATED SKULL FX COMA  1 HR OR NO COMA,,Relative Weights,"$3,264.10 ",IP,"3,264.10","3,264.10",,,,,,
Meridian Medicaid,DRG,562,BRAIN CONTUSIONLACERATION and COMPLICATED SKULL FX COMA  1 HR OR NO COMA,,Relative Weights,"$4,370.58 ",IP,"4,370.58","4,370.58",,,,,,
Meridian Medicaid,DRG,563,BRAIN CONTUSIONLACERATION and COMPLICATED SKULL FX COMA  1 HR OR NO COMA,,Relative Weights,"$6,249.87 ",IP,"6,249.87","6,249.87",,,,,,
Meridian Medicaid,DRG,564,BRAIN CONTUSIONLACERATION and COMPLICATED SKULL FX COMA  1 HR OR NO COMA,,Relative Weights,"$13,974.93 ",IP,"13,974.93","13,974.93",,,,,,
Meridian Medicaid,DRG,571,CONCUSSION CLOSED SKULL FX NOSUNCOMPLICATED INTRACRANIAL INJURY COMA  1 HR OR NO COMA,,Relative Weights,"$2,653.48 ",IP,"2,653.48","2,653.48",,,,,,
Meridian Medicaid,DRG,572,CONCUSSION CLOSED SKULL FX NOSUNCOMPLICATED INTRACRANIAL INJURY COMA  1 HR OR NO COMA,,Relative Weights,"$3,996.71 ",IP,"3,996.71","3,996.71",,,,,,
Meridian Medicaid,DRG,573,CONCUSSION CLOSED SKULL FX NOSUNCOMPLICATED INTRACRANIAL INJURY COMA  1 HR OR NO COMA,,Relative Weights,"$5,550.25 ",IP,"5,550.25","5,550.25",,,,,,
Meridian Medicaid,DRG,574,CONCUSSION CLOSED SKULL FX NOSUNCOMPLICATED INTRACRANIAL INJURY COMA  1 HR OR NO COMA,,Relative Weights,"$10,437.98 ",IP,"10,437.98","10,437.98",,,,,,
Meridian Medicaid,DRG,581,OTHER DISORDERS OF NERVOUS SYSTEM,,Relative Weights,"$3,385.75 ",IP,"3,385.75","3,385.75",,,,,,
Meridian Medicaid,DRG,582,OTHER DISORDERS OF NERVOUS SYSTEM,,Relative Weights,"$4,062.35 ",IP,"4,062.35","4,062.35",,,,,,
Meridian Medicaid,DRG,583,OTHER DISORDERS OF NERVOUS SYSTEM,,Relative Weights,"$5,313.15 ",IP,"5,313.15","5,313.15",,,,,,
Meridian Medicaid,DRG,584,OTHER DISORDERS OF NERVOUS SYSTEM,,Relative Weights,"$10,386.78 ",IP,"10,386.78","10,386.78",,,,,,
Meridian Medicaid,DRG,591,ANOXIC and OTHER SEVERE BRAIN DAMAGE,,Relative Weights,"$3,746.90 ",IP,"3,746.90","3,746.90",,,,,,
Meridian Medicaid,DRG,592,ANOXIC and OTHER SEVERE BRAIN DAMAGE,,Relative Weights,"$4,463.01 ",IP,"4,463.01","4,463.01",,,,,,
Meridian Medicaid,DRG,593,ANOXIC and OTHER SEVERE BRAIN DAMAGE,,Relative Weights,"$6,809.98 ",IP,"6,809.98","6,809.98",,,,,,
Meridian Medicaid,DRG,594,ANOXIC & OTHER SEVERE BRAIN DAMAGE,,Relative Weights,"$11,699.43 ",IP,"11,699.43","11,699.43",,,,,,
Meridian Medicaid,DRG,731,ORBIT AND EYE PROCEDURES,,Relative Weights,"$5,014.53 ",IP,"5,014.53","5,014.53",,,,,,
Meridian Medicaid,DRG,732,ORBIT AND EYE PROCEDURES,,Relative Weights,"$6,421.34 ",IP,"6,421.34","6,421.34",,,,,,
Meridian Medicaid,DRG,733,ORBIT AND EYE PROCEDURES,,Relative Weights,"$9,718.43 ",IP,"9,718.43","9,718.43",,,,,,
Meridian Medicaid,DRG,734,ORBIT AND EYE PROCEDURES,,Relative Weights,"$22,403.73 ",IP,"22,403.73","22,403.73",,,,,,
Meridian Medicaid,DRG,821,EYE INFECTIONS AND OTHER EYE DISORDERS,,Relative Weights,"$2,633.21 ",IP,"2,633.21","2,633.21",,,,,,
Meridian Medicaid,DRG,822,EYE INFECTIONS AND OTHER EYE DISORDERS,,Relative Weights,"$3,410.83 ",IP,"3,410.83","3,410.83",,,,,,
Meridian Medicaid,DRG,823,EYE INFECTIONS AND OTHER EYE DISORDERS,,Relative Weights,"$4,809.73 ",IP,"4,809.73","4,809.73",,,,,,
Meridian Medicaid,DRG,824,EYE INFECTIONS AND OTHER EYE DISORDERS,,Relative Weights,"$13,027.89 ",IP,"13,027.89","13,027.89",,,,,,
Meridian Medicaid,DRG,891,MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$9,059.01 ",IP,"9,059.01","9,059.01",,,,,,
Meridian Medicaid,DRG,892,MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$11,457.52 ",IP,"11,457.52","11,457.52",,,,,,
Meridian Medicaid,DRG,893,MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$17,804.98 ",IP,"17,804.98","17,804.98",,,,,,
Meridian Medicaid,DRG,894,MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$32,041.75 ",IP,"32,041.75","32,041.75",,,,,,
Meridian Medicaid,DRG,911,OTHER MAJOR HEAD and NECK PROCEDURES,,Relative Weights,"$6,729.57 ",IP,"6,729.57","6,729.57",,,,,,
Meridian Medicaid,DRG,912,OTHER MAJOR HEAD and NECK PROCEDURES,,Relative Weights,"$9,964.47 ",IP,"9,964.47","9,964.47",,,,,,
Meridian Medicaid,DRG,913,OTHER MAJOR HEAD and NECK PROCEDURES,,Relative Weights,"$16,613.29 ",IP,"16,613.29","16,613.29",,,,,,
Meridian Medicaid,DRG,914,OTHER MAJOR HEAD and NECK PROCEDURES,,Relative Weights,"$32,825.56 ",IP,"32,825.56","32,825.56",,,,,,
Meridian Medicaid,DRG,921,FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$6,039.23 ",IP,"6,039.23","6,039.23",,,,,,
Meridian Medicaid,DRG,922,FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$8,191.36 ",IP,"8,191.36","8,191.36",,,,,,
Meridian Medicaid,DRG,923,FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$13,246.44 ",IP,"13,246.44","13,246.44",,,,,,
Meridian Medicaid,DRG,924,FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$30,839.40 ",IP,"30,839.40","30,839.40",,,,,,
Meridian Medicaid,DRG,951,CLEFT LIP and PALATE REPAIR,,Relative Weights,"$4,246.53 ",IP,"4,246.53","4,246.53",,,,,,
Meridian Medicaid,DRG,952,CLEFT LIP and PALATE REPAIR,,Relative Weights,"$4,867.46 ",IP,"4,867.46","4,867.46",,,,,,
Meridian Medicaid,DRG,953,CLEFT LIP & PALATE REPAIR,,Relative Weights,"$7,436.75 ",IP,"7,436.75","7,436.75",,,,,,
Meridian Medicaid,DRG,954,CLEFT LIP and PALATE REPAIR,,Relative Weights,"$14,987.25 ",IP,"14,987.25","14,987.25",,,,,,
Meridian Medicaid,DRG,971,TONSIL and ADENOID PROCEDURES,,Relative Weights,"$2,853.47 ",IP,"2,853.47","2,853.47",,,,,,
Meridian Medicaid,DRG,972,TONSIL & ADENOID PROCEDURES,,Relative Weights,"$3,981.59 ",IP,"3,981.59","3,981.59",,,,,,
Meridian Medicaid,DRG,973,TONSIL & ADENOID PROCEDURES,,Relative Weights,"$6,406.56 ",IP,"6,406.56","6,406.56",,,,,,
Meridian Medicaid,DRG,974,TONSIL and ADENOID PROCEDURES,,Relative Weights,"$15,100.30 ",IP,"15,100.30","15,100.30",,,,,,
Meridian Medicaid,DRG,981,OTHER EAR NOSE MOUTH and THROAT PROCEDURES,,Relative Weights,"$4,806.30 ",IP,"4,806.30","4,806.30",,,,,,
Meridian Medicaid,DRG,982,OTHER EAR NOSE MOUTH and THROAT PROCEDURES,,Relative Weights,"$6,289.73 ",IP,"6,289.73","6,289.73",,,,,,
Meridian Medicaid,DRG,983,"OTHER EAR, NOSE, MOUTH & THROAT PROCEDURES",,Relative Weights,"$10,153.46 ",IP,"10,153.46","10,153.46",,,,,,
Meridian Medicaid,DRG,984,OTHER EAR NOSE MOUTH and THROAT PROCEDURES,,Relative Weights,"$19,630.32 ",IP,"19,630.32","19,630.32",,,,,,
Meridian Medicaid,DRG,1101,EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES,,Relative Weights,"$4,539.30 ",IP,"4,539.30","4,539.30",,,,,,
Meridian Medicaid,DRG,1102,EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES,,Relative Weights,"$4,571.26 ",IP,"4,571.26","4,571.26",,,,,,
Meridian Medicaid,DRG,1103,EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES,,Relative Weights,"$6,424.43 ",IP,"6,424.43","6,424.43",,,,,,
Meridian Medicaid,DRG,1104,EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES,,Relative Weights,"$10,388.84 ",IP,"10,388.84","10,388.84",,,,,,
Meridian Medicaid,DRG,1111,VERTIGO and OTHER LABYRINTH DISORDERS,,Relative Weights,"$3,014.97 ",IP,"3,014.97","3,014.97",,,,,,
Meridian Medicaid,DRG,1112,VERTIGO and OTHER LABYRINTH DISORDERS,,Relative Weights,"$3,232.83 ",IP,"3,232.83","3,232.83",,,,,,
Meridian Medicaid,DRG,1113,VERTIGO and OTHER LABYRINTH DISORDERS,,Relative Weights,"$3,830.06 ",IP,"3,830.06","3,830.06",,,,,,
Meridian Medicaid,DRG,1114,VERTIGO and OTHER LABYRINTH DISORDERS,,Relative Weights,"$5,856.07 ",IP,"5,856.07","5,856.07",,,,,,
Meridian Medicaid,DRG,1131,INFECTIONS OF UPPER RESPIRATORY TRACT,,Relative Weights,"$1,710.57 ",IP,"1,710.57","1,710.57",,,,,,
Meridian Medicaid,DRG,1132,INFECTIONS OF UPPER RESPIRATORY TRACT,,Relative Weights,"$2,449.71 ",IP,"2,449.71","2,449.71",,,,,,
Meridian Medicaid,DRG,1133,INFECTIONS OF UPPER RESPIRATORY TRACT,,Relative Weights,"$3,709.10 ",IP,"3,709.10","3,709.10",,,,,,
Meridian Medicaid,DRG,1134,INFECTIONS OF UPPER RESPIRATORY TRACT,,Relative Weights,"$7,363.91 ",IP,"7,363.91","7,363.91",,,,,,
Meridian Medicaid,DRG,1141,DENTAL DISEASES AND DISORDERS,,Relative Weights,"$2,233.23 ",IP,"2,233.23","2,233.23",,,,,,
Meridian Medicaid,DRG,1142,DENTAL DISEASES AND DISORDERS,,Relative Weights,"$3,024.94 ",IP,"3,024.94","3,024.94",,,,,,
Meridian Medicaid,DRG,1143,DENTAL DISEASES AND DISORDERS,,Relative Weights,"$4,392.57 ",IP,"4,392.57","4,392.57",,,,,,
Meridian Medicaid,DRG,1144,DENTAL DISEASES AND DISORDERS,,Relative Weights,"$11,476.08 ",IP,"11,476.08","11,476.08",,,,,,
Meridian Medicaid,DRG,1151,OTHER EAR NOSE MOUTHTHROAT and CRANIALFACIAL DIAGNOSES,,Relative Weights,"$2,472.39 ",IP,"2,472.39","2,472.39",,,,,,
Meridian Medicaid,DRG,1152,OTHER EAR NOSE MOUTHTHROAT and CRANIALFACIAL DIAGNOSES,,Relative Weights,"$3,380.25 ",IP,"3,380.25","3,380.25",,,,,,
Meridian Medicaid,DRG,1153,"OTHER EAR, NOSE, MOUTH,THROAT & CRANIAL/FACIAL DIAGNOSES",,Relative Weights,"$4,829.66 ",IP,"4,829.66","4,829.66",,,,,,
Meridian Medicaid,DRG,1154,"OTHER EAR, NOSE, MOUTH,THROAT & CRANIAL/FACIAL DIAGNOSES",,Relative Weights,"$10,560.66 ",IP,"10,560.66","10,560.66",,,,,,
Meridian Medicaid,DRG,1201,MAJOR RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$8,978.60 ",IP,"8,978.60","8,978.60",,,,,,
Meridian Medicaid,DRG,1202,MAJOR RESPIRATORY & CHEST PROCEDURES,,Relative Weights,"$10,724.22 ",IP,"10,724.22","10,724.22",,,,,,
Meridian Medicaid,DRG,1203,MAJOR RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$15,096.86 ",IP,"15,096.86","15,096.86",,,,,,
Meridian Medicaid,DRG,1204,MAJOR RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$30,187.20 ",IP,"30,187.20","30,187.20",,,,,,
Meridian Medicaid,DRG,1211,OTHER RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$6,647.79 ",IP,"6,647.79","6,647.79",,,,,,
Meridian Medicaid,DRG,1212,OTHER RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$8,066.62 ",IP,"8,066.62","8,066.62",,,,,,
Meridian Medicaid,DRG,1213,OTHER RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$12,267.10 ",IP,"12,267.10","12,267.10",,,,,,
Meridian Medicaid,DRG,1214,OTHER RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$23,708.13 ",IP,"23,708.13","23,708.13",,,,,,
Meridian Medicaid,DRG,1301,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96 HOURS,,Relative Weights,"$15,152.88 ",IP,"15,152.88","15,152.88",,,,,,
Meridian Medicaid,DRG,1302,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS,,Relative Weights,"$17,209.82 ",IP,"17,209.82","17,209.82",,,,,,
Meridian Medicaid,DRG,1303,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96 HOURS,,Relative Weights,"$20,315.17 ",IP,"20,315.17","20,315.17",,,,,,
Meridian Medicaid,DRG,1304,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96 HOURS,,Relative Weights,"$28,326.47 ",IP,"28,326.47","28,326.47",,,,,,
Meridian Medicaid,DRG,1311,CYSTIC FIBROSIS  PULMONARY DISEASE,,Relative Weights,"$6,540.23 ",IP,"6,540.23","6,540.23",,,,,,
Meridian Medicaid,DRG,1312,CYSTIC FIBROSIS - PULMONARY DISEASE,,Relative Weights,"$9,797.46 ",IP,"9,797.46","9,797.46",,,,,,
Meridian Medicaid,DRG,1313,CYSTIC FIBROSIS - PULMONARY DISEASE,,Relative Weights,"$13,253.65 ",IP,"13,253.65","13,253.65",,,,,,
Meridian Medicaid,DRG,1314,CYSTIC FIBROSIS  PULMONARY DISEASE,,Relative Weights,"$17,241.78 ",IP,"17,241.78","17,241.78",,,,,,
Meridian Medicaid,DRG,1321,BPD and OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,,Relative Weights,"$2,377.20 ",IP,"2,377.20","2,377.20",,,,,,
Meridian Medicaid,DRG,1322,BPD and OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,,Relative Weights,"$3,157.24 ",IP,"3,157.24","3,157.24",,,,,,
Meridian Medicaid,DRG,1323,BPD & OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,,Relative Weights,"$5,204.90 ",IP,"5,204.90","5,204.90",,,,,,
Meridian Medicaid,DRG,1324,BPD and OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,,Relative Weights,"$9,706.75 ",IP,"9,706.75","9,706.75",,,,,,
Meridian Medicaid,DRG,1331,RESPIRATORY FAILURE,,Relative Weights,"$2,072.41 ",IP,"2,072.41","2,072.41",,,,,,
Meridian Medicaid,DRG,1332,RESPIRATORY FAILURE,,Relative Weights,"$3,703.26 ",IP,"3,703.26","3,703.26",,,,,,
Meridian Medicaid,DRG,1333,RESPIRATORY FAILURE,,Relative Weights,"$5,064.70 ",IP,"5,064.70","5,064.70",,,,,,
Meridian Medicaid,DRG,1334,RESPIRATORY FAILURE,,Relative Weights,"$9,349.38 ",IP,"9,349.38","9,349.38",,,,,,
Meridian Medicaid,DRG,1341,PULMONARY EMBOLISM,,Relative Weights,"$2,977.18 ",IP,"2,977.18","2,977.18",,,,,,
Meridian Medicaid,DRG,1342,PULMONARY EMBOLISM,,Relative Weights,"$3,832.12 ",IP,"3,832.12","3,832.12",,,,,,
Meridian Medicaid,DRG,1343,PULMONARY EMBOLISM,,Relative Weights,"$5,276.03 ",IP,"5,276.03","5,276.03",,,,,,
Meridian Medicaid,DRG,1344,PULMONARY EMBOLISM,,Relative Weights,"$8,166.27 ",IP,"8,166.27","8,166.27",,,,,,
Meridian Medicaid,DRG,1351,MAJOR CHEST and RESPIRAZORY TRAUMA,,Relative Weights,"$3,792.26 ",IP,"3,792.26","3,792.26",,,,,,
Meridian Medicaid,DRG,1352,MAJOR CHEST & RESPIRATORY TRAUMA,,Relative Weights,"$3,955.48 ",IP,"3,955.48","3,955.48",,,,,,
Meridian Medicaid,DRG,1353,MAJOR CHEST and RESPIRATORY TRAUMA,,Relative Weights,"$5,683.92 ",IP,"5,683.92","5,683.92",,,,,,
Meridian Medicaid,DRG,1354,MAJOR CHEST and RESPIRATORY TRAUMA,,Relative Weights,"$10,178.89 ",IP,"10,178.89","10,178.89",,,,,,
Meridian Medicaid,DRG,1361,RESPIRATORY MALIGNANCY,,Relative Weights,"$4,244.47 ",IP,"4,244.47","4,244.47",,,,,,
Meridian Medicaid,DRG,1362,RESPIRATORY MALIGNANCY,,Relative Weights,"$4,742.73 ",IP,"4,742.73","4,742.73",,,,,,
Meridian Medicaid,DRG,1363,RESPIRATORY MALIGNANCY,,Relative Weights,"$6,049.19 ",IP,"6,049.19","6,049.19",,,,,,
Meridian Medicaid,DRG,1364,RESPIRATORY MALIGNANCY,,Relative Weights,"$9,049.05 ",IP,"9,049.05","9,049.05",,,,,,
Meridian Medicaid,DRG,1371,MAJOR RESPIRATORY INFECTIONS and INFLAMMATIONS,,Relative Weights,"$3,151.74 ",IP,"3,151.74","3,151.74",,,,,,
Meridian Medicaid,DRG,1372,MAJOR RESPIRATORY INFECTIONS and INFLAMMATIONS,,Relative Weights,"$3,930.39 ",IP,"3,930.39","3,930.39",,,,,,
Meridian Medicaid,DRG,1373,MAJOR RESPIRATORY INFECTIONS & INFLAMMATIONS,,Relative Weights,"$5,471.90 ",IP,"5,471.90","5,471.90",,,,,,
Meridian Medicaid,DRG,1374,MAJOR RESPIRATORY INFECTIONS and INFLAMMATIONS,,Relative Weights,"$8,758.68 ",IP,"8,758.68","8,758.68",,,,,,
Meridian Medicaid,DRG,1381,BRONCHIOLITIS and RSV PNEUMONIA,,Relative Weights,"$1,796.82 ",IP,"1,796.82","1,796.82",,,,,,
Meridian Medicaid,DRG,1382,BRONCHIOLITIS and RSV PNEUMONIA,,Relative Weights,"$2,575.82 ",IP,"2,575.82","2,575.82",,,,,,
Meridian Medicaid,DRG,1383,BRONCHIOLITIS and RSV PNEUMONIA,,Relative Weights,"$4,712.83 ",IP,"4,712.83","4,712.83",,,,,,
Meridian Medicaid,DRG,1384,BRONCHIOLITIS and RSV PNEUMONIA,,Relative Weights,"$9,865.85 ",IP,"9,865.85","9,865.85",,,,,,
Meridian Medicaid,DRG,1391,OTHER PNEUMONIA,,Relative Weights,"$2,182.71 ",IP,"2,182.71","2,182.71",,,,,,
Meridian Medicaid,DRG,1392,OTHER PNEUMONIA,,Relative Weights,"$3,016.35 ",IP,"3,016.35","3,016.35",,,,,,
Meridian Medicaid,DRG,1393,OTHER PNEUMONIA,,Relative Weights,"$4,342.75 ",IP,"4,342.75","4,342.75",,,,,,
Meridian Medicaid,DRG,1394,OTHER PNEUMONIA,,Relative Weights,"$7,186.59 ",IP,"7,186.59","7,186.59",,,,,,
Meridian Medicaid,DRG,1401,CHRONIC OBSTRUCTIVE PULMONARY DISEASE,,Relative Weights,"$2,639.05 ",IP,"2,639.05","2,639.05",,,,,,
Meridian Medicaid,DRG,1402,CHRONIC OBSTRUCTIVE PULMONARY DISEASE,,Relative Weights,"$3,167.20 ",IP,"3,167.20","3,167.20",,,,,,
Meridian Medicaid,DRG,1403,CHRONIC OBSTRUCTIVE PULMONARY DISEASE,,Relative Weights,"$3,958.92 ",IP,"3,958.92","3,958.92",,,,,,
Meridian Medicaid,DRG,1404,CHRONIC OBSTRUCTIVE PULMONARY DISEASE,,Relative Weights,"$5,969.47 ",IP,"5,969.47","5,969.47",,,,,,
Meridian Medicaid,DRG,1411,ASTHMA,,Relative Weights,"$2,018.80 ",IP,"2,018.80","2,018.80",,,,,,
Meridian Medicaid,DRG,1412,ASTHMA,,Relative Weights,"$2,763.78 ",IP,"2,763.78","2,763.78",,,,,,
Meridian Medicaid,DRG,1413,ASTHMA,,Relative Weights,"$4,049.98 ",IP,"4,049.98","4,049.98",,,,,,
Meridian Medicaid,DRG,1414,ASTHMA,,Relative Weights,"$6,508.28 ",IP,"6,508.28","6,508.28",,,,,,
Meridian Medicaid,DRG,1421,INTERSTITIAL and ALVEOLAR LUNG DISEASES,,Relative Weights,"$3,358.26 ",IP,"3,358.26","3,358.26",,,,,,
Meridian Medicaid,DRG,1422,INTERSTITIAL and ALVEOLAR LUNG DISEASES,,Relative Weights,"$3,679.89 ",IP,"3,679.89","3,679.89",,,,,,
Meridian Medicaid,DRG,1423,INTERSTITIAL and ALVEOLAR LUNG DISEASES,,Relative Weights,"$4,888.08 ",IP,"4,888.08","4,888.08",,,,,,
Meridian Medicaid,DRG,1424,INTERSTITIAL and ALVEOLAR LUNG DISEASES,,Relative Weights,"$7,901.68 ",IP,"7,901.68","7,901.68",,,,,,
Meridian Medicaid,DRG,1431,OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$2,504.69 ",IP,"2,504.69","2,504.69",,,,,,
Meridian Medicaid,DRG,1432,OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$3,509.11 ",IP,"3,509.11","3,509.11",,,,,,
Meridian Medicaid,DRG,1433,OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$5,145.11 ",IP,"5,145.11","5,145.11",,,,,,
Meridian Medicaid,DRG,1434,OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$8,358.70 ",IP,"8,358.70","8,358.70",,,,,,
Meridian Medicaid,DRG,1441,"RESPIRATORY SIGNS, SYMPTOMS & MINOR DIAGNOSES",,Relative Weights,"$2,636.99 ",IP,"2,636.99","2,636.99",,,,,,
Meridian Medicaid,DRG,1442,RESPIRATORY SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$3,405.68 ",IP,"3,405.68","3,405.68",,,,,,
Meridian Medicaid,DRG,1443,RESPIRATORY SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$4,454.42 ",IP,"4,454.42","4,454.42",,,,,,
Meridian Medicaid,DRG,1444,RESPIRATORY SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$7,998.24 ",IP,"7,998.24","7,998.24",,,,,,
Meridian Medicaid,DRG,1451,ACUTE BRONCHITIS AND RELATED SYMPTOMS,,Relative Weights,"$2,478.23 ",IP,"2,478.23","2,478.23",,,,,,
Meridian Medicaid,DRG,1452,ACUTE BRONCHITIS AND RELATED SYMPTOMS,,Relative Weights,"$2,974.43 ",IP,"2,974.43","2,974.43",,,,,,
Meridian Medicaid,DRG,1453,ACUTE BRONCHITIS AND RELATED SYMPTOMS,,Relative Weights,"$3,820.09 ",IP,"3,820.09","3,820.09",,,,,,
Meridian Medicaid,DRG,1454,ACUTE BRONCHITIS AND RELATED SYMPTOMS,,Relative Weights,"$6,746.07 ",IP,"6,746.07","6,746.07",,,,,,
Meridian Medicaid,DRG,1601,MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,,Relative Weights,"$19,007.33 ",IP,"19,007.33","19,007.33",,,,,,
Meridian Medicaid,DRG,1602,MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,,Relative Weights,"$21,418.55 ",IP,"21,418.55","21,418.55",,,,,,
Meridian Medicaid,DRG,1603,MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,,Relative Weights,"$29,897.52 ",IP,"29,897.52","29,897.52",,,,,,
Meridian Medicaid,DRG,1604,MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,,Relative Weights,"$58,616.75 ",IP,"58,616.75","58,616.75",,,,,,
Meridian Medicaid,DRG,1611,CARDIAC DEFIBRILLATOR and HEART ASSIST IMPLANT,,Relative Weights,"$21,623.70 ",IP,"21,623.70","21,623.70",,,,,,
Meridian Medicaid,DRG,1612,CARDIAC DEFIBRILLATOR and HEART ASSIST IMPLANT,,Relative Weights,"$25,324.21 ",IP,"25,324.21","25,324.21",,,,,,
Meridian Medicaid,DRG,1613,CARDIAC DEFIBRILLATOR and HEART ASSIST IMPLANT,,Relative Weights,"$37,168.99 ",IP,"37,168.99","37,168.99",,,,,,
Meridian Medicaid,DRG,1614,CARDIAC DEFIBRILLATOR and HEART ASSIST IMPLANT,,Relative Weights,"$84,952.59 ",IP,"84,952.59","84,952.59",,,,,,
Meridian Medicaid,DRG,1621,CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX,,Relative Weights,"$21,734.00 ",IP,"21,734.00","21,734.00",,,,,,
Meridian Medicaid,DRG,1622,CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX,,Relative Weights,"$25,647.21 ",IP,"25,647.21","25,647.21",,,,,,
Meridian Medicaid,DRG,1623,CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX,,Relative Weights,"$32,557.19 ",IP,"32,557.19","32,557.19",,,,,,
Meridian Medicaid,DRG,1624,CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX,,Relative Weights,"$51,493.39 ",IP,"51,493.39","51,493.39",,,,,,
Meridian Medicaid,DRG,1631,CARDIAC VALVE PROCEDURES WO AMI OR COMPLEX PDX,,Relative Weights,"$18,870.57 ",IP,"18,870.57","18,870.57",,,,,,
Meridian Medicaid,DRG,1632,CARDIAC VALVE PROCEDURES WO AMI OR COMPLEX PDX,,Relative Weights,"$20,678.38 ",IP,"20,678.38","20,678.38",,,,,,
Meridian Medicaid,DRG,1633,CARDIAC VALVE PROCEDURES WO AMI OR COMPLEX PDX,,Relative Weights,"$25,441.73 ",IP,"25,441.73","25,441.73",,,,,,
Meridian Medicaid,DRG,1634,CARDIAC VALVE PROCEDURES WO AMI OR COMPLEX PDX,,Relative Weights,"$42,290.40 ",IP,"42,290.40","42,290.40",,,,,,
Meridian Medicaid,DRG,1651,CORONARY BYPASS W AMI OR COMPLEX PDX,,Relative Weights,"$17,424.93 ",IP,"17,424.93","17,424.93",,,,,,
Meridian Medicaid,DRG,1652,CORONARY BYPASS W AMI OR COMPLEX PDX,,Relative Weights,"$20,592.13 ",IP,"20,592.13","20,592.13",,,,,,
Meridian Medicaid,DRG,1653,CORONARY BYPASS W AMI OR COMPLEX PDX,,Relative Weights,"$24,876.46 ",IP,"24,876.46","24,876.46",,,,,,
Meridian Medicaid,DRG,1654,CORONARY BYPASS W AMI OR COMPLEX PDX,,Relative Weights,"$37,414.00 ",IP,"37,414.00","37,414.00",,,,,,
Meridian Medicaid,DRG,1661,CORONARY BYPASS W/O AMI OR COMPLEX PDX,,Relative Weights,"$16,087.19 ",IP,"16,087.19","16,087.19",,,,,,
Meridian Medicaid,DRG,1662,CORONARY BYPASS WO AMI OR COMPLEX PDX,,Relative Weights,"$17,173.40 ",IP,"17,173.40","17,173.40",,,,,,
Meridian Medicaid,DRG,1663,CORONARY BYPASS WO AMI OR COMPLEX PDX,,Relative Weights,"$20,743.67 ",IP,"20,743.67","20,743.67",,,,,,
Meridian Medicaid,DRG,1664,CORONARY BYPASS WO AMI OR COMPLEX PDX,,Relative Weights,"$33,503.88 ",IP,"33,503.88","33,503.88",,,,,,
Meridian Medicaid,DRG,1671,OTHER CARDIOTHORACIC and THORACIC VASCULAR PROCEDURES,,Relative Weights,"$15,753.88 ",IP,"15,753.88","15,753.88",,,,,,
Meridian Medicaid,DRG,1672,OTHER CARDIOTHORACIC & THORACIC VASCULAR PROCEDURES,,Relative Weights,"$16,654.52 ",IP,"16,654.52","16,654.52",,,,,,
Meridian Medicaid,DRG,1673,OTHER CARDIOTHORACIC & THORACIC VASCULAR PROCEDURES,,Relative Weights,"$20,943.66 ",IP,"20,943.66","20,943.66",,,,,,
Meridian Medicaid,DRG,1674,OTHER CARDIOTHORACIC and THORACIC VASCULAR PROCEDURES,,Relative Weights,"$39,564.41 ",IP,"39,564.41","39,564.41",,,,,,
Meridian Medicaid,DRG,1691,MAJOR ABDOMINAL VASCULAR PROCEDURES,,Relative Weights,"$9,314.67 ",IP,"9,314.67","9,314.67",,,,,,
Meridian Medicaid,DRG,1692,MAJOR ABDOMINAL VASCULAR PROCEDURES,,Relative Weights,"$12,244.08 ",IP,"12,244.08","12,244.08",,,,,,
Meridian Medicaid,DRG,1693,MAJOR ABDOMINAL VASCULAR PROCEDURES,,Relative Weights,"$19,456.45 ",IP,"19,456.45","19,456.45",,,,,,
Meridian Medicaid,DRG,1694,MAJOR ABDOMINAL VASCULAR PROCEDURES,,Relative Weights,"$33,906.95 ",IP,"33,906.95","33,906.95",,,,,,
Meridian Medicaid,DRG,1701,PERMANENT CARDIAC PACEMAKER IMPLANT W AMI HEART FAILURE OR SHOCK,,Relative Weights,"$10,265.14 ",IP,"10,265.14","10,265.14",,,,,,
Meridian Medicaid,DRG,1702,PERMANENT CARDIAC PACEMAKER IMPLANT W AMI HEART FAILURE OR SHOCK,,Relative Weights,"$10,949.99 ",IP,"10,949.99","10,949.99",,,,,,
Meridian Medicaid,DRG,1703,PERMANENT CARDIAC PACEMAKER IMPLANT W AMI HEART FAILURE OR SHOCK,,Relative Weights,"$13,975.61 ",IP,"13,975.61","13,975.61",,,,,,
Meridian Medicaid,DRG,1704,"PERMANENT CARDIAC PACEMAKER IMPLANT W AMI, HEART FAILURE OR SHOCK",,Relative Weights,"$19,895.26 ",IP,"19,895.26","19,895.26",,,,,,
Meridian Medicaid,DRG,1711,PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK,,Relative Weights,"$8,272.45 ",IP,"8,272.45","8,272.45",,,,,,
Meridian Medicaid,DRG,1712,PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK,,Relative Weights,"$9,180.66 ",IP,"9,180.66","9,180.66",,,,,,
Meridian Medicaid,DRG,1713,PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK,,Relative Weights,"$10,971.29 ",IP,"10,971.29","10,971.29",,,,,,
Meridian Medicaid,DRG,1714,PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK,,Relative Weights,"$17,965.80 ",IP,"17,965.80","17,965.80",,,,,,
Meridian Medicaid,DRG,1741,PERCUTANEOUS CORONARY INTERVENTION W AMI,,Relative Weights,"$9,597.47 ",IP,"9,597.47","9,597.47",,,,,,
Meridian Medicaid,DRG,1742,PERCUTANEOUS CORONARY INTERVENTION W AMI,,Relative Weights,"$10,364.10 ",IP,"10,364.10","10,364.10",,,,,,
Meridian Medicaid,DRG,1743,PERCUTANEOUS CORONARY INTERVENTION W AMI,,Relative Weights,"$12,874.29 ",IP,"12,874.29","12,874.29",,,,,,
Meridian Medicaid,DRG,1744,PERCUTANEOUS CORONARY INTERVENTION W AMI,,Relative Weights,"$19,364.01 ",IP,"19,364.01","19,364.01",,,,,,
Meridian Medicaid,DRG,1751,PERCUTANEOUS CORONARY INTERVENTION WO AMI,,Relative Weights,"$11,256.84 ",IP,"11,256.84","11,256.84",,,,,,
Meridian Medicaid,DRG,1752,PERCUTANEOUS CORONARY INTERVENTION WO AMI,,Relative Weights,"$12,009.39 ",IP,"12,009.39","12,009.39",,,,,,
Meridian Medicaid,DRG,1753,PERCUTANEOUS CORONARY INTERVENTION WO AMI,,Relative Weights,"$14,253.95 ",IP,"14,253.95","14,253.95",,,,,,
Meridian Medicaid,DRG,1754,PERCUTANEOUS CORONARY INTERVENTION WO AMI,,Relative Weights,"$25,147.58 ",IP,"25,147.58","25,147.58",,,,,,
Meridian Medicaid,DRG,1761,CARDIAC PACEMAKER and DEFIBRILLATOR DEVICE REPLACEMENT,,Relative Weights,"$9,268.97 ",IP,"9,268.97","9,268.97",,,,,,
Meridian Medicaid,DRG,1762,CARDIAC PACEMAKER and DEFIBRILLATOR DEVICE REPLACEMENT,,Relative Weights,"$10,537.63 ",IP,"10,537.63","10,537.63",,,,,,
Meridian Medicaid,DRG,1763,CARDIAC PACEMAKER & DEFIBRILLATOR DEVICE REPLACEMENT,,Relative Weights,"$15,961.08 ",IP,"15,961.08","15,961.08",,,,,,
Meridian Medicaid,DRG,1764,CARDIAC PACEMAKER and DEFIBRILLATOR DEVICE REPLACEMENT,,Relative Weights,"$25,961.29 ",IP,"25,961.29","25,961.29",,,,,,
Meridian Medicaid,DRG,1771,CARDIAC PACEMAKER and DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,,Relative Weights,"$6,530.96 ",IP,"6,530.96","6,530.96",,,,,,
Meridian Medicaid,DRG,1772,CARDIAC PACEMAKER and DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,,Relative Weights,"$9,029.80 ",IP,"9,029.80","9,029.80",,,,,,
Meridian Medicaid,DRG,1773,CARDIAC PACEMAKER & DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,,Relative Weights,"$11,280.21 ",IP,"11,280.21","11,280.21",,,,,,
Meridian Medicaid,DRG,1774,CARDIAC PACEMAKER & DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,,Relative Weights,"$17,033.20 ",IP,"17,033.20","17,033.20",,,,,,
Meridian Medicaid,DRG,1801,OTHER CIRCULATORY SYSTEM PROCEDURES,,Relative Weights,"$6,351.58 ",IP,"6,351.58","6,351.58",,,,,,
Meridian Medicaid,DRG,1802,OTHER CIRCULATORY SYSTEM PROCEDURES,,Relative Weights,"$7,715.78 ",IP,"7,715.78","7,715.78",,,,,,
Meridian Medicaid,DRG,1803,OTHER CIRCULATORY SYSTEM PROCEDURES,,Relative Weights,"$10,872.33 ",IP,"10,872.33","10,872.33",,,,,,
Meridian Medicaid,DRG,1804,OTHER CIRCULATORY SYSTEM PROCEDURES,,Relative Weights,"$20,062.95 ",IP,"20,062.95","20,062.95",,,,,,
Meridian Medicaid,DRG,1811,LOWER EXTREMITY ARTERIAL PROCEDURES,,Relative Weights,"$9,268.28 ",IP,"9,268.28","9,268.28",,,,,,
Meridian Medicaid,DRG,1812,LOWER EXTREMITY ARTERIAL PROCEDURES,,Relative Weights,"$11,438.97 ",IP,"11,438.97","11,438.97",,,,,,
Meridian Medicaid,DRG,1813,LOWER EXTREMITY ARTERIAL PROCEDURES,,Relative Weights,"$16,303.68 ",IP,"16,303.68","16,303.68",,,,,,
Meridian Medicaid,DRG,1814,LOWER EXTREMITY ARTERIAL PROCEDURES,,Relative Weights,"$27,105.22 ",IP,"27,105.22","27,105.22",,,,,,
Meridian Medicaid,DRG,1821,OTHER PERIPHERAL VASCULAR PROCEDURES,,Relative Weights,"$9,585.79 ",IP,"9,585.79","9,585.79",,,,,,
Meridian Medicaid,DRG,1822,OTHER PERIPHERAL VASCULAR PROCEDURES,,Relative Weights,"$11,451.68 ",IP,"11,451.68","11,451.68",,,,,,
Meridian Medicaid,DRG,1823,OTHER PERIPHERAL VASCULAR PROCEDURES,,Relative Weights,"$12,966.73 ",IP,"12,966.73","12,966.73",,,,,,
Meridian Medicaid,DRG,1824,OTHER PERIPHERAL VASCULAR PROCEDURES,,Relative Weights,"$25,526.94 ",IP,"25,526.94","25,526.94",,,,,,
Meridian Medicaid,DRG,1901,ACUTE MYOCARDIAL INFARCTION,,Relative Weights,"$3,454.82 ",IP,"3,454.82","3,454.82",,,,,,
Meridian Medicaid,DRG,1902,ACUTE MYOCARDIAL INFARCTION,,Relative Weights,"$4,023.17 ",IP,"4,023.17","4,023.17",,,,,,
Meridian Medicaid,DRG,1903,ACUTE MYOCARDIAL INFARCTION,,Relative Weights,"$5,278.78 ",IP,"5,278.78","5,278.78",,,,,,
Meridian Medicaid,DRG,1904,ACUTE MYOCARDIAL INFARCTION,,Relative Weights,"$8,568.66 ",IP,"8,568.66","8,568.66",,,,,,
Meridian Medicaid,DRG,1911,CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,,Relative Weights,"$4,795.99 ",IP,"4,795.99","4,795.99",,,,,,
Meridian Medicaid,DRG,1912,CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,,Relative Weights,"$5,349.23 ",IP,"5,349.23","5,349.23",,,,,,
Meridian Medicaid,DRG,1913,CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,,Relative Weights,"$6,652.26 ",IP,"6,652.26","6,652.26",,,,,,
Meridian Medicaid,DRG,1914,CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,,Relative Weights,"$10,568.22 ",IP,"10,568.22","10,568.22",,,,,,
Meridian Medicaid,DRG,1921,CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS,,Relative Weights,"$5,126.56 ",IP,"5,126.56","5,126.56",,,,,,
Meridian Medicaid,DRG,1922,CARDIAC CATHETERIZATION FOR OTHER NONCORONARY CONDITIONS,,Relative Weights,"$5,995.59 ",IP,"5,995.59","5,995.59",,,,,,
Meridian Medicaid,DRG,1923,CARDIAC CATHETERIZATION FOR OTHER NONCORONARY CONDITIONS,,Relative Weights,"$8,192.04 ",IP,"8,192.04","8,192.04",,,,,,
Meridian Medicaid,DRG,1924,CARDIAC CATHETERIZATION FOR OTHER NONCORONARY CONDITIONS,,Relative Weights,"$14,030.25 ",IP,"14,030.25","14,030.25",,,,,,
Meridian Medicaid,DRG,1931,ACUTE & SUBACUTE ENDOCARDITIS,,Relative Weights,"$4,156.16 ",IP,"4,156.16","4,156.16",,,,,,
Meridian Medicaid,DRG,1932,ACUTE & SUBACUTE ENDOCARDITIS,,Relative Weights,"$5,201.81 ",IP,"5,201.81","5,201.81",,,,,,
Meridian Medicaid,DRG,1933,ACUTE and SUBACUTE ENDOCARDITIS,,Relative Weights,"$7,472.15 ",IP,"7,472.15","7,472.15",,,,,,
Meridian Medicaid,DRG,1934,ACUTE and SUBACUTE ENDOCARDITIS,,Relative Weights,"$12,655.75 ",IP,"12,655.75","12,655.75",,,,,,
Meridian Medicaid,DRG,1941,HEART FAILURE,,Relative Weights,"$2,590.60 ",IP,"2,590.60","2,590.60",,,,,,
Meridian Medicaid,DRG,1942,HEART FAILURE,,Relative Weights,"$3,135.24 ",IP,"3,135.24","3,135.24",,,,,,
Meridian Medicaid,DRG,1943,HEART FAILURE,,Relative Weights,"$4,368.86 ",IP,"4,368.86","4,368.86",,,,,,
Meridian Medicaid,DRG,1944,HEART FAILURE,,Relative Weights,"$7,070.79 ",IP,"7,070.79","7,070.79",,,,,,
Meridian Medicaid,DRG,1961,CARDIAC ARREST and SHOCK,,Relative Weights,"$2,365.52 ",IP,"2,365.52","2,365.52",,,,,,
Meridian Medicaid,DRG,1962,CARDIAC ARREST and SHOCK,,Relative Weights,"$2,596.44 ",IP,"2,596.44","2,596.44",,,,,,
Meridian Medicaid,DRG,1963,CARDIAC ARREST & SHOCK,,Relative Weights,"$4,010.12 ",IP,"4,010.12","4,010.12",,,,,,
Meridian Medicaid,DRG,1964,CARDIAC ARREST & SHOCK,,Relative Weights,"$8,325.03 ",IP,"8,325.03","8,325.03",,,,,,
Meridian Medicaid,DRG,1971,PERIPHERAL and OTHER VASCULAR DISORDERS,,Relative Weights,"$2,758.63 ",IP,"2,758.63","2,758.63",,,,,,
Meridian Medicaid,DRG,1972,PERIPHERAL and OTHER VASCULAR DISORDERS,,Relative Weights,"$3,488.49 ",IP,"3,488.49","3,488.49",,,,,,
Meridian Medicaid,DRG,1973,PERIPHERAL and OTHER VASCULAR DISORDERS,,Relative Weights,"$4,794.61 ",IP,"4,794.61","4,794.61",,,,,,
Meridian Medicaid,DRG,1974,PERIPHERAL & OTHER VASCULAR DISORDERS,,Relative Weights,"$9,053.51 ",IP,"9,053.51","9,053.51",,,,,,
Meridian Medicaid,DRG,1981,ANGINA PECTORIS & CORONARY ATHEROSCLEROSIS,,Relative Weights,"$2,680.28 ",IP,"2,680.28","2,680.28",,,,,,
Meridian Medicaid,DRG,1982,ANGINA PECTORIS and CORONARY ATHEROSCLEROSIS,,Relative Weights,"$2,985.77 ",IP,"2,985.77","2,985.77",,,,,,
Meridian Medicaid,DRG,1983,ANGINA PECTORIS and CORONARY ATHEROSCLEROSIS,,Relative Weights,"$3,628.00 ",IP,"3,628.00","3,628.00",,,,,,
Meridian Medicaid,DRG,1984,ANGINA PECTORIS and CORONARY ATHEROSCLEROSIS,,Relative Weights,"$6,763.25 ",IP,"6,763.25","6,763.25",,,,,,
Meridian Medicaid,DRG,1991,HYPERTENSION,,Relative Weights,"$2,662.41 ",IP,"2,662.41","2,662.41",,,,,,
Meridian Medicaid,DRG,1992,HYPERTENSION,,Relative Weights,"$2,956.56 ",IP,"2,956.56","2,956.56",,,,,,
Meridian Medicaid,DRG,1993,HYPERTENSION,,Relative Weights,"$3,736.93 ",IP,"3,736.93","3,736.93",,,,,,
Meridian Medicaid,DRG,1994,HYPERTENSION,,Relative Weights,"$6,634.39 ",IP,"6,634.39","6,634.39",,,,,,
Meridian Medicaid,DRG,2001,CARDIAC STRUCTURAL and VALVULAR DISORDERS,,Relative Weights,"$2,919.45 ",IP,"2,919.45","2,919.45",,,,,,
Meridian Medicaid,DRG,2002,CARDIAC STRUCTURAL and VALVULAR DISORDERS,,Relative Weights,"$3,565.12 ",IP,"3,565.12","3,565.12",,,,,,
Meridian Medicaid,DRG,2003,CARDIAC STRUCTURAL & VALVULAR DISORDERS,,Relative Weights,"$4,853.03 ",IP,"4,853.03","4,853.03",,,,,,
Meridian Medicaid,DRG,2004,CARDIAC STRUCTURAL and VALVULAR DISORDERS,,Relative Weights,"$10,524.92 ",IP,"10,524.92","10,524.92",,,,,,
Meridian Medicaid,DRG,2011,CARDIAC ARRHYTHMIA and CONDUCTION DISORDERS,,Relative Weights,"$2,322.91 ",IP,"2,322.91","2,322.91",,,,,,
Meridian Medicaid,DRG,2012,CARDIAC ARRHYTHMIA and CONDUCTION DISORDERS,,Relative Weights,"$2,865.50 ",IP,"2,865.50","2,865.50",,,,,,
Meridian Medicaid,DRG,2013,CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS,,Relative Weights,"$3,988.81 ",IP,"3,988.81","3,988.81",,,,,,
Meridian Medicaid,DRG,2014,CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS,,Relative Weights,"$7,490.70 ",IP,"7,490.70","7,490.70",,,,,,
Meridian Medicaid,DRG,2031,CHEST PAIN,,Relative Weights,"$2,896.08 ",IP,"2,896.08","2,896.08",,,,,,
Meridian Medicaid,DRG,2032,CHEST PAIN,,Relative Weights,"$3,156.55 ",IP,"3,156.55","3,156.55",,,,,,
Meridian Medicaid,DRG,2033,CHEST PAIN,,Relative Weights,"$3,647.25 ",IP,"3,647.25","3,647.25",,,,,,
Meridian Medicaid,DRG,2034,CHEST PAIN,,Relative Weights,"$5,656.08 ",IP,"5,656.08","5,656.08",,,,,,
Meridian Medicaid,DRG,2041,SYNCOPE and COLLAPSE,,Relative Weights,"$3,210.15 ",IP,"3,210.15","3,210.15",,,,,,
Meridian Medicaid,DRG,2042,SYNCOPE and COLLAPSE,,Relative Weights,"$3,469.25 ",IP,"3,469.25","3,469.25",,,,,,
Meridian Medicaid,DRG,2043,SYNCOPE and COLLAPSE,,Relative Weights,"$3,913.56 ",IP,"3,913.56","3,913.56",,,,,,
Meridian Medicaid,DRG,2044,SYNCOPE and COLLAPSE,,Relative Weights,"$6,621.67 ",IP,"6,621.67","6,621.67",,,,,,
Meridian Medicaid,DRG,2051,CARDIOMYOPATHY,,Relative Weights,"$3,094.70 ",IP,"3,094.70","3,094.70",,,,,,
Meridian Medicaid,DRG,2052,CARDIOMYOPATHY,,Relative Weights,"$3,108.78 ",IP,"3,108.78","3,108.78",,,,,,
Meridian Medicaid,DRG,2053,CARDIOMYOPATHY,,Relative Weights,"$4,834.47 ",IP,"4,834.47","4,834.47",,,,,,
Meridian Medicaid,DRG,2054,CARDIOMYOPATHY,,Relative Weights,"$12,099.76 ",IP,"12,099.76","12,099.76",,,,,,
Meridian Medicaid,DRG,2061,MALFUNCTIONREACTIONCOMPLICATION OF CARDIACVASC DEVICE OR PROCEDURE,,Relative Weights,"$3,915.62 ",IP,"3,915.62","3,915.62",,,,,,
Meridian Medicaid,DRG,2062,MALFUNCTIONREACTIONCOMPLICATION OF CARDIACVASC DEVICE OR PROCEDURE,,Relative Weights,"$4,064.41 ",IP,"4,064.41","4,064.41",,,,,,
Meridian Medicaid,DRG,2063,"MALFUNCTION,REACTION,COMPLICATION OF CARDIAC/VASC DEVICE OR PROCEDURE",,Relative Weights,"$5,616.22 ",IP,"5,616.22","5,616.22",,,,,,
Meridian Medicaid,DRG,2064,MALFUNCTIONREACTIONCOMPLICATION OF CARDIACVASC DEVICE OR PROCEDURE,,Relative Weights,"$11,629.68 ",IP,"11,629.68","11,629.68",,,,,,
Meridian Medicaid,DRG,2071,OTHER CIRCULATORY SYSTEM DIAGNOSES,,Relative Weights,"$2,947.97 ",IP,"2,947.97","2,947.97",,,,,,
Meridian Medicaid,DRG,2072,OTHER CIRCULATORY SYSTEM DIAGNOSES,,Relative Weights,"$3,511.17 ",IP,"3,511.17","3,511.17",,,,,,
Meridian Medicaid,DRG,2073,OTHER CIRCULATORY SYSTEM DIAGNOSES,,Relative Weights,"$4,590.50 ",IP,"4,590.50","4,590.50",,,,,,
Meridian Medicaid,DRG,2074,OTHER CIRCULATORY SYSTEM DIAGNOSES,,Relative Weights,"$8,837.72 ",IP,"8,837.72","8,837.72",,,,,,
Meridian Medicaid,DRG,2201,MAJOR STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$7,004.47 ",IP,"7,004.47","7,004.47",,,,,,
Meridian Medicaid,DRG,2202,MAJOR STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$10,124.94 ",IP,"10,124.94","10,124.94",,,,,,
Meridian Medicaid,DRG,2203,MAJOR STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$15,446.33 ",IP,"15,446.33","15,446.33",,,,,,
Meridian Medicaid,DRG,2204,MAJOR STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$29,728.80 ",IP,"29,728.80","29,728.80",,,,,,
Meridian Medicaid,DRG,2221,OTHER STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$3,629.38 ",IP,"3,629.38","3,629.38",,,,,,
Meridian Medicaid,DRG,2222,OTHER STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$5,962.94 ",IP,"5,962.94","5,962.94",,,,,,
Meridian Medicaid,DRG,2223,OTHER STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$9,116.74 ",IP,"9,116.74","9,116.74",,,,,,
Meridian Medicaid,DRG,2224,"OTHER STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES",,Relative Weights,"$19,946.46 ",IP,"19,946.46","19,946.46",,,,,,
Meridian Medicaid,DRG,2231,OTHER SMALL & LARGE BOWEL PROCEDURES,,Relative Weights,"$5,180.51 ",IP,"5,180.51","5,180.51",,,,,,
Meridian Medicaid,DRG,2232,OTHER SMALL and LARGE BOWEL PROCEDURES,,Relative Weights,"$7,107.90 ",IP,"7,107.90","7,107.90",,,,,,
Meridian Medicaid,DRG,2233,OTHER SMALL and LARGE BOWEL PROCEDURES,,Relative Weights,"$10,759.27 ",IP,"10,759.27","10,759.27",,,,,,
Meridian Medicaid,DRG,2234,OTHER SMALL and LARGE BOWEL PROCEDURES,,Relative Weights,"$20,449.53 ",IP,"20,449.53","20,449.53",,,,,,
Meridian Medicaid,DRG,2241,PERITONEAL ADHESIOLYSIS,,Relative Weights,"$6,143.69 ",IP,"6,143.69","6,143.69",,,,,,
Meridian Medicaid,DRG,2242,PERITONEAL ADHESIOLYSIS,,Relative Weights,"$7,746.36 ",IP,"7,746.36","7,746.36",,,,,,
Meridian Medicaid,DRG,2243,PERITONEAL ADHESIOLYSIS,,Relative Weights,"$11,242.41 ",IP,"11,242.41","11,242.41",,,,,,
Meridian Medicaid,DRG,2244,PERITONEAL ADHESIOLYSIS,,Relative Weights,"$20,422.04 ",IP,"20,422.04","20,422.04",,,,,,
Meridian Medicaid,DRG,2261,ANAL PROCEDURES,,Relative Weights,"$4,263.71 ",IP,"4,263.71","4,263.71",,,,,,
Meridian Medicaid,DRG,2262,ANAL PROCEDURES,,Relative Weights,"$5,861.92 ",IP,"5,861.92","5,861.92",,,,,,
Meridian Medicaid,DRG,2263,ANAL PROCEDURES,,Relative Weights,"$7,950.47 ",IP,"7,950.47","7,950.47",,,,,,
Meridian Medicaid,DRG,2264,ANAL PROCEDURES,,Relative Weights,"$17,017.73 ",IP,"17,017.73","17,017.73",,,,,,
Meridian Medicaid,DRG,2271,HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL and UMBILICAL,,Relative Weights,"$5,689.07 ",IP,"5,689.07","5,689.07",,,,,,
Meridian Medicaid,DRG,2272,HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL and UMBILICAL,,Relative Weights,"$6,795.89 ",IP,"6,795.89","6,795.89",,,,,,
Meridian Medicaid,DRG,2273,"HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL & UMBILICAL",,Relative Weights,"$10,114.97 ",IP,"10,114.97","10,114.97",,,,,,
Meridian Medicaid,DRG,2274,"HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL & UMBILICAL",,Relative Weights,"$20,038.21 ",IP,"20,038.21","20,038.21",,,,,,
Meridian Medicaid,DRG,2281,INGUINAL FEMORAL and UMBILICAL HERNIA PROCEDURES,,Relative Weights,"$4,335.53 ",IP,"4,335.53","4,335.53",,,,,,
Meridian Medicaid,DRG,2282,INGUINAL FEMORAL and UMBILICAL HERNIA PROCEDURES,,Relative Weights,"$5,502.48 ",IP,"5,502.48","5,502.48",,,,,,
Meridian Medicaid,DRG,2283,INGUINAL FEMORAL and UMBILICAL HERNIA PROCEDURES,,Relative Weights,"$7,788.28 ",IP,"7,788.28","7,788.28",,,,,,
Meridian Medicaid,DRG,2284,"INGUINAL, FEMORAL & UMBILICAL HERNIA PROCEDURES",,Relative Weights,"$16,501.95 ",IP,"16,501.95","16,501.95",,,,,,
Meridian Medicaid,DRG,2291,OTHER DIGESTIVE SYSTEM & ABDOMINAL PROCEDURES,,Relative Weights,"$5,564.34 ",IP,"5,564.34","5,564.34",,,,,,
Meridian Medicaid,DRG,2292,OTHER DIGESTIVE SYSTEM and ABDOMINAL PROCEDURES,,Relative Weights,"$7,117.87 ",IP,"7,117.87","7,117.87",,,,,,
Meridian Medicaid,DRG,2293,OTHER DIGESTIVE SYSTEM and ABDOMINAL PROCEDURES,,Relative Weights,"$10,259.30 ",IP,"10,259.30","10,259.30",,,,,,
Meridian Medicaid,DRG,2294,OTHER DIGESTIVE SYSTEM and ABDOMINAL PROCEDURES,,Relative Weights,"$20,018.28 ",IP,"20,018.28","20,018.28",,,,,,
Meridian Medicaid,DRG,2301,MAJOR SMALL BOWEL PROCEDURES,,Relative Weights,"$6,770.12 ",IP,"6,770.12","6,770.12",,,,,,
Meridian Medicaid,DRG,2302,MAJOR SMALL BOWEL PROCEDURES,,Relative Weights,"$8,787.20 ",IP,"8,787.20","8,787.20",,,,,,
Meridian Medicaid,DRG,2303,MAJOR SMALL BOWEL PROCEDURES,,Relative Weights,"$13,506.56 ",IP,"13,506.56","13,506.56",,,,,,
Meridian Medicaid,DRG,2304,MAJOR SMALL BOWEL PROCEDURES,,Relative Weights,"$27,168.10 ",IP,"27,168.10","27,168.10",,,,,,
Meridian Medicaid,DRG,2311,MAJOR LARGE BOWEL PROCEDURES,,Relative Weights,"$6,900.01 ",IP,"6,900.01","6,900.01",,,,,,
Meridian Medicaid,DRG,2312,MAJOR LARGE BOWEL PROCEDURES,,Relative Weights,"$8,451.83 ",IP,"8,451.83","8,451.83",,,,,,
Meridian Medicaid,DRG,2313,MAJOR LARGE BOWEL PROCEDURES,,Relative Weights,"$12,656.43 ",IP,"12,656.43","12,656.43",,,,,,
Meridian Medicaid,DRG,2314,MAJOR LARGE BOWEL PROCEDURES,,Relative Weights,"$23,212.62 ",IP,"23,212.62","23,212.62",,,,,,
Meridian Medicaid,DRG,2321,GASTRIC FUNDOPLICATION,,Relative Weights,"$5,317.96 ",IP,"5,317.96","5,317.96",,,,,,
Meridian Medicaid,DRG,2322,GASTRIC FUNDOPLICATION,,Relative Weights,"$6,619.27 ",IP,"6,619.27","6,619.27",,,,,,
Meridian Medicaid,DRG,2323,GASTRIC FUNDOPLICATION,,Relative Weights,"$9,668.60 ",IP,"9,668.60","9,668.60",,,,,,
Meridian Medicaid,DRG,2324,GASTRIC FUNDOPLICATION,,Relative Weights,"$26,510.06 ",IP,"26,510.06","26,510.06",,,,,,
Meridian Medicaid,DRG,2331,APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$5,328.61 ",IP,"5,328.61","5,328.61",,,,,,
Meridian Medicaid,DRG,2332,APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$6,525.46 ",IP,"6,525.46","6,525.46",,,,,,
Meridian Medicaid,DRG,2333,APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$9,426.35 ",IP,"9,426.35","9,426.35",,,,,,
Meridian Medicaid,DRG,2334,APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$16,969.28 ",IP,"16,969.28","16,969.28",,,,,,
Meridian Medicaid,DRG,2341,APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$3,837.96 ",IP,"3,837.96","3,837.96",,,,,,
Meridian Medicaid,DRG,2342,APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$4,853.72 ",IP,"4,853.72","4,853.72",,,,,,
Meridian Medicaid,DRG,2343,APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$7,767.67 ",IP,"7,767.67","7,767.67",,,,,,
Meridian Medicaid,DRG,2344,APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$15,153.91 ",IP,"15,153.91","15,153.91",,,,,,
Meridian Medicaid,DRG,2401,DIGESTIVE MALIGNANCY,,Relative Weights,"$4,130.38 ",IP,"4,130.38","4,130.38",,,,,,
Meridian Medicaid,DRG,2402,DIGESTIVE MALIGNANCY,,Relative Weights,"$4,471.61 ",IP,"4,471.61","4,471.61",,,,,,
Meridian Medicaid,DRG,2403,DIGESTIVE MALIGNANCY,,Relative Weights,"$5,940.95 ",IP,"5,940.95","5,940.95",,,,,,
Meridian Medicaid,DRG,2404,DIGESTIVE MALIGNANCY,,Relative Weights,"$10,480.94 ",IP,"10,480.94","10,480.94",,,,,,
Meridian Medicaid,DRG,2411,PEPTIC ULCER & GASTRITIS,,Relative Weights,"$3,142.46 ",IP,"3,142.46","3,142.46",,,,,,
Meridian Medicaid,DRG,2412,PEPTIC ULCER and GASTRITIS,,Relative Weights,"$3,833.49 ",IP,"3,833.49","3,833.49",,,,,,
Meridian Medicaid,DRG,2413,PEPTIC ULCER and GASTRITIS,,Relative Weights,"$5,293.90 ",IP,"5,293.90","5,293.90",,,,,,
Meridian Medicaid,DRG,2414,PEPTIC ULCER and GASTRITIS,,Relative Weights,"$11,497.38 ",IP,"11,497.38","11,497.38",,,,,,
Meridian Medicaid,DRG,2421,MAJOR ESOPHAGEAL DISORDERS,,Relative Weights,"$2,834.23 ",IP,"2,834.23","2,834.23",,,,,,
Meridian Medicaid,DRG,2422,MAJOR ESOPHAGEAL DISORDERS,,Relative Weights,"$3,630.75 ",IP,"3,630.75","3,630.75",,,,,,
Meridian Medicaid,DRG,2423,MAJOR ESOPHAGEAL DISORDERS,,Relative Weights,"$5,095.29 ",IP,"5,095.29","5,095.29",,,,,,
Meridian Medicaid,DRG,2424,MAJOR ESOPHAGEAL DISORDERS,,Relative Weights,"$11,235.54 ",IP,"11,235.54","11,235.54",,,,,,
Meridian Medicaid,DRG,2431,OTHER ESOPHAGEAL DISORDERS,,Relative Weights,"$2,619.12 ",IP,"2,619.12","2,619.12",,,,,,
Meridian Medicaid,DRG,2432,OTHER ESOPHAGEAL DISORDERS,,Relative Weights,"$3,394.34 ",IP,"3,394.34","3,394.34",,,,,,
Meridian Medicaid,DRG,2433,OTHER ESOPHAGEAL DISORDERS,,Relative Weights,"$4,672.28 ",IP,"4,672.28","4,672.28",,,,,,
Meridian Medicaid,DRG,2434,OTHER ESOPHAGEAL DISORDERS,,Relative Weights,"$10,028.72 ",IP,"10,028.72","10,028.72",,,,,,
Meridian Medicaid,DRG,2441,DIVERTICULITIS and DIVERTICULOSIS,,Relative Weights,"$2,541.46 ",IP,"2,541.46","2,541.46",,,,,,
Meridian Medicaid,DRG,2442,DIVERTICULITIS and DIVERTICULOSIS,,Relative Weights,"$3,268.57 ",IP,"3,268.57","3,268.57",,,,,,
Meridian Medicaid,DRG,2443,DIVERTICULITIS & DIVERTICULOSIS,,Relative Weights,"$4,670.91 ",IP,"4,670.91","4,670.91",,,,,,
Meridian Medicaid,DRG,2444,DIVERTICULITIS & DIVERTICULOSIS,,Relative Weights,"$10,075.80 ",IP,"10,075.80","10,075.80",,,,,,
Meridian Medicaid,DRG,2451,INFLAMMATORY BOWEL DISEASE,,Relative Weights,"$3,109.82 ",IP,"3,109.82","3,109.82",,,,,,
Meridian Medicaid,DRG,2452,INFLAMMATORY BOWEL DISEASE,,Relative Weights,"$3,884.35 ",IP,"3,884.35","3,884.35",,,,,,
Meridian Medicaid,DRG,2453,INFLAMMATORY BOWEL DISEASE,,Relative Weights,"$5,370.53 ",IP,"5,370.53","5,370.53",,,,,,
Meridian Medicaid,DRG,2454,INFLAMMATORY BOWEL DISEASE,,Relative Weights,"$12,127.25 ",IP,"12,127.25","12,127.25",,,,,,
Meridian Medicaid,DRG,2461,GASTROINTESTINAL VASCULAR INSUFFICIENCY,,Relative Weights,"$3,009.82 ",IP,"3,009.82","3,009.82",,,,,,
Meridian Medicaid,DRG,2462,GASTROINTESTINAL VASCULAR INSUFFICIENCY,,Relative Weights,"$3,644.84 ",IP,"3,644.84","3,644.84",,,,,,
Meridian Medicaid,DRG,2463,GASTROINTESTINAL VASCULAR INSUFFICIENCY,,Relative Weights,"$5,068.14 ",IP,"5,068.14","5,068.14",,,,,,
Meridian Medicaid,DRG,2464,GASTROINTESTINAL VASCULAR INSUFFICIENCY,,Relative Weights,"$9,550.40 ",IP,"9,550.40","9,550.40",,,,,,
Meridian Medicaid,DRG,2471,INTESTINAL OBSTRUCTION,,Relative Weights,"$2,323.60 ",IP,"2,323.60","2,323.60",,,,,,
Meridian Medicaid,DRG,2472,INTESTINAL OBSTRUCTION,,Relative Weights,"$2,999.17 ",IP,"2,999.17","2,999.17",,,,,,
Meridian Medicaid,DRG,2473,INTESTINAL OBSTRUCTION,,Relative Weights,"$4,431.74 ",IP,"4,431.74","4,431.74",,,,,,
Meridian Medicaid,DRG,2474,INTESTINAL OBSTRUCTION,,Relative Weights,"$9,108.15 ",IP,"9,108.15","9,108.15",,,,,,
Meridian Medicaid,DRG,2481,MAJOR GASTROINTESTINAL and PERITONEAL INFECTIONS,,Relative Weights,"$2,573.42 ",IP,"2,573.42","2,573.42",,,,,,
Meridian Medicaid,DRG,2482,MAJOR GASTROINTESTINAL and PERITONEAL INFECTIONS,,Relative Weights,"$3,590.89 ",IP,"3,590.89","3,590.89",,,,,,
Meridian Medicaid,DRG,2483,MAJOR GASTROINTESTINAL & PERITONEAL INFECTIONS,,Relative Weights,"$4,839.63 ",IP,"4,839.63","4,839.63",,,,,,
Meridian Medicaid,DRG,2484,MAJOR GASTROINTESTINAL and PERITONEAL INFECTIONS,,Relative Weights,"$10,133.19 ",IP,"10,133.19","10,133.19",,,,,,
Meridian Medicaid,DRG,2491,OTHER GASTROENTERITIS NAUSEA and VOMITING,,Relative Weights,"$2,187.52 ",IP,"2,187.52","2,187.52",,,,,,
Meridian Medicaid,DRG,2492,OTHER GASTROENTERITIS NAUSEA and VOMITING,,Relative Weights,"$2,797.80 ",IP,"2,797.80","2,797.80",,,,,,
Meridian Medicaid,DRG,2493,"OTHER GASTROENTERITIS, NAUSEA & VOMITING",,Relative Weights,"$3,754.80 ",IP,"3,754.80","3,754.80",,,,,,
Meridian Medicaid,DRG,2494,"OTHER GASTROENTERITIS, NAUSEA & VOMITING",,Relative Weights,"$8,298.22 ",IP,"8,298.22","8,298.22",,,,,,
Meridian Medicaid,DRG,2511,ABDOMINAL PAIN,,Relative Weights,"$2,520.84 ",IP,"2,520.84","2,520.84",,,,,,
Meridian Medicaid,DRG,2512,ABDOMINAL PAIN,,Relative Weights,"$3,175.79 ",IP,"3,175.79","3,175.79",,,,,,
Meridian Medicaid,DRG,2513,ABDOMINAL PAIN,,Relative Weights,"$4,112.86 ",IP,"4,112.86","4,112.86",,,,,,
Meridian Medicaid,DRG,2514,ABDOMINAL PAIN,,Relative Weights,"$7,334.01 ",IP,"7,334.01","7,334.01",,,,,,
Meridian Medicaid,DRG,2521,MALFUNCTION REACTION and COMPLICATION OF GI DEVICE OR PROCEDURE,,Relative Weights,"$2,913.26 ",IP,"2,913.26","2,913.26",,,,,,
Meridian Medicaid,DRG,2522,MALFUNCTION REACTION and COMPLICATION OF GI DEVICE OR PROCEDURE,,Relative Weights,"$3,639.34 ",IP,"3,639.34","3,639.34",,,,,,
Meridian Medicaid,DRG,2523,MALFUNCTION REACTION and COMPLICATION OF GI DEVICE OR PROCEDURE,,Relative Weights,"$5,172.60 ",IP,"5,172.60","5,172.60",,,,,,
Meridian Medicaid,DRG,2524,MALFUNCTION REACTION and COMPLICATION OF GI DEVICE OR PROCEDURE,,Relative Weights,"$11,168.53 ",IP,"11,168.53","11,168.53",,,,,,
Meridian Medicaid,DRG,2531,OTHER and UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,,Relative Weights,"$2,890.24 ",IP,"2,890.24","2,890.24",,,,,,
Meridian Medicaid,DRG,2532,OTHER and UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,,Relative Weights,"$3,602.23 ",IP,"3,602.23","3,602.23",,,,,,
Meridian Medicaid,DRG,2533,OTHER and UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,,Relative Weights,"$5,054.39 ",IP,"5,054.39","5,054.39",,,,,,
Meridian Medicaid,DRG,2534,OTHER and UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,,Relative Weights,"$9,586.48 ",IP,"9,586.48","9,586.48",,,,,,
Meridian Medicaid,DRG,2541,OTHER DIGESTIVE SYSTEM DIAGNOSES,,Relative Weights,"$2,614.99 ",IP,"2,614.99","2,614.99",,,,,,
Meridian Medicaid,DRG,2542,OTHER DIGESTIVE SYSTEM DIAGNOSES,,Relative Weights,"$3,386.43 ",IP,"3,386.43","3,386.43",,,,,,
Meridian Medicaid,DRG,2543,OTHER DIGESTIVE SYSTEM DIAGNOSES,,Relative Weights,"$4,771.93 ",IP,"4,771.93","4,771.93",,,,,,
Meridian Medicaid,DRG,2544,OTHER DIGESTIVE SYSTEM DIAGNOSES,,Relative Weights,"$9,778.91 ",IP,"9,778.91","9,778.91",,,,,,
Meridian Medicaid,DRG,2601,MAJOR PANCREAS LIVER and SHUNT PROCEDURES,,Relative Weights,"$9,438.72 ",IP,"9,438.72","9,438.72",,,,,,
Meridian Medicaid,DRG,2602,MAJOR PANCREAS LIVER and SHUNT PROCEDURES,,Relative Weights,"$11,500.13 ",IP,"11,500.13","11,500.13",,,,,,
Meridian Medicaid,DRG,2603,MAJOR PANCREAS LIVER and SHUNT PROCEDURES,,Relative Weights,"$16,312.61 ",IP,"16,312.61","16,312.61",,,,,,
Meridian Medicaid,DRG,2604,MAJOR PANCREAS LIVER and SHUNT PROCEDURES,,Relative Weights,"$34,324.11 ",IP,"34,324.11","34,324.11",,,,,,
Meridian Medicaid,DRG,2611,MAJOR BILIARY TRACT PROCEDURES,,Relative Weights,"$6,801.05 ",IP,"6,801.05","6,801.05",,,,,,
Meridian Medicaid,DRG,2612,MAJOR BILIARY TRACT PROCEDURES,,Relative Weights,"$10,119.10 ",IP,"10,119.10","10,119.10",,,,,,
Meridian Medicaid,DRG,2613,MAJOR BILIARY TRACT PROCEDURES,,Relative Weights,"$14,491.05 ",IP,"14,491.05","14,491.05",,,,,,
Meridian Medicaid,DRG,2614,MAJOR BILIARY TRACT PROCEDURES,,Relative Weights,"$28,576.97 ",IP,"28,576.97","28,576.97",,,,,,
Meridian Medicaid,DRG,2631,CHOLECYSTECTOMY,,Relative Weights,"$5,153.36 ",IP,"5,153.36","5,153.36",,,,,,
Meridian Medicaid,DRG,2632,CHOLECYSTECTOMY,,Relative Weights,"$6,574.60 ",IP,"6,574.60","6,574.60",,,,,,
Meridian Medicaid,DRG,2633,CHOLECYSTECTOMY,,Relative Weights,"$8,823.28 ",IP,"8,823.28","8,823.28",,,,,,
Meridian Medicaid,DRG,2634,CHOLECYSTECTOMY,,Relative Weights,"$16,983.37 ",IP,"16,983.37","16,983.37",,,,,,
Meridian Medicaid,DRG,2641,OTHER HEPATOBILIARY PANCREAS and ABDOMINAL PROCEDURES,,Relative Weights,"$6,826.47 ",IP,"6,826.47","6,826.47",,,,,,
Meridian Medicaid,DRG,2642,OTHER HEPATOBILIARY PANCREAS and ABDOMINAL PROCEDURES,,Relative Weights,"$7,584.86 ",IP,"7,584.86","7,584.86",,,,,,
Meridian Medicaid,DRG,2643,"OTHER HEPATOBILIARY, PANCREAS & ABDOMINAL PROCEDURES",,Relative Weights,"$11,612.15 ",IP,"11,612.15","11,612.15",,,,,,
Meridian Medicaid,DRG,2644,OTHER HEPATOBILIARY PANCREAS and ABDOMINAL PROCEDURES,,Relative Weights,"$29,218.86 ",IP,"29,218.86","29,218.86",,,,,,
Meridian Medicaid,DRG,2791,HEPATIC COMA and OTHER MAJOR ACUTE LIVER DISORDERS,,Relative Weights,"$2,567.92 ",IP,"2,567.92","2,567.92",,,,,,
Meridian Medicaid,DRG,2792,HEPATIC COMA and OTHER MAJOR ACUTE LIVER DISORDERS,,Relative Weights,"$3,323.89 ",IP,"3,323.89","3,323.89",,,,,,
Meridian Medicaid,DRG,2793,HEPATIC COMA & OTHER MAJOR ACUTE LIVER DISORDERS,,Relative Weights,"$4,704.93 ",IP,"4,704.93","4,704.93",,,,,,
Meridian Medicaid,DRG,2794,HEPATIC COMA and OTHER MAJOR ACUTE LIVER DISORDERS,,Relative Weights,"$11,290.86 ",IP,"11,290.86","11,290.86",,,,,,
Meridian Medicaid,DRG,2801,ALCOHOLIC LIVER DISEASE,,Relative Weights,"$2,499.54 ",IP,"2,499.54","2,499.54",,,,,,
Meridian Medicaid,DRG,2802,ALCOHOLIC LIVER DISEASE,,Relative Weights,"$3,093.32 ",IP,"3,093.32","3,093.32",,,,,,
Meridian Medicaid,DRG,2803,ALCOHOLIC LIVER DISEASE,,Relative Weights,"$4,638.26 ",IP,"4,638.26","4,638.26",,,,,,
Meridian Medicaid,DRG,2804,ALCOHOLIC LIVER DISEASE,,Relative Weights,"$10,324.24 ",IP,"10,324.24","10,324.24",,,,,,
Meridian Medicaid,DRG,2811,MALIGNANCY OF HEPATOBILIARY SYSTEM & PANCREAS,,Relative Weights,"$3,619.41 ",IP,"3,619.41","3,619.41",,,,,,
Meridian Medicaid,DRG,2812,MALIGNANCY OF HEPATOBILIARY SYSTEM and PANCREAS,,Relative Weights,"$4,564.04 ",IP,"4,564.04","4,564.04",,,,,,
Meridian Medicaid,DRG,2813,MALIGNANCY OF HEPATOBILIARY SYSTEM and PANCREAS,,Relative Weights,"$5,844.73 ",IP,"5,844.73","5,844.73",,,,,,
Meridian Medicaid,DRG,2814,MALIGNANCY OF HEPATOBILIARY SYSTEM and PANCREAS,,Relative Weights,"$9,186.50 ",IP,"9,186.50","9,186.50",,,,,,
Meridian Medicaid,DRG,2821,DISORDERS OF PANCREAS EXCEPT MALIGNANCY,,Relative Weights,"$2,462.42 ",IP,"2,462.42","2,462.42",,,,,,
Meridian Medicaid,DRG,2822,DISORDERS OF PANCREAS EXCEPT MALIGNANCY,,Relative Weights,"$3,135.24 ",IP,"3,135.24","3,135.24",,,,,,
Meridian Medicaid,DRG,2823,DISORDERS OF PANCREAS EXCEPT MALIGNANCY,,Relative Weights,"$4,746.16 ",IP,"4,746.16","4,746.16",,,,,,
Meridian Medicaid,DRG,2824,DISORDERS OF PANCREAS EXCEPT MALIGNANCY,,Relative Weights,"$12,503.18 ",IP,"12,503.18","12,503.18",,,,,,
Meridian Medicaid,DRG,2831,OTHER DISORDERS OF THE LIVER,,Relative Weights,"$2,720.83 ",IP,"2,720.83","2,720.83",,,,,,
Meridian Medicaid,DRG,2832,OTHER DISORDERS OF THE LIVER,,Relative Weights,"$3,349.67 ",IP,"3,349.67","3,349.67",,,,,,
Meridian Medicaid,DRG,2833,OTHER DISORDERS OF THE LIVER,,Relative Weights,"$4,885.67 ",IP,"4,885.67","4,885.67",,,,,,
Meridian Medicaid,DRG,2834,OTHER DISORDERS OF THE LIVER,,Relative Weights,"$10,248.65 ",IP,"10,248.65","10,248.65",,,,,,
Meridian Medicaid,DRG,2841,DISORDERS OF GALLBLADDER and BILIARY TRACT,,Relative Weights,"$3,351.73 ",IP,"3,351.73","3,351.73",,,,,,
Meridian Medicaid,DRG,2842,DISORDERS OF GALLBLADDER and BILIARY TRACT,,Relative Weights,"$4,147.57 ",IP,"4,147.57","4,147.57",,,,,,
Meridian Medicaid,DRG,2843,DISORDERS OF GALLBLADDER and BILIARY TRACT,,Relative Weights,"$5,552.31 ",IP,"5,552.31","5,552.31",,,,,,
Meridian Medicaid,DRG,2844,DISORDERS OF GALLBLADDER and BILIARY TRACT,,Relative Weights,"$10,788.48 ",IP,"10,788.48","10,788.48",,,,,,
Meridian Medicaid,DRG,3011,HIP JOINT REPLACEMENT,,Relative Weights,"$7,771.10 ",IP,"7,771.10","7,771.10",,,,,,
Meridian Medicaid,DRG,3012,HIP JOINT REPLACEMENT,,Relative Weights,"$8,122.29 ",IP,"8,122.29","8,122.29",,,,,,
Meridian Medicaid,DRG,3013,HIP JOINT REPLACEMENT,,Relative Weights,"$10,480.59 ",IP,"10,480.59","10,480.59",,,,,,
Meridian Medicaid,DRG,3014,HIP JOINT REPLACEMENT,,Relative Weights,"$16,617.41 ",IP,"16,617.41","16,617.41",,,,,,
Meridian Medicaid,DRG,3021,KNEE JOINT REPLACEMENT,,Relative Weights,"$7,208.24 ",IP,"7,208.24","7,208.24",,,,,,
Meridian Medicaid,DRG,3022,KNEE JOINT REPLACEMENT,,Relative Weights,"$7,702.03 ",IP,"7,702.03","7,702.03",,,,,,
Meridian Medicaid,DRG,3023,KNEE JOINT REPLACEMENT,,Relative Weights,"$9,864.13 ",IP,"9,864.13","9,864.13",,,,,,
Meridian Medicaid,DRG,3024,KNEE JOINT REPLACEMENT,,Relative Weights,"$17,075.12 ",IP,"17,075.12","17,075.12",,,,,,
Meridian Medicaid,DRG,3031,DORSAL and LUMBAR FUSION PROC FOR CURVATURE OF BACK,,Relative Weights,"$22,622.27 ",IP,"22,622.27","22,622.27",,,,,,
Meridian Medicaid,DRG,3032,DORSAL and LUMBAR FUSION PROC FOR CURVATURE OF BACK,,Relative Weights,"$26,401.82 ",IP,"26,401.82","26,401.82",,,,,,
Meridian Medicaid,DRG,3033,DORSAL and LUMBAR FUSION PROC FOR CURVATURE OF BACK,,Relative Weights,"$36,462.15 ",IP,"36,462.15","36,462.15",,,,,,
Meridian Medicaid,DRG,3034,DORSAL and LUMBAR FUSION PROC FOR CURVATURE OF BACK,,Relative Weights,"$46,680.22 ",IP,"46,680.22","46,680.22",,,,,,
Meridian Medicaid,DRG,3041,DORSAL and LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK,,Relative Weights,"$13,662.91 ",IP,"13,662.91","13,662.91",,,,,,
Meridian Medicaid,DRG,3042,DORSAL and LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK,,Relative Weights,"$15,568.66 ",IP,"15,568.66","15,568.66",,,,,,
Meridian Medicaid,DRG,3043,DORSAL and LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK,,Relative Weights,"$23,409.86 ",IP,"23,409.86","23,409.86",,,,,,
Meridian Medicaid,DRG,3044,DORSAL and LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK,,Relative Weights,"$37,522.24 ",IP,"37,522.24","37,522.24",,,,,,
Meridian Medicaid,DRG,3051,AMPUTATION OF LOWER LIMB EXCEPT TOES,,Relative Weights,"$4,866.09 ",IP,"4,866.09","4,866.09",,,,,,
Meridian Medicaid,DRG,3052,AMPUTATION OF LOWER LIMB EXCEPT TOES,,Relative Weights,"$6,637.82 ",IP,"6,637.82","6,637.82",,,,,,
Meridian Medicaid,DRG,3053,AMPUTATION OF LOWER LIMB EXCEPT TOES,,Relative Weights,"$10,080.61 ",IP,"10,080.61","10,080.61",,,,,,
Meridian Medicaid,DRG,3054,AMPUTATION OF LOWER LIMB EXCEPT TOES,,Relative Weights,"$19,786.33 ",IP,"19,786.33","19,786.33",,,,,,
Meridian Medicaid,DRG,3081,HIP and FEMUR FRACTURE REPAIR,,Relative Weights,"$6,633.70 ",IP,"6,633.70","6,633.70",,,,,,
Meridian Medicaid,DRG,3082,HIP and FEMUR FRACTURE REPAIR,,Relative Weights,"$7,529.88 ",IP,"7,529.88","7,529.88",,,,,,
Meridian Medicaid,DRG,3083,HIP & FEMUR FRACTURE REPAIR,,Relative Weights,"$9,249.72 ",IP,"9,249.72","9,249.72",,,,,,
Meridian Medicaid,DRG,3084,HIP and FEMUR FRACTURE REPAIR,,Relative Weights,"$14,744.30 ",IP,"14,744.30","14,744.30",,,,,,
Meridian Medicaid,DRG,3091,OTHER SIGNIFICANT HIP and FEMUR SURGERY,,Relative Weights,"$7,238.83 ",IP,"7,238.83","7,238.83",,,,,,
Meridian Medicaid,DRG,3092,OTHER SIGNIFICANT HIP and FEMUR SURGERY,,Relative Weights,"$9,130.83 ",IP,"9,130.83","9,130.83",,,,,,
Meridian Medicaid,DRG,3093,OTHER SIGNIFICANT HIP & FEMUR SURGERY,,Relative Weights,"$12,063.33 ",IP,"12,063.33","12,063.33",,,,,,
Meridian Medicaid,DRG,3094,OTHER SIGNIFICANT HIP & FEMUR SURGERY,,Relative Weights,"$21,019.95 ",IP,"21,019.95","21,019.95",,,,,,
Meridian Medicaid,DRG,3101,INTERVERTEBRAL DISC EXCISION and DECOMPRESSION,,Relative Weights,"$5,634.78 ",IP,"5,634.78","5,634.78",,,,,,
Meridian Medicaid,DRG,3102,INTERVERTEBRAL DISC EXCISION and DECOMPRESSION,,Relative Weights,"$6,775.27 ",IP,"6,775.27","6,775.27",,,,,,
Meridian Medicaid,DRG,3103,INTERVERTEBRAL DISC EXCISION and DECOMPRESSION,,Relative Weights,"$9,328.07 ",IP,"9,328.07","9,328.07",,,,,,
Meridian Medicaid,DRG,3104,INTERVERTEBRAL DISC EXCISION & DECOMPRESSION,,Relative Weights,"$18,301.18 ",IP,"18,301.18","18,301.18",,,,,,
Meridian Medicaid,DRG,3121,SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$6,515.49 ",IP,"6,515.49","6,515.49",,,,,,
Meridian Medicaid,DRG,3122,SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$8,587.21 ",IP,"8,587.21","8,587.21",,,,,,
Meridian Medicaid,DRG,3123,SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$12,636.50 ",IP,"12,636.50","12,636.50",,,,,,
Meridian Medicaid,DRG,3124,SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$31,602.60 ",IP,"31,602.60","31,602.60",,,,,,
Meridian Medicaid,DRG,3131,KNEE & LOWER LEG PROCEDURES EXCEPT FOOT,,Relative Weights,"$5,906.59 ",IP,"5,906.59","5,906.59",,,,,,
Meridian Medicaid,DRG,3132,KNEE and LOWER LEG PROCEDURES EXCEPT FOOT,,Relative Weights,"$7,791.03 ",IP,"7,791.03","7,791.03",,,,,,
Meridian Medicaid,DRG,3133,KNEE and LOWER LEG PROCEDURES EXCEPT FOOT,,Relative Weights,"$10,674.40 ",IP,"10,674.40","10,674.40",,,,,,
Meridian Medicaid,DRG,3134,KNEE and LOWER LEG PROCEDURES EXCEPT FOOT,,Relative Weights,"$18,704.94 ",IP,"18,704.94","18,704.94",,,,,,
Meridian Medicaid,DRG,3141,FOOT & TOE PROCEDURES,,Relative Weights,"$5,184.29 ",IP,"5,184.29","5,184.29",,,,,,
Meridian Medicaid,DRG,3142,FOOT and TOE PROCEDURES,,Relative Weights,"$5,760.89 ",IP,"5,760.89","5,760.89",,,,,,
Meridian Medicaid,DRG,3143,FOOT and TOE PROCEDURES,,Relative Weights,"$7,587.61 ",IP,"7,587.61","7,587.61",,,,,,
Meridian Medicaid,DRG,3144,FOOT and TOE PROCEDURES,,Relative Weights,"$15,541.86 ",IP,"15,541.86","15,541.86",,,,,,
Meridian Medicaid,DRG,3151,SHOULDER UPPER ARM and FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT,,Relative Weights,"$4,407.35 ",IP,"4,407.35","4,407.35",,,,,,
Meridian Medicaid,DRG,3152,SHOULDER UPPER ARM and FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT,,Relative Weights,"$7,204.46 ",IP,"7,204.46","7,204.46",,,,,,
Meridian Medicaid,DRG,3153,SHOULDER UPPER ARM and FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT,,Relative Weights,"$9,814.99 ",IP,"9,814.99","9,814.99",,,,,,
Meridian Medicaid,DRG,3154,SHOULDER UPPER ARM and FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT,,Relative Weights,"$17,630.42 ",IP,"17,630.42","17,630.42",,,,,,
Meridian Medicaid,DRG,3161,HAND and WRIST PROCEDURES,,Relative Weights,"$4,228.66 ",IP,"4,228.66","4,228.66",,,,,,
Meridian Medicaid,DRG,3162,HAND and WRIST PROCEDURES,,Relative Weights,"$5,513.82 ",IP,"5,513.82","5,513.82",,,,,,
Meridian Medicaid,DRG,3163,HAND and WRIST PROCEDURES,,Relative Weights,"$8,327.78 ",IP,"8,327.78","8,327.78",,,,,,
Meridian Medicaid,DRG,3164,HAND and WRIST PROCEDURES,,Relative Weights,"$17,742.44 ",IP,"17,742.44","17,742.44",,,,,,
Meridian Medicaid,DRG,3171,TENDON MUSCLE and OTHER SOFT TISSUE PROCEDURES,,Relative Weights,"$4,914.20 ",IP,"4,914.20","4,914.20",,,,,,
Meridian Medicaid,DRG,3172,TENDON MUSCLE and OTHER SOFT TISSUE PROCEDURES,,Relative Weights,"$6,410.69 ",IP,"6,410.69","6,410.69",,,,,,
Meridian Medicaid,DRG,3173,TENDON MUSCLE and OTHER SOFT TISSUE PROCEDURES,,Relative Weights,"$9,611.56 ",IP,"9,611.56","9,611.56",,,,,,
Meridian Medicaid,DRG,3174,TENDON MUSCLE and OTHER SOFT TISSUE PROCEDURES,,Relative Weights,"$20,290.08 ",IP,"20,290.08","20,290.08",,,,,,
Meridian Medicaid,DRG,3201,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE PROCEDURES,,Relative Weights,"$5,415.55 ",IP,"5,415.55","5,415.55",,,,,,
Meridian Medicaid,DRG,3202,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE PROCEDURES,,Relative Weights,"$6,995.19 ",IP,"6,995.19","6,995.19",,,,,,
Meridian Medicaid,DRG,3203,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE PROCEDURES,,Relative Weights,"$10,390.22 ",IP,"10,390.22","10,390.22",,,,,,
Meridian Medicaid,DRG,3204,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE PROCEDURES,,Relative Weights,"$19,965.01 ",IP,"19,965.01","19,965.01",,,,,,
Meridian Medicaid,DRG,3211,CERVICAL SPINAL FUSION and OTHER BACKNECK PROC EXC DISC EXCISDECOMP,,Relative Weights,"$8,441.17 ",IP,"8,441.17","8,441.17",,,,,,
Meridian Medicaid,DRG,3212,CERVICAL SPINAL FUSION and OTHER BACKNECK PROC EXC DISC EXCISDECOMP,,Relative Weights,"$10,023.57 ",IP,"10,023.57","10,023.57",,,,,,
Meridian Medicaid,DRG,3213,CERVICAL SPINAL FUSION and OTHER BACKNECK PROC EXC DISC EXCISDECOMP,,Relative Weights,"$14,027.50 ",IP,"14,027.50","14,027.50",,,,,,
Meridian Medicaid,DRG,3214,CERVICAL SPINAL FUSION and OTHER BACKNECK PROC EXC DISC EXCISDECOMP,,Relative Weights,"$25,569.90 ",IP,"25,569.90","25,569.90",,,,,,
Meridian Medicaid,DRG,3221,SHOULDER and ELBOW JOINT REPLACEMENT,,Relative Weights,"$8,466.60 ",IP,"8,466.60","8,466.60",,,,,,
Meridian Medicaid,DRG,3222,SHOULDER and ELBOW JOINT REPLACEMENT,,Relative Weights,"$8,949.40 ",IP,"8,949.40","8,949.40",,,,,,
Meridian Medicaid,DRG,3223,SHOULDER and ELBOW JOINT REPLACEMENT,,Relative Weights,"$11,526.59 ",IP,"11,526.59","11,526.59",,,,,,
Meridian Medicaid,DRG,3224,SHOULDER and ELBOW JOINT REPLACEMENT,,Relative Weights,"$17,494.69 ",IP,"17,494.69","17,494.69",,,,,,
Meridian Medicaid,DRG,3401,FRACTURE OF FEMUR,,Relative Weights,"$2,284.43 ",IP,"2,284.43","2,284.43",,,,,,
Meridian Medicaid,DRG,3402,FRACTURE OF FEMUR,,Relative Weights,"$2,649.70 ",IP,"2,649.70","2,649.70",,,,,,
Meridian Medicaid,DRG,3403,FRACTURE OF FEMUR,,Relative Weights,"$3,664.08 ",IP,"3,664.08","3,664.08",,,,,,
Meridian Medicaid,DRG,3404,FRACTURE OF FEMUR,,Relative Weights,"$6,893.48 ",IP,"6,893.48","6,893.48",,,,,,
Meridian Medicaid,DRG,3411,FRACTURE OF PELVIS OR DISLOCATION OF HIP,,Relative Weights,"$2,584.41 ",IP,"2,584.41","2,584.41",,,,,,
Meridian Medicaid,DRG,3412,FRACTURE OF PELVIS OR DISLOCATION OF HIP,,Relative Weights,"$2,958.62 ",IP,"2,958.62","2,958.62",,,,,,
Meridian Medicaid,DRG,3413,FRACTURE OF PELVIS OR DISLOCATION OF HIP,,Relative Weights,"$3,751.71 ",IP,"3,751.71","3,751.71",,,,,,
Meridian Medicaid,DRG,3414,FRACTURE OF PELVIS OR DISLOCATION OF HIP,,Relative Weights,"$8,259.05 ",IP,"8,259.05","8,259.05",,,,,,
Meridian Medicaid,DRG,3421,FRACTURES and DISLOCATIONS EXCEPT FEMUR PELVIS and BACK,,Relative Weights,"$2,677.53 ",IP,"2,677.53","2,677.53",,,,,,
Meridian Medicaid,DRG,3422,"FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK",,Relative Weights,"$3,262.04 ",IP,"3,262.04","3,262.04",,,,,,
Meridian Medicaid,DRG,3423,"FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK",,Relative Weights,"$4,236.57 ",IP,"4,236.57","4,236.57",,,,,,
Meridian Medicaid,DRG,3424,FRACTURES and DISLOCATIONS EXCEPT FEMUR PELVIS and BACK,,Relative Weights,"$8,410.59 ",IP,"8,410.59","8,410.59",,,,,,
Meridian Medicaid,DRG,3431,MUSCULOSKELETAL MALIGNANCY and PATHOL FRACTURE DT MUSCSKEL MALIG,,Relative Weights,"$4,528.30 ",IP,"4,528.30","4,528.30",,,,,,
Meridian Medicaid,DRG,3432,MUSCULOSKELETAL MALIGNANCY and PATHOL FRACTURE DT MUSCSKEL MALIG,,Relative Weights,"$4,916.60 ",IP,"4,916.60","4,916.60",,,,,,
Meridian Medicaid,DRG,3433,MUSCULOSKELETAL MALIGNANCY & PATHOL FRACTURE D/T MUSCSKEL MALIG,,Relative Weights,"$6,907.57 ",IP,"6,907.57","6,907.57",,,,,,
Meridian Medicaid,DRG,3434,MUSCULOSKELETAL MALIGNANCY and PATHOL FRACTURE DT MUSCSKEL MALIG,,Relative Weights,"$11,710.09 ",IP,"11,710.09","11,710.09",,,,,,
Meridian Medicaid,DRG,3441,OSTEOMYELITIS SEPTIC ARTHRITIS and OTHER MUSCULOSKELETAL INFECTIONS,,Relative Weights,"$3,603.61 ",IP,"3,603.61","3,603.61",,,,,,
Meridian Medicaid,DRG,3442,OSTEOMYELITIS SEPTIC ARTHRITIS and OTHER MUSCULOSKELETAL INFECTIONS,,Relative Weights,"$4,272.99 ",IP,"4,272.99","4,272.99",,,,,,
Meridian Medicaid,DRG,3443,OSTEOMYELITIS SEPTIC ARTHRITIS and OTHER MUSCULOSKELETAL INFECTIONS,,Relative Weights,"$5,859.85 ",IP,"5,859.85","5,859.85",,,,,,
Meridian Medicaid,DRG,3444,OSTEOMYELITIS SEPTIC ARTHRITIS and OTHER MUSCULOSKELETAL INFECTIONS,,Relative Weights,"$10,885.73 ",IP,"10,885.73","10,885.73",,,,,,
Meridian Medicaid,DRG,3461,CONNECTIVE TISSUE DISORDERS,,Relative Weights,"$3,601.54 ",IP,"3,601.54","3,601.54",,,,,,
Meridian Medicaid,DRG,3462,CONNECTIVE TISSUE DISORDERS,,Relative Weights,"$4,539.99 ",IP,"4,539.99","4,539.99",,,,,,
Meridian Medicaid,DRG,3463,CONNECTIVE TISSUE DISORDERS,,Relative Weights,"$6,445.74 ",IP,"6,445.74","6,445.74",,,,,,
Meridian Medicaid,DRG,3464,CONNECTIVE TISSUE DISORDERS,,Relative Weights,"$15,116.11 ",IP,"15,116.11","15,116.11",,,,,,
Meridian Medicaid,DRG,3471,OTHER BACK and NECK DISORDERS FRACTURES and INJURIES,,Relative Weights,"$3,279.91 ",IP,"3,279.91","3,279.91",,,,,,
Meridian Medicaid,DRG,3472,"OTHER BACK & NECK DISORDERS, FRACTURES & INJURIES",,Relative Weights,"$3,772.33 ",IP,"3,772.33","3,772.33",,,,,,
Meridian Medicaid,DRG,3473,OTHER BACK and NECK DISORDERS FRACTURES and INJURIES,,Relative Weights,"$4,894.95 ",IP,"4,894.95","4,894.95",,,,,,
Meridian Medicaid,DRG,3474,OTHER BACK and NECK DISORDERS FRACTURES and INJURIES,,Relative Weights,"$9,864.13 ",IP,"9,864.13","9,864.13",,,,,,
Meridian Medicaid,DRG,3491,MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE,,Relative Weights,"$2,603.31 ",IP,"2,603.31","2,603.31",,,,,,
Meridian Medicaid,DRG,3492,MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE,,Relative Weights,"$3,535.91 ",IP,"3,535.91","3,535.91",,,,,,
Meridian Medicaid,DRG,3493,MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE,,Relative Weights,"$5,006.97 ",IP,"5,006.97","5,006.97",,,,,,
Meridian Medicaid,DRG,3494,MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE,,Relative Weights,"$9,666.89 ",IP,"9,666.89","9,666.89",,,,,,
Meridian Medicaid,DRG,3511,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$2,708.80 ",IP,"2,708.80","2,708.80",,,,,,
Meridian Medicaid,DRG,3512,OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$3,066.17 ",IP,"3,066.17","3,066.17",,,,,,
Meridian Medicaid,DRG,3513,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$4,449.61 ",IP,"4,449.61","4,449.61",,,,,,
Meridian Medicaid,DRG,3514,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$8,785.14 ",IP,"8,785.14","8,785.14",,,,,,
Meridian Medicaid,DRG,3611,SKIN GRAFT FOR SKIN and SUBCUTANEOUS TISSUE DIAGNOSES,,Relative Weights,"$5,861.92 ",IP,"5,861.92","5,861.92",,,,,,
Meridian Medicaid,DRG,3612,SKIN GRAFT FOR SKIN and SUBCUTANEOUS TISSUE DIAGNOSES,,Relative Weights,"$6,759.47 ",IP,"6,759.47","6,759.47",,,,,,
Meridian Medicaid,DRG,3613,SKIN GRAFT FOR SKIN and SUBCUTANEOUS TISSUE DIAGNOSES,,Relative Weights,"$10,411.18 ",IP,"10,411.18","10,411.18",,,,,,
Meridian Medicaid,DRG,3614,SKIN GRAFT FOR SKIN & SUBCUTANEOUS TISSUE DIAGNOSES,,Relative Weights,"$23,051.12 ",IP,"23,051.12","23,051.12",,,,,,
Meridian Medicaid,DRG,3621,MASTECTOMY PROCEDURES,,Relative Weights,"$5,733.06 ",IP,"5,733.06","5,733.06",,,,,,
Meridian Medicaid,DRG,3622,MASTECTOMY PROCEDURES,,Relative Weights,"$6,783.86 ",IP,"6,783.86","6,783.86",,,,,,
Meridian Medicaid,DRG,3623,MASTECTOMY PROCEDURES,,Relative Weights,"$8,730.85 ",IP,"8,730.85","8,730.85",,,,,,
Meridian Medicaid,DRG,3624,MASTECTOMY PROCEDURES,,Relative Weights,"$15,662.13 ",IP,"15,662.13","15,662.13",,,,,,
Meridian Medicaid,DRG,3631,BREAST PROCEDURES EXCEPT MASTECTOMY,,Relative Weights,"$5,772.23 ",IP,"5,772.23","5,772.23",,,,,,
Meridian Medicaid,DRG,3632,BREAST PROCEDURES EXCEPT MASTECTOMY,,Relative Weights,"$7,919.20 ",IP,"7,919.20","7,919.20",,,,,,
Meridian Medicaid,DRG,3633,BREAST PROCEDURES EXCEPT MASTECTOMY,,Relative Weights,"$10,641.07 ",IP,"10,641.07","10,641.07",,,,,,
Meridian Medicaid,DRG,3634,BREAST PROCEDURES EXCEPT MASTECTOMY,,Relative Weights,"$13,007.96 ",IP,"13,007.96","13,007.96",,,,,,
Meridian Medicaid,DRG,3641,OTHER SKIN SUBCUTANEOUS TISSUE and RELATED PROCEDURES,,Relative Weights,"$3,659.27 ",IP,"3,659.27","3,659.27",,,,,,
Meridian Medicaid,DRG,3642,"OTHER SKIN, SUBCUTANEOUS TISSUE & RELATED PROCEDURES",,Relative Weights,"$5,232.39 ",IP,"5,232.39","5,232.39",,,,,,
Meridian Medicaid,DRG,3643,OTHER SKIN SUBCUTANEOUS TISSUE and RELATED PROCEDURES,,Relative Weights,"$8,152.18 ",IP,"8,152.18","8,152.18",,,,,,
Meridian Medicaid,DRG,3644,OTHER SKIN SUBCUTANEOUS TISSUE and RELATED PROCEDURES,,Relative Weights,"$16,685.79 ",IP,"16,685.79","16,685.79",,,,,,
Meridian Medicaid,DRG,3801,SKIN ULCERS,,Relative Weights,"$2,950.72 ",IP,"2,950.72","2,950.72",,,,,,
Meridian Medicaid,DRG,3802,SKIN ULCERS,,Relative Weights,"$3,415.64 ",IP,"3,415.64","3,415.64",,,,,,
Meridian Medicaid,DRG,3803,SKIN ULCERS,,Relative Weights,"$4,667.13 ",IP,"4,667.13","4,667.13",,,,,,
Meridian Medicaid,DRG,3804,SKIN ULCERS,,Relative Weights,"$9,197.15 ",IP,"9,197.15","9,197.15",,,,,,
Meridian Medicaid,DRG,3811,MAJOR SKIN DISORDERS,,Relative Weights,"$2,135.64 ",IP,"2,135.64","2,135.64",,,,,,
Meridian Medicaid,DRG,3812,MAJOR SKIN DISORDERS,,Relative Weights,"$3,426.98 ",IP,"3,426.98","3,426.98",,,,,,
Meridian Medicaid,DRG,3813,MAJOR SKIN DISORDERS,,Relative Weights,"$6,058.47 ",IP,"6,058.47","6,058.47",,,,,,
Meridian Medicaid,DRG,3814,MAJOR SKIN DISORDERS,,Relative Weights,"$15,997.51 ",IP,"15,997.51","15,997.51",,,,,,
Meridian Medicaid,DRG,3821,MALIGNANT BREAST DISORDERS,,Relative Weights,"$3,708.41 ",IP,"3,708.41","3,708.41",,,,,,
Meridian Medicaid,DRG,3822,MALIGNANT BREAST DISORDERS,,Relative Weights,"$3,837.96 ",IP,"3,837.96","3,837.96",,,,,,
Meridian Medicaid,DRG,3823,MALIGNANT BREAST DISORDERS,,Relative Weights,"$5,221.05 ",IP,"5,221.05","5,221.05",,,,,,
Meridian Medicaid,DRG,3824,MALIGNANT BREAST DISORDERS,,Relative Weights,"$8,582.75 ",IP,"8,582.75","8,582.75",,,,,,
Meridian Medicaid,DRG,3831,CELLULITIS & OTHER SKIN INFECTIONS,,Relative Weights,"$2,128.08 ",IP,"2,128.08","2,128.08",,,,,,
Meridian Medicaid,DRG,3832,CELLULITIS and OTHER SKIN INFECTIONS,,Relative Weights,"$2,886.11 ",IP,"2,886.11","2,886.11",,,,,,
Meridian Medicaid,DRG,3833,CELLULITIS and OTHER SKIN INFECTIONS,,Relative Weights,"$4,151.00 ",IP,"4,151.00","4,151.00",,,,,,
Meridian Medicaid,DRG,3834,CELLULITIS and OTHER SKIN INFECTIONS,,Relative Weights,"$8,552.16 ",IP,"8,552.16","8,552.16",,,,,,
Meridian Medicaid,DRG,3841,CONTUSION OPEN WOUND and OTHER TRAUMA TO SKIN and SUBCUTANEOUS TISSUE,,Relative Weights,"$2,690.94 ",IP,"2,690.94","2,690.94",,,,,,
Meridian Medicaid,DRG,3842,CONTUSION OPEN WOUND and OTHER TRAUMA TO SKIN and SUBCUTANEOUS TISSUE,,Relative Weights,"$3,464.09 ",IP,"3,464.09","3,464.09",,,,,,
Meridian Medicaid,DRG,3843,CONTUSION OPEN WOUND and OTHER TRAUMA TO SKIN and SUBCUTANEOUS TISSUE,,Relative Weights,"$4,737.92 ",IP,"4,737.92","4,737.92",,,,,,
Meridian Medicaid,DRG,3844,CONTUSION OPEN WOUND and OTHER TRAUMA TO SKIN and SUBCUTANEOUS TISSUE,,Relative Weights,"$9,439.41 ",IP,"9,439.41","9,439.41",,,,,,
Meridian Medicaid,DRG,3851,OTHER SKIN SUBCUTANEOUS TISSUE and BREAST DISORDERS,,Relative Weights,"$2,189.24 ",IP,"2,189.24","2,189.24",,,,,,
Meridian Medicaid,DRG,3852,OTHER SKIN SUBCUTANEOUS TISSUE and BREAST DISORDERS,,Relative Weights,"$2,880.96 ",IP,"2,880.96","2,880.96",,,,,,
Meridian Medicaid,DRG,3853,"OTHER SKIN, SUBCUTANEOUS TISSUE & BREAST DISORDERS",,Relative Weights,"$4,186.05 ",IP,"4,186.05","4,186.05",,,,,,
Meridian Medicaid,DRG,3854,OTHER SKIN SUBCUTANEOUS TISSUE and BREAST DISORDERS,,Relative Weights,"$8,871.05 ",IP,"8,871.05","8,871.05",,,,,,
Meridian Medicaid,DRG,4011,ADRENAL PROCEDURES,,Relative Weights,"$6,855.68 ",IP,"6,855.68","6,855.68",,,,,,
Meridian Medicaid,DRG,4012,ADRENAL PROCEDURES,,Relative Weights,"$10,778.52 ",IP,"10,778.52","10,778.52",,,,,,
Meridian Medicaid,DRG,4013,ADRENAL PROCEDURES,,Relative Weights,"$13,300.04 ",IP,"13,300.04","13,300.04",,,,,,
Meridian Medicaid,DRG,4014,ADRENAL PROCEDURES,,Relative Weights,"$24,027.70 ",IP,"24,027.70","24,027.70",,,,,,
Meridian Medicaid,DRG,4031,PROCEDURES FOR OBESITY,,Relative Weights,"$5,110.06 ",IP,"5,110.06","5,110.06",,,,,,
Meridian Medicaid,DRG,4032,PROCEDURES FOR OBESITY,,Relative Weights,"$6,108.30 ",IP,"6,108.30","6,108.30",,,,,,
Meridian Medicaid,DRG,4033,PROCEDURES FOR OBESITY,,Relative Weights,"$9,074.13 ",IP,"9,074.13","9,074.13",,,,,,
Meridian Medicaid,DRG,4034,PROCEDURES FOR OBESITY,,Relative Weights,"$26,392.19 ",IP,"26,392.19","26,392.19",,,,,,
Meridian Medicaid,DRG,4041,"THYROID, PARATHYROID & THYROGLOSSAL PROCEDURES",,Relative Weights,"$4,728.64 ",IP,"4,728.64","4,728.64",,,,,,
Meridian Medicaid,DRG,4042,THYROID PARATHYROID and THYROGLOSSAL PROCEDURES,,Relative Weights,"$6,537.48 ",IP,"6,537.48","6,537.48",,,,,,
Meridian Medicaid,DRG,4043,THYROID PARATHYROID and THYROGLOSSAL PROCEDURES,,Relative Weights,"$10,989.85 ",IP,"10,989.85","10,989.85",,,,,,
Meridian Medicaid,DRG,4044,THYROID PARATHYROID and THYROGLOSSAL PROCEDURES,,Relative Weights,"$24,206.39 ",IP,"24,206.39","24,206.39",,,,,,
Meridian Medicaid,DRG,4051,OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL and METABOLIC DISORDERS,,Relative Weights,"$7,505.82 ",IP,"7,505.82","7,505.82",,,,,,
Meridian Medicaid,DRG,4052,OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL and METABOLIC DISORDERS,,Relative Weights,"$8,475.19 ",IP,"8,475.19","8,475.19",,,,,,
Meridian Medicaid,DRG,4053,OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL and METABOLIC DISORDERS,,Relative Weights,"$12,612.79 ",IP,"12,612.79","12,612.79",,,,,,
Meridian Medicaid,DRG,4054,OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL and METABOLIC DISORDERS,,Relative Weights,"$26,164.03 ",IP,"26,164.03","26,164.03",,,,,,
Meridian Medicaid,DRG,4201,DIABETES,,Relative Weights,"$2,259.68 ",IP,"2,259.68","2,259.68",,,,,,
Meridian Medicaid,DRG,4202,DIABETES,,Relative Weights,"$2,723.24 ",IP,"2,723.24","2,723.24",,,,,,
Meridian Medicaid,DRG,4203,DIABETES,,Relative Weights,"$3,776.79 ",IP,"3,776.79","3,776.79",,,,,,
Meridian Medicaid,DRG,4204,DIABETES,,Relative Weights,"$8,028.82 ",IP,"8,028.82","8,028.82",,,,,,
Meridian Medicaid,DRG,4211,MALNUTRITION FAILURE TO THRIVE and OTHER NUTRITIONAL DISORDERS,,Relative Weights,"$2,343.53 ",IP,"2,343.53","2,343.53",,,,,,
Meridian Medicaid,DRG,4212,MALNUTRITION FAILURE TO THRIVE and OTHER NUTRITIONAL DISORDERS,,Relative Weights,"$3,329.74 ",IP,"3,329.74","3,329.74",,,,,,
Meridian Medicaid,DRG,4213,"MALNUTRITION, FAILURE TO THRIVE & OTHER NUTRITIONAL DISORDERS",,Relative Weights,"$5,181.88 ",IP,"5,181.88","5,181.88",,,,,,
Meridian Medicaid,DRG,4214,MALNUTRITION FAILURE TO THRIVE and OTHER NUTRITIONAL DISORDERS,,Relative Weights,"$10,295.72 ",IP,"10,295.72","10,295.72",,,,,,
Meridian Medicaid,DRG,4221,HYPOVOLEMIA and RELATED ELECTROLYTE DISORDERS,,Relative Weights,"$1,870.01 ",IP,"1,870.01","1,870.01",,,,,,
Meridian Medicaid,DRG,4222,HYPOVOLEMIA and RELATED ELECTROLYTE DISORDERS,,Relative Weights,"$2,609.84 ",IP,"2,609.84","2,609.84",,,,,,
Meridian Medicaid,DRG,4223,HYPOVOLEMIA and RELATED ELECTROLYTE DISORDERS,,Relative Weights,"$3,459.28 ",IP,"3,459.28","3,459.28",,,,,,
Meridian Medicaid,DRG,4224,HYPOVOLEMIA and RELATED ELECTROLYTE DISORDERS,,Relative Weights,"$7,038.84 ",IP,"7,038.84","7,038.84",,,,,,
Meridian Medicaid,DRG,4231,INBORN ERRORS OF METABOLISM,,Relative Weights,"$5,529.29 ",IP,"5,529.29","5,529.29",,,,,,
Meridian Medicaid,DRG,4232,INBORN ERRORS OF METABOLISM,,Relative Weights,"$5,948.85 ",IP,"5,948.85","5,948.85",,,,,,
Meridian Medicaid,DRG,4233,INBORN ERRORS OF METABOLISM,,Relative Weights,"$8,447.01 ",IP,"8,447.01","8,447.01",,,,,,
Meridian Medicaid,DRG,4234,INBORN ERRORS OF METABOLISM,,Relative Weights,"$27,194.91 ",IP,"27,194.91","27,194.91",,,,,,
Meridian Medicaid,DRG,4241,OTHER ENDOCRINE DISORDERS,,Relative Weights,"$2,869.62 ",IP,"2,869.62","2,869.62",,,,,,
Meridian Medicaid,DRG,4242,OTHER ENDOCRINE DISORDERS,,Relative Weights,"$3,662.02 ",IP,"3,662.02","3,662.02",,,,,,
Meridian Medicaid,DRG,4243,OTHER ENDOCRINE DISORDERS,,Relative Weights,"$5,028.28 ",IP,"5,028.28","5,028.28",,,,,,
Meridian Medicaid,DRG,4244,OTHER ENDOCRINE DISORDERS,,Relative Weights,"$10,807.73 ",IP,"10,807.73","10,807.73",,,,,,
Meridian Medicaid,DRG,4251,OTHER NONHYPOVOLEMIC ELECTROLYTE DISORDERS,,Relative Weights,"$2,221.89 ",IP,"2,221.89","2,221.89",,,,,,
Meridian Medicaid,DRG,4252,OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS,,Relative Weights,"$2,908.79 ",IP,"2,908.79","2,908.79",,,,,,
Meridian Medicaid,DRG,4253,OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS,,Relative Weights,"$3,943.11 ",IP,"3,943.11","3,943.11",,,,,,
Meridian Medicaid,DRG,4254,OTHER NONHYPOVOLEMIC ELECTROLYTE DISORDERS,,Relative Weights,"$7,662.17 ",IP,"7,662.17","7,662.17",,,,,,
Meridian Medicaid,DRG,4261,NONHYPOVOLEMIC SODIUM DISORDERS,,Relative Weights,"$2,409.16 ",IP,"2,409.16","2,409.16",,,,,,
Meridian Medicaid,DRG,4262,NONHYPOVOLEMIC SODIUM DISORDERS,,Relative Weights,"$2,941.78 ",IP,"2,941.78","2,941.78",,,,,,
Meridian Medicaid,DRG,4263,NON-HYPOVOLEMIC SODIUM DISORDERS,,Relative Weights,"$4,191.21 ",IP,"4,191.21","4,191.21",,,,,,
Meridian Medicaid,DRG,4264,NONHYPOVOLEMIC SODIUM DISORDERS,,Relative Weights,"$8,224.69 ",IP,"8,224.69","8,224.69",,,,,,
Meridian Medicaid,DRG,4271,THYROID DISORDERS,,Relative Weights,"$2,411.91 ",IP,"2,411.91","2,411.91",,,,,,
Meridian Medicaid,DRG,4272,THYROID DISORDERS,,Relative Weights,"$3,208.44 ",IP,"3,208.44","3,208.44",,,,,,
Meridian Medicaid,DRG,4273,THYROID DISORDERS,,Relative Weights,"$4,621.77 ",IP,"4,621.77","4,621.77",,,,,,
Meridian Medicaid,DRG,4274,THYROID DISORDERS,,Relative Weights,"$9,834.92 ",IP,"9,834.92","9,834.92",,,,,,
Meridian Medicaid,DRG,4401,KIDNEY TRANSPLANT,,Relative Weights,"$26,376.39 ",IP,"26,376.39","26,376.39",,,,,,
Meridian Medicaid,DRG,4402,KIDNEY TRANSPLANT,,Relative Weights,"$28,441.58 ",IP,"28,441.58","28,441.58",,,,,,
Meridian Medicaid,DRG,4403,KIDNEY TRANSPLANT,,Relative Weights,"$31,863.75 ",IP,"31,863.75","31,863.75",,,,,,
Meridian Medicaid,DRG,4404,KIDNEY TRANSPLANT,,Relative Weights,"$48,433.40 ",IP,"48,433.40","48,433.40",,,,,,
Meridian Medicaid,DRG,4411,MAJOR BLADDER PROCEDURES,,Relative Weights,"$7,124.74 ",IP,"7,124.74","7,124.74",,,,,,
Meridian Medicaid,DRG,4412,MAJOR BLADDER PROCEDURES,,Relative Weights,"$11,337.94 ",IP,"11,337.94","11,337.94",,,,,,
Meridian Medicaid,DRG,4413,MAJOR BLADDER PROCEDURES,,Relative Weights,"$14,853.23 ",IP,"14,853.23","14,853.23",,,,,,
Meridian Medicaid,DRG,4414,MAJOR BLADDER PROCEDURES,,Relative Weights,"$32,299.47 ",IP,"32,299.47","32,299.47",,,,,,
Meridian Medicaid,DRG,4421,KIDNEY and URINARY TRACT PROCEDURES FOR MALIGNANCY,,Relative Weights,"$7,007.22 ",IP,"7,007.22","7,007.22",,,,,,
Meridian Medicaid,DRG,4422,KIDNEY and URINARY TRACT PROCEDURES FOR MALIGNANCY,,Relative Weights,"$7,784.16 ",IP,"7,784.16","7,784.16",,,,,,
Meridian Medicaid,DRG,4423,KIDNEY & URINARY TRACT PROCEDURES FOR MALIGNANCY,,Relative Weights,"$11,551.33 ",IP,"11,551.33","11,551.33",,,,,,
Meridian Medicaid,DRG,4424,KIDNEY and URINARY TRACT PROCEDURES FOR MALIGNANCY,,Relative Weights,"$20,973.56 ",IP,"20,973.56","20,973.56",,,,,,
Meridian Medicaid,DRG,4431,KIDNEY and URINARY TRACT PROCEDURES FOR NONMALIGNANCY,,Relative Weights,"$5,745.77 ",IP,"5,745.77","5,745.77",,,,,,
Meridian Medicaid,DRG,4432,KIDNEY and URINARY TRACT PROCEDURES FOR NONMALIGNANCY,,Relative Weights,"$6,928.19 ",IP,"6,928.19","6,928.19",,,,,,
Meridian Medicaid,DRG,4433,KIDNEY & URINARY TRACT PROCEDURES FOR NONMALIGNANCY,,Relative Weights,"$10,300.53 ",IP,"10,300.53","10,300.53",,,,,,
Meridian Medicaid,DRG,4434,KIDNEY & URINARY TRACT PROCEDURES FOR NONMALIGNANCY,,Relative Weights,"$21,259.80 ",IP,"21,259.80","21,259.80",,,,,,
Meridian Medicaid,DRG,4441,RENAL DIALYSIS ACCESS DEVICE AND VESSEL REPAIR,,Relative Weights,"$6,643.67 ",IP,"6,643.67","6,643.67",,,,,,
Meridian Medicaid,DRG,4442,RENAL DIALYSIS ACCESS DEVICE AND VESSEL REPAIR,,Relative Weights,"$8,351.49 ",IP,"8,351.49","8,351.49",,,,,,
Meridian Medicaid,DRG,4443,RENAL DIALYSIS ACCESS DEVICE AND VESSEL REPAIR,,Relative Weights,"$12,840.62 ",IP,"12,840.62","12,840.62",,,,,,
Meridian Medicaid,DRG,4444,RENAL DIALYSIS ACCESS DEVICE AND VESSEL REPAIR,,Relative Weights,"$25,251.70 ",IP,"25,251.70","25,251.70",,,,,,
Meridian Medicaid,DRG,4451,OTHER BLADDER PROCEDURES,,Relative Weights,"$4,867.46 ",IP,"4,867.46","4,867.46",,,,,,
Meridian Medicaid,DRG,4452,OTHER BLADDER PROCEDURES,,Relative Weights,"$6,607.93 ",IP,"6,607.93","6,607.93",,,,,,
Meridian Medicaid,DRG,4453,OTHER BLADDER PROCEDURES,,Relative Weights,"$8,634.63 ",IP,"8,634.63","8,634.63",,,,,,
Meridian Medicaid,DRG,4454,OTHER BLADDER PROCEDURES,,Relative Weights,"$17,913.22 ",IP,"17,913.22","17,913.22",,,,,,
Meridian Medicaid,DRG,4461,URETHRAL & TRANSURETHRAL PROCEDURES,,Relative Weights,"$4,096.37 ",IP,"4,096.37","4,096.37",,,,,,
Meridian Medicaid,DRG,4462,URETHRAL & TRANSURETHRAL PROCEDURES,,Relative Weights,"$5,093.91 ",IP,"5,093.91","5,093.91",,,,,,
Meridian Medicaid,DRG,4463,URETHRAL and TRANSURETHRAL PROCEDURES,,Relative Weights,"$7,454.97 ",IP,"7,454.97","7,454.97",,,,,,
Meridian Medicaid,DRG,4464,URETHRAL and TRANSURETHRAL PROCEDURES,,Relative Weights,"$15,279.67 ",IP,"15,279.67","15,279.67",,,,,,
Meridian Medicaid,DRG,4471,OTHER KIDNEY URINARY TRACT and RELATED PROCEDURES,,Relative Weights,"$6,383.54 ",IP,"6,383.54","6,383.54",,,,,,
Meridian Medicaid,DRG,4472,"OTHER KIDNEY, URINARY TRACT & RELATED PROCEDURES",,Relative Weights,"$7,988.27 ",IP,"7,988.27","7,988.27",,,,,,
Meridian Medicaid,DRG,4473,OTHER KIDNEY URINARY TRACT and RELATED PROCEDURES,,Relative Weights,"$11,578.48 ",IP,"11,578.48","11,578.48",,,,,,
Meridian Medicaid,DRG,4474,OTHER KIDNEY URINARY TRACT and RELATED PROCEDURES,,Relative Weights,"$26,335.15 ",IP,"26,335.15","26,335.15",,,,,,
Meridian Medicaid,DRG,4611,KIDNEY and URINARY TRACT MALIGNANCY,,Relative Weights,"$4,213.89 ",IP,"4,213.89","4,213.89",,,,,,
Meridian Medicaid,DRG,4612,KIDNEY and URINARY TRACT MALIGNANCY,,Relative Weights,"$4,354.09 ",IP,"4,354.09","4,354.09",,,,,,
Meridian Medicaid,DRG,4613,KIDNEY and URINARY TRACT MALIGNANCY,,Relative Weights,"$5,833.40 ",IP,"5,833.40","5,833.40",,,,,,
Meridian Medicaid,DRG,4614,KIDNEY & URINARY TRACT MALIGNANCY,,Relative Weights,"$10,495.71 ",IP,"10,495.71","10,495.71",,,,,,
Meridian Medicaid,DRG,4621,NEPHRITIS and NEPHROSIS,,Relative Weights,"$2,361.40 ",IP,"2,361.40","2,361.40",,,,,,
Meridian Medicaid,DRG,4622,NEPHRITIS and NEPHROSIS,,Relative Weights,"$3,007.07 ",IP,"3,007.07","3,007.07",,,,,,
Meridian Medicaid,DRG,4623,NEPHRITIS and NEPHROSIS,,Relative Weights,"$5,343.04 ",IP,"5,343.04","5,343.04",,,,,,
Meridian Medicaid,DRG,4624,NEPHRITIS and NEPHROSIS,,Relative Weights,"$14,645.34 ",IP,"14,645.34","14,645.34",,,,,,
Meridian Medicaid,DRG,4631,KIDNEY and URINARY TRACT INFECTIONS,,Relative Weights,"$2,386.48 ",IP,"2,386.48","2,386.48",,,,,,
Meridian Medicaid,DRG,4632,KIDNEY and URINARY TRACT INFECTIONS,,Relative Weights,"$2,925.29 ",IP,"2,925.29","2,925.29",,,,,,
Meridian Medicaid,DRG,4633,KIDNEY and URINARY TRACT INFECTIONS,,Relative Weights,"$3,755.49 ",IP,"3,755.49","3,755.49",,,,,,
Meridian Medicaid,DRG,4634,KIDNEY and URINARY TRACT INFECTIONS,,Relative Weights,"$6,746.75 ",IP,"6,746.75","6,746.75",,,,,,
Meridian Medicaid,DRG,4651,URINARY STONES & ACQUIRED UPPER URINARY TRACT OBSTRUCTION,,Relative Weights,"$2,676.16 ",IP,"2,676.16","2,676.16",,,,,,
Meridian Medicaid,DRG,4652,URINARY STONES and ACQUIRED UPPER URINARY TRACT OBSTRUCTION,,Relative Weights,"$3,212.22 ",IP,"3,212.22","3,212.22",,,,,,
Meridian Medicaid,DRG,4653,URINARY STONES and ACQUIRED UPPER URINARY TRACT OBSTRUCTION,,Relative Weights,"$4,385.36 ",IP,"4,385.36","4,385.36",,,,,,
Meridian Medicaid,DRG,4654,URINARY STONES and ACQUIRED UPPER URINARY TRACT OBSTRUCTION,,Relative Weights,"$8,949.40 ",IP,"8,949.40","8,949.40",,,,,,
Meridian Medicaid,DRG,4661,"MALFUNCTION, REACTION, COMPLIC OF GENITOURINARY DEVICE OR PROC",,Relative Weights,"$2,602.62 ",IP,"2,602.62","2,602.62",,,,,,
Meridian Medicaid,DRG,4662,"MALFUNCTION, REACTION, COMPLIC OF GENITOURINARY DEVICE OR PROC",,Relative Weights,"$3,336.61 ",IP,"3,336.61","3,336.61",,,,,,
Meridian Medicaid,DRG,4663,MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC,,Relative Weights,"$4,821.07 ",IP,"4,821.07","4,821.07",,,,,,
Meridian Medicaid,DRG,4664,MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC,,Relative Weights,"$8,281.73 ",IP,"8,281.73","8,281.73",,,,,,
Meridian Medicaid,DRG,4681,OTHER KIDNEY and URINARY TRACT DIAGNOSES SIGNS and SYMPTOMS,,Relative Weights,"$2,645.58 ",IP,"2,645.58","2,645.58",,,,,,
Meridian Medicaid,DRG,4682,OTHER KIDNEY and URINARY TRACT DIAGNOSES SIGNS and SYMPTOMS,,Relative Weights,"$3,341.08 ",IP,"3,341.08","3,341.08",,,,,,
Meridian Medicaid,DRG,4683,"OTHER KIDNEY & URINARY TRACT DIAGNOSES, SIGNS & SYMPTOMS",,Relative Weights,"$4,559.92 ",IP,"4,559.92","4,559.92",,,,,,
Meridian Medicaid,DRG,4684,OTHER KIDNEY and URINARY TRACT DIAGNOSES SIGNS and SYMPTOMS,,Relative Weights,"$9,588.20 ",IP,"9,588.20","9,588.20",,,,,,
Meridian Medicaid,DRG,4691,ACUTE KIDNEY INJURY,,Relative Weights,"$2,379.95 ",IP,"2,379.95","2,379.95",,,,,,
Meridian Medicaid,DRG,4692,ACUTE KIDNEY INJURY,,Relative Weights,"$3,050.71 ",IP,"3,050.71","3,050.71",,,,,,
Meridian Medicaid,DRG,4693,ACUTE KIDNEY INJURY,,Relative Weights,"$4,563.35 ",IP,"4,563.35","4,563.35",,,,,,
Meridian Medicaid,DRG,4694,ACUTE KIDNEY INJURY,,Relative Weights,"$9,568.95 ",IP,"9,568.95","9,568.95",,,,,,
Meridian Medicaid,DRG,4701,CHRONIC KIDNEY DISEASE,,Relative Weights,"$2,503.66 ",IP,"2,503.66","2,503.66",,,,,,
Meridian Medicaid,DRG,4702,CHRONIC KIDNEY DISEASE,,Relative Weights,"$3,283.35 ",IP,"3,283.35","3,283.35",,,,,,
Meridian Medicaid,DRG,4703,CHRONIC KIDNEY DISEASE,,Relative Weights,"$4,530.02 ",IP,"4,530.02","4,530.02",,,,,,
Meridian Medicaid,DRG,4704,CHRONIC KIDNEY DISEASE,,Relative Weights,"$8,193.42 ",IP,"8,193.42","8,193.42",,,,,,
Meridian Medicaid,DRG,4801,MAJOR MALE PELVIC PROCEDURES,,Relative Weights,"$6,131.66 ",IP,"6,131.66","6,131.66",,,,,,
Meridian Medicaid,DRG,4802,MAJOR MALE PELVIC PROCEDURES,,Relative Weights,"$6,485.60 ",IP,"6,485.60","6,485.60",,,,,,
Meridian Medicaid,DRG,4803,MAJOR MALE PELVIC PROCEDURES,,Relative Weights,"$10,188.85 ",IP,"10,188.85","10,188.85",,,,,,
Meridian Medicaid,DRG,4804,MAJOR MALE PELVIC PROCEDURES,,Relative Weights,"$21,900.66 ",IP,"21,900.66","21,900.66",,,,,,
Meridian Medicaid,DRG,4821,TRANSURETHRAL PROSTATECTOMY,,Relative Weights,"$4,027.30 ",IP,"4,027.30","4,027.30",,,,,,
Meridian Medicaid,DRG,4822,TRANSURETHRAL PROSTATECTOMY,,Relative Weights,"$4,459.58 ",IP,"4,459.58","4,459.58",,,,,,
Meridian Medicaid,DRG,4823,TRANSURETHRAL PROSTATECTOMY,,Relative Weights,"$7,759.08 ",IP,"7,759.08","7,759.08",,,,,,
Meridian Medicaid,DRG,4824,TRANSURETHRAL PROSTATECTOMY,,Relative Weights,"$15,069.03 ",IP,"15,069.03","15,069.03",,,,,,
Meridian Medicaid,DRG,4831,PENIS TESTES and SCROTAL PROCEDURES,,Relative Weights,"$5,523.10 ",IP,"5,523.10","5,523.10",,,,,,
Meridian Medicaid,DRG,4832,PENIS TESTES and SCROTAL PROCEDURES,,Relative Weights,"$6,593.84 ",IP,"6,593.84","6,593.84",,,,,,
Meridian Medicaid,DRG,4833,PENIS TESTES and SCROTAL PROCEDURES,,Relative Weights,"$8,503.71 ",IP,"8,503.71","8,503.71",,,,,,
Meridian Medicaid,DRG,4834,PENIS TESTES and SCROTAL PROCEDURES,,Relative Weights,"$16,764.14 ",IP,"16,764.14","16,764.14",,,,,,
Meridian Medicaid,DRG,4841,OTHER MALE REPRODUCTIVE SYSTEM and RELATED PROCEDURES,,Relative Weights,"$6,414.47 ",IP,"6,414.47","6,414.47",,,,,,
Meridian Medicaid,DRG,4842,OTHER MALE REPRODUCTIVE SYSTEM and RELATED PROCEDURES,,Relative Weights,"$6,893.48 ",IP,"6,893.48","6,893.48",,,,,,
Meridian Medicaid,DRG,4843,OTHER MALE REPRODUCTIVE SYSTEM and RELATED PROCEDURES,,Relative Weights,"$7,922.98 ",IP,"7,922.98","7,922.98",,,,,,
Meridian Medicaid,DRG,4844,OTHER MALE REPRODUCTIVE SYSTEM and RELATED PROCEDURES,,Relative Weights,"$22,148.41 ",IP,"22,148.41","22,148.41",,,,,,
Meridian Medicaid,DRG,5001,MALIGNANCY MALE REPRODUCTIVE SYSTEM,,Relative Weights,"$3,471.31 ",IP,"3,471.31","3,471.31",,,,,,
Meridian Medicaid,DRG,5002,MALIGNANCY MALE REPRODUCTIVE SYSTEM,,Relative Weights,"$3,960.98 ",IP,"3,960.98","3,960.98",,,,,,
Meridian Medicaid,DRG,5003,"MALIGNANCY, MALE REPRODUCTIVE SYSTEM",,Relative Weights,"$5,381.18 ",IP,"5,381.18","5,381.18",,,,,,
Meridian Medicaid,DRG,5004,MALIGNANCY MALE REPRODUCTIVE SYSTEM,,Relative Weights,"$8,653.88 ",IP,"8,653.88","8,653.88",,,,,,
Meridian Medicaid,DRG,5011,MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,,Relative Weights,"$2,269.65 ",IP,"2,269.65","2,269.65",,,,,,
Meridian Medicaid,DRG,5012,MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,,Relative Weights,"$2,988.52 ",IP,"2,988.52","2,988.52",,,,,,
Meridian Medicaid,DRG,5013,MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,,Relative Weights,"$4,126.95 ",IP,"4,126.95","4,126.95",,,,,,
Meridian Medicaid,DRG,5014,MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,,Relative Weights,"$8,519.52 ",IP,"8,519.52","8,519.52",,,,,,
Meridian Medicaid,DRG,5101,PELVIC EVISCERATION RADICAL HYSTERECTOMY and OTHER RADICAL GYN PROCS,,Relative Weights,"$6,667.03 ",IP,"6,667.03","6,667.03",,,,,,
Meridian Medicaid,DRG,5102,PELVIC EVISCERATION RADICAL HYSTERECTOMY and OTHER RADICAL GYN PROCS,,Relative Weights,"$7,636.06 ",IP,"7,636.06","7,636.06",,,,,,
Meridian Medicaid,DRG,5103,"PELVIC EVISCERATION, RADICAL HYSTERECTOMY & OTHER RADICAL GYN PROCS",,Relative Weights,"$12,159.55 ",IP,"12,159.55","12,159.55",,,,,,
Meridian Medicaid,DRG,5104,PELVIC EVISCERATION RADICAL HYSTERECTOMY and OTHER RADICAL GYN PROCS,,Relative Weights,"$22,308.54 ",IP,"22,308.54","22,308.54",,,,,,
Meridian Medicaid,DRG,5111,UTERINE and ADNEXA PROCEDURES FOR OVARIAN and ADNEXAL MALIGNANCY,,Relative Weights,"$6,477.69 ",IP,"6,477.69","6,477.69",,,,,,
Meridian Medicaid,DRG,5112,UTERINE and ADNEXA PROCEDURES FOR OVARIAN and ADNEXAL MALIGNANCY,,Relative Weights,"$7,830.89 ",IP,"7,830.89","7,830.89",,,,,,
Meridian Medicaid,DRG,5113,UTERINE & ADNEXA PROCEDURES FOR OVARIAN & ADNEXAL MALIGNANCY,,Relative Weights,"$10,746.90 ",IP,"10,746.90","10,746.90",,,,,,
Meridian Medicaid,DRG,5114,UTERINE & ADNEXA PROCEDURES FOR OVARIAN & ADNEXAL MALIGNANCY,,Relative Weights,"$23,120.88 ",IP,"23,120.88","23,120.88",,,,,,
Meridian Medicaid,DRG,5121,UTERINE and ADNEXA PROCEDURES FOR NONOVARIAN and NONADNEXAL MALIG,,Relative Weights,"$6,341.62 ",IP,"6,341.62","6,341.62",,,,,,
Meridian Medicaid,DRG,5122,UTERINE and ADNEXA PROCEDURES FOR NONOVARIAN and NONADNEXAL MALIG,,Relative Weights,"$7,038.84 ",IP,"7,038.84","7,038.84",,,,,,
Meridian Medicaid,DRG,5123,UTERINE and ADNEXA PROCEDURES FOR NONOVARIAN and NONADNEXAL MALIG,,Relative Weights,"$9,937.66 ",IP,"9,937.66","9,937.66",,,,,,
Meridian Medicaid,DRG,5124,UTERINE & ADNEXA PROCEDURES FOR NON-OVARIAN & NON-ADNEXAL MALIG,,Relative Weights,"$20,453.99 ",IP,"20,453.99","20,453.99",,,,,,
Meridian Medicaid,DRG,5131,UTERINE & ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA,,Relative Weights,"$4,384.67 ",IP,"4,384.67","4,384.67",,,,,,
Meridian Medicaid,DRG,5132,UTERINE and ADNEXA PROCEDURES FOR NONMALIGNANCY EXCEPT LEIOMYOMA,,Relative Weights,"$5,107.31 ",IP,"5,107.31","5,107.31",,,,,,
Meridian Medicaid,DRG,5133,UTERINE and ADNEXA PROCEDURES FOR NONMALIGNANCY EXCEPT LEIOMYOMA,,Relative Weights,"$8,107.86 ",IP,"8,107.86","8,107.86",,,,,,
Meridian Medicaid,DRG,5134,UTERINE and ADNEXA PROCEDURES FOR NONMALIGNANCY EXCEPT LEIOMYOMA,,Relative Weights,"$16,632.53 ",IP,"16,632.53","16,632.53",,,,,,
Meridian Medicaid,DRG,5141,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,,Relative Weights,"$3,945.51 ",IP,"3,945.51","3,945.51",,,,,,
Meridian Medicaid,DRG,5142,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,,Relative Weights,"$5,893.19 ",IP,"5,893.19","5,893.19",,,,,,
Meridian Medicaid,DRG,5143,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,,Relative Weights,"$10,581.96 ",IP,"10,581.96","10,581.96",,,,,,
Meridian Medicaid,DRG,5144,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,,Relative Weights,"$22,849.41 ",IP,"22,849.41","22,849.41",,,,,,
Meridian Medicaid,DRG,5171,DILATION and CURETTAGE FOR NONOBSTETRIC DIAGNOSES,,Relative Weights,"$3,258.61 ",IP,"3,258.61","3,258.61",,,,,,
Meridian Medicaid,DRG,5172,DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES,,Relative Weights,"$4,494.28 ",IP,"4,494.28","4,494.28",,,,,,
Meridian Medicaid,DRG,5173,DILATION and CURETTAGE FOR NONOBSTETRIC DIAGNOSES,,Relative Weights,"$6,942.62 ",IP,"6,942.62","6,942.62",,,,,,
Meridian Medicaid,DRG,5174,DILATION and CURETTAGE FOR NONOBSTETRIC DIAGNOSES,,Relative Weights,"$14,767.33 ",IP,"14,767.33","14,767.33",,,,,,
Meridian Medicaid,DRG,5181,OTHER FEMALE REPRODUCTIVE SYSTEM and RELATED PROCEDURES,,Relative Weights,"$4,123.51 ",IP,"4,123.51","4,123.51",,,,,,
Meridian Medicaid,DRG,5182,OTHER FEMALE REPRODUCTIVE SYSTEM & RELATED PROCEDURES,,Relative Weights,"$5,436.16 ",IP,"5,436.16","5,436.16",,,,,,
Meridian Medicaid,DRG,5183,OTHER FEMALE REPRODUCTIVE SYSTEM & RELATED PROCEDURES,,Relative Weights,"$9,420.16 ",IP,"9,420.16","9,420.16",,,,,,
Meridian Medicaid,DRG,5184,OTHER FEMALE REPRODUCTIVE SYSTEM and RELATED PROCEDURES,,Relative Weights,"$21,115.47 ",IP,"21,115.47","21,115.47",,,,,,
Meridian Medicaid,DRG,5191,UTERINE and ADNEXA PROCEDURES FOR LEIOMYOMA,,Relative Weights,"$3,160.33 ",IP,"3,160.33","3,160.33",,,,,,
Meridian Medicaid,DRG,5192,UTERINE and ADNEXA PROCEDURES FOR LEIOMYOMA,,Relative Weights,"$3,849.30 ",IP,"3,849.30","3,849.30",,,,,,
Meridian Medicaid,DRG,5193,UTERINE & ADNEXA PROCEDURES FOR LEIOMYOMA,,Relative Weights,"$7,527.81 ",IP,"7,527.81","7,527.81",,,,,,
Meridian Medicaid,DRG,5194,UTERINE and ADNEXA PROCEDURES FOR LEIOMYOMA,,Relative Weights,"$15,622.96 ",IP,"15,622.96","15,622.96",,,,,,
Meridian Medicaid,DRG,5301,FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,,Relative Weights,"$3,382.31 ",IP,"3,382.31","3,382.31",,,,,,
Meridian Medicaid,DRG,5302,FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,,Relative Weights,"$3,815.97 ",IP,"3,815.97","3,815.97",,,,,,
Meridian Medicaid,DRG,5303,FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,,Relative Weights,"$5,327.23 ",IP,"5,327.23","5,327.23",,,,,,
Meridian Medicaid,DRG,5304,FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,,Relative Weights,"$9,039.08 ",IP,"9,039.08","9,039.08",,,,,,
Meridian Medicaid,DRG,5311,FEMALE REPRODUCTIVE SYSTEM INFECTIONS,,Relative Weights,"$2,096.46 ",IP,"2,096.46","2,096.46",,,,,,
Meridian Medicaid,DRG,5312,FEMALE REPRODUCTIVE SYSTEM INFECTIONS,,Relative Weights,"$2,868.93 ",IP,"2,868.93","2,868.93",,,,,,
Meridian Medicaid,DRG,5313,FEMALE REPRODUCTIVE SYSTEM INFECTIONS,,Relative Weights,"$4,503.56 ",IP,"4,503.56","4,503.56",,,,,,
Meridian Medicaid,DRG,5314,FEMALE REPRODUCTIVE SYSTEM INFECTIONS,,Relative Weights,"$9,958.97 ",IP,"9,958.97","9,958.97",,,,,,
Meridian Medicaid,DRG,5321,MENSTRUAL and OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,,Relative Weights,"$2,302.29 ",IP,"2,302.29","2,302.29",,,,,,
Meridian Medicaid,DRG,5322,MENSTRUAL and OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,,Relative Weights,"$2,696.78 ",IP,"2,696.78","2,696.78",,,,,,
Meridian Medicaid,DRG,5323,MENSTRUAL and OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,,Relative Weights,"$4,143.44 ",IP,"4,143.44","4,143.44",,,,,,
Meridian Medicaid,DRG,5324,MENSTRUAL and OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,,Relative Weights,"$9,044.24 ",IP,"9,044.24","9,044.24",,,,,,
Meridian Medicaid,DRG,5401,CESAREAN DELIVERY,,Relative Weights,"$2,493.69 ",IP,"2,493.69","2,493.69",,,,,,
Meridian Medicaid,DRG,5402,CESAREAN DELIVERY,,Relative Weights,"$2,909.48 ",IP,"2,909.48","2,909.48",,,,,,
Meridian Medicaid,DRG,5403,CESAREAN DELIVERY,,Relative Weights,"$4,140.35 ",IP,"4,140.35","4,140.35",,,,,,
Meridian Medicaid,DRG,5404,CESAREAN DELIVERY,,Relative Weights,"$8,525.02 ",IP,"8,525.02","8,525.02",,,,,,
Meridian Medicaid,DRG,5411,VAGINAL DELIVERY W STERILIZATION &/OR D&C,,Relative Weights,"$2,683.03 ",IP,"2,683.03","2,683.03",,,,,,
Meridian Medicaid,DRG,5412,VAGINAL DELIVERY W STERILIZATION andOR DandC,,Relative Weights,"$2,694.03 ",IP,"2,694.03","2,694.03",,,,,,
Meridian Medicaid,DRG,5413,VAGINAL DELIVERY W STERILIZATION andOR DandC,,Relative Weights,"$3,800.85 ",IP,"3,800.85","3,800.85",,,,,,
Meridian Medicaid,DRG,5414,VAGINAL DELIVERY W STERILIZATION andOR DandC,,Relative Weights,"$9,356.59 ",IP,"9,356.59","9,356.59",,,,,,
Meridian Medicaid,DRG,5421,VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION &/OR D&C,,Relative Weights,"$1,729.81 ",IP,"1,729.81","1,729.81",,,,,,
Meridian Medicaid,DRG,5422,VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION andOR DandC,,Relative Weights,"$1,962.10 ",IP,"1,962.10","1,962.10",,,,,,
Meridian Medicaid,DRG,5423,VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION andOR DandC,,Relative Weights,"$2,979.24 ",IP,"2,979.24","2,979.24",,,,,,
Meridian Medicaid,DRG,5424,VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION andOR DandC,,Relative Weights,"$11,346.53 ",IP,"11,346.53","11,346.53",,,,,,
Meridian Medicaid,DRG,5441,DandC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES,,Relative Weights,"$1,946.30 ",IP,"1,946.30","1,946.30",,,,,,
Meridian Medicaid,DRG,5442,"D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES",,Relative Weights,"$2,595.06 ",IP,"2,595.06","2,595.06",,,,,,
Meridian Medicaid,DRG,5443,"D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES",,Relative Weights,"$3,856.51 ",IP,"3,856.51","3,856.51",,,,,,
Meridian Medicaid,DRG,5444,DandC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES,,Relative Weights,"$14,310.30 ",IP,"14,310.30","14,310.30",,,,,,
Meridian Medicaid,DRG,5451,ECTOPIC PREGNANCY PROCEDURE,,Relative Weights,"$2,785.09 ",IP,"2,785.09","2,785.09",,,,,,
Meridian Medicaid,DRG,5452,ECTOPIC PREGNANCY PROCEDURE,,Relative Weights,"$3,114.63 ",IP,"3,114.63","3,114.63",,,,,,
Meridian Medicaid,DRG,5453,ECTOPIC PREGNANCY PROCEDURE,,Relative Weights,"$3,214.96 ",IP,"3,214.96","3,214.96",,,,,,
Meridian Medicaid,DRG,5454,ECTOPIC PREGNANCY PROCEDURE,,Relative Weights,"$4,812.48 ",IP,"4,812.48","4,812.48",,,,,,
Meridian Medicaid,DRG,5461,OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES,,Relative Weights,"$2,385.45 ",IP,"2,385.45","2,385.45",,,,,,
Meridian Medicaid,DRG,5462,OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES,,Relative Weights,"$4,587.41 ",IP,"4,587.41","4,587.41",,,,,,
Meridian Medicaid,DRG,5463,OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES,,Relative Weights,"$5,857.79 ",IP,"5,857.79","5,857.79",,,,,,
Meridian Medicaid,DRG,5464,OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES,,Relative Weights,"$11,895.30 ",IP,"11,895.30","11,895.30",,,,,,
Meridian Medicaid,DRG,5601,VAGINAL DELIVERY,VAGINAL DELIVERY,Relative Weights,"$1,539.10 ",IP,"1,539.10","1,539.10",,,,,,
Meridian Medicaid,DRG,5602,VAGINAL DELIVERY,VAGINAL DELIVERY,Relative Weights,"$1,659.37 ",IP,"1,659.37","1,659.37",,,,,,
Meridian Medicaid,DRG,5603,VAGINAL DELIVERY,VAGINAL DELIVERY,Relative Weights,"$2,337.34 ",IP,"2,337.34","2,337.34",,,,,,
Meridian Medicaid,DRG,5604,VAGINAL DELIVERY,VAGINAL DELIVERY,Relative Weights,"$4,292.23 ",IP,"4,292.23","4,292.23",,,,,,
Meridian Medicaid,DRG,5611,POSTPARTUM and POST ABORTION DIAGNOSES WO PROCEDURE,,Relative Weights,"$1,236.71 ",IP,"1,236.71","1,236.71",,,,,,
Meridian Medicaid,DRG,5612,POSTPARTUM and POST ABORTION DIAGNOSES WO PROCEDURE,,Relative Weights,"$1,778.26 ",IP,"1,778.26","1,778.26",,,,,,
Meridian Medicaid,DRG,5613,POSTPARTUM and POST ABORTION DIAGNOSES WO PROCEDURE,,Relative Weights,"$2,747.29 ",IP,"2,747.29","2,747.29",,,,,,
Meridian Medicaid,DRG,5614,POSTPARTUM and POST ABORTION DIAGNOSES WO PROCEDURE,,Relative Weights,"$5,898.34 ",IP,"5,898.34","5,898.34",,,,,,
Meridian Medicaid,DRG,5631,PRETERM LABOR,,Relative Weights,"$1,387.56 ",IP,"1,387.56","1,387.56",,,,,,
Meridian Medicaid,DRG,5632,PRETERM LABOR,,Relative Weights,"$1,719.85 ",IP,"1,719.85","1,719.85",,,,,,
Meridian Medicaid,DRG,5633,PRETERM LABOR,,Relative Weights,"$2,634.92 ",IP,"2,634.92","2,634.92",,,,,,
Meridian Medicaid,DRG,5634,PRETERM LABOR,,Relative Weights,"$4,637.23 ",IP,"4,637.23","4,637.23",,,,,,
Meridian Medicaid,DRG,5641,ABORTION WO DandC ASPIRATION CURETTAGE OR HYSTEROTOMY,,Relative Weights,"$1,463.85 ",IP,"1,463.85","1,463.85",,,,,,
Meridian Medicaid,DRG,5642,"ABORTION W/O D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",,Relative Weights,"$1,520.55 ",IP,"1,520.55","1,520.55",,,,,,
Meridian Medicaid,DRG,5643,"ABORTION W/O D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",,Relative Weights,"$2,435.62 ",IP,"2,435.62","2,435.62",,,,,,
Meridian Medicaid,DRG,5644,ABORTION WO DandC ASPIRATION CURETTAGE OR HYSTEROTOMY,,Relative Weights,"$3,935.55 ",IP,"3,935.55","3,935.55",,,,,,
Meridian Medicaid,DRG,5651,FALSE LABOR,FALSE LABOR,Relative Weights,$992.39 ,IP,992.39,992.39,,,,,,
Meridian Medicaid,DRG,5652,FALSE LABOR,FALSE LABOR,Relative Weights,"$1,254.23 ",IP,"1,254.23","1,254.23",,,,,,
Meridian Medicaid,DRG,5653,FALSE LABOR,FALSE LABOR,Relative Weights,"$2,123.61 ",IP,"2,123.61","2,123.61",,,,,,
Meridian Medicaid,DRG,5654,FALSE LABOR,FALSE LABOR,Relative Weights,"$2,123.61 ",IP,"2,123.61","2,123.61",,,,,,
Meridian Medicaid,DRG,5661,OTHER ANTEPARTUM DIAGNOSES,,Relative Weights,"$1,462.82 ",IP,"1,462.82","1,462.82",,,,,,
Meridian Medicaid,DRG,5662,OTHER ANTEPARTUM DIAGNOSES,,Relative Weights,"$1,906.44 ",IP,"1,906.44","1,906.44",,,,,,
Meridian Medicaid,DRG,5663,OTHER ANTEPARTUM DIAGNOSES,,Relative Weights,"$2,718.08 ",IP,"2,718.08","2,718.08",,,,,,
Meridian Medicaid,DRG,5664,OTHER ANTEPARTUM DIAGNOSES,,Relative Weights,"$5,715.19 ",IP,"5,715.19","5,715.19",,,,,,
Meridian Medicaid,DRG,5801,NEONATE TRANSFERRED 5 DAYS OLD NOT BORN HERE,,Relative Weights,"$1,625.35 ",IP,"1,625.35","1,625.35",,,,,,
Meridian Medicaid,DRG,5802,NEONATE TRANSFERRED 5 DAYS OLD NOT BORN HERE,,Relative Weights,"$2,301.61 ",IP,"2,301.61","2,301.61",,,,,,
Meridian Medicaid,DRG,5803,NEONATE TRANSFERRED 5 DAYS OLD NOT BORN HERE,,Relative Weights,"$3,477.84 ",IP,"3,477.84","3,477.84",,,,,,
Meridian Medicaid,DRG,5804,NEONATE TRANSFERRED 5 DAYS OLD NOT BORN HERE,,Relative Weights,"$6,537.48 ",IP,"6,537.48","6,537.48",,,,,,
Meridian Medicaid,DRG,5811,NEONATE TRANSFERRED  5 DAYS OLD BORN HERE,,Relative Weights,$559.42 ,IP,559.42,559.42,,,,,,
Meridian Medicaid,DRG,5812,NEONATE TRANSFERRED  5 DAYS OLD BORN HERE,,Relative Weights,$716.80 ,IP,716.8,716.8,,,,,,
Meridian Medicaid,DRG,5813,NEONATE TRANSFERRED  5 DAYS OLD BORN HERE,,Relative Weights,"$1,204.41 ",IP,"1,204.41","1,204.41",,,,,,
Meridian Medicaid,DRG,5814,NEONATE TRANSFERRED  5 DAYS OLD BORN HERE,,Relative Weights,"$2,109.52 ",IP,"2,109.52","2,109.52",,,,,,
Meridian Medicaid,DRG,5831,NEONATE W ECMO,,Relative Weights,"$87,271.04 ",IP,"87,271.04","87,271.04",,,,,,
Meridian Medicaid,DRG,5832,NEONATE W ECMO,,Relative Weights,"$87,459.00 ",IP,"87,459.00","87,459.00",,,,,,
Meridian Medicaid,DRG,5833,NEONATE W ECMO,,Relative Weights,"$148,358.12 ",IP,"148,358.12","148,358.12",,,,,,
Meridian Medicaid,DRG,5834,NEONATE W ECMO,,Relative Weights,"$163,193.83 ",IP,"163,193.83","163,193.83",,,,,,
Meridian Medicaid,DRG,5881,NEONATE BWT <1500G W MAJOR PROCEDURE,,Relative Weights,"$67,852.39 ",IP,"67,852.39","67,852.39",,,,,,
Meridian Medicaid,DRG,5882,NEONATE BWT <1500G W MAJOR PROCEDURE,,Relative Weights,"$75,391.54 ",IP,"75,391.54","75,391.54",,,,,,
Meridian Medicaid,DRG,5883,NEONATE BWT 1500G W MAJOR PROCEDURE,,Relative Weights,"$83,636.16 ",IP,"83,636.16","83,636.16",,,,,,
Meridian Medicaid,DRG,5884,NEONATE BWT 1500G W MAJOR PROCEDURE,,Relative Weights,"$133,619.66 ",IP,"133,619.66","133,619.66",,,,,,
Meridian Medicaid,DRG,5891,NEONATE BWT 500G OR GA 24 WEEKS,,Relative Weights,"$98,896.59 ",IP,"98,896.59","98,896.59",,,,,,
Meridian Medicaid,DRG,5892,NEONATE BWT 500G OR GA 24 WEEKS,,Relative Weights,"$69,370.87 ",IP,"69,370.87","69,370.87",,,,,,
Meridian Medicaid,DRG,5893,NEONATE BWT 500G OR GA 24 WEEKS,,Relative Weights,"$63,064.65 ",IP,"63,064.65","63,064.65",,,,,,
Meridian Medicaid,DRG,5894,NEONATE BWT <500G OR GA <24 WEEKS,,Relative Weights,"$11,889.12 ",IP,"11,889.12","11,889.12",,,,,,
Meridian Medicaid,DRG,5911,NEONATE BIRTHWT 500749G WO MAJOR PROCEDURE,,Relative Weights,"$57,344.65 ",IP,"57,344.65","57,344.65",,,,,,
Meridian Medicaid,DRG,5912,NEONATE BIRTHWT 500749G WO MAJOR PROCEDURE,,Relative Weights,"$79,559.04 ",IP,"79,559.04","79,559.04",,,,,,
Meridian Medicaid,DRG,5913,NEONATE BIRTHWT 500749G WO MAJOR PROCEDURE,,Relative Weights,"$85,488.65 ",IP,"85,488.65","85,488.65",,,,,,
Meridian Medicaid,DRG,5914,NEONATE BIRTHWT 500-749G W/O MAJOR PROCEDURE,,Relative Weights,"$110,417.00 ",IP,"110,417.00","110,417.00",,,,,,
Meridian Medicaid,DRG,5931,NEONATE BIRTHWT 750-999G W/O MAJOR PROCEDURE,,Relative Weights,"$37,781.34 ",IP,"37,781.34","37,781.34",,,,,,
Meridian Medicaid,DRG,5932,NEONATE BIRTHWT 750999G WO MAJOR PROCEDURE,,Relative Weights,"$59,330.12 ",IP,"59,330.12","59,330.12",,,,,,
Meridian Medicaid,DRG,5933,NEONATE BIRTHWT 750999G WO MAJOR PROCEDURE,,Relative Weights,"$71,323.01 ",IP,"71,323.01","71,323.01",,,,,,
Meridian Medicaid,DRG,5934,NEONATE BIRTHWT 750999G WO MAJOR PROCEDURE,,Relative Weights,"$96,423.52 ",IP,"96,423.52","96,423.52",,,,,,
Meridian Medicaid,DRG,6021,NEONATE BWT 10001249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$36,367.31 ",IP,"36,367.31","36,367.31",,,,,,
Meridian Medicaid,DRG,6022,NEONATE BWT 10001249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$43,081.42 ",IP,"43,081.42","43,081.42",,,,,,
Meridian Medicaid,DRG,6023,NEONATE BWT 10001249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$56,708.94 ",IP,"56,708.94","56,708.94",,,,,,
Meridian Medicaid,DRG,6024,NEONATE BWT 10001249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$82,218.02 ",IP,"82,218.02","82,218.02",,,,,,
Meridian Medicaid,DRG,6031,NEONATE BIRTHWT 10001249G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$21,131.62 ",IP,"21,131.62","21,131.62",,,,,,
Meridian Medicaid,DRG,6032,NEONATE BIRTHWT 10001249G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$31,760.66 ",IP,"31,760.66","31,760.66",,,,,,
Meridian Medicaid,DRG,6033,NEONATE BIRTHWT 10001249G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$45,733.18 ",IP,"45,733.18","45,733.18",,,,,,
Meridian Medicaid,DRG,6034,NEONATE BIRTHWT 10001249G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$71,521.63 ",IP,"71,521.63","71,521.63",,,,,,
Meridian Medicaid,DRG,6071,NEONATE BWT 1250-1499G W RESP DIST SYND/OTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$24,973.02 ",IP,"24,973.02","24,973.02",,,,,,
Meridian Medicaid,DRG,6072,NEONATE BWT 12501499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$31,699.15 ",IP,"31,699.15","31,699.15",,,,,,
Meridian Medicaid,DRG,6073,NEONATE BWT 12501499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$41,632.01 ",IP,"41,632.01","41,632.01",,,,,,
Meridian Medicaid,DRG,6074,NEONATE BWT 12501499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$64,492.07 ",IP,"64,492.07","64,492.07",,,,,,
Meridian Medicaid,DRG,6081,NEONATE BWT 12501499G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$16,607.44 ",IP,"16,607.44","16,607.44",,,,,,
Meridian Medicaid,DRG,6082,NEONATE BWT 12501499G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$23,967.23 ",IP,"23,967.23","23,967.23",,,,,,
Meridian Medicaid,DRG,6083,NEONATE BWT 12501499G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$34,646.09 ",IP,"34,646.09","34,646.09",,,,,,
Meridian Medicaid,DRG,6084,NEONATE BWT 12501499G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$60,788.81 ",IP,"60,788.81","60,788.81",,,,,,
Meridian Medicaid,DRG,6091,NEONATE BWT 15002499G W MAJOR PROCEDURE,,Relative Weights,"$25,499.11 ",IP,"25,499.11","25,499.11",,,,,,
Meridian Medicaid,DRG,6092,NEONATE BWT 15002499G W MAJOR PROCEDURE,,Relative Weights,"$27,431.32 ",IP,"27,431.32","27,431.32",,,,,,
Meridian Medicaid,DRG,6093,NEONATE BWT 15002499G W MAJOR PROCEDURE,,Relative Weights,"$47,002.54 ",IP,"47,002.54","47,002.54",,,,,,
Meridian Medicaid,DRG,6094,NEONATE BWT 15002499G W MAJOR PROCEDURE,,Relative Weights,"$99,687.62 ",IP,"99,687.62","99,687.62",,,,,,
Meridian Medicaid,DRG,6111,NEONATE BIRTHWT 15001999G W MAJOR ANOMALY,,Relative Weights,"$12,585.30 ",IP,"12,585.30","12,585.30",,,,,,
Meridian Medicaid,DRG,6112,NEONATE BIRTHWT 15001999G W MAJOR ANOMALY,,Relative Weights,"$19,393.91 ",IP,"19,393.91","19,393.91",,,,,,
Meridian Medicaid,DRG,6113,NEONATE BIRTHWT 15001999G W MAJOR ANOMALY,,Relative Weights,"$32,347.92 ",IP,"32,347.92","32,347.92",,,,,,
Meridian Medicaid,DRG,6114,NEONATE BIRTHWT 15001999G W MAJOR ANOMALY,,Relative Weights,"$58,174.51 ",IP,"58,174.51","58,174.51",,,,,,
Meridian Medicaid,DRG,6121,NEONATE BWT 1500-1999G W RESP DIST SYND/OTH MAJ RESP COND,,Relative Weights,"$16,224.65 ",IP,"16,224.65","16,224.65",,,,,,
Meridian Medicaid,DRG,6122,NEONATE BWT 15001999G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$21,637.79 ",IP,"21,637.79","21,637.79",,,,,,
Meridian Medicaid,DRG,6123,NEONATE BWT 15001999G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$29,186.22 ",IP,"29,186.22","29,186.22",,,,,,
Meridian Medicaid,DRG,6124,NEONATE BWT 15001999G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$42,407.23 ",IP,"42,407.23","42,407.23",,,,,,
Meridian Medicaid,DRG,6131,NEONATE BIRTHWT 1500-1999G W CONGENITAL/PERINATAL INFECTION,,Relative Weights,"$13,196.61 ",IP,"13,196.61","13,196.61",,,,,,
Meridian Medicaid,DRG,6132,NEONATE BIRTHWT 15001999G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$21,189.35 ",IP,"21,189.35","21,189.35",,,,,,
Meridian Medicaid,DRG,6133,NEONATE BIRTHWT 15001999G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$27,656.40 ",IP,"27,656.40","27,656.40",,,,,,
Meridian Medicaid,DRG,6134,NEONATE BIRTHWT 15001999G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$47,731.03 ",IP,"47,731.03","47,731.03",,,,,,
Meridian Medicaid,DRG,6141,NEONATE BWT 15001999G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$8,925.34 ",IP,"8,925.34","8,925.34",,,,,,
Meridian Medicaid,DRG,6142,NEONATE BWT 1500-1999G W OR W/O OTHER SIGNIFICANT CONDITION,,Relative Weights,"$15,030.54 ",IP,"15,030.54","15,030.54",,,,,,
Meridian Medicaid,DRG,6143,NEONATE BWT 1500-1999G W OR W/O OTHER SIGNIFICANT CONDITION,,Relative Weights,"$25,580.55 ",IP,"25,580.55","25,580.55",,,,,,
Meridian Medicaid,DRG,6144,NEONATE BWT 15001999G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$45,341.79 ",IP,"45,341.79","45,341.79",,,,,,
Meridian Medicaid,DRG,6211,NEONATE BWT 20002499G W MAJOR ANOMALY,,Relative Weights,"$6,929.91 ",IP,"6,929.91","6,929.91",,,,,,
Meridian Medicaid,DRG,6212,NEONATE BWT 20002499G W MAJOR ANOMALY,,Relative Weights,"$14,367.69 ",IP,"14,367.69","14,367.69",,,,,,
Meridian Medicaid,DRG,6213,NEONATE BWT 20002499G W MAJOR ANOMALY,,Relative Weights,"$26,320.72 ",IP,"26,320.72","26,320.72",,,,,,
Meridian Medicaid,DRG,6214,NEONATE BWT 20002499G W MAJOR ANOMALY,,Relative Weights,"$49,514.79 ",IP,"49,514.79","49,514.79",,,,,,
Meridian Medicaid,DRG,6221,NEONATE BWT 20002499G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$10,129.06 ",IP,"10,129.06","10,129.06",,,,,,
Meridian Medicaid,DRG,6222,NEONATE BWT 20002499G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$13,681.47 ",IP,"13,681.47","13,681.47",,,,,,
Meridian Medicaid,DRG,6223,NEONATE BWT 20002499G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$17,417.03 ",IP,"17,417.03","17,417.03",,,,,,
Meridian Medicaid,DRG,6224,NEONATE BWT 20002499G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$32,501.52 ",IP,"32,501.52","32,501.52",,,,,,
Meridian Medicaid,DRG,6231,NEONATE BWT 20002499G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$7,947.73 ",IP,"7,947.73","7,947.73",,,,,,
Meridian Medicaid,DRG,6232,NEONATE BWT 20002499G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$11,704.59 ",IP,"11,704.59","11,704.59",,,,,,
Meridian Medicaid,DRG,6233,NEONATE BWT 20002499G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$18,604.26 ",IP,"18,604.26","18,604.26",,,,,,
Meridian Medicaid,DRG,6234,NEONATE BWT 2000-2499G W CONGENITAL/PERINATAL INFECTION,,Relative Weights,"$29,470.40 ",IP,"29,470.40","29,470.40",,,,,,
Meridian Medicaid,DRG,6251,NEONATE BWT 20002499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$8,481.72 ",IP,"8,481.72","8,481.72",,,,,,
Meridian Medicaid,DRG,6252,NEONATE BWT 20002499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$12,056.81 ",IP,"12,056.81","12,056.81",,,,,,
Meridian Medicaid,DRG,6253,NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$17,253.12 ",IP,"17,253.12","17,253.12",,,,,,
Meridian Medicaid,DRG,6254,NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$25,500.83 ",IP,"25,500.83","25,500.83",,,,,,
Meridian Medicaid,DRG,6261,NEONATE BWT 20002499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM,,Relative Weights,"$1,026.75 ",IP,"1,026.75","1,026.75",,,,,,
Meridian Medicaid,DRG,6262,NEONATE BWT 20002499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM,,Relative Weights,"$1,832.56 ",IP,"1,832.56","1,832.56",,,,,,
Meridian Medicaid,DRG,6263,NEONATE BWT 20002499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM,,Relative Weights,"$5,129.99 ",IP,"5,129.99","5,129.99",,,,,,
Meridian Medicaid,DRG,6264,"NEONATE BWT 2000-2499G, NORMAL NEWBORN OR NEONATE W OTHER PROBLEM",,Relative Weights,"$14,511.67 ",IP,"14,511.67","14,511.67",,,,,,
Meridian Medicaid,DRG,6301,NEONATE BIRTHWT 2499G W MAJOR CARDIOVASCULAR PROCEDURE,,Relative Weights,"$14,642.59 ",IP,"14,642.59","14,642.59",,,,,,
Meridian Medicaid,DRG,6302,NEONATE BIRTHWT 2499G W MAJOR CARDIOVASCULAR PROCEDURE,,Relative Weights,"$26,499.41 ",IP,"26,499.41","26,499.41",,,,,,
Meridian Medicaid,DRG,6303,NEONATE BIRTHWT 2499G W MAJOR CARDIOVASCULAR PROCEDURE,,Relative Weights,"$44,508.84 ",IP,"44,508.84","44,508.84",,,,,,
Meridian Medicaid,DRG,6304,NEONATE BIRTHWT >2499G W MAJOR CARDIOVASCULAR PROCEDURE,,Relative Weights,"$79,154.59 ",IP,"79,154.59","79,154.59",,,,,,
Meridian Medicaid,DRG,6311,NEONATE BIRTHWT 2499G W OTHER MAJOR PROCEDURE,,Relative Weights,"$11,884.65 ",IP,"11,884.65","11,884.65",,,,,,
Meridian Medicaid,DRG,6312,NEONATE BIRTHWT 2499G W OTHER MAJOR PROCEDURE,,Relative Weights,"$19,077.77 ",IP,"19,077.77","19,077.77",,,,,,
Meridian Medicaid,DRG,6313,NEONATE BIRTHWT 2499G W OTHER MAJOR PROCEDURE,,Relative Weights,"$33,764.00 ",IP,"33,764.00","33,764.00",,,,,,
Meridian Medicaid,DRG,6314,NEONATE BIRTHWT 2499G W OTHER MAJOR PROCEDURE,,Relative Weights,"$74,464.79 ",IP,"74,464.79","74,464.79",,,,,,
Meridian Medicaid,DRG,6331,NEONATE BIRTHWT 2499G W MAJOR ANOMALY,,Relative Weights,"$2,688.87 ",IP,"2,688.87","2,688.87",,,,,,
Meridian Medicaid,DRG,6332,NEONATE BIRTHWT 2499G W MAJOR ANOMALY,,Relative Weights,"$7,851.51 ",IP,"7,851.51","7,851.51",,,,,,
Meridian Medicaid,DRG,6333,NEONATE BIRTHWT 2499G W MAJOR ANOMALY,,Relative Weights,"$17,713.92 ",IP,"17,713.92","17,713.92",,,,,,
Meridian Medicaid,DRG,6334,NEONATE BIRTHWT 2499G W MAJOR ANOMALY,,Relative Weights,"$44,843.19 ",IP,"44,843.19","44,843.19",,,,,,
Meridian Medicaid,DRG,6341,"NEONATE, BIRTHWT >2499G W RESP DIST SYND/OTH MAJ RESP COND",,Relative Weights,"$4,461.64 ",IP,"4,461.64","4,461.64",,,,,,
Meridian Medicaid,DRG,6342,"NEONATE, BIRTHWT >2499G W RESP DIST SYND/OTH MAJ RESP COND",,Relative Weights,"$7,881.41 ",IP,"7,881.41","7,881.41",,,,,,
Meridian Medicaid,DRG,6343,NEONATE BIRTHWT 2499G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$11,444.81 ",IP,"11,444.81","11,444.81",,,,,,
Meridian Medicaid,DRG,6344,NEONATE BIRTHWT 2499G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$28,806.17 ",IP,"28,806.17","28,806.17",,,,,,
Meridian Medicaid,DRG,6361,NEONATE BIRTHWT 2499G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$4,375.39 ",IP,"4,375.39","4,375.39",,,,,,
Meridian Medicaid,DRG,6362,NEONATE BIRTHWT 2499G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$6,615.83 ",IP,"6,615.83","6,615.83",,,,,,
Meridian Medicaid,DRG,6363,NEONATE BIRTHWT >2499G W CONGENITAL/PERINATAL INFECTION,,Relative Weights,"$13,140.60 ",IP,"13,140.60","13,140.60",,,,,,
Meridian Medicaid,DRG,6364,NEONATE BIRTHWT 2499G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$22,289.30 ",IP,"22,289.30","22,289.30",,,,,,
Meridian Medicaid,DRG,6391,NEONATE BIRTHWT 2499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$4,122.14 ",IP,"4,122.14","4,122.14",,,,,,
Meridian Medicaid,DRG,6392,NEONATE BIRTHWT >2499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$7,440.19 ",IP,"7,440.19","7,440.19",,,,,,
Meridian Medicaid,DRG,6393,NEONATE BIRTHWT >2499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$11,681.22 ",IP,"11,681.22","11,681.22",,,,,,
Meridian Medicaid,DRG,6394,NEONATE BIRTHWT 2499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$20,735.08 ",IP,"20,735.08","20,735.08",,,,,,
Meridian Medicaid,DRG,6401,NEONATE BIRTHWT 2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM,,Relative Weights,$571.11 ,IP,571.11,571.11,,,,,,
Meridian Medicaid,DRG,6402,NEONATE BIRTHWT 2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM,,Relative Weights,$900.64 ,IP,900.64,900.64,,,,,,
Meridian Medicaid,DRG,6403,"NEONATE BIRTHWT >2499G, NORMAL NEWBORN OR NEONATE W OTHER PROBLEM",,Relative Weights,"$2,228.41 ",IP,"2,228.41","2,228.41",,,,,,
Meridian Medicaid,DRG,6404,NEONATE BIRTHWT 2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM,,Relative Weights,"$13,890.74 ",IP,"13,890.74","13,890.74",,,,,,
Meridian Medicaid,DRG,6501,SPLENECTOMY,,Relative Weights,"$6,304.16 ",IP,"6,304.16","6,304.16",,,,,,
Meridian Medicaid,DRG,6502,SPLENECTOMY,,Relative Weights,"$8,491.69 ",IP,"8,491.69","8,491.69",,,,,,
Meridian Medicaid,DRG,6503,SPLENECTOMY,,Relative Weights,"$13,332.00 ",IP,"13,332.00","13,332.00",,,,,,
Meridian Medicaid,DRG,6504,SPLENECTOMY,,Relative Weights,"$23,483.06 ",IP,"23,483.06","23,483.06",,,,,,
Meridian Medicaid,DRG,6511,OTHER PROCEDURES OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$5,293.90 ",IP,"5,293.90","5,293.90",,,,,,
Meridian Medicaid,DRG,6512,OTHER PROCEDURES OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$7,236.76 ",IP,"7,236.76","7,236.76",,,,,,
Meridian Medicaid,DRG,6513,OTHER PROCEDURES OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$10,916.31 ",IP,"10,916.31","10,916.31",,,,,,
Meridian Medicaid,DRG,6514,OTHER PROCEDURES OF BLOOD & BLOOD-FORMING ORGANS,,Relative Weights,"$33,538.24 ",IP,"33,538.24","33,538.24",,,,,,
Meridian Medicaid,DRG,6601,MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS and COAGUL,,Relative Weights,"$3,747.59 ",IP,"3,747.59","3,747.59",,,,,,
Meridian Medicaid,DRG,6602,MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS and COAGUL,,Relative Weights,"$4,287.77 ",IP,"4,287.77","4,287.77",,,,,,
Meridian Medicaid,DRG,6603,MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS and COAGUL,,Relative Weights,"$6,366.70 ",IP,"6,366.70","6,366.70",,,,,,
Meridian Medicaid,DRG,6604,MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS and COAGUL,,Relative Weights,"$16,194.41 ",IP,"16,194.41","16,194.41",,,,,,
Meridian Medicaid,DRG,6611,COAGULATION and PLATELET DISORDERS,,Relative Weights,"$3,902.56 ",IP,"3,902.56","3,902.56",,,,,,
Meridian Medicaid,DRG,6612,COAGULATION and PLATELET DISORDERS,,Relative Weights,"$5,668.11 ",IP,"5,668.11","5,668.11",,,,,,
Meridian Medicaid,DRG,6613,COAGULATION and PLATELET DISORDERS,,Relative Weights,"$9,739.74 ",IP,"9,739.74","9,739.74",,,,,,
Meridian Medicaid,DRG,6614,COAGULATION and PLATELET DISORDERS,,Relative Weights,"$15,545.30 ",IP,"15,545.30","15,545.30",,,,,,
Meridian Medicaid,DRG,6621,SICKLE CELL ANEMIA CRISIS,,Relative Weights,"$2,821.17 ",IP,"2,821.17","2,821.17",,,,,,
Meridian Medicaid,DRG,6622,SICKLE CELL ANEMIA CRISIS,,Relative Weights,"$3,681.27 ",IP,"3,681.27","3,681.27",,,,,,
Meridian Medicaid,DRG,6623,SICKLE CELL ANEMIA CRISIS,,Relative Weights,"$5,206.96 ",IP,"5,206.96","5,206.96",,,,,,
Meridian Medicaid,DRG,6624,SICKLE CELL ANEMIA CRISIS,,Relative Weights,"$10,694.33 ",IP,"10,694.33","10,694.33",,,,,,
Meridian Medicaid,DRG,6631,OTHER ANEMIA and DISORDERS OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$2,701.59 ",IP,"2,701.59","2,701.59",,,,,,
Meridian Medicaid,DRG,6632,OTHER ANEMIA and DISORDERS OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$3,327.33 ",IP,"3,327.33","3,327.33",,,,,,
Meridian Medicaid,DRG,6633,OTHER ANEMIA and DISORDERS OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$4,391.20 ",IP,"4,391.20","4,391.20",,,,,,
Meridian Medicaid,DRG,6634,OTHER ANEMIA and DISORDERS OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$8,007.52 ",IP,"8,007.52","8,007.52",,,,,,
Meridian Medicaid,DRG,6801,MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$7,740.52 ",IP,"7,740.52","7,740.52",,,,,,
Meridian Medicaid,DRG,6802,MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$10,236.62 ",IP,"10,236.62","10,236.62",,,,,,
Meridian Medicaid,DRG,6803,MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$16,199.56 ",IP,"16,199.56","16,199.56",,,,,,
Meridian Medicaid,DRG,6804,MAJOR O.R. PROCEDURES FOR LYMPHATIC/HEMATOPOIETIC/OTHER NEOPLASMS,,Relative Weights,"$34,974.94 ",IP,"34,974.94","34,974.94",,,,,,
Meridian Medicaid,DRG,6811,OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$6,220.66 ",IP,"6,220.66","6,220.66",,,,,,
Meridian Medicaid,DRG,6812,OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$7,805.46 ",IP,"7,805.46","7,805.46",,,,,,
Meridian Medicaid,DRG,6813,OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$13,731.30 ",IP,"13,731.30","13,731.30",,,,,,
Meridian Medicaid,DRG,6814,OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$32,311.50 ",IP,"32,311.50","32,311.50",,,,,,
Meridian Medicaid,DRG,6901,ACUTE LEUKEMIA,,Relative Weights,"$8,376.23 ",IP,"8,376.23","8,376.23",,,,,,
Meridian Medicaid,DRG,6902,ACUTE LEUKEMIA,,Relative Weights,"$11,965.06 ",IP,"11,965.06","11,965.06",,,,,,
Meridian Medicaid,DRG,6903,ACUTE LEUKEMIA,,Relative Weights,"$18,264.07 ",IP,"18,264.07","18,264.07",,,,,,
Meridian Medicaid,DRG,6904,ACUTE LEUKEMIA,,Relative Weights,"$33,495.63 ",IP,"33,495.63","33,495.63",,,,,,
Meridian Medicaid,DRG,6911,LYMPHOMA MYELOMA and NONACUTE LEUKEMIA,,Relative Weights,"$6,184.92 ",IP,"6,184.92","6,184.92",,,,,,
Meridian Medicaid,DRG,6912,"LYMPHOMA, MYELOMA & NON-ACUTE LEUKEMIA",,Relative Weights,"$6,251.93 ",IP,"6,251.93","6,251.93",,,,,,
Meridian Medicaid,DRG,6913,LYMPHOMA MYELOMA and NONACUTE LEUKEMIA,,Relative Weights,"$9,090.97 ",IP,"9,090.97","9,090.97",,,,,,
Meridian Medicaid,DRG,6914,LYMPHOMA MYELOMA and NONACUTE LEUKEMIA,,Relative Weights,"$18,806.65 ",IP,"18,806.65","18,806.65",,,,,,
Meridian Medicaid,DRG,6921,RADIOTHERAPY,,Relative Weights,"$5,028.28 ",IP,"5,028.28","5,028.28",,,,,,
Meridian Medicaid,DRG,6922,RADIOTHERAPY,,Relative Weights,"$8,603.36 ",IP,"8,603.36","8,603.36",,,,,,
Meridian Medicaid,DRG,6923,RADIOTHERAPY,,Relative Weights,"$11,232.45 ",IP,"11,232.45","11,232.45",,,,,,
Meridian Medicaid,DRG,6924,RADIOTHERAPY,,Relative Weights,"$22,232.95 ",IP,"22,232.95","22,232.95",,,,,,
Meridian Medicaid,DRG,6941,LYMPHATIC & OTHER MALIGNANCIES & NEOPLASMS OF UNCERTAIN BEHAVIOR,,Relative Weights,"$3,669.93 ",IP,"3,669.93","3,669.93",,,,,,
Meridian Medicaid,DRG,6942,LYMPHATIC and OTHER MALIGNANCIES and NEOPLASMS OF UNCERTAIN BEHAVIOR,,Relative Weights,"$4,230.04 ",IP,"4,230.04","4,230.04",,,,,,
Meridian Medicaid,DRG,6943,LYMPHATIC and OTHER MALIGNANCIES and NEOPLASMS OF UNCERTAIN BEHAVIOR,,Relative Weights,"$5,867.41 ",IP,"5,867.41","5,867.41",,,,,,
Meridian Medicaid,DRG,6944,LYMPHATIC and OTHER MALIGNANCIES and NEOPLASMS OF UNCERTAIN BEHAVIOR,,Relative Weights,"$11,092.25 ",IP,"11,092.25","11,092.25",,,,,,
Meridian Medicaid,DRG,6951,CHEMOTHERAPY FOR ACUTE LEUKEMIA,,Relative Weights,"$3,844.14 ",IP,"3,844.14","3,844.14",,,,,,
Meridian Medicaid,DRG,6952,CHEMOTHERAPY FOR ACUTE LEUKEMIA,,Relative Weights,"$4,908.70 ",IP,"4,908.70","4,908.70",,,,,,
Meridian Medicaid,DRG,6953,CHEMOTHERAPY FOR ACUTE LEUKEMIA,,Relative Weights,"$11,375.74 ",IP,"11,375.74","11,375.74",,,,,,
Meridian Medicaid,DRG,6954,CHEMOTHERAPY FOR ACUTE LEUKEMIA,,Relative Weights,"$32,868.17 ",IP,"32,868.17","32,868.17",,,,,,
Meridian Medicaid,DRG,6961,OTHER CHEMOTHERAPY,,Relative Weights,"$4,174.03 ",IP,"4,174.03","4,174.03",,,,,,
Meridian Medicaid,DRG,6962,OTHER CHEMOTHERAPY,,Relative Weights,"$5,397.68 ",IP,"5,397.68","5,397.68",,,,,,
Meridian Medicaid,DRG,6963,OTHER CHEMOTHERAPY,,Relative Weights,"$7,757.01 ",IP,"7,757.01","7,757.01",,,,,,
Meridian Medicaid,DRG,6964,OTHER CHEMOTHERAPY,,Relative Weights,"$17,845.53 ",IP,"17,845.53","17,845.53",,,,,,
Meridian Medicaid,DRG,7101,INFECTIOUS & PARASITIC DISEASES INCLUDING HIV W O.R. PROCEDURE,,Relative Weights,"$5,318.64 ",IP,"5,318.64","5,318.64",,,,,,
Meridian Medicaid,DRG,7102,INFECTIOUS and PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE,,Relative Weights,"$7,922.30 ",IP,"7,922.30","7,922.30",,,,,,
Meridian Medicaid,DRG,7103,INFECTIOUS and PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE,,Relative Weights,"$12,117.63 ",IP,"12,117.63","12,117.63",,,,,,
Meridian Medicaid,DRG,7104,INFECTIOUS and PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE,,Relative Weights,"$24,582.32 ",IP,"24,582.32","24,582.32",,,,,,
Meridian Medicaid,DRG,7111,POSTOP POSTTRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE,,Relative Weights,"$5,432.73 ",IP,"5,432.73","5,432.73",,,,,,
Meridian Medicaid,DRG,7112,POSTOP POSTTRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE,,Relative Weights,"$7,124.05 ",IP,"7,124.05","7,124.05",,,,,,
Meridian Medicaid,DRG,7113,POSTOP POSTTRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE,,Relative Weights,"$12,166.42 ",IP,"12,166.42","12,166.42",,,,,,
Meridian Medicaid,DRG,7114,POSTOP POSTTRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE,,Relative Weights,"$25,010.82 ",IP,"25,010.82","25,010.82",,,,,,
Meridian Medicaid,DRG,7201,SEPTICEMIA and DISSEMINATED INFECTIONS,,Relative Weights,"$2,801.24 ",IP,"2,801.24","2,801.24",,,,,,
Meridian Medicaid,DRG,7202,SEPTICEMIA and DISSEMINATED INFECTIONS,,Relative Weights,"$3,678.52 ",IP,"3,678.52","3,678.52",,,,,,
Meridian Medicaid,DRG,7203,SEPTICEMIA and DISSEMINATED INFECTIONS,,Relative Weights,"$5,399.74 ",IP,"5,399.74","5,399.74",,,,,,
Meridian Medicaid,DRG,7204,SEPTICEMIA and DISSEMINATED INFECTIONS,,Relative Weights,"$10,740.72 ",IP,"10,740.72","10,740.72",,,,,,
Meridian Medicaid,DRG,7211,"POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS",,Relative Weights,"$2,917.38 ",IP,"2,917.38","2,917.38",,,,,,
Meridian Medicaid,DRG,7212,POSTOPERATIVE POSTTRAUMATIC OTHER DEVICE INFECTIONS,,Relative Weights,"$3,837.27 ",IP,"3,837.27","3,837.27",,,,,,
Meridian Medicaid,DRG,7213,POSTOPERATIVE POSTTRAUMATIC OTHER DEVICE INFECTIONS,,Relative Weights,"$6,182.18 ",IP,"6,182.18","6,182.18",,,,,,
Meridian Medicaid,DRG,7214,POSTOPERATIVE POSTTRAUMATIC OTHER DEVICE INFECTIONS,,Relative Weights,"$12,158.86 ",IP,"12,158.86","12,158.86",,,,,,
Meridian Medicaid,DRG,7221,FEVER,,Relative Weights,"$1,952.14 ",IP,"1,952.14","1,952.14",,,,,,
Meridian Medicaid,DRG,7222,FEVER,,Relative Weights,"$2,920.13 ",IP,"2,920.13","2,920.13",,,,,,
Meridian Medicaid,DRG,7223,FEVER,,Relative Weights,"$3,952.39 ",IP,"3,952.39","3,952.39",,,,,,
Meridian Medicaid,DRG,7224,FEVER,,Relative Weights,"$6,941.25 ",IP,"6,941.25","6,941.25",,,,,,
Meridian Medicaid,DRG,7231,VIRAL ILLNESS,,Relative Weights,"$1,908.50 ",IP,"1,908.50","1,908.50",,,,,,
Meridian Medicaid,DRG,7232,VIRAL ILLNESS,,Relative Weights,"$2,685.44 ",IP,"2,685.44","2,685.44",,,,,,
Meridian Medicaid,DRG,7233,VIRAL ILLNESS,,Relative Weights,"$4,131.07 ",IP,"4,131.07","4,131.07",,,,,,
Meridian Medicaid,DRG,7234,VIRAL ILLNESS,,Relative Weights,"$10,429.39 ",IP,"10,429.39","10,429.39",,,,,,
Meridian Medicaid,DRG,7241,OTHER INFECTIOUS and PARASITIC DISEASES,,Relative Weights,"$3,048.31 ",IP,"3,048.31","3,048.31",,,,,,
Meridian Medicaid,DRG,7242,OTHER INFECTIOUS and PARASITIC DISEASES,,Relative Weights,"$3,655.49 ",IP,"3,655.49","3,655.49",,,,,,
Meridian Medicaid,DRG,7243,OTHER INFECTIOUS and PARASITIC DISEASES,,Relative Weights,"$5,820.68 ",IP,"5,820.68","5,820.68",,,,,,
Meridian Medicaid,DRG,7244,OTHER INFECTIOUS and PARASITIC DISEASES,,Relative Weights,"$13,099.02 ",IP,"13,099.02","13,099.02",,,,,,
Meridian Medicaid,DRG,7401,MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE,,Relative Weights,"$6,032.70 ",IP,"6,032.70","6,032.70",,,,,,
Meridian Medicaid,DRG,7402,MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE,,Relative Weights,"$6,703.46 ",IP,"6,703.46","6,703.46",,,,,,
Meridian Medicaid,DRG,7403,MENTAL ILLNESS DIAGNOSIS W O.R. PROCEDURE,,Relative Weights,"$13,324.79 ",IP,"13,324.79","13,324.79",,,,,,
Meridian Medicaid,DRG,7404,MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE,,Relative Weights,"$26,668.81 ",IP,"26,668.81","26,668.81",,,,,,
Meridian Medicaid,DRG,7501,SCHIZOPHRENIA,,Relative Weights,"$2,530.12 ",IP,"2,530.12","2,530.12",,,,,,
Meridian Medicaid,DRG,7502,SCHIZOPHRENIA,,Relative Weights,"$2,708.80 ",IP,"2,708.80","2,708.80",,,,,,
Meridian Medicaid,DRG,7503,SCHIZOPHRENIA,,Relative Weights,"$4,799.08 ",IP,"4,799.08","4,799.08",,,,,,
Meridian Medicaid,DRG,7504,SCHIZOPHRENIA,,Relative Weights,"$13,473.58 ",IP,"13,473.58","13,473.58",,,,,,
Meridian Medicaid,DRG,7511,MAJOR DEPRESSIVE DISORDERS and OTHERUNSPECIFIED PSYCHOSES,,Relative Weights,"$1,760.40 ",IP,"1,760.40","1,760.40",,,,,,
Meridian Medicaid,DRG,7512,MAJOR DEPRESSIVE DISORDERS & OTHER/UNSPECIFIED PSYCHOSES,,Relative Weights,"$2,237.01 ",IP,"2,237.01","2,237.01",,,,,,
Meridian Medicaid,DRG,7513,MAJOR DEPRESSIVE DISORDERS and OTHERUNSPECIFIED PSYCHOSES,,Relative Weights,"$3,773.70 ",IP,"3,773.70","3,773.70",,,,,,
Meridian Medicaid,DRG,7514,MAJOR DEPRESSIVE DISORDERS and OTHERUNSPECIFIED PSYCHOSES,,Relative Weights,"$8,518.14 ",IP,"8,518.14","8,518.14",,,,,,
Meridian Medicaid,DRG,7521,DISORDERS OF PERSONALITY and IMPULSE CONTROL,,Relative Weights,"$1,687.20 ",IP,"1,687.20","1,687.20",,,,,,
Meridian Medicaid,DRG,7522,DISORDERS OF PERSONALITY & IMPULSE CONTROL,,Relative Weights,"$2,102.30 ",IP,"2,102.30","2,102.30",,,,,,
Meridian Medicaid,DRG,7523,DISORDERS OF PERSONALITY & IMPULSE CONTROL,,Relative Weights,"$3,885.72 ",IP,"3,885.72","3,885.72",,,,,,
Meridian Medicaid,DRG,7524,DISORDERS OF PERSONALITY and IMPULSE CONTROL,,Relative Weights,"$13,737.14 ",IP,"13,737.14","13,737.14",,,,,,
Meridian Medicaid,DRG,7531,BIPOLAR DISORDERS,,Relative Weights,"$1,873.11 ",IP,"1,873.11","1,873.11",,,,,,
Meridian Medicaid,DRG,7532,BIPOLAR DISORDERS,,Relative Weights,"$2,183.40 ",IP,"2,183.40","2,183.40",,,,,,
Meridian Medicaid,DRG,7533,BIPOLAR DISORDERS,,Relative Weights,"$3,541.07 ",IP,"3,541.07","3,541.07",,,,,,
Meridian Medicaid,DRG,7534,BIPOLAR DISORDERS,,Relative Weights,"$10,043.84 ",IP,"10,043.84","10,043.84",,,,,,
Meridian Medicaid,DRG,7541,DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,,Relative Weights,"$1,523.64 ",IP,"1,523.64","1,523.64",,,,,,
Meridian Medicaid,DRG,7542,DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,,Relative Weights,"$2,007.46 ",IP,"2,007.46","2,007.46",,,,,,
Meridian Medicaid,DRG,7543,DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,,Relative Weights,"$3,012.23 ",IP,"3,012.23","3,012.23",,,,,,
Meridian Medicaid,DRG,7544,DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,,Relative Weights,"$7,979.68 ",IP,"7,979.68","7,979.68",,,,,,
Meridian Medicaid,DRG,7551,ADJUSTMENT DISORDERS and NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,,Relative Weights,"$1,532.57 ",IP,"1,532.57","1,532.57",,,,,,
Meridian Medicaid,DRG,7552,ADJUSTMENT DISORDERS and NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,,Relative Weights,"$2,506.06 ",IP,"2,506.06","2,506.06",,,,,,
Meridian Medicaid,DRG,7553,ADJUSTMENT DISORDERS and NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,,Relative Weights,"$3,538.32 ",IP,"3,538.32","3,538.32",,,,,,
Meridian Medicaid,DRG,7554,ADJUSTMENT DISORDERS and NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,,Relative Weights,"$6,118.26 ",IP,"6,118.26","6,118.26",,,,,,
Meridian Medicaid,DRG,7561,ACUTE ANXIETY and DELIRIUM STATES,,Relative Weights,"$2,496.79 ",IP,"2,496.79","2,496.79",,,,,,
Meridian Medicaid,DRG,7562,ACUTE ANXIETY & DELIRIUM STATES,,Relative Weights,"$3,057.58 ",IP,"3,057.58","3,057.58",,,,,,
Meridian Medicaid,DRG,7563,ACUTE ANXIETY and DELIRIUM STATES,,Relative Weights,"$3,397.43 ",IP,"3,397.43","3,397.43",,,,,,
Meridian Medicaid,DRG,7564,ACUTE ANXIETY and DELIRIUM STATES,,Relative Weights,"$7,384.52 ",IP,"7,384.52","7,384.52",,,,,,
Meridian Medicaid,DRG,7571,ORGANIC MENTAL HEALTH DISTURBANCES,,Relative Weights,"$2,504.35 ",IP,"2,504.35","2,504.35",,,,,,
Meridian Medicaid,DRG,7572,ORGANIC MENTAL HEALTH DISTURBANCES,,Relative Weights,"$3,161.02 ",IP,"3,161.02","3,161.02",,,,,,
Meridian Medicaid,DRG,7573,ORGANIC MENTAL HEALTH DISTURBANCES,,Relative Weights,"$5,750.24 ",IP,"5,750.24","5,750.24",,,,,,
Meridian Medicaid,DRG,7574,ORGANIC MENTAL HEALTH DISTURBANCES,,Relative Weights,"$15,933.94 ",IP,"15,933.94","15,933.94",,,,,,
Meridian Medicaid,DRG,7581,BEHAVIORAL DISORDERS,,Relative Weights,"$2,326.35 ",IP,"2,326.35","2,326.35",,,,,,
Meridian Medicaid,DRG,7582,BEHAVIORAL DISORDERS,,Relative Weights,"$2,881.65 ",IP,"2,881.65","2,881.65",,,,,,
Meridian Medicaid,DRG,7583,BEHAVIORAL DISORDERS,,Relative Weights,"$4,037.26 ",IP,"4,037.26","4,037.26",,,,,,
Meridian Medicaid,DRG,7584,BEHAVIORAL DISORDERS,,Relative Weights,"$5,464.00 ",IP,"5,464.00","5,464.00",,,,,,
Meridian Medicaid,DRG,7591,EATING DISORDERS,,Relative Weights,"$4,564.04 ",IP,"4,564.04","4,564.04",,,,,,
Meridian Medicaid,DRG,7592,EATING DISORDERS,,Relative Weights,"$5,955.04 ",IP,"5,955.04","5,955.04",,,,,,
Meridian Medicaid,DRG,7593,EATING DISORDERS,,Relative Weights,"$9,440.78 ",IP,"9,440.78","9,440.78",,,,,,
Meridian Medicaid,DRG,7594,EATING DISORDERS,,Relative Weights,"$12,954.01 ",IP,"12,954.01","12,954.01",,,,,,
Meridian Medicaid,DRG,7601,OTHER MENTAL HEALTH DISORDERS,,Relative Weights,"$2,553.48 ",IP,"2,553.48","2,553.48",,,,,,
Meridian Medicaid,DRG,7602,OTHER MENTAL HEALTH DISORDERS,,Relative Weights,"$3,467.19 ",IP,"3,467.19","3,467.19",,,,,,
Meridian Medicaid,DRG,7603,OTHER MENTAL HEALTH DISORDERS,,Relative Weights,"$6,902.07 ",IP,"6,902.07","6,902.07",,,,,,
Meridian Medicaid,DRG,7604,OTHER MENTAL HEALTH DISORDERS,,Relative Weights,"$12,546.82 ",IP,"12,546.82","12,546.82",,,,,,
Meridian Medicaid,DRG,7701,DRUG and ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE,,Relative Weights,"$1,041.53 ",IP,"1,041.53","1,041.53",,,,,,
Meridian Medicaid,DRG,7702,"DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE",,Relative Weights,"$1,522.95 ",IP,"1,522.95","1,522.95",,,,,,
Meridian Medicaid,DRG,7703,"DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE",,Relative Weights,"$2,633.89 ",IP,"2,633.89","2,633.89",,,,,,
Meridian Medicaid,DRG,7704,DRUG and ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE,,Relative Weights,"$6,153.65 ",IP,"6,153.65","6,153.65",,,,,,
Meridian Medicaid,DRG,7721,ALCOHOL and DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY,,Relative Weights,"$2,743.85 ",IP,"2,743.85","2,743.85",,,,,,
Meridian Medicaid,DRG,7722,ALCOHOL and DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY,,Relative Weights,"$3,502.58 ",IP,"3,502.58","3,502.58",,,,,,
Meridian Medicaid,DRG,7723,ALCOHOL and DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY,,Relative Weights,"$4,241.72 ",IP,"4,241.72","4,241.72",,,,,,
Meridian Medicaid,DRG,7724,ALCOHOL & DRUG DEPENDENCE W REHAB OR REHAB/DETOX THERAPY,,Relative Weights,"$9,550.40 ",IP,"9,550.40","9,550.40",,,,,,
Meridian Medicaid,DRG,7731,OPIOID ABUSE and DEPENDENCE,,Relative Weights,"$1,275.88 ",IP,"1,275.88","1,275.88",,,,,,
Meridian Medicaid,DRG,7732,OPIOID ABUSE and DEPENDENCE,,Relative Weights,"$1,881.01 ",IP,"1,881.01","1,881.01",,,,,,
Meridian Medicaid,DRG,7733,OPIOID ABUSE and DEPENDENCE,,Relative Weights,"$3,476.12 ",IP,"3,476.12","3,476.12",,,,,,
Meridian Medicaid,DRG,7734,OPIOID ABUSE & DEPENDENCE,,Relative Weights,"$9,565.86 ",IP,"9,565.86","9,565.86",,,,,,
Meridian Medicaid,DRG,7741,COCAINE ABUSE and DEPENDENCE,,Relative Weights,"$1,761.43 ",IP,"1,761.43","1,761.43",,,,,,
Meridian Medicaid,DRG,7742,COCAINE ABUSE and DEPENDENCE,,Relative Weights,"$1,956.95 ",IP,"1,956.95","1,956.95",,,,,,
Meridian Medicaid,DRG,7743,COCAINE ABUSE and DEPENDENCE,,Relative Weights,"$3,314.62 ",IP,"3,314.62","3,314.62",,,,,,
Meridian Medicaid,DRG,7744,COCAINE ABUSE and DEPENDENCE,,Relative Weights,"$9,105.40 ",IP,"9,105.40","9,105.40",,,,,,
Meridian Medicaid,DRG,7751,ALCOHOL ABUSE and DEPENDENCE,,Relative Weights,"$1,741.50 ",IP,"1,741.50","1,741.50",,,,,,
Meridian Medicaid,DRG,7752,ALCOHOL ABUSE & DEPENDENCE,,Relative Weights,"$2,441.81 ",IP,"2,441.81","2,441.81",,,,,,
Meridian Medicaid,DRG,7753,ALCOHOL ABUSE and DEPENDENCE,,Relative Weights,"$3,986.06 ",IP,"3,986.06","3,986.06",,,,,,
Meridian Medicaid,DRG,7754,ALCOHOL ABUSE and DEPENDENCE,,Relative Weights,"$10,751.37 ",IP,"10,751.37","10,751.37",,,,,,
Meridian Medicaid,DRG,7761,OTHER DRUG ABUSE and DEPENDENCE,,Relative Weights,"$2,414.66 ",IP,"2,414.66","2,414.66",,,,,,
Meridian Medicaid,DRG,7762,OTHER DRUG ABUSE & DEPENDENCE,,Relative Weights,"$2,653.48 ",IP,"2,653.48","2,653.48",,,,,,
Meridian Medicaid,DRG,7763,OTHER DRUG ABUSE & DEPENDENCE,,Relative Weights,"$4,175.40 ",IP,"4,175.40","4,175.40",,,,,,
Meridian Medicaid,DRG,7764,OTHER DRUG ABUSE and DEPENDENCE,,Relative Weights,"$7,699.28 ",IP,"7,699.28","7,699.28",,,,,,
Meridian Medicaid,DRG,7921,EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$7,773.51 ",IP,"7,773.51","7,773.51",,,,,,
Meridian Medicaid,DRG,7922,EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$8,931.53 ",IP,"8,931.53","8,931.53",,,,,,
Meridian Medicaid,DRG,7923,EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$13,005.21 ",IP,"13,005.21","13,005.21",,,,,,
Meridian Medicaid,DRG,7924,EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$27,591.45 ",IP,"27,591.45","27,591.45",,,,,,
Meridian Medicaid,DRG,7931,MODERATELY EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$4,608.37 ",IP,"4,608.37","4,608.37",,,,,,
Meridian Medicaid,DRG,7932,MODERATELY EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$6,350.90 ",IP,"6,350.90","6,350.90",,,,,,
Meridian Medicaid,DRG,7933,MODERATELY EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$9,808.12 ",IP,"9,808.12","9,808.12",,,,,,
Meridian Medicaid,DRG,7934,MODERATELY EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$20,177.03 ",IP,"20,177.03","20,177.03",,,,,,
Meridian Medicaid,DRG,7941,NONEXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$3,990.87 ",IP,"3,990.87","3,990.87",,,,,,
Meridian Medicaid,DRG,7942,NONEXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$5,327.92 ",IP,"5,327.92","5,327.92",,,,,,
Meridian Medicaid,DRG,7943,NONEXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$7,911.30 ",IP,"7,911.30","7,911.30",,,,,,
Meridian Medicaid,DRG,7944,NON-EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$16,457.28 ",IP,"16,457.28","16,457.28",,,,,,
Meridian Medicaid,DRG,8101,HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION,,Relative Weights,"$2,594.03 ",IP,"2,594.03","2,594.03",,,,,,
Meridian Medicaid,DRG,8102,HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION,,Relative Weights,"$3,420.11 ",IP,"3,420.11","3,420.11",,,,,,
Meridian Medicaid,DRG,8103,HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION,,Relative Weights,"$5,351.98 ",IP,"5,351.98","5,351.98",,,,,,
Meridian Medicaid,DRG,8104,HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION,,Relative Weights,"$10,772.68 ",IP,"10,772.68","10,772.68",,,,,,
Meridian Medicaid,DRG,8111,ALLERGIC REACTIONS,,Relative Weights,"$1,582.40 ",IP,"1,582.40","1,582.40",,,,,,
Meridian Medicaid,DRG,8112,ALLERGIC REACTIONS,,Relative Weights,"$2,325.66 ",IP,"2,325.66","2,325.66",,,,,,
Meridian Medicaid,DRG,8113,ALLERGIC REACTIONS,,Relative Weights,"$4,003.24 ",IP,"4,003.24","4,003.24",,,,,,
Meridian Medicaid,DRG,8114,ALLERGIC REACTIONS,,Relative Weights,"$9,358.65 ",IP,"9,358.65","9,358.65",,,,,,
Meridian Medicaid,DRG,8121,POISONING OF MEDICINAL AGENTS,,Relative Weights,"$1,778.95 ",IP,"1,778.95","1,778.95",,,,,,
Meridian Medicaid,DRG,8122,POISONING OF MEDICINAL AGENTS,,Relative Weights,"$2,471.70 ",IP,"2,471.70","2,471.70",,,,,,
Meridian Medicaid,DRG,8123,POISONING OF MEDICINAL AGENTS,,Relative Weights,"$3,713.91 ",IP,"3,713.91","3,713.91",,,,,,
Meridian Medicaid,DRG,8124,POISONING OF MEDICINAL AGENTS,,Relative Weights,"$7,487.95 ",IP,"7,487.95","7,487.95",,,,,,
Meridian Medicaid,DRG,8131,OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$2,963.09 ",IP,"2,963.09","2,963.09",,,,,,
Meridian Medicaid,DRG,8132,OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$3,546.91 ",IP,"3,546.91","3,546.91",,,,,,
Meridian Medicaid,DRG,8133,OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$5,048.90 ",IP,"5,048.90","5,048.90",,,,,,
Meridian Medicaid,DRG,8134,OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$10,108.45 ",IP,"10,108.45","10,108.45",,,,,,
Meridian Medicaid,DRG,8151,OTHER INJURY POISONING and TOXIC EFFECT DIAGNOSES,,Relative Weights,"$2,225.32 ",IP,"2,225.32","2,225.32",,,,,,
Meridian Medicaid,DRG,8152,"OTHER INJURY, POISONING & TOXIC EFFECT DIAGNOSES",,Relative Weights,"$3,062.74 ",IP,"3,062.74","3,062.74",,,,,,
Meridian Medicaid,DRG,8153,OTHER INJURY POISONING and TOXIC EFFECT DIAGNOSES,,Relative Weights,"$5,006.29 ",IP,"5,006.29","5,006.29",,,,,,
Meridian Medicaid,DRG,8154,OTHER INJURY POISONING and TOXIC EFFECT DIAGNOSES,,Relative Weights,"$14,243.99 ",IP,"14,243.99","14,243.99",,,,,,
Meridian Medicaid,DRG,8161,TOXIC EFFECTS OF NONMEDICINAL SUBSTANCES,,Relative Weights,"$2,832.85 ",IP,"2,832.85","2,832.85",,,,,,
Meridian Medicaid,DRG,8162,TOXIC EFFECTS OF NONMEDICINAL SUBSTANCES,,Relative Weights,"$3,147.27 ",IP,"3,147.27","3,147.27",,,,,,
Meridian Medicaid,DRG,8163,TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES,,Relative Weights,"$3,543.13 ",IP,"3,543.13","3,543.13",,,,,,
Meridian Medicaid,DRG,8164,TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES,,Relative Weights,"$7,485.21 ",IP,"7,485.21","7,485.21",,,,,,
Meridian Medicaid,DRG,8171,OVERDOSE,,Relative Weights,"$1,970.70 ",IP,"1,970.70","1,970.70",,,,,,
Meridian Medicaid,DRG,8172,OVERDOSE,,Relative Weights,"$2,320.16 ",IP,"2,320.16","2,320.16",,,,,,
Meridian Medicaid,DRG,8173,OVERDOSE,,Relative Weights,"$3,714.94 ",IP,"3,714.94","3,714.94",,,,,,
Meridian Medicaid,DRG,8174,OVERDOSE,,Relative Weights,"$7,902.37 ",IP,"7,902.37","7,902.37",,,,,,
Meridian Medicaid,DRG,8411,EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT,,Relative Weights,"$22,662.13 ",IP,"22,662.13","22,662.13",,,,,,
Meridian Medicaid,DRG,8412,EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT,,Relative Weights,"$23,053.18 ",IP,"23,053.18","23,053.18",,,,,,
Meridian Medicaid,DRG,8413,EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT,,Relative Weights,"$35,475.26 ",IP,"35,475.26","35,475.26",,,,,,
Meridian Medicaid,DRG,8414,EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT,,Relative Weights,"$76,935.80 ",IP,"76,935.80","76,935.80",,,,,,
Meridian Medicaid,DRG,8421,BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS,,Relative Weights,"$7,378.34 ",IP,"7,378.34","7,378.34",,,,,,
Meridian Medicaid,DRG,8422,BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS,,Relative Weights,"$11,298.08 ",IP,"11,298.08","11,298.08",,,,,,
Meridian Medicaid,DRG,8423,BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS,,Relative Weights,"$20,251.94 ",IP,"20,251.94","20,251.94",,,,,,
Meridian Medicaid,DRG,8424,BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS,,Relative Weights,"$47,998.02 ",IP,"47,998.02","47,998.02",,,,,,
Meridian Medicaid,DRG,8431,EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT,,Relative Weights,"$3,499.14 ",IP,"3,499.14","3,499.14",,,,,,
Meridian Medicaid,DRG,8432,EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT,,Relative Weights,"$3,888.47 ",IP,"3,888.47","3,888.47",,,,,,
Meridian Medicaid,DRG,8433,EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT,,Relative Weights,"$4,320.07 ",IP,"4,320.07","4,320.07",,,,,,
Meridian Medicaid,DRG,8434,EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS W/O SKIN GRAFT,,Relative Weights,"$12,575.34 ",IP,"12,575.34","12,575.34",,,,,,
Meridian Medicaid,DRG,8441,PARTIAL THICKNESS BURNS WO SKIN GRAFT,,Relative Weights,"$2,201.96 ",IP,"2,201.96","2,201.96",,,,,,
Meridian Medicaid,DRG,8442,PARTIAL THICKNESS BURNS WO SKIN GRAFT,,Relative Weights,"$3,652.06 ",IP,"3,652.06","3,652.06",,,,,,
Meridian Medicaid,DRG,8443,PARTIAL THICKNESS BURNS WO SKIN GRAFT,,Relative Weights,"$7,050.86 ",IP,"7,050.86","7,050.86",,,,,,
Meridian Medicaid,DRG,8444,PARTIAL THICKNESS BURNS W/O SKIN GRAFT,,Relative Weights,"$19,183.95 ",IP,"19,183.95","19,183.95",,,,,,
Meridian Medicaid,DRG,8501,PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE,,Relative Weights,"$9,879.93 ",IP,"9,879.93","9,879.93",,,,,,
Meridian Medicaid,DRG,8502,PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE,,Relative Weights,"$12,498.36 ",IP,"12,498.36","12,498.36",,,,,,
Meridian Medicaid,DRG,8503,PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE,,Relative Weights,"$15,265.59 ",IP,"15,265.59","15,265.59",,,,,,
Meridian Medicaid,DRG,8504,"PROCEDURE W DIAG OF REHAB, AFTERCARE OR OTH CONTACT W HEALTH SERVICE",,Relative Weights,"$33,306.29 ",IP,"33,306.29","33,306.29",,,,,,
Meridian Medicaid,DRG,8601,REHABILITATION,REHABILITATION,Relative Weights,"$2,725.99 ",IP,"2,725.99","2,725.99",,,,,,
Meridian Medicaid,DRG,8602,REHABILITATION,REHABILITATION,Relative Weights,"$2,784.40 ",IP,"2,784.40","2,784.40",,,,,,
Meridian Medicaid,DRG,8603,REHABILITATION,REHABILITATION,Relative Weights,"$4,569.88 ",IP,"4,569.88","4,569.88",,,,,,
Meridian Medicaid,DRG,8604,REHABILITATION,REHABILITATION,Relative Weights,"$7,353.25 ",IP,"7,353.25","7,353.25",,,,,,
Meridian Medicaid,DRG,8611,"SIGNS, SYMPTOMS & OTHER FACTORS INFLUENCING HEALTH STATUS",,Relative Weights,"$2,528.74 ",IP,"2,528.74","2,528.74",,,,,,
Meridian Medicaid,DRG,8612,SIGNS SYMPTOMS and OTHER FACTORS INFLUENCING HEALTH STATUS,,Relative Weights,"$3,061.36 ",IP,"3,061.36","3,061.36",,,,,,
Meridian Medicaid,DRG,8613,SIGNS SYMPTOMS and OTHER FACTORS INFLUENCING HEALTH STATUS,,Relative Weights,"$4,043.10 ",IP,"4,043.10","4,043.10",,,,,,
Meridian Medicaid,DRG,8614,SIGNS SYMPTOMS and OTHER FACTORS INFLUENCING HEALTH STATUS,,Relative Weights,"$7,783.47 ",IP,"7,783.47","7,783.47",,,,,,
Meridian Medicaid,DRG,8621,OTHER AFTERCARE and CONVALESCENCE,,Relative Weights,"$2,738.70 ",IP,"2,738.70","2,738.70",,,,,,
Meridian Medicaid,DRG,8622,OTHER AFTERCARE and CONVALESCENCE,,Relative Weights,"$3,392.96 ",IP,"3,392.96","3,392.96",,,,,,
Meridian Medicaid,DRG,8623,OTHER AFTERCARE and CONVALESCENCE,,Relative Weights,"$4,971.92 ",IP,"4,971.92","4,971.92",,,,,,
Meridian Medicaid,DRG,8624,OTHER AFTERCARE and CONVALESCENCE,,Relative Weights,"$9,845.92 ",IP,"9,845.92","9,845.92",,,,,,
Meridian Medicaid,DRG,8631,NEONATAL AFTERCARE,,Relative Weights,"$4,260.96 ",IP,"4,260.96","4,260.96",,,,,,
Meridian Medicaid,DRG,8632,NEONATAL AFTERCARE,,Relative Weights,"$10,340.39 ",IP,"10,340.39","10,340.39",,,,,,
Meridian Medicaid,DRG,8633,NEONATAL AFTERCARE,,Relative Weights,"$23,505.05 ",IP,"23,505.05","23,505.05",,,,,,
Meridian Medicaid,DRG,8634,NEONATAL AFTERCARE,,Relative Weights,"$48,982.51 ",IP,"48,982.51","48,982.51",,,,,,
Meridian Medicaid,DRG,8901,HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS,,Relative Weights,"$3,464.78 ",IP,"3,464.78","3,464.78",,,,,,
Meridian Medicaid,DRG,8902,HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS,,Relative Weights,"$4,475.73 ",IP,"4,475.73","4,475.73",,,,,,
Meridian Medicaid,DRG,8903,HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS,,Relative Weights,"$6,306.22 ",IP,"6,306.22","6,306.22",,,,,,
Meridian Medicaid,DRG,8904,HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS,,Relative Weights,"$13,523.40 ",IP,"13,523.40","13,523.40",,,,,,
Meridian Medicaid,DRG,8921,HIV W MAJOR HIV RELATED CONDITION,,Relative Weights,"$3,450.69 ",IP,"3,450.69","3,450.69",,,,,,
Meridian Medicaid,DRG,8922,HIV W MAJOR HIV RELATED CONDITION,,Relative Weights,"$4,178.15 ",IP,"4,178.15","4,178.15",,,,,,
Meridian Medicaid,DRG,8923,HIV W MAJOR HIV RELATED CONDITION,,Relative Weights,"$4,816.26 ",IP,"4,816.26","4,816.26",,,,,,
Meridian Medicaid,DRG,8924,HIV W MAJOR HIV RELATED CONDITION,,Relative Weights,"$8,453.20 ",IP,"8,453.20","8,453.20",,,,,,
Meridian Medicaid,DRG,8931,HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,,Relative Weights,"$2,817.73 ",IP,"2,817.73","2,817.73",,,,,,
Meridian Medicaid,DRG,8932,HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,,Relative Weights,"$4,010.80 ",IP,"4,010.80","4,010.80",,,,,,
Meridian Medicaid,DRG,8933,HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,,Relative Weights,"$5,201.12 ",IP,"5,201.12","5,201.12",,,,,,
Meridian Medicaid,DRG,8934,HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,,Relative Weights,"$9,134.61 ",IP,"9,134.61","9,134.61",,,,,,
Meridian Medicaid,DRG,8941,HIV W ONE SIGNIF HIV COND OR W/O SIGNIF RELATED COND,,Relative Weights,"$2,969.96 ",IP,"2,969.96","2,969.96",,,,,,
Meridian Medicaid,DRG,8942,HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND,,Relative Weights,"$3,496.05 ",IP,"3,496.05","3,496.05",,,,,,
Meridian Medicaid,DRG,8943,HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND,,Relative Weights,"$4,518.34 ",IP,"4,518.34","4,518.34",,,,,,
Meridian Medicaid,DRG,8944,HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND,,Relative Weights,"$6,751.91 ",IP,"6,751.91","6,751.91",,,,,,
Meridian Medicaid,DRG,9101,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$13,920.63 ",IP,"13,920.63","13,920.63",,,,,,
Meridian Medicaid,DRG,9102,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$15,317.47 ",IP,"15,317.47","15,317.47",,,,,,
Meridian Medicaid,DRG,9103,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$18,619.37 ",IP,"18,619.37","18,619.37",,,,,,
Meridian Medicaid,DRG,9104,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$36,457.00 ",IP,"36,457.00","36,457.00",,,,,,
Meridian Medicaid,DRG,9111,EXTENSIVE ABDOMINAL/THORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA,,Relative Weights,"$7,838.80 ",IP,"7,838.80","7,838.80",,,,,,
Meridian Medicaid,DRG,9112,EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA,,Relative Weights,"$10,303.63 ",IP,"10,303.63","10,303.63",,,,,,
Meridian Medicaid,DRG,9113,EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA,,Relative Weights,"$13,414.47 ",IP,"13,414.47","13,414.47",,,,,,
Meridian Medicaid,DRG,9114,EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA,,Relative Weights,"$32,085.73 ",IP,"32,085.73","32,085.73",,,,,,
Meridian Medicaid,DRG,9121,MUSCULOSKELETAL and OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$8,688.93 ",IP,"8,688.93","8,688.93",,,,,,
Meridian Medicaid,DRG,9122,MUSCULOSKELETAL and OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$9,567.24 ",IP,"9,567.24","9,567.24",,,,,,
Meridian Medicaid,DRG,9123,MUSCULOSKELETAL & OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$14,948.76 ",IP,"14,948.76","14,948.76",,,,,,
Meridian Medicaid,DRG,9124,MUSCULOSKELETAL & OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$30,211.60 ",IP,"30,211.60","30,211.60",,,,,,
Meridian Medicaid,DRG,9301,MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE,,Relative Weights,"$3,875.76 ",IP,"3,875.76","3,875.76",,,,,,
Meridian Medicaid,DRG,9302,MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE,,Relative Weights,"$4,609.06 ",IP,"4,609.06","4,609.06",,,,,,
Meridian Medicaid,DRG,9303,MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE,,Relative Weights,"$7,139.17 ",IP,"7,139.17","7,139.17",,,,,,
Meridian Medicaid,DRG,9304,MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE,,Relative Weights,"$15,709.89 ",IP,"15,709.89","15,709.89",,,,,,
Meridian Medicaid,DRG,9501,EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$7,265.63 ",IP,"7,265.63","7,265.63",,,,,,
Meridian Medicaid,DRG,9502,EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$9,410.20 ",IP,"9,410.20","9,410.20",,,,,,
Meridian Medicaid,DRG,9503,EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$12,679.80 ",IP,"12,679.80","12,679.80",,,,,,
Meridian Medicaid,DRG,9504,EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$27,388.02 ",IP,"27,388.02","27,388.02",,,,,,
Meridian Medicaid,DRG,9511,MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$5,641.31 ",IP,"5,641.31","5,641.31",,,,,,
Meridian Medicaid,DRG,9512,MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$7,394.49 ",IP,"7,394.49","7,394.49",,,,,,
Meridian Medicaid,DRG,9513,MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$11,184.68 ",IP,"11,184.68","11,184.68",,,,,,
Meridian Medicaid,DRG,9514,MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$22,584.13 ",IP,"22,584.13","22,584.13",,,,,,
Meridian Medicaid,DRG,9521,NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$4,663.69 ",IP,"4,663.69","4,663.69",,,,,,
Meridian Medicaid,DRG,9522,NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$6,212.76 ",IP,"6,212.76","6,212.76",,,,,,
Meridian Medicaid,DRG,9523,NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$9,852.10 ",IP,"9,852.10","9,852.10",,,,,,
Meridian Medicaid,DRG,9524,NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$20,519.28 ",IP,"20,519.28","20,519.28",,,,,,
Meridian Medicaid,CPT,100,Anesth salivary gland,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,102,Anesth repair of cleft lip,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,103,Anesth blepharoplasty,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,104,Anesth electroshock,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,120,Anesth ear surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,124,Anesth ear exam,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,126,Anesth tympanotomy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,140,Anesth procedures on eye,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,142,Anesth lens surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,144,Anesth corneal transplant,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,145,Anesth vitreoretinal surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,147,Anesth iridectomy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,148,Anesth eye exam,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,160,Anesth nose/sinus surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,162,Anesth nose/sinus surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,164,Anesth biopsy of nose,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,170,Anesth procedure on mouth,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,172,Anesth cleft palate repair,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,174,Anesth pharyngeal surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,176,Anesth pharyngeal surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,190,Anesth face/skull bone surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,192,Anesth facial bone surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,210,Anesth cranial surg nos,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,211,Anesth cran surg hemotoma,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,212,Anesth skull drainage,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,214,Anesth skull drainage,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,215,Anesth skull repair/fract,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,216,Anesth head vessel surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,218,Anesth special head surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,220,Anesth intrcrn nerve,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,222,Anesth head nerve surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,300,Anesth head/neck/ptrunk,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,320,Anesth neck organ 1yr/>,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,322,Anesth biopsy of thyroid,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,326,Anesth larynx/trach < 1 yr,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,350,Anesth neck vessel surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,352,Anesth neck vessel surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,400,Anesth skin ext/per/atrunk,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,402,Anesth surgery of breast,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,404,Anesth surgery of breast,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,406,Anesth surgery of breast,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,410,Anesth correct heart rhythm,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,450,Anesth surgery of shoulder,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,454,Anesth collar bone biopsy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,470,Anesth removal of rib,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,472,Anesth chest wall repair,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,474,Anesth surgery of rib,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,500,Anesth esophageal surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,520,Anesth chest procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,522,Anesth chest lining biopsy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,524,Anesth chest drainage,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,528,Anes mediascpy & dx thorscpy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,529,Anes medscpy&thorscpy 1 lung,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,530,Anesth pacemaker insertion,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,532,Anesth vascular access,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,534,Anesth cardioverter/defib,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,537,Anesth cardiac electrophys,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,539,Anesth trach-bronch reconst,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,540,Anesth chest surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,541,Anesth one lung ventilation,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,542,Anesthesia removal pleura,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,546,Anesth lung chest wall surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,548,Anesth trachea bronchi surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,550,Anesth sternal debridement,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,560,Anesth heart surg w/o pump,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,561,Anesth heart surg <1 yr,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,562,Anesth hrt surg w/pmp age 1+,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,563,Anesth heart surg w/arrest,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,566,Anesth cabg w/o pump,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,567,Anesth cabg w/pump,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,580,Anesth heart/lung transplnt,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,600,Anesth spine cord surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,604,Anesth sitting procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,620,Anesth spine cord surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,625,Anes spine tranthor w/o vent,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,626,Anes spine transthor w/vent,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,630,Anesth spine cord surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,632,Anesth removal of nerves,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,635,Anesth lumbar puncture,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,640,Anesth spine manipulation,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,670,Anesth spine cord surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,700,Anesth abdominal wall surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,702,Anesth for liver biopsy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,730,Anesth abdominal wall surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,731,Anes upr gi ndsc px nos,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,732,Anes upr gi ndsc px ercp,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,740,Anesth upper gi visualize,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,750,Anesth repair of hernia,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,752,Anesth repair of hernia,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,754,Anesth repair of hernia,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,756,Anesth repair of hernia,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,770,Anesth blood vessel repair,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,790,Anesth surg upper abdomen,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,792,Anesth hemorr/excise liver,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,794,Anesth pancreas removal,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,796,Anesth for liver transplant,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,797,Anesth surgery for obesity,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,800,Anesth abdominal wall surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,802,Anesth fat layer removal,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,810,Anesth low intestine scope,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,811,Anes lwr intst ndsc nos,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,812,Anes lwr intst scr colsc,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,813,Anes upr lwr gi ndsc px,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,820,Anesth abdominal wall surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,830,Anesth repair of hernia,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,832,Anesth repair of hernia,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,834,Anesth hernia repair < 1 yr,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,836,Anesth hernia repair preemie,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,840,Anesth surg lower abdomen,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,842,Anesth amniocentesis,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,844,Anesth pelvis surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,846,Anesth hysterectomy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,848,Anesth pelvic organ surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,851,Anesth tubal ligation,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,860,Anesth surgery of abdomen,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,862,Anesth kidney/ureter surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,864,Anesth removal of bladder,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,865,Anesth removal of prostate,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,866,Anesth removal of adrenal,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,868,Anesth kidney transplant,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,870,Anesth bladder stone surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,872,Anesth kidney stone destruct,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,873,Anesth kidney stone destruct,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,880,Anesth abdomen vessel surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,882,Anesth major vein ligation,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,902,Anesth anorectal surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,904,Anesth perineal surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,906,Anesth removal of vulva,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,908,Anesth removal of prostate,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,910,Anesth bladder surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,912,Anesth bladder tumor surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,914,Anesth removal of prostate,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,916,Anesth bleeding control,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,918,Anesth stone removal,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,920,Anesth genitalia surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,921,Anesth vasectomy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,922,Anesth sperm duct surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,924,Anesth testis exploration,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,926,Anesth removal of testis,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,928,Anesth removal of testis,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,930,Anesth testis suspension,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,932,Anesth amputation of penis,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,934,Anesth penis nodes removal,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,936,Anesth penis nodes removal,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,938,Anesth insert penis device,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,940,Anesth vaginal procedures,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,942,Anesth surg on vag/urethral,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,944,Anesth vaginal hysterectomy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,948,Anesth repair of cervix,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,950,Anesth vaginal endoscopy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,952,Anesth hysteroscope/graph,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1112,Anesth bone aspirate/bx,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1120,Anesth pelvis surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1130,Anesth body cast procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1140,Anesth amputation at pelvis,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1150,Anesth pelvic tumor surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1160,Anesth pelvis procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1170,Anesth pelvis surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1173,Anesth fx repair pelvis,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1180,Anesth pelvis nerve removal,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1190,Anesth pelvis nerve removal,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1200,Anesth hip joint procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1202,Anesth arthroscopy of hip,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1210,Anesth hip joint surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1212,Anesth hip disarticulation,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1214,Anesth hip arthroplasty,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1215,Anesth revise hip repair,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1220,Anesth procedure on femur,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1230,Anesth surgery of femur,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1232,Anesth amputation of femur,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1234,Anesth radical femur surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1250,Anesth upper leg surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1260,Anesth upper leg veins surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1270,Anesth thigh arteries surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1272,Anesth femoral artery surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1274,Anesth femoral embolectomy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1320,Anesth knee area surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1340,Anesth knee area procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1360,Anesth knee area surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1380,Anesth knee joint procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1382,Anesth dx knee arthroscopy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1390,Anesth knee area procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1392,Anesth knee area surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1400,Anesth knee joint surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1402,Anesth knee arthroplasty,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1404,Anesth amputation at knee,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1420,Anesth knee joint casting,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1430,Anesth knee veins surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1432,Anesth knee vessel surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1440,Anesth knee arteries surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1442,Anesth knee artery surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1444,Anesth knee artery repair,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1462,Anesth lower leg procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1464,Anesth ankle/ft arthroscopy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1470,Anesth lower leg surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1472,Anesth achilles tendon surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1474,Anesth lower leg surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1480,Anesth lower leg bone surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1482,Anesth radical leg surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1484,Anesth lower leg revision,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1486,Anesth ankle replacement,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1490,Anesth lower leg casting,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1500,Anesth leg arteries surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1502,Anesth lwr leg embolectomy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1520,Anesth lower leg vein surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1522,Anesth lower leg vein surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1610,Anesth surgery of shoulder,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1620,Anesth shoulder procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1622,Anes dx shoulder arthroscopy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1630,Anesth surgery of shoulder,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1634,Anesth shoulder joint amput,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1636,Anesth forequarter amput,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1638,Anesth shoulder replacement,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1650,Anesth shoulder artery surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1652,Anesth shoulder vessel surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1654,Anesth shoulder vessel surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1656,Anesth arm-leg vessel surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1670,Anesth shoulder vein surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1680,Anesth shoulder casting,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1682,Anesth airplane cast,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1710,Anesth elbow area surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1712,Anesth uppr arm tendon surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1714,Anesth uppr arm tendon surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1716,Anesth biceps tendon repair,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1730,Anesth uppr arm procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1732,Anesth dx elbow arthroscopy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1740,Anesth upper arm surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1742,Anesth humerus surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1744,Anesth humerus repair,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1756,Anesth radical humerus surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1758,Anesth humeral lesion surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1760,Anesth elbow replacement,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1770,Anesth uppr arm artery surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1772,Anesth uppr arm embolectomy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1780,Anesth upper arm vein surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1782,Anesth uppr arm vein repair,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1810,Anesth lower arm surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1820,Anesth lower arm procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1829,Anesth dx wrist arthroscopy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1830,Anesth lower arm surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1832,Anesth wrist replacement,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1840,Anesth lwr arm artery surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1842,Anesth lwr arm embolectomy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1844,Anesth vascular shunt surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1850,Anesth lower arm vein surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1852,Anesth lwr arm vein repair,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1860,Anesth lower arm casting,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1916,Anesth dx arteriography,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1920,Anesth catheterize heart,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1922,Anesth cat or mri scan,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1924,Anes ther interven rad artrl,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1925,Anes ther interven rad card,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1926,Anes tx interv rad hrt/cran,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1930,Anes ther interven rad vein,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1931,Anes ther interven rad tips,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1932,Anes tx interv rad th vein,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1933,Anes tx interv rad cran vein,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1935,Anesth perc img dx sp proc,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1936,Anesth perc img tx sp proc,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1951,Anesth burn less 4 percent,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1952,Anesth burn 4-9 percent,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1953,Anesth burn each 9 percent,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1958,Anesth antepartum manipul,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1960,Anesth vaginal delivery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1961,Anesth cs delivery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1962,Anesth emer hysterectomy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1963,Anesth cs hysterectomy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1965,Anesth inc/missed ab proc,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1966,Anesth induced ab procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1967,Anesth/analg vag delivery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1968,Anes/analg cs deliver add-on,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1969,Anesth/analg cs hyst add-on,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1991,Anesth nerve block/inj,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1992,Anesth n block/inj prone,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1996,Hosp manage cont drug admin,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,1999,Unlisted anesth procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,10004,Fna bx w/o img gdn ea addl,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
Meridian Medicaid,CPT,10005,Fna bx w/us gdn 1st les,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
Meridian Medicaid,CPT,10006,Fna bx w/us gdn ea addl,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
Meridian Medicaid,CPT,10007,Fna bx w/fluor gdn 1st les,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
Meridian Medicaid,CPT,10008,Fna bx w/fluor gdn ea addl,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
Meridian Medicaid,CPT,10009,Fna bx w/ct gdn 1st les,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
Meridian Medicaid,CPT,10010,Fna bx w/ct gdn ea addl,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
Meridian Medicaid,CPT,10011,Fna bx w/mr gdn 1st les,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
Meridian Medicaid,CPT,10012,Fna bx w/mr gdn ea addl,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
Meridian Medicaid,CPT,10021,Fna bx w/o img gdn 1st les,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
Meridian Medicaid,CPT,10022,Fna w/image,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
Meridian Medicaid,CPT,10030,Guide cathet fluid drainage,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
Meridian Medicaid,CPT,10040,Acne surgery,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,10060,Drainage of skin abscess,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,10061,Drainage of skin abscess,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,10080,Drainage of pilonidal cyst,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,10081,Drainage of pilonidal cyst,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
Meridian Medicaid,CPT,10120,Remove foreign body,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,10121,Remove foreign body,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Meridian Medicaid,CPT,10140,Drainage of hematoma/fluid,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
Meridian Medicaid,CPT,10160,Puncture drainage of lesion,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,11055,Trim skin lesion,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,11056,Trim skin lesions 2 to 4,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,11057,Trim skin lesions over 4,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,11100,Biopsy skin lesion,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,11101,Biopsy skin add-on,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,11102,Tangntl bx skin single les,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,11103,Tangntl bx skin ea sep/addl,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,11104,Punch bx skin single lesion,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,11105,Punch bx skin ea sep/addl,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,11106,Incal bx skn single les,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,11107,Incal bx skn ea sep/addl,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,11200,Removal of skin tags <w/15,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,11201,Remove skin tags add-on,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,11300,Shave skin lesion 0.5 cm/<,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,11301,Shave skin lesion 0.6-1.0 cm,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,11302,Shave skin lesion 1.1-2.0 cm,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,11303,Shave skin lesion >2.0 cm,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,11305,Shave skin lesion 0.5 cm/<,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,11306,Shave skin lesion 0.6-1.0 cm,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,11307,Shave skin lesion 1.1-2.0 cm,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,11308,Shave skin lesion >2.0 cm,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,11310,Shave skin lesion 0.5 cm/<,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,11311,Shave skin lesion 0.6-1.0 cm,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,11312,Shave skin lesion 1.1-2.0 cm,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,11313,Shave skin lesion >2.0 cm,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,11400,Exc tr-ext b9+marg 0.5 cm<,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,11401,Exc tr-ext b9+marg 0.6-1 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,11402,Exc tr-ext b9+marg 1.1-2 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,11403,Exc tr-ext b9+marg 2.1-3cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,11404,Exc tr-ext b9+marg 3.1-4 cm,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Meridian Medicaid,CPT,11406,Exc tr-ext b9+marg >4.0 cm,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Meridian Medicaid,CPT,11420,Exc h-f-nk-sp b9+marg 0.5/<,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Meridian Medicaid,CPT,11421,Exc h-f-nk-sp b9+marg 0.6-1,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,11422,Exc h-f-nk-sp b9+marg 1.1-2,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Meridian Medicaid,CPT,11423,Exc h-f-nk-sp b9+marg 2.1-3,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Meridian Medicaid,CPT,11424,Exc h-f-nk-sp b9+marg 3.1-4,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Meridian Medicaid,CPT,11426,Exc h-f-nk-sp b9+marg >4 cm,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Meridian Medicaid,CPT,11440,Exc face-mm b9+marg 0.5 cm/<,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,11441,Exc face-mm b9+marg 0.6-1 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,11442,Exc face-mm b9+marg 1.1-2 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,11443,Exc face-mm b9+marg 2.1-3 cm,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Meridian Medicaid,CPT,11444,Exc face-mm b9+marg 3.1-4 cm,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Meridian Medicaid,CPT,11446,Exc face-mm b9+marg >4 cm,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Meridian Medicaid,CPT,11450,Removal sweat gland lesion,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Meridian Medicaid,CPT,11451,Removal sweat gland lesion,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Meridian Medicaid,CPT,11462,Removal sweat gland lesion,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Meridian Medicaid,CPT,11463,Removal sweat gland lesion,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Meridian Medicaid,CPT,11470,Removal sweat gland lesion,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Meridian Medicaid,CPT,11471,Removal sweat gland lesion,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Meridian Medicaid,CPT,11600,Exc tr-ext mal+marg 0.5 cm/<,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,11601,Exc tr-ext mal+marg 0.6-1 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,11602,Exc tr-ext mal+marg 1.1-2 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,11603,Exc tr-ext mal+marg 2.1-3 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,11604,Exc tr-ext mal+marg 3.1-4 cm,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Meridian Medicaid,CPT,11606,Exc tr-ext mal+marg >4 cm,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Meridian Medicaid,CPT,11620,Exc h-f-nk-sp mal+marg 0.5/<,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Meridian Medicaid,CPT,11621,Exc s/n/h/f/g mal+mrg 0.6-1,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,11622,Exc s/n/h/f/g mal+mrg 1.1-2,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,11623,Exc s/n/h/f/g mal+mrg 2.1-3,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Meridian Medicaid,CPT,11624,Exc s/n/h/f/g mal+mrg 3.1-4,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Meridian Medicaid,CPT,11626,Exc s/n/h/f/g mal+mrg >4 cm,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Meridian Medicaid,CPT,11640,Exc f/e/e/n/l mal+mrg 0.5cm<,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,11641,Exc f/e/e/n/l mal+mrg 0.6-1,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,11642,Exc f/e/e/n/l mal+mrg 1.1-2,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,11643,Exc f/e/e/n/l mal+mrg 2.1-3,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Meridian Medicaid,CPT,11644,Exc f/e/e/n/l mal+mrg 3.1-4,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Meridian Medicaid,CPT,11646,Exc f/e/e/n/l mal+mrg >4 cm,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Meridian Medicaid,CPT,11719,Trim nail(s) any number,General Surgery,Per Unit,$46.77 ,OP,46.77,46.77,,,,,,
Meridian Medicaid,CPT,11720,Debride nail 1-5,General Surgery,Per Unit,$46.77 ,OP,46.77,46.77,,,,,,
Meridian Medicaid,CPT,11721,Debride nail 6 or more,General Surgery,Per Unit,$46.77 ,OP,46.77,46.77,,,,,,
Meridian Medicaid,CPT,11730,Removal of nail plate,General Surgery,Per Unit,$46.77 ,OP,46.77,46.77,,,,,,
Meridian Medicaid,CPT,11732,Remove nail plate add-on,General Surgery,Per Unit,$46.77 ,OP,46.77,46.77,,,,,,
Meridian Medicaid,CPT,11740,Drain blood from under nail,General Surgery,Per Unit,$46.77 ,OP,46.77,46.77,,,,,,
Meridian Medicaid,CPT,11750,Removal of nail bed,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,11752,Remove nail bed/tip,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Meridian Medicaid,CPT,11755,Biopsy nail unit,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,11760,Repair of nail bed,General Surgery,Per Unit,$46.77 ,OP,46.77,46.77,,,,,,
Meridian Medicaid,CPT,11762,Reconstruction of nail bed,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Meridian Medicaid,CPT,11765,Excision of nail fold toe,General Surgery,Per Unit,$46.77 ,OP,46.77,46.77,,,,,,
Meridian Medicaid,CPT,11770,Remove pilonidal cyst simple,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Meridian Medicaid,CPT,11771,Remove pilonidal cyst exten,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Meridian Medicaid,CPT,11772,Remove pilonidal cyst compl,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Meridian Medicaid,CPT,11900,Inject skin lesions </w 7,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,11901,Inject skin lesions >7,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,11920,Correct skin color 6.0 cm/<,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,11921,Correct skn color 6.1-20.0cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,11922,Correct skin color ea 20.0cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,11950,Tx contour defects 1 cc/<,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,11951,Tx contour defects 1.1-5.0cc,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,11952,Tx contour defects 5.1-10cc,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,11954,Tx contour defects >10.0 cc,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Meridian Medicaid,CPT,11960,Insert tissue expander(s),General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Meridian Medicaid,CPT,11971,Rmvl tis xpndr wo insj implt,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Meridian Medicaid,CPT,11976,Remove contraceptive capsule,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,11980,Implant hormone pellet(s),General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,11981,Insert drug implant device,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,11982,Remove drug implant device,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,11983,Remove/insert drug implant,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
Meridian Medicaid,CPT,13100,Cmplx rpr trunk 1.1-2.5 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,13101,Cmplx rpr trunk 2.6-7.5 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,13102,Cmplx rpr trunk addl 5cm/<,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,13120,Cmplx rpr s/a/l 1.1-2.5 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,13121,Cmplx rpr s/a/l 2.6-7.5 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,13122,Cmplx rpr s/a/l addl 5 cm/>,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,13131,Cmplx rpr f/c/c/m/n/ax/g/h/f,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,13132,Cmplx rpr f/c/c/m/n/ax/g/h/f,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,13133,Cmplx rpr f/c/c/m/n/ax/g/h/f,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,13151,Cmplx rpr e/n/e/l 1.1-2.5 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,13152,Cmplx rpr e/n/e/l 2.6-7.5 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,13153,Cmplx rpr e/n/e/l addl 5cm/<,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Meridian Medicaid,CPT,15050,Skin pinch graft,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,15775,Hair trnspl 1-15 punch grfts,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,15776,Hair trnspl >15 punch grafts,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,15780,Dermabrasion total face,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
Meridian Medicaid,CPT,15781,Dermabrasion segmental face,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
Meridian Medicaid,CPT,15782,Dermabrasion other than face,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
Meridian Medicaid,CPT,15783,Dermabrasion suprfl any site,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
Meridian Medicaid,CPT,15786,Abrasion lesion single,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,15787,Abrasion lesions add-on,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,15788,Chemical peel face epiderm,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,15789,Chemical peel face dermal,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,15792,Chemical peel nonfacial,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,15793,Chemical peel nonfacial,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
Meridian Medicaid,CPT,15819,Plastic surgery neck,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Meridian Medicaid,CPT,15820,Revision of lower eyelid,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Meridian Medicaid,CPT,15821,Revision of lower eyelid,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Meridian Medicaid,CPT,15822,Revision of upper eyelid,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Meridian Medicaid,CPT,15823,Revision of upper eyelid,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Meridian Medicaid,CPT,15824,Removal of forehead wrinkles,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Meridian Medicaid,CPT,15825,Removal of neck wrinkles,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Meridian Medicaid,CPT,15826,Removal of brow wrinkles,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Meridian Medicaid,CPT,15828,Removal of face wrinkles,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Meridian Medicaid,CPT,15829,Removal of skin wrinkles,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Meridian Medicaid,CPT,15830,Exc skin abd,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Meridian Medicaid,CPT,15832,Excise excessive skin thigh,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Meridian Medicaid,CPT,15833,Excise excessive skin leg,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Meridian Medicaid,CPT,15834,Excise excessive skin hip,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Meridian Medicaid,CPT,15835,Excise excessive skin buttck,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Meridian Medicaid,CPT,15836,Excise excessive skin arm,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Meridian Medicaid,CPT,15837,Excise excess skin arm/hand,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Meridian Medicaid,CPT,15838,Excise excess skin fat pad,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Meridian Medicaid,CPT,15839,Excise excess skin & tissue,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Meridian Medicaid,CPT,15847,Exc skin abd add-on,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Meridian Medicaid,CPT,15850,Remove sutures same surgeon,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Meridian Medicaid,CPT,15851,Remove sutures diff surgeon,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Meridian Medicaid,CPT,15876,Suction lipectomy head&neck,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Meridian Medicaid,CPT,15877,Suction lipectomy trunk,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Meridian Medicaid,CPT,15878,Suction lipectomy upr extrem,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Meridian Medicaid,CPT,15879,Suction lipectomy lwr extrem,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Meridian Medicaid,CPT,17000,Destruct premalg lesion,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,17003,Destruct premalg les 2-14,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,17004,Destroy premal lesions 15/>,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,17106,Destruction of skin lesions,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
Meridian Medicaid,CPT,17107,Destruction of skin lesions,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
Meridian Medicaid,CPT,17108,Destruction of skin lesions,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
Meridian Medicaid,CPT,17110,Destruct b9 lesion 1-14,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,17111,Destruct lesion 15 or more,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,17250,Chem caut of granltj tissue,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,17260,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,17261,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,17262,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,17263,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,17264,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,17266,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,17270,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,17271,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,17272,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,17273,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,17274,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,17276,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,17280,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,17281,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,17282,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,17283,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,17284,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,17286,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,17340,Cryotherapy of skin,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,17360,Skin peel therapy,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,17380,Hair removal by electrolysis,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,17999,Skin tissue procedure,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,19000,Drainage of breast lesion,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
Meridian Medicaid,CPT,19001,Drain breast lesion add-on,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
Meridian Medicaid,CPT,19020,Incision of breast lesion,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Meridian Medicaid,CPT,19081,Bx breast 1st lesion strtctc,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Meridian Medicaid,CPT,19082,Bx breast add lesion strtctc,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Meridian Medicaid,CPT,19083,Bx breast 1st lesion us imag,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Meridian Medicaid,CPT,19084,Bx breast add lesion us imag,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Meridian Medicaid,CPT,19085,Bx breast 1st lesion mr imag,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Meridian Medicaid,CPT,19086,Bx breast add lesion mr imag,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Meridian Medicaid,CPT,19100,Bx breast percut w/o image,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Meridian Medicaid,CPT,19101,Biopsy of breast open,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Meridian Medicaid,CPT,19105,Cryosurg ablate fa each,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Meridian Medicaid,CPT,19110,Nipple exploration,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Meridian Medicaid,CPT,19112,Excise breast duct fistula,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Meridian Medicaid,CPT,19120,Removal of breast lesion,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Meridian Medicaid,CPT,19125,Excision breast lesion,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Meridian Medicaid,CPT,19126,Excision addl breast lesion,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Meridian Medicaid,CPT,19294,Prep tum cav iort prtl mast,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
Meridian Medicaid,CPT,19297,Place breast cath for rad,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Meridian Medicaid,CPT,19298,Place breast rad tube/caths,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Meridian Medicaid,CPT,19300,Removal of breast tissue,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Meridian Medicaid,CPT,19301,Partial mastectomy,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Meridian Medicaid,CPT,19302,P-mastectomy w/ln removal,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Meridian Medicaid,CPT,19303,Mast simple complete,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Meridian Medicaid,CPT,19304,Mast subq,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Meridian Medicaid,CPT,19305,Mast radical,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
Meridian Medicaid,CPT,19306,Mast rad urban type,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
Meridian Medicaid,CPT,19307,Mast mod rad,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
Meridian Medicaid,CPT,19316,Suspension of breast,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Meridian Medicaid,CPT,19318,Breast reduction,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
Meridian Medicaid,CPT,19324,Enlarge breast,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Meridian Medicaid,CPT,19325,Breast augmentation w/implt,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Meridian Medicaid,CPT,19328,Rmvl intact breast implant,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Meridian Medicaid,CPT,19330,Rmvl ruptured breast implant,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Meridian Medicaid,CPT,19340,Insj breast implt sm d mast,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Meridian Medicaid,CPT,19342,Insj/rplcmt brst implt sep d,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Meridian Medicaid,CPT,19350,Breast reconstruction,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Meridian Medicaid,CPT,19355,Correct inverted nipple(s),General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Meridian Medicaid,CPT,19357,Tiss xpndr plmt brst rcnstj,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
Meridian Medicaid,CPT,19361,Brst rcnstj latsms drsi flap,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
Meridian Medicaid,CPT,19364,Brst rcnstj free flap,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
Meridian Medicaid,CPT,19366,Breast reconstruction,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
Meridian Medicaid,CPT,19367,Brst rcnstj 1 pdcl tram flap,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Meridian Medicaid,CPT,19368,Brst rcnstj 1pdcl tram anast,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
Meridian Medicaid,CPT,19369,Brst rcnstj 2 pdcl tram flap,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Meridian Medicaid,CPT,19370,Revj peri-implt capsule brst,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Meridian Medicaid,CPT,19371,Peri-implt capslc brst compl,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Meridian Medicaid,CPT,19380,Revj reconstructed breast,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Meridian Medicaid,CPT,19396,Design custom breast implant,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Meridian Medicaid,CPT,19499,Breast surgery procedure,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Meridian Medicaid,CPT,20206,Needle biopsy muscle,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
Meridian Medicaid,CPT,20220,Bone biopsy trocar/needle,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
Meridian Medicaid,CPT,20500,Injection of sinus tract,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,20526,Ther injection carp tunnel,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
Meridian Medicaid,CPT,20527,Inj dupuytren cord w/enzyme,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
Meridian Medicaid,CPT,20550,Inj tendon sheath/ligament,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
Meridian Medicaid,CPT,20551,Inj tendon origin/insertion,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
Meridian Medicaid,CPT,20552,Inj trigger point 1/2 muscl,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
Meridian Medicaid,CPT,20553,Inject trigger points 3/>,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
Meridian Medicaid,CPT,20560,Ndl insj w/o njx 1 or 2 musc,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,20561,Ndl insj w/o njx 3+ musc,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,20600,Drain/inj joint/bursa w/o us,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
Meridian Medicaid,CPT,20605,Drain/inj joint/bursa w/o us,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
Meridian Medicaid,CPT,20610,Drain/inj joint/bursa w/o us,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
Meridian Medicaid,CPT,20612,Aspirate/inj ganglion cyst,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
Meridian Medicaid,CPT,20822,Replantation digit complete,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,20824,Replantation thumb complete,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,20827,Replantation thumb complete,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,20957,Mt bone graft microvasc,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,20972,Bone/skin graft metatarsal,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,20973,Bone/skin graft great toe,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,20999,Musculoskeletal surgery,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,21010,Incision of jaw joint,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,21025,Excision of bone lower jaw,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,21030,Excise max/zygoma b9 tumor,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Meridian Medicaid,CPT,21031,Remove exostosis mandible,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Meridian Medicaid,CPT,21032,Remove exostosis maxilla,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,21034,Excise max/zygoma mal tumor,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,21040,Excise mandible lesion,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,21044,Removal of jaw bone lesion,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,21045,Extensive jaw surgery,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,21046,Remove mandible cyst complex,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Meridian Medicaid,CPT,21047,Excise lwr jaw cyst w/repair,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,21048,Remove maxilla cyst complex,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,21049,Excis uppr jaw cyst w/repair,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,21050,Removal of jaw joint,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,21060,Remove jaw joint cartilage,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,21070,Remove coronoid process,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,21073,Mnpj of tmj w/anesth,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,21076,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Meridian Medicaid,CPT,21077,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Meridian Medicaid,CPT,21079,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Meridian Medicaid,CPT,21080,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Meridian Medicaid,CPT,21081,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Meridian Medicaid,CPT,21082,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Meridian Medicaid,CPT,21083,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Meridian Medicaid,CPT,21084,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Meridian Medicaid,CPT,21085,Prepare face/oral prosthesis,Dental,Per Unit,$30.61 ,OP,30.61,30.61,,,,,,
Meridian Medicaid,CPT,21086,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Meridian Medicaid,CPT,21087,Prepare face/oral prosthesis,Dental,Per Unit,$30.61 ,OP,30.61,30.61,,,,,,
Meridian Medicaid,CPT,21088,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Meridian Medicaid,CPT,21089,Prepare face/oral prosthesis,Dental,Per Unit,$30.61 ,OP,30.61,30.61,,,,,,
Meridian Medicaid,CPT,21100,Maxillofacial fixation,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Meridian Medicaid,CPT,21110,Interdental fixation,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,21120,Reconstruction of chin,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,21121,Reconstruction of chin,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,21122,Reconstruction of chin,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Meridian Medicaid,CPT,21123,Reconstruction of chin,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,21125,Augmentation lower jaw bone,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,21127,Augmentation lower jaw bone,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,21138,Reduction of forehead,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,21172,Reconstruct orbit/forehead,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,21175,Reconstruct orbit/forehead,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,21193,Reconst lwr jaw w/o graft,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,21195,Reconst lwr jaw w/o fixation,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,21196,Reconst lwr jaw w/fixation,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,21198,Reconstr lwr jaw segment,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,21199,Reconstr lwr jaw w/advance,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,21206,Reconstruct upper jaw bone,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,21215,Lower jaw bone graft,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,21235,Ear cartilage graft,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,21240,Reconstruction of jaw joint,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,21242,Reconstruction of jaw joint,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,21243,Reconstruction of jaw joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Meridian Medicaid,CPT,21244,Reconstruction of lower jaw,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,21245,Reconstruction of jaw,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,21246,Reconstruction of jaw,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,21248,Reconstruction of jaw,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,21249,Reconstruction of jaw,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,21270,Augmentation cheek bone,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,21280,Revision of eyelid,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,21282,Revision of eyelid,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,21295,Revision of jaw muscle/bone,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,21296,Revision of jaw muscle/bone,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,21315,Closed tx nose fx w/o stablj,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,21320,Closed tx nose fx w/ stablj,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,21336,Open tx septal fx w/wo stabj,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,21337,Closed tx septal&nose fx,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,21345,Closed tx nose/jaw fx,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,21346,Opn tx nasomax fx w/fixj,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,21400,Closed tx orbit w/o manipulj,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,21401,Closed tx orbit w/manipulj,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,21421,Treat mouth roof fracture,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Meridian Medicaid,CPT,21422,Treat mouth roof fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,21440,Treat dental ridge fracture,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Meridian Medicaid,CPT,21445,Treat dental ridge fracture,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Meridian Medicaid,CPT,21450,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,21451,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,21452,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Meridian Medicaid,CPT,21453,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,21454,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,21461,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,21462,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,21465,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,21470,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,21485,Reset dislocated jaw,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,21490,Repair dislocated jaw,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,21495,Treat hyoid bone fracture,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,21497,Interdental wiring,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,21685,Hyoid myotomy & suspension,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,21805,Treatment of rib fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,21811,Optx of rib fx w/fixj scope,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,21812,Treatment of rib fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,21813,Treatment of rib fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,21820,Treat sternum fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,21825,Treat sternum fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,22305,Closed tx spine process fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,22310,Closed tx vert fx w/o manj,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,22315,Closed tx vert fx w/manj,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,22505,Manipulation of spine,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Meridian Medicaid,CPT,22515,Perq vertebral augmentation,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"7,098.75","7,098.75",,,,,,
Meridian Medicaid,CPT,22999,Abdomen surgery procedure,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,23470,Reconstruct shoulder joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Meridian Medicaid,CPT,23472,Reconstruct shoulder joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Meridian Medicaid,CPT,23473,Revis reconst shoulder joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Meridian Medicaid,CPT,23474,Revis reconst shoulder joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Meridian Medicaid,CPT,23500,Treat clavicle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,23505,Treat clavicle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,23515,Treat clavicle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,23520,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,23525,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,23530,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,23532,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,23540,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,23545,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,23550,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,23552,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,23570,Treat shoulder blade fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,23575,Treat shoulder blade fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,23585,Treat scapula fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,23600,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,23605,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,23615,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,23616,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,23620,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,23625,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,23630,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,23650,Treat shoulder dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,23655,Treat shoulder dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Meridian Medicaid,CPT,23660,Treat shoulder dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,23665,Treat dislocation/fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,23670,Treat dislocation/fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,23675,Treat dislocation/fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,23680,Treat dislocation/fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,23700,Fixation of shoulder,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Meridian Medicaid,CPT,23929,Shoulder surgery procedure,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,24300,Manipulate elbow w/anesth,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Meridian Medicaid,CPT,24360,Reconstruct elbow joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
Meridian Medicaid,CPT,24361,Reconstruct elbow joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Meridian Medicaid,CPT,24362,Reconstruct elbow joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Meridian Medicaid,CPT,24363,Replace elbow joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Meridian Medicaid,CPT,24365,Reconstruct head of radius,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Meridian Medicaid,CPT,24366,Reconstruct head of radius,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Meridian Medicaid,CPT,24370,Revise reconst elbow joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Meridian Medicaid,CPT,24371,Revise reconst elbow joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Meridian Medicaid,CPT,24500,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,24505,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,24515,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,24516,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,24530,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,24535,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,24538,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,24545,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,24546,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,24560,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,24565,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,24566,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,24575,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,24576,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,24577,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,24579,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,24582,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,24586,Treat elbow fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,24587,Treat elbow fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,24600,Treat elbow dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,24605,Treat elbow dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Meridian Medicaid,CPT,24615,Treat elbow dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,24620,Treat elbow fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,24635,Treat elbow fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,24640,Treat elbow dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,24650,Treat radius fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,24655,Treat radius fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,24665,Treat radius fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,24666,Treat radius fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,24670,Treat ulnar fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,24675,Treat ulnar fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,24685,Treat ulnar fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,24999,Upper arm/elbow surgery,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,25001,Incise flexor carpi radialis,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,25111,Remove wrist tendon lesion,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,25112,Reremove wrist tendon lesion,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,25136,Remove & graft wrist lesion,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,25210,Removal of wrist bone,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,25215,Removal of wrist bones,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,25259,Manipulate wrist w/anesthes,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Meridian Medicaid,CPT,25315,Revise palsy hand tendon(s),Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,25316,Revise palsy hand tendon(s),Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,25332,Revise wrist joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
Meridian Medicaid,CPT,25394,Repair carpal bone shorten,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,25430,Vasc graft into carpal bone,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,25431,Repair nonunion carpal bone,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,25441,Reconstruct wrist joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Meridian Medicaid,CPT,25442,Reconstruct wrist joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Meridian Medicaid,CPT,25443,Reconstruct wrist joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
Meridian Medicaid,CPT,25444,Reconstruct wrist joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Meridian Medicaid,CPT,25445,Reconstruct wrist joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
Meridian Medicaid,CPT,25446,Wrist replacement,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Meridian Medicaid,CPT,25447,Repair wrist joints,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
Meridian Medicaid,CPT,25449,Remove wrist joint implant,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
Meridian Medicaid,CPT,25500,Treat fracture of radius,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,25505,Treat fracture of radius,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,25515,Treat fracture of radius,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,25520,Treat fracture of radius,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,25525,Treat fracture of radius,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,25526,Treat fracture of radius,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,25530,Treat fracture of ulna,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,25535,Treat fracture of ulna,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,25545,Treat fracture of ulna,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,25560,Treat fracture radius & ulna,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,25565,Treat fracture radius & ulna,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,25574,Treat fracture radius & ulna,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,25575,Treat fracture radius/ulna,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,25600,Treat fracture radius/ulna,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,25605,Treat fracture radius/ulna,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,25606,Treat fx distal radial,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,25607,Treat fx rad extra-articul,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,25608,Treat fx rad intra-articul,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,25609,Treat fx radial 3+ frag,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,25622,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,25624,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,25628,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,25630,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,25635,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,25645,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,25650,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,25651,Pin ulnar styloid fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,25652,Treat fracture ulnar styloid,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,25660,Treat wrist dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,25670,Treat wrist dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,25671,Pin radioulnar dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,25675,Treat wrist dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,25676,Treat wrist dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,25680,Treat wrist fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,25685,Treat wrist fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,25690,Treat wrist dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,25695,Treat wrist dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,25820,Fusion of hand bones,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,25825,Fuse hand bones with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,25929,Amputation follow-up surgery,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,25999,Forearm or wrist surgery,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,26010,Drainage of finger abscess,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,26011,Drainage of finger abscess,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
Meridian Medicaid,CPT,26020,Drain hand tendon sheath,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26025,Drainage of palm bursa,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26030,Drainage of palm bursas,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26034,Treat hand bone lesion,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26035,Decompress fingers/hand,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26037,Decompress fingers/hand,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26040,Release palm contracture,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26045,Release palm contracture,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26055,Incise finger tendon sheath,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26060,Incision of finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26070,Explore/treat hand joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26075,Explore/treat finger joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26080,Explore/treat finger joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26100,Biopsy hand joint lining,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26105,Biopsy finger joint lining,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26110,Biopsy finger joint lining,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26111,Exc hand les sc 1.5 cm/>,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26113,Exc hand tum deep 1.5 cm/>,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26115,Exc hand les sc < 1.5 cm,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26116,Exc hand tum deep < 1.5 cm,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26117,Rad resect hand tumor < 3 cm,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26118,Rad resect hand tumor 3 cm/>,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26121,Release palm contracture,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26123,Release palm contracture,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26125,Release palm contracture,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26130,Remove wrist joint lining,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26135,Revise finger joint each,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26140,Revise finger joint each,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26145,Tendon excision palm/finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26160,Remove tendon sheath lesion,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26170,Removal of palm tendon each,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26180,Removal of finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26185,Remove finger bone,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26200,Remove hand bone lesion,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26205,Remove/graft bone lesion,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26210,Removal of finger lesion,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26215,Remove/graft finger lesion,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26230,Partial removal of hand bone,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26235,Partial removal finger bone,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26236,Partial removal finger bone,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26250,Extensive hand surgery,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26260,Resect prox finger tumor,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26262,Resect distal finger tumor,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26320,Removal of implant from hand,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26340,Manipulate finger w/anesth,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Meridian Medicaid,CPT,26341,Manipulat palm cord post inj,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,26350,Repair finger/hand tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26352,Repair/graft hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26356,Repair finger/hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26357,Repair finger/hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26358,Repair/graft hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26370,Repair finger/hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26372,Repair/graft hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26373,Repair finger/hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26390,Revise hand/finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26392,Repair/graft hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26410,Repair hand tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26412,Repair/graft hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26415,Excision hand/finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26416,Graft hand or finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26418,Repair finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26420,Repair/graft finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26426,Repair finger/hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26428,Repair/graft finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26432,Repair finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26433,Repair finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26434,Repair/graft finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26437,Realignment of tendons,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26440,Release palm/finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26442,Release palm & finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26445,Release hand/finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26449,Release forearm/hand tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26450,Incision of palm tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26455,Incision of finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26460,Incise hand/finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26471,Fusion of finger tendons,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26474,Fusion of finger tendons,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26476,Tendon lengthening,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26477,Tendon shortening,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26478,Lengthening of hand tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26479,Shortening of hand tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26480,Transplant hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26483,Transplant/graft hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26485,Transplant palm tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26489,Transplant/graft palm tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26490,Revise thumb tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26492,Tendon transfer with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26494,Hand tendon/muscle transfer,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26496,Revise thumb tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26497,Finger tendon transfer,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26498,Finger tendon transfer,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26499,Revision of finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26500,Hand tendon reconstruction,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26502,Hand tendon reconstruction,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26508,Release thumb contracture,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26510,Thumb tendon transfer,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26516,Fusion of knuckle joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26517,Fusion of knuckle joints,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26518,Fusion of knuckle joints,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26520,Release knuckle contracture,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26525,Release finger contracture,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26530,Revise knuckle joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
Meridian Medicaid,CPT,26531,Revise knuckle with implant,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
Meridian Medicaid,CPT,26535,Revise finger joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
Meridian Medicaid,CPT,26536,Revise/implant finger joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
Meridian Medicaid,CPT,26540,Repair hand joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26541,Repair hand joint with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26542,Repair hand joint with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26545,Reconstruct finger joint,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26546,Repair nonunion hand,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26548,Reconstruct finger joint,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26550,Construct thumb replacement,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26555,Positional change of finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26560,Repair of web finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26561,Repair of web finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26562,Repair of web finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26565,Correct metacarpal flaw,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26567,Correct finger deformity,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26568,Lengthen metacarpal/finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26580,Repair hand deformity,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26587,Reconstruct extra finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26590,Repair finger deformity,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26591,Repair muscles of hand,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26593,Release muscles of hand,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26596,Excision constricting tissue,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26600,Treat metacarpal fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,26605,Treat metacarpal fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,26607,Treat metacarpal fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,26608,Treat metacarpal fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,26615,Treat metacarpal fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,26641,Treat thumb dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,26645,Treat thumb fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,26650,Treat thumb fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,26665,Treat thumb fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,26670,Treat hand dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,26675,Treat hand dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Meridian Medicaid,CPT,26676,Pin hand dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,26685,Treat hand dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,26686,Treat hand dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,26700,Treat knuckle dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,26705,Treat knuckle dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Meridian Medicaid,CPT,26706,Pin knuckle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,26715,Treat knuckle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,26720,Treat finger fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,26725,Treat finger fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,26727,Treat finger fracture each,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,26735,Treat finger fracture each,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,26740,Treat finger fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,26742,Treat finger fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,26746,Treat finger fracture each,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,26750,Treat finger fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,26755,Treat finger fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,26756,Pin finger fracture each,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,26765,Treat finger fracture each,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,26770,Treat finger dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,26775,Treat finger dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Meridian Medicaid,CPT,26776,Pin finger dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,26785,Treat finger dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,26820,Thumb fusion with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26841,Fusion of thumb,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26842,Thumb fusion with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26843,Fusion of hand joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26844,Fusion/graft of hand joint,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26850,Fusion of knuckle,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26852,Fusion of knuckle with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26860,Fusion of finger joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26861,Fusion of finger jnt add-on,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26862,Fusion/graft of finger joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26863,Fuse/graft added joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26910,Amputate metacarpal bone,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26951,Amputation of finger/thumb,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Meridian Medicaid,CPT,26952,Amputation of finger/thumb,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Meridian Medicaid,CPT,26989,Hand/finger surgery,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27125,Partial hip replacement,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
Meridian Medicaid,CPT,27130,Total hip arthroplasty,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Meridian Medicaid,CPT,27132,Total hip arthroplasty,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Meridian Medicaid,CPT,27134,Revise hip joint replacement,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Meridian Medicaid,CPT,27137,Revise hip joint replacement,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Meridian Medicaid,CPT,27138,Revise hip joint replacement,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Meridian Medicaid,CPT,27175,Treat slipped epiphysis,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,27178,Treat slipped epiphysis,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,27181,Treat slipped epiphysis,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,27193,Treat pelvic ring fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27194,Treat pelvic ring fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27197,Clsd tx pelvic ring fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27198,Clsd tx pelvic ring fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27200,Treat tail bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27202,Treat tail bone fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,27215,Treat pelvic fracture(s),Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,27216,Treat pelvic ring fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,27217,Treat pelvic ring fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,27218,Treat pelvic ring fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,27220,Treat hip socket fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27222,Treat hip socket fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27226,Treat hip wall fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,27227,Treat hip fracture(s),Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,27230,Treat thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27232,Treat thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27235,Treat thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,27236,Treat thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,27238,Treat thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27240,Treat thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27246,Treat thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27248,Treat thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,27250,Treat hip dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27252,Treat hip dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Meridian Medicaid,CPT,27253,Treat hip dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,27256,Treat hip dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27257,Treat hip dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Meridian Medicaid,CPT,27265,Treat hip dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27266,Treat hip dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Meridian Medicaid,CPT,27267,Cltx thigh fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27268,Cltx thigh fx w/mnpj,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27269,Optx thigh fx,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,27275,Manipulation of hip joint,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Meridian Medicaid,CPT,27299,Pelvis/hip joint surgery,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27412,Autochondrocyte implant knee,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Meridian Medicaid,CPT,27415,Osteochondral knee allograft,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Meridian Medicaid,CPT,27437,Revise kneecap,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
Meridian Medicaid,CPT,27438,Revise kneecap with implant,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Meridian Medicaid,CPT,27440,Revision of knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Meridian Medicaid,CPT,27441,Revision of knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Meridian Medicaid,CPT,27442,Revision of knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Meridian Medicaid,CPT,27443,Revision of knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Meridian Medicaid,CPT,27445,Revision of knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Meridian Medicaid,CPT,27446,Revision of knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Meridian Medicaid,CPT,27447,Total knee arthroplasty,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Meridian Medicaid,CPT,27486,Revise/replace knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Meridian Medicaid,CPT,27487,Revise/replace knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Meridian Medicaid,CPT,27500,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27501,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27502,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27503,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27507,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,27508,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27509,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,27510,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27511,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,27513,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,27514,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,27516,Treat thigh fx growth plate,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27517,Treat thigh fx growth plate,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27520,Treat kneecap fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27524,Treat kneecap fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,27530,Treat knee fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27532,Treat knee fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27535,Treat knee fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,27536,Treat knee fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,27538,Treat knee fracture(s),Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27540,Treat knee fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,27550,Treat knee dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27552,Treat knee dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Meridian Medicaid,CPT,27560,Treat kneecap dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27562,Treat kneecap dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Meridian Medicaid,CPT,27566,Treat kneecap dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,27570,Fixation of knee joint,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Meridian Medicaid,CPT,27599,Leg surgery procedure,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27605,Incision of achilles tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,27700,Revision of ankle joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
Meridian Medicaid,CPT,27702,Reconstruct ankle joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Meridian Medicaid,CPT,27703,Reconstruction ankle joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Meridian Medicaid,CPT,27720,Repair of tibia,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,27722,Repair/graft of tibia,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,27724,Repair/graft of tibia,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,27726,Repair fibula nonunion,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,27750,Treatment of tibia fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27752,Treatment of tibia fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27756,Treatment of tibia fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,27758,Treatment of tibia fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,27759,Treatment of tibia fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,27760,Cltx medial ankle fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27762,Cltx med ankle fx w/mnpj,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27766,Optx medial ankle fx,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,27767,Cltx post ankle fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27768,Cltx post ankle fx w/mnpj,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27769,Optx post ankle fx,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,27780,Treatment of fibula fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27781,Treatment of fibula fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27784,Treatment of fibula fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,27786,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27788,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27792,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,27808,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27810,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27814,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,27816,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27818,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27822,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,27823,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,27824,Treat lower leg fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27825,Treat lower leg fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27826,Treat lower leg fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,27827,Treat lower leg fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,27828,Treat lower leg fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,27829,Treat lower leg joint,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,27830,Treat lower leg dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27831,Treat lower leg dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27832,Treat lower leg dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,27840,Treat ankle dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,27842,Treat ankle dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Meridian Medicaid,CPT,27846,Treat ankle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,27848,Treat ankle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,27860,Fixation of ankle joint,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Meridian Medicaid,CPT,27899,Leg/ankle surgery procedure,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,28001,Drainage of bursa of foot,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28002,Treatment of foot infection,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28005,Treat foot bone lesion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28008,Incision of foot fascia,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28010,Incision of toe tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28011,Incision of toe tendons,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28020,Exploration of foot joint,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28022,Exploration of foot joint,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28024,Exploration of toe joint,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28039,Exc foot/toe tum sc 1.5 cm/>,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28041,Exc foot/toe tum dep 1.5cm/>,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28045,Exc foot/toe tum deep <1.5cm,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28046,Resect foot/toe tumor < 3 cm,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28047,Resect foot/toe tumor 3 cm/>,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28050,Biopsy of foot joint lining,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28052,Biopsy of foot joint lining,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28054,Biopsy of toe joint lining,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28055,Neurectomy foot,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28060,Partial removal foot fascia,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28062,Removal of foot fascia,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28070,Removal of foot joint lining,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28072,Removal of foot joint lining,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28080,Removal of foot lesion,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28086,Excise foot tendon sheath,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28088,Excise foot tendon sheath,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28090,Removal of foot lesion,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28092,Removal of toe lesions,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28100,Removal of ankle/heel lesion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28102,Remove/graft foot lesion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28103,Remove/graft foot lesion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28104,Removal of foot lesion,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28106,Remove/graft foot lesion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28107,Remove/graft foot lesion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28108,Removal of toe lesions,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28110,Part removal of metatarsal,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28111,Part removal of metatarsal,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28112,Part removal of metatarsal,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28113,Part removal of metatarsal,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28114,Removal of metatarsal heads,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28116,Revision of foot,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28118,Removal of heel bone,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28119,Removal of heel spur,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28120,Part removal of ankle/heel,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28122,Partial removal of foot bone,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28124,Partial removal of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28126,Partial removal of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28130,Removal of ankle bone,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28140,Removal of metatarsal,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28150,Removal of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28153,Partial removal of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28160,Partial removal of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28171,Resect tarsal tumor,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28173,Resect metatarsal tumor,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28175,Resect phalanx of toe tumor,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28190,Removal of foot foreign body,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,28193,Removal of foot foreign body,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28200,Repair of foot tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28202,Repair/graft of foot tendon,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28208,Repair of foot tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28210,Repair/graft of foot tendon,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28220,Release of foot tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28222,Release of foot tendons,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28225,Release of foot tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28226,Release of foot tendons,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28230,Incision of foot tendon(s),Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28232,Incision of toe tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28234,Incision of foot tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28238,Revision of foot tendon,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28240,Release of big toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28250,Revision of foot fascia,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28260,Release of midfoot joint,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28261,Revision of foot tendon,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28262,Revision of foot and ankle,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28264,Release of midfoot joint,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28270,Release of foot contracture,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28272,Release of toe joint each,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28280,Fusion of toes,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28285,Repair of hammertoe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28286,Repair of hammertoe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28288,Partial removal of foot bone,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28289,Corrj halux rigdus w/o implt,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28290,Correction of bunion,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28291,Corrj halux rigdus w/implt,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28292,Correction hallux valgus,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28293,Correction of bunion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28294,Correction of bunion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28295,Correction hallux valgus,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28296,Correction hallux valgus,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28297,Correction hallux valgus,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28298,Correction hallux valgus,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28299,Correction hallux valgus,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28300,Incision of heel bone,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28302,Incision of ankle bone,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28304,Incision of midfoot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28305,Incise/graft midfoot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28306,Incision of metatarsal,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28307,Incision of metatarsal,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28308,Incision of metatarsal,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28309,Incision of metatarsals,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28310,Revision of big toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28312,Revision of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28313,Repair deformity of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28315,Removal of sesamoid bone,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28320,Repair of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28322,Repair of metatarsals,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28340,Resect enlarged toe tissue,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28341,Resect enlarged toe,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28344,Repair extra toe(s),Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28345,Repair webbed toe(s),Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28360,Reconstruct cleft foot,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28400,Treatment of heel fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,28405,Treatment of heel fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,28406,Treatment of heel fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,28415,Treat heel fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,28420,Treat/graft heel fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,28430,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,28435,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,28436,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,28445,Treat ankle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,28446,Osteochondral talus autogrft,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28450,Treat midfoot fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,28455,Treat midfoot fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,28456,Treat midfoot fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,28465,Treat midfoot fracture each,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,28470,Treat metatarsal fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,28475,Treat metatarsal fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,28476,Treat metatarsal fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,28485,Treat metatarsal fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,28490,Treat big toe fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,28495,Treat big toe fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,28496,Treat big toe fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,28505,Treat big toe fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,28510,Treatment of toe fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,28515,Treatment of toe fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,28525,Treat toe fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,28530,Treat sesamoid bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,28531,Treat sesamoid bone fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,28540,Treat foot dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,28545,Treat foot dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Meridian Medicaid,CPT,28546,Treat foot dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,28555,Repair foot dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,28570,Treat foot dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,28575,Treat foot dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Meridian Medicaid,CPT,28576,Treat foot dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,28585,Repair foot dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,28600,Treat foot dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,28605,Treat foot dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Meridian Medicaid,CPT,28606,Treat foot dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,28615,Repair foot dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,28630,Treat toe dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,28635,Treat toe dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Meridian Medicaid,CPT,28636,Treat toe dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,28645,Repair toe dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,28660,Treat toe dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,28665,Treat toe dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Meridian Medicaid,CPT,28666,Treat toe dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,28675,Repair of toe dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,28705,Fusion of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28715,Fusion of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28725,Fusion of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28730,Fusion of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28735,Fusion of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28737,Revision of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28740,Fusion of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28750,Fusion of big toe joint,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28755,Fusion of big toe joint,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28760,Fusion of big toe joint,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28805,Amputation thru metatarsal,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28810,Amputation toe & metatarsal,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,28820,Amputation of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28825,Partial amputation of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28890,Hi enrgy eswt plantar fascia,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,28899,Foot/toes surgery procedure,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,29000,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Meridian Medicaid,CPT,29010,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Meridian Medicaid,CPT,29015,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Meridian Medicaid,CPT,29035,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Meridian Medicaid,CPT,29040,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Meridian Medicaid,CPT,29044,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Meridian Medicaid,CPT,29046,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Meridian Medicaid,CPT,29049,Application of figure eight,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Meridian Medicaid,CPT,29055,Application of shoulder cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Meridian Medicaid,CPT,29058,Application of shoulder cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Meridian Medicaid,CPT,29065,Application of long arm cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Meridian Medicaid,CPT,29075,Application of forearm cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Meridian Medicaid,CPT,29085,Apply hand/wrist cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Meridian Medicaid,CPT,29086,Apply finger cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Meridian Medicaid,CPT,29105,Apply long arm splint,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Meridian Medicaid,CPT,29125,Apply forearm splint,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Meridian Medicaid,CPT,29126,Apply forearm splint,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Meridian Medicaid,CPT,29130,Application of finger splint,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Meridian Medicaid,CPT,29131,Application of finger splint,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Meridian Medicaid,CPT,29200,Strapping of chest,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Meridian Medicaid,CPT,29240,Strapping of shoulder,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Meridian Medicaid,CPT,29260,Strapping of elbow or wrist,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Meridian Medicaid,CPT,29280,Strapping of hand or finger,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Meridian Medicaid,CPT,29305,Application of hip cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Meridian Medicaid,CPT,29325,Application of hip casts,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Meridian Medicaid,CPT,29345,Application of long leg cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Meridian Medicaid,CPT,29355,Application of long leg cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Meridian Medicaid,CPT,29358,Apply long leg cast brace,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Meridian Medicaid,CPT,29365,Application of long leg cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Meridian Medicaid,CPT,29405,Apply short leg cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Meridian Medicaid,CPT,29425,Apply short leg cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Meridian Medicaid,CPT,29435,Apply short leg cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Meridian Medicaid,CPT,29440,Addition of walker to cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Meridian Medicaid,CPT,29445,Apply rigid leg cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Meridian Medicaid,CPT,29450,Application of leg cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Meridian Medicaid,CPT,29505,Application long leg splint,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Meridian Medicaid,CPT,29515,Application lower leg splint,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Meridian Medicaid,CPT,29520,Strapping of hip,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Meridian Medicaid,CPT,29530,Strapping of knee,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Meridian Medicaid,CPT,29540,Strapping of ankle and/or ft,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Meridian Medicaid,CPT,29550,Strapping of toes,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Meridian Medicaid,CPT,29580,Application of paste boot,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Meridian Medicaid,CPT,29581,Apply multlay comprs lwr leg,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Meridian Medicaid,CPT,29582,Apply multlay comprs upr leg,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Meridian Medicaid,CPT,29583,Apply multlay comprs upr arm,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Meridian Medicaid,CPT,29584,Appl multlay comprs arm/hand,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Meridian Medicaid,CPT,29700,Removal/revision of cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Meridian Medicaid,CPT,29705,Removal/revision of cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Meridian Medicaid,CPT,29710,Removal/revision of cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Meridian Medicaid,CPT,29720,Repair of body cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Meridian Medicaid,CPT,29730,Windowing of cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Meridian Medicaid,CPT,29740,Wedging of cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Meridian Medicaid,CPT,29750,Wedging of clubfoot cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Meridian Medicaid,CPT,29799,Casting/strapping procedure,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Meridian Medicaid,CPT,29800,Jaw arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29804,Jaw arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29805,Sho arthrs dx +- synovial bx,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29806,Sho arthrs srg capsulorpaphy,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Meridian Medicaid,CPT,29807,Sho arthrs srg rpr slap les,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Meridian Medicaid,CPT,29819,Sho arthrs srg rmvl loose/fb,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29820,Sho arthrs srg prtl synvct,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29821,Sho arthrs srg compl synvct,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Meridian Medicaid,CPT,29822,Sho arthrs srg lmtd dbrdmt,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29823,Sho arthrs srg xtnsv dbrdmt,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29824,Sho arthrs srg dstl claviclc,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29825,Sho arthrs srg lss&rescj ads,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29826,Sho arthrs srg decompression,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29827,Sho arthrs srg rt8tr cuf rpr,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Meridian Medicaid,CPT,29828,Sho arthrs srg bicp tenodsis,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Meridian Medicaid,CPT,29830,Elbow arthroscopy,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29834,Elbow arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29835,Elbow arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29836,Elbow arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Meridian Medicaid,CPT,29837,Elbow arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29838,Elbow arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29840,Wrist arthroscopy,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29843,Wrist arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29844,Wrist arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29845,Wrist arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29846,Wrist arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29847,Wrist arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Meridian Medicaid,CPT,29848,Wrist endoscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29850,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29851,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29855,Tibial arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Meridian Medicaid,CPT,29856,Tibial arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Meridian Medicaid,CPT,29860,Hip arthroscopy dx,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Meridian Medicaid,CPT,29861,Hip arthro w/fb removal,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29862,Hip arthr0 w/debridement,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Meridian Medicaid,CPT,29863,Hip arthr0 w/synovectomy,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29866,Autgrft implnt knee w/scope,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Meridian Medicaid,CPT,29867,Allgrft implnt knee w/scope,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Meridian Medicaid,CPT,29868,Meniscal trnspl knee w/scpe,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Meridian Medicaid,CPT,29870,Knee arthroscopy dx,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29871,Knee arthroscopy/drainage,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29873,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29874,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29875,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29876,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29877,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29879,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29880,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29881,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29882,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29883,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29884,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29885,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Meridian Medicaid,CPT,29886,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29887,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Meridian Medicaid,CPT,29888,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Meridian Medicaid,CPT,29889,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Meridian Medicaid,CPT,29891,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29892,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Meridian Medicaid,CPT,29893,Scope plantar fasciotomy,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,29894,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29895,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29897,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29898,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29899,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Meridian Medicaid,CPT,29900,Mcp joint arthroscopy dx,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29901,Mcp joint arthroscopy surg,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29902,Mcp joint arthroscopy surg,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29904,Subtalar arthro w/fb rmvl,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29905,Subtalar arthro w/exc,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29906,Subtalar arthro w/deb,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,29907,Subtalar arthro w/fusion,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Meridian Medicaid,CPT,29914,Hip arthro w/femoroplasty,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Meridian Medicaid,CPT,29915,Hip arthro acetabuloplasty,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Meridian Medicaid,CPT,29916,Hip arthro w/labral repair,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Meridian Medicaid,CPT,29999,Arthroscopy of joint,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,30020,Drainage of nose lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,30100,Intranasal biopsy,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,30110,Removal of nose polyp(s),Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,30115,Removal of nose polyp(s),Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,30117,Removal of intranasal lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,30118,Removal of intranasal lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,30120,Revision of nose,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,30124,Removal of nose lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,30125,Removal of nose lesion,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,30130,Excise inferior turbinate,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,30140,Resect inferior turbinate,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,30150,Partial removal of nose,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,30160,Removal of nose,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,30200,Injection treatment of nose,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,30220,Insert nasal septal button,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,30310,Remove nasal foreign body,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,30320,Remove nasal foreign body,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,30400,Reconstruction of nose,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,30410,Reconstruction of nose,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,30420,Reconstruction of nose,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,30430,Revision of nose,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,30435,Revision of nose,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,30450,Revision of nose,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,30460,Revision of nose,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,30462,Revision of nose,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,30465,Repair nasal stenosis,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,30468,Rpr nsl vlv collapse w/implt,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,30520,Repair of nasal septum,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,30540,Repair nasal defect,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,30560,Release of nasal adhesions,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,30580,Repair upper jaw fistula,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,30600,Repair mouth/nose fistula,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,30620,Intranasal reconstruction,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,30630,Repair nasal septum defect,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,30801,Ablate inf turbinate superf,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,30802,Ablate inf turbinate submuc,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,30915,Ligation nasal sinus artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Meridian Medicaid,CPT,30920,Ligation upper jaw artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Meridian Medicaid,CPT,30930,Ther fx nasal inf turbinate,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,30999,Nasal surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,31000,Irrigation maxillary sinus,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,31002,Irrigation sphenoid sinus,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,31020,Exploration maxillary sinus,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,31030,Exploration maxillary sinus,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,31032,Explore sinus remove polyps,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,31050,Exploration sphenoid sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,31051,Sphenoid sinus surgery,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,31070,Exploration of frontal sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,31075,Exploration of frontal sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,31080,Removal of frontal sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,31081,Removal of frontal sinus,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,31084,Removal of frontal sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,31085,Removal of frontal sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,31086,Removal of frontal sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,31087,Removal of frontal sinus,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,31090,Exploration of sinuses,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,31200,Removal of ethmoid sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,31201,Removal of ethmoid sinus,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,31205,Removal of ethmoid sinus,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,31225,Removal of upper jaw,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Meridian Medicaid,CPT,31233,Nsl/sins ndsc dx max sinusc,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Meridian Medicaid,CPT,31235,Nsl/sins ndsc dx sphn sinusc,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Meridian Medicaid,CPT,31237,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Meridian Medicaid,CPT,31238,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Meridian Medicaid,CPT,31239,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Meridian Medicaid,CPT,31240,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Meridian Medicaid,CPT,31241,Nsl/sins ndsc w/artery lig,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Meridian Medicaid,CPT,31253,Nsl/sins ndsc total,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,31254,Nsl/sins ndsc w/prtl ethmdct,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Meridian Medicaid,CPT,31255,Nsl/sins ndsc w/tot ethmdct,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Meridian Medicaid,CPT,31256,Exploration maxillary sinus,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Meridian Medicaid,CPT,31257,Nsl/sins ndsc tot w/sphendt,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,31259,Nsl/sins ndsc sphn tiss rmvl,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,31267,Endoscopy maxillary sinus,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Meridian Medicaid,CPT,31276,Nsl/sins ndsc frnt tiss rmvl,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Meridian Medicaid,CPT,31287,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Meridian Medicaid,CPT,31288,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Meridian Medicaid,CPT,31290,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Meridian Medicaid,CPT,31291,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Meridian Medicaid,CPT,31292,Nsl/sins ndsc med/inf dcmprn,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Meridian Medicaid,CPT,31293,Nsl/sins ndsc med&inf dcmprn,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Meridian Medicaid,CPT,31294,Nsl/sins ndsc surg on dcmprn,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Meridian Medicaid,CPT,31295,Nsl/sins ndsc surg max sins,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Meridian Medicaid,CPT,31296,Nsl/sins ndsc surg frnt sins,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Meridian Medicaid,CPT,31297,Nsl/sins ndsc surg sphn sins,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Meridian Medicaid,CPT,31298,Nsl/sins ndsc surg frnt&sphn,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Meridian Medicaid,CPT,31299,Sinus surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,31300,Removal of larynx lesion,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,31320,Diagnostic incision larynx,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,31375,Partial removal of larynx,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,31400,Revision of larynx,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,31420,Removal of epiglottis,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,31500,Insert emergency airway,General Medicine,Per Unit,$385.17 ,OP,385.17,385.17,,,,,,
Meridian Medicaid,CPT,31510,Laryngoscopy with biopsy,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Meridian Medicaid,CPT,31512,Removal of larynx lesion,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Meridian Medicaid,CPT,31513,Injection into vocal cord,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Meridian Medicaid,CPT,31515,Laryngoscopy for aspiration,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Meridian Medicaid,CPT,31520,Dx laryngoscopy newborn,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Meridian Medicaid,CPT,31525,Dx laryngoscopy excl nb,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Meridian Medicaid,CPT,31526,Dx laryngoscopy w/oper scope,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Meridian Medicaid,CPT,31527,Laryngoscopy for treatment,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Meridian Medicaid,CPT,31528,Laryngoscopy and dilation,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Meridian Medicaid,CPT,31529,Laryngoscopy and dilation,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Meridian Medicaid,CPT,31530,Laryngoscopy w/fb removal,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Meridian Medicaid,CPT,31531,Laryngoscopy w/fb & op scope,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Meridian Medicaid,CPT,31535,Laryngoscopy w/biopsy,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Meridian Medicaid,CPT,31536,Laryngoscopy w/bx & op scope,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Meridian Medicaid,CPT,31540,Laryngoscopy w/exc of tumor,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Meridian Medicaid,CPT,31541,Larynscop w/tumr exc + scope,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Meridian Medicaid,CPT,31545,Remove vc lesion w/scope,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Meridian Medicaid,CPT,31546,Remove vc lesion scope/graft,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Meridian Medicaid,CPT,31551,Laryngoplasty laryngeal sten,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,31552,Laryngoplasty laryngeal sten,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,31553,Laryngoplasty laryngeal sten,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,31554,Laryngoplasty laryngeal sten,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,31560,Laryngoscop w/arytenoidectom,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Meridian Medicaid,CPT,31561,Larynscop remve cart + scop,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Meridian Medicaid,CPT,31570,Laryngoscope w/vc inj,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Meridian Medicaid,CPT,31571,Laryngoscop w/vc inj + scope,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Meridian Medicaid,CPT,31572,Largsc w/laser dstrj les,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Meridian Medicaid,CPT,31573,Largsc w/ther injection,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Meridian Medicaid,CPT,31574,Largsc w/njx augmentation,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Meridian Medicaid,CPT,31576,Laryngoscopy with biopsy,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Meridian Medicaid,CPT,31577,Largsc w/rmvl foreign bdy(s),Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Meridian Medicaid,CPT,31578,Largsc w/removal lesion,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Meridian Medicaid,CPT,31579,Laryngoscopy telescopic,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Meridian Medicaid,CPT,31580,Laryngoplasty laryngeal web,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,31582,Revision of larynx,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,31584,Laryngoplasty fx rdctj fixj,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,31587,Laryngoplasty cricoid split,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,31588,Revision of larynx,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,31590,Reinnervate larynx,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,31591,Laryngoplasty medialization,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,31595,Larynx nerve surgery,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,31599,Larynx surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,31615,Visualization of windpipe,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
Meridian Medicaid,CPT,31622,Dx bronchoscope/wash,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
Meridian Medicaid,CPT,31623,Dx bronchoscope/brush,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
Meridian Medicaid,CPT,31624,Dx bronchoscope/lavage,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
Meridian Medicaid,CPT,31625,Bronchoscopy w/biopsy(s),Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
Meridian Medicaid,CPT,31626,Bronchoscopy w/markers,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
Meridian Medicaid,CPT,31627,Navigational bronchoscopy,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,31628,Bronchoscopy/lung bx each,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
Meridian Medicaid,CPT,31629,Bronchoscopy/needle bx each,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
Meridian Medicaid,CPT,31632,Bronchoscopy/lung bx addl,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
Meridian Medicaid,CPT,31633,Bronchoscopy/needle bx addl,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
Meridian Medicaid,CPT,31635,Bronchoscopy w/fb removal,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
Meridian Medicaid,CPT,31643,Diag bronchoscope/catheter,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
Meridian Medicaid,CPT,31645,Brnchsc w/ther aspir 1st,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
Meridian Medicaid,CPT,31646,Brnchsc w/ther aspir sbsq,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
Meridian Medicaid,CPT,31720,Clearance of airways,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
Meridian Medicaid,CPT,31725,Clearance of airways,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Meridian Medicaid,CPT,31899,Airways surgical procedure,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
Meridian Medicaid,CPT,33206,Insert heart pm atrial,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Meridian Medicaid,CPT,33207,Insert heart pm ventricular,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Meridian Medicaid,CPT,33208,Insrt heart pm atrial & vent,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Meridian Medicaid,CPT,33212,Insert pulse gen sngl lead,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Meridian Medicaid,CPT,33213,Insert pulse gen dual leads,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Meridian Medicaid,CPT,33214,Upgrade of pacemaker system,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Meridian Medicaid,CPT,33221,Insert pulse gen mult leads,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Meridian Medicaid,CPT,33224,Insert pacing lead & connect,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Meridian Medicaid,CPT,33225,L ventric pacing lead add-on,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Meridian Medicaid,CPT,33226,Reposition l ventric lead,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
Meridian Medicaid,CPT,33227,Remove&replace pm gen singl,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Meridian Medicaid,CPT,33228,Remv&replc pm gen dual lead,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Meridian Medicaid,CPT,33229,Remv&replc pm gen mult leads,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Meridian Medicaid,CPT,33230,Insrt pulse gen w/dual leads,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Meridian Medicaid,CPT,33231,Insrt pulse gen w/mult leads,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Meridian Medicaid,CPT,33233,Removal of pm generator,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
Meridian Medicaid,CPT,33240,Insrt pulse gen w/singl lead,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Meridian Medicaid,CPT,33241,Remove pulse generator,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
Meridian Medicaid,CPT,33249,Insj/rplcmt defib w/lead(s),Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Meridian Medicaid,CPT,33262,Rmvl& replc pulse gen 1 lead,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Meridian Medicaid,CPT,33263,Rmvl & rplcmt dfb gen 2 lead,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Meridian Medicaid,CPT,33264,Rmvl & rplcmt dfb gen mlt ld,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Meridian Medicaid,CPT,33270,Ins/rep subq defibrillator,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Meridian Medicaid,CPT,33274,Tcat insj/rpl perm ldls pm,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Meridian Medicaid,CPT,33275,Tcat rmvl perm ldls pm w/img,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
Meridian Medicaid,CPT,33282,Implant pat-active ht record,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Meridian Medicaid,CPT,33285,Insj subq car rhythm mntr,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Meridian Medicaid,CPT,33289,Tcat impl wrls p-art prs snr,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Meridian Medicaid,CPT,33889,Artery transpose/endovas taa,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,33967,Insert i-aort percut device,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Meridian Medicaid,CPT,33968,Remove aortic assist device,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
Meridian Medicaid,CPT,33990,Insj perq vad l hrt arterial,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Meridian Medicaid,CPT,33991,Insj perq vad l hrt artl&ven,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Meridian Medicaid,CPT,33992,Rmvl perq left heart vad,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
Meridian Medicaid,CPT,33993,Reposg perq r/l hrt vad,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
Meridian Medicaid,CPT,33995,Insj perq vad r hrt venous,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Meridian Medicaid,CPT,33997,Rmvl perq right heart vad,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
Meridian Medicaid,CPT,33999,Cardiac surgery procedure,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Meridian Medicaid,CPT,34001,Removal of artery clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,34101,Removal of artery clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,34111,Removal of arm artery clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,34201,Removal of artery clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,34203,Removal of leg artery clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,34421,Removal of vein clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,34471,Removal of vein clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,34490,Removal of vein clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,34501,Repair valve femoral vein,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,34510,Transposition of vein valve,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,34520,Cross-over vein graft,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,34530,Leg vein fusion,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,34714,Opn fem art expos cndt crtj,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,34715,Opn ax/subcla art expos,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,34716,Opn ax/subcla art expos cndt,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,34812,Opn fem art expos,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,34834,Opn brach art expos,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,35011,Repair defect of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,35013,Repair artery rupture arm,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,35045,Repair defect of arm artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,35180,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Meridian Medicaid,CPT,35184,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Meridian Medicaid,CPT,35188,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Meridian Medicaid,CPT,35190,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Meridian Medicaid,CPT,35201,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Meridian Medicaid,CPT,35206,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Meridian Medicaid,CPT,35207,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Meridian Medicaid,CPT,35226,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Meridian Medicaid,CPT,35231,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Meridian Medicaid,CPT,35236,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Meridian Medicaid,CPT,35256,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,35261,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,35266,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Meridian Medicaid,CPT,35301,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,35302,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,35303,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,35304,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,35305,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,35306,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,35321,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,35355,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,35371,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,35372,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,35390,Reoperation carotid add-on,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,35400,Angioscopy,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,35452,Repair arterial blockage,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Meridian Medicaid,CPT,35472,Repair arterial blockage,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Meridian Medicaid,CPT,35694,Art trnsposj subclav carotid,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,35697,Reimplant artery each,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,35700,Reoperation bypass graft,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,35701,Expl n/flwd surg neck art,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,35702,Expl n/flwd surg uxtr art,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,35703,Expl n/flwd surg lxtr art,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,35721,Exploration femoral artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,35741,Exploration popliteal artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,35761,Exploration of artery/vein,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,35800,Explore neck vessels,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,35820,Explore chest vessels,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,35860,Explore limb vessels,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,35875,Removal of clot in graft,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,35876,Removal of clot in graft,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,35901,Excision graft neck,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,35903,Excision graft extremity,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Meridian Medicaid,CPT,36005,Injection ext venography,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Meridian Medicaid,CPT,36010,Place catheter in vein,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Meridian Medicaid,CPT,36011,Place catheter in vein,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Meridian Medicaid,CPT,36012,Place catheter in vein,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Meridian Medicaid,CPT,36013,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Meridian Medicaid,CPT,36014,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Meridian Medicaid,CPT,36015,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Meridian Medicaid,CPT,36100,Establish access to artery,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Meridian Medicaid,CPT,36120,Establish access to artery,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Meridian Medicaid,CPT,36140,Intro ndl icath upr/lxtr art,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Meridian Medicaid,CPT,36160,Establish access to aorta,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Meridian Medicaid,CPT,36200,Place catheter in aorta,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Meridian Medicaid,CPT,36215,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Meridian Medicaid,CPT,36216,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Meridian Medicaid,CPT,36217,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Meridian Medicaid,CPT,36218,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Meridian Medicaid,CPT,36221,Place cath thoracic aorta,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Meridian Medicaid,CPT,36222,Place cath carotid/inom art,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Meridian Medicaid,CPT,36223,Place cath carotid/inom art,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Meridian Medicaid,CPT,36224,Place cath carotd art,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Meridian Medicaid,CPT,36225,Place cath subclavian art,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Meridian Medicaid,CPT,36226,Place cath vertebral art,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Meridian Medicaid,CPT,36227,Place cath xtrnl carotid,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Meridian Medicaid,CPT,36228,Place cath intracranial art,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Meridian Medicaid,CPT,36245,Ins cath abd/l-ext art 1st,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Meridian Medicaid,CPT,36246,Ins cath abd/l-ext art 2nd,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Meridian Medicaid,CPT,36247,Ins cath abd/l-ext art 3rd,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Meridian Medicaid,CPT,36248,Ins cath abd/l-ext art addl,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Meridian Medicaid,CPT,36251,Ins cath ren art 1st unilat,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Meridian Medicaid,CPT,36252,Ins cath ren art 1st bilat,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Meridian Medicaid,CPT,36253,Ins cath ren art 2nd+ unilat,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Meridian Medicaid,CPT,36254,Ins cath ren art 2nd+ bilat,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Meridian Medicaid,CPT,36260,Insertion of infusion pump,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Meridian Medicaid,CPT,36299,Vessel injection procedure,Vascular Surgery,Per Unit,$500.46 ,OP,500.46,500.46,,,,,,
Meridian Medicaid,CPT,36430,Blood transfusion service,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,36440,Bl push transfuse 2 yr/<,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,36450,Bl exchange/transfuse nb,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,36455,Bl exchange/transfuse non-nb,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,36456,Prtl exchange transfuse nb,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,36460,Transfusion service fetal,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,36465,Njx noncmpnd sclrsnt 1 vein,Vascular Surgery,Per Unit,$500.46 ,OP,500.46,500.46,,,,,,
Meridian Medicaid,CPT,36466,Njx noncmpnd sclrsnt mlt vn,Vascular Surgery,Per Unit,$500.46 ,OP,500.46,500.46,,,,,,
Meridian Medicaid,CPT,36468,Njx sclrsnt spider veins,Vascular Surgery,Per Unit,$500.46 ,OP,500.46,500.46,,,,,,
Meridian Medicaid,CPT,36470,Njx sclrsnt 1 incmptnt vein,Vascular Surgery,Per Unit,$500.46 ,OP,500.46,500.46,,,,,,
Meridian Medicaid,CPT,36471,Njx sclrsnt mlt incmptnt vn,Vascular Surgery,Per Unit,$500.46 ,OP,500.46,500.46,,,,,,
Meridian Medicaid,CPT,36481,Insertion of catheter vein,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Meridian Medicaid,CPT,36500,Insertion of catheter vein,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Meridian Medicaid,CPT,36511,Apheresis wbc,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Meridian Medicaid,CPT,36512,Apheresis rbc,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Meridian Medicaid,CPT,36513,Apheresis platelets,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,36514,Apheresis plasma,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Meridian Medicaid,CPT,36515,Apheresis adsorp/reinfuse,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Meridian Medicaid,CPT,36516,Apheresis immunoads slctv,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Meridian Medicaid,CPT,36522,Photopheresis,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Meridian Medicaid,CPT,36557,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
Meridian Medicaid,CPT,36558,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
Meridian Medicaid,CPT,36560,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
Meridian Medicaid,CPT,36561,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
Meridian Medicaid,CPT,36563,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
Meridian Medicaid,CPT,36565,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
Meridian Medicaid,CPT,36566,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
Meridian Medicaid,CPT,36581,Replace tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
Meridian Medicaid,CPT,36582,Replace tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
Meridian Medicaid,CPT,36583,Replace tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
Meridian Medicaid,CPT,36593,Declot vascular device,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Meridian Medicaid,CPT,36620,Insertion catheter artery,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Meridian Medicaid,CPT,36625,Insertion catheter artery,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Meridian Medicaid,CPT,36640,Insertion catheter artery,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Meridian Medicaid,CPT,36680,Insert needle bone cavity,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
Meridian Medicaid,CPT,36800,Insertion of cannula,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
Meridian Medicaid,CPT,36810,Insertion of cannula,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
Meridian Medicaid,CPT,36815,Insertion of cannula,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
Meridian Medicaid,CPT,36823,Insertion of cannula(s),Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,36838,Dist revas ligation hemo,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,36860,External cannula declotting,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Meridian Medicaid,CPT,36903,Intro cath dialysis circuit,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,36905,Thrmbc/nfs dialysis circuit,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,36906,Thrmbc/nfs dialysis circuit,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,36907,Balo angiop ctr dialysis seg,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,36908,Stent plmt ctr dialysis seg,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,36909,Dialysis circuit embolj,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,37145,Revision of circulation,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,37182,Insert hepatic shunt (tips),Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,37183,Remove hepatic shunt (tips),Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,37184,Prim art m-thrmbc 1st vsl,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,37185,Prim art m-thrmbc sbsq vsl,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,37186,Sec art thrombectomy add-on,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,37195,Thrombolytic therapy stroke,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Meridian Medicaid,CPT,37202,Transcatheter therapy infuse,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Meridian Medicaid,CPT,37215,Transcath stent cca w/eps,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,37216,Transcath stent cca w/o eps,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,37217,Stent placemt retro carotid,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,37218,Stent placemt ante carotid,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,37220,Iliac revasc,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,37221,Iliac revasc w/stent,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,37222,Iliac revasc add-on,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,37223,Iliac revasc w/stent add-on,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,37224,Fem/popl revas w/tla,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,37225,Fem/popl revas w/ather,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,37226,Fem/popl revasc w/stent,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,37227,Fem/popl revasc stnt & ather,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,37228,Tib/per revasc w/tla,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,37229,Tib/per revasc w/ather,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,37230,Tib/per revasc w/stent,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,37231,Tib/per revasc stent & ather,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,37232,Tib/per revasc add-on,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,37233,Tibper revasc w/ather add-on,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,37234,Revsc opn/prq tib/pero stent,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,37235,Tib/per revasc stnt & ather,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,37236,Open/perq place stent 1st,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,37237,Open/perq place stent ea add,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,37238,Open/perq place stent same,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,37239,Open/perq place stent ea add,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,37241,Vasc embolize/occlude venous,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,37242,Vasc embolize/occlude artery,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,37243,Vasc embolize/occlude organ,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,37244,Vasc embolize/occlude bleed,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,37247,Trluml balo angiop addl art,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,37249,Trluml balo angiop addl vein,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,37250,Iv us first vessel add-on,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Meridian Medicaid,CPT,37251,Iv us each add vessel add-on,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Meridian Medicaid,CPT,37500,Endoscopy ligate perf veins,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,37501,Vascular endoscopy procedure,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,37565,Ligation of neck vein,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Meridian Medicaid,CPT,37600,Ligation of neck artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Meridian Medicaid,CPT,37605,Ligation of neck artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Meridian Medicaid,CPT,37606,Ligation of neck artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Meridian Medicaid,CPT,37607,Ligation of a-v fistula,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Meridian Medicaid,CPT,37609,Temporal artery procedure,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Meridian Medicaid,CPT,37615,Ligation of neck artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Meridian Medicaid,CPT,37618,Ligation of extremity artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Meridian Medicaid,CPT,37619,Ligation of inf vena cava,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,37650,Revision of major vein,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Meridian Medicaid,CPT,37790,Penile venous occlusion,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,37799,Vascular surgery procedure,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Meridian Medicaid,CPT,38102,Removal of spleen total,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,38120,Laparoscopy splenectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Meridian Medicaid,CPT,38129,Laparoscope proc spleen,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Meridian Medicaid,CPT,38205,Harvest allogeneic stem cell,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Meridian Medicaid,CPT,38206,Harvest auto stem cells,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Meridian Medicaid,CPT,38207,Cryopreserve stem cells,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Meridian Medicaid,CPT,38208,Thaw preserved stem cells,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,38209,Wash harvest stem cells,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Meridian Medicaid,CPT,38210,T-cell depletion of harvest,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,38211,Tumor cell deplete of harvst,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,38212,Rbc depletion of harvest,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,38213,Platelet deplete of harvest,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,38214,Volume deplete of harvest,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Meridian Medicaid,CPT,38215,Harvest stem cell concentrte,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Meridian Medicaid,CPT,38230,Bone marrow harvest allogen,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Meridian Medicaid,CPT,38232,Bone marrow harvest autolog,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Meridian Medicaid,CPT,38240,Transplt allo hct/donor,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Meridian Medicaid,CPT,38241,Transplt autol hct/donor,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Meridian Medicaid,CPT,38242,Transplt allo lymphocytes,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Meridian Medicaid,CPT,38243,Transplj hematopoietic boost,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Meridian Medicaid,CPT,38300,Drainage lymph node lesion,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
Meridian Medicaid,CPT,38305,Drainage lymph node lesion,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
Meridian Medicaid,CPT,38308,Incision of lymph channels,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
Meridian Medicaid,CPT,38380,Thoracic duct procedure,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,38500,Biopsy/removal lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
Meridian Medicaid,CPT,38505,Needle biopsy lymph nodes,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Meridian Medicaid,CPT,38510,Biopsy/removal lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
Meridian Medicaid,CPT,38520,Biopsy/removal lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
Meridian Medicaid,CPT,38525,Biopsy/removal lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
Meridian Medicaid,CPT,38530,Biopsy/removal lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
Meridian Medicaid,CPT,38531,Open bx/exc inguinofem nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
Meridian Medicaid,CPT,38542,Explore deep node(s) neck,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,38550,Removal neck/armpit lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,38555,Removal neck/armpit lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,38562,Removal pelvic lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
Meridian Medicaid,CPT,38570,Laparoscopy lymph node biop,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Meridian Medicaid,CPT,38571,Laparoscopy lymphadenectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Meridian Medicaid,CPT,38572,Laparoscopy lymphadenectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Meridian Medicaid,CPT,38573,Laps pelvic lymphadec,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Meridian Medicaid,CPT,38589,Laparoscope proc lymphatic,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Meridian Medicaid,CPT,38700,Removal of lymph nodes neck,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,38720,Removal of lymph nodes neck,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,38724,Removal of lymph nodes neck,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
Meridian Medicaid,CPT,38740,Remove armpit lymph nodes,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Meridian Medicaid,CPT,38745,Remove armpit lymph nodes,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Meridian Medicaid,CPT,38747,Remove abdominal lymph nodes,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,38760,Remove groin lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
Meridian Medicaid,CPT,38792,Ra tracer id of sentinl node,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,38794,Access thoracic lymph duct,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Meridian Medicaid,CPT,38999,Blood/lymph system procedure,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
Meridian Medicaid,CPT,39545,Revision of diaphragm,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,39599,Diaphragm surgery procedure,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Meridian Medicaid,CPT,40490,Biopsy of lip,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,40500,Partial excision of lip,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,40510,Partial excision of lip,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,40520,Partial excision of lip,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,40525,Reconstruct lip with flap,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,40527,Reconstruct lip with flap,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,40530,Partial removal of lip,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,40650,Repair lip,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,40652,Repair lip,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,40654,Repair lip,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,40799,Lip surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,40801,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,40805,Removal foreign body mouth,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,40806,Incision of lip fold,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,40808,Biopsy of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,40810,Excision of mouth lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,40812,Excise/repair mouth lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,40814,Excise/repair mouth lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,40816,Excision of mouth lesion,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,40818,Excise oral mucosa for graft,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,40819,Excise lip or cheek fold,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,40820,Treatment of mouth lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,40830,Repair mouth laceration,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,40831,Repair mouth laceration,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,40840,Reconstruction of mouth,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,40842,Reconstruction of mouth,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,40843,Reconstruction of mouth,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,40844,Reconstruction of mouth,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,40845,Reconstruction of mouth,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,40899,Mouth surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,41000,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,41005,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,41006,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,41007,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,41008,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,41009,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,41010,Incision of tongue fold,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,41015,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,41016,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,41017,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,41018,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,41100,Biopsy of tongue,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,41105,Biopsy of tongue,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,41108,Biopsy of floor of mouth,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,41110,Excision of tongue lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,41112,Excision of tongue lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,41113,Excision of tongue lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,41114,Excision of tongue lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,41115,Excision of tongue fold,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,41116,Excision of mouth lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,41120,Partial removal of tongue,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,41130,Partial removal of tongue,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,41135,Tongue and neck surgery,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,41150,Tongue mouth jaw surgery,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,41500,Fixation of tongue,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,41510,Tongue to lip surgery,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,41512,Tongue suspension,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,41520,Reconstruction tongue fold,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,41530,Tongue base vol reduction,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,41599,Tongue and mouth surgery,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,41805,Removal foreign body gum,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,41806,Removal foreign body jawbone,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Meridian Medicaid,CPT,41820,Excision gum each quadrant,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Meridian Medicaid,CPT,41821,Excision of gum flap,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,41822,Excision of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,41823,Excision of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,41825,Excision of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Meridian Medicaid,CPT,41826,Excision of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Meridian Medicaid,CPT,41827,Excision of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Meridian Medicaid,CPT,41828,Excision of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Meridian Medicaid,CPT,41830,Removal of gum tissue,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Meridian Medicaid,CPT,41850,Treatment of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Meridian Medicaid,CPT,41870,Gum graft,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,41872,Repair gum,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Meridian Medicaid,CPT,41874,Repair tooth socket,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,41899,Dental surgery procedure,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,42100,Biopsy roof of mouth,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,42104,Excision lesion mouth roof,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,42106,Excision lesion mouth roof,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,42107,Excision lesion mouth roof,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,42120,Remove palate/lesion,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,42140,Excision of uvula,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,42160,Treatment mouth roof lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,42180,Repair palate,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,42182,Repair palate,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,42260,Repair nose to lip fistula,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,42280,Preparation palate mold,Dental,Per Unit,$30.61 ,OP,30.61,30.61,,,,,,
Meridian Medicaid,CPT,42281,Insertion palate prosthesis,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,42299,Palate/uvula surgery,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,42300,Drainage of salivary gland,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,42305,Drainage of salivary gland,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,42310,Drainage of salivary gland,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,42320,Drainage of salivary gland,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,42330,Removal of salivary stone,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,42335,Removal of salivary stone,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,42340,Removal of salivary stone,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,42400,Biopsy of salivary gland,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,42405,Biopsy of salivary gland,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,42408,Excision of salivary cyst,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,42409,Drainage of salivary cyst,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,42410,Excise parotid gland/lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,42415,Excise parotid gland/lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,42420,Excise parotid gland/lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,42425,Excise parotid gland/lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,42426,Excise parotid gland/lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,42440,Excise submaxillary gland,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,42450,Excise sublingual gland,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,42500,Repair salivary duct,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,42505,Repair salivary duct,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,42507,Parotid duct diversion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,42509,Parotid duct diversion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,42510,Parotid duct diversion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,42600,Closure of salivary fistula,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,42650,Dilation of salivary duct,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,42660,Dilation of salivary duct,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,42665,Ligation of salivary duct,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,42699,Salivary surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,42720,Drainage of throat abscess,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,42725,Drainage of throat abscess,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,42800,Biopsy of throat,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,42804,Biopsy of upper nose/throat,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,42806,Biopsy of upper nose/throat,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,42808,Excise pharynx lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,42810,Excision of neck cyst,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,42815,Excision of neck cyst,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,42820,Remove tonsils and adenoids,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
Meridian Medicaid,CPT,42821,Remove tonsils and adenoids,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
Meridian Medicaid,CPT,42825,Removal of tonsils,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
Meridian Medicaid,CPT,42826,Removal of tonsils,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
Meridian Medicaid,CPT,42830,Removal of adenoids,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
Meridian Medicaid,CPT,42831,Removal of adenoids,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
Meridian Medicaid,CPT,42835,Removal of adenoids,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
Meridian Medicaid,CPT,42836,Removal of adenoids,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
Meridian Medicaid,CPT,42842,Extensive surgery of throat,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
Meridian Medicaid,CPT,42844,Extensive surgery of throat,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
Meridian Medicaid,CPT,42860,Excision of tonsil tags,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
Meridian Medicaid,CPT,42870,Excision of lingual tonsil,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
Meridian Medicaid,CPT,42890,Partial removal of pharynx,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,42892,Revision of pharyngeal walls,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,42900,Repair throat wound,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,42950,Reconstruction of throat,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,42953,Repair throat esophagus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,42955,Surgical opening of throat,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,42960,Control throat bleeding,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,42962,Control throat bleeding,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,42970,Control nose/throat bleeding,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,42972,Control nose/throat bleeding,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,42999,Throat surgery procedure,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
Meridian Medicaid,CPT,43020,Incision of esophagus,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,43030,Throat muscle surgery,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,43100,Excision of esophagus lesion,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,43130,Removal of esophagus pouch,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,43191,Esophagoscopy rigid trnso dx,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Meridian Medicaid,CPT,43192,Esophagoscp rig trnso inject,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Meridian Medicaid,CPT,43193,Esophagoscp rig trnso biopsy,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Meridian Medicaid,CPT,43194,Esophagoscp rig trnso rem fb,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Meridian Medicaid,CPT,43196,Esophagoscp guide wire dilat,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Meridian Medicaid,CPT,43197,Esophagoscopy flex dx brush,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Meridian Medicaid,CPT,43198,Esophagosc flex trnsn biopsy,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Meridian Medicaid,CPT,43200,Esophagoscopy flexible brush,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Meridian Medicaid,CPT,43201,Esoph scope w/submucous inj,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Meridian Medicaid,CPT,43202,Esophagoscopy flex biopsy,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Meridian Medicaid,CPT,43204,Esoph scope w/sclerosis inj,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Meridian Medicaid,CPT,43205,Esophagus endoscopy/ligation,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Meridian Medicaid,CPT,43206,Esoph optical endomicroscopy,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Meridian Medicaid,CPT,43211,Esophagoscop mucosal resect,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Meridian Medicaid,CPT,43213,Esophagoscopy retro balloon,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Meridian Medicaid,CPT,43214,Esophagosc dilate balloon 30,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Meridian Medicaid,CPT,43215,Esophagoscopy flex remove fb,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Meridian Medicaid,CPT,43216,Esophagoscopy lesion removal,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Meridian Medicaid,CPT,43217,Esophagoscopy snare les remv,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Meridian Medicaid,CPT,43220,Esophagoscopy balloon <30mm,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Meridian Medicaid,CPT,43226,Esoph endoscopy dilation,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Meridian Medicaid,CPT,43227,Esophagoscopy control bleed,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Meridian Medicaid,CPT,43229,Esophagoscopy lesion ablate,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Meridian Medicaid,CPT,43231,Esophagoscop ultrasound exam,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Meridian Medicaid,CPT,43232,Esophagoscopy w/us needle bx,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Meridian Medicaid,CPT,43233,Egd balloon dil esoph30 mm/>,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Meridian Medicaid,CPT,43235,Egd diagnostic brush wash,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Meridian Medicaid,CPT,43236,Uppr gi scope w/submuc inj,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Meridian Medicaid,CPT,43237,Endoscopic us exam esoph,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Meridian Medicaid,CPT,43238,Egd us fine needle bx/aspir,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Meridian Medicaid,CPT,43239,Egd biopsy single/multiple,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Meridian Medicaid,CPT,43241,Egd tube/cath insertion,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Meridian Medicaid,CPT,43242,Egd us fine needle bx/aspir,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Meridian Medicaid,CPT,43243,Egd injection varices,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Meridian Medicaid,CPT,43244,Egd varices ligation,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Meridian Medicaid,CPT,43245,Egd dilate stricture,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Meridian Medicaid,CPT,43246,Egd place gastrostomy tube,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Meridian Medicaid,CPT,43247,Egd remove foreign body,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Meridian Medicaid,CPT,43248,Egd guide wire insertion,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Meridian Medicaid,CPT,43249,Esoph egd dilation <30 mm,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Meridian Medicaid,CPT,43250,Egd cautery tumor polyp,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Meridian Medicaid,CPT,43251,Egd remove lesion snare,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Meridian Medicaid,CPT,43253,Egd us transmural injxn/mark,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Meridian Medicaid,CPT,43254,Egd endo mucosal resection,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Meridian Medicaid,CPT,43255,Egd control bleeding any,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Meridian Medicaid,CPT,43257,Egd w/thrml txmnt gerd,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Meridian Medicaid,CPT,43259,Egd us exam duodenum/jejunum,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Meridian Medicaid,CPT,43260,Ercp w/specimen collection,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
Meridian Medicaid,CPT,43261,Endo cholangiopancreatograph,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
Meridian Medicaid,CPT,43262,Endo cholangiopancreatograph,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
Meridian Medicaid,CPT,43263,Ercp sphincter pressure meas,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
Meridian Medicaid,CPT,43270,Egd lesion ablation,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Meridian Medicaid,CPT,43275,Ercp remove forgn body duct,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
Meridian Medicaid,CPT,43276,Ercp stent exchange w/dilate,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
Meridian Medicaid,CPT,43277,Ercp ea duct/ampulla dilate,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
Meridian Medicaid,CPT,43279,Lap myotomy heller,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Meridian Medicaid,CPT,43280,Laparoscopy fundoplasty,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Meridian Medicaid,CPT,43281,Lap paraesophag hern repair,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Meridian Medicaid,CPT,43282,Lap paraesoph her rpr w/mesh,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Meridian Medicaid,CPT,43283,Lap esoph lengthening,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Meridian Medicaid,CPT,43284,Laps esophgl sphnctr agmntj,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Meridian Medicaid,CPT,43285,Rmvl esophgl sphnctr dev,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Meridian Medicaid,CPT,43289,Laparoscope proc esoph,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Meridian Medicaid,CPT,43300,Repair of esophagus,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,43305,Repair esophagus and fistula,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,43320,Fuse esophagus & stomach,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,43332,Transab esoph hiat hern rpr,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Meridian Medicaid,CPT,43333,Transab esoph hiat hern rpr,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Meridian Medicaid,CPT,43334,Transthor diaphrag hern rpr,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Meridian Medicaid,CPT,43335,Transthor diaphrag hern rpr,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Meridian Medicaid,CPT,43336,Thorabd diaphr hern repair,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Meridian Medicaid,CPT,43337,Thorabd diaphr hern repair,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Meridian Medicaid,CPT,43338,Esoph lengthening,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Meridian Medicaid,CPT,43401,Esophagus surgery for veins,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,43410,Repair esophagus wound,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,43420,Repair esophagus opening,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,43450,Dilate esophagus 1/mult pass,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Meridian Medicaid,CPT,43453,Dilate esophagus,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Meridian Medicaid,CPT,43499,Esophagus surgery procedure,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Meridian Medicaid,CPT,43500,Surgical opening of stomach,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,43510,Surgical opening of stomach,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Meridian Medicaid,CPT,43520,Incision of pyloric muscle,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Meridian Medicaid,CPT,43610,Excision of stomach lesion,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,43644,Lap gastric bypass/roux-en-y,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Meridian Medicaid,CPT,43645,Lap gastr bypass incl smll i,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Meridian Medicaid,CPT,43647,Lap impl electrode antrum,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Meridian Medicaid,CPT,43648,Lap revise/remv eltrd antrum,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Meridian Medicaid,CPT,43651,Laparoscopy vagus nerve,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Meridian Medicaid,CPT,43652,Laparoscopy vagus nerve,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Meridian Medicaid,CPT,43653,Laparoscopy gastrostomy,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Meridian Medicaid,CPT,43659,Laparoscope proc stom,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Meridian Medicaid,CPT,43752,Nasal/orogastric w/tube plmt,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Meridian Medicaid,CPT,43753,Tx gastro intub w/asp,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Meridian Medicaid,CPT,43754,Dx gastr intub w/asp spec,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Meridian Medicaid,CPT,43755,Dx gastr intub w/asp specs,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Meridian Medicaid,CPT,43756,Dx duod intub w/asp spec,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Meridian Medicaid,CPT,43757,Dx duod intub w/asp specs,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Meridian Medicaid,CPT,43760,Change gastrostomy tube,Gastroenterology,Per Unit,$119.18 ,OP,119.18,119.18,,,,,,
Meridian Medicaid,CPT,43761,Reposition gastrostomy tube,Gastroenterology,Per Unit,$119.18 ,OP,119.18,119.18,,,,,,
Meridian Medicaid,CPT,43762,Rplc gtube no revj trc,Gastroenterology,Per Unit,$119.18 ,OP,119.18,119.18,,,,,,
Meridian Medicaid,CPT,43763,Rplc gtube revj gstrst trc,Gastroenterology,Per Unit,$119.18 ,OP,119.18,119.18,,,,,,
Meridian Medicaid,CPT,43770,Lap place gastr adj device,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Meridian Medicaid,CPT,43771,Lap revise gastr adj device,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Meridian Medicaid,CPT,43772,Lap rmvl gastr adj device,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Meridian Medicaid,CPT,43773,Lap replace gastr adj device,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Meridian Medicaid,CPT,43774,Lap rmvl gastr adj all parts,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Meridian Medicaid,CPT,43775,Lap sleeve gastrectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Meridian Medicaid,CPT,43830,Place gastrostomy tube,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Meridian Medicaid,CPT,43831,Place gastrostomy tube,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Meridian Medicaid,CPT,43832,Place gastrostomy tube,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,43842,V-band gastroplasty,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Meridian Medicaid,CPT,43843,Gastroplasty w/o v-band,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,43848,Revision gastroplasty,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,43860,Revise stomach-bowel fusion,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,43870,Repair stomach opening,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Meridian Medicaid,CPT,43880,Repair stomach-bowel fistula,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,43881,Impl/redo electrd antrum,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,43882,Revise/remove electrd antrum,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,43886,Revise gastric port open,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Meridian Medicaid,CPT,43887,Remove gastric port open,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Meridian Medicaid,CPT,43888,Change gastric port open,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Meridian Medicaid,CPT,43999,Stomach surgery procedure,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Meridian Medicaid,CPT,44005,Freeing of bowel adhesion,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,44015,Insert needle cath bowel,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
Meridian Medicaid,CPT,44020,Explore small intestine,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,44050,Reduce bowel obstruction,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,44055,Correct malrotation of bowel,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,44100,Biopsy of bowel,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,44110,Excise intestine lesion(s),General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,44111,Excision of bowel lesion(s),General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,44125,Removal of small intestine,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,44130,Bowel to bowel fusion,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,44139,Mobilization of colon,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,44141,Partial removal of colon,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,44143,Partial removal of colon,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,44180,Lap enterolysis,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Meridian Medicaid,CPT,44186,Lap jejunostomy,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Meridian Medicaid,CPT,44187,Lap ileo/jejuno-stomy,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Meridian Medicaid,CPT,44188,Lap colostomy,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Meridian Medicaid,CPT,44204,Laparo partial colectomy,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Meridian Medicaid,CPT,44206,Lap part colectomy w/stoma,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Meridian Medicaid,CPT,44207,L colectomy/coloproctostomy,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Meridian Medicaid,CPT,44208,L colectomy/coloproctostomy,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Meridian Medicaid,CPT,44213,Lap mobil splenic fl add-on,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Meridian Medicaid,CPT,44238,Laparoscope proc intestine,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Meridian Medicaid,CPT,44300,Open bowel to skin,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,44312,Revision of ileostomy,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,44320,Colostomy,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,44340,Revision of colostomy,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,44346,Revision of colostomy,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,44360,Small bowel endoscopy,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Meridian Medicaid,CPT,44361,Small bowel endoscopy/biopsy,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Meridian Medicaid,CPT,44363,Small bowel endoscopy,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Meridian Medicaid,CPT,44364,Small bowel endoscopy,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Meridian Medicaid,CPT,44365,Small bowel endoscopy,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Meridian Medicaid,CPT,44366,Small bowel endoscopy,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Meridian Medicaid,CPT,44369,Small bowel endoscopy,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Meridian Medicaid,CPT,44370,Small bowel endoscopy/stent,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Meridian Medicaid,CPT,44372,Small bowel endoscopy,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Meridian Medicaid,CPT,44373,Small bowel endoscopy,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Meridian Medicaid,CPT,44376,Small bowel endoscopy,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Meridian Medicaid,CPT,44377,Small bowel endoscopy/biopsy,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Meridian Medicaid,CPT,44378,Small bowel endoscopy,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Meridian Medicaid,CPT,44379,S bowel endoscope w/stent,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Meridian Medicaid,CPT,44380,Small bowel endoscopy br/wa,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,44381,Small bowel endoscopy br/wa,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,44382,Small bowel endoscopy,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,44384,Small bowel endoscopy,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Meridian Medicaid,CPT,44385,Endoscopy of bowel pouch,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,44386,Endoscopy bowel pouch/biop,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,44388,Colonoscopy thru stoma spx,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,44389,Colonoscopy with biopsy,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,44390,Colonoscopy for foreign body,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,44391,Colonoscopy for bleeding,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,44392,Colonoscopy & polypectomy,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,44394,Colonoscopy w/snare,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,44401,Colonoscopy with ablation,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,44402,Colonoscopy w/stent plcmt,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Meridian Medicaid,CPT,44403,Colonoscopy w/resection,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,44404,Colonoscopy w/injection,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,44405,Colonoscopy w/dilation,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,44406,Colonoscopy w/ultrasound,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,44407,Colonoscopy w/ndl aspir/bx,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,44408,Colonoscopy w/decompression,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,44500,Intro gastrointestinal tube,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Meridian Medicaid,CPT,44602,Suture small intestine,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,44603,Suture small intestine,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,44615,Intestinal stricturoplasty,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,44620,Repair bowel opening,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,44640,Repair bowel-skin fistula,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,44650,Repair bowel fistula,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,44799,Unlisted px small intestine,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Meridian Medicaid,CPT,44800,Excision of bowel pouch,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,44820,Excision of mesentery lesion,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,44850,Repair of mesentery,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,44899,Bowel surgery procedure,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Meridian Medicaid,CPT,44900,Drain appendix abscess open,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,44950,Appendectomy,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,44955,Appendectomy add-on,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,44960,Appendectomy,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,44970,Laparoscopy appendectomy,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Meridian Medicaid,CPT,44979,Laparoscope proc app,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Meridian Medicaid,CPT,45000,Drainage of pelvic abscess,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,45005,Drainage of rectal abscess,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Meridian Medicaid,CPT,45020,Drainage of rectal abscess,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,45100,Biopsy of rectum,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Meridian Medicaid,CPT,45108,Removal of anorectal lesion,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,45113,Partial proctectomy,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,45123,Partial proctectomy,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,45130,Excision of rectal prolapse,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,45136,Excise ileoanal reservior,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,45150,Excision of rectal stricture,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,45160,Excision of rectal lesion,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,45171,Exc rect tum transanal part,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,45172,Exc rect tum transanal full,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,45190,Destruction rectal tumor,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,45300,Proctosigmoidoscopy dx,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,45303,Proctosigmoidoscopy dilate,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Meridian Medicaid,CPT,45305,Proctosigmoidoscopy w/bx,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,45307,Proctosigmoidoscopy fb,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,45308,Proctosigmoidoscopy removal,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Meridian Medicaid,CPT,45309,Proctosigmoidoscopy removal,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,45315,Proctosigmoidoscopy removal,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,45317,Proctosigmoidoscopy bleed,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Meridian Medicaid,CPT,45320,Proctosigmoidoscopy ablate,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Meridian Medicaid,CPT,45321,Proctosigmoidoscopy volvul,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Meridian Medicaid,CPT,45327,Proctosigmoidoscopy w/stent,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Meridian Medicaid,CPT,45330,Diagnostic sigmoidoscopy,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,45331,Sigmoidoscopy and biopsy,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,45332,Sigmoidoscopy w/fb removal,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,45333,Sigmoidoscopy & polypectomy,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,45334,Sigmoidoscopy for bleeding,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,45335,Sigmoidoscopy w/submuc inj,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,45337,Sigmoidoscopy & decompress,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,45338,Sigmoidoscopy w/tumr remove,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,45340,Sig w/tndsc balloon dilation,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,45341,Sigmoidoscopy w/ultrasound,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,45342,Sigmoidoscopy w/us guide bx,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,45346,Sigmoidoscopy w/ablation,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,45347,Sigmoidoscopy w/plcmt stent,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Meridian Medicaid,CPT,45349,Sigmoidoscopy w/resection,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Meridian Medicaid,CPT,45350,Sgmdsc w/band ligation,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,45378,Diagnostic colonoscopy,Preventive Care,Per Unit,$387.00 ,OP,387,387,,,,,,
Meridian Medicaid,CPT,45379,Colonoscopy w/fb removal,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,45380,Colonoscopy and biopsy,Preventive Care,Per Unit,$387.00 ,OP,387,387,,,,,,
Meridian Medicaid,CPT,45381,Colonoscopy submucous njx,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,45382,Colonoscopy w/control bleed,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,45384,Colonoscopy w/lesion removal,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,45385,Colonoscopy w/lesion removal,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,45386,Colonoscopy w/balloon dilat,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,45388,Colonoscopy w/ablation,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,45389,Colonoscopy w/stent plcmt,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Meridian Medicaid,CPT,45390,Colonoscopy w/resection,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Meridian Medicaid,CPT,45391,Colonoscopy w/endoscope us,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,45392,Colonoscopy w/endoscopic fnb,Preventive Care,Per Unit,$387.00 ,OP,387,387,,,,,,
Meridian Medicaid,CPT,45393,Colonoscopy w/decompression,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,45398,Colonoscopy w/band ligation,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,45399,Unlisted procedure colon,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,45400,Laparoscopic proc,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Meridian Medicaid,CPT,45402,Lap proctopexy w/sig resect,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Meridian Medicaid,CPT,45499,Laparoscope proc rectum,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Meridian Medicaid,CPT,45500,Repair of rectum,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,45505,Repair of rectum,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,45520,Treatment of rectal prolapse,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Meridian Medicaid,CPT,45541,Correct rectal prolapse,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,45560,Repair of rectocele,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,45562,Exploration/repair of rectum,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,45800,Repair rect/bladder fistula,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,45820,Repair rectourethral fistula,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,45900,Reduction of rectal prolapse,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Meridian Medicaid,CPT,45905,Dilation of anal sphincter,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Meridian Medicaid,CPT,45910,Dilation of rectal narrowing,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Meridian Medicaid,CPT,45915,Remove rectal obstruction,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Meridian Medicaid,CPT,45990,Surg dx exam anorectal,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Meridian Medicaid,CPT,45999,Rectum surgery procedure,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Meridian Medicaid,CPT,46020,Placement of seton,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Meridian Medicaid,CPT,46030,Removal of rectal marker,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Meridian Medicaid,CPT,46040,Incision of rectal abscess,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Meridian Medicaid,CPT,46045,Incision of rectal abscess,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,46050,Incision of anal abscess,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Meridian Medicaid,CPT,46060,Incision of rectal abscess,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,46070,Incision of anal septum,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Meridian Medicaid,CPT,46080,Incision of anal sphincter,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Meridian Medicaid,CPT,46083,Incise external hemorrhoid,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Meridian Medicaid,CPT,46200,Removal of anal fissure,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Meridian Medicaid,CPT,46220,Excise anal ext tag/papilla,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Meridian Medicaid,CPT,46221,Ligation of hemorrhoid(s),General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Meridian Medicaid,CPT,46230,Removal of anal tags,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Meridian Medicaid,CPT,46250,Remove ext hem groups 2+,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,46255,Remove int/ext hem 1 group,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,46257,Remove in/ex hem grp & fiss,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,46258,Remove in/ex hem grp w/fistu,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,46260,Remove in/ex hem groups 2+,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,46261,Remove in/ex hem grps & fiss,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,46262,Remove in/ex hem grps w/fist,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,46270,Remove anal fist subq,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,46275,Remove anal fist inter,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,46280,Remove anal fist complex,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,46285,Remove anal fist 2 stage,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Meridian Medicaid,CPT,46288,Repair anal fistula,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,46320,Removal of hemorrhoid clot,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Meridian Medicaid,CPT,46500,Injection into hemorrhoid(s),General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Meridian Medicaid,CPT,46505,Chemodenervation anal musc,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Meridian Medicaid,CPT,46600,Diagnostic anoscopy spx,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,46601,Diagnostic anoscopy,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,46604,Anoscopy and dilation,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,46606,Anoscopy and biopsy,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,46607,Diagnostic anoscopy & biopsy,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Meridian Medicaid,CPT,46608,Anoscopy remove for body,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,46610,Anoscopy remove lesion,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Meridian Medicaid,CPT,46611,Anoscopy,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,46612,Anoscopy remove lesions,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Meridian Medicaid,CPT,46614,Anoscopy control bleeding,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,46615,Anoscopy,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Meridian Medicaid,CPT,46700,Repair of anal stricture,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,46705,Repair of anal stricture,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,46706,Repr of anal fistula w/glue,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Meridian Medicaid,CPT,46707,Repair anorectal fist w/plug,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Meridian Medicaid,CPT,46710,Repr per/vag pouch sngl proc,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,46712,Repr per/vag pouch dbl proc,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,46715,Rep perf anoper fistu,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,46716,Rep perf anoper/vestib fistu,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,46740,Construction of absent anus,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,46750,Repair of anal sphincter,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,46751,Repair of anal sphincter,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,46753,Reconstruction of anus,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,46754,Removal of suture from anus,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Meridian Medicaid,CPT,46760,Repair of anal sphincter,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,46761,Repair of anal sphincter,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,46762,Implant artificial sphincter,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,46900,Destruction anal lesion(s),General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Meridian Medicaid,CPT,46910,Destruction anal lesion(s),General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Meridian Medicaid,CPT,46916,Cryosurgery anal lesion(s),General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Meridian Medicaid,CPT,46917,Laser surgery anal lesions,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Meridian Medicaid,CPT,46922,Excision of anal lesion(s),General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Meridian Medicaid,CPT,46924,Destruction anal lesion(s),General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Meridian Medicaid,CPT,46930,Destroy internal hemorrhoids,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Meridian Medicaid,CPT,46940,Treatment of anal fissure,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Meridian Medicaid,CPT,46942,Treatment of anal fissure,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Meridian Medicaid,CPT,46945,Int hrhc lig 1 hroid w/o img,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Meridian Medicaid,CPT,46946,Int hrhc lig 2+hroid w/o img,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Meridian Medicaid,CPT,46947,Hemorrhoidopexy by stapling,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,46948,Int hrhc tranal dartlzj 2+,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,46999,Anus surgery procedure,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Meridian Medicaid,CPT,47370,Laparo ablate liver tumor rf,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Meridian Medicaid,CPT,47371,Laparo ablate liver cryosurg,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Meridian Medicaid,CPT,47379,Laparoscope procedure liver,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Meridian Medicaid,CPT,47510,Insert catheter bile duct,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
Meridian Medicaid,CPT,47511,Insert bile duct drain,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
Meridian Medicaid,CPT,47525,Change bile duct catheter,Gastroenterology,Per Unit,$119.18 ,OP,119.18,119.18,,,,,,
Meridian Medicaid,CPT,47530,Revise/reinsert bile tube,Gastroenterology,Per Unit,$119.18 ,OP,119.18,119.18,,,,,,
Meridian Medicaid,CPT,47537,Removal biliary drg cath,Gastroenterology,Per Unit,$119.18 ,OP,119.18,119.18,,,,,,
Meridian Medicaid,CPT,47560,Laparoscopy w/cholangio,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Meridian Medicaid,CPT,47561,Laparo w/cholangio/biopsy,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Meridian Medicaid,CPT,47562,Laparoscopic cholecystectomy,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Meridian Medicaid,CPT,47563,Laparo cholecystectomy/graph,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Meridian Medicaid,CPT,47564,Laparo cholecystectomy/explr,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Meridian Medicaid,CPT,47570,Laparo cholecystoenterostomy,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Meridian Medicaid,CPT,47579,Laparoscope proc biliary,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Meridian Medicaid,CPT,47630,Remove bile duct stone,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
Meridian Medicaid,CPT,48550,Donor pancreatectomy,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,49000,Exploration of abdomen,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,49002,Reopening of abdomen,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,49010,Exploration behind abdomen,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,49203,Exc abd tum 5 cm or less,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,49204,Exc abd tum over 5 cm,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,49205,Exc abd tum over 10 cm,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,49215,Excise sacral spine tumor,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,49220,Multiple surgery abdomen,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,49250,Excision of umbilicus,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Meridian Medicaid,CPT,49255,Removal of omentum,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,49320,Diag laparo separate proc,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Meridian Medicaid,CPT,49321,Laparoscopy biopsy,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Meridian Medicaid,CPT,49322,Laparoscopy aspiration,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Meridian Medicaid,CPT,49323,Laparo drain lymphocele,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Meridian Medicaid,CPT,49324,Lap insert tunnel ip cath,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Meridian Medicaid,CPT,49325,Lap revision perm ip cath,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Meridian Medicaid,CPT,49326,Lap w/omentopexy add-on,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Meridian Medicaid,CPT,49329,Laparo proc abdm/per/oment,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Meridian Medicaid,CPT,49402,Remove foreign body adbomen,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Meridian Medicaid,CPT,49425,Insert abdomen-venous drain,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,49426,Revise abdomen-venous shunt,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Meridian Medicaid,CPT,49428,Ligation of shunt,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,49429,Removal of shunt,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Meridian Medicaid,CPT,49440,Place gastrostomy tube perc,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Meridian Medicaid,CPT,49441,Place duod/jej tube perc,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Meridian Medicaid,CPT,49442,Place cecostomy tube perc,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,49446,Change g-tube to g-j perc,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Meridian Medicaid,CPT,49450,Replace g/c tube perc,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Meridian Medicaid,CPT,49451,Replace duod/jej tube perc,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Meridian Medicaid,CPT,49452,Replace g-j tube perc,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Meridian Medicaid,CPT,49460,Fix g/colon tube w/device,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Meridian Medicaid,CPT,49491,Rpr hern preemie reduc,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Meridian Medicaid,CPT,49492,Rpr ing hern premie blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Meridian Medicaid,CPT,49495,Rpr ing hernia baby reduc,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Meridian Medicaid,CPT,49496,Rpr ing hernia baby blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Meridian Medicaid,CPT,49500,Rpr ing hernia init reduce,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Meridian Medicaid,CPT,49501,Rpr ing hernia init blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Meridian Medicaid,CPT,49505,Prp i/hern init reduc >5 yr,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Meridian Medicaid,CPT,49507,Prp i/hern init block >5 yr,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Meridian Medicaid,CPT,49520,Rerepair ing hernia reduce,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Meridian Medicaid,CPT,49521,Rerepair ing hernia blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Meridian Medicaid,CPT,49525,Repair ing hernia sliding,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Meridian Medicaid,CPT,49540,Repair lumbar hernia,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Meridian Medicaid,CPT,49550,Rpr rem hernia init reduce,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Meridian Medicaid,CPT,49553,Rpr fem hernia init blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Meridian Medicaid,CPT,49555,Rerepair fem hernia reduce,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Meridian Medicaid,CPT,49557,Rerepair fem hernia blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Meridian Medicaid,CPT,49560,Rpr ventral hern init reduc,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Meridian Medicaid,CPT,49561,Rpr ventral hern init block,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Meridian Medicaid,CPT,49565,Rerepair ventrl hern reduce,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Meridian Medicaid,CPT,49566,Rerepair ventrl hern block,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Meridian Medicaid,CPT,49568,Hernia repair w/mesh,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Meridian Medicaid,CPT,49570,Rpr epigastric hern reduce,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Meridian Medicaid,CPT,49572,Rpr epigastric hern blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Meridian Medicaid,CPT,49580,Rpr umbil hern reduc < 5 yr,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Meridian Medicaid,CPT,49582,Rpr umbil hern block < 5 yr,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Meridian Medicaid,CPT,49585,Rpr umbil hern reduc > 5 yr,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Meridian Medicaid,CPT,49587,Rpr umbil hern block > 5 yr,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Meridian Medicaid,CPT,49590,Repair spigelian hernia,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Meridian Medicaid,CPT,49600,Repair umbilical lesion,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Meridian Medicaid,CPT,49606,Repair umbilical lesion,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Meridian Medicaid,CPT,49610,Repair umbilical lesion,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Meridian Medicaid,CPT,49650,Lap ing hernia repair init,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Meridian Medicaid,CPT,49651,Lap ing hernia repair recur,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Meridian Medicaid,CPT,49652,Lap vent/abd hernia repair,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Meridian Medicaid,CPT,49653,Lap vent/abd hern proc comp,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Meridian Medicaid,CPT,49654,Lap inc hernia repair,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Meridian Medicaid,CPT,49655,Lap inc hern repair comp,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Meridian Medicaid,CPT,49656,Lap inc hernia repair recur,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Meridian Medicaid,CPT,49657,Lap inc hern recur comp,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Meridian Medicaid,CPT,49659,Laparo proc hernia repair,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Meridian Medicaid,CPT,49900,Repair of abdominal wall,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,49904,Omental flap extra-abdom,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Meridian Medicaid,CPT,49905,Omental flap intra-abdom,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Meridian Medicaid,CPT,49906,Free omental flap microvasc,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Meridian Medicaid,CPT,49999,Abdomen surgery procedure,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Meridian Medicaid,CPT,50389,Remove renal tube w/fluoro,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Meridian Medicaid,CPT,50390,Drainage of kidney lesion,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Meridian Medicaid,CPT,50391,Instll rx agnt into rnal tub,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Meridian Medicaid,CPT,50396,Measure kidney pressure,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Meridian Medicaid,CPT,50398,Change kidney tube,Gastroenterology,Per Unit,$119.18 ,OP,119.18,119.18,,,,,,
Meridian Medicaid,CPT,50430,Njx px nfrosgrm &/urtrgrm,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Meridian Medicaid,CPT,50431,Njx px nfrosgrm &/urtrgrm,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Meridian Medicaid,CPT,50541,Laparo ablate renal cyst,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Meridian Medicaid,CPT,50542,Laparo ablate renal mass,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Meridian Medicaid,CPT,50543,Laparo partial nephrectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Meridian Medicaid,CPT,50544,Laparoscopy pyeloplasty,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Meridian Medicaid,CPT,50549,Laparoscope proc renal,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Meridian Medicaid,CPT,50945,Laparoscopy ureterolithotomy,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Meridian Medicaid,CPT,50947,Laparo new ureter/bladder,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Meridian Medicaid,CPT,50948,Laparo new ureter/bladder,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Meridian Medicaid,CPT,50949,Laparoscope proc ureter,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Meridian Medicaid,CPT,51100,Drain bladder by needle,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Meridian Medicaid,CPT,51500,Removal of bladder cyst,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Meridian Medicaid,CPT,51705,Change of bladder tube,Gastroenterology,Per Unit,$119.18 ,OP,119.18,119.18,,,,,,
Meridian Medicaid,CPT,51710,Change of bladder tube,Gastroenterology,Per Unit,$119.18 ,OP,119.18,119.18,,,,,,
Meridian Medicaid,CPT,51715,Endoscopic injection/implant,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Meridian Medicaid,CPT,51720,Treatment of bladder lesion,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Meridian Medicaid,CPT,51725,Simple cystometrogram,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Meridian Medicaid,CPT,51726,Complex cystometrogram,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Meridian Medicaid,CPT,51727,Cystometrogram w/up,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Meridian Medicaid,CPT,51728,Cystometrogram w/vp,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Meridian Medicaid,CPT,51729,Cystometrogram w/vp&up,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Meridian Medicaid,CPT,51741,Electro-uroflowmetry first,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Meridian Medicaid,CPT,51784,Anal/urinary muscle study,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,51785,Anal/urinary muscle study,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,51792,Urinary reflex study,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Meridian Medicaid,CPT,51990,Laparo urethral suspension,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Meridian Medicaid,CPT,51992,Laparo sling operation,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Meridian Medicaid,CPT,51999,Laparoscope proc bla,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Meridian Medicaid,CPT,52010,Cystoscopy & duct catheter,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Meridian Medicaid,CPT,52270,Cystoscopy & revise urethra,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Meridian Medicaid,CPT,52275,Cystoscopy & revise urethra,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Meridian Medicaid,CPT,52276,Cystoscopy and treatment,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Meridian Medicaid,CPT,52277,Cystoscopy and treatment,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Meridian Medicaid,CPT,52282,Cystoscopy implant stent,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Meridian Medicaid,CPT,52283,Cystoscopy and treatment,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Meridian Medicaid,CPT,52285,Cystoscopy and treatment,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Meridian Medicaid,CPT,52400,Cystouretero w/congen repr,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Meridian Medicaid,CPT,52402,Cystourethro cut ejacul duct,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Meridian Medicaid,CPT,52442,Cystourethro w/addl implant,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Meridian Medicaid,CPT,52601,Prostatectomy (turp),Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Meridian Medicaid,CPT,52630,Remove prostate regrowth,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Meridian Medicaid,CPT,52647,Laser surgery of prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Meridian Medicaid,CPT,52648,Laser surgery of prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Meridian Medicaid,CPT,52649,Prostate laser enucleation,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Meridian Medicaid,CPT,53000,Incision of urethra,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Meridian Medicaid,CPT,53010,Incision of urethra,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Meridian Medicaid,CPT,53020,Incision of urethra,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Meridian Medicaid,CPT,53025,Incision of urethra,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Meridian Medicaid,CPT,53040,Drainage of urethra abscess,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Meridian Medicaid,CPT,53060,Drainage of urethra abscess,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Meridian Medicaid,CPT,53080,Drainage of urinary leakage,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Meridian Medicaid,CPT,53085,Drainage of urinary leakage,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Meridian Medicaid,CPT,53200,Biopsy of urethra,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Meridian Medicaid,CPT,53210,Removal of urethra,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Meridian Medicaid,CPT,53215,Removal of urethra,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Meridian Medicaid,CPT,53220,Treatment of urethra lesion,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Meridian Medicaid,CPT,53230,Removal of urethra lesion,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Meridian Medicaid,CPT,53235,Removal of urethra lesion,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Meridian Medicaid,CPT,53240,Surgery for urethra pouch,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Meridian Medicaid,CPT,53250,Removal of urethra gland,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Meridian Medicaid,CPT,53260,Treatment of urethra lesion,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Meridian Medicaid,CPT,53265,Treatment of urethra lesion,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Meridian Medicaid,CPT,53270,Removal of urethra gland,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Meridian Medicaid,CPT,53275,Repair of urethra defect,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Meridian Medicaid,CPT,53400,Revise urethra stage 1,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Meridian Medicaid,CPT,53405,Revise urethra stage 2,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Meridian Medicaid,CPT,53410,Reconstruction of urethra,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Meridian Medicaid,CPT,53415,Reconstruction of urethra,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Meridian Medicaid,CPT,53420,Reconstruct urethra stage 1,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Meridian Medicaid,CPT,53425,Reconstruct urethra stage 2,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Meridian Medicaid,CPT,53430,Reconstruction of urethra,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Meridian Medicaid,CPT,53431,Reconstruct urethra/bladder,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Meridian Medicaid,CPT,53440,Male sling procedure,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Meridian Medicaid,CPT,53442,Remove/revise male sling,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Meridian Medicaid,CPT,53444,Insert tandem cuff,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Meridian Medicaid,CPT,53446,Remove uro sphincter,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Meridian Medicaid,CPT,53448,Remov/replc ur sphinctr comp,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Meridian Medicaid,CPT,53449,Repair uro sphincter,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Meridian Medicaid,CPT,53450,Revision of urethra,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Meridian Medicaid,CPT,53460,Revision of urethra,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Meridian Medicaid,CPT,53500,Urethrlys transvag w/ scope,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Meridian Medicaid,CPT,53502,Repair of urethra injury,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Meridian Medicaid,CPT,53505,Repair of urethra injury,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Meridian Medicaid,CPT,53510,Repair of urethra injury,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Meridian Medicaid,CPT,53515,Repair of urethra injury,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Meridian Medicaid,CPT,53520,Repair of urethra defect,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Meridian Medicaid,CPT,53605,Dilate urethra stricture,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Meridian Medicaid,CPT,53620,Dilate urethra stricture,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Meridian Medicaid,CPT,53621,Dilate urethra stricture,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Meridian Medicaid,CPT,53665,Dilation of urethra,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Meridian Medicaid,CPT,53855,Insert prost urethral stent,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Meridian Medicaid,CPT,53860,Transurethral rf treatment,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Meridian Medicaid,CPT,54000,Slitting of prepuce,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Meridian Medicaid,CPT,54001,Slitting of prepuce,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,54015,Drain penis lesion,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,54050,Destruction penis lesion(s),Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Meridian Medicaid,CPT,54055,Destruction penis lesion(s),Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,54056,Cryosurgery penis lesion(s),Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Meridian Medicaid,CPT,54057,Laser surg penis lesion(s),Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,54060,Excision of penis lesion(s),Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,54065,Destruction penis lesion(s),Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,54100,Biopsy of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,54105,Biopsy of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,54110,Treatment of penis lesion,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,54115,Treatment of penis lesion,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,54150,Circumcision w/regionl block,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,54160,Circumcision neonate,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,54161,Circum 28 days or older,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,54162,Lysis penil circumic lesion,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,54163,Repair of circumcision,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,54164,Frenulotomy of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,54230,Prepare penis study,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,54231,Dynamic cavernosometry,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,54300,Revision of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,54304,Revision of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,54340,Secondary urethral surgery,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,54360,Penis plastic surgery,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,54380,Repair penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,54385,Repair penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,54400,Insert semi-rigid prosthesis,Urological Surgery,Per Unit,"$6,916.67 ",OP,"6,916.67","6,916.67",,,,,,
Meridian Medicaid,CPT,54401,Insert self-contd prosthesis,Urological Surgery,Per Unit,"$6,916.67 ",OP,"6,916.67","6,916.67",,,,,,
Meridian Medicaid,CPT,54405,Insert multi-comp penis pros,Urological Surgery,Per Unit,"$6,916.67 ",OP,"6,916.67","6,916.67",,,,,,
Meridian Medicaid,CPT,54406,Remove muti-comp penis pros,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,54408,Repair multi-comp penis pros,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,54410,Remove/replace penis prosth,Urological Surgery,Per Unit,"$6,916.67 ",OP,"6,916.67","6,916.67",,,,,,
Meridian Medicaid,CPT,54411,Remov/replc penis pros comp,Urological Surgery,Per Unit,"$6,916.67 ",OP,"6,916.67","6,916.67",,,,,,
Meridian Medicaid,CPT,54415,Remove self-contd penis pros,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,54416,Remv/repl penis contain pros,Urological Surgery,Per Unit,"$6,916.67 ",OP,"6,916.67","6,916.67",,,,,,
Meridian Medicaid,CPT,54417,Remv/replc penis pros compl,Urological Surgery,Per Unit,"$6,916.67 ",OP,"6,916.67","6,916.67",,,,,,
Meridian Medicaid,CPT,54420,Revision of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,54430,Revision of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,54435,Revision of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,54440,Repair of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,54450,Preputial stretching,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Meridian Medicaid,CPT,54500,Biopsy of testis,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Meridian Medicaid,CPT,54505,Biopsy of testis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,54512,Excise lesion testis,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Meridian Medicaid,CPT,54520,Removal of testis,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Meridian Medicaid,CPT,54522,Orchiectomy partial,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,54530,Removal of testis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,54535,Extensive testis surgery,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,54550,Exploration for testis,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Meridian Medicaid,CPT,54560,Exploration for testis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,54600,Reduce testis torsion,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Meridian Medicaid,CPT,54620,Suspension of testis,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Meridian Medicaid,CPT,54640,Orchiopexy ingun/scrot appr,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Meridian Medicaid,CPT,54650,Orchiopexy (fowler-stephens),Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,54660,Revision of testis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,54670,Repair testis injury,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Meridian Medicaid,CPT,54680,Relocation of testis(es),Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,54690,Laparoscopy orchiectomy,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,54692,Laparoscopy orchiopexy,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,54699,Laparoscope proc testis,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Meridian Medicaid,CPT,54700,Drainage of scrotum,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Meridian Medicaid,CPT,54800,Biopsy of epididymis,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Meridian Medicaid,CPT,54830,Remove epididymis lesion,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Meridian Medicaid,CPT,54840,Remove epididymis lesion,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Meridian Medicaid,CPT,54860,Removal of epididymis,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Meridian Medicaid,CPT,54861,Removal of epididymis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,54865,Explore epididymis,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Meridian Medicaid,CPT,54900,Fusion of spermatic ducts,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Meridian Medicaid,CPT,54901,Fusion of spermatic ducts,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,55040,Removal of hydrocele,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,55041,Removal of hydroceles,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,55060,Repair of hydrocele,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Meridian Medicaid,CPT,55100,Drainage of scrotum abscess,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Meridian Medicaid,CPT,55110,Explore scrotum,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,55120,Removal of scrotum lesion,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Meridian Medicaid,CPT,55150,Removal of scrotum,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Meridian Medicaid,CPT,55175,Revision of scrotum,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Meridian Medicaid,CPT,55180,Revision of scrotum,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,55200,Incision of sperm duct,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Meridian Medicaid,CPT,55250,Removal of sperm duct(s),Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Meridian Medicaid,CPT,55400,Repair of sperm duct,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,55450,Ligation of sperm duct,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Meridian Medicaid,CPT,55500,Removal of hydrocele,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Meridian Medicaid,CPT,55520,Removal of sperm cord lesion,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Meridian Medicaid,CPT,55530,Revise spermatic cord veins,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,55535,Revise spermatic cord veins,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Meridian Medicaid,CPT,55540,Revise hernia & sperm veins,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,55550,Laparo ligate spermatic vein,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,55559,Laparo proc spermatic cord,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Meridian Medicaid,CPT,55600,Incise sperm duct pouch,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Meridian Medicaid,CPT,55605,Incise sperm duct pouch,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,55650,Remove sperm duct pouch,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,55680,Remove sperm pouch lesion,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Meridian Medicaid,CPT,55801,Removal of prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Meridian Medicaid,CPT,55810,Extensive prostate surgery,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Meridian Medicaid,CPT,55815,Extensive prostate surgery,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Meridian Medicaid,CPT,55821,Removal of prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Meridian Medicaid,CPT,55831,Removal of prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Meridian Medicaid,CPT,55840,Extensive prostate surgery,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Meridian Medicaid,CPT,55842,Extensive prostate surgery,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Meridian Medicaid,CPT,55845,Extensive prostate surgery,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Meridian Medicaid,CPT,55860,Surgical exposure prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Meridian Medicaid,CPT,55866,Laparo radical prostatectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Meridian Medicaid,CPT,55870,Electroejaculation,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Meridian Medicaid,CPT,55873,Cryoablate prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Meridian Medicaid,CPT,55874,Tprnl plmt biodegrdabl matrl,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Meridian Medicaid,CPT,55880,Abltj mal prst8 tiss hifu,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Meridian Medicaid,CPT,55899,Genital surgery procedure,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Meridian Medicaid,CPT,56405,I & d of vulva/perineum,Gynecology,Per Unit,$102.34 ,OP,102.34,102.34,,,,,,
Meridian Medicaid,CPT,56420,Drainage of gland abscess,Gynecology,Per Unit,$102.34 ,OP,102.34,102.34,,,,,,
Meridian Medicaid,CPT,56820,Exam of vulva w/scope,Gynecology,Per Unit,$102.34 ,OP,102.34,102.34,,,,,,
Meridian Medicaid,CPT,57150,Treat vagina infection,Gynecology,Per Unit,$102.34 ,OP,102.34,102.34,,,,,,
Meridian Medicaid,CPT,57160,Insert pessary/other device,Gynecology,Per Unit,$102.34 ,OP,102.34,102.34,,,,,,
Meridian Medicaid,CPT,57170,Fitting of diaphragm/cap,Gynecology,Per Unit,$102.34 ,OP,102.34,102.34,,,,,,
Meridian Medicaid,CPT,57220,Revision of urethra,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Meridian Medicaid,CPT,57230,Repair of urethral lesion,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Meridian Medicaid,CPT,57240,Anterior colporrhaphy,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Meridian Medicaid,CPT,57250,Repair rectum & vagina,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Meridian Medicaid,CPT,57260,Cmbn ant pst colprhy,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Meridian Medicaid,CPT,57265,Cmbn ap colprhy w/ntrcl rpr,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Meridian Medicaid,CPT,57267,Insert mesh/pelvic flr addon,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Meridian Medicaid,CPT,57268,Repair of bowel bulge,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Meridian Medicaid,CPT,57270,Repair of bowel pouch,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Meridian Medicaid,CPT,57287,Revise/remove sling repair,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Meridian Medicaid,CPT,57288,Repair bladder defect,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Meridian Medicaid,CPT,57289,Repair bladder & vagina,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Meridian Medicaid,CPT,57410,Pelvic examination,Gynecology,Per Unit,$102.34 ,OP,102.34,102.34,,,,,,
Meridian Medicaid,CPT,58300,Insert intrauterine device,Gynecology,Per Unit,$102.34 ,OP,102.34,102.34,,,,,,
Meridian Medicaid,CPT,58301,Remove intrauterine device,Gynecology,Per Unit,$102.34 ,OP,102.34,102.34,,,,,,
Meridian Medicaid,CPT,58321,Artificial insemination,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Meridian Medicaid,CPT,58322,Artificial insemination,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Meridian Medicaid,CPT,58323,Sperm washing,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Meridian Medicaid,CPT,58970,Retrieval of oocyte,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Meridian Medicaid,CPT,58974,Transfer of embryo,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Meridian Medicaid,CPT,58976,Transfer of embryo,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Meridian Medicaid,CPT,59020,Fetal contract stress test,Obstetrics,Per Unit,$139.58 ,OP,139.58,139.58,,,,,,
Meridian Medicaid,CPT,59025,Fetal non-stress test,Obstetrics,Per Unit,$139.58 ,OP,139.58,139.58,,,,,,
Meridian Medicaid,CPT,59030,Fetal scalp blood sample,Obstetrics,Per Unit,$139.58 ,OP,139.58,139.58,,,,,,
Meridian Medicaid,CPT,59050,Fetal monitor w/report,Obstetrics,Per Unit,$139.58 ,OP,139.58,139.58,,,,,,
Meridian Medicaid,CPT,59072,Umbilical cord occlud w/us,Obstetrics,Per Unit,$482.07 ,OP,482.07,482.07,,,,,,
Meridian Medicaid,CPT,59074,Fetal fluid drainage w/us,Obstetrics,Per Unit,$139.58 ,OP,139.58,139.58,,,,,,
Meridian Medicaid,CPT,59076,Fetal shunt placement w/us,Obstetrics,Per Unit,$482.07 ,OP,482.07,482.07,,,,,,
Meridian Medicaid,CPT,59400,Obstetrical care,Obstetrics,Per Unit,"$1,075.20 ",OP,"1,075.20","1,075.20",,,,,,
Meridian Medicaid,CPT,59409,Obstetrical care,Obstetrics,Per Unit,"$1,075.20 ",OP,"1,075.20","1,075.20",,,,,,
Meridian Medicaid,CPT,59410,Obstetrical care,Obstetrics,Per Unit,"$1,075.20 ",OP,"1,075.20","1,075.20",,,,,,
Meridian Medicaid,CPT,59610,Vbac delivery,Obstetrics,Per Unit,"$1,075.20 ",OP,"1,075.20","1,075.20",,,,,,
Meridian Medicaid,CPT,59612,Vbac delivery only,Obstetrics,Per Unit,"$1,075.20 ",OP,"1,075.20","1,075.20",,,,,,
Meridian Medicaid,CPT,59614,Vbac care after delivery,Obstetrics,Per Unit,"$1,075.20 ",OP,"1,075.20","1,075.20",,,,,,
Meridian Medicaid,CPT,59812,Treatment of miscarriage,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Meridian Medicaid,CPT,59820,Care of miscarriage,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Meridian Medicaid,CPT,59821,Treatment of miscarriage,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Meridian Medicaid,CPT,59830,Treat uterus infection,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Meridian Medicaid,CPT,59840,Abortion,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Meridian Medicaid,CPT,59841,Abortion,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Meridian Medicaid,CPT,59850,Abortion,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Meridian Medicaid,CPT,59851,Abortion,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Meridian Medicaid,CPT,59852,Abortion,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Meridian Medicaid,CPT,59855,Abortion,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Meridian Medicaid,CPT,59856,Abortion,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Meridian Medicaid,CPT,59857,Abortion,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Meridian Medicaid,CPT,59866,Abortion (mpr),Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Meridian Medicaid,CPT,59897,Fetal invas px w/us,Obstetrics,Per Unit,$139.58 ,OP,139.58,139.58,,,,,,
Meridian Medicaid,CPT,60000,Drain thyroid/tongue cyst,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,60100,Biopsy of thyroid,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,60300,Aspir/inj thyroid cyst,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,60650,Laparoscopy adrenalectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Meridian Medicaid,CPT,60659,Laparo proc endocrine,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Meridian Medicaid,CPT,60699,Endocrine surgery procedure,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
Meridian Medicaid,CPT,61000,Remove cranial cavity fluid,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Meridian Medicaid,CPT,61001,Remove cranial cavity fluid,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Meridian Medicaid,CPT,61020,Remove brain cavity fluid,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Meridian Medicaid,CPT,61026,Injection into brain canal,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Meridian Medicaid,CPT,61070,Brain canal shunt procedure,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Meridian Medicaid,CPT,61215,Insert brain-fluid device,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,61623,Endovasc tempory vessel occl,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,61624,Transcath occlusion cns,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,61626,Transcath occlusion non-cns,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,61630,Intracranial angioplasty,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,61635,Intracran angioplsty w/stent,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,61640,Dilate ic vasospasm init,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,61641,Dilat ic vspsm ea vsl sm ter,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,61642,Dilat ic vspsm ea diff ter,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,61645,Perq art m-thrombect &/nfs,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,61651,Evasc prlng admn rx agnt add,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,61720,Incise skull/brain surgery,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,61770,Incise skull for treatment,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,61790,Treat trigeminal nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,61791,Treat trigeminal tract,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,61796,Srs cranial lesion simple,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"2,592.65","2,592.65",,,,,,
Meridian Medicaid,CPT,61797,Srs cran les simple addl,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"2,592.65","2,592.65",,,,,,
Meridian Medicaid,CPT,61798,Srs cranial lesion complex,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"2,592.65","2,592.65",,,,,,
Meridian Medicaid,CPT,61799,Srs cran les complex addl,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"2,592.65","2,592.65",,,,,,
Meridian Medicaid,CPT,61800,Apply srs headframe add-on,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"2,592.65","2,592.65",,,,,,
Meridian Medicaid,CPT,61850,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Meridian Medicaid,CPT,61880,Revise/remove neuroelectrode,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,61885,Insrt/redo neurostim 1 array,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Meridian Medicaid,CPT,61886,Implant neurostim arrays,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Meridian Medicaid,CPT,61888,Revise/remove neuroreceiver,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,62000,Treat skull fracture,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,62194,Replace/irrigate catheter,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,62225,Replace/irrigate catheter,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,62230,Replace/revise brain shunt,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,62252,Csf shunt reprogram,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,62292,Njx chemonucleolysis lmbr,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,62302,Myelography lumbar injection,Diagnostic Radiology,Per Unit,$345.35 ,OP,345.35,345.35,,,,,,
Meridian Medicaid,CPT,62303,Myelography lumbar injection,Diagnostic Radiology,Per Unit,$345.35 ,OP,345.35,345.35,,,,,,
Meridian Medicaid,CPT,62304,Myelography lumbar injection,Diagnostic Radiology,Per Unit,$345.35 ,OP,345.35,345.35,,,,,,
Meridian Medicaid,CPT,62305,Myelography lumbar injection,Diagnostic Radiology,Per Unit,$345.35 ,OP,345.35,345.35,,,,,,
Meridian Medicaid,CPT,62310,Inject spine cerv/thoracic,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Meridian Medicaid,CPT,62311,Inject spine lumbar/sacral,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Meridian Medicaid,CPT,62318,Inject spine w/cath crv/thrc,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Meridian Medicaid,CPT,62319,Inject spine w/cath lmb/scrl,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Meridian Medicaid,CPT,62350,Implant spinal canal cath,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,62355,Remove spinal canal catheter,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,62360,Insert spine infusion device,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"7,098.75","7,098.75",,,,,,
Meridian Medicaid,CPT,62361,Implant spine infusion pump,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"7,098.75","7,098.75",,,,,,
Meridian Medicaid,CPT,62362,Implant spine infusion pump,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"7,098.75","7,098.75",,,,,,
Meridian Medicaid,CPT,62365,Remove spine infusion device,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,62367,Analyze spine infus pump,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Meridian Medicaid,CPT,62368,Analyze sp inf pump w/reprog,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Meridian Medicaid,CPT,62369,Anal sp inf pmp w/reprg&fill,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Meridian Medicaid,CPT,62370,Anl sp inf pmp w/mdreprg&fil,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Meridian Medicaid,CPT,63600,Remove spinal cord lesion,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,63610,Stimulation of spinal cord,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,63615,Remove lesion of spinal cord,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,63620,Srs spinal lesion,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"2,592.65","2,592.65",,,,,,
Meridian Medicaid,CPT,63621,Srs spinal lesion addl,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"2,592.65","2,592.65",,,,,,
Meridian Medicaid,CPT,63650,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,63661,Remove spine eltrd perq aray,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,63662,Remove spine eltrd plate,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,63663,Revise spine eltrd perq aray,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,63664,Revise spine eltrd plate,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Meridian Medicaid,CPT,63685,Insrt/redo spine n generator,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Meridian Medicaid,CPT,63688,Revise/remove neuroreceiver,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,63707,Repair spinal fluid leakage,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,63741,Install spinal shunt,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,63744,Revision of spinal shunt,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,63746,Removal of spinal shunt,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64400,Njx aa&/strd trigeminal nrv,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Meridian Medicaid,CPT,64402,N block inj facial,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Meridian Medicaid,CPT,64405,Njx aa&/strd gr ocpl nrv,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Meridian Medicaid,CPT,64408,Njx aa&/strd vagus nrv,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Meridian Medicaid,CPT,64410,N block inj phrenic,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Meridian Medicaid,CPT,64412,N block inj spinal accessor,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Meridian Medicaid,CPT,64413,N block inj cervical plexus,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Meridian Medicaid,CPT,64415,Njx aa&/strd brach plexus,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Meridian Medicaid,CPT,64416,Njx aa&/strd brach plex nfs,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Meridian Medicaid,CPT,64417,Njx aa&/strd axillary nrv,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Meridian Medicaid,CPT,64418,Njx aa&/strd sprscap nrv,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Meridian Medicaid,CPT,64420,Njx aa&/strd ntrcost nrv 1,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Meridian Medicaid,CPT,64421,Njx aa&/strd ntrcost nrv ea,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Meridian Medicaid,CPT,64425,Njx aa&/strd ii ih nerves,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Meridian Medicaid,CPT,64430,Njx aa&/strd pudendal nerve,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Meridian Medicaid,CPT,64435,Njx aa&/strd paracrv nrv,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Meridian Medicaid,CPT,64445,Njx aa&/strd sciatic nerve,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Meridian Medicaid,CPT,64446,Njx aa&/strd sciatic nrv nfs,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Meridian Medicaid,CPT,64447,Njx aa&/strd femoral nerve,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Meridian Medicaid,CPT,64448,Njx aa&/strd fem nerve nfs,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Meridian Medicaid,CPT,64449,Njx aa&/strd lmbr plex nfs,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Meridian Medicaid,CPT,64450,Njx aa&/strd other pn/branch,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Meridian Medicaid,CPT,64454,Njx aa&/strd gnclr nrv brnch,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Meridian Medicaid,CPT,64455,Njx aa&/strd pltr com dg nrv,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Meridian Medicaid,CPT,64486,Tap block unil by injection,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Meridian Medicaid,CPT,64487,Tap block uni by infusion,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Meridian Medicaid,CPT,64488,Tap block bi injection,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Meridian Medicaid,CPT,64489,Tap block bi by infusion,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Meridian Medicaid,CPT,64505,N block spenopalatine gangl,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Meridian Medicaid,CPT,64508,N block carotid sinus s/p,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Meridian Medicaid,CPT,64510,N block stellate ganglion,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Meridian Medicaid,CPT,64517,N block inj hypogas plxs,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Meridian Medicaid,CPT,64530,N block inj celiac pelus,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Meridian Medicaid,CPT,64550,Appl surface neurostimulator,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,64553,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,64555,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,64561,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,64565,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,64566,Neuroeltrd stim post tibial,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Meridian Medicaid,CPT,64568,Inc for vagus n elect impl,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Meridian Medicaid,CPT,64569,Revise/repl vagus n eltrd,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Meridian Medicaid,CPT,64570,Remove vagus n eltrd,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64575,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Meridian Medicaid,CPT,64580,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"7,098.75","7,098.75",,,,,,
Meridian Medicaid,CPT,64581,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"7,098.75","7,098.75",,,,,,
Meridian Medicaid,CPT,64585,Revise/remove neuroelectrode,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64590,Insrt/redo pn/gastr stimul,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"7,098.75","7,098.75",,,,,,
Meridian Medicaid,CPT,64595,Revise/rmv pn/gastr stimul,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,64600,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Meridian Medicaid,CPT,64605,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Meridian Medicaid,CPT,64610,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Meridian Medicaid,CPT,64611,Chemodenerv saliv glands,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Meridian Medicaid,CPT,64612,Destroy nerve face muscle,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Meridian Medicaid,CPT,64615,Chemodenerv musc migraine,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Meridian Medicaid,CPT,64616,Chemodenerv musc neck dyston,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Meridian Medicaid,CPT,64617,Chemodener muscle larynx emg,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Meridian Medicaid,CPT,64620,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Meridian Medicaid,CPT,64624,Dstrj nulyt agt gnclr nrv,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Meridian Medicaid,CPT,64625,Rf abltj nrv nrvtg si jt,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64630,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Meridian Medicaid,CPT,64632,N block inj common digit,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Meridian Medicaid,CPT,64640,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Meridian Medicaid,CPT,64642,Chemodenerv 1 extremity 1-4,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Meridian Medicaid,CPT,64643,Chemodenerv 1 extrem 1-4 ea,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Meridian Medicaid,CPT,64644,Chemodenerv 1 extrem 5/> mus,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Meridian Medicaid,CPT,64645,Chemodenerv 1 extrem 5/> ea,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Meridian Medicaid,CPT,64646,Chemodenerv trunk musc 1-5,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Meridian Medicaid,CPT,64647,Chemodenerv trunk musc 6/>,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Meridian Medicaid,CPT,64650,Chemodenerv eccrine glands,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Meridian Medicaid,CPT,64653,Chemodenerv eccrine glands,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Meridian Medicaid,CPT,64680,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Meridian Medicaid,CPT,64681,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Meridian Medicaid,CPT,64702,Revise finger/toe nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64704,Revise hand/foot nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64708,Revise arm/leg nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64712,Revision of sciatic nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64713,Revision of arm nerve(s),Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,64714,Revise low back nerve(s),Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,64716,Revision of cranial nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,64718,Revise ulnar nerve at elbow,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64719,Revise ulnar nerve at wrist,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64721,Carpal tunnel surgery,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64722,Relieve pressure on nerve(s),Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64726,Release foot/toe nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64727,Internal nerve revision,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,64732,Incision of brow nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64734,Incision of cheek nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,64736,Incision of chin nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64738,Incision of jaw nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64740,Incision of tongue nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64742,Incision of facial nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,64744,Incise nerve back of head,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64746,Incise diaphragm nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,64763,Incise hip/thigh nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64766,Incise hip/thigh nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64771,Sever cranial nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64772,Incision of spinal nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64774,Remove skin nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64776,Remove digit nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64778,Digit nerve surgery add-on,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64782,Remove limb nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64783,Limb nerve surgery add-on,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64784,Remove nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64786,Remove sciatic nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64787,Implant nerve end,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64788,Remove skin nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64790,Removal of nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64792,Removal of nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64795,Biopsy of nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64802,Sympathectomy cervical,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64804,Remove sympathetic nerves,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64818,Remove sympathetic nerves,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64820,Sympathectomy digital artery,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64821,Remove sympathetic nerves,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,64822,Remove sympathetic nerves,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,64823,Sympathectomy supfc palmar,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,64831,Repair of digit nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64832,Repair nerve add-on,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64834,Repair of hand or foot nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64835,Repair of hand or foot nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64836,Repair of hand or foot nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64837,Repair nerve add-on,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64840,Repair of leg nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,64856,Repair/transpose nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64857,Repair arm/leg nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64858,Repair sciatic nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,64859,Nerve surgery,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,64861,Repair of arm nerves,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64862,Repair of low back nerves,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,64864,Repair of facial nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,64865,Repair of facial nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,64866,Fusion of facial/other nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,64868,Fusion of facial/other nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,64872,Subsequent repair of nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64874,Repair & revise nerve add-on,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64876,Repair nerve/shorten bone,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64885,Nerve graft head/neck </4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,64886,Nerve graft head/neck >4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,64890,Nerve graft hand/foot </4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,64891,Nerve graft hand/foot >4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,64892,Nerve graft arm/leg <4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,64893,Nerve graft arm/leg >4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,64895,Nerve graft hand/foot </4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,64896,Nerve graft hand/foot >4 cm,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"7,098.75","7,098.75",,,,,,
Meridian Medicaid,CPT,64897,Nerve graft arm/leg </4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,64898,Nerve graft arm/leg >4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,64901,Nerve graft add-on,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,64902,Nerve graft add-on,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,64905,Nerve pedicle transfer,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,64907,Nerve pedicle transfer,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,64910,Nerve repair w/allograft,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,64911,Neurorraphy w/vein autograft,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,64912,Nrv rpr w/nrv algrft 1st,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,64913,Nrv rpr w/nrv algrft ea addl,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,64999,Nervous system surgery,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Meridian Medicaid,CPT,65091,Revise eye,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,65093,Revise eye with implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,65101,Removal of eye,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,65103,Remove eye/insert implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,65105,Remove eye/attach implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,65110,Removal of eye,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,65112,Remove eye/revise socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,65114,Remove eye/revise socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,65125,Revise ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,65130,Insert ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,65135,Insert ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,65140,Attach ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,65150,Revise ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,65155,Reinsert ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,65175,Removal of ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,65205,Remove foreign body from eye,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,65210,Remove foreign body from eye,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,65220,Remove foreign body from eye,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,65222,Remove foreign body from eye,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,65235,Remove foreign body from eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Meridian Medicaid,CPT,65260,Remove foreign body from eye,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Meridian Medicaid,CPT,65265,Remove foreign body from eye,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Meridian Medicaid,CPT,65270,Repair of eye wound,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Meridian Medicaid,CPT,65272,Repair of eye wound,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Meridian Medicaid,CPT,65275,Repair of eye wound,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Meridian Medicaid,CPT,65280,Repair of eye wound,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Meridian Medicaid,CPT,65285,Repair of eye wound,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Meridian Medicaid,CPT,65286,Repair of eye wound,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Meridian Medicaid,CPT,65290,Repair of eye socket wound,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
Meridian Medicaid,CPT,65400,Removal of eye lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Meridian Medicaid,CPT,65410,Biopsy of cornea,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Meridian Medicaid,CPT,65420,Removal of eye lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Meridian Medicaid,CPT,65426,Removal of eye lesion,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Meridian Medicaid,CPT,65430,Corneal smear,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Meridian Medicaid,CPT,65435,Curette/treat cornea,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Meridian Medicaid,CPT,65436,Curette/treat cornea,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Meridian Medicaid,CPT,65450,Treatment of corneal lesion,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Meridian Medicaid,CPT,65600,Revision of cornea,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Meridian Medicaid,CPT,65710,Corneal transplant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Meridian Medicaid,CPT,65730,Corneal transplant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Meridian Medicaid,CPT,65750,Corneal transplant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Meridian Medicaid,CPT,65755,Corneal transplant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Meridian Medicaid,CPT,65756,Corneal trnspl endothelial,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Meridian Medicaid,CPT,65757,Prep corneal endo allograft,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Meridian Medicaid,CPT,65760,Revision of cornea,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Meridian Medicaid,CPT,65765,Revision of cornea,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Meridian Medicaid,CPT,65767,Corneal tissue transplant,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Meridian Medicaid,CPT,65770,Revise cornea with implant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Meridian Medicaid,CPT,65771,Radial keratotomy,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Meridian Medicaid,CPT,65772,Correction of astigmatism,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Meridian Medicaid,CPT,65775,Correction of astigmatism,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Meridian Medicaid,CPT,65778,Cover eye w/membrane,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Meridian Medicaid,CPT,65779,Cover eye w/membrane suture,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Meridian Medicaid,CPT,65780,Ocular reconst transplant,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Meridian Medicaid,CPT,65781,Ocular reconst transplant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Meridian Medicaid,CPT,65782,Ocular reconst transplant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Meridian Medicaid,CPT,65785,Impltj ntrstrml crnl rng seg,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Meridian Medicaid,CPT,65800,Drainage of eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Meridian Medicaid,CPT,65810,Drainage of eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Meridian Medicaid,CPT,65815,Drainage of eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Meridian Medicaid,CPT,65820,Relieve inner eye pressure,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Meridian Medicaid,CPT,65850,Incision of eye,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Meridian Medicaid,CPT,65855,Trabeculoplasty laser surg,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Meridian Medicaid,CPT,65860,Incise inner eye adhesions,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Meridian Medicaid,CPT,65865,Incise inner eye adhesions,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Meridian Medicaid,CPT,65870,Incise inner eye adhesions,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Meridian Medicaid,CPT,65875,Incise inner eye adhesions,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Meridian Medicaid,CPT,65880,Incise inner eye adhesions,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Meridian Medicaid,CPT,65900,Remove eye lesion,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Meridian Medicaid,CPT,65920,Remove implant of eye,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Meridian Medicaid,CPT,65930,Remove blood clot from eye,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Meridian Medicaid,CPT,66020,Injection treatment of eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Meridian Medicaid,CPT,66030,Injection treatment of eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Meridian Medicaid,CPT,66130,Remove eye lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Meridian Medicaid,CPT,66150,Glaucoma surgery,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Meridian Medicaid,CPT,66155,Glaucoma surgery,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Meridian Medicaid,CPT,66160,Glaucoma surgery,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Meridian Medicaid,CPT,66170,Glaucoma surgery,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Meridian Medicaid,CPT,66172,Incision of eye,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Meridian Medicaid,CPT,66174,Translum dil eye canal,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Meridian Medicaid,CPT,66175,Trnslum dil eye canal w/stnt,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Meridian Medicaid,CPT,66179,Aqueous shunt eye w/o graft,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Meridian Medicaid,CPT,66180,Aqueous shunt eye w/graft,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Meridian Medicaid,CPT,66183,Insert ant drainage device,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Meridian Medicaid,CPT,66184,Revision of aqueous shunt,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Meridian Medicaid,CPT,66185,Revise aqueous shunt eye,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Meridian Medicaid,CPT,66220,Repair eye lesion,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Meridian Medicaid,CPT,66225,Repair/graft eye lesion,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Meridian Medicaid,CPT,66250,Follow-up surgery of eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Meridian Medicaid,CPT,66500,Incision of iris,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Meridian Medicaid,CPT,66505,Incision of iris,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Meridian Medicaid,CPT,66600,Remove iris and lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Meridian Medicaid,CPT,66605,Removal of iris,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Meridian Medicaid,CPT,66625,Removal of iris,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Meridian Medicaid,CPT,66630,Removal of iris,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Meridian Medicaid,CPT,66635,Removal of iris,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Meridian Medicaid,CPT,66680,Repair iris & ciliary body,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Meridian Medicaid,CPT,66682,Repair iris & ciliary body,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Meridian Medicaid,CPT,66700,Destruction ciliary body,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Meridian Medicaid,CPT,66710,Ciliary transsleral therapy,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Meridian Medicaid,CPT,66711,Ecp ciliary body destruction,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Meridian Medicaid,CPT,66720,Destruction ciliary body,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Meridian Medicaid,CPT,66740,Destruction ciliary body,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Meridian Medicaid,CPT,66761,Revision of iris,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Meridian Medicaid,CPT,66762,Revision of iris,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Meridian Medicaid,CPT,66770,Removal of inner eye lesion,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Meridian Medicaid,CPT,66820,Incision secondary cataract,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
Meridian Medicaid,CPT,66821,After cataract laser surgery,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Meridian Medicaid,CPT,66825,Reposition intraocular lens,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
Meridian Medicaid,CPT,66830,Removal of lens lesion,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
Meridian Medicaid,CPT,66840,Removal of lens material,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
Meridian Medicaid,CPT,66850,Removal of lens material,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
Meridian Medicaid,CPT,66852,Removal of lens material,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Meridian Medicaid,CPT,66920,Extraction of lens,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
Meridian Medicaid,CPT,66930,Extraction of lens,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
Meridian Medicaid,CPT,66940,Extraction of lens,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
Meridian Medicaid,CPT,66982,Xcapsl ctrc rmvl cplx wo ecp,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
Meridian Medicaid,CPT,66983,Cataract surg w/iol 1 stage,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
Meridian Medicaid,CPT,66984,Xcapsl ctrc rmvl w/o ecp,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
Meridian Medicaid,CPT,66985,Insert lens prosthesis,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
Meridian Medicaid,CPT,66986,Exchange lens prosthesis,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
Meridian Medicaid,CPT,66987,Xcapsl ctrc rmvl cplx w/ecp,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
Meridian Medicaid,CPT,66988,Xcapsl ctrc rmvl w/ecp,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
Meridian Medicaid,CPT,66999,Eye surgery procedure,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Meridian Medicaid,CPT,67005,Partial removal of eye fluid,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Meridian Medicaid,CPT,67010,Partial removal of eye fluid,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Meridian Medicaid,CPT,67015,Release of eye fluid,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Meridian Medicaid,CPT,67025,Replace eye fluid,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Meridian Medicaid,CPT,67027,Implant eye drug system,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Meridian Medicaid,CPT,67028,Injection eye drug,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Meridian Medicaid,CPT,67030,Incise inner eye strands,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Meridian Medicaid,CPT,67031,Laser surgery eye strands,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Meridian Medicaid,CPT,67036,Removal of inner eye fluid,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Meridian Medicaid,CPT,67039,Laser treatment of retina,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Meridian Medicaid,CPT,67040,Laser treatment of retina,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Meridian Medicaid,CPT,67041,Vit for macular pucker,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Meridian Medicaid,CPT,67042,Vit for macular hole,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Meridian Medicaid,CPT,67043,Vit for membrane dissect,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Meridian Medicaid,CPT,67101,Repair detached retina crtx,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Meridian Medicaid,CPT,67105,Repair detached retina pc,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Meridian Medicaid,CPT,67107,Repair detached retina,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Meridian Medicaid,CPT,67108,Repair detached retina,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Meridian Medicaid,CPT,67110,Repair detached retina,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Meridian Medicaid,CPT,67112,Rerepair detached retina,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Meridian Medicaid,CPT,67113,Repair retinal detach cplx,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Meridian Medicaid,CPT,67115,Release encircling material,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Meridian Medicaid,CPT,67120,Remove eye implant material,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Meridian Medicaid,CPT,67121,Remove eye implant material,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Meridian Medicaid,CPT,67141,Treatment of retina,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Meridian Medicaid,CPT,67145,Treatment of retina,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Meridian Medicaid,CPT,67208,Treatment of retinal lesion,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Meridian Medicaid,CPT,67210,Treatment of retinal lesion,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Meridian Medicaid,CPT,67218,Treatment of retinal lesion,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Meridian Medicaid,CPT,67220,Treatment of choroid lesion,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Meridian Medicaid,CPT,67221,Ocular photodynamic ther,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Meridian Medicaid,CPT,67225,Eye photodynamic ther add-on,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Meridian Medicaid,CPT,67227,Dstrj extensive retinopathy,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Meridian Medicaid,CPT,67228,Treatment x10sv retinopathy,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Meridian Medicaid,CPT,67229,Tr retinal les preterm inf,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Meridian Medicaid,CPT,67250,Reinforce eye wall,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Meridian Medicaid,CPT,67255,Reinforce/graft eye wall,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Meridian Medicaid,CPT,67299,Eye surgery procedure,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Meridian Medicaid,CPT,67311,Revise eye muscle,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
Meridian Medicaid,CPT,67312,Revise two eye muscles,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
Meridian Medicaid,CPT,67314,Revise eye muscle,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
Meridian Medicaid,CPT,67316,Revise two eye muscles,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
Meridian Medicaid,CPT,67318,Revise eye muscle(s),Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
Meridian Medicaid,CPT,67320,Revise eye muscle(s) add-on,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
Meridian Medicaid,CPT,67331,Eye surgery follow-up add-on,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
Meridian Medicaid,CPT,67332,Rerevise eye muscles add-on,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
Meridian Medicaid,CPT,67334,Revise eye muscle w/suture,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
Meridian Medicaid,CPT,67335,Eye suture during surgery,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
Meridian Medicaid,CPT,67340,Revise eye muscle add-on,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
Meridian Medicaid,CPT,67343,Release eye tissue,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
Meridian Medicaid,CPT,67345,Destroy nerve of eye muscle,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
Meridian Medicaid,CPT,67346,Biopsy eye muscle,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Meridian Medicaid,CPT,67399,Unlisted px extraocular musc,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
Meridian Medicaid,CPT,67400,Explore/biopsy eye socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,67405,Explore/drain eye socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,67412,Explore/treat eye socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,67413,Explore/treat eye socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,67414,Explr/decompress eye socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,67415,Aspiration orbital contents,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Meridian Medicaid,CPT,67445,Explr/decompress eye socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,67500,Inject/treat eye socket,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Meridian Medicaid,CPT,67505,Inject/treat eye socket,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Meridian Medicaid,CPT,67515,Inject/treat eye socket,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Meridian Medicaid,CPT,67550,Insert eye socket implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,67560,Revise eye socket implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,67570,Decompress optic nerve,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,67599,Orbit surgery procedure,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Meridian Medicaid,CPT,67700,Drainage of eyelid abscess,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Meridian Medicaid,CPT,67710,Incision of eyelid,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Meridian Medicaid,CPT,67715,Incision of eyelid fold,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Meridian Medicaid,CPT,67800,Remove eyelid lesion,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Meridian Medicaid,CPT,67801,Remove eyelid lesions,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Meridian Medicaid,CPT,67805,Remove eyelid lesions,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Meridian Medicaid,CPT,67808,Remove eyelid lesion(s),Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Meridian Medicaid,CPT,67810,Biopsy eyelid & lid margin,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Meridian Medicaid,CPT,67820,Revise eyelashes,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Meridian Medicaid,CPT,67825,Revise eyelashes,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Meridian Medicaid,CPT,67830,Revise eyelashes,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Meridian Medicaid,CPT,67835,Revise eyelashes,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,67840,Remove eyelid lesion,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Meridian Medicaid,CPT,67850,Treat eyelid lesion,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Meridian Medicaid,CPT,67875,Closure of eyelid by suture,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Meridian Medicaid,CPT,67880,Revision of eyelid,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Meridian Medicaid,CPT,67882,Revision of eyelid,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Meridian Medicaid,CPT,67900,Repair brow defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,67901,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,67902,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,67903,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,67904,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,67906,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,67908,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,67909,Revise eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,67911,Revise eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,67912,Correction eyelid w/implant,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Meridian Medicaid,CPT,67914,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Meridian Medicaid,CPT,67915,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Meridian Medicaid,CPT,67916,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Meridian Medicaid,CPT,67917,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,67921,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Meridian Medicaid,CPT,67922,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Meridian Medicaid,CPT,67923,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Meridian Medicaid,CPT,67924,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,67930,Repair eyelid wound,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Meridian Medicaid,CPT,67935,Repair eyelid wound,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Meridian Medicaid,CPT,67938,Remove eyelid foreign body,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Meridian Medicaid,CPT,67950,Revision of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,67961,Revision of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,67966,Revision of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,67971,Reconstruction of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,67973,Reconstruction of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,67974,Reconstruction of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,67975,Reconstruction of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,67999,Revision of eyelid,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Meridian Medicaid,CPT,68020,Incise/drain eyelid lining,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Meridian Medicaid,CPT,68040,Treatment of eyelid lesions,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Meridian Medicaid,CPT,68100,Biopsy of eyelid lining,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Meridian Medicaid,CPT,68110,Remove eyelid lining lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Meridian Medicaid,CPT,68115,Remove eyelid lining lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Meridian Medicaid,CPT,68130,Remove eyelid lining lesion,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Meridian Medicaid,CPT,68135,Remove eyelid lining lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Meridian Medicaid,CPT,68200,Treat eyelid by injection,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Meridian Medicaid,CPT,68320,Revise/graft eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Meridian Medicaid,CPT,68325,Revise/graft eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Meridian Medicaid,CPT,68326,Revise/graft eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Meridian Medicaid,CPT,68328,Revise/graft eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Meridian Medicaid,CPT,68330,Revise eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Meridian Medicaid,CPT,68335,Revise/graft eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Meridian Medicaid,CPT,68340,Separate eyelid adhesions,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Meridian Medicaid,CPT,68360,Revise eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Meridian Medicaid,CPT,68362,Revise eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Meridian Medicaid,CPT,68371,Harvest eye tissue alograft,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Meridian Medicaid,CPT,68399,Eyelid lining surgery,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Meridian Medicaid,CPT,68400,Incise/drain tear gland,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Meridian Medicaid,CPT,68420,Incise/drain tear sac,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Meridian Medicaid,CPT,68440,Incise tear duct opening,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Meridian Medicaid,CPT,68500,Removal of tear gland,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,68505,Partial removal tear gland,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,68510,Biopsy of tear gland,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Meridian Medicaid,CPT,68520,Removal of tear sac,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,68525,Biopsy of tear sac,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Meridian Medicaid,CPT,68530,Clearance of tear duct,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Meridian Medicaid,CPT,68540,Remove tear gland lesion,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,68550,Remove tear gland lesion,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,68700,Repair tear ducts,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,68705,Revise tear duct opening,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Meridian Medicaid,CPT,68720,Create tear sac drain,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,68745,Create tear duct drain,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,68750,Create tear duct drain,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,68760,Close tear duct opening,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Meridian Medicaid,CPT,68761,Close tear duct opening,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Meridian Medicaid,CPT,68770,Close tear system fistula,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Meridian Medicaid,CPT,68801,Dilate tear duct opening,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Meridian Medicaid,CPT,68810,Probe nasolacrimal duct,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Meridian Medicaid,CPT,68811,Probe nasolacrimal duct,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Meridian Medicaid,CPT,68815,Probe nasolacrimal duct,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Meridian Medicaid,CPT,68816,Probe nl duct w/balloon,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Meridian Medicaid,CPT,68840,Explore/irrigate tear ducts,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Meridian Medicaid,CPT,68899,Tear duct system surgery,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Meridian Medicaid,CPT,69005,Drain external ear lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,69100,Biopsy of external ear,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,69105,Biopsy of external ear canal,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,69110,Remove external ear partial,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,69120,Removal of external ear,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,69140,Remove ear canal lesion(s),Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,69145,Remove ear canal lesion(s),Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,69150,Extensive ear canal surgery,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,69155,Extensive ear/neck surgery,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,69205,Clear outer ear canal,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,69222,Clean out mastoid cavity,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,69300,Revise external ear,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,69310,Rebuild outer ear canal,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,69320,Rebuild outer ear canal,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,69399,Outer ear surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,69421,Incision of eardrum,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,69424,Remove ventilating tube,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,69433,Create eardrum opening,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,69436,Create eardrum opening,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,69440,Exploration of middle ear,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,69450,Eardrum revision,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,69501,Mastoidectomy,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,69502,Mastoidectomy,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,69505,Remove mastoid structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,69511,Extensive mastoid surgery,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,69530,Extensive mastoid surgery,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,69540,Remove ear lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,69550,Remove ear lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,69552,Remove ear lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,69601,Mastoid surgery revision,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,69602,Mastoid surgery revision,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,69603,Mastoid surgery revision,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,69604,Mastoid surgery revision,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,69605,Mastoid surgery revision,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,69610,Repair of eardrum,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,69620,Repair of eardrum,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,69631,Repair eardrum structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,69632,Rebuild eardrum structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,69633,Rebuild eardrum structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,69635,Repair eardrum structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,69636,Rebuild eardrum structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,69637,Rebuild eardrum structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,69641,Revise middle ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,69642,Revise middle ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,69643,Revise middle ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,69644,Revise middle ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,69645,Revise middle ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,69646,Revise middle ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,69650,Release middle ear bone,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,69660,Revise middle ear bone,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,69661,Revise middle ear bone,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,69662,Revise middle ear bone,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,69666,Repair middle ear structures,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,69667,Repair middle ear structures,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,69670,Remove mastoid air cells,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,69676,Remove middle ear nerve,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,69700,Close mastoid fistula,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,69705,Nps surg dilat eust tube uni,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Meridian Medicaid,CPT,69706,Nps surg dilat eust tube bi,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Meridian Medicaid,CPT,69710,Implant/replace hearing aid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,69711,Remove/repair hearing aid,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,69714,Implant temple bone w/stimul,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,69715,Temple bne implnt w/stimulat,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,69717,Temple bone implant revision,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,69718,Revise temple bone implant,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,69720,Release facial nerve,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,69725,Release facial nerve,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,69740,Repair facial nerve,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,69745,Repair facial nerve,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,69799,Middle ear surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,69801,Incise inner ear,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,69805,Explore inner ear,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,69806,Explore inner ear,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,69820,Establish inner ear window,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,69840,Revise inner ear window,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,69905,Remove inner ear,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Meridian Medicaid,CPT,69910,Remove inner ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,69915,Incise inner ear nerve,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,69930,Implant cochlear device,Otolaryngology Surgery,Per Unit,"$15,529.51 ",OP,"15,529.51","15,529.51",,,,,,
Meridian Medicaid,CPT,69949,Inner ear surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,69955,Release facial nerve,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,69960,Release inner ear canal,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Meridian Medicaid,CPT,70010,Contrast x-ray of brain,Diagnostic Radiology,Per Unit,$345.35 ,OP,345.35,345.35,,,,,,
Meridian Medicaid,CPT,70015,Contrast x-ray of brain,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Meridian Medicaid,CPT,70030,X-ray eye for foreign body,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,70100,X-ray exam of jaw <4views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,70110,X-ray exam of jaw 4/> views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,70120,X-ray exam of mastoids,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,70130,X-ray exam of mastoids,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,70134,X-ray exam of middle ear,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,70140,X-ray exam of facial bones,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,70150,X-ray exam of facial bones,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,70160,X-ray exam of nasal bones,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,70190,X-ray exam of eye sockets,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,70200,X-ray exam of eye sockets,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,70210,X-ray exam of sinuses,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,70220,X-ray exam of sinuses,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,70240,X-ray exam pituitary saddle,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,70250,X-ray exam of skull,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,70260,X-ray exam of skull,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,70300,X-ray exam of teeth,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,70310,X-ray exam of teeth,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,70320,Full mouth x-ray of teeth,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,70328,X-ray exam of jaw joint,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,70330,X-ray exam of jaw joints,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,70336,Magnetic image jaw joint,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Meridian Medicaid,CPT,70350,X-ray head for orthodontia,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,70355,Panoramic x-ray of jaws,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,70360,X-ray exam of neck,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,70370,Throat x-ray & fluoroscopy,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,70373,Contrast x-ray of larynx,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,70380,X-ray exam of salivary gland,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,70450,Ct head/brain w/o dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Meridian Medicaid,CPT,70460,Ct head/brain w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Meridian Medicaid,CPT,70470,Ct head/brain w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Meridian Medicaid,CPT,70480,Ct orbit/ear/fossa w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Meridian Medicaid,CPT,70481,Ct orbit/ear/fossa w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Meridian Medicaid,CPT,70482,Ct orbit/ear/fossa w/o&w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Meridian Medicaid,CPT,70486,Ct maxillofacial w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Meridian Medicaid,CPT,70487,Ct maxillofacial w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Meridian Medicaid,CPT,70488,Ct maxillofacial w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Meridian Medicaid,CPT,70490,Ct soft tissue neck w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Meridian Medicaid,CPT,70491,Ct soft tissue neck w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Meridian Medicaid,CPT,70492,Ct sft tsue nck w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Meridian Medicaid,CPT,70496,Ct angiography head,Interventional Radiology,Per Unit,$178.94 ,OP,178.94,178.94,,,,,,
Meridian Medicaid,CPT,70498,Ct angiography neck,Interventional Radiology,Per Unit,$178.94 ,OP,178.94,178.94,,,,,,
Meridian Medicaid,CPT,70540,Mri orbit/face/neck w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Meridian Medicaid,CPT,70542,Mri orbit/face/neck w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Meridian Medicaid,CPT,70543,Mri orbt/fac/nck w/o &w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Meridian Medicaid,CPT,70544,Mr angiography head w/o dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Meridian Medicaid,CPT,70545,Mr angiography head w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Meridian Medicaid,CPT,70546,Mr angiograph head w/o&w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Meridian Medicaid,CPT,70547,Mr angiography neck w/o dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Meridian Medicaid,CPT,70548,Mr angiography neck w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Meridian Medicaid,CPT,70549,Mr angiograph neck w/o&w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Meridian Medicaid,CPT,70551,Mri brain stem w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Meridian Medicaid,CPT,70552,Mri brain stem w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Meridian Medicaid,CPT,70553,Mri brain stem w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Meridian Medicaid,CPT,70554,Fmri brain by tech,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Meridian Medicaid,CPT,70555,Fmri brain by phys/psych,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Meridian Medicaid,CPT,70557,Mri brain w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Meridian Medicaid,CPT,70558,Mri brain w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Meridian Medicaid,CPT,70559,Mri brain w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Meridian Medicaid,CPT,71010,Chest x-ray 1 view frontal,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,71015,Chest x-ray stereo frontal,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,71020,Chest x-ray 2vw frontal&latl,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,71021,Chest x-ray frnt lat lordotc,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,71022,Chest x-ray frnt lat oblique,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,71023,Chest x-ray and fluoroscopy,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,71030,Chest x-ray 4/> views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,71034,Chest x-ray&fluoro 4/> views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,71035,Chest x-ray special views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,71045,X-ray exam chest 1 view,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,71046,X-ray exam chest 2 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,71047,X-ray exam chest 3 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,71048,X-ray exam chest 4+ views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,71100,X-ray exam ribs uni 2 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,71101,X-ray exam unilat ribs/chest,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,71110,X-ray exam ribs bil 3 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,71111,X-ray exam ribs/chest4/> vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,71120,X-ray exam breastbone 2/>vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,71130,X-ray strenoclavic jt 3/>vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,71250,Ct thorax dx c-,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Meridian Medicaid,CPT,71260,Ct thorax dx c+,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Meridian Medicaid,CPT,71270,Ct thorax dx c-/c+,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Meridian Medicaid,CPT,71271,Ct thorax lung cancer scr c-,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Meridian Medicaid,CPT,71275,Ct angiography chest,Interventional Radiology,Per Unit,$178.94 ,OP,178.94,178.94,,,,,,
Meridian Medicaid,CPT,71550,Mri chest w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Meridian Medicaid,CPT,71551,Mri chest w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Meridian Medicaid,CPT,71552,Mri chest w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Meridian Medicaid,CPT,71555,Mri angio chest w or w/o dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Meridian Medicaid,CPT,72010,X-ray exam spine ap&lat,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,72020,X-ray exam of spine 1 view,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,72040,X-ray exam neck spine 2-3 vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,72050,X-ray exam neck spine 4/5vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,72052,X-ray exam neck spine 6/>vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,72069,X-ray exam trunk spine stand,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,72070,X-ray exam thorac spine 2vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,72072,X-ray exam thorac spine 3vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,72074,X-ray exam thorac spine4/>vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,72080,X-ray exam thoracolmb 2/> vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,72081,X-ray exam entire spi 1 vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,72082,X-ray exam entire spi 2/3 vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,72083,X-ray exam entire spi 4/5 vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,72084,X-ray exam entire spi 6/> vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,72090,X-ray exam scloiosis erect,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,72100,X-ray exam l-s spine 2/3 vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,72110,X-ray exam l-2 spine 4/>vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,72114,X-ray exam l-s spine bending,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,72120,X-ray bend only l-s spine,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,72125,Ct neck spine w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Meridian Medicaid,CPT,72126,Ct neck spine w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Meridian Medicaid,CPT,72127,Ct neck spine w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Meridian Medicaid,CPT,72128,Ct chest spine w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Meridian Medicaid,CPT,72129,Ct chest spine w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Meridian Medicaid,CPT,72130,Ct chest spine w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Meridian Medicaid,CPT,72131,Ct lumbar spine w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Meridian Medicaid,CPT,72132,Ct lumbar spine w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Meridian Medicaid,CPT,72133,Ct lumbar spine w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Meridian Medicaid,CPT,72141,Mri neck spine w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Meridian Medicaid,CPT,72142,Mri neck spine w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Meridian Medicaid,CPT,72146,Mri chest spine w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Meridian Medicaid,CPT,72147,Mri chest spine w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Meridian Medicaid,CPT,72148,Mri lumbar spine w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Meridian Medicaid,CPT,72149,Mri lumbar spine w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Meridian Medicaid,CPT,72156,Mri neck spine w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Meridian Medicaid,CPT,72157,Mri chest spine w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Meridian Medicaid,CPT,72158,Mri lumbar spine w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Meridian Medicaid,CPT,72159,Mr angio spine w/o&w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Meridian Medicaid,CPT,72170,X-ray exam of pelvis,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,72190,X-ray exam of pelvis,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,72191,Ct angiograph pelv w/o&w/dye,Interventional Radiology,Per Unit,$178.94 ,OP,178.94,178.94,,,,,,
Meridian Medicaid,CPT,72192,Ct pelvis w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Meridian Medicaid,CPT,72193,Ct pelvis w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Meridian Medicaid,CPT,72194,Ct pelvis w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Meridian Medicaid,CPT,72195,Mri pelvis w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Meridian Medicaid,CPT,72196,Mri pelvis w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Meridian Medicaid,CPT,72197,Mri pelvis w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Meridian Medicaid,CPT,72198,Mr angio pelvis w/o & w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Meridian Medicaid,CPT,72200,X-ray exam si joints,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,72202,X-ray exam si joints 3/> vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,72220,X-ray exam sacrum tailbone,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,72240,Myelography neck spine,Diagnostic Radiology,Per Unit,$345.35 ,OP,345.35,345.35,,,,,,
Meridian Medicaid,CPT,72255,Myelography thoracic spine,Diagnostic Radiology,Per Unit,$345.35 ,OP,345.35,345.35,,,,,,
Meridian Medicaid,CPT,72265,Myelography l-s spine,Diagnostic Radiology,Per Unit,$345.35 ,OP,345.35,345.35,,,,,,
Meridian Medicaid,CPT,72270,Myelogphy 2/> spine regions,Diagnostic Radiology,Per Unit,$345.35 ,OP,345.35,345.35,,,,,,
Meridian Medicaid,CPT,72275,Epidurography,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,72285,Discography cerv/thor spine,Diagnostic Radiology,Per Unit,$345.35 ,OP,345.35,345.35,,,,,,
Meridian Medicaid,CPT,72295,X-ray of lower spine disk,Diagnostic Radiology,Per Unit,$345.35 ,OP,345.35,345.35,,,,,,
Meridian Medicaid,CPT,73000,X-ray exam of collar bone,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,73010,X-ray exam of shoulder blade,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,73020,X-ray exam of shoulder,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,73030,X-ray exam of shoulder,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,73050,X-ray exam of shoulders,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,73060,X-ray exam of humerus,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,73070,X-ray exam of elbow,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,73080,X-ray exam of elbow,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,73090,X-ray exam of forearm,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,73092,X-ray exam of arm infant,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,73100,X-ray exam of wrist,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,73110,X-ray exam of wrist,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,73120,X-ray exam of hand,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,73130,X-ray exam of hand,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,73140,X-ray exam of finger(s),Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,73200,Ct upper extremity w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Meridian Medicaid,CPT,73201,Ct upper extremity w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Meridian Medicaid,CPT,73202,Ct uppr extremity w/o&w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Meridian Medicaid,CPT,73206,Ct angio upr extrm w/o&w/dye,Interventional Radiology,Per Unit,$178.94 ,OP,178.94,178.94,,,,,,
Meridian Medicaid,CPT,73218,Mri upper extremity w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Meridian Medicaid,CPT,73219,Mri upper extremity w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Meridian Medicaid,CPT,73220,Mri uppr extremity w/o&w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Meridian Medicaid,CPT,73221,Mri joint upr extrem w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Meridian Medicaid,CPT,73222,Mri joint upr extrem w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Meridian Medicaid,CPT,73223,Mri joint upr extr w/o&w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Meridian Medicaid,CPT,73225,Mr angio upr extr w/o&w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Meridian Medicaid,CPT,73500,X-ray exam of hip,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,73501,X-ray exam hip uni 1 view,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,73502,X-ray exam hip uni 2-3 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,73503,X-ray exam hip uni 4/> views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,73510,X-ray exam of hip,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,73520,X-ray exam of hips,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,73521,X-ray exam hips bi 2 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,73522,X-ray exam hips bi 3-4 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,73523,X-ray exam hips bi 5/> views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,73530,X-ray exam of hip,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,73540,X-ray exam of pelvis & hips,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,73550,X-ray exam of thigh,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,73551,X-ray exam of femur 1,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,73552,X-ray exam of femur 2/>,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,73560,X-ray exam of knee 1 or 2,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,73562,X-ray exam of knee 3,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,73564,X-ray exam knee 4 or more,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,73565,X-ray exam of knees,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,73590,X-ray exam of lower leg,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,73592,X-ray exam of leg infant,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,73600,X-ray exam of ankle,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,73610,X-ray exam of ankle,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,73620,X-ray exam of foot,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,73630,X-ray exam of foot,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,73650,X-ray exam of heel,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,73660,X-ray exam of toe(s),Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,73700,Ct lower extremity w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Meridian Medicaid,CPT,73701,Ct lower extremity w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Meridian Medicaid,CPT,73702,Ct lwr extremity w/o&w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Meridian Medicaid,CPT,73706,Ct angio lwr extr w/o&w/dye,Interventional Radiology,Per Unit,$178.94 ,OP,178.94,178.94,,,,,,
Meridian Medicaid,CPT,73718,Mri lower extremity w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Meridian Medicaid,CPT,73719,Mri lower extremity w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Meridian Medicaid,CPT,73720,Mri lwr extremity w/o&w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Meridian Medicaid,CPT,73721,Mri jnt of lwr extre w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Meridian Medicaid,CPT,73722,Mri joint of lwr extr w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Meridian Medicaid,CPT,73723,Mri joint lwr extr w/o&w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Meridian Medicaid,CPT,73725,Mr ang lwr ext w or w/o dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Meridian Medicaid,CPT,74000,X-ray exam of abdomen,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,74010,X-ray exam of abdomen,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,74018,X-ray exam abdomen 1 view,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,74019,X-ray exam abdomen 2 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,74020,X-ray exam of abdomen,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,74021,X-ray exam abdomen 3+ views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,74022,X-ray exam complete abdomen,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,74150,Ct abdomen w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Meridian Medicaid,CPT,74160,Ct abdomen w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Meridian Medicaid,CPT,74170,Ct abdomen w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Meridian Medicaid,CPT,74174,Ct angio abd&pelv w/o&w/dye,Interventional Radiology,Per Unit,$178.94 ,OP,178.94,178.94,,,,,,
Meridian Medicaid,CPT,74175,Ct angio abdom w/o & w/dye,Interventional Radiology,Per Unit,$178.94 ,OP,178.94,178.94,,,,,,
Meridian Medicaid,CPT,74176,Ct abd & pelvis w/o contrast,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Meridian Medicaid,CPT,74177,Ct abd & pelv w/contrast,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Meridian Medicaid,CPT,74178,Ct abd & pelv 1/> regns,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Meridian Medicaid,CPT,74181,Mri abdomen w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Meridian Medicaid,CPT,74182,Mri abdomen w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Meridian Medicaid,CPT,74183,Mri abdomen w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Meridian Medicaid,CPT,74185,Mri angio abdom w orw/o dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Meridian Medicaid,CPT,74210,X-ray xm phrnx&/crv esoph c+,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,74220,X-ray xm esophagus 1cntrst,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,74235,Remove esophagus obstruction,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,74261,Ct colonography dx,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Meridian Medicaid,CPT,74262,Ct colonography dx w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Meridian Medicaid,CPT,74263,Ct colonography screening,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Meridian Medicaid,CPT,74300,X-ray bile ducts/pancreas,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,74301,X-rays at surgery add-on,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,74305,X-ray bile ducts/pancreas,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,74320,Contrast x-ray of bile ducts,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,74327,X-ray bile stone removal,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,74328,X-ray bile duct endoscopy,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,74329,X-ray for pancreas endoscopy,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,74330,X-ray bile/panc endoscopy,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,74340,X-ray guide for gi tube,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,74355,X-ray guide intestinal tube,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,74360,X-ray guide gi dilation,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,74363,X-ray bile duct dilation,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,74475,X-ray control cath insert,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,74480,X-ray control cath insert,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,74485,Dilation urtr/urt rs&i,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,74710,X-ray measurement of pelvis,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,74712,Mri fetal sngl/1st gestation,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Meridian Medicaid,CPT,74713,Mri fetal ea addl gestation,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Meridian Medicaid,CPT,74742,X-ray fallopian tube,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,75557,Cardiac mri for morph,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Meridian Medicaid,CPT,75559,Cardiac mri w/stress img,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Meridian Medicaid,CPT,75561,Cardiac mri for morph w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Meridian Medicaid,CPT,75563,Card mri w/stress img & dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Meridian Medicaid,CPT,75565,Card mri veloc flow mapping,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Meridian Medicaid,CPT,75571,Ct hrt w/o dye w/ca test,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Meridian Medicaid,CPT,75572,Ct hrt w/3d image,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Meridian Medicaid,CPT,75573,Ct hrt w/3d image congen,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Meridian Medicaid,CPT,75574,Ct angio hrt w/3d image,Interventional Radiology,Per Unit,$178.94 ,OP,178.94,178.94,,,,,,
Meridian Medicaid,CPT,75605,Contrast exam thoracic aorta,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Meridian Medicaid,CPT,75635,Ct angio abdominal arteries,Interventional Radiology,Per Unit,$178.94 ,OP,178.94,178.94,,,,,,
Meridian Medicaid,CPT,75705,Artery x-rays spine,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Meridian Medicaid,CPT,75726,Artery x-rays abdomen,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Meridian Medicaid,CPT,75736,Artery x-rays pelvis,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Meridian Medicaid,CPT,75774,Artery x-ray each vessel,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Meridian Medicaid,CPT,75791,Av dialysis shunt imaging,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,75842,Vein x-ray adrenal glands,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Meridian Medicaid,CPT,75893,Venous sampling by catheter,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Meridian Medicaid,CPT,75894,X-rays transcath therapy,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,75896,X-rays transcath therapy,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,75901,Remove cva device obstruct,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,75902,Remove cva lumen obstruct,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,75945,Intravascular us,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Meridian Medicaid,CPT,75946,Intravascular us add-on,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Meridian Medicaid,CPT,75952,Endovasc repair abdom aorta,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,75953,Abdom aneurysm endovas rpr,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,75954,Iliac aneurysm endovas rpr,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,75956,Xray endovasc thor ao repr,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,75957,Xray endovasc thor ao repr,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,75958,Xray place prox ext thor ao,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,75959,Xray place dist ext thor ao,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,75962,Repair arterial blockage,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,75964,Repair artery blockage each,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,75966,Repair arterial blockage,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,75968,Repair artery blockage each,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,75970,Vascular biopsy,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,75980,Contrast xray exam bile duct,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,75982,Contrast xray exam bile duct,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,75984,Xray control catheter change,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,75989,Abscess drainage under x-ray,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,76010,X-ray nose to rectum,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,76100,X-ray exam of body section,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,76101,Complex body section x-ray,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,76102,Complex body section x-rays,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,76120,Cine/video x-rays,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,76125,Cine/video x-rays add-on,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,76145,Med physic dos eval rad exps,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Meridian Medicaid,CPT,76380,Cat scan follow-up study,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Meridian Medicaid,CPT,76390,Mr spectroscopy,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Meridian Medicaid,CPT,76391,Mr elastography,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Meridian Medicaid,CPT,76496,Fluoroscopic procedure,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,76497,Ct procedure,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Meridian Medicaid,CPT,76498,Mri procedure,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Meridian Medicaid,CPT,76499,Radiographic procedure,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,76506,Echo exam of head,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,76510,Oph us dx b-scan&quan a-scan,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,76511,Oph us dx quan a-scan only,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,76512,Oph us dx b-scan,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,76513,Oph us dx ant sgm us uni/bi,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,76514,Echo exam of eye thickness,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,76516,Echo exam of eye,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,76519,Echo exam of eye,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,76529,Echo exam of eye,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,76536,Us exam of head and neck,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,76604,Us exam chest,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,76641,Ultrasound breast complete,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,76642,Ultrasound breast limited,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,76700,Us exam abdom complete,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Meridian Medicaid,CPT,76705,Echo exam of abdomen,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,76706,Us abdl aorta screen aaa,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,76770,Us exam abdo back wall comp,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Meridian Medicaid,CPT,76775,Us exam abdo back wall lim,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,76776,Us exam k transpl w/doppler,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,76800,Us exam spinal canal,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,76801,Ob us < 14 wks single fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Meridian Medicaid,CPT,76802,Ob us < 14 wks addl fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Meridian Medicaid,CPT,76805,Ob us >= 14 wks sngl fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Meridian Medicaid,CPT,76810,Ob us >= 14 wks addl fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Meridian Medicaid,CPT,76811,Ob us detailed sngl fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Meridian Medicaid,CPT,76812,Ob us detailed addl fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Meridian Medicaid,CPT,76813,Ob us nuchal meas 1 gest,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Meridian Medicaid,CPT,76814,Ob us nuchal meas add-on,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Meridian Medicaid,CPT,76815,Ob us limited fetus(s),Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Meridian Medicaid,CPT,76816,Ob us follow-up per fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Meridian Medicaid,CPT,76817,Transvaginal us obstetric,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Meridian Medicaid,CPT,76818,Fetal biophys profile w/nst,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Meridian Medicaid,CPT,76819,Fetal biophys profil w/o nst,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Meridian Medicaid,CPT,76820,Umbilical artery echo,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Meridian Medicaid,CPT,76821,Middle cerebral artery echo,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Meridian Medicaid,CPT,76825,Echo exam of fetal heart,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Meridian Medicaid,CPT,76826,Echo exam of fetal heart,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Meridian Medicaid,CPT,76827,Echo exam of fetal heart,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Meridian Medicaid,CPT,76828,Echo exam of fetal heart,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Meridian Medicaid,CPT,76830,Transvaginal us non-ob,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,76831,Echo exam uterus,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Meridian Medicaid,CPT,76856,Us exam pelvic complete,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Meridian Medicaid,CPT,76857,Us exam pelvic limited,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,76870,Us exam scrotum,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,76872,Us transrectal,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,76873,Echograp trans r pros study,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Meridian Medicaid,CPT,76881,Us compl joint r-t w/img,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,76882,Us lmtd jt/nonvasc xtr strux,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,76885,Us exam infant hips dynamic,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,76886,Us exam infant hips static,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,76930,Echo guide cardiocentesis,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Meridian Medicaid,CPT,76932,Echo guide for heart biopsy,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Meridian Medicaid,CPT,76936,Echo guide for artery repair,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,76937,Us guide vascular access,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Meridian Medicaid,CPT,76940,Us guide tissue ablation,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Meridian Medicaid,CPT,76941,Echo guide for transfusion,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Meridian Medicaid,CPT,76942,Echo guide for biopsy,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Meridian Medicaid,CPT,76945,Echo guide villus sampling,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Meridian Medicaid,CPT,76946,Echo guide for amniocentesis,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Meridian Medicaid,CPT,76948,Echo guide ova aspiration,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Meridian Medicaid,CPT,76965,Echo guidance radiotherapy,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Meridian Medicaid,CPT,76970,Ultrasound exam follow-up,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,76975,Gi endoscopic ultrasound,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Meridian Medicaid,CPT,76977,Us bone density measure,Diagnostic Radiology,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
Meridian Medicaid,CPT,76978,Us trgt dyn mbubb 1st les,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Meridian Medicaid,CPT,76979,Us trgt dyn mbubb ea addl,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Meridian Medicaid,CPT,76981,Use parenchyma,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,76982,Use 1st target lesion,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,76983,Use ea addl target lesion,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,76998,Us guide intraop,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Meridian Medicaid,CPT,76999,Echo examination procedure,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,77001,Fluoroguide for vein device,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,77002,Needle localization by xray,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,77003,Fluoroguide for spine inject,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,77011,Ct scan for localization,Interventional Radiology,Per Unit,$61.07 ,OP,61.07,61.07,,,,,,
Meridian Medicaid,CPT,77012,Ct scan for needle biopsy,Interventional Radiology,Per Unit,$61.07 ,OP,61.07,61.07,,,,,,
Meridian Medicaid,CPT,77013,Ct guide for tissue ablation,Interventional Radiology,Per Unit,$61.07 ,OP,61.07,61.07,,,,,,
Meridian Medicaid,CPT,77014,Ct scan for therapy guide,Interventional Radiology,Per Unit,$61.07 ,OP,61.07,61.07,,,,,,
Meridian Medicaid,CPT,77021,Mri guidance ndl plmt rs&i,Interventional Radiology,Per Unit,$108.13 ,OP,108.13,108.13,,,,,,
Meridian Medicaid,CPT,77022,Mri gdn parnchyma tiss abltj,Interventional Radiology,Per Unit,$108.13 ,OP,108.13,108.13,,,,,,
Meridian Medicaid,CPT,77046,Mri breast c- unilateral,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Meridian Medicaid,CPT,77047,Mri breast c- bilateral,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Meridian Medicaid,CPT,77048,Mri breast c-+ w/cad uni,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Meridian Medicaid,CPT,77049,Mri breast c-+ w/cad bi,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Meridian Medicaid,CPT,77055,Mammogram one breast,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
Meridian Medicaid,CPT,77056,Mammogram both breasts,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
Meridian Medicaid,CPT,77057,Mammogram screening,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
Meridian Medicaid,CPT,77058,Mri one breast,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Meridian Medicaid,CPT,77059,Mri both breasts,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Meridian Medicaid,CPT,77061,Breast tomosynthesis uni,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
Meridian Medicaid,CPT,77062,Breast tomosynthesis bi,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
Meridian Medicaid,CPT,77063,Breast tomosynthesis bi,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
Meridian Medicaid,CPT,77065,Dx mammo incl cad uni,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
Meridian Medicaid,CPT,77066,Dx mammo incl cad bi,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
Meridian Medicaid,CPT,77067,Scr mammo bi incl cad,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
Meridian Medicaid,CPT,77072,X-rays for bone age,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,77073,X-rays bone length studies,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,77074,X-rays bone survey limited,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,77076,X-rays bone survey infant,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,77077,Joint survey single view,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,77078,Ct bone density axial,Diagnostic Radiology,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
Meridian Medicaid,CPT,77080,Dxa bone density axial,Diagnostic Radiology,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
Meridian Medicaid,CPT,77081,Dxa bone density/peripheral,Diagnostic Radiology,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
Meridian Medicaid,CPT,77084,Magnetic image bone marrow,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Meridian Medicaid,CPT,77085,Dxa bone density study,Diagnostic Radiology,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
Meridian Medicaid,CPT,77086,Fracture assessment via dxa,Diagnostic Radiology,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
Meridian Medicaid,CPT,77261,Radiation therapy planning,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Meridian Medicaid,CPT,77262,Radiation therapy planning,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Meridian Medicaid,CPT,77263,Radiation therapy planning,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Meridian Medicaid,CPT,77280,Set radiation therapy field,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Meridian Medicaid,CPT,77285,Set radiation therapy field,Therapeutic Radiology,Per Unit,$434.17 ,OP,434.17,434.17,,,,,,
Meridian Medicaid,CPT,77290,Set radiation therapy field,Therapeutic Radiology,Per Unit,$434.17 ,OP,434.17,434.17,,,,,,
Meridian Medicaid,CPT,77293,Respirator motion mgmt simul,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Meridian Medicaid,CPT,77295,3-d radiotherapy plan,Therapeutic Radiology,Per Unit,$68.45 ,OP,68.45,68.45,,,,,,
Meridian Medicaid,CPT,77299,Radiation therapy planning,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Meridian Medicaid,CPT,77300,Radiation therapy dose plan,Therapeutic Radiology,Per Unit,$434.17 ,OP,434.17,434.17,,,,,,
Meridian Medicaid,CPT,77301,Radiotherapy dose plan imrt,Therapeutic Radiology,Per Unit,$68.45 ,OP,68.45,68.45,,,,,,
Meridian Medicaid,CPT,77306,Telethx isodose plan simple,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Meridian Medicaid,CPT,77307,Telethx isodose plan cplx,Therapeutic Radiology,Per Unit,$434.17 ,OP,434.17,434.17,,,,,,
Meridian Medicaid,CPT,77316,Brachytx isodose plan simple,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Meridian Medicaid,CPT,77317,Brachytx isodose intermed,Therapeutic Radiology,Per Unit,$434.17 ,OP,434.17,434.17,,,,,,
Meridian Medicaid,CPT,77318,Brachytx isodose complex,Therapeutic Radiology,Per Unit,$434.17 ,OP,434.17,434.17,,,,,,
Meridian Medicaid,CPT,77321,Special teletx port plan,Therapeutic Radiology,Per Unit,$434.17 ,OP,434.17,434.17,,,,,,
Meridian Medicaid,CPT,77331,Special radiation dosimetry,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Meridian Medicaid,CPT,77332,Radiation treatment aid(s),Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Meridian Medicaid,CPT,77333,Radiation treatment aid(s),Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Meridian Medicaid,CPT,77334,Radiation treatment aid(s),Therapeutic Radiology,Per Unit,$434.17 ,OP,434.17,434.17,,,,,,
Meridian Medicaid,CPT,77336,Radiation physics consult,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Meridian Medicaid,CPT,77338,Design mlc device for imrt,Therapeutic Radiology,Per Unit,$434.17 ,OP,434.17,434.17,,,,,,
Meridian Medicaid,CPT,77370,Radiation physics consult,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Meridian Medicaid,CPT,77371,Srs multisource,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"2,592.65","2,592.65",,,,,,
Meridian Medicaid,CPT,77372,Srs linear based,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"2,592.65","2,592.65",,,,,,
Meridian Medicaid,CPT,77373,Sbrt delivery,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
Meridian Medicaid,CPT,77385,Ntsty modul rad tx dlvr smpl,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Meridian Medicaid,CPT,77386,Ntsty modul rad tx dlvr cplx,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Meridian Medicaid,CPT,77387,Guidance for radj tx dlvr,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Meridian Medicaid,CPT,77399,External radiation dosimetry,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Meridian Medicaid,CPT,77401,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Meridian Medicaid,CPT,77402,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Meridian Medicaid,CPT,77407,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Meridian Medicaid,CPT,77412,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Meridian Medicaid,CPT,77417,Radiology port images(s),Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,77422,Neutron beam tx simple,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Meridian Medicaid,CPT,77423,Neutron beam tx complex,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Meridian Medicaid,CPT,77424,Io rad tx delivery by x-ray,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
Meridian Medicaid,CPT,77425,Io rad tx deliver by elctrns,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
Meridian Medicaid,CPT,77427,Radiation tx management x5,Therapeutic Radiology,Per Unit,$70.25 ,OP,70.25,70.25,,,,,,
Meridian Medicaid,CPT,77431,Radiation therapy management,Therapeutic Radiology,Per Unit,$70.25 ,OP,70.25,70.25,,,,,,
Meridian Medicaid,CPT,77432,Stereotactic radiation trmt,Therapeutic Radiology,Per Unit,$70.25 ,OP,70.25,70.25,,,,,,
Meridian Medicaid,CPT,77435,Sbrt management,Therapeutic Radiology,Per Unit,$70.25 ,OP,70.25,70.25,,,,,,
Meridian Medicaid,CPT,77469,Io radiation tx management,Therapeutic Radiology,Per Unit,$70.25 ,OP,70.25,70.25,,,,,,
Meridian Medicaid,CPT,77470,Special radiation treatment,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Meridian Medicaid,CPT,77499,Radiation therapy management,Therapeutic Radiology,Per Unit,$70.25 ,OP,70.25,70.25,,,,,,
Meridian Medicaid,CPT,77520,Proton trmt simple w/o comp,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Meridian Medicaid,CPT,77522,Proton trmt simple w/comp,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
Meridian Medicaid,CPT,77523,Proton trmt intermediate,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
Meridian Medicaid,CPT,77525,Proton treatment complex,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
Meridian Medicaid,CPT,77600,Hyperthermia treatment,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Meridian Medicaid,CPT,77605,Hyperthermia treatment,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Meridian Medicaid,CPT,77610,Hyperthermia treatment,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Meridian Medicaid,CPT,77615,Hyperthermia treatment,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Meridian Medicaid,CPT,77620,Hyperthermia treatment,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Meridian Medicaid,CPT,77750,Infuse radioactive materials,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Meridian Medicaid,CPT,77761,Apply intrcav radiat simple,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Meridian Medicaid,CPT,77762,Apply intrcav radiat interm,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
Meridian Medicaid,CPT,77763,Apply intrcav radiat compl,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
Meridian Medicaid,CPT,77767,Hdr rdncl skn surf brachytx,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Meridian Medicaid,CPT,77768,Hdr rdncl skn surf brachytx,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Meridian Medicaid,CPT,77770,Hdr rdncl ntrstl/icav brchtx,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Meridian Medicaid,CPT,77771,Hdr rdncl ntrstl/icav brchtx,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
Meridian Medicaid,CPT,77772,Hdr rdncl ntrstl/icav brchtx,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
Meridian Medicaid,CPT,77776,Apply interstit radiat simpl,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Meridian Medicaid,CPT,77777,Apply interstit radiat inter,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Meridian Medicaid,CPT,77778,Apply interstit radiat compl,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
Meridian Medicaid,CPT,77785,Hdr brachytx 1 channel,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Meridian Medicaid,CPT,77786,Hdr brachytx 2-12 channel,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
Meridian Medicaid,CPT,77787,Hdr brachytx over 12 chan,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
Meridian Medicaid,CPT,77789,Apply surf ldr radionuclide,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Meridian Medicaid,CPT,77790,Radiation handling,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Meridian Medicaid,CPT,77799,Radium/radioisotope therapy,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Meridian Medicaid,CPT,78012,Thyroid uptake measurement,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78013,Thyroid imaging w/blood flow,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78014,Thyroid imaging w/blood flow,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78015,Thyroid met imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78016,Thyroid met imaging/studies,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78018,Thyroid met imaging body,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78020,Thyroid met uptake,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78070,Parathyroid planar imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Meridian Medicaid,CPT,78071,Parathyrd planar w/wo subtrj,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78072,Parathyrd planar w/spect&ct,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78075,Adrenal cortex & medulla img,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Meridian Medicaid,CPT,78099,Endocrine nuclear procedure,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78102,Bone marrow imaging ltd,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78103,Bone marrow imaging mult,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78104,Bone marrow imaging body,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78110,Plasma volume single,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Meridian Medicaid,CPT,78111,Plasma volume multiple,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Meridian Medicaid,CPT,78120,Red cell mass single,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78121,Red cell mass multiple,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78122,Blood volume,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Meridian Medicaid,CPT,78130,Red cell survival study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78135,Red cell survival kinetics,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78140,Red cell sequestration,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78185,Spleen imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78190,Platelet survival kinetics,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78191,Platelet survival,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78195,Lymph system imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Meridian Medicaid,CPT,78199,Blood/lymph nuclear exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78201,Liver imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Meridian Medicaid,CPT,78202,Liver imaging with flow,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Meridian Medicaid,CPT,78205,Liver imaging (3d),Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Meridian Medicaid,CPT,78206,Liver image (3d) with flow,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Meridian Medicaid,CPT,78215,Liver and spleen imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Meridian Medicaid,CPT,78216,Liver & spleen image/flow,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Meridian Medicaid,CPT,78226,Hepatobiliary system imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78227,Hepatobil syst image w/drug,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78230,Salivary gland imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78231,Serial salivary imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78232,Salivary gland function exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78258,Esophageal motility study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78261,Gastric mucosa imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78262,Gastroesophageal reflux exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78264,Gastric emptying imag study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78265,Gastric emptying imag study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78266,Gastric emptying imag study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78267,Breath tst attain/anal c-14,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,78270,Vit b-12 absorption exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78271,Vit b-12 absrp exam int fac,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78272,Vit b-12 absorp combined,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78278,Acute gi blood loss imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Meridian Medicaid,CPT,78282,Gi protein loss exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78290,Meckels divert exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78291,Leveen/shunt patency exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78299,Gi nuclear procedure,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78300,Bone imaging limited area,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78305,Bone imaging multiple areas,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78306,Bone imaging whole body,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78315,Bone imaging 3 phase,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78320,Bone imaging (3d),Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78350,Bone mineral single photon,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78351,Bone mineral dual photon,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78399,Musculoskeletal nuclear exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78414,Non-imaging heart function,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78428,Cardiac shunt imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78429,Myocrd img pet 1 std w/ct,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Meridian Medicaid,CPT,78430,Myocrd img pet rst/strs w/ct,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Meridian Medicaid,CPT,78431,Myocrd img pet rst&strs ct,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Meridian Medicaid,CPT,78432,Myocrd img pet 2rtracer,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Meridian Medicaid,CPT,78433,Myocrd img pet 2rtracer ct,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Meridian Medicaid,CPT,78434,Aqmbf pet rest & rx stress,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Meridian Medicaid,CPT,78445,Vascular flow imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78451,Ht muscle image spect sing,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Meridian Medicaid,CPT,78452,Ht muscle image spect mult,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Meridian Medicaid,CPT,78453,Ht muscle image planar sing,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Meridian Medicaid,CPT,78454,Ht musc image planar mult,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Meridian Medicaid,CPT,78456,Acute venous thrombus image,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78457,Venous thrombosis imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Meridian Medicaid,CPT,78458,Ven thrombosis images bilat,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78459,Myocrd img pet single study,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Meridian Medicaid,CPT,78466,Heart infarct image,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78468,Heart infarct image (ef),Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78469,Heart infarct image (3d),Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Meridian Medicaid,CPT,78472,Gated heart planar single,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78473,Gated heart multiple,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78481,Heart first pass single,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78483,Heart first pass multiple,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Meridian Medicaid,CPT,78491,Myocrd img pet 1std rst/strs,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Meridian Medicaid,CPT,78492,Myocrd img pet mlt rst&strs,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Meridian Medicaid,CPT,78494,Heart image spect,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78496,Heart first pass add-on,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78499,Cardiovascular nuclear exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78579,Lung ventilation imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Meridian Medicaid,CPT,78580,Lung perfusion imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Meridian Medicaid,CPT,78582,Lung ventilat&perfus imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Meridian Medicaid,CPT,78597,Lung perfusion differential,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Meridian Medicaid,CPT,78598,Lung perf&ventilat diferentl,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Meridian Medicaid,CPT,78599,Respiratory nuclear exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78600,Brain image < 4 views,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78601,Brain image w/flow < 4 views,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78605,Brain image 4+ views,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78606,Brain image w/flow 4 + views,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78607,Brain imaging (3d),Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Meridian Medicaid,CPT,78608,Brain imaging (pet),Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Meridian Medicaid,CPT,78609,Brain imaging (pet),Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Meridian Medicaid,CPT,78610,Brain flow imaging only,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78630,Cerebrospinal fluid scan,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Meridian Medicaid,CPT,78635,Csf ventriculography,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78645,Csf shunt evaluation,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Meridian Medicaid,CPT,78647,Cerebrospinal fluid scan,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Meridian Medicaid,CPT,78650,Csf leakage imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Meridian Medicaid,CPT,78660,Nuclear exam of tear flow,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78699,Nervous system nuclear exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78700,Kidney imaging morphol,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78701,Kidney imaging with flow,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78707,K flow/funct image w/o drug,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78708,K flow/funct image w/drug,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78709,K flow/funct image multiple,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78710,Kidney imaging (3d),Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78725,Kidney function study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78730,Urinary bladder retention,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78740,Ureteral reflux study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78761,Testicular imaging w/flow,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78799,Genitourinary nuclear exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78800,Rp loclzj tum 1 area 1 d img,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Meridian Medicaid,CPT,78801,Rp loclzj tum 2+area 1+d img,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Meridian Medicaid,CPT,78802,Rp loclzj tum whbdy 1 d img,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Meridian Medicaid,CPT,78803,Rp loclzj tum spect 1 area,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Meridian Medicaid,CPT,78804,Rp loclzj tum whbdy 2+d img,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Meridian Medicaid,CPT,78805,Abscess imaging ltd area,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Meridian Medicaid,CPT,78806,Abscess imaging whole body,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Meridian Medicaid,CPT,78807,Nuclear localization/abscess,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Meridian Medicaid,CPT,78811,Pet image ltd area,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Meridian Medicaid,CPT,78812,Pet image skull-thigh,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Meridian Medicaid,CPT,78813,Pet image full body,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Meridian Medicaid,CPT,78814,Pet image w/ct lmtd,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Meridian Medicaid,CPT,78815,Pet image w/ct skull-thigh,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Meridian Medicaid,CPT,78816,Pet image w/ct full body,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Meridian Medicaid,CPT,78830,Rp loclzj tum spect w/ct 1,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Meridian Medicaid,CPT,78831,Rp loclzj tum spect 2 areas,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Meridian Medicaid,CPT,78832,Rp loclzj tum spect w/ct 2,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Meridian Medicaid,CPT,78835,Rp quan meas single area,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,78999,Nuclear diagnostic exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,79005,Nuclear rx oral admin,Therapeutic Radiology,Per Unit,$174.28 ,OP,174.28,174.28,,,,,,
Meridian Medicaid,CPT,79101,Nuclear rx iv admin,Therapeutic Radiology,Per Unit,$174.28 ,OP,174.28,174.28,,,,,,
Meridian Medicaid,CPT,79200,Nuclear rx intracav admin,Therapeutic Radiology,Per Unit,$174.28 ,OP,174.28,174.28,,,,,,
Meridian Medicaid,CPT,79300,Nuclr rx interstit colloid,Therapeutic Radiology,Per Unit,$174.28 ,OP,174.28,174.28,,,,,,
Meridian Medicaid,CPT,79403,Hematopoietic nuclear tx,Therapeutic Radiology,Per Unit,$174.28 ,OP,174.28,174.28,,,,,,
Meridian Medicaid,CPT,79440,Nuclear rx intra-articular,Therapeutic Radiology,Per Unit,$174.28 ,OP,174.28,174.28,,,,,,
Meridian Medicaid,CPT,79445,Nuclear rx intra-arterial,Therapeutic Radiology,Per Unit,$174.28 ,OP,174.28,174.28,,,,,,
Meridian Medicaid,CPT,79999,Nuclear medicine therapy,Therapeutic Radiology,Per Unit,$174.28 ,OP,174.28,174.28,,,,,,
Meridian Medicaid,CPT,80047,Metabolic panel ionized ca,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
Meridian Medicaid,CPT,80048,Metabolic panel total ca,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
Meridian Medicaid,CPT,80050,General health panel,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
Meridian Medicaid,CPT,80051,Electrolyte panel,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
Meridian Medicaid,CPT,80053,Comprehen metabolic panel,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
Meridian Medicaid,CPT,80055,Obstetric panel,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
Meridian Medicaid,CPT,80061,Lipid panel,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
Meridian Medicaid,CPT,80069,Renal function panel,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
Meridian Medicaid,CPT,80074,Acute hepatitis panel,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
Meridian Medicaid,CPT,80076,Hepatic function panel,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
Meridian Medicaid,CPT,80081,Obstetric panel,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
Meridian Medicaid,CPT,80143,Drug assay acetaminophen,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80145,Drug assay adalimumab,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80150,Assay of amikacin,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80151,Drug assay amiodarone,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80155,Drug assay caffeine,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80156,Assay carbamazepine total,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80157,Assay carbamazepine free,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80158,Drug assay cyclosporine,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80159,Drug assay clozapine,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80161,"Asy carbamazepin 10,11-epxid",Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80162,Assay of digoxin total,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80163,Assay of digoxin free,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80164,Assay dipropylacetic acd tot,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80165,Dipropylacetic acid free,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80167,Drug assay felbamate,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80168,Assay of ethosuximide,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80169,Drug assay everolimus,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80170,Assay of gentamicin,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80171,Drug screen quant gabapentin,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80173,Assay of haloperidol,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80175,Drug screen quan lamotrigine,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80176,Assay of lidocaine,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80177,Drug scrn quan levetiracetam,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80178,Assay of lithium,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80179,Drug assay salicylate,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80180,Drug scrn quan mycophenolate,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80181,Drug assay flecainide,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80183,Drug scrn quant oxcarbazepin,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80184,Assay of phenobarbital,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80185,Assay of phenytoin total,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80186,Assay of phenytoin free,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80187,Drug assay posaconazole,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80188,Assay of primidone,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80189,Drug assay itraconzaole,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80190,Assay of procainamide,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80192,Assay of procainamide,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80193,Drug assay leflunomide,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80194,Assay of quinidine,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80195,Assay of sirolimus,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80197,Assay of tacrolimus,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80198,Assay of theophylline,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80199,Drug screen quant tiagabine,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80200,Assay of tobramycin,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80201,Assay of topiramate,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80202,Assay of vancomycin,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80203,Drug screen quant zonisamide,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80204,Drug assay methotrexate,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80210,Drug assay rufinamide,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80230,Drug assay infliximab,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80235,Drug assay lacosamide,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80280,Drug assay vedolizumab,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80285,Drug assay voriconazole,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80299,Quantitative assay drug,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80300,Drug screen non tlc devices,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Meridian Medicaid,CPT,80301,Drug screen class list a,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Meridian Medicaid,CPT,80302,Drug screen prsmptv 1 class,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,80303,Drug screen one/mult class,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Meridian Medicaid,CPT,80304,Drug screen one/mult class,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Meridian Medicaid,CPT,80305,Drug test prsmv dir opt obs,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,80306,Drug test prsmv instrmnt,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,80307,Drug test prsmv chem anlyzr,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,80320,Drug screen quantalcohols,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,80321,Alcohols biomarkers 1or 2,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,80322,Alcohols biomarkers 3/more,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,80323,Alkaloids nos,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,80324,Drug screen amphetamines 1/2,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,80325,Amphetamines 3or 4,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,80326,Amphetamines 5 or more,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,80327,Anabolic steroid 1 or 2,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,80328,Anabolic steroid 3 or more,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,80329,Analgesics non-opioid 1 or 2,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,80330,Analgesics non-opioid 3-5,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,80331,Analgesics non-opioid 6/more,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,80332,Antidepressants class 1 or 2,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,80333,Antidepressants class 3-5,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,80334,Antidepressants class 6/more,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,80335,Antidepressant tricyclic 1/2,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,80336,Antidepressant tricyclic 3-5,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,80337,Tricyclic & cyclicals 6/more,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,80338,Antidepressant not specified,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,80339,Antiepileptics nos 1-3,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,80340,Antiepileptics nos 4-6,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,80341,Antiepileptics nos 7/more,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,80342,Antipsychotics nos 1-3,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,80343,Antipsychotics nos 4-6,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,80344,Antipsychotics nos 7/more,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,80345,Drug screening barbiturates,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,80346,Benzodiazepines1-12,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,80347,Benzodiazepines 13 or more,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,80348,Drug screening buprenorphine,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,80349,Cannabinoids natural,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,80350,Cannabinoids synthetic 1-3,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,80351,Cannabinoids synthetic 4-6,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,80352,Cannabinoid synthetic 7/more,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,80353,Drug screening cocaine,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,80354,Drug screening fentanyl,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,80355,Gabapentin non-blood,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,80356,Heroin metabolite,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,80357,Ketamine and norketamine,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,80358,Drug screening methadone,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,80359,Methylenedioxyamphetamines,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,80360,Methylphenidate,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,80361,Opiates 1 or more,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,80362,Opioids & opiate analogs 1/2,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,80363,Opioids & opiate analogs 3/4,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,80364,Opioid &opiate analog 5/more,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,80365,Drug screening oxycodone,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,80366,Drug screening pregabalin,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,80367,Drug screening propoxyphene,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,80368,Sedative hypnotics,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,80369,Skeletal muscle relaxant 1/2,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,80370,Skel musc relaxant 3 or more,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,80371,Stimulants synthetic,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,80372,Drug screening tapentadol,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,80373,Drug screening tramadol,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,80374,Stereoisomer analysis,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,80375,Drug/substance nos 1-3,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,80376,Drug/substance nos 4-6,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,80377,Drug/substance nos 7/more,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,80400,Acth stimulation panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Meridian Medicaid,CPT,80402,Acth stimulation panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Meridian Medicaid,CPT,80406,Acth stimulation panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Meridian Medicaid,CPT,80408,Aldosterone suppression eval,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Meridian Medicaid,CPT,80410,Calcitonin stimul panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Meridian Medicaid,CPT,80412,Crh stimulation panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Meridian Medicaid,CPT,80414,Testosterone response panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Meridian Medicaid,CPT,80415,Tot estradiol response panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Meridian Medicaid,CPT,80416,Renin stimulation panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Meridian Medicaid,CPT,80417,Renin stimulation panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Meridian Medicaid,CPT,80418,Pituitary evaluation panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Meridian Medicaid,CPT,80420,Dexamethasone panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Meridian Medicaid,CPT,80422,Glucagon tolerance panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Meridian Medicaid,CPT,80424,Glucagon tolerance panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Meridian Medicaid,CPT,80426,Gonadotropin hormone panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Meridian Medicaid,CPT,80428,Growth hormone panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Meridian Medicaid,CPT,80430,Growth hormone panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Meridian Medicaid,CPT,80432,Insulin suppression panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Meridian Medicaid,CPT,80434,Insulin tolerance panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Meridian Medicaid,CPT,80435,Insulin tolerance panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Meridian Medicaid,CPT,80436,Metyrapone panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Meridian Medicaid,CPT,80438,Trh stimulation panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Meridian Medicaid,CPT,80439,Trh stimulation panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Meridian Medicaid,CPT,80500,Lab pathology consultation,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,80502,Lab pathology consultation,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,81000,Urinalysis nonauto w/scope,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
Meridian Medicaid,CPT,81001,Urinalysis auto w/scope,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
Meridian Medicaid,CPT,81002,Urinalysis nonauto w/o scope,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
Meridian Medicaid,CPT,81003,Urinalysis auto w/o scope,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
Meridian Medicaid,CPT,81005,Urinalysis,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
Meridian Medicaid,CPT,81007,Urine screen for bacteria,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
Meridian Medicaid,CPT,81015,Microscopic exam of urine,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
Meridian Medicaid,CPT,81020,Urinalysis glass test,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
Meridian Medicaid,CPT,81025,Urine pregnancy test,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
Meridian Medicaid,CPT,81050,Urinalysis volume measure,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
Meridian Medicaid,CPT,81099,Urinalysis test procedure,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
Meridian Medicaid,CPT,81105,Hpa-1 genotyping,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81106,Hpa-2 genotyping,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81107,Hpa-3 genotyping,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81108,Hpa-4 genotyping,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81109,Hpa-5 genotyping,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81110,Hpa-6 genotyping,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81111,Hpa-9 genotyping,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81112,Hpa-15 genotyping,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81120,Idh1 common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81121,Idh2 common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81161,Dmd dup/delet analysis,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81162,Brca1&2 gen full seq dup/del,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81163,Brca1&2 gene full seq alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81164,Brca1&2 gen ful dup/del alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81165,Brca1 gene full seq alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81166,Brca1 gene full dup/del alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81167,Brca2 gene full dup/del alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81168,Ccnd1/igh translocation alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81170,Abl1 gene,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81171,Aff2 gene detc abnor alleles,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81172,Aff2 gene charac alleles,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81173,Ar gene full gene sequence,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81174,Ar gene known famil variant,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81175,Asxl1 full gene sequence,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81176,Asxl1 gene target seq alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81177,Atn1 gene detc abnor alleles,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81178,Atxn1 gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81179,Atxn2 gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81180,Atxn3 gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81181,Atxn7 gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81182,Atxn8os gen detc abnor allel,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81183,Atxn10 gene detc abnor allel,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81184,Cacna1a gen detc abnor allel,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81185,Cacna1a gene full gene seq,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81186,Cacna1a gen known famil vrnt,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81187,Cnbp gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81188,Cstb gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81189,Cstb gene full gene sequence,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81190,Cstb gene known famil vrnt,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81191,Ntrk1 translocation analysis,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81192,Ntrk2 translocation analysis,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81193,Ntrk3 translocation analysis,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81194,Ntrk translocation analysis,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81200,Aspa gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81201,Apc gene full sequence,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81202,Apc gene known fam variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81203,Apc gene dup/delet variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81204,Ar gene charac alleles,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81205,Bckdhb gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81206,Bcr/abl1 gene major bp,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81207,Bcr/abl1 gene minor bp,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81208,Bcr/abl1 gene other bp,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81209,Blm gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81210,Braf gene,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81211,Brca1&2 seq & com dup/del,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81212,Brca1&2 185&5385&6174 vrnt,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81213,Brca1&2 uncom dup/del var,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81214,Brca1 full seq & com dup/del,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81215,Brca1 gene known famil vrnt,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81216,Brca2 gene full seq alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81217,Brca2 gene known famil vrnt,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81218,Cebpa gene full sequence,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81219,Calr gene com variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81220,Cftr gene com variants,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81221,Cftr gene known fam variants,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81222,Cftr gene dup/delet variants,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81223,Cftr gene full sequence,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81224,Cftr gene intron poly t,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81225,Cyp2c19 gene com variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81226,Cyp2d6 gene com variants,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81227,Cyp2c9 gene com variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81228,Cytogen micrarray copy nmbr,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81229,Cytogen m array copy no&snp,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81230,Cyp3a4 gene common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81231,Cyp3a5 gene common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81232,Dpyd gene common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81233,Btk gene common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81234,Dmpk gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81235,Egfr gene com variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81236,Ezh2 gene full gene sequence,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81237,Ezh2 gene common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81238,F9 full gene sequence,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81239,Dmpk gene charac alleles,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81240,F2 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81241,F5 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81242,Fancc gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81243,Fmr1 gene detection,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81244,Fmr1 gene charac alleles,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81245,Flt3 gene,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81246,Flt3 gene analysis,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81247,G6pd gene alys cmn variant,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81248,G6pd known familial variant,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81249,G6pd full gene sequence,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81250,G6pc gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81251,Gba gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81252,Gjb2 gene full sequence,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81253,Gjb2 gene known fam variants,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81254,Gjb6 gene com variants,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81255,Hexa gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81256,Hfe gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81257,Hba1/hba2 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81258,Hba1/hba2 gene fam vrnt,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81259,Hba1/hba2 full gene sequence,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81260,Ikbkap gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81261,Igh gene rearrange amp meth,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81262,Igh gene rearrang dir probe,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81263,Igh vari regional mutation,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81264,Igk rearrangeabn clonal pop,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81265,Str markers specimen anal,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81266,Str markers spec anal addl,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81267,Chimerism anal no cell selec,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81268,Chimerism anal w/cell select,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81269,Hba1/hba2 gene dup/del vrnts,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81270,Jak2 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81271,Htt gene detc abnor alleles,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81272,Kit gene targeted seq analys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81273,Kit gene analys d816 variant,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81274,Htt gene charac alleles,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81275,Kras gene variants exon 2,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81276,Kras gene addl variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81277,Cytogenomic neo microra alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81278,Igh/bcl2 translocation alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81279,Jak2 gene trgt sequence alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81280,Long qt synd gene full seq,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81281,Long qt synd known fam var,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81282,Long qt syn gene dup/dlt var,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81283,Ifnl3 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81284,Fxn gene detc abnor alleles,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81285,Fxn gene charac alleles,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81286,Fxn gene full gene sequence,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81287,Mgmt gene prmtr mthyltn alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81288,Mlh1 gene,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81289,Fxn gene known famil variant,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81290,Mcoln1 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81291,Mthfr gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81292,Mlh1 gene full seq,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81293,Mlh1 gene known variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81294,Mlh1 gene dup/delete variant,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81295,Msh2 gene full seq,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81296,Msh2 gene known variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81297,Msh2 gene dup/delete variant,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81298,Msh6 gene full seq,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81299,Msh6 gene known variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81300,Msh6 gene dup/delete variant,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81301,Microsatellite instability,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81302,Mecp2 gene full seq,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81303,Mecp2 gene known variant,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81304,Mecp2 gene dup/delet variant,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81305,Myd88 gene p.leu265pro vrnt,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81306,Nudt15 gene common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81307,Palb2 gene full gene seq,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81308,Palb2 gene known famil vrnt,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81309,Pik3ca gene trgt seq alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81310,Npm1 gene,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81311,Nras gene variants exon 2&3,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81312,Pabpn1 gene detc abnor allel,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81313,Pca3/klk3 antigen,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81314,Pdgfra gene,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81315,Pml/raralpha com breakpoints,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81316,Pml/raralpha 1 breakpoint,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81317,Pms2 gene full seq analysis,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81318,Pms2 known familial variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81319,Pms2 gene dup/delet variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81320,Plcg2 gene common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81321,Pten gene full sequence,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81322,Pten gene known fam variant,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81323,Pten gene dup/delet variant,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81324,Pmp22 gene dup/delet,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81325,Pmp22 gene full sequence,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81326,Pmp22 gene known fam variant,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81327,Sept9 gen prmtr mthyltn alys,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81328,Slco1b1 gene com variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81329,Smn1 gene dos/deletion alys,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81330,Smpd1 gene common variants,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81331,Snrpn/ube3a gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81332,Serpina1 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81333,Tgfbi gene common variants,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81334,Runx1 gene targeted seq alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81335,Tpmt gene com variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81336,Smn1 gene full gene sequence,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81337,Smn1 gen nown famil seq vrnt,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81338,Mpl gene common variants,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81339,Mpl gene seq alys exon 10,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81340,Trb@ gene rearrange amplify,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81341,Trb@ gene rearrange dirprobe,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81342,Trg gene rearrangement anal,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81343,Ppp2r2b gen detc abnor allel,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81344,Tbp gene detc abnor alleles,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81345,Tert gene targeted seq alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81346,Tyms gene com variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81347,Sf3b1 gene common variants,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81348,Srsf2 gene common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81350,Ugt1a1 gene common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81351,Tp53 gene full gene sequence,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81352,Tp53 gene trgt sequence alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81353,Tp53 gene known famil vrnt,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81355,Vkorc1 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81357,U2af1 gene common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81360,Zrsr2 gene common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81361,Hbb gene com variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81362,Hbb gene known fam variant,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81363,Hbb gene dup/del variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81364,Hbb full gene sequence,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81370,Hla i & ii typing lr,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81371,Hla i & ii type verify lr,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81372,Hla i typing complete lr,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81373,Hla i typing 1 locus lr,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81374,Hla i typing 1 antigen lr,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81375,Hla ii typing ag equiv lr,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81376,Hla ii typing 1 locus lr,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81377,Hla ii type 1 ag equiv lr,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81378,Hla i & ii typing hr,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81379,Hla i typing complete hr,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81380,Hla i typing 1 locus hr,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81381,Hla i typing 1 allele hr,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81382,Hla ii typing 1 loc hr,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81383,Hla ii typing 1 allele hr,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81400,Mopath procedure level 1,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81401,Mopath procedure level 2,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81402,Mopath procedure level 3,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81403,Mopath procedure level 4,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81404,Mopath procedure level 5,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81405,Mopath procedure level 6,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81406,Mopath procedure level 7,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81407,Mopath procedure level 8,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81408,Mopath procedure level 9,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81410,Aortic dysfunction/dilation,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81411,Aortic dysfunction/dilation,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81412,Ashkenazi jewish assoc dis,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81413,Car ion chnnlpath inc 10 gns,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81414,Car ion chnnlpath inc 2 gns,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81415,Exome sequence analysis,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81416,Exome sequence analysis,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81417,Exome re-evaluation,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81419,Epilepsy gen seq alys panel,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81420,Fetal chrmoml aneuploidy,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81422,Fetal chrmoml microdeltj,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81425,Genome sequence analysis,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81426,Genome sequence analysis,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81427,Genome re-evaluation,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81430,Hearing loss sequence analys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81431,Hearing loss dup/del analys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81432,Hrdtry brst ca-rlatd dsordrs,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81433,Hrdtry brst ca-rlatd dsordrs,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81434,Hereditary retinal disorders,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81435,Hereditary colon ca dsordrs,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81436,Hereditary colon ca dsordrs,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81437,Heredtry nurondcrn tum dsrdr,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81438,Heredtry nurondcrn tum dsrdr,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81439,Hrdtry cardmypy gene panel,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81440,Mitochondrial gene,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81442,Noonan spectrum disorders,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81443,Genetic tstg severe inh cond,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81445,Targeted genomic seq analys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81448,Hrdtry perph neurphy panel,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81450,Targeted genomic seq analys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81455,Targeted genomic seq analys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81460,Whole mitochondrial genome,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81465,Whole mitochondrial genome,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81470,X-linked intellectual dblt,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81471,X-linked intellectual dblt,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81479,Unlisted molecular pathology,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81490,Autoimmune rheumatoid arthr,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81493,Cor artery disease mrna,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81500,Onco (ovar) two proteins,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81503,Onco (ovar) five proteins,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81504,Oncology tissue of origin,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81506,Endo assay seven anal,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81507,Fetal aneuploidy trisom risk,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81508,Ftl cgen abnor two proteins,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81509,Ftl cgen abnor 3 proteins,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81510,Ftl cgen abnor three anal,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81511,Ftl cgen abnor four anal,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81512,Ftl cgen abnor five anal,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81513,Nfct ds bv rna vag flu alg,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81514,Nfct ds bv&vaginitis dna alg,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81518,Onc brst mrna 11 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81519,Oncology breast mrna,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81520,Onc breast mrna 58 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81521,Onc breast mrna 70 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81522,Onc breast mrna 12 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81525,Oncology colon mrna,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81528,Oncology colorectal scr,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81529,Onc cutan mlnma mrna 31 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81535,Oncology gynecologic,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81536,Oncology gynecologic,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81538,Oncology lung,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81539,Oncology prostate prob score,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81540,Oncology tum unknown origin,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81541,Onc prostate mrna 46 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81542,Onc prostate mrna 22 cnt gen,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81545,Oncology thyroid,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81546,"Onc thyr mrna 10,196 gen alg",Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81551,Onc prostate 3 genes,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81552,Onc uveal mlnma mrna 15 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81554,Pulm ds ipf mrna 190 gen alg,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,81595,Cardiology hrt trnspl mrna,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,81596,Nfct ds chrnc hcv 6 assays,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,81599,Unlisted maaa,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,82009,Test for acetone/ketones,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,82010,Acetone assay,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82013,Acetylcholinesterase assay,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82016,Acylcarnitines qual,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82017,Acylcarnitines quant,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82024,Assay of acth,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Meridian Medicaid,CPT,82030,Assay of adp & amp,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,82040,Assay of serum albumin,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,82042,Other source albumin quan ea,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,82043,Ur albumin quantitative,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
Meridian Medicaid,CPT,82044,Ur albumin semiquantitative,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
Meridian Medicaid,CPT,82045,Albumin ischemia modified,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,82075,Assay of breath ethanol,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82077,Assay spec xcp ur&breath ia,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82085,Assay of aldolase,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82088,Assay of aldosterone,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Meridian Medicaid,CPT,82103,Alpha-1-antitrypsin total,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82104,Alpha-1-antitrypsin pheno,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82105,Alpha-fetoprotein serum,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82106,Alpha-fetoprotein amniotic,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82107,Alpha-fetoprotein l3,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,82108,Assay of aluminum,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Meridian Medicaid,CPT,82120,Amines vaginal fluid qual,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,82127,Amino acid single qual,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82128,Amino acids mult qual,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82131,Amino acids single quant,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82135,Assay aminolevulinic acid,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82136,Amino acids quant 2-5,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82139,Amino acids quan 6 or more,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82140,Assay of ammonia,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82143,Amniotic fluid scan,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,82150,Assay of amylase,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,82154,Androstanediol glucuronide,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,82157,Assay of androstenedione,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,82160,Assay of androsterone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,82163,Assay of angiotensin ii,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,82164,Angiotensin i enzyme test,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82172,Assay of apolipoprotein,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82175,Assay of arsenic,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Meridian Medicaid,CPT,82180,Assay of ascorbic acid,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82190,Atomic absorption,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82232,Assay of beta-2 protein,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,82239,Bile acids total,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82240,Bile acids cholylglycine,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82247,Bilirubin total,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,82248,Bilirubin direct,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,82252,Fecal bilirubin test,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,82261,Assay of biotinidase,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82270,Occult blood feces,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,82271,Occult blood other sources,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,82272,Occult bld feces 1-3 tests,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,82274,Assay test for blood fecal,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82286,Assay of bradykinin,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,82300,Assay of cadmium,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Meridian Medicaid,CPT,82306,Vitamin d 25 hydroxy,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,82308,Assay of calcitonin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,82310,Assay of calcium,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,82330,Assay of calcium,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82331,Calcium infusion test,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82340,Assay of calcium in urine,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,82355,Calculus analysis qual,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82360,Calculus assay quant,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82365,Calculus spectroscopy,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82370,X-ray assay calculus,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82373,Assay c-d transfer measure,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82374,Assay blood carbon dioxide,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,82375,Assay carboxyhb quant,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82376,Assay carboxyhb qual,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82378,Carcinoembryonic antigen,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82379,Assay of carnitine,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82380,Assay of carotene,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82382,Assay urine catecholamines,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,82383,Assay blood catecholamines,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,82384,Assay three catecholamines,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,82387,Assay of cathepsin-d,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82390,Assay of ceruloplasmin,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82397,Chemiluminescent assay,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82415,Assay of chloramphenicol,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,82435,Assay of blood chloride,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,82436,Assay of urine chloride,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,82438,Assay other fluid chlorides,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,82441,Test for chlorohydrocarbons,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Meridian Medicaid,CPT,82465,Assay bld/serum cholesterol,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,82480,Assay serum cholinesterase,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,82482,Assay rbc cholinesterase,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,82485,Assay chondroitin sulfate,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,82486,Gas/liquid chromatography,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,82487,Paper chromatography,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,82488,Paper chromatography,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,82489,Thin layer chromatography,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,82491,Chromotography quant sing,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82492,Chromotography quant mult,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,82495,Assay of chromium,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Meridian Medicaid,CPT,82507,Assay of citrate,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82523,Collagen crosslinks,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82525,Assay of copper,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Meridian Medicaid,CPT,82528,Assay of corticosterone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,82530,Cortisol free,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82533,Total cortisol,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,82540,Assay of creatine,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,82541,Column chromotography qual,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,82542,Col chromotography qual/quan,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82543,Column chromotograph/isotope,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,82544,Column chromotograph/isotope,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,82550,Assay of ck (cpk),Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,82552,Assay of cpk in blood,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82553,Creatine mb fraction,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82554,Creatine isoforms,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82565,Assay of creatinine,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,82570,Assay of urine creatinine,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,82575,Creatinine clearance test,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82585,Assay of cryofibrinogen,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82595,Assay of cryoglobulin,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,82600,Assay of cyanide,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Meridian Medicaid,CPT,82607,Vitamin b-12,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,82608,B-12 binding capacity,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82610,Cystatin c,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82615,Test for urine cystines,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82626,Dehydroepiandrosterone,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82627,Dehydroepiandrosterone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,82633,Desoxycorticosterone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,82634,Deoxycortisol,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,82638,Assay of dibucaine number,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82642,Dihydrotestosterone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,82652,Vit d 1 25-dihydroxy,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,82656,Pancreatic elastase fecal,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82657,Enzyme cell activity,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82658,Enzyme cell activity ra,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,82664,Electrophoretic test,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,82668,Assay of erythropoietin,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82670,Assay of total estradiol,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,82671,Assay of estrogens,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,82672,Assay of estrogen,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,82677,Assay of estriol,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,82679,Assay of estrone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,82681,Assay dir meas fr estradiol,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,82693,Assay of ethylene glycol,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Meridian Medicaid,CPT,82696,Assay of etiocholanolone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,82705,Fats/lipids feces qual,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,82710,Fats/lipids feces quant,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82715,Assay of fecal fat,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82725,Assay of blood fatty acids,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82726,Long chain fatty acids,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82728,Assay of ferritin,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82731,Assay of fetal fibronectin,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,82735,Assay of fluoride,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Meridian Medicaid,CPT,82746,Assay of folic acid serum,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82747,Assay of folic acid rbc,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
Meridian Medicaid,CPT,82757,Assay of semen fructose,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82759,Assay of rbc galactokinase,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82760,Assay of galactose,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82775,Assay galactose transferase,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82776,Galactose transferase test,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82777,Galectin-3,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,82784,Assay iga/igd/igg/igm each,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82785,Assay of ige,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82787,Igg 1 2 3 or 4 each,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82800,Blood ph,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82803,Blood gases any combination,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82805,Blood gases w/o2 saturation,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,82810,Blood gases o2 sat only,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82820,Hemoglobin-oxygen affinity,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Meridian Medicaid,CPT,82930,Gastric analy w/ph ea spec,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,82938,Gastrin test,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,82941,Assay of gastrin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,82943,Assay of glucagon,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,82945,Glucose other fluid,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,82946,Glucagon tolerance test,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82947,Assay glucose blood quant,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,82948,Reagent strip/blood glucose,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,82950,Glucose test,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,82951,Glucose tolerance test (gtt),Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82952,Gtt-added samples,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,82955,Assay of g6pd enzyme,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82960,Test for g6pd enzyme,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,82962,Glucose blood test,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,82963,Assay of glucosidase,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82965,Assay of gdh enzyme,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82977,Assay of ggt,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,82978,Assay of glutathione,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82979,Assay rbc glutathione,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,82985,Assay of glycated protein,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,83001,Assay of gonadotropin (fsh),Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,83002,Assay of gonadotropin (lh),Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,83003,Assay growth hormone (hgh),Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,83006,Growth stimulation gene 2,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Meridian Medicaid,CPT,83009,H pylori (c-13) blood,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,83010,Assay of haptoglobin quant,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,83012,Assay of haptoglobins,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,83013,H pylori (c-13) breath,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,83014,H pylori drug admin,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,83015,Heavy metal qual any anal,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Meridian Medicaid,CPT,83018,Heavy metal quant each nes,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Meridian Medicaid,CPT,83020,Hemoglobin electrophoresis,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,83021,Hemoglobin chromotography,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
Meridian Medicaid,CPT,83026,Hemoglobin copper sulfate,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Meridian Medicaid,CPT,83030,Fetal hemoglobin chemical,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,83033,Fetal hemoglobin assay qual,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,83036,Glycosylated hemoglobin test,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,83037,Glycosylated hb home device,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,83045,Blood methemoglobin test,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,83050,Blood methemoglobin assay,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,83051,Assay of plasma hemoglobin,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,83060,Blood sulfhemoglobin assay,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,83065,Assay of hemoglobin heat,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,83068,Hemoglobin stability screen,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,83069,Assay of urine hemoglobin,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,83070,Assay of hemosiderin qual,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,83080,Assay of b hexosaminidase,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,83088,Assay of histamine,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,83090,Assay of homocystine,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,83150,Assay of homovanillic acid,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,83491,Assay of corticosteroids 17,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,83497,Assay of 5-hiaa,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,83498,Assay of progesterone 17-d,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,83499,Assay of progesterone 20-,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Meridian Medicaid,CPT,83500,Assay free hydroxyproline,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,83505,Assay total hydroxyproline,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,83516,Immunoassay nonantibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,83518,Immunoassay dipstick,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,83519,Ria nonantibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,83520,Immunoassay quant nos nonab,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,83525,Assay of insulin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,83527,Assay of insulin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,83528,Assay of intrinsic factor,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,83540,Assay of iron,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,83550,Iron binding test,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,83570,Assay of idh enzyme,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,83582,Assay of ketogenic steroids,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,83586,Assay 17- ketosteroids,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,83593,Fractionation ketosteroids,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,83605,Assay of lactic acid,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,83615,Lactate (ld) (ldh) enzyme,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,83625,Assay of ldh enzymes,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,83630,Lactoferrin fecal (qual),Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,83631,Lactoferrin fecal (quant),Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,83632,Placental lactogen,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,83633,Test urine for lactose,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,83655,Assay of lead,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Meridian Medicaid,CPT,83661,L/s ratio fetal lung,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,83662,Foam stability fetal lung,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,83663,Fluoro polarize fetal lung,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,83664,Lamellar bdy fetal lung,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,83670,Assay of lap enzyme,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,83690,Assay of lipase,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,83695,Assay of lipoprotein(a),Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,83698,Assay lipoprotein pla2,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,83700,Lipopro bld electrophoretic,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,83701,Lipoprotein bld hr fraction,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,83704,Lipoprotein bld quan part,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,83718,Assay of lipoprotein,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,83719,Assay of blood lipoprotein,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,83721,Assay of blood lipoprotein,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,83722,Lipoprtn dir meas sd ldl chl,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,83727,Assay of lrh hormone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,83735,Assay of magnesium,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,83775,Assay malate dehydrogenase,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,83785,Assay of manganese,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Meridian Medicaid,CPT,83788,Mass spectrometry qual,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,83789,Mass spectrometry qual/quan,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,83825,Assay of mercury,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Meridian Medicaid,CPT,83835,Assay of metanephrines,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,83857,Assay of methemalbumin,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,83861,Microfluid analy tears,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,83864,Mucopolysaccharides,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,83872,Assay synovial fluid mucin,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,83873,Assay of csf protein,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,83874,Assay of myoglobin,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,83876,Assay myeloperoxidase,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,83880,Assay of natriuretic peptide,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,83883,Assay nephelometry not spec,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,83885,Assay of nickel,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Meridian Medicaid,CPT,83915,Assay of nucleotidase,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,83916,Oligoclonal bands,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,83918,Organic acids total quant,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Meridian Medicaid,CPT,83919,Organic acids qual each,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,83921,Organic acid single quant,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,83930,Assay of blood osmolality,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,83935,Assay of urine osmolality,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,83937,Assay of osteocalcin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,83945,Assay of oxalate,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,83950,Oncoprotein her-2/neu,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,83951,Oncoprotein dcp,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,83970,Assay of parathormone,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Meridian Medicaid,CPT,83986,Assay ph body fluid nos,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,83987,Exhaled breath condensate,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,83992,Assay for phencyclidine,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Meridian Medicaid,CPT,83993,Assay for calprotectin fecal,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,84030,Assay of blood pku,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,84035,Assay of phenylketones,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,84060,Assay acid phosphatase,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,84061,Phosphatase forensic exam,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,84066,Assay prostate phosphatase,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,84075,Assay alkaline phosphatase,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,84078,Assay alkaline phosphatase,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,84080,Assay alkaline phosphatases,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,84081,Assay phosphatidylglycerol,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,84085,Assay of rbc pg6d enzyme,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,84087,Assay phosphohexose enzymes,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,84100,Assay of phosphorus,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,84105,Assay of urine phosphorus,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,84106,Test for porphobilinogen,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,84110,Assay of porphobilinogen,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,84112,Eval amniotic fluid protein,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,84119,Test urine for porphyrins,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,84120,Assay of urine porphyrins,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,84126,Assay of feces porphyrins,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,84132,Assay of serum potassium,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,84133,Assay of urine potassium,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,84134,Assay of prealbumin,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,84135,Assay of pregnanediol,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,84138,Assay of pregnanetriol,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,84140,Assay of pregnenolone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,84143,Assay of 17-hydroxypregneno,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,84144,Assay of progesterone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,84145,Procalcitonin (pct),Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,84146,Assay of prolactin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,84150,Assay of prostaglandin,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Meridian Medicaid,CPT,84152,Assay of psa complexed,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,84153,Assay of psa total,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,84154,Assay of psa free,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,84155,Assay of protein serum,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,84156,Assay of protein urine,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,84157,Assay of protein other,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,84160,Assay of protein any source,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,84163,Pappa serum,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,84165,Protein e-phoresis serum,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,84166,Protein e-phoresis/urine/csf,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,84181,Western blot test,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,84182,Protein western blot test,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,84202,Assay rbc protoporphyrin,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,84203,Test rbc protoporphyrin,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,84206,Assay of proinsulin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,84207,Assay of vitamin b-6,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,84210,Assay of pyruvate,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,84220,Assay of pyruvate kinase,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,84228,Assay of quinine,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,84233,Assay of estrogen,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Meridian Medicaid,CPT,84234,Assay of progesterone,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Meridian Medicaid,CPT,84235,Assay of endocrine hormone,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Meridian Medicaid,CPT,84238,Assay nonendocrine receptor,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,84244,Assay of renin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,84252,Assay of vitamin b-2,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,84255,Assay of selenium,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,84260,Assay of serotonin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,84270,Assay of sex hormone globul,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,84275,Assay of sialic acid,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,84285,Assay of silica,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Meridian Medicaid,CPT,84295,Assay of serum sodium,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,84300,Assay of urine sodium,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,84302,Assay of sweat sodium,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,84305,Assay of somatomedin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,84307,Assay of somatostatin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,84311,Spectrophotometry,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,84315,Body fluid specific gravity,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,84375,Chromatogram assay sugars,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,84376,Sugars single qual,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,84377,Sugars multiple qual,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,84378,Sugars single quant,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,84379,Sugars multiple quant,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,84392,Assay of urine sulfate,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
Meridian Medicaid,CPT,84402,Assay of free testosterone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,84403,Assay of total testosterone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,84410,Testosterone bioavailable,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Meridian Medicaid,CPT,84425,Assay of vitamin b-1,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,84430,Assay of thiocyanate,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Meridian Medicaid,CPT,84431,Thromboxane urine,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,84432,Assay of thyroglobulin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,84436,Assay of total thyroxine,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,84437,Assay of neonatal thyroxine,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,84439,Assay of free thyroxine,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,84442,Assay of thyroid activity,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,84443,Assay thyroid stim hormone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,84445,Assay of tsi globulin,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Meridian Medicaid,CPT,84446,Assay of vitamin e,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,84449,Assay of transcortin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,84450,Transferase (ast) (sgot),Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,84460,Alanine amino (alt) (sgpt),Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,84466,Assay of transferrin,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,84478,Assay of triglycerides,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,84479,Assay of thyroid (t3 or t4),Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,84480,Assay triiodothyronine (t3),Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,84481,Free assay (ft-3),Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,84482,T3 reverse,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,84484,Assay of troponin quant,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,84485,Assay duodenal fluid trypsin,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,84488,Test feces for trypsin,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,84490,Assay of feces for trypsin,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,84510,Assay of tyrosine,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,84512,Assay of troponin qual,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,84520,Assay of urea nitrogen,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,84525,Urea nitrogen semi-quant,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,84540,Assay of urine/urea-n,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,84545,Urea-n clearance test,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,84550,Assay of blood/uric acid,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,84560,Assay of urine/uric acid,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,84577,Assay of feces/urobilinogen,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,84578,Test urine urobilinogen,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,84580,Assay of urine urobilinogen,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,84583,Assay of urine urobilinogen,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,84585,Assay of urine vma,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,84586,Assay of vip,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Meridian Medicaid,CPT,84588,Assay of vasopressin,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Meridian Medicaid,CPT,84590,Assay of vitamin a,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,84591,Assay of nos vitamin,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,84597,Assay of vitamin k,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,84600,Assay of volatiles,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,84620,Xylose tolerance test,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,84630,Assay of zinc,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Meridian Medicaid,CPT,84681,Assay of c-peptide,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,84702,Chorionic gonadotropin test,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,84703,Chorionic gonadotropin assay,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,84704,Hcg free betachain test,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,84830,Ovulation tests,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,84999,Clinical chemistry test,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,85002,Bleeding time test,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Meridian Medicaid,CPT,85004,Automated diff wbc count,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Meridian Medicaid,CPT,85007,Bl smear w/diff wbc count,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Meridian Medicaid,CPT,85008,Bl smear w/o diff wbc count,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Meridian Medicaid,CPT,85009,Manual diff wbc count b-coat,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Meridian Medicaid,CPT,85013,Spun microhematocrit,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Meridian Medicaid,CPT,85014,Hematocrit,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Meridian Medicaid,CPT,85018,Hemoglobin,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Meridian Medicaid,CPT,85025,Complete cbc w/auto diff wbc,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Meridian Medicaid,CPT,85027,Complete cbc automated,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Meridian Medicaid,CPT,85032,Manual cell count each,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Meridian Medicaid,CPT,85041,Automated rbc count,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Meridian Medicaid,CPT,85044,Manual reticulocyte count,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Meridian Medicaid,CPT,85045,Automated reticulocyte count,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Meridian Medicaid,CPT,85046,Reticyte/hgb concentrate,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Meridian Medicaid,CPT,85048,Automated leukocyte count,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Meridian Medicaid,CPT,85049,Automated platelet count,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Meridian Medicaid,CPT,85055,Reticulated platelet assay,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Meridian Medicaid,CPT,85060,Blood smear interpretation,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,85097,Bone marrow interpretation,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,85130,Chromogenic substrate assay,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
Meridian Medicaid,CPT,85170,Blood clot retraction,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Meridian Medicaid,CPT,85175,Blood clot lysis time,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Meridian Medicaid,CPT,85210,Clot factor ii prothrom spec,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Meridian Medicaid,CPT,85220,Blooc clot factor v test,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Meridian Medicaid,CPT,85230,Clot factor vii proconvertin,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Meridian Medicaid,CPT,85240,Clot factor viii ahg 1 stage,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Meridian Medicaid,CPT,85244,Clot factor viii reltd antgn,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Meridian Medicaid,CPT,85245,Clot factor viii vw ristoctn,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Meridian Medicaid,CPT,85246,Clot factor viii vw antigen,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Meridian Medicaid,CPT,85247,Clot factor viii multimetric,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Meridian Medicaid,CPT,85250,Clot factor ix ptc/chrstmas,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Meridian Medicaid,CPT,85260,Clot factor x stuart-power,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Meridian Medicaid,CPT,85270,Clot factor xi pta,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Meridian Medicaid,CPT,85280,Clot factor xii hageman,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Meridian Medicaid,CPT,85290,Clot factor xiii fibrin stab,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Meridian Medicaid,CPT,85291,Clot factor xiii fibrin scrn,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Meridian Medicaid,CPT,85292,Clot factor fletcher fact,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Meridian Medicaid,CPT,85293,Clot factor wght kininogen,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Meridian Medicaid,CPT,85300,Antithrombin iii activity,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Meridian Medicaid,CPT,85301,Antithrombin iii antigen,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Meridian Medicaid,CPT,85302,Clot inhibit prot c antigen,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Meridian Medicaid,CPT,85303,Clot inhibit prot c activity,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Meridian Medicaid,CPT,85305,Clot inhibit prot s total,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Meridian Medicaid,CPT,85306,Clot inhibit prot s free,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Meridian Medicaid,CPT,85307,Assay activated protein c,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,85335,Factor inhibitor test,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Meridian Medicaid,CPT,85337,Thrombomodulin,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Meridian Medicaid,CPT,85345,Coagulation time lee & white,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Meridian Medicaid,CPT,85347,Coagulation time activated,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Meridian Medicaid,CPT,85348,Coagulation time otr method,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Meridian Medicaid,CPT,85360,Euglobulin lysis,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
Meridian Medicaid,CPT,85362,Fibrin degradation products,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Meridian Medicaid,CPT,85366,Fibrinogen test,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Meridian Medicaid,CPT,85370,Fibrinogen test,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Meridian Medicaid,CPT,85378,Fibrin degrade semiquant,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Meridian Medicaid,CPT,85379,Fibrin degradation quant,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Meridian Medicaid,CPT,85380,Fibrin degradj d-dimer,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
Meridian Medicaid,CPT,85384,Fibrinogen activity,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Meridian Medicaid,CPT,85385,Fibrinogen antigen,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Meridian Medicaid,CPT,85390,Fibrinolysins screen i&r,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Meridian Medicaid,CPT,85396,Clotting assay whole blood,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Meridian Medicaid,CPT,85397,Clotting funct activity,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Meridian Medicaid,CPT,85400,Fibrinolytic plasmin,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Meridian Medicaid,CPT,85410,Fibrinolytic antiplasmin,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Meridian Medicaid,CPT,85415,Fibrinolytic plasminogen,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Meridian Medicaid,CPT,85420,Fibrinolytic plasminogen,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Meridian Medicaid,CPT,85421,Fibrinolytic plasminogen,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Meridian Medicaid,CPT,85441,Heinz bodies direct,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Meridian Medicaid,CPT,85445,Heinz bodies induced,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Meridian Medicaid,CPT,85460,Hemoglobin fetal,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
Meridian Medicaid,CPT,85461,Hemoglobin fetal,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Meridian Medicaid,CPT,85475,Hemolysin acid,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Meridian Medicaid,CPT,85520,Heparin assay,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Meridian Medicaid,CPT,85525,Heparin neutralization,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Meridian Medicaid,CPT,85530,Heparin-protamine tolerance,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Meridian Medicaid,CPT,85536,Iron stain peripheral blood,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Meridian Medicaid,CPT,85540,Wbc alkaline phosphatase,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
Meridian Medicaid,CPT,85547,Rbc mechanical fragility,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
Meridian Medicaid,CPT,85549,Muramidase,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,85555,Rbc osmotic fragility,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
Meridian Medicaid,CPT,85557,Rbc osmotic fragility,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
Meridian Medicaid,CPT,85576,Blood platelet aggregation,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Meridian Medicaid,CPT,85597,Phospholipid pltlt neutraliz,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Meridian Medicaid,CPT,85598,Hexagnal phosph pltlt neutrl,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Meridian Medicaid,CPT,85610,Prothrombin time,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Meridian Medicaid,CPT,85611,Prothrombin test,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Meridian Medicaid,CPT,85612,Viper venom prothrombin time,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Meridian Medicaid,CPT,85613,Russell viper venom diluted,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Meridian Medicaid,CPT,85635,Reptilase test,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
Meridian Medicaid,CPT,85651,Rbc sed rate nonautomated,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Meridian Medicaid,CPT,85652,Rbc sed rate automated,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Meridian Medicaid,CPT,85660,Rbc sickle cell test,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Meridian Medicaid,CPT,85670,Thrombin time plasma,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Meridian Medicaid,CPT,85675,Thrombin time titer,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Meridian Medicaid,CPT,85705,Thromboplastin inhibition,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Meridian Medicaid,CPT,85730,Thromboplastin time partial,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Meridian Medicaid,CPT,85732,Thromboplastin time partial,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Meridian Medicaid,CPT,85810,Blood viscosity examination,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
Meridian Medicaid,CPT,85999,Hematology procedure,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Meridian Medicaid,CPT,86000,Agglutinins febrile antigen,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86001,Allergen specific igg,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86003,Allg spec ige crude xtrc ea,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86005,Allg spec ige multiallg scr,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86008,Allg spec ige recomb ea,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86021,Wbc antibody identification,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86022,Platelet antibodies,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86023,Immunoglobulin assay,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86038,Antinuclear antibodies,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86039,Antinuclear antibodies (ana),Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86060,Antistreptolysin o titer,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86063,Antistreptolysin o screen,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86140,C-reactive protein,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86141,C-reactive protein hs,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86146,Beta-2 glycoprotein antibody,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,86147,Cardiolipin antibody ea ig,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Meridian Medicaid,CPT,86148,Anti-phospholipid antibody,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,86152,Cell enumeration & id,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Meridian Medicaid,CPT,86153,Cell enumeration phys interp,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86155,Chemotaxis assay,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86156,Cold agglutinin screen,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86157,Cold agglutinin titer,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86160,Complement antigen,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86161,Complement/function activity,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86162,Complement total (ch50),Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86171,Complement fixation each,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86185,Counterimmunoelectrophoresis,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86200,Ccp antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86215,Deoxyribonuclease antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86225,Dna antibody native,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86226,Dna antibody single strand,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86235,Nuclear antigen antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86243,Fc receptor,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Meridian Medicaid,CPT,86255,Fluorescent antibody screen,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86256,Fluorescent antibody titer,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86277,Growth hormone antibody,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,86280,Hemagglutination inhibition,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86294,Immunoassay tumor qual,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,86300,Immunoassay tumor ca 15-3,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,86301,Immunoassay tumor ca 19-9,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,86304,Immunoassay tumor ca 125,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,86305,Human epididymis protein 4,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,86308,Heterophile antibody screen,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86309,Heterophile antibody titer,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86310,Heterophile antibody absrbj,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86316,Immunoassay tumor other,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,86317,Immunoassay infectious agent,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86318,Ia infectious agent antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86320,Serum immunoelectrophoresis,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,86325,Other immunoelectrophoresis,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,86327,Immunoelectrophoresis assay,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,86328,Ia nfct ab sarscov2 covid19,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86329,Immunodiffusion nes,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86331,Immunodiffusion ouchterlony,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86332,Immune complex assay,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Meridian Medicaid,CPT,86334,Immunofix e-phoresis serum,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86335,Immunfix e-phorsis/urine/csf,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Meridian Medicaid,CPT,86336,Inhibin a,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,86337,Insulin antibodies,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,86340,Intrinsic factor antibody,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,86341,Islet cell antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86343,Leukocyte histamine release,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86344,Leukocyte phagocytosis,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86352,Cell function assay w/stim,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Meridian Medicaid,CPT,86353,Lymphocyte transformation,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Meridian Medicaid,CPT,86355,B cells total count,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Meridian Medicaid,CPT,86356,Mononuclear cell antigen,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Meridian Medicaid,CPT,86357,Nk cells total count,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Meridian Medicaid,CPT,86359,T cells total count,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Meridian Medicaid,CPT,86360,T cell absolute count/ratio,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Meridian Medicaid,CPT,86361,T cell absolute count,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Meridian Medicaid,CPT,86367,Stem cells total count,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Meridian Medicaid,CPT,86376,Microsomal antibody each,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,86378,Migration inhibitory factor,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Meridian Medicaid,CPT,86382,Neutralization test viral,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86384,Nitroblue tetrazolium dye,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86386,Nuclear matrix protein 22,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86403,Particle agglut antbdy scrn,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86406,Particle agglut antbdy titr,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86408,Neutrlzg antb sarscov2 scr,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86409,Neutrlzg antb sarscov2 titer,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86413,Sars-cov-2 antb quantitative,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86430,Rheumatoid factor test qual,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86431,Rheumatoid factor quant,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86480,Tb test cell immun measure,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Meridian Medicaid,CPT,86481,Tb ag response t-cell susp,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Meridian Medicaid,CPT,86485,Skin test candida,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Meridian Medicaid,CPT,86486,Skin test nos antigen,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86490,Coccidioidomycosis skin test,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Meridian Medicaid,CPT,86510,Histoplasmosis skin test,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Meridian Medicaid,CPT,86580,Tb intradermal test,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86590,Streptokinase antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86592,Syphilis test non-trep qual,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86593,Syphilis test non-trep quant,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86602,Antinomyces antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86603,Adenovirus antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86606,Aspergillus antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86609,Bacterium antibody,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,86611,Bartonella antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86612,Blastomyces antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86615,Bordetella antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86617,Lyme disease antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86618,Lyme disease antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86619,Borrelia antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86622,Brucella antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86625,Campylobacter antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86628,Candida antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86631,Chlamydia antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86632,Chlamydia igm antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86635,Coccidioides antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86638,Q fever antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86641,Cryptococcus antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86644,Cmv antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86645,Cmv antibody igm,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86648,Diphtheria antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86651,Encephalitis californ antbdy,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86652,Encephaltis east eqne anbdy,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86653,Encephaltis st louis antbody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86654,Encephaltis west eqne antbdy,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86658,Enterovirus antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86663,Epstein-barr antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86664,Epstein-barr nuclear antigen,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86665,Epstein-barr capsid vca,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86666,Ehrlichia antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86668,Francisella tularensis,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86671,Fungus nes antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86674,Giardia lamblia antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86677,Helicobacter pylori antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86682,Helminth antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86684,Hemophilus influenza antibdy,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86687,Htlv-i antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86688,Htlv-ii antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86689,Htlv/hiv confirmj antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86692,Hepatitis delta agent antbdy,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86694,Herpes simplex nes antbdy,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86695,Herpes simplex type 1 test,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86696,Herpes simplex type 2 test,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86698,Histoplasma antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86701,Hiv-1antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86702,Hiv-2 antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86703,Hiv-1/hiv-2 1 result antbdy,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86704,Hep b core antibody total,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86705,Hep b core antibody igm,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86706,Hep b surface antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86707,Hepatitis be antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86708,Hepatitis a antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86709,Hepatitis a igm antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86710,Influenza virus antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86711,John cunningham antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86713,Legionella antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86717,Leishmania antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86720,Leptospira antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86723,Listeria monocytogenes,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86727,Lymph choriomeningitis ab,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86729,Lympho venereum antibody,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Meridian Medicaid,CPT,86732,Mucormycosis antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86735,Mumps antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86738,Mycoplasma antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86741,Neisseria meningitidis,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86744,Nocardia antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86747,Parvovirus antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86750,Malaria antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86753,Protozoa antibody nos,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86756,Respiratory virus antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86757,Rickettsia antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86759,Rotavirus antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86762,Rubella antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86765,Rubeola antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86768,Salmonella antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86769,Sars-cov-2 covid-19 antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86771,Shigella antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86774,Tetanus antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86777,Toxoplasma antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86778,Toxoplasma antibody igm,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86780,Treponema pallidum,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86784,Trichinella antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86787,Varicella-zoster antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86788,West nile virus ab igm,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86789,West nile virus antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86790,Virus antibody nos,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86793,Yersinia antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86794,Zika virus igm antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86800,Thyroglobulin antibody,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Meridian Medicaid,CPT,86803,Hepatitis c ab test,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86804,Hep c ab test confirm,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,86805,Lymphocytotoxicity assay,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Meridian Medicaid,CPT,86806,Lymphocytotoxicity assay,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
Meridian Medicaid,CPT,86807,Cytotoxic antibody screening,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Meridian Medicaid,CPT,86808,Cytotoxic antibody screening,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
Meridian Medicaid,CPT,86812,Hla typing a b or c,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
Meridian Medicaid,CPT,86813,Hla typing a b or c,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Meridian Medicaid,CPT,86816,Hla typing dr/dq,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
Meridian Medicaid,CPT,86817,Hla typing dr/dq,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Meridian Medicaid,CPT,86821,Lymphocyte culture mixed,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
Meridian Medicaid,CPT,86822,Lymphocyte culture primed,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Meridian Medicaid,CPT,86825,Hla x-math non-cytotoxic,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Meridian Medicaid,CPT,86826,Hla x-match noncytotoxc addl,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
Meridian Medicaid,CPT,86828,Hla class i&ii antibody qual,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
Meridian Medicaid,CPT,86829,Hla class i/ii antibody qual,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
Meridian Medicaid,CPT,86830,Hla class i phenotype qual,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Meridian Medicaid,CPT,86831,Hla class ii phenotype qual,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Meridian Medicaid,CPT,86832,Hla class i high defin qual,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Meridian Medicaid,CPT,86833,Hla class ii high defin qual,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Meridian Medicaid,CPT,86834,Hla class i semiquant panel,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Meridian Medicaid,CPT,86835,Hla class ii semiquant panel,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Meridian Medicaid,CPT,86849,Immunology procedure,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86850,Rbc antibody screen,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Meridian Medicaid,CPT,86860,Rbc antibody elution,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Meridian Medicaid,CPT,86870,Rbc antibody identification,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Meridian Medicaid,CPT,86880,Coombs test direct,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Meridian Medicaid,CPT,86885,Coombs test indirect qual,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Meridian Medicaid,CPT,86886,Coombs test indirect titer,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Meridian Medicaid,CPT,86900,Blood typing serologic abo,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Meridian Medicaid,CPT,86901,Blood typing serologic rh(d),Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
Meridian Medicaid,CPT,86902,Blood type antigen donor ea,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Meridian Medicaid,CPT,86904,Blood typing patient serum,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
Meridian Medicaid,CPT,86905,Blood typing rbc antigens,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Meridian Medicaid,CPT,86906,Bld typing serologic rh phnt,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
Meridian Medicaid,CPT,86910,Blood typing paternity test,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
Meridian Medicaid,CPT,86911,Blood typing antigen system,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
Meridian Medicaid,CPT,86920,Compatibility test spin,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Meridian Medicaid,CPT,86921,Compatibility test incubate,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Meridian Medicaid,CPT,86922,Compatibility test antiglob,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Meridian Medicaid,CPT,86923,Compatibility test electric,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Meridian Medicaid,CPT,86940,Hemolysins/agglutinins auto,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86941,Hemolysins/agglutinins,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,86999,Transfusion procedure,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
Meridian Medicaid,CPT,87003,Small animal inoculation,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87015,Specimen infect agnt concntj,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87040,Blood culture for bacteria,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87045,Feces culture aerobic bact,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87046,Stool cultr aerobic bact ea,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87070,Culture othr specimn aerobic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87071,Culture aerobic quant other,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87073,Culture bacteria anaerobic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87075,Cultr bacteria except blood,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87076,Culture anaerobe ident each,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87077,Culture aerobic identify,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87081,Culture screen only,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87084,Culture of specimen by kit,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87086,Urine culture/colony count,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87088,Urine bacteria culture,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87101,Skin fungi culture,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87102,Fungus isolation culture,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87103,Blood fungus culture,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87106,Fungi identification yeast,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87107,Fungi identification mold,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87109,Mycoplasma,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87110,Chlamydia culture,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87116,Mycobacteria culture,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87118,Mycobacteric identification,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87140,Culture type immunofluoresc,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87143,Culture typing glc/hplc,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87147,Culture type immunologic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87149,Dna/rna direct probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87150,Dna/rna amplified probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87152,Culture type pulse field gel,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87158,Culture typing added method,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87164,Dark field examination,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87166,Dark field examination,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87168,Macroscopic exam arthropod,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87169,Macroscopic exam parasite,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87172,Pinworm exam,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87176,Tissue homogenization cultr,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87177,Ova and parasites smears,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87181,Microbe susceptible diffuse,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87184,Microbe susceptible disk,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87185,Microbe susceptible enzyme,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87186,Microbe susceptible mic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87187,Microbe susceptible mlc,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87188,Microbe suscept macrobroth,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87190,Microbe suscept mycobacteri,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87197,Bactericidal level serum,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87205,Smear gram stain,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87206,Smear fluorescent/acid stai,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87207,Smear special stain,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87209,Smear complex stain,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87210,Smear wet mount saline/ink,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87220,Tissue exam for fungi,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87230,Assay toxin or antitoxin,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87250,Virus inoculate eggs/animal,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87252,Virus inoculation tissue,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87253,Virus inoculate tissue addl,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87254,Virus inoculation shell via,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87255,Genet virus isolate hsv,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87260,Adenovirus ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87265,Pertussis ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87267,Enterovirus antibody dfa,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87269,Giardia ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87270,Chlamydia trachomatis ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87271,Cytomegalovirus dfa,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87272,Cryptosporidium ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87273,Herpes simplex 2 ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87274,Herpes simplex 1 ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87275,Influenza b ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87276,Influenza a ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87277,Legionella micdadei ag if,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,87278,Legion pneumophilia ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87279,Parainfluenza ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87280,Respiratory syncytial ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87281,Pneumocystis carinii ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87283,Rubeola ag if,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87285,Treponema pallidum ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87290,Varicella zoster ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87299,Antibody detection nos if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87300,Ag detection polyval if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87301,Adenovirus ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87305,Aspergillus ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87320,Chylmd trach ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87324,Clostridium ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87327,Cryptococcus neoform ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87328,Cryptosporidium ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87329,Giardia ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87332,Cytomegalovirus ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87335,E coli 0157 ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87336,Entamoeb hist dispr ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87337,Entamoeb hist group ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87338,Hpylori stool ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87339,H pylori ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87340,Hepatitis b surface ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87341,Hepatitis b surface ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87350,Hepatitis be ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87380,Hepatitis delta agent ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87385,Histoplasma capsul ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87389,Hiv-1 ag w/hiv-1&2 ab ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87390,Hiv-1 ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87391,Hiv-2 ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87400,Influenza a/b each ag ia,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,87420,Resp syncytial virus ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87425,Rotavirus ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87426,Sarscov coronavirus ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87427,Shiga-like toxin ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87428,Sarscov & inf vir a&b ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87430,Strep a ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87449,Nos each organism ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87450,Ag detect nos ia single,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87451,Polyvalent mult org ea ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87470,Bartonella dna dir probe,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,87471,Bartonella dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87472,Bartonella dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87475,Lyme dis dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87476,Lyme dis dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87477,Lyme dis dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87480,Candida dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87481,Candida dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87482,Candida dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87485,Chylmd pneum dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87486,Chylmd pneum dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87487,Chylmd pneum dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87490,Chylmd trach dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87491,Chylmd trach dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87492,Chylmd trach dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87493,C diff amplified probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87495,Cytomeg dna dir probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87496,Cytomeg dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87497,Cytomeg dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87498,Enterovirus probe&revrs trns,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87500,Vanomycin dna amp probe,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Meridian Medicaid,CPT,87501,Influenza dna amp prob 1+,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87502,Influenza dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87503,Influenza dna amp prob addl,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Meridian Medicaid,CPT,87510,Gardner vag dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87511,Gardner vag dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87512,Gardner vag dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87515,Hepatitis b dna dir probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87516,Hepatitis b dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87517,Hepatitis b dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87520,Hepatitis c rna dir probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87521,Hepatitis c probe&rvrs trnsc,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87522,Hepatitis c revrs trnscrpj,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87525,Hepatitis g dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87526,Hepatitis g dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87527,Hepatitis g dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87528,Hsv dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87529,Hsv dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87530,Hsv dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87531,Hhv-6 dna dir probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87532,Hhv-6 dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87533,Hhv-6 dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87534,Hiv-1 dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87535,Hiv-1 probe&reverse trnscrpj,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87536,Hiv-1 quant&revrse trnscrpj,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87537,Hiv-2 dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87538,Hiv-2 probe&revrse trnscripj,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87539,Hiv-2 quant&revrse trnscripj,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87540,Legion pneumo dna dir prob,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87541,Legion pneumo dna amp prob,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87542,Legion pneumo dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87550,Mycobacteria dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87551,Mycobacteria dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87552,Mycobacteria dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87555,M.tuberculo dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87556,M.tuberculo dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87557,M.tuberculo dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87560,M.avium-intra dna dir prob,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87561,M.avium-intra dna amp prob,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87562,M.avium-intra dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87563,M. genitalium amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87580,M.pneumon dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87581,M.pneumon dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87590,N.gonorrhoeae dna dir prob,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87591,N.gonorrhoeae dna amp prob,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87592,N.gonorrhoeae dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87623,Hpv low-risk types,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87624,Hpv high-risk types,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87625,Hpv types 16 & 18 only,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87634,Rsv dna/rna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87635,Sars-cov-2 covid-19 amp prb,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87636,Sarscov2 & inf a&b amp prb,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87637,Sarscov2&inf a&b&rsv amp prb,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87640,Staph a dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87641,Mr-staph dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87650,Strep a dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87651,Strep a dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87652,Strep a dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87653,Strep b dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87660,Trichomonas vagin dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87661,Trichomonas vaginalis amplif,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87662,Zika virus dna/rna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87797,Detect agent nos dna dir,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87798,Detect agent nos dna amp,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87799,Detect agent nos dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87800,Detect agnt mult dna direc,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87801,Detect agnt mult dna ampli,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87802,Strep b assay w/optic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87803,Clostridium toxin a w/optic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87804,Influenza assay w/optic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87806,Hiv w/hiv1&2 antb w/optic,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87807,Rsv assay w/optic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87808,Trichomonas assay w/optic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87809,Adenovirus assay w/optic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87810,Chylmd trach assay w/optic,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87811,Sars-cov-2 covid19 w/optic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87850,N. gonorrhoeae assay w/optic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87880,Strep a assay w/optic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87899,Agent nos assay w/optic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87904,Phenotype dna hiv w/clt add,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,87905,Sialidase enzyme assay,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,87999,Microbiology procedure,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,88104,Cytopath fl nongyn smears,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,88106,Cytopath fl nongyn filter,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,88108,Cytopath concentrate tech,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,88112,Cytopath cell enhance tech,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,88120,Cytp urne 3-5 probes ea spec,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,88125,Forensic cytopathology,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,88130,Sex chromatin identification,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,88140,Sex chromatin identification,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,88141,Cytopath c/v interpret,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Meridian Medicaid,CPT,88142,Cytopath c/v thin layer,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Meridian Medicaid,CPT,88143,Cytopath c/v thin layer redo,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Meridian Medicaid,CPT,88147,Cytopath c/v automated,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Meridian Medicaid,CPT,88148,Cytopath c/v auto rescreen,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Meridian Medicaid,CPT,88150,Cytopath c/v manual,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Meridian Medicaid,CPT,88152,Cytopath c/v auto redo,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Meridian Medicaid,CPT,88153,Cytopath c/v redo,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Meridian Medicaid,CPT,88154,Cytopath c/v select,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Meridian Medicaid,CPT,88155,Cytopath c/v index add-on,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Meridian Medicaid,CPT,88160,Cytopath smear other source,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,88161,Cytopath smear other source,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,88162,Cytopath smear other source,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,88164,Cytopath tbs c/v manual,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Meridian Medicaid,CPT,88165,Cytopath tbs c/v redo,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Meridian Medicaid,CPT,88166,Cytopath tbs c/v auto redo,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Meridian Medicaid,CPT,88167,Cytopath tbs c/v select,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Meridian Medicaid,CPT,88172,Cytp dx eval fna 1st ea site,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,88173,Cytopath eval fna report,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,88174,Cytopath c/v auto in fluid,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Meridian Medicaid,CPT,88175,Cytopath c/v auto fluid redo,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Meridian Medicaid,CPT,88177,Cytp fna eval ea addl,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,88182,Cell marker study,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,88184,Flowcytometry/ tc 1 marker,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,88187,Flowcytometry/read 2-8,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,88188,Flowcytometry/read 9-15,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,88189,Flowcytometry/read 16 & >,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,88199,Cytopathology procedure,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,88240,Cell cryopreserve/storage,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,88241,Frozen cell preparation,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,88245,Chromosome analysis 20-25,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,88248,Chromosome analysis 50-100,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,88249,Chromosome analysis 100,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,88261,Chromosome analysis 5,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,88262,Chromosome analysis 15-20,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,88263,Chromosome analysis 45,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,88264,Chromosome analysis 20-25,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,88267,Chromosome analys placenta,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,88269,Chromosome analys amniotic,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,88271,Cytogenetics dna probe,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,88272,Cytogenetics 3-5,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,88273,Cytogenetics 10-30,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,88274,Cytogenetics 25-99,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,88275,Cytogenetics 100-300,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,88280,Chromosome karyotype study,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,88283,Chromosome banding study,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,88285,Chromosome count additional,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,88289,Chromosome study additional,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,88291,Cyto/molecular report,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,88299,Cytogenetic study,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,88300,Surgical path gross,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,88302,Tissue exam by pathologist,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,88304,Tissue exam by pathologist,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,88305,Tissue exam by pathologist,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,88311,Decalcify tissue,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,88312,Special stains group 1,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,88313,Special stains group 2,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,88314,Histochemical stains add-on,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,88321,Microslide consultation,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,88323,Microslide consultation,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,88325,Comprehensive review of data,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,88329,Path consult introp,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,88331,Path consult intraop 1 bloc,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,88332,Path consult intraop addl,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,88333,Intraop cyto path consult 1,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,88334,Intraop cyto path consult 2,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,88342,Immunohisto antb 1st stain,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,88346,Immunofluor antb 1st stain,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,88347,Immunofluorescent study,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,88355,Analysis skeletal muscle,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,88356,Analysis nerve,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,88358,Analysis tumor,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,88363,Xm archive tissue molec anal,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,88364,Insitu hybridization (fish),Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,88369,M/phmtrc alysishquant/semiq,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,88371,Protein western blot tissue,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,88372,Protein analysis w/probe,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,88373,M/phmtrc alys ishquant/semiq,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,88374,M/phmtrc alys ishquant/semiq,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,88375,Optical endomicroscpy interp,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,88377,M/phmtrc alys ishquant/semiq,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,88380,Microdissection laser,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,88381,Microdissection manual,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,88387,Tiss exam molecular study,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,88388,Tiss ex molecul study add-on,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,88399,Surgical pathology procedure,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,88720,Bilirubin total transcut,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,88738,Hgb quant transcutaneous,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Meridian Medicaid,CPT,88740,Transcutaneous carboxyhb,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Meridian Medicaid,CPT,88741,Transcutaneous methb,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Meridian Medicaid,CPT,88749,In vivo lab service,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,89050,Body fluid cell count,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,89051,Body fluid cell count,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,89055,Leukocyte assessment fecal,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Meridian Medicaid,CPT,89060,Exam synovial fluid crystals,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,89125,Specimen fat stain,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,89160,Exam feces for meat fibers,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,89190,Nasal smear for eosinophils,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,89220,Sputum specimen collection,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,89230,Collect sweat for test,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,89240,Pathology lab procedure,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,89250,Cultr oocyte/embryo <4 days,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,89253,Embryo hatching,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,89254,Oocyte identification,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,89255,Prepare embryo for transfer,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,89257,Sperm identification,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,89260,Sperm isolation simple,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,89261,Sperm isolation complex,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,89264,Identify sperm tissue,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,89281,Assist oocyte fertilization,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,89290,Biopsy oocyte polar body,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,89291,Biopsy oocyte polar body,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,89300,Semen analysis w/huhner,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,89310,Semen analysis w/count,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,89320,Semen anal vol/count/mot,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,89321,Semen anal sperm detection,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,89322,Semen anal strict criteria,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,89325,Sperm antibody test,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,89329,Sperm evaluation test,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,89330,Evaluation cervical mucus,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,89331,Retrograde ejaculation anal,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,89335,Cryopreserve testicular tiss,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,89353,Thawing cryopresrved sperm,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,89398,Unlisted reprod med lab proc,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,90287,Botulinum antitoxin,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,90288,Botulism ig iv,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,90291,Cmv ig iv,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,90371,Hep b ig im,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Meridian Medicaid,CPT,90375,Rabies ig im/sc,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Meridian Medicaid,CPT,90376,Rabies ig heat treated,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Meridian Medicaid,CPT,90377,Rabies ig ht&sol human im/sc,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Meridian Medicaid,CPT,90378,Rsv mab im 50mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Meridian Medicaid,CPT,90384,Rh ig full-dose im,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,90386,Rh ig iv,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Meridian Medicaid,CPT,90389,Tetanus ig im,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,90393,Vaccina ig im,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,90396,Varicella-zoster ig im,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,90460,Im admin 1st/only component,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,90461,Im admin each addl component,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,90471,Immunization admin,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,90472,Immunization admin each add,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,90473,Immune admin oral/nasal,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,90474,Immune admin oral/nasal addl,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,90476,Adenovirus vaccine type 4,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90477,Adenovirus vaccine type 7,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90581,Anthrax vaccine sc or im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Meridian Medicaid,CPT,90585,Bcg vaccine percut,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90586,Bcg vaccine intravesical,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Meridian Medicaid,CPT,90587,Dengue vacc quad 3 dose subq,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Meridian Medicaid,CPT,90619,Menacwy-tt vaccine im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Meridian Medicaid,CPT,90620,Menb-4c vacc 2 dose im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Meridian Medicaid,CPT,90621,Menb-fhbp vacc 2/3 dose im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Meridian Medicaid,CPT,90625,Cholera vaccine live oral,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90630,Flu vacc iiv4 no preserv id,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90632,Hepa vaccine adult im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90633,Hepa vacc ped/adol 2 dose im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90634,Hepa vacc ped/adol 3 dose,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90636,Hep a/hep b vacc adult im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Meridian Medicaid,CPT,90644,Hib-mency vacc 6wk-18m0 im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Meridian Medicaid,CPT,90645,Hib vaccine hboc im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Meridian Medicaid,CPT,90646,Hib vaccine prp-d im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Meridian Medicaid,CPT,90647,Hib prp-omp vacc 3 dose im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90648,Hib prp-t vaccine 4 dose im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90649,4vhpv vaccine 3 dose im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Meridian Medicaid,CPT,90650,2vhpv vaccine 3 dose im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90651,9vhpv vaccine 2/3 dose im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Meridian Medicaid,CPT,90653,Iiv adjuvant vaccine im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90654,Flu vacc iiv3 no preserv id,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90655,Iiv3 vacc no prsv 0.25 ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90656,Iiv3 vacc no prsv 0.5 ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90657,Iiv3 vaccine splt 0.25 ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90658,Iiv3 vaccine splt 0.5 ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90660,Laiv3 vaccine intranasal,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90661,Cciiv3 vac no prsv 0.5 ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90662,Iiv no prsv increased ag im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90664,Laiv vacc pandemic intranasl,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90666,Flu vac pandem prsrv free im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90667,Iiv vacc pandemic adjuvt im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90668,Iiv vaccine pandemic im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90669,Pneumococcal vacc 7 val im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Meridian Medicaid,CPT,90670,Pcv13 vaccine im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Meridian Medicaid,CPT,90672,Laiv4 vaccine intranasal,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90673,Riv3 vaccine no preserv im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90674,Cciiv4 vac no prsv 0.5 ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90675,Rabies vaccine im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Meridian Medicaid,CPT,90676,Rabies vaccine id,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Meridian Medicaid,CPT,90680,Rv5 vacc 3 dose live oral,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Meridian Medicaid,CPT,90681,Rv1 vacc 2 dose live oral,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90682,Riv4 vacc recombinant dna im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90685,Iiv4 vacc no prsv 0.25 ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90686,Iiv4 vacc no prsv 0.5 ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90687,Iiv4 vaccine splt 0.25 ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90688,Iiv4 vaccine splt 0.5 ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90689,Vacc iiv4 no prsrv 0.25ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90690,Typhoid vaccine oral,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90691,Typhoid vaccine im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90692,Typhoid vaccine h-p sc/id,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90693,Typhoid vaccine akd sc,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90694,Vacc aiiv4 no prsrv 0.5ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90696,Dtap-ipv vaccine 4-6 yrs im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90697,Dtap-ipv-hib-hepb vaccine im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90698,Dtap-ipv/hib vaccine im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90700,Dtap vaccine < 7 yrs im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90702,Dt vaccine under 7 yrs im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90703,Tetanus vaccine im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90704,Mumps vaccine sc,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90705,Measles vaccine sc,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90706,Rubella vaccine sc,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90707,Mmr vaccine sc,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90708,Measles-rubella vaccine sc,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90710,Mmrv vaccine sc,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90712,Oral poliovirus vaccine,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Meridian Medicaid,CPT,90713,Poliovirus ipv sc/im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90714,Td vacc no presv 7 yrs+ im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90715,Tdap vaccine 7 yrs/> im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90716,Var vaccine live subq,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Meridian Medicaid,CPT,90717,Yellow fever vaccine subq,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Meridian Medicaid,CPT,90719,Diphtheria vaccine im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90720,Dtp/hib vaccine im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Meridian Medicaid,CPT,90721,Dtap/hib vaccine im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Meridian Medicaid,CPT,90723,Dtap-hep b-ipv vaccine im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90725,Cholera vaccine injectable,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90727,Plague vaccine im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Meridian Medicaid,CPT,90732,Ppsv23 vacc 2 yrs+ subq/im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90733,Mpsv4 vaccine subq,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Meridian Medicaid,CPT,90734,Menacwyd/menacwycrm vacc im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Meridian Medicaid,CPT,90735,Encephalitis vaccine sc,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Meridian Medicaid,CPT,90736,Hzv vaccine live subq,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Meridian Medicaid,CPT,90738,Inactivated je vacc im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Meridian Medicaid,CPT,90739,Hepb vacc 2 dose adult im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90740,Hepb vacc 3 dose immunsup im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Meridian Medicaid,CPT,90743,Hepb vacc 2 dose adolesc im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90744,Hepb vacc 3 dose ped/adol im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90746,Hepb vaccine 3 dose adult im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90747,Hepb vacc 4 dose immunsup im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Meridian Medicaid,CPT,90748,Hib-hepb vaccine im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90749,Vaccine toxoid,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90750,Hzv vacc recombinant im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Meridian Medicaid,CPT,90756,Cciiv4 vacc abx free im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,90785,Psytx complex interactive,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Meridian Medicaid,CPT,90791,Psych diagnostic evaluation,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
Meridian Medicaid,CPT,90792,Psych diag eval w/med srvcs,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
Meridian Medicaid,CPT,90832,Psytx w pt 30 minutes,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Meridian Medicaid,CPT,90833,Psytx w pt w e/m 30 min,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Meridian Medicaid,CPT,90834,Psytx w pt 45 minutes,Behavioral Health,Per Unit,$84.55 ,OP,84.55,84.55,,,,,,
Meridian Medicaid,CPT,90836,Psytx w pt w e/m 45 min,Behavioral Health,Per Unit,$84.55 ,OP,84.55,84.55,,,,,,
Meridian Medicaid,CPT,90837,Psytx w pt 60 minutes,Behavioral Health,Per Unit,$84.55 ,OP,84.55,84.55,,,,,,
Meridian Medicaid,CPT,90838,Psytx w pt w e/m 60 min,Behavioral Health,Per Unit,$84.55 ,OP,84.55,84.55,,,,,,
Meridian Medicaid,CPT,90839,Psytx crisis initial 60 min,Behavioral Health,Per Unit,$84.55 ,OP,84.55,84.55,,,,,,
Meridian Medicaid,CPT,90840,Psytx crisis ea addl 30 min,Behavioral Health,Per Unit,$84.55 ,OP,84.55,84.55,,,,,,
Meridian Medicaid,CPT,90845,Psychoanalysis,Behavioral Health,Per Unit,$84.55 ,OP,84.55,84.55,,,,,,
Meridian Medicaid,CPT,90846,Family psytx w/o pt 50 min,Behavioral Health,Per Unit,$89.14 ,OP,89.14,89.14,,,,,,
Meridian Medicaid,CPT,90847,Family psytx w/pt 50 min,Behavioral Health,Per Unit,$89.14 ,OP,89.14,89.14,,,,,,
Meridian Medicaid,CPT,90849,Multiple family group psytx,Behavioral Health,Per Unit,$119.88 ,OP,119.88,119.88,,,,,,
Meridian Medicaid,CPT,90853,Group psychotherapy,Behavioral Health,Per Unit,$119.88 ,OP,119.88,119.88,,,,,,
Meridian Medicaid,CPT,90863,Pharmacologic mgmt w/psytx,Behavioral Health,Per Unit,$80.13 ,OP,80.13,80.13,,,,,,
Meridian Medicaid,CPT,90865,Narcosynthesis,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
Meridian Medicaid,CPT,90867,Tcranial magn stim tx plan,Behavioral Health,Per Unit,$276.44 ,OP,276.44,276.44,,,,,,
Meridian Medicaid,CPT,90868,Tcranial magn stim tx deli,Behavioral Health,Per Unit,$276.44 ,OP,276.44,276.44,,,,,,
Meridian Medicaid,CPT,90869,Tcran magn stim redetemine,Behavioral Health,Per Unit,$276.44 ,OP,276.44,276.44,,,,,,
Meridian Medicaid,CPT,90870,Electroconvulsive therapy,Behavioral Health,Per Unit,$276.44 ,OP,276.44,276.44,,,,,,
Meridian Medicaid,CPT,90875,Psychophysiological therapy,Ancillary Services,Per Unit,$123.52 ,OP,123.52,123.52,,,,,,
Meridian Medicaid,CPT,90876,Psychophysiological therapy,Ancillary Services,Per Unit,$123.52 ,OP,123.52,123.52,,,,,,
Meridian Medicaid,CPT,90880,Hypnotherapy,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Meridian Medicaid,CPT,90882,Environmental manipulation,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Meridian Medicaid,CPT,90885,Psy evaluation of records,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Meridian Medicaid,CPT,90887,Consultation with family,Behavioral Health,Per Unit,$89.14 ,OP,89.14,89.14,,,,,,
Meridian Medicaid,CPT,90889,Preparation of report,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Meridian Medicaid,CPT,90899,Psychiatric service/therapy,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Meridian Medicaid,CPT,90901,Biofeedback train any meth,Ancillary Services,Per Unit,$123.52 ,OP,123.52,123.52,,,,,,
Meridian Medicaid,CPT,90911,Biofeedback peri/uro/rectal,Ancillary Services,Per Unit,$123.52 ,OP,123.52,123.52,,,,,,
Meridian Medicaid,CPT,90912,Bfb training 1st 15 min,Ancillary Services,Per Unit,$123.52 ,OP,123.52,123.52,,,,,,
Meridian Medicaid,CPT,90913,Bfb training ea addl 15 min,Ancillary Services,Per Unit,$123.52 ,OP,123.52,123.52,,,,,,
Meridian Medicaid,CPT,90935,Hemodialysis one evaluation,Nephrology,Per Unit,$540.95 ,OP,540.95,540.95,,,,,,
Meridian Medicaid,CPT,90937,Hemodialysis repeated eval,Nephrology,Per Unit,$540.95 ,OP,540.95,540.95,,,,,,
Meridian Medicaid,CPT,90940,Hemodialysis access study,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Meridian Medicaid,CPT,90945,Dialysis one evaluation,Nephrology,Per Unit,$540.95 ,OP,540.95,540.95,,,,,,
Meridian Medicaid,CPT,90947,Dialysis repeated eval,Nephrology,Per Unit,$540.95 ,OP,540.95,540.95,,,,,,
Meridian Medicaid,CPT,90989,Dialysis training complete,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Meridian Medicaid,CPT,90993,Dialysis training incompl,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Meridian Medicaid,CPT,90997,Hemoperfusion,Nephrology,Per Unit,$540.95 ,OP,540.95,540.95,,,,,,
Meridian Medicaid,CPT,90999,Dialysis procedure,Nephrology,Per Unit,$540.95 ,OP,540.95,540.95,,,,,,
Meridian Medicaid,CPT,91010,Esophagus motility study,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Meridian Medicaid,CPT,91013,Esophgl motil w/stim/perfus,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Meridian Medicaid,CPT,91020,Gastric motility studies,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Meridian Medicaid,CPT,91022,Duodenal motility study,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Meridian Medicaid,CPT,91030,Acid perfusion of esophagus,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Meridian Medicaid,CPT,91034,Gastroesophageal reflux test,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Meridian Medicaid,CPT,91035,G-esoph reflx tst w/electrod,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Meridian Medicaid,CPT,91037,Esoph imped function test,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Meridian Medicaid,CPT,91038,Esoph imped funct test > 1hr,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Meridian Medicaid,CPT,91040,Esoph balloon distension tst,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Meridian Medicaid,CPT,91110,Gi tract capsule endoscopy,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
Meridian Medicaid,CPT,91111,Esophageal capsule endoscopy,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Meridian Medicaid,CPT,91112,Gi wireless capsule measure,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Meridian Medicaid,CPT,91117,Colon motility 6 hr study,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Meridian Medicaid,CPT,91120,Rectal sensation test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,91122,Anal pressure record,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,91132,Electrogastrography,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,91133,Electrogastrography w/test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,91200,Liver elastography,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,91299,Gastroenterology procedure,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Meridian Medicaid,CPT,91300,Sarscov2 vac 30mcg/0.3ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,91301,Sarscov2 vac 100mcg/0.5ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,91302,Coronavirus vaccine 3,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,91303,Coronavirus vaccine 4,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,91304,Coronavirus vaccine 5,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,91305,Coronavirus vaccine 6,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,91306,Coronavirus vaccine 7,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,91307,Coronavirus vaccine 8,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,91308,Coronavirus vaccine 9,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,91309,Coronavirus vaccine 10,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,91310,Coronavirus vaccine 11,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,92015,Determine refractive state,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92018,New eye exam & treatment,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Meridian Medicaid,CPT,92019,Eye exam & treatment,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Meridian Medicaid,CPT,92020,Special eye evaluation,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92025,Corneal topography,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92060,Special eye evaluation,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92065,Orthoptic/pleoptic training,Ancillary Services,Per Unit,$123.52 ,OP,123.52,123.52,,,,,,
Meridian Medicaid,CPT,92071,Contact lens fitting for tx,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92072,Fit contac lens for managmnt,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92081,Visual field examination(s),Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92082,Visual field examination(s),Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92083,Visual field examination(s),Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92100,Serial tonometry exam(s),Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92132,Cmptr ophth dx img ant segmt,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92133,Cmptr ophth img optic nerve,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92134,Cptr ophth dx img post segmt,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92136,Ophthalmic biometry,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92140,Glaucoma provocative tests,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92145,Corneal hysteresis deter,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92201,Opscpy extnd rta draw uni/bi,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92202,Opscpy extnd on/mac draw,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92225,Special eye exam initial,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92226,Special eye exam subsequent,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92227,Img rta detcj/mntr ds staff,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92228,Img rta detc/mntr ds phy/qhp,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Meridian Medicaid,CPT,92229,Img rta detc/mntr ds poc aly,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92230,Eye exam with photos,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Meridian Medicaid,CPT,92235,Fluorescein angrph uni/bi,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Meridian Medicaid,CPT,92240,Icg angiography uni/bi,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Meridian Medicaid,CPT,92242,Fluorescein icg angiography,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Meridian Medicaid,CPT,92250,Eye exam with photos,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92260,Ophthalmoscopy/dynamometry,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92265,Eye muscle evaluation,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92270,Electro-oculography,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Meridian Medicaid,CPT,92273,Full field erg w/i&r,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Meridian Medicaid,CPT,92274,Multifocal erg w/i&r,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Meridian Medicaid,CPT,92275,Electroretinography,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Meridian Medicaid,CPT,92283,Color vision examination,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92284,Dark adaptation eye exam,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92285,Eye photography,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92286,Internal eye photography,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92287,Internal eye photography,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92310,Contact lens fitting,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92311,Contact lens fitting,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92312,Contact lens fitting,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92313,Contact lens fitting,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92314,Prescription of contact lens,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92315,Rx cntact lens aphakia 1 eye,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92316,Rx cntact lens aphakia 2 eye,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92317,Rx corneoscleral cntact lens,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92325,Modification of contact lens,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92326,Replacement of contact lens,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92340,Fit spectacles monofocal,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92341,Fit spectacles bifocal,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92342,Fit spectacles multifocal,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92352,Fit aphakia spectcl monofocl,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92353,Fit aphakia spectcl multifoc,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92354,Fit spectacles single system,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92355,Fit spectacles compound lens,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92358,Aphakia prosth service temp,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92370,Repair & adjust spectacles,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92371,Repair & adjust spectacles,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92499,Eye service or procedure,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,92507,Speech/hearing therapy,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Meridian Medicaid,CPT,92516,Facial nerve function test,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
Meridian Medicaid,CPT,92517,Vemp test i&r cervical,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
Meridian Medicaid,CPT,92518,Vemp test i&r ocular,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
Meridian Medicaid,CPT,92519,Vemp tst i&r cervical&ocular,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
Meridian Medicaid,CPT,92520,Laryngeal function studies,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
Meridian Medicaid,CPT,92521,Evaluation of speech fluency,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Meridian Medicaid,CPT,92522,Evaluate speech production,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Meridian Medicaid,CPT,92523,Speech sound lang comprehen,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Meridian Medicaid,CPT,92524,Behavral qualit analys voice,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Meridian Medicaid,CPT,92534,Optokinetic nystagmus test,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
Meridian Medicaid,CPT,92537,Caloric vstblr test w/rec,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
Meridian Medicaid,CPT,92538,Caloric vstblr test w/rec,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
Meridian Medicaid,CPT,92540,Basic vestibular evaluation,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
Meridian Medicaid,CPT,92543,Caloric vestibular test,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
Meridian Medicaid,CPT,92546,Sinusoidal rotational test,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
Meridian Medicaid,CPT,92547,Supplemental electrical test,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
Meridian Medicaid,CPT,92548,Cdp-sot 6 cond w/i&r,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
Meridian Medicaid,CPT,92549,Cdp-sot 6 cond w/i&r mct&adt,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
Meridian Medicaid,CPT,92550,Tympanometry & reflex thresh,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Meridian Medicaid,CPT,92553,Audiometry air & bone,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Meridian Medicaid,CPT,92557,Comprehensive hearing test,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Meridian Medicaid,CPT,92558,Evoked auditory test qual,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Meridian Medicaid,CPT,92570,Acoustic immitance testing,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Meridian Medicaid,CPT,92572,Staggered spondaic word test,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Meridian Medicaid,CPT,92577,Stenger test speech,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Meridian Medicaid,CPT,92579,Visual audiometry (vra),Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Meridian Medicaid,CPT,92582,Conditioning play audiometry,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Meridian Medicaid,CPT,92584,Electrocochleography,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Meridian Medicaid,CPT,92585,Auditor evoke potent compre,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Meridian Medicaid,CPT,92586,Auditor evoke potent limit,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Meridian Medicaid,CPT,92587,Evoked auditory test limited,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Meridian Medicaid,CPT,92588,Evoked auditory tst complete,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Meridian Medicaid,CPT,92597,Oral speech device eval,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Meridian Medicaid,CPT,92601,Cochlear implt f/up exam <7,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,92602,Reprogram cochlear implt <7,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,92603,Cochlear implt f/up exam 7/>,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,92604,Reprogram cochlear implt 7/>,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,92605,Ex for nonspeech device rx,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Meridian Medicaid,CPT,92606,Non-speech device service,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,92607,Ex for speech device rx 1hr,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Meridian Medicaid,CPT,92608,Ex for speech device rx addl,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Meridian Medicaid,CPT,92610,Evaluate swallowing function,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Meridian Medicaid,CPT,92618,Ex for nonspeech dev rx add,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Meridian Medicaid,CPT,92620,Auditory function 60 min,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Meridian Medicaid,CPT,92621,Auditory function + 15 min,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Meridian Medicaid,CPT,92625,Tinnitus assessment,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Meridian Medicaid,CPT,92626,Eval aud funcj 1st hour,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Meridian Medicaid,CPT,92627,Eval aud funcj ea addl 15,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Meridian Medicaid,CPT,92630,Aud rehab pre-ling hear loss,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,92633,Aud rehab postling hear loss,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,92651,Aep hearing status deter i&r,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Meridian Medicaid,CPT,92652,Aep thrshld est mlt freq i&r,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Meridian Medicaid,CPT,92653,Aep neurodiagnostic i&r,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Meridian Medicaid,CPT,92920,Prq cardiac angioplast 1 art,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Meridian Medicaid,CPT,92921,Prq cardiac angio addl art,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Meridian Medicaid,CPT,92924,Prq card angio/athrect 1 art,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Meridian Medicaid,CPT,92925,Prq card angio/athrect addl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Meridian Medicaid,CPT,92928,Prq card stent w/angio 1 vsl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Meridian Medicaid,CPT,92929,Prq card stent w/angio addl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Meridian Medicaid,CPT,92933,Prq card stent/ath/angio,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Meridian Medicaid,CPT,92934,Prq card stent/ath/angio,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Meridian Medicaid,CPT,92937,Prq revasc byp graft 1 vsl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Meridian Medicaid,CPT,92938,Prq revasc byp graft addl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Meridian Medicaid,CPT,92941,Prq card revasc mi 1 vsl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Meridian Medicaid,CPT,92943,Prq card revasc chronic 1vsl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Meridian Medicaid,CPT,92944,Prq card revasc chronic addl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Meridian Medicaid,CPT,92950,Heart/lung resuscitation cpr,General Medicine,Per Unit,$385.17 ,OP,385.17,385.17,,,,,,
Meridian Medicaid,CPT,92953,Temporary external pacing,Cardiology,Per Unit,$347.43 ,OP,347.43,347.43,,,,,,
Meridian Medicaid,CPT,92960,Cardioversion electric ext,Cardiology,Per Unit,$347.43 ,OP,347.43,347.43,,,,,,
Meridian Medicaid,CPT,92961,Cardioversion electric int,Cardiology,Per Unit,$347.43 ,OP,347.43,347.43,,,,,,
Meridian Medicaid,CPT,92971,Cardioassist external,Cardiology,Per Unit,$347.43 ,OP,347.43,347.43,,,,,,
Meridian Medicaid,CPT,92973,Prq coronary mech thrombect,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Meridian Medicaid,CPT,92975,Dissolve clot heart vessel,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Meridian Medicaid,CPT,92977,Dissolve clot heart vessel,General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
Meridian Medicaid,CPT,92978,Endoluminl ivus oct c 1st,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,92979,Endoluminl ivus oct c ea,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,92986,Revision of aortic valve,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Meridian Medicaid,CPT,92987,Revision of mitral valve,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Meridian Medicaid,CPT,92990,Revision of pulmonary valve,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Meridian Medicaid,CPT,92997,Pul art balloon repr percut,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Meridian Medicaid,CPT,92998,Pul art balloon repr percut,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Meridian Medicaid,CPT,93000,Electrocardiogram complete,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Meridian Medicaid,CPT,93005,Electrocardiogram tracing,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Meridian Medicaid,CPT,93010,Electrocardiogram report,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Meridian Medicaid,CPT,93015,Cardiovascular stress test,Cardiology,Per Unit,$174.07 ,OP,174.07,174.07,,,,,,
Meridian Medicaid,CPT,93016,Cardiovascular stress test,Cardiology,Per Unit,$174.07 ,OP,174.07,174.07,,,,,,
Meridian Medicaid,CPT,93017,Cardiovascular stress test,Cardiology,Per Unit,$174.07 ,OP,174.07,174.07,,,,,,
Meridian Medicaid,CPT,93018,Cardiovascular stress test,Cardiology,Per Unit,$174.07 ,OP,174.07,174.07,,,,,,
Meridian Medicaid,CPT,93024,Cardiac drug stress test,Cardiology,Per Unit,$174.07 ,OP,174.07,174.07,,,,,,
Meridian Medicaid,CPT,93025,Microvolt t-wave assess,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,93040,Rhythm ecg with report,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Meridian Medicaid,CPT,93041,Rhythm ecg tracing,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Meridian Medicaid,CPT,93042,Rhythm ecg report,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Meridian Medicaid,CPT,93050,Art pressure waveform analys,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,93224,Ecg monit/reprt up to 48 hrs,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,93225,Ecg monit/reprt up to 48 hrs,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,93226,Ecg monit/reprt up to 48 hrs,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,93227,Ecg monit/reprt up to 48 hrs,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,93228,Remote 30 day ecg rev/report,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,93229,Remote 30 day ecg tech supp,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,93241,Ext ecg>48hr<7d rec scan a/r,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,93242,Ext ecg>48hr<7d recording,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,93243,Ext ecg>48hr<7d scan a/r,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,93244,Ext ecg>48hr<7d rev&interpj,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,93245,Ext ecg>7d<15d rec scan a/r,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,93246,Ext ecg>7d<15d recording,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,93247,Ext ecg>7d<15d scan a/r,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,93248,Ext ecg>7d<15d rev&interpj,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,93260,Prgrmg dev eval impltbl sys,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,93261,Interrogate subq defib,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,93264,Rem mntr wrls p-art prs snr,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,93268,Ecg record/review,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,93270,Remote 30 day ecg rev/report,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,93271,Ecg/monitoring and analysis,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,93272,Ecg/review interpret only,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,93278,Ecg/signal-averaged,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Meridian Medicaid,CPT,93279,Prgrmg dev eval pm/ldls pm,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,93280,Pm device progr eval dual,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,93281,Pm device progr eval multi,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,93282,Prgrmg eval implantable dfb,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,93283,Prgrmg eval implantable dfb,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,93284,Prgrmg eval implantable dfb,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,93285,Prgrmg dev eval scrms ip,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,93286,Peri-px eval pm/ldls pm ip,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,93287,Peri-px device eval & prgr,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,93288,Interrog evl pm/ldls pm ip,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,93289,Interrog device eval heart,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,93290,Interrog dev eval icpms ip,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,93291,Interrog dev eval scrms ip,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,93292,Wcd device interrogate,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,93293,Pm phone r-strip device eval,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,93294,Rem interrog evl pm/ldls pm,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,93295,Dev interrog remote 1/2/mlt,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,93296,Rem interrog evl pm/ids,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,93297,Rem interrog dev eval icpms,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,93298,Rem interrog dev eval scrms,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,93299,Interrog eval icpms/scrms,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,93303,Echo transthoracic,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Meridian Medicaid,CPT,93304,Echo transthoracic,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Meridian Medicaid,CPT,93306,Tte w/doppler complete,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Meridian Medicaid,CPT,93307,Tte w/o doppler complete,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Meridian Medicaid,CPT,93308,Tte f-up or lmtd,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Meridian Medicaid,CPT,93312,Echo transesophageal,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Meridian Medicaid,CPT,93313,Echo transesophageal,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Meridian Medicaid,CPT,93314,Echo transesophageal,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Meridian Medicaid,CPT,93315,Echo transesophageal,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Meridian Medicaid,CPT,93316,Echo transesophageal,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Meridian Medicaid,CPT,93317,Echo transesophageal,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Meridian Medicaid,CPT,93318,Echo transesophageal intraop,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Meridian Medicaid,CPT,93320,Doppler echo exam heart,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Meridian Medicaid,CPT,93321,Doppler echo exam heart,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Meridian Medicaid,CPT,93325,Doppler color flow add-on,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,93350,Stress tte only,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Meridian Medicaid,CPT,93351,Stress tte complete,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Meridian Medicaid,CPT,93352,Admin ecg contrast agent,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Meridian Medicaid,CPT,93355,Echo transesophageal (tee),Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Meridian Medicaid,CPT,93356,Myocrd strain img spckl trck,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Meridian Medicaid,CPT,93451,Right heart cath,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Meridian Medicaid,CPT,93452,Left hrt cath w/ventrclgrphy,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Meridian Medicaid,CPT,93453,R&l hrt cath w/ventriclgrphy,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Meridian Medicaid,CPT,93454,Coronary artery angio s&i,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Meridian Medicaid,CPT,93455,Coronary art/grft angio s&i,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Meridian Medicaid,CPT,93456,R hrt coronary artery angio,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Meridian Medicaid,CPT,93457,R hrt art/grft angio,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Meridian Medicaid,CPT,93458,L hrt artery/ventricle angio,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Meridian Medicaid,CPT,93459,L hrt art/grft angio,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Meridian Medicaid,CPT,93460,R&l hrt art/ventricle angio,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Meridian Medicaid,CPT,93461,R&l hrt art/ventricle angio,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Meridian Medicaid,CPT,93462,L hrt cath trnsptl puncture,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Meridian Medicaid,CPT,93464,Exercise w/hemodynamic meas,Cardiology,Per Unit,$174.07 ,OP,174.07,174.07,,,,,,
Meridian Medicaid,CPT,93505,Biopsy of heart lining,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Meridian Medicaid,CPT,93530,Rt heart cath congenital,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Meridian Medicaid,CPT,93531,R & l heart cath congenital,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Meridian Medicaid,CPT,93532,R & l heart cath congenital,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Meridian Medicaid,CPT,93533,R & l heart cath congenital,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Meridian Medicaid,CPT,93600,Bundle of his recording,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
Meridian Medicaid,CPT,93602,Intra-atrial recording,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
Meridian Medicaid,CPT,93603,Right ventricular recording,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
Meridian Medicaid,CPT,93609,Map tachycardia add-on,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
Meridian Medicaid,CPT,93610,Intra-atrial pacing,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
Meridian Medicaid,CPT,93612,Intraventricular pacing,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
Meridian Medicaid,CPT,93613,Electrophys map 3d add-on,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
Meridian Medicaid,CPT,93615,Esophageal recording,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
Meridian Medicaid,CPT,93616,Esophageal recording,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
Meridian Medicaid,CPT,93618,Heart rhythm pacing,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
Meridian Medicaid,CPT,93619,Electrophysiology evaluation,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
Meridian Medicaid,CPT,93620,Electrophysiology evaluation,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
Meridian Medicaid,CPT,93621,Electrophysiology evaluation,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
Meridian Medicaid,CPT,93622,Electrophysiology evaluation,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
Meridian Medicaid,CPT,93623,Stimulation pacing heart,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
Meridian Medicaid,CPT,93624,Electrophysiologic study,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
Meridian Medicaid,CPT,93631,Heart pacing mapping,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
Meridian Medicaid,CPT,93640,Evaluation heart device,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
Meridian Medicaid,CPT,93641,Electrophysiology evaluation,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
Meridian Medicaid,CPT,93642,Electrophysiology evaluation,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
Meridian Medicaid,CPT,93644,Electrophysiology evaluation,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
Meridian Medicaid,CPT,93650,Ablate heart dysrhythm focus,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
Meridian Medicaid,CPT,93653,Ep & ablate supravent arrhyt,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
Meridian Medicaid,CPT,93654,Ep & ablate ventric tachy,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
Meridian Medicaid,CPT,93655,Ablate arrhythmia add on,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
Meridian Medicaid,CPT,93656,Tx atrial fib pulm vein isol,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
Meridian Medicaid,CPT,93657,Tx l/r atrial fib addl,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
Meridian Medicaid,CPT,93660,Tilt table evaluation,Cardiology,Per Unit,$174.07 ,OP,174.07,174.07,,,,,,
Meridian Medicaid,CPT,93662,Intracardiac ecg (ice),Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
Meridian Medicaid,CPT,93668,Peripheral vascular rehab,Cardiology,Per Unit,$174.07 ,OP,174.07,174.07,,,,,,
Meridian Medicaid,CPT,93701,Bioimpedance cv analysis,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,93702,Bis xtracell fluid analysis,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,93724,Analyze pacemaker system,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Meridian Medicaid,CPT,93745,Set-up cardiovert-defibrill,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,93750,Interrogation vad in person,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,93770,Measure venous pressure,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,93784,Ambl bp mntr w/software,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,93786,Ambl bp mntr w/sw rec only,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,93788,Ambl bp mntr w/sw a/r,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,93790,Ambl bp mntr w/sw i&r,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,93792,Pt/caregiver traing home inr,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Meridian Medicaid,CPT,93793,Anticoag mgmt pt warfarin,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,93797,Cardiac rehab,Rehabilitation,Per Unit,$274.82 ,OP,274.82,274.82,,,,,,
Meridian Medicaid,CPT,93798,Cardiac rehab/monitor,Rehabilitation,Per Unit,$274.82 ,OP,274.82,274.82,,,,,,
Meridian Medicaid,CPT,93799,Cardiovascular procedure,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Meridian Medicaid,CPT,93880,Extracranial bilat study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,93882,Extracranial uni/ltd study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,93886,Intracranial complete study,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Meridian Medicaid,CPT,93888,Intracranial limited study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,93890,Tcd vasoreactivity study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,93892,Tcd emboli detect w/o inj,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Meridian Medicaid,CPT,93893,Tcd emboli detect w/inj,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,93895,Carotid intima atheroma eval,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,93922,Upr/l xtremity art 2 levels,Cardiology,Per Unit,$174.07 ,OP,174.07,174.07,,,,,,
Meridian Medicaid,CPT,93923,Upr/lxtr art stdy 3+ lvls,Cardiology,Per Unit,$174.07 ,OP,174.07,174.07,,,,,,
Meridian Medicaid,CPT,93924,Lwr xtr vasc stdy bilat,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,93925,Lower extremity study,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Meridian Medicaid,CPT,93926,Lower extremity study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,93930,Upper extremity study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,93931,Upper extremity study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,93965,Extremity study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,93970,Extremity study,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Meridian Medicaid,CPT,93971,Extremity study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,93975,Vascular study,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Meridian Medicaid,CPT,93976,Vascular study,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Meridian Medicaid,CPT,93978,Vascular study,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Meridian Medicaid,CPT,93979,Vascular study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,93980,Penile vascular study,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Meridian Medicaid,CPT,93981,Penile vascular study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,93982,Aneurysm pressure sens study,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,93985,Dup-scan hemo compl bi std,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,93986,Dup-scan hemo compl uni std,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,93990,Doppler flow testing,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,93998,Noninvas vasc dx study proc,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,94002,Vent mgmt inpat init day,Pulmonary,Per Unit,$417.61 ,OP,417.61,417.61,,,,,,
Meridian Medicaid,CPT,94003,Vent mgmt inpat subq day,Pulmonary,Per Unit,$417.61 ,OP,417.61,417.61,,,,,,
Meridian Medicaid,CPT,94004,Vent mgmt nf per day,Pulmonary,Per Unit,$417.61 ,OP,417.61,417.61,,,,,,
Meridian Medicaid,CPT,94005,Home vent mgmt supervision,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,94010,Breathing capacity test,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Meridian Medicaid,CPT,94011,Spirometry up to 2 yrs old,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Meridian Medicaid,CPT,94012,Spirmtry w/brnchdil inf-2 yr,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Meridian Medicaid,CPT,94013,Meas lung vol thru 2 yrs,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Meridian Medicaid,CPT,94014,Patient recorded spirometry,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Meridian Medicaid,CPT,94015,Patient recorded spirometry,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Meridian Medicaid,CPT,94016,Review patient spirometry,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Meridian Medicaid,CPT,94060,Evaluation of wheezing,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Meridian Medicaid,CPT,94070,Evaluation of wheezing,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Meridian Medicaid,CPT,94150,Vital capacity test,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Meridian Medicaid,CPT,94200,Lung function test (mbc/mvv),Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Meridian Medicaid,CPT,94250,Expired gas collection,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Meridian Medicaid,CPT,94375,Respiratory flow volume loop,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Meridian Medicaid,CPT,94400,Co2 breathing response curve,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Meridian Medicaid,CPT,94450,Hypoxia response curve,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Meridian Medicaid,CPT,94452,Hast w/report,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Meridian Medicaid,CPT,94453,Hast w/oxygen titrate,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Meridian Medicaid,CPT,94610,Surfactant admin thru tube,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
Meridian Medicaid,CPT,94617,Exercise tst brncspsm w/ecg,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Meridian Medicaid,CPT,94618,Pulmonary stress testing,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Meridian Medicaid,CPT,94619,Exercise tst brncspsm wo ecg,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Meridian Medicaid,CPT,94620,Pulmonary stress test/simple,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Meridian Medicaid,CPT,94621,Cardiopulm exercise testing,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Meridian Medicaid,CPT,94640,Airway inhalation treatment,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
Meridian Medicaid,CPT,94642,Aerosol inhalation treatment,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
Meridian Medicaid,CPT,94644,Cbt 1st hour,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
Meridian Medicaid,CPT,94645,Cbt each addl hour,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
Meridian Medicaid,CPT,94660,Pos airway pressure cpap,Pulmonary,Per Unit,$417.61 ,OP,417.61,417.61,,,,,,
Meridian Medicaid,CPT,94662,Neg press ventilation cnp,Pulmonary,Per Unit,$417.61 ,OP,417.61,417.61,,,,,,
Meridian Medicaid,CPT,94664,Evaluate pt use of inhaler,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
Meridian Medicaid,CPT,94667,Chest wall manipulation,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
Meridian Medicaid,CPT,94668,Chest wall manipulation,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
Meridian Medicaid,CPT,94669,Mechanical chest wall oscill,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
Meridian Medicaid,CPT,94680,Exhaled air analysis o2,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Meridian Medicaid,CPT,94681,Exhaled air analysis o2/co2,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Meridian Medicaid,CPT,94690,Exhaled air analysis,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Meridian Medicaid,CPT,94726,Pulm funct tst plethysmograp,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Meridian Medicaid,CPT,94727,Pulm function test by gas,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Meridian Medicaid,CPT,94728,Airwy resist by oscillometry,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Meridian Medicaid,CPT,94729,Co/membane diffuse capacity,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Meridian Medicaid,CPT,94750,Pulmonary compliance study,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Meridian Medicaid,CPT,94762,Measure blood oxygen level,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Meridian Medicaid,CPT,94770,Exhaled carbon dioxide test,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Meridian Medicaid,CPT,94772,Breath recording infant,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Meridian Medicaid,CPT,94774,Ped home apnea rec compl,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Meridian Medicaid,CPT,94775,Ped home apnea rec hk-up,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Meridian Medicaid,CPT,94776,Ped home apnea rec downld,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Meridian Medicaid,CPT,94777,Ped home apnea rec report,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Meridian Medicaid,CPT,94780,Cars/bd tst inft-12mo 60 min,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Meridian Medicaid,CPT,94781,Cars/bd tst inft-12mo +30min,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Meridian Medicaid,CPT,94799,Pulmonary service/procedure,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Meridian Medicaid,CPT,95004,Percut allergy skin tests,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
Meridian Medicaid,CPT,95012,Exhaled nitric oxide meas,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Meridian Medicaid,CPT,95017,Perq & icut allg test venoms,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
Meridian Medicaid,CPT,95018,Perq&ic allg test drugs/biol,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
Meridian Medicaid,CPT,95024,Icut allergy test drug/bug,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
Meridian Medicaid,CPT,95027,Icut allergy titrate-airborn,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
Meridian Medicaid,CPT,95028,Icut allergy test-delayed,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
Meridian Medicaid,CPT,95044,Allergy patch tests,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
Meridian Medicaid,CPT,95052,Photo patch test,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
Meridian Medicaid,CPT,95056,Photosensitivity tests,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
Meridian Medicaid,CPT,95060,Eye allergy tests,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
Meridian Medicaid,CPT,95065,Nose allergy test,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
Meridian Medicaid,CPT,95070,Bronchial allergy tests,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
Meridian Medicaid,CPT,95071,Bronchial allergy tests,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
Meridian Medicaid,CPT,95076,Ingest challenge ini 120 min,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Meridian Medicaid,CPT,95079,Ingest challenge addl 60 min,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Meridian Medicaid,CPT,95115,Immunotherapy one injection,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Meridian Medicaid,CPT,95117,Immunotherapy injections,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Meridian Medicaid,CPT,95120,Immunotherapy one injection,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Meridian Medicaid,CPT,95125,Immunotherapy 2/> injections,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Meridian Medicaid,CPT,95130,Immntx 1 sting insect,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Meridian Medicaid,CPT,95131,Immntx 2 sting insects,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Meridian Medicaid,CPT,95132,Immntx 3 sting insects,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Meridian Medicaid,CPT,95133,Immntx 4 sting insects,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Meridian Medicaid,CPT,95134,Immntx 5 sting insects,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Meridian Medicaid,CPT,95144,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Meridian Medicaid,CPT,95145,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Meridian Medicaid,CPT,95146,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Meridian Medicaid,CPT,95147,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Meridian Medicaid,CPT,95148,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Meridian Medicaid,CPT,95149,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Meridian Medicaid,CPT,95165,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Meridian Medicaid,CPT,95170,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Meridian Medicaid,CPT,95180,Rapid desensitization,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
Meridian Medicaid,CPT,95199,Allergy immunology services,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
Meridian Medicaid,CPT,95249,Cont gluc mntr pt prov eqp,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,95250,Cont gluc mntr phys/qhp eqp,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,95251,Cont gluc mntr analysis i&r,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,95700,Eeg cont rec w/vid eeg tech,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Meridian Medicaid,CPT,95705,Eeg w/o vid 2-12 hr unmntr,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Meridian Medicaid,CPT,95706,Eeg wo vid 2-12hr intmt mntr,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Meridian Medicaid,CPT,95707,Eeg w/o vid 2-12hr cont mntr,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Meridian Medicaid,CPT,95708,Eeg wo vid ea 12-26hr unmntr,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Meridian Medicaid,CPT,95709,Eeg w/o vid ea 12-26hr intmt,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Meridian Medicaid,CPT,95710,Eeg w/o vid ea 12-26hr cont,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Meridian Medicaid,CPT,95711,Veeg 2-12 hr unmonitored,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Meridian Medicaid,CPT,95712,Veeg 2-12 hr intmt mntr,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Meridian Medicaid,CPT,95713,Veeg 2-12 hr cont mntr,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Meridian Medicaid,CPT,95714,Veeg ea 12-26 hr unmntr,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Meridian Medicaid,CPT,95715,Veeg ea 12-26hr intmt mntr,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Meridian Medicaid,CPT,95716,Veeg ea 12-26hr cont mntr,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Meridian Medicaid,CPT,95717,Eeg phys/qhp 2-12 hr w/o vid,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Meridian Medicaid,CPT,95718,Eeg phys/qhp 2-12 hr w/veeg,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Meridian Medicaid,CPT,95719,Eeg phys/qhp ea incr w/o vid,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Meridian Medicaid,CPT,95720,Eeg phy/qhp ea incr w/veeg,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Meridian Medicaid,CPT,95721,Eeg phy/qhp>36<60 hr w/o vid,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Meridian Medicaid,CPT,95722,Eeg phy/qhp>36<60 hr w/veeg,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Meridian Medicaid,CPT,95723,Eeg phy/qhp>60<84 hr w/o vid,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Meridian Medicaid,CPT,95724,Eeg phy/qhp>60<84 hr w/veeg,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Meridian Medicaid,CPT,95725,Eeg phy/qhp>84 hr w/o vid,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Meridian Medicaid,CPT,95726,Eeg phy/qhp>84 hr w/veeg,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Meridian Medicaid,CPT,95782,Polysom <6 yrs 4/> paramtrs,Pulmonary,Per Unit,$437.56 ,OP,437.56,437.56,,,,,,
Meridian Medicaid,CPT,95783,Polysom <6 yrs cpap/bilvl,Pulmonary,Per Unit,$437.56 ,OP,437.56,437.56,,,,,,
Meridian Medicaid,CPT,95803,Actigraphy testing,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,95805,Multiple sleep latency test,Pulmonary,Per Unit,$437.56 ,OP,437.56,437.56,,,,,,
Meridian Medicaid,CPT,95807,Sleep study attended,Pulmonary,Per Unit,$437.56 ,OP,437.56,437.56,,,,,,
Meridian Medicaid,CPT,95808,Polysom any age 1-3> param,Pulmonary,Per Unit,$437.56 ,OP,437.56,437.56,,,,,,
Meridian Medicaid,CPT,95810,Polysom 6/> yrs 4/> param,Pulmonary,Per Unit,$437.56 ,OP,437.56,437.56,,,,,,
Meridian Medicaid,CPT,95811,Polysom 6/>yrs cpap 4/> parm,Pulmonary,Per Unit,$437.56 ,OP,437.56,437.56,,,,,,
Meridian Medicaid,CPT,95812,Eeg 41-60 minutes,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Meridian Medicaid,CPT,95813,Eeg extnd mntr 61-119 min,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Meridian Medicaid,CPT,95816,Eeg awake and drowsy,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Meridian Medicaid,CPT,95819,Eeg awake and asleep,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Meridian Medicaid,CPT,95822,Eeg coma or sleep only,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Meridian Medicaid,CPT,95824,Eeg cerebral death only,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Meridian Medicaid,CPT,95827,Eeg all night recording,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Meridian Medicaid,CPT,95829,Surgery electrocorticogram,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Meridian Medicaid,CPT,95836,Ecog impltd brn npgt <30 d,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Meridian Medicaid,CPT,95857,Cholinesterase challenge,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,95860,Muscle test one limb,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,95861,Muscle test 2 limbs,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,95863,Muscle test 3 limbs,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,95864,Muscle test 4 limbs,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,95865,Muscle test larynx,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,95866,Muscle test hemidiaphragm,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,95867,Muscle test cran nerv unilat,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,95868,Muscle test cran nerve bilat,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,95869,Muscle test thor paraspinal,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,95870,Muscle test nonparaspinal,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,95872,Muscle test one fiber,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,95873,Guide nerv destr elec stim,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Meridian Medicaid,CPT,95874,Guide nerv destr needle emg,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Meridian Medicaid,CPT,95875,Limb exercise test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,95885,Musc tst done w/nerv tst lim,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,95886,Musc test done w/n test comp,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,95887,Musc tst done w/n tst nonext,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,95905,Motor &/ sens nrve cndj test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,95907,Nvr cndj tst 1-2 studies,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,95908,Nrv cndj tst 3-4 studies,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,95909,Nrv cndj tst 5-6 studies,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,95910,Nrv cndj test 7-8 studies,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,95911,Nrv cndj test 9-10 studies,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,95912,Nrv cndj test 11-12 studies,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,95913,Nrv cndj test 13/> studies,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,95921,Autonomic nrv parasym inervj,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,95922,Autonomic nrv adrenrg inervj,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,95923,Autonomic nrv syst funj test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,95924,Ans parasymp & symp w/tilt,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,95925,Somatosensory testing,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,95926,Somatosensory testing,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,95927,Somatosensory testing,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,95928,C motor evoked uppr limbs,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,95929,C motor evoked lwr limbs,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,95930,Visual ep test cns w/i&r,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,95933,Blink reflex test,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,95937,Neuromuscular junction test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,95938,Somatosensory testing,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,95939,C motor evoked upr&lwr limbs,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,95943,Parasymp&symp hrt rate test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,95950,Ambulatory eeg monitoring,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Meridian Medicaid,CPT,95951,Eeg monitoring/videorecord,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Meridian Medicaid,CPT,95953,Eeg monitoring/computer,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Meridian Medicaid,CPT,95954,Eeg monitoring/giving drugs,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Meridian Medicaid,CPT,95955,Eeg during surgery,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Meridian Medicaid,CPT,95956,Eeg monitor technol attended,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Meridian Medicaid,CPT,95957,Eeg digital analysis,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,95958,Eeg monitoring/function test,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Meridian Medicaid,CPT,95965,Meg spontaneous,Diagnostic Radiology,Per Unit,$221.34 ,OP,221.34,221.34,,,,,,
Meridian Medicaid,CPT,95966,Meg evoked single,Diagnostic Radiology,Per Unit,$221.34 ,OP,221.34,221.34,,,,,,
Meridian Medicaid,CPT,95967,Meg evoked each addl,Diagnostic Radiology,Per Unit,$221.34 ,OP,221.34,221.34,,,,,,
Meridian Medicaid,CPT,95970,Alys npgt w/o prgrmg,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Meridian Medicaid,CPT,95971,Alys smpl sp/pn npgt w/prgrm,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Meridian Medicaid,CPT,95972,Alys cplx sp/pn npgt w/prgrm,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Meridian Medicaid,CPT,95973,Analyze neurostim complex,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Meridian Medicaid,CPT,95974,Cranial neurostim complex,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Meridian Medicaid,CPT,95975,Cranial neurostim complex,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Meridian Medicaid,CPT,95976,Alys smpl cn npgt prgrmg,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Meridian Medicaid,CPT,95977,Alys cplx cn npgt prgrmg,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Meridian Medicaid,CPT,95978,Analyze neurostim brain/1h,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Meridian Medicaid,CPT,95979,Analyz neurostim brain addon,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Meridian Medicaid,CPT,95980,Io anal gast n-stim init,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Meridian Medicaid,CPT,95981,Io anal gast n-stim subsq,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,95982,Io ga n-stim subsq w/reprog,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,95983,Alys brn npgt prgrmg 15 min,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Meridian Medicaid,CPT,95984,Alys brn npgt prgrmg addl 15,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Meridian Medicaid,CPT,95999,Neurological procedure,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Meridian Medicaid,CPT,96000,Motion analysis video/3d,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,96001,Motion test w/ft press meas,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,96002,Dynamic surface emg,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,96003,Dynamic fine wire emg,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,96020,Functional brain mapping,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Meridian Medicaid,CPT,96101,Psycho testing by psych/phys,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Meridian Medicaid,CPT,96102,Psycho testing by technician,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Meridian Medicaid,CPT,96103,Psycho testing admin by comp,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Meridian Medicaid,CPT,96105,Assessment of aphasia,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Meridian Medicaid,CPT,96110,Developmental screen w/score,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Meridian Medicaid,CPT,96111,Developmental test extend,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Meridian Medicaid,CPT,96112,Devel tst phys/qhp 1st hr,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Meridian Medicaid,CPT,96113,Devel tst phys/qhp ea addl,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Meridian Medicaid,CPT,96116,Nubhvl xm phys/qhp 1st hr,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Meridian Medicaid,CPT,96118,Neuropsych tst by psych/phys,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Meridian Medicaid,CPT,96119,Neuropsych testing by tec,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Meridian Medicaid,CPT,96120,Neuropsych tst admin w/comp,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Meridian Medicaid,CPT,96121,Nubhvl xm phy/qhp ea addl hr,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Meridian Medicaid,CPT,96125,Cognitive test by hc pro,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Meridian Medicaid,CPT,96127,Brief emotional/behav assmt,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Meridian Medicaid,CPT,96130,Psycl tst eval phys/qhp 1st,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Meridian Medicaid,CPT,96131,Psycl tst eval phys/qhp ea,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Meridian Medicaid,CPT,96132,Nrpsyc tst eval phys/qhp 1st,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Meridian Medicaid,CPT,96133,Nrpsyc tst eval phys/qhp ea,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Meridian Medicaid,CPT,96136,Psycl/nrpsyc tst phy/qhp 1st,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Meridian Medicaid,CPT,96137,Psycl/nrpsyc tst phy/qhp ea,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Meridian Medicaid,CPT,96138,Psycl/nrpsyc tech 1st,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Meridian Medicaid,CPT,96139,Psycl/nrpsyc tst tech ea,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Meridian Medicaid,CPT,96146,Psycl/nrpsyc tst auto result,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Meridian Medicaid,CPT,96150,Assess hlth/behave init,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
Meridian Medicaid,CPT,96151,Assess hlth/behave subseq,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
Meridian Medicaid,CPT,96153,Intervene hlth/behave group,Behavioral Health,Per Unit,$119.88 ,OP,119.88,119.88,,,,,,
Meridian Medicaid,CPT,96154,Interv hlth/behav fam w/pt,Behavioral Health,Per Unit,$89.14 ,OP,89.14,89.14,,,,,,
Meridian Medicaid,CPT,96155,Interv hlth/behav fam no pt,Behavioral Health,Per Unit,$89.14 ,OP,89.14,89.14,,,,,,
Meridian Medicaid,CPT,96156,Hlth bhv assmt/reassessment,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
Meridian Medicaid,CPT,96160,Pt-focused hlth risk assmt,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Meridian Medicaid,CPT,96161,Caregiver health risk assmt,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Meridian Medicaid,CPT,96360,Hydration iv infusion init,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Meridian Medicaid,CPT,96361,Hydrate iv infusion add-on,General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
Meridian Medicaid,CPT,96365,Ther/proph/diag iv inf init,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Meridian Medicaid,CPT,96366,Ther/proph/diag iv inf addon,General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
Meridian Medicaid,CPT,96367,Tx/proph/dg addl seq iv inf,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Meridian Medicaid,CPT,96368,Ther/diag concurrent inf,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Meridian Medicaid,CPT,96369,Sc ther infusion up to 1 hr,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Meridian Medicaid,CPT,96370,Sc ther infusion addl hr,General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
Meridian Medicaid,CPT,96371,Sc ther infusion reset pump,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Meridian Medicaid,CPT,96413,Chemo iv infusion 1 hr,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Meridian Medicaid,CPT,96415,Chemo iv infusion addl hr,General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
Meridian Medicaid,CPT,96416,Chemo prolong infuse w/pump,General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
Meridian Medicaid,CPT,96417,Chemo iv infus each addl seq,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Meridian Medicaid,CPT,96422,Chemo ia infusion up to 1 hr,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Meridian Medicaid,CPT,96423,Chemo ia infuse each addl hr,General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
Meridian Medicaid,CPT,96425,Chemotherapy infusion method,General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
Meridian Medicaid,CPT,96446,Chemotx admn prtl cavity,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Meridian Medicaid,CPT,96450,Chemotherapy into cns,General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
Meridian Medicaid,CPT,96549,Chemotherapy unspecified,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Meridian Medicaid,CPT,96567,Pdt dstr prmlg les skn,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,96570,Photodynmc tx 30 min add-on,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,96571,Photodynamic tx addl 15 min,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,96573,Pdt dstr prmlg les phys/qhp,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,96574,Dbrdmt prmlg les w/pdt,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,96900,Ultraviolet light therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,96902,Trichogram,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,96913,Photochemotherapy uv-a or b,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,96920,Laser tx skin < 250 sq cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,96921,Laser tx skin 250-500 sq cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,96922,Laser tx skin >500 sq cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,96931,Rcm celulr subcelulr img skn,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,96932,Rcm celulr subcelulr img skn,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,96933,Rcm celulr subcelulr img skn,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,96934,Rcm celulr subcelulr img skn,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,96935,Rcm celulr subcelulr img skn,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,96936,Rcm celulr subcelulr img skn,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,96999,Dermatological procedure,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,97001,Pt evaluation,Rehabilitation,Per Unit,$192.71 ,OP,192.71,192.71,,,,,,
Meridian Medicaid,CPT,97002,Pt re-evaluation,Rehabilitation,Per Unit,$192.71 ,OP,192.71,192.71,,,,,,
Meridian Medicaid,CPT,97003,Ot evaluation,Rehabilitation,Per Unit,$306.55 ,OP,306.55,306.55,,,,,,
Meridian Medicaid,CPT,97004,Ot re-evaluation,Rehabilitation,Per Unit,$306.55 ,OP,306.55,306.55,,,,,,
Meridian Medicaid,CPT,97010,Hot or cold packs therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,97012,Mechanical traction therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,97014,Electric stimulation therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,97016,Vasopneumatic device therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,97018,Paraffin bath therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,97022,Whirlpool therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,97024,Diathermy eg microwave,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,97026,Infrared therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,97028,Ultraviolet therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,97032,Electrical stimulation,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,97033,Electric current therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,97034,Contrast bath therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,97035,Ultrasound therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,97039,Physical therapy treatment,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,97116,Gait training therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,97124,Massage therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,97139,Physical medicine procedure,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,97161,Pt eval low complex 20 min,Rehabilitation,Per Unit,$192.71 ,OP,192.71,192.71,,,,,,
Meridian Medicaid,CPT,97162,Pt eval mod complex 30 min,Rehabilitation,Per Unit,$192.71 ,OP,192.71,192.71,,,,,,
Meridian Medicaid,CPT,97163,Pt eval high complex 45 min,Rehabilitation,Per Unit,$192.71 ,OP,192.71,192.71,,,,,,
Meridian Medicaid,CPT,97164,Pt re-eval est plan care,Rehabilitation,Per Unit,$192.71 ,OP,192.71,192.71,,,,,,
Meridian Medicaid,CPT,97165,Ot eval low complex 30 min,Rehabilitation,Per Unit,$306.55 ,OP,306.55,306.55,,,,,,
Meridian Medicaid,CPT,97166,Ot eval mod complex 45 min,Rehabilitation,Per Unit,$306.55 ,OP,306.55,306.55,,,,,,
Meridian Medicaid,CPT,97167,Ot eval high complex 60 min,Rehabilitation,Per Unit,$306.55 ,OP,306.55,306.55,,,,,,
Meridian Medicaid,CPT,97168,Ot re-eval est plan care,Rehabilitation,Per Unit,$306.55 ,OP,306.55,306.55,,,,,,
Meridian Medicaid,CPT,97535,Self care mngment training,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,97545,Work hardening,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,97546,Work hardening add-on,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,97755,Assistive technology assess,Rehabilitation,Per Unit,$192.71 ,OP,192.71,192.71,,,,,,
Meridian Medicaid,CPT,97762,C/o for orthotic/prosth use,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,97799,Physical medicine procedure,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,97802,Medical nutrition indiv in,Ancillary Services,Per Unit,$100.15 ,OP,100.15,100.15,,,,,,
Meridian Medicaid,CPT,97803,Med nutrition indiv subseq,Ancillary Services,Per Unit,$100.15 ,OP,100.15,100.15,,,,,,
Meridian Medicaid,CPT,97804,Medical nutrition group,Ancillary Services,Per Unit,$100.15 ,OP,100.15,100.15,,,,,,
Meridian Medicaid,CPT,97810,Acupunct w/o stimul 15 min,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,97811,Acupunct w/o stimul addl 15m,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,97813,Acupunct w/stimul 15 min,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,97814,Acupunct w/stimul addl 15m,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,98925,Osteopath manj 1-2 regions,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,98926,Osteopath manj 3-4 regions,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,98927,Osteopath manj 5-6 regions,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,98928,Osteopath manj 7-8 regions,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,98929,Osteopath manj 9-10 regions,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,98940,Chiropract manj 1-2 regions,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,98941,Chiropract manj 3-4 regions,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,98942,Chiropractic manj 5 regions,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,98943,Chiropract manj xtrspinl 1/>,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,98960,Self-mgmt educ & train 1 pt,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Meridian Medicaid,CPT,98961,Self-mgmt educ/train 2-4 pt,Preventive Care,Per Unit,$26.23 ,OP,26.23,26.23,,,,,,
Meridian Medicaid,CPT,98962,Self-mgmt educ/train 5-8 pt,Preventive Care,Per Unit,$26.23 ,OP,26.23,26.23,,,,,,
Meridian Medicaid,CPT,99050,Medical services after hrs,Ancillary Services,Per Unit,$26.19 ,OP,26.19,26.19,,,,,,
Meridian Medicaid,CPT,99051,Med serv eve/wkend/holiday,Ancillary Services,Per Unit,$26.19 ,OP,26.19,26.19,,,,,,
Meridian Medicaid,CPT,99053,Med serv 10pm-8am 24 hr fac,Ancillary Services,Per Unit,$26.19 ,OP,26.19,26.19,,,,,,
Meridian Medicaid,CPT,99058,Office emergency care,Ancillary Services,Per Unit,$26.19 ,OP,26.19,26.19,,,,,,
Meridian Medicaid,CPT,99060,Out of office emerg med serv,Ancillary Services,Per Unit,$26.19 ,OP,26.19,26.19,,,,,,
Meridian Medicaid,CPT,99078,Group health education,Preventive Care,Per Unit,$26.23 ,OP,26.23,26.23,,,,,,
Meridian Medicaid,CPT,99091,Collj & interpj data ea 30 d,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,99100,Special anesthesia service,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,99116,Anesthesia with hypothermia,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,99135,Special anesthesia procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,99140,Emergency anesthesia,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,99143,Mod sedat phys/qhp <5 yrs,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,99144,Mod sedat phys/qhp 5yrs/>,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,99145,Mod sedat phys/qhp ea 15 min,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,99148,Mod sed diff phys/qhp<5 yrs,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,99149,Mod sed diff phys/qhp 5/>yrs,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,99150,Mod sed diff phys/qhp add on,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,99151,Mod sed same phys/qhp <5 yrs,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,99152,Mod sed same phys/qhp 5/>yrs,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,99153,Mod sed same phys/qhp ea,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,99155,Mod sed oth phys/qhp <5 yrs,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,99156,Mod sed oth phys/qhp 5/>yrs,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,99157,Mod sed other phys/qhp ea,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,99172,Ocular function screen,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,99173,Visual acuity screen,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,99174,Ocular instrumnt screen bil,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,99175,Induction of vomiting,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Meridian Medicaid,CPT,99177,Ocular instrumnt screen bil,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,99188,App topical fluoride varnish,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Meridian Medicaid,CPT,99238,Hospital discharge day,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,99239,Hospital discharge day,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,99363,Anticoagulant mgmt initial,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,99364,Anticoagulant mgmt subseq,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,99366,Team conf w/pat by hc prof,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,99367,Team conf w/o pat by phys,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,99368,Team conf w/o pat by hc pro,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,99374,Home health care supervision,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,99375,Home health care supervision,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,99377,Hospice care supervision,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,99378,Hospice care supervision,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,99379,Nursing fac care supervision,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,99380,Nursing fac care supervision,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,99406,Behav chng smoking 3-10 min,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Meridian Medicaid,CPT,99407,Behav chng smoking > 10 min,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Meridian Medicaid,CPT,99408,Audit/dast 15-30 min,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Meridian Medicaid,CPT,99409,Audit/dast over 30 min,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Meridian Medicaid,CPT,99439,Chrnc care mgmt svc ea addl,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,99453,Rem mntr physiol param setup,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Meridian Medicaid,CPT,99454,Rem mntr physiol param dev,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,99457,Rem physiol mntr 1st 20 min,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,99458,Rem physiol mntr ea addl 20,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,99465,Nb resuscitation,General Medicine,Per Unit,$385.17 ,OP,385.17,385.17,,,,,,
Meridian Medicaid,CPT,99473,Self-meas bp pt educaj/train,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,99474,Self-meas bp 2 readg bid 30d,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,99483,Assmt & care pln pt cog imp,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Meridian Medicaid,CPT,99484,Care mgmt svc bhvl hlth cond,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Meridian Medicaid,CPT,99487,Cplx chrnc care 1st 60 min,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,99489,Cplx chrnc care ea addl 30,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,99490,Chrnc care mgmt svc 1st 20,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,99491,Chrnc care mgmt svc 30 min,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,99492,1st psyc collab care mgmt,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Meridian Medicaid,CPT,99493,Sbsq psyc collab care mgmt,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Meridian Medicaid,CPT,99494,1st/sbsq psyc collab care,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Meridian Medicaid,CPT,99495,Trans care mgmt 14 day disch,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,99496,Trans care mgmt 7 day disch,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,99497,Advncd care plan 30 min,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,99498,Advncd care plan addl 30 min,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,99503,Home visit resp therapy,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
Meridian Medicaid,CPT,99504,Home visit mech ventilator,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
Meridian Medicaid,CPT,0001A,Adm sarscov2 30mcg/0.3ml 1st,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,0001M,Nfct ds chrnc hcv 6 assays,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,0001U,Rbc dna hea 35 ag 11 bld grp,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0002A,Adm sarscov2 30mcg/0.3ml 2nd,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,0002M,Liver dis 10 assays w/ash,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0002U,Onc clrct 3 ur metab alg plp,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0003A,Fee covid-19 vac 1 booster,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,0003M,Liver dis 10 assays w/nash,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0003U,Onc ovar 5 prtn ser alg scor,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0004A,Fee covid-19 vac 1 res,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,0004M,Scoliosis dna alys,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0004U,Nfct ds dna 27 resist genes,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0005U,Onco prst8 3 gene ur alg,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0006M,Onc hep gene risk classifier,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0006U,Detc ia meds 120+ analytes,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,0007M,Onc gastro 51 gene nomogram,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,0008M,Onc breast risk score,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0008U,Hpylori detcj abx rstnc dna,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Meridian Medicaid,CPT,0009M,Fetal aneuploidy trisom risk,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0009U,Onc brst ca erbb2 amp/nonamp,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0010M,Onc prostate prob score,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0010U,Nfct ds strn typ whl gen seq,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0011A,Adm sarscov2 100mcg/0.5ml1st,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,0011M,Onc prst8 ca mrna 12 gen alg,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0011U,Rx mntr lc-ms/ms oral fluid,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,0012A,Adm sarscov2 100mcg/0.5ml2nd,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,0012M,Onc mrna 5 gen rsk urthl ca,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0012U,Germln do gene reargmt detcj,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0013A,Fee covid-19 vac 2 booster,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,0013M,Onc mrna 5 gen recr urthl ca,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0013U,Onc sld org neo gene reargmt,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0014A,Fee covid-19 vac 2 res,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,0014M,Liver ds alys 3 bmrk srm alg,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0014U,Hem hmtlmf neo gene reargmt,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0015M,Adrnl cortcl tum bchm asy 25,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0015U,Rx metab advrs rx rxn dna,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0016M,Onc bladder mrna 209 gen alg,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0016U,Onc hmtlmf neo rna bcr/abl1,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,0017M,Onc dlbcl mrna 20 genes alg,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0017U,Onc hmtlmf neo jak2 mut dna,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0018U,Onc thyr 10 microrna seq alg,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0019T,Extracorp shock wv tx ms nos,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,0019U,Onc rna tiss predict alg,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0020U,Rx test prsmv ur w/def conf,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,0021A,Fee covid-19 vac 3 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,0021U,Onc prst8 detcj 8 autoantb,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0022A,Fee covid-19 vac 3 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,0022U,Trgt gen seq dna&rna 23 gene,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0023A,Fee covid-19 vac 3 booster,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,0023U,Onc aml dna detcj/nondetcj,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,0024A,Fee covid-19 vac 3 res,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,0024U,Glyca nuc mr spectrsc quan,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,0025U,Tenofovir liq chrom ur quan,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,0026U,Onc thyr dna&mrna 112 genes,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0027U,Jak2 gene trgt seq alys,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0028U,Cyp2d6 gene cpy nmr cmn vrnt,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0029U,Rx metab advrs trgt seq alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0030U,Rx metab warf trgt seq alys,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0031A,Fee covid-19 vac 4 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,0031U,Cyp1a2 gene,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,0032A,Fee covid-19 vac 4 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,0032U,Comt gene,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,0033A,Fee covid-19 vac 4 booster,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,0033U,Htr2a htr2c genes,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0034A,Fee covid-19 vac 4 res,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,0034U,Tpmt nudt15 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0035U,Neuro csf prion prtn qual,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0036U,Xome tum & nml spec seq alys,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0037U,Trgt gen seq dna 324 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0038U,Vitamin d srm microsamp quan,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,0039U,Dna antb 2strand hi avidity,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,0040U,Bcr/abl1 gene major bp quan,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0041A,Fee covid-19 vac 5 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,0041U,B brgdrferi antb 5 prtn igm,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Meridian Medicaid,CPT,0042A,Fee covid-19 vac 5 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,0042T,Ct perfusion w/contrast cbf,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Meridian Medicaid,CPT,0042U,B brgdrferi antb 12 prtn igg,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Meridian Medicaid,CPT,0043A,Fee covid-19 vac 5 booster,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,0043U,Tbrf b grp antb 4 prtn igm,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,0044A,Fee covid-19 vac 5 res,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,0044U,Tbrf b grp antb 4 prtn igg,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,0045U,Onc brst dux carc is 12 gene,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,0046U,Flt3 gene itd variants quan,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,0047U,Onc prst8 mrna 17 gene alg,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0048U,Onc sld org neo dna 468 gene,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0049U,Npm1 gene analysis quan,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,0050U,Trgt gen seq dna 194 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0051A,Fee covid-19 vac 6 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,0051U,Rx mntr lc-ms/ms ur 31 pnl,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,0052A,Fee covid-19 vac 6 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,0052U,Lpoprtn bld w/5 maj classes,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,0053A,Fee covid-19 vac 6 booster,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,0053U,Onc prst8 ca fish alys 4 gen,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0054A,Fee covid-19 vac 6 res,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,0054U,Rx mntr 14+ drugs & sbsts,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,0055U,Card hrt trnspl 96 dna seq,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0056U,Hem aml dna gene reargmt,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0057U,Onc sld org neo mrna 51 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0058T,Cryopreservation ovary tiss,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,0058U,Onc merkel cll carc srm quan,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Meridian Medicaid,CPT,0059U,Onc merkel cll carc srm +/-,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Meridian Medicaid,CPT,0060U,Twn zyg gen seq alys chrms2,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0061A,Fee covid-19 vac 7 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,0061U,Tc meas 5 bmrk sfdi m-s alys,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
Meridian Medicaid,CPT,0062A,Fee covid-19 vac 7 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,0062U,Ai sle igg&igm alys 80 bmrk,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,0063A,Fee covid-19 vac 7 booster,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,0063U,Neuro autism 32 amines alg,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0064A,Fee covid-19 vac 7 res,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,0064U,Antb tp total&rpr ia qual,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,0065U,Syfls tst nontreponemal antb,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,0066U,Pamg-1 ia cervico-vag fluid,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,0067U,Onc brst imhchem prfl 4 bmrk,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,0069U,Onc clrct microrna mir-31-3p,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,0070U,Cyp2d6 gen com&slct rar vrnt,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0071A,Fee covid-19 vac 8 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,0071U,Cyp2d6 full gene sequence,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,0072A,Fee covid-19 vac 8 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,0072U,Cyp2d6 gen cyp2d6-2d7 hybrid,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0073A,Fee covid-19 vac 8 booster,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,0073U,Cyp2d6 gen cyp2d7-2d6 hybrid,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0074A,Fee covid-19 vac 8 res,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,0074U,Cyp2d6 nonduplicated gene,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0075T,Perq stent/chest vert art,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,0075U,Cyp2d6 5' gene dup/mlt,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0076T,S&i stent/chest vert art,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,0076U,Cyp2d6 3' gene dup/mlt,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0077U,Ig paraprotein qual bld/ur,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Meridian Medicaid,CPT,0078U,Pain mgt opi use gnotyp pnl,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,0079U,Cmprtv dna alys mlt snps,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0080U,Onc lng 5 clin rsk factr alg,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0081A,Fee covid-19 vac 9 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,0081U,Onc uveal mlnma mrna 15 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0082A,Fee covid-19 vac 9 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,0083A,Fee covid-19 vac 9 booster,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,0083U,Onc rspse chemo cntrst tomog,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,0084A,Fee covid-19 vac 9 res,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,0084U,Rbc dna gnotyp 10 bld groups,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0085T,Breath test heart reject,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,0085U,Cdtb&vinculin igg antb ia,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Meridian Medicaid,CPT,0086U,Nfct ds bact&fng org id 6+,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,0087U,Crd hrt trnspl mrna 1283 gen,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0088U,Trnsplj kdn algrft rej 1494,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0089U,Onc mlnma prame & linc00518,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0090U,Onc cutan mlnma mrna 23 gene,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0091A,Fee covid-19 vac 10 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,0091U,Onc clrct scr whl bld alg,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Meridian Medicaid,CPT,0092A,Fee covid-19 vac 10 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,0092U,Onc lng 3 prtn bmrk plsm alg,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0093A,Fee covid-19 vac 10 booster,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,0093U,Rx mntr 65 com drugs urine,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,0094A,Fee covid-19 vac 10 res,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,0094U,Genome rapid sequence alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0095U,Inflm ee elisa alys alg,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0096U,Hpv hi risk types male urine,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,0099T,Implant corneal ring,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Meridian Medicaid,CPT,0100T,Prosth retina receive&gen,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Meridian Medicaid,CPT,0101A,Fee covid-19 vac 11 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,0101T,Extracorp shockwv tx hi enrg,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Meridian Medicaid,CPT,0101U,Hered colon ca do 15 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0102A,Fee covid-19 vac 11 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,0102U,Hered brst ca rltd do 17 gen,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0103A,Fee covid-19 vac 11 booster,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,0103T,Holotranscobalamin,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,0103U,Hered ova ca pnl 24 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0104A,Fee covid-19 vac 11 res,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,0104U,Hered pan ca pnl 32 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0105U,Neph ckd mult eclia tum nec,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0106T,Touch quant sensory test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,0107T,Vibrate quant sensory test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,0107U,C diff tox ag detcj ia stool,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,0108T,Cool quant sensory test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,0108U,Gi barrett esoph 9 prtn bmrk,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0109T,Heat quant sensory test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,0109U,Id aspergillus dna 4 species,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,0110T,Nos quant sensory test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,0110U,Rx mntr 1+oral onc rx&sbsts,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,0111T,Rbc membranes fatty acids,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Meridian Medicaid,CPT,0111U,Onc colon ca kras&nras alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0112U,Iadi 16s&18s rrna genes,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,0113U,Onc prst8 pca3&tmprss2-erg,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0114U,Gi barretts esoph vim&ccna1,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0115U,Respir iadna 18 viral&2 bact,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,0116U,Rx mntr nzm ia 35+oral flu,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,0117U,Pain mgmt 11 endogenous anal,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0118U,Trnsplj don-drv cll-fr dna,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0119U,Crd ceramides liq chrom plsm,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,0120U,Onc b cll lymphm mrna 58 gen,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0121U,Sc dis vcam-1 whole blood,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
Meridian Medicaid,CPT,0122U,Sc dis p-selectin whl blood,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
Meridian Medicaid,CPT,0123T,Scleral fistulization,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Meridian Medicaid,CPT,0123U,Mchnl fragility rbc prflg,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Meridian Medicaid,CPT,0124U,Ftl cgen abnor 3 analytes,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0125U,Ftl cgen abnor prnt comp 5,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0126T,Chd risk imt study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,0126U,Ftl cgen abnor prnt comp 5 y,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0127U,Ob pe 3 analytes,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0128U,Ob pe 3 analytes y chrmsm,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0129U,Hered brst ca rltd do panel,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0130U,Hered colon ca do mrna pnl,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0131U,Hered brst ca rltd do pnl 13,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0132U,Hered ova ca rltd do pnl 17,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0133U,Hered prst8 ca rltd do 11,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0134U,Hered pan ca mrna pnl 18 gen,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0135U,Hered gyn ca mrna pnl 12 gen,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0136U,Atm mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0137U,Palb2 mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0138U,Brca1 brca2 mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0139U,Neuro austm meas 6 c metablt,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0140U,Nfct ds fungi dna 15 trgt,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,0141U,Nfct ds bact&fng gram pos,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,0142U,Nfct ds bact&fng gram neg,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,0145U,Drug assay 65+ rx/metablt,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,0146U,Drug assay 80+ rx/metablt,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,0147U,Drug assay 85+ rx/metablt,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,0148U,Drug assay 100+ rx/metablt,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,0149U,Drug assay 60+ rx/metablt,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,0151U,Nfct bct/vir resp nfctj 33,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,0152U,Nfct ds dna untrgt ngnrj seq,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,0153U,Onc breast mrna 101 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0154U,Onc urthl ca rna fgfr3 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0155U,Onc brst ca dna pik3ca gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0156U,Copy number sequence alys,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0157U,Apc mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0158U,Mlh1 mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0159U,Msh2 mrna seq alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,0160U,Msh6 mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0161U,Pms2 mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0162U,Hered colon ca trgt mrna pnl,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0163U,Onc clrct scr 3 prtn alg,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0164U,Gi ibs ia anti-cdtb&vinculin,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,0165U,Peanut allg asmt epi,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Meridian Medicaid,CPT,0166U,Liver ds 10 biochem asy srm,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0167U,Chornc gonadotropin hcg ia,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Meridian Medicaid,CPT,0168U,Ftl aneuploidy dna seq alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0169U,Nudt15&tpmt gene com vrnt,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,0170U,Neuro asd rna next gen seq,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0171U,Trgt gen seq alys pnl dna 23,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0172T,Lumbar spine process addl,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"7,098.75","7,098.75",,,,,,
Meridian Medicaid,CPT,0172U,Onc sld tum alys brca1 brca2,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0173U,Psyc gen alys panel 14 genes,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0174U,Onc solid tumor 30 prtn trgt,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0175U,Psyc gen alys panel 15 genes,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0176U,Cdtb&vinculin igg antb ia,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0177U,Onc brst ca dna pik3ca 11,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0178T,64 lead ecg w/i&r,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Meridian Medicaid,CPT,0178U,Peanut allg asmt epi clin rx,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Meridian Medicaid,CPT,0179T,64 lead ecg w/tracing,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Meridian Medicaid,CPT,0179U,Onc nonsm cll lng ca alys 23,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0180U,Abo gnotyp abo 7 exons,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0181U,Co gnotyp aqp1 exon 1,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0182T,Hdr elect brachytherapy,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Meridian Medicaid,CPT,0182U,Crom gnotyp cd55 exons 1-10,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0183U,Di gnotyp slc4a1 exon 19,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0184T,Exc rectal tumor endoscopic,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Meridian Medicaid,CPT,0184U,Do gnotyp art4 exon 2,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0185U,Fut1 gnotyp fut1 exon 4,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0186U,Fut2 gnotyp fut2 exon 2,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0187U,Fy gnotyp ackr1 exons 1-2,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0188U,Ge gnotyp gypc exons 1-4,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0189U,Gypa gnotyp ntrns 1 5 exon 2,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0190U,Gypb gnotyp ntrns 1 5 seux 3,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0191T,Insert ant segment drain int,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Meridian Medicaid,CPT,0191U,In gnotyp cd44 exons 2 3 6,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0192U,Jk gnotyp slc14a1 exon 9,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0193U,Jr gnotyp abcg2 exons 2-26,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0194U,Kel gnotyp kel exon 8,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0195U,Klf1 targeted sequencing,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0196U,Lu gnotyp bcam exon 3,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0197U,Lw gnotyp icam4 exon 1,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0198T,Ocular blood flow measure,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,0198U,Rhd&rhce gntyp rhd1-10&rhce5,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0199U,Sc gnotyp ermap exons 4 12,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0200U,Xk gnotyp xk exons 1-3,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0201U,Yt gnotyp ache exon 2,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0203U,Ai ibd mrna xprsn prfl 17,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0204U,Onc thyr mrna xprsn alys 593,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0205T,Inirs each vessel add-on,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,0205U,Oph amd alys 3 gene variants,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0206T,Cptr dbs alys car elec dta,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,0206U,Neuro alzheimer cell aggregj,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0207T,Clear eyelid gland w/heat,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,0207U,Neuro alzheimer quan imaging,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,0208U,Onc mtc mrna xprsn alys 108,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0209U,Cytog const alys interrog,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0210U,Syphilis tst antb ia quan,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,0211U,Onc pan-tum dna&rna gnrj seq,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0212T,Compre audiometry evaluation,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Meridian Medicaid,CPT,0212U,Rare ds gen dna alys proband,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0213U,Rare ds gen dna alys ea comp,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0214U,Rare ds xom dna alys proband,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0215T,Njx paravert w/us cer/thor,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Meridian Medicaid,CPT,0215U,Rare ds xom dna alys ea comp,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0216U,Neuro inh ataxia dna 12 com,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0217U,Neuro inh ataxia dna 51 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0218U,Neuro musc dys dmd seq alys,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0219U,Nfct agt hiv gnrj seq alys,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Meridian Medicaid,CPT,0220U,Onc brst ca ai assmt 12 feat,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,0221U,Abo gnotyp next gnrj seq abo,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0222U,Rhd&rhce gntyp next gnrj seq,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0223T,Acoustic ecg w/i&r,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Meridian Medicaid,CPT,0224T,Acoustic ecg 1+ analysis,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,0224U,Antibody sars-cov-2 titer(s),Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,0225T,Acoustic ecg analy & reprog,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,0226U,Svnt sarscov2 elisa plsm srm,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Meridian Medicaid,CPT,0227U,Rx asy prsmv30+rx/metablt,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,0228T,Njx tfrml eprl w/us cer/thor,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Meridian Medicaid,CPT,0228U,Onc prst8 ma molec prfl alg,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0229T,Njx tfrml eprl w/us cer/thor,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Meridian Medicaid,CPT,0229U,Bcat1 promoter mthyltn alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,0230U,Ar full sequence analysis,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0231U,Cacna1a full gene analysis,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0232T,Njx platelet plasma,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,0232U,Cstb full gene analysis,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0233T,Skin glycation spectroscopy,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,0233U,Fxn gene analysis,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,0234U,Mecp2 full gene analysis,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0235T,Trluml perip athrc visceral,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,0235U,Pten full gene analysis,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0236T,Trluml perip athrc abd aorta,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,0236U,Smn1&smn2 full gene analysis,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Meridian Medicaid,CPT,0237T,Trluml perip athrc brchiocph,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,0237U,Car ion chnlpthy gen seq pnl,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0238T,Trluml perip athrc iliac art,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,0238U,Onc lnch syn gen dna seq aly,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0239U,Trgt gen seq alys pnl 311+,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,0240T,Esoph motility 3d topography,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Meridian Medicaid,CPT,0241T,Esoph motility w/stim/perf,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Meridian Medicaid,CPT,0243T,Intm msr bronchodil wheeze,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Meridian Medicaid,CPT,0244T,Cont msr bronchodil wheeze,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Meridian Medicaid,CPT,0249T,Ligation hemorrhoid w/us,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Meridian Medicaid,CPT,0253T,Insert aqueous drain device,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Meridian Medicaid,CPT,0255T,Evasc rpr iliac art bifr s&i,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Meridian Medicaid,CPT,0263T,Im b1 mrw cel ther cmpl,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Meridian Medicaid,CPT,0264T,Im b1 mrw cel ther xcl hrvst,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Meridian Medicaid,CPT,0265T,Im b1 mrw cel ther hrvst onl,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Meridian Medicaid,CPT,0266T,Implt/rpl crtd sns dev total,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Meridian Medicaid,CPT,0267T,Implt/rpl crtd sns dev lead,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,0268T,Implt/rpl crtd sns dev gen,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Meridian Medicaid,CPT,0269T,Rev/remvl crtd sns dev total,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,0270T,Rev/remvl crtd sns dev lead,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,0271T,Rev/remvl crtd sns dev gen,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,0272T,Interrogate crtd sns dev,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,0273T,Interrogate crtd sns w/pgrmg,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,0278T,Tempr,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,0282T,Periph field stimul trial,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,0283T,Periph field stimul perm,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Meridian Medicaid,CPT,0284T,Periph field stimul revise,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,0285T,Periph field stimul analys,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,0286T,Near ifr spectrsc of wounds,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,0288T,Anoscopy w/rf delivery,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Meridian Medicaid,CPT,0289T,Laser inc for pkp/lkp donor,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Meridian Medicaid,CPT,0290T,Laser inc for pkp/lkp recip,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Meridian Medicaid,CPT,0294T,Ins lt atrl mont pres lead,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Meridian Medicaid,CPT,0295T,Ext ecg complete,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,0296T,Ext ecg recording,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,0297T,Ext ecg scan w/report,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,0298T,Ext ecg review and interp,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,0301T,Mw therapy for breast tumor,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Meridian Medicaid,CPT,0302T,Icar ischm mntrng sys compl,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Meridian Medicaid,CPT,0303T,Icar ischm mntrng sys eltrd,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Meridian Medicaid,CPT,0304T,Icar ischm mntrng sys device,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Meridian Medicaid,CPT,0305T,Icar ischm mntrng prgrm eval,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,0306T,Icar ischm mntr interr eval,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,0307T,Rmvl icar ischm mntrng dvce,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
Meridian Medicaid,CPT,0308T,Insj ocular telescope prosth,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Meridian Medicaid,CPT,0310T,Motor function mapping ntms,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,0311T,Cal & alys cntrl artl press,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,0312T,Laps impltj nstim vagus,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Meridian Medicaid,CPT,0313T,Laps rmvl nstim array vagus,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,0314T,Laps rmvl vgl arry&pls gen,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,0315T,Rmvl vagus nerve pls gen,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,0316T,Replc vagus nerve pls gen,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Meridian Medicaid,CPT,0317T,Elec alys vagus nrv pls gen,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,0329T,Mntr io press 24hrs/> uni/bi,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Meridian Medicaid,CPT,0330T,Tear film img uni/bi w/i&r,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Meridian Medicaid,CPT,0331T,Heart symp image plnr,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Meridian Medicaid,CPT,0332T,Heart symp image plnr spect,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Meridian Medicaid,CPT,0333T,Visual ep scr acuity auto,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,0335T,Insj sinus tarsi implant,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,0337T,Endothel fxnassmnt non-invas,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,0341T,Quant pupillometry w/ rprt,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,0342T,Thxp apheresis w/hdl delip,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Meridian Medicaid,CPT,0346T,Ultrasound elastography,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,0348T,Rsa spine exam,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,0349T,Rsa upper extr exam,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,0350T,Rsa lower extr exam,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,0352T,Oct brst/node i&r per spec,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,0354T,Oct breast surg cavity i&r,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,0355T,Gi tract capsule endoscopy,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,0356T,Insrt drug device for iop,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Meridian Medicaid,CPT,0357T,Cryopreservation oocyte(s),Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,0358T,Bia whole body,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,0362T,Bhv id suprt assmt ea 15 min,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
Meridian Medicaid,CPT,0373T,Adapt bhv tx ea 15 min,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
Meridian Medicaid,CPT,0376T,Insert ant segment drain int,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Meridian Medicaid,CPT,0377T,Anoscpy inj agent for incont,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Meridian Medicaid,CPT,0378T,Visual field assmnt rev/rprt,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,0379T,Vis field assmnt tech suppt,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,0380T,Comp animat ret imag series,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,0381T,Ext h rate epi sz 14 days,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,0382T,Ext h rate sz 14 day ri only,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,0383T,Ext h rate sz up to 30 days,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,0384T,Ex h rate sz 30 day ri only,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,0385T,Ex h rate for sz ovr 30 day,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,0386T,Ex h rate sz 30+ day ri only,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,0387T,Leadless c pm ins/rpl ventr,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Meridian Medicaid,CPT,0388T,Leadless c pm remove ventr,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
Meridian Medicaid,CPT,0389T,Prog eval inper leadls pm,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,0390T,Periproc eval inper ledls pm,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,0391T,Intergt eval inper leadls pm,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,0392T,Lap es sph augment dev place,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Meridian Medicaid,CPT,0393T,Es sph augmnt device removal,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Meridian Medicaid,CPT,0394T,Hdr elctrnc skn surf brchytx,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Meridian Medicaid,CPT,0395T,Hdr elctr ntrst/ntrcv brchtx,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Meridian Medicaid,CPT,0398T,Mrgfus strtctc les abltj,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Meridian Medicaid,CPT,0399T,Myocardial strain imaging,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Meridian Medicaid,CPT,0400T,Mltispectrl digital les alys,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,0401T,Mltispectrl digital les alys,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,0402T,Colgn cross-link crn med sep,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Meridian Medicaid,CPT,0403T,Diabetes prev standard curr,Preventive Care,Per Unit,$26.23 ,OP,26.23,26.23,,,,,,
Meridian Medicaid,CPT,0406T,Sin ndsc plmt drg elut mplnt,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Meridian Medicaid,CPT,0407T,Sin ndsc plmt drg elut mplnt,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Meridian Medicaid,CPT,0408T,Insj/rplc cardiac modulj sys,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Meridian Medicaid,CPT,0409T,Insj/rplc car modulj pls gn,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Meridian Medicaid,CPT,0412T,Rmvl cardiac modulj pls gen,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
Meridian Medicaid,CPT,0414T,Rmvl & rpl car modulj pls gn,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Meridian Medicaid,CPT,0417T,Prgrmg eval cardiac modulj,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,0418T,Interro eval cardiac modulj,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,0419T,Dstrj neurofibroma xtnsv,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,0420T,Dstrj neurofibroma xtnsv,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,0421T,Waterjet prostate abltj cmpl,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Meridian Medicaid,CPT,0422T,Tactile breast img uni/bi,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
Meridian Medicaid,CPT,0423T,Assay secretory type ii pla2,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,0424T,Insj/rplc nstim apnea compl,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Meridian Medicaid,CPT,0425T,Insj/rplc nstim apnea sen ld,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,0426T,Insj/rplc nstim apnea stm ld,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Meridian Medicaid,CPT,0427T,Insj/rplc nstim apnea pls gn,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"7,098.75","7,098.75",,,,,,
Meridian Medicaid,CPT,0428T,Rmvl nstim apnea pls gen,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,0429T,Rmvl nstim apnea sen ld,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,0430T,Rmvl nstim apnea stimj ld,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,0431T,Rmvl/rplc nstim apnea pls gn,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"7,098.75","7,098.75",,,,,,
Meridian Medicaid,CPT,0432T,Repos nstim apnea stimj ld,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,0433T,Repos nstim apnea sensing ld,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,0434T,Interro eval npgs apnea,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,0435T,Prgrmg eval npgs apnea 1 ses,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,0436T,Prgrmg eval npgs apnea study,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,0437T,Impltj synth rnfcmt abdl wal,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Meridian Medicaid,CPT,0438T,Tprnl plmt biodegrdabl matrl,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Meridian Medicaid,CPT,0439T,Myocrd contrast prfuj echo,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Meridian Medicaid,CPT,0440T,Abltj perc uxtr/perph nrv,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,0441T,Abltj perc lxtr/perph nrv,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,0442T,Abltj perc plex/trncl nrv,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,0443T,R-t spctrl alys prst8 tiss,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,0446T,Insj impltbl glucose sensor,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,0447T,Rmvl impltbl glucose sensor,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,0448T,Remvl insj impltbl gluc sens,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Meridian Medicaid,CPT,0449T,Insj aqueous drain dev 1st,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Meridian Medicaid,CPT,0450T,Insj aqueous drain dev each,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Meridian Medicaid,CPT,0453T,Insj/rplcmt mech-elec ntrfce,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Meridian Medicaid,CPT,0457T,Remvl mech-elec skin ntrfce,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
Meridian Medicaid,CPT,0462T,Prgrmg eval aortic ventr sys,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,0463T,Interrog aortic ventr sys,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,0464T,Visual ep test for glaucoma,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Meridian Medicaid,CPT,0466T,Insj ch wal respir eltrd/ra,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Meridian Medicaid,CPT,0467T,Revj/rplmnt ch respir eltrd,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,0468T,Rmvl ch wal respir eltrd/ra,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Meridian Medicaid,CPT,0469T,Rta polarize scan oc scr bi,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Meridian Medicaid,CPT,0470T,Oct skn img acquisj i&r 1st,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Meridian Medicaid,CPT,0471T,Oct skn img acquisj i&r addl,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Meridian Medicaid,CPT,0472T,Prgrmg io rta eltrd ra,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,0473T,Reprgrmg io rta eltrd ra,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,0474T,Insj aqueous drg dev io rsvr,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Meridian Medicaid,CPT,0475T,Rec ftl car sgl 3 ch i&r,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Meridian Medicaid,CPT,0476T,Rec ftl car sgl elec tr data,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Meridian Medicaid,CPT,0477T,Rec ftl car sgl xrtj alys,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Meridian Medicaid,CPT,0478T,Rec ftl car 3 ch rev i&r,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Meridian Medicaid,CPT,0481T,Njx autol wbc concentrate,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,0482T,Absl quan myocrd bld flo pet,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Meridian Medicaid,CPT,0485T,Oct mid ear i&r unilateral,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,0486T,Oct mid ear i&r bilateral,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,0487T,Trvg biomchn mapg w/reprt,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,0488T,Diabetes prev online/elec,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Meridian Medicaid,CPT,0489T,Regn cell tx scldr hands,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,0490T,Regn cell tx scldr h mlt inj,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,0497T,Xtrnl pt act ecg in-off conn,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Meridian Medicaid,CPT,0498T,Xtrnl pt act ecg r&i pr 30 d,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Meridian Medicaid,CPT,0499T,Cysto f/urtl strix/stenosis,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Meridian Medicaid,CPT,0500T,Hpv 5+ hi risk hpv types,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,0501T,Cor ffr derived cor cta data,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Meridian Medicaid,CPT,0502T,Cor ffr data prep & transmis,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Meridian Medicaid,CPT,0503T,Cor ffr alys gnrj ffr mdl,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Meridian Medicaid,CPT,0504T,Cor ffr data review i&r,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Meridian Medicaid,CPT,0505T,Ev fempop artl revsc,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,0506T,Mac pgmt opt dns meas hfp,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,0507T,Near ifr 2img mibmn glnd i&r,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,0508T,Pls echo us b1 dns meas tib,Diagnostic Radiology,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
Meridian Medicaid,CPT,0509T,Pattern erg w/i&r,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Meridian Medicaid,CPT,0510T,Rmvl sinus tarsi implant,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Meridian Medicaid,CPT,0511T,Rmvl&rinsj sinus tarsi implt,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Meridian Medicaid,CPT,0514T,Intraop vis axis id pt fixj,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,0515T,Insj wcs lv compl sys,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Meridian Medicaid,CPT,0517T,Insj wcs lv pg compnt,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Meridian Medicaid,CPT,0518T,Rmvl pg compnt wcs,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
Meridian Medicaid,CPT,0519T,Rmvl & rplcmt pg compnt wcs,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Meridian Medicaid,CPT,0520T,Rmvl&rplcmt pg wcs new eltrd,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Meridian Medicaid,CPT,0521T,Interrog dev eval wcs ip,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,0522T,Prgrmg dev eval wcs ip,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,0525T,Insj/rplcmt compl iims,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Meridian Medicaid,CPT,0527T,Insj/rplcmt iims implt mntr,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Meridian Medicaid,CPT,0528T,Prgrmg dev eval iims ip,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,0529T,Interrog dev eval iims ip,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,0530T,Removal complete iims,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
Meridian Medicaid,CPT,0532T,Removal iims implt mntr only,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
Meridian Medicaid,CPT,0533T,Cont rec mvmt do 6-10 days,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,0534T,Cont rec mvmt do setup&train,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,0535T,Cont rec mvmt do reprt cnfig,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,0536T,Cont rec mvmt do dl w/i&r,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,0541T,Myocardial imaging mcg,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Meridian Medicaid,CPT,0542T,Myocardial imaging mcg i&r,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Meridian Medicaid,CPT,0546T,Rf spectrsc ntraop mrgn asmt,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,0547T,B1 matrl qual tst mcrind tib,Diagnostic Radiology,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
Meridian Medicaid,CPT,0548T,Tprnl balo cntnc dev bi,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Meridian Medicaid,CPT,0549T,Tprnl balo cntnc dev uni,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Meridian Medicaid,CPT,0550T,Tprnl balo cntnc dev rmvl ea,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Meridian Medicaid,CPT,0551T,Tprnl balo cntnc dev adjmt,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Meridian Medicaid,CPT,0552T,Low-level laser therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,0553T,Perq tcat iliac anast implt,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,0554T,B1 str & fx rsk analysis,Diagnostic Radiology,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
Meridian Medicaid,CPT,0556T,B1 str & fx rsk assessment,Diagnostic Radiology,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
Meridian Medicaid,CPT,0558T,Ct scan f/biomchn ct alys,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Meridian Medicaid,CPT,0563T,Evac meibomian glnd heat bi,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,0564T,Onc chemo rx cytotox csc 14,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,0566T,Autol cell implt adps njx,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
Meridian Medicaid,CPT,0568T,Intro mix saline&air f/ssg,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,0571T,Insj/rplcmt icds ss eltrd,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Meridian Medicaid,CPT,0575T,Prgrmg dev eval icds ss ip,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,0576T,Interrog dev eval icds ss ip,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,0577T,Ephys eval icds ss,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Meridian Medicaid,CPT,0578T,Rem interrog dev icds phys,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,0579T,Rem interrog dev icds tech,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,0581T,Abltj mal brst tum perq crtx,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Meridian Medicaid,CPT,0582T,Trurl abltj mal prst8 tiss,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Meridian Medicaid,CPT,0583T,Tmpst auto tube dlvr sys,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,0587T,Perq impltj/rplcmt isdns ptn,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Meridian Medicaid,CPT,0588T,Revision/removal isdns ptn,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Meridian Medicaid,CPT,0589T,Elec alys smpl prgrmg iins,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Meridian Medicaid,CPT,0590T,Elec alys cplx prgrmg iins,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Meridian Medicaid,CPT,0591T,Hlth&wb coaching indiv 1st,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Meridian Medicaid,CPT,0592T,Hlth&wb coaching indiv f-up,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Meridian Medicaid,CPT,0593T,Hlth&wb coaching group,Preventive Care,Per Unit,$26.23 ,OP,26.23,26.23,,,,,,
Meridian Medicaid,CPT,0596T,Temp fml iu vlv-pmp 1st insj,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Meridian Medicaid,CPT,0597T,Temp fml iu valve-pmp rplcmt,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Meridian Medicaid,CPT,0602T,Transdermal gfr measurements,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,0603T,Transdermal gfr monitoring,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,0604T,Rem oct rta dev setup&educaj,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,0605T,Rem oct rta techl sprt min 8,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,0607T,Rem mntr pulm flu mntr setup,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,0608T,Rem mntr pulm flu mntr alys,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,0609T,Mrs disc pain acquisj data,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Meridian Medicaid,CPT,0610T,Mrs disc pain transmis data,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,0611T,Mrs disc pain alg alys data,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,0614T,Rmvl&rplcmt ss impl dfb pg,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Meridian Medicaid,CPT,0615T,Eye mvmt alys w/o calbrj i&r,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,0616T,Insertion of iris prosthesis,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Meridian Medicaid,CPT,0617T,Insj iris prosth w/rmvl&insj,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Meridian Medicaid,CPT,0618T,Insj iris prosth sec io lens,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Meridian Medicaid,CPT,0619T,Cysto w/prst8 commissurotomy,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Meridian Medicaid,CPT,0620T,Evasc ven artlz tibl/prnl vn,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,0621T,Trabeculostomy interno laser,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Meridian Medicaid,CPT,0622T,Trabeculostomy int lsr w/scp,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Meridian Medicaid,CPT,0623T,Auto quantification c plaque,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Meridian Medicaid,CPT,0632T,Perq tcat us abltj nrv p-art,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Meridian Medicaid,CPT,0633T,Ct breast w/3d uni c-,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Meridian Medicaid,CPT,0634T,Ct breast w/3d uni c+,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Meridian Medicaid,CPT,0635T,Ct breast w/3d uni c-/c+,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Meridian Medicaid,CPT,0636T,Ct breast w/3d bi c-,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Meridian Medicaid,CPT,0637T,Ct breast w/3d bi c+,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Meridian Medicaid,CPT,0638T,Ct breast w/3d bi c-/c+,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Meridian Medicaid,CPT,0639T,Wrls skn snr anisotropy meas,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,C1762,"Conn tiss, human(inc fascia)",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,C1763,"Conn tiss, non-human",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,C1849,"Skin substitute, synthetic",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,C1878,Matrl for vocal cord,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,C2615,"Sealant, pulmonary, liquid",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,C8900,"Mra w/cont, abd",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Meridian Medicaid,CPT,C8901,"Mra w/o cont, abd",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Meridian Medicaid,CPT,C8902,"Mra w/o fol w/cont, abd",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Meridian Medicaid,CPT,C8903,"Mri w/cont, breast, uni",Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Meridian Medicaid,CPT,C8904,"Mri w/o cont, breast, uni",Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Meridian Medicaid,CPT,C8905,"Mri w/o fol w/cont, brst, un",Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Meridian Medicaid,CPT,C8906,"Mri w/cont, breast, bi",Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Meridian Medicaid,CPT,C8907,"Mri w/o cont, breast, bi",Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Meridian Medicaid,CPT,C8908,"Mri w/o fol w/cont, breast,",Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Meridian Medicaid,CPT,C8909,"Mra w/cont, chest",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Meridian Medicaid,CPT,C8910,"Mra w/o cont, chest",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Meridian Medicaid,CPT,C8911,"Mra w/o fol w/cont, chest",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Meridian Medicaid,CPT,C8912,"Mra w/cont, lwr ext",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Meridian Medicaid,CPT,C8913,"Mra w/o cont, lwr ext",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Meridian Medicaid,CPT,C8914,"Mra w/o fol w/cont, lwr ext",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Meridian Medicaid,CPT,C8918,"Mra w/cont, pelvis",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Meridian Medicaid,CPT,C8919,"Mra w/o cont, pelvis",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Meridian Medicaid,CPT,C8920,"Mra w/o fol w/cont, pelvis",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Meridian Medicaid,CPT,C8921,"Tte w or w/o fol w/cont, com",Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Meridian Medicaid,CPT,C8922,"Tte w or w/o fol w/cont, f/u",Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Meridian Medicaid,CPT,C8923,"2d tte w or w/o fol w/con,co",Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Meridian Medicaid,CPT,C8924,"2d tte w or w/o fol w/con,fu",Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Meridian Medicaid,CPT,C8925,"2d tee w or w/o fol w/con,in",Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Meridian Medicaid,CPT,C8926,"Tee w or w/o fol w/cont,cong",Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Meridian Medicaid,CPT,C8927,"Tee w or w/o fol w/cont, mon",Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Meridian Medicaid,CPT,C8928,"Tte w or w/o fol w/con,stres",Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Meridian Medicaid,CPT,C8929,"Tte w or wo fol wcon,doppler",Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Meridian Medicaid,CPT,C8930,"Tte w or w/o contr, cont ecg",Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Meridian Medicaid,CPT,C8931,"Mra, w/dye, spinal canal",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Meridian Medicaid,CPT,C8932,"Mra, w/o dye, spinal canal",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Meridian Medicaid,CPT,C8933,"Mra, w/o&w/dye, spinal canal",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Meridian Medicaid,CPT,C8934,"Mra, w/dye, upper extremity",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Meridian Medicaid,CPT,C8935,"Mra, w/o dye, upper extr",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Meridian Medicaid,CPT,C8936,"Mra, w/o&w/dye, upper extr",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Meridian Medicaid,CPT,C8957,"Prolonged iv inf, req pump",General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
Meridian Medicaid,CPT,C9014,"Injection, cerliponase alfa",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,C9015,"C-1 esterase, haegarda",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,C9016,"Inj, triptorelin ext rel",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,C9024,"Inj, daunorubicin-cytarabine",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Meridian Medicaid,CPT,C9025,"Injection, ramucirumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,C9026,"Injection, vedolizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,C9027,"Injection, pembrolizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Meridian Medicaid,CPT,C9028,Inj. inotuzumab ozogamicin,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Meridian Medicaid,CPT,C9029,"Injection, guselkumab",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Meridian Medicaid,CPT,C9030,Inj copanlisib,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,C9031,"Lutetium Lu 177 dotatate, tx",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,C9032,Voretigene neparvovec-rzyl,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,C9033,"Inj, akynzeo",Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,189.67,189.67,,,,,,
Meridian Medicaid,CPT,C9034,"Injection, dexamethasone 9%",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,C9035,"Injection, Aristada Initio",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Meridian Medicaid,CPT,C9036,"Injection, patisiran",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,C9037,"Injection, risperidone",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,C9038,Inj mogamulizumab-kpkc,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,C9040,"Injection, fremanezumab-vfrm",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,C9041,"Inj, coagulation factor xa",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,C9042,"Inj., belrapzo 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,C9043,"Injection, levoleucovorin",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Meridian Medicaid,CPT,C9044,"Injection, cemiplimab-rwlc",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,C9045,Moxetumomab pasudotox-tdfk,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,C9047,"Injection, caplacizumab-yhdp",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,C9048,Dexamethasone ophth insert,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,C9049,"Injection, tagraxofusp-erzs",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,C9050,"Injection, emapalumab-lzsg",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Meridian Medicaid,CPT,C9051,"Injection, omadacycline",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Meridian Medicaid,CPT,C9052,"Injection, ravulizumab-cwv",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,C9053,"Inj, crizanlizumab-tmca",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Meridian Medicaid,CPT,C9054,"Injection, lefamulin",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,C9055,"Inj, brexanolone",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,C9056,"Injection, givosiran",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,C9057,Inj cetirizine hydrochloride,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,C9058,"Injection,pegfilgrastim-bmez",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,C9059,"Injection, meloxicam",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,C9061,"Injection, teprotumumab-trbw",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,C9062,Daratumumab hyaluronidase,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,C9063,"Injection, eptinezumab-jjmr",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,C9064,Mitomycin pyelocalyceal inst,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,C9065,Romidepsin non-lyophilized,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,C9066,Sacituzumab govitecan-hziy,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,C9069,Belantamab mafodontin-blmf,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Meridian Medicaid,CPT,C9070,"Injection, tafasitamab-cxix",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,C9071,"Injection, viltolarsen",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,C9072,"Inj, imm glob asceniv",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Meridian Medicaid,CPT,C9121,"Injection, argatroban",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Meridian Medicaid,CPT,C9122,Mometasone furoate (sinuva),Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Meridian Medicaid,CPT,C9132,"Kcentra, per i.u.",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,C9137,Adynovate Factor VIII recom,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,C9138,Nuwiq Factor VIII recomb,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,C9139,"Idelvion, 1 i.u.",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,C9140,Afstyla factor viii recomb,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,C9141,Factor viii pegylated-aucl,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,C9248,"Inj, clevidipine butyrate",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,C9250,Artiss fibrin sealant,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,C9257,Bevacizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Meridian Medicaid,CPT,C9293,"Injection, glucarpidase",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,C9349,"Puraply, puraply antimic",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,C9352,"Neuragen nerve guide, per cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,C9353,"Neurawrap nerve protector,cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,C9354,"Veritas collagen matrix, cm2",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,C9355,"Neuromatrix nerve cuff, cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,C9356,"Tenoglide tendon prot, cm2",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,C9358,"Surgimend, fetal",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,C9359,"Implnt,bon void filler-putty",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,C9360,"Surgimend, neonatal",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,C9361,Neuromend nerve wrap,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,C9362,"Implnt,bon void filler-strip",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,C9363,Integra meshed bil wound mat,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,C9364,"Porcine implant, permacol",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,C9408,"Iodine i-131 iobenguane, tx",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,C9442,"Injection, belinostat",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,C9443,"Injection, dalbavancin",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Meridian Medicaid,CPT,C9444,"Injection, oritavancin",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Meridian Medicaid,CPT,C9445,"C-1 esterase, Ruconest",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,C9446,"Inj, tedizolid phosphate",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,C9447,"Inj, phenylephrine ketorolac",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,C9448,Oral netupitant palonosetron,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
Meridian Medicaid,CPT,C9449,"Inj, blinatumomab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,C9450,Fluocinolone acetonide implt,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,C9451,"Injection, peramivir",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Meridian Medicaid,CPT,C9452,"Inj, ceftolozane/tazobactam",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,C9453,"Injection, nivolumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,C9454,"Inj, pasireotide long acting",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,C9455,"Injection, siltuximab",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Meridian Medicaid,CPT,C9456,"Inj, isavuconazonium sulfate",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,C9460,"Injection, cangrelor",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,C9465,"Injection, Durolane",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,C9466,"Injection, benralizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,C9467,Inj rituximab hyaluronidase,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,C9468,"Inj, factor ix, Rebinyn",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,C9469,Inj triamcinolone acetonide,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,C9470,Aripiprazole lauroxil im,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,C9471,"Hymovis, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Meridian Medicaid,CPT,C9472,Inj talimogene laherparepvec,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,C9473,"Injection, mepolizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Meridian Medicaid,CPT,C9474,"Inj, irinotecan liposome",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,C9475,"Injection, necitumumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,C9476,"Injection, daratumumab",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Meridian Medicaid,CPT,C9477,"Injection, elotuzumab",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Meridian Medicaid,CPT,C9478,"Injection, sebelipase alfa",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,C9480,"Injection, trabectedin",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,C9481,"Injection, reslizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Meridian Medicaid,CPT,C9482,Sotalol hydrochloride iv,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,C9483,"Injection, atezolizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,C9484,"Injection, eteplirsen",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,C9485,"Injection, olaratumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,C9487,"Ustekinumab IV inj, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Meridian Medicaid,CPT,C9488,Conivaptan hcl,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,C9489,"Injection, nusinersen",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,C9490,"Injection, bezlotoxumab",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Meridian Medicaid,CPT,C9491,"Injection, avelumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,C9492,"Injection, durvalumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,C9493,"Injection, edaravone",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Meridian Medicaid,CPT,C9494,"Injection, ocrelizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,C9497,"Loxapine, inhalation powder",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,C9600,Perc drug-el cor stent sing,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Meridian Medicaid,CPT,C9601,Perc drug-el cor stent bran,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Meridian Medicaid,CPT,C9602,Perc d-e cor stent ather s,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Meridian Medicaid,CPT,C9603,Perc d-e cor stent ather br,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Meridian Medicaid,CPT,C9604,Perc d-e cor revasc t cabg s,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Meridian Medicaid,CPT,C9605,Perc d-e cor revasc t cabg b,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Meridian Medicaid,CPT,C9606,Perc d-e cor revasc w ami s,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Meridian Medicaid,CPT,C9607,Perc d-e cor revasc chro sin,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Meridian Medicaid,CPT,C9608,Perc d-e cor revasc chro add,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Meridian Medicaid,CPT,C9724,Eps stomach plic,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Meridian Medicaid,CPT,C9726,Rxt breast appl place/remov,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Meridian Medicaid,CPT,C9728,"Place device/marker, non pro",Therapeutic Radiology,Per Unit,$68.45 ,OP,68.45,68.45,,,,,,
Meridian Medicaid,CPT,C9734,"U/s trtmt, not leiomyomata",General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Meridian Medicaid,CPT,C9737,Lap esoph augmentation,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Meridian Medicaid,CPT,C9739,Cystoscopy prostatic imp 1-3,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Meridian Medicaid,CPT,C9740,Cysto impl 4 or more,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Meridian Medicaid,CPT,C9741,Impl pressure sensor w/angio,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Meridian Medicaid,CPT,C9742,Laryngoscopy with injection,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Meridian Medicaid,CPT,C9743,Bulking/spacer material impl,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,C9744,Abd us w/contrast,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Meridian Medicaid,CPT,C9745,Nasal endo eustachian tube,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Meridian Medicaid,CPT,C9747,"Ablation, hifu, prostate",Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Meridian Medicaid,CPT,C9749,Repair nasal stenosis w/imp,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,C9750,Ins/rem-replace compl iims,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Meridian Medicaid,CPT,C9762,Cardiac mri seg dys strain,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Meridian Medicaid,CPT,C9763,Cardiac mri seg dys stress,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Meridian Medicaid,CPT,C9765,Revasc intra lithotrip-stent,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,C9767,Revasc lithotrip-stent-ather,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,C9768,Endo us-guide hep porto grad,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Meridian Medicaid,CPT,C9769,Cysto w/temp pros implant,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Meridian Medicaid,CPT,C9770,"Vitrec/mech pars, subret inj",Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Meridian Medicaid,CPT,C9771,Nsl/sins cryo post nasal tis,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Meridian Medicaid,CPT,C9772,Revasc lithotrip tibi/perone,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,C9773,Revasc lithotr-stent tib/per,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,C9774,Revasc lithotr-ather tib/per,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,C9775,Revasc lith-sten-ath tib/per,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Meridian Medicaid,CPT,C9803,Hopd covid-19 spec collect,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,D0120,Periodic oral evaluation,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Meridian Medicaid,CPT,D0140,Limit oral eval problm focus,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Meridian Medicaid,CPT,D0145,"Oral evaluation, pt < 3yrs",Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Meridian Medicaid,CPT,D0150,Comprehensve oral evaluation,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Meridian Medicaid,CPT,D0160,Extensv oral eval prob focus,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Meridian Medicaid,CPT,D0170,"Re-eval,est pt,problem focus",Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Meridian Medicaid,CPT,D0171,Re-eval post-op visit,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Meridian Medicaid,CPT,D0180,Comp periodontal evaluation,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Meridian Medicaid,CPT,D0190,Screening of a patient,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Meridian Medicaid,CPT,D0191,Assessment of a patient,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Meridian Medicaid,CPT,D0210,Intraor complete film series,Dental,Per Unit,$87.62 ,OP,87.62,87.62,,,,,,
Meridian Medicaid,CPT,D0220,Intraoral periapical first,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Meridian Medicaid,CPT,D0230,Intraoral periapical ea add,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Meridian Medicaid,CPT,D0240,Intraoral occlusal film,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Meridian Medicaid,CPT,D0250,Extraoral 2d project image,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Meridian Medicaid,CPT,D0251,Extraoral posterior image,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Meridian Medicaid,CPT,D0260,Extraoral ea additional film,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Meridian Medicaid,CPT,D0270,Dental bitewing single image,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Meridian Medicaid,CPT,D0272,Dental bitewings two images,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Meridian Medicaid,CPT,D0273,Bitewings - three images,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Meridian Medicaid,CPT,D0274,Bitewings four images,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Meridian Medicaid,CPT,D0277,Vert bitewings 7 to 8 images,Dental,Per Unit,$87.62 ,OP,87.62,87.62,,,,,,
Meridian Medicaid,CPT,D0290,Skull/facial bone image,Dental,Per Unit,$87.62 ,OP,87.62,87.62,,,,,,
Meridian Medicaid,CPT,D0310,Dental saliography,Dental,Per Unit,$87.62 ,OP,87.62,87.62,,,,,,
Meridian Medicaid,CPT,D0320,Dental tmj arthrogram incl i,Dental,Per Unit,$87.62 ,OP,87.62,87.62,,,,,,
Meridian Medicaid,CPT,D0321,Other tmj images by report,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Meridian Medicaid,CPT,D0322,Dental tomographic survey,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Meridian Medicaid,CPT,D0330,Panoramic image,Dental,Per Unit,$87.62 ,OP,87.62,87.62,,,,,,
Meridian Medicaid,CPT,D0340,2d cephalometric image,Dental,Per Unit,$87.62 ,OP,87.62,87.62,,,,,,
Meridian Medicaid,CPT,D0350,Oral/facial photo images,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Meridian Medicaid,CPT,D0351,3d photographic image,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Meridian Medicaid,CPT,D0364,Cone beam ct capt & interp,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Meridian Medicaid,CPT,D0365,Cone beam ct interprete man,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Meridian Medicaid,CPT,D0366,Cone beam ct interprete max,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Meridian Medicaid,CPT,D0367,Cone beam ct interp both jaw,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Meridian Medicaid,CPT,D0368,Cone beam ct interprete tmj,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Meridian Medicaid,CPT,D0369,Max mri capture & interprete,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Meridian Medicaid,CPT,D0370,Max ultrasound capt & interp,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,D0371,Sialoendoscopy capt & interp,Dental,Per Unit,$87.62 ,OP,87.62,87.62,,,,,,
Meridian Medicaid,CPT,D0380,Cone beam ct capture limited,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Meridian Medicaid,CPT,D0381,Cone beam ct capt mandible,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Meridian Medicaid,CPT,D0382,Cone beam ct capt maxilla,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Meridian Medicaid,CPT,D0383,Cone beam ct both jaws,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Meridian Medicaid,CPT,D0384,Cone beam ct capture tmj,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Meridian Medicaid,CPT,D0385,Max mri image capture,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Meridian Medicaid,CPT,D0386,Max ultrasound image capture,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,D0391,Imterprete diagnostic image,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Meridian Medicaid,CPT,D0393,Trtmnt simulation 3d image,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Meridian Medicaid,CPT,D0394,Digital sub 2 or more images,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Meridian Medicaid,CPT,D0395,Fusion 2 or more 3d images,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Meridian Medicaid,CPT,D0411,Hba1c in office testing,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,D0412,Blood glucose level test,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,D0414,Lab process microbial spec,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,D0415,Collection of microorganisms,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,D0416,Viral culture,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,D0418,Analysis of saliva sample,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,D0419,Assess of salivary flow,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Meridian Medicaid,CPT,D0421,Gen tst suscept oral disease,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,D0422,Collect & prep genetic samp,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,D0423,Genetic test spec analysis,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,D0425,Caries susceptibility test,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,D0431,Diag tst detect mucos abnorm,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Meridian Medicaid,CPT,D0460,Pulp vitality test,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Meridian Medicaid,CPT,D0470,Diagnostic casts,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Meridian Medicaid,CPT,D0472,"Gross exam, prep & report",Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,D0473,"Micro exam, prep & report",Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,D0474,Micro w exam of surg margins,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D0475,Decalcification procedure,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,D0476,Spec stains for microorganis,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,D0477,Spec stains not for microorg,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,D0478,Immunohistochemical stains,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,D0479,Tissue in-situ hybridization,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,D0480,Cytopath smear prep & report,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,D0481,Electron microscopy,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,D0482,Direct immunofluorescence,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,D0483,Indirect immunofluorescence,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,D0484,Consult slides prep elsewher,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Meridian Medicaid,CPT,D0485,Consult inc prep of slides,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D0486,Access of transep cytol samp,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,D0502,Other oral pathology procedu,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Meridian Medicaid,CPT,D0600,Non-ionizing diag proc,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Meridian Medicaid,CPT,D0601,Caries risk assess low risk,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Meridian Medicaid,CPT,D0602,Caries risk assess mod risk,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Meridian Medicaid,CPT,D0603,Caries risk assess high risk,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Meridian Medicaid,CPT,D0604,Antigen test pub hlth pathog,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,D0605,Antibody test pub hlth path,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,D0701,Pano radio image,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Meridian Medicaid,CPT,D0702,2d cephal radio image,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Meridian Medicaid,CPT,D0703,2d oral/facial photo image,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Meridian Medicaid,CPT,D0704,3d photo image capture only,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Meridian Medicaid,CPT,D0705,Extra oral post radio image,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Meridian Medicaid,CPT,D0706,Intraoral occlus radio image,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Meridian Medicaid,CPT,D0707,Intraoral periap radio image,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Meridian Medicaid,CPT,D0708,Intraoral bite radio image,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Meridian Medicaid,CPT,D0709,Intraoral cmplt radio images,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Meridian Medicaid,CPT,D0999,Unspecified diagnostic proce,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Meridian Medicaid,CPT,D1110,Dental prophylaxis adult,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Meridian Medicaid,CPT,D1120,Dental prophylaxis child,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Meridian Medicaid,CPT,D1206,Topical fluoride varnish,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Meridian Medicaid,CPT,D1208,Topical app fluorid ex vrnsh,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Meridian Medicaid,CPT,D1310,Nutri counsel-control caries,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Meridian Medicaid,CPT,D1320,Tobacco counseling,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Meridian Medicaid,CPT,D1321,Couns for high risk sub use,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Meridian Medicaid,CPT,D1330,Oral hygiene instruction,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Meridian Medicaid,CPT,D1351,Dental sealant per tooth,Dental,Per Unit,$24.50 ,OP,24.5,24.5,,,,,,
Meridian Medicaid,CPT,D1352,"Prev resin rest, perm tooth",Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Meridian Medicaid,CPT,D1353,Sealant repair per tooth,Dental,Per Unit,$24.50 ,OP,24.5,24.5,,,,,,
Meridian Medicaid,CPT,D1354,Int caries med app per tooth,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Meridian Medicaid,CPT,D1355,Caries med app per tooth,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Meridian Medicaid,CPT,D1510,Space maintainer fxd unilat,Dental,Per Unit,$156.21 ,OP,156.21,156.21,,,,,,
Meridian Medicaid,CPT,D1515,Fixed bilat space maintainer,Dental,Per Unit,$156.21 ,OP,156.21,156.21,,,,,,
Meridian Medicaid,CPT,D1516,"Fixed bilat space maint, max",Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Meridian Medicaid,CPT,D1517,"Fixed bilat space maint, man",Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Meridian Medicaid,CPT,D1520,Remove unilat space maintain,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Meridian Medicaid,CPT,D1525,Remove bilat space maintain,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Meridian Medicaid,CPT,D1526,"Remove bilat space main, max",Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Meridian Medicaid,CPT,D1527,"Remove bilat space main, man",Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Meridian Medicaid,CPT,D1550,Recement space maintainer,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D1551,Recement space maint - max,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Meridian Medicaid,CPT,D1552,Recement space maint - man,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Meridian Medicaid,CPT,D1553,Recement unilat space maint,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Meridian Medicaid,CPT,D1555,Remove fix space maintainer,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Meridian Medicaid,CPT,D1556,Rem fixed unilat space maint,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Meridian Medicaid,CPT,D1557,Remove fixed bilat maint max,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Meridian Medicaid,CPT,D1558,Remove fixed bilat man,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Meridian Medicaid,CPT,D1575,"Dist space maint, fixed unil",Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Meridian Medicaid,CPT,D1999,Unspecified preventive proc,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Meridian Medicaid,CPT,D2140,Amalgam one surface permanen,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2150,Amalgam two surfaces permane,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2160,Amalgam three surfaces perma,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Meridian Medicaid,CPT,D2161,Amalgam 4 or > surfaces perm,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Meridian Medicaid,CPT,D2330,Resin one surface-anterior,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2331,Resin two surfaces-anterior,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2332,Resin three surfaces-anterio,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2335,Resin 4/> surf or w incis an,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Meridian Medicaid,CPT,D2390,Ant resin-based cmpst crown,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2391,Post 1 srfc resinbased cmpst,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2392,Post 2 srfc resinbased cmpst,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2393,Post 3 srfc resinbased cmpst,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2394,Post >=4srfc resinbase cmpst,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2410,Dental gold foil one surface,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2420,Dental gold foil two surface,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2430,Dental gold foil three surfa,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2510,Dental inlay metalic 1 surf,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2520,Dental inlay metallic 2 surf,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2530,Dental inlay metl 3/more sur,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2542,Dental onlay metallic 2 surf,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2543,Dental onlay metallic 3 surf,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2544,Dental onlay metl 4/more sur,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2610,Inlay porcelain/ceramic 1 su,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2620,Inlay porcelain/ceramic 2 su,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2630,Dental onlay porc 3/more sur,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Meridian Medicaid,CPT,D2642,Dental onlay porcelin 2 surf,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2643,Dental onlay porcelin 3 surf,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2644,Dental onlay porc 4/more sur,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2650,Inlay composite/resin one su,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2651,Inlay composite/resin two su,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2652,Dental inlay resin 3/mre sur,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2662,Dental onlay resin 2 surface,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2663,Dental onlay resin 3 surface,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2664,Dental onlay resin 4/mre sur,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2710,Crown resin-based indirect,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Meridian Medicaid,CPT,D2712,Crown 3/4 resin-based compos,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Meridian Medicaid,CPT,D2720,Crown resin w/ high noble me,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Meridian Medicaid,CPT,D2721,Crown resin w/ base metal,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Meridian Medicaid,CPT,D2722,Crown resin w/ noble metal,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Meridian Medicaid,CPT,D2740,Crown porcelain/ceramic,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Meridian Medicaid,CPT,D2750,Crown porcelain w/ h noble m,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Meridian Medicaid,CPT,D2751,Crown porcelain fused base m,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Meridian Medicaid,CPT,D2752,Crown porcelain w/ noble met,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Meridian Medicaid,CPT,D2753,Crown porc fused to titanium,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Meridian Medicaid,CPT,D2780,Crown 3/4 cast hi noble met,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Meridian Medicaid,CPT,D2781,Crown 3/4 cast base metal,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Meridian Medicaid,CPT,D2782,Crown 3/4 cast noble metal,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Meridian Medicaid,CPT,D2783,Crown 3/4 porcelain/ceramic,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Meridian Medicaid,CPT,D2790,Crown full cast high noble m,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Meridian Medicaid,CPT,D2791,Crown full cast base metal,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Meridian Medicaid,CPT,D2792,Crown full cast noble metal,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Meridian Medicaid,CPT,D2794,Crown-titanium,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Meridian Medicaid,CPT,D2799,Provisional crown,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2910,Recement inlay onlay or part,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2915,Recement cast or prefab post,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2920,Re-cement or re-bond crown,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2921,Reattach tooth fragment,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2928,Prefab porc/cer crown perm,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Meridian Medicaid,CPT,D2929,Prefab porc/ceram crown pri,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Meridian Medicaid,CPT,D2930,Prefab stnlss steel crwn pri,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Meridian Medicaid,CPT,D2931,Prefab stnlss steel crown pe,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Meridian Medicaid,CPT,D2932,Prefabricated resin crown,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Meridian Medicaid,CPT,D2933,Prefab stainless steel crown,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Meridian Medicaid,CPT,D2934,Prefab steel crown primary,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Meridian Medicaid,CPT,D2941,Int therapeutic restoration,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Meridian Medicaid,CPT,D2950,Core build-up incl any pins,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Meridian Medicaid,CPT,D2951,Tooth pin retention,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Meridian Medicaid,CPT,D2952,Post and core cast + crown,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Meridian Medicaid,CPT,D2953,Each addtnl cast post,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Meridian Medicaid,CPT,D2954,Prefab post/core + crown,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Meridian Medicaid,CPT,D2955,Post removal,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2957,Each addtnl prefab post,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Meridian Medicaid,CPT,D2960,Labial veneer resin direct,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2961,Labial veneer resin indirect,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2962,Labial veneer porc indirect,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2970,Temp crown (fractured tooth),Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2971,Add proc construct new crown,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2975,Coping,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2980,Crown repair,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2981,Inlay repair,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2982,Onlay repair,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2983,Veneer repair,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2990,Resin infiltration of lesion,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D2999,Dental unspec restorative pr,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Meridian Medicaid,CPT,D3110,Pulp cap direct,Dental,Per Unit,$74.70 ,OP,74.7,74.7,,,,,,
Meridian Medicaid,CPT,D3120,Pulp cap indirect,Dental,Per Unit,$74.70 ,OP,74.7,74.7,,,,,,
Meridian Medicaid,CPT,D3220,Therapeutic pulpotomy,Dental,Per Unit,$74.70 ,OP,74.7,74.7,,,,,,
Meridian Medicaid,CPT,D3221,Gross pulpal debridement,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Meridian Medicaid,CPT,D3222,Part pulp for apexogenesis,Dental,Per Unit,$74.70 ,OP,74.7,74.7,,,,,,
Meridian Medicaid,CPT,D3230,Pulpal therapy anterior prim,Dental,Per Unit,$74.70 ,OP,74.7,74.7,,,,,,
Meridian Medicaid,CPT,D3240,Pulpal therapy posterior pri,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Meridian Medicaid,CPT,D3310,"End thxpy, anterior tooth",Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Meridian Medicaid,CPT,D3320,"End thxpy, premolar tooth",Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Meridian Medicaid,CPT,D3330,"End thxpy, molar tooth",Dental,Per Unit,$135.31 ,OP,135.31,135.31,,,,,,
Meridian Medicaid,CPT,D3331,Non-surg tx root canal obs,Dental,Per Unit,$135.31 ,OP,135.31,135.31,,,,,,
Meridian Medicaid,CPT,D3332,Incomplete endodontic tx,Dental,Per Unit,$135.31 ,OP,135.31,135.31,,,,,,
Meridian Medicaid,CPT,D3333,Internal root repair,Dental,Per Unit,$135.31 ,OP,135.31,135.31,,,,,,
Meridian Medicaid,CPT,D3346,Retreat root canal anterior,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Meridian Medicaid,CPT,D3347,Retreat root canal premolar,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Meridian Medicaid,CPT,D3348,Retreat root canal molar,Dental,Per Unit,$135.31 ,OP,135.31,135.31,,,,,,
Meridian Medicaid,CPT,D3351,Apexification/recalc initial,Dental,Per Unit,$74.70 ,OP,74.7,74.7,,,,,,
Meridian Medicaid,CPT,D3352,Apexification/recalc interim,Dental,Per Unit,$74.70 ,OP,74.7,74.7,,,,,,
Meridian Medicaid,CPT,D3353,Apexification/recalc final,Dental,Per Unit,$74.70 ,OP,74.7,74.7,,,,,,
Meridian Medicaid,CPT,D3355,Pulpal regeneration initial,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Meridian Medicaid,CPT,D3356,Pulpal regeneration interim,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Meridian Medicaid,CPT,D3357,Pulpal regeneration complete,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Meridian Medicaid,CPT,D3410,Apicoectomy - anterior,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Meridian Medicaid,CPT,D3421,Root surgery premolar,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Meridian Medicaid,CPT,D3425,Root surgery molar,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Meridian Medicaid,CPT,D3426,Root surgery ea add root,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Meridian Medicaid,CPT,D3427,Periradicular surgery,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Meridian Medicaid,CPT,D3428,Bone graft peri per tooth,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Meridian Medicaid,CPT,D3429,Bone graft peri each addl,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Meridian Medicaid,CPT,D3430,Retrograde filling,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Meridian Medicaid,CPT,D3431,Biological materials,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Meridian Medicaid,CPT,D3432,Guided tissue regeneration,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Meridian Medicaid,CPT,D3450,Root amputation,Dental,Per Unit,$135.31 ,OP,135.31,135.31,,,,,,
Meridian Medicaid,CPT,D3460,Endodontic endosseous implan,Dental,Per Unit,$135.31 ,OP,135.31,135.31,,,,,,
Meridian Medicaid,CPT,D3470,Intentional replantation,Dental,Per Unit,$135.31 ,OP,135.31,135.31,,,,,,
Meridian Medicaid,CPT,D3471,Surg rep root res anterior,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Meridian Medicaid,CPT,D3472,Surg rep root res premolar,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Meridian Medicaid,CPT,D3473,Surg rep root res molar,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Meridian Medicaid,CPT,D3501,Surg exp root surf anterior,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Meridian Medicaid,CPT,D3502,Surg exp root surf premolar,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Meridian Medicaid,CPT,D3503,Surg exp root surf molar,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Meridian Medicaid,CPT,D3910,Isolation- tooth w rubb dam,Dental,Per Unit,$135.31 ,OP,135.31,135.31,,,,,,
Meridian Medicaid,CPT,D3920,Tooth splitting,Dental,Per Unit,$135.31 ,OP,135.31,135.31,,,,,,
Meridian Medicaid,CPT,D3950,Canal prep/fitting of dowel,Dental,Per Unit,$135.31 ,OP,135.31,135.31,,,,,,
Meridian Medicaid,CPT,D3999,Endodontic procedure,Dental,Per Unit,$74.70 ,OP,74.7,74.7,,,,,,
Meridian Medicaid,CPT,D4210,Gingivectomy/plasty 4 or mor,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Meridian Medicaid,CPT,D4211,Gingivectomy/plasty 1 to 3,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Meridian Medicaid,CPT,D4212,Gingivectomy/plasty rest,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Meridian Medicaid,CPT,D4230,Ana crown exp 4 or> per quad,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Meridian Medicaid,CPT,D4231,Ana crown exp 1-3 per quad,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Meridian Medicaid,CPT,D4240,Gingival flap proc w/ planin,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Meridian Medicaid,CPT,D4241,Gngvl flap w rootplan 1-3 th,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Meridian Medicaid,CPT,D4245,Apically positioned flap,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Meridian Medicaid,CPT,D4249,Crown lengthen hard tissue,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Meridian Medicaid,CPT,D4260,Osseous surgery 4 or more,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Meridian Medicaid,CPT,D4261,Osseous surg 1 to 3 teeth,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Meridian Medicaid,CPT,D4263,Bone replce graft first site,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Meridian Medicaid,CPT,D4264,Bone replce graft each add,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Meridian Medicaid,CPT,D4265,Bio mtrls to aid soft/os reg,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Meridian Medicaid,CPT,D4266,Guided tiss regen resorble,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Meridian Medicaid,CPT,D4267,Guided tiss regen nonresorb,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Meridian Medicaid,CPT,D4268,Surgical revision procedure,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Meridian Medicaid,CPT,D4270,Pedicle soft tissue graft pr,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Meridian Medicaid,CPT,D4273,Auto tissue graft 1st tooth,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Meridian Medicaid,CPT,D4274,Mesial/distal wedge proc,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Meridian Medicaid,CPT,D4275,Non-auto graft 1st tooth,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Meridian Medicaid,CPT,D4276,Con tissue w dble ped graft,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Meridian Medicaid,CPT,D4277,Soft tissue graft firsttooth,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Meridian Medicaid,CPT,D4278,Soft tissue graft addl tooth,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Meridian Medicaid,CPT,D4283,Auto tissue graft addl tooth,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Meridian Medicaid,CPT,D4285,Non-auto graft addl tooth,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Meridian Medicaid,CPT,D4320,Provision splnt intracoronal,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Meridian Medicaid,CPT,D4321,Provisional splint extracoro,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Meridian Medicaid,CPT,D4341,Periodontal scaling & root,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Meridian Medicaid,CPT,D4342,Periodontal scaling 1-3teeth,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Meridian Medicaid,CPT,D4346,Scaling gingiv inflammation,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Meridian Medicaid,CPT,D4355,Full mouth debridement,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Meridian Medicaid,CPT,D4381,Localized delivery antimicro,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Meridian Medicaid,CPT,D4910,Periodontal maint procedures,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Meridian Medicaid,CPT,D4920,Unscheduled dressing change,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Meridian Medicaid,CPT,D4921,Gingival irrigation per quad,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Meridian Medicaid,CPT,D4999,Unspecified periodontal proc,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Meridian Medicaid,CPT,D5110,Dentures complete maxillary,Dental,Per Unit,$162.24 ,OP,162.24,162.24,,,,,,
Meridian Medicaid,CPT,D5120,Dentures complete mandible,Dental,Per Unit,$162.24 ,OP,162.24,162.24,,,,,,
Meridian Medicaid,CPT,D5130,Dentures immediat maxillary,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
Meridian Medicaid,CPT,D5140,Dentures immediat mandible,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
Meridian Medicaid,CPT,D5211,Dentures maxill part resin,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
Meridian Medicaid,CPT,D5212,Dentures mand part resin,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
Meridian Medicaid,CPT,D5213,Dentures maxill part metal,Dental,Per Unit,$162.24 ,OP,162.24,162.24,,,,,,
Meridian Medicaid,CPT,D5214,Dentures mandibl part metal,Dental,Per Unit,$162.24 ,OP,162.24,162.24,,,,,,
Meridian Medicaid,CPT,D5221,Immed max part denture resin,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
Meridian Medicaid,CPT,D5222,Immed man part denture resin,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
Meridian Medicaid,CPT,D5223,Immed max part dent metal,Dental,Per Unit,$162.24 ,OP,162.24,162.24,,,,,,
Meridian Medicaid,CPT,D5224,Immed mand part dent metal,Dental,Per Unit,$162.24 ,OP,162.24,162.24,,,,,,
Meridian Medicaid,CPT,D5225,Maxillary part denture flex,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
Meridian Medicaid,CPT,D5226,Mandibular part denture flex,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
Meridian Medicaid,CPT,D5281,Removable partial denture,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
Meridian Medicaid,CPT,D5282,"Remove unil part denture,max",Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
Meridian Medicaid,CPT,D5283,"Remove unil part denture,man",Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
Meridian Medicaid,CPT,D5284,Rem unilat dent flex base,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
Meridian Medicaid,CPT,D5286,Rem unilat dent 1 pc resin,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
Meridian Medicaid,CPT,D5410,Dentures adjust cmplt maxil,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D5411,Dentures adjust cmplt mand,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D5421,Dentures adjust part maxill,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D5422,Dentures adjust part mandbl,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D5510,Dentur repr broken compl bas,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Meridian Medicaid,CPT,D5511,Rep broke comp dent base man,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Meridian Medicaid,CPT,D5512,Rep broke comp dent base max,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Meridian Medicaid,CPT,D5520,Replace denture teeth complt,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Meridian Medicaid,CPT,D5610,Dentures repair resin base,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Meridian Medicaid,CPT,D5611,Rep resin part dent base man,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Meridian Medicaid,CPT,D5612,Rep resin part dent base max,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Meridian Medicaid,CPT,D5620,Rep part denture cast frame,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Meridian Medicaid,CPT,D5621,Rep cast part frame man,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Meridian Medicaid,CPT,D5622,Rep cast part frame max,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Meridian Medicaid,CPT,D5630,Rep partial denture clasp,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Meridian Medicaid,CPT,D5640,Replace part denture teeth,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Meridian Medicaid,CPT,D5650,Add tooth to partial denture,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Meridian Medicaid,CPT,D5660,Add clasp to partial denture,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Meridian Medicaid,CPT,D5670,Replc tth&acrlc on mtl frmwk,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
Meridian Medicaid,CPT,D5671,Replc tth&acrlc mandibular,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
Meridian Medicaid,CPT,D5710,Dentures rebase cmplt maxil,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Meridian Medicaid,CPT,D5711,Dentures rebase cmplt mand,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Meridian Medicaid,CPT,D5720,Dentures rebase part maxill,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Meridian Medicaid,CPT,D5721,Dentures rebase part mandbl,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Meridian Medicaid,CPT,D5730,Denture reln cmplt max dir,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Meridian Medicaid,CPT,D5731,Denture reln cmplt mand dir,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Meridian Medicaid,CPT,D5740,Denture reln part max dir,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Meridian Medicaid,CPT,D5741,Denture reln part mand dir,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Meridian Medicaid,CPT,D5750,Denture reln cmplt max indir,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Meridian Medicaid,CPT,D5751,Denture reln cmplt mand ind,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Meridian Medicaid,CPT,D5760,Denture reln part max indir,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Meridian Medicaid,CPT,D5761,Denture reln part mand indir,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Meridian Medicaid,CPT,D5810,Denture interm cmplt maxill,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Meridian Medicaid,CPT,D5811,Denture interm cmplt mandbl,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Meridian Medicaid,CPT,D5820,Denture interm part maxill,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Meridian Medicaid,CPT,D5821,Denture interm part mandbl,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Meridian Medicaid,CPT,D5850,Denture tiss conditn maxill,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Meridian Medicaid,CPT,D5851,Denture tiss condtin mandbl,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Meridian Medicaid,CPT,D5862,Precision attachment,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Meridian Medicaid,CPT,D5863,Overdenture complete max,Dental,Per Unit,$162.24 ,OP,162.24,162.24,,,,,,
Meridian Medicaid,CPT,D5864,Overdenture partial max,Dental,Per Unit,$162.24 ,OP,162.24,162.24,,,,,,
Meridian Medicaid,CPT,D5865,Overdenture complete mandib,Dental,Per Unit,$162.24 ,OP,162.24,162.24,,,,,,
Meridian Medicaid,CPT,D5866,Overdenture partial mandib,Dental,Per Unit,$162.24 ,OP,162.24,162.24,,,,,,
Meridian Medicaid,CPT,D5867,Replacement of precision att,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Meridian Medicaid,CPT,D5875,Prosthesis modification,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Meridian Medicaid,CPT,D5876,Add metal sub to acrylc dent,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Meridian Medicaid,CPT,D5899,Removable prosthodontic proc,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Meridian Medicaid,CPT,D5911,Facial moulage sectional,Dental,Per Unit,$30.61 ,OP,30.61,30.61,,,,,,
Meridian Medicaid,CPT,D5912,Facial moulage complete,Dental,Per Unit,$30.61 ,OP,30.61,30.61,,,,,,
Meridian Medicaid,CPT,D5913,Nasal prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Meridian Medicaid,CPT,D5914,Auricular prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Meridian Medicaid,CPT,D5915,Orbital prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Meridian Medicaid,CPT,D5916,Ocular prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Meridian Medicaid,CPT,D5919,Facial prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Meridian Medicaid,CPT,D5922,Nasal septal prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Meridian Medicaid,CPT,D5923,Ocular prosthesis interim,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Meridian Medicaid,CPT,D5924,Cranial prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Meridian Medicaid,CPT,D5925,Facial augmentation implant,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Meridian Medicaid,CPT,D5926,Replacement nasal prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Meridian Medicaid,CPT,D5927,Auricular replacement,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Meridian Medicaid,CPT,D5928,Orbital replacement,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Meridian Medicaid,CPT,D5929,Facial replacement,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Meridian Medicaid,CPT,D5931,Surgical obturator,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Meridian Medicaid,CPT,D5932,Postsurgical obturator,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Meridian Medicaid,CPT,D5933,Refitting of obturator,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Meridian Medicaid,CPT,D5934,Mandibular flange prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Meridian Medicaid,CPT,D5935,Mandibular denture prosth,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Meridian Medicaid,CPT,D5936,Temp obturator prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Meridian Medicaid,CPT,D5937,Trismus appliance,Dental,Per Unit,$30.61 ,OP,30.61,30.61,,,,,,
Meridian Medicaid,CPT,D5951,Feeding aid,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Meridian Medicaid,CPT,D5952,Pediatric speech aid,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Meridian Medicaid,CPT,D5953,Adult speech aid,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Meridian Medicaid,CPT,D5954,Superimposed prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Meridian Medicaid,CPT,D5955,Palatal lift prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Meridian Medicaid,CPT,D5958,Intraoral con def inter plt,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Meridian Medicaid,CPT,D5959,Intraoral con def mod palat,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Meridian Medicaid,CPT,D5960,Modify speech aid prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Meridian Medicaid,CPT,D5982,Surgical stent,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Meridian Medicaid,CPT,D5983,Radiation applicator,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Meridian Medicaid,CPT,D5984,Radiation shield,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Meridian Medicaid,CPT,D5985,Radiation cone locator,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Meridian Medicaid,CPT,D5986,Fluoride applicator,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D5987,Commissure splint,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Meridian Medicaid,CPT,D5988,Surgical splint,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Meridian Medicaid,CPT,D5991,Vesiculobullous disease carr,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D5992,Adjust max prost appliance,Dental,Per Unit,$30.61 ,OP,30.61,30.61,,,,,,
Meridian Medicaid,CPT,D5993,Main/clean max prosthesis,Dental,Per Unit,$30.61 ,OP,30.61,30.61,,,,,,
Meridian Medicaid,CPT,D5994,Peridontal medicament,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Meridian Medicaid,CPT,D5995,"Peri medicament w/seal, max",Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Meridian Medicaid,CPT,D5996,"Peri medicament w/seal, mand",Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Meridian Medicaid,CPT,D5999,Maxillofacial prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Meridian Medicaid,CPT,D6010,Odontics endosteal implant,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Meridian Medicaid,CPT,D6011,Second stage implant surgery,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Meridian Medicaid,CPT,D6012,Endosteal implant,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Meridian Medicaid,CPT,D6013,Surgical place mini implant,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Meridian Medicaid,CPT,D6040,Odontics eposteal implant,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Meridian Medicaid,CPT,D6050,Odontics transosteal implnt,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Meridian Medicaid,CPT,D6051,Interim abutment,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6055,Implant connecting bar,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6056,Prefabricated abutment,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6057,Custom abutment,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6058,Abutment supported crown,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6059,Abutment supported mtl crown,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6060,Abutment supported mtl crown,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6061,Abutment supported mtl crown,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6062,Abutment supported mtl crown,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6063,Abutment supported mtl crown,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6064,Abutment supported mtl crown,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6065,Implant supported crown,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6066,Implant supported mtl crown,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6067,Implant supported mtl crown,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6068,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6069,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6070,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6071,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6072,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6073,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6074,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6075,Implant supported retainer,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6076,Implant supported retainer,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6077,Implant supported retainer,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6080,Implant maintenance,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Meridian Medicaid,CPT,D6081,"Scale & debride, single imp",Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Meridian Medicaid,CPT,D6082,Imp crown porc to base alloy,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6083,Imp crown porc to noble allo,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6084,Imp crown porc to titanium,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6085,Provisional implant crown,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Meridian Medicaid,CPT,D6086,Imp crown base alloys,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6087,Implant crown noble alloys,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6088,Imp crown titanium alloys,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6090,Repair implant,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Meridian Medicaid,CPT,D6091,Repl semi/precision attach,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Meridian Medicaid,CPT,D6092,Recement supp crown,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Meridian Medicaid,CPT,D6093,Recement supp part denture,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Meridian Medicaid,CPT,D6094,Abut support crown titanium,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6095,Odontics repr abutment,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Meridian Medicaid,CPT,D6096,Remove broken imp ret screw,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Meridian Medicaid,CPT,D6097,Abut crown porc to titanium,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6098,Imp retain porc to base allo,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6099,Imp retainer for fpd,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6100,Removal of implant,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Meridian Medicaid,CPT,D6101,Debridement of a periimplant,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Meridian Medicaid,CPT,D6102,Debridement & contouring,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Meridian Medicaid,CPT,D6103,Bone graft repair perimplant,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Meridian Medicaid,CPT,D6104,Bone graft time of implant,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Meridian Medicaid,CPT,D6110,Implnt/abut remov dent max,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6111,Implnt/abut remov dent mand,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6112,Imp/abut rem dent part max,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6113,Imp/abut rem dent part mand,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6114,Implnt/abut fixed dent max,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6115,Implnt/abut fixed dent mand,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6116,Imp/abut fixed dent part max,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6117,Imp/abut fixed dent part man,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6118,Imp/abut int fixed dent man,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6119,Int/abut int fixed dent max,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6120,Imp retain porc to titanium,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6121,Retain metal fpd base alloys,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6122,Retain metal fpd noble alloy,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6123,Retain metal fpd titanium,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6190,Radio/surgical implant index,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Meridian Medicaid,CPT,D6191,Semi precision abutment,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Meridian Medicaid,CPT,D6192,Semi precision attachment,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Meridian Medicaid,CPT,D6194,Abut support retainer titani,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6195,Abut retain porc to titanium,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Meridian Medicaid,CPT,D6199,Implant procedure,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Meridian Medicaid,CPT,D6205,Pontic-indirect resin based,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
Meridian Medicaid,CPT,D6210,Prosthodont high noble metal,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
Meridian Medicaid,CPT,D6211,Bridge base metal cast,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
Meridian Medicaid,CPT,D6212,Bridge noble metal cast,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
Meridian Medicaid,CPT,D6214,Pontic titanium,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
Meridian Medicaid,CPT,D6240,Bridge porcelain high noble,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
Meridian Medicaid,CPT,D6241,Bridge porcelain base metal,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
Meridian Medicaid,CPT,D6242,Bridge porcelain nobel metal,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
Meridian Medicaid,CPT,D6243,Pontic porcelain to titanium,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
Meridian Medicaid,CPT,D6245,Bridge porcelain/ceramic,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
Meridian Medicaid,CPT,D6250,Bridge resin w/high noble,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
Meridian Medicaid,CPT,D6251,Bridge resin base metal,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
Meridian Medicaid,CPT,D6252,Bridge resin w/noble metal,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
Meridian Medicaid,CPT,D6253,Provisional pontic,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
Meridian Medicaid,CPT,D6545,Dental retainr cast metl,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Meridian Medicaid,CPT,D6548,Porcelain/ceramic retainer,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Meridian Medicaid,CPT,D6549,Resin retainer,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Meridian Medicaid,CPT,D6600,Porcelain/ceramic inlay 2srf,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Meridian Medicaid,CPT,D6601,Porc/ceram inlay >= 3 surfac,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Meridian Medicaid,CPT,D6602,Cst hgh nble mtl inlay 2 srf,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Meridian Medicaid,CPT,D6603,Cst hgh nble mtl inlay >=3sr,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Meridian Medicaid,CPT,D6604,Cst bse mtl inlay 2 surfaces,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Meridian Medicaid,CPT,D6605,Cst bse mtl inlay >= 3 surfa,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Meridian Medicaid,CPT,D6606,Cast noble metal inlay 2 sur,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Meridian Medicaid,CPT,D6607,Cst noble mtl inlay >=3 surf,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Meridian Medicaid,CPT,D6608,Onlay porc/crmc 2 surfaces,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Meridian Medicaid,CPT,D6609,Onlay porc/crmc >=3 surfaces,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Meridian Medicaid,CPT,D6610,Onlay cst hgh nbl mtl 2 srfc,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Meridian Medicaid,CPT,D6611,Onlay cst hgh nbl mtl >=3srf,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Meridian Medicaid,CPT,D6612,Onlay cst base mtl 2 surface,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Meridian Medicaid,CPT,D6613,Onlay cst base mtl >=3 surfa,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Meridian Medicaid,CPT,D6614,Onlay cst nbl mtl 2 surfaces,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Meridian Medicaid,CPT,D6615,Onlay cst nbl mtl >=3 surfac,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Meridian Medicaid,CPT,D6624,Inlay titanium,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Meridian Medicaid,CPT,D6634,Onlay titanium,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Meridian Medicaid,CPT,D6710,Crown-indirect resin based,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Meridian Medicaid,CPT,D6720,Retain crown resin w hi nble,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Meridian Medicaid,CPT,D6721,Crown resin w/base metal,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Meridian Medicaid,CPT,D6722,Crown resin w/noble metal,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Meridian Medicaid,CPT,D6740,Crown porcelain/ceramic,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Meridian Medicaid,CPT,D6750,Crown porcelain high noble,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Meridian Medicaid,CPT,D6751,Crown porcelain base metal,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Meridian Medicaid,CPT,D6752,Crown porcelain noble metal,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Meridian Medicaid,CPT,D6753,Retain crown porc to titaniu,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Meridian Medicaid,CPT,D6780,Crown 3/4 high noble metal,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Meridian Medicaid,CPT,D6781,Crown 3/4 cast based metal,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Meridian Medicaid,CPT,D6782,Crown 3/4 cast noble metal,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Meridian Medicaid,CPT,D6783,Crown 3/4 porcelain/ceramic,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Meridian Medicaid,CPT,D6784,Retainer crown 3/4 titanium,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Meridian Medicaid,CPT,D6790,Crown full high noble metal,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Meridian Medicaid,CPT,D6791,Crown full base metal cast,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Meridian Medicaid,CPT,D6792,Crown full noble metal cast,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Meridian Medicaid,CPT,D6793,Provisional retainer crown,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Meridian Medicaid,CPT,D6794,Crown titanium,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Meridian Medicaid,CPT,D6920,Dental connector bar,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Meridian Medicaid,CPT,D6930,Recement/bond part denture,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Meridian Medicaid,CPT,D6940,Stress breaker,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Meridian Medicaid,CPT,D6950,Precision attachment,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Meridian Medicaid,CPT,D6980,Fixed partial repair,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Meridian Medicaid,CPT,D6985,Pediatric partial denture fx,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
Meridian Medicaid,CPT,D6999,Fixed prosthodontic proc,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Meridian Medicaid,CPT,D7111,Extraction coronal remnants,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7140,Extraction erupted tooth/exr,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7210,Rem imp tooth w mucoper flp,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7220,Impact tooth remov soft tiss,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7230,Impact tooth remov part bony,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7240,Impact tooth remov comp bony,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7241,Impact tooth rem bony w/comp,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Meridian Medicaid,CPT,D7250,Tooth root removal,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7251,Coronectomy,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Meridian Medicaid,CPT,D7260,Oral antral fistula closure,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7261,Primary closure sinus perf,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Meridian Medicaid,CPT,D7270,Tooth reimplantation,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7272,Tooth transplantation,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7280,Exposure of unerupted tooth,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Meridian Medicaid,CPT,D7282,Mobilize erupted/malpos toot,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7283,Place device impacted tooth,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7285,Biopsy of oral tissue hard,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7286,Biopsy of oral tissue soft,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D7287,Exfoliative cytolog collect,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7288,Brush biopsy,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7290,Repositioning of teeth,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D7291,Transseptal fiberotomy,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7292,Screw retained plate,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7293,Temp anchorage dev w flap,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7294,Temp anchorage dev w/o flap,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7295,"Bone harvest,auto graft proc",Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7296,"Corticotomy, 1-3 teeth",Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Meridian Medicaid,CPT,D7297,"Corticotomy, 4 or more teeth",Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Meridian Medicaid,CPT,D7310,Alveoplasty w/ extraction,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7311,Alveoloplasty w/extract 1-3,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7320,Alveoplasty w/o extraction,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7321,Alveoloplasty not w/extracts,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7340,Vestibuloplasty ridge extens,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Meridian Medicaid,CPT,D7350,Vestibuloplasty exten graft,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,D7410,Rad exc lesion up to 1.25 cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7411,Excision benign lesion>1.25c,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7412,Excision benign lesion compl,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7413,Excision malig lesion<=1.25c,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7414,Excision malig lesion>1.25cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7415,Excision malig les complicat,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7440,Malig tumor exc to 1.25 cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7441,Malig tumor > 1.25 cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7450,Rem odontogen cyst to 1.25cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7451,Rem odontogen cyst > 1.25 cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7460,Rem nonodonto cyst to 1.25cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7461,Rem nonodonto cyst > 1.25 cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7465,Lesion destruction,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7471,Rem exostosis any site,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7472,Removal of torus palatinus,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Meridian Medicaid,CPT,D7473,Remove torus mandibularis,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7485,Surg reduct osseoustuberosit,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7490,Maxilla or mandible resectio,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Meridian Medicaid,CPT,D7510,I&d absc intraoral soft tiss,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D7511,Incision/drain abscess intra,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7520,I&d abscess extraoral,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7521,Incision/drain abscess extra,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7530,Removal fb skin/areolar tiss,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7540,Removal of fb reaction,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Meridian Medicaid,CPT,D7550,Removal of sloughed off bone,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7560,Maxillary sinusotomy,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Meridian Medicaid,CPT,D7610,Maxilla open reduct simple,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,D7620,Clsd reduct simpl maxilla fx,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Meridian Medicaid,CPT,D7630,Open red simpl mandible fx,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,D7640,Clsd red simpl mandible fx,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Meridian Medicaid,CPT,D7650,Open red simp malar/zygom fx,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Meridian Medicaid,CPT,D7660,Clsd red simp malar/zygom fx,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7670,Closd rductn splint alveolus,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7671,Alveolus open reduction,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7680,Reduct simple facial bone fx,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Meridian Medicaid,CPT,D7710,Maxilla open reduct compound,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,D7720,Clsd reduct compd maxilla fx,Dental,Per Unit,$156.21 ,OP,156.21,156.21,,,,,,
Meridian Medicaid,CPT,D7730,Open reduct compd mandble fx,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,D7740,Clsd reduct compd mandble fx,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Meridian Medicaid,CPT,D7750,Open red comp malar/zygma fx,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Meridian Medicaid,CPT,D7760,Clsd red comp malar/zygma fx,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7770,Open reduc compd alveolus fx,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7771,Alveolus clsd reduc stblz te,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7780,Reduct compnd facial bone fx,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7810,Tmj open reduct-dislocation,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,D7820,Closed tmp manipulation,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7830,Tmj manipulation under anest,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7840,Removal of tmj condyle,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,D7850,Tmj meniscectomy,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,D7852,Tmj repair of joint disc,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,D7854,Tmj excisn of joint membrane,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,D7856,Tmj cutting of a muscle,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,D7858,Tmj reconstruction,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,D7860,Tmj cutting into joint,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,D7865,Tmj reshaping components,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,D7870,Tmj aspiration joint fluid,Dental,Per Unit,$156.21 ,OP,156.21,156.21,,,,,,
Meridian Medicaid,CPT,D7871,Lysis + lavage w catheters,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7872,Tmj diagnostic arthroscopy,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D7873,Tmj arthroscopy lysis adhesn,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,D7874,Tmj arthroscopy disc reposit,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,D7875,Tmj arthroscopy synovectomy,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,D7876,Tmj arthroscopy discectomy,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,D7877,Tmj arthroscopy debridement,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,D7880,Occlusal orthotic appliance,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7881,Occ orthotic device adjust,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D7899,Tmj unspecified therapy,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7910,Dent sutur recent wnd to 5cm,Dental,Per Unit,$156.21 ,OP,156.21,156.21,,,,,,
Meridian Medicaid,CPT,D7911,Dental suture wound to 5 cm,Dental,Per Unit,$156.21 ,OP,156.21,156.21,,,,,,
Meridian Medicaid,CPT,D7912,Suture complicate wnd > 5 cm,Dental,Per Unit,$156.21 ,OP,156.21,156.21,,,,,,
Meridian Medicaid,CPT,D7920,Dental skin graft,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7921,Collect & appl blood product,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7922,Place intra-socket bio dress,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7940,Reshaping bone orthognathic,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7941,Bone cutting ramus closed,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,D7943,Cutting ramus open w/graft,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,D7944,Bone cutting segmented,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,D7945,Bone cutting body mandible,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,D7946,Reconstruction maxilla total,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,D7947,Reconstruct maxilla segment,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,D7948,Reconstruct midface no graft,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,D7949,Reconstruct midface w/graft,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,D7950,Mandible graft,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Meridian Medicaid,CPT,D7951,Sinus aug w bone or bone sub,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Meridian Medicaid,CPT,D7952,Sinus augmentation vertical,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Meridian Medicaid,CPT,D7953,Bone replacement graft,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Meridian Medicaid,CPT,D7955,Repair maxillofacial defects,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Meridian Medicaid,CPT,D7960,Frenulectomy/frenectomy,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D7961,Buccal/labial frenectomy,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7962,Lingual frenectomy,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7963,Frenuloplasty,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7970,Excision hyperplastic tissue,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Meridian Medicaid,CPT,D7971,Excision pericoronal gingiva,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7972,Surg redct fibrous tuberosit,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7979,Non-surgical sialolithotomy,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7980,Surgical sialolithotomy,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Meridian Medicaid,CPT,D7981,Excision of salivary gland,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7982,Sialodochoplasty,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,D7983,Closure of salivary fistula,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7990,Emergency tracheotomy,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,D7991,Dental coronoidectomy,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Meridian Medicaid,CPT,D7993,Surg place craniofacial impl,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Meridian Medicaid,CPT,D7994,Surg place zygomatic impl,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Meridian Medicaid,CPT,D7995,Synthetic graft facial bones,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7996,Implant mandible for augment,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Meridian Medicaid,CPT,D7997,Appliance removal,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7998,Intraoral place of fix dev,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D7999,Oral surgery procedure,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Meridian Medicaid,CPT,D8010,Limited dental tx primary,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Meridian Medicaid,CPT,D8020,Limited dental tx transition,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Meridian Medicaid,CPT,D8030,Limited dental tx adolescent,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Meridian Medicaid,CPT,D8040,Limited dental tx adult,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Meridian Medicaid,CPT,D8050,Intercep dental tx primary,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Meridian Medicaid,CPT,D8060,Intercep dental tx transitn,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Meridian Medicaid,CPT,D8070,Compre dental tx transition,Dental,Per Unit,$195.04 ,OP,195.04,195.04,,,,,,
Meridian Medicaid,CPT,D8080,Compre dental tx adolescent,Dental,Per Unit,$195.04 ,OP,195.04,195.04,,,,,,
Meridian Medicaid,CPT,D8090,Compre dental tx adult,Dental,Per Unit,$195.04 ,OP,195.04,195.04,,,,,,
Meridian Medicaid,CPT,D8210,Orthodontic rem appliance tx,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Meridian Medicaid,CPT,D8220,Fixed appliance therapy habt,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Meridian Medicaid,CPT,D8660,Preorthodontic tx visit,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Meridian Medicaid,CPT,D8670,Periodic orthodontc tx visit,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Meridian Medicaid,CPT,D8680,Orthodontic retention,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Meridian Medicaid,CPT,D8681,Removable retainer adjust,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D8690,Orthodontic treatment,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Meridian Medicaid,CPT,D8691,Repair ortho appliance,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Meridian Medicaid,CPT,D8692,Replacement retainer,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Meridian Medicaid,CPT,D8693,Rebond/recement retainers,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Meridian Medicaid,CPT,D8694,Repair fixed retainers,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Meridian Medicaid,CPT,D8695,Remove fixed ortho appliance,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Meridian Medicaid,CPT,D8696,Rep of ortho appliance max,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Meridian Medicaid,CPT,D8697,Rep of ortho appliance man,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Meridian Medicaid,CPT,D8698,Recement fixed retainer max,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Meridian Medicaid,CPT,D8699,Recement fixed retainer man,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Meridian Medicaid,CPT,D8701,Repair fixed retainer max,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Meridian Medicaid,CPT,D8702,Repair of fixed retainer man,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Meridian Medicaid,CPT,D8703,Replace broken retainer max,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Meridian Medicaid,CPT,D8704,Replace broken retainer man,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Meridian Medicaid,CPT,D8999,Orthodontic procedure,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Meridian Medicaid,CPT,D9110,Tx dental pain minor proc,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D9120,Fix partial denture section,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Meridian Medicaid,CPT,D9130,Temporomandibular joint dysf,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,D9210,Dent anesthesia w/o surgery,Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
Meridian Medicaid,CPT,D9211,Regional block anesthesia,Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
Meridian Medicaid,CPT,D9212,Trigeminal block anesthesia,Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
Meridian Medicaid,CPT,D9215,Local anesthesia,Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
Meridian Medicaid,CPT,D9219,Eval mod/deep sed/gen anest,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Meridian Medicaid,CPT,D9220,General anesthesia,Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
Meridian Medicaid,CPT,D9221,General anesthesia ea ad 15m,Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
Meridian Medicaid,CPT,D9222,"Deep anest, 1st 15 min",Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
Meridian Medicaid,CPT,D9223,General anesth ea addl 15 mi,Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
Meridian Medicaid,CPT,D9230,Analgesia,Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
Meridian Medicaid,CPT,D9239,"Iv mod sedation, 1st 15 min",Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
Meridian Medicaid,CPT,D9241,Intravenous sedation,Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
Meridian Medicaid,CPT,D9242,Iv sedation ea ad 15 m,Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
Meridian Medicaid,CPT,D9243,Iv sedation ea addl 15m,Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
Meridian Medicaid,CPT,D9248,Sedation (non-iv),Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
Meridian Medicaid,CPT,D9310,Dental consultation,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D9311,Consult w/med hlth care prof,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D9410,Dental house call,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D9420,Hospital/asc call,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D9430,Office visit during hours,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D9440,Office visit after hours,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D9450,Case presentation tx plan,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,D9610,Dent therapeutic drug inject,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D9612,Thera par drugs 2 or > admin,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D9613,Infiltration thera drug,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D9630,Drugs/meds disp for home use,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D9910,Dent appl desensitizing med,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D9911,Appl desensitizing resin,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D9920,Behavior management,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D9930,Treatment of complications,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D9931,Clean/inspect rem appliance,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D9932,Clean & inspect rem dent max,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D9933,Clean & inspect rem dent man,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D9934,Clean rem part denture max,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D9935,Clean rem part denture mand,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D9940,Dental occlusal guard,Dental,Per Unit,$156.21 ,OP,156.21,156.21,,,,,,
Meridian Medicaid,CPT,D9941,Fabrication athletic guard,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D9942,Repair/reline occlusal guard,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D9943,Occlusal guard adjustment,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D9944,"Occ guard, hard, full arch",Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D9945,"Occ guard, soft, full arch",Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D9946,"Occ guard, hard, part arch",Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D9950,Occlusion analysis,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D9951,Limited occlusal adjustment,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D9952,Complete occlusal adjustment,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D9970,Enamel microabrasion,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D9971,Odontoplasty per tooth,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D9972,Extrnl bleaching per arch,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D9973,Extrnl bleaching per tooth,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D9974,Intrnl bleaching per tooth,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D9975,External bleaching home app,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D9991,"Case mgmt, appt barriers",Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,D9992,"Case mgmt, care coordination",Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,D9993,"Case mgmt, interviewing",Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,D9994,"Case mgmt, pt education",Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Meridian Medicaid,CPT,D9995,Teledentistry real-time,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D9996,Teledentistry dent review,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,D9997,Dent case mgmt special needs,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,D9999,Adjunctive procedure,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Meridian Medicaid,CPT,G0008,Admin influenza virus vac,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,G0009,Admin pneumococcal vaccine,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,G0010,Admin hepatitis b vaccine,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Meridian Medicaid,CPT,G0027,Semen analysis,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,G0068,Adm iv infusion drug in home,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Meridian Medicaid,CPT,G0069,Adm sq infusion drug in home,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Meridian Medicaid,CPT,G0070,Adm of chemo drug in home,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Meridian Medicaid,CPT,G0071,Comm svcs by rhc/fqhc 5 min,Ancillary Services,Per Unit,$26.19 ,OP,26.19,26.19,,,,,,
Meridian Medicaid,CPT,G0076,Care manag h vst new pt 20 m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,G0077,Care manag h vst new pt 30 m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,G0078,Care manag h vst new pt 45 m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,G0079,Care manag h vst new pt 60 m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,G0080,Care manag h vst new pt 75 m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,G0081,Care man h v ext pt 20 mi,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,G0082,Care man h v ext pt 30 m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,G0083,Care man h v ext pt 45 m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,G0084,Care man h v ext pt 60 m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,G0085,Care man h v ext pt 75 m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,G0086,Care man home care plan 30 m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,G0087,Care man home care plan 60 m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,G0088,Adm iv drug 1st home visit,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Meridian Medicaid,CPT,G0089,Adm subq drug 1st home visit,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Meridian Medicaid,CPT,G0090,Adm iv chemo 1st home visit,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Meridian Medicaid,CPT,G0103,Psa screening,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,G0104,Ca screen;flexi sigmoidscope,Preventive Care,Per Unit,$387.00 ,OP,387,387,,,,,,
Meridian Medicaid,CPT,G0105,Colorectal scrn; hi risk ind,Preventive Care,Per Unit,$387.00 ,OP,387,387,,,,,,
Meridian Medicaid,CPT,G0108,Diab manage trn per indiv,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Meridian Medicaid,CPT,G0109,Diab manage trn ind/group,Preventive Care,Per Unit,$26.23 ,OP,26.23,26.23,,,,,,
Meridian Medicaid,CPT,G0117,Glaucoma scrn hgh risk direc,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,G0118,Glaucoma scrn hgh risk direc,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,G0121,Colon ca scrn not hi rsk ind,Preventive Care,Per Unit,$387.00 ,OP,387,387,,,,,,
Meridian Medicaid,CPT,G0122,Colon ca scrn; barium enema,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Meridian Medicaid,CPT,G0123,Screen cerv/vag thin layer,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Meridian Medicaid,CPT,G0124,Screen c/v thin layer by md,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Meridian Medicaid,CPT,G0127,Trim nail(s),General Surgery,Per Unit,$46.77 ,OP,46.77,46.77,,,,,,
Meridian Medicaid,CPT,G0128,Corf skilled nursing service,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,G0130,Single energy x-ray study,Diagnostic Radiology,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
Meridian Medicaid,CPT,G0141,"Scr c/v cyto,autosys and md",Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Meridian Medicaid,CPT,G0143,"Scr c/v cyto,thinlayer,rescr",Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Meridian Medicaid,CPT,G0144,"Scr c/v cyto,thinlayer,rescr",Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Meridian Medicaid,CPT,G0145,"Scr c/v cyto,thinlayer,rescr",Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Meridian Medicaid,CPT,G0147,"Scr c/v cyto, automated sys",Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Meridian Medicaid,CPT,G0148,"Scr c/v cyto, autosys, rescr",Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Meridian Medicaid,CPT,G0151,"Hhcp-serv of pt,ea 15 min",Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,G0152,"Hhcp-serv of ot,ea 15 min",Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,G0153,"Hhcp-svs of s/l path,ea 15mn",Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,G0155,"Hhcp-svs of csw,ea 15 min",Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,G0157,Hhc pt assistant ea 15,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,G0158,Hhc ot assistant ea 15,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,G0159,Hhc pt maint ea 15 min,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,G0160,Hhc occup therapy ea 15,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,G0161,Hhc slp ea 15 min,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,G0162,"Hhc rn e&m plan svs, 15 min",Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,G0166,"Extrnl counterpulse, per tx",Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,G0175,"Opps service,sched team conf",Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,G0176,Opps/php;activity therapy,Behavioral Health,Per Unit,$48.15 ,OP,48.15,48.15,,,,,,
Meridian Medicaid,CPT,G0177,Opps/php; train & educ serv,Behavioral Health,Per Unit,$48.15 ,OP,48.15,48.15,,,,,,
Meridian Medicaid,CPT,G0179,Md recertification hha pt,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,G0180,Md certification hha patient,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,G0181,Home health care supervision,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,G0182,Hospice care supervision,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,G0186,"Dstry eye lesn,fdr vssl tech",Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Meridian Medicaid,CPT,G0202,Scr mammo bi incl cad,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
Meridian Medicaid,CPT,G0204,Dx mammo incl cad bi,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
Meridian Medicaid,CPT,G0206,Dx mammo incl cad uni,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
Meridian Medicaid,CPT,G0219,Pet img wholbod melano nonco,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Meridian Medicaid,CPT,G0235,Pet not otherwise specified,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Meridian Medicaid,CPT,G0237,Therapeutic procd strg endur,Rehabilitation,Per Unit,$73.11 ,OP,73.11,73.11,,,,,,
Meridian Medicaid,CPT,G0238,"Oth resp proc, indiv",Rehabilitation,Per Unit,$73.11 ,OP,73.11,73.11,,,,,,
Meridian Medicaid,CPT,G0239,"Oth resp proc, group",Rehabilitation,Per Unit,$73.11 ,OP,73.11,73.11,,,,,,
Meridian Medicaid,CPT,G0248,Demonstrate use home inr mon,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Meridian Medicaid,CPT,G0252,Pet imaging initial dx,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Meridian Medicaid,CPT,G0255,Current percep threshold tst,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,G0257,Unsched dialysis esrd pt hos,Nephrology,Per Unit,$540.95 ,OP,540.95,540.95,,,,,,
Meridian Medicaid,CPT,G0270,Mnt subs tx for change dx,Ancillary Services,Per Unit,$100.15 ,OP,100.15,100.15,,,,,,
Meridian Medicaid,CPT,G0271,Group mnt 2 or more 30 mins,Ancillary Services,Per Unit,$100.15 ,OP,100.15,100.15,,,,,,
Meridian Medicaid,CPT,G0278,"Iliac art angio,cardiac cath",Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Meridian Medicaid,CPT,G0279,"Tomosynthesis, mammo",Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
Meridian Medicaid,CPT,G0283,Elec stim other than wound,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,G0289,"Arthro, loose body + chondro",Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,G0293,"Non-cov surg proc,clin trial",Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,G0297,Ldct for lung ca screen,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Meridian Medicaid,CPT,G0306,Cbc/diffwbc w/o platelet,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Meridian Medicaid,CPT,G0307,Cbc without platelet,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Meridian Medicaid,CPT,G0328,Fecal blood scrn immunoassay,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,G0339,"Robot lin-radsurg com, first",Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"2,592.65","2,592.65",,,,,,
Meridian Medicaid,CPT,G0340,Robt lin-radsurg fractx 2-5,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"2,592.65","2,592.65",,,,,,
Meridian Medicaid,CPT,G0365,Vessel mapping hemo access,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Meridian Medicaid,CPT,G0378,Hospital observation per hr,Ancillary Services,Per Unit,$651.20 ,OP,651.2,651.2,,,,,,
Meridian Medicaid,CPT,G0389,Ultrasound exam aaa screen,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,G0396,Alcohol/subs interv 15-30mn,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Meridian Medicaid,CPT,G0397,Alcohol/subs interv >30 min,Behavioral Health,Per Unit,$84.55 ,OP,84.55,84.55,,,,,,
Meridian Medicaid,CPT,G0403,Ekg for initial prevent exam,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Meridian Medicaid,CPT,G0404,Ekg tracing for initial prev,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Meridian Medicaid,CPT,G0405,Ekg interpret & report preve,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Meridian Medicaid,CPT,G0409,Corf related serv 15 mins ea,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Meridian Medicaid,CPT,G0410,Grp psych partial hosp 45-50,Behavioral Health,Per Unit,$119.88 ,OP,119.88,119.88,,,,,,
Meridian Medicaid,CPT,G0411,Inter active grp psych parti,Behavioral Health,Per Unit,$119.88 ,OP,119.88,119.88,,,,,,
Meridian Medicaid,CPT,G0412,Open tx iliac spine uni/bil,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,G0413,Pelvic ring fracture uni/bil,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,G0414,Pelvic ring fx treat int fix,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,G0415,Open tx post pelvic fxcture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Meridian Medicaid,CPT,G0420,Ed svc ckd ind per session,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Meridian Medicaid,CPT,G0421,Ed svc ckd grp per session,Preventive Care,Per Unit,$26.23 ,OP,26.23,26.23,,,,,,
Meridian Medicaid,CPT,G0422,Intens cardiac rehab w/exerc,Rehabilitation,Per Unit,$274.82 ,OP,274.82,274.82,,,,,,
Meridian Medicaid,CPT,G0423,Intens cardiac rehab no exer,Rehabilitation,Per Unit,$274.82 ,OP,274.82,274.82,,,,,,
Meridian Medicaid,CPT,G0424,Pulmonary rehab w exer,Rehabilitation,Per Unit,$73.11 ,OP,73.11,73.11,,,,,,
Meridian Medicaid,CPT,G0431,Drug screen multiple class,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,G0432,Eia hiv-1/hiv-2 screen,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,G0433,Elisa hiv-1/hiv-2 screen,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,G0434,Drug screen multi drug class,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,G0435,Oral hiv-1/hiv-2 screen,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,G0436,Tobacco-use counsel 3-10 min,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Meridian Medicaid,CPT,G0437,Tobacco-use counsel>10min,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Meridian Medicaid,CPT,G0442,Annual alcohol screen 15 min,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Meridian Medicaid,CPT,G0443,Brief alcohol misuse counsel,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Meridian Medicaid,CPT,G0444,Depression screen annual,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Meridian Medicaid,CPT,G0445,High inten beh couns std 30m,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Meridian Medicaid,CPT,G0446,Intens behave ther cardio dx,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Meridian Medicaid,CPT,G0447,Behavior counsel obesity 15m,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Meridian Medicaid,CPT,G0448,Place perm pacing cardiovert,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Meridian Medicaid,CPT,G0451,Devlopment test interpt&rep,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Meridian Medicaid,CPT,G0452,Molecular pathology interpr,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Meridian Medicaid,CPT,G0459,Telehealth inpt pharm mgmt,Behavioral Health,Per Unit,$80.13 ,OP,80.13,80.13,,,,,,
Meridian Medicaid,CPT,G0464,"Colorec CA scr, sto bas DNA",Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Meridian Medicaid,CPT,G0472,Hep c screen high risk/other,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,G0473,Group behave couns 2-10,Behavioral Health,Per Unit,$119.88 ,OP,119.88,119.88,,,,,,
Meridian Medicaid,CPT,G0475,Hiv combination assay,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,G0476,Hpv combo assay ca screen,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,G0477,Drug test presump optical,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,G0478,Drug test presump opt inst,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,G0479,Drug test presump not opt,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,G0480,Drug test def 1-7 classes,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,G0491,Dialysis acu kidney no esrd,Nephrology,Per Unit,$540.95 ,OP,540.95,540.95,,,,,,
Meridian Medicaid,CPT,G0492,Md/oth eval acut kid no esrd,Nephrology,Per Unit,$540.95 ,OP,540.95,540.95,,,,,,
Meridian Medicaid,CPT,G0495,Rn care train/edu in hh,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Meridian Medicaid,CPT,G0496,Lpn care train/edu in hh,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Meridian Medicaid,CPT,G0498,Chemo extend iv infus w/pump,General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
Meridian Medicaid,CPT,G0499,Hepb screen high risk indiv,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,G0500,Mod sedat endo service >5yrs,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Meridian Medicaid,CPT,G0502,"Init psych care manag, 70min",Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Meridian Medicaid,CPT,G0503,"Subseq  psych care man,60mi",Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Meridian Medicaid,CPT,G0504,Init/sub psych care add 30 m,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Meridian Medicaid,CPT,G0506,Comp asses care plan ccm svc,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,G0507,Care manage serv minimum 20,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Meridian Medicaid,CPT,G0511,Ccm/bhi by rhc/fqhc 20min mo,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,G0512,Cocm by rhc/fqhc 60 min mo,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Meridian Medicaid,CPT,G0515,Cognitive skills development,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,G0516,"Insert drug del implant, >=4",General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,G0517,Remove drug implant,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Meridian Medicaid,CPT,G0518,Remove w insert drug implant,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
Meridian Medicaid,CPT,G0659,Drug test def simple all cl,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Meridian Medicaid,CPT,G2000,Blinded conv. tx mdd clin tr,Behavioral Health,Per Unit,$276.44 ,OP,276.44,276.44,,,,,,
Meridian Medicaid,CPT,G2010,Remot image submit by pt,Ancillary Services,Per Unit,$26.19 ,OP,26.19,26.19,,,,,,
Meridian Medicaid,CPT,G2011,Alcohol/sub misuse assess,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Meridian Medicaid,CPT,G2012,Brief check in by md/qhp,Ancillary Services,Per Unit,$26.19 ,OP,26.19,26.19,,,,,,
Meridian Medicaid,CPT,G2014,Post-d/c care plan overs 30m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,G2015,Post-d/c care plan overs 60m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,G2058,Ccm add 20min,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,G2064,Md mang high risk dx 30,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,G2065,Clin mang h risk dx 30,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,G2066,Inter devc remote 30d,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Meridian Medicaid,CPT,G2082,Visit esketamine 56m or less,Behavioral Health,Per Unit,$80.13 ,OP,80.13,80.13,,,,,,
Meridian Medicaid,CPT,G2083,"Visit esketamine, > 56m",Behavioral Health,Per Unit,$80.13 ,OP,80.13,80.13,,,,,,
Meridian Medicaid,CPT,G2168,Svs by pt in home health,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,G2169,Svs by ot in home health,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,G2213,Initiat med assist tx in er,Behavioral Health,Per Unit,$80.13 ,OP,80.13,80.13,,,,,,
Meridian Medicaid,CPT,G2214,Init/sub psych care m 1st 30,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Meridian Medicaid,CPT,G2250,"Remot img sub by pt, non e/m",Ancillary Services,Per Unit,$26.19 ,OP,26.19,26.19,,,,,,
Meridian Medicaid,CPT,G2251,"Brief chkin, 5-10, non-e/m",Ancillary Services,Per Unit,$26.19 ,OP,26.19,26.19,,,,,,
Meridian Medicaid,CPT,G2252,"Brief chkin by md/qhp, 11-20",Ancillary Services,Per Unit,$26.19 ,OP,26.19,26.19,,,,,,
Meridian Medicaid,CPT,G3001,"Admin + supply, tositumomab",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Meridian Medicaid,CPT,G6001,Echo guidance radiotherapy,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Meridian Medicaid,CPT,G6002,Stereoscopic x-ray guidance,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Meridian Medicaid,CPT,G6003,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Meridian Medicaid,CPT,G6004,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Meridian Medicaid,CPT,G6005,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Meridian Medicaid,CPT,G6006,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Meridian Medicaid,CPT,G6007,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Meridian Medicaid,CPT,G6008,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Meridian Medicaid,CPT,G6009,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Meridian Medicaid,CPT,G6010,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Meridian Medicaid,CPT,G6011,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Meridian Medicaid,CPT,G6012,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Meridian Medicaid,CPT,G6013,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Meridian Medicaid,CPT,G6014,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Meridian Medicaid,CPT,G6015,Radiation tx delivery imrt,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Meridian Medicaid,CPT,G6016,Delivery comp imrt,Therapeutic Radiology,Per Unit,$434.17 ,OP,434.17,434.17,,,,,,
Meridian Medicaid,CPT,G6018,Ileoscopy w/stent,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
Meridian Medicaid,CPT,G6019,Colonoscopy lesion removal,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Meridian Medicaid,CPT,G6020,Colonoscopy w/stent,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Meridian Medicaid,CPT,G6021,Unlisted px small intestine,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Meridian Medicaid,CPT,G6022,Sigmoidoscopy w/ablate tumr,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,G6023,Sigmoidoscopy w/stent,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Meridian Medicaid,CPT,G6024,Lesion removal colonoscopy,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,G6025,Colonoscopy w/stent,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Meridian Medicaid,CPT,G6027,Anoscopy hra w/spec collect,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,G6028,Anoscopy hra w/biopsy,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Meridian Medicaid,CPT,G6030,Assay of amitriptyline,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,G6031,Assay of benzodiazepines,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,G6032,Assay of desipramine,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,G6034,Assay of doxepin,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,G6035,Assay of  gold,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,G6036,Assay of Imipramine,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,G6037,Assay of nortiptyline,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,G6038,Assay of salicylate,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Meridian Medicaid,CPT,G6039,Assay of acetaminophen,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Meridian Medicaid,CPT,G6040,Assay of ethanol,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Meridian Medicaid,CPT,G6041,Assay of urine alkaloids,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Meridian Medicaid,CPT,G6042,Assay of amphetamines,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Meridian Medicaid,CPT,G6043,Assay of barbiturates,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Meridian Medicaid,CPT,G6044,Assay of cocaine,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Meridian Medicaid,CPT,G6045,Assay of dihydrocodeinone,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Meridian Medicaid,CPT,G6046,Assay of dihydromorphinone,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Meridian Medicaid,CPT,G6047,Assay of dihydrotestosterone,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Meridian Medicaid,CPT,G6048,Assay of dimethadione,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Meridian Medicaid,CPT,G6049,Assay of Epiandrosterone,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Meridian Medicaid,CPT,G6050,Assay of Ethchlorvynol,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Meridian Medicaid,CPT,G6051,Assay of flurazepam,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Meridian Medicaid,CPT,G6052,Assay of meprobamate,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Meridian Medicaid,CPT,G6053,Assay of methadone,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Meridian Medicaid,CPT,G6054,Assay of methsuximide,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Meridian Medicaid,CPT,G6055,Assay of nicotine,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Meridian Medicaid,CPT,G6056,Assay of opiates,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Meridian Medicaid,CPT,G6057,Assay of phenothiazine,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Meridian Medicaid,CPT,G6058,Drug confirmation,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Meridian Medicaid,CPT,G9012,Other specified case mgmt,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,G9016,Demo-smoking cessation coun,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Meridian Medicaid,CPT,G9020,Rimantadine hcl 100mg oral,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,G9034,"Zanamivir, inh pwdr, brand",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Meridian Medicaid,CPT,G9035,"Oseltamivir phosp, brand",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Meridian Medicaid,CPT,G9143,Warfarin respon genetic test,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,G9147,Outpt iv insulin tx any mea,General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
Meridian Medicaid,CPT,G9157,Transesoph doppl cardiac mon,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Meridian Medicaid,CPT,G9187,Bpci home visit,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,G9477,Care coord at hospice,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,G9686,Nursing facility conference,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,G9873,1 em core session,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Meridian Medicaid,CPT,G9874,4 em core sessions,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Meridian Medicaid,CPT,G9875,9 em core sessions,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Meridian Medicaid,CPT,G9876,2 em core ms mo 7-9 no wl,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Meridian Medicaid,CPT,G9877,2 em core ms mo 10-12 no wl,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Meridian Medicaid,CPT,G9878,2 em core ms mo 7-9 wl,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Meridian Medicaid,CPT,G9879,2 em core ms mo 10-12 wl,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Meridian Medicaid,CPT,G9880,Em 5 percent wl,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Meridian Medicaid,CPT,G9881,Em 9 percent wl,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Meridian Medicaid,CPT,G9882,2 em ongoing ms mo 13-15 wl,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Meridian Medicaid,CPT,G9883,2 em ongoing ms mo 16-18 wl,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Meridian Medicaid,CPT,G9884,2 em ongoing ms mo 19-21 wl,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Meridian Medicaid,CPT,G9885,2 em ongoing ms mo 22-24 wl,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Meridian Medicaid,CPT,G9890,Em bridge payment,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Meridian Medicaid,CPT,G9987,Bpci advanced in home visit,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,H0001,Alcohol and/or drug assess,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
Meridian Medicaid,CPT,H0002,Alcohol and/or drug screenin,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
Meridian Medicaid,CPT,H0003,Alcohol and/or drug screenin,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,H0004,Alcohol and/or drug services,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Meridian Medicaid,CPT,H0005,Alcohol and/or drug services,Behavioral Health,Per Unit,$119.88 ,OP,119.88,119.88,,,,,,
Meridian Medicaid,CPT,H0006,Alcohol and/or drug services,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Meridian Medicaid,CPT,H0007,Alcohol and/or drug services,Behavioral Health,Per Unit,$135.70 ,OP,135.7,135.7,,,,,,
Meridian Medicaid,CPT,H0014,Alcohol and/or drug services,Behavioral Health,Per Unit,$80.13 ,OP,80.13,80.13,,,,,,
Meridian Medicaid,CPT,H0015,Alcohol and/or drug services,Behavioral Health,Per Unit,$339.88 ,OP,339.88,339.88,,,,,,
Meridian Medicaid,CPT,H0020,Alcohol and/or drug services,Behavioral Health,Per Unit,$80.13 ,OP,80.13,80.13,,,,,,
Meridian Medicaid,CPT,H0022,Alcohol and/or drug interven,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Meridian Medicaid,CPT,H0031,Mh health assess by non-md,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
Meridian Medicaid,CPT,H0032,Mh svc plan dev by non-md,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Meridian Medicaid,CPT,H0033,Oral med adm direct observe,Behavioral Health,Per Unit,$80.13 ,OP,80.13,80.13,,,,,,
Meridian Medicaid,CPT,H0034,Med trng & support per 15min,Behavioral Health,Per Unit,$80.13 ,OP,80.13,80.13,,,,,,
Meridian Medicaid,CPT,H0035,Mh partial hosp tx under 24h,Behavioral Health,Per Unit,$220.60 ,OP,220.6,220.6,,,,,,
Meridian Medicaid,CPT,H0037,Comm psy sup tx pgm per diem,Behavioral Health,Per Unit,$220.60 ,OP,220.6,220.6,,,,,,
Meridian Medicaid,CPT,H0046,"Mental health service, nos",Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Meridian Medicaid,CPT,H0047,Alcohol/drug abuse svc nos,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Meridian Medicaid,CPT,H0049,Alcohol/drug screening,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Meridian Medicaid,CPT,H0050,Alcohol/drug service 15 min,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Meridian Medicaid,CPT,H1002,Carecoordination prenatal,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,H1003,Prenatal at risk education,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Meridian Medicaid,CPT,H1011,Family assessment,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
Meridian Medicaid,CPT,H2000,Comp multidisipln evaluation,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Meridian Medicaid,CPT,H2001,Rehabilitation program 1/2 d,Behavioral Health,Per Unit,$166.94 ,OP,166.94,166.94,,,,,,
Meridian Medicaid,CPT,H2010,Comprehensive med svc 15 min,Behavioral Health,Per Unit,$80.13 ,OP,80.13,80.13,,,,,,
Meridian Medicaid,CPT,H2011,"Crisis interven svc, 15 min",Behavioral Health,Per Unit,$135.70 ,OP,135.7,135.7,,,,,,
Meridian Medicaid,CPT,H2012,"Behav hlth day treat, per hr",Behavioral Health,Per Unit,$276.34 ,OP,276.34,276.34,,,,,,
Meridian Medicaid,CPT,H2014,"Skills train and dev, 15 min",Behavioral Health,Per Unit,$48.15 ,OP,48.15,48.15,,,,,,
Meridian Medicaid,CPT,H2017,"Psysoc rehab svc, per 15 min",Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Meridian Medicaid,CPT,H2018,"Psysoc rehab svc, per diem",Behavioral Health,Per Unit,$220.60 ,OP,220.6,220.6,,,,,,
Meridian Medicaid,CPT,H2019,"Ther behav svc, per 15 min",Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Meridian Medicaid,CPT,H2020,"Ther behav svc, per diem",Behavioral Health,Per Unit,$220.60 ,OP,220.6,220.6,,,,,,
Meridian Medicaid,CPT,H2027,"Psychoed svc, per 15 min",Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Meridian Medicaid,CPT,H2028,"Sex offend tx svc, 15 min",Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Meridian Medicaid,CPT,H2029,"Sex offend tx svc, per diem",Behavioral Health,Per Unit,$220.60 ,OP,220.6,220.6,,,,,,
Meridian Medicaid,CPT,H2032,"Activity therapy, per 15 min",Behavioral Health,Per Unit,$48.15 ,OP,48.15,48.15,,,,,,
Meridian Medicaid,CPT,H2033,Multisys ther/juvenile 15min,Behavioral Health,Per Unit,$48.15 ,OP,48.15,48.15,,,,,,
Meridian Medicaid,CPT,H2035,"A/d tx program, per hour",Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Meridian Medicaid,CPT,H2036,"A/d tx program, per diem",Behavioral Health,Per Unit,$220.60 ,OP,220.6,220.6,,,,,,
Meridian Medicaid,CPT,J0121,"Inj., omadacycline, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Meridian Medicaid,CPT,J0122,"Inj., eravacycline, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,J0129,Abatacept injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Meridian Medicaid,CPT,J0130,Abciximab injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Meridian Medicaid,CPT,J0135,Adalimumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,518.96,518.96,,,,,,
Meridian Medicaid,CPT,J0178,Aflibercept injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Meridian Medicaid,CPT,J0179,"Inj, brolucizumab-dbll, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Meridian Medicaid,CPT,J0180,Agalsidase beta injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Meridian Medicaid,CPT,J0185,"Inj., aprepitant, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Meridian Medicaid,CPT,J0202,"Injection, alemtuzumab",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,J0205,Alglucerase injection,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Meridian Medicaid,CPT,J0207,Amifostine,Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,244.88,244.88,,,,,,
Meridian Medicaid,CPT,J0210,Methyldopate hcl injection,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Meridian Medicaid,CPT,J0215,Alefacept,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Meridian Medicaid,CPT,J0220,Alglucosidase alfa injection,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,J0221,Lumizyme injection,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,J0222,"Inj., patisiran, 0.1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,J0223,Inj givosiran 0.5 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,J0256,Alpha 1 proteinase inhibitor,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Meridian Medicaid,CPT,J0257,Glassia injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Meridian Medicaid,CPT,J0287,Amphotericin b lipid complex,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,J0288,Ampho b cholesteryl sulfate,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,J0289,Amphotericin b liposome inj,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,J0291,"Inj., plazomicin, 5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,J0348,Anidulafungin injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,J0350,Injection anistreplase 30 u,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,J0364,Apomorphine hydrochloride,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,J0365,"Aprotonin, 10,000 kiu",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Meridian Medicaid,CPT,J0401,Inj aripiprazole ext rel 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Meridian Medicaid,CPT,J0475,Baclofen 10 mg injection,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,384.11,384.11,,,,,,
Meridian Medicaid,CPT,J0480,Basiliximab,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Meridian Medicaid,CPT,J0485,Belatacept injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Meridian Medicaid,CPT,J0490,Belimumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Meridian Medicaid,CPT,J0517,"Inj., benralizumab, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,J0558,Peng benzathine/procaine inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,J0561,Penicillin g benzathine inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,J0565,"Inj, bezlotoxumab, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Meridian Medicaid,CPT,J0567,"Inj., cerliponase alfa 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,J0570,Buprenorphine implant 74.2mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Meridian Medicaid,CPT,J0583,Bivalirudin,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,J0584,"Injection, burosumab-twza 1m",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,J0585,"Injection,onabotulinumtoxina",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,J0586,Abobotulinumtoxina,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,384.11,384.11,,,,,,
Meridian Medicaid,CPT,J0587,"Inj, rimabotulinumtoxinb",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,J0588,Incobotulinumtoxin a,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,J0591,"Inj deoxycholic acid, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,J0593,"Inj., lanadelumab-flyo, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,J0594,Busulfan injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Meridian Medicaid,CPT,J0596,"Injection, ruconest",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J0597,"C-1 esterase, berinert",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,J0598,"C-1 esterase, cinryze",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,J0599,"Inj., haegarda 10 units",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,J0600,Edetate calcium disodium inj,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J0604,"Cinacalcet, esrd on dialysis",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,J0606,"Inj, etelcalcetide, 0.1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,J0630,Calcitonin salmon injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Meridian Medicaid,CPT,J0637,Caspofungin acetate,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,J0638,Canakinumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Meridian Medicaid,CPT,J0641,Inj levoleucovorin nos 0.5mg,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
Meridian Medicaid,CPT,J0642,"Injection, khapzory, 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,J0691,Inj lefamulin 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Meridian Medicaid,CPT,J0693,"Inj., cefiderocol, 5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Meridian Medicaid,CPT,J0695,Inj ceftolozane tazobactam,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Meridian Medicaid,CPT,J0712,Ceftaroline fosamil inj,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
Meridian Medicaid,CPT,J0714,Ceftazidime and avibactam,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,J0716,Centruroides immune f(ab),Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Meridian Medicaid,CPT,J0717,Certolizumab pegol inj 1mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Meridian Medicaid,CPT,J0740,Cidofovir injection,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Meridian Medicaid,CPT,J0742,Inj imip 4 cilas 4 releb 2mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Meridian Medicaid,CPT,J0775,"Collagenase, clost hist inj",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Meridian Medicaid,CPT,J0791,Inj crizanlizumab-tmca 5mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Meridian Medicaid,CPT,J0795,Corticorelin ovine triflutal,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Meridian Medicaid,CPT,J0800,Corticotropin injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,J0833,Cosyntropin injection nos,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,J0840,Crotalidae poly immune fab,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Meridian Medicaid,CPT,J0841,Inj crotalidae im f(ab')2 eq,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Meridian Medicaid,CPT,J0850,Cytomegalovirus imm iv /vial,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Meridian Medicaid,CPT,J0875,"Injection, dalbavancin",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,J0878,Daptomycin injection,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,189.67,189.67,,,,,,
Meridian Medicaid,CPT,J0881,"Darbepoetin alfa, non-esrd",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,J0882,"Darbepoetin alfa, esrd use",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Meridian Medicaid,CPT,J0883,Argatroban nonesrd use 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,J0884,Argatroban esrd dialysis 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,J0885,"Epoetin alfa, non-esrd",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,J0886,Epoetin alfa 1000 units esrd,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,J0890,Peginesatide injection,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Meridian Medicaid,CPT,J0894,Decitabine injection,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Meridian Medicaid,CPT,J0896,Inj luspatercept-aamt 0.25mg,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Meridian Medicaid,CPT,J0897,Denosumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,518.96,518.96,,,,,,
Meridian Medicaid,CPT,J1095,"Injection, dexamethasone 9%",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,J1096,Dexametha opth insert 0.1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,J1097,Phenylep ketorolac opth soln,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,J1162,Digoxin immune fab (ovine),Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J1190,Dexrazoxane hcl injection,Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,244.88,244.88,,,,,,
Meridian Medicaid,CPT,J1201,Inj. cetirizine hcl 0.5mg,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,J1205,Chlorothiazide sodium inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,J1212,Dimethyl sulfoxide 50% 50 ml,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,J1267,Doripenem injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,J1290,Ecallantide injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Meridian Medicaid,CPT,J1300,Eculizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,J1301,"Injection, edaravone, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Meridian Medicaid,CPT,J1303,"Inj., ravulizumab-cwvz 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,J1322,"Elosulfase alfa, injection",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,J1327,Eptifibatide injection,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Meridian Medicaid,CPT,J1410,Inj estrogen conjugate 25 mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Meridian Medicaid,CPT,J1428,"Inj, eteplirsen, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,J1429,Inj golodirsen 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,J1430,Ethanolamine oleate 100 mg,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,384.11,384.11,,,,,,
Meridian Medicaid,CPT,J1436,Etidronate disodium inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,J1437,Inj. fe derisomaltose 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,J1438,Etanercept injection,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,J1439,Inj ferric carboxymaltos 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,J1442,Inj filgrastim excl biosimil,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,J1446,"Inj, tbo-filgrastim, 5 mcg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,J1447,Inj tbo filgrastim 1 microg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,J1451,"Fomepizole, 15 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,J1452,Intraocular fomivirsen na,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,J1453,Fosaprepitant injection,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Meridian Medicaid,CPT,J1454,"Inj fosnetupitant, palonoset",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,J1455,Foscarnet sodium injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,J1457,Gallium nitrate injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,J1458,Galsulfase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,J1459,Inj ivig privigen 500 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Meridian Medicaid,CPT,J1460,Gamma globulin 1 cc inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,J1555,"Inj cuvitru, 100 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Meridian Medicaid,CPT,J1556,"Inj, imm glob bivigam, 500mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,J1557,Gammaplex injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,J1558,"Inj. xembify, 100 mg",Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,384.11,384.11,,,,,,
Meridian Medicaid,CPT,J1559,Hizentra injection,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,384.11,384.11,,,,,,
Meridian Medicaid,CPT,J1560,Gamma globulin > 10 cc inj,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,J1561,Gamunex-c/gammaked,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Meridian Medicaid,CPT,J1562,"Vivaglobin, inj",Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,384.11,384.11,,,,,,
Meridian Medicaid,CPT,J1566,"Immune globulin, powder",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Meridian Medicaid,CPT,J1568,Octagam injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Meridian Medicaid,CPT,J1569,Gammagard liquid injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Meridian Medicaid,CPT,J1570,Ganciclovir sodium injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,J1571,Hepagam b im injection,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,J1572,Flebogamma injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Meridian Medicaid,CPT,J1573,"Hepagam b intravenous, inj",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,J1575,Hyqvia 100mg immuneglobulin,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,J1595,Injection glatiramer acetate,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,J1599,"Ivig non-lyophilized, nos",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Meridian Medicaid,CPT,J1602,Golimumab for iv use 1mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Meridian Medicaid,CPT,J1610,Glucagon hydrochloride/1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Meridian Medicaid,CPT,J1628,"Inj., guselkumab, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Meridian Medicaid,CPT,J1632,"Inj., brexanolone, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J1640,"Hemin, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J1670,Tetanus immune globulin inj,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,J1675,Histrelin acetate,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Meridian Medicaid,CPT,J1738,Inj. meloxicam 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,J1740,Ibandronate sodium injection,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Meridian Medicaid,CPT,J1742,Ibutilide fumarate injection,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
Meridian Medicaid,CPT,J1743,Idursulfase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Meridian Medicaid,CPT,J1744,Icatibant injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J1745,Infliximab not biosimil 10mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Meridian Medicaid,CPT,J1746,"Inj., ibalizumab-uiyk, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J1750,Inj iron dextran,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,J1756,Iron sucrose injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,J1786,Imuglucerase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Meridian Medicaid,CPT,J1823,"Inj. inebilizumab-cdon, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,J1826,Interferon beta-1a inj,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
Meridian Medicaid,CPT,J1830,Interferon beta-1b / .25 mg,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,J1833,"Injection, isavuconazonium",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,J1930,Lanreotide injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,J1931,Laronidase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Meridian Medicaid,CPT,J1942,Aripiprazole lauroxil 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Meridian Medicaid,CPT,J1943,"Inj., aristada initio, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Meridian Medicaid,CPT,J1944,Aripirazole lauroxil 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Meridian Medicaid,CPT,J1945,Lepirudin,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Meridian Medicaid,CPT,J1950,Leuprolide acetate /3.75 mg,Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,244.88,244.88,,,,,,
Meridian Medicaid,CPT,J2062,Loxapine for inhalation 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,J2170,Mecasermin injection,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,J2182,"Injection, mepolizumab, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Meridian Medicaid,CPT,J2186,"Inj., meropenem, vaborbactam",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Meridian Medicaid,CPT,J2248,Micafungin sodium injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,J2278,Ziconotide injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Meridian Medicaid,CPT,J2315,"Naltrexone, depot form",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Meridian Medicaid,CPT,J2323,Natalizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,J2325,Nesiritide injection,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,384.11,384.11,,,,,,
Meridian Medicaid,CPT,J2326,"Inj, nusinersen, 0.1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,J2350,"Injection, ocrelizumab, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,J2353,"Octreotide injection, depot",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,J2355,Oprelvekin injection,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,J2357,Omalizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Meridian Medicaid,CPT,J2407,"Injection, oritavancin",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Meridian Medicaid,CPT,J2425,Palifermin injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Meridian Medicaid,CPT,J2426,Paliperidone palmitate inj,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Meridian Medicaid,CPT,J2469,Palonosetron hcl,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
Meridian Medicaid,CPT,J2502,"Inj, pasireotide long acting",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,J2503,Pegaptanib sodium injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Meridian Medicaid,CPT,J2504,"Pegademase bovine, 25 iu",Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,518.96,518.96,,,,,,
Meridian Medicaid,CPT,J2505,"Injection, pegfilgrastim 6mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,J2507,Pegloticase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Meridian Medicaid,CPT,J2513,Pentastarch 10% solution,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
Meridian Medicaid,CPT,J2515,Pentobarbital sodium inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,J2545,Pentamidine non-comp unit,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,J2547,"Injection, peramivir",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Meridian Medicaid,CPT,J2562,Plerixafor injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J2597,Inj desmopressin acetate,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Meridian Medicaid,CPT,J2724,Protein c concentrate,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Meridian Medicaid,CPT,J2730,Pralidoxime chloride inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,J2770,Quinupristin/dalfopristin,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,189.67,189.67,,,,,,
Meridian Medicaid,CPT,J2778,Ranibizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Meridian Medicaid,CPT,J2783,Rasburicase,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Meridian Medicaid,CPT,J2786,"Injection, reslizumab, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Meridian Medicaid,CPT,J2790,Rho d immune globulin inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,J2791,Rhophylac injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,J2792,"Rho(d) immune globulin h, sd",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,J2793,Rilonacept injection,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,J2794,"Inj risperdal consta, 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,J2796,Romiplostim injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Meridian Medicaid,CPT,J2797,"Inj., rolapitant, 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Meridian Medicaid,CPT,J2798,"Inj., perseris, 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,J2805,Sincalide injection,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
Meridian Medicaid,CPT,J2820,Sargramostim injection,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,J2840,Inj sebelipase alfa 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,J2850,Inj secretin synthetic human,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,J2860,"Injection, siltuximab",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Meridian Medicaid,CPT,J2993,Reteplase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,J2997,Alteplase recombinant,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,J3031,"Inj., fremanezumab-vfrm 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,J3032,Inj. eptinezumab-jjmr 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,J3060,"Inj, taliglucerase alfa 10 u",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Meridian Medicaid,CPT,J3090,Inj tedizolid phosphate,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Meridian Medicaid,CPT,J3095,Telavancin injection,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,J3101,Tenecteplase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J3110,Teriparatide injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Meridian Medicaid,CPT,J3111,Inj. romosozumab-aqqg 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Meridian Medicaid,CPT,J3145,Testosterone undecanoate 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,J3240,Thyrotropin injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Meridian Medicaid,CPT,J3241,Inj. teprotumumab-trbw 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,J3243,Tigecycline injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,J3245,"Inj., tildrakizumab, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Meridian Medicaid,CPT,J3246,Tirofiban hcl,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Meridian Medicaid,CPT,J3262,Tocilizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Meridian Medicaid,CPT,J3285,Treprostinil injection,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,J3300,Triamcinolone a inj prs-free,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,J3304,Inj triamcinolone ace xr 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,J3315,Triptorelin pamoate,Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,244.88,244.88,,,,,,
Meridian Medicaid,CPT,J3316,"Inj., triptorelin xr 3.75 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,J3355,"Urofollitropin, 75 iu",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Meridian Medicaid,CPT,J3357,"Ustekinumab sub cu inj, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Meridian Medicaid,CPT,J3358,"Ustekinumab, iv inject, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J3365,"Urokinase 250,000 iu inj",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,J3380,"Injection, vedolizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,J3385,Velaglucerase alfa,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Meridian Medicaid,CPT,J3396,Verteporfin injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Meridian Medicaid,CPT,J3397,"Inj., vestronidase alfa-vjbk",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,J3398,Inj luxturna 1 billion vec g,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,J3399,Inj onase abepar-xioi treat,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,J3470,Hyaluronidase injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,J3471,"Ovine, up to 999 usp units",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,J3472,"Ovine, 1000 usp units",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,J3473,Hyaluronidase recombinant,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,J7169,"Inj andexxa, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,J7170,"Inj., emicizumab-kxwh 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,J7175,"Inj, factor x, (human), 1iu",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,J7177,"Inj., fibryga, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Meridian Medicaid,CPT,J7178,Inj human fibrinogen con nos,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Meridian Medicaid,CPT,J7179,Vonvendi inj 1 iu vwf:rco,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J7180,Factor xiii anti-hem factor,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,J7181,Factor xiii recomb a-subunit,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,J7182,Factor viii recomb novoeight,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J7183,Wilate injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J7185,Xyntha inj,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J7186,Antihemophilic viii/vwf comp,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J7187,"Humate-p, inj",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J7188,Factor viii recomb obizur,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J7189,Factor viia recomb novoseven,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J7190,Factor viii,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J7191,Factor viii (porcine),Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J7192,Factor viii recombinant nos,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J7193,Factor ix non-recombinant,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J7194,Factor ix complex,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J7195,Factor ix recombinant nos,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J7196,Antithrombin recombinant,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,J7197,Antithrombin iii injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J7198,Anti-inhibitor,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Meridian Medicaid,CPT,J7199,Hemophilia clot factor noc,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Meridian Medicaid,CPT,J7200,Factor ix recombinan rixubis,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J7201,Factor ix alprolix recomb,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J7202,Factor ix idelvion inj,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J7203,Factor ix recomb gly rebinyn,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J7204,Inj recombin esperoct per iu,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J7205,Factor viii fc fusion recomb,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J7207,Factor viii pegylated recomb,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J7208,Inj. jivi 1 iu,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J7209,Factor viii nuwiq recomb 1iu,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J7210,"Inj, afstyla, 1 i.u.",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J7211,"Inj, kovaltry, 1 i.u.",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J7212,Factor viia recomb sevenfact,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J7296,"Kyleena, 19.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,J7297,"Liletta, 52 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,J7298,"Mirena, 52 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,J7300,Intraut copper contraceptive,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,J7301,"Skyla, 13.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,J7302,Levonorgestrel iu 52 mg,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,J7303,Contraceptive vaginal ring,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,J7304,Contraceptive hormone patch,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,J7306,Levonorgestrel implant sys,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Meridian Medicaid,CPT,J7307,Etonogestrel implant system,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,J7308,Aminolevulinic acid hcl top,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,J7309,"Methyl aminolevulinate, top",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,J7310,Ganciclovir long act implant,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,J7311,"Inj., retisert, 0.01 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,J7312,Dexamethasone intra implant,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Meridian Medicaid,CPT,J7313,"Inj., iluvien, 0.01 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J7314,"Inj., yutiq, 0.01 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J7315,Ophthalmic mitomycin,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,J7316,"Inj, ocriplasmin, 0.125 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,J7318,"Inj, durolane 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,J7320,"Genvisc 850, inj, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Meridian Medicaid,CPT,J7321,Hyalgan or supartz inj dose,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,J7322,Hymovis injection 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Meridian Medicaid,CPT,J7323,Euflexxa inj per dose,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Meridian Medicaid,CPT,J7324,Orthovisc inj per dose,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Meridian Medicaid,CPT,J7325,Synvisc or synvisc-one,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,J7326,Gel-one,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,J7327,Monovisc inj per dose,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,384.11,384.11,,,,,,
Meridian Medicaid,CPT,J7328,Gelsyn-3 injection 0.1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Meridian Medicaid,CPT,J7329,"Inj, trivisc 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,J7330,Cultured chondrocytes implnt,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,J7331,"Synojoynt, inj., 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,J7332,"Inj., triluron, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,J7333,Visco-3 inj dose,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,J7336,Capsaicin 8% patch,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,J7340,Carbidopa levodopa ent 100ml,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,J7345,"Aminolevulinic acid, 10% gel",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,J7351,Inj bimatoprost itc imp1mcg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Meridian Medicaid,CPT,J7352,"Afamelanotide implant, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,J7401,Mometasone furoate sinus imp,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,384.11,384.11,,,,,,
Meridian Medicaid,CPT,J7501,Azathioprine parenteral,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
Meridian Medicaid,CPT,J7504,Lymphocyte immune globulin,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J7505,Monoclonal antibodies,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,518.96,518.96,,,,,,
Meridian Medicaid,CPT,J7511,Antithymocyte globuln rabbit,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Meridian Medicaid,CPT,J7513,"Daclizumab, parenteral",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Meridian Medicaid,CPT,J7525,Tacrolimus injection,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Meridian Medicaid,CPT,J7639,Dornase alfa non-comp unit,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,J7685,Tobramycin comp unit,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,J7686,"Treprostinil, non-comp unit",Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Meridian Medicaid,CPT,J8501,Oral aprepitant,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
Meridian Medicaid,CPT,J8560,Etoposide oral 50 mg,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
Meridian Medicaid,CPT,J8562,Oral fludarabine phosphate,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Meridian Medicaid,CPT,J8565,Gefitinib oral,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Meridian Medicaid,CPT,J8655,"Oral netupitant, palonosetro",Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,189.67,189.67,,,,,,
Meridian Medicaid,CPT,J8670,"Rolapitant, oral, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
Meridian Medicaid,CPT,J8705,Topotecan oral,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,J9010,Alemtuzumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Meridian Medicaid,CPT,J9015,Aldesleukin injection,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,518.96,518.96,,,,,,
Meridian Medicaid,CPT,J9017,Arsenic trioxide injection,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Meridian Medicaid,CPT,J9019,Erwinaze injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Meridian Medicaid,CPT,J9020,"Asparaginase, nos",Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
Meridian Medicaid,CPT,J9022,"Inj, atezolizumab,10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Meridian Medicaid,CPT,J9023,"Injection, avelumab, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J9025,Azacitidine injection,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
Meridian Medicaid,CPT,J9027,Clofarabine injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,J9030,Bcg live intravesical 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
Meridian Medicaid,CPT,J9031,Bcg live intravesical vac,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
Meridian Medicaid,CPT,J9032,"Injection, belinostat, 10mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,J9033,"Inj., treanda 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,J9034,"Inj., bendeka 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,J9035,Bevacizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,J9036,Inj. belrapzo/bendamustine,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,J9039,"Injection, blinatumomab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,J9040,Bleomycin sulfate injection,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
Meridian Medicaid,CPT,J9041,"Inj., velcade 0.1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,244.88,244.88,,,,,,
Meridian Medicaid,CPT,J9042,Brentuximab vedotin inj,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Meridian Medicaid,CPT,J9043,Cabazitaxel injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J9044,"Inj, bortezomib, nos, 0.1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Meridian Medicaid,CPT,J9047,"Injection, carfilzomib, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Meridian Medicaid,CPT,J9050,Carmustine injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J9055,Cetuximab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Meridian Medicaid,CPT,J9057,"Inj., copanlisib, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,J9065,Inj cladribine per 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,189.67,189.67,,,,,,
Meridian Medicaid,CPT,J9070,Cyclophosphamide 100 mg inj,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
Meridian Medicaid,CPT,J9098,Cytarabine liposome inj,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Meridian Medicaid,CPT,J9118,Inj. calaspargase pegol-mknl,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Meridian Medicaid,CPT,J9119,"Inj., cemiplimab-rwlc, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J9120,Dactinomycin injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Meridian Medicaid,CPT,J9144,"Daratumumab, hyaluronidase",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,J9145,"Injection, daratumumab 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,J9150,Daunorubicin injection,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,189.67,189.67,,,,,,
Meridian Medicaid,CPT,J9151,Daunorubicin citrate inj,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
Meridian Medicaid,CPT,J9153,"Inj daunorubicin, cytarabine",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Meridian Medicaid,CPT,J9155,Degarelix injection,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,189.67,189.67,,,,,,
Meridian Medicaid,CPT,J9160,Denileukin diftitox inj,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J9171,Docetaxel injection,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
Meridian Medicaid,CPT,J9173,"Inj., durvalumab, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J9176,"Injection, elotuzumab, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,J9177,Inj enfort vedo-ejfv 0.25mg,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J9179,Eribulin mesylate injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Meridian Medicaid,CPT,J9185,Fludarabine phosphate inj,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
Meridian Medicaid,CPT,J9198,"Inj. infugem, 100 mg",Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,189.67,189.67,,,,,,
Meridian Medicaid,CPT,J9199,"Injection, infugem, 200 mg",Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,189.67,189.67,,,,,,
Meridian Medicaid,CPT,J9200,Floxuridine injection,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
Meridian Medicaid,CPT,J9202,Goserelin acetate implant,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Meridian Medicaid,CPT,J9203,Gemtuzumab ozogamicin 0.1 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J9204,"Inj mogamulizumab-kpkc, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Meridian Medicaid,CPT,J9205,Inj irinotecan liposome 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,J9207,Ixabepilone injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Meridian Medicaid,CPT,J9208,Ifosfamide injection,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
Meridian Medicaid,CPT,J9210,"Inj., emapalumab-lzsg, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,J9211,Idarubicin hcl injection,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
Meridian Medicaid,CPT,J9213,Interferon alfa-2a inj,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Meridian Medicaid,CPT,J9214,Interferon alfa-2b inj,Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,244.88,244.88,,,,,,
Meridian Medicaid,CPT,J9216,Interferon gamma 1-b inj,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Meridian Medicaid,CPT,J9217,Leuprolide acetate suspnsion,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Meridian Medicaid,CPT,J9219,Leuprolide acetate implant,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J9223,"Inj. lurbinectedin, 0.1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,J9225,Vantas implant,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,J9226,Supprelin la implant,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,J9227,Inj. isatuximab-irfc 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,J9228,Ipilimumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,J9229,Inj inotuzumab ozogam 0.1 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Meridian Medicaid,CPT,J9230,Mechlorethamine hcl inj,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
Meridian Medicaid,CPT,J9245,Inj melpha hydroch nos 50 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J9246,"Inj., evomela, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J9261,Nelarabine injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J9262,"Inj, omacetaxine mep, 0.01mg",Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Meridian Medicaid,CPT,J9264,Paclitaxel protein bound,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Meridian Medicaid,CPT,J9266,Pegaspargase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Meridian Medicaid,CPT,J9268,Pentostatin injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Meridian Medicaid,CPT,J9269,Inj. tagraxofusp-erzs 10 mcg,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,J9270,Plicamycin (mithramycin) inj,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Meridian Medicaid,CPT,J9271,Inj pembrolizumab,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Meridian Medicaid,CPT,J9280,Mitomycin injection,Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,244.88,244.88,,,,,,
Meridian Medicaid,CPT,J9281,Mitomycin instillation,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,J9285,"Inj, olaratumab, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J9293,Mitoxantrone hydrochl / 5 mg,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
Meridian Medicaid,CPT,J9295,"Injection, necitumumab, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J9299,"Injection, nivolumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J9300,Gemtuzumab ozogamicin inj,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J9301,Obinutuzumab inj,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J9302,Ofatumumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Meridian Medicaid,CPT,J9303,Panitumumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,J9304,"Inj. pemetrexed, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J9305,Inj. pemetrexed nos 10mg,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J9306,"Injection, pertuzumab, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,J9307,Pralatrexate injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J9308,"Injection, ramucirumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,J9309,"Inj, polatuzumab vedotin 1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Meridian Medicaid,CPT,J9310,Rituximab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,J9311,"Inj rituximab, hyaluronidase",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J9312,"Inj., rituximab, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J9313,"Inj., lumoxiti, 0.01 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J9315,Romidepsin injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J9316,"Pertuzu, trastuzu, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,J9317,Sacituzumab govitecan-hziy,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,518.96,518.96,,,,,,
Meridian Medicaid,CPT,J9320,Streptozocin injection,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,189.67,189.67,,,,,,
Meridian Medicaid,CPT,J9325,Inj talimogene laherparepvec,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J9328,Temozolomide injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Meridian Medicaid,CPT,J9330,Temsirolimus injection,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,518.96,518.96,,,,,,
Meridian Medicaid,CPT,J9340,Thiotepa injection,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,189.67,189.67,,,,,,
Meridian Medicaid,CPT,J9352,Injection trabectedin 0.1mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,J9354,"Inj, ado-trastuzumab emt 1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J9355,Inj trastuzumab excl biosimi,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,J9356,"Inj. herceptin hylecta, 10mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,J9357,Valrubicin injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,J9358,Inj fam-trastu deru-nxki 1mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,J9371,"Inj, vincristine sul lip 1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,J9395,"Injection, fulvestrant",Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,518.96,518.96,,,,,,
Meridian Medicaid,CPT,J9400,"Inj, ziv-aflibercept, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Meridian Medicaid,CPT,J9600,Porfimer sodium injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,L8604,Dextranomer/hyaluronic acid,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,L8605,Inj bulking agent anal canal,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,L8607,Inj vocal cord bulking agent,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,M0239,Bamlanivimab-xxxx infusion,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Meridian Medicaid,CPT,M0243,Casirivi and imdevi infusion,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Meridian Medicaid,CPT,P2028,Cephalin floculation test,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,P2029,Congo red blood test,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,P2031,Hair analysis,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,P2033,Blood thymol turbidity,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,P2038,Blood mucoprotein,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,P3000,Screen pap by tech w md supv,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Meridian Medicaid,CPT,P3001,Screening pap smear by phys,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Meridian Medicaid,CPT,P7001,Culture bacterial urine,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,P9010,Whole blood for transfusion,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,P9011,Blood split unit,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,P9012,Cryoprecipitate each unit,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,P9016,Rbc leukocytes reduced,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,P9017,Plasma 1 donor frz w/in 8 hr,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,P9019,"Platelets, each unit",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,P9020,Plaelet rich plasma unit,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,P9021,Red blood cells unit,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,P9022,Washed red blood cells unit,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,P9023,"Frozen plasma, pooled, sd",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,P9031,Platelets leukocytes reduced,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,P9032,"Platelets, irradiated",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,P9033,Platelets leukoreduced irrad,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,P9034,"Platelets, pheresis",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,P9035,Platelet pheres leukoreduced,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,P9036,Platelet pheresis irradiated,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,P9037,Plate pheres leukoredu irrad,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,P9038,Rbc irradiated,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,P9039,Rbc deglycerolized,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,P9040,Rbc leukoreduced irradiated,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,P9041,"Albumin (human),5%, 50ml",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,P9043,"Plasma protein fract,5%,50ml",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,P9044,Cryoprecipitatereducedplasma,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,P9045,"Albumin (human), 5%, 250 ml",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,P9046,"Albumin (human), 25%, 20 ml",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,P9047,"Albumin (human), 25%, 50ml",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,P9048,"Plasmaprotein fract,5%,250ml",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,P9050,"Granulocytes, pheresis unit",Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Meridian Medicaid,CPT,P9051,"Blood, l/r, cmv-neg",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,P9052,"Platelets, hla-m, l/r, unit",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,P9053,"Plt, pher, l/r cmv-neg, irr",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,P9054,"Blood, l/r, froz/degly/wash",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,P9055,"Plt, aph/pher, l/r, cmv-neg",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,P9056,"Blood, l/r, irradiated",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,P9057,"Rbc, frz/deg/wsh, l/r, irrad",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,P9058,"Rbc, l/r, cmv-neg, irrad",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,P9059,"Plasma, frz between 8-24hour",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,P9060,Fr frz plasma donor retested,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,P9070,Pathogen reduced plasma pool,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,P9071,Pathogen reduced plasma sing,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,P9072,Plate path red/rapid bac tes,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,P9073,Platelets pheresis path redu,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,P9099,Blood component/product noc,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,P9100,Pathogen test for platelets,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,Q0035,Cardiokymography,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Meridian Medicaid,CPT,Q0081,Infusion ther other than che,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Meridian Medicaid,CPT,Q0084,Chemotherapy by infusion,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Meridian Medicaid,CPT,Q0085,Chemo by both infusion and o,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Meridian Medicaid,CPT,Q0091,Obtaining screen pap smear,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Meridian Medicaid,CPT,Q0111,Wet mounts/ w preparations,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,Q0112,Potassium hydroxide preps,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,Q0113,Pinworm examinations,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,Q0114,Fern test,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Meridian Medicaid,CPT,Q0115,Post-coital mucous exam,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,Q0138,"Ferumoxytol, non-esrd",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,Q0139,"Ferumoxytol, esrd use",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,Q0239,Bamlanivimab-xxxx,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Meridian Medicaid,CPT,Q0243,Casirivimab and imdevimab,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Meridian Medicaid,CPT,Q0515,Sermorelin acetate injection,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,518.96,518.96,,,,,,
Meridian Medicaid,CPT,Q2017,"Teniposide, 50 mg",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Meridian Medicaid,CPT,Q2028,"Inj, sculptra, 0.5mg",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q2034,Agriflu vaccine,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,Q2035,"Afluria vacc, 3 yrs & >, im",Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,Q2036,"Flulaval vacc, 3 yrs & >, im",Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,Q2037,"Fluvirin vacc, 3 yrs & >, im",Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,Q2038,"Fluzone vacc, 3 yrs & >, im",Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,Q2039,"Influenza virus vaccine, nos",Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Meridian Medicaid,CPT,Q2040,Tisagenlecleucel car-pos t,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,Q2043,Sipuleucel-t auto cd54+,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,Q2049,Imported lipodox inj,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,Q2050,Doxorubicin inj 10mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Meridian Medicaid,CPT,Q3014,Telehealth facility fee,Ancillary Services,Per Unit,$8.33 ,OP,8.33,8.33,,,,,,
Meridian Medicaid,CPT,Q3027,Inj beta interferon im 1 mcg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Meridian Medicaid,CPT,Q3028,Inj beta interferon sq 1 mcg,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,Q4074,Iloprost non-comp unit dose,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,Q4081,"Epoetin alfa, 100 units esrd",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,Q4100,"Skin substitute, nos",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4101,Apligraf,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4102,Oasis wound matrix,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4103,Oasis burn matrix,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4104,Integra bmwd,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4105,Integra drt or omnigraft,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4106,Dermagraft,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4107,Graftjacket,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4108,Integra matrix,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4110,Primatrix,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4111,Gammagraft,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4112,Cymetra injectable,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4113,Graftjacket xpress,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4114,Integra flowable wound matri,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4115,Alloskin,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4116,Alloderm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4117,Hyalomatrix,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4118,Matristem micromatrix,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4119,Matristem wound matrix,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4120,Matristem burn matrix,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4121,Theraskin,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4122,"Dermacell, awm, porous sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4123,Alloskin,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4124,Oasis tri-layer wound matrix,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4125,Arthroflex,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4126,Memoderm/derma/tranz/integup,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4127,Talymed,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4128,Flexhd/allopatchhd/matrixhd,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4129,Unite biomatrix,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4130,Strattice tm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4131,Epifix or epicord,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4132,"Grafix core, grafixpl core",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4133,Grafix stravix prime pl sqcm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4134,Hmatrix,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4135,Mediskin,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4136,Ezderm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4137,Amnioexcel biodexcel 1sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4138,"Biodfence dryflex, 1cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4139,"Amnio or biodmatrix, inj 1cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4140,Biodfence 1cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4141,"Alloskin ac, 1 cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4142,Xcm biologic tiss matrix 1cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4143,"Repriza, 1cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4145,"Epifix, inj, 1mg",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4146,"Tensix, 1cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4147,Architect ecm px fx 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4148,Neox neox rt or clarix cord,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4149,"Excellagen, 0.1 cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4150,Allowrap ds or dry 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4151,"Amnioband, guardian 1 sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4152,Dermapure 1 square cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4153,"Dermavest, plurivest sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4154,Biovance 1 square cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4155,Neoxflo or clarixflo 1 mg,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4156,Neox 100 or clarix 100,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4157,Revitalon 1 square cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4158,"Kerecis omega3, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4159,Affinity1 square cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4160,Nushield 1 square cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4161,Bio-connekt per square cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4162,"Wndex flw, bioskn flw, 0.5cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4163,"Woundex, bioskin, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4164,"Helicoll, per square cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4165,"Keramatrix, kerasorb sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4166,"Cytal, per square centimeter",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4167,"Truskin, per sq centimeter",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4168,"Amnioband, 1 mg",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4169,"Artacent wound, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4170,"Cygnus, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4171,"Interfyl, 1 mg",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4172,Puraply or puraply am,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4173,Palingen or palingen xplus,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4174,Palingen or promatrx,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4175,Miroderm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4176,"Neopatch or therion, 1 sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4177,"Floweramnioflo, 0.1 cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4178,"Floweramniopatch, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4179,"Flowerderm, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4180,"Revita, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4181,"Amnio wound, per square cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4182,"Transcyte, per sq centimeter",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4183,"Surgigraft, 1 sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4184,Cellesta or duo per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4185,Cellesta flowab amnion 0.5cc,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4186,Epifix 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4187,Epicord 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4188,Amnioarmor 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4189,"Artacent ac, 1 mg",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4190,Artacent ac 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4191,Restorigin 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4192,"Restorigin, 1 cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4193,Coll-e-derm 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4194,Novachor 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4195,Puraply 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4196,Puraply am 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4197,Puraply xt 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4198,Genesis amnio membrane 1sqcm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4200,Skin te 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4201,Matrion 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4202,"Keroxx (2.5g/cc), 1cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4203,"Derma-gide, 1 sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4204,Xwrap 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4205,Membrane graft or wrap sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4206,Fluid flow or fluid gf 1 cc,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4208,Novafix per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4209,Surgraft per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4210,Axolotl graf dualgraf sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4211,Amnion bio or axobio sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4212,"Allogen, per cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4213,"Ascent, 0.5 mg",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4214,Cellesta cord per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4215,"Axolotl ambient, cryo 0.1 mg",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4216,Artacent cord per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4217,Woundfix biowound plus xplus,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4218,Surgicord per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4219,Surgigraft dual per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4220,"Bellacell hd, surederm sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4221,Amniowrap2 per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4222,"Progenamatrix, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4226,Myown harv prep proc sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4227,Amniocore per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4228,"Bionextpatch, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4229,Cogenex amnio memb per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4230,Cogenex flow amnion 0.5 cc,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4231,"Corplex p, per cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4232,"Corplex, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4233,Surfactor /nudyn per 0.5 cc,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4234,"Xcellerate, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4235,Amniorepair or altiply sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4236,Carepatch per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4237,"Cryo-cord, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4238,"Derm-maxx, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4239,Amnio-maxx or lite per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4240,Corecyte topical only 0.5 cc,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4241,"Polycyte, topical only 0.5cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4242,"Amniocyte plus, per 0.5 cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4244,"Procenta, per 200 mg",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4245,"Amniotext, per cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4246,"Coretext or protext, per cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4247,"Amniotext patch, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4248,Dermacyte amn mem allo sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4249,"Amniply, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4250,Amnioamp-mp per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4254,Novafix dl per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q4255,"Reguard, topical use per sq",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,Q5101,"Injection, zarxio",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,Q5102,"Inj., infliximab biosimilar",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Meridian Medicaid,CPT,Q5103,"Injection, inflectra",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Meridian Medicaid,CPT,Q5104,"Injection, renflexis",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Meridian Medicaid,CPT,Q5105,Inj retacrit esrd on dialysi,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,Q5106,Inj retacrit non-esrd use,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,Q5107,Inj mvasi 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,Q5108,"Injection, fulphila",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,Q5109,"Injection, ixifi, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,Q5110,Nivestym,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Meridian Medicaid,CPT,Q5111,"Injection, udenyca 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,Q5112,Inj ontruzant 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,Q5113,Inj herzuma 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,Q5114,Inj ogivri 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,Q5115,Inj truxima 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,Q5116,"Inj., trazimera, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,Q5117,"Inj., kanjinti, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,Q5118,"Inj., zirabev, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,Q5119,"Inj ruxience, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,Q5120,Inj pegfilgrastim-bmez 0.5mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,Q5121,"Inj. avsola, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Meridian Medicaid,CPT,Q5122,"Inj, nyvepria",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Meridian Medicaid,CPT,Q9975,Factor VIII FC Fusion Recomb,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Meridian Medicaid,CPT,Q9979,"Injection, Alemtuzumab",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Meridian Medicaid,CPT,Q9980,"Genvisc, inj, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Meridian Medicaid,CPT,Q9984,Kyleena,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,Q9987,Pathogen test for platelets,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,Q9988,Platelet pheresis path reduc,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,Q9989,"Ustekinumab IV Inj, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Meridian Medicaid,CPT,Q9991,Buprenorph xr 100 mg or less,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,Q9992,Buprenorphine xr over 100 mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Meridian Medicaid,CPT,Q9993,"Inj., triamcinolone ext rel",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,Q9995,"inj. emicizumab-kxwh, 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Meridian Medicaid,CPT,S0013,"Esketamine, nasal spray",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Meridian Medicaid,CPT,S0040,"Injection, ticarcillin disod",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Meridian Medicaid,CPT,S0088,Imatinib 100 mg,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Meridian Medicaid,CPT,S0126,Inj follitropin alfa 75 iu,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,S0132,Inj ganirelix acetat 250 mcg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Meridian Medicaid,CPT,S0140,"Saquinavir, 200 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Meridian Medicaid,CPT,S0142,Colistimethate inh sol mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Meridian Medicaid,CPT,S0145,Peg interferon alfa-2a/180,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,S0148,Peg interferon alfa-2b/10,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Meridian Medicaid,CPT,S0155,Epoprostenol dilutant,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Meridian Medicaid,CPT,S0166,Inj olanzapine 2.5mg,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,S0175,Flutamide 125 mg,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
Meridian Medicaid,CPT,S0178,Lomustine 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Meridian Medicaid,CPT,S0190,"Mifepristone, oral, 200 mg",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Meridian Medicaid,CPT,S0195,Pneumo vaccine 5-9 yrs,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Meridian Medicaid,CPT,S0199,Med abortion inc all ex drug,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Meridian Medicaid,CPT,S0201,Partial hospitalization serv,Behavioral Health,Per Unit,$220.60 ,OP,220.6,220.6,,,,,,
Meridian Medicaid,CPT,S0220,Medical conference by physic,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,S0221,"Medical conference, 60 min",Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,S0250,Comp geriatr assmt team,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,S0257,End of life counseling,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,S0271,Home hospice case 30 days,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,S0280,"Medical home, initial plan",Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,S0281,"Medical home, maintenance",Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,S0311,Comp mgmt care coord adv ill,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,S0315,Disease management program,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,S0316,Follow-up/reassessment,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,S0340,Lifestyle mod 1st stage,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,S0353,Cancer treatmentplan initial,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,S0354,Cancer treatment plan change,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,S0390,Rout foot care per visit,General Surgery,Per Unit,$46.77 ,OP,46.77,46.77,,,,,,
Meridian Medicaid,CPT,S0395,Impression casting ft,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Meridian Medicaid,CPT,S0592,Comp cont lens eval,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Meridian Medicaid,CPT,S0601,Screening proctoscopy,Preventive Care,Per Unit,$387.00 ,OP,387,387,,,,,,
Meridian Medicaid,CPT,S0618,Audiometry for hearing aid,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Meridian Medicaid,CPT,S0800,Laser in situ keratomileusis,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Meridian Medicaid,CPT,S0810,Photorefractive keratectomy,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Meridian Medicaid,CPT,S0812,Phototherap keratect,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Meridian Medicaid,CPT,S2066,Breast gap flap reconst,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
Meridian Medicaid,CPT,S2067,"Breast ""stacked"" diep/gap",General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
Meridian Medicaid,CPT,S2068,Breast diep or siea flap,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
Meridian Medicaid,CPT,S2083,Adjustment gastric band,Gastroenterology,Per Unit,$119.18 ,OP,119.18,119.18,,,,,,
Meridian Medicaid,CPT,S2112,Knee arthroscp harv,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,S2202,Echosclerotherapy,Vascular Surgery,Per Unit,$500.46 ,OP,500.46,500.46,,,,,,
Meridian Medicaid,CPT,S2225,Myringotomy laser-assist,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Meridian Medicaid,CPT,S2230,Implant semi-imp hear,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,S2235,Implant auditory brain imp,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,S2260,Induced abortion 17-24 weeks,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Meridian Medicaid,CPT,S2265,Induced abortion 25-28 wks,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Meridian Medicaid,CPT,S2266,Induced abortion 29-31 wks,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Meridian Medicaid,CPT,S2267,Induced abortion 32 or more,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Meridian Medicaid,CPT,S2300,"Arthroscopy, shoulder, surgi",Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Meridian Medicaid,CPT,S2340,Chemodenervation of abductor,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,S2341,Chemodenerv adduct vocal,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Meridian Medicaid,CPT,S2342,Nasal endoscop po debrid,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Meridian Medicaid,CPT,S2400,Fetal surg congen hernia,Obstetrics,Per Unit,$139.58 ,OP,139.58,139.58,,,,,,
Meridian Medicaid,CPT,S2401,Fetal surg urin trac obstr,Obstetrics,Per Unit,$482.07 ,OP,482.07,482.07,,,,,,
Meridian Medicaid,CPT,S2402,Fetal surg cong cyst malf,Obstetrics,Per Unit,$482.07 ,OP,482.07,482.07,,,,,,
Meridian Medicaid,CPT,S2403,Fetal surg pulmon sequest,Obstetrics,Per Unit,$482.07 ,OP,482.07,482.07,,,,,,
Meridian Medicaid,CPT,S2404,Fetal surg myelomeningo,Obstetrics,Per Unit,$482.07 ,OP,482.07,482.07,,,,,,
Meridian Medicaid,CPT,S2405,Fetal surg sacrococ teratoma,Obstetrics,Per Unit,$139.58 ,OP,139.58,139.58,,,,,,
Meridian Medicaid,CPT,S2409,Fetal surg noc,Obstetrics,Per Unit,$139.58 ,OP,139.58,139.58,,,,,,
Meridian Medicaid,CPT,S2411,Fetoscop laser ther ttts,Obstetrics,Per Unit,$139.58 ,OP,139.58,139.58,,,,,,
Meridian Medicaid,CPT,S3620,Newborn metabolic screening,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
Meridian Medicaid,CPT,S3630,Eosinophil blood count,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Meridian Medicaid,CPT,S3645,Hiv-1 antibody testing of or,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,S3650,"Saliva test, hormone level;",Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,S3652,"Saliva test, hormone level;",Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,S3655,Antisperm antibodies test,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Meridian Medicaid,CPT,S3708,Gastrointestinal fat absorpt,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,S3721,Pca3 testing,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Meridian Medicaid,CPT,S3722,Dose optimization auc - 5fu,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Meridian Medicaid,CPT,S3800,Genetic testing als,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,S3840,Dna analysis ret-oncogene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,S3841,Gene test retinoblastoma,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,S3842,Gene test hippel-lindau,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,S3844,Dna analysis deafness,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,S3845,Gene test alpha-thalassemia,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,S3846,Gene test beta-thalassemia,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,S3849,Gene test niemann-pick,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,S3850,Gene test sickle cell,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,S3852,Dna analysis apoe alzheimer,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,S3853,Gene test myo musclr dyst,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,S3854,Gene profile panel breast,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,S3861,Genetic test brugada,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,S3865,Comp genet test hyp cardiomy,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,S3866,Spec gene test hyp cardiomy,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,S3870,Cgh test developmental delay,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,S3890,Fecal dna analysis,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Meridian Medicaid,CPT,S3900,Surface emg,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,S3902,Ballistocardiogram,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,S3904,Masters two step,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Meridian Medicaid,CPT,S4011,Ivf package,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Meridian Medicaid,CPT,S4013,Compl gift case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Meridian Medicaid,CPT,S4014,Compl zift case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Meridian Medicaid,CPT,S4015,Complete ivf nos case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Meridian Medicaid,CPT,S4016,Frozen ivf case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Meridian Medicaid,CPT,S4017,Ivf canc a stim case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Meridian Medicaid,CPT,S4018,F emb trns canc case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Meridian Medicaid,CPT,S4020,Ivf canc a aspir case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Meridian Medicaid,CPT,S4021,Ivf canc p aspir case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Meridian Medicaid,CPT,S4022,Asst oocyte fert case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Meridian Medicaid,CPT,S4023,Incompl donor egg case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Meridian Medicaid,CPT,S4025,Donor serv ivf case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Meridian Medicaid,CPT,S4026,Procure donor sperm,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Meridian Medicaid,CPT,S4027,Store prev froz embryos,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Meridian Medicaid,CPT,S4028,Microsurg epi sperm asp,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Meridian Medicaid,CPT,S4030,Sperm procure init visit,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Meridian Medicaid,CPT,S4031,Sperm procure subs visit,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Meridian Medicaid,CPT,S4035,Stimulated iui case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Meridian Medicaid,CPT,S4037,Cryo embryo transf case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Meridian Medicaid,CPT,S4040,Monit store cryo embryo 30 d,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Meridian Medicaid,CPT,S4042,Ovulation mgmt per cycle,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,S4981,Insert levonorgestrel ius,Gynecology,Per Unit,$102.34 ,OP,102.34,102.34,,,,,,
Meridian Medicaid,CPT,S4989,Contracept iud,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Meridian Medicaid,CPT,S5180,Hh respiratory thrpy in eval,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
Meridian Medicaid,CPT,S5181,Hh respiratory thrpy nos/day,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
Meridian Medicaid,CPT,S8032,Low dose CT lung screening,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Meridian Medicaid,CPT,S8035,Magnetic source imaging,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Meridian Medicaid,CPT,S8037,Mrcp,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Meridian Medicaid,CPT,S8055,Us guidance fetal reduct,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Meridian Medicaid,CPT,S8080,Scintimammography,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Meridian Medicaid,CPT,S8092,Electron beam computed tomog,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Meridian Medicaid,CPT,S8110,Peak expiratory flow rate (p,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Meridian Medicaid,CPT,S8930,Auricular electrostimulation,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Meridian Medicaid,CPT,S8940,Hippotherapy per session,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,S8948,Low-level laser trmt 15 min,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,S8950,"Complex lymphedema therapy,",Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,S8990,Pt or manip for maint,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,S9015,Automated eeg monitoring,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Meridian Medicaid,CPT,S9024,Paranasal sinus ultrasound,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Meridian Medicaid,CPT,S9061,Medical supplies and equipme,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,S9090,Vertebral axial decompressio,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,S9098,Home phototherapy visit,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,S9128,"Speech therapy, in the home,",Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Meridian Medicaid,CPT,S9129,"Occupational therapy, in the",Rehabilitation,Per Unit,$306.55 ,OP,306.55,306.55,,,,,,
Meridian Medicaid,CPT,S9131,Pt in the home per diem,Rehabilitation,Per Unit,$192.71 ,OP,192.71,192.71,,,,,,
Meridian Medicaid,CPT,S9140,"Diabetic management program,",Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Meridian Medicaid,CPT,S9141,"Diabetic management program,",Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Meridian Medicaid,CPT,S9145,Insulin pump initiation,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Meridian Medicaid,CPT,S9152,"Speech therapy, re-eval",Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Meridian Medicaid,CPT,S9211,Home mgmt gest hypertension,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,S9213,Hm preeclamp per diem,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,S9214,Hm gest dm per diem,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,S9335,Ht hemodialysis diem,Nephrology,Per Unit,$540.95 ,OP,540.95,540.95,,,,,,
Meridian Medicaid,CPT,S9339,Hit periton dialysis diem,Nephrology,Per Unit,$540.95 ,OP,540.95,540.95,,,,,,
Meridian Medicaid,CPT,S9370,Ht inj antiemetic diem,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,S9372,Ht inj anticoag diem,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,S9445,Pt education noc individ,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Meridian Medicaid,CPT,S9446,Pt education noc group,Preventive Care,Per Unit,$26.23 ,OP,26.23,26.23,,,,,,
Meridian Medicaid,CPT,S9452,Nutrition class,Preventive Care,Per Unit,$26.23 ,OP,26.23,26.23,,,,,,
Meridian Medicaid,CPT,S9453,Smoking cessation class,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Meridian Medicaid,CPT,S9455,"Diabetic management program,",Preventive Care,Per Unit,$26.23 ,OP,26.23,26.23,,,,,,
Meridian Medicaid,CPT,S9465,"Diabetic management program,",Ancillary Services,Per Unit,$100.15 ,OP,100.15,100.15,,,,,,
Meridian Medicaid,CPT,S9470,"Nutritional counseling, diet",Ancillary Services,Per Unit,$100.15 ,OP,100.15,100.15,,,,,,
Meridian Medicaid,CPT,S9472,Cardiac rehabilitation progr,Rehabilitation,Per Unit,$274.82 ,OP,274.82,274.82,,,,,,
Meridian Medicaid,CPT,S9473,Pulmonary rehabilitation pro,Rehabilitation,Per Unit,$73.11 ,OP,73.11,73.11,,,,,,
Meridian Medicaid,CPT,S9475,Ambulatory setting substance,Behavioral Health,Per Unit,$220.60 ,OP,220.6,220.6,,,,,,
Meridian Medicaid,CPT,S9476,Vestibular rehab per diem,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Meridian Medicaid,CPT,S9480,Intensive outpatient psychia,Behavioral Health,Per Unit,$339.88 ,OP,339.88,339.88,,,,,,
Meridian Medicaid,CPT,S9482,Family stabilization 15 min,Behavioral Health,Per Unit,$89.14 ,OP,89.14,89.14,,,,,,
Meridian Medicaid,CPT,S9484,Crisis intervention per hour,Behavioral Health,Per Unit,$135.70 ,OP,135.7,135.7,,,,,,
Meridian Medicaid,CPT,S9485,Crisis intervention mental h,Behavioral Health,Per Unit,$220.60 ,OP,220.6,220.6,,,,,,
Meridian Medicaid,CPT,S9537,Ht hem horm inj diem,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,S9538,Hit blood products diem,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Meridian Medicaid,CPT,S9558,Ht inj growth horm diem,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,S9559,Hit inj interferon diem,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,S9560,Ht inj hormone diem,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,S9562,Ht inj palivizumab diem,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,T1006,Family/couple counseling,Behavioral Health,Per Unit,$89.14 ,OP,89.14,89.14,,,,,,
Meridian Medicaid,CPT,T1007,Treatment plan development,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Meridian Medicaid,CPT,T1012,Alcohol/substance abuse skil,Behavioral Health,Per Unit,$48.15 ,OP,48.15,48.15,,,,,,
Meridian Medicaid,CPT,T1016,Case management,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,T1017,Targeted case management,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,T1023,Program intake assessment,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Meridian Medicaid,CPT,T1040,Comm bh clinic svc per diem,Behavioral Health,Per Unit,$220.60 ,OP,220.6,220.6,,,,,,
Meridian Medicaid,CPT,T2022,"Case management, per month",Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,T2023,Targeted case mgmt per month,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Meridian Medicaid,CPT,U0001,2019-ncov diagnostic p,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Meridian Medicaid,CPT,U0002,Covid-19 lab test non-cdc,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,U0005,Infec agen detec ampli probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Meridian Medicaid,CPT,V2785,Corneal tissue processing,Ophthalmology,Per Unit,"$1,390.89 ",OP,"1,390.89","1,390.89",,,,,,
Meridian Medicaid,CPT,V2790,Amniotic membrane,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Meridian Medicaid,CPT,V5362,Speech screening,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,V5363,Language screening,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Meridian Medicaid,CPT,V5364,Dysphagia screening,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Duals,DRG,MS-001,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W MCC,Surgical,Relative Weights,"$168,855.33 ",IP,"17,718.00","557,099.42",,,,,,
Molina Duals,DRG,MS-002,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W/O MCC,Surgical,Relative Weights,"$87,426.55 ",IP,"17,718.00","282,516.19",,,,,,
Molina Duals,DRG,MS-003,ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITH MAJOR O.R. PROCEDURES,Surgical,Relative Weights,"$111,577.60 ",IP,"111,577.60","382,110.62",,,,,,
Molina Duals,DRG,MS-004,TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES,Surgical,Relative Weights,"$69,628.33 ",IP,"69,628.33","232,723.01",,,,,,
Molina Duals,DRG,MS-005,LIVER TRANSPLANT W MCC OR INTESTINAL TRANSPLANT,Surgical,Relative Weights,"$59,773.19 ",IP,"59,773.19","207,904.03",,,,,,
Molina Duals,DRG,MS-006,LIVER TRANSPLANT W/O MCC,Surgical,Relative Weights,"$27,427.34 ",IP,"27,427.34","98,217.50",,,,,,
Molina Duals,DRG,MS-007,LUNG TRANSPLANT,Surgical,Relative Weights,"$67,628.10 ",IP,"67,628.10","217,451.81",,,,,,
Molina Duals,DRG,MS-008,SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,Surgical,Relative Weights,"$31,730.89 ",IP,"31,730.89","113,220.58",,,,,,
Molina Duals,DRG,MS-010,PANCREAS TRANSPLANT,Surgical,Relative Weights,"$21,141.08 ",IP,"2,420.00","80,158.18",,,,,,
Molina Duals,DRG,MS-011,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC,Surgical,Relative Weights,"$29,325.37 ",IP,"2,420.00","99,667.01",,,,,,
Molina Duals,DRG,MS-012,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC,Surgical,Relative Weights,"$22,383.85 ",IP,"2,420.00","76,083.84",,,,,,
Molina Duals,DRG,MS-013,TRACHEOSTOMY FOR FACE -  MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC,Surgical,Relative Weights,"$15,907.20 ",IP,"2,420.00","48,894.05",,,,,,
Molina Duals,DRG,MS-014,ALLOGENEIC BONE MARROW TRANSPLANT,Surgical,Relative Weights,"$62,354.51 ",IP,"2,420.00","257,136.77",,,,,,
Molina Duals,DRG,MS-016,AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,Surgical,Relative Weights,"$39,340.51 ",IP,"2,420.00","138,805.63",,,,,,
Molina Duals,DRG,MS-017,AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,Surgical,Relative Weights,"$28,357.66 ",IP,"2,420.00","89,659.58",,,,,,
Molina Duals,DRG,MS-018,CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,Medical,Relative Weights,"$218,711.49 ",IP,"2,420.00","218,711.49",,,,,,
Molina Duals,DRG,MS-019,SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,Surgical,Relative Weights,"$39,009.97 ",IP,"2,420.00","39,009.97",,,,,,
Molina Duals,DRG,MS-020,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,Surgical,Relative Weights,"$60,368.88 ",IP,"2,420.00","218,151.36",,,,,,
Molina Duals,DRG,MS-021,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,Surgical,Relative Weights,"$44,054.63 ",IP,"2,420.00","166,797.79",,,,,,
Molina Duals,DRG,MS-022,INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W/O CC/MCC,Surgical,Relative Weights,"$28,282.33 ",IP,"2,420.00","99,425.09",,,,,,
Molina Duals,DRG,MS-023,CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX CNS PDX W MCC OR CHEMO IMPLANT,Surgical,Relative Weights,"$33,124.34 ",IP,"2,420.00","113,240.74",,,,,,
Molina Duals,DRG,MS-024,CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,Surgical,Relative Weights,"$23,004.07 ",IP,"2,420.00","80,972.64",,,,,,
Molina Duals,DRG,MS-025,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$26,265.17 ",IP,"2,420.00","88,593.12",,,,,,
Molina Duals,DRG,MS-026,CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC,Surgical,Relative Weights,"$17,882.32 ",IP,"2,420.00","61,403.33",,,,,,
Molina Duals,DRG,MS-027,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$14,683.71 ",IP,"2,420.00","48,317.47",,,,,,
Molina Duals,DRG,MS-028,SPINAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$34,007.36 ",IP,"2,420.00","112,702.46",,,,,,
Molina Duals,DRG,MS-029,SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,Surgical,Relative Weights,"$19,253.57 ",IP,"2,420.00","64,653.12",,,,,,
Molina Duals,DRG,MS-030,SPINAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$13,763.89 ",IP,"2,420.00","45,805.54",,,,,,
Molina Duals,DRG,MS-031,VENTRICULAR SHUNT PROCEDURES WITH MCC,Surgical,Relative Weights,"$25,531.07 ",IP,"2,420.00","88,189.92",,,,,,
Molina Duals,DRG,MS-032,VENTRICULAR SHUNT PROCEDURES WITH CC,Surgical,Relative Weights,"$12,944.53 ",IP,"2,420.00","44,192.74",,,,,,
Molina Duals,DRG,MS-033,VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,057.78 ",IP,"2,420.00","34,290.14",,,,,,
Molina Duals,DRG,MS-034,CAROTID ARTERY STENT PROCEDURE W MCC,Surgical,Relative Weights,"$23,232.41 ",IP,"2,420.00","75,674.59",,,,,,
Molina Duals,DRG,MS-035,CAROTID ARTERY STENT PROCEDURES WITH CC,Surgical,Relative Weights,"$13,664.03 ",IP,"2,420.00","46,412.35",,,,,,
Molina Duals,DRG,MS-036,CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,817.58 ",IP,"2,420.00","35,300.16",,,,,,
Molina Duals,DRG,MS-037,EXTRACRANIAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$19,141.44 ",IP,"2,420.00","65,384.93",,,,,,
Molina Duals,DRG,MS-038,EXTRACRANIAL PROCEDURES WITH CC,Surgical,Relative Weights,"$9,687.52 ",IP,"2,420.00","33,772.03",,,,,,
Molina Duals,DRG,MS-039,EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,652.43 ",IP,"2,420.00","22,807.01",,,,,,
Molina Duals,DRG,MS-040,PERIPHERAL- CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC,Surgical,Relative Weights,"$22,570.73 ",IP,"2,420.00","79,438.46",,,,,,
Molina Duals,DRG,MS-041,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W CC OR PERIPH NEUROSTIM,Surgical,Relative Weights,"$13,722.43 ",IP,"2,420.00","47,809.44",,,,,,
Molina Duals,DRG,MS-042,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W/O CC/MCC,Surgical,Relative Weights,"$11,103.16 ",IP,"2,420.00","37,261.73",,,,,,
Molina Duals,DRG,MS-052,SPINAL DISORDERS AND INJURIES WITH CC/MCC,Medical,Relative Weights,"$10,824.58 ",IP,"2,420.00","32,838.62",,,,,,
Molina Duals,DRG,MS-053,SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,Medical,Relative Weights,"$6,636.66 ",IP,"2,420.00","19,476.58",,,,,,
Molina Duals,DRG,MS-054,NERVOUS SYSTEM NEOPLASMS WITH MCC,Medical,Relative Weights,"$7,990.98 ",IP,"2,420.00","27,016.42",,,,,,
Molina Duals,DRG,MS-055,NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,Medical,Relative Weights,"$6,100.55 ",IP,"2,420.00","19,877.76",,,,,,
Molina Duals,DRG,MS-056,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,Medical,Relative Weights,"$12,820.72 ",IP,"2,420.00","44,198.78",,,,,,
Molina Duals,DRG,MS-057,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,Medical,Relative Weights,"$7,402.30 ",IP,"2,420.00","24,409.73",,,,,,
Molina Duals,DRG,MS-058,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,Medical,Relative Weights,"$10,148.89 ",IP,"2,420.00","39,406.75",,,,,,
Molina Duals,DRG,MS-059,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,Medical,Relative Weights,"$6,583.52 ",IP,"2,420.00","21,984.48",,,,,,
Molina Duals,DRG,MS-060,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,Medical,Relative Weights,"$5,359.44 ",IP,"2,420.00","17,775.07",,,,,,
Molina Duals,DRG,MS-061,ISCHEMIC STROKE -  PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC,Medical,Relative Weights,"$16,884.83 ",IP,"2,420.00","56,316.96",,,,,,
Molina Duals,DRG,MS-062,ISCHEMIC STROKE -  PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC,Medical,Relative Weights,"$11,611.83 ",IP,"2,420.00","40,545.79",,,,,,
Molina Duals,DRG,MS-063,ISCHEMIC STROKE- PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC,Medical,Relative Weights,"$9,984.78 ",IP,"2,420.00","33,884.93",,,,,,
Molina Duals,DRG,MS-064,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,Medical,Relative Weights,"$11,206.52 ",IP,"2,420.00","37,795.97",,,,,,
Molina Duals,DRG,MS-065,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC,Medical,Relative Weights,"$5,956.88 ",IP,"2,420.00","20,718.43",,,,,,
Molina Duals,DRG,MS-066,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,Medical,Relative Weights,"$4,155.80 ",IP,"2,420.00","14,454.72",,,,,,
Molina Duals,DRG,MS-067,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,Medical,Relative Weights,"$8,326.78 ",IP,"2,420.00","29,524.32",,,,,,
Molina Duals,DRG,MS-068,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,Medical,Relative Weights,"$5,191.24 ",IP,"2,420.00","18,212.54",,,,,,
Molina Duals,DRG,MS-069,TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,Medical,Relative Weights,"$4,596.73 ",IP,"2,420.00","15,730.85",,,,,,
Molina Duals,DRG,MS-070,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC,Medical,Relative Weights,"$9,808.99 ",IP,"2,420.00","33,725.66",,,,,,
Molina Duals,DRG,MS-071,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC,Medical,Relative Weights,"$5,908.99 ",IP,"2,420.00","20,053.15",,,,,,
Molina Duals,DRG,MS-072,NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$4,506.79 ",IP,"2,420.00","14,888.16",,,,,,
Molina Duals,DRG,MS-073,CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,Medical,Relative Weights,"$8,485.05 ",IP,"2,420.00","28,538.50",,,,,,
Molina Duals,DRG,MS-074,CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,Medical,Relative Weights,"$5,951.04 ",IP,"2,420.00","19,920.10",,,,,,
Molina Duals,DRG,MS-075,VIRAL MENINGITIS WITH CC/MCC,Medical,Relative Weights,"$9,501.81 ",IP,"2,420.00","32,421.31",,,,,,
Molina Duals,DRG,MS-076,VIRAL MENINGITIS WITHOUT CC/MCC,Medical,Relative Weights,"$5,751.89 ",IP,"2,420.00","18,194.40",,,,,,
Molina Duals,DRG,MS-077,HYPERTENSIVE ENCEPHALOPATHY WITH MCC,Medical,Relative Weights,"$8,952.25 ",IP,"2,420.00","31,096.80",,,,,,
Molina Duals,DRG,MS-078,HYPERTENSIVE ENCEPHALOPATHY WITH CC,Medical,Relative Weights,"$5,547.49 ",IP,"2,420.00","19,393.92",,,,,,
Molina Duals,DRG,MS-079,HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC,Medical,Relative Weights,"$4,256.25 ",IP,"2,420.00","14,940.58",,,,,,
Molina Duals,DRG,MS-080,NONTRAUMATIC STUPOR & COMA W MCC,Medical,Relative Weights,"$12,237.30 ",IP,"2,420.00","38,632.61",,,,,,
Molina Duals,DRG,MS-081,NONTRAUMATIC STUPOR & COMA W/O MCC,Medical,Relative Weights,"$4,515.55 ",IP,"2,420.00","17,722.66",,,,,,
Molina Duals,DRG,MS-082,TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,Medical,Relative Weights,"$13,221.35 ",IP,"2,420.00","45,396.29",,,,,,
Molina Duals,DRG,MS-083,TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,Medical,Relative Weights,"$7,849.06 ",IP,"2,420.00","26,423.71",,,,,,
Molina Duals,DRG,MS-084,TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,Medical,Relative Weights,"$5,288.77 ",IP,"2,420.00","18,089.57",,,,,,
Molina Duals,DRG,MS-085,TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,Medical,Relative Weights,"$13,500.51 ",IP,"2,420.00","45,275.33",,,,,,
Molina Duals,DRG,MS-086,TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,Medical,Relative Weights,"$7,443.18 ",IP,"2,420.00","24,954.05",,,,,,
Molina Duals,DRG,MS-087,TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,Medical,Relative Weights,"$5,043.49 ",IP,"2,420.00","16,918.27",,,,,,
Molina Duals,DRG,MS-088,CONCUSSION WITH MCC,Medical,Relative Weights,"$8,498.48 ",IP,"2,420.00","28,004.26",,,,,,
Molina Duals,DRG,MS-089,CONCUSSION WITH CC,Medical,Relative Weights,"$6,210.92 ",IP,"2,420.00","19,883.81",,,,,,
Molina Duals,DRG,MS-090,CONCUSSION WITHOUT CC/MCC,Medical,Relative Weights,"$4,990.93 ",IP,"2,420.00","17,101.73",,,,,,
Molina Duals,DRG,MS-091,OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,Medical,Relative Weights,"$9,640.80 ",IP,"2,420.00","31,552.42",,,,,,
Molina Duals,DRG,MS-092,OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,Medical,Relative Weights,"$5,775.25 ",IP,"2,420.00","19,476.58",,,,,,
Molina Duals,DRG,MS-093,OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,Medical,Relative Weights,"$4,568.11 ",IP,"2,420.00","15,345.79",,,,,,
Molina Duals,DRG,MS-094,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,Medical,Relative Weights,"$21,245.62 ",IP,"2,420.00","72,269.57",,,,,,
Molina Duals,DRG,MS-095,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,Medical,Relative Weights,"$14,642.83 ",IP,"2,420.00","48,527.14",,,,,,
Molina Duals,DRG,MS-096,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,Medical,Relative Weights,"$13,623.15 ",IP,"2,420.00","45,603.94",,,,,,
Molina Duals,DRG,MS-097,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,Medical,Relative Weights,"$21,961.03 ",IP,"2,420.00","72,090.14",,,,,,
Molina Duals,DRG,MS-098,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,Medical,Relative Weights,"$12,337.16 ",IP,"2,420.00","39,412.80",,,,,,
Molina Duals,DRG,MS-099,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,Medical,Relative Weights,"$8,187.20 ",IP,"2,420.00","25,853.18",,,,,,
Molina Duals,DRG,MS-100,SEIZURES WITH MCC,Medical,Relative Weights,"$10,958.32 ",IP,"2,420.00","36,695.23",,,,,,
Molina Duals,DRG,MS-101,SEIZURES WITHOUT MCC,Medical,Relative Weights,"$5,188.32 ",IP,"2,420.00","17,799.26",,,,,,
Molina Duals,DRG,MS-102,HEADACHES WITH MCC,Medical,Relative Weights,"$6,734.19 ",IP,"2,420.00","24,042.82",,,,,,
Molina Duals,DRG,MS-103,HEADACHES W/O MCC,Medical,Relative Weights,"$4,844.34 ",IP,"2,420.00","16,117.92",,,,,,
Molina Duals,DRG,MS-113,ORBITAL PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$12,815.47 ",IP,"2,420.00","42,983.14",,,,,,
Molina Duals,DRG,MS-114,ORBITAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,454.10 ",IP,"2,420.00","24,006.53",,,,,,
Molina Duals,DRG,MS-115,EXTRAOCULAR PROCEDURES EXCEPT ORBIT,Surgical,Relative Weights,"$8,506.66 ",IP,"2,420.00","29,957.76",,,,,,
Molina Duals,DRG,MS-116,INTRAOCULAR PROCEDURES W CC/MCC,Surgical,Relative Weights,"$10,995.11 ",IP,"2,420.00","38,122.56",,,,,,
Molina Duals,DRG,MS-117,INTRAOCULAR PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$6,080.69 ",IP,"2,420.00","22,109.47",,,,,,
Molina Duals,DRG,MS-121,ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,Medical,Relative Weights,"$6,953.20 ",IP,"2,420.00","25,558.85",,,,,,
Molina Duals,DRG,MS-122,ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,Medical,Relative Weights,"$3,769.77 ",IP,"2,420.00","15,575.62",,,,,,
Molina Duals,DRG,MS-123,NEUROLOGICAL EYE DISORDERS,Medical,Relative Weights,"$4,478.17 ",IP,"2,420.00","15,740.93",,,,,,
Molina Duals,DRG,MS-124,OTHER DISORDERS OF THE EYE WITH MCC,Medical,Relative Weights,"$8,187.79 ",IP,"2,420.00","28,010.30",,,,,,
Molina Duals,DRG,MS-125,OTHER DISORDERS OF THE EYE WITHOUT MCC,Medical,Relative Weights,"$4,888.14 ",IP,"2,420.00","15,914.30",,,,,,
Molina Duals,DRG,MS-135,SINUS AND MASTOID PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$12,518.21 ",IP,"2,420.00","46,057.54",,,,,,
Molina Duals,DRG,MS-136,SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,332.22 ",IP,"2,420.00","23,990.40",,,,,,
Molina Duals,DRG,MS-137,MOUTH PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$8,816.77 ",IP,"2,420.00","26,879.33",,,,,,
Molina Duals,DRG,MS-138,MOUTH PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$5,002.03 ",IP,"2,420.00","17,365.82",,,,,,
Molina Duals,DRG,MS-139,SALIVARY GLAND PROCEDURES,Surgical,Relative Weights,"$7,207.24 ",IP,"2,420.00","24,883.49",,,,,,
Molina Duals,DRG,MS-140,MAJOR HEAD AND NECK PROCEDURES WITH MCC,Medical,Relative Weights,"$23,231.24 ",IP,"2,420.00","23,231.24",,,,,,
Molina Duals,DRG,MS-141,MAJOR HEAD AND NECK PROCEDURES WITH CC,Medical,Relative Weights,"$12,883.80 ",IP,"2,420.00","12,883.80",,,,,,
Molina Duals,DRG,MS-142,MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,Medical,Relative Weights,"$9,373.91 ",IP,"2,420.00","9,373.91",,,,,,
Molina Duals,DRG,MS-143,OTHER EAR- NOSE- MOUTH AND THROAT O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$17,402.26 ",IP,"2,420.00","17,402.26",,,,,,
Molina Duals,DRG,MS-144,HERNIA PROCEDURES AGE 0-17,Surgical,Relative Weights,"$10,287.30 ",IP,"2,420.00","10,287.30",,,,,,
Molina Duals,DRG,MS-145,OTHER EAR -  NOSE -  MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC,Medical,Relative Weights,"$7,151.76 ",IP,"2,420.00","7,151.76",,,,,,
Molina Duals,DRG,MS-146,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH MCC,Medical,Relative Weights,"$11,920.18 ",IP,"2,420.00","38,880.58",,,,,,
Molina Duals,DRG,MS-147,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH CC,Medical,Relative Weights,"$7,598.52 ",IP,"2,420.00","25,016.54",,,,,,
Molina Duals,DRG,MS-148,EAR - NOSE - MOUTH & THROAT MALIGNANCY W/O CC/MCC,Medical,Relative Weights,"$4,596.14 ",IP,"2,420.00","15,329.66",,,,,,
Molina Duals,DRG,MS-149,DYSEQUILIBRIUM,Medical,Relative Weights,"$4,304.14 ",IP,"2,420.00","14,726.88",,,,,,
Molina Duals,DRG,MS-150,EPISTAXIS WITH MCC,Medical,Relative Weights,"$7,752.70 ",IP,"2,420.00","26,036.64",,,,,,
Molina Duals,DRG,MS-151,EPISTAXIS WITHOUT MCC,Medical,Relative Weights,"$4,312.31 ",IP,"2,420.00","14,093.86",,,,,,
Molina Duals,DRG,MS-152,OTITIS MEDIA AND URI WITH MCC,Medical,Relative Weights,"$6,310.20 ",IP,"2,420.00","20,946.24",,,,,,
Molina Duals,DRG,MS-153,OTITIS MEDIA AND URI WITHOUT MCC,Medical,Relative Weights,"$4,165.14 ",IP,"2,420.00","14,241.02",,,,,,
Molina Duals,DRG,MS-154,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH MCC,Medical,Relative Weights,"$9,033.43 ",IP,"2,420.00","28,969.92",,,,,,
Molina Duals,DRG,MS-155,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH CC,Medical,Relative Weights,"$5,311.55 ",IP,"2,420.00","18,166.18",,,,,,
Molina Duals,DRG,MS-156,OTHER EAR -  NOSE -  MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$3,845.11 ",IP,"2,420.00","13,194.72",,,,,,
Molina Duals,DRG,MS-157,DENTAL AND ORAL DISEASES WITH MCC,Medical,Relative Weights,"$9,205.13 ",IP,"2,420.00","31,508.06",,,,,,
Molina Duals,DRG,MS-158,DENTAL AND ORAL DISEASES WITH CC,Medical,Relative Weights,"$5,257.24 ",IP,"2,420.00","17,470.66",,,,,,
Molina Duals,DRG,MS-159,DENTAL AND ORAL DISEASES WITHOUT CC/MCC,Medical,Relative Weights,"$3,872.56 ",IP,"2,420.00","13,565.66",,,,,,
Molina Duals,DRG,MS-163,MAJOR CHEST PROCEDURES WITH MCC,Surgical,Relative Weights,"$29,240.10 ",IP,"2,420.00","98,253.79",,,,,,
Molina Duals,DRG,MS-164,MAJOR CHEST PROCEDURES WITH CC,Surgical,Relative Weights,"$15,508.91 ",IP,"2,420.00","51,037.06",,,,,,
Molina Duals,DRG,MS-165,MAJOR CHEST PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$11,193.09 ",IP,"2,420.00","37,279.87",,,,,,
Molina Duals,DRG,MS-166,OTHER RESP SYSTEM O.R. PROCEDURES W MCC,Surgical,Relative Weights,"$21,745.53 ",IP,"2,420.00","75,210.91",,,,,,
Molina Duals,DRG,MS-167,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$10,621.35 ",IP,"2,420.00","38,594.30",,,,,,
Molina Duals,DRG,MS-168,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,909.80 ",IP,"2,420.00","26,746.27",,,,,,
Molina Duals,DRG,MS-175,PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,Medical,Relative Weights,"$9,028.76 ",IP,"2,420.00","29,119.10",,,,,,
Molina Duals,DRG,MS-176,PULMONARY EMBOLISM WITHOUT MCC,Medical,Relative Weights,"$5,184.82 ",IP,"2,420.00","17,103.74",,,,,,
Molina Duals,DRG,MS-177,RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC,Medical,Relative Weights,"$10,798.89 ",IP,"2,420.00","38,126.59",,,,,,
Molina Duals,DRG,MS-178,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,Medical,Relative Weights,"$7,053.65 ",IP,"2,420.00","25,064.93",,,,,,
Molina Duals,DRG,MS-179,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,Medical,Relative Weights,"$5,096.64 ",IP,"2,420.00","17,460.58",,,,,,
Molina Duals,DRG,MS-180,RESPIRATORY NEOPLASMS WITH MCC,Medical,Relative Weights,"$10,161.15 ",IP,"2,420.00","34,773.98",,,,,,
Molina Duals,DRG,MS-181,RESPIRATORY NEOPLASMS WITH CC,Medical,Relative Weights,"$6,541.47 ",IP,"2,420.00","23,224.32",,,,,,
Molina Duals,DRG,MS-182,RESPIRATORY NEOPLASMS WITHOUT CC/MCC,Medical,Relative Weights,"$4,625.34 ",IP,"2,420.00","16,990.85",,,,,,
Molina Duals,DRG,MS-183,MAJOR CHEST TRAUMA WITH MCC,Medical,Relative Weights,"$9,104.10 ",IP,"2,420.00","30,425.47",,,,,,
Molina Duals,DRG,MS-184,MAJOR CHEST TRAUMA WITH CC,Medical,Relative Weights,"$6,078.94 ",IP,"2,420.00","20,526.91",,,,,,
Molina Duals,DRG,MS-185,MAJOR CHEST TRAUMA W/O CC/MCC,Medical,Relative Weights,"$4,525.48 ",IP,"2,420.00","14,797.44",,,,,,
Molina Duals,DRG,MS-186,PLEURAL EFFUSION WITH MCC,Medical,Relative Weights,"$9,015.91 ",IP,"2,420.00","31,104.86",,,,,,
Molina Duals,DRG,MS-187,PLEURAL EFFUSION WITH CC,Medical,Relative Weights,"$6,032.22 ",IP,"2,420.00","20,722.46",,,,,,
Molina Duals,DRG,MS-188,PLEURAL EFFUSION WITHOUT CC/MCC,Medical,Relative Weights,"$4,260.34 ",IP,"2,420.00","14,734.94",,,,,,
Molina Duals,DRG,MS-189,PULMONARY EDEMA AND RESPIRATORY FAILURE,Medical,Relative Weights,"$7,160.52 ",IP,"2,420.00","24,508.51",,,,,,
Molina Duals,DRG,MS-190,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,Medical,Relative Weights,"$6,570.67 ",IP,"2,420.00","23,063.04",,,,,,
Molina Duals,DRG,MS-191,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,Medical,Relative Weights,"$5,164.38 ",IP,"2,420.00","17,998.85",,,,,,
Molina Duals,DRG,MS-192,CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC,Medical,Relative Weights,"$4,062.36 ",IP,"2,420.00","14,297.47",,,,,,
Molina Duals,DRG,MS-193,SIMPLE PNEUMONIA & PLEURISY W MCC,Medical,Relative Weights,"$7,662.18 ",IP,"2,420.00","26,883.36",,,,,,
Molina Duals,DRG,MS-194,SIMPLE PNEUMONIA AND PLEURISY WITH CC,Medical,Relative Weights,"$5,045.24 ",IP,"2,420.00","17,914.18",,,,,,
Molina Duals,DRG,MS-195,SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,Medical,Relative Weights,"$3,888.32 ",IP,"2,420.00","13,751.14",,,,,,
Molina Duals,DRG,MS-196,INTERSTITIAL LUNG DISEASE WITH MCC,Medical,Relative Weights,"$10,153.56 ",IP,"2,420.00","33,776.06",,,,,,
Molina Duals,DRG,MS-197,INTERSTITIAL LUNG DISEASE WITH CC,Medical,Relative Weights,"$5,880.96 ",IP,"2,420.00","20,593.44",,,,,,
Molina Duals,DRG,MS-198,INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,Medical,Relative Weights,"$4,341.51 ",IP,"2,420.00","15,220.80",,,,,,
Molina Duals,DRG,MS-199,PNEUMOTHORAX WITH MCC,Medical,Relative Weights,"$10,453.74 ",IP,"2,420.00","36,169.06",,,,,,
Molina Duals,DRG,MS-200,PNEUMOTHORAX WITH CC,Medical,Relative Weights,"$6,286.84 ",IP,"2,420.00","21,815.14",,,,,,
Molina Duals,DRG,MS-201,PNEUMOTHORAX WITHOUT CC/MCC,Medical,Relative Weights,"$4,144.12 ",IP,"2,420.00","14,474.88",,,,,,
Molina Duals,DRG,MS-202,BRONCHITIS AND ASTHMA WITH CC/MCC,Medical,Relative Weights,"$5,647.36 ",IP,"2,420.00","19,111.68",,,,,,
Molina Duals,DRG,MS-203,BRONCHITIS AND ASTHMA WITHOUT CC/MCC,Medical,Relative Weights,"$4,128.93 ",IP,"2,420.00","13,987.01",,,,,,
Molina Duals,DRG,MS-204,RESPIRATORY SIGNS AND SYMPTOMS,Medical,Relative Weights,"$4,634.69 ",IP,"2,420.00","16,380.00",,,,,,
Molina Duals,DRG,MS-205,OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,Medical,Relative Weights,"$9,839.36 ",IP,"2,420.00","32,945.47",,,,,,
Molina Duals,DRG,MS-206,OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,Medical,Relative Weights,"$5,174.31 ",IP,"2,420.00","17,589.60",,,,,,
Molina Duals,DRG,MS-207,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS,Medical,Relative Weights,"$33,499.27 ",IP,"2,420.00","115,629.70",,,,,,
Molina Duals,DRG,MS-208,RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,Medical,Relative Weights,"$14,861.83 ",IP,"2,420.00","50,079.46",,,,,,
Molina Duals,DRG,MS-215,OTHER HEART ASSIST SYSTEM IMPLANT,Surgical,Relative Weights,"$61,661.88 ",IP,"61,661.88","259,783.78",,,,,,
Molina Duals,DRG,MS-216,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$58,630.29 ",IP,"58,630.29","202,454.78",,,,,,
Molina Duals,DRG,MS-217,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,Surgical,Relative Weights,"$37,864.14 ",IP,"37,864.14","134,096.26",,,,,,
Molina Duals,DRG,MS-218,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,Surgical,Relative Weights,"$35,678.79 ",IP,"35,678.79","108,892.22",,,,,,
Molina Duals,DRG,MS-219,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$47,057.01 ",IP,"47,057.01","158,056.42",,,,,,
Molina Duals,DRG,MS-220,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,Surgical,Relative Weights,"$31,567.37 ",IP,"31,567.37","106,966.94",,,,,,
Molina Duals,DRG,MS-221,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,Surgical,Relative Weights,"$26,746.97 ",IP,"26,746.97","92,659.39",,,,,,
Molina Duals,DRG,MS-222,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITH MCC,Surgical,Relative Weights,"$46,434.46 ",IP,"46,434.46","168,227.14",,,,,,
Molina Duals,DRG,MS-223,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITHOUT MCC,Surgical,Relative Weights,"$33,864.27 ",IP,"33,864.27","121,018.46",,,,,,
Molina Duals,DRG,MS-224,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITH MCC,Surgical,Relative Weights,"$43,912.13 ",IP,"43,912.13","149,107.39",,,,,,
Molina Duals,DRG,MS-225,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITHOUT MCC,Surgical,Relative Weights,"$32,808.39 ",IP,"32,808.39","113,879.81",,,,,,
Molina Duals,DRG,MS-226,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$38,340.11 ",IP,"25,420.00","134,824.03",,,,,,
Molina Duals,DRG,MS-227,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Surgical,Relative Weights,"$30,439.07 ",IP,"25,420.00","105,420.67",,,,,,
Molina Duals,DRG,MS-228,OTHER CARDIOTHORACIC PROCEDURES WITH MCC,Surgical,Relative Weights,"$31,129.37 ",IP,"31,129.37","126,731.81",,,,,,
Molina Duals,DRG,MS-229,OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$20,096.88 ",IP,"20,096.88","82,754.78",,,,,,
Molina Duals,DRG,MS-231,CORONARY BYPASS W PTCA W MCC,Surgical,Relative Weights,"$50,901.53 ",IP,"50,901.53","165,543.84",,,,,,
Molina Duals,DRG,MS-232,CORONARY BYPASS W PTCA W/O MCC,Surgical,Relative Weights,"$34,770.65 ",IP,"34,770.65","120,687.84",,,,,,
Molina Duals,DRG,MS-233,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,Surgical,Relative Weights,"$46,266.85 ",IP,"42,365.00","156,621.02",,,,,,
Molina Duals,DRG,MS-234,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,Surgical,Relative Weights,"$31,162.65 ",IP,"31,162.65","104,959.01",,,,,,
Molina Duals,DRG,MS-235,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$35,648.42 ",IP,"32,351.00","118,633.54",,,,,,
Molina Duals,DRG,MS-236,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Surgical,Relative Weights,"$23,926.80 ",IP,"23,926.80","81,226.66",,,,,,
Molina Duals,DRG,MS-239,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,Surgical,Relative Weights,"$28,125.81 ",IP,"2,420.00","94,141.15",,,,,,
Molina Duals,DRG,MS-240,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,Surgical,Relative Weights,"$16,286.81 ",IP,"2,420.00","55,641.60",,,,,,
Molina Duals,DRG,MS-241,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,Surgical,Relative Weights,"$9,299.74 ",IP,"2,420.00","30,568.61",,,,,,
Molina Duals,DRG,MS-242,PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,Surgical,Relative Weights,"$21,769.47 ",IP,"15,407.00","74,815.78",,,,,,
Molina Duals,DRG,MS-243,PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,Surgical,Relative Weights,"$14,708.24 ",IP,"14,708.24","50,992.70",,,,,,
Molina Duals,DRG,MS-244,PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,Surgical,Relative Weights,"$12,049.83 ",IP,"12,049.83","41,840.06",,,,,,
Molina Duals,DRG,MS-245,AICD GENERATOR PROCEDURES,Surgical,Relative Weights,"$31,640.37 ",IP,"15,407.00","104,989.25",,,,,,
Molina Duals,DRG,MS-246,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Surgical,Relative Weights,"$18,246.15 ",IP,"18,246.15","63,963.65",,,,,,
Molina Duals,DRG,MS-247,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITHOUT MCC,Surgical,Relative Weights,"$11,523.64 ",IP,"11,523.64","41,019.55",,,,,,
Molina Duals,DRG,MS-248,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Surgical,Relative Weights,"$18,467.49 ",IP,"18,467.49","62,425.44",,,,,,
Molina Duals,DRG,MS-249,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITHOUT MCC,Surgical,Relative Weights,"$10,942.55 ",IP,"10,942.55","38,638.66",,,,,,
Molina Duals,DRG,MS-250,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT CORONARY ARTERY STENT WITH MCC,Surgical,Relative Weights,"$14,727.51 ",IP,"14,727.51","51,410.02",,,,,,
Molina Duals,DRG,MS-251,PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W/O MCC,Surgical,Relative Weights,"$9,685.18 ",IP,"2,420.00","33,929.28",,,,,,
Molina Duals,DRG,MS-252,OTHER VASCULAR PROCEDURES W MCC,Surgical,Relative Weights,"$19,422.35 ",IP,"2,420.00","66,132.86",,,,,,
Molina Duals,DRG,MS-253,OTHER VASCULAR PROCEDURES WITH CC,Surgical,Relative Weights,"$15,497.23 ",IP,"2,420.00","52,549.06",,,,,,
Molina Duals,DRG,MS-254,OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,605.00 ",IP,"2,420.00","36,693.22",,,,,,
Molina Duals,DRG,MS-255,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,Surgical,Relative Weights,"$14,806.35 ",IP,"2,420.00","53,415.94",,,,,,
Molina Duals,DRG,MS-256,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,Surgical,Relative Weights,"$9,602.26 ",IP,"2,420.00","34,604.64",,,,,,
Molina Duals,DRG,MS-257,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$6,804.86 ",IP,"2,420.00","22,869.50",,,,,,
Molina Duals,DRG,MS-258,CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,Surgical,Relative Weights,"$18,501.95 ",IP,"11,861.00","61,663.39",,,,,,
Molina Duals,DRG,MS-259,CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,Surgical,Relative Weights,"$12,201.09 ",IP,"11,861.00","41,985.22",,,,,,
Molina Duals,DRG,MS-260,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,Surgical,Relative Weights,"$20,833.31 ",IP,"10,167.00","74,583.94",,,,,,
Molina Duals,DRG,MS-261,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,Surgical,Relative Weights,"$11,644.53 ",IP,"10,167.00","39,281.76",,,,,,
Molina Duals,DRG,MS-262,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,Surgical,Relative Weights,"$9,964.34 ",IP,"9,964.34","33,820.42",,,,,,
Molina Duals,DRG,MS-263,VEIN LIGATION AND STRIPPING,Surgical,Relative Weights,"$13,509.27 ",IP,"2,420.00","47,559.46",,,,,,
Molina Duals,DRG,MS-264,OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,Surgical,Relative Weights,"$19,001.28 ",IP,"2,420.00","65,278.08",,,,,,
Molina Duals,DRG,MS-265,AICD LEAD PROCEDURES,Surgical,Relative Weights,"$19,654.78 ",IP,"2,420.00","62,925.41",,,,,,
Molina Duals,DRG,MS-266,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,Surgical,Relative Weights,"$41,160.28 ",IP,"41,160.28","143,567.42",,,,,,
Molina Duals,DRG,MS-267,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$32,692.75 ",IP,"32,692.75","114,420.10",,,,,,
Molina Duals,DRG,MS-268,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,Surgical,Relative Weights,"$40,666.21 ",IP,"32,968.00","136,737.22",,,,,,
Molina Duals,DRG,MS-269,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,Surgical,Relative Weights,"$25,200.52 ",IP,"25,200.52","86,010.62",,,,,,
Molina Duals,DRG,MS-270,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,Surgical,Relative Weights,"$30,292.48 ",IP,"30,292.48","103,021.63",,,,,,
Molina Duals,DRG,MS-271,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,Surgical,Relative Weights,"$20,822.21 ",IP,"20,822.21","71,527.68",,,,,,
Molina Duals,DRG,MS-272,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$15,699.88 ",IP,"15,699.88","52,442.21",,,,,,
Molina Duals,DRG,MS-273,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,Surgical,Relative Weights,"$22,348.22 ",IP,"16,176.00","74,799.65",,,,,,
Molina Duals,DRG,MS-274,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$19,194.00 ",IP,"16,176.00","63,701.57",,,,,,
Molina Duals,DRG,MS-280,ACUTE MYOCARDIAL INFARCTION - DISCHARGED ALIVE W MCC,Medical,Relative Weights,"$9,384.42 ",IP,"2,420.00","32,878.94",,,,,,
Molina Duals,DRG,MS-281,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITH CC,Medical,Relative Weights,"$5,434.78 ",IP,"2,420.00","19,528.99",,,,,,
Molina Duals,DRG,MS-282,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITHOUT CC/MCC,Medical,Relative Weights,"$4,240.48 ",IP,"2,420.00","14,876.06",,,,,,
Molina Duals,DRG,MS-283,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH MCC,Medical,Relative Weights,"$10,889.99 ",IP,"2,420.00","36,281.95",,,,,,
Molina Duals,DRG,MS-284,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH CC,Medical,Relative Weights,"$4,224.71 ",IP,"2,420.00","14,622.05",,,,,,
Molina Duals,DRG,MS-285,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITHOUT CC/MCC,Medical,Relative Weights,"$2,889.09 ",IP,"2,420.00","10,438.85",,,,,,
Molina Duals,DRG,MS-286,CIRCULATORY DISORDERS EXCEPT AMI- WITH CARDIAC CATHETERIZATION WITH MCC,Medical,Relative Weights,"$12,476.16 ",IP,"2,420.00","44,299.58",,,,,,
Molina Duals,DRG,MS-287,CIRCULATORY DISORDERS EXCEPT AMI -  WITH CARDIAC CATHETERIZATION WITHOUT MCC,Medical,Relative Weights,"$6,512.27 ",IP,"6,512.27","23,228.35",,,,,,
Molina Duals,DRG,MS-288,ACUTE & SUBACUTE ENDOCARDITIS W MCC,Medical,Relative Weights,"$15,682.94 ",IP,"2,420.00","53,573.18",,,,,,
Molina Duals,DRG,MS-289,ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,Medical,Relative Weights,"$9,598.75 ",IP,"9,181.00","33,542.21",,,,,,
Molina Duals,DRG,MS-290,ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,Medical,Relative Weights,"$5,997.18 ",IP,"2,420.00","20,172.10",,,,,,
Molina Duals,DRG,MS-291,HEART FAILURE AND SHOCK WITH MCC,Medical,Relative Weights,"$7,406.97 ",IP,"2,420.00","27,131.33",,,,,,
Molina Duals,DRG,MS-292,HEART FAILURE AND SHOCK WITH CC,Medical,Relative Weights,"$5,042.91 ",IP,"2,420.00","18,254.88",,,,,,
Molina Duals,DRG,MS-293,HEART FAILURE AND SHOCK WITHOUT CC/MCC,Medical,Relative Weights,"$3,445.06 ",IP,"2,420.00","13,210.85",,,,,,
Molina Duals,DRG,MS-294,DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC,Medical,Relative Weights,"$7,491.65 ",IP,"2,420.00","25,641.50",,,,,,
Molina Duals,DRG,MS-295,DEEP VEIN THROMBOPHLEBITIS W/O CC/MCC,Medical,Relative Weights,"$5,747.22 ",IP,"2,420.00","11,632.32",,,,,,
Molina Duals,DRG,MS-296,CARDIAC ARREST - UNEXPLAINED W MCC,Medical,Relative Weights,"$9,316.09 ",IP,"2,420.00","31,659.26",,,,,,
Molina Duals,DRG,MS-297,CARDIAC ARREST- UNEXPLAINED WITH CC,Medical,Relative Weights,"$4,128.93 ",IP,"2,420.00","14,575.68",,,,,,
Molina Duals,DRG,MS-298,CARDIAC ARREST- UNEXPLAINED WITHOUT CC/MCC,Medical,Relative Weights,"$2,854.63 ",IP,"2,420.00","10,144.51",,,,,,
Molina Duals,DRG,MS-299,PERIPHERAL VASCULAR DISORDERS WITH MCC,Medical,Relative Weights,"$8,950.50 ",IP,"2,420.00","29,225.95",,,,,,
Molina Duals,DRG,MS-300,PERIPHERAL VASCULAR DISORDERS WITH CC,Medical,Relative Weights,"$6,095.87 ",IP,"2,420.00","20,716.42",,,,,,
Molina Duals,DRG,MS-301,PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$4,339.76 ",IP,"2,420.00","14,632.13",,,,,,
Molina Duals,DRG,MS-302,ATHEROSCLEROSIS WITH MCC,Medical,Relative Weights,"$6,393.72 ",IP,"2,420.00","22,222.37",,,,,,
Molina Duals,DRG,MS-303,ATHEROSCLEROSIS WITHOUT MCC,Medical,Relative Weights,"$3,957.24 ",IP,"2,420.00","13,622.11",,,,,,
Molina Duals,DRG,MS-304,HYPERTENSION WITH MCC,Medical,Relative Weights,"$6,406.57 ",IP,"2,420.00","22,004.64",,,,,,
Molina Duals,DRG,MS-305,HYPERTENSION WITHOUT MCC,Medical,Relative Weights,"$4,321.07 ",IP,"2,420.00","14,747.04",,,,,,
Molina Duals,DRG,MS-306,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,Medical,Relative Weights,"$8,803.33 ",IP,"2,420.00","28,516.32",,,,,,
Molina Duals,DRG,MS-307,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,Medical,Relative Weights,"$5,083.20 ",IP,"2,420.00","17,785.15",,,,,,
Molina Duals,DRG,MS-308,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,Medical,Relative Weights,"$7,013.35 ",IP,"2,420.00","23,944.03",,,,,,
Molina Duals,DRG,MS-309,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,Medical,Relative Weights,"$4,382.98 ",IP,"2,420.00","15,247.01",,,,,,
Molina Duals,DRG,MS-310,CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC,Medical,Relative Weights,"$3,265.77 ",IP,"2,420.00","11,275.49",,,,,,
Molina Duals,DRG,MS-311,ANGINA PECTORIS,Medical,Relative Weights,"$4,079.29 ",IP,"2,420.00","13,809.60",,,,,,
Molina Duals,DRG,MS-312,SYNCOPE AND COLLAPSE,Medical,Relative Weights,"$4,898.07 ",IP,"2,420.00","16,462.66",,,,,,
Molina Duals,DRG,MS-313,CHEST PAIN,Medical,Relative Weights,"$4,213.03 ",IP,"2,420.00","14,420.45",,,,,,
Molina Duals,DRG,MS-314,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,Medical,Relative Weights,"$12,174.81 ",IP,"2,420.00","40,914.72",,,,,,
Molina Duals,DRG,MS-315,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,Medical,Relative Weights,"$5,684.73 ",IP,"2,420.00","19,563.26",,,,,,
Molina Duals,DRG,MS-316,OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$4,224.71 ",IP,"2,420.00","14,962.75",,,,,,
Molina Duals,DRG,MS-319,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,Surgical,Relative Weights,"$25,216.87 ",IP,"2,420.00","82,670.11",,,,,,
Molina Duals,DRG,MS-320,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$14,048.89 ",IP,"2,420.00","47,329.63",,,,,,
Molina Duals,DRG,MS-326,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$31,047.60 ",IP,"2,420.00","106,253.28",,,,,,
Molina Duals,DRG,MS-327,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC,Surgical,Relative Weights,"$14,978.05 ",IP,"2,420.00","51,869.66",,,,,,
Molina Duals,DRG,MS-328,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$9,734.83 ",IP,"2,420.00","31,752.00",,,,,,
Molina Duals,DRG,MS-329,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Surgical,Relative Weights,"$28,535.79 ",IP,"2,420.00","98,929.15",,,,,,
Molina Duals,DRG,MS-330,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Surgical,Relative Weights,"$14,888.11 ",IP,"2,420.00","50,940.29",,,,,,
Molina Duals,DRG,MS-331,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$9,989.45 ",IP,"2,420.00","34,054.27",,,,,,
Molina Duals,DRG,MS-332,RECTAL RESECTION WITH MCC,Surgical,Relative Weights,"$24,303.48 ",IP,"2,420.00","70,396.70",,,,,,
Molina Duals,DRG,MS-333,RECTAL RESECTION WITH CC,Surgical,Relative Weights,"$12,505.36 ",IP,"2,420.00","45,626.11",,,,,,
Molina Duals,DRG,MS-334,RECTAL RESECTION WITHOUT CC/MCC,Surgical,Relative Weights,"$9,394.35 ",IP,"2,420.00","31,052.45",,,,,,
Molina Duals,DRG,MS-335,PERITONEAL ADHESIOLYSIS WITH MCC,Surgical,Relative Weights,"$22,855.14 ",IP,"2,420.00","81,549.22",,,,,,
Molina Duals,DRG,MS-336,PERITONEAL ADHESIOLYSIS WITH CC,Surgical,Relative Weights,"$13,381.37 ",IP,"2,420.00","45,686.59",,,,,,
Molina Duals,DRG,MS-337,PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$9,561.96 ",IP,"2,420.00","33,056.35",,,,,,
Molina Duals,DRG,MS-338,APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$16,336.45 ",IP,"2,420.00","58,667.62",,,,,,
Molina Duals,DRG,MS-339,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W CC,Surgical,Relative Weights,"$9,912.95 ",IP,"2,420.00","34,596.58",,,,,,
Molina Duals,DRG,MS-340,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC/MCC,Surgical,Relative Weights,"$7,173.37 ",IP,"2,420.00","24,948.00",,,,,,
Molina Duals,DRG,MS-341,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$13,563.00 ",IP,"2,420.00","51,571.30",,,,,,
Molina Duals,DRG,MS-342,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH CC,Surgical,Relative Weights,"$8,368.25 ",IP,"2,420.00","32,463.65",,,,,,
Molina Duals,DRG,MS-343,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$6,474.31 ",IP,"2,420.00","23,216.26",,,,,,
Molina Duals,DRG,MS-344,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Surgical,Relative Weights,"$16,459.67 ",IP,"2,420.00","60,381.22",,,,,,
Molina Duals,DRG,MS-345,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Surgical,Relative Weights,"$9,220.31 ",IP,"2,420.00","32,927.33",,,,,,
Molina Duals,DRG,MS-346,MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,448.43 ",IP,"2,420.00","25,859.23",,,,,,
Molina Duals,DRG,MS-347,ANAL AND STOMAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$14,394.04 ",IP,"2,420.00","53,149.82",,,,,,
Molina Duals,DRG,MS-348,ANAL AND STOMAL PROCEDURES WITH CC,Surgical,Relative Weights,"$7,873.01 ",IP,"2,420.00","28,411.49",,,,,,
Molina Duals,DRG,MS-349,ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$5,719.19 ",IP,"2,420.00","19,774.94",,,,,,
Molina Duals,DRG,MS-350,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,Surgical,Relative Weights,"$14,336.22 ",IP,"2,420.00","49,176.29",,,,,,
Molina Duals,DRG,MS-351,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,Surgical,Relative Weights,"$8,717.48 ",IP,"2,420.00","29,399.33",,,,,,
Molina Duals,DRG,MS-352,INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,449.78 ",IP,"2,420.00","21,708.29",,,,,,
Molina Duals,DRG,MS-353,HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,Surgical,Relative Weights,"$17,665.65 ",IP,"2,420.00","59,812.70",,,,,,
Molina Duals,DRG,MS-354,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W CC,Surgical,Relative Weights,"$10,423.37 ",IP,"2,420.00","34,717.54",,,,,,
Molina Duals,DRG,MS-355,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W/O CC/MCC,Surgical,Relative Weights,"$7,943.67 ",IP,"2,420.00","27,667.58",,,,,,
Molina Duals,DRG,MS-356,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$25,157.89 ",IP,"2,420.00","82,196.35",,,,,,
Molina Duals,DRG,MS-357,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$13,248.22 ",IP,"2,420.00","45,368.06",,,,,,
Molina Duals,DRG,MS-358,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,878.85 ",IP,"2,420.00","27,653.47",,,,,,
Molina Duals,DRG,MS-368,MAJOR ESOPHAGEAL DISORDERS WITH MCC,Medical,Relative Weights,"$11,382.90 ",IP,"2,420.00","38,376.58",,,,,,
Molina Duals,DRG,MS-369,MAJOR ESOPHAGEAL DISORDERS WITH CC,Medical,Relative Weights,"$6,290.93 ",IP,"2,420.00","21,432.10",,,,,,
Molina Duals,DRG,MS-370,MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$4,368.96 ",IP,"2,420.00","15,065.57",,,,,,
Molina Duals,DRG,MS-371,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,Medical,Relative Weights,"$10,110.34 ",IP,"2,420.00","34,786.08",,,,,,
Molina Duals,DRG,MS-372,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,Medical,Relative Weights,"$6,011.19 ",IP,"2,420.00","20,613.60",,,,,,
Molina Duals,DRG,MS-373,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,Medical,Relative Weights,"$4,348.52 ",IP,"2,420.00","14,954.69",,,,,,
Molina Duals,DRG,MS-374,DIGESTIVE MALIGNANCY WITH MCC,Medical,Relative Weights,"$12,110.57 ",IP,"2,420.00","40,269.60",,,,,,
Molina Duals,DRG,MS-375,DIGESTIVE MALIGNANCY WITH CC,Medical,Relative Weights,"$7,052.48 ",IP,"2,420.00","24,339.17",,,,,,
Molina Duals,DRG,MS-376,DIGESTIVE MALIGNANCY WITHOUT CC/MCC,Medical,Relative Weights,"$5,249.65 ",IP,"2,420.00","20,186.21",,,,,,
Molina Duals,DRG,MS-377,GASTROINTESTINAL HEMORRHAGE WITH MCC,Medical,Relative Weights,"$10,519.15 ",IP,"2,420.00","35,681.18",,,,,,
Molina Duals,DRG,MS-378,GASTROINTESTINAL HEMORRHAGE WITH CC,Medical,Relative Weights,"$5,802.12 ",IP,"2,420.00","19,920.10",,,,,,
Molina Duals,DRG,MS-379,GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,Medical,Relative Weights,"$3,721.30 ",IP,"2,420.00","13,017.31",,,,,,
Molina Duals,DRG,MS-380,COMPLICATED PEPTIC ULCER WITH MCC,Medical,Relative Weights,"$11,017.89 ",IP,"2,420.00","38,054.02",,,,,,
Molina Duals,DRG,MS-381,COMPLICATED PEPTIC ULCER WITH CC,Medical,Relative Weights,"$6,186.39 ",IP,"2,420.00","21,706.27",,,,,,
Molina Duals,DRG,MS-382,COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,Medical,Relative Weights,"$4,488.68 ",IP,"2,420.00","15,954.62",,,,,,
Molina Duals,DRG,MS-383,UNCOMPLICATED PEPTIC ULCER WITH MCC,Medical,Relative Weights,"$7,665.69 ",IP,"2,420.00","26,738.21",,,,,,
Molina Duals,DRG,MS-384,UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,Medical,Relative Weights,"$5,214.02 ",IP,"2,420.00","17,543.23",,,,,,
Molina Duals,DRG,MS-385,INFLAMMATORY BOWEL DISEASE WITH MCC,Medical,Relative Weights,"$9,474.36 ",IP,"2,420.00","32,463.65",,,,,,
Molina Duals,DRG,MS-386,INFLAMMATORY BOWEL DISEASE W CC,Medical,Relative Weights,"$5,811.46 ",IP,"2,420.00","19,861.63",,,,,,
Molina Duals,DRG,MS-387,INFLAMMATORY BOWEL DISEASE W/O CC/MCC,Medical,Relative Weights,"$4,173.90 ",IP,"2,420.00","14,126.11",,,,,,
Molina Duals,DRG,MS-388,GASTROINTESTINAL OBSTRUCTION WITH MCC,Medical,Relative Weights,"$8,845.38 ",IP,"2,420.00","30,746.02",,,,,,
Molina Duals,DRG,MS-389,GASTROINTESTINAL OBSTRUCTION WITH CC,Medical,Relative Weights,"$4,807.55 ",IP,"2,420.00","16,928.35",,,,,,
Molina Duals,DRG,MS-390,GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,Medical,Relative Weights,"$3,405.35 ",IP,"2,420.00","11,684.74",,,,,,
Molina Duals,DRG,MS-391,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC,Medical,Relative Weights,"$7,295.42 ",IP,"2,420.00","24,897.60",,,,,,
Molina Duals,DRG,MS-392,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC,Medical,Relative Weights,"$4,472.33 ",IP,"2,420.00","15,351.84",,,,,,
Molina Duals,DRG,MS-393,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,Medical,Relative Weights,"$9,701.54 ",IP,"2,420.00","32,749.92",,,,,,
Molina Duals,DRG,MS-394,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,Medical,Relative Weights,"$5,494.93 ",IP,"2,420.00","18,912.10",,,,,,
Molina Duals,DRG,MS-395,OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$3,804.81 ",IP,"2,420.00","13,192.70",,,,,,
Molina Duals,DRG,MS-405,PANCREAS- LIVER AND SHUNT PROCEDURES WITH MCC,Surgical,Relative Weights,"$33,508.03 ",IP,"2,420.00","109,412.35",,,,,,
Molina Duals,DRG,MS-406,PANCREAS -  LIVER AND SHUNT PROCEDURES WITH CC,Surgical,Relative Weights,"$16,824.68 ",IP,"2,420.00","56,264.54",,,,,,
Molina Duals,DRG,MS-407,PANCREAS -  LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$12,369.28 ",IP,"2,420.00","42,059.81",,,,,,
Molina Duals,DRG,MS-408,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,Surgical,Relative Weights,"$21,917.23 ",IP,"2,420.00","71,842.18",,,,,,
Molina Duals,DRG,MS-409,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,Surgical,Relative Weights,"$12,359.94 ",IP,"2,420.00","48,259.01",,,,,,
Molina Duals,DRG,MS-410,BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W/O CC/MCC,Surgical,Relative Weights,"$9,158.99 ",IP,"2,420.00","33,465.60",,,,,,
Molina Duals,DRG,MS-411,CHOLECYSTECTOMY W C.D.E. W MCC,Surgical,Relative Weights,"$21,920.73 ",IP,"2,420.00","77,220.86",,,,,,
Molina Duals,DRG,MS-412,CHOLECYSTECTOMY WITH C.D.E. WITH CC,Surgical,Relative Weights,"$13,300.78 ",IP,"2,420.00","47,920.32",,,,,,
Molina Duals,DRG,MS-413,CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,Surgical,Relative Weights,"$10,108.59 ",IP,"2,420.00","32,604.77",,,,,,
Molina Duals,DRG,MS-414,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,Surgical,Relative Weights,"$21,189.55 ",IP,"2,420.00","68,874.62",,,,,,
Molina Duals,DRG,MS-415,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,Surgical,Relative Weights,"$11,865.29 ",IP,"2,420.00","41,362.27",,,,,,
Molina Duals,DRG,MS-416,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,Surgical,Relative Weights,"$8,306.34 ",IP,"2,420.00","27,222.05",,,,,,
Molina Duals,DRG,MS-417,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,Surgical,Relative Weights,"$14,158.10 ",IP,"2,420.00","48,599.71",,,,,,
Molina Duals,DRG,MS-418,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,Surgical,Relative Weights,"$9,863.89 ",IP,"2,420.00","33,645.02",,,,,,
Molina Duals,DRG,MS-419,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,Surgical,Relative Weights,"$7,681.45 ",IP,"2,420.00","26,345.09",,,,,,
Molina Duals,DRG,MS-420,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,Surgical,Relative Weights,"$20,536.63 ",IP,"2,420.00","69,245.57",,,,,,
Molina Duals,DRG,MS-421,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,Surgical,Relative Weights,"$11,139.95 ",IP,"2,420.00","37,118.59",,,,,,
Molina Duals,DRG,MS-422,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,489.14 ",IP,"2,420.00","28,314.72",,,,,,
Molina Duals,DRG,MS-423,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$24,445.98 ",IP,"2,420.00","85,442.11",,,,,,
Molina Duals,DRG,MS-424,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$13,339.32 ",IP,"2,420.00","45,388.22",,,,,,
Molina Duals,DRG,MS-425,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$9,009.49 ",IP,"2,420.00","29,463.84",,,,,,
Molina Duals,DRG,MS-432,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,Medical,Relative Weights,"$10,984.02 ",IP,"2,420.00","36,759.74",,,,,,
Molina Duals,DRG,MS-433,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,Medical,Relative Weights,"$6,014.70 ",IP,"2,420.00","20,805.12",,,,,,
Molina Duals,DRG,MS-434,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Medical,Relative Weights,"$3,624.94 ",IP,"2,420.00","12,900.38",,,,,,
Molina Duals,DRG,MS-435,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,Medical,Relative Weights,"$10,239.99 ",IP,"2,420.00","34,213.54",,,,,,
Molina Duals,DRG,MS-436,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,Medical,Relative Weights,"$6,549.65 ",IP,"2,420.00","22,694.11",,,,,,
Molina Duals,DRG,MS-437,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,Medical,Relative Weights,"$5,232.13 ",IP,"2,420.00","17,698.46",,,,,,
Molina Duals,DRG,MS-438,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,Medical,Relative Weights,"$9,331.28 ",IP,"2,420.00","33,028.13",,,,,,
Molina Duals,DRG,MS-439,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,Medical,Relative Weights,"$4,936.03 ",IP,"2,420.00","17,079.55",,,,,,
Molina Duals,DRG,MS-440,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,Medical,Relative Weights,"$3,540.84 ",IP,"2,420.00","12,410.50",,,,,,
Molina Duals,DRG,MS-441,DISORDERS OF LIVER EXCEPT MALIGNANCY- CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC,Medical,Relative Weights,"$10,976.43 ",IP,"2,420.00","37,306.08",,,,,,
Molina Duals,DRG,MS-442,DISORDERS OF LIVER EXCEPT MALIGNANCY -  CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC,Medical,Relative Weights,"$5,431.27 ",IP,"2,420.00","18,817.34",,,,,,
Molina Duals,DRG,MS-443,DISORDERS OF LIVER EXCEPT MALIGNANCY -  CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Medical,Relative Weights,"$3,873.14 ",IP,"2,420.00","13,714.85",,,,,,
Molina Duals,DRG,MS-444,DISORDERS OF THE BILIARY TRACT WITH MCC,Medical,Relative Weights,"$9,762.27 ",IP,"2,420.00","32,782.18",,,,,,
Molina Duals,DRG,MS-445,DISORDERS OF THE BILIARY TRACT WITH CC,Medical,Relative Weights,"$6,292.68 ",IP,"2,420.00","21,661.92",,,,,,
Molina Duals,DRG,MS-446,DISORDERS OF THE BILIARY TRACT W/O CC/MCC,Medical,Relative Weights,"$4,769.01 ",IP,"2,420.00","16,384.03",,,,,,
Molina Duals,DRG,MS-453,COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W MCC,Surgical,Relative Weights,"$53,658.63 ",IP,"2,420.00","189,645.12",,,,,,
Molina Duals,DRG,MS-454,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC,Surgical,Relative Weights,"$35,584.18 ",IP,"2,420.00","123,480.00",,,,,,
Molina Duals,DRG,MS-455,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CC/MCC,Surgical,Relative Weights,"$27,923.16 ",IP,"2,420.00","97,036.13",,,,,,
Molina Duals,DRG,MS-456,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH MCC,Surgical,Relative Weights,"$50,224.67 ",IP,"2,420.00","183,076.99",,,,,,
Molina Duals,DRG,MS-457,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH CC,Surgical,Relative Weights,"$37,936.56 ",IP,"2,420.00","131,308.13",,,,,,
Molina Duals,DRG,MS-458,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC,Surgical,Relative Weights,"$29,244.77 ",IP,"2,420.00","94,629.02",,,,,,
Molina Duals,DRG,MS-459,SPINAL FUSION EXCEPT CERVICAL WITH MCC,Surgical,Relative Weights,"$39,324.16 ",IP,"21,658.00","138,136.32",,,,,,
Molina Duals,DRG,MS-460,SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,Surgical,Relative Weights,"$22,955.59 ",IP,"21,658.00","79,841.66",,,,,,
Molina Duals,DRG,MS-461,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,Surgical,Relative Weights,"$35,517.60 ",IP,"2,420.00","108,436.61",,,,,,
Molina Duals,DRG,MS-462,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,Surgical,Relative Weights,"$18,346.02 ",IP,"2,420.00","63,229.82",,,,,,
Molina Duals,DRG,MS-463,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,Surgical,Relative Weights,"$31,362.97 ",IP,"2,420.00","105,392.45",,,,,,
Molina Duals,DRG,MS-464,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,Surgical,Relative Weights,"$17,379.49 ",IP,"2,420.00","59,526.43",,,,,,
Molina Duals,DRG,MS-465,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$10,769.69 ",IP,"2,420.00","38,610.43",,,,,,
Molina Duals,DRG,MS-466,REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,Surgical,Relative Weights,"$31,219.30 ",IP,"2,420.00","102,797.86",,,,,,
Molina Duals,DRG,MS-467,REVISION OF HIP OR KNEE REPLACEMENT W CC,Surgical,Relative Weights,"$20,892.88 ",IP,"2,420.00","70,803.94",,,,,,
Molina Duals,DRG,MS-468,REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,Surgical,Relative Weights,"$16,366.23 ",IP,"2,420.00","56,691.94",,,,,,
Molina Duals,DRG,MS-469,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,Surgical,Relative Weights,"$18,021.90 ",IP,"2,420.00","63,300.38",,,,,,
Molina Duals,DRG,MS-470,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,Surgical,Relative Weights,"$11,097.90 ",IP,"2,420.00","39,682.94",,,,,,
Molina Duals,DRG,MS-471,CERVICAL SPINAL FUSION WITH MCC,Surgical,Relative Weights,"$29,315.44 ",IP,"15,407.00","100,687.10",,,,,,
Molina Duals,DRG,MS-472,CERVICAL SPINAL FUSION WITH CC,Surgical,Relative Weights,"$17,833.84 ",IP,"15,407.00","61,316.64",,,,,,
Molina Duals,DRG,MS-473,CERVICAL SPINAL FUSION WITHOUT CC/MCC,Surgical,Relative Weights,"$14,827.96 ",IP,"14,827.96","50,649.98",,,,,,
Molina Duals,DRG,MS-474,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,Surgical,Relative Weights,"$23,804.74 ",IP,"2,420.00","78,117.98",,,,,,
Molina Duals,DRG,MS-475,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,Surgical,Relative Weights,"$12,826.56 ",IP,"2,420.00","42,356.16",,,,,,
Molina Duals,DRG,MS-476,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$6,776.24 ",IP,"2,420.00","23,480.35",,,,,,
Molina Duals,DRG,MS-477,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Surgical,Relative Weights,"$19,616.24 ",IP,"2,420.00","65,626.85",,,,,,
Molina Duals,DRG,MS-478,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Surgical,Relative Weights,"$13,773.24 ",IP,"2,420.00","46,712.74",,,,,,
Molina Duals,DRG,MS-479,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Surgical,Relative Weights,"$10,567.62 ",IP,"2,420.00","35,929.15",,,,,,
Molina Duals,DRG,MS-480,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,Surgical,Relative Weights,"$17,670.91 ",IP,"2,420.00","60,852.96",,,,,,
Molina Duals,DRG,MS-481,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,Surgical,Relative Weights,"$12,241.39 ",IP,"2,420.00","42,090.05",,,,,,
Molina Duals,DRG,MS-482,HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC,Surgical,Relative Weights,"$9,611.60 ",IP,"2,420.00","33,169.25",,,,,,
Molina Duals,DRG,MS-483,MAJOR JOINT & LIMB REATTACHMENT PROC OF UPPER EXTREMITY W CC/MCC,Surgical,Relative Weights,"$13,932.67 ",IP,"2,420.00","48,224.74",,,,,,
Molina Duals,DRG,MS-485,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,Surgical,Relative Weights,"$19,912.33 ",IP,"2,420.00","66,104.64",,,,,,
Molina Duals,DRG,MS-486,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,Surgical,Relative Weights,"$12,552.66 ",IP,"2,420.00","43,356.10",,,,,,
Molina Duals,DRG,MS-487,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Surgical,Relative Weights,"$9,578.90 ",IP,"2,420.00","32,401.15",,,,,,
Molina Duals,DRG,MS-488,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,Surgical,Relative Weights,"$11,538.24 ",IP,"2,420.00","39,699.07",,,,,,
Molina Duals,DRG,MS-489,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Surgical,Relative Weights,"$7,581.59 ",IP,"2,420.00","25,381.44",,,,,,
Molina Duals,DRG,MS-492,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH MCC,Surgical,Relative Weights,"$20,265.07 ",IP,"2,420.00","69,457.25",,,,,,
Molina Duals,DRG,MS-493,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH CC,Surgical,Relative Weights,"$13,582.85 ",IP,"2,420.00","46,408.32",,,,,,
Molina Duals,DRG,MS-494,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITHOUT CC/MCC,Surgical,Relative Weights,"$10,814.07 ",IP,"2,420.00","36,517.82",,,,,,
Molina Duals,DRG,MS-495,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,Surgical,Relative Weights,"$21,268.98 ",IP,"2,420.00","69,201.22",,,,,,
Molina Duals,DRG,MS-496,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,Surgical,Relative Weights,"$11,600.73 ",IP,"2,420.00","41,136.48",,,,,,
Molina Duals,DRG,MS-497,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,Surgical,Relative Weights,"$8,476.87 ",IP,"2,420.00","29,621.09",,,,,,
Molina Duals,DRG,MS-498,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,Surgical,Relative Weights,"$15,089.01 ",IP,"2,420.00","49,353.70",,,,,,
Molina Duals,DRG,MS-499,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,Surgical,Relative Weights,"$7,002.25 ",IP,"2,420.00","23,202.14",,,,,,
Molina Duals,DRG,MS-500,SOFT TISSUE PROCEDURES WITH MCC,Surgical,Relative Weights,"$18,626.93 ",IP,"2,420.00","60,786.43",,,,,,
Molina Duals,DRG,MS-501,SOFT TISSUE PROCEDURES WITH CC,Surgical,Relative Weights,"$10,244.08 ",IP,"2,420.00","33,828.48",,,,,,
Molina Duals,DRG,MS-502,SOFT TISSUE PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,783.66 ",IP,"2,420.00","26,625.31",,,,,,
Molina Duals,DRG,MS-503,FOOT PROCEDURES WITH MCC,Surgical,Relative Weights,"$15,421.31 ",IP,"2,420.00","54,766.66",,,,,,
Molina Duals,DRG,MS-504,FOOT PROCEDURES WITH CC,Surgical,Relative Weights,"$10,366.14 ",IP,"2,420.00","35,007.84",,,,,,
Molina Duals,DRG,MS-505,FOOT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,366.14 ",IP,"2,420.00","33,899.04",,,,,,
Molina Duals,DRG,MS-506,MAJOR THUMB OR JOINT PROCEDURES,Surgical,Relative Weights,"$8,664.34 ",IP,"2,420.00","26,986.18",,,,,,
Molina Duals,DRG,MS-507,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W CC/MCC,Surgical,Relative Weights,"$12,035.82 ",IP,"2,420.00","42,336.00",,,,,,
Molina Duals,DRG,MS-508,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$8,232.76 ",IP,"2,420.00","31,417.34",,,,,,
Molina Duals,DRG,MS-509,ARTHROSCOPY,Surgical,Relative Weights,"$9,849.29 ",IP,"2,420.00","28,056.67",,,,,,
Molina Duals,DRG,MS-510,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH MCC,Surgical,Relative Weights,"$16,023.42 ",IP,"2,420.00","56,206.08",,,,,,
Molina Duals,DRG,MS-511,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH CC,Surgical,Relative Weights,"$11,489.77 ",IP,"2,420.00","37,985.47",,,,,,
Molina Duals,DRG,MS-512,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$9,078.40 ",IP,"2,420.00","30,518.21",,,,,,
Molina Duals,DRG,MS-513,HAND OR WRIST PROCEDURES- EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$9,180.60 ",IP,"2,420.00","31,794.34",,,,,,
Molina Duals,DRG,MS-514,HAND OR WRIST PROCEDURES -  EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$5,834.82 ",IP,"2,420.00","21,506.69",,,,,,
Molina Duals,DRG,MS-515,OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W MCC,Surgical,Relative Weights,"$18,341.35 ",IP,"2,420.00","63,584.64",,,,,,
Molina Duals,DRG,MS-516,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$11,462.90 ",IP,"2,420.00","39,092.26",,,,,,
Molina Duals,DRG,MS-517,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,165.60 ",IP,"2,420.00","28,532.45",,,,,,
Molina Duals,DRG,MS-518,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,Surgical,Relative Weights,"$20,947.77 ",IP,"10,289.00","68,717.38",,,,,,
Molina Duals,DRG,MS-519,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,Surgical,Relative Weights,"$11,446.55 ",IP,"10,289.00","38,479.39",,,,,,
Molina Duals,DRG,MS-520,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,Surgical,Relative Weights,"$8,282.98 ",IP,"8,282.98","26,974.08",,,,,,
Molina Duals,DRG,MS-521,HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,Surgical,Relative Weights,"$17,906.85 ",IP,"2,420.00","17,906.85",,,,,,
Molina Duals,DRG,MS-522,HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,Surgical,Relative Weights,"$12,786.27 ",IP,"2,420.00","12,786.27",,,,,,
Molina Duals,DRG,MS-533,FRACTURES OF FEMUR WITH MCC,Medical,Relative Weights,"$8,270.72 ",IP,"2,420.00","29,421.50",,,,,,
Molina Duals,DRG,MS-534,FRACTURES OF FEMUR WITHOUT MCC,Medical,Relative Weights,"$4,614.83 ",IP,"2,420.00","15,680.45",,,,,,
Molina Duals,DRG,MS-535,FRACTURES OF HIP AND PELVIS WITH MCC,Medical,Relative Weights,"$7,199.65 ",IP,"2,420.00","24,738.34",,,,,,
Molina Duals,DRG,MS-536,FRACTURES OF HIP AND PELVIS WITHOUT MCC,Medical,Relative Weights,"$4,506.79 ",IP,"2,420.00","15,291.36",,,,,,
Molina Duals,DRG,MS-537,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITH CC/MCC,Medical,Relative Weights,"$5,462.81 ",IP,"2,420.00","18,363.74",,,,,,
Molina Duals,DRG,MS-538,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITHOUT CC/MCC,Medical,Relative Weights,"$4,223.54 ",IP,"2,420.00","14,535.36",,,,,,
Molina Duals,DRG,MS-539,OSTEOMYELITIS WITH MCC,Medical,Relative Weights,"$11,374.72 ",IP,"2,420.00","38,005.63",,,,,,
Molina Duals,DRG,MS-540,OSTEOMYELITIS WITH CC,Medical,Relative Weights,"$7,601.45 ",IP,"2,420.00","26,208.00",,,,,,
Molina Duals,DRG,MS-541,OSTEOMYELITIS WITHOUT CC/MCC,Medical,Relative Weights,"$4,924.35 ",IP,"2,420.00","18,279.07",,,,,,
Molina Duals,DRG,MS-542,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,Medical,Relative Weights,"$10,565.87 ",IP,"2,420.00","36,787.97",,,,,,
Molina Duals,DRG,MS-543,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,Medical,Relative Weights,"$6,104.05 ",IP,"2,420.00","21,295.01",,,,,,
Molina Duals,DRG,MS-544,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,Medical,Relative Weights,"$4,541.83 ",IP,"2,420.00","15,289.34",,,,,,
Molina Duals,DRG,MS-545,CONNECTIVE TISSUE DISORDERS WITH MCC,Medical,Relative Weights,"$14,618.30 ",IP,"2,420.00","50,964.48",,,,,,
Molina Duals,DRG,MS-546,CONNECTIVE TISSUE DISORDERS WITH CC,Medical,Relative Weights,"$7,054.81 ",IP,"2,420.00","24,260.54",,,,,,
Molina Duals,DRG,MS-547,CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$4,868.29 ",IP,"2,420.00","16,331.62",,,,,,
Molina Duals,DRG,MS-548,SEPTIC ARTHRITIS WITH MCC,Medical,Relative Weights,"$11,976.83 ",IP,"2,420.00","39,983.33",,,,,,
Molina Duals,DRG,MS-549,SEPTIC ARTHRITIS W CC,Medical,Relative Weights,"$7,299.51 ",IP,"2,420.00","24,052.90",,,,,,
Molina Duals,DRG,MS-550,SEPTIC ARTHRITIS W/O CC/MCC,Medical,Relative Weights,"$5,132.84 ",IP,"2,420.00","17,418.24",,,,,,
Molina Duals,DRG,MS-551,MEDICAL BACK PROBLEMS WITH MCC,Medical,Relative Weights,"$9,504.14 ",IP,"2,420.00","32,042.30",,,,,,
Molina Duals,DRG,MS-552,MEDICAL BACK PROBLEMS WITHOUT MCC,Medical,Relative Weights,"$5,509.53 ",IP,"2,420.00","18,383.90",,,,,,
Molina Duals,DRG,MS-553,BONE DISEASES AND ARTHROPATHIES WITH MCC,Medical,Relative Weights,"$7,425.66 ",IP,"2,420.00","25,915.68",,,,,,
Molina Duals,DRG,MS-554,BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,Medical,Relative Weights,"$4,628.26 ",IP,"2,420.00","15,869.95",,,,,,
Molina Duals,DRG,MS-555,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Medical,Relative Weights,"$7,992.15 ",IP,"2,420.00","26,516.45",,,,,,
Molina Duals,DRG,MS-556,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,Medical,Relative Weights,"$4,722.87 ",IP,"2,420.00","15,962.69",,,,,,
Molina Duals,DRG,MS-557,TENDONITIS -  MYOSITIS AND BURSITIS WITH MCC,Medical,Relative Weights,"$8,170.85 ",IP,"2,420.00","29,397.31",,,,,,
Molina Duals,DRG,MS-558,TENDONITIS- MYOSITIS AND BURSITIS WITHOUT MCC,Medical,Relative Weights,"$5,030.64 ",IP,"2,420.00","17,365.82",,,,,,
Molina Duals,DRG,MS-559,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Medical,Relative Weights,"$10,893.50 ",IP,"2,420.00","36,324.29",,,,,,
Molina Duals,DRG,MS-560,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Medical,Relative Weights,"$6,283.92 ",IP,"2,420.00","21,036.96",,,,,,
Molina Duals,DRG,MS-561,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Medical,Relative Weights,"$4,627.68 ",IP,"2,420.00","15,067.58",,,,,,
Molina Duals,DRG,MS-562,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITH MCC,Medical,Relative Weights,"$8,245.02 ",IP,"2,420.00","27,157.54",,,,,,
Molina Duals,DRG,MS-563,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITHOUT MCC,Medical,Relative Weights,"$5,093.72 ",IP,"2,420.00","17,216.64",,,,,,
Molina Duals,DRG,MS-564,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,Medical,Relative Weights,"$8,897.94 ",IP,"2,420.00","30,481.92",,,,,,
Molina Duals,DRG,MS-565,OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W CC,Medical,Relative Weights,"$5,894.39 ",IP,"2,420.00","19,766.88",,,,,,
Molina Duals,DRG,MS-566,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$4,391.15 ",IP,"2,420.00","15,275.23",,,,,,
Molina Duals,DRG,MS-570,SKIN DEBRIDEMENT WITH MCC,Surgical,Relative Weights,"$16,595.75 ",IP,"2,420.00","57,923.71",,,,,,
Molina Duals,DRG,MS-571,SKIN DEBRIDEMENT WITH CC,Surgical,Relative Weights,"$9,550.86 ",IP,"2,420.00","33,713.57",,,,,,
Molina Duals,DRG,MS-572,SKIN DEBRIDEMENT WITHOUT CC/MCC,Surgical,Relative Weights,"$6,449.78 ",IP,"2,420.00","22,613.47",,,,,,
Molina Duals,DRG,MS-573,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,Surgical,Relative Weights,"$32,348.77 ",IP,"2,420.00","107,156.45",,,,,,
Molina Duals,DRG,MS-574,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,Surgical,Relative Weights,"$18,959.81 ",IP,"2,420.00","62,935.49",,,,,,
Molina Duals,DRG,MS-575,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS W/O CC/MCC,Surgical,Relative Weights,"$10,297.22 ",IP,"2,420.00","35,421.12",,,,,,
Molina Duals,DRG,MS-576,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,Surgical,Relative Weights,"$29,572.40 ",IP,"2,420.00","97,759.87",,,,,,
Molina Duals,DRG,MS-577,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,Surgical,Relative Weights,"$14,889.86 ",IP,"2,420.00","48,698.50",,,,,,
Molina Duals,DRG,MS-578,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,Surgical,Relative Weights,"$9,316.09 ",IP,"2,420.00","32,808.38",,,,,,
Molina Duals,DRG,MS-579,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC,Surgical,Relative Weights,"$18,366.46 ",IP,"2,420.00","60,199.78",,,,,,
Molina Duals,DRG,MS-580,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC,Surgical,Relative Weights,"$10,096.33 ",IP,"2,420.00","32,431.39",,,,,,
Molina Duals,DRG,MS-581,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,040.62 ",IP,"2,420.00","25,296.77",,,,,,
Molina Duals,DRG,MS-582,MASTECTOMY FOR MALIGNANCY WITH CC/MCC,Surgical,Relative Weights,"$9,595.83 ",IP,"2,420.00","31,826.59",,,,,,
Molina Duals,DRG,MS-583,MASTECTOMY FOR MALIGNANCY W/O CC/MCC,Surgical,Relative Weights,"$9,002.48 ",IP,"2,420.00","29,461.82",,,,,,
Molina Duals,DRG,MS-584,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$10,726.47 ",IP,"2,420.00","36,860.54",,,,,,
Molina Duals,DRG,MS-585,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,159.40 ",IP,"2,420.00","34,217.57",,,,,,
Molina Duals,DRG,MS-592,SKIN ULCERS WITH MCC,Medical,Relative Weights,"$9,894.84 ",IP,"2,420.00","35,971.49",,,,,,
Molina Duals,DRG,MS-593,SKIN ULCERS WITH CC,Medical,Relative Weights,"$6,661.19 ",IP,"2,420.00","23,139.65",,,,,,
Molina Duals,DRG,MS-594,SKIN ULCERS WITHOUT CC/MCC,Medical,Relative Weights,"$4,765.50 ",IP,"2,420.00","16,323.55",,,,,,
Molina Duals,DRG,MS-595,MAJOR SKIN DISORDERS WITH MCC,Medical,Relative Weights,"$11,776.52 ",IP,"2,420.00","40,977.22",,,,,,
Molina Duals,DRG,MS-596,MAJOR SKIN DISORDERS W/O MCC,Medical,Relative Weights,"$5,809.13 ",IP,"2,420.00","19,637.86",,,,,,
Molina Duals,DRG,MS-597,MALIGNANT BREAST DISORDERS W MCC,Medical,Relative Weights,"$9,601.09 ",IP,"2,420.00","34,128.86",,,,,,
Molina Duals,DRG,MS-598,MALIGNANT BREAST DISORDERS WITH CC,Medical,Relative Weights,"$6,499.42 ",IP,"2,420.00","21,946.18",,,,,,
Molina Duals,DRG,MS-599,MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$3,921.03 ",IP,"2,420.00","14,019.26",,,,,,
Molina Duals,DRG,MS-600,NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,Medical,Relative Weights,"$5,821.97 ",IP,"2,420.00","19,337.47",,,,,,
Molina Duals,DRG,MS-601,NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$4,010.97 ",IP,"2,420.00","12,475.01",,,,,,
Molina Duals,DRG,MS-602,CELLULITIS WITH MCC,Medical,Relative Weights,"$8,468.11 ",IP,"2,420.00","28,824.77",,,,,,
Molina Duals,DRG,MS-603,CELLULITIS WITHOUT MCC,Medical,Relative Weights,"$4,985.09 ",IP,"2,420.00","17,004.96",,,,,,
Molina Duals,DRG,MS-604,TRAUMA TO THE SKIN -  SUBCUTANEOUS TISSUE AND BREAST WITH MCC,Medical,Relative Weights,"$8,631.05 ",IP,"2,420.00","29,524.32",,,,,,
Molina Duals,DRG,MS-605,TRAUMA TO THE SKIN- SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC,Medical,Relative Weights,"$5,278.85 ",IP,"2,420.00","17,654.11",,,,,,
Molina Duals,DRG,MS-606,MINOR SKIN DISORDERS WITH MCC,Medical,Relative Weights,"$8,830.78 ",IP,"2,420.00","30,149.28",,,,,,
Molina Duals,DRG,MS-607,MINOR SKIN DISORDERS WITHOUT MCC,Medical,Relative Weights,"$4,836.75 ",IP,"2,420.00","16,654.18",,,,,,
Molina Duals,DRG,MS-614,ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$13,956.03 ",IP,"2,420.00","49,055.33",,,,,,
Molina Duals,DRG,MS-615,ADRENAL & PITUITARY PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$9,198.12 ",IP,"2,420.00","29,919.46",,,,,,
Molina Duals,DRG,MS-616,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Surgical,Relative Weights,"$23,162.92 ",IP,"2,420.00","80,656.13",,,,,,
Molina Duals,DRG,MS-617,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Surgical,Relative Weights,"$11,854.19 ",IP,"2,420.00","41,354.21",,,,,,
Molina Duals,DRG,MS-618,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$7,610.79 ",IP,"2,420.00","25,290.72",,,,,,
Molina Duals,DRG,MS-619,O.R. PROCEDURES FOR OBESITY WITH MCC,Surgical,Relative Weights,"$17,880.57 ",IP,"2,420.00","62,062.56",,,,,,
Molina Duals,DRG,MS-620,O.R. PROCEDURES FOR OBESITY WITH CC,Surgical,Relative Weights,"$10,294.30 ",IP,"2,420.00","36,179.14",,,,,,
Molina Duals,DRG,MS-621,O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,Surgical,Relative Weights,"$9,327.19 ",IP,"2,420.00","31,691.52",,,,,,
Molina Duals,DRG,MS-622,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Surgical,Relative Weights,"$21,111.30 ",IP,"2,420.00","76,114.08",,,,,,
Molina Duals,DRG,MS-623,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE -  NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Surgical,Relative Weights,"$10,929.71 ",IP,"2,420.00","39,364.42",,,,,,
Molina Duals,DRG,MS-624,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$6,417.66 ",IP,"2,420.00","22,216.32",,,,,,
Molina Duals,DRG,MS-625,THYROID- PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$16,586.99 ",IP,"2,420.00","58,970.02",,,,,,
Molina Duals,DRG,MS-626,THYROID -  PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC,Surgical,Relative Weights,"$9,653.06 ",IP,"2,420.00","33,925.25",,,,,,
Molina Duals,DRG,MS-627,THYROID -  PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,907.64 ",IP,"2,420.00","23,016.67",,,,,,
Molina Duals,DRG,MS-628,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$21,487.98 ",IP,"2,420.00","74,376.29",,,,,,
Molina Duals,DRG,MS-629,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$13,696.73 ",IP,"2,420.00","46,827.65",,,,,,
Molina Duals,DRG,MS-630,OTHER ENDOCRINE - NUTRIT & METAB O.R. PROC W/O CC/MCC,Surgical,Relative Weights,"$8,230.42 ",IP,"2,420.00","29,207.81",,,,,,
Molina Duals,DRG,MS-637,DIABETES WITH MCC,Medical,Relative Weights,"$8,039.45 ",IP,"2,420.00","27,935.71",,,,,,
Molina Duals,DRG,MS-638,DIABETES WITH CC,Medical,Relative Weights,"$5,135.76 ",IP,"2,420.00","17,823.46",,,,,,
Molina Duals,DRG,MS-639,DIABETES WITHOUT CC/MCC,Medical,Relative Weights,"$3,560.11 ",IP,"2,420.00","12,362.11",,,,,,
Molina Duals,DRG,MS-640,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITH MCC,Medical,Relative Weights,"$7,187.97 ",IP,"2,420.00","24,478.27",,,,,,
Molina Duals,DRG,MS-641,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITHOUT MCC,Medical,Relative Weights,"$4,404.59 ",IP,"2,420.00","15,253.06",,,,,,
Molina Duals,DRG,MS-642,INBORN AND OTHER DISORDERS OF METABOLISM,Medical,Relative Weights,"$7,532.53 ",IP,"2,420.00","24,510.53",,,,,,
Molina Duals,DRG,MS-643,ENDOCRINE DISORDERS WITH MCC,Medical,Relative Weights,"$9,739.50 ",IP,"2,420.00","32,770.08",,,,,,
Molina Duals,DRG,MS-644,ENDOCRINE DISORDERS WITH CC,Medical,Relative Weights,"$5,955.71 ",IP,"2,420.00","20,726.50",,,,,,
Molina Duals,DRG,MS-645,ENDOCRINE DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$4,488.68 ",IP,"2,420.00","15,426.43",,,,,,
Molina Duals,DRG,MS-650,KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,Neonate,Relative Weights,"$26,401.24 ",IP,"2,420.00","26,401.24",,,,,,
Molina Duals,DRG,MS-651,KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,Neonate,Relative Weights,"$21,598.94 ",IP,"2,420.00","21,598.94",,,,,,
Molina Duals,DRG,MS-652,KIDNEY TRANSPLANT,Surgical,Relative Weights,"$18,601.23 ",IP,"2,420.00","68,239.58",,,,,,
Molina Duals,DRG,MS-653,MAJOR BLADDER PROCEDURES WITH MCC,Surgical,Relative Weights,"$31,882.15 ",IP,"2,420.00","111,615.84",,,,,,
Molina Duals,DRG,MS-654,MAJOR BLADDER PROCEDURES WITH CC,Surgical,Relative Weights,"$16,952.58 ",IP,"2,420.00","56,693.95",,,,,,
Molina Duals,DRG,MS-655,MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$12,149.11 ",IP,"2,420.00","41,577.98",,,,,,
Molina Duals,DRG,MS-656,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,Surgical,Relative Weights,"$19,184.65 ",IP,"2,420.00","65,733.70",,,,,,
Molina Duals,DRG,MS-657,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,Surgical,Relative Weights,"$11,298.80 ",IP,"2,420.00","38,993.47",,,,,,
Molina Duals,DRG,MS-658,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,Surgical,Relative Weights,"$9,215.06 ",IP,"2,420.00","31,649.18",,,,,,
Molina Duals,DRG,MS-659,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,Surgical,Relative Weights,"$15,571.98 ",IP,"2,420.00","54,024.77",,,,,,
Molina Duals,DRG,MS-660,KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC,Surgical,Relative Weights,"$8,427.82 ",IP,"2,420.00","28,641.31",,,,,,
Molina Duals,DRG,MS-661,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,Surgical,Relative Weights,"$6,212.09 ",IP,"2,420.00","21,976.42",,,,,,
Molina Duals,DRG,MS-662,MINOR BLADDER PROCEDURES WITH MCC,Surgical,Relative Weights,"$17,154.06 ",IP,"2,420.00","63,800.35",,,,,,
Molina Duals,DRG,MS-663,MINOR BLADDER PROCEDURES WITH CC,Surgical,Relative Weights,"$9,341.20 ",IP,"2,420.00","30,711.74",,,,,,
Molina Duals,DRG,MS-664,MINOR BLADDER PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,913.48 ",IP,"2,420.00","22,309.06",,,,,,
Molina Duals,DRG,MS-665,PROSTATECTOMY WITH MCC,Surgical,Relative Weights,"$17,763.76 ",IP,"2,420.00","59,844.96",,,,,,
Molina Duals,DRG,MS-666,PROSTATECTOMY WITH CC,Surgical,Relative Weights,"$10,159.98 ",IP,"2,420.00","35,665.06",,,,,,
Molina Duals,DRG,MS-667,PROSTATECTOMY W/O CC/MCC,Surgical,Relative Weights,"$5,825.48 ",IP,"2,420.00","18,924.19",,,,,,
Molina Duals,DRG,MS-668,TRANSURETHRAL PROCEDURES W MCC,Surgical,Relative Weights,"$16,389.01 ",IP,"2,420.00","56,212.13",,,,,,
Molina Duals,DRG,MS-669,TRANSURETHRAL PROCEDURES WITH CC,Surgical,Relative Weights,"$9,130.96 ",IP,"2,420.00","31,161.31",,,,,,
Molina Duals,DRG,MS-670,TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$5,714.52 ",IP,"2,420.00","19,730.59",,,,,,
Molina Duals,DRG,MS-671,URETHRAL PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$10,402.93 ",IP,"2,420.00","36,844.42",,,,,,
Molina Duals,DRG,MS-672,URETHRAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,718.43 ",IP,"2,420.00","20,829.31",,,,,,
Molina Duals,DRG,MS-673,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,Surgical,Relative Weights,"$20,255.14 ",IP,"2,420.00","72,063.94",,,,,,
Molina Duals,DRG,MS-674,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,Surgical,Relative Weights,"$13,918.07 ",IP,"2,420.00","49,275.07",,,,,,
Molina Duals,DRG,MS-675,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,247.58 ",IP,"2,420.00","32,901.12",,,,,,
Molina Duals,DRG,MS-682,RENAL FAILURE WITH MCC,Medical,Relative Weights,"$8,600.68 ",IP,"2,420.00","29,796.48",,,,,,
Molina Duals,DRG,MS-683,RENAL FAILURE WITH CC,Medical,Relative Weights,"$5,135.18 ",IP,"2,420.00","18,089.57",,,,,,
Molina Duals,DRG,MS-684,RENAL FAILURE WITHOUT CC/MCC,Medical,Relative Weights,"$3,550.18 ",IP,"2,420.00","12,404.45",,,,,,
Molina Duals,DRG,MS-686,KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,Medical,Relative Weights,"$10,951.90 ",IP,"2,420.00","35,402.98",,,,,,
Molina Duals,DRG,MS-687,KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,Medical,Relative Weights,"$6,132.67 ",IP,"2,420.00","21,220.42",,,,,,
Molina Duals,DRG,MS-688,KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,Medical,Relative Weights,"$4,005.13 ",IP,"2,420.00","15,549.41",,,,,,
Molina Duals,DRG,MS-689,KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,Medical,Relative Weights,"$6,507.01 ",IP,"2,420.00","22,550.98",,,,,,
Molina Duals,DRG,MS-690,KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,Medical,Relative Weights,"$4,637.02 ",IP,"2,420.00","15,942.53",,,,,,
Molina Duals,DRG,MS-693,URINARY STONES WITH MCC,Medical,Relative Weights,"$7,799.42 ",IP,"2,420.00","27,282.53",,,,,,
Molina Duals,DRG,MS-694,URINARY STONES WITHOUT MCC,Medical,Relative Weights,"$4,503.87 ",IP,"2,420.00","14,926.46",,,,,,
Molina Duals,DRG,MS-695,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,Medical,Relative Weights,"$6,644.26 ",IP,"2,420.00","23,633.57",,,,,,
Molina Duals,DRG,MS-696,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,Medical,Relative Weights,"$4,040.75 ",IP,"2,420.00","13,696.70",,,,,,
Molina Duals,DRG,MS-697,URETHRAL STRICTURE,Medical,Relative Weights,"$5,835.99 ",IP,"2,420.00","19,633.82",,,,,,
Molina Duals,DRG,MS-698,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,Medical,Relative Weights,"$9,406.03 ",IP,"2,420.00","32,630.98",,,,,,
Molina Duals,DRG,MS-699,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,Medical,Relative Weights,"$5,997.76 ",IP,"2,420.00","20,819.23",,,,,,
Molina Duals,DRG,MS-700,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$4,359.62 ",IP,"2,420.00","14,952.67",,,,,,
Molina Duals,DRG,MS-707,MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$11,225.80 ",IP,"2,420.00","37,697.18",,,,,,
Molina Duals,DRG,MS-708,MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,708.72 ",IP,"2,420.00","29,272.32",,,,,,
Molina Duals,DRG,MS-709,PENIS PROCEDURES W CC/MCC,Surgical,Relative Weights,"$13,525.04 ",IP,"2,420.00","48,496.90",,,,,,
Molina Duals,DRG,MS-710,PENIS PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$9,353.47 ",IP,"2,420.00","30,961.73",,,,,,
Molina Duals,DRG,MS-711,TESTES PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$12,448.71 ",IP,"2,420.00","43,206.91",,,,,,
Molina Duals,DRG,MS-712,TESTES PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,190.48 ",IP,"2,420.00","20,567.23",,,,,,
Molina Duals,DRG,MS-713,TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,Surgical,Relative Weights,"$8,721.57 ",IP,"2,420.00","29,473.92",,,,,,
Molina Duals,DRG,MS-714,TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,Surgical,Relative Weights,"$5,424.26 ",IP,"2,420.00","18,454.46",,,,,,
Molina Duals,DRG,MS-715,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,Surgical,Relative Weights,"$11,806.30 ",IP,"2,420.00","43,071.84",,,,,,
Molina Duals,DRG,MS-716,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$7,450.77 ",IP,"2,420.00","29,544.48",,,,,,
Molina Duals,DRG,MS-717,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,Surgical,Relative Weights,"$10,515.64 ",IP,"2,420.00","35,568.29",,,,,,
Molina Duals,DRG,MS-718,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$7,210.16 ",IP,"2,420.00","24,583.10",,,,,,
Molina Duals,DRG,MS-722,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH MCC,Medical,Relative Weights,"$10,001.72 ",IP,"2,420.00","36,386.78",,,,,,
Molina Duals,DRG,MS-723,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH CC,Medical,Relative Weights,"$6,376.78 ",IP,"2,420.00","22,325.18",,,,,,
Molina Duals,DRG,MS-724,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Medical,Relative Weights,"$3,784.95 ",IP,"2,420.00","11,902.46",,,,,,
Molina Duals,DRG,MS-725,BENIGN PROSTATIC HYPERTROPHY WITH MCC,Medical,Relative Weights,"$7,507.42 ",IP,"2,420.00","25,308.86",,,,,,
Molina Duals,DRG,MS-726,BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,Medical,Relative Weights,"$4,349.11 ",IP,"2,420.00","15,416.35",,,,,,
Molina Duals,DRG,MS-727,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,Medical,Relative Weights,"$8,298.75 ",IP,"2,420.00","28,774.37",,,,,,
Molina Duals,DRG,MS-728,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,Medical,Relative Weights,"$4,705.35 ",IP,"2,420.00","16,178.40",,,,,,
Molina Duals,DRG,MS-729,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,Medical,Relative Weights,"$5,883.88 ",IP,"2,420.00","21,649.82",,,,,,
Molina Duals,DRG,MS-730,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$3,322.42 ",IP,"2,420.00","12,733.06",,,,,,
Molina Duals,DRG,MS-734,PELVIC EVISCERATION -  RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC,Surgical,Relative Weights,"$12,990.08 ",IP,"2,420.00","44,188.70",,,,,,
Molina Duals,DRG,MS-735,PELVIC EVISCERATION -  RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC,Surgical,Relative Weights,"$8,255.53 ",IP,"2,420.00","27,703.87",,,,,,
Molina Duals,DRG,MS-736,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,Surgical,Relative Weights,"$24,882.82 ",IP,"2,420.00","87,109.34",,,,,,
Molina Duals,DRG,MS-737,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,Surgical,Relative Weights,"$12,019.46 ",IP,"2,420.00","40,059.94",,,,,,
Molina Duals,DRG,MS-738,UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY W/O CC/MCC,Surgical,Relative Weights,"$8,619.37 ",IP,"2,420.00","27,798.62",,,,,,
Molina Duals,DRG,MS-739,UTERINE -ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W MCC,Surgical,Relative Weights,"$22,332.46 ",IP,"2,420.00","75,489.12",,,,,,
Molina Duals,DRG,MS-740,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,Surgical,Relative Weights,"$10,521.48 ",IP,"2,420.00","35,983.58",,,,,,
Molina Duals,DRG,MS-741,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$7,474.72 ",IP,"2,420.00","26,802.72",,,,,,
Molina Duals,DRG,MS-742,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,Surgical,Relative Weights,"$10,033.84 ",IP,"2,420.00","34,060.32",,,,,,
Molina Duals,DRG,MS-743,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$6,615.64 ",IP,"2,420.00","23,153.76",,,,,,
Molina Duals,DRG,MS-744,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC,Surgical,Relative Weights,"$10,485.28 ",IP,"2,420.00","35,088.48",,,,,,
Molina Duals,DRG,MS-745,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC,Surgical,Relative Weights,"$6,832.89 ",IP,"2,420.00","21,476.45",,,,,,
Molina Duals,DRG,MS-746,VAGINA -  CERVIX AND VULVA PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$9,411.29 ",IP,"2,420.00","32,880.96",,,,,,
Molina Duals,DRG,MS-747,VAGINA- CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$5,484.42 ",IP,"2,420.00","18,793.15",,,,,,
Molina Duals,DRG,MS-748,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,Surgical,Relative Weights,"$7,870.09 ",IP,"2,420.00","26,645.47",,,,,,
Molina Duals,DRG,MS-749,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$15,848.80 ",IP,"2,420.00","52,258.75",,,,,,
Molina Duals,DRG,MS-750,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,548.71 ",IP,"2,420.00","26,836.99",,,,,,
Molina Duals,DRG,MS-754,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH MCC,Medical,Relative Weights,"$10,665.15 ",IP,"2,420.00","35,519.90",,,,,,
Molina Duals,DRG,MS-755,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH CC,Medical,Relative Weights,"$6,595.20 ",IP,"2,420.00","20,639.81",,,,,,
Molina Duals,DRG,MS-756,MALIGNANCY - FEMALE REPRODUCTIVE SYSTEM W/O CC/MCC,Medical,Relative Weights,"$5,363.53 ",IP,"2,420.00","17,676.29",,,,,,
Molina Duals,DRG,MS-757,INFECTIONS - FEMALE REPRODUCTIVE SYSTEM W MCC,Medical,Relative Weights,"$8,904.37 ",IP,"2,420.00","28,633.25",,,,,,
Molina Duals,DRG,MS-758,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITH CC,Medical,Relative Weights,"$5,663.12 ",IP,"2,420.00","19,462.46",,,,,,
Molina Duals,DRG,MS-759,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Medical,Relative Weights,"$3,991.11 ",IP,"2,420.00","13,311.65",,,,,,
Molina Duals,DRG,MS-760,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,Medical,Relative Weights,"$5,373.46 ",IP,"2,420.00","18,194.40",,,,,,
Molina Duals,DRG,MS-761,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$3,450.32 ",IP,"2,420.00","11,398.46",,,,,,
Molina Duals,DRG,MS-768,VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C,Surgical,Relative Weights,"$6,830.55 ",IP,"2,420.00","20,311.20",,,,,,
Molina Duals,DRG,MS-769,POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,Surgical,Relative Weights,"$9,446.91 ",IP,"2,420.00","29,090.88",,,,,,
Molina Duals,DRG,MS-770,ABORTION WITH D&C- ASPIRATION CURETTAGE OR HYSTEROTOMY,Surgical,Relative Weights,"$5,196.50 ",IP,"2,420.00","15,851.81",,,,,,
Molina Duals,DRG,MS-776,POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,Medical,Relative Weights,"$4,523.14 ",IP,"2,420.00","14,311.58",,,,,,
Molina Duals,DRG,MS-779,ABORTION WITHOUT D&C,Medical,Relative Weights,"$6,184.64 ",IP,"2,420.00","23,018.69",,,,,,
Molina Duals,DRG,MS-783,CESAREAN SECTION WITH STERILIZATION WITH MCC,C-Section,Relative Weights,"$10,949.56 ",IP,"2,420.00","43,239.17",,,,,,
Molina Duals,DRG,MS-784,CESAREAN SECTION WITH STERILIZATION WITH CC,C-Section,Relative Weights,"$6,400.14 ",IP,"2,420.00","21,071.23",,,,,,
Molina Duals,DRG,MS-785,CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,C-Section,Relative Weights,"$5,354.18 ",IP,"2,420.00","17,305.34",,,,,,
Molina Duals,DRG,MS-786,CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,C-Section,Relative Weights,"$9,311.42 ",IP,"2,420.00","34,564.32",,,,,,
Molina Duals,DRG,MS-787,CESAREAN SECTION WITHOUT STERILIZATION WITH CC,C-Section,Relative Weights,"$6,216.18 ",IP,"2,420.00","21,077.28",,,,,,
Molina Duals,DRG,MS-788,CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,C-Section,Relative Weights,"$5,182.48 ",IP,"2,420.00","18,268.99",,,,,,
Molina Duals,DRG,MS-789,NEONATES- DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY,Medical,Relative Weights,"$10,044.93 ",IP,"2,420.00","34,070.40",,,,,,
Molina Duals,DRG,MS-790,EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME- NEONATE,Medical,Relative Weights,"$33,125.50 ",IP,"2,420.00","112,351.68",,,,,,
Molina Duals,DRG,MS-791,PREMATURITY W MAJOR PROBLEMS,Medical,Relative Weights,"$22,623.29 ",IP,"2,420.00","76,732.99",,,,,,
Molina Duals,DRG,MS-792,PREMATURITY W/O MAJOR PROBLEMS,Medical,Relative Weights,"$13,650.60 ",IP,"2,420.00","46,297.44",,,,,,
Molina Duals,DRG,MS-793,FULL TERM NEONATE WITH MAJOR PROBLEMS,Medical,Relative Weights,"$23,238.84 ",IP,"2,420.00","78,819.55",,,,,,
Molina Duals,DRG,MS-794,NEONATE WITH OTHER SIGNIFICANT PROBLEMS,Medical,Relative Weights,"$8,225.17 ",IP,"2,420.00","27,897.41",,,,,,
Molina Duals,DRG,MS-795,NORMAL NEWBORN,Medical,Relative Weights,"$1,113.70 ",IP,"1,113.70","3,775.97",,,,,,
Molina Duals,DRG,MS-796,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,Vaginal Delivery,Relative Weights,"$6,253.56 ",IP,"2,420.00","39,761.57",,,,,,
Molina Duals,DRG,MS-797,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,Vaginal Delivery,Relative Weights,"$5,369.37 ",IP,"2,420.00","17,394.05",,,,,,
Molina Duals,DRG,MS-798,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,Vaginal Delivery,Relative Weights,"$4,832.66 ",IP,"2,420.00","17,394.05",,,,,,
Molina Duals,DRG,MS-799,SPLENECTOMY WITH MCC,Surgical,Relative Weights,"$30,061.22 ",IP,"2,420.00","99,677.09",,,,,,
Molina Duals,DRG,MS-800,SPLENECTOMY WITH CC,Surgical,Relative Weights,"$17,251.01 ",IP,"2,420.00","57,294.72",,,,,,
Molina Duals,DRG,MS-801,SPLENECTOMY WITHOUT CC/MCC,Surgical,Relative Weights,"$9,834.69 ",IP,"2,420.00","37,763.71",,,,,,
Molina Duals,DRG,MS-802,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,Surgical,Relative Weights,"$21,676.62 ",IP,"2,420.00","63,552.38",,,,,,
Molina Duals,DRG,MS-803,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,Surgical,Relative Weights,"$11,017.31 ",IP,"2,420.00","35,917.06",,,,,,
Molina Duals,DRG,MS-804,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,Surgical,Relative Weights,"$7,976.96 ",IP,"2,420.00","27,470.02",,,,,,
Molina Duals,DRG,MS-805,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,Vaginal Delivery,Relative Weights,"$6,014.70 ",IP,"2,420.00","20,980.51",,,,,,
Molina Duals,DRG,MS-806,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,Vaginal Delivery,Relative Weights,"$4,290.12 ",IP,"2,420.00","14,297.47",,,,,,
Molina Duals,DRG,MS-807,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,Vaginal Delivery,Relative Weights,"$3,751.08 ",IP,"2,420.00","12,636.29",,,,,,
Molina Duals,DRG,MS-808,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,Medical,Relative Weights,"$12,765.24 ",IP,"2,420.00","42,932.74",,,,,,
Molina Duals,DRG,MS-809,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,Medical,Relative Weights,"$7,144.75 ",IP,"2,420.00","24,512.54",,,,,,
Molina Duals,DRG,MS-810,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$5,616.40 ",IP,"2,420.00","18,857.66",,,,,,
Molina Duals,DRG,MS-811,RED BLOOD CELL DISORDERS WITH MCC,Medical,Relative Weights,"$8,055.22 ",IP,"2,420.00","27,020.45",,,,,,
Molina Duals,DRG,MS-812,RED BLOOD CELL DISORDERS WITHOUT MCC,Medical,Relative Weights,"$5,141.02 ",IP,"2,420.00","17,553.31",,,,,,
Molina Duals,DRG,MS-813,COAGULATION DISORDERS,Medical,Relative Weights,"$9,023.50 ",IP,"2,420.00","31,957.63",,,,,,
Molina Duals,DRG,MS-814,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,Medical,Relative Weights,"$11,047.67 ",IP,"2,420.00","35,261.86",,,,,,
Molina Duals,DRG,MS-815,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,Medical,Relative Weights,"$5,801.53 ",IP,"2,420.00","20,418.05",,,,,,
Molina Duals,DRG,MS-816,RETICULOENDOTHELIAL & IMMUNITY DISORDERS W/O CC/MCC,Medical,Relative Weights,"$3,860.88 ",IP,"2,420.00","14,432.54",,,,,,
Molina Duals,DRG,MS-817,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$13,471.89 ",IP,"2,420.00","50,726.59",,,,,,
Molina Duals,DRG,MS-818,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$7,941.34 ",IP,"2,420.00","25,681.82",,,,,,
Molina Duals,DRG,MS-819,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$5,765.32 ",IP,"2,420.00","16,085.66",,,,,,
Molina Duals,DRG,MS-820,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$33,239.97 ",IP,"2,420.00","115,248.67",,,,,,
Molina Duals,DRG,MS-821,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$12,586.54 ",IP,"2,420.00","45,003.17",,,,,,
Molina Duals,DRG,MS-822,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,308.86 ",IP,"2,420.00","25,490.30",,,,,,
Molina Duals,DRG,MS-823,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,Surgical,Relative Weights,"$26,290.86 ",IP,"2,420.00","85,280.83",,,,,,
Molina Duals,DRG,MS-824,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,Surgical,Relative Weights,"$13,808.28 ",IP,"2,420.00","46,874.02",,,,,,
Molina Duals,DRG,MS-825,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,184.87 ",IP,"2,420.00","27,306.72",,,,,,
Molina Duals,DRG,MS-826,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$29,460.27 ",IP,"2,420.00","101,102.40",,,,,,
Molina Duals,DRG,MS-827,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$14,603.70 ",IP,"2,420.00","46,694.59",,,,,,
Molina Duals,DRG,MS-828,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$9,776.29 ",IP,"2,420.00","33,288.19",,,,,,
Molina Duals,DRG,MS-829,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$18,737.31 ",IP,"2,420.00","63,300.38",,,,,,
Molina Duals,DRG,MS-830,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,655.00 ",IP,"2,420.00","27,796.61",,,,,,
Molina Duals,DRG,MS-831,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,Medical,Relative Weights,"$6,551.40 ",IP,"2,420.00","21,742.56",,,,,,
Molina Duals,DRG,MS-832,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,Medical,Relative Weights,"$4,545.33 ",IP,"2,420.00","14,424.48",,,,,,
Molina Duals,DRG,MS-833,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,Medical,Relative Weights,"$3,136.12 ",IP,"2,420.00","10,727.14",,,,,,
Molina Duals,DRG,MS-834,ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W MCC,Medical,Relative Weights,"$35,345.32 ",IP,"2,420.00","117,784.80",,,,,,
Molina Duals,DRG,MS-835,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC,Medical,Relative Weights,"$12,344.17 ",IP,"2,420.00","40,888.51",,,,,,
Molina Duals,DRG,MS-836,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Medical,Relative Weights,"$6,853.33 ",IP,"2,420.00","26,562.82",,,,,,
Molina Duals,DRG,MS-837,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,Medical,Relative Weights,"$33,284.35 ",IP,"2,420.00","120,774.53",,,,,,
Molina Duals,DRG,MS-838,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,Medical,Relative Weights,"$13,199.74 ",IP,"2,420.00","44,108.06",,,,,,
Molina Duals,DRG,MS-839,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Medical,Relative Weights,"$8,685.36 ",IP,"2,420.00","25,728.19",,,,,,
Molina Duals,DRG,MS-840,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,Medical,Relative Weights,"$18,807.97 ",IP,"2,420.00","64,415.23",,,,,,
Molina Duals,DRG,MS-841,LYMPHOMA & NON-ACUTE LEUKEMIA W CC,Medical,Relative Weights,"$9,470.27 ",IP,"2,420.00","32,491.87",,,,,,
Molina Duals,DRG,MS-842,LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,Medical,Relative Weights,"$6,406.57 ",IP,"2,420.00","23,115.46",,,,,,
Molina Duals,DRG,MS-843,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,Medical,Relative Weights,"$11,140.53 ",IP,"2,420.00","38,461.25",,,,,,
Molina Duals,DRG,MS-844,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,Medical,Relative Weights,"$6,915.82 ",IP,"2,420.00","24,353.28",,,,,,
Molina Duals,DRG,MS-845,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$4,957.64 ",IP,"2,420.00","17,456.54",,,,,,
Molina Duals,DRG,MS-846,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,Medical,Relative Weights,"$15,609.94 ",IP,"2,420.00","52,952.26",,,,,,
Molina Duals,DRG,MS-847,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,Medical,Relative Weights,"$7,802.93 ",IP,"2,420.00","26,528.54",,,,,,
Molina Duals,DRG,MS-848,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Medical,Relative Weights,"$6,028.71 ",IP,"2,420.00","19,785.02",,,,,,
Molina Duals,DRG,MS-849,RADIOTHERAPY,Medical,Relative Weights,"$14,562.82 ",IP,"2,420.00","42,856.13",,,,,,
Molina Duals,DRG,MS-853,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$29,012.34 ",IP,"2,420.00","102,787.78",,,,,,
Molina Duals,DRG,MS-854,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$12,393.81 ",IP,"2,420.00","43,569.79",,,,,,
Molina Duals,DRG,MS-855,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,875.75 ",IP,"2,420.00","32,322.53",,,,,,
Molina Duals,DRG,MS-856,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$27,237.54 ",IP,"2,420.00","89,222.11",,,,,,
Molina Duals,DRG,MS-857,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$12,278.18 ",IP,"2,420.00","40,991.33",,,,,,
Molina Duals,DRG,MS-858,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,940.17 ",IP,"2,420.00","27,748.22",,,,,,
Molina Duals,DRG,MS-862,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W MCC,Medical,Relative Weights,"$11,076.88 ",IP,"2,420.00","37,308.10",,,,,,
Molina Duals,DRG,MS-863,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W/O MCC,Medical,Relative Weights,"$5,906.65 ",IP,"2,420.00","19,918.08",,,,,,
Molina Duals,DRG,MS-864,FEVER AND INFLAMMATORY CONDITIONS,Medical,Relative Weights,"$5,118.83 ",IP,"2,420.00","17,083.58",,,,,,
Molina Duals,DRG,MS-865,VIRAL ILLNESS WITH MCC,Medical,Relative Weights,"$8,630.47 ",IP,"2,420.00","28,088.93",,,,,,
Molina Duals,DRG,MS-866,VIRAL ILLNESS WITHOUT MCC,Medical,Relative Weights,"$4,899.83 ",IP,"2,420.00","16,504.99",,,,,,
Molina Duals,DRG,MS-867,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,Medical,Relative Weights,"$13,064.84 ",IP,"2,420.00","44,053.63",,,,,,
Molina Duals,DRG,MS-868,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,Medical,Relative Weights,"$6,225.52 ",IP,"2,420.00","22,115.52",,,,,,
Molina Duals,DRG,MS-869,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$4,254.50 ",IP,"2,420.00","14,968.80",,,,,,
Molina Duals,DRG,MS-870,SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,Medical,Relative Weights,"$37,604.26 ",IP,"2,420.00","127,497.89",,,,,,
Molina Duals,DRG,MS-871,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,Medical,Relative Weights,"$10,933.79 ",IP,"2,420.00","37,624.61",,,,,,
Molina Duals,DRG,MS-872,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,Medical,Relative Weights,"$5,993.67 ",IP,"2,420.00","20,952.29",,,,,,
Molina Duals,DRG,MS-876,O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,Surgical,Relative Weights,"$19,085.37 ",IP,"2,420.00","73,382.40",,,,,,
Molina Duals,DRG,MS-880,ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,Medical,Relative Weights,"$5,048.75 ",IP,"2,420.00","17,275.10",,,,,,
Molina Duals,DRG,MS-881,DEPRESSIVE NEUROSES,Medical,Relative Weights,"$4,683.74 ",IP,"2,420.00","16,517.09",,,,,,
Molina Duals,DRG,MS-882,NEUROSES EXCEPT DEPRESSIVE,Medical,Relative Weights,"$4,809.89 ",IP,"2,420.00","15,922.37",,,,,,
Molina Duals,DRG,MS-883,DISORDERS OF PERSONALITY & IMPULSE CONTROL,Medical,Relative Weights,"$9,237.83 ",IP,"2,420.00","26,945.86",,,,,,
Molina Duals,DRG,MS-884,ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,Medical,Relative Weights,"$8,452.34 ",IP,"2,420.00","28,990.08",,,,,,
Molina Duals,DRG,MS-885,PSYCHOSES,Medical,Relative Weights,"$7,238.19 ",IP,"2,420.00","24,502.46",,,,,,
Molina Duals,DRG,MS-886,BEHAVIORAL AND DEVELOPMENTAL DISORDERS,Medical,Relative Weights,"$7,146.50 ",IP,"2,420.00","27,127.30",,,,,,
Molina Duals,DRG,MS-887,OTHER MENTAL DISORDER DIAGNOSES,Medical,Relative Weights,"$6,306.12 ",IP,"2,420.00","21,936.10",,,,,,
Molina Duals,DRG,MS-894,ALCOHOL- DRUG ABUSE OR DEPENDENCE- LEFT AMA,Medical,Relative Weights,"$3,206.20 ",IP,"2,420.00","11,700.86",,,,,,
Molina Duals,DRG,MS-895,ALCOHOL- DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY,Medical,Relative Weights,"$9,339.45 ",IP,"2,420.00","32,798.30",,,,,,
Molina Duals,DRG,MS-896,ALCOHOL -  DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC,Medical,Relative Weights,"$10,397.09 ",IP,"2,420.00","34,669.15",,,,,,
Molina Duals,DRG,MS-897,ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC,Medical,Relative Weights,"$4,829.74 ",IP,"2,420.00","16,567.49",,,,,,
Molina Duals,DRG,MS-901,WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,Surgical,Relative Weights,"$24,929.54 ",IP,"2,420.00","87,236.35",,,,,,
Molina Duals,DRG,MS-902,WOUND DEBRIDEMENTS FOR INJURIES WITH CC,Surgical,Relative Weights,"$11,471.66 ",IP,"2,420.00","39,652.70",,,,,,
Molina Duals,DRG,MS-903,WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,630.24 ",IP,"2,420.00","23,063.04",,,,,,
Molina Duals,DRG,MS-904,SKIN GRAFTS FOR INJURIES WITH CC/MCC,Surgical,Relative Weights,"$21,765.97 ",IP,"2,420.00","71,313.98",,,,,,
Molina Duals,DRG,MS-905,SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,Surgical,Relative Weights,"$9,636.13 ",IP,"2,420.00","33,554.30",,,,,,
Molina Duals,DRG,MS-906,HAND PROCEDURES FOR INJURIES,Surgical,Relative Weights,"$10,534.33 ",IP,"2,420.00","35,096.54",,,,,,
Molina Duals,DRG,MS-907,OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,Surgical,Relative Weights,"$23,057.79 ",IP,"2,420.00","80,430.34",,,,,,
Molina Duals,DRG,MS-908,OTHER O.R. PROCEDURES FOR INJURIES WITH CC,Surgical,Relative Weights,"$11,974.50 ",IP,"2,420.00","41,592.10",,,,,,
Molina Duals,DRG,MS-909,OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,006.75 ",IP,"2,420.00","26,584.99",,,,,,
Molina Duals,DRG,MS-913,TRAUMATIC INJURY WITH MCC,Medical,Relative Weights,"$9,569.55 ",IP,"2,420.00","29,762.21",,,,,,
Molina Duals,DRG,MS-914,TRAUMATIC INJURY WITHOUT MCC,Medical,Relative Weights,"$5,179.56 ",IP,"2,420.00","17,371.87",,,,,,
Molina Duals,DRG,MS-915,ALLERGIC REACTIONS WITH MCC,Medical,Relative Weights,"$9,925.21 ",IP,"2,420.00","34,253.86",,,,,,
Molina Duals,DRG,MS-916,ALLERGIC REACTIONS WITHOUT MCC,Medical,Relative Weights,"$3,845.11 ",IP,"2,420.00","12,765.31",,,,,,
Molina Duals,DRG,MS-917,POISONING & TOXIC EFFECTS OF DRUGS W MCC,Medical,Relative Weights,"$8,634.55 ",IP,"2,420.00","29,498.11",,,,,,
Molina Duals,DRG,MS-918,POISONING & TOXIC EFFECTS OF DRUGS W/O MCC,Medical,Relative Weights,"$4,623.01 ",IP,"2,420.00","15,805.44",,,,,,
Molina Duals,DRG,MS-919,COMPLICATIONS OF TREATMENT WITH MCC,Medical,Relative Weights,"$10,769.69 ",IP,"2,420.00","36,798.05",,,,,,
Molina Duals,DRG,MS-920,COMPLICATIONS OF TREATMENT WITH CC,Medical,Relative Weights,"$5,983.74 ",IP,"2,420.00","20,311.20",,,,,,
Molina Duals,DRG,MS-921,COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,Medical,Relative Weights,"$4,075.79 ",IP,"2,420.00","13,922.50",,,,,,
Molina Duals,DRG,MS-922,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC,Medical,Relative Weights,"$9,275.21 ",IP,"2,420.00","32,328.58",,,,,,
Molina Duals,DRG,MS-923,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC,Medical,Relative Weights,"$5,488.50 ",IP,"2,420.00","17,448.48",,,,,,
Molina Duals,DRG,MS-927,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,Surgical,Relative Weights,"$123,174.83 ",IP,"2,420.00","402,060.96",,,,,,
Molina Duals,DRG,MS-928,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,Surgical,Relative Weights,"$38,145.05 ",IP,"2,420.00","124,889.18",,,,,,
Molina Duals,DRG,MS-929,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,Surgical,Relative Weights,"$17,601.41 ",IP,"2,420.00","59,300.64",,,,,,
Molina Duals,DRG,MS-933,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,Medical,Relative Weights,"$13,215.51 ",IP,"2,420.00","63,306.43",,,,,,
Molina Duals,DRG,MS-934,FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,Medical,Relative Weights,"$11,335.01 ",IP,"2,420.00","36,485.57",,,,,,
Molina Duals,DRG,MS-935,NON-EXTENSIVE BURNS,Medical,Relative Weights,"$11,288.29 ",IP,"2,420.00","38,955.17",,,,,,
Molina Duals,DRG,MS-939,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,Surgical,Relative Weights,"$19,707.93 ",IP,"2,420.00","73,672.70",,,,,,
Molina Duals,DRG,MS-940,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,Surgical,Relative Weights,"$12,970.23 ",IP,"2,420.00","45,799.49",,,,,,
Molina Duals,DRG,MS-941,O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W/O CC/MCC,Surgical,Relative Weights,"$11,231.05 ",IP,"2,420.00","38,922.91",,,,,,
Molina Duals,DRG,MS-945,REHABILITATION WITH CC/MCC,Medical,Relative Weights,"$8,654.41 ",IP,"2,420.00","29,338.85",,,,,,
Molina Duals,DRG,MS-946,REHABILITATION WITHOUT CC/MCC,Medical,Relative Weights,"$6,577.10 ",IP,"2,420.00","21,913.92",,,,,,
Molina Duals,DRG,MS-947,SIGNS AND SYMPTOMS WITH MCC,Medical,Relative Weights,"$6,973.05 ",IP,"2,420.00","24,137.57",,,,,,
Molina Duals,DRG,MS-948,SIGNS AND SYMPTOMS WITHOUT MCC,Medical,Relative Weights,"$4,596.73 ",IP,"2,420.00","15,716.74",,,,,,
Molina Duals,DRG,MS-949,AFTERCARE WITH CC/MCC,Medical,Relative Weights,"$6,481.90 ",IP,"2,420.00","21,952.22",,,,,,
Molina Duals,DRG,MS-950,AFTERCARE WITHOUT CC/MCC,Medical,Relative Weights,"$4,322.83 ",IP,"2,420.00","14,936.54",,,,,,
Molina Duals,DRG,MS-951,OTHER FACTORS INFLUENCING HEALTH STATUS,Medical,Relative Weights,"$3,268.11 ",IP,"2,420.00","11,823.84",,,,,,
Molina Duals,DRG,MS-955,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,Surgical,Relative Weights,"$36,730.00 ",IP,"2,420.00","122,582.88",,,,,,
Molina Duals,DRG,MS-956,LIMB REATTACHMENT- HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,Surgical,Relative Weights,"$22,484.30 ",IP,"2,420.00","79,093.73",,,,,,
Molina Duals,DRG,MS-957,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Surgical,Relative Weights,"$43,338.63 ",IP,"2,420.00","151,879.39",,,,,,
Molina Duals,DRG,MS-958,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,Surgical,Relative Weights,"$24,561.61 ",IP,"2,420.00","84,488.54",,,,,,
Molina Duals,DRG,MS-959,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,Surgical,Relative Weights,"$15,979.04 ",IP,"2,420.00","56,458.08",,,,,,
Molina Duals,DRG,MS-963,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Medical,Relative Weights,"$15,942.83 ",IP,"2,420.00","54,938.02",,,,,,
Molina Duals,DRG,MS-964,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,Medical,Relative Weights,"$8,712.23 ",IP,"2,420.00","30,108.96",,,,,,
Molina Duals,DRG,MS-965,OTHER MULTIPLE SIGNIFICANT TRAUMA W/O CC/MCC,Medical,Relative Weights,"$5,329.07 ",IP,"2,420.00","18,488.74",,,,,,
Molina Duals,DRG,MS-969,HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$34,175.55 ",IP,"2,420.00","116,982.43",,,,,,
Molina Duals,DRG,MS-970,HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$17,454.24 ",IP,"2,420.00","58,806.72",,,,,,
Molina Duals,DRG,MS-974,HIV WITH MAJOR RELATED CONDITION WITH MCC,Medical,Relative Weights,"$15,712.73 ",IP,"2,420.00","53,905.82",,,,,,
Molina Duals,DRG,MS-975,HIV WITH MAJOR RELATED CONDITION WITH CC,Medical,Relative Weights,"$7,487.56 ",IP,"2,420.00","27,054.72",,,,,,
Molina Duals,DRG,MS-976,HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,Medical,Relative Weights,"$5,545.74 ",IP,"2,420.00","18,430.27",,,,,,
Molina Duals,DRG,MS-977,HIV WITH OR WITHOUT OTHER RELATED CONDITION,Medical,Relative Weights,"$7,734.01 ",IP,"2,420.00","26,218.08",,,,,,
Molina Duals,DRG,MS-981,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$26,949.04 ",IP,"2,420.00","90,532.51",,,,,,
Molina Duals,DRG,MS-982,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Surgical,Relative Weights,"$14,813.94 ",IP,"2,420.00","49,152.10",,,,,,
Molina Duals,DRG,MS-983,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$9,649.56 ",IP,"2,420.00","33,003.94",,,,,,
Molina Duals,DRG,MS-987,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$19,131.51 ",IP,"2,420.00","67,207.39",,,,,,
Molina Duals,DRG,MS-988,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Surgical,Relative Weights,"$9,965.51 ",IP,"2,420.00","34,640.93",,,,,,
Molina Duals,DRG,MS-989,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$6,561.91 ",IP,"2,420.00","23,232.38",,,,,,
Molina Duals,CPT,176,Anesth pharyngeal surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,211,Anesth cran surg hemotoma,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,214,Anesth skull drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,215,Anesth skull repair/fract,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,524,Anesth chest drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,540,Anesth chest surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,542,Anesthesia removal pleura,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,546,Anesth lung chest wall surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,560,Anesth heart surg w/o pump,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,561,Anesth heart surg <1 yr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,562,Anesth hrt surg w/pmp age 1+,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,567,Anesth cabg w/pump,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,580,Anesth heart/lung transplnt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,632,Anesth removal of nerves,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,792,Anesth hemorr/excise liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,794,Anesth pancreas removal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,796,Anesth for liver transplant,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,844,Anesth pelvis surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,846,Anesth hysterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,848,Anesth pelvic organ surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,864,Anesth removal of bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,866,Anesth removal of adrenal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,868,Anesth kidney transplant,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,882,Anesth major vein ligation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,908,Anesth removal of prostate,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,932,Anesth amputation of penis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,934,Anesth penis nodes removal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,936,Anesth penis nodes removal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,1272,Anesth femoral artery surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,1442,Anesth knee artery surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,1444,Anesth knee artery repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,1502,Anesth lwr leg embolectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,1652,Anesth shoulder vessel surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,1654,Anesth shoulder vessel surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,1656,Anesth arm-leg vessel surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,1990,Support for organ donor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,10005,Fna bx w/us gdn 1st les,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,10007,Fna bx w/fluor gdn 1st les,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,10009,Fna bx w/ct gdn 1st les,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,10011,Fna bx w/mr gdn 1st les,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,10021,Fna bx w/o img gdn 1st les,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,10030,Guide cathet fluid drainage,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,10035,Perq dev soft tiss 1st imag,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,10040,Acne surgery,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,10060,Drainage of skin abscess,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,10061,Drainage of skin abscess,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,10080,Drainage of pilonidal cyst,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,10081,Drainage of pilonidal cyst,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,10120,Remove foreign body,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,10121,Remove foreign body,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,10140,Drainage of hematoma/fluid,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,10160,Puncture drainage of lesion,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,10180,Complex drainage wound,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,11000,Debride infected skin,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Molina Duals,CPT,11004,Debride genitalia & perineum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,11005,Debride abdom wall,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,11006,Debride genit/per/abdom wall,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,11008,Remove mesh from abd wall,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,11010,Debride skin at fx site,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,11011,Debride skin musc at fx site,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,11012,Deb skin bone at fx site,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,11042,Deb subq tissue 20 sq cm/<,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,11043,Deb musc/fascia 20 sq cm/<,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Molina Duals,CPT,11044,Deb bone 20 sq cm/<,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,11055,Trim skin lesion,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,11056,Trim skin lesions 2 to 4,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,11057,Trim skin lesions over 4,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,11102,Tangntl bx skin single les,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,11104,Punch bx skin single lesion,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,11106,Incal bx skn single les,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Molina Duals,CPT,11200,Removal of skin tags <w/15,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,11300,Shave skin lesion 0.5 cm/<,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,11301,Shave skin lesion 0.6-1.0 cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,11302,Shave skin lesion 1.1-2.0 cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,11303,Shave skin lesion >2.0 cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,11305,Shave skin lesion 0.5 cm/<,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,11306,Shave skin lesion 0.6-1.0 cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,11307,Shave skin lesion 1.1-2.0 cm,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,11308,Shave skin lesion >2.0 cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,11310,Shave skin lesion 0.5 cm/<,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,11311,Shave skin lesion 0.6-1.0 cm,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,11312,Shave skin lesion 1.1-2.0 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,11313,Shave skin lesion >2.0 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,11400,Exc tr-ext b9+marg 0.5 cm<,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,11401,Exc tr-ext b9+marg 0.6-1 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,11402,Exc tr-ext b9+marg 1.1-2 cm,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,11403,Exc tr-ext b9+marg 2.1-3cm,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,11404,Exc tr-ext b9+marg 3.1-4 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,11406,Exc tr-ext b9+marg >4.0 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,11420,Exc h-f-nk-sp b9+marg 0.5/<,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,11421,Exc h-f-nk-sp b9+marg 0.6-1,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,11422,Exc h-f-nk-sp b9+marg 1.1-2,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,11423,Exc h-f-nk-sp b9+marg 2.1-3,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,11424,Exc h-f-nk-sp b9+marg 3.1-4,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,11426,Exc h-f-nk-sp b9+marg >4 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,11440,Exc face-mm b9+marg 0.5 cm/<,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,11441,Exc face-mm b9+marg 0.6-1 cm,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,11442,Exc face-mm b9+marg 1.1-2 cm,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,11443,Exc face-mm b9+marg 2.1-3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,11444,Exc face-mm b9+marg 3.1-4 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,11446,Exc face-mm b9+marg >4 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,11450,Removal sweat gland lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,11451,Removal sweat gland lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,11462,Removal sweat gland lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,11463,Removal sweat gland lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,11470,Removal sweat gland lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,11471,Removal sweat gland lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,11600,Exc tr-ext mal+marg 0.5 cm/<,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,11601,Exc tr-ext mal+marg 0.6-1 cm,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,11602,Exc tr-ext mal+marg 1.1-2 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,11603,Exc tr-ext mal+marg 2.1-3 cm,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,11604,Exc tr-ext mal+marg 3.1-4 cm,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,11606,Exc tr-ext mal+marg >4 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,11620,Exc h-f-nk-sp mal+marg 0.5/<,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,11621,Exc s/n/h/f/g mal+mrg 0.6-1,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,11622,Exc s/n/h/f/g mal+mrg 1.1-2,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,11623,Exc s/n/h/f/g mal+mrg 2.1-3,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,11624,Exc s/n/h/f/g mal+mrg 3.1-4,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,11626,Exc s/n/h/f/g mal+mrg >4 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,11640,Exc f/e/e/n/l mal+mrg 0.5cm<,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,11641,Exc f/e/e/n/l mal+mrg 0.6-1,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,11642,Exc f/e/e/n/l mal+mrg 1.1-2,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,11643,Exc f/e/e/n/l mal+mrg 2.1-3,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,11644,Exc f/e/e/n/l mal+mrg 3.1-4,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,11646,Exc f/e/e/n/l mal+mrg >4 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,11719,Trim nail(s) any number,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Molina Duals,CPT,11720,Debride nail 1-5,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Molina Duals,CPT,11721,Debride nail 6 or more,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Molina Duals,CPT,11730,Removal of nail plate,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,11740,Drain blood from under nail,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Molina Duals,CPT,11750,Removal of nail bed,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,11755,Biopsy nail unit,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,11760,Repair of nail bed,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Molina Duals,CPT,11762,Reconstruction of nail bed,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,11765,Excision of nail fold toe,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,11770,Remove pilonidal cyst simple,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,11771,Remove pilonidal cyst exten,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,11772,Remove pilonidal cyst compl,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,11900,Inject skin lesions </w 7,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,11901,Inject skin lesions >7,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,11920,Correct skin color 6.0 cm/<,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Molina Duals,CPT,11921,Correct skn color 6.1-20.0cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Molina Duals,CPT,11950,Tx contour defects 1 cc/<,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,11951,Tx contour defects 1.1-5.0cc,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Molina Duals,CPT,11952,Tx contour defects 5.1-10cc,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Molina Duals,CPT,11954,Tx contour defects >10.0 cc,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Molina Duals,CPT,11960,Insert tissue expander(s),APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Molina Duals,CPT,11970,Rplcmt tiss xpndr perm implt,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,11971,Rmvl tis xpndr wo insj implt,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,11976,Remove contraceptive capsule,APC 5071,RVU Per Case,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,11980,Implant hormone pellet(s),APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Molina Duals,CPT,11981,Insert drug implant device,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Molina Duals,CPT,11982,Remove drug implant device,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Molina Duals,CPT,11983,Remove/insert drug implant,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Molina Duals,CPT,12001,Rpr s/n/ax/gen/trnk 2.5cm/<,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,12002,Rpr s/n/ax/gen/trnk2.6-7.5cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,12004,Rpr s/n/ax/gen/trk7.6-12.5cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,12005,Rpr s/n/a/gen/trk12.6-20.0cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,12006,Rpr s/n/a/gen/trk20.1-30.0cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,12007,Rpr s/n/ax/gen/trnk >30.0 cm,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,12011,Rpr f/e/e/n/l/m 2.5 cm/<,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,12013,Rpr f/e/e/n/l/m 2.6-5.0 cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,12014,Rpr f/e/e/n/l/m 5.1-7.5 cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,12015,Rpr f/e/e/n/l/m 7.6-12.5 cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,12016,Rpr fe/e/en/l/m 12.6-20.0 cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,12017,Rpr fe/e/en/l/m 20.1-30.0 cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,12018,Rpr f/e/e/n/l/m >30.0 cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,12020,Closure of split wound,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Molina Duals,CPT,12021,Closure of split wound,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,12031,Intmd rpr s/a/t/ext 2.5 cm/<,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,12032,Intmd rpr s/a/t/ext 2.6-7.5,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,12034,Intmd rpr s/tr/ext 7.6-12.5,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,12035,Intmd rpr s/a/t/ext 12.6-20,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,12036,Intmd rpr s/a/t/ext 20.1-30,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Molina Duals,CPT,12037,Intmd rpr s/tr/ext >30.0 cm,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,12041,Intmd rpr n-hf/genit 2.5cm/<,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,12042,Intmd rpr n-hf/genit2.6-7.5,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,12044,Intmd rpr n-hf/genit7.6-12.5,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Molina Duals,CPT,12045,Intmd rpr n-hf/genit12.6-20,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Molina Duals,CPT,12046,Intmd rpr n-hf/genit20.1-30,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Molina Duals,CPT,12047,Intmd rpr n-hf/genit >30.0cm,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,12051,Intmd rpr face/mm 2.5 cm/<,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,12052,Intmd rpr face/mm 2.6-5.0 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,12053,Intmd rpr face/mm 5.1-7.5 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,12054,Intmd rpr face/mm 7.6-12.5cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,12055,Intmd rpr face/mm 12.6-20 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,12056,Intmd rpr face/mm 20.1-30.0,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,12057,Intmd rpr face/mm >30.0 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,13100,Cmplx rpr trunk 1.1-2.5 cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Molina Duals,CPT,13101,Cmplx rpr trunk 2.6-7.5 cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Molina Duals,CPT,13120,Cmplx rpr s/a/l 1.1-2.5 cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Molina Duals,CPT,13121,Cmplx rpr s/a/l 2.6-7.5 cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Molina Duals,CPT,13131,Cmplx rpr f/c/c/m/n/ax/g/h/f,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,13132,Cmplx rpr f/c/c/m/n/ax/g/h/f,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Molina Duals,CPT,13151,Cmplx rpr e/n/e/l 1.1-2.5 cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Molina Duals,CPT,13152,Cmplx rpr e/n/e/l 2.6-7.5 cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Molina Duals,CPT,13160,Late closure of wound,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,14000,Tis trnfr trunk 10 sq cm/<,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,14001,Tis trnfr trunk 10.1-30sqcm,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,14020,Tis trnfr s/a/l 10 sq cm/<,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,14021,Tis trnfr s/a/l 10.1-30 sqcm,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,14040,Tis trnfr f/c/c/m/n/a/g/h/f,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,14041,Tis trnfr f/c/c/m/n/a/g/h/f,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,14060,Tis trnfr e/n/e/l 10 sq cm/<,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,14061,Tis trnfr e/n/e/l10.1-30sqcm,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,14301,Tis trnfr any 30.1-60 sq cm,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Molina Duals,CPT,14350,Filleted finger/toe flap,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,15002,Wound prep trk/arm/leg,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,15004,Wound prep f/n/hf/g,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Molina Duals,CPT,15040,Harvest cultured skin graft,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,15050,Skin pinch graft,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Molina Duals,CPT,15100,Skin splt grft trnk/arm/leg,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,15110,Epidrm autogrft trnk/arm/leg,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,15115,Epidrm a-grft face/nck/hf/g,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,15120,Skn splt a-grft fac/nck/hf/g,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Molina Duals,CPT,15130,Derm autograft trnk/arm/leg,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,15135,Derm autograft face/nck/hf/g,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Molina Duals,CPT,15150,Cult skin grft t/arm/leg,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,15155,Cult skin graft f/n/hf/g,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Molina Duals,CPT,15200,Skin full graft trunk,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,15220,Skin full graft sclp/arm/leg,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,15240,Skin full grft face/genit/hf,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,15260,Skin full graft een & lips,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,15271,Skin sub graft trnk/arm/leg,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,15273,Skin sub grft t/arm/lg child,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Molina Duals,CPT,15275,Skin sub graft face/nk/hf/g,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,15277,Skn sub grft f/n/hf/g child,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,15570,Skin pedicle flap trunk,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,15572,Skin pedicle flap arms/legs,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Molina Duals,CPT,15574,Pedcle fh/ch/ch/m/n/ax/g/h/f,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,15576,Pedicle e/n/e/l/ntroral,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,15600,Delay flap trunk,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Molina Duals,CPT,15610,Delay flap arms/legs,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,15620,Delay flap f/c/c/n/ax/g/h/f,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,15630,Delay flap eye/nos/ear/lip,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,15650,Transfer skin pedicle flap,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,15730,Mdfc flap w/prsrv vasc pedcl,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Molina Duals,CPT,15731,Forehead flap w/vasc pedicle,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Molina Duals,CPT,15733,Musc myoq/fscq flp h&n pedcl,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","9,201.00",,,,,,
Molina Duals,CPT,15734,Muscle-skin graft trunk,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Molina Duals,CPT,15736,Muscle-skin graft arm,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,15738,Muscle-skin graft leg,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Molina Duals,CPT,15740,Island pedicle flap graft,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,15750,Neurovascular pedicle flap,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Molina Duals,CPT,15756,Free myo/skin flap microvasc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,15757,Free skin flap microvasc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,15758,Free fascial flap microvasc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,15760,Composite skin graft,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,15769,Grfg autol soft tiss dir exc,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Molina Duals,CPT,15770,Derma-fat-fascia graft,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Molina Duals,CPT,15771,Grfg autol fat lipo 50 cc/<,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Molina Duals,CPT,15773,Grfg autol fat lipo 25 cc/<,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,15775,Hair trnspl 1-15 punch grfts,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,15776,Hair trnspl >15 punch grafts,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,15780,Dermabrasion total face,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,15781,Dermabrasion segmental face,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,15782,Dermabrasion other than face,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,15783,Dermabrasion suprfl any site,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,15786,Abrasion lesion single,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,15788,Chemical peel face epiderm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,15789,Chemical peel face dermal,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Molina Duals,CPT,15792,Chemical peel nonfacial,APC 5053,RVU Per Case,$536.39 ,OP,536.39,"4,314.00",,,,,,
Molina Duals,CPT,15793,Chemical peel nonfacial,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,15819,Plastic surgery neck,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,15820,Revision of lower eyelid,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,15821,Revision of lower eyelid,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,15822,Revision of upper eyelid,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,15823,Revision of upper eyelid,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,15824,Removal of forehead wrinkles,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,15825,Removal of neck wrinkles,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Molina Duals,CPT,15826,Removal of brow wrinkles,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Molina Duals,CPT,15828,Removal of face wrinkles,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Molina Duals,CPT,15829,Removal of skin wrinkles,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Molina Duals,CPT,15830,Exc skin abd,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,15832,Excise excessive skin thigh,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,15833,Excise excessive skin leg,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,15834,Excise excessive skin hip,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,15835,Excise excessive skin buttck,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,15836,Excise excessive skin arm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,15837,Excise excess skin arm/hand,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,15838,Excise excess skin fat pad,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,15839,Excise excess skin & tissue,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,15840,Nerve palsy fascial graft,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Molina Duals,CPT,15841,Nerve palsy muscle graft,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Molina Duals,CPT,15842,Nerve palsy microsurg graft,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,15845,Skin and muscle repair face,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Molina Duals,CPT,15850,Remove sutures same surgeon,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Molina Duals,CPT,15851,Remove sutures diff surgeon,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,15852,Dressing change not for burn,APC 5053,RVU Per Case,$536.39 ,OP,536.39,"4,314.00",,,,,,
Molina Duals,CPT,15860,Test for blood flow in graft,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Molina Duals,CPT,15876,Suction lipectomy head&neck,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Molina Duals,CPT,15877,Suction lipectomy trunk,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Molina Duals,CPT,15878,Suction lipectomy upr extrem,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,15879,Suction lipectomy lwr extrem,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Molina Duals,CPT,15920,Removal of tail bone ulcer,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,15922,Removal of tail bone ulcer,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Molina Duals,CPT,15931,Remove sacrum pressure sore,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,15933,Remove sacrum pressure sore,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,15934,Remove sacrum pressure sore,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Molina Duals,CPT,15935,Remove sacrum pressure sore,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Molina Duals,CPT,15936,Remove sacrum pressure sore,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,15937,Remove sacrum pressure sore,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,15940,Remove hip pressure sore,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,15941,Remove hip pressure sore,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,15944,Remove hip pressure sore,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Molina Duals,CPT,15945,Remove hip pressure sore,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,15946,Remove hip pressure sore,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,15950,Remove thigh pressure sore,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,15951,Remove thigh pressure sore,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,15952,Remove thigh pressure sore,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,15953,Remove thigh pressure sore,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Molina Duals,CPT,15956,Remove thigh pressure sore,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,15958,Remove thigh pressure sore,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Molina Duals,CPT,15999,Removal of pressure sore,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,16000,Initial treatment of burn(s),APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,16020,Dress/debrid p-thick burn s,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,16025,Dress/debrid p-thick burn m,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,16030,Dress/debrid p-thick burn l,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,16035,Incision of burn scab initi,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,16036,Escharotomy addl incision,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,17000,Destruct premalg lesion,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,17004,Destroy premal lesions 15/>,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,17106,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,17107,Destruction of skin lesions,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Molina Duals,CPT,17108,Destruction of skin lesions,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,17110,Destruct b9 lesion 1-14,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,17111,Destruct lesion 15 or more,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,17250,Chem caut of granltj tissue,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,17260,Destruction of skin lesions,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,17261,Destruction of skin lesions,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,17262,Destruction of skin lesions,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,17263,Destruction of skin lesions,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,17264,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,17266,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,17270,Destruction of skin lesions,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,17271,Destruction of skin lesions,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,17272,Destruction of skin lesions,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,17273,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,17274,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,17276,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,17280,Destruction of skin lesions,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,17281,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,17282,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,17283,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,17284,Destruction of skin lesions,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Molina Duals,CPT,17286,Destruction of skin lesions,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Molina Duals,CPT,17311,Mohs 1 stage h/n/hf/g,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Molina Duals,CPT,17313,Mohs 1 stage t/a/l,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Molina Duals,CPT,17340,Cryotherapy of skin,APC 5732,RVU Per Case,$34.63 ,OP,34.63,"4,314.00",,,,,,
Molina Duals,CPT,17360,Skin peel therapy,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,17380,Hair removal by electrolysis,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Molina Duals,CPT,17999,Skin tissue procedure,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,19000,Drainage of breast lesion,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,19020,Incision of breast lesion,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,19081,Bx breast 1st lesion strtctc,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,19083,Bx breast 1st lesion us imag,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,19085,Bx breast 1st lesion mr imag,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,19100,Bx breast percut w/o image,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,19101,Biopsy of breast open,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Molina Duals,CPT,19105,Cryosurg ablate fa each,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Molina Duals,CPT,19110,Nipple exploration,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Molina Duals,CPT,19112,Excise breast duct fistula,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Molina Duals,CPT,19120,Removal of breast lesion,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Molina Duals,CPT,19125,Excision breast lesion,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Molina Duals,CPT,19281,Perq device breast 1st imag,APC 5071,RVU Per Case,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,19283,Perq dev breast 1st strtctc,APC 5071,RVU Per Case,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,19285,Perq dev breast 1st us imag,APC 5071,RVU Per Case,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,19287,Perq dev breast 1st mr guide,APC 5071,RVU Per Case,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,19296,Place po breast cath for rad,APC 5093,RVU Per Case,"$9,128.05 ",OP,"4,314.00","9,128.05",,,,,,
Molina Duals,CPT,19298,Place breast rad tube/caths,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
Molina Duals,CPT,19300,Removal of breast tissue,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","9,201.00",,,,,,
Molina Duals,CPT,19301,Partial mastectomy,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Molina Duals,CPT,19302,P-mastectomy w/ln removal,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
Molina Duals,CPT,19303,Mast simple complete,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
Molina Duals,CPT,19305,Mast radical,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,19306,Mast rad urban type,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,19307,Mast mod rad,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,19316,Suspension of breast,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
Molina Duals,CPT,19318,Breast reduction,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,19325,Breast augmentation w/implt,APC 5093,RVU Per Case,"$9,128.05 ",OP,"4,314.00","9,128.05",,,,,,
Molina Duals,CPT,19328,Rmvl intact breast implant,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Molina Duals,CPT,19330,Rmvl ruptured breast implant,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Molina Duals,CPT,19340,Insj breast implt sm d mast,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,19342,Insj/rplcmt brst implt sep d,APC 5093,RVU Per Case,"$9,128.05 ",OP,"4,314.00","9,128.05",,,,,,
Molina Duals,CPT,19350,Breast reconstruction,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Molina Duals,CPT,19355,Correct inverted nipple(s),APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Molina Duals,CPT,19357,Tiss xpndr plmt brst rcnstj,APC 5094,RVU Per Case,"$15,276.83 ",OP,"4,140.35","15,276.83",,,,,,
Molina Duals,CPT,19361,Brst rcnstj latsms drsi flap,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,19364,Brst rcnstj free flap,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,19367,Brst rcnstj 1 pdcl tram flap,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,19368,Brst rcnstj 1pdcl tram anast,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,19369,Brst rcnstj 2 pdcl tram flap,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,19370,Revj peri-implt capsule brst,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Molina Duals,CPT,19371,Peri-implt capslc brst compl,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Molina Duals,CPT,19380,Revj reconstructed breast,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
Molina Duals,CPT,19396,Design custom breast implant,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Molina Duals,CPT,19499,Breast surgery procedure,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Molina Duals,CPT,20100,Explore wound neck,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Molina Duals,CPT,20101,Explore wound chest,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,20102,Explore wound abdomen,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,20103,Explore wound extremity,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,20150,Excise epiphyseal bar,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,20200,Muscle biopsy,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,20205,Deep muscle biopsy,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,20206,Needle biopsy muscle,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,20220,Bone biopsy trocar/needle,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,20225,Bone biopsy trocar/needle,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,20240,Bone biopsy open superficial,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,20245,Bone biopsy open deep,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,20250,Open bone biopsy,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,20251,Open bone biopsy,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,20500,Injection of sinus tract,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,20520,Removal of foreign body,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,20525,Removal of foreign body,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,20526,Ther injection carp tunnel,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Molina Duals,CPT,20527,Inj dupuytren cord w/enzyme,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Molina Duals,CPT,20550,Inj tendon sheath/ligament,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Molina Duals,CPT,20551,Inj tendon origin/insertion,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Molina Duals,CPT,20552,Inj trigger point 1/2 muscl,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Molina Duals,CPT,20553,Inject trigger points 3/>,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Molina Duals,CPT,20555,Place ndl musc/tis for rt,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,20560,Ndl insj w/o njx 1 or 2 musc,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,"4,314.00",,,,,,
Molina Duals,CPT,20561,Ndl insj w/o njx 3+ musc,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,"4,314.00",,,,,,
Molina Duals,CPT,20600,Drain/inj joint/bursa w/o us,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Molina Duals,CPT,20604,Drain/inj joint/bursa w/us,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Molina Duals,CPT,20605,Drain/inj joint/bursa w/o us,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Molina Duals,CPT,20606,Drain/inj joint/bursa w/us,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Molina Duals,CPT,20610,Drain/inj joint/bursa w/o us,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Molina Duals,CPT,20611,Drain/inj joint/bursa w/us,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Molina Duals,CPT,20612,Aspirate/inj ganglion cyst,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Molina Duals,CPT,20615,Treatment of bone cyst,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,20650,Insert and remove bone pin,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,20660,Apply rem fixation device,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,20661,Application of head brace,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,20662,Application of pelvis brace,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,20663,Application of thigh brace,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,20664,Application of halo,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,20665,Removal of fixation device,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Molina Duals,CPT,20670,Removal of support implant,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,20680,Removal of support implant,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,20690,Apply bone fixation device,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,20692,Apply bone fixation device,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,20693,Adjust bone fixation device,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,20694,Remove bone fixation device,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,20696,Comp multiplane ext fixation,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,20697,Comp ext fixate strut change,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,20802,Replantation arm complete,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,20805,Replant forearm complete,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,20808,Replantation hand complete,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,20816,Replantation digit complete,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,20822,Replantation digit complete,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,20824,Replantation thumb complete,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,20827,Replantation thumb complete,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,20838,Replantation foot complete,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,20900,Removal of bone for graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,20902,Removal of bone for graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,20910,Remove cartilage for graft,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
Molina Duals,CPT,20912,Remove cartilage for graft,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Molina Duals,CPT,20920,Removal of fascia for graft,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,20922,Removal of fascia for graft,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,20924,Removal of tendon for graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,20950,Fluid pressure muscle,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,20955,Fibula bone graft microvasc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,20956,Iliac bone graft microvasc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,20957,Mt bone graft microvasc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,20962,Other bone graft microvasc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,20969,Bone/skin graft microvasc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,20970,Bone/skin graft iliac crest,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,20972,Bone/skin graft metatarsal,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,20973,Bone/skin graft great toe,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,20974,Electrical bone stimulation,Physician,Per Unit,$50.41 ,OP,50.41,"4,314.00",,,,,,
Molina Duals,CPT,20979,Us bone stimulation,APC 5731,RVU Per Case,$25.25 ,OP,25.25,"4,314.00",,,,,,
Molina Duals,CPT,20982,Ablate bone tumor(s) perq,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,20983,Ablate bone tumor(s) perq,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,20999,Musculoskeletal surgery,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,21010,Incision of jaw joint,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,21011,Exc face les sc <2 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,21012,Exc face les sbq 2 cm/>,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,21013,Exc face tum deep < 2 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,21014,Exc face tum deep 2 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,21015,Resect face/scalp tum < 2 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,21016,Resect face/scalp tum 2 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,21025,Excision of bone lower jaw,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21026,Excision of facial bone(s),APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21029,Contour of face bone lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,21030,Excise max/zygoma b9 tumor,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21031,Remove exostosis mandible,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,21032,Remove exostosis maxilla,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,21034,Excise max/zygoma mal tumor,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21040,Excise mandible lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,21044,Removal of jaw bone lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21045,Extensive jaw surgery,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21046,Remove mandible cyst complex,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21047,Excise lwr jaw cyst w/repair,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21048,Remove maxilla cyst complex,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21049,Excis uppr jaw cyst w/repair,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21050,Removal of jaw joint,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21060,Remove jaw joint cartilage,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21070,Remove coronoid process,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21073,Mnpj of tmj w/anesth,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,21076,Prepare face/oral prosthesis,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,21077,Prepare face/oral prosthesis,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21079,Prepare face/oral prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,21080,Prepare face/oral prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,21081,Prepare face/oral prosthesis,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21082,Prepare face/oral prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,21083,Prepare face/oral prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,21084,Prepare face/oral prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,21085,Prepare face/oral prosthesis,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Molina Duals,CPT,21086,Prepare face/oral prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,21087,Prepare face/oral prosthesis,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21088,Prepare face/oral prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,21089,Prepare face/oral prosthesis,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Molina Duals,CPT,21100,Maxillofacial fixation,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21110,Interdental fixation,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,21120,Reconstruction of chin,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21121,Reconstruction of chin,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,21122,Reconstruction of chin,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21123,Reconstruction of chin,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,21125,Augmentation lower jaw bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21127,Augmentation lower jaw bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21137,Reduction of forehead,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,21138,Reduction of forehead,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21139,Reduction of forehead,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21141,Lefort i-1 piece w/o graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21142,Lefort i-2 piece w/o graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21143,Lefort i-3/> piece w/o graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21145,Lefort i-1 piece w/ graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21146,Lefort i-2 piece w/ graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21147,Lefort i-3/> piece w/ graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21150,Lefort ii anterior intrusion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21151,Lefort ii w/bone grafts,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21154,Lefort iii w/o lefort i,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21155,Lefort iii w/ lefort i,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21159,Lefort iii w/fhdw/o lefort i,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21160,Lefort iii w/fhd w/ lefort i,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21172,Reconstruct orbit/forehead,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21175,Reconstruct orbit/forehead,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21179,Reconstruct entire forehead,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21180,Reconstruct entire forehead,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21181,Contour cranial bone lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21182,Reconstruct cranial bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21183,Reconstruct cranial bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21184,Reconstruct cranial bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21188,Reconstruction of midface,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21193,Reconst lwr jaw w/o graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,21194,Reconst lwr jaw w/graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21195,Reconst lwr jaw w/o fixation,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21196,Reconst lwr jaw w/fixation,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21198,Reconstr lwr jaw segment,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21199,Reconstr lwr jaw w/advance,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21206,Reconstruct upper jaw bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21208,Augmentation of facial bones,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21209,Reduction of facial bones,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21210,Face bone graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21215,Lower jaw bone graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21230,Rib cartilage graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21235,Ear cartilage graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21240,Reconstruction of jaw joint,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21242,Reconstruction of jaw joint,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21243,Reconstruction of jaw joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,21244,Reconstruction of lower jaw,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21245,Reconstruction of jaw,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21246,Reconstruction of jaw,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21247,Reconstruct lower jaw bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21248,Reconstruction of jaw,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21249,Reconstruction of jaw,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21255,Reconstruct lower jaw bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21256,Reconstruction of orbit,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21260,Revise eye sockets,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21261,Revise eye sockets,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21263,Revise eye sockets,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21267,Revise eye sockets,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21268,Revise eye sockets,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21270,Augmentation cheek bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21275,Revision orbitofacial bones,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21280,Revision of eyelid,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,21282,Revision of eyelid,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,21295,Revision of jaw muscle/bone,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,21296,Revision of jaw muscle/bone,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,21299,Cranio/maxillofacial surgery,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Molina Duals,CPT,21310,Closed tx nose fx w/o manj,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,21315,Closed tx nose fx w/o stablj,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,21320,Closed tx nose fx w/ stablj,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,21325,Open tx nose fx uncomplicatd,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,21330,Open tx nose fx w/skele fixj,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21335,Open tx nose & septal fx,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,21336,Open tx septal fx w/wo stabj,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,21337,Closed tx septal&nose fx,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,21338,Open nasoethmoid fx w/o fixj,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21339,Open nasoethmoid fx w/ fixj,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21340,Perq tx nasoethmoid fx,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,21343,Open tx dprsd front sinus fx,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21344,Open tx compl front sinus fx,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21345,Closed tx nose/jaw fx,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,21346,Opn tx nasomax fx w/fixj,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21347,Opn tx nasomax fx multple,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21348,Opn tx nasomax fx w/graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21355,Perq tx malar fracture,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,21356,Opn tx dprsd zygomatic arch,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21360,Opn tx dprsd malar fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21365,Opn tx complx malar fx,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21366,Opn tx complx malar w/grft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21385,Opn tx orbit fx transantral,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21386,Opn tx orbit fx periorbital,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21387,Opn tx orbit fx combined,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21390,Opn tx orbit periorbtl implt,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21395,Opn tx orbit periorbt w/grft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21400,Closed tx orbit w/o manipulj,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Molina Duals,CPT,21401,Closed tx orbit w/manipulj,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,21406,Opn tx orbit fx w/o implant,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21407,Opn tx orbit fx w/implant,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21408,Opn tx orbit fx w/bone grft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21421,Treat mouth roof fracture,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,21422,Treat mouth roof fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21423,Treat mouth roof fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21431,Treat craniofacial fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21432,Treat craniofacial fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21433,Treat craniofacial fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21435,Treat craniofacial fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21436,Treat craniofacial fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21440,Treat dental ridge fracture,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,21445,Treat dental ridge fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21450,Treat lower jaw fracture,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Molina Duals,CPT,21451,Treat lower jaw fracture,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,21452,Treat lower jaw fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21453,Treat lower jaw fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21454,Treat lower jaw fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21461,Treat lower jaw fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21462,Treat lower jaw fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,21465,Treat lower jaw fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21470,Treat lower jaw fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21480,Reset dislocated jaw,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,21485,Reset dislocated jaw,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,21490,Repair dislocated jaw,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,21497,Interdental wiring,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,21499,Head surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Molina Duals,CPT,21501,Drain neck/chest lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,21502,Drain chest lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,21510,Drainage of bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,21550,Biopsy of neck/chest,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,21552,Exc neck les sc 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,21554,Exc neck tum deep 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,21555,Exc neck les sc < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,21556,Exc neck tum deep < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,21557,Resect neck thorax tumor<5cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,21558,Resect neck tumor 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,21600,Partial removal of rib,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,21601,Exc chest wall tumor w/ribs,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,21602,Exc ch wal tum w/o lymphadec,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,21603,Exc ch wal tum w/lymphadec,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,21610,Partial removal of rib,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,21615,Removal of rib,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,21616,Removal of rib and nerves,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,21620,Partial removal of sternum,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,21627,Sternal debridement,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,21630,Extensive sternum surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,21632,Extensive sternum surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,21685,Hyoid myotomy & suspension,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,21700,Revision of neck muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,21705,Revision of neck muscle/rib,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,21720,Revision of neck muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,21725,Revision of neck muscle,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,21740,Reconstruction of sternum,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,21742,Repair stern/nuss w/o scope,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,21743,Repair sternum/nuss w/scope,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,21750,Repair of sternum separation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,21811,Optx of rib fx w/fixj scope,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,21812,Treatment of rib fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,21813,Treatment of rib fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,21820,Treat sternum fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,21825,Treat sternum fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,21899,Neck/chest surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Molina Duals,CPT,21920,Biopsy soft tissue of back,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,21925,Biopsy soft tissue of back,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,21930,Exc back les sc < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,21931,Exc back les sc 3 cm/>,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,21932,Exc back tum deep < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,21933,Exc back tum deep 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,21935,Resect back tum < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,21936,Resect back tum 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,22010,I&d p-spine c/t/cerv-thor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,22015,I&d abscess p-spine l/s/ls,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,22100,Remove part of neck vertebra,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,22101,Remove part thorax vertebra,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,22102,Remove part lumbar vertebra,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,22110,Remove part of neck vertebra,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,22112,Remove part thorax vertebra,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,22114,Remove part lumbar vertebra,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,22206,Incis spine 3 column thorac,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,22207,Incis spine 3 column lumbar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,22210,Incis 1 vertebral seg cerv,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,22212,Incis 1 vertebral seg thorac,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,22214,Incis 1 vertebral seg lumbar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,22220,Incis w/discectomy cervical,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,22222,Incis w/discectomy thoracic,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,22224,Incis w/discectomy lumbar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,22310,Closed tx vert fx w/o manj,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,22315,Closed tx vert fx w/manj,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,22318,Treat odontoid fx w/o graft,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,22319,Treat odontoid fx w/graft,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,22325,Treat spine fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,22326,Treat neck spine fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,22327,Treat thorax spine fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,22505,Manipulation of spine,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,22510,Perq cervicothoracic inject,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","15,496.26",,,,,,
Molina Duals,CPT,22511,Perq lumbosacral injection,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","9,201.00",,,,,,
Molina Duals,CPT,22513,Perq vertebral augmentation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,22514,Perq vertebral augmentation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,22532,Lat thorax spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,22533,Lat lumbar spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,22548,Neck spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,22551,Neck spine fuse&remov bel c2,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Molina Duals,CPT,22554,Neck spine fusion,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,22556,Thorax spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,22558,Lumbar spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,22586,Prescrl fuse w/ instr l5-s1,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,22590,Spine & skull spinal fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,22595,Neck spinal fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,22600,Neck spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,22610,Thorax spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,22612,Lumbar spine fusion,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,22630,Lumbar spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,22633,Lumbar spine fusion combined,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,22800,Post fusion </6 vert seg,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,22802,Post fusion 7-12 vert seg,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,22804,Post fusion 13/> vert seg,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,22808,Ant fusion 2-3 vert seg,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,22810,Ant fusion 4-7 vert seg,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,22812,Ant fusion 8/> vert seg,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,22818,Kyphectomy 1-2 segments,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,22819,Kyphectomy 3 or more,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,22830,Exploration of spinal fusion,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,22849,Reinsert spinal fixation,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,22850,Remove spine fixation device,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,22852,Remove spine fixation device,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,22855,Remove spine fixation device,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,22856,Cerv artific diskectomy,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,140.35","16,238.16",,,,,,
Molina Duals,CPT,22857,Lumbar artif diskectomy,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,22861,Revise cerv artific disc,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,22862,Revise lumbar artif disc,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,22864,Remove cerv artif disc,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,22865,Remove lumb artif disc,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,22867,Insj stablj dev w/dcmprn,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,22869,Insj stablj dev w/o dcmprn,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,22899,Spine surgery procedure,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,22900,Exc abdl tum deep < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,22901,Exc abdl tum deep 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,22902,Exc abd les sc < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,22903,Exc abd les sc 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,22904,Radical resect abd tumor<5cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,22905,Rad resect abd tumor 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,22999,Abdomen surgery procedure,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,23000,Removal of calcium deposits,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,23020,Release shoulder joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,23030,Drain shoulder lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,23031,Drain shoulder bursa,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,23035,Drain shoulder bone lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,23040,Exploratory shoulder surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,23044,Exploratory shoulder surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,23065,Biopsy shoulder tissues,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,23066,Biopsy shoulder tissues,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,23071,Exc shoulder les sc 3 cm/>,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,23073,Exc shoulder tum deep 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,23075,Exc shoulder les sc < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,23076,Exc shoulder tum deep < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,23077,Resect shoulder tumor < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,23078,Resect shoulder tumor 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,23100,Biopsy of shoulder joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,23101,Shoulder joint surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,23105,Remove shoulder joint lining,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,23106,Incision of collarbone joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,23107,Explore treat shoulder joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,23120,Partial removal collar bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,23125,Removal of collar bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,23130,Remove shoulder bone part,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,23140,Removal of bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,23145,Removal of bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,23146,Removal of bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,23150,Removal of humerus lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,23155,Removal of humerus lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,23156,Removal of humerus lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,23170,Remove collar bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,23172,Remove shoulder blade lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,23174,Remove humerus lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,23180,Remove collar bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,23182,Remove shoulder blade lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,23184,Remove humerus lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,23190,Partial removal of scapula,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,23195,Removal of head of humerus,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,23200,Resect clavicle tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,23210,Resect scapula tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,23220,Resect prox humerus tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,23330,Remove shoulder foreign body,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,23333,Remove shoulder fb deep,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,23334,Shoulder prosthesis removal,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,23335,Shoulder prosthesis removal,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,23395,Muscle transfer shoulder/arm,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,23397,Muscle transfers,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,23400,Fixation of shoulder blade,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,23405,Incision of tendon & muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,23406,Incise tendon(s) & muscle(s),APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,23410,Repair rotator cuff acute,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,23412,Repair rotator cuff chronic,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,23415,Release of shoulder ligament,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,23420,Repair of shoulder,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,23430,Repair biceps tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,23440,Remove/transplant tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,23450,Repair shoulder capsule,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,23455,Repair shoulder capsule,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,23460,Repair shoulder capsule,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,23462,Repair shoulder capsule,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,23465,Repair shoulder capsule,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,23466,Repair shoulder capsule,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,23470,Reconstruct shoulder joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,23472,Reconstruct shoulder joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,23473,Revis reconst shoulder joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,23474,Revis reconst shoulder joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,23480,Revision of collar bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,23485,Revision of collar bone,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,23490,Reinforce clavicle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,23491,Reinforce shoulder bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,23500,Treat clavicle fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,23505,Treat clavicle fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,23515,Treat clavicle fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,23520,Treat clavicle dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,23525,Treat clavicle dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,23530,Treat clavicle dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,23532,Treat clavicle dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,23540,Treat clavicle dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,23545,Treat clavicle dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,23550,Treat clavicle dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,23552,Treat clavicle dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,23570,Treat shoulder blade fx,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,23575,Treat shoulder blade fx,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,23585,Treat scapula fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,23600,Treat humerus fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,23605,Treat humerus fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,23615,Treat humerus fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Molina Duals,CPT,23616,Treat humerus fracture,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,23620,Treat humerus fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,23625,Treat humerus fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,23630,Treat humerus fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,23650,Treat shoulder dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,23655,Treat shoulder dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,23660,Treat shoulder dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,23665,Treat dislocation/fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,23670,Treat dislocation/fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,23675,Treat dislocation/fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,23680,Treat dislocation/fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,23700,Fixation of shoulder,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,23800,Fusion of shoulder joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,23802,Fusion of shoulder joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,23900,Amputation of arm & girdle,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,23920,Amputation at shoulder joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,23921,Amputation follow-up surgery,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,23929,Shoulder surgery procedure,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,23930,Drainage of arm lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,23931,Drainage of arm bursa,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,23935,Drain arm/elbow bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,24000,Exploratory elbow surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,24006,Release elbow joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,24065,Biopsy arm/elbow soft tissue,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,24066,Biopsy arm/elbow soft tissue,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,24071,Exc arm/elbow les sc 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,24073,Ex arm/elbow tum deep 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,24075,Exc arm/elbow les sc < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,24076,Ex arm/elbow tum deep < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,24077,Resect arm/elbow tum < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,24079,Resect arm/elbow tum 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,24100,Biopsy elbow joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,24101,Explore/treat elbow joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,24102,Remove elbow joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,24105,Removal of elbow bursa,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,24110,Remove humerus lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,24115,Remove/graft bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,24116,Remove/graft bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,24120,Remove elbow lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,24125,Remove/graft bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,24126,Remove/graft bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,24130,Removal of head of radius,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,24134,Removal of arm bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,24136,Remove radius bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,24138,Remove elbow bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,24140,Partial removal of arm bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,24145,Partial removal of radius,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,24147,Partial removal of elbow,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,24149,Radical resection of elbow,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,24150,Resect distal humerus tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,24152,Resect radius tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,24155,Removal of elbow joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,24160,Remove elbow joint implant,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,24164,Remove radius head implant,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,24200,Removal of arm foreign body,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,24201,Removal of arm foreign body,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,24300,Manipulate elbow w/anesth,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,24301,Muscle/tendon transfer,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,24305,Arm tendon lengthening,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,24310,Revision of arm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,24320,Repair of arm tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,24330,Revision of arm muscles,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,24331,Revision of arm muscles,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,24332,Tenolysis triceps,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,24340,Repair of biceps tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,24341,Repair arm tendon/muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,24342,Repair of ruptured tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,24343,Repr elbow lat ligmnt w/tiss,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,24344,Reconstruct elbow lat ligmnt,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,24345,Repr elbw med ligmnt w/tissu,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,24346,Reconstruct elbow med ligmnt,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,24357,Repair elbow perc,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,24358,Repair elbow w/deb open,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,24359,Repair elbow deb/attch open,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,24360,Reconstruct elbow joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,24361,Reconstruct elbow joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,24362,Reconstruct elbow joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,24363,Replace elbow joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,24365,Reconstruct head of radius,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,24366,Reconstruct head of radius,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,24370,Revise reconst elbow joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,24371,Revise reconst elbow joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,24400,Revision of humerus,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,24410,Revision of humerus,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,24420,Revision of humerus,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,24430,Repair of humerus,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,24435,Repair humerus with graft,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,24470,Revision of elbow joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,24495,Decompression of forearm,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,24498,Reinforce humerus,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,24500,Treat humerus fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,24505,Treat humerus fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,24515,Treat humerus fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Molina Duals,CPT,24516,Treat humerus fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,24530,Treat humerus fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,24535,Treat humerus fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,24538,Treat humerus fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,24545,Treat humerus fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Molina Duals,CPT,24546,Treat humerus fracture,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,24560,Treat humerus fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,24565,Treat humerus fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,24566,Treat humerus fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,24575,Treat humerus fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,24576,Treat humerus fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,24577,Treat humerus fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,24579,Treat humerus fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,24582,Treat humerus fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,24586,Treat elbow fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,24587,Treat elbow fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,24600,Treat elbow dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,24605,Treat elbow dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,24615,Treat elbow dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,24620,Treat elbow fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,24635,Treat elbow fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,24640,Treat elbow dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,24650,Treat radius fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,24655,Treat radius fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,24665,Treat radius fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,24666,Treat radius fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Molina Duals,CPT,24670,Treat ulnar fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,24675,Treat ulnar fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,24685,Treat ulnar fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,24800,Fusion of elbow joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,24802,Fusion/graft of elbow joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,24900,Amputation of upper arm,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,24920,Amputation of upper arm,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,24925,Amputation follow-up surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,24930,Amputation follow-up surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,24931,Amputate upper arm & implant,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,24935,Revision of amputation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,24940,Revision of upper arm,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,24999,Upper arm/elbow surgery,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,25000,Incision of tendon sheath,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,25001,Incise flexor carpi radialis,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25020,Decompress forearm 1 space,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,25023,Decompress forearm 1 space,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25024,Decompress forearm 2 spaces,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25025,Decompress forearm 2 spaces,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,25028,Drainage of forearm lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25031,Drainage of forearm bursa,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,25035,Treat forearm bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,25040,Explore/treat wrist joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25065,Biopsy forearm soft tissues,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,25066,Biopsy forearm soft tissues,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,25071,Exc forearm les sc 3 cm/>,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,25073,Exc forearm tum deep 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,25075,Exc forearm les sc < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,25076,Exc forearm tum deep < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,25077,Resect forearm/wrist tum<3cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,25078,Resect forarm/wrist tum 3cm>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,25085,Incision of wrist capsule,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25100,Biopsy of wrist joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25101,Explore/treat wrist joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25105,Remove wrist joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25107,Remove wrist joint cartilage,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25109,Excise tendon forearm/wrist,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25110,Remove wrist tendon lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,25111,Remove wrist tendon lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,25112,Reremove wrist tendon lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,25115,Remove wrist/forearm lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,25116,Remove wrist/forearm lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25118,Excise wrist tendon sheath,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,25119,Partial removal of ulna,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25120,Removal of forearm lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25125,Remove/graft forearm lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,25126,Remove/graft forearm lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25130,Removal of wrist lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25135,Remove & graft wrist lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,25136,Remove & graft wrist lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,25145,Remove forearm bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25150,Partial removal of ulna,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25151,Partial removal of radius,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","9,201.00",,,,,,
Molina Duals,CPT,25170,Resect radius/ulnar tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,25210,Removal of wrist bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25215,Removal of wrist bones,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25230,Partial removal of radius,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25240,Partial removal of ulna,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25248,Remove forearm foreign body,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,25250,Removal of wrist prosthesis,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,25251,Removal of wrist prosthesis,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25259,Manipulate wrist w/anesthes,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,25260,Repair forearm tendon/muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25263,Repair forearm tendon/muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,25265,Repair forearm tendon/muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25270,Repair forearm tendon/muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25272,Repair forearm tendon/muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25274,Repair forearm tendon/muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25275,Repair forearm tendon sheath,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25280,Revise wrist/forearm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25290,Incise wrist/forearm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25295,Release wrist/forearm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25300,Fusion of tendons at wrist,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25301,Fusion of tendons at wrist,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25310,Transplant forearm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25312,Transplant forearm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25315,Revise palsy hand tendon(s),APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,25316,Revise palsy hand tendon(s),APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,25320,Repair/revise wrist joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,25332,Revise wrist joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25335,Realignment of hand,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25337,Reconstruct ulna/radioulnar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,25350,Revision of radius,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,25355,Revision of radius,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25360,Revision of ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,25365,Revise radius & ulna,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,25370,Revise radius or ulna,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25375,Revise radius & ulna,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25390,Shorten radius or ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,25391,Lengthen radius or ulna,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,25392,Shorten radius & ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,25393,Lengthen radius & ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,25394,Repair carpal bone shorten,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25400,Repair radius or ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,25405,Repair/graft radius or ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,25415,Repair radius & ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,25420,Repair/graft radius & ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,25425,Repair/graft radius or ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,25426,Repair/graft radius & ulna,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25430,Vasc graft into carpal bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25431,Repair nonunion carpal bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,25440,Repair/graft wrist bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,25441,Reconstruct wrist joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,25442,Reconstruct wrist joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,25443,Reconstruct wrist joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,25444,Reconstruct wrist joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,25445,Reconstruct wrist joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,25446,Wrist replacement,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,25447,Repair wrist joints,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25449,Remove wrist joint implant,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,25450,Revision of wrist joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25455,Revision of wrist joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25490,Reinforce radius,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,25491,Reinforce ulna,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,25492,Reinforce radius and ulna,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25500,Treat fracture of radius,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,25505,Treat fracture of radius,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,25515,Treat fracture of radius,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,25520,Treat fracture of radius,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,25525,Treat fracture of radius,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,25526,Treat fracture of radius,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,25530,Treat fracture of ulna,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,25535,Treat fracture of ulna,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,25545,Treat fracture of ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,25560,Treat fracture radius & ulna,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,25565,Treat fracture radius & ulna,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,25574,Treat fracture radius & ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,25575,Treat fracture radius/ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,25600,Treat fracture radius/ulna,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,25605,Treat fracture radius/ulna,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,25606,Treat fx distal radial,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25607,Treat fx rad extra-articul,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,25608,Treat fx rad intra-articul,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,25609,Treat fx radial 3+ frag,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,25622,Treat wrist bone fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,25624,Treat wrist bone fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,25628,Treat wrist bone fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,25630,Treat wrist bone fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,25635,Treat wrist bone fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,25645,Treat wrist bone fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25650,Treat wrist bone fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,25651,Pin ulnar styloid fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25652,Treat fracture ulnar styloid,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,25660,Treat wrist dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,25670,Treat wrist dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,25671,Pin radioulnar dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25675,Treat wrist dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,25676,Treat wrist dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,25680,Treat wrist fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,25685,Treat wrist fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,25690,Treat wrist dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,25695,Treat wrist dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,25800,Fusion of wrist joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,25805,Fusion/graft of wrist joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,25810,Fusion/graft of wrist joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,25820,Fusion of hand bones,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,25825,Fuse hand bones with graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,25830,Fusion radioulnar jnt/ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,25900,Amputation of forearm,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,25905,Amputation of forearm,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,25907,Amputation follow-up surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25909,Amputation follow-up surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,25915,Amputation of forearm,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,25920,Amputate hand at wrist,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,25922,Amputate hand at wrist,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,25924,Amputation follow-up surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,25927,Amputation of hand,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25929,Amputation follow-up surgery,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,25931,Amputation follow-up surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,25999,Forearm or wrist surgery,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,26010,Drainage of finger abscess,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,26011,Drainage of finger abscess,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,26020,Drain hand tendon sheath,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26025,Drainage of palm bursa,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26030,Drainage of palm bursas,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26034,Treat hand bone lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,26035,Decompress fingers/hand,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26037,Decompress fingers/hand,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26040,Release palm contracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,26045,Release palm contracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26055,Incise finger tendon sheath,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,26060,Incision of finger tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,26070,Explore/treat hand joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,26075,Explore/treat finger joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26080,Explore/treat finger joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,26100,Biopsy hand joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26105,Biopsy finger joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26110,Biopsy finger joint lining,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,26111,Exc hand les sc 1.5 cm/>,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,26113,Exc hand tum deep 1.5 cm/>,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,26115,Exc hand les sc < 1.5 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,26116,Exc hand tum deep < 1.5 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,26117,Rad resect hand tumor < 3 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,26118,Rad resect hand tumor 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,26121,Release palm contracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26123,Release palm contracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26130,Remove wrist joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26135,Revise finger joint each,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26140,Revise finger joint each,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,26145,Tendon excision palm/finger,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,26160,Remove tendon sheath lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,26170,Removal of palm tendon each,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,26180,Removal of finger tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,26185,Remove finger bone,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,26200,Remove hand bone lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,26205,Remove/graft bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,26210,Removal of finger lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,26215,Remove/graft finger lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26230,Partial removal of hand bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26235,Partial removal finger bone,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,26236,Partial removal finger bone,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,26250,Extensive hand surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26260,Resect prox finger tumor,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26262,Resect distal finger tumor,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,26320,Removal of implant from hand,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,26340,Manipulate finger w/anesth,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,26341,Manipulat palm cord post inj,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,26350,Repair finger/hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26352,Repair/graft hand tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,26356,Repair finger/hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26357,Repair finger/hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26358,Repair/graft hand tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,26370,Repair finger/hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","9,201.00",,,,,,
Molina Duals,CPT,26372,Repair/graft hand tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,26373,Repair finger/hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26390,Revise hand/finger tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,26392,Repair/graft hand tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,26410,Repair hand tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,26412,Repair/graft hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26415,Excision hand/finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26416,Graft hand or finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26418,Repair finger tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,26420,Repair/graft finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26426,Repair finger/hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26428,Repair/graft finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26432,Repair finger tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,26433,Repair finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26434,Repair/graft finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26437,Realignment of tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26440,Release palm/finger tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,26442,Release palm & finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26445,Release hand/finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26449,Release forearm/hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26450,Incision of palm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26455,Incision of finger tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,26460,Incise hand/finger tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,26471,Fusion of finger tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26474,Fusion of finger tendons,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,26476,Tendon lengthening,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26477,Tendon shortening,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26478,Lengthening of hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26479,Shortening of hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26480,Transplant hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26483,Transplant/graft hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26485,Transplant palm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26489,Transplant/graft palm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26490,Revise thumb tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26492,Tendon transfer with graft,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26494,Hand tendon/muscle transfer,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26496,Revise thumb tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26497,Finger tendon transfer,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26498,Finger tendon transfer,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26499,Revision of finger,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26500,Hand tendon reconstruction,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,26502,Hand tendon reconstruction,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26508,Release thumb contracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26510,Thumb tendon transfer,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26516,Fusion of knuckle joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26517,Fusion of knuckle joints,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26518,Fusion of knuckle joints,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,26520,Release knuckle contracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26525,Release finger contracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,26530,Revise knuckle joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,26531,Revise knuckle with implant,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,26535,Revise finger joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26536,Revise/implant finger joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,26540,Repair hand joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26541,Repair hand joint with graft,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26542,Repair hand joint with graft,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26545,Reconstruct finger joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26546,Repair nonunion hand,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,26548,Reconstruct finger joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26550,Construct thumb replacement,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26551,Great toe-hand transfer,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,26553,Single transfer toe-hand,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,26554,Double transfer toe-hand,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,26555,Positional change of finger,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,26556,Toe joint transfer,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,26560,Repair of web finger,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,26561,Repair of web finger,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26562,Repair of web finger,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26565,Correct metacarpal flaw,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26567,Correct finger deformity,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26568,Lengthen metacarpal/finger,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,26580,Repair hand deformity,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26587,Reconstruct extra finger,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26590,Repair finger deformity,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,26591,Repair muscles of hand,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26593,Release muscles of hand,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26596,Excision constricting tissue,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26600,Treat metacarpal fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,26605,Treat metacarpal fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,26607,Treat metacarpal fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26608,Treat metacarpal fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26615,Treat metacarpal fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26641,Treat thumb dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,26645,Treat thumb fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,26650,Treat thumb fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26665,Treat thumb fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26670,Treat hand dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,26675,Treat hand dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,26676,Pin hand dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26685,Treat hand dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26686,Treat hand dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26700,Treat knuckle dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,26705,Treat knuckle dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,26706,Pin knuckle dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26715,Treat knuckle dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26720,Treat finger fracture each,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,26725,Treat finger fracture each,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,26727,Treat finger fracture each,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26735,Treat finger fracture each,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26740,Treat finger fracture each,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,26742,Treat finger fracture each,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,26746,Treat finger fracture each,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26750,Treat finger fracture each,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,26755,Treat finger fracture each,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,26756,Pin finger fracture each,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26765,Treat finger fracture each,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26770,Treat finger dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,26775,Treat finger dislocation,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Molina Duals,CPT,26776,Pin finger dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26785,Treat finger dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26820,Thumb fusion with graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,26841,Fusion of thumb,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,26842,Thumb fusion with graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,26843,Fusion of hand joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,26844,Fusion/graft of hand joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,26850,Fusion of knuckle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,26852,Fusion of knuckle with graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,26860,Fusion of finger joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26862,Fusion/graft of finger joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26910,Amputate metacarpal bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26951,Amputation of finger/thumb,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26952,Amputation of finger/thumb,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26989,Hand/finger surgery,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,26990,Drainage of pelvis lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,26991,Drainage of pelvis bursa,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,26992,Drainage of bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27000,Incision of hip tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,27001,Incision of hip tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27003,Incision of hip tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27005,Incision of hip tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27006,Incision of hip tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27025,Incision of hip/thigh fascia,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27027,Buttock fasciotomy,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27030,Drainage of hip joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27033,Exploration of hip joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27035,Denervation of hip joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27036,Excision of hip joint/muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27040,Biopsy of soft tissues,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,27041,Biopsy of soft tissues,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,27043,Exc hip pelvis les sc 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,27045,Exc hip/pelv tum deep 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,27047,Exc hip/pelvis les sc < 3 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,27048,Exc hip/pelv tum deep < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,27049,Resect hip/pelv tum < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,27050,Biopsy of sacroiliac joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,27052,Biopsy of hip joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,27054,Removal of hip joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27057,Buttock fasciotomy w/dbrdmt,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,27059,Resect hip/pelv tum 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,27060,Removal of ischial bursa,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27062,Remove femur lesion/bursa,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27065,Remove hip bone les super,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27066,Remove hip bone les deep,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27067,Remove/graft hip bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27070,Part remove hip bone super,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27071,Part removal hip bone deep,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27075,Resect hip tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27076,Resect hip tum incl acetabul,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27077,Resect hip tum w/innom bone,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,27078,Rsect hip tum incl femur,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,27080,Removal of tail bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27086,Remove hip foreign body,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,27087,Remove hip foreign body,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27090,Removal of hip prosthesis,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,27091,Removal of hip prosthesis,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,27097,Revision of hip tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27098,Transfer tendon to pelvis,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27100,Transfer of abdominal muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27105,Transfer of spinal muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27110,Transfer of iliopsoas muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27111,Transfer of iliopsoas muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27120,Reconstruction of hip socket,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,27122,Reconstruction of hip socket,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,27125,Partial hip replacement,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,27130,Total hip arthroplasty,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,27132,Total hip arthroplasty,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,27134,Revise hip joint replacement,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,27137,Revise hip joint replacement,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,27138,Revise hip joint replacement,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,27140,Transplant femur ridge,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,27146,Incision of hip bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27147,Revision of hip bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27151,Incision of hip bones,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27156,Revision of hip bones,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27158,Revision of pelvis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27161,Incision of neck of femur,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27165,Incision/fixation of femur,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27170,Repair/graft femur head/neck,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27175,Treat slipped epiphysis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27176,Treat slipped epiphysis,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,27177,Treat slipped epiphysis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27178,Treat slipped epiphysis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27179,Revise head/neck of femur,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27181,Treat slipped epiphysis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27185,Revision of femur epiphysis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27187,Reinforce hip bones,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27197,Clsd tx pelvic ring fx,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,27198,Clsd tx pelvic ring fx,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,27200,Treat tail bone fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,27202,Treat tail bone fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27220,Treat hip socket fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,27222,Treat hip socket fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,27226,Treat hip wall fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27227,Treat hip fracture(s),APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27228,Treat hip fracture(s),APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27230,Treat thigh fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,27232,Treat thigh fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,27235,Treat thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27236,Treat thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27238,Treat thigh fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,27240,Treat thigh fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,27244,Treat thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27245,Treat thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27246,Treat thigh fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,27248,Treat thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27250,Treat hip dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,27252,Treat hip dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,27253,Treat hip dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27254,Treat hip dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27256,Treat hip dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,27257,Treat hip dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,27258,Treat hip dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27259,Treat hip dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27265,Treat hip dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,27266,Treat hip dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,27267,Cltx thigh fx,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27268,Cltx thigh fx w/mnpj,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27269,Optx thigh fx,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,27275,Manipulation of hip joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,27279,Arthrodesis sacroiliac joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,27280,Fusion of sacroiliac joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,27282,Fusion of pubic bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,27284,Fusion of hip joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,27286,Fusion of hip joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,27290,Amputation of leg at hip,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,27295,Amputation of leg at hip,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,27299,Pelvis/hip joint surgery,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,27301,Drain thigh/knee lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,27303,Drainage of bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27305,Incise thigh tendon & fascia,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27306,Incision of thigh tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27307,Incision of thigh tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27310,Exploration of knee joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27323,Biopsy thigh soft tissues,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,27324,Biopsy thigh soft tissues,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,27325,Neurectomy hamstring,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,27326,Neurectomy popliteal,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,27327,Exc thigh/knee les sc < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,27328,Exc thigh/knee tum deep <5cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,27329,Resect thigh/knee tum < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,27330,Biopsy knee joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27331,Explore/treat knee joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27332,Removal of knee cartilage,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27333,Removal of knee cartilage,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27334,Remove knee joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27335,Remove knee joint lining,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27337,Exc thigh/knee les sc 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,27339,Exc thigh/knee tum dep 5cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,27340,Removal of kneecap bursa,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27345,Removal of knee cyst,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27347,Remove knee cyst,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27350,Removal of kneecap,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27355,Remove femur lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27356,Remove femur lesion/graft,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,27357,Remove femur lesion/graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27360,Partial removal leg bone(s),APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27364,Resect thigh/knee tum 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,27365,Resect femur/knee tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27372,Removal of foreign body,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,27380,Repair of kneecap tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27381,Repair/graft kneecap tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27385,Repair of thigh muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27386,Repair/graft of thigh muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27390,Incision of thigh tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27391,Incision of thigh tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27392,Incision of thigh tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27393,Lengthening of thigh tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27394,Lengthening of thigh tendons,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27395,Lengthening of thigh tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27396,Transplant of thigh tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27397,Transplants of thigh tendons,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27400,Revise thigh muscles/tendons,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27403,Repair of knee cartilage,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27405,Repair of knee ligament,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,27407,Repair of knee ligament,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,27409,Repair of knee ligaments,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,27412,Autochondrocyte implant knee,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27415,Osteochondral knee allograft,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,27416,Osteochondral knee autograft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27418,Repair degenerated kneecap,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27420,Revision of unstable kneecap,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27422,Revision of unstable kneecap,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27424,Revision/removal of kneecap,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27425,Lat retinacular release open,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27427,Reconstruction knee,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,27428,Reconstruction knee,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Molina Duals,CPT,27429,Reconstruction knee,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Molina Duals,CPT,27430,Revision of thigh muscles,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27435,Incision of knee joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27437,Revise kneecap,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27438,Revise kneecap with implant,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,27440,Revision of knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,27441,Revision of knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,27442,Revision of knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,27443,Revision of knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,27445,Revision of knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,27446,Revision of knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Molina Duals,CPT,27447,Total knee arthroplasty,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,27448,Incision of thigh,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27450,Incision of thigh,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27454,Realignment of thigh bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27455,Realignment of knee,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27457,Realignment of knee,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27465,Shortening of thigh bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27466,Lengthening of thigh bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27468,Shorten/lengthen thighs,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27470,Repair of thigh,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27472,Repair/graft of thigh,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27475,Surgery to stop leg growth,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27477,Surgery to stop leg growth,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27479,Surgery to stop leg growth,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27485,Surgery to stop leg growth,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27486,Revise/replace knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,27487,Revise/replace knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,27488,Removal of knee prosthesis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27495,Reinforce thigh,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27496,Decompression of thigh/knee,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27497,Decompression of thigh/knee,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27498,Decompression of thigh/knee,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,27499,Decompression of thigh/knee,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27500,Treatment of thigh fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,27501,Treatment of thigh fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,27502,Treatment of thigh fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,27503,Treatment of thigh fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,27506,Treatment of thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27507,Treatment of thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27508,Treatment of thigh fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,27509,Treatment of thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27510,Treatment of thigh fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,27511,Treatment of thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27513,Treatment of thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27514,Treatment of thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27516,Treat thigh fx growth plate,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,27517,Treat thigh fx growth plate,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,27519,Treat thigh fx growth plate,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27520,Treat kneecap fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,27524,Treat kneecap fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27530,Treat knee fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,27532,Treat knee fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27535,Treat knee fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27536,Treat knee fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27538,Treat knee fracture(s),APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,27540,Treat knee fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27550,Treat knee dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,27552,Treat knee dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,27556,Treat knee dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27557,Treat knee dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27558,Treat knee dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27560,Treat kneecap dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,27562,Treat kneecap dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,27566,Treat kneecap dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27570,Fixation of knee joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,27580,Fusion of knee,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,27590,Amputate leg at thigh,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,27591,Amputate leg at thigh,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,27592,Amputate leg at thigh,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,27594,Amputation follow-up surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27596,Amputation follow-up surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27598,Amputate lower leg at knee,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,27599,Leg surgery procedure,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,27600,Decompression of lower leg,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27601,Decompression of lower leg,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27602,Decompression of lower leg,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27603,Drain lower leg lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,27604,Drain lower leg bursa,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27605,Incision of achilles tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,27606,Incision of achilles tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27607,Treat lower leg bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27610,Explore/treat ankle joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27612,Exploration of ankle joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27613,Biopsy lower leg soft tissue,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,27614,Biopsy lower leg soft tissue,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,27615,Resect leg/ankle tum < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,27616,Resect leg/ankle tum 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,27618,Exc leg/ankle tum < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,27619,Exc leg/ankle tum deep <5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,27620,Explore/treat ankle joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27625,Remove ankle joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27626,Remove ankle joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27630,Removal of tendon lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27632,Exc leg/ankle les sc 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,27634,Exc leg/ankle tum dep 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,27635,Remove lower leg bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27637,Remove/graft leg bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27638,Remove/graft leg bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27640,Partial removal of tibia,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27641,Partial removal of fibula,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27645,Resect tibia tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27646,Resect fibula tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27647,Resect talus/calcaneus tum,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27650,Repair achilles tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27652,Repair/graft achilles tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,27654,Repair of achilles tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,27656,Repair leg fascia defect,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27658,Repair of leg tendon each,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27659,Repair of leg tendon each,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27664,Repair of leg tendon each,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27665,Repair of leg tendon each,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27675,Repair lower leg tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27676,Repair lower leg tendons,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27680,Release of lower leg tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27681,Release of lower leg tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27685,Revision of lower leg tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27686,Revise lower leg tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27687,Revision of calf tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27690,Revise lower leg tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27691,Revise lower leg tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,27695,Repair of ankle ligament,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27696,Repair of ankle ligaments,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27698,Repair of ankle ligament,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27700,Revision of ankle joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27702,Reconstruct ankle joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,27703,Reconstruction ankle joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,27704,Removal of ankle implant,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27705,Incision of tibia,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27707,Incision of fibula,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27709,Incision of tibia & fibula,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,27712,Realignment of lower leg,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,27715,Revision of lower leg,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,27720,Repair of tibia,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27722,Repair/graft of tibia,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27724,Repair/graft of tibia,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,27725,Repair of lower leg,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27726,Repair fibula nonunion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,27727,Repair of lower leg,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27730,Repair of tibia epiphysis,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27732,Repair of fibula epiphysis,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27734,Repair lower leg epiphyses,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27740,Repair of leg epiphyses,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27742,Repair of leg epiphyses,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27745,Reinforce tibia,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27750,Treatment of tibia fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,27752,Treatment of tibia fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,27756,Treatment of tibia fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27758,Treatment of tibia fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Molina Duals,CPT,27759,Treatment of tibia fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,27760,Cltx medial ankle fx,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,27762,Cltx med ankle fx w/mnpj,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,27766,Optx medial ankle fx,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27767,Cltx post ankle fx,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,27768,Cltx post ankle fx w/mnpj,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,27769,Optx post ankle fx,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27780,Treatment of fibula fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,27781,Treatment of fibula fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,27784,Treatment of fibula fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27786,Treatment of ankle fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,27788,Treatment of ankle fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,27792,Treatment of ankle fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27808,Treatment of ankle fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,27810,Treatment of ankle fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,27814,Treatment of ankle fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,27816,Treatment of ankle fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,27818,Treatment of ankle fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,27822,Treatment of ankle fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27823,Treatment of ankle fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27824,Treat lower leg fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,27825,Treat lower leg fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,27826,Treat lower leg fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27827,Treat lower leg fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,27828,Treat lower leg fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Molina Duals,CPT,27829,Treat lower leg joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27830,Treat lower leg dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,27831,Treat lower leg dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27832,Treat lower leg dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27840,Treat ankle dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,27842,Treat ankle dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,27846,Treat ankle dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27848,Treat ankle dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27860,Fixation of ankle joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27870,Fusion of ankle joint open,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Molina Duals,CPT,27871,Fusion of tibiofibular joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Molina Duals,CPT,27880,Amputation of lower leg,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,27881,Amputation of lower leg,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27882,Amputation of lower leg,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27884,Amputation follow-up surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27886,Amputation follow-up surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27888,Amputation of foot at ankle,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,27889,Amputation of foot at ankle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27892,Decompression of leg,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27893,Decompression of leg,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,27894,Decompression of leg,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,27899,Leg/ankle surgery procedure,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,28001,Drainage of bursa of foot,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,28002,Treatment of foot infection,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,28003,Treatment of foot infection,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28005,Treat foot bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28008,Incision of foot fascia,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28010,Incision of toe tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,28011,Incision of toe tendons,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,28020,Exploration of foot joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28022,Exploration of foot joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28024,Exploration of toe joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,28035,Decompression of tibia nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,28039,Exc foot/toe tum sc 1.5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,28041,Exc foot/toe tum dep 1.5cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,28043,Exc foot/toe tum sc < 1.5 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,28045,Exc foot/toe tum deep <1.5cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,28046,Resect foot/toe tumor < 3 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,28047,Resect foot/toe tumor 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,28050,Biopsy of foot joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28052,Biopsy of foot joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28054,Biopsy of toe joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28055,Neurectomy foot,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,28060,Partial removal foot fascia,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28062,Removal of foot fascia,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28070,Removal of foot joint lining,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,28072,Removal of foot joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28080,Removal of foot lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,28086,Excise foot tendon sheath,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28088,Excise foot tendon sheath,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28090,Removal of foot lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,28092,Removal of toe lesions,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,28100,Removal of ankle/heel lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28102,Remove/graft foot lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,28103,Remove/graft foot lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,28104,Removal of foot lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28106,Remove/graft foot lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,28107,Remove/graft foot lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,28108,Removal of toe lesions,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,28110,Part removal of metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28111,Part removal of metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28112,Part removal of metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28113,Part removal of metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28114,Removal of metatarsal heads,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28116,Revision of foot,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28118,Removal of heel bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28119,Removal of heel spur,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28120,Part removal of ankle/heel,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28122,Partial removal of foot bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28124,Partial removal of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28126,Partial removal of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28130,Removal of ankle bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,28140,Removal of metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28150,Removal of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28153,Partial removal of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28160,Partial removal of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28171,Resect tarsal tumor,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28173,Resect metatarsal tumor,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28175,Resect phalanx of toe tumor,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,28190,Removal of foot foreign body,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,28192,Removal of foot foreign body,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,28193,Removal of foot foreign body,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,28200,Repair of foot tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28202,Repair/graft of foot tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,28208,Repair of foot tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28210,Repair/graft of foot tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,28220,Release of foot tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,28222,Release of foot tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28225,Release of foot tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28226,Release of foot tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28230,Incision of foot tendon(s),APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,28232,Incision of toe tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,28234,Incision of foot tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,28238,Revision of foot tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,28240,Release of big toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28250,Revision of foot fascia,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28260,Release of midfoot joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28261,Revision of foot tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,28262,Revision of foot and ankle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,28264,Release of midfoot joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,28270,Release of foot contracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28272,Release of toe joint each,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,28280,Fusion of toes,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28285,Repair of hammertoe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28286,Repair of hammertoe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28288,Partial removal of foot bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28289,Corrj halux rigdus w/o implt,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28291,Corrj halux rigdus w/implt,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,28292,Correction hallux valgus,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28295,Correction hallux valgus,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28296,Correction hallux valgus,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28297,Correction hallux valgus,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,28298,Correction hallux valgus,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,28299,Correction hallux valgus,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,28300,Incision of heel bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,28302,Incision of ankle bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,28304,Incision of midfoot bones,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,28305,Incise/graft midfoot bones,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,28306,Incision of metatarsal,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,28307,Incision of metatarsal,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,28308,Incision of metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28309,Incision of metatarsals,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,28310,Revision of big toe,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,28312,Revision of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28313,Repair deformity of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28315,Removal of sesamoid bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28320,Repair of foot bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,28322,Repair of metatarsals,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,28340,Resect enlarged toe tissue,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28341,Resect enlarged toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28344,Repair extra toe(s),APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28345,Repair webbed toe(s),APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,28360,Reconstruct cleft foot,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,28400,Treatment of heel fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,28405,Treatment of heel fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,28406,Treatment of heel fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,28415,Treat heel fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,28420,Treat/graft heel fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,28430,Treatment of ankle fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,28435,Treatment of ankle fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,28436,Treatment of ankle fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,28445,Treat ankle fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,28446,Osteochondral talus autogrft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,28450,Treat midfoot fracture each,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,28455,Treat midfoot fracture each,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,28456,Treat midfoot fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,28465,Treat midfoot fracture each,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,28470,Treat metatarsal fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,28475,Treat metatarsal fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,28476,Treat metatarsal fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28485,Treat metatarsal fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,28490,Treat big toe fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,28495,Treat big toe fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,28496,Treat big toe fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28505,Treat big toe fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28510,Treatment of toe fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,28515,Treatment of toe fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,28525,Treat toe fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28530,Treat sesamoid bone fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,28531,Treat sesamoid bone fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,28540,Treat foot dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,28545,Treat foot dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28546,Treat foot dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,28555,Repair foot dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,28570,Treat foot dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,28575,Treat foot dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28576,Treat foot dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,28585,Repair foot dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,28600,Treat foot dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,28605,Treat foot dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,28606,Treat foot dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28615,Repair foot dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,28630,Treat toe dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,28635,Treat toe dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,28636,Treat toe dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28645,Repair toe dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28660,Treat toe dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,28665,Treat toe dislocation,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Molina Duals,CPT,28666,Treat toe dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28675,Repair of toe dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28705,Fusion of foot bones,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,28715,Fusion of foot bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Molina Duals,CPT,28725,Fusion of foot bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Molina Duals,CPT,28730,Fusion of foot bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Molina Duals,CPT,28735,Fusion of foot bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,28737,Revision of foot bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,28740,Fusion of foot bones,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,28750,Fusion of big toe joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,28755,Fusion of big toe joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,28760,Fusion of big toe joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,28800,Amputation of midfoot,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28805,Amputation thru metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28810,Amputation toe & metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28820,Amputation of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28825,Partial amputation of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,28890,Hi enrgy eswt plantar fascia,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,28899,Foot/toes surgery procedure,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,29000,Application of body cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Molina Duals,CPT,29010,Application of body cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Molina Duals,CPT,29015,Application of body cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Molina Duals,CPT,29035,Application of body cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Molina Duals,CPT,29040,Application of body cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Molina Duals,CPT,29044,Application of body cast,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Molina Duals,CPT,29046,Application of body cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Molina Duals,CPT,29049,Application of figure eight,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Molina Duals,CPT,29055,Application of shoulder cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Molina Duals,CPT,29058,Application of shoulder cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Molina Duals,CPT,29065,Application of long arm cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Molina Duals,CPT,29075,Application of forearm cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Molina Duals,CPT,29085,Apply hand/wrist cast,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Molina Duals,CPT,29086,Apply finger cast,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Molina Duals,CPT,29105,Apply long arm splint,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Molina Duals,CPT,29125,Apply forearm splint,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Molina Duals,CPT,29126,Apply forearm splint,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Molina Duals,CPT,29130,Application of finger splint,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Molina Duals,CPT,29131,Application of finger splint,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Molina Duals,CPT,29200,Strapping of chest,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Molina Duals,CPT,29240,Strapping of shoulder,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Molina Duals,CPT,29260,Strapping of elbow or wrist,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Molina Duals,CPT,29280,Strapping of hand or finger,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Molina Duals,CPT,29305,Application of hip cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Molina Duals,CPT,29325,Application of hip casts,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Molina Duals,CPT,29345,Application of long leg cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Molina Duals,CPT,29355,Application of long leg cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Molina Duals,CPT,29358,Apply long leg cast brace,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Molina Duals,CPT,29365,Application of long leg cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Molina Duals,CPT,29405,Apply short leg cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Molina Duals,CPT,29425,Apply short leg cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Molina Duals,CPT,29435,Apply short leg cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Molina Duals,CPT,29440,Addition of walker to cast,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Molina Duals,CPT,29445,Apply rigid leg cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Molina Duals,CPT,29450,Application of leg cast,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Molina Duals,CPT,29505,Application long leg splint,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Molina Duals,CPT,29515,Application lower leg splint,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Molina Duals,CPT,29520,Strapping of hip,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Molina Duals,CPT,29530,Strapping of knee,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Molina Duals,CPT,29540,Strapping of ankle and/or ft,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Molina Duals,CPT,29550,Strapping of toes,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Molina Duals,CPT,29580,Application of paste boot,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Molina Duals,CPT,29581,Apply multlay comprs lwr leg,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Molina Duals,CPT,29584,Appl multlay comprs arm/hand,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Molina Duals,CPT,29700,Removal/revision of cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Molina Duals,CPT,29705,Removal/revision of cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Molina Duals,CPT,29710,Removal/revision of cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Molina Duals,CPT,29720,Repair of body cast,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Molina Duals,CPT,29730,Windowing of cast,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Molina Duals,CPT,29740,Wedging of cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Molina Duals,CPT,29750,Wedging of clubfoot cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
Molina Duals,CPT,29799,Casting/strapping procedure,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
Molina Duals,CPT,29800,Jaw arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,29804,Jaw arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,29805,Sho arthrs dx +- synovial bx,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,29806,Sho arthrs srg capsulorpaphy,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,29807,Sho arthrs srg rpr slap les,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,29819,Sho arthrs srg rmvl loose/fb,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,29820,Sho arthrs srg prtl synvct,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,29821,Sho arthrs srg compl synvct,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,29822,Sho arthrs srg lmtd dbrdmt,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,29823,Sho arthrs srg xtnsv dbrdmt,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,29824,Sho arthrs srg dstl claviclc,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,29825,Sho arthrs srg lss&rescj ads,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,29827,Sho arthrs srg rt8tr cuf rpr,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,29828,Sho arthrs srg bicp tenodsis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,29830,Elbow arthroscopy,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,29834,Elbow arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,29835,Elbow arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,29836,Elbow arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,29837,Elbow arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,29838,Elbow arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,29840,Wrist arthroscopy,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,29843,Wrist arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,29844,Wrist arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,29845,Wrist arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,29846,Wrist arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,29847,Wrist arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,29848,Wrist endoscopy/surgery,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,29850,Knee arthroscopy/surgery,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,29851,Knee arthroscopy/surgery,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,29855,Tibial arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,29856,Tibial arthroscopy/surgery,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,29860,Hip arthroscopy dx,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,29861,Hip arthro w/fb removal,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,29862,Hip arthr0 w/debridement,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,29863,Hip arthr0 w/synovectomy,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,29866,Autgrft implnt knee w/scope,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,29867,Allgrft implnt knee w/scope,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,29868,Meniscal trnspl knee w/scpe,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,29870,Knee arthroscopy dx,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,29871,Knee arthroscopy/drainage,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,29873,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,29874,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,29875,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,29876,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,29877,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,29879,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,29880,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,29881,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,29882,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,29883,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,29884,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,29885,Knee arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,29886,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,29887,Knee arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,29888,Knee arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,29889,Knee arthroscopy/surgery,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
Molina Duals,CPT,29891,Ankle arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,29892,Ankle arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,29893,Scope plantar fasciotomy,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,29894,Ankle arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,29895,Ankle arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,29897,Ankle arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,29898,Ankle arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,29899,Ankle arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,29900,Mcp joint arthroscopy dx,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,29901,Mcp joint arthroscopy surg,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,29902,Mcp joint arthroscopy surg,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
Molina Duals,CPT,29904,Subtalar arthro w/fb rmvl,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,29905,Subtalar arthro w/exc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,29906,Subtalar arthro w/deb,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,29907,Subtalar arthro w/fusion,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,29914,Hip arthro w/femoroplasty,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,29915,Hip arthro acetabuloplasty,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,29916,Hip arthro w/labral repair,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,29999,Arthroscopy of joint,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
Molina Duals,CPT,30000,Drainage of nose lesion,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Molina Duals,CPT,30020,Drainage of nose lesion,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Molina Duals,CPT,30100,Intranasal biopsy,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,30110,Removal of nose polyp(s),APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,30115,Removal of nose polyp(s),APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,30117,Removal of intranasal lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,30118,Removal of intranasal lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,30120,Revision of nose,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,30124,Removal of nose lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,30125,Removal of nose lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,30130,Excise inferior turbinate,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,30140,Resect inferior turbinate,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,30150,Partial removal of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,30160,Removal of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,30200,Injection treatment of nose,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Molina Duals,CPT,30210,Nasal sinus therapy,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,30220,Insert nasal septal button,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,30300,Remove nasal foreign body,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Molina Duals,CPT,30310,Remove nasal foreign body,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,30320,Remove nasal foreign body,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,30400,Reconstruction of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,30410,Reconstruction of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,30420,Reconstruction of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,30430,Revision of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,30435,Revision of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,30450,Revision of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,30460,Revision of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,30462,Revision of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,30465,Repair nasal stenosis,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,30468,Rpr nsl vlv collapse w/implt,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,30520,Repair of nasal septum,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,30540,Repair nasal defect,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,30545,Repair nasal defect,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,30560,Release of nasal adhesions,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Molina Duals,CPT,30580,Repair upper jaw fistula,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,30600,Repair mouth/nose fistula,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,30620,Intranasal reconstruction,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,30630,Repair nasal septum defect,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,30801,Ablate inf turbinate superf,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,30802,Ablate inf turbinate submuc,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,30901,Control of nosebleed,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Molina Duals,CPT,30903,Control of nosebleed,APC 5734,RVU Per Unit,$114.56 ,OP,114.56,"4,314.00",,,,,,
Molina Duals,CPT,30905,Control of nosebleed,APC 5734,RVU Per Unit,$114.56 ,OP,114.56,"4,314.00",,,,,,
Molina Duals,CPT,30906,Repeat control of nosebleed,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Molina Duals,CPT,30915,Ligation nasal sinus artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,30920,Ligation upper jaw artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,30930,Ther fx nasal inf turbinate,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,30999,Nasal surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Molina Duals,CPT,31000,Irrigation maxillary sinus,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Molina Duals,CPT,31002,Irrigation sphenoid sinus,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,31020,Exploration maxillary sinus,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,31030,Exploration maxillary sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,31032,Explore sinus remove polyps,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,31040,Exploration behind upper jaw,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,31050,Exploration sphenoid sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,31051,Sphenoid sinus surgery,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,31070,Exploration of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,31075,Exploration of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,31080,Removal of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,31081,Removal of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,31084,Removal of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,31085,Removal of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,31086,Removal of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,31087,Removal of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,31090,Exploration of sinuses,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,31200,Removal of ethmoid sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,31201,Removal of ethmoid sinus,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,31205,Removal of ethmoid sinus,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,31225,Removal of upper jaw,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,31230,Removal of upper jaw,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,31231,Nasal endoscopy dx,APC 5151,RVU Per Unit,$168.23 ,OP,168.23,"4,314.00",,,,,,
Molina Duals,CPT,31233,Nsl/sins ndsc dx max sinusc,APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
Molina Duals,CPT,31235,Nsl/sins ndsc dx sphn sinusc,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Molina Duals,CPT,31237,Nasal/sinus endoscopy surg,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Molina Duals,CPT,31238,Nasal/sinus endoscopy surg,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Molina Duals,CPT,31239,Nasal/sinus endoscopy surg,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Molina Duals,CPT,31240,Nasal/sinus endoscopy surg,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Molina Duals,CPT,31241,Nsl/sins ndsc w/artery lig,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Molina Duals,CPT,31253,Nsl/sins ndsc total,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,31254,Nsl/sins ndsc w/prtl ethmdct,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Molina Duals,CPT,31255,Nsl/sins ndsc w/tot ethmdct,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,31256,Exploration maxillary sinus,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Molina Duals,CPT,31257,Nsl/sins ndsc tot w/sphendt,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,31259,Nsl/sins ndsc sphn tiss rmvl,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,31267,Endoscopy maxillary sinus,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Molina Duals,CPT,31276,Nsl/sins ndsc frnt tiss rmvl,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,31287,Nasal/sinus endoscopy surg,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,31288,Nasal/sinus endoscopy surg,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,31290,Nasal/sinus endoscopy surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,31291,Nasal/sinus endoscopy surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,31292,Nsl/sins ndsc med/inf dcmprn,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Molina Duals,CPT,31293,Nsl/sins ndsc med&inf dcmprn,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Molina Duals,CPT,31294,Nsl/sins ndsc surg on dcmprn,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Molina Duals,CPT,31295,Nsl/sins ndsc surg max sins,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Molina Duals,CPT,31296,Nsl/sins ndsc surg frnt sins,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,31297,Nsl/sins ndsc surg sphn sins,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Molina Duals,CPT,31298,Nsl/sins ndsc surg frnt&sphn,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,31299,Sinus surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Molina Duals,CPT,31300,Removal of larynx lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,31360,Removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,31365,Removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,31367,Partial removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,31368,Partial removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,31370,Partial removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,31375,Partial removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,31380,Partial removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,31382,Partial removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,31390,Removal of larynx & pharynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,31395,Reconstruct larynx & pharynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,31400,Revision of larynx,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,31420,Removal of epiglottis,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,31500,Insert emergency airway,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Molina Duals,CPT,31502,Change of windpipe airway,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Molina Duals,CPT,31505,Diagnostic laryngoscopy,APC 5151,RVU Per Unit,$168.23 ,OP,168.23,"4,314.00",,,,,,
Molina Duals,CPT,31510,Laryngoscopy with biopsy,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Molina Duals,CPT,31511,Remove foreign body larynx,APC 5151,RVU Per Unit,$168.23 ,OP,168.23,"4,314.00",,,,,,
Molina Duals,CPT,31512,Removal of larynx lesion,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Molina Duals,CPT,31513,Injection into vocal cord,APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
Molina Duals,CPT,31515,Laryngoscopy for aspiration,APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
Molina Duals,CPT,31520,Dx laryngoscopy newborn,APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
Molina Duals,CPT,31525,Dx laryngoscopy excl nb,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Molina Duals,CPT,31526,Dx laryngoscopy w/oper scope,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Molina Duals,CPT,31527,Laryngoscopy for treatment,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Molina Duals,CPT,31528,Laryngoscopy and dilation,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Molina Duals,CPT,31529,Laryngoscopy and dilation,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Molina Duals,CPT,31530,Laryngoscopy w/fb removal,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Molina Duals,CPT,31531,Laryngoscopy w/fb & op scope,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Molina Duals,CPT,31535,Laryngoscopy w/biopsy,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Molina Duals,CPT,31536,Laryngoscopy w/bx & op scope,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Molina Duals,CPT,31540,Laryngoscopy w/exc of tumor,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Molina Duals,CPT,31541,Larynscop w/tumr exc + scope,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Molina Duals,CPT,31545,Remove vc lesion w/scope,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Molina Duals,CPT,31546,Remove vc lesion scope/graft,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Molina Duals,CPT,31551,Laryngoplasty laryngeal sten,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,31552,Laryngoplasty laryngeal sten,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,31553,Laryngoplasty laryngeal sten,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,31554,Laryngoplasty laryngeal sten,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,31560,Laryngoscop w/arytenoidectom,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Molina Duals,CPT,31561,Larynscop remve cart + scop,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Molina Duals,CPT,31570,Laryngoscope w/vc inj,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Molina Duals,CPT,31571,Laryngoscop w/vc inj + scope,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Molina Duals,CPT,31572,Largsc w/laser dstrj les,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Molina Duals,CPT,31573,Largsc w/ther injection,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Molina Duals,CPT,31574,Largsc w/njx augmentation,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Molina Duals,CPT,31575,Diagnostic laryngoscopy,APC 5151,RVU Per Unit,$168.23 ,OP,168.23,"4,314.00",,,,,,
Molina Duals,CPT,31576,Laryngoscopy with biopsy,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Molina Duals,CPT,31577,Largsc w/rmvl foreign bdy(s),APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
Molina Duals,CPT,31578,Largsc w/removal lesion,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Molina Duals,CPT,31579,Laryngoscopy telescopic,APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
Molina Duals,CPT,31580,Laryngoplasty laryngeal web,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,31584,Laryngoplasty fx rdctj fixj,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,31587,Laryngoplasty cricoid split,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,31590,Reinnervate larynx,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,31591,Laryngoplasty medialization,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,31592,Cricotracheal resection,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,31599,Larynx surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Molina Duals,CPT,31600,Incision of windpipe,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,31601,Incision of windpipe,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,31603,Incision of windpipe,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,31605,Incision of windpipe,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Molina Duals,CPT,31610,Incision of windpipe,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,31611,Surgery/speech prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,31612,Puncture/clear windpipe,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,31613,Repair windpipe opening,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,31614,Repair windpipe opening,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,31615,Visualization of windpipe,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Molina Duals,CPT,31622,Dx bronchoscope/wash,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Molina Duals,CPT,31623,Dx bronchoscope/brush,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Molina Duals,CPT,31624,Dx bronchoscope/lavage,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Molina Duals,CPT,31625,Bronchoscopy w/biopsy(s),APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Molina Duals,CPT,31626,Bronchoscopy w/markers,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Molina Duals,CPT,31628,Bronchoscopy/lung bx each,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Molina Duals,CPT,31629,Bronchoscopy/needle bx each,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Molina Duals,CPT,31630,Bronchoscopy dilate/fx repr,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Molina Duals,CPT,31631,Bronchoscopy dilate w/stent,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Molina Duals,CPT,31634,Bronch w/balloon occlusion,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Molina Duals,CPT,31635,Bronchoscopy w/fb removal,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Molina Duals,CPT,31636,Bronchoscopy bronch stents,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Molina Duals,CPT,31638,Bronchoscopy revise stent,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Molina Duals,CPT,31640,Bronchoscopy w/tumor excise,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Molina Duals,CPT,31641,Bronchoscopy treat blockage,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Molina Duals,CPT,31643,Diag bronchoscope/catheter,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Molina Duals,CPT,31645,Brnchsc w/ther aspir 1st,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Molina Duals,CPT,31646,Brnchsc w/ther aspir sbsq,APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
Molina Duals,CPT,31647,Bronchial valve init insert,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Molina Duals,CPT,31648,Bronchial valve remov init,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Molina Duals,CPT,31649,Bronchial valve remov addl,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Molina Duals,CPT,31652,Bronch ebus samplng 1/2 node,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Molina Duals,CPT,31653,Bronch ebus samplng 3/> node,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
Molina Duals,CPT,31660,Bronch thermoplsty 1 lobe,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Molina Duals,CPT,31661,Bronch thermoplsty 2/> lobes,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
Molina Duals,CPT,31717,Bronchial brush biopsy,APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
Molina Duals,CPT,31720,Clearance of airways,APC 5791,RVU Per Case,$192.26 ,OP,192.26,"4,314.00",,,,,,
Molina Duals,CPT,31725,Clearance of airways,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,31730,Intro windpipe wire/tube,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
Molina Duals,CPT,31750,Repair of windpipe,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,31755,Repair of windpipe,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,31760,Repair of windpipe,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,31766,Reconstruction of windpipe,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,31770,Repair/graft of bronchus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,31775,Reconstruct bronchus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,31780,Reconstruct windpipe,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,31781,Reconstruct windpipe,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,31785,Remove windpipe lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,31786,Remove windpipe lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,31800,Repair of windpipe injury,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,31805,Repair of windpipe injury,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,31820,Closure of windpipe lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,31825,Repair of windpipe defect,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,31830,Revise windpipe scar,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,31899,Airways surgical procedure,APC 5151,RVU Per Unit,$168.23 ,OP,168.23,"4,314.00",,,,,,
Molina Duals,CPT,32035,Thoracostomy w/rib resection,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32036,Thoracostomy w/flap drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32096,Open wedge/bx lung infiltr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32097,Open wedge/bx lung nodule,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32098,Open biopsy of lung pleura,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32100,Exploration of chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32110,Explore/repair chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32120,Re-exploration of chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32124,Explore chest free adhesions,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32140,Removal of lung lesion(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32141,Remove/treat lung lesions,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32150,Removal of lung lesion(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32151,Remove lung foreign body,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32160,Open chest heart massage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32200,Drain open lung lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32215,Treat chest lining,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32220,Release of lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32225,Partial release of lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32310,Removal of chest lining,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32320,Free/remove chest lining,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32400,Needle biopsy chest lining,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,32408,Core ndl bx lng/med perq,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,32440,Remove lung pneumonectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32442,Sleeve pneumonectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32445,Removal of lung extrapleural,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32480,Partial removal of lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32482,Bilobectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32484,Segmentectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32486,Sleeve lobectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32488,Completion pneumonectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32491,Lung volume reduction,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32501,Repair bronchus add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32503,Resect apical lung tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32504,Resect apical lung tum/chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32505,Wedge resect of lung initial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32506,Wedge resect of lung add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32507,Wedge resect of lung diag,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32540,Removal of lung lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32550,Insert pleural cath,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Molina Duals,CPT,32551,Insertion of chest tube,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Molina Duals,CPT,32552,Remove lung catheter,APC 5181,RVU Per Case,$554.25 ,OP,554.25,"4,314.00",,,,,,
Molina Duals,CPT,32553,Ins mark thor for rt perq,APC 5613,RVU Per Unit,"$1,291.62 ",OP,"1,291.62","4,314.00",,,,,,
Molina Duals,CPT,32554,Aspirate pleura w/o imaging,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Molina Duals,CPT,32555,Aspirate pleura w/ imaging,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Molina Duals,CPT,32556,Insert cath pleura w/o image,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,32557,Insert cath pleura w/ image,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Molina Duals,CPT,32560,Treat pleurodesis w/agent,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Molina Duals,CPT,32561,Lyse chest fibrin init day,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Molina Duals,CPT,32562,Lyse chest fibrin subq day,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Molina Duals,CPT,32601,Thoracoscopy diagnostic,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,32604,Thoracoscopy wbx sac,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,32606,Thoracoscopy w/bx med space,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,32607,Thoracoscopy w/bx infiltrate,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,32608,Thoracoscopy w/bx nodule,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,32609,Thoracoscopy w/bx pleura,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,32650,Thoracoscopy w/pleurodesis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32651,Thoracoscopy remove cortex,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32652,Thoracoscopy rem totl cortex,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32653,Thoracoscopy remov fb/fibrin,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32654,Thoracoscopy contrl bleeding,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32655,Thoracoscopy resect bullae,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32656,Thoracoscopy w/pleurectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32658,Thoracoscopy w/sac fb remove,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32659,Thoracoscopy w/sac drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32661,Thoracoscopy w/pericard exc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32662,Thoracoscopy w/mediast exc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32663,Thoracoscopy w/lobectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32664,Thoracoscopy w/ th nrv exc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32665,Thoracoscop w/esoph musc exc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32666,Thoracoscopy w/wedge resect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32667,Thoracoscopy w/w resect addl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32668,Thoracoscopy w/w resect diag,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32669,Thoracoscopy remove segment,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32670,Thoracoscopy bilobectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32671,Thoracoscopy pneumonectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32672,Thoracoscopy for lvrs,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32673,Thoracoscopy w/thymus resect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32674,Thoracoscopy lymph node exc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32800,Repair lung hernia,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32810,Close chest after drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32815,Close bronchial fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32820,Reconstruct injured chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32850,Donor pneumonectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32851,Lung transplant single,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32852,Lung transplant with bypass,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32853,Lung transplant double,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32854,Lung transplant with bypass,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32855,Prepare donor lung single,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32856,Prepare donor lung double,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32900,Removal of rib(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32905,Revise & repair chest wall,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32906,Revise & repair chest wall,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32940,Revision of lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32960,Therapeutic pneumothorax,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Molina Duals,CPT,32994,Ablate pulm tumor perq crybl,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,32997,Total lung lavage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,32998,Ablate pulm tumor perq rf,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,32999,Chest surgery procedure,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Molina Duals,CPT,33016,Pericardiocentesis w/imaging,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Molina Duals,CPT,33017,Prcrd drg 6yr+ w/o cgen car,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33018,Prcrd drg 0-5yr or w/anomly,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33019,Perq prcrd drg insj cath ct,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33020,Incision of heart sac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33025,Incision of heart sac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33030,Partial removal of heart sac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33031,Partial removal of heart sac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33050,Resect heart sac lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33120,Removal of heart lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33130,Removal of heart lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33140,Heart revascularize (tmr),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33141,Heart tmr w/other procedure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33202,Insert epicard eltrd open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33203,Insert epicard eltrd endo,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33206,Insert heart pm atrial,APC 5223,RVU Per Case,"$10,642.67 ",OP,"4,314.00","10,642.67",,,,,,
Molina Duals,CPT,33207,Insert heart pm ventricular,APC 5223,RVU Per Case,"$10,642.67 ",OP,"4,314.00","10,642.67",,,,,,
Molina Duals,CPT,33208,Insrt heart pm atrial & vent,APC 5223,RVU Per Case,"$10,642.67 ",OP,"4,314.00","10,642.67",,,,,,
Molina Duals,CPT,33210,Insert electrd/pm cath sngl,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
Molina Duals,CPT,33211,Insert card electrodes dual,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
Molina Duals,CPT,33212,Insert pulse gen sngl lead,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
Molina Duals,CPT,33213,Insert pulse gen dual leads,APC 5223,RVU Per Case,"$10,642.67 ",OP,"4,314.00","10,642.67",,,,,,
Molina Duals,CPT,33214,Upgrade of pacemaker system,APC 5223,RVU Per Case,"$10,642.67 ",OP,"4,314.00","10,642.67",,,,,,
Molina Duals,CPT,33215,Reposition pacing-defib lead,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,33216,Insert 1 electrode pm-defib,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
Molina Duals,CPT,33217,Insert 2 electrode pm-defib,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
Molina Duals,CPT,33218,Repair lead pace-defib one,APC 5221,RVU Per Unit,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Molina Duals,CPT,33220,Repair lead pace-defib dual,APC 5221,RVU Per Unit,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Molina Duals,CPT,33221,Insert pulse gen mult leads,APC 5224,RVU Per Case,"$19,045.26 ",OP,"4,314.00","19,045.26",,,,,,
Molina Duals,CPT,33222,Relocation pocket pacemaker,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,33223,Relocate pocket for defib,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,33224,Insert pacing lead & connect,APC 5223,RVU Per Case,"$10,642.67 ",OP,"4,314.00","10,642.67",,,,,,
Molina Duals,CPT,33226,Reposition l ventric lead,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,33227,Remove&replace pm gen singl,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
Molina Duals,CPT,33228,Remv&replc pm gen dual lead,APC 5223,RVU Per Case,"$10,642.67 ",OP,"4,140.35","10,642.67",,,,,,
Molina Duals,CPT,33229,Remv&replc pm gen mult leads,APC 5224,RVU Per Case,"$19,045.26 ",OP,"4,314.00","19,045.26",,,,,,
Molina Duals,CPT,33230,Insrt pulse gen w/dual leads,APC 5231,RVU Per Case,"$23,577.44 ",OP,"4,314.00","23,577.44",,,,,,
Molina Duals,CPT,33231,Insrt pulse gen w/mult leads,APC 5232,RVU Per Case,"$33,604.66 ",OP,"4,314.00","33,604.66",,,,,,
Molina Duals,CPT,33233,Removal of pm generator,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
Molina Duals,CPT,33234,Removal of pacemaker system,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Molina Duals,CPT,33235,Removal pacemaker electrode,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Molina Duals,CPT,33236,Remove electrode/thoracotomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33237,Remove electrode/thoracotomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33238,Remove electrode/thoracotomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33240,Insrt pulse gen w/singl lead,APC 5231,RVU Per Case,"$23,577.44 ",OP,"4,140.35","23,577.44",,,,,,
Molina Duals,CPT,33241,Remove pulse generator,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Molina Duals,CPT,33243,Remove eltrd/thoracotomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33244,Remove elctrd transvenously,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Molina Duals,CPT,33249,Insj/rplcmt defib w/lead(s),APC 5232,RVU Per Case,"$33,604.66 ",OP,"4,140.35","33,604.66",,,,,,
Molina Duals,CPT,33250,Ablate heart dysrhythm focus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33251,Ablate heart dysrhythm focus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33254,Ablate atria lmtd,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33255,Ablate atria w/o bypass ext,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33256,Ablate atria w/bypass exten,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33257,Ablate atria lmtd add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33258,Ablate atria x10sv add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33259,Ablate atria w/bypass add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33261,Ablate heart dysrhythm focus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33262,Rmvl& replc pulse gen 1 lead,APC 5231,RVU Per Case,"$23,577.44 ",OP,"4,314.00","23,577.44",,,,,,
Molina Duals,CPT,33263,Rmvl & rplcmt dfb gen 2 lead,APC 5231,RVU Per Case,"$23,577.44 ",OP,"4,140.35","23,577.44",,,,,,
Molina Duals,CPT,33264,Rmvl & rplcmt dfb gen mlt ld,APC 5232,RVU Per Case,"$33,604.66 ",OP,"4,314.00","33,604.66",,,,,,
Molina Duals,CPT,33265,Ablate atria lmtd endo,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33266,Ablate atria x10sv endo,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33270,Ins/rep subq defibrillator,APC 5232,RVU Per Case,"$33,604.66 ",OP,"4,314.00","33,604.66",,,,,,
Molina Duals,CPT,33271,Insj subq impltbl dfb elctrd,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
Molina Duals,CPT,33272,Rmvl of subq defibrillator,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Molina Duals,CPT,33273,Repos prev impltbl subq dfb,APC 5221,RVU Per Unit,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Molina Duals,CPT,33274,Tcat insj/rpl perm ldls pm,APC 5194,RVU Per Case,"$16,438.60 ",OP,"4,314.00","16,438.60",,,,,,
Molina Duals,CPT,33275,Tcat rmvl perm ldls pm w/img,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,33285,Insj subq car rhythm mntr,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
Molina Duals,CPT,33286,Rmvl subq car rhythm mntr,APC 5071,RVU Per Case,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,33289,Tcat impl wrls p-art prs snr,APC 5200,RVU Per Case,"$29,487.35 ",OP,"4,314.00","29,487.35",,,,,,
Molina Duals,CPT,33300,Repair of heart wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33305,Repair of heart wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33310,Exploratory heart surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33315,Exploratory heart surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33320,Repair major blood vessel(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33321,Repair major vessel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33322,Repair major blood vessel(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33330,Insert major vessel graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33335,Insert major vessel graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33340,Perq clsr tcat l atr apndge,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33361,Replace aortic valve perq,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33362,Replace aortic valve open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33363,Replace aortic valve open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33364,Replace aortic valve open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33365,Replace aortic valve open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33366,Trcath replace aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33367,Replace aortic valve w/byp,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33368,Replace aortic valve w/byp,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33369,Replace aortic valve w/byp,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33390,Valvuloplasty aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33391,Valvuloplasty aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33404,Prepare heart-aorta conduit,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33405,Replacement aortic valve opn,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33406,Replacement aortic valve opn,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33410,Replacement aortic valve opn,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33411,Replacement of aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33412,Replacement of aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33413,Replacement of aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33414,Repair of aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33415,Revision subvalvular tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33416,Revise ventricle muscle,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33417,Repair of aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33418,Repair tcat mitral valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33420,Revision of mitral valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33422,Revision of mitral valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33425,Repair of mitral valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33426,Repair of mitral valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33427,Repair of mitral valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33430,Replacement of mitral valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33440,Rplcmt a-valve tlcj autol pv,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33460,Revision of tricuspid valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33463,Valvuloplasty tricuspid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33464,Valvuloplasty tricuspid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33465,Replace tricuspid valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33468,Revision of tricuspid valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33470,Revision of pulmonary valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33471,Valvotomy pulmonary valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33474,Revision of pulmonary valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33475,Replacement pulmonary valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33476,Revision of heart chamber,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33477,Implant tcat pulm vlv perq,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33478,Revision of heart chamber,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33496,Repair prosth valve clot,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33500,Repair heart vessel fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33501,Repair heart vessel fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33502,Coronary artery correction,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33503,Coronary artery graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33504,Coronary artery graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33505,Repair artery w/tunnel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33506,Repair artery translocation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33507,Repair art intramural,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33510,Cabg vein single,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33511,Cabg vein two,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33512,Cabg vein three,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33513,Cabg vein four,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33514,Cabg vein five,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33516,Cabg vein six or more,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33517,Cabg artery-vein single,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33518,Cabg artery-vein two,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33519,Cabg artery-vein three,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33521,Cabg artery-vein four,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33522,Cabg artery-vein five,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33523,Cabg art-vein six or more,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33530,Coronary artery bypass/reop,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33533,Cabg arterial single,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33534,Cabg arterial two,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33535,Cabg arterial three,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33536,Cabg arterial four or more,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33542,Removal of heart lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33545,Repair of heart damage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33548,Restore/remodel ventricle,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33572,Open coronary endarterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33600,Closure of valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33602,Closure of valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33606,Anastomosis/artery-aorta,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33608,Repair anomaly w/conduit,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33610,Repair by enlargement,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33611,Repair double ventricle,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33612,Repair double ventricle,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33615,Repair modified fontan,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33617,Repair single ventricle,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33619,Repair single ventricle,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33620,Apply r&l pulm art bands,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33621,Transthor cath for stent,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33622,Redo compl cardiac anomaly,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33641,Repair heart septum defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33645,Revision of heart veins,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33647,Repair heart septum defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33660,Repair of heart defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33665,Repair of heart defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33670,Repair of heart chambers,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33675,Close mult vsd,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33676,Close mult vsd w/resection,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33677,Cl mult vsd w/rem pul band,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33681,Repair heart septum defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33684,Repair heart septum defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33688,Repair heart septum defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33690,Reinforce pulmonary artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33692,Repair of heart defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33694,Repair of heart defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33697,Repair of heart defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33702,Repair of heart defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33710,Repair of heart defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33720,Repair of heart defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33722,Repair of heart defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33724,Repair venous anomaly,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33726,Repair pul venous stenosis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33730,Repair heart-vein defect(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33732,Repair heart-vein defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33735,Revision of heart chamber,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33736,Revision of heart chamber,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33737,Revision of heart chamber,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33741,Tas congenital car anomal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33745,Tis cgen car anomal 1st shnt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33746,Tis cgen car anomal ea addl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33750,Major vessel shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33755,Major vessel shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33762,Major vessel shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33764,Major vessel shunt & graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33766,Major vessel shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33767,Major vessel shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33768,Cavopulmonary shunting,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33770,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33771,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33774,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33775,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33776,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33777,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33778,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33779,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33780,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33781,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33782,Nikaidoh proc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33783,Nikaidoh proc w/ostia implt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33786,Repair arterial trunk,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33788,Revision of pulmonary artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33800,Aortic suspension,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33802,Repair vessel defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33803,Repair vessel defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33813,Repair septal defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33814,Repair septal defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33820,Revise major vessel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33822,Revise major vessel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33824,Revise major vessel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33840,Remove aorta constriction,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33845,Remove aorta constriction,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33851,Remove aorta constriction,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33852,Repair septal defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33853,Repair septal defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33858,As-aort grf f/aortic dsj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33859,As-aort grf f/ds oth/thn dsj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33863,Ascending aortic graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33864,Ascending aortic graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33871,Transvrs a-arch grf hypthrm,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33875,Thoracic aortic graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33877,Thoracoabdominal graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33880,Endovasc taa repr incl subcl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33881,Endovasc taa repr w/o subcl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33883,Insert endovasc prosth taa,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33884,Endovasc prosth taa add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33886,Endovasc prosth delayed,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33889,Artery transpose/endovas taa,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33891,Car-car bp grft/endovas taa,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33910,Remove lung artery emboli,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33915,Remove lung artery emboli,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33916,Surgery of great vessel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33917,Repair pulmonary artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33920,Repair pulmonary atresia,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33922,Transect pulmonary artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33924,Remove pulmonary shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33925,Rpr pul art unifocal w/o cpb,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33926,Repr pul art unifocal w/cpb,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33927,Impltj tot rplcmt hrt sys,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33928,Rmvl & rplcmt tot hrt sys,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33929,Rmvl rplcmt hrt sys f/trnspl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33930,Removal of donor heart/lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33933,Prepare donor heart/lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33935,Transplantation heart/lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33940,Removal of donor heart,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33944,Prepare donor heart,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33945,Transplantation of heart,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33946,Ecmo/ecls initiation venous,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33947,Ecmo/ecls initiation artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33948,Ecmo/ecls daily mgmt-venous,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33949,Ecmo/ecls daily mgmt artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33951,Ecmo/ecls insj prph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33952,Ecmo/ecls insj prph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33953,Ecmo/ecls insj prph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33954,Ecmo/ecls insj prph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33955,Ecmo/ecls insj ctr cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33956,Ecmo/ecls insj ctr cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33957,Ecmo/ecls repos perph cnula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33958,Ecmo/ecls repos perph cnula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33959,Ecmo/ecls repos perph cnula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33962,Ecmo/ecls repos perph cnula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33963,Ecmo/ecls repos perph cnula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33964,Ecmo/ecls repos perph cnula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33965,Ecmo/ecls rmvl perph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33966,Ecmo/ecls rmvl prph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33967,Insert i-aort percut device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33968,Remove aortic assist device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33969,Ecmo/ecls rmvl perph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33970,Aortic circulation assist,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33971,Aortic circulation assist,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33973,Insert balloon device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33974,Remove intra-aortic balloon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33975,Implant ventricular device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33976,Implant ventricular device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33977,Remove ventricular device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33978,Remove ventricular device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33979,Insert intracorporeal device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33980,Remove intracorporeal device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33981,Replace vad pump ext,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33982,Replace vad intra w/o bp,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33983,Replace vad intra w/bp,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33984,Ecmo/ecls rmvl prph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33985,Ecmo/ecls rmvl ctr cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33986,Ecmo/ecls rmvl ctr cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33987,Artery expos/graft artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33988,Insertion of left heart vent,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33989,Removal of left heart vent,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33990,Insj perq vad l hrt arterial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33991,Insj perq vad l hrt artl&ven,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33992,Rmvl perq left heart vad,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33993,Reposg perq r/l hrt vad,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33995,Insj perq vad r hrt venous,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33997,Rmvl perq right heart vad,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,33999,Cardiac surgery procedure,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Molina Duals,CPT,34001,Removal of artery clot,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,34051,Removal of artery clot,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,34101,Removal of artery clot,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,34111,Removal of arm artery clot,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,34151,Removal of artery clot,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,34201,Removal of artery clot,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,34203,Removal of leg artery clot,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,34401,Removal of vein clot,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,34421,Removal of vein clot,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,34451,Removal of vein clot,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,34471,Removal of vein clot,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Molina Duals,CPT,34490,Removal of vein clot,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,34501,Repair valve femoral vein,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,34502,Reconstruct vena cava,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,34510,Transposition of vein valve,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,34520,Cross-over vein graft,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,34530,Leg vein fusion,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,34701,Evasc rpr a-ao ndgft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,34702,Evasc rpr a-ao ndgft rpt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,34703,Evasc rpr a-unilac ndgft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,34704,Evasc rpr a-unilac ndgft rpt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,34705,Evac rpr a-biiliac ndgft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,34706,Evasc rpr a-biiliac rpt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,34707,Evasc rpr ilio-iliac ndgft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,34708,Evasc rpr ilio-iliac rpt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,34709,Plmt xtn prosth evasc rpr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,34710,Dlyd plmt xtn prosth 1st vsl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,34711,Dlyd plmt xtn prosth ea addl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,34712,Tcat dlvr enhncd fixj dev,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,34717,Evasc rpr a-iliac ndgft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,34718,Evasc rpr n/a a-iliac ndgft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,34808,Endovas iliac a device addon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,34812,Opn fem art expos,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,34813,Femoral endovas graft add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,34820,Opn iliac art expos,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,34830,Open aortic tube prosth repr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,34831,Open aortoiliac prosth repr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,34832,Open aortofemor prosth repr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,34833,Opn ilac art expos cndt crtj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,34834,Opn brach art expos,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,34841,Endovasc visc aorta 1 graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,34842,Endovasc visc aorta 2 graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,34843,Endovasc visc aorta 3 graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,34844,Endovasc visc aorta 4 graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,34845,Visc & infraren abd 1 prosth,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,34846,Visc & infraren abd 2 prosth,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,34847,Visc & infraren abd 3 prosth,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,34848,Visc & infraren abd 4+ prost,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35001,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35002,Repair artery rupture neck,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35005,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35011,Repair defect of artery,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,35013,Repair artery rupture arm,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35021,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35022,Repair artery rupture chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35045,Repair defect of arm artery,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,35081,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35082,Repair artery rupture aorta,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35091,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35092,Repair artery rupture aorta,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35102,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35103,Repair artery rupture aorta,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35111,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35112,Repair artery rupture spleen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35121,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35122,Repair artery rupture belly,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35131,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35132,Repair artery rupture groin,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35141,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35142,Repair artery rupture thigh,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35151,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35152,Repair ruptd popliteal art,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35180,Repair blood vessel lesion,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Molina Duals,CPT,35182,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35184,Repair blood vessel lesion,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,35188,Repair blood vessel lesion,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,35189,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35190,Repair blood vessel lesion,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,35201,Repair blood vessel lesion,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,35206,Repair blood vessel lesion,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,35207,Repair blood vessel lesion,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,35211,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35216,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35221,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35226,Repair blood vessel lesion,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,35231,Repair blood vessel lesion,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,35236,Repair blood vessel lesion,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,35241,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35246,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35251,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35256,Repair blood vessel lesion,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,35261,Repair blood vessel lesion,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,35266,Repair blood vessel lesion,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,35271,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35276,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35281,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35286,Repair blood vessel lesion,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,35301,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35302,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35303,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35304,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35305,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35306,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35311,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35321,Rechanneling of artery,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,35331,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35341,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35351,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35355,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35361,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35363,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35371,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35372,Rechanneling of artery,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,35390,Reoperation carotid add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35400,Angioscopy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35501,Art byp grft ipsilat carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35506,Art byp grft subclav-carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35508,Art byp grft carotid-vertbrl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35509,Art byp grft contral carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35510,Art byp grft carotid-brchial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35511,Art byp grft subclav-subclav,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35512,Art byp grft subclav-brchial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35515,Art byp grft subclav-vertbrl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35516,Art byp grft subclav-axilary,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35518,Art byp grft axillary-axilry,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35521,Art byp grft axill-femoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35522,Art byp grft axill-brachial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35523,Art byp grft brchl-ulnr-rdl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35525,Art byp grft brachial-brchl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35526,Art byp grft aor/carot/innom,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35531,Art byp grft aorcel/aormesen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35533,Art byp grft axill/fem/fem,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35535,Art byp grft hepatorenal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35536,Art byp grft splenorenal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35537,Art byp grft aortoiliac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35538,Art byp grft aortobi-iliac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35539,Art byp grft aortofemoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35540,Art byp grft aortbifemoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35556,Art byp grft fem-popliteal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35558,Art byp grft fem-femoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35560,Art byp grft aortorenal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35563,Art byp grft ilioiliac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35565,Art byp grft iliofemoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35566,Art byp fem-ant-post tib/prl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35570,Art byp tibial-tib/peroneal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35571,Art byp pop-tibl-prl-other,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35583,Vein byp grft fem-popliteal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35585,Vein byp fem-tibial peroneal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35587,Vein byp pop-tibl peroneal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35600,Harvest art for cabg add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35601,Art byp common ipsi carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35606,Art byp carotid-subclavian,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35612,Art byp subclav-subclavian,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35616,Art byp subclav-axillary,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35621,Art byp axillary-femoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35623,Art byp axillary-pop-tibial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35626,Art byp aorsubcl/carot/innom,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35631,Art byp aor-celiac-msn-renal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35632,Art byp ilio-celiac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35633,Art byp ilio-mesenteric,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35634,Art byp iliorenal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35636,Art byp spenorenal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35637,Art byp aortoiliac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35638,Art byp aortobi-iliac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35642,Art byp carotid-vertebral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35645,Art byp subclav-vertebrl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35646,Art byp aortobifemoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35647,Art byp aortofemoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35650,Art byp axillary-axillary,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35654,Art byp axill-fem-femoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35656,Art byp femoral-popliteal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35661,Art byp femoral-femoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35663,Art byp ilioiliac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35665,Art byp iliofemoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35666,Art byp fem-ant-post tib/prl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35671,Art byp pop-tibl-prl-other,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35681,Composite byp grft pros&vein,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35682,Composite byp grft 2 veins,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35683,Composite byp grft 3/> segmt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35691,Art trnsposj vertbrl carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35693,Art trnsposj subclavian,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35694,Art trnsposj subclav carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35695,Art trnsposj carotid subclav,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35697,Reimplant artery each,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35700,Reoperation bypass graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35701,Expl n/flwd surg neck art,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35702,Expl n/flwd surg uxtr art,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35703,Expl n/flwd surg lxtr art,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35800,Explore neck vessels,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,35820,Explore chest vessels,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35840,Explore abdominal vessels,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35860,Explore limb vessels,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,35870,Repair vessel graft defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35875,Removal of clot in graft,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,35876,Removal of clot in graft,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,35879,Revise graft w/vein,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,35881,Revise graft w/vein,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,35883,Revise graft w/nonauto graft,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,35884,Revise graft w/vein,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,35901,Excision graft neck,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35903,Excision graft extremity,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,35905,Excision graft thorax,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,35907,Excision graft abdomen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,36002,Pseudoaneurysm injection trt,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Molina Duals,CPT,36221,Place cath thoracic aorta,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,36222,Place cath carotid/inom art,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,36223,Place cath carotid/inom art,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,36224,Place cath carotd art,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,36225,Place cath subclavian art,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,36226,Place cath vertebral art,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,36251,Ins cath ren art 1st unilat,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,36252,Ins cath ren art 1st bilat,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,36253,Ins cath ren art 2nd+ unilat,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,36254,Ins cath ren art 2nd+ bilat,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,36260,Insertion of infusion pump,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,36261,Revision of infusion pump,APC 5221,RVU Per Unit,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Molina Duals,CPT,36262,Removal of infusion pump,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
Molina Duals,CPT,36415,Routine venipuncture,Lab Services,Per Unit,$3.00 ,OP,3,"4,314.00",,,,,,
Molina Duals,CPT,36420,Vein access cutdown < 1 yr,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Molina Duals,CPT,36425,Vein access cutdown > 1 yr,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Molina Duals,CPT,36430,Blood transfusion service,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Molina Duals,CPT,36440,Bl push transfuse 2 yr/<,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Molina Duals,CPT,36450,Bl exchange/transfuse nb,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Molina Duals,CPT,36455,Bl exchange/transfuse non-nb,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Molina Duals,CPT,36456,Prtl exchange transfuse nb,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Molina Duals,CPT,36460,Transfusion service fetal,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Molina Duals,CPT,36465,Njx noncmpnd sclrsnt 1 vein,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,36466,Njx noncmpnd sclrsnt mlt vn,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,36468,Njx sclrsnt spider veins,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,36470,Njx sclrsnt 1 incmptnt vein,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,36471,Njx sclrsnt mlt incmptnt vn,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,36473,Endovenous mchnchem 1st vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,36475,Endovenous rf 1st vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,36478,Endovenous laser 1st vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,36482,Endoven ther chem adhes 1st,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,36511,Apheresis wbc,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
Molina Duals,CPT,36512,Apheresis rbc,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
Molina Duals,CPT,36513,Apheresis platelets,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Molina Duals,CPT,36514,Apheresis plasma,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
Molina Duals,CPT,36516,Apheresis immunoads slctv,APC 5243,RVU Per Unit,"$4,131.87 ",OP,"4,131.87","4,314.00",,,,,,
Molina Duals,CPT,36522,Photopheresis,APC 5243,RVU Per Unit,"$4,131.87 ",OP,"4,131.87","4,314.00",,,,,,
Molina Duals,CPT,36555,Insert non-tunnel cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,36556,Insert non-tunnel cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,36557,Insert tunneled cv cath,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,36558,Insert tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,36560,Insert tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,36561,Insert tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,36563,Insert tunneled cv cath,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,36565,Insert tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,36566,Insert tunneled cv cath,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,36568,Insj picc <5 yr w/o imaging,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Molina Duals,CPT,36569,Insj picc 5 yr+ w/o imaging,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Molina Duals,CPT,36570,Insert picvad cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,36571,Insert picvad cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,36572,Insj picc rs&i <5 yr,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Molina Duals,CPT,36573,Insj picc rs&i 5 yr+,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Molina Duals,CPT,36575,Repair tunneled cv cath,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Molina Duals,CPT,36576,Repair tunneled cv cath,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Molina Duals,CPT,36578,Replace tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,36580,Replace cvad cath,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Molina Duals,CPT,36581,Replace tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,36582,Replace tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,36583,Replace tunneled cv cath,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,36584,Compl rplcmt picc rs&i,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Molina Duals,CPT,36585,Replace picvad cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,36589,Removal tunneled cv cath,APC 5181,RVU Per Case,$554.25 ,OP,554.25,"4,314.00",,,,,,
Molina Duals,CPT,36590,Removal tunneled cv cath,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Molina Duals,CPT,36591,Draw blood off venous device,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Molina Duals,CPT,36592,Collect blood from picc,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Molina Duals,CPT,36593,Declot vascular device,APC 5694,RVU Per Unit,$318.00 ,OP,318,"4,314.00",,,,,,
Molina Duals,CPT,36595,Mech remov tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,36596,Mech remov tunneled cv cath,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Molina Duals,CPT,36597,Reposition venous catheter,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Molina Duals,CPT,36598,Inj w/fluor eval cv device,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,"4,314.00",,,,,,
Molina Duals,CPT,36600,Withdrawal of arterial blood,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Molina Duals,CPT,36640,Insertion catheter artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,36660,Insertion catheter artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,36680,Insert needle bone cavity,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Molina Duals,CPT,36800,Insertion of cannula,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,36810,Insertion of cannula,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,36815,Insertion of cannula,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,36818,Av fuse uppr arm cephalic,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,36819,Av fuse uppr arm basilic,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,36820,Av fusion/forearm vein,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,36821,Av fusion direct any site,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","9,201.00",,,,,,
Molina Duals,CPT,36823,Insertion of cannula(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,36825,Artery-vein autograft,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,36830,Artery-vein nonautograft,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,36831,Open thrombect av fistula,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,36832,Av fistula revision open,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,36833,Av fistula revision,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,36835,Artery to vein shunt,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,36838,Dist revas ligation hemo,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,36860,External cannula declotting,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Molina Duals,CPT,36861,Cannula declotting,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,36901,Intro cath dialysis circuit,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
Molina Duals,CPT,36902,Intro cath dialysis circuit,APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,314.00","5,072.43",,,,,,
Molina Duals,CPT,36903,Intro cath dialysis circuit,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Molina Duals,CPT,36904,Thrmbc/nfs dialysis circuit,APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,314.00","5,072.43",,,,,,
Molina Duals,CPT,36905,Thrmbc/nfs dialysis circuit,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Molina Duals,CPT,36906,Thrmbc/nfs dialysis circuit,APC 5194,RVU Per Case,"$16,438.60 ",OP,"4,140.35","16,438.60",,,,,,
Molina Duals,CPT,37140,Revision of circulation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,37145,Revision of circulation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,37160,Revision of circulation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,37180,Revision of circulation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,37181,Splice spleen/kidney veins,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,37182,Insert hepatic shunt (tips),APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Molina Duals,CPT,37183,Remove hepatic shunt (tips),APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,314.00","5,072.43",,,,,,
Molina Duals,CPT,37184,Prim art m-thrmbc 1st vsl,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Molina Duals,CPT,37187,Venous mech thrombectomy,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
Molina Duals,CPT,37188,Ven mechnl thrmbc repeat tx,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,37191,Ins endovas vena cava filtr,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,37192,Redo endovas vena cava filtr,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,37193,Rem endovas vena cava filter,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,37195,Thrombolytic therapy stroke,APC 5694,RVU Per Unit,$318.00 ,OP,318,"4,314.00",,,,,,
Molina Duals,CPT,37197,Remove intrvas foreign body,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,37200,Transcatheter biopsy,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,37211,Thrombolytic art therapy,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,37212,Thrombolytic venous therapy,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,37213,Thromblytic art/ven therapy,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,37214,Cessj therapy cath removal,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,37215,Transcath stent cca w/eps,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,37217,Stent placemt retro carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,37218,Stent placemt ante carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,37220,Iliac revasc,APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,314.00","5,072.43",,,,,,
Molina Duals,CPT,37221,Iliac revasc w/stent,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
Molina Duals,CPT,37224,Fem/popl revas w/tla,APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,314.00","5,072.43",,,,,,
Molina Duals,CPT,37225,Fem/popl revas w/ather,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Molina Duals,CPT,37226,Fem/popl revasc w/stent,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
Molina Duals,CPT,37227,Fem/popl revasc stnt & ather,APC 5194,RVU Per Case,"$16,438.60 ",OP,"4,314.00","16,438.60",,,,,,
Molina Duals,CPT,37228,Tib/per revasc w/tla,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Molina Duals,CPT,37229,Tib/per revasc w/ather,APC 5194,RVU Per Case,"$16,438.60 ",OP,"4,314.00","16,438.60",,,,,,
Molina Duals,CPT,37230,Tib/per revasc w/stent,APC 5194,RVU Per Case,"$16,438.60 ",OP,"4,314.00","16,438.60",,,,,,
Molina Duals,CPT,37231,Tib/per revasc stent & ather,APC 5194,RVU Per Case,"$16,438.60 ",OP,"4,314.00","16,438.60",,,,,,
Molina Duals,CPT,37236,Open/perq place stent 1st,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Molina Duals,CPT,37238,Open/perq place stent same,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
Molina Duals,CPT,37241,Vasc embolize/occlude venous,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Molina Duals,CPT,37242,Vasc embolize/occlude artery,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
Molina Duals,CPT,37243,Vasc embolize/occlude organ,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Molina Duals,CPT,37244,Vasc embolize/occlude bleed,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
Molina Duals,CPT,37246,Trluml balo angiop 1st art,APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,314.00","5,072.43",,,,,,
Molina Duals,CPT,37248,Trluml balo angiop 1st vein,APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,314.00","5,072.43",,,,,,
Molina Duals,CPT,37500,Endoscopy ligate perf veins,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,37501,Vascular endoscopy procedure,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Molina Duals,CPT,37565,Ligation of neck vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,37600,Ligation of neck artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,37605,Ligation of neck artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,37606,Ligation of neck artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,37607,Ligation of a-v fistula,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,37609,Temporal artery procedure,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,37615,Ligation of neck artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,37616,Ligation of chest artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,37617,Ligation of abdomen artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,37618,Ligation of extremity artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,37619,Ligation of inf vena cava,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,37650,Revision of major vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,37660,Revision of major vein,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,37700,Revise leg vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,37718,Ligate/strip short leg vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,37722,Ligate/strip long leg vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,37735,Removal of leg veins/lesion,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,37760,Ligate leg veins radical,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,37761,Ligate leg veins open,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,37765,Stab phleb veins xtr 10-20,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,37766,Phleb veins - extrem 20+,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,37780,Revision of leg vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,37785,Ligate/divide/excise vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,37788,Revascularization penis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,37790,Penile venous occlusion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,37799,Vascular surgery procedure,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
Molina Duals,CPT,38100,Removal of spleen total,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,38101,Removal of spleen partial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,38102,Removal of spleen total,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,38115,Repair of ruptured spleen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,38120,Laparoscopy splenectomy,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Molina Duals,CPT,38129,Laparoscope proc spleen,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,38206,Harvest auto stem cells,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
Molina Duals,CPT,38207,Cryopreserve stem cells,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Molina Duals,CPT,38208,Thaw preserved stem cells,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Molina Duals,CPT,38209,Wash harvest stem cells,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Molina Duals,CPT,38210,T-cell depletion of harvest,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Molina Duals,CPT,38211,Tumor cell deplete of harvst,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Molina Duals,CPT,38212,Rbc depletion of harvest,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Molina Duals,CPT,38213,Platelet deplete of harvest,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Molina Duals,CPT,38214,Volume deplete of harvest,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Molina Duals,CPT,38215,Harvest stem cell concentrte,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Molina Duals,CPT,38220,Dx bone marrow aspirations,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,38221,Dx bone marrow biopsies,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,38222,Dx bone marrow bx & aspir,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,38230,Bone marrow harvest allogen,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
Molina Duals,CPT,38232,Bone marrow harvest autolog,APC 5243,RVU Per Unit,"$4,131.87 ",OP,"4,131.87","4,314.00",,,,,,
Molina Duals,CPT,38240,Transplt allo hct/donor,APC 5244,RVU Per Case,"$32,580.57 ",OP,"4,314.00","32,580.57",,,,,,
Molina Duals,CPT,38241,Transplt autol hct/donor,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
Molina Duals,CPT,38242,Transplt allo lymphocytes,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
Molina Duals,CPT,38243,Transplj hematopoietic boost,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
Molina Duals,CPT,38300,Drainage lymph node lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,38305,Drainage lymph node lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,38308,Incision of lymph channels,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Molina Duals,CPT,38380,Thoracic duct procedure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,38381,Thoracic duct procedure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,38382,Thoracic duct procedure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,38500,Biopsy/removal lymph nodes,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Molina Duals,CPT,38505,Needle biopsy lymph nodes,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,38510,Biopsy/removal lymph nodes,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Molina Duals,CPT,38520,Biopsy/removal lymph nodes,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Molina Duals,CPT,38525,Biopsy/removal lymph nodes,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Molina Duals,CPT,38530,Biopsy/removal lymph nodes,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Molina Duals,CPT,38531,Open bx/exc inguinofem nodes,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Molina Duals,CPT,38542,Explore deep node(s) neck,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,38550,Removal neck/armpit lesion,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
Molina Duals,CPT,38555,Removal neck/armpit lesion,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
Molina Duals,CPT,38562,Removal pelvic lymph nodes,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Molina Duals,CPT,38564,Removal abdomen lymph nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,38570,Laparoscopy lymph node biop,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,38571,Laparoscopy lymphadenectomy,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,38572,Laparoscopy lymphadenectomy,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,38573,Laps pelvic lymphadec,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,38589,Laparoscope proc lymphatic,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,38700,Removal of lymph nodes neck,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
Molina Duals,CPT,38720,Removal of lymph nodes neck,APC 5093,RVU Per Case,"$9,128.05 ",OP,"4,314.00","9,128.05",,,,,,
Molina Duals,CPT,38724,Removal of lymph nodes neck,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,38740,Remove armpit lymph nodes,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,38745,Remove armpit lymph nodes,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,38746,Remove thoracic lymph nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,38747,Remove abdominal lymph nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,38760,Remove groin lymph nodes,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
Molina Duals,CPT,38765,Remove groin lymph nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,38770,Remove pelvis lymph nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,38780,Remove abdomen lymph nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,38792,Ra tracer id of sentinl node,APC 5591,RVU Per Case,$385.91 ,OP,385.91,"4,314.00",,,,,,
Molina Duals,CPT,38999,Blood/lymph system procedure,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
Molina Duals,CPT,39000,Exploration of chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,39010,Exploration of chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,39200,Resect mediastinal cyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,39220,Resect mediastinal tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,39401,Mediastinoscpy w/medstnl bx,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,39402,Mediastinoscpy w/lmph nod bx,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,39499,Chest procedure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,39501,Repair diaphragm laceration,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,39503,Repair of diaphragm hernia,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,39540,Repair of diaphragm hernia,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,39541,Repair of diaphragm hernia,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,39545,Revision of diaphragm,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,39560,Resect diaphragm simple,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,39561,Resect diaphragm complex,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,39599,Diaphragm surgery procedure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,40490,Biopsy of lip,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Molina Duals,CPT,40500,Partial excision of lip,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,40510,Partial excision of lip,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,40520,Partial excision of lip,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,40525,Reconstruct lip with flap,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,40527,Reconstruct lip with flap,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,40530,Partial removal of lip,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,40650,Repair lip,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Molina Duals,CPT,40652,Repair lip,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Molina Duals,CPT,40654,Repair lip,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,40700,Repair cleft lip/nasal,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,40701,Repair cleft lip/nasal,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,40702,Repair cleft lip/nasal,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,40720,Repair cleft lip/nasal,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,40761,Repair cleft lip/nasal,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,40799,Lip surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Molina Duals,CPT,40800,Drainage of mouth lesion,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,40801,Drainage of mouth lesion,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Molina Duals,CPT,40804,Removal foreign body mouth,APC 5301,RVU Per Case,$828.48 ,OP,828.48,"4,314.00",,,,,,
Molina Duals,CPT,40805,Removal foreign body mouth,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Molina Duals,CPT,40806,Incision of lip fold,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Molina Duals,CPT,40808,Biopsy of mouth lesion,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Molina Duals,CPT,40810,Excision of mouth lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,40812,Excise/repair mouth lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,40814,Excise/repair mouth lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,40816,Excision of mouth lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,40818,Excise oral mucosa for graft,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Molina Duals,CPT,40819,Excise lip or cheek fold,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,40820,Treatment of mouth lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,40830,Repair mouth laceration,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Molina Duals,CPT,40831,Repair mouth laceration,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Molina Duals,CPT,40840,Reconstruction of mouth,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,40842,Reconstruction of mouth,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,40843,Reconstruction of mouth,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,40844,Reconstruction of mouth,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,40845,Reconstruction of mouth,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,40899,Mouth surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Molina Duals,CPT,41000,Drainage of mouth lesion,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Molina Duals,CPT,41005,Drainage of mouth lesion,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Molina Duals,CPT,41006,Drainage of mouth lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,41007,Drainage of mouth lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,41008,Drainage of mouth lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,41009,Drainage of mouth lesion,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Molina Duals,CPT,41010,Incision of tongue fold,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,41015,Drainage of mouth lesion,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Molina Duals,CPT,41016,Drainage of mouth lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,41017,Drainage of mouth lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,41018,Drainage of mouth lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,41019,Place needles h&n for rt,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,41100,Biopsy of tongue,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Molina Duals,CPT,41105,Biopsy of tongue,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,41108,Biopsy of floor of mouth,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,41110,Excision of tongue lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,41112,Excision of tongue lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,41113,Excision of tongue lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,41114,Excision of tongue lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,41115,Excision of tongue fold,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,41116,Excision of mouth lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,41120,Partial removal of tongue,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,41130,Partial removal of tongue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,41135,Tongue and neck surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,41140,Removal of tongue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,41145,Tongue removal neck surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,41150,Tongue mouth jaw surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,41153,Tongue mouth neck surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,41155,Tongue jaw & neck surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,41250,Repair tongue laceration,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Molina Duals,CPT,41251,Repair tongue laceration,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Molina Duals,CPT,41252,Repair tongue laceration,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Molina Duals,CPT,41510,Tongue to lip surgery,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,41512,Tongue suspension,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,41520,Reconstruction tongue fold,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,41530,Tongue base vol reduction,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,41599,Tongue and mouth surgery,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Molina Duals,CPT,41800,Drainage of gum lesion,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Molina Duals,CPT,41805,Removal foreign body gum,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,41806,Removal foreign body jawbone,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,41820,Excision gum each quadrant,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,41821,Excision of gum flap,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,41822,Excision of gum lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,41823,Excision of gum lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,41825,Excision of gum lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,41826,Excision of gum lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,41827,Excision of gum lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,41828,Excision of gum lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,41830,Removal of gum tissue,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,41850,Treatment of gum lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,41870,Gum graft,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,41872,Repair gum,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,41874,Repair tooth socket,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,41899,Dental surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Molina Duals,CPT,42000,Drainage mouth roof lesion,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Molina Duals,CPT,42100,Biopsy roof of mouth,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,42104,Excision lesion mouth roof,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,42106,Excision lesion mouth roof,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,42107,Excision lesion mouth roof,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,42120,Remove palate/lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,42140,Excision of uvula,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,42145,Repair palate pharynx/uvula,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,42160,Treatment mouth roof lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,42180,Repair palate,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Molina Duals,CPT,42182,Repair palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,42200,Reconstruct cleft palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,42205,Reconstruct cleft palate,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,42210,Reconstruct cleft palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,42215,Reconstruct cleft palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,42220,Reconstruct cleft palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,42225,Reconstruct cleft palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,42226,Lengthening of palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,42227,Lengthening of palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,42235,Repair palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,42260,Repair nose to lip fistula,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,42280,Preparation palate mold,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Molina Duals,CPT,42281,Insertion palate prosthesis,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,42299,Palate/uvula surgery,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Molina Duals,CPT,42300,Drainage of salivary gland,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,42305,Drainage of salivary gland,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,42310,Drainage of salivary gland,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Molina Duals,CPT,42320,Drainage of salivary gland,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Molina Duals,CPT,42330,Removal of salivary stone,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,42335,Removal of salivary stone,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,42340,Removal of salivary stone,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,42400,Biopsy of salivary gland,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,42405,Biopsy of salivary gland,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,42408,Excision of salivary cyst,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,42409,Drainage of salivary cyst,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,42410,Excise parotid gland/lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,42415,Excise parotid gland/lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,42420,Excise parotid gland/lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,42425,Excise parotid gland/lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,42426,Excise parotid gland/lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,42440,Excise submaxillary gland,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,42450,Excise sublingual gland,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,42500,Repair salivary duct,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,42505,Repair salivary duct,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,42507,Parotid duct diversion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,42509,Parotid duct diversion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,42510,Parotid duct diversion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,42600,Closure of salivary fistula,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,42650,Dilation of salivary duct,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,42660,Dilation of salivary duct,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Molina Duals,CPT,42665,Ligation of salivary duct,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,42699,Salivary surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Molina Duals,CPT,42700,Drainage of tonsil abscess,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Molina Duals,CPT,42720,Drainage of throat abscess,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,42725,Drainage of throat abscess,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,42800,Biopsy of throat,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,42804,Biopsy of upper nose/throat,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,42806,Biopsy of upper nose/throat,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,42808,Excise pharynx lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,42809,Remove pharynx foreign body,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Molina Duals,CPT,42810,Excision of neck cyst,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,42815,Excision of neck cyst,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,42820,Remove tonsils and adenoids,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,42821,Remove tonsils and adenoids,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,42825,Removal of tonsils,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,42826,Removal of tonsils,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,42830,Removal of adenoids,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,42831,Removal of adenoids,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,42835,Removal of adenoids,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,42836,Removal of adenoids,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,42842,Extensive surgery of throat,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,42844,Extensive surgery of throat,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,42845,Extensive surgery of throat,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,42860,Excision of tonsil tags,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,42870,Excision of lingual tonsil,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,42890,Partial removal of pharynx,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,42892,Revision of pharyngeal walls,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,42894,Revision of pharyngeal walls,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,42900,Repair throat wound,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,42950,Reconstruction of throat,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,42953,Repair throat esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,42955,Surgical opening of throat,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,42960,Control throat bleeding,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Molina Duals,CPT,42961,Control throat bleeding,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,42962,Control throat bleeding,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,42970,Control nose/throat bleeding,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Molina Duals,CPT,42971,Control nose/throat bleeding,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,42972,Control nose/throat bleeding,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,42999,Throat surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Molina Duals,CPT,43020,Incision of esophagus,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,43030,Throat muscle surgery,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,43045,Incision of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43100,Excision of esophagus lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43101,Excision of esophagus lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43107,Removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43108,Removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43112,Esphg tot w/thrcm,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43113,Removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43116,Partial removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43117,Partial removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43118,Partial removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43121,Partial removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43122,Partial removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43123,Partial removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43124,Removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43130,Removal of esophagus pouch,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,43135,Removal of esophagus pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43180,Esophagoscopy rigid trnso,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,43191,Esophagoscopy rigid trnso dx,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,43192,Esophagoscp rig trnso inject,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,43193,Esophagoscp rig trnso biopsy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,43194,Esophagoscp rig trnso rem fb,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,43195,Esophagoscopy rigid balloon,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Molina Duals,CPT,43196,Esophagoscp guide wire dilat,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Molina Duals,CPT,43197,Esophagoscopy flex dx brush,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Molina Duals,CPT,43198,Esophagosc flex trnsn biopsy,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Molina Duals,CPT,43200,Esophagoscopy flexible brush,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Molina Duals,CPT,43201,Esoph scope w/submucous inj,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,43202,Esophagoscopy flex biopsy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,43204,Esoph scope w/sclerosis inj,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,43205,Esophagus endoscopy/ligation,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,43206,Esoph optical endomicroscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,43210,Egd esophagogastrc fndoplsty,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Molina Duals,CPT,43211,Esophagoscop mucosal resect,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,43212,Esophagoscop stent placement,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Molina Duals,CPT,43213,Esophagoscopy retro balloon,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,43214,Esophagosc dilate balloon 30,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,43215,Esophagoscopy flex remove fb,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,43216,Esophagoscopy lesion removal,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,43217,Esophagoscopy snare les remv,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,43220,Esophagoscopy balloon <30mm,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,43226,Esoph endoscopy dilation,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,43227,Esophagoscopy control bleed,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,43229,Esophagoscopy lesion ablate,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Molina Duals,CPT,43231,Esophagoscop ultrasound exam,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,43232,Esophagoscopy w/us needle bx,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,43233,Egd balloon dil esoph30 mm/>,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,43235,Egd diagnostic brush wash,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Molina Duals,CPT,43236,Uppr gi scope w/submuc inj,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Molina Duals,CPT,43237,Endoscopic us exam esoph,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,43238,Egd us fine needle bx/aspir,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,43239,Egd biopsy single/multiple,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Molina Duals,CPT,43240,Egd w/transmural drain cyst,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Molina Duals,CPT,43241,Egd tube/cath insertion,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,43242,Egd us fine needle bx/aspir,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,43243,Egd injection varices,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,43244,Egd varices ligation,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,43245,Egd dilate stricture,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,43246,Egd place gastrostomy tube,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,43247,Egd remove foreign body,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Molina Duals,CPT,43248,Egd guide wire insertion,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Molina Duals,CPT,43249,Esoph egd dilation <30 mm,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,43250,Egd cautery tumor polyp,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,43251,Egd remove lesion snare,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,43252,Egd optical endomicroscopy,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Molina Duals,CPT,43253,Egd us transmural injxn/mark,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,43254,Egd endo mucosal resection,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,43255,Egd control bleeding any,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,43257,Egd w/thrml txmnt gerd,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Molina Duals,CPT,43259,Egd us exam duodenum/jejunum,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,43260,Ercp w/specimen collection,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Molina Duals,CPT,43261,Endo cholangiopancreatograph,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Molina Duals,CPT,43262,Endo cholangiopancreatograph,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Molina Duals,CPT,43263,Ercp sphincter pressure meas,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Molina Duals,CPT,43264,Ercp remove duct calculi,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Molina Duals,CPT,43265,Ercp lithotripsy calculi,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Molina Duals,CPT,43266,Egd endoscopic stent place,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Molina Duals,CPT,43270,Egd lesion ablation,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,43274,Ercp duct stent placement,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Molina Duals,CPT,43275,Ercp remove forgn body duct,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Molina Duals,CPT,43276,Ercp stent exchange w/dilate,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Molina Duals,CPT,43277,Ercp ea duct/ampulla dilate,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Molina Duals,CPT,43278,Ercp lesion ablate w/dilate,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Molina Duals,CPT,43279,Lap myotomy heller,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43280,Laparoscopy fundoplasty,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Molina Duals,CPT,43281,Lap paraesophag hern repair,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Molina Duals,CPT,43282,Lap paraesoph her rpr w/mesh,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Molina Duals,CPT,43283,Lap esoph lengthening,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43284,Laps esophgl sphnctr agmntj,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Molina Duals,CPT,43285,Rmvl esophgl sphnctr dev,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,43286,Esphg tot w/laps moblj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43287,Esphg dstl 2/3 w/laps moblj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43288,Esphg thrsc moblj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43289,Laparoscope proc esoph,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,43300,Repair of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43305,Repair esophagus and fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43310,Repair of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43312,Repair esophagus and fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43313,Esophagoplasty congenital,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43314,Tracheo-esophagoplasty cong,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43320,Fuse esophagus & stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43325,Revise esophagus & stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43327,Esoph fundoplasty lap,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43328,Esoph fundoplasty thor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43330,Esophagomyotomy abdominal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43331,Esophagomyotomy thoracic,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43332,Transab esoph hiat hern rpr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43333,Transab esoph hiat hern rpr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43334,Transthor diaphrag hern rpr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43335,Transthor diaphrag hern rpr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43336,Thorabd diaphr hern repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43337,Thorabd diaphr hern repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43338,Esoph lengthening,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43340,Fuse esophagus & intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43341,Fuse esophagus & intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43351,Surgical opening esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43352,Surgical opening esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43360,Gastrointestinal repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43361,Gastrointestinal repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43400,Ligate esophagus veins,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43405,Ligate/staple esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43410,Repair esophagus wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43415,Repair esophagus wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43420,Repair esophagus opening,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,43425,Repair esophagus opening,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43450,Dilate esophagus 1/mult pass,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Molina Duals,CPT,43453,Dilate esophagus,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,43460,Pressure treatment esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43496,Free jejunum flap microvasc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43499,Esophagus surgery procedure,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Molina Duals,CPT,43500,Surgical opening of stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43501,Surgical repair of stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43502,Surgical repair of stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43510,Surgical opening of stomach,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Molina Duals,CPT,43520,Incision of pyloric muscle,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43605,Biopsy of stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43610,Excision of stomach lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43611,Excision of stomach lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43620,Removal of stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43621,Removal of stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43622,Removal of stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43631,Removal of stomach partial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43632,Removal of stomach partial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43633,Removal of stomach partial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43634,Removal of stomach partial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43635,Removal of stomach partial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43640,Vagotomy & pylorus repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43641,Vagotomy & pylorus repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43644,Lap gastric bypass/roux-en-y,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43645,Lap gastr bypass incl smll i,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43647,Lap impl electrode antrum,APC 5463,RVU Per Case,"$11,498.23 ",OP,"4,314.00","11,498.23",,,,,,
Molina Duals,CPT,43648,Lap revise/remv eltrd antrum,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,43651,Laparoscopy vagus nerve,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,43652,Laparoscopy vagus nerve,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,43653,Laparoscopy gastrostomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,43659,Laparoscope proc stom,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,43752,Nasal/orogastric w/tube plmt,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Molina Duals,CPT,43753,Tx gastro intub w/asp,APC 5722,RVU Per Case,$270.61 ,OP,270.61,"4,314.00",,,,,,
Molina Duals,CPT,43754,Dx gastr intub w/asp spec,APC 5722,RVU Per Case,$270.61 ,OP,270.61,"4,314.00",,,,,,
Molina Duals,CPT,43755,Dx gastr intub w/asp specs,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,"4,314.00",,,,,,
Molina Duals,CPT,43756,Dx duod intub w/asp spec,APC 5301,RVU Per Case,$828.48 ,OP,828.48,"4,314.00",,,,,,
Molina Duals,CPT,43757,Dx duod intub w/asp specs,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Molina Duals,CPT,43761,Reposition gastrostomy tube,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Molina Duals,CPT,43762,Rplc gtube no revj trc,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Molina Duals,CPT,43763,Rplc gtube revj gstrst trc,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Molina Duals,CPT,43770,Lap place gastr adj device,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,43771,Lap revise gastr adj device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43772,Lap rmvl gastr adj device,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Molina Duals,CPT,43773,Lap replace gastr adj device,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,43774,Lap rmvl gastr adj all parts,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Molina Duals,CPT,43775,Lap sleeve gastrectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43800,Reconstruction of pylorus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43810,Fusion of stomach and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43820,Fusion of stomach and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43825,Fusion of stomach and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43830,Place gastrostomy tube,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,43831,Place gastrostomy tube,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Molina Duals,CPT,43832,Place gastrostomy tube,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43840,Repair of stomach lesion,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Molina Duals,CPT,43843,Gastroplasty w/o v-band,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43845,Gastroplasty duodenal switch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43846,Gastric bypass for obesity,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43847,Gastric bypass incl small i,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43848,Revision gastroplasty,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43850,Revise stomach-bowel fusion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43855,Revise stomach-bowel fusion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43860,Revise stomach-bowel fusion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43865,Revise stomach-bowel fusion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43870,Repair stomach opening,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Molina Duals,CPT,43880,Repair stomach-bowel fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43881,Impl/redo electrd antrum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43882,Revise/remove electrd antrum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,43886,Revise gastric port open,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Molina Duals,CPT,43887,Remove gastric port open,APC 5054,RVU Per Case,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,43888,Change gastric port open,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Molina Duals,CPT,43999,Stomach surgery procedure,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Molina Duals,CPT,44005,Freeing of bowel adhesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44010,Incision of small bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44015,Insert needle cath bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44020,Explore small intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44021,Decompress small bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44025,Incision of large bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44050,Reduce bowel obstruction,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44055,Correct malrotation of bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44100,Biopsy of bowel,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Molina Duals,CPT,44110,Excise intestine lesion(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44111,Excision of bowel lesion(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44120,Removal of small intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44121,Removal of small intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44125,Removal of small intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44126,Enterectomy w/o taper cong,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44127,Enterectomy w/taper cong,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44128,Enterectomy cong add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44130,Bowel to bowel fusion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44132,Enterectomy cadaver donor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44133,Enterectomy live donor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44135,Intestine transplnt cadaver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44136,Intestine transplant live,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44137,Remove intestinal allograft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44139,Mobilization of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44140,Partial removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44141,Partial removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44143,Partial removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44144,Partial removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44145,Partial removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44146,Partial removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44147,Partial removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44150,Removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44151,Removal of colon/ileostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44155,Removal of colon/ileostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44156,Removal of colon/ileostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44157,Colectomy w/ileoanal anast,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44158,Colectomy w/neo-rectum pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44160,Removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44180,Lap enterolysis,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,44186,Lap jejunostomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,44187,Lap ileo/jejuno-stomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44188,Lap colostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44202,Lap enterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44203,Lap resect s/intestine addl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44204,Laparo partial colectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44205,Lap colectomy part w/ileum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44206,Lap part colectomy w/stoma,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44207,L colectomy/coloproctostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44208,L colectomy/coloproctostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44210,Laparo total proctocolectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44211,Lap colectomy w/proctectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44212,Laparo total proctocolectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44213,Lap mobil splenic fl add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44227,Lap close enterostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44238,Laparoscope proc intestine,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,44300,Open bowel to skin,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,44310,Ileostomy/jejunostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44312,Revision of ileostomy,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Molina Duals,CPT,44314,Revision of ileostomy,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Molina Duals,CPT,44316,Devise bowel pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44320,Colostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44322,Colostomy with biopsies,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44340,Revision of colostomy,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
Molina Duals,CPT,44345,Revision of colostomy,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Molina Duals,CPT,44346,Revision of colostomy,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Molina Duals,CPT,44360,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,44361,Small bowel endoscopy/biopsy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,44363,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,44364,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,44365,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,44366,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,44369,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,44370,Small bowel endoscopy/stent,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Molina Duals,CPT,44372,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,44373,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,44376,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,44377,Small bowel endoscopy/biopsy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,44378,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,44379,S bowel endoscope w/stent,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Molina Duals,CPT,44380,Small bowel endoscopy br/wa,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Molina Duals,CPT,44381,Small bowel endoscopy br/wa,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,44382,Small bowel endoscopy,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Molina Duals,CPT,44384,Small bowel endoscopy,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Molina Duals,CPT,44385,Endoscopy of bowel pouch,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Molina Duals,CPT,44386,Endoscopy bowel pouch/biop,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Molina Duals,CPT,44388,Colonoscopy thru stoma spx,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Molina Duals,CPT,44389,Colonoscopy with biopsy,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,44390,Colonoscopy for foreign body,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Molina Duals,CPT,44391,Colonoscopy for bleeding,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,44392,Colonoscopy & polypectomy,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,44394,Colonoscopy w/snare,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,44401,Colonoscopy with ablation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,44402,Colonoscopy w/stent plcmt,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Molina Duals,CPT,44403,Colonoscopy w/resection,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,44404,Colonoscopy w/injection,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,44405,Colonoscopy w/dilation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,44406,Colonoscopy w/ultrasound,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,44407,Colonoscopy w/ndl aspir/bx,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,44408,Colonoscopy w/decompression,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Molina Duals,CPT,44500,Intro gastrointestinal tube,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Molina Duals,CPT,44602,Suture small intestine,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
Molina Duals,CPT,44603,Suture small intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44604,Suture large intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44605,Repair of bowel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44615,Intestinal stricturoplasty,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44620,Repair bowel opening,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44625,Repair bowel opening,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44626,Repair bowel opening,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44640,Repair bowel-skin fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44650,Repair bowel fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44660,Repair bowel-bladder fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44661,Repair bowel-bladder fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44680,Surgical revision intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44700,Suspend bowel w/prosthesis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44715,Prepare donor intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44720,Prep donor intestine/venous,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44721,Prep donor intestine/artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44799,Unlisted px small intestine,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Molina Duals,CPT,44800,Excision of bowel pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44820,Excision of mesentery lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44850,Repair of mesentery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44899,Bowel surgery procedure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44900,Drain appendix abscess open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44950,Appendectomy,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Molina Duals,CPT,44960,Appendectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,44970,Laparoscopy appendectomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,44979,Laparoscope proc app,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,45000,Drainage of pelvic abscess,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,45005,Drainage of rectal abscess,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,45020,Drainage of rectal abscess,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,45100,Biopsy of rectum,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,45108,Removal of anorectal lesion,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,45110,Removal of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,45111,Partial removal of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,45112,Removal of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,45113,Partial proctectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,45114,Partial removal of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,45116,Partial removal of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,45119,Remove rectum w/reservoir,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,45120,Removal of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,45121,Removal of rectum and colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,45123,Partial proctectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,45126,Pelvic exenteration,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,45130,Excision of rectal prolapse,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,45135,Excision of rectal prolapse,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,45136,Excise ileoanal reservior,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,45150,Excision of rectal stricture,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,45160,Excision of rectal lesion,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,45171,Exc rect tum transanal part,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,45172,Exc rect tum transanal full,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,45190,Destruction rectal tumor,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,45300,Proctosigmoidoscopy dx,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Molina Duals,CPT,45303,Proctosigmoidoscopy dilate,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,45305,Proctosigmoidoscopy w/bx,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,45307,Proctosigmoidoscopy fb,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,45308,Proctosigmoidoscopy removal,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,45309,Proctosigmoidoscopy removal,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,45315,Proctosigmoidoscopy removal,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,45317,Proctosigmoidoscopy bleed,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,45320,Proctosigmoidoscopy ablate,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,45321,Proctosigmoidoscopy volvul,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,45327,Proctosigmoidoscopy w/stent,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Molina Duals,CPT,45330,Diagnostic sigmoidoscopy,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Molina Duals,CPT,45331,Sigmoidoscopy and biopsy,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Molina Duals,CPT,45332,Sigmoidoscopy w/fb removal,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,45333,Sigmoidoscopy & polypectomy,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Molina Duals,CPT,45334,Sigmoidoscopy for bleeding,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,45335,Sigmoidoscopy w/submuc inj,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Molina Duals,CPT,45337,Sigmoidoscopy & decompress,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Molina Duals,CPT,45338,Sigmoidoscopy w/tumr remove,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,45340,Sig w/tndsc balloon dilation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,45341,Sigmoidoscopy w/ultrasound,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Molina Duals,CPT,45342,Sigmoidoscopy w/us guide bx,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,45346,Sigmoidoscopy w/ablation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,45347,Sigmoidoscopy w/plcmt stent,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Molina Duals,CPT,45349,Sigmoidoscopy w/resection,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,45350,Sgmdsc w/band ligation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,45378,Diagnostic colonoscopy,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Molina Duals,CPT,45379,Colonoscopy w/fb removal,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,45380,Colonoscopy and biopsy,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,45381,Colonoscopy submucous njx,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,45382,Colonoscopy w/control bleed,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,45384,Colonoscopy w/lesion removal,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,45385,Colonoscopy w/lesion removal,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,45386,Colonoscopy w/balloon dilat,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,45388,Colonoscopy w/ablation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,45389,Colonoscopy w/stent plcmt,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
Molina Duals,CPT,45390,Colonoscopy w/resection,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,45391,Colonoscopy w/endoscope us,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,45392,Colonoscopy w/endoscopic fnb,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,45393,Colonoscopy w/decompression,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,45395,Lap removal of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,45397,Lap remove rectum w/pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,45398,Colonoscopy w/band ligation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,45399,Unlisted procedure colon,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Molina Duals,CPT,45400,Laparoscopic proc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,45402,Lap proctopexy w/sig resect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,45499,Laparoscope proc rectum,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,45500,Repair of rectum,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,45505,Repair of rectum,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,45520,Treatment of rectal prolapse,APC 5311,RVU Per Case,$812.16 ,OP,812.16,"4,314.00",,,,,,
Molina Duals,CPT,45540,Correct rectal prolapse,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,45541,Correct rectal prolapse,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,45550,Repair rectum/remove sigmoid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,45560,Repair of rectocele,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,45562,Exploration/repair of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,45563,Exploration/repair of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,45800,Repair rect/bladder fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,45805,Repair fistula w/colostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,45820,Repair rectourethral fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,45825,Repair fistula w/colostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,45900,Reduction of rectal prolapse,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Molina Duals,CPT,45905,Dilation of anal sphincter,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,45910,Dilation of rectal narrowing,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,45915,Remove rectal obstruction,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,45990,Surg dx exam anorectal,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,45999,Rectum surgery procedure,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Molina Duals,CPT,46020,Placement of seton,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,46030,Removal of rectal marker,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,46040,Incision of rectal abscess,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,46045,Incision of rectal abscess,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,46050,Incision of anal abscess,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Molina Duals,CPT,46060,Incision of rectal abscess,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,46070,Incision of anal septum,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,46080,Incision of anal sphincter,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,46083,Incise external hemorrhoid,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Molina Duals,CPT,46200,Removal of anal fissure,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,46220,Excise anal ext tag/papilla,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,46221,Ligation of hemorrhoid(s),APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Molina Duals,CPT,46230,Removal of anal tags,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,46250,Remove ext hem groups 2+,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,46255,Remove int/ext hem 1 group,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,46257,Remove in/ex hem grp & fiss,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,46258,Remove in/ex hem grp w/fistu,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,46260,Remove in/ex hem groups 2+,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,46261,Remove in/ex hem grps & fiss,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,46262,Remove in/ex hem grps w/fist,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,46270,Remove anal fist subq,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,46275,Remove anal fist inter,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,46280,Remove anal fist complex,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,46285,Remove anal fist 2 stage,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,46288,Repair anal fistula,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,46320,Removal of hemorrhoid clot,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,46500,Injection into hemorrhoid(s),APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Molina Duals,CPT,46505,Chemodenervation anal musc,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,46600,Diagnostic anoscopy spx,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Molina Duals,CPT,46601,Diagnostic anoscopy,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Molina Duals,CPT,46604,Anoscopy and dilation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,46606,Anoscopy and biopsy,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,46607,Diagnostic anoscopy & biopsy,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,46608,Anoscopy remove for body,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Molina Duals,CPT,46610,Anoscopy remove lesion,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,46611,Anoscopy,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Molina Duals,CPT,46612,Anoscopy remove lesions,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,46614,Anoscopy control bleeding,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,46615,Anoscopy,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,46700,Repair of anal stricture,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,46705,Repair of anal stricture,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,46706,Repr of anal fistula w/glue,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,46707,Repair anorectal fist w/plug,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,46710,Repr per/vag pouch sngl proc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,46712,Repr per/vag pouch dbl proc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,46715,Rep perf anoper fistu,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,46716,Rep perf anoper/vestib fistu,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,46730,Construction of absent anus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,46735,Construction of absent anus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,46740,Construction of absent anus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,46742,Repair of imperforated anus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,46744,Repair of cloacal anomaly,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,46746,Repair of cloacal anomaly,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,46748,Repair of cloacal anomaly,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,46750,Repair of anal sphincter,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,46751,Repair of anal sphincter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,46753,Reconstruction of anus,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,46754,Removal of suture from anus,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,46760,Repair of anal sphincter,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,46761,Repair of anal sphincter,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,46900,Destruction anal lesion(s),APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,46910,Destruction anal lesion(s),APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,46916,Cryosurgery anal lesion(s),APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,46917,Laser surgery anal lesions,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,46922,Excision of anal lesion(s),APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,46924,Destruction anal lesion(s),APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,46930,Destroy internal hemorrhoids,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,46940,Treatment of anal fissure,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,46942,Treatment of anal fissure,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Molina Duals,CPT,46945,Int hrhc lig 1 hroid w/o img,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,46946,Int hrhc lig 2+hroid w/o img,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,46947,Hemorrhoidopexy by stapling,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,46948,Int hrhc tranal dartlzj 2+,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
Molina Duals,CPT,46999,Anus surgery procedure,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
Molina Duals,CPT,47000,Needle biopsy of liver,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,47010,Open drainage liver lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47015,Inject/aspirate liver cyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47100,Wedge biopsy of liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47120,Partial removal of liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47122,Extensive removal of liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47125,Partial removal of liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47130,Partial removal of liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47133,Removal of donor liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47135,Transplantation of liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47140,Partial removal donor liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47141,Partial removal donor liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47142,Partial removal donor liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47143,Prep donor liver whole,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47144,Prep donor liver 3-segment,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47145,Prep donor liver lobe split,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47146,Prep donor liver/venous,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47147,Prep donor liver/arterial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47300,Surgery for liver lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47350,Repair liver wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47360,Repair liver wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47361,Repair liver wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47362,Repair liver wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47370,Laparo ablate liver tumor rf,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Molina Duals,CPT,47371,Laparo ablate liver cryosurg,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Molina Duals,CPT,47379,Laparoscope procedure liver,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,47380,Open ablate liver tumor rf,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47381,Open ablate liver tumor cryo,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47382,Percut ablate liver rf,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,47383,Perq abltj lvr cryoablation,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,47399,Liver surgery procedure,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,47400,Incision of liver duct,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47420,Incision of bile duct,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47425,Incision of bile duct,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47460,Incise bile duct sphincter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47480,Incision of gallbladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47490,Incision of gallbladder,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Molina Duals,CPT,47531,Injection for cholangiogram,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Molina Duals,CPT,47532,Injection for cholangiogram,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Molina Duals,CPT,47533,Plmt biliary drainage cath,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Molina Duals,CPT,47534,Plmt biliary drainage cath,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Molina Duals,CPT,47535,Conversion ext bil drg cath,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Molina Duals,CPT,47536,Exchange biliary drg cath,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Molina Duals,CPT,47537,Removal biliary drg cath,APC 5301,RVU Per Case,$828.48 ,OP,828.48,"4,314.00",,,,,,
Molina Duals,CPT,47538,Perq plmt bile duct stent,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,47539,Perq plmt bile duct stent,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,47540,Perq plmt bile duct stent,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,47541,Plmt access bil tree sm bwl,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Molina Duals,CPT,47550,Bile duct endoscopy add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47552,Biliary endo perq dx w/speci,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Molina Duals,CPT,47553,Biliary endoscopy thru skin,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Molina Duals,CPT,47554,Biliary endoscopy thru skin,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,47555,Biliary endoscopy thru skin,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Molina Duals,CPT,47556,Biliary endoscopy thru skin,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,47562,Laparoscopic cholecystectomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,47563,Laparo cholecystectomy/graph,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,47564,Laparo cholecystectomy/explr,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,47570,Laparo cholecystoenterostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47579,Laparoscope proc biliary,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,47600,Removal of gallbladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,47605,Removal of gallbladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,47610,Removal of gallbladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,47612,Removal of gallbladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,47620,Removal of gallbladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,47700,Exploration of bile ducts,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47701,Bile duct revision,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47711,Excision of bile duct tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47712,Excision of bile duct tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47715,Excision of bile duct cyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47720,Fuse gallbladder & bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47721,Fuse upper gi structures,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47740,Fuse gallbladder & bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47741,Fuse gallbladder & bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47760,Fuse bile ducts and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47765,Fuse liver ducts & bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47780,Fuse bile ducts and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47785,Fuse bile ducts and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47800,Reconstruction of bile ducts,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47801,Placement bile duct support,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47802,Fuse liver duct & intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47900,Suture bile duct injury,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,47999,Bile tract surgery procedure,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Molina Duals,CPT,48000,Drainage of abdomen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,48001,Placement of drain pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,48020,Removal of pancreatic stone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,48100,Biopsy of pancreas open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,48102,Needle biopsy pancreas,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,48105,Resect/debride pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,48120,Removal of pancreas lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,48140,Partial removal of pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,48145,Partial removal of pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,48146,Pancreatectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,48148,Removal of pancreatic duct,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,48150,Partial removal of pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,48152,Pancreatectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,48153,Pancreatectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,48154,Pancreatectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,48155,Removal of pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,48400,Injection intraop add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,48500,Surgery of pancreatic cyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,48510,Drain pancreatic pseudocyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,48520,Fuse pancreas cyst and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,48540,Fuse pancreas cyst and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,48545,Pancreatorrhaphy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,48547,Duodenal exclusion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,48548,Fuse pancreas and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,48551,Prep donor pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,48552,Prep donor pancreas/venous,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,48554,Transpl allograft pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,48556,Removal allograft pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,48999,Pancreas surgery procedure,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,49000,Exploration of abdomen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,49002,Reopening of abdomen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,49010,Exploration behind abdomen,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Molina Duals,CPT,49013,Prpertl pel pack hemrrg trma,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,49014,Reexploration pelvic wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,49020,Drainage abdom abscess open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,49040,Drain open abdom abscess,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,49060,Drain open retroperi abscess,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,49062,Drain to peritoneal cavity,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,49082,Abd paracentesis,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Molina Duals,CPT,49083,Abd paracentesis w/imaging,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Molina Duals,CPT,49084,Peritoneal lavage,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Molina Duals,CPT,49180,Biopsy abdominal mass,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,49185,Sclerotx fluid collection,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,49203,Exc abd tum 5 cm or less,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,49204,Exc abd tum over 5 cm,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,49205,Exc abd tum over 10 cm,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,49215,Excise sacral spine tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,49250,Excision of umbilicus,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Molina Duals,CPT,49255,Removal of omentum,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Molina Duals,CPT,49320,Diag laparo separate proc,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,49321,Laparoscopy biopsy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,49322,Laparoscopy aspiration,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,49323,Laparo drain lymphocele,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,49324,Lap insert tunnel ip cath,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,49325,Lap revision perm ip cath,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,49329,Laparo proc abdm/per/oment,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,49402,Remove foreign body adbomen,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Molina Duals,CPT,49405,Image cath fluid colxn visc,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,49406,Image cath fluid peri/retro,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,49407,Image cath fluid trns/vgnl,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,49411,Ins mark abd/pel for rt perq,APC 5613,RVU Per Unit,"$1,291.62 ",OP,"1,291.62","4,314.00",,,,,,
Molina Duals,CPT,49412,Ins device for rt guide open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,49418,Insert tun ip cath perc,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Molina Duals,CPT,49419,Insert tun ip cath w/port,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
Molina Duals,CPT,49421,Ins tun ip cath for dial opn,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Molina Duals,CPT,49422,Remove tunneled ip cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,49423,Exchange drainage catheter,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,49425,Insert abdomen-venous drain,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,49426,Revise abdomen-venous shunt,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Molina Duals,CPT,49428,Ligation of shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,49429,Removal of shunt,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
Molina Duals,CPT,49436,Embedded ip cath exit-site,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,49440,Place gastrostomy tube perc,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,49441,Place duod/jej tube perc,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,49442,Place cecostomy tube perc,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
Molina Duals,CPT,49446,Change g-tube to g-j perc,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
Molina Duals,CPT,49450,Replace g/c tube perc,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Molina Duals,CPT,49451,Replace duod/jej tube perc,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Molina Duals,CPT,49452,Replace g-j tube perc,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Molina Duals,CPT,49460,Fix g/colon tube w/device,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Molina Duals,CPT,49465,Fluoro exam of g/colon tube,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"4,314.00",,,,,,
Molina Duals,CPT,49491,Rpr hern preemie reduc,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,49492,Rpr ing hern premie blocked,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Molina Duals,CPT,49495,Rpr ing hernia baby reduc,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Molina Duals,CPT,49496,Rpr ing hernia baby blocked,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Molina Duals,CPT,49500,Rpr ing hernia init reduce,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Molina Duals,CPT,49501,Rpr ing hernia init blocked,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Molina Duals,CPT,49505,Prp i/hern init reduc >5 yr,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Molina Duals,CPT,49507,Prp i/hern init block >5 yr,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Molina Duals,CPT,49520,Rerepair ing hernia reduce,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Molina Duals,CPT,49521,Rerepair ing hernia blocked,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Molina Duals,CPT,49525,Repair ing hernia sliding,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Molina Duals,CPT,49540,Repair lumbar hernia,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,49550,Rpr rem hernia init reduce,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Molina Duals,CPT,49553,Rpr fem hernia init blocked,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Molina Duals,CPT,49555,Rerepair fem hernia reduce,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Molina Duals,CPT,49557,Rerepair fem hernia blocked,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Molina Duals,CPT,49560,Rpr ventral hern init reduc,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Molina Duals,CPT,49561,Rpr ventral hern init block,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Molina Duals,CPT,49565,Rerepair ventrl hern reduce,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,49566,Rerepair ventrl hern block,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,49570,Rpr epigastric hern reduce,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Molina Duals,CPT,49572,Rpr epigastric hern blocked,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Molina Duals,CPT,49580,Rpr umbil hern reduc < 5 yr,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Molina Duals,CPT,49582,Rpr umbil hern block < 5 yr,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Molina Duals,CPT,49585,Rpr umbil hern reduc > 5 yr,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Molina Duals,CPT,49587,Rpr umbil hern block > 5 yr,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Molina Duals,CPT,49590,Repair spigelian hernia,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Molina Duals,CPT,49600,Repair umbilical lesion,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Molina Duals,CPT,49605,Repair umbilical lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,49606,Repair umbilical lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,49610,Repair umbilical lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,49611,Repair umbilical lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,49650,Lap ing hernia repair init,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,49651,Lap ing hernia repair recur,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,49652,Lap vent/abd hernia repair,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,49653,Lap vent/abd hern proc comp,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,49654,Lap inc hernia repair,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,49655,Lap inc hern repair comp,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Molina Duals,CPT,49656,Lap inc hernia repair recur,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Molina Duals,CPT,49657,Lap inc hern recur comp,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Molina Duals,CPT,49659,Laparo proc hernia repair,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,49900,Repair of abdominal wall,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,49904,Omental flap extra-abdom,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,49905,Omental flap intra-abdom,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,49906,Free omental flap microvasc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,49999,Abdomen surgery procedure,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
Molina Duals,CPT,50010,Exploration of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50020,Renal abscess open drain,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,50040,Drainage of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50045,Exploration of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50060,Removal of kidney stone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50065,Incision of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50070,Incision of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50075,Removal of kidney stone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50080,Removal of kidney stone,APC 5376,RVU Per Case,"$8,450.70 ",OP,"4,314.00","8,450.70",,,,,,
Molina Duals,CPT,50081,Removal of kidney stone,APC 5376,RVU Per Case,"$8,450.70 ",OP,"4,314.00","8,450.70",,,,,,
Molina Duals,CPT,50100,Revise kidney blood vessels,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50120,Exploration of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50125,Explore and drain kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50130,Removal of kidney stone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50135,Exploration of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50200,Renal biopsy perq,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,50205,Renal biopsy open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50220,Remove kidney open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50225,Removal kidney open complex,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50230,Removal kidney open radical,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50234,Removal of kidney & ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50236,Removal of kidney & ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50240,Partial removal of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50250,Cryoablate renal mass open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50280,Removal of kidney lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50290,Removal of kidney lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50300,Remove cadaver donor kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50320,Remove kidney living donor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50323,Prep cadaver renal allograft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50325,Prep donor renal graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50327,Prep renal graft/venous,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50328,Prep renal graft/arterial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50329,Prep renal graft/ureteral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50340,Removal of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50360,Transplantation of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50365,Transplantation of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50370,Remove transplanted kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50380,Reimplantation of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50382,Change ureter stent percut,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,50384,Remove ureter stent percut,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,50385,Change stent via transureth,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,50386,Remove stent via transureth,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,50387,Change nephroureteral cath,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,50389,Remove renal tube w/fluoro,APC 5372,RVU Per Case,$588.17 ,OP,588.17,"4,314.00",,,,,,
Molina Duals,CPT,50390,Drainage of kidney lesion,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,50391,Instll rx agnt into rnal tub,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Molina Duals,CPT,50396,Measure kidney pressure,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Molina Duals,CPT,50400,Revision of kidney/ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50405,Revision of kidney/ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50430,Njx px nfrosgrm &/urtrgrm,APC 5372,RVU Per Case,$588.17 ,OP,588.17,"4,314.00",,,,,,
Molina Duals,CPT,50431,Njx px nfrosgrm &/urtrgrm,APC 5372,RVU Per Case,$588.17 ,OP,588.17,"4,314.00",,,,,,
Molina Duals,CPT,50432,Plmt nephrostomy catheter,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,50433,Plmt nephroureteral catheter,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,50434,Convert nephrostomy catheter,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,50435,Exchange nephrostomy cath,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,50436,Dilat xst trc ndurlgc px,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,50437,Dilat xst trc new access rcs,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,50500,Repair of kidney wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50520,Close kidney-skin fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50525,Close nephrovisceral fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50526,Close nephrovisceral fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50540,Revision of horseshoe kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50541,Laparo ablate renal cyst,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,50542,Laparo ablate renal mass,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Molina Duals,CPT,50543,Laparo partial nephrectomy,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Molina Duals,CPT,50544,Laparoscopy pyeloplasty,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,50545,Laparo radical nephrectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50546,Laparoscopic nephrectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50547,Laparo removal donor kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50548,Laparo remove w/ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50549,Laparoscope proc renal,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,50551,Kidney endoscopy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,50553,Kidney endoscopy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,50555,Kidney endoscopy & biopsy,APC 5376,RVU Per Case,"$8,450.70 ",OP,"4,314.00","8,450.70",,,,,,
Molina Duals,CPT,50557,Kidney endoscopy & treatment,APC 5376,RVU Per Case,"$8,450.70 ",OP,"4,314.00","8,450.70",,,,,,
Molina Duals,CPT,50561,Kidney endoscopy & treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,50562,Renal scope w/tumor resect,APC 5376,RVU Per Case,"$8,450.70 ",OP,"4,314.00","8,450.70",,,,,,
Molina Duals,CPT,50570,Kidney endoscopy,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,50572,Kidney endoscopy,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Molina Duals,CPT,50574,Kidney endoscopy & biopsy,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,50575,Kidney endoscopy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,50576,Kidney endoscopy & treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,50580,Kidney endoscopy & treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,50590,Fragmenting of kidney stone,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,50592,Perc rf ablate renal tumor,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,50593,Perc cryo ablate renal tum,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Molina Duals,CPT,50600,Exploration of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50605,Insert ureteral support,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50610,Removal of ureter stone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50620,Removal of ureter stone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50630,Removal of ureter stone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50650,Removal of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50660,Removal of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50686,Measure ureter pressure,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,"4,314.00",,,,,,
Molina Duals,CPT,50688,Change of ureter tube/stent,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,50693,Plmt ureteral stent prq,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,50694,Plmt ureteral stent prq,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,50695,Plmt ureteral stent prq,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,50700,Revision of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50715,Release of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50722,Release of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50725,Release/revise ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50727,Revise ureter,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,50728,Revise ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50740,Fusion of ureter & kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50750,Fusion of ureter & kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50760,Fusion of ureters,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50770,Splicing of ureters,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50780,Reimplant ureter in bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50782,Reimplant ureter in bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50783,Reimplant ureter in bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50785,Reimplant ureter in bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50800,Implant ureter in bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50810,Fusion of ureter & bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50815,Urine shunt to intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50820,Construct bowel bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50825,Construct bowel bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50830,Revise urine flow,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50840,Replace ureter by bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50845,Appendico-vesicostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50860,Transplant ureter to skin,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50900,Repair of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50920,Closure ureter/skin fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50930,Closure ureter/bowel fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50940,Release of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,50945,Laparoscopy ureterolithotomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,50947,Laparo new ureter/bladder,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,50948,Laparo new ureter/bladder,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Molina Duals,CPT,50949,Laparoscope proc ureter,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,50951,Endoscopy of ureter,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,50953,Endoscopy of ureter,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,50955,Ureter endoscopy & biopsy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,50957,Ureter endoscopy & treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,50961,Ureter endoscopy & treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,50970,Ureter endoscopy,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,50972,Ureter endoscopy & catheter,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,50974,Ureter endoscopy & biopsy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,50976,Ureter endoscopy & treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,50980,Ureter endoscopy & treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,51020,Incise & treat bladder,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,51030,Incise & treat bladder,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,51040,Incise & drain bladder,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,51045,Incise bladder/drain ureter,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,51050,Removal of bladder stone,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,51060,Removal of ureter stone,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,51065,Remove ureter calculus,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,51080,Drainage of bladder abscess,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,51100,Drain bladder by needle,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Molina Duals,CPT,51101,Drain bladder by trocar/cath,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"4,314.00",,,,,,
Molina Duals,CPT,51102,Drain bl w/cath insertion,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,51500,Removal of bladder cyst,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,51520,Removal of bladder lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,51525,Removal of bladder lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,51530,Removal of bladder lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,51535,Repair of ureter lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,51550,Partial removal of bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,51555,Partial removal of bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,51565,Revise bladder & ureter(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,51570,Removal of bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,51575,Removal of bladder & nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,51580,Remove bladder/revise tract,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,51585,Removal of bladder & nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,51590,Remove bladder/revise tract,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,51595,Remove bladder/revise tract,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,51596,Remove bladder/create pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,51597,Removal of pelvic structures,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,51700,Irrigation of bladder,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Molina Duals,CPT,51701,Insert bladder catheter,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Molina Duals,CPT,51702,Insert temp bladder cath,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Molina Duals,CPT,51703,Insert bladder cath complex,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,"4,314.00",,,,,,
Molina Duals,CPT,51705,Change of bladder tube,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Molina Duals,CPT,51710,Change of bladder tube,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Molina Duals,CPT,51715,Endoscopic injection/implant,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,51720,Treatment of bladder lesion,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Molina Duals,CPT,51725,Simple cystometrogram,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Molina Duals,CPT,51726,Complex cystometrogram,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Molina Duals,CPT,51727,Cystometrogram w/up,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Molina Duals,CPT,51728,Cystometrogram w/vp,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Molina Duals,CPT,51729,Cystometrogram w/vp&up,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Molina Duals,CPT,51736,Urine flow measurement,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Molina Duals,CPT,51741,Electro-uroflowmetry first,APC 5721,RVU Per Case,$142.80 ,OP,142.8,"4,314.00",,,,,,
Molina Duals,CPT,51784,Anal/urinary muscle study,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,"4,314.00",,,,,,
Molina Duals,CPT,51785,Anal/urinary muscle study,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Molina Duals,CPT,51792,Urinary reflex study,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Molina Duals,CPT,51798,Us urine capacity measure,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Molina Duals,CPT,51800,Revision of bladder/urethra,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,51820,Revision of urinary tract,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,51840,Attach bladder/urethra,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Molina Duals,CPT,51841,Attach bladder/urethra,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,51845,Repair bladder neck,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Molina Duals,CPT,51860,Repair of bladder wound,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,51865,Repair of bladder wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,51880,Repair of bladder opening,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,51900,Repair bladder/vagina lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,51920,Close bladder-uterus fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,51925,Hysterectomy/bladder repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,51940,Correction of bladder defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,51960,Revision of bladder & bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,51980,Construct bladder opening,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,51990,Laparo urethral suspension,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,51992,Laparo sling operation,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,51999,Laparoscope proc bla,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,52000,Cystoscopy,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Molina Duals,CPT,52001,Cystoscopy removal of clots,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,52005,Cystoscopy & ureter catheter,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,52007,Cystoscopy and biopsy,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,52010,Cystoscopy & duct catheter,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Molina Duals,CPT,52204,Cystoscopy w/biopsy(s),APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,52214,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,52224,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,52234,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,52235,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,52240,Cystoscopy and treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,52250,Cystoscopy and radiotracer,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,52260,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,52265,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,52270,Cystoscopy & revise urethra,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,52275,Cystoscopy & revise urethra,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,52276,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,52277,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,52281,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,52282,Cystoscopy implant stent,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,52283,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,52285,Cystoscopy and treatment,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Molina Duals,CPT,52287,Cystoscopy chemodenervation,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,52290,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,52300,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,52301,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,52305,Cystoscopy and treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,52310,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,52315,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,52317,Remove bladder stone,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,52318,Remove bladder stone,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,52320,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,52325,Cystoscopy stone removal,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,52327,Cystoscopy inject material,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,52330,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,52332,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,52334,Create passage to kidney,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,52341,Cysto w/ureter stricture tx,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,52342,Cysto w/up stricture tx,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,52343,Cysto w/renal stricture tx,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,52344,Cysto/uretero stricture tx,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,52345,Cysto/uretero w/up stricture,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,52346,Cystouretero w/renal strict,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,52351,Cystouretero & or pyeloscope,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,52352,Cystouretero w/stone remove,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,52353,Cystouretero w/lithotripsy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,52354,Cystouretero w/biopsy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,52355,Cystouretero w/excise tumor,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,52356,Cysto/uretero w/lithotripsy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,52400,Cystouretero w/congen repr,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,52402,Cystourethro cut ejacul duct,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,52450,Incision of prostate,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,52500,Revision of bladder neck,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,52601,Prostatectomy (turp),APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,52630,Remove prostate regrowth,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,52640,Relieve bladder contracture,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,52647,Laser surgery of prostate,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,52648,Laser surgery of prostate,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,52649,Prostate laser enucleation,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,52700,Drainage of prostate abscess,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,53000,Incision of urethra,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,53010,Incision of urethra,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,53020,Incision of urethra,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,53025,Incision of urethra,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,53040,Drainage of urethra abscess,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,53060,Drainage of urethra abscess,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,53080,Drainage of urinary leakage,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Molina Duals,CPT,53085,Drainage of urinary leakage,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,53200,Biopsy of urethra,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,53210,Removal of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,53215,Removal of urethra,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,53220,Treatment of urethra lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,53230,Removal of urethra lesion,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,53235,Removal of urethra lesion,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,53240,Surgery for urethra pouch,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,53250,Removal of urethra gland,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,53260,Treatment of urethra lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,53265,Treatment of urethra lesion,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,53270,Removal of urethra gland,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,53275,Repair of urethra defect,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,53400,Revise urethra stage 1,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,53405,Revise urethra stage 2,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,53410,Reconstruction of urethra,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,53415,Reconstruction of urethra,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,53420,Reconstruct urethra stage 1,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,53425,Reconstruct urethra stage 2,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,53430,Reconstruction of urethra,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,53431,Reconstruct urethra/bladder,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,53440,Male sling procedure,APC 5377,RVU Per Case,"$11,755.91 ",OP,"4,140.35","11,755.91",,,,,,
Molina Duals,CPT,53442,Remove/revise male sling,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,53444,Insert tandem cuff,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,314.00","18,684.12",,,,,,
Molina Duals,CPT,53445,Insert uro/ves nck sphincter,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,140.35","18,684.12",,,,,,
Molina Duals,CPT,53446,Remove uro sphincter,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,53447,Remove/replace ur sphincter,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,314.00","18,684.12",,,,,,
Molina Duals,CPT,53448,Remov/replc ur sphinctr comp,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,53449,Repair uro sphincter,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,53450,Revision of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,53460,Revision of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,53500,Urethrlys transvag w/ scope,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,53502,Repair of urethra injury,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,53505,Repair of urethra injury,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,53510,Repair of urethra injury,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,53515,Repair of urethra injury,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,53520,Repair of urethra defect,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,53600,Dilate urethra stricture,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Molina Duals,CPT,53601,Dilate urethra stricture,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Molina Duals,CPT,53605,Dilate urethra stricture,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,53620,Dilate urethra stricture,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Molina Duals,CPT,53621,Dilate urethra stricture,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Molina Duals,CPT,53660,Dilation of urethra,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,"4,314.00",,,,,,
Molina Duals,CPT,53661,Dilation of urethra,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Molina Duals,CPT,53665,Dilation of urethra,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,53850,Prostatic microwave thermotx,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,53852,Prostatic rf thermotx,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,53854,Trurl dstrj prst8 tiss rf wv,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,53855,Insert prost urethral stent,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,53860,Transurethral rf treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,53899,Urology surgery procedure,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Molina Duals,CPT,54000,Slitting of prepuce,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,54001,Slitting of prepuce,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,54015,Drain penis lesion,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,54050,Destruction penis lesion(s),APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
Molina Duals,CPT,54055,Destruction penis lesion(s),APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,54056,Cryosurgery penis lesion(s),APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,54057,Laser surg penis lesion(s),APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,54060,Excision of penis lesion(s),APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,54065,Destruction penis lesion(s),APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,54100,Biopsy of penis,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,54105,Biopsy of penis,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,54110,Treatment of penis lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,54111,Treat penis lesion graft,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,54112,Treat penis lesion graft,APC 5376,RVU Per Case,"$8,450.70 ",OP,"4,314.00","8,450.70",,,,,,
Molina Duals,CPT,54115,Treatment of penis lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,54120,Partial removal of penis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,54125,Removal of penis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,54130,Remove penis & nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,54135,Remove penis & nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,54150,Circumcision w/regionl block,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,54160,Circumcision neonate,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
Molina Duals,CPT,54161,Circum 28 days or older,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,54162,Lysis penil circumic lesion,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,54163,Repair of circumcision,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,54164,Frenulotomy of penis,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,54200,Treatment of penis lesion,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Molina Duals,CPT,54205,Treatment of penis lesion,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,54220,Treatment of penis lesion,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Molina Duals,CPT,54231,Dynamic cavernosometry,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Molina Duals,CPT,54235,Penile injection,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Molina Duals,CPT,54240,Penis study,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"4,314.00",,,,,,
Molina Duals,CPT,54250,Penis study,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Molina Duals,CPT,54300,Revision of penis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,54304,Revision of penis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,54308,Reconstruction of urethra,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,54312,Reconstruction of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,54316,Reconstruction of urethra,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,54318,Reconstruction of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,54322,Reconstruction of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,54324,Reconstruction of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,54326,Reconstruction of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,54328,Revise penis/urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,54332,Revise penis/urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,54336,Revise penis/urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,54340,Secondary urethral surgery,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,54344,Secondary urethral surgery,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,54348,Secondary urethral surgery,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,54352,Reconstruct urethra/penis,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,54360,Penis plastic surgery,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,54380,Repair penis,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,54385,Repair penis,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,54390,Repair penis and bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,54400,Insert semi-rigid prosthesis,APC 5377,RVU Per Case,"$11,755.91 ",OP,"4,314.00","11,755.91",,,,,,
Molina Duals,CPT,54401,Insert self-contd prosthesis,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,314.00","18,684.12",,,,,,
Molina Duals,CPT,54405,Insert multi-comp penis pros,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,140.35","18,684.12",,,,,,
Molina Duals,CPT,54406,Remove muti-comp penis pros,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,54408,Repair multi-comp penis pros,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,54410,Remove/replace penis prosth,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,140.35","18,684.12",,,,,,
Molina Duals,CPT,54411,Remov/replc penis pros comp,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,314.00","18,684.12",,,,,,
Molina Duals,CPT,54415,Remove self-contd penis pros,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,54416,Remv/repl penis contain pros,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,314.00","18,684.12",,,,,,
Molina Duals,CPT,54417,Remv/replc penis pros compl,APC 5377,RVU Per Case,"$11,755.91 ",OP,"4,314.00","11,755.91",,,,,,
Molina Duals,CPT,54420,Revision of penis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,54430,Revision of penis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,54435,Revision of penis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,54437,Repair corporeal tear,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,54438,Replantation of penis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,54440,Repair of penis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,54450,Preputial stretching,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Molina Duals,CPT,54500,Biopsy of testis,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,54505,Biopsy of testis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,54512,Excise lesion testis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,54520,Removal of testis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,54522,Orchiectomy partial,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,54530,Removal of testis,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Molina Duals,CPT,54535,Extensive testis surgery,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,54550,Exploration for testis,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Molina Duals,CPT,54560,Exploration for testis,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,54600,Reduce testis torsion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,54620,Suspension of testis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,54640,Orchiopexy ingun/scrot appr,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Molina Duals,CPT,54650,Orchiopexy (fowler-stephens),APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Molina Duals,CPT,54660,Revision of testis,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,54670,Repair testis injury,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,54680,Relocation of testis(es),APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,54690,Laparoscopy orchiectomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,54692,Laparoscopy orchiopexy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,54699,Laparoscope proc testis,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,54700,Drainage of scrotum,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,54800,Biopsy of epididymis,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,54830,Remove epididymis lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,54840,Remove epididymis lesion,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,54860,Removal of epididymis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,54861,Removal of epididymis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,54865,Explore epididymis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,54900,Fusion of spermatic ducts,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,54901,Fusion of spermatic ducts,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,55000,Drainage of hydrocele,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,55040,Removal of hydrocele,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Molina Duals,CPT,55041,Removal of hydroceles,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Molina Duals,CPT,55060,Repair of hydrocele,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,55100,Drainage of scrotum abscess,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,55110,Explore scrotum,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,55120,Removal of scrotum lesion,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,55150,Removal of scrotum,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,55175,Revision of scrotum,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,55180,Revision of scrotum,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,55200,Incision of sperm duct,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,55250,Removal of sperm duct(s),APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,55400,Repair of sperm duct,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,55500,Removal of hydrocele,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,55520,Removal of sperm cord lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,55530,Revise spermatic cord veins,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,55535,Revise spermatic cord veins,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
Molina Duals,CPT,55540,Revise hernia & sperm veins,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
Molina Duals,CPT,55550,Laparo ligate spermatic vein,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,55559,Laparo proc spermatic cord,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,55600,Incise sperm duct pouch,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,55605,Incise sperm duct pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,55650,Remove sperm duct pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,55680,Remove sperm pouch lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,55700,Biopsy of prostate,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
Molina Duals,CPT,55705,Biopsy of prostate,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,55706,Prostate saturation sampling,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,55720,Drainage of prostate abscess,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,55725,Drainage of prostate abscess,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,55801,Removal of prostate,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,55810,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,55812,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,55815,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,55821,Removal of prostate,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,55831,Removal of prostate,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,55840,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,55842,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,55845,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,55860,Surgical exposure prostate,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,55862,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,55865,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,55866,Laparo radical prostatectomy,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Molina Duals,CPT,55870,Electroejaculation,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Molina Duals,CPT,55873,Cryoablate prostate,APC 5376,RVU Per Case,"$8,450.70 ",OP,"4,314.00","8,450.70",,,,,,
Molina Duals,CPT,55874,Tprnl plmt biodegrdabl matrl,APC 5375,RVU Per Unit,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,55875,Transperi needle place pros,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,55876,Place rt device/marker pros,APC 5613,RVU Per Unit,"$1,291.62 ",OP,"1,291.62","4,314.00",,,,,,
Molina Duals,CPT,55880,Abltj mal prst8 tiss hifu,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
Molina Duals,CPT,55899,Genital surgery procedure,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
Molina Duals,CPT,55920,Place needles pelvic for rt,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Molina Duals,CPT,55970,Sex transformation m to f,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Molina Duals,CPT,55980,Sex transformation f to m,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
Molina Duals,CPT,56405,I & d of vulva/perineum,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Molina Duals,CPT,56420,Drainage of gland abscess,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Molina Duals,CPT,56440,Surgery for vulva lesion,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,56441,Lysis of labial lesion(s),APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,56442,Hymenotomy,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,56501,Destroy vulva lesions sim,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,56515,Destroy vulva lesion/s compl,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
Molina Duals,CPT,56605,Biopsy of vulva/perineum,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Molina Duals,CPT,56620,Partial removal of vulva,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,56625,Complete removal of vulva,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,56630,Extensive vulva surgery,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Molina Duals,CPT,56631,Extensive vulva surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,56632,Extensive vulva surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,56633,Extensive vulva surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,56634,Extensive vulva surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,56637,Extensive vulva surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,56640,Extensive vulva surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,56700,Partial removal of hymen,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,56740,Remove vagina gland lesion,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,56800,Repair of vagina,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,56805,Repair clitoris,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,56810,Repair of perineum,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,56820,Exam of vulva w/scope,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Molina Duals,CPT,56821,Exam/biopsy of vulva w/scope,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Molina Duals,CPT,57000,Exploration of vagina,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,57010,Drainage of pelvic abscess,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,57020,Drainage of pelvic fluid,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Molina Duals,CPT,57022,I & d vaginal hematoma pp,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,57023,I & d vag hematoma non-ob,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,57061,Destroy vag lesions simple,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,57065,Destroy vag lesions complex,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,57100,Biopsy of vagina,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Molina Duals,CPT,57105,Biopsy of vagina,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,57106,Remove vagina wall partial,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,57107,Remove vagina tissue part,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,57109,Vaginectomy partial w/nodes,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,57110,Remove vagina wall complete,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,57111,Remove vagina tissue compl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,57120,Closure of vagina,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Molina Duals,CPT,57130,Remove vagina lesion,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,57135,Remove vagina lesion,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,57150,Treat vagina infection,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Molina Duals,CPT,57155,Insert uteri tandem/ovoids,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Molina Duals,CPT,57156,Ins vag brachytx device,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Molina Duals,CPT,57160,Insert pessary/other device,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Molina Duals,CPT,57170,Fitting of diaphragm/cap,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Molina Duals,CPT,57180,Treat vaginal bleeding,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Molina Duals,CPT,57200,Repair of vagina,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,57210,Repair vagina/perineum,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,57220,Revision of urethra,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Molina Duals,CPT,57230,Repair of urethral lesion,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,57240,Anterior colporrhaphy,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Molina Duals,CPT,57250,Repair rectum & vagina,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Molina Duals,CPT,57260,Cmbn ant pst colprhy,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Molina Duals,CPT,57265,Cmbn ap colprhy w/ntrcl rpr,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Molina Duals,CPT,57268,Repair of bowel bulge,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Molina Duals,CPT,57270,Repair of bowel pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,57280,Suspension of vagina,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,57282,Colpopexy extraperitoneal,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,57283,Colpopexy intraperitoneal,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,57284,Repair paravag defect open,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Molina Duals,CPT,57285,Repair paravag defect vag,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,57287,Revise/remove sling repair,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,57288,Repair bladder defect,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,57289,Repair bladder & vagina,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,314.00","6,952.74",,,,,,
Molina Duals,CPT,57291,Construction of vagina,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Molina Duals,CPT,57292,Construct vagina with graft,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Molina Duals,CPT,57295,Revise vag graft via vagina,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,57296,Revise vag graft open abd,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,57300,Repair rectum-vagina fistula,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,57305,Repair rectum-vagina fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,57307,Fistula repair & colostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,57308,Fistula repair transperine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,57310,Repair urethrovaginal lesion,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,314.00","6,952.74",,,,,,
Molina Duals,CPT,57311,Repair urethrovaginal lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,57320,Repair bladder-vagina lesion,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Molina Duals,CPT,57330,Repair bladder-vagina lesion,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,314.00","6,952.74",,,,,,
Molina Duals,CPT,57335,Repair vagina,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Molina Duals,CPT,57400,Dilation of vagina,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,57410,Pelvic examination,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,57415,Remove vaginal foreign body,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,57420,Exam of vagina w/scope,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Molina Duals,CPT,57421,Exam/biopsy of vag w/scope,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Molina Duals,CPT,57423,Repair paravag defect lap,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
Molina Duals,CPT,57425,Laparoscopy surg colpopexy,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,57426,Revise prosth vag graft lap,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,314.00","6,952.74",,,,,,
Molina Duals,CPT,57452,Exam of cervix w/scope,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Molina Duals,CPT,57454,Bx/curett of cervix w/scope,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Molina Duals,CPT,57455,Biopsy of cervix w/scope,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Molina Duals,CPT,57456,Endocerv curettage w/scope,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Molina Duals,CPT,57460,Bx of cervix w/scope leep,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,57461,Conz of cervix w/scope leep,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,57500,Biopsy of cervix,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Molina Duals,CPT,57505,Endocervical curettage,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Molina Duals,CPT,57510,Cauterization of cervix,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,57511,Cryocautery of cervix,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Molina Duals,CPT,57513,Laser surgery of cervix,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,57520,Conization of cervix,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,57522,Conization of cervix,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,57530,Removal of cervix,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Molina Duals,CPT,57531,Removal of cervix radical,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,57540,Removal of residual cervix,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,57545,Remove cervix/repair pelvis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,57550,Removal of residual cervix,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Molina Duals,CPT,57555,Remove cervix/repair vagina,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Molina Duals,CPT,57556,Remove cervix repair bowel,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Molina Duals,CPT,57558,D&c of cervical stump,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,57700,Revision of cervix,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,57720,Revision of cervix,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,57800,Dilation of cervical canal,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,58100,Biopsy of uterus lining,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Molina Duals,CPT,58120,Dilation and curettage,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,58140,Myomectomy abdom method,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,58145,Myomectomy vag method,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","9,201.00",,,,,,
Molina Duals,CPT,58146,Myomectomy abdom complex,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,58150,Total hysterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,58152,Total hysterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,58180,Partial hysterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,58200,Extensive hysterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,58210,Extensive hysterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,58240,Removal of pelvis contents,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,58260,Vaginal hysterectomy,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Molina Duals,CPT,58262,Vag hyst including t/o,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Molina Duals,CPT,58263,Vag hyst w/t/o & vag repair,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Molina Duals,CPT,58267,Vag hyst w/urinary repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,58270,Vag hyst w/enterocele repair,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Molina Duals,CPT,58275,Hysterectomy/revise vagina,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,58280,Hysterectomy/revise vagina,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,58285,Extensive hysterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,58290,Vag hyst complex,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,314.00","6,952.74",,,,,,
Molina Duals,CPT,58291,Vag hyst incl t/o complex,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Molina Duals,CPT,58292,Vag hyst t/o & repair compl,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,314.00","6,952.74",,,,,,
Molina Duals,CPT,58294,Vag hyst w/enterocele compl,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Molina Duals,CPT,58301,Remove intrauterine device,APC 5412,RVU Per Case,$288.05 ,OP,288.05,"4,314.00",,,,,,
Molina Duals,CPT,58321,Artificial insemination,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Molina Duals,CPT,58322,Artificial insemination,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Molina Duals,CPT,58323,Sperm washing,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Molina Duals,CPT,58345,Reopen fallopian tube,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,58346,Insert heyman uteri capsule,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Molina Duals,CPT,58350,Reopen fallopian tube,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Molina Duals,CPT,58353,Endometr ablate thermal,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Molina Duals,CPT,58356,Endometrial cryoablation,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Molina Duals,CPT,58400,Suspension of uterus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,58410,Suspension of uterus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,58520,Repair of ruptured uterus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,58540,Revision of uterus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,58541,Lsh uterus 250 g or less,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,58542,Lsh w/t/o ut 250 g or less,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,58543,Lsh uterus above 250 g,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,58544,Lsh w/t/o uterus above 250 g,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,58545,Laparoscopic myomectomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,58546,Laparo-myomectomy complex,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,58548,Lap radical hyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,58550,Laparo-asst vag hysterectomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,58552,Laparo-vag hyst incl t/o,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,58553,Laparo-vag hyst complex,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,58554,Laparo-vag hyst w/t/o compl,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,58555,Hysteroscopy dx sep proc,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,58558,Hysteroscopy biopsy,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","9,201.00",,,,,,
Molina Duals,CPT,58559,Hysteroscopy lysis,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,58560,Hysteroscopy resect septum,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,58561,Hysteroscopy remove myoma,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,58562,Hysteroscopy remove fb,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,58563,Hysteroscopy ablation,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Molina Duals,CPT,58565,Hysteroscopy sterilization,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,58570,Tlh uterus 250 g or less,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,58571,Tlh w/t/o 250 g or less,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,58572,Tlh uterus over 250 g,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,58573,Tlh w/t/o uterus over 250 g,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,58575,Laps tot hyst resj mal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,58578,Laparo proc uterus,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,58579,Hysteroscope procedure,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Molina Duals,CPT,58600,Division of fallopian tube,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,58605,Division of fallopian tube,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,58611,Ligate oviduct(s) add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,58615,Occlude fallopian tube(s),APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,58660,Laparoscopy lysis,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,58661,Laparoscopy remove adnexa,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,58662,Laparoscopy excise lesions,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,58670,Laparoscopy tubal cautery,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,58671,Laparoscopy tubal block,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,58672,Laparoscopy fimbrioplasty,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,58673,Laparoscopy salpingostomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,58674,Laps abltj uterine fibroids,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,58679,Laparo proc oviduct-ovary,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,58700,Removal of fallopian tube,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,58720,Removal of ovary/tube(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,58740,Adhesiolysis tube ovary,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,58750,Repair oviduct,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,58752,Revise ovarian tube(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,58760,Fimbrioplasty,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,58770,Create new tubal opening,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,58800,Drainage of ovarian cyst(s),APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,58805,Drainage of ovarian cyst(s),APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,58820,Drain ovary abscess open,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,58822,Drain ovary abscess percut,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,58825,Transposition ovary(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,58900,Biopsy of ovary(s),APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,58920,Partial removal of ovary(s),APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,314.00","6,952.74",,,,,,
Molina Duals,CPT,58925,Removal of ovarian cyst(s),APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Molina Duals,CPT,58940,Removal of ovary(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,58943,Removal of ovary(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,58950,Resect ovarian malignancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,58951,Resect ovarian malignancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,58952,Resect ovarian malignancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,58953,Tah rad dissect for debulk,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,58954,Tah rad debulk/lymph remove,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,58956,Bso omentectomy w/tah,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,58957,Resect recurrent gyn mal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,58958,Resect recur gyn mal w/lym,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,58960,Exploration of abdomen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,58970,Retrieval of oocyte,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Molina Duals,CPT,58974,Transfer of embryo,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Molina Duals,CPT,58976,Transfer of embryo,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Molina Duals,CPT,58999,Genital surgery procedure,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Molina Duals,CPT,59000,Amniocentesis diagnostic,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Molina Duals,CPT,59001,Amniocentesis therapeutic,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Molina Duals,CPT,59012,Fetal cord puncture prenatal,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Molina Duals,CPT,59015,Chorion biopsy,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
Molina Duals,CPT,59020,Fetal contract stress test,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Molina Duals,CPT,59025,Fetal non-stress test,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Molina Duals,CPT,59030,Fetal scalp blood sample,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Molina Duals,CPT,59070,Transabdom amnioinfus w/us,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Molina Duals,CPT,59072,Umbilical cord occlud w/us,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Molina Duals,CPT,59074,Fetal fluid drainage w/us,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Molina Duals,CPT,59076,Fetal shunt placement w/us,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Molina Duals,CPT,59100,Remove uterus lesion,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
Molina Duals,CPT,59120,Treat ectopic pregnancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,59121,Treat ectopic pregnancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,59130,Treat ectopic pregnancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,59135,Treat ectopic pregnancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,59136,Treat ectopic pregnancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,59140,Treat ectopic pregnancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,59150,Treat ectopic pregnancy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,59151,Treat ectopic pregnancy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,59160,D & c after delivery,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,59200,Insert cervical dilator,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Molina Duals,CPT,59300,Episiotomy or vaginal repair,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,59320,Revision of cervix,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,59325,Revision of cervix,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,59350,Repair of uterus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,59409,Obstetrical care,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,59412,Antepartum manipulation,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,59414,Deliver placenta,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,59514,Cesarean delivery only,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,59525,Remove uterus after cesarean,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,59612,Vbac delivery only,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,59620,Attempted vbac delivery only,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,59812,Treatment of miscarriage,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,59820,Care of miscarriage,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,59821,Treatment of miscarriage,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,59830,Treat uterus infection,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,59840,Abortion,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,59841,Abortion,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,59850,Abortion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,59851,Abortion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,59852,Abortion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,59855,Abortion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,59856,Abortion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,59857,Abortion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,59866,Abortion (mpr),APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
Molina Duals,CPT,59870,Evacuate mole of uterus,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,59871,Remove cerclage suture,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
Molina Duals,CPT,59897,Fetal invas px w/us,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Molina Duals,CPT,59898,Laparo proc ob care/deliver,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,59899,Maternity care procedure,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
Molina Duals,CPT,60000,Drain thyroid/tongue cyst,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,60100,Biopsy of thyroid,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,60200,Remove thyroid lesion,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,60210,Partial thyroid excision,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,60212,Partial thyroid excision,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,60220,Partial removal of thyroid,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,60225,Partial removal of thyroid,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,60240,Removal of thyroid,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,60252,Removal of thyroid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,60254,Extensive thyroid surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,60260,Repeat thyroid surgery,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,60270,Removal of thyroid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,60271,Removal of thyroid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,60280,Remove thyroid duct lesion,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,60281,Remove thyroid duct lesion,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,60300,Aspir/inj thyroid cyst,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,60500,Explore parathyroid glands,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,60502,Re-explore parathyroids,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,60505,Explore parathyroid glands,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,60520,Removal of thymus gland,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,60521,Removal of thymus gland,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,60522,Removal of thymus gland,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,60540,Explore adrenal gland,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,60545,Explore adrenal gland,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,60600,Remove carotid body lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,60605,Remove carotid body lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,60650,Laparoscopy adrenalectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,60659,Laparo proc endocrine,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,60699,Endocrine surgery procedure,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
Molina Duals,CPT,61000,Remove cranial cavity fluid,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Molina Duals,CPT,61001,Remove cranial cavity fluid,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Molina Duals,CPT,61020,Remove brain cavity fluid,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Molina Duals,CPT,61026,Injection into brain canal,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Molina Duals,CPT,61050,Remove brain canal fluid,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Molina Duals,CPT,61055,Injection into brain canal,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Molina Duals,CPT,61070,Brain canal shunt procedure,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Molina Duals,CPT,61105,Twist drill hole,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61107,Drill skull for implantation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61108,Drill skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61120,Burr hole for puncture,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61140,Pierce skull for biopsy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61150,Pierce skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61151,Pierce skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61154,Pierce skull & remove clot,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61156,Pierce skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61210,Pierce skull implant device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61215,Insert brain-fluid device,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Molina Duals,CPT,61250,Pierce skull & explore,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61253,Pierce skull & explore,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61304,Open skull for exploration,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61305,Open skull for exploration,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61312,Open skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61313,Open skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61314,Open skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61315,Open skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61316,Implt cran bone flap to abdo,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61320,Open skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61321,Open skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61322,Decompressive craniotomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61323,Decompressive lobectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61330,Decompress eye socket,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,61333,Explore orbit/remove lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61340,Subtemporal decompression,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61343,Incise skull (press relief),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61345,Relieve cranial pressure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61450,Incise skull for surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61458,Incise skull for brain wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61460,Incise skull for surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61500,Removal of skull lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61501,Remove infected skull bone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61510,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61512,Remove brain lining lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61514,Removal of brain abscess,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61516,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61517,Implt brain chemotx add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61518,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61519,Remove brain lining lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61520,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61521,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61522,Removal of brain abscess,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61524,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61526,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61530,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61531,Implant brain electrodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61533,Implant brain electrodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61534,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61535,Remove brain electrodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61536,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61537,Removal of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61538,Removal of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61539,Removal of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61540,Removal of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61541,Incision of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61543,Removal of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61544,Remove & treat brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61545,Excision of brain tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61546,Removal of pituitary gland,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61548,Removal of pituitary gland,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61550,Release of skull seams,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61552,Release of skull seams,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61556,Incise skull/sutures,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61557,Incise skull/sutures,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61558,Excision of skull/sutures,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61559,Excision of skull/sutures,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61563,Excision of skull tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61564,Excision of skull tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61566,Removal of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61567,Incision of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61570,Remove foreign body brain,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61571,Incise skull for brain wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61575,Skull base/brainstem surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61576,Skull base/brainstem surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61580,Craniofacial approach skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61581,Craniofacial approach skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61582,Craniofacial approach skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61583,Craniofacial approach skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61584,Orbitocranial approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61585,Orbitocranial approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61586,Resect nasopharynx skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61590,Infratemporal approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61591,Infratemporal approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61592,Orbitocranial approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61595,Transtemporal approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61596,Transcochlear approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61597,Transcondylar approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61598,Transpetrosal approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61600,Resect/excise cranial lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61601,Resect/excise cranial lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61605,Resect/excise cranial lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61606,Resect/excise cranial lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61607,Resect/excise cranial lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61608,Resect/excise cranial lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61611,Transect artery sinus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61613,Remove aneurysm sinus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61615,Resect/excise lesion skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61616,Resect/excise lesion skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61618,Repair dura,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61619,Repair dura,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61623,Endovasc tempory vessel occl,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Molina Duals,CPT,61624,Transcath occlusion cns,APC 5194,RVU Per Case,"$16,438.60 ",OP,"4,314.00","16,438.60",,,,,,
Molina Duals,CPT,61626,Transcath occlusion non-cns,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
Molina Duals,CPT,61630,Intracranial angioplasty,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61635,Intracran angioplsty w/stent,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61645,Perq art m-thrombect &/nfs,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61650,Evasc prlng admn rx agnt 1st,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61651,Evasc prlng admn rx agnt add,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61680,Intracranial vessel surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61682,Intracranial vessel surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61684,Intracranial vessel surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61686,Intracranial vessel surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61690,Intracranial vessel surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61692,Intracranial vessel surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61697,Brain aneurysm repr complx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61698,Brain aneurysm repr complx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61700,Brain aneurysm repr simple,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61702,Inner skull vessel surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61703,Clamp neck artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61705,Revise circulation to head,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61708,Revise circulation to head,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61710,Revise circulation to head,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61711,Fusion of skull arteries,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61720,Incise skull/brain surgery,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Molina Duals,CPT,61735,Incise skull/brain surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61750,Incise skull/brain biopsy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61751,Brain biopsy w/ct/mr guide,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61760,Implant brain electrodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61770,Incise skull for treatment,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Molina Duals,CPT,61790,Treat trigeminal nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,61791,Treat trigeminal tract,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,61850,Implant neuroelectrodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61860,Implant neuroelectrodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61863,Implant neuroelectrode,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61864,Implant neuroelectrde addl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61867,Implant neuroelectrode,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61868,Implant neuroelectrde addl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,61880,Revise/remove neuroelectrode,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","4,314.00",,,,,,
Molina Duals,CPT,61885,Insrt/redo neurostim 1 array,APC 5464,RVU Per Case,"$20,957.35 ",OP,"4,140.35","20,957.35",,,,,,
Molina Duals,CPT,61886,Implant neurostim arrays,APC 5465,RVU Per Case,"$30,131.14 ",OP,"4,314.00","30,131.14",,,,,,
Molina Duals,CPT,61888,Revise/remove neuroreceiver,APC 5463,RVU Per Case,"$11,498.23 ",OP,"4,314.00","11,498.23",,,,,,
Molina Duals,CPT,62000,Treat skull fracture,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,62005,Treat skull fracture,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,62010,Treatment of head injury,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,62100,Repair brain fluid leakage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,62115,Reduction of skull defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,62117,Reduction of skull defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,62120,Repair skull cavity lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,62121,Incise skull repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,62140,Repair of skull defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,62141,Repair of skull defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,62142,Remove skull plate/flap,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,62143,Replace skull plate/flap,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,62145,Repair of skull & brain,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,62146,Repair of skull with graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,62147,Repair of skull with graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,62148,Retr bone flap to fix skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,62161,Dissect brain w/scope,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,62162,Remove colloid cyst w/scope,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,62164,Remove brain tumor w/scope,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,62165,Remove pituit tumor w/scope,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,62180,Establish brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,62190,Establish brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,62192,Establish brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,62194,Replace/irrigate catheter,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,62200,Establish brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,62201,Brain cavity shunt w/scope,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,62220,Establish brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,62223,Establish brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,62225,Replace/irrigate catheter,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Molina Duals,CPT,62230,Replace/revise brain shunt,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Molina Duals,CPT,62252,Csf shunt reprogram,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,"4,314.00",,,,,,
Molina Duals,CPT,62256,Remove brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,62258,Replace brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,62263,Epidural lysis mult sessions,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Molina Duals,CPT,62264,Epidural lysis on single day,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Molina Duals,CPT,62267,Interdiscal perq aspir dx,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,62268,Drain spinal cord cyst,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Molina Duals,CPT,62269,Needle biopsy spinal cord,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,62270,Dx lmbr spi pnxr,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Molina Duals,CPT,62272,Ther spi pnxr drg csf,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Molina Duals,CPT,62273,Inject epidural patch,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Molina Duals,CPT,62280,Treat spinal cord lesion,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Molina Duals,CPT,62281,Treat spinal cord lesion,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Molina Duals,CPT,62282,Treat spinal canal lesion,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Molina Duals,CPT,62287,Percutaneous diskectomy,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,62292,Njx chemonucleolysis lmbr,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,62294,Injection into spinal artery,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Molina Duals,CPT,62302,Myelography lumbar injection,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"4,314.00",,,,,,
Molina Duals,CPT,62303,Myelography lumbar injection,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"4,314.00",,,,,,
Molina Duals,CPT,62304,Myelography lumbar injection,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"4,314.00",,,,,,
Molina Duals,CPT,62305,Myelography lumbar injection,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"4,314.00",,,,,,
Molina Duals,CPT,62320,Njx interlaminar crv/thrc,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Molina Duals,CPT,62321,Njx interlaminar crv/thrc,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Molina Duals,CPT,62322,Njx interlaminar lmbr/sac,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Molina Duals,CPT,62323,Njx interlaminar lmbr/sac,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Molina Duals,CPT,62324,Njx interlaminar crv/thrc,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Molina Duals,CPT,62325,Njx interlaminar crv/thrc,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Molina Duals,CPT,62326,Njx interlaminar lmbr/sac,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Molina Duals,CPT,62327,Njx interlaminar lmbr/sac,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Molina Duals,CPT,62328,Dx lmbr spi pnxr w/fluor/ct,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Molina Duals,CPT,62329,Ther spi pnxr csf fluor/ct,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Molina Duals,CPT,62350,Implant spinal canal cath,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Molina Duals,CPT,62351,Implant spinal canal cath,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,62355,Remove spinal canal catheter,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,62360,Insert spine infusion device,APC 5471,RVU Per Case,"$17,429.07 ",OP,"4,314.00","17,429.07",,,,,,
Molina Duals,CPT,62361,Implant spine infusion pump,APC 5471,RVU Per Case,"$17,429.07 ",OP,"4,314.00","17,429.07",,,,,,
Molina Duals,CPT,62362,Implant spine infusion pump,APC 5471,RVU Per Case,"$17,429.07 ",OP,"4,140.35","17,429.07",,,,,,
Molina Duals,CPT,62365,Remove spine infusion device,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Molina Duals,CPT,62367,Analyze spine infus pump,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,"4,314.00",,,,,,
Molina Duals,CPT,62368,Analyze sp inf pump w/reprog,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,"4,314.00",,,,,,
Molina Duals,CPT,62369,Anal sp inf pmp w/reprg&fill,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,"4,314.00",,,,,,
Molina Duals,CPT,62370,Anl sp inf pmp w/mdreprg&fil,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,"4,314.00",,,,,,
Molina Duals,CPT,62380,Ndsc dcmprn 1 ntrspc lumbar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,63001,Remove spine lamina 1/2 crvl,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,63003,Remove spine lamina 1/2 thrc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,63005,Remove spine lamina 1/2 lmbr,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,63011,Remove spine lamina 1/2 scrl,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,63012,Remove lamina/facets lumbar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,63015,Remove spine lamina >2 crvcl,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,63016,Remove spine lamina >2 thrc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,63017,Remove spine lamina >2 lmbr,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,63020,Neck spine disk surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,63030,Low back disk surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,63040,Laminotomy single cervical,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,63042,Laminotomy single lumbar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,63045,Remove spine lamina 1 crvl,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,63046,Remove spine lamina 1 thrc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,63047,Remove spine lamina 1 lmbr,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,63050,Cervical laminoplsty 2/> seg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63051,C-laminoplasty w/graft/plate,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63055,Decompress spinal cord thrc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,63056,Decompress spinal cord lmbr,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,63064,Decompress spinal cord thrc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,63075,Neck spine disk surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,63077,Spine disk surgery thorax,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63078,Spine disk surgery thorax,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63081,Remove vert body dcmprn crvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63082,Remove vertebral body add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63085,Remove vert body dcmprn thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63086,Remove vertebral body add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63087,Remov vertbr dcmprn thrclmbr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63088,Remove vertebral body add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63090,Remove vert body dcmprn lmbr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63091,Remove vertebral body add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63101,Remove vert body dcmprn thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63102,Remove vert body dcmprn lmbr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63103,Remove vertebral body add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63170,Incise spinal cord tract(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63172,Drainage of spinal cyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63173,Drainage of spinal cyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63185,Incise spine nrv half segmnt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63190,Incise spine nrv >2 segmnts,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63191,Incise spine accessory nerve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63194,Incise spine & cord cervical,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63195,Incise spine & cord thoracic,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63196,Incise spine&cord 2 trx crvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63197,Incise spine&cord 2 trx thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63198,Incise spin&cord 2 stgs crvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63199,Incise spin&cord 2 stgs thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63200,Release spinal cord lumbar,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63250,Revise spinal cord vsls crvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63251,Revise spinal cord vsls thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63252,Revise spine cord vsl thrlmb,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63265,Excise intraspinl lesion crv,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,63266,Excise intrspinl lesion thrc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,63267,Excise intrspinl lesion lmbr,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,63268,Excise intrspinl lesion scrl,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,63270,Excise intrspinl lesion crvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63271,Excise intrspinl lesion thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63272,Excise intrspinl lesion lmbr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63273,Excise intrspinl lesion scrl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63275,Bx/exc xdrl spine lesn crvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63276,Bx/exc xdrl spine lesn thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63277,Bx/exc xdrl spine lesn lmbr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63278,Bx/exc xdrl spine lesn scrl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63280,Bx/exc idrl spine lesn crvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63281,Bx/exc idrl spine lesn thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63282,Bx/exc idrl spine lesn lmbr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63283,Bx/exc idrl spine lesn scrl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63285,Bx/exc idrl imed lesn cervl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63286,Bx/exc idrl imed lesn thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63287,Bx/exc idrl imed lesn thrlmb,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63290,Bx/exc xdrl/idrl lsn any lvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63295,Repair laminectomy defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63300,Remove vert xdrl body crvcl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63301,Remove vert xdrl body thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63302,Remove vert xdrl body thrlmb,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63303,Remov vert xdrl bdy lmbr/sac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63304,Remove vert idrl body crvcl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63305,Remove vert idrl body thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63306,Remov vert idrl bdy thrclmbr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63307,Remov vert idrl bdy lmbr/sac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63308,Remove vertebral body add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63600,Remove spinal cord lesion,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,63610,Stimulation of spinal cord,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,63650,Implant neuroelectrodes,APC 5462,RVU Per Case,"$6,304.35 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,63655,Implant neuroelectrodes,APC 5464,RVU Per Case,"$20,957.35 ",OP,"4,140.35","20,957.35",,,,,,
Molina Duals,CPT,63661,Remove spine eltrd perq aray,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,63662,Remove spine eltrd plate,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","4,314.00",,,,,,
Molina Duals,CPT,63663,Revise spine eltrd perq aray,APC 5462,RVU Per Case,"$6,304.35 ",OP,"4,314.00","6,304.35",,,,,,
Molina Duals,CPT,63664,Revise spine eltrd plate,APC 5463,RVU Per Case,"$11,498.23 ",OP,"4,314.00","11,498.23",,,,,,
Molina Duals,CPT,63685,Insrt/redo spine n generator,APC 5465,RVU Per Case,"$30,131.14 ",OP,"4,140.35","30,131.14",,,,,,
Molina Duals,CPT,63688,Revise/remove neuroreceiver,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","4,314.00",,,,,,
Molina Duals,CPT,63700,Repair of spinal herniation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63702,Repair of spinal herniation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63704,Repair of spinal herniation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63706,Repair of spinal herniation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63707,Repair spinal fluid leakage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63709,Repair spinal fluid leakage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63710,Graft repair of spine defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63740,Install spinal shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,63741,Install spinal shunt,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Molina Duals,CPT,63744,Revision of spinal shunt,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Molina Duals,CPT,63746,Removal of spinal shunt,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,64400,Njx aa&/strd trigeminal nrv,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Molina Duals,CPT,64405,Njx aa&/strd gr ocpl nrv,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Molina Duals,CPT,64408,Njx aa&/strd vagus nrv,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Molina Duals,CPT,64415,Njx aa&/strd brach plexus,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Molina Duals,CPT,64416,Njx aa&/strd brach plex nfs,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Molina Duals,CPT,64417,Njx aa&/strd axillary nrv,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Molina Duals,CPT,64418,Njx aa&/strd sprscap nrv,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Molina Duals,CPT,64420,Njx aa&/strd ntrcost nrv 1,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Molina Duals,CPT,64421,Njx aa&/strd ntrcost nrv ea,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Molina Duals,CPT,64425,Njx aa&/strd ii ih nerves,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Molina Duals,CPT,64430,Njx aa&/strd pudendal nerve,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Molina Duals,CPT,64435,Njx aa&/strd paracrv nrv,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Molina Duals,CPT,64445,Njx aa&/strd sciatic nerve,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Molina Duals,CPT,64446,Njx aa&/strd sciatic nrv nfs,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Molina Duals,CPT,64447,Njx aa&/strd femoral nerve,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Molina Duals,CPT,64448,Njx aa&/strd fem nerve nfs,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Molina Duals,CPT,64449,Njx aa&/strd lmbr plex nfs,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Molina Duals,CPT,64450,Njx aa&/strd other pn/branch,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Molina Duals,CPT,64451,Njx aa&/strd nrv nrvtg si jt,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Molina Duals,CPT,64454,Njx aa&/strd gnclr nrv brnch,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Molina Duals,CPT,64455,Njx aa&/strd pltr com dg nrv,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Molina Duals,CPT,64461,Pvb thoracic single inj site,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Molina Duals,CPT,64463,Pvb thoracic cont infusion,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Molina Duals,CPT,64479,Njx aa&/strd tfrm epi c/t 1,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Molina Duals,CPT,64483,Njx aa&/strd tfrm epi l/s 1,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Molina Duals,CPT,64490,Inj paravert f jnt c/t 1 lev,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Molina Duals,CPT,64493,Inj paravert f jnt l/s 1 lev,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Molina Duals,CPT,64505,N block spenopalatine gangl,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Molina Duals,CPT,64510,N block stellate ganglion,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Molina Duals,CPT,64517,N block inj hypogas plxs,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Molina Duals,CPT,64520,N block lumbar/thoracic,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Molina Duals,CPT,64530,N block inj celiac pelus,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Molina Duals,CPT,64553,Implant neuroelectrodes,APC 5463,RVU Per Case,"$11,498.23 ",OP,"4,314.00","11,498.23",,,,,,
Molina Duals,CPT,64555,Implant neuroelectrodes,APC 5462,RVU Per Case,"$6,304.35 ",OP,"4,314.00","6,304.35",,,,,,
Molina Duals,CPT,64561,Implant neuroelectrodes,APC 5462,RVU Per Case,"$6,304.35 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,64566,Neuroeltrd stim post tibial,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Molina Duals,CPT,64568,Inc for vagus n elect impl,APC 5465,RVU Per Case,"$30,131.14 ",OP,"4,140.35","30,131.14",,,,,,
Molina Duals,CPT,64569,Revise/repl vagus n eltrd,APC 5463,RVU Per Case,"$11,498.23 ",OP,"4,314.00","11,498.23",,,,,,
Molina Duals,CPT,64570,Remove vagus n eltrd,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Molina Duals,CPT,64575,Implant neuroelectrodes,APC 5463,RVU Per Case,"$11,498.23 ",OP,"4,314.00","11,498.23",,,,,,
Molina Duals,CPT,64580,Implant neuroelectrodes,APC 5464,RVU Per Case,"$20,957.35 ",OP,"4,314.00","20,957.35",,,,,,
Molina Duals,CPT,64581,Implant neuroelectrodes,APC 5462,RVU Per Case,"$6,304.35 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,64585,Revise/remove neuroelectrode,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","4,314.00",,,,,,
Molina Duals,CPT,64590,Insrt/redo pn/gastr stimul,APC 5464,RVU Per Case,"$20,957.35 ",OP,"4,140.35","20,957.35",,,,,,
Molina Duals,CPT,64595,Revise/rmv pn/gastr stimul,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","4,314.00",,,,,,
Molina Duals,CPT,64600,Injection treatment of nerve,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Molina Duals,CPT,64605,Injection treatment of nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,64610,Injection treatment of nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,64611,Chemodenerv saliv glands,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Molina Duals,CPT,64612,Destroy nerve face muscle,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Molina Duals,CPT,64615,Chemodenerv musc migraine,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Molina Duals,CPT,64616,Chemodenerv musc neck dyston,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Molina Duals,CPT,64617,Chemodener muscle larynx emg,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Molina Duals,CPT,64620,Injection treatment of nerve,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Molina Duals,CPT,64624,Dstrj nulyt agt gnclr nrv,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,64625,Rf abltj nrv nrvtg si jt,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,64630,Injection treatment of nerve,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Molina Duals,CPT,64632,N block inj common digit,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Molina Duals,CPT,64633,Destroy cerv/thor facet jnt,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,64635,Destroy lumb/sac facet jnt,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,64640,Injection treatment of nerve,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Molina Duals,CPT,64642,Chemodenerv 1 extremity 1-4,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Molina Duals,CPT,64644,Chemodenerv 1 extrem 5/> mus,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Molina Duals,CPT,64646,Chemodenerv trunk musc 1-5,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Molina Duals,CPT,64647,Chemodenerv trunk musc 6/>,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
Molina Duals,CPT,64650,Chemodenerv eccrine glands,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Molina Duals,CPT,64653,Chemodenerv eccrine glands,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Molina Duals,CPT,64680,Injection treatment of nerve,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Molina Duals,CPT,64681,Injection treatment of nerve,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
Molina Duals,CPT,64702,Revise finger/toe nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,64704,Revise hand/foot nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,64708,Revise arm/leg nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,64712,Revision of sciatic nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,64713,Revision of arm nerve(s),APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,64714,Revise low back nerve(s),APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,64716,Revision of cranial nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,64718,Revise ulnar nerve at elbow,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,64719,Revise ulnar nerve at wrist,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,64721,Carpal tunnel surgery,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,64722,Relieve pressure on nerve(s),APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,64726,Release foot/toe nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,64732,Incision of brow nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,64734,Incision of cheek nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,64736,Incision of chin nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,64738,Incision of jaw nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,64740,Incision of tongue nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,64742,Incision of facial nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,64744,Incise nerve back of head,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,64746,Incise diaphragm nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,64755,Incision of stomach nerves,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,64760,Incision of vagus nerve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,64763,Incise hip/thigh nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,64766,Incise hip/thigh nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,64771,Sever cranial nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,64772,Incision of spinal nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,64774,Remove skin nerve lesion,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,64776,Remove digit nerve lesion,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,64782,Remove limb nerve lesion,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,64784,Remove nerve lesion,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,64786,Remove sciatic nerve lesion,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Molina Duals,CPT,64788,Remove skin nerve lesion,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,64790,Removal of nerve lesion,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,64792,Removal of nerve lesion,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Molina Duals,CPT,64795,Biopsy of nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,64802,Sympathectomy cervical,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,64804,Remove sympathetic nerves,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,64809,Remove sympathetic nerves,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,64818,Remove sympathetic nerves,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,64820,Sympathectomy digital artery,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,64821,Remove sympathetic nerves,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,64822,Remove sympathetic nerves,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,64823,Sympathectomy supfc palmar,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
Molina Duals,CPT,64831,Repair of digit nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,64834,Repair of hand or foot nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Molina Duals,CPT,64835,Repair of hand or foot nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Molina Duals,CPT,64836,Repair of hand or foot nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Molina Duals,CPT,64840,Repair of leg nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Molina Duals,CPT,64856,Repair/transpose nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Molina Duals,CPT,64857,Repair arm/leg nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Molina Duals,CPT,64858,Repair sciatic nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,64861,Repair of arm nerves,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
Molina Duals,CPT,64862,Repair of low back nerves,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Molina Duals,CPT,64864,Repair of facial nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Molina Duals,CPT,64865,Repair of facial nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Molina Duals,CPT,64866,Fusion of facial/other nerve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,64868,Fusion of facial/other nerve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,64885,Nerve graft head/neck </4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Molina Duals,CPT,64886,Nerve graft head/neck >4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Molina Duals,CPT,64890,Nerve graft hand/foot </4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Molina Duals,CPT,64891,Nerve graft hand/foot >4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Molina Duals,CPT,64892,Nerve graft arm/leg <4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Molina Duals,CPT,64893,Nerve graft arm/leg >4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Molina Duals,CPT,64895,Nerve graft hand/foot </4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Molina Duals,CPT,64896,Nerve graft hand/foot >4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Molina Duals,CPT,64897,Nerve graft arm/leg </4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Molina Duals,CPT,64898,Nerve graft arm/leg >4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Molina Duals,CPT,64905,Nerve pedicle transfer,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Molina Duals,CPT,64907,Nerve pedicle transfer,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Molina Duals,CPT,64910,Nerve repair w/allograft,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Molina Duals,CPT,64911,Neurorraphy w/vein autograft,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Molina Duals,CPT,64912,Nrv rpr w/nrv algrft 1st,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
Molina Duals,CPT,64999,Nervous system surgery,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
Molina Duals,CPT,65091,Revise eye,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,65093,Revise eye with implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,65101,Removal of eye,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,65103,Remove eye/insert implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,65105,Remove eye/attach implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,65110,Removal of eye,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,65112,Remove eye/revise socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,65114,Remove eye/revise socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,65125,Revise ocular implant,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,65130,Insert ocular implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,65135,Insert ocular implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,65140,Attach ocular implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,65150,Revise ocular implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,65155,Reinsert ocular implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,65175,Removal of ocular implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,65205,Remove foreign body from eye,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Molina Duals,CPT,65210,Remove foreign body from eye,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Molina Duals,CPT,65220,Remove foreign body from eye,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Molina Duals,CPT,65222,Remove foreign body from eye,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Molina Duals,CPT,65235,Remove foreign body from eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,65260,Remove foreign body from eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,65265,Remove foreign body from eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,65270,Repair of eye wound,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,65272,Repair of eye wound,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,65273,Repair of eye wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,65275,Repair of eye wound,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,65280,Repair of eye wound,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Molina Duals,CPT,65285,Repair of eye wound,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Molina Duals,CPT,65286,Repair of eye wound,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,65290,Repair of eye socket wound,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,65400,Removal of eye lesion,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Molina Duals,CPT,65410,Biopsy of cornea,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,65420,Removal of eye lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,65426,Removal of eye lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,65430,Corneal smear,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Molina Duals,CPT,65435,Curette/treat cornea,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Molina Duals,CPT,65436,Curette/treat cornea,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,65450,Treatment of corneal lesion,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Molina Duals,CPT,65600,Revision of cornea,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,65710,Corneal transplant,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Molina Duals,CPT,65730,Corneal transplant,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","9,201.00",,,,,,
Molina Duals,CPT,65750,Corneal transplant,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Molina Duals,CPT,65755,Corneal transplant,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Molina Duals,CPT,65756,Corneal trnspl endothelial,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","9,201.00",,,,,,
Molina Duals,CPT,65770,Revise cornea with implant,APC 5493,RVU Per Case,"$7,506.93 ",OP,"4,314.00","7,506.93",,,,,,
Molina Duals,CPT,65772,Correction of astigmatism,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Molina Duals,CPT,65775,Correction of astigmatism,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,65778,Cover eye w/membrane,APC 5502,RVU Per Case,$828.42 ,OP,828.42,"4,314.00",,,,,,
Molina Duals,CPT,65779,Cover eye w/membrane suture,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,65780,Ocular reconst transplant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,65781,Ocular reconst transplant,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Molina Duals,CPT,65782,Ocular reconst transplant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,65785,Impltj ntrstrml crnl rng seg,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Molina Duals,CPT,65800,Drainage of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,65810,Drainage of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,65815,Drainage of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,65820,Relieve inner eye pressure,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Molina Duals,CPT,65850,Incision of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,65855,Trabeculoplasty laser surg,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Molina Duals,CPT,65860,Incise inner eye adhesions,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Molina Duals,CPT,65865,Incise inner eye adhesions,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,65870,Incise inner eye adhesions,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,65875,Incise inner eye adhesions,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,65880,Incise inner eye adhesions,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Molina Duals,CPT,65900,Remove eye lesion,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,65920,Remove implant of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,65930,Remove blood clot from eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,66020,Injection treatment of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,66030,Injection treatment of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,66130,Remove eye lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,66150,Glaucoma surgery,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Molina Duals,CPT,66155,Glaucoma surgery,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Molina Duals,CPT,66160,Glaucoma surgery,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,66170,Glaucoma surgery,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,66172,Incision of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,66174,Translum dil eye canal,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Molina Duals,CPT,66175,Trnslum dil eye canal w/stnt,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Molina Duals,CPT,66179,Aqueous shunt eye w/o graft,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Molina Duals,CPT,66180,Aqueous shunt eye w/graft,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","9,201.00",,,,,,
Molina Duals,CPT,66183,Insert ant drainage device,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Molina Duals,CPT,66184,Revision of aqueous shunt,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,66185,Revise aqueous shunt eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,66225,Repair/graft eye lesion,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Molina Duals,CPT,66250,Follow-up surgery of eye,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,66500,Incision of iris,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,66505,Incision of iris,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,66600,Remove iris and lesion,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Molina Duals,CPT,66605,Removal of iris,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,66625,Removal of iris,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,66630,Removal of iris,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,66635,Removal of iris,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,66680,Repair iris & ciliary body,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,66682,Repair iris & ciliary body,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,66700,Destruction ciliary body,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,66710,Ciliary transsleral therapy,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,66711,Ecp ciliary body destruction,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,66720,Destruction ciliary body,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,66740,Destruction ciliary body,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,66761,Revision of iris,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Molina Duals,CPT,66762,Revision of iris,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Molina Duals,CPT,66770,Removal of inner eye lesion,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Molina Duals,CPT,66820,Incision secondary cataract,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,66821,After cataract laser surgery,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Molina Duals,CPT,66825,Reposition intraocular lens,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,66830,Removal of lens lesion,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,66840,Removal of lens material,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,66850,Removal of lens material,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,66852,Removal of lens material,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Molina Duals,CPT,66920,Extraction of lens,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,66930,Extraction of lens,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Molina Duals,CPT,66940,Extraction of lens,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,66982,Xcapsl ctrc rmvl cplx wo ecp,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,66983,Cataract surg w/iol 1 stage,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,66984,Xcapsl ctrc rmvl w/o ecp,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,66985,Insert lens prosthesis,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,66986,Exchange lens prosthesis,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,66987,Xcapsl ctrc rmvl cplx w/ecp,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Molina Duals,CPT,66988,Xcapsl ctrc rmvl w/ecp,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Molina Duals,CPT,66999,Eye surgery procedure,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,67005,Partial removal of eye fluid,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,67010,Partial removal of eye fluid,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,67015,Release of eye fluid,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,67025,Replace eye fluid,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,67027,Implant eye drug system,APC 5494,RVU Per Case,"$15,359.39 ",OP,"4,314.00","15,359.39",,,,,,
Molina Duals,CPT,67028,Injection eye drug,APC 5694,RVU Per Unit,$318.00 ,OP,318,"4,314.00",,,,,,
Molina Duals,CPT,67030,Incise inner eye strands,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,67031,Laser surgery eye strands,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Molina Duals,CPT,67036,Removal of inner eye fluid,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Molina Duals,CPT,67039,Laser treatment of retina,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Molina Duals,CPT,67040,Laser treatment of retina,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Molina Duals,CPT,67041,Vit for macular pucker,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Molina Duals,CPT,67042,Vit for macular hole,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Molina Duals,CPT,67043,Vit for membrane dissect,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Molina Duals,CPT,67101,Repair detached retina crtx,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,67105,Repair detached retina pc,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Molina Duals,CPT,67107,Repair detached retina,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Molina Duals,CPT,67108,Repair detached retina,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","9,201.00",,,,,,
Molina Duals,CPT,67110,Repair detached retina,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,67113,Repair retinal detach cplx,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","9,201.00",,,,,,
Molina Duals,CPT,67115,Release encircling material,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
Molina Duals,CPT,67120,Remove eye implant material,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,67121,Remove eye implant material,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,67141,Treatment of retina,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Molina Duals,CPT,67145,Treatment of retina,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Molina Duals,CPT,67208,Treatment of retinal lesion,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Molina Duals,CPT,67210,Treatment of retinal lesion,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Molina Duals,CPT,67218,Treatment of retinal lesion,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,67220,Treatment of choroid lesion,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Molina Duals,CPT,67221,Ocular photodynamic ther,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Molina Duals,CPT,67227,Dstrj extensive retinopathy,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,67228,Treatment x10sv retinopathy,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Molina Duals,CPT,67229,Tr retinal les preterm inf,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
Molina Duals,CPT,67250,Reinforce eye wall,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,67255,Reinforce/graft eye wall,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,67299,Eye surgery procedure,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,67311,Revise eye muscle,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,67312,Revise two eye muscles,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,67314,Revise eye muscle,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,67316,Revise two eye muscles,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,67318,Revise eye muscle(s),APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,67343,Release eye tissue,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,67345,Destroy nerve of eye muscle,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Molina Duals,CPT,67346,Biopsy eye muscle,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,67399,Unlisted px extraocular musc,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Molina Duals,CPT,67400,Explore/biopsy eye socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,67405,Explore/drain eye socket,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,67412,Explore/treat eye socket,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,67413,Explore/treat eye socket,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,67414,Explr/decompress eye socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,67415,Aspiration orbital contents,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,67420,Explore/treat eye socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,67430,Explore/treat eye socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,67440,Explore/drain eye socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,67445,Explr/decompress eye socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,67450,Explore/biopsy eye socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,67500,Inject/treat eye socket,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Molina Duals,CPT,67505,Inject/treat eye socket,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Molina Duals,CPT,67515,Inject/treat eye socket,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Molina Duals,CPT,67550,Insert eye socket implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,67560,Revise eye socket implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,67570,Decompress optic nerve,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,67599,Orbit surgery procedure,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Molina Duals,CPT,67700,Drainage of eyelid abscess,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Molina Duals,CPT,67710,Incision of eyelid,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Molina Duals,CPT,67715,Incision of eyelid fold,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,67800,Remove eyelid lesion,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Molina Duals,CPT,67801,Remove eyelid lesions,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Molina Duals,CPT,67805,Remove eyelid lesions,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Molina Duals,CPT,67808,Remove eyelid lesion(s),APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,67810,Biopsy eyelid & lid margin,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Molina Duals,CPT,67820,Revise eyelashes,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Molina Duals,CPT,67825,Revise eyelashes,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Molina Duals,CPT,67830,Revise eyelashes,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Molina Duals,CPT,67835,Revise eyelashes,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,67840,Remove eyelid lesion,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Molina Duals,CPT,67850,Treat eyelid lesion,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Molina Duals,CPT,67875,Closure of eyelid by suture,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Molina Duals,CPT,67880,Revision of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,67882,Revision of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,67900,Repair brow defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,67901,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,67902,Repair eyelid defect,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,67903,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,67904,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,67906,Repair eyelid defect,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,67908,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,67909,Revise eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,67911,Revise eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,67912,Correction eyelid w/implant,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,67914,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,67915,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,67916,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,67917,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,67921,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,67922,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,67923,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,67924,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,67930,Repair eyelid wound,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,67935,Repair eyelid wound,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,67938,Remove eyelid foreign body,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Molina Duals,CPT,67950,Revision of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,67961,Revision of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,67966,Revision of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,67971,Reconstruction of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,67973,Reconstruction of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,67974,Reconstruction of eyelid,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,67975,Reconstruction of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,67999,Revision of eyelid,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Molina Duals,CPT,68020,Incise/drain eyelid lining,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Molina Duals,CPT,68040,Treatment of eyelid lesions,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Molina Duals,CPT,68100,Biopsy of eyelid lining,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,68110,Remove eyelid lining lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,68115,Remove eyelid lining lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,68130,Remove eyelid lining lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,68135,Remove eyelid lining lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,68200,Treat eyelid by injection,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Molina Duals,CPT,68320,Revise/graft eyelid lining,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,68325,Revise/graft eyelid lining,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,68326,Revise/graft eyelid lining,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,68328,Revise/graft eyelid lining,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,68330,Revise eyelid lining,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
Molina Duals,CPT,68335,Revise/graft eyelid lining,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,68340,Separate eyelid adhesions,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,68360,Revise eyelid lining,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,68362,Revise eyelid lining,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,68371,Harvest eye tissue alograft,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,68399,Eyelid lining surgery,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Molina Duals,CPT,68400,Incise/drain tear gland,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
Molina Duals,CPT,68420,Incise/drain tear sac,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,68440,Incise tear duct opening,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Molina Duals,CPT,68500,Removal of tear gland,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,68505,Partial removal tear gland,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,68510,Biopsy of tear gland,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,68520,Removal of tear sac,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,68525,Biopsy of tear sac,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,68530,Clearance of tear duct,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Molina Duals,CPT,68540,Remove tear gland lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,68550,Remove tear gland lesion,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,68700,Repair tear ducts,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,68705,Revise tear duct opening,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Molina Duals,CPT,68720,Create tear sac drain,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,68745,Create tear duct drain,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,68750,Create tear duct drain,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
Molina Duals,CPT,68760,Close tear duct opening,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Molina Duals,CPT,68761,Close tear duct opening,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Molina Duals,CPT,68770,Close tear system fistula,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,68801,Dilate tear duct opening,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
Molina Duals,CPT,68810,Probe nasolacrimal duct,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Molina Duals,CPT,68811,Probe nasolacrimal duct,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,68815,Probe nasolacrimal duct,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,68816,Probe nl duct w/balloon,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
Molina Duals,CPT,68840,Explore/irrigate tear ducts,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Molina Duals,CPT,68899,Tear duct system surgery,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
Molina Duals,CPT,69000,Drain external ear lesion,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,69005,Drain external ear lesion,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,69020,Drain outer ear canal lesion,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
Molina Duals,CPT,69100,Biopsy of external ear,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Molina Duals,CPT,69105,Biopsy of external ear canal,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,69110,Remove external ear partial,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,69120,Removal of external ear,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,69140,Remove ear canal lesion(s),APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,69145,Remove ear canal lesion(s),APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
Molina Duals,CPT,69150,Extensive ear canal surgery,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,69155,Extensive ear/neck surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,69200,Clear outer ear canal,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
Molina Duals,CPT,69205,Clear outer ear canal,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
Molina Duals,CPT,69209,Remove impacted ear wax uni,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Molina Duals,CPT,69210,Remove impacted ear wax uni,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
Molina Duals,CPT,69220,Clean out mastoid cavity,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
Molina Duals,CPT,69222,Clean out mastoid cavity,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Molina Duals,CPT,69300,Revise external ear,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,69310,Rebuild outer ear canal,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,69320,Rebuild outer ear canal,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,69399,Outer ear surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Molina Duals,CPT,69420,Incision of eardrum,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Molina Duals,CPT,69421,Incision of eardrum,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,69424,Remove ventilating tube,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,69433,Create eardrum opening,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
Molina Duals,CPT,69436,Create eardrum opening,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,69440,Exploration of middle ear,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,69450,Eardrum revision,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,69501,Mastoidectomy,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,69502,Mastoidectomy,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,69505,Remove mastoid structures,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,69511,Extensive mastoid surgery,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,69530,Extensive mastoid surgery,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,69535,Remove part of temporal bone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,69540,Remove ear lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,69550,Remove ear lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,69552,Remove ear lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,69554,Remove ear lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,69601,Mastoid surgery revision,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,69602,Mastoid surgery revision,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,69603,Mastoid surgery revision,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,69604,Mastoid surgery revision,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,69610,Repair of eardrum,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,69620,Repair of eardrum,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,69631,Repair eardrum structures,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,69632,Rebuild eardrum structures,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,69633,Rebuild eardrum structures,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,69635,Repair eardrum structures,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,69636,Rebuild eardrum structures,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,69637,Rebuild eardrum structures,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,69641,Revise middle ear & mastoid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,69642,Revise middle ear & mastoid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,69643,Revise middle ear & mastoid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,69644,Revise middle ear & mastoid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,69645,Revise middle ear & mastoid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,69646,Revise middle ear & mastoid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,69650,Release middle ear bone,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,69660,Revise middle ear bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,69661,Revise middle ear bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,69662,Revise middle ear bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,69666,Repair middle ear structures,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,69667,Repair middle ear structures,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,69670,Remove mastoid air cells,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,69676,Remove middle ear nerve,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,69700,Close mastoid fistula,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,69705,Nps surg dilat eust tube uni,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,69706,Nps surg dilat eust tube bi,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,69711,Remove/repair hearing aid,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,69714,Implant temple bone w/stimul,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,69715,Temple bne implnt w/stimulat,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
Molina Duals,CPT,69717,Temple bone implant revision,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
Molina Duals,CPT,69718,Revise temple bone implant,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
Molina Duals,CPT,69720,Release facial nerve,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,69725,Release facial nerve,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,69740,Repair facial nerve,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,69745,Repair facial nerve,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,69799,Middle ear surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Molina Duals,CPT,69801,Incise inner ear,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
Molina Duals,CPT,69805,Explore inner ear,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,69806,Explore inner ear,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,69905,Remove inner ear,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,69910,Remove inner ear & mastoid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,69915,Incise inner ear nerve,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
Molina Duals,CPT,69930,Implant cochlear device,APC 5166,RVU Per Case,"$35,230.37 ",OP,"4,140.35","35,230.37",,,,,,
Molina Duals,CPT,69949,Inner ear surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Molina Duals,CPT,69950,Incise inner ear nerve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
Molina Duals,CPT,69955,Release facial nerve,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,69960,Release inner ear canal,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,69970,Remove inner ear lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
Molina Duals,CPT,69979,Temporal bone surgery,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
Molina Duals,CPT,70010,Contrast x-ray of brain,APC 5572,RVU Per Case,$376.70 ,OP,376.7,899.79,,,,,,
Molina Duals,CPT,70015,Contrast x-ray of brain,APC 5573,RVU Per Case,$731.85 ,OP,731.85,735.85,,,,,,
Molina Duals,CPT,70030,X-ray eye for foreign body,APC 5521,RVU Per Case,$82.79 ,OP,82.79,144.88,,,,,,
Molina Duals,CPT,70100,X-ray exam of jaw <4views,APC 5521,RVU Per Case,$82.79 ,OP,82.79,156.32,,,,,,
Molina Duals,CPT,70110,X-ray exam of jaw 4/> views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,202.07,,,,,,
Molina Duals,CPT,70120,X-ray exam of mastoids,APC 5522,RVU Per Case,$111.51 ,OP,111.51,171.58,,,,,,
Molina Duals,CPT,70130,X-ray exam of mastoids,APC 5522,RVU Per Case,$111.51 ,OP,111.51,282.14,,,,,,
Molina Duals,CPT,70134,X-ray exam of middle ear,APC 5524,RVU Per Case,$494.15 ,OP,244.01,494.15,,,,,,
Molina Duals,CPT,70140,X-ray exam of facial bones,APC 5521,RVU Per Case,$82.79 ,OP,82.79,156.32,,,,,,
Molina Duals,CPT,70150,X-ray exam of facial bones,APC 5522,RVU Per Case,$111.51 ,OP,111.51,221.14,,,,,,
Molina Duals,CPT,70160,X-ray exam of nasal bones,APC 5521,RVU Per Case,$82.79 ,OP,82.79,163.95,,,,,,
Molina Duals,CPT,70170,X-ray exam of tear duct,APC 5523,RVU Per Case,$235.49 ,OP,235.49,274.51,,,,,,
Molina Duals,CPT,70190,X-ray exam of eye sockets,APC 5521,RVU Per Case,$82.79 ,OP,82.79,183.02,,,,,,
Molina Duals,CPT,70200,X-ray exam of eye sockets,APC 5522,RVU Per Case,$111.51 ,OP,111.51,228.77,,,,,,
Molina Duals,CPT,70210,X-ray exam of sinuses,APC 5521,RVU Per Case,$82.79 ,OP,82.79,156.32,,,,,,
Molina Duals,CPT,70220,X-ray exam of sinuses,APC 5521,RVU Per Case,$82.79 ,OP,82.79,202.07,,,,,,
Molina Duals,CPT,70240,X-ray exam pituitary saddle,APC 5521,RVU Per Case,$82.79 ,OP,82.79,148.69,,,,,,
Molina Duals,CPT,70250,X-ray exam of skull,APC 5522,RVU Per Case,$111.51 ,OP,111.51,186.82,,,,,,
Molina Duals,CPT,70260,X-ray exam of skull,APC 5522,RVU Per Case,$111.51 ,OP,111.51,251.64,,,,,,
Molina Duals,CPT,70300,X-ray exam of teeth,APC 5521,RVU Per Case,$82.79 ,OP,76.26,82.79,,,,,,
Molina Duals,CPT,70310,X-ray exam of teeth,APC 5523,RVU Per Case,$235.49 ,OP,235.49,235.49,,,,,,
Molina Duals,CPT,70320,Full mouth x-ray of teeth,APC 5523,RVU Per Case,$235.49 ,OP,235.49,247.83,,,,,,
Molina Duals,CPT,70328,X-ray exam of jaw joint,APC 5521,RVU Per Case,$82.79 ,OP,82.79,152.51,,,,,,
Molina Duals,CPT,70330,X-ray exam of jaw joints,APC 5521,RVU Per Case,$82.79 ,OP,82.79,244.01,,,,,,
Molina Duals,CPT,70332,X-ray exam of jaw joint,APC 5523,RVU Per Case,$235.49 ,OP,235.49,446.08,,,,,,
Molina Duals,CPT,70336,Magnetic image jaw joint,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Molina Duals,CPT,70350,X-ray head for orthodontia,APC 5521,RVU Per Case,$82.79 ,OP,82.79,106.76,,,,,,
Molina Duals,CPT,70355,Panoramic x-ray of jaws,APC 5521,RVU Per Case,$82.79 ,OP,82.79,122,,,,,,
Molina Duals,CPT,70360,X-ray exam of neck,APC 5521,RVU Per Case,$82.79 ,OP,82.79,137.25,,,,,,
Molina Duals,CPT,70370,Throat x-ray & fluoroscopy,APC 5521,RVU Per Case,$82.79 ,OP,82.79,381.27,,,,,,
Molina Duals,CPT,70371,Speech evaluation complex,APC 5523,RVU Per Case,$235.49 ,OP,235.49,510.9,,,,,,
Molina Duals,CPT,70380,X-ray exam of salivary gland,APC 5521,RVU Per Case,$82.79 ,OP,82.79,190.64,,,,,,
Molina Duals,CPT,70390,X-ray exam of salivary duct,APC 5523,RVU Per Case,$235.49 ,OP,235.49,235.49,,,,,,
Molina Duals,CPT,70450,Ct head/brain w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Molina Duals,CPT,70460,Ct head/brain w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Molina Duals,CPT,70470,Ct head/brain w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Molina Duals,CPT,70480,Ct orbit/ear/fossa w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Molina Duals,CPT,70481,Ct orbit/ear/fossa w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Molina Duals,CPT,70482,Ct orbit/ear/fossa w/o&w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Molina Duals,CPT,70486,Ct maxillofacial w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Molina Duals,CPT,70487,Ct maxillofacial w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Molina Duals,CPT,70488,Ct maxillofacial w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Molina Duals,CPT,70490,Ct soft tissue neck w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Molina Duals,CPT,70491,Ct soft tissue neck w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Molina Duals,CPT,70492,Ct sft tsue nck w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Molina Duals,CPT,70496,Ct angiography head,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Molina Duals,CPT,70498,Ct angiography neck,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Molina Duals,CPT,70540,Mri orbit/face/neck w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Molina Duals,CPT,70542,Mri orbit/face/neck w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Molina Duals,CPT,70543,Mri orbt/fac/nck w/o &w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Molina Duals,CPT,70544,Mr angiography head w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Molina Duals,CPT,70545,Mr angiography head w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Molina Duals,CPT,70546,Mr angiograph head w/o&w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Molina Duals,CPT,70547,Mr angiography neck w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Molina Duals,CPT,70548,Mr angiography neck w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Molina Duals,CPT,70549,Mr angiograph neck w/o&w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Molina Duals,CPT,70551,Mri brain stem w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Molina Duals,CPT,70552,Mri brain stem w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Molina Duals,CPT,70553,Mri brain stem w/o & w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Molina Duals,CPT,70554,Fmri brain by tech,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Molina Duals,CPT,70555,Fmri brain by phys/psych,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,507.00",,,,,,
Molina Duals,CPT,70557,Mri brain w/o dye,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,149.44",,,,,,
Molina Duals,CPT,70558,Mri brain w/dye,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,"1,609.22",,,,,,
Molina Duals,CPT,70559,Mri brain w/o & w/dye,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,"1,609.22",,,,,,
Molina Duals,CPT,71045,X-ray exam chest 1 view,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,152.51,,,,,,
Molina Duals,CPT,71046,X-ray exam chest 2 views,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,167.76,,,,,,
Molina Duals,CPT,71047,X-ray exam chest 3 views,APC 5521,RVU Per Case,$82.79 ,OP,82.79,240.2,,,,,,
Molina Duals,CPT,71048,X-ray exam chest 4+ views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,240.2,,,,,,
Molina Duals,CPT,71100,X-ray exam ribs uni 2 views,APC 5521,RVU Per Case,$82.79 ,OP,82.79,171.58,,,,,,
Molina Duals,CPT,71101,X-ray exam unilat ribs/chest,APC 5522,RVU Per Case,$111.51 ,OP,111.51,202.07,,,,,,
Molina Duals,CPT,71110,X-ray exam ribs bil 3 views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,213.51,,,,,,
Molina Duals,CPT,71111,X-ray exam ribs/chest4/> vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,270.71,,,,,,
Molina Duals,CPT,71120,X-ray exam breastbone 2/>vws,APC 5521,RVU Per Case,$82.79 ,OP,82.79,171.58,,,,,,
Molina Duals,CPT,71130,X-ray strenoclavic jt 3/>vws,APC 5521,RVU Per Case,$82.79 ,OP,82.79,194.45,,,,,,
Molina Duals,CPT,71250,Ct thorax dx c-,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Molina Duals,CPT,71260,Ct thorax dx c+,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Molina Duals,CPT,71270,Ct thorax dx c-/c+,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Molina Duals,CPT,71271,Ct thorax lung cancer scr c-,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,927,,,,,,
Molina Duals,CPT,71275,Ct angiography chest,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Molina Duals,CPT,71550,Mri chest w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Molina Duals,CPT,71551,Mri chest w/dye,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"1,609.22",,,,,,
Molina Duals,CPT,71552,Mri chest w/o & w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Molina Duals,CPT,72020,X-ray exam of spine 1 view,APC 5521,RVU Per Case,$82.79 ,OP,82.79,122,,,,,,
Molina Duals,CPT,72040,X-ray exam neck spine 2-3 vw,APC 5521,RVU Per Case,$82.79 ,OP,82.79,190.64,,,,,,
Molina Duals,CPT,72050,X-ray exam neck spine 4/5vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,293.57,,,,,,
Molina Duals,CPT,72052,X-ray exam neck spine 6/>vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,339.33,,,,,,
Molina Duals,CPT,72070,X-ray exam thorac spine 2vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,175.39,,,,,,
Molina Duals,CPT,72072,X-ray exam thorac spine 3vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,202.07,,,,,,
Molina Duals,CPT,72074,X-ray exam thorac spine4/>vw,APC 5522,RVU Per Case,$111.51 ,OP,111.51,236.38,,,,,,
Molina Duals,CPT,72080,X-ray exam thoracolmb 2/> vw,APC 5521,RVU Per Case,$82.79 ,OP,82.79,183.02,,,,,,
Molina Duals,CPT,72081,X-ray exam entire spi 1 vw,APC 5521,RVU Per Case,$82.79 ,OP,82.79,354.58,,,,,,
Molina Duals,CPT,72082,X-ray exam entire spi 2/3 vw,APC 5522,RVU Per Case,$111.51 ,OP,111.51,354.58,,,,,,
Molina Duals,CPT,72083,X-ray exam entire spi 4/5 vw,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,354.58,,,,,,
Molina Duals,CPT,72084,X-ray exam entire spi 6/> vw,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,354.58,,,,,,
Molina Duals,CPT,72100,X-ray exam l-s spine 2/3 vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,202.07,,,,,,
Molina Duals,CPT,72110,X-ray exam l-2 spine 4/>vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,301.2,,,,,,
Molina Duals,CPT,72114,X-ray exam l-s spine bending,APC 5522,RVU Per Case,$111.51 ,OP,111.51,362.21,,,,,,
Molina Duals,CPT,72120,X-ray bend only l-s spine,APC 5522,RVU Per Case,$111.51 ,OP,111.51,251.64,,,,,,
Molina Duals,CPT,72125,Ct neck spine w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Molina Duals,CPT,72126,Ct neck spine w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,965.53,,,,,,
Molina Duals,CPT,72127,Ct neck spine w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Molina Duals,CPT,72128,Ct chest spine w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Molina Duals,CPT,72129,Ct chest spine w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Molina Duals,CPT,72130,Ct chest spine w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Molina Duals,CPT,72131,Ct lumbar spine w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Molina Duals,CPT,72132,Ct lumbar spine w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,965.53,,,,,,
Molina Duals,CPT,72133,Ct lumbar spine w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Molina Duals,CPT,72141,Mri neck spine w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Molina Duals,CPT,72142,Mri neck spine w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Molina Duals,CPT,72146,Mri chest spine w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Molina Duals,CPT,72147,Mri chest spine w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Molina Duals,CPT,72148,Mri lumbar spine w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Molina Duals,CPT,72149,Mri lumbar spine w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Molina Duals,CPT,72156,Mri neck spine w/o & w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Molina Duals,CPT,72157,Mri chest spine w/o & w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Molina Duals,CPT,72158,Mri lumbar spine w/o & w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Molina Duals,CPT,72170,X-ray exam of pelvis,APC 5522,RVU Per Case,$111.51 ,OP,111.51,133.45,,,,,,
Molina Duals,CPT,72190,X-ray exam of pelvis,APC 5522,RVU Per Case,$111.51 ,OP,111.51,205.88,,,,,,
Molina Duals,CPT,72191,Ct angiograph pelv w/o&w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Molina Duals,CPT,72192,Ct pelvis w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Molina Duals,CPT,72193,Ct pelvis w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Molina Duals,CPT,72194,Ct pelvis w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Molina Duals,CPT,72195,Mri pelvis w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Molina Duals,CPT,72196,Mri pelvis w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Molina Duals,CPT,72197,Mri pelvis w/o & w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Molina Duals,CPT,72200,X-ray exam si joints,APC 5522,RVU Per Case,$111.51 ,OP,111.51,148.69,,,,,,
Molina Duals,CPT,72202,X-ray exam si joints 3/> vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,183.02,,,,,,
Molina Duals,CPT,72220,X-ray exam sacrum tailbone,APC 5521,RVU Per Case,$82.79 ,OP,82.79,156.32,,,,,,
Molina Duals,CPT,72240,Myelography neck spine,APC 5573,RVU Per Case,$731.85 ,OP,731.85,842.61,,,,,,
Molina Duals,CPT,72255,Myelography thoracic spine,APC 5573,RVU Per Case,$731.85 ,OP,731.85,766.35,,,,,,
Molina Duals,CPT,72265,Myelography l-s spine,APC 5573,RVU Per Case,$731.85 ,OP,731.85,781.61,,,,,,
Molina Duals,CPT,72270,Myelogphy 2/> spine regions,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"1,216.24",,,,,,
Molina Duals,CPT,72285,Discography cerv/thor spine,APC 5431,RVU Per Case,"$1,795.30 ",OP,976.05,"1,795.30",,,,,,
Molina Duals,CPT,72295,X-ray of lower spine disk,APC 5431,RVU Per Case,"$1,795.30 ",OP,873.11,"1,795.30",,,,,,
Molina Duals,CPT,73000,X-ray exam of collar bone,APC 5521,RVU Per Case,$82.79 ,OP,82.79,141.07,,,,,,
Molina Duals,CPT,73010,X-ray exam of shoulder blade,APC 5522,RVU Per Case,$111.51 ,OP,111.51,144.88,,,,,,
Molina Duals,CPT,73020,X-ray exam of shoulder,APC 5521,RVU Per Case,$82.79 ,OP,82.79,122,,,,,,
Molina Duals,CPT,73030,X-ray exam of shoulder,APC 5521,RVU Per Case,$82.79 ,OP,82.79,163.95,,,,,,
Molina Duals,CPT,73040,Contrast x-ray of shoulder,APC 5572,RVU Per Case,$376.70 ,OP,376.7,552.84,,,,,,
Molina Duals,CPT,73050,X-ray exam of shoulders,APC 5521,RVU Per Case,$82.79 ,OP,82.79,186.82,,,,,,
Molina Duals,CPT,73060,X-ray exam of humerus,APC 5521,RVU Per Case,$82.79 ,OP,82.79,152.51,,,,,,
Molina Duals,CPT,73070,X-ray exam of elbow,APC 5521,RVU Per Case,$82.79 ,OP,82.79,137.25,,,,,,
Molina Duals,CPT,73080,X-ray exam of elbow,APC 5521,RVU Per Case,$82.79 ,OP,82.79,179.2,,,,,,
Molina Duals,CPT,73085,Contrast x-ray of elbow,APC 5572,RVU Per Case,$376.70 ,OP,376.7,503.28,,,,,,
Molina Duals,CPT,73090,X-ray exam of forearm,APC 5521,RVU Per Case,$82.79 ,OP,82.79,137.25,,,,,,
Molina Duals,CPT,73092,X-ray exam of arm infant,APC 5522,RVU Per Case,$111.51 ,OP,111.51,141.07,,,,,,
Molina Duals,CPT,73100,X-ray exam of wrist,APC 5521,RVU Per Case,$82.79 ,OP,82.79,144.88,,,,,,
Molina Duals,CPT,73110,X-ray exam of wrist,APC 5521,RVU Per Case,$82.79 ,OP,82.79,171.58,,,,,,
Molina Duals,CPT,73115,Contrast x-ray of wrist,APC 5572,RVU Per Case,$376.70 ,OP,376.7,526.16,,,,,,
Molina Duals,CPT,73120,X-ray exam of hand,APC 5522,RVU Per Case,$111.51 ,OP,111.51,137.25,,,,,,
Molina Duals,CPT,73130,X-ray exam of hand,APC 5521,RVU Per Case,$82.79 ,OP,82.79,156.32,,,,,,
Molina Duals,CPT,73140,X-ray exam of finger(s),APC 5521,RVU Per Case,$82.79 ,OP,82.79,160.13,,,,,,
Molina Duals,CPT,73200,Ct upper extremity w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Molina Duals,CPT,73201,Ct upper extremity w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,965.53,,,,,,
Molina Duals,CPT,73202,Ct uppr extremity w/o&w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Molina Duals,CPT,73206,Ct angio upr extrm w/o&w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Molina Duals,CPT,73218,Mri upper extremity w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Molina Duals,CPT,73219,Mri upper extremity w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Molina Duals,CPT,73220,Mri uppr extremity w/o&w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Molina Duals,CPT,73221,Mri joint upr extrem w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Molina Duals,CPT,73222,Mri joint upr extrem w/dye,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"1,609.22",,,,,,
Molina Duals,CPT,73223,Mri joint upr extr w/o&w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Molina Duals,CPT,73501,X-ray exam hip uni 1 view,APC 5521,RVU Per Case,$82.79 ,OP,82.79,129.64,,,,,,
Molina Duals,CPT,73502,X-ray exam hip uni 2-3 views,APC 5521,RVU Per Case,$82.79 ,OP,82.79,198.25,,,,,,
Molina Duals,CPT,73503,X-ray exam hip uni 4/> views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,198.25,,,,,,
Molina Duals,CPT,73521,X-ray exam hips bi 2 views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,202.07,,,,,,
Molina Duals,CPT,73522,X-ray exam hips bi 3-4 views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,202.07,,,,,,
Molina Duals,CPT,73523,X-ray exam hips bi 5/> views,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,202.07,,,,,,
Molina Duals,CPT,73525,Contrast x-ray of hip,APC 5572,RVU Per Case,$376.70 ,OP,376.7,503.28,,,,,,
Molina Duals,CPT,73551,X-ray exam of femur 1,APC 5521,RVU Per Case,$82.79 ,OP,82.79,148.69,,,,,,
Molina Duals,CPT,73552,X-ray exam of femur 2/>,APC 5521,RVU Per Case,$82.79 ,OP,82.79,148.69,,,,,,
Molina Duals,CPT,73560,X-ray exam of knee 1 or 2,APC 5521,RVU Per Case,$82.79 ,OP,82.79,144.88,,,,,,
Molina Duals,CPT,73562,X-ray exam of knee 3,APC 5521,RVU Per Case,$82.79 ,OP,82.79,186.82,,,,,,
Molina Duals,CPT,73564,X-ray exam knee 4 or more,APC 5522,RVU Per Case,$111.51 ,OP,111.51,205.88,,,,,,
Molina Duals,CPT,73565,X-ray exam of knees,APC 5521,RVU Per Case,$82.79 ,OP,82.79,152.51,,,,,,
Molina Duals,CPT,73580,Contrast x-ray of knee joint,APC 5572,RVU Per Case,$376.70 ,OP,376.7,625.29,,,,,,
Molina Duals,CPT,73590,X-ray exam of lower leg,APC 5521,RVU Per Case,$82.79 ,OP,82.79,137.25,,,,,,
Molina Duals,CPT,73592,X-ray exam of leg infant,APC 5521,RVU Per Case,$82.79 ,OP,82.79,141.07,,,,,,
Molina Duals,CPT,73600,X-ray exam of ankle,APC 5521,RVU Per Case,$82.79 ,OP,82.79,137.25,,,,,,
Molina Duals,CPT,73610,X-ray exam of ankle,APC 5521,RVU Per Case,$82.79 ,OP,82.79,156.32,,,,,,
Molina Duals,CPT,73615,Contrast x-ray of ankle,APC 5572,RVU Per Case,$376.70 ,OP,376.7,376.7,,,,,,
Molina Duals,CPT,73620,X-ray exam of foot,APC 5521,RVU Per Case,$82.79 ,OP,82.79,133.45,,,,,,
Molina Duals,CPT,73630,X-ray exam of foot,APC 5521,RVU Per Case,$82.79 ,OP,82.79,156.32,,,,,,
Molina Duals,CPT,73650,X-ray exam of heel,APC 5521,RVU Per Case,$82.79 ,OP,82.79,137.25,,,,,,
Molina Duals,CPT,73660,X-ray exam of toe(s),APC 5521,RVU Per Case,$82.79 ,OP,82.79,141.07,,,,,,
Molina Duals,CPT,73700,Ct lower extremity w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Molina Duals,CPT,73701,Ct lower extremity w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Molina Duals,CPT,73702,Ct lwr extremity w/o&w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Molina Duals,CPT,73706,Ct angio lwr extr w/o&w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Molina Duals,CPT,73718,Mri lower extremity w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Molina Duals,CPT,73719,Mri lower extremity w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Molina Duals,CPT,73720,Mri lwr extremity w/o&w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Molina Duals,CPT,73721,Mri jnt of lwr extre w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Molina Duals,CPT,73722,Mri joint of lwr extr w/dye,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"1,609.22",,,,,,
Molina Duals,CPT,73723,Mri joint lwr extr w/o&w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Molina Duals,CPT,74018,X-ray exam abdomen 1 view,APC 5521,RVU Per Case,$82.79 ,OP,82.79,137.25,,,,,,
Molina Duals,CPT,74019,X-ray exam abdomen 2 views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,194.45,,,,,,
Molina Duals,CPT,74021,X-ray exam abdomen 3+ views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,205.88,,,,,,
Molina Duals,CPT,74022,X-ray exam complete abdomen,APC 5522,RVU Per Case,$111.51 ,OP,111.51,251.64,,,,,,
Molina Duals,CPT,74150,Ct abdomen w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Molina Duals,CPT,74160,Ct abdomen w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Molina Duals,CPT,74170,Ct abdomen w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Molina Duals,CPT,74174,Ct angio abd&pelv w/o&w/dye,APC 5572,RVU Per Unit,$376.70 ,OP,376.7,965.53,,,,,,
Molina Duals,CPT,74175,Ct angio abdom w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Molina Duals,CPT,74176,Ct abd & pelvis w/o contrast,APC 5523,RVU Per Case,$235.49 ,OP,235.49,927,,,,,,
Molina Duals,CPT,74177,Ct abd & pelv w/contrast,APC 5572,RVU Per Case,$376.70 ,OP,376.7,965.53,,,,,,
Molina Duals,CPT,74178,Ct abd & pelv 1/> regns,APC 5572,RVU Per Case,$376.70 ,OP,376.7,927,,,,,,
Molina Duals,CPT,74181,Mri abdomen w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Molina Duals,CPT,74182,Mri abdomen w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Molina Duals,CPT,74183,Mri abdomen w/o & w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Molina Duals,CPT,74190,X-ray exam of peritoneum,APC 5524,RVU Per Case,$494.15 ,OP,400.34,494.15,,,,,,
Molina Duals,CPT,74210,X-ray xm phrnx&/crv esoph c+,APC 5571,RVU Per Case,$182.72 ,OP,182.72,182.72,,,,,,
Molina Duals,CPT,74220,X-ray xm esophagus 1cntrst,APC 5571,RVU Per Case,$182.72 ,OP,182.72,446.08,,,,,,
Molina Duals,CPT,74221,X-ray xm esophagus 2cntrst,APC 5571,RVU Per Case,$182.72 ,OP,182.72,446.08,,,,,,
Molina Duals,CPT,74230,X-ray xm swlng funcj c+,APC 5571,RVU Per Case,$182.72 ,OP,182.72,457.52,,,,,,
Molina Duals,CPT,74240,X-ray xm upr gi trc 1cntrst,APC 5571,RVU Per Case,$182.72 ,OP,182.72,552.84,,,,,,
Molina Duals,CPT,74246,X-ray xm upr gi trc 2cntrst,APC 5571,RVU Per Case,$182.72 ,OP,182.72,632.91,,,,,,
Molina Duals,CPT,74250,X-ray xm sm int 1cntrst std,APC 5571,RVU Per Case,$182.72 ,OP,182.72,518.52,,,,,,
Molina Duals,CPT,74251,X-ray xm sm int 2cntrst std,APC 5571,RVU Per Case,$182.72 ,OP,182.72,"1,593.72",,,,,,
Molina Duals,CPT,74261,Ct colonography dx,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
Molina Duals,CPT,74262,Ct colonography dx w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,182.72,,,,,,
Molina Duals,CPT,74270,X-ray xm colon 1cntrst std,APC 5571,RVU Per Case,$182.72 ,OP,182.72,747.28,,,,,,
Molina Duals,CPT,74280,X-ray xm colon 2cntrst std,APC 5571,RVU Per Case,$182.72 ,OP,182.72,"1,029.43",,,,,,
Molina Duals,CPT,74283,Ther nma rdctj intus/obstrcj,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,182.72,,,,,,
Molina Duals,CPT,74290,Contrast x-ray gallbladder,APC 5571,RVU Per Case,$182.72 ,OP,182.72,331.7,,,,,,
Molina Duals,CPT,74400,Urography iv +-kub tomog,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,568.09,,,,,,
Molina Duals,CPT,74410,Urography nfs drip&/bolus,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,598.59,,,,,,
Molina Duals,CPT,74415,Urography nfs drip&/bls w/nf,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,682.47,,,,,,
Molina Duals,CPT,74420,Urography rtrgr +-kub,APC 5572,RVU Per Unit,$376.70 ,OP,376.7,659.6,,,,,,
Molina Duals,CPT,74425,Urography antegrade rs&i,APC 5572,RVU Per Case,$376.70 ,OP,366.02,376.7,,,,,,
Molina Duals,CPT,74430,Contrast x-ray bladder,APC 5572,RVU Per Case,$376.70 ,OP,376.7,404.14,,,,,,
Molina Duals,CPT,74440,X-ray male genital tract,APC 5523,RVU Per Case,$235.49 ,OP,235.49,434.65,,,,,,
Molina Duals,CPT,74445,X-ray exam of penis,APC 5522,RVU Per Case,$111.51 ,OP,111.51,545.21,,,,,,
Molina Duals,CPT,74450,X-ray urethra/bladder,APC 5523,RVU Per Case,$235.49 ,OP,235.49,396.52,,,,,,
Molina Duals,CPT,74455,X-ray urethra/bladder,APC 5523,RVU Per Case,$235.49 ,OP,235.49,472.78,,,,,,
Molina Duals,CPT,74470,X-ray exam of kidney lesion,APC 5524,RVU Per Case,$494.15 ,OP,400.34,494.15,,,,,,
Molina Duals,CPT,74485,Dilation urtr/urt rs&i,APC 5373,RVU Per Case,"$1,834.80 ",OP,629.1,"1,834.80",,,,,,
Molina Duals,CPT,74710,X-ray measurement of pelvis,APC 5521,RVU Per Case,$82.79 ,OP,82.79,232.58,,,,,,
Molina Duals,CPT,74712,Mri fetal sngl/1st gestation,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,507.00",,,,,,
Molina Duals,CPT,74740,X-ray female genital tract,APC 5523,RVU Per Case,$235.49 ,OP,235.49,404.14,,,,,,
Molina Duals,CPT,74775,X-ray exam of perineum,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,457.52,,,,,,
Molina Duals,CPT,75557,Cardiac mri for morph,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Molina Duals,CPT,75559,Cardiac mri w/stress img,APC 5524,RVU Per Case,$494.15 ,OP,494.15,"1,507.00",,,,,,
Molina Duals,CPT,75561,Cardiac mri for morph w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
Molina Duals,CPT,75563,Card mri w/stress img & dye,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"1,609.22",,,,,,
Molina Duals,CPT,75571,Ct hrt w/o dye w/ca test,APC 5521,RVU Per Case,$82.79 ,OP,82.79,927,,,,,,
Molina Duals,CPT,75572,Ct hrt w/3d image,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,927,,,,,,
Molina Duals,CPT,75573,Ct hrt w/3d image congen,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,927,,,,,,
Molina Duals,CPT,75574,Ct angio hrt w/3d image,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,927,,,,,,
Molina Duals,CPT,75600,Contrast exam thoracic aorta,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,742.41","2,928.39",,,,,,
Molina Duals,CPT,75605,Contrast exam thoracic aorta,APC 5184,RVU Per Case,"$4,881.61 ",OP,"1,506.03","4,881.61",,,,,,
Molina Duals,CPT,75625,Contrast exam abdominl aorta,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,486.95","2,928.39",,,,,,
Molina Duals,CPT,75630,X-ray aorta leg arteries,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","2,928.39",,,,,,
Molina Duals,CPT,75635,Ct angio abdominal arteries,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
Molina Duals,CPT,75705,Artery x-rays spine,APC 5184,RVU Per Case,"$4,881.61 ",OP,"1,826.28","4,881.61",,,,,,
Molina Duals,CPT,75710,Artery x-rays arm/leg,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,567.02","2,928.39",,,,,,
Molina Duals,CPT,75716,Artery x-rays arms/legs,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,730.97","2,928.39",,,,,,
Molina Duals,CPT,75726,Artery x-rays abdomen,APC 5184,RVU Per Case,"$4,881.61 ",OP,"1,547.95","4,881.61",,,,,,
Molina Duals,CPT,75731,Artery x-rays adrenal gland,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,601.33","2,928.39",,,,,,
Molina Duals,CPT,75733,Artery x-rays adrenals,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,795.78","2,928.39",,,,,,
Molina Duals,CPT,75736,Artery x-rays pelvis,APC 5184,RVU Per Case,"$4,881.61 ",OP,"1,563.20","4,881.61",,,,,,
Molina Duals,CPT,75741,Artery x-rays lung,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,506.03","2,928.39",,,,,,
Molina Duals,CPT,75743,Artery x-rays lungs,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,635.64","2,928.39",,,,,,
Molina Duals,CPT,75746,Artery x-rays lung,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,517.46","2,928.39",,,,,,
Molina Duals,CPT,75756,Artery x-rays chest,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,601.33","2,928.39",,,,,,
Molina Duals,CPT,75801,Lymph vessel x-ray arm/leg,APC 5181,RVU Per Case,$554.25 ,OP,554.25,"1,281.07",,,,,,
Molina Duals,CPT,75803,Lymph vessel x-ray arms/legs,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,437.39","1,438.93",,,,,,
Molina Duals,CPT,75805,Lymph vessel x-ray trunk,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,483.14","2,928.39",,,,,,
Molina Duals,CPT,75807,Lymph vessel x-ray trunk,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,582.28","2,928.39",,,,,,
Molina Duals,CPT,75809,Nonvascular shunt x-ray,APC 5522,RVU Per Case,$111.51 ,OP,111.51,446.08,,,,,,
Molina Duals,CPT,75810,Vein x-ray spleen/liver,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,836.65","2,928.39",,,,,,
Molina Duals,CPT,75820,Vein x-ray arm/leg,APC 5182,RVU Per Case,"$1,438.93 ",OP,610.03,"1,438.93",,,,,,
Molina Duals,CPT,75822,Vein x-ray arms/legs,APC 5182,RVU Per Case,"$1,438.93 ",OP,747.28,"1,438.93",,,,,,
Molina Duals,CPT,75825,Vein x-ray trunk,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,441.20","2,928.39",,,,,,
Molina Duals,CPT,75827,Vein x-ray chest,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,433.58","1,438.93",,,,,,
Molina Duals,CPT,75831,Vein x-ray kidney,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,456.44","2,928.39",,,,,,
Molina Duals,CPT,75833,Vein x-ray kidneys,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,608.95","2,928.39",,,,,,
Molina Duals,CPT,75840,Vein x-ray adrenal gland,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,445.01","2,928.39",,,,,,
Molina Duals,CPT,75842,Vein x-ray adrenal glands,APC 5184,RVU Per Case,"$4,881.61 ",OP,"1,616.58","4,881.61",,,,,,
Molina Duals,CPT,75860,Vein x-ray neck,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,479.33","2,928.39",,,,,,
Molina Duals,CPT,75870,Vein x-ray skull,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,467.89","2,928.39",,,,,,
Molina Duals,CPT,75872,Vein x-ray skull epidural,APC 5181,RVU Per Case,$554.25 ,OP,554.25,"1,608.95",,,,,,
Molina Duals,CPT,75880,Vein x-ray eye socket,APC 5181,RVU Per Case,$554.25 ,OP,554.25,613.85,,,,,,
Molina Duals,CPT,75885,Vein x-ray liver w/hemodynam,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,536.51","2,928.39",,,,,,
Molina Duals,CPT,75887,Vein x-ray liver w/o hemodyn,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,547.95","2,928.39",,,,,,
Molina Duals,CPT,75889,Vein x-ray liver w/hemodynam,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,456.44","2,928.39",,,,,,
Molina Duals,CPT,75891,Vein x-ray liver,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,456.44","2,928.39",,,,,,
Molina Duals,CPT,75893,Venous sampling by catheter,APC 5184,RVU Per Case,"$4,881.61 ",OP,"1,296.32","4,881.61",,,,,,
Molina Duals,CPT,75898,Follow-up angiography,APC 5183,RVU Per Case,"$2,928.39 ",OP,655.78,"2,928.39",,,,,,
Molina Duals,CPT,75956,Xray endovasc thor ao repr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,75957,Xray endovasc thor ao repr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,597.52","8,948.83",,,,,,
Molina Duals,CPT,75958,Xray place prox ext thor ao,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,052.29","8,948.83",,,,,,
Molina Duals,CPT,75959,Xray place dist ext thor ao,APC 5881,RVU Per Case,"$8,948.83 ",OP,926.48,"8,948.83",,,,,,
Molina Duals,CPT,76000,Fluoroscopy <1 hr phys/qhp,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,495.65,,,,,,
Molina Duals,CPT,76010,X-ray nose to rectum,APC 5521,RVU Per Case,$82.79 ,OP,82.79,144.88,,,,,,
Molina Duals,CPT,76080,X-ray exam of fistula,APC 5524,RVU Per Case,$494.15 ,OP,331.7,494.15,,,,,,
Molina Duals,CPT,76098,X-ray exam surgical specimen,APC 5524,RVU Per Case,$494.15 ,OP,102.95,494.15,,,,,,
Molina Duals,CPT,76100,X-ray exam of body section,APC 5522,RVU Per Case,$111.51 ,OP,111.51,690.1,,,,,,
Molina Duals,CPT,76101,Complex body section x-ray,APC 5522,RVU Per Case,$111.51 ,OP,111.51,949.36,,,,,,
Molina Duals,CPT,76102,Complex body section x-rays,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,111.51,,,,,,
Molina Duals,CPT,76120,Cine/video x-rays,APC 5522,RVU Per Case,$111.51 ,OP,111.51,392.7,,,,,,
Molina Duals,CPT,76145,Med physic dos eval rad exps,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,129.83,,,,,,
Molina Duals,CPT,76380,Cat scan follow-up study,APC 5521,RVU Per Case,$82.79 ,OP,82.79,689.66,,,,,,
Molina Duals,CPT,76390,Mr spectroscopy,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,"1,507.00",,,,,,
Molina Duals,CPT,76391,Mr elastography,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Molina Duals,CPT,76496,Fluoroscopic procedure,APC 5521,RVU Per Case,$82.79 ,OP,82.79,82.79,,,,,,
Molina Duals,CPT,76497,Ct procedure,APC 5521,RVU Per Case,$82.79 ,OP,82.79,927,,,,,,
Molina Duals,CPT,76498,Mri procedure,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,"1,507.00",,,,,,
Molina Duals,CPT,76499,Radiographic procedure,APC 5521,RVU Per Case,$82.79 ,OP,82.79,82.79,,,,,,
Molina Duals,CPT,76506,Echo exam of head,APC 5522,RVU Per Case,$111.51 ,OP,111.51,602.41,,,,,,
Molina Duals,CPT,76510,Oph us dx b-scan&quan a-scan,APC 5734,RVU Per Case,$114.56 ,OP,114.56,751.1,,,,,,
Molina Duals,CPT,76511,Oph us dx quan a-scan only,APC 5522,RVU Per Case,$111.51 ,OP,111.51,495.65,,,,,,
Molina Duals,CPT,76512,Oph us dx b-scan,APC 5522,RVU Per Case,$111.51 ,OP,111.51,468.96,,,,,,
Molina Duals,CPT,76513,Oph us dx ant sgm us uni/bi,APC 5522,RVU Per Case,$111.51 ,OP,111.51,438.47,,,,,,
Molina Duals,CPT,76514,Echo exam of eye thickness,APC 5731,RVU Per Case,$25.25 ,OP,25.25,64.82,,,,,,
Molina Duals,CPT,76516,Echo exam of eye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,346.96,,,,,,
Molina Duals,CPT,76519,Echo exam of eye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,369.83,,,,,,
Molina Duals,CPT,76529,Echo exam of eye,APC 5521,RVU Per Case,$82.79 ,OP,82.79,354.58,,,,,,
Molina Duals,CPT,76536,Us exam of head and neck,APC 5522,RVU Per Case,$111.51 ,OP,111.51,594.77,,,,,,
Molina Duals,CPT,76604,Us exam chest,APC 5522,RVU Per Case,$111.51 ,OP,111.51,446.08,,,,,,
Molina Duals,CPT,76641,Ultrasound breast complete,APC 5522,RVU Per Case,$111.51 ,OP,111.51,174.71,,,,,,
Molina Duals,CPT,76642,Ultrasound breast limited,APC 5521,RVU Per Case,$82.79 ,OP,82.79,174.71,,,,,,
Molina Duals,CPT,76700,Us exam abdom complete,APC 5522,RVU Per Case,$111.51 ,OP,111.51,739.67,,,,,,
Molina Duals,CPT,76705,Echo exam of abdomen,APC 5522,RVU Per Case,$111.51 ,OP,111.51,537.6,,,,,,
Molina Duals,CPT,76706,Us abdl aorta screen aaa,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,575.73,,,,,,
Molina Duals,CPT,76770,Us exam abdo back wall comp,APC 5522,RVU Per Case,$111.51 ,OP,111.51,678.66,,,,,,
Molina Duals,CPT,76775,Us exam abdo back wall lim,APC 5522,RVU Per Case,$111.51 ,OP,111.51,602.41,,,,,,
Molina Duals,CPT,76776,Us exam k transpl w/doppler,APC 5522,RVU Per Case,$111.51 ,OP,111.51,751.1,,,,,,
Molina Duals,CPT,76800,Us exam spinal canal,APC 5522,RVU Per Case,$111.51 ,OP,111.51,632.91,,,,,,
Molina Duals,CPT,76801,Ob us < 14 wks single fetus,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,712.98,,,,,,
Molina Duals,CPT,76805,Ob us >= 14 wks sngl fetus,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,789.23,,,,,,
Molina Duals,CPT,76811,Ob us detailed sngl fetus,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,204.81",,,,,,
Molina Duals,CPT,76813,Ob us nuchal meas 1 gest,APC 5522,RVU Per Case,$111.51 ,OP,111.51,667.22,,,,,,
Molina Duals,CPT,76815,Ob us limited fetus(s),APC 5522,RVU Per Case,$111.51 ,OP,111.51,472.78,,,,,,
Molina Duals,CPT,76816,Ob us follow-up per fetus,APC 5522,RVU Per Case,$111.51 ,OP,111.51,571.91,,,,,,
Molina Duals,CPT,76817,Transvaginal us obstetric,APC 5522,RVU Per Case,$111.51 ,OP,111.51,560.47,,,,,,
Molina Duals,CPT,76818,Fetal biophys profile w/nst,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,625.29,,,,,,
Molina Duals,CPT,76819,Fetal biophys profil w/o nst,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,526.16,,,,,,
Molina Duals,CPT,76820,Umbilical artery echo,APC 5522,RVU Per Case,$111.51 ,OP,111.51,297.39,,,,,,
Molina Duals,CPT,76821,Middle cerebral artery echo,APC 5522,RVU Per Case,$111.51 ,OP,111.51,510.9,,,,,,
Molina Duals,CPT,76825,Echo exam of fetal heart,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,067.55",,,,,,
Molina Duals,CPT,76826,Echo exam of fetal heart,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,587.16,,,,,,
Molina Duals,CPT,76827,Echo exam of fetal heart,APC 5522,RVU Per Case,$111.51 ,OP,111.51,381.27,,,,,,
Molina Duals,CPT,76828,Echo exam of fetal heart,APC 5522,RVU Per Case,$111.51 ,OP,111.51,282.14,,,,,,
Molina Duals,CPT,76830,Transvaginal us non-ob,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,651.97,,,,,,
Molina Duals,CPT,76831,Echo exam uterus,APC 5523,RVU Per Case,$235.49 ,OP,235.49,621.47,,,,,,
Molina Duals,CPT,76856,Us exam pelvic complete,APC 5522,RVU Per Case,$111.51 ,OP,111.51,655.78,,,,,,
Molina Duals,CPT,76857,Us exam pelvic limited,APC 5522,RVU Per Case,$111.51 ,OP,111.51,518.52,,,,,,
Molina Duals,CPT,76870,Us exam scrotum,APC 5522,RVU Per Case,$111.51 ,OP,111.51,621.47,,,,,,
Molina Duals,CPT,76872,Us transrectal,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,735.85,,,,,,
Molina Duals,CPT,76873,Echograp trans r pros study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,934.12,,,,,,
Molina Duals,CPT,76881,Us compl joint r-t w/img,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,644.34,,,,,,
Molina Duals,CPT,76882,Us lmtd jt/nonvasc xtr strux,APC 5522,RVU Per Case,$111.51 ,OP,111.51,644.34,,,,,,
Molina Duals,CPT,76885,Us exam infant hips dynamic,APC 5521,RVU Per Case,$82.79 ,OP,82.79,701.54,,,,,,
Molina Duals,CPT,76886,Us exam infant hips static,APC 5521,RVU Per Case,$82.79 ,OP,82.79,518.52,,,,,,
Molina Duals,CPT,76936,Echo guide for artery repair,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,654.72",,,,,,
Molina Duals,CPT,76975,Gi endoscopic ultrasound,APC 5523,RVU Per Case,$235.49 ,OP,235.49,529.96,,,,,,
Molina Duals,CPT,76977,Us bone density measure,APC 5522,RVU Per Unit,$111.51 ,OP,80.07,111.51,,,,,,
Molina Duals,CPT,76978,Us trgt dyn mbubb 1st les,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,182.72,,,,,,
Molina Duals,CPT,76981,Use parenchyma,APC 5522,RVU Per Case,$111.51 ,OP,111.51,111.51,,,,,,
Molina Duals,CPT,76982,Use 1st target lesion,APC 5522,RVU Per Case,$111.51 ,OP,111.51,111.51,,,,,,
Molina Duals,CPT,76999,Echo examination procedure,APC 5521,RVU Per Case,$82.79 ,OP,82.79,82.79,,,,,,
Molina Duals,CPT,77046,Mri breast c- unilateral,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Molina Duals,CPT,77047,Mri breast c- bilateral,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Molina Duals,CPT,77053,X-ray of mammary duct,APC 5523,RVU Per Case,$235.49 ,OP,235.49,411.78,,,,,,
Molina Duals,CPT,77054,X-ray of mammary ducts,APC 5523,RVU Per Case,$235.49 ,OP,235.49,235.49,,,,,,
Molina Duals,CPT,77063,Breast tomosynthesis bi,Physician,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Molina Duals,CPT,77065,Dx mammo incl cad uni,Physician,Per Unit,$83.47 ,OP,83.47,275.87,,,,,,
Molina Duals,CPT,77066,Dx mammo incl cad bi,Physician,Per Unit,$106.70 ,OP,106.7,275.87,,,,,,
Molina Duals,CPT,77067,Scr mammo bi incl cad,Physician,Per Unit,$88.24 ,OP,88.24,275.87,,,,,,
Molina Duals,CPT,77071,X-ray stress view,APC 5521,RVU Per Case,$82.79 ,OP,82.79,205.88,,,,,,
Molina Duals,CPT,77072,X-rays for bone age,APC 5522,RVU Per Case,$111.51 ,OP,111.51,122,,,,,,
Molina Duals,CPT,77073,X-rays bone length studies,APC 5522,RVU Per Case,$111.51 ,OP,111.51,198.25,,,,,,
Molina Duals,CPT,77074,X-rays bone survey limited,APC 5522,RVU Per Case,$111.51 ,OP,111.51,358.39,,,,,,
Molina Duals,CPT,77075,X-rays bone survey complete,APC 5522,RVU Per Case,$111.51 ,OP,111.51,514.72,,,,,,
Molina Duals,CPT,77076,X-rays bone survey infant,APC 5522,RVU Per Case,$111.51 ,OP,111.51,476.6,,,,,,
Molina Duals,CPT,77077,Joint survey single view,APC 5522,RVU Per Case,$111.51 ,OP,111.51,224.95,,,,,,
Molina Duals,CPT,77078,Ct bone density axial,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,927,,,,,,
Molina Duals,CPT,77080,Dxa bone density axial,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,537.6,,,,,,
Molina Duals,CPT,77081,Dxa bone density/peripheral,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,167.76,,,,,,
Molina Duals,CPT,77084,Magnetic image bone marrow,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,507.00",,,,,,
Molina Duals,CPT,77085,Dxa bone density study,APC 5522,RVU Per Case,$111.51 ,OP,111.51,111.51,,,,,,
Molina Duals,CPT,77086,Fracture assessment via dxa,APC 5521,RVU Per Case,$82.79 ,OP,82.79,213.51,,,,,,
Molina Duals,CPT,77280,Set radiation therapy field,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,964.61,,,,,,
Molina Duals,CPT,77285,Set radiation therapy field,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,"1,662.33",,,,,,
Molina Duals,CPT,77290,Set radiation therapy field,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,"2,558.32",,,,,,
Molina Duals,CPT,77295,3-d radiotherapy plan,APC 5613,RVU Per Unit,"$1,291.62 ",OP,"1,291.62","3,736.44",,,,,,
Molina Duals,CPT,77299,Radiation therapy planning,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,129.83,,,,,,
Molina Duals,CPT,77300,Radiation therapy dose plan,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,388.89,,,,,,
Molina Duals,CPT,77301,Radiotherapy dose plan imrt,APC 5613,RVU Per Unit,"$1,291.62 ",OP,"1,291.62","11,205.50",,,,,,
Molina Duals,CPT,77306,Telethx isodose plan simple,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,392.7,,,,,,
Molina Duals,CPT,77307,Telethx isodose plan cplx,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,777.79,,,,,,
Molina Duals,CPT,77316,Brachytx isodose plan simple,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,747.28,,,,,,
Molina Duals,CPT,77317,Brachytx isodose intermed,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,"1,059.93",,,,,,
Molina Duals,CPT,77318,Brachytx isodose complex,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,"1,456.44",,,,,,
Molina Duals,CPT,77321,Special teletx port plan,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,659.6,,,,,,
Molina Duals,CPT,77331,Special radiation dosimetry,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,320.27,,,,,,
Molina Duals,CPT,77332,Radiation treatment aid(s),APC 5611,RVU Per Unit,$129.83 ,OP,129.83,407.96,,,,,,
Molina Duals,CPT,77333,Radiation treatment aid(s),APC 5611,RVU Per Unit,$129.83 ,OP,129.83,369.83,,,,,,
Molina Duals,CPT,77334,Radiation treatment aid(s),APC 5612,RVU Per Unit,$346.58 ,OP,346.58,869.3,,,,,,
Molina Duals,CPT,77336,Radiation physics consult,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,343.14,,,,,,
Molina Duals,CPT,77338,Design mlc device for imrt,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,346.58,,,,,,
Molina Duals,CPT,77370,Radiation physics consult,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,629.1,,,,,,
Molina Duals,CPT,77371,Srs multisource,APC 5627,RVU Per Case,"$7,954.01 ",OP,"6,969.60","7,954.01",,,,,,
Molina Duals,CPT,77372,Srs linear based,APC 5627,RVU Per Case,"$7,954.01 ",OP,"4,148.22","7,954.01",,,,,,
Molina Duals,CPT,77373,Sbrt delivery,APC 5626,RVU Per Unit,"$1,774.17 ",OP,"1,774.17","13,221.44",,,,,,
Molina Duals,CPT,77385,Ntsty modul rad tx dlvr smpl,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"1,379.33",,,,,,
Molina Duals,CPT,77386,Ntsty modul rad tx dlvr cplx,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"1,379.33",,,,,,
Molina Duals,CPT,77399,External radiation dosimetry,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,129.83,,,,,,
Molina Duals,CPT,77401,Radiation treatment delivery,APC 5621,RVU Per Unit,$123.36 ,OP,123.36,183.02,,,,,,
Molina Duals,CPT,77402,Radiation treatment delivery,APC 5621,RVU Per Unit,$123.36 ,OP,123.36,123.36,,,,,,
Molina Duals,CPT,77407,Radiation treatment delivery,APC 5622,RVU Per Unit,$247.32 ,OP,247.32,247.32,,,,,,
Molina Duals,CPT,77412,Radiation treatment delivery,APC 5622,RVU Per Unit,$247.32 ,OP,247.32,"1,067.55",,,,,,
Molina Duals,CPT,77423,Neutron beam tx complex,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"1,235.32",,,,,,
Molina Duals,CPT,77424,Io rad tx delivery by x-ray,APC 5627,RVU Per Case,"$7,954.01 ",OP,"7,954.01","7,954.01",,,,,,
Molina Duals,CPT,77425,Io rad tx deliver by elctrns,APC 5627,RVU Per Case,"$7,954.01 ",OP,"7,954.01","7,954.01",,,,,,
Molina Duals,CPT,77470,Special radiation treatment,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"1,509.83",,,,,,
Molina Duals,CPT,77520,Proton trmt simple w/o comp,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,555.2,,,,,,
Molina Duals,CPT,77522,Proton trmt simple w/comp,APC 5625,RVU Per Unit,"$1,328.18 ",OP,"1,328.18","1,328.18",,,,,,
Molina Duals,CPT,77523,Proton trmt intermediate,APC 5625,RVU Per Unit,"$1,328.18 ",OP,"1,328.18","1,328.18",,,,,,
Molina Duals,CPT,77525,Proton treatment complex,APC 5625,RVU Per Unit,"$1,328.18 ",OP,"1,328.18","1,328.18",,,,,,
Molina Duals,CPT,77600,Hyperthermia treatment,APC 5622,RVU Per Unit,$247.32 ,OP,247.32,"1,902.54",,,,,,
Molina Duals,CPT,77605,Hyperthermia treatment,APC 5624,RVU Per Unit,$724.98 ,OP,724.98,"3,397.11",,,,,,
Molina Duals,CPT,77610,Hyperthermia treatment,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"3,156.91",,,,,,
Molina Duals,CPT,77615,Hyperthermia treatment,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"4,464.67",,,,,,
Molina Duals,CPT,77620,Hyperthermia treatment,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"2,013.11",,,,,,
Molina Duals,CPT,77750,Infuse radioactive materials,APC 5622,RVU Per Unit,$247.32 ,OP,247.32,"1,730.97",,,,,,
Molina Duals,CPT,77761,Apply intrcav radiat simple,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"1,803.41",,,,,,
Molina Duals,CPT,77762,Apply intrcav radiat interm,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"2,463.00",,,,,,
Molina Duals,CPT,77763,Apply intrcav radiat compl,APC 5624,RVU Per Unit,$724.98 ,OP,724.98,724.98,,,,,,
Molina Duals,CPT,77767,Hdr rdncl skn surf brachytx,APC 5622,RVU Per Unit,$247.32 ,OP,247.32,247.32,,,,,,
Molina Duals,CPT,77768,Hdr rdncl skn surf brachytx,APC 5622,RVU Per Unit,$247.32 ,OP,247.32,247.32,,,,,,
Molina Duals,CPT,77770,Hdr rdncl ntrstl/icav brchtx,APC 5624,RVU Per Unit,$724.98 ,OP,724.98,964.61,,,,,,
Molina Duals,CPT,77771,Hdr rdncl ntrstl/icav brchtx,APC 5624,RVU Per Unit,$724.98 ,OP,724.98,"2,882.39",,,,,,
Molina Duals,CPT,77772,Hdr rdncl ntrstl/icav brchtx,APC 5624,RVU Per Unit,$724.98 ,OP,724.98,"4,285.47",,,,,,
Molina Duals,CPT,77778,Apply interstit radiat compl,APC 5624,RVU Per Unit,$724.98 ,OP,724.98,"4,209.21",,,,,,
Molina Duals,CPT,77789,Apply surf ldr radionuclide,APC 5621,RVU Per Unit,$123.36 ,OP,123.36,533.78,,,,,,
Molina Duals,CPT,77799,Radium/radioisotope therapy,APC 5621,RVU Per Unit,$123.36 ,OP,123.36,123.36,,,,,,
Molina Duals,CPT,78012,Thyroid uptake measurement,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,453.71,,,,,,
Molina Duals,CPT,78013,Thyroid imaging w/blood flow,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,884.55,,,,,,
Molina Duals,CPT,78014,Thyroid imaging w/blood flow,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,105.68",,,,,,
Molina Duals,CPT,78015,Thyroid met imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,044.69",,,,,,
Molina Duals,CPT,78016,Thyroid met imaging/studies,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,578.46",,,,,,
Molina Duals,CPT,78018,Thyroid met imaging body,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,616.58",,,,,,
Molina Duals,CPT,78070,Parathyroid planar imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,884.55,,,,,,
Molina Duals,CPT,78071,Parathyrd planar w/wo subtrj,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,884.55,,,,,,
Molina Duals,CPT,78072,Parathyrd planar w/spect&ct,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,884.55,,,,,,
Molina Duals,CPT,78075,Adrenal cortex & medulla img,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","2,085.54",,,,,,
Molina Duals,CPT,78099,Endocrine nuclear procedure,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Molina Duals,CPT,78102,Bone marrow imaging ltd,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Molina Duals,CPT,78103,Bone marrow imaging mult,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,109.50",,,,,,
Molina Duals,CPT,78104,Bone marrow imaging body,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,273.44",,,,,,
Molina Duals,CPT,78110,Plasma volume single,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,336.39",,,,,,
Molina Duals,CPT,78111,Plasma volume multiple,APC 5593,RVU Per Unit,"$1,336.39 ",OP,518.52,"1,336.39",,,,,,
Molina Duals,CPT,78120,Red cell mass single,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Molina Duals,CPT,78121,Red cell mass multiple,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,552.84,,,,,,
Molina Duals,CPT,78122,Blood volume,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,701.54,,,,,,
Molina Duals,CPT,78130,Red cell survival study,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,793.05,,,,,,
Molina Duals,CPT,78140,Red cell sequestration,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,781.61,,,,,,
Molina Duals,CPT,78185,Spleen imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Molina Duals,CPT,78191,Platelet survival,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,067.55",,,,,,
Molina Duals,CPT,78195,Lymph system imaging,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,704.28",,,,,,
Molina Duals,CPT,78199,Blood/lymph nuclear exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Molina Duals,CPT,78201,Liver imaging,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,884.55,,,,,,
Molina Duals,CPT,78202,Liver imaging with flow,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,014.17",,,,,,
Molina Duals,CPT,78215,Liver and spleen imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,941.74,,,,,,
Molina Duals,CPT,78216,Liver & spleen image/flow,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,728.23,,,,,,
Molina Duals,CPT,78226,Hepatobiliary system imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,570.83",,,,,,
Molina Duals,CPT,78227,Hepatobil syst image w/drug,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,570.83",,,,,,
Molina Duals,CPT,78230,Salivary gland imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,804.48,,,,,,
Molina Duals,CPT,78231,Serial salivary imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,697.72,,,,,,
Molina Duals,CPT,78232,Salivary gland function exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,712.98,,,,,,
Molina Duals,CPT,78258,Esophageal motility study,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,113.30",,,,,,
Molina Duals,CPT,78261,Gastric mucosa imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,242.94",,,,,,
Molina Duals,CPT,78262,Gastroesophageal reflux exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,227.68",,,,,,
Molina Duals,CPT,78264,Gastric emptying imag study,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,403.08",,,,,,
Molina Duals,CPT,78265,Gastric emptying imag study,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,403.08",,,,,,
Molina Duals,CPT,78266,Gastric emptying imag study,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,403.08",,,,,,
Molina Duals,CPT,78267,Breath tst attain/anal c-14,Lab Services,Per Unit,$11.06 ,OP,11.06,11.06,,,,,,
Molina Duals,CPT,78268,Breath test analysis c-14,Lab Services,Per Unit,$94.41 ,OP,94.41,301.2,,,,,,
Molina Duals,CPT,78278,Acute gi blood loss imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Molina Duals,CPT,78282,Gi protein loss exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,407.96,,,,,,
Molina Duals,CPT,78290,Meckels divert exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,498.39",,,,,,
Molina Duals,CPT,78291,Leveen/shunt patency exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,227.68",,,,,,
Molina Duals,CPT,78299,Gi nuclear procedure,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Molina Duals,CPT,78300,Bone imaging limited area,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,869.3,,,,,,
Molina Duals,CPT,78305,Bone imaging multiple areas,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,155.24",,,,,,
Molina Duals,CPT,78306,Bone imaging whole body,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,281.07",,,,,,
Molina Duals,CPT,78315,Bone imaging 3 phase,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,692.84",,,,,,
Molina Duals,CPT,78399,Musculoskeletal nuclear exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Molina Duals,CPT,78414,Non-imaging heart function,APC 5592,RVU Per Unit,$500.81 ,OP,377.46,500.81,,,,,,
Molina Duals,CPT,78428,Cardiac shunt imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,998.92,,,,,,
Molina Duals,CPT,78429,Myocrd img pet 1 std w/ct,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,240.30",,,,,,
Molina Duals,CPT,78430,Myocrd img pet rst/strs w/ct,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,217.42",,,,,,
Molina Duals,CPT,78431,Myocrd img pet rst&strs ct,APC 1522,RVU Per Unit,"$2,150.30 ",OP,"2,150.30","7,339.44",,,,,,
Molina Duals,CPT,78432,Myocrd img pet 2rtracer,APC 1523,RVU Per Unit,"$2,628.05 ",OP,"2,628.05","8,030.21",,,,,,
Molina Duals,CPT,78433,Myocrd img pet 2rtracer ct,APC 1523,RVU Per Unit,"$2,628.05 ",OP,"2,628.05","8,778.55",,,,,,
Molina Duals,CPT,78445,Vascular flow imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,838.79,,,,,,
Molina Duals,CPT,78451,Ht muscle image spect sing,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","2,116.06",,,,,,
Molina Duals,CPT,78452,Ht muscle image spect mult,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","3,343.73",,,,,,
Molina Duals,CPT,78453,Ht muscle image planar sing,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,631.84",,,,,,
Molina Duals,CPT,78454,Ht musc image planar mult,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,772.90",,,,,,
Molina Duals,CPT,78456,Acute venous thrombus image,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,784.34",,,,,,
Molina Duals,CPT,78457,Venous thrombosis imaging,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,964.61,,,,,,
Molina Duals,CPT,78458,Ven thrombosis images bilat,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,078.99",,,,,,
Molina Duals,CPT,78459,Myocrd img pet single study,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","7,240.30",,,,,,
Molina Duals,CPT,78466,Heart infarct image,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,922.67,,,,,,
Molina Duals,CPT,78468,Heart infarct image (ef),APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,166.68",,,,,,
Molina Duals,CPT,78469,Heart infarct image (3d),APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,338.26",,,,,,
Molina Duals,CPT,78472,Gated heart planar single,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,368.75",,,,,,
Molina Duals,CPT,78473,Gated heart multiple,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,872.03",,,,,,
Molina Duals,CPT,78481,Heart first pass single,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,201.00",,,,,,
Molina Duals,CPT,78483,Heart first pass multiple,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,700.46",,,,,,
Molina Duals,CPT,78491,Myocrd img pet 1std rst/strs,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,217.42",,,,,,
Molina Duals,CPT,78492,Myocrd img pet mlt rst&strs,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,339.44",,,,,,
Molina Duals,CPT,78494,Heart image spect,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,486.95",,,,,,
Molina Duals,CPT,78499,Cardiovascular nuclear exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Molina Duals,CPT,78579,Lung ventilation imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,155.24",,,,,,
Molina Duals,CPT,78580,Lung perfusion imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,071.37",,,,,,
Molina Duals,CPT,78582,Lung ventilat&perfus imaging,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,769.09",,,,,,
Molina Duals,CPT,78597,Lung perfusion differential,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,906.36",,,,,,
Molina Duals,CPT,78598,Lung perf&ventilat diferentl,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,906.36",,,,,,
Molina Duals,CPT,78599,Respiratory nuclear exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Molina Duals,CPT,78600,Brain image < 4 views,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,888.36,,,,,,
Molina Duals,CPT,78601,Brain image w/flow < 4 views,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,059.93",,,,,,
Molina Duals,CPT,78605,Brain image 4+ views,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,991.29,,,,,,
Molina Duals,CPT,78606,Brain image w/flow 4 + views,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,540.33",,,,,,
Molina Duals,CPT,78608,Brain imaging (pet),APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,209.80",,,,,,
Molina Duals,CPT,78610,Brain flow imaging only,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,888.36,,,,,,
Molina Duals,CPT,78630,Cerebrospinal fluid scan,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,647.08",,,,,,
Molina Duals,CPT,78635,Csf ventriculography,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,475.51",,,,,,
Molina Duals,CPT,78645,Csf shunt evaluation,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,502.21",,,,,,
Molina Duals,CPT,78650,Csf leakage imaging,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,601.33",,,,,,
Molina Duals,CPT,78660,Nuclear exam of tear flow,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,831.17,,,,,,
Molina Duals,CPT,78699,Nervous system nuclear exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Molina Duals,CPT,78700,Kidney imaging morphol,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,884.55,,,,,,
Molina Duals,CPT,78701,Kidney imaging with flow,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,056.11",,,,,,
Molina Duals,CPT,78707,K flow/funct image w/o drug,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,235.32",,,,,,
Molina Duals,CPT,78708,K flow/funct image w/drug,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,014.17",,,,,,
Molina Duals,CPT,78709,K flow/funct image multiple,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,795.78",,,,,,
Molina Duals,CPT,78725,Kidney function study,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,518.52,,,,,,
Molina Duals,CPT,78740,Ureteral reflux study,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,040.87",,,,,,
Molina Duals,CPT,78761,Testicular imaging w/flow,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,052.29",,,,,,
Molina Duals,CPT,78799,Genitourinary nuclear exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Molina Duals,CPT,78800,Rp loclzj tum 1 area 1 d img,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,949.36,,,,,,
Molina Duals,CPT,78801,Rp loclzj tum 2+area 1+d img,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,265.81",,,,,,
Molina Duals,CPT,78802,Rp loclzj tum whbdy 1 d img,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,654.72",,,,,,
Molina Duals,CPT,78803,Rp loclzj tum spect 1 area,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,826.28",,,,,,
Molina Duals,CPT,78804,Rp loclzj tum whbdy 2+d img,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","2,870.96",,,,,,
Molina Duals,CPT,78808,Iv inj ra drug dx study,APC 5591,RVU Per Case,$385.91 ,OP,385.91,385.91,,,,,,
Molina Duals,CPT,78811,Pet image ltd area,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,336.39",,,,,,
Molina Duals,CPT,78812,Pet image skull-thigh,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,347.07",,,,,,
Molina Duals,CPT,78813,Pet image full body,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,354.67",,,,,,
Molina Duals,CPT,78814,Pet image w/ct lmtd,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,404.24",,,,,,
Molina Duals,CPT,78815,Pet image w/ct skull-thigh,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,446.19",,,,,,
Molina Duals,CPT,78816,Pet image w/ct full body,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,461.44",,,,,,
Molina Duals,CPT,78830,Rp loclzj tum spect w/ct 1,APC 5593,RVU Per Unit,"$1,336.39 ",OP,927,"2,600.43",,,,,,
Molina Duals,CPT,78831,Rp loclzj tum spect 2 areas,APC 5593,RVU Per Unit,"$1,336.39 ",OP,927,"3,860.65",,,,,,
Molina Duals,CPT,78832,Rp loclzj tum spect w/ct 2,APC 5594,RVU Per Unit,"$1,514.86 ",OP,927,"5,097.10",,,,,,
Molina Duals,CPT,78999,Nuclear diagnostic exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
Molina Duals,CPT,79005,Nuclear rx oral admin,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,800.67,,,,,,
Molina Duals,CPT,79101,Nuclear rx iv admin,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,896,,,,,,
Molina Duals,CPT,79200,Nuclear rx intracav admin,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,911.23,,,,,,
Molina Duals,CPT,79300,Nuclr rx interstit colloid,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,724.42,,,,,,
Molina Duals,CPT,79403,Hematopoietic nuclear tx,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,"1,132.37",,,,,,
Molina Duals,CPT,79440,Nuclear rx intra-articular,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,838.79,,,,,,
Molina Duals,CPT,79445,Nuclear rx intra-arterial,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,"1,162.87",,,,,,
Molina Duals,CPT,79999,Nuclear medicine therapy,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,255.45,,,,,,
Molina Duals,CPT,80047,Metabolic panel ionized ca,Lab Services,Per Unit,$13.73 ,OP,13.73,41.94,,,,,,
Molina Duals,CPT,80048,Metabolic panel total ca,Lab Services,Per Unit,$8.46 ,OP,8.46,132.19,,,,,,
Molina Duals,CPT,80051,Electrolyte panel,Lab Services,Per Unit,$7.01 ,OP,7.01,34.31,,,,,,
Molina Duals,CPT,80053,Comprehen metabolic panel,Lab Services,Per Unit,$10.56 ,OP,10.56,172.42,,,,,,
Molina Duals,CPT,80055,Obstetric panel,Lab Services,Per Unit,$47.81 ,OP,47.81,301.2,,,,,,
Molina Duals,CPT,80061,Lipid panel,Lab Services,Per Unit,$13.39 ,OP,13.39,68.63,,,,,,
Molina Duals,CPT,80069,Renal function panel,Lab Services,Per Unit,$8.68 ,OP,8.68,38.13,,,,,,
Molina Duals,CPT,80074,Acute hepatitis panel,Lab Services,Per Unit,$47.63 ,OP,47.63,213.51,,,,,,
Molina Duals,CPT,80076,Hepatic function panel,Lab Services,Per Unit,$8.17 ,OP,8.17,126.44,,,,,,
Molina Duals,CPT,80081,Obstetric panel,Lab Services,Per Unit,$74.86 ,OP,74.86,74.86,,,,,,
Molina Duals,CPT,80143,Drug assay acetaminophen,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,
Molina Duals,CPT,80145,Drug assay adalimumab,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,
Molina Duals,CPT,80150,Assay of amikacin,Lab Services,Per Unit,$15.08 ,OP,15.08,49.56,,,,,,
Molina Duals,CPT,80151,Drug assay amiodarone,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,
Molina Duals,CPT,80155,Drug assay caffeine,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,
Molina Duals,CPT,80156,Assay carbamazepine total,Lab Services,Per Unit,$14.57 ,OP,14.57,64.82,,,,,,
Molina Duals,CPT,80157,Assay carbamazepine free,Lab Services,Per Unit,$13.25 ,OP,13.25,57.19,,,,,,
Molina Duals,CPT,80158,Drug assay cyclosporine,Lab Services,Per Unit,$18.05 ,OP,18.05,80.07,,,,,,
Molina Duals,CPT,80159,Drug assay clozapine,Lab Services,Per Unit,$20.15 ,OP,20.15,20.15,,,,,,
Molina Duals,CPT,80161,Asy carbamazepin 10-11-epxid,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,
Molina Duals,CPT,80162,Assay of digoxin total,Lab Services,Per Unit,$13.28 ,OP,13.28,61,,,,,,
Molina Duals,CPT,80163,Assay of digoxin free,Lab Services,Per Unit,$13.28 ,OP,13.28,61,,,,,,
Molina Duals,CPT,80164,Assay dipropylacetic acd tot,Lab Services,Per Unit,$13.54 ,OP,13.54,61,,,,,,
Molina Duals,CPT,80165,Dipropylacetic acid free,Lab Services,Per Unit,$13.54 ,OP,13.54,61,,,,,,
Molina Duals,CPT,80167,Drug assay felbamate,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,
Molina Duals,CPT,80168,Assay of ethosuximide,Lab Services,Per Unit,$16.34 ,OP,16.34,72.44,,,,,,
Molina Duals,CPT,80169,Drug assay everolimus,Lab Services,Per Unit,$13.73 ,OP,13.73,13.73,,,,,,
Molina Duals,CPT,80170,Assay of gentamicin,Lab Services,Per Unit,$16.38 ,OP,16.38,72.44,,,,,,
Molina Duals,CPT,80171,Drug screen quant gabapentin,Lab Services,Per Unit,$21.67 ,OP,21.67,21.67,,,,,,
Molina Duals,CPT,80173,Assay of haloperidol,Lab Services,Per Unit,$15.78 ,OP,15.78,15.78,,,,,,
Molina Duals,CPT,80175,Drug screen quan lamotrigine,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,
Molina Duals,CPT,80176,Assay of lidocaine,Lab Services,Per Unit,$14.69 ,OP,14.69,64.82,,,,,,
Molina Duals,CPT,80177,Drug scrn quan levetiracetam,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,
Molina Duals,CPT,80178,Assay of lithium,Lab Services,Per Unit,$6.61 ,OP,6.61,30.51,,,,,,
Molina Duals,CPT,80179,Drug assay salicylate,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,
Molina Duals,CPT,80180,Drug scrn quan mycophenolate,Lab Services,Per Unit,$18.05 ,OP,18.05,18.05,,,,,,
Molina Duals,CPT,80181,Drug assay flecainide,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,
Molina Duals,CPT,80183,Drug scrn quant oxcarbazepin,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,
Molina Duals,CPT,80184,Assay of phenobarbital,Lab Services,Per Unit,$15.30 ,OP,15.3,49.56,,,,,,
Molina Duals,CPT,80185,Assay of phenytoin total,Lab Services,Per Unit,$13.25 ,OP,13.25,57.19,,,,,,
Molina Duals,CPT,80186,Assay of phenytoin free,Lab Services,Per Unit,$13.76 ,OP,13.76,61,,,,,,
Molina Duals,CPT,80187,Drug assay posaconazole,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,
Molina Duals,CPT,80188,Assay of primidone,Lab Services,Per Unit,$16.59 ,OP,16.59,72.44,,,,,,
Molina Duals,CPT,80189,Drug assay itraconzaole,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,
Molina Duals,CPT,80190,Assay of procainamide,Lab Services,Per Unit,$60.00 ,OP,60,76.26,,,,,,
Molina Duals,CPT,80192,Assay of procainamide,Lab Services,Per Unit,$16.75 ,OP,16.75,76.26,,,,,,
Molina Duals,CPT,80193,Drug assay leflunomide,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,
Molina Duals,CPT,80194,Assay of quinidine,Lab Services,Per Unit,$14.60 ,OP,14.6,64.82,,,,,,
Molina Duals,CPT,80195,Assay of sirolimus,Lab Services,Per Unit,$13.73 ,OP,13.73,61,,,,,,
Molina Duals,CPT,80197,Assay of tacrolimus,Lab Services,Per Unit,$13.73 ,OP,13.73,61,,,,,,
Molina Duals,CPT,80198,Assay of theophylline,Lab Services,Per Unit,$14.14 ,OP,14.14,64.82,,,,,,
Molina Duals,CPT,80199,Drug screen quant tiagabine,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,
Molina Duals,CPT,80200,Assay of tobramycin,Lab Services,Per Unit,$16.13 ,OP,16.13,49.56,,,,,,
Molina Duals,CPT,80201,Assay of topiramate,Lab Services,Per Unit,$11.92 ,OP,11.92,53.38,,,,,,
Molina Duals,CPT,80202,Assay of vancomycin,Lab Services,Per Unit,$13.54 ,OP,13.54,61,,,,,,
Molina Duals,CPT,80203,Drug screen quant zonisamide,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,
Molina Duals,CPT,80204,Drug assay methotrexate,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,
Molina Duals,CPT,80210,Drug assay rufinamide,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,
Molina Duals,CPT,80230,Drug assay infliximab,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,
Molina Duals,CPT,80235,Drug assay lacosamide,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,
Molina Duals,CPT,80280,Drug assay vedolizumab,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,
Molina Duals,CPT,80285,Drug assay voriconazole,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,
Molina Duals,CPT,80299,Quantitative assay drug,Lab Services,Per Unit,$18.64 ,OP,18.64,61,,,,,,
Molina Duals,CPT,80305,Drug test prsmv dir opt obs,Lab Services,Per Unit,$12.60 ,OP,12.6,64.82,,,,,,
Molina Duals,CPT,80306,Drug test prsmv instrmnt,Lab Services,Per Unit,$17.14 ,OP,17.14,64.82,,,,,,
Molina Duals,CPT,80307,Drug test prsmv chem anlyzr,Lab Services,Per Unit,$62.14 ,OP,62.14,62.14,,,,,,
Molina Duals,CPT,80400,Acth stimulation panel,Lab Services,Per Unit,$32.62 ,OP,32.62,144.88,,,,,,
Molina Duals,CPT,80402,Acth stimulation panel,Lab Services,Per Unit,$86.96 ,OP,86.96,388.89,,,,,,
Molina Duals,CPT,80406,Acth stimulation panel,Lab Services,Per Unit,$78.26 ,OP,78.26,346.96,,,,,,
Molina Duals,CPT,80408,Aldosterone suppression eval,Lab Services,Per Unit,$125.50 ,OP,125.5,560.47,,,,,,
Molina Duals,CPT,80410,Calcitonin stimul panel,Lab Services,Per Unit,$80.37 ,OP,80.37,358.39,,,,,,
Molina Duals,CPT,80412,Crh stimulation panel,Lab Services,Per Unit,$801.62 ,OP,801.62,"1,467.89",,,,,,
Molina Duals,CPT,80414,Testosterone response panel,Lab Services,Per Unit,$51.64 ,OP,51.64,228.77,,,,,,
Molina Duals,CPT,80415,Tot estradiol response panel,Lab Services,Per Unit,$55.89 ,OP,55.89,99.13,,,,,,
Molina Duals,CPT,80416,Renin stimulation panel,Lab Services,Per Unit,$209.32 ,OP,209.32,587.16,,,,,,
Molina Duals,CPT,80417,Renin stimulation panel,Lab Services,Per Unit,$43.99 ,OP,43.99,194.45,,,,,,
Molina Duals,CPT,80418,Pituitary evaluation panel,Lab Services,Per Unit,$579.48 ,OP,579.48,"2,573.58",,,,,,
Molina Duals,CPT,80420,Dexamethasone panel,Lab Services,Per Unit,$161.88 ,OP,161.88,320.27,,,,,,
Molina Duals,CPT,80422,Glucagon tolerance panel,Lab Services,Per Unit,$46.07 ,OP,46.07,205.88,,,,,,
Molina Duals,CPT,80424,Glucagon tolerance panel,Lab Services,Per Unit,$50.50 ,OP,50.5,224.95,,,,,,
Molina Duals,CPT,80426,Gonadotropin hormone panel,Lab Services,Per Unit,$148.41 ,OP,148.41,659.6,,,,,,
Molina Duals,CPT,80428,Growth hormone panel,Lab Services,Per Unit,$66.70 ,OP,66.7,289.76,,,,,,
Molina Duals,CPT,80430,Growth hormone panel,Lab Services,Per Unit,$129.33 ,OP,129.33,343.14,,,,,,
Molina Duals,CPT,80432,Insulin suppression panel,Lab Services,Per Unit,$165.61 ,OP,165.61,602.41,,,,,,
Molina Duals,CPT,80434,Insulin tolerance panel,Lab Services,Per Unit,$285.03 ,OP,285.03,449.9,,,,,,
Molina Duals,CPT,80435,Insulin tolerance panel,Lab Services,Per Unit,$103.00 ,OP,103,449.9,,,,,,
Molina Duals,CPT,80436,Metyrapone panel,Lab Services,Per Unit,$91.16 ,OP,91.16,301.2,,,,,,
Molina Duals,CPT,80438,Trh stimulation panel,Lab Services,Per Unit,$50.41 ,OP,50.41,224.95,,,,,,
Molina Duals,CPT,80439,Trh stimulation panel,Lab Services,Per Unit,$67.21 ,OP,67.21,297.39,,,,,,
Molina Duals,CPT,80500,Lab pathology consultation,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Molina Duals,CPT,80502,Lab pathology consultation,APC 5672,RVU Per Case,$152.64 ,OP,152.64,320.27,,,,,,
Molina Duals,CPT,81000,Urinalysis nonauto w/scope,Lab Services,Per Unit,$4.02 ,OP,4.02,15.26,,,,,,
Molina Duals,CPT,81001,Urinalysis auto w/scope,Lab Services,Per Unit,$3.17 ,OP,3.17,15.26,,,,,,
Molina Duals,CPT,81002,Urinalysis nonauto w/o scope,Lab Services,Per Unit,$3.48 ,OP,3.48,11.44,,,,,,
Molina Duals,CPT,81003,Urinalysis auto w/o scope,Lab Services,Per Unit,$2.25 ,OP,2.25,11.44,,,,,,
Molina Duals,CPT,81005,Urinalysis,Lab Services,Per Unit,$2.17 ,OP,2.17,11.44,,,,,,
Molina Duals,CPT,81007,Urine screen for bacteria,Lab Services,Per Unit,$29.98 ,OP,11.44,29.98,,,,,,
Molina Duals,CPT,81015,Microscopic exam of urine,Lab Services,Per Unit,$3.05 ,OP,3.05,15.26,,,,,,
Molina Duals,CPT,81020,Urinalysis glass test,Lab Services,Per Unit,$4.70 ,OP,4.7,15.26,,,,,,
Molina Duals,CPT,81025,Urine pregnancy test,Lab Services,Per Unit,$8.61 ,OP,8.61,30.51,,,,,,
Molina Duals,CPT,81050,Urinalysis volume measure,Lab Services,Per Unit,$3.64 ,OP,3.64,11.44,,,,,,
Molina Duals,CPT,81105,Hpa-1 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
Molina Duals,CPT,81106,Hpa-2 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
Molina Duals,CPT,81107,Hpa-3 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
Molina Duals,CPT,81108,Hpa-4 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
Molina Duals,CPT,81109,Hpa-5 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
Molina Duals,CPT,81110,Hpa-6 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
Molina Duals,CPT,81111,Hpa-9 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
Molina Duals,CPT,81112,Hpa-15 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
Molina Duals,CPT,81120,Idh1 common variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,
Molina Duals,CPT,81121,Idh2 common variants,Lab Services,Per Unit,$295.79 ,OP,295.79,295.79,,,,,,
Molina Duals,CPT,81161,Dmd dup/delet analysis,Lab Services,Per Unit,$279.00 ,OP,279,279,,,,,,
Molina Duals,CPT,81162,Brca1&2 gen full seq dup/del,Lab Services,Per Unit,"$1,824.88 ",OP,"1,824.88","1,824.88",,,,,,
Molina Duals,CPT,81163,Brca1&2 gene full seq alys,Lab Services,Per Unit,$468.00 ,OP,468,468,,,,,,
Molina Duals,CPT,81164,Brca1&2 gen ful dup/del alys,Lab Services,Per Unit,$584.23 ,OP,584.23,584.23,,,,,,
Molina Duals,CPT,81165,Brca1 gene full seq alys,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,
Molina Duals,CPT,81166,Brca1 gene full dup/del alys,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,
Molina Duals,CPT,81167,Brca2 gene full dup/del alys,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,
Molina Duals,CPT,81168,Ccnd1/igh translocation alys,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,
Molina Duals,CPT,81170,Abl1 gene,Lab Services,Per Unit,$300.00 ,OP,300,300,,,,,,
Molina Duals,CPT,81171,Aff2 gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Molina Duals,CPT,81172,Aff2 gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Molina Duals,CPT,81173,Ar gene full gene sequence,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,
Molina Duals,CPT,81174,Ar gene known famil variant,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Molina Duals,CPT,81175,Asxl1 full gene sequence,Lab Services,Per Unit,$676.50 ,OP,676.5,676.5,,,,,,
Molina Duals,CPT,81176,Asxl1 gene target seq alys,Lab Services,Per Unit,$241.90 ,OP,241.9,241.9,,,,,,
Molina Duals,CPT,81177,Atn1 gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Molina Duals,CPT,81178,Atxn1 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Molina Duals,CPT,81179,Atxn2 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Molina Duals,CPT,81180,Atxn3 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Molina Duals,CPT,81181,Atxn7 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Molina Duals,CPT,81182,Atxn8os gen detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Molina Duals,CPT,81183,Atxn10 gene detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Molina Duals,CPT,81184,Cacna1a gen detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Molina Duals,CPT,81185,Cacna1a gene full gene seq,Lab Services,Per Unit,$846.27 ,OP,846.27,846.27,,,,,,
Molina Duals,CPT,81186,Cacna1a gen known famil vrnt,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Molina Duals,CPT,81187,Cnbp gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Molina Duals,CPT,81188,Cstb gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Molina Duals,CPT,81189,Cstb gene full gene sequence,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Molina Duals,CPT,81190,Cstb gene known famil vrnt,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Molina Duals,CPT,81191,Ntrk1 translocation analysis,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,
Molina Duals,CPT,81192,Ntrk2 translocation analysis,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,
Molina Duals,CPT,81193,Ntrk3 translocation analysis,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,
Molina Duals,CPT,81194,Ntrk translocation analysis,Lab Services,Per Unit,$518.28 ,OP,518.28,518.28,,,,,,
Molina Duals,CPT,81200,Aspa gene,Lab Services,Per Unit,$47.25 ,OP,47.25,47.25,,,,,,
Molina Duals,CPT,81201,Apc gene full sequence,Lab Services,Per Unit,$780.00 ,OP,780,780,,,,,,
Molina Duals,CPT,81202,Apc gene known fam variants,Lab Services,Per Unit,$280.00 ,OP,280,280,,,,,,
Molina Duals,CPT,81203,Apc gene dup/delet variants,Lab Services,Per Unit,$200.00 ,OP,200,200,,,,,,
Molina Duals,CPT,81204,Ar gene charac alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Molina Duals,CPT,81205,Bckdhb gene,Lab Services,Per Unit,$94.99 ,OP,94.99,94.99,,,,,,
Molina Duals,CPT,81206,Bcr/abl1 gene major bp,Lab Services,Per Unit,$163.96 ,OP,163.96,163.96,,,,,,
Molina Duals,CPT,81207,Bcr/abl1 gene minor bp,Lab Services,Per Unit,$144.84 ,OP,144.84,144.84,,,,,,
Molina Duals,CPT,81208,Bcr/abl1 gene other bp,Lab Services,Per Unit,$214.62 ,OP,214.62,214.62,,,,,,
Molina Duals,CPT,81209,Blm gene,Lab Services,Per Unit,$39.31 ,OP,39.31,39.31,,,,,,
Molina Duals,CPT,81210,Braf gene,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,
Molina Duals,CPT,81212,Brca1&2 185&5385&6174 vrnt,Lab Services,Per Unit,$440.00 ,OP,440,440,,,,,,
Molina Duals,CPT,81215,Brca1 gene known famil vrnt,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,
Molina Duals,CPT,81216,Brca2 gene full seq alys,Lab Services,Per Unit,$185.12 ,OP,185.12,185.12,,,,,,
Molina Duals,CPT,81217,Brca2 gene known famil vrnt,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,
Molina Duals,CPT,81218,Cebpa gene full sequence,Lab Services,Per Unit,$241.90 ,OP,241.9,241.9,,,,,,
Molina Duals,CPT,81219,Calr gene com variants,Lab Services,Per Unit,$121.63 ,OP,121.63,121.63,,,,,,
Molina Duals,CPT,81220,Cftr gene com variants,Lab Services,Per Unit,$556.60 ,OP,556.6,556.6,,,,,,
Molina Duals,CPT,81221,Cftr gene known fam variants,Lab Services,Per Unit,$97.22 ,OP,97.22,97.22,,,,,,
Molina Duals,CPT,81222,Cftr gene dup/delet variants,Lab Services,Per Unit,$435.07 ,OP,435.07,435.07,,,,,,
Molina Duals,CPT,81223,Cftr gene full sequence,Lab Services,Per Unit,$499.00 ,OP,499,499,,,,,,
Molina Duals,CPT,81224,Cftr gene intron poly t,Lab Services,Per Unit,$168.75 ,OP,168.75,168.75,,,,,,
Molina Duals,CPT,81225,Cyp2c19 gene com variants,Lab Services,Per Unit,$291.36 ,OP,291.36,291.36,,,,,,
Molina Duals,CPT,81226,Cyp2d6 gene com variants,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,
Molina Duals,CPT,81227,Cyp2c9 gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Molina Duals,CPT,81228,Cytogen micrarray copy nmbr,Lab Services,Per Unit,$900.00 ,OP,900,900,,,,,,
Molina Duals,CPT,81229,Cytogen m array copy no&snp,Lab Services,Per Unit,"$1,160.00 ",OP,"1,160.00","1,160.00",,,,,,
Molina Duals,CPT,81230,Cyp3a4 gene common variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Molina Duals,CPT,81231,Cyp3a5 gene common variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Molina Duals,CPT,81232,Dpyd gene common variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Molina Duals,CPT,81233,Btk gene common variants,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,
Molina Duals,CPT,81234,Dmpk gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Molina Duals,CPT,81235,Egfr gene com variants,Lab Services,Per Unit,$324.58 ,OP,324.58,324.58,,,,,,
Molina Duals,CPT,81236,Ezh2 gene full gene sequence,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,
Molina Duals,CPT,81237,Ezh2 gene common variants,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,
Molina Duals,CPT,81238,F9 full gene sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,
Molina Duals,CPT,81239,Dmpk gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Molina Duals,CPT,81240,F2 gene,Lab Services,Per Unit,$65.69 ,OP,65.69,65.69,,,,,,
Molina Duals,CPT,81241,F5 gene,Lab Services,Per Unit,$73.37 ,OP,73.37,73.37,,,,,,
Molina Duals,CPT,81242,Fancc gene,Lab Services,Per Unit,$36.62 ,OP,36.62,36.62,,,,,,
Molina Duals,CPT,81243,Fmr1 gene detection,Lab Services,Per Unit,$57.04 ,OP,57.04,57.04,,,,,,
Molina Duals,CPT,81244,Fmr1 gene charac alleles,Lab Services,Per Unit,$44.89 ,OP,44.89,44.89,,,,,,
Molina Duals,CPT,81245,Flt3 gene,Lab Services,Per Unit,$165.51 ,OP,165.51,165.51,,,,,,
Molina Duals,CPT,81246,Flt3 gene analysis,Lab Services,Per Unit,$83.00 ,OP,83,83,,,,,,
Molina Duals,CPT,81247,G6pd gene alys cmn variant,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Molina Duals,CPT,81248,G6pd known familial variant,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,
Molina Duals,CPT,81249,G6pd full gene sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,
Molina Duals,CPT,81250,G6pc gene,Lab Services,Per Unit,$58.49 ,OP,58.49,58.49,,,,,,
Molina Duals,CPT,81251,Gba gene,Lab Services,Per Unit,$47.25 ,OP,47.25,47.25,,,,,,
Molina Duals,CPT,81252,Gjb2 gene full sequence,Lab Services,Per Unit,$101.12 ,OP,101.12,101.12,,,,,,
Molina Duals,CPT,81253,Gjb2 gene known fam variants,Lab Services,Per Unit,$61.52 ,OP,61.52,61.52,,,,,,
Molina Duals,CPT,81254,Gjb6 gene com variants,Lab Services,Per Unit,$35.00 ,OP,35,35,,,,,,
Molina Duals,CPT,81255,Hexa gene,Lab Services,Per Unit,$51.45 ,OP,51.45,51.45,,,,,,
Molina Duals,CPT,81256,Hfe gene,Lab Services,Per Unit,$65.36 ,OP,65.36,65.36,,,,,,
Molina Duals,CPT,81257,Hba1/hba2 gene,Lab Services,Per Unit,$102.26 ,OP,102.26,102.26,,,,,,
Molina Duals,CPT,81258,Hba1/hba2 gene fam vrnt,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,
Molina Duals,CPT,81259,Hba1/hba2 full gene sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,
Molina Duals,CPT,81260,Ikbkap gene,Lab Services,Per Unit,$39.31 ,OP,39.31,39.31,,,,,,
Molina Duals,CPT,81261,Igh gene rearrange amp meth,Lab Services,Per Unit,$197.99 ,OP,197.99,197.99,,,,,,
Molina Duals,CPT,81262,Igh gene rearrang dir probe,Lab Services,Per Unit,$68.55 ,OP,68.55,68.55,,,,,,
Molina Duals,CPT,81263,Igh vari regional mutation,Lab Services,Per Unit,$294.52 ,OP,294.52,294.52,,,,,,
Molina Duals,CPT,81264,Igk rearrangeabn clonal pop,Lab Services,Per Unit,$172.73 ,OP,172.73,172.73,,,,,,
Molina Duals,CPT,81265,Str markers specimen anal,Lab Services,Per Unit,$233.07 ,OP,233.07,233.07,,,,,,
Molina Duals,CPT,81266,Str markers spec anal addl,Lab Services,Per Unit,$304.81 ,OP,304.81,304.81,,,,,,
Molina Duals,CPT,81267,Chimerism anal no cell selec,Lab Services,Per Unit,$207.46 ,OP,207.46,207.46,,,,,,
Molina Duals,CPT,81268,Chimerism anal w/cell select,Lab Services,Per Unit,$260.79 ,OP,260.79,260.79,,,,,,
Molina Duals,CPT,81269,Hba1/hba2 gene dup/del vrnts,Lab Services,Per Unit,$202.40 ,OP,202.4,202.4,,,,,,
Molina Duals,CPT,81270,Jak2 gene,Lab Services,Per Unit,$91.66 ,OP,91.66,91.66,,,,,,
Molina Duals,CPT,81271,Htt gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Molina Duals,CPT,81272,Kit gene targeted seq analys,Lab Services,Per Unit,$329.51 ,OP,329.51,329.51,,,,,,
Molina Duals,CPT,81273,Kit gene analys d816 variant,Lab Services,Per Unit,$124.87 ,OP,124.87,124.87,,,,,,
Molina Duals,CPT,81274,Htt gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Molina Duals,CPT,81275,Kras gene variants exon 2,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,
Molina Duals,CPT,81276,Kras gene addl variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,
Molina Duals,CPT,81277,Cytogenomic neo microra alys,Lab Services,Per Unit,"$1,160.00 ",OP,"1,160.00","1,160.00",,,,,,
Molina Duals,CPT,81278,Igh@/bcl2 translocation alys,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,
Molina Duals,CPT,81279,Jak2 gene trgt sequence alys,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Molina Duals,CPT,81283,Ifnl3 gene,Lab Services,Per Unit,$73.37 ,OP,73.37,73.37,,,,,,
Molina Duals,CPT,81284,Fxn gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Molina Duals,CPT,81285,Fxn gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Molina Duals,CPT,81286,Fxn gene full gene sequence,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Molina Duals,CPT,81287,Mgmt gene prmtr mthyltn alys,Lab Services,Per Unit,$124.64 ,OP,124.64,124.64,,,,,,
Molina Duals,CPT,81288,Mlh1 gene,Lab Services,Per Unit,$192.32 ,OP,192.32,192.32,,,,,,
Molina Duals,CPT,81289,Fxn gene known famil variant,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Molina Duals,CPT,81290,Mcoln1 gene,Lab Services,Per Unit,$39.31 ,OP,39.31,39.31,,,,,,
Molina Duals,CPT,81291,Mthfr gene,Lab Services,Per Unit,$65.34 ,OP,65.34,65.34,,,,,,
Molina Duals,CPT,81292,Mlh1 gene full seq,Lab Services,Per Unit,$675.40 ,OP,675.4,675.4,,,,,,
Molina Duals,CPT,81293,Mlh1 gene known variants,Lab Services,Per Unit,$331.00 ,OP,331,331,,,,,,
Molina Duals,CPT,81294,Mlh1 gene dup/delete variant,Lab Services,Per Unit,$202.40 ,OP,202.4,202.4,,,,,,
Molina Duals,CPT,81295,Msh2 gene full seq,Lab Services,Per Unit,$381.70 ,OP,381.7,381.7,,,,,,
Molina Duals,CPT,81296,Msh2 gene known variants,Lab Services,Per Unit,$337.73 ,OP,337.73,337.73,,,,,,
Molina Duals,CPT,81297,Msh2 gene dup/delete variant,Lab Services,Per Unit,$213.30 ,OP,213.3,213.3,,,,,,
Molina Duals,CPT,81298,Msh6 gene full seq,Lab Services,Per Unit,$641.85 ,OP,641.85,641.85,,,,,,
Molina Duals,CPT,81299,Msh6 gene known variants,Lab Services,Per Unit,$308.00 ,OP,308,308,,,,,,
Molina Duals,CPT,81300,Msh6 gene dup/delete variant,Lab Services,Per Unit,$238.00 ,OP,238,238,,,,,,
Molina Duals,CPT,81301,Microsatellite instability,Lab Services,Per Unit,$348.56 ,OP,348.56,348.56,,,,,,
Molina Duals,CPT,81302,Mecp2 gene full seq,Lab Services,Per Unit,$527.87 ,OP,527.87,527.87,,,,,,
Molina Duals,CPT,81303,Mecp2 gene known variant,Lab Services,Per Unit,$120.00 ,OP,120,120,,,,,,
Molina Duals,CPT,81304,Mecp2 gene dup/delet variant,Lab Services,Per Unit,$150.00 ,OP,150,150,,,,,,
Molina Duals,CPT,81305,Myd88 gene p.leu265pro vrnt,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,
Molina Duals,CPT,81306,Nudt15 gene common variants,Lab Services,Per Unit,$291.36 ,OP,291.36,291.36,,,,,,
Molina Duals,CPT,81307,Palb2 gene full gene seq,Lab Services,Per Unit,$676.50 ,OP,676.5,676.5,,,,,,
Molina Duals,CPT,81308,Palb2 gene known famil vrnt,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,
Molina Duals,CPT,81309,Pik3ca gene trgt seq alys,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Molina Duals,CPT,81310,Npm1 gene,Lab Services,Per Unit,$246.52 ,OP,246.52,246.52,,,,,,
Molina Duals,CPT,81311,Nras gene variants exon 2&3,Lab Services,Per Unit,$295.79 ,OP,295.79,295.79,,,,,,
Molina Duals,CPT,81312,Pabpn1 gene detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Molina Duals,CPT,81313,Pca3/klk3 antigen,Lab Services,Per Unit,$255.05 ,OP,255.05,255.05,,,,,,
Molina Duals,CPT,81314,Pdgfra gene,Lab Services,Per Unit,$329.51 ,OP,329.51,329.51,,,,,,
Molina Duals,CPT,81315,Pml/raralpha com breakpoints,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,
Molina Duals,CPT,81316,Pml/raralpha 1 breakpoint,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,
Molina Duals,CPT,81317,Pms2 gene full seq analysis,Lab Services,Per Unit,$676.50 ,OP,676.5,676.5,,,,,,
Molina Duals,CPT,81318,Pms2 known familial variants,Lab Services,Per Unit,$331.00 ,OP,331,331,,,,,,
Molina Duals,CPT,81319,Pms2 gene dup/delet variants,Lab Services,Per Unit,$203.50 ,OP,203.5,203.5,,,,,,
Molina Duals,CPT,81320,Plcg2 gene common variants,Lab Services,Per Unit,$291.36 ,OP,291.36,291.36,,,,,,
Molina Duals,CPT,81321,Pten gene full sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,
Molina Duals,CPT,81322,Pten gene known fam variant,Lab Services,Per Unit,$46.60 ,OP,46.6,46.6,,,,,,
Molina Duals,CPT,81323,Pten gene dup/delet variant,Lab Services,Per Unit,$300.00 ,OP,300,300,,,,,,
Molina Duals,CPT,81324,Pmp22 gene dup/delet,Lab Services,Per Unit,$758.36 ,OP,758.36,758.36,,,,,,
Molina Duals,CPT,81325,Pmp22 gene full sequence,Lab Services,Per Unit,$769.58 ,OP,769.58,769.58,,,,,,
Molina Duals,CPT,81326,Pmp22 gene known fam variant,Lab Services,Per Unit,$46.60 ,OP,46.6,46.6,,,,,,
Molina Duals,CPT,81327,Sept9 gen prmtr mthyltn alys,Lab Services,Per Unit,$192.00 ,OP,192,192,,,,,,
Molina Duals,CPT,81328,Slco1b1 gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Molina Duals,CPT,81329,Smn1 gene dos/deletion alys,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Molina Duals,CPT,81330,Smpd1 gene common variants,Lab Services,Per Unit,$47.00 ,OP,47,47,,,,,,
Molina Duals,CPT,81331,Snrpn/ube3a gene,Lab Services,Per Unit,$51.07 ,OP,51.07,51.07,,,,,,
Molina Duals,CPT,81332,Serpina1 gene,Lab Services,Per Unit,$43.65 ,OP,43.65,43.65,,,,,,
Molina Duals,CPT,81333,Tgfbi gene common variants,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Molina Duals,CPT,81334,Runx1 gene targeted seq alys,Lab Services,Per Unit,$329.51 ,OP,329.51,329.51,,,,,,
Molina Duals,CPT,81335,Tpmt gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Molina Duals,CPT,81336,Smn1 gene full gene sequence,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,
Molina Duals,CPT,81337,Smn1 gen nown famil seq vrnt,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Molina Duals,CPT,81338,Mpl gene common variants,Lab Services,Per Unit,$150.33 ,OP,150.33,150.33,,,,,,
Molina Duals,CPT,81339,Mpl gene seq alys exon 10,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Molina Duals,CPT,81340,Trb@ gene rearrange amplify,Lab Services,Per Unit,$208.92 ,OP,208.92,208.92,,,,,,
Molina Duals,CPT,81341,Trb@ gene rearrange dirprobe,Lab Services,Per Unit,$49.59 ,OP,49.59,49.59,,,,,,
Molina Duals,CPT,81342,Trg gene rearrangement anal,Lab Services,Per Unit,$201.50 ,OP,201.5,201.5,,,,,,
Molina Duals,CPT,81343,Ppp2r2b gen detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Molina Duals,CPT,81344,Tbp gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Molina Duals,CPT,81345,Tert gene targeted seq alys,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Molina Duals,CPT,81346,Tyms gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Molina Duals,CPT,81347,Sf3b1 gene common variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,
Molina Duals,CPT,81348,Srsf2 gene common variants,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,
Molina Duals,CPT,81350,Ugt1a1 gene common variants,Lab Services,Per Unit,$234.00 ,OP,234,234,,,,,,
Molina Duals,CPT,81351,Tp53 gene full gene sequence,Lab Services,Per Unit,$641.85 ,OP,641.85,641.85,,,,,,
Molina Duals,CPT,81352,Tp53 gene trgt sequence alys,Lab Services,Per Unit,$329.51 ,OP,329.51,329.51,,,,,,
Molina Duals,CPT,81353,Tp53 gene known famil vrnt,Lab Services,Per Unit,$308.00 ,OP,308,308,,,,,,
Molina Duals,CPT,81355,Vkorc1 gene,Lab Services,Per Unit,$88.20 ,OP,88.2,88.2,,,,,,
Molina Duals,CPT,81357,U2af1 gene common variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,
Molina Duals,CPT,81360,Zrsr2 gene common variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,
Molina Duals,CPT,81361,Hbb gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Molina Duals,CPT,81362,Hbb gene known fam variant,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,
Molina Duals,CPT,81363,Hbb gene dup/del variants,Lab Services,Per Unit,$202.40 ,OP,202.4,202.4,,,,,,
Molina Duals,CPT,81364,Hbb full gene sequence,Lab Services,Per Unit,$324.58 ,OP,324.58,324.58,,,,,,
Molina Duals,CPT,81370,Hla i & ii typing lr,Lab Services,Per Unit,$402.12 ,OP,402.12,402.12,,,,,,
Molina Duals,CPT,81371,Hla i & ii type verify lr,Lab Services,Per Unit,$404.52 ,OP,404.52,404.52,,,,,,
Molina Duals,CPT,81372,Hla i typing complete lr,Lab Services,Per Unit,$403.59 ,OP,403.59,403.59,,,,,,
Molina Duals,CPT,81373,Hla i typing 1 locus lr,Lab Services,Per Unit,$127.43 ,OP,127.43,127.43,,,,,,
Molina Duals,CPT,81374,Hla i typing 1 antigen lr,Lab Services,Per Unit,$74.33 ,OP,74.33,74.33,,,,,,
Molina Duals,CPT,81375,Hla ii typing ag equiv lr,Lab Services,Per Unit,$220.74 ,OP,220.74,220.74,,,,,,
Molina Duals,CPT,81376,Hla ii typing 1 locus lr,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
Molina Duals,CPT,81377,Hla ii type 1 ag equiv lr,Lab Services,Per Unit,$94.74 ,OP,94.74,94.74,,,,,,
Molina Duals,CPT,81378,Hla i & ii typing hr,Lab Services,Per Unit,$345.57 ,OP,345.57,345.57,,,,,,
Molina Duals,CPT,81379,Hla i typing complete hr,Lab Services,Per Unit,$335.38 ,OP,335.38,335.38,,,,,,
Molina Duals,CPT,81380,Hla i typing 1 locus hr,Lab Services,Per Unit,$177.25 ,OP,177.25,177.25,,,,,,
Molina Duals,CPT,81381,Hla i typing 1 allele hr,Lab Services,Per Unit,$169.90 ,OP,169.9,169.9,,,,,,
Molina Duals,CPT,81382,Hla ii typing 1 loc hr,Lab Services,Per Unit,$123.68 ,OP,123.68,123.68,,,,,,
Molina Duals,CPT,81383,Hla ii typing 1 allele hr,Lab Services,Per Unit,$109.13 ,OP,109.13,109.13,,,,,,
Molina Duals,CPT,81400,Mopath procedure level 1,Lab Services,Per Unit,$63.96 ,OP,63.96,63.96,,,,,,
Molina Duals,CPT,81401,Mopath procedure level 2,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
Molina Duals,CPT,81402,Mopath procedure level 3,Lab Services,Per Unit,$150.33 ,OP,150.33,150.33,,,,,,
Molina Duals,CPT,81403,Mopath procedure level 4,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Molina Duals,CPT,81404,Mopath procedure level 5,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Molina Duals,CPT,81405,Mopath procedure level 6,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,
Molina Duals,CPT,81406,Mopath procedure level 7,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,
Molina Duals,CPT,81407,Mopath procedure level 8,Lab Services,Per Unit,$846.27 ,OP,846.27,846.27,,,,,,
Molina Duals,CPT,81408,Mopath procedure level 9,Lab Services,Per Unit,"$2,000.00 ",OP,"2,000.00","2,000.00",,,,,,
Molina Duals,CPT,81410,Aortic dysfunction/dilation,Lab Services,Per Unit,$504.00 ,OP,504,504,,,,,,
Molina Duals,CPT,81411,Aortic dysfunction/dilation,Lab Services,Per Unit,"$1,350.19 ",OP,"1,350.19","1,350.19",,,,,,
Molina Duals,CPT,81412,Ashkenazi jewish assoc dis,Lab Services,Per Unit,"$2,448.56 ",OP,"2,448.56","2,448.56",,,,,,
Molina Duals,CPT,81413,Car ion chnnlpath inc 10 gns,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,
Molina Duals,CPT,81414,Car ion chnnlpath inc 2 gns,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,
Molina Duals,CPT,81415,Exome sequence analysis,Lab Services,Per Unit,"$4,780.00 ",OP,"4,780.00","4,780.00",,,,,,
Molina Duals,CPT,81416,Exome sequence analysis,Lab Services,Per Unit,"$12,000.00 ",OP,"12,000.00","12,000.00",,,,,,
Molina Duals,CPT,81417,Exome re-evaluation,Lab Services,Per Unit,$320.00 ,OP,320,320,,,,,,
Molina Duals,CPT,81419,Epilepsy gen seq alys panel,Lab Services,Per Unit,"$2,448.56 ",OP,"2,448.56","2,448.56",,,,,,
Molina Duals,CPT,81420,Fetal chrmoml aneuploidy,Lab Services,Per Unit,$759.05 ,OP,759.05,759.05,,,,,,
Molina Duals,CPT,81422,Fetal chrmoml microdeltj,Lab Services,Per Unit,$759.05 ,OP,759.05,759.05,,,,,,
Molina Duals,CPT,81425,Genome sequence analysis,Lab Services,Per Unit,"$5,031.20 ",OP,"5,031.20","5,031.20",,,,,,
Molina Duals,CPT,81426,Genome sequence analysis,Lab Services,Per Unit,"$2,709.95 ",OP,"2,709.95","2,709.95",,,,,,
Molina Duals,CPT,81427,Genome re-evaluation,Lab Services,Per Unit,"$2,337.65 ",OP,"2,337.65","2,337.65",,,,,,
Molina Duals,CPT,81430,Hearing loss sequence analys,Lab Services,Per Unit,"$1,625.00 ",OP,"1,625.00","1,625.00",,,,,,
Molina Duals,CPT,81431,Hearing loss dup/del analys,Lab Services,Per Unit,$679.57 ,OP,679.57,679.57,,,,,,
Molina Duals,CPT,81432,Hrdtry brst ca-rlatd dsordrs,Lab Services,Per Unit,$679.05 ,OP,679.05,679.05,,,,,,
Molina Duals,CPT,81433,Hrdtry brst ca-rlatd dsordrs,Lab Services,Per Unit,$438.93 ,OP,438.93,438.93,,,,,,
Molina Duals,CPT,81434,Hereditary retinal disorders,Lab Services,Per Unit,$597.91 ,OP,597.91,597.91,,,,,,
Molina Duals,CPT,81435,Hereditary colon ca dsordrs,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,
Molina Duals,CPT,81436,Hereditary colon ca dsordrs,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,
Molina Duals,CPT,81437,Heredtry nurondcrn tum dsrdr,Lab Services,Per Unit,$438.93 ,OP,438.93,438.93,,,,,,
Molina Duals,CPT,81438,Heredtry nurondcrn tum dsrdr,Lab Services,Per Unit,$438.93 ,OP,438.93,438.93,,,,,,
Molina Duals,CPT,81439,Hrdtry cardmypy gene panel,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,
Molina Duals,CPT,81440,Mitochondrial gene,Lab Services,Per Unit,"$3,324.00 ",OP,"3,324.00","3,324.00",,,,,,
Molina Duals,CPT,81442,Noonan spectrum disorders,Lab Services,Per Unit,"$2,143.60 ",OP,"2,143.60","2,143.60",,,,,,
Molina Duals,CPT,81443,Genetic tstg severe inh cond,Lab Services,Per Unit,"$2,448.56 ",OP,"2,448.56","2,448.56",,,,,,
Molina Duals,CPT,81445,Targeted genomic seq analys,Lab Services,Per Unit,$597.91 ,OP,597.91,597.91,,,,,,
Molina Duals,CPT,81448,Hrdtry perph neurphy panel,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,
Molina Duals,CPT,81450,Targeted genomic seq analys,Lab Services,Per Unit,$759.53 ,OP,759.53,759.53,,,,,,
Molina Duals,CPT,81455,Targeted genomic seq analys,Lab Services,Per Unit,"$2,919.60 ",OP,"2,919.60","2,919.60",,,,,,
Molina Duals,CPT,81460,Whole mitochondrial genome,Lab Services,Per Unit,"$1,287.00 ",OP,"1,287.00","1,287.00",,,,,,
Molina Duals,CPT,81465,Whole mitochondrial genome,Lab Services,Per Unit,$936.00 ,OP,936,936,,,,,,
Molina Duals,CPT,81470,X-linked intellectual dblt,Lab Services,Per Unit,$914.00 ,OP,914,914,,,,,,
Molina Duals,CPT,81471,X-linked intellectual dblt,Lab Services,Per Unit,$914.00 ,OP,914,914,,,,,,
Molina Duals,CPT,81490,Autoimmune rheumatoid arthr,Lab Services,Per Unit,$840.65 ,OP,840.65,840.65,,,,,,
Molina Duals,CPT,81493,Cor artery disease mrna,Lab Services,Per Unit,"$1,050.00 ",OP,"1,050.00","1,050.00",,,,,,
Molina Duals,CPT,81500,Onco (ovar) two proteins,Lab Services,Per Unit,$260.50 ,OP,91.51,260.5,,,,,,
Molina Duals,CPT,81503,Onco (ovar) five proteins,Lab Services,Per Unit,$897.00 ,OP,91.51,897,,,,,,
Molina Duals,CPT,81504,Oncology tissue of origin,Lab Services,Per Unit,$520.00 ,OP,520,520,,,,,,
Molina Duals,CPT,81506,Endo assay seven anal,Lab Services,Per Unit,$68.92 ,OP,57.19,68.92,,,,,,
Molina Duals,CPT,81507,Fetal aneuploidy trisom risk,Lab Services,Per Unit,$795.00 ,OP,795,795,,,,,,
Molina Duals,CPT,81508,Ftl cgen abnor two proteins,Lab Services,Per Unit,$54.30 ,OP,54.3,144.88,,,,,,
Molina Duals,CPT,81509,Ftl cgen abnor 3 proteins,Lab Services,Per Unit,"$1,487.37 ",OP,213.51,"1,487.37",,,,,,
Molina Duals,CPT,81510,Ftl cgen abnor three anal,Lab Services,Per Unit,$55.54 ,OP,55.54,202.07,,,,,,
Molina Duals,CPT,81511,Ftl cgen abnor four anal,Lab Services,Per Unit,$153.50 ,OP,153.5,270.71,,,,,,
Molina Duals,CPT,81512,Ftl cgen abnor five anal,Lab Services,Per Unit,$69.52 ,OP,69.52,270.71,,,,,,
Molina Duals,CPT,81513,Nfct ds bv rna vag flu alg,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
Molina Duals,CPT,81514,Nfct ds bv&vaginitis dna alg,Lab Services,Per Unit,$262.99 ,OP,262.99,262.99,,,,,,
Molina Duals,CPT,81518,Onc brst mrna 11 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
Molina Duals,CPT,81519,Oncology breast mrna,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
Molina Duals,CPT,81520,Onc breast mrna 58 genes,Lab Services,Per Unit,"$2,510.21 ",OP,"2,510.21","2,510.21",,,,,,
Molina Duals,CPT,81521,Onc breast mrna 70 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
Molina Duals,CPT,81522,Onc breast mrna 12 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
Molina Duals,CPT,81525,Oncology colon mrna,Lab Services,Per Unit,"$3,116.00 ",OP,"3,116.00","3,116.00",,,,,,
Molina Duals,CPT,81528,Oncology colorectal scr,Lab Services,Per Unit,$508.87 ,OP,508.87,508.87,,,,,,
Molina Duals,CPT,81529,Onc cutan mlnma mrna 31 gene,Lab Services,Per Unit,"$7,193.00 ",OP,"7,193.00","7,193.00",,,,,,
Molina Duals,CPT,81535,Oncology gynecologic,Lab Services,Per Unit,$579.46 ,OP,579.46,579.46,,,,,,
Molina Duals,CPT,81536,Oncology gynecologic,Lab Services,Per Unit,$177.56 ,OP,177.56,177.56,,,,,,
Molina Duals,CPT,81538,Oncology lung,Lab Services,Per Unit,"$2,871.00 ",OP,"2,871.00","2,871.00",,,,,,
Molina Duals,CPT,81539,Oncology prostate prob score,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
Molina Duals,CPT,81540,Oncology tum unknown origin,Lab Services,Per Unit,"$3,750.00 ",OP,"3,750.00","3,750.00",,,,,,
Molina Duals,CPT,81541,Onc prostate mrna 46 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
Molina Duals,CPT,81542,Onc prostate mrna 22 cnt gen,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
Molina Duals,CPT,81546,Onc thyr mrna 10-196 gen alg,Lab Services,Per Unit,"$3,600.00 ",OP,"3,600.00","3,600.00",,,,,,
Molina Duals,CPT,81551,Onc prostate 3 genes,Lab Services,Per Unit,"$2,030.00 ",OP,"2,030.00","2,030.00",,,,,,
Molina Duals,CPT,81552,Onc uveal mlnma mrna 15 gene,Lab Services,Per Unit,"$7,776.00 ",OP,"7,776.00","7,776.00",,,,,,
Molina Duals,CPT,81554,Pulm ds ipf mrna 190 gen alg,Lab Services,Per Unit,"$5,500.00 ",OP,"5,500.00","5,500.00",,,,,,
Molina Duals,CPT,81595,Cardiology hrt trnspl mrna,Lab Services,Per Unit,"$3,240.00 ",OP,"3,240.00","3,240.00",,,,,,
Molina Duals,CPT,81596,Nfct ds chrnc hcv 6 assays,Lab Services,Per Unit,$72.19 ,OP,72.19,72.19,,,,,,
Molina Duals,CPT,82009,Test for acetone/ketones,Lab Services,Per Unit,$4.52 ,OP,4.52,19.07,,,,,,
Molina Duals,CPT,82010,Acetone assay,Lab Services,Per Unit,$8.17 ,OP,8.17,41.94,,,,,,
Molina Duals,CPT,82013,Acetylcholinesterase assay,Lab Services,Per Unit,$12.29 ,OP,12.29,12.29,,,,,,
Molina Duals,CPT,82016,Acylcarnitines qual,Lab Services,Per Unit,$16.49 ,OP,16.49,61,,,,,,
Molina Duals,CPT,82017,Acylcarnitines quant,Lab Services,Per Unit,$16.87 ,OP,16.87,76.26,,,,,,
Molina Duals,CPT,82024,Assay of acth,Lab Services,Per Unit,$38.62 ,OP,38.62,171.58,,,,,,
Molina Duals,CPT,82030,Assay of adp & amp,Lab Services,Per Unit,$25.80 ,OP,25.8,99.13,,,,,,
Molina Duals,CPT,82040,Assay of serum albumin,Lab Services,Per Unit,$4.95 ,OP,4.95,22.88,,,,,,
Molina Duals,CPT,82042,Other source albumin quan ea,Lab Services,Per Unit,$7.78 ,OP,7.78,26.7,,,,,,
Molina Duals,CPT,82043,Ur albumin quantitative,Lab Services,Per Unit,$5.78 ,OP,5.78,26.7,,,,,,
Molina Duals,CPT,82044,Ur albumin semiquantitative,Lab Services,Per Unit,$6.23 ,OP,6.23,22.88,,,,,,
Molina Duals,CPT,82045,Albumin ischemia modified,Lab Services,Per Unit,$33.94 ,OP,33.94,125.82,,,,,,
Molina Duals,CPT,82075,Assay of breath ethanol,Lab Services,Per Unit,$30.00 ,OP,30,45.74,,,,,,
Molina Duals,CPT,82077,Assay spec xcp ur&breath ia,Lab Services,Per Unit,$17.27 ,OP,17.27,17.27,,,,,,
Molina Duals,CPT,82085,Assay of aldolase,Lab Services,Per Unit,$9.71 ,OP,9.71,41.94,,,,,,
Molina Duals,CPT,82088,Assay of aldosterone,Lab Services,Per Unit,$40.75 ,OP,40.75,183.02,,,,,,
Molina Duals,CPT,82103,Alpha-1-antitrypsin total,Lab Services,Per Unit,$13.44 ,OP,13.44,61,,,,,,
Molina Duals,CPT,82104,Alpha-1-antitrypsin pheno,Lab Services,Per Unit,$14.46 ,OP,14.46,64.82,,,,,,
Molina Duals,CPT,82105,Alpha-fetoprotein serum,Lab Services,Per Unit,$16.77 ,OP,16.77,76.26,,,,,,
Molina Duals,CPT,82106,Alpha-fetoprotein amniotic,Lab Services,Per Unit,$17.00 ,OP,17,76.26,,,,,,
Molina Duals,CPT,82107,Alpha-fetoprotein l3,Lab Services,Per Unit,$64.41 ,OP,64.41,209.7,,,,,,
Molina Duals,CPT,82108,Assay of aluminum,Lab Services,Per Unit,$25.48 ,OP,25.48,114.39,,,,,,
Molina Duals,CPT,82120,Amines vaginal fluid qual,Lab Services,Per Unit,$5.99 ,OP,5.99,19.07,,,,,,
Molina Duals,CPT,82127,Amino acid single qual,Lab Services,Per Unit,$14.18 ,OP,14.18,61,,,,,,
Molina Duals,CPT,82128,Amino acids mult qual,Lab Services,Per Unit,$13.87 ,OP,13.87,61,,,,,,
Molina Duals,CPT,82131,Amino acids single quant,Lab Services,Per Unit,$22.98 ,OP,22.98,76.26,,,,,,
Molina Duals,CPT,82135,Assay aminolevulinic acid,Lab Services,Per Unit,$16.45 ,OP,16.45,64.82,,,,,,
Molina Duals,CPT,82136,Amino acids quant 2-5,Lab Services,Per Unit,$19.61 ,OP,19.61,76.26,,,,,,
Molina Duals,CPT,82139,Amino acids quan 6 or more,Lab Services,Per Unit,$16.87 ,OP,16.87,16.87,,,,,,
Molina Duals,CPT,82140,Assay of ammonia,Lab Services,Per Unit,$14.57 ,OP,14.57,64.82,,,,,,
Molina Duals,CPT,82143,Amniotic fluid scan,Lab Services,Per Unit,$9.35 ,OP,9.35,30.51,,,,,,
Molina Duals,CPT,82150,Assay of amylase,Lab Services,Per Unit,$6.48 ,OP,6.48,34.31,,,,,,
Molina Duals,CPT,82154,Androstanediol glucuronide,Lab Services,Per Unit,$28.83 ,OP,28.83,28.83,,,,,,
Molina Duals,CPT,82157,Assay of androstenedione,Lab Services,Per Unit,$29.28 ,OP,29.28,129.64,,,,,,
Molina Duals,CPT,82160,Assay of androsterone,Lab Services,Per Unit,$25.55 ,OP,25.55,110.57,,,,,,
Molina Duals,CPT,82163,Assay of angiotensin ii,Lab Services,Per Unit,$20.52 ,OP,20.52,91.51,,,,,,
Molina Duals,CPT,82164,Angiotensin i enzyme test,Lab Services,Per Unit,$14.60 ,OP,14.6,64.82,,,,,,
Molina Duals,CPT,82172,Assay of apolipoprotein,Lab Services,Per Unit,$21.09 ,OP,21.09,68.63,,,,,,
Molina Duals,CPT,82175,Assay of arsenic,Lab Services,Per Unit,$18.97 ,OP,18.97,83.87,,,,,,
Molina Duals,CPT,82180,Assay of ascorbic acid,Lab Services,Per Unit,$9.89 ,OP,9.89,9.89,,,,,,
Molina Duals,CPT,82190,Atomic absorption,Lab Services,Per Unit,$15.90 ,OP,15.9,64.82,,,,,,
Molina Duals,CPT,82232,Assay of beta-2 protein,Lab Services,Per Unit,$16.18 ,OP,16.18,72.44,,,,,,
Molina Duals,CPT,82239,Bile acids total,Lab Services,Per Unit,$17.12 ,OP,17.12,76.26,,,,,,
Molina Duals,CPT,82240,Bile acids cholylglycine,Lab Services,Per Unit,$26.58 ,OP,26.58,64.82,,,,,,
Molina Duals,CPT,82247,Bilirubin total,Lab Services,Per Unit,$5.02 ,OP,5.02,26.7,,,,,,
Molina Duals,CPT,82248,Bilirubin direct,Lab Services,Per Unit,$5.02 ,OP,5.02,26.7,,,,,,
Molina Duals,CPT,82252,Fecal bilirubin test,Lab Services,Per Unit,$4.56 ,OP,4.56,19.07,,,,,,
Molina Duals,CPT,82261,Assay of biotinidase,Lab Services,Per Unit,$16.87 ,OP,16.87,76.26,,,,,,
Molina Duals,CPT,82270,Occult blood feces,Lab Services,Per Unit,$4.38 ,OP,4.38,15.26,,,,,,
Molina Duals,CPT,82271,Occult blood other sources,Lab Services,Per Unit,$5.32 ,OP,5.32,15.26,,,,,,
Molina Duals,CPT,82272,Occult bld feces 1-3 tests,Lab Services,Per Unit,$4.23 ,OP,4.23,15.26,,,,,,
Molina Duals,CPT,82274,Assay test for blood fecal,Lab Services,Per Unit,$15.92 ,OP,15.92,80.07,,,,,,
Molina Duals,CPT,82286,Assay of bradykinin,Lab Services,Per Unit,$5.16 ,OP,5.16,30.51,,,,,,
Molina Duals,CPT,82300,Assay of cadmium,Lab Services,Per Unit,$23.64 ,OP,23.64,102.95,,,,,,
Molina Duals,CPT,82306,Vitamin d 25 hydroxy,Lab Services,Per Unit,$29.60 ,OP,29.6,356.68,,,,,,
Molina Duals,CPT,82308,Assay of calcitonin,Lab Services,Per Unit,$26.79 ,OP,26.79,118.19,,,,,,
Molina Duals,CPT,82310,Assay of calcium,Lab Services,Per Unit,$5.16 ,OP,5.16,22.88,,,,,,
Molina Duals,CPT,82330,Assay of calcium,Lab Services,Per Unit,$13.68 ,OP,13.68,61,,,,,,
Molina Duals,CPT,82331,Calcium infusion test,Lab Services,Per Unit,$13.34 ,OP,13.34,22.88,,,,,,
Molina Duals,CPT,82340,Assay of calcium in urine,Lab Services,Per Unit,$6.03 ,OP,6.03,26.7,,,,,,
Molina Duals,CPT,82355,Calculus analysis qual,Lab Services,Per Unit,$11.58 ,OP,11.58,53.38,,,,,,
Molina Duals,CPT,82360,Calculus assay quant,Lab Services,Per Unit,$12.87 ,OP,12.87,45.74,,,,,,
Molina Duals,CPT,82365,Calculus spectroscopy,Lab Services,Per Unit,$12.90 ,OP,12.9,45.74,,,,,,
Molina Duals,CPT,82370,X-ray assay calculus,Lab Services,Per Unit,$12.52 ,OP,12.52,45.74,,,,,,
Molina Duals,CPT,82373,Assay c-d transfer measure,Lab Services,Per Unit,$18.06 ,OP,18.06,80.07,,,,,,
Molina Duals,CPT,82374,Assay blood carbon dioxide,Lab Services,Per Unit,$4.88 ,OP,4.88,22.88,,,,,,
Molina Duals,CPT,82375,Assay carboxyhb quant,Lab Services,Per Unit,$12.32 ,OP,12.32,26.7,,,,,,
Molina Duals,CPT,82376,Assay carboxyhb qual,Lab Services,Per Unit,$14.07 ,OP,14.07,26.7,,,,,,
Molina Duals,CPT,82378,Carcinoembryonic antigen,Lab Services,Per Unit,$18.96 ,OP,18.96,83.87,,,,,,
Molina Duals,CPT,82379,Assay of carnitine,Lab Services,Per Unit,$16.87 ,OP,16.87,76.26,,,,,,
Molina Duals,CPT,82380,Assay of carotene,Lab Services,Per Unit,$9.22 ,OP,9.22,41.94,,,,,,
Molina Duals,CPT,82382,Assay urine catecholamines,Lab Services,Per Unit,$27.30 ,OP,27.3,76.26,,,,,,
Molina Duals,CPT,82383,Assay blood catecholamines,Lab Services,Per Unit,$29.08 ,OP,29.08,110.57,,,,,,
Molina Duals,CPT,82384,Assay three catecholamines,Lab Services,Per Unit,$25.25 ,OP,25.25,110.57,,,,,,
Molina Duals,CPT,82387,Assay of cathepsin-d,Lab Services,Per Unit,$18.06 ,OP,18.06,91.51,,,,,,
Molina Duals,CPT,82390,Assay of ceruloplasmin,Lab Services,Per Unit,$10.74 ,OP,10.74,49.56,,,,,,
Molina Duals,CPT,82397,Chemiluminescent assay,Lab Services,Per Unit,$14.12 ,OP,14.12,64.82,,,,,,
Molina Duals,CPT,82415,Assay of chloramphenicol,Lab Services,Per Unit,$12.67 ,OP,12.67,57.19,,,,,,
Molina Duals,CPT,82435,Assay of blood chloride,Lab Services,Per Unit,$4.60 ,OP,4.6,19.07,,,,,,
Molina Duals,CPT,82436,Assay of urine chloride,Lab Services,Per Unit,$5.75 ,OP,5.75,22.88,,,,,,
Molina Duals,CPT,82438,Assay other fluid chlorides,Lab Services,Per Unit,$5.00 ,OP,5,5,,,,,,
Molina Duals,CPT,82441,Test for chlorohydrocarbons,Lab Services,Per Unit,$6.01 ,OP,6.01,26.7,,,,,,
Molina Duals,CPT,82465,Assay bld/serum cholesterol,Lab Services,Per Unit,$4.35 ,OP,4.35,22.88,,,,,,
Molina Duals,CPT,82480,Assay serum cholinesterase,Lab Services,Per Unit,$7.87 ,OP,7.87,34.31,,,,,,
Molina Duals,CPT,82482,Assay rbc cholinesterase,Lab Services,Per Unit,$9.81 ,OP,9.81,34.31,,,,,,
Molina Duals,CPT,82485,Assay chondroitin sulfate,Lab Services,Per Unit,$20.65 ,OP,20.65,91.51,,,,,,
Molina Duals,CPT,82495,Assay of chromium,Lab Services,Per Unit,$20.28 ,OP,20.28,91.51,,,,,,
Molina Duals,CPT,82507,Assay of citrate,Lab Services,Per Unit,$27.80 ,OP,27.8,57.19,,,,,,
Molina Duals,CPT,82523,Collagen crosslinks,Lab Services,Per Unit,$18.68 ,OP,18.68,95.32,,,,,,
Molina Duals,CPT,82525,Assay of copper,Lab Services,Per Unit,$12.41 ,OP,12.41,53.38,,,,,,
Molina Duals,CPT,82528,Assay of corticosterone,Lab Services,Per Unit,$22.52 ,OP,22.52,99.13,,,,,,
Molina Duals,CPT,82530,Cortisol free,Lab Services,Per Unit,$16.71 ,OP,16.71,76.26,,,,,,
Molina Duals,CPT,82533,Total cortisol,Lab Services,Per Unit,$16.30 ,OP,16.3,72.44,,,,,,
Molina Duals,CPT,82540,Assay of creatine,Lab Services,Per Unit,$4.64 ,OP,4.64,19.07,,,,,,
Molina Duals,CPT,82542,Col chromotography qual/quan,Lab Services,Per Unit,$24.09 ,OP,24.09,80.07,,,,,,
Molina Duals,CPT,82550,Assay of ck (cpk),Lab Services,Per Unit,$6.51 ,OP,6.51,30.51,,,,,,
Molina Duals,CPT,82552,Assay of cpk in blood,Lab Services,Per Unit,$13.39 ,OP,13.39,61,,,,,,
Molina Duals,CPT,82553,Creatine mb fraction,Lab Services,Per Unit,$11.55 ,OP,11.55,49.56,,,,,,
Molina Duals,CPT,82554,Creatine isoforms,Lab Services,Per Unit,$11.87 ,OP,11.87,53.38,,,,,,
Molina Duals,CPT,82565,Assay of creatinine,Lab Services,Per Unit,$5.12 ,OP,5.12,22.88,,,,,,
Molina Duals,CPT,82570,Assay of urine creatinine,Lab Services,Per Unit,$5.18 ,OP,5.18,26.7,,,,,,
Molina Duals,CPT,82575,Creatinine clearance test,Lab Services,Per Unit,$9.46 ,OP,9.46,41.94,,,,,,
Molina Duals,CPT,82585,Assay of cryofibrinogen,Lab Services,Per Unit,$14.14 ,OP,14.14,38.13,,,,,,
Molina Duals,CPT,82595,Assay of cryoglobulin,Lab Services,Per Unit,$6.47 ,OP,6.47,30.51,,,,,,
Molina Duals,CPT,82600,Assay of cyanide,Lab Services,Per Unit,$19.40 ,OP,19.4,19.4,,,,,,
Molina Duals,CPT,82607,Vitamin b-12,Lab Services,Per Unit,$15.08 ,OP,15.08,68.63,,,,,,
Molina Duals,CPT,82608,B-12 binding capacity,Lab Services,Per Unit,$14.32 ,OP,14.32,14.32,,,,,,
Molina Duals,CPT,82610,Cystatin c,Lab Services,Per Unit,$18.52 ,OP,18.52,61,,,,,,
Molina Duals,CPT,82615,Test for urine cystines,Lab Services,Per Unit,$9.55 ,OP,9.55,38.13,,,,,,
Molina Duals,CPT,82626,Dehydroepiandrosterone,Lab Services,Per Unit,$25.27 ,OP,25.27,114.39,,,,,,
Molina Duals,CPT,82627,Dehydroepiandrosterone,Lab Services,Per Unit,$22.23 ,OP,22.23,99.13,,,,,,
Molina Duals,CPT,82633,Desoxycorticosterone,Lab Services,Per Unit,$30.98 ,OP,30.98,122,,,,,,
Molina Duals,CPT,82634,Deoxycortisol,Lab Services,Per Unit,$29.28 ,OP,29.28,76.26,,,,,,
Molina Duals,CPT,82638,Assay of dibucaine number,Lab Services,Per Unit,$12.25 ,OP,12.25,53.38,,,,,,
Molina Duals,CPT,82642,Dihydrotestosterone,Lab Services,Per Unit,$29.28 ,OP,29.28,114.39,,,,,,
Molina Duals,CPT,82652,Vit d 1 25-dihydroxy,Lab Services,Per Unit,$38.50 ,OP,38.5,171.58,,,,,,
Molina Duals,CPT,82656,Pancreatic elastase fecal,Lab Services,Per Unit,$11.53 ,OP,11.53,11.53,,,,,,
Molina Duals,CPT,82657,Enzyme cell activity,Lab Services,Per Unit,$22.17 ,OP,22.17,80.07,,,,,,
Molina Duals,CPT,82658,Enzyme cell activity ra,Lab Services,Per Unit,$44.03 ,OP,44.03,44.03,,,,,,
Molina Duals,CPT,82664,Electrophoretic test,Lab Services,Per Unit,$61.50 ,OP,61.5,122,,,,,,
Molina Duals,CPT,82668,Assay of erythropoietin,Lab Services,Per Unit,$18.79 ,OP,18.79,83.87,,,,,,
Molina Duals,CPT,82670,Assay of total estradiol,Lab Services,Per Unit,$27.94 ,OP,27.94,49.56,,,,,,
Molina Duals,CPT,82671,Assay of estrogens,Lab Services,Per Unit,$32.30 ,OP,32.3,114.39,,,,,,
Molina Duals,CPT,82672,Assay of estrogen,Lab Services,Per Unit,$21.70 ,OP,21.7,95.32,,,,,,
Molina Duals,CPT,82677,Assay of estriol,Lab Services,Per Unit,$24.18 ,OP,24.18,49.56,,,,,,
Molina Duals,CPT,82679,Assay of estrone,Lab Services,Per Unit,$24.95 ,OP,24.95,57.19,,,,,,
Molina Duals,CPT,82681,Assay dir meas fr estradiol,Lab Services,Per Unit,$27.94 ,OP,27.94,27.94,,,,,,
Molina Duals,CPT,82693,Assay of ethylene glycol,Lab Services,Per Unit,$14.90 ,OP,14.9,64.82,,,,,,
Molina Duals,CPT,82696,Assay of etiocholanolone,Lab Services,Per Unit,$26.24 ,OP,26.24,64.82,,,,,,
Molina Duals,CPT,82705,Fats/lipids feces qual,Lab Services,Per Unit,$5.10 ,OP,5.1,5.1,,,,,,
Molina Duals,CPT,82710,Fats/lipids feces quant,Lab Services,Per Unit,$16.80 ,OP,16.8,16.8,,,,,,
Molina Duals,CPT,82715,Assay of fecal fat,Lab Services,Per Unit,$22.97 ,OP,15.26,22.97,,,,,,
Molina Duals,CPT,82725,Assay of blood fatty acids,Lab Services,Per Unit,$18.77 ,OP,18.77,18.77,,,,,,
Molina Duals,CPT,82726,Long chain fatty acids,Lab Services,Per Unit,$19.75 ,OP,19.75,80.07,,,,,,
Molina Duals,CPT,82728,Assay of ferritin,Lab Services,Per Unit,$13.63 ,OP,13.63,61,,,,,,
Molina Duals,CPT,82731,Assay of fetal fibronectin,Lab Services,Per Unit,$64.41 ,OP,64.41,236.38,,,,,,
Molina Duals,CPT,82735,Assay of fluoride,Lab Services,Per Unit,$18.54 ,OP,18.54,83.87,,,,,,
Molina Duals,CPT,82746,Assay of folic acid serum,Lab Services,Per Unit,$14.70 ,OP,14.7,64.82,,,,,,
Molina Duals,CPT,82747,Assay of folic acid rbc,Lab Services,Per Unit,$17.65 ,OP,17.65,76.26,,,,,,
Molina Duals,CPT,82757,Assay of semen fructose,Lab Services,Per Unit,$17.34 ,OP,17.34,76.26,,,,,,
Molina Duals,CPT,82759,Assay of rbc galactokinase,Lab Services,Per Unit,$21.48 ,OP,21.48,95.32,,,,,,
Molina Duals,CPT,82760,Assay of galactose,Lab Services,Per Unit,$11.20 ,OP,11.2,49.56,,,,,,
Molina Duals,CPT,82775,Assay galactose transferase,Lab Services,Per Unit,$21.07 ,OP,21.07,80.07,,,,,,
Molina Duals,CPT,82776,Galactose transferase test,Lab Services,Per Unit,$11.74 ,OP,11.74,26.7,,,,,,
Molina Duals,CPT,82777,Galectin-3,Lab Services,Per Unit,$44.25 ,OP,44.25,44.25,,,,,,
Molina Duals,CPT,82784,Assay iga/igd/igg/igm each,Lab Services,Per Unit,$9.30 ,OP,9.3,41.94,,,,,,
Molina Duals,CPT,82785,Assay of ige,Lab Services,Per Unit,$16.46 ,OP,16.46,72.44,,,,,,
Molina Duals,CPT,82787,Igg 1 2 3 or 4 each,Lab Services,Per Unit,$8.02 ,OP,8.02,34.31,,,,,,
Molina Duals,CPT,82800,Blood ph,Lab Services,Per Unit,$11.00 ,OP,11,30.51,,,,,,
Molina Duals,CPT,82803,Blood gases any combination,Lab Services,Per Unit,$26.07 ,OP,26.07,61,,,,,,
Molina Duals,CPT,82805,Blood gases w/o2 saturation,Lab Services,Per Unit,$78.77 ,OP,78.77,141.07,,,,,,
Molina Duals,CPT,82810,Blood gases o2 sat only,Lab Services,Per Unit,$9.77 ,OP,9.77,9.77,,,,,,
Molina Duals,CPT,82820,Hemoglobin-oxygen affinity,Lab Services,Per Unit,$13.34 ,OP,13.34,49.56,,,,,,
Molina Duals,CPT,82930,Gastric analy w/ph ea spec,Lab Services,Per Unit,$6.71 ,OP,6.71,6.71,,,,,,
Molina Duals,CPT,82938,Gastrin test,Lab Services,Per Unit,$17.69 ,OP,17.69,80.07,,,,,,
Molina Duals,CPT,82941,Assay of gastrin,Lab Services,Per Unit,$17.63 ,OP,17.63,80.07,,,,,,
Molina Duals,CPT,82943,Assay of glucagon,Lab Services,Per Unit,$14.29 ,OP,14.29,34.31,,,,,,
Molina Duals,CPT,82945,Glucose other fluid,Lab Services,Per Unit,$3.93 ,OP,3.93,19.07,,,,,,
Molina Duals,CPT,82946,Glucagon tolerance test,Lab Services,Per Unit,$17.77 ,OP,17.77,68.63,,,,,,
Molina Duals,CPT,82947,Assay glucose blood quant,Lab Services,Per Unit,$3.93 ,OP,3.93,19.07,,,,,,
Molina Duals,CPT,82948,Reagent strip/blood glucose,Lab Services,Per Unit,$5.04 ,OP,5.04,15.26,,,,,,
Molina Duals,CPT,82950,Glucose test,Lab Services,Per Unit,$4.75 ,OP,4.75,22.88,,,,,,
Molina Duals,CPT,82951,Glucose tolerance test (gtt),Lab Services,Per Unit,$12.87 ,OP,12.87,64.82,,,,,,
Molina Duals,CPT,82952,Gtt-added samples,Lab Services,Per Unit,$3.92 ,OP,3.92,19.07,,,,,,
Molina Duals,CPT,82955,Assay of g6pd enzyme,Lab Services,Per Unit,$9.70 ,OP,9.7,41.94,,,,,,
Molina Duals,CPT,82960,Test for g6pd enzyme,Lab Services,Per Unit,$6.05 ,OP,6.05,6.05,,,,,,
Molina Duals,CPT,82962,Glucose blood test,Lab Services,Per Unit,$3.28 ,OP,3.28,11.44,,,,,,
Molina Duals,CPT,82963,Assay of glucosidase,Lab Services,Per Unit,$21.48 ,OP,21.48,80.07,,,,,,
Molina Duals,CPT,82965,Assay of gdh enzyme,Lab Services,Per Unit,$13.15 ,OP,13.15,34.31,,,,,,
Molina Duals,CPT,82977,Assay of ggt,Lab Services,Per Unit,$7.20 ,OP,7.2,34.31,,,,,,
Molina Duals,CPT,82978,Assay of glutathione,Lab Services,Per Unit,$15.45 ,OP,15.45,64.82,,,,,,
Molina Duals,CPT,82979,Assay rbc glutathione,Lab Services,Per Unit,$9.44 ,OP,9.44,30.51,,,,,,
Molina Duals,CPT,82985,Assay of glycated protein,Lab Services,Per Unit,$16.76 ,OP,16.76,76.26,,,,,,
Molina Duals,CPT,83001,Assay of gonadotropin (fsh),Lab Services,Per Unit,$18.58 ,OP,18.58,91.51,,,,,,
Molina Duals,CPT,83002,Assay of gonadotropin (lh),Lab Services,Per Unit,$18.52 ,OP,18.52,91.51,,,,,,
Molina Duals,CPT,83003,Assay growth hormone (hgh),Lab Services,Per Unit,$16.67 ,OP,16.67,72.44,,,,,,
Molina Duals,CPT,83006,Growth stimulation gene 2,Lab Services,Per Unit,$75.60 ,OP,75.6,75.6,,,,,,
Molina Duals,CPT,83009,H pylori (c-13) blood,Lab Services,Per Unit,$67.36 ,OP,67.36,301.2,,,,,,
Molina Duals,CPT,83010,Assay of haptoglobin quant,Lab Services,Per Unit,$12.58 ,OP,12.58,57.19,,,,,,
Molina Duals,CPT,83012,Assay of haptoglobins,Lab Services,Per Unit,$26.89 ,OP,26.89,72.44,,,,,,
Molina Duals,CPT,83013,H pylori (c-13) breath,Lab Services,Per Unit,$67.36 ,OP,67.36,301.2,,,,,,
Molina Duals,CPT,83014,H pylori drug admin,Lab Services,Per Unit,$7.86 ,OP,7.86,34.31,,,,,,
Molina Duals,CPT,83015,Heavy metal qual any anal,Lab Services,Per Unit,$20.94 ,OP,20.94,83.87,,,,,,
Molina Duals,CPT,83018,Heavy metal quant each nes,Lab Services,Per Unit,$21.96 ,OP,21.96,99.13,,,,,,
Molina Duals,CPT,83020,Hemoglobin electrophoresis,Lab Services,Per Unit,$12.87 ,OP,12.87,45.74,,,,,,
Molina Duals,CPT,83021,Hemoglobin chromotography,Lab Services,Per Unit,$18.06 ,OP,18.06,80.07,,,,,,
Molina Duals,CPT,83026,Hemoglobin copper sulfate,Lab Services,Per Unit,$4.01 ,OP,4.01,4.01,,,,,,
Molina Duals,CPT,83030,Fetal hemoglobin chemical,Lab Services,Per Unit,$10.74 ,OP,10.74,10.74,,,,,,
Molina Duals,CPT,83033,Fetal hemoglobin assay qual,Lab Services,Per Unit,$8.00 ,OP,8,8,,,,,,
Molina Duals,CPT,83036,Glycosylated hemoglobin test,Lab Services,Per Unit,$9.71 ,OP,9.71,49.56,,,,,,
Molina Duals,CPT,83037,Glycosylated hb home device,Lab Services,Per Unit,$9.71 ,OP,9.71,41.94,,,,,,
Molina Duals,CPT,83045,Blood methemoglobin test,Lab Services,Per Unit,$6.49 ,OP,6.49,22.88,,,,,,
Molina Duals,CPT,83050,Blood methemoglobin assay,Lab Services,Per Unit,$8.20 ,OP,8.2,15.26,,,,,,
Molina Duals,CPT,83051,Assay of plasma hemoglobin,Lab Services,Per Unit,$7.31 ,OP,7.31,7.31,,,,,,
Molina Duals,CPT,83060,Blood sulfhemoglobin assay,Lab Services,Per Unit,$8.80 ,OP,8.8,15.26,,,,,,
Molina Duals,CPT,83065,Assay of hemoglobin heat,Lab Services,Per Unit,$9.00 ,OP,9,15.26,,,,,,
Molina Duals,CPT,83068,Hemoglobin stability screen,Lab Services,Per Unit,$9.47 ,OP,9.47,9.47,,,,,,
Molina Duals,CPT,83069,Assay of urine hemoglobin,Lab Services,Per Unit,$3.95 ,OP,3.95,7.62,,,,,,
Molina Duals,CPT,83070,Assay of hemosiderin qual,Lab Services,Per Unit,$4.75 ,OP,4.75,15.26,,,,,,
Molina Duals,CPT,83080,Assay of b hexosaminidase,Lab Services,Per Unit,$16.87 ,OP,16.87,76.26,,,,,,
Molina Duals,CPT,83088,Assay of histamine,Lab Services,Per Unit,$29.53 ,OP,29.53,129.64,,,,,,
Molina Duals,CPT,83090,Assay of homocystine,Lab Services,Per Unit,$17.92 ,OP,17.92,76.26,,,,,,
Molina Duals,CPT,83150,Assay of homovanillic acid,Lab Services,Per Unit,$22.41 ,OP,22.41,87.69,,,,,,
Molina Duals,CPT,83491,Assay of corticosteroids 17,Lab Services,Per Unit,$17.90 ,OP,17.9,76.26,,,,,,
Molina Duals,CPT,83497,Assay of 5-hiaa,Lab Services,Per Unit,$12.90 ,OP,12.9,57.19,,,,,,
Molina Duals,CPT,83498,Assay of progesterone 17-d,Lab Services,Per Unit,$27.17 ,OP,27.17,122,,,,,,
Molina Duals,CPT,83500,Assay free hydroxyproline,Lab Services,Per Unit,$22.65 ,OP,22.65,99.13,,,,,,
Molina Duals,CPT,83505,Assay total hydroxyproline,Lab Services,Per Unit,$24.30 ,OP,24.3,106.76,,,,,,
Molina Duals,CPT,83516,Immunoassay nonantibody,Lab Services,Per Unit,$11.53 ,OP,11.53,49.56,,,,,,
Molina Duals,CPT,83518,Immunoassay dipstick,Lab Services,Per Unit,$9.64 ,OP,9.64,9.64,,,,,,
Molina Duals,CPT,83519,Ria nonantibody,Lab Services,Per Unit,$18.40 ,OP,18.4,61,,,,,,
Molina Duals,CPT,83520,Immunoassay quant nos nonab,Lab Services,Per Unit,$17.27 ,OP,17.27,57.19,,,,,,
Molina Duals,CPT,83525,Assay of insulin,Lab Services,Per Unit,$11.43 ,OP,11.43,49.56,,,,,,
Molina Duals,CPT,83527,Assay of insulin,Lab Services,Per Unit,$12.95 ,OP,12.95,57.19,,,,,,
Molina Duals,CPT,83528,Assay of intrinsic factor,Lab Services,Per Unit,$19.82 ,OP,19.82,72.44,,,,,,
Molina Duals,CPT,83540,Assay of iron,Lab Services,Per Unit,$6.47 ,OP,6.47,30.51,,,,,,
Molina Duals,CPT,83550,Iron binding test,Lab Services,Per Unit,$8.74 ,OP,8.74,38.13,,,,,,
Molina Duals,CPT,83570,Assay of idh enzyme,Lab Services,Per Unit,$8.85 ,OP,8.85,38.13,,,,,,
Molina Duals,CPT,83582,Assay of ketogenic steroids,Lab Services,Per Unit,$15.47 ,OP,15.47,15.47,,,,,,
Molina Duals,CPT,83586,Assay 17- ketosteroids,Lab Services,Per Unit,$12.80 ,OP,12.8,57.19,,,,,,
Molina Duals,CPT,83593,Fractionation ketosteroids,Lab Services,Per Unit,$28.50 ,OP,28.5,118.19,,,,,,
Molina Duals,CPT,83605,Assay of lactic acid,Lab Services,Per Unit,$11.57 ,OP,11.57,53.38,,,,,,
Molina Duals,CPT,83615,Lactate (ld) (ldh) enzyme,Lab Services,Per Unit,$6.04 ,OP,6.04,26.7,,,,,,
Molina Duals,CPT,83625,Assay of ldh enzymes,Lab Services,Per Unit,$12.79 ,OP,12.79,49.56,,,,,,
Molina Duals,CPT,83630,Lactoferrin fecal (qual),Lab Services,Per Unit,$19.70 ,OP,19.7,87.69,,,,,,
Molina Duals,CPT,83631,Lactoferrin fecal (quant),Lab Services,Per Unit,$19.63 ,OP,19.63,87.69,,,,,,
Molina Duals,CPT,83632,Placental lactogen,Lab Services,Per Unit,$20.22 ,OP,20.22,91.51,,,,,,
Molina Duals,CPT,83633,Test urine for lactose,Lab Services,Per Unit,$11.25 ,OP,11.25,22.88,,,,,,
Molina Duals,CPT,83655,Assay of lead,Lab Services,Per Unit,$12.11 ,OP,12.11,53.38,,,,,,
Molina Duals,CPT,83661,L/s ratio fetal lung,Lab Services,Per Unit,$21.99 ,OP,21.99,99.13,,,,,,
Molina Duals,CPT,83662,Foam stability fetal lung,Lab Services,Per Unit,$18.91 ,OP,18.91,83.87,,,,,,
Molina Duals,CPT,83663,Fluoro polarize fetal lung,Lab Services,Per Unit,$18.91 ,OP,18.91,83.87,,,,,,
Molina Duals,CPT,83664,Lamellar bdy fetal lung,Lab Services,Per Unit,$19.32 ,OP,19.32,83.87,,,,,,
Molina Duals,CPT,83670,Assay of lap enzyme,Lab Services,Per Unit,$9.81 ,OP,9.81,41.94,,,,,,
Molina Duals,CPT,83690,Assay of lipase,Lab Services,Per Unit,$6.89 ,OP,6.89,61.5,,,,,,
Molina Duals,CPT,83695,Assay of lipoprotein(a),Lab Services,Per Unit,$14.32 ,OP,14.32,57.19,,,,,,
Molina Duals,CPT,83698,Assay lipoprotein pla2,Lab Services,Per Unit,$46.31 ,OP,46.31,125.82,,,,,,
Molina Duals,CPT,83700,Lipopro bld electrophoretic,Lab Services,Per Unit,$11.26 ,OP,11.26,49.56,,,,,,
Molina Duals,CPT,83701,Lipoprotein bld hr fraction,Lab Services,Per Unit,$33.86 ,OP,33.86,110.57,,,,,,
Molina Duals,CPT,83704,Lipoprotein bld quan part,Lab Services,Per Unit,$34.19 ,OP,34.19,141.07,,,,,,
Molina Duals,CPT,83718,Assay of lipoprotein,Lab Services,Per Unit,$8.19 ,OP,8.19,41.94,,,,,,
Molina Duals,CPT,83719,Assay of blood lipoprotein,Lab Services,Per Unit,$12.75 ,OP,12.75,53.38,,,,,,
Molina Duals,CPT,83721,Assay of blood lipoprotein,Lab Services,Per Unit,$10.50 ,OP,10.5,41.94,,,,,,
Molina Duals,CPT,83722,Lipoprtn dir meas sd ldl chl,Lab Services,Per Unit,$34.19 ,OP,34.19,141.07,,,,,,
Molina Duals,CPT,83727,Assay of lrh hormone,Lab Services,Per Unit,$17.19 ,OP,17.19,76.26,,,,,,
Molina Duals,CPT,83735,Assay of magnesium,Lab Services,Per Unit,$6.70 ,OP,6.7,34.31,,,,,,
Molina Duals,CPT,83775,Assay malate dehydrogenase,Lab Services,Per Unit,$7.37 ,OP,7.37,34.31,,,,,,
Molina Duals,CPT,83785,Assay of manganese,Lab Services,Per Unit,$26.65 ,OP,26.65,110.57,,,,,,
Molina Duals,CPT,83789,Mass spectrometry qual/quan,Lab Services,Per Unit,$24.11 ,OP,24.11,80.07,,,,,,
Molina Duals,CPT,83825,Assay of mercury,Lab Services,Per Unit,$16.26 ,OP,16.26,72.44,,,,,,
Molina Duals,CPT,83835,Assay of metanephrines,Lab Services,Per Unit,$16.94 ,OP,16.94,76.26,,,,,,
Molina Duals,CPT,83857,Assay of methemalbumin,Lab Services,Per Unit,$10.74 ,OP,10.74,49.56,,,,,,
Molina Duals,CPT,83861,Microfluid analy tears,Lab Services,Per Unit,$22.48 ,OP,22.48,22.48,,,,,,
Molina Duals,CPT,83864,Mucopolysaccharides,Lab Services,Per Unit,$28.50 ,OP,28.5,87.69,,,,,,
Molina Duals,CPT,83872,Assay synovial fluid mucin,Lab Services,Per Unit,$5.86 ,OP,5.86,26.7,,,,,,
Molina Duals,CPT,83873,Assay of csf protein,Lab Services,Per Unit,$17.20 ,OP,17.2,72.44,,,,,,
Molina Duals,CPT,83874,Assay of myoglobin,Lab Services,Per Unit,$12.92 ,OP,12.92,57.19,,,,,,
Molina Duals,CPT,83876,Assay myeloperoxidase,Lab Services,Per Unit,$50.86 ,OP,50.86,57.19,,,,,,
Molina Duals,CPT,83880,Assay of natriuretic peptide,Lab Services,Per Unit,$39.26 ,OP,39.26,245.98,,,,,,
Molina Duals,CPT,83883,Assay nephelometry not spec,Lab Services,Per Unit,$13.60 ,OP,13.6,61,,,,,,
Molina Duals,CPT,83885,Assay of nickel,Lab Services,Per Unit,$24.51 ,OP,24.51,45.74,,,,,,
Molina Duals,CPT,83915,Assay of nucleotidase,Lab Services,Per Unit,$11.15 ,OP,11.15,11.15,,,,,,
Molina Duals,CPT,83916,Oligoclonal bands,Lab Services,Per Unit,$27.39 ,OP,27.39,87.69,,,,,,
Molina Duals,CPT,83918,Organic acids total quant,Lab Services,Per Unit,$23.60 ,OP,23.6,72.44,,,,,,
Molina Duals,CPT,83919,Organic acids qual each,Lab Services,Per Unit,$16.45 ,OP,16.45,16.45,,,,,,
Molina Duals,CPT,83921,Organic acid single quant,Lab Services,Per Unit,$21.21 ,OP,21.21,72.44,,,,,,
Molina Duals,CPT,83930,Assay of blood osmolality,Lab Services,Per Unit,$6.61 ,OP,6.61,26.7,,,,,,
Molina Duals,CPT,83935,Assay of urine osmolality,Lab Services,Per Unit,$6.82 ,OP,6.82,30.51,,,,,,
Molina Duals,CPT,83937,Assay of osteocalcin,Lab Services,Per Unit,$29.85 ,OP,29.85,133.45,,,,,,
Molina Duals,CPT,83945,Assay of oxalate,Lab Services,Per Unit,$14.45 ,OP,14.45,57.19,,,,,,
Molina Duals,CPT,83950,Oncoprotein her-2/neu,Lab Services,Per Unit,$64.41 ,OP,64.41,209.7,,,,,,
Molina Duals,CPT,83951,Oncoprotein dcp,Lab Services,Per Unit,$64.41 ,OP,64.41,209.7,,,,,,
Molina Duals,CPT,83970,Assay of parathormone,Lab Services,Per Unit,$41.28 ,OP,41.28,183.02,,,,,,
Molina Duals,CPT,83986,Assay ph body fluid nos,Lab Services,Per Unit,$3.58 ,OP,3.58,19.07,,,,,,
Molina Duals,CPT,83987,Exhaled breath condensate,Lab Services,Per Unit,$3.58 ,OP,3.58,3.58,,,,,,
Molina Duals,CPT,83993,Assay for calprotectin fecal,Lab Services,Per Unit,$19.63 ,OP,19.63,87.69,,,,,,
Molina Duals,CPT,84030,Assay of blood pku,Lab Services,Per Unit,$5.50 ,OP,5.5,26.7,,,,,,
Molina Duals,CPT,84035,Assay of phenylketones,Lab Services,Per Unit,$3.98 ,OP,3.98,15.26,,,,,,
Molina Duals,CPT,84060,Assay acid phosphatase,Lab Services,Per Unit,$7.64 ,OP,7.64,34.31,,,,,,
Molina Duals,CPT,84066,Assay prostate phosphatase,Lab Services,Per Unit,$9.66 ,OP,9.66,41.94,,,,,,
Molina Duals,CPT,84075,Assay alkaline phosphatase,Lab Services,Per Unit,$5.18 ,OP,5.18,26.7,,,,,,
Molina Duals,CPT,84078,Assay alkaline phosphatase,Lab Services,Per Unit,$8.26 ,OP,8.26,34.31,,,,,,
Molina Duals,CPT,84080,Assay alkaline phosphatases,Lab Services,Per Unit,$14.78 ,OP,14.78,64.82,,,,,,
Molina Duals,CPT,84081,Assay phosphatidylglycerol,Lab Services,Per Unit,$16.52 ,OP,16.52,72.44,,,,,,
Molina Duals,CPT,84085,Assay of rbc pg6d enzyme,Lab Services,Per Unit,$9.44 ,OP,9.44,30.51,,,,,,
Molina Duals,CPT,84087,Assay phosphohexose enzymes,Lab Services,Per Unit,$10.73 ,OP,10.73,45.74,,,,,,
Molina Duals,CPT,84100,Assay of phosphorus,Lab Services,Per Unit,$4.74 ,OP,4.74,22.88,,,,,,
Molina Duals,CPT,84105,Assay of urine phosphorus,Lab Services,Per Unit,$5.78 ,OP,5.78,22.88,,,,,,
Molina Duals,CPT,84106,Test for porphobilinogen,Lab Services,Per Unit,$5.82 ,OP,5.82,19.07,,,,,,
Molina Duals,CPT,84110,Assay of porphobilinogen,Lab Services,Per Unit,$8.44 ,OP,8.44,38.13,,,,,,
Molina Duals,CPT,84112,Eval amniotic fluid protein,Lab Services,Per Unit,$98.11 ,OP,98.11,98.11,,,,,,
Molina Duals,CPT,84119,Test urine for porphyrins,Lab Services,Per Unit,$13.36 ,OP,13.36,13.36,,,,,,
Molina Duals,CPT,84120,Assay of urine porphyrins,Lab Services,Per Unit,$14.71 ,OP,14.71,64.82,,,,,,
Molina Duals,CPT,84126,Assay of feces porphyrins,Lab Services,Per Unit,$39.11 ,OP,39.11,114.39,,,,,,
Molina Duals,CPT,84132,Assay of serum potassium,Lab Services,Per Unit,$4.76 ,OP,4.76,22.88,,,,,,
Molina Duals,CPT,84133,Assay of urine potassium,Lab Services,Per Unit,$4.73 ,OP,4.73,19.07,,,,,,
Molina Duals,CPT,84134,Assay of prealbumin,Lab Services,Per Unit,$14.59 ,OP,14.59,64.82,,,,,,
Molina Duals,CPT,84135,Assay of pregnanediol,Lab Services,Per Unit,$21.27 ,OP,21.27,57.19,,,,,,
Molina Duals,CPT,84138,Assay of pregnanetriol,Lab Services,Per Unit,$21.05 ,OP,21.05,83.87,,,,,,
Molina Duals,CPT,84140,Assay of pregnenolone,Lab Services,Per Unit,$20.67 ,OP,20.67,91.51,,,,,,
Molina Duals,CPT,84143,Assay of 17-hydroxypregneno,Lab Services,Per Unit,$22.81 ,OP,22.81,102.95,,,,,,
Molina Duals,CPT,84144,Assay of progesterone,Lab Services,Per Unit,$20.86 ,OP,20.86,91.51,,,,,,
Molina Duals,CPT,84145,Procalcitonin (pct),Lab Services,Per Unit,$27.22 ,OP,27.22,27.22,,,,,,
Molina Duals,CPT,84146,Assay of prolactin,Lab Services,Per Unit,$19.38 ,OP,19.38,87.69,,,,,,
Molina Duals,CPT,84150,Assay of prostaglandin,Lab Services,Per Unit,$41.77 ,OP,41.77,41.77,,,,,,
Molina Duals,CPT,84152,Assay of psa complexed,Lab Services,Per Unit,$18.39 ,OP,18.39,80.07,,,,,,
Molina Duals,CPT,84153,Assay of psa total,Lab Services,Per Unit,$18.39 ,OP,18.39,80.07,,,,,,
Molina Duals,CPT,84154,Assay of psa free,Lab Services,Per Unit,$18.39 ,OP,18.39,80.07,,,,,,
Molina Duals,CPT,84155,Assay of protein serum,Lab Services,Per Unit,$3.67 ,OP,3.67,15.26,,,,,,
Molina Duals,CPT,84156,Assay of protein urine,Lab Services,Per Unit,$3.67 ,OP,3.67,15.26,,,,,,
Molina Duals,CPT,84157,Assay of protein other,Lab Services,Per Unit,$4.00 ,OP,4,19.07,,,,,,
Molina Duals,CPT,84160,Assay of protein any source,Lab Services,Per Unit,$5.61 ,OP,5.61,22.88,,,,,,
Molina Duals,CPT,84163,Pappa serum,Lab Services,Per Unit,$15.05 ,OP,15.05,68.63,,,,,,
Molina Duals,CPT,84165,Protein e-phoresis serum,Lab Services,Per Unit,$10.74 ,OP,10.74,49.56,,,,,,
Molina Duals,CPT,84166,Protein e-phoresis/urine/csf,Lab Services,Per Unit,$17.83 ,OP,17.83,80.07,,,,,,
Molina Duals,CPT,84181,Western blot test,Lab Services,Per Unit,$17.03 ,OP,17.03,118.19,,,,,,
Molina Duals,CPT,84182,Protein western blot test,Lab Services,Per Unit,$29.21 ,OP,29.21,129.64,,,,,,
Molina Duals,CPT,84202,Assay rbc protoporphyrin,Lab Services,Per Unit,$14.35 ,OP,14.35,64.82,,,,,,
Molina Duals,CPT,84203,Test rbc protoporphyrin,Lab Services,Per Unit,$9.74 ,OP,9.74,38.13,,,,,,
Molina Duals,CPT,84206,Assay of proinsulin,Lab Services,Per Unit,$26.69 ,OP,26.69,80.07,,,,,,
Molina Duals,CPT,84207,Assay of vitamin b-6,Lab Services,Per Unit,$28.10 ,OP,28.1,125.82,,,,,,
Molina Duals,CPT,84210,Assay of pyruvate,Lab Services,Per Unit,$14.48 ,OP,14.48,49.56,,,,,,
Molina Duals,CPT,84220,Assay of pyruvate kinase,Lab Services,Per Unit,$9.44 ,OP,9.44,41.94,,,,,,
Molina Duals,CPT,84228,Assay of quinine,Lab Services,Per Unit,$11.63 ,OP,11.63,53.38,,,,,,
Molina Duals,CPT,84233,Assay of estrogen,Lab Services,Per Unit,$87.88 ,OP,87.88,209.7,,,,,,
Molina Duals,CPT,84234,Assay of progesterone,Lab Services,Per Unit,$64.88 ,OP,64.88,183.02,,,,,,
Molina Duals,CPT,84235,Assay of endocrine hormone,Lab Services,Per Unit,$71.23 ,OP,71.23,163.95,,,,,,
Molina Duals,CPT,84238,Assay nonendocrine receptor,Lab Services,Per Unit,$36.57 ,OP,36.57,163.95,,,,,,
Molina Duals,CPT,84244,Assay of renin,Lab Services,Per Unit,$21.99 ,OP,21.99,99.13,,,,,,
Molina Duals,CPT,84252,Assay of vitamin b-2,Lab Services,Per Unit,$20.24 ,OP,20.24,20.24,,,,,,
Molina Duals,CPT,84255,Assay of selenium,Lab Services,Per Unit,$25.53 ,OP,25.53,114.39,,,,,,
Molina Duals,CPT,84260,Assay of serotonin,Lab Services,Per Unit,$30.98 ,OP,30.98,30.98,,,,,,
Molina Duals,CPT,84270,Assay of sex hormone globul,Lab Services,Per Unit,$21.73 ,OP,21.73,95.32,,,,,,
Molina Duals,CPT,84275,Assay of sialic acid,Lab Services,Per Unit,$13.44 ,OP,13.44,13.44,,,,,,
Molina Duals,CPT,84285,Assay of silica,Lab Services,Per Unit,$25.21 ,OP,25.21,38.13,,,,,,
Molina Duals,CPT,84295,Assay of serum sodium,Lab Services,Per Unit,$4.81 ,OP,4.81,22.88,,,,,,
Molina Duals,CPT,84300,Assay of urine sodium,Lab Services,Per Unit,$5.06 ,OP,5.06,22.88,,,,,,
Molina Duals,CPT,84302,Assay of sweat sodium,Lab Services,Per Unit,$4.86 ,OP,4.86,22.88,,,,,,
Molina Duals,CPT,84305,Assay of somatomedin,Lab Services,Per Unit,$21.26 ,OP,21.26,95.32,,,,,,
Molina Duals,CPT,84307,Assay of somatostatin,Lab Services,Per Unit,$18.28 ,OP,18.28,80.07,,,,,,
Molina Duals,CPT,84311,Spectrophotometry,Lab Services,Per Unit,$8.10 ,OP,8.1,30.51,,,,,,
Molina Duals,CPT,84315,Body fluid specific gravity,Lab Services,Per Unit,$3.28 ,OP,3.28,11.44,,,,,,
Molina Duals,CPT,84375,Chromatogram assay sugars,Lab Services,Per Unit,$39.00 ,OP,39,39,,,,,,
Molina Duals,CPT,84376,Sugars single qual,Lab Services,Per Unit,$5.50 ,OP,5.5,22.88,,,,,,
Molina Duals,CPT,84377,Sugars multiple qual,Lab Services,Per Unit,$5.50 ,OP,5.5,22.88,,,,,,
Molina Duals,CPT,84378,Sugars single quant,Lab Services,Per Unit,$11.53 ,OP,11.53,49.56,,,,,,
Molina Duals,CPT,84379,Sugars multiple quant,Lab Services,Per Unit,$11.53 ,OP,11.53,49.56,,,,,,
Molina Duals,CPT,84392,Assay of urine sulfate,Lab Services,Per Unit,$5.49 ,OP,5.49,22.88,,,,,,
Molina Duals,CPT,84402,Assay of free testosterone,Lab Services,Per Unit,$25.47 ,OP,25.47,114.39,,,,,,
Molina Duals,CPT,84403,Assay of total testosterone,Lab Services,Per Unit,$25.81 ,OP,25.81,114.39,,,,,,
Molina Duals,CPT,84410,Testosterone bioavailable,Lab Services,Per Unit,$51.28 ,OP,51.28,51.28,,,,,,
Molina Duals,CPT,84425,Assay of vitamin b-1,Lab Services,Per Unit,$21.23 ,OP,21.23,95.32,,,,,,
Molina Duals,CPT,84430,Assay of thiocyanate,Lab Services,Per Unit,$11.63 ,OP,11.63,53.38,,,,,,
Molina Duals,CPT,84431,Thromboxane urine,Lab Services,Per Unit,$35.11 ,OP,35.11,35.11,,,,,,
Molina Duals,CPT,84432,Assay of thyroglobulin,Lab Services,Per Unit,$16.06 ,OP,16.06,72.44,,,,,,
Molina Duals,CPT,84436,Assay of total thyroxine,Lab Services,Per Unit,$6.87 ,OP,6.87,30.51,,,,,,
Molina Duals,CPT,84437,Assay of neonatal thyroxine,Lab Services,Per Unit,$6.47 ,OP,6.47,30.51,,,,,,
Molina Duals,CPT,84439,Assay of free thyroxine,Lab Services,Per Unit,$9.02 ,OP,9.02,41.94,,,,,,
Molina Duals,CPT,84442,Assay of thyroid activity,Lab Services,Per Unit,$14.78 ,OP,14.78,64.82,,,,,,
Molina Duals,CPT,84443,Assay thyroid stim hormone,Lab Services,Per Unit,$16.80 ,OP,16.8,76.26,,,,,,
Molina Duals,CPT,84445,Assay of tsi globulin,Lab Services,Per Unit,$50.86 ,OP,50.86,224.95,,,,,,
Molina Duals,CPT,84446,Assay of vitamin e,Lab Services,Per Unit,$14.18 ,OP,14.18,64.82,,,,,,
Molina Duals,CPT,84449,Assay of transcortin,Lab Services,Per Unit,$18.00 ,OP,18,80.07,,,,,,
Molina Duals,CPT,84450,Transferase (ast) (sgot),Lab Services,Per Unit,$5.18 ,OP,5.18,22.88,,,,,,
Molina Duals,CPT,84460,Alanine amino (alt) (sgpt),Lab Services,Per Unit,$5.30 ,OP,5.3,26.7,,,,,,
Molina Duals,CPT,84466,Assay of transferrin,Lab Services,Per Unit,$12.76 ,OP,12.76,57.19,,,,,,
Molina Duals,CPT,84478,Assay of triglycerides,Lab Services,Per Unit,$5.74 ,OP,5.74,30.51,,,,,,
Molina Duals,CPT,84479,Assay of thyroid (t3 or t4),Lab Services,Per Unit,$6.47 ,OP,6.47,30.51,,,,,,
Molina Duals,CPT,84480,Assay triiodothyronine (t3),Lab Services,Per Unit,$14.18 ,OP,14.18,49.56,,,,,,
Molina Duals,CPT,84481,Free assay (ft-3),Lab Services,Per Unit,$16.94 ,OP,16.94,49.56,,,,,,
Molina Duals,CPT,84482,T3 reverse,Lab Services,Per Unit,$15.76 ,OP,15.76,68.63,,,,,,
Molina Duals,CPT,84484,Assay of troponin quant,Lab Services,Per Unit,$12.47 ,OP,12.47,92.24,,,,,,
Molina Duals,CPT,84485,Assay duodenal fluid trypsin,Lab Services,Per Unit,$7.20 ,OP,7.2,7.2,,,,,,
Molina Duals,CPT,84488,Test feces for trypsin,Lab Services,Per Unit,$7.30 ,OP,7.3,34.31,,,,,,
Molina Duals,CPT,84490,Assay of feces for trypsin,Lab Services,Per Unit,$9.93 ,OP,9.93,26.7,,,,,,
Molina Duals,CPT,84510,Assay of tyrosine,Lab Services,Per Unit,$10.63 ,OP,10.63,45.74,,,,,,
Molina Duals,CPT,84512,Assay of troponin qual,Lab Services,Per Unit,$10.09 ,OP,10.09,34.31,,,,,,
Molina Duals,CPT,84520,Assay of urea nitrogen,Lab Services,Per Unit,$3.95 ,OP,3.95,19.07,,,,,,
Molina Duals,CPT,84525,Urea nitrogen semi-quant,Lab Services,Per Unit,$5.13 ,OP,5.13,15.26,,,,,,
Molina Duals,CPT,84540,Assay of urine/urea-n,Lab Services,Per Unit,$5.56 ,OP,5.56,22.88,,,,,,
Molina Duals,CPT,84545,Urea-n clearance test,Lab Services,Per Unit,$7.20 ,OP,7.2,19.07,,,,,,
Molina Duals,CPT,84550,Assay of blood/uric acid,Lab Services,Per Unit,$4.52 ,OP,4.52,19.07,,,,,,
Molina Duals,CPT,84560,Assay of urine/uric acid,Lab Services,Per Unit,$5.08 ,OP,5.08,22.88,,,,,,
Molina Duals,CPT,84577,Assay of feces/urobilinogen,Lab Services,Per Unit,$16.80 ,OP,16.8,57.19,,,,,,
Molina Duals,CPT,84578,Test urine urobilinogen,Lab Services,Per Unit,$4.47 ,OP,4.47,15.26,,,,,,
Molina Duals,CPT,84580,Assay of urine urobilinogen,Lab Services,Per Unit,$9.55 ,OP,9.55,19.07,,,,,,
Molina Duals,CPT,84583,Assay of urine urobilinogen,Lab Services,Per Unit,$6.05 ,OP,6.05,22.88,,,,,,
Molina Duals,CPT,84585,Assay of urine vma,Lab Services,Per Unit,$15.50 ,OP,15.5,68.63,,,,,,
Molina Duals,CPT,84586,Assay of vip,Lab Services,Per Unit,$35.33 ,OP,35.33,156.32,,,,,,
Molina Duals,CPT,84588,Assay of vasopressin,Lab Services,Per Unit,$33.94 ,OP,33.94,125.82,,,,,,
Molina Duals,CPT,84590,Assay of vitamin a,Lab Services,Per Unit,$11.61 ,OP,11.61,53.38,,,,,,
Molina Duals,CPT,84591,Assay of nos vitamin,Lab Services,Per Unit,$17.06 ,OP,17.06,53.38,,,,,,
Molina Duals,CPT,84597,Assay of vitamin k,Lab Services,Per Unit,$13.72 ,OP,13.72,49.56,,,,,,
Molina Duals,CPT,84600,Assay of volatiles,Lab Services,Per Unit,$17.11 ,OP,17.11,72.44,,,,,,
Molina Duals,CPT,84620,Xylose tolerance test,Lab Services,Per Unit,$12.91 ,OP,12.91,38.13,,,,,,
Molina Duals,CPT,84630,Assay of zinc,Lab Services,Per Unit,$11.39 ,OP,11.39,49.56,,,,,,
Molina Duals,CPT,84681,Assay of c-peptide,Lab Services,Per Unit,$20.81 ,OP,20.81,91.51,,,,,,
Molina Duals,CPT,84702,Chorionic gonadotropin test,Lab Services,Per Unit,$15.05 ,OP,15.05,76.26,,,,,,
Molina Duals,CPT,84703,Chorionic gonadotropin assay,Lab Services,Per Unit,$7.52 ,OP,7.52,38.13,,,,,,
Molina Duals,CPT,84704,Hcg free betachain test,Lab Services,Per Unit,$15.29 ,OP,15.29,68.63,,,,,,
Molina Duals,CPT,84830,Ovulation tests,Lab Services,Per Unit,$12.70 ,OP,12.7,49.56,,,,,,
Molina Duals,CPT,85002,Bleeding time test,Lab Services,Per Unit,$4.82 ,OP,4.82,22.88,,,,,,
Molina Duals,CPT,85004,Automated diff wbc count,Lab Services,Per Unit,$6.47 ,OP,6.47,34.31,,,,,,
Molina Duals,CPT,85007,Bl smear w/diff wbc count,Lab Services,Per Unit,$3.80 ,OP,3.8,19.07,,,,,,
Molina Duals,CPT,85008,Bl smear w/o diff wbc count,Lab Services,Per Unit,$3.43 ,OP,3.43,19.07,,,,,,
Molina Duals,CPT,85009,Manual diff wbc count b-coat,Lab Services,Per Unit,$5.07 ,OP,5.07,19.07,,,,,,
Molina Duals,CPT,85013,Spun microhematocrit,Lab Services,Per Unit,$7.00 ,OP,7,7,,,,,,
Molina Duals,CPT,85014,Hematocrit,Lab Services,Per Unit,$2.37 ,OP,2.37,11.44,,,,,,
Molina Duals,CPT,85018,Hemoglobin,Lab Services,Per Unit,$2.37 ,OP,2.37,11.44,,,,,,
Molina Duals,CPT,85025,Complete cbc w/auto diff wbc,Lab Services,Per Unit,$7.77 ,OP,7.77,67.65,,,,,,
Molina Duals,CPT,85027,Complete cbc automated,Lab Services,Per Unit,$6.47 ,OP,6.47,34.31,,,,,,
Molina Duals,CPT,85032,Manual cell count each,Lab Services,Per Unit,$4.31 ,OP,4.31,22.88,,,,,,
Molina Duals,CPT,85041,Automated rbc count,Lab Services,Per Unit,$3.02 ,OP,3.02,11.44,,,,,,
Molina Duals,CPT,85044,Manual reticulocyte count,Lab Services,Per Unit,$4.31 ,OP,4.31,4.31,,,,,,
Molina Duals,CPT,85045,Automated reticulocyte count,Lab Services,Per Unit,$3.99 ,OP,3.99,19.07,,,,,,
Molina Duals,CPT,85046,Reticyte/hgb concentrate,Lab Services,Per Unit,$5.57 ,OP,5.57,26.7,,,,,,
Molina Duals,CPT,85048,Automated leukocyte count,Lab Services,Per Unit,$2.54 ,OP,2.54,11.44,,,,,,
Molina Duals,CPT,85049,Automated platelet count,Lab Services,Per Unit,$4.48 ,OP,4.48,22.88,,,,,,
Molina Duals,CPT,85055,Reticulated platelet assay,Lab Services,Per Unit,$35.74 ,OP,35.74,61,,,,,,
Molina Duals,CPT,85097,Bone marrow interpretation,APC 5674,RVU Per Case,$671.45 ,OP,438.47,671.45,,,,,,
Molina Duals,CPT,85130,Chromogenic substrate assay,Lab Services,Per Unit,$11.89 ,OP,11.89,53.38,,,,,,
Molina Duals,CPT,85170,Blood clot retraction,Lab Services,Per Unit,$16.30 ,OP,16.3,16.3,,,,,,
Molina Duals,CPT,85175,Blood clot lysis time,Lab Services,Per Unit,$20.37 ,OP,19.07,20.37,,,,,,
Molina Duals,CPT,85210,Clot factor ii prothrom spec,Lab Services,Per Unit,$12.98 ,OP,12.98,64.82,,,,,,
Molina Duals,CPT,85220,Blooc clot factor v test,Lab Services,Per Unit,$17.65 ,OP,17.65,80.07,,,,,,
Molina Duals,CPT,85230,Clot factor vii proconvertin,Lab Services,Per Unit,$17.90 ,OP,17.9,80.07,,,,,,
Molina Duals,CPT,85240,Clot factor viii ahg 1 stage,Lab Services,Per Unit,$17.90 ,OP,17.9,80.07,,,,,,
Molina Duals,CPT,85244,Clot factor viii reltd antgn,Lab Services,Per Unit,$20.42 ,OP,20.42,91.51,,,,,,
Molina Duals,CPT,85245,Clot factor viii vw ristoctn,Lab Services,Per Unit,$22.94 ,OP,22.94,64.82,,,,,,
Molina Duals,CPT,85246,Clot factor viii vw antigen,Lab Services,Per Unit,$22.94 ,OP,22.94,64.82,,,,,,
Molina Duals,CPT,85247,Clot factor viii multimetric,Lab Services,Per Unit,$22.94 ,OP,22.94,22.94,,,,,,
Molina Duals,CPT,85250,Clot factor ix ptc/chrstmas,Lab Services,Per Unit,$19.04 ,OP,19.04,83.87,,,,,,
Molina Duals,CPT,85260,Clot factor x stuart-power,Lab Services,Per Unit,$17.90 ,OP,17.9,80.07,,,,,,
Molina Duals,CPT,85270,Clot factor xi pta,Lab Services,Per Unit,$17.90 ,OP,17.9,80.07,,,,,,
Molina Duals,CPT,85280,Clot factor xii hageman,Lab Services,Per Unit,$19.35 ,OP,19.35,87.69,,,,,,
Molina Duals,CPT,85290,Clot factor xiii fibrin stab,Lab Services,Per Unit,$16.34 ,OP,16.34,72.44,,,,,,
Molina Duals,CPT,85291,Clot factor xiii fibrin scrn,Lab Services,Per Unit,$9.11 ,OP,9.11,38.13,,,,,,
Molina Duals,CPT,85292,Clot factor fletcher fact,Lab Services,Per Unit,$18.93 ,OP,18.93,83.87,,,,,,
Molina Duals,CPT,85293,Clot factor wght kininogen,Lab Services,Per Unit,$18.93 ,OP,18.93,83.87,,,,,,
Molina Duals,CPT,85300,Antithrombin iii activity,Lab Services,Per Unit,$11.85 ,OP,11.85,53.38,,,,,,
Molina Duals,CPT,85301,Antithrombin iii antigen,Lab Services,Per Unit,$10.81 ,OP,10.81,49.56,,,,,,
Molina Duals,CPT,85302,Clot inhibit prot c antigen,Lab Services,Per Unit,$12.01 ,OP,12.01,53.38,,,,,,
Molina Duals,CPT,85303,Clot inhibit prot c activity,Lab Services,Per Unit,$13.84 ,OP,13.84,61,,,,,,
Molina Duals,CPT,85305,Clot inhibit prot s total,Lab Services,Per Unit,$11.61 ,OP,11.61,53.38,,,,,,
Molina Duals,CPT,85306,Clot inhibit prot s free,Lab Services,Per Unit,$15.32 ,OP,15.32,68.63,,,,,,
Molina Duals,CPT,85307,Assay activated protein c,Lab Services,Per Unit,$15.32 ,OP,15.32,68.63,,,,,,
Molina Duals,CPT,85335,Factor inhibitor test,Lab Services,Per Unit,$12.87 ,OP,12.87,12.87,,,,,,
Molina Duals,CPT,85337,Thrombomodulin,Lab Services,Per Unit,$17.27 ,OP,17.27,45.74,,,,,,
Molina Duals,CPT,85345,Coagulation time lee & white,Lab Services,Per Unit,$4.69 ,OP,4.69,4.69,,,,,,
Molina Duals,CPT,85347,Coagulation time activated,Lab Services,Per Unit,$4.28 ,OP,4.28,15.26,,,,,,
Molina Duals,CPT,85348,Coagulation time otr method,Lab Services,Per Unit,$4.49 ,OP,4.49,15.26,,,,,,
Molina Duals,CPT,85360,Euglobulin lysis,Lab Services,Per Unit,$8.41 ,OP,8.41,38.13,,,,,,
Molina Duals,CPT,85362,Fibrin degradation products,Lab Services,Per Unit,$6.89 ,OP,6.89,30.51,,,,,,
Molina Duals,CPT,85366,Fibrinogen test,Lab Services,Per Unit,$80.46 ,OP,30.51,80.46,,,,,,
Molina Duals,CPT,85370,Fibrinogen test,Lab Services,Per Unit,$12.43 ,OP,12.43,49.56,,,,,,
Molina Duals,CPT,85378,Fibrin degrade semiquant,Lab Services,Per Unit,$9.72 ,OP,9.72,30.51,,,,,,
Molina Duals,CPT,85379,Fibrin degradation quant,Lab Services,Per Unit,$10.18 ,OP,10.18,135.29,,,,,,
Molina Duals,CPT,85380,Fibrin degradj d-dimer,Lab Services,Per Unit,$10.18 ,OP,10.18,45.74,,,,,,
Molina Duals,CPT,85384,Fibrinogen activity,Lab Services,Per Unit,$9.72 ,OP,9.72,38.13,,,,,,
Molina Duals,CPT,85385,Fibrinogen antigen,Lab Services,Per Unit,$14.46 ,OP,14.46,38.13,,,,,,
Molina Duals,CPT,85390,Fibrinolysins screen i&r,Lab Services,Per Unit,$15.48 ,OP,15.48,38.13,,,,,,
Molina Duals,CPT,85397,Clotting funct activity,Lab Services,Per Unit,$30.86 ,OP,30.86,30.86,,,,,,
Molina Duals,CPT,85400,Fibrinolytic plasmin,Lab Services,Per Unit,$7.71 ,OP,7.71,38.13,,,,,,
Molina Duals,CPT,85410,Fibrinolytic antiplasmin,Lab Services,Per Unit,$7.71 ,OP,7.71,34.31,,,,,,
Molina Duals,CPT,85415,Fibrinolytic plasminogen,Lab Services,Per Unit,$17.19 ,OP,17.19,76.26,,,,,,
Molina Duals,CPT,85420,Fibrinolytic plasminogen,Lab Services,Per Unit,$6.53 ,OP,6.53,6.53,,,,,,
Molina Duals,CPT,85421,Fibrinolytic plasminogen,Lab Services,Per Unit,$10.18 ,OP,10.18,45.74,,,,,,
Molina Duals,CPT,85441,Heinz bodies direct,Lab Services,Per Unit,$4.20 ,OP,4.2,19.07,,,,,,
Molina Duals,CPT,85445,Heinz bodies induced,Lab Services,Per Unit,$6.82 ,OP,6.82,30.51,,,,,,
Molina Duals,CPT,85460,Hemoglobin fetal,Lab Services,Per Unit,$7.73 ,OP,7.73,7.73,,,,,,
Molina Duals,CPT,85461,Hemoglobin fetal,Lab Services,Per Unit,$9.36 ,OP,9.36,30.51,,,,,,
Molina Duals,CPT,85475,Hemolysin acid,Lab Services,Per Unit,$8.87 ,OP,8.87,38.13,,,,,,
Molina Duals,CPT,85520,Heparin assay,Lab Services,Per Unit,$13.09 ,OP,13.09,57.19,,,,,,
Molina Duals,CPT,85525,Heparin neutralization,Lab Services,Per Unit,$11.84 ,OP,11.84,53.38,,,,,,
Molina Duals,CPT,85530,Heparin-protamine tolerance,Lab Services,Per Unit,$13.09 ,OP,13.09,48.46,,,,,,
Molina Duals,CPT,85536,Iron stain peripheral blood,Lab Services,Per Unit,$6.88 ,OP,6.88,30.51,,,,,,
Molina Duals,CPT,85540,Wbc alkaline phosphatase,Lab Services,Per Unit,$8.60 ,OP,8.6,38.13,,,,,,
Molina Duals,CPT,85547,Rbc mechanical fragility,Lab Services,Per Unit,$8.60 ,OP,8.6,11.44,,,,,,
Molina Duals,CPT,85549,Muramidase,Lab Services,Per Unit,$18.75 ,OP,18.75,83.87,,,,,,
Molina Duals,CPT,85555,Rbc osmotic fragility,Lab Services,Per Unit,$7.47 ,OP,7.47,30.51,,,,,,
Molina Duals,CPT,85557,Rbc osmotic fragility,Lab Services,Per Unit,$13.36 ,OP,13.36,13.36,,,,,,
Molina Duals,CPT,85576,Blood platelet aggregation,Lab Services,Per Unit,$24.91 ,OP,24.91,95.32,,,,,,
Molina Duals,CPT,85597,Phospholipid pltlt neutraliz,Lab Services,Per Unit,$17.98 ,OP,17.98,80.07,,,,,,
Molina Duals,CPT,85598,Hexagnal phosph pltlt neutrl,Lab Services,Per Unit,$17.98 ,OP,17.98,17.98,,,,,,
Molina Duals,CPT,85610,Prothrombin time,Lab Services,Per Unit,$4.29 ,OP,4.29,19.07,,,,,,
Molina Duals,CPT,85611,Prothrombin test,Lab Services,Per Unit,$3.94 ,OP,3.94,19.07,,,,,,
Molina Duals,CPT,85612,Viper venom prothrombin time,Lab Services,Per Unit,$17.49 ,OP,17.49,17.49,,,,,,
Molina Duals,CPT,85613,Russell viper venom diluted,Lab Services,Per Unit,$9.58 ,OP,9.58,41.94,,,,,,
Molina Duals,CPT,85635,Reptilase test,Lab Services,Per Unit,$9.85 ,OP,9.85,19.07,,,,,,
Molina Duals,CPT,85651,Rbc sed rate nonautomated,Lab Services,Per Unit,$4.27 ,OP,4.27,19.07,,,,,,
Molina Duals,CPT,85652,Rbc sed rate automated,Lab Services,Per Unit,$2.70 ,OP,2.7,15.26,,,,,,
Molina Duals,CPT,85660,Rbc sickle cell test,Lab Services,Per Unit,$5.51 ,OP,5.51,22.88,,,,,,
Molina Duals,CPT,85670,Thrombin time plasma,Lab Services,Per Unit,$5.77 ,OP,5.77,26.7,,,,,,
Molina Duals,CPT,85675,Thrombin time titer,Lab Services,Per Unit,$6.85 ,OP,6.85,30.51,,,,,,
Molina Duals,CPT,85705,Thromboplastin inhibition,Lab Services,Per Unit,$9.63 ,OP,9.63,41.94,,,,,,
Molina Duals,CPT,85730,Thromboplastin time partial,Lab Services,Per Unit,$6.01 ,OP,6.01,30.51,,,,,,
Molina Duals,CPT,85732,Thromboplastin time partial,Lab Services,Per Unit,$6.47 ,OP,6.47,30.51,,,,,,
Molina Duals,CPT,85810,Blood viscosity examination,Lab Services,Per Unit,$11.67 ,OP,11.67,53.38,,,,,,
Molina Duals,CPT,86000,Agglutinins febrile antigen,Lab Services,Per Unit,$6.98 ,OP,6.98,6.98,,,,,,
Molina Duals,CPT,86001,Allergen specific igg,Lab Services,Per Unit,$7.82 ,OP,7.82,22.88,,,,,,
Molina Duals,CPT,86003,Allg spec ige crude xtrc ea,Lab Services,Per Unit,$5.22 ,OP,5.22,22.88,,,,,,
Molina Duals,CPT,86005,Allg spec ige multiallg scr,Lab Services,Per Unit,$7.97 ,OP,7.97,7.97,,,,,,
Molina Duals,CPT,86008,Allg spec ige recomb ea,Lab Services,Per Unit,$17.93 ,OP,17.93,80.07,,,,,,
Molina Duals,CPT,86021,Wbc antibody identification,Lab Services,Per Unit,$15.05 ,OP,15.05,68.63,,,,,,
Molina Duals,CPT,86022,Platelet antibodies,Lab Services,Per Unit,$18.37 ,OP,18.37,64.82,,,,,,
Molina Duals,CPT,86023,Immunoglobulin assay,Lab Services,Per Unit,$12.46 ,OP,12.46,57.19,,,,,,
Molina Duals,CPT,86038,Antinuclear antibodies,Lab Services,Per Unit,$12.09 ,OP,12.09,53.38,,,,,,
Molina Duals,CPT,86039,Antinuclear antibodies (ana),Lab Services,Per Unit,$11.16 ,OP,11.16,49.56,,,,,,
Molina Duals,CPT,86060,Antistreptolysin o titer,Lab Services,Per Unit,$7.30 ,OP,7.3,34.31,,,,,,
Molina Duals,CPT,86063,Antistreptolysin o screen,Lab Services,Per Unit,$5.77 ,OP,5.77,26.7,,,,,,
Molina Duals,CPT,86077,Phys blood bank serv xmatch,APC 5731,RVU Per Case,$25.25 ,OP,25.25,244.01,,,,,,
Molina Duals,CPT,86078,Phys blood bank serv reactj,APC 5672,RVU Per Case,$152.64 ,OP,152.64,247.83,,,,,,
Molina Duals,CPT,86079,Phys blood bank serv authrj,APC 5671,RVU Per Case,$50.92 ,OP,50.92,251.64,,,,,,
Molina Duals,CPT,86140,C-reactive protein,Lab Services,Per Unit,$5.18 ,OP,5.18,22.88,,,,,,
Molina Duals,CPT,86141,C-reactive protein hs,Lab Services,Per Unit,$12.95 ,OP,12.95,57.19,,,,,,
Molina Duals,CPT,86146,Beta-2 glycoprotein antibody,Lab Services,Per Unit,$25.45 ,OP,25.45,114.39,,,,,,
Molina Duals,CPT,86147,Cardiolipin antibody ea ig,Lab Services,Per Unit,$25.45 ,OP,25.45,114.39,,,,,,
Molina Duals,CPT,86148,Anti-phospholipid antibody,Lab Services,Per Unit,$16.07 ,OP,16.07,72.44,,,,,,
Molina Duals,CPT,86152,Cell enumeration & id,Lab Services,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Molina Duals,CPT,86155,Chemotaxis assay,Lab Services,Per Unit,$15.99 ,OP,15.99,72.44,,,,,,
Molina Duals,CPT,86156,Cold agglutinin screen,Lab Services,Per Unit,$8.07 ,OP,8.07,30.51,,,,,,
Molina Duals,CPT,86157,Cold agglutinin titer,Lab Services,Per Unit,$8.06 ,OP,8.06,34.31,,,,,,
Molina Duals,CPT,86160,Complement antigen,Lab Services,Per Unit,$12.00 ,OP,12,53.38,,,,,,
Molina Duals,CPT,86161,Complement/function activity,Lab Services,Per Unit,$12.00 ,OP,12,53.38,,,,,,
Molina Duals,CPT,86162,Complement total (ch50),Lab Services,Per Unit,$20.32 ,OP,20.32,91.51,,,,,,
Molina Duals,CPT,86171,Complement fixation each,Lab Services,Per Unit,$10.01 ,OP,10.01,45.74,,,,,,
Molina Duals,CPT,86200,Ccp antibody,Lab Services,Per Unit,$12.95 ,OP,12.95,57.19,,,,,,
Molina Duals,CPT,86215,Deoxyribonuclease antibody,Lab Services,Per Unit,$13.25 ,OP,13.25,57.19,,,,,,
Molina Duals,CPT,86225,Dna antibody native,Lab Services,Per Unit,$13.74 ,OP,13.74,61,,,,,,
Molina Duals,CPT,86226,Dna antibody single strand,Lab Services,Per Unit,$12.11 ,OP,12.11,53.38,,,,,,
Molina Duals,CPT,86235,Nuclear antigen antibody,Lab Services,Per Unit,$17.93 ,OP,17.93,80.07,,,,,,
Molina Duals,CPT,86255,Fluorescent antibody screen,Lab Services,Per Unit,$12.05 ,OP,12.05,53.38,,,,,,
Molina Duals,CPT,86256,Fluorescent antibody titer,Lab Services,Per Unit,$12.05 ,OP,12.05,53.38,,,,,,
Molina Duals,CPT,86277,Growth hormone antibody,Lab Services,Per Unit,$15.74 ,OP,15.74,68.63,,,,,,
Molina Duals,CPT,86280,Hemagglutination inhibition,Lab Services,Per Unit,$8.19 ,OP,8.19,8.19,,,,,,
Molina Duals,CPT,86294,Immunoassay tumor qual,Lab Services,Per Unit,$25.57 ,OP,25.57,80.07,,,,,,
Molina Duals,CPT,86300,Immunoassay tumor ca 15-3,Lab Services,Per Unit,$20.81 ,OP,20.81,91.51,,,,,,
Molina Duals,CPT,86301,Immunoassay tumor ca 19-9,Lab Services,Per Unit,$20.81 ,OP,20.81,91.51,,,,,,
Molina Duals,CPT,86304,Immunoassay tumor ca 125,Lab Services,Per Unit,$20.81 ,OP,20.81,91.51,,,,,,
Molina Duals,CPT,86305,Human epididymis protein 4,Lab Services,Per Unit,$20.81 ,OP,20.81,20.81,,,,,,
Molina Duals,CPT,86308,Heterophile antibody screen,Lab Services,Per Unit,$5.18 ,OP,5.18,26.7,,,,,,
Molina Duals,CPT,86309,Heterophile antibody titer,Lab Services,Per Unit,$6.47 ,OP,6.47,30.51,,,,,,
Molina Duals,CPT,86310,Heterophile antibody absrbj,Lab Services,Per Unit,$7.37 ,OP,7.37,7.37,,,,,,
Molina Duals,CPT,86316,Immunoassay tumor other,Lab Services,Per Unit,$20.81 ,OP,20.81,91.51,,,,,,
Molina Duals,CPT,86317,Immunoassay infectious agent,Lab Services,Per Unit,$14.99 ,OP,14.99,68.63,,,,,,
Molina Duals,CPT,86318,Ia infectious agent antibody,Lab Services,Per Unit,$18.09 ,OP,18.09,64.82,,,,,,
Molina Duals,CPT,86320,Serum immunoelectrophoresis,Lab Services,Per Unit,$29.92 ,OP,29.92,99.13,,,,,,
Molina Duals,CPT,86325,Other immunoelectrophoresis,Lab Services,Per Unit,$23.13 ,OP,23.13,99.13,,,,,,
Molina Duals,CPT,86327,Immunoelectrophoresis assay,Lab Services,Per Unit,$29.92 ,OP,29.92,72.44,,,,,,
Molina Duals,CPT,86328,Ia nfct ab sarscov2 covid19,Lab Services,Per Unit,$45.23 ,OP,45.23,64.82,,,,,,
Molina Duals,CPT,86329,Immunodiffusion nes,Lab Services,Per Unit,$14.05 ,OP,14.05,14.05,,,,,,
Molina Duals,CPT,86331,Immunodiffusion ouchterlony,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Molina Duals,CPT,86332,Immune complex assay,Lab Services,Per Unit,$24.37 ,OP,24.37,106.76,,,,,,
Molina Duals,CPT,86334,Immunofix e-phoresis serum,Lab Services,Per Unit,$22.34 ,OP,22.34,99.13,,,,,,
Molina Duals,CPT,86335,Immunfix e-phorsis/urine/csf,Lab Services,Per Unit,$29.35 ,OP,29.35,129.64,,,,,,
Molina Duals,CPT,86336,Inhibin a,Lab Services,Per Unit,$15.59 ,OP,15.59,68.63,,,,,,
Molina Duals,CPT,86337,Insulin antibodies,Lab Services,Per Unit,$21.41 ,OP,21.41,95.32,,,,,,
Molina Duals,CPT,86340,Intrinsic factor antibody,Lab Services,Per Unit,$15.08 ,OP,15.08,68.63,,,,,,
Molina Duals,CPT,86341,Islet cell antibody,Lab Services,Per Unit,$23.57 ,OP,23.57,87.69,,,,,,
Molina Duals,CPT,86343,Leukocyte histamine release,Lab Services,Per Unit,$12.46 ,OP,12.46,57.19,,,,,,
Molina Duals,CPT,86344,Leukocyte phagocytosis,Lab Services,Per Unit,$10.39 ,OP,10.39,34.31,,,,,,
Molina Duals,CPT,86352,Cell function assay w/stim,Lab Services,Per Unit,$135.86 ,OP,135.86,135.86,,,,,,
Molina Duals,CPT,86353,Lymphocyte transformation,Lab Services,Per Unit,$49.03 ,OP,49.03,217.32,,,,,,
Molina Duals,CPT,86355,B cells total count,Lab Services,Per Unit,$37.73 ,OP,37.73,167.76,,,,,,
Molina Duals,CPT,86356,Mononuclear cell antigen,Lab Services,Per Unit,$26.78 ,OP,26.78,61,,,,,,
Molina Duals,CPT,86357,Nk cells total count,Lab Services,Per Unit,$37.73 ,OP,37.73,167.76,,,,,,
Molina Duals,CPT,86359,T cells total count,Lab Services,Per Unit,$37.73 ,OP,37.73,167.76,,,,,,
Molina Duals,CPT,86360,T cell absolute count/ratio,Lab Services,Per Unit,$46.98 ,OP,46.98,209.7,,,,,,
Molina Duals,CPT,86361,T cell absolute count,Lab Services,Per Unit,$26.78 ,OP,26.78,61,,,,,,
Molina Duals,CPT,86367,Stem cells total count,Lab Services,Per Unit,$77.78 ,OP,77.78,167.76,,,,,,
Molina Duals,CPT,86376,Microsomal antibody each,Lab Services,Per Unit,$14.55 ,OP,14.55,64.82,,,,,,
Molina Duals,CPT,86382,Neutralization test viral,Lab Services,Per Unit,$16.91 ,OP,16.91,76.26,,,,,,
Molina Duals,CPT,86384,Nitroblue tetrazolium dye,Lab Services,Per Unit,$13.61 ,OP,13.61,13.61,,,,,,
Molina Duals,CPT,86386,Nuclear matrix protein 22,Lab Services,Per Unit,$21.78 ,OP,21.78,21.78,,,,,,
Molina Duals,CPT,86403,Particle agglut antbdy scrn,Lab Services,Per Unit,$11.54 ,OP,11.54,26.7,,,,,,
Molina Duals,CPT,86406,Particle agglut antbdy titr,Lab Services,Per Unit,$10.64 ,OP,10.64,45.74,,,,,,
Molina Duals,CPT,86408,Neutrlzg antb sarscov2 scr,Lab Services,Per Unit,$42.13 ,OP,42.13,42.13,,,,,,
Molina Duals,CPT,86409,Neutrlzg antb sarscov2 titer,Lab Services,Per Unit,$105.33 ,OP,105.33,105.33,,,,,,
Molina Duals,CPT,86413,Sars-cov-2 antb quantitative,Lab Services,Per Unit,$51.43 ,OP,51.43,51.43,,,,,,
Molina Duals,CPT,86430,Rheumatoid factor test qual,Lab Services,Per Unit,$6.14 ,OP,6.14,26.7,,,,,,
Molina Duals,CPT,86431,Rheumatoid factor quant,Lab Services,Per Unit,$5.67 ,OP,5.67,26.7,,,,,,
Molina Duals,CPT,86480,Tb test cell immun measure,Lab Services,Per Unit,$61.98 ,OP,61.98,274.51,,,,,,
Molina Duals,CPT,86481,Tb ag response t-cell susp,Lab Services,Per Unit,$100.00 ,OP,100,100,,,,,,
Molina Duals,CPT,86485,Skin test candida,APC 5731,RVU Per Case,$25.25 ,OP,25.25,61,,,,,,
Molina Duals,CPT,86486,Skin test nos antigen,APC 5731,RVU Per Case,$25.25 ,OP,25.25,30.51,,,,,,
Molina Duals,CPT,86490,Coccidioidomycosis skin test,APC 5733,RVU Per Case,$56.95 ,OP,38.13,56.95,,,,,,
Molina Duals,CPT,86510,Histoplasmosis skin test,APC 5733,RVU Per Case,$56.95 ,OP,38.13,56.95,,,,,,
Molina Duals,CPT,86580,Tb intradermal test,APC 5731,RVU Per Case,$25.25 ,OP,25.25,38.13,,,,,,
Molina Duals,CPT,86590,Streptokinase antibody,Lab Services,Per Unit,$12.66 ,OP,12.66,49.56,,,,,,
Molina Duals,CPT,86592,Syphilis test non-trep qual,Lab Services,Per Unit,$4.27 ,OP,4.27,19.07,,,,,,
Molina Duals,CPT,86593,Syphilis test non-trep quant,Lab Services,Per Unit,$4.40 ,OP,4.4,19.07,,,,,,
Molina Duals,CPT,86602,Antinomyces antibody,Lab Services,Per Unit,$10.18 ,OP,10.18,45.74,,,,,,
Molina Duals,CPT,86603,Adenovirus antibody,Lab Services,Per Unit,$12.87 ,OP,12.87,12.87,,,,,,
Molina Duals,CPT,86606,Aspergillus antibody,Lab Services,Per Unit,$15.05 ,OP,15.05,68.63,,,,,,
Molina Duals,CPT,86609,Bacterium antibody,Lab Services,Per Unit,$12.88 ,OP,12.88,57.19,,,,,,
Molina Duals,CPT,86611,Bartonella antibody,Lab Services,Per Unit,$10.18 ,OP,10.18,45.74,,,,,,
Molina Duals,CPT,86612,Blastomyces antibody,Lab Services,Per Unit,$12.90 ,OP,12.9,57.19,,,,,,
Molina Duals,CPT,86615,Bordetella antibody,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
Molina Duals,CPT,86617,Lyme disease antibody,Lab Services,Per Unit,$15.49 ,OP,15.49,68.63,,,,,,
Molina Duals,CPT,86618,Lyme disease antibody,Lab Services,Per Unit,$17.03 ,OP,17.03,83.87,,,,,,
Molina Duals,CPT,86619,Borrelia antibody,Lab Services,Per Unit,$13.38 ,OP,13.38,61,,,,,,
Molina Duals,CPT,86622,Brucella antibody,Lab Services,Per Unit,$8.93 ,OP,8.93,38.13,,,,,,
Molina Duals,CPT,86625,Campylobacter antibody,Lab Services,Per Unit,$13.12 ,OP,13.12,57.19,,,,,,
Molina Duals,CPT,86628,Candida antibody,Lab Services,Per Unit,$12.01 ,OP,12.01,53.38,,,,,,
Molina Duals,CPT,86631,Chlamydia antibody,Lab Services,Per Unit,$11.82 ,OP,11.82,53.38,,,,,,
Molina Duals,CPT,86632,Chlamydia igm antibody,Lab Services,Per Unit,$12.68 ,OP,12.68,57.19,,,,,,
Molina Duals,CPT,86635,Coccidioides antibody,Lab Services,Per Unit,$11.47 ,OP,11.47,49.56,,,,,,
Molina Duals,CPT,86638,Q fever antibody,Lab Services,Per Unit,$12.12 ,OP,12.12,53.38,,,,,,
Molina Duals,CPT,86641,Cryptococcus antibody,Lab Services,Per Unit,$14.41 ,OP,14.41,64.82,,,,,,
Molina Duals,CPT,86644,Cmv antibody,Lab Services,Per Unit,$14.39 ,OP,14.39,64.82,,,,,,
Molina Duals,CPT,86645,Cmv antibody igm,Lab Services,Per Unit,$16.85 ,OP,16.85,76.26,,,,,,
Molina Duals,CPT,86648,Diphtheria antibody,Lab Services,Per Unit,$15.21 ,OP,15.21,68.63,,,,,,
Molina Duals,CPT,86651,Encephalitis californ antbdy,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
Molina Duals,CPT,86652,Encephaltis east eqne anbdy,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
Molina Duals,CPT,86653,Encephaltis st louis antbody,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
Molina Duals,CPT,86654,Encephaltis west eqne antbdy,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
Molina Duals,CPT,86658,Enterovirus antibody,Lab Services,Per Unit,$13.03 ,OP,13.03,57.19,,,,,,
Molina Duals,CPT,86663,Epstein-barr antibody,Lab Services,Per Unit,$13.12 ,OP,13.12,57.19,,,,,,
Molina Duals,CPT,86664,Epstein-barr nuclear antigen,Lab Services,Per Unit,$15.29 ,OP,15.29,68.63,,,,,,
Molina Duals,CPT,86665,Epstein-barr capsid vca,Lab Services,Per Unit,$18.14 ,OP,18.14,80.07,,,,,,
Molina Duals,CPT,86666,Ehrlichia antibody,Lab Services,Per Unit,$10.18 ,OP,10.18,45.74,,,,,,
Molina Duals,CPT,86668,Francisella tularensis,Lab Services,Per Unit,$14.16 ,OP,14.16,45.74,,,,,,
Molina Duals,CPT,86671,Fungus nes antibody,Lab Services,Per Unit,$12.25 ,OP,12.25,53.38,,,,,,
Molina Duals,CPT,86674,Giardia lamblia antibody,Lab Services,Per Unit,$14.72 ,OP,14.72,14.72,,,,,,
Molina Duals,CPT,86677,Helicobacter pylori antibody,Lab Services,Per Unit,$16.85 ,OP,16.85,64.82,,,,,,
Molina Duals,CPT,86682,Helminth antibody,Lab Services,Per Unit,$13.01 ,OP,13.01,57.19,,,,,,
Molina Duals,CPT,86684,Hemophilus influenza antibdy,Lab Services,Per Unit,$15.84 ,OP,15.84,72.44,,,,,,
Molina Duals,CPT,86687,Htlv-i antibody,Lab Services,Per Unit,$9.09 ,OP,9.09,38.13,,,,,,
Molina Duals,CPT,86688,Htlv-ii antibody,Lab Services,Per Unit,$14.00 ,OP,14,61,,,,,,
Molina Duals,CPT,86689,Htlv/hiv confirmj antibody,Lab Services,Per Unit,$19.35 ,OP,19.35,87.69,,,,,,
Molina Duals,CPT,86692,Hepatitis delta agent antbdy,Lab Services,Per Unit,$17.16 ,OP,17.16,76.26,,,,,,
Molina Duals,CPT,86694,Herpes simplex nes antbdy,Lab Services,Per Unit,$14.39 ,OP,14.39,64.82,,,,,,
Molina Duals,CPT,86695,Herpes simplex type 1 test,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
Molina Duals,CPT,86696,Herpes simplex type 2 test,Lab Services,Per Unit,$19.35 ,OP,19.35,87.69,,,,,,
Molina Duals,CPT,86698,Histoplasma antibody,Lab Services,Per Unit,$13.79 ,OP,13.79,57.19,,,,,,
Molina Duals,CPT,86701,Hiv-1antibody,Lab Services,Per Unit,$8.89 ,OP,8.89,38.13,,,,,,
Molina Duals,CPT,86702,Hiv-2 antibody,Lab Services,Per Unit,$13.52 ,OP,13.52,61,,,,,,
Molina Duals,CPT,86703,Hiv-1/hiv-2 1 result antbdy,Lab Services,Per Unit,$13.71 ,OP,13.71,61,,,,,,
Molina Duals,CPT,86704,Hep b core antibody total,Lab Services,Per Unit,$12.05 ,OP,12.05,53.38,,,,,,
Molina Duals,CPT,86705,Hep b core antibody igm,Lab Services,Per Unit,$11.77 ,OP,11.77,53.38,,,,,,
Molina Duals,CPT,86706,Hep b surface antibody,Lab Services,Per Unit,$10.74 ,OP,10.74,49.56,,,,,,
Molina Duals,CPT,86707,Hepatitis be antibody,Lab Services,Per Unit,$11.57 ,OP,11.57,53.38,,,,,,
Molina Duals,CPT,86708,Hepatitis a antibody,Lab Services,Per Unit,$12.39 ,OP,12.39,53.38,,,,,,
Molina Duals,CPT,86709,Hepatitis a igm antibody,Lab Services,Per Unit,$11.26 ,OP,11.26,49.56,,,,,,
Molina Duals,CPT,86710,Influenza virus antibody,Lab Services,Per Unit,$13.55 ,OP,13.55,68.63,,,,,,
Molina Duals,CPT,86711,John cunningham antibody,Lab Services,Per Unit,$16.89 ,OP,16.89,16.89,,,,,,
Molina Duals,CPT,86713,Legionella antibody,Lab Services,Per Unit,$15.30 ,OP,15.3,68.63,,,,,,
Molina Duals,CPT,86717,Leishmania antibody,Lab Services,Per Unit,$12.25 ,OP,12.25,53.38,,,,,,
Molina Duals,CPT,86720,Leptospira antibody,Lab Services,Per Unit,$16.20 ,OP,16.2,57.19,,,,,,
Molina Duals,CPT,86723,Listeria monocytogenes,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,
Molina Duals,CPT,86727,Lymph choriomeningitis ab,Lab Services,Per Unit,$12.87 ,OP,12.87,57.19,,,,,,
Molina Duals,CPT,86732,Mucormycosis antibody,Lab Services,Per Unit,$15.00 ,OP,15,57.19,,,,,,
Molina Duals,CPT,86735,Mumps antibody,Lab Services,Per Unit,$13.05 ,OP,13.05,57.19,,,,,,
Molina Duals,CPT,86738,Mycoplasma antibody,Lab Services,Per Unit,$13.24 ,OP,13.24,57.19,,,,,,
Molina Duals,CPT,86741,Neisseria meningitidis,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
Molina Duals,CPT,86744,Nocardia antibody,Lab Services,Per Unit,$15.99 ,OP,15.99,57.19,,,,,,
Molina Duals,CPT,86747,Parvovirus antibody,Lab Services,Per Unit,$15.03 ,OP,15.03,68.63,,,,,,
Molina Duals,CPT,86750,Malaria antibody,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
Molina Duals,CPT,86753,Protozoa antibody nos,Lab Services,Per Unit,$12.39 ,OP,12.39,53.38,,,,,,
Molina Duals,CPT,86756,Respiratory virus antibody,Lab Services,Per Unit,$15.89 ,OP,15.89,57.19,,,,,,
Molina Duals,CPT,86757,Rickettsia antibody,Lab Services,Per Unit,$19.35 ,OP,19.35,87.69,,,,,,
Molina Duals,CPT,86759,Rotavirus antibody,Lab Services,Per Unit,$18.23 ,OP,18.23,57.19,,,,,,
Molina Duals,CPT,86762,Rubella antibody,Lab Services,Per Unit,$14.39 ,OP,14.39,64.82,,,,,,
Molina Duals,CPT,86765,Rubeola antibody,Lab Services,Per Unit,$12.88 ,OP,12.88,57.19,,,,,,
Molina Duals,CPT,86768,Salmonella antibody,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,
Molina Duals,CPT,86769,Sars-cov-2 covid-19 antibody,Lab Services,Per Unit,$42.13 ,OP,42.13,57.19,,,,,,
Molina Duals,CPT,86771,Shigella antibody,Lab Services,Per Unit,$24.48 ,OP,24.48,57.19,,,,,,
Molina Duals,CPT,86774,Tetanus antibody,Lab Services,Per Unit,$14.80 ,OP,14.8,64.82,,,,,,
Molina Duals,CPT,86777,Toxoplasma antibody,Lab Services,Per Unit,$14.39 ,OP,14.39,64.82,,,,,,
Molina Duals,CPT,86778,Toxoplasma antibody igm,Lab Services,Per Unit,$14.41 ,OP,14.41,64.82,,,,,,
Molina Duals,CPT,86780,Treponema pallidum,Lab Services,Per Unit,$13.24 ,OP,13.24,13.24,,,,,,
Molina Duals,CPT,86784,Trichinella antibody,Lab Services,Per Unit,$12.56 ,OP,12.56,12.56,,,,,,
Molina Duals,CPT,86787,Varicella-zoster antibody,Lab Services,Per Unit,$12.88 ,OP,12.88,57.19,,,,,,
Molina Duals,CPT,86788,West nile virus ab igm,Lab Services,Per Unit,$16.85 ,OP,16.85,76.26,,,,,,
Molina Duals,CPT,86789,West nile virus antibody,Lab Services,Per Unit,$14.39 ,OP,14.39,64.82,,,,,,
Molina Duals,CPT,86790,Virus antibody nos,Lab Services,Per Unit,$12.88 ,OP,12.88,57.19,,,,,,
Molina Duals,CPT,86793,Yersinia antibody,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
Molina Duals,CPT,86794,Zika virus igm antibody,Lab Services,Per Unit,$16.85 ,OP,16.85,16.85,,,,,,
Molina Duals,CPT,86800,Thyroglobulin antibody,Lab Services,Per Unit,$15.91 ,OP,15.91,72.44,,,,,,
Molina Duals,CPT,86803,Hepatitis c ab test,Lab Services,Per Unit,$14.27 ,OP,14.27,64.82,,,,,,
Molina Duals,CPT,86804,Hep c ab test confirm,Lab Services,Per Unit,$15.49 ,OP,15.49,68.63,,,,,,
Molina Duals,CPT,86805,Lymphocytotoxicity assay,Lab Services,Per Unit,$189.51 ,OP,189.51,232.58,,,,,,
Molina Duals,CPT,86806,Lymphocytotoxicity assay,Lab Services,Per Unit,$47.59 ,OP,47.59,213.51,,,,,,
Molina Duals,CPT,86807,Cytotoxic antibody screening,Lab Services,Per Unit,$78.65 ,OP,78.65,175.39,,,,,,
Molina Duals,CPT,86808,Cytotoxic antibody screening,Lab Services,Per Unit,$29.68 ,OP,29.68,133.45,,,,,,
Molina Duals,CPT,86812,Hla typing a b or c,Lab Services,Per Unit,$25.81 ,OP,25.81,114.39,,,,,,
Molina Duals,CPT,86813,Hla typing a b or c,Lab Services,Per Unit,$58.00 ,OP,58,247.83,,,,,,
Molina Duals,CPT,86816,Hla typing dr/dq,Lab Services,Per Unit,$30.17 ,OP,30.17,102.95,,,,,,
Molina Duals,CPT,86817,Hla typing dr/dq,Lab Services,Per Unit,$106.14 ,OP,106.14,247.83,,,,,,
Molina Duals,CPT,86821,Lymphocyte culture mixed,Lab Services,Per Unit,$36.56 ,OP,36.56,251.64,,,,,,
Molina Duals,CPT,86825,Hla x-math non-cytotoxic,Lab Services,Per Unit,$109.49 ,OP,109.49,109.49,,,,,,
Molina Duals,CPT,86826,Hla x-match noncytotoxc addl,Lab Services,Per Unit,$36.53 ,OP,36.53,36.53,,,,,,
Molina Duals,CPT,86828,Hla class i&ii antibody qual,Lab Services,Per Unit,$64.19 ,OP,64.19,64.19,,,,,,
Molina Duals,CPT,86829,Hla class i/ii antibody qual,Lab Services,Per Unit,$64.19 ,OP,64.19,64.19,,,,,,
Molina Duals,CPT,86830,Hla class i phenotype qual,Lab Services,Per Unit,$95.52 ,OP,95.52,95.52,,,,,,
Molina Duals,CPT,86831,Hla class ii phenotype qual,Lab Services,Per Unit,$81.88 ,OP,81.88,81.88,,,,,,
Molina Duals,CPT,86832,Hla class i high defin qual,Lab Services,Per Unit,$323.75 ,OP,323.75,323.75,,,,,,
Molina Duals,CPT,86833,Hla class ii high defin qual,Lab Services,Per Unit,$325.80 ,OP,325.8,325.8,,,,,,
Molina Duals,CPT,86834,Hla class i semiquant panel,Lab Services,Per Unit,$357.56 ,OP,357.56,357.56,,,,,,
Molina Duals,CPT,86835,Hla class ii semiquant panel,Lab Services,Per Unit,$322.96 ,OP,322.96,322.96,,,,,,
Molina Duals,CPT,86850,Rbc antibody screen,APC 5671,RVU Per Case,$50.92 ,OP,50.92,76.26,,,,,,
Molina Duals,CPT,86860,Rbc antibody elution,APC 5672,RVU Per Case,$152.64 ,OP,91.51,152.64,,,,,,
Molina Duals,CPT,86870,Rbc antibody identification,APC 5673,RVU Per Case,$298.05 ,OP,141.07,298.05,,,,,,
Molina Duals,CPT,86880,Coombs test direct,APC 5733,RVU Per Case,$56.95 ,OP,22.88,56.95,,,,,,
Molina Duals,CPT,86885,Coombs test indirect qual,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Molina Duals,CPT,86886,Coombs test indirect titer,APC 5672,RVU Per Case,$152.64 ,OP,22.88,152.64,,,,,,
Molina Duals,CPT,86890,Autologous blood process,APC 5672,RVU Per Case,$152.64 ,OP,152.64,308.83,,,,,,
Molina Duals,CPT,86891,Autologous blood op salvage,APC 5674,RVU Per Case,$671.45 ,OP,480.4,671.45,,,,,,
Molina Duals,CPT,86900,Blood typing serologic abo,APC 5734,RVU Per Case,$114.56 ,OP,11.44,114.56,,,,,,
Molina Duals,CPT,86901,Blood typing serologic rh(d),APC 5732,RVU Per Case,$34.63 ,OP,22.88,34.63,,,,,,
Molina Duals,CPT,86902,Blood type antigen donor ea,APC 5673,RVU Per Case,$298.05 ,OP,41.94,298.05,,,,,,
Molina Duals,CPT,86904,Blood typing patient serum,APC 5732,RVU Per Case,$34.63 ,OP,34.63,41.94,,,,,,
Molina Duals,CPT,86905,Blood typing rbc antigens,APC 5673,RVU Per Case,$298.05 ,OP,15.26,298.05,,,,,,
Molina Duals,CPT,86906,Bld typing serologic rh phnt,APC 5732,RVU Per Case,$34.63 ,OP,34.31,34.63,,,,,,
Molina Duals,CPT,86920,Compatibility test spin,APC 5672,RVU Per Case,$152.64 ,OP,125.82,152.64,,,,,,
Molina Duals,CPT,86921,Compatibility test incubate,APC 5672,RVU Per Case,$152.64 ,OP,102.95,152.64,,,,,,
Molina Duals,CPT,86922,Compatibility test antiglob,APC 5672,RVU Per Case,$152.64 ,OP,118.19,152.64,,,,,,
Molina Duals,CPT,86923,Compatibility test electric,APC 5672,RVU Per Case,$152.64 ,OP,91.51,152.64,,,,,,
Molina Duals,CPT,86927,Plasma fresh frozen,APC 5672,RVU Per Unit,$152.64 ,OP,49.56,152.64,,,,,,
Molina Duals,CPT,86930,Frozen blood prep,APC 5673,RVU Per Case,$298.05 ,OP,298.05,385.09,,,,,,
Molina Duals,CPT,86931,Frozen blood thaw,APC 5673,RVU Per Case,$298.05 ,OP,289.76,298.05,,,,,,
Molina Duals,CPT,86932,Frozen blood freeze/thaw,APC 5732,RVU Per Case,$34.63 ,OP,34.63,385.09,,,,,,
Molina Duals,CPT,86940,Hemolysins/agglutinins auto,Lab Services,Per Unit,$8.77 ,OP,8.77,38.13,,,,,,
Molina Duals,CPT,86941,Hemolysins/agglutinins,Lab Services,Per Unit,$12.11 ,OP,12.11,53.38,,,,,,
Molina Duals,CPT,86945,Blood product/irradiation,APC 5732,RVU Per Case,$34.63 ,OP,34.63,110.57,,,,,,
Molina Duals,CPT,86950,Leukacyte transfusion,APC 5672,RVU Per Case,$152.64 ,OP,152.64,240.2,,,,,,
Molina Duals,CPT,86960,Vol reduction of blood/prod,APC 5672,RVU Per Case,$152.64 ,OP,110.57,152.64,,,,,,
Molina Duals,CPT,86965,Pooling blood platelets,APC 5672,RVU Per Case,$152.64 ,OP,95.32,152.64,,,,,,
Molina Duals,CPT,86970,Rbc pretx incubatj w/chemicl,APC 5732,RVU Per Case,$34.63 ,OP,34.63,76.26,,,,,,
Molina Duals,CPT,86971,Rbc pretx incubatj w/enzymes,APC 5673,RVU Per Case,$298.05 ,OP,298.05,298.05,,,,,,
Molina Duals,CPT,86972,Rbc pretx incubatj w/density,APC 5672,RVU Per Case,$152.64 ,OP,122,152.64,,,,,,
Molina Duals,CPT,86975,Rbc serum pretx incubj drugs,APC 5735,RVU Per Case,$276.53 ,OP,102.95,276.53,,,,,,
Molina Duals,CPT,86976,Rbc serum pretx id dilution,APC 5731,RVU Per Case,$25.25 ,OP,25.25,118.19,,,,,,
Molina Duals,CPT,86977,Rbc serum pretx incubj/inhib,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Molina Duals,CPT,86978,Rbc pretreatment serum,APC 5732,RVU Per Case,$34.63 ,OP,34.63,102.95,,,,,,
Molina Duals,CPT,86985,Split blood or products,APC 5672,RVU Per Case,$152.64 ,OP,76.26,152.64,,,,,,
Molina Duals,CPT,86999,Transfusion procedure,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Molina Duals,CPT,87003,Small animal inoculation,Lab Services,Per Unit,$16.84 ,OP,16.84,76.26,,,,,,
Molina Duals,CPT,87015,Specimen infect agnt concntj,Lab Services,Per Unit,$6.68 ,OP,6.68,30.51,,,,,,
Molina Duals,CPT,87040,Blood culture for bacteria,Lab Services,Per Unit,$10.32 ,OP,10.32,45.74,,,,,,
Molina Duals,CPT,87045,Feces culture aerobic bact,Lab Services,Per Unit,$9.44 ,OP,9.44,41.94,,,,,,
Molina Duals,CPT,87046,Stool cultr aerobic bact ea,Lab Services,Per Unit,$9.44 ,OP,9.44,41.94,,,,,,
Molina Duals,CPT,87070,Culture othr specimn aerobic,Lab Services,Per Unit,$8.62 ,OP,8.62,41.94,,,,,,
Molina Duals,CPT,87071,Culture aerobic quant other,Lab Services,Per Unit,$9.89 ,OP,9.89,41.94,,,,,,
Molina Duals,CPT,87073,Culture bacteria anaerobic,Lab Services,Per Unit,$9.66 ,OP,9.66,41.94,,,,,,
Molina Duals,CPT,87075,Cultr bacteria except blood,Lab Services,Per Unit,$9.47 ,OP,9.47,41.94,,,,,,
Molina Duals,CPT,87076,Culture anaerobe ident each,Lab Services,Per Unit,$8.08 ,OP,8.08,19.07,,,,,,
Molina Duals,CPT,87077,Culture aerobic identify,Lab Services,Per Unit,$8.08 ,OP,8.08,22.88,,,,,,
Molina Duals,CPT,87081,Culture screen only,Lab Services,Per Unit,$6.63 ,OP,6.63,34.31,,,,,,
Molina Duals,CPT,87084,Culture of specimen by kit,Lab Services,Per Unit,$27.07 ,OP,22.88,27.07,,,,,,
Molina Duals,CPT,87086,Urine culture/colony count,Lab Services,Per Unit,$8.07 ,OP,8.07,41.94,,,,,,
Molina Duals,CPT,87088,Urine bacteria culture,Lab Services,Per Unit,$8.09 ,OP,8.09,41.94,,,,,,
Molina Duals,CPT,87101,Skin fungi culture,Lab Services,Per Unit,$7.71 ,OP,7.71,34.31,,,,,,
Molina Duals,CPT,87102,Fungus isolation culture,Lab Services,Per Unit,$8.41 ,OP,8.41,38.13,,,,,,
Molina Duals,CPT,87103,Blood fungus culture,Lab Services,Per Unit,$20.46 ,OP,20.46,41.94,,,,,,
Molina Duals,CPT,87106,Fungi identification yeast,Lab Services,Per Unit,$10.32 ,OP,10.32,45.74,,,,,,
Molina Duals,CPT,87107,Fungi identification mold,Lab Services,Per Unit,$10.32 ,OP,10.32,45.74,,,,,,
Molina Duals,CPT,87109,Mycoplasma,Lab Services,Per Unit,$15.39 ,OP,15.39,68.63,,,,,,
Molina Duals,CPT,87110,Chlamydia culture,Lab Services,Per Unit,$19.60 ,OP,19.6,87.69,,,,,,
Molina Duals,CPT,87116,Mycobacteria culture,Lab Services,Per Unit,$10.80 ,OP,10.8,49.56,,,,,,
Molina Duals,CPT,87118,Mycobacteric identification,Lab Services,Per Unit,$14.61 ,OP,14.61,49.56,,,,,,
Molina Duals,CPT,87140,Culture type immunofluoresc,Lab Services,Per Unit,$5.57 ,OP,5.57,26.7,,,,,,
Molina Duals,CPT,87143,Culture typing glc/hplc,Lab Services,Per Unit,$12.52 ,OP,12.52,57.19,,,,,,
Molina Duals,CPT,87147,Culture type immunologic,Lab Services,Per Unit,$5.18 ,OP,5.18,22.88,,,,,,
Molina Duals,CPT,87149,Dna/rna direct probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
Molina Duals,CPT,87150,Dna/rna amplified probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,
Molina Duals,CPT,87152,Culture type pulse field gel,Lab Services,Per Unit,$7.74 ,OP,7.74,22.88,,,,,,
Molina Duals,CPT,87153,Dna/rna sequencing,Lab Services,Per Unit,$115.36 ,OP,115.36,115.36,,,,,,
Molina Duals,CPT,87158,Culture typing added method,Lab Services,Per Unit,$7.74 ,OP,7.74,7.74,,,,,,
Molina Duals,CPT,87164,Dark field examination,Lab Services,Per Unit,$10.74 ,OP,10.74,49.56,,,,,,
Molina Duals,CPT,87166,Dark field examination,Lab Services,Per Unit,$11.30 ,OP,11.3,49.56,,,,,,
Molina Duals,CPT,87168,Macroscopic exam arthropod,Lab Services,Per Unit,$4.27 ,OP,4.27,19.07,,,,,,
Molina Duals,CPT,87169,Macroscopic exam parasite,Lab Services,Per Unit,$4.31 ,OP,4.31,19.07,,,,,,
Molina Duals,CPT,87172,Pinworm exam,Lab Services,Per Unit,$4.27 ,OP,4.27,22.88,,,,,,
Molina Duals,CPT,87176,Tissue homogenization cultr,Lab Services,Per Unit,$5.88 ,OP,5.88,26.7,,,,,,
Molina Duals,CPT,87177,Ova and parasites smears,Lab Services,Per Unit,$8.90 ,OP,8.9,41.94,,,,,,
Molina Duals,CPT,87181,Microbe susceptible diffuse,Lab Services,Per Unit,$4.75 ,OP,4.75,22.88,,,,,,
Molina Duals,CPT,87184,Microbe susceptible disk,Lab Services,Per Unit,$7.48 ,OP,7.48,34.31,,,,,,
Molina Duals,CPT,87185,Microbe susceptible enzyme,Lab Services,Per Unit,$4.75 ,OP,4.75,22.88,,,,,,
Molina Duals,CPT,87186,Microbe susceptible mic,Lab Services,Per Unit,$8.65 ,OP,8.65,38.13,,,,,,
Molina Duals,CPT,87187,Microbe susceptible mlc,Lab Services,Per Unit,$40.17 ,OP,40.17,45.74,,,,,,
Molina Duals,CPT,87188,Microbe suscept macrobroth,Lab Services,Per Unit,$6.64 ,OP,6.64,30.51,,,,,,
Molina Duals,CPT,87190,Microbe suscept mycobacteri,Lab Services,Per Unit,$7.31 ,OP,7.31,26.7,,,,,,
Molina Duals,CPT,87197,Bactericidal level serum,Lab Services,Per Unit,$15.02 ,OP,15.02,68.63,,,,,,
Molina Duals,CPT,87205,Smear gram stain,Lab Services,Per Unit,$4.27 ,OP,4.27,22.88,,,,,,
Molina Duals,CPT,87206,Smear fluorescent/acid stai,Lab Services,Per Unit,$5.39 ,OP,5.39,26.7,,,,,,
Molina Duals,CPT,87207,Smear special stain,Lab Services,Per Unit,$5.99 ,OP,5.99,41.94,,,,,,
Molina Duals,CPT,87209,Smear complex stain,Lab Services,Per Unit,$17.98 ,OP,17.98,80.07,,,,,,
Molina Duals,CPT,87210,Smear wet mount saline/ink,Lab Services,Per Unit,$5.82 ,OP,5.82,22.88,,,,,,
Molina Duals,CPT,87220,Tissue exam for fungi,Lab Services,Per Unit,$4.27 ,OP,4.27,22.88,,,,,,
Molina Duals,CPT,87230,Assay toxin or antitoxin,Lab Services,Per Unit,$19.74 ,OP,19.74,87.69,,,,,,
Molina Duals,CPT,87250,Virus inoculate eggs/animal,Lab Services,Per Unit,$19.56 ,OP,19.56,87.69,,,,,,
Molina Duals,CPT,87252,Virus inoculation tissue,Lab Services,Per Unit,$26.07 ,OP,26.07,102.95,,,,,,
Molina Duals,CPT,87253,Virus inoculate tissue addl,Lab Services,Per Unit,$20.20 ,OP,20.2,91.51,,,,,,
Molina Duals,CPT,87254,Virus inoculation shell via,Lab Services,Per Unit,$19.56 ,OP,19.56,87.69,,,,,,
Molina Duals,CPT,87255,Genet virus isolate hsv,Lab Services,Per Unit,$33.86 ,OP,33.86,152.51,,,,,,
Molina Duals,CPT,87260,Adenovirus ag if,Lab Services,Per Unit,$14.43 ,OP,14.43,14.43,,,,,,
Molina Duals,CPT,87265,Pertussis ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Molina Duals,CPT,87267,Enterovirus antibody dfa,Lab Services,Per Unit,$13.42 ,OP,13.42,53.38,,,,,,
Molina Duals,CPT,87269,Giardia ag if,Lab Services,Per Unit,$13.61 ,OP,13.61,53.38,,,,,,
Molina Duals,CPT,87270,Chlamydia trachomatis ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Molina Duals,CPT,87271,Cytomegalovirus dfa,Lab Services,Per Unit,$13.42 ,OP,13.42,53.38,,,,,,
Molina Duals,CPT,87272,Cryptosporidium ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Molina Duals,CPT,87273,Herpes simplex 2 ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,
Molina Duals,CPT,87274,Herpes simplex 1 ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,
Molina Duals,CPT,87275,Influenza b ag if,Lab Services,Per Unit,$12.25 ,OP,12.25,53.38,,,,,,
Molina Duals,CPT,87276,Influenza a ag if,Lab Services,Per Unit,$16.07 ,OP,16.07,53.38,,,,,,
Molina Duals,CPT,87278,Legion pneumophilia ag if,Lab Services,Per Unit,$15.60 ,OP,15.6,53.38,,,,,,
Molina Duals,CPT,87279,Parainfluenza ag if,Lab Services,Per Unit,$16.43 ,OP,16.43,53.38,,,,,,
Molina Duals,CPT,87280,Respiratory syncytial ag if,Lab Services,Per Unit,$13.42 ,OP,13.42,53.38,,,,,,
Molina Duals,CPT,87281,Pneumocystis carinii ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Molina Duals,CPT,87283,Rubeola ag if,Lab Services,Per Unit,$60.80 ,OP,53.38,60.8,,,,,,
Molina Duals,CPT,87285,Treponema pallidum ag if,Lab Services,Per Unit,$12.18 ,OP,12.18,53.38,,,,,,
Molina Duals,CPT,87290,Varicella zoster ag if,Lab Services,Per Unit,$13.42 ,OP,13.42,53.38,,,,,,
Molina Duals,CPT,87299,Antibody detection nos if,Lab Services,Per Unit,$16.10 ,OP,16.1,53.38,,,,,,
Molina Duals,CPT,87300,Ag detection polyval if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,
Molina Duals,CPT,87301,Adenovirus ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Molina Duals,CPT,87305,Aspergillus ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Molina Duals,CPT,87320,Chylmd trach ag ia,Lab Services,Per Unit,$15.00 ,OP,15,53.38,,,,,,
Molina Duals,CPT,87324,Clostridium ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Molina Duals,CPT,87327,Cryptococcus neoform ag ia,Lab Services,Per Unit,$13.42 ,OP,13.42,53.38,,,,,,
Molina Duals,CPT,87328,Cryptosporidium ag ia,Lab Services,Per Unit,$13.82 ,OP,13.82,53.38,,,,,,
Molina Duals,CPT,87329,Giardia ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Molina Duals,CPT,87332,Cytomegalovirus ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Molina Duals,CPT,87335,E coli 0157 ag ia,Lab Services,Per Unit,$12.66 ,OP,12.66,53.38,,,,,,
Molina Duals,CPT,87336,Entamoeb hist dispr ag ia,Lab Services,Per Unit,$16.00 ,OP,16,53.38,,,,,,
Molina Duals,CPT,87337,Entamoeb hist group ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Molina Duals,CPT,87338,Hpylori stool ag ia,Lab Services,Per Unit,$14.38 ,OP,14.38,64.82,,,,,,
Molina Duals,CPT,87339,H pylori ag ia,Lab Services,Per Unit,$16.00 ,OP,16,53.38,,,,,,
Molina Duals,CPT,87340,Hepatitis b surface ag ia,Lab Services,Per Unit,$10.33 ,OP,10.33,45.74,,,,,,
Molina Duals,CPT,87341,Hepatitis b surface ag ia,Lab Services,Per Unit,$10.33 ,OP,10.33,45.74,,,,,,
Molina Duals,CPT,87350,Hepatitis be ag ia,Lab Services,Per Unit,$11.53 ,OP,11.53,49.56,,,,,,
Molina Duals,CPT,87380,Hepatitis delta agent ag ia,Lab Services,Per Unit,$18.36 ,OP,18.36,72.44,,,,,,
Molina Duals,CPT,87385,Histoplasma capsul ag ia,Lab Services,Per Unit,$13.25 ,OP,13.25,53.38,,,,,,
Molina Duals,CPT,87389,Hiv-1 ag w/hiv-1&2 ab ag ia,Lab Services,Per Unit,$24.08 ,OP,24.08,24.08,,,,,,
Molina Duals,CPT,87390,Hiv-1 ag ia,Lab Services,Per Unit,$24.06 ,OP,24.06,24.06,,,,,,
Molina Duals,CPT,87391,Hiv-2 ag ia,Lab Services,Per Unit,$21.90 ,OP,21.9,80.07,,,,,,
Molina Duals,CPT,87400,Influenza a/b each ag ia,Lab Services,Per Unit,$14.13 ,OP,14.13,61,,,,,,
Molina Duals,CPT,87420,Resp syncytial virus ag ia,Lab Services,Per Unit,$13.91 ,OP,13.91,53.38,,,,,,
Molina Duals,CPT,87425,Rotavirus ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Molina Duals,CPT,87426,Sarscov coronavirus ag ia,Lab Services,Per Unit,$35.33 ,OP,35.33,35.33,,,,,,
Molina Duals,CPT,87427,Shiga-like toxin ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
Molina Duals,CPT,87428,Sarscov & inf vir a&b ag ia,Lab Services,Per Unit,$63.59 ,OP,63.59,63.59,,,,,,
Molina Duals,CPT,87430,Strep a ag ia,Lab Services,Per Unit,$16.81 ,OP,16.81,61,,,,,,
Molina Duals,CPT,87449,Nos each organism ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,61,,,,,,
Molina Duals,CPT,87451,Polyvalent mult org ea ag ia,Lab Services,Per Unit,$10.51 ,OP,10.51,41.94,,,,,,
Molina Duals,CPT,87471,Bartonella dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,
Molina Duals,CPT,87472,Bartonella dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Molina Duals,CPT,87475,Lyme dis dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
Molina Duals,CPT,87476,Lyme dis dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Molina Duals,CPT,87480,Candida dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,99.13,,,,,,
Molina Duals,CPT,87481,Candida dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Molina Duals,CPT,87482,Candida dna quant,Lab Services,Per Unit,$55.74 ,OP,55.74,186.82,,,,,,
Molina Duals,CPT,87483,Cns dna amp probe type 12-25,Lab Services,Per Unit,$416.78 ,OP,416.78,416.78,,,,,,
Molina Duals,CPT,87485,Chylmd pneum dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
Molina Duals,CPT,87486,Chylmd pneum dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Molina Duals,CPT,87487,Chylmd pneum dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Molina Duals,CPT,87490,Chylmd trach dna dir probe,Lab Services,Per Unit,$22.75 ,OP,22.75,99.13,,,,,,
Molina Duals,CPT,87491,Chylmd trach dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Molina Duals,CPT,87492,Chylmd trach dna quant,Lab Services,Per Unit,$53.47 ,OP,53.47,156.32,,,,,,
Molina Duals,CPT,87493,C diff amplified probe,Lab Services,Per Unit,$37.27 ,OP,37.27,37.27,,,,,,
Molina Duals,CPT,87495,Cytomeg dna dir probe,Lab Services,Per Unit,$30.03 ,OP,30.03,30.03,,,,,,
Molina Duals,CPT,87496,Cytomeg dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Molina Duals,CPT,87497,Cytomeg dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Molina Duals,CPT,87498,Enterovirus probe&revrs trns,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Molina Duals,CPT,87500,Vanomycin dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Molina Duals,CPT,87501,Influenza dna amp prob 1+,Lab Services,Per Unit,$51.31 ,OP,51.31,51.31,,,,,,
Molina Duals,CPT,87502,Influenza dna amp probe,Lab Services,Per Unit,$95.80 ,OP,95.8,95.8,,,,,,
Molina Duals,CPT,87503,Influenza dna amp prob addl,Lab Services,Per Unit,$29.22 ,OP,29.22,29.22,,,,,,
Molina Duals,CPT,87505,Nfct agent detection gi,Lab Services,Per Unit,$128.29 ,OP,128.29,128.29,,,,,,
Molina Duals,CPT,87506,Iadna-dna/rna probe tq 6-11,Lab Services,Per Unit,$262.99 ,OP,262.99,262.99,,,,,,
Molina Duals,CPT,87507,Iadna-dna/rna probe tq 12-25,Lab Services,Per Unit,$416.78 ,OP,416.78,416.78,,,,,,
Molina Duals,CPT,87510,Gardner vag dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,99.13,,,,,,
Molina Duals,CPT,87511,Gardner vag dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Molina Duals,CPT,87512,Gardner vag dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,186.82,,,,,,
Molina Duals,CPT,87516,Hepatitis b dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Molina Duals,CPT,87517,Hepatitis b dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Molina Duals,CPT,87520,Hepatitis c rna dir probe,Lab Services,Per Unit,$31.22 ,OP,31.22,87.69,,,,,,
Molina Duals,CPT,87521,Hepatitis c probe&rvrs trnsc,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Molina Duals,CPT,87522,Hepatitis c revrs trnscrpj,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Molina Duals,CPT,87525,Hepatitis g dna dir probe,Lab Services,Per Unit,$29.80 ,OP,29.8,87.69,,,,,,
Molina Duals,CPT,87526,Hepatitis g dna amp probe,Lab Services,Per Unit,$39.26 ,OP,39.26,156.32,,,,,,
Molina Duals,CPT,87527,Hepatitis g dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,186.82,,,,,,
Molina Duals,CPT,87528,Hsv dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
Molina Duals,CPT,87529,Hsv dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Molina Duals,CPT,87530,Hsv dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Molina Duals,CPT,87531,Hhv-6 dna dir probe,Lab Services,Per Unit,$58.00 ,OP,58,87.69,,,,,,
Molina Duals,CPT,87532,Hhv-6 dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,
Molina Duals,CPT,87533,Hhv-6 dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,186.82,,,,,,
Molina Duals,CPT,87534,Hiv-1 dna dir probe,Lab Services,Per Unit,$21.92 ,OP,21.92,87.69,,,,,,
Molina Duals,CPT,87535,Hiv-1 probe&reverse trnscrpj,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Molina Duals,CPT,87536,Hiv-1 quant&revrse trnscrpj,Lab Services,Per Unit,$85.10 ,OP,85.1,377.46,,,,,,
Molina Duals,CPT,87537,Hiv-2 dna dir probe,Lab Services,Per Unit,$21.92 ,OP,21.92,87.69,,,,,,
Molina Duals,CPT,87538,Hiv-2 probe&revrse trnscripj,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Molina Duals,CPT,87539,Hiv-2 quant&revrse trnscripj,Lab Services,Per Unit,$58.62 ,OP,58.62,190.64,,,,,,
Molina Duals,CPT,87540,Legion pneumo dna dir prob,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
Molina Duals,CPT,87541,Legion pneumo dna amp prob,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Molina Duals,CPT,87542,Legion pneumo dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,186.82,,,,,,
Molina Duals,CPT,87550,Mycobacteria dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
Molina Duals,CPT,87551,Mycobacteria dna amp probe,Lab Services,Per Unit,$48.24 ,OP,48.24,156.32,,,,,,
Molina Duals,CPT,87552,Mycobacteria dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Molina Duals,CPT,87555,M.tuberculo dna dir probe,Lab Services,Per Unit,$26.88 ,OP,26.88,87.69,,,,,,
Molina Duals,CPT,87556,M.tuberculo dna amp probe,Lab Services,Per Unit,$41.68 ,OP,41.68,156.32,,,,,,
Molina Duals,CPT,87557,M.tuberculo dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Molina Duals,CPT,87560,M.avium-intra dna dir prob,Lab Services,Per Unit,$27.29 ,OP,27.29,87.69,,,,,,
Molina Duals,CPT,87561,M.avium-intra dna amp prob,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Molina Duals,CPT,87562,M.avium-intra dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Molina Duals,CPT,87563,M. genitalium amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Molina Duals,CPT,87580,M.pneumon dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
Molina Duals,CPT,87581,M.pneumon dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Molina Duals,CPT,87582,M.pneumon dna quant,Lab Services,Per Unit,$302.62 ,OP,186.82,302.62,,,,,,
Molina Duals,CPT,87590,N.gonorrhoeae dna dir prob,Lab Services,Per Unit,$26.88 ,OP,26.88,99.13,,,,,,
Molina Duals,CPT,87591,N.gonorrhoeae dna amp prob,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Molina Duals,CPT,87592,N.gonorrhoeae dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,
Molina Duals,CPT,87623,Hpv low-risk types,Lab Services,Per Unit,$35.09 ,OP,35.09,93.87,,,,,,
Molina Duals,CPT,87624,Hpv high-risk types,Lab Services,Per Unit,$35.09 ,OP,35.09,93.87,,,,,,
Molina Duals,CPT,87625,Hpv types 16 & 18 only,Lab Services,Per Unit,$40.55 ,OP,40.55,93.87,,,,,,
Molina Duals,CPT,87631,Resp virus 3-5 targets,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
Molina Duals,CPT,87632,Resp virus 6-11 targets,Lab Services,Per Unit,$218.06 ,OP,218.06,218.06,,,,,,
Molina Duals,CPT,87633,Resp virus 12-25 targets,Lab Services,Per Unit,$416.78 ,OP,416.78,416.78,,,,,,
Molina Duals,CPT,87634,Rsv dna/rna amp probe,Lab Services,Per Unit,$70.20 ,OP,70.2,70.2,,,,,,
Molina Duals,CPT,87635,Sars-cov-2 covid-19 amp prb,Lab Services,Per Unit,$51.31 ,OP,51.31,51.31,,,,,,
Molina Duals,CPT,87636,Sarscov2 & inf a&b amp prb,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
Molina Duals,CPT,87637,Sarscov2&inf a&b&rsv amp prb,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
Molina Duals,CPT,87640,Staph a dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Molina Duals,CPT,87641,Mr-staph dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Molina Duals,CPT,87650,Strep a dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
Molina Duals,CPT,87651,Strep a dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Molina Duals,CPT,87652,Strep a dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,186.82,,,,,,
Molina Duals,CPT,87653,Strep b dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,
Molina Duals,CPT,87660,Trichomonas vagin dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
Molina Duals,CPT,87661,Trichomonas vaginalis amplif,Lab Services,Per Unit,$35.09 ,OP,35.09,87.69,,,,,,
Molina Duals,CPT,87662,Zika virus dna/rna amp probe,Lab Services,Per Unit,$51.31 ,OP,51.31,51.31,,,,,,
Molina Duals,CPT,87797,Detect agent nos dna dir,Lab Services,Per Unit,$30.03 ,OP,30.03,99.13,,,,,,
Molina Duals,CPT,87798,Detect agent nos dna amp,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
Molina Duals,CPT,87799,Detect agent nos dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
Molina Duals,CPT,87800,Detect agnt mult dna direc,Lab Services,Per Unit,$43.67 ,OP,43.67,179.2,,,,,,
Molina Duals,CPT,87801,Detect agnt mult dna ampli,Lab Services,Per Unit,$70.20 ,OP,70.2,312.64,,,,,,
Molina Duals,CPT,87802,Strep b assay w/optic,Lab Services,Per Unit,$12.73 ,OP,12.73,61,,,,,,
Molina Duals,CPT,87803,Clostridium toxin a w/optic,Lab Services,Per Unit,$16.00 ,OP,16,61,,,,,,
Molina Duals,CPT,87804,Influenza assay w/optic,Lab Services,Per Unit,$16.55 ,OP,16.55,61,,,,,,
Molina Duals,CPT,87806,Hiv w/hiv1&2 antb w/optic,Lab Services,Per Unit,$32.77 ,OP,32.77,61,,,,,,
Molina Duals,CPT,87807,Rsv assay w/optic,Lab Services,Per Unit,$13.10 ,OP,13.1,53.38,,,,,,
Molina Duals,CPT,87808,Trichomonas assay w/optic,Lab Services,Per Unit,$15.29 ,OP,15.29,61,,,,,,
Molina Duals,CPT,87809,Adenovirus assay w/optic,Lab Services,Per Unit,$21.76 ,OP,21.76,53.38,,,,,,
Molina Duals,CPT,87810,Chylmd trach assay w/optic,Lab Services,Per Unit,$35.29 ,OP,35.29,53.38,,,,,,
Molina Duals,CPT,87811,Sars-cov-2 covid19 w/optic,Lab Services,Per Unit,$41.38 ,OP,41.38,41.38,,,,,,
Molina Duals,CPT,87850,N. gonorrhoeae assay w/optic,Lab Services,Per Unit,$24.56 ,OP,24.56,53.38,,,,,,
Molina Duals,CPT,87880,Strep a assay w/optic,Lab Services,Per Unit,$16.53 ,OP,16.53,61,,,,,,
Molina Duals,CPT,87899,Agent nos assay w/optic,Lab Services,Per Unit,$16.07 ,OP,16.07,61,,,,,,
Molina Duals,CPT,87900,Phenotype infect agent drug,Lab Services,Per Unit,$130.35 ,OP,130.35,518.52,,,,,,
Molina Duals,CPT,87901,Genotype dna hiv reverse t,Lab Services,Per Unit,$257.45 ,OP,257.45,"1,147.62",,,,,,
Molina Duals,CPT,87902,Genotype dna/rna hep c,Lab Services,Per Unit,$257.45 ,OP,257.45,"1,147.62",,,,,,
Molina Duals,CPT,87903,Phenotype dna hiv w/culture,Lab Services,Per Unit,$488.66 ,OP,488.66,488.66,,,,,,
Molina Duals,CPT,87904,Phenotype dna hiv w/clt add,Lab Services,Per Unit,$26.07 ,OP,26.07,26.07,,,,,,
Molina Duals,CPT,87905,Sialidase enzyme assay,Lab Services,Per Unit,$12.22 ,OP,12.22,53.38,,,,,,
Molina Duals,CPT,87906,Genotype dna/rna hiv,Lab Services,Per Unit,$128.73 ,OP,128.73,128.73,,,,,,
Molina Duals,CPT,87910,Genotype cytomegalovirus,Lab Services,Per Unit,$257.45 ,OP,257.45,257.45,,,,,,
Molina Duals,CPT,87912,Genotype dna hepatitis b,Lab Services,Per Unit,$257.45 ,OP,257.45,257.45,,,,,,
Molina Duals,CPT,88104,Cytopath fl nongyn smears,APC 5732,RVU Per Case,$34.63 ,OP,34.63,175.39,,,,,,
Molina Duals,CPT,88106,Cytopath fl nongyn filter,APC 5731,RVU Per Case,$25.25 ,OP,25.25,247.83,,,,,,
Molina Duals,CPT,88108,Cytopath concentrate tech,APC 5732,RVU Per Case,$34.63 ,OP,34.63,228.77,,,,,,
Molina Duals,CPT,88112,Cytopath cell enhance tech,APC 5671,RVU Per Case,$50.92 ,OP,50.92,232.58,,,,,,
Molina Duals,CPT,88120,Cytp urne 3-5 probes ea spec,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Molina Duals,CPT,88121,Cytp urine 3-5 probes cmptr,APC 5673,RVU Per Case,$298.05 ,OP,298.05,298.05,,,,,,
Molina Duals,CPT,88125,Forensic cytopathology,APC 5671,RVU Per Case,$50.92 ,OP,45.74,50.92,,,,,,
Molina Duals,CPT,88130,Sex chromatin identification,Lab Services,Per Unit,$17.98 ,OP,17.98,68.63,,,,,,
Molina Duals,CPT,88140,Sex chromatin identification,Lab Services,Per Unit,$7.99 ,OP,7.99,34.31,,,,,,
Molina Duals,CPT,88142,Cytopath c/v thin layer,Lab Services,Per Unit,$20.26 ,OP,20.26,91.51,,,,,,
Molina Duals,CPT,88143,Cytopath c/v thin layer redo,Lab Services,Per Unit,$23.04 ,OP,23.04,91.51,,,,,,
Molina Duals,CPT,88147,Cytopath c/v automated,Lab Services,Per Unit,$50.56 ,OP,45.74,50.56,,,,,,
Molina Duals,CPT,88148,Cytopath c/v auto rescreen,Lab Services,Per Unit,$16.00 ,OP,16,45.74,,,,,,
Molina Duals,CPT,88150,Cytopath c/v manual,Lab Services,Per Unit,$15.15 ,OP,15.15,45.74,,,,,,
Molina Duals,CPT,88152,Cytopath c/v auto redo,Lab Services,Per Unit,$27.64 ,OP,27.64,45.74,,,,,,
Molina Duals,CPT,88153,Cytopath c/v redo,Lab Services,Per Unit,$24.03 ,OP,24.03,45.74,,,,,,
Molina Duals,CPT,88155,Cytopath c/v index add-on,Lab Services,Per Unit,$14.65 ,OP,14.65,26.7,,,,,,
Molina Duals,CPT,88160,Cytopath smear other source,APC 5731,RVU Per Case,$25.25 ,OP,25.25,141.07,,,,,,
Molina Duals,CPT,88161,Cytopath smear other source,APC 5731,RVU Per Case,$25.25 ,OP,25.25,152.51,,,,,,
Molina Duals,CPT,88162,Cytopath smear other source,APC 5671,RVU Per Case,$50.92 ,OP,50.92,205.88,,,,,,
Molina Duals,CPT,88164,Cytopath tbs c/v manual,Lab Services,Per Unit,$15.15 ,OP,15.15,45.74,,,,,,
Molina Duals,CPT,88165,Cytopath tbs c/v redo,Lab Services,Per Unit,$42.22 ,OP,42.22,45.74,,,,,,
Molina Duals,CPT,88166,Cytopath tbs c/v auto redo,Lab Services,Per Unit,$15.15 ,OP,15.15,45.74,,,,,,
Molina Duals,CPT,88167,Cytopath tbs c/v select,Lab Services,Per Unit,$15.15 ,OP,15.15,45.74,,,,,,
Molina Duals,CPT,88172,Cytp dx eval fna 1st ea site,APC 5672,RVU Per Case,$152.64 ,OP,118.19,152.64,,,,,,
Molina Duals,CPT,88173,Cytopath eval fna report,APC 5671,RVU Per Case,$50.92 ,OP,50.92,327.9,,,,,,
Molina Duals,CPT,88174,Cytopath c/v auto in fluid,Lab Services,Per Unit,$25.37 ,OP,25.37,95.32,,,,,,
Molina Duals,CPT,88175,Cytopath c/v auto fluid redo,Lab Services,Per Unit,$26.61 ,OP,26.61,118.19,,,,,,
Molina Duals,CPT,88182,Cell marker study,APC 5671,RVU Per Case,$50.92 ,OP,50.92,339.33,,,,,,
Molina Duals,CPT,88184,Flowcytometry/ tc 1 marker,APC 5673,RVU Per Case,$298.05 ,OP,298.05,404.14,,,,,,
Molina Duals,CPT,88199,Cytopathology procedure,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Molina Duals,CPT,88230,Tissue culture lymphocyte,Lab Services,Per Unit,$116.49 ,OP,116.49,518.52,,,,,,
Molina Duals,CPT,88233,Tissue culture skin/biopsy,Lab Services,Per Unit,$140.73 ,OP,140.73,625.29,,,,,,
Molina Duals,CPT,88235,Tissue culture placenta,Lab Services,Per Unit,$150.30 ,OP,150.3,655.78,,,,,,
Molina Duals,CPT,88237,Tissue culture bone marrow,Lab Services,Per Unit,$143.75 ,OP,143.75,564.29,,,,,,
Molina Duals,CPT,88239,Tissue culture tumor,Lab Services,Per Unit,$147.52 ,OP,147.52,655.78,,,,,,
Molina Duals,CPT,88240,Cell cryopreserve/storage,Lab Services,Per Unit,$13.07 ,OP,13.07,45.74,,,,,,
Molina Duals,CPT,88241,Frozen cell preparation,Lab Services,Per Unit,$12.09 ,OP,12.09,45.74,,,,,,
Molina Duals,CPT,88245,Chromosome analysis 20-25,Lab Services,Per Unit,$173.17 ,OP,173.17,648.16,,,,,,
Molina Duals,CPT,88248,Chromosome analysis 50-100,Lab Services,Per Unit,$173.17 ,OP,173.17,770.16,,,,,,
Molina Duals,CPT,88249,Chromosome analysis 100,Lab Services,Per Unit,$173.17 ,OP,173.17,770.16,,,,,,
Molina Duals,CPT,88261,Chromosome analysis 5,Lab Services,Per Unit,$264.34 ,OP,264.34,785.42,,,,,,
Molina Duals,CPT,88262,Chromosome analysis 15-20,Lab Services,Per Unit,$125.49 ,OP,125.49,556.65,,,,,,
Molina Duals,CPT,88263,Chromosome analysis 45,Lab Services,Per Unit,$150.29 ,OP,150.29,671.03,,,,,,
Molina Duals,CPT,88264,Chromosome analysis 20-25,Lab Services,Per Unit,$144.61 ,OP,144.61,556.65,,,,,,
Molina Duals,CPT,88267,Chromosome analys placenta,Lab Services,Per Unit,$188.57 ,OP,188.57,800.67,,,,,,
Molina Duals,CPT,88269,Chromosome analys amniotic,Lab Services,Per Unit,$173.66 ,OP,173.66,739.67,,,,,,
Molina Duals,CPT,88271,Cytogenetics dna probe,Lab Services,Per Unit,$21.42 ,OP,21.42,64.82,,,,,,
Molina Duals,CPT,88272,Cytogenetics 3-5,Lab Services,Per Unit,$40.70 ,OP,40.7,114.39,,,,,,
Molina Duals,CPT,88273,Cytogenetics 10-30,Lab Services,Per Unit,$34.81 ,OP,34.81,144.88,,,,,,
Molina Duals,CPT,88274,Cytogenetics 25-99,Lab Services,Per Unit,$42.38 ,OP,42.38,156.32,,,,,,
Molina Duals,CPT,88275,Cytogenetics 100-300,Lab Services,Per Unit,$51.19 ,OP,51.19,179.2,,,,,,
Molina Duals,CPT,88280,Chromosome karyotype study,Lab Services,Per Unit,$33.47 ,OP,33.47,110.57,,,,,,
Molina Duals,CPT,88283,Chromosome banding study,Lab Services,Per Unit,$68.60 ,OP,68.6,68.6,,,,,,
Molina Duals,CPT,88285,Chromosome count additional,Lab Services,Per Unit,$26.91 ,OP,26.91,83.87,,,,,,
Molina Duals,CPT,88289,Chromosome study additional,Lab Services,Per Unit,$34.43 ,OP,34.43,129.64,,,,,,
Molina Duals,CPT,88299,Cytogenetic study,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Molina Duals,CPT,88300,Surgical path gross,APC 5731,RVU Per Case,$25.25 ,OP,25.25,99.13,,,,,,
Molina Duals,CPT,88302,Tissue exam by pathologist,APC 5731,RVU Per Case,$25.25 ,OP,25.25,217.32,,,,,,
Molina Duals,CPT,88304,Tissue exam by pathologist,APC 5671,RVU Per Case,$50.92 ,OP,50.92,263.08,,,,,,
Molina Duals,CPT,88305,Tissue exam by pathologist,APC 5671,RVU Per Case,$50.92 ,OP,50.92,362.21,,,,,,
Molina Duals,CPT,88307,Tissue exam by pathologist,APC 5673,RVU Per Case,$298.05 ,OP,298.05,671.03,,,,,,
Molina Duals,CPT,88309,Tissue exam by pathologist,APC 5674,RVU Per Case,$671.45 ,OP,671.45,911.23,,,,,,
Molina Duals,CPT,88312,Special stains group 1,APC 5671,RVU Per Case,$50.92 ,OP,50.92,366.02,,,,,,
Molina Duals,CPT,88313,Special stains group 2,APC 5732,RVU Per Case,$34.63 ,OP,34.63,308.83,,,,,,
Molina Duals,CPT,88319,Enzyme histochemistry,APC 5674,RVU Per Case,$671.45 ,OP,568.09,671.45,,,,,,
Molina Duals,CPT,88321,Microslide consultation,APC 5732,RVU Per Case,$34.63 ,OP,34.63,438.47,,,,,,
Molina Duals,CPT,88323,Microslide consultation,APC 5671,RVU Per Case,$50.92 ,OP,50.92,289.76,,,,,,
Molina Duals,CPT,88325,Comprehensive review of data,APC 5672,RVU Per Case,$152.64 ,OP,152.64,949.36,,,,,,
Molina Duals,CPT,88329,Path consult introp,APC 5732,RVU Per Case,$34.63 ,OP,34.63,247.83,,,,,,
Molina Duals,CPT,88331,Path consult intraop 1 bloc,APC 5672,RVU Per Case,$152.64 ,OP,152.51,152.64,,,,,,
Molina Duals,CPT,88333,Intraop cyto path consult 1,APC 5674,RVU Per Case,$671.45 ,OP,163.95,671.45,,,,,,
Molina Duals,CPT,88342,Immunohisto antb 1st stain,APC 5672,RVU Per Case,$152.64 ,OP,152.64,297.39,,,,,,
Molina Duals,CPT,88344,Immunohisto antibody slide,APC 5673,RVU Per Case,$298.05 ,OP,297.39,298.05,,,,,,
Molina Duals,CPT,88346,Immunofluor antb 1st stain,APC 5673,RVU Per Case,$298.05 ,OP,293.57,298.05,,,,,,
Molina Duals,CPT,88348,Electron microscopy,APC 5674,RVU Per Case,$671.45 ,OP,671.45,"2,794.70",,,,,,
Molina Duals,CPT,88355,Analysis skeletal muscle,APC 5672,RVU Per Case,$152.64 ,OP,152.64,777.79,,,,,,
Molina Duals,CPT,88356,Analysis nerve,APC 5671,RVU Per Case,$50.92 ,OP,50.92,766.35,,,,,,
Molina Duals,CPT,88358,Analysis tumor,APC 5672,RVU Per Case,$152.64 ,OP,152.64,171.58,,,,,,
Molina Duals,CPT,88360,Tumor immunohistochem/manual,APC 5672,RVU Per Case,$152.64 ,OP,152.64,335.53,,,,,,
Molina Duals,CPT,88361,Tumor immunohistochem/comput,APC 5673,RVU Per Case,$298.05 ,OP,298.05,484.22,,,,,,
Molina Duals,CPT,88362,Nerve teasing preparations,APC 5674,RVU Per Case,$671.45 ,OP,671.45,793.05,,,,,,
Molina Duals,CPT,88363,Xm archive tissue molec anal,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Molina Duals,CPT,88365,Insitu hybridization (fish),APC 5672,RVU Per Case,$152.64 ,OP,152.64,499.47,,,,,,
Molina Duals,CPT,88366,Insitu hybridization (fish),APC 5673,RVU Per Case,$298.05 ,OP,298.05,499.47,,,,,,
Molina Duals,CPT,88367,Insitu hybridization auto,APC 5673,RVU Per Case,$298.05 ,OP,298.05,907.42,,,,,,
Molina Duals,CPT,88368,Insitu hybridization manual,APC 5673,RVU Per Case,$298.05 ,OP,298.05,747.28,,,,,,
Molina Duals,CPT,88374,M/phmtrc alys ishquant/semiq,APC 5672,RVU Per Case,$152.64 ,OP,152.64,907.42,,,,,,
Molina Duals,CPT,88377,M/phmtrc alys ishquant/semiq,APC 5672,RVU Per Case,$152.64 ,OP,152.64,747.28,,,,,,
Molina Duals,CPT,88399,Surgical pathology procedure,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Molina Duals,CPT,88720,Bilirubin total transcut,Lab Services,Per Unit,$5.02 ,OP,5.02,22.88,,,,,,
Molina Duals,CPT,88738,Hgb quant transcutaneous,Lab Services,Per Unit,$5.02 ,OP,5.02,5.02,,,,,,
Molina Duals,CPT,88740,Transcutaneous carboxyhb,Lab Services,Per Unit,$9.37 ,OP,9.37,22.88,,,,,,
Molina Duals,CPT,88741,Transcutaneous methb,Lab Services,Per Unit,$9.37 ,OP,9.37,22.88,,,,,,
Molina Duals,CPT,89049,Chct for mal hyperthermia,APC 5672,RVU Per Case,$152.64 ,OP,152.64,"1,201.00",,,,,,
Molina Duals,CPT,89050,Body fluid cell count,Lab Services,Per Unit,$4.72 ,OP,4.72,22.88,,,,,,
Molina Duals,CPT,89051,Body fluid cell count,Lab Services,Per Unit,$5.60 ,OP,5.6,26.7,,,,,,
Molina Duals,CPT,89055,Leukocyte assessment fecal,Lab Services,Per Unit,$4.27 ,OP,4.27,22.88,,,,,,
Molina Duals,CPT,89060,Exam synovial fluid crystals,Lab Services,Per Unit,$7.33 ,OP,7.33,30.51,,,,,,
Molina Duals,CPT,89125,Specimen fat stain,Lab Services,Per Unit,$5.88 ,OP,5.88,11.44,,,,,,
Molina Duals,CPT,89160,Exam feces for meat fibers,Lab Services,Per Unit,$4.85 ,OP,4.85,15.26,,,,,,
Molina Duals,CPT,89190,Nasal smear for eosinophils,Lab Services,Per Unit,$5.79 ,OP,5.79,22.88,,,,,,
Molina Duals,CPT,89220,Sputum specimen collection,APC 5672,RVU Per Case,$152.64 ,OP,80.07,152.64,,,,,,
Molina Duals,CPT,89230,Collect sweat for test,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Molina Duals,CPT,89240,Pathology lab procedure,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Molina Duals,CPT,89250,Cultr oocyte/embryo <4 days,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Molina Duals,CPT,89251,Cultr oocyte/embryo <4 days,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Molina Duals,CPT,89253,Embryo hatching,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Molina Duals,CPT,89254,Oocyte identification,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Molina Duals,CPT,89255,Prepare embryo for transfer,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Molina Duals,CPT,89257,Sperm identification,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Molina Duals,CPT,89258,Cryopreservation embryo(s),APC 5674,RVU Per Case,$671.45 ,OP,671.45,671.45,,,,,,
Molina Duals,CPT,89259,Cryopreservation sperm,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Molina Duals,CPT,89260,Sperm isolation simple,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Molina Duals,CPT,89261,Sperm isolation complex,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Molina Duals,CPT,89264,Identify sperm tissue,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Molina Duals,CPT,89268,Insemination of oocytes,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Molina Duals,CPT,89272,Extended culture of oocytes,APC 5674,RVU Per Case,$671.45 ,OP,671.45,671.45,,,,,,
Molina Duals,CPT,89280,Assist oocyte fertilization,APC 5674,RVU Per Case,$671.45 ,OP,671.45,671.45,,,,,,
Molina Duals,CPT,89281,Assist oocyte fertilization,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Molina Duals,CPT,89290,Biopsy oocyte polar body,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Molina Duals,CPT,89291,Biopsy oocyte polar body,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Molina Duals,CPT,89300,Semen analysis w/huhner,Lab Services,Per Unit,$9.84 ,OP,9.84,45.74,,,,,,
Molina Duals,CPT,89310,Semen analysis w/count,Lab Services,Per Unit,$8.61 ,OP,8.61,30.51,,,,,,
Molina Duals,CPT,89320,Semen anal vol/count/mot,Lab Services,Per Unit,$12.31 ,OP,12.31,49.56,,,,,,
Molina Duals,CPT,89321,Semen anal sperm detection,Lab Services,Per Unit,$12.05 ,OP,12.05,49.56,,,,,,
Molina Duals,CPT,89322,Semen anal strict criteria,Lab Services,Per Unit,$15.50 ,OP,15.5,61,,,,,,
Molina Duals,CPT,89325,Sperm antibody test,Lab Services,Per Unit,$10.67 ,OP,10.67,10.67,,,,,,
Molina Duals,CPT,89329,Sperm evaluation test,Lab Services,Per Unit,$19.59 ,OP,19.59,91.51,,,,,,
Molina Duals,CPT,89330,Evaluation cervical mucus,Lab Services,Per Unit,$10.38 ,OP,10.38,45.74,,,,,,
Molina Duals,CPT,89331,Retrograde ejaculation anal,Lab Services,Per Unit,$19.59 ,OP,19.59,83.87,,,,,,
Molina Duals,CPT,89335,Cryopreserve testicular tiss,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Molina Duals,CPT,89337,Cryopreservation oocyte(s),APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Molina Duals,CPT,89342,Storage/year embryo(s),APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Molina Duals,CPT,89343,Storage/year sperm/semen,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Molina Duals,CPT,89344,Storage/year reprod tissue,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Molina Duals,CPT,89346,Storage/year oocyte(s),APC 5673,RVU Per Case,$298.05 ,OP,298.05,298.05,,,,,,
Molina Duals,CPT,89352,Thawing cryopresrved embryo,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Molina Duals,CPT,89353,Thawing cryopresrved sperm,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Molina Duals,CPT,89354,Thaw cryoprsvrd reprod tiss,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Molina Duals,CPT,89356,Thawing cryopresrved oocyte,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
Molina Duals,CPT,89398,Unlisted reprod med lab proc,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Molina Duals,CPT,90371,Hep b ig im,APC 1630,Per Unit,$130.31 ,OP,130.31,735.85,,,,,,
Molina Duals,CPT,90375,Rabies ig im/sc,APC 9133,Per Unit,$267.30 ,OP,267.3,617.65,,,,,,
Molina Duals,CPT,90376,Rabies ig heat treated,APC 9134,Per Unit,$287.38 ,OP,287.38,617.65,,,,,,
Molina Duals,CPT,90378,Rsv mab im 50mg,APC 9003,Per Unit,"$1,185.67 ",OP,"1,185.67","3,154.20",,,,,,
Molina Duals,CPT,90385,Rh ig minidose im,APC 9063,Per Unit,$151.41 ,OP,151.41,202.07,,,,,,
Molina Duals,CPT,90396,Varicella-zoster ig im,APC 9135,Per Unit,"$1,965.97 ",OP,495.65,"1,965.97",,,,,,
Molina Duals,CPT,90471,Immunization admin,APC 5692,RVU Per Case,$63.42 ,OP,57.19,63.42,,,,,,
Molina Duals,CPT,90473,Immune admin oral/nasal,APC 5692,RVU Per Case,$63.42 ,OP,57.19,63.42,,,,,,
Molina Duals,CPT,90630,Flu vacc iiv4 no preserv id,Other,Straight Discount,29.70%,OP,,,,,,,,
Molina Duals,CPT,90653,Iiv adjuvant vaccine im,Other,Straight Discount,29.70%,OP,,,,,,,,
Molina Duals,CPT,90654,Flu vacc iiv3 no preserv id,Other,Straight Discount,29.70%,OP,,,,,,,,
Molina Duals,CPT,90655,Iiv3 vacc no prsv 0.25 ml im,Other,Straight Discount,29.70%,OP,68.63,68.63,,,,,,
Molina Duals,CPT,90656,Iiv3 vacc no prsv 0.5 ml im,Other,Straight Discount,29.70%,OP,76.26,76.26,,,,,,
Molina Duals,CPT,90657,Iiv3 vaccine splt 0.25 ml im,Other,Straight Discount,29.70%,OP,110.57,110.57,,,,,,
Molina Duals,CPT,90660,Laiv3 vaccine intranasal,Other,Straight Discount,29.70%,OP,122,122,,,,,,
Molina Duals,CPT,90661,Cciiv3 vac no prsv 0.5 ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Molina Duals,CPT,90662,Iiv no prsv increased ag im,Other,Straight Discount,29.70%,OP,,,,,,,,
Molina Duals,CPT,90670,Pcv13 vaccine im,Other,Straight Discount,29.70%,OP,,,,,,,,
Molina Duals,CPT,90672,Laiv4 vaccine intranasal,Other,Straight Discount,29.70%,OP,,,,,,,,
Molina Duals,CPT,90673,Riv3 vaccine no preserv im,Other,Straight Discount,29.70%,OP,,,,,,,,
Molina Duals,CPT,90674,Cciiv4 vac no prsv 0.5 ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Molina Duals,CPT,90675,Rabies vaccine im,APC 9139,Per Unit,$327.53 ,OP,327.53,945.56,,,,,,
Molina Duals,CPT,90676,Rabies vaccine id,APC 9140,Per Unit,$189.63 ,OP,189.63,945.56,,,,,,
Molina Duals,CPT,90677,Pcv20 vaccine im,Other,Straight Discount,29.70%,OP,,,,,,,,
Molina Duals,CPT,90682,Riv4 vacc recombinant dna im,Other,Straight Discount,29.70%,OP,,,,,,,,
Molina Duals,CPT,90685,Iiv4 vacc no prsv 0.25 ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Molina Duals,CPT,90686,Iiv4 vacc no prsv 0.5 ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Molina Duals,CPT,90687,Iiv4 vaccine splt 0.25 ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Molina Duals,CPT,90688,Iiv4 vaccine splt 0.5 ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Molina Duals,CPT,90689,Vacc iiv4 no prsrv 0.25ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Molina Duals,CPT,90694,Vacc aiiv4 no prsrv 0.5ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Molina Duals,CPT,90732,Ppsv23 vacc 2 yrs+ subq/im,Other,Straight Discount,29.70%,OP,228.77,228.77,,,,,,
Molina Duals,CPT,90739,Hepb vacc 2 dose adult im,Other,Straight Discount,29.70%,OP,,,,,,,,
Molina Duals,CPT,90740,Hepb vacc 3 dose immunsup im,Other,Straight Discount,29.70%,OP,"1,029.43","1,029.43",,,,,,
Molina Duals,CPT,90743,Hepb vacc 2 dose adolesc im,Other,Straight Discount,29.70%,OP,141.07,141.07,,,,,,
Molina Duals,CPT,90744,Hepb vacc 3 dose ped/adol im,Other,Straight Discount,29.70%,OP,141.07,141.07,,,,,,
Molina Duals,CPT,90746,Hepb vaccine 3 dose adult im,Other,Straight Discount,29.70%,OP,369.83,369.83,,,,,,
Molina Duals,CPT,90747,Hepb vacc 4 dose immunsup im,Other,Straight Discount,29.70%,OP,"1,029.43","1,029.43",,,,,,
Molina Duals,CPT,90756,Cciiv4 vacc abx free im,Other,Straight Discount,29.70%,OP,,,,,,,,
Molina Duals,CPT,90791,Psych diagnostic evaluation,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,789.23,,,,,,
Molina Duals,CPT,90792,Psych diag eval w/med srvcs,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,789.23,,,,,,
Molina Duals,CPT,90832,Psytx w pt 30 minutes,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,331.7,,,,,,
Molina Duals,CPT,90834,Psytx w pt 45 minutes,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,480.4,,,,,,
Molina Duals,CPT,90837,Psytx w pt 60 minutes,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,705.35,,,,,,
Molina Duals,CPT,90839,Psytx crisis initial 60 min,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,136.74,,,,,,
Molina Duals,CPT,90845,Psychoanalysis,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,423.22,,,,,,
Molina Duals,CPT,90846,Family psytx w/o pt 50 min,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,449.9,,,,,,
Molina Duals,CPT,90847,Family psytx w/pt 50 min,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,583.35,,,,,,
Molina Duals,CPT,90849,Multiple family group psytx,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,171.58,,,,,,
Molina Duals,CPT,90853,Group psychotherapy,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,368.97,,,,,,
Molina Duals,CPT,90865,Narcosynthesis,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,808.29,,,,,,
Molina Duals,CPT,90867,Tcranial magn stim tx plan,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Molina Duals,CPT,90868,Tcranial magn stim tx deli,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Molina Duals,CPT,90869,Tcran magn stim redetemine,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Molina Duals,CPT,90870,Electroconvulsive therapy,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,709.16,,,,,,
Molina Duals,CPT,90880,Hypnotherapy,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,545.21,,,,,,
Molina Duals,CPT,90899,Psychiatric service/therapy,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Molina Duals,CPT,90901,Biofeedback train any meth,Physician,Per Unit,$19.59 ,OP,19.59,19.59,,,,,,
Molina Duals,CPT,90912,Bfb training 1st 15 min,Physician,Per Unit,$43.33 ,OP,43.33,476.6,,,,,,
Molina Duals,CPT,90913,Bfb training ea addl 15 min,Physician,Per Unit,$24.51 ,OP,24.51,264.78,,,,,,
Molina Duals,CPT,90935,Hemodialysis one evaluation,APC 5401,RVU Per Unit,$669.60 ,OP,373.65,669.6,,,,,,
Molina Duals,CPT,90945,Dialysis one evaluation,APC 5024,RVU Per Unit,$372.22 ,OP,372.22,388.89,,,,,,
Molina Duals,CPT,91010,Esophagus motility study,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Molina Duals,CPT,91020,Gastric motility studies,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,"1,265.81",,,,,,
Molina Duals,CPT,91022,Duodenal motility study,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,"1,044.69",,,,,,
Molina Duals,CPT,91030,Acid perfusion of esophagus,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,754.91,,,,,,
Molina Duals,CPT,91034,Gastroesophageal reflux test,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Molina Duals,CPT,91035,G-esoph reflx tst w/electrod,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Molina Duals,CPT,91037,Esoph imped function test,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Molina Duals,CPT,91038,Esoph imped funct test > 1hr,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Molina Duals,CPT,91040,Esoph balloon distension tst,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Molina Duals,CPT,91065,Breath hydrogen/methane test,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Molina Duals,CPT,91110,Gi tract capsule endoscopy,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,828.48,,,,,,
Molina Duals,CPT,91111,Esophageal capsule endoscopy,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,828.48,,,,,,
Molina Duals,CPT,91112,Gi wireless capsule measure,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,828.48,,,,,,
Molina Duals,CPT,91117,Colon motility 6 hr study,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,272.35,,,,,,
Molina Duals,CPT,91120,Rectal sensation test,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Molina Duals,CPT,91122,Anal pressure record,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,272.35,,,,,,
Molina Duals,CPT,91132,Electrogastrography,APC 5722,RVU Per Unit,$270.61 ,OP,244.01,270.61,,,,,,
Molina Duals,CPT,91133,Electrogastrography w/test,APC 5734,RVU Per Case,$114.56 ,OP,114.56,312.64,,,,,,
Molina Duals,CPT,91200,Liver elastography,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
Molina Duals,CPT,91299,Gastroenterology procedure,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Molina Duals,CPT,91300,Sarscov2 vac 30mcg/0.3ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Molina Duals,CPT,91301,Sarscov2 vac 100mcg/0.5ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Molina Duals,CPT,91303,Sarscov2 vac ad26 .5ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
Molina Duals,CPT,92002,Eye exam new patient,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,354.58,,,,,,
Molina Duals,CPT,92004,Eye exam new patient,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,663.41,,,,,,
Molina Duals,CPT,92012,Eye exam establish patient,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,373.65,,,,,,
Molina Duals,CPT,92014,Eye exam&tx estab pt 1/>vst,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,545.21,,,,,,
Molina Duals,CPT,92018,New eye exam & treatment,APC 5503,RVU Per Case,"$2,049.05 ",OP,671.03,"2,049.05",,,,,,
Molina Duals,CPT,92019,Eye exam & treatment,APC 5503,RVU Per Case,"$2,049.05 ",OP,331.7,"2,049.05",,,,,,
Molina Duals,CPT,92020,Special eye evaluation,APC 5734,RVU Per Case,$114.56 ,OP,114.56,125.82,,,,,,
Molina Duals,CPT,92025,Corneal topography,APC 5733,RVU Per Case,$56.95 ,OP,56.95,167.76,,,,,,
Molina Duals,CPT,92060,Special eye evaluation,APC 5733,RVU Per Case,$56.95 ,OP,56.95,285.96,,,,,,
Molina Duals,CPT,92065,Orthoptic/pleoptic training,APC 5733,RVU Per Case,$56.95 ,OP,56.95,224.95,,,,,,
Molina Duals,CPT,92081,Visual field examination(s),APC 5733,RVU Per Case,$56.95 ,OP,56.95,255.45,,,,,,
Molina Duals,CPT,92082,Visual field examination(s),APC 5733,RVU Per Case,$56.95 ,OP,56.95,339.33,,,,,,
Molina Duals,CPT,92083,Visual field examination(s),APC 5734,RVU Per Case,$114.56 ,OP,114.56,385.09,,,,,,
Molina Duals,CPT,92132,Cmptr ophth dx img ant segmt,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Molina Duals,CPT,92133,Cmptr ophth img optic nerve,APC 5733,RVU Per Case,$56.95 ,OP,56.95,224.95,,,,,,
Molina Duals,CPT,92134,Cptr ophth dx img post segmt,APC 5733,RVU Per Case,$56.95 ,OP,56.95,224.95,,,,,,
Molina Duals,CPT,92136,Ophthalmic biometry,APC 5734,RVU Per Case,$114.56 ,OP,114.56,411.78,,,,,,
Molina Duals,CPT,92145,Corneal hysteresis deter,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Molina Duals,CPT,92201,Opscpy extnd rta draw uni/bi,APC 5733,RVU Per Case,$56.95 ,OP,56.95,118.19,,,,,,
Molina Duals,CPT,92202,Opscpy extnd on/mac draw,APC 5733,RVU Per Case,$56.95 ,OP,56.95,76.37,,,,,,
Molina Duals,CPT,92227,Img rta detcj/mntr ds staff,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Molina Duals,CPT,92228,Img rta detc/mntr ds phy/qhp,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Molina Duals,CPT,92229,Img rta detc/mntr ds poc aly,APC 5733,RVU Per Unit,$56.95 ,OP,56.95,56.95,,,,,,
Molina Duals,CPT,92230,Eye exam with photos,APC 5723,RVU Per Case,$499.16 ,OP,289.76,499.16,,,,,,
Molina Duals,CPT,92235,Fluorescein angrph uni/bi,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,629.1,,,,,,
Molina Duals,CPT,92240,Icg angiography uni/bi,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,162.87",,,,,,
Molina Duals,CPT,92242,Fluorescein icg angiography,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,791.98",,,,,,
Molina Duals,CPT,92250,Eye exam with photos,APC 5734,RVU Per Case,$114.56 ,OP,114.56,346.96,,,,,,
Molina Duals,CPT,92260,Ophthalmoscopy/dynamometry,APC 5732,RVU Per Case,$34.63 ,OP,34.63,87.69,,,,,,
Molina Duals,CPT,92265,Eye muscle evaluation,APC 5733,RVU Per Case,$56.95 ,OP,56.95,381.27,,,,,,
Molina Duals,CPT,92270,Electro-oculography,APC 5734,RVU Per Case,$114.56 ,OP,114.56,438.47,,,,,,
Molina Duals,CPT,92273,Full field erg w/i&r,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,648.16,,,,,,
Molina Duals,CPT,92274,Multifocal erg w/i&r,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,386.03,,,,,,
Molina Duals,CPT,92283,Color vision examination,APC 5733,RVU Per Case,$56.95 ,OP,56.95,224.95,,,,,,
Molina Duals,CPT,92284,Dark adaptation eye exam,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
Molina Duals,CPT,92285,Eye photography,APC 5733,RVU Per Case,$56.95 ,OP,56.95,205.88,,,,,,
Molina Duals,CPT,92286,Internal eye photography,APC 5734,RVU Per Case,$114.56 ,OP,114.56,583.35,,,,,,
Molina Duals,CPT,92287,Internal eye photography,APC 5734,RVU Per Case,$114.56 ,OP,114.56,549.03,,,,,,
Molina Duals,CPT,92311,Contact lens fitting,APC 5735,RVU Per Case,$276.53 ,OP,276.53,449.9,,,,,,
Molina Duals,CPT,92312,Contact lens fitting,APC 5734,RVU Per Case,$114.56 ,OP,114.56,510.9,,,,,,
Molina Duals,CPT,92313,Contact lens fitting,APC 5734,RVU Per Case,$114.56 ,OP,114.56,434.65,,,,,,
Molina Duals,CPT,92315,Rx cntact lens aphakia 1 eye,APC 5734,RVU Per Case,$114.56 ,OP,114.56,312.64,,,,,,
Molina Duals,CPT,92316,Rx cntact lens aphakia 2 eye,APC 5734,RVU Per Case,$114.56 ,OP,114.56,411.78,,,,,,
Molina Duals,CPT,92317,Rx corneoscleral cntact lens,APC 5732,RVU Per Case,$34.63 ,OP,34.63,324.09,,,,,,
Molina Duals,CPT,92325,Modification of contact lens,APC 5734,RVU Per Case,$114.56 ,OP,114.56,141.07,,,,,,
Molina Duals,CPT,92326,Replacement of contact lens,APC 5733,RVU Per Case,$56.95 ,OP,56.95,205.88,,,,,,
Molina Duals,CPT,92352,Fit aphakia spectcl monofocl,APC 5733,RVU Per Case,$56.95 ,OP,56.95,198.25,,,,,,
Molina Duals,CPT,92353,Fit aphakia spectcl multifoc,APC 5733,RVU Per Case,$56.95 ,OP,56.95,232.58,,,,,,
Molina Duals,CPT,92354,Fit spectacles single system,APC 5732,RVU Per Case,$34.63 ,OP,34.63,510.9,,,,,,
Molina Duals,CPT,92355,Fit spectacles compound lens,APC 5732,RVU Per Case,$34.63 ,OP,34.63,285.96,,,,,,
Molina Duals,CPT,92358,Aphakia prosth service temp,APC 5733,RVU Per Case,$56.95 ,OP,56.95,102.95,,,,,,
Molina Duals,CPT,92371,Repair & adjust spectacles,APC 5733,RVU Per Case,$56.95 ,OP,56.95,76.26,,,,,,
Molina Duals,CPT,92499,Eye service or procedure,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Molina Duals,CPT,92502,Ear and throat examination,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,526.16,,,,,,
Molina Duals,CPT,92507,Speech/hearing therapy,Physician,Per Unit,$75.75 ,OP,75.75,354.58,,,,,,
Molina Duals,CPT,92508,Speech/hearing therapy,Physician,Per Unit,$23.07 ,OP,23.07,171.58,,,,,,
Molina Duals,CPT,92511,Nasopharyngoscopy,APC 5151,RVU Per Unit,$168.23 ,OP,168.23,842.61,,,,,,
Molina Duals,CPT,92512,Nasal function studies,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,331.7,,,,,,
Molina Duals,CPT,92516,Facial nerve function test,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Molina Duals,CPT,92517,Vemp test i&r cervical,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Molina Duals,CPT,92518,Vemp test i&r ocular,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Molina Duals,CPT,92519,Vemp tst i&r cervical&ocular,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Molina Duals,CPT,92520,Laryngeal function studies,APC 5734,RVU Per Case,$114.56 ,OP,114.56,339.33,,,,,,
Molina Duals,CPT,92521,Evaluation of speech fluency,Physician,Per Unit,$132.47 ,OP,132.47,857.86,,,,,,
Molina Duals,CPT,92522,Evaluate speech production,Physician,Per Unit,$111.22 ,OP,111.22,857.86,,,,,,
Molina Duals,CPT,92523,Speech sound lang comprehen,Physician,Per Unit,$227.69 ,OP,227.69,857.86,,,,,,
Molina Duals,CPT,92524,Behavral qualit analys voice,Physician,Per Unit,$108.89 ,OP,108.89,857.86,,,,,,
Molina Duals,CPT,92526,Oral function therapy,Physician,Per Unit,$83.51 ,OP,83.51,453.71,,,,,,
Molina Duals,CPT,92537,Caloric vstblr test w/rec,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,163.95,,,,,,
Molina Duals,CPT,92538,Caloric vstblr test w/rec,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,163.95,,,,,,
Molina Duals,CPT,92540,Basic vestibular evaluation,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Molina Duals,CPT,92541,Spontaneous nystagmus test,APC 5734,RVU Per Case,$114.56 ,OP,114.56,335.53,,,,,,
Molina Duals,CPT,92542,Positional nystagmus test,APC 5734,RVU Per Case,$114.56 ,OP,114.56,346.96,,,,,,
Molina Duals,CPT,92544,Optokinetic nystagmus test,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,282.14,,,,,,
Molina Duals,CPT,92545,Oscillating tracking test,APC 5722,RVU Per Unit,$270.61 ,OP,263.08,270.61,,,,,,
Molina Duals,CPT,92546,Sinusoidal rotational test,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,468.96,,,,,,
Molina Duals,CPT,92548,Cdp-sot 6 cond w/i&r,APC 5734,RVU Per Case,$114.56 ,OP,114.56,556.65,,,,,,
Molina Duals,CPT,92549,Cdp-sot 6 cond w/i&r mct&adt,APC 5734,RVU Per Case,$114.56 ,OP,114.56,556.65,,,,,,
Molina Duals,CPT,92550,Tympanometry & reflex thresh,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
Molina Duals,CPT,92552,Pure tone audiometry air,APC 5734,RVU Per Case,$114.56 ,OP,114.56,129.64,,,,,,
Molina Duals,CPT,92553,Audiometry air & bone,APC 5721,RVU Per Case,$142.80 ,OP,142.8,175.39,,,,,,
Molina Duals,CPT,92555,Speech threshold audiometry,APC 5732,RVU Per Case,$34.63 ,OP,34.63,99.13,,,,,,
Molina Duals,CPT,92556,Speech audiometry complete,APC 5733,RVU Per Case,$56.95 ,OP,56.95,152.51,,,,,,
Molina Duals,CPT,92557,Comprehensive hearing test,APC 5721,RVU Per Case,$142.80 ,OP,142.8,278.32,,,,,,
Molina Duals,CPT,92561,Bekesy audiometry diagnosis,APC 5734,RVU Per Case,$114.56 ,OP,114.56,171.58,,,,,,
Molina Duals,CPT,92562,Loudness balance test,APC 5721,RVU Per Case,$142.80 ,OP,137.25,142.8,,,,,,
Molina Duals,CPT,92563,Tone decay hearing test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,125.82,,,,,,
Molina Duals,CPT,92564,Sisi hearing test,APC 5731,RVU Per Case,$25.25 ,OP,25.25,122,,,,,,
Molina Duals,CPT,92565,Stenger test pure tone,APC 5732,RVU Per Case,$34.63 ,OP,34.63,80.07,,,,,,
Molina Duals,CPT,92567,Tympanometry,APC 5732,RVU Per Case,$34.63 ,OP,34.63,110.57,,,,,,
Molina Duals,CPT,92568,Acoustic refl threshold tst,APC 5732,RVU Per Case,$34.63 ,OP,34.63,110.57,,,,,,
Molina Duals,CPT,92570,Acoustic immitance testing,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
Molina Duals,CPT,92571,Filtered speech hearing test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,102.95,,,,,,
Molina Duals,CPT,92572,Staggered spondaic word test,APC 5721,RVU Per Case,$142.80 ,OP,99.13,142.8,,,,,,
Molina Duals,CPT,92575,Sensorineural acuity test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,202.07,,,,,,
Molina Duals,CPT,92576,Synthetic sentence test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,129.64,,,,,,
Molina Duals,CPT,92577,Stenger test speech,APC 5723,RVU Per Case,$499.16 ,OP,114.39,499.16,,,,,,
Molina Duals,CPT,92579,Visual audiometry (vra),APC 5721,RVU Per Case,$142.80 ,OP,142.8,259.27,,,,,,
Molina Duals,CPT,92582,Conditioning play audiometry,APC 5721,RVU Per Case,$142.80 ,OP,142.8,247.83,,,,,,
Molina Duals,CPT,92583,Select picture audiometry,APC 5733,RVU Per Case,$56.95 ,OP,56.95,205.88,,,,,,
Molina Duals,CPT,92584,Electrocochleography,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,427.03,,,,,,
Molina Duals,CPT,92587,Evoked auditory test limited,APC 5722,RVU Per Unit,$270.61 ,OP,244.01,270.61,,,,,,
Molina Duals,CPT,92588,Evoked auditory tst complete,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,385.09,,,,,,
Molina Duals,CPT,92596,Ear protector evaluation,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Molina Duals,CPT,92597,Oral speech device eval,Physician,Per Unit,$70.53 ,OP,70.53,583.35,,,,,,
Molina Duals,CPT,92601,Cochlear implt f/up exam <7,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Molina Duals,CPT,92602,Reprogram cochlear implt <7,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Molina Duals,CPT,92603,Cochlear implt f/up exam 7/>,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Molina Duals,CPT,92604,Reprogram cochlear implt 7/>,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Molina Duals,CPT,92607,Ex for speech device rx 1hr,Physician,Per Unit,$122.72 ,OP,122.72,804.48,,,,,,
Molina Duals,CPT,92608,Ex for speech device rx addl,Physician,Per Unit,$49.31 ,OP,49.31,163.95,,,,,,
Molina Duals,CPT,92609,Use of speech device service,Physician,Per Unit,$102.45 ,OP,102.45,430.83,,,,,,
Molina Duals,CPT,92610,Evaluate swallowing function,Physician,Per Unit,$69.06 ,OP,69.06,423.22,,,,,,
Molina Duals,CPT,92611,Motion fluoroscopy/swallow,Physician,Per Unit,$90.57 ,OP,90.57,461.34,,,,,,
Molina Duals,CPT,92612,Endoscopy swallow (fees) vid,Physician,Per Unit,$65.56 ,OP,65.56,796.85,,,,,,
Molina Duals,CPT,92614,Laryngoscopic sensory vid,Physician,Per Unit,$64.93 ,OP,64.93,709.16,,,,,,
Molina Duals,CPT,92616,Fees w/laryngeal sense test,Physician,Per Unit,$97.82 ,OP,97.82,972.25,,,,,,
Molina Duals,CPT,92620,Auditory function 60 min,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
Molina Duals,CPT,92625,Tinnitus assessment,APC 5721,RVU Per Case,$142.80 ,OP,142.8,293.57,,,,,,
Molina Duals,CPT,92626,Eval aud funcj 1st hour,APC 5721,RVU Per Case,$142.80 ,OP,142.8,407.96,,,,,,
Molina Duals,CPT,92640,Aud brainstem implt programg,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,385.09,,,,,,
Molina Duals,CPT,92651,Aep hearing status deter i&r,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Molina Duals,CPT,92652,Aep thrshld est mlt freq i&r,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Molina Duals,CPT,92653,Aep neurodiagnostic i&r,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Molina Duals,CPT,92700,Ent procedure/service,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Molina Duals,CPT,92920,Prq cardiac angioplast 1 art,APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,92924,Prq card angio/athrect 1 art,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
Molina Duals,CPT,92928,Prq card stent w/angio 1 vsl,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Molina Duals,CPT,92933,Prq card stent/ath/angio,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Molina Duals,CPT,92937,Prq revasc byp graft 1 vsl,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Molina Duals,CPT,92941,Prq card revasc mi 1 vsl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,92943,Prq card revasc chronic 1vsl,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Molina Duals,CPT,92950,Heart/lung resuscitation cpr,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,567.02",,,,,,
Molina Duals,CPT,92953,Temporary external pacing,APC 5781,RVU Per Unit,$575.01 ,OP,575.01,575.01,,,,,,
Molina Duals,CPT,92960,Cardioversion electric ext,APC 5781,RVU Per Unit,$575.01 ,OP,575.01,"1,460.26",,,,,,
Molina Duals,CPT,92961,Cardioversion electric int,APC 5781,RVU Per Unit,$575.01 ,OP,575.01,"1,513.64",,,,,,
Molina Duals,CPT,92970,Cardioassist internal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,040.87","8,948.83",,,,,,
Molina Duals,CPT,92971,Cardioassist external,APC 5881,RVU Per Case,"$8,948.83 ",OP,590.97,"8,948.83",,,,,,
Molina Duals,CPT,92975,Dissolve clot heart vessel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"2,367.69","8,948.83",,,,,,
Molina Duals,CPT,92977,Dissolve clot heart vessel,APC 5694,RVU Per Unit,$318.00 ,OP,318,850.23,,,,,,
Molina Duals,CPT,92986,Revision of aortic valve,APC 5192,RVU Per Case,"$5,072.43 ",OP,"5,072.43","8,048.60",,,,,,
Molina Duals,CPT,92987,Revision of mitral valve,APC 5193,RVU Per Case,"$10,277.14 ",OP,"8,338.36","10,277.14",,,,,,
Molina Duals,CPT,92990,Revision of pulmonary valve,APC 5193,RVU Per Case,"$10,277.14 ",OP,"6,409.14","10,277.14",,,,,,
Molina Duals,CPT,92997,Pul art balloon repr percut,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
Molina Duals,CPT,93005,Electrocardiogram tracing,APC 5733,RVU Per Case,$56.95 ,OP,56.95,72.44,,,,,,
Molina Duals,CPT,93017,Cardiovascular stress test,APC 5722,RVU Per Case,$270.61 ,OP,270.61,362.21,,,,,,
Molina Duals,CPT,93024,Cardiac drug stress test,APC 5735,RVU Per Case,$276.53 ,OP,276.53,712.98,,,,,,
Molina Duals,CPT,93025,Microvolt t-wave assess,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,"1,246.76",,,,,,
Molina Duals,CPT,93041,Rhythm ecg tracing,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Molina Duals,CPT,93050,Art pressure waveform analys,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Molina Duals,CPT,93225,Ecg monit/reprt up to 48 hrs,APC 5734,RVU Per Case,$114.56 ,OP,114.56,224.95,,,,,,
Molina Duals,CPT,93226,Ecg monit/reprt up to 48 hrs,APC 5734,RVU Per Case,$114.56 ,OP,114.56,926.48,,,,,,
Molina Duals,CPT,93229,Remote 30 day ecg tech supp,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Molina Duals,CPT,93242,Ext ecg>48hr<7d recording,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Molina Duals,CPT,93243,Ext ecg>48hr<7d scan a/r,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Molina Duals,CPT,93246,Ext ecg>7d<15d recording,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Molina Duals,CPT,93247,Ext ecg>7d<15d scan a/r,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Molina Duals,CPT,93260,Prgrmg dev eval impltbl sys,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Molina Duals,CPT,93261,Interrogate subq defib,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Molina Duals,CPT,93270,Remote 30 day ecg rev/report,APC 5741,RVU Per Case,$38.02 ,OP,38.02,137.25,,,,,,
Molina Duals,CPT,93271,Ecg/monitoring and analysis,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,"1,281.07",,,,,,
Molina Duals,CPT,93278,Ecg/signal-averaged,APC 5733,RVU Per Case,$56.95 ,OP,56.95,251.64,,,,,,
Molina Duals,CPT,93279,Prgrmg dev eval pm/ldls pm,APC 5741,RVU Per Case,$38.02 ,OP,38.02,327.9,,,,,,
Molina Duals,CPT,93280,Pm device progr eval dual,APC 5741,RVU Per Case,$38.02 ,OP,38.02,381.27,,,,,,
Molina Duals,CPT,93281,Pm device progr eval multi,APC 5741,RVU Per Case,$38.02 ,OP,38.02,446.08,,,,,,
Molina Duals,CPT,93282,Prgrmg eval implantable dfb,APC 5741,RVU Per Case,$38.02 ,OP,38.02,415.59,,,,,,
Molina Duals,CPT,93283,Prgrmg eval implantable dfb,APC 5741,RVU Per Case,$38.02 ,OP,38.02,503.28,,,,,,
Molina Duals,CPT,93284,Prgrmg eval implantable dfb,APC 5741,RVU Per Case,$38.02 ,OP,38.02,587.16,,,,,,
Molina Duals,CPT,93285,Prgrmg dev eval scrms ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,282.14,,,,,,
Molina Duals,CPT,93288,Interrog evl pm/ldls pm ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,255.45,,,,,,
Molina Duals,CPT,93289,Interrog device eval heart,APC 5741,RVU Per Case,$38.02 ,OP,38.02,385.09,,,,,,
Molina Duals,CPT,93290,Interrog dev eval icpms ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,190.64,,,,,,
Molina Duals,CPT,93291,Interrog dev eval scrms ip,APC 5731,RVU Per Case,$25.25 ,OP,25.25,244.01,,,,,,
Molina Duals,CPT,93292,Wcd device interrogate,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Molina Duals,CPT,93293,Pm phone r-strip device eval,APC 5741,RVU Per Case,$38.02 ,OP,38.02,366.02,,,,,,
Molina Duals,CPT,93296,Rem interrog evl pm/ids,APC 5741,RVU Per Case,$38.02 ,OP,38.02,213.51,,,,,,
Molina Duals,CPT,93303,Echo transthoracic,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,292.50",,,,,,
Molina Duals,CPT,93304,Echo transthoracic,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,796.85,,,,,,
Molina Duals,CPT,93306,Tte w/doppler complete,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,593.72",,,,,,
Molina Duals,CPT,93307,Tte w/o doppler complete,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,056.11",,,,,,
Molina Duals,CPT,93308,Tte f-up or lmtd,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,667.22,,,,,,
Molina Duals,CPT,93312,Echo transesophageal,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,921.59",,,,,,
Molina Duals,CPT,93313,Echo transesophageal,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,494.15,,,,,,
Molina Duals,CPT,93315,Echo transesophageal,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,738.59",,,,,,
Molina Duals,CPT,93316,Echo transesophageal,APC 5524,RVU Per Unit,$494.15 ,OP,259.27,494.15,,,,,,
Molina Duals,CPT,93318,Echo transesophageal intraop,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,330.63",,,,,,
Molina Duals,CPT,93350,Stress tte only,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,239.13",,,,,,
Molina Duals,CPT,93351,Stress tte complete,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,635.64",,,,,,
Molina Duals,CPT,93451,Right heart cath,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Molina Duals,CPT,93452,Left hrt cath w/ventrclgrphy,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Molina Duals,CPT,93453,R&l hrt cath w/ventriclgrphy,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Molina Duals,CPT,93454,Coronary artery angio s&i,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","2,966.62",,,,,,
Molina Duals,CPT,93455,Coronary art/grft angio s&i,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","2,966.62",,,,,,
Molina Duals,CPT,93456,R hrt coronary artery angio,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Molina Duals,CPT,93457,R hrt art/grft angio,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Molina Duals,CPT,93458,L hrt artery/ventricle angio,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Molina Duals,CPT,93459,L hrt art/grft angio,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Molina Duals,CPT,93460,R&l hrt art/ventricle angio,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Molina Duals,CPT,93461,R&l hrt art/ventricle angio,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Molina Duals,CPT,93503,Insert/place heart catheter,APC 5182,RVU Per Case,"$1,438.93 ",OP,651.97,"1,438.93",,,,,,
Molina Duals,CPT,93505,Biopsy of heart lining,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,346.47",,,,,,
Molina Duals,CPT,93530,Rt heart cath congenital,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
Molina Duals,CPT,93531,R & l heart cath congenital,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","16,124.56",,,,,,
Molina Duals,CPT,93532,R & l heart cath congenital,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","16,600.26",,,,,,
Molina Duals,CPT,93533,R & l heart cath congenital,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","16,111.09",,,,,,
Molina Duals,CPT,93580,Transcath closure of asd,APC 5194,RVU Per Case,"$16,438.60 ",OP,"5,905.86","16,438.60",,,,,,
Molina Duals,CPT,93581,Transcath closure of vsd,APC 5194,RVU Per Case,"$16,438.60 ",OP,"7,739.77","16,438.60",,,,,,
Molina Duals,CPT,93582,Perq transcath closure pda,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Molina Duals,CPT,93583,Perq transcath septal reduxn,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,93590,Perq transcath cls mitral,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Molina Duals,CPT,93591,Perq transcath cls aortic,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Molina Duals,CPT,93600,Bundle of his recording,APC 5212,RVU Per Case,"$6,220.22 ",OP,"6,220.22","6,220.22",,,,,,
Molina Duals,CPT,93602,Intra-atrial recording,APC 5212,RVU Per Case,"$6,220.22 ",OP,968.43,"6,220.22",,,,,,
Molina Duals,CPT,93603,Right ventricular recording,APC 5211,RVU Per Case,"$1,138.72 ",OP,"1,117.12","1,138.72",,,,,,
Molina Duals,CPT,93610,Intra-atrial pacing,APC 5212,RVU Per Case,"$6,220.22 ",OP,"1,323.01","6,220.22",,,,,,
Molina Duals,CPT,93612,Intraventricular pacing,APC 5212,RVU Per Case,"$6,220.22 ",OP,"1,376.38","6,220.22",,,,,,
Molina Duals,CPT,93615,Esophageal recording,APC 5211,RVU Per Case,"$1,138.72 ",OP,392.7,"1,138.72",,,,,,
Molina Duals,CPT,93616,Esophageal recording,APC 5211,RVU Per Case,"$1,138.72 ",OP,"1,138.72","1,138.72",,,,,,
Molina Duals,CPT,93618,Heart rhythm pacing,APC 5211,RVU Per Case,"$1,138.72 ",OP,"1,138.72","2,367.69",,,,,,
Molina Duals,CPT,93619,Electrophysiology evaluation,APC 5212,RVU Per Case,"$6,220.22 ",OP,"4,312.16","6,220.22",,,,,,
Molina Duals,CPT,93620,Electrophysiology evaluation,APC 5212,RVU Per Case,"$6,220.22 ",OP,"5,112.83","6,220.22",,,,,,
Molina Duals,CPT,93624,Electrophysiologic study,APC 5212,RVU Per Case,"$6,220.22 ",OP,"2,051.24","6,220.22",,,,,,
Molina Duals,CPT,93642,Electrophysiology evaluation,APC 5211,RVU Per Case,"$1,138.72 ",OP,"1,138.72","2,775.65",,,,,,
Molina Duals,CPT,93650,Ablate heart dysrhythm focus,APC 5212,RVU Per Case,"$6,220.22 ",OP,"3,488.62","6,220.22",,,,,,
Molina Duals,CPT,93653,Ep & ablate supravent arrhyt,APC 5213,RVU Per Case,"$21,964.94 ",OP,"10,420.09","21,964.94",,,,,,
Molina Duals,CPT,93654,Ep & ablate ventric tachy,APC 5213,RVU Per Case,"$21,964.94 ",OP,"10,889.05","21,964.94",,,,,,
Molina Duals,CPT,93656,Tx atrial fib pulm vein isol,APC 5213,RVU Per Case,"$21,964.94 ",OP,"10,420.09","21,964.94",,,,,,
Molina Duals,CPT,93660,Tilt table evaluation,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,983.68,,,,,,
Molina Duals,CPT,93668,Peripheral vascular rehab,APC 5733,RVU Per Unit,$56.95 ,OP,56.95,99.13,,,,,,
Molina Duals,CPT,93701,Bioimpedance cv analysis,APC 5734,RVU Per Case,$114.56 ,OP,114.56,198.25,,,,,,
Molina Duals,CPT,93702,Bis xtracell fluid analysis,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Molina Duals,CPT,93724,Analyze pacemaker system,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,"1,948.29",,,,,,
Molina Duals,CPT,93740,Temperature gradient studies,APC 5721,RVU Per Case,$142.80 ,OP,57.19,142.8,,,,,,
Molina Duals,CPT,93745,Set-up cardiovert-defibrill,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,278.82,,,,,,
Molina Duals,CPT,93750,Interrogation vad in person,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,102.65,,,,,,
Molina Duals,CPT,93786,Ambl bp mntr w/sw rec only,APC 5734,RVU Per Case,$114.56 ,OP,114.56,171.58,,,,,,
Molina Duals,CPT,93788,Ambl bp mntr w/sw a/r,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Molina Duals,CPT,93797,Cardiac rehab,APC 5771,RVU Per Unit,$118.77 ,OP,102.95,118.77,,,,,,
Molina Duals,CPT,93798,Cardiac rehab/monitor,APC 5771,RVU Per Unit,$118.77 ,OP,118.77,148.69,,,,,,
Molina Duals,CPT,93799,Cardiovascular procedure,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Molina Duals,CPT,93880,Extracranial bilat study,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,239.13",,,,,,
Molina Duals,CPT,93882,Extracranial uni/ltd study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,815.92,,,,,,
Molina Duals,CPT,93886,Intracranial complete study,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,483.14",,,,,,
Molina Duals,CPT,93888,Intracranial limited study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,"1,010.37",,,,,,
Molina Duals,CPT,93890,Tcd vasoreactivity study,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,307.75",,,,,,
Molina Duals,CPT,93892,Tcd emboli detect w/o inj,APC 5522,RVU Per Case,$111.51 ,OP,111.51,"1,425.95",,,,,,
Molina Duals,CPT,93893,Tcd emboli detect w/inj,APC 5522,RVU Per Case,$111.51 ,OP,111.51,"1,422.14",,,,,,
Molina Duals,CPT,93922,Upr/l xtremity art 2 levels,APC 5734,RVU Per Case,$114.56 ,OP,114.56,594.77,,,,,,
Molina Duals,CPT,93923,Upr/lxtr art stdy 3+ lvls,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,922.67,,,,,,
Molina Duals,CPT,93924,Lwr xtr vasc stdy bilat,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,136.19",,,,,,
Molina Duals,CPT,93925,Lower extremity study,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,525.07",,,,,,
Molina Duals,CPT,93926,Lower extremity study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,976.05,,,,,,
Molina Duals,CPT,93930,Upper extremity study,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,223.88",,,,,,
Molina Duals,CPT,93931,Upper extremity study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,815.92,,,,,,
Molina Duals,CPT,93970,Extremity study,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,273.44",,,,,,
Molina Duals,CPT,93971,Extremity study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,842.61,,,,,,
Molina Duals,CPT,93975,Vascular study,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,367.82,,,,,,
Molina Duals,CPT,93976,Vascular study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,"1,082.81",,,,,,
Molina Duals,CPT,93978,Vascular study,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,197.20",,,,,,
Molina Duals,CPT,93979,Vascular study,APC 5522,RVU Per Case,$111.51 ,OP,111.51,823.54,,,,,,
Molina Duals,CPT,93980,Penile vascular study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,934.12,,,,,,
Molina Duals,CPT,93981,Penile vascular study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,667.22,,,,,,
Molina Duals,CPT,93985,Dup-scan hemo compl bi std,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,136.19",,,,,,
Molina Duals,CPT,93986,Dup-scan hemo compl uni std,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,646.72,,,,,,
Molina Duals,CPT,93990,Doppler flow testing,APC 5522,RVU Per Case,$111.51 ,OP,111.51,956.99,,,,,,
Molina Duals,CPT,93998,Noninvas vasc dx study proc,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Molina Duals,CPT,94002,Vent mgmt inpat init day,APC 5801,RVU Per Unit,$496.58 ,OP,496.58,541.4,,,,,,
Molina Duals,CPT,94003,Vent mgmt inpat subq day,APC 5801,RVU Per Unit,$496.58 ,OP,496.58,496.58,,,,,,
Molina Duals,CPT,94010,Breathing capacity test,APC 5721,RVU Per Case,$142.80 ,OP,142.8,209.7,,,,,,
Molina Duals,CPT,94011,Spirometry up to 2 yrs old,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
Molina Duals,CPT,94012,Spirmtry w/brnchdil inf-2 yr,APC 5722,RVU Per Case,$270.61 ,OP,270.61,270.61,,,,,,
Molina Duals,CPT,94013,Meas lung vol thru 2 yrs,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Molina Duals,CPT,94014,Patient recorded spirometry,APC 5735,RVU Per Case,$276.53 ,OP,276.53,301.2,,,,,,
Molina Duals,CPT,94015,Patient recorded spirometry,APC 5722,RVU Per Case,$270.61 ,OP,148.69,270.61,,,,,,
Molina Duals,CPT,94016,Review patient spirometry,Physician,Per Unit,$24.70 ,OP,24.7,152.51,,,,,,
Molina Duals,CPT,94060,Evaluation of wheezing,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,369.83,,,,,,
Molina Duals,CPT,94070,Evaluation of wheezing,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,392.7,,,,,,
Molina Duals,CPT,94150,Vital capacity test,APC 5721,RVU Per Case,$142.80 ,OP,141.07,142.8,,,,,,
Molina Duals,CPT,94200,Lung function test (mbc/mvv),APC 5733,RVU Per Case,$56.95 ,OP,56.95,144.88,,,,,,
Molina Duals,CPT,94375,Respiratory flow volume loop,APC 5722,RVU Per Case,$270.61 ,OP,232.58,270.61,,,,,,
Molina Duals,CPT,94450,Hypoxia response curve,APC 5722,RVU Per Case,$270.61 ,OP,270.61,316.46,,,,,,
Molina Duals,CPT,94452,Hast w/report,APC 5734,RVU Per Case,$114.56 ,OP,114.56,346.96,,,,,,
Molina Duals,CPT,94453,Hast w/oxygen titrate,APC 5734,RVU Per Case,$114.56 ,OP,114.56,461.34,,,,,,
Molina Duals,CPT,94610,Surfactant admin thru tube,APC 5791,RVU Per Case,$192.26 ,OP,192.26,438.47,,,,,,
Molina Duals,CPT,94617,Exercise tst brncspsm w/ecg,APC 5734,RVU Per Case,$114.56 ,OP,114.56,465.15,,,,,,
Molina Duals,CPT,94618,Pulmonary stress testing,APC 5734,RVU Per Case,$114.56 ,OP,114.56,465.15,,,,,,
Molina Duals,CPT,94619,Exercise tst brncspsm wo ecg,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Molina Duals,CPT,94621,Cardiopulm exercise testing,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,017.99",,,,,,
Molina Duals,CPT,94640,Airway inhalation treatment,APC 5791,RVU Per Case,$192.26 ,OP,87.69,192.26,,,,,,
Molina Duals,CPT,94642,Aerosol inhalation treatment,APC 5791,RVU Per Case,$192.26 ,OP,192.26,255.45,,,,,,
Molina Duals,CPT,94644,Cbt 1st hour,APC 5734,RVU Per Case,$114.56 ,OP,114.56,217.32,,,,,,
Molina Duals,CPT,94660,Pos airway pressure cpap,APC 5791,RVU Per Case,$192.26 ,OP,192.26,346.96,,,,,,
Molina Duals,CPT,94662,Neg press ventilation cnp,APC 5801,RVU Per Unit,$496.58 ,OP,221.14,496.58,,,,,,
Molina Duals,CPT,94664,Evaluate pt use of inhaler,APC 5791,RVU Per Case,$192.26 ,OP,99.13,192.26,,,,,,
Molina Duals,CPT,94667,Chest wall manipulation,APC 5734,RVU Per Case,$114.56 ,OP,114.56,137.25,,,,,,
Molina Duals,CPT,94668,Chest wall manipulation,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Molina Duals,CPT,94669,Mechanical chest wall oscill,APC 5791,RVU Per Case,$192.26 ,OP,192.26,192.26,,,,,,
Molina Duals,CPT,94680,Exhaled air analysis o2,APC 5721,RVU Per Case,$142.80 ,OP,142.8,369.83,,,,,,
Molina Duals,CPT,94681,Exhaled air analysis o2/co2,APC 5722,RVU Per Case,$270.61 ,OP,270.61,270.61,,,,,,
Molina Duals,CPT,94690,Exhaled air analysis,APC 5733,RVU Per Case,$56.95 ,OP,56.95,320.27,,,,,,
Molina Duals,CPT,94726,Pulm funct tst plethysmograp,APC 5722,RVU Per Case,$270.61 ,OP,270.61,282.14,,,,,,
Molina Duals,CPT,94727,Pulm function test by gas,APC 5721,RVU Per Case,$142.80 ,OP,142.8,221.14,,,,,,
Molina Duals,CPT,94728,Airwy resist by oscillometry,APC 5722,RVU Per Case,$270.61 ,OP,270.61,282.14,,,,,,
Molina Duals,CPT,94762,Measure blood oxygen level,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,202.07,,,,,,
Molina Duals,CPT,94772,Breath recording infant,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Molina Duals,CPT,94775,Ped home apnea rec hk-up,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Molina Duals,CPT,94776,Ped home apnea rec downld,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Molina Duals,CPT,94780,Cars/bd tst inft-12mo 60 min,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Molina Duals,CPT,94799,Pulmonary service/procedure,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
Molina Duals,CPT,95004,Percut allergy skin tests,APC 5724,RVU Per Case,$941.27 ,OP,30.51,941.27,,,,,,
Molina Duals,CPT,95012,Exhaled nitric oxide meas,APC 5732,RVU Per Case,$34.63 ,OP,34.63,102.95,,,,,,
Molina Duals,CPT,95017,Perq & icut allg test venoms,APC 5731,RVU Per Case,$25.25 ,OP,25.25,87.69,,,,,,
Molina Duals,CPT,95018,Perq&ic allg test drugs/biol,APC 5732,RVU Per Case,$34.63 ,OP,34.63,87.69,,,,,,
Molina Duals,CPT,95024,Icut allergy test drug/bug,APC 5733,RVU Per Case,$56.95 ,OP,38.13,56.95,,,,,,
Molina Duals,CPT,95027,Icut allergy titrate-airborn,APC 5731,RVU Per Case,$25.25 ,OP,25.25,26.7,,,,,,
Molina Duals,CPT,95028,Icut allergy test-delayed,APC 5732,RVU Per Case,$34.63 ,OP,34.63,57.19,,,,,,
Molina Duals,CPT,95044,Allergy patch tests,APC 5724,RVU Per Case,$941.27 ,OP,34.31,941.27,,,,,,
Molina Duals,CPT,95052,Photo patch test,APC 5733,RVU Per Case,$56.95 ,OP,38.13,56.95,,,,,,
Molina Duals,CPT,95056,Photosensitivity tests,APC 5734,RVU Per Case,$114.56 ,OP,114.56,179.2,,,,,,
Molina Duals,CPT,95060,Eye allergy tests,APC 5734,RVU Per Case,$114.56 ,OP,114.56,122,,,,,,
Molina Duals,CPT,95065,Nose allergy test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,110.57,,,,,,
Molina Duals,CPT,95070,Bronchial allergy tests,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Molina Duals,CPT,95076,Ingest challenge ini 120 min,APC 5723,RVU Per Unit,$499.16 ,OP,320.27,499.16,,,,,,
Molina Duals,CPT,95115,Immunotherapy one injection,APC 5691,RVU Per Case,$40.93 ,OP,40.93,57.19,,,,,,
Molina Duals,CPT,95117,Immunotherapy injections,APC 5691,RVU Per Case,$40.93 ,OP,40.93,68.63,,,,,,
Molina Duals,CPT,95144,Antigen therapy services,APC 5691,RVU Per Case,$40.93 ,OP,40.93,61,,,,,,
Molina Duals,CPT,95145,Antigen therapy services,APC 5691,RVU Per Case,$40.93 ,OP,40.93,80.07,,,,,,
Molina Duals,CPT,95146,Antigen therapy services,APC 5691,RVU Per Case,$40.93 ,OP,40.93,129.64,,,,,,
Molina Duals,CPT,95147,Antigen therapy services,APC 5692,RVU Per Case,$63.42 ,OP,63.42,125.82,,,,,,
Molina Duals,CPT,95148,Antigen therapy services,APC 5692,RVU Per Case,$63.42 ,OP,63.42,179.2,,,,,,
Molina Duals,CPT,95149,Antigen therapy services,APC 5692,RVU Per Case,$63.42 ,OP,63.42,232.58,,,,,,
Molina Duals,CPT,95165,Antigen therapy services,APC 5691,RVU Per Case,$40.93 ,OP,40.93,61,,,,,,
Molina Duals,CPT,95170,Antigen therapy services,APC 5691,RVU Per Case,$40.93 ,OP,40.93,49.56,,,,,,
Molina Duals,CPT,95180,Rapid desensitization,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
Molina Duals,CPT,95199,Allergy immunology services,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Molina Duals,CPT,95249,Cont gluc mntr pt prov eqp,APC 5733,RVU Per Unit,$56.95 ,OP,56.95,686.28,,,,,,
Molina Duals,CPT,95250,Cont gluc mntr phys/qhp eqp,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,686.28,,,,,,
Molina Duals,CPT,95700,Eeg cont rec w/vid eeg tech,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Molina Duals,CPT,95705,Eeg w/o vid 2-12 hr unmntr,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Molina Duals,CPT,95706,Eeg wo vid 2-12hr intmt mntr,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Molina Duals,CPT,95707,Eeg w/o vid 2-12hr cont mntr,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Molina Duals,CPT,95708,Eeg wo vid ea 12-26hr unmntr,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Molina Duals,CPT,95709,Eeg w/o vid ea 12-26hr intmt,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Molina Duals,CPT,95710,Eeg w/o vid ea 12-26hr cont,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Molina Duals,CPT,95711,Veeg 2-12 hr unmonitored,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Molina Duals,CPT,95712,Veeg 2-12 hr intmt mntr,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Molina Duals,CPT,95713,Veeg 2-12 hr cont mntr,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Molina Duals,CPT,95714,Veeg ea 12-26 hr unmntr,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Molina Duals,CPT,95715,Veeg ea 12-26hr intmt mntr,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Molina Duals,CPT,95716,Veeg ea 12-26hr cont mntr,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,941.27,,,,,,
Molina Duals,CPT,95782,Polysom <6 yrs 4/> paramtrs,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"4,472.29",,,,,,
Molina Duals,CPT,95783,Polysom <6 yrs cpap/bilvl,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"4,472.29",,,,,,
Molina Duals,CPT,95800,Slp stdy unattended,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Molina Duals,CPT,95801,Slp stdy unatnd w/anal,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Molina Duals,CPT,95803,Actigraphy testing,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Molina Duals,CPT,95805,Multiple sleep latency test,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,"2,249.49",,,,,,
Molina Duals,CPT,95806,Sleep study unatt&resp efft,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,413.8,,,,,,
Molina Duals,CPT,95807,Sleep study attended,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,"2,638.38",,,,,,
Molina Duals,CPT,95808,Polysom any age 1-3> param,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,941.27,,,,,,
Molina Duals,CPT,95810,Polysom 6/> yrs 4/> param,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"1,103.46",,,,,,
Molina Duals,CPT,95811,Polysom 6/>yrs cpap 4/> parm,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"1,103.46",,,,,,
Molina Duals,CPT,95812,Eeg 41-60 minutes,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,242.94",,,,,,
Molina Duals,CPT,95813,Eeg extnd mntr 61-119 min,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,521.26",,,,,,
Molina Duals,CPT,95816,Eeg awake and drowsy,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,139.99",,,,,,
Molina Duals,CPT,95819,Eeg awake and asleep,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,223.88",,,,,,
Molina Duals,CPT,95822,Eeg coma or sleep only,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,223.88",,,,,,
Molina Duals,CPT,95824,Eeg cerebral death only,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,503.28,,,,,,
Molina Duals,CPT,95836,Ecog impltd brn npgt <30 d,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Molina Duals,CPT,95851,Range of motion measurements,Physician,Per Unit,$7.59 ,OP,7.59,83.87,,,,,,
Molina Duals,CPT,95852,Range of motion measurements,Physician,Per Unit,$5.52 ,OP,5.52,64.82,,,,,,
Molina Duals,CPT,95857,Cholinesterase challenge,APC 5722,RVU Per Unit,$270.61 ,OP,209.7,270.61,,,,,,
Molina Duals,CPT,95860,Muscle test one limb,APC 5734,RVU Per Case,$114.56 ,OP,114.56,423.22,,,,,,
Molina Duals,CPT,95861,Muscle test 2 limbs,APC 5734,RVU Per Case,$114.56 ,OP,114.56,613.85,,,,,,
Molina Duals,CPT,95863,Muscle test 3 limbs,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,732.04,,,,,,
Molina Duals,CPT,95864,Muscle test 4 limbs,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,850.23,,,,,,
Molina Duals,CPT,95865,Muscle test larynx,APC 5734,RVU Per Case,$114.56 ,OP,114.56,439,,,,,,
Molina Duals,CPT,95866,Muscle test hemidiaphragm,APC 5721,RVU Per Case,$142.80 ,OP,142.8,480.4,,,,,,
Molina Duals,CPT,95867,Muscle test cran nerv unilat,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,369.83,,,,,,
Molina Duals,CPT,95868,Muscle test cran nerve bilat,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,503.28,,,,,,
Molina Duals,CPT,95869,Muscle test thor paraspinal,APC 5721,RVU Per Case,$142.80 ,OP,142.8,236.38,,,,,,
Molina Duals,CPT,95870,Muscle test nonparaspinal,APC 5734,RVU Per Case,$114.56 ,OP,114.56,228.77,,,,,,
Molina Duals,CPT,95872,Muscle test one fiber,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,635.69,,,,,,
Molina Duals,CPT,95875,Limb exercise test,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,364.88,,,,,,
Molina Duals,CPT,95905,Motor &/ sens nrve cndj test,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
Molina Duals,CPT,95907,Nvr cndj tst 1-2 studies,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Molina Duals,CPT,95908,Nrv cndj tst 3-4 studies,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Molina Duals,CPT,95909,Nrv cndj tst 5-6 studies,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Molina Duals,CPT,95910,Nrv cndj test 7-8 studies,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Molina Duals,CPT,95911,Nrv cndj test 9-10 studies,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Molina Duals,CPT,95912,Nrv cndj test 11-12 studies,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Molina Duals,CPT,95913,Nrv cndj test 13/> studies,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Molina Duals,CPT,95921,Autonomic nrv parasym inervj,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,282.21,,,,,,
Molina Duals,CPT,95922,Autonomic nrv adrenrg inervj,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Molina Duals,CPT,95923,Autonomic nrv syst funj test,APC 5734,RVU Per Case,$114.56 ,OP,114.56,447.55,,,,,,
Molina Duals,CPT,95924,Ans parasymp & symp w/tilt,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Molina Duals,CPT,95925,Somatosensory testing,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,461.8,,,,,,
Molina Duals,CPT,95926,Somatosensory testing,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,602.41,,,,,,
Molina Duals,CPT,95927,Somatosensory testing,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,621.47,,,,,,
Molina Duals,CPT,95928,C motor evoked uppr limbs,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,964.61,,,,,,
Molina Duals,CPT,95929,C motor evoked lwr limbs,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,"1,017.99",,,,,,
Molina Duals,CPT,95930,Visual ep test cns w/i&r,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,537.6,,,,,,
Molina Duals,CPT,95933,Blink reflex test,APC 5733,RVU Per Case,$56.95 ,OP,56.95,339.33,,,,,,
Molina Duals,CPT,95937,Neuromuscular junction test,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,305.01,,,,,,
Molina Duals,CPT,95938,Somatosensory testing,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Molina Duals,CPT,95939,C motor evoked upr&lwr limbs,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,941.27,,,,,,
Molina Duals,CPT,95943,Parasymp&symp hrt rate test,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Molina Duals,CPT,95954,Eeg monitoring/giving drugs,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,"1,277.26",,,,,,
Molina Duals,CPT,95958,Eeg monitoring/function test,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"1,982.60",,,,,,
Molina Duals,CPT,95961,Electrode stimulation brain,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"1,265.81",,,,,,
Molina Duals,CPT,95965,Meg spontaneous,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"10,992.00",,,,,,
Molina Duals,CPT,95966,Meg evoked single,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"5,455.97",,,,,,
Molina Duals,CPT,95970,Alys npgt w/o prgrmg,APC 5734,RVU Per Case,$114.56 ,OP,114.56,255.45,,,,,,
Molina Duals,CPT,95971,Alys smpl sp/pn npgt w/prgrm,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,297.39,,,,,,
Molina Duals,CPT,95972,Alys cplx sp/pn npgt w/prgrm,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,533.78,,,,,,
Molina Duals,CPT,95976,Alys smpl cn npgt prgrmg,APC 5741,RVU Per Unit,$38.02 ,OP,38.02,657.7,,,,,,
Molina Duals,CPT,95977,Alys cplx cn npgt prgrmg,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,876.92,,,,,,
Molina Duals,CPT,95981,Io anal gast n-stim subsq,APC 5734,RVU Per Case,$114.56 ,OP,114.56,144.88,,,,,,
Molina Duals,CPT,95982,Io ga n-stim subsq w/reprog,APC 5741,RVU Per Case,$38.02 ,OP,38.02,224.95,,,,,,
Molina Duals,CPT,95983,Alys brn npgt prgrmg 15 min,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,260.22,,,,,,
Molina Duals,CPT,95990,Spin/brain pump refil & main,APC 5694,RVU Per Unit,$318.00 ,OP,312.64,318,,,,,,
Molina Duals,CPT,95991,Spin/brain pump refil & main,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,453.71,,,,,,
Molina Duals,CPT,95992,Canalith repositioning proc,Physician,Per Unit,$36.73 ,OP,36.73,36.73,,,,,,
Molina Duals,CPT,95999,Neurological procedure,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
Molina Duals,CPT,96000,Motion analysis video/3d,APC 5723,RVU Per Unit,$499.16 ,OP,449.9,499.16,,,,,,
Molina Duals,CPT,96001,Motion test w/ft press meas,APC 5724,RVU Per Unit,$941.27 ,OP,526.16,941.27,,,,,,
Molina Duals,CPT,96002,Dynamic surface emg,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Molina Duals,CPT,96003,Dynamic fine wire emg,APC 5722,RVU Per Case,$270.61 ,OP,91.51,270.61,,,,,,
Molina Duals,CPT,96105,Assessment of aphasia,Physician,Per Unit,$98.92 ,OP,98.92,419.4,,,,,,
Molina Duals,CPT,96112,Devel tst phys/qhp 1st hr,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,693.9,,,,,,
Molina Duals,CPT,96116,Nubhvl xm phys/qhp 1st hr,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,518.52,,,,,,
Molina Duals,CPT,96125,Cognitive test by hc pro,Physician,Per Unit,$103.76 ,OP,103.76,510.9,,,,,,
Molina Duals,CPT,96127,Brief emotional/behav assmt,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Molina Duals,CPT,96130,Psycl tst eval phys/qhp 1st,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,438.47,,,,,,
Molina Duals,CPT,96132,Nrpsyc tst eval phys/qhp 1st,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,583.35,,,,,,
Molina Duals,CPT,96136,Psycl/nrpsyc tst phy/qhp 1st,APC 5734,RVU Per Unit,$114.56 ,OP,114.56,219.24,,,,,,
Molina Duals,CPT,96138,Psycl/nrpsyc tech 1st,APC 5735,RVU Per Unit,$276.53 ,OP,133.45,276.53,,,,,,
Molina Duals,CPT,96146,Psycl/nrpsyc tst auto result,APC 5731,RVU Per Unit,$25.25 ,OP,18.8,25.25,,,,,,
Molina Duals,CPT,96156,Hlth bhv assmt/reassessment,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,526.34,,,,,,
Molina Duals,CPT,96158,Hlth bhv ivntj indiv 1st 30,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,236.39,,,,,,
Molina Duals,CPT,96160,Pt-focused hlth risk assmt,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Molina Duals,CPT,96161,Caregiver health risk assmt,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Molina Duals,CPT,96164,Hlth bhv ivntj grp 1st 30,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,61.03,,,,,,
Molina Duals,CPT,96167,Hlth bhv ivntj fam 1st 30,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,236.39,,,,,,
Molina Duals,CPT,96360,Hydration iv infusion init,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,293.57,,,,,,
Molina Duals,CPT,96361,Hydrate iv infusion add-on,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,122.99,,,,,,
Molina Duals,CPT,96365,Ther/proph/diag iv inf init,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,354.58,,,,,,
Molina Duals,CPT,96366,Ther/proph/diag iv inf addon,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,114.39,,,,,,
Molina Duals,CPT,96367,Tx/proph/dg addl seq iv inf,APC 5692,RVU Per Unit,$63.42 ,OP,63.42,179.2,,,,,,
Molina Duals,CPT,96369,Sc ther infusion up to 1 hr,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,758.72,,,,,,
Molina Duals,CPT,96370,Sc ther infusion addl hr,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,83.87,,,,,,
Molina Duals,CPT,96371,Sc ther infusion reset pump,APC 5692,RVU Per Case,$63.42 ,OP,63.42,366.02,,,,,,
Molina Duals,CPT,96372,Ther/proph/diag inj sc/im,APC 5692,RVU Per Case,$63.42 ,OP,63.42,106.76,,,,,,
Molina Duals,CPT,96373,Ther/proph/diag inj ia,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,208.24,,,,,,
Molina Duals,CPT,96374,Ther/proph/diag inj iv push,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,278.32,,,,,,
Molina Duals,CPT,96375,Tx/pro/dx inj new drug addon,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,202.94,,,,,,
Molina Duals,CPT,96377,Applicaton on-body injector,APC 5691,RVU Per Case,$40.93 ,OP,40.93,40.93,,,,,,
Molina Duals,CPT,96379,Ther/prop/diag inj/inf proc,APC 5691,RVU Per Case,$40.93 ,OP,40.93,40.93,,,,,,
Molina Duals,CPT,96401,Chemo anti-neopl sq/im,APC 5692,RVU Per Case,$63.42 ,OP,63.42,377.46,,,,,,
Molina Duals,CPT,96402,Chemo hormon antineopl sq/im,APC 5692,RVU Per Case,$63.42 ,OP,63.42,205.88,,,,,,
Molina Duals,CPT,96405,Chemo intralesional up to 7,APC 5692,RVU Per Case,$63.42 ,OP,63.42,468.96,,,,,,
Molina Duals,CPT,96406,Chemo intralesional over 7,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,648.16,,,,,,
Molina Duals,CPT,96409,Chemo iv push sngl drug,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,629.1,,,,,,
Molina Duals,CPT,96411,Chemo iv push addl drug,APC 5692,RVU Per Unit,$63.42 ,OP,63.42,362.21,,,,,,
Molina Duals,CPT,96413,Chemo iv infusion 1 hr,APC 5694,RVU Per Unit,$318.00 ,OP,133.34,318,,,,,,
Molina Duals,CPT,96415,Chemo iv infusion addl hr,APC 5692,RVU Per Unit,$63.42 ,OP,63.42,202.07,,,,,,
Molina Duals,CPT,96416,Chemo prolong infuse w/pump,APC 5694,RVU Per Unit,$318.00 ,OP,318,926.48,,,,,,
Molina Duals,CPT,96417,Chemo iv infus each addl seq,APC 5692,RVU Per Unit,$63.42 ,OP,63.42,427.03,,,,,,
Molina Duals,CPT,96420,Chemo ia push tecnique,APC 5694,RVU Per Unit,$318.00 ,OP,318,613.85,,,,,,
Molina Duals,CPT,96422,Chemo ia infusion up to 1 hr,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,979.86,,,,,,
Molina Duals,CPT,96423,Chemo ia infuse each addl hr,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,434.65,,,,,,
Molina Duals,CPT,96425,Chemotherapy infusion method,APC 5694,RVU Per Unit,$318.00 ,OP,318,968.43,,,,,,
Molina Duals,CPT,96440,Chemotherapy intracavitary,APC 5694,RVU Per Unit,$318.00 ,OP,318,"3,339.91",,,,,,
Molina Duals,CPT,96446,Chemotx admn prtl cavity,APC 5694,RVU Per Unit,$318.00 ,OP,318,318,,,,,,
Molina Duals,CPT,96450,Chemotherapy into cns,APC 5694,RVU Per Unit,$318.00 ,OP,318,"1,159.06",,,,,,
Molina Duals,CPT,96521,Refill/maint portable pump,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,716.79,,,,,,
Molina Duals,CPT,96522,Refill/maint pump/resvr syst,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,610.03,,,,,,
Molina Duals,CPT,96523,Irrig drug delivery device,APC 5733,RVU Per Case,$56.95 ,OP,56.95,141.07,,,,,,
Molina Duals,CPT,96542,Chemotherapy injection,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,751.1,,,,,,
Molina Duals,CPT,96549,Chemotherapy unspecified,APC 5691,RVU Per Case,$40.93 ,OP,40.93,40.93,,,,,,
Molina Duals,CPT,96567,Pdt dstr prmlg les skn,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
Molina Duals,CPT,96573,Pdt dstr prmlg les phys/qhp,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
Molina Duals,CPT,96574,Dbrdmt prmlg les w/pdt,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
Molina Duals,CPT,96900,Ultraviolet light therapy,APC 5732,RVU Per Case,$34.63 ,OP,34.63,114.39,,,,,,
Molina Duals,CPT,96910,Photochemotherapy with uv-b,APC 5733,RVU Per Case,$56.95 ,OP,56.95,335.53,,,,,,
Molina Duals,CPT,96912,Photochemotherapy with uv-a,APC 5733,RVU Per Case,$56.95 ,OP,56.95,430.83,,,,,,
Molina Duals,CPT,96913,Photochemotherapy uv-a or b,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,651.97,,,,,,
Molina Duals,CPT,96920,Laser tx skin < 250 sq cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
Molina Duals,CPT,96921,Laser tx skin 250-500 sq cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
Molina Duals,CPT,96922,Laser tx skin >500 sq cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"1,307.75",,,,,,
Molina Duals,CPT,96999,Dermatological procedure,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
Molina Duals,CPT,97012,Mechanical traction therapy,Physician,Per Unit,$14.55 ,OP,14.55,68.63,,,,,,
Molina Duals,CPT,97016,Vasopneumatic device therapy,Physician,Per Unit,$11.78 ,OP,11.78,72.44,,,,,,
Molina Duals,CPT,97018,Paraffin bath therapy,Physician,Per Unit,$5.69 ,OP,5.69,5.69,,,,,,
Molina Duals,CPT,97022,Whirlpool therapy,Physician,Per Unit,$17.16 ,OP,17.16,83.87,,,,,,
Molina Duals,CPT,97024,Diathermy eg microwave,Physician,Per Unit,$6.96 ,OP,6.96,26.7,,,,,,
Molina Duals,CPT,97026,Infrared therapy,Physician,Per Unit,$6.32 ,OP,6.32,26.7,,,,,,
Molina Duals,CPT,97028,Ultraviolet therapy,Physician,Per Unit,$7.98 ,OP,7.98,7.98,,,,,,
Molina Duals,CPT,97032,Electrical stimulation,Physician,Per Unit,$14.55 ,OP,14.55,76.26,,,,,,
Molina Duals,CPT,97033,Electric current therapy,Physician,Per Unit,$19.67 ,OP,19.67,114.39,,,,,,
Molina Duals,CPT,97034,Contrast bath therapy,Physician,Per Unit,$14.42 ,OP,14.42,68.63,,,,,,
Molina Duals,CPT,97035,Ultrasound therapy,Physician,Per Unit,$14.10 ,OP,14.1,53.38,,,,,,
Molina Duals,CPT,97036,Hydrotherapy,Physician,Per Unit,$33.09 ,OP,33.09,118.19,,,,,,
Molina Duals,CPT,97110,Therapeutic exercises,Physician,Per Unit,$29.26 ,OP,29.26,133.45,,,,,,
Molina Duals,CPT,97112,Neuromuscular reeducation,Physician,Per Unit,$33.86 ,OP,33.86,137.25,,,,,,
Molina Duals,CPT,97113,Aquatic therapy/exercises,Physician,Per Unit,$36.67 ,OP,36.67,160.13,,,,,,
Molina Duals,CPT,97116,Gait training therapy,Physician,Per Unit,$29.26 ,OP,29.26,114.39,,,,,,
Molina Duals,CPT,97124,Massage therapy,Physician,Per Unit,$28.22 ,OP,28.22,106.76,,,,,,
Molina Duals,CPT,97129,Ther ivntj 1st 15 min,Physician,Per Unit,$23.04 ,OP,23.04,114.39,,,,,,
Molina Duals,CPT,97130,Ther ivntj ea addl 15 min,Physician,Per Unit,$22.35 ,OP,22.35,110.97,,,,,,
Molina Duals,CPT,97140,Manual therapy 1/> regions,Physician,Per Unit,$26.97 ,OP,26.97,122,,,,,,
Molina Duals,CPT,97150,Group therapeutic procedures,Physician,Per Unit,$17.53 ,OP,17.53,83.87,,,,,,
Molina Duals,CPT,97151,Bhv id assmt by phys/qhp,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Molina Duals,CPT,97152,Bhv id suprt assmt by 1 tech,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Molina Duals,CPT,97153,Adaptive behavior tx by tech,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Molina Duals,CPT,97154,Grp adapt bhv tx by tech,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Molina Duals,CPT,97155,Adapt behavior tx phys/qhp,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Molina Duals,CPT,97156,Fam adapt bhv tx gdn phy/qhp,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Molina Duals,CPT,97157,Mult fam adapt bhv tx gdn,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Molina Duals,CPT,97158,Grp adapt bhv tx by phy/qhp,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Molina Duals,CPT,97161,Pt eval low complex 20 min,Physician,Per Unit,$98.12 ,OP,98.12,330.81,,,,,,
Molina Duals,CPT,97162,Pt eval mod complex 30 min,Physician,Per Unit,$98.12 ,OP,98.12,331.7,,,,,,
Molina Duals,CPT,97163,Pt eval high complex 45 min,Physician,Per Unit,$98.12 ,OP,98.12,331.7,,,,,,
Molina Duals,CPT,97164,Pt re-eval est plan care,Physician,Per Unit,$66.97 ,OP,66.97,175.39,,,,,,
Molina Duals,CPT,97165,Ot eval low complex 30 min,Physician,Per Unit,$95.26 ,OP,95.26,354.58,,,,,,
Molina Duals,CPT,97166,Ot eval mod complex 45 min,Physician,Per Unit,$95.26 ,OP,95.26,354.58,,,,,,
Molina Duals,CPT,97167,Ot eval high complex 60 min,Physician,Per Unit,$95.26 ,OP,95.26,354.58,,,,,,
Molina Duals,CPT,97168,Ot re-eval est plan care,Physician,Per Unit,$64.11 ,OP,64.11,202.07,,,,,,
Molina Duals,CPT,97530,Therapeutic activities,Physician,Per Unit,$37.50 ,OP,37.5,137.25,,,,,,
Molina Duals,CPT,97533,Sensory integration,Physician,Per Unit,$57.03 ,OP,57.03,122,,,,,,
Molina Duals,CPT,97535,Self care mngment training,Physician,Per Unit,$32.44 ,OP,32.44,137.25,,,,,,
Molina Duals,CPT,97537,Community/work reintegration,Physician,Per Unit,$31.26 ,OP,31.26,125.82,,,,,,
Molina Duals,CPT,97542,Wheelchair mngment training,Physician,Per Unit,$31.58 ,OP,31.58,125.82,,,,,,
Molina Duals,CPT,97597,Rmvl devital tis 20 cm/<,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,282.14,,,,,,
Molina Duals,CPT,97602,Wound(s) care non-selective,APC 5051,RVU Per Case,$183.73 ,OP,171.58,183.73,,,,,,
Molina Duals,CPT,97605,Neg press wound tx <=50 cm,APC 5051,RVU Per Case,$183.73 ,OP,163.95,183.73,,,,,,
Molina Duals,CPT,97606,Neg press wound tx >50 cm,APC 5052,RVU Per Case,$353.91 ,OP,175.39,353.91,,,,,,
Molina Duals,CPT,97607,Neg press wnd tx <=50 sq cm,APC 5052,RVU Per Unit,$353.91 ,OP,163.95,353.91,,,,,,
Molina Duals,CPT,97608,Neg press wound tx >50 cm,APC 5052,RVU Per Unit,$353.91 ,OP,175.39,353.91,,,,,,
Molina Duals,CPT,97610,Low frequency non-thermal us,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
Molina Duals,CPT,97750,Physical performance test,Physician,Per Unit,$33.07 ,OP,33.07,137.25,,,,,,
Molina Duals,CPT,97755,Assistive technology assess,Physician,Per Unit,$37.42 ,OP,37.42,156.32,,,,,,
Molina Duals,CPT,97760,Orthotic mgmt&traing 1st enc,Physician,Per Unit,$47.55 ,OP,47.55,152.51,,,,,,
Molina Duals,CPT,97761,Prosthetic traing 1st enc,Physician,Per Unit,$40.55 ,OP,40.55,133.45,,,,,,
Molina Duals,CPT,97763,Orthc/prostc mgmt sbsq enc,Physician,Per Unit,$51.94 ,OP,51.94,160.13,,,,,,
Molina Duals,CPT,97802,Medical nutrition indiv in,Physician,Per Unit,$30.75 ,OP,30.75,148.69,,,,,,
Molina Duals,CPT,97803,Med nutrition indiv subseq,Physician,Per Unit,$31.17 ,OP,31.17,129.64,,,,,,
Molina Duals,CPT,97804,Medical nutrition group,Physician,Per Unit,$16.45 ,OP,16.45,64.82,,,,,,
Molina Duals,CPT,97810,Acupunct w/o stimul 15 min,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,186.82,,,,,,
Molina Duals,CPT,97813,Acupunct w/stimul 15 min,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,198.25,,,,,,
Molina Duals,CPT,98925,Osteopath manj 1-2 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,141.07,,,,,,
Molina Duals,CPT,98926,Osteopath manj 3-4 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,27.17,,,,,,
Molina Duals,CPT,98927,Osteopath manj 5-6 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,251.64,,,,,,
Molina Duals,CPT,98928,Osteopath manj 7-8 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,297.39,,,,,,
Molina Duals,CPT,98929,Osteopath manj 9-10 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,343.14,,,,,,
Molina Duals,CPT,98940,Chiropract manj 1-2 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,125.82,,,,,,
Molina Duals,CPT,98941,Chiropract manj 3-4 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,171.58,,,,,,
Molina Duals,CPT,98942,Chiropractic manj 5 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,224.95,,,,,,
Molina Duals,CPT,98966,Hc pro phone call 5-10 min,Physician,Per Unit,$12.73 ,OP,12.73,61,,,,,,
Molina Duals,CPT,98967,Hc pro phone call 11-20 min,Physician,Per Unit,$25.14 ,OP,25.14,118.19,,,,,,
Molina Duals,CPT,98968,Hc pro phone call 21-30 min,Physician,Per Unit,$37.46 ,OP,37.46,171.58,,,,,,
Molina Duals,CPT,98970,Qnhp ol dig assmt&mgmt 5-10,Physician,Per Unit,$11.36 ,OP,11.36,11.36,,,,,,
Molina Duals,CPT,98971,Qnhp ol dig assmt&mgmt 11-20,Physician,Per Unit,$20.31 ,OP,20.31,20.31,,,,,,
Molina Duals,CPT,98972,Qnhp ol dig assmt&mgmt 21+,Physician,Per Unit,$32.41 ,OP,32.41,32.41,,,,,,
Molina Duals,CPT,99170,Anogenital exam child w imag,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,663.41,,,,,,
Molina Duals,CPT,99184,Hypothermia ill neonate,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,99190,Special pump services,APC 5881,RVU Per Case,"$8,948.83 ",OP,"2,299.05","8,948.83",,,,,,
Molina Duals,CPT,99191,Special pump services,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,612.76","8,948.83",,,,,,
Molina Duals,CPT,99192,Special pump services,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,151.42","8,948.83",,,,,,
Molina Duals,CPT,99195,Phlebotomy,APC 5734,RVU Per Case,$114.56 ,OP,114.56,331.7,,,,,,
Molina Duals,CPT,99281,Emergency dept visit,APC 5021,RVU Per Case,$74.29 ,OP,74.29,245.98,,,,,,
Molina Duals,CPT,99282,Emergency dept visit,APC 5022,RVU Per Case,$134.66 ,OP,134.66,368.97,,,,,,
Molina Duals,CPT,99283,Emergency dept visit,APC 5023,RVU Per Case,$237.00 ,OP,237,737.94,,,,,,
Molina Duals,CPT,99284,Emergency dept visit,APC 5024,RVU Per Case,$372.22 ,OP,372.22,"1,291.40",,,,,,
Molina Duals,CPT,99285,Emergency dept visit,APC 5025,RVU Per Case,$534.29 ,OP,534.29,"1,967.84",,,,,,
Molina Duals,CPT,99291,Critical care first hour,APC 5041,RVU Per Case,$708.83 ,OP,708.83,"1,197.20",,,,,,
Molina Duals,CPT,99356,Prolng svc i/p/obs 1st hour,APC 5881,RVU Per Case,"$8,948.83 ",OP,499.47,"8,948.83",,,,,,
Molina Duals,CPT,99357,Prolng svc i/p/obs ea addl,APC 5881,RVU Per Case,"$8,948.83 ",OP,507.08,"8,948.83",,,,,,
Molina Duals,CPT,99406,Behav chng smoking 3-10 min,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,64.82,,,,,,
Molina Duals,CPT,99407,Behav chng smoking > 10 min,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,125.82,,,,,,
Molina Duals,CPT,99453,Rem mntr physiol param setup,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,121.51,,,,,,
Molina Duals,CPT,99454,Rem mntr physiol param dev,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Molina Duals,CPT,99460,Init nb em per day hosp,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,305.01,,,,,,
Molina Duals,CPT,99462,Sbsq nb em per day hosp,APC 5881,RVU Per Case,"$8,948.83 ",OP,160.13,"8,948.83",,,,,,
Molina Duals,CPT,99463,Same day nb discharge,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,404.14,,,,,,
Molina Duals,CPT,99465,Nb resuscitation,APC 5781,RVU Per Unit,$575.01 ,OP,575.01,781.61,,,,,,
Molina Duals,CPT,99468,Neonate crit care initial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,510.41","8,948.83",,,,,,
Molina Duals,CPT,99469,Neonate crit care subsq,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,936.85","8,948.83",,,,,,
Molina Duals,CPT,99471,Ped critical care initial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,049.07","8,948.83",,,,,,
Molina Duals,CPT,99472,Ped critical care subsq,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,982.60","8,948.83",,,,,,
Molina Duals,CPT,99473,Self-meas bp pt educaj/train,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Molina Duals,CPT,99475,Ped crit care age 2-5 init,APC 5881,RVU Per Case,"$8,948.83 ",OP,"2,790.89","8,948.83",,,,,,
Molina Duals,CPT,99476,Ped crit care age 2-5 subsq,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,643.28","8,948.83",,,,,,
Molina Duals,CPT,99477,Init day hosp neonate care,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,734.78","8,948.83",,,,,,
Molina Duals,CPT,99478,Ic lbw inf < 1500 gm subsq,APC 5881,RVU Per Case,"$8,948.83 ",OP,716.79,"8,948.83",,,,,,
Molina Duals,CPT,99479,Ic lbw inf 1500-2500 g subsq,APC 5881,RVU Per Case,"$8,948.83 ",OP,629.1,"8,948.83",,,,,,
Molina Duals,CPT,99480,Ic inf pbw 2501-5000 g subsq,APC 5881,RVU Per Case,"$8,948.83 ",OP,606.21,"8,948.83",,,,,,
Molina Duals,CPT,99483,Assmt & care pln pt cog imp,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Molina Duals,CPT,99484,Care mgmt svc bhvl hlth cond,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Molina Duals,CPT,99487,Cplx chrnc care 1st 60 min,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,136.74,,,,,,
Molina Duals,CPT,99490,Chrnc care mgmt svc 1st 20,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Molina Duals,CPT,99492,1st psyc collab care mgmt,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Molina Duals,CPT,99493,Sbsq psyc collab care mgmt,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Molina Duals,CPT,99495,Trans care mgmt 14 day disch,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,121.51,,,,,,
Molina Duals,CPT,99496,Trans care mgmt 7 day disch,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,121.51,,,,,,
Molina Duals,CPT,99497,Advncd care plan 30 min,APC 5822,RVU Per Case,$76.62 ,OP,76.62,76.62,,,,,,
Molina Duals,CPT,0001A,Adm sarscov2 30mcg/0.3ml 1st,APC 9397,RVU Per Unit,$40.93 ,OP,40.93,40.93,,,,,,
Molina Duals,CPT,0001U,Rbc dna hea 35 ag 11 bld grp,Lab Services,Per Unit,$720.00 ,OP,720,720,,,,,,
Molina Duals,CPT,0002A,Adm sarscov2 30mcg/0.3ml 2nd,APC 9398,RVU Per Unit,$40.93 ,OP,40.93,40.93,,,,,,
Molina Duals,CPT,0002M,Liver dis 10 assays w/ash,Lab Services,Per Unit,$503.40 ,OP,503.4,503.4,,,,,,
Molina Duals,CPT,0002U,Onc clrct 3 ur metab alg plp,Lab Services,Per Unit,$25.00 ,OP,25,25,,,,,,
Molina Duals,CPT,0003A,Adm sarscov2 30mcg/0.3ml 3rd,APC 9398,RVU Per Unit,$40.93 ,OP,40.93,40.93,,,,,,
Molina Duals,CPT,0003M,Liver dis 10 assays w/nash,Lab Services,Per Unit,$503.40 ,OP,503.4,503.4,,,,,,
Molina Duals,CPT,0003U,Onc ovar 5 prtn ser alg scor,Lab Services,Per Unit,$950.00 ,OP,950,950,,,,,,
Molina Duals,CPT,0004M,Scoliosis dna alys,Lab Services,Per Unit,$79.00 ,OP,79,79,,,,,,
Molina Duals,CPT,0005U,Onco prst8 3 gene ur alg,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
Molina Duals,CPT,0006M,Onc hep gene risk classifier,Lab Services,Per Unit,$150.00 ,OP,150,150,,,,,,
Molina Duals,CPT,0007M,Onc gastro 51 gene nomogram,Lab Services,Per Unit,$375.00 ,OP,375,375,,,,,,
Molina Duals,CPT,0007U,Rx test prsmv ur w/def conf,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
Molina Duals,CPT,0008U,Hpylori detcj abx rstnc dna,Lab Services,Per Unit,$597.91 ,OP,597.91,597.91,,,,,,
Molina Duals,CPT,0009U,Onc brst ca erbb2 amp/nonamp,Lab Services,Per Unit,$107.00 ,OP,107,107,,,,,,
Molina Duals,CPT,0010U,Nfct ds strn typ whl gen seq,Lab Services,Per Unit,$427.26 ,OP,427.26,427.26,,,,,,
Molina Duals,CPT,0011A,Adm sarscov2 100mcg/0.5ml1st,APC 9397,RVU Per Unit,$40.93 ,OP,40.93,40.93,,,,,,
Molina Duals,CPT,0011M,Onc prst8 ca mrna 12 gen alg,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
Molina Duals,CPT,0011U,Rx mntr lc-ms/ms oral fluid,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
Molina Duals,CPT,0012A,Adm sarscov2 100mcg/0.5ml2nd,APC 9398,RVU Per Unit,$40.93 ,OP,40.93,40.93,,,,,,
Molina Duals,CPT,0012M,Onc mrna 5 gen rsk urthl ca,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
Molina Duals,CPT,0012U,Germln do gene reargmt detcj,Lab Services,Per Unit,"$2,515.60 ",OP,"2,515.60","2,515.60",,,,,,
Molina Duals,CPT,0013A,Adm sarscov2 100mcg/0.5ml3rd,APC 9398,RVU Per Unit,$40.93 ,OP,40.93,40.93,,,,,,
Molina Duals,CPT,0013M,Onc mrna 5 gen recr urthl ca,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
Molina Duals,CPT,0013U,Onc sld org neo gene reargmt,Lab Services,Per Unit,"$2,515.60 ",OP,"2,515.60","2,515.60",,,,,,
Molina Duals,CPT,0014M,Liver ds alys 3 bmrk srm alg,Lab Services,Per Unit,$176.19 ,OP,176.19,176.19,,,,,,
Molina Duals,CPT,0014U,Hem hmtlmf neo gene reargmt,Lab Services,Per Unit,"$2,515.60 ",OP,"2,515.60","2,515.60",,,,,,
Molina Duals,CPT,0016U,Onc hmtlmf neo rna bcr/abl1,Lab Services,Per Unit,$163.96 ,OP,163.96,163.96,,,,,,
Molina Duals,CPT,0017U,Onc hmtlmf neo jak2 mut dna,Lab Services,Per Unit,$91.66 ,OP,91.66,91.66,,,,,,
Molina Duals,CPT,0018U,Onc thyr 10 microrna seq alg,Lab Services,Per Unit,"$3,002.09 ",OP,"3,002.09","3,002.09",,,,,,
Molina Duals,CPT,0019U,Onc rna tiss predict alg,Lab Services,Per Unit,"$3,675.00 ",OP,"3,675.00","3,675.00",,,,,,
Molina Duals,CPT,0021U,Onc prst8 detcj 8 autoantb,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
Molina Duals,CPT,0022U,Trgt gen seq dna&rna 23 gene,Lab Services,Per Unit,"$1,950.00 ",OP,"1,950.00","1,950.00",,,,,,
Molina Duals,CPT,0023U,Onc aml dna detcj/nondetcj,Lab Services,Per Unit,$248.51 ,OP,248.51,248.51,,,,,,
Molina Duals,CPT,0024U,Glyca nuc mr spectrsc quan,Lab Services,Per Unit,$34.19 ,OP,34.19,34.19,,,,,,
Molina Duals,CPT,0025U,Tenofovir liq chrom ur quan,Lab Services,Per Unit,$85.77 ,OP,85.77,85.77,,,,,,
Molina Duals,CPT,0026U,Onc thyr dna&mrna 112 genes,Lab Services,Per Unit,"$3,600.00 ",OP,"3,600.00","3,600.00",,,,,,
Molina Duals,CPT,0027U,Jak2 gene trgt seq alys,Lab Services,Per Unit,$121.91 ,OP,121.91,121.91,,,,,,
Molina Duals,CPT,0029U,Rx metab advrs trgt seq alys,Lab Services,Per Unit,$742.27 ,OP,742.27,742.27,,,,,,
Molina Duals,CPT,0030U,Rx metab warf trgt seq alys,Lab Services,Per Unit,$134.13 ,OP,134.13,134.13,,,,,,
Molina Duals,CPT,0031A,Adm sarscov2 vac ad26 .5ml,APC 9398,RVU Per Unit,$40.93 ,OP,40.93,40.93,,,,,,
Molina Duals,CPT,0031U,Cyp1a2 gene,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Molina Duals,CPT,0032U,Comt gene,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
Molina Duals,CPT,0033U,Htr2a htr2c genes,Lab Services,Per Unit,$349.62 ,OP,349.62,349.62,,,,,,
Molina Duals,CPT,0034U,Tpmt nudt15 genes,Lab Services,Per Unit,$466.17 ,OP,466.17,466.17,,,,,,
Molina Duals,CPT,0035U,Neuro csf prion prtn qual,Lab Services,Per Unit,$540.99 ,OP,540.99,540.99,,,,,,
Molina Duals,CPT,0036U,Xome tum & nml spec seq alys,Lab Services,Per Unit,"$4,780.00 ",OP,"4,780.00","4,780.00",,,,,,
Molina Duals,CPT,0037U,Trgt gen seq dna 324 genes,Lab Services,Per Unit,"$3,500.00 ",OP,"3,500.00","3,500.00",,,,,,
Molina Duals,CPT,0038U,Vitamin d srm microsamp quan,Lab Services,Per Unit,$29.60 ,OP,29.6,29.6,,,,,,
Molina Duals,CPT,0039U,Dna antb 2strand hi avidity,Lab Services,Per Unit,$13.74 ,OP,13.74,13.74,,,,,,
Molina Duals,CPT,0040U,Bcr/abl1 gene major bp quan,Lab Services,Per Unit,$409.90 ,OP,409.9,409.9,,,,,,
Molina Duals,CPT,0041U,B brgdrferi antb 5 prtn igm,Lab Services,Per Unit,$17.21 ,OP,17.21,17.21,,,,,,
Molina Duals,CPT,0042U,B brgdrferi antb 12 prtn igg,Lab Services,Per Unit,$17.21 ,OP,17.21,17.21,,,,,,
Molina Duals,CPT,0043U,Tbrf b grp antb 4 prtn igm,Lab Services,Per Unit,$14.86 ,OP,14.86,14.86,,,,,,
Molina Duals,CPT,0044U,Tbrf b grp antb 4 prtn igg,Lab Services,Per Unit,$14.86 ,OP,14.86,14.86,,,,,,
Molina Duals,CPT,0045U,Onc brst dux carc is 12 gene,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
Molina Duals,CPT,0046U,Flt3 gene itd variants quan,Lab Services,Per Unit,$407.43 ,OP,407.43,407.43,,,,,,
Molina Duals,CPT,0047U,Onc prst8 mrna 17 gene alg,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
Molina Duals,CPT,0048U,Onc sld org neo dna 468 gene,Lab Services,Per Unit,"$2,919.60 ",OP,"2,919.60","2,919.60",,,,,,
Molina Duals,CPT,0049U,Npm1 gene analysis quan,Lab Services,Per Unit,$407.43 ,OP,407.43,407.43,,,,,,
Molina Duals,CPT,0050U,Trgt gen seq dna 194 genes,Lab Services,Per Unit,"$2,916.60 ",OP,"2,916.60","2,916.60",,,,,,
Molina Duals,CPT,0051U,Rx mntr lc-ms/ms ur 31 pnl,Lab Services,Per Unit,$193.71 ,OP,193.71,193.71,,,,,,
Molina Duals,CPT,0052U,Lpoprtn bld w/5 maj classes,Lab Services,Per Unit,$33.86 ,OP,33.86,33.86,,,,,,
Molina Duals,CPT,0053U,Onc prst8 ca fish alys 4 gen,Lab Services,Per Unit,"$2,030.00 ",OP,"2,030.00","2,030.00",,,,,,
Molina Duals,CPT,0054U,Rx mntr 14+ drugs & sbsts,Lab Services,Per Unit,$148.96 ,OP,148.96,148.96,,,,,,
Molina Duals,CPT,0055U,Card hrt trnspl 96 dna seq,Lab Services,Per Unit,"$3,240.00 ",OP,"3,240.00","3,240.00",,,,,,
Molina Duals,CPT,0056U,Hem aml dna gene reargmt,Lab Services,Per Unit,"$2,515.60 ",OP,"2,515.60","2,515.60",,,,,,
Molina Duals,CPT,0058U,Onc merkel cll carc srm quan,Lab Services,Per Unit,$322.96 ,OP,322.96,322.96,,,,,,
Molina Duals,CPT,0059U,Onc merkel cll carc srm +/-,Lab Services,Per Unit,$322.96 ,OP,322.96,322.96,,,,,,
Molina Duals,CPT,0060U,Twn zyg gen seq alys chrms2,Lab Services,Per Unit,$759.05 ,OP,759.05,759.05,,,,,,
Molina Duals,CPT,0061U,Tc meas 5 bmrk sfdi m-s alys,Lab Services,Per Unit,$25.10 ,OP,25.1,25.1,,,,,,
Molina Duals,CPT,0062U,Ai sle igg&igm alys 80 bmrk,Lab Services,Per Unit,$380.72 ,OP,380.72,380.72,,,,,,
Molina Duals,CPT,0063U,Neuro autism 32 amines alg,Lab Services,Per Unit,$750.00 ,OP,750,750,,,,,,
Molina Duals,CPT,0064U,Antb tp total&rpr ia qual,Lab Services,Per Unit,$31.33 ,OP,31.33,31.33,,,,,,
Molina Duals,CPT,0065U,Syfls tst nontreponemal antb,Lab Services,Per Unit,$18.09 ,OP,18.09,18.09,,,,,,
Molina Duals,CPT,0066U,Pamg-1 ia cervico-vag fluid,Lab Services,Per Unit,$15.29 ,OP,15.29,15.29,,,,,,
Molina Duals,CPT,0067U,Onc brst imhchem prfl 4 bmrk,Lab Services,Per Unit,"$1,897.00 ",OP,"1,897.00","1,897.00",,,,,,
Molina Duals,CPT,0068U,Candida species pnl amp prb,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
Molina Duals,CPT,0069U,Onc clrct microrna mir-31-3p,Lab Services,Per Unit,$380.00 ,OP,380,380,,,,,,
Molina Duals,CPT,0070U,Cyp2d6 gen com&slct rar vrnt,Lab Services,Per Unit,$676.37 ,OP,676.37,676.37,,,,,,
Molina Duals,CPT,0071T,Us leiomyomata ablate <200,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","2,684.38",,,,,,
Molina Duals,CPT,0071U,Cyp2d6 full gene sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,
Molina Duals,CPT,0072T,Us leiomyomata ablate >200,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","2,684.38",,,,,,
Molina Duals,CPT,0072U,Cyp2d6 gen cyp2d6-2d7 hybrid,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,
Molina Duals,CPT,0073U,Cyp2d6 gen cyp2d7-2d6 hybrid,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,
Molina Duals,CPT,0074U,Cyp2d6 nonduplicated gene,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,
Molina Duals,CPT,0075T,Perq stent/chest vert art,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,0075U,Cyp2d6 5' gene dup/mlt,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,
Molina Duals,CPT,0076T,S&i stent/chest vert art,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,0076U,Cyp2d6 3' gene dup/mlt,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,
Molina Duals,CPT,0077U,Ig paraprotein qual bld/ur,Lab Services,Per Unit,$43.43 ,OP,43.43,43.43,,,,,,
Molina Duals,CPT,0078U,Pain mgt opi use gnotyp pnl,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,
Molina Duals,CPT,0080U,Onc lng 5 clin rsk factr alg,Lab Services,Per Unit,"$3,520.00 ",OP,"3,520.00","3,520.00",,,,,,
Molina Duals,CPT,0082U,Rx test def 90+ rx/sbsts ur,Lab Services,Per Unit,$246.92 ,OP,246.92,246.92,,,,,,
Molina Duals,CPT,0083U,Onc rspse chemo cntrst tomog,Lab Services,Per Unit,$167.35 ,OP,167.35,167.35,,,,,,
Molina Duals,CPT,0084U,Rbc dna gnotyp 10 bld groups,Lab Services,Per Unit,$720.00 ,OP,720,720,,,,,,
Molina Duals,CPT,0086U,Nfct ds bact&fng org id 6+,Lab Services,Per Unit,$200.00 ,OP,200,200,,,,,,
Molina Duals,CPT,0087U,Crd hrt trnspl mrna 1283 gen,Lab Services,Per Unit,"$3,159.42 ",OP,"3,159.42","3,159.42",,,,,,
Molina Duals,CPT,0088U,Trnsplj kdn algrft rej 1494,Lab Services,Per Unit,"$3,159.42 ",OP,"3,159.42","3,159.42",,,,,,
Molina Duals,CPT,0089U,Onc mlnma prame & linc00518,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
Molina Duals,CPT,0090U,Onc cutan mlnma mrna 23 gene,Lab Services,Per Unit,"$1,755.00 ",OP,"1,755.00","1,755.00",,,,,,
Molina Duals,CPT,0092U,Onc lng 3 prtn bmrk plsm alg,Lab Services,Per Unit,"$2,488.00 ",OP,"2,488.00","2,488.00",,,,,,
Molina Duals,CPT,0093U,Rx mntr 65 com drugs urine,Lab Services,Per Unit,$62.14 ,OP,62.14,62.14,,,,,,
Molina Duals,CPT,0094U,Genome rapid sequence alys,Lab Services,Per Unit,"$7,582.20 ",OP,"7,582.20","7,582.20",,,,,,
Molina Duals,CPT,0095U,Inflm ee elisa alys alg,Lab Services,Per Unit,$771.98 ,OP,771.98,771.98,,,,,,
Molina Duals,CPT,0096U,Hpv hi risk types male urine,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,
Molina Duals,CPT,0097U,Gi pathogen 22 targets,Lab Services,Per Unit,$363.04 ,OP,363.04,363.04,,,,,,
Molina Duals,CPT,0101T,Extracorp shockwv tx hi enrg,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","2,896.40",,,,,,
Molina Duals,CPT,0102T,Extracorp shockwv tx anesth,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","2,896.40",,,,,,
Molina Duals,CPT,0105U,Neph ckd mult eclia tum nec,Lab Services,Per Unit,$950.00 ,OP,950,950,,,,,,
Molina Duals,CPT,0106T,Touch quant sensory test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Molina Duals,CPT,0106U,Gstr emptg 7 timed brth spec,Lab Services,Per Unit,$874.49 ,OP,874.49,874.49,,,,,,
Molina Duals,CPT,0107T,Vibrate quant sensory test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Molina Duals,CPT,0107U,C diff tox ag detcj ia stool,Lab Services,Per Unit,$16.00 ,OP,16,16,,,,,,
Molina Duals,CPT,0108T,Cool quant sensory test,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Molina Duals,CPT,0108U,Gi barrett esoph 9 prtn bmrk,Lab Services,Per Unit,"$2,513.25 ",OP,"2,513.25","2,513.25",,,,,,
Molina Duals,CPT,0109T,Heat quant sensory test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Molina Duals,CPT,0109U,Id aspergillus dna 4 species,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
Molina Duals,CPT,0110T,Nos quant sensory test,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Molina Duals,CPT,0110U,Rx mntr 1+oral onc rx&sbsts,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,
Molina Duals,CPT,0111U,Onc colon ca kras&nras alys,Lab Services,Per Unit,$682.29 ,OP,682.29,682.29,,,,,,
Molina Duals,CPT,0112U,Iadi 16s&18s rrna genes,Lab Services,Per Unit,$356.13 ,OP,356.13,356.13,,,,,,
Molina Duals,CPT,0113U,Onc prst8 pca3&tmprss2-erg,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
Molina Duals,CPT,0114U,Gi barretts esoph vim&ccna1,Lab Services,Per Unit,"$1,938.01 ",OP,"1,938.01","1,938.01",,,,,,
Molina Duals,CPT,0115U,Respir iadna 18 viral&2 bact,Lab Services,Per Unit,$275.35 ,OP,275.35,275.35,,,,,,
Molina Duals,CPT,0116U,Rx mntr nzm ia 35+oral flu,Lab Services,Per Unit,$246.92 ,OP,246.92,246.92,,,,,,
Molina Duals,CPT,0117U,Pain mgmt 11 endogenous anal,Lab Services,Per Unit,$840.65 ,OP,840.65,840.65,,,,,,
Molina Duals,CPT,0118U,Trnsplj don-drv cll-fr dna,Lab Services,Per Unit,"$2,753.25 ",OP,"2,753.25","2,753.25",,,,,,
Molina Duals,CPT,0119U,Crd ceramides liq chrom plsm,Lab Services,Per Unit,$83.76 ,OP,83.76,83.76,,,,,,
Molina Duals,CPT,0120U,Onc b cll lymphm mrna 58 gen,Lab Services,Per Unit,"$2,510.21 ",OP,"2,510.21","2,510.21",,,,,,
Molina Duals,CPT,0121U,Sc dis vcam-1 whole blood,Lab Services,Per Unit,$509.20 ,OP,509.2,509.2,,,,,,
Molina Duals,CPT,0122U,Sc dis p-selectin whl blood,Lab Services,Per Unit,$526.23 ,OP,526.23,526.23,,,,,,
Molina Duals,CPT,0123U,Mchnl fragility rbc prflg,Lab Services,Per Unit,$357.63 ,OP,357.63,357.63,,,,,,
Molina Duals,CPT,0130U,Hered colon ca do mrna pnl,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,
Molina Duals,CPT,0131U,Hered brst ca rltd do pnl 13,Lab Services,Per Unit,$710.00 ,OP,710,710,,,,,,
Molina Duals,CPT,0132U,Hered ova ca rltd do pnl 17,Lab Services,Per Unit,$741.64 ,OP,741.64,741.64,,,,,,
Molina Duals,CPT,0133U,Hered prst8 ca rltd do 11,Lab Services,Per Unit,$690.29 ,OP,690.29,690.29,,,,,,
Molina Duals,CPT,0134U,Hered pan ca mrna pnl 18 gen,Lab Services,Per Unit,$748.39 ,OP,748.39,748.39,,,,,,
Molina Duals,CPT,0135U,Hered gyn ca mrna pnl 12 gen,Lab Services,Per Unit,$700.56 ,OP,700.56,700.56,,,,,,
Molina Duals,CPT,0136U,Atm mrna seq alys,Lab Services,Per Unit,$407.43 ,OP,407.43,407.43,,,,,,
Molina Duals,CPT,0137U,Palb2 mrna seq alys,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,
Molina Duals,CPT,0138U,Brca1 brca2 mrna seq alys,Lab Services,Per Unit,$468.33 ,OP,468.33,468.33,,,,,,
Molina Duals,CPT,0145U,Drug assay 65+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
Molina Duals,CPT,0146U,Drug assay 80+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
Molina Duals,CPT,0147U,Drug assay 85+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
Molina Duals,CPT,0148U,Drug assay 100+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
Molina Duals,CPT,0149U,Drug assay 60+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
Molina Duals,CPT,0150U,Drug assay 120+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
Molina Duals,CPT,0154U,Onc urthl ca rna fgfr3 gene,Lab Services,Per Unit,$482.14 ,OP,482.14,482.14,,,,,,
Molina Duals,CPT,0155U,Onc brst ca dna pik3ca gene,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Molina Duals,CPT,0166U,Liver ds 10 biochem asy srm,Lab Services,Per Unit,$503.40 ,OP,503.4,503.4,,,,,,
Molina Duals,CPT,0167U,Chornc gonadotropin hcg ia,Lab Services,Per Unit,$7.52 ,OP,7.52,7.52,,,,,,
Molina Duals,CPT,0169U,Nudt15&tpmt gene com vrnt,Lab Services,Per Unit,$466.17 ,OP,466.17,466.17,,,,,,
Molina Duals,CPT,0170U,Neuro asd rna next gen seq,Lab Services,Per Unit,"$1,755.00 ",OP,"1,755.00","1,755.00",,,,,,
Molina Duals,CPT,0172U,Onc sld tum alys brca1 brca2,Lab Services,Per Unit,"$3,030.00 ",OP,"3,030.00","3,030.00",,,,,,
Molina Duals,CPT,0176U,Cdtb&vinculin igg antb ia,Lab Services,Per Unit,$64.19 ,OP,64.19,64.19,,,,,,
Molina Duals,CPT,0177U,Onc brst ca dna pik3ca 11,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Molina Duals,CPT,0181U,Co gnotyp aqp1 exon 1,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Molina Duals,CPT,0182U,Crom gnotyp cd55 exons 1-10,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,
Molina Duals,CPT,0183U,Di gnotyp slc4a1 exon 19,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Molina Duals,CPT,0184T,Exc rectal tumor endoscopic,APC 5331,RVU Per Case,"$5,145.78 ",OP,"5,145.78","5,145.78",,,,,,
Molina Duals,CPT,0184U,Do gnotyp art4 exon 2,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Molina Duals,CPT,0185U,Fut1 gnotyp fut1 exon 4,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Molina Duals,CPT,0186U,Fut2 gnotyp fut2 exon 2,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Molina Duals,CPT,0187U,Fy gnotyp ackr1 exons 1-2,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Molina Duals,CPT,0188U,Ge gnotyp gypc exons 1-4,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Molina Duals,CPT,0189U,Gypa gnotyp ntrns 1 5 exon 2,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Molina Duals,CPT,0190U,Gypb gnotyp ntrns 1 5 seux 3,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Molina Duals,CPT,0191T,Insert ant segment drain int,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,009.10",,,,,,
Molina Duals,CPT,0191U,In gnotyp cd44 exons 2 3 6,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Molina Duals,CPT,0192U,Jk gnotyp slc14a1 exon 9,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Molina Duals,CPT,0193U,Jr gnotyp abcg2 exons 2-26,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,
Molina Duals,CPT,0194U,Kel gnotyp kel exon 8,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Molina Duals,CPT,0195U,Klf1 targeted sequencing,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,
Molina Duals,CPT,0196U,Lu gnotyp bcam exon 3,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Molina Duals,CPT,0197U,Lw gnotyp icam4 exon 1,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Molina Duals,CPT,0198T,Ocular blood flow measure,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Molina Duals,CPT,0198U,Rhd&rhce gntyp rhd1-10&rhce5,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,
Molina Duals,CPT,0199U,Sc gnotyp ermap exons 4 12,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Molina Duals,CPT,0200T,Perq sacral augmt unilat inj,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
Molina Duals,CPT,0200U,Xk gnotyp xk exons 1-3,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
Molina Duals,CPT,0201T,Perq sacral augmt bilat inj,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
Molina Duals,CPT,0201U,Yt gnotyp ache exon 2,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
Molina Duals,CPT,0202T,Post vert arthrplst 1 lumbar,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
Molina Duals,CPT,0202U,Nfct ds 22 trgt sars-cov-2,Lab Services,Per Unit,$416.78 ,OP,416.78,416.78,,,,,,
Molina Duals,CPT,0203U,Ai ibd mrna xprsn prfl 17,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
Molina Duals,CPT,0204U,Onc thyr mrna xprsn alys 593,Lab Services,Per Unit,"$2,919.60 ",OP,"2,919.60","2,919.60",,,,,,
Molina Duals,CPT,0205U,Oph amd alys 3 gene variants,Lab Services,Per Unit,$47.00 ,OP,47,47,,,,,,
Molina Duals,CPT,0207T,Clear eyelid gland w/heat,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Molina Duals,CPT,0208T,Audiometry air only,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Molina Duals,CPT,0209T,Audiometry air & bone,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Molina Duals,CPT,0210T,Speech audiometry threshold,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Molina Duals,CPT,0210U,Syphilis tst antb ia quan,Lab Services,Per Unit,$18.63 ,OP,18.63,18.63,,,,,,
Molina Duals,CPT,0211T,Speech audiom thresh & recog,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Molina Duals,CPT,0212T,Compre audiometry evaluation,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
Molina Duals,CPT,0213T,Njx paravert w/us cer/thor,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,841.63,,,,,,
Molina Duals,CPT,0216T,Njx paravert w/us lumb/sac,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,841.63,,,,,,
Molina Duals,CPT,0218U,Neuro musc dys dmd seq alys,Lab Services,Per Unit,"$2,279.00 ",OP,"2,279.00","2,279.00",,,,,,
Molina Duals,CPT,0219T,Plmt post facet implt cerv,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
Molina Duals,CPT,0220T,Plmt post facet implt thor,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
Molina Duals,CPT,0221T,Plmt post facet implt lumb,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
Molina Duals,CPT,0224U,Antibody sars-cov-2 titer(s),Lab Services,Per Unit,$42.13 ,OP,42.13,42.13,,,,,,
Molina Duals,CPT,0226U,Svnt sarscov2 elisa plsm srm,Lab Services,Per Unit,$42.28 ,OP,42.28,42.28,,,,,,
Molina Duals,CPT,0232T,Njx platelet plasma,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
Molina Duals,CPT,0234T,Trluml perip athrc renal art,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Molina Duals,CPT,0235T,Trluml perip athrc visceral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,0236T,Trluml perip athrc abd aorta,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Molina Duals,CPT,0237T,Trluml perip athrc brchiocph,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Molina Duals,CPT,0238T,Trluml perip athrc iliac art,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Molina Duals,CPT,0239U,Trgt gen seq alys pnl 311+,Lab Services,Per Unit,"$3,500.00 ",OP,"3,500.00","3,500.00",,,,,,
Molina Duals,CPT,0240U,Nfct ds vir resp rna 3 trgt,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
Molina Duals,CPT,0241U,Nfct ds vir resp rna 4 trgt,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
Molina Duals,CPT,0242U,Trgt gen seq alys pnl 55-74,Lab Services,Per Unit,"$5,000.00 ",OP,"5,000.00","5,000.00",,,,,,
Molina Duals,CPT,0253T,Insert aqueous drain device,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,009.10",,,,,,
Molina Duals,CPT,0263T,Im b1 mrw cel ther cmpl,APC 5243,RVU Per Unit,"$4,131.87 ",OP,"4,131.87","4,131.87",,,,,,
Molina Duals,CPT,0264T,Im b1 mrw cel ther xcl hrvst,APC 5243,RVU Per Unit,"$4,131.87 ",OP,"4,131.87","4,131.87",,,,,,
Molina Duals,CPT,0265T,Im b1 mrw cel ther hrvst onl,APC 5243,RVU Per Unit,"$4,131.87 ",OP,"4,131.87","4,131.87",,,,,,
Molina Duals,CPT,0266T,Implt/rpl crtd sns dev total,APC 5465,RVU Per Case,"$30,131.14 ",OP,"30,131.14","30,131.14",,,,,,
Molina Duals,CPT,0267T,Implt/rpl crtd sns dev lead,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Molina Duals,CPT,0268T,Implt/rpl crtd sns dev gen,APC 5465,RVU Per Case,"$30,131.14 ",OP,"30,131.14","30,131.14",,,,,,
Molina Duals,CPT,0269T,Rev/remvl crtd sns dev total,APC 5432,RVU Per Case,"$5,833.22 ",OP,"5,833.22","5,833.22",,,,,,
Molina Duals,CPT,0270T,Rev/remvl crtd sns dev lead,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Molina Duals,CPT,0271T,Rev/remvl crtd sns dev gen,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Molina Duals,CPT,0272T,Interrogate crtd sns dev,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Molina Duals,CPT,0273T,Interrogate crtd sns w/pgrmg,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Molina Duals,CPT,0274T,Perq lamot/lam crv/thrc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
Molina Duals,CPT,0275T,Perq lamot/lam lumbar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
Molina Duals,CPT,0278T,Tempr,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
Molina Duals,CPT,0308T,Insj ocular telescope prosth,APC 5495,RVU Per Case,"$21,250.81 ",OP,"21,250.81","21,250.81",,,,,,
Molina Duals,CPT,0312T,Laps impltj nstim vagus,APC 5465,RVU Per Case,"$30,131.14 ",OP,"30,131.14","30,131.14",,,,,,
Molina Duals,CPT,0313T,Laps rmvl nstim array vagus,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Molina Duals,CPT,0314T,Laps rmvl vgl arry&pls gen,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Molina Duals,CPT,0315T,Rmvl vagus nerve pls gen,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Molina Duals,CPT,0316T,Replc vagus nerve pls gen,APC 5465,RVU Per Case,"$30,131.14 ",OP,"30,131.14","30,131.14",,,,,,
Molina Duals,CPT,0317T,Elec alys vagus nrv pls gen,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Molina Duals,CPT,0330T,Tear film img uni/bi w/i&r,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Molina Duals,CPT,0331T,Heart symp image plnr,APC 5593,RVU Per Unit,"$1,336.39 ",OP,922.67,"1,336.39",,,,,,
Molina Duals,CPT,0332T,Heart symp image plnr spect,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,338.26",,,,,,
Molina Duals,CPT,0335T,Insj sinus tarsi implant,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
Molina Duals,CPT,0338T,Trnscth renal symp denrv unl,APC 5192,RVU Per Case,"$5,072.43 ",OP,"5,072.43","5,072.43",,,,,,
Molina Duals,CPT,0339T,Trnscth renal symp denrv bil,APC 5192,RVU Per Case,"$5,072.43 ",OP,"5,072.43","5,072.43",,,,,,
Molina Duals,CPT,0342T,Thxp apheresis w/hdl delip,APC 5243,RVU Per Unit,"$4,131.87 ",OP,"4,131.87","4,131.87",,,,,,
Molina Duals,CPT,0345T,Transcath mtral vlve repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,0347T,Ins bone device for rsa,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Molina Duals,CPT,0348T,Rsa spine exam,APC 5522,RVU Per Case,$111.51 ,OP,111.51,111.51,,,,,,
Molina Duals,CPT,0349T,Rsa upper extr exam,APC 5522,RVU Per Case,$111.51 ,OP,111.51,111.51,,,,,,
Molina Duals,CPT,0350T,Rsa lower extr exam,APC 5521,RVU Per Case,$82.79 ,OP,82.79,82.79,,,,,,
Molina Duals,CPT,0355T,Gi tract capsule endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","1,662.91",,,,,,
Molina Duals,CPT,0356T,Insrt drug device for iop,APC 5692,RVU Per Case,$63.42 ,OP,63.42,63.42,,,,,,
Molina Duals,CPT,0358T,Bia whole body,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Molina Duals,CPT,0362T,Bhv id suprt assmt ea 15 min,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Molina Duals,CPT,0373T,Adapt bhv tx ea 15 min,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Molina Duals,CPT,0379T,Vis field assmnt tech suppt,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Molina Duals,CPT,0394T,Hdr elctrnc skn surf brchytx,APC 5622,RVU Per Unit,$247.32 ,OP,247.32,247.32,,,,,,
Molina Duals,CPT,0395T,Hdr elctr ntrst/ntrcv brchtx,APC 5624,RVU Per Unit,$724.98 ,OP,724.98,724.98,,,,,,
Molina Duals,CPT,0398T,Mrgfus strtctc les abltj,APC 5463,RVU Per Case,"$11,498.23 ",OP,"11,498.23","11,498.23",,,,,,
Molina Duals,CPT,0402T,Colgn cross-link crn med sep,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","2,049.05",,,,,,
Molina Duals,CPT,0404T,Trnscrv uterin fibroid abltj,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,140.35","9,201.00",,,,,,
Molina Duals,CPT,0408T,Insj/rplc cardiac modulj sys,APC 5231,RVU Per Case,"$23,577.44 ",OP,"23,577.44","23,577.44",,,,,,
Molina Duals,CPT,0409T,Insj/rplc car modulj pls gn,APC 5231,RVU Per Case,"$23,577.44 ",OP,"23,577.44","23,577.44",,,,,,
Molina Duals,CPT,0410T,Insj/rplc car modulj atr elt,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
Molina Duals,CPT,0411T,Insj/rplc car modulj vnt elt,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
Molina Duals,CPT,0412T,Rmvl cardiac modulj pls gen,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Molina Duals,CPT,0413T,Rmvl car modulj tranvns elt,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Molina Duals,CPT,0414T,Rmvl & rpl car modulj pls gn,APC 5231,RVU Per Case,"$23,577.44 ",OP,"23,577.44","23,577.44",,,,,,
Molina Duals,CPT,0415T,Repos car modulj tranvns elt,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,554.25,,,,,,
Molina Duals,CPT,0416T,Reloc skin pocket pls gen,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","1,755.36",,,,,,
Molina Duals,CPT,0417T,Prgrmg eval cardiac modulj,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Molina Duals,CPT,0418T,Interro eval cardiac modulj,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Molina Duals,CPT,0419T,Dstrj neurofibroma xtnsv,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,536.39,,,,,,
Molina Duals,CPT,0420T,Dstrj neurofibroma xtnsv,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,536.39,,,,,,
Molina Duals,CPT,0421T,Waterjet prostate abltj cmpl,APC 5376,RVU Per Case,"$8,450.70 ",OP,"8,450.70","8,450.70",,,,,,
Molina Duals,CPT,0422T,Tactile breast img uni/bi,APC 5521,RVU Per Case,$82.79 ,OP,82.79,82.79,,,,,,
Molina Duals,CPT,0424T,Insj/rplc nstim apnea compl,APC 5465,RVU Per Case,"$30,131.14 ",OP,"30,131.14","30,131.14",,,,,,
Molina Duals,CPT,0425T,Insj/rplc nstim apnea sen ld,APC 5463,RVU Per Case,"$11,498.23 ",OP,"11,498.23","11,498.23",,,,,,
Molina Duals,CPT,0426T,Insj/rplc nstim apnea stm ld,APC 5463,RVU Per Case,"$11,498.23 ",OP,"11,498.23","11,498.23",,,,,,
Molina Duals,CPT,0427T,Insj/rplc nstim apnea pls gn,APC 5465,RVU Per Case,"$30,131.14 ",OP,"30,131.14","30,131.14",,,,,,
Molina Duals,CPT,0428T,Rmvl nstim apnea pls gen,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Molina Duals,CPT,0429T,Rmvl nstim apnea sen ld,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Molina Duals,CPT,0430T,Rmvl nstim apnea stimj ld,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Molina Duals,CPT,0431T,Rmvl/rplc nstim apnea pls gn,APC 5465,RVU Per Case,"$30,131.14 ",OP,"30,131.14","30,131.14",,,,,,
Molina Duals,CPT,0432T,Repos nstim apnea stimj ld,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Molina Duals,CPT,0433T,Repos nstim apnea sensing ld,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Molina Duals,CPT,0434T,Interro eval npgs apnea,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,102.65,,,,,,
Molina Duals,CPT,0435T,Prgrmg eval npgs apnea 1 ses,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,102.65,,,,,,
Molina Duals,CPT,0436T,Prgrmg eval npgs apnea study,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,941.27,,,,,,
Molina Duals,CPT,0440T,Abltj perc uxtr/perph nrv,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","1,795.30",,,,,,
Molina Duals,CPT,0441T,Abltj perc lxtr/perph nrv,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","1,795.30",,,,,,
Molina Duals,CPT,0442T,Abltj perc plex/trncl nrv,APC 5432,RVU Per Case,"$5,833.22 ",OP,"5,833.22","5,833.22",,,,,,
Molina Duals,CPT,0446T,Insj impltbl glucose sensor,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","1,755.36",,,,,,
Molina Duals,CPT,0447T,Rmvl impltbl glucose sensor,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
Molina Duals,CPT,0448T,Remvl insj impltbl gluc sens,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","1,755.36",,,,,,
Molina Duals,CPT,0449T,Insj aqueous drain dev 1st,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,009.10",,,,,,
Molina Duals,CPT,0451T,Insj/rplcmt aortic ventr sys,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,0452T,Insj/rplcmt dev vasc seal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,0453T,Insj/rplcmt mech-elec ntrfce,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
Molina Duals,CPT,0454T,Insj/rplcmt subq electrode,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
Molina Duals,CPT,0455T,Remvl aortic ventr cmpl sys,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,0456T,Remvl aortic dev vasc seal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,0457T,Remvl mech-elec skin ntrfce,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Molina Duals,CPT,0458T,Remvl subq electrode,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Molina Duals,CPT,0459T,Relocaj rplcmt aortic ventr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,0460T,Repos aortic ventr dev eltrd,APC 5221,RVU Per Unit,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Molina Duals,CPT,0461T,Repos aortic contrpulsj dev,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,0462T,Prgrmg eval aortic ventr sys,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,278.82,,,,,,
Molina Duals,CPT,0463T,Interrog aortic ventr sys,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,278.82,,,,,,
Molina Duals,CPT,0464T,Visual ep test for glaucoma,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Molina Duals,CPT,0465T,Supchrdl njx rx w/o supply,APC 5694,RVU Per Unit,$318.00 ,OP,318,318,,,,,,
Molina Duals,CPT,0467T,Revj/rplmnt ch respir eltrd,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Molina Duals,CPT,0468T,Rmvl ch wal respir eltrd/ra,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Molina Duals,CPT,0472T,Prgrmg io rta eltrd ra,APC 5743,RVU Per Case,$278.82 ,OP,278.82,278.82,,,,,,
Molina Duals,CPT,0473T,Reprgrmg io rta eltrd ra,APC 5742,RVU Per Case,$102.65 ,OP,102.65,102.65,,,,,,
Molina Duals,CPT,0476T,Rec ftl car sgl elec tr data,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Molina Duals,CPT,0477T,Rec ftl car sgl xrtj alys,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Molina Duals,CPT,0479T,Fxjl abl lsr 1st 100 sq cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,536.39,,,,,,
Molina Duals,CPT,0481T,Njx autol wbc concentrate,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
Molina Duals,CPT,0483T,Tmvi percutaneous approach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,0484T,Tmvi transthoracic exposure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,0485T,Oct mid ear i&r unilateral,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Molina Duals,CPT,0486T,Oct mid ear i&r bilateral,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Molina Duals,CPT,0487T,Trvg biomchn mapg w/reprt,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Molina Duals,CPT,0491T,Abl lsr opn wnd 1st 20 sqcm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,353.91,,,,,,
Molina Duals,CPT,0494T,Prep & cannulj cdvr don lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,0495T,Mntr cdvr don lng 1st 2 hrs,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,0496T,Mntr cdvr don lng ea addl hr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,0497T,Xtrnl pt act ecg in-off conn,APC 5741,RVU Per Case,$38.02 ,OP,38.02,"1,574.64",,,,,,
Molina Duals,CPT,0499T,Cysto f/urtl strix/stenosis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","3,148.08",,,,,,
Molina Duals,CPT,0503T,Cor ffr alys gnrj ffr mdl,APC 1511,RVU Per Unit,$908.19 ,OP,908.19,972.67,,,,,,
Molina Duals,CPT,0505T,Ev fempop artl revsc,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Molina Duals,CPT,0506T,Mac pgmt opt dns meas hfp,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Molina Duals,CPT,0507T,Near ifr 2img mibmn glnd i&r,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Molina Duals,CPT,0508T,Pls echo us b1 dns meas tib,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,111.51,,,,,,
Molina Duals,CPT,0509T,Pattern erg w/i&r,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,386.03,,,,,,
Molina Duals,CPT,0510T,Rmvl sinus tarsi implant,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","2,896.40",,,,,,
Molina Duals,CPT,0511T,Rmvl&rinsj sinus tarsi implt,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
Molina Duals,CPT,0512T,Esw integ wnd hlg 1st wnd,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,183.73,,,,,,
Molina Duals,CPT,0515T,Insj wcs lv compl sys,APC 5231,RVU Per Case,"$23,577.44 ",OP,"23,577.44","23,577.44",,,,,,
Molina Duals,CPT,0516T,Insj wcs lv eltrd only,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
Molina Duals,CPT,0517T,Insj wcs lv pg compnt,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
Molina Duals,CPT,0518T,Rmvl pg compnt wcs,APC 5221,RVU Per Unit,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Molina Duals,CPT,0519T,Rmvl & rplcmt pg compnt wcs,APC 5221,RVU Per Unit,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Molina Duals,CPT,0520T,Rmvl&rplcmt pg wcs new eltrd,APC 5231,RVU Per Case,"$23,577.44 ",OP,"23,577.44","23,577.44",,,,,,
Molina Duals,CPT,0521T,Interrog dev eval wcs ip,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Molina Duals,CPT,0522T,Prgrmg dev eval wcs ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Molina Duals,CPT,0524T,Ev cath dir chem abltj w/img,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","2,928.39",,,,,,
Molina Duals,CPT,0525T,Insj/rplcmt compl iims,APC 5223,RVU Per Case,"$10,642.67 ",OP,"10,642.67","10,642.67",,,,,,
Molina Duals,CPT,0526T,Insj/rplcmt iims eltrd only,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
Molina Duals,CPT,0527T,Insj/rplcmt iims implt mntr,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
Molina Duals,CPT,0528T,Prgrmg dev eval iims ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Molina Duals,CPT,0529T,Interrog dev eval iims ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Molina Duals,CPT,0530T,Removal complete iims,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Molina Duals,CPT,0531T,Removal iims electrode only,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Molina Duals,CPT,0532T,Removal iims implt mntr only,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Molina Duals,CPT,0534T,Cont rec mvmt do setup&train,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Molina Duals,CPT,0535T,Cont rec mvmt do reprt cnfig,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Molina Duals,CPT,0540T,Car-t cll admn autologous,APC 5694,RVU Per Unit,$318.00 ,OP,318,318,,,,,,
Molina Duals,CPT,0541T,Myocardial imaging mcg,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Molina Duals,CPT,0543T,Ta mv rpr w/artif chord tend,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,0544T,Tcat mv annulus rcnstj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,0545T,Tcat tv annulus rcnstj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,0548T,Tprnl balo cntnc dev bi,APC 5377,RVU Per Case,"$11,755.91 ",OP,"11,755.91","11,755.91",,,,,,
Molina Duals,CPT,0549T,Tprnl balo cntnc dev uni,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,516.83","4,516.83",,,,,,
Molina Duals,CPT,0550T,Tprnl balo cntnc dev rmvl ea,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","3,148.08",,,,,,
Molina Duals,CPT,0551T,Tprnl balo cntnc dev adjmt,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,272.35,,,,,,
Molina Duals,CPT,0555T,B1 str&fx rsk transmis data,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,25.25,,,,,,
Molina Duals,CPT,0556T,B1 str & fx rsk assessment,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,235.49,,,,,,
Molina Duals,CPT,0558T,Ct scan f/biomchn ct alys,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,927,,,,,,
Molina Duals,CPT,0559T,Antmc mdl 3d print 1st cmpnt,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Molina Duals,CPT,0561T,Antmc guide 3d print 1st gd,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Molina Duals,CPT,0563T,Evac meibomian glnd heat bi,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Molina Duals,CPT,0564T,Onc chemo rx cytotox csc 14,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
Molina Duals,CPT,0565T,Autol cell implt adps hrvg,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Molina Duals,CPT,0566T,Autol cell implt adps njx,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,267.26,,,,,,
Molina Duals,CPT,0569T,Ttvr perq appr 1st prosth,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,0570T,Ttvr perq ea addl prosth,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,0571T,Insj/rplcmt icds ss eltrd,APC 5232,RVU Per Case,"$33,604.66 ",OP,"33,604.66","33,604.66",,,,,,
Molina Duals,CPT,0572T,Insertion ss dfb electrode,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
Molina Duals,CPT,0573T,Removal ss dfb electrode,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Molina Duals,CPT,0574T,Repos prev ss impl dfb eltrd,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Molina Duals,CPT,0575T,Prgrmg dev eval icds ss ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Molina Duals,CPT,0576T,Interrog dev eval icds ss ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Molina Duals,CPT,0577T,Ephys eval icds ss,APC 5211,RVU Per Case,"$1,138.72 ",OP,"1,138.72","2,775.65",,,,,,
Molina Duals,CPT,0579T,Rem interrog dev icds tech,APC 5741,RVU Per Case,$38.02 ,OP,38.02,213.51,,,,,,
Molina Duals,CPT,0580T,Rmvl ss impl dfb pg only,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
Molina Duals,CPT,0583T,Tmpst auto tube dlvr sys,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","1,384.33",,,,,,
Molina Duals,CPT,0584T,Perq islet cell transplant,APC 5881,RVU Per Case,"$8,948.83 ",OP,"2,508.76","8,948.83",,,,,,
Molina Duals,CPT,0585T,Laps islet cell transplant,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,254.96","8,948.83",,,,,,
Molina Duals,CPT,0586T,Open islet cell transplant,APC 5881,RVU Per Case,"$8,948.83 ",OP,"6,965.79","8,948.83",,,,,,
Molina Duals,CPT,0587T,Perq impltj/rplcmt isdns ptn,APC 5462,RVU Per Case,"$6,304.35 ",OP,"6,304.35","6,304.35",,,,,,
Molina Duals,CPT,0588T,Revision/removal isdns ptn,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
Molina Duals,CPT,0589T,Elec alys smpl prgrmg iins,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,255.45,,,,,,
Molina Duals,CPT,0590T,Elec alys cplx prgrmg iins,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,255.45,,,,,,
Molina Duals,CPT,0594T,Osteot hum xtrnl lngth dev,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
Molina Duals,CPT,0596T,Temp fml iu vlv-pmp 1st insj,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,588.17,,,,,,
Molina Duals,CPT,0597T,Temp fml iu valve-pmp rplcmt,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,588.17,,,,,,
Molina Duals,CPT,0598T,Ncntc r-t fluor wnd img 1st,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Molina Duals,CPT,0600T,Ire abltj 1+tum organ perq,APC 5362,RVU Per Case,"$9,115.38 ",OP,"9,115.38","9,115.38",,,,,,
Molina Duals,CPT,0601T,Ire abltj 1+tumors open,APC 5362,RVU Per Case,"$9,115.38 ",OP,"9,115.38","9,115.38",,,,,,
Molina Duals,CPT,0604T,Rem oct rta dev setup&educaj,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,121.51,,,,,,
Molina Duals,CPT,0605T,Rem oct rta techl sprt min 8,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Molina Duals,CPT,0607T,Rem mntr pulm flu mntr setup,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,121.51,,,,,,
Molina Duals,CPT,0608T,Rem mntr pulm flu mntr alys,APC 5741,RVU Per Unit,$38.02 ,OP,38.02,38.02,,,,,,
Molina Duals,CPT,0609T,Mrs disc pain acquisj data,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Molina Duals,CPT,0611T,Mrs disc pain alg alys data,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,507.00",,,,,,
Molina Duals,CPT,0614T,Rmvl&rplcmt ss impl dfb pg,APC 5231,RVU Per Case,"$23,577.44 ",OP,"23,577.44","23,577.44",,,,,,
Molina Duals,CPT,0615T,Eye mvmt alys w/o calbrj i&r,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Molina Duals,CPT,0616T,Insertion of iris prosthesis,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","2,127.64",,,,,,
Molina Duals,CPT,0617T,Insj iris prosth w/rmvl&insj,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,009.10",,,,,,
Molina Duals,CPT,0618T,Insj iris prosth sec io lens,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,009.10",,,,,,
Molina Duals,CPT,0619T,Cysto w/prst8 commissurotomy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,516.83","4,516.83",,,,,,
Molina Duals,CPT,0620T,Evasc ven artlz tibl/prnl vn,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Molina Duals,CPT,0627T,Perq njx algc fluor lmbr 1st,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
Molina Duals,CPT,0629T,Perq njx algc ct lmbr 1st,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
Molina Duals,CPT,0631T,Tc vis lit hyperspectral img,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Molina Duals,CPT,0632T,Perq tcat us abltj nrv p-art,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Molina Duals,CPT,0633T,Ct breast w/3d uni c-,APC 5522,RVU Per Case,$111.51 ,OP,111.51,111.51,,,,,,
Molina Duals,CPT,0634T,Ct breast w/3d uni c+,APC 5571,RVU Per Case,$182.72 ,OP,182.72,182.72,,,,,,
Molina Duals,CPT,0635T,Ct breast w/3d uni c-/c+,APC 5571,RVU Per Case,$182.72 ,OP,182.72,182.72,,,,,,
Molina Duals,CPT,0636T,Ct breast w/3d bi c-,APC 5523,RVU Per Case,$235.49 ,OP,235.49,235.49,,,,,,
Molina Duals,CPT,0637T,Ct breast w/3d bi c+,APC 5572,RVU Per Case,$376.70 ,OP,376.7,376.7,,,,,,
Molina Duals,CPT,0638T,Ct breast w/3d bi c-/c+,APC 5572,RVU Per Case,$376.70 ,OP,376.7,376.7,,,,,,
Molina Duals,CPT,0641T,Ncntc nr ifr spctrsc wnd img,APC 5732,RVU Per Unit,$34.63 ,OP,34.63,34.63,,,,,,
Molina Duals,CPT,0644T,Tcat rmvl/dblk icar mas perq,APC 5192,RVU Per Case,"$5,072.43 ",OP,"5,072.43","5,072.43",,,,,,
Molina Duals,CPT,0647T,Insj gtube perq mag gastrpxy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","1,662.91",,,,,,
Molina Duals,CPT,0648T,Quan mr alys tiss w/o mri,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,235.49,,,,,,
Molina Duals,CPT,0650T,Prgrmg dev eval scrms remote,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Molina Duals,CPT,0651T,Mag ctrld capsule endoscopy,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,828.48,,,,,,
Molina Duals,CPT,0652T,Egd flx transnasal dx br/wa,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,828.48,,,,,,
Molina Duals,CPT,0653T,Egd flx transnasal bx 1/ml,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,828.48,,,,,,
Molina Duals,CPT,0654T,Egd flx transnasal tube/cath,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","1,662.91",,,,,,
Molina Duals,CPT,0655T,Tprnl focal abltj mal prst8,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","3,148.08",,,,,,
Molina Duals,CPT,0656T,Vrt bdy tethering ant,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,0657T,Vrt bdy tethering ant 8+ seg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,0658T,Elec impd spectrsc 1+skn les,APC 5733,RVU Per Unit,$56.95 ,OP,56.95,56.95,,,,,,
Molina Duals,CPT,0659T,Tcat intra-c nfs supersat o2,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,0662T,Scalp cool 1st meas&calbrj,APC 5732,RVU Per Unit,$34.63 ,OP,34.63,34.63,,,,,,
Molina Duals,CPT,A0425,Ground mileage,Ambulance,Per Unit,$7.47 ,OP,7.47,7.47,,,,,,
Molina Duals,CPT,A0426,Als 1,Ambulance,Per Case,$231.98 ,OP,231.98,"2,249.49",,,,,,
Molina Duals,CPT,A0427,Als1-emergency,Ambulance,Per Case,$231.98 ,OP,231.98,"2,287.62",,,,,,
Molina Duals,CPT,A0428,Bls,Ambulance,Per Case,$231.98 ,OP,231.98,231.98,,,,,,
Molina Duals,CPT,A0429,Bls-emergency,Ambulance,Per Case,$231.98 ,OP,231.98,"1,883.47",,,,,,
Molina Duals,CPT,A0430,Fixed wing air transport,Ambulance,Per Case,"$3,147.91 ",OP,"3,147.91","3,147.91",,,,,,
Molina Duals,CPT,A0431,Rotary wing air transport,Ambulance,Per Case,"$3,659.92 ",OP,"3,659.92","3,659.92",,,,,,
Molina Duals,CPT,A0432,Pi volunteer ambulance co,Ambulance,Per Case,$231.98 ,OP,231.98,231.98,,,,,,
Molina Duals,CPT,A0433,Als 2,Ambulance,Per Case,$231.98 ,OP,231.98,"2,859.52",,,,,,
Molina Duals,CPT,A0434,Specialty care transport,Ambulance,Per Case,$231.98 ,OP,231.98,"6,100.31",,,,,,
Molina Duals,CPT,A0435,Fixed wing air mileage,Ambulance,Per Unit,$8.93 ,OP,8.93,8.93,,,,,,
Molina Duals,CPT,A0436,Rotary wing air mileage,Ambulance,Per Unit,$23.83 ,OP,23.83,23.83,,,,,,
Molina Duals,CPT,A4563,Vag inser rectal control sys,Durable Medical Equipment,Per Unit,"$1,372.71 ",OP,"1,372.71","1,372.71",,,,,,
Molina Duals,CPT,A9513,Lutetium lu 177 dotatat ther,APC 9067,Per Unit,$274.33 ,OP,274.33,274.33,,,,,,
Molina Duals,CPT,A9517,I131 iodide cap- rx,APC 1064,Per Unit,$20.12 ,OP,20.12,32.18,,,,,,
Molina Duals,CPT,A9527,Iodine i-125 sodium iodide,APC 2632,Per Unit,$30.66 ,OP,30.66,30.66,,,,,,
Molina Duals,CPT,A9530,I131 iodide sol- rx,APC 1150,Per Unit,$13.34 ,OP,13.34,13.34,,,,,,
Molina Duals,CPT,A9543,Y90 ibritumomab- rx,APC 1643,Per Unit,"$59,793.85 ",OP,"59,793.85","59,793.85",,,,,,
Molina Duals,CPT,A9563,P32 na phosphate,APC 1675,Per Unit,$458.34 ,OP,458.34,458.34,,,,,,
Molina Duals,CPT,A9590,Iodine i-131 iobenguane 1mci,APC 9339,Per Unit,$320.12 ,OP,320.12,320.12,,,,,,
Molina Duals,CPT,A9591,Fluoroestradiol f 18,APC 9370,Per Unit,$644.83 ,OP,644.83,644.83,,,,,,
Molina Duals,CPT,A9592,Copper cu 64 dotatate diag,APC 9383,Per Unit,$918.21 ,OP,918.21,918.21,,,,,,
Molina Duals,CPT,A9593,Gallium ga-68 psma-11 ucsf,APC 9409,Per Unit,$732.86 ,OP,732.86,732.86,,,,,,
Molina Duals,CPT,A9594,Gallium ga-68 psma-11- ucla,APC 9410,Per Unit,$717.55 ,OP,717.55,717.55,,,,,,
Molina Duals,CPT,A9600,Sr89 strontium,APC 0701,Per Unit,"$3,975.00 ",OP,"3,975.00","4,407.46",,,,,,
Molina Duals,CPT,A9604,Sm 153 lexidronam,APC 1295,Per Unit,"$17,259.85 ",OP,"17,259.85","17,259.85",,,,,,
Molina Duals,CPT,A9606,Radium ra223 dichloride ther,APC 1745,Per Unit,$145.65 ,OP,145.65,145.65,,,,,,
Molina Duals,CPT,C1052,Hemostatic agent- gi- topic,APC 2031,Straight Discount,29.70%,OP,,,,,,,,
Molina Duals,CPT,C1062,Intravertebral fx aug impl,APC 2032,Straight Discount,29.70%,OP,,,,,,,,
Molina Duals,CPT,C1716,Brachytx- non-str- gold-198,APC 2645,Per Unit,$330.76 ,OP,330.76,330.76,,,,,,
Molina Duals,CPT,C1717,Brachytx- non-str-hdr ir-192,APC 2646,Per Unit,$383.90 ,OP,383.9,383.9,,,,,,
Molina Duals,CPT,C1719,Brachytx- ns- non-hdrir-192,APC 2647,Per Unit,$323.97 ,OP,323.97,323.97,,,,,,
Molina Duals,CPT,C1734,Orth/devic/drug bn/bn-tis/bn,APC 2026,Straight Discount,29.70%,OP,,,,,,,,
Molina Duals,CPT,C1748,Endoscope- single- ugi,APC 2029,Straight Discount,29.70%,OP,,,,,,,,
Molina Duals,CPT,C1761,Cath- trans intra litho/coro,APC 2033,Straight Discount,29.70%,OP,,,,,,,,
Molina Duals,CPT,C1823,Gen- neuro- trans sen/stim,APC 2993,Straight Discount,29.70%,OP,,,,,,,,
Molina Duals,CPT,C1824,Generator- ccm- implant,APC 2024,Straight Discount,29.70%,OP,,,,,,,,
Molina Duals,CPT,C1825,Gen- neuro- carot sinus baro,APC 2030,Straight Discount,29.70%,OP,,,,,,,,
Molina Duals,CPT,C1831,Personalized interbody cage,APC 2034,Straight Discount,29.70%,OP,,,,,,,,
Molina Duals,CPT,C1839,Iris prosthesis,APC 2028,Straight Discount,29.70%,OP,,,,,,,,
Molina Duals,CPT,C1982,Cath- pressure-valve-occlu,APC 2025,Straight Discount,29.70%,OP,,,,,,,,
Molina Duals,CPT,C2596,Probe- robotic- water-jet,APC 2027,Straight Discount,29.70%,OP,,,,,,,,
Molina Duals,CPT,C2616,Brachytx- non-str-yttrium-90,APC 2616,Per Unit,"$19,955.81 ",OP,"19,955.81","19,955.81",,,,,,
Molina Duals,CPT,C2634,Brachytx- non-str- ha- i-125,APC 2634,Per Unit,$169.87 ,OP,169.87,169.87,,,,,,
Molina Duals,CPT,C2635,Brachytx- non-str- ha- p-103,APC 2635,Per Unit,$52.25 ,OP,52.25,52.25,,,,,,
Molina Duals,CPT,C2636,Brachy linear- non-str-p-103,APC 2636,Per Unit,$36.02 ,OP,36.02,36.02,,,,,,
Molina Duals,CPT,C2638,Brachytx- stranded- i-125,APC 2638,Per Unit,$42.90 ,OP,42.9,42.9,,,,,,
Molina Duals,CPT,C2639,Brachytx- non-stranded-i-125,APC 2639,Per Unit,$39.11 ,OP,39.11,39.11,,,,,,
Molina Duals,CPT,C2640,Brachytx- stranded- p-103,APC 2640,Per Unit,$100.65 ,OP,100.65,100.65,,,,,,
Molina Duals,CPT,C2641,Brachytx- non-stranded-p-103,APC 2641,Per Unit,$79.72 ,OP,79.72,79.72,,,,,,
Molina Duals,CPT,C2642,Brachytx- stranded- c-131,APC 2642,Per Unit,$82.43 ,OP,82.43,82.43,,,,,,
Molina Duals,CPT,C2643,Brachytx- non-stranded-c-131,APC 2643,Per Unit,$92.16 ,OP,92.16,92.16,,,,,,
Molina Duals,CPT,C2645,Brachytx planar- p-103,APC 2648,Per Unit,$5.38 ,OP,5.38,5.38,,,,,,
Molina Duals,CPT,C2698,Brachytx- stranded- nos,APC 2698,Per Unit,$42.90 ,OP,42.9,42.9,,,,,,
Molina Duals,CPT,C2699,Brachytx- non-stranded- nos,APC 2699,Per Unit,$36.02 ,OP,36.02,36.02,,,,,,
Molina Duals,CPT,C5271,Low cost skin substitute app,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,536.39,,,,,,
Molina Duals,CPT,C5273,Low cost skin substitute app,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","1,755.36",,,,,,
Molina Duals,CPT,C5275,Low cost skin substitute app,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,536.39,,,,,,
Molina Duals,CPT,C5277,Low cost skin substitute app,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,536.39,,,,,,
Molina Duals,CPT,C8900,Mra w/cont- abd,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Molina Duals,CPT,C8901,Mra w/o cont- abd,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Molina Duals,CPT,C8902,Mra w/o fol w/cont- abd,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Molina Duals,CPT,C8903,Mri w/cont- breast-  uni,APC 5571,RVU Per Case,$182.72 ,OP,182.72,"1,507.00",,,,,,
Molina Duals,CPT,C8905,Mri w/o fol w/cont- brst- un,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Molina Duals,CPT,C8906,Mri w/cont- breast-  bi,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Molina Duals,CPT,C8908,Mri w/o fol w/cont- breast-,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Molina Duals,CPT,C8909,Mra w/cont- chest,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Molina Duals,CPT,C8910,Mra w/o cont- chest,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Molina Duals,CPT,C8911,Mra w/o fol w/cont- chest,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Molina Duals,CPT,C8912,Mra w/cont- lwr ext,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Molina Duals,CPT,C8913,Mra w/o cont- lwr ext,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Molina Duals,CPT,C8914,Mra w/o fol w/cont- lwr ext,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Molina Duals,CPT,C8918,Mra w/cont- pelvis,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Molina Duals,CPT,C8919,Mra w/o cont- pelvis,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Molina Duals,CPT,C8920,Mra w/o fol w/cont- pelvis,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Molina Duals,CPT,C8921,Tte w or w/o fol w/cont- com,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
Molina Duals,CPT,C8922,Tte w or w/o fol w/cont- f/u,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
Molina Duals,CPT,C8923,2d tte w or w/o fol w/con-co,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
Molina Duals,CPT,C8924,2d tte w or w/o fol w/con-fu,APC 5572,RVU Per Unit,$376.70 ,OP,376.7,376.7,,,,,,
Molina Duals,CPT,C8925,2d tee w or w/o fol w/con-in,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
Molina Duals,CPT,C8926,Tee w or w/o fol w/cont-cong,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
Molina Duals,CPT,C8927,Tee w or w/o fol w/cont- mon,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
Molina Duals,CPT,C8928,Tte w or w/o fol w/con-stres,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
Molina Duals,CPT,C8929,Tte w or wo fol wcon-doppler,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
Molina Duals,CPT,C8930,Tte w or w/o contr- cont ecg,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
Molina Duals,CPT,C8931,Mra- w/dye- spinal canal,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Molina Duals,CPT,C8932,Mra- w/o dye- spinal canal,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
Molina Duals,CPT,C8933,Mra- w/o&w/dye- spinal canal,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Molina Duals,CPT,C8934,Mra- w/dye- upper extremity,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
Molina Duals,CPT,C8935,Mra- w/o dye- upper extr,APC 5523,RVU Per Case,$235.49 ,OP,235.49,235.49,,,,,,
Molina Duals,CPT,C8936,Mra- w/o&w/dye- upper extr,APC 5572,RVU Per Case,$376.70 ,OP,376.7,376.7,,,,,,
Molina Duals,CPT,C8957,Prolonged iv inf- req pump,APC 5694,RVU Per Unit,$318.00 ,OP,318,318,,,,,,
Molina Duals,CPT,C9046,Cocaine hcl nasal solution,APC 9307,Per Unit,$1.33 ,OP,1.33,1.33,,,,,,
Molina Duals,CPT,C9047,Injection- caplacizumab-yhdp,APC 9199,Per Unit,$691.29 ,OP,691.29,691.29,,,,,,
Molina Duals,CPT,C9067,Gallium ga-68 dotatoc,APC 9323,Per Unit,$8.64 ,OP,8.64,8.64,,,,,,
Molina Duals,CPT,C9081,Idecabtagene car pos t,APC 9422,Per Unit,"$432,085.00 ",OP,"432,085.00","432,085.00",,,,,,
Molina Duals,CPT,C9082,Inj dostarlimab-gxly- 100 mg,APC 9423,Per Unit,"$2,136.09 ",OP,"2,136.09","2,136.09",,,,,,
Molina Duals,CPT,C9083,Inj- amivantamab-vmjw- 10 mg,APC 9424,Per Unit,$87.89 ,OP,87.89,87.89,,,,,,
Molina Duals,CPT,C9084,loncastuximab-lpyl- 0.1 mg,APC 9425,Per Unit,$242.05 ,OP,242.05,242.05,,,,,,
Molina Duals,CPT,C9248,Inj- clevidipine butyrate,APC 9087,Per Unit,$2.91 ,OP,2.91,2.91,,,,,,
Molina Duals,CPT,C9250,Artiss fibrin sealant,APC 1848,Per Unit,$156.84 ,OP,156.84,156.84,,,,,,
Molina Duals,CPT,C9257,Bevacizumab injection,APC 1281,Per Unit,$1.76 ,OP,1.76,1.76,,,,,,
Molina Duals,CPT,C9460,Injection- cangrelor,APC 9460,Per Unit,$16.32 ,OP,16.32,16.32,,,,,,
Molina Duals,CPT,C9462,Injection- delafloxacin,APC 9462,Per Unit,$0.37 ,OP,0.37,0.37,,,,,,
Molina Duals,CPT,C9482,Sotalol hydrochloride iv,APC 9482,Per Unit,$17.58 ,OP,17.58,17.58,,,,,,
Molina Duals,CPT,C9488,Conivaptan hcl,APC 9488,Per Unit,$43.94 ,OP,43.94,43.94,,,,,,
Molina Duals,CPT,C9600,Perc drug-el cor stent sing,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Molina Duals,CPT,C9602,Perc d-e cor stent ather s,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Molina Duals,CPT,C9604,Perc d-e cor revasc t cabg s,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Molina Duals,CPT,C9606,Perc d-e cor revasc w ami s,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
Molina Duals,CPT,C9607,Perc d-e cor revasc chro sin,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Molina Duals,CPT,C9725,Place endorectal app,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,812.16,,,,,,
Molina Duals,CPT,C9727,Insert palate implants,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","1,384.33",,,,,,
Molina Duals,CPT,C9728,Place device/marker- non pro,APC 5613,RVU Per Unit,"$1,291.62 ",OP,"1,291.62","1,291.62",,,,,,
Molina Duals,CPT,C9733,Non-ophthalmic fva,APC 5572,RVU Per Case,$376.70 ,OP,376.7,376.7,,,,,,
Molina Duals,CPT,C9734,U/s trtmt- not leiomyomata,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
Molina Duals,CPT,C9739,Cystoscopy prostatic imp 1-3,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,516.83","4,516.83",,,,,,
Molina Duals,CPT,C9740,Cysto impl 4 or more,APC 5376,RVU Per Case,"$8,450.70 ",OP,"8,450.70","8,450.70",,,,,,
Molina Duals,CPT,C9752,Intraosseous des lumb/sacrum,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
Molina Duals,CPT,C9757,Spine/lumbar disk surgery,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
Molina Duals,CPT,C9761,Cysto- litho- vacuum kidney,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,516.83","4,516.83",,,,,,
Molina Duals,CPT,C9762,Cardiac mri seg dys strain,APC 5524,RVU Per Case,$494.15 ,OP,494.15,494.15,,,,,,
Molina Duals,CPT,C9763,Cardiac mri seg dys stress,APC 5524,RVU Per Case,$494.15 ,OP,494.15,494.15,,,,,,
Molina Duals,CPT,C9764,Revasc intravasc lithotripsy,APC 5192,RVU Per Case,"$5,072.43 ",OP,"5,072.43","5,072.43",,,,,,
Molina Duals,CPT,C9765,Revasc intra lithotrip-stent,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Molina Duals,CPT,C9766,Revasc intra lithotrip-ather,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Molina Duals,CPT,C9767,Revasc lithotrip-stent-ather,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Molina Duals,CPT,C9769,Cysto w/temp pros implant,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,516.83","4,516.83",,,,,,
Molina Duals,CPT,C9771,Nsl/sins cryo post nasal tis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","2,800.20",,,,,,
Molina Duals,CPT,C9772,Revasc lithotrip tibi/perone,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
Molina Duals,CPT,C9773,Revasc lithotr-stent tib/per,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Molina Duals,CPT,C9774,Revasc lithotr-ather tib/per,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Molina Duals,CPT,C9775,Revasc lith-sten-ath tib/per,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Molina Duals,CPT,C9778,Colpopexy- min/inv- ex-perit,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","2,684.38",,,,,,
Molina Duals,CPT,C9779,ESD endoscopy or colonoscopy,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","2,500.37",,,,,,
Molina Duals,CPT,C9780,Insert cv cath inf & sup app,APC 1534,RVU Per Unit,"$7,883.19 ",OP,"7,883.19","8,442.89",,,,,,
Molina Duals,CPT,C9803,Hopd covid-19 spec collect,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
Molina Duals,CPT,D0150,Comprehensve oral evaluation,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D0240,Intraoral occlusal film,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D0250,Extraoral 2d project image,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D0251,Extraoral posterior image,APC 5521,RVU Per Case,$82.79 ,OP,82.79,82.79,,,,,,
Molina Duals,CPT,D0270,Dental bitewing single image,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D0272,Dental bitewings two images,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D0274,Bitewings four images,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D0277,Vert bitewings 7 to 8 images,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D0460,Pulp vitality test,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D0600,Non-ionizing diag proc,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D1510,Space maintainer fxd unilat,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D1516,Fixed bilat space maint- max,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D1517,Fixed bilat space maint- man,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D1520,Remove unilat space maintain,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D1526,Remove bilat space main- max,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D1527,Remove bilat space main- man,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D1551,Recement space maint - max,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D1552,Recement space maint - man,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D1553,Recement unilat space maint,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D1575,Dist space maint- fixed unil,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D2999,Dental unspec restorative pr,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D3460,Endodontic endosseous implan,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D3999,Endodontic procedure,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D4260,Osseous surgery 4 or more,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D4263,Bone replce graft first site,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D4264,Bone replce graft each add,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D4268,Surgical revision procedure,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D4270,Pedicle soft tissue graft pr,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D4273,Auto tissue graft 1st tooth,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D4355,Full mouth debridement,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D4381,Localized delivery antimicro,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D5911,Facial moulage sectional,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D5912,Facial moulage complete,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D5983,Radiation applicator,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D5984,Radiation shield,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D5985,Radiation cone locator,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D5987,Commissure splint,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D6920,Dental connector bar,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D7111,Extraction coronal remnants,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D7140,Extraction erupted tooth/exr,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D7210,Rem imp tooth w mucoper flp,APC 5871,RVU Per Unit,"$1,426.03 ",OP,953.17,"1,426.03",,,,,,
Molina Duals,CPT,D7220,Impact tooth remov soft tiss,APC 5871,RVU Per Unit,"$1,426.03 ",OP,953.17,"1,426.03",,,,,,
Molina Duals,CPT,D7230,Impact tooth remov part bony,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,391.64","1,426.03",,,,,,
Molina Duals,CPT,D7240,Impact tooth remov comp bony,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,715.71",,,,,,
Molina Duals,CPT,D7241,Impact tooth rem bony w/comp,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","2,001.67",,,,,,
Molina Duals,CPT,D7250,Tooth root removal,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D7260,Oral antral fistula closure,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D7261,Primary closure sinus perf,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D7291,Transseptal fiberotomy,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D7940,Reshaping bone orthognathic,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D9930,Treatment of complications,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D9944,Occ guard- hard- full arch,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D9945,Occ guard- soft- full arch,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D9946,Occ guard- hard- part arch,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D9950,Occlusion analysis,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D9951,Limited occlusal adjustment,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,D9952,Complete occlusal adjustment,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
Molina Duals,CPT,G0008,Admin influenza virus vac,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,57.19,,,,,,
Molina Duals,CPT,G0009,Admin pneumococcal vaccine,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,57.19,,,,,,
Molina Duals,CPT,G0010,Admin hepatitis b vaccine,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,57.19,,,,,,
Molina Duals,CPT,G0027,Semen analysis,Lab Services,Per Unit,$6.50 ,OP,6.5,34.31,,,,,,
Molina Duals,CPT,G0101,Ca screen-pelvic/breast exam,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,186.82,,,,,,
Molina Duals,CPT,G0103,Psa screening,Lab Services,Per Unit,$19.31 ,OP,19.31,80.07,,,,,,
Molina Duals,CPT,G0104,Ca screen-flexi sigmoidscope,APC 5311,RVU Per Unit,$812.16 ,OP,678.66,812.16,,,,,,
Molina Duals,CPT,G0105,Colorectal scrn- hi risk ind,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,812.16,,,,,,
Molina Duals,CPT,G0106,Colon ca screen-barium enema,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,"1,090.43",,,,,,
Molina Duals,CPT,G0108,Diab manage trn  per indiv,Physician,Per Unit,$54.47 ,OP,54.47,125.82,,,,,,
Molina Duals,CPT,G0109,Diab manage trn ind/group,Physician,Per Unit,$15.18 ,OP,15.18,72.44,,,,,,
Molina Duals,CPT,G0117,Glaucoma scrn hgh risk direc,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,232.58,,,,,,
Molina Duals,CPT,G0118,Glaucoma scrn hgh risk direc,APC 5732,RVU Per Unit,$34.63 ,OP,34.63,160.13,,,,,,
Molina Duals,CPT,G0120,Colon ca scrn- barium enema,APC 5572,RVU Per Unit,$376.70 ,OP,376.7,"1,090.43",,,,,,
Molina Duals,CPT,G0121,Colon ca scrn not hi rsk ind,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,812.16,,,,,,
Molina Duals,CPT,G0123,Screen cerv/vag thin layer,Lab Services,Per Unit,$20.26 ,OP,20.26,91.51,,,,,,
Molina Duals,CPT,G0127,Trim nail(s),APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
Molina Duals,CPT,G0129,Partial hosp prog service,APC 5853,RVU Per Case,$266.56 ,OP,266.56,266.56,,,,,,
Molina Duals,CPT,G0130,Single energy x-ray study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,171.58,,,,,,
Molina Duals,CPT,G0143,Scr c/v cyto-thinlayer-rescr,Lab Services,Per Unit,$27.05 ,OP,27.05,91.51,,,,,,
Molina Duals,CPT,G0144,Scr c/v cyto-thinlayer-rescr,Lab Services,Per Unit,$43.97 ,OP,43.97,95.32,,,,,,
Molina Duals,CPT,G0145,Scr c/v cyto-thinlayer-rescr,Lab Services,Per Unit,$26.49 ,OP,26.49,118.19,,,,,,
Molina Duals,CPT,G0147,Scr c/v cyto- automated sys,Lab Services,Per Unit,$15.15 ,OP,15.15,45.74,,,,,,
Molina Duals,CPT,G0148,Scr c/v cyto- autosys- rescr,Lab Services,Per Unit,$31.94 ,OP,31.94,45.74,,,,,,
Molina Duals,CPT,G0166,Extrnl counterpulse- per tx,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
Molina Duals,CPT,G0175,Opps service-sched team conf,APC 5024,RVU Per Unit,$372.22 ,OP,372.22,392.7,,,,,,
Molina Duals,CPT,G0176,Opps/php-activity therapy,APC 5853,RVU Per Case,$266.56 ,OP,266.56,266.56,,,,,,
Molina Duals,CPT,G0186,Dstry eye lesn-fdr vssl tech,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,515.61,,,,,,
Molina Duals,CPT,G0235,Pet not otherwise specified,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"7,236.50",,,,,,
Molina Duals,CPT,G0237,Therapeutic procd strg endur,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,61,,,,,,
Molina Duals,CPT,G0238,Oth resp proc- indiv,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,64.82,,,,,,
Molina Duals,CPT,G0239,Oth resp proc- group,APC 5732,RVU Per Unit,$34.63 ,OP,34.63,64.82,,,,,,
Molina Duals,CPT,G0245,Initial foot exam pt lops,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,339.33,,,,,,
Molina Duals,CPT,G0246,Followup eval of foot pt lop,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,198.25,,,,,,
Molina Duals,CPT,G0247,Routine footcare pt w lops,APC 5051,RVU Per Case,$183.73 ,OP,183.73,232.58,,,,,,
Molina Duals,CPT,G0248,Demonstrate use home inr mon,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,804.48,,,,,,
Molina Duals,CPT,G0249,Provide inr test mater/equip,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,686.28,,,,,,
Molina Duals,CPT,G0257,Unsched dialysis esrd pt hos,APC 5401,RVU Per Unit,$669.60 ,OP,669.6,669.6,,,,,,
Molina Duals,CPT,G0260,Inj for sacroiliac jt anesth,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,649.39,,,,,,
Molina Duals,CPT,G0270,Mnt subs tx for change dx,Physician,Per Unit,$26.49 ,OP,26.49,122,,,,,,
Molina Duals,CPT,G0271,Group mnt 2 or more 30 mins,Physician,Per Unit,$13.98 ,OP,13.98,68.63,,,,,,
Molina Duals,CPT,G0276,Pild/placebo control clin tr,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
Molina Duals,CPT,G0277,Hbot- full body chamber- 30m,APC 5061,RVU Per Unit,$122.06 ,OP,122.06,122.06,,,,,,
Molina Duals,CPT,G0279,Tomosynthesis- mammo,Physician,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Molina Duals,CPT,G0281,Elec stim unattend for press,Physician,Per Unit,$12.74 ,OP,12.74,61,,,,,,
Molina Duals,CPT,G0283,Elec stim other than wound,Physician,Per Unit,$12.74 ,OP,12.74,61,,,,,,
Molina Duals,CPT,G0293,Non-cov surg proc-clin trial,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Molina Duals,CPT,G0294,Non-cov proc- clinical trial,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
Molina Duals,CPT,G0296,Visit to determ ldct elig,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Molina Duals,CPT,G0302,Pre-op service lvrs complete,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Molina Duals,CPT,G0303,Pre-op service lvrs 10-15dos,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
Molina Duals,CPT,G0304,Pre-op service lvrs 1-9 dos,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Molina Duals,CPT,G0305,Post op service lvrs min 6,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Molina Duals,CPT,G0306,Cbc/diffwbc w/o platelet,Lab Services,Per Unit,$7.77 ,OP,7.77,34.31,,,,,,
Molina Duals,CPT,G0307,Cbc without platelet,Lab Services,Per Unit,$6.47 ,OP,6.47,30.51,,,,,,
Molina Duals,CPT,G0328,Fecal blood scrn immunoassay,Lab Services,Per Unit,$18.05 ,OP,18.05,72.44,,,,,,
Molina Duals,CPT,G0329,Electromagntic tx for ulcers,Physician,Per Unit,$10.46 ,OP,10.46,45.74,,,,,,
Molina Duals,CPT,G0341,Percutaneous islet celltrans,APC 5881,RVU Per Case,"$8,948.83 ",OP,"2,508.76","8,948.83",,,,,,
Molina Duals,CPT,G0342,Laparoscopy islet cell trans,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,254.96","8,948.83",,,,,,
Molina Duals,CPT,G0343,Laparotomy islet cell transp,APC 5881,RVU Per Case,"$8,948.83 ",OP,"6,965.79","8,948.83",,,,,,
Molina Duals,CPT,G0379,Direct refer hospital observ,APC 5025,RVU Per Case,$534.29 ,OP,534.29,534.29,,,,,,
Molina Duals,CPT,G0380,Lev 1 hosp type b ed visit,APC 5031,RVU Per Case,$72.19 ,OP,72.19,72.19,,,,,,
Molina Duals,CPT,G0381,Lev 2 hosp type b ed visit,APC 5032,RVU Per Case,$97.63 ,OP,97.63,97.63,,,,,,
Molina Duals,CPT,G0382,Lev 3 hosp type b ed visit,APC 5033,RVU Per Case,$185.19 ,OP,185.19,185.19,,,,,,
Molina Duals,CPT,G0383,Lev 4 hosp type b ed visit,APC 5034,RVU Per Case,$233.92 ,OP,233.92,233.92,,,,,,
Molina Duals,CPT,G0384,Lev 5 hosp type b ed visit,APC 5035,RVU Per Case,$325.81 ,OP,325.81,325.81,,,,,,
Molina Duals,CPT,G0390,Trauma respons w/hosp criti,APC 5045,RVU Per Unit,$964.64 ,OP,964.64,964.64,,,,,,
Molina Duals,CPT,G0396,Alcohol/subs interv 15-30mn,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,163.95,,,,,,
Molina Duals,CPT,G0397,Alcohol/subs interv >30 min,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,136.74,,,,,,
Molina Duals,CPT,G0398,Home sleep test/type 2 porta,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,367.82,,,,,,
Molina Duals,CPT,G0399,Home sleep test/type 3 porta,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
Molina Duals,CPT,G0400,Home sleep test/type 4 porta,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,367.82,,,,,,
Molina Duals,CPT,G0402,Initial preventive exam,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,491.83,,,,,,
Molina Duals,CPT,G0404,Ekg tracing for initial prev,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,25.25,,,,,,
Molina Duals,CPT,G0410,Grp psych partial hosp 45-50,APC 5853,RVU Per Case,$266.56 ,OP,266.56,266.56,,,,,,
Molina Duals,CPT,G0411,Inter active grp psych parti,APC 5853,RVU Per Case,$266.56 ,OP,266.56,266.56,,,,,,
Molina Duals,CPT,G0412,Open tx iliac spine uni/bil,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,510.41","6,411.04",,,,,,
Molina Duals,CPT,G0413,Pelvic ring fracture uni/bil,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,527.33",,,,,,
Molina Duals,CPT,G0414,Pelvic ring fx treat int fix,APC 5115,RVU Per Case,"$12,601.93 ",OP,"6,161.31","12,601.93",,,,,,
Molina Duals,CPT,G0415,Open tx post pelvic fxcture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"8,452.74","12,601.93",,,,,,
Molina Duals,CPT,G0416,Prostate biopsy- any mthd,APC 5673,RVU Per Case,$298.05 ,OP,298.05,"3,297.99",,,,,,
Molina Duals,CPT,G0420,Ed svc ckd ind per session,Physician,Per Unit,$111.79 ,OP,111.79,111.79,,,,,,
Molina Duals,CPT,G0421,Ed svc ckd grp per session,Physician,Per Unit,$26.73 ,OP,26.73,26.73,,,,,,
Molina Duals,CPT,G0422,Intens cardiac rehab w/exerc,APC 5771,RVU Per Unit,$118.77 ,OP,118.77,118.77,,,,,,
Molina Duals,CPT,G0423,Intens cardiac rehab no exer,APC 5771,RVU Per Unit,$118.77 ,OP,118.77,118.77,,,,,,
Molina Duals,CPT,G0424,Pulmonary rehab w exer,APC 5733,RVU Per Unit,$56.95 ,OP,56.95,56.95,,,,,,
Molina Duals,CPT,G0429,Dermal filler injection(s),APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","1,755.36",,,,,,
Molina Duals,CPT,G0432,Eia hiv-1/hiv-2 screen,Lab Services,Per Unit,$19.57 ,OP,19.57,19.57,,,,,,
Molina Duals,CPT,G0433,Elisa hiv-1/hiv-2 screen,Lab Services,Per Unit,$18.29 ,OP,18.29,18.29,,,,,,
Molina Duals,CPT,G0435,Oral hiv-1/hiv-2 screen,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,
Molina Duals,CPT,G0438,Ppps- initial visit,Physician,Per Unit,$163.74 ,OP,163.74,163.74,,,,,,
Molina Duals,CPT,G0439,Ppps- subseq visit,Physician,Per Unit,$129.00 ,OP,129,129,,,,,,
Molina Duals,CPT,G0442,Annual alcohol screen 15 min,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Molina Duals,CPT,G0443,Brief alcohol misuse counsel,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Molina Duals,CPT,G0444,Depression screen annual,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Molina Duals,CPT,G0445,High inten beh couns std 30m,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Molina Duals,CPT,G0446,Intens behave ther cardio dx,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Molina Duals,CPT,G0447,Behavior counsel obesity 15m,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Molina Duals,CPT,G0451,Devlopment test interpt&rep,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Molina Duals,CPT,G0455,Fecal microbiota prep instil,APC 5301,RVU Per Case,$828.48 ,OP,828.48,828.48,,,,,,
Molina Duals,CPT,G0460,Autologous prp for ulcers,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","1,755.36",,,,,,
Molina Duals,CPT,G0463,Hospital outpt clinic visit,APC 5012,RVU Per Case,$121.51 ,OP,95.32,121.51,,,,,,
Molina Duals,CPT,G0471,Ven blood coll snf/hha,Lab Services,Per Unit,$5.00 ,OP,5,5,,,,,,
Molina Duals,CPT,G0472,Hep c screen high risk/other,Lab Services,Per Unit,$46.35 ,OP,46.35,46.35,,,,,,
Molina Duals,CPT,G0473,Group behave couns 2-10,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
Molina Duals,CPT,G0475,Hiv combination assay,Lab Services,Per Unit,$24.08 ,OP,24.08,24.08,,,,,,
Molina Duals,CPT,G0476,Hpv combo assay ca screen,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,
Molina Duals,CPT,G0480,Drug test def 1-7 classes,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
Molina Duals,CPT,G0481,Drug test def 8-14 classes,Lab Services,Per Unit,$156.59 ,OP,156.59,156.59,,,,,,
Molina Duals,CPT,G0482,Drug test def 15-21 classes,Lab Services,Per Unit,$198.74 ,OP,198.74,198.74,,,,,,
Molina Duals,CPT,G0483,Drug test def 22+ classes,Lab Services,Per Unit,$246.92 ,OP,246.92,246.92,,,,,,
Molina Duals,CPT,G0498,Chemo extend iv infus w/pump,APC 5694,RVU Per Unit,$318.00 ,OP,318,318,,,,,,
Molina Duals,CPT,G0499,Hepb screen high risk indiv,Lab Services,Per Unit,$28.27 ,OP,28.27,28.27,,,,,,
Molina Duals,CPT,G0516,Insert drug del implant- >=4,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
Molina Duals,CPT,G0517,Remove drug implant,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
Molina Duals,CPT,G0518,Remove w insert drug implant,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
Molina Duals,CPT,G0659,Drug test def simple all cl,Lab Services,Per Unit,$62.14 ,OP,62.14,62.14,,,,,,
Molina Duals,CPT,G2000,Blinded conv. tx mdd clin tr,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
Molina Duals,CPT,G2011,Alcohol/sub misuse assess,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,25.25,,,,,,
Molina Duals,CPT,G2065,Clin mang h risk dx 30,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Molina Duals,CPT,G2066,Inter devc remote 30d,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
Molina Duals,CPT,G2082,Visit esketamine 56m or less,APC 1508,RVU Per Unit,$621.54 ,OP,621.54,665.67,,,,,,
Molina Duals,CPT,G2083,Visit esketamine- > 56m,APC 1511,RVU Per Unit,$972.67 ,OP,972.67,972.67,,,,,,
Molina Duals,CPT,G2086,Off base opioid tx 70min,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,136.74,,,,,,
Molina Duals,CPT,G2087,Off base opioid tx- 60 m,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,136.74,,,,,,
Molina Duals,CPT,G2170,Avf by tissue w thermal e,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Molina Duals,CPT,G2171,Avf use magnetic/art/ven,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
Molina Duals,CPT,G2214,Init/sub psych care m 1st 30,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
Molina Duals,CPT,G2250,Remot img sub by pt- non e/m,Physician,Per Unit,$9.24 ,OP,9.24,9.24,,,,,,
Molina Duals,CPT,G2251,Brief chkin- 5-10- non-e/m,Physician,Per Unit,$13.05 ,OP,13.05,13.05,,,,,,
Molina Duals,CPT,G2252,Brief chkin by md/qhp- 11-20,Physician,Per Unit,$25.14 ,OP,25.14,25.14,,,,,,
Molina Duals,CPT,J0121,Inj.- omadacycline- 1 mg,APC 9311,Per Unit,$3.30 ,OP,3.3,3.3,,,,,,
Molina Duals,CPT,J0129,Abatacept injection,APC 9230,Per Unit,$45.27 ,OP,45.27,73.44,,,,,,
Molina Duals,CPT,J0135,Adalimumab injection,APC 1083,Per Unit,"$1,581.57 ",OP,"1,581.57","1,581.57",,,,,,
Molina Duals,CPT,J0178,Aflibercept injection,APC 1420,Per Unit,$917.94 ,OP,917.94,917.94,,,,,,
Molina Duals,CPT,J0179,Inj- brolucizumab-dbll- 1 mg,APC 9340,Per Unit,$312.01 ,OP,312.01,312.01,,,,,,
Molina Duals,CPT,J0180,Agalsidase beta injection,APC 9208,Per Unit,$198.14 ,OP,198.14,508.92,,,,,,
Molina Duals,CPT,J0185,Inj.- aprepitant- 1 mg,APC 9463,Per Unit,$1.69 ,OP,1.69,1.69,,,,,,
Molina Duals,CPT,J0202,Injection- alemtuzumab,APC 1809,Per Unit,"$2,086.32 ",OP,277.19,"2,086.32",,,,,,
Molina Duals,CPT,J0207,Amifostine,APC 7000,Per Unit,"$1,135.69 ",OP,"1,135.69","1,985.16",,,,,,
Molina Duals,CPT,J0220,Alglucosidase alfa injection,APC 9234,Per Unit,$117.07 ,OP,117.07,474.68,,,,,,
Molina Duals,CPT,J0221,Lumizyme injection,APC 1413,Per Unit,$180.35 ,OP,180.35,180.35,,,,,,
Molina Duals,CPT,J0222,Inj.- patisiran- 0.1 mg,APC 9180,Per Unit,$97.75 ,OP,97.75,97.75,,,,,,
Molina Duals,CPT,J0223,Inj givosiran 0.5 mg,APC 9343,Per Unit,$106.76 ,OP,106.76,106.76,,,,,,
Molina Duals,CPT,J0224,Inj. lumasiran- 0.5 mg,APC 9407,Per Unit,$302.30 ,OP,302.3,302.3,,,,,,
Molina Duals,CPT,J0256,Alpha 1 proteinase inhibitor,APC 0901,Per Unit,$4.54 ,OP,4.54,7.9,,,,,,
Molina Duals,CPT,J0257,Glassia injection,APC 1415,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,
Molina Duals,CPT,J0287,Amphotericin b lipid complex,APC 9024,Per Unit,$9.50 ,OP,9.5,49.56,,,,,,
Molina Duals,CPT,J0289,Amphotericin b liposome inj,APC 0736,Per Unit,$28.75 ,OP,28.75,118.19,,,,,,
Molina Duals,CPT,J0291,Inj.- plazomicin- 5 mg,APC 9183,Per Unit,$3.05 ,OP,3.05,3.05,,,,,,
Molina Duals,CPT,J0300,Amobarbital 125 mg inj,APC 1341,Per Unit,$125.22 ,OP,30.51,125.22,,,,,,
Molina Duals,CPT,J0390,Chloroquine injection,APC 9352,Per Unit,$165.22 ,OP,83.87,165.22,,,,,,
Molina Duals,CPT,J0401,Inj aripiprazole ext rel 1mg,APC 1468,Per Unit,$6.01 ,OP,6.01,7.62,,,,,,
Molina Duals,CPT,J0475,Baclofen 10 mg injection,APC 9032,Per Unit,$177.43 ,OP,177.43,826.29,,,,,,
Molina Duals,CPT,J0480,Basiliximab,APC 1683,Per Unit,"$4,013.08 ",OP,"4,013.08","7,724.52",,,,,,
Molina Duals,CPT,J0485,Belatacept injection,APC 9286,Per Unit,$3.80 ,OP,3.8,3.8,,,,,,
Molina Duals,CPT,J0490,Belimumab injection,APC 1353,Per Unit,$47.57 ,OP,47.57,47.57,,,,,,
Molina Duals,CPT,J0517,Inj.- benralizumab- 1 mg,APC 9466,Per Unit,$170.80 ,OP,170.8,170.8,,,,,,
Molina Duals,CPT,J0558,Peng benzathine/procaine inj,APC 9088,Per Unit,$11.79 ,OP,11.79,11.79,,,,,,
Molina Duals,CPT,J0561,Penicillin g benzathine inj,APC 1829,Per Unit,$14.95 ,OP,14.95,14.95,,,,,,
Molina Duals,CPT,J0565,Inj- bezlotoxumab- 10 mg,APC 9490,Per Unit,$39.77 ,OP,39.77,39.77,,,,,,
Molina Duals,CPT,J0570,Buprenorphine implant 74.2mg,APC 9058,Per Unit,"$1,311.75 ",OP,209.7,"1,311.75",,,,,,
Molina Duals,CPT,J0584,Injection- burosumab-twza 1m,APC 9187,Per Unit,$369.11 ,OP,369.11,369.11,,,,,,
Molina Duals,CPT,J0585,Injection-onabotulinumtoxina,APC 0902,Per Unit,$6.09 ,OP,6.09,6.09,,,,,,
Molina Duals,CPT,J0586,Abobotulinumtoxina,APC 1289,Per Unit,$8.41 ,OP,8.41,8.41,,,,,,
Molina Duals,CPT,J0587,Inj- rimabotulinumtoxinb,APC 9018,Per Unit,$12.05 ,OP,12.05,39.5,,,,,,
Molina Duals,CPT,J0588,Incobotulinumtoxin a,APC 9278,Per Unit,$5.05 ,OP,5.05,5.05,,,,,,
Molina Duals,CPT,J0594,Busulfan injection,APC 1178,Per Unit,$1.71 ,OP,1.71,61,,,,,,
Molina Duals,CPT,J0596,Injection- ruconest,APC 9445,Per Unit,$29.97 ,OP,29.97,29.97,,,,,,
Molina Duals,CPT,J0597,C-1 esterase- berinert,APC 9269,Per Unit,$57.39 ,OP,57.39,57.39,,,,,,
Molina Duals,CPT,J0598,C-1 esterase- cinryze,APC 9251,Per Unit,$58.93 ,OP,58.93,58.93,,,,,,
Molina Duals,CPT,J0599,Inj.- haegarda 10 units,APC 9015,Per Unit,$10.25 ,OP,10.25,10.25,,,,,,
Molina Duals,CPT,J0600,Edetate calcium disodium inj,APC 1274,Per Unit,"$5,708.59 ",OP,362.21,"5,708.59",,,,,,
Molina Duals,CPT,J0630,Calcitonin salmon injection,APC 1433,Per Unit,"$3,100.79 ",OP,191.13,"3,100.79",,,,,,
Molina Duals,CPT,J0638,Canakinumab injection,APC 1311,Per Unit,$115.61 ,OP,115.61,115.61,,,,,,
Molina Duals,CPT,J0641,Inj levoleucovorin nos 0.5mg,APC 1236,Per Unit,$0.09 ,OP,0.09,0.09,,,,,,
Molina Duals,CPT,J0642,Injection- khapzory- 0.5 mg,APC 9334,Per Unit,$1.86 ,OP,1.86,1.86,,,,,,
Molina Duals,CPT,J0691,Inj lefamulin 1 mg,APC 9332,Per Unit,$0.72 ,OP,0.72,0.72,,,,,,
Molina Duals,CPT,J0695,Inj ceftolozane tazobactam,APC 9452,Per Unit,$6.64 ,OP,6.64,6.64,,,,,,
Molina Duals,CPT,J0699,Inj- cefiderocol- 10 mg,APC 9426,Per Unit,$2.01 ,OP,2.01,2.01,,,,,,
Molina Duals,CPT,J0712,Ceftaroline fosamil inj,APC 1824,Per Unit,$3.51 ,OP,3.51,3.51,,,,,,
Molina Duals,CPT,J0714,Ceftazidime and avibactam,APC 1825,Per Unit,$92.39 ,OP,92.39,92.39,,,,,,
Molina Duals,CPT,J0716,Centruroides immune f(ab),APC 1431,Per Unit,"$5,190.15 ",OP,"5,190.15","5,190.15",,,,,,
Molina Duals,CPT,J0717,Certolizumab pegol inj 1mg,APC 1474,Per Unit,$6.27 ,OP,6.27,6.27,,,,,,
Molina Duals,CPT,J0740,Cidofovir injection,APC 9033,Per Unit,$563.76 ,OP,563.76,"3,694.50",,,,,,
Molina Duals,CPT,J0741,Inj- cabote rilpivir 2mg 3mg,APC 9414,Per Unit,$20.56 ,OP,20.56,20.56,,,,,,
Molina Duals,CPT,J0742,Inj imip 4 cilas 4 releb 2mg,APC 9362,Per Unit,$2.32 ,OP,2.32,2.32,,,,,,
Molina Duals,CPT,J0745,Inj codeine phosphate /30 mg,APC 9393,Per Unit,$135.64 ,OP,7.62,135.64,,,,,,
Molina Duals,CPT,J0775,Collagenase- clost hist inj,APC 1340,Per Unit,$56.66 ,OP,56.66,56.66,,,,,,
Molina Duals,CPT,J0791,Inj crizanlizumab-tmca 5mg,APC 9359,Per Unit,$123.29 ,OP,123.29,123.29,,,,,,
Molina Duals,CPT,J0795,Corticorelin ovine triflutal,APC 1684,Per Unit,$9.67 ,OP,9.67,22.88,,,,,,
Molina Duals,CPT,J0840,Crotalidae poly immune fab,APC 9274,Per Unit,"$2,743.36 ",OP,"2,743.36","2,743.36",,,,,,
Molina Duals,CPT,J0841,Inj crotalidae im f(ab)2 eq,APC 9188,Per Unit,"$1,189.81 ",OP,"1,189.81","1,189.81",,,,,,
Molina Duals,CPT,J0850,Cytomegalovirus imm iv /vial,APC 0903,Per Unit,"$1,538.70 ",OP,"1,538.70","4,266.40",,,,,,
Molina Duals,CPT,J0875,Injection- dalbavancin,APC 1823,Per Unit,$15.89 ,OP,15.89,15.89,,,,,,
Molina Duals,CPT,J0881,Darbepoetin alfa- non-esrd,APC 1685,Per Unit,$3.15 ,OP,3.15,15.26,,,,,,
Molina Duals,CPT,J0882,Darbepoetin alfa- esrd use,APC 1482,Per Unit,$3.15 ,OP,3.15,15.26,,,,,,
Molina Duals,CPT,J0883,Argatroban nonesrd use 1mg,APC 1859,Per Unit,$1.20 ,OP,1.2,1.2,,,,,,
Molina Duals,CPT,J0884,Argatroban esrd dialysis 1mg,APC 9065,Per Unit,$1.20 ,OP,1.2,1.2,,,,,,
Molina Duals,CPT,J0885,Epoetin alfa- non-esrd,APC 1686,Per Unit,$8.15 ,OP,8.15,45.74,,,,,,
Molina Duals,CPT,J0888,Epoetin beta non esrd,APC 9077,Per Unit,$1.51 ,OP,1.51,1.51,,,,,,
Molina Duals,CPT,J0894,Decitabine injection,APC 9231,Per Unit,$3.45 ,OP,3.45,3.45,,,,,,
Molina Duals,CPT,J0896,Inj luspatercept-aamt 0.25mg,APC 9347,Per Unit,$36.85 ,OP,36.85,36.85,,,,,,
Molina Duals,CPT,J0897,Denosumab injection,APC 9272,Per Unit,$21.19 ,OP,21.19,21.19,,,,,,
Molina Duals,CPT,J1095,Injection- dexamethasone 9%,APC 9172,Per Unit,$1.04 ,OP,1.04,1.04,,,,,,
Molina Duals,CPT,J1096,Dexametha opth insert 0.1 mg,APC 9308,Per Unit,$133.30 ,OP,133.3,133.3,,,,,,
Molina Duals,CPT,J1162,Digoxin immune fab (ovine),APC 1687,Per Unit,"$4,128.19 ",OP,"2,344.81","4,128.19",,,,,,
Molina Duals,CPT,J1190,Dexrazoxane hcl injection,APC 0726,Per Unit,$192.33 ,OP,192.33,"1,849.16",,,,,,
Molina Duals,CPT,J1201,Inj. cetirizine hcl 0.5mg,APC 9361,Per Unit,$15.38 ,OP,15.38,15.38,,,,,,
Molina Duals,CPT,J1212,Dimethyl sulfoxide 50% 50 ml,APC 1832,Per Unit,$637.11 ,OP,339.33,637.11,,,,,,
Molina Duals,CPT,J1290,Ecallantide injection,APC 9263,Per Unit,$503.88 ,OP,503.88,503.88,,,,,,
Molina Duals,CPT,J1300,Eculizumab injection,APC 9236,Per Unit,$229.23 ,OP,229.23,679.45,,,,,,
Molina Duals,CPT,J1301,Injection- edaravone- 1 mg,APC 9493,Per Unit,$20.51 ,OP,20.51,20.51,,,,,,
Molina Duals,CPT,J1303,Inj.- ravulizumab-cwvz 10 mg,APC 9312,Per Unit,$224.68 ,OP,224.68,224.68,,,,,,
Molina Duals,CPT,J1305,Inj- evinacumab-dgnb- 5mg,APC 9416,Per Unit,$165.63 ,OP,165.63,165.63,,,,,,
Molina Duals,CPT,J1322,Elosulfase alfa- injection,APC 1480,Per Unit,$250.33 ,OP,250.33,250.33,,,,,,
Molina Duals,CPT,J1364,Erythro lactobionate /500 mg,APC 1669,Per Unit,$77.75 ,OP,38.13,77.75,,,,,,
Molina Duals,CPT,J1410,Inj estrogen conjugate 25 mg,APC 9038,Per Unit,$341.46 ,OP,341.46,381.27,,,,,,
Molina Duals,CPT,J1426,Injection- casimersen- 10 mg,APC 9412,Per Unit,$166.47 ,OP,166.47,166.47,,,,,,
Molina Duals,CPT,J1427,Inj. viltolarsen,APC 9386,Per Unit,$59.05 ,OP,59.05,59.05,,,,,,
Molina Duals,CPT,J1429,Inj golodirsen 10 mg,APC 9356,Per Unit,$166.21 ,OP,166.21,166.21,,,,,,
Molina Duals,CPT,J1430,Ethanolamine oleate 100 mg,APC 1688,Per Unit,$444.10 ,OP,444.1,728.23,,,,,,
Molina Duals,CPT,J1437,Inj. fe derisomaltose 10 mg,APC 9388,Per Unit,$24.87 ,OP,24.87,24.87,,,,,,
Molina Duals,CPT,J1438,Etanercept injection,APC 1608,Per Unit,$790.78 ,OP,714.31,790.78,,,,,,
Molina Duals,CPT,J1439,Inj ferric carboxymaltos 1mg,APC 9441,Per Unit,$1.12 ,OP,1.12,1.12,,,,,,
Molina Duals,CPT,J1442,Inj filgrastim excl biosimil,APC 1469,Per Unit,$0.97 ,OP,0.97,3.09,,,,,,
Molina Duals,CPT,J1447,Inj tbo filgrastim 1 microg,APC 1748,Per Unit,$0.46 ,OP,0.46,3.1,,,,,,
Molina Duals,CPT,J1448,Injection- trilaciclib- 1mg,APC 9415,Per Unit,$4.97 ,OP,4.97,4.97,,,,,,
Molina Duals,CPT,J1451,Fomepizole- 15 mg,APC 1689,Per Unit,$5.98 ,OP,5.98,49.56,,,,,,
Molina Duals,CPT,J1453,Fosaprepitant injection,APC 9242,Per Unit,$0.24 ,OP,0.24,7.62,,,,,,
Molina Duals,CPT,J1454,Inj fosnetupitant- palonoset,APC 9099,Per Unit,$571.22 ,OP,571.22,571.22,,,,,,
Molina Duals,CPT,J1455,Foscarnet sodium injection,APC 1849,Per Unit,$72.86 ,OP,49.56,72.86,,,,,,
Molina Duals,CPT,J1458,Galsulfase injection,APC 9224,Per Unit,$411.92 ,OP,411.92,"1,289.57",,,,,,
Molina Duals,CPT,J1459,Inj ivig privigen 500 mg,APC 1214,Per Unit,$44.48 ,OP,44.48,143.18,,,,,,
Molina Duals,CPT,J1460,Gamma globulin 1 cc inj,APC 1850,Per Unit,$44.13 ,OP,44.13,61,,,,,,
Molina Duals,CPT,J1554,Inj. asceniv,APC 9392,Per Unit,$481.77 ,OP,481.77,481.77,,,,,,
Molina Duals,CPT,J1555,Inj cuvitru- 100 mg,APC 9034,Per Unit,$14.50 ,OP,14.5,14.5,,,,,,
Molina Duals,CPT,J1556,Inj- imm glob bivigam- 500mg,APC 9130,Per Unit,$70.49 ,OP,70.49,70.49,,,,,,
Molina Duals,CPT,J1557,Gammaplex injection,APC 9270,Per Unit,$48.53 ,OP,48.53,48.53,,,,,,
Molina Duals,CPT,J1558,Inj. xembify- 100 mg,APC 9372,Per Unit,$13.61 ,OP,13.61,13.61,,,,,,
Molina Duals,CPT,J1559,Hizentra injection,APC 1312,Per Unit,$11.58 ,OP,11.58,11.58,,,,,,
Molina Duals,CPT,J1560,Gamma globulin > 10 cc inj,APC 1851,Per Unit,$441.31 ,OP,441.31,621.47,,,,,,
Molina Duals,CPT,J1561,Gamunex-c/gammaked,APC 0948,Per Unit,$48.22 ,OP,48.22,158.91,,,,,,
Molina Duals,CPT,J1566,Immune globulin- powder,APC 2731,Per Unit,$65.49 ,OP,65.49,152.51,,,,,,
Molina Duals,CPT,J1568,Octagam injection,APC 0943,Per Unit,$41.63 ,OP,41.63,41.63,,,,,,
Molina Duals,CPT,J1569,Gammagard liquid injection,APC 0944,Per Unit,$44.49 ,OP,44.49,171.58,,,,,,
Molina Duals,CPT,J1571,Hepagam b im injection,APC 0946,Per Unit,$70.94 ,OP,70.94,213.51,,,,,,
Molina Duals,CPT,J1572,Flebogamma injection,APC 0947,Per Unit,$36.80 ,OP,36.8,171.58,,,,,,
Molina Duals,CPT,J1573,Hepagam b intravenous- inj,APC 1138,Per Unit,$71.24 ,OP,71.24,213.51,,,,,,
Molina Duals,CPT,J1575,Hyqvia 100mg immuneglobulin,APC 1826,Per Unit,$15.16 ,OP,15.16,15.16,,,,,,
Molina Duals,CPT,J1595,Injection glatiramer acetate,APC 1015,Per Unit,$141.29 ,OP,141.29,298.68,,,,,,
Molina Duals,CPT,J1602,Golimumab for iv use 1mg,APC 1475,Per Unit,$16.82 ,OP,16.82,16.82,,,,,,
Molina Duals,CPT,J1610,Glucagon hydrochloride/1 mg,APC 9042,Per Unit,$171.74 ,OP,171.74,343.14,,,,,,
Molina Duals,CPT,J1628,Inj.- guselkumab- 1 mg,APC 9029,Per Unit,$82.56 ,OP,82.56,82.56,,,,,,
Molina Duals,CPT,J1632,Inj.- brexanolone- 1 mg,APC 9333,Per Unit,$74.65 ,OP,74.65,74.65,,,,,,
Molina Duals,CPT,J1640,Hemin- 1 mg,APC 1690,Per Unit,$26.64 ,OP,26.64,38.13,,,,,,
Molina Duals,CPT,J1670,Tetanus immune globulin inj,APC 1670,Per Unit,$441.70 ,OP,441.7,"1,040.87",,,,,,
Molina Duals,CPT,J1726,Makena- 10 mg,APC 9074,Per Unit,$16.82 ,OP,16.82,16.82,,,,,,
Molina Duals,CPT,J1729,Inj hydroxyprogst capoat nos,APC 9318,Per Unit,$21.54 ,OP,21.54,21.54,,,,,,
Molina Duals,CPT,J1738,Inj. meloxicam 1 mg,APC 9371,Per Unit,$3.18 ,OP,3.18,3.18,,,,,,
Molina Duals,CPT,J1740,Ibandronate sodium injection,APC 9229,Per Unit,$37.09 ,OP,37.09,674.85,,,,,,
Molina Duals,CPT,J1742,Ibutilide fumarate injection,APC 9044,Per Unit,$205.06 ,OP,205.06,"1,898.73",,,,,,
Molina Duals,CPT,J1744,Icatibant injection,APC 1443,Per Unit,$204.96 ,OP,204.96,204.96,,,,,,
Molina Duals,CPT,J1745,Infliximab not biosimil 10mg,APC 7043,Per Unit,$39.53 ,OP,39.53,301.32,,,,,,
Molina Duals,CPT,J1746,Inj.- ibalizumab-uiyk- 10 mg,APC 9189,Per Unit,$66.39 ,OP,66.39,66.39,,,,,,
Molina Duals,CPT,J1750,Inj iron dextran,APC 1237,Per Unit,$15.84 ,OP,15.84,15.84,,,,,,
Molina Duals,CPT,J1786,Imuglucerase injection,APC 1327,Per Unit,$44.05 ,OP,44.05,44.05,,,,,,
Molina Duals,CPT,J1823,Inj. inebilizumab-cdon- 1 mg,APC 9394,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Molina Duals,CPT,J1826,Interferon beta-1a inj,APC 1852,Per Unit,"$2,293.85 ",OP,"2,293.85","2,293.85",,,,,,
Molina Duals,CPT,J1830,Interferon beta-1b / .25 mg,APC 0910,Per Unit,$406.24 ,OP,406.24,538.7,,,,,,
Molina Duals,CPT,J1833,Injection- isavuconazonium,APC 9456,Per Unit,$0.83 ,OP,0.83,0.83,,,,,,
Molina Duals,CPT,J1930,Lanreotide injection,APC 9237,Per Unit,$67.64 ,OP,67.64,129.64,,,,,,
Molina Duals,CPT,J1931,Laronidase injection,APC 9209,Per Unit,$34.75 ,OP,34.75,95.46,,,,,,
Molina Duals,CPT,J1943,Inj.- aristada initio- 1 mg,APC 9179,Per Unit,$3.05 ,OP,3.05,3.05,,,,,,
Molina Duals,CPT,J1944,Aripirazole lauroxil 1 mg,APC 9470,Per Unit,$2.99 ,OP,2.99,2.99,,,,,,
Molina Duals,CPT,J1950,Leuprolide acetate /3.75 mg,APC 0800,Per Unit,"$1,406.37 ",OP,"1,406.37","1,525.07",,,,,,
Molina Duals,CPT,J1951,Inj fensolvi 0.25 mg,APC 9419,Per Unit,$126.28 ,OP,126.28,126.28,,,,,,
Molina Duals,CPT,J2182,Injection- mepolizumab- 1mg,APC 9473,Per Unit,$28.29 ,OP,28.29,28.29,,,,,,
Molina Duals,CPT,J2186,Inj.- meropenem- vaborbactam,APC 9178,Per Unit,$1.76 ,OP,1.76,1.76,,,,,,
Molina Duals,CPT,J2248,Micafungin sodium injection,APC 9227,Per Unit,$0.97 ,OP,0.97,0.97,,,,,,
Molina Duals,CPT,J2265,Minocycline hydrochloride,APC 1853,Per Unit,$2.00 ,OP,2,2,,,,,,
Molina Duals,CPT,J2278,Ziconotide injection,APC 1694,Per Unit,$8.69 ,OP,8.69,30.51,,,,,,
Molina Duals,CPT,J2315,Naltrexone- depot form,APC 0759,Per Unit,$3.53 ,OP,3.53,3.53,,,,,,
Molina Duals,CPT,J2323,Natalizumab injection,APC 9126,Per Unit,$23.24 ,OP,23.24,103.45,,,,,,
Molina Duals,CPT,J2326,Inj- nusinersen- 0.1mg,APC 9489,Per Unit,"$1,122.13 ",OP,"1,122.13","1,122.13",,,,,,
Molina Duals,CPT,J2350,Injection- ocrelizumab- 1 mg,APC 9494,Per Unit,$58.29 ,OP,58.29,58.29,,,,,,
Molina Duals,CPT,J2353,Octreotide injection- depot,APC 1207,Per Unit,$205.37 ,OP,205.37,408.99,,,,,,
Molina Duals,CPT,J2357,Omalizumab injection,APC 9300,Per Unit,$37.67 ,OP,37.67,70.74,,,,,,
Molina Duals,CPT,J2358,Olanzapine long-acting inj,APC 1331,Per Unit,$2.91 ,OP,2.91,2.91,,,,,,
Molina Duals,CPT,J2406,Injection- oritavancin 10 mg,APC 9427,Per Unit,$41.92 ,OP,41.92,41.92,,,,,,
Molina Duals,CPT,J2407,Injection- oritavancin,APC 1660,Per Unit,$23.63 ,OP,23.63,23.63,,,,,,
Molina Duals,CPT,J2425,Palifermin injection,APC 1696,Per Unit,$23.93 ,OP,23.93,23.93,,,,,,
Molina Duals,CPT,J2426,Paliperidone palmitate inj,APC 9255,Per Unit,$12.66 ,OP,12.66,12.66,,,,,,
Molina Duals,CPT,J2502,Inj- pasireotide long acting,APC 9454,Per Unit,$359.03 ,OP,359.03,359.03,,,,,,
Molina Duals,CPT,J2504,Pegademase bovine- 25 iu,APC 1739,Per Unit,$4.06 ,OP,4.06,"1,098.07",,,,,,
Molina Duals,CPT,J2505,Injection- pegfilgrastim 6mg,APC 9119,Per Unit,"$2,221.63 ",OP,"2,221.63","10,481.09",,,,,,
Molina Duals,CPT,J2507,Pegloticase injection,APC 9281,Per Unit,"$2,960.91 ",OP,"2,960.91","2,960.91",,,,,,
Molina Duals,CPT,J2515,Pentobarbital sodium inj,APC 1854,Per Unit,$26.41 ,OP,26.41,26.41,,,,,,
Molina Duals,CPT,J2547,Injection- peramivir,APC 9451,Per Unit,$1.68 ,OP,1.68,1.68,,,,,,
Molina Duals,CPT,J2560,Phenobarbital sodium inj,APC 9069,Per Unit,$40.22 ,OP,40.22,40.22,,,,,,
Molina Duals,CPT,J2562,Plerixafor injection,APC 9252,Per Unit,$382.85 ,OP,382.85,382.85,,,,,,
Molina Duals,CPT,J2597,Inj desmopressin acetate,APC 1440,Per Unit,$9.40 ,OP,9.4,9.4,,,,,,
Molina Duals,CPT,J2724,Protein c concentrate,APC 1139,Per Unit,$15.13 ,OP,15.13,61,,,,,,
Molina Duals,CPT,J2760,Phentolaine mesylate inj,APC 1458,Per Unit,$416.00 ,OP,255.45,416,,,,,,
Molina Duals,CPT,J2770,Quinupristin/dalfopristin,APC 2770,Per Unit,$444.67 ,OP,444.67,712.98,,,,,,
Molina Duals,CPT,J2778,Ranibizumab injection,APC 9233,Per Unit,$318.47 ,OP,318.47,318.47,,,,,,
Molina Duals,CPT,J2783,Rasburicase,APC 0738,Per Unit,$315.06 ,OP,315.06,804.48,,,,,,
Molina Duals,CPT,J2786,Injection- reslizumab- 1mg,APC 9481,Per Unit,$10.11 ,OP,10.11,10.11,,,,,,
Molina Duals,CPT,J2792,Rho(d) immune globulin h- sd,APC 1609,Per Unit,$31.42 ,OP,31.42,80.07,,,,,,
Molina Duals,CPT,J2794,Inj risperdal consta- 0.5 mg,APC 9125,Per Unit,$11.04 ,OP,11.04,19.71,,,,,,
Molina Duals,CPT,J2796,Romiplostim injection,APC 9245,Per Unit,$83.47 ,OP,83.47,83.47,,,,,,
Molina Duals,CPT,J2798,Inj.- perseris- 0.5 mg,APC 9181,Per Unit,$10.69 ,OP,10.69,10.69,,,,,,
Molina Duals,CPT,J2820,Sargramostim injection,APC 0731,Per Unit,$51.55 ,OP,51.55,122,,,,,,
Molina Duals,CPT,J2840,Inj sebelipase alfa 1 mg,APC 9478,Per Unit,$539.91 ,OP,539.91,539.91,,,,,,
Molina Duals,CPT,J2850,Inj secretin synthetic human,APC 1700,Per Unit,$34.78 ,OP,34.78,129.64,,,,,,
Molina Duals,CPT,J2860,Injection- siltuximab,APC 9455,Per Unit,$124.09 ,OP,124.09,124.09,,,,,,
Molina Duals,CPT,J2941,Somatropin injection,APC 9319,Per Unit,$36.54 ,OP,36.54,226.93,,,,,,
Molina Duals,CPT,J2993,Reteplase injection,APC 9005,Per Unit,"$2,506.51 ",OP,"2,506.51","4,712.48",,,,,,
Molina Duals,CPT,J2997,Alteplase recombinant,APC 7048,Per Unit,$87.75 ,OP,87.75,163.95,,,,,,
Molina Duals,CPT,J3031,Inj.- fremanezumab-vfrm 1 mg,APC 9197,Per Unit,$2.34 ,OP,2.34,2.34,,,,,,
Molina Duals,CPT,J3032,Inj. eptinezumab-jjmr 1 mg,APC 9357,Per Unit,$15.64 ,OP,15.64,15.64,,,,,,
Molina Duals,CPT,J3060,Inj- taliglucerase alfa 10 u,APC 9294,Per Unit,$41.32 ,OP,41.32,41.32,,,,,,
Molina Duals,CPT,J3090,Inj tedizolid phosphate,APC 1662,Per Unit,$1.60 ,OP,1.6,1.6,,,,,,
Molina Duals,CPT,J3095,Telavancin injection,APC 9258,Per Unit,$6.16 ,OP,6.16,6.16,,,,,,
Molina Duals,CPT,J3101,Tenecteplase injection,APC 9002,Per Unit,$134.74 ,OP,134.74,202.07,,,,,,
Molina Duals,CPT,J3111,Inj. romosozumab-aqqg 1 mg,APC 9327,Per Unit,$9.34 ,OP,9.34,9.34,,,,,,
Molina Duals,CPT,J3145,Testosterone undecanoate 1mg,APC 9078,Per Unit,$1.63 ,OP,1.63,1.63,,,,,,
Molina Duals,CPT,J3240,Thyrotropin injection,APC 9108,Per Unit,"$1,837.25 ",OP,"1,837.25","3,617.49",,,,,,
Molina Duals,CPT,J3241,Inj. teprotumumab-trbw 10 mg,APC 9355,Per Unit,$315.88 ,OP,315.88,315.88,,,,,,
Molina Duals,CPT,J3243,Tigecycline injection,APC 9228,Per Unit,$1.12 ,OP,1.12,3.82,,,,,,
Molina Duals,CPT,J3245,Inj.- tildrakizumab- 1 mg,APC 9306,Per Unit,$134.08 ,OP,134.08,134.08,,,,,,
Molina Duals,CPT,J3246,Tirofiban hcl,APC 7041,Per Unit,$3.83 ,OP,3.83,3.83,,,,,,
Molina Duals,CPT,J3262,Tocilizumab injection,APC 9264,Per Unit,$5.55 ,OP,5.55,5.55,,,,,,
Molina Duals,CPT,J3285,Treprostinil injection,APC 1701,Per Unit,$59.68 ,OP,59.68,238.44,,,,,,
Molina Duals,CPT,J3304,Inj triamcinolone ace xr 1mg,APC 9469,Per Unit,$17.75 ,OP,17.75,17.75,,,,,,
Molina Duals,CPT,J3315,Triptorelin pamoate,APC 9122,Per Unit,$379.90 ,OP,379.9,379.9,,,,,,
Molina Duals,CPT,J3316,Inj.- triptorelin xr 3.75 mg,APC 9016,Per Unit,"$3,120.11 ",OP,"3,120.11","3,120.11",,,,,,
Molina Duals,CPT,J3357,Ustekinumab sub cu inj- 1 mg,APC 9261,Per Unit,$176.65 ,OP,176.65,176.65,,,,,,
Molina Duals,CPT,J3358,Ustekinumab- iv inject- 1 mg,APC 9487,Per Unit,$11.68 ,OP,11.68,11.68,,,,,,
Molina Duals,CPT,J3380,Injection- vedolizumab,APC 1489,Per Unit,$21.28 ,OP,21.28,21.28,,,,,,
Molina Duals,CPT,J3385,Velaglucerase alfa,APC 9271,Per Unit,$359.29 ,OP,359.29,359.29,,,,,,
Molina Duals,CPT,J3396,Verteporfin injection,APC 1203,Per Unit,$11.25 ,OP,11.25,37.64,,,,,,
Molina Duals,CPT,J3398,Inj luxturna 1 billion vec g,APC 9070,Per Unit,"$2,953.71 ",OP,"2,953.71","2,953.71",,,,,,
Molina Duals,CPT,J7168,Prothrombin complex kcentra,APC 9132,Per Unit,$1.99 ,OP,1.99,1.99,,,,,,
Molina Duals,CPT,J7169,Inj andexxa- 10 mg,APC 9198,Per Unit,$289.93 ,OP,289.93,289.93,,,,,,
Molina Duals,CPT,J7170,Inj.- emicizumab-kxwh 0.5 mg,APC 9257,Per Unit,$48.88 ,OP,48.88,48.88,,,,,,
Molina Duals,CPT,J7175,Inj- factor x- (human)- 1iu,APC 1857,Per Unit,$8.20 ,OP,8.2,8.2,,,,,,
Molina Duals,CPT,J7178,Inj human fibrinogen con nos,APC 1478,Per Unit,$1.30 ,OP,1.3,1.3,,,,,,
Molina Duals,CPT,J7179,Vonvendi inj 1 iu vwf:rco,APC 9059,Per Unit,$1.85 ,OP,1.85,1.85,,,,,,
Molina Duals,CPT,J7180,Factor xiii anti-hem factor,APC 1416,Per Unit,$9.14 ,OP,9.14,9.14,,,,,,
Molina Duals,CPT,J7181,Factor xiii recomb a-subunit,APC 1746,Per Unit,$15.87 ,OP,15.87,15.87,,,,,,
Molina Duals,CPT,J7182,Factor viii recomb novoeight,APC 1856,Per Unit,$1.51 ,OP,1.51,1.51,,,,,,
Molina Duals,CPT,J7183,Wilate injection,APC 1352,Per Unit,$1.16 ,OP,1.16,1.16,,,,,,
Molina Duals,CPT,J7185,Xyntha inj,APC 1268,Per Unit,$1.33 ,OP,1.33,1.33,,,,,,
Molina Duals,CPT,J7186,Antihemophilic viii/vwf comp,APC 1213,Per Unit,$1.14 ,OP,1.14,3.82,,,,,,
Molina Duals,CPT,J7187,Humate-p- inj,APC 1704,Per Unit,$1.26 ,OP,1.26,2.98,,,,,,
Molina Duals,CPT,J7188,Factor viii recomb obizur,APC 1827,Per Unit,$3.19 ,OP,3.19,3.19,,,,,,
Molina Duals,CPT,J7189,Factor viia recomb novoseven,APC 1705,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Molina Duals,CPT,J7190,Factor viii,APC 0925,Per Unit,$1.12 ,OP,1.12,3.02,,,,,,
Molina Duals,CPT,J7192,Factor viii recombinant nos,APC 0927,Per Unit,$1.43 ,OP,1.43,3.85,,,,,,
Molina Duals,CPT,J7193,Factor ix non-recombinant,APC 0931,Per Unit,$1.17 ,OP,1.17,3.36,,,,,,
Molina Duals,CPT,J7194,Factor ix complex,APC 0928,Per Unit,$1.54 ,OP,1.54,2.52,,,,,,
Molina Duals,CPT,J7195,Factor ix recombinant nos,APC 0932,Per Unit,$1.61 ,OP,1.61,3.57,,,,,,
Molina Duals,CPT,J7197,Antithrombin iii injection,APC 1263,Per Unit,$3.20 ,OP,3.2,10.61,,,,,,
Molina Duals,CPT,J7198,Anti-inhibitor,APC 0929,Per Unit,$2.21 ,OP,2.21,5.2,,,,,,
Molina Duals,CPT,J7200,Factor ix recombinan rixubis,APC 1467,Per Unit,$1.54 ,OP,1.54,1.54,,,,,,
Molina Duals,CPT,J7201,Factor ix alprolix recomb,APC 1486,Per Unit,$3.28 ,OP,3.28,3.28,,,,,,
Molina Duals,CPT,J7202,Factor ix idelvion inj,APC 9171,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Duals,CPT,J7203,Factor ix recomb gly rebinyn,APC 9468,Per Unit,$4.23 ,OP,4.23,4.23,,,,,,
Molina Duals,CPT,J7204,Inj recombin esperoct per iu,APC 9354,Per Unit,$2.23 ,OP,2.23,2.23,,,,,,
Molina Duals,CPT,J7205,Factor viii fc fusion recomb,APC 1656,Per Unit,$2.15 ,OP,2.15,2.15,,,,,,
Molina Duals,CPT,J7207,Factor viii pegylated recomb,APC 1844,Per Unit,$1.92 ,OP,1.92,1.92,,,,,,
Molina Duals,CPT,J7208,Inj. jivi 1 iu,APC 9299,Per Unit,$2.10 ,OP,2.1,2.1,,,,,,
Molina Duals,CPT,J7209,Factor viii nuwiq recomb 1iu,APC 1846,Per Unit,$1.24 ,OP,1.24,1.24,,,,,,
Molina Duals,CPT,J7210,Inj- afstyla- 1 i.u.,APC 9043,Per Unit,$1.36 ,OP,1.36,1.36,,,,,,
Molina Duals,CPT,J7211,Inj- kovaltry- 1 i.u.,APC 9075,Per Unit,$1.24 ,OP,1.24,1.24,,,,,,
Molina Duals,CPT,J7212,Factor viia recomb sevenfact,APC 9395,Per Unit,$2.27 ,OP,2.27,2.27,,,,,,
Molina Duals,CPT,J7308,Aminolevulinic acid hcl top,APC 7308,Per Unit,$392.48 ,OP,392.48,392.48,,,,,,
Molina Duals,CPT,J7311,Inj.- retisert- 0.01 mg,APC 9225,Per Unit,$339.00 ,OP,339,"93,937.12",,,,,,
Molina Duals,CPT,J7312,Dexamethasone intra implant,APC 9256,Per Unit,$199.69 ,OP,199.69,199.69,,,,,,
Molina Duals,CPT,J7313,Inj.- iluvien- 0.01 mg,APC 9450,Per Unit,$490.95 ,OP,490.95,490.95,,,,,,
Molina Duals,CPT,J7314,Inj.- yutiq- 0.01 mg,APC 9328,Per Unit,$513.16 ,OP,513.16,513.16,,,,,,
Molina Duals,CPT,J7316,Inj- ocriplasmin- 0.125 mg,APC 9298,Per Unit,"$1,046.93 ",OP,"1,046.93","1,046.93",,,,,,
Molina Duals,CPT,J7318,Inj- durolane 1 mg,APC 9174,Per Unit,$17.23 ,OP,17.23,17.23,,,,,,
Molina Duals,CPT,J7320,Genvisc 850- inj- 1mg,APC 9079,Per Unit,$16.92 ,OP,16.92,16.92,,,,,,
Molina Duals,CPT,J7322,Hymovis injection 1 mg,APC 9471,Per Unit,$31.67 ,OP,31.67,903.6,,,,,,
Molina Duals,CPT,J7323,Euflexxa inj per dose,APC 0875,Per Unit,$138.82 ,OP,138.82,590.67,,,,,,
Molina Duals,CPT,J7324,Orthovisc inj per dose,APC 0877,Per Unit,$148.74 ,OP,148.74,880.74,,,,,,
Molina Duals,CPT,J7325,Synvisc or synvisc-one,APC 0874,Per Unit,$11.24 ,OP,11.24,11.24,,,,,,
Molina Duals,CPT,J7326,Gel-one,APC 1417,Per Unit,"$1,219.00 ",OP,"1,219.00","1,219.00",,,,,,
Molina Duals,CPT,J7327,Monovisc inj per dose,APC 1747,Per Unit,$762.80 ,OP,762.8,762.8,,,,,,
Molina Duals,CPT,J7328,Gelsyn-3 injection 0.1 mg,APC 1862,Per Unit,$2.18 ,OP,2.18,2.18,,,,,,
Molina Duals,CPT,J7329,Inj- trivisc 1 mg,APC 9196,Per Unit,$19.12 ,OP,19.12,19.12,,,,,,
Molina Duals,CPT,J7331,Synojoynt- inj.- 1 mg,APC 9337,Per Unit,$18.02 ,OP,18.02,18.02,,,,,,
Molina Duals,CPT,J7336,Capsaicin 8% patch,APC 9071,Per Unit,$3.23 ,OP,3.23,3.23,,,,,,
Molina Duals,CPT,J7340,Carbidopa levodopa ent 100ml,APC 9320,Per Unit,$211.70 ,OP,211.7,211.7,,,,,,
Molina Duals,CPT,J7342,Ciprofloxacin otic susp 6 mg,APC 9479,Per Unit,$29.98 ,OP,29.98,29.98,,,,,,
Molina Duals,CPT,J7345,Aminolevulinic acid- 10% gel,APC 9301,Per Unit,$1.59 ,OP,1.59,1.59,,,,,,
Molina Duals,CPT,J7351,Inj bimatoprost itc imp1mcg,APC 9351,Per Unit,$205.63 ,OP,205.63,205.63,,,,,,
Molina Duals,CPT,J7352,Afamelanotide implant- 1 mg,APC 9396,Per Unit,"$3,218.90 ",OP,"3,218.90","3,218.90",,,,,,
Molina Duals,CPT,J7402,Mometasone sinus sinuva,APC 9346,Per Unit,$10.56 ,OP,10.56,10.56,,,,,,
Molina Duals,CPT,J7501,Azathioprine parenteral,APC 0887,Per Unit,$245.02 ,OP,245.02,442.27,,,,,,
Molina Duals,CPT,J7504,Lymphocyte immune globulin,APC 0890,Per Unit,"$2,355.53 ",OP,"2,245.67","2,355.53",,,,,,
Molina Duals,CPT,J7511,Antithymocyte globuln rabbit,APC 9104,Per Unit,$837.42 ,OP,837.42,"1,807.23",,,,,,
Molina Duals,CPT,J7525,Tacrolimus injection,APC 9006,Per Unit,$219.33 ,OP,219.33,540.46,,,,,,
Molina Duals,CPT,J8560,Etoposide oral 50 mg,APC 0802,Per Unit,$75.63 ,OP,75.63,75.63,,,,,,
Molina Duals,CPT,J8655,Oral netupitant- palonosetro,APC 9448,Per Unit,$315.59 ,OP,315.59,315.59,,,,,,
Molina Duals,CPT,J8670,Rolapitant- oral- 1mg,APC 1761,Per Unit,$1.75 ,OP,1.75,1.75,,,,,,
Molina Duals,CPT,J9015,Aldesleukin injection,APC 0807,Per Unit,"$3,795.26 ",OP,"3,795.26","3,795.26",,,,,,
Molina Duals,CPT,J9017,Arsenic trioxide injection,APC 9012,Per Unit,$13.11 ,OP,13.11,179.2,,,,,,
Molina Duals,CPT,J9019,Erwinaze injection,APC 9289,Per Unit,$427.27 ,OP,427.27,427.27,,,,,,
Molina Duals,CPT,J9022,Inj- atezolizumab-10 mg,APC 9483,Per Unit,$79.75 ,OP,79.75,79.75,,,,,,
Molina Duals,CPT,J9023,Injection- avelumab- 10 mg,APC 9491,Per Unit,$86.19 ,OP,86.19,86.19,,,,,,
Molina Duals,CPT,J9025,Azacitidine injection,APC 1709,Per Unit,$0.93 ,OP,0.93,22.88,,,,,,
Molina Duals,CPT,J9027,Clofarabine injection,APC 1710,Per Unit,$53.15 ,OP,53.15,564.29,,,,,,
Molina Duals,CPT,J9032,Injection- belinostat- 10mg,APC 1658,Per Unit,$42.77 ,OP,42.77,42.77,,,,,,
Molina Duals,CPT,J9033,Inj.- treanda 1 mg,APC 9243,Per Unit,$22.01 ,OP,22.01,91.51,,,,,,
Molina Duals,CPT,J9034,Inj.- bendeka 1 mg,APC 1861,Per Unit,$19.65 ,OP,19.65,19.65,,,,,,
Molina Duals,CPT,J9035,Bevacizumab injection,APC 9214,Per Unit,$70.41 ,OP,70.41,278.32,,,,,,
Molina Duals,CPT,J9036,Inj. belrapzo/bendamustine,APC 9313,Per Unit,$21.47 ,OP,21.47,21.47,,,,,,
Molina Duals,CPT,J9037,Inj belantamab mafodont blmf,APC 9384,Per Unit,$42.78 ,OP,42.78,42.78,,,,,,
Molina Duals,CPT,J9039,Injection- blinatumomab,APC 9449,Per Unit,$123.88 ,OP,123.88,123.88,,,,,,
Molina Duals,CPT,J9041,Inj.- velcade 0.1 mg,APC 9207,Per Unit,$45.16 ,OP,45.16,175.39,,,,,,
Molina Duals,CPT,J9042,Brentuximab vedotin inj,APC 9287,Per Unit,$189.34 ,OP,189.34,189.34,,,,,,
Molina Duals,CPT,J9043,Cabazitaxel injection,APC 9276,Per Unit,$189.00 ,OP,189,189,,,,,,
Molina Duals,CPT,J9044,Inj- bortezomib- nos- 0.1 mg,APC 9192,Per Unit,$18.31 ,OP,18.31,18.31,,,,,,
Molina Duals,CPT,J9047,Injection- carfilzomib- 1 mg,APC 9295,Per Unit,$41.10 ,OP,41.1,41.1,,,,,,
Molina Duals,CPT,J9050,Carmustine injection,APC 0812,Per Unit,"$1,234.46 ",OP,"1,234.46","1,234.46",,,,,,
Molina Duals,CPT,J9055,Cetuximab injection,APC 9215,Per Unit,$66.71 ,OP,66.71,240.2,,,,,,
Molina Duals,CPT,J9057,Inj.- copanlisib- 1 mg,APC 9030,Per Unit,$80.96 ,OP,80.96,80.96,,,,,,
Molina Duals,CPT,J9065,Inj cladribine per 1 mg,APC 0858,Per Unit,$18.02 ,OP,18.02,144.88,,,,,,
Molina Duals,CPT,J9070,Cyclophosphamide 100 mg inj,APC 1408,Per Unit,$29.15 ,OP,19.07,29.15,,,,,,
Molina Duals,CPT,J9119,Inj.- cemiplimab-rwlc- 1 mg,APC 9304,Per Unit,$27.54 ,OP,27.54,27.54,,,,,,
Molina Duals,CPT,J9120,Dactinomycin injection,APC 0752,Per Unit,$890.64 ,OP,890.64,"2,634.57",,,,,,
Molina Duals,CPT,J9144,Daratumumab- hyaluronidase,APC 9378,Per Unit,$45.10 ,OP,45.1,45.1,,,,,,
Molina Duals,CPT,J9145,Injection- daratumumab 10 mg,APC 9476,Per Unit,$57.55 ,OP,57.55,57.55,,,,,,
Molina Duals,CPT,J9150,Daunorubicin injection,APC 0820,Per Unit,$40.36 ,OP,40.36,80.07,,,,,,
Molina Duals,CPT,J9153,Inj daunorubicin- cytarabine,APC 9302,Per Unit,$202.60 ,OP,202.6,202.6,,,,,,
Molina Duals,CPT,J9155,Degarelix injection,APC 1296,Per Unit,$4.12 ,OP,4.12,4.12,,,,,,
Molina Duals,CPT,J9173,Inj.- durvalumab- 10 mg,APC 9492,Per Unit,$76.86 ,OP,76.86,76.86,,,,,,
Molina Duals,CPT,J9176,Injection- elotuzumab- 1mg,APC 9477,Per Unit,$6.77 ,OP,6.77,6.77,,,,,,
Molina Duals,CPT,J9177,Inj enfort vedo-ejfv 0.25mg,APC 9364,Per Unit,$30.17 ,OP,30.17,30.17,,,,,,
Molina Duals,CPT,J9179,Eribulin mesylate injection,APC 1426,Per Unit,$123.93 ,OP,123.93,123.93,,,,,,
Molina Duals,CPT,J9198,Inj. infugem- 100 mg,APC 9387,Per Unit,$34.00 ,OP,34,34,,,,,,
Molina Duals,CPT,J9202,Goserelin acetate implant,APC 0810,Per Unit,$525.21 ,OP,525.21,915.04,,,,,,
Molina Duals,CPT,J9203,Gemtuzumab ozogamicin 0.1 mg,APC 9495,Per Unit,$207.99 ,OP,207.99,207.99,,,,,,
Molina Duals,CPT,J9204,Inj mogamulizumab-kpkc- 1 mg,APC 9182,Per Unit,$210.05 ,OP,210.05,210.05,,,,,,
Molina Duals,CPT,J9205,Inj irinotecan liposome 1 mg,APC 9474,Per Unit,$57.20 ,OP,57.2,57.2,,,,,,
Molina Duals,CPT,J9207,Ixabepilone injection,APC 9240,Per Unit,$112.12 ,OP,112.12,308.83,,,,,,
Molina Duals,CPT,J9210,Inj.- emapalumab-lzsg- 1 mg,APC 9310,Per Unit,$376.03 ,OP,376.03,376.03,,,,,,
Molina Duals,CPT,J9214,Interferon alfa-2b inj,APC 0836,Per Unit,$33.24 ,OP,33.24,72.44,,,,,,
Molina Duals,CPT,J9217,Leuprolide acetate suspnsion,APC 9217,Per Unit,$139.09 ,OP,139.09,987.49,,,,,,
Molina Duals,CPT,J9223,Inj. lurbinectedin- 0.1 mg,APC 9389,Per Unit,$174.03 ,OP,174.03,174.03,,,,,,
Molina Duals,CPT,J9225,Vantas implant,APC 1711,Per Unit,"$5,166.29 ",OP,"5,166.29","7,613.94",,,,,,
Molina Duals,CPT,J9226,Supprelin la implant,APC 1142,Per Unit,"$43,467.03 ",OP,"43,467.03","71,949.32",,,,,,
Molina Duals,CPT,J9227,Inj. isatuximab-irfc 10 mg,APC 9377,Per Unit,$67.60 ,OP,67.6,67.6,,,,,,
Molina Duals,CPT,J9228,Ipilimumab injection,APC 9284,Per Unit,$158.65 ,OP,158.65,158.65,,,,,,
Molina Duals,CPT,J9229,Inj inotuzumab ozogam 0.1 mg,APC 9028,Per Unit,"$2,371.62 ",OP,"2,371.62","2,371.62",,,,,,
Molina Duals,CPT,J9230,Mechlorethamine hcl inj,APC 0751,Per Unit,$11.74 ,OP,11.74,712.98,,,,,,
Molina Duals,CPT,J9245,Inj melpha hydroch nos 50 mg,APC 0840,Per Unit,$208.41 ,OP,208.41,"7,888.46",,,,,,
Molina Duals,CPT,J9246,Inj.- evomela- 1 mg,APC 9375,Per Unit,$18.20 ,OP,18.2,18.2,,,,,,
Molina Duals,CPT,J9247,Inj- melphalan flufenami 1mg,APC 9417,Per Unit,$499.86 ,OP,499.86,499.86,,,,,,
Molina Duals,CPT,J9261,Nelarabine injection,APC 0825,Per Unit,$155.90 ,OP,155.9,488.04,,,,,,
Molina Duals,CPT,J9262,Inj- omacetaxine mep- 0.01mg,APC 9297,Per Unit,$3.30 ,OP,3.3,3.3,,,,,,
Molina Duals,CPT,J9264,Paclitaxel protein bound,APC 1712,Per Unit,$14.08 ,OP,14.08,45.74,,,,,,
Molina Duals,CPT,J9266,Pegaspargase injection,APC 0843,Per Unit,"$21,561.05 ",OP,"12,715.34","21,561.05",,,,,,
Molina Duals,CPT,J9268,Pentostatin injection,APC 0844,Per Unit,"$1,880.67 ",OP,"1,880.67","7,030.61",,,,,,
Molina Duals,CPT,J9269,Inj. tagraxofusp-erzs 10 mcg,APC 9309,Per Unit,$290.37 ,OP,290.37,290.37,,,,,,
Molina Duals,CPT,J9270,Plicamycin (mithramycin) inj,APC 9093,Per Unit,$115.40 ,OP,115.4,385.09,,,,,,
Molina Duals,CPT,J9271,Inj pembrolizumab,APC 1490,Per Unit,$52.75 ,OP,52.75,52.75,,,,,,
Molina Duals,CPT,J9280,Mitomycin injection,APC 1232,Per Unit,$38.63 ,OP,38.63,76.26,,,,,,
Molina Duals,CPT,J9281,Mitomycin instillation,APC 9374,Per Unit,$281.88 ,OP,281.88,281.88,,,,,,
Molina Duals,CPT,J9285,Inj- olaratumab- 10 mg,APC 9485,Per Unit,$52.07 ,OP,52.07,52.07,,,,,,
Molina Duals,CPT,J9293,Mitoxantrone hydrochl / 5 mg,APC 0864,Per Unit,$26.29 ,OP,26.29,392.7,,,,,,
Molina Duals,CPT,J9295,Injection- necitumumab- 1 mg,APC 9475,Per Unit,$5.74 ,OP,5.74,5.74,,,,,,
Molina Duals,CPT,J9299,Injection- nivolumab,APC 9453,Per Unit,$28.86 ,OP,28.86,28.86,,,,,,
Molina Duals,CPT,J9301,Obinutuzumab inj,APC 1476,Per Unit,$64.54 ,OP,64.54,64.54,,,,,,
Molina Duals,CPT,J9302,Ofatumumab injection,APC 9260,Per Unit,$63.96 ,OP,63.96,63.96,,,,,,
Molina Duals,CPT,J9303,Panitumumab injection,APC 9235,Per Unit,$130.38 ,OP,130.38,130.38,,,,,,
Molina Duals,CPT,J9305,Inj. pemetrexed nos 10mg,APC 9213,Per Unit,$74.93 ,OP,74.93,232.58,,,,,,
Molina Duals,CPT,J9306,Injection- pertuzumab- 1 mg,APC 1471,Per Unit,$13.56 ,OP,13.56,13.56,,,,,,
Molina Duals,CPT,J9307,Pralatrexate injection,APC 9259,Per Unit,$314.84 ,OP,314.84,314.84,,,,,,
Molina Duals,CPT,J9308,Injection- ramucirumab,APC 1488,Per Unit,$62.69 ,OP,62.69,62.69,,,,,,
Molina Duals,CPT,J9309,Inj- polatuzumab vedotin 1mg,APC 9331,Per Unit,$113.57 ,OP,113.57,113.57,,,,,,
Molina Duals,CPT,J9311,Inj rituximab- hyaluronidase,APC 9467,Per Unit,$37.94 ,OP,37.94,37.94,,,,,,
Molina Duals,CPT,J9312,Inj.- rituximab- 10 mg,APC 9186,Per Unit,$86.94 ,OP,86.94,86.94,,,,,,
Molina Duals,CPT,J9313,Inj.- lumoxiti- 0.01 mg,APC 9305,Per Unit,$23.39 ,OP,23.39,23.39,,,,,,
Molina Duals,CPT,J9316,Pertuzu- trastuzu- 10 mg,APC 9390,Per Unit,$72.15 ,OP,72.15,72.15,,,,,,
Molina Duals,CPT,J9317,Sacituzumab govitecan-hziy,APC 9376,Per Unit,$30.35 ,OP,30.35,30.35,,,,,,
Molina Duals,CPT,J9318,Inj romidepsin non-lyo 0.1mg,APC 9428,Per Unit,$33.91 ,OP,33.91,33.91,,,,,,
Molina Duals,CPT,J9319,Inj romidepsin lyophil 0.1mg,APC 9429,Per Unit,$33.68 ,OP,33.68,33.68,,,,,,
Molina Duals,CPT,J9320,Streptozocin injection,APC 0850,Per Unit,$348.51 ,OP,348.51,"1,372.57",,,,,,
Molina Duals,CPT,J9325,Inj talimogene laherparepvec,APC 9472,Per Unit,$57.26 ,OP,57.26,57.26,,,,,,
Molina Duals,CPT,J9328,Temozolomide injection,APC 9253,Per Unit,$10.41 ,OP,10.41,10.41,,,,,,
Molina Duals,CPT,J9330,Temsirolimus injection,APC 1168,Per Unit,$38.25 ,OP,38.25,38.25,,,,,,
Molina Duals,CPT,J9340,Thiotepa injection,APC 0851,Per Unit,$305.84 ,OP,305.84,446.08,,,,,,
Molina Duals,CPT,J9348,Inj. naxitamab-gqgk- 1 mg,APC 9408,Per Unit,$539.07 ,OP,539.07,539.07,,,,,,
Molina Duals,CPT,J9349,Inj.- tafasitamab-cxix,APC 9385,Per Unit,$12.62 ,OP,12.62,12.62,,,,,,
Molina Duals,CPT,J9352,Injection trabectedin 0.1mg,APC 9480,Per Unit,$325.03 ,OP,325.03,325.03,,,,,,
Molina Duals,CPT,J9353,Inj. margetuximab-cmkb- 5 mg,APC 9418,Per Unit,$42.99 ,OP,42.99,42.99,,,,,,
Molina Duals,CPT,J9354,Inj- ado-trastuzumab emt 1mg,APC 9131,Per Unit,$34.18 ,OP,34.18,34.18,,,,,,
Molina Duals,CPT,J9355,Inj trastuzumab excl biosimi,APC 1613,Per Unit,$89.81 ,OP,89.81,238.1,,,,,,
Molina Duals,CPT,J9356,Inj. herceptin hylecta- 10mg,APC 9314,Per Unit,$71.85 ,OP,71.85,71.85,,,,,,
Molina Duals,CPT,J9357,Valrubicin injection,APC 1235,Per Unit,"$1,425.37 ",OP,"1,425.37","1,795.78",,,,,,
Molina Duals,CPT,J9358,Inj fam-trastu deru-nxki 1mg,APC 9353,Per Unit,$24.27 ,OP,24.27,24.27,,,,,,
Molina Duals,CPT,J9371,Inj- vincristine sul lip 1mg,APC 1466,Per Unit,"$3,370.23 ",OP,28.22,"3,370.23",,,,,,
Molina Duals,CPT,J9395,Injection- fulvestrant,APC 9120,Per Unit,$15.98 ,OP,15.98,396.52,,,,,,
Molina Duals,CPT,J9400,Inj- ziv-aflibercept- 1mg,APC 9296,Per Unit,$8.42 ,OP,8.42,8.42,,,,,,
Molina Duals,CPT,J9600,Porfimer sodium injection,APC 0856,Per Unit,"$21,856.35 ",OP,"13,169.04","21,856.35",,,,,,
Molina Duals,CPT,K0672,Removable soft interface le,Durable Medical Equipment,Per Unit,$85.14 ,OP,85.14,85.14,,,,,,
Molina Duals,CPT,L0112,Cranial cervical orthosis,Durable Medical Equipment,Per Unit,"$1,404.96 ",OP,"1,404.96","4,830.68",,,,,,
Molina Duals,CPT,L0113,Cranial cervical torticollis,Durable Medical Equipment,Per Unit,$286.27 ,OP,286.27,286.27,,,,,,
Molina Duals,CPT,L0120,Cerv flex n/adj foam pre ots,Durable Medical Equipment,Per Unit,$26.55 ,OP,26.55,91.51,,,,,,
Molina Duals,CPT,L0130,Flex thermoplastic collar mo,Durable Medical Equipment,Per Unit,$153.23 ,OP,153.23,526.16,,,,,,
Molina Duals,CPT,L0140,Cervical semi-rigid adjustab,Durable Medical Equipment,Per Unit,$60.09 ,OP,60.09,205.88,,,,,,
Molina Duals,CPT,L0150,Cerv semi-rig adj molded chn,Durable Medical Equipment,Per Unit,$107.45 ,OP,107.45,369.83,,,,,,
Molina Duals,CPT,L0160,Cerv sr wire occ/man pre ots,Durable Medical Equipment,Per Unit,$156.89 ,OP,156.89,541.4,,,,,,
Molina Duals,CPT,L0170,Cervical collar molded to pt,Durable Medical Equipment,Per Unit,$807.10 ,OP,807.1,"2,775.65",,,,,,
Molina Duals,CPT,L0172,Cerv col sr foam 2pc pre ots,Durable Medical Equipment,Per Unit,$142.17 ,OP,142.17,488.04,,,,,,
Molina Duals,CPT,L0174,Cerv sr 2pc thor ext pre ots,Durable Medical Equipment,Per Unit,$279.55 ,OP,279.55,960.8,,,,,,
Molina Duals,CPT,L0180,Cer post col occ/man sup adj,Durable Medical Equipment,Per Unit,$452.88 ,OP,452.88,"1,559.39",,,,,,
Molina Duals,CPT,L0190,Cerv collar supp adj cerv ba,Durable Medical Equipment,Per Unit,$534.12 ,OP,534.12,"1,837.71",,,,,,
Molina Duals,CPT,L0200,Cerv col supp adj bar & thor,Durable Medical Equipment,Per Unit,$619.54 ,OP,619.54,"2,131.30",,,,,,
Molina Duals,CPT,L0220,Thor rib belt custom fabrica,Durable Medical Equipment,Per Unit,$129.68 ,OP,129.68,446.08,,,,,,
Molina Duals,CPT,L0450,Tlso flex trunk/thor pre ots,Durable Medical Equipment,Per Unit,$128.11 ,OP,128.11,560.47,,,,,,
Molina Duals,CPT,L0454,Tlso trnk sj-t9 pre cst,Durable Medical Equipment,Per Unit,$348.14 ,OP,348.14,"1,197.20",,,,,,
Molina Duals,CPT,L0455,Tlso flex trnk sj-t9 pre ots,Durable Medical Equipment,Per Unit,$249.16 ,OP,249.16,249.16,,,,,,
Molina Duals,CPT,L0456,Tlso flex trnk sj-ss pre cst,Durable Medical Equipment,Per Unit,$998.38 ,OP,998.38,"3,435.25",,,,,,
Molina Duals,CPT,L0457,Tlso flex trnk sj-ss pre ots,Durable Medical Equipment,Per Unit,$714.52 ,OP,714.52,714.52,,,,,,
Molina Duals,CPT,L0458,Tlso 2mod symphis-xipho pre,Durable Medical Equipment,Per Unit,$895.27 ,OP,895.27,"3,080.66",,,,,,
Molina Duals,CPT,L0460,Tlso 2 shl symphys-stern cst,Durable Medical Equipment,Per Unit,"$1,007.68 ",OP,"1,007.68","3,465.73",,,,,,
Molina Duals,CPT,L0462,Tlso 3mod sacro-scap pre,Durable Medical Equipment,Per Unit,"$1,253.37 ",OP,"1,253.37","4,312.16",,,,,,
Molina Duals,CPT,L0464,Tlso 4mod sacro-scap pre,Durable Medical Equipment,Per Unit,"$1,492.13 ",OP,"1,492.13","5,131.88",,,,,,
Molina Duals,CPT,L0466,Tlso r fram soft ant pre cst,Durable Medical Equipment,Per Unit,$380.86 ,OP,380.86,"1,311.56",,,,,,
Molina Duals,CPT,L0467,Tlso r fram soft pre ots,Durable Medical Equipment,Per Unit,$277.04 ,OP,277.04,277.04,,,,,,
Molina Duals,CPT,L0468,Tlso rig fram pelvic pre cst,Durable Medical Equipment,Per Unit,$477.29 ,OP,477.29,"1,643.28",,,,,,
Molina Duals,CPT,L0469,Tlso rig fram pelvic pre ots,Durable Medical Equipment,Per Unit,$351.00 ,OP,351,351,,,,,,
Molina Duals,CPT,L0470,Tlso rigid frame pre subclav,Durable Medical Equipment,Per Unit,$660.47 ,OP,660.47,"2,272.36",,,,,,
Molina Duals,CPT,L0472,Tlso rigid frame hyperex pre,Durable Medical Equipment,Per Unit,$406.41 ,OP,406.41,"1,399.26",,,,,,
Molina Duals,CPT,L0480,Tlso rigid plastic custom fa,Durable Medical Equipment,Per Unit,"$1,516.23 ",OP,"1,516.23","5,215.77",,,,,,
Molina Duals,CPT,L0482,Tlso rigid lined custom fab,Durable Medical Equipment,Per Unit,"$1,693.64 ",OP,"1,693.64","5,825.80",,,,,,
Molina Duals,CPT,L0484,Tlso rigid plastic cust fab,Durable Medical Equipment,Per Unit,"$1,829.06 ",OP,"1,829.06","6,290.94",,,,,,
Molina Duals,CPT,L0486,Tlso rigidlined cust fab two,Durable Medical Equipment,Per Unit,"$2,054.11 ",OP,"2,054.11","7,064.92",,,,,,
Molina Duals,CPT,L0488,Tlso rigid lined pre one pie,Durable Medical Equipment,Per Unit,"$1,007.68 ",OP,"1,007.68","3,465.73",,,,,,
Molina Duals,CPT,L0490,Tlso rigid plastic pre one,Durable Medical Equipment,Per Unit,$283.96 ,OP,283.96,976.05,,,,,,
Molina Duals,CPT,L0491,Tlso 2 piece rigid shell,Durable Medical Equipment,Per Unit,$770.93 ,OP,770.93,"2,649.83",,,,,,
Molina Duals,CPT,L0492,Tlso 3 piece rigid shell,Durable Medical Equipment,Per Unit,$502.01 ,OP,502.01,"1,727.15",,,,,,
Molina Duals,CPT,L0621,Sio flex pelvic/sacr pre ots,Durable Medical Equipment,Per Unit,$67.68 ,OP,67.68,446.08,,,,,,
Molina Duals,CPT,L0622,Sio flex pelvisacral custom,Durable Medical Equipment,Per Unit,$268.31 ,OP,268.31,"1,384.01",,,,,,
Molina Duals,CPT,L0623,Sio rig pnl pelv/sac pre ots,Durable Medical Equipment,Per Unit,$126.95 ,OP,126.95,126.95,,,,,,
Molina Duals,CPT,L0625,Lo flex l1-below l5 pre ots,Durable Medical Equipment,Per Unit,$39.58 ,OP,39.58,285.96,,,,,,
Molina Duals,CPT,L0626,Lo sag rig pnl stays pre cst,Durable Medical Equipment,Per Unit,$78.25 ,OP,78.25,404.14,,,,,,
Molina Duals,CPT,L0627,Lo sag ri an/pos pnl pre cst,Durable Medical Equipment,Per Unit,$412.59 ,OP,412.59,"2,127.49",,,,,,
Molina Duals,CPT,L0628,Lso flex no ri stays pre ots,Durable Medical Equipment,Per Unit,$60.27 ,OP,60.27,434.65,,,,,,
Molina Duals,CPT,L0630,Lso r post pnl sj-t9 pre cst,Durable Medical Equipment,Per Unit,$162.59 ,OP,162.59,838.79,,,,,,
Molina Duals,CPT,L0631,Lso sag r an/pos pnl pre cst,Durable Medical Equipment,Per Unit,"$1,030.49 ",OP,"1,030.49","5,314.90",,,,,,
Molina Duals,CPT,L0633,Lso sc r pos/lat pnl pre cst,Durable Medical Equipment,Per Unit,$287.85 ,OP,287.85,"1,483.14",,,,,,
Molina Duals,CPT,L0635,Lso sagit rigid panel prefab,Durable Medical Equipment,Per Unit,"$1,003.05 ",OP,"1,003.05","5,173.83",,,,,,
Molina Duals,CPT,L0636,Lso sagittal rigid panel cus,Durable Medical Equipment,Per Unit,"$1,360.98 ",OP,"1,360.98","7,019.17",,,,,,
Molina Duals,CPT,L0637,Lso sc r ant/pos pnl pre cst,Durable Medical Equipment,Per Unit,"$1,300.47 ",OP,"1,300.47","6,710.34",,,,,,
Molina Duals,CPT,L0638,Lso sag-coronal panel custom,Durable Medical Equipment,Per Unit,"$1,323.97 ",OP,"1,323.97","6,828.54",,,,,,
Molina Duals,CPT,L0639,Lso s/c shell/panel prefab,Durable Medical Equipment,Per Unit,"$1,300.47 ",OP,"1,300.47","6,710.34",,,,,,
Molina Duals,CPT,L0640,Lso s/c shell/panel custom,Durable Medical Equipment,Per Unit,"$1,050.39 ",OP,"1,050.39","5,417.84",,,,,,
Molina Duals,CPT,L0641,Lo rig pos pnl l1-l5 pre ots,Durable Medical Equipment,Per Unit,$56.00 ,OP,56,56,,,,,,
Molina Duals,CPT,L0642,Lo sag ri an/pos pnl pre ots,Durable Medical Equipment,Per Unit,$295.35 ,OP,295.35,295.35,,,,,,
Molina Duals,CPT,L0643,Lso sag ctr rigi pos pre ots,Durable Medical Equipment,Per Unit,$116.37 ,OP,116.37,116.37,,,,,,
Molina Duals,CPT,L0648,Lso sag r an/pos pnl pre ots,Durable Medical Equipment,Per Unit,$737.61 ,OP,737.61,737.61,,,,,,
Molina Duals,CPT,L0649,Lso sc r pos/lat pnl pre ots,Durable Medical Equipment,Per Unit,$206.04 ,OP,206.04,206.04,,,,,,
Molina Duals,CPT,L0650,Lso sc r ant/pos pnl pre ots,Durable Medical Equipment,Per Unit,$880.49 ,OP,880.49,880.49,,,,,,
Molina Duals,CPT,L0651,Lso sag-co shell pnl pre ots,Durable Medical Equipment,Per Unit,$880.49 ,OP,880.49,880.49,,,,,,
Molina Duals,CPT,L0700,Ctlso a-p-l control molded,Durable Medical Equipment,Per Unit,"$1,998.37 ",OP,"1,998.37","6,874.29",,,,,,
Molina Duals,CPT,L0710,Ctlso a-p-l control w/ inter,Durable Medical Equipment,Per Unit,"$2,196.75 ",OP,"2,196.75","7,552.94",,,,,,
Molina Duals,CPT,L0810,Halo cervical into jckt vest,Durable Medical Equipment,Per Unit,"$2,683.14 ",OP,"2,683.14","9,226.72",,,,,,
Molina Duals,CPT,L0820,Halo cervical into body jack,Durable Medical Equipment,Per Unit,"$2,110.65 ",OP,"2,110.65","7,259.37",,,,,,
Molina Duals,CPT,L0830,Halo cerv into milwaukee typ,Durable Medical Equipment,Per Unit,"$3,229.60 ",OP,"3,229.60","11,106.37",,,,,,
Molina Duals,CPT,L0859,Mri compatible system,Durable Medical Equipment,Per Unit,"$1,143.45 ",OP,"1,143.45","3,930.89",,,,,,
Molina Duals,CPT,L0861,Halo repl liner/interface,Durable Medical Equipment,Per Unit,$216.37 ,OP,216.37,743.48,,,,,,
Molina Duals,CPT,L0970,Tlso corset front,Durable Medical Equipment,Per Unit,$107.27 ,OP,107.27,369.83,,,,,,
Molina Duals,CPT,L0972,Lso corset front,Durable Medical Equipment,Per Unit,$97.64 ,OP,97.64,335.53,,,,,,
Molina Duals,CPT,L0974,Tlso full corset,Durable Medical Equipment,Per Unit,$175.42 ,OP,175.42,602.41,,,,,,
Molina Duals,CPT,L0976,Lso full corset,Durable Medical Equipment,Per Unit,$150.09 ,OP,150.09,150.09,,,,,,
Molina Duals,CPT,L0978,Axillary crutch extension,Durable Medical Equipment,Per Unit,$188.90 ,OP,188.9,648.16,,,,,,
Molina Duals,CPT,L0980,Peroneal straps pair pre ots,Durable Medical Equipment,Per Unit,$17.15 ,OP,17.15,57.19,,,,,,
Molina Duals,CPT,L0982,Stocking sup grips 4 pre ots,Durable Medical Equipment,Per Unit,$15.70 ,OP,15.7,53.38,,,,,,
Molina Duals,CPT,L0984,Protect body sock ea pre ots,Durable Medical Equipment,Per Unit,$67.93 ,OP,67.93,232.58,,,,,,
Molina Duals,CPT,L1000,Ctlso milwauke initial model,Durable Medical Equipment,Per Unit,"$2,035.53 ",OP,"2,035.53","7,000.10",,,,,,
Molina Duals,CPT,L1005,Tension based scoliosis orth,Durable Medical Equipment,Per Unit,"$3,212.88 ",OP,"3,212.88","11,049.19",,,,,,
Molina Duals,CPT,L1010,Ctlso axilla sling,Durable Medical Equipment,Per Unit,$83.99 ,OP,83.99,289.76,,,,,,
Molina Duals,CPT,L1020,Kyphosis pad,Durable Medical Equipment,Per Unit,$108.17 ,OP,108.17,373.65,,,,,,
Molina Duals,CPT,L1025,Kyphosis pad floating,Durable Medical Equipment,Per Unit,$156.06 ,OP,156.06,537.6,,,,,,
Molina Duals,CPT,L1030,Lumbar bolster pad,Durable Medical Equipment,Per Unit,$78.60 ,OP,78.6,270.71,,,,,,
Molina Duals,CPT,L1040,Lumbar or lumbar rib pad,Durable Medical Equipment,Per Unit,$89.00 ,OP,89,305.01,,,,,,
Molina Duals,CPT,L1050,Sternal pad,Durable Medical Equipment,Per Unit,$100.72 ,OP,100.72,346.96,,,,,,
Molina Duals,CPT,L1060,Thoracic pad,Durable Medical Equipment,Per Unit,$108.72 ,OP,108.72,373.65,,,,,,
Molina Duals,CPT,L1070,Trapezius sling,Durable Medical Equipment,Per Unit,$112.62 ,OP,112.62,388.89,,,,,,
Molina Duals,CPT,L1080,Outrigger,Durable Medical Equipment,Per Unit,$52.52 ,OP,52.52,179.2,,,,,,
Molina Duals,CPT,L1085,Outrigger bil w/ vert extens,Durable Medical Equipment,Per Unit,$175.83 ,OP,175.83,606.21,,,,,,
Molina Duals,CPT,L1090,Lumbar sling,Durable Medical Equipment,Per Unit,$101.01 ,OP,101.01,346.96,,,,,,
Molina Duals,CPT,L1100,Ring flange plastic/leather,Durable Medical Equipment,Per Unit,$190.64 ,OP,190.64,655.78,,,,,,
Molina Duals,CPT,L1110,Ring flange plas/leather mol,Durable Medical Equipment,Per Unit,$319.63 ,OP,319.63,"1,098.07",,,,,,
Molina Duals,CPT,L1120,Covers for upright each,Durable Medical Equipment,Per Unit,$38.18 ,OP,38.18,129.64,,,,,,
Molina Duals,CPT,L1200,Furnsh initial orthosis only,Durable Medical Equipment,Per Unit,"$1,796.37 ",OP,"1,796.37","6,176.57",,,,,,
Molina Duals,CPT,L1210,Lateral thoracic extension,Durable Medical Equipment,Per Unit,$245.60 ,OP,245.6,846.41,,,,,,
Molina Duals,CPT,L1220,Anterior thoracic extension,Durable Medical Equipment,Per Unit,$239.05 ,OP,239.05,823.54,,,,,,
Molina Duals,CPT,L1230,Milwaukee type superstructur,Durable Medical Equipment,Per Unit,$669.67 ,OP,669.67,"2,302.87",,,,,,
Molina Duals,CPT,L1240,Lumbar derotation pad,Durable Medical Equipment,Per Unit,$91.29 ,OP,91.29,312.64,,,,,,
Molina Duals,CPT,L1250,Anterior asis pad,Durable Medical Equipment,Per Unit,$79.39 ,OP,79.39,274.51,,,,,,
Molina Duals,CPT,L1260,Anterior thoracic derotation,Durable Medical Equipment,Per Unit,$94.68 ,OP,94.68,324.09,,,,,,
Molina Duals,CPT,L1270,Abdominal pad,Durable Medical Equipment,Per Unit,$83.20 ,OP,83.2,285.96,,,,,,
Molina Duals,CPT,L1280,Rib gusset (elastic) each,Durable Medical Equipment,Per Unit,$87.71 ,OP,87.71,301.2,,,,,,
Molina Duals,CPT,L1290,Lateral trochanteric pad,Durable Medical Equipment,Per Unit,$78.00 ,OP,78,266.89,,,,,,
Molina Duals,CPT,L1300,Body jacket mold to patient,Durable Medical Equipment,Per Unit,"$1,730.06 ",OP,"1,730.06","5,951.62",,,,,,
Molina Duals,CPT,L1310,Post-operative body jacket,Durable Medical Equipment,Per Unit,"$1,802.00 ",OP,"1,802.00","6,195.63",,,,,,
Molina Duals,CPT,L1600,Ho flex frejka w/cov pre cst,Durable Medical Equipment,Per Unit,$129.35 ,OP,129.35,446.08,,,,,,
Molina Duals,CPT,L1610,Ho frejka cov only pre cst,Durable Medical Equipment,Per Unit,$54.94 ,OP,54.94,190.64,,,,,,
Molina Duals,CPT,L1620,Ho flex pavlik harns pre cst,Durable Medical Equipment,Per Unit,$157.73 ,OP,157.73,541.4,,,,,,
Molina Duals,CPT,L1630,Abduct control hip semi-flex,Durable Medical Equipment,Per Unit,$212.06 ,OP,212.06,728.23,,,,,,
Molina Duals,CPT,L1640,Pelv band/spread bar thigh c,Durable Medical Equipment,Per Unit,$475.20 ,OP,475.2,"1,635.64",,,,,,
Molina Duals,CPT,L1650,Ho abduction hip adjustable,Durable Medical Equipment,Per Unit,$247.55 ,OP,247.55,850.23,,,,,,
Molina Duals,CPT,L1652,Ho bi thighcuffs w sprdr bar,Durable Medical Equipment,Per Unit,$357.83 ,OP,357.83,"1,231.50",,,,,,
Molina Duals,CPT,L1660,Ho abduction static plastic,Durable Medical Equipment,Per Unit,$181.40 ,OP,181.4,625.29,,,,,,
Molina Duals,CPT,L1680,Pelvic & hip control thigh c,Durable Medical Equipment,Per Unit,"$1,143.62 ",OP,"1,143.62","3,934.69",,,,,,
Molina Duals,CPT,L1685,Post-op hip abduct custom fa,Durable Medical Equipment,Per Unit,"$1,116.47 ",OP,"1,116.47","3,839.39",,,,,,
Molina Duals,CPT,L1686,Ho post-op hip abduction,Durable Medical Equipment,Per Unit,$940.60 ,OP,940.6,"3,233.17",,,,,,
Molina Duals,CPT,L1690,Combination bilateral ho,Durable Medical Equipment,Per Unit,"$1,941.15 ",OP,"1,941.15","6,676.03",,,,,,
Molina Duals,CPT,L1700,Leg perthes orth toronto typ,Durable Medical Equipment,Per Unit,"$1,561.78 ",OP,"1,561.78","5,372.08",,,,,,
Molina Duals,CPT,L1710,Legg perthes orth newington,Durable Medical Equipment,Per Unit,"$1,988.75 ",OP,"1,988.75","6,839.98",,,,,,
Molina Duals,CPT,L1720,Legg perthes orthosis trilat,Durable Medical Equipment,Per Unit,"$1,480.82 ",OP,"1,480.82","5,093.76",,,,,,
Molina Duals,CPT,L1730,Legg perthes orth scottish r,Durable Medical Equipment,Per Unit,"$1,250.14 ",OP,"1,250.14","4,300.73",,,,,,
Molina Duals,CPT,L1755,Legg perthes patten bottom t,Durable Medical Equipment,Per Unit,"$1,797.35 ",OP,"1,797.35","6,180.39",,,,,,
Molina Duals,CPT,L1810,Ko elastic with joints,Durable Medical Equipment,Per Unit,$103.34 ,OP,103.34,103.34,,,,,,
Molina Duals,CPT,L1812,Ko elastic w/joints pre ots,Durable Medical Equipment,Per Unit,$81.50 ,OP,81.5,81.5,,,,,,
Molina Duals,CPT,L1820,Ko elas w/ condyle pads & jo,Durable Medical Equipment,Per Unit,$142.66 ,OP,142.66,142.66,,,,,,
Molina Duals,CPT,L1830,Ko immob canvas long pre ots,Durable Medical Equipment,Per Unit,$71.04 ,OP,71.04,285.96,,,,,,
Molina Duals,CPT,L1831,Knee orth pos locking joint,Durable Medical Equipment,Per Unit,$295.44 ,OP,295.44,"1,017.99",,,,,,
Molina Duals,CPT,L1832,Ko adj jnt pos r sup pre cst,Durable Medical Equipment,Per Unit,$691.44 ,OP,691.44,"2,379.12",,,,,,
Molina Duals,CPT,L1833,Ko adj jnt pos r sup pre ots,Durable Medical Equipment,Per Unit,$534.19 ,OP,534.19,534.19,,,,,,
Molina Duals,CPT,L1834,Ko w/0 joint rigid molded to,Durable Medical Equipment,Per Unit,$728.61 ,OP,728.61,"2,504.94",,,,,,
Molina Duals,CPT,L1836,Ko rigid w/o joints pre ots,Durable Medical Equipment,Per Unit,$104.41 ,OP,104.41,104.41,,,,,,
Molina Duals,CPT,L1840,Ko derot ant cruciate custom,Durable Medical Equipment,Per Unit,$944.00 ,OP,944,"3,248.41",,,,,,
Molina Duals,CPT,L1843,Ko single upright pre cst,Durable Medical Equipment,Per Unit,$900.70 ,OP,900.7,"3,095.90",,,,,,
Molina Duals,CPT,L1844,Ko w/adj jt rot cntrl molded,Durable Medical Equipment,Per Unit,"$1,528.66 ",OP,"1,528.66","5,257.70",,,,,,
Molina Duals,CPT,L1845,Ko double upright pre cst,Durable Medical Equipment,Per Unit,$840.88 ,OP,840.88,840.88,,,,,,
Molina Duals,CPT,L1846,Ko w adj flex/ext rotat mold,Durable Medical Equipment,Per Unit,"$1,174.51 ",OP,"1,174.51","1,174.51",,,,,,
Molina Duals,CPT,L1847,Ko dbl upright w/air pre cst,Durable Medical Equipment,Per Unit,$577.37 ,OP,577.37,"1,986.41",,,,,,
Molina Duals,CPT,L1848,Ko dbl upright w/air pre ots,Durable Medical Equipment,Per Unit,$577.37 ,OP,577.37,577.37,,,,,,
Molina Duals,CPT,L1850,Ko swedish type pre ots,Durable Medical Equipment,Per Unit,$234.85 ,OP,234.85,983.68,,,,,,
Molina Duals,CPT,L1851,Ko single upright prefab ots,Durable Medical Equipment,Per Unit,$702.11 ,OP,702.11,702.11,,,,,,
Molina Duals,CPT,L1852,Ko double upright prefab ots,Durable Medical Equipment,Per Unit,$665.20 ,OP,665.2,665.2,,,,,,
Molina Duals,CPT,L1860,Ko supracondylar socket mold,Durable Medical Equipment,Per Unit,"$1,251.75 ",OP,"1,251.75","4,304.53",,,,,,
Molina Duals,CPT,L1900,Afo sprng wir drsflx calf bd,Durable Medical Equipment,Per Unit,$286.39 ,OP,286.39,983.68,,,,,,
Molina Duals,CPT,L1902,Afo ankle gauntlet pre ots,Durable Medical Equipment,Per Unit,$74.93 ,OP,74.93,259.27,,,,,,
Molina Duals,CPT,L1904,Afo molded ankle gauntlet,Durable Medical Equipment,Per Unit,$453.09 ,OP,453.09,"1,559.39",,,,,,
Molina Duals,CPT,L1906,Afo multilig ank sup pre ots,Durable Medical Equipment,Per Unit,$112.88 ,OP,112.88,388.89,,,,,,
Molina Duals,CPT,L1907,Afo supramalleolar custom,Durable Medical Equipment,Per Unit,$564.86 ,OP,564.86,"1,944.48",,,,,,
Molina Duals,CPT,L1910,Afo sing bar clasp attach sh,Durable Medical Equipment,Per Unit,$281.51 ,OP,281.51,968.43,,,,,,
Molina Duals,CPT,L1920,Afo sing upright w/ adjust s,Durable Medical Equipment,Per Unit,$412.37 ,OP,412.37,"1,418.32",,,,,,
Molina Duals,CPT,L1930,Afo plastic,Durable Medical Equipment,Per Unit,$252.89 ,OP,252.89,869.3,,,,,,
Molina Duals,CPT,L1932,Afo rig ant tib prefab tcf/=,Durable Medical Equipment,Per Unit,$895.75 ,OP,895.75,"3,080.66",,,,,,
Molina Duals,CPT,L1940,Afo molded to patient plasti,Durable Medical Equipment,Per Unit,$488.84 ,OP,488.84,"1,681.40",,,,,,
Molina Duals,CPT,L1945,Afo molded plas rig ant tib,Durable Medical Equipment,Per Unit,"$1,126.77 ",OP,"1,126.77","3,873.69",,,,,,
Molina Duals,CPT,L1950,Afo spiral molded to pt plas,Durable Medical Equipment,Per Unit,$772.00 ,OP,772,"2,653.63",,,,,,
Molina Duals,CPT,L1951,Afo spiral prefabricated,Durable Medical Equipment,Per Unit,$843.02 ,OP,843.02,"2,897.65",,,,,,
Molina Duals,CPT,L1960,Afo pos solid ank plastic mo,Durable Medical Equipment,Per Unit,$622.25 ,OP,622.25,"2,138.93",,,,,,
Molina Duals,CPT,L1970,Afo plastic molded w/ankle j,Durable Medical Equipment,Per Unit,$694.78 ,OP,694.78,"2,390.56",,,,,,
Molina Duals,CPT,L1971,Afo w/ankle joint- prefab,Durable Medical Equipment,Per Unit,$470.55 ,OP,470.55,"1,616.58",,,,,,
Molina Duals,CPT,L1980,Afo sing solid stirrup calf,Durable Medical Equipment,Per Unit,$405.31 ,OP,405.31,"1,395.45",,,,,,
Molina Duals,CPT,L1990,Afo doub solid stirrup calf,Durable Medical Equipment,Per Unit,$469.10 ,OP,469.1,"1,612.76",,,,,,
Molina Duals,CPT,L2000,Kafo sing fre stirr thi/calf,Durable Medical Equipment,Per Unit,"$1,122.95 ",OP,"1,122.95","3,862.25",,,,,,
Molina Duals,CPT,L2005,Kafo sng/dbl mechanical act,Durable Medical Equipment,Per Unit,"$4,113.39 ",OP,"4,113.39","14,145.09",,,,,,
Molina Duals,CPT,L2010,Kafo sng solid stirrup w/o j,Durable Medical Equipment,Per Unit,$875.89 ,OP,875.89,"3,012.03",,,,,,
Molina Duals,CPT,L2020,Kafo dbl solid stirrup band/,Durable Medical Equipment,Per Unit,"$1,106.22 ",OP,"1,106.22","3,805.07",,,,,,
Molina Duals,CPT,L2030,Kafo dbl solid stirrup w/o j,Durable Medical Equipment,Per Unit,"$1,087.33 ",OP,"1,087.33","3,740.26",,,,,,
Molina Duals,CPT,L2034,Kafo pla sin up w/wo k/a cus,Durable Medical Equipment,Per Unit,"$2,039.24 ",OP,"2,039.24","7,011.54",,,,,,
Molina Duals,CPT,L2035,Kafo plastic pediatric size,Durable Medical Equipment,Per Unit,$173.91 ,OP,173.91,598.59,,,,,,
Molina Duals,CPT,L2036,Kafo plas doub free knee mol,Durable Medical Equipment,Per Unit,"$1,861.04 ",OP,"1,861.04","6,401.51",,,,,,
Molina Duals,CPT,L2037,Kafo plas sing free knee mol,Durable Medical Equipment,Per Unit,"$1,664.67 ",OP,"1,664.67","5,726.65",,,,,,
Molina Duals,CPT,L2038,Kafo w/o joint multi-axis an,Durable Medical Equipment,Per Unit,"$1,341.97 ",OP,"1,341.97","4,613.36",,,,,,
Molina Duals,CPT,L2040,Hkafo torsion bil rot straps,Durable Medical Equipment,Per Unit,$203.08 ,OP,203.08,697.72,,,,,,
Molina Duals,CPT,L2050,Hkafo torsion cable hip pelv,Durable Medical Equipment,Per Unit,$489.17 ,OP,489.17,"1,681.40",,,,,,
Molina Duals,CPT,L2060,Hkafo torsion ball bearing j,Durable Medical Equipment,Per Unit,$611.86 ,OP,611.86,"2,104.61",,,,,,
Molina Duals,CPT,L2070,Hkafo torsion unilat rot str,Durable Medical Equipment,Per Unit,$155.80 ,OP,155.8,537.6,,,,,,
Molina Duals,CPT,L2080,Hkafo unilat torsion cable,Durable Medical Equipment,Per Unit,$374.61 ,OP,374.61,"1,288.69",,,,,,
Molina Duals,CPT,L2090,Hkafo unilat torsion ball br,Durable Medical Equipment,Per Unit,$499.12 ,OP,499.12,"1,715.71",,,,,,
Molina Duals,CPT,L2106,Afo tib fx cast plaster mold,Durable Medical Equipment,Per Unit,$791.23 ,OP,791.23,"2,722.27",,,,,,
Molina Duals,CPT,L2108,Afo tib fx cast molded to pt,Durable Medical Equipment,Per Unit,"$1,154.03 ",OP,"1,154.03","3,969.02",,,,,,
Molina Duals,CPT,L2112,Afo tibial fracture soft,Durable Medical Equipment,Per Unit,$506.43 ,OP,506.43,"1,742.41",,,,,,
Molina Duals,CPT,L2114,Afo tib fx semi-rigid,Durable Medical Equipment,Per Unit,$634.33 ,OP,634.33,634.33,,,,,,
Molina Duals,CPT,L2116,Afo tibial fracture rigid,Durable Medical Equipment,Per Unit,$773.69 ,OP,773.69,773.69,,,,,,
Molina Duals,CPT,L2126,Kafo fem fx cast thermoplas,Durable Medical Equipment,Per Unit,"$1,281.77 ",OP,"1,281.77","4,407.46",,,,,,
Molina Duals,CPT,L2128,Kafo fem fx cast molded to p,Durable Medical Equipment,Per Unit,"$1,609.47 ",OP,"1,609.47","5,536.03",,,,,,
Molina Duals,CPT,L2132,Kafo femoral fx cast soft,Durable Medical Equipment,Per Unit,$976.92 ,OP,976.92,"3,358.99",,,,,,
Molina Duals,CPT,L2134,Kafo fem fx cast semi-rigid,Durable Medical Equipment,Per Unit,"$1,156.80 ",OP,"1,156.80","3,976.64",,,,,,
Molina Duals,CPT,L2136,Kafo femoral fx cast rigid,Durable Medical Equipment,Per Unit,"$1,265.95 ",OP,"1,265.95","4,354.09",,,,,,
Molina Duals,CPT,L2180,Plas shoe insert w ank joint,Durable Medical Equipment,Per Unit,$133.08 ,OP,133.08,457.52,,,,,,
Molina Duals,CPT,L2182,Drop lock knee,Durable Medical Equipment,Per Unit,$114.71 ,OP,114.71,392.7,,,,,,
Molina Duals,CPT,L2184,Limited motion knee joint,Durable Medical Equipment,Per Unit,$116.27 ,OP,116.27,400.34,,,,,,
Molina Duals,CPT,L2186,Adj motion knee jnt lerman t,Durable Medical Equipment,Per Unit,$154.63 ,OP,154.63,529.96,,,,,,
Molina Duals,CPT,L2188,Quadrilateral brim,Durable Medical Equipment,Per Unit,$281.10 ,OP,281.1,968.43,,,,,,
Molina Duals,CPT,L2190,Waist belt,Durable Medical Equipment,Per Unit,$85.62 ,OP,85.62,293.57,,,,,,
Molina Duals,CPT,L2192,Pelvic band & belt thigh fla,Durable Medical Equipment,Per Unit,$334.67 ,OP,334.67,"1,151.42",,,,,,
Molina Duals,CPT,L2200,Limited ankle motion ea jnt,Durable Medical Equipment,Per Unit,$50.44 ,OP,50.44,175.39,,,,,,
Molina Duals,CPT,L2210,Dorsiflexion assist each joi,Durable Medical Equipment,Per Unit,$63.09 ,OP,63.09,217.32,,,,,,
Molina Duals,CPT,L2220,Dorsi & plantar flex ass/res,Durable Medical Equipment,Per Unit,$81.22 ,OP,81.22,278.32,,,,,,
Molina Duals,CPT,L2230,Split flat caliper stirr & p,Durable Medical Equipment,Per Unit,$96.02 ,OP,96.02,331.7,,,,,,
Molina Duals,CPT,L2232,Rocker bottom- contact afo,Durable Medical Equipment,Per Unit,$97.51 ,OP,97.51,335.53,,,,,,
Molina Duals,CPT,L2240,Round caliper and plate atta,Durable Medical Equipment,Per Unit,$95.58 ,OP,95.58,327.9,,,,,,
Molina Duals,CPT,L2250,Foot plate molded stirrup at,Durable Medical Equipment,Per Unit,$335.30 ,OP,335.3,"1,151.42",,,,,,
Molina Duals,CPT,L2260,Reinforced solid stirrup,Durable Medical Equipment,Per Unit,$188.16 ,OP,188.16,648.16,,,,,,
Molina Duals,CPT,L2265,Long tongue stirrup,Durable Medical Equipment,Per Unit,$134.94 ,OP,134.94,465.15,,,,,,
Molina Duals,CPT,L2270,Varus/valgus strap padded/li,Durable Medical Equipment,Per Unit,$61.87 ,OP,61.87,213.51,,,,,,
Molina Duals,CPT,L2275,Plastic mod low ext pad/line,Durable Medical Equipment,Per Unit,$130.85 ,OP,130.85,449.9,,,,,,
Molina Duals,CPT,L2280,Molded inner boot,Durable Medical Equipment,Per Unit,$566.69 ,OP,566.69,"1,948.29",,,,,,
Molina Duals,CPT,L2300,Abduction bar jointed adjust,Durable Medical Equipment,Per Unit,$252.72 ,OP,252.72,869.3,,,,,,
Molina Duals,CPT,L2310,Abduction bar-straight,Durable Medical Equipment,Per Unit,$115.47 ,OP,115.47,396.52,,,,,,
Molina Duals,CPT,L2320,Non-molded lacer,Durable Medical Equipment,Per Unit,$193.64 ,OP,193.64,667.22,,,,,,
Molina Duals,CPT,L2330,Lacer molded to patient mode,Durable Medical Equipment,Per Unit,$368.55 ,OP,368.55,"1,265.81",,,,,,
Molina Duals,CPT,L2335,Anterior swing band,Durable Medical Equipment,Per Unit,$282.18 ,OP,282.18,972.25,,,,,,
Molina Duals,CPT,L2340,Pre-tibial shell molded to p,Durable Medical Equipment,Per Unit,$419.50 ,OP,419.5,"1,441.20",,,,,,
Molina Duals,CPT,L2350,Prosthetic type socket molde,Durable Medical Equipment,Per Unit,$836.35 ,OP,836.35,"2,874.78",,,,,,
Molina Duals,CPT,L2360,Extended steel shank,Durable Medical Equipment,Per Unit,$51.76 ,OP,51.76,179.2,,,,,,
Molina Duals,CPT,L2370,Patten bottom,Durable Medical Equipment,Per Unit,$321.26 ,OP,321.26,"1,105.68",,,,,,
Molina Duals,CPT,L2375,Torsion ank & half solid sti,Durable Medical Equipment,Per Unit,$123.52 ,OP,123.52,423.22,,,,,,
Molina Duals,CPT,L2380,Torsion straight knee joint,Durable Medical Equipment,Per Unit,$129.54 ,OP,129.54,446.08,,,,,,
Molina Duals,CPT,L2385,Straight knee joint heavy du,Durable Medical Equipment,Per Unit,$147.50 ,OP,147.5,507.08,,,,,,
Molina Duals,CPT,L2387,Add le poly knee custom kafo,Durable Medical Equipment,Per Unit,$191.63 ,OP,191.63,659.6,,,,,,
Molina Duals,CPT,L2390,Offset knee joint each,Durable Medical Equipment,Per Unit,$102.75 ,OP,102.75,354.58,,,,,,
Molina Duals,CPT,L2395,Offset knee joint heavy duty,Durable Medical Equipment,Per Unit,$146.86 ,OP,146.86,503.28,,,,,,
Molina Duals,CPT,L2397,Suspension sleeve lower ext,Durable Medical Equipment,Per Unit,$122.52 ,OP,122.52,423.22,,,,,,
Molina Duals,CPT,L2405,Knee joint drop lock ea jnt,Durable Medical Equipment,Per Unit,$87.52 ,OP,87.52,301.2,,,,,,
Molina Duals,CPT,L2415,Knee joint cam lock each joi,Durable Medical Equipment,Per Unit,$121.95 ,OP,121.95,419.4,,,,,,
Molina Duals,CPT,L2425,Knee disc/dial lock/adj flex,Durable Medical Equipment,Per Unit,$143.90 ,OP,143.9,495.65,,,,,,
Molina Duals,CPT,L2430,Knee jnt ratchet lock ea jnt,Durable Medical Equipment,Per Unit,$143.90 ,OP,143.9,495.65,,,,,,
Molina Duals,CPT,L2492,Knee lift loop drop lock rin,Durable Medical Equipment,Per Unit,$117.74 ,OP,117.74,404.14,,,,,,
Molina Duals,CPT,L2500,Thi/glut/ischia wgt bearing,Durable Medical Equipment,Per Unit,$314.13 ,OP,314.13,"1,078.99",,,,,,
Molina Duals,CPT,L2510,Th/wght bear quad-lat brim m,Durable Medical Equipment,Per Unit,$809.60 ,OP,809.6,"2,783.26",,,,,,
Molina Duals,CPT,L2520,Th/wght bear quad-lat brim c,Durable Medical Equipment,Per Unit,$539.56 ,OP,539.56,"1,856.79",,,,,,
Molina Duals,CPT,L2525,Th/wght bear nar m-l brim mo,Durable Medical Equipment,Per Unit,"$1,144.16 ",OP,"1,144.16","3,934.69",,,,,,
Molina Duals,CPT,L2526,Th/wght bear nar m-l brim cu,Durable Medical Equipment,Per Unit,$642.90 ,OP,642.9,"2,211.37",,,,,,
Molina Duals,CPT,L2530,Thigh/wght bear lacer non-mo,Durable Medical Equipment,Per Unit,$240.74 ,OP,240.74,827.35,,,,,,
Molina Duals,CPT,L2540,Thigh/wght bear lacer molded,Durable Medical Equipment,Per Unit,$455.54 ,OP,455.54,"1,567.02",,,,,,
Molina Duals,CPT,L2550,Thigh/wght bear high roll cu,Durable Medical Equipment,Per Unit,$341.55 ,OP,341.55,"1,174.31",,,,,,
Molina Duals,CPT,L2570,Hip clevis type 2 posit jnt,Durable Medical Equipment,Per Unit,$447.07 ,OP,447.07,"1,536.51",,,,,,
Molina Duals,CPT,L2580,Pelvic control pelvic sling,Durable Medical Equipment,Per Unit,$435.62 ,OP,435.62,"1,498.39",,,,,,
Molina Duals,CPT,L2600,Hip clevis/thrust bearing fr,Durable Medical Equipment,Per Unit,$214.10 ,OP,214.1,735.85,,,,,,
Molina Duals,CPT,L2610,Hip clevis/thrust bearing lo,Durable Medical Equipment,Per Unit,$236.58 ,OP,236.58,812.11,,,,,,
Molina Duals,CPT,L2620,Pelvic control hip heavy dut,Durable Medical Equipment,Per Unit,$250.96 ,OP,250.96,861.67,,,,,,
Molina Duals,CPT,L2622,Hip joint adjustable flexion,Durable Medical Equipment,Per Unit,$319.42 ,OP,319.42,"1,098.07",,,,,,
Molina Duals,CPT,L2624,Hip adj flex ext abduct cont,Durable Medical Equipment,Per Unit,$391.68 ,OP,391.68,"1,345.89",,,,,,
Molina Duals,CPT,L2627,Plastic mold recipro hip & c,Durable Medical Equipment,Per Unit,"$2,145.41 ",OP,"2,145.41","7,377.56",,,,,,
Molina Duals,CPT,L2628,Metal frame recipro hip & ca,Durable Medical Equipment,Per Unit,"$1,572.54 ",OP,"1,572.54","5,406.41",,,,,,
Molina Duals,CPT,L2630,Pelvic control band & belt u,Durable Medical Equipment,Per Unit,$232.43 ,OP,232.43,800.67,,,,,,
Molina Duals,CPT,L2640,Pelvic control band & belt b,Durable Medical Equipment,Per Unit,$315.42 ,OP,315.42,"1,086.62",,,,,,
Molina Duals,CPT,L2650,Pelv & thor control gluteal,Durable Medical Equipment,Per Unit,$138.91 ,OP,138.91,476.6,,,,,,
Molina Duals,CPT,L2660,Thoracic control thoracic ba,Durable Medical Equipment,Per Unit,$179.86 ,OP,179.86,617.65,,,,,,
Molina Duals,CPT,L2670,Thorac cont paraspinal uprig,Durable Medical Equipment,Per Unit,$160.11 ,OP,160.11,549.03,,,,,,
Molina Duals,CPT,L2680,Thorac cont lat support upri,Durable Medical Equipment,Per Unit,$146.88 ,OP,146.88,503.28,,,,,,
Molina Duals,CPT,L2750,Plating chrome/nickel pr bar,Durable Medical Equipment,Per Unit,$78.45 ,OP,78.45,270.71,,,,,,
Molina Duals,CPT,L2755,Carbon graphite lamination,Durable Medical Equipment,Per Unit,$131.16 ,OP,131.16,449.9,,,,,,
Molina Duals,CPT,L2760,Extension per extension per,Durable Medical Equipment,Per Unit,$57.03 ,OP,57.03,194.45,,,,,,
Molina Duals,CPT,L2768,Ortho sidebar disconnect,Durable Medical Equipment,Per Unit,$130.78 ,OP,130.78,449.9,,,,,,
Molina Duals,CPT,L2780,Non-corrosive finish,Durable Medical Equipment,Per Unit,$63.53 ,OP,63.53,217.32,,,,,,
Molina Duals,CPT,L2785,Drop lock retainer each,Durable Medical Equipment,Per Unit,$29.75 ,OP,29.75,102.95,,,,,,
Molina Duals,CPT,L2795,Knee control full kneecap,Durable Medical Equipment,Per Unit,$82.32 ,OP,82.32,282.14,,,,,,
Molina Duals,CPT,L2800,Knee cap medial or lateral p,Durable Medical Equipment,Per Unit,$101.09 ,OP,101.09,101.09,,,,,,
Molina Duals,CPT,L2810,Knee control condylar pad,Durable Medical Equipment,Per Unit,$81.98 ,OP,81.98,282.14,,,,,,
Molina Duals,CPT,L2820,Soft interface below knee se,Durable Medical Equipment,Per Unit,$81.51 ,OP,81.51,282.14,,,,,,
Molina Duals,CPT,L2830,Soft interface above knee se,Durable Medical Equipment,Per Unit,$88.18 ,OP,88.18,305.01,,,,,,
Molina Duals,CPT,L2840,Tibial length sock fx or equ,Durable Medical Equipment,Per Unit,$43.30 ,OP,43.3,148.69,,,,,,
Molina Duals,CPT,L2850,Femoral lgth sock fx or equa,Durable Medical Equipment,Per Unit,$60.72 ,OP,60.72,209.7,,,,,,
Molina Duals,CPT,L3000,Ft insert ucb berkeley shell,Durable Medical Equipment,Per Unit,$315.34 ,OP,315.34,"1,082.81",,,,,,
Molina Duals,CPT,L3001,Foot insert remov molded spe,Durable Medical Equipment,Per Unit,$132.78 ,OP,132.78,686.28,,,,,,
Molina Duals,CPT,L3002,Foot insert plastazote or eq,Durable Medical Equipment,Per Unit,$162.12 ,OP,162.12,834.98,,,,,,
Molina Duals,CPT,L3003,Foot insert silicone gel eac,Durable Medical Equipment,Per Unit,$174.89 ,OP,174.89,903.6,,,,,,
Molina Duals,CPT,L3010,Foot longitudinal arch suppo,Durable Medical Equipment,Per Unit,$174.89 ,OP,174.89,903.6,,,,,,
Molina Duals,CPT,L3020,Foot longitud/metatarsal sup,Durable Medical Equipment,Per Unit,$199.16 ,OP,199.16,"1,025.61",,,,,,
Molina Duals,CPT,L3030,Foot arch support remov prem,Durable Medical Equipment,Per Unit,$76.59 ,OP,76.59,"1,239.13",,,,,,
Molina Duals,CPT,L3031,Foot lamin/prepreg composite,Durable Medical Equipment,Per Unit,$122.94 ,OP,122.94,"1,334.45",,,,,,
Molina Duals,CPT,L3040,Ft arch suprt premold longit,Durable Medical Equipment,Per Unit,$47.25 ,OP,47.25,163.95,,,,,,
Molina Duals,CPT,L3050,Foot arch supp premold metat,Durable Medical Equipment,Per Unit,$47.25 ,OP,47.25,163.95,,,,,,
Molina Duals,CPT,L3060,Foot arch supp longitud/meta,Durable Medical Equipment,Per Unit,$74.04 ,OP,74.04,255.45,,,,,,
Molina Duals,CPT,L3070,Arch suprt att to sho longit,Durable Medical Equipment,Per Unit,$31.91 ,OP,31.91,110.57,,,,,,
Molina Duals,CPT,L3080,Arch supp att to shoe metata,Durable Medical Equipment,Per Unit,$31.91 ,OP,31.91,110.57,,,,,,
Molina Duals,CPT,L3090,Arch supp att to shoe long/m,Durable Medical Equipment,Per Unit,$40.86 ,OP,40.86,141.07,,,,,,
Molina Duals,CPT,L3100,Hallus-valgus nt dyn pre ots,Durable Medical Equipment,Per Unit,$43.43 ,OP,43.43,148.69,,,,,,
Molina Duals,CPT,L3140,Abduction rotation bar shoe,Durable Medical Equipment,Per Unit,$89.37 ,OP,89.37,308.83,,,,,,
Molina Duals,CPT,L3150,Abduct rotation bar w/o shoe,Durable Medical Equipment,Per Unit,$81.72 ,OP,81.72,282.14,,,,,,
Molina Duals,CPT,L3170,Foot plas heel stabi pre ots,Durable Medical Equipment,Per Unit,$51.06 ,OP,51.06,175.39,,,,,,
Molina Duals,CPT,L3224,Woman's shoe oxford brace,Durable Medical Equipment,Per Unit,$67.83 ,OP,67.83,232.58,,,,,,
Molina Duals,CPT,L3225,Man's shoe oxford brace,Durable Medical Equipment,Per Unit,$74.09 ,OP,74.09,255.45,,,,,,
Molina Duals,CPT,L3300,Sho lift taper to metatarsal,Durable Medical Equipment,Per Unit,$52.35 ,OP,52.35,179.2,,,,,,
Molina Duals,CPT,L3310,Shoe lift elev heel/sole neo,Durable Medical Equipment,Per Unit,$81.72 ,OP,81.72,282.14,,,,,,
Molina Duals,CPT,L3330,Lifts elevation metal extens,Durable Medical Equipment,Per Unit,$568.10 ,OP,568.1,"1,952.10",,,,,,
Molina Duals,CPT,L3332,Shoe lifts tapered to one-ha,Durable Medical Equipment,Per Unit,$74.04 ,OP,74.04,255.45,,,,,,
Molina Duals,CPT,L3334,Shoe lifts elevation heel /i,Durable Medical Equipment,Per Unit,$38.28 ,OP,38.28,133.45,,,,,,
Molina Duals,CPT,L3340,Shoe wedge sach,Durable Medical Equipment,Per Unit,$85.56 ,OP,85.56,293.57,,,,,,
Molina Duals,CPT,L3350,Shoe heel wedge,Durable Medical Equipment,Per Unit,$22.96 ,OP,22.96,80.07,,,,,,
Molina Duals,CPT,L3360,Shoe sole wedge outside sole,Durable Medical Equipment,Per Unit,$35.74 ,OP,35.74,122,,,,,,
Molina Duals,CPT,L3370,Shoe sole wedge between sole,Durable Medical Equipment,Per Unit,$49.79 ,OP,49.79,171.58,,,,,,
Molina Duals,CPT,L3380,Shoe clubfoot wedge,Durable Medical Equipment,Per Unit,$49.79 ,OP,49.79,171.58,,,,,,
Molina Duals,CPT,L3390,Shoe outflare wedge,Durable Medical Equipment,Per Unit,$49.79 ,OP,49.79,171.58,,,,,,
Molina Duals,CPT,L3400,Shoe metatarsal bar wedge ro,Durable Medical Equipment,Per Unit,$40.86 ,OP,40.86,141.07,,,,,,
Molina Duals,CPT,L3410,Shoe metatarsal bar between,Durable Medical Equipment,Per Unit,$93.19 ,OP,93.19,320.27,,,,,,
Molina Duals,CPT,L3420,Full sole/heel wedge btween,Durable Medical Equipment,Per Unit,$54.90 ,OP,54.9,190.64,,,,,,
Molina Duals,CPT,L3430,Sho heel count plast reinfor,Durable Medical Equipment,Per Unit,$160.86 ,OP,160.86,552.84,,,,,,
Molina Duals,CPT,L3440,Heel leather reinforced,Durable Medical Equipment,Per Unit,$76.59 ,OP,76.59,263.08,,,,,,
Molina Duals,CPT,L3450,Shoe heel sach cushion type,Durable Medical Equipment,Per Unit,$105.93 ,OP,105.93,105.93,,,,,,
Molina Duals,CPT,L3455,Shoe heel new leather standa,Durable Medical Equipment,Per Unit,$40.86 ,OP,40.86,141.07,,,,,,
Molina Duals,CPT,L3460,Shoe heel new rubber standar,Durable Medical Equipment,Per Unit,$34.49 ,OP,34.49,118.19,,,,,,
Molina Duals,CPT,L3465,Shoe heel thomas with wedge,Durable Medical Equipment,Per Unit,$58.76 ,OP,58.76,202.07,,,,,,
Molina Duals,CPT,L3470,Shoe heel thomas extend to b,Durable Medical Equipment,Per Unit,$62.54 ,OP,62.54,213.51,,,,,,
Molina Duals,CPT,L3480,Shoe heel pad & depress for,Durable Medical Equipment,Per Unit,$62.54 ,OP,62.54,213.51,,,,,,
Molina Duals,CPT,L3500,Ortho shoe add leather insol,Durable Medical Equipment,Per Unit,$29.35 ,OP,29.35,99.13,,,,,,
Molina Duals,CPT,L3510,Orthopedic shoe add rub insl,Durable Medical Equipment,Per Unit,$29.35 ,OP,29.35,99.13,,,,,,
Molina Duals,CPT,L3520,O shoe add felt w leath insl,Durable Medical Equipment,Per Unit,$31.91 ,OP,31.91,110.57,,,,,,
Molina Duals,CPT,L3530,Ortho shoe add half sole,Durable Medical Equipment,Per Unit,$31.91 ,OP,31.91,110.57,,,,,,
Molina Duals,CPT,L3540,Ortho shoe add full sole,Durable Medical Equipment,Per Unit,$51.06 ,OP,51.06,175.39,,,,,,
Molina Duals,CPT,L3550,O shoe add standard toe tap,Durable Medical Equipment,Per Unit,$8.97 ,OP,8.97,30.51,,,,,,
Molina Duals,CPT,L3560,O shoe add horseshoe toe tap,Durable Medical Equipment,Per Unit,$22.96 ,OP,22.96,80.07,,,,,,
Molina Duals,CPT,L3570,O shoe add instep extension,Durable Medical Equipment,Per Unit,$85.56 ,OP,85.56,293.57,,,,,,
Molina Duals,CPT,L3580,O shoe add instep velcro clo,Durable Medical Equipment,Per Unit,$65.11 ,OP,65.11,224.95,,,,,,
Molina Duals,CPT,L3590,O shoe convert to sof counte,Durable Medical Equipment,Per Unit,$53.63 ,OP,53.63,183.02,,,,,,
Molina Duals,CPT,L3595,Ortho shoe add march bar,Durable Medical Equipment,Per Unit,$42.10 ,OP,42.1,144.88,,,,,,
Molina Duals,CPT,L3600,Trans shoe calip plate exist,Durable Medical Equipment,Per Unit,$76.59 ,OP,76.59,263.08,,,,,,
Molina Duals,CPT,L3610,Trans shoe caliper plate new,Durable Medical Equipment,Per Unit,$100.86 ,OP,100.86,346.96,,,,,,
Molina Duals,CPT,L3620,Trans shoe solid stirrup exi,Durable Medical Equipment,Per Unit,$76.59 ,OP,76.59,263.08,,,,,,
Molina Duals,CPT,L3630,Trans shoe solid stirrup new,Durable Medical Equipment,Per Unit,$100.86 ,OP,100.86,346.96,,,,,,
Molina Duals,CPT,L3640,Shoe dennis browne splint bo,Durable Medical Equipment,Per Unit,$43.43 ,OP,43.43,148.69,,,,,,
Molina Duals,CPT,L3650,So 8 abd restraint pre ots,Durable Medical Equipment,Per Unit,$65.83 ,OP,65.83,224.95,,,,,,
Molina Duals,CPT,L3660,So 8 ab rstr can/web pre ots,Durable Medical Equipment,Per Unit,$94.40 ,OP,94.4,324.09,,,,,,
Molina Duals,CPT,L3670,So acro/clav can web pre ots,Durable Medical Equipment,Per Unit,$103.86 ,OP,103.86,358.39,,,,,,
Molina Duals,CPT,L3671,So cap design w/o jnts cf,Durable Medical Equipment,Per Unit,$823.17 ,OP,823.17,"2,832.83",,,,,,
Molina Duals,CPT,L3674,So airplane w/wo joint cf,Durable Medical Equipment,Per Unit,"$1,079.87 ",OP,"1,079.87","1,079.87",,,,,,
Molina Duals,CPT,L3675,So vest canvas/web pre ots,Durable Medical Equipment,Per Unit,$160.35 ,OP,160.35,552.84,,,,,,
Molina Duals,CPT,L3702,Eo w/o joints cf,Durable Medical Equipment,Per Unit,$263.81 ,OP,263.81,907.42,,,,,,
Molina Duals,CPT,L3710,Eo elas w/metal jnts pre ots,Durable Medical Equipment,Per Unit,$130.45 ,OP,130.45,449.9,,,,,,
Molina Duals,CPT,L3720,Forearm/arm cuffs free motio,Durable Medical Equipment,Per Unit,$624.22 ,OP,624.22,"2,146.54",,,,,,
Molina Duals,CPT,L3730,Forearm/arm cuffs ext/flex a,Durable Medical Equipment,Per Unit,$827.96 ,OP,827.96,"2,848.08",,,,,,
Molina Duals,CPT,L3740,Cuffs adj lock w/ active con,Durable Medical Equipment,Per Unit,$981.62 ,OP,981.62,"3,374.24",,,,,,
Molina Duals,CPT,L3760,Eo adj jt prefab custom fit,Durable Medical Equipment,Per Unit,$456.89 ,OP,456.89,"1,570.83",,,,,,
Molina Duals,CPT,L3761,Eo- adj lock joint prefab ot,Durable Medical Equipment,Per Unit,$456.89 ,OP,456.89,456.89,,,,,,
Molina Duals,CPT,L3762,Eo rigid w/o joints pre ots,Durable Medical Equipment,Per Unit,$98.22 ,OP,98.22,339.33,,,,,,
Molina Duals,CPT,L3763,Ewho rigid w/o jnts cf,Durable Medical Equipment,Per Unit,$683.66 ,OP,683.66,"2,352.44",,,,,,
Molina Duals,CPT,L3764,Ewho w/joint(s) cf,Durable Medical Equipment,Per Unit,$715.47 ,OP,715.47,"2,459.19",,,,,,
Molina Duals,CPT,L3765,Ewhfo rigid w/o jnts cf,Durable Medical Equipment,Per Unit,"$1,171.43 ",OP,"1,171.43","4,030.02",,,,,,
Molina Duals,CPT,L3766,Ewhfo w/joint(s) cf,Durable Medical Equipment,Per Unit,"$1,240.47 ",OP,"1,240.47","4,266.40",,,,,,
Molina Duals,CPT,L3806,Whfo w/joint(s) custom fab,Durable Medical Equipment,Per Unit,$414.97 ,OP,414.97,"1,425.95",,,,,,
Molina Duals,CPT,L3807,Whfo w/o joints pre cst,Durable Medical Equipment,Per Unit,$228.43 ,OP,228.43,785.42,,,,,,
Molina Duals,CPT,L3808,Whfo- rigid w/o joints,Durable Medical Equipment,Per Unit,$325.43 ,OP,325.43,"1,120.94",,,,,,
Molina Duals,CPT,L3809,Whfo w/o joints pre ots,Durable Medical Equipment,Per Unit,$228.43 ,OP,228.43,228.43,,,,,,
Molina Duals,CPT,L3900,Hinge extension/flex wrist/f,Durable Medical Equipment,Per Unit,"$1,479.93 ",OP,"1,479.93","5,089.95",,,,,,
Molina Duals,CPT,L3901,Hinge ext/flex wrist finger,Durable Medical Equipment,Per Unit,"$1,939.53 ",OP,"1,939.53","6,668.40",,,,,,
Molina Duals,CPT,L3904,Whfo electric custom fitted,Durable Medical Equipment,Per Unit,"$3,083.64 ",OP,"3,083.64","10,603.11",,,,,,
Molina Duals,CPT,L3905,Who w/nontorsion jnt(s) cf,Durable Medical Equipment,Per Unit,$905.97 ,OP,905.97,"3,114.97",,,,,,
Molina Duals,CPT,L3906,Who w/o joints cf,Durable Medical Equipment,Per Unit,$462.97 ,OP,462.97,"1,593.72",,,,,,
Molina Duals,CPT,L3908,Who cock-up nonmolde pre ots,Durable Medical Equipment,Per Unit,$66.98 ,OP,66.98,228.77,,,,,,
Molina Duals,CPT,L3912,Hfo flexion glove pre ots,Durable Medical Equipment,Per Unit,$96.25 ,OP,96.25,331.7,,,,,,
Molina Duals,CPT,L3913,Hfo w/o joints cf,Durable Medical Equipment,Per Unit,$247.41 ,OP,247.41,850.23,,,,,,
Molina Duals,CPT,L3915,Who nontorsion jnts pre cst,Durable Medical Equipment,Per Unit,$485.63 ,OP,485.63,"1,669.97",,,,,,
Molina Duals,CPT,L3916,Who nontorsion jnts pre ots,Durable Medical Equipment,Per Unit,$485.63 ,OP,485.63,485.63,,,,,,
Molina Duals,CPT,L3917,Metacarp fx orthosis pre cst,Durable Medical Equipment,Per Unit,$96.47 ,OP,96.47,331.7,,,,,,
Molina Duals,CPT,L3918,Metacarp fx orthosis pre ots,Durable Medical Equipment,Per Unit,$96.47 ,OP,96.47,96.47,,,,,,
Molina Duals,CPT,L3919,Ho w/o joints cf,Durable Medical Equipment,Per Unit,$247.41 ,OP,247.41,850.23,,,,,,
Molina Duals,CPT,L3921,Hfo w/joint(s) cf,Durable Medical Equipment,Per Unit,$293.46 ,OP,293.46,"1,010.37",,,,,,
Molina Duals,CPT,L3923,Hfo without joints pre cst,Durable Medical Equipment,Per Unit,$88.25 ,OP,88.25,305.01,,,,,,
Molina Duals,CPT,L3924,Hfo without joints pre ots,Durable Medical Equipment,Per Unit,$88.25 ,OP,88.25,88.25,,,,,,
Molina Duals,CPT,L3925,Fo pip dip jnt/sprng pre ots,Durable Medical Equipment,Per Unit,$60.01 ,OP,60.01,205.88,,,,,,
Molina Duals,CPT,L3927,Fo pip dip no jt spr pre ots,Durable Medical Equipment,Per Unit,$31.98 ,OP,31.98,110.57,,,,,,
Molina Duals,CPT,L3929,Hfo nontorsion jnts pre cst,Durable Medical Equipment,Per Unit,$83.44 ,OP,83.44,285.96,,,,,,
Molina Duals,CPT,L3930,Hfo nontorsion jnts pre ots,Durable Medical Equipment,Per Unit,$83.44 ,OP,83.44,83.44,,,,,,
Molina Duals,CPT,L3931,Whfo nontorsion joint prefab,Durable Medical Equipment,Per Unit,$190.48 ,OP,190.48,655.78,,,,,,
Molina Duals,CPT,L3933,Fo w/o joints cf,Durable Medical Equipment,Per Unit,$194.93 ,OP,194.93,671.03,,,,,,
Molina Duals,CPT,L3935,Fo nontorsion joint cf,Durable Medical Equipment,Per Unit,$201.82 ,OP,201.82,693.9,,,,,,
Molina Duals,CPT,L3960,Sewho airplan desig abdu pos,Durable Medical Equipment,Per Unit,$728.64 ,OP,728.64,"2,504.94",,,,,,
Molina Duals,CPT,L3961,Sewho cap design w/o jnts cf,Durable Medical Equipment,Per Unit,"$1,534.92 ",OP,"1,534.92","5,280.58",,,,,,
Molina Duals,CPT,L3962,Sewho erbs palsey design abd,Durable Medical Equipment,Per Unit,$659.00 ,OP,659,"2,264.75",,,,,,
Molina Duals,CPT,L3967,Sewho airplane w/o jnts cf,Durable Medical Equipment,Per Unit,"$1,812.20 ",OP,"1,812.20","6,233.76",,,,,,
Molina Duals,CPT,L3971,Sewho cap design w/jnt(s) cf,Durable Medical Equipment,Per Unit,"$1,720.20 ",OP,"1,720.20","5,917.29",,,,,,
Molina Duals,CPT,L3973,Sewho airplane w/jnt(s) cf,Durable Medical Equipment,Per Unit,"$1,812.20 ",OP,"1,812.20","6,233.76",,,,,,
Molina Duals,CPT,L3975,Sewhfo cap design w/o jnt cf,Durable Medical Equipment,Per Unit,"$1,534.92 ",OP,"1,534.92","5,280.58",,,,,,
Molina Duals,CPT,L3976,Sewhfo airplane w/o jnts cf,Durable Medical Equipment,Per Unit,"$1,534.92 ",OP,"1,534.92","5,280.58",,,,,,
Molina Duals,CPT,L3977,Sewhfo cap desgn w/jnt(s) cf,Durable Medical Equipment,Per Unit,"$1,720.20 ",OP,"1,720.20","5,917.29",,,,,,
Molina Duals,CPT,L3978,Sewhfo airplane w/jnt(s) cf,Durable Medical Equipment,Per Unit,"$1,812.20 ",OP,"1,812.20","6,233.76",,,,,,
Molina Duals,CPT,L3980,Up ext fx orthos humeral nos,Durable Medical Equipment,Per Unit,$353.43 ,OP,353.43,"1,216.24",,,,,,
Molina Duals,CPT,L3981,Ue fx orth shoul cap forearm,Durable Medical Equipment,Per Unit,$919.57 ,OP,919.57,919.57,,,,,,
Molina Duals,CPT,L3982,Upper ext fx orthosis rad/ul,Durable Medical Equipment,Per Unit,$358.87 ,OP,358.87,"1,235.32",,,,,,
Molina Duals,CPT,L3984,Upper ext fx orthosis wrist,Durable Medical Equipment,Per Unit,$316.13 ,OP,316.13,"1,086.62",,,,,,
Molina Duals,CPT,L3995,Sock fracture or equal each,Durable Medical Equipment,Per Unit,$37.51 ,OP,37.51,129.64,,,,,,
Molina Duals,CPT,L4000,Repl girdle milwaukee orth,Durable Medical Equipment,Per Unit,"$1,326.47 ",OP,"1,326.47","4,559.97",,,,,,
Molina Duals,CPT,L4010,Replace trilateral socket br,Durable Medical Equipment,Per Unit,$806.25 ,OP,806.25,"2,771.83",,,,,,
Molina Duals,CPT,L4020,Replace quadlat socket brim,Durable Medical Equipment,Per Unit,$968.52 ,OP,968.52,"3,332.30",,,,,,
Molina Duals,CPT,L4030,Replace socket brim cust fit,Durable Medical Equipment,Per Unit,$615.47 ,OP,615.47,"2,116.06",,,,,,
Molina Duals,CPT,L4040,Replace molded thigh lacer,Durable Medical Equipment,Per Unit,$416.80 ,OP,416.8,"1,433.58",,,,,,
Molina Duals,CPT,L4045,Replace non-molded thigh lac,Durable Medical Equipment,Per Unit,$307.89 ,OP,307.89,"1,059.93",,,,,,
Molina Duals,CPT,L4050,Replace molded calf lacer,Durable Medical Equipment,Per Unit,$412.80 ,OP,412.8,"1,418.32",,,,,,
Molina Duals,CPT,L4055,Replace non-molded calf lace,Durable Medical Equipment,Per Unit,$250.92 ,OP,250.92,861.67,,,,,,
Molina Duals,CPT,L4060,Replace high roll cuff,Durable Medical Equipment,Per Unit,$326.17 ,OP,326.17,"1,120.94",,,,,,
Molina Duals,CPT,L4070,Replace prox & dist upright,Durable Medical Equipment,Per Unit,$264.15 ,OP,264.15,907.42,,,,,,
Molina Duals,CPT,L4080,Repl met band kafo-afo prox,Durable Medical Equipment,Per Unit,$99.72 ,OP,99.72,343.14,,,,,,
Molina Duals,CPT,L4090,Repl met band kafo-afo calf/,Durable Medical Equipment,Per Unit,$84.84 ,OP,84.84,293.57,,,,,,
Molina Duals,CPT,L4100,Repl leath cuff kafo prox th,Durable Medical Equipment,Per Unit,$101.94 ,OP,101.94,350.76,,,,,,
Molina Duals,CPT,L4110,Repl leath cuff kafo-afo cal,Durable Medical Equipment,Per Unit,$79.60 ,OP,79.6,274.51,,,,,,
Molina Duals,CPT,L4130,Replace pretibial shell,Durable Medical Equipment,Per Unit,$481.14 ,OP,481.14,"1,654.72",,,,,,
Molina Duals,CPT,L4350,Ankle control ortho pre ots,Durable Medical Equipment,Per Unit,$97.13 ,OP,97.13,335.53,,,,,,
Molina Duals,CPT,L4360,Pneumat walking boot pre cst,Durable Medical Equipment,Per Unit,$259.89 ,OP,259.89,892.18,,,,,,
Molina Duals,CPT,L4361,Pneuma/vac walk boot pre ots,Durable Medical Equipment,Per Unit,$259.89 ,OP,259.89,259.89,,,,,,
Molina Duals,CPT,L4370,Pneum full leg splnt pre ots,Durable Medical Equipment,Per Unit,$236.26 ,OP,236.26,812.11,,,,,,
Molina Duals,CPT,L4386,Non-pneum walk boot pre cst,Durable Medical Equipment,Per Unit,$159.16 ,OP,159.16,549.03,,,,,,
Molina Duals,CPT,L4387,Non-pneum walk boot pre ots,Durable Medical Equipment,Per Unit,$159.16 ,OP,159.16,159.16,,,,,,
Molina Duals,CPT,L4392,Replace afo soft interface,Durable Medical Equipment,Per Unit,$23.62 ,OP,23.62,80.07,,,,,,
Molina Duals,CPT,L4394,Replace foot drop spint,Durable Medical Equipment,Per Unit,$17.23 ,OP,17.23,61,,,,,,
Molina Duals,CPT,L4396,Static or dynami afo pre cst,Durable Medical Equipment,Per Unit,$168.46 ,OP,168.46,579.53,,,,,,
Molina Duals,CPT,L4397,Static or dynami afo pre ots,Durable Medical Equipment,Per Unit,$168.46 ,OP,168.46,168.46,,,,,,
Molina Duals,CPT,L4398,Foot drop splint pre ots,Durable Medical Equipment,Per Unit,$77.54 ,OP,77.54,266.89,,,,,,
Molina Duals,CPT,L4631,Afo- walk boot type- cus fab,Durable Medical Equipment,Per Unit,"$1,479.79 ",OP,"1,479.79","1,479.79",,,,,,
Molina Duals,CPT,L5000,Sho insert w arch toe filler,Durable Medical Equipment,Per Unit,$576.42 ,OP,576.42,"1,982.60",,,,,,
Molina Duals,CPT,L5010,Mold socket ank hgt w/ toe f,Durable Medical Equipment,Per Unit,"$1,610.60 ",OP,"1,610.60","5,539.84",,,,,,
Molina Duals,CPT,L5020,Tibial tubercle hgt w/ toe f,Durable Medical Equipment,Per Unit,"$2,523.29 ",OP,"2,523.29","8,677.68",,,,,,
Molina Duals,CPT,L5050,Ank symes mold sckt sach ft,Durable Medical Equipment,Per Unit,"$2,755.91 ",OP,"2,755.91","9,478.35",,,,,,
Molina Duals,CPT,L5060,Symes met fr leath socket ar,Durable Medical Equipment,Per Unit,"$3,397.24 ",OP,"3,397.24","11,682.09",,,,,,
Molina Duals,CPT,L5100,Molded socket shin sach foot,Durable Medical Equipment,Per Unit,"$2,744.12 ",OP,"2,744.12","9,436.43",,,,,,
Molina Duals,CPT,L5105,Plast socket jts/thgh lacer,Durable Medical Equipment,Per Unit,"$3,872.55 ",OP,"3,872.55","13,317.74",,,,,,
Molina Duals,CPT,L5150,Mold sckt ext knee shin sach,Durable Medical Equipment,Per Unit,"$4,305.35 ",OP,"4,305.35","14,804.69",,,,,,
Molina Duals,CPT,L5160,Mold socket bent knee shin s,Durable Medical Equipment,Per Unit,"$4,727.07 ",OP,"4,727.07","16,257.32",,,,,,
Molina Duals,CPT,L5200,Kne sing axis fric shin sach,Durable Medical Equipment,Per Unit,"$3,656.04 ",OP,"3,656.04","12,574.26",,,,,,
Molina Duals,CPT,L5210,No knee/ankle joints w/ ft b,Durable Medical Equipment,Per Unit,"$2,902.89 ",OP,"2,902.89","9,981.64",,,,,,
Molina Duals,CPT,L5220,No knee joint with artic ali,Durable Medical Equipment,Per Unit,"$3,197.74 ",OP,"3,197.74","10,995.81",,,,,,
Molina Duals,CPT,L5230,Fem focal defic constant fri,Durable Medical Equipment,Per Unit,"$4,796.11 ",OP,"4,796.11","16,493.71",,,,,,
Molina Duals,CPT,L5250,Hip canad sing axi cons fric,Durable Medical Equipment,Per Unit,"$5,623.57 ",OP,"5,623.57","19,341.79",,,,,,
Molina Duals,CPT,L5270,Tilt table locking hip sing,Durable Medical Equipment,Per Unit,"$6,265.76 ",OP,"6,265.76","21,549.33",,,,,,
Molina Duals,CPT,L5280,Hemipelvect canad sing axis,Durable Medical Equipment,Per Unit,"$6,090.55 ",OP,"6,090.55","20,946.94",,,,,,
Molina Duals,CPT,L5301,Bk mold socket sach ft endo,Durable Medical Equipment,Per Unit,"$2,694.66 ",OP,"2,694.66","9,268.66",,,,,,
Molina Duals,CPT,L5312,Knee disart- sach ft- endo,Durable Medical Equipment,Per Unit,"$4,245.62 ",OP,"4,245.62","4,245.62",,,,,,
Molina Duals,CPT,L5321,Ak open end sach,Durable Medical Equipment,Per Unit,"$3,593.24 ",OP,"3,593.24","12,356.94",,,,,,
Molina Duals,CPT,L5331,Hip disart canadian sach ft,Durable Medical Equipment,Per Unit,"$5,262.80 ",OP,"5,262.80","18,098.85",,,,,,
Molina Duals,CPT,L5341,Hemipelvectomy canadian sach,Durable Medical Equipment,Per Unit,"$5,594.28 ",OP,"5,594.28","19,238.85",,,,,,
Molina Duals,CPT,L5400,Postop dress & 1 cast chg bk,Durable Medical Equipment,Per Unit,"$1,604.68 ",OP,"1,604.68","5,516.97",,,,,,
Molina Duals,CPT,L5410,Postop dsg bk ea add cast ch,Durable Medical Equipment,Per Unit,$443.32 ,OP,443.32,"1,525.07",,,,,,
Molina Duals,CPT,L5420,Postop dsg & 1 cast chg ak/d,Durable Medical Equipment,Per Unit,"$2,026.64 ",OP,"2,026.64","6,969.60",,,,,,
Molina Duals,CPT,L5430,Postop dsg ak ea add cast ch,Durable Medical Equipment,Per Unit,$550.12 ,OP,550.12,"1,891.10",,,,,,
Molina Duals,CPT,L5450,Postop app non-wgt bear dsg,Durable Medical Equipment,Per Unit,$475.67 ,OP,475.67,"1,635.64",,,,,,
Molina Duals,CPT,L5460,Postop app non-wgt bear dsg,Durable Medical Equipment,Per Unit,$623.89 ,OP,623.89,"2,146.54",,,,,,
Molina Duals,CPT,L5500,Init bk ptb plaster direct,Durable Medical Equipment,Per Unit,"$1,483.19 ",OP,"1,483.19","5,101.39",,,,,,
Molina Duals,CPT,L5505,Init ak ischal plstr direct,Durable Medical Equipment,Per Unit,"$2,086.44 ",OP,"2,086.44","7,175.49",,,,,,
Molina Duals,CPT,L5510,Prep bk ptb plaster molded,Durable Medical Equipment,Per Unit,"$1,771.18 ",OP,"1,771.18","6,092.69",,,,,,
Molina Duals,CPT,L5520,Perp bk ptb thermopls direct,Durable Medical Equipment,Per Unit,"$1,587.65 ",OP,"1,587.65","5,459.77",,,,,,
Molina Duals,CPT,L5530,Prep bk ptb thermopls molded,Durable Medical Equipment,Per Unit,"$2,087.07 ",OP,"2,087.07","7,179.30",,,,,,
Molina Duals,CPT,L5535,Prep bk ptb open end socket,Durable Medical Equipment,Per Unit,"$1,945.59 ",OP,"1,945.59","6,691.29",,,,,,
Molina Duals,CPT,L5540,Prep bk ptb laminated socket,Durable Medical Equipment,Per Unit,"$2,060.66 ",OP,"2,060.66","7,087.80",,,,,,
Molina Duals,CPT,L5560,Prep ak ischial plast molded,Durable Medical Equipment,Per Unit,"$2,348.01 ",OP,"2,348.01","8,075.28",,,,,,
Molina Duals,CPT,L5570,Prep ak ischial direct form,Durable Medical Equipment,Per Unit,"$2,278.83 ",OP,"2,278.83","7,838.89",,,,,,
Molina Duals,CPT,L5580,Prep ak ischial thermo mold,Durable Medical Equipment,Per Unit,"$2,828.36 ",OP,"2,828.36","9,726.18",,,,,,
Molina Duals,CPT,L5585,Prep ak ischial open end,Durable Medical Equipment,Per Unit,"$3,312.24 ",OP,"3,312.24","11,392.33",,,,,,
Molina Duals,CPT,L5590,Prep ak ischial laminated,Durable Medical Equipment,Per Unit,"$2,948.85 ",OP,"2,948.85","10,141.77",,,,,,
Molina Duals,CPT,L5595,Hip disartic sach thermopls,Durable Medical Equipment,Per Unit,"$4,608.29 ",OP,"4,608.29","15,849.36",,,,,,
Molina Duals,CPT,L5600,Hip disart sach laminat mold,Durable Medical Equipment,Per Unit,"$5,244.91 ",OP,"5,244.91","18,037.85",,,,,,
Molina Duals,CPT,L5610,Above knee hydracadence,Durable Medical Equipment,Per Unit,"$2,529.59 ",OP,"2,529.59","8,700.56",,,,,,
Molina Duals,CPT,L5611,Ak 4 bar link w/fric swing,Durable Medical Equipment,Per Unit,"$1,611.13 ",OP,"1,611.13","5,539.84",,,,,,
Molina Duals,CPT,L5613,Ak 4 bar ling w/hydraul swig,Durable Medical Equipment,Per Unit,"$2,450.64 ",OP,"2,450.64","8,429.87",,,,,,
Molina Duals,CPT,L5614,4-bar link above knee w/swng,Durable Medical Equipment,Per Unit,"$1,697.23 ",OP,"1,697.23","5,837.23",,,,,,
Molina Duals,CPT,L5616,Ak univ multiplex sys frict,Durable Medical Equipment,Per Unit,"$1,477.66 ",OP,"1,477.66","5,082.32",,,,,,
Molina Duals,CPT,L5617,Ak/bk self-aligning unit ea,Durable Medical Equipment,Per Unit,$562.74 ,OP,562.74,"1,936.85",,,,,,
Molina Duals,CPT,L5618,Test socket symes,Durable Medical Equipment,Per Unit,$336.06 ,OP,336.06,"1,155.24",,,,,,
Molina Duals,CPT,L5620,Test socket below knee,Durable Medical Equipment,Per Unit,$298.16 ,OP,298.16,"1,025.61",,,,,,
Molina Duals,CPT,L5622,Test socket knee disarticula,Durable Medical Equipment,Per Unit,$401.70 ,OP,401.7,"1,380.19",,,,,,
Molina Duals,CPT,L5624,Test socket above knee,Durable Medical Equipment,Per Unit,$401.54 ,OP,401.54,"1,380.19",,,,,,
Molina Duals,CPT,L5626,Test socket hip disarticulat,Durable Medical Equipment,Per Unit,$635.70 ,OP,635.7,"2,184.67",,,,,,
Molina Duals,CPT,L5628,Test socket hemipelvectomy,Durable Medical Equipment,Per Unit,$643.74 ,OP,643.74,"2,215.19",,,,,,
Molina Duals,CPT,L5629,Below knee acrylic socket,Durable Medical Equipment,Per Unit,$317.79 ,OP,317.79,"1,094.25",,,,,,
Molina Duals,CPT,L5630,Syme typ expandabl wall sckt,Durable Medical Equipment,Per Unit,$552.17 ,OP,552.17,"1,898.73",,,,,,
Molina Duals,CPT,L5631,Ak/knee disartic acrylic soc,Durable Medical Equipment,Per Unit,$439.37 ,OP,439.37,"1,509.83",,,,,,
Molina Duals,CPT,L5632,Symes type ptb brim design s,Durable Medical Equipment,Per Unit,$270.81 ,OP,270.81,930.3,,,,,,
Molina Duals,CPT,L5634,Symes type poster opening so,Durable Medical Equipment,Per Unit,$338.66 ,OP,338.66,"1,162.87",,,,,,
Molina Duals,CPT,L5636,Symes type medial opening so,Durable Medical Equipment,Per Unit,$258.86 ,OP,258.86,888.36,,,,,,
Molina Duals,CPT,L5637,Below knee total contact,Durable Medical Equipment,Per Unit,$385.17 ,OP,385.17,"1,323.01",,,,,,
Molina Duals,CPT,L5638,Below knee leather socket,Durable Medical Equipment,Per Unit,$648.87 ,OP,648.87,"2,230.43",,,,,,
Molina Duals,CPT,L5639,Below knee wood socket,Durable Medical Equipment,Per Unit,"$1,121.15 ",OP,"1,121.15","3,854.63",,,,,,
Molina Duals,CPT,L5640,Knee disarticulat leather so,Durable Medical Equipment,Per Unit,$736.94 ,OP,736.94,"2,535.44",,,,,,
Molina Duals,CPT,L5642,Above knee leather socket,Durable Medical Equipment,Per Unit,$683.11 ,OP,683.11,"2,348.62",,,,,,
Molina Duals,CPT,L5643,Hip flex inner socket ext fr,Durable Medical Equipment,Per Unit,"$2,014.84 ",OP,"2,014.84","6,927.67",,,,,,
Molina Duals,CPT,L5644,Above knee wood socket,Durable Medical Equipment,Per Unit,$590.63 ,OP,590.63,"2,032.17",,,,,,
Molina Duals,CPT,L5645,Bk flex inner socket ext fra,Durable Medical Equipment,Per Unit,$979.82 ,OP,979.82,"3,370.43",,,,,,
Molina Duals,CPT,L5646,Below knee cushion socket,Durable Medical Equipment,Per Unit,$620.93 ,OP,620.93,"2,135.11",,,,,,
Molina Duals,CPT,L5647,Below knee suction socket,Durable Medical Equipment,Per Unit,$795.44 ,OP,795.44,"2,733.70",,,,,,
Molina Duals,CPT,L5648,Above knee cushion socket,Durable Medical Equipment,Per Unit,$733.68 ,OP,733.68,"2,524.00",,,,,,
Molina Duals,CPT,L5649,Isch containmt/narrow m-l so,Durable Medical Equipment,Per Unit,"$2,465.24 ",OP,"2,465.24","8,479.43",,,,,,
Molina Duals,CPT,L5650,Tot contact ak/knee disart s,Durable Medical Equipment,Per Unit,$488.17 ,OP,488.17,"1,677.58",,,,,,
Molina Duals,CPT,L5651,Ak flex inner socket ext fra,Durable Medical Equipment,Per Unit,"$1,430.29 ",OP,"1,430.29","4,918.37",,,,,,
Molina Duals,CPT,L5652,Suction susp ak/knee disart,Durable Medical Equipment,Per Unit,$435.97 ,OP,435.97,"1,498.39",,,,,,
Molina Duals,CPT,L5653,Knee disart expand wall sock,Durable Medical Equipment,Per Unit,$680.24 ,OP,680.24,"2,341.00",,,,,,
Molina Duals,CPT,L5654,Socket insert symes,Durable Medical Equipment,Per Unit,$394.33 ,OP,394.33,"1,357.32",,,,,,
Molina Duals,CPT,L5655,Socket insert below knee,Durable Medical Equipment,Per Unit,$284.71 ,OP,284.71,979.86,,,,,,
Molina Duals,CPT,L5656,Socket insert knee articulat,Durable Medical Equipment,Per Unit,$432.53 ,OP,432.53,"1,486.95",,,,,,
Molina Duals,CPT,L5658,Socket insert above knee,Durable Medical Equipment,Per Unit,$456.55 ,OP,456.55,"1,570.83",,,,,,
Molina Duals,CPT,L5661,Multi-durometer symes,Durable Medical Equipment,Per Unit,$655.04 ,OP,655.04,"2,253.31",,,,,,
Molina Duals,CPT,L5665,Multi-durometer below knee,Durable Medical Equipment,Per Unit,$582.36 ,OP,582.36,"2,001.67",,,,,,
Molina Duals,CPT,L5666,Below knee cuff suspension,Durable Medical Equipment,Per Unit,$77.11 ,OP,77.11,266.89,,,,,,
Molina Duals,CPT,L5668,Bk molded distal cushion,Durable Medical Equipment,Per Unit,$114.86 ,OP,114.86,396.52,,,,,,
Molina Duals,CPT,L5670,Bk molded supracondylar susp,Durable Medical Equipment,Per Unit,$271.35 ,OP,271.35,934.12,,,,,,
Molina Duals,CPT,L5671,Bk/ak locking mechanism,Durable Medical Equipment,Per Unit,$497.40 ,OP,497.4,"1,711.89",,,,,,
Molina Duals,CPT,L5672,Bk removable medial brim sus,Durable Medical Equipment,Per Unit,$359.07 ,OP,359.07,"1,235.32",,,,,,
Molina Duals,CPT,L5673,Socket insert w lock mech,Durable Medical Equipment,Per Unit,$790.52 ,OP,790.52,"2,718.45",,,,,,
Molina Duals,CPT,L5676,Bk knee joints single axis p,Durable Medical Equipment,Per Unit,$362.36 ,OP,362.36,"1,246.76",,,,,,
Molina Duals,CPT,L5677,Bk knee joints polycentric p,Durable Medical Equipment,Per Unit,$554.97 ,OP,554.97,"1,910.16",,,,,,
Molina Duals,CPT,L5678,Bk joint covers pair,Durable Medical Equipment,Per Unit,$39.70 ,OP,39.7,137.25,,,,,,
Molina Duals,CPT,L5679,Socket insert w/o lock mech,Durable Medical Equipment,Per Unit,$658.75 ,OP,658.75,"2,264.75",,,,,,
Molina Duals,CPT,L5680,Bk thigh lacer non-molded,Durable Medical Equipment,Per Unit,$304.37 ,OP,304.37,"1,048.50",,,,,,
Molina Duals,CPT,L5681,Intl custm cong/latyp insert,Durable Medical Equipment,Per Unit,"$1,323.02 ",OP,"1,323.02","4,548.54",,,,,,
Molina Duals,CPT,L5682,Bk thigh lacer glut/ischia m,Durable Medical Equipment,Per Unit,$625.37 ,OP,625.37,"2,150.36",,,,,,
Molina Duals,CPT,L5683,Initial custom socket insert,Durable Medical Equipment,Per Unit,"$1,323.02 ",OP,"1,323.02","4,548.54",,,,,,
Molina Duals,CPT,L5684,Bk fork strap,Durable Medical Equipment,Per Unit,$48.13 ,OP,48.13,163.95,,,,,,
Molina Duals,CPT,L5685,Below knee sus/seal sleeve,Durable Medical Equipment,Per Unit,$128.85 ,OP,128.85,442.27,,,,,,
Molina Duals,CPT,L5686,Bk back check,Durable Medical Equipment,Per Unit,$57.89 ,OP,57.89,198.25,,,,,,
Molina Duals,CPT,L5688,Bk waist belt webbing,Durable Medical Equipment,Per Unit,$61.48 ,OP,61.48,209.7,,,,,,
Molina Duals,CPT,L5690,Bk waist belt padded and lin,Durable Medical Equipment,Per Unit,$125.50 ,OP,125.5,430.83,,,,,,
Molina Duals,CPT,L5692,Ak pelvic control belt light,Durable Medical Equipment,Per Unit,$132.88 ,OP,132.88,457.52,,,,,,
Molina Duals,CPT,L5694,Ak pelvic control belt pad/l,Durable Medical Equipment,Per Unit,$181.41 ,OP,181.41,625.29,,,,,,
Molina Duals,CPT,L5695,Ak sleeve susp neoprene/equa,Durable Medical Equipment,Per Unit,$163.08 ,OP,163.08,560.47,,,,,,
Molina Duals,CPT,L5696,Ak/knee disartic pelvic join,Durable Medical Equipment,Per Unit,$196.99 ,OP,196.99,678.66,,,,,,
Molina Duals,CPT,L5697,Ak/knee disartic pelvic band,Durable Medical Equipment,Per Unit,$93.55 ,OP,93.55,320.27,,,,,,
Molina Duals,CPT,L5698,Ak/knee disartic silesian ba,Durable Medical Equipment,Per Unit,$120.01 ,OP,120.01,411.78,,,,,,
Molina Duals,CPT,L5699,Shoulder harness,Durable Medical Equipment,Per Unit,$205.11 ,OP,205.11,705.35,,,,,,
Molina Duals,CPT,L5700,Replace socket below knee,Durable Medical Equipment,Per Unit,"$3,085.07 ",OP,"3,085.07","10,610.72",,,,,,
Molina Duals,CPT,L5701,Replace socket above knee,Durable Medical Equipment,Per Unit,"$3,827.32 ",OP,"3,827.32","13,161.41",,,,,,
Molina Duals,CPT,L5702,Replace socket hip,Durable Medical Equipment,Per Unit,"$4,823.75 ",OP,"4,823.75","16,589.03",,,,,,
Molina Duals,CPT,L5703,Symes ankle w/o (sach) foot,Durable Medical Equipment,Per Unit,"$2,537.43 ",OP,"2,537.43","8,727.25",,,,,,
Molina Duals,CPT,L5704,Custom shape cover bk,Durable Medical Equipment,Per Unit,$629.03 ,OP,629.03,"2,161.80",,,,,,
Molina Duals,CPT,L5705,Custom shape cover ak,Durable Medical Equipment,Per Unit,"$1,153.25 ",OP,"1,153.25","3,965.20",,,,,,
Molina Duals,CPT,L5706,Custom shape cvr knee disart,Durable Medical Equipment,Per Unit,"$1,124.85 ",OP,"1,124.85","3,869.89",,,,,,
Molina Duals,CPT,L5707,Custom shape cvr hip disart,Durable Medical Equipment,Per Unit,"$1,511.27 ",OP,"1,511.27","5,196.70",,,,,,
Molina Duals,CPT,L5710,Kne-shin exo sng axi mnl loc,Durable Medical Equipment,Per Unit,$359.65 ,OP,359.65,"1,235.32",,,,,,
Molina Duals,CPT,L5711,Knee-shin exo mnl lock ultra,Durable Medical Equipment,Per Unit,$603.60 ,OP,603.6,"2,074.10",,,,,,
Molina Duals,CPT,L5712,Knee-shin exo frict swg & st,Durable Medical Equipment,Per Unit,$430.88 ,OP,430.88,"1,483.14",,,,,,
Molina Duals,CPT,L5714,Knee-shin exo variable frict,Durable Medical Equipment,Per Unit,$438.43 ,OP,438.43,"1,506.03",,,,,,
Molina Duals,CPT,L5716,Knee-shin exo mech stance ph,Durable Medical Equipment,Per Unit,$866.93 ,OP,866.93,"2,981.52",,,,,,
Molina Duals,CPT,L5718,Knee-shin exo frct swg & sta,Durable Medical Equipment,Per Unit,$927.01 ,OP,927.01,"3,187.41",,,,,,
Molina Duals,CPT,L5722,Knee-shin pneum swg frct exo,Durable Medical Equipment,Per Unit,"$1,127.32 ",OP,"1,127.32","3,877.51",,,,,,
Molina Duals,CPT,L5724,Knee-shin exo fluid swing ph,Durable Medical Equipment,Per Unit,"$1,737.57 ",OP,"1,737.57","5,974.48",,,,,,
Molina Duals,CPT,L5726,Knee-shin ext jnts fld swg e,Durable Medical Equipment,Per Unit,"$2,068.65 ",OP,"2,068.65","7,114.49",,,,,,
Molina Duals,CPT,L5728,Knee-shin fluid swg & stance,Durable Medical Equipment,Per Unit,"$2,424.23 ",OP,"2,424.23","8,338.36",,,,,,
Molina Duals,CPT,L5780,Knee-shin pneum/hydra pneum,Durable Medical Equipment,Per Unit,"$1,334.72 ",OP,"1,334.72","4,590.49",,,,,,
Molina Duals,CPT,L5781,Lower limb pros vacuum pump,Durable Medical Equipment,Per Unit,"$4,024.33 ",OP,"4,024.33","13,840.07",,,,,,
Molina Duals,CPT,L5782,Hd low limb pros vacuum pump,Durable Medical Equipment,Per Unit,"$4,242.55 ",OP,"4,242.55","14,591.17",,,,,,
Molina Duals,CPT,L5785,Exoskeletal bk ultralt mater,Durable Medical Equipment,Per Unit,$519.54 ,OP,519.54,"1,788.15",,,,,,
Molina Duals,CPT,L5790,Exoskeletal ak ultra-light m,Durable Medical Equipment,Per Unit,$749.83 ,OP,749.83,"2,577.38",,,,,,
Molina Duals,CPT,L5795,Exoskel hip ultra-light mate,Durable Medical Equipment,Per Unit,"$1,073.66 ",OP,"1,073.66","3,690.70",,,,,,
Molina Duals,CPT,L5810,Endoskel knee-shin mnl lock,Durable Medical Equipment,Per Unit,$572.04 ,OP,572.04,"1,967.35",,,,,,
Molina Duals,CPT,L5811,Endo knee-shin mnl lck ultra,Durable Medical Equipment,Per Unit,$789.42 ,OP,789.42,"2,714.64",,,,,,
Molina Duals,CPT,L5812,Endo knee-shin frct swg & st,Durable Medical Equipment,Per Unit,$594.07 ,OP,594.07,"2,043.61",,,,,,
Molina Duals,CPT,L5814,Endo knee-shin hydral swg ph,Durable Medical Equipment,Per Unit,"$3,735.37 ",OP,"3,735.37","12,844.96",,,,,,
Molina Duals,CPT,L5816,Endo knee-shin polyc mch sta,Durable Medical Equipment,Per Unit,$850.43 ,OP,850.43,"2,924.33",,,,,,
Molina Duals,CPT,L5818,Endo knee-shin frct swg & st,Durable Medical Equipment,Per Unit,$960.30 ,OP,960.3,"3,301.79",,,,,,
Molina Duals,CPT,L5822,Endo knee-shin pneum swg frc,Durable Medical Equipment,Per Unit,"$1,761.65 ",OP,"1,761.65","6,058.37",,,,,,
Molina Duals,CPT,L5824,Endo knee-shin fluid swing p,Durable Medical Equipment,Per Unit,"$1,665.27 ",OP,"1,665.27","5,726.65",,,,,,
Molina Duals,CPT,L5826,Miniature knee joint,Durable Medical Equipment,Per Unit,"$3,140.97 ",OP,"3,140.97","10,801.35",,,,,,
Molina Duals,CPT,L5828,Endo knee-shin fluid swg/sta,Durable Medical Equipment,Per Unit,"$2,963.78 ",OP,"2,963.78","10,191.33",,,,,,
Molina Duals,CPT,L5830,Endo knee-shin pneum/swg pha,Durable Medical Equipment,Per Unit,"$1,998.37 ",OP,"1,998.37","6,874.29",,,,,,
Molina Duals,CPT,L5840,Multi-axial knee/shin system,Durable Medical Equipment,Per Unit,"$3,922.28 ",OP,"3,922.28","13,489.32",,,,,,
Molina Duals,CPT,L5845,Knee-shin sys stance flexion,Durable Medical Equipment,Per Unit,"$1,802.73 ",OP,"1,802.73","6,199.43",,,,,,
Molina Duals,CPT,L5848,Knee-shin sys hydraul stance,Durable Medical Equipment,Per Unit,"$1,081.55 ",OP,"1,081.55","3,721.19",,,,,,
Molina Duals,CPT,L5850,Endo ak/hip knee extens assi,Durable Medical Equipment,Per Unit,$127.92 ,OP,127.92,438.47,,,,,,
Molina Duals,CPT,L5855,Mech hip extension assist,Durable Medical Equipment,Per Unit,$308.82 ,OP,308.82,"1,063.73",,,,,,
Molina Duals,CPT,L5856,Elec knee-shin swing/stance,Durable Medical Equipment,Per Unit,"$24,144.68 ",OP,"24,144.68","83,036.63",,,,,,
Molina Duals,CPT,L5857,Elec knee-shin swing only,Durable Medical Equipment,Per Unit,"$8,567.44 ",OP,"8,567.44","29,464.49",,,,,,
Molina Duals,CPT,L5858,Stance phase only,Durable Medical Equipment,Per Unit,"$18,692.70 ",OP,"18,692.70","64,285.82",,,,,,
Molina Duals,CPT,L5859,Knee-shin pro flex/ext cont,Durable Medical Equipment,Per Unit,"$14,593.21 ",OP,"14,593.21","14,593.21",,,,,,
Molina Duals,CPT,L5910,Endo below knee alignable sy,Durable Medical Equipment,Per Unit,$362.17 ,OP,362.17,"1,246.76",,,,,,
Molina Duals,CPT,L5920,Endo ak/hip alignable system,Durable Medical Equipment,Per Unit,$530.58 ,OP,530.58,"1,826.28",,,,,,
Molina Duals,CPT,L5925,Above knee manual lock,Durable Medical Equipment,Per Unit,$336.00 ,OP,336,"1,155.24",,,,,,
Molina Duals,CPT,L5930,High activity knee frame,Durable Medical Equipment,Per Unit,"$3,385.39 ",OP,"3,385.39","11,643.96",,,,,,
Molina Duals,CPT,L5940,Endo bk ultra-light material,Durable Medical Equipment,Per Unit,$501.60 ,OP,501.6,"1,723.33",,,,,,
Molina Duals,CPT,L5950,Endo ak ultra-light material,Durable Medical Equipment,Per Unit,$777.99 ,OP,777.99,"2,676.51",,,,,,
Molina Duals,CPT,L5960,Endo hip ultra-light materia,Durable Medical Equipment,Per Unit,"$1,163.29 ",OP,"1,163.29","3,999.51",,,,,,
Molina Duals,CPT,L5961,Endo poly hip- pneu/hyd/rot,Durable Medical Equipment,Per Unit,"$4,800.88 ",OP,"4,800.88","4,800.88",,,,,,
Molina Duals,CPT,L5962,Below knee flex cover system,Durable Medical Equipment,Per Unit,$587.78 ,OP,587.78,"2,020.72",,,,,,
Molina Duals,CPT,L5964,Above knee flex cover system,Durable Medical Equipment,Per Unit,"$1,127.47 ",OP,"1,127.47","3,877.51",,,,,,
Molina Duals,CPT,L5966,Hip flexible cover system,Durable Medical Equipment,Per Unit,"$1,452.38 ",OP,"1,452.38","4,994.63",,,,,,
Molina Duals,CPT,L5968,Multiaxial ankle w dorsiflex,Durable Medical Equipment,Per Unit,"$3,654.91 ",OP,"3,654.91","12,570.45",,,,,,
Molina Duals,CPT,L5970,Foot external keel sach foot,Durable Medical Equipment,Per Unit,$218.47 ,OP,218.47,751.1,,,,,,
Molina Duals,CPT,L5971,Sach foot- replacement,Durable Medical Equipment,Per Unit,$218.47 ,OP,218.47,751.1,,,,,,
Molina Duals,CPT,L5972,Flexible keel foot,Durable Medical Equipment,Per Unit,$397.97 ,OP,397.97,"1,368.75",,,,,,
Molina Duals,CPT,L5973,Ank-foot sys dors-plant flex,Durable Medical Equipment,Per Unit,"$17,757.02 ",OP,"17,757.02","17,757.02",,,,,,
Molina Duals,CPT,L5974,Foot single axis ankle/foot,Durable Medical Equipment,Per Unit,$233.03 ,OP,233.03,800.67,,,,,,
Molina Duals,CPT,L5975,Combo ankle/foot prosthesis,Durable Medical Equipment,Per Unit,$466.28 ,OP,466.28,"1,605.15",,,,,,
Molina Duals,CPT,L5976,Energy storing foot,Durable Medical Equipment,Per Unit,$591.07 ,OP,591.07,"2,032.17",,,,,,
Molina Duals,CPT,L5978,Ft prosth multiaxial ankl/ft,Durable Medical Equipment,Per Unit,$313.20 ,OP,313.2,"1,078.99",,,,,,
Molina Duals,CPT,L5979,Multi-axial ankle/ft prosth,Durable Medical Equipment,Per Unit,"$2,507.69 ",OP,"2,507.69","8,624.30",,,,,,
Molina Duals,CPT,L5980,Flex foot system,Durable Medical Equipment,Per Unit,"$3,820.69 ",OP,"3,820.69","13,138.54",,,,,,
Molina Duals,CPT,L5981,Flex-walk sys low ext prosth,Durable Medical Equipment,Per Unit,"$3,431.91 ",OP,"3,431.91","11,804.09",,,,,,
Molina Duals,CPT,L5982,Exoskeletal axial rotation u,Durable Medical Equipment,Per Unit,$644.71 ,OP,644.71,"2,218.98",,,,,,
Molina Duals,CPT,L5984,Endoskeletal axial rotation,Durable Medical Equipment,Per Unit,$646.71 ,OP,646.71,"2,222.79",,,,,,
Molina Duals,CPT,L5985,Lwr ext dynamic prosth pylon,Durable Medical Equipment,Per Unit,$284.02 ,OP,284.02,976.05,,,,,,
Molina Duals,CPT,L5986,Multi-axial rotation unit,Durable Medical Equipment,Per Unit,$780.11 ,OP,780.11,"2,684.14",,,,,,
Molina Duals,CPT,L5987,Shank ft w vert load pylon,Durable Medical Equipment,Per Unit,"$7,235.38 ",OP,"7,235.38","24,881.63",,,,,,
Molina Duals,CPT,L5988,Vertical shock reducing pylo,Durable Medical Equipment,Per Unit,"$2,009.25 ",OP,"2,009.25","6,908.59",,,,,,
Molina Duals,CPT,L5990,User adjustable heel height,Durable Medical Equipment,Per Unit,"$1,824.64 ",OP,"1,824.64","6,275.69",,,,,,
Molina Duals,CPT,L6000,Part hand thumb rem,Durable Medical Equipment,Per Unit,"$1,771.55 ",OP,"1,771.55","6,092.69",,,,,,
Molina Duals,CPT,L6010,Part hand little/ring,Durable Medical Equipment,Per Unit,"$1,971.44 ",OP,"1,971.44","6,778.98",,,,,,
Molina Duals,CPT,L6020,Part hand no fingers,Durable Medical Equipment,Per Unit,"$1,838.05 ",OP,"1,838.05","6,321.45",,,,,,
Molina Duals,CPT,L6026,Part hand myo exclu term dev,Durable Medical Equipment,Per Unit,"$4,375.03 ",OP,"4,375.03","4,375.03",,,,,,
Molina Duals,CPT,L6050,Wrst mld sck flx hng tri pad,Durable Medical Equipment,Per Unit,"$2,500.12 ",OP,"2,500.12","8,597.63",,,,,,
Molina Duals,CPT,L6055,Wrst mold sock w/exp interfa,Durable Medical Equipment,Per Unit,"$3,189.04 ",OP,"3,189.04","10,969.11",,,,,,
Molina Duals,CPT,L6100,Elb mold sock flex hinge pad,Durable Medical Equipment,Per Unit,"$2,530.04 ",OP,"2,530.04","8,700.56",,,,,,
Molina Duals,CPT,L6110,Elbow mold sock suspension t,Durable Medical Equipment,Per Unit,"$2,676.61 ",OP,"2,676.61","9,203.84",,,,,,
Molina Duals,CPT,L6120,Elbow mold doub splt soc ste,Durable Medical Equipment,Per Unit,"$3,027.26 ",OP,"3,027.26","10,412.46",,,,,,
Molina Duals,CPT,L6130,Elbow stump activated lock h,Durable Medical Equipment,Per Unit,"$3,193.82 ",OP,"3,193.82","10,984.37",,,,,,
Molina Duals,CPT,L6200,Elbow mold outsid lock hinge,Durable Medical Equipment,Per Unit,"$3,290.01 ",OP,"3,290.01","11,316.08",,,,,,
Molina Duals,CPT,L6205,Elbow molded w/ expand inter,Durable Medical Equipment,Per Unit,"$4,538.50 ",OP,"4,538.50","15,609.16",,,,,,
Molina Duals,CPT,L6250,Elbow inter loc elbow forarm,Durable Medical Equipment,Per Unit,"$3,236.79 ",OP,"3,236.79","11,133.06",,,,,,
Molina Duals,CPT,L6300,Shlder disart int lock elbow,Durable Medical Equipment,Per Unit,"$4,464.43 ",OP,"4,464.43","15,353.72",,,,,,
Molina Duals,CPT,L6310,Shoulder passive restor comp,Durable Medical Equipment,Per Unit,"$4,046.04 ",OP,"4,046.04","13,916.32",,,,,,
Molina Duals,CPT,L6320,Shoulder passive restor cap,Durable Medical Equipment,Per Unit,"$2,108.67 ",OP,"2,108.67","7,251.74",,,,,,
Molina Duals,CPT,L6350,Thoracic intern lock elbow,Durable Medical Equipment,Per Unit,"$4,891.63 ",OP,"4,891.63","16,821.60",,,,,,
Molina Duals,CPT,L6360,Thoracic passive restor comp,Durable Medical Equipment,Per Unit,"$4,246.80 ",OP,"4,246.80","14,606.43",,,,,,
Molina Duals,CPT,L6370,Thoracic passive restor cap,Durable Medical Equipment,Per Unit,"$2,462.85 ",OP,"2,462.85","8,471.79",,,,,,
Molina Duals,CPT,L6380,Postop dsg cast chg wrst/elb,Durable Medical Equipment,Per Unit,"$1,424.44 ",OP,"1,424.44","4,899.32",,,,,,
Molina Duals,CPT,L6382,Postop dsg cast chg elb dis/,Durable Medical Equipment,Per Unit,"$1,695.74 ",OP,"1,695.74","5,833.42",,,,,,
Molina Duals,CPT,L6384,Postop dsg cast chg shlder/t,Durable Medical Equipment,Per Unit,"$2,145.20 ",OP,"2,145.20","7,377.56",,,,,,
Molina Duals,CPT,L6386,Postop ea cast chg & realign,Durable Medical Equipment,Per Unit,$470.24 ,OP,470.24,"1,616.58",,,,,,
Molina Duals,CPT,L6388,Postop applicat rigid dsg on,Durable Medical Equipment,Per Unit,$517.85 ,OP,517.85,"1,780.53",,,,,,
Molina Duals,CPT,L6400,Below elbow prosth tiss shap,Durable Medical Equipment,Per Unit,"$2,736.86 ",OP,"2,736.86","9,413.54",,,,,,
Molina Duals,CPT,L6450,Elb disart prosth tiss shap,Durable Medical Equipment,Per Unit,"$3,576.94 ",OP,"3,576.94","12,299.74",,,,,,
Molina Duals,CPT,L6500,Above elbow prosth tiss shap,Durable Medical Equipment,Per Unit,"$3,512.48 ",OP,"3,512.48","12,078.62",,,,,,
Molina Duals,CPT,L6550,Shldr disar prosth tiss shap,Durable Medical Equipment,Per Unit,"$4,549.39 ",OP,"4,549.39","15,647.29",,,,,,
Molina Duals,CPT,L6570,Scap thorac prosth tiss shap,Durable Medical Equipment,Per Unit,"$5,078.79 ",OP,"5,078.79","17,465.96",,,,,,
Molina Duals,CPT,L6580,Wrist/elbow bowden cable mol,Durable Medical Equipment,Per Unit,"$2,030.62 ",OP,"2,030.62","6,984.85",,,,,,
Molina Duals,CPT,L6582,Wrist/elbow bowden cbl dir f,Durable Medical Equipment,Per Unit,"$1,705.44 ",OP,"1,705.44","5,863.93",,,,,,
Molina Duals,CPT,L6584,Elbow fair lead cable molded,Durable Medical Equipment,Per Unit,"$2,525.30 ",OP,"2,525.30","8,685.31",,,,,,
Molina Duals,CPT,L6586,Elbow fair lead cable dir fo,Durable Medical Equipment,Per Unit,"$2,250.20 ",OP,"2,250.20","7,739.77",,,,,,
Molina Duals,CPT,L6588,Shdr fair lead cable molded,Durable Medical Equipment,Per Unit,"$3,583.73 ",OP,"3,583.73","12,326.44",,,,,,
Molina Duals,CPT,L6590,Shdr fair lead cable direct,Durable Medical Equipment,Per Unit,"$3,123.36 ",OP,"3,123.36","10,740.36",,,,,,
Molina Duals,CPT,L6600,Polycentric hinge pair,Durable Medical Equipment,Per Unit,$228.13 ,OP,228.13,785.42,,,,,,
Molina Duals,CPT,L6605,Single pivot hinge pair,Durable Medical Equipment,Per Unit,$234.81 ,OP,234.81,808.29,,,,,,
Molina Duals,CPT,L6610,Flexible metal hinge pair,Durable Medical Equipment,Per Unit,$221.98 ,OP,221.98,762.54,,,,,,
Molina Duals,CPT,L6611,Additional switch- ext power,Durable Medical Equipment,Per Unit,$414.10 ,OP,414.1,"1,425.95",,,,,,
Molina Duals,CPT,L6615,Disconnect locking wrist uni,Durable Medical Equipment,Per Unit,$215.48 ,OP,215.48,739.67,,,,,,
Molina Duals,CPT,L6616,Disconnect insert locking wr,Durable Medical Equipment,Per Unit,$64.86 ,OP,64.86,224.95,,,,,,
Molina Duals,CPT,L6620,Flexion/extension wrist unit,Durable Medical Equipment,Per Unit,$376.69 ,OP,376.69,"1,296.32",,,,,,
Molina Duals,CPT,L6621,Flex/ext wrist w/wo friction,Durable Medical Equipment,Per Unit,"$2,300.54 ",OP,"2,300.54","7,911.34",,,,,,
Molina Duals,CPT,L6623,Spring-ass rot wrst w/ latch,Durable Medical Equipment,Per Unit,$717.59 ,OP,717.59,"2,466.81",,,,,,
Molina Duals,CPT,L6624,Flex/ext/rotation wrist unit,Durable Medical Equipment,Per Unit,"$3,787.86 ",OP,"3,787.86","13,027.98",,,,,,
Molina Duals,CPT,L6625,Rotation wrst w/ cable lock,Durable Medical Equipment,Per Unit,$531.84 ,OP,531.84,"1,830.09",,,,,,
Molina Duals,CPT,L6628,Quick disconn hook adapter o,Durable Medical Equipment,Per Unit,$572.47 ,OP,572.47,"1,967.35",,,,,,
Molina Duals,CPT,L6629,Lamination collar w/ couplin,Durable Medical Equipment,Per Unit,$195.07 ,OP,195.07,671.03,,,,,,
Molina Duals,CPT,L6630,Stainless steel any wrist,Durable Medical Equipment,Per Unit,$287.35 ,OP,287.35,987.49,,,,,,
Molina Duals,CPT,L6632,Latex suspension sleeve each,Durable Medical Equipment,Per Unit,$64.97 ,OP,64.97,224.95,,,,,,
Molina Duals,CPT,L6635,Lift assist for elbow,Durable Medical Equipment,Per Unit,$207.68 ,OP,207.68,712.98,,,,,,
Molina Duals,CPT,L6637,Nudge control elbow lock,Durable Medical Equipment,Per Unit,$406.60 ,OP,406.6,"1,399.26",,,,,,
Molina Duals,CPT,L6638,Elec lock on manual pw elbow,Durable Medical Equipment,Per Unit,"$2,515.20 ",OP,"2,515.20","8,651.00",,,,,,
Molina Duals,CPT,L6640,Shoulder abduction joint pai,Durable Medical Equipment,Per Unit,$338.63 ,OP,338.63,"1,162.87",,,,,,
Molina Duals,CPT,L6641,Excursion amplifier pulley t,Durable Medical Equipment,Per Unit,$197.18 ,OP,197.18,678.66,,,,,,
Molina Duals,CPT,L6642,Excursion amplifier lever ty,Durable Medical Equipment,Per Unit,$289.92 ,OP,289.92,998.92,,,,,,
Molina Duals,CPT,L6645,Shoulder flexion-abduction j,Durable Medical Equipment,Per Unit,$366.21 ,OP,366.21,"1,258.19",,,,,,
Molina Duals,CPT,L6646,Multipo locking shoulder jnt,Durable Medical Equipment,Per Unit,"$3,172.24 ",OP,"3,172.24","10,908.12",,,,,,
Molina Duals,CPT,L6647,Shoulder lock actuator,Durable Medical Equipment,Per Unit,$522.26 ,OP,522.26,"1,795.78",,,,,,
Molina Duals,CPT,L6648,Ext pwrd shlder lock/unlock,Durable Medical Equipment,Per Unit,"$3,271.71 ",OP,"3,271.71","11,251.26",,,,,,
Molina Duals,CPT,L6650,Shoulder universal joint,Durable Medical Equipment,Per Unit,$397.20 ,OP,397.2,"1,364.94",,,,,,
Molina Duals,CPT,L6655,Standard control cable extra,Durable Medical Equipment,Per Unit,$77.05 ,OP,77.05,263.08,,,,,,
Molina Duals,CPT,L6660,Heavy duty control cable,Durable Medical Equipment,Per Unit,$103.11 ,OP,103.11,354.58,,,,,,
Molina Duals,CPT,L6665,Teflon or equal cable lining,Durable Medical Equipment,Per Unit,$46.05 ,OP,46.05,160.13,,,,,,
Molina Duals,CPT,L6670,Hook to hand cable adapter,Durable Medical Equipment,Per Unit,$47.96 ,OP,47.96,163.95,,,,,,
Molina Duals,CPT,L6672,Harness chest/shlder saddle,Durable Medical Equipment,Per Unit,$220.08 ,OP,220.08,758.72,,,,,,
Molina Duals,CPT,L6675,Harness figure of 8 sing con,Durable Medical Equipment,Per Unit,$120.09 ,OP,120.09,411.78,,,,,,
Molina Duals,CPT,L6676,Harness figure of 8 dual con,Durable Medical Equipment,Per Unit,$125.64 ,OP,125.64,430.83,,,,,,
Molina Duals,CPT,L6677,Ue triple control harness,Durable Medical Equipment,Per Unit,$298.35 ,OP,298.35,"1,025.61",,,,,,
Molina Duals,CPT,L6680,Test sock wrist disart/bel e,Durable Medical Equipment,Per Unit,$309.33 ,OP,309.33,"1,063.73",,,,,,
Molina Duals,CPT,L6682,Test sock elbw disart/above,Durable Medical Equipment,Per Unit,$342.01 ,OP,342.01,"1,178.12",,,,,,
Molina Duals,CPT,L6684,Test socket shldr disart/tho,Durable Medical Equipment,Per Unit,$464.75 ,OP,464.75,"1,597.52",,,,,,
Molina Duals,CPT,L6686,Suction socket,Durable Medical Equipment,Per Unit,$689.63 ,OP,689.63,"2,371.49",,,,,,
Molina Duals,CPT,L6687,Frame typ socket bel elbow/w,Durable Medical Equipment,Per Unit,$576.80 ,OP,576.8,"1,982.60",,,,,,
Molina Duals,CPT,L6688,Frame typ sock above elb/dis,Durable Medical Equipment,Per Unit,$638.36 ,OP,638.36,"2,196.11",,,,,,
Molina Duals,CPT,L6689,Frame typ socket shoulder di,Durable Medical Equipment,Per Unit,$760.81 ,OP,760.81,"2,615.51",,,,,,
Molina Duals,CPT,L6690,Frame typ sock interscap-tho,Durable Medical Equipment,Per Unit,$895.74 ,OP,895.74,"3,080.66",,,,,,
Molina Duals,CPT,L6691,Removable insert each,Durable Medical Equipment,Per Unit,$353.58 ,OP,353.58,"1,216.24",,,,,,
Molina Duals,CPT,L6692,Silicone gel insert or equal,Durable Medical Equipment,Per Unit,$643.25 ,OP,643.25,"2,211.37",,,,,,
Molina Duals,CPT,L6693,Lockingelbow forearm cntrbal,Durable Medical Equipment,Per Unit,"$2,855.43 ",OP,"2,855.43","9,821.50",,,,,,
Molina Duals,CPT,L6694,Elbow socket ins use w/lock,Durable Medical Equipment,Per Unit,$790.52 ,OP,790.52,"2,718.45",,,,,,
Molina Duals,CPT,L6695,Elbow socket ins use w/o lck,Durable Medical Equipment,Per Unit,$658.75 ,OP,658.75,"2,264.75",,,,,,
Molina Duals,CPT,L6696,Cus elbo skt in for con/atyp,Durable Medical Equipment,Per Unit,"$1,323.02 ",OP,"1,323.02","4,548.54",,,,,,
Molina Duals,CPT,L6697,Cus elbo skt in not con/atyp,Durable Medical Equipment,Per Unit,"$1,323.02 ",OP,"1,323.02","4,548.54",,,,,,
Molina Duals,CPT,L6698,Below/above elbow lock mech,Durable Medical Equipment,Per Unit,$497.40 ,OP,497.4,"1,711.89",,,,,,
Molina Duals,CPT,L6703,Term dev- passive hand mitt,Durable Medical Equipment,Per Unit,$351.79 ,OP,351.79,"1,208.62",,,,,,
Molina Duals,CPT,L6704,Term dev- sport/rec/work att,Durable Medical Equipment,Per Unit,$679.06 ,OP,679.06,"2,337.18",,,,,,
Molina Duals,CPT,L6706,Term dev mech hook vol open,Durable Medical Equipment,Per Unit,$421.40 ,OP,421.4,"1,448.82",,,,,,
Molina Duals,CPT,L6707,Term dev mech hook vol close,Durable Medical Equipment,Per Unit,"$1,490.70 ",OP,"1,490.70","5,128.07",,,,,,
Molina Duals,CPT,L6708,Term dev mech hand vol open,Durable Medical Equipment,Per Unit,$985.41 ,OP,985.41,"3,389.47",,,,,,
Molina Duals,CPT,L6709,Term dev mech hand vol close,Durable Medical Equipment,Per Unit,"$1,398.55 ",OP,"1,398.55","4,811.61",,,,,,
Molina Duals,CPT,L6711,Ped term dev- hook- vol open,Durable Medical Equipment,Per Unit,$676.19 ,OP,676.19,"2,325.74",,,,,,
Molina Duals,CPT,L6712,Ped term dev- hook- vol clos,Durable Medical Equipment,Per Unit,"$1,245.05 ",OP,"1,245.05","4,281.66",,,,,,
Molina Duals,CPT,L6713,Ped term dev- hand- vol open,Durable Medical Equipment,Per Unit,"$1,571.33 ",OP,"1,571.33","5,402.59",,,,,,
Molina Duals,CPT,L6714,Ped term dev- hand- vol clos,Durable Medical Equipment,Per Unit,"$1,330.91 ",OP,"1,330.91","4,579.05",,,,,,
Molina Duals,CPT,L6715,Term device- multi art digit,Durable Medical Equipment,Per Unit,"$3,175.42 ",OP,"3,175.42","3,175.42",,,,,,
Molina Duals,CPT,L6721,Hook/hand- hvy dty- vol open,Durable Medical Equipment,Per Unit,"$2,365.59 ",OP,"2,365.59","8,136.28",,,,,,
Molina Duals,CPT,L6722,Hook/hand- hvy dty- vol clos,Durable Medical Equipment,Per Unit,"$2,039.28 ",OP,"2,039.28","7,011.54",,,,,,
Molina Duals,CPT,L6805,Term dev modifier wrist unit,Durable Medical Equipment,Per Unit,$385.75 ,OP,385.75,"1,326.82",,,,,,
Molina Duals,CPT,L6810,Term dev precision pinch dev,Durable Medical Equipment,Per Unit,$205.07 ,OP,205.07,705.35,,,,,,
Molina Duals,CPT,L6880,Elec hand ind art digits,Durable Medical Equipment,Per Unit,"$24,030.68 ",OP,"24,030.68","24,030.68",,,,,,
Molina Duals,CPT,L6881,Term dev auto grasp feature,Durable Medical Equipment,Per Unit,"$4,111.91 ",OP,"4,111.91","14,141.27",,,,,,
Molina Duals,CPT,L6882,Microprocessor control uplmb,Durable Medical Equipment,Per Unit,"$3,119.08 ",OP,"3,119.08","10,725.10",,,,,,
Molina Duals,CPT,L6883,Replc sockt below e/w disa,Durable Medical Equipment,Per Unit,"$1,997.96 ",OP,"1,997.96","6,870.47",,,,,,
Molina Duals,CPT,L6884,Replc sockt above elbow disa,Durable Medical Equipment,Per Unit,"$2,733.67 ",OP,"2,733.67","9,402.10",,,,,,
Molina Duals,CPT,L6885,Replc sockt shldr dis/interc,Durable Medical Equipment,Per Unit,"$4,246.80 ",OP,"4,246.80","14,606.43",,,,,,
Molina Duals,CPT,L6890,Prefab glove for term device,Durable Medical Equipment,Per Unit,$200.88 ,OP,200.88,690.1,,,,,,
Molina Duals,CPT,L6895,Custom glove for term device,Durable Medical Equipment,Per Unit,$671.68 ,OP,671.68,"2,310.49",,,,,,
Molina Duals,CPT,L6900,Hand restorat thumb/1 finger,Durable Medical Equipment,Per Unit,"$1,950.52 ",OP,"1,950.52","6,706.52",,,,,,
Molina Duals,CPT,L6905,Hand restoration multiple fi,Durable Medical Equipment,Per Unit,"$1,930.47 ",OP,"1,930.47","6,637.91",,,,,,
Molina Duals,CPT,L6910,Hand restoration no fingers,Durable Medical Equipment,Per Unit,"$1,897.78 ",OP,"1,897.78","6,527.33",,,,,,
Molina Duals,CPT,L6915,Hand restoration replacmnt g,Durable Medical Equipment,Per Unit,$815.40 ,OP,815.4,"2,806.14",,,,,,
Molina Duals,CPT,L6920,Wrist disarticul switch ctrl,Durable Medical Equipment,Per Unit,"$8,425.39 ",OP,"8,425.39","28,976.47",,,,,,
Molina Duals,CPT,L6925,Wrist disart myoelectronic c,Durable Medical Equipment,Per Unit,"$9,001.12 ",OP,"9,001.12","30,955.25",,,,,,
Molina Duals,CPT,L6930,Below elbow switch control,Durable Medical Equipment,Per Unit,"$8,114.82 ",OP,"8,114.82","27,908.91",,,,,,
Molina Duals,CPT,L6935,Below elbow myoelectronic ct,Durable Medical Equipment,Per Unit,"$8,958.82 ",OP,"8,958.82","30,810.37",,,,,,
Molina Duals,CPT,L6940,Elbow disarticulation switch,Durable Medical Equipment,Per Unit,"$10,478.90 ",OP,"10,478.90","36,037.57",,,,,,
Molina Duals,CPT,L6945,Elbow disart myoelectronic c,Durable Medical Equipment,Per Unit,"$11,690.57 ",OP,"11,690.57","40,204.84",,,,,,
Molina Duals,CPT,L6950,Above elbow switch control,Durable Medical Equipment,Per Unit,"$10,459.47 ",OP,"10,459.47","35,972.77",,,,,,
Molina Duals,CPT,L6955,Above elbow myoelectronic ct,Durable Medical Equipment,Per Unit,"$12,129.70 ",OP,"12,129.70","41,714.68",,,,,,
Molina Duals,CPT,L6960,Shldr disartic switch contro,Durable Medical Equipment,Per Unit,"$12,759.97 ",OP,"12,759.97","43,884.09",,,,,,
Molina Duals,CPT,L6965,Shldr disartic myoelectronic,Durable Medical Equipment,Per Unit,"$15,116.16 ",OP,"15,116.16","51,986.07",,,,,,
Molina Duals,CPT,L6970,Interscapular-thor switch ct,Durable Medical Equipment,Per Unit,"$16,180.17 ",OP,"16,180.17","55,646.26",,,,,,
Molina Duals,CPT,L6975,Interscap-thor myoelectronic,Durable Medical Equipment,Per Unit,"$17,834.37 ",OP,"17,834.37","61,334.79",,,,,,
Molina Duals,CPT,L7007,Adult electric hand,Durable Medical Equipment,Per Unit,"$3,673.63 ",OP,"3,673.63","12,635.27",,,,,,
Molina Duals,CPT,L7008,Pediatric electric hand,Durable Medical Equipment,Per Unit,"$5,696.71 ",OP,"5,696.71","19,593.43",,,,,,
Molina Duals,CPT,L7009,Adult electric hook,Durable Medical Equipment,Per Unit,"$3,758.57 ",OP,"3,758.57","12,925.03",,,,,,
Molina Duals,CPT,L7040,Prehensile actuator,Durable Medical Equipment,Per Unit,"$3,059.23 ",OP,"3,059.23","10,519.22",,,,,,
Molina Duals,CPT,L7045,Pediatric electric hook,Durable Medical Equipment,Per Unit,"$1,616.29 ",OP,"1,616.29","5,558.92",,,,,,
Molina Duals,CPT,L7170,Electronic elbow hosmer swit,Durable Medical Equipment,Per Unit,"$6,050.00 ",OP,"6,050.00","20,805.87",,,,,,
Molina Duals,CPT,L7180,Electronic elbow sequential,Durable Medical Equipment,Per Unit,"$39,141.46 ",OP,"39,141.46","134,610.92",,,,,,
Molina Duals,CPT,L7181,Electronic elbo simultaneous,Durable Medical Equipment,Per Unit,"$40,299.84 ",OP,"40,299.84","138,595.19",,,,,,
Molina Duals,CPT,L7185,Electron elbow adolescent sw,Durable Medical Equipment,Per Unit,"$6,360.51 ",OP,"6,360.51","21,873.42",,,,,,
Molina Duals,CPT,L7186,Electron elbow child switch,Durable Medical Equipment,Per Unit,"$10,692.92 ",OP,"10,692.92","36,773.42",,,,,,
Molina Duals,CPT,L7190,Elbow adolescent myoelectron,Durable Medical Equipment,Per Unit,"$8,439.80 ",OP,"8,439.80","29,026.03",,,,,,
Molina Duals,CPT,L7191,Elbow child myoelectronic ct,Durable Medical Equipment,Per Unit,"$11,247.26 ",OP,"11,247.26","38,679.77",,,,,,
Molina Duals,CPT,L7259,Electronic wrist rotator any,Durable Medical Equipment,Per Unit,"$4,121.94 ",OP,"4,121.94","4,121.94",,,,,,
Molina Duals,CPT,L7360,Six volt bat otto bock/eq ea,Durable Medical Equipment,Per Unit,$266.08 ,OP,266.08,915.04,,,,,,
Molina Duals,CPT,L7362,Battery chrgr six volt otto,Durable Medical Equipment,Per Unit,$290.68 ,OP,290.68,998.92,,,,,,
Molina Duals,CPT,L7364,Twelve volt battery utah/equ,Durable Medical Equipment,Per Unit,$514.33 ,OP,514.33,"1,769.09",,,,,,
Molina Duals,CPT,L7366,Battery chrgr 12 volt utah/e,Durable Medical Equipment,Per Unit,$707.34 ,OP,707.34,"2,432.50",,,,,,
Molina Duals,CPT,L7367,Replacemnt lithium ionbatter,Durable Medical Equipment,Per Unit,$391.59 ,OP,391.59,"1,345.89",,,,,,
Molina Duals,CPT,L7368,Lithium ion battery charger,Durable Medical Equipment,Per Unit,$507.61 ,OP,507.61,"1,746.22",,,,,,
Molina Duals,CPT,L7400,Add ue prost be/wd- ultlite,Durable Medical Equipment,Per Unit,$308.25 ,OP,308.25,"1,059.93",,,,,,
Molina Duals,CPT,L7401,Add ue prost a/e ultlite mat,Durable Medical Equipment,Per Unit,$345.06 ,OP,345.06,"1,185.76",,,,,,
Molina Duals,CPT,L7402,Add ue prost s/d ultlite mat,Durable Medical Equipment,Per Unit,$372.68 ,OP,372.68,"1,281.07",,,,,,
Molina Duals,CPT,L7403,Add ue prost b/e acrylic,Durable Medical Equipment,Per Unit,$370.41 ,OP,370.41,"1,273.44",,,,,,
Molina Duals,CPT,L7404,Add ue prost a/e acrylic,Durable Medical Equipment,Per Unit,$559.06 ,OP,559.06,"1,921.59",,,,,,
Molina Duals,CPT,L7405,Add ue prost s/d acrylic,Durable Medical Equipment,Per Unit,$731.10 ,OP,731.1,"2,512.57",,,,,,
Molina Duals,CPT,L7700,Pros soc insert gasket/seal,Durable Medical Equipment,Per Unit,$150.48 ,OP,150.48,150.48,,,,,,
Molina Duals,CPT,L8000,Mastectomy bra,Durable Medical Equipment,Per Unit,$42.59 ,OP,42.59,144.88,,,,,,
Molina Duals,CPT,L8001,Breast prosthesis bra & form,Durable Medical Equipment,Per Unit,$126.18 ,OP,126.18,434.65,,,,,,
Molina Duals,CPT,L8002,Brst prsth bra & bilat form,Durable Medical Equipment,Per Unit,$165.94 ,OP,165.94,571.91,,,,,,
Molina Duals,CPT,L8015,Ext breastprosthesis garment,Durable Medical Equipment,Per Unit,$60.29 ,OP,60.29,205.88,,,,,,
Molina Duals,CPT,L8020,Mastectomy form,Durable Medical Equipment,Per Unit,$227.40 ,OP,227.4,781.61,,,,,,
Molina Duals,CPT,L8030,Breast prosthes w/o adhesive,Durable Medical Equipment,Per Unit,$351.55 ,OP,351.55,"1,208.62",,,,,,
Molina Duals,CPT,L8031,Breast prosthesis w adhesive,Durable Medical Equipment,Per Unit,$351.55 ,OP,351.55,351.55,,,,,,
Molina Duals,CPT,L8032,Reusable nipple prosthesis,Durable Medical Equipment,Per Unit,$39.39 ,OP,39.39,39.39,,,,,,
Molina Duals,CPT,L8035,Custom breast prosthesis,Durable Medical Equipment,Per Unit,"$3,684.79 ",OP,"3,684.79","12,673.39",,,,,,
Molina Duals,CPT,L8040,Nasal prosthesis,Durable Medical Equipment,Per Unit,"$2,493.50 ",OP,"2,493.50","8,574.74",,,,,,
Molina Duals,CPT,L8041,Midfacial prosthesis,Durable Medical Equipment,Per Unit,"$3,005.20 ",OP,"3,005.20","10,336.21",,,,,,
Molina Duals,CPT,L8042,Orbital prosthesis,Durable Medical Equipment,Per Unit,"$3,376.62 ",OP,"3,376.62","11,613.47",,,,,,
Molina Duals,CPT,L8043,Upper facial prosthesis,Durable Medical Equipment,Per Unit,"$3,781.84 ",OP,"3,781.84","13,005.10",,,,,,
Molina Duals,CPT,L8044,Hemi-facial prosthesis,Durable Medical Equipment,Per Unit,"$4,187.02 ",OP,"4,187.02","14,400.54",,,,,,
Molina Duals,CPT,L8045,Auricular prosthesis,Durable Medical Equipment,Per Unit,"$3,278.72 ",OP,"3,278.72","11,274.13",,,,,,
Molina Duals,CPT,L8046,Partial facial prosthesis,Durable Medical Equipment,Per Unit,"$2,701.33 ",OP,"2,701.33","9,291.53",,,,,,
Molina Duals,CPT,L8047,Nasal septal prosthesis,Durable Medical Equipment,Per Unit,"$1,384.42 ",OP,"1,384.42","4,762.05",,,,,,
Molina Duals,CPT,L8300,Truss single w/ standard pad,Durable Medical Equipment,Per Unit,$84.35 ,OP,84.35,289.76,,,,,,
Molina Duals,CPT,L8310,Truss double w/ standard pad,Durable Medical Equipment,Per Unit,$149.44 ,OP,149.44,514.72,,,,,,
Molina Duals,CPT,L8320,Truss addition to std pad wa,Durable Medical Equipment,Per Unit,$62.00 ,OP,62,213.51,,,,,,
Molina Duals,CPT,L8330,Truss add to std pad scrotal,Durable Medical Equipment,Per Unit,$49.37 ,OP,49.37,171.58,,,,,,
Molina Duals,CPT,L8400,Sheath below knee,Durable Medical Equipment,Per Unit,$15.74 ,OP,15.74,53.38,,,,,,
Molina Duals,CPT,L8410,Sheath above knee,Durable Medical Equipment,Per Unit,$20.72 ,OP,20.72,72.44,,,,,,
Molina Duals,CPT,L8415,Sheath upper limb,Durable Medical Equipment,Per Unit,$21.44 ,OP,21.44,72.44,,,,,,
Molina Duals,CPT,L8417,Pros sheath/sock w gel cushn,Durable Medical Equipment,Per Unit,$75.64 ,OP,75.64,259.27,,,,,,
Molina Duals,CPT,L8420,Prosthetic sock multi ply bk,Durable Medical Equipment,Per Unit,$20.98 ,OP,20.98,72.44,,,,,,
Molina Duals,CPT,L8430,Prosthetic sock multi ply ak,Durable Medical Equipment,Per Unit,$23.76 ,OP,23.76,80.07,,,,,,
Molina Duals,CPT,L8435,Pros sock multi ply upper lm,Durable Medical Equipment,Per Unit,$22.58 ,OP,22.58,76.26,,,,,,
Molina Duals,CPT,L8440,Shrinker below knee,Durable Medical Equipment,Per Unit,$46.88 ,OP,46.88,160.13,,,,,,
Molina Duals,CPT,L8460,Shrinker above knee,Durable Medical Equipment,Per Unit,$66.65 ,OP,66.65,228.77,,,,,,
Molina Duals,CPT,L8465,Shrinker upper limb,Durable Medical Equipment,Per Unit,$61.60 ,OP,61.6,213.51,,,,,,
Molina Duals,CPT,L8470,Pros sock single ply bk,Durable Medical Equipment,Per Unit,$6.67 ,OP,6.67,22.88,,,,,,
Molina Duals,CPT,L8480,Pros sock single ply ak,Durable Medical Equipment,Per Unit,$9.20 ,OP,9.2,30.51,,,,,,
Molina Duals,CPT,L8485,Pros sock single ply upper l,Durable Medical Equipment,Per Unit,$12.39 ,OP,12.39,41.94,,,,,,
Molina Duals,CPT,L8500,Artificial larynx,Durable Medical Equipment,Per Unit,$661.87 ,OP,661.87,"2,276.18",,,,,,
Molina Duals,CPT,L8501,Tracheostomy speaking valve,Durable Medical Equipment,Per Unit,$120.80 ,OP,120.8,415.59,,,,,,
Molina Duals,CPT,L8507,Trach-esoph voice pros pt in,Durable Medical Equipment,Per Unit,$42.11 ,OP,42.11,144.88,,,,,,
Molina Duals,CPT,L8509,Trach-esoph voice pros md in,Durable Medical Equipment,Per Unit,$109.85 ,OP,109.85,377.46,,,,,,
Molina Duals,CPT,L8510,Voice amplifier,Durable Medical Equipment,Per Unit,$254.17 ,OP,254.17,873.11,,,,,,
Molina Duals,CPT,L8511,Indwelling trach insert,Durable Medical Equipment,Per Unit,$73.14 ,OP,73.14,251.64,,,,,,
Molina Duals,CPT,L8512,Gel cap for trach voice pros,Durable Medical Equipment,Per Unit,$2.19 ,OP,2.19,7.62,,,,,,
Molina Duals,CPT,L8513,Trach pros cleaning device,Durable Medical Equipment,Per Unit,$5.22 ,OP,5.22,19.07,,,,,,
Molina Duals,CPT,L8514,Repl trach puncture dilator,Durable Medical Equipment,Per Unit,$94.85 ,OP,94.85,327.9,,,,,,
Molina Duals,CPT,L8515,Gel cap app device for trach,Durable Medical Equipment,Per Unit,$63.49 ,OP,63.49,217.32,,,,,,
Molina Duals,CPT,L8615,Coch implant headset replace,Durable Medical Equipment,Per Unit,$453.62 ,OP,453.62,"1,559.39",,,,,,
Molina Duals,CPT,L8616,Coch implant microphone repl,Durable Medical Equipment,Per Unit,$105.64 ,OP,105.64,362.21,,,,,,
Molina Duals,CPT,L8617,Coch implant trans coil repl,Durable Medical Equipment,Per Unit,$92.27 ,OP,92.27,92.27,,,,,,
Molina Duals,CPT,L8618,Coch implant tran cable repl,Durable Medical Equipment,Per Unit,$26.38 ,OP,26.38,91.51,,,,,,
Molina Duals,CPT,L8619,Coch imp ext proc/contr rplc,Durable Medical Equipment,Per Unit,"$8,454.02 ",OP,"8,454.02","29,075.59",,,,,,
Molina Duals,CPT,L8621,Repl zinc air battery,Durable Medical Equipment,Per Unit,$0.62 ,OP,0.62,3.82,,,,,,
Molina Duals,CPT,L8622,Repl alkaline battery,Durable Medical Equipment,Per Unit,$0.32 ,OP,0.32,1.9,,,,,,
Molina Duals,CPT,L8623,Lith ion batt cid-non-earlvl,Durable Medical Equipment,Per Unit,$65.06 ,OP,65.06,65.06,,,,,,
Molina Duals,CPT,L8624,Lith ion batt cid- ear level,Durable Medical Equipment,Per Unit,$162.20 ,OP,162.2,556.65,,,,,,
Molina Duals,CPT,L8625,Charger coch impl/aoi battry,Durable Medical Equipment,Per Unit,$189.97 ,OP,189.97,189.97,,,,,,
Molina Duals,CPT,L8627,Cid ext speech process repl,Durable Medical Equipment,Per Unit,"$7,175.59 ",OP,"7,175.59","7,175.59",,,,,,
Molina Duals,CPT,L8628,Cid ext controller repl,Durable Medical Equipment,Per Unit,"$1,278.42 ",OP,"1,278.42","1,278.42",,,,,,
Molina Duals,CPT,L8629,Cid transmit coil and cable,Durable Medical Equipment,Per Unit,$180.09 ,OP,180.09,180.09,,,,,,
Molina Duals,CPT,L8681,Pt prgrm for implt neurostim,Durable Medical Equipment,Per Unit,"$1,147.11 ",OP,"1,147.11","3,946.14",,,,,,
Molina Duals,CPT,L8683,Radiofq trsmtr for implt neu,Durable Medical Equipment,Per Unit,"$5,420.03 ",OP,"5,420.03","18,640.24",,,,,,
Molina Duals,CPT,L8684,Radiof trsmtr implt scrl neu,Durable Medical Equipment,Per Unit,$850.48 ,OP,850.48,"2,924.33",,,,,,
Molina Duals,CPT,L8689,External recharg sys intern,Durable Medical Equipment,Per Unit,"$1,734.92 ",OP,"1,734.92","5,966.87",,,,,,
Molina Duals,CPT,L8691,Aoi snd proc repl excl actua,Durable Medical Equipment,Per Unit,"$1,732.10 ",OP,"1,732.10","9,222.90",,,,,,
Molina Duals,CPT,L8693,Aud osseo dev- abutment,Durable Medical Equipment,Per Unit,"$1,525.09 ",OP,"1,525.09","1,525.09",,,,,,
Molina Duals,CPT,L8694,Aoi transducer/actuator repl,Durable Medical Equipment,Per Unit,$949.85 ,OP,949.85,949.85,,,,,,
Molina Duals,CPT,L8695,External recharg sys extern,Durable Medical Equipment,Per Unit,$16.77 ,OP,16.77,57.19,,,,,,
Molina Duals,CPT,L8696,Ext antenna phren nerve stim,Durable Medical Equipment,Per Unit,$217.98 ,OP,217.98,217.98,,,,,,
Molina Duals,CPT,M0201,Covid-19 vaccine home admin,APC 1494,RVU Per Unit,$36.33 ,OP,36.33,36.33,,,,,,
Molina Duals,CPT,M0240,Casiri and imdev repeat,APC 1506,RVU Per Unit,$430.44 ,OP,430.44,461,,,,,,
Molina Duals,CPT,M0241,Casiri and imdev repeat hm,APC 1509,RVU Per Unit,$768.00 ,OP,768,768,,,,,,
Molina Duals,CPT,M0243,Casirivi and imdevi inj,APC 1506,RVU Per Unit,$461.00 ,OP,461,461,,,,,,
Molina Duals,CPT,M0244,Casirivi and imdevi inj hm,APC 1509,RVU Per Unit,$717.08 ,OP,717.08,768,,,,,,
Molina Duals,CPT,M0245,Bamlan and etesev infusion,APC 1506,RVU Per Unit,$430.44 ,OP,430.44,461,,,,,,
Molina Duals,CPT,M0246,Bamlan and etesev infus home,APC 1509,RVU Per Unit,$717.08 ,OP,717.08,768,,,,,,
Molina Duals,CPT,M0247,Sotrovimab infusion,APC 1506,RVU Per Unit,$430.44 ,OP,430.44,461,,,,,,
Molina Duals,CPT,M0248,Sotrovimab inf- home admin,APC 1509,RVU Per Unit,$717.08 ,OP,717.08,768,,,,,,
Molina Duals,CPT,M0249,Adm tocilizu covid-19 1st,APC 1506,RVU Per Unit,$430.44 ,OP,430.44,461,,,,,,
Molina Duals,CPT,M0250,Adm tocilizu covid-19 2nd,APC 1506,RVU Per Unit,$430.44 ,OP,430.44,461,,,,,,
Molina Duals,CPT,P2028,Cephalin floculation test,Lab Services,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,
Molina Duals,CPT,P2029,Congo red blood test,Lab Services,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,
Molina Duals,CPT,P2033,Blood thymol turbidity,Lab Services,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,
Molina Duals,CPT,P2038,Blood mucoprotein,Lab Services,Per Unit,$4.95 ,OP,4.95,22.88,,,,,,
Molina Duals,CPT,P3000,Screen pap by tech w md supv,Lab Services,Per Unit,$15.15 ,OP,15.15,45.74,,,,,,
Molina Duals,CPT,P9010,Whole blood for transfusion,APC 9510,Per Unit,$172.22 ,OP,172.22,172.22,,,,,,
Molina Duals,CPT,P9011,Blood split unit,APC 9520,Per Unit,$169.28 ,OP,169.28,169.28,,,,,,
Molina Duals,CPT,P9012,Cryoprecipitate each unit,APC 9511,Per Unit,$91.59 ,OP,91.59,91.59,,,,,,
Molina Duals,CPT,P9016,Rbc leukocytes reduced,APC 9512,Per Unit,$216.23 ,OP,216.23,216.23,,,,,,
Molina Duals,CPT,P9017,Plasma 1 donor frz w/in 8 hr,APC 9508,Per Unit,$94.81 ,OP,94.81,94.81,,,,,,
Molina Duals,CPT,P9019,Platelets- each unit,APC 9515,Per Unit,$81.77 ,OP,81.77,81.77,,,,,,
Molina Duals,CPT,P9020,Plaelet rich plasma unit,APC 9516,Per Unit,$229.41 ,OP,229.41,229.41,,,,,,
Molina Duals,CPT,P9021,Red blood cells unit,APC 9517,Per Unit,$157.87 ,OP,157.87,157.87,,,,,,
Molina Duals,CPT,P9022,Washed red blood cells unit,APC 9518,Per Unit,$435.72 ,OP,435.72,435.72,,,,,,
Molina Duals,CPT,P9023,Frozen plasma- pooled- sd,APC 9509,Per Unit,$102.26 ,OP,102.26,102.26,,,,,,
Molina Duals,CPT,P9025,Plasma cryo redu path each,APC 9538,Per Unit,$75.36 ,OP,75.36,75.36,,,,,,
Molina Duals,CPT,P9026,Cryo fib comp path redu each,APC 9539,Per Unit,$91.59 ,OP,91.59,91.59,,,,,,
Molina Duals,CPT,P9031,Platelets leukocytes reduced,APC 9526,Per Unit,$171.96 ,OP,171.96,171.96,,,,,,
Molina Duals,CPT,P9032,Platelets- irradiated,APC 9500,Per Unit,$162.52 ,OP,162.52,162.52,,,,,,
Molina Duals,CPT,P9033,Platelets leukoreduced irrad,APC 9521,Per Unit,$244.54 ,OP,244.54,244.54,,,,,,
Molina Duals,CPT,P9034,Platelets- pheresis,APC 9507,Per Unit,$371.63 ,OP,371.63,371.63,,,,,,
Molina Duals,CPT,P9035,Platelet pheres leukoreduced,APC 9501,Per Unit,$558.38 ,OP,558.38,558.38,,,,,,
Molina Duals,CPT,P9036,Platelet pheresis irradiated,APC 9502,Per Unit,$693.83 ,OP,693.83,693.83,,,,,,
Molina Duals,CPT,P9037,Plate pheres leukoredu irrad,APC 9530,Per Unit,$708.10 ,OP,708.1,708.1,,,,,,
Molina Duals,CPT,P9038,Rbc irradiated,APC 9505,Per Unit,$194.21 ,OP,194.21,194.21,,,,,,
Molina Duals,CPT,P9039,Rbc deglycerolized,APC 9504,Per Unit,$500.86 ,OP,500.86,500.86,,,,,,
Molina Duals,CPT,P9040,Rbc leukoreduced irradiated,APC 9522,Per Unit,$298.86 ,OP,298.86,298.86,,,,,,
Molina Duals,CPT,P9041,Albumin (human)-5%- 50ml,APC 0961,Per Unit,$10.49 ,OP,10.49,10.49,,,,,,
Molina Duals,CPT,P9043,Plasma protein fract-5%-50ml,APC 9514,Per Unit,$9.16 ,OP,9.16,106.76,,,,,,
Molina Duals,CPT,P9044,Cryoprecipitatereducedplasma,APC 9523,Per Unit,$75.36 ,OP,75.36,75.36,,,,,,
Molina Duals,CPT,P9045,Albumin (human)- 5%- 250 ml,APC 0963,Per Unit,$52.45 ,OP,52.45,274.51,,,,,,
Molina Duals,CPT,P9046,Albumin (human)- 25%- 20 ml,APC 0964,Per Unit,$20.98 ,OP,20.98,129.64,,,,,,
Molina Duals,CPT,P9047,Albumin (human)- 25%- 50ml,APC 0965,Per Unit,$52.45 ,OP,52.45,255.45,,,,,,
Molina Duals,CPT,P9048,Plasmaprotein fract-5%-250ml,APC 9519,Per Unit,$183.92 ,OP,183.92,198.25,,,,,,
Molina Duals,CPT,P9051,Blood- l/r- cmv-neg,APC 9524,Per Unit,$243.44 ,OP,243.44,243.44,,,,,,
Molina Duals,CPT,P9052,Platelets- hla-m- l/r- unit,APC 9525,Per Unit,$923.57 ,OP,923.57,923.57,,,,,,
Molina Duals,CPT,P9053,Plt- pher- l/r cmv-neg- irr,APC 9531,Per Unit,$513.08 ,OP,513.08,513.08,,,,,,
Molina Duals,CPT,P9054,Blood- l/r- froz/degly/wash,APC 9527,Per Unit,$356.39 ,OP,356.39,356.39,,,,,,
Molina Duals,CPT,P9055,Plt- aph/pher- l/r- cmv-neg,APC 9528,Per Unit,$550.63 ,OP,550.63,550.63,,,,,,
Molina Duals,CPT,P9056,Blood- l/r- irradiated,APC 9529,Per Unit,$176.83 ,OP,176.83,176.83,,,,,,
Molina Duals,CPT,P9057,Rbc- frz/deg/wsh- l/r- irrad,APC 9532,Per Unit,$298.91 ,OP,298.91,298.91,,,,,,
Molina Duals,CPT,P9058,Rbc- l/r- cmv-neg- irrad,APC 9533,Per Unit,$279.73 ,OP,279.73,279.73,,,,,,
Molina Duals,CPT,P9059,Plasma- frz between 8-24hour,APC 9513,Per Unit,$81.61 ,OP,81.61,81.61,,,,,,
Molina Duals,CPT,P9060,Fr frz plasma donor retested,APC 9503,Per Unit,$74.65 ,OP,74.65,74.65,,,,,,
Molina Duals,CPT,P9070,Pathogen reduced plasma pool,APC 9534,Per Unit,$60.91 ,OP,60.91,60.91,,,,,,
Molina Duals,CPT,P9071,Pathogen reduced plasma sing,APC 9535,Per Unit,$140.88 ,OP,140.88,140.88,,,,,,
Molina Duals,CPT,P9073,Platelets pheresis path redu,APC 9536,Per Unit,$669.72 ,OP,669.72,669.72,,,,,,
Molina Duals,CPT,P9099,Blood component/product noc,APC 9537,Per Unit,$9.16 ,OP,9.16,9.16,,,,,,
Molina Duals,CPT,P9100,Pathogen test for platelets,APC 5732,RVU Per Unit,$34.63 ,OP,34.63,34.63,,,,,,
Molina Duals,CPT,P9612,Catheterize for urine spec,Lab Services,Per Unit,$3.00 ,OP,3,3,,,,,,
Molina Duals,CPT,Q0035,Cardiokymography,APC 5732,RVU Per Case,$34.63 ,OP,34.63,106.76,,,,,,
Molina Duals,CPT,Q0091,Obtaining screen pap smear,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,205.88,,,,,,
Molina Duals,CPT,Q0111,Wet mounts/ w preparations,Lab Services,Per Unit,$15.15 ,OP,15.15,15.15,,,,,,
Molina Duals,CPT,Q0112,Potassium hydroxide preps,Lab Services,Per Unit,$5.83 ,OP,5.83,22.88,,,,,,
Molina Duals,CPT,Q0113,Pinworm examinations,Lab Services,Per Unit,$4.27 ,OP,4.27,26.7,,,,,,
Molina Duals,CPT,Q0114,Fern test,Lab Services,Per Unit,$9.74 ,OP,9.74,34.31,,,,,,
Molina Duals,CPT,Q0115,Post-coital mucous exam,Lab Services,Per Unit,$25.00 ,OP,25,49.56,,,,,,
Molina Duals,CPT,Q0138,Ferumoxytol- non-esrd,APC 1297,Per Unit,$1.00 ,OP,1,1,,,,,,
Molina Duals,CPT,Q0139,Ferumoxytol- esrd use,APC 1485,Per Unit,$1.00 ,OP,1,1,,,,,,
Molina Duals,CPT,Q0240,Casirivi and imdevi 600 mg,Other,Straight Discount,29.70%,OP,,,,,,,,
Molina Duals,CPT,Q0243,Casirivimab and imdevimab,Other,Straight Discount,29.70%,OP,,,,,,,,
Molina Duals,CPT,Q0244,Casirivi and imdevi 1200 mg,Other,Straight Discount,29.70%,OP,,,,,,,,
Molina Duals,CPT,Q0245,Bamlanivimab and etesevima,Other,Straight Discount,29.70%,OP,,,,,,,,
Molina Duals,CPT,Q0247,Sotrovimab,Other,Straight Discount,29.70%,OP,,,,,,,,
Molina Duals,CPT,Q0249,Tocilizumab for covid-19,Other,Straight Discount,29.70%,OP,,,,,,,,
Molina Duals,CPT,Q0477,Pwr module pt cable lvad rpl,Durable Medical Equipment,Per Unit,$780.34 ,OP,780.34,780.34,,,,,,
Molina Duals,CPT,Q0478,Power adapter- combo vad,Durable Medical Equipment,Per Unit,$184.82 ,OP,184.82,184.82,,,,,,
Molina Duals,CPT,Q0479,Power module combo vad- rep,Durable Medical Equipment,Per Unit,"$12,073.17 ",OP,"12,073.17","12,073.17",,,,,,
Molina Duals,CPT,Q0480,Driver pneumatic vad- rep,Durable Medical Equipment,Per Unit,"$90,585.51 ",OP,"90,585.51","311,531.29",,,,,,
Molina Duals,CPT,Q0481,Microprcsr cu elec vad- rep,Durable Medical Equipment,Per Unit,"$14,614.95 ",OP,"14,614.95","50,262.72",,,,,,
Molina Duals,CPT,Q0482,Microprcsr cu combo vad- rep,Durable Medical Equipment,Per Unit,"$4,577.67 ",OP,"4,577.67","15,742.60",,,,,,
Molina Duals,CPT,Q0483,Monitor elec vad- rep,Durable Medical Equipment,Per Unit,"$18,857.93 ",OP,"18,857.93","64,853.90",,,,,,
Molina Duals,CPT,Q0484,Monitor elec or comb vad rep,Durable Medical Equipment,Per Unit,"$3,662.14 ",OP,"3,662.14","12,593.32",,,,,,
Molina Duals,CPT,Q0485,Monitor cable elec vad- rep,Durable Medical Equipment,Per Unit,$353.60 ,OP,353.6,"1,216.24",,,,,,
Molina Duals,CPT,Q0486,Mon cable elec/pneum vad rep,Durable Medical Equipment,Per Unit,$294.28 ,OP,294.28,"1,010.37",,,,,,
Molina Duals,CPT,Q0487,Leads any type vad- rep only,Durable Medical Equipment,Per Unit,$343.31 ,OP,343.31,"1,181.94",,,,,,
Molina Duals,CPT,Q0489,Pwr pck base combo vad- rep,Durable Medical Equipment,Per Unit,"$16,348.80 ",OP,"16,348.80","56,225.77",,,,,,
Molina Duals,CPT,Q0490,Emr pwr source elec vad- rep,Durable Medical Equipment,Per Unit,$707.17 ,OP,707.17,"2,432.50",,,,,,
Molina Duals,CPT,Q0491,Emr pwr source combo vad rep,Durable Medical Equipment,Per Unit,"$1,111.75 ",OP,"1,111.75","3,824.13",,,,,,
Molina Duals,CPT,Q0492,Emr pwr cbl elec vad- rep,Durable Medical Equipment,Per Unit,$89.58 ,OP,89.58,308.83,,,,,,
Molina Duals,CPT,Q0493,Emr pwr cbl combo vad- rep,Durable Medical Equipment,Per Unit,$255.02 ,OP,255.02,876.92,,,,,,
Molina Duals,CPT,Q0494,Emr hd pmp elec/combo- rep,Durable Medical Equipment,Per Unit,$215.79 ,OP,215.79,743.48,,,,,,
Molina Duals,CPT,Q0495,Charger elec/combo vad- rep,Durable Medical Equipment,Per Unit,"$4,201.23 ",OP,"4,201.23","14,450.10",,,,,,
Molina Duals,CPT,Q0496,Battery elec/combo vad- rep,Durable Medical Equipment,Per Unit,"$1,507.90 ",OP,"1,507.90","5,185.26",,,,,,
Molina Duals,CPT,Q0497,Bat clps elec/comb vad- rep,Durable Medical Equipment,Per Unit,$470.84 ,OP,470.84,"1,620.40",,,,,,
Molina Duals,CPT,Q0498,Holster elec/combo vad- rep,Durable Medical Equipment,Per Unit,$516.61 ,OP,516.61,"1,776.71",,,,,,
Molina Duals,CPT,Q0499,Belt/vest elec/combo vad rep,Durable Medical Equipment,Per Unit,$167.86 ,OP,167.86,575.73,,,,,,
Molina Duals,CPT,Q0500,Filters elec/combo vad- rep,Durable Medical Equipment,Per Unit,$30.69 ,OP,30.69,106.76,,,,,,
Molina Duals,CPT,Q0501,Shwr cov elec/combo vad- rep,Durable Medical Equipment,Per Unit,$513.63 ,OP,513.63,"1,765.27",,,,,,
Molina Duals,CPT,Q0502,Mobility cart pneum vad- rep,Durable Medical Equipment,Per Unit,$653.97 ,OP,653.97,"2,249.49",,,,,,
Molina Duals,CPT,Q0503,Battery pneum vad replacemnt,Durable Medical Equipment,Per Unit,"$1,307.87 ",OP,"1,307.87","4,498.98",,,,,,
Molina Duals,CPT,Q0504,Pwr adpt pneum vad- rep veh,Durable Medical Equipment,Per Unit,$690.16 ,OP,690.16,"2,375.30",,,,,,
Molina Duals,CPT,Q0506,Lith-ion batt elec/pneum vad,Durable Medical Equipment,Per Unit,$859.04 ,OP,859.04,859.04,,,,,,
Molina Duals,CPT,Q2017,Teniposide- 50 mg,APC 7035,Per Unit,"$2,645.71 ",OP,"1,582.28","2,645.71",,,,,,
Molina Duals,CPT,Q2026,Radiesse injection,APC 9094,Per Unit,$257.37 ,OP,257.37,257.37,,,,,,
Molina Duals,CPT,Q2028,Inj- sculptra- 0.5mg,APC 9095,Per Unit,$2.49 ,OP,2.49,2.49,,,,,,
Molina Duals,CPT,Q2034,Agriflu vaccine,Other,Straight Discount,29.70%,OP,,,,,,,,
Molina Duals,CPT,Q2035,Afluria vacc- 3 yrs & >- im,Other,Straight Discount,29.70%,OP,,,,,,,,
Molina Duals,CPT,Q2036,Flulaval vacc- 3 yrs & >- im,Other,Straight Discount,29.70%,OP,,,,,,,,
Molina Duals,CPT,Q2037,Fluvirin vacc- 3 yrs & >- im,Other,Straight Discount,29.70%,OP,,,,,,,,
Molina Duals,CPT,Q2038,Fluzone vacc- 3 yrs & >- im,Other,Straight Discount,29.70%,OP,,,,,,,,
Molina Duals,CPT,Q2039,Influenza virus vaccine- nos,Other,Straight Discount,29.70%,OP,,,,,,,,
Molina Duals,CPT,Q2041,Axicabtagene ciloleucel car+,APC 9035,Per Unit,"$395,380.00 ",OP,"395,380.00","395,380.00",,,,,,
Molina Duals,CPT,Q2042,Tisagenlecleucel car-pos t,APC 9194,Per Unit,"$434,337.60 ",OP,"434,337.60","434,337.60",,,,,,
Molina Duals,CPT,Q2043,Sipuleucel-t auto cd54+,APC 9273,Per Unit,"$53,017.58 ",OP,"53,017.58","53,017.58",,,,,,
Molina Duals,CPT,Q2049,Imported lipodox inj,APC 1421,Per Unit,$311.04 ,OP,311.04,311.04,,,,,,
Molina Duals,CPT,Q2050,Doxorubicin inj 10mg,APC 7046,Per Unit,$234.03 ,OP,234.03,"1,719.01",,,,,,
Molina Duals,CPT,Q2053,Brexucabtagene car pos t,APC 9391,Per Unit,"$395,380.00 ",OP,"395,380.00","395,380.00",,,,,,
Molina Duals,CPT,Q2054,Lisocabtagene mara car pos t,APC 9413,Per Unit,"$422,609.00 ",OP,"422,609.00","422,609.00",,,,,,
Molina Duals,CPT,Q3027,Inj beta interferon im 1 mcg,APC 1472,Per Unit,$55.29 ,OP,55.29,74.17,,,,,,
Molina Duals,CPT,Q5101,Injection- zarxio,APC 1822,Per Unit,$0.32 ,OP,0.32,0.32,,,,,,
Molina Duals,CPT,Q5103,Injection- inflectra,APC 1847,Per Unit,$41.19 ,OP,41.19,41.19,,,,,,
Molina Duals,CPT,Q5104,Injection- renflexis,APC 9036,Per Unit,$38.79 ,OP,38.79,38.79,,,,,,
Molina Duals,CPT,Q5106,Inj retacrit non-esrd use,APC 9097,Per Unit,$8.66 ,OP,8.66,8.66,,,,,,
Molina Duals,CPT,Q5107,Inj mvasi 10 mg,APC 9329,Per Unit,$44.56 ,OP,44.56,44.56,,,,,,
Molina Duals,CPT,Q5108,Injection- fulphila,APC 9173,Per Unit,$211.19 ,OP,211.19,211.19,,,,,,
Molina Duals,CPT,Q5110,Nivestym,APC 9193,Per Unit,$0.33 ,OP,0.33,0.33,,,,,,
Molina Duals,CPT,Q5111,Injection- udenyca 0.5 mg,APC 9195,Per Unit,$222.38 ,OP,222.38,222.38,,,,,,
Molina Duals,CPT,Q5112,Inj ontruzant 10 mg,APC 9382,Per Unit,$66.55 ,OP,66.55,66.55,,,,,,
Molina Duals,CPT,Q5113,Inj herzuma 10 mg,APC 9349,Per Unit,$57.30 ,OP,57.3,57.3,,,,,,
Molina Duals,CPT,Q5114,Inj ogivri 10 mg,APC 9341,Per Unit,$59.91 ,OP,59.91,59.91,,,,,,
Molina Duals,CPT,Q5115,Inj truxima 10 mg,APC 9336,Per Unit,$60.58 ,OP,60.58,60.58,,,,,,
Molina Duals,CPT,Q5116,Inj.- trazimera- 10 mg,APC 9350,Per Unit,$59.93 ,OP,59.93,59.93,,,,,,
Molina Duals,CPT,Q5117,Inj.- kanjinti- 10 mg,APC 9330,Per Unit,$53.18 ,OP,53.18,53.18,,,,,,
Molina Duals,CPT,Q5118,Inj.- zirabev- 10 mg,APC 9348,Per Unit,$52.37 ,OP,52.37,52.37,,,,,,
Molina Duals,CPT,Q5119,Inj ruxience- 10 mg,APC 9367,Per Unit,$58.80 ,OP,58.8,58.8,,,,,,
Molina Duals,CPT,Q5120,Inj pegfilgrastim-bmez 0.5mg,APC 9345,Per Unit,$245.43 ,OP,245.43,245.43,,,,,,
Molina Duals,CPT,Q5121,Inj. avsola- 10 mg,APC 9381,Per Unit,$47.12 ,OP,47.12,47.12,,,,,,
Molina Duals,CPT,Q5122,Inj- nyvepria,APC 9406,Per Unit,$284.69 ,OP,284.69,284.69,,,,,,
Molina Duals,CPT,Q5123,Inj. riabni- 10 mg,APC 9411,Per Unit,$72.23 ,OP,72.23,72.23,,,,,,
Molina Duals,CPT,Q9968,Visualization adjunct,APC 1446,Per Unit,$6.73 ,OP,6.73,6.73,,,,,,
Molina Duals,CPT,Q9969,Non-heu tc-99m add-on/dose,APC 1442,Per Unit,$10.00 ,OP,10,10,,,,,,
Molina Duals,CPT,Q9991,Buprenorph xr 100 mg or less,APC 9073,Per Unit,"$1,796.80 ",OP,"1,796.80","1,796.80",,,,,,
Molina Duals,CPT,Q9992,Buprenorphine xr over 100 mg,APC 9239,Per Unit,"$1,796.80 ",OP,"1,796.80","1,796.80",,,,,,
Molina Duals,CPT,U0001,2019-ncov diagnostic p,Lab Services,Per Unit,$35.91 ,OP,35.91,35.91,,,,,,
Molina Duals,CPT,U0002,Covid-19 lab test non-cdc,Lab Services,Per Unit,$51.31 ,OP,51.31,51.31,,,,,,
Molina Duals,CPT,U0003,Cov-19 amp prb hgh thruput,Lab Services,Per Unit,$75.00 ,OP,75,75,,,,,,
Molina Duals,CPT,U0004,Cov-19 test non-cdc hgh thru,Lab Services,Per Unit,$75.00 ,OP,75,75,,,,,,
Molina Duals,CPT,U0005,Infec agen detec ampli probe,Lab Services,Per Unit,$25.00 ,OP,25,25,,,,,,
Molina Duals,CPT,V2020,Vision svcs frames purchases,Durable Medical Equipment,Per Unit,$75.22 ,OP,75.22,388.89,,,,,,
Molina Duals,CPT,V2100,Lens spher single plano 4.00,Durable Medical Equipment,Per Unit,$46.49 ,OP,46.49,240.2,,,,,,
Molina Duals,CPT,V2101,Single visn sphere 4.12-7.00,Durable Medical Equipment,Per Unit,$44.67 ,OP,44.67,228.77,,,,,,
Molina Duals,CPT,V2102,Singl visn sphere 7.12-20.00,Durable Medical Equipment,Per Unit,$77.24 ,OP,77.24,400.34,,,,,,
Molina Duals,CPT,V2103,Spherocylindr 4.00d/12-2.00d,Durable Medical Equipment,Per Unit,$39.13 ,OP,39.13,202.07,,,,,,
Molina Duals,CPT,V2104,Spherocylindr 4.00d/2.12-4d,Durable Medical Equipment,Per Unit,$40.34 ,OP,40.34,209.7,,,,,,
Molina Duals,CPT,V2105,Spherocylinder 4.00d/4.25-6d,Durable Medical Equipment,Per Unit,$47.98 ,OP,47.98,247.83,,,,,,
Molina Duals,CPT,V2106,Spherocylinder 4.00d/>6.00d,Durable Medical Equipment,Per Unit,$53.15 ,OP,53.15,274.51,,,,,,
Molina Duals,CPT,V2107,Spherocylinder 4.25d/12-2d,Durable Medical Equipment,Per Unit,$47.33 ,OP,47.33,244.01,,,,,,
Molina Duals,CPT,V2108,Spherocylinder 4.25d/2.12-4d,Durable Medical Equipment,Per Unit,$47.46 ,OP,47.46,244.01,,,,,,
Molina Duals,CPT,V2109,Spherocylinder 4.25d/4.25-6d,Durable Medical Equipment,Per Unit,$66.10 ,OP,66.1,339.33,,,,,,
Molina Duals,CPT,V2110,Spherocylinder 4.25d/over 6d,Durable Medical Equipment,Per Unit,$53.39 ,OP,53.39,274.51,,,,,,
Molina Duals,CPT,V2111,Spherocylindr 7.25d/.25-2.25,Durable Medical Equipment,Per Unit,$64.70 ,OP,64.7,335.53,,,,,,
Molina Duals,CPT,V2112,Spherocylindr 7.25d/2.25-4d,Durable Medical Equipment,Per Unit,$73.09 ,OP,73.09,377.46,,,,,,
Molina Duals,CPT,V2113,Spherocylindr 7.25d/4.25-6d,Durable Medical Equipment,Per Unit,$73.91 ,OP,73.91,381.27,,,,,,
Molina Duals,CPT,V2114,Spherocylinder over 12.00d,Durable Medical Equipment,Per Unit,$87.57 ,OP,87.57,453.71,,,,,,
Molina Duals,CPT,V2115,Lens lenticular bifocal,Durable Medical Equipment,Per Unit,$88.27 ,OP,88.27,453.71,,,,,,
Molina Duals,CPT,V2118,Lens aniseikonic single,Durable Medical Equipment,Per Unit,$96.05 ,OP,96.05,495.65,,,,,,
Molina Duals,CPT,V2121,Lenticular lens- single,Durable Medical Equipment,Per Unit,$86.61 ,OP,86.61,446.08,,,,,,
Molina Duals,CPT,V2200,Lens spher bifoc plano 4.00d,Durable Medical Equipment,Per Unit,$52.35 ,OP,52.35,270.71,,,,,,
Molina Duals,CPT,V2201,Lens sphere bifocal 4.12-7.0,Durable Medical Equipment,Per Unit,$56.09 ,OP,56.09,289.76,,,,,,
Molina Duals,CPT,V2202,Lens sphere bifocal 7.12-20.,Durable Medical Equipment,Per Unit,$69.53 ,OP,69.53,358.39,,,,,,
Molina Duals,CPT,V2203,Lens sphcyl bifocal 4.00d/.1,Durable Medical Equipment,Per Unit,$53.92 ,OP,53.92,278.32,,,,,,
Molina Duals,CPT,V2204,Lens sphcy bifocal 4.00d/2.1,Durable Medical Equipment,Per Unit,$55.48 ,OP,55.48,285.96,,,,,,
Molina Duals,CPT,V2205,Lens sphcy bifocal 4.00d/4.2,Durable Medical Equipment,Per Unit,$61.51 ,OP,61.51,316.46,,,,,,
Molina Duals,CPT,V2206,Lens sphcy bifocal 4.00d/ove,Durable Medical Equipment,Per Unit,$72.21 ,OP,72.21,373.65,,,,,,
Molina Duals,CPT,V2207,Lens sphcy bifocal 4.25-7d/.,Durable Medical Equipment,Per Unit,$61.03 ,OP,61.03,316.46,,,,,,
Molina Duals,CPT,V2208,Lens sphcy bifocal 4.25-7/2.,Durable Medical Equipment,Per Unit,$59.97 ,OP,59.97,308.83,,,,,,
Molina Duals,CPT,V2209,Lens sphcy bifocal 4.25-7/4.,Durable Medical Equipment,Per Unit,$70.40 ,OP,70.4,362.21,,,,,,
Molina Duals,CPT,V2210,Lens sphcy bifocal 4.25-7/ov,Durable Medical Equipment,Per Unit,$75.86 ,OP,75.86,392.7,,,,,,
Molina Duals,CPT,V2211,Lens sphcy bifo 7.25-12/.25-,Durable Medical Equipment,Per Unit,$73.85 ,OP,73.85,381.27,,,,,,
Molina Duals,CPT,V2212,Lens sphcyl bifo 7.25-12/2.2,Durable Medical Equipment,Per Unit,$77.30 ,OP,77.3,400.34,,,,,,
Molina Duals,CPT,V2213,Lens sphcyl bifo 7.25-12/4.2,Durable Medical Equipment,Per Unit,$81.28 ,OP,81.28,419.4,,,,,,
Molina Duals,CPT,V2214,Lens sphcyl bifocal over 12.,Durable Medical Equipment,Per Unit,$84.95 ,OP,84.95,438.47,,,,,,
Molina Duals,CPT,V2215,Lens lenticular bifocal,Durable Medical Equipment,Per Unit,$106.06 ,OP,106.06,549.03,,,,,,
Molina Duals,CPT,V2218,Lens aniseikonic bifocal,Durable Medical Equipment,Per Unit,$108.09 ,OP,108.09,556.65,,,,,,
Molina Duals,CPT,V2219,Lens bifocal seg width over,Durable Medical Equipment,Per Unit,$49.86 ,OP,49.86,255.45,,,,,,
Molina Duals,CPT,V2220,Lens bifocal add over 3.25d,Durable Medical Equipment,Per Unit,$44.28 ,OP,44.28,228.77,,,,,,
Molina Duals,CPT,V2221,Lenticular lens- bifocal,Durable Medical Equipment,Per Unit,$88.33 ,OP,88.33,457.52,,,,,,
Molina Duals,CPT,V2300,Lens sphere trifocal 4.00d,Durable Medical Equipment,Per Unit,$71.57 ,OP,71.57,369.83,,,,,,
Molina Duals,CPT,V2301,Lens sphere trifocal 4.12-7.,Durable Medical Equipment,Per Unit,$87.77 ,OP,87.77,453.71,,,,,,
Molina Duals,CPT,V2302,Lens sphere trifocal 7.12-20,Durable Medical Equipment,Per Unit,$82.00 ,OP,82,423.22,,,,,,
Molina Duals,CPT,V2303,Lens sphcy trifocal 4.0/.12-,Durable Medical Equipment,Per Unit,$68.89 ,OP,68.89,354.58,,,,,,
Molina Duals,CPT,V2304,Lens sphcy trifocal 4.0/2.25,Durable Medical Equipment,Per Unit,$69.70 ,OP,69.7,358.39,,,,,,
Molina Duals,CPT,V2305,Lens sphcy trifocal 4.0/4.25,Durable Medical Equipment,Per Unit,$77.86 ,OP,77.86,400.34,,,,,,
Molina Duals,CPT,V2306,Lens sphcyl trifocal 4.00/>6,Durable Medical Equipment,Per Unit,$80.17 ,OP,80.17,411.78,,,,,,
Molina Duals,CPT,V2307,Lens sphcy trifocal 4.25-7/.,Durable Medical Equipment,Per Unit,$76.33 ,OP,76.33,392.7,,,,,,
Molina Duals,CPT,V2308,Lens sphc trifocal 4.25-7/2.,Durable Medical Equipment,Per Unit,$83.26 ,OP,83.26,430.83,,,,,,
Molina Duals,CPT,V2309,Lens sphc trifocal 4.25-7/4.,Durable Medical Equipment,Per Unit,$87.13 ,OP,87.13,449.9,,,,,,
Molina Duals,CPT,V2310,Lens sphc trifocal 4.25-7/>6,Durable Medical Equipment,Per Unit,$91.01 ,OP,91.01,468.96,,,,,,
Molina Duals,CPT,V2311,Lens sphc trifo 7.25-12/.25-,Durable Medical Equipment,Per Unit,$105.08 ,OP,105.08,541.4,,,,,,
Molina Duals,CPT,V2312,Lens sphc trifo 7.25-12/2.25,Durable Medical Equipment,Per Unit,$96.32 ,OP,96.32,495.65,,,,,,
Molina Duals,CPT,V2313,Lens sphc trifo 7.25-12/4.25,Durable Medical Equipment,Per Unit,$105.15 ,OP,105.15,541.4,,,,,,
Molina Duals,CPT,V2314,Lens sphcyl trifocal over 12,Durable Medical Equipment,Per Unit,$107.48 ,OP,107.48,552.84,,,,,,
Molina Duals,CPT,V2315,Lens lenticular trifocal,Durable Medical Equipment,Per Unit,$119.32 ,OP,119.32,613.85,,,,,,
Molina Duals,CPT,V2318,Lens aniseikonic trifocal,Durable Medical Equipment,Per Unit,$146.68 ,OP,146.68,754.91,,,,,,
Molina Duals,CPT,V2319,Lens trifocal seg width > 28,Durable Medical Equipment,Per Unit,$66.22 ,OP,66.22,343.14,,,,,,
Molina Duals,CPT,V2320,Lens trifocal add over 3.25d,Durable Medical Equipment,Per Unit,$69.85 ,OP,69.85,362.21,,,,,,
Molina Duals,CPT,V2321,Lenticular lens- trifocal,Durable Medical Equipment,Per Unit,$117.61 ,OP,117.61,606.21,,,,,,
Molina Duals,CPT,V2410,Lens variab asphericity sing,Durable Medical Equipment,Per Unit,$102.83 ,OP,102.83,529.96,,,,,,
Molina Duals,CPT,V2430,Lens variable asphericity bi,Durable Medical Equipment,Per Unit,$108.84 ,OP,108.84,560.47,,,,,,
Molina Duals,CPT,V2500,Contact lens pmma spherical,Durable Medical Equipment,Per Unit,$92.01 ,OP,92.01,92.01,,,,,,
Molina Duals,CPT,V2501,Cntct lens pmma-toric/prism,Durable Medical Equipment,Per Unit,$130.56 ,OP,130.56,674.85,,,,,,
Molina Duals,CPT,V2502,Contact lens pmma bifocal,Durable Medical Equipment,Per Unit,$176.91 ,OP,176.91,911.23,,,,,,
Molina Duals,CPT,V2503,Cntct lens pmma color vision,Durable Medical Equipment,Per Unit,$170.87 ,OP,170.87,880.74,,,,,,
Molina Duals,CPT,V2510,Cntct gas permeable sphericl,Durable Medical Equipment,Per Unit,$122.68 ,OP,122.68,632.91,,,,,,
Molina Duals,CPT,V2511,Cntct toric prism ballast,Durable Medical Equipment,Per Unit,$181.84 ,OP,181.84,937.93,,,,,,
Molina Duals,CPT,V2512,Cntct lens gas permbl bifocl,Durable Medical Equipment,Per Unit,$209.31 ,OP,209.31,"1,078.99",,,,,,
Molina Duals,CPT,V2513,Contact lens extended wear,Durable Medical Equipment,Per Unit,$210.87 ,OP,210.87,"1,086.62",,,,,,
Molina Duals,CPT,V2520,Contact lens hydrophilic,Durable Medical Equipment,Per Unit,$122.25 ,OP,122.25,629.1,,,,,,
Molina Duals,CPT,V2521,Cntct lens hydrophilic toric,Durable Medical Equipment,Per Unit,$242.09 ,OP,242.09,"1,250.57",,,,,,
Molina Duals,CPT,V2522,Cntct lens hydrophil bifocl,Durable Medical Equipment,Per Unit,$177.16 ,OP,177.16,915.04,,,,,,
Molina Duals,CPT,V2523,Cntct lens hydrophil extend,Durable Medical Equipment,Per Unit,$186.00 ,OP,186,960.8,,,,,,
Molina Duals,CPT,V2530,Contact lens gas impermeable,Durable Medical Equipment,Per Unit,$297.37 ,OP,297.37,"1,532.70",,,,,,
Molina Duals,CPT,V2531,Contact lens gas permeable,Durable Medical Equipment,Per Unit,$544.58 ,OP,544.58,"2,809.96",,,,,,
Molina Duals,CPT,V2623,Plastic eye prosth custom,Durable Medical Equipment,Per Unit,$942.94 ,OP,942.94,"4,864.99",,,,,,
Molina Duals,CPT,V2624,Polishing artifical eye,Durable Medical Equipment,Per Unit,$60.88 ,OP,60.88,312.64,,,,,,
Molina Duals,CPT,V2625,Enlargemnt of eye prosthesis,Durable Medical Equipment,Per Unit,$482.12 ,OP,482.12,"2,485.87",,,,,,
Molina Duals,CPT,V2626,Reduction of eye prosthesis,Durable Medical Equipment,Per Unit,$199.51 ,OP,199.51,"1,029.43",,,,,,
Molina Duals,CPT,V2627,Scleral cover shell,Durable Medical Equipment,Per Unit,"$1,430.28 ",OP,"1,430.28","7,377.56",,,,,,
Molina Duals,CPT,V2628,Fabrication & fitting,Durable Medical Equipment,Per Unit,$304.24 ,OP,304.24,"1,570.83",,,,,,
Molina Duals,CPT,V2700,Balance lens,Durable Medical Equipment,Per Unit,$44.84 ,OP,44.84,232.58,,,,,,
Molina Duals,CPT,V2710,Glass/plastic slab off prism,Durable Medical Equipment,Per Unit,$73.51 ,OP,73.51,377.46,,,,,,
Molina Duals,CPT,V2715,Prism lens/es,Durable Medical Equipment,Per Unit,$14.41 ,OP,14.41,72.44,,,,,,
Molina Duals,CPT,V2718,Fresnell prism press-on lens,Durable Medical Equipment,Per Unit,$31.12 ,OP,31.12,160.13,,,,,,
Molina Duals,CPT,V2730,Special base curve,Durable Medical Equipment,Per Unit,$26.06 ,OP,26.06,133.45,,,,,,
Molina Duals,CPT,V2744,Tint photochromatic lens/es,Durable Medical Equipment,Per Unit,$17.83 ,OP,17.83,91.51,,,,,,
Molina Duals,CPT,V2745,Tint- any color/solid/grad,Durable Medical Equipment,Per Unit,$10.27 ,OP,10.27,53.38,,,,,,
Molina Duals,CPT,V2750,Anti-reflective coating,Durable Medical Equipment,Per Unit,$20.02 ,OP,20.02,102.95,,,,,,
Molina Duals,CPT,V2755,Uv lens/es,Durable Medical Equipment,Per Unit,$16.76 ,OP,16.76,87.69,,,,,,
Molina Duals,CPT,V2770,Occluder lens/es,Durable Medical Equipment,Per Unit,$19.52 ,OP,19.52,99.13,,,,,,
Molina Duals,CPT,V2780,Oversize lens/es,Durable Medical Equipment,Per Unit,$12.53 ,OP,12.53,64.82,,,,,,
Molina Duals,CPT,V2782,Lens- 1.54-1.65 p/1.60-1.79g,Durable Medical Equipment,Per Unit,$64.75 ,OP,64.75,335.53,,,,,,
Molina Duals,CPT,V2783,Lens- >= 1.66 p/>=1.80 g,Durable Medical Equipment,Per Unit,$73.02 ,OP,73.02,377.46,,,,,,
Molina Duals,CPT,V2784,Lens polycarb or equal,Durable Medical Equipment,Per Unit,$47.48 ,OP,47.48,244.01,,,,,,
Molina Duals,CPT,V2785,Corneal tissue processing,Other,Straight Discount,29.70%,OP,,,,,,,,
Molina Medicaid,DRG,11,LIVER TRANSPLANT andOR INTESTINAL TRANSPLANT,,Relative Weights,"$38,043.18 ",IP,"38,043.18","38,043.18",,,,,,
Molina Medicaid,DRG,12,LIVER TRANSPLANT andOR INTESTINAL TRANSPLANT,,Relative Weights,"$40,281.56 ",IP,"40,281.56","40,281.56",,,,,,
Molina Medicaid,DRG,13,LIVER TRANSPLANT andOR INTESTINAL TRANSPLANT,,Relative Weights,"$42,053.29 ",IP,"42,053.29","42,053.29",,,,,,
Molina Medicaid,DRG,14,LIVER TRANSPLANT andOR INTESTINAL TRANSPLANT,,Relative Weights,"$78,175.26 ",IP,"78,175.26","78,175.26",,,,,,
Molina Medicaid,DRG,21,HEART andOR LUNG TRANSPLANT,,Relative Weights,"$45,599.51 ",IP,"45,599.51","45,599.51",,,,,,
Molina Medicaid,DRG,22,HEART &/OR LUNG TRANSPLANT,,Relative Weights,"$58,026.75 ",IP,"58,026.75","58,026.75",,,,,,
Molina Medicaid,DRG,23,HEART andOR LUNG TRANSPLANT,,Relative Weights,"$74,400.53 ",IP,"74,400.53","74,400.53",,,,,,
Molina Medicaid,DRG,24,HEART andOR LUNG TRANSPLANT,,Relative Weights,"$107,953.54 ",IP,"107,953.54","107,953.54",,,,,,
Molina Medicaid,DRG,41,TRACHEOSTOMY W MV 96+ HOURS W EXTENSIVE PROCEDURE,,Relative Weights,"$33,014.21 ",IP,"33,014.21","33,014.21",,,,,,
Molina Medicaid,DRG,42,TRACHEOSTOMY W MV 96+ HOURS W EXTENSIVE PROCEDURE,,Relative Weights,"$37,820.51 ",IP,"37,820.51","37,820.51",,,,,,
Molina Medicaid,DRG,43,TRACHEOSTOMY W MV 96 HOURS W EXTENSIVE PROCEDURE,,Relative Weights,"$49,052.96 ",IP,"49,052.96","49,052.96",,,,,,
Molina Medicaid,DRG,44,TRACHEOSTOMY W MV 96 HOURS W EXTENSIVE PROCEDURE,,Relative Weights,"$72,921.22 ",IP,"72,921.22","72,921.22",,,,,,
Molina Medicaid,DRG,51,TRACHEOSTOMY W MV 96 HOURS WO EXTENSIVE PROCEDURE,,Relative Weights,"$23,684.08 ",IP,"23,684.08","23,684.08",,,,,,
Molina Medicaid,DRG,52,TRACHEOSTOMY W MV 96+ HOURS W/O EXTENSIVE PROCEDURE,,Relative Weights,"$26,315.91 ",IP,"26,315.91","26,315.91",,,,,,
Molina Medicaid,DRG,53,TRACHEOSTOMY W MV 96 HOURS WO EXTENSIVE PROCEDURE,,Relative Weights,"$36,197.91 ",IP,"36,197.91","36,197.91",,,,,,
Molina Medicaid,DRG,54,TRACHEOSTOMY W MV 96 HOURS WO EXTENSIVE PROCEDURE,,Relative Weights,"$48,934.75 ",IP,"48,934.75","48,934.75",,,,,,
Molina Medicaid,DRG,61,PANCREAS TRANSPLANT,,Relative Weights,"$40,520.03 ",IP,"40,520.03","40,520.03",,,,,,
Molina Medicaid,DRG,62,PANCREAS TRANSPLANT,,Relative Weights,"$45,022.22 ",IP,"45,022.22","45,022.22",,,,,,
Molina Medicaid,DRG,63,PANCREAS TRANSPLANT,,Relative Weights,"$47,794.94 ",IP,"47,794.94","47,794.94",,,,,,
Molina Medicaid,DRG,64,PANCREAS TRANSPLANT,,Relative Weights,"$66,459.33 ",IP,"66,459.33","66,459.33",,,,,,
Molina Medicaid,DRG,71,ALLOGENEIC BONE MARROW TRANSPLANT,,Relative Weights,"$38,434.91 ",IP,"38,434.91","38,434.91",,,,,,
Molina Medicaid,DRG,72,ALLOGENEIC BONE MARROW TRANSPLANT,,Relative Weights,"$48,059.19 ",IP,"48,059.19","48,059.19",,,,,,
Molina Medicaid,DRG,73,ALLOGENEIC BONE MARROW TRANSPLANT,,Relative Weights,"$59,827.69 ",IP,"59,827.69","59,827.69",,,,,,
Molina Medicaid,DRG,74,ALLOGENEIC BONE MARROW TRANSPLANT,,Relative Weights,"$99,672.84 ",IP,"99,672.84","99,672.84",,,,,,
Molina Medicaid,DRG,81,AUTOLOGOUS BONE MARROW TRANSPLANT,,Relative Weights,"$22,091.37 ",IP,"22,091.37","22,091.37",,,,,,
Molina Medicaid,DRG,82,AUTOLOGOUS BONE MARROW TRANSPLANT,,Relative Weights,"$27,118.96 ",IP,"27,118.96","27,118.96",,,,,,
Molina Medicaid,DRG,83,AUTOLOGOUS BONE MARROW TRANSPLANT,,Relative Weights,"$32,175.76 ",IP,"32,175.76","32,175.76",,,,,,
Molina Medicaid,DRG,84,AUTOLOGOUS BONE MARROW TRANSPLANT,,Relative Weights,"$51,576.54 ",IP,"51,576.54","51,576.54",,,,,,
Molina Medicaid,DRG,91,EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO),,Relative Weights,"$27,699.69 ",IP,"27,699.69","27,699.69",,,,,,
Molina Medicaid,DRG,92,EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO),,Relative Weights,"$30,776.86 ",IP,"30,776.86","30,776.86",,,,,,
Molina Medicaid,DRG,93,EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO),,Relative Weights,"$36,358.72 ",IP,"36,358.72","36,358.72",,,,,,
Molina Medicaid,DRG,94,EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO),,Relative Weights,"$79,300.63 ",IP,"79,300.63","79,300.63",,,,,,
Molina Medicaid,DRG,101,HEAD TRAUMA WITH DEEP COMA,,Relative Weights,"$4,104.27 ",IP,"4,104.27","4,104.27",,,,,,
Molina Medicaid,DRG,102,HEAD TRAUMA WITH DEEP COMA,,Relative Weights,"$7,527.81 ",IP,"7,527.81","7,527.81",,,,,,
Molina Medicaid,DRG,103,HEAD TRAUMA WITH DEEP COMA,,Relative Weights,"$12,592.86 ",IP,"12,592.86","12,592.86",,,,,,
Molina Medicaid,DRG,104,HEAD TRAUMA WITH DEEP COMA,,Relative Weights,"$37,584.09 ",IP,"37,584.09","37,584.09",,,,,,
Molina Medicaid,DRG,201,CRANIOTOMY FOR TRAUMA,,Relative Weights,"$9,991.61 ",IP,"9,991.61","9,991.61",,,,,,
Molina Medicaid,DRG,202,CRANIOTOMY FOR TRAUMA,,Relative Weights,"$11,868.15 ",IP,"11,868.15","11,868.15",,,,,,
Molina Medicaid,DRG,203,CRANIOTOMY FOR TRAUMA,,Relative Weights,"$16,002.32 ",IP,"16,002.32","16,002.32",,,,,,
Molina Medicaid,DRG,204,CRANIOTOMY FOR TRAUMA,,Relative Weights,"$28,673.87 ",IP,"28,673.87","28,673.87",,,,,,
Molina Medicaid,DRG,211,CRANIOTOMY EXCEPT FOR TRAUMA,,Relative Weights,"$9,882.68 ",IP,"9,882.68","9,882.68",,,,,,
Molina Medicaid,DRG,212,CRANIOTOMY EXCEPT FOR TRAUMA,,Relative Weights,"$13,243.69 ",IP,"13,243.69","13,243.69",,,,,,
Molina Medicaid,DRG,213,CRANIOTOMY EXCEPT FOR TRAUMA,,Relative Weights,"$18,834.48 ",IP,"18,834.48","18,834.48",,,,,,
Molina Medicaid,DRG,214,CRANIOTOMY EXCEPT FOR TRAUMA,,Relative Weights,"$27,671.86 ",IP,"27,671.86","27,671.86",,,,,,
Molina Medicaid,DRG,221,VENTRICULAR SHUNT PROCEDURES,,Relative Weights,"$6,449.86 ",IP,"6,449.86","6,449.86",,,,,,
Molina Medicaid,DRG,222,VENTRICULAR SHUNT PROCEDURES,,Relative Weights,"$7,492.76 ",IP,"7,492.76","7,492.76",,,,,,
Molina Medicaid,DRG,223,VENTRICULAR SHUNT PROCEDURES,,Relative Weights,"$10,628.01 ",IP,"10,628.01","10,628.01",,,,,,
Molina Medicaid,DRG,224,VENTRICULAR SHUNT PROCEDURES,,Relative Weights,"$25,450.32 ",IP,"25,450.32","25,450.32",,,,,,
Molina Medicaid,DRG,231,SPINAL PROCEDURES,,Relative Weights,"$7,646.71 ",IP,"7,646.71","7,646.71",,,,,,
Molina Medicaid,DRG,232,SPINAL PROCEDURES,,Relative Weights,"$9,630.12 ",IP,"9,630.12","9,630.12",,,,,,
Molina Medicaid,DRG,233,SPINAL PROCEDURES,,Relative Weights,"$16,000.26 ",IP,"16,000.26","16,000.26",,,,,,
Molina Medicaid,DRG,234,SPINAL PROCEDURES,,Relative Weights,"$29,075.91 ",IP,"29,075.91","29,075.91",,,,,,
Molina Medicaid,DRG,241,EXTRACRANIAL VASCULAR PROCEDURES,,Relative Weights,"$5,741.65 ",IP,"5,741.65","5,741.65",,,,,,
Molina Medicaid,DRG,242,EXTRACRANIAL VASCULAR PROCEDURES,,Relative Weights,"$6,726.14 ",IP,"6,726.14","6,726.14",,,,,,
Molina Medicaid,DRG,243,EXTRACRANIAL VASCULAR PROCEDURES,,Relative Weights,"$13,747.79 ",IP,"13,747.79","13,747.79",,,,,,
Molina Medicaid,DRG,244,EXTRACRANIAL VASCULAR PROCEDURES,,Relative Weights,"$24,782.31 ",IP,"24,782.31","24,782.31",,,,,,
Molina Medicaid,DRG,261,OTHER NERVOUS SYSTEM and RELATED PROCEDURES,,Relative Weights,"$7,157.39 ",IP,"7,157.39","7,157.39",,,,,,
Molina Medicaid,DRG,262,OTHER NERVOUS SYSTEM and RELATED PROCEDURES,,Relative Weights,"$8,935.31 ",IP,"8,935.31","8,935.31",,,,,,
Molina Medicaid,DRG,263,OTHER NERVOUS SYSTEM and RELATED PROCEDURES,,Relative Weights,"$12,455.76 ",IP,"12,455.76","12,455.76",,,,,,
Molina Medicaid,DRG,264,OTHER NERVOUS SYSTEM & RELATED PROCEDURES,,Relative Weights,"$22,781.03 ",IP,"22,781.03","22,781.03",,,,,,
Molina Medicaid,DRG,401,SPINAL DISORDERS and INJURIES,,Relative Weights,"$5,482.55 ",IP,"5,482.55","5,482.55",,,,,,
Molina Medicaid,DRG,402,SPINAL DISORDERS and INJURIES,,Relative Weights,"$5,877.72 ",IP,"5,877.72","5,877.72",,,,,,
Molina Medicaid,DRG,403,SPINAL DISORDERS and INJURIES,,Relative Weights,"$8,545.98 ",IP,"8,545.98","8,545.98",,,,,,
Molina Medicaid,DRG,404,SPINAL DISORDERS and INJURIES,,Relative Weights,"$17,945.87 ",IP,"17,945.87","17,945.87",,,,,,
Molina Medicaid,DRG,411,NERVOUS SYSTEM MALIGNANCY,,Relative Weights,"$4,340.00 ",IP,"4,340.00","4,340.00",,,,,,
Molina Medicaid,DRG,412,NERVOUS SYSTEM MALIGNANCY,,Relative Weights,"$4,441.02 ",IP,"4,441.02","4,441.02",,,,,,
Molina Medicaid,DRG,413,NERVOUS SYSTEM MALIGNANCY,,Relative Weights,"$5,802.81 ",IP,"5,802.81","5,802.81",,,,,,
Molina Medicaid,DRG,414,NERVOUS SYSTEM MALIGNANCY,,Relative Weights,"$8,029.51 ",IP,"8,029.51","8,029.51",,,,,,
Molina Medicaid,DRG,421,DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS,,Relative Weights,"$3,328.02 ",IP,"3,328.02","3,328.02",,,,,,
Molina Medicaid,DRG,422,DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS,,Relative Weights,"$3,814.25 ",IP,"3,814.25","3,814.25",,,,,,
Molina Medicaid,DRG,423,DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS,,Relative Weights,"$5,381.53 ",IP,"5,381.53","5,381.53",,,,,,
Molina Medicaid,DRG,424,DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS,,Relative Weights,"$12,544.07 ",IP,"12,544.07","12,544.07",,,,,,
Molina Medicaid,DRG,431,MULTIPLE SCLEROSIS and OTHER DEMYELINATING DISEASES,,Relative Weights,"$4,040.70 ",IP,"4,040.70","4,040.70",,,,,,
Molina Medicaid,DRG,432,MULTIPLE SCLEROSIS and OTHER DEMYELINATING DISEASES,,Relative Weights,"$5,014.88 ",IP,"5,014.88","5,014.88",,,,,,
Molina Medicaid,DRG,433,MULTIPLE SCLEROSIS and OTHER DEMYELINATING DISEASES,,Relative Weights,"$7,268.72 ",IP,"7,268.72","7,268.72",,,,,,
Molina Medicaid,DRG,434,MULTIPLE SCLEROSIS & OTHER DEMYELINATING DISEASES,,Relative Weights,"$15,032.61 ",IP,"15,032.61","15,032.61",,,,,,
Molina Medicaid,DRG,441,INTRACRANIAL HEMORRHAGE,,Relative Weights,"$3,968.19 ",IP,"3,968.19","3,968.19",,,,,,
Molina Medicaid,DRG,442,INTRACRANIAL HEMORRHAGE,,Relative Weights,"$4,927.25 ",IP,"4,927.25","4,927.25",,,,,,
Molina Medicaid,DRG,443,INTRACRANIAL HEMORRHAGE,,Relative Weights,"$6,702.77 ",IP,"6,702.77","6,702.77",,,,,,
Molina Medicaid,DRG,444,INTRACRANIAL HEMORRHAGE,,Relative Weights,"$9,326.01 ",IP,"9,326.01","9,326.01",,,,,,
Molina Medicaid,DRG,451,CVA and PRECEREBRAL OCCLUSION W INFARCT,,Relative Weights,"$3,612.20 ",IP,"3,612.20","3,612.20",,,,,,
Molina Medicaid,DRG,452,CVA and PRECEREBRAL OCCLUSION W INFARCT,,Relative Weights,"$4,429.34 ",IP,"4,429.34","4,429.34",,,,,,
Molina Medicaid,DRG,453,CVA and PRECEREBRAL OCCLUSION W INFARCT,,Relative Weights,"$5,951.60 ",IP,"5,951.60","5,951.60",,,,,,
Molina Medicaid,DRG,454,CVA and PRECEREBRAL OCCLUSION W INFARCT,,Relative Weights,"$10,976.10 ",IP,"10,976.10","10,976.10",,,,,,
Molina Medicaid,DRG,461,NONSPECIFIC CVA and PRECEREBRAL OCCLUSION WO INFARCT,,Relative Weights,"$3,784.70 ",IP,"3,784.70","3,784.70",,,,,,
Molina Medicaid,DRG,462,NONSPECIFIC CVA and PRECEREBRAL OCCLUSION WO INFARCT,,Relative Weights,"$4,264.40 ",IP,"4,264.40","4,264.40",,,,,,
Molina Medicaid,DRG,463,NONSPECIFIC CVA and PRECEREBRAL OCCLUSION WO INFARCT,,Relative Weights,"$5,292.53 ",IP,"5,292.53","5,292.53",,,,,,
Molina Medicaid,DRG,464,NONSPECIFIC CVA and PRECEREBRAL OCCLUSION WO INFARCT,,Relative Weights,"$10,621.82 ",IP,"10,621.82","10,621.82",,,,,,
Molina Medicaid,DRG,471,TRANSIENT ISCHEMIA,,Relative Weights,"$3,321.15 ",IP,"3,321.15","3,321.15",,,,,,
Molina Medicaid,DRG,472,TRANSIENT ISCHEMIA,,Relative Weights,"$3,597.42 ",IP,"3,597.42","3,597.42",,,,,,
Molina Medicaid,DRG,473,TRANSIENT ISCHEMIA,,Relative Weights,"$4,242.41 ",IP,"4,242.41","4,242.41",,,,,,
Molina Medicaid,DRG,474,TRANSIENT ISCHEMIA,,Relative Weights,"$7,719.21 ",IP,"7,719.21","7,719.21",,,,,,
Molina Medicaid,DRG,481,PERIPHERAL CRANIAL and AUTONOMIC NERVE DISORDERS,,Relative Weights,"$3,400.87 ",IP,"3,400.87","3,400.87",,,,,,
Molina Medicaid,DRG,482,PERIPHERAL CRANIAL and AUTONOMIC NERVE DISORDERS,,Relative Weights,"$3,627.32 ",IP,"3,627.32","3,627.32",,,,,,
Molina Medicaid,DRG,483,PERIPHERAL CRANIAL and AUTONOMIC NERVE DISORDERS,,Relative Weights,"$4,545.48 ",IP,"4,545.48","4,545.48",,,,,,
Molina Medicaid,DRG,484,"PERIPHERAL, CRANIAL & AUTONOMIC NERVE DISORDERS",,Relative Weights,"$10,429.39 ",IP,"10,429.39","10,429.39",,,,,,
Molina Medicaid,DRG,491,BACTERIAL and TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,,Relative Weights,"$5,943.01 ",IP,"5,943.01","5,943.01",,,,,,
Molina Medicaid,DRG,492,BACTERIAL and TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,,Relative Weights,"$9,716.03 ",IP,"9,716.03","9,716.03",,,,,,
Molina Medicaid,DRG,493,BACTERIAL and TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,,Relative Weights,"$11,066.13 ",IP,"11,066.13","11,066.13",,,,,,
Molina Medicaid,DRG,494,BACTERIAL and TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,,Relative Weights,"$20,732.33 ",IP,"20,732.33","20,732.33",,,,,,
Molina Medicaid,DRG,501,NONBACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS,,Relative Weights,"$3,211.53 ",IP,"3,211.53","3,211.53",,,,,,
Molina Medicaid,DRG,502,NONBACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS,,Relative Weights,"$6,688.34 ",IP,"6,688.34","6,688.34",,,,,,
Molina Medicaid,DRG,503,NONBACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS,,Relative Weights,"$10,165.49 ",IP,"10,165.49","10,165.49",,,,,,
Molina Medicaid,DRG,504,NONBACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS,,Relative Weights,"$22,308.54 ",IP,"22,308.54","22,308.54",,,,,,
Molina Medicaid,DRG,511,VIRAL MENINGITIS,,Relative Weights,"$2,048.35 ",IP,"2,048.35","2,048.35",,,,,,
Molina Medicaid,DRG,512,VIRAL MENINGITIS,,Relative Weights,"$3,205.00 ",IP,"3,205.00","3,205.00",,,,,,
Molina Medicaid,DRG,513,VIRAL MENINGITIS,,Relative Weights,"$5,993.52 ",IP,"5,993.52","5,993.52",,,,,,
Molina Medicaid,DRG,514,VIRAL MENINGITIS,,Relative Weights,"$12,441.32 ",IP,"12,441.32","12,441.32",,,,,,
Molina Medicaid,DRG,521,ALTERATION IN CONSCIOUSNESS,,Relative Weights,"$3,101.91 ",IP,"3,101.91","3,101.91",,,,,,
Molina Medicaid,DRG,522,ALTERATION IN CONSCIOUSNESS,,Relative Weights,"$3,492.61 ",IP,"3,492.61","3,492.61",,,,,,
Molina Medicaid,DRG,523,ALTERATION IN CONSCIOUSNESS,,Relative Weights,"$4,423.15 ",IP,"4,423.15","4,423.15",,,,,,
Molina Medicaid,DRG,524,ALTERATION IN CONSCIOUSNESS,,Relative Weights,"$9,303.33 ",IP,"9,303.33","9,303.33",,,,,,
Molina Medicaid,DRG,531,SEIZURE,,Relative Weights,"$2,710.87 ",IP,"2,710.87","2,710.87",,,,,,
Molina Medicaid,DRG,532,SEIZURE,,Relative Weights,"$3,311.87 ",IP,"3,311.87","3,311.87",,,,,,
Molina Medicaid,DRG,533,SEIZURE,,Relative Weights,"$4,410.44 ",IP,"4,410.44","4,410.44",,,,,,
Molina Medicaid,DRG,534,SEIZURE,,Relative Weights,"$10,918.03 ",IP,"10,918.03","10,918.03",,,,,,
Molina Medicaid,DRG,541,MIGRAINE and OTHER HEADACHES,,Relative Weights,"$2,681.66 ",IP,"2,681.66","2,681.66",,,,,,
Molina Medicaid,DRG,542,MIGRAINE and OTHER HEADACHES,,Relative Weights,"$3,180.26 ",IP,"3,180.26","3,180.26",,,,,,
Molina Medicaid,DRG,543,MIGRAINE and OTHER HEADACHES,,Relative Weights,"$3,960.98 ",IP,"3,960.98","3,960.98",,,,,,
Molina Medicaid,DRG,544,MIGRAINE and OTHER HEADACHES,,Relative Weights,"$6,681.46 ",IP,"6,681.46","6,681.46",,,,,,
Molina Medicaid,DRG,551,HEAD TRAUMA W COMA 1 HR OR HEMORRHAGE,,Relative Weights,"$3,376.47 ",IP,"3,376.47","3,376.47",,,,,,
Molina Medicaid,DRG,552,HEAD TRAUMA W COMA 1 HR OR HEMORRHAGE,,Relative Weights,"$4,570.57 ",IP,"4,570.57","4,570.57",,,,,,
Molina Medicaid,DRG,553,HEAD TRAUMA W COMA 1 HR OR HEMORRHAGE,,Relative Weights,"$6,561.54 ",IP,"6,561.54","6,561.54",,,,,,
Molina Medicaid,DRG,554,HEAD TRAUMA W COMA 1 HR OR HEMORRHAGE,,Relative Weights,"$13,008.65 ",IP,"13,008.65","13,008.65",,,,,,
Molina Medicaid,DRG,561,BRAIN CONTUSIONLACERATION and COMPLICATED SKULL FX COMA  1 HR OR NO COMA,,Relative Weights,"$3,264.10 ",IP,"3,264.10","3,264.10",,,,,,
Molina Medicaid,DRG,562,BRAIN CONTUSIONLACERATION and COMPLICATED SKULL FX COMA  1 HR OR NO COMA,,Relative Weights,"$4,370.58 ",IP,"4,370.58","4,370.58",,,,,,
Molina Medicaid,DRG,563,BRAIN CONTUSIONLACERATION and COMPLICATED SKULL FX COMA  1 HR OR NO COMA,,Relative Weights,"$6,249.87 ",IP,"6,249.87","6,249.87",,,,,,
Molina Medicaid,DRG,564,BRAIN CONTUSIONLACERATION and COMPLICATED SKULL FX COMA  1 HR OR NO COMA,,Relative Weights,"$13,974.93 ",IP,"13,974.93","13,974.93",,,,,,
Molina Medicaid,DRG,571,CONCUSSION CLOSED SKULL FX NOSUNCOMPLICATED INTRACRANIAL INJURY COMA  1 HR OR NO COMA,,Relative Weights,"$2,653.48 ",IP,"2,653.48","2,653.48",,,,,,
Molina Medicaid,DRG,572,CONCUSSION CLOSED SKULL FX NOSUNCOMPLICATED INTRACRANIAL INJURY COMA  1 HR OR NO COMA,,Relative Weights,"$3,996.71 ",IP,"3,996.71","3,996.71",,,,,,
Molina Medicaid,DRG,573,CONCUSSION CLOSED SKULL FX NOSUNCOMPLICATED INTRACRANIAL INJURY COMA  1 HR OR NO COMA,,Relative Weights,"$5,550.25 ",IP,"5,550.25","5,550.25",,,,,,
Molina Medicaid,DRG,574,CONCUSSION CLOSED SKULL FX NOSUNCOMPLICATED INTRACRANIAL INJURY COMA  1 HR OR NO COMA,,Relative Weights,"$10,437.98 ",IP,"10,437.98","10,437.98",,,,,,
Molina Medicaid,DRG,581,OTHER DISORDERS OF NERVOUS SYSTEM,,Relative Weights,"$3,385.75 ",IP,"3,385.75","3,385.75",,,,,,
Molina Medicaid,DRG,582,OTHER DISORDERS OF NERVOUS SYSTEM,,Relative Weights,"$4,062.35 ",IP,"4,062.35","4,062.35",,,,,,
Molina Medicaid,DRG,583,OTHER DISORDERS OF NERVOUS SYSTEM,,Relative Weights,"$5,313.15 ",IP,"5,313.15","5,313.15",,,,,,
Molina Medicaid,DRG,584,OTHER DISORDERS OF NERVOUS SYSTEM,,Relative Weights,"$10,386.78 ",IP,"10,386.78","10,386.78",,,,,,
Molina Medicaid,DRG,591,ANOXIC and OTHER SEVERE BRAIN DAMAGE,,Relative Weights,"$3,746.90 ",IP,"3,746.90","3,746.90",,,,,,
Molina Medicaid,DRG,592,ANOXIC and OTHER SEVERE BRAIN DAMAGE,,Relative Weights,"$4,463.01 ",IP,"4,463.01","4,463.01",,,,,,
Molina Medicaid,DRG,593,ANOXIC and OTHER SEVERE BRAIN DAMAGE,,Relative Weights,"$6,809.98 ",IP,"6,809.98","6,809.98",,,,,,
Molina Medicaid,DRG,594,ANOXIC & OTHER SEVERE BRAIN DAMAGE,,Relative Weights,"$11,699.43 ",IP,"11,699.43","11,699.43",,,,,,
Molina Medicaid,DRG,731,ORBIT AND EYE PROCEDURES,,Relative Weights,"$5,014.53 ",IP,"5,014.53","5,014.53",,,,,,
Molina Medicaid,DRG,732,ORBIT AND EYE PROCEDURES,,Relative Weights,"$6,421.34 ",IP,"6,421.34","6,421.34",,,,,,
Molina Medicaid,DRG,733,ORBIT AND EYE PROCEDURES,,Relative Weights,"$9,718.43 ",IP,"9,718.43","9,718.43",,,,,,
Molina Medicaid,DRG,734,ORBIT AND EYE PROCEDURES,,Relative Weights,"$22,403.73 ",IP,"22,403.73","22,403.73",,,,,,
Molina Medicaid,DRG,821,EYE INFECTIONS AND OTHER EYE DISORDERS,,Relative Weights,"$2,633.21 ",IP,"2,633.21","2,633.21",,,,,,
Molina Medicaid,DRG,822,EYE INFECTIONS AND OTHER EYE DISORDERS,,Relative Weights,"$3,410.83 ",IP,"3,410.83","3,410.83",,,,,,
Molina Medicaid,DRG,823,EYE INFECTIONS AND OTHER EYE DISORDERS,,Relative Weights,"$4,809.73 ",IP,"4,809.73","4,809.73",,,,,,
Molina Medicaid,DRG,824,EYE INFECTIONS AND OTHER EYE DISORDERS,,Relative Weights,"$13,027.89 ",IP,"13,027.89","13,027.89",,,,,,
Molina Medicaid,DRG,891,MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$9,059.01 ",IP,"9,059.01","9,059.01",,,,,,
Molina Medicaid,DRG,892,MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$11,457.52 ",IP,"11,457.52","11,457.52",,,,,,
Molina Medicaid,DRG,893,MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$17,804.98 ",IP,"17,804.98","17,804.98",,,,,,
Molina Medicaid,DRG,894,MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$32,041.75 ",IP,"32,041.75","32,041.75",,,,,,
Molina Medicaid,DRG,911,OTHER MAJOR HEAD and NECK PROCEDURES,,Relative Weights,"$6,729.57 ",IP,"6,729.57","6,729.57",,,,,,
Molina Medicaid,DRG,912,OTHER MAJOR HEAD and NECK PROCEDURES,,Relative Weights,"$9,964.47 ",IP,"9,964.47","9,964.47",,,,,,
Molina Medicaid,DRG,913,OTHER MAJOR HEAD and NECK PROCEDURES,,Relative Weights,"$16,613.29 ",IP,"16,613.29","16,613.29",,,,,,
Molina Medicaid,DRG,914,OTHER MAJOR HEAD and NECK PROCEDURES,,Relative Weights,"$32,825.56 ",IP,"32,825.56","32,825.56",,,,,,
Molina Medicaid,DRG,921,FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$6,039.23 ",IP,"6,039.23","6,039.23",,,,,,
Molina Medicaid,DRG,922,FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$8,191.36 ",IP,"8,191.36","8,191.36",,,,,,
Molina Medicaid,DRG,923,FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$13,246.44 ",IP,"13,246.44","13,246.44",,,,,,
Molina Medicaid,DRG,924,FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$30,839.40 ",IP,"30,839.40","30,839.40",,,,,,
Molina Medicaid,DRG,951,CLEFT LIP and PALATE REPAIR,,Relative Weights,"$4,246.53 ",IP,"4,246.53","4,246.53",,,,,,
Molina Medicaid,DRG,952,CLEFT LIP and PALATE REPAIR,,Relative Weights,"$4,867.46 ",IP,"4,867.46","4,867.46",,,,,,
Molina Medicaid,DRG,953,CLEFT LIP & PALATE REPAIR,,Relative Weights,"$7,436.75 ",IP,"7,436.75","7,436.75",,,,,,
Molina Medicaid,DRG,954,CLEFT LIP and PALATE REPAIR,,Relative Weights,"$14,987.25 ",IP,"14,987.25","14,987.25",,,,,,
Molina Medicaid,DRG,971,TONSIL and ADENOID PROCEDURES,,Relative Weights,"$2,853.47 ",IP,"2,853.47","2,853.47",,,,,,
Molina Medicaid,DRG,972,TONSIL & ADENOID PROCEDURES,,Relative Weights,"$3,981.59 ",IP,"3,981.59","3,981.59",,,,,,
Molina Medicaid,DRG,973,TONSIL & ADENOID PROCEDURES,,Relative Weights,"$6,406.56 ",IP,"6,406.56","6,406.56",,,,,,
Molina Medicaid,DRG,974,TONSIL and ADENOID PROCEDURES,,Relative Weights,"$15,100.30 ",IP,"15,100.30","15,100.30",,,,,,
Molina Medicaid,DRG,981,OTHER EAR NOSE MOUTH and THROAT PROCEDURES,,Relative Weights,"$4,806.30 ",IP,"4,806.30","4,806.30",,,,,,
Molina Medicaid,DRG,982,OTHER EAR NOSE MOUTH and THROAT PROCEDURES,,Relative Weights,"$6,289.73 ",IP,"6,289.73","6,289.73",,,,,,
Molina Medicaid,DRG,983,"OTHER EAR, NOSE, MOUTH & THROAT PROCEDURES",,Relative Weights,"$10,153.46 ",IP,"10,153.46","10,153.46",,,,,,
Molina Medicaid,DRG,984,OTHER EAR NOSE MOUTH and THROAT PROCEDURES,,Relative Weights,"$19,630.32 ",IP,"19,630.32","19,630.32",,,,,,
Molina Medicaid,DRG,1101,EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES,,Relative Weights,"$4,539.30 ",IP,"4,539.30","4,539.30",,,,,,
Molina Medicaid,DRG,1102,EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES,,Relative Weights,"$4,571.26 ",IP,"4,571.26","4,571.26",,,,,,
Molina Medicaid,DRG,1103,EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES,,Relative Weights,"$6,424.43 ",IP,"6,424.43","6,424.43",,,,,,
Molina Medicaid,DRG,1104,EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES,,Relative Weights,"$10,388.84 ",IP,"10,388.84","10,388.84",,,,,,
Molina Medicaid,DRG,1111,VERTIGO and OTHER LABYRINTH DISORDERS,,Relative Weights,"$3,014.97 ",IP,"3,014.97","3,014.97",,,,,,
Molina Medicaid,DRG,1112,VERTIGO and OTHER LABYRINTH DISORDERS,,Relative Weights,"$3,232.83 ",IP,"3,232.83","3,232.83",,,,,,
Molina Medicaid,DRG,1113,VERTIGO and OTHER LABYRINTH DISORDERS,,Relative Weights,"$3,830.06 ",IP,"3,830.06","3,830.06",,,,,,
Molina Medicaid,DRG,1114,VERTIGO and OTHER LABYRINTH DISORDERS,,Relative Weights,"$5,856.07 ",IP,"5,856.07","5,856.07",,,,,,
Molina Medicaid,DRG,1131,INFECTIONS OF UPPER RESPIRATORY TRACT,,Relative Weights,"$1,710.57 ",IP,"1,710.57","1,710.57",,,,,,
Molina Medicaid,DRG,1132,INFECTIONS OF UPPER RESPIRATORY TRACT,,Relative Weights,"$2,449.71 ",IP,"2,449.71","2,449.71",,,,,,
Molina Medicaid,DRG,1133,INFECTIONS OF UPPER RESPIRATORY TRACT,,Relative Weights,"$3,709.10 ",IP,"3,709.10","3,709.10",,,,,,
Molina Medicaid,DRG,1134,INFECTIONS OF UPPER RESPIRATORY TRACT,,Relative Weights,"$7,363.91 ",IP,"7,363.91","7,363.91",,,,,,
Molina Medicaid,DRG,1141,DENTAL DISEASES AND DISORDERS,,Relative Weights,"$2,233.23 ",IP,"2,233.23","2,233.23",,,,,,
Molina Medicaid,DRG,1142,DENTAL DISEASES AND DISORDERS,,Relative Weights,"$3,024.94 ",IP,"3,024.94","3,024.94",,,,,,
Molina Medicaid,DRG,1143,DENTAL DISEASES AND DISORDERS,,Relative Weights,"$4,392.57 ",IP,"4,392.57","4,392.57",,,,,,
Molina Medicaid,DRG,1144,DENTAL DISEASES AND DISORDERS,,Relative Weights,"$11,476.08 ",IP,"11,476.08","11,476.08",,,,,,
Molina Medicaid,DRG,1151,OTHER EAR NOSE MOUTHTHROAT and CRANIALFACIAL DIAGNOSES,,Relative Weights,"$2,472.39 ",IP,"2,472.39","2,472.39",,,,,,
Molina Medicaid,DRG,1152,OTHER EAR NOSE MOUTHTHROAT and CRANIALFACIAL DIAGNOSES,,Relative Weights,"$3,380.25 ",IP,"3,380.25","3,380.25",,,,,,
Molina Medicaid,DRG,1153,"OTHER EAR, NOSE, MOUTH,THROAT & CRANIAL/FACIAL DIAGNOSES",,Relative Weights,"$4,829.66 ",IP,"4,829.66","4,829.66",,,,,,
Molina Medicaid,DRG,1154,"OTHER EAR, NOSE, MOUTH,THROAT & CRANIAL/FACIAL DIAGNOSES",,Relative Weights,"$10,560.66 ",IP,"10,560.66","10,560.66",,,,,,
Molina Medicaid,DRG,1201,MAJOR RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$8,978.60 ",IP,"8,978.60","8,978.60",,,,,,
Molina Medicaid,DRG,1202,MAJOR RESPIRATORY & CHEST PROCEDURES,,Relative Weights,"$10,724.22 ",IP,"10,724.22","10,724.22",,,,,,
Molina Medicaid,DRG,1203,MAJOR RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$15,096.86 ",IP,"15,096.86","15,096.86",,,,,,
Molina Medicaid,DRG,1204,MAJOR RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$30,187.20 ",IP,"30,187.20","30,187.20",,,,,,
Molina Medicaid,DRG,1211,OTHER RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$6,647.79 ",IP,"6,647.79","6,647.79",,,,,,
Molina Medicaid,DRG,1212,OTHER RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$8,066.62 ",IP,"8,066.62","8,066.62",,,,,,
Molina Medicaid,DRG,1213,OTHER RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$12,267.10 ",IP,"12,267.10","12,267.10",,,,,,
Molina Medicaid,DRG,1214,OTHER RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$23,708.13 ",IP,"23,708.13","23,708.13",,,,,,
Molina Medicaid,DRG,1301,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96 HOURS,,Relative Weights,"$15,152.88 ",IP,"15,152.88","15,152.88",,,,,,
Molina Medicaid,DRG,1302,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS,,Relative Weights,"$17,209.82 ",IP,"17,209.82","17,209.82",,,,,,
Molina Medicaid,DRG,1303,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96 HOURS,,Relative Weights,"$20,315.17 ",IP,"20,315.17","20,315.17",,,,,,
Molina Medicaid,DRG,1304,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96 HOURS,,Relative Weights,"$28,326.47 ",IP,"28,326.47","28,326.47",,,,,,
Molina Medicaid,DRG,1311,CYSTIC FIBROSIS  PULMONARY DISEASE,,Relative Weights,"$6,540.23 ",IP,"6,540.23","6,540.23",,,,,,
Molina Medicaid,DRG,1312,CYSTIC FIBROSIS - PULMONARY DISEASE,,Relative Weights,"$9,797.46 ",IP,"9,797.46","9,797.46",,,,,,
Molina Medicaid,DRG,1313,CYSTIC FIBROSIS - PULMONARY DISEASE,,Relative Weights,"$13,253.65 ",IP,"13,253.65","13,253.65",,,,,,
Molina Medicaid,DRG,1314,CYSTIC FIBROSIS  PULMONARY DISEASE,,Relative Weights,"$17,241.78 ",IP,"17,241.78","17,241.78",,,,,,
Molina Medicaid,DRG,1321,BPD and OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,,Relative Weights,"$2,377.20 ",IP,"2,377.20","2,377.20",,,,,,
Molina Medicaid,DRG,1322,BPD and OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,,Relative Weights,"$3,157.24 ",IP,"3,157.24","3,157.24",,,,,,
Molina Medicaid,DRG,1323,BPD & OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,,Relative Weights,"$5,204.90 ",IP,"5,204.90","5,204.90",,,,,,
Molina Medicaid,DRG,1324,BPD and OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,,Relative Weights,"$9,706.75 ",IP,"9,706.75","9,706.75",,,,,,
Molina Medicaid,DRG,1331,RESPIRATORY FAILURE,,Relative Weights,"$2,072.41 ",IP,"2,072.41","2,072.41",,,,,,
Molina Medicaid,DRG,1332,RESPIRATORY FAILURE,,Relative Weights,"$3,703.26 ",IP,"3,703.26","3,703.26",,,,,,
Molina Medicaid,DRG,1333,RESPIRATORY FAILURE,,Relative Weights,"$5,064.70 ",IP,"5,064.70","5,064.70",,,,,,
Molina Medicaid,DRG,1334,RESPIRATORY FAILURE,,Relative Weights,"$9,349.38 ",IP,"9,349.38","9,349.38",,,,,,
Molina Medicaid,DRG,1341,PULMONARY EMBOLISM,,Relative Weights,"$2,977.18 ",IP,"2,977.18","2,977.18",,,,,,
Molina Medicaid,DRG,1342,PULMONARY EMBOLISM,,Relative Weights,"$3,832.12 ",IP,"3,832.12","3,832.12",,,,,,
Molina Medicaid,DRG,1343,PULMONARY EMBOLISM,,Relative Weights,"$5,276.03 ",IP,"5,276.03","5,276.03",,,,,,
Molina Medicaid,DRG,1344,PULMONARY EMBOLISM,,Relative Weights,"$8,166.27 ",IP,"8,166.27","8,166.27",,,,,,
Molina Medicaid,DRG,1351,MAJOR CHEST and RESPIRAZORY TRAUMA,,Relative Weights,"$3,792.26 ",IP,"3,792.26","3,792.26",,,,,,
Molina Medicaid,DRG,1352,MAJOR CHEST & RESPIRATORY TRAUMA,,Relative Weights,"$3,955.48 ",IP,"3,955.48","3,955.48",,,,,,
Molina Medicaid,DRG,1353,MAJOR CHEST and RESPIRATORY TRAUMA,,Relative Weights,"$5,683.92 ",IP,"5,683.92","5,683.92",,,,,,
Molina Medicaid,DRG,1354,MAJOR CHEST and RESPIRATORY TRAUMA,,Relative Weights,"$10,178.89 ",IP,"10,178.89","10,178.89",,,,,,
Molina Medicaid,DRG,1361,RESPIRATORY MALIGNANCY,,Relative Weights,"$4,244.47 ",IP,"4,244.47","4,244.47",,,,,,
Molina Medicaid,DRG,1362,RESPIRATORY MALIGNANCY,,Relative Weights,"$4,742.73 ",IP,"4,742.73","4,742.73",,,,,,
Molina Medicaid,DRG,1363,RESPIRATORY MALIGNANCY,,Relative Weights,"$6,049.19 ",IP,"6,049.19","6,049.19",,,,,,
Molina Medicaid,DRG,1364,RESPIRATORY MALIGNANCY,,Relative Weights,"$9,049.05 ",IP,"9,049.05","9,049.05",,,,,,
Molina Medicaid,DRG,1371,MAJOR RESPIRATORY INFECTIONS and INFLAMMATIONS,,Relative Weights,"$3,151.74 ",IP,"3,151.74","3,151.74",,,,,,
Molina Medicaid,DRG,1372,MAJOR RESPIRATORY INFECTIONS and INFLAMMATIONS,,Relative Weights,"$3,930.39 ",IP,"3,930.39","3,930.39",,,,,,
Molina Medicaid,DRG,1373,MAJOR RESPIRATORY INFECTIONS & INFLAMMATIONS,,Relative Weights,"$5,471.90 ",IP,"5,471.90","5,471.90",,,,,,
Molina Medicaid,DRG,1374,MAJOR RESPIRATORY INFECTIONS and INFLAMMATIONS,,Relative Weights,"$8,758.68 ",IP,"8,758.68","8,758.68",,,,,,
Molina Medicaid,DRG,1381,BRONCHIOLITIS and RSV PNEUMONIA,,Relative Weights,"$1,796.82 ",IP,"1,796.82","1,796.82",,,,,,
Molina Medicaid,DRG,1382,BRONCHIOLITIS and RSV PNEUMONIA,,Relative Weights,"$2,575.82 ",IP,"2,575.82","2,575.82",,,,,,
Molina Medicaid,DRG,1383,BRONCHIOLITIS and RSV PNEUMONIA,,Relative Weights,"$4,712.83 ",IP,"4,712.83","4,712.83",,,,,,
Molina Medicaid,DRG,1384,BRONCHIOLITIS and RSV PNEUMONIA,,Relative Weights,"$9,865.85 ",IP,"9,865.85","9,865.85",,,,,,
Molina Medicaid,DRG,1391,OTHER PNEUMONIA,,Relative Weights,"$2,182.71 ",IP,"2,182.71","2,182.71",,,,,,
Molina Medicaid,DRG,1392,OTHER PNEUMONIA,,Relative Weights,"$3,016.35 ",IP,"3,016.35","3,016.35",,,,,,
Molina Medicaid,DRG,1393,OTHER PNEUMONIA,,Relative Weights,"$4,342.75 ",IP,"4,342.75","4,342.75",,,,,,
Molina Medicaid,DRG,1394,OTHER PNEUMONIA,,Relative Weights,"$7,186.59 ",IP,"7,186.59","7,186.59",,,,,,
Molina Medicaid,DRG,1401,CHRONIC OBSTRUCTIVE PULMONARY DISEASE,,Relative Weights,"$2,639.05 ",IP,"2,639.05","2,639.05",,,,,,
Molina Medicaid,DRG,1402,CHRONIC OBSTRUCTIVE PULMONARY DISEASE,,Relative Weights,"$3,167.20 ",IP,"3,167.20","3,167.20",,,,,,
Molina Medicaid,DRG,1403,CHRONIC OBSTRUCTIVE PULMONARY DISEASE,,Relative Weights,"$3,958.92 ",IP,"3,958.92","3,958.92",,,,,,
Molina Medicaid,DRG,1404,CHRONIC OBSTRUCTIVE PULMONARY DISEASE,,Relative Weights,"$5,969.47 ",IP,"5,969.47","5,969.47",,,,,,
Molina Medicaid,DRG,1411,ASTHMA,,Relative Weights,"$2,018.80 ",IP,"2,018.80","2,018.80",,,,,,
Molina Medicaid,DRG,1412,ASTHMA,,Relative Weights,"$2,763.78 ",IP,"2,763.78","2,763.78",,,,,,
Molina Medicaid,DRG,1413,ASTHMA,,Relative Weights,"$4,049.98 ",IP,"4,049.98","4,049.98",,,,,,
Molina Medicaid,DRG,1414,ASTHMA,,Relative Weights,"$6,508.28 ",IP,"6,508.28","6,508.28",,,,,,
Molina Medicaid,DRG,1421,INTERSTITIAL and ALVEOLAR LUNG DISEASES,,Relative Weights,"$3,358.26 ",IP,"3,358.26","3,358.26",,,,,,
Molina Medicaid,DRG,1422,INTERSTITIAL and ALVEOLAR LUNG DISEASES,,Relative Weights,"$3,679.89 ",IP,"3,679.89","3,679.89",,,,,,
Molina Medicaid,DRG,1423,INTERSTITIAL and ALVEOLAR LUNG DISEASES,,Relative Weights,"$4,888.08 ",IP,"4,888.08","4,888.08",,,,,,
Molina Medicaid,DRG,1424,INTERSTITIAL and ALVEOLAR LUNG DISEASES,,Relative Weights,"$7,901.68 ",IP,"7,901.68","7,901.68",,,,,,
Molina Medicaid,DRG,1431,OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$2,504.69 ",IP,"2,504.69","2,504.69",,,,,,
Molina Medicaid,DRG,1432,OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$3,509.11 ",IP,"3,509.11","3,509.11",,,,,,
Molina Medicaid,DRG,1433,OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$5,145.11 ",IP,"5,145.11","5,145.11",,,,,,
Molina Medicaid,DRG,1434,OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$8,358.70 ",IP,"8,358.70","8,358.70",,,,,,
Molina Medicaid,DRG,1441,"RESPIRATORY SIGNS, SYMPTOMS & MINOR DIAGNOSES",,Relative Weights,"$2,636.99 ",IP,"2,636.99","2,636.99",,,,,,
Molina Medicaid,DRG,1442,RESPIRATORY SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$3,405.68 ",IP,"3,405.68","3,405.68",,,,,,
Molina Medicaid,DRG,1443,RESPIRATORY SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$4,454.42 ",IP,"4,454.42","4,454.42",,,,,,
Molina Medicaid,DRG,1444,RESPIRATORY SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$7,998.24 ",IP,"7,998.24","7,998.24",,,,,,
Molina Medicaid,DRG,1451,ACUTE BRONCHITIS AND RELATED SYMPTOMS,,Relative Weights,"$2,478.23 ",IP,"2,478.23","2,478.23",,,,,,
Molina Medicaid,DRG,1452,ACUTE BRONCHITIS AND RELATED SYMPTOMS,,Relative Weights,"$2,974.43 ",IP,"2,974.43","2,974.43",,,,,,
Molina Medicaid,DRG,1453,ACUTE BRONCHITIS AND RELATED SYMPTOMS,,Relative Weights,"$3,820.09 ",IP,"3,820.09","3,820.09",,,,,,
Molina Medicaid,DRG,1454,ACUTE BRONCHITIS AND RELATED SYMPTOMS,,Relative Weights,"$6,746.07 ",IP,"6,746.07","6,746.07",,,,,,
Molina Medicaid,DRG,1601,MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,,Relative Weights,"$19,007.33 ",IP,"19,007.33","19,007.33",,,,,,
Molina Medicaid,DRG,1602,MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,,Relative Weights,"$21,418.55 ",IP,"21,418.55","21,418.55",,,,,,
Molina Medicaid,DRG,1603,MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,,Relative Weights,"$29,897.52 ",IP,"29,897.52","29,897.52",,,,,,
Molina Medicaid,DRG,1604,MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,,Relative Weights,"$58,616.75 ",IP,"58,616.75","58,616.75",,,,,,
Molina Medicaid,DRG,1611,CARDIAC DEFIBRILLATOR and HEART ASSIST IMPLANT,,Relative Weights,"$21,623.70 ",IP,"21,623.70","21,623.70",,,,,,
Molina Medicaid,DRG,1612,CARDIAC DEFIBRILLATOR and HEART ASSIST IMPLANT,,Relative Weights,"$25,324.21 ",IP,"25,324.21","25,324.21",,,,,,
Molina Medicaid,DRG,1613,CARDIAC DEFIBRILLATOR and HEART ASSIST IMPLANT,,Relative Weights,"$37,168.99 ",IP,"37,168.99","37,168.99",,,,,,
Molina Medicaid,DRG,1614,CARDIAC DEFIBRILLATOR and HEART ASSIST IMPLANT,,Relative Weights,"$84,952.59 ",IP,"84,952.59","84,952.59",,,,,,
Molina Medicaid,DRG,1621,CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX,,Relative Weights,"$21,734.00 ",IP,"21,734.00","21,734.00",,,,,,
Molina Medicaid,DRG,1622,CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX,,Relative Weights,"$25,647.21 ",IP,"25,647.21","25,647.21",,,,,,
Molina Medicaid,DRG,1623,CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX,,Relative Weights,"$32,557.19 ",IP,"32,557.19","32,557.19",,,,,,
Molina Medicaid,DRG,1624,CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX,,Relative Weights,"$51,493.39 ",IP,"51,493.39","51,493.39",,,,,,
Molina Medicaid,DRG,1631,CARDIAC VALVE PROCEDURES WO AMI OR COMPLEX PDX,,Relative Weights,"$18,870.57 ",IP,"18,870.57","18,870.57",,,,,,
Molina Medicaid,DRG,1632,CARDIAC VALVE PROCEDURES WO AMI OR COMPLEX PDX,,Relative Weights,"$20,678.38 ",IP,"20,678.38","20,678.38",,,,,,
Molina Medicaid,DRG,1633,CARDIAC VALVE PROCEDURES WO AMI OR COMPLEX PDX,,Relative Weights,"$25,441.73 ",IP,"25,441.73","25,441.73",,,,,,
Molina Medicaid,DRG,1634,CARDIAC VALVE PROCEDURES WO AMI OR COMPLEX PDX,,Relative Weights,"$42,290.40 ",IP,"42,290.40","42,290.40",,,,,,
Molina Medicaid,DRG,1651,CORONARY BYPASS W AMI OR COMPLEX PDX,,Relative Weights,"$17,424.93 ",IP,"17,424.93","17,424.93",,,,,,
Molina Medicaid,DRG,1652,CORONARY BYPASS W AMI OR COMPLEX PDX,,Relative Weights,"$20,592.13 ",IP,"20,592.13","20,592.13",,,,,,
Molina Medicaid,DRG,1653,CORONARY BYPASS W AMI OR COMPLEX PDX,,Relative Weights,"$24,876.46 ",IP,"24,876.46","24,876.46",,,,,,
Molina Medicaid,DRG,1654,CORONARY BYPASS W AMI OR COMPLEX PDX,,Relative Weights,"$37,414.00 ",IP,"37,414.00","37,414.00",,,,,,
Molina Medicaid,DRG,1661,CORONARY BYPASS W/O AMI OR COMPLEX PDX,,Relative Weights,"$16,087.19 ",IP,"16,087.19","16,087.19",,,,,,
Molina Medicaid,DRG,1662,CORONARY BYPASS WO AMI OR COMPLEX PDX,,Relative Weights,"$17,173.40 ",IP,"17,173.40","17,173.40",,,,,,
Molina Medicaid,DRG,1663,CORONARY BYPASS WO AMI OR COMPLEX PDX,,Relative Weights,"$20,743.67 ",IP,"20,743.67","20,743.67",,,,,,
Molina Medicaid,DRG,1664,CORONARY BYPASS WO AMI OR COMPLEX PDX,,Relative Weights,"$33,503.88 ",IP,"33,503.88","33,503.88",,,,,,
Molina Medicaid,DRG,1671,OTHER CARDIOTHORACIC and THORACIC VASCULAR PROCEDURES,,Relative Weights,"$15,753.88 ",IP,"15,753.88","15,753.88",,,,,,
Molina Medicaid,DRG,1672,OTHER CARDIOTHORACIC & THORACIC VASCULAR PROCEDURES,,Relative Weights,"$16,654.52 ",IP,"16,654.52","16,654.52",,,,,,
Molina Medicaid,DRG,1673,OTHER CARDIOTHORACIC & THORACIC VASCULAR PROCEDURES,,Relative Weights,"$20,943.66 ",IP,"20,943.66","20,943.66",,,,,,
Molina Medicaid,DRG,1674,OTHER CARDIOTHORACIC and THORACIC VASCULAR PROCEDURES,,Relative Weights,"$39,564.41 ",IP,"39,564.41","39,564.41",,,,,,
Molina Medicaid,DRG,1691,MAJOR ABDOMINAL VASCULAR PROCEDURES,,Relative Weights,"$9,314.67 ",IP,"9,314.67","9,314.67",,,,,,
Molina Medicaid,DRG,1692,MAJOR ABDOMINAL VASCULAR PROCEDURES,,Relative Weights,"$12,244.08 ",IP,"12,244.08","12,244.08",,,,,,
Molina Medicaid,DRG,1693,MAJOR ABDOMINAL VASCULAR PROCEDURES,,Relative Weights,"$19,456.45 ",IP,"19,456.45","19,456.45",,,,,,
Molina Medicaid,DRG,1694,MAJOR ABDOMINAL VASCULAR PROCEDURES,,Relative Weights,"$33,906.95 ",IP,"33,906.95","33,906.95",,,,,,
Molina Medicaid,DRG,1701,PERMANENT CARDIAC PACEMAKER IMPLANT W AMI HEART FAILURE OR SHOCK,,Relative Weights,"$10,265.14 ",IP,"10,265.14","10,265.14",,,,,,
Molina Medicaid,DRG,1702,PERMANENT CARDIAC PACEMAKER IMPLANT W AMI HEART FAILURE OR SHOCK,,Relative Weights,"$10,949.99 ",IP,"10,949.99","10,949.99",,,,,,
Molina Medicaid,DRG,1703,PERMANENT CARDIAC PACEMAKER IMPLANT W AMI HEART FAILURE OR SHOCK,,Relative Weights,"$13,975.61 ",IP,"13,975.61","13,975.61",,,,,,
Molina Medicaid,DRG,1704,"PERMANENT CARDIAC PACEMAKER IMPLANT W AMI, HEART FAILURE OR SHOCK",,Relative Weights,"$19,895.26 ",IP,"19,895.26","19,895.26",,,,,,
Molina Medicaid,DRG,1711,PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK,,Relative Weights,"$8,272.45 ",IP,"8,272.45","8,272.45",,,,,,
Molina Medicaid,DRG,1712,PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK,,Relative Weights,"$9,180.66 ",IP,"9,180.66","9,180.66",,,,,,
Molina Medicaid,DRG,1713,PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK,,Relative Weights,"$10,971.29 ",IP,"10,971.29","10,971.29",,,,,,
Molina Medicaid,DRG,1714,PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK,,Relative Weights,"$17,965.80 ",IP,"17,965.80","17,965.80",,,,,,
Molina Medicaid,DRG,1741,PERCUTANEOUS CORONARY INTERVENTION W AMI,,Relative Weights,"$9,597.47 ",IP,"9,597.47","9,597.47",,,,,,
Molina Medicaid,DRG,1742,PERCUTANEOUS CORONARY INTERVENTION W AMI,,Relative Weights,"$10,364.10 ",IP,"10,364.10","10,364.10",,,,,,
Molina Medicaid,DRG,1743,PERCUTANEOUS CORONARY INTERVENTION W AMI,,Relative Weights,"$12,874.29 ",IP,"12,874.29","12,874.29",,,,,,
Molina Medicaid,DRG,1744,PERCUTANEOUS CORONARY INTERVENTION W AMI,,Relative Weights,"$19,364.01 ",IP,"19,364.01","19,364.01",,,,,,
Molina Medicaid,DRG,1751,PERCUTANEOUS CORONARY INTERVENTION WO AMI,,Relative Weights,"$11,256.84 ",IP,"11,256.84","11,256.84",,,,,,
Molina Medicaid,DRG,1752,PERCUTANEOUS CORONARY INTERVENTION WO AMI,,Relative Weights,"$12,009.39 ",IP,"12,009.39","12,009.39",,,,,,
Molina Medicaid,DRG,1753,PERCUTANEOUS CORONARY INTERVENTION WO AMI,,Relative Weights,"$14,253.95 ",IP,"14,253.95","14,253.95",,,,,,
Molina Medicaid,DRG,1754,PERCUTANEOUS CORONARY INTERVENTION WO AMI,,Relative Weights,"$25,147.58 ",IP,"25,147.58","25,147.58",,,,,,
Molina Medicaid,DRG,1761,CARDIAC PACEMAKER and DEFIBRILLATOR DEVICE REPLACEMENT,,Relative Weights,"$9,268.97 ",IP,"9,268.97","9,268.97",,,,,,
Molina Medicaid,DRG,1762,CARDIAC PACEMAKER and DEFIBRILLATOR DEVICE REPLACEMENT,,Relative Weights,"$10,537.63 ",IP,"10,537.63","10,537.63",,,,,,
Molina Medicaid,DRG,1763,CARDIAC PACEMAKER & DEFIBRILLATOR DEVICE REPLACEMENT,,Relative Weights,"$15,961.08 ",IP,"15,961.08","15,961.08",,,,,,
Molina Medicaid,DRG,1764,CARDIAC PACEMAKER and DEFIBRILLATOR DEVICE REPLACEMENT,,Relative Weights,"$25,961.29 ",IP,"25,961.29","25,961.29",,,,,,
Molina Medicaid,DRG,1771,CARDIAC PACEMAKER and DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,,Relative Weights,"$6,530.96 ",IP,"6,530.96","6,530.96",,,,,,
Molina Medicaid,DRG,1772,CARDIAC PACEMAKER and DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,,Relative Weights,"$9,029.80 ",IP,"9,029.80","9,029.80",,,,,,
Molina Medicaid,DRG,1773,CARDIAC PACEMAKER & DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,,Relative Weights,"$11,280.21 ",IP,"11,280.21","11,280.21",,,,,,
Molina Medicaid,DRG,1774,CARDIAC PACEMAKER & DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,,Relative Weights,"$17,033.20 ",IP,"17,033.20","17,033.20",,,,,,
Molina Medicaid,DRG,1801,OTHER CIRCULATORY SYSTEM PROCEDURES,,Relative Weights,"$6,351.58 ",IP,"6,351.58","6,351.58",,,,,,
Molina Medicaid,DRG,1802,OTHER CIRCULATORY SYSTEM PROCEDURES,,Relative Weights,"$7,715.78 ",IP,"7,715.78","7,715.78",,,,,,
Molina Medicaid,DRG,1803,OTHER CIRCULATORY SYSTEM PROCEDURES,,Relative Weights,"$10,872.33 ",IP,"10,872.33","10,872.33",,,,,,
Molina Medicaid,DRG,1804,OTHER CIRCULATORY SYSTEM PROCEDURES,,Relative Weights,"$20,062.95 ",IP,"20,062.95","20,062.95",,,,,,
Molina Medicaid,DRG,1811,LOWER EXTREMITY ARTERIAL PROCEDURES,,Relative Weights,"$9,268.28 ",IP,"9,268.28","9,268.28",,,,,,
Molina Medicaid,DRG,1812,LOWER EXTREMITY ARTERIAL PROCEDURES,,Relative Weights,"$11,438.97 ",IP,"11,438.97","11,438.97",,,,,,
Molina Medicaid,DRG,1813,LOWER EXTREMITY ARTERIAL PROCEDURES,,Relative Weights,"$16,303.68 ",IP,"16,303.68","16,303.68",,,,,,
Molina Medicaid,DRG,1814,LOWER EXTREMITY ARTERIAL PROCEDURES,,Relative Weights,"$27,105.22 ",IP,"27,105.22","27,105.22",,,,,,
Molina Medicaid,DRG,1821,OTHER PERIPHERAL VASCULAR PROCEDURES,,Relative Weights,"$9,585.79 ",IP,"9,585.79","9,585.79",,,,,,
Molina Medicaid,DRG,1822,OTHER PERIPHERAL VASCULAR PROCEDURES,,Relative Weights,"$11,451.68 ",IP,"11,451.68","11,451.68",,,,,,
Molina Medicaid,DRG,1823,OTHER PERIPHERAL VASCULAR PROCEDURES,,Relative Weights,"$12,966.73 ",IP,"12,966.73","12,966.73",,,,,,
Molina Medicaid,DRG,1824,OTHER PERIPHERAL VASCULAR PROCEDURES,,Relative Weights,"$25,526.94 ",IP,"25,526.94","25,526.94",,,,,,
Molina Medicaid,DRG,1901,ACUTE MYOCARDIAL INFARCTION,,Relative Weights,"$3,454.82 ",IP,"3,454.82","3,454.82",,,,,,
Molina Medicaid,DRG,1902,ACUTE MYOCARDIAL INFARCTION,,Relative Weights,"$4,023.17 ",IP,"4,023.17","4,023.17",,,,,,
Molina Medicaid,DRG,1903,ACUTE MYOCARDIAL INFARCTION,,Relative Weights,"$5,278.78 ",IP,"5,278.78","5,278.78",,,,,,
Molina Medicaid,DRG,1904,ACUTE MYOCARDIAL INFARCTION,,Relative Weights,"$8,568.66 ",IP,"8,568.66","8,568.66",,,,,,
Molina Medicaid,DRG,1911,CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,,Relative Weights,"$4,795.99 ",IP,"4,795.99","4,795.99",,,,,,
Molina Medicaid,DRG,1912,CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,,Relative Weights,"$5,349.23 ",IP,"5,349.23","5,349.23",,,,,,
Molina Medicaid,DRG,1913,CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,,Relative Weights,"$6,652.26 ",IP,"6,652.26","6,652.26",,,,,,
Molina Medicaid,DRG,1914,CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,,Relative Weights,"$10,568.22 ",IP,"10,568.22","10,568.22",,,,,,
Molina Medicaid,DRG,1921,CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS,,Relative Weights,"$5,126.56 ",IP,"5,126.56","5,126.56",,,,,,
Molina Medicaid,DRG,1922,CARDIAC CATHETERIZATION FOR OTHER NONCORONARY CONDITIONS,,Relative Weights,"$5,995.59 ",IP,"5,995.59","5,995.59",,,,,,
Molina Medicaid,DRG,1923,CARDIAC CATHETERIZATION FOR OTHER NONCORONARY CONDITIONS,,Relative Weights,"$8,192.04 ",IP,"8,192.04","8,192.04",,,,,,
Molina Medicaid,DRG,1924,CARDIAC CATHETERIZATION FOR OTHER NONCORONARY CONDITIONS,,Relative Weights,"$14,030.25 ",IP,"14,030.25","14,030.25",,,,,,
Molina Medicaid,DRG,1931,ACUTE & SUBACUTE ENDOCARDITIS,,Relative Weights,"$4,156.16 ",IP,"4,156.16","4,156.16",,,,,,
Molina Medicaid,DRG,1932,ACUTE & SUBACUTE ENDOCARDITIS,,Relative Weights,"$5,201.81 ",IP,"5,201.81","5,201.81",,,,,,
Molina Medicaid,DRG,1933,ACUTE and SUBACUTE ENDOCARDITIS,,Relative Weights,"$7,472.15 ",IP,"7,472.15","7,472.15",,,,,,
Molina Medicaid,DRG,1934,ACUTE and SUBACUTE ENDOCARDITIS,,Relative Weights,"$12,655.75 ",IP,"12,655.75","12,655.75",,,,,,
Molina Medicaid,DRG,1941,HEART FAILURE,,Relative Weights,"$2,590.60 ",IP,"2,590.60","2,590.60",,,,,,
Molina Medicaid,DRG,1942,HEART FAILURE,,Relative Weights,"$3,135.24 ",IP,"3,135.24","3,135.24",,,,,,
Molina Medicaid,DRG,1943,HEART FAILURE,,Relative Weights,"$4,368.86 ",IP,"4,368.86","4,368.86",,,,,,
Molina Medicaid,DRG,1944,HEART FAILURE,,Relative Weights,"$7,070.79 ",IP,"7,070.79","7,070.79",,,,,,
Molina Medicaid,DRG,1961,CARDIAC ARREST and SHOCK,,Relative Weights,"$2,365.52 ",IP,"2,365.52","2,365.52",,,,,,
Molina Medicaid,DRG,1962,CARDIAC ARREST and SHOCK,,Relative Weights,"$2,596.44 ",IP,"2,596.44","2,596.44",,,,,,
Molina Medicaid,DRG,1963,CARDIAC ARREST & SHOCK,,Relative Weights,"$4,010.12 ",IP,"4,010.12","4,010.12",,,,,,
Molina Medicaid,DRG,1964,CARDIAC ARREST & SHOCK,,Relative Weights,"$8,325.03 ",IP,"8,325.03","8,325.03",,,,,,
Molina Medicaid,DRG,1971,PERIPHERAL and OTHER VASCULAR DISORDERS,,Relative Weights,"$2,758.63 ",IP,"2,758.63","2,758.63",,,,,,
Molina Medicaid,DRG,1972,PERIPHERAL and OTHER VASCULAR DISORDERS,,Relative Weights,"$3,488.49 ",IP,"3,488.49","3,488.49",,,,,,
Molina Medicaid,DRG,1973,PERIPHERAL and OTHER VASCULAR DISORDERS,,Relative Weights,"$4,794.61 ",IP,"4,794.61","4,794.61",,,,,,
Molina Medicaid,DRG,1974,PERIPHERAL & OTHER VASCULAR DISORDERS,,Relative Weights,"$9,053.51 ",IP,"9,053.51","9,053.51",,,,,,
Molina Medicaid,DRG,1981,ANGINA PECTORIS & CORONARY ATHEROSCLEROSIS,,Relative Weights,"$2,680.28 ",IP,"2,680.28","2,680.28",,,,,,
Molina Medicaid,DRG,1982,ANGINA PECTORIS and CORONARY ATHEROSCLEROSIS,,Relative Weights,"$2,985.77 ",IP,"2,985.77","2,985.77",,,,,,
Molina Medicaid,DRG,1983,ANGINA PECTORIS and CORONARY ATHEROSCLEROSIS,,Relative Weights,"$3,628.00 ",IP,"3,628.00","3,628.00",,,,,,
Molina Medicaid,DRG,1984,ANGINA PECTORIS and CORONARY ATHEROSCLEROSIS,,Relative Weights,"$6,763.25 ",IP,"6,763.25","6,763.25",,,,,,
Molina Medicaid,DRG,1991,HYPERTENSION,,Relative Weights,"$2,662.41 ",IP,"2,662.41","2,662.41",,,,,,
Molina Medicaid,DRG,1992,HYPERTENSION,,Relative Weights,"$2,956.56 ",IP,"2,956.56","2,956.56",,,,,,
Molina Medicaid,DRG,1993,HYPERTENSION,,Relative Weights,"$3,736.93 ",IP,"3,736.93","3,736.93",,,,,,
Molina Medicaid,DRG,1994,HYPERTENSION,,Relative Weights,"$6,634.39 ",IP,"6,634.39","6,634.39",,,,,,
Molina Medicaid,DRG,2001,CARDIAC STRUCTURAL and VALVULAR DISORDERS,,Relative Weights,"$2,919.45 ",IP,"2,919.45","2,919.45",,,,,,
Molina Medicaid,DRG,2002,CARDIAC STRUCTURAL and VALVULAR DISORDERS,,Relative Weights,"$3,565.12 ",IP,"3,565.12","3,565.12",,,,,,
Molina Medicaid,DRG,2003,CARDIAC STRUCTURAL & VALVULAR DISORDERS,,Relative Weights,"$4,853.03 ",IP,"4,853.03","4,853.03",,,,,,
Molina Medicaid,DRG,2004,CARDIAC STRUCTURAL and VALVULAR DISORDERS,,Relative Weights,"$10,524.92 ",IP,"10,524.92","10,524.92",,,,,,
Molina Medicaid,DRG,2011,CARDIAC ARRHYTHMIA and CONDUCTION DISORDERS,,Relative Weights,"$2,322.91 ",IP,"2,322.91","2,322.91",,,,,,
Molina Medicaid,DRG,2012,CARDIAC ARRHYTHMIA and CONDUCTION DISORDERS,,Relative Weights,"$2,865.50 ",IP,"2,865.50","2,865.50",,,,,,
Molina Medicaid,DRG,2013,CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS,,Relative Weights,"$3,988.81 ",IP,"3,988.81","3,988.81",,,,,,
Molina Medicaid,DRG,2014,CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS,,Relative Weights,"$7,490.70 ",IP,"7,490.70","7,490.70",,,,,,
Molina Medicaid,DRG,2031,CHEST PAIN,,Relative Weights,"$2,896.08 ",IP,"2,896.08","2,896.08",,,,,,
Molina Medicaid,DRG,2032,CHEST PAIN,,Relative Weights,"$3,156.55 ",IP,"3,156.55","3,156.55",,,,,,
Molina Medicaid,DRG,2033,CHEST PAIN,,Relative Weights,"$3,647.25 ",IP,"3,647.25","3,647.25",,,,,,
Molina Medicaid,DRG,2034,CHEST PAIN,,Relative Weights,"$5,656.08 ",IP,"5,656.08","5,656.08",,,,,,
Molina Medicaid,DRG,2041,SYNCOPE and COLLAPSE,,Relative Weights,"$3,210.15 ",IP,"3,210.15","3,210.15",,,,,,
Molina Medicaid,DRG,2042,SYNCOPE and COLLAPSE,,Relative Weights,"$3,469.25 ",IP,"3,469.25","3,469.25",,,,,,
Molina Medicaid,DRG,2043,SYNCOPE and COLLAPSE,,Relative Weights,"$3,913.56 ",IP,"3,913.56","3,913.56",,,,,,
Molina Medicaid,DRG,2044,SYNCOPE and COLLAPSE,,Relative Weights,"$6,621.67 ",IP,"6,621.67","6,621.67",,,,,,
Molina Medicaid,DRG,2051,CARDIOMYOPATHY,,Relative Weights,"$3,094.70 ",IP,"3,094.70","3,094.70",,,,,,
Molina Medicaid,DRG,2052,CARDIOMYOPATHY,,Relative Weights,"$3,108.78 ",IP,"3,108.78","3,108.78",,,,,,
Molina Medicaid,DRG,2053,CARDIOMYOPATHY,,Relative Weights,"$4,834.47 ",IP,"4,834.47","4,834.47",,,,,,
Molina Medicaid,DRG,2054,CARDIOMYOPATHY,,Relative Weights,"$12,099.76 ",IP,"12,099.76","12,099.76",,,,,,
Molina Medicaid,DRG,2061,MALFUNCTIONREACTIONCOMPLICATION OF CARDIACVASC DEVICE OR PROCEDURE,,Relative Weights,"$3,915.62 ",IP,"3,915.62","3,915.62",,,,,,
Molina Medicaid,DRG,2062,MALFUNCTIONREACTIONCOMPLICATION OF CARDIACVASC DEVICE OR PROCEDURE,,Relative Weights,"$4,064.41 ",IP,"4,064.41","4,064.41",,,,,,
Molina Medicaid,DRG,2063,"MALFUNCTION,REACTION,COMPLICATION OF CARDIAC/VASC DEVICE OR PROCEDURE",,Relative Weights,"$5,616.22 ",IP,"5,616.22","5,616.22",,,,,,
Molina Medicaid,DRG,2064,MALFUNCTIONREACTIONCOMPLICATION OF CARDIACVASC DEVICE OR PROCEDURE,,Relative Weights,"$11,629.68 ",IP,"11,629.68","11,629.68",,,,,,
Molina Medicaid,DRG,2071,OTHER CIRCULATORY SYSTEM DIAGNOSES,,Relative Weights,"$2,947.97 ",IP,"2,947.97","2,947.97",,,,,,
Molina Medicaid,DRG,2072,OTHER CIRCULATORY SYSTEM DIAGNOSES,,Relative Weights,"$3,511.17 ",IP,"3,511.17","3,511.17",,,,,,
Molina Medicaid,DRG,2073,OTHER CIRCULATORY SYSTEM DIAGNOSES,,Relative Weights,"$4,590.50 ",IP,"4,590.50","4,590.50",,,,,,
Molina Medicaid,DRG,2074,OTHER CIRCULATORY SYSTEM DIAGNOSES,,Relative Weights,"$8,837.72 ",IP,"8,837.72","8,837.72",,,,,,
Molina Medicaid,DRG,2201,MAJOR STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$7,004.47 ",IP,"7,004.47","7,004.47",,,,,,
Molina Medicaid,DRG,2202,MAJOR STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$10,124.94 ",IP,"10,124.94","10,124.94",,,,,,
Molina Medicaid,DRG,2203,MAJOR STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$15,446.33 ",IP,"15,446.33","15,446.33",,,,,,
Molina Medicaid,DRG,2204,MAJOR STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$29,728.80 ",IP,"29,728.80","29,728.80",,,,,,
Molina Medicaid,DRG,2221,OTHER STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$3,629.38 ",IP,"3,629.38","3,629.38",,,,,,
Molina Medicaid,DRG,2222,OTHER STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$5,962.94 ",IP,"5,962.94","5,962.94",,,,,,
Molina Medicaid,DRG,2223,OTHER STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$9,116.74 ",IP,"9,116.74","9,116.74",,,,,,
Molina Medicaid,DRG,2224,"OTHER STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES",,Relative Weights,"$19,946.46 ",IP,"19,946.46","19,946.46",,,,,,
Molina Medicaid,DRG,2231,OTHER SMALL & LARGE BOWEL PROCEDURES,,Relative Weights,"$5,180.51 ",IP,"5,180.51","5,180.51",,,,,,
Molina Medicaid,DRG,2232,OTHER SMALL and LARGE BOWEL PROCEDURES,,Relative Weights,"$7,107.90 ",IP,"7,107.90","7,107.90",,,,,,
Molina Medicaid,DRG,2233,OTHER SMALL and LARGE BOWEL PROCEDURES,,Relative Weights,"$10,759.27 ",IP,"10,759.27","10,759.27",,,,,,
Molina Medicaid,DRG,2234,OTHER SMALL and LARGE BOWEL PROCEDURES,,Relative Weights,"$20,449.53 ",IP,"20,449.53","20,449.53",,,,,,
Molina Medicaid,DRG,2241,PERITONEAL ADHESIOLYSIS,,Relative Weights,"$6,143.69 ",IP,"6,143.69","6,143.69",,,,,,
Molina Medicaid,DRG,2242,PERITONEAL ADHESIOLYSIS,,Relative Weights,"$7,746.36 ",IP,"7,746.36","7,746.36",,,,,,
Molina Medicaid,DRG,2243,PERITONEAL ADHESIOLYSIS,,Relative Weights,"$11,242.41 ",IP,"11,242.41","11,242.41",,,,,,
Molina Medicaid,DRG,2244,PERITONEAL ADHESIOLYSIS,,Relative Weights,"$20,422.04 ",IP,"20,422.04","20,422.04",,,,,,
Molina Medicaid,DRG,2261,ANAL PROCEDURES,,Relative Weights,"$4,263.71 ",IP,"4,263.71","4,263.71",,,,,,
Molina Medicaid,DRG,2262,ANAL PROCEDURES,,Relative Weights,"$5,861.92 ",IP,"5,861.92","5,861.92",,,,,,
Molina Medicaid,DRG,2263,ANAL PROCEDURES,,Relative Weights,"$7,950.47 ",IP,"7,950.47","7,950.47",,,,,,
Molina Medicaid,DRG,2264,ANAL PROCEDURES,,Relative Weights,"$17,017.73 ",IP,"17,017.73","17,017.73",,,,,,
Molina Medicaid,DRG,2271,HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL and UMBILICAL,,Relative Weights,"$5,689.07 ",IP,"5,689.07","5,689.07",,,,,,
Molina Medicaid,DRG,2272,HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL and UMBILICAL,,Relative Weights,"$6,795.89 ",IP,"6,795.89","6,795.89",,,,,,
Molina Medicaid,DRG,2273,"HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL & UMBILICAL",,Relative Weights,"$10,114.97 ",IP,"10,114.97","10,114.97",,,,,,
Molina Medicaid,DRG,2274,"HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL & UMBILICAL",,Relative Weights,"$20,038.21 ",IP,"20,038.21","20,038.21",,,,,,
Molina Medicaid,DRG,2281,INGUINAL FEMORAL and UMBILICAL HERNIA PROCEDURES,,Relative Weights,"$4,335.53 ",IP,"4,335.53","4,335.53",,,,,,
Molina Medicaid,DRG,2282,INGUINAL FEMORAL and UMBILICAL HERNIA PROCEDURES,,Relative Weights,"$5,502.48 ",IP,"5,502.48","5,502.48",,,,,,
Molina Medicaid,DRG,2283,INGUINAL FEMORAL and UMBILICAL HERNIA PROCEDURES,,Relative Weights,"$7,788.28 ",IP,"7,788.28","7,788.28",,,,,,
Molina Medicaid,DRG,2284,"INGUINAL, FEMORAL & UMBILICAL HERNIA PROCEDURES",,Relative Weights,"$16,501.95 ",IP,"16,501.95","16,501.95",,,,,,
Molina Medicaid,DRG,2291,OTHER DIGESTIVE SYSTEM & ABDOMINAL PROCEDURES,,Relative Weights,"$5,564.34 ",IP,"5,564.34","5,564.34",,,,,,
Molina Medicaid,DRG,2292,OTHER DIGESTIVE SYSTEM and ABDOMINAL PROCEDURES,,Relative Weights,"$7,117.87 ",IP,"7,117.87","7,117.87",,,,,,
Molina Medicaid,DRG,2293,OTHER DIGESTIVE SYSTEM and ABDOMINAL PROCEDURES,,Relative Weights,"$10,259.30 ",IP,"10,259.30","10,259.30",,,,,,
Molina Medicaid,DRG,2294,OTHER DIGESTIVE SYSTEM and ABDOMINAL PROCEDURES,,Relative Weights,"$20,018.28 ",IP,"20,018.28","20,018.28",,,,,,
Molina Medicaid,DRG,2301,MAJOR SMALL BOWEL PROCEDURES,,Relative Weights,"$6,770.12 ",IP,"6,770.12","6,770.12",,,,,,
Molina Medicaid,DRG,2302,MAJOR SMALL BOWEL PROCEDURES,,Relative Weights,"$8,787.20 ",IP,"8,787.20","8,787.20",,,,,,
Molina Medicaid,DRG,2303,MAJOR SMALL BOWEL PROCEDURES,,Relative Weights,"$13,506.56 ",IP,"13,506.56","13,506.56",,,,,,
Molina Medicaid,DRG,2304,MAJOR SMALL BOWEL PROCEDURES,,Relative Weights,"$27,168.10 ",IP,"27,168.10","27,168.10",,,,,,
Molina Medicaid,DRG,2311,MAJOR LARGE BOWEL PROCEDURES,,Relative Weights,"$6,900.01 ",IP,"6,900.01","6,900.01",,,,,,
Molina Medicaid,DRG,2312,MAJOR LARGE BOWEL PROCEDURES,,Relative Weights,"$8,451.83 ",IP,"8,451.83","8,451.83",,,,,,
Molina Medicaid,DRG,2313,MAJOR LARGE BOWEL PROCEDURES,,Relative Weights,"$12,656.43 ",IP,"12,656.43","12,656.43",,,,,,
Molina Medicaid,DRG,2314,MAJOR LARGE BOWEL PROCEDURES,,Relative Weights,"$23,212.62 ",IP,"23,212.62","23,212.62",,,,,,
Molina Medicaid,DRG,2321,GASTRIC FUNDOPLICATION,,Relative Weights,"$5,317.96 ",IP,"5,317.96","5,317.96",,,,,,
Molina Medicaid,DRG,2322,GASTRIC FUNDOPLICATION,,Relative Weights,"$6,619.27 ",IP,"6,619.27","6,619.27",,,,,,
Molina Medicaid,DRG,2323,GASTRIC FUNDOPLICATION,,Relative Weights,"$9,668.60 ",IP,"9,668.60","9,668.60",,,,,,
Molina Medicaid,DRG,2324,GASTRIC FUNDOPLICATION,,Relative Weights,"$26,510.06 ",IP,"26,510.06","26,510.06",,,,,,
Molina Medicaid,DRG,2331,APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$5,328.61 ",IP,"5,328.61","5,328.61",,,,,,
Molina Medicaid,DRG,2332,APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$6,525.46 ",IP,"6,525.46","6,525.46",,,,,,
Molina Medicaid,DRG,2333,APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$9,426.35 ",IP,"9,426.35","9,426.35",,,,,,
Molina Medicaid,DRG,2334,APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$16,969.28 ",IP,"16,969.28","16,969.28",,,,,,
Molina Medicaid,DRG,2341,APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$3,837.96 ",IP,"3,837.96","3,837.96",,,,,,
Molina Medicaid,DRG,2342,APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$4,853.72 ",IP,"4,853.72","4,853.72",,,,,,
Molina Medicaid,DRG,2343,APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$7,767.67 ",IP,"7,767.67","7,767.67",,,,,,
Molina Medicaid,DRG,2344,APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$15,153.91 ",IP,"15,153.91","15,153.91",,,,,,
Molina Medicaid,DRG,2401,DIGESTIVE MALIGNANCY,,Relative Weights,"$4,130.38 ",IP,"4,130.38","4,130.38",,,,,,
Molina Medicaid,DRG,2402,DIGESTIVE MALIGNANCY,,Relative Weights,"$4,471.61 ",IP,"4,471.61","4,471.61",,,,,,
Molina Medicaid,DRG,2403,DIGESTIVE MALIGNANCY,,Relative Weights,"$5,940.95 ",IP,"5,940.95","5,940.95",,,,,,
Molina Medicaid,DRG,2404,DIGESTIVE MALIGNANCY,,Relative Weights,"$10,480.94 ",IP,"10,480.94","10,480.94",,,,,,
Molina Medicaid,DRG,2411,PEPTIC ULCER & GASTRITIS,,Relative Weights,"$3,142.46 ",IP,"3,142.46","3,142.46",,,,,,
Molina Medicaid,DRG,2412,PEPTIC ULCER and GASTRITIS,,Relative Weights,"$3,833.49 ",IP,"3,833.49","3,833.49",,,,,,
Molina Medicaid,DRG,2413,PEPTIC ULCER and GASTRITIS,,Relative Weights,"$5,293.90 ",IP,"5,293.90","5,293.90",,,,,,
Molina Medicaid,DRG,2414,PEPTIC ULCER and GASTRITIS,,Relative Weights,"$11,497.38 ",IP,"11,497.38","11,497.38",,,,,,
Molina Medicaid,DRG,2421,MAJOR ESOPHAGEAL DISORDERS,,Relative Weights,"$2,834.23 ",IP,"2,834.23","2,834.23",,,,,,
Molina Medicaid,DRG,2422,MAJOR ESOPHAGEAL DISORDERS,,Relative Weights,"$3,630.75 ",IP,"3,630.75","3,630.75",,,,,,
Molina Medicaid,DRG,2423,MAJOR ESOPHAGEAL DISORDERS,,Relative Weights,"$5,095.29 ",IP,"5,095.29","5,095.29",,,,,,
Molina Medicaid,DRG,2424,MAJOR ESOPHAGEAL DISORDERS,,Relative Weights,"$11,235.54 ",IP,"11,235.54","11,235.54",,,,,,
Molina Medicaid,DRG,2431,OTHER ESOPHAGEAL DISORDERS,,Relative Weights,"$2,619.12 ",IP,"2,619.12","2,619.12",,,,,,
Molina Medicaid,DRG,2432,OTHER ESOPHAGEAL DISORDERS,,Relative Weights,"$3,394.34 ",IP,"3,394.34","3,394.34",,,,,,
Molina Medicaid,DRG,2433,OTHER ESOPHAGEAL DISORDERS,,Relative Weights,"$4,672.28 ",IP,"4,672.28","4,672.28",,,,,,
Molina Medicaid,DRG,2434,OTHER ESOPHAGEAL DISORDERS,,Relative Weights,"$10,028.72 ",IP,"10,028.72","10,028.72",,,,,,
Molina Medicaid,DRG,2441,DIVERTICULITIS and DIVERTICULOSIS,,Relative Weights,"$2,541.46 ",IP,"2,541.46","2,541.46",,,,,,
Molina Medicaid,DRG,2442,DIVERTICULITIS and DIVERTICULOSIS,,Relative Weights,"$3,268.57 ",IP,"3,268.57","3,268.57",,,,,,
Molina Medicaid,DRG,2443,DIVERTICULITIS & DIVERTICULOSIS,,Relative Weights,"$4,670.91 ",IP,"4,670.91","4,670.91",,,,,,
Molina Medicaid,DRG,2444,DIVERTICULITIS & DIVERTICULOSIS,,Relative Weights,"$10,075.80 ",IP,"10,075.80","10,075.80",,,,,,
Molina Medicaid,DRG,2451,INFLAMMATORY BOWEL DISEASE,,Relative Weights,"$3,109.82 ",IP,"3,109.82","3,109.82",,,,,,
Molina Medicaid,DRG,2452,INFLAMMATORY BOWEL DISEASE,,Relative Weights,"$3,884.35 ",IP,"3,884.35","3,884.35",,,,,,
Molina Medicaid,DRG,2453,INFLAMMATORY BOWEL DISEASE,,Relative Weights,"$5,370.53 ",IP,"5,370.53","5,370.53",,,,,,
Molina Medicaid,DRG,2454,INFLAMMATORY BOWEL DISEASE,,Relative Weights,"$12,127.25 ",IP,"12,127.25","12,127.25",,,,,,
Molina Medicaid,DRG,2461,GASTROINTESTINAL VASCULAR INSUFFICIENCY,,Relative Weights,"$3,009.82 ",IP,"3,009.82","3,009.82",,,,,,
Molina Medicaid,DRG,2462,GASTROINTESTINAL VASCULAR INSUFFICIENCY,,Relative Weights,"$3,644.84 ",IP,"3,644.84","3,644.84",,,,,,
Molina Medicaid,DRG,2463,GASTROINTESTINAL VASCULAR INSUFFICIENCY,,Relative Weights,"$5,068.14 ",IP,"5,068.14","5,068.14",,,,,,
Molina Medicaid,DRG,2464,GASTROINTESTINAL VASCULAR INSUFFICIENCY,,Relative Weights,"$9,550.40 ",IP,"9,550.40","9,550.40",,,,,,
Molina Medicaid,DRG,2471,INTESTINAL OBSTRUCTION,,Relative Weights,"$2,323.60 ",IP,"2,323.60","2,323.60",,,,,,
Molina Medicaid,DRG,2472,INTESTINAL OBSTRUCTION,,Relative Weights,"$2,999.17 ",IP,"2,999.17","2,999.17",,,,,,
Molina Medicaid,DRG,2473,INTESTINAL OBSTRUCTION,,Relative Weights,"$4,431.74 ",IP,"4,431.74","4,431.74",,,,,,
Molina Medicaid,DRG,2474,INTESTINAL OBSTRUCTION,,Relative Weights,"$9,108.15 ",IP,"9,108.15","9,108.15",,,,,,
Molina Medicaid,DRG,2481,MAJOR GASTROINTESTINAL and PERITONEAL INFECTIONS,,Relative Weights,"$2,573.42 ",IP,"2,573.42","2,573.42",,,,,,
Molina Medicaid,DRG,2482,MAJOR GASTROINTESTINAL and PERITONEAL INFECTIONS,,Relative Weights,"$3,590.89 ",IP,"3,590.89","3,590.89",,,,,,
Molina Medicaid,DRG,2483,MAJOR GASTROINTESTINAL & PERITONEAL INFECTIONS,,Relative Weights,"$4,839.63 ",IP,"4,839.63","4,839.63",,,,,,
Molina Medicaid,DRG,2484,MAJOR GASTROINTESTINAL and PERITONEAL INFECTIONS,,Relative Weights,"$10,133.19 ",IP,"10,133.19","10,133.19",,,,,,
Molina Medicaid,DRG,2491,OTHER GASTROENTERITIS NAUSEA and VOMITING,,Relative Weights,"$2,187.52 ",IP,"2,187.52","2,187.52",,,,,,
Molina Medicaid,DRG,2492,OTHER GASTROENTERITIS NAUSEA and VOMITING,,Relative Weights,"$2,797.80 ",IP,"2,797.80","2,797.80",,,,,,
Molina Medicaid,DRG,2493,"OTHER GASTROENTERITIS, NAUSEA & VOMITING",,Relative Weights,"$3,754.80 ",IP,"3,754.80","3,754.80",,,,,,
Molina Medicaid,DRG,2494,"OTHER GASTROENTERITIS, NAUSEA & VOMITING",,Relative Weights,"$8,298.22 ",IP,"8,298.22","8,298.22",,,,,,
Molina Medicaid,DRG,2511,ABDOMINAL PAIN,,Relative Weights,"$2,520.84 ",IP,"2,520.84","2,520.84",,,,,,
Molina Medicaid,DRG,2512,ABDOMINAL PAIN,,Relative Weights,"$3,175.79 ",IP,"3,175.79","3,175.79",,,,,,
Molina Medicaid,DRG,2513,ABDOMINAL PAIN,,Relative Weights,"$4,112.86 ",IP,"4,112.86","4,112.86",,,,,,
Molina Medicaid,DRG,2514,ABDOMINAL PAIN,,Relative Weights,"$7,334.01 ",IP,"7,334.01","7,334.01",,,,,,
Molina Medicaid,DRG,2521,MALFUNCTION REACTION and COMPLICATION OF GI DEVICE OR PROCEDURE,,Relative Weights,"$2,913.26 ",IP,"2,913.26","2,913.26",,,,,,
Molina Medicaid,DRG,2522,MALFUNCTION REACTION and COMPLICATION OF GI DEVICE OR PROCEDURE,,Relative Weights,"$3,639.34 ",IP,"3,639.34","3,639.34",,,,,,
Molina Medicaid,DRG,2523,MALFUNCTION REACTION and COMPLICATION OF GI DEVICE OR PROCEDURE,,Relative Weights,"$5,172.60 ",IP,"5,172.60","5,172.60",,,,,,
Molina Medicaid,DRG,2524,MALFUNCTION REACTION and COMPLICATION OF GI DEVICE OR PROCEDURE,,Relative Weights,"$11,168.53 ",IP,"11,168.53","11,168.53",,,,,,
Molina Medicaid,DRG,2531,OTHER and UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,,Relative Weights,"$2,890.24 ",IP,"2,890.24","2,890.24",,,,,,
Molina Medicaid,DRG,2532,OTHER and UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,,Relative Weights,"$3,602.23 ",IP,"3,602.23","3,602.23",,,,,,
Molina Medicaid,DRG,2533,OTHER and UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,,Relative Weights,"$5,054.39 ",IP,"5,054.39","5,054.39",,,,,,
Molina Medicaid,DRG,2534,OTHER and UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,,Relative Weights,"$9,586.48 ",IP,"9,586.48","9,586.48",,,,,,
Molina Medicaid,DRG,2541,OTHER DIGESTIVE SYSTEM DIAGNOSES,,Relative Weights,"$2,614.99 ",IP,"2,614.99","2,614.99",,,,,,
Molina Medicaid,DRG,2542,OTHER DIGESTIVE SYSTEM DIAGNOSES,,Relative Weights,"$3,386.43 ",IP,"3,386.43","3,386.43",,,,,,
Molina Medicaid,DRG,2543,OTHER DIGESTIVE SYSTEM DIAGNOSES,,Relative Weights,"$4,771.93 ",IP,"4,771.93","4,771.93",,,,,,
Molina Medicaid,DRG,2544,OTHER DIGESTIVE SYSTEM DIAGNOSES,,Relative Weights,"$9,778.91 ",IP,"9,778.91","9,778.91",,,,,,
Molina Medicaid,DRG,2601,MAJOR PANCREAS LIVER and SHUNT PROCEDURES,,Relative Weights,"$9,438.72 ",IP,"9,438.72","9,438.72",,,,,,
Molina Medicaid,DRG,2602,MAJOR PANCREAS LIVER and SHUNT PROCEDURES,,Relative Weights,"$11,500.13 ",IP,"11,500.13","11,500.13",,,,,,
Molina Medicaid,DRG,2603,MAJOR PANCREAS LIVER and SHUNT PROCEDURES,,Relative Weights,"$16,312.61 ",IP,"16,312.61","16,312.61",,,,,,
Molina Medicaid,DRG,2604,MAJOR PANCREAS LIVER and SHUNT PROCEDURES,,Relative Weights,"$34,324.11 ",IP,"34,324.11","34,324.11",,,,,,
Molina Medicaid,DRG,2611,MAJOR BILIARY TRACT PROCEDURES,,Relative Weights,"$6,801.05 ",IP,"6,801.05","6,801.05",,,,,,
Molina Medicaid,DRG,2612,MAJOR BILIARY TRACT PROCEDURES,,Relative Weights,"$10,119.10 ",IP,"10,119.10","10,119.10",,,,,,
Molina Medicaid,DRG,2613,MAJOR BILIARY TRACT PROCEDURES,,Relative Weights,"$14,491.05 ",IP,"14,491.05","14,491.05",,,,,,
Molina Medicaid,DRG,2614,MAJOR BILIARY TRACT PROCEDURES,,Relative Weights,"$28,576.97 ",IP,"28,576.97","28,576.97",,,,,,
Molina Medicaid,DRG,2631,CHOLECYSTECTOMY,,Relative Weights,"$5,153.36 ",IP,"5,153.36","5,153.36",,,,,,
Molina Medicaid,DRG,2632,CHOLECYSTECTOMY,,Relative Weights,"$6,574.60 ",IP,"6,574.60","6,574.60",,,,,,
Molina Medicaid,DRG,2633,CHOLECYSTECTOMY,,Relative Weights,"$8,823.28 ",IP,"8,823.28","8,823.28",,,,,,
Molina Medicaid,DRG,2634,CHOLECYSTECTOMY,,Relative Weights,"$16,983.37 ",IP,"16,983.37","16,983.37",,,,,,
Molina Medicaid,DRG,2641,OTHER HEPATOBILIARY PANCREAS and ABDOMINAL PROCEDURES,,Relative Weights,"$6,826.47 ",IP,"6,826.47","6,826.47",,,,,,
Molina Medicaid,DRG,2642,OTHER HEPATOBILIARY PANCREAS and ABDOMINAL PROCEDURES,,Relative Weights,"$7,584.86 ",IP,"7,584.86","7,584.86",,,,,,
Molina Medicaid,DRG,2643,"OTHER HEPATOBILIARY, PANCREAS & ABDOMINAL PROCEDURES",,Relative Weights,"$11,612.15 ",IP,"11,612.15","11,612.15",,,,,,
Molina Medicaid,DRG,2644,OTHER HEPATOBILIARY PANCREAS and ABDOMINAL PROCEDURES,,Relative Weights,"$29,218.86 ",IP,"29,218.86","29,218.86",,,,,,
Molina Medicaid,DRG,2791,HEPATIC COMA and OTHER MAJOR ACUTE LIVER DISORDERS,,Relative Weights,"$2,567.92 ",IP,"2,567.92","2,567.92",,,,,,
Molina Medicaid,DRG,2792,HEPATIC COMA and OTHER MAJOR ACUTE LIVER DISORDERS,,Relative Weights,"$3,323.89 ",IP,"3,323.89","3,323.89",,,,,,
Molina Medicaid,DRG,2793,HEPATIC COMA & OTHER MAJOR ACUTE LIVER DISORDERS,,Relative Weights,"$4,704.93 ",IP,"4,704.93","4,704.93",,,,,,
Molina Medicaid,DRG,2794,HEPATIC COMA and OTHER MAJOR ACUTE LIVER DISORDERS,,Relative Weights,"$11,290.86 ",IP,"11,290.86","11,290.86",,,,,,
Molina Medicaid,DRG,2801,ALCOHOLIC LIVER DISEASE,,Relative Weights,"$2,499.54 ",IP,"2,499.54","2,499.54",,,,,,
Molina Medicaid,DRG,2802,ALCOHOLIC LIVER DISEASE,,Relative Weights,"$3,093.32 ",IP,"3,093.32","3,093.32",,,,,,
Molina Medicaid,DRG,2803,ALCOHOLIC LIVER DISEASE,,Relative Weights,"$4,638.26 ",IP,"4,638.26","4,638.26",,,,,,
Molina Medicaid,DRG,2804,ALCOHOLIC LIVER DISEASE,,Relative Weights,"$10,324.24 ",IP,"10,324.24","10,324.24",,,,,,
Molina Medicaid,DRG,2811,MALIGNANCY OF HEPATOBILIARY SYSTEM & PANCREAS,,Relative Weights,"$3,619.41 ",IP,"3,619.41","3,619.41",,,,,,
Molina Medicaid,DRG,2812,MALIGNANCY OF HEPATOBILIARY SYSTEM and PANCREAS,,Relative Weights,"$4,564.04 ",IP,"4,564.04","4,564.04",,,,,,
Molina Medicaid,DRG,2813,MALIGNANCY OF HEPATOBILIARY SYSTEM and PANCREAS,,Relative Weights,"$5,844.73 ",IP,"5,844.73","5,844.73",,,,,,
Molina Medicaid,DRG,2814,MALIGNANCY OF HEPATOBILIARY SYSTEM and PANCREAS,,Relative Weights,"$9,186.50 ",IP,"9,186.50","9,186.50",,,,,,
Molina Medicaid,DRG,2821,DISORDERS OF PANCREAS EXCEPT MALIGNANCY,,Relative Weights,"$2,462.42 ",IP,"2,462.42","2,462.42",,,,,,
Molina Medicaid,DRG,2822,DISORDERS OF PANCREAS EXCEPT MALIGNANCY,,Relative Weights,"$3,135.24 ",IP,"3,135.24","3,135.24",,,,,,
Molina Medicaid,DRG,2823,DISORDERS OF PANCREAS EXCEPT MALIGNANCY,,Relative Weights,"$4,746.16 ",IP,"4,746.16","4,746.16",,,,,,
Molina Medicaid,DRG,2824,DISORDERS OF PANCREAS EXCEPT MALIGNANCY,,Relative Weights,"$12,503.18 ",IP,"12,503.18","12,503.18",,,,,,
Molina Medicaid,DRG,2831,OTHER DISORDERS OF THE LIVER,,Relative Weights,"$2,720.83 ",IP,"2,720.83","2,720.83",,,,,,
Molina Medicaid,DRG,2832,OTHER DISORDERS OF THE LIVER,,Relative Weights,"$3,349.67 ",IP,"3,349.67","3,349.67",,,,,,
Molina Medicaid,DRG,2833,OTHER DISORDERS OF THE LIVER,,Relative Weights,"$4,885.67 ",IP,"4,885.67","4,885.67",,,,,,
Molina Medicaid,DRG,2834,OTHER DISORDERS OF THE LIVER,,Relative Weights,"$10,248.65 ",IP,"10,248.65","10,248.65",,,,,,
Molina Medicaid,DRG,2841,DISORDERS OF GALLBLADDER and BILIARY TRACT,,Relative Weights,"$3,351.73 ",IP,"3,351.73","3,351.73",,,,,,
Molina Medicaid,DRG,2842,DISORDERS OF GALLBLADDER and BILIARY TRACT,,Relative Weights,"$4,147.57 ",IP,"4,147.57","4,147.57",,,,,,
Molina Medicaid,DRG,2843,DISORDERS OF GALLBLADDER and BILIARY TRACT,,Relative Weights,"$5,552.31 ",IP,"5,552.31","5,552.31",,,,,,
Molina Medicaid,DRG,2844,DISORDERS OF GALLBLADDER and BILIARY TRACT,,Relative Weights,"$10,788.48 ",IP,"10,788.48","10,788.48",,,,,,
Molina Medicaid,DRG,3011,HIP JOINT REPLACEMENT,,Relative Weights,"$7,771.10 ",IP,"7,771.10","7,771.10",,,,,,
Molina Medicaid,DRG,3012,HIP JOINT REPLACEMENT,,Relative Weights,"$8,122.29 ",IP,"8,122.29","8,122.29",,,,,,
Molina Medicaid,DRG,3013,HIP JOINT REPLACEMENT,,Relative Weights,"$10,480.59 ",IP,"10,480.59","10,480.59",,,,,,
Molina Medicaid,DRG,3014,HIP JOINT REPLACEMENT,,Relative Weights,"$16,617.41 ",IP,"16,617.41","16,617.41",,,,,,
Molina Medicaid,DRG,3021,KNEE JOINT REPLACEMENT,,Relative Weights,"$7,208.24 ",IP,"7,208.24","7,208.24",,,,,,
Molina Medicaid,DRG,3022,KNEE JOINT REPLACEMENT,,Relative Weights,"$7,702.03 ",IP,"7,702.03","7,702.03",,,,,,
Molina Medicaid,DRG,3023,KNEE JOINT REPLACEMENT,,Relative Weights,"$9,864.13 ",IP,"9,864.13","9,864.13",,,,,,
Molina Medicaid,DRG,3024,KNEE JOINT REPLACEMENT,,Relative Weights,"$17,075.12 ",IP,"17,075.12","17,075.12",,,,,,
Molina Medicaid,DRG,3031,DORSAL and LUMBAR FUSION PROC FOR CURVATURE OF BACK,,Relative Weights,"$22,622.27 ",IP,"22,622.27","22,622.27",,,,,,
Molina Medicaid,DRG,3032,DORSAL and LUMBAR FUSION PROC FOR CURVATURE OF BACK,,Relative Weights,"$26,401.82 ",IP,"26,401.82","26,401.82",,,,,,
Molina Medicaid,DRG,3033,DORSAL and LUMBAR FUSION PROC FOR CURVATURE OF BACK,,Relative Weights,"$36,462.15 ",IP,"36,462.15","36,462.15",,,,,,
Molina Medicaid,DRG,3034,DORSAL and LUMBAR FUSION PROC FOR CURVATURE OF BACK,,Relative Weights,"$46,680.22 ",IP,"46,680.22","46,680.22",,,,,,
Molina Medicaid,DRG,3041,DORSAL and LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK,,Relative Weights,"$13,662.91 ",IP,"13,662.91","13,662.91",,,,,,
Molina Medicaid,DRG,3042,DORSAL and LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK,,Relative Weights,"$15,568.66 ",IP,"15,568.66","15,568.66",,,,,,
Molina Medicaid,DRG,3043,DORSAL and LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK,,Relative Weights,"$23,409.86 ",IP,"23,409.86","23,409.86",,,,,,
Molina Medicaid,DRG,3044,DORSAL and LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK,,Relative Weights,"$37,522.24 ",IP,"37,522.24","37,522.24",,,,,,
Molina Medicaid,DRG,3051,AMPUTATION OF LOWER LIMB EXCEPT TOES,,Relative Weights,"$4,866.09 ",IP,"4,866.09","4,866.09",,,,,,
Molina Medicaid,DRG,3052,AMPUTATION OF LOWER LIMB EXCEPT TOES,,Relative Weights,"$6,637.82 ",IP,"6,637.82","6,637.82",,,,,,
Molina Medicaid,DRG,3053,AMPUTATION OF LOWER LIMB EXCEPT TOES,,Relative Weights,"$10,080.61 ",IP,"10,080.61","10,080.61",,,,,,
Molina Medicaid,DRG,3054,AMPUTATION OF LOWER LIMB EXCEPT TOES,,Relative Weights,"$19,786.33 ",IP,"19,786.33","19,786.33",,,,,,
Molina Medicaid,DRG,3081,HIP and FEMUR FRACTURE REPAIR,,Relative Weights,"$6,633.70 ",IP,"6,633.70","6,633.70",,,,,,
Molina Medicaid,DRG,3082,HIP and FEMUR FRACTURE REPAIR,,Relative Weights,"$7,529.88 ",IP,"7,529.88","7,529.88",,,,,,
Molina Medicaid,DRG,3083,HIP & FEMUR FRACTURE REPAIR,,Relative Weights,"$9,249.72 ",IP,"9,249.72","9,249.72",,,,,,
Molina Medicaid,DRG,3084,HIP and FEMUR FRACTURE REPAIR,,Relative Weights,"$14,744.30 ",IP,"14,744.30","14,744.30",,,,,,
Molina Medicaid,DRG,3091,OTHER SIGNIFICANT HIP and FEMUR SURGERY,,Relative Weights,"$7,238.83 ",IP,"7,238.83","7,238.83",,,,,,
Molina Medicaid,DRG,3092,OTHER SIGNIFICANT HIP and FEMUR SURGERY,,Relative Weights,"$9,130.83 ",IP,"9,130.83","9,130.83",,,,,,
Molina Medicaid,DRG,3093,OTHER SIGNIFICANT HIP & FEMUR SURGERY,,Relative Weights,"$12,063.33 ",IP,"12,063.33","12,063.33",,,,,,
Molina Medicaid,DRG,3094,OTHER SIGNIFICANT HIP & FEMUR SURGERY,,Relative Weights,"$21,019.95 ",IP,"21,019.95","21,019.95",,,,,,
Molina Medicaid,DRG,3101,INTERVERTEBRAL DISC EXCISION and DECOMPRESSION,,Relative Weights,"$5,634.78 ",IP,"5,634.78","5,634.78",,,,,,
Molina Medicaid,DRG,3102,INTERVERTEBRAL DISC EXCISION and DECOMPRESSION,,Relative Weights,"$6,775.27 ",IP,"6,775.27","6,775.27",,,,,,
Molina Medicaid,DRG,3103,INTERVERTEBRAL DISC EXCISION and DECOMPRESSION,,Relative Weights,"$9,328.07 ",IP,"9,328.07","9,328.07",,,,,,
Molina Medicaid,DRG,3104,INTERVERTEBRAL DISC EXCISION & DECOMPRESSION,,Relative Weights,"$18,301.18 ",IP,"18,301.18","18,301.18",,,,,,
Molina Medicaid,DRG,3121,SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$6,515.49 ",IP,"6,515.49","6,515.49",,,,,,
Molina Medicaid,DRG,3122,SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$8,587.21 ",IP,"8,587.21","8,587.21",,,,,,
Molina Medicaid,DRG,3123,SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$12,636.50 ",IP,"12,636.50","12,636.50",,,,,,
Molina Medicaid,DRG,3124,SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$31,602.60 ",IP,"31,602.60","31,602.60",,,,,,
Molina Medicaid,DRG,3131,KNEE & LOWER LEG PROCEDURES EXCEPT FOOT,,Relative Weights,"$5,906.59 ",IP,"5,906.59","5,906.59",,,,,,
Molina Medicaid,DRG,3132,KNEE and LOWER LEG PROCEDURES EXCEPT FOOT,,Relative Weights,"$7,791.03 ",IP,"7,791.03","7,791.03",,,,,,
Molina Medicaid,DRG,3133,KNEE and LOWER LEG PROCEDURES EXCEPT FOOT,,Relative Weights,"$10,674.40 ",IP,"10,674.40","10,674.40",,,,,,
Molina Medicaid,DRG,3134,KNEE and LOWER LEG PROCEDURES EXCEPT FOOT,,Relative Weights,"$18,704.94 ",IP,"18,704.94","18,704.94",,,,,,
Molina Medicaid,DRG,3141,FOOT & TOE PROCEDURES,,Relative Weights,"$5,184.29 ",IP,"5,184.29","5,184.29",,,,,,
Molina Medicaid,DRG,3142,FOOT and TOE PROCEDURES,,Relative Weights,"$5,760.89 ",IP,"5,760.89","5,760.89",,,,,,
Molina Medicaid,DRG,3143,FOOT and TOE PROCEDURES,,Relative Weights,"$7,587.61 ",IP,"7,587.61","7,587.61",,,,,,
Molina Medicaid,DRG,3144,FOOT and TOE PROCEDURES,,Relative Weights,"$15,541.86 ",IP,"15,541.86","15,541.86",,,,,,
Molina Medicaid,DRG,3151,SHOULDER UPPER ARM and FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT,,Relative Weights,"$4,407.35 ",IP,"4,407.35","4,407.35",,,,,,
Molina Medicaid,DRG,3152,SHOULDER UPPER ARM and FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT,,Relative Weights,"$7,204.46 ",IP,"7,204.46","7,204.46",,,,,,
Molina Medicaid,DRG,3153,SHOULDER UPPER ARM and FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT,,Relative Weights,"$9,814.99 ",IP,"9,814.99","9,814.99",,,,,,
Molina Medicaid,DRG,3154,SHOULDER UPPER ARM and FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT,,Relative Weights,"$17,630.42 ",IP,"17,630.42","17,630.42",,,,,,
Molina Medicaid,DRG,3161,HAND and WRIST PROCEDURES,,Relative Weights,"$4,228.66 ",IP,"4,228.66","4,228.66",,,,,,
Molina Medicaid,DRG,3162,HAND and WRIST PROCEDURES,,Relative Weights,"$5,513.82 ",IP,"5,513.82","5,513.82",,,,,,
Molina Medicaid,DRG,3163,HAND and WRIST PROCEDURES,,Relative Weights,"$8,327.78 ",IP,"8,327.78","8,327.78",,,,,,
Molina Medicaid,DRG,3164,HAND and WRIST PROCEDURES,,Relative Weights,"$17,742.44 ",IP,"17,742.44","17,742.44",,,,,,
Molina Medicaid,DRG,3171,TENDON MUSCLE and OTHER SOFT TISSUE PROCEDURES,,Relative Weights,"$4,914.20 ",IP,"4,914.20","4,914.20",,,,,,
Molina Medicaid,DRG,3172,TENDON MUSCLE and OTHER SOFT TISSUE PROCEDURES,,Relative Weights,"$6,410.69 ",IP,"6,410.69","6,410.69",,,,,,
Molina Medicaid,DRG,3173,TENDON MUSCLE and OTHER SOFT TISSUE PROCEDURES,,Relative Weights,"$9,611.56 ",IP,"9,611.56","9,611.56",,,,,,
Molina Medicaid,DRG,3174,TENDON MUSCLE and OTHER SOFT TISSUE PROCEDURES,,Relative Weights,"$20,290.08 ",IP,"20,290.08","20,290.08",,,,,,
Molina Medicaid,DRG,3201,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE PROCEDURES,,Relative Weights,"$5,415.55 ",IP,"5,415.55","5,415.55",,,,,,
Molina Medicaid,DRG,3202,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE PROCEDURES,,Relative Weights,"$6,995.19 ",IP,"6,995.19","6,995.19",,,,,,
Molina Medicaid,DRG,3203,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE PROCEDURES,,Relative Weights,"$10,390.22 ",IP,"10,390.22","10,390.22",,,,,,
Molina Medicaid,DRG,3204,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE PROCEDURES,,Relative Weights,"$19,965.01 ",IP,"19,965.01","19,965.01",,,,,,
Molina Medicaid,DRG,3211,CERVICAL SPINAL FUSION and OTHER BACKNECK PROC EXC DISC EXCISDECOMP,,Relative Weights,"$8,441.17 ",IP,"8,441.17","8,441.17",,,,,,
Molina Medicaid,DRG,3212,CERVICAL SPINAL FUSION and OTHER BACKNECK PROC EXC DISC EXCISDECOMP,,Relative Weights,"$10,023.57 ",IP,"10,023.57","10,023.57",,,,,,
Molina Medicaid,DRG,3213,CERVICAL SPINAL FUSION and OTHER BACKNECK PROC EXC DISC EXCISDECOMP,,Relative Weights,"$14,027.50 ",IP,"14,027.50","14,027.50",,,,,,
Molina Medicaid,DRG,3214,CERVICAL SPINAL FUSION and OTHER BACKNECK PROC EXC DISC EXCISDECOMP,,Relative Weights,"$25,569.90 ",IP,"25,569.90","25,569.90",,,,,,
Molina Medicaid,DRG,3221,SHOULDER and ELBOW JOINT REPLACEMENT,,Relative Weights,"$8,466.60 ",IP,"8,466.60","8,466.60",,,,,,
Molina Medicaid,DRG,3222,SHOULDER and ELBOW JOINT REPLACEMENT,,Relative Weights,"$8,949.40 ",IP,"8,949.40","8,949.40",,,,,,
Molina Medicaid,DRG,3223,SHOULDER and ELBOW JOINT REPLACEMENT,,Relative Weights,"$11,526.59 ",IP,"11,526.59","11,526.59",,,,,,
Molina Medicaid,DRG,3224,SHOULDER and ELBOW JOINT REPLACEMENT,,Relative Weights,"$17,494.69 ",IP,"17,494.69","17,494.69",,,,,,
Molina Medicaid,DRG,3401,FRACTURE OF FEMUR,,Relative Weights,"$2,284.43 ",IP,"2,284.43","2,284.43",,,,,,
Molina Medicaid,DRG,3402,FRACTURE OF FEMUR,,Relative Weights,"$2,649.70 ",IP,"2,649.70","2,649.70",,,,,,
Molina Medicaid,DRG,3403,FRACTURE OF FEMUR,,Relative Weights,"$3,664.08 ",IP,"3,664.08","3,664.08",,,,,,
Molina Medicaid,DRG,3404,FRACTURE OF FEMUR,,Relative Weights,"$6,893.48 ",IP,"6,893.48","6,893.48",,,,,,
Molina Medicaid,DRG,3411,FRACTURE OF PELVIS OR DISLOCATION OF HIP,,Relative Weights,"$2,584.41 ",IP,"2,584.41","2,584.41",,,,,,
Molina Medicaid,DRG,3412,FRACTURE OF PELVIS OR DISLOCATION OF HIP,,Relative Weights,"$2,958.62 ",IP,"2,958.62","2,958.62",,,,,,
Molina Medicaid,DRG,3413,FRACTURE OF PELVIS OR DISLOCATION OF HIP,,Relative Weights,"$3,751.71 ",IP,"3,751.71","3,751.71",,,,,,
Molina Medicaid,DRG,3414,FRACTURE OF PELVIS OR DISLOCATION OF HIP,,Relative Weights,"$8,259.05 ",IP,"8,259.05","8,259.05",,,,,,
Molina Medicaid,DRG,3421,FRACTURES and DISLOCATIONS EXCEPT FEMUR PELVIS and BACK,,Relative Weights,"$2,677.53 ",IP,"2,677.53","2,677.53",,,,,,
Molina Medicaid,DRG,3422,"FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK",,Relative Weights,"$3,262.04 ",IP,"3,262.04","3,262.04",,,,,,
Molina Medicaid,DRG,3423,"FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK",,Relative Weights,"$4,236.57 ",IP,"4,236.57","4,236.57",,,,,,
Molina Medicaid,DRG,3424,FRACTURES and DISLOCATIONS EXCEPT FEMUR PELVIS and BACK,,Relative Weights,"$8,410.59 ",IP,"8,410.59","8,410.59",,,,,,
Molina Medicaid,DRG,3431,MUSCULOSKELETAL MALIGNANCY and PATHOL FRACTURE DT MUSCSKEL MALIG,,Relative Weights,"$4,528.30 ",IP,"4,528.30","4,528.30",,,,,,
Molina Medicaid,DRG,3432,MUSCULOSKELETAL MALIGNANCY and PATHOL FRACTURE DT MUSCSKEL MALIG,,Relative Weights,"$4,916.60 ",IP,"4,916.60","4,916.60",,,,,,
Molina Medicaid,DRG,3433,MUSCULOSKELETAL MALIGNANCY & PATHOL FRACTURE D/T MUSCSKEL MALIG,,Relative Weights,"$6,907.57 ",IP,"6,907.57","6,907.57",,,,,,
Molina Medicaid,DRG,3434,MUSCULOSKELETAL MALIGNANCY and PATHOL FRACTURE DT MUSCSKEL MALIG,,Relative Weights,"$11,710.09 ",IP,"11,710.09","11,710.09",,,,,,
Molina Medicaid,DRG,3441,OSTEOMYELITIS SEPTIC ARTHRITIS and OTHER MUSCULOSKELETAL INFECTIONS,,Relative Weights,"$3,603.61 ",IP,"3,603.61","3,603.61",,,,,,
Molina Medicaid,DRG,3442,OSTEOMYELITIS SEPTIC ARTHRITIS and OTHER MUSCULOSKELETAL INFECTIONS,,Relative Weights,"$4,272.99 ",IP,"4,272.99","4,272.99",,,,,,
Molina Medicaid,DRG,3443,OSTEOMYELITIS SEPTIC ARTHRITIS and OTHER MUSCULOSKELETAL INFECTIONS,,Relative Weights,"$5,859.85 ",IP,"5,859.85","5,859.85",,,,,,
Molina Medicaid,DRG,3444,OSTEOMYELITIS SEPTIC ARTHRITIS and OTHER MUSCULOSKELETAL INFECTIONS,,Relative Weights,"$10,885.73 ",IP,"10,885.73","10,885.73",,,,,,
Molina Medicaid,DRG,3461,CONNECTIVE TISSUE DISORDERS,,Relative Weights,"$3,601.54 ",IP,"3,601.54","3,601.54",,,,,,
Molina Medicaid,DRG,3462,CONNECTIVE TISSUE DISORDERS,,Relative Weights,"$4,539.99 ",IP,"4,539.99","4,539.99",,,,,,
Molina Medicaid,DRG,3463,CONNECTIVE TISSUE DISORDERS,,Relative Weights,"$6,445.74 ",IP,"6,445.74","6,445.74",,,,,,
Molina Medicaid,DRG,3464,CONNECTIVE TISSUE DISORDERS,,Relative Weights,"$15,116.11 ",IP,"15,116.11","15,116.11",,,,,,
Molina Medicaid,DRG,3471,OTHER BACK and NECK DISORDERS FRACTURES and INJURIES,,Relative Weights,"$3,279.91 ",IP,"3,279.91","3,279.91",,,,,,
Molina Medicaid,DRG,3472,"OTHER BACK & NECK DISORDERS, FRACTURES & INJURIES",,Relative Weights,"$3,772.33 ",IP,"3,772.33","3,772.33",,,,,,
Molina Medicaid,DRG,3473,OTHER BACK and NECK DISORDERS FRACTURES and INJURIES,,Relative Weights,"$4,894.95 ",IP,"4,894.95","4,894.95",,,,,,
Molina Medicaid,DRG,3474,OTHER BACK and NECK DISORDERS FRACTURES and INJURIES,,Relative Weights,"$9,864.13 ",IP,"9,864.13","9,864.13",,,,,,
Molina Medicaid,DRG,3491,MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE,,Relative Weights,"$2,603.31 ",IP,"2,603.31","2,603.31",,,,,,
Molina Medicaid,DRG,3492,MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE,,Relative Weights,"$3,535.91 ",IP,"3,535.91","3,535.91",,,,,,
Molina Medicaid,DRG,3493,MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE,,Relative Weights,"$5,006.97 ",IP,"5,006.97","5,006.97",,,,,,
Molina Medicaid,DRG,3494,MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE,,Relative Weights,"$9,666.89 ",IP,"9,666.89","9,666.89",,,,,,
Molina Medicaid,DRG,3511,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$2,708.80 ",IP,"2,708.80","2,708.80",,,,,,
Molina Medicaid,DRG,3512,OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$3,066.17 ",IP,"3,066.17","3,066.17",,,,,,
Molina Medicaid,DRG,3513,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$4,449.61 ",IP,"4,449.61","4,449.61",,,,,,
Molina Medicaid,DRG,3514,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$8,785.14 ",IP,"8,785.14","8,785.14",,,,,,
Molina Medicaid,DRG,3611,SKIN GRAFT FOR SKIN and SUBCUTANEOUS TISSUE DIAGNOSES,,Relative Weights,"$5,861.92 ",IP,"5,861.92","5,861.92",,,,,,
Molina Medicaid,DRG,3612,SKIN GRAFT FOR SKIN and SUBCUTANEOUS TISSUE DIAGNOSES,,Relative Weights,"$6,759.47 ",IP,"6,759.47","6,759.47",,,,,,
Molina Medicaid,DRG,3613,SKIN GRAFT FOR SKIN and SUBCUTANEOUS TISSUE DIAGNOSES,,Relative Weights,"$10,411.18 ",IP,"10,411.18","10,411.18",,,,,,
Molina Medicaid,DRG,3614,SKIN GRAFT FOR SKIN & SUBCUTANEOUS TISSUE DIAGNOSES,,Relative Weights,"$23,051.12 ",IP,"23,051.12","23,051.12",,,,,,
Molina Medicaid,DRG,3621,MASTECTOMY PROCEDURES,,Relative Weights,"$5,733.06 ",IP,"5,733.06","5,733.06",,,,,,
Molina Medicaid,DRG,3622,MASTECTOMY PROCEDURES,,Relative Weights,"$6,783.86 ",IP,"6,783.86","6,783.86",,,,,,
Molina Medicaid,DRG,3623,MASTECTOMY PROCEDURES,,Relative Weights,"$8,730.85 ",IP,"8,730.85","8,730.85",,,,,,
Molina Medicaid,DRG,3624,MASTECTOMY PROCEDURES,,Relative Weights,"$15,662.13 ",IP,"15,662.13","15,662.13",,,,,,
Molina Medicaid,DRG,3631,BREAST PROCEDURES EXCEPT MASTECTOMY,,Relative Weights,"$5,772.23 ",IP,"5,772.23","5,772.23",,,,,,
Molina Medicaid,DRG,3632,BREAST PROCEDURES EXCEPT MASTECTOMY,,Relative Weights,"$7,919.20 ",IP,"7,919.20","7,919.20",,,,,,
Molina Medicaid,DRG,3633,BREAST PROCEDURES EXCEPT MASTECTOMY,,Relative Weights,"$10,641.07 ",IP,"10,641.07","10,641.07",,,,,,
Molina Medicaid,DRG,3634,BREAST PROCEDURES EXCEPT MASTECTOMY,,Relative Weights,"$13,007.96 ",IP,"13,007.96","13,007.96",,,,,,
Molina Medicaid,DRG,3641,OTHER SKIN SUBCUTANEOUS TISSUE and RELATED PROCEDURES,,Relative Weights,"$3,659.27 ",IP,"3,659.27","3,659.27",,,,,,
Molina Medicaid,DRG,3642,"OTHER SKIN, SUBCUTANEOUS TISSUE & RELATED PROCEDURES",,Relative Weights,"$5,232.39 ",IP,"5,232.39","5,232.39",,,,,,
Molina Medicaid,DRG,3643,OTHER SKIN SUBCUTANEOUS TISSUE and RELATED PROCEDURES,,Relative Weights,"$8,152.18 ",IP,"8,152.18","8,152.18",,,,,,
Molina Medicaid,DRG,3644,OTHER SKIN SUBCUTANEOUS TISSUE and RELATED PROCEDURES,,Relative Weights,"$16,685.79 ",IP,"16,685.79","16,685.79",,,,,,
Molina Medicaid,DRG,3801,SKIN ULCERS,,Relative Weights,"$2,950.72 ",IP,"2,950.72","2,950.72",,,,,,
Molina Medicaid,DRG,3802,SKIN ULCERS,,Relative Weights,"$3,415.64 ",IP,"3,415.64","3,415.64",,,,,,
Molina Medicaid,DRG,3803,SKIN ULCERS,,Relative Weights,"$4,667.13 ",IP,"4,667.13","4,667.13",,,,,,
Molina Medicaid,DRG,3804,SKIN ULCERS,,Relative Weights,"$9,197.15 ",IP,"9,197.15","9,197.15",,,,,,
Molina Medicaid,DRG,3811,MAJOR SKIN DISORDERS,,Relative Weights,"$2,135.64 ",IP,"2,135.64","2,135.64",,,,,,
Molina Medicaid,DRG,3812,MAJOR SKIN DISORDERS,,Relative Weights,"$3,426.98 ",IP,"3,426.98","3,426.98",,,,,,
Molina Medicaid,DRG,3813,MAJOR SKIN DISORDERS,,Relative Weights,"$6,058.47 ",IP,"6,058.47","6,058.47",,,,,,
Molina Medicaid,DRG,3814,MAJOR SKIN DISORDERS,,Relative Weights,"$15,997.51 ",IP,"15,997.51","15,997.51",,,,,,
Molina Medicaid,DRG,3821,MALIGNANT BREAST DISORDERS,,Relative Weights,"$3,708.41 ",IP,"3,708.41","3,708.41",,,,,,
Molina Medicaid,DRG,3822,MALIGNANT BREAST DISORDERS,,Relative Weights,"$3,837.96 ",IP,"3,837.96","3,837.96",,,,,,
Molina Medicaid,DRG,3823,MALIGNANT BREAST DISORDERS,,Relative Weights,"$5,221.05 ",IP,"5,221.05","5,221.05",,,,,,
Molina Medicaid,DRG,3824,MALIGNANT BREAST DISORDERS,,Relative Weights,"$8,582.75 ",IP,"8,582.75","8,582.75",,,,,,
Molina Medicaid,DRG,3831,CELLULITIS & OTHER SKIN INFECTIONS,,Relative Weights,"$2,128.08 ",IP,"2,128.08","2,128.08",,,,,,
Molina Medicaid,DRG,3832,CELLULITIS and OTHER SKIN INFECTIONS,,Relative Weights,"$2,886.11 ",IP,"2,886.11","2,886.11",,,,,,
Molina Medicaid,DRG,3833,CELLULITIS and OTHER SKIN INFECTIONS,,Relative Weights,"$4,151.00 ",IP,"4,151.00","4,151.00",,,,,,
Molina Medicaid,DRG,3834,CELLULITIS and OTHER SKIN INFECTIONS,,Relative Weights,"$8,552.16 ",IP,"8,552.16","8,552.16",,,,,,
Molina Medicaid,DRG,3841,CONTUSION OPEN WOUND and OTHER TRAUMA TO SKIN and SUBCUTANEOUS TISSUE,,Relative Weights,"$2,690.94 ",IP,"2,690.94","2,690.94",,,,,,
Molina Medicaid,DRG,3842,CONTUSION OPEN WOUND and OTHER TRAUMA TO SKIN and SUBCUTANEOUS TISSUE,,Relative Weights,"$3,464.09 ",IP,"3,464.09","3,464.09",,,,,,
Molina Medicaid,DRG,3843,CONTUSION OPEN WOUND and OTHER TRAUMA TO SKIN and SUBCUTANEOUS TISSUE,,Relative Weights,"$4,737.92 ",IP,"4,737.92","4,737.92",,,,,,
Molina Medicaid,DRG,3844,CONTUSION OPEN WOUND and OTHER TRAUMA TO SKIN and SUBCUTANEOUS TISSUE,,Relative Weights,"$9,439.41 ",IP,"9,439.41","9,439.41",,,,,,
Molina Medicaid,DRG,3851,OTHER SKIN SUBCUTANEOUS TISSUE and BREAST DISORDERS,,Relative Weights,"$2,189.24 ",IP,"2,189.24","2,189.24",,,,,,
Molina Medicaid,DRG,3852,OTHER SKIN SUBCUTANEOUS TISSUE and BREAST DISORDERS,,Relative Weights,"$2,880.96 ",IP,"2,880.96","2,880.96",,,,,,
Molina Medicaid,DRG,3853,"OTHER SKIN, SUBCUTANEOUS TISSUE & BREAST DISORDERS",,Relative Weights,"$4,186.05 ",IP,"4,186.05","4,186.05",,,,,,
Molina Medicaid,DRG,3854,OTHER SKIN SUBCUTANEOUS TISSUE and BREAST DISORDERS,,Relative Weights,"$8,871.05 ",IP,"8,871.05","8,871.05",,,,,,
Molina Medicaid,DRG,4011,ADRENAL PROCEDURES,,Relative Weights,"$6,855.68 ",IP,"6,855.68","6,855.68",,,,,,
Molina Medicaid,DRG,4012,ADRENAL PROCEDURES,,Relative Weights,"$10,778.52 ",IP,"10,778.52","10,778.52",,,,,,
Molina Medicaid,DRG,4013,ADRENAL PROCEDURES,,Relative Weights,"$13,300.04 ",IP,"13,300.04","13,300.04",,,,,,
Molina Medicaid,DRG,4014,ADRENAL PROCEDURES,,Relative Weights,"$24,027.70 ",IP,"24,027.70","24,027.70",,,,,,
Molina Medicaid,DRG,4031,PROCEDURES FOR OBESITY,,Relative Weights,"$5,110.06 ",IP,"5,110.06","5,110.06",,,,,,
Molina Medicaid,DRG,4032,PROCEDURES FOR OBESITY,,Relative Weights,"$6,108.30 ",IP,"6,108.30","6,108.30",,,,,,
Molina Medicaid,DRG,4033,PROCEDURES FOR OBESITY,,Relative Weights,"$9,074.13 ",IP,"9,074.13","9,074.13",,,,,,
Molina Medicaid,DRG,4034,PROCEDURES FOR OBESITY,,Relative Weights,"$26,392.19 ",IP,"26,392.19","26,392.19",,,,,,
Molina Medicaid,DRG,4041,"THYROID, PARATHYROID & THYROGLOSSAL PROCEDURES",,Relative Weights,"$4,728.64 ",IP,"4,728.64","4,728.64",,,,,,
Molina Medicaid,DRG,4042,THYROID PARATHYROID and THYROGLOSSAL PROCEDURES,,Relative Weights,"$6,537.48 ",IP,"6,537.48","6,537.48",,,,,,
Molina Medicaid,DRG,4043,THYROID PARATHYROID and THYROGLOSSAL PROCEDURES,,Relative Weights,"$10,989.85 ",IP,"10,989.85","10,989.85",,,,,,
Molina Medicaid,DRG,4044,THYROID PARATHYROID and THYROGLOSSAL PROCEDURES,,Relative Weights,"$24,206.39 ",IP,"24,206.39","24,206.39",,,,,,
Molina Medicaid,DRG,4051,OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL and METABOLIC DISORDERS,,Relative Weights,"$7,505.82 ",IP,"7,505.82","7,505.82",,,,,,
Molina Medicaid,DRG,4052,OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL and METABOLIC DISORDERS,,Relative Weights,"$8,475.19 ",IP,"8,475.19","8,475.19",,,,,,
Molina Medicaid,DRG,4053,OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL and METABOLIC DISORDERS,,Relative Weights,"$12,612.79 ",IP,"12,612.79","12,612.79",,,,,,
Molina Medicaid,DRG,4054,OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL and METABOLIC DISORDERS,,Relative Weights,"$26,164.03 ",IP,"26,164.03","26,164.03",,,,,,
Molina Medicaid,DRG,4201,DIABETES,,Relative Weights,"$2,259.68 ",IP,"2,259.68","2,259.68",,,,,,
Molina Medicaid,DRG,4202,DIABETES,,Relative Weights,"$2,723.24 ",IP,"2,723.24","2,723.24",,,,,,
Molina Medicaid,DRG,4203,DIABETES,,Relative Weights,"$3,776.79 ",IP,"3,776.79","3,776.79",,,,,,
Molina Medicaid,DRG,4204,DIABETES,,Relative Weights,"$8,028.82 ",IP,"8,028.82","8,028.82",,,,,,
Molina Medicaid,DRG,4211,MALNUTRITION FAILURE TO THRIVE and OTHER NUTRITIONAL DISORDERS,,Relative Weights,"$2,343.53 ",IP,"2,343.53","2,343.53",,,,,,
Molina Medicaid,DRG,4212,MALNUTRITION FAILURE TO THRIVE and OTHER NUTRITIONAL DISORDERS,,Relative Weights,"$3,329.74 ",IP,"3,329.74","3,329.74",,,,,,
Molina Medicaid,DRG,4213,"MALNUTRITION, FAILURE TO THRIVE & OTHER NUTRITIONAL DISORDERS",,Relative Weights,"$5,181.88 ",IP,"5,181.88","5,181.88",,,,,,
Molina Medicaid,DRG,4214,MALNUTRITION FAILURE TO THRIVE and OTHER NUTRITIONAL DISORDERS,,Relative Weights,"$10,295.72 ",IP,"10,295.72","10,295.72",,,,,,
Molina Medicaid,DRG,4221,HYPOVOLEMIA and RELATED ELECTROLYTE DISORDERS,,Relative Weights,"$1,870.01 ",IP,"1,870.01","1,870.01",,,,,,
Molina Medicaid,DRG,4222,HYPOVOLEMIA and RELATED ELECTROLYTE DISORDERS,,Relative Weights,"$2,609.84 ",IP,"2,609.84","2,609.84",,,,,,
Molina Medicaid,DRG,4223,HYPOVOLEMIA and RELATED ELECTROLYTE DISORDERS,,Relative Weights,"$3,459.28 ",IP,"3,459.28","3,459.28",,,,,,
Molina Medicaid,DRG,4224,HYPOVOLEMIA and RELATED ELECTROLYTE DISORDERS,,Relative Weights,"$7,038.84 ",IP,"7,038.84","7,038.84",,,,,,
Molina Medicaid,DRG,4231,INBORN ERRORS OF METABOLISM,,Relative Weights,"$5,529.29 ",IP,"5,529.29","5,529.29",,,,,,
Molina Medicaid,DRG,4232,INBORN ERRORS OF METABOLISM,,Relative Weights,"$5,948.85 ",IP,"5,948.85","5,948.85",,,,,,
Molina Medicaid,DRG,4233,INBORN ERRORS OF METABOLISM,,Relative Weights,"$8,447.01 ",IP,"8,447.01","8,447.01",,,,,,
Molina Medicaid,DRG,4234,INBORN ERRORS OF METABOLISM,,Relative Weights,"$27,194.91 ",IP,"27,194.91","27,194.91",,,,,,
Molina Medicaid,DRG,4241,OTHER ENDOCRINE DISORDERS,,Relative Weights,"$2,869.62 ",IP,"2,869.62","2,869.62",,,,,,
Molina Medicaid,DRG,4242,OTHER ENDOCRINE DISORDERS,,Relative Weights,"$3,662.02 ",IP,"3,662.02","3,662.02",,,,,,
Molina Medicaid,DRG,4243,OTHER ENDOCRINE DISORDERS,,Relative Weights,"$5,028.28 ",IP,"5,028.28","5,028.28",,,,,,
Molina Medicaid,DRG,4244,OTHER ENDOCRINE DISORDERS,,Relative Weights,"$10,807.73 ",IP,"10,807.73","10,807.73",,,,,,
Molina Medicaid,DRG,4251,OTHER NONHYPOVOLEMIC ELECTROLYTE DISORDERS,,Relative Weights,"$2,221.89 ",IP,"2,221.89","2,221.89",,,,,,
Molina Medicaid,DRG,4252,OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS,,Relative Weights,"$2,908.79 ",IP,"2,908.79","2,908.79",,,,,,
Molina Medicaid,DRG,4253,OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS,,Relative Weights,"$3,943.11 ",IP,"3,943.11","3,943.11",,,,,,
Molina Medicaid,DRG,4254,OTHER NONHYPOVOLEMIC ELECTROLYTE DISORDERS,,Relative Weights,"$7,662.17 ",IP,"7,662.17","7,662.17",,,,,,
Molina Medicaid,DRG,4261,NONHYPOVOLEMIC SODIUM DISORDERS,,Relative Weights,"$2,409.16 ",IP,"2,409.16","2,409.16",,,,,,
Molina Medicaid,DRG,4262,NONHYPOVOLEMIC SODIUM DISORDERS,,Relative Weights,"$2,941.78 ",IP,"2,941.78","2,941.78",,,,,,
Molina Medicaid,DRG,4263,NON-HYPOVOLEMIC SODIUM DISORDERS,,Relative Weights,"$4,191.21 ",IP,"4,191.21","4,191.21",,,,,,
Molina Medicaid,DRG,4264,NONHYPOVOLEMIC SODIUM DISORDERS,,Relative Weights,"$8,224.69 ",IP,"8,224.69","8,224.69",,,,,,
Molina Medicaid,DRG,4271,THYROID DISORDERS,,Relative Weights,"$2,411.91 ",IP,"2,411.91","2,411.91",,,,,,
Molina Medicaid,DRG,4272,THYROID DISORDERS,,Relative Weights,"$3,208.44 ",IP,"3,208.44","3,208.44",,,,,,
Molina Medicaid,DRG,4273,THYROID DISORDERS,,Relative Weights,"$4,621.77 ",IP,"4,621.77","4,621.77",,,,,,
Molina Medicaid,DRG,4274,THYROID DISORDERS,,Relative Weights,"$9,834.92 ",IP,"9,834.92","9,834.92",,,,,,
Molina Medicaid,DRG,4401,KIDNEY TRANSPLANT,,Relative Weights,"$26,376.39 ",IP,"26,376.39","26,376.39",,,,,,
Molina Medicaid,DRG,4402,KIDNEY TRANSPLANT,,Relative Weights,"$28,441.58 ",IP,"28,441.58","28,441.58",,,,,,
Molina Medicaid,DRG,4403,KIDNEY TRANSPLANT,,Relative Weights,"$31,863.75 ",IP,"31,863.75","31,863.75",,,,,,
Molina Medicaid,DRG,4404,KIDNEY TRANSPLANT,,Relative Weights,"$48,433.40 ",IP,"48,433.40","48,433.40",,,,,,
Molina Medicaid,DRG,4411,MAJOR BLADDER PROCEDURES,,Relative Weights,"$7,124.74 ",IP,"7,124.74","7,124.74",,,,,,
Molina Medicaid,DRG,4412,MAJOR BLADDER PROCEDURES,,Relative Weights,"$11,337.94 ",IP,"11,337.94","11,337.94",,,,,,
Molina Medicaid,DRG,4413,MAJOR BLADDER PROCEDURES,,Relative Weights,"$14,853.23 ",IP,"14,853.23","14,853.23",,,,,,
Molina Medicaid,DRG,4414,MAJOR BLADDER PROCEDURES,,Relative Weights,"$32,299.47 ",IP,"32,299.47","32,299.47",,,,,,
Molina Medicaid,DRG,4421,KIDNEY and URINARY TRACT PROCEDURES FOR MALIGNANCY,,Relative Weights,"$7,007.22 ",IP,"7,007.22","7,007.22",,,,,,
Molina Medicaid,DRG,4422,KIDNEY and URINARY TRACT PROCEDURES FOR MALIGNANCY,,Relative Weights,"$7,784.16 ",IP,"7,784.16","7,784.16",,,,,,
Molina Medicaid,DRG,4423,KIDNEY & URINARY TRACT PROCEDURES FOR MALIGNANCY,,Relative Weights,"$11,551.33 ",IP,"11,551.33","11,551.33",,,,,,
Molina Medicaid,DRG,4424,KIDNEY and URINARY TRACT PROCEDURES FOR MALIGNANCY,,Relative Weights,"$20,973.56 ",IP,"20,973.56","20,973.56",,,,,,
Molina Medicaid,DRG,4431,KIDNEY and URINARY TRACT PROCEDURES FOR NONMALIGNANCY,,Relative Weights,"$5,745.77 ",IP,"5,745.77","5,745.77",,,,,,
Molina Medicaid,DRG,4432,KIDNEY and URINARY TRACT PROCEDURES FOR NONMALIGNANCY,,Relative Weights,"$6,928.19 ",IP,"6,928.19","6,928.19",,,,,,
Molina Medicaid,DRG,4433,KIDNEY & URINARY TRACT PROCEDURES FOR NONMALIGNANCY,,Relative Weights,"$10,300.53 ",IP,"10,300.53","10,300.53",,,,,,
Molina Medicaid,DRG,4434,KIDNEY & URINARY TRACT PROCEDURES FOR NONMALIGNANCY,,Relative Weights,"$21,259.80 ",IP,"21,259.80","21,259.80",,,,,,
Molina Medicaid,DRG,4441,RENAL DIALYSIS ACCESS DEVICE AND VESSEL REPAIR,,Relative Weights,"$6,643.67 ",IP,"6,643.67","6,643.67",,,,,,
Molina Medicaid,DRG,4442,RENAL DIALYSIS ACCESS DEVICE AND VESSEL REPAIR,,Relative Weights,"$8,351.49 ",IP,"8,351.49","8,351.49",,,,,,
Molina Medicaid,DRG,4443,RENAL DIALYSIS ACCESS DEVICE AND VESSEL REPAIR,,Relative Weights,"$12,840.62 ",IP,"12,840.62","12,840.62",,,,,,
Molina Medicaid,DRG,4444,RENAL DIALYSIS ACCESS DEVICE AND VESSEL REPAIR,,Relative Weights,"$25,251.70 ",IP,"25,251.70","25,251.70",,,,,,
Molina Medicaid,DRG,4451,OTHER BLADDER PROCEDURES,,Relative Weights,"$4,867.46 ",IP,"4,867.46","4,867.46",,,,,,
Molina Medicaid,DRG,4452,OTHER BLADDER PROCEDURES,,Relative Weights,"$6,607.93 ",IP,"6,607.93","6,607.93",,,,,,
Molina Medicaid,DRG,4453,OTHER BLADDER PROCEDURES,,Relative Weights,"$8,634.63 ",IP,"8,634.63","8,634.63",,,,,,
Molina Medicaid,DRG,4454,OTHER BLADDER PROCEDURES,,Relative Weights,"$17,913.22 ",IP,"17,913.22","17,913.22",,,,,,
Molina Medicaid,DRG,4461,URETHRAL & TRANSURETHRAL PROCEDURES,,Relative Weights,"$4,096.37 ",IP,"4,096.37","4,096.37",,,,,,
Molina Medicaid,DRG,4462,URETHRAL & TRANSURETHRAL PROCEDURES,,Relative Weights,"$5,093.91 ",IP,"5,093.91","5,093.91",,,,,,
Molina Medicaid,DRG,4463,URETHRAL and TRANSURETHRAL PROCEDURES,,Relative Weights,"$7,454.97 ",IP,"7,454.97","7,454.97",,,,,,
Molina Medicaid,DRG,4464,URETHRAL and TRANSURETHRAL PROCEDURES,,Relative Weights,"$15,279.67 ",IP,"15,279.67","15,279.67",,,,,,
Molina Medicaid,DRG,4471,OTHER KIDNEY URINARY TRACT and RELATED PROCEDURES,,Relative Weights,"$6,383.54 ",IP,"6,383.54","6,383.54",,,,,,
Molina Medicaid,DRG,4472,"OTHER KIDNEY, URINARY TRACT & RELATED PROCEDURES",,Relative Weights,"$7,988.27 ",IP,"7,988.27","7,988.27",,,,,,
Molina Medicaid,DRG,4473,OTHER KIDNEY URINARY TRACT and RELATED PROCEDURES,,Relative Weights,"$11,578.48 ",IP,"11,578.48","11,578.48",,,,,,
Molina Medicaid,DRG,4474,OTHER KIDNEY URINARY TRACT and RELATED PROCEDURES,,Relative Weights,"$26,335.15 ",IP,"26,335.15","26,335.15",,,,,,
Molina Medicaid,DRG,4611,KIDNEY and URINARY TRACT MALIGNANCY,,Relative Weights,"$4,213.89 ",IP,"4,213.89","4,213.89",,,,,,
Molina Medicaid,DRG,4612,KIDNEY and URINARY TRACT MALIGNANCY,,Relative Weights,"$4,354.09 ",IP,"4,354.09","4,354.09",,,,,,
Molina Medicaid,DRG,4613,KIDNEY and URINARY TRACT MALIGNANCY,,Relative Weights,"$5,833.40 ",IP,"5,833.40","5,833.40",,,,,,
Molina Medicaid,DRG,4614,KIDNEY & URINARY TRACT MALIGNANCY,,Relative Weights,"$10,495.71 ",IP,"10,495.71","10,495.71",,,,,,
Molina Medicaid,DRG,4621,NEPHRITIS and NEPHROSIS,,Relative Weights,"$2,361.40 ",IP,"2,361.40","2,361.40",,,,,,
Molina Medicaid,DRG,4622,NEPHRITIS and NEPHROSIS,,Relative Weights,"$3,007.07 ",IP,"3,007.07","3,007.07",,,,,,
Molina Medicaid,DRG,4623,NEPHRITIS and NEPHROSIS,,Relative Weights,"$5,343.04 ",IP,"5,343.04","5,343.04",,,,,,
Molina Medicaid,DRG,4624,NEPHRITIS and NEPHROSIS,,Relative Weights,"$14,645.34 ",IP,"14,645.34","14,645.34",,,,,,
Molina Medicaid,DRG,4631,KIDNEY and URINARY TRACT INFECTIONS,,Relative Weights,"$2,386.48 ",IP,"2,386.48","2,386.48",,,,,,
Molina Medicaid,DRG,4632,KIDNEY and URINARY TRACT INFECTIONS,,Relative Weights,"$2,925.29 ",IP,"2,925.29","2,925.29",,,,,,
Molina Medicaid,DRG,4633,KIDNEY and URINARY TRACT INFECTIONS,,Relative Weights,"$3,755.49 ",IP,"3,755.49","3,755.49",,,,,,
Molina Medicaid,DRG,4634,KIDNEY and URINARY TRACT INFECTIONS,,Relative Weights,"$6,746.75 ",IP,"6,746.75","6,746.75",,,,,,
Molina Medicaid,DRG,4651,URINARY STONES & ACQUIRED UPPER URINARY TRACT OBSTRUCTION,,Relative Weights,"$2,676.16 ",IP,"2,676.16","2,676.16",,,,,,
Molina Medicaid,DRG,4652,URINARY STONES and ACQUIRED UPPER URINARY TRACT OBSTRUCTION,,Relative Weights,"$3,212.22 ",IP,"3,212.22","3,212.22",,,,,,
Molina Medicaid,DRG,4653,URINARY STONES and ACQUIRED UPPER URINARY TRACT OBSTRUCTION,,Relative Weights,"$4,385.36 ",IP,"4,385.36","4,385.36",,,,,,
Molina Medicaid,DRG,4654,URINARY STONES and ACQUIRED UPPER URINARY TRACT OBSTRUCTION,,Relative Weights,"$8,949.40 ",IP,"8,949.40","8,949.40",,,,,,
Molina Medicaid,DRG,4661,"MALFUNCTION, REACTION, COMPLIC OF GENITOURINARY DEVICE OR PROC",,Relative Weights,"$2,602.62 ",IP,"2,602.62","2,602.62",,,,,,
Molina Medicaid,DRG,4662,"MALFUNCTION, REACTION, COMPLIC OF GENITOURINARY DEVICE OR PROC",,Relative Weights,"$3,336.61 ",IP,"3,336.61","3,336.61",,,,,,
Molina Medicaid,DRG,4663,MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC,,Relative Weights,"$4,821.07 ",IP,"4,821.07","4,821.07",,,,,,
Molina Medicaid,DRG,4664,MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC,,Relative Weights,"$8,281.73 ",IP,"8,281.73","8,281.73",,,,,,
Molina Medicaid,DRG,4681,OTHER KIDNEY and URINARY TRACT DIAGNOSES SIGNS and SYMPTOMS,,Relative Weights,"$2,645.58 ",IP,"2,645.58","2,645.58",,,,,,
Molina Medicaid,DRG,4682,OTHER KIDNEY and URINARY TRACT DIAGNOSES SIGNS and SYMPTOMS,,Relative Weights,"$3,341.08 ",IP,"3,341.08","3,341.08",,,,,,
Molina Medicaid,DRG,4683,"OTHER KIDNEY & URINARY TRACT DIAGNOSES, SIGNS & SYMPTOMS",,Relative Weights,"$4,559.92 ",IP,"4,559.92","4,559.92",,,,,,
Molina Medicaid,DRG,4684,OTHER KIDNEY and URINARY TRACT DIAGNOSES SIGNS and SYMPTOMS,,Relative Weights,"$9,588.20 ",IP,"9,588.20","9,588.20",,,,,,
Molina Medicaid,DRG,4691,ACUTE KIDNEY INJURY,,Relative Weights,"$2,379.95 ",IP,"2,379.95","2,379.95",,,,,,
Molina Medicaid,DRG,4692,ACUTE KIDNEY INJURY,,Relative Weights,"$3,050.71 ",IP,"3,050.71","3,050.71",,,,,,
Molina Medicaid,DRG,4693,ACUTE KIDNEY INJURY,,Relative Weights,"$4,563.35 ",IP,"4,563.35","4,563.35",,,,,,
Molina Medicaid,DRG,4694,ACUTE KIDNEY INJURY,,Relative Weights,"$9,568.95 ",IP,"9,568.95","9,568.95",,,,,,
Molina Medicaid,DRG,4701,CHRONIC KIDNEY DISEASE,,Relative Weights,"$2,503.66 ",IP,"2,503.66","2,503.66",,,,,,
Molina Medicaid,DRG,4702,CHRONIC KIDNEY DISEASE,,Relative Weights,"$3,283.35 ",IP,"3,283.35","3,283.35",,,,,,
Molina Medicaid,DRG,4703,CHRONIC KIDNEY DISEASE,,Relative Weights,"$4,530.02 ",IP,"4,530.02","4,530.02",,,,,,
Molina Medicaid,DRG,4704,CHRONIC KIDNEY DISEASE,,Relative Weights,"$8,193.42 ",IP,"8,193.42","8,193.42",,,,,,
Molina Medicaid,DRG,4801,MAJOR MALE PELVIC PROCEDURES,,Relative Weights,"$6,131.66 ",IP,"6,131.66","6,131.66",,,,,,
Molina Medicaid,DRG,4802,MAJOR MALE PELVIC PROCEDURES,,Relative Weights,"$6,485.60 ",IP,"6,485.60","6,485.60",,,,,,
Molina Medicaid,DRG,4803,MAJOR MALE PELVIC PROCEDURES,,Relative Weights,"$10,188.85 ",IP,"10,188.85","10,188.85",,,,,,
Molina Medicaid,DRG,4804,MAJOR MALE PELVIC PROCEDURES,,Relative Weights,"$21,900.66 ",IP,"21,900.66","21,900.66",,,,,,
Molina Medicaid,DRG,4821,TRANSURETHRAL PROSTATECTOMY,,Relative Weights,"$4,027.30 ",IP,"4,027.30","4,027.30",,,,,,
Molina Medicaid,DRG,4822,TRANSURETHRAL PROSTATECTOMY,,Relative Weights,"$4,459.58 ",IP,"4,459.58","4,459.58",,,,,,
Molina Medicaid,DRG,4823,TRANSURETHRAL PROSTATECTOMY,,Relative Weights,"$7,759.08 ",IP,"7,759.08","7,759.08",,,,,,
Molina Medicaid,DRG,4824,TRANSURETHRAL PROSTATECTOMY,,Relative Weights,"$15,069.03 ",IP,"15,069.03","15,069.03",,,,,,
Molina Medicaid,DRG,4831,PENIS TESTES and SCROTAL PROCEDURES,,Relative Weights,"$5,523.10 ",IP,"5,523.10","5,523.10",,,,,,
Molina Medicaid,DRG,4832,PENIS TESTES and SCROTAL PROCEDURES,,Relative Weights,"$6,593.84 ",IP,"6,593.84","6,593.84",,,,,,
Molina Medicaid,DRG,4833,PENIS TESTES and SCROTAL PROCEDURES,,Relative Weights,"$8,503.71 ",IP,"8,503.71","8,503.71",,,,,,
Molina Medicaid,DRG,4834,PENIS TESTES and SCROTAL PROCEDURES,,Relative Weights,"$16,764.14 ",IP,"16,764.14","16,764.14",,,,,,
Molina Medicaid,DRG,4841,OTHER MALE REPRODUCTIVE SYSTEM and RELATED PROCEDURES,,Relative Weights,"$6,414.47 ",IP,"6,414.47","6,414.47",,,,,,
Molina Medicaid,DRG,4842,OTHER MALE REPRODUCTIVE SYSTEM and RELATED PROCEDURES,,Relative Weights,"$6,893.48 ",IP,"6,893.48","6,893.48",,,,,,
Molina Medicaid,DRG,4843,OTHER MALE REPRODUCTIVE SYSTEM and RELATED PROCEDURES,,Relative Weights,"$7,922.98 ",IP,"7,922.98","7,922.98",,,,,,
Molina Medicaid,DRG,4844,OTHER MALE REPRODUCTIVE SYSTEM and RELATED PROCEDURES,,Relative Weights,"$22,148.41 ",IP,"22,148.41","22,148.41",,,,,,
Molina Medicaid,DRG,5001,MALIGNANCY MALE REPRODUCTIVE SYSTEM,,Relative Weights,"$3,471.31 ",IP,"3,471.31","3,471.31",,,,,,
Molina Medicaid,DRG,5002,MALIGNANCY MALE REPRODUCTIVE SYSTEM,,Relative Weights,"$3,960.98 ",IP,"3,960.98","3,960.98",,,,,,
Molina Medicaid,DRG,5003,"MALIGNANCY, MALE REPRODUCTIVE SYSTEM",,Relative Weights,"$5,381.18 ",IP,"5,381.18","5,381.18",,,,,,
Molina Medicaid,DRG,5004,MALIGNANCY MALE REPRODUCTIVE SYSTEM,,Relative Weights,"$8,653.88 ",IP,"8,653.88","8,653.88",,,,,,
Molina Medicaid,DRG,5011,MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,,Relative Weights,"$2,269.65 ",IP,"2,269.65","2,269.65",,,,,,
Molina Medicaid,DRG,5012,MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,,Relative Weights,"$2,988.52 ",IP,"2,988.52","2,988.52",,,,,,
Molina Medicaid,DRG,5013,MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,,Relative Weights,"$4,126.95 ",IP,"4,126.95","4,126.95",,,,,,
Molina Medicaid,DRG,5014,MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,,Relative Weights,"$8,519.52 ",IP,"8,519.52","8,519.52",,,,,,
Molina Medicaid,DRG,5101,PELVIC EVISCERATION RADICAL HYSTERECTOMY and OTHER RADICAL GYN PROCS,,Relative Weights,"$6,667.03 ",IP,"6,667.03","6,667.03",,,,,,
Molina Medicaid,DRG,5102,PELVIC EVISCERATION RADICAL HYSTERECTOMY and OTHER RADICAL GYN PROCS,,Relative Weights,"$7,636.06 ",IP,"7,636.06","7,636.06",,,,,,
Molina Medicaid,DRG,5103,"PELVIC EVISCERATION, RADICAL HYSTERECTOMY & OTHER RADICAL GYN PROCS",,Relative Weights,"$12,159.55 ",IP,"12,159.55","12,159.55",,,,,,
Molina Medicaid,DRG,5104,PELVIC EVISCERATION RADICAL HYSTERECTOMY and OTHER RADICAL GYN PROCS,,Relative Weights,"$22,308.54 ",IP,"22,308.54","22,308.54",,,,,,
Molina Medicaid,DRG,5111,UTERINE and ADNEXA PROCEDURES FOR OVARIAN and ADNEXAL MALIGNANCY,,Relative Weights,"$6,477.69 ",IP,"6,477.69","6,477.69",,,,,,
Molina Medicaid,DRG,5112,UTERINE and ADNEXA PROCEDURES FOR OVARIAN and ADNEXAL MALIGNANCY,,Relative Weights,"$7,830.89 ",IP,"7,830.89","7,830.89",,,,,,
Molina Medicaid,DRG,5113,UTERINE & ADNEXA PROCEDURES FOR OVARIAN & ADNEXAL MALIGNANCY,,Relative Weights,"$10,746.90 ",IP,"10,746.90","10,746.90",,,,,,
Molina Medicaid,DRG,5114,UTERINE & ADNEXA PROCEDURES FOR OVARIAN & ADNEXAL MALIGNANCY,,Relative Weights,"$23,120.88 ",IP,"23,120.88","23,120.88",,,,,,
Molina Medicaid,DRG,5121,UTERINE and ADNEXA PROCEDURES FOR NONOVARIAN and NONADNEXAL MALIG,,Relative Weights,"$6,341.62 ",IP,"6,341.62","6,341.62",,,,,,
Molina Medicaid,DRG,5122,UTERINE and ADNEXA PROCEDURES FOR NONOVARIAN and NONADNEXAL MALIG,,Relative Weights,"$7,038.84 ",IP,"7,038.84","7,038.84",,,,,,
Molina Medicaid,DRG,5123,UTERINE and ADNEXA PROCEDURES FOR NONOVARIAN and NONADNEXAL MALIG,,Relative Weights,"$9,937.66 ",IP,"9,937.66","9,937.66",,,,,,
Molina Medicaid,DRG,5124,UTERINE & ADNEXA PROCEDURES FOR NON-OVARIAN & NON-ADNEXAL MALIG,,Relative Weights,"$20,453.99 ",IP,"20,453.99","20,453.99",,,,,,
Molina Medicaid,DRG,5131,UTERINE & ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA,,Relative Weights,"$4,384.67 ",IP,"4,384.67","4,384.67",,,,,,
Molina Medicaid,DRG,5132,UTERINE and ADNEXA PROCEDURES FOR NONMALIGNANCY EXCEPT LEIOMYOMA,,Relative Weights,"$5,107.31 ",IP,"5,107.31","5,107.31",,,,,,
Molina Medicaid,DRG,5133,UTERINE and ADNEXA PROCEDURES FOR NONMALIGNANCY EXCEPT LEIOMYOMA,,Relative Weights,"$8,107.86 ",IP,"8,107.86","8,107.86",,,,,,
Molina Medicaid,DRG,5134,UTERINE and ADNEXA PROCEDURES FOR NONMALIGNANCY EXCEPT LEIOMYOMA,,Relative Weights,"$16,632.53 ",IP,"16,632.53","16,632.53",,,,,,
Molina Medicaid,DRG,5141,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,,Relative Weights,"$3,945.51 ",IP,"3,945.51","3,945.51",,,,,,
Molina Medicaid,DRG,5142,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,,Relative Weights,"$5,893.19 ",IP,"5,893.19","5,893.19",,,,,,
Molina Medicaid,DRG,5143,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,,Relative Weights,"$10,581.96 ",IP,"10,581.96","10,581.96",,,,,,
Molina Medicaid,DRG,5144,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,,Relative Weights,"$22,849.41 ",IP,"22,849.41","22,849.41",,,,,,
Molina Medicaid,DRG,5171,DILATION and CURETTAGE FOR NONOBSTETRIC DIAGNOSES,,Relative Weights,"$3,258.61 ",IP,"3,258.61","3,258.61",,,,,,
Molina Medicaid,DRG,5172,DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES,,Relative Weights,"$4,494.28 ",IP,"4,494.28","4,494.28",,,,,,
Molina Medicaid,DRG,5173,DILATION and CURETTAGE FOR NONOBSTETRIC DIAGNOSES,,Relative Weights,"$6,942.62 ",IP,"6,942.62","6,942.62",,,,,,
Molina Medicaid,DRG,5174,DILATION and CURETTAGE FOR NONOBSTETRIC DIAGNOSES,,Relative Weights,"$14,767.33 ",IP,"14,767.33","14,767.33",,,,,,
Molina Medicaid,DRG,5181,OTHER FEMALE REPRODUCTIVE SYSTEM and RELATED PROCEDURES,,Relative Weights,"$4,123.51 ",IP,"4,123.51","4,123.51",,,,,,
Molina Medicaid,DRG,5182,OTHER FEMALE REPRODUCTIVE SYSTEM & RELATED PROCEDURES,,Relative Weights,"$5,436.16 ",IP,"5,436.16","5,436.16",,,,,,
Molina Medicaid,DRG,5183,OTHER FEMALE REPRODUCTIVE SYSTEM & RELATED PROCEDURES,,Relative Weights,"$9,420.16 ",IP,"9,420.16","9,420.16",,,,,,
Molina Medicaid,DRG,5184,OTHER FEMALE REPRODUCTIVE SYSTEM and RELATED PROCEDURES,,Relative Weights,"$21,115.47 ",IP,"21,115.47","21,115.47",,,,,,
Molina Medicaid,DRG,5191,UTERINE and ADNEXA PROCEDURES FOR LEIOMYOMA,,Relative Weights,"$3,160.33 ",IP,"3,160.33","3,160.33",,,,,,
Molina Medicaid,DRG,5192,UTERINE and ADNEXA PROCEDURES FOR LEIOMYOMA,,Relative Weights,"$3,849.30 ",IP,"3,849.30","3,849.30",,,,,,
Molina Medicaid,DRG,5193,UTERINE & ADNEXA PROCEDURES FOR LEIOMYOMA,,Relative Weights,"$7,527.81 ",IP,"7,527.81","7,527.81",,,,,,
Molina Medicaid,DRG,5194,UTERINE and ADNEXA PROCEDURES FOR LEIOMYOMA,,Relative Weights,"$15,622.96 ",IP,"15,622.96","15,622.96",,,,,,
Molina Medicaid,DRG,5301,FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,,Relative Weights,"$3,382.31 ",IP,"3,382.31","3,382.31",,,,,,
Molina Medicaid,DRG,5302,FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,,Relative Weights,"$3,815.97 ",IP,"3,815.97","3,815.97",,,,,,
Molina Medicaid,DRG,5303,FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,,Relative Weights,"$5,327.23 ",IP,"5,327.23","5,327.23",,,,,,
Molina Medicaid,DRG,5304,FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,,Relative Weights,"$9,039.08 ",IP,"9,039.08","9,039.08",,,,,,
Molina Medicaid,DRG,5311,FEMALE REPRODUCTIVE SYSTEM INFECTIONS,,Relative Weights,"$2,096.46 ",IP,"2,096.46","2,096.46",,,,,,
Molina Medicaid,DRG,5312,FEMALE REPRODUCTIVE SYSTEM INFECTIONS,,Relative Weights,"$2,868.93 ",IP,"2,868.93","2,868.93",,,,,,
Molina Medicaid,DRG,5313,FEMALE REPRODUCTIVE SYSTEM INFECTIONS,,Relative Weights,"$4,503.56 ",IP,"4,503.56","4,503.56",,,,,,
Molina Medicaid,DRG,5314,FEMALE REPRODUCTIVE SYSTEM INFECTIONS,,Relative Weights,"$9,958.97 ",IP,"9,958.97","9,958.97",,,,,,
Molina Medicaid,DRG,5321,MENSTRUAL and OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,,Relative Weights,"$2,302.29 ",IP,"2,302.29","2,302.29",,,,,,
Molina Medicaid,DRG,5322,MENSTRUAL and OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,,Relative Weights,"$2,696.78 ",IP,"2,696.78","2,696.78",,,,,,
Molina Medicaid,DRG,5323,MENSTRUAL and OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,,Relative Weights,"$4,143.44 ",IP,"4,143.44","4,143.44",,,,,,
Molina Medicaid,DRG,5324,MENSTRUAL and OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,,Relative Weights,"$9,044.24 ",IP,"9,044.24","9,044.24",,,,,,
Molina Medicaid,DRG,5401,CESAREAN DELIVERY,,Relative Weights,"$2,493.69 ",IP,"2,493.69","2,493.69",,,,,,
Molina Medicaid,DRG,5402,CESAREAN DELIVERY,,Relative Weights,"$2,909.48 ",IP,"2,909.48","2,909.48",,,,,,
Molina Medicaid,DRG,5403,CESAREAN DELIVERY,,Relative Weights,"$4,140.35 ",IP,"4,140.35","4,140.35",,,,,,
Molina Medicaid,DRG,5404,CESAREAN DELIVERY,,Relative Weights,"$8,525.02 ",IP,"8,525.02","8,525.02",,,,,,
Molina Medicaid,DRG,5411,VAGINAL DELIVERY W STERILIZATION &/OR D&C,,Relative Weights,"$2,683.03 ",IP,"2,683.03","2,683.03",,,,,,
Molina Medicaid,DRG,5412,VAGINAL DELIVERY W STERILIZATION andOR DandC,,Relative Weights,"$2,694.03 ",IP,"2,694.03","2,694.03",,,,,,
Molina Medicaid,DRG,5413,VAGINAL DELIVERY W STERILIZATION andOR DandC,,Relative Weights,"$3,800.85 ",IP,"3,800.85","3,800.85",,,,,,
Molina Medicaid,DRG,5414,VAGINAL DELIVERY W STERILIZATION andOR DandC,,Relative Weights,"$9,356.59 ",IP,"9,356.59","9,356.59",,,,,,
Molina Medicaid,DRG,5421,VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION &/OR D&C,,Relative Weights,"$1,729.81 ",IP,"1,729.81","1,729.81",,,,,,
Molina Medicaid,DRG,5422,VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION andOR DandC,,Relative Weights,"$1,962.10 ",IP,"1,962.10","1,962.10",,,,,,
Molina Medicaid,DRG,5423,VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION andOR DandC,,Relative Weights,"$2,979.24 ",IP,"2,979.24","2,979.24",,,,,,
Molina Medicaid,DRG,5424,VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION andOR DandC,,Relative Weights,"$11,346.53 ",IP,"11,346.53","11,346.53",,,,,,
Molina Medicaid,DRG,5441,DandC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES,,Relative Weights,"$1,946.30 ",IP,"1,946.30","1,946.30",,,,,,
Molina Medicaid,DRG,5442,"D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES",,Relative Weights,"$2,595.06 ",IP,"2,595.06","2,595.06",,,,,,
Molina Medicaid,DRG,5443,"D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES",,Relative Weights,"$3,856.51 ",IP,"3,856.51","3,856.51",,,,,,
Molina Medicaid,DRG,5444,DandC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES,,Relative Weights,"$14,310.30 ",IP,"14,310.30","14,310.30",,,,,,
Molina Medicaid,DRG,5451,ECTOPIC PREGNANCY PROCEDURE,,Relative Weights,"$2,785.09 ",IP,"2,785.09","2,785.09",,,,,,
Molina Medicaid,DRG,5452,ECTOPIC PREGNANCY PROCEDURE,,Relative Weights,"$3,114.63 ",IP,"3,114.63","3,114.63",,,,,,
Molina Medicaid,DRG,5453,ECTOPIC PREGNANCY PROCEDURE,,Relative Weights,"$3,214.96 ",IP,"3,214.96","3,214.96",,,,,,
Molina Medicaid,DRG,5454,ECTOPIC PREGNANCY PROCEDURE,,Relative Weights,"$4,812.48 ",IP,"4,812.48","4,812.48",,,,,,
Molina Medicaid,DRG,5461,OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES,,Relative Weights,"$2,385.45 ",IP,"2,385.45","2,385.45",,,,,,
Molina Medicaid,DRG,5462,OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES,,Relative Weights,"$4,587.41 ",IP,"4,587.41","4,587.41",,,,,,
Molina Medicaid,DRG,5463,OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES,,Relative Weights,"$5,857.79 ",IP,"5,857.79","5,857.79",,,,,,
Molina Medicaid,DRG,5464,OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES,,Relative Weights,"$11,895.30 ",IP,"11,895.30","11,895.30",,,,,,
Molina Medicaid,DRG,5601,VAGINAL DELIVERY,VAGINAL DELIVERY,Relative Weights,"$1,539.10 ",IP,"1,539.10","1,539.10",,,,,,
Molina Medicaid,DRG,5602,VAGINAL DELIVERY,VAGINAL DELIVERY,Relative Weights,"$1,659.37 ",IP,"1,659.37","1,659.37",,,,,,
Molina Medicaid,DRG,5603,VAGINAL DELIVERY,VAGINAL DELIVERY,Relative Weights,"$2,337.34 ",IP,"2,337.34","2,337.34",,,,,,
Molina Medicaid,DRG,5604,VAGINAL DELIVERY,VAGINAL DELIVERY,Relative Weights,"$4,292.23 ",IP,"4,292.23","4,292.23",,,,,,
Molina Medicaid,DRG,5611,POSTPARTUM and POST ABORTION DIAGNOSES WO PROCEDURE,,Relative Weights,"$1,236.71 ",IP,"1,236.71","1,236.71",,,,,,
Molina Medicaid,DRG,5612,POSTPARTUM and POST ABORTION DIAGNOSES WO PROCEDURE,,Relative Weights,"$1,778.26 ",IP,"1,778.26","1,778.26",,,,,,
Molina Medicaid,DRG,5613,POSTPARTUM and POST ABORTION DIAGNOSES WO PROCEDURE,,Relative Weights,"$2,747.29 ",IP,"2,747.29","2,747.29",,,,,,
Molina Medicaid,DRG,5614,POSTPARTUM and POST ABORTION DIAGNOSES WO PROCEDURE,,Relative Weights,"$5,898.34 ",IP,"5,898.34","5,898.34",,,,,,
Molina Medicaid,DRG,5631,PRETERM LABOR,,Relative Weights,"$1,387.56 ",IP,"1,387.56","1,387.56",,,,,,
Molina Medicaid,DRG,5632,PRETERM LABOR,,Relative Weights,"$1,719.85 ",IP,"1,719.85","1,719.85",,,,,,
Molina Medicaid,DRG,5633,PRETERM LABOR,,Relative Weights,"$2,634.92 ",IP,"2,634.92","2,634.92",,,,,,
Molina Medicaid,DRG,5634,PRETERM LABOR,,Relative Weights,"$4,637.23 ",IP,"4,637.23","4,637.23",,,,,,
Molina Medicaid,DRG,5641,ABORTION WO DandC ASPIRATION CURETTAGE OR HYSTEROTOMY,,Relative Weights,"$1,463.85 ",IP,"1,463.85","1,463.85",,,,,,
Molina Medicaid,DRG,5642,"ABORTION W/O D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",,Relative Weights,"$1,520.55 ",IP,"1,520.55","1,520.55",,,,,,
Molina Medicaid,DRG,5643,"ABORTION W/O D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",,Relative Weights,"$2,435.62 ",IP,"2,435.62","2,435.62",,,,,,
Molina Medicaid,DRG,5644,ABORTION WO DandC ASPIRATION CURETTAGE OR HYSTEROTOMY,,Relative Weights,"$3,935.55 ",IP,"3,935.55","3,935.55",,,,,,
Molina Medicaid,DRG,5651,FALSE LABOR,FALSE LABOR,Relative Weights,$992.39 ,IP,992.39,992.39,,,,,,
Molina Medicaid,DRG,5652,FALSE LABOR,FALSE LABOR,Relative Weights,"$1,254.23 ",IP,"1,254.23","1,254.23",,,,,,
Molina Medicaid,DRG,5653,FALSE LABOR,FALSE LABOR,Relative Weights,"$2,123.61 ",IP,"2,123.61","2,123.61",,,,,,
Molina Medicaid,DRG,5654,FALSE LABOR,FALSE LABOR,Relative Weights,"$2,123.61 ",IP,"2,123.61","2,123.61",,,,,,
Molina Medicaid,DRG,5661,OTHER ANTEPARTUM DIAGNOSES,,Relative Weights,"$1,462.82 ",IP,"1,462.82","1,462.82",,,,,,
Molina Medicaid,DRG,5662,OTHER ANTEPARTUM DIAGNOSES,,Relative Weights,"$1,906.44 ",IP,"1,906.44","1,906.44",,,,,,
Molina Medicaid,DRG,5663,OTHER ANTEPARTUM DIAGNOSES,,Relative Weights,"$2,718.08 ",IP,"2,718.08","2,718.08",,,,,,
Molina Medicaid,DRG,5664,OTHER ANTEPARTUM DIAGNOSES,,Relative Weights,"$5,715.19 ",IP,"5,715.19","5,715.19",,,,,,
Molina Medicaid,DRG,5801,NEONATE TRANSFERRED 5 DAYS OLD NOT BORN HERE,,Relative Weights,"$1,625.35 ",IP,"1,625.35","1,625.35",,,,,,
Molina Medicaid,DRG,5802,NEONATE TRANSFERRED 5 DAYS OLD NOT BORN HERE,,Relative Weights,"$2,301.61 ",IP,"2,301.61","2,301.61",,,,,,
Molina Medicaid,DRG,5803,NEONATE TRANSFERRED 5 DAYS OLD NOT BORN HERE,,Relative Weights,"$3,477.84 ",IP,"3,477.84","3,477.84",,,,,,
Molina Medicaid,DRG,5804,NEONATE TRANSFERRED 5 DAYS OLD NOT BORN HERE,,Relative Weights,"$6,537.48 ",IP,"6,537.48","6,537.48",,,,,,
Molina Medicaid,DRG,5811,NEONATE TRANSFERRED  5 DAYS OLD BORN HERE,,Relative Weights,$559.42 ,IP,559.42,559.42,,,,,,
Molina Medicaid,DRG,5812,NEONATE TRANSFERRED  5 DAYS OLD BORN HERE,,Relative Weights,$716.80 ,IP,716.8,716.8,,,,,,
Molina Medicaid,DRG,5813,NEONATE TRANSFERRED  5 DAYS OLD BORN HERE,,Relative Weights,"$1,204.41 ",IP,"1,204.41","1,204.41",,,,,,
Molina Medicaid,DRG,5814,NEONATE TRANSFERRED  5 DAYS OLD BORN HERE,,Relative Weights,"$2,109.52 ",IP,"2,109.52","2,109.52",,,,,,
Molina Medicaid,DRG,5831,NEONATE W ECMO,,Relative Weights,"$87,271.04 ",IP,"87,271.04","87,271.04",,,,,,
Molina Medicaid,DRG,5832,NEONATE W ECMO,,Relative Weights,"$87,459.00 ",IP,"87,459.00","87,459.00",,,,,,
Molina Medicaid,DRG,5833,NEONATE W ECMO,,Relative Weights,"$148,358.12 ",IP,"148,358.12","148,358.12",,,,,,
Molina Medicaid,DRG,5834,NEONATE W ECMO,,Relative Weights,"$163,193.83 ",IP,"163,193.83","163,193.83",,,,,,
Molina Medicaid,DRG,5881,NEONATE BWT <1500G W MAJOR PROCEDURE,,Relative Weights,"$67,852.39 ",IP,"67,852.39","67,852.39",,,,,,
Molina Medicaid,DRG,5882,NEONATE BWT <1500G W MAJOR PROCEDURE,,Relative Weights,"$75,391.54 ",IP,"75,391.54","75,391.54",,,,,,
Molina Medicaid,DRG,5883,NEONATE BWT 1500G W MAJOR PROCEDURE,,Relative Weights,"$83,636.16 ",IP,"83,636.16","83,636.16",,,,,,
Molina Medicaid,DRG,5884,NEONATE BWT 1500G W MAJOR PROCEDURE,,Relative Weights,"$133,619.66 ",IP,"133,619.66","133,619.66",,,,,,
Molina Medicaid,DRG,5891,NEONATE BWT 500G OR GA 24 WEEKS,,Relative Weights,"$98,896.59 ",IP,"98,896.59","98,896.59",,,,,,
Molina Medicaid,DRG,5892,NEONATE BWT 500G OR GA 24 WEEKS,,Relative Weights,"$69,370.87 ",IP,"69,370.87","69,370.87",,,,,,
Molina Medicaid,DRG,5893,NEONATE BWT 500G OR GA 24 WEEKS,,Relative Weights,"$63,064.65 ",IP,"63,064.65","63,064.65",,,,,,
Molina Medicaid,DRG,5894,NEONATE BWT <500G OR GA <24 WEEKS,,Relative Weights,"$11,889.12 ",IP,"11,889.12","11,889.12",,,,,,
Molina Medicaid,DRG,5911,NEONATE BIRTHWT 500749G WO MAJOR PROCEDURE,,Relative Weights,"$57,344.65 ",IP,"57,344.65","57,344.65",,,,,,
Molina Medicaid,DRG,5912,NEONATE BIRTHWT 500749G WO MAJOR PROCEDURE,,Relative Weights,"$79,559.04 ",IP,"79,559.04","79,559.04",,,,,,
Molina Medicaid,DRG,5913,NEONATE BIRTHWT 500749G WO MAJOR PROCEDURE,,Relative Weights,"$85,488.65 ",IP,"85,488.65","85,488.65",,,,,,
Molina Medicaid,DRG,5914,NEONATE BIRTHWT 500-749G W/O MAJOR PROCEDURE,,Relative Weights,"$110,417.00 ",IP,"110,417.00","110,417.00",,,,,,
Molina Medicaid,DRG,5931,NEONATE BIRTHWT 750-999G W/O MAJOR PROCEDURE,,Relative Weights,"$37,781.34 ",IP,"37,781.34","37,781.34",,,,,,
Molina Medicaid,DRG,5932,NEONATE BIRTHWT 750999G WO MAJOR PROCEDURE,,Relative Weights,"$59,330.12 ",IP,"59,330.12","59,330.12",,,,,,
Molina Medicaid,DRG,5933,NEONATE BIRTHWT 750999G WO MAJOR PROCEDURE,,Relative Weights,"$71,323.01 ",IP,"71,323.01","71,323.01",,,,,,
Molina Medicaid,DRG,5934,NEONATE BIRTHWT 750999G WO MAJOR PROCEDURE,,Relative Weights,"$96,423.52 ",IP,"96,423.52","96,423.52",,,,,,
Molina Medicaid,DRG,6021,NEONATE BWT 10001249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$36,367.31 ",IP,"36,367.31","36,367.31",,,,,,
Molina Medicaid,DRG,6022,NEONATE BWT 10001249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$43,081.42 ",IP,"43,081.42","43,081.42",,,,,,
Molina Medicaid,DRG,6023,NEONATE BWT 10001249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$56,708.94 ",IP,"56,708.94","56,708.94",,,,,,
Molina Medicaid,DRG,6024,NEONATE BWT 10001249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$82,218.02 ",IP,"82,218.02","82,218.02",,,,,,
Molina Medicaid,DRG,6031,NEONATE BIRTHWT 10001249G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$21,131.62 ",IP,"21,131.62","21,131.62",,,,,,
Molina Medicaid,DRG,6032,NEONATE BIRTHWT 10001249G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$31,760.66 ",IP,"31,760.66","31,760.66",,,,,,
Molina Medicaid,DRG,6033,NEONATE BIRTHWT 10001249G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$45,733.18 ",IP,"45,733.18","45,733.18",,,,,,
Molina Medicaid,DRG,6034,NEONATE BIRTHWT 10001249G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$71,521.63 ",IP,"71,521.63","71,521.63",,,,,,
Molina Medicaid,DRG,6071,NEONATE BWT 1250-1499G W RESP DIST SYND/OTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$24,973.02 ",IP,"24,973.02","24,973.02",,,,,,
Molina Medicaid,DRG,6072,NEONATE BWT 12501499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$31,699.15 ",IP,"31,699.15","31,699.15",,,,,,
Molina Medicaid,DRG,6073,NEONATE BWT 12501499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$41,632.01 ",IP,"41,632.01","41,632.01",,,,,,
Molina Medicaid,DRG,6074,NEONATE BWT 12501499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$64,492.07 ",IP,"64,492.07","64,492.07",,,,,,
Molina Medicaid,DRG,6081,NEONATE BWT 12501499G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$16,607.44 ",IP,"16,607.44","16,607.44",,,,,,
Molina Medicaid,DRG,6082,NEONATE BWT 12501499G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$23,967.23 ",IP,"23,967.23","23,967.23",,,,,,
Molina Medicaid,DRG,6083,NEONATE BWT 12501499G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$34,646.09 ",IP,"34,646.09","34,646.09",,,,,,
Molina Medicaid,DRG,6084,NEONATE BWT 12501499G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$60,788.81 ",IP,"60,788.81","60,788.81",,,,,,
Molina Medicaid,DRG,6091,NEONATE BWT 15002499G W MAJOR PROCEDURE,,Relative Weights,"$25,499.11 ",IP,"25,499.11","25,499.11",,,,,,
Molina Medicaid,DRG,6092,NEONATE BWT 15002499G W MAJOR PROCEDURE,,Relative Weights,"$27,431.32 ",IP,"27,431.32","27,431.32",,,,,,
Molina Medicaid,DRG,6093,NEONATE BWT 15002499G W MAJOR PROCEDURE,,Relative Weights,"$47,002.54 ",IP,"47,002.54","47,002.54",,,,,,
Molina Medicaid,DRG,6094,NEONATE BWT 15002499G W MAJOR PROCEDURE,,Relative Weights,"$99,687.62 ",IP,"99,687.62","99,687.62",,,,,,
Molina Medicaid,DRG,6111,NEONATE BIRTHWT 15001999G W MAJOR ANOMALY,,Relative Weights,"$12,585.30 ",IP,"12,585.30","12,585.30",,,,,,
Molina Medicaid,DRG,6112,NEONATE BIRTHWT 15001999G W MAJOR ANOMALY,,Relative Weights,"$19,393.91 ",IP,"19,393.91","19,393.91",,,,,,
Molina Medicaid,DRG,6113,NEONATE BIRTHWT 15001999G W MAJOR ANOMALY,,Relative Weights,"$32,347.92 ",IP,"32,347.92","32,347.92",,,,,,
Molina Medicaid,DRG,6114,NEONATE BIRTHWT 15001999G W MAJOR ANOMALY,,Relative Weights,"$58,174.51 ",IP,"58,174.51","58,174.51",,,,,,
Molina Medicaid,DRG,6121,NEONATE BWT 1500-1999G W RESP DIST SYND/OTH MAJ RESP COND,,Relative Weights,"$16,224.65 ",IP,"16,224.65","16,224.65",,,,,,
Molina Medicaid,DRG,6122,NEONATE BWT 15001999G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$21,637.79 ",IP,"21,637.79","21,637.79",,,,,,
Molina Medicaid,DRG,6123,NEONATE BWT 15001999G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$29,186.22 ",IP,"29,186.22","29,186.22",,,,,,
Molina Medicaid,DRG,6124,NEONATE BWT 15001999G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$42,407.23 ",IP,"42,407.23","42,407.23",,,,,,
Molina Medicaid,DRG,6131,NEONATE BIRTHWT 1500-1999G W CONGENITAL/PERINATAL INFECTION,,Relative Weights,"$13,196.61 ",IP,"13,196.61","13,196.61",,,,,,
Molina Medicaid,DRG,6132,NEONATE BIRTHWT 15001999G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$21,189.35 ",IP,"21,189.35","21,189.35",,,,,,
Molina Medicaid,DRG,6133,NEONATE BIRTHWT 15001999G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$27,656.40 ",IP,"27,656.40","27,656.40",,,,,,
Molina Medicaid,DRG,6134,NEONATE BIRTHWT 15001999G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$47,731.03 ",IP,"47,731.03","47,731.03",,,,,,
Molina Medicaid,DRG,6141,NEONATE BWT 15001999G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$8,925.34 ",IP,"8,925.34","8,925.34",,,,,,
Molina Medicaid,DRG,6142,NEONATE BWT 1500-1999G W OR W/O OTHER SIGNIFICANT CONDITION,,Relative Weights,"$15,030.54 ",IP,"15,030.54","15,030.54",,,,,,
Molina Medicaid,DRG,6143,NEONATE BWT 1500-1999G W OR W/O OTHER SIGNIFICANT CONDITION,,Relative Weights,"$25,580.55 ",IP,"25,580.55","25,580.55",,,,,,
Molina Medicaid,DRG,6144,NEONATE BWT 15001999G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$45,341.79 ",IP,"45,341.79","45,341.79",,,,,,
Molina Medicaid,DRG,6211,NEONATE BWT 20002499G W MAJOR ANOMALY,,Relative Weights,"$6,929.91 ",IP,"6,929.91","6,929.91",,,,,,
Molina Medicaid,DRG,6212,NEONATE BWT 20002499G W MAJOR ANOMALY,,Relative Weights,"$14,367.69 ",IP,"14,367.69","14,367.69",,,,,,
Molina Medicaid,DRG,6213,NEONATE BWT 20002499G W MAJOR ANOMALY,,Relative Weights,"$26,320.72 ",IP,"26,320.72","26,320.72",,,,,,
Molina Medicaid,DRG,6214,NEONATE BWT 20002499G W MAJOR ANOMALY,,Relative Weights,"$49,514.79 ",IP,"49,514.79","49,514.79",,,,,,
Molina Medicaid,DRG,6221,NEONATE BWT 20002499G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$10,129.06 ",IP,"10,129.06","10,129.06",,,,,,
Molina Medicaid,DRG,6222,NEONATE BWT 20002499G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$13,681.47 ",IP,"13,681.47","13,681.47",,,,,,
Molina Medicaid,DRG,6223,NEONATE BWT 20002499G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$17,417.03 ",IP,"17,417.03","17,417.03",,,,,,
Molina Medicaid,DRG,6224,NEONATE BWT 20002499G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$32,501.52 ",IP,"32,501.52","32,501.52",,,,,,
Molina Medicaid,DRG,6231,NEONATE BWT 20002499G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$7,947.73 ",IP,"7,947.73","7,947.73",,,,,,
Molina Medicaid,DRG,6232,NEONATE BWT 20002499G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$11,704.59 ",IP,"11,704.59","11,704.59",,,,,,
Molina Medicaid,DRG,6233,NEONATE BWT 20002499G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$18,604.26 ",IP,"18,604.26","18,604.26",,,,,,
Molina Medicaid,DRG,6234,NEONATE BWT 2000-2499G W CONGENITAL/PERINATAL INFECTION,,Relative Weights,"$29,470.40 ",IP,"29,470.40","29,470.40",,,,,,
Molina Medicaid,DRG,6251,NEONATE BWT 20002499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$8,481.72 ",IP,"8,481.72","8,481.72",,,,,,
Molina Medicaid,DRG,6252,NEONATE BWT 20002499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$12,056.81 ",IP,"12,056.81","12,056.81",,,,,,
Molina Medicaid,DRG,6253,NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$17,253.12 ",IP,"17,253.12","17,253.12",,,,,,
Molina Medicaid,DRG,6254,NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$25,500.83 ",IP,"25,500.83","25,500.83",,,,,,
Molina Medicaid,DRG,6261,NEONATE BWT 20002499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM,,Relative Weights,"$1,026.75 ",IP,"1,026.75","1,026.75",,,,,,
Molina Medicaid,DRG,6262,NEONATE BWT 20002499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM,,Relative Weights,"$1,832.56 ",IP,"1,832.56","1,832.56",,,,,,
Molina Medicaid,DRG,6263,NEONATE BWT 20002499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM,,Relative Weights,"$5,129.99 ",IP,"5,129.99","5,129.99",,,,,,
Molina Medicaid,DRG,6264,"NEONATE BWT 2000-2499G, NORMAL NEWBORN OR NEONATE W OTHER PROBLEM",,Relative Weights,"$14,511.67 ",IP,"14,511.67","14,511.67",,,,,,
Molina Medicaid,DRG,6301,NEONATE BIRTHWT 2499G W MAJOR CARDIOVASCULAR PROCEDURE,,Relative Weights,"$14,642.59 ",IP,"14,642.59","14,642.59",,,,,,
Molina Medicaid,DRG,6302,NEONATE BIRTHWT 2499G W MAJOR CARDIOVASCULAR PROCEDURE,,Relative Weights,"$26,499.41 ",IP,"26,499.41","26,499.41",,,,,,
Molina Medicaid,DRG,6303,NEONATE BIRTHWT 2499G W MAJOR CARDIOVASCULAR PROCEDURE,,Relative Weights,"$44,508.84 ",IP,"44,508.84","44,508.84",,,,,,
Molina Medicaid,DRG,6304,NEONATE BIRTHWT >2499G W MAJOR CARDIOVASCULAR PROCEDURE,,Relative Weights,"$79,154.59 ",IP,"79,154.59","79,154.59",,,,,,
Molina Medicaid,DRG,6311,NEONATE BIRTHWT 2499G W OTHER MAJOR PROCEDURE,,Relative Weights,"$11,884.65 ",IP,"11,884.65","11,884.65",,,,,,
Molina Medicaid,DRG,6312,NEONATE BIRTHWT 2499G W OTHER MAJOR PROCEDURE,,Relative Weights,"$19,077.77 ",IP,"19,077.77","19,077.77",,,,,,
Molina Medicaid,DRG,6313,NEONATE BIRTHWT 2499G W OTHER MAJOR PROCEDURE,,Relative Weights,"$33,764.00 ",IP,"33,764.00","33,764.00",,,,,,
Molina Medicaid,DRG,6314,NEONATE BIRTHWT 2499G W OTHER MAJOR PROCEDURE,,Relative Weights,"$74,464.79 ",IP,"74,464.79","74,464.79",,,,,,
Molina Medicaid,DRG,6331,NEONATE BIRTHWT 2499G W MAJOR ANOMALY,,Relative Weights,"$2,688.87 ",IP,"2,688.87","2,688.87",,,,,,
Molina Medicaid,DRG,6332,NEONATE BIRTHWT 2499G W MAJOR ANOMALY,,Relative Weights,"$7,851.51 ",IP,"7,851.51","7,851.51",,,,,,
Molina Medicaid,DRG,6333,NEONATE BIRTHWT 2499G W MAJOR ANOMALY,,Relative Weights,"$17,713.92 ",IP,"17,713.92","17,713.92",,,,,,
Molina Medicaid,DRG,6334,NEONATE BIRTHWT 2499G W MAJOR ANOMALY,,Relative Weights,"$44,843.19 ",IP,"44,843.19","44,843.19",,,,,,
Molina Medicaid,DRG,6341,"NEONATE, BIRTHWT >2499G W RESP DIST SYND/OTH MAJ RESP COND",,Relative Weights,"$4,461.64 ",IP,"4,461.64","4,461.64",,,,,,
Molina Medicaid,DRG,6342,"NEONATE, BIRTHWT >2499G W RESP DIST SYND/OTH MAJ RESP COND",,Relative Weights,"$7,881.41 ",IP,"7,881.41","7,881.41",,,,,,
Molina Medicaid,DRG,6343,NEONATE BIRTHWT 2499G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$11,444.81 ",IP,"11,444.81","11,444.81",,,,,,
Molina Medicaid,DRG,6344,NEONATE BIRTHWT 2499G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$28,806.17 ",IP,"28,806.17","28,806.17",,,,,,
Molina Medicaid,DRG,6361,NEONATE BIRTHWT 2499G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$4,375.39 ",IP,"4,375.39","4,375.39",,,,,,
Molina Medicaid,DRG,6362,NEONATE BIRTHWT 2499G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$6,615.83 ",IP,"6,615.83","6,615.83",,,,,,
Molina Medicaid,DRG,6363,NEONATE BIRTHWT >2499G W CONGENITAL/PERINATAL INFECTION,,Relative Weights,"$13,140.60 ",IP,"13,140.60","13,140.60",,,,,,
Molina Medicaid,DRG,6364,NEONATE BIRTHWT 2499G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$22,289.30 ",IP,"22,289.30","22,289.30",,,,,,
Molina Medicaid,DRG,6391,NEONATE BIRTHWT 2499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$4,122.14 ",IP,"4,122.14","4,122.14",,,,,,
Molina Medicaid,DRG,6392,NEONATE BIRTHWT >2499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$7,440.19 ",IP,"7,440.19","7,440.19",,,,,,
Molina Medicaid,DRG,6393,NEONATE BIRTHWT >2499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$11,681.22 ",IP,"11,681.22","11,681.22",,,,,,
Molina Medicaid,DRG,6394,NEONATE BIRTHWT 2499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$20,735.08 ",IP,"20,735.08","20,735.08",,,,,,
Molina Medicaid,DRG,6401,NEONATE BIRTHWT 2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM,,Relative Weights,$571.11 ,IP,571.11,571.11,,,,,,
Molina Medicaid,DRG,6402,NEONATE BIRTHWT 2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM,,Relative Weights,$900.64 ,IP,900.64,900.64,,,,,,
Molina Medicaid,DRG,6403,"NEONATE BIRTHWT >2499G, NORMAL NEWBORN OR NEONATE W OTHER PROBLEM",,Relative Weights,"$2,228.41 ",IP,"2,228.41","2,228.41",,,,,,
Molina Medicaid,DRG,6404,NEONATE BIRTHWT 2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM,,Relative Weights,"$13,890.74 ",IP,"13,890.74","13,890.74",,,,,,
Molina Medicaid,DRG,6501,SPLENECTOMY,,Relative Weights,"$6,304.16 ",IP,"6,304.16","6,304.16",,,,,,
Molina Medicaid,DRG,6502,SPLENECTOMY,,Relative Weights,"$8,491.69 ",IP,"8,491.69","8,491.69",,,,,,
Molina Medicaid,DRG,6503,SPLENECTOMY,,Relative Weights,"$13,332.00 ",IP,"13,332.00","13,332.00",,,,,,
Molina Medicaid,DRG,6504,SPLENECTOMY,,Relative Weights,"$23,483.06 ",IP,"23,483.06","23,483.06",,,,,,
Molina Medicaid,DRG,6511,OTHER PROCEDURES OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$5,293.90 ",IP,"5,293.90","5,293.90",,,,,,
Molina Medicaid,DRG,6512,OTHER PROCEDURES OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$7,236.76 ",IP,"7,236.76","7,236.76",,,,,,
Molina Medicaid,DRG,6513,OTHER PROCEDURES OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$10,916.31 ",IP,"10,916.31","10,916.31",,,,,,
Molina Medicaid,DRG,6514,OTHER PROCEDURES OF BLOOD & BLOOD-FORMING ORGANS,,Relative Weights,"$33,538.24 ",IP,"33,538.24","33,538.24",,,,,,
Molina Medicaid,DRG,6601,MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS and COAGUL,,Relative Weights,"$3,747.59 ",IP,"3,747.59","3,747.59",,,,,,
Molina Medicaid,DRG,6602,MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS and COAGUL,,Relative Weights,"$4,287.77 ",IP,"4,287.77","4,287.77",,,,,,
Molina Medicaid,DRG,6603,MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS and COAGUL,,Relative Weights,"$6,366.70 ",IP,"6,366.70","6,366.70",,,,,,
Molina Medicaid,DRG,6604,MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS and COAGUL,,Relative Weights,"$16,194.41 ",IP,"16,194.41","16,194.41",,,,,,
Molina Medicaid,DRG,6611,COAGULATION and PLATELET DISORDERS,,Relative Weights,"$3,902.56 ",IP,"3,902.56","3,902.56",,,,,,
Molina Medicaid,DRG,6612,COAGULATION and PLATELET DISORDERS,,Relative Weights,"$5,668.11 ",IP,"5,668.11","5,668.11",,,,,,
Molina Medicaid,DRG,6613,COAGULATION and PLATELET DISORDERS,,Relative Weights,"$9,739.74 ",IP,"9,739.74","9,739.74",,,,,,
Molina Medicaid,DRG,6614,COAGULATION and PLATELET DISORDERS,,Relative Weights,"$15,545.30 ",IP,"15,545.30","15,545.30",,,,,,
Molina Medicaid,DRG,6621,SICKLE CELL ANEMIA CRISIS,,Relative Weights,"$2,821.17 ",IP,"2,821.17","2,821.17",,,,,,
Molina Medicaid,DRG,6622,SICKLE CELL ANEMIA CRISIS,,Relative Weights,"$3,681.27 ",IP,"3,681.27","3,681.27",,,,,,
Molina Medicaid,DRG,6623,SICKLE CELL ANEMIA CRISIS,,Relative Weights,"$5,206.96 ",IP,"5,206.96","5,206.96",,,,,,
Molina Medicaid,DRG,6624,SICKLE CELL ANEMIA CRISIS,,Relative Weights,"$10,694.33 ",IP,"10,694.33","10,694.33",,,,,,
Molina Medicaid,DRG,6631,OTHER ANEMIA and DISORDERS OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$2,701.59 ",IP,"2,701.59","2,701.59",,,,,,
Molina Medicaid,DRG,6632,OTHER ANEMIA and DISORDERS OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$3,327.33 ",IP,"3,327.33","3,327.33",,,,,,
Molina Medicaid,DRG,6633,OTHER ANEMIA and DISORDERS OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$4,391.20 ",IP,"4,391.20","4,391.20",,,,,,
Molina Medicaid,DRG,6634,OTHER ANEMIA and DISORDERS OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$8,007.52 ",IP,"8,007.52","8,007.52",,,,,,
Molina Medicaid,DRG,6801,MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$7,740.52 ",IP,"7,740.52","7,740.52",,,,,,
Molina Medicaid,DRG,6802,MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$10,236.62 ",IP,"10,236.62","10,236.62",,,,,,
Molina Medicaid,DRG,6803,MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$16,199.56 ",IP,"16,199.56","16,199.56",,,,,,
Molina Medicaid,DRG,6804,MAJOR O.R. PROCEDURES FOR LYMPHATIC/HEMATOPOIETIC/OTHER NEOPLASMS,,Relative Weights,"$34,974.94 ",IP,"34,974.94","34,974.94",,,,,,
Molina Medicaid,DRG,6811,OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$6,220.66 ",IP,"6,220.66","6,220.66",,,,,,
Molina Medicaid,DRG,6812,OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$7,805.46 ",IP,"7,805.46","7,805.46",,,,,,
Molina Medicaid,DRG,6813,OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$13,731.30 ",IP,"13,731.30","13,731.30",,,,,,
Molina Medicaid,DRG,6814,OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$32,311.50 ",IP,"32,311.50","32,311.50",,,,,,
Molina Medicaid,DRG,6901,ACUTE LEUKEMIA,,Relative Weights,"$8,376.23 ",IP,"8,376.23","8,376.23",,,,,,
Molina Medicaid,DRG,6902,ACUTE LEUKEMIA,,Relative Weights,"$11,965.06 ",IP,"11,965.06","11,965.06",,,,,,
Molina Medicaid,DRG,6903,ACUTE LEUKEMIA,,Relative Weights,"$18,264.07 ",IP,"18,264.07","18,264.07",,,,,,
Molina Medicaid,DRG,6904,ACUTE LEUKEMIA,,Relative Weights,"$33,495.63 ",IP,"33,495.63","33,495.63",,,,,,
Molina Medicaid,DRG,6911,LYMPHOMA MYELOMA and NONACUTE LEUKEMIA,,Relative Weights,"$6,184.92 ",IP,"6,184.92","6,184.92",,,,,,
Molina Medicaid,DRG,6912,"LYMPHOMA, MYELOMA & NON-ACUTE LEUKEMIA",,Relative Weights,"$6,251.93 ",IP,"6,251.93","6,251.93",,,,,,
Molina Medicaid,DRG,6913,LYMPHOMA MYELOMA and NONACUTE LEUKEMIA,,Relative Weights,"$9,090.97 ",IP,"9,090.97","9,090.97",,,,,,
Molina Medicaid,DRG,6914,LYMPHOMA MYELOMA and NONACUTE LEUKEMIA,,Relative Weights,"$18,806.65 ",IP,"18,806.65","18,806.65",,,,,,
Molina Medicaid,DRG,6921,RADIOTHERAPY,,Relative Weights,"$5,028.28 ",IP,"5,028.28","5,028.28",,,,,,
Molina Medicaid,DRG,6922,RADIOTHERAPY,,Relative Weights,"$8,603.36 ",IP,"8,603.36","8,603.36",,,,,,
Molina Medicaid,DRG,6923,RADIOTHERAPY,,Relative Weights,"$11,232.45 ",IP,"11,232.45","11,232.45",,,,,,
Molina Medicaid,DRG,6924,RADIOTHERAPY,,Relative Weights,"$22,232.95 ",IP,"22,232.95","22,232.95",,,,,,
Molina Medicaid,DRG,6941,LYMPHATIC & OTHER MALIGNANCIES & NEOPLASMS OF UNCERTAIN BEHAVIOR,,Relative Weights,"$3,669.93 ",IP,"3,669.93","3,669.93",,,,,,
Molina Medicaid,DRG,6942,LYMPHATIC and OTHER MALIGNANCIES and NEOPLASMS OF UNCERTAIN BEHAVIOR,,Relative Weights,"$4,230.04 ",IP,"4,230.04","4,230.04",,,,,,
Molina Medicaid,DRG,6943,LYMPHATIC and OTHER MALIGNANCIES and NEOPLASMS OF UNCERTAIN BEHAVIOR,,Relative Weights,"$5,867.41 ",IP,"5,867.41","5,867.41",,,,,,
Molina Medicaid,DRG,6944,LYMPHATIC and OTHER MALIGNANCIES and NEOPLASMS OF UNCERTAIN BEHAVIOR,,Relative Weights,"$11,092.25 ",IP,"11,092.25","11,092.25",,,,,,
Molina Medicaid,DRG,6951,CHEMOTHERAPY FOR ACUTE LEUKEMIA,,Relative Weights,"$3,844.14 ",IP,"3,844.14","3,844.14",,,,,,
Molina Medicaid,DRG,6952,CHEMOTHERAPY FOR ACUTE LEUKEMIA,,Relative Weights,"$4,908.70 ",IP,"4,908.70","4,908.70",,,,,,
Molina Medicaid,DRG,6953,CHEMOTHERAPY FOR ACUTE LEUKEMIA,,Relative Weights,"$11,375.74 ",IP,"11,375.74","11,375.74",,,,,,
Molina Medicaid,DRG,6954,CHEMOTHERAPY FOR ACUTE LEUKEMIA,,Relative Weights,"$32,868.17 ",IP,"32,868.17","32,868.17",,,,,,
Molina Medicaid,DRG,6961,OTHER CHEMOTHERAPY,,Relative Weights,"$4,174.03 ",IP,"4,174.03","4,174.03",,,,,,
Molina Medicaid,DRG,6962,OTHER CHEMOTHERAPY,,Relative Weights,"$5,397.68 ",IP,"5,397.68","5,397.68",,,,,,
Molina Medicaid,DRG,6963,OTHER CHEMOTHERAPY,,Relative Weights,"$7,757.01 ",IP,"7,757.01","7,757.01",,,,,,
Molina Medicaid,DRG,6964,OTHER CHEMOTHERAPY,,Relative Weights,"$17,845.53 ",IP,"17,845.53","17,845.53",,,,,,
Molina Medicaid,DRG,7101,INFECTIOUS & PARASITIC DISEASES INCLUDING HIV W O.R. PROCEDURE,,Relative Weights,"$5,318.64 ",IP,"5,318.64","5,318.64",,,,,,
Molina Medicaid,DRG,7102,INFECTIOUS and PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE,,Relative Weights,"$7,922.30 ",IP,"7,922.30","7,922.30",,,,,,
Molina Medicaid,DRG,7103,INFECTIOUS and PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE,,Relative Weights,"$12,117.63 ",IP,"12,117.63","12,117.63",,,,,,
Molina Medicaid,DRG,7104,INFECTIOUS and PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE,,Relative Weights,"$24,582.32 ",IP,"24,582.32","24,582.32",,,,,,
Molina Medicaid,DRG,7111,POSTOP POSTTRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE,,Relative Weights,"$5,432.73 ",IP,"5,432.73","5,432.73",,,,,,
Molina Medicaid,DRG,7112,POSTOP POSTTRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE,,Relative Weights,"$7,124.05 ",IP,"7,124.05","7,124.05",,,,,,
Molina Medicaid,DRG,7113,POSTOP POSTTRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE,,Relative Weights,"$12,166.42 ",IP,"12,166.42","12,166.42",,,,,,
Molina Medicaid,DRG,7114,POSTOP POSTTRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE,,Relative Weights,"$25,010.82 ",IP,"25,010.82","25,010.82",,,,,,
Molina Medicaid,DRG,7201,SEPTICEMIA and DISSEMINATED INFECTIONS,,Relative Weights,"$2,801.24 ",IP,"2,801.24","2,801.24",,,,,,
Molina Medicaid,DRG,7202,SEPTICEMIA and DISSEMINATED INFECTIONS,,Relative Weights,"$3,678.52 ",IP,"3,678.52","3,678.52",,,,,,
Molina Medicaid,DRG,7203,SEPTICEMIA and DISSEMINATED INFECTIONS,,Relative Weights,"$5,399.74 ",IP,"5,399.74","5,399.74",,,,,,
Molina Medicaid,DRG,7204,SEPTICEMIA and DISSEMINATED INFECTIONS,,Relative Weights,"$10,740.72 ",IP,"10,740.72","10,740.72",,,,,,
Molina Medicaid,DRG,7211,"POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS",,Relative Weights,"$2,917.38 ",IP,"2,917.38","2,917.38",,,,,,
Molina Medicaid,DRG,7212,POSTOPERATIVE POSTTRAUMATIC OTHER DEVICE INFECTIONS,,Relative Weights,"$3,837.27 ",IP,"3,837.27","3,837.27",,,,,,
Molina Medicaid,DRG,7213,POSTOPERATIVE POSTTRAUMATIC OTHER DEVICE INFECTIONS,,Relative Weights,"$6,182.18 ",IP,"6,182.18","6,182.18",,,,,,
Molina Medicaid,DRG,7214,POSTOPERATIVE POSTTRAUMATIC OTHER DEVICE INFECTIONS,,Relative Weights,"$12,158.86 ",IP,"12,158.86","12,158.86",,,,,,
Molina Medicaid,DRG,7221,FEVER,,Relative Weights,"$1,952.14 ",IP,"1,952.14","1,952.14",,,,,,
Molina Medicaid,DRG,7222,FEVER,,Relative Weights,"$2,920.13 ",IP,"2,920.13","2,920.13",,,,,,
Molina Medicaid,DRG,7223,FEVER,,Relative Weights,"$3,952.39 ",IP,"3,952.39","3,952.39",,,,,,
Molina Medicaid,DRG,7224,FEVER,,Relative Weights,"$6,941.25 ",IP,"6,941.25","6,941.25",,,,,,
Molina Medicaid,DRG,7231,VIRAL ILLNESS,,Relative Weights,"$1,908.50 ",IP,"1,908.50","1,908.50",,,,,,
Molina Medicaid,DRG,7232,VIRAL ILLNESS,,Relative Weights,"$2,685.44 ",IP,"2,685.44","2,685.44",,,,,,
Molina Medicaid,DRG,7233,VIRAL ILLNESS,,Relative Weights,"$4,131.07 ",IP,"4,131.07","4,131.07",,,,,,
Molina Medicaid,DRG,7234,VIRAL ILLNESS,,Relative Weights,"$10,429.39 ",IP,"10,429.39","10,429.39",,,,,,
Molina Medicaid,DRG,7241,OTHER INFECTIOUS and PARASITIC DISEASES,,Relative Weights,"$3,048.31 ",IP,"3,048.31","3,048.31",,,,,,
Molina Medicaid,DRG,7242,OTHER INFECTIOUS and PARASITIC DISEASES,,Relative Weights,"$3,655.49 ",IP,"3,655.49","3,655.49",,,,,,
Molina Medicaid,DRG,7243,OTHER INFECTIOUS and PARASITIC DISEASES,,Relative Weights,"$5,820.68 ",IP,"5,820.68","5,820.68",,,,,,
Molina Medicaid,DRG,7244,OTHER INFECTIOUS and PARASITIC DISEASES,,Relative Weights,"$13,099.02 ",IP,"13,099.02","13,099.02",,,,,,
Molina Medicaid,DRG,7401,MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE,,Relative Weights,"$6,032.70 ",IP,"6,032.70","6,032.70",,,,,,
Molina Medicaid,DRG,7402,MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE,,Relative Weights,"$6,703.46 ",IP,"6,703.46","6,703.46",,,,,,
Molina Medicaid,DRG,7403,MENTAL ILLNESS DIAGNOSIS W O.R. PROCEDURE,,Relative Weights,"$13,324.79 ",IP,"13,324.79","13,324.79",,,,,,
Molina Medicaid,DRG,7404,MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE,,Relative Weights,"$26,668.81 ",IP,"26,668.81","26,668.81",,,,,,
Molina Medicaid,DRG,7501,SCHIZOPHRENIA,,Relative Weights,"$2,530.12 ",IP,"2,530.12","2,530.12",,,,,,
Molina Medicaid,DRG,7502,SCHIZOPHRENIA,,Relative Weights,"$2,708.80 ",IP,"2,708.80","2,708.80",,,,,,
Molina Medicaid,DRG,7503,SCHIZOPHRENIA,,Relative Weights,"$4,799.08 ",IP,"4,799.08","4,799.08",,,,,,
Molina Medicaid,DRG,7504,SCHIZOPHRENIA,,Relative Weights,"$13,473.58 ",IP,"13,473.58","13,473.58",,,,,,
Molina Medicaid,DRG,7511,MAJOR DEPRESSIVE DISORDERS and OTHERUNSPECIFIED PSYCHOSES,,Relative Weights,"$1,760.40 ",IP,"1,760.40","1,760.40",,,,,,
Molina Medicaid,DRG,7512,MAJOR DEPRESSIVE DISORDERS & OTHER/UNSPECIFIED PSYCHOSES,,Relative Weights,"$2,237.01 ",IP,"2,237.01","2,237.01",,,,,,
Molina Medicaid,DRG,7513,MAJOR DEPRESSIVE DISORDERS and OTHERUNSPECIFIED PSYCHOSES,,Relative Weights,"$3,773.70 ",IP,"3,773.70","3,773.70",,,,,,
Molina Medicaid,DRG,7514,MAJOR DEPRESSIVE DISORDERS and OTHERUNSPECIFIED PSYCHOSES,,Relative Weights,"$8,518.14 ",IP,"8,518.14","8,518.14",,,,,,
Molina Medicaid,DRG,7521,DISORDERS OF PERSONALITY and IMPULSE CONTROL,,Relative Weights,"$1,687.20 ",IP,"1,687.20","1,687.20",,,,,,
Molina Medicaid,DRG,7522,DISORDERS OF PERSONALITY & IMPULSE CONTROL,,Relative Weights,"$2,102.30 ",IP,"2,102.30","2,102.30",,,,,,
Molina Medicaid,DRG,7523,DISORDERS OF PERSONALITY & IMPULSE CONTROL,,Relative Weights,"$3,885.72 ",IP,"3,885.72","3,885.72",,,,,,
Molina Medicaid,DRG,7524,DISORDERS OF PERSONALITY and IMPULSE CONTROL,,Relative Weights,"$13,737.14 ",IP,"13,737.14","13,737.14",,,,,,
Molina Medicaid,DRG,7531,BIPOLAR DISORDERS,,Relative Weights,"$1,873.11 ",IP,"1,873.11","1,873.11",,,,,,
Molina Medicaid,DRG,7532,BIPOLAR DISORDERS,,Relative Weights,"$2,183.40 ",IP,"2,183.40","2,183.40",,,,,,
Molina Medicaid,DRG,7533,BIPOLAR DISORDERS,,Relative Weights,"$3,541.07 ",IP,"3,541.07","3,541.07",,,,,,
Molina Medicaid,DRG,7534,BIPOLAR DISORDERS,,Relative Weights,"$10,043.84 ",IP,"10,043.84","10,043.84",,,,,,
Molina Medicaid,DRG,7541,DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,,Relative Weights,"$1,523.64 ",IP,"1,523.64","1,523.64",,,,,,
Molina Medicaid,DRG,7542,DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,,Relative Weights,"$2,007.46 ",IP,"2,007.46","2,007.46",,,,,,
Molina Medicaid,DRG,7543,DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,,Relative Weights,"$3,012.23 ",IP,"3,012.23","3,012.23",,,,,,
Molina Medicaid,DRG,7544,DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,,Relative Weights,"$7,979.68 ",IP,"7,979.68","7,979.68",,,,,,
Molina Medicaid,DRG,7551,ADJUSTMENT DISORDERS and NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,,Relative Weights,"$1,532.57 ",IP,"1,532.57","1,532.57",,,,,,
Molina Medicaid,DRG,7552,ADJUSTMENT DISORDERS and NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,,Relative Weights,"$2,506.06 ",IP,"2,506.06","2,506.06",,,,,,
Molina Medicaid,DRG,7553,ADJUSTMENT DISORDERS and NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,,Relative Weights,"$3,538.32 ",IP,"3,538.32","3,538.32",,,,,,
Molina Medicaid,DRG,7554,ADJUSTMENT DISORDERS and NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,,Relative Weights,"$6,118.26 ",IP,"6,118.26","6,118.26",,,,,,
Molina Medicaid,DRG,7561,ACUTE ANXIETY and DELIRIUM STATES,,Relative Weights,"$2,496.79 ",IP,"2,496.79","2,496.79",,,,,,
Molina Medicaid,DRG,7562,ACUTE ANXIETY & DELIRIUM STATES,,Relative Weights,"$3,057.58 ",IP,"3,057.58","3,057.58",,,,,,
Molina Medicaid,DRG,7563,ACUTE ANXIETY and DELIRIUM STATES,,Relative Weights,"$3,397.43 ",IP,"3,397.43","3,397.43",,,,,,
Molina Medicaid,DRG,7564,ACUTE ANXIETY and DELIRIUM STATES,,Relative Weights,"$7,384.52 ",IP,"7,384.52","7,384.52",,,,,,
Molina Medicaid,DRG,7571,ORGANIC MENTAL HEALTH DISTURBANCES,,Relative Weights,"$2,504.35 ",IP,"2,504.35","2,504.35",,,,,,
Molina Medicaid,DRG,7572,ORGANIC MENTAL HEALTH DISTURBANCES,,Relative Weights,"$3,161.02 ",IP,"3,161.02","3,161.02",,,,,,
Molina Medicaid,DRG,7573,ORGANIC MENTAL HEALTH DISTURBANCES,,Relative Weights,"$5,750.24 ",IP,"5,750.24","5,750.24",,,,,,
Molina Medicaid,DRG,7574,ORGANIC MENTAL HEALTH DISTURBANCES,,Relative Weights,"$15,933.94 ",IP,"15,933.94","15,933.94",,,,,,
Molina Medicaid,DRG,7581,BEHAVIORAL DISORDERS,,Relative Weights,"$2,326.35 ",IP,"2,326.35","2,326.35",,,,,,
Molina Medicaid,DRG,7582,BEHAVIORAL DISORDERS,,Relative Weights,"$2,881.65 ",IP,"2,881.65","2,881.65",,,,,,
Molina Medicaid,DRG,7583,BEHAVIORAL DISORDERS,,Relative Weights,"$4,037.26 ",IP,"4,037.26","4,037.26",,,,,,
Molina Medicaid,DRG,7584,BEHAVIORAL DISORDERS,,Relative Weights,"$5,464.00 ",IP,"5,464.00","5,464.00",,,,,,
Molina Medicaid,DRG,7591,EATING DISORDERS,,Relative Weights,"$4,564.04 ",IP,"4,564.04","4,564.04",,,,,,
Molina Medicaid,DRG,7592,EATING DISORDERS,,Relative Weights,"$5,955.04 ",IP,"5,955.04","5,955.04",,,,,,
Molina Medicaid,DRG,7593,EATING DISORDERS,,Relative Weights,"$9,440.78 ",IP,"9,440.78","9,440.78",,,,,,
Molina Medicaid,DRG,7594,EATING DISORDERS,,Relative Weights,"$12,954.01 ",IP,"12,954.01","12,954.01",,,,,,
Molina Medicaid,DRG,7601,OTHER MENTAL HEALTH DISORDERS,,Relative Weights,"$2,553.48 ",IP,"2,553.48","2,553.48",,,,,,
Molina Medicaid,DRG,7602,OTHER MENTAL HEALTH DISORDERS,,Relative Weights,"$3,467.19 ",IP,"3,467.19","3,467.19",,,,,,
Molina Medicaid,DRG,7603,OTHER MENTAL HEALTH DISORDERS,,Relative Weights,"$6,902.07 ",IP,"6,902.07","6,902.07",,,,,,
Molina Medicaid,DRG,7604,OTHER MENTAL HEALTH DISORDERS,,Relative Weights,"$12,546.82 ",IP,"12,546.82","12,546.82",,,,,,
Molina Medicaid,DRG,7701,DRUG and ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE,,Relative Weights,"$1,041.53 ",IP,"1,041.53","1,041.53",,,,,,
Molina Medicaid,DRG,7702,"DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE",,Relative Weights,"$1,522.95 ",IP,"1,522.95","1,522.95",,,,,,
Molina Medicaid,DRG,7703,"DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE",,Relative Weights,"$2,633.89 ",IP,"2,633.89","2,633.89",,,,,,
Molina Medicaid,DRG,7704,DRUG and ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE,,Relative Weights,"$6,153.65 ",IP,"6,153.65","6,153.65",,,,,,
Molina Medicaid,DRG,7721,ALCOHOL and DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY,,Relative Weights,"$2,743.85 ",IP,"2,743.85","2,743.85",,,,,,
Molina Medicaid,DRG,7722,ALCOHOL and DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY,,Relative Weights,"$3,502.58 ",IP,"3,502.58","3,502.58",,,,,,
Molina Medicaid,DRG,7723,ALCOHOL and DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY,,Relative Weights,"$4,241.72 ",IP,"4,241.72","4,241.72",,,,,,
Molina Medicaid,DRG,7724,ALCOHOL & DRUG DEPENDENCE W REHAB OR REHAB/DETOX THERAPY,,Relative Weights,"$9,550.40 ",IP,"9,550.40","9,550.40",,,,,,
Molina Medicaid,DRG,7731,OPIOID ABUSE and DEPENDENCE,,Relative Weights,"$1,275.88 ",IP,"1,275.88","1,275.88",,,,,,
Molina Medicaid,DRG,7732,OPIOID ABUSE and DEPENDENCE,,Relative Weights,"$1,881.01 ",IP,"1,881.01","1,881.01",,,,,,
Molina Medicaid,DRG,7733,OPIOID ABUSE and DEPENDENCE,,Relative Weights,"$3,476.12 ",IP,"3,476.12","3,476.12",,,,,,
Molina Medicaid,DRG,7734,OPIOID ABUSE & DEPENDENCE,,Relative Weights,"$9,565.86 ",IP,"9,565.86","9,565.86",,,,,,
Molina Medicaid,DRG,7741,COCAINE ABUSE and DEPENDENCE,,Relative Weights,"$1,761.43 ",IP,"1,761.43","1,761.43",,,,,,
Molina Medicaid,DRG,7742,COCAINE ABUSE and DEPENDENCE,,Relative Weights,"$1,956.95 ",IP,"1,956.95","1,956.95",,,,,,
Molina Medicaid,DRG,7743,COCAINE ABUSE and DEPENDENCE,,Relative Weights,"$3,314.62 ",IP,"3,314.62","3,314.62",,,,,,
Molina Medicaid,DRG,7744,COCAINE ABUSE and DEPENDENCE,,Relative Weights,"$9,105.40 ",IP,"9,105.40","9,105.40",,,,,,
Molina Medicaid,DRG,7751,ALCOHOL ABUSE and DEPENDENCE,,Relative Weights,"$1,741.50 ",IP,"1,741.50","1,741.50",,,,,,
Molina Medicaid,DRG,7752,ALCOHOL ABUSE & DEPENDENCE,,Relative Weights,"$2,441.81 ",IP,"2,441.81","2,441.81",,,,,,
Molina Medicaid,DRG,7753,ALCOHOL ABUSE and DEPENDENCE,,Relative Weights,"$3,986.06 ",IP,"3,986.06","3,986.06",,,,,,
Molina Medicaid,DRG,7754,ALCOHOL ABUSE and DEPENDENCE,,Relative Weights,"$10,751.37 ",IP,"10,751.37","10,751.37",,,,,,
Molina Medicaid,DRG,7761,OTHER DRUG ABUSE and DEPENDENCE,,Relative Weights,"$2,414.66 ",IP,"2,414.66","2,414.66",,,,,,
Molina Medicaid,DRG,7762,OTHER DRUG ABUSE & DEPENDENCE,,Relative Weights,"$2,653.48 ",IP,"2,653.48","2,653.48",,,,,,
Molina Medicaid,DRG,7763,OTHER DRUG ABUSE & DEPENDENCE,,Relative Weights,"$4,175.40 ",IP,"4,175.40","4,175.40",,,,,,
Molina Medicaid,DRG,7764,OTHER DRUG ABUSE and DEPENDENCE,,Relative Weights,"$7,699.28 ",IP,"7,699.28","7,699.28",,,,,,
Molina Medicaid,DRG,7921,EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$7,773.51 ",IP,"7,773.51","7,773.51",,,,,,
Molina Medicaid,DRG,7922,EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$8,931.53 ",IP,"8,931.53","8,931.53",,,,,,
Molina Medicaid,DRG,7923,EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$13,005.21 ",IP,"13,005.21","13,005.21",,,,,,
Molina Medicaid,DRG,7924,EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$27,591.45 ",IP,"27,591.45","27,591.45",,,,,,
Molina Medicaid,DRG,7931,MODERATELY EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$4,608.37 ",IP,"4,608.37","4,608.37",,,,,,
Molina Medicaid,DRG,7932,MODERATELY EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$6,350.90 ",IP,"6,350.90","6,350.90",,,,,,
Molina Medicaid,DRG,7933,MODERATELY EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$9,808.12 ",IP,"9,808.12","9,808.12",,,,,,
Molina Medicaid,DRG,7934,MODERATELY EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$20,177.03 ",IP,"20,177.03","20,177.03",,,,,,
Molina Medicaid,DRG,7941,NONEXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$3,990.87 ",IP,"3,990.87","3,990.87",,,,,,
Molina Medicaid,DRG,7942,NONEXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$5,327.92 ",IP,"5,327.92","5,327.92",,,,,,
Molina Medicaid,DRG,7943,NONEXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$7,911.30 ",IP,"7,911.30","7,911.30",,,,,,
Molina Medicaid,DRG,7944,NON-EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$16,457.28 ",IP,"16,457.28","16,457.28",,,,,,
Molina Medicaid,DRG,8101,HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION,,Relative Weights,"$2,594.03 ",IP,"2,594.03","2,594.03",,,,,,
Molina Medicaid,DRG,8102,HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION,,Relative Weights,"$3,420.11 ",IP,"3,420.11","3,420.11",,,,,,
Molina Medicaid,DRG,8103,HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION,,Relative Weights,"$5,351.98 ",IP,"5,351.98","5,351.98",,,,,,
Molina Medicaid,DRG,8104,HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION,,Relative Weights,"$10,772.68 ",IP,"10,772.68","10,772.68",,,,,,
Molina Medicaid,DRG,8111,ALLERGIC REACTIONS,,Relative Weights,"$1,582.40 ",IP,"1,582.40","1,582.40",,,,,,
Molina Medicaid,DRG,8112,ALLERGIC REACTIONS,,Relative Weights,"$2,325.66 ",IP,"2,325.66","2,325.66",,,,,,
Molina Medicaid,DRG,8113,ALLERGIC REACTIONS,,Relative Weights,"$4,003.24 ",IP,"4,003.24","4,003.24",,,,,,
Molina Medicaid,DRG,8114,ALLERGIC REACTIONS,,Relative Weights,"$9,358.65 ",IP,"9,358.65","9,358.65",,,,,,
Molina Medicaid,DRG,8121,POISONING OF MEDICINAL AGENTS,,Relative Weights,"$1,778.95 ",IP,"1,778.95","1,778.95",,,,,,
Molina Medicaid,DRG,8122,POISONING OF MEDICINAL AGENTS,,Relative Weights,"$2,471.70 ",IP,"2,471.70","2,471.70",,,,,,
Molina Medicaid,DRG,8123,POISONING OF MEDICINAL AGENTS,,Relative Weights,"$3,713.91 ",IP,"3,713.91","3,713.91",,,,,,
Molina Medicaid,DRG,8124,POISONING OF MEDICINAL AGENTS,,Relative Weights,"$7,487.95 ",IP,"7,487.95","7,487.95",,,,,,
Molina Medicaid,DRG,8131,OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$2,963.09 ",IP,"2,963.09","2,963.09",,,,,,
Molina Medicaid,DRG,8132,OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$3,546.91 ",IP,"3,546.91","3,546.91",,,,,,
Molina Medicaid,DRG,8133,OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$5,048.90 ",IP,"5,048.90","5,048.90",,,,,,
Molina Medicaid,DRG,8134,OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$10,108.45 ",IP,"10,108.45","10,108.45",,,,,,
Molina Medicaid,DRG,8151,OTHER INJURY POISONING and TOXIC EFFECT DIAGNOSES,,Relative Weights,"$2,225.32 ",IP,"2,225.32","2,225.32",,,,,,
Molina Medicaid,DRG,8152,"OTHER INJURY, POISONING & TOXIC EFFECT DIAGNOSES",,Relative Weights,"$3,062.74 ",IP,"3,062.74","3,062.74",,,,,,
Molina Medicaid,DRG,8153,OTHER INJURY POISONING and TOXIC EFFECT DIAGNOSES,,Relative Weights,"$5,006.29 ",IP,"5,006.29","5,006.29",,,,,,
Molina Medicaid,DRG,8154,OTHER INJURY POISONING and TOXIC EFFECT DIAGNOSES,,Relative Weights,"$14,243.99 ",IP,"14,243.99","14,243.99",,,,,,
Molina Medicaid,DRG,8161,TOXIC EFFECTS OF NONMEDICINAL SUBSTANCES,,Relative Weights,"$2,832.85 ",IP,"2,832.85","2,832.85",,,,,,
Molina Medicaid,DRG,8162,TOXIC EFFECTS OF NONMEDICINAL SUBSTANCES,,Relative Weights,"$3,147.27 ",IP,"3,147.27","3,147.27",,,,,,
Molina Medicaid,DRG,8163,TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES,,Relative Weights,"$3,543.13 ",IP,"3,543.13","3,543.13",,,,,,
Molina Medicaid,DRG,8164,TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES,,Relative Weights,"$7,485.21 ",IP,"7,485.21","7,485.21",,,,,,
Molina Medicaid,DRG,8171,OVERDOSE,,Relative Weights,"$1,970.70 ",IP,"1,970.70","1,970.70",,,,,,
Molina Medicaid,DRG,8172,OVERDOSE,,Relative Weights,"$2,320.16 ",IP,"2,320.16","2,320.16",,,,,,
Molina Medicaid,DRG,8173,OVERDOSE,,Relative Weights,"$3,714.94 ",IP,"3,714.94","3,714.94",,,,,,
Molina Medicaid,DRG,8174,OVERDOSE,,Relative Weights,"$7,902.37 ",IP,"7,902.37","7,902.37",,,,,,
Molina Medicaid,DRG,8411,EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT,,Relative Weights,"$22,662.13 ",IP,"22,662.13","22,662.13",,,,,,
Molina Medicaid,DRG,8412,EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT,,Relative Weights,"$23,053.18 ",IP,"23,053.18","23,053.18",,,,,,
Molina Medicaid,DRG,8413,EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT,,Relative Weights,"$35,475.26 ",IP,"35,475.26","35,475.26",,,,,,
Molina Medicaid,DRG,8414,EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT,,Relative Weights,"$76,935.80 ",IP,"76,935.80","76,935.80",,,,,,
Molina Medicaid,DRG,8421,BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS,,Relative Weights,"$7,378.34 ",IP,"7,378.34","7,378.34",,,,,,
Molina Medicaid,DRG,8422,BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS,,Relative Weights,"$11,298.08 ",IP,"11,298.08","11,298.08",,,,,,
Molina Medicaid,DRG,8423,BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS,,Relative Weights,"$20,251.94 ",IP,"20,251.94","20,251.94",,,,,,
Molina Medicaid,DRG,8424,BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS,,Relative Weights,"$47,998.02 ",IP,"47,998.02","47,998.02",,,,,,
Molina Medicaid,DRG,8431,EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT,,Relative Weights,"$3,499.14 ",IP,"3,499.14","3,499.14",,,,,,
Molina Medicaid,DRG,8432,EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT,,Relative Weights,"$3,888.47 ",IP,"3,888.47","3,888.47",,,,,,
Molina Medicaid,DRG,8433,EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT,,Relative Weights,"$4,320.07 ",IP,"4,320.07","4,320.07",,,,,,
Molina Medicaid,DRG,8434,EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS W/O SKIN GRAFT,,Relative Weights,"$12,575.34 ",IP,"12,575.34","12,575.34",,,,,,
Molina Medicaid,DRG,8441,PARTIAL THICKNESS BURNS WO SKIN GRAFT,,Relative Weights,"$2,201.96 ",IP,"2,201.96","2,201.96",,,,,,
Molina Medicaid,DRG,8442,PARTIAL THICKNESS BURNS WO SKIN GRAFT,,Relative Weights,"$3,652.06 ",IP,"3,652.06","3,652.06",,,,,,
Molina Medicaid,DRG,8443,PARTIAL THICKNESS BURNS WO SKIN GRAFT,,Relative Weights,"$7,050.86 ",IP,"7,050.86","7,050.86",,,,,,
Molina Medicaid,DRG,8444,PARTIAL THICKNESS BURNS W/O SKIN GRAFT,,Relative Weights,"$19,183.95 ",IP,"19,183.95","19,183.95",,,,,,
Molina Medicaid,DRG,8501,PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE,,Relative Weights,"$9,879.93 ",IP,"9,879.93","9,879.93",,,,,,
Molina Medicaid,DRG,8502,PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE,,Relative Weights,"$12,498.36 ",IP,"12,498.36","12,498.36",,,,,,
Molina Medicaid,DRG,8503,PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE,,Relative Weights,"$15,265.59 ",IP,"15,265.59","15,265.59",,,,,,
Molina Medicaid,DRG,8504,"PROCEDURE W DIAG OF REHAB, AFTERCARE OR OTH CONTACT W HEALTH SERVICE",,Relative Weights,"$33,306.29 ",IP,"33,306.29","33,306.29",,,,,,
Molina Medicaid,DRG,8601,REHABILITATION,REHABILITATION,Relative Weights,"$2,725.99 ",IP,"2,725.99","2,725.99",,,,,,
Molina Medicaid,DRG,8602,REHABILITATION,REHABILITATION,Relative Weights,"$2,784.40 ",IP,"2,784.40","2,784.40",,,,,,
Molina Medicaid,DRG,8603,REHABILITATION,REHABILITATION,Relative Weights,"$4,569.88 ",IP,"4,569.88","4,569.88",,,,,,
Molina Medicaid,DRG,8604,REHABILITATION,REHABILITATION,Relative Weights,"$7,353.25 ",IP,"7,353.25","7,353.25",,,,,,
Molina Medicaid,DRG,8611,"SIGNS, SYMPTOMS & OTHER FACTORS INFLUENCING HEALTH STATUS",,Relative Weights,"$2,528.74 ",IP,"2,528.74","2,528.74",,,,,,
Molina Medicaid,DRG,8612,SIGNS SYMPTOMS and OTHER FACTORS INFLUENCING HEALTH STATUS,,Relative Weights,"$3,061.36 ",IP,"3,061.36","3,061.36",,,,,,
Molina Medicaid,DRG,8613,SIGNS SYMPTOMS and OTHER FACTORS INFLUENCING HEALTH STATUS,,Relative Weights,"$4,043.10 ",IP,"4,043.10","4,043.10",,,,,,
Molina Medicaid,DRG,8614,SIGNS SYMPTOMS and OTHER FACTORS INFLUENCING HEALTH STATUS,,Relative Weights,"$7,783.47 ",IP,"7,783.47","7,783.47",,,,,,
Molina Medicaid,DRG,8621,OTHER AFTERCARE and CONVALESCENCE,,Relative Weights,"$2,738.70 ",IP,"2,738.70","2,738.70",,,,,,
Molina Medicaid,DRG,8622,OTHER AFTERCARE and CONVALESCENCE,,Relative Weights,"$3,392.96 ",IP,"3,392.96","3,392.96",,,,,,
Molina Medicaid,DRG,8623,OTHER AFTERCARE and CONVALESCENCE,,Relative Weights,"$4,971.92 ",IP,"4,971.92","4,971.92",,,,,,
Molina Medicaid,DRG,8624,OTHER AFTERCARE and CONVALESCENCE,,Relative Weights,"$9,845.92 ",IP,"9,845.92","9,845.92",,,,,,
Molina Medicaid,DRG,8631,NEONATAL AFTERCARE,,Relative Weights,"$4,260.96 ",IP,"4,260.96","4,260.96",,,,,,
Molina Medicaid,DRG,8632,NEONATAL AFTERCARE,,Relative Weights,"$10,340.39 ",IP,"10,340.39","10,340.39",,,,,,
Molina Medicaid,DRG,8633,NEONATAL AFTERCARE,,Relative Weights,"$23,505.05 ",IP,"23,505.05","23,505.05",,,,,,
Molina Medicaid,DRG,8634,NEONATAL AFTERCARE,,Relative Weights,"$48,982.51 ",IP,"48,982.51","48,982.51",,,,,,
Molina Medicaid,DRG,8901,HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS,,Relative Weights,"$3,464.78 ",IP,"3,464.78","3,464.78",,,,,,
Molina Medicaid,DRG,8902,HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS,,Relative Weights,"$4,475.73 ",IP,"4,475.73","4,475.73",,,,,,
Molina Medicaid,DRG,8903,HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS,,Relative Weights,"$6,306.22 ",IP,"6,306.22","6,306.22",,,,,,
Molina Medicaid,DRG,8904,HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS,,Relative Weights,"$13,523.40 ",IP,"13,523.40","13,523.40",,,,,,
Molina Medicaid,DRG,8921,HIV W MAJOR HIV RELATED CONDITION,,Relative Weights,"$3,450.69 ",IP,"3,450.69","3,450.69",,,,,,
Molina Medicaid,DRG,8922,HIV W MAJOR HIV RELATED CONDITION,,Relative Weights,"$4,178.15 ",IP,"4,178.15","4,178.15",,,,,,
Molina Medicaid,DRG,8923,HIV W MAJOR HIV RELATED CONDITION,,Relative Weights,"$4,816.26 ",IP,"4,816.26","4,816.26",,,,,,
Molina Medicaid,DRG,8924,HIV W MAJOR HIV RELATED CONDITION,,Relative Weights,"$8,453.20 ",IP,"8,453.20","8,453.20",,,,,,
Molina Medicaid,DRG,8931,HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,,Relative Weights,"$2,817.73 ",IP,"2,817.73","2,817.73",,,,,,
Molina Medicaid,DRG,8932,HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,,Relative Weights,"$4,010.80 ",IP,"4,010.80","4,010.80",,,,,,
Molina Medicaid,DRG,8933,HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,,Relative Weights,"$5,201.12 ",IP,"5,201.12","5,201.12",,,,,,
Molina Medicaid,DRG,8934,HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,,Relative Weights,"$9,134.61 ",IP,"9,134.61","9,134.61",,,,,,
Molina Medicaid,DRG,8941,HIV W ONE SIGNIF HIV COND OR W/O SIGNIF RELATED COND,,Relative Weights,"$2,969.96 ",IP,"2,969.96","2,969.96",,,,,,
Molina Medicaid,DRG,8942,HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND,,Relative Weights,"$3,496.05 ",IP,"3,496.05","3,496.05",,,,,,
Molina Medicaid,DRG,8943,HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND,,Relative Weights,"$4,518.34 ",IP,"4,518.34","4,518.34",,,,,,
Molina Medicaid,DRG,8944,HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND,,Relative Weights,"$6,751.91 ",IP,"6,751.91","6,751.91",,,,,,
Molina Medicaid,DRG,9101,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$13,920.63 ",IP,"13,920.63","13,920.63",,,,,,
Molina Medicaid,DRG,9102,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$15,317.47 ",IP,"15,317.47","15,317.47",,,,,,
Molina Medicaid,DRG,9103,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$18,619.37 ",IP,"18,619.37","18,619.37",,,,,,
Molina Medicaid,DRG,9104,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$36,457.00 ",IP,"36,457.00","36,457.00",,,,,,
Molina Medicaid,DRG,9111,EXTENSIVE ABDOMINAL/THORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA,,Relative Weights,"$7,838.80 ",IP,"7,838.80","7,838.80",,,,,,
Molina Medicaid,DRG,9112,EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA,,Relative Weights,"$10,303.63 ",IP,"10,303.63","10,303.63",,,,,,
Molina Medicaid,DRG,9113,EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA,,Relative Weights,"$13,414.47 ",IP,"13,414.47","13,414.47",,,,,,
Molina Medicaid,DRG,9114,EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA,,Relative Weights,"$32,085.73 ",IP,"32,085.73","32,085.73",,,,,,
Molina Medicaid,DRG,9121,MUSCULOSKELETAL and OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$8,688.93 ",IP,"8,688.93","8,688.93",,,,,,
Molina Medicaid,DRG,9122,MUSCULOSKELETAL and OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$9,567.24 ",IP,"9,567.24","9,567.24",,,,,,
Molina Medicaid,DRG,9123,MUSCULOSKELETAL & OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$14,948.76 ",IP,"14,948.76","14,948.76",,,,,,
Molina Medicaid,DRG,9124,MUSCULOSKELETAL & OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$30,211.60 ",IP,"30,211.60","30,211.60",,,,,,
Molina Medicaid,DRG,9301,MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE,,Relative Weights,"$3,875.76 ",IP,"3,875.76","3,875.76",,,,,,
Molina Medicaid,DRG,9302,MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE,,Relative Weights,"$4,609.06 ",IP,"4,609.06","4,609.06",,,,,,
Molina Medicaid,DRG,9303,MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE,,Relative Weights,"$7,139.17 ",IP,"7,139.17","7,139.17",,,,,,
Molina Medicaid,DRG,9304,MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE,,Relative Weights,"$15,709.89 ",IP,"15,709.89","15,709.89",,,,,,
Molina Medicaid,DRG,9501,EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$7,265.63 ",IP,"7,265.63","7,265.63",,,,,,
Molina Medicaid,DRG,9502,EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$9,410.20 ",IP,"9,410.20","9,410.20",,,,,,
Molina Medicaid,DRG,9503,EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$12,679.80 ",IP,"12,679.80","12,679.80",,,,,,
Molina Medicaid,DRG,9504,EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$27,388.02 ",IP,"27,388.02","27,388.02",,,,,,
Molina Medicaid,DRG,9511,MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$5,641.31 ",IP,"5,641.31","5,641.31",,,,,,
Molina Medicaid,DRG,9512,MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$7,394.49 ",IP,"7,394.49","7,394.49",,,,,,
Molina Medicaid,DRG,9513,MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$11,184.68 ",IP,"11,184.68","11,184.68",,,,,,
Molina Medicaid,DRG,9514,MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$22,584.13 ",IP,"22,584.13","22,584.13",,,,,,
Molina Medicaid,DRG,9521,NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$4,663.69 ",IP,"4,663.69","4,663.69",,,,,,
Molina Medicaid,DRG,9522,NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$6,212.76 ",IP,"6,212.76","6,212.76",,,,,,
Molina Medicaid,DRG,9523,NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$9,852.10 ",IP,"9,852.10","9,852.10",,,,,,
Molina Medicaid,DRG,9524,NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$20,519.28 ",IP,"20,519.28","20,519.28",,,,,,
Molina Medicaid,CPT,100,Anesth salivary gland,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,102,Anesth repair of cleft lip,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,103,Anesth blepharoplasty,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,104,Anesth electroshock,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,120,Anesth ear surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,124,Anesth ear exam,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,126,Anesth tympanotomy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,140,Anesth procedures on eye,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,142,Anesth lens surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,144,Anesth corneal transplant,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,145,Anesth vitreoretinal surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,147,Anesth iridectomy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,148,Anesth eye exam,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,160,Anesth nose/sinus surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,162,Anesth nose/sinus surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,164,Anesth biopsy of nose,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,170,Anesth procedure on mouth,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,172,Anesth cleft palate repair,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,174,Anesth pharyngeal surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,176,Anesth pharyngeal surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,190,Anesth face/skull bone surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,192,Anesth facial bone surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,210,Anesth cranial surg nos,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,211,Anesth cran surg hemotoma,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,212,Anesth skull drainage,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,214,Anesth skull drainage,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,215,Anesth skull repair/fract,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,216,Anesth head vessel surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,218,Anesth special head surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,220,Anesth intrcrn nerve,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,222,Anesth head nerve surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,300,Anesth head/neck/ptrunk,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,320,Anesth neck organ 1yr/>,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,322,Anesth biopsy of thyroid,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,326,Anesth larynx/trach < 1 yr,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,350,Anesth neck vessel surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,352,Anesth neck vessel surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,400,Anesth skin ext/per/atrunk,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,402,Anesth surgery of breast,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,404,Anesth surgery of breast,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,406,Anesth surgery of breast,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,410,Anesth correct heart rhythm,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,450,Anesth surgery of shoulder,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,454,Anesth collar bone biopsy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,470,Anesth removal of rib,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,472,Anesth chest wall repair,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,474,Anesth surgery of rib,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,500,Anesth esophageal surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,520,Anesth chest procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,522,Anesth chest lining biopsy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,524,Anesth chest drainage,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,528,Anes mediascpy & dx thorscpy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,529,Anes medscpy&thorscpy 1 lung,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,530,Anesth pacemaker insertion,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,532,Anesth vascular access,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,534,Anesth cardioverter/defib,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,537,Anesth cardiac electrophys,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,539,Anesth trach-bronch reconst,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,540,Anesth chest surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,541,Anesth one lung ventilation,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,542,Anesthesia removal pleura,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,546,Anesth lung chest wall surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,548,Anesth trachea bronchi surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,550,Anesth sternal debridement,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,560,Anesth heart surg w/o pump,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,561,Anesth heart surg <1 yr,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,562,Anesth hrt surg w/pmp age 1+,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,563,Anesth heart surg w/arrest,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,566,Anesth cabg w/o pump,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,567,Anesth cabg w/pump,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,580,Anesth heart/lung transplnt,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,600,Anesth spine cord surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,604,Anesth sitting procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,620,Anesth spine cord surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,625,Anes spine tranthor w/o vent,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,626,Anes spine transthor w/vent,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,630,Anesth spine cord surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,632,Anesth removal of nerves,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,635,Anesth lumbar puncture,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,640,Anesth spine manipulation,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,670,Anesth spine cord surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,700,Anesth abdominal wall surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,702,Anesth for liver biopsy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,730,Anesth abdominal wall surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,731,Anes upr gi ndsc px nos,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,732,Anes upr gi ndsc px ercp,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,740,Anesth upper gi visualize,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,750,Anesth repair of hernia,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,752,Anesth repair of hernia,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,754,Anesth repair of hernia,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,756,Anesth repair of hernia,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,770,Anesth blood vessel repair,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,790,Anesth surg upper abdomen,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,792,Anesth hemorr/excise liver,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,794,Anesth pancreas removal,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,796,Anesth for liver transplant,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,797,Anesth surgery for obesity,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,800,Anesth abdominal wall surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,802,Anesth fat layer removal,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,810,Anesth low intestine scope,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,811,Anes lwr intst ndsc nos,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,812,Anes lwr intst scr colsc,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,813,Anes upr lwr gi ndsc px,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,820,Anesth abdominal wall surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,830,Anesth repair of hernia,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,832,Anesth repair of hernia,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,834,Anesth hernia repair < 1 yr,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,836,Anesth hernia repair preemie,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,840,Anesth surg lower abdomen,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,842,Anesth amniocentesis,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,844,Anesth pelvis surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,846,Anesth hysterectomy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,848,Anesth pelvic organ surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,851,Anesth tubal ligation,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,860,Anesth surgery of abdomen,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,862,Anesth kidney/ureter surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,864,Anesth removal of bladder,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,865,Anesth removal of prostate,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,866,Anesth removal of adrenal,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,868,Anesth kidney transplant,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,870,Anesth bladder stone surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,872,Anesth kidney stone destruct,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,873,Anesth kidney stone destruct,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,880,Anesth abdomen vessel surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,882,Anesth major vein ligation,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,902,Anesth anorectal surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,904,Anesth perineal surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,906,Anesth removal of vulva,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,908,Anesth removal of prostate,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,910,Anesth bladder surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,912,Anesth bladder tumor surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,914,Anesth removal of prostate,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,916,Anesth bleeding control,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,918,Anesth stone removal,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,920,Anesth genitalia surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,921,Anesth vasectomy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,922,Anesth sperm duct surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,924,Anesth testis exploration,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,926,Anesth removal of testis,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,928,Anesth removal of testis,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,930,Anesth testis suspension,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,932,Anesth amputation of penis,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,934,Anesth penis nodes removal,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,936,Anesth penis nodes removal,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,938,Anesth insert penis device,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,940,Anesth vaginal procedures,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,942,Anesth surg on vag/urethral,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,944,Anesth vaginal hysterectomy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,948,Anesth repair of cervix,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,950,Anesth vaginal endoscopy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,952,Anesth hysteroscope/graph,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1112,Anesth bone aspirate/bx,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1120,Anesth pelvis surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1130,Anesth body cast procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1140,Anesth amputation at pelvis,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1150,Anesth pelvic tumor surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1160,Anesth pelvis procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1170,Anesth pelvis surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1173,Anesth fx repair pelvis,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1180,Anesth pelvis nerve removal,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1190,Anesth pelvis nerve removal,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1200,Anesth hip joint procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1202,Anesth arthroscopy of hip,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1210,Anesth hip joint surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1212,Anesth hip disarticulation,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1214,Anesth hip arthroplasty,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1215,Anesth revise hip repair,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1220,Anesth procedure on femur,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1230,Anesth surgery of femur,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1232,Anesth amputation of femur,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1234,Anesth radical femur surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1250,Anesth upper leg surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1260,Anesth upper leg veins surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1270,Anesth thigh arteries surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1272,Anesth femoral artery surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1274,Anesth femoral embolectomy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1320,Anesth knee area surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1340,Anesth knee area procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1360,Anesth knee area surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1380,Anesth knee joint procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1382,Anesth dx knee arthroscopy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1390,Anesth knee area procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1392,Anesth knee area surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1400,Anesth knee joint surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1402,Anesth knee arthroplasty,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1404,Anesth amputation at knee,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1420,Anesth knee joint casting,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1430,Anesth knee veins surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1432,Anesth knee vessel surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1440,Anesth knee arteries surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1442,Anesth knee artery surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1444,Anesth knee artery repair,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1462,Anesth lower leg procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1464,Anesth ankle/ft arthroscopy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1470,Anesth lower leg surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1472,Anesth achilles tendon surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1474,Anesth lower leg surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1480,Anesth lower leg bone surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1482,Anesth radical leg surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1484,Anesth lower leg revision,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1486,Anesth ankle replacement,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1490,Anesth lower leg casting,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1500,Anesth leg arteries surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1502,Anesth lwr leg embolectomy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1520,Anesth lower leg vein surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1522,Anesth lower leg vein surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1610,Anesth surgery of shoulder,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1620,Anesth shoulder procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1622,Anes dx shoulder arthroscopy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1630,Anesth surgery of shoulder,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1634,Anesth shoulder joint amput,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1636,Anesth forequarter amput,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1638,Anesth shoulder replacement,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1650,Anesth shoulder artery surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1652,Anesth shoulder vessel surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1654,Anesth shoulder vessel surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1656,Anesth arm-leg vessel surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1670,Anesth shoulder vein surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1680,Anesth shoulder casting,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1682,Anesth airplane cast,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1710,Anesth elbow area surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1712,Anesth uppr arm tendon surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1714,Anesth uppr arm tendon surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1716,Anesth biceps tendon repair,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1730,Anesth uppr arm procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1732,Anesth dx elbow arthroscopy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1740,Anesth upper arm surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1742,Anesth humerus surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1744,Anesth humerus repair,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1756,Anesth radical humerus surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1758,Anesth humeral lesion surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1760,Anesth elbow replacement,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1770,Anesth uppr arm artery surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1772,Anesth uppr arm embolectomy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1780,Anesth upper arm vein surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1782,Anesth uppr arm vein repair,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1810,Anesth lower arm surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1820,Anesth lower arm procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1829,Anesth dx wrist arthroscopy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1830,Anesth lower arm surgery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1832,Anesth wrist replacement,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1840,Anesth lwr arm artery surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1842,Anesth lwr arm embolectomy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1844,Anesth vascular shunt surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1850,Anesth lower arm vein surg,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1852,Anesth lwr arm vein repair,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1860,Anesth lower arm casting,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1916,Anesth dx arteriography,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1920,Anesth catheterize heart,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1922,Anesth cat or mri scan,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1924,Anes ther interven rad artrl,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1925,Anes ther interven rad card,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1926,Anes tx interv rad hrt/cran,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1930,Anes ther interven rad vein,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1931,Anes ther interven rad tips,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1932,Anes tx interv rad th vein,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1933,Anes tx interv rad cran vein,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1935,Anesth perc img dx sp proc,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1936,Anesth perc img tx sp proc,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1951,Anesth burn less 4 percent,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1952,Anesth burn 4-9 percent,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1953,Anesth burn each 9 percent,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1958,Anesth antepartum manipul,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1960,Anesth vaginal delivery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1961,Anesth cs delivery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1962,Anesth emer hysterectomy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1963,Anesth cs hysterectomy,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1965,Anesth inc/missed ab proc,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1966,Anesth induced ab procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1967,Anesth/analg vag delivery,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1968,Anes/analg cs deliver add-on,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1969,Anesth/analg cs hyst add-on,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1991,Anesth nerve block/inj,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1992,Anesth n block/inj prone,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1996,Hosp manage cont drug admin,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,1999,Unlisted anesth procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,10004,Fna bx w/o img gdn ea addl,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
Molina Medicaid,CPT,10005,Fna bx w/us gdn 1st les,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
Molina Medicaid,CPT,10006,Fna bx w/us gdn ea addl,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
Molina Medicaid,CPT,10007,Fna bx w/fluor gdn 1st les,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
Molina Medicaid,CPT,10008,Fna bx w/fluor gdn ea addl,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
Molina Medicaid,CPT,10009,Fna bx w/ct gdn 1st les,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
Molina Medicaid,CPT,10010,Fna bx w/ct gdn ea addl,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
Molina Medicaid,CPT,10011,Fna bx w/mr gdn 1st les,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
Molina Medicaid,CPT,10012,Fna bx w/mr gdn ea addl,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
Molina Medicaid,CPT,10021,Fna bx w/o img gdn 1st les,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
Molina Medicaid,CPT,10022,Fna w/image,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
Molina Medicaid,CPT,10030,Guide cathet fluid drainage,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
Molina Medicaid,CPT,10040,Acne surgery,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,10060,Drainage of skin abscess,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,10061,Drainage of skin abscess,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,10080,Drainage of pilonidal cyst,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,10081,Drainage of pilonidal cyst,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
Molina Medicaid,CPT,10120,Remove foreign body,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,10121,Remove foreign body,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Molina Medicaid,CPT,10140,Drainage of hematoma/fluid,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
Molina Medicaid,CPT,10160,Puncture drainage of lesion,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,11055,Trim skin lesion,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,11056,Trim skin lesions 2 to 4,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,11057,Trim skin lesions over 4,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,11100,Biopsy skin lesion,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,11101,Biopsy skin add-on,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,11102,Tangntl bx skin single les,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,11103,Tangntl bx skin ea sep/addl,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,11104,Punch bx skin single lesion,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,11105,Punch bx skin ea sep/addl,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,11106,Incal bx skn single les,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,11107,Incal bx skn ea sep/addl,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,11200,Removal of skin tags <w/15,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,11201,Remove skin tags add-on,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,11300,Shave skin lesion 0.5 cm/<,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,11301,Shave skin lesion 0.6-1.0 cm,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,11302,Shave skin lesion 1.1-2.0 cm,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,11303,Shave skin lesion >2.0 cm,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,11305,Shave skin lesion 0.5 cm/<,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,11306,Shave skin lesion 0.6-1.0 cm,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,11307,Shave skin lesion 1.1-2.0 cm,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,11308,Shave skin lesion >2.0 cm,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,11310,Shave skin lesion 0.5 cm/<,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,11311,Shave skin lesion 0.6-1.0 cm,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,11312,Shave skin lesion 1.1-2.0 cm,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,11313,Shave skin lesion >2.0 cm,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,11400,Exc tr-ext b9+marg 0.5 cm<,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,11401,Exc tr-ext b9+marg 0.6-1 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,11402,Exc tr-ext b9+marg 1.1-2 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,11403,Exc tr-ext b9+marg 2.1-3cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,11404,Exc tr-ext b9+marg 3.1-4 cm,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Molina Medicaid,CPT,11406,Exc tr-ext b9+marg >4.0 cm,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Molina Medicaid,CPT,11420,Exc h-f-nk-sp b9+marg 0.5/<,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Molina Medicaid,CPT,11421,Exc h-f-nk-sp b9+marg 0.6-1,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,11422,Exc h-f-nk-sp b9+marg 1.1-2,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Molina Medicaid,CPT,11423,Exc h-f-nk-sp b9+marg 2.1-3,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Molina Medicaid,CPT,11424,Exc h-f-nk-sp b9+marg 3.1-4,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Molina Medicaid,CPT,11426,Exc h-f-nk-sp b9+marg >4 cm,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Molina Medicaid,CPT,11440,Exc face-mm b9+marg 0.5 cm/<,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,11441,Exc face-mm b9+marg 0.6-1 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,11442,Exc face-mm b9+marg 1.1-2 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,11443,Exc face-mm b9+marg 2.1-3 cm,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Molina Medicaid,CPT,11444,Exc face-mm b9+marg 3.1-4 cm,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Molina Medicaid,CPT,11446,Exc face-mm b9+marg >4 cm,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Molina Medicaid,CPT,11450,Removal sweat gland lesion,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Molina Medicaid,CPT,11451,Removal sweat gland lesion,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Molina Medicaid,CPT,11462,Removal sweat gland lesion,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Molina Medicaid,CPT,11463,Removal sweat gland lesion,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Molina Medicaid,CPT,11470,Removal sweat gland lesion,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Molina Medicaid,CPT,11471,Removal sweat gland lesion,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Molina Medicaid,CPT,11600,Exc tr-ext mal+marg 0.5 cm/<,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,11601,Exc tr-ext mal+marg 0.6-1 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,11602,Exc tr-ext mal+marg 1.1-2 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,11603,Exc tr-ext mal+marg 2.1-3 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,11604,Exc tr-ext mal+marg 3.1-4 cm,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Molina Medicaid,CPT,11606,Exc tr-ext mal+marg >4 cm,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Molina Medicaid,CPT,11620,Exc h-f-nk-sp mal+marg 0.5/<,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Molina Medicaid,CPT,11621,Exc s/n/h/f/g mal+mrg 0.6-1,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,11622,Exc s/n/h/f/g mal+mrg 1.1-2,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,11623,Exc s/n/h/f/g mal+mrg 2.1-3,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Molina Medicaid,CPT,11624,Exc s/n/h/f/g mal+mrg 3.1-4,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Molina Medicaid,CPT,11626,Exc s/n/h/f/g mal+mrg >4 cm,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Molina Medicaid,CPT,11640,Exc f/e/e/n/l mal+mrg 0.5cm<,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,11641,Exc f/e/e/n/l mal+mrg 0.6-1,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,11642,Exc f/e/e/n/l mal+mrg 1.1-2,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,11643,Exc f/e/e/n/l mal+mrg 2.1-3,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Molina Medicaid,CPT,11644,Exc f/e/e/n/l mal+mrg 3.1-4,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Molina Medicaid,CPT,11646,Exc f/e/e/n/l mal+mrg >4 cm,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Molina Medicaid,CPT,11719,Trim nail(s) any number,General Surgery,Per Unit,$46.77 ,OP,46.77,46.77,,,,,,
Molina Medicaid,CPT,11720,Debride nail 1-5,General Surgery,Per Unit,$46.77 ,OP,46.77,46.77,,,,,,
Molina Medicaid,CPT,11721,Debride nail 6 or more,General Surgery,Per Unit,$46.77 ,OP,46.77,46.77,,,,,,
Molina Medicaid,CPT,11730,Removal of nail plate,General Surgery,Per Unit,$46.77 ,OP,46.77,46.77,,,,,,
Molina Medicaid,CPT,11732,Remove nail plate add-on,General Surgery,Per Unit,$46.77 ,OP,46.77,46.77,,,,,,
Molina Medicaid,CPT,11740,Drain blood from under nail,General Surgery,Per Unit,$46.77 ,OP,46.77,46.77,,,,,,
Molina Medicaid,CPT,11750,Removal of nail bed,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,11752,Remove nail bed/tip,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Molina Medicaid,CPT,11755,Biopsy nail unit,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,11760,Repair of nail bed,General Surgery,Per Unit,$46.77 ,OP,46.77,46.77,,,,,,
Molina Medicaid,CPT,11762,Reconstruction of nail bed,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Molina Medicaid,CPT,11765,Excision of nail fold toe,General Surgery,Per Unit,$46.77 ,OP,46.77,46.77,,,,,,
Molina Medicaid,CPT,11770,Remove pilonidal cyst simple,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Molina Medicaid,CPT,11771,Remove pilonidal cyst exten,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Molina Medicaid,CPT,11772,Remove pilonidal cyst compl,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Molina Medicaid,CPT,11900,Inject skin lesions </w 7,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,11901,Inject skin lesions >7,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,11920,Correct skin color 6.0 cm/<,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,11921,Correct skn color 6.1-20.0cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,11922,Correct skin color ea 20.0cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,11950,Tx contour defects 1 cc/<,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,11951,Tx contour defects 1.1-5.0cc,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,11952,Tx contour defects 5.1-10cc,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,11954,Tx contour defects >10.0 cc,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Molina Medicaid,CPT,11960,Insert tissue expander(s),General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Molina Medicaid,CPT,11971,Rmvl tis xpndr wo insj implt,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Molina Medicaid,CPT,11976,Remove contraceptive capsule,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,11980,Implant hormone pellet(s),General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,11981,Insert drug implant device,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,11982,Remove drug implant device,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,11983,Remove/insert drug implant,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
Molina Medicaid,CPT,13100,Cmplx rpr trunk 1.1-2.5 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,13101,Cmplx rpr trunk 2.6-7.5 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,13102,Cmplx rpr trunk addl 5cm/<,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,13120,Cmplx rpr s/a/l 1.1-2.5 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,13121,Cmplx rpr s/a/l 2.6-7.5 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,13122,Cmplx rpr s/a/l addl 5 cm/>,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,13131,Cmplx rpr f/c/c/m/n/ax/g/h/f,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,13132,Cmplx rpr f/c/c/m/n/ax/g/h/f,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,13133,Cmplx rpr f/c/c/m/n/ax/g/h/f,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,13151,Cmplx rpr e/n/e/l 1.1-2.5 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,13152,Cmplx rpr e/n/e/l 2.6-7.5 cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,13153,Cmplx rpr e/n/e/l addl 5cm/<,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Molina Medicaid,CPT,15050,Skin pinch graft,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,15775,Hair trnspl 1-15 punch grfts,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,15776,Hair trnspl >15 punch grafts,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,15780,Dermabrasion total face,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
Molina Medicaid,CPT,15781,Dermabrasion segmental face,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
Molina Medicaid,CPT,15782,Dermabrasion other than face,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
Molina Medicaid,CPT,15783,Dermabrasion suprfl any site,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
Molina Medicaid,CPT,15786,Abrasion lesion single,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,15787,Abrasion lesions add-on,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,15788,Chemical peel face epiderm,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,15789,Chemical peel face dermal,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,15792,Chemical peel nonfacial,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,15793,Chemical peel nonfacial,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
Molina Medicaid,CPT,15819,Plastic surgery neck,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Molina Medicaid,CPT,15820,Revision of lower eyelid,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Molina Medicaid,CPT,15821,Revision of lower eyelid,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Molina Medicaid,CPT,15822,Revision of upper eyelid,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Molina Medicaid,CPT,15823,Revision of upper eyelid,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Molina Medicaid,CPT,15824,Removal of forehead wrinkles,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Molina Medicaid,CPT,15825,Removal of neck wrinkles,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Molina Medicaid,CPT,15826,Removal of brow wrinkles,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Molina Medicaid,CPT,15828,Removal of face wrinkles,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Molina Medicaid,CPT,15829,Removal of skin wrinkles,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Molina Medicaid,CPT,15830,Exc skin abd,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Molina Medicaid,CPT,15832,Excise excessive skin thigh,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Molina Medicaid,CPT,15833,Excise excessive skin leg,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Molina Medicaid,CPT,15834,Excise excessive skin hip,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Molina Medicaid,CPT,15835,Excise excessive skin buttck,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Molina Medicaid,CPT,15836,Excise excessive skin arm,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Molina Medicaid,CPT,15837,Excise excess skin arm/hand,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Molina Medicaid,CPT,15838,Excise excess skin fat pad,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Molina Medicaid,CPT,15839,Excise excess skin & tissue,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Molina Medicaid,CPT,15847,Exc skin abd add-on,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Molina Medicaid,CPT,15850,Remove sutures same surgeon,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Molina Medicaid,CPT,15851,Remove sutures diff surgeon,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Molina Medicaid,CPT,15876,Suction lipectomy head&neck,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Molina Medicaid,CPT,15877,Suction lipectomy trunk,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Molina Medicaid,CPT,15878,Suction lipectomy upr extrem,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Molina Medicaid,CPT,15879,Suction lipectomy lwr extrem,General Surgery,Per Unit,"$1,792.83 ",OP,"1,792.83","1,792.83",,,,,,
Molina Medicaid,CPT,17000,Destruct premalg lesion,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,17003,Destruct premalg les 2-14,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,17004,Destroy premal lesions 15/>,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,17106,Destruction of skin lesions,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
Molina Medicaid,CPT,17107,Destruction of skin lesions,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
Molina Medicaid,CPT,17108,Destruction of skin lesions,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
Molina Medicaid,CPT,17110,Destruct b9 lesion 1-14,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,17111,Destruct lesion 15 or more,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,17250,Chem caut of granltj tissue,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,17260,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,17261,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,17262,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,17263,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,17264,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,17266,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,17270,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,17271,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,17272,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,17273,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,17274,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,17276,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,17280,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,17281,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,17282,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,17283,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,17284,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,17286,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,17340,Cryotherapy of skin,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,17360,Skin peel therapy,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,17380,Hair removal by electrolysis,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,17999,Skin tissue procedure,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,19000,Drainage of breast lesion,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
Molina Medicaid,CPT,19001,Drain breast lesion add-on,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
Molina Medicaid,CPT,19020,Incision of breast lesion,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Molina Medicaid,CPT,19081,Bx breast 1st lesion strtctc,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Molina Medicaid,CPT,19082,Bx breast add lesion strtctc,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Molina Medicaid,CPT,19083,Bx breast 1st lesion us imag,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Molina Medicaid,CPT,19084,Bx breast add lesion us imag,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Molina Medicaid,CPT,19085,Bx breast 1st lesion mr imag,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Molina Medicaid,CPT,19086,Bx breast add lesion mr imag,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Molina Medicaid,CPT,19100,Bx breast percut w/o image,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Molina Medicaid,CPT,19101,Biopsy of breast open,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Molina Medicaid,CPT,19105,Cryosurg ablate fa each,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Molina Medicaid,CPT,19110,Nipple exploration,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Molina Medicaid,CPT,19112,Excise breast duct fistula,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Molina Medicaid,CPT,19120,Removal of breast lesion,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Molina Medicaid,CPT,19125,Excision breast lesion,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Molina Medicaid,CPT,19126,Excision addl breast lesion,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Molina Medicaid,CPT,19294,Prep tum cav iort prtl mast,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
Molina Medicaid,CPT,19297,Place breast cath for rad,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Molina Medicaid,CPT,19298,Place breast rad tube/caths,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Molina Medicaid,CPT,19300,Removal of breast tissue,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Molina Medicaid,CPT,19301,Partial mastectomy,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Molina Medicaid,CPT,19302,P-mastectomy w/ln removal,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Molina Medicaid,CPT,19303,Mast simple complete,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Molina Medicaid,CPT,19304,Mast subq,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Molina Medicaid,CPT,19305,Mast radical,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
Molina Medicaid,CPT,19306,Mast rad urban type,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
Molina Medicaid,CPT,19307,Mast mod rad,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
Molina Medicaid,CPT,19316,Suspension of breast,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Molina Medicaid,CPT,19318,Breast reduction,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
Molina Medicaid,CPT,19324,Enlarge breast,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Molina Medicaid,CPT,19325,Breast augmentation w/implt,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Molina Medicaid,CPT,19328,Rmvl intact breast implant,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Molina Medicaid,CPT,19330,Rmvl ruptured breast implant,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Molina Medicaid,CPT,19340,Insj breast implt sm d mast,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Molina Medicaid,CPT,19342,Insj/rplcmt brst implt sep d,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Molina Medicaid,CPT,19350,Breast reconstruction,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Molina Medicaid,CPT,19355,Correct inverted nipple(s),General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Molina Medicaid,CPT,19357,Tiss xpndr plmt brst rcnstj,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
Molina Medicaid,CPT,19361,Brst rcnstj latsms drsi flap,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
Molina Medicaid,CPT,19364,Brst rcnstj free flap,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
Molina Medicaid,CPT,19366,Breast reconstruction,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
Molina Medicaid,CPT,19367,Brst rcnstj 1 pdcl tram flap,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Molina Medicaid,CPT,19368,Brst rcnstj 1pdcl tram anast,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
Molina Medicaid,CPT,19369,Brst rcnstj 2 pdcl tram flap,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Molina Medicaid,CPT,19370,Revj peri-implt capsule brst,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Molina Medicaid,CPT,19371,Peri-implt capslc brst compl,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Molina Medicaid,CPT,19380,Revj reconstructed breast,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Molina Medicaid,CPT,19396,Design custom breast implant,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Molina Medicaid,CPT,19499,Breast surgery procedure,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Molina Medicaid,CPT,20206,Needle biopsy muscle,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
Molina Medicaid,CPT,20220,Bone biopsy trocar/needle,General Surgery,Per Unit,$346.87 ,OP,346.87,346.87,,,,,,
Molina Medicaid,CPT,20500,Injection of sinus tract,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,20526,Ther injection carp tunnel,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
Molina Medicaid,CPT,20527,Inj dupuytren cord w/enzyme,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
Molina Medicaid,CPT,20550,Inj tendon sheath/ligament,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
Molina Medicaid,CPT,20551,Inj tendon origin/insertion,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
Molina Medicaid,CPT,20552,Inj trigger point 1/2 muscl,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
Molina Medicaid,CPT,20553,Inject trigger points 3/>,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
Molina Medicaid,CPT,20560,Ndl insj w/o njx 1 or 2 musc,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,20561,Ndl insj w/o njx 3+ musc,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,20600,Drain/inj joint/bursa w/o us,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
Molina Medicaid,CPT,20605,Drain/inj joint/bursa w/o us,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
Molina Medicaid,CPT,20610,Drain/inj joint/bursa w/o us,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
Molina Medicaid,CPT,20612,Aspirate/inj ganglion cyst,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
Molina Medicaid,CPT,20822,Replantation digit complete,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,20824,Replantation thumb complete,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,20827,Replantation thumb complete,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,20957,Mt bone graft microvasc,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,20972,Bone/skin graft metatarsal,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,20973,Bone/skin graft great toe,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,20999,Musculoskeletal surgery,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,21010,Incision of jaw joint,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,21025,Excision of bone lower jaw,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,21030,Excise max/zygoma b9 tumor,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Molina Medicaid,CPT,21031,Remove exostosis mandible,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Molina Medicaid,CPT,21032,Remove exostosis maxilla,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,21034,Excise max/zygoma mal tumor,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,21040,Excise mandible lesion,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,21044,Removal of jaw bone lesion,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,21045,Extensive jaw surgery,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,21046,Remove mandible cyst complex,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Molina Medicaid,CPT,21047,Excise lwr jaw cyst w/repair,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,21048,Remove maxilla cyst complex,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,21049,Excis uppr jaw cyst w/repair,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,21050,Removal of jaw joint,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,21060,Remove jaw joint cartilage,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,21070,Remove coronoid process,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,21073,Mnpj of tmj w/anesth,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,21076,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Molina Medicaid,CPT,21077,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Molina Medicaid,CPT,21079,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Molina Medicaid,CPT,21080,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Molina Medicaid,CPT,21081,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Molina Medicaid,CPT,21082,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Molina Medicaid,CPT,21083,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Molina Medicaid,CPT,21084,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Molina Medicaid,CPT,21085,Prepare face/oral prosthesis,Dental,Per Unit,$30.61 ,OP,30.61,30.61,,,,,,
Molina Medicaid,CPT,21086,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Molina Medicaid,CPT,21087,Prepare face/oral prosthesis,Dental,Per Unit,$30.61 ,OP,30.61,30.61,,,,,,
Molina Medicaid,CPT,21088,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Molina Medicaid,CPT,21089,Prepare face/oral prosthesis,Dental,Per Unit,$30.61 ,OP,30.61,30.61,,,,,,
Molina Medicaid,CPT,21100,Maxillofacial fixation,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Molina Medicaid,CPT,21110,Interdental fixation,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,21120,Reconstruction of chin,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,21121,Reconstruction of chin,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,21122,Reconstruction of chin,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Molina Medicaid,CPT,21123,Reconstruction of chin,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,21125,Augmentation lower jaw bone,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,21127,Augmentation lower jaw bone,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,21138,Reduction of forehead,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,21172,Reconstruct orbit/forehead,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,21175,Reconstruct orbit/forehead,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,21193,Reconst lwr jaw w/o graft,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,21195,Reconst lwr jaw w/o fixation,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,21196,Reconst lwr jaw w/fixation,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,21198,Reconstr lwr jaw segment,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,21199,Reconstr lwr jaw w/advance,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,21206,Reconstruct upper jaw bone,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,21215,Lower jaw bone graft,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,21235,Ear cartilage graft,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,21240,Reconstruction of jaw joint,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,21242,Reconstruction of jaw joint,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,21243,Reconstruction of jaw joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Molina Medicaid,CPT,21244,Reconstruction of lower jaw,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,21245,Reconstruction of jaw,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,21246,Reconstruction of jaw,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,21248,Reconstruction of jaw,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,21249,Reconstruction of jaw,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,21270,Augmentation cheek bone,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,21280,Revision of eyelid,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,21282,Revision of eyelid,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,21295,Revision of jaw muscle/bone,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,21296,Revision of jaw muscle/bone,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,21315,Closed tx nose fx w/o stablj,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,21320,Closed tx nose fx w/ stablj,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,21336,Open tx septal fx w/wo stabj,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,21337,Closed tx septal&nose fx,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,21345,Closed tx nose/jaw fx,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,21346,Opn tx nasomax fx w/fixj,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,21400,Closed tx orbit w/o manipulj,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,21401,Closed tx orbit w/manipulj,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,21421,Treat mouth roof fracture,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Molina Medicaid,CPT,21422,Treat mouth roof fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,21440,Treat dental ridge fracture,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Molina Medicaid,CPT,21445,Treat dental ridge fracture,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Molina Medicaid,CPT,21450,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,21451,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,21452,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Molina Medicaid,CPT,21453,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,21454,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,21461,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,21462,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,21465,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,21470,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,21485,Reset dislocated jaw,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,21490,Repair dislocated jaw,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,21495,Treat hyoid bone fracture,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,21497,Interdental wiring,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,21685,Hyoid myotomy & suspension,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,21805,Treatment of rib fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,21811,Optx of rib fx w/fixj scope,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,21812,Treatment of rib fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,21813,Treatment of rib fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,21820,Treat sternum fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,21825,Treat sternum fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,22305,Closed tx spine process fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,22310,Closed tx vert fx w/o manj,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,22315,Closed tx vert fx w/manj,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,22505,Manipulation of spine,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Molina Medicaid,CPT,22515,Perq vertebral augmentation,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"7,098.75","7,098.75",,,,,,
Molina Medicaid,CPT,22999,Abdomen surgery procedure,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,23470,Reconstruct shoulder joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Molina Medicaid,CPT,23472,Reconstruct shoulder joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Molina Medicaid,CPT,23473,Revis reconst shoulder joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Molina Medicaid,CPT,23474,Revis reconst shoulder joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Molina Medicaid,CPT,23500,Treat clavicle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,23505,Treat clavicle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,23515,Treat clavicle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,23520,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,23525,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,23530,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,23532,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,23540,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,23545,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,23550,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,23552,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,23570,Treat shoulder blade fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,23575,Treat shoulder blade fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,23585,Treat scapula fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,23600,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,23605,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,23615,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,23616,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,23620,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,23625,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,23630,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,23650,Treat shoulder dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,23655,Treat shoulder dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Molina Medicaid,CPT,23660,Treat shoulder dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,23665,Treat dislocation/fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,23670,Treat dislocation/fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,23675,Treat dislocation/fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,23680,Treat dislocation/fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,23700,Fixation of shoulder,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Molina Medicaid,CPT,23929,Shoulder surgery procedure,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,24300,Manipulate elbow w/anesth,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Molina Medicaid,CPT,24360,Reconstruct elbow joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
Molina Medicaid,CPT,24361,Reconstruct elbow joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Molina Medicaid,CPT,24362,Reconstruct elbow joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Molina Medicaid,CPT,24363,Replace elbow joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Molina Medicaid,CPT,24365,Reconstruct head of radius,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Molina Medicaid,CPT,24366,Reconstruct head of radius,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Molina Medicaid,CPT,24370,Revise reconst elbow joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Molina Medicaid,CPT,24371,Revise reconst elbow joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Molina Medicaid,CPT,24500,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,24505,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,24515,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,24516,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,24530,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,24535,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,24538,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,24545,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,24546,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,24560,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,24565,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,24566,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,24575,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,24576,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,24577,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,24579,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,24582,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,24586,Treat elbow fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,24587,Treat elbow fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,24600,Treat elbow dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,24605,Treat elbow dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Molina Medicaid,CPT,24615,Treat elbow dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,24620,Treat elbow fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,24635,Treat elbow fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,24640,Treat elbow dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,24650,Treat radius fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,24655,Treat radius fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,24665,Treat radius fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,24666,Treat radius fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,24670,Treat ulnar fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,24675,Treat ulnar fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,24685,Treat ulnar fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,24999,Upper arm/elbow surgery,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,25001,Incise flexor carpi radialis,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,25111,Remove wrist tendon lesion,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,25112,Reremove wrist tendon lesion,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,25136,Remove & graft wrist lesion,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,25210,Removal of wrist bone,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,25215,Removal of wrist bones,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,25259,Manipulate wrist w/anesthes,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Molina Medicaid,CPT,25315,Revise palsy hand tendon(s),Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,25316,Revise palsy hand tendon(s),Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,25332,Revise wrist joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
Molina Medicaid,CPT,25394,Repair carpal bone shorten,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,25430,Vasc graft into carpal bone,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,25431,Repair nonunion carpal bone,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,25441,Reconstruct wrist joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Molina Medicaid,CPT,25442,Reconstruct wrist joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Molina Medicaid,CPT,25443,Reconstruct wrist joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
Molina Medicaid,CPT,25444,Reconstruct wrist joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Molina Medicaid,CPT,25445,Reconstruct wrist joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
Molina Medicaid,CPT,25446,Wrist replacement,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Molina Medicaid,CPT,25447,Repair wrist joints,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
Molina Medicaid,CPT,25449,Remove wrist joint implant,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
Molina Medicaid,CPT,25500,Treat fracture of radius,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,25505,Treat fracture of radius,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,25515,Treat fracture of radius,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,25520,Treat fracture of radius,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,25525,Treat fracture of radius,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,25526,Treat fracture of radius,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,25530,Treat fracture of ulna,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,25535,Treat fracture of ulna,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,25545,Treat fracture of ulna,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,25560,Treat fracture radius & ulna,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,25565,Treat fracture radius & ulna,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,25574,Treat fracture radius & ulna,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,25575,Treat fracture radius/ulna,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,25600,Treat fracture radius/ulna,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,25605,Treat fracture radius/ulna,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,25606,Treat fx distal radial,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,25607,Treat fx rad extra-articul,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,25608,Treat fx rad intra-articul,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,25609,Treat fx radial 3+ frag,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,25622,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,25624,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,25628,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,25630,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,25635,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,25645,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,25650,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,25651,Pin ulnar styloid fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,25652,Treat fracture ulnar styloid,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,25660,Treat wrist dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,25670,Treat wrist dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,25671,Pin radioulnar dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,25675,Treat wrist dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,25676,Treat wrist dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,25680,Treat wrist fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,25685,Treat wrist fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,25690,Treat wrist dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,25695,Treat wrist dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,25820,Fusion of hand bones,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,25825,Fuse hand bones with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,25929,Amputation follow-up surgery,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,25999,Forearm or wrist surgery,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,26010,Drainage of finger abscess,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,26011,Drainage of finger abscess,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
Molina Medicaid,CPT,26020,Drain hand tendon sheath,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26025,Drainage of palm bursa,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26030,Drainage of palm bursas,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26034,Treat hand bone lesion,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26035,Decompress fingers/hand,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26037,Decompress fingers/hand,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26040,Release palm contracture,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26045,Release palm contracture,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26055,Incise finger tendon sheath,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26060,Incision of finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26070,Explore/treat hand joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26075,Explore/treat finger joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26080,Explore/treat finger joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26100,Biopsy hand joint lining,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26105,Biopsy finger joint lining,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26110,Biopsy finger joint lining,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26111,Exc hand les sc 1.5 cm/>,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26113,Exc hand tum deep 1.5 cm/>,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26115,Exc hand les sc < 1.5 cm,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26116,Exc hand tum deep < 1.5 cm,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26117,Rad resect hand tumor < 3 cm,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26118,Rad resect hand tumor 3 cm/>,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26121,Release palm contracture,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26123,Release palm contracture,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26125,Release palm contracture,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26130,Remove wrist joint lining,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26135,Revise finger joint each,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26140,Revise finger joint each,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26145,Tendon excision palm/finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26160,Remove tendon sheath lesion,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26170,Removal of palm tendon each,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26180,Removal of finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26185,Remove finger bone,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26200,Remove hand bone lesion,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26205,Remove/graft bone lesion,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26210,Removal of finger lesion,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26215,Remove/graft finger lesion,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26230,Partial removal of hand bone,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26235,Partial removal finger bone,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26236,Partial removal finger bone,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26250,Extensive hand surgery,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26260,Resect prox finger tumor,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26262,Resect distal finger tumor,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26320,Removal of implant from hand,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26340,Manipulate finger w/anesth,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Molina Medicaid,CPT,26341,Manipulat palm cord post inj,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,26350,Repair finger/hand tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26352,Repair/graft hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26356,Repair finger/hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26357,Repair finger/hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26358,Repair/graft hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26370,Repair finger/hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26372,Repair/graft hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26373,Repair finger/hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26390,Revise hand/finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26392,Repair/graft hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26410,Repair hand tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26412,Repair/graft hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26415,Excision hand/finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26416,Graft hand or finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26418,Repair finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26420,Repair/graft finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26426,Repair finger/hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26428,Repair/graft finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26432,Repair finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26433,Repair finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26434,Repair/graft finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26437,Realignment of tendons,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26440,Release palm/finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26442,Release palm & finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26445,Release hand/finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26449,Release forearm/hand tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26450,Incision of palm tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26455,Incision of finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26460,Incise hand/finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26471,Fusion of finger tendons,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26474,Fusion of finger tendons,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26476,Tendon lengthening,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26477,Tendon shortening,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26478,Lengthening of hand tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26479,Shortening of hand tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26480,Transplant hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26483,Transplant/graft hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26485,Transplant palm tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26489,Transplant/graft palm tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26490,Revise thumb tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26492,Tendon transfer with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26494,Hand tendon/muscle transfer,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26496,Revise thumb tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26497,Finger tendon transfer,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26498,Finger tendon transfer,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26499,Revision of finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26500,Hand tendon reconstruction,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26502,Hand tendon reconstruction,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26508,Release thumb contracture,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26510,Thumb tendon transfer,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26516,Fusion of knuckle joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26517,Fusion of knuckle joints,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26518,Fusion of knuckle joints,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26520,Release knuckle contracture,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26525,Release finger contracture,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26530,Revise knuckle joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
Molina Medicaid,CPT,26531,Revise knuckle with implant,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
Molina Medicaid,CPT,26535,Revise finger joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
Molina Medicaid,CPT,26536,Revise/implant finger joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
Molina Medicaid,CPT,26540,Repair hand joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26541,Repair hand joint with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26542,Repair hand joint with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26545,Reconstruct finger joint,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26546,Repair nonunion hand,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26548,Reconstruct finger joint,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26550,Construct thumb replacement,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26555,Positional change of finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26560,Repair of web finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26561,Repair of web finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26562,Repair of web finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26565,Correct metacarpal flaw,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26567,Correct finger deformity,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26568,Lengthen metacarpal/finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26580,Repair hand deformity,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26587,Reconstruct extra finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26590,Repair finger deformity,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26591,Repair muscles of hand,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26593,Release muscles of hand,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26596,Excision constricting tissue,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26600,Treat metacarpal fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,26605,Treat metacarpal fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,26607,Treat metacarpal fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,26608,Treat metacarpal fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,26615,Treat metacarpal fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,26641,Treat thumb dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,26645,Treat thumb fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,26650,Treat thumb fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,26665,Treat thumb fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,26670,Treat hand dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,26675,Treat hand dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Molina Medicaid,CPT,26676,Pin hand dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,26685,Treat hand dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,26686,Treat hand dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,26700,Treat knuckle dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,26705,Treat knuckle dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Molina Medicaid,CPT,26706,Pin knuckle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,26715,Treat knuckle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,26720,Treat finger fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,26725,Treat finger fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,26727,Treat finger fracture each,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,26735,Treat finger fracture each,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,26740,Treat finger fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,26742,Treat finger fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,26746,Treat finger fracture each,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,26750,Treat finger fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,26755,Treat finger fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,26756,Pin finger fracture each,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,26765,Treat finger fracture each,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,26770,Treat finger dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,26775,Treat finger dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Molina Medicaid,CPT,26776,Pin finger dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,26785,Treat finger dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,26820,Thumb fusion with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26841,Fusion of thumb,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26842,Thumb fusion with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26843,Fusion of hand joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26844,Fusion/graft of hand joint,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26850,Fusion of knuckle,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26852,Fusion of knuckle with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26860,Fusion of finger joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26861,Fusion of finger jnt add-on,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26862,Fusion/graft of finger joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26863,Fuse/graft added joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26910,Amputate metacarpal bone,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26951,Amputation of finger/thumb,Orthopedic Surgery,Per Unit,$661.08 ,OP,661.08,661.08,,,,,,
Molina Medicaid,CPT,26952,Amputation of finger/thumb,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"1,085.51","1,085.51",,,,,,
Molina Medicaid,CPT,26989,Hand/finger surgery,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27125,Partial hip replacement,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
Molina Medicaid,CPT,27130,Total hip arthroplasty,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Molina Medicaid,CPT,27132,Total hip arthroplasty,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Molina Medicaid,CPT,27134,Revise hip joint replacement,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Molina Medicaid,CPT,27137,Revise hip joint replacement,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Molina Medicaid,CPT,27138,Revise hip joint replacement,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Molina Medicaid,CPT,27175,Treat slipped epiphysis,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,27178,Treat slipped epiphysis,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,27181,Treat slipped epiphysis,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,27193,Treat pelvic ring fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27194,Treat pelvic ring fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27197,Clsd tx pelvic ring fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27198,Clsd tx pelvic ring fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27200,Treat tail bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27202,Treat tail bone fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,27215,Treat pelvic fracture(s),Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,27216,Treat pelvic ring fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,27217,Treat pelvic ring fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,27218,Treat pelvic ring fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,27220,Treat hip socket fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27222,Treat hip socket fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27226,Treat hip wall fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,27227,Treat hip fracture(s),Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,27230,Treat thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27232,Treat thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27235,Treat thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,27236,Treat thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,27238,Treat thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27240,Treat thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27246,Treat thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27248,Treat thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,27250,Treat hip dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27252,Treat hip dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Molina Medicaid,CPT,27253,Treat hip dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,27256,Treat hip dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27257,Treat hip dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Molina Medicaid,CPT,27265,Treat hip dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27266,Treat hip dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Molina Medicaid,CPT,27267,Cltx thigh fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27268,Cltx thigh fx w/mnpj,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27269,Optx thigh fx,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,27275,Manipulation of hip joint,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Molina Medicaid,CPT,27299,Pelvis/hip joint surgery,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27412,Autochondrocyte implant knee,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Molina Medicaid,CPT,27415,Osteochondral knee allograft,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Molina Medicaid,CPT,27437,Revise kneecap,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
Molina Medicaid,CPT,27438,Revise kneecap with implant,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Molina Medicaid,CPT,27440,Revision of knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Molina Medicaid,CPT,27441,Revision of knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Molina Medicaid,CPT,27442,Revision of knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Molina Medicaid,CPT,27443,Revision of knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Molina Medicaid,CPT,27445,Revision of knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Molina Medicaid,CPT,27446,Revision of knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Molina Medicaid,CPT,27447,Total knee arthroplasty,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Molina Medicaid,CPT,27486,Revise/replace knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Molina Medicaid,CPT,27487,Revise/replace knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Molina Medicaid,CPT,27500,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27501,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27502,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27503,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27507,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,27508,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27509,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,27510,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27511,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,27513,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,27514,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,27516,Treat thigh fx growth plate,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27517,Treat thigh fx growth plate,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27520,Treat kneecap fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27524,Treat kneecap fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,27530,Treat knee fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27532,Treat knee fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27535,Treat knee fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,27536,Treat knee fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,27538,Treat knee fracture(s),Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27540,Treat knee fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,27550,Treat knee dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27552,Treat knee dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Molina Medicaid,CPT,27560,Treat kneecap dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27562,Treat kneecap dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Molina Medicaid,CPT,27566,Treat kneecap dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,27570,Fixation of knee joint,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Molina Medicaid,CPT,27599,Leg surgery procedure,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27605,Incision of achilles tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,27700,Revision of ankle joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"1,410.56","1,410.56",,,,,,
Molina Medicaid,CPT,27702,Reconstruct ankle joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Molina Medicaid,CPT,27703,Reconstruction ankle joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"4,978.29","4,978.29",,,,,,
Molina Medicaid,CPT,27720,Repair of tibia,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,27722,Repair/graft of tibia,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,27724,Repair/graft of tibia,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,27726,Repair fibula nonunion,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,27750,Treatment of tibia fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27752,Treatment of tibia fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27756,Treatment of tibia fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,27758,Treatment of tibia fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,27759,Treatment of tibia fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,27760,Cltx medial ankle fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27762,Cltx med ankle fx w/mnpj,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27766,Optx medial ankle fx,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,27767,Cltx post ankle fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27768,Cltx post ankle fx w/mnpj,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27769,Optx post ankle fx,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,27780,Treatment of fibula fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27781,Treatment of fibula fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27784,Treatment of fibula fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,27786,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27788,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27792,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,27808,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27810,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27814,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,27816,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27818,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27822,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,27823,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,27824,Treat lower leg fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27825,Treat lower leg fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27826,Treat lower leg fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,27827,Treat lower leg fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,27828,Treat lower leg fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,27829,Treat lower leg joint,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,27830,Treat lower leg dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27831,Treat lower leg dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27832,Treat lower leg dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,27840,Treat ankle dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,27842,Treat ankle dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Molina Medicaid,CPT,27846,Treat ankle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,27848,Treat ankle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,27860,Fixation of ankle joint,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Molina Medicaid,CPT,27899,Leg/ankle surgery procedure,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,28001,Drainage of bursa of foot,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28002,Treatment of foot infection,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28005,Treat foot bone lesion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28008,Incision of foot fascia,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28010,Incision of toe tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28011,Incision of toe tendons,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28020,Exploration of foot joint,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28022,Exploration of foot joint,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28024,Exploration of toe joint,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28039,Exc foot/toe tum sc 1.5 cm/>,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28041,Exc foot/toe tum dep 1.5cm/>,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28045,Exc foot/toe tum deep <1.5cm,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28046,Resect foot/toe tumor < 3 cm,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28047,Resect foot/toe tumor 3 cm/>,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28050,Biopsy of foot joint lining,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28052,Biopsy of foot joint lining,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28054,Biopsy of toe joint lining,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28055,Neurectomy foot,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28060,Partial removal foot fascia,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28062,Removal of foot fascia,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28070,Removal of foot joint lining,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28072,Removal of foot joint lining,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28080,Removal of foot lesion,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28086,Excise foot tendon sheath,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28088,Excise foot tendon sheath,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28090,Removal of foot lesion,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28092,Removal of toe lesions,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28100,Removal of ankle/heel lesion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28102,Remove/graft foot lesion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28103,Remove/graft foot lesion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28104,Removal of foot lesion,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28106,Remove/graft foot lesion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28107,Remove/graft foot lesion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28108,Removal of toe lesions,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28110,Part removal of metatarsal,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28111,Part removal of metatarsal,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28112,Part removal of metatarsal,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28113,Part removal of metatarsal,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28114,Removal of metatarsal heads,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28116,Revision of foot,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28118,Removal of heel bone,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28119,Removal of heel spur,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28120,Part removal of ankle/heel,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28122,Partial removal of foot bone,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28124,Partial removal of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28126,Partial removal of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28130,Removal of ankle bone,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28140,Removal of metatarsal,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28150,Removal of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28153,Partial removal of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28160,Partial removal of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28171,Resect tarsal tumor,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28173,Resect metatarsal tumor,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28175,Resect phalanx of toe tumor,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28190,Removal of foot foreign body,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,28193,Removal of foot foreign body,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28200,Repair of foot tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28202,Repair/graft of foot tendon,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28208,Repair of foot tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28210,Repair/graft of foot tendon,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28220,Release of foot tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28222,Release of foot tendons,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28225,Release of foot tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28226,Release of foot tendons,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28230,Incision of foot tendon(s),Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28232,Incision of toe tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28234,Incision of foot tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28238,Revision of foot tendon,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28240,Release of big toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28250,Revision of foot fascia,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28260,Release of midfoot joint,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28261,Revision of foot tendon,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28262,Revision of foot and ankle,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28264,Release of midfoot joint,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28270,Release of foot contracture,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28272,Release of toe joint each,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28280,Fusion of toes,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28285,Repair of hammertoe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28286,Repair of hammertoe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28288,Partial removal of foot bone,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28289,Corrj halux rigdus w/o implt,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28290,Correction of bunion,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28291,Corrj halux rigdus w/implt,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28292,Correction hallux valgus,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28293,Correction of bunion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28294,Correction of bunion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28295,Correction hallux valgus,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28296,Correction hallux valgus,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28297,Correction hallux valgus,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28298,Correction hallux valgus,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28299,Correction hallux valgus,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28300,Incision of heel bone,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28302,Incision of ankle bone,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28304,Incision of midfoot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28305,Incise/graft midfoot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28306,Incision of metatarsal,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28307,Incision of metatarsal,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28308,Incision of metatarsal,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28309,Incision of metatarsals,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28310,Revision of big toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28312,Revision of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28313,Repair deformity of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28315,Removal of sesamoid bone,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28320,Repair of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28322,Repair of metatarsals,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28340,Resect enlarged toe tissue,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28341,Resect enlarged toe,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28344,Repair extra toe(s),Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28345,Repair webbed toe(s),Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28360,Reconstruct cleft foot,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28400,Treatment of heel fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,28405,Treatment of heel fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,28406,Treatment of heel fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,28415,Treat heel fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,28420,Treat/graft heel fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,28430,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,28435,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,28436,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,28445,Treat ankle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,28446,Osteochondral talus autogrft,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28450,Treat midfoot fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,28455,Treat midfoot fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,28456,Treat midfoot fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,28465,Treat midfoot fracture each,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,28470,Treat metatarsal fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,28475,Treat metatarsal fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,28476,Treat metatarsal fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,28485,Treat metatarsal fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,28490,Treat big toe fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,28495,Treat big toe fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,28496,Treat big toe fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,28505,Treat big toe fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,28510,Treatment of toe fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,28515,Treatment of toe fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,28525,Treat toe fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,28530,Treat sesamoid bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,28531,Treat sesamoid bone fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,28540,Treat foot dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,28545,Treat foot dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Molina Medicaid,CPT,28546,Treat foot dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,28555,Repair foot dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,28570,Treat foot dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,28575,Treat foot dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Molina Medicaid,CPT,28576,Treat foot dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,28585,Repair foot dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,28600,Treat foot dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,28605,Treat foot dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Molina Medicaid,CPT,28606,Treat foot dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,28615,Repair foot dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,28630,Treat toe dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,28635,Treat toe dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Molina Medicaid,CPT,28636,Treat toe dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,28645,Repair toe dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,28660,Treat toe dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,28665,Treat toe dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,578.65,578.65,,,,,,
Molina Medicaid,CPT,28666,Treat toe dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,28675,Repair of toe dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,28705,Fusion of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28715,Fusion of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28725,Fusion of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28730,Fusion of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28735,Fusion of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28737,Revision of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28740,Fusion of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28750,Fusion of big toe joint,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28755,Fusion of big toe joint,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28760,Fusion of big toe joint,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28805,Amputation thru metatarsal,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28810,Amputation toe & metatarsal,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,28820,Amputation of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28825,Partial amputation of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28890,Hi enrgy eswt plantar fascia,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,28899,Foot/toes surgery procedure,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,29000,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Molina Medicaid,CPT,29010,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Molina Medicaid,CPT,29015,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Molina Medicaid,CPT,29035,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Molina Medicaid,CPT,29040,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Molina Medicaid,CPT,29044,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Molina Medicaid,CPT,29046,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Molina Medicaid,CPT,29049,Application of figure eight,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Molina Medicaid,CPT,29055,Application of shoulder cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Molina Medicaid,CPT,29058,Application of shoulder cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Molina Medicaid,CPT,29065,Application of long arm cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Molina Medicaid,CPT,29075,Application of forearm cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Molina Medicaid,CPT,29085,Apply hand/wrist cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Molina Medicaid,CPT,29086,Apply finger cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Molina Medicaid,CPT,29105,Apply long arm splint,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Molina Medicaid,CPT,29125,Apply forearm splint,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Molina Medicaid,CPT,29126,Apply forearm splint,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Molina Medicaid,CPT,29130,Application of finger splint,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Molina Medicaid,CPT,29131,Application of finger splint,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Molina Medicaid,CPT,29200,Strapping of chest,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Molina Medicaid,CPT,29240,Strapping of shoulder,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Molina Medicaid,CPT,29260,Strapping of elbow or wrist,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Molina Medicaid,CPT,29280,Strapping of hand or finger,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Molina Medicaid,CPT,29305,Application of hip cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Molina Medicaid,CPT,29325,Application of hip casts,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Molina Medicaid,CPT,29345,Application of long leg cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Molina Medicaid,CPT,29355,Application of long leg cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Molina Medicaid,CPT,29358,Apply long leg cast brace,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Molina Medicaid,CPT,29365,Application of long leg cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Molina Medicaid,CPT,29405,Apply short leg cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Molina Medicaid,CPT,29425,Apply short leg cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Molina Medicaid,CPT,29435,Apply short leg cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Molina Medicaid,CPT,29440,Addition of walker to cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Molina Medicaid,CPT,29445,Apply rigid leg cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Molina Medicaid,CPT,29450,Application of leg cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Molina Medicaid,CPT,29505,Application long leg splint,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Molina Medicaid,CPT,29515,Application lower leg splint,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Molina Medicaid,CPT,29520,Strapping of hip,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Molina Medicaid,CPT,29530,Strapping of knee,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Molina Medicaid,CPT,29540,Strapping of ankle and/or ft,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Molina Medicaid,CPT,29550,Strapping of toes,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Molina Medicaid,CPT,29580,Application of paste boot,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Molina Medicaid,CPT,29581,Apply multlay comprs lwr leg,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Molina Medicaid,CPT,29582,Apply multlay comprs upr leg,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Molina Medicaid,CPT,29583,Apply multlay comprs upr arm,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Molina Medicaid,CPT,29584,Appl multlay comprs arm/hand,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Molina Medicaid,CPT,29700,Removal/revision of cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Molina Medicaid,CPT,29705,Removal/revision of cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Molina Medicaid,CPT,29710,Removal/revision of cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Molina Medicaid,CPT,29720,Repair of body cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Molina Medicaid,CPT,29730,Windowing of cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Molina Medicaid,CPT,29740,Wedging of cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Molina Medicaid,CPT,29750,Wedging of clubfoot cast,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Molina Medicaid,CPT,29799,Casting/strapping procedure,Orthopedics,Per Unit,$143.71 ,OP,143.71,143.71,,,,,,
Molina Medicaid,CPT,29800,Jaw arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29804,Jaw arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29805,Sho arthrs dx +- synovial bx,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29806,Sho arthrs srg capsulorpaphy,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Molina Medicaid,CPT,29807,Sho arthrs srg rpr slap les,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Molina Medicaid,CPT,29819,Sho arthrs srg rmvl loose/fb,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29820,Sho arthrs srg prtl synvct,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29821,Sho arthrs srg compl synvct,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Molina Medicaid,CPT,29822,Sho arthrs srg lmtd dbrdmt,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29823,Sho arthrs srg xtnsv dbrdmt,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29824,Sho arthrs srg dstl claviclc,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29825,Sho arthrs srg lss&rescj ads,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29826,Sho arthrs srg decompression,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29827,Sho arthrs srg rt8tr cuf rpr,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Molina Medicaid,CPT,29828,Sho arthrs srg bicp tenodsis,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Molina Medicaid,CPT,29830,Elbow arthroscopy,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29834,Elbow arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29835,Elbow arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29836,Elbow arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Molina Medicaid,CPT,29837,Elbow arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29838,Elbow arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29840,Wrist arthroscopy,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29843,Wrist arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29844,Wrist arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29845,Wrist arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29846,Wrist arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29847,Wrist arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Molina Medicaid,CPT,29848,Wrist endoscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29850,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29851,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29855,Tibial arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Molina Medicaid,CPT,29856,Tibial arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Molina Medicaid,CPT,29860,Hip arthroscopy dx,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Molina Medicaid,CPT,29861,Hip arthro w/fb removal,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29862,Hip arthr0 w/debridement,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Molina Medicaid,CPT,29863,Hip arthr0 w/synovectomy,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29866,Autgrft implnt knee w/scope,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Molina Medicaid,CPT,29867,Allgrft implnt knee w/scope,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Molina Medicaid,CPT,29868,Meniscal trnspl knee w/scpe,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Molina Medicaid,CPT,29870,Knee arthroscopy dx,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29871,Knee arthroscopy/drainage,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29873,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29874,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29875,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29876,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29877,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29879,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29880,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29881,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29882,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29883,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29884,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29885,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Molina Medicaid,CPT,29886,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29887,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Molina Medicaid,CPT,29888,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Molina Medicaid,CPT,29889,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Molina Medicaid,CPT,29891,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29892,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Molina Medicaid,CPT,29893,Scope plantar fasciotomy,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,29894,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29895,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29897,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29898,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29899,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Molina Medicaid,CPT,29900,Mcp joint arthroscopy dx,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29901,Mcp joint arthroscopy surg,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29902,Mcp joint arthroscopy surg,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29904,Subtalar arthro w/fb rmvl,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29905,Subtalar arthro w/exc,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29906,Subtalar arthro w/deb,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,29907,Subtalar arthro w/fusion,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Molina Medicaid,CPT,29914,Hip arthro w/femoroplasty,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Molina Medicaid,CPT,29915,Hip arthro acetabuloplasty,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Molina Medicaid,CPT,29916,Hip arthro w/labral repair,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"2,793.83","2,793.83",,,,,,
Molina Medicaid,CPT,29999,Arthroscopy of joint,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,30020,Drainage of nose lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,30100,Intranasal biopsy,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,30110,Removal of nose polyp(s),Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,30115,Removal of nose polyp(s),Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,30117,Removal of intranasal lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,30118,Removal of intranasal lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,30120,Revision of nose,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,30124,Removal of nose lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,30125,Removal of nose lesion,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,30130,Excise inferior turbinate,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,30140,Resect inferior turbinate,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,30150,Partial removal of nose,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,30160,Removal of nose,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,30200,Injection treatment of nose,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,30220,Insert nasal septal button,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,30310,Remove nasal foreign body,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,30320,Remove nasal foreign body,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,30400,Reconstruction of nose,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,30410,Reconstruction of nose,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,30420,Reconstruction of nose,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,30430,Revision of nose,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,30435,Revision of nose,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,30450,Revision of nose,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,30460,Revision of nose,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,30462,Revision of nose,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,30465,Repair nasal stenosis,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,30468,Rpr nsl vlv collapse w/implt,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,30520,Repair of nasal septum,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,30540,Repair nasal defect,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,30560,Release of nasal adhesions,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,30580,Repair upper jaw fistula,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,30600,Repair mouth/nose fistula,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,30620,Intranasal reconstruction,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,30630,Repair nasal septum defect,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,30801,Ablate inf turbinate superf,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,30802,Ablate inf turbinate submuc,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,30915,Ligation nasal sinus artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Molina Medicaid,CPT,30920,Ligation upper jaw artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Molina Medicaid,CPT,30930,Ther fx nasal inf turbinate,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,30999,Nasal surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,31000,Irrigation maxillary sinus,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,31002,Irrigation sphenoid sinus,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,31020,Exploration maxillary sinus,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,31030,Exploration maxillary sinus,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,31032,Explore sinus remove polyps,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,31050,Exploration sphenoid sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,31051,Sphenoid sinus surgery,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,31070,Exploration of frontal sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,31075,Exploration of frontal sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,31080,Removal of frontal sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,31081,Removal of frontal sinus,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,31084,Removal of frontal sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,31085,Removal of frontal sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,31086,Removal of frontal sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,31087,Removal of frontal sinus,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,31090,Exploration of sinuses,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,31200,Removal of ethmoid sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,31201,Removal of ethmoid sinus,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,31205,Removal of ethmoid sinus,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,31225,Removal of upper jaw,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Molina Medicaid,CPT,31233,Nsl/sins ndsc dx max sinusc,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Molina Medicaid,CPT,31235,Nsl/sins ndsc dx sphn sinusc,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Molina Medicaid,CPT,31237,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Molina Medicaid,CPT,31238,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Molina Medicaid,CPT,31239,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Molina Medicaid,CPT,31240,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Molina Medicaid,CPT,31241,Nsl/sins ndsc w/artery lig,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Molina Medicaid,CPT,31253,Nsl/sins ndsc total,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,31254,Nsl/sins ndsc w/prtl ethmdct,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Molina Medicaid,CPT,31255,Nsl/sins ndsc w/tot ethmdct,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Molina Medicaid,CPT,31256,Exploration maxillary sinus,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Molina Medicaid,CPT,31257,Nsl/sins ndsc tot w/sphendt,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,31259,Nsl/sins ndsc sphn tiss rmvl,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,31267,Endoscopy maxillary sinus,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Molina Medicaid,CPT,31276,Nsl/sins ndsc frnt tiss rmvl,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Molina Medicaid,CPT,31287,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Molina Medicaid,CPT,31288,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Molina Medicaid,CPT,31290,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Molina Medicaid,CPT,31291,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Molina Medicaid,CPT,31292,Nsl/sins ndsc med/inf dcmprn,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Molina Medicaid,CPT,31293,Nsl/sins ndsc med&inf dcmprn,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Molina Medicaid,CPT,31294,Nsl/sins ndsc surg on dcmprn,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Molina Medicaid,CPT,31295,Nsl/sins ndsc surg max sins,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Molina Medicaid,CPT,31296,Nsl/sins ndsc surg frnt sins,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Molina Medicaid,CPT,31297,Nsl/sins ndsc surg sphn sins,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Molina Medicaid,CPT,31298,Nsl/sins ndsc surg frnt&sphn,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Molina Medicaid,CPT,31299,Sinus surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,31300,Removal of larynx lesion,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,31320,Diagnostic incision larynx,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,31375,Partial removal of larynx,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,31400,Revision of larynx,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,31420,Removal of epiglottis,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,31500,Insert emergency airway,General Medicine,Per Unit,$385.17 ,OP,385.17,385.17,,,,,,
Molina Medicaid,CPT,31510,Laryngoscopy with biopsy,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Molina Medicaid,CPT,31512,Removal of larynx lesion,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Molina Medicaid,CPT,31513,Injection into vocal cord,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Molina Medicaid,CPT,31515,Laryngoscopy for aspiration,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Molina Medicaid,CPT,31520,Dx laryngoscopy newborn,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Molina Medicaid,CPT,31525,Dx laryngoscopy excl nb,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Molina Medicaid,CPT,31526,Dx laryngoscopy w/oper scope,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Molina Medicaid,CPT,31527,Laryngoscopy for treatment,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Molina Medicaid,CPT,31528,Laryngoscopy and dilation,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Molina Medicaid,CPT,31529,Laryngoscopy and dilation,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Molina Medicaid,CPT,31530,Laryngoscopy w/fb removal,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Molina Medicaid,CPT,31531,Laryngoscopy w/fb & op scope,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Molina Medicaid,CPT,31535,Laryngoscopy w/biopsy,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Molina Medicaid,CPT,31536,Laryngoscopy w/bx & op scope,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Molina Medicaid,CPT,31540,Laryngoscopy w/exc of tumor,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Molina Medicaid,CPT,31541,Larynscop w/tumr exc + scope,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Molina Medicaid,CPT,31545,Remove vc lesion w/scope,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Molina Medicaid,CPT,31546,Remove vc lesion scope/graft,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Molina Medicaid,CPT,31551,Laryngoplasty laryngeal sten,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,31552,Laryngoplasty laryngeal sten,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,31553,Laryngoplasty laryngeal sten,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,31554,Laryngoplasty laryngeal sten,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,31560,Laryngoscop w/arytenoidectom,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Molina Medicaid,CPT,31561,Larynscop remve cart + scop,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Molina Medicaid,CPT,31570,Laryngoscope w/vc inj,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Molina Medicaid,CPT,31571,Laryngoscop w/vc inj + scope,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Molina Medicaid,CPT,31572,Largsc w/laser dstrj les,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Molina Medicaid,CPT,31573,Largsc w/ther injection,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Molina Medicaid,CPT,31574,Largsc w/njx augmentation,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Molina Medicaid,CPT,31576,Laryngoscopy with biopsy,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Molina Medicaid,CPT,31577,Largsc w/rmvl foreign bdy(s),Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Molina Medicaid,CPT,31578,Largsc w/removal lesion,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Molina Medicaid,CPT,31579,Laryngoscopy telescopic,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Molina Medicaid,CPT,31580,Laryngoplasty laryngeal web,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,31582,Revision of larynx,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,31584,Laryngoplasty fx rdctj fixj,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,31587,Laryngoplasty cricoid split,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,31588,Revision of larynx,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,31590,Reinnervate larynx,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,31591,Laryngoplasty medialization,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,31595,Larynx nerve surgery,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,31599,Larynx surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,31615,Visualization of windpipe,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
Molina Medicaid,CPT,31622,Dx bronchoscope/wash,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
Molina Medicaid,CPT,31623,Dx bronchoscope/brush,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
Molina Medicaid,CPT,31624,Dx bronchoscope/lavage,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
Molina Medicaid,CPT,31625,Bronchoscopy w/biopsy(s),Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
Molina Medicaid,CPT,31626,Bronchoscopy w/markers,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
Molina Medicaid,CPT,31627,Navigational bronchoscopy,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,31628,Bronchoscopy/lung bx each,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
Molina Medicaid,CPT,31629,Bronchoscopy/needle bx each,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
Molina Medicaid,CPT,31632,Bronchoscopy/lung bx addl,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
Molina Medicaid,CPT,31633,Bronchoscopy/needle bx addl,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
Molina Medicaid,CPT,31635,Bronchoscopy w/fb removal,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
Molina Medicaid,CPT,31643,Diag bronchoscope/catheter,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
Molina Medicaid,CPT,31645,Brnchsc w/ther aspir 1st,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
Molina Medicaid,CPT,31646,Brnchsc w/ther aspir sbsq,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
Molina Medicaid,CPT,31720,Clearance of airways,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
Molina Medicaid,CPT,31725,Clearance of airways,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Molina Medicaid,CPT,31899,Airways surgical procedure,Pulmonary,Per Unit,$987.23 ,OP,987.23,987.23,,,,,,
Molina Medicaid,CPT,33206,Insert heart pm atrial,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Molina Medicaid,CPT,33207,Insert heart pm ventricular,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Molina Medicaid,CPT,33208,Insrt heart pm atrial & vent,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Molina Medicaid,CPT,33212,Insert pulse gen sngl lead,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Molina Medicaid,CPT,33213,Insert pulse gen dual leads,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Molina Medicaid,CPT,33214,Upgrade of pacemaker system,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Molina Medicaid,CPT,33221,Insert pulse gen mult leads,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Molina Medicaid,CPT,33224,Insert pacing lead & connect,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Molina Medicaid,CPT,33225,L ventric pacing lead add-on,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Molina Medicaid,CPT,33226,Reposition l ventric lead,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
Molina Medicaid,CPT,33227,Remove&replace pm gen singl,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Molina Medicaid,CPT,33228,Remv&replc pm gen dual lead,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Molina Medicaid,CPT,33229,Remv&replc pm gen mult leads,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Molina Medicaid,CPT,33230,Insrt pulse gen w/dual leads,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Molina Medicaid,CPT,33231,Insrt pulse gen w/mult leads,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Molina Medicaid,CPT,33233,Removal of pm generator,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
Molina Medicaid,CPT,33240,Insrt pulse gen w/singl lead,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Molina Medicaid,CPT,33241,Remove pulse generator,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
Molina Medicaid,CPT,33249,Insj/rplcmt defib w/lead(s),Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Molina Medicaid,CPT,33262,Rmvl& replc pulse gen 1 lead,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Molina Medicaid,CPT,33263,Rmvl & rplcmt dfb gen 2 lead,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Molina Medicaid,CPT,33264,Rmvl & rplcmt dfb gen mlt ld,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Molina Medicaid,CPT,33270,Ins/rep subq defibrillator,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Molina Medicaid,CPT,33274,Tcat insj/rpl perm ldls pm,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Molina Medicaid,CPT,33275,Tcat rmvl perm ldls pm w/img,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
Molina Medicaid,CPT,33282,Implant pat-active ht record,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Molina Medicaid,CPT,33285,Insj subq car rhythm mntr,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Molina Medicaid,CPT,33289,Tcat impl wrls p-art prs snr,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Molina Medicaid,CPT,33889,Artery transpose/endovas taa,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,33967,Insert i-aort percut device,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Molina Medicaid,CPT,33968,Remove aortic assist device,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
Molina Medicaid,CPT,33990,Insj perq vad l hrt arterial,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Molina Medicaid,CPT,33991,Insj perq vad l hrt artl&ven,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Molina Medicaid,CPT,33992,Rmvl perq left heart vad,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
Molina Medicaid,CPT,33993,Reposg perq r/l hrt vad,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
Molina Medicaid,CPT,33995,Insj perq vad r hrt venous,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Molina Medicaid,CPT,33997,Rmvl perq right heart vad,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
Molina Medicaid,CPT,33999,Cardiac surgery procedure,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Molina Medicaid,CPT,34001,Removal of artery clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,34101,Removal of artery clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,34111,Removal of arm artery clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,34201,Removal of artery clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,34203,Removal of leg artery clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,34421,Removal of vein clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,34471,Removal of vein clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,34490,Removal of vein clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,34501,Repair valve femoral vein,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,34510,Transposition of vein valve,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,34520,Cross-over vein graft,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,34530,Leg vein fusion,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,34714,Opn fem art expos cndt crtj,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,34715,Opn ax/subcla art expos,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,34716,Opn ax/subcla art expos cndt,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,34812,Opn fem art expos,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,34834,Opn brach art expos,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,35011,Repair defect of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,35013,Repair artery rupture arm,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,35045,Repair defect of arm artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,35180,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Molina Medicaid,CPT,35184,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Molina Medicaid,CPT,35188,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Molina Medicaid,CPT,35190,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Molina Medicaid,CPT,35201,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Molina Medicaid,CPT,35206,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Molina Medicaid,CPT,35207,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Molina Medicaid,CPT,35226,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Molina Medicaid,CPT,35231,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Molina Medicaid,CPT,35236,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Molina Medicaid,CPT,35256,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,35261,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,35266,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Molina Medicaid,CPT,35301,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,35302,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,35303,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,35304,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,35305,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,35306,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,35321,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,35355,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,35371,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,35372,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,35390,Reoperation carotid add-on,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,35400,Angioscopy,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,35452,Repair arterial blockage,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Molina Medicaid,CPT,35472,Repair arterial blockage,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Molina Medicaid,CPT,35694,Art trnsposj subclav carotid,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,35697,Reimplant artery each,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,35700,Reoperation bypass graft,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,35701,Expl n/flwd surg neck art,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,35702,Expl n/flwd surg uxtr art,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,35703,Expl n/flwd surg lxtr art,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,35721,Exploration femoral artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,35741,Exploration popliteal artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,35761,Exploration of artery/vein,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,35800,Explore neck vessels,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,35820,Explore chest vessels,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,35860,Explore limb vessels,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,35875,Removal of clot in graft,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,35876,Removal of clot in graft,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,35901,Excision graft neck,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,35903,Excision graft extremity,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Molina Medicaid,CPT,36005,Injection ext venography,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Molina Medicaid,CPT,36010,Place catheter in vein,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Molina Medicaid,CPT,36011,Place catheter in vein,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Molina Medicaid,CPT,36012,Place catheter in vein,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Molina Medicaid,CPT,36013,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Molina Medicaid,CPT,36014,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Molina Medicaid,CPT,36015,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Molina Medicaid,CPT,36100,Establish access to artery,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Molina Medicaid,CPT,36120,Establish access to artery,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Molina Medicaid,CPT,36140,Intro ndl icath upr/lxtr art,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Molina Medicaid,CPT,36160,Establish access to aorta,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Molina Medicaid,CPT,36200,Place catheter in aorta,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Molina Medicaid,CPT,36215,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Molina Medicaid,CPT,36216,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Molina Medicaid,CPT,36217,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Molina Medicaid,CPT,36218,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Molina Medicaid,CPT,36221,Place cath thoracic aorta,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Molina Medicaid,CPT,36222,Place cath carotid/inom art,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Molina Medicaid,CPT,36223,Place cath carotid/inom art,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Molina Medicaid,CPT,36224,Place cath carotd art,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Molina Medicaid,CPT,36225,Place cath subclavian art,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Molina Medicaid,CPT,36226,Place cath vertebral art,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Molina Medicaid,CPT,36227,Place cath xtrnl carotid,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Molina Medicaid,CPT,36228,Place cath intracranial art,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Molina Medicaid,CPT,36245,Ins cath abd/l-ext art 1st,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Molina Medicaid,CPT,36246,Ins cath abd/l-ext art 2nd,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Molina Medicaid,CPT,36247,Ins cath abd/l-ext art 3rd,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Molina Medicaid,CPT,36248,Ins cath abd/l-ext art addl,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Molina Medicaid,CPT,36251,Ins cath ren art 1st unilat,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Molina Medicaid,CPT,36252,Ins cath ren art 1st bilat,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Molina Medicaid,CPT,36253,Ins cath ren art 2nd+ unilat,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Molina Medicaid,CPT,36254,Ins cath ren art 2nd+ bilat,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Molina Medicaid,CPT,36260,Insertion of infusion pump,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Molina Medicaid,CPT,36299,Vessel injection procedure,Vascular Surgery,Per Unit,$500.46 ,OP,500.46,500.46,,,,,,
Molina Medicaid,CPT,36430,Blood transfusion service,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,36440,Bl push transfuse 2 yr/<,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,36450,Bl exchange/transfuse nb,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,36455,Bl exchange/transfuse non-nb,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,36456,Prtl exchange transfuse nb,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,36460,Transfusion service fetal,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,36465,Njx noncmpnd sclrsnt 1 vein,Vascular Surgery,Per Unit,$500.46 ,OP,500.46,500.46,,,,,,
Molina Medicaid,CPT,36466,Njx noncmpnd sclrsnt mlt vn,Vascular Surgery,Per Unit,$500.46 ,OP,500.46,500.46,,,,,,
Molina Medicaid,CPT,36468,Njx sclrsnt spider veins,Vascular Surgery,Per Unit,$500.46 ,OP,500.46,500.46,,,,,,
Molina Medicaid,CPT,36470,Njx sclrsnt 1 incmptnt vein,Vascular Surgery,Per Unit,$500.46 ,OP,500.46,500.46,,,,,,
Molina Medicaid,CPT,36471,Njx sclrsnt mlt incmptnt vn,Vascular Surgery,Per Unit,$500.46 ,OP,500.46,500.46,,,,,,
Molina Medicaid,CPT,36481,Insertion of catheter vein,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Molina Medicaid,CPT,36500,Insertion of catheter vein,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Molina Medicaid,CPT,36511,Apheresis wbc,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Molina Medicaid,CPT,36512,Apheresis rbc,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Molina Medicaid,CPT,36513,Apheresis platelets,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,36514,Apheresis plasma,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Molina Medicaid,CPT,36515,Apheresis adsorp/reinfuse,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Molina Medicaid,CPT,36516,Apheresis immunoads slctv,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Molina Medicaid,CPT,36522,Photopheresis,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Molina Medicaid,CPT,36557,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
Molina Medicaid,CPT,36558,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
Molina Medicaid,CPT,36560,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
Molina Medicaid,CPT,36561,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
Molina Medicaid,CPT,36563,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
Molina Medicaid,CPT,36565,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
Molina Medicaid,CPT,36566,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
Molina Medicaid,CPT,36581,Replace tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
Molina Medicaid,CPT,36582,Replace tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
Molina Medicaid,CPT,36583,Replace tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
Molina Medicaid,CPT,36593,Declot vascular device,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Molina Medicaid,CPT,36620,Insertion catheter artery,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Molina Medicaid,CPT,36625,Insertion catheter artery,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Molina Medicaid,CPT,36640,Insertion catheter artery,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Molina Medicaid,CPT,36680,Insert needle bone cavity,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
Molina Medicaid,CPT,36800,Insertion of cannula,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
Molina Medicaid,CPT,36810,Insertion of cannula,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
Molina Medicaid,CPT,36815,Insertion of cannula,Interventional Radiology,Per Unit,$970.64 ,OP,970.64,970.64,,,,,,
Molina Medicaid,CPT,36823,Insertion of cannula(s),Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,36838,Dist revas ligation hemo,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,36860,External cannula declotting,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Molina Medicaid,CPT,36903,Intro cath dialysis circuit,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,36905,Thrmbc/nfs dialysis circuit,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,36906,Thrmbc/nfs dialysis circuit,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,36907,Balo angiop ctr dialysis seg,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,36908,Stent plmt ctr dialysis seg,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,36909,Dialysis circuit embolj,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,37145,Revision of circulation,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,37182,Insert hepatic shunt (tips),Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,37183,Remove hepatic shunt (tips),Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,37184,Prim art m-thrmbc 1st vsl,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,37185,Prim art m-thrmbc sbsq vsl,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,37186,Sec art thrombectomy add-on,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,37195,Thrombolytic therapy stroke,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Molina Medicaid,CPT,37202,Transcatheter therapy infuse,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Molina Medicaid,CPT,37215,Transcath stent cca w/eps,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,37216,Transcath stent cca w/o eps,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,37217,Stent placemt retro carotid,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,37218,Stent placemt ante carotid,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,37220,Iliac revasc,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,37221,Iliac revasc w/stent,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,37222,Iliac revasc add-on,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,37223,Iliac revasc w/stent add-on,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,37224,Fem/popl revas w/tla,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,37225,Fem/popl revas w/ather,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,37226,Fem/popl revasc w/stent,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,37227,Fem/popl revasc stnt & ather,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,37228,Tib/per revasc w/tla,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,37229,Tib/per revasc w/ather,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,37230,Tib/per revasc w/stent,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,37231,Tib/per revasc stent & ather,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,37232,Tib/per revasc add-on,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,37233,Tibper revasc w/ather add-on,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,37234,Revsc opn/prq tib/pero stent,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,37235,Tib/per revasc stnt & ather,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,37236,Open/perq place stent 1st,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,37237,Open/perq place stent ea add,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,37238,Open/perq place stent same,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,37239,Open/perq place stent ea add,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,37241,Vasc embolize/occlude venous,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,37242,Vasc embolize/occlude artery,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,37243,Vasc embolize/occlude organ,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,37244,Vasc embolize/occlude bleed,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,37247,Trluml balo angiop addl art,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,37249,Trluml balo angiop addl vein,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,37250,Iv us first vessel add-on,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Molina Medicaid,CPT,37251,Iv us each add vessel add-on,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Molina Medicaid,CPT,37500,Endoscopy ligate perf veins,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,37501,Vascular endoscopy procedure,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,37565,Ligation of neck vein,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Molina Medicaid,CPT,37600,Ligation of neck artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Molina Medicaid,CPT,37605,Ligation of neck artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Molina Medicaid,CPT,37606,Ligation of neck artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Molina Medicaid,CPT,37607,Ligation of a-v fistula,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Molina Medicaid,CPT,37609,Temporal artery procedure,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Molina Medicaid,CPT,37615,Ligation of neck artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Molina Medicaid,CPT,37618,Ligation of extremity artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Molina Medicaid,CPT,37619,Ligation of inf vena cava,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,37650,Revision of major vein,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Molina Medicaid,CPT,37790,Penile venous occlusion,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,37799,Vascular surgery procedure,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"1,174.75","1,174.75",,,,,,
Molina Medicaid,CPT,38102,Removal of spleen total,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,38120,Laparoscopy splenectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Molina Medicaid,CPT,38129,Laparoscope proc spleen,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Molina Medicaid,CPT,38205,Harvest allogeneic stem cell,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Molina Medicaid,CPT,38206,Harvest auto stem cells,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Molina Medicaid,CPT,38207,Cryopreserve stem cells,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Molina Medicaid,CPT,38208,Thaw preserved stem cells,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,38209,Wash harvest stem cells,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Molina Medicaid,CPT,38210,T-cell depletion of harvest,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,38211,Tumor cell deplete of harvst,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,38212,Rbc depletion of harvest,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,38213,Platelet deplete of harvest,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,38214,Volume deplete of harvest,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Molina Medicaid,CPT,38215,Harvest stem cell concentrte,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Molina Medicaid,CPT,38230,Bone marrow harvest allogen,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Molina Medicaid,CPT,38232,Bone marrow harvest autolog,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Molina Medicaid,CPT,38240,Transplt allo hct/donor,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Molina Medicaid,CPT,38241,Transplt autol hct/donor,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Molina Medicaid,CPT,38242,Transplt allo lymphocytes,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Molina Medicaid,CPT,38243,Transplj hematopoietic boost,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Molina Medicaid,CPT,38300,Drainage lymph node lesion,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
Molina Medicaid,CPT,38305,Drainage lymph node lesion,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
Molina Medicaid,CPT,38308,Incision of lymph channels,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
Molina Medicaid,CPT,38380,Thoracic duct procedure,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,38500,Biopsy/removal lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
Molina Medicaid,CPT,38505,Needle biopsy lymph nodes,General Surgery,Per Unit,$734.97 ,OP,734.97,734.97,,,,,,
Molina Medicaid,CPT,38510,Biopsy/removal lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
Molina Medicaid,CPT,38520,Biopsy/removal lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
Molina Medicaid,CPT,38525,Biopsy/removal lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
Molina Medicaid,CPT,38530,Biopsy/removal lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
Molina Medicaid,CPT,38531,Open bx/exc inguinofem nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
Molina Medicaid,CPT,38542,Explore deep node(s) neck,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,38550,Removal neck/armpit lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,38555,Removal neck/armpit lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,38562,Removal pelvic lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
Molina Medicaid,CPT,38570,Laparoscopy lymph node biop,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Molina Medicaid,CPT,38571,Laparoscopy lymphadenectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Molina Medicaid,CPT,38572,Laparoscopy lymphadenectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Molina Medicaid,CPT,38573,Laps pelvic lymphadec,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Molina Medicaid,CPT,38589,Laparoscope proc lymphatic,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Molina Medicaid,CPT,38700,Removal of lymph nodes neck,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,38720,Removal of lymph nodes neck,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,38724,Removal of lymph nodes neck,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
Molina Medicaid,CPT,38740,Remove armpit lymph nodes,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Molina Medicaid,CPT,38745,Remove armpit lymph nodes,General Surgery,Per Unit,"$1,609.30 ",OP,"1,609.30","1,609.30",,,,,,
Molina Medicaid,CPT,38747,Remove abdominal lymph nodes,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,38760,Remove groin lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
Molina Medicaid,CPT,38792,Ra tracer id of sentinl node,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,38794,Access thoracic lymph duct,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Molina Medicaid,CPT,38999,Blood/lymph system procedure,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
Molina Medicaid,CPT,39545,Revision of diaphragm,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,39599,Diaphragm surgery procedure,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Molina Medicaid,CPT,40490,Biopsy of lip,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,40500,Partial excision of lip,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,40510,Partial excision of lip,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,40520,Partial excision of lip,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,40525,Reconstruct lip with flap,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,40527,Reconstruct lip with flap,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,40530,Partial removal of lip,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,40650,Repair lip,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,40652,Repair lip,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,40654,Repair lip,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,40799,Lip surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,40801,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,40805,Removal foreign body mouth,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,40806,Incision of lip fold,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,40808,Biopsy of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,40810,Excision of mouth lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,40812,Excise/repair mouth lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,40814,Excise/repair mouth lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,40816,Excision of mouth lesion,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,40818,Excise oral mucosa for graft,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,40819,Excise lip or cheek fold,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,40820,Treatment of mouth lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,40830,Repair mouth laceration,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,40831,Repair mouth laceration,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,40840,Reconstruction of mouth,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,40842,Reconstruction of mouth,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,40843,Reconstruction of mouth,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,40844,Reconstruction of mouth,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,40845,Reconstruction of mouth,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,40899,Mouth surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,41000,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,41005,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,41006,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,41007,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,41008,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,41009,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,41010,Incision of tongue fold,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,41015,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,41016,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,41017,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,41018,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,41100,Biopsy of tongue,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,41105,Biopsy of tongue,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,41108,Biopsy of floor of mouth,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,41110,Excision of tongue lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,41112,Excision of tongue lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,41113,Excision of tongue lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,41114,Excision of tongue lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,41115,Excision of tongue fold,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,41116,Excision of mouth lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,41120,Partial removal of tongue,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,41130,Partial removal of tongue,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,41135,Tongue and neck surgery,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,41150,Tongue mouth jaw surgery,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,41500,Fixation of tongue,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,41510,Tongue to lip surgery,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,41512,Tongue suspension,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,41520,Reconstruction tongue fold,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,41530,Tongue base vol reduction,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,41599,Tongue and mouth surgery,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,41805,Removal foreign body gum,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,41806,Removal foreign body jawbone,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Molina Medicaid,CPT,41820,Excision gum each quadrant,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Molina Medicaid,CPT,41821,Excision of gum flap,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,41822,Excision of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,41823,Excision of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,41825,Excision of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Molina Medicaid,CPT,41826,Excision of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Molina Medicaid,CPT,41827,Excision of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Molina Medicaid,CPT,41828,Excision of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Molina Medicaid,CPT,41830,Removal of gum tissue,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Molina Medicaid,CPT,41850,Treatment of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Molina Medicaid,CPT,41870,Gum graft,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,41872,Repair gum,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Molina Medicaid,CPT,41874,Repair tooth socket,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,41899,Dental surgery procedure,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,42100,Biopsy roof of mouth,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,42104,Excision lesion mouth roof,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,42106,Excision lesion mouth roof,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,42107,Excision lesion mouth roof,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,42120,Remove palate/lesion,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,42140,Excision of uvula,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,42160,Treatment mouth roof lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,42180,Repair palate,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,42182,Repair palate,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,42260,Repair nose to lip fistula,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,42280,Preparation palate mold,Dental,Per Unit,$30.61 ,OP,30.61,30.61,,,,,,
Molina Medicaid,CPT,42281,Insertion palate prosthesis,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,42299,Palate/uvula surgery,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,42300,Drainage of salivary gland,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,42305,Drainage of salivary gland,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,42310,Drainage of salivary gland,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,42320,Drainage of salivary gland,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,42330,Removal of salivary stone,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,42335,Removal of salivary stone,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,42340,Removal of salivary stone,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,42400,Biopsy of salivary gland,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,42405,Biopsy of salivary gland,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,42408,Excision of salivary cyst,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,42409,Drainage of salivary cyst,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,42410,Excise parotid gland/lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,42415,Excise parotid gland/lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,42420,Excise parotid gland/lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,42425,Excise parotid gland/lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,42426,Excise parotid gland/lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,42440,Excise submaxillary gland,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,42450,Excise sublingual gland,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,42500,Repair salivary duct,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,42505,Repair salivary duct,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,42507,Parotid duct diversion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,42509,Parotid duct diversion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,42510,Parotid duct diversion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,42600,Closure of salivary fistula,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,42650,Dilation of salivary duct,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,42660,Dilation of salivary duct,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,42665,Ligation of salivary duct,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,42699,Salivary surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,42720,Drainage of throat abscess,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,42725,Drainage of throat abscess,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,42800,Biopsy of throat,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,42804,Biopsy of upper nose/throat,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,42806,Biopsy of upper nose/throat,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,42808,Excise pharynx lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,42810,Excision of neck cyst,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,42815,Excision of neck cyst,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,42820,Remove tonsils and adenoids,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
Molina Medicaid,CPT,42821,Remove tonsils and adenoids,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
Molina Medicaid,CPT,42825,Removal of tonsils,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
Molina Medicaid,CPT,42826,Removal of tonsils,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
Molina Medicaid,CPT,42830,Removal of adenoids,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
Molina Medicaid,CPT,42831,Removal of adenoids,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
Molina Medicaid,CPT,42835,Removal of adenoids,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
Molina Medicaid,CPT,42836,Removal of adenoids,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
Molina Medicaid,CPT,42842,Extensive surgery of throat,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
Molina Medicaid,CPT,42844,Extensive surgery of throat,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
Molina Medicaid,CPT,42860,Excision of tonsil tags,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
Molina Medicaid,CPT,42870,Excision of lingual tonsil,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
Molina Medicaid,CPT,42890,Partial removal of pharynx,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,42892,Revision of pharyngeal walls,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,42900,Repair throat wound,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,42950,Reconstruction of throat,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,42953,Repair throat esophagus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,42955,Surgical opening of throat,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,42960,Control throat bleeding,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,42962,Control throat bleeding,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,42970,Control nose/throat bleeding,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,42972,Control nose/throat bleeding,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,42999,Throat surgery procedure,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"1,027.68","1,027.68",,,,,,
Molina Medicaid,CPT,43020,Incision of esophagus,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,43030,Throat muscle surgery,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,43100,Excision of esophagus lesion,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,43130,Removal of esophagus pouch,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,43191,Esophagoscopy rigid trnso dx,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Molina Medicaid,CPT,43192,Esophagoscp rig trnso inject,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Molina Medicaid,CPT,43193,Esophagoscp rig trnso biopsy,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Molina Medicaid,CPT,43194,Esophagoscp rig trnso rem fb,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Molina Medicaid,CPT,43196,Esophagoscp guide wire dilat,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Molina Medicaid,CPT,43197,Esophagoscopy flex dx brush,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Molina Medicaid,CPT,43198,Esophagosc flex trnsn biopsy,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Molina Medicaid,CPT,43200,Esophagoscopy flexible brush,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Molina Medicaid,CPT,43201,Esoph scope w/submucous inj,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Molina Medicaid,CPT,43202,Esophagoscopy flex biopsy,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Molina Medicaid,CPT,43204,Esoph scope w/sclerosis inj,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Molina Medicaid,CPT,43205,Esophagus endoscopy/ligation,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Molina Medicaid,CPT,43206,Esoph optical endomicroscopy,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Molina Medicaid,CPT,43211,Esophagoscop mucosal resect,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Molina Medicaid,CPT,43213,Esophagoscopy retro balloon,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Molina Medicaid,CPT,43214,Esophagosc dilate balloon 30,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Molina Medicaid,CPT,43215,Esophagoscopy flex remove fb,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Molina Medicaid,CPT,43216,Esophagoscopy lesion removal,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Molina Medicaid,CPT,43217,Esophagoscopy snare les remv,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Molina Medicaid,CPT,43220,Esophagoscopy balloon <30mm,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Molina Medicaid,CPT,43226,Esoph endoscopy dilation,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Molina Medicaid,CPT,43227,Esophagoscopy control bleed,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Molina Medicaid,CPT,43229,Esophagoscopy lesion ablate,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Molina Medicaid,CPT,43231,Esophagoscop ultrasound exam,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Molina Medicaid,CPT,43232,Esophagoscopy w/us needle bx,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Molina Medicaid,CPT,43233,Egd balloon dil esoph30 mm/>,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Molina Medicaid,CPT,43235,Egd diagnostic brush wash,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Molina Medicaid,CPT,43236,Uppr gi scope w/submuc inj,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Molina Medicaid,CPT,43237,Endoscopic us exam esoph,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Molina Medicaid,CPT,43238,Egd us fine needle bx/aspir,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Molina Medicaid,CPT,43239,Egd biopsy single/multiple,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Molina Medicaid,CPT,43241,Egd tube/cath insertion,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Molina Medicaid,CPT,43242,Egd us fine needle bx/aspir,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Molina Medicaid,CPT,43243,Egd injection varices,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Molina Medicaid,CPT,43244,Egd varices ligation,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Molina Medicaid,CPT,43245,Egd dilate stricture,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Molina Medicaid,CPT,43246,Egd place gastrostomy tube,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Molina Medicaid,CPT,43247,Egd remove foreign body,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Molina Medicaid,CPT,43248,Egd guide wire insertion,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Molina Medicaid,CPT,43249,Esoph egd dilation <30 mm,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Molina Medicaid,CPT,43250,Egd cautery tumor polyp,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Molina Medicaid,CPT,43251,Egd remove lesion snare,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Molina Medicaid,CPT,43253,Egd us transmural injxn/mark,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Molina Medicaid,CPT,43254,Egd endo mucosal resection,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Molina Medicaid,CPT,43255,Egd control bleeding any,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Molina Medicaid,CPT,43257,Egd w/thrml txmnt gerd,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Molina Medicaid,CPT,43259,Egd us exam duodenum/jejunum,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Molina Medicaid,CPT,43260,Ercp w/specimen collection,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
Molina Medicaid,CPT,43261,Endo cholangiopancreatograph,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
Molina Medicaid,CPT,43262,Endo cholangiopancreatograph,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
Molina Medicaid,CPT,43263,Ercp sphincter pressure meas,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
Molina Medicaid,CPT,43270,Egd lesion ablation,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Molina Medicaid,CPT,43275,Ercp remove forgn body duct,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
Molina Medicaid,CPT,43276,Ercp stent exchange w/dilate,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
Molina Medicaid,CPT,43277,Ercp ea duct/ampulla dilate,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
Molina Medicaid,CPT,43279,Lap myotomy heller,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Molina Medicaid,CPT,43280,Laparoscopy fundoplasty,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Molina Medicaid,CPT,43281,Lap paraesophag hern repair,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Molina Medicaid,CPT,43282,Lap paraesoph her rpr w/mesh,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Molina Medicaid,CPT,43283,Lap esoph lengthening,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Molina Medicaid,CPT,43284,Laps esophgl sphnctr agmntj,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Molina Medicaid,CPT,43285,Rmvl esophgl sphnctr dev,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Molina Medicaid,CPT,43289,Laparoscope proc esoph,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Molina Medicaid,CPT,43300,Repair of esophagus,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,43305,Repair esophagus and fistula,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,43320,Fuse esophagus & stomach,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,43332,Transab esoph hiat hern rpr,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Molina Medicaid,CPT,43333,Transab esoph hiat hern rpr,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Molina Medicaid,CPT,43334,Transthor diaphrag hern rpr,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Molina Medicaid,CPT,43335,Transthor diaphrag hern rpr,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Molina Medicaid,CPT,43336,Thorabd diaphr hern repair,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Molina Medicaid,CPT,43337,Thorabd diaphr hern repair,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Molina Medicaid,CPT,43338,Esoph lengthening,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Molina Medicaid,CPT,43401,Esophagus surgery for veins,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,43410,Repair esophagus wound,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,43420,Repair esophagus opening,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,43450,Dilate esophagus 1/mult pass,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Molina Medicaid,CPT,43453,Dilate esophagus,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Molina Medicaid,CPT,43499,Esophagus surgery procedure,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Molina Medicaid,CPT,43500,Surgical opening of stomach,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,43510,Surgical opening of stomach,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Molina Medicaid,CPT,43520,Incision of pyloric muscle,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Molina Medicaid,CPT,43610,Excision of stomach lesion,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,43644,Lap gastric bypass/roux-en-y,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Molina Medicaid,CPT,43645,Lap gastr bypass incl smll i,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Molina Medicaid,CPT,43647,Lap impl electrode antrum,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Molina Medicaid,CPT,43648,Lap revise/remv eltrd antrum,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Molina Medicaid,CPT,43651,Laparoscopy vagus nerve,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Molina Medicaid,CPT,43652,Laparoscopy vagus nerve,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Molina Medicaid,CPT,43653,Laparoscopy gastrostomy,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Molina Medicaid,CPT,43659,Laparoscope proc stom,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Molina Medicaid,CPT,43752,Nasal/orogastric w/tube plmt,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Molina Medicaid,CPT,43753,Tx gastro intub w/asp,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Molina Medicaid,CPT,43754,Dx gastr intub w/asp spec,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Molina Medicaid,CPT,43755,Dx gastr intub w/asp specs,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Molina Medicaid,CPT,43756,Dx duod intub w/asp spec,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Molina Medicaid,CPT,43757,Dx duod intub w/asp specs,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Molina Medicaid,CPT,43760,Change gastrostomy tube,Gastroenterology,Per Unit,$119.18 ,OP,119.18,119.18,,,,,,
Molina Medicaid,CPT,43761,Reposition gastrostomy tube,Gastroenterology,Per Unit,$119.18 ,OP,119.18,119.18,,,,,,
Molina Medicaid,CPT,43762,Rplc gtube no revj trc,Gastroenterology,Per Unit,$119.18 ,OP,119.18,119.18,,,,,,
Molina Medicaid,CPT,43763,Rplc gtube revj gstrst trc,Gastroenterology,Per Unit,$119.18 ,OP,119.18,119.18,,,,,,
Molina Medicaid,CPT,43770,Lap place gastr adj device,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Molina Medicaid,CPT,43771,Lap revise gastr adj device,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Molina Medicaid,CPT,43772,Lap rmvl gastr adj device,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Molina Medicaid,CPT,43773,Lap replace gastr adj device,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Molina Medicaid,CPT,43774,Lap rmvl gastr adj all parts,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Molina Medicaid,CPT,43775,Lap sleeve gastrectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Molina Medicaid,CPT,43830,Place gastrostomy tube,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Molina Medicaid,CPT,43831,Place gastrostomy tube,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Molina Medicaid,CPT,43832,Place gastrostomy tube,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,43842,V-band gastroplasty,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Molina Medicaid,CPT,43843,Gastroplasty w/o v-band,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,43848,Revision gastroplasty,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,43860,Revise stomach-bowel fusion,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,43870,Repair stomach opening,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Molina Medicaid,CPT,43880,Repair stomach-bowel fistula,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,43881,Impl/redo electrd antrum,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,43882,Revise/remove electrd antrum,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,43886,Revise gastric port open,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Molina Medicaid,CPT,43887,Remove gastric port open,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Molina Medicaid,CPT,43888,Change gastric port open,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Molina Medicaid,CPT,43999,Stomach surgery procedure,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Molina Medicaid,CPT,44005,Freeing of bowel adhesion,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,44015,Insert needle cath bowel,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
Molina Medicaid,CPT,44020,Explore small intestine,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,44050,Reduce bowel obstruction,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,44055,Correct malrotation of bowel,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,44100,Biopsy of bowel,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,44110,Excise intestine lesion(s),General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,44111,Excision of bowel lesion(s),General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,44125,Removal of small intestine,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,44130,Bowel to bowel fusion,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,44139,Mobilization of colon,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,44141,Partial removal of colon,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,44143,Partial removal of colon,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,44180,Lap enterolysis,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Molina Medicaid,CPT,44186,Lap jejunostomy,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Molina Medicaid,CPT,44187,Lap ileo/jejuno-stomy,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Molina Medicaid,CPT,44188,Lap colostomy,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Molina Medicaid,CPT,44204,Laparo partial colectomy,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Molina Medicaid,CPT,44206,Lap part colectomy w/stoma,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Molina Medicaid,CPT,44207,L colectomy/coloproctostomy,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Molina Medicaid,CPT,44208,L colectomy/coloproctostomy,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Molina Medicaid,CPT,44213,Lap mobil splenic fl add-on,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Molina Medicaid,CPT,44238,Laparoscope proc intestine,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Molina Medicaid,CPT,44300,Open bowel to skin,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,44312,Revision of ileostomy,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,44320,Colostomy,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,44340,Revision of colostomy,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,44346,Revision of colostomy,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,44360,Small bowel endoscopy,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Molina Medicaid,CPT,44361,Small bowel endoscopy/biopsy,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Molina Medicaid,CPT,44363,Small bowel endoscopy,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Molina Medicaid,CPT,44364,Small bowel endoscopy,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Molina Medicaid,CPT,44365,Small bowel endoscopy,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Molina Medicaid,CPT,44366,Small bowel endoscopy,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Molina Medicaid,CPT,44369,Small bowel endoscopy,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Molina Medicaid,CPT,44370,Small bowel endoscopy/stent,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Molina Medicaid,CPT,44372,Small bowel endoscopy,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Molina Medicaid,CPT,44373,Small bowel endoscopy,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Molina Medicaid,CPT,44376,Small bowel endoscopy,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Molina Medicaid,CPT,44377,Small bowel endoscopy/biopsy,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Molina Medicaid,CPT,44378,Small bowel endoscopy,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Molina Medicaid,CPT,44379,S bowel endoscope w/stent,Gastroenterology,Per Unit,$446.31 ,OP,446.31,446.31,,,,,,
Molina Medicaid,CPT,44380,Small bowel endoscopy br/wa,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,44381,Small bowel endoscopy br/wa,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,44382,Small bowel endoscopy,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,44384,Small bowel endoscopy,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Molina Medicaid,CPT,44385,Endoscopy of bowel pouch,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,44386,Endoscopy bowel pouch/biop,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,44388,Colonoscopy thru stoma spx,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,44389,Colonoscopy with biopsy,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,44390,Colonoscopy for foreign body,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,44391,Colonoscopy for bleeding,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,44392,Colonoscopy & polypectomy,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,44394,Colonoscopy w/snare,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,44401,Colonoscopy with ablation,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,44402,Colonoscopy w/stent plcmt,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Molina Medicaid,CPT,44403,Colonoscopy w/resection,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,44404,Colonoscopy w/injection,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,44405,Colonoscopy w/dilation,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,44406,Colonoscopy w/ultrasound,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,44407,Colonoscopy w/ndl aspir/bx,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,44408,Colonoscopy w/decompression,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,44500,Intro gastrointestinal tube,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Molina Medicaid,CPT,44602,Suture small intestine,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,44603,Suture small intestine,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,44615,Intestinal stricturoplasty,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,44620,Repair bowel opening,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,44640,Repair bowel-skin fistula,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,44650,Repair bowel fistula,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,44799,Unlisted px small intestine,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Molina Medicaid,CPT,44800,Excision of bowel pouch,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,44820,Excision of mesentery lesion,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,44850,Repair of mesentery,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,44899,Bowel surgery procedure,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Molina Medicaid,CPT,44900,Drain appendix abscess open,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,44950,Appendectomy,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,44955,Appendectomy add-on,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,44960,Appendectomy,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,44970,Laparoscopy appendectomy,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Molina Medicaid,CPT,44979,Laparoscope proc app,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Molina Medicaid,CPT,45000,Drainage of pelvic abscess,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,45005,Drainage of rectal abscess,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Molina Medicaid,CPT,45020,Drainage of rectal abscess,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,45100,Biopsy of rectum,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Molina Medicaid,CPT,45108,Removal of anorectal lesion,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,45113,Partial proctectomy,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,45123,Partial proctectomy,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,45130,Excision of rectal prolapse,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,45136,Excise ileoanal reservior,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,45150,Excision of rectal stricture,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,45160,Excision of rectal lesion,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,45171,Exc rect tum transanal part,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,45172,Exc rect tum transanal full,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,45190,Destruction rectal tumor,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,45300,Proctosigmoidoscopy dx,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,45303,Proctosigmoidoscopy dilate,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Molina Medicaid,CPT,45305,Proctosigmoidoscopy w/bx,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,45307,Proctosigmoidoscopy fb,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,45308,Proctosigmoidoscopy removal,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Molina Medicaid,CPT,45309,Proctosigmoidoscopy removal,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,45315,Proctosigmoidoscopy removal,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,45317,Proctosigmoidoscopy bleed,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Molina Medicaid,CPT,45320,Proctosigmoidoscopy ablate,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Molina Medicaid,CPT,45321,Proctosigmoidoscopy volvul,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Molina Medicaid,CPT,45327,Proctosigmoidoscopy w/stent,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Molina Medicaid,CPT,45330,Diagnostic sigmoidoscopy,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,45331,Sigmoidoscopy and biopsy,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,45332,Sigmoidoscopy w/fb removal,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,45333,Sigmoidoscopy & polypectomy,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,45334,Sigmoidoscopy for bleeding,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,45335,Sigmoidoscopy w/submuc inj,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,45337,Sigmoidoscopy & decompress,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,45338,Sigmoidoscopy w/tumr remove,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,45340,Sig w/tndsc balloon dilation,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,45341,Sigmoidoscopy w/ultrasound,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,45342,Sigmoidoscopy w/us guide bx,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,45346,Sigmoidoscopy w/ablation,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,45347,Sigmoidoscopy w/plcmt stent,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Molina Medicaid,CPT,45349,Sigmoidoscopy w/resection,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Molina Medicaid,CPT,45350,Sgmdsc w/band ligation,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,45378,Diagnostic colonoscopy,Preventive Care,Per Unit,$387.00 ,OP,387,387,,,,,,
Molina Medicaid,CPT,45379,Colonoscopy w/fb removal,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,45380,Colonoscopy and biopsy,Preventive Care,Per Unit,$387.00 ,OP,387,387,,,,,,
Molina Medicaid,CPT,45381,Colonoscopy submucous njx,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,45382,Colonoscopy w/control bleed,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,45384,Colonoscopy w/lesion removal,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,45385,Colonoscopy w/lesion removal,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,45386,Colonoscopy w/balloon dilat,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,45388,Colonoscopy w/ablation,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,45389,Colonoscopy w/stent plcmt,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Molina Medicaid,CPT,45390,Colonoscopy w/resection,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Molina Medicaid,CPT,45391,Colonoscopy w/endoscope us,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,45392,Colonoscopy w/endoscopic fnb,Preventive Care,Per Unit,$387.00 ,OP,387,387,,,,,,
Molina Medicaid,CPT,45393,Colonoscopy w/decompression,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,45398,Colonoscopy w/band ligation,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,45399,Unlisted procedure colon,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,45400,Laparoscopic proc,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Molina Medicaid,CPT,45402,Lap proctopexy w/sig resect,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Molina Medicaid,CPT,45499,Laparoscope proc rectum,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Molina Medicaid,CPT,45500,Repair of rectum,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,45505,Repair of rectum,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,45520,Treatment of rectal prolapse,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Molina Medicaid,CPT,45541,Correct rectal prolapse,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,45560,Repair of rectocele,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,45562,Exploration/repair of rectum,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,45800,Repair rect/bladder fistula,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,45820,Repair rectourethral fistula,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,45900,Reduction of rectal prolapse,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Molina Medicaid,CPT,45905,Dilation of anal sphincter,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Molina Medicaid,CPT,45910,Dilation of rectal narrowing,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Molina Medicaid,CPT,45915,Remove rectal obstruction,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Molina Medicaid,CPT,45990,Surg dx exam anorectal,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Molina Medicaid,CPT,45999,Rectum surgery procedure,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Molina Medicaid,CPT,46020,Placement of seton,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Molina Medicaid,CPT,46030,Removal of rectal marker,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Molina Medicaid,CPT,46040,Incision of rectal abscess,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Molina Medicaid,CPT,46045,Incision of rectal abscess,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,46050,Incision of anal abscess,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Molina Medicaid,CPT,46060,Incision of rectal abscess,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,46070,Incision of anal septum,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Molina Medicaid,CPT,46080,Incision of anal sphincter,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Molina Medicaid,CPT,46083,Incise external hemorrhoid,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Molina Medicaid,CPT,46200,Removal of anal fissure,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Molina Medicaid,CPT,46220,Excise anal ext tag/papilla,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Molina Medicaid,CPT,46221,Ligation of hemorrhoid(s),General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Molina Medicaid,CPT,46230,Removal of anal tags,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Molina Medicaid,CPT,46250,Remove ext hem groups 2+,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,46255,Remove int/ext hem 1 group,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,46257,Remove in/ex hem grp & fiss,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,46258,Remove in/ex hem grp w/fistu,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,46260,Remove in/ex hem groups 2+,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,46261,Remove in/ex hem grps & fiss,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,46262,Remove in/ex hem grps w/fist,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,46270,Remove anal fist subq,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,46275,Remove anal fist inter,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,46280,Remove anal fist complex,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,46285,Remove anal fist 2 stage,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Molina Medicaid,CPT,46288,Repair anal fistula,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,46320,Removal of hemorrhoid clot,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Molina Medicaid,CPT,46500,Injection into hemorrhoid(s),General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Molina Medicaid,CPT,46505,Chemodenervation anal musc,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Molina Medicaid,CPT,46600,Diagnostic anoscopy spx,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,46601,Diagnostic anoscopy,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,46604,Anoscopy and dilation,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,46606,Anoscopy and biopsy,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,46607,Diagnostic anoscopy & biopsy,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Molina Medicaid,CPT,46608,Anoscopy remove for body,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,46610,Anoscopy remove lesion,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Molina Medicaid,CPT,46611,Anoscopy,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,46612,Anoscopy remove lesions,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Molina Medicaid,CPT,46614,Anoscopy control bleeding,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,46615,Anoscopy,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Molina Medicaid,CPT,46700,Repair of anal stricture,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,46705,Repair of anal stricture,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,46706,Repr of anal fistula w/glue,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Molina Medicaid,CPT,46707,Repair anorectal fist w/plug,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Molina Medicaid,CPT,46710,Repr per/vag pouch sngl proc,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,46712,Repr per/vag pouch dbl proc,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,46715,Rep perf anoper fistu,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,46716,Rep perf anoper/vestib fistu,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,46740,Construction of absent anus,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,46750,Repair of anal sphincter,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,46751,Repair of anal sphincter,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,46753,Reconstruction of anus,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,46754,Removal of suture from anus,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Molina Medicaid,CPT,46760,Repair of anal sphincter,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,46761,Repair of anal sphincter,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,46762,Implant artificial sphincter,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,46900,Destruction anal lesion(s),General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Molina Medicaid,CPT,46910,Destruction anal lesion(s),General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Molina Medicaid,CPT,46916,Cryosurgery anal lesion(s),General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Molina Medicaid,CPT,46917,Laser surgery anal lesions,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Molina Medicaid,CPT,46922,Excision of anal lesion(s),General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Molina Medicaid,CPT,46924,Destruction anal lesion(s),General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Molina Medicaid,CPT,46930,Destroy internal hemorrhoids,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Molina Medicaid,CPT,46940,Treatment of anal fissure,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Molina Medicaid,CPT,46942,Treatment of anal fissure,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Molina Medicaid,CPT,46945,Int hrhc lig 1 hroid w/o img,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Molina Medicaid,CPT,46946,Int hrhc lig 2+hroid w/o img,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Molina Medicaid,CPT,46947,Hemorrhoidopexy by stapling,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,46948,Int hrhc tranal dartlzj 2+,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,46999,Anus surgery procedure,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Molina Medicaid,CPT,47370,Laparo ablate liver tumor rf,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Molina Medicaid,CPT,47371,Laparo ablate liver cryosurg,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Molina Medicaid,CPT,47379,Laparoscope procedure liver,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Molina Medicaid,CPT,47510,Insert catheter bile duct,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
Molina Medicaid,CPT,47511,Insert bile duct drain,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
Molina Medicaid,CPT,47525,Change bile duct catheter,Gastroenterology,Per Unit,$119.18 ,OP,119.18,119.18,,,,,,
Molina Medicaid,CPT,47530,Revise/reinsert bile tube,Gastroenterology,Per Unit,$119.18 ,OP,119.18,119.18,,,,,,
Molina Medicaid,CPT,47537,Removal biliary drg cath,Gastroenterology,Per Unit,$119.18 ,OP,119.18,119.18,,,,,,
Molina Medicaid,CPT,47560,Laparoscopy w/cholangio,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Molina Medicaid,CPT,47561,Laparo w/cholangio/biopsy,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Molina Medicaid,CPT,47562,Laparoscopic cholecystectomy,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Molina Medicaid,CPT,47563,Laparo cholecystectomy/graph,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Molina Medicaid,CPT,47564,Laparo cholecystectomy/explr,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Molina Medicaid,CPT,47570,Laparo cholecystoenterostomy,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Molina Medicaid,CPT,47579,Laparoscope proc biliary,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Molina Medicaid,CPT,47630,Remove bile duct stone,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
Molina Medicaid,CPT,48550,Donor pancreatectomy,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,49000,Exploration of abdomen,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,49002,Reopening of abdomen,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,49010,Exploration behind abdomen,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,49203,Exc abd tum 5 cm or less,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,49204,Exc abd tum over 5 cm,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,49205,Exc abd tum over 10 cm,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,49215,Excise sacral spine tumor,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,49220,Multiple surgery abdomen,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,49250,Excision of umbilicus,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Molina Medicaid,CPT,49255,Removal of omentum,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,49320,Diag laparo separate proc,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Molina Medicaid,CPT,49321,Laparoscopy biopsy,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Molina Medicaid,CPT,49322,Laparoscopy aspiration,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Molina Medicaid,CPT,49323,Laparo drain lymphocele,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Molina Medicaid,CPT,49324,Lap insert tunnel ip cath,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Molina Medicaid,CPT,49325,Lap revision perm ip cath,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Molina Medicaid,CPT,49326,Lap w/omentopexy add-on,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Molina Medicaid,CPT,49329,Laparo proc abdm/per/oment,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Molina Medicaid,CPT,49402,Remove foreign body adbomen,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Molina Medicaid,CPT,49425,Insert abdomen-venous drain,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,49426,Revise abdomen-venous shunt,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Molina Medicaid,CPT,49428,Ligation of shunt,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,49429,Removal of shunt,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Molina Medicaid,CPT,49440,Place gastrostomy tube perc,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Molina Medicaid,CPT,49441,Place duod/jej tube perc,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Molina Medicaid,CPT,49442,Place cecostomy tube perc,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,49446,Change g-tube to g-j perc,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Molina Medicaid,CPT,49450,Replace g/c tube perc,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Molina Medicaid,CPT,49451,Replace duod/jej tube perc,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Molina Medicaid,CPT,49452,Replace g-j tube perc,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Molina Medicaid,CPT,49460,Fix g/colon tube w/device,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Molina Medicaid,CPT,49491,Rpr hern preemie reduc,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Molina Medicaid,CPT,49492,Rpr ing hern premie blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Molina Medicaid,CPT,49495,Rpr ing hernia baby reduc,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Molina Medicaid,CPT,49496,Rpr ing hernia baby blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Molina Medicaid,CPT,49500,Rpr ing hernia init reduce,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Molina Medicaid,CPT,49501,Rpr ing hernia init blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Molina Medicaid,CPT,49505,Prp i/hern init reduc >5 yr,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Molina Medicaid,CPT,49507,Prp i/hern init block >5 yr,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Molina Medicaid,CPT,49520,Rerepair ing hernia reduce,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Molina Medicaid,CPT,49521,Rerepair ing hernia blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Molina Medicaid,CPT,49525,Repair ing hernia sliding,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Molina Medicaid,CPT,49540,Repair lumbar hernia,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Molina Medicaid,CPT,49550,Rpr rem hernia init reduce,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Molina Medicaid,CPT,49553,Rpr fem hernia init blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Molina Medicaid,CPT,49555,Rerepair fem hernia reduce,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Molina Medicaid,CPT,49557,Rerepair fem hernia blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Molina Medicaid,CPT,49560,Rpr ventral hern init reduc,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Molina Medicaid,CPT,49561,Rpr ventral hern init block,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Molina Medicaid,CPT,49565,Rerepair ventrl hern reduce,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Molina Medicaid,CPT,49566,Rerepair ventrl hern block,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Molina Medicaid,CPT,49568,Hernia repair w/mesh,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Molina Medicaid,CPT,49570,Rpr epigastric hern reduce,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Molina Medicaid,CPT,49572,Rpr epigastric hern blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Molina Medicaid,CPT,49580,Rpr umbil hern reduc < 5 yr,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Molina Medicaid,CPT,49582,Rpr umbil hern block < 5 yr,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Molina Medicaid,CPT,49585,Rpr umbil hern reduc > 5 yr,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Molina Medicaid,CPT,49587,Rpr umbil hern block > 5 yr,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Molina Medicaid,CPT,49590,Repair spigelian hernia,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Molina Medicaid,CPT,49600,Repair umbilical lesion,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Molina Medicaid,CPT,49606,Repair umbilical lesion,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Molina Medicaid,CPT,49610,Repair umbilical lesion,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Molina Medicaid,CPT,49650,Lap ing hernia repair init,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Molina Medicaid,CPT,49651,Lap ing hernia repair recur,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Molina Medicaid,CPT,49652,Lap vent/abd hernia repair,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Molina Medicaid,CPT,49653,Lap vent/abd hern proc comp,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Molina Medicaid,CPT,49654,Lap inc hernia repair,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Molina Medicaid,CPT,49655,Lap inc hern repair comp,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Molina Medicaid,CPT,49656,Lap inc hernia repair recur,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Molina Medicaid,CPT,49657,Lap inc hern recur comp,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Molina Medicaid,CPT,49659,Laparo proc hernia repair,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Molina Medicaid,CPT,49900,Repair of abdominal wall,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,49904,Omental flap extra-abdom,General Surgery,Per Unit,"$2,599.18 ",OP,"2,599.18","2,599.18",,,,,,
Molina Medicaid,CPT,49905,Omental flap intra-abdom,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Molina Medicaid,CPT,49906,Free omental flap microvasc,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Molina Medicaid,CPT,49999,Abdomen surgery procedure,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Molina Medicaid,CPT,50389,Remove renal tube w/fluoro,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Molina Medicaid,CPT,50390,Drainage of kidney lesion,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Molina Medicaid,CPT,50391,Instll rx agnt into rnal tub,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Molina Medicaid,CPT,50396,Measure kidney pressure,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Molina Medicaid,CPT,50398,Change kidney tube,Gastroenterology,Per Unit,$119.18 ,OP,119.18,119.18,,,,,,
Molina Medicaid,CPT,50430,Njx px nfrosgrm &/urtrgrm,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Molina Medicaid,CPT,50431,Njx px nfrosgrm &/urtrgrm,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Molina Medicaid,CPT,50541,Laparo ablate renal cyst,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Molina Medicaid,CPT,50542,Laparo ablate renal mass,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Molina Medicaid,CPT,50543,Laparo partial nephrectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Molina Medicaid,CPT,50544,Laparoscopy pyeloplasty,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Molina Medicaid,CPT,50549,Laparoscope proc renal,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Molina Medicaid,CPT,50945,Laparoscopy ureterolithotomy,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Molina Medicaid,CPT,50947,Laparo new ureter/bladder,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Molina Medicaid,CPT,50948,Laparo new ureter/bladder,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Molina Medicaid,CPT,50949,Laparoscope proc ureter,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Molina Medicaid,CPT,51100,Drain bladder by needle,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Molina Medicaid,CPT,51500,Removal of bladder cyst,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Molina Medicaid,CPT,51705,Change of bladder tube,Gastroenterology,Per Unit,$119.18 ,OP,119.18,119.18,,,,,,
Molina Medicaid,CPT,51710,Change of bladder tube,Gastroenterology,Per Unit,$119.18 ,OP,119.18,119.18,,,,,,
Molina Medicaid,CPT,51715,Endoscopic injection/implant,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Molina Medicaid,CPT,51720,Treatment of bladder lesion,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Molina Medicaid,CPT,51725,Simple cystometrogram,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Molina Medicaid,CPT,51726,Complex cystometrogram,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Molina Medicaid,CPT,51727,Cystometrogram w/up,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Molina Medicaid,CPT,51728,Cystometrogram w/vp,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Molina Medicaid,CPT,51729,Cystometrogram w/vp&up,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Molina Medicaid,CPT,51741,Electro-uroflowmetry first,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Molina Medicaid,CPT,51784,Anal/urinary muscle study,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,51785,Anal/urinary muscle study,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,51792,Urinary reflex study,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Molina Medicaid,CPT,51990,Laparo urethral suspension,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Molina Medicaid,CPT,51992,Laparo sling operation,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Molina Medicaid,CPT,51999,Laparoscope proc bla,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Molina Medicaid,CPT,52010,Cystoscopy & duct catheter,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Molina Medicaid,CPT,52270,Cystoscopy & revise urethra,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Molina Medicaid,CPT,52275,Cystoscopy & revise urethra,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Molina Medicaid,CPT,52276,Cystoscopy and treatment,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Molina Medicaid,CPT,52277,Cystoscopy and treatment,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Molina Medicaid,CPT,52282,Cystoscopy implant stent,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Molina Medicaid,CPT,52283,Cystoscopy and treatment,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Molina Medicaid,CPT,52285,Cystoscopy and treatment,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Molina Medicaid,CPT,52400,Cystouretero w/congen repr,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Molina Medicaid,CPT,52402,Cystourethro cut ejacul duct,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Molina Medicaid,CPT,52442,Cystourethro w/addl implant,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Molina Medicaid,CPT,52601,Prostatectomy (turp),Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Molina Medicaid,CPT,52630,Remove prostate regrowth,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Molina Medicaid,CPT,52647,Laser surgery of prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Molina Medicaid,CPT,52648,Laser surgery of prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Molina Medicaid,CPT,52649,Prostate laser enucleation,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Molina Medicaid,CPT,53000,Incision of urethra,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Molina Medicaid,CPT,53010,Incision of urethra,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Molina Medicaid,CPT,53020,Incision of urethra,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Molina Medicaid,CPT,53025,Incision of urethra,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Molina Medicaid,CPT,53040,Drainage of urethra abscess,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Molina Medicaid,CPT,53060,Drainage of urethra abscess,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Molina Medicaid,CPT,53080,Drainage of urinary leakage,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Molina Medicaid,CPT,53085,Drainage of urinary leakage,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Molina Medicaid,CPT,53200,Biopsy of urethra,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Molina Medicaid,CPT,53210,Removal of urethra,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Molina Medicaid,CPT,53215,Removal of urethra,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Molina Medicaid,CPT,53220,Treatment of urethra lesion,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Molina Medicaid,CPT,53230,Removal of urethra lesion,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Molina Medicaid,CPT,53235,Removal of urethra lesion,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Molina Medicaid,CPT,53240,Surgery for urethra pouch,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Molina Medicaid,CPT,53250,Removal of urethra gland,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Molina Medicaid,CPT,53260,Treatment of urethra lesion,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Molina Medicaid,CPT,53265,Treatment of urethra lesion,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Molina Medicaid,CPT,53270,Removal of urethra gland,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Molina Medicaid,CPT,53275,Repair of urethra defect,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Molina Medicaid,CPT,53400,Revise urethra stage 1,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Molina Medicaid,CPT,53405,Revise urethra stage 2,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Molina Medicaid,CPT,53410,Reconstruction of urethra,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Molina Medicaid,CPT,53415,Reconstruction of urethra,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Molina Medicaid,CPT,53420,Reconstruct urethra stage 1,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Molina Medicaid,CPT,53425,Reconstruct urethra stage 2,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Molina Medicaid,CPT,53430,Reconstruction of urethra,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Molina Medicaid,CPT,53431,Reconstruct urethra/bladder,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Molina Medicaid,CPT,53440,Male sling procedure,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Molina Medicaid,CPT,53442,Remove/revise male sling,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Molina Medicaid,CPT,53444,Insert tandem cuff,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Molina Medicaid,CPT,53446,Remove uro sphincter,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Molina Medicaid,CPT,53448,Remov/replc ur sphinctr comp,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Molina Medicaid,CPT,53449,Repair uro sphincter,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Molina Medicaid,CPT,53450,Revision of urethra,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Molina Medicaid,CPT,53460,Revision of urethra,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Molina Medicaid,CPT,53500,Urethrlys transvag w/ scope,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Molina Medicaid,CPT,53502,Repair of urethra injury,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Molina Medicaid,CPT,53505,Repair of urethra injury,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Molina Medicaid,CPT,53510,Repair of urethra injury,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Molina Medicaid,CPT,53515,Repair of urethra injury,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Molina Medicaid,CPT,53520,Repair of urethra defect,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Molina Medicaid,CPT,53605,Dilate urethra stricture,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Molina Medicaid,CPT,53620,Dilate urethra stricture,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Molina Medicaid,CPT,53621,Dilate urethra stricture,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Molina Medicaid,CPT,53665,Dilation of urethra,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Molina Medicaid,CPT,53855,Insert prost urethral stent,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Molina Medicaid,CPT,53860,Transurethral rf treatment,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Molina Medicaid,CPT,54000,Slitting of prepuce,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Molina Medicaid,CPT,54001,Slitting of prepuce,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,54015,Drain penis lesion,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,54050,Destruction penis lesion(s),Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Molina Medicaid,CPT,54055,Destruction penis lesion(s),Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,54056,Cryosurgery penis lesion(s),Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Molina Medicaid,CPT,54057,Laser surg penis lesion(s),Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,54060,Excision of penis lesion(s),Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,54065,Destruction penis lesion(s),Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,54100,Biopsy of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,54105,Biopsy of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,54110,Treatment of penis lesion,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,54115,Treatment of penis lesion,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,54150,Circumcision w/regionl block,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,54160,Circumcision neonate,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,54161,Circum 28 days or older,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,54162,Lysis penil circumic lesion,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,54163,Repair of circumcision,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,54164,Frenulotomy of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,54230,Prepare penis study,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,54231,Dynamic cavernosometry,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,54300,Revision of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,54304,Revision of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,54340,Secondary urethral surgery,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,54360,Penis plastic surgery,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,54380,Repair penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,54385,Repair penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,54400,Insert semi-rigid prosthesis,Urological Surgery,Per Unit,"$6,916.67 ",OP,"6,916.67","6,916.67",,,,,,
Molina Medicaid,CPT,54401,Insert self-contd prosthesis,Urological Surgery,Per Unit,"$6,916.67 ",OP,"6,916.67","6,916.67",,,,,,
Molina Medicaid,CPT,54405,Insert multi-comp penis pros,Urological Surgery,Per Unit,"$6,916.67 ",OP,"6,916.67","6,916.67",,,,,,
Molina Medicaid,CPT,54406,Remove muti-comp penis pros,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,54408,Repair multi-comp penis pros,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,54410,Remove/replace penis prosth,Urological Surgery,Per Unit,"$6,916.67 ",OP,"6,916.67","6,916.67",,,,,,
Molina Medicaid,CPT,54411,Remov/replc penis pros comp,Urological Surgery,Per Unit,"$6,916.67 ",OP,"6,916.67","6,916.67",,,,,,
Molina Medicaid,CPT,54415,Remove self-contd penis pros,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,54416,Remv/repl penis contain pros,Urological Surgery,Per Unit,"$6,916.67 ",OP,"6,916.67","6,916.67",,,,,,
Molina Medicaid,CPT,54417,Remv/replc penis pros compl,Urological Surgery,Per Unit,"$6,916.67 ",OP,"6,916.67","6,916.67",,,,,,
Molina Medicaid,CPT,54420,Revision of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,54430,Revision of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,54435,Revision of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,54440,Repair of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,54450,Preputial stretching,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Molina Medicaid,CPT,54500,Biopsy of testis,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Molina Medicaid,CPT,54505,Biopsy of testis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,54512,Excise lesion testis,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Molina Medicaid,CPT,54520,Removal of testis,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Molina Medicaid,CPT,54522,Orchiectomy partial,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,54530,Removal of testis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,54535,Extensive testis surgery,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,54550,Exploration for testis,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Molina Medicaid,CPT,54560,Exploration for testis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,54600,Reduce testis torsion,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Molina Medicaid,CPT,54620,Suspension of testis,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Molina Medicaid,CPT,54640,Orchiopexy ingun/scrot appr,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Molina Medicaid,CPT,54650,Orchiopexy (fowler-stephens),Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,54660,Revision of testis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,54670,Repair testis injury,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Molina Medicaid,CPT,54680,Relocation of testis(es),Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,54690,Laparoscopy orchiectomy,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,54692,Laparoscopy orchiopexy,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,54699,Laparoscope proc testis,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Molina Medicaid,CPT,54700,Drainage of scrotum,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Molina Medicaid,CPT,54800,Biopsy of epididymis,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Molina Medicaid,CPT,54830,Remove epididymis lesion,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Molina Medicaid,CPT,54840,Remove epididymis lesion,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Molina Medicaid,CPT,54860,Removal of epididymis,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Molina Medicaid,CPT,54861,Removal of epididymis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,54865,Explore epididymis,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Molina Medicaid,CPT,54900,Fusion of spermatic ducts,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Molina Medicaid,CPT,54901,Fusion of spermatic ducts,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,55040,Removal of hydrocele,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,55041,Removal of hydroceles,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,55060,Repair of hydrocele,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Molina Medicaid,CPT,55100,Drainage of scrotum abscess,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Molina Medicaid,CPT,55110,Explore scrotum,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,55120,Removal of scrotum lesion,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Molina Medicaid,CPT,55150,Removal of scrotum,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Molina Medicaid,CPT,55175,Revision of scrotum,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Molina Medicaid,CPT,55180,Revision of scrotum,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,55200,Incision of sperm duct,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Molina Medicaid,CPT,55250,Removal of sperm duct(s),Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Molina Medicaid,CPT,55400,Repair of sperm duct,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,55450,Ligation of sperm duct,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Molina Medicaid,CPT,55500,Removal of hydrocele,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Molina Medicaid,CPT,55520,Removal of sperm cord lesion,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Molina Medicaid,CPT,55530,Revise spermatic cord veins,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,55535,Revise spermatic cord veins,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Molina Medicaid,CPT,55540,Revise hernia & sperm veins,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,55550,Laparo ligate spermatic vein,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,55559,Laparo proc spermatic cord,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Molina Medicaid,CPT,55600,Incise sperm duct pouch,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Molina Medicaid,CPT,55605,Incise sperm duct pouch,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,55650,Remove sperm duct pouch,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,55680,Remove sperm pouch lesion,Urological Surgery,Per Unit,"$1,364.21 ",OP,"1,364.21","1,364.21",,,,,,
Molina Medicaid,CPT,55801,Removal of prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Molina Medicaid,CPT,55810,Extensive prostate surgery,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Molina Medicaid,CPT,55815,Extensive prostate surgery,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Molina Medicaid,CPT,55821,Removal of prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Molina Medicaid,CPT,55831,Removal of prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Molina Medicaid,CPT,55840,Extensive prostate surgery,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Molina Medicaid,CPT,55842,Extensive prostate surgery,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Molina Medicaid,CPT,55845,Extensive prostate surgery,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Molina Medicaid,CPT,55860,Surgical exposure prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Molina Medicaid,CPT,55866,Laparo radical prostatectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Molina Medicaid,CPT,55870,Electroejaculation,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Molina Medicaid,CPT,55873,Cryoablate prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Molina Medicaid,CPT,55874,Tprnl plmt biodegrdabl matrl,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Molina Medicaid,CPT,55880,Abltj mal prst8 tiss hifu,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Molina Medicaid,CPT,55899,Genital surgery procedure,Urological Surgery,Per Unit,$977.77 ,OP,977.77,977.77,,,,,,
Molina Medicaid,CPT,56405,I & d of vulva/perineum,Gynecology,Per Unit,$102.34 ,OP,102.34,102.34,,,,,,
Molina Medicaid,CPT,56420,Drainage of gland abscess,Gynecology,Per Unit,$102.34 ,OP,102.34,102.34,,,,,,
Molina Medicaid,CPT,56820,Exam of vulva w/scope,Gynecology,Per Unit,$102.34 ,OP,102.34,102.34,,,,,,
Molina Medicaid,CPT,57150,Treat vagina infection,Gynecology,Per Unit,$102.34 ,OP,102.34,102.34,,,,,,
Molina Medicaid,CPT,57160,Insert pessary/other device,Gynecology,Per Unit,$102.34 ,OP,102.34,102.34,,,,,,
Molina Medicaid,CPT,57170,Fitting of diaphragm/cap,Gynecology,Per Unit,$102.34 ,OP,102.34,102.34,,,,,,
Molina Medicaid,CPT,57220,Revision of urethra,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Molina Medicaid,CPT,57230,Repair of urethral lesion,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Molina Medicaid,CPT,57240,Anterior colporrhaphy,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Molina Medicaid,CPT,57250,Repair rectum & vagina,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Molina Medicaid,CPT,57260,Cmbn ant pst colprhy,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Molina Medicaid,CPT,57265,Cmbn ap colprhy w/ntrcl rpr,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Molina Medicaid,CPT,57267,Insert mesh/pelvic flr addon,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Molina Medicaid,CPT,57268,Repair of bowel bulge,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Molina Medicaid,CPT,57270,Repair of bowel pouch,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Molina Medicaid,CPT,57287,Revise/remove sling repair,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Molina Medicaid,CPT,57288,Repair bladder defect,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Molina Medicaid,CPT,57289,Repair bladder & vagina,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Molina Medicaid,CPT,57410,Pelvic examination,Gynecology,Per Unit,$102.34 ,OP,102.34,102.34,,,,,,
Molina Medicaid,CPT,58300,Insert intrauterine device,Gynecology,Per Unit,$102.34 ,OP,102.34,102.34,,,,,,
Molina Medicaid,CPT,58301,Remove intrauterine device,Gynecology,Per Unit,$102.34 ,OP,102.34,102.34,,,,,,
Molina Medicaid,CPT,58321,Artificial insemination,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Molina Medicaid,CPT,58322,Artificial insemination,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Molina Medicaid,CPT,58323,Sperm washing,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Molina Medicaid,CPT,58970,Retrieval of oocyte,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Molina Medicaid,CPT,58974,Transfer of embryo,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Molina Medicaid,CPT,58976,Transfer of embryo,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Molina Medicaid,CPT,59020,Fetal contract stress test,Obstetrics,Per Unit,$139.58 ,OP,139.58,139.58,,,,,,
Molina Medicaid,CPT,59025,Fetal non-stress test,Obstetrics,Per Unit,$139.58 ,OP,139.58,139.58,,,,,,
Molina Medicaid,CPT,59030,Fetal scalp blood sample,Obstetrics,Per Unit,$139.58 ,OP,139.58,139.58,,,,,,
Molina Medicaid,CPT,59050,Fetal monitor w/report,Obstetrics,Per Unit,$139.58 ,OP,139.58,139.58,,,,,,
Molina Medicaid,CPT,59072,Umbilical cord occlud w/us,Obstetrics,Per Unit,$482.07 ,OP,482.07,482.07,,,,,,
Molina Medicaid,CPT,59074,Fetal fluid drainage w/us,Obstetrics,Per Unit,$139.58 ,OP,139.58,139.58,,,,,,
Molina Medicaid,CPT,59076,Fetal shunt placement w/us,Obstetrics,Per Unit,$482.07 ,OP,482.07,482.07,,,,,,
Molina Medicaid,CPT,59400,Obstetrical care,Obstetrics,Per Unit,"$1,075.20 ",OP,"1,075.20","1,075.20",,,,,,
Molina Medicaid,CPT,59409,Obstetrical care,Obstetrics,Per Unit,"$1,075.20 ",OP,"1,075.20","1,075.20",,,,,,
Molina Medicaid,CPT,59410,Obstetrical care,Obstetrics,Per Unit,"$1,075.20 ",OP,"1,075.20","1,075.20",,,,,,
Molina Medicaid,CPT,59610,Vbac delivery,Obstetrics,Per Unit,"$1,075.20 ",OP,"1,075.20","1,075.20",,,,,,
Molina Medicaid,CPT,59612,Vbac delivery only,Obstetrics,Per Unit,"$1,075.20 ",OP,"1,075.20","1,075.20",,,,,,
Molina Medicaid,CPT,59614,Vbac care after delivery,Obstetrics,Per Unit,"$1,075.20 ",OP,"1,075.20","1,075.20",,,,,,
Molina Medicaid,CPT,59812,Treatment of miscarriage,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Molina Medicaid,CPT,59820,Care of miscarriage,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Molina Medicaid,CPT,59821,Treatment of miscarriage,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Molina Medicaid,CPT,59830,Treat uterus infection,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Molina Medicaid,CPT,59840,Abortion,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Molina Medicaid,CPT,59841,Abortion,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Molina Medicaid,CPT,59850,Abortion,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Molina Medicaid,CPT,59851,Abortion,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Molina Medicaid,CPT,59852,Abortion,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Molina Medicaid,CPT,59855,Abortion,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Molina Medicaid,CPT,59856,Abortion,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Molina Medicaid,CPT,59857,Abortion,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Molina Medicaid,CPT,59866,Abortion (mpr),Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Molina Medicaid,CPT,59897,Fetal invas px w/us,Obstetrics,Per Unit,$139.58 ,OP,139.58,139.58,,,,,,
Molina Medicaid,CPT,60000,Drain thyroid/tongue cyst,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,60100,Biopsy of thyroid,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,60300,Aspir/inj thyroid cyst,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,60650,Laparoscopy adrenalectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Molina Medicaid,CPT,60659,Laparo proc endocrine,General Surgery,Per Unit,"$1,656.92 ",OP,"1,656.92","1,656.92",,,,,,
Molina Medicaid,CPT,60699,Endocrine surgery procedure,General Surgery,Per Unit,"$1,380.09 ",OP,"1,380.09","1,380.09",,,,,,
Molina Medicaid,CPT,61000,Remove cranial cavity fluid,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Molina Medicaid,CPT,61001,Remove cranial cavity fluid,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Molina Medicaid,CPT,61020,Remove brain cavity fluid,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Molina Medicaid,CPT,61026,Injection into brain canal,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Molina Medicaid,CPT,61070,Brain canal shunt procedure,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Molina Medicaid,CPT,61215,Insert brain-fluid device,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,61623,Endovasc tempory vessel occl,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,61624,Transcath occlusion cns,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,61626,Transcath occlusion non-cns,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,61630,Intracranial angioplasty,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,61635,Intracran angioplsty w/stent,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,61640,Dilate ic vasospasm init,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,61641,Dilat ic vspsm ea vsl sm ter,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,61642,Dilat ic vspsm ea diff ter,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,61645,Perq art m-thrombect &/nfs,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,61651,Evasc prlng admn rx agnt add,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,61720,Incise skull/brain surgery,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,61770,Incise skull for treatment,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,61790,Treat trigeminal nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,61791,Treat trigeminal tract,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,61796,Srs cranial lesion simple,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"2,592.65","2,592.65",,,,,,
Molina Medicaid,CPT,61797,Srs cran les simple addl,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"2,592.65","2,592.65",,,,,,
Molina Medicaid,CPT,61798,Srs cranial lesion complex,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"2,592.65","2,592.65",,,,,,
Molina Medicaid,CPT,61799,Srs cran les complex addl,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"2,592.65","2,592.65",,,,,,
Molina Medicaid,CPT,61800,Apply srs headframe add-on,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"2,592.65","2,592.65",,,,,,
Molina Medicaid,CPT,61850,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Molina Medicaid,CPT,61880,Revise/remove neuroelectrode,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,61885,Insrt/redo neurostim 1 array,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Molina Medicaid,CPT,61886,Implant neurostim arrays,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Molina Medicaid,CPT,61888,Revise/remove neuroreceiver,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,62000,Treat skull fracture,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,62194,Replace/irrigate catheter,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,62225,Replace/irrigate catheter,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,62230,Replace/revise brain shunt,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,62252,Csf shunt reprogram,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,62292,Njx chemonucleolysis lmbr,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,62302,Myelography lumbar injection,Diagnostic Radiology,Per Unit,$345.35 ,OP,345.35,345.35,,,,,,
Molina Medicaid,CPT,62303,Myelography lumbar injection,Diagnostic Radiology,Per Unit,$345.35 ,OP,345.35,345.35,,,,,,
Molina Medicaid,CPT,62304,Myelography lumbar injection,Diagnostic Radiology,Per Unit,$345.35 ,OP,345.35,345.35,,,,,,
Molina Medicaid,CPT,62305,Myelography lumbar injection,Diagnostic Radiology,Per Unit,$345.35 ,OP,345.35,345.35,,,,,,
Molina Medicaid,CPT,62310,Inject spine cerv/thoracic,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Molina Medicaid,CPT,62311,Inject spine lumbar/sacral,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Molina Medicaid,CPT,62318,Inject spine w/cath crv/thrc,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Molina Medicaid,CPT,62319,Inject spine w/cath lmb/scrl,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Molina Medicaid,CPT,62350,Implant spinal canal cath,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,62355,Remove spinal canal catheter,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,62360,Insert spine infusion device,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"7,098.75","7,098.75",,,,,,
Molina Medicaid,CPT,62361,Implant spine infusion pump,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"7,098.75","7,098.75",,,,,,
Molina Medicaid,CPT,62362,Implant spine infusion pump,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"7,098.75","7,098.75",,,,,,
Molina Medicaid,CPT,62365,Remove spine infusion device,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,62367,Analyze spine infus pump,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Molina Medicaid,CPT,62368,Analyze sp inf pump w/reprog,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Molina Medicaid,CPT,62369,Anal sp inf pmp w/reprg&fill,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Molina Medicaid,CPT,62370,Anl sp inf pmp w/mdreprg&fil,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Molina Medicaid,CPT,63600,Remove spinal cord lesion,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,63610,Stimulation of spinal cord,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,63615,Remove lesion of spinal cord,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,63620,Srs spinal lesion,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"2,592.65","2,592.65",,,,,,
Molina Medicaid,CPT,63621,Srs spinal lesion addl,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"2,592.65","2,592.65",,,,,,
Molina Medicaid,CPT,63650,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,63661,Remove spine eltrd perq aray,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,63662,Remove spine eltrd plate,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,63663,Revise spine eltrd perq aray,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,63664,Revise spine eltrd plate,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Molina Medicaid,CPT,63685,Insrt/redo spine n generator,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Molina Medicaid,CPT,63688,Revise/remove neuroreceiver,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,63707,Repair spinal fluid leakage,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,63741,Install spinal shunt,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,63744,Revision of spinal shunt,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,63746,Removal of spinal shunt,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64400,Njx aa&/strd trigeminal nrv,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Molina Medicaid,CPT,64402,N block inj facial,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Molina Medicaid,CPT,64405,Njx aa&/strd gr ocpl nrv,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Molina Medicaid,CPT,64408,Njx aa&/strd vagus nrv,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Molina Medicaid,CPT,64410,N block inj phrenic,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Molina Medicaid,CPT,64412,N block inj spinal accessor,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Molina Medicaid,CPT,64413,N block inj cervical plexus,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Molina Medicaid,CPT,64415,Njx aa&/strd brach plexus,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Molina Medicaid,CPT,64416,Njx aa&/strd brach plex nfs,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Molina Medicaid,CPT,64417,Njx aa&/strd axillary nrv,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Molina Medicaid,CPT,64418,Njx aa&/strd sprscap nrv,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Molina Medicaid,CPT,64420,Njx aa&/strd ntrcost nrv 1,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Molina Medicaid,CPT,64421,Njx aa&/strd ntrcost nrv ea,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Molina Medicaid,CPT,64425,Njx aa&/strd ii ih nerves,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Molina Medicaid,CPT,64430,Njx aa&/strd pudendal nerve,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Molina Medicaid,CPT,64435,Njx aa&/strd paracrv nrv,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Molina Medicaid,CPT,64445,Njx aa&/strd sciatic nerve,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Molina Medicaid,CPT,64446,Njx aa&/strd sciatic nrv nfs,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Molina Medicaid,CPT,64447,Njx aa&/strd femoral nerve,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Molina Medicaid,CPT,64448,Njx aa&/strd fem nerve nfs,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Molina Medicaid,CPT,64449,Njx aa&/strd lmbr plex nfs,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Molina Medicaid,CPT,64450,Njx aa&/strd other pn/branch,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Molina Medicaid,CPT,64454,Njx aa&/strd gnclr nrv brnch,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Molina Medicaid,CPT,64455,Njx aa&/strd pltr com dg nrv,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Molina Medicaid,CPT,64486,Tap block unil by injection,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Molina Medicaid,CPT,64487,Tap block uni by infusion,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Molina Medicaid,CPT,64488,Tap block bi injection,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Molina Medicaid,CPT,64489,Tap block bi by infusion,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Molina Medicaid,CPT,64505,N block spenopalatine gangl,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Molina Medicaid,CPT,64508,N block carotid sinus s/p,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Molina Medicaid,CPT,64510,N block stellate ganglion,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Molina Medicaid,CPT,64517,N block inj hypogas plxs,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Molina Medicaid,CPT,64530,N block inj celiac pelus,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Molina Medicaid,CPT,64550,Appl surface neurostimulator,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,64553,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,64555,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,64561,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,64565,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,64566,Neuroeltrd stim post tibial,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Molina Medicaid,CPT,64568,Inc for vagus n elect impl,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Molina Medicaid,CPT,64569,Revise/repl vagus n eltrd,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Molina Medicaid,CPT,64570,Remove vagus n eltrd,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64575,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Molina Medicaid,CPT,64580,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"7,098.75","7,098.75",,,,,,
Molina Medicaid,CPT,64581,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"7,098.75","7,098.75",,,,,,
Molina Medicaid,CPT,64585,Revise/remove neuroelectrode,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64590,Insrt/redo pn/gastr stimul,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"7,098.75","7,098.75",,,,,,
Molina Medicaid,CPT,64595,Revise/rmv pn/gastr stimul,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,64600,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Molina Medicaid,CPT,64605,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Molina Medicaid,CPT,64610,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Molina Medicaid,CPT,64611,Chemodenerv saliv glands,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Molina Medicaid,CPT,64612,Destroy nerve face muscle,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Molina Medicaid,CPT,64615,Chemodenerv musc migraine,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Molina Medicaid,CPT,64616,Chemodenerv musc neck dyston,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Molina Medicaid,CPT,64617,Chemodener muscle larynx emg,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Molina Medicaid,CPT,64620,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Molina Medicaid,CPT,64624,Dstrj nulyt agt gnclr nrv,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Molina Medicaid,CPT,64625,Rf abltj nrv nrvtg si jt,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64630,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Molina Medicaid,CPT,64632,N block inj common digit,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Molina Medicaid,CPT,64640,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Molina Medicaid,CPT,64642,Chemodenerv 1 extremity 1-4,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Molina Medicaid,CPT,64643,Chemodenerv 1 extrem 1-4 ea,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Molina Medicaid,CPT,64644,Chemodenerv 1 extrem 5/> mus,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Molina Medicaid,CPT,64645,Chemodenerv 1 extrem 5/> ea,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Molina Medicaid,CPT,64646,Chemodenerv trunk musc 1-5,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Molina Medicaid,CPT,64647,Chemodenerv trunk musc 6/>,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Molina Medicaid,CPT,64650,Chemodenerv eccrine glands,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Molina Medicaid,CPT,64653,Chemodenerv eccrine glands,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Molina Medicaid,CPT,64680,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Molina Medicaid,CPT,64681,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Molina Medicaid,CPT,64702,Revise finger/toe nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64704,Revise hand/foot nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64708,Revise arm/leg nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64712,Revision of sciatic nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64713,Revision of arm nerve(s),Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,64714,Revise low back nerve(s),Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,64716,Revision of cranial nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,64718,Revise ulnar nerve at elbow,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64719,Revise ulnar nerve at wrist,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64721,Carpal tunnel surgery,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64722,Relieve pressure on nerve(s),Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64726,Release foot/toe nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64727,Internal nerve revision,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,64732,Incision of brow nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64734,Incision of cheek nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,64736,Incision of chin nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64738,Incision of jaw nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64740,Incision of tongue nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64742,Incision of facial nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,64744,Incise nerve back of head,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64746,Incise diaphragm nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,64763,Incise hip/thigh nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64766,Incise hip/thigh nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64771,Sever cranial nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64772,Incision of spinal nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64774,Remove skin nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64776,Remove digit nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64778,Digit nerve surgery add-on,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64782,Remove limb nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64783,Limb nerve surgery add-on,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64784,Remove nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64786,Remove sciatic nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64787,Implant nerve end,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64788,Remove skin nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64790,Removal of nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64792,Removal of nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64795,Biopsy of nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64802,Sympathectomy cervical,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64804,Remove sympathetic nerves,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64818,Remove sympathetic nerves,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64820,Sympathectomy digital artery,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64821,Remove sympathetic nerves,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,64822,Remove sympathetic nerves,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,64823,Sympathectomy supfc palmar,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,64831,Repair of digit nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64832,Repair nerve add-on,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64834,Repair of hand or foot nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64835,Repair of hand or foot nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64836,Repair of hand or foot nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64837,Repair nerve add-on,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64840,Repair of leg nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,64856,Repair/transpose nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64857,Repair arm/leg nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64858,Repair sciatic nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,64859,Nerve surgery,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,64861,Repair of arm nerves,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64862,Repair of low back nerves,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,64864,Repair of facial nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,64865,Repair of facial nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,64866,Fusion of facial/other nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,64868,Fusion of facial/other nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,64872,Subsequent repair of nerve,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64874,Repair & revise nerve add-on,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64876,Repair nerve/shorten bone,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64885,Nerve graft head/neck </4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,64886,Nerve graft head/neck >4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,64890,Nerve graft hand/foot </4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,64891,Nerve graft hand/foot >4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,64892,Nerve graft arm/leg <4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,64893,Nerve graft arm/leg >4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,64895,Nerve graft hand/foot </4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,64896,Nerve graft hand/foot >4 cm,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"7,098.75","7,098.75",,,,,,
Molina Medicaid,CPT,64897,Nerve graft arm/leg </4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,64898,Nerve graft arm/leg >4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,64901,Nerve graft add-on,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,64902,Nerve graft add-on,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,64905,Nerve pedicle transfer,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,64907,Nerve pedicle transfer,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,64910,Nerve repair w/allograft,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,64911,Neurorraphy w/vein autograft,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,64912,Nrv rpr w/nrv algrft 1st,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,64913,Nrv rpr w/nrv algrft ea addl,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,64999,Nervous system surgery,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Molina Medicaid,CPT,65091,Revise eye,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,65093,Revise eye with implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,65101,Removal of eye,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,65103,Remove eye/insert implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,65105,Remove eye/attach implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,65110,Removal of eye,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,65112,Remove eye/revise socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,65114,Remove eye/revise socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,65125,Revise ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,65130,Insert ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,65135,Insert ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,65140,Attach ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,65150,Revise ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,65155,Reinsert ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,65175,Removal of ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,65205,Remove foreign body from eye,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,65210,Remove foreign body from eye,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,65220,Remove foreign body from eye,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,65222,Remove foreign body from eye,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,65235,Remove foreign body from eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Molina Medicaid,CPT,65260,Remove foreign body from eye,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Molina Medicaid,CPT,65265,Remove foreign body from eye,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Molina Medicaid,CPT,65270,Repair of eye wound,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Molina Medicaid,CPT,65272,Repair of eye wound,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Molina Medicaid,CPT,65275,Repair of eye wound,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Molina Medicaid,CPT,65280,Repair of eye wound,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Molina Medicaid,CPT,65285,Repair of eye wound,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Molina Medicaid,CPT,65286,Repair of eye wound,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Molina Medicaid,CPT,65290,Repair of eye socket wound,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
Molina Medicaid,CPT,65400,Removal of eye lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Molina Medicaid,CPT,65410,Biopsy of cornea,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Molina Medicaid,CPT,65420,Removal of eye lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Molina Medicaid,CPT,65426,Removal of eye lesion,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Molina Medicaid,CPT,65430,Corneal smear,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Molina Medicaid,CPT,65435,Curette/treat cornea,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Molina Medicaid,CPT,65436,Curette/treat cornea,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Molina Medicaid,CPT,65450,Treatment of corneal lesion,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Molina Medicaid,CPT,65600,Revision of cornea,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Molina Medicaid,CPT,65710,Corneal transplant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Molina Medicaid,CPT,65730,Corneal transplant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Molina Medicaid,CPT,65750,Corneal transplant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Molina Medicaid,CPT,65755,Corneal transplant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Molina Medicaid,CPT,65756,Corneal trnspl endothelial,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Molina Medicaid,CPT,65757,Prep corneal endo allograft,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Molina Medicaid,CPT,65760,Revision of cornea,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Molina Medicaid,CPT,65765,Revision of cornea,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Molina Medicaid,CPT,65767,Corneal tissue transplant,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Molina Medicaid,CPT,65770,Revise cornea with implant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Molina Medicaid,CPT,65771,Radial keratotomy,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Molina Medicaid,CPT,65772,Correction of astigmatism,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Molina Medicaid,CPT,65775,Correction of astigmatism,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Molina Medicaid,CPT,65778,Cover eye w/membrane,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Molina Medicaid,CPT,65779,Cover eye w/membrane suture,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Molina Medicaid,CPT,65780,Ocular reconst transplant,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Molina Medicaid,CPT,65781,Ocular reconst transplant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Molina Medicaid,CPT,65782,Ocular reconst transplant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Molina Medicaid,CPT,65785,Impltj ntrstrml crnl rng seg,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Molina Medicaid,CPT,65800,Drainage of eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Molina Medicaid,CPT,65810,Drainage of eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Molina Medicaid,CPT,65815,Drainage of eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Molina Medicaid,CPT,65820,Relieve inner eye pressure,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Molina Medicaid,CPT,65850,Incision of eye,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Molina Medicaid,CPT,65855,Trabeculoplasty laser surg,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Molina Medicaid,CPT,65860,Incise inner eye adhesions,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Molina Medicaid,CPT,65865,Incise inner eye adhesions,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Molina Medicaid,CPT,65870,Incise inner eye adhesions,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Molina Medicaid,CPT,65875,Incise inner eye adhesions,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Molina Medicaid,CPT,65880,Incise inner eye adhesions,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Molina Medicaid,CPT,65900,Remove eye lesion,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Molina Medicaid,CPT,65920,Remove implant of eye,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Molina Medicaid,CPT,65930,Remove blood clot from eye,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Molina Medicaid,CPT,66020,Injection treatment of eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Molina Medicaid,CPT,66030,Injection treatment of eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Molina Medicaid,CPT,66130,Remove eye lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Molina Medicaid,CPT,66150,Glaucoma surgery,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Molina Medicaid,CPT,66155,Glaucoma surgery,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Molina Medicaid,CPT,66160,Glaucoma surgery,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Molina Medicaid,CPT,66170,Glaucoma surgery,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Molina Medicaid,CPT,66172,Incision of eye,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Molina Medicaid,CPT,66174,Translum dil eye canal,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Molina Medicaid,CPT,66175,Trnslum dil eye canal w/stnt,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Molina Medicaid,CPT,66179,Aqueous shunt eye w/o graft,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Molina Medicaid,CPT,66180,Aqueous shunt eye w/graft,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Molina Medicaid,CPT,66183,Insert ant drainage device,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Molina Medicaid,CPT,66184,Revision of aqueous shunt,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Molina Medicaid,CPT,66185,Revise aqueous shunt eye,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Molina Medicaid,CPT,66220,Repair eye lesion,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Molina Medicaid,CPT,66225,Repair/graft eye lesion,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Molina Medicaid,CPT,66250,Follow-up surgery of eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Molina Medicaid,CPT,66500,Incision of iris,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Molina Medicaid,CPT,66505,Incision of iris,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Molina Medicaid,CPT,66600,Remove iris and lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Molina Medicaid,CPT,66605,Removal of iris,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Molina Medicaid,CPT,66625,Removal of iris,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Molina Medicaid,CPT,66630,Removal of iris,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Molina Medicaid,CPT,66635,Removal of iris,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Molina Medicaid,CPT,66680,Repair iris & ciliary body,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Molina Medicaid,CPT,66682,Repair iris & ciliary body,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Molina Medicaid,CPT,66700,Destruction ciliary body,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Molina Medicaid,CPT,66710,Ciliary transsleral therapy,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Molina Medicaid,CPT,66711,Ecp ciliary body destruction,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Molina Medicaid,CPT,66720,Destruction ciliary body,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Molina Medicaid,CPT,66740,Destruction ciliary body,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Molina Medicaid,CPT,66761,Revision of iris,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Molina Medicaid,CPT,66762,Revision of iris,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Molina Medicaid,CPT,66770,Removal of inner eye lesion,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Molina Medicaid,CPT,66820,Incision secondary cataract,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
Molina Medicaid,CPT,66821,After cataract laser surgery,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Molina Medicaid,CPT,66825,Reposition intraocular lens,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
Molina Medicaid,CPT,66830,Removal of lens lesion,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
Molina Medicaid,CPT,66840,Removal of lens material,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
Molina Medicaid,CPT,66850,Removal of lens material,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
Molina Medicaid,CPT,66852,Removal of lens material,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Molina Medicaid,CPT,66920,Extraction of lens,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
Molina Medicaid,CPT,66930,Extraction of lens,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
Molina Medicaid,CPT,66940,Extraction of lens,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
Molina Medicaid,CPT,66982,Xcapsl ctrc rmvl cplx wo ecp,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
Molina Medicaid,CPT,66983,Cataract surg w/iol 1 stage,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
Molina Medicaid,CPT,66984,Xcapsl ctrc rmvl w/o ecp,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
Molina Medicaid,CPT,66985,Insert lens prosthesis,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
Molina Medicaid,CPT,66986,Exchange lens prosthesis,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
Molina Medicaid,CPT,66987,Xcapsl ctrc rmvl cplx w/ecp,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
Molina Medicaid,CPT,66988,Xcapsl ctrc rmvl w/ecp,Ophthalmology Surgery,Per Unit,$925.52 ,OP,925.52,925.52,,,,,,
Molina Medicaid,CPT,66999,Eye surgery procedure,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Molina Medicaid,CPT,67005,Partial removal of eye fluid,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Molina Medicaid,CPT,67010,Partial removal of eye fluid,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Molina Medicaid,CPT,67015,Release of eye fluid,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Molina Medicaid,CPT,67025,Replace eye fluid,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Molina Medicaid,CPT,67027,Implant eye drug system,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Molina Medicaid,CPT,67028,Injection eye drug,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Molina Medicaid,CPT,67030,Incise inner eye strands,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Molina Medicaid,CPT,67031,Laser surgery eye strands,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Molina Medicaid,CPT,67036,Removal of inner eye fluid,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Molina Medicaid,CPT,67039,Laser treatment of retina,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Molina Medicaid,CPT,67040,Laser treatment of retina,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Molina Medicaid,CPT,67041,Vit for macular pucker,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Molina Medicaid,CPT,67042,Vit for macular hole,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Molina Medicaid,CPT,67043,Vit for membrane dissect,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Molina Medicaid,CPT,67101,Repair detached retina crtx,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Molina Medicaid,CPT,67105,Repair detached retina pc,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Molina Medicaid,CPT,67107,Repair detached retina,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Molina Medicaid,CPT,67108,Repair detached retina,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Molina Medicaid,CPT,67110,Repair detached retina,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Molina Medicaid,CPT,67112,Rerepair detached retina,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Molina Medicaid,CPT,67113,Repair retinal detach cplx,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Molina Medicaid,CPT,67115,Release encircling material,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Molina Medicaid,CPT,67120,Remove eye implant material,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Molina Medicaid,CPT,67121,Remove eye implant material,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Molina Medicaid,CPT,67141,Treatment of retina,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Molina Medicaid,CPT,67145,Treatment of retina,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Molina Medicaid,CPT,67208,Treatment of retinal lesion,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Molina Medicaid,CPT,67210,Treatment of retinal lesion,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Molina Medicaid,CPT,67218,Treatment of retinal lesion,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Molina Medicaid,CPT,67220,Treatment of choroid lesion,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Molina Medicaid,CPT,67221,Ocular photodynamic ther,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Molina Medicaid,CPT,67225,Eye photodynamic ther add-on,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Molina Medicaid,CPT,67227,Dstrj extensive retinopathy,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Molina Medicaid,CPT,67228,Treatment x10sv retinopathy,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Molina Medicaid,CPT,67229,Tr retinal les preterm inf,Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Molina Medicaid,CPT,67250,Reinforce eye wall,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Molina Medicaid,CPT,67255,Reinforce/graft eye wall,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Molina Medicaid,CPT,67299,Eye surgery procedure,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"1,212.94","1,212.94",,,,,,
Molina Medicaid,CPT,67311,Revise eye muscle,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
Molina Medicaid,CPT,67312,Revise two eye muscles,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
Molina Medicaid,CPT,67314,Revise eye muscle,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
Molina Medicaid,CPT,67316,Revise two eye muscles,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
Molina Medicaid,CPT,67318,Revise eye muscle(s),Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
Molina Medicaid,CPT,67320,Revise eye muscle(s) add-on,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
Molina Medicaid,CPT,67331,Eye surgery follow-up add-on,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
Molina Medicaid,CPT,67332,Rerevise eye muscles add-on,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
Molina Medicaid,CPT,67334,Revise eye muscle w/suture,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
Molina Medicaid,CPT,67335,Eye suture during surgery,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
Molina Medicaid,CPT,67340,Revise eye muscle add-on,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
Molina Medicaid,CPT,67343,Release eye tissue,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
Molina Medicaid,CPT,67345,Destroy nerve of eye muscle,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
Molina Medicaid,CPT,67346,Biopsy eye muscle,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Molina Medicaid,CPT,67399,Unlisted px extraocular musc,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"1,086.25","1,086.25",,,,,,
Molina Medicaid,CPT,67400,Explore/biopsy eye socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,67405,Explore/drain eye socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,67412,Explore/treat eye socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,67413,Explore/treat eye socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,67414,Explr/decompress eye socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,67415,Aspiration orbital contents,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Molina Medicaid,CPT,67445,Explr/decompress eye socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,67500,Inject/treat eye socket,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Molina Medicaid,CPT,67505,Inject/treat eye socket,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Molina Medicaid,CPT,67515,Inject/treat eye socket,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Molina Medicaid,CPT,67550,Insert eye socket implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,67560,Revise eye socket implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,67570,Decompress optic nerve,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,67599,Orbit surgery procedure,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Molina Medicaid,CPT,67700,Drainage of eyelid abscess,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Molina Medicaid,CPT,67710,Incision of eyelid,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Molina Medicaid,CPT,67715,Incision of eyelid fold,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Molina Medicaid,CPT,67800,Remove eyelid lesion,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Molina Medicaid,CPT,67801,Remove eyelid lesions,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Molina Medicaid,CPT,67805,Remove eyelid lesions,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Molina Medicaid,CPT,67808,Remove eyelid lesion(s),Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Molina Medicaid,CPT,67810,Biopsy eyelid & lid margin,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Molina Medicaid,CPT,67820,Revise eyelashes,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Molina Medicaid,CPT,67825,Revise eyelashes,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Molina Medicaid,CPT,67830,Revise eyelashes,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Molina Medicaid,CPT,67835,Revise eyelashes,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,67840,Remove eyelid lesion,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Molina Medicaid,CPT,67850,Treat eyelid lesion,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Molina Medicaid,CPT,67875,Closure of eyelid by suture,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Molina Medicaid,CPT,67880,Revision of eyelid,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Molina Medicaid,CPT,67882,Revision of eyelid,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Molina Medicaid,CPT,67900,Repair brow defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,67901,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,67902,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,67903,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,67904,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,67906,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,67908,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,67909,Revise eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,67911,Revise eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,67912,Correction eyelid w/implant,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Molina Medicaid,CPT,67914,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Molina Medicaid,CPT,67915,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Molina Medicaid,CPT,67916,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Molina Medicaid,CPT,67917,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,67921,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Molina Medicaid,CPT,67922,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Molina Medicaid,CPT,67923,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Molina Medicaid,CPT,67924,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,67930,Repair eyelid wound,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Molina Medicaid,CPT,67935,Repair eyelid wound,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Molina Medicaid,CPT,67938,Remove eyelid foreign body,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Molina Medicaid,CPT,67950,Revision of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,67961,Revision of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,67966,Revision of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,67971,Reconstruction of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,67973,Reconstruction of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,67974,Reconstruction of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,67975,Reconstruction of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,67999,Revision of eyelid,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Molina Medicaid,CPT,68020,Incise/drain eyelid lining,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Molina Medicaid,CPT,68040,Treatment of eyelid lesions,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Molina Medicaid,CPT,68100,Biopsy of eyelid lining,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Molina Medicaid,CPT,68110,Remove eyelid lining lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Molina Medicaid,CPT,68115,Remove eyelid lining lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Molina Medicaid,CPT,68130,Remove eyelid lining lesion,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Molina Medicaid,CPT,68135,Remove eyelid lining lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Molina Medicaid,CPT,68200,Treat eyelid by injection,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Molina Medicaid,CPT,68320,Revise/graft eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Molina Medicaid,CPT,68325,Revise/graft eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Molina Medicaid,CPT,68326,Revise/graft eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Molina Medicaid,CPT,68328,Revise/graft eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Molina Medicaid,CPT,68330,Revise eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Molina Medicaid,CPT,68335,Revise/graft eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Molina Medicaid,CPT,68340,Separate eyelid adhesions,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Molina Medicaid,CPT,68360,Revise eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Molina Medicaid,CPT,68362,Revise eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Molina Medicaid,CPT,68371,Harvest eye tissue alograft,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Molina Medicaid,CPT,68399,Eyelid lining surgery,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Molina Medicaid,CPT,68400,Incise/drain tear gland,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Molina Medicaid,CPT,68420,Incise/drain tear sac,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Molina Medicaid,CPT,68440,Incise tear duct opening,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Molina Medicaid,CPT,68500,Removal of tear gland,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,68505,Partial removal tear gland,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,68510,Biopsy of tear gland,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Molina Medicaid,CPT,68520,Removal of tear sac,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,68525,Biopsy of tear sac,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Molina Medicaid,CPT,68530,Clearance of tear duct,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Molina Medicaid,CPT,68540,Remove tear gland lesion,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,68550,Remove tear gland lesion,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,68700,Repair tear ducts,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,68705,Revise tear duct opening,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Molina Medicaid,CPT,68720,Create tear sac drain,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,68745,Create tear duct drain,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,68750,Create tear duct drain,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,68760,Close tear duct opening,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Molina Medicaid,CPT,68761,Close tear duct opening,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Molina Medicaid,CPT,68770,Close tear system fistula,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Molina Medicaid,CPT,68801,Dilate tear duct opening,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Molina Medicaid,CPT,68810,Probe nasolacrimal duct,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Molina Medicaid,CPT,68811,Probe nasolacrimal duct,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Molina Medicaid,CPT,68815,Probe nasolacrimal duct,Ophthalmology Surgery,Per Unit,$925.56 ,OP,925.56,925.56,,,,,,
Molina Medicaid,CPT,68816,Probe nl duct w/balloon,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Molina Medicaid,CPT,68840,Explore/irrigate tear ducts,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Molina Medicaid,CPT,68899,Tear duct system surgery,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Molina Medicaid,CPT,69005,Drain external ear lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,69100,Biopsy of external ear,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,69105,Biopsy of external ear canal,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,69110,Remove external ear partial,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,69120,Removal of external ear,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,69140,Remove ear canal lesion(s),Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,69145,Remove ear canal lesion(s),Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,69150,Extensive ear canal surgery,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,69155,Extensive ear/neck surgery,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,69205,Clear outer ear canal,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,69222,Clean out mastoid cavity,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,69300,Revise external ear,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,69310,Rebuild outer ear canal,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,69320,Rebuild outer ear canal,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,69399,Outer ear surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,69421,Incision of eardrum,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,69424,Remove ventilating tube,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,69433,Create eardrum opening,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,69436,Create eardrum opening,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,69440,Exploration of middle ear,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,69450,Eardrum revision,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,69501,Mastoidectomy,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,69502,Mastoidectomy,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,69505,Remove mastoid structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,69511,Extensive mastoid surgery,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,69530,Extensive mastoid surgery,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,69540,Remove ear lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,69550,Remove ear lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,69552,Remove ear lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,69601,Mastoid surgery revision,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,69602,Mastoid surgery revision,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,69603,Mastoid surgery revision,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,69604,Mastoid surgery revision,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,69605,Mastoid surgery revision,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,69610,Repair of eardrum,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,69620,Repair of eardrum,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,69631,Repair eardrum structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,69632,Rebuild eardrum structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,69633,Rebuild eardrum structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,69635,Repair eardrum structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,69636,Rebuild eardrum structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,69637,Rebuild eardrum structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,69641,Revise middle ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,69642,Revise middle ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,69643,Revise middle ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,69644,Revise middle ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,69645,Revise middle ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,69646,Revise middle ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,69650,Release middle ear bone,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,69660,Revise middle ear bone,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,69661,Revise middle ear bone,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,69662,Revise middle ear bone,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,69666,Repair middle ear structures,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,69667,Repair middle ear structures,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,69670,Remove mastoid air cells,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,69676,Remove middle ear nerve,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,69700,Close mastoid fistula,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,69705,Nps surg dilat eust tube uni,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Molina Medicaid,CPT,69706,Nps surg dilat eust tube bi,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Molina Medicaid,CPT,69710,Implant/replace hearing aid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,69711,Remove/repair hearing aid,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,69714,Implant temple bone w/stimul,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,69715,Temple bne implnt w/stimulat,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,69717,Temple bone implant revision,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,69718,Revise temple bone implant,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,69720,Release facial nerve,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,69725,Release facial nerve,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,69740,Repair facial nerve,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,69745,Repair facial nerve,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,69799,Middle ear surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,69801,Incise inner ear,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,69805,Explore inner ear,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,69806,Explore inner ear,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,69820,Establish inner ear window,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,69840,Revise inner ear window,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,69905,Remove inner ear,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"1,520.70","1,520.70",,,,,,
Molina Medicaid,CPT,69910,Remove inner ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,69915,Incise inner ear nerve,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,69930,Implant cochlear device,Otolaryngology Surgery,Per Unit,"$15,529.51 ",OP,"15,529.51","15,529.51",,,,,,
Molina Medicaid,CPT,69949,Inner ear surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,69955,Release facial nerve,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,69960,Release inner ear canal,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"2,241.51","2,241.51",,,,,,
Molina Medicaid,CPT,70010,Contrast x-ray of brain,Diagnostic Radiology,Per Unit,$345.35 ,OP,345.35,345.35,,,,,,
Molina Medicaid,CPT,70015,Contrast x-ray of brain,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Molina Medicaid,CPT,70030,X-ray eye for foreign body,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,70100,X-ray exam of jaw <4views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,70110,X-ray exam of jaw 4/> views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,70120,X-ray exam of mastoids,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,70130,X-ray exam of mastoids,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,70134,X-ray exam of middle ear,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,70140,X-ray exam of facial bones,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,70150,X-ray exam of facial bones,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,70160,X-ray exam of nasal bones,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,70190,X-ray exam of eye sockets,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,70200,X-ray exam of eye sockets,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,70210,X-ray exam of sinuses,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,70220,X-ray exam of sinuses,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,70240,X-ray exam pituitary saddle,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,70250,X-ray exam of skull,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,70260,X-ray exam of skull,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,70300,X-ray exam of teeth,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,70310,X-ray exam of teeth,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,70320,Full mouth x-ray of teeth,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,70328,X-ray exam of jaw joint,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,70330,X-ray exam of jaw joints,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,70336,Magnetic image jaw joint,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Molina Medicaid,CPT,70350,X-ray head for orthodontia,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,70355,Panoramic x-ray of jaws,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,70360,X-ray exam of neck,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,70370,Throat x-ray & fluoroscopy,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,70373,Contrast x-ray of larynx,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,70380,X-ray exam of salivary gland,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,70450,Ct head/brain w/o dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Molina Medicaid,CPT,70460,Ct head/brain w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Molina Medicaid,CPT,70470,Ct head/brain w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Molina Medicaid,CPT,70480,Ct orbit/ear/fossa w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Molina Medicaid,CPT,70481,Ct orbit/ear/fossa w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Molina Medicaid,CPT,70482,Ct orbit/ear/fossa w/o&w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Molina Medicaid,CPT,70486,Ct maxillofacial w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Molina Medicaid,CPT,70487,Ct maxillofacial w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Molina Medicaid,CPT,70488,Ct maxillofacial w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Molina Medicaid,CPT,70490,Ct soft tissue neck w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Molina Medicaid,CPT,70491,Ct soft tissue neck w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Molina Medicaid,CPT,70492,Ct sft tsue nck w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Molina Medicaid,CPT,70496,Ct angiography head,Interventional Radiology,Per Unit,$178.94 ,OP,178.94,178.94,,,,,,
Molina Medicaid,CPT,70498,Ct angiography neck,Interventional Radiology,Per Unit,$178.94 ,OP,178.94,178.94,,,,,,
Molina Medicaid,CPT,70540,Mri orbit/face/neck w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Molina Medicaid,CPT,70542,Mri orbit/face/neck w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Molina Medicaid,CPT,70543,Mri orbt/fac/nck w/o &w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Molina Medicaid,CPT,70544,Mr angiography head w/o dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Molina Medicaid,CPT,70545,Mr angiography head w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Molina Medicaid,CPT,70546,Mr angiograph head w/o&w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Molina Medicaid,CPT,70547,Mr angiography neck w/o dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Molina Medicaid,CPT,70548,Mr angiography neck w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Molina Medicaid,CPT,70549,Mr angiograph neck w/o&w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Molina Medicaid,CPT,70551,Mri brain stem w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Molina Medicaid,CPT,70552,Mri brain stem w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Molina Medicaid,CPT,70553,Mri brain stem w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Molina Medicaid,CPT,70554,Fmri brain by tech,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Molina Medicaid,CPT,70555,Fmri brain by phys/psych,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Molina Medicaid,CPT,70557,Mri brain w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Molina Medicaid,CPT,70558,Mri brain w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Molina Medicaid,CPT,70559,Mri brain w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Molina Medicaid,CPT,71010,Chest x-ray 1 view frontal,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,71015,Chest x-ray stereo frontal,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,71020,Chest x-ray 2vw frontal&latl,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,71021,Chest x-ray frnt lat lordotc,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,71022,Chest x-ray frnt lat oblique,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,71023,Chest x-ray and fluoroscopy,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,71030,Chest x-ray 4/> views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,71034,Chest x-ray&fluoro 4/> views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,71035,Chest x-ray special views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,71045,X-ray exam chest 1 view,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,71046,X-ray exam chest 2 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,71047,X-ray exam chest 3 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,71048,X-ray exam chest 4+ views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,71100,X-ray exam ribs uni 2 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,71101,X-ray exam unilat ribs/chest,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,71110,X-ray exam ribs bil 3 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,71111,X-ray exam ribs/chest4/> vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,71120,X-ray exam breastbone 2/>vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,71130,X-ray strenoclavic jt 3/>vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,71250,Ct thorax dx c-,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Molina Medicaid,CPT,71260,Ct thorax dx c+,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Molina Medicaid,CPT,71270,Ct thorax dx c-/c+,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Molina Medicaid,CPT,71271,Ct thorax lung cancer scr c-,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Molina Medicaid,CPT,71275,Ct angiography chest,Interventional Radiology,Per Unit,$178.94 ,OP,178.94,178.94,,,,,,
Molina Medicaid,CPT,71550,Mri chest w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Molina Medicaid,CPT,71551,Mri chest w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Molina Medicaid,CPT,71552,Mri chest w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Molina Medicaid,CPT,71555,Mri angio chest w or w/o dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Molina Medicaid,CPT,72010,X-ray exam spine ap&lat,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,72020,X-ray exam of spine 1 view,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,72040,X-ray exam neck spine 2-3 vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,72050,X-ray exam neck spine 4/5vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,72052,X-ray exam neck spine 6/>vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,72069,X-ray exam trunk spine stand,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,72070,X-ray exam thorac spine 2vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,72072,X-ray exam thorac spine 3vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,72074,X-ray exam thorac spine4/>vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,72080,X-ray exam thoracolmb 2/> vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,72081,X-ray exam entire spi 1 vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,72082,X-ray exam entire spi 2/3 vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,72083,X-ray exam entire spi 4/5 vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,72084,X-ray exam entire spi 6/> vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,72090,X-ray exam scloiosis erect,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,72100,X-ray exam l-s spine 2/3 vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,72110,X-ray exam l-2 spine 4/>vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,72114,X-ray exam l-s spine bending,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,72120,X-ray bend only l-s spine,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,72125,Ct neck spine w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Molina Medicaid,CPT,72126,Ct neck spine w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Molina Medicaid,CPT,72127,Ct neck spine w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Molina Medicaid,CPT,72128,Ct chest spine w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Molina Medicaid,CPT,72129,Ct chest spine w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Molina Medicaid,CPT,72130,Ct chest spine w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Molina Medicaid,CPT,72131,Ct lumbar spine w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Molina Medicaid,CPT,72132,Ct lumbar spine w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Molina Medicaid,CPT,72133,Ct lumbar spine w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Molina Medicaid,CPT,72141,Mri neck spine w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Molina Medicaid,CPT,72142,Mri neck spine w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Molina Medicaid,CPT,72146,Mri chest spine w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Molina Medicaid,CPT,72147,Mri chest spine w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Molina Medicaid,CPT,72148,Mri lumbar spine w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Molina Medicaid,CPT,72149,Mri lumbar spine w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Molina Medicaid,CPT,72156,Mri neck spine w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Molina Medicaid,CPT,72157,Mri chest spine w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Molina Medicaid,CPT,72158,Mri lumbar spine w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Molina Medicaid,CPT,72159,Mr angio spine w/o&w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Molina Medicaid,CPT,72170,X-ray exam of pelvis,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,72190,X-ray exam of pelvis,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,72191,Ct angiograph pelv w/o&w/dye,Interventional Radiology,Per Unit,$178.94 ,OP,178.94,178.94,,,,,,
Molina Medicaid,CPT,72192,Ct pelvis w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Molina Medicaid,CPT,72193,Ct pelvis w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Molina Medicaid,CPT,72194,Ct pelvis w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Molina Medicaid,CPT,72195,Mri pelvis w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Molina Medicaid,CPT,72196,Mri pelvis w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Molina Medicaid,CPT,72197,Mri pelvis w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Molina Medicaid,CPT,72198,Mr angio pelvis w/o & w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Molina Medicaid,CPT,72200,X-ray exam si joints,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,72202,X-ray exam si joints 3/> vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,72220,X-ray exam sacrum tailbone,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,72240,Myelography neck spine,Diagnostic Radiology,Per Unit,$345.35 ,OP,345.35,345.35,,,,,,
Molina Medicaid,CPT,72255,Myelography thoracic spine,Diagnostic Radiology,Per Unit,$345.35 ,OP,345.35,345.35,,,,,,
Molina Medicaid,CPT,72265,Myelography l-s spine,Diagnostic Radiology,Per Unit,$345.35 ,OP,345.35,345.35,,,,,,
Molina Medicaid,CPT,72270,Myelogphy 2/> spine regions,Diagnostic Radiology,Per Unit,$345.35 ,OP,345.35,345.35,,,,,,
Molina Medicaid,CPT,72275,Epidurography,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,72285,Discography cerv/thor spine,Diagnostic Radiology,Per Unit,$345.35 ,OP,345.35,345.35,,,,,,
Molina Medicaid,CPT,72295,X-ray of lower spine disk,Diagnostic Radiology,Per Unit,$345.35 ,OP,345.35,345.35,,,,,,
Molina Medicaid,CPT,73000,X-ray exam of collar bone,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,73010,X-ray exam of shoulder blade,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,73020,X-ray exam of shoulder,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,73030,X-ray exam of shoulder,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,73050,X-ray exam of shoulders,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,73060,X-ray exam of humerus,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,73070,X-ray exam of elbow,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,73080,X-ray exam of elbow,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,73090,X-ray exam of forearm,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,73092,X-ray exam of arm infant,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,73100,X-ray exam of wrist,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,73110,X-ray exam of wrist,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,73120,X-ray exam of hand,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,73130,X-ray exam of hand,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,73140,X-ray exam of finger(s),Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,73200,Ct upper extremity w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Molina Medicaid,CPT,73201,Ct upper extremity w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Molina Medicaid,CPT,73202,Ct uppr extremity w/o&w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Molina Medicaid,CPT,73206,Ct angio upr extrm w/o&w/dye,Interventional Radiology,Per Unit,$178.94 ,OP,178.94,178.94,,,,,,
Molina Medicaid,CPT,73218,Mri upper extremity w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Molina Medicaid,CPT,73219,Mri upper extremity w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Molina Medicaid,CPT,73220,Mri uppr extremity w/o&w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Molina Medicaid,CPT,73221,Mri joint upr extrem w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Molina Medicaid,CPT,73222,Mri joint upr extrem w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Molina Medicaid,CPT,73223,Mri joint upr extr w/o&w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Molina Medicaid,CPT,73225,Mr angio upr extr w/o&w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Molina Medicaid,CPT,73500,X-ray exam of hip,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,73501,X-ray exam hip uni 1 view,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,73502,X-ray exam hip uni 2-3 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,73503,X-ray exam hip uni 4/> views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,73510,X-ray exam of hip,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,73520,X-ray exam of hips,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,73521,X-ray exam hips bi 2 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,73522,X-ray exam hips bi 3-4 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,73523,X-ray exam hips bi 5/> views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,73530,X-ray exam of hip,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,73540,X-ray exam of pelvis & hips,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,73550,X-ray exam of thigh,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,73551,X-ray exam of femur 1,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,73552,X-ray exam of femur 2/>,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,73560,X-ray exam of knee 1 or 2,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,73562,X-ray exam of knee 3,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,73564,X-ray exam knee 4 or more,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,73565,X-ray exam of knees,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,73590,X-ray exam of lower leg,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,73592,X-ray exam of leg infant,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,73600,X-ray exam of ankle,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,73610,X-ray exam of ankle,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,73620,X-ray exam of foot,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,73630,X-ray exam of foot,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,73650,X-ray exam of heel,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,73660,X-ray exam of toe(s),Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,73700,Ct lower extremity w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Molina Medicaid,CPT,73701,Ct lower extremity w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Molina Medicaid,CPT,73702,Ct lwr extremity w/o&w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Molina Medicaid,CPT,73706,Ct angio lwr extr w/o&w/dye,Interventional Radiology,Per Unit,$178.94 ,OP,178.94,178.94,,,,,,
Molina Medicaid,CPT,73718,Mri lower extremity w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Molina Medicaid,CPT,73719,Mri lower extremity w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Molina Medicaid,CPT,73720,Mri lwr extremity w/o&w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Molina Medicaid,CPT,73721,Mri jnt of lwr extre w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Molina Medicaid,CPT,73722,Mri joint of lwr extr w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Molina Medicaid,CPT,73723,Mri joint lwr extr w/o&w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Molina Medicaid,CPT,73725,Mr ang lwr ext w or w/o dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Molina Medicaid,CPT,74000,X-ray exam of abdomen,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,74010,X-ray exam of abdomen,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,74018,X-ray exam abdomen 1 view,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,74019,X-ray exam abdomen 2 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,74020,X-ray exam of abdomen,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,74021,X-ray exam abdomen 3+ views,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,74022,X-ray exam complete abdomen,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,74150,Ct abdomen w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Molina Medicaid,CPT,74160,Ct abdomen w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Molina Medicaid,CPT,74170,Ct abdomen w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Molina Medicaid,CPT,74174,Ct angio abd&pelv w/o&w/dye,Interventional Radiology,Per Unit,$178.94 ,OP,178.94,178.94,,,,,,
Molina Medicaid,CPT,74175,Ct angio abdom w/o & w/dye,Interventional Radiology,Per Unit,$178.94 ,OP,178.94,178.94,,,,,,
Molina Medicaid,CPT,74176,Ct abd & pelvis w/o contrast,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Molina Medicaid,CPT,74177,Ct abd & pelv w/contrast,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Molina Medicaid,CPT,74178,Ct abd & pelv 1/> regns,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Molina Medicaid,CPT,74181,Mri abdomen w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Molina Medicaid,CPT,74182,Mri abdomen w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Molina Medicaid,CPT,74183,Mri abdomen w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Molina Medicaid,CPT,74185,Mri angio abdom w orw/o dye,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Molina Medicaid,CPT,74210,X-ray xm phrnx&/crv esoph c+,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,74220,X-ray xm esophagus 1cntrst,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,74235,Remove esophagus obstruction,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,74261,Ct colonography dx,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Molina Medicaid,CPT,74262,Ct colonography dx w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Molina Medicaid,CPT,74263,Ct colonography screening,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Molina Medicaid,CPT,74300,X-ray bile ducts/pancreas,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,74301,X-rays at surgery add-on,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,74305,X-ray bile ducts/pancreas,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,74320,Contrast x-ray of bile ducts,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,74327,X-ray bile stone removal,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,74328,X-ray bile duct endoscopy,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,74329,X-ray for pancreas endoscopy,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,74330,X-ray bile/panc endoscopy,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,74340,X-ray guide for gi tube,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,74355,X-ray guide intestinal tube,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,74360,X-ray guide gi dilation,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,74363,X-ray bile duct dilation,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,74475,X-ray control cath insert,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,74480,X-ray control cath insert,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,74485,Dilation urtr/urt rs&i,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,74710,X-ray measurement of pelvis,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,74712,Mri fetal sngl/1st gestation,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Molina Medicaid,CPT,74713,Mri fetal ea addl gestation,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Molina Medicaid,CPT,74742,X-ray fallopian tube,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,75557,Cardiac mri for morph,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Molina Medicaid,CPT,75559,Cardiac mri w/stress img,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Molina Medicaid,CPT,75561,Cardiac mri for morph w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Molina Medicaid,CPT,75563,Card mri w/stress img & dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Molina Medicaid,CPT,75565,Card mri veloc flow mapping,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Molina Medicaid,CPT,75571,Ct hrt w/o dye w/ca test,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Molina Medicaid,CPT,75572,Ct hrt w/3d image,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Molina Medicaid,CPT,75573,Ct hrt w/3d image congen,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Molina Medicaid,CPT,75574,Ct angio hrt w/3d image,Interventional Radiology,Per Unit,$178.94 ,OP,178.94,178.94,,,,,,
Molina Medicaid,CPT,75605,Contrast exam thoracic aorta,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Molina Medicaid,CPT,75635,Ct angio abdominal arteries,Interventional Radiology,Per Unit,$178.94 ,OP,178.94,178.94,,,,,,
Molina Medicaid,CPT,75705,Artery x-rays spine,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Molina Medicaid,CPT,75726,Artery x-rays abdomen,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Molina Medicaid,CPT,75736,Artery x-rays pelvis,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Molina Medicaid,CPT,75774,Artery x-ray each vessel,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Molina Medicaid,CPT,75791,Av dialysis shunt imaging,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,75842,Vein x-ray adrenal glands,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Molina Medicaid,CPT,75893,Venous sampling by catheter,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Molina Medicaid,CPT,75894,X-rays transcath therapy,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,75896,X-rays transcath therapy,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,75901,Remove cva device obstruct,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,75902,Remove cva lumen obstruct,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,75945,Intravascular us,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Molina Medicaid,CPT,75946,Intravascular us add-on,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Molina Medicaid,CPT,75952,Endovasc repair abdom aorta,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,75953,Abdom aneurysm endovas rpr,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,75954,Iliac aneurysm endovas rpr,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,75956,Xray endovasc thor ao repr,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,75957,Xray endovasc thor ao repr,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,75958,Xray place prox ext thor ao,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,75959,Xray place dist ext thor ao,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,75962,Repair arterial blockage,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,75964,Repair artery blockage each,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,75966,Repair arterial blockage,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,75968,Repair artery blockage each,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,75970,Vascular biopsy,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,75980,Contrast xray exam bile duct,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,75982,Contrast xray exam bile duct,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,75984,Xray control catheter change,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,75989,Abscess drainage under x-ray,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,76010,X-ray nose to rectum,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,76100,X-ray exam of body section,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,76101,Complex body section x-ray,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,76102,Complex body section x-rays,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,76120,Cine/video x-rays,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,76125,Cine/video x-rays add-on,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,76145,Med physic dos eval rad exps,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Molina Medicaid,CPT,76380,Cat scan follow-up study,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Molina Medicaid,CPT,76390,Mr spectroscopy,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Molina Medicaid,CPT,76391,Mr elastography,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Molina Medicaid,CPT,76496,Fluoroscopic procedure,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,76497,Ct procedure,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Molina Medicaid,CPT,76498,Mri procedure,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Molina Medicaid,CPT,76499,Radiographic procedure,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,76506,Echo exam of head,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,76510,Oph us dx b-scan&quan a-scan,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,76511,Oph us dx quan a-scan only,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,76512,Oph us dx b-scan,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,76513,Oph us dx ant sgm us uni/bi,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,76514,Echo exam of eye thickness,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,76516,Echo exam of eye,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,76519,Echo exam of eye,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,76529,Echo exam of eye,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,76536,Us exam of head and neck,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,76604,Us exam chest,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,76641,Ultrasound breast complete,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,76642,Ultrasound breast limited,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,76700,Us exam abdom complete,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Molina Medicaid,CPT,76705,Echo exam of abdomen,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,76706,Us abdl aorta screen aaa,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,76770,Us exam abdo back wall comp,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Molina Medicaid,CPT,76775,Us exam abdo back wall lim,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,76776,Us exam k transpl w/doppler,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,76800,Us exam spinal canal,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,76801,Ob us < 14 wks single fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Molina Medicaid,CPT,76802,Ob us < 14 wks addl fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Molina Medicaid,CPT,76805,Ob us >= 14 wks sngl fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Molina Medicaid,CPT,76810,Ob us >= 14 wks addl fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Molina Medicaid,CPT,76811,Ob us detailed sngl fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Molina Medicaid,CPT,76812,Ob us detailed addl fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Molina Medicaid,CPT,76813,Ob us nuchal meas 1 gest,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Molina Medicaid,CPT,76814,Ob us nuchal meas add-on,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Molina Medicaid,CPT,76815,Ob us limited fetus(s),Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Molina Medicaid,CPT,76816,Ob us follow-up per fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Molina Medicaid,CPT,76817,Transvaginal us obstetric,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Molina Medicaid,CPT,76818,Fetal biophys profile w/nst,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Molina Medicaid,CPT,76819,Fetal biophys profil w/o nst,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Molina Medicaid,CPT,76820,Umbilical artery echo,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Molina Medicaid,CPT,76821,Middle cerebral artery echo,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Molina Medicaid,CPT,76825,Echo exam of fetal heart,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Molina Medicaid,CPT,76826,Echo exam of fetal heart,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Molina Medicaid,CPT,76827,Echo exam of fetal heart,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Molina Medicaid,CPT,76828,Echo exam of fetal heart,Diagnostic Radiology,Per Unit,$56.13 ,OP,56.13,56.13,,,,,,
Molina Medicaid,CPT,76830,Transvaginal us non-ob,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,76831,Echo exam uterus,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Molina Medicaid,CPT,76856,Us exam pelvic complete,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Molina Medicaid,CPT,76857,Us exam pelvic limited,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,76870,Us exam scrotum,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,76872,Us transrectal,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,76873,Echograp trans r pros study,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Molina Medicaid,CPT,76881,Us compl joint r-t w/img,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,76882,Us lmtd jt/nonvasc xtr strux,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,76885,Us exam infant hips dynamic,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,76886,Us exam infant hips static,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,76930,Echo guide cardiocentesis,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Molina Medicaid,CPT,76932,Echo guide for heart biopsy,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Molina Medicaid,CPT,76936,Echo guide for artery repair,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,76937,Us guide vascular access,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Molina Medicaid,CPT,76940,Us guide tissue ablation,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Molina Medicaid,CPT,76941,Echo guide for transfusion,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Molina Medicaid,CPT,76942,Echo guide for biopsy,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Molina Medicaid,CPT,76945,Echo guide villus sampling,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Molina Medicaid,CPT,76946,Echo guide for amniocentesis,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Molina Medicaid,CPT,76948,Echo guide ova aspiration,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Molina Medicaid,CPT,76965,Echo guidance radiotherapy,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Molina Medicaid,CPT,76970,Ultrasound exam follow-up,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,76975,Gi endoscopic ultrasound,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Molina Medicaid,CPT,76977,Us bone density measure,Diagnostic Radiology,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
Molina Medicaid,CPT,76978,Us trgt dyn mbubb 1st les,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Molina Medicaid,CPT,76979,Us trgt dyn mbubb ea addl,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Molina Medicaid,CPT,76981,Use parenchyma,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,76982,Use 1st target lesion,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,76983,Use ea addl target lesion,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,76998,Us guide intraop,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Molina Medicaid,CPT,76999,Echo examination procedure,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,77001,Fluoroguide for vein device,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,77002,Needle localization by xray,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,77003,Fluoroguide for spine inject,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,77011,Ct scan for localization,Interventional Radiology,Per Unit,$61.07 ,OP,61.07,61.07,,,,,,
Molina Medicaid,CPT,77012,Ct scan for needle biopsy,Interventional Radiology,Per Unit,$61.07 ,OP,61.07,61.07,,,,,,
Molina Medicaid,CPT,77013,Ct guide for tissue ablation,Interventional Radiology,Per Unit,$61.07 ,OP,61.07,61.07,,,,,,
Molina Medicaid,CPT,77014,Ct scan for therapy guide,Interventional Radiology,Per Unit,$61.07 ,OP,61.07,61.07,,,,,,
Molina Medicaid,CPT,77021,Mri guidance ndl plmt rs&i,Interventional Radiology,Per Unit,$108.13 ,OP,108.13,108.13,,,,,,
Molina Medicaid,CPT,77022,Mri gdn parnchyma tiss abltj,Interventional Radiology,Per Unit,$108.13 ,OP,108.13,108.13,,,,,,
Molina Medicaid,CPT,77046,Mri breast c- unilateral,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Molina Medicaid,CPT,77047,Mri breast c- bilateral,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Molina Medicaid,CPT,77048,Mri breast c-+ w/cad uni,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Molina Medicaid,CPT,77049,Mri breast c-+ w/cad bi,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Molina Medicaid,CPT,77055,Mammogram one breast,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
Molina Medicaid,CPT,77056,Mammogram both breasts,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
Molina Medicaid,CPT,77057,Mammogram screening,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
Molina Medicaid,CPT,77058,Mri one breast,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Molina Medicaid,CPT,77059,Mri both breasts,Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Molina Medicaid,CPT,77061,Breast tomosynthesis uni,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
Molina Medicaid,CPT,77062,Breast tomosynthesis bi,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
Molina Medicaid,CPT,77063,Breast tomosynthesis bi,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
Molina Medicaid,CPT,77065,Dx mammo incl cad uni,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
Molina Medicaid,CPT,77066,Dx mammo incl cad bi,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
Molina Medicaid,CPT,77067,Scr mammo bi incl cad,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
Molina Medicaid,CPT,77072,X-rays for bone age,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,77073,X-rays bone length studies,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,77074,X-rays bone survey limited,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,77076,X-rays bone survey infant,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,77077,Joint survey single view,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,77078,Ct bone density axial,Diagnostic Radiology,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
Molina Medicaid,CPT,77080,Dxa bone density axial,Diagnostic Radiology,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
Molina Medicaid,CPT,77081,Dxa bone density/peripheral,Diagnostic Radiology,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
Molina Medicaid,CPT,77084,Magnetic image bone marrow,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Molina Medicaid,CPT,77085,Dxa bone density study,Diagnostic Radiology,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
Molina Medicaid,CPT,77086,Fracture assessment via dxa,Diagnostic Radiology,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
Molina Medicaid,CPT,77261,Radiation therapy planning,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Molina Medicaid,CPT,77262,Radiation therapy planning,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Molina Medicaid,CPT,77263,Radiation therapy planning,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Molina Medicaid,CPT,77280,Set radiation therapy field,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Molina Medicaid,CPT,77285,Set radiation therapy field,Therapeutic Radiology,Per Unit,$434.17 ,OP,434.17,434.17,,,,,,
Molina Medicaid,CPT,77290,Set radiation therapy field,Therapeutic Radiology,Per Unit,$434.17 ,OP,434.17,434.17,,,,,,
Molina Medicaid,CPT,77293,Respirator motion mgmt simul,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Molina Medicaid,CPT,77295,3-d radiotherapy plan,Therapeutic Radiology,Per Unit,$68.45 ,OP,68.45,68.45,,,,,,
Molina Medicaid,CPT,77299,Radiation therapy planning,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Molina Medicaid,CPT,77300,Radiation therapy dose plan,Therapeutic Radiology,Per Unit,$434.17 ,OP,434.17,434.17,,,,,,
Molina Medicaid,CPT,77301,Radiotherapy dose plan imrt,Therapeutic Radiology,Per Unit,$68.45 ,OP,68.45,68.45,,,,,,
Molina Medicaid,CPT,77306,Telethx isodose plan simple,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Molina Medicaid,CPT,77307,Telethx isodose plan cplx,Therapeutic Radiology,Per Unit,$434.17 ,OP,434.17,434.17,,,,,,
Molina Medicaid,CPT,77316,Brachytx isodose plan simple,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Molina Medicaid,CPT,77317,Brachytx isodose intermed,Therapeutic Radiology,Per Unit,$434.17 ,OP,434.17,434.17,,,,,,
Molina Medicaid,CPT,77318,Brachytx isodose complex,Therapeutic Radiology,Per Unit,$434.17 ,OP,434.17,434.17,,,,,,
Molina Medicaid,CPT,77321,Special teletx port plan,Therapeutic Radiology,Per Unit,$434.17 ,OP,434.17,434.17,,,,,,
Molina Medicaid,CPT,77331,Special radiation dosimetry,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Molina Medicaid,CPT,77332,Radiation treatment aid(s),Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Molina Medicaid,CPT,77333,Radiation treatment aid(s),Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Molina Medicaid,CPT,77334,Radiation treatment aid(s),Therapeutic Radiology,Per Unit,$434.17 ,OP,434.17,434.17,,,,,,
Molina Medicaid,CPT,77336,Radiation physics consult,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Molina Medicaid,CPT,77338,Design mlc device for imrt,Therapeutic Radiology,Per Unit,$434.17 ,OP,434.17,434.17,,,,,,
Molina Medicaid,CPT,77370,Radiation physics consult,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Molina Medicaid,CPT,77371,Srs multisource,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"2,592.65","2,592.65",,,,,,
Molina Medicaid,CPT,77372,Srs linear based,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"2,592.65","2,592.65",,,,,,
Molina Medicaid,CPT,77373,Sbrt delivery,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
Molina Medicaid,CPT,77385,Ntsty modul rad tx dlvr smpl,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Molina Medicaid,CPT,77386,Ntsty modul rad tx dlvr cplx,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Molina Medicaid,CPT,77387,Guidance for radj tx dlvr,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Molina Medicaid,CPT,77399,External radiation dosimetry,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Molina Medicaid,CPT,77401,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Molina Medicaid,CPT,77402,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Molina Medicaid,CPT,77407,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Molina Medicaid,CPT,77412,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Molina Medicaid,CPT,77417,Radiology port images(s),Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,77422,Neutron beam tx simple,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Molina Medicaid,CPT,77423,Neutron beam tx complex,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Molina Medicaid,CPT,77424,Io rad tx delivery by x-ray,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
Molina Medicaid,CPT,77425,Io rad tx deliver by elctrns,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
Molina Medicaid,CPT,77427,Radiation tx management x5,Therapeutic Radiology,Per Unit,$70.25 ,OP,70.25,70.25,,,,,,
Molina Medicaid,CPT,77431,Radiation therapy management,Therapeutic Radiology,Per Unit,$70.25 ,OP,70.25,70.25,,,,,,
Molina Medicaid,CPT,77432,Stereotactic radiation trmt,Therapeutic Radiology,Per Unit,$70.25 ,OP,70.25,70.25,,,,,,
Molina Medicaid,CPT,77435,Sbrt management,Therapeutic Radiology,Per Unit,$70.25 ,OP,70.25,70.25,,,,,,
Molina Medicaid,CPT,77469,Io radiation tx management,Therapeutic Radiology,Per Unit,$70.25 ,OP,70.25,70.25,,,,,,
Molina Medicaid,CPT,77470,Special radiation treatment,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Molina Medicaid,CPT,77499,Radiation therapy management,Therapeutic Radiology,Per Unit,$70.25 ,OP,70.25,70.25,,,,,,
Molina Medicaid,CPT,77520,Proton trmt simple w/o comp,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Molina Medicaid,CPT,77522,Proton trmt simple w/comp,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
Molina Medicaid,CPT,77523,Proton trmt intermediate,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
Molina Medicaid,CPT,77525,Proton treatment complex,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
Molina Medicaid,CPT,77600,Hyperthermia treatment,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Molina Medicaid,CPT,77605,Hyperthermia treatment,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Molina Medicaid,CPT,77610,Hyperthermia treatment,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Molina Medicaid,CPT,77615,Hyperthermia treatment,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Molina Medicaid,CPT,77620,Hyperthermia treatment,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Molina Medicaid,CPT,77750,Infuse radioactive materials,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Molina Medicaid,CPT,77761,Apply intrcav radiat simple,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Molina Medicaid,CPT,77762,Apply intrcav radiat interm,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
Molina Medicaid,CPT,77763,Apply intrcav radiat compl,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
Molina Medicaid,CPT,77767,Hdr rdncl skn surf brachytx,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Molina Medicaid,CPT,77768,Hdr rdncl skn surf brachytx,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Molina Medicaid,CPT,77770,Hdr rdncl ntrstl/icav brchtx,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Molina Medicaid,CPT,77771,Hdr rdncl ntrstl/icav brchtx,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
Molina Medicaid,CPT,77772,Hdr rdncl ntrstl/icav brchtx,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
Molina Medicaid,CPT,77776,Apply interstit radiat simpl,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Molina Medicaid,CPT,77777,Apply interstit radiat inter,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Molina Medicaid,CPT,77778,Apply interstit radiat compl,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
Molina Medicaid,CPT,77785,Hdr brachytx 1 channel,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Molina Medicaid,CPT,77786,Hdr brachytx 2-12 channel,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
Molina Medicaid,CPT,77787,Hdr brachytx over 12 chan,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"1,627.76","1,627.76",,,,,,
Molina Medicaid,CPT,77789,Apply surf ldr radionuclide,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Molina Medicaid,CPT,77790,Radiation handling,Therapeutic Radiology,Per Unit,$194.79 ,OP,194.79,194.79,,,,,,
Molina Medicaid,CPT,77799,Radium/radioisotope therapy,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Molina Medicaid,CPT,78012,Thyroid uptake measurement,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78013,Thyroid imaging w/blood flow,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78014,Thyroid imaging w/blood flow,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78015,Thyroid met imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78016,Thyroid met imaging/studies,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78018,Thyroid met imaging body,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78020,Thyroid met uptake,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78070,Parathyroid planar imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Molina Medicaid,CPT,78071,Parathyrd planar w/wo subtrj,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78072,Parathyrd planar w/spect&ct,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78075,Adrenal cortex & medulla img,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Molina Medicaid,CPT,78099,Endocrine nuclear procedure,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78102,Bone marrow imaging ltd,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78103,Bone marrow imaging mult,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78104,Bone marrow imaging body,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78110,Plasma volume single,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Molina Medicaid,CPT,78111,Plasma volume multiple,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Molina Medicaid,CPT,78120,Red cell mass single,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78121,Red cell mass multiple,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78122,Blood volume,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Molina Medicaid,CPT,78130,Red cell survival study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78135,Red cell survival kinetics,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78140,Red cell sequestration,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78185,Spleen imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78190,Platelet survival kinetics,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78191,Platelet survival,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78195,Lymph system imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Molina Medicaid,CPT,78199,Blood/lymph nuclear exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78201,Liver imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Molina Medicaid,CPT,78202,Liver imaging with flow,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Molina Medicaid,CPT,78205,Liver imaging (3d),Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Molina Medicaid,CPT,78206,Liver image (3d) with flow,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Molina Medicaid,CPT,78215,Liver and spleen imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Molina Medicaid,CPT,78216,Liver & spleen image/flow,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Molina Medicaid,CPT,78226,Hepatobiliary system imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78227,Hepatobil syst image w/drug,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78230,Salivary gland imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78231,Serial salivary imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78232,Salivary gland function exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78258,Esophageal motility study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78261,Gastric mucosa imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78262,Gastroesophageal reflux exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78264,Gastric emptying imag study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78265,Gastric emptying imag study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78266,Gastric emptying imag study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78267,Breath tst attain/anal c-14,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,78270,Vit b-12 absorption exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78271,Vit b-12 absrp exam int fac,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78272,Vit b-12 absorp combined,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78278,Acute gi blood loss imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Molina Medicaid,CPT,78282,Gi protein loss exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78290,Meckels divert exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78291,Leveen/shunt patency exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78299,Gi nuclear procedure,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78300,Bone imaging limited area,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78305,Bone imaging multiple areas,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78306,Bone imaging whole body,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78315,Bone imaging 3 phase,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78320,Bone imaging (3d),Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78350,Bone mineral single photon,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78351,Bone mineral dual photon,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78399,Musculoskeletal nuclear exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78414,Non-imaging heart function,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78428,Cardiac shunt imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78429,Myocrd img pet 1 std w/ct,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Molina Medicaid,CPT,78430,Myocrd img pet rst/strs w/ct,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Molina Medicaid,CPT,78431,Myocrd img pet rst&strs ct,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Molina Medicaid,CPT,78432,Myocrd img pet 2rtracer,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Molina Medicaid,CPT,78433,Myocrd img pet 2rtracer ct,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Molina Medicaid,CPT,78434,Aqmbf pet rest & rx stress,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Molina Medicaid,CPT,78445,Vascular flow imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78451,Ht muscle image spect sing,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Molina Medicaid,CPT,78452,Ht muscle image spect mult,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Molina Medicaid,CPT,78453,Ht muscle image planar sing,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Molina Medicaid,CPT,78454,Ht musc image planar mult,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Molina Medicaid,CPT,78456,Acute venous thrombus image,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78457,Venous thrombosis imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Molina Medicaid,CPT,78458,Ven thrombosis images bilat,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78459,Myocrd img pet single study,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Molina Medicaid,CPT,78466,Heart infarct image,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78468,Heart infarct image (ef),Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78469,Heart infarct image (3d),Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Molina Medicaid,CPT,78472,Gated heart planar single,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78473,Gated heart multiple,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78481,Heart first pass single,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78483,Heart first pass multiple,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Molina Medicaid,CPT,78491,Myocrd img pet 1std rst/strs,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Molina Medicaid,CPT,78492,Myocrd img pet mlt rst&strs,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Molina Medicaid,CPT,78494,Heart image spect,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78496,Heart first pass add-on,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78499,Cardiovascular nuclear exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78579,Lung ventilation imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Molina Medicaid,CPT,78580,Lung perfusion imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Molina Medicaid,CPT,78582,Lung ventilat&perfus imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Molina Medicaid,CPT,78597,Lung perfusion differential,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Molina Medicaid,CPT,78598,Lung perf&ventilat diferentl,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Molina Medicaid,CPT,78599,Respiratory nuclear exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78600,Brain image < 4 views,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78601,Brain image w/flow < 4 views,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78605,Brain image 4+ views,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78606,Brain image w/flow 4 + views,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78607,Brain imaging (3d),Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Molina Medicaid,CPT,78608,Brain imaging (pet),Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Molina Medicaid,CPT,78609,Brain imaging (pet),Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Molina Medicaid,CPT,78610,Brain flow imaging only,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78630,Cerebrospinal fluid scan,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Molina Medicaid,CPT,78635,Csf ventriculography,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78645,Csf shunt evaluation,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Molina Medicaid,CPT,78647,Cerebrospinal fluid scan,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Molina Medicaid,CPT,78650,Csf leakage imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Molina Medicaid,CPT,78660,Nuclear exam of tear flow,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78699,Nervous system nuclear exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78700,Kidney imaging morphol,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78701,Kidney imaging with flow,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78707,K flow/funct image w/o drug,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78708,K flow/funct image w/drug,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78709,K flow/funct image multiple,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78710,Kidney imaging (3d),Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78725,Kidney function study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78730,Urinary bladder retention,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78740,Ureteral reflux study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78761,Testicular imaging w/flow,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78799,Genitourinary nuclear exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78800,Rp loclzj tum 1 area 1 d img,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Molina Medicaid,CPT,78801,Rp loclzj tum 2+area 1+d img,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Molina Medicaid,CPT,78802,Rp loclzj tum whbdy 1 d img,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Molina Medicaid,CPT,78803,Rp loclzj tum spect 1 area,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Molina Medicaid,CPT,78804,Rp loclzj tum whbdy 2+d img,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Molina Medicaid,CPT,78805,Abscess imaging ltd area,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Molina Medicaid,CPT,78806,Abscess imaging whole body,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Molina Medicaid,CPT,78807,Nuclear localization/abscess,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Molina Medicaid,CPT,78811,Pet image ltd area,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Molina Medicaid,CPT,78812,Pet image skull-thigh,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Molina Medicaid,CPT,78813,Pet image full body,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Molina Medicaid,CPT,78814,Pet image w/ct lmtd,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Molina Medicaid,CPT,78815,Pet image w/ct skull-thigh,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Molina Medicaid,CPT,78816,Pet image w/ct full body,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Molina Medicaid,CPT,78830,Rp loclzj tum spect w/ct 1,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Molina Medicaid,CPT,78831,Rp loclzj tum spect 2 areas,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Molina Medicaid,CPT,78832,Rp loclzj tum spect w/ct 2,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Molina Medicaid,CPT,78835,Rp quan meas single area,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,78999,Nuclear diagnostic exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,79005,Nuclear rx oral admin,Therapeutic Radiology,Per Unit,$174.28 ,OP,174.28,174.28,,,,,,
Molina Medicaid,CPT,79101,Nuclear rx iv admin,Therapeutic Radiology,Per Unit,$174.28 ,OP,174.28,174.28,,,,,,
Molina Medicaid,CPT,79200,Nuclear rx intracav admin,Therapeutic Radiology,Per Unit,$174.28 ,OP,174.28,174.28,,,,,,
Molina Medicaid,CPT,79300,Nuclr rx interstit colloid,Therapeutic Radiology,Per Unit,$174.28 ,OP,174.28,174.28,,,,,,
Molina Medicaid,CPT,79403,Hematopoietic nuclear tx,Therapeutic Radiology,Per Unit,$174.28 ,OP,174.28,174.28,,,,,,
Molina Medicaid,CPT,79440,Nuclear rx intra-articular,Therapeutic Radiology,Per Unit,$174.28 ,OP,174.28,174.28,,,,,,
Molina Medicaid,CPT,79445,Nuclear rx intra-arterial,Therapeutic Radiology,Per Unit,$174.28 ,OP,174.28,174.28,,,,,,
Molina Medicaid,CPT,79999,Nuclear medicine therapy,Therapeutic Radiology,Per Unit,$174.28 ,OP,174.28,174.28,,,,,,
Molina Medicaid,CPT,80047,Metabolic panel ionized ca,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
Molina Medicaid,CPT,80048,Metabolic panel total ca,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
Molina Medicaid,CPT,80050,General health panel,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
Molina Medicaid,CPT,80051,Electrolyte panel,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
Molina Medicaid,CPT,80053,Comprehen metabolic panel,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
Molina Medicaid,CPT,80055,Obstetric panel,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
Molina Medicaid,CPT,80061,Lipid panel,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
Molina Medicaid,CPT,80069,Renal function panel,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
Molina Medicaid,CPT,80074,Acute hepatitis panel,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
Molina Medicaid,CPT,80076,Hepatic function panel,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
Molina Medicaid,CPT,80081,Obstetric panel,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
Molina Medicaid,CPT,80143,Drug assay acetaminophen,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80145,Drug assay adalimumab,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80150,Assay of amikacin,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80151,Drug assay amiodarone,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80155,Drug assay caffeine,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80156,Assay carbamazepine total,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80157,Assay carbamazepine free,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80158,Drug assay cyclosporine,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80159,Drug assay clozapine,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80161,"Asy carbamazepin 10,11-epxid",Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80162,Assay of digoxin total,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80163,Assay of digoxin free,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80164,Assay dipropylacetic acd tot,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80165,Dipropylacetic acid free,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80167,Drug assay felbamate,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80168,Assay of ethosuximide,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80169,Drug assay everolimus,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80170,Assay of gentamicin,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80171,Drug screen quant gabapentin,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80173,Assay of haloperidol,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80175,Drug screen quan lamotrigine,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80176,Assay of lidocaine,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80177,Drug scrn quan levetiracetam,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80178,Assay of lithium,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80179,Drug assay salicylate,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80180,Drug scrn quan mycophenolate,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80181,Drug assay flecainide,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80183,Drug scrn quant oxcarbazepin,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80184,Assay of phenobarbital,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80185,Assay of phenytoin total,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80186,Assay of phenytoin free,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80187,Drug assay posaconazole,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80188,Assay of primidone,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80189,Drug assay itraconzaole,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80190,Assay of procainamide,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80192,Assay of procainamide,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80193,Drug assay leflunomide,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80194,Assay of quinidine,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80195,Assay of sirolimus,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80197,Assay of tacrolimus,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80198,Assay of theophylline,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80199,Drug screen quant tiagabine,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80200,Assay of tobramycin,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80201,Assay of topiramate,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80202,Assay of vancomycin,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80203,Drug screen quant zonisamide,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80204,Drug assay methotrexate,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80210,Drug assay rufinamide,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80230,Drug assay infliximab,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80235,Drug assay lacosamide,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80280,Drug assay vedolizumab,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80285,Drug assay voriconazole,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80299,Quantitative assay drug,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80300,Drug screen non tlc devices,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Molina Medicaid,CPT,80301,Drug screen class list a,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Molina Medicaid,CPT,80302,Drug screen prsmptv 1 class,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,80303,Drug screen one/mult class,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Molina Medicaid,CPT,80304,Drug screen one/mult class,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Molina Medicaid,CPT,80305,Drug test prsmv dir opt obs,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,80306,Drug test prsmv instrmnt,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,80307,Drug test prsmv chem anlyzr,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,80320,Drug screen quantalcohols,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,80321,Alcohols biomarkers 1or 2,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,80322,Alcohols biomarkers 3/more,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,80323,Alkaloids nos,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,80324,Drug screen amphetamines 1/2,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,80325,Amphetamines 3or 4,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,80326,Amphetamines 5 or more,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,80327,Anabolic steroid 1 or 2,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,80328,Anabolic steroid 3 or more,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,80329,Analgesics non-opioid 1 or 2,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,80330,Analgesics non-opioid 3-5,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,80331,Analgesics non-opioid 6/more,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,80332,Antidepressants class 1 or 2,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,80333,Antidepressants class 3-5,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,80334,Antidepressants class 6/more,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,80335,Antidepressant tricyclic 1/2,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,80336,Antidepressant tricyclic 3-5,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,80337,Tricyclic & cyclicals 6/more,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,80338,Antidepressant not specified,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,80339,Antiepileptics nos 1-3,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,80340,Antiepileptics nos 4-6,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,80341,Antiepileptics nos 7/more,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,80342,Antipsychotics nos 1-3,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,80343,Antipsychotics nos 4-6,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,80344,Antipsychotics nos 7/more,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,80345,Drug screening barbiturates,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,80346,Benzodiazepines1-12,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,80347,Benzodiazepines 13 or more,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,80348,Drug screening buprenorphine,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,80349,Cannabinoids natural,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,80350,Cannabinoids synthetic 1-3,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,80351,Cannabinoids synthetic 4-6,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,80352,Cannabinoid synthetic 7/more,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,80353,Drug screening cocaine,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,80354,Drug screening fentanyl,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,80355,Gabapentin non-blood,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,80356,Heroin metabolite,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,80357,Ketamine and norketamine,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,80358,Drug screening methadone,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,80359,Methylenedioxyamphetamines,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,80360,Methylphenidate,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,80361,Opiates 1 or more,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,80362,Opioids & opiate analogs 1/2,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,80363,Opioids & opiate analogs 3/4,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,80364,Opioid &opiate analog 5/more,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,80365,Drug screening oxycodone,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,80366,Drug screening pregabalin,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,80367,Drug screening propoxyphene,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,80368,Sedative hypnotics,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,80369,Skeletal muscle relaxant 1/2,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,80370,Skel musc relaxant 3 or more,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,80371,Stimulants synthetic,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,80372,Drug screening tapentadol,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,80373,Drug screening tramadol,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,80374,Stereoisomer analysis,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,80375,Drug/substance nos 1-3,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,80376,Drug/substance nos 4-6,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,80377,Drug/substance nos 7/more,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,80400,Acth stimulation panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Molina Medicaid,CPT,80402,Acth stimulation panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Molina Medicaid,CPT,80406,Acth stimulation panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Molina Medicaid,CPT,80408,Aldosterone suppression eval,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Molina Medicaid,CPT,80410,Calcitonin stimul panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Molina Medicaid,CPT,80412,Crh stimulation panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Molina Medicaid,CPT,80414,Testosterone response panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Molina Medicaid,CPT,80415,Tot estradiol response panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Molina Medicaid,CPT,80416,Renin stimulation panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Molina Medicaid,CPT,80417,Renin stimulation panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Molina Medicaid,CPT,80418,Pituitary evaluation panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Molina Medicaid,CPT,80420,Dexamethasone panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Molina Medicaid,CPT,80422,Glucagon tolerance panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Molina Medicaid,CPT,80424,Glucagon tolerance panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Molina Medicaid,CPT,80426,Gonadotropin hormone panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Molina Medicaid,CPT,80428,Growth hormone panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Molina Medicaid,CPT,80430,Growth hormone panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Molina Medicaid,CPT,80432,Insulin suppression panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Molina Medicaid,CPT,80434,Insulin tolerance panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Molina Medicaid,CPT,80435,Insulin tolerance panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Molina Medicaid,CPT,80436,Metyrapone panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Molina Medicaid,CPT,80438,Trh stimulation panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Molina Medicaid,CPT,80439,Trh stimulation panel,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Molina Medicaid,CPT,80500,Lab pathology consultation,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,80502,Lab pathology consultation,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,81000,Urinalysis nonauto w/scope,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
Molina Medicaid,CPT,81001,Urinalysis auto w/scope,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
Molina Medicaid,CPT,81002,Urinalysis nonauto w/o scope,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
Molina Medicaid,CPT,81003,Urinalysis auto w/o scope,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
Molina Medicaid,CPT,81005,Urinalysis,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
Molina Medicaid,CPT,81007,Urine screen for bacteria,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
Molina Medicaid,CPT,81015,Microscopic exam of urine,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
Molina Medicaid,CPT,81020,Urinalysis glass test,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
Molina Medicaid,CPT,81025,Urine pregnancy test,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
Molina Medicaid,CPT,81050,Urinalysis volume measure,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
Molina Medicaid,CPT,81099,Urinalysis test procedure,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
Molina Medicaid,CPT,81105,Hpa-1 genotyping,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81106,Hpa-2 genotyping,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81107,Hpa-3 genotyping,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81108,Hpa-4 genotyping,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81109,Hpa-5 genotyping,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81110,Hpa-6 genotyping,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81111,Hpa-9 genotyping,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81112,Hpa-15 genotyping,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81120,Idh1 common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81121,Idh2 common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81161,Dmd dup/delet analysis,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81162,Brca1&2 gen full seq dup/del,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81163,Brca1&2 gene full seq alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81164,Brca1&2 gen ful dup/del alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81165,Brca1 gene full seq alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81166,Brca1 gene full dup/del alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81167,Brca2 gene full dup/del alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81168,Ccnd1/igh translocation alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81170,Abl1 gene,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81171,Aff2 gene detc abnor alleles,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81172,Aff2 gene charac alleles,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81173,Ar gene full gene sequence,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81174,Ar gene known famil variant,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81175,Asxl1 full gene sequence,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81176,Asxl1 gene target seq alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81177,Atn1 gene detc abnor alleles,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81178,Atxn1 gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81179,Atxn2 gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81180,Atxn3 gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81181,Atxn7 gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81182,Atxn8os gen detc abnor allel,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81183,Atxn10 gene detc abnor allel,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81184,Cacna1a gen detc abnor allel,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81185,Cacna1a gene full gene seq,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81186,Cacna1a gen known famil vrnt,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81187,Cnbp gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81188,Cstb gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81189,Cstb gene full gene sequence,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81190,Cstb gene known famil vrnt,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81191,Ntrk1 translocation analysis,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81192,Ntrk2 translocation analysis,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81193,Ntrk3 translocation analysis,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81194,Ntrk translocation analysis,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81200,Aspa gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81201,Apc gene full sequence,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81202,Apc gene known fam variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81203,Apc gene dup/delet variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81204,Ar gene charac alleles,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81205,Bckdhb gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81206,Bcr/abl1 gene major bp,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81207,Bcr/abl1 gene minor bp,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81208,Bcr/abl1 gene other bp,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81209,Blm gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81210,Braf gene,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81211,Brca1&2 seq & com dup/del,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81212,Brca1&2 185&5385&6174 vrnt,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81213,Brca1&2 uncom dup/del var,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81214,Brca1 full seq & com dup/del,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81215,Brca1 gene known famil vrnt,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81216,Brca2 gene full seq alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81217,Brca2 gene known famil vrnt,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81218,Cebpa gene full sequence,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81219,Calr gene com variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81220,Cftr gene com variants,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81221,Cftr gene known fam variants,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81222,Cftr gene dup/delet variants,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81223,Cftr gene full sequence,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81224,Cftr gene intron poly t,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81225,Cyp2c19 gene com variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81226,Cyp2d6 gene com variants,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81227,Cyp2c9 gene com variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81228,Cytogen micrarray copy nmbr,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81229,Cytogen m array copy no&snp,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81230,Cyp3a4 gene common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81231,Cyp3a5 gene common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81232,Dpyd gene common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81233,Btk gene common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81234,Dmpk gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81235,Egfr gene com variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81236,Ezh2 gene full gene sequence,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81237,Ezh2 gene common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81238,F9 full gene sequence,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81239,Dmpk gene charac alleles,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81240,F2 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81241,F5 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81242,Fancc gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81243,Fmr1 gene detection,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81244,Fmr1 gene charac alleles,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81245,Flt3 gene,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81246,Flt3 gene analysis,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81247,G6pd gene alys cmn variant,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81248,G6pd known familial variant,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81249,G6pd full gene sequence,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81250,G6pc gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81251,Gba gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81252,Gjb2 gene full sequence,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81253,Gjb2 gene known fam variants,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81254,Gjb6 gene com variants,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81255,Hexa gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81256,Hfe gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81257,Hba1/hba2 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81258,Hba1/hba2 gene fam vrnt,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81259,Hba1/hba2 full gene sequence,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81260,Ikbkap gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81261,Igh gene rearrange amp meth,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81262,Igh gene rearrang dir probe,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81263,Igh vari regional mutation,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81264,Igk rearrangeabn clonal pop,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81265,Str markers specimen anal,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81266,Str markers spec anal addl,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81267,Chimerism anal no cell selec,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81268,Chimerism anal w/cell select,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81269,Hba1/hba2 gene dup/del vrnts,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81270,Jak2 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81271,Htt gene detc abnor alleles,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81272,Kit gene targeted seq analys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81273,Kit gene analys d816 variant,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81274,Htt gene charac alleles,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81275,Kras gene variants exon 2,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81276,Kras gene addl variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81277,Cytogenomic neo microra alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81278,Igh/bcl2 translocation alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81279,Jak2 gene trgt sequence alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81280,Long qt synd gene full seq,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81281,Long qt synd known fam var,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81282,Long qt syn gene dup/dlt var,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81283,Ifnl3 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81284,Fxn gene detc abnor alleles,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81285,Fxn gene charac alleles,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81286,Fxn gene full gene sequence,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81287,Mgmt gene prmtr mthyltn alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81288,Mlh1 gene,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81289,Fxn gene known famil variant,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81290,Mcoln1 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81291,Mthfr gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81292,Mlh1 gene full seq,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81293,Mlh1 gene known variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81294,Mlh1 gene dup/delete variant,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81295,Msh2 gene full seq,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81296,Msh2 gene known variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81297,Msh2 gene dup/delete variant,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81298,Msh6 gene full seq,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81299,Msh6 gene known variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81300,Msh6 gene dup/delete variant,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81301,Microsatellite instability,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81302,Mecp2 gene full seq,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81303,Mecp2 gene known variant,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81304,Mecp2 gene dup/delet variant,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81305,Myd88 gene p.leu265pro vrnt,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81306,Nudt15 gene common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81307,Palb2 gene full gene seq,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81308,Palb2 gene known famil vrnt,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81309,Pik3ca gene trgt seq alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81310,Npm1 gene,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81311,Nras gene variants exon 2&3,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81312,Pabpn1 gene detc abnor allel,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81313,Pca3/klk3 antigen,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81314,Pdgfra gene,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81315,Pml/raralpha com breakpoints,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81316,Pml/raralpha 1 breakpoint,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81317,Pms2 gene full seq analysis,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81318,Pms2 known familial variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81319,Pms2 gene dup/delet variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81320,Plcg2 gene common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81321,Pten gene full sequence,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81322,Pten gene known fam variant,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81323,Pten gene dup/delet variant,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81324,Pmp22 gene dup/delet,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81325,Pmp22 gene full sequence,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81326,Pmp22 gene known fam variant,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81327,Sept9 gen prmtr mthyltn alys,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81328,Slco1b1 gene com variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81329,Smn1 gene dos/deletion alys,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81330,Smpd1 gene common variants,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81331,Snrpn/ube3a gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81332,Serpina1 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81333,Tgfbi gene common variants,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81334,Runx1 gene targeted seq alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81335,Tpmt gene com variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81336,Smn1 gene full gene sequence,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81337,Smn1 gen nown famil seq vrnt,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81338,Mpl gene common variants,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81339,Mpl gene seq alys exon 10,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81340,Trb@ gene rearrange amplify,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81341,Trb@ gene rearrange dirprobe,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81342,Trg gene rearrangement anal,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81343,Ppp2r2b gen detc abnor allel,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81344,Tbp gene detc abnor alleles,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81345,Tert gene targeted seq alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81346,Tyms gene com variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81347,Sf3b1 gene common variants,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81348,Srsf2 gene common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81350,Ugt1a1 gene common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81351,Tp53 gene full gene sequence,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81352,Tp53 gene trgt sequence alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81353,Tp53 gene known famil vrnt,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81355,Vkorc1 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81357,U2af1 gene common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81360,Zrsr2 gene common variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81361,Hbb gene com variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81362,Hbb gene known fam variant,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81363,Hbb gene dup/del variants,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81364,Hbb full gene sequence,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81370,Hla i & ii typing lr,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81371,Hla i & ii type verify lr,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81372,Hla i typing complete lr,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81373,Hla i typing 1 locus lr,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81374,Hla i typing 1 antigen lr,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81375,Hla ii typing ag equiv lr,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81376,Hla ii typing 1 locus lr,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81377,Hla ii type 1 ag equiv lr,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81378,Hla i & ii typing hr,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81379,Hla i typing complete hr,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81380,Hla i typing 1 locus hr,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81381,Hla i typing 1 allele hr,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81382,Hla ii typing 1 loc hr,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81383,Hla ii typing 1 allele hr,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81400,Mopath procedure level 1,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81401,Mopath procedure level 2,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81402,Mopath procedure level 3,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81403,Mopath procedure level 4,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81404,Mopath procedure level 5,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81405,Mopath procedure level 6,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81406,Mopath procedure level 7,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81407,Mopath procedure level 8,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81408,Mopath procedure level 9,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81410,Aortic dysfunction/dilation,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81411,Aortic dysfunction/dilation,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81412,Ashkenazi jewish assoc dis,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81413,Car ion chnnlpath inc 10 gns,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81414,Car ion chnnlpath inc 2 gns,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81415,Exome sequence analysis,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81416,Exome sequence analysis,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81417,Exome re-evaluation,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81419,Epilepsy gen seq alys panel,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81420,Fetal chrmoml aneuploidy,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81422,Fetal chrmoml microdeltj,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81425,Genome sequence analysis,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81426,Genome sequence analysis,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81427,Genome re-evaluation,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81430,Hearing loss sequence analys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81431,Hearing loss dup/del analys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81432,Hrdtry brst ca-rlatd dsordrs,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81433,Hrdtry brst ca-rlatd dsordrs,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81434,Hereditary retinal disorders,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81435,Hereditary colon ca dsordrs,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81436,Hereditary colon ca dsordrs,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81437,Heredtry nurondcrn tum dsrdr,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81438,Heredtry nurondcrn tum dsrdr,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81439,Hrdtry cardmypy gene panel,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81440,Mitochondrial gene,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81442,Noonan spectrum disorders,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81443,Genetic tstg severe inh cond,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81445,Targeted genomic seq analys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81448,Hrdtry perph neurphy panel,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81450,Targeted genomic seq analys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81455,Targeted genomic seq analys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81460,Whole mitochondrial genome,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81465,Whole mitochondrial genome,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81470,X-linked intellectual dblt,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81471,X-linked intellectual dblt,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81479,Unlisted molecular pathology,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81490,Autoimmune rheumatoid arthr,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81493,Cor artery disease mrna,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81500,Onco (ovar) two proteins,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81503,Onco (ovar) five proteins,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81504,Oncology tissue of origin,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81506,Endo assay seven anal,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81507,Fetal aneuploidy trisom risk,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81508,Ftl cgen abnor two proteins,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81509,Ftl cgen abnor 3 proteins,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81510,Ftl cgen abnor three anal,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81511,Ftl cgen abnor four anal,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81512,Ftl cgen abnor five anal,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81513,Nfct ds bv rna vag flu alg,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81514,Nfct ds bv&vaginitis dna alg,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81518,Onc brst mrna 11 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81519,Oncology breast mrna,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81520,Onc breast mrna 58 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81521,Onc breast mrna 70 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81522,Onc breast mrna 12 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81525,Oncology colon mrna,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81528,Oncology colorectal scr,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81529,Onc cutan mlnma mrna 31 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81535,Oncology gynecologic,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81536,Oncology gynecologic,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81538,Oncology lung,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81539,Oncology prostate prob score,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81540,Oncology tum unknown origin,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81541,Onc prostate mrna 46 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81542,Onc prostate mrna 22 cnt gen,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81545,Oncology thyroid,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81546,"Onc thyr mrna 10,196 gen alg",Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81551,Onc prostate 3 genes,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81552,Onc uveal mlnma mrna 15 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81554,Pulm ds ipf mrna 190 gen alg,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,81595,Cardiology hrt trnspl mrna,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,81596,Nfct ds chrnc hcv 6 assays,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,81599,Unlisted maaa,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,82009,Test for acetone/ketones,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,82010,Acetone assay,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82013,Acetylcholinesterase assay,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82016,Acylcarnitines qual,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82017,Acylcarnitines quant,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82024,Assay of acth,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Molina Medicaid,CPT,82030,Assay of adp & amp,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,82040,Assay of serum albumin,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,82042,Other source albumin quan ea,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,82043,Ur albumin quantitative,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
Molina Medicaid,CPT,82044,Ur albumin semiquantitative,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
Molina Medicaid,CPT,82045,Albumin ischemia modified,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,82075,Assay of breath ethanol,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82077,Assay spec xcp ur&breath ia,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82085,Assay of aldolase,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82088,Assay of aldosterone,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Molina Medicaid,CPT,82103,Alpha-1-antitrypsin total,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82104,Alpha-1-antitrypsin pheno,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82105,Alpha-fetoprotein serum,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82106,Alpha-fetoprotein amniotic,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82107,Alpha-fetoprotein l3,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,82108,Assay of aluminum,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Molina Medicaid,CPT,82120,Amines vaginal fluid qual,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,82127,Amino acid single qual,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82128,Amino acids mult qual,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82131,Amino acids single quant,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82135,Assay aminolevulinic acid,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82136,Amino acids quant 2-5,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82139,Amino acids quan 6 or more,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82140,Assay of ammonia,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82143,Amniotic fluid scan,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,82150,Assay of amylase,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,82154,Androstanediol glucuronide,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,82157,Assay of androstenedione,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,82160,Assay of androsterone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,82163,Assay of angiotensin ii,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,82164,Angiotensin i enzyme test,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82172,Assay of apolipoprotein,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82175,Assay of arsenic,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Molina Medicaid,CPT,82180,Assay of ascorbic acid,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82190,Atomic absorption,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82232,Assay of beta-2 protein,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,82239,Bile acids total,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82240,Bile acids cholylglycine,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82247,Bilirubin total,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,82248,Bilirubin direct,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,82252,Fecal bilirubin test,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,82261,Assay of biotinidase,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82270,Occult blood feces,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,82271,Occult blood other sources,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,82272,Occult bld feces 1-3 tests,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,82274,Assay test for blood fecal,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82286,Assay of bradykinin,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,82300,Assay of cadmium,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Molina Medicaid,CPT,82306,Vitamin d 25 hydroxy,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,82308,Assay of calcitonin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,82310,Assay of calcium,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,82330,Assay of calcium,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82331,Calcium infusion test,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82340,Assay of calcium in urine,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,82355,Calculus analysis qual,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82360,Calculus assay quant,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82365,Calculus spectroscopy,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82370,X-ray assay calculus,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82373,Assay c-d transfer measure,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82374,Assay blood carbon dioxide,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,82375,Assay carboxyhb quant,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82376,Assay carboxyhb qual,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82378,Carcinoembryonic antigen,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82379,Assay of carnitine,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82380,Assay of carotene,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82382,Assay urine catecholamines,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,82383,Assay blood catecholamines,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,82384,Assay three catecholamines,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,82387,Assay of cathepsin-d,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82390,Assay of ceruloplasmin,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82397,Chemiluminescent assay,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82415,Assay of chloramphenicol,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,82435,Assay of blood chloride,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,82436,Assay of urine chloride,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,82438,Assay other fluid chlorides,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,82441,Test for chlorohydrocarbons,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Molina Medicaid,CPT,82465,Assay bld/serum cholesterol,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,82480,Assay serum cholinesterase,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,82482,Assay rbc cholinesterase,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,82485,Assay chondroitin sulfate,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,82486,Gas/liquid chromatography,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,82487,Paper chromatography,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,82488,Paper chromatography,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,82489,Thin layer chromatography,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,82491,Chromotography quant sing,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82492,Chromotography quant mult,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,82495,Assay of chromium,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Molina Medicaid,CPT,82507,Assay of citrate,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82523,Collagen crosslinks,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82525,Assay of copper,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Molina Medicaid,CPT,82528,Assay of corticosterone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,82530,Cortisol free,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82533,Total cortisol,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,82540,Assay of creatine,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,82541,Column chromotography qual,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,82542,Col chromotography qual/quan,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82543,Column chromotograph/isotope,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,82544,Column chromotograph/isotope,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,82550,Assay of ck (cpk),Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,82552,Assay of cpk in blood,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82553,Creatine mb fraction,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82554,Creatine isoforms,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82565,Assay of creatinine,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,82570,Assay of urine creatinine,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,82575,Creatinine clearance test,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82585,Assay of cryofibrinogen,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82595,Assay of cryoglobulin,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,82600,Assay of cyanide,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Molina Medicaid,CPT,82607,Vitamin b-12,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,82608,B-12 binding capacity,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82610,Cystatin c,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82615,Test for urine cystines,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82626,Dehydroepiandrosterone,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82627,Dehydroepiandrosterone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,82633,Desoxycorticosterone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,82634,Deoxycortisol,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,82638,Assay of dibucaine number,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82642,Dihydrotestosterone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,82652,Vit d 1 25-dihydroxy,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,82656,Pancreatic elastase fecal,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82657,Enzyme cell activity,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82658,Enzyme cell activity ra,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,82664,Electrophoretic test,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,82668,Assay of erythropoietin,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82670,Assay of total estradiol,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,82671,Assay of estrogens,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,82672,Assay of estrogen,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,82677,Assay of estriol,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,82679,Assay of estrone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,82681,Assay dir meas fr estradiol,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,82693,Assay of ethylene glycol,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Molina Medicaid,CPT,82696,Assay of etiocholanolone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,82705,Fats/lipids feces qual,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,82710,Fats/lipids feces quant,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82715,Assay of fecal fat,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82725,Assay of blood fatty acids,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82726,Long chain fatty acids,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82728,Assay of ferritin,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82731,Assay of fetal fibronectin,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,82735,Assay of fluoride,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Molina Medicaid,CPT,82746,Assay of folic acid serum,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82747,Assay of folic acid rbc,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
Molina Medicaid,CPT,82757,Assay of semen fructose,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82759,Assay of rbc galactokinase,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82760,Assay of galactose,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82775,Assay galactose transferase,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82776,Galactose transferase test,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82777,Galectin-3,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,82784,Assay iga/igd/igg/igm each,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82785,Assay of ige,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82787,Igg 1 2 3 or 4 each,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82800,Blood ph,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82803,Blood gases any combination,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82805,Blood gases w/o2 saturation,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,82810,Blood gases o2 sat only,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82820,Hemoglobin-oxygen affinity,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Molina Medicaid,CPT,82930,Gastric analy w/ph ea spec,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,82938,Gastrin test,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,82941,Assay of gastrin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,82943,Assay of glucagon,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,82945,Glucose other fluid,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,82946,Glucagon tolerance test,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82947,Assay glucose blood quant,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,82948,Reagent strip/blood glucose,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,82950,Glucose test,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,82951,Glucose tolerance test (gtt),Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82952,Gtt-added samples,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,82955,Assay of g6pd enzyme,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82960,Test for g6pd enzyme,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,82962,Glucose blood test,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,82963,Assay of glucosidase,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82965,Assay of gdh enzyme,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82977,Assay of ggt,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,82978,Assay of glutathione,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82979,Assay rbc glutathione,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,82985,Assay of glycated protein,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,83001,Assay of gonadotropin (fsh),Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,83002,Assay of gonadotropin (lh),Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,83003,Assay growth hormone (hgh),Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,83006,Growth stimulation gene 2,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Molina Medicaid,CPT,83009,H pylori (c-13) blood,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,83010,Assay of haptoglobin quant,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,83012,Assay of haptoglobins,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,83013,H pylori (c-13) breath,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,83014,H pylori drug admin,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,83015,Heavy metal qual any anal,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Molina Medicaid,CPT,83018,Heavy metal quant each nes,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Molina Medicaid,CPT,83020,Hemoglobin electrophoresis,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,83021,Hemoglobin chromotography,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
Molina Medicaid,CPT,83026,Hemoglobin copper sulfate,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Molina Medicaid,CPT,83030,Fetal hemoglobin chemical,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,83033,Fetal hemoglobin assay qual,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,83036,Glycosylated hemoglobin test,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,83037,Glycosylated hb home device,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,83045,Blood methemoglobin test,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,83050,Blood methemoglobin assay,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,83051,Assay of plasma hemoglobin,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,83060,Blood sulfhemoglobin assay,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,83065,Assay of hemoglobin heat,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,83068,Hemoglobin stability screen,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,83069,Assay of urine hemoglobin,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,83070,Assay of hemosiderin qual,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,83080,Assay of b hexosaminidase,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,83088,Assay of histamine,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,83090,Assay of homocystine,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,83150,Assay of homovanillic acid,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,83491,Assay of corticosteroids 17,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,83497,Assay of 5-hiaa,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,83498,Assay of progesterone 17-d,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,83499,Assay of progesterone 20-,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Molina Medicaid,CPT,83500,Assay free hydroxyproline,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,83505,Assay total hydroxyproline,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,83516,Immunoassay nonantibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,83518,Immunoassay dipstick,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,83519,Ria nonantibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,83520,Immunoassay quant nos nonab,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,83525,Assay of insulin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,83527,Assay of insulin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,83528,Assay of intrinsic factor,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,83540,Assay of iron,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,83550,Iron binding test,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,83570,Assay of idh enzyme,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,83582,Assay of ketogenic steroids,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,83586,Assay 17- ketosteroids,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,83593,Fractionation ketosteroids,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,83605,Assay of lactic acid,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,83615,Lactate (ld) (ldh) enzyme,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,83625,Assay of ldh enzymes,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,83630,Lactoferrin fecal (qual),Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,83631,Lactoferrin fecal (quant),Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,83632,Placental lactogen,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,83633,Test urine for lactose,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,83655,Assay of lead,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Molina Medicaid,CPT,83661,L/s ratio fetal lung,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,83662,Foam stability fetal lung,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,83663,Fluoro polarize fetal lung,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,83664,Lamellar bdy fetal lung,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,83670,Assay of lap enzyme,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,83690,Assay of lipase,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,83695,Assay of lipoprotein(a),Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,83698,Assay lipoprotein pla2,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,83700,Lipopro bld electrophoretic,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,83701,Lipoprotein bld hr fraction,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,83704,Lipoprotein bld quan part,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,83718,Assay of lipoprotein,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,83719,Assay of blood lipoprotein,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,83721,Assay of blood lipoprotein,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,83722,Lipoprtn dir meas sd ldl chl,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,83727,Assay of lrh hormone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,83735,Assay of magnesium,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,83775,Assay malate dehydrogenase,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,83785,Assay of manganese,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Molina Medicaid,CPT,83788,Mass spectrometry qual,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,83789,Mass spectrometry qual/quan,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,83825,Assay of mercury,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Molina Medicaid,CPT,83835,Assay of metanephrines,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,83857,Assay of methemalbumin,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,83861,Microfluid analy tears,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,83864,Mucopolysaccharides,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,83872,Assay synovial fluid mucin,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,83873,Assay of csf protein,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,83874,Assay of myoglobin,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,83876,Assay myeloperoxidase,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,83880,Assay of natriuretic peptide,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,83883,Assay nephelometry not spec,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,83885,Assay of nickel,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Molina Medicaid,CPT,83915,Assay of nucleotidase,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,83916,Oligoclonal bands,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,83918,Organic acids total quant,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Molina Medicaid,CPT,83919,Organic acids qual each,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,83921,Organic acid single quant,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,83930,Assay of blood osmolality,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,83935,Assay of urine osmolality,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,83937,Assay of osteocalcin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,83945,Assay of oxalate,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,83950,Oncoprotein her-2/neu,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,83951,Oncoprotein dcp,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,83970,Assay of parathormone,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Molina Medicaid,CPT,83986,Assay ph body fluid nos,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,83987,Exhaled breath condensate,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,83992,Assay for phencyclidine,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Molina Medicaid,CPT,83993,Assay for calprotectin fecal,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,84030,Assay of blood pku,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,84035,Assay of phenylketones,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,84060,Assay acid phosphatase,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,84061,Phosphatase forensic exam,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,84066,Assay prostate phosphatase,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,84075,Assay alkaline phosphatase,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,84078,Assay alkaline phosphatase,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,84080,Assay alkaline phosphatases,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,84081,Assay phosphatidylglycerol,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,84085,Assay of rbc pg6d enzyme,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,84087,Assay phosphohexose enzymes,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,84100,Assay of phosphorus,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,84105,Assay of urine phosphorus,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,84106,Test for porphobilinogen,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,84110,Assay of porphobilinogen,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,84112,Eval amniotic fluid protein,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,84119,Test urine for porphyrins,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,84120,Assay of urine porphyrins,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,84126,Assay of feces porphyrins,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,84132,Assay of serum potassium,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,84133,Assay of urine potassium,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,84134,Assay of prealbumin,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,84135,Assay of pregnanediol,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,84138,Assay of pregnanetriol,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,84140,Assay of pregnenolone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,84143,Assay of 17-hydroxypregneno,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,84144,Assay of progesterone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,84145,Procalcitonin (pct),Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,84146,Assay of prolactin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,84150,Assay of prostaglandin,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Molina Medicaid,CPT,84152,Assay of psa complexed,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,84153,Assay of psa total,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,84154,Assay of psa free,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,84155,Assay of protein serum,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,84156,Assay of protein urine,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,84157,Assay of protein other,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,84160,Assay of protein any source,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,84163,Pappa serum,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,84165,Protein e-phoresis serum,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,84166,Protein e-phoresis/urine/csf,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,84181,Western blot test,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,84182,Protein western blot test,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,84202,Assay rbc protoporphyrin,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,84203,Test rbc protoporphyrin,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,84206,Assay of proinsulin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,84207,Assay of vitamin b-6,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,84210,Assay of pyruvate,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,84220,Assay of pyruvate kinase,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,84228,Assay of quinine,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,84233,Assay of estrogen,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Molina Medicaid,CPT,84234,Assay of progesterone,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Molina Medicaid,CPT,84235,Assay of endocrine hormone,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Molina Medicaid,CPT,84238,Assay nonendocrine receptor,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,84244,Assay of renin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,84252,Assay of vitamin b-2,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,84255,Assay of selenium,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,84260,Assay of serotonin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,84270,Assay of sex hormone globul,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,84275,Assay of sialic acid,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,84285,Assay of silica,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Molina Medicaid,CPT,84295,Assay of serum sodium,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,84300,Assay of urine sodium,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,84302,Assay of sweat sodium,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,84305,Assay of somatomedin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,84307,Assay of somatostatin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,84311,Spectrophotometry,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,84315,Body fluid specific gravity,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,84375,Chromatogram assay sugars,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,84376,Sugars single qual,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,84377,Sugars multiple qual,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,84378,Sugars single quant,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,84379,Sugars multiple quant,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,84392,Assay of urine sulfate,Laboratory,Per Unit,$2.29 ,OP,2.29,2.29,,,,,,
Molina Medicaid,CPT,84402,Assay of free testosterone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,84403,Assay of total testosterone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,84410,Testosterone bioavailable,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Molina Medicaid,CPT,84425,Assay of vitamin b-1,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,84430,Assay of thiocyanate,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Molina Medicaid,CPT,84431,Thromboxane urine,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,84432,Assay of thyroglobulin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,84436,Assay of total thyroxine,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,84437,Assay of neonatal thyroxine,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,84439,Assay of free thyroxine,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,84442,Assay of thyroid activity,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,84443,Assay thyroid stim hormone,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,84445,Assay of tsi globulin,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Molina Medicaid,CPT,84446,Assay of vitamin e,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,84449,Assay of transcortin,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,84450,Transferase (ast) (sgot),Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,84460,Alanine amino (alt) (sgpt),Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,84466,Assay of transferrin,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,84478,Assay of triglycerides,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,84479,Assay of thyroid (t3 or t4),Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,84480,Assay triiodothyronine (t3),Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,84481,Free assay (ft-3),Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,84482,T3 reverse,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,84484,Assay of troponin quant,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,84485,Assay duodenal fluid trypsin,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,84488,Test feces for trypsin,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,84490,Assay of feces for trypsin,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,84510,Assay of tyrosine,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,84512,Assay of troponin qual,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,84520,Assay of urea nitrogen,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,84525,Urea nitrogen semi-quant,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,84540,Assay of urine/urea-n,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,84545,Urea-n clearance test,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,84550,Assay of blood/uric acid,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,84560,Assay of urine/uric acid,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,84577,Assay of feces/urobilinogen,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,84578,Test urine urobilinogen,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,84580,Assay of urine urobilinogen,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,84583,Assay of urine urobilinogen,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,84585,Assay of urine vma,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,84586,Assay of vip,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Molina Medicaid,CPT,84588,Assay of vasopressin,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Molina Medicaid,CPT,84590,Assay of vitamin a,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,84591,Assay of nos vitamin,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,84597,Assay of vitamin k,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,84600,Assay of volatiles,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,84620,Xylose tolerance test,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,84630,Assay of zinc,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Molina Medicaid,CPT,84681,Assay of c-peptide,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,84702,Chorionic gonadotropin test,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,84703,Chorionic gonadotropin assay,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,84704,Hcg free betachain test,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,84830,Ovulation tests,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,84999,Clinical chemistry test,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,85002,Bleeding time test,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Molina Medicaid,CPT,85004,Automated diff wbc count,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Molina Medicaid,CPT,85007,Bl smear w/diff wbc count,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Molina Medicaid,CPT,85008,Bl smear w/o diff wbc count,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Molina Medicaid,CPT,85009,Manual diff wbc count b-coat,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Molina Medicaid,CPT,85013,Spun microhematocrit,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Molina Medicaid,CPT,85014,Hematocrit,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Molina Medicaid,CPT,85018,Hemoglobin,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Molina Medicaid,CPT,85025,Complete cbc w/auto diff wbc,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Molina Medicaid,CPT,85027,Complete cbc automated,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Molina Medicaid,CPT,85032,Manual cell count each,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Molina Medicaid,CPT,85041,Automated rbc count,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Molina Medicaid,CPT,85044,Manual reticulocyte count,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Molina Medicaid,CPT,85045,Automated reticulocyte count,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Molina Medicaid,CPT,85046,Reticyte/hgb concentrate,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Molina Medicaid,CPT,85048,Automated leukocyte count,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Molina Medicaid,CPT,85049,Automated platelet count,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Molina Medicaid,CPT,85055,Reticulated platelet assay,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Molina Medicaid,CPT,85060,Blood smear interpretation,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,85097,Bone marrow interpretation,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,85130,Chromogenic substrate assay,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
Molina Medicaid,CPT,85170,Blood clot retraction,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Molina Medicaid,CPT,85175,Blood clot lysis time,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Molina Medicaid,CPT,85210,Clot factor ii prothrom spec,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Molina Medicaid,CPT,85220,Blooc clot factor v test,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Molina Medicaid,CPT,85230,Clot factor vii proconvertin,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Molina Medicaid,CPT,85240,Clot factor viii ahg 1 stage,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Molina Medicaid,CPT,85244,Clot factor viii reltd antgn,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Molina Medicaid,CPT,85245,Clot factor viii vw ristoctn,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Molina Medicaid,CPT,85246,Clot factor viii vw antigen,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Molina Medicaid,CPT,85247,Clot factor viii multimetric,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Molina Medicaid,CPT,85250,Clot factor ix ptc/chrstmas,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Molina Medicaid,CPT,85260,Clot factor x stuart-power,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Molina Medicaid,CPT,85270,Clot factor xi pta,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Molina Medicaid,CPT,85280,Clot factor xii hageman,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Molina Medicaid,CPT,85290,Clot factor xiii fibrin stab,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Molina Medicaid,CPT,85291,Clot factor xiii fibrin scrn,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Molina Medicaid,CPT,85292,Clot factor fletcher fact,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Molina Medicaid,CPT,85293,Clot factor wght kininogen,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Molina Medicaid,CPT,85300,Antithrombin iii activity,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Molina Medicaid,CPT,85301,Antithrombin iii antigen,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Molina Medicaid,CPT,85302,Clot inhibit prot c antigen,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Molina Medicaid,CPT,85303,Clot inhibit prot c activity,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Molina Medicaid,CPT,85305,Clot inhibit prot s total,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Molina Medicaid,CPT,85306,Clot inhibit prot s free,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Molina Medicaid,CPT,85307,Assay activated protein c,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,85335,Factor inhibitor test,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Molina Medicaid,CPT,85337,Thrombomodulin,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Molina Medicaid,CPT,85345,Coagulation time lee & white,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Molina Medicaid,CPT,85347,Coagulation time activated,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Molina Medicaid,CPT,85348,Coagulation time otr method,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Molina Medicaid,CPT,85360,Euglobulin lysis,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
Molina Medicaid,CPT,85362,Fibrin degradation products,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Molina Medicaid,CPT,85366,Fibrinogen test,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Molina Medicaid,CPT,85370,Fibrinogen test,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Molina Medicaid,CPT,85378,Fibrin degrade semiquant,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Molina Medicaid,CPT,85379,Fibrin degradation quant,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Molina Medicaid,CPT,85380,Fibrin degradj d-dimer,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
Molina Medicaid,CPT,85384,Fibrinogen activity,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Molina Medicaid,CPT,85385,Fibrinogen antigen,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Molina Medicaid,CPT,85390,Fibrinolysins screen i&r,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Molina Medicaid,CPT,85396,Clotting assay whole blood,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Molina Medicaid,CPT,85397,Clotting funct activity,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Molina Medicaid,CPT,85400,Fibrinolytic plasmin,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Molina Medicaid,CPT,85410,Fibrinolytic antiplasmin,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Molina Medicaid,CPT,85415,Fibrinolytic plasminogen,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Molina Medicaid,CPT,85420,Fibrinolytic plasminogen,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Molina Medicaid,CPT,85421,Fibrinolytic plasminogen,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Molina Medicaid,CPT,85441,Heinz bodies direct,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Molina Medicaid,CPT,85445,Heinz bodies induced,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Molina Medicaid,CPT,85460,Hemoglobin fetal,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
Molina Medicaid,CPT,85461,Hemoglobin fetal,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Molina Medicaid,CPT,85475,Hemolysin acid,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Molina Medicaid,CPT,85520,Heparin assay,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Molina Medicaid,CPT,85525,Heparin neutralization,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Molina Medicaid,CPT,85530,Heparin-protamine tolerance,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Molina Medicaid,CPT,85536,Iron stain peripheral blood,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Molina Medicaid,CPT,85540,Wbc alkaline phosphatase,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
Molina Medicaid,CPT,85547,Rbc mechanical fragility,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
Molina Medicaid,CPT,85549,Muramidase,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,85555,Rbc osmotic fragility,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
Molina Medicaid,CPT,85557,Rbc osmotic fragility,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
Molina Medicaid,CPT,85576,Blood platelet aggregation,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Molina Medicaid,CPT,85597,Phospholipid pltlt neutraliz,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Molina Medicaid,CPT,85598,Hexagnal phosph pltlt neutrl,Laboratory,Per Unit,$6.92 ,OP,6.92,6.92,,,,,,
Molina Medicaid,CPT,85610,Prothrombin time,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Molina Medicaid,CPT,85611,Prothrombin test,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Molina Medicaid,CPT,85612,Viper venom prothrombin time,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Molina Medicaid,CPT,85613,Russell viper venom diluted,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Molina Medicaid,CPT,85635,Reptilase test,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
Molina Medicaid,CPT,85651,Rbc sed rate nonautomated,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Molina Medicaid,CPT,85652,Rbc sed rate automated,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Molina Medicaid,CPT,85660,Rbc sickle cell test,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Molina Medicaid,CPT,85670,Thrombin time plasma,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Molina Medicaid,CPT,85675,Thrombin time titer,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Molina Medicaid,CPT,85705,Thromboplastin inhibition,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Molina Medicaid,CPT,85730,Thromboplastin time partial,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Molina Medicaid,CPT,85732,Thromboplastin time partial,Laboratory,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
Molina Medicaid,CPT,85810,Blood viscosity examination,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
Molina Medicaid,CPT,85999,Hematology procedure,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Molina Medicaid,CPT,86000,Agglutinins febrile antigen,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86001,Allergen specific igg,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86003,Allg spec ige crude xtrc ea,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86005,Allg spec ige multiallg scr,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86008,Allg spec ige recomb ea,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86021,Wbc antibody identification,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86022,Platelet antibodies,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86023,Immunoglobulin assay,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86038,Antinuclear antibodies,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86039,Antinuclear antibodies (ana),Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86060,Antistreptolysin o titer,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86063,Antistreptolysin o screen,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86140,C-reactive protein,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86141,C-reactive protein hs,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86146,Beta-2 glycoprotein antibody,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,86147,Cardiolipin antibody ea ig,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Molina Medicaid,CPT,86148,Anti-phospholipid antibody,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,86152,Cell enumeration & id,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Molina Medicaid,CPT,86153,Cell enumeration phys interp,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86155,Chemotaxis assay,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86156,Cold agglutinin screen,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86157,Cold agglutinin titer,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86160,Complement antigen,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86161,Complement/function activity,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86162,Complement total (ch50),Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86171,Complement fixation each,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86185,Counterimmunoelectrophoresis,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86200,Ccp antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86215,Deoxyribonuclease antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86225,Dna antibody native,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86226,Dna antibody single strand,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86235,Nuclear antigen antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86243,Fc receptor,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Molina Medicaid,CPT,86255,Fluorescent antibody screen,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86256,Fluorescent antibody titer,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86277,Growth hormone antibody,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,86280,Hemagglutination inhibition,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86294,Immunoassay tumor qual,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,86300,Immunoassay tumor ca 15-3,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,86301,Immunoassay tumor ca 19-9,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,86304,Immunoassay tumor ca 125,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,86305,Human epididymis protein 4,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,86308,Heterophile antibody screen,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86309,Heterophile antibody titer,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86310,Heterophile antibody absrbj,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86316,Immunoassay tumor other,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,86317,Immunoassay infectious agent,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86318,Ia infectious agent antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86320,Serum immunoelectrophoresis,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,86325,Other immunoelectrophoresis,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,86327,Immunoelectrophoresis assay,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,86328,Ia nfct ab sarscov2 covid19,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86329,Immunodiffusion nes,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86331,Immunodiffusion ouchterlony,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86332,Immune complex assay,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Molina Medicaid,CPT,86334,Immunofix e-phoresis serum,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86335,Immunfix e-phorsis/urine/csf,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Molina Medicaid,CPT,86336,Inhibin a,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,86337,Insulin antibodies,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,86340,Intrinsic factor antibody,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,86341,Islet cell antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86343,Leukocyte histamine release,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86344,Leukocyte phagocytosis,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86352,Cell function assay w/stim,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Molina Medicaid,CPT,86353,Lymphocyte transformation,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Molina Medicaid,CPT,86355,B cells total count,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Molina Medicaid,CPT,86356,Mononuclear cell antigen,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Molina Medicaid,CPT,86357,Nk cells total count,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Molina Medicaid,CPT,86359,T cells total count,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Molina Medicaid,CPT,86360,T cell absolute count/ratio,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Molina Medicaid,CPT,86361,T cell absolute count,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Molina Medicaid,CPT,86367,Stem cells total count,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Molina Medicaid,CPT,86376,Microsomal antibody each,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,86378,Migration inhibitory factor,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Molina Medicaid,CPT,86382,Neutralization test viral,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86384,Nitroblue tetrazolium dye,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86386,Nuclear matrix protein 22,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86403,Particle agglut antbdy scrn,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86406,Particle agglut antbdy titr,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86408,Neutrlzg antb sarscov2 scr,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86409,Neutrlzg antb sarscov2 titer,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86413,Sars-cov-2 antb quantitative,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86430,Rheumatoid factor test qual,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86431,Rheumatoid factor quant,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86480,Tb test cell immun measure,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Molina Medicaid,CPT,86481,Tb ag response t-cell susp,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Molina Medicaid,CPT,86485,Skin test candida,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Molina Medicaid,CPT,86486,Skin test nos antigen,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86490,Coccidioidomycosis skin test,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Molina Medicaid,CPT,86510,Histoplasmosis skin test,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Molina Medicaid,CPT,86580,Tb intradermal test,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86590,Streptokinase antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86592,Syphilis test non-trep qual,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86593,Syphilis test non-trep quant,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86602,Antinomyces antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86603,Adenovirus antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86606,Aspergillus antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86609,Bacterium antibody,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,86611,Bartonella antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86612,Blastomyces antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86615,Bordetella antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86617,Lyme disease antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86618,Lyme disease antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86619,Borrelia antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86622,Brucella antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86625,Campylobacter antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86628,Candida antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86631,Chlamydia antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86632,Chlamydia igm antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86635,Coccidioides antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86638,Q fever antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86641,Cryptococcus antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86644,Cmv antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86645,Cmv antibody igm,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86648,Diphtheria antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86651,Encephalitis californ antbdy,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86652,Encephaltis east eqne anbdy,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86653,Encephaltis st louis antbody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86654,Encephaltis west eqne antbdy,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86658,Enterovirus antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86663,Epstein-barr antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86664,Epstein-barr nuclear antigen,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86665,Epstein-barr capsid vca,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86666,Ehrlichia antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86668,Francisella tularensis,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86671,Fungus nes antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86674,Giardia lamblia antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86677,Helicobacter pylori antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86682,Helminth antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86684,Hemophilus influenza antibdy,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86687,Htlv-i antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86688,Htlv-ii antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86689,Htlv/hiv confirmj antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86692,Hepatitis delta agent antbdy,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86694,Herpes simplex nes antbdy,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86695,Herpes simplex type 1 test,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86696,Herpes simplex type 2 test,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86698,Histoplasma antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86701,Hiv-1antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86702,Hiv-2 antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86703,Hiv-1/hiv-2 1 result antbdy,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86704,Hep b core antibody total,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86705,Hep b core antibody igm,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86706,Hep b surface antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86707,Hepatitis be antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86708,Hepatitis a antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86709,Hepatitis a igm antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86710,Influenza virus antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86711,John cunningham antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86713,Legionella antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86717,Leishmania antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86720,Leptospira antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86723,Listeria monocytogenes,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86727,Lymph choriomeningitis ab,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86729,Lympho venereum antibody,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Molina Medicaid,CPT,86732,Mucormycosis antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86735,Mumps antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86738,Mycoplasma antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86741,Neisseria meningitidis,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86744,Nocardia antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86747,Parvovirus antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86750,Malaria antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86753,Protozoa antibody nos,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86756,Respiratory virus antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86757,Rickettsia antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86759,Rotavirus antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86762,Rubella antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86765,Rubeola antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86768,Salmonella antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86769,Sars-cov-2 covid-19 antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86771,Shigella antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86774,Tetanus antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86777,Toxoplasma antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86778,Toxoplasma antibody igm,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86780,Treponema pallidum,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86784,Trichinella antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86787,Varicella-zoster antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86788,West nile virus ab igm,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86789,West nile virus antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86790,Virus antibody nos,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86793,Yersinia antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86794,Zika virus igm antibody,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86800,Thyroglobulin antibody,Laboratory,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,
Molina Medicaid,CPT,86803,Hepatitis c ab test,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86804,Hep c ab test confirm,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,86805,Lymphocytotoxicity assay,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Molina Medicaid,CPT,86806,Lymphocytotoxicity assay,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
Molina Medicaid,CPT,86807,Cytotoxic antibody screening,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Molina Medicaid,CPT,86808,Cytotoxic antibody screening,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
Molina Medicaid,CPT,86812,Hla typing a b or c,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
Molina Medicaid,CPT,86813,Hla typing a b or c,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Molina Medicaid,CPT,86816,Hla typing dr/dq,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
Molina Medicaid,CPT,86817,Hla typing dr/dq,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Molina Medicaid,CPT,86821,Lymphocyte culture mixed,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
Molina Medicaid,CPT,86822,Lymphocyte culture primed,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Molina Medicaid,CPT,86825,Hla x-math non-cytotoxic,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Molina Medicaid,CPT,86826,Hla x-match noncytotoxc addl,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
Molina Medicaid,CPT,86828,Hla class i&ii antibody qual,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
Molina Medicaid,CPT,86829,Hla class i/ii antibody qual,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
Molina Medicaid,CPT,86830,Hla class i phenotype qual,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Molina Medicaid,CPT,86831,Hla class ii phenotype qual,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Molina Medicaid,CPT,86832,Hla class i high defin qual,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Molina Medicaid,CPT,86833,Hla class ii high defin qual,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Molina Medicaid,CPT,86834,Hla class i semiquant panel,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Molina Medicaid,CPT,86835,Hla class ii semiquant panel,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Molina Medicaid,CPT,86849,Immunology procedure,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86850,Rbc antibody screen,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Molina Medicaid,CPT,86860,Rbc antibody elution,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Molina Medicaid,CPT,86870,Rbc antibody identification,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Molina Medicaid,CPT,86880,Coombs test direct,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Molina Medicaid,CPT,86885,Coombs test indirect qual,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Molina Medicaid,CPT,86886,Coombs test indirect titer,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Molina Medicaid,CPT,86900,Blood typing serologic abo,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Molina Medicaid,CPT,86901,Blood typing serologic rh(d),Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
Molina Medicaid,CPT,86902,Blood type antigen donor ea,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Molina Medicaid,CPT,86904,Blood typing patient serum,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
Molina Medicaid,CPT,86905,Blood typing rbc antigens,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Molina Medicaid,CPT,86906,Bld typing serologic rh phnt,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
Molina Medicaid,CPT,86910,Blood typing paternity test,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
Molina Medicaid,CPT,86911,Blood typing antigen system,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
Molina Medicaid,CPT,86920,Compatibility test spin,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Molina Medicaid,CPT,86921,Compatibility test incubate,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Molina Medicaid,CPT,86922,Compatibility test antiglob,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Molina Medicaid,CPT,86923,Compatibility test electric,Pathology,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
Molina Medicaid,CPT,86940,Hemolysins/agglutinins auto,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86941,Hemolysins/agglutinins,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,86999,Transfusion procedure,Pathology,Per Unit,$3.57 ,OP,3.57,3.57,,,,,,
Molina Medicaid,CPT,87003,Small animal inoculation,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87015,Specimen infect agnt concntj,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87040,Blood culture for bacteria,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87045,Feces culture aerobic bact,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87046,Stool cultr aerobic bact ea,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87070,Culture othr specimn aerobic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87071,Culture aerobic quant other,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87073,Culture bacteria anaerobic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87075,Cultr bacteria except blood,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87076,Culture anaerobe ident each,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87077,Culture aerobic identify,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87081,Culture screen only,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87084,Culture of specimen by kit,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87086,Urine culture/colony count,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87088,Urine bacteria culture,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87101,Skin fungi culture,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87102,Fungus isolation culture,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87103,Blood fungus culture,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87106,Fungi identification yeast,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87107,Fungi identification mold,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87109,Mycoplasma,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87110,Chlamydia culture,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87116,Mycobacteria culture,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87118,Mycobacteric identification,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87140,Culture type immunofluoresc,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87143,Culture typing glc/hplc,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87147,Culture type immunologic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87149,Dna/rna direct probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87150,Dna/rna amplified probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87152,Culture type pulse field gel,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87158,Culture typing added method,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87164,Dark field examination,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87166,Dark field examination,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87168,Macroscopic exam arthropod,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87169,Macroscopic exam parasite,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87172,Pinworm exam,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87176,Tissue homogenization cultr,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87177,Ova and parasites smears,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87181,Microbe susceptible diffuse,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87184,Microbe susceptible disk,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87185,Microbe susceptible enzyme,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87186,Microbe susceptible mic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87187,Microbe susceptible mlc,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87188,Microbe suscept macrobroth,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87190,Microbe suscept mycobacteri,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87197,Bactericidal level serum,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87205,Smear gram stain,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87206,Smear fluorescent/acid stai,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87207,Smear special stain,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87209,Smear complex stain,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87210,Smear wet mount saline/ink,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87220,Tissue exam for fungi,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87230,Assay toxin or antitoxin,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87250,Virus inoculate eggs/animal,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87252,Virus inoculation tissue,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87253,Virus inoculate tissue addl,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87254,Virus inoculation shell via,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87255,Genet virus isolate hsv,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87260,Adenovirus ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87265,Pertussis ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87267,Enterovirus antibody dfa,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87269,Giardia ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87270,Chlamydia trachomatis ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87271,Cytomegalovirus dfa,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87272,Cryptosporidium ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87273,Herpes simplex 2 ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87274,Herpes simplex 1 ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87275,Influenza b ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87276,Influenza a ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87277,Legionella micdadei ag if,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,87278,Legion pneumophilia ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87279,Parainfluenza ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87280,Respiratory syncytial ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87281,Pneumocystis carinii ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87283,Rubeola ag if,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87285,Treponema pallidum ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87290,Varicella zoster ag if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87299,Antibody detection nos if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87300,Ag detection polyval if,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87301,Adenovirus ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87305,Aspergillus ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87320,Chylmd trach ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87324,Clostridium ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87327,Cryptococcus neoform ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87328,Cryptosporidium ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87329,Giardia ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87332,Cytomegalovirus ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87335,E coli 0157 ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87336,Entamoeb hist dispr ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87337,Entamoeb hist group ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87338,Hpylori stool ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87339,H pylori ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87340,Hepatitis b surface ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87341,Hepatitis b surface ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87350,Hepatitis be ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87380,Hepatitis delta agent ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87385,Histoplasma capsul ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87389,Hiv-1 ag w/hiv-1&2 ab ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87390,Hiv-1 ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87391,Hiv-2 ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87400,Influenza a/b each ag ia,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,87420,Resp syncytial virus ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87425,Rotavirus ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87426,Sarscov coronavirus ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87427,Shiga-like toxin ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87428,Sarscov & inf vir a&b ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87430,Strep a ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87449,Nos each organism ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87450,Ag detect nos ia single,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87451,Polyvalent mult org ea ag ia,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87470,Bartonella dna dir probe,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,87471,Bartonella dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87472,Bartonella dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87475,Lyme dis dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87476,Lyme dis dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87477,Lyme dis dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87480,Candida dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87481,Candida dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87482,Candida dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87485,Chylmd pneum dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87486,Chylmd pneum dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87487,Chylmd pneum dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87490,Chylmd trach dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87491,Chylmd trach dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87492,Chylmd trach dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87493,C diff amplified probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87495,Cytomeg dna dir probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87496,Cytomeg dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87497,Cytomeg dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87498,Enterovirus probe&revrs trns,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87500,Vanomycin dna amp probe,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Molina Medicaid,CPT,87501,Influenza dna amp prob 1+,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87502,Influenza dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87503,Influenza dna amp prob addl,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Molina Medicaid,CPT,87510,Gardner vag dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87511,Gardner vag dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87512,Gardner vag dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87515,Hepatitis b dna dir probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87516,Hepatitis b dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87517,Hepatitis b dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87520,Hepatitis c rna dir probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87521,Hepatitis c probe&rvrs trnsc,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87522,Hepatitis c revrs trnscrpj,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87525,Hepatitis g dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87526,Hepatitis g dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87527,Hepatitis g dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87528,Hsv dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87529,Hsv dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87530,Hsv dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87531,Hhv-6 dna dir probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87532,Hhv-6 dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87533,Hhv-6 dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87534,Hiv-1 dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87535,Hiv-1 probe&reverse trnscrpj,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87536,Hiv-1 quant&revrse trnscrpj,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87537,Hiv-2 dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87538,Hiv-2 probe&revrse trnscripj,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87539,Hiv-2 quant&revrse trnscripj,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87540,Legion pneumo dna dir prob,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87541,Legion pneumo dna amp prob,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87542,Legion pneumo dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87550,Mycobacteria dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87551,Mycobacteria dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87552,Mycobacteria dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87555,M.tuberculo dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87556,M.tuberculo dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87557,M.tuberculo dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87560,M.avium-intra dna dir prob,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87561,M.avium-intra dna amp prob,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87562,M.avium-intra dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87563,M. genitalium amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87580,M.pneumon dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87581,M.pneumon dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87590,N.gonorrhoeae dna dir prob,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87591,N.gonorrhoeae dna amp prob,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87592,N.gonorrhoeae dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87623,Hpv low-risk types,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87624,Hpv high-risk types,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87625,Hpv types 16 & 18 only,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87634,Rsv dna/rna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87635,Sars-cov-2 covid-19 amp prb,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87636,Sarscov2 & inf a&b amp prb,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87637,Sarscov2&inf a&b&rsv amp prb,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87640,Staph a dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87641,Mr-staph dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87650,Strep a dna dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87651,Strep a dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87652,Strep a dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87653,Strep b dna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87660,Trichomonas vagin dir probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87661,Trichomonas vaginalis amplif,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87662,Zika virus dna/rna amp probe,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87797,Detect agent nos dna dir,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87798,Detect agent nos dna amp,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87799,Detect agent nos dna quant,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87800,Detect agnt mult dna direc,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87801,Detect agnt mult dna ampli,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87802,Strep b assay w/optic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87803,Clostridium toxin a w/optic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87804,Influenza assay w/optic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87806,Hiv w/hiv1&2 antb w/optic,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87807,Rsv assay w/optic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87808,Trichomonas assay w/optic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87809,Adenovirus assay w/optic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87810,Chylmd trach assay w/optic,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87811,Sars-cov-2 covid19 w/optic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87850,N. gonorrhoeae assay w/optic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87880,Strep a assay w/optic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87899,Agent nos assay w/optic,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87904,Phenotype dna hiv w/clt add,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,87905,Sialidase enzyme assay,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,87999,Microbiology procedure,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,88104,Cytopath fl nongyn smears,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,88106,Cytopath fl nongyn filter,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,88108,Cytopath concentrate tech,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,88112,Cytopath cell enhance tech,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,88120,Cytp urne 3-5 probes ea spec,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,88125,Forensic cytopathology,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,88130,Sex chromatin identification,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,88140,Sex chromatin identification,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,88141,Cytopath c/v interpret,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Molina Medicaid,CPT,88142,Cytopath c/v thin layer,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Molina Medicaid,CPT,88143,Cytopath c/v thin layer redo,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Molina Medicaid,CPT,88147,Cytopath c/v automated,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Molina Medicaid,CPT,88148,Cytopath c/v auto rescreen,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Molina Medicaid,CPT,88150,Cytopath c/v manual,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Molina Medicaid,CPT,88152,Cytopath c/v auto redo,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Molina Medicaid,CPT,88153,Cytopath c/v redo,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Molina Medicaid,CPT,88154,Cytopath c/v select,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Molina Medicaid,CPT,88155,Cytopath c/v index add-on,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Molina Medicaid,CPT,88160,Cytopath smear other source,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,88161,Cytopath smear other source,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,88162,Cytopath smear other source,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,88164,Cytopath tbs c/v manual,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Molina Medicaid,CPT,88165,Cytopath tbs c/v redo,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Molina Medicaid,CPT,88166,Cytopath tbs c/v auto redo,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Molina Medicaid,CPT,88167,Cytopath tbs c/v select,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Molina Medicaid,CPT,88172,Cytp dx eval fna 1st ea site,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,88173,Cytopath eval fna report,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,88174,Cytopath c/v auto in fluid,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Molina Medicaid,CPT,88175,Cytopath c/v auto fluid redo,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Molina Medicaid,CPT,88177,Cytp fna eval ea addl,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,88182,Cell marker study,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,88184,Flowcytometry/ tc 1 marker,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,88187,Flowcytometry/read 2-8,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,88188,Flowcytometry/read 9-15,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,88189,Flowcytometry/read 16 & >,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,88199,Cytopathology procedure,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,88240,Cell cryopreserve/storage,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,88241,Frozen cell preparation,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,88245,Chromosome analysis 20-25,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,88248,Chromosome analysis 50-100,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,88249,Chromosome analysis 100,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,88261,Chromosome analysis 5,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,88262,Chromosome analysis 15-20,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,88263,Chromosome analysis 45,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,88264,Chromosome analysis 20-25,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,88267,Chromosome analys placenta,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,88269,Chromosome analys amniotic,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,88271,Cytogenetics dna probe,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,88272,Cytogenetics 3-5,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,88273,Cytogenetics 10-30,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,88274,Cytogenetics 25-99,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,88275,Cytogenetics 100-300,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,88280,Chromosome karyotype study,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,88283,Chromosome banding study,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,88285,Chromosome count additional,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,88289,Chromosome study additional,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,88291,Cyto/molecular report,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,88299,Cytogenetic study,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,88300,Surgical path gross,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,88302,Tissue exam by pathologist,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,88304,Tissue exam by pathologist,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,88305,Tissue exam by pathologist,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,88311,Decalcify tissue,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,88312,Special stains group 1,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,88313,Special stains group 2,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,88314,Histochemical stains add-on,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,88321,Microslide consultation,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,88323,Microslide consultation,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,88325,Comprehensive review of data,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,88329,Path consult introp,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,88331,Path consult intraop 1 bloc,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,88332,Path consult intraop addl,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,88333,Intraop cyto path consult 1,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,88334,Intraop cyto path consult 2,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,88342,Immunohisto antb 1st stain,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,88346,Immunofluor antb 1st stain,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,88347,Immunofluorescent study,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,88355,Analysis skeletal muscle,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,88356,Analysis nerve,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,88358,Analysis tumor,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,88363,Xm archive tissue molec anal,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,88364,Insitu hybridization (fish),Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,88369,M/phmtrc alysishquant/semiq,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,88371,Protein western blot tissue,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,88372,Protein analysis w/probe,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,88373,M/phmtrc alys ishquant/semiq,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,88374,M/phmtrc alys ishquant/semiq,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,88375,Optical endomicroscpy interp,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,88377,M/phmtrc alys ishquant/semiq,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,88380,Microdissection laser,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,88381,Microdissection manual,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,88387,Tiss exam molecular study,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,88388,Tiss ex molecul study add-on,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,88399,Surgical pathology procedure,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,88720,Bilirubin total transcut,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,88738,Hgb quant transcutaneous,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Molina Medicaid,CPT,88740,Transcutaneous carboxyhb,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Molina Medicaid,CPT,88741,Transcutaneous methb,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Molina Medicaid,CPT,88749,In vivo lab service,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,89050,Body fluid cell count,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,89051,Body fluid cell count,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,89055,Leukocyte assessment fecal,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Molina Medicaid,CPT,89060,Exam synovial fluid crystals,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,89125,Specimen fat stain,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,89160,Exam feces for meat fibers,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,89190,Nasal smear for eosinophils,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,89220,Sputum specimen collection,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,89230,Collect sweat for test,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,89240,Pathology lab procedure,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,89250,Cultr oocyte/embryo <4 days,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,89253,Embryo hatching,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,89254,Oocyte identification,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,89255,Prepare embryo for transfer,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,89257,Sperm identification,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,89260,Sperm isolation simple,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,89261,Sperm isolation complex,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,89264,Identify sperm tissue,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,89281,Assist oocyte fertilization,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,89290,Biopsy oocyte polar body,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,89291,Biopsy oocyte polar body,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,89300,Semen analysis w/huhner,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,89310,Semen analysis w/count,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,89320,Semen anal vol/count/mot,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,89321,Semen anal sperm detection,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,89322,Semen anal strict criteria,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,89325,Sperm antibody test,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,89329,Sperm evaluation test,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,89330,Evaluation cervical mucus,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,89331,Retrograde ejaculation anal,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,89335,Cryopreserve testicular tiss,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,89353,Thawing cryopresrved sperm,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,89398,Unlisted reprod med lab proc,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,90287,Botulinum antitoxin,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,90288,Botulism ig iv,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,90291,Cmv ig iv,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,90371,Hep b ig im,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Molina Medicaid,CPT,90375,Rabies ig im/sc,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Molina Medicaid,CPT,90376,Rabies ig heat treated,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Molina Medicaid,CPT,90377,Rabies ig ht&sol human im/sc,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Molina Medicaid,CPT,90378,Rsv mab im 50mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Molina Medicaid,CPT,90384,Rh ig full-dose im,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,90386,Rh ig iv,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Molina Medicaid,CPT,90389,Tetanus ig im,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,90393,Vaccina ig im,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,90396,Varicella-zoster ig im,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,90460,Im admin 1st/only component,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,90461,Im admin each addl component,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,90471,Immunization admin,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,90472,Immunization admin each add,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,90473,Immune admin oral/nasal,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,90474,Immune admin oral/nasal addl,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,90476,Adenovirus vaccine type 4,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90477,Adenovirus vaccine type 7,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90581,Anthrax vaccine sc or im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Molina Medicaid,CPT,90585,Bcg vaccine percut,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90586,Bcg vaccine intravesical,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Molina Medicaid,CPT,90587,Dengue vacc quad 3 dose subq,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Molina Medicaid,CPT,90619,Menacwy-tt vaccine im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Molina Medicaid,CPT,90620,Menb-4c vacc 2 dose im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Molina Medicaid,CPT,90621,Menb-fhbp vacc 2/3 dose im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Molina Medicaid,CPT,90625,Cholera vaccine live oral,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90630,Flu vacc iiv4 no preserv id,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90632,Hepa vaccine adult im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90633,Hepa vacc ped/adol 2 dose im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90634,Hepa vacc ped/adol 3 dose,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90636,Hep a/hep b vacc adult im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Molina Medicaid,CPT,90644,Hib-mency vacc 6wk-18m0 im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Molina Medicaid,CPT,90645,Hib vaccine hboc im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Molina Medicaid,CPT,90646,Hib vaccine prp-d im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Molina Medicaid,CPT,90647,Hib prp-omp vacc 3 dose im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90648,Hib prp-t vaccine 4 dose im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90649,4vhpv vaccine 3 dose im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Molina Medicaid,CPT,90650,2vhpv vaccine 3 dose im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90651,9vhpv vaccine 2/3 dose im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Molina Medicaid,CPT,90653,Iiv adjuvant vaccine im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90654,Flu vacc iiv3 no preserv id,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90655,Iiv3 vacc no prsv 0.25 ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90656,Iiv3 vacc no prsv 0.5 ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90657,Iiv3 vaccine splt 0.25 ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90658,Iiv3 vaccine splt 0.5 ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90660,Laiv3 vaccine intranasal,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90661,Cciiv3 vac no prsv 0.5 ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90662,Iiv no prsv increased ag im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90664,Laiv vacc pandemic intranasl,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90666,Flu vac pandem prsrv free im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90667,Iiv vacc pandemic adjuvt im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90668,Iiv vaccine pandemic im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90669,Pneumococcal vacc 7 val im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Molina Medicaid,CPT,90670,Pcv13 vaccine im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Molina Medicaid,CPT,90672,Laiv4 vaccine intranasal,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90673,Riv3 vaccine no preserv im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90674,Cciiv4 vac no prsv 0.5 ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90675,Rabies vaccine im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Molina Medicaid,CPT,90676,Rabies vaccine id,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Molina Medicaid,CPT,90680,Rv5 vacc 3 dose live oral,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Molina Medicaid,CPT,90681,Rv1 vacc 2 dose live oral,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90682,Riv4 vacc recombinant dna im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90685,Iiv4 vacc no prsv 0.25 ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90686,Iiv4 vacc no prsv 0.5 ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90687,Iiv4 vaccine splt 0.25 ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90688,Iiv4 vaccine splt 0.5 ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90689,Vacc iiv4 no prsrv 0.25ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90690,Typhoid vaccine oral,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90691,Typhoid vaccine im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90692,Typhoid vaccine h-p sc/id,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90693,Typhoid vaccine akd sc,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90694,Vacc aiiv4 no prsrv 0.5ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90696,Dtap-ipv vaccine 4-6 yrs im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90697,Dtap-ipv-hib-hepb vaccine im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90698,Dtap-ipv/hib vaccine im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90700,Dtap vaccine < 7 yrs im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90702,Dt vaccine under 7 yrs im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90703,Tetanus vaccine im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90704,Mumps vaccine sc,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90705,Measles vaccine sc,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90706,Rubella vaccine sc,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90707,Mmr vaccine sc,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90708,Measles-rubella vaccine sc,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90710,Mmrv vaccine sc,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90712,Oral poliovirus vaccine,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Molina Medicaid,CPT,90713,Poliovirus ipv sc/im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90714,Td vacc no presv 7 yrs+ im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90715,Tdap vaccine 7 yrs/> im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90716,Var vaccine live subq,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Molina Medicaid,CPT,90717,Yellow fever vaccine subq,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Molina Medicaid,CPT,90719,Diphtheria vaccine im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90720,Dtp/hib vaccine im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Molina Medicaid,CPT,90721,Dtap/hib vaccine im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Molina Medicaid,CPT,90723,Dtap-hep b-ipv vaccine im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90725,Cholera vaccine injectable,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90727,Plague vaccine im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Molina Medicaid,CPT,90732,Ppsv23 vacc 2 yrs+ subq/im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90733,Mpsv4 vaccine subq,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Molina Medicaid,CPT,90734,Menacwyd/menacwycrm vacc im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Molina Medicaid,CPT,90735,Encephalitis vaccine sc,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Molina Medicaid,CPT,90736,Hzv vaccine live subq,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Molina Medicaid,CPT,90738,Inactivated je vacc im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Molina Medicaid,CPT,90739,Hepb vacc 2 dose adult im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90740,Hepb vacc 3 dose immunsup im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Molina Medicaid,CPT,90743,Hepb vacc 2 dose adolesc im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90744,Hepb vacc 3 dose ped/adol im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90746,Hepb vaccine 3 dose adult im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90747,Hepb vacc 4 dose immunsup im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Molina Medicaid,CPT,90748,Hib-hepb vaccine im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90749,Vaccine toxoid,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90750,Hzv vacc recombinant im,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Molina Medicaid,CPT,90756,Cciiv4 vacc abx free im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,90785,Psytx complex interactive,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Molina Medicaid,CPT,90791,Psych diagnostic evaluation,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
Molina Medicaid,CPT,90792,Psych diag eval w/med srvcs,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
Molina Medicaid,CPT,90832,Psytx w pt 30 minutes,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Molina Medicaid,CPT,90833,Psytx w pt w e/m 30 min,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Molina Medicaid,CPT,90834,Psytx w pt 45 minutes,Behavioral Health,Per Unit,$84.55 ,OP,84.55,84.55,,,,,,
Molina Medicaid,CPT,90836,Psytx w pt w e/m 45 min,Behavioral Health,Per Unit,$84.55 ,OP,84.55,84.55,,,,,,
Molina Medicaid,CPT,90837,Psytx w pt 60 minutes,Behavioral Health,Per Unit,$84.55 ,OP,84.55,84.55,,,,,,
Molina Medicaid,CPT,90838,Psytx w pt w e/m 60 min,Behavioral Health,Per Unit,$84.55 ,OP,84.55,84.55,,,,,,
Molina Medicaid,CPT,90839,Psytx crisis initial 60 min,Behavioral Health,Per Unit,$84.55 ,OP,84.55,84.55,,,,,,
Molina Medicaid,CPT,90840,Psytx crisis ea addl 30 min,Behavioral Health,Per Unit,$84.55 ,OP,84.55,84.55,,,,,,
Molina Medicaid,CPT,90845,Psychoanalysis,Behavioral Health,Per Unit,$84.55 ,OP,84.55,84.55,,,,,,
Molina Medicaid,CPT,90846,Family psytx w/o pt 50 min,Behavioral Health,Per Unit,$89.14 ,OP,89.14,89.14,,,,,,
Molina Medicaid,CPT,90847,Family psytx w/pt 50 min,Behavioral Health,Per Unit,$89.14 ,OP,89.14,89.14,,,,,,
Molina Medicaid,CPT,90849,Multiple family group psytx,Behavioral Health,Per Unit,$119.88 ,OP,119.88,119.88,,,,,,
Molina Medicaid,CPT,90853,Group psychotherapy,Behavioral Health,Per Unit,$119.88 ,OP,119.88,119.88,,,,,,
Molina Medicaid,CPT,90863,Pharmacologic mgmt w/psytx,Behavioral Health,Per Unit,$80.13 ,OP,80.13,80.13,,,,,,
Molina Medicaid,CPT,90865,Narcosynthesis,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
Molina Medicaid,CPT,90867,Tcranial magn stim tx plan,Behavioral Health,Per Unit,$276.44 ,OP,276.44,276.44,,,,,,
Molina Medicaid,CPT,90868,Tcranial magn stim tx deli,Behavioral Health,Per Unit,$276.44 ,OP,276.44,276.44,,,,,,
Molina Medicaid,CPT,90869,Tcran magn stim redetemine,Behavioral Health,Per Unit,$276.44 ,OP,276.44,276.44,,,,,,
Molina Medicaid,CPT,90870,Electroconvulsive therapy,Behavioral Health,Per Unit,$276.44 ,OP,276.44,276.44,,,,,,
Molina Medicaid,CPT,90875,Psychophysiological therapy,Ancillary Services,Per Unit,$123.52 ,OP,123.52,123.52,,,,,,
Molina Medicaid,CPT,90876,Psychophysiological therapy,Ancillary Services,Per Unit,$123.52 ,OP,123.52,123.52,,,,,,
Molina Medicaid,CPT,90880,Hypnotherapy,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Molina Medicaid,CPT,90882,Environmental manipulation,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Molina Medicaid,CPT,90885,Psy evaluation of records,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Molina Medicaid,CPT,90887,Consultation with family,Behavioral Health,Per Unit,$89.14 ,OP,89.14,89.14,,,,,,
Molina Medicaid,CPT,90889,Preparation of report,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Molina Medicaid,CPT,90899,Psychiatric service/therapy,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Molina Medicaid,CPT,90901,Biofeedback train any meth,Ancillary Services,Per Unit,$123.52 ,OP,123.52,123.52,,,,,,
Molina Medicaid,CPT,90911,Biofeedback peri/uro/rectal,Ancillary Services,Per Unit,$123.52 ,OP,123.52,123.52,,,,,,
Molina Medicaid,CPT,90912,Bfb training 1st 15 min,Ancillary Services,Per Unit,$123.52 ,OP,123.52,123.52,,,,,,
Molina Medicaid,CPT,90913,Bfb training ea addl 15 min,Ancillary Services,Per Unit,$123.52 ,OP,123.52,123.52,,,,,,
Molina Medicaid,CPT,90935,Hemodialysis one evaluation,Nephrology,Per Unit,$540.95 ,OP,540.95,540.95,,,,,,
Molina Medicaid,CPT,90937,Hemodialysis repeated eval,Nephrology,Per Unit,$540.95 ,OP,540.95,540.95,,,,,,
Molina Medicaid,CPT,90940,Hemodialysis access study,Ancillary Services,Per Unit,$159.07 ,OP,159.07,159.07,,,,,,
Molina Medicaid,CPT,90945,Dialysis one evaluation,Nephrology,Per Unit,$540.95 ,OP,540.95,540.95,,,,,,
Molina Medicaid,CPT,90947,Dialysis repeated eval,Nephrology,Per Unit,$540.95 ,OP,540.95,540.95,,,,,,
Molina Medicaid,CPT,90989,Dialysis training complete,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Molina Medicaid,CPT,90993,Dialysis training incompl,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Molina Medicaid,CPT,90997,Hemoperfusion,Nephrology,Per Unit,$540.95 ,OP,540.95,540.95,,,,,,
Molina Medicaid,CPT,90999,Dialysis procedure,Nephrology,Per Unit,$540.95 ,OP,540.95,540.95,,,,,,
Molina Medicaid,CPT,91010,Esophagus motility study,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Molina Medicaid,CPT,91013,Esophgl motil w/stim/perfus,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Molina Medicaid,CPT,91020,Gastric motility studies,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Molina Medicaid,CPT,91022,Duodenal motility study,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Molina Medicaid,CPT,91030,Acid perfusion of esophagus,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Molina Medicaid,CPT,91034,Gastroesophageal reflux test,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Molina Medicaid,CPT,91035,G-esoph reflx tst w/electrod,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Molina Medicaid,CPT,91037,Esoph imped function test,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Molina Medicaid,CPT,91038,Esoph imped funct test > 1hr,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Molina Medicaid,CPT,91040,Esoph balloon distension tst,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Molina Medicaid,CPT,91110,Gi tract capsule endoscopy,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
Molina Medicaid,CPT,91111,Esophageal capsule endoscopy,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Molina Medicaid,CPT,91112,Gi wireless capsule measure,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Molina Medicaid,CPT,91117,Colon motility 6 hr study,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Molina Medicaid,CPT,91120,Rectal sensation test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,91122,Anal pressure record,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,91132,Electrogastrography,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,91133,Electrogastrography w/test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,91200,Liver elastography,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,91299,Gastroenterology procedure,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Molina Medicaid,CPT,91300,Sarscov2 vac 30mcg/0.3ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,91301,Sarscov2 vac 100mcg/0.5ml im,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,91302,Coronavirus vaccine 3,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,91303,Coronavirus vaccine 4,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,91304,Coronavirus vaccine 5,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,91305,Coronavirus vaccine 6,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,91306,Coronavirus vaccine 7,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,91307,Coronavirus vaccine 8,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,91308,Coronavirus vaccine 9,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,91309,Coronavirus vaccine 10,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,91310,Coronavirus vaccine 11,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,92015,Determine refractive state,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92018,New eye exam & treatment,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Molina Medicaid,CPT,92019,Eye exam & treatment,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Molina Medicaid,CPT,92020,Special eye evaluation,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92025,Corneal topography,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92060,Special eye evaluation,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92065,Orthoptic/pleoptic training,Ancillary Services,Per Unit,$123.52 ,OP,123.52,123.52,,,,,,
Molina Medicaid,CPT,92071,Contact lens fitting for tx,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92072,Fit contac lens for managmnt,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92081,Visual field examination(s),Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92082,Visual field examination(s),Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92083,Visual field examination(s),Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92100,Serial tonometry exam(s),Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92132,Cmptr ophth dx img ant segmt,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92133,Cmptr ophth img optic nerve,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92134,Cptr ophth dx img post segmt,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92136,Ophthalmic biometry,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92140,Glaucoma provocative tests,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92145,Corneal hysteresis deter,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92201,Opscpy extnd rta draw uni/bi,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92202,Opscpy extnd on/mac draw,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92225,Special eye exam initial,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92226,Special eye exam subsequent,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92227,Img rta detcj/mntr ds staff,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92228,Img rta detc/mntr ds phy/qhp,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Molina Medicaid,CPT,92229,Img rta detc/mntr ds poc aly,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92230,Eye exam with photos,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Molina Medicaid,CPT,92235,Fluorescein angrph uni/bi,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Molina Medicaid,CPT,92240,Icg angiography uni/bi,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Molina Medicaid,CPT,92242,Fluorescein icg angiography,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Molina Medicaid,CPT,92250,Eye exam with photos,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92260,Ophthalmoscopy/dynamometry,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92265,Eye muscle evaluation,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92270,Electro-oculography,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Molina Medicaid,CPT,92273,Full field erg w/i&r,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Molina Medicaid,CPT,92274,Multifocal erg w/i&r,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Molina Medicaid,CPT,92275,Electroretinography,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Molina Medicaid,CPT,92283,Color vision examination,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92284,Dark adaptation eye exam,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92285,Eye photography,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92286,Internal eye photography,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92287,Internal eye photography,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92310,Contact lens fitting,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92311,Contact lens fitting,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92312,Contact lens fitting,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92313,Contact lens fitting,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92314,Prescription of contact lens,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92315,Rx cntact lens aphakia 1 eye,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92316,Rx cntact lens aphakia 2 eye,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92317,Rx corneoscleral cntact lens,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92325,Modification of contact lens,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92326,Replacement of contact lens,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92340,Fit spectacles monofocal,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92341,Fit spectacles bifocal,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92342,Fit spectacles multifocal,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92352,Fit aphakia spectcl monofocl,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92353,Fit aphakia spectcl multifoc,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92354,Fit spectacles single system,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92355,Fit spectacles compound lens,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92358,Aphakia prosth service temp,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92370,Repair & adjust spectacles,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92371,Repair & adjust spectacles,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92499,Eye service or procedure,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,92507,Speech/hearing therapy,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Molina Medicaid,CPT,92516,Facial nerve function test,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
Molina Medicaid,CPT,92517,Vemp test i&r cervical,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
Molina Medicaid,CPT,92518,Vemp test i&r ocular,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
Molina Medicaid,CPT,92519,Vemp tst i&r cervical&ocular,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
Molina Medicaid,CPT,92520,Laryngeal function studies,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
Molina Medicaid,CPT,92521,Evaluation of speech fluency,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Molina Medicaid,CPT,92522,Evaluate speech production,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Molina Medicaid,CPT,92523,Speech sound lang comprehen,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Molina Medicaid,CPT,92524,Behavral qualit analys voice,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Molina Medicaid,CPT,92534,Optokinetic nystagmus test,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
Molina Medicaid,CPT,92537,Caloric vstblr test w/rec,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
Molina Medicaid,CPT,92538,Caloric vstblr test w/rec,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
Molina Medicaid,CPT,92540,Basic vestibular evaluation,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
Molina Medicaid,CPT,92543,Caloric vestibular test,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
Molina Medicaid,CPT,92546,Sinusoidal rotational test,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
Molina Medicaid,CPT,92547,Supplemental electrical test,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
Molina Medicaid,CPT,92548,Cdp-sot 6 cond w/i&r,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
Molina Medicaid,CPT,92549,Cdp-sot 6 cond w/i&r mct&adt,Otolaryngology,Per Unit,$124.37 ,OP,124.37,124.37,,,,,,
Molina Medicaid,CPT,92550,Tympanometry & reflex thresh,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Molina Medicaid,CPT,92553,Audiometry air & bone,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Molina Medicaid,CPT,92557,Comprehensive hearing test,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Molina Medicaid,CPT,92558,Evoked auditory test qual,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Molina Medicaid,CPT,92570,Acoustic immitance testing,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Molina Medicaid,CPT,92572,Staggered spondaic word test,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Molina Medicaid,CPT,92577,Stenger test speech,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Molina Medicaid,CPT,92579,Visual audiometry (vra),Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Molina Medicaid,CPT,92582,Conditioning play audiometry,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Molina Medicaid,CPT,92584,Electrocochleography,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Molina Medicaid,CPT,92585,Auditor evoke potent compre,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Molina Medicaid,CPT,92586,Auditor evoke potent limit,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Molina Medicaid,CPT,92587,Evoked auditory test limited,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Molina Medicaid,CPT,92588,Evoked auditory tst complete,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Molina Medicaid,CPT,92597,Oral speech device eval,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Molina Medicaid,CPT,92601,Cochlear implt f/up exam <7,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,92602,Reprogram cochlear implt <7,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,92603,Cochlear implt f/up exam 7/>,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,92604,Reprogram cochlear implt 7/>,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,92605,Ex for nonspeech device rx,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Molina Medicaid,CPT,92606,Non-speech device service,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,92607,Ex for speech device rx 1hr,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Molina Medicaid,CPT,92608,Ex for speech device rx addl,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Molina Medicaid,CPT,92610,Evaluate swallowing function,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Molina Medicaid,CPT,92618,Ex for nonspeech dev rx add,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Molina Medicaid,CPT,92620,Auditory function 60 min,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Molina Medicaid,CPT,92621,Auditory function + 15 min,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Molina Medicaid,CPT,92625,Tinnitus assessment,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Molina Medicaid,CPT,92626,Eval aud funcj 1st hour,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Molina Medicaid,CPT,92627,Eval aud funcj ea addl 15,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Molina Medicaid,CPT,92630,Aud rehab pre-ling hear loss,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,92633,Aud rehab postling hear loss,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,92651,Aep hearing status deter i&r,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Molina Medicaid,CPT,92652,Aep thrshld est mlt freq i&r,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Molina Medicaid,CPT,92653,Aep neurodiagnostic i&r,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Molina Medicaid,CPT,92920,Prq cardiac angioplast 1 art,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Molina Medicaid,CPT,92921,Prq cardiac angio addl art,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Molina Medicaid,CPT,92924,Prq card angio/athrect 1 art,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Molina Medicaid,CPT,92925,Prq card angio/athrect addl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Molina Medicaid,CPT,92928,Prq card stent w/angio 1 vsl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Molina Medicaid,CPT,92929,Prq card stent w/angio addl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Molina Medicaid,CPT,92933,Prq card stent/ath/angio,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Molina Medicaid,CPT,92934,Prq card stent/ath/angio,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Molina Medicaid,CPT,92937,Prq revasc byp graft 1 vsl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Molina Medicaid,CPT,92938,Prq revasc byp graft addl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Molina Medicaid,CPT,92941,Prq card revasc mi 1 vsl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Molina Medicaid,CPT,92943,Prq card revasc chronic 1vsl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Molina Medicaid,CPT,92944,Prq card revasc chronic addl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Molina Medicaid,CPT,92950,Heart/lung resuscitation cpr,General Medicine,Per Unit,$385.17 ,OP,385.17,385.17,,,,,,
Molina Medicaid,CPT,92953,Temporary external pacing,Cardiology,Per Unit,$347.43 ,OP,347.43,347.43,,,,,,
Molina Medicaid,CPT,92960,Cardioversion electric ext,Cardiology,Per Unit,$347.43 ,OP,347.43,347.43,,,,,,
Molina Medicaid,CPT,92961,Cardioversion electric int,Cardiology,Per Unit,$347.43 ,OP,347.43,347.43,,,,,,
Molina Medicaid,CPT,92971,Cardioassist external,Cardiology,Per Unit,$347.43 ,OP,347.43,347.43,,,,,,
Molina Medicaid,CPT,92973,Prq coronary mech thrombect,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Molina Medicaid,CPT,92975,Dissolve clot heart vessel,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Molina Medicaid,CPT,92977,Dissolve clot heart vessel,General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
Molina Medicaid,CPT,92978,Endoluminl ivus oct c 1st,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,92979,Endoluminl ivus oct c ea,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,92986,Revision of aortic valve,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Molina Medicaid,CPT,92987,Revision of mitral valve,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Molina Medicaid,CPT,92990,Revision of pulmonary valve,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Molina Medicaid,CPT,92997,Pul art balloon repr percut,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Molina Medicaid,CPT,92998,Pul art balloon repr percut,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Molina Medicaid,CPT,93000,Electrocardiogram complete,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Molina Medicaid,CPT,93005,Electrocardiogram tracing,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Molina Medicaid,CPT,93010,Electrocardiogram report,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Molina Medicaid,CPT,93015,Cardiovascular stress test,Cardiology,Per Unit,$174.07 ,OP,174.07,174.07,,,,,,
Molina Medicaid,CPT,93016,Cardiovascular stress test,Cardiology,Per Unit,$174.07 ,OP,174.07,174.07,,,,,,
Molina Medicaid,CPT,93017,Cardiovascular stress test,Cardiology,Per Unit,$174.07 ,OP,174.07,174.07,,,,,,
Molina Medicaid,CPT,93018,Cardiovascular stress test,Cardiology,Per Unit,$174.07 ,OP,174.07,174.07,,,,,,
Molina Medicaid,CPT,93024,Cardiac drug stress test,Cardiology,Per Unit,$174.07 ,OP,174.07,174.07,,,,,,
Molina Medicaid,CPT,93025,Microvolt t-wave assess,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,93040,Rhythm ecg with report,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Molina Medicaid,CPT,93041,Rhythm ecg tracing,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Molina Medicaid,CPT,93042,Rhythm ecg report,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Molina Medicaid,CPT,93050,Art pressure waveform analys,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,93224,Ecg monit/reprt up to 48 hrs,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,93225,Ecg monit/reprt up to 48 hrs,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,93226,Ecg monit/reprt up to 48 hrs,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,93227,Ecg monit/reprt up to 48 hrs,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,93228,Remote 30 day ecg rev/report,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,93229,Remote 30 day ecg tech supp,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,93241,Ext ecg>48hr<7d rec scan a/r,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,93242,Ext ecg>48hr<7d recording,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,93243,Ext ecg>48hr<7d scan a/r,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,93244,Ext ecg>48hr<7d rev&interpj,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,93245,Ext ecg>7d<15d rec scan a/r,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,93246,Ext ecg>7d<15d recording,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,93247,Ext ecg>7d<15d scan a/r,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,93248,Ext ecg>7d<15d rev&interpj,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,93260,Prgrmg dev eval impltbl sys,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,93261,Interrogate subq defib,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,93264,Rem mntr wrls p-art prs snr,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,93268,Ecg record/review,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,93270,Remote 30 day ecg rev/report,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,93271,Ecg/monitoring and analysis,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,93272,Ecg/review interpret only,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,93278,Ecg/signal-averaged,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Molina Medicaid,CPT,93279,Prgrmg dev eval pm/ldls pm,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,93280,Pm device progr eval dual,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,93281,Pm device progr eval multi,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,93282,Prgrmg eval implantable dfb,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,93283,Prgrmg eval implantable dfb,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,93284,Prgrmg eval implantable dfb,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,93285,Prgrmg dev eval scrms ip,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,93286,Peri-px eval pm/ldls pm ip,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,93287,Peri-px device eval & prgr,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,93288,Interrog evl pm/ldls pm ip,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,93289,Interrog device eval heart,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,93290,Interrog dev eval icpms ip,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,93291,Interrog dev eval scrms ip,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,93292,Wcd device interrogate,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,93293,Pm phone r-strip device eval,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,93294,Rem interrog evl pm/ldls pm,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,93295,Dev interrog remote 1/2/mlt,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,93296,Rem interrog evl pm/ids,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,93297,Rem interrog dev eval icpms,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,93298,Rem interrog dev eval scrms,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,93299,Interrog eval icpms/scrms,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,93303,Echo transthoracic,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Molina Medicaid,CPT,93304,Echo transthoracic,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Molina Medicaid,CPT,93306,Tte w/doppler complete,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Molina Medicaid,CPT,93307,Tte w/o doppler complete,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Molina Medicaid,CPT,93308,Tte f-up or lmtd,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Molina Medicaid,CPT,93312,Echo transesophageal,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Molina Medicaid,CPT,93313,Echo transesophageal,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Molina Medicaid,CPT,93314,Echo transesophageal,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Molina Medicaid,CPT,93315,Echo transesophageal,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Molina Medicaid,CPT,93316,Echo transesophageal,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Molina Medicaid,CPT,93317,Echo transesophageal,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Molina Medicaid,CPT,93318,Echo transesophageal intraop,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Molina Medicaid,CPT,93320,Doppler echo exam heart,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Molina Medicaid,CPT,93321,Doppler echo exam heart,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Molina Medicaid,CPT,93325,Doppler color flow add-on,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,93350,Stress tte only,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Molina Medicaid,CPT,93351,Stress tte complete,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Molina Medicaid,CPT,93352,Admin ecg contrast agent,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Molina Medicaid,CPT,93355,Echo transesophageal (tee),Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Molina Medicaid,CPT,93356,Myocrd strain img spckl trck,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Molina Medicaid,CPT,93451,Right heart cath,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Molina Medicaid,CPT,93452,Left hrt cath w/ventrclgrphy,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Molina Medicaid,CPT,93453,R&l hrt cath w/ventriclgrphy,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Molina Medicaid,CPT,93454,Coronary artery angio s&i,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Molina Medicaid,CPT,93455,Coronary art/grft angio s&i,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Molina Medicaid,CPT,93456,R hrt coronary artery angio,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Molina Medicaid,CPT,93457,R hrt art/grft angio,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Molina Medicaid,CPT,93458,L hrt artery/ventricle angio,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Molina Medicaid,CPT,93459,L hrt art/grft angio,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Molina Medicaid,CPT,93460,R&l hrt art/ventricle angio,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Molina Medicaid,CPT,93461,R&l hrt art/ventricle angio,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Molina Medicaid,CPT,93462,L hrt cath trnsptl puncture,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Molina Medicaid,CPT,93464,Exercise w/hemodynamic meas,Cardiology,Per Unit,$174.07 ,OP,174.07,174.07,,,,,,
Molina Medicaid,CPT,93505,Biopsy of heart lining,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Molina Medicaid,CPT,93530,Rt heart cath congenital,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Molina Medicaid,CPT,93531,R & l heart cath congenital,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Molina Medicaid,CPT,93532,R & l heart cath congenital,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Molina Medicaid,CPT,93533,R & l heart cath congenital,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"1,389.31","1,389.31",,,,,,
Molina Medicaid,CPT,93600,Bundle of his recording,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
Molina Medicaid,CPT,93602,Intra-atrial recording,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
Molina Medicaid,CPT,93603,Right ventricular recording,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
Molina Medicaid,CPT,93609,Map tachycardia add-on,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
Molina Medicaid,CPT,93610,Intra-atrial pacing,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
Molina Medicaid,CPT,93612,Intraventricular pacing,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
Molina Medicaid,CPT,93613,Electrophys map 3d add-on,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
Molina Medicaid,CPT,93615,Esophageal recording,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
Molina Medicaid,CPT,93616,Esophageal recording,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
Molina Medicaid,CPT,93618,Heart rhythm pacing,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
Molina Medicaid,CPT,93619,Electrophysiology evaluation,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
Molina Medicaid,CPT,93620,Electrophysiology evaluation,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
Molina Medicaid,CPT,93621,Electrophysiology evaluation,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
Molina Medicaid,CPT,93622,Electrophysiology evaluation,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
Molina Medicaid,CPT,93623,Stimulation pacing heart,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
Molina Medicaid,CPT,93624,Electrophysiologic study,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
Molina Medicaid,CPT,93631,Heart pacing mapping,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
Molina Medicaid,CPT,93640,Evaluation heart device,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
Molina Medicaid,CPT,93641,Electrophysiology evaluation,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
Molina Medicaid,CPT,93642,Electrophysiology evaluation,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
Molina Medicaid,CPT,93644,Electrophysiology evaluation,Cardiology,Per Unit,"$2,978.06 ",OP,"2,978.06","2,978.06",,,,,,
Molina Medicaid,CPT,93650,Ablate heart dysrhythm focus,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
Molina Medicaid,CPT,93653,Ep & ablate supravent arrhyt,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
Molina Medicaid,CPT,93654,Ep & ablate ventric tachy,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
Molina Medicaid,CPT,93655,Ablate arrhythmia add on,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
Molina Medicaid,CPT,93656,Tx atrial fib pulm vein isol,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
Molina Medicaid,CPT,93657,Tx l/r atrial fib addl,Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
Molina Medicaid,CPT,93660,Tilt table evaluation,Cardiology,Per Unit,$174.07 ,OP,174.07,174.07,,,,,,
Molina Medicaid,CPT,93662,Intracardiac ecg (ice),Cardiology,Per Unit,"$6,831.73 ",OP,"6,831.73","6,831.73",,,,,,
Molina Medicaid,CPT,93668,Peripheral vascular rehab,Cardiology,Per Unit,$174.07 ,OP,174.07,174.07,,,,,,
Molina Medicaid,CPT,93701,Bioimpedance cv analysis,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,93702,Bis xtracell fluid analysis,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,93724,Analyze pacemaker system,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Molina Medicaid,CPT,93745,Set-up cardiovert-defibrill,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,93750,Interrogation vad in person,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,93770,Measure venous pressure,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,93784,Ambl bp mntr w/software,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,93786,Ambl bp mntr w/sw rec only,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,93788,Ambl bp mntr w/sw a/r,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,93790,Ambl bp mntr w/sw i&r,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,93792,Pt/caregiver traing home inr,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Molina Medicaid,CPT,93793,Anticoag mgmt pt warfarin,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,93797,Cardiac rehab,Rehabilitation,Per Unit,$274.82 ,OP,274.82,274.82,,,,,,
Molina Medicaid,CPT,93798,Cardiac rehab/monitor,Rehabilitation,Per Unit,$274.82 ,OP,274.82,274.82,,,,,,
Molina Medicaid,CPT,93799,Cardiovascular procedure,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Molina Medicaid,CPT,93880,Extracranial bilat study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,93882,Extracranial uni/ltd study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,93886,Intracranial complete study,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Molina Medicaid,CPT,93888,Intracranial limited study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,93890,Tcd vasoreactivity study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,93892,Tcd emboli detect w/o inj,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Molina Medicaid,CPT,93893,Tcd emboli detect w/inj,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,93895,Carotid intima atheroma eval,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,93922,Upr/l xtremity art 2 levels,Cardiology,Per Unit,$174.07 ,OP,174.07,174.07,,,,,,
Molina Medicaid,CPT,93923,Upr/lxtr art stdy 3+ lvls,Cardiology,Per Unit,$174.07 ,OP,174.07,174.07,,,,,,
Molina Medicaid,CPT,93924,Lwr xtr vasc stdy bilat,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,93925,Lower extremity study,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Molina Medicaid,CPT,93926,Lower extremity study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,93930,Upper extremity study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,93931,Upper extremity study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,93965,Extremity study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,93970,Extremity study,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Molina Medicaid,CPT,93971,Extremity study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,93975,Vascular study,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Molina Medicaid,CPT,93976,Vascular study,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Molina Medicaid,CPT,93978,Vascular study,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Molina Medicaid,CPT,93979,Vascular study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,93980,Penile vascular study,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Molina Medicaid,CPT,93981,Penile vascular study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,93982,Aneurysm pressure sens study,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,93985,Dup-scan hemo compl bi std,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,93986,Dup-scan hemo compl uni std,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,93990,Doppler flow testing,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,93998,Noninvas vasc dx study proc,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,94002,Vent mgmt inpat init day,Pulmonary,Per Unit,$417.61 ,OP,417.61,417.61,,,,,,
Molina Medicaid,CPT,94003,Vent mgmt inpat subq day,Pulmonary,Per Unit,$417.61 ,OP,417.61,417.61,,,,,,
Molina Medicaid,CPT,94004,Vent mgmt nf per day,Pulmonary,Per Unit,$417.61 ,OP,417.61,417.61,,,,,,
Molina Medicaid,CPT,94005,Home vent mgmt supervision,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,94010,Breathing capacity test,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Molina Medicaid,CPT,94011,Spirometry up to 2 yrs old,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Molina Medicaid,CPT,94012,Spirmtry w/brnchdil inf-2 yr,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Molina Medicaid,CPT,94013,Meas lung vol thru 2 yrs,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Molina Medicaid,CPT,94014,Patient recorded spirometry,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Molina Medicaid,CPT,94015,Patient recorded spirometry,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Molina Medicaid,CPT,94016,Review patient spirometry,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Molina Medicaid,CPT,94060,Evaluation of wheezing,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Molina Medicaid,CPT,94070,Evaluation of wheezing,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Molina Medicaid,CPT,94150,Vital capacity test,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Molina Medicaid,CPT,94200,Lung function test (mbc/mvv),Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Molina Medicaid,CPT,94250,Expired gas collection,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Molina Medicaid,CPT,94375,Respiratory flow volume loop,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Molina Medicaid,CPT,94400,Co2 breathing response curve,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Molina Medicaid,CPT,94450,Hypoxia response curve,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Molina Medicaid,CPT,94452,Hast w/report,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Molina Medicaid,CPT,94453,Hast w/oxygen titrate,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Molina Medicaid,CPT,94610,Surfactant admin thru tube,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
Molina Medicaid,CPT,94617,Exercise tst brncspsm w/ecg,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Molina Medicaid,CPT,94618,Pulmonary stress testing,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Molina Medicaid,CPT,94619,Exercise tst brncspsm wo ecg,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Molina Medicaid,CPT,94620,Pulmonary stress test/simple,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Molina Medicaid,CPT,94621,Cardiopulm exercise testing,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Molina Medicaid,CPT,94640,Airway inhalation treatment,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
Molina Medicaid,CPT,94642,Aerosol inhalation treatment,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
Molina Medicaid,CPT,94644,Cbt 1st hour,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
Molina Medicaid,CPT,94645,Cbt each addl hour,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
Molina Medicaid,CPT,94660,Pos airway pressure cpap,Pulmonary,Per Unit,$417.61 ,OP,417.61,417.61,,,,,,
Molina Medicaid,CPT,94662,Neg press ventilation cnp,Pulmonary,Per Unit,$417.61 ,OP,417.61,417.61,,,,,,
Molina Medicaid,CPT,94664,Evaluate pt use of inhaler,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
Molina Medicaid,CPT,94667,Chest wall manipulation,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
Molina Medicaid,CPT,94668,Chest wall manipulation,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
Molina Medicaid,CPT,94669,Mechanical chest wall oscill,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
Molina Medicaid,CPT,94680,Exhaled air analysis o2,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Molina Medicaid,CPT,94681,Exhaled air analysis o2/co2,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Molina Medicaid,CPT,94690,Exhaled air analysis,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Molina Medicaid,CPT,94726,Pulm funct tst plethysmograp,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Molina Medicaid,CPT,94727,Pulm function test by gas,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Molina Medicaid,CPT,94728,Airwy resist by oscillometry,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Molina Medicaid,CPT,94729,Co/membane diffuse capacity,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Molina Medicaid,CPT,94750,Pulmonary compliance study,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Molina Medicaid,CPT,94762,Measure blood oxygen level,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Molina Medicaid,CPT,94770,Exhaled carbon dioxide test,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Molina Medicaid,CPT,94772,Breath recording infant,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Molina Medicaid,CPT,94774,Ped home apnea rec compl,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Molina Medicaid,CPT,94775,Ped home apnea rec hk-up,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Molina Medicaid,CPT,94776,Ped home apnea rec downld,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Molina Medicaid,CPT,94777,Ped home apnea rec report,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Molina Medicaid,CPT,94780,Cars/bd tst inft-12mo 60 min,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Molina Medicaid,CPT,94781,Cars/bd tst inft-12mo +30min,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Molina Medicaid,CPT,94799,Pulmonary service/procedure,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Molina Medicaid,CPT,95004,Percut allergy skin tests,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
Molina Medicaid,CPT,95012,Exhaled nitric oxide meas,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Molina Medicaid,CPT,95017,Perq & icut allg test venoms,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
Molina Medicaid,CPT,95018,Perq&ic allg test drugs/biol,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
Molina Medicaid,CPT,95024,Icut allergy test drug/bug,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
Molina Medicaid,CPT,95027,Icut allergy titrate-airborn,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
Molina Medicaid,CPT,95028,Icut allergy test-delayed,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
Molina Medicaid,CPT,95044,Allergy patch tests,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
Molina Medicaid,CPT,95052,Photo patch test,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
Molina Medicaid,CPT,95056,Photosensitivity tests,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
Molina Medicaid,CPT,95060,Eye allergy tests,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
Molina Medicaid,CPT,95065,Nose allergy test,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
Molina Medicaid,CPT,95070,Bronchial allergy tests,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
Molina Medicaid,CPT,95071,Bronchial allergy tests,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
Molina Medicaid,CPT,95076,Ingest challenge ini 120 min,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Molina Medicaid,CPT,95079,Ingest challenge addl 60 min,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Molina Medicaid,CPT,95115,Immunotherapy one injection,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Molina Medicaid,CPT,95117,Immunotherapy injections,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Molina Medicaid,CPT,95120,Immunotherapy one injection,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Molina Medicaid,CPT,95125,Immunotherapy 2/> injections,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Molina Medicaid,CPT,95130,Immntx 1 sting insect,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Molina Medicaid,CPT,95131,Immntx 2 sting insects,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Molina Medicaid,CPT,95132,Immntx 3 sting insects,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Molina Medicaid,CPT,95133,Immntx 4 sting insects,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Molina Medicaid,CPT,95134,Immntx 5 sting insects,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Molina Medicaid,CPT,95144,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Molina Medicaid,CPT,95145,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Molina Medicaid,CPT,95146,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Molina Medicaid,CPT,95147,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Molina Medicaid,CPT,95148,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Molina Medicaid,CPT,95149,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Molina Medicaid,CPT,95165,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Molina Medicaid,CPT,95170,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,14.01,14.01,,,,,,
Molina Medicaid,CPT,95180,Rapid desensitization,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
Molina Medicaid,CPT,95199,Allergy immunology services,Ancillary Services,Per Unit,$22.49 ,OP,22.49,22.49,,,,,,
Molina Medicaid,CPT,95249,Cont gluc mntr pt prov eqp,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,95250,Cont gluc mntr phys/qhp eqp,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,95251,Cont gluc mntr analysis i&r,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,95700,Eeg cont rec w/vid eeg tech,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Molina Medicaid,CPT,95705,Eeg w/o vid 2-12 hr unmntr,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Molina Medicaid,CPT,95706,Eeg wo vid 2-12hr intmt mntr,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Molina Medicaid,CPT,95707,Eeg w/o vid 2-12hr cont mntr,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Molina Medicaid,CPT,95708,Eeg wo vid ea 12-26hr unmntr,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Molina Medicaid,CPT,95709,Eeg w/o vid ea 12-26hr intmt,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Molina Medicaid,CPT,95710,Eeg w/o vid ea 12-26hr cont,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Molina Medicaid,CPT,95711,Veeg 2-12 hr unmonitored,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Molina Medicaid,CPT,95712,Veeg 2-12 hr intmt mntr,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Molina Medicaid,CPT,95713,Veeg 2-12 hr cont mntr,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Molina Medicaid,CPT,95714,Veeg ea 12-26 hr unmntr,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Molina Medicaid,CPT,95715,Veeg ea 12-26hr intmt mntr,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Molina Medicaid,CPT,95716,Veeg ea 12-26hr cont mntr,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Molina Medicaid,CPT,95717,Eeg phys/qhp 2-12 hr w/o vid,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Molina Medicaid,CPT,95718,Eeg phys/qhp 2-12 hr w/veeg,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Molina Medicaid,CPT,95719,Eeg phys/qhp ea incr w/o vid,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Molina Medicaid,CPT,95720,Eeg phy/qhp ea incr w/veeg,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Molina Medicaid,CPT,95721,Eeg phy/qhp>36<60 hr w/o vid,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Molina Medicaid,CPT,95722,Eeg phy/qhp>36<60 hr w/veeg,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Molina Medicaid,CPT,95723,Eeg phy/qhp>60<84 hr w/o vid,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Molina Medicaid,CPT,95724,Eeg phy/qhp>60<84 hr w/veeg,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Molina Medicaid,CPT,95725,Eeg phy/qhp>84 hr w/o vid,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Molina Medicaid,CPT,95726,Eeg phy/qhp>84 hr w/veeg,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Molina Medicaid,CPT,95782,Polysom <6 yrs 4/> paramtrs,Pulmonary,Per Unit,$437.56 ,OP,437.56,437.56,,,,,,
Molina Medicaid,CPT,95783,Polysom <6 yrs cpap/bilvl,Pulmonary,Per Unit,$437.56 ,OP,437.56,437.56,,,,,,
Molina Medicaid,CPT,95803,Actigraphy testing,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,95805,Multiple sleep latency test,Pulmonary,Per Unit,$437.56 ,OP,437.56,437.56,,,,,,
Molina Medicaid,CPT,95807,Sleep study attended,Pulmonary,Per Unit,$437.56 ,OP,437.56,437.56,,,,,,
Molina Medicaid,CPT,95808,Polysom any age 1-3> param,Pulmonary,Per Unit,$437.56 ,OP,437.56,437.56,,,,,,
Molina Medicaid,CPT,95810,Polysom 6/> yrs 4/> param,Pulmonary,Per Unit,$437.56 ,OP,437.56,437.56,,,,,,
Molina Medicaid,CPT,95811,Polysom 6/>yrs cpap 4/> parm,Pulmonary,Per Unit,$437.56 ,OP,437.56,437.56,,,,,,
Molina Medicaid,CPT,95812,Eeg 41-60 minutes,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Molina Medicaid,CPT,95813,Eeg extnd mntr 61-119 min,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Molina Medicaid,CPT,95816,Eeg awake and drowsy,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Molina Medicaid,CPT,95819,Eeg awake and asleep,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Molina Medicaid,CPT,95822,Eeg coma or sleep only,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Molina Medicaid,CPT,95824,Eeg cerebral death only,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Molina Medicaid,CPT,95827,Eeg all night recording,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Molina Medicaid,CPT,95829,Surgery electrocorticogram,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Molina Medicaid,CPT,95836,Ecog impltd brn npgt <30 d,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Molina Medicaid,CPT,95857,Cholinesterase challenge,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,95860,Muscle test one limb,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,95861,Muscle test 2 limbs,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,95863,Muscle test 3 limbs,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,95864,Muscle test 4 limbs,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,95865,Muscle test larynx,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,95866,Muscle test hemidiaphragm,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,95867,Muscle test cran nerv unilat,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,95868,Muscle test cran nerve bilat,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,95869,Muscle test thor paraspinal,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,95870,Muscle test nonparaspinal,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,95872,Muscle test one fiber,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,95873,Guide nerv destr elec stim,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Molina Medicaid,CPT,95874,Guide nerv destr needle emg,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Molina Medicaid,CPT,95875,Limb exercise test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,95885,Musc tst done w/nerv tst lim,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,95886,Musc test done w/n test comp,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,95887,Musc tst done w/n tst nonext,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,95905,Motor &/ sens nrve cndj test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,95907,Nvr cndj tst 1-2 studies,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,95908,Nrv cndj tst 3-4 studies,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,95909,Nrv cndj tst 5-6 studies,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,95910,Nrv cndj test 7-8 studies,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,95911,Nrv cndj test 9-10 studies,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,95912,Nrv cndj test 11-12 studies,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,95913,Nrv cndj test 13/> studies,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,95921,Autonomic nrv parasym inervj,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,95922,Autonomic nrv adrenrg inervj,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,95923,Autonomic nrv syst funj test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,95924,Ans parasymp & symp w/tilt,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,95925,Somatosensory testing,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,95926,Somatosensory testing,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,95927,Somatosensory testing,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,95928,C motor evoked uppr limbs,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,95929,C motor evoked lwr limbs,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,95930,Visual ep test cns w/i&r,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,95933,Blink reflex test,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,95937,Neuromuscular junction test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,95938,Somatosensory testing,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,95939,C motor evoked upr&lwr limbs,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,95943,Parasymp&symp hrt rate test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,95950,Ambulatory eeg monitoring,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Molina Medicaid,CPT,95951,Eeg monitoring/videorecord,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Molina Medicaid,CPT,95953,Eeg monitoring/computer,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Molina Medicaid,CPT,95954,Eeg monitoring/giving drugs,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Molina Medicaid,CPT,95955,Eeg during surgery,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Molina Medicaid,CPT,95956,Eeg monitor technol attended,Neurology,Per Unit,$261.51 ,OP,261.51,261.51,,,,,,
Molina Medicaid,CPT,95957,Eeg digital analysis,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,95958,Eeg monitoring/function test,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Molina Medicaid,CPT,95965,Meg spontaneous,Diagnostic Radiology,Per Unit,$221.34 ,OP,221.34,221.34,,,,,,
Molina Medicaid,CPT,95966,Meg evoked single,Diagnostic Radiology,Per Unit,$221.34 ,OP,221.34,221.34,,,,,,
Molina Medicaid,CPT,95967,Meg evoked each addl,Diagnostic Radiology,Per Unit,$221.34 ,OP,221.34,221.34,,,,,,
Molina Medicaid,CPT,95970,Alys npgt w/o prgrmg,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Molina Medicaid,CPT,95971,Alys smpl sp/pn npgt w/prgrm,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Molina Medicaid,CPT,95972,Alys cplx sp/pn npgt w/prgrm,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Molina Medicaid,CPT,95973,Analyze neurostim complex,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Molina Medicaid,CPT,95974,Cranial neurostim complex,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Molina Medicaid,CPT,95975,Cranial neurostim complex,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Molina Medicaid,CPT,95976,Alys smpl cn npgt prgrmg,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Molina Medicaid,CPT,95977,Alys cplx cn npgt prgrmg,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Molina Medicaid,CPT,95978,Analyze neurostim brain/1h,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Molina Medicaid,CPT,95979,Analyz neurostim brain addon,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Molina Medicaid,CPT,95980,Io anal gast n-stim init,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Molina Medicaid,CPT,95981,Io anal gast n-stim subsq,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,95982,Io ga n-stim subsq w/reprog,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,95983,Alys brn npgt prgrmg 15 min,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Molina Medicaid,CPT,95984,Alys brn npgt prgrmg addl 15,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Molina Medicaid,CPT,95999,Neurological procedure,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Molina Medicaid,CPT,96000,Motion analysis video/3d,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,96001,Motion test w/ft press meas,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,96002,Dynamic surface emg,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,96003,Dynamic fine wire emg,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,96020,Functional brain mapping,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Molina Medicaid,CPT,96101,Psycho testing by psych/phys,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Molina Medicaid,CPT,96102,Psycho testing by technician,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Molina Medicaid,CPT,96103,Psycho testing admin by comp,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Molina Medicaid,CPT,96105,Assessment of aphasia,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Molina Medicaid,CPT,96110,Developmental screen w/score,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Molina Medicaid,CPT,96111,Developmental test extend,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Molina Medicaid,CPT,96112,Devel tst phys/qhp 1st hr,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Molina Medicaid,CPT,96113,Devel tst phys/qhp ea addl,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Molina Medicaid,CPT,96116,Nubhvl xm phys/qhp 1st hr,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Molina Medicaid,CPT,96118,Neuropsych tst by psych/phys,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Molina Medicaid,CPT,96119,Neuropsych testing by tec,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Molina Medicaid,CPT,96120,Neuropsych tst admin w/comp,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Molina Medicaid,CPT,96121,Nubhvl xm phy/qhp ea addl hr,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Molina Medicaid,CPT,96125,Cognitive test by hc pro,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Molina Medicaid,CPT,96127,Brief emotional/behav assmt,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Molina Medicaid,CPT,96130,Psycl tst eval phys/qhp 1st,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Molina Medicaid,CPT,96131,Psycl tst eval phys/qhp ea,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Molina Medicaid,CPT,96132,Nrpsyc tst eval phys/qhp 1st,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Molina Medicaid,CPT,96133,Nrpsyc tst eval phys/qhp ea,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Molina Medicaid,CPT,96136,Psycl/nrpsyc tst phy/qhp 1st,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Molina Medicaid,CPT,96137,Psycl/nrpsyc tst phy/qhp ea,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Molina Medicaid,CPT,96138,Psycl/nrpsyc tech 1st,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Molina Medicaid,CPT,96139,Psycl/nrpsyc tst tech ea,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Molina Medicaid,CPT,96146,Psycl/nrpsyc tst auto result,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Molina Medicaid,CPT,96150,Assess hlth/behave init,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
Molina Medicaid,CPT,96151,Assess hlth/behave subseq,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
Molina Medicaid,CPT,96153,Intervene hlth/behave group,Behavioral Health,Per Unit,$119.88 ,OP,119.88,119.88,,,,,,
Molina Medicaid,CPT,96154,Interv hlth/behav fam w/pt,Behavioral Health,Per Unit,$89.14 ,OP,89.14,89.14,,,,,,
Molina Medicaid,CPT,96155,Interv hlth/behav fam no pt,Behavioral Health,Per Unit,$89.14 ,OP,89.14,89.14,,,,,,
Molina Medicaid,CPT,96156,Hlth bhv assmt/reassessment,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
Molina Medicaid,CPT,96160,Pt-focused hlth risk assmt,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Molina Medicaid,CPT,96161,Caregiver health risk assmt,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Molina Medicaid,CPT,96360,Hydration iv infusion init,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Molina Medicaid,CPT,96361,Hydrate iv infusion add-on,General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
Molina Medicaid,CPT,96365,Ther/proph/diag iv inf init,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Molina Medicaid,CPT,96366,Ther/proph/diag iv inf addon,General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
Molina Medicaid,CPT,96367,Tx/proph/dg addl seq iv inf,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Molina Medicaid,CPT,96368,Ther/diag concurrent inf,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Molina Medicaid,CPT,96369,Sc ther infusion up to 1 hr,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Molina Medicaid,CPT,96370,Sc ther infusion addl hr,General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
Molina Medicaid,CPT,96371,Sc ther infusion reset pump,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Molina Medicaid,CPT,96413,Chemo iv infusion 1 hr,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Molina Medicaid,CPT,96415,Chemo iv infusion addl hr,General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
Molina Medicaid,CPT,96416,Chemo prolong infuse w/pump,General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
Molina Medicaid,CPT,96417,Chemo iv infus each addl seq,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Molina Medicaid,CPT,96422,Chemo ia infusion up to 1 hr,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Molina Medicaid,CPT,96423,Chemo ia infuse each addl hr,General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
Molina Medicaid,CPT,96425,Chemotherapy infusion method,General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
Molina Medicaid,CPT,96446,Chemotx admn prtl cavity,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Molina Medicaid,CPT,96450,Chemotherapy into cns,General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
Molina Medicaid,CPT,96549,Chemotherapy unspecified,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Molina Medicaid,CPT,96567,Pdt dstr prmlg les skn,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,96570,Photodynmc tx 30 min add-on,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,96571,Photodynamic tx addl 15 min,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,96573,Pdt dstr prmlg les phys/qhp,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,96574,Dbrdmt prmlg les w/pdt,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,96900,Ultraviolet light therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,96902,Trichogram,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,96913,Photochemotherapy uv-a or b,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,96920,Laser tx skin < 250 sq cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,96921,Laser tx skin 250-500 sq cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,96922,Laser tx skin >500 sq cm,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,96931,Rcm celulr subcelulr img skn,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,96932,Rcm celulr subcelulr img skn,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,96933,Rcm celulr subcelulr img skn,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,96934,Rcm celulr subcelulr img skn,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,96935,Rcm celulr subcelulr img skn,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,96936,Rcm celulr subcelulr img skn,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,96999,Dermatological procedure,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,97001,Pt evaluation,Rehabilitation,Per Unit,$192.71 ,OP,192.71,192.71,,,,,,
Molina Medicaid,CPT,97002,Pt re-evaluation,Rehabilitation,Per Unit,$192.71 ,OP,192.71,192.71,,,,,,
Molina Medicaid,CPT,97003,Ot evaluation,Rehabilitation,Per Unit,$306.55 ,OP,306.55,306.55,,,,,,
Molina Medicaid,CPT,97004,Ot re-evaluation,Rehabilitation,Per Unit,$306.55 ,OP,306.55,306.55,,,,,,
Molina Medicaid,CPT,97010,Hot or cold packs therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,97012,Mechanical traction therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,97014,Electric stimulation therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,97016,Vasopneumatic device therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,97018,Paraffin bath therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,97022,Whirlpool therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,97024,Diathermy eg microwave,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,97026,Infrared therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,97028,Ultraviolet therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,97032,Electrical stimulation,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,97033,Electric current therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,97034,Contrast bath therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,97035,Ultrasound therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,97039,Physical therapy treatment,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,97116,Gait training therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,97124,Massage therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,97139,Physical medicine procedure,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,97161,Pt eval low complex 20 min,Rehabilitation,Per Unit,$192.71 ,OP,192.71,192.71,,,,,,
Molina Medicaid,CPT,97162,Pt eval mod complex 30 min,Rehabilitation,Per Unit,$192.71 ,OP,192.71,192.71,,,,,,
Molina Medicaid,CPT,97163,Pt eval high complex 45 min,Rehabilitation,Per Unit,$192.71 ,OP,192.71,192.71,,,,,,
Molina Medicaid,CPT,97164,Pt re-eval est plan care,Rehabilitation,Per Unit,$192.71 ,OP,192.71,192.71,,,,,,
Molina Medicaid,CPT,97165,Ot eval low complex 30 min,Rehabilitation,Per Unit,$306.55 ,OP,306.55,306.55,,,,,,
Molina Medicaid,CPT,97166,Ot eval mod complex 45 min,Rehabilitation,Per Unit,$306.55 ,OP,306.55,306.55,,,,,,
Molina Medicaid,CPT,97167,Ot eval high complex 60 min,Rehabilitation,Per Unit,$306.55 ,OP,306.55,306.55,,,,,,
Molina Medicaid,CPT,97168,Ot re-eval est plan care,Rehabilitation,Per Unit,$306.55 ,OP,306.55,306.55,,,,,,
Molina Medicaid,CPT,97535,Self care mngment training,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,97545,Work hardening,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,97546,Work hardening add-on,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,97755,Assistive technology assess,Rehabilitation,Per Unit,$192.71 ,OP,192.71,192.71,,,,,,
Molina Medicaid,CPT,97762,C/o for orthotic/prosth use,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,97799,Physical medicine procedure,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,97802,Medical nutrition indiv in,Ancillary Services,Per Unit,$100.15 ,OP,100.15,100.15,,,,,,
Molina Medicaid,CPT,97803,Med nutrition indiv subseq,Ancillary Services,Per Unit,$100.15 ,OP,100.15,100.15,,,,,,
Molina Medicaid,CPT,97804,Medical nutrition group,Ancillary Services,Per Unit,$100.15 ,OP,100.15,100.15,,,,,,
Molina Medicaid,CPT,97810,Acupunct w/o stimul 15 min,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,97811,Acupunct w/o stimul addl 15m,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,97813,Acupunct w/stimul 15 min,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,97814,Acupunct w/stimul addl 15m,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,98925,Osteopath manj 1-2 regions,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,98926,Osteopath manj 3-4 regions,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,98927,Osteopath manj 5-6 regions,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,98928,Osteopath manj 7-8 regions,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,98929,Osteopath manj 9-10 regions,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,98940,Chiropract manj 1-2 regions,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,98941,Chiropract manj 3-4 regions,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,98942,Chiropractic manj 5 regions,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,98943,Chiropract manj xtrspinl 1/>,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,98960,Self-mgmt educ & train 1 pt,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Molina Medicaid,CPT,98961,Self-mgmt educ/train 2-4 pt,Preventive Care,Per Unit,$26.23 ,OP,26.23,26.23,,,,,,
Molina Medicaid,CPT,98962,Self-mgmt educ/train 5-8 pt,Preventive Care,Per Unit,$26.23 ,OP,26.23,26.23,,,,,,
Molina Medicaid,CPT,99050,Medical services after hrs,Ancillary Services,Per Unit,$26.19 ,OP,26.19,26.19,,,,,,
Molina Medicaid,CPT,99051,Med serv eve/wkend/holiday,Ancillary Services,Per Unit,$26.19 ,OP,26.19,26.19,,,,,,
Molina Medicaid,CPT,99053,Med serv 10pm-8am 24 hr fac,Ancillary Services,Per Unit,$26.19 ,OP,26.19,26.19,,,,,,
Molina Medicaid,CPT,99058,Office emergency care,Ancillary Services,Per Unit,$26.19 ,OP,26.19,26.19,,,,,,
Molina Medicaid,CPT,99060,Out of office emerg med serv,Ancillary Services,Per Unit,$26.19 ,OP,26.19,26.19,,,,,,
Molina Medicaid,CPT,99078,Group health education,Preventive Care,Per Unit,$26.23 ,OP,26.23,26.23,,,,,,
Molina Medicaid,CPT,99091,Collj & interpj data ea 30 d,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,99100,Special anesthesia service,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,99116,Anesthesia with hypothermia,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,99135,Special anesthesia procedure,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,99140,Emergency anesthesia,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,99143,Mod sedat phys/qhp <5 yrs,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,99144,Mod sedat phys/qhp 5yrs/>,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,99145,Mod sedat phys/qhp ea 15 min,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,99148,Mod sed diff phys/qhp<5 yrs,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,99149,Mod sed diff phys/qhp 5/>yrs,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,99150,Mod sed diff phys/qhp add on,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,99151,Mod sed same phys/qhp <5 yrs,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,99152,Mod sed same phys/qhp 5/>yrs,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,99153,Mod sed same phys/qhp ea,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,99155,Mod sed oth phys/qhp <5 yrs,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,99156,Mod sed oth phys/qhp 5/>yrs,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,99157,Mod sed other phys/qhp ea,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,99172,Ocular function screen,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,99173,Visual acuity screen,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,99174,Ocular instrumnt screen bil,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,99175,Induction of vomiting,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Molina Medicaid,CPT,99177,Ocular instrumnt screen bil,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,99188,App topical fluoride varnish,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Molina Medicaid,CPT,99238,Hospital discharge day,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,99239,Hospital discharge day,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,99363,Anticoagulant mgmt initial,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,99364,Anticoagulant mgmt subseq,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,99366,Team conf w/pat by hc prof,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,99367,Team conf w/o pat by phys,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,99368,Team conf w/o pat by hc pro,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,99374,Home health care supervision,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,99375,Home health care supervision,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,99377,Hospice care supervision,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,99378,Hospice care supervision,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,99379,Nursing fac care supervision,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,99380,Nursing fac care supervision,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,99406,Behav chng smoking 3-10 min,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Molina Medicaid,CPT,99407,Behav chng smoking > 10 min,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Molina Medicaid,CPT,99408,Audit/dast 15-30 min,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Molina Medicaid,CPT,99409,Audit/dast over 30 min,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Molina Medicaid,CPT,99439,Chrnc care mgmt svc ea addl,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,99453,Rem mntr physiol param setup,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Molina Medicaid,CPT,99454,Rem mntr physiol param dev,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,99457,Rem physiol mntr 1st 20 min,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,99458,Rem physiol mntr ea addl 20,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,99465,Nb resuscitation,General Medicine,Per Unit,$385.17 ,OP,385.17,385.17,,,,,,
Molina Medicaid,CPT,99473,Self-meas bp pt educaj/train,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,99474,Self-meas bp 2 readg bid 30d,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,99483,Assmt & care pln pt cog imp,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Molina Medicaid,CPT,99484,Care mgmt svc bhvl hlth cond,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Molina Medicaid,CPT,99487,Cplx chrnc care 1st 60 min,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,99489,Cplx chrnc care ea addl 30,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,99490,Chrnc care mgmt svc 1st 20,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,99491,Chrnc care mgmt svc 30 min,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,99492,1st psyc collab care mgmt,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Molina Medicaid,CPT,99493,Sbsq psyc collab care mgmt,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Molina Medicaid,CPT,99494,1st/sbsq psyc collab care,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Molina Medicaid,CPT,99495,Trans care mgmt 14 day disch,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,99496,Trans care mgmt 7 day disch,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,99497,Advncd care plan 30 min,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,99498,Advncd care plan addl 30 min,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,99503,Home visit resp therapy,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
Molina Medicaid,CPT,99504,Home visit mech ventilator,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
Molina Medicaid,CPT,0001A,Adm sarscov2 30mcg/0.3ml 1st,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,0001M,Nfct ds chrnc hcv 6 assays,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,0001U,Rbc dna hea 35 ag 11 bld grp,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0002A,Adm sarscov2 30mcg/0.3ml 2nd,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,0002M,Liver dis 10 assays w/ash,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0002U,Onc clrct 3 ur metab alg plp,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0003A,Fee covid-19 vac 1 booster,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,0003M,Liver dis 10 assays w/nash,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0003U,Onc ovar 5 prtn ser alg scor,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0004A,Fee covid-19 vac 1 res,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,0004M,Scoliosis dna alys,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0004U,Nfct ds dna 27 resist genes,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0005U,Onco prst8 3 gene ur alg,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0006M,Onc hep gene risk classifier,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0006U,Detc ia meds 120+ analytes,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,0007M,Onc gastro 51 gene nomogram,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,0008M,Onc breast risk score,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0008U,Hpylori detcj abx rstnc dna,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Molina Medicaid,CPT,0009M,Fetal aneuploidy trisom risk,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0009U,Onc brst ca erbb2 amp/nonamp,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0010M,Onc prostate prob score,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0010U,Nfct ds strn typ whl gen seq,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0011A,Adm sarscov2 100mcg/0.5ml1st,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,0011M,Onc prst8 ca mrna 12 gen alg,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0011U,Rx mntr lc-ms/ms oral fluid,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,0012A,Adm sarscov2 100mcg/0.5ml2nd,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,0012M,Onc mrna 5 gen rsk urthl ca,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0012U,Germln do gene reargmt detcj,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0013A,Fee covid-19 vac 2 booster,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,0013M,Onc mrna 5 gen recr urthl ca,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0013U,Onc sld org neo gene reargmt,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0014A,Fee covid-19 vac 2 res,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,0014M,Liver ds alys 3 bmrk srm alg,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0014U,Hem hmtlmf neo gene reargmt,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0015M,Adrnl cortcl tum bchm asy 25,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0015U,Rx metab advrs rx rxn dna,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0016M,Onc bladder mrna 209 gen alg,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0016U,Onc hmtlmf neo rna bcr/abl1,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,0017M,Onc dlbcl mrna 20 genes alg,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0017U,Onc hmtlmf neo jak2 mut dna,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0018U,Onc thyr 10 microrna seq alg,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0019T,Extracorp shock wv tx ms nos,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,0019U,Onc rna tiss predict alg,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0020U,Rx test prsmv ur w/def conf,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,0021A,Fee covid-19 vac 3 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,0021U,Onc prst8 detcj 8 autoantb,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0022A,Fee covid-19 vac 3 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,0022U,Trgt gen seq dna&rna 23 gene,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0023A,Fee covid-19 vac 3 booster,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,0023U,Onc aml dna detcj/nondetcj,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,0024A,Fee covid-19 vac 3 res,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,0024U,Glyca nuc mr spectrsc quan,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,0025U,Tenofovir liq chrom ur quan,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,0026U,Onc thyr dna&mrna 112 genes,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0027U,Jak2 gene trgt seq alys,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0028U,Cyp2d6 gene cpy nmr cmn vrnt,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0029U,Rx metab advrs trgt seq alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0030U,Rx metab warf trgt seq alys,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0031A,Fee covid-19 vac 4 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,0031U,Cyp1a2 gene,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,0032A,Fee covid-19 vac 4 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,0032U,Comt gene,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,0033A,Fee covid-19 vac 4 booster,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,0033U,Htr2a htr2c genes,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0034A,Fee covid-19 vac 4 res,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,0034U,Tpmt nudt15 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0035U,Neuro csf prion prtn qual,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0036U,Xome tum & nml spec seq alys,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0037U,Trgt gen seq dna 324 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0038U,Vitamin d srm microsamp quan,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,0039U,Dna antb 2strand hi avidity,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,0040U,Bcr/abl1 gene major bp quan,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0041A,Fee covid-19 vac 5 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,0041U,B brgdrferi antb 5 prtn igm,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Molina Medicaid,CPT,0042A,Fee covid-19 vac 5 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,0042T,Ct perfusion w/contrast cbf,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Molina Medicaid,CPT,0042U,B brgdrferi antb 12 prtn igg,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Molina Medicaid,CPT,0043A,Fee covid-19 vac 5 booster,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,0043U,Tbrf b grp antb 4 prtn igm,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,0044A,Fee covid-19 vac 5 res,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,0044U,Tbrf b grp antb 4 prtn igg,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,0045U,Onc brst dux carc is 12 gene,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,0046U,Flt3 gene itd variants quan,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,0047U,Onc prst8 mrna 17 gene alg,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0048U,Onc sld org neo dna 468 gene,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0049U,Npm1 gene analysis quan,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,0050U,Trgt gen seq dna 194 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0051A,Fee covid-19 vac 6 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,0051U,Rx mntr lc-ms/ms ur 31 pnl,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,0052A,Fee covid-19 vac 6 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,0052U,Lpoprtn bld w/5 maj classes,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,0053A,Fee covid-19 vac 6 booster,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,0053U,Onc prst8 ca fish alys 4 gen,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0054A,Fee covid-19 vac 6 res,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,0054U,Rx mntr 14+ drugs & sbsts,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,0055U,Card hrt trnspl 96 dna seq,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0056U,Hem aml dna gene reargmt,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0057U,Onc sld org neo mrna 51 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0058T,Cryopreservation ovary tiss,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,0058U,Onc merkel cll carc srm quan,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Molina Medicaid,CPT,0059U,Onc merkel cll carc srm +/-,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Molina Medicaid,CPT,0060U,Twn zyg gen seq alys chrms2,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0061A,Fee covid-19 vac 7 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,0061U,Tc meas 5 bmrk sfdi m-s alys,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
Molina Medicaid,CPT,0062A,Fee covid-19 vac 7 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,0062U,Ai sle igg&igm alys 80 bmrk,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,0063A,Fee covid-19 vac 7 booster,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,0063U,Neuro autism 32 amines alg,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0064A,Fee covid-19 vac 7 res,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,0064U,Antb tp total&rpr ia qual,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,0065U,Syfls tst nontreponemal antb,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,0066U,Pamg-1 ia cervico-vag fluid,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,0067U,Onc brst imhchem prfl 4 bmrk,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,0069U,Onc clrct microrna mir-31-3p,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,0070U,Cyp2d6 gen com&slct rar vrnt,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0071A,Fee covid-19 vac 8 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,0071U,Cyp2d6 full gene sequence,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,0072A,Fee covid-19 vac 8 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,0072U,Cyp2d6 gen cyp2d6-2d7 hybrid,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0073A,Fee covid-19 vac 8 booster,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,0073U,Cyp2d6 gen cyp2d7-2d6 hybrid,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0074A,Fee covid-19 vac 8 res,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,0074U,Cyp2d6 nonduplicated gene,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0075T,Perq stent/chest vert art,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,0075U,Cyp2d6 5' gene dup/mlt,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0076T,S&i stent/chest vert art,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,0076U,Cyp2d6 3' gene dup/mlt,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0077U,Ig paraprotein qual bld/ur,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Molina Medicaid,CPT,0078U,Pain mgt opi use gnotyp pnl,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,0079U,Cmprtv dna alys mlt snps,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0080U,Onc lng 5 clin rsk factr alg,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0081A,Fee covid-19 vac 9 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,0081U,Onc uveal mlnma mrna 15 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0082A,Fee covid-19 vac 9 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,0083A,Fee covid-19 vac 9 booster,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,0083U,Onc rspse chemo cntrst tomog,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,0084A,Fee covid-19 vac 9 res,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,0084U,Rbc dna gnotyp 10 bld groups,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0085T,Breath test heart reject,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,0085U,Cdtb&vinculin igg antb ia,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Molina Medicaid,CPT,0086U,Nfct ds bact&fng org id 6+,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,0087U,Crd hrt trnspl mrna 1283 gen,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0088U,Trnsplj kdn algrft rej 1494,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0089U,Onc mlnma prame & linc00518,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0090U,Onc cutan mlnma mrna 23 gene,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0091A,Fee covid-19 vac 10 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,0091U,Onc clrct scr whl bld alg,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Molina Medicaid,CPT,0092A,Fee covid-19 vac 10 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,0092U,Onc lng 3 prtn bmrk plsm alg,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0093A,Fee covid-19 vac 10 booster,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,0093U,Rx mntr 65 com drugs urine,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,0094A,Fee covid-19 vac 10 res,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,0094U,Genome rapid sequence alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0095U,Inflm ee elisa alys alg,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0096U,Hpv hi risk types male urine,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,0099T,Implant corneal ring,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Molina Medicaid,CPT,0100T,Prosth retina receive&gen,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Molina Medicaid,CPT,0101A,Fee covid-19 vac 11 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,0101T,Extracorp shockwv tx hi enrg,Orthopedic Surgery,Per Unit,$323.78 ,OP,323.78,323.78,,,,,,
Molina Medicaid,CPT,0101U,Hered colon ca do 15 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0102A,Fee covid-19 vac 11 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,0102U,Hered brst ca rltd do 17 gen,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0103A,Fee covid-19 vac 11 booster,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,0103T,Holotranscobalamin,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,0103U,Hered ova ca pnl 24 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0104A,Fee covid-19 vac 11 res,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,0104U,Hered pan ca pnl 32 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0105U,Neph ckd mult eclia tum nec,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0106T,Touch quant sensory test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,0107T,Vibrate quant sensory test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,0107U,C diff tox ag detcj ia stool,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,0108T,Cool quant sensory test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,0108U,Gi barrett esoph 9 prtn bmrk,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0109T,Heat quant sensory test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,0109U,Id aspergillus dna 4 species,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,0110T,Nos quant sensory test,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,0110U,Rx mntr 1+oral onc rx&sbsts,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,0111T,Rbc membranes fatty acids,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Molina Medicaid,CPT,0111U,Onc colon ca kras&nras alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0112U,Iadi 16s&18s rrna genes,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,0113U,Onc prst8 pca3&tmprss2-erg,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0114U,Gi barretts esoph vim&ccna1,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0115U,Respir iadna 18 viral&2 bact,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,0116U,Rx mntr nzm ia 35+oral flu,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,0117U,Pain mgmt 11 endogenous anal,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0118U,Trnsplj don-drv cll-fr dna,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0119U,Crd ceramides liq chrom plsm,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,0120U,Onc b cll lymphm mrna 58 gen,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0121U,Sc dis vcam-1 whole blood,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
Molina Medicaid,CPT,0122U,Sc dis p-selectin whl blood,Laboratory,Per Unit,$6.07 ,OP,6.07,6.07,,,,,,
Molina Medicaid,CPT,0123T,Scleral fistulization,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Molina Medicaid,CPT,0123U,Mchnl fragility rbc prflg,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Molina Medicaid,CPT,0124U,Ftl cgen abnor 3 analytes,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0125U,Ftl cgen abnor prnt comp 5,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0126T,Chd risk imt study,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,0126U,Ftl cgen abnor prnt comp 5 y,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0127U,Ob pe 3 analytes,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0128U,Ob pe 3 analytes y chrmsm,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0129U,Hered brst ca rltd do panel,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0130U,Hered colon ca do mrna pnl,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0131U,Hered brst ca rltd do pnl 13,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0132U,Hered ova ca rltd do pnl 17,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0133U,Hered prst8 ca rltd do 11,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0134U,Hered pan ca mrna pnl 18 gen,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0135U,Hered gyn ca mrna pnl 12 gen,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0136U,Atm mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0137U,Palb2 mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0138U,Brca1 brca2 mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0139U,Neuro austm meas 6 c metablt,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0140U,Nfct ds fungi dna 15 trgt,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,0141U,Nfct ds bact&fng gram pos,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,0142U,Nfct ds bact&fng gram neg,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,0145U,Drug assay 65+ rx/metablt,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,0146U,Drug assay 80+ rx/metablt,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,0147U,Drug assay 85+ rx/metablt,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,0148U,Drug assay 100+ rx/metablt,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,0149U,Drug assay 60+ rx/metablt,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,0151U,Nfct bct/vir resp nfctj 33,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,0152U,Nfct ds dna untrgt ngnrj seq,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,0153U,Onc breast mrna 101 genes,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0154U,Onc urthl ca rna fgfr3 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0155U,Onc brst ca dna pik3ca gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0156U,Copy number sequence alys,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0157U,Apc mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0158U,Mlh1 mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0159U,Msh2 mrna seq alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,0160U,Msh6 mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0161U,Pms2 mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0162U,Hered colon ca trgt mrna pnl,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0163U,Onc clrct scr 3 prtn alg,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0164U,Gi ibs ia anti-cdtb&vinculin,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,0165U,Peanut allg asmt epi,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Molina Medicaid,CPT,0166U,Liver ds 10 biochem asy srm,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0167U,Chornc gonadotropin hcg ia,Laboratory,Per Unit,$15.04 ,OP,15.04,15.04,,,,,,
Molina Medicaid,CPT,0168U,Ftl aneuploidy dna seq alys,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0169U,Nudt15&tpmt gene com vrnt,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,0170U,Neuro asd rna next gen seq,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0171U,Trgt gen seq alys pnl dna 23,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0172T,Lumbar spine process addl,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"7,098.75","7,098.75",,,,,,
Molina Medicaid,CPT,0172U,Onc sld tum alys brca1 brca2,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0173U,Psyc gen alys panel 14 genes,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0174U,Onc solid tumor 30 prtn trgt,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0175U,Psyc gen alys panel 15 genes,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0176U,Cdtb&vinculin igg antb ia,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0177U,Onc brst ca dna pik3ca 11,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0178T,64 lead ecg w/i&r,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Molina Medicaid,CPT,0178U,Peanut allg asmt epi clin rx,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Molina Medicaid,CPT,0179T,64 lead ecg w/tracing,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Molina Medicaid,CPT,0179U,Onc nonsm cll lng ca alys 23,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0180U,Abo gnotyp abo 7 exons,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0181U,Co gnotyp aqp1 exon 1,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0182T,Hdr elect brachytherapy,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Molina Medicaid,CPT,0182U,Crom gnotyp cd55 exons 1-10,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0183U,Di gnotyp slc4a1 exon 19,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0184T,Exc rectal tumor endoscopic,General Surgery,Per Unit,"$1,129.81 ",OP,"1,129.81","1,129.81",,,,,,
Molina Medicaid,CPT,0184U,Do gnotyp art4 exon 2,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0185U,Fut1 gnotyp fut1 exon 4,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0186U,Fut2 gnotyp fut2 exon 2,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0187U,Fy gnotyp ackr1 exons 1-2,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0188U,Ge gnotyp gypc exons 1-4,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0189U,Gypa gnotyp ntrns 1 5 exon 2,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0190U,Gypb gnotyp ntrns 1 5 seux 3,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0191T,Insert ant segment drain int,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Molina Medicaid,CPT,0191U,In gnotyp cd44 exons 2 3 6,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0192U,Jk gnotyp slc14a1 exon 9,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0193U,Jr gnotyp abcg2 exons 2-26,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0194U,Kel gnotyp kel exon 8,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0195U,Klf1 targeted sequencing,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0196U,Lu gnotyp bcam exon 3,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0197U,Lw gnotyp icam4 exon 1,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0198T,Ocular blood flow measure,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,0198U,Rhd&rhce gntyp rhd1-10&rhce5,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0199U,Sc gnotyp ermap exons 4 12,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0200U,Xk gnotyp xk exons 1-3,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0201U,Yt gnotyp ache exon 2,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0203U,Ai ibd mrna xprsn prfl 17,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0204U,Onc thyr mrna xprsn alys 593,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0205T,Inirs each vessel add-on,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,0205U,Oph amd alys 3 gene variants,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0206T,Cptr dbs alys car elec dta,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,0206U,Neuro alzheimer cell aggregj,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0207T,Clear eyelid gland w/heat,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,0207U,Neuro alzheimer quan imaging,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,0208U,Onc mtc mrna xprsn alys 108,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0209U,Cytog const alys interrog,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0210U,Syphilis tst antb ia quan,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,0211U,Onc pan-tum dna&rna gnrj seq,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0212T,Compre audiometry evaluation,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Molina Medicaid,CPT,0212U,Rare ds gen dna alys proband,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0213U,Rare ds gen dna alys ea comp,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0214U,Rare ds xom dna alys proband,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0215T,Njx paravert w/us cer/thor,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Molina Medicaid,CPT,0215U,Rare ds xom dna alys ea comp,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0216U,Neuro inh ataxia dna 12 com,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0217U,Neuro inh ataxia dna 51 gene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0218U,Neuro musc dys dmd seq alys,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0219U,Nfct agt hiv gnrj seq alys,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Molina Medicaid,CPT,0220U,Onc brst ca ai assmt 12 feat,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,0221U,Abo gnotyp next gnrj seq abo,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0222U,Rhd&rhce gntyp next gnrj seq,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0223T,Acoustic ecg w/i&r,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Molina Medicaid,CPT,0224T,Acoustic ecg 1+ analysis,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,0224U,Antibody sars-cov-2 titer(s),Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,0225T,Acoustic ecg analy & reprog,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,0226U,Svnt sarscov2 elisa plsm srm,Laboratory,Per Unit,$9.92 ,OP,9.92,9.92,,,,,,
Molina Medicaid,CPT,0227U,Rx asy prsmv30+rx/metablt,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,0228T,Njx tfrml eprl w/us cer/thor,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Molina Medicaid,CPT,0228U,Onc prst8 ma molec prfl alg,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0229T,Njx tfrml eprl w/us cer/thor,Neurology,Per Unit,$454.82 ,OP,454.82,454.82,,,,,,
Molina Medicaid,CPT,0229U,Bcat1 promoter mthyltn alys,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,0230U,Ar full sequence analysis,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0231U,Cacna1a full gene analysis,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0232T,Njx platelet plasma,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,0232U,Cstb full gene analysis,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0233T,Skin glycation spectroscopy,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,0233U,Fxn gene analysis,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,0234U,Mecp2 full gene analysis,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0235T,Trluml perip athrc visceral,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,0235U,Pten full gene analysis,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0236T,Trluml perip athrc abd aorta,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,0236U,Smn1&smn2 full gene analysis,Laboratory,Per Unit,$74.24 ,OP,74.24,74.24,,,,,,
Molina Medicaid,CPT,0237T,Trluml perip athrc brchiocph,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,0237U,Car ion chnlpthy gen seq pnl,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0238T,Trluml perip athrc iliac art,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,0238U,Onc lnch syn gen dna seq aly,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0239U,Trgt gen seq alys pnl 311+,Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,0240T,Esoph motility 3d topography,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Molina Medicaid,CPT,0241T,Esoph motility w/stim/perf,Gastroenterology,Per Unit,$343.37 ,OP,343.37,343.37,,,,,,
Molina Medicaid,CPT,0243T,Intm msr bronchodil wheeze,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Molina Medicaid,CPT,0244T,Cont msr bronchodil wheeze,Pulmonary,Per Unit,$130.30 ,OP,130.3,130.3,,,,,,
Molina Medicaid,CPT,0249T,Ligation hemorrhoid w/us,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Molina Medicaid,CPT,0253T,Insert aqueous drain device,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Molina Medicaid,CPT,0255T,Evasc rpr iliac art bifr s&i,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"1,375.47","1,375.47",,,,,,
Molina Medicaid,CPT,0263T,Im b1 mrw cel ther cmpl,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Molina Medicaid,CPT,0264T,Im b1 mrw cel ther xcl hrvst,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Molina Medicaid,CPT,0265T,Im b1 mrw cel ther hrvst onl,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Molina Medicaid,CPT,0266T,Implt/rpl crtd sns dev total,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Molina Medicaid,CPT,0267T,Implt/rpl crtd sns dev lead,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,0268T,Implt/rpl crtd sns dev gen,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Molina Medicaid,CPT,0269T,Rev/remvl crtd sns dev total,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,0270T,Rev/remvl crtd sns dev lead,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,0271T,Rev/remvl crtd sns dev gen,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,0272T,Interrogate crtd sns dev,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,0273T,Interrogate crtd sns w/pgrmg,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,0278T,Tempr,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,0282T,Periph field stimul trial,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,0283T,Periph field stimul perm,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Molina Medicaid,CPT,0284T,Periph field stimul revise,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,0285T,Periph field stimul analys,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,0286T,Near ifr spectrsc of wounds,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,0288T,Anoscopy w/rf delivery,General Surgery,Per Unit,$798.86 ,OP,798.86,798.86,,,,,,
Molina Medicaid,CPT,0289T,Laser inc for pkp/lkp donor,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Molina Medicaid,CPT,0290T,Laser inc for pkp/lkp recip,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Molina Medicaid,CPT,0294T,Ins lt atrl mont pres lead,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Molina Medicaid,CPT,0295T,Ext ecg complete,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,0296T,Ext ecg recording,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,0297T,Ext ecg scan w/report,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,0298T,Ext ecg review and interp,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,0301T,Mw therapy for breast tumor,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Molina Medicaid,CPT,0302T,Icar ischm mntrng sys compl,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Molina Medicaid,CPT,0303T,Icar ischm mntrng sys eltrd,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Molina Medicaid,CPT,0304T,Icar ischm mntrng sys device,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Molina Medicaid,CPT,0305T,Icar ischm mntrng prgrm eval,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,0306T,Icar ischm mntr interr eval,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,0307T,Rmvl icar ischm mntrng dvce,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
Molina Medicaid,CPT,0308T,Insj ocular telescope prosth,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Molina Medicaid,CPT,0310T,Motor function mapping ntms,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,0311T,Cal & alys cntrl artl press,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,0312T,Laps impltj nstim vagus,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Molina Medicaid,CPT,0313T,Laps rmvl nstim array vagus,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,0314T,Laps rmvl vgl arry&pls gen,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,0315T,Rmvl vagus nerve pls gen,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,0316T,Replc vagus nerve pls gen,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Molina Medicaid,CPT,0317T,Elec alys vagus nrv pls gen,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,0329T,Mntr io press 24hrs/> uni/bi,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Molina Medicaid,CPT,0330T,Tear film img uni/bi w/i&r,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Molina Medicaid,CPT,0331T,Heart symp image plnr,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Molina Medicaid,CPT,0332T,Heart symp image plnr spect,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,525.42,525.42,,,,,,
Molina Medicaid,CPT,0333T,Visual ep scr acuity auto,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,0335T,Insj sinus tarsi implant,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,0337T,Endothel fxnassmnt non-invas,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,0341T,Quant pupillometry w/ rprt,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,0342T,Thxp apheresis w/hdl delip,Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Molina Medicaid,CPT,0346T,Ultrasound elastography,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,0348T,Rsa spine exam,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,0349T,Rsa upper extr exam,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,0350T,Rsa lower extr exam,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,0352T,Oct brst/node i&r per spec,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,0354T,Oct breast surg cavity i&r,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,0355T,Gi tract capsule endoscopy,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,0356T,Insrt drug device for iop,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Molina Medicaid,CPT,0357T,Cryopreservation oocyte(s),Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,0358T,Bia whole body,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,0362T,Bhv id suprt assmt ea 15 min,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
Molina Medicaid,CPT,0373T,Adapt bhv tx ea 15 min,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
Molina Medicaid,CPT,0376T,Insert ant segment drain int,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Molina Medicaid,CPT,0377T,Anoscpy inj agent for incont,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Molina Medicaid,CPT,0378T,Visual field assmnt rev/rprt,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,0379T,Vis field assmnt tech suppt,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,0380T,Comp animat ret imag series,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,0381T,Ext h rate epi sz 14 days,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,0382T,Ext h rate sz 14 day ri only,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,0383T,Ext h rate sz up to 30 days,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,0384T,Ex h rate sz 30 day ri only,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,0385T,Ex h rate for sz ovr 30 day,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,0386T,Ex h rate sz 30+ day ri only,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,0387T,Leadless c pm ins/rpl ventr,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Molina Medicaid,CPT,0388T,Leadless c pm remove ventr,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
Molina Medicaid,CPT,0389T,Prog eval inper leadls pm,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,0390T,Periproc eval inper ledls pm,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,0391T,Intergt eval inper leadls pm,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,0392T,Lap es sph augment dev place,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Molina Medicaid,CPT,0393T,Es sph augmnt device removal,General Surgery,Per Unit,"$2,104.05 ",OP,"2,104.05","2,104.05",,,,,,
Molina Medicaid,CPT,0394T,Hdr elctrnc skn surf brchytx,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Molina Medicaid,CPT,0395T,Hdr elctr ntrst/ntrcv brchtx,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Molina Medicaid,CPT,0398T,Mrgfus strtctc les abltj,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Molina Medicaid,CPT,0399T,Myocardial strain imaging,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Molina Medicaid,CPT,0400T,Mltispectrl digital les alys,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,0401T,Mltispectrl digital les alys,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,0402T,Colgn cross-link crn med sep,Ophthalmology Surgery,Per Unit,$345.84 ,OP,345.84,345.84,,,,,,
Molina Medicaid,CPT,0403T,Diabetes prev standard curr,Preventive Care,Per Unit,$26.23 ,OP,26.23,26.23,,,,,,
Molina Medicaid,CPT,0406T,Sin ndsc plmt drg elut mplnt,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Molina Medicaid,CPT,0407T,Sin ndsc plmt drg elut mplnt,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Molina Medicaid,CPT,0408T,Insj/rplc cardiac modulj sys,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Molina Medicaid,CPT,0409T,Insj/rplc car modulj pls gn,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Molina Medicaid,CPT,0412T,Rmvl cardiac modulj pls gen,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
Molina Medicaid,CPT,0414T,Rmvl & rpl car modulj pls gn,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Molina Medicaid,CPT,0417T,Prgrmg eval cardiac modulj,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,0418T,Interro eval cardiac modulj,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,0419T,Dstrj neurofibroma xtnsv,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,0420T,Dstrj neurofibroma xtnsv,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,0421T,Waterjet prostate abltj cmpl,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Molina Medicaid,CPT,0422T,Tactile breast img uni/bi,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
Molina Medicaid,CPT,0423T,Assay secretory type ii pla2,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,0424T,Insj/rplc nstim apnea compl,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Molina Medicaid,CPT,0425T,Insj/rplc nstim apnea sen ld,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,0426T,Insj/rplc nstim apnea stm ld,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"2,795.98","2,795.98",,,,,,
Molina Medicaid,CPT,0427T,Insj/rplc nstim apnea pls gn,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"7,098.75","7,098.75",,,,,,
Molina Medicaid,CPT,0428T,Rmvl nstim apnea pls gen,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,0429T,Rmvl nstim apnea sen ld,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,0430T,Rmvl nstim apnea stimj ld,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,0431T,Rmvl/rplc nstim apnea pls gn,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"7,098.75","7,098.75",,,,,,
Molina Medicaid,CPT,0432T,Repos nstim apnea stimj ld,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,0433T,Repos nstim apnea sensing ld,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,0434T,Interro eval npgs apnea,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,0435T,Prgrmg eval npgs apnea 1 ses,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,0436T,Prgrmg eval npgs apnea study,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,0437T,Impltj synth rnfcmt abdl wal,General Surgery,Per Unit,"$1,330.49 ",OP,"1,330.49","1,330.49",,,,,,
Molina Medicaid,CPT,0438T,Tprnl plmt biodegrdabl matrl,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Molina Medicaid,CPT,0439T,Myocrd contrast prfuj echo,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Molina Medicaid,CPT,0440T,Abltj perc uxtr/perph nrv,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,0441T,Abltj perc lxtr/perph nrv,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,0442T,Abltj perc plex/trncl nrv,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,0443T,R-t spctrl alys prst8 tiss,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,0446T,Insj impltbl glucose sensor,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,0447T,Rmvl impltbl glucose sensor,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,0448T,Remvl insj impltbl gluc sens,General Surgery,Per Unit,$367.48 ,OP,367.48,367.48,,,,,,
Molina Medicaid,CPT,0449T,Insj aqueous drain dev 1st,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Molina Medicaid,CPT,0450T,Insj aqueous drain dev each,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Molina Medicaid,CPT,0453T,Insj/rplcmt mech-elec ntrfce,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Molina Medicaid,CPT,0457T,Remvl mech-elec skin ntrfce,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
Molina Medicaid,CPT,0462T,Prgrmg eval aortic ventr sys,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,0463T,Interrog aortic ventr sys,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,0464T,Visual ep test for glaucoma,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Molina Medicaid,CPT,0466T,Insj ch wal respir eltrd/ra,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"12,849.88","12,849.88",,,,,,
Molina Medicaid,CPT,0467T,Revj/rplmnt ch respir eltrd,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,0468T,Rmvl ch wal respir eltrd/ra,Neurological Surgery,Per Unit,$610.14 ,OP,610.14,610.14,,,,,,
Molina Medicaid,CPT,0469T,Rta polarize scan oc scr bi,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Molina Medicaid,CPT,0470T,Oct skn img acquisj i&r 1st,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Molina Medicaid,CPT,0471T,Oct skn img acquisj i&r addl,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Molina Medicaid,CPT,0472T,Prgrmg io rta eltrd ra,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,0473T,Reprgrmg io rta eltrd ra,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,0474T,Insj aqueous drg dev io rsvr,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"1,563.30","1,563.30",,,,,,
Molina Medicaid,CPT,0475T,Rec ftl car sgl 3 ch i&r,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Molina Medicaid,CPT,0476T,Rec ftl car sgl elec tr data,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Molina Medicaid,CPT,0477T,Rec ftl car sgl xrtj alys,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Molina Medicaid,CPT,0478T,Rec ftl car 3 ch rev i&r,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Molina Medicaid,CPT,0481T,Njx autol wbc concentrate,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,0482T,Absl quan myocrd bld flo pet,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Molina Medicaid,CPT,0485T,Oct mid ear i&r unilateral,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,0486T,Oct mid ear i&r bilateral,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,0487T,Trvg biomchn mapg w/reprt,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,0488T,Diabetes prev online/elec,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Molina Medicaid,CPT,0489T,Regn cell tx scldr hands,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,0490T,Regn cell tx scldr h mlt inj,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,0497T,Xtrnl pt act ecg in-off conn,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Molina Medicaid,CPT,0498T,Xtrnl pt act ecg r&i pr 30 d,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Molina Medicaid,CPT,0499T,Cysto f/urtl strix/stenosis,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Molina Medicaid,CPT,0500T,Hpv 5+ hi risk hpv types,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,0501T,Cor ffr derived cor cta data,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Molina Medicaid,CPT,0502T,Cor ffr data prep & transmis,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Molina Medicaid,CPT,0503T,Cor ffr alys gnrj ffr mdl,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Molina Medicaid,CPT,0504T,Cor ffr data review i&r,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Molina Medicaid,CPT,0505T,Ev fempop artl revsc,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,0506T,Mac pgmt opt dns meas hfp,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,0507T,Near ifr 2img mibmn glnd i&r,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,0508T,Pls echo us b1 dns meas tib,Diagnostic Radiology,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
Molina Medicaid,CPT,0509T,Pattern erg w/i&r,Ophthalmology,Per Unit,$200.58 ,OP,200.58,200.58,,,,,,
Molina Medicaid,CPT,0510T,Rmvl sinus tarsi implant,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"1,076.12","1,076.12",,,,,,
Molina Medicaid,CPT,0511T,Rmvl&rinsj sinus tarsi implt,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"2,502.66","2,502.66",,,,,,
Molina Medicaid,CPT,0514T,Intraop vis axis id pt fixj,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,0515T,Insj wcs lv compl sys,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Molina Medicaid,CPT,0517T,Insj wcs lv pg compnt,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Molina Medicaid,CPT,0518T,Rmvl pg compnt wcs,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
Molina Medicaid,CPT,0519T,Rmvl & rplcmt pg compnt wcs,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Molina Medicaid,CPT,0520T,Rmvl&rplcmt pg wcs new eltrd,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Molina Medicaid,CPT,0521T,Interrog dev eval wcs ip,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,0522T,Prgrmg dev eval wcs ip,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,0525T,Insj/rplcmt compl iims,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Molina Medicaid,CPT,0527T,Insj/rplcmt iims implt mntr,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Molina Medicaid,CPT,0528T,Prgrmg dev eval iims ip,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,0529T,Interrog dev eval iims ip,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,0530T,Removal complete iims,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
Molina Medicaid,CPT,0532T,Removal iims implt mntr only,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"3,320.20","3,320.20",,,,,,
Molina Medicaid,CPT,0533T,Cont rec mvmt do 6-10 days,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,0534T,Cont rec mvmt do setup&train,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,0535T,Cont rec mvmt do reprt cnfig,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,0536T,Cont rec mvmt do dl w/i&r,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,0541T,Myocardial imaging mcg,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Molina Medicaid,CPT,0542T,Myocardial imaging mcg i&r,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Molina Medicaid,CPT,0546T,Rf spectrsc ntraop mrgn asmt,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,0547T,B1 matrl qual tst mcrind tib,Diagnostic Radiology,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
Molina Medicaid,CPT,0548T,Tprnl balo cntnc dev bi,Urological Surgery,Per Unit,"$2,714.29 ",OP,"2,714.29","2,714.29",,,,,,
Molina Medicaid,CPT,0549T,Tprnl balo cntnc dev uni,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Molina Medicaid,CPT,0550T,Tprnl balo cntnc dev rmvl ea,Urological Surgery,Per Unit,$834.13 ,OP,834.13,834.13,,,,,,
Molina Medicaid,CPT,0551T,Tprnl balo cntnc dev adjmt,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Molina Medicaid,CPT,0552T,Low-level laser therapy,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,0553T,Perq tcat iliac anast implt,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,0554T,B1 str & fx rsk analysis,Diagnostic Radiology,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
Molina Medicaid,CPT,0556T,B1 str & fx rsk assessment,Diagnostic Radiology,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
Molina Medicaid,CPT,0558T,Ct scan f/biomchn ct alys,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Molina Medicaid,CPT,0563T,Evac meibomian glnd heat bi,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,0564T,Onc chemo rx cytotox csc 14,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,0566T,Autol cell implt adps njx,Orthopedics,Per Unit,$184.59 ,OP,184.59,184.59,,,,,,
Molina Medicaid,CPT,0568T,Intro mix saline&air f/ssg,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,0571T,Insj/rplcmt icds ss eltrd,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Molina Medicaid,CPT,0575T,Prgrmg dev eval icds ss ip,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,0576T,Interrog dev eval icds ss ip,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,0577T,Ephys eval icds ss,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Molina Medicaid,CPT,0578T,Rem interrog dev icds phys,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,0579T,Rem interrog dev icds tech,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,0581T,Abltj mal brst tum perq crtx,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Molina Medicaid,CPT,0582T,Trurl abltj mal prst8 tiss,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Molina Medicaid,CPT,0583T,Tmpst auto tube dlvr sys,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,0587T,Perq impltj/rplcmt isdns ptn,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Molina Medicaid,CPT,0588T,Revision/removal isdns ptn,Neurology,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
Molina Medicaid,CPT,0589T,Elec alys smpl prgrmg iins,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Molina Medicaid,CPT,0590T,Elec alys cplx prgrmg iins,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Molina Medicaid,CPT,0591T,Hlth&wb coaching indiv 1st,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Molina Medicaid,CPT,0592T,Hlth&wb coaching indiv f-up,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Molina Medicaid,CPT,0593T,Hlth&wb coaching group,Preventive Care,Per Unit,$26.23 ,OP,26.23,26.23,,,,,,
Molina Medicaid,CPT,0596T,Temp fml iu vlv-pmp 1st insj,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Molina Medicaid,CPT,0597T,Temp fml iu valve-pmp rplcmt,Urology,Per Unit,$236.52 ,OP,236.52,236.52,,,,,,
Molina Medicaid,CPT,0602T,Transdermal gfr measurements,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,0603T,Transdermal gfr monitoring,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,0604T,Rem oct rta dev setup&educaj,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,0605T,Rem oct rta techl sprt min 8,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,0607T,Rem mntr pulm flu mntr setup,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,0608T,Rem mntr pulm flu mntr alys,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,0609T,Mrs disc pain acquisj data,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Molina Medicaid,CPT,0610T,Mrs disc pain transmis data,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,0611T,Mrs disc pain alg alys data,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,0614T,Rmvl&rplcmt ss impl dfb pg,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Molina Medicaid,CPT,0615T,Eye mvmt alys w/o calbrj i&r,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,0616T,Insertion of iris prosthesis,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Molina Medicaid,CPT,0617T,Insj iris prosth w/rmvl&insj,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Molina Medicaid,CPT,0618T,Insj iris prosth sec io lens,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Molina Medicaid,CPT,0619T,Cysto w/prst8 commissurotomy,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Molina Medicaid,CPT,0620T,Evasc ven artlz tibl/prnl vn,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,0621T,Trabeculostomy interno laser,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Molina Medicaid,CPT,0622T,Trabeculostomy int lsr w/scp,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Molina Medicaid,CPT,0623T,Auto quantification c plaque,Cardiology,Per Unit,$144.45 ,OP,144.45,144.45,,,,,,
Molina Medicaid,CPT,0632T,Perq tcat us abltj nrv p-art,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Molina Medicaid,CPT,0633T,Ct breast w/3d uni c-,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Molina Medicaid,CPT,0634T,Ct breast w/3d uni c+,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Molina Medicaid,CPT,0635T,Ct breast w/3d uni c-/c+,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Molina Medicaid,CPT,0636T,Ct breast w/3d bi c-,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Molina Medicaid,CPT,0637T,Ct breast w/3d bi c+,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Molina Medicaid,CPT,0638T,Ct breast w/3d bi c-/c+,Diagnostic Radiology,Per Unit,$179.12 ,OP,179.12,179.12,,,,,,
Molina Medicaid,CPT,0639T,Wrls skn snr anisotropy meas,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,C1762,"Conn tiss, human(inc fascia)",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,C1763,"Conn tiss, non-human",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,C1849,"Skin substitute, synthetic",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,C1878,Matrl for vocal cord,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,C2615,"Sealant, pulmonary, liquid",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,C8900,"Mra w/cont, abd",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Molina Medicaid,CPT,C8901,"Mra w/o cont, abd",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Molina Medicaid,CPT,C8902,"Mra w/o fol w/cont, abd",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Molina Medicaid,CPT,C8903,"Mri w/cont, breast, uni",Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Molina Medicaid,CPT,C8904,"Mri w/o cont, breast, uni",Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Molina Medicaid,CPT,C8905,"Mri w/o fol w/cont, brst, un",Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Molina Medicaid,CPT,C8906,"Mri w/cont, breast, bi",Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Molina Medicaid,CPT,C8907,"Mri w/o cont, breast, bi",Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Molina Medicaid,CPT,C8908,"Mri w/o fol w/cont, breast,",Diagnostic Radiology,Per Unit,$271.57 ,OP,271.57,271.57,,,,,,
Molina Medicaid,CPT,C8909,"Mra w/cont, chest",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Molina Medicaid,CPT,C8910,"Mra w/o cont, chest",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Molina Medicaid,CPT,C8911,"Mra w/o fol w/cont, chest",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Molina Medicaid,CPT,C8912,"Mra w/cont, lwr ext",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Molina Medicaid,CPT,C8913,"Mra w/o cont, lwr ext",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Molina Medicaid,CPT,C8914,"Mra w/o fol w/cont, lwr ext",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Molina Medicaid,CPT,C8918,"Mra w/cont, pelvis",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Molina Medicaid,CPT,C8919,"Mra w/o cont, pelvis",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Molina Medicaid,CPT,C8920,"Mra w/o fol w/cont, pelvis",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Molina Medicaid,CPT,C8921,"Tte w or w/o fol w/cont, com",Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Molina Medicaid,CPT,C8922,"Tte w or w/o fol w/cont, f/u",Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Molina Medicaid,CPT,C8923,"2d tte w or w/o fol w/con,co",Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Molina Medicaid,CPT,C8924,"2d tte w or w/o fol w/con,fu",Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Molina Medicaid,CPT,C8925,"2d tee w or w/o fol w/con,in",Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Molina Medicaid,CPT,C8926,"Tee w or w/o fol w/cont,cong",Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Molina Medicaid,CPT,C8927,"Tee w or w/o fol w/cont, mon",Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Molina Medicaid,CPT,C8928,"Tte w or w/o fol w/con,stres",Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Molina Medicaid,CPT,C8929,"Tte w or wo fol wcon,doppler",Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Molina Medicaid,CPT,C8930,"Tte w or w/o contr, cont ecg",Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Molina Medicaid,CPT,C8931,"Mra, w/dye, spinal canal",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Molina Medicaid,CPT,C8932,"Mra, w/o dye, spinal canal",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Molina Medicaid,CPT,C8933,"Mra, w/o&w/dye, spinal canal",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Molina Medicaid,CPT,C8934,"Mra, w/dye, upper extremity",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Molina Medicaid,CPT,C8935,"Mra, w/o dye, upper extr",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Molina Medicaid,CPT,C8936,"Mra, w/o&w/dye, upper extr",Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Molina Medicaid,CPT,C8957,"Prolonged iv inf, req pump",General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
Molina Medicaid,CPT,C9014,"Injection, cerliponase alfa",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,C9015,"C-1 esterase, haegarda",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,C9016,"Inj, triptorelin ext rel",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,C9024,"Inj, daunorubicin-cytarabine",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Molina Medicaid,CPT,C9025,"Injection, ramucirumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,C9026,"Injection, vedolizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,C9027,"Injection, pembrolizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Molina Medicaid,CPT,C9028,Inj. inotuzumab ozogamicin,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Molina Medicaid,CPT,C9029,"Injection, guselkumab",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Molina Medicaid,CPT,C9030,Inj copanlisib,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,C9031,"Lutetium Lu 177 dotatate, tx",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,C9032,Voretigene neparvovec-rzyl,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,C9033,"Inj, akynzeo",Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,189.67,189.67,,,,,,
Molina Medicaid,CPT,C9034,"Injection, dexamethasone 9%",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,C9035,"Injection, Aristada Initio",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Molina Medicaid,CPT,C9036,"Injection, patisiran",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,C9037,"Injection, risperidone",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,C9038,Inj mogamulizumab-kpkc,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,C9040,"Injection, fremanezumab-vfrm",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,C9041,"Inj, coagulation factor xa",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,C9042,"Inj., belrapzo 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,C9043,"Injection, levoleucovorin",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Molina Medicaid,CPT,C9044,"Injection, cemiplimab-rwlc",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,C9045,Moxetumomab pasudotox-tdfk,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,C9047,"Injection, caplacizumab-yhdp",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,C9048,Dexamethasone ophth insert,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,C9049,"Injection, tagraxofusp-erzs",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,C9050,"Injection, emapalumab-lzsg",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Molina Medicaid,CPT,C9051,"Injection, omadacycline",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Molina Medicaid,CPT,C9052,"Injection, ravulizumab-cwv",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,C9053,"Inj, crizanlizumab-tmca",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Molina Medicaid,CPT,C9054,"Injection, lefamulin",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,C9055,"Inj, brexanolone",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,C9056,"Injection, givosiran",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,C9057,Inj cetirizine hydrochloride,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,C9058,"Injection,pegfilgrastim-bmez",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,C9059,"Injection, meloxicam",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,C9061,"Injection, teprotumumab-trbw",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,C9062,Daratumumab hyaluronidase,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,C9063,"Injection, eptinezumab-jjmr",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,C9064,Mitomycin pyelocalyceal inst,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,C9065,Romidepsin non-lyophilized,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,C9066,Sacituzumab govitecan-hziy,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,C9069,Belantamab mafodontin-blmf,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Molina Medicaid,CPT,C9070,"Injection, tafasitamab-cxix",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,C9071,"Injection, viltolarsen",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,C9072,"Inj, imm glob asceniv",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Molina Medicaid,CPT,C9121,"Injection, argatroban",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Molina Medicaid,CPT,C9122,Mometasone furoate (sinuva),Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Molina Medicaid,CPT,C9132,"Kcentra, per i.u.",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,C9137,Adynovate Factor VIII recom,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,C9138,Nuwiq Factor VIII recomb,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,C9139,"Idelvion, 1 i.u.",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,C9140,Afstyla factor viii recomb,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,C9141,Factor viii pegylated-aucl,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,C9248,"Inj, clevidipine butyrate",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,C9250,Artiss fibrin sealant,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,C9257,Bevacizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Molina Medicaid,CPT,C9293,"Injection, glucarpidase",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,C9349,"Puraply, puraply antimic",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,C9352,"Neuragen nerve guide, per cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,C9353,"Neurawrap nerve protector,cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,C9354,"Veritas collagen matrix, cm2",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,C9355,"Neuromatrix nerve cuff, cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,C9356,"Tenoglide tendon prot, cm2",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,C9358,"Surgimend, fetal",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,C9359,"Implnt,bon void filler-putty",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,C9360,"Surgimend, neonatal",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,C9361,Neuromend nerve wrap,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,C9362,"Implnt,bon void filler-strip",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,C9363,Integra meshed bil wound mat,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,C9364,"Porcine implant, permacol",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,C9408,"Iodine i-131 iobenguane, tx",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,C9442,"Injection, belinostat",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,C9443,"Injection, dalbavancin",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Molina Medicaid,CPT,C9444,"Injection, oritavancin",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Molina Medicaid,CPT,C9445,"C-1 esterase, Ruconest",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,C9446,"Inj, tedizolid phosphate",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,C9447,"Inj, phenylephrine ketorolac",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,C9448,Oral netupitant palonosetron,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
Molina Medicaid,CPT,C9449,"Inj, blinatumomab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,C9450,Fluocinolone acetonide implt,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,C9451,"Injection, peramivir",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Molina Medicaid,CPT,C9452,"Inj, ceftolozane/tazobactam",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,C9453,"Injection, nivolumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,C9454,"Inj, pasireotide long acting",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,C9455,"Injection, siltuximab",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Molina Medicaid,CPT,C9456,"Inj, isavuconazonium sulfate",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,C9460,"Injection, cangrelor",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,C9465,"Injection, Durolane",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,C9466,"Injection, benralizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,C9467,Inj rituximab hyaluronidase,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,C9468,"Inj, factor ix, Rebinyn",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,C9469,Inj triamcinolone acetonide,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,C9470,Aripiprazole lauroxil im,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,C9471,"Hymovis, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Molina Medicaid,CPT,C9472,Inj talimogene laherparepvec,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,C9473,"Injection, mepolizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Molina Medicaid,CPT,C9474,"Inj, irinotecan liposome",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,C9475,"Injection, necitumumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,C9476,"Injection, daratumumab",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Molina Medicaid,CPT,C9477,"Injection, elotuzumab",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Molina Medicaid,CPT,C9478,"Injection, sebelipase alfa",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,C9480,"Injection, trabectedin",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,C9481,"Injection, reslizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Molina Medicaid,CPT,C9482,Sotalol hydrochloride iv,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,C9483,"Injection, atezolizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,C9484,"Injection, eteplirsen",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,C9485,"Injection, olaratumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,C9487,"Ustekinumab IV inj, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Molina Medicaid,CPT,C9488,Conivaptan hcl,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,C9489,"Injection, nusinersen",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,C9490,"Injection, bezlotoxumab",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Molina Medicaid,CPT,C9491,"Injection, avelumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,C9492,"Injection, durvalumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,C9493,"Injection, edaravone",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Molina Medicaid,CPT,C9494,"Injection, ocrelizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,C9497,"Loxapine, inhalation powder",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,C9600,Perc drug-el cor stent sing,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Molina Medicaid,CPT,C9601,Perc drug-el cor stent bran,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Molina Medicaid,CPT,C9602,Perc d-e cor stent ather s,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Molina Medicaid,CPT,C9603,Perc d-e cor stent ather br,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Molina Medicaid,CPT,C9604,Perc d-e cor revasc t cabg s,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Molina Medicaid,CPT,C9605,Perc d-e cor revasc t cabg b,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Molina Medicaid,CPT,C9606,Perc d-e cor revasc w ami s,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Molina Medicaid,CPT,C9607,Perc d-e cor revasc chro sin,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Molina Medicaid,CPT,C9608,Perc d-e cor revasc chro add,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"4,903.27","4,903.27",,,,,,
Molina Medicaid,CPT,C9724,Eps stomach plic,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Molina Medicaid,CPT,C9726,Rxt breast appl place/remov,General Surgery,Per Unit,$702.95 ,OP,702.95,702.95,,,,,,
Molina Medicaid,CPT,C9728,"Place device/marker, non pro",Therapeutic Radiology,Per Unit,$68.45 ,OP,68.45,68.45,,,,,,
Molina Medicaid,CPT,C9734,"U/s trtmt, not leiomyomata",General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Molina Medicaid,CPT,C9737,Lap esoph augmentation,General Surgery,Per Unit,"$3,851.80 ",OP,"3,851.80","3,851.80",,,,,,
Molina Medicaid,CPT,C9739,Cystoscopy prostatic imp 1-3,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Molina Medicaid,CPT,C9740,Cysto impl 4 or more,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Molina Medicaid,CPT,C9741,Impl pressure sensor w/angio,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Molina Medicaid,CPT,C9742,Laryngoscopy with injection,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Molina Medicaid,CPT,C9743,Bulking/spacer material impl,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,C9744,Abd us w/contrast,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Molina Medicaid,CPT,C9745,Nasal endo eustachian tube,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Molina Medicaid,CPT,C9747,"Ablation, hifu, prostate",Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Molina Medicaid,CPT,C9749,Repair nasal stenosis w/imp,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,C9750,Ins/rem-replace compl iims,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"4,587.29","4,587.29",,,,,,
Molina Medicaid,CPT,C9762,Cardiac mri seg dys strain,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Molina Medicaid,CPT,C9763,Cardiac mri seg dys stress,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Molina Medicaid,CPT,C9765,Revasc intra lithotrip-stent,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,C9767,Revasc lithotrip-stent-ather,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,C9768,Endo us-guide hep porto grad,Gastroenterology,Per Unit,$616.04 ,OP,616.04,616.04,,,,,,
Molina Medicaid,CPT,C9769,Cysto w/temp pros implant,Urological Surgery,Per Unit,"$1,672.81 ",OP,"1,672.81","1,672.81",,,,,,
Molina Medicaid,CPT,C9770,"Vitrec/mech pars, subret inj",Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"1,690.18","1,690.18",,,,,,
Molina Medicaid,CPT,C9771,Nsl/sins cryo post nasal tis,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"1,674.71","1,674.71",,,,,,
Molina Medicaid,CPT,C9772,Revasc lithotrip tibi/perone,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,C9773,Revasc lithotr-stent tib/per,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,C9774,Revasc lithotr-ather tib/per,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,C9775,Revasc lith-sten-ath tib/per,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"2,821.82","2,821.82",,,,,,
Molina Medicaid,CPT,C9803,Hopd covid-19 spec collect,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,D0120,Periodic oral evaluation,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Molina Medicaid,CPT,D0140,Limit oral eval problm focus,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Molina Medicaid,CPT,D0145,"Oral evaluation, pt < 3yrs",Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Molina Medicaid,CPT,D0150,Comprehensve oral evaluation,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Molina Medicaid,CPT,D0160,Extensv oral eval prob focus,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Molina Medicaid,CPT,D0170,"Re-eval,est pt,problem focus",Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Molina Medicaid,CPT,D0171,Re-eval post-op visit,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Molina Medicaid,CPT,D0180,Comp periodontal evaluation,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Molina Medicaid,CPT,D0190,Screening of a patient,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Molina Medicaid,CPT,D0191,Assessment of a patient,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Molina Medicaid,CPT,D0210,Intraor complete film series,Dental,Per Unit,$87.62 ,OP,87.62,87.62,,,,,,
Molina Medicaid,CPT,D0220,Intraoral periapical first,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Molina Medicaid,CPT,D0230,Intraoral periapical ea add,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Molina Medicaid,CPT,D0240,Intraoral occlusal film,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Molina Medicaid,CPT,D0250,Extraoral 2d project image,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Molina Medicaid,CPT,D0251,Extraoral posterior image,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Molina Medicaid,CPT,D0260,Extraoral ea additional film,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Molina Medicaid,CPT,D0270,Dental bitewing single image,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Molina Medicaid,CPT,D0272,Dental bitewings two images,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Molina Medicaid,CPT,D0273,Bitewings - three images,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Molina Medicaid,CPT,D0274,Bitewings four images,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Molina Medicaid,CPT,D0277,Vert bitewings 7 to 8 images,Dental,Per Unit,$87.62 ,OP,87.62,87.62,,,,,,
Molina Medicaid,CPT,D0290,Skull/facial bone image,Dental,Per Unit,$87.62 ,OP,87.62,87.62,,,,,,
Molina Medicaid,CPT,D0310,Dental saliography,Dental,Per Unit,$87.62 ,OP,87.62,87.62,,,,,,
Molina Medicaid,CPT,D0320,Dental tmj arthrogram incl i,Dental,Per Unit,$87.62 ,OP,87.62,87.62,,,,,,
Molina Medicaid,CPT,D0321,Other tmj images by report,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Molina Medicaid,CPT,D0322,Dental tomographic survey,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Molina Medicaid,CPT,D0330,Panoramic image,Dental,Per Unit,$87.62 ,OP,87.62,87.62,,,,,,
Molina Medicaid,CPT,D0340,2d cephalometric image,Dental,Per Unit,$87.62 ,OP,87.62,87.62,,,,,,
Molina Medicaid,CPT,D0350,Oral/facial photo images,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Molina Medicaid,CPT,D0351,3d photographic image,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Molina Medicaid,CPT,D0364,Cone beam ct capt & interp,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Molina Medicaid,CPT,D0365,Cone beam ct interprete man,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Molina Medicaid,CPT,D0366,Cone beam ct interprete max,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Molina Medicaid,CPT,D0367,Cone beam ct interp both jaw,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Molina Medicaid,CPT,D0368,Cone beam ct interprete tmj,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Molina Medicaid,CPT,D0369,Max mri capture & interprete,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Molina Medicaid,CPT,D0370,Max ultrasound capt & interp,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,D0371,Sialoendoscopy capt & interp,Dental,Per Unit,$87.62 ,OP,87.62,87.62,,,,,,
Molina Medicaid,CPT,D0380,Cone beam ct capture limited,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Molina Medicaid,CPT,D0381,Cone beam ct capt mandible,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Molina Medicaid,CPT,D0382,Cone beam ct capt maxilla,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Molina Medicaid,CPT,D0383,Cone beam ct both jaws,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Molina Medicaid,CPT,D0384,Cone beam ct capture tmj,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Molina Medicaid,CPT,D0385,Max mri image capture,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Molina Medicaid,CPT,D0386,Max ultrasound image capture,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,D0391,Imterprete diagnostic image,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Molina Medicaid,CPT,D0393,Trtmnt simulation 3d image,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Molina Medicaid,CPT,D0394,Digital sub 2 or more images,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Molina Medicaid,CPT,D0395,Fusion 2 or more 3d images,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Molina Medicaid,CPT,D0411,Hba1c in office testing,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,D0412,Blood glucose level test,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,D0414,Lab process microbial spec,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,D0415,Collection of microorganisms,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,D0416,Viral culture,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,D0418,Analysis of saliva sample,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,D0419,Assess of salivary flow,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Molina Medicaid,CPT,D0421,Gen tst suscept oral disease,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,D0422,Collect & prep genetic samp,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,D0423,Genetic test spec analysis,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,D0425,Caries susceptibility test,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,D0431,Diag tst detect mucos abnorm,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Molina Medicaid,CPT,D0460,Pulp vitality test,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Molina Medicaid,CPT,D0470,Diagnostic casts,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Molina Medicaid,CPT,D0472,"Gross exam, prep & report",Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,D0473,"Micro exam, prep & report",Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,D0474,Micro w exam of surg margins,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D0475,Decalcification procedure,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,D0476,Spec stains for microorganis,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,D0477,Spec stains not for microorg,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,D0478,Immunohistochemical stains,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,D0479,Tissue in-situ hybridization,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,D0480,Cytopath smear prep & report,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,D0481,Electron microscopy,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,D0482,Direct immunofluorescence,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,D0483,Indirect immunofluorescence,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,D0484,Consult slides prep elsewher,Pathology,Per Unit,$20.19 ,OP,20.19,20.19,,,,,,
Molina Medicaid,CPT,D0485,Consult inc prep of slides,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D0486,Access of transep cytol samp,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,D0502,Other oral pathology procedu,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Molina Medicaid,CPT,D0600,Non-ionizing diag proc,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Molina Medicaid,CPT,D0601,Caries risk assess low risk,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Molina Medicaid,CPT,D0602,Caries risk assess mod risk,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Molina Medicaid,CPT,D0603,Caries risk assess high risk,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Molina Medicaid,CPT,D0604,Antigen test pub hlth pathog,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,D0605,Antibody test pub hlth path,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,D0701,Pano radio image,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Molina Medicaid,CPT,D0702,2d cephal radio image,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Molina Medicaid,CPT,D0703,2d oral/facial photo image,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Molina Medicaid,CPT,D0704,3d photo image capture only,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Molina Medicaid,CPT,D0705,Extra oral post radio image,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Molina Medicaid,CPT,D0706,Intraoral occlus radio image,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Molina Medicaid,CPT,D0707,Intraoral periap radio image,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Molina Medicaid,CPT,D0708,Intraoral bite radio image,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Molina Medicaid,CPT,D0709,Intraoral cmplt radio images,Dental,Per Unit,$31.95 ,OP,31.95,31.95,,,,,,
Molina Medicaid,CPT,D0999,Unspecified diagnostic proce,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Molina Medicaid,CPT,D1110,Dental prophylaxis adult,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Molina Medicaid,CPT,D1120,Dental prophylaxis child,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Molina Medicaid,CPT,D1206,Topical fluoride varnish,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Molina Medicaid,CPT,D1208,Topical app fluorid ex vrnsh,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Molina Medicaid,CPT,D1310,Nutri counsel-control caries,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Molina Medicaid,CPT,D1320,Tobacco counseling,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Molina Medicaid,CPT,D1321,Couns for high risk sub use,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Molina Medicaid,CPT,D1330,Oral hygiene instruction,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Molina Medicaid,CPT,D1351,Dental sealant per tooth,Dental,Per Unit,$24.50 ,OP,24.5,24.5,,,,,,
Molina Medicaid,CPT,D1352,"Prev resin rest, perm tooth",Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Molina Medicaid,CPT,D1353,Sealant repair per tooth,Dental,Per Unit,$24.50 ,OP,24.5,24.5,,,,,,
Molina Medicaid,CPT,D1354,Int caries med app per tooth,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Molina Medicaid,CPT,D1355,Caries med app per tooth,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Molina Medicaid,CPT,D1510,Space maintainer fxd unilat,Dental,Per Unit,$156.21 ,OP,156.21,156.21,,,,,,
Molina Medicaid,CPT,D1515,Fixed bilat space maintainer,Dental,Per Unit,$156.21 ,OP,156.21,156.21,,,,,,
Molina Medicaid,CPT,D1516,"Fixed bilat space maint, max",Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Molina Medicaid,CPT,D1517,"Fixed bilat space maint, man",Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Molina Medicaid,CPT,D1520,Remove unilat space maintain,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Molina Medicaid,CPT,D1525,Remove bilat space maintain,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Molina Medicaid,CPT,D1526,"Remove bilat space main, max",Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Molina Medicaid,CPT,D1527,"Remove bilat space main, man",Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Molina Medicaid,CPT,D1550,Recement space maintainer,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D1551,Recement space maint - max,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Molina Medicaid,CPT,D1552,Recement space maint - man,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Molina Medicaid,CPT,D1553,Recement unilat space maint,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Molina Medicaid,CPT,D1555,Remove fix space maintainer,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Molina Medicaid,CPT,D1556,Rem fixed unilat space maint,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Molina Medicaid,CPT,D1557,Remove fixed bilat maint max,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Molina Medicaid,CPT,D1558,Remove fixed bilat man,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Molina Medicaid,CPT,D1575,"Dist space maint, fixed unil",Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Molina Medicaid,CPT,D1999,Unspecified preventive proc,Preventive Care,Per Unit,$98.77 ,OP,98.77,98.77,,,,,,
Molina Medicaid,CPT,D2140,Amalgam one surface permanen,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2150,Amalgam two surfaces permane,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2160,Amalgam three surfaces perma,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Molina Medicaid,CPT,D2161,Amalgam 4 or > surfaces perm,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Molina Medicaid,CPT,D2330,Resin one surface-anterior,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2331,Resin two surfaces-anterior,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2332,Resin three surfaces-anterio,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2335,Resin 4/> surf or w incis an,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Molina Medicaid,CPT,D2390,Ant resin-based cmpst crown,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2391,Post 1 srfc resinbased cmpst,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2392,Post 2 srfc resinbased cmpst,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2393,Post 3 srfc resinbased cmpst,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2394,Post >=4srfc resinbase cmpst,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2410,Dental gold foil one surface,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2420,Dental gold foil two surface,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2430,Dental gold foil three surfa,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2510,Dental inlay metalic 1 surf,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2520,Dental inlay metallic 2 surf,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2530,Dental inlay metl 3/more sur,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2542,Dental onlay metallic 2 surf,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2543,Dental onlay metallic 3 surf,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2544,Dental onlay metl 4/more sur,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2610,Inlay porcelain/ceramic 1 su,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2620,Inlay porcelain/ceramic 2 su,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2630,Dental onlay porc 3/more sur,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Molina Medicaid,CPT,D2642,Dental onlay porcelin 2 surf,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2643,Dental onlay porcelin 3 surf,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2644,Dental onlay porc 4/more sur,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2650,Inlay composite/resin one su,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2651,Inlay composite/resin two su,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2652,Dental inlay resin 3/mre sur,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2662,Dental onlay resin 2 surface,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2663,Dental onlay resin 3 surface,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2664,Dental onlay resin 4/mre sur,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2710,Crown resin-based indirect,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Molina Medicaid,CPT,D2712,Crown 3/4 resin-based compos,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Molina Medicaid,CPT,D2720,Crown resin w/ high noble me,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Molina Medicaid,CPT,D2721,Crown resin w/ base metal,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Molina Medicaid,CPT,D2722,Crown resin w/ noble metal,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Molina Medicaid,CPT,D2740,Crown porcelain/ceramic,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Molina Medicaid,CPT,D2750,Crown porcelain w/ h noble m,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Molina Medicaid,CPT,D2751,Crown porcelain fused base m,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Molina Medicaid,CPT,D2752,Crown porcelain w/ noble met,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Molina Medicaid,CPT,D2753,Crown porc fused to titanium,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Molina Medicaid,CPT,D2780,Crown 3/4 cast hi noble met,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Molina Medicaid,CPT,D2781,Crown 3/4 cast base metal,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Molina Medicaid,CPT,D2782,Crown 3/4 cast noble metal,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Molina Medicaid,CPT,D2783,Crown 3/4 porcelain/ceramic,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Molina Medicaid,CPT,D2790,Crown full cast high noble m,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Molina Medicaid,CPT,D2791,Crown full cast base metal,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Molina Medicaid,CPT,D2792,Crown full cast noble metal,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Molina Medicaid,CPT,D2794,Crown-titanium,Dental,Per Unit,"$1,115.94 ",OP,"1,115.94","1,115.94",,,,,,
Molina Medicaid,CPT,D2799,Provisional crown,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2910,Recement inlay onlay or part,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2915,Recement cast or prefab post,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2920,Re-cement or re-bond crown,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2921,Reattach tooth fragment,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2928,Prefab porc/cer crown perm,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Molina Medicaid,CPT,D2929,Prefab porc/ceram crown pri,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Molina Medicaid,CPT,D2930,Prefab stnlss steel crwn pri,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Molina Medicaid,CPT,D2931,Prefab stnlss steel crown pe,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Molina Medicaid,CPT,D2932,Prefabricated resin crown,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Molina Medicaid,CPT,D2933,Prefab stainless steel crown,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Molina Medicaid,CPT,D2934,Prefab steel crown primary,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Molina Medicaid,CPT,D2941,Int therapeutic restoration,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Molina Medicaid,CPT,D2950,Core build-up incl any pins,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Molina Medicaid,CPT,D2951,Tooth pin retention,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Molina Medicaid,CPT,D2952,Post and core cast + crown,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Molina Medicaid,CPT,D2953,Each addtnl cast post,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Molina Medicaid,CPT,D2954,Prefab post/core + crown,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Molina Medicaid,CPT,D2955,Post removal,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2957,Each addtnl prefab post,Dental,Per Unit,"$1,014.48 ",OP,"1,014.48","1,014.48",,,,,,
Molina Medicaid,CPT,D2960,Labial veneer resin direct,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2961,Labial veneer resin indirect,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2962,Labial veneer porc indirect,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2970,Temp crown (fractured tooth),Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2971,Add proc construct new crown,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2975,Coping,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2980,Crown repair,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2981,Inlay repair,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2982,Onlay repair,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2983,Veneer repair,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2990,Resin infiltration of lesion,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D2999,Dental unspec restorative pr,Dental,Per Unit,$936.64 ,OP,936.64,936.64,,,,,,
Molina Medicaid,CPT,D3110,Pulp cap direct,Dental,Per Unit,$74.70 ,OP,74.7,74.7,,,,,,
Molina Medicaid,CPT,D3120,Pulp cap indirect,Dental,Per Unit,$74.70 ,OP,74.7,74.7,,,,,,
Molina Medicaid,CPT,D3220,Therapeutic pulpotomy,Dental,Per Unit,$74.70 ,OP,74.7,74.7,,,,,,
Molina Medicaid,CPT,D3221,Gross pulpal debridement,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Molina Medicaid,CPT,D3222,Part pulp for apexogenesis,Dental,Per Unit,$74.70 ,OP,74.7,74.7,,,,,,
Molina Medicaid,CPT,D3230,Pulpal therapy anterior prim,Dental,Per Unit,$74.70 ,OP,74.7,74.7,,,,,,
Molina Medicaid,CPT,D3240,Pulpal therapy posterior pri,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Molina Medicaid,CPT,D3310,"End thxpy, anterior tooth",Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Molina Medicaid,CPT,D3320,"End thxpy, premolar tooth",Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Molina Medicaid,CPT,D3330,"End thxpy, molar tooth",Dental,Per Unit,$135.31 ,OP,135.31,135.31,,,,,,
Molina Medicaid,CPT,D3331,Non-surg tx root canal obs,Dental,Per Unit,$135.31 ,OP,135.31,135.31,,,,,,
Molina Medicaid,CPT,D3332,Incomplete endodontic tx,Dental,Per Unit,$135.31 ,OP,135.31,135.31,,,,,,
Molina Medicaid,CPT,D3333,Internal root repair,Dental,Per Unit,$135.31 ,OP,135.31,135.31,,,,,,
Molina Medicaid,CPT,D3346,Retreat root canal anterior,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Molina Medicaid,CPT,D3347,Retreat root canal premolar,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Molina Medicaid,CPT,D3348,Retreat root canal molar,Dental,Per Unit,$135.31 ,OP,135.31,135.31,,,,,,
Molina Medicaid,CPT,D3351,Apexification/recalc initial,Dental,Per Unit,$74.70 ,OP,74.7,74.7,,,,,,
Molina Medicaid,CPT,D3352,Apexification/recalc interim,Dental,Per Unit,$74.70 ,OP,74.7,74.7,,,,,,
Molina Medicaid,CPT,D3353,Apexification/recalc final,Dental,Per Unit,$74.70 ,OP,74.7,74.7,,,,,,
Molina Medicaid,CPT,D3355,Pulpal regeneration initial,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Molina Medicaid,CPT,D3356,Pulpal regeneration interim,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Molina Medicaid,CPT,D3357,Pulpal regeneration complete,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Molina Medicaid,CPT,D3410,Apicoectomy - anterior,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Molina Medicaid,CPT,D3421,Root surgery premolar,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Molina Medicaid,CPT,D3425,Root surgery molar,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Molina Medicaid,CPT,D3426,Root surgery ea add root,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Molina Medicaid,CPT,D3427,Periradicular surgery,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Molina Medicaid,CPT,D3428,Bone graft peri per tooth,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Molina Medicaid,CPT,D3429,Bone graft peri each addl,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Molina Medicaid,CPT,D3430,Retrograde filling,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Molina Medicaid,CPT,D3431,Biological materials,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Molina Medicaid,CPT,D3432,Guided tissue regeneration,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Molina Medicaid,CPT,D3450,Root amputation,Dental,Per Unit,$135.31 ,OP,135.31,135.31,,,,,,
Molina Medicaid,CPT,D3460,Endodontic endosseous implan,Dental,Per Unit,$135.31 ,OP,135.31,135.31,,,,,,
Molina Medicaid,CPT,D3470,Intentional replantation,Dental,Per Unit,$135.31 ,OP,135.31,135.31,,,,,,
Molina Medicaid,CPT,D3471,Surg rep root res anterior,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Molina Medicaid,CPT,D3472,Surg rep root res premolar,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Molina Medicaid,CPT,D3473,Surg rep root res molar,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Molina Medicaid,CPT,D3501,Surg exp root surf anterior,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Molina Medicaid,CPT,D3502,Surg exp root surf premolar,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Molina Medicaid,CPT,D3503,Surg exp root surf molar,Dental,Per Unit,$134.32 ,OP,134.32,134.32,,,,,,
Molina Medicaid,CPT,D3910,Isolation- tooth w rubb dam,Dental,Per Unit,$135.31 ,OP,135.31,135.31,,,,,,
Molina Medicaid,CPT,D3920,Tooth splitting,Dental,Per Unit,$135.31 ,OP,135.31,135.31,,,,,,
Molina Medicaid,CPT,D3950,Canal prep/fitting of dowel,Dental,Per Unit,$135.31 ,OP,135.31,135.31,,,,,,
Molina Medicaid,CPT,D3999,Endodontic procedure,Dental,Per Unit,$74.70 ,OP,74.7,74.7,,,,,,
Molina Medicaid,CPT,D4210,Gingivectomy/plasty 4 or mor,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Molina Medicaid,CPT,D4211,Gingivectomy/plasty 1 to 3,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Molina Medicaid,CPT,D4212,Gingivectomy/plasty rest,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Molina Medicaid,CPT,D4230,Ana crown exp 4 or> per quad,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Molina Medicaid,CPT,D4231,Ana crown exp 1-3 per quad,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Molina Medicaid,CPT,D4240,Gingival flap proc w/ planin,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Molina Medicaid,CPT,D4241,Gngvl flap w rootplan 1-3 th,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Molina Medicaid,CPT,D4245,Apically positioned flap,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Molina Medicaid,CPT,D4249,Crown lengthen hard tissue,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Molina Medicaid,CPT,D4260,Osseous surgery 4 or more,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Molina Medicaid,CPT,D4261,Osseous surg 1 to 3 teeth,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Molina Medicaid,CPT,D4263,Bone replce graft first site,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Molina Medicaid,CPT,D4264,Bone replce graft each add,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Molina Medicaid,CPT,D4265,Bio mtrls to aid soft/os reg,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Molina Medicaid,CPT,D4266,Guided tiss regen resorble,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Molina Medicaid,CPT,D4267,Guided tiss regen nonresorb,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Molina Medicaid,CPT,D4268,Surgical revision procedure,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Molina Medicaid,CPT,D4270,Pedicle soft tissue graft pr,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Molina Medicaid,CPT,D4273,Auto tissue graft 1st tooth,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Molina Medicaid,CPT,D4274,Mesial/distal wedge proc,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Molina Medicaid,CPT,D4275,Non-auto graft 1st tooth,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Molina Medicaid,CPT,D4276,Con tissue w dble ped graft,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Molina Medicaid,CPT,D4277,Soft tissue graft firsttooth,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Molina Medicaid,CPT,D4278,Soft tissue graft addl tooth,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Molina Medicaid,CPT,D4283,Auto tissue graft addl tooth,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Molina Medicaid,CPT,D4285,Non-auto graft addl tooth,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Molina Medicaid,CPT,D4320,Provision splnt intracoronal,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Molina Medicaid,CPT,D4321,Provisional splint extracoro,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Molina Medicaid,CPT,D4341,Periodontal scaling & root,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Molina Medicaid,CPT,D4342,Periodontal scaling 1-3teeth,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Molina Medicaid,CPT,D4346,Scaling gingiv inflammation,Dental,Per Unit,$596.23 ,OP,596.23,596.23,,,,,,
Molina Medicaid,CPT,D4355,Full mouth debridement,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Molina Medicaid,CPT,D4381,Localized delivery antimicro,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Molina Medicaid,CPT,D4910,Periodontal maint procedures,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Molina Medicaid,CPT,D4920,Unscheduled dressing change,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Molina Medicaid,CPT,D4921,Gingival irrigation per quad,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Molina Medicaid,CPT,D4999,Unspecified periodontal proc,Dental,Per Unit,$561.92 ,OP,561.92,561.92,,,,,,
Molina Medicaid,CPT,D5110,Dentures complete maxillary,Dental,Per Unit,$162.24 ,OP,162.24,162.24,,,,,,
Molina Medicaid,CPT,D5120,Dentures complete mandible,Dental,Per Unit,$162.24 ,OP,162.24,162.24,,,,,,
Molina Medicaid,CPT,D5130,Dentures immediat maxillary,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
Molina Medicaid,CPT,D5140,Dentures immediat mandible,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
Molina Medicaid,CPT,D5211,Dentures maxill part resin,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
Molina Medicaid,CPT,D5212,Dentures mand part resin,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
Molina Medicaid,CPT,D5213,Dentures maxill part metal,Dental,Per Unit,$162.24 ,OP,162.24,162.24,,,,,,
Molina Medicaid,CPT,D5214,Dentures mandibl part metal,Dental,Per Unit,$162.24 ,OP,162.24,162.24,,,,,,
Molina Medicaid,CPT,D5221,Immed max part denture resin,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
Molina Medicaid,CPT,D5222,Immed man part denture resin,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
Molina Medicaid,CPT,D5223,Immed max part dent metal,Dental,Per Unit,$162.24 ,OP,162.24,162.24,,,,,,
Molina Medicaid,CPT,D5224,Immed mand part dent metal,Dental,Per Unit,$162.24 ,OP,162.24,162.24,,,,,,
Molina Medicaid,CPT,D5225,Maxillary part denture flex,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
Molina Medicaid,CPT,D5226,Mandibular part denture flex,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
Molina Medicaid,CPT,D5281,Removable partial denture,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
Molina Medicaid,CPT,D5282,"Remove unil part denture,max",Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
Molina Medicaid,CPT,D5283,"Remove unil part denture,man",Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
Molina Medicaid,CPT,D5284,Rem unilat dent flex base,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
Molina Medicaid,CPT,D5286,Rem unilat dent 1 pc resin,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
Molina Medicaid,CPT,D5410,Dentures adjust cmplt maxil,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D5411,Dentures adjust cmplt mand,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D5421,Dentures adjust part maxill,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D5422,Dentures adjust part mandbl,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D5510,Dentur repr broken compl bas,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Molina Medicaid,CPT,D5511,Rep broke comp dent base man,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Molina Medicaid,CPT,D5512,Rep broke comp dent base max,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Molina Medicaid,CPT,D5520,Replace denture teeth complt,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Molina Medicaid,CPT,D5610,Dentures repair resin base,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Molina Medicaid,CPT,D5611,Rep resin part dent base man,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Molina Medicaid,CPT,D5612,Rep resin part dent base max,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Molina Medicaid,CPT,D5620,Rep part denture cast frame,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Molina Medicaid,CPT,D5621,Rep cast part frame man,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Molina Medicaid,CPT,D5622,Rep cast part frame max,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Molina Medicaid,CPT,D5630,Rep partial denture clasp,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Molina Medicaid,CPT,D5640,Replace part denture teeth,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Molina Medicaid,CPT,D5650,Add tooth to partial denture,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Molina Medicaid,CPT,D5660,Add clasp to partial denture,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Molina Medicaid,CPT,D5670,Replc tth&acrlc on mtl frmwk,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
Molina Medicaid,CPT,D5671,Replc tth&acrlc mandibular,Dental,Per Unit,$136.23 ,OP,136.23,136.23,,,,,,
Molina Medicaid,CPT,D5710,Dentures rebase cmplt maxil,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Molina Medicaid,CPT,D5711,Dentures rebase cmplt mand,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Molina Medicaid,CPT,D5720,Dentures rebase part maxill,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Molina Medicaid,CPT,D5721,Dentures rebase part mandbl,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Molina Medicaid,CPT,D5730,Denture reln cmplt max dir,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Molina Medicaid,CPT,D5731,Denture reln cmplt mand dir,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Molina Medicaid,CPT,D5740,Denture reln part max dir,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Molina Medicaid,CPT,D5741,Denture reln part mand dir,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Molina Medicaid,CPT,D5750,Denture reln cmplt max indir,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Molina Medicaid,CPT,D5751,Denture reln cmplt mand ind,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Molina Medicaid,CPT,D5760,Denture reln part max indir,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Molina Medicaid,CPT,D5761,Denture reln part mand indir,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Molina Medicaid,CPT,D5810,Denture interm cmplt maxill,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Molina Medicaid,CPT,D5811,Denture interm cmplt mandbl,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Molina Medicaid,CPT,D5820,Denture interm part maxill,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Molina Medicaid,CPT,D5821,Denture interm part mandbl,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Molina Medicaid,CPT,D5850,Denture tiss conditn maxill,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Molina Medicaid,CPT,D5851,Denture tiss condtin mandbl,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Molina Medicaid,CPT,D5862,Precision attachment,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Molina Medicaid,CPT,D5863,Overdenture complete max,Dental,Per Unit,$162.24 ,OP,162.24,162.24,,,,,,
Molina Medicaid,CPT,D5864,Overdenture partial max,Dental,Per Unit,$162.24 ,OP,162.24,162.24,,,,,,
Molina Medicaid,CPT,D5865,Overdenture complete mandib,Dental,Per Unit,$162.24 ,OP,162.24,162.24,,,,,,
Molina Medicaid,CPT,D5866,Overdenture partial mandib,Dental,Per Unit,$162.24 ,OP,162.24,162.24,,,,,,
Molina Medicaid,CPT,D5867,Replacement of precision att,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Molina Medicaid,CPT,D5875,Prosthesis modification,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Molina Medicaid,CPT,D5876,Add metal sub to acrylc dent,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Molina Medicaid,CPT,D5899,Removable prosthodontic proc,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Molina Medicaid,CPT,D5911,Facial moulage sectional,Dental,Per Unit,$30.61 ,OP,30.61,30.61,,,,,,
Molina Medicaid,CPT,D5912,Facial moulage complete,Dental,Per Unit,$30.61 ,OP,30.61,30.61,,,,,,
Molina Medicaid,CPT,D5913,Nasal prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Molina Medicaid,CPT,D5914,Auricular prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Molina Medicaid,CPT,D5915,Orbital prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Molina Medicaid,CPT,D5916,Ocular prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Molina Medicaid,CPT,D5919,Facial prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Molina Medicaid,CPT,D5922,Nasal septal prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Molina Medicaid,CPT,D5923,Ocular prosthesis interim,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Molina Medicaid,CPT,D5924,Cranial prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Molina Medicaid,CPT,D5925,Facial augmentation implant,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Molina Medicaid,CPT,D5926,Replacement nasal prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Molina Medicaid,CPT,D5927,Auricular replacement,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Molina Medicaid,CPT,D5928,Orbital replacement,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Molina Medicaid,CPT,D5929,Facial replacement,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Molina Medicaid,CPT,D5931,Surgical obturator,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Molina Medicaid,CPT,D5932,Postsurgical obturator,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Molina Medicaid,CPT,D5933,Refitting of obturator,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Molina Medicaid,CPT,D5934,Mandibular flange prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Molina Medicaid,CPT,D5935,Mandibular denture prosth,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Molina Medicaid,CPT,D5936,Temp obturator prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Molina Medicaid,CPT,D5937,Trismus appliance,Dental,Per Unit,$30.61 ,OP,30.61,30.61,,,,,,
Molina Medicaid,CPT,D5951,Feeding aid,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Molina Medicaid,CPT,D5952,Pediatric speech aid,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Molina Medicaid,CPT,D5953,Adult speech aid,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Molina Medicaid,CPT,D5954,Superimposed prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Molina Medicaid,CPT,D5955,Palatal lift prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Molina Medicaid,CPT,D5958,Intraoral con def inter plt,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Molina Medicaid,CPT,D5959,Intraoral con def mod palat,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Molina Medicaid,CPT,D5960,Modify speech aid prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Molina Medicaid,CPT,D5982,Surgical stent,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Molina Medicaid,CPT,D5983,Radiation applicator,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Molina Medicaid,CPT,D5984,Radiation shield,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Molina Medicaid,CPT,D5985,Radiation cone locator,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Molina Medicaid,CPT,D5986,Fluoride applicator,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D5987,Commissure splint,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Molina Medicaid,CPT,D5988,Surgical splint,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Molina Medicaid,CPT,D5991,Vesiculobullous disease carr,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D5992,Adjust max prost appliance,Dental,Per Unit,$30.61 ,OP,30.61,30.61,,,,,,
Molina Medicaid,CPT,D5993,Main/clean max prosthesis,Dental,Per Unit,$30.61 ,OP,30.61,30.61,,,,,,
Molina Medicaid,CPT,D5994,Peridontal medicament,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Molina Medicaid,CPT,D5995,"Peri medicament w/seal, max",Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Molina Medicaid,CPT,D5996,"Peri medicament w/seal, mand",Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Molina Medicaid,CPT,D5999,Maxillofacial prosthesis,Dental,Per Unit,$159.88 ,OP,159.88,159.88,,,,,,
Molina Medicaid,CPT,D6010,Odontics endosteal implant,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Molina Medicaid,CPT,D6011,Second stage implant surgery,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Molina Medicaid,CPT,D6012,Endosteal implant,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Molina Medicaid,CPT,D6013,Surgical place mini implant,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Molina Medicaid,CPT,D6040,Odontics eposteal implant,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Molina Medicaid,CPT,D6050,Odontics transosteal implnt,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Molina Medicaid,CPT,D6051,Interim abutment,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6055,Implant connecting bar,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6056,Prefabricated abutment,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6057,Custom abutment,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6058,Abutment supported crown,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6059,Abutment supported mtl crown,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6060,Abutment supported mtl crown,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6061,Abutment supported mtl crown,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6062,Abutment supported mtl crown,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6063,Abutment supported mtl crown,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6064,Abutment supported mtl crown,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6065,Implant supported crown,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6066,Implant supported mtl crown,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6067,Implant supported mtl crown,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6068,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6069,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6070,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6071,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6072,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6073,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6074,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6075,Implant supported retainer,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6076,Implant supported retainer,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6077,Implant supported retainer,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6080,Implant maintenance,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Molina Medicaid,CPT,D6081,"Scale & debride, single imp",Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Molina Medicaid,CPT,D6082,Imp crown porc to base alloy,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6083,Imp crown porc to noble allo,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6084,Imp crown porc to titanium,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6085,Provisional implant crown,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Molina Medicaid,CPT,D6086,Imp crown base alloys,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6087,Implant crown noble alloys,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6088,Imp crown titanium alloys,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6090,Repair implant,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Molina Medicaid,CPT,D6091,Repl semi/precision attach,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Molina Medicaid,CPT,D6092,Recement supp crown,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Molina Medicaid,CPT,D6093,Recement supp part denture,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Molina Medicaid,CPT,D6094,Abut support crown titanium,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6095,Odontics repr abutment,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Molina Medicaid,CPT,D6096,Remove broken imp ret screw,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Molina Medicaid,CPT,D6097,Abut crown porc to titanium,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6098,Imp retain porc to base allo,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6099,Imp retainer for fpd,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6100,Removal of implant,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Molina Medicaid,CPT,D6101,Debridement of a periimplant,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Molina Medicaid,CPT,D6102,Debridement & contouring,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Molina Medicaid,CPT,D6103,Bone graft repair perimplant,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Molina Medicaid,CPT,D6104,Bone graft time of implant,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Molina Medicaid,CPT,D6110,Implnt/abut remov dent max,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6111,Implnt/abut remov dent mand,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6112,Imp/abut rem dent part max,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6113,Imp/abut rem dent part mand,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6114,Implnt/abut fixed dent max,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6115,Implnt/abut fixed dent mand,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6116,Imp/abut fixed dent part max,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6117,Imp/abut fixed dent part man,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6118,Imp/abut int fixed dent man,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6119,Int/abut int fixed dent max,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6120,Imp retain porc to titanium,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6121,Retain metal fpd base alloys,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6122,Retain metal fpd noble alloy,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6123,Retain metal fpd titanium,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6190,Radio/surgical implant index,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Molina Medicaid,CPT,D6191,Semi precision abutment,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Molina Medicaid,CPT,D6192,Semi precision attachment,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Molina Medicaid,CPT,D6194,Abut support retainer titani,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6195,Abut retain porc to titanium,Dental,Per Unit,$757.63 ,OP,757.63,757.63,,,,,,
Molina Medicaid,CPT,D6199,Implant procedure,Dental,Per Unit,$688.76 ,OP,688.76,688.76,,,,,,
Molina Medicaid,CPT,D6205,Pontic-indirect resin based,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
Molina Medicaid,CPT,D6210,Prosthodont high noble metal,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
Molina Medicaid,CPT,D6211,Bridge base metal cast,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
Molina Medicaid,CPT,D6212,Bridge noble metal cast,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
Molina Medicaid,CPT,D6214,Pontic titanium,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
Molina Medicaid,CPT,D6240,Bridge porcelain high noble,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
Molina Medicaid,CPT,D6241,Bridge porcelain base metal,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
Molina Medicaid,CPT,D6242,Bridge porcelain nobel metal,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
Molina Medicaid,CPT,D6243,Pontic porcelain to titanium,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
Molina Medicaid,CPT,D6245,Bridge porcelain/ceramic,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
Molina Medicaid,CPT,D6250,Bridge resin w/high noble,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
Molina Medicaid,CPT,D6251,Bridge resin base metal,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
Molina Medicaid,CPT,D6252,Bridge resin w/noble metal,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
Molina Medicaid,CPT,D6253,Provisional pontic,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
Molina Medicaid,CPT,D6545,Dental retainr cast metl,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Molina Medicaid,CPT,D6548,Porcelain/ceramic retainer,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Molina Medicaid,CPT,D6549,Resin retainer,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Molina Medicaid,CPT,D6600,Porcelain/ceramic inlay 2srf,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Molina Medicaid,CPT,D6601,Porc/ceram inlay >= 3 surfac,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Molina Medicaid,CPT,D6602,Cst hgh nble mtl inlay 2 srf,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Molina Medicaid,CPT,D6603,Cst hgh nble mtl inlay >=3sr,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Molina Medicaid,CPT,D6604,Cst bse mtl inlay 2 surfaces,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Molina Medicaid,CPT,D6605,Cst bse mtl inlay >= 3 surfa,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Molina Medicaid,CPT,D6606,Cast noble metal inlay 2 sur,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Molina Medicaid,CPT,D6607,Cst noble mtl inlay >=3 surf,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Molina Medicaid,CPT,D6608,Onlay porc/crmc 2 surfaces,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Molina Medicaid,CPT,D6609,Onlay porc/crmc >=3 surfaces,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Molina Medicaid,CPT,D6610,Onlay cst hgh nbl mtl 2 srfc,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Molina Medicaid,CPT,D6611,Onlay cst hgh nbl mtl >=3srf,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Molina Medicaid,CPT,D6612,Onlay cst base mtl 2 surface,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Molina Medicaid,CPT,D6613,Onlay cst base mtl >=3 surfa,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Molina Medicaid,CPT,D6614,Onlay cst nbl mtl 2 surfaces,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Molina Medicaid,CPT,D6615,Onlay cst nbl mtl >=3 surfac,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Molina Medicaid,CPT,D6624,Inlay titanium,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Molina Medicaid,CPT,D6634,Onlay titanium,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Molina Medicaid,CPT,D6710,Crown-indirect resin based,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Molina Medicaid,CPT,D6720,Retain crown resin w hi nble,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Molina Medicaid,CPT,D6721,Crown resin w/base metal,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Molina Medicaid,CPT,D6722,Crown resin w/noble metal,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Molina Medicaid,CPT,D6740,Crown porcelain/ceramic,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Molina Medicaid,CPT,D6750,Crown porcelain high noble,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Molina Medicaid,CPT,D6751,Crown porcelain base metal,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Molina Medicaid,CPT,D6752,Crown porcelain noble metal,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Molina Medicaid,CPT,D6753,Retain crown porc to titaniu,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Molina Medicaid,CPT,D6780,Crown 3/4 high noble metal,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Molina Medicaid,CPT,D6781,Crown 3/4 cast based metal,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Molina Medicaid,CPT,D6782,Crown 3/4 cast noble metal,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Molina Medicaid,CPT,D6783,Crown 3/4 porcelain/ceramic,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Molina Medicaid,CPT,D6784,Retainer crown 3/4 titanium,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Molina Medicaid,CPT,D6790,Crown full high noble metal,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Molina Medicaid,CPT,D6791,Crown full base metal cast,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Molina Medicaid,CPT,D6792,Crown full noble metal cast,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Molina Medicaid,CPT,D6793,Provisional retainer crown,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Molina Medicaid,CPT,D6794,Crown titanium,Dental,Per Unit,$251.59 ,OP,251.59,251.59,,,,,,
Molina Medicaid,CPT,D6920,Dental connector bar,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Molina Medicaid,CPT,D6930,Recement/bond part denture,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Molina Medicaid,CPT,D6940,Stress breaker,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Molina Medicaid,CPT,D6950,Precision attachment,Dental,Per Unit,$54.36 ,OP,54.36,54.36,,,,,,
Molina Medicaid,CPT,D6980,Fixed partial repair,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Molina Medicaid,CPT,D6985,Pediatric partial denture fx,Dental,Per Unit,$203.37 ,OP,203.37,203.37,,,,,,
Molina Medicaid,CPT,D6999,Fixed prosthodontic proc,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Molina Medicaid,CPT,D7111,Extraction coronal remnants,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7140,Extraction erupted tooth/exr,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7210,Rem imp tooth w mucoper flp,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7220,Impact tooth remov soft tiss,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7230,Impact tooth remov part bony,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7240,Impact tooth remov comp bony,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7241,Impact tooth rem bony w/comp,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Molina Medicaid,CPT,D7250,Tooth root removal,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7251,Coronectomy,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Molina Medicaid,CPT,D7260,Oral antral fistula closure,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7261,Primary closure sinus perf,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Molina Medicaid,CPT,D7270,Tooth reimplantation,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7272,Tooth transplantation,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7280,Exposure of unerupted tooth,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Molina Medicaid,CPT,D7282,Mobilize erupted/malpos toot,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7283,Place device impacted tooth,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7285,Biopsy of oral tissue hard,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7286,Biopsy of oral tissue soft,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D7287,Exfoliative cytolog collect,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7288,Brush biopsy,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7290,Repositioning of teeth,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D7291,Transseptal fiberotomy,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7292,Screw retained plate,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7293,Temp anchorage dev w flap,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7294,Temp anchorage dev w/o flap,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7295,"Bone harvest,auto graft proc",Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7296,"Corticotomy, 1-3 teeth",Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Molina Medicaid,CPT,D7297,"Corticotomy, 4 or more teeth",Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Molina Medicaid,CPT,D7310,Alveoplasty w/ extraction,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7311,Alveoloplasty w/extract 1-3,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7320,Alveoplasty w/o extraction,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7321,Alveoloplasty not w/extracts,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7340,Vestibuloplasty ridge extens,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Molina Medicaid,CPT,D7350,Vestibuloplasty exten graft,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,D7410,Rad exc lesion up to 1.25 cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7411,Excision benign lesion>1.25c,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7412,Excision benign lesion compl,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7413,Excision malig lesion<=1.25c,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7414,Excision malig lesion>1.25cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7415,Excision malig les complicat,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7440,Malig tumor exc to 1.25 cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7441,Malig tumor > 1.25 cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7450,Rem odontogen cyst to 1.25cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7451,Rem odontogen cyst > 1.25 cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7460,Rem nonodonto cyst to 1.25cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7461,Rem nonodonto cyst > 1.25 cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7465,Lesion destruction,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7471,Rem exostosis any site,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7472,Removal of torus palatinus,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Molina Medicaid,CPT,D7473,Remove torus mandibularis,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7485,Surg reduct osseoustuberosit,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7490,Maxilla or mandible resectio,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Molina Medicaid,CPT,D7510,I&d absc intraoral soft tiss,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D7511,Incision/drain abscess intra,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7520,I&d abscess extraoral,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7521,Incision/drain abscess extra,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7530,Removal fb skin/areolar tiss,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7540,Removal of fb reaction,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Molina Medicaid,CPT,D7550,Removal of sloughed off bone,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7560,Maxillary sinusotomy,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Molina Medicaid,CPT,D7610,Maxilla open reduct simple,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,D7620,Clsd reduct simpl maxilla fx,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Molina Medicaid,CPT,D7630,Open red simpl mandible fx,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,D7640,Clsd red simpl mandible fx,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Molina Medicaid,CPT,D7650,Open red simp malar/zygom fx,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Molina Medicaid,CPT,D7660,Clsd red simp malar/zygom fx,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7670,Closd rductn splint alveolus,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7671,Alveolus open reduction,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7680,Reduct simple facial bone fx,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Molina Medicaid,CPT,D7710,Maxilla open reduct compound,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,D7720,Clsd reduct compd maxilla fx,Dental,Per Unit,$156.21 ,OP,156.21,156.21,,,,,,
Molina Medicaid,CPT,D7730,Open reduct compd mandble fx,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,D7740,Clsd reduct compd mandble fx,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Molina Medicaid,CPT,D7750,Open red comp malar/zygma fx,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Molina Medicaid,CPT,D7760,Clsd red comp malar/zygma fx,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7770,Open reduc compd alveolus fx,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7771,Alveolus clsd reduc stblz te,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7780,Reduct compnd facial bone fx,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7810,Tmj open reduct-dislocation,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,D7820,Closed tmp manipulation,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7830,Tmj manipulation under anest,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7840,Removal of tmj condyle,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,D7850,Tmj meniscectomy,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,D7852,Tmj repair of joint disc,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,D7854,Tmj excisn of joint membrane,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,D7856,Tmj cutting of a muscle,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,D7858,Tmj reconstruction,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,D7860,Tmj cutting into joint,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,D7865,Tmj reshaping components,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,D7870,Tmj aspiration joint fluid,Dental,Per Unit,$156.21 ,OP,156.21,156.21,,,,,,
Molina Medicaid,CPT,D7871,Lysis + lavage w catheters,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7872,Tmj diagnostic arthroscopy,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D7873,Tmj arthroscopy lysis adhesn,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,D7874,Tmj arthroscopy disc reposit,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,D7875,Tmj arthroscopy synovectomy,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,D7876,Tmj arthroscopy discectomy,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,D7877,Tmj arthroscopy debridement,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,D7880,Occlusal orthotic appliance,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7881,Occ orthotic device adjust,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D7899,Tmj unspecified therapy,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7910,Dent sutur recent wnd to 5cm,Dental,Per Unit,$156.21 ,OP,156.21,156.21,,,,,,
Molina Medicaid,CPT,D7911,Dental suture wound to 5 cm,Dental,Per Unit,$156.21 ,OP,156.21,156.21,,,,,,
Molina Medicaid,CPT,D7912,Suture complicate wnd > 5 cm,Dental,Per Unit,$156.21 ,OP,156.21,156.21,,,,,,
Molina Medicaid,CPT,D7920,Dental skin graft,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7921,Collect & appl blood product,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7922,Place intra-socket bio dress,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7940,Reshaping bone orthognathic,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7941,Bone cutting ramus closed,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,D7943,Cutting ramus open w/graft,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,D7944,Bone cutting segmented,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,D7945,Bone cutting body mandible,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,D7946,Reconstruction maxilla total,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,D7947,Reconstruct maxilla segment,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,D7948,Reconstruct midface no graft,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,D7949,Reconstruct midface w/graft,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,D7950,Mandible graft,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Molina Medicaid,CPT,D7951,Sinus aug w bone or bone sub,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Molina Medicaid,CPT,D7952,Sinus augmentation vertical,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Molina Medicaid,CPT,D7953,Bone replacement graft,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Molina Medicaid,CPT,D7955,Repair maxillofacial defects,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Molina Medicaid,CPT,D7960,Frenulectomy/frenectomy,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D7961,Buccal/labial frenectomy,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7962,Lingual frenectomy,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7963,Frenuloplasty,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7970,Excision hyperplastic tissue,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Molina Medicaid,CPT,D7971,Excision pericoronal gingiva,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7972,Surg redct fibrous tuberosit,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7979,Non-surgical sialolithotomy,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7980,Surgical sialolithotomy,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Molina Medicaid,CPT,D7981,Excision of salivary gland,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7982,Sialodochoplasty,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,D7983,Closure of salivary fistula,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7990,Emergency tracheotomy,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,D7991,Dental coronoidectomy,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,451.22,451.22,,,,,,
Molina Medicaid,CPT,D7993,Surg place craniofacial impl,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Molina Medicaid,CPT,D7994,Surg place zygomatic impl,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Molina Medicaid,CPT,D7995,Synthetic graft facial bones,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7996,Implant mandible for augment,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,410.2,410.2,,,,,,
Molina Medicaid,CPT,D7997,Appliance removal,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7998,Intraoral place of fix dev,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D7999,Oral surgery procedure,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,394.52,394.52,,,,,,
Molina Medicaid,CPT,D8010,Limited dental tx primary,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Molina Medicaid,CPT,D8020,Limited dental tx transition,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Molina Medicaid,CPT,D8030,Limited dental tx adolescent,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Molina Medicaid,CPT,D8040,Limited dental tx adult,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Molina Medicaid,CPT,D8050,Intercep dental tx primary,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Molina Medicaid,CPT,D8060,Intercep dental tx transitn,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Molina Medicaid,CPT,D8070,Compre dental tx transition,Dental,Per Unit,$195.04 ,OP,195.04,195.04,,,,,,
Molina Medicaid,CPT,D8080,Compre dental tx adolescent,Dental,Per Unit,$195.04 ,OP,195.04,195.04,,,,,,
Molina Medicaid,CPT,D8090,Compre dental tx adult,Dental,Per Unit,$195.04 ,OP,195.04,195.04,,,,,,
Molina Medicaid,CPT,D8210,Orthodontic rem appliance tx,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Molina Medicaid,CPT,D8220,Fixed appliance therapy habt,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Molina Medicaid,CPT,D8660,Preorthodontic tx visit,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Molina Medicaid,CPT,D8670,Periodic orthodontc tx visit,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Molina Medicaid,CPT,D8680,Orthodontic retention,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Molina Medicaid,CPT,D8681,Removable retainer adjust,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D8690,Orthodontic treatment,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Molina Medicaid,CPT,D8691,Repair ortho appliance,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Molina Medicaid,CPT,D8692,Replacement retainer,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Molina Medicaid,CPT,D8693,Rebond/recement retainers,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Molina Medicaid,CPT,D8694,Repair fixed retainers,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Molina Medicaid,CPT,D8695,Remove fixed ortho appliance,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Molina Medicaid,CPT,D8696,Rep of ortho appliance max,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Molina Medicaid,CPT,D8697,Rep of ortho appliance man,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Molina Medicaid,CPT,D8698,Recement fixed retainer max,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Molina Medicaid,CPT,D8699,Recement fixed retainer man,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Molina Medicaid,CPT,D8701,Repair fixed retainer max,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Molina Medicaid,CPT,D8702,Repair of fixed retainer man,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Molina Medicaid,CPT,D8703,Replace broken retainer max,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Molina Medicaid,CPT,D8704,Replace broken retainer man,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Molina Medicaid,CPT,D8999,Orthodontic procedure,Dental,Per Unit,$177.32 ,OP,177.32,177.32,,,,,,
Molina Medicaid,CPT,D9110,Tx dental pain minor proc,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D9120,Fix partial denture section,Dental,Per Unit,$110.21 ,OP,110.21,110.21,,,,,,
Molina Medicaid,CPT,D9130,Temporomandibular joint dysf,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,D9210,Dent anesthesia w/o surgery,Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
Molina Medicaid,CPT,D9211,Regional block anesthesia,Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
Molina Medicaid,CPT,D9212,Trigeminal block anesthesia,Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
Molina Medicaid,CPT,D9215,Local anesthesia,Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
Molina Medicaid,CPT,D9219,Eval mod/deep sed/gen anest,Dental,Per Unit,$130.37 ,OP,130.37,130.37,,,,,,
Molina Medicaid,CPT,D9220,General anesthesia,Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
Molina Medicaid,CPT,D9221,General anesthesia ea ad 15m,Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
Molina Medicaid,CPT,D9222,"Deep anest, 1st 15 min",Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
Molina Medicaid,CPT,D9223,General anesth ea addl 15 mi,Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
Molina Medicaid,CPT,D9230,Analgesia,Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
Molina Medicaid,CPT,D9239,"Iv mod sedation, 1st 15 min",Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
Molina Medicaid,CPT,D9241,Intravenous sedation,Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
Molina Medicaid,CPT,D9242,Iv sedation ea ad 15 m,Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
Molina Medicaid,CPT,D9243,Iv sedation ea addl 15m,Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
Molina Medicaid,CPT,D9248,Sedation (non-iv),Dental,Per Unit,$24.43 ,OP,24.43,24.43,,,,,,
Molina Medicaid,CPT,D9310,Dental consultation,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D9311,Consult w/med hlth care prof,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D9410,Dental house call,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D9420,Hospital/asc call,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D9430,Office visit during hours,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D9440,Office visit after hours,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D9450,Case presentation tx plan,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,D9610,Dent therapeutic drug inject,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D9612,Thera par drugs 2 or > admin,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D9613,Infiltration thera drug,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D9630,Drugs/meds disp for home use,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D9910,Dent appl desensitizing med,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D9911,Appl desensitizing resin,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D9920,Behavior management,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D9930,Treatment of complications,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D9931,Clean/inspect rem appliance,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D9932,Clean & inspect rem dent max,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D9933,Clean & inspect rem dent man,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D9934,Clean rem part denture max,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D9935,Clean rem part denture mand,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D9940,Dental occlusal guard,Dental,Per Unit,$156.21 ,OP,156.21,156.21,,,,,,
Molina Medicaid,CPT,D9941,Fabrication athletic guard,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D9942,Repair/reline occlusal guard,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D9943,Occlusal guard adjustment,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D9944,"Occ guard, hard, full arch",Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D9945,"Occ guard, soft, full arch",Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D9946,"Occ guard, hard, part arch",Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D9950,Occlusion analysis,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D9951,Limited occlusal adjustment,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D9952,Complete occlusal adjustment,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D9970,Enamel microabrasion,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D9971,Odontoplasty per tooth,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D9972,Extrnl bleaching per arch,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D9973,Extrnl bleaching per tooth,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D9974,Intrnl bleaching per tooth,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D9975,External bleaching home app,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D9991,"Case mgmt, appt barriers",Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,D9992,"Case mgmt, care coordination",Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,D9993,"Case mgmt, interviewing",Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,D9994,"Case mgmt, pt education",Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Molina Medicaid,CPT,D9995,Teledentistry real-time,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D9996,Teledentistry dent review,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,D9997,Dent case mgmt special needs,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,D9999,Adjunctive procedure,Dental,Per Unit,$136.51 ,OP,136.51,136.51,,,,,,
Molina Medicaid,CPT,G0008,Admin influenza virus vac,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,G0009,Admin pneumococcal vaccine,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,G0010,Admin hepatitis b vaccine,Ancillary Services,Per Unit,$23.26 ,OP,23.26,23.26,,,,,,
Molina Medicaid,CPT,G0027,Semen analysis,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,G0068,Adm iv infusion drug in home,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Molina Medicaid,CPT,G0069,Adm sq infusion drug in home,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Molina Medicaid,CPT,G0070,Adm of chemo drug in home,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Molina Medicaid,CPT,G0071,Comm svcs by rhc/fqhc 5 min,Ancillary Services,Per Unit,$26.19 ,OP,26.19,26.19,,,,,,
Molina Medicaid,CPT,G0076,Care manag h vst new pt 20 m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,G0077,Care manag h vst new pt 30 m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,G0078,Care manag h vst new pt 45 m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,G0079,Care manag h vst new pt 60 m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,G0080,Care manag h vst new pt 75 m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,G0081,Care man h v ext pt 20 mi,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,G0082,Care man h v ext pt 30 m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,G0083,Care man h v ext pt 45 m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,G0084,Care man h v ext pt 60 m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,G0085,Care man h v ext pt 75 m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,G0086,Care man home care plan 30 m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,G0087,Care man home care plan 60 m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,G0088,Adm iv drug 1st home visit,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Molina Medicaid,CPT,G0089,Adm subq drug 1st home visit,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Molina Medicaid,CPT,G0090,Adm iv chemo 1st home visit,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Molina Medicaid,CPT,G0103,Psa screening,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,G0104,Ca screen;flexi sigmoidscope,Preventive Care,Per Unit,$387.00 ,OP,387,387,,,,,,
Molina Medicaid,CPT,G0105,Colorectal scrn; hi risk ind,Preventive Care,Per Unit,$387.00 ,OP,387,387,,,,,,
Molina Medicaid,CPT,G0108,Diab manage trn per indiv,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Molina Medicaid,CPT,G0109,Diab manage trn ind/group,Preventive Care,Per Unit,$26.23 ,OP,26.23,26.23,,,,,,
Molina Medicaid,CPT,G0117,Glaucoma scrn hgh risk direc,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,G0118,Glaucoma scrn hgh risk direc,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,G0121,Colon ca scrn not hi rsk ind,Preventive Care,Per Unit,$387.00 ,OP,387,387,,,,,,
Molina Medicaid,CPT,G0122,Colon ca scrn; barium enema,Diagnostic Radiology,Per Unit,$31.74 ,OP,31.74,31.74,,,,,,
Molina Medicaid,CPT,G0123,Screen cerv/vag thin layer,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Molina Medicaid,CPT,G0124,Screen c/v thin layer by md,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Molina Medicaid,CPT,G0127,Trim nail(s),General Surgery,Per Unit,$46.77 ,OP,46.77,46.77,,,,,,
Molina Medicaid,CPT,G0128,Corf skilled nursing service,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,G0130,Single energy x-ray study,Diagnostic Radiology,Per Unit,$50.13 ,OP,50.13,50.13,,,,,,
Molina Medicaid,CPT,G0141,"Scr c/v cyto,autosys and md",Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Molina Medicaid,CPT,G0143,"Scr c/v cyto,thinlayer,rescr",Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Molina Medicaid,CPT,G0144,"Scr c/v cyto,thinlayer,rescr",Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Molina Medicaid,CPT,G0145,"Scr c/v cyto,thinlayer,rescr",Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Molina Medicaid,CPT,G0147,"Scr c/v cyto, automated sys",Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Molina Medicaid,CPT,G0148,"Scr c/v cyto, autosys, rescr",Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Molina Medicaid,CPT,G0151,"Hhcp-serv of pt,ea 15 min",Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,G0152,"Hhcp-serv of ot,ea 15 min",Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,G0153,"Hhcp-svs of s/l path,ea 15mn",Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,G0155,"Hhcp-svs of csw,ea 15 min",Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,G0157,Hhc pt assistant ea 15,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,G0158,Hhc ot assistant ea 15,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,G0159,Hhc pt maint ea 15 min,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,G0160,Hhc occup therapy ea 15,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,G0161,Hhc slp ea 15 min,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,G0162,"Hhc rn e&m plan svs, 15 min",Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,G0166,"Extrnl counterpulse, per tx",Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,G0175,"Opps service,sched team conf",Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,G0176,Opps/php;activity therapy,Behavioral Health,Per Unit,$48.15 ,OP,48.15,48.15,,,,,,
Molina Medicaid,CPT,G0177,Opps/php; train & educ serv,Behavioral Health,Per Unit,$48.15 ,OP,48.15,48.15,,,,,,
Molina Medicaid,CPT,G0179,Md recertification hha pt,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,G0180,Md certification hha patient,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,G0181,Home health care supervision,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,G0182,Hospice care supervision,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,G0186,"Dstry eye lesn,fdr vssl tech",Ophthalmology Surgery,Per Unit,$312.24 ,OP,312.24,312.24,,,,,,
Molina Medicaid,CPT,G0202,Scr mammo bi incl cad,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
Molina Medicaid,CPT,G0204,Dx mammo incl cad bi,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
Molina Medicaid,CPT,G0206,Dx mammo incl cad uni,Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
Molina Medicaid,CPT,G0219,Pet img wholbod melano nonco,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Molina Medicaid,CPT,G0235,Pet not otherwise specified,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Molina Medicaid,CPT,G0237,Therapeutic procd strg endur,Rehabilitation,Per Unit,$73.11 ,OP,73.11,73.11,,,,,,
Molina Medicaid,CPT,G0238,"Oth resp proc, indiv",Rehabilitation,Per Unit,$73.11 ,OP,73.11,73.11,,,,,,
Molina Medicaid,CPT,G0239,"Oth resp proc, group",Rehabilitation,Per Unit,$73.11 ,OP,73.11,73.11,,,,,,
Molina Medicaid,CPT,G0248,Demonstrate use home inr mon,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Molina Medicaid,CPT,G0252,Pet imaging initial dx,Diagnostic Radiology,Per Unit,$697.72 ,OP,697.72,697.72,,,,,,
Molina Medicaid,CPT,G0255,Current percep threshold tst,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,G0257,Unsched dialysis esrd pt hos,Nephrology,Per Unit,$540.95 ,OP,540.95,540.95,,,,,,
Molina Medicaid,CPT,G0270,Mnt subs tx for change dx,Ancillary Services,Per Unit,$100.15 ,OP,100.15,100.15,,,,,,
Molina Medicaid,CPT,G0271,Group mnt 2 or more 30 mins,Ancillary Services,Per Unit,$100.15 ,OP,100.15,100.15,,,,,,
Molina Medicaid,CPT,G0278,"Iliac art angio,cardiac cath",Interventional Radiology,Per Unit,"$1,525.89 ",OP,"1,525.89","1,525.89",,,,,,
Molina Medicaid,CPT,G0279,"Tomosynthesis, mammo",Diagnostic Radiology,Per Unit,$39.40 ,OP,39.4,39.4,,,,,,
Molina Medicaid,CPT,G0283,Elec stim other than wound,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,G0289,"Arthro, loose body + chondro",Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,G0293,"Non-cov surg proc,clin trial",Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,G0297,Ldct for lung ca screen,Diagnostic Radiology,Per Unit,$162.95 ,OP,162.95,162.95,,,,,,
Molina Medicaid,CPT,G0306,Cbc/diffwbc w/o platelet,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Molina Medicaid,CPT,G0307,Cbc without platelet,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Molina Medicaid,CPT,G0328,Fecal blood scrn immunoassay,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,G0339,"Robot lin-radsurg com, first",Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"2,592.65","2,592.65",,,,,,
Molina Medicaid,CPT,G0340,Robt lin-radsurg fractx 2-5,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"2,592.65","2,592.65",,,,,,
Molina Medicaid,CPT,G0365,Vessel mapping hemo access,Diagnostic Radiology,Per Unit,$114.16 ,OP,114.16,114.16,,,,,,
Molina Medicaid,CPT,G0378,Hospital observation per hr,Ancillary Services,Per Unit,$651.20 ,OP,651.2,651.2,,,,,,
Molina Medicaid,CPT,G0389,Ultrasound exam aaa screen,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,G0396,Alcohol/subs interv 15-30mn,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Molina Medicaid,CPT,G0397,Alcohol/subs interv >30 min,Behavioral Health,Per Unit,$84.55 ,OP,84.55,84.55,,,,,,
Molina Medicaid,CPT,G0403,Ekg for initial prevent exam,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Molina Medicaid,CPT,G0404,Ekg tracing for initial prev,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Molina Medicaid,CPT,G0405,Ekg interpret & report preve,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Molina Medicaid,CPT,G0409,Corf related serv 15 mins ea,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Molina Medicaid,CPT,G0410,Grp psych partial hosp 45-50,Behavioral Health,Per Unit,$119.88 ,OP,119.88,119.88,,,,,,
Molina Medicaid,CPT,G0411,Inter active grp psych parti,Behavioral Health,Per Unit,$119.88 ,OP,119.88,119.88,,,,,,
Molina Medicaid,CPT,G0412,Open tx iliac spine uni/bil,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,G0413,Pelvic ring fracture uni/bil,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,G0414,Pelvic ring fx treat int fix,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,G0415,Open tx post pelvic fxcture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"2,555.93","2,555.93",,,,,,
Molina Medicaid,CPT,G0420,Ed svc ckd ind per session,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Molina Medicaid,CPT,G0421,Ed svc ckd grp per session,Preventive Care,Per Unit,$26.23 ,OP,26.23,26.23,,,,,,
Molina Medicaid,CPT,G0422,Intens cardiac rehab w/exerc,Rehabilitation,Per Unit,$274.82 ,OP,274.82,274.82,,,,,,
Molina Medicaid,CPT,G0423,Intens cardiac rehab no exer,Rehabilitation,Per Unit,$274.82 ,OP,274.82,274.82,,,,,,
Molina Medicaid,CPT,G0424,Pulmonary rehab w exer,Rehabilitation,Per Unit,$73.11 ,OP,73.11,73.11,,,,,,
Molina Medicaid,CPT,G0431,Drug screen multiple class,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,G0432,Eia hiv-1/hiv-2 screen,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,G0433,Elisa hiv-1/hiv-2 screen,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,G0434,Drug screen multi drug class,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,G0435,Oral hiv-1/hiv-2 screen,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,G0436,Tobacco-use counsel 3-10 min,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Molina Medicaid,CPT,G0437,Tobacco-use counsel>10min,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Molina Medicaid,CPT,G0442,Annual alcohol screen 15 min,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Molina Medicaid,CPT,G0443,Brief alcohol misuse counsel,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Molina Medicaid,CPT,G0444,Depression screen annual,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Molina Medicaid,CPT,G0445,High inten beh couns std 30m,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Molina Medicaid,CPT,G0446,Intens behave ther cardio dx,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Molina Medicaid,CPT,G0447,Behavior counsel obesity 15m,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Molina Medicaid,CPT,G0448,Place perm pacing cardiovert,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"13,158.48","13,158.48",,,,,,
Molina Medicaid,CPT,G0451,Devlopment test interpt&rep,Behavioral Health,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
Molina Medicaid,CPT,G0452,Molecular pathology interpr,Pathology,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,
Molina Medicaid,CPT,G0459,Telehealth inpt pharm mgmt,Behavioral Health,Per Unit,$80.13 ,OP,80.13,80.13,,,,,,
Molina Medicaid,CPT,G0464,"Colorec CA scr, sto bas DNA",Laboratory,Per Unit,$210.68 ,OP,210.68,210.68,,,,,,
Molina Medicaid,CPT,G0472,Hep c screen high risk/other,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,G0473,Group behave couns 2-10,Behavioral Health,Per Unit,$119.88 ,OP,119.88,119.88,,,,,,
Molina Medicaid,CPT,G0475,Hiv combination assay,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,G0476,Hpv combo assay ca screen,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,G0477,Drug test presump optical,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,G0478,Drug test presump opt inst,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,G0479,Drug test presump not opt,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,G0480,Drug test def 1-7 classes,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,G0491,Dialysis acu kidney no esrd,Nephrology,Per Unit,$540.95 ,OP,540.95,540.95,,,,,,
Molina Medicaid,CPT,G0492,Md/oth eval acut kid no esrd,Nephrology,Per Unit,$540.95 ,OP,540.95,540.95,,,,,,
Molina Medicaid,CPT,G0495,Rn care train/edu in hh,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Molina Medicaid,CPT,G0496,Lpn care train/edu in hh,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Molina Medicaid,CPT,G0498,Chemo extend iv infus w/pump,General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
Molina Medicaid,CPT,G0499,Hepb screen high risk indiv,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,G0500,Mod sedat endo service >5yrs,Anesthesia,Per Unit,$13.45 ,OP,13.45,13.45,,,,,,
Molina Medicaid,CPT,G0502,"Init psych care manag, 70min",Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Molina Medicaid,CPT,G0503,"Subseq  psych care man,60mi",Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Molina Medicaid,CPT,G0504,Init/sub psych care add 30 m,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Molina Medicaid,CPT,G0506,Comp asses care plan ccm svc,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,G0507,Care manage serv minimum 20,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Molina Medicaid,CPT,G0511,Ccm/bhi by rhc/fqhc 20min mo,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,G0512,Cocm by rhc/fqhc 60 min mo,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Molina Medicaid,CPT,G0515,Cognitive skills development,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,G0516,"Insert drug del implant, >=4",General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,G0517,Remove drug implant,General Surgery,Per Unit,$171.35 ,OP,171.35,171.35,,,,,,
Molina Medicaid,CPT,G0518,Remove w insert drug implant,General Surgery,Per Unit,$597.65 ,OP,597.65,597.65,,,,,,
Molina Medicaid,CPT,G0659,Drug test def simple all cl,Laboratory,Per Unit,$17.30 ,OP,17.3,17.3,,,,,,
Molina Medicaid,CPT,G2000,Blinded conv. tx mdd clin tr,Behavioral Health,Per Unit,$276.44 ,OP,276.44,276.44,,,,,,
Molina Medicaid,CPT,G2010,Remot image submit by pt,Ancillary Services,Per Unit,$26.19 ,OP,26.19,26.19,,,,,,
Molina Medicaid,CPT,G2011,Alcohol/sub misuse assess,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Molina Medicaid,CPT,G2012,Brief check in by md/qhp,Ancillary Services,Per Unit,$26.19 ,OP,26.19,26.19,,,,,,
Molina Medicaid,CPT,G2014,Post-d/c care plan overs 30m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,G2015,Post-d/c care plan overs 60m,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,G2058,Ccm add 20min,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,G2064,Md mang high risk dx 30,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,G2065,Clin mang h risk dx 30,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,G2066,Inter devc remote 30d,Ancillary Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,
Molina Medicaid,CPT,G2082,Visit esketamine 56m or less,Behavioral Health,Per Unit,$80.13 ,OP,80.13,80.13,,,,,,
Molina Medicaid,CPT,G2083,"Visit esketamine, > 56m",Behavioral Health,Per Unit,$80.13 ,OP,80.13,80.13,,,,,,
Molina Medicaid,CPT,G2168,Svs by pt in home health,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,G2169,Svs by ot in home health,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,G2213,Initiat med assist tx in er,Behavioral Health,Per Unit,$80.13 ,OP,80.13,80.13,,,,,,
Molina Medicaid,CPT,G2214,Init/sub psych care m 1st 30,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Molina Medicaid,CPT,G2250,"Remot img sub by pt, non e/m",Ancillary Services,Per Unit,$26.19 ,OP,26.19,26.19,,,,,,
Molina Medicaid,CPT,G2251,"Brief chkin, 5-10, non-e/m",Ancillary Services,Per Unit,$26.19 ,OP,26.19,26.19,,,,,,
Molina Medicaid,CPT,G2252,"Brief chkin by md/qhp, 11-20",Ancillary Services,Per Unit,$26.19 ,OP,26.19,26.19,,,,,,
Molina Medicaid,CPT,G3001,"Admin + supply, tositumomab",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Molina Medicaid,CPT,G6001,Echo guidance radiotherapy,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Molina Medicaid,CPT,G6002,Stereoscopic x-ray guidance,Interventional Radiology,Per Unit,$180.85 ,OP,180.85,180.85,,,,,,
Molina Medicaid,CPT,G6003,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Molina Medicaid,CPT,G6004,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Molina Medicaid,CPT,G6005,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Molina Medicaid,CPT,G6006,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Molina Medicaid,CPT,G6007,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Molina Medicaid,CPT,G6008,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Molina Medicaid,CPT,G6009,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Molina Medicaid,CPT,G6010,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Molina Medicaid,CPT,G6011,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Molina Medicaid,CPT,G6012,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Molina Medicaid,CPT,G6013,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Molina Medicaid,CPT,G6014,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,469.79,469.79,,,,,,
Molina Medicaid,CPT,G6015,Radiation tx delivery imrt,Therapeutic Radiology,Per Unit,$279.80 ,OP,279.8,279.8,,,,,,
Molina Medicaid,CPT,G6016,Delivery comp imrt,Therapeutic Radiology,Per Unit,$434.17 ,OP,434.17,434.17,,,,,,
Molina Medicaid,CPT,G6018,Ileoscopy w/stent,Gastroenterology,Per Unit,"$1,302.71 ",OP,"1,302.71","1,302.71",,,,,,
Molina Medicaid,CPT,G6019,Colonoscopy lesion removal,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Molina Medicaid,CPT,G6020,Colonoscopy w/stent,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Molina Medicaid,CPT,G6021,Unlisted px small intestine,General Surgery,Per Unit,$960.01 ,OP,960.01,960.01,,,,,,
Molina Medicaid,CPT,G6022,Sigmoidoscopy w/ablate tumr,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,G6023,Sigmoidoscopy w/stent,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Molina Medicaid,CPT,G6024,Lesion removal colonoscopy,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,G6025,Colonoscopy w/stent,Gastroenterology,Per Unit,$476.14 ,OP,476.14,476.14,,,,,,
Molina Medicaid,CPT,G6027,Anoscopy hra w/spec collect,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,G6028,Anoscopy hra w/biopsy,Gastroenterology,Per Unit,$427.85 ,OP,427.85,427.85,,,,,,
Molina Medicaid,CPT,G6030,Assay of amitriptyline,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,G6031,Assay of benzodiazepines,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,G6032,Assay of desipramine,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,G6034,Assay of doxepin,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,G6035,Assay of  gold,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,G6036,Assay of Imipramine,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,G6037,Assay of nortiptyline,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,G6038,Assay of salicylate,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Molina Medicaid,CPT,G6039,Assay of acetaminophen,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Molina Medicaid,CPT,G6040,Assay of ethanol,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Molina Medicaid,CPT,G6041,Assay of urine alkaloids,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Molina Medicaid,CPT,G6042,Assay of amphetamines,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Molina Medicaid,CPT,G6043,Assay of barbiturates,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Molina Medicaid,CPT,G6044,Assay of cocaine,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Molina Medicaid,CPT,G6045,Assay of dihydrocodeinone,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Molina Medicaid,CPT,G6046,Assay of dihydromorphinone,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Molina Medicaid,CPT,G6047,Assay of dihydrotestosterone,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Molina Medicaid,CPT,G6048,Assay of dimethadione,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Molina Medicaid,CPT,G6049,Assay of Epiandrosterone,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Molina Medicaid,CPT,G6050,Assay of Ethchlorvynol,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Molina Medicaid,CPT,G6051,Assay of flurazepam,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Molina Medicaid,CPT,G6052,Assay of meprobamate,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Molina Medicaid,CPT,G6053,Assay of methadone,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Molina Medicaid,CPT,G6054,Assay of methsuximide,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Molina Medicaid,CPT,G6055,Assay of nicotine,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Molina Medicaid,CPT,G6056,Assay of opiates,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Molina Medicaid,CPT,G6057,Assay of phenothiazine,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Molina Medicaid,CPT,G6058,Drug confirmation,Laboratory,Per Unit,$7.84 ,OP,7.84,7.84,,,,,,
Molina Medicaid,CPT,G9012,Other specified case mgmt,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,G9016,Demo-smoking cessation coun,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Molina Medicaid,CPT,G9020,Rimantadine hcl 100mg oral,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,G9034,"Zanamivir, inh pwdr, brand",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Molina Medicaid,CPT,G9035,"Oseltamivir phosp, brand",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Molina Medicaid,CPT,G9143,Warfarin respon genetic test,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,G9147,Outpt iv insulin tx any mea,General Medicine,Per Unit,$278.91 ,OP,278.91,278.91,,,,,,
Molina Medicaid,CPT,G9157,Transesoph doppl cardiac mon,Cardiology,Per Unit,$276.65 ,OP,276.65,276.65,,,,,,
Molina Medicaid,CPT,G9187,Bpci home visit,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,G9477,Care coord at hospice,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,G9686,Nursing facility conference,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,G9873,1 em core session,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Molina Medicaid,CPT,G9874,4 em core sessions,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Molina Medicaid,CPT,G9875,9 em core sessions,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Molina Medicaid,CPT,G9876,2 em core ms mo 7-9 no wl,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Molina Medicaid,CPT,G9877,2 em core ms mo 10-12 no wl,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Molina Medicaid,CPT,G9878,2 em core ms mo 7-9 wl,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Molina Medicaid,CPT,G9879,2 em core ms mo 10-12 wl,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Molina Medicaid,CPT,G9880,Em 5 percent wl,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Molina Medicaid,CPT,G9881,Em 9 percent wl,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Molina Medicaid,CPT,G9882,2 em ongoing ms mo 13-15 wl,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Molina Medicaid,CPT,G9883,2 em ongoing ms mo 16-18 wl,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Molina Medicaid,CPT,G9884,2 em ongoing ms mo 19-21 wl,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Molina Medicaid,CPT,G9885,2 em ongoing ms mo 22-24 wl,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Molina Medicaid,CPT,G9890,Em bridge payment,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Molina Medicaid,CPT,G9987,Bpci advanced in home visit,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,H0001,Alcohol and/or drug assess,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
Molina Medicaid,CPT,H0002,Alcohol and/or drug screenin,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
Molina Medicaid,CPT,H0003,Alcohol and/or drug screenin,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,H0004,Alcohol and/or drug services,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Molina Medicaid,CPT,H0005,Alcohol and/or drug services,Behavioral Health,Per Unit,$119.88 ,OP,119.88,119.88,,,,,,
Molina Medicaid,CPT,H0006,Alcohol and/or drug services,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Molina Medicaid,CPT,H0007,Alcohol and/or drug services,Behavioral Health,Per Unit,$135.70 ,OP,135.7,135.7,,,,,,
Molina Medicaid,CPT,H0014,Alcohol and/or drug services,Behavioral Health,Per Unit,$80.13 ,OP,80.13,80.13,,,,,,
Molina Medicaid,CPT,H0015,Alcohol and/or drug services,Behavioral Health,Per Unit,$339.88 ,OP,339.88,339.88,,,,,,
Molina Medicaid,CPT,H0020,Alcohol and/or drug services,Behavioral Health,Per Unit,$80.13 ,OP,80.13,80.13,,,,,,
Molina Medicaid,CPT,H0022,Alcohol and/or drug interven,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Molina Medicaid,CPT,H0031,Mh health assess by non-md,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
Molina Medicaid,CPT,H0032,Mh svc plan dev by non-md,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Molina Medicaid,CPT,H0033,Oral med adm direct observe,Behavioral Health,Per Unit,$80.13 ,OP,80.13,80.13,,,,,,
Molina Medicaid,CPT,H0034,Med trng & support per 15min,Behavioral Health,Per Unit,$80.13 ,OP,80.13,80.13,,,,,,
Molina Medicaid,CPT,H0035,Mh partial hosp tx under 24h,Behavioral Health,Per Unit,$220.60 ,OP,220.6,220.6,,,,,,
Molina Medicaid,CPT,H0037,Comm psy sup tx pgm per diem,Behavioral Health,Per Unit,$220.60 ,OP,220.6,220.6,,,,,,
Molina Medicaid,CPT,H0046,"Mental health service, nos",Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Molina Medicaid,CPT,H0047,Alcohol/drug abuse svc nos,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Molina Medicaid,CPT,H0049,Alcohol/drug screening,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Molina Medicaid,CPT,H0050,Alcohol/drug service 15 min,Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Molina Medicaid,CPT,H1002,Carecoordination prenatal,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,H1003,Prenatal at risk education,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Molina Medicaid,CPT,H1011,Family assessment,Behavioral Health,Per Unit,$156.88 ,OP,156.88,156.88,,,,,,
Molina Medicaid,CPT,H2000,Comp multidisipln evaluation,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Molina Medicaid,CPT,H2001,Rehabilitation program 1/2 d,Behavioral Health,Per Unit,$166.94 ,OP,166.94,166.94,,,,,,
Molina Medicaid,CPT,H2010,Comprehensive med svc 15 min,Behavioral Health,Per Unit,$80.13 ,OP,80.13,80.13,,,,,,
Molina Medicaid,CPT,H2011,"Crisis interven svc, 15 min",Behavioral Health,Per Unit,$135.70 ,OP,135.7,135.7,,,,,,
Molina Medicaid,CPT,H2012,"Behav hlth day treat, per hr",Behavioral Health,Per Unit,$276.34 ,OP,276.34,276.34,,,,,,
Molina Medicaid,CPT,H2014,"Skills train and dev, 15 min",Behavioral Health,Per Unit,$48.15 ,OP,48.15,48.15,,,,,,
Molina Medicaid,CPT,H2017,"Psysoc rehab svc, per 15 min",Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Molina Medicaid,CPT,H2018,"Psysoc rehab svc, per diem",Behavioral Health,Per Unit,$220.60 ,OP,220.6,220.6,,,,,,
Molina Medicaid,CPT,H2019,"Ther behav svc, per 15 min",Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Molina Medicaid,CPT,H2020,"Ther behav svc, per diem",Behavioral Health,Per Unit,$220.60 ,OP,220.6,220.6,,,,,,
Molina Medicaid,CPT,H2027,"Psychoed svc, per 15 min",Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Molina Medicaid,CPT,H2028,"Sex offend tx svc, 15 min",Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Molina Medicaid,CPT,H2029,"Sex offend tx svc, per diem",Behavioral Health,Per Unit,$220.60 ,OP,220.6,220.6,,,,,,
Molina Medicaid,CPT,H2032,"Activity therapy, per 15 min",Behavioral Health,Per Unit,$48.15 ,OP,48.15,48.15,,,,,,
Molina Medicaid,CPT,H2033,Multisys ther/juvenile 15min,Behavioral Health,Per Unit,$48.15 ,OP,48.15,48.15,,,,,,
Molina Medicaid,CPT,H2035,"A/d tx program, per hour",Behavioral Health,Per Unit,$84.40 ,OP,84.4,84.4,,,,,,
Molina Medicaid,CPT,H2036,"A/d tx program, per diem",Behavioral Health,Per Unit,$220.60 ,OP,220.6,220.6,,,,,,
Molina Medicaid,CPT,J0121,"Inj., omadacycline, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Molina Medicaid,CPT,J0122,"Inj., eravacycline, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,J0129,Abatacept injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Molina Medicaid,CPT,J0130,Abciximab injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Molina Medicaid,CPT,J0135,Adalimumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,518.96,518.96,,,,,,
Molina Medicaid,CPT,J0178,Aflibercept injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Molina Medicaid,CPT,J0179,"Inj, brolucizumab-dbll, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Molina Medicaid,CPT,J0180,Agalsidase beta injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Molina Medicaid,CPT,J0185,"Inj., aprepitant, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Molina Medicaid,CPT,J0202,"Injection, alemtuzumab",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,J0205,Alglucerase injection,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Molina Medicaid,CPT,J0207,Amifostine,Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,244.88,244.88,,,,,,
Molina Medicaid,CPT,J0210,Methyldopate hcl injection,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Molina Medicaid,CPT,J0215,Alefacept,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Molina Medicaid,CPT,J0220,Alglucosidase alfa injection,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,J0221,Lumizyme injection,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,J0222,"Inj., patisiran, 0.1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,J0223,Inj givosiran 0.5 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,J0256,Alpha 1 proteinase inhibitor,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Molina Medicaid,CPT,J0257,Glassia injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Molina Medicaid,CPT,J0287,Amphotericin b lipid complex,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,J0288,Ampho b cholesteryl sulfate,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,J0289,Amphotericin b liposome inj,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,J0291,"Inj., plazomicin, 5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,J0348,Anidulafungin injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,J0350,Injection anistreplase 30 u,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,J0364,Apomorphine hydrochloride,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,J0365,"Aprotonin, 10,000 kiu",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Molina Medicaid,CPT,J0401,Inj aripiprazole ext rel 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Molina Medicaid,CPT,J0475,Baclofen 10 mg injection,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,384.11,384.11,,,,,,
Molina Medicaid,CPT,J0480,Basiliximab,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Molina Medicaid,CPT,J0485,Belatacept injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Molina Medicaid,CPT,J0490,Belimumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Molina Medicaid,CPT,J0517,"Inj., benralizumab, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,J0558,Peng benzathine/procaine inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,J0561,Penicillin g benzathine inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,J0565,"Inj, bezlotoxumab, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Molina Medicaid,CPT,J0567,"Inj., cerliponase alfa 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,J0570,Buprenorphine implant 74.2mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Molina Medicaid,CPT,J0583,Bivalirudin,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,J0584,"Injection, burosumab-twza 1m",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,J0585,"Injection,onabotulinumtoxina",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,J0586,Abobotulinumtoxina,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,384.11,384.11,,,,,,
Molina Medicaid,CPT,J0587,"Inj, rimabotulinumtoxinb",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,J0588,Incobotulinumtoxin a,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,J0591,"Inj deoxycholic acid, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,J0593,"Inj., lanadelumab-flyo, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,J0594,Busulfan injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Molina Medicaid,CPT,J0596,"Injection, ruconest",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J0597,"C-1 esterase, berinert",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,J0598,"C-1 esterase, cinryze",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,J0599,"Inj., haegarda 10 units",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,J0600,Edetate calcium disodium inj,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J0604,"Cinacalcet, esrd on dialysis",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,J0606,"Inj, etelcalcetide, 0.1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,J0630,Calcitonin salmon injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Molina Medicaid,CPT,J0637,Caspofungin acetate,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,J0638,Canakinumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Molina Medicaid,CPT,J0641,Inj levoleucovorin nos 0.5mg,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
Molina Medicaid,CPT,J0642,"Injection, khapzory, 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,J0691,Inj lefamulin 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Molina Medicaid,CPT,J0693,"Inj., cefiderocol, 5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Molina Medicaid,CPT,J0695,Inj ceftolozane tazobactam,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Molina Medicaid,CPT,J0712,Ceftaroline fosamil inj,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
Molina Medicaid,CPT,J0714,Ceftazidime and avibactam,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,J0716,Centruroides immune f(ab),Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Molina Medicaid,CPT,J0717,Certolizumab pegol inj 1mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Molina Medicaid,CPT,J0740,Cidofovir injection,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Molina Medicaid,CPT,J0742,Inj imip 4 cilas 4 releb 2mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Molina Medicaid,CPT,J0775,"Collagenase, clost hist inj",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Molina Medicaid,CPT,J0791,Inj crizanlizumab-tmca 5mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Molina Medicaid,CPT,J0795,Corticorelin ovine triflutal,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Molina Medicaid,CPT,J0800,Corticotropin injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,J0833,Cosyntropin injection nos,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,J0840,Crotalidae poly immune fab,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Molina Medicaid,CPT,J0841,Inj crotalidae im f(ab')2 eq,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Molina Medicaid,CPT,J0850,Cytomegalovirus imm iv /vial,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Molina Medicaid,CPT,J0875,"Injection, dalbavancin",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,J0878,Daptomycin injection,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,189.67,189.67,,,,,,
Molina Medicaid,CPT,J0881,"Darbepoetin alfa, non-esrd",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,J0882,"Darbepoetin alfa, esrd use",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Molina Medicaid,CPT,J0883,Argatroban nonesrd use 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,J0884,Argatroban esrd dialysis 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,J0885,"Epoetin alfa, non-esrd",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,J0886,Epoetin alfa 1000 units esrd,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,J0890,Peginesatide injection,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Molina Medicaid,CPT,J0894,Decitabine injection,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Molina Medicaid,CPT,J0896,Inj luspatercept-aamt 0.25mg,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Molina Medicaid,CPT,J0897,Denosumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,518.96,518.96,,,,,,
Molina Medicaid,CPT,J1095,"Injection, dexamethasone 9%",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,J1096,Dexametha opth insert 0.1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,J1097,Phenylep ketorolac opth soln,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,J1162,Digoxin immune fab (ovine),Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J1190,Dexrazoxane hcl injection,Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,244.88,244.88,,,,,,
Molina Medicaid,CPT,J1201,Inj. cetirizine hcl 0.5mg,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,J1205,Chlorothiazide sodium inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,J1212,Dimethyl sulfoxide 50% 50 ml,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,J1267,Doripenem injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,J1290,Ecallantide injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Molina Medicaid,CPT,J1300,Eculizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,J1301,"Injection, edaravone, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Molina Medicaid,CPT,J1303,"Inj., ravulizumab-cwvz 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,J1322,"Elosulfase alfa, injection",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,J1327,Eptifibatide injection,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Molina Medicaid,CPT,J1410,Inj estrogen conjugate 25 mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Molina Medicaid,CPT,J1428,"Inj, eteplirsen, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,J1429,Inj golodirsen 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,J1430,Ethanolamine oleate 100 mg,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,384.11,384.11,,,,,,
Molina Medicaid,CPT,J1436,Etidronate disodium inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,J1437,Inj. fe derisomaltose 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,J1438,Etanercept injection,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,J1439,Inj ferric carboxymaltos 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,J1442,Inj filgrastim excl biosimil,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,J1446,"Inj, tbo-filgrastim, 5 mcg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,J1447,Inj tbo filgrastim 1 microg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,J1451,"Fomepizole, 15 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,J1452,Intraocular fomivirsen na,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,J1453,Fosaprepitant injection,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Molina Medicaid,CPT,J1454,"Inj fosnetupitant, palonoset",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,J1455,Foscarnet sodium injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,J1457,Gallium nitrate injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,J1458,Galsulfase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,J1459,Inj ivig privigen 500 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Molina Medicaid,CPT,J1460,Gamma globulin 1 cc inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,J1555,"Inj cuvitru, 100 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Molina Medicaid,CPT,J1556,"Inj, imm glob bivigam, 500mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,J1557,Gammaplex injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,J1558,"Inj. xembify, 100 mg",Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,384.11,384.11,,,,,,
Molina Medicaid,CPT,J1559,Hizentra injection,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,384.11,384.11,,,,,,
Molina Medicaid,CPT,J1560,Gamma globulin > 10 cc inj,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,J1561,Gamunex-c/gammaked,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Molina Medicaid,CPT,J1562,"Vivaglobin, inj",Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,384.11,384.11,,,,,,
Molina Medicaid,CPT,J1566,"Immune globulin, powder",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Molina Medicaid,CPT,J1568,Octagam injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Molina Medicaid,CPT,J1569,Gammagard liquid injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Molina Medicaid,CPT,J1570,Ganciclovir sodium injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,J1571,Hepagam b im injection,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,J1572,Flebogamma injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Molina Medicaid,CPT,J1573,"Hepagam b intravenous, inj",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,J1575,Hyqvia 100mg immuneglobulin,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,J1595,Injection glatiramer acetate,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,J1599,"Ivig non-lyophilized, nos",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Molina Medicaid,CPT,J1602,Golimumab for iv use 1mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Molina Medicaid,CPT,J1610,Glucagon hydrochloride/1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Molina Medicaid,CPT,J1628,"Inj., guselkumab, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Molina Medicaid,CPT,J1632,"Inj., brexanolone, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J1640,"Hemin, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J1670,Tetanus immune globulin inj,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,J1675,Histrelin acetate,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Molina Medicaid,CPT,J1738,Inj. meloxicam 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,J1740,Ibandronate sodium injection,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Molina Medicaid,CPT,J1742,Ibutilide fumarate injection,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
Molina Medicaid,CPT,J1743,Idursulfase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Molina Medicaid,CPT,J1744,Icatibant injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J1745,Infliximab not biosimil 10mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Molina Medicaid,CPT,J1746,"Inj., ibalizumab-uiyk, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J1750,Inj iron dextran,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,J1756,Iron sucrose injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,J1786,Imuglucerase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Molina Medicaid,CPT,J1823,"Inj. inebilizumab-cdon, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,J1826,Interferon beta-1a inj,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
Molina Medicaid,CPT,J1830,Interferon beta-1b / .25 mg,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,J1833,"Injection, isavuconazonium",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,J1930,Lanreotide injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,J1931,Laronidase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Molina Medicaid,CPT,J1942,Aripiprazole lauroxil 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Molina Medicaid,CPT,J1943,"Inj., aristada initio, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Molina Medicaid,CPT,J1944,Aripirazole lauroxil 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Molina Medicaid,CPT,J1945,Lepirudin,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Molina Medicaid,CPT,J1950,Leuprolide acetate /3.75 mg,Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,244.88,244.88,,,,,,
Molina Medicaid,CPT,J2062,Loxapine for inhalation 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,J2170,Mecasermin injection,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,J2182,"Injection, mepolizumab, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Molina Medicaid,CPT,J2186,"Inj., meropenem, vaborbactam",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Molina Medicaid,CPT,J2248,Micafungin sodium injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,J2278,Ziconotide injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Molina Medicaid,CPT,J2315,"Naltrexone, depot form",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Molina Medicaid,CPT,J2323,Natalizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,J2325,Nesiritide injection,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,384.11,384.11,,,,,,
Molina Medicaid,CPT,J2326,"Inj, nusinersen, 0.1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,J2350,"Injection, ocrelizumab, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,J2353,"Octreotide injection, depot",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,J2355,Oprelvekin injection,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,J2357,Omalizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Molina Medicaid,CPT,J2407,"Injection, oritavancin",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Molina Medicaid,CPT,J2425,Palifermin injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Molina Medicaid,CPT,J2426,Paliperidone palmitate inj,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Molina Medicaid,CPT,J2469,Palonosetron hcl,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
Molina Medicaid,CPT,J2502,"Inj, pasireotide long acting",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,J2503,Pegaptanib sodium injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Molina Medicaid,CPT,J2504,"Pegademase bovine, 25 iu",Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,518.96,518.96,,,,,,
Molina Medicaid,CPT,J2505,"Injection, pegfilgrastim 6mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,J2507,Pegloticase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Molina Medicaid,CPT,J2513,Pentastarch 10% solution,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
Molina Medicaid,CPT,J2515,Pentobarbital sodium inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,J2545,Pentamidine non-comp unit,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,J2547,"Injection, peramivir",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Molina Medicaid,CPT,J2562,Plerixafor injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J2597,Inj desmopressin acetate,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Molina Medicaid,CPT,J2724,Protein c concentrate,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Molina Medicaid,CPT,J2730,Pralidoxime chloride inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,J2770,Quinupristin/dalfopristin,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,189.67,189.67,,,,,,
Molina Medicaid,CPT,J2778,Ranibizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Molina Medicaid,CPT,J2783,Rasburicase,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Molina Medicaid,CPT,J2786,"Injection, reslizumab, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Molina Medicaid,CPT,J2790,Rho d immune globulin inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,J2791,Rhophylac injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,J2792,"Rho(d) immune globulin h, sd",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,J2793,Rilonacept injection,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,J2794,"Inj risperdal consta, 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,J2796,Romiplostim injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Molina Medicaid,CPT,J2797,"Inj., rolapitant, 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Molina Medicaid,CPT,J2798,"Inj., perseris, 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,J2805,Sincalide injection,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
Molina Medicaid,CPT,J2820,Sargramostim injection,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,J2840,Inj sebelipase alfa 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,J2850,Inj secretin synthetic human,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,J2860,"Injection, siltuximab",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Molina Medicaid,CPT,J2993,Reteplase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,J2997,Alteplase recombinant,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,J3031,"Inj., fremanezumab-vfrm 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,J3032,Inj. eptinezumab-jjmr 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,J3060,"Inj, taliglucerase alfa 10 u",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Molina Medicaid,CPT,J3090,Inj tedizolid phosphate,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Molina Medicaid,CPT,J3095,Telavancin injection,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,J3101,Tenecteplase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J3110,Teriparatide injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Molina Medicaid,CPT,J3111,Inj. romosozumab-aqqg 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Molina Medicaid,CPT,J3145,Testosterone undecanoate 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,J3240,Thyrotropin injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Molina Medicaid,CPT,J3241,Inj. teprotumumab-trbw 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,J3243,Tigecycline injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,J3245,"Inj., tildrakizumab, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Molina Medicaid,CPT,J3246,Tirofiban hcl,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Molina Medicaid,CPT,J3262,Tocilizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Molina Medicaid,CPT,J3285,Treprostinil injection,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,J3300,Triamcinolone a inj prs-free,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,J3304,Inj triamcinolone ace xr 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,J3315,Triptorelin pamoate,Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,244.88,244.88,,,,,,
Molina Medicaid,CPT,J3316,"Inj., triptorelin xr 3.75 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,J3355,"Urofollitropin, 75 iu",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Molina Medicaid,CPT,J3357,"Ustekinumab sub cu inj, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Molina Medicaid,CPT,J3358,"Ustekinumab, iv inject, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J3365,"Urokinase 250,000 iu inj",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,J3380,"Injection, vedolizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,J3385,Velaglucerase alfa,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Molina Medicaid,CPT,J3396,Verteporfin injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Molina Medicaid,CPT,J3397,"Inj., vestronidase alfa-vjbk",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,J3398,Inj luxturna 1 billion vec g,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,J3399,Inj onase abepar-xioi treat,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,J3470,Hyaluronidase injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,J3471,"Ovine, up to 999 usp units",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,J3472,"Ovine, 1000 usp units",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,J3473,Hyaluronidase recombinant,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,J7169,"Inj andexxa, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,J7170,"Inj., emicizumab-kxwh 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,J7175,"Inj, factor x, (human), 1iu",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,J7177,"Inj., fibryga, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Molina Medicaid,CPT,J7178,Inj human fibrinogen con nos,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Molina Medicaid,CPT,J7179,Vonvendi inj 1 iu vwf:rco,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J7180,Factor xiii anti-hem factor,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,J7181,Factor xiii recomb a-subunit,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,J7182,Factor viii recomb novoeight,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J7183,Wilate injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J7185,Xyntha inj,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J7186,Antihemophilic viii/vwf comp,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J7187,"Humate-p, inj",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J7188,Factor viii recomb obizur,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J7189,Factor viia recomb novoseven,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J7190,Factor viii,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J7191,Factor viii (porcine),Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J7192,Factor viii recombinant nos,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J7193,Factor ix non-recombinant,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J7194,Factor ix complex,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J7195,Factor ix recombinant nos,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J7196,Antithrombin recombinant,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,J7197,Antithrombin iii injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J7198,Anti-inhibitor,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Molina Medicaid,CPT,J7199,Hemophilia clot factor noc,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Molina Medicaid,CPT,J7200,Factor ix recombinan rixubis,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J7201,Factor ix alprolix recomb,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J7202,Factor ix idelvion inj,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J7203,Factor ix recomb gly rebinyn,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J7204,Inj recombin esperoct per iu,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J7205,Factor viii fc fusion recomb,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J7207,Factor viii pegylated recomb,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J7208,Inj. jivi 1 iu,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J7209,Factor viii nuwiq recomb 1iu,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J7210,"Inj, afstyla, 1 i.u.",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J7211,"Inj, kovaltry, 1 i.u.",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J7212,Factor viia recomb sevenfact,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J7296,"Kyleena, 19.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,J7297,"Liletta, 52 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,J7298,"Mirena, 52 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,J7300,Intraut copper contraceptive,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,J7301,"Skyla, 13.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,J7302,Levonorgestrel iu 52 mg,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,J7303,Contraceptive vaginal ring,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,J7304,Contraceptive hormone patch,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,J7306,Levonorgestrel implant sys,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Molina Medicaid,CPT,J7307,Etonogestrel implant system,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,J7308,Aminolevulinic acid hcl top,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,J7309,"Methyl aminolevulinate, top",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,J7310,Ganciclovir long act implant,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,J7311,"Inj., retisert, 0.01 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,J7312,Dexamethasone intra implant,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Molina Medicaid,CPT,J7313,"Inj., iluvien, 0.01 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J7314,"Inj., yutiq, 0.01 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J7315,Ophthalmic mitomycin,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,J7316,"Inj, ocriplasmin, 0.125 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,J7318,"Inj, durolane 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,J7320,"Genvisc 850, inj, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Molina Medicaid,CPT,J7321,Hyalgan or supartz inj dose,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,J7322,Hymovis injection 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Molina Medicaid,CPT,J7323,Euflexxa inj per dose,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Molina Medicaid,CPT,J7324,Orthovisc inj per dose,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Molina Medicaid,CPT,J7325,Synvisc or synvisc-one,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,J7326,Gel-one,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,J7327,Monovisc inj per dose,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,384.11,384.11,,,,,,
Molina Medicaid,CPT,J7328,Gelsyn-3 injection 0.1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Molina Medicaid,CPT,J7329,"Inj, trivisc 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,J7330,Cultured chondrocytes implnt,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,J7331,"Synojoynt, inj., 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,J7332,"Inj., triluron, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,J7333,Visco-3 inj dose,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,J7336,Capsaicin 8% patch,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,J7340,Carbidopa levodopa ent 100ml,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,J7345,"Aminolevulinic acid, 10% gel",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,J7351,Inj bimatoprost itc imp1mcg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Molina Medicaid,CPT,J7352,"Afamelanotide implant, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,J7401,Mometasone furoate sinus imp,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,384.11,384.11,,,,,,
Molina Medicaid,CPT,J7501,Azathioprine parenteral,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
Molina Medicaid,CPT,J7504,Lymphocyte immune globulin,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J7505,Monoclonal antibodies,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,518.96,518.96,,,,,,
Molina Medicaid,CPT,J7511,Antithymocyte globuln rabbit,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Molina Medicaid,CPT,J7513,"Daclizumab, parenteral",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Molina Medicaid,CPT,J7525,Tacrolimus injection,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Molina Medicaid,CPT,J7639,Dornase alfa non-comp unit,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,J7685,Tobramycin comp unit,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,J7686,"Treprostinil, non-comp unit",Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Molina Medicaid,CPT,J8501,Oral aprepitant,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
Molina Medicaid,CPT,J8560,Etoposide oral 50 mg,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
Molina Medicaid,CPT,J8562,Oral fludarabine phosphate,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Molina Medicaid,CPT,J8565,Gefitinib oral,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Molina Medicaid,CPT,J8655,"Oral netupitant, palonosetro",Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,189.67,189.67,,,,,,
Molina Medicaid,CPT,J8670,"Rolapitant, oral, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
Molina Medicaid,CPT,J8705,Topotecan oral,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,J9010,Alemtuzumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Molina Medicaid,CPT,J9015,Aldesleukin injection,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,518.96,518.96,,,,,,
Molina Medicaid,CPT,J9017,Arsenic trioxide injection,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Molina Medicaid,CPT,J9019,Erwinaze injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Molina Medicaid,CPT,J9020,"Asparaginase, nos",Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
Molina Medicaid,CPT,J9022,"Inj, atezolizumab,10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Molina Medicaid,CPT,J9023,"Injection, avelumab, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J9025,Azacitidine injection,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
Molina Medicaid,CPT,J9027,Clofarabine injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,J9030,Bcg live intravesical 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
Molina Medicaid,CPT,J9031,Bcg live intravesical vac,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
Molina Medicaid,CPT,J9032,"Injection, belinostat, 10mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,J9033,"Inj., treanda 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,J9034,"Inj., bendeka 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,J9035,Bevacizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,J9036,Inj. belrapzo/bendamustine,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,J9039,"Injection, blinatumomab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,J9040,Bleomycin sulfate injection,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
Molina Medicaid,CPT,J9041,"Inj., velcade 0.1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,244.88,244.88,,,,,,
Molina Medicaid,CPT,J9042,Brentuximab vedotin inj,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Molina Medicaid,CPT,J9043,Cabazitaxel injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J9044,"Inj, bortezomib, nos, 0.1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Molina Medicaid,CPT,J9047,"Injection, carfilzomib, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Molina Medicaid,CPT,J9050,Carmustine injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J9055,Cetuximab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Molina Medicaid,CPT,J9057,"Inj., copanlisib, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,J9065,Inj cladribine per 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,189.67,189.67,,,,,,
Molina Medicaid,CPT,J9070,Cyclophosphamide 100 mg inj,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
Molina Medicaid,CPT,J9098,Cytarabine liposome inj,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Molina Medicaid,CPT,J9118,Inj. calaspargase pegol-mknl,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Molina Medicaid,CPT,J9119,"Inj., cemiplimab-rwlc, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J9120,Dactinomycin injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Molina Medicaid,CPT,J9144,"Daratumumab, hyaluronidase",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,J9145,"Injection, daratumumab 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,J9150,Daunorubicin injection,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,189.67,189.67,,,,,,
Molina Medicaid,CPT,J9151,Daunorubicin citrate inj,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
Molina Medicaid,CPT,J9153,"Inj daunorubicin, cytarabine",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Molina Medicaid,CPT,J9155,Degarelix injection,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,189.67,189.67,,,,,,
Molina Medicaid,CPT,J9160,Denileukin diftitox inj,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J9171,Docetaxel injection,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
Molina Medicaid,CPT,J9173,"Inj., durvalumab, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J9176,"Injection, elotuzumab, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,J9177,Inj enfort vedo-ejfv 0.25mg,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J9179,Eribulin mesylate injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Molina Medicaid,CPT,J9185,Fludarabine phosphate inj,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
Molina Medicaid,CPT,J9198,"Inj. infugem, 100 mg",Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,189.67,189.67,,,,,,
Molina Medicaid,CPT,J9199,"Injection, infugem, 200 mg",Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,189.67,189.67,,,,,,
Molina Medicaid,CPT,J9200,Floxuridine injection,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
Molina Medicaid,CPT,J9202,Goserelin acetate implant,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Molina Medicaid,CPT,J9203,Gemtuzumab ozogamicin 0.1 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J9204,"Inj mogamulizumab-kpkc, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Molina Medicaid,CPT,J9205,Inj irinotecan liposome 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,J9207,Ixabepilone injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Molina Medicaid,CPT,J9208,Ifosfamide injection,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
Molina Medicaid,CPT,J9210,"Inj., emapalumab-lzsg, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,J9211,Idarubicin hcl injection,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,77.84,77.84,,,,,,
Molina Medicaid,CPT,J9213,Interferon alfa-2a inj,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Molina Medicaid,CPT,J9214,Interferon alfa-2b inj,Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,244.88,244.88,,,,,,
Molina Medicaid,CPT,J9216,Interferon gamma 1-b inj,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Molina Medicaid,CPT,J9217,Leuprolide acetate suspnsion,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Molina Medicaid,CPT,J9219,Leuprolide acetate implant,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J9223,"Inj. lurbinectedin, 0.1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,J9225,Vantas implant,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,J9226,Supprelin la implant,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,J9227,Inj. isatuximab-irfc 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,J9228,Ipilimumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,J9229,Inj inotuzumab ozogam 0.1 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Molina Medicaid,CPT,J9230,Mechlorethamine hcl inj,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
Molina Medicaid,CPT,J9245,Inj melpha hydroch nos 50 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J9246,"Inj., evomela, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J9261,Nelarabine injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J9262,"Inj, omacetaxine mep, 0.01mg",Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Molina Medicaid,CPT,J9264,Paclitaxel protein bound,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Molina Medicaid,CPT,J9266,Pegaspargase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Molina Medicaid,CPT,J9268,Pentostatin injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Molina Medicaid,CPT,J9269,Inj. tagraxofusp-erzs 10 mcg,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,J9270,Plicamycin (mithramycin) inj,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Molina Medicaid,CPT,J9271,Inj pembrolizumab,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Molina Medicaid,CPT,J9280,Mitomycin injection,Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,244.88,244.88,,,,,,
Molina Medicaid,CPT,J9281,Mitomycin instillation,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,J9285,"Inj, olaratumab, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J9293,Mitoxantrone hydrochl / 5 mg,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
Molina Medicaid,CPT,J9295,"Injection, necitumumab, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J9299,"Injection, nivolumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J9300,Gemtuzumab ozogamicin inj,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J9301,Obinutuzumab inj,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J9302,Ofatumumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Molina Medicaid,CPT,J9303,Panitumumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,J9304,"Inj. pemetrexed, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J9305,Inj. pemetrexed nos 10mg,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J9306,"Injection, pertuzumab, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,J9307,Pralatrexate injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J9308,"Injection, ramucirumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,J9309,"Inj, polatuzumab vedotin 1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"4,027.28","4,027.28",,,,,,
Molina Medicaid,CPT,J9310,Rituximab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,J9311,"Inj rituximab, hyaluronidase",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J9312,"Inj., rituximab, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J9313,"Inj., lumoxiti, 0.01 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J9315,Romidepsin injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J9316,"Pertuzu, trastuzu, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,J9317,Sacituzumab govitecan-hziy,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,518.96,518.96,,,,,,
Molina Medicaid,CPT,J9320,Streptozocin injection,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,189.67,189.67,,,,,,
Molina Medicaid,CPT,J9325,Inj talimogene laherparepvec,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J9328,Temozolomide injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Molina Medicaid,CPT,J9330,Temsirolimus injection,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,518.96,518.96,,,,,,
Molina Medicaid,CPT,J9340,Thiotepa injection,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,189.67,189.67,,,,,,
Molina Medicaid,CPT,J9352,Injection trabectedin 0.1mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,J9354,"Inj, ado-trastuzumab emt 1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J9355,Inj trastuzumab excl biosimi,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,J9356,"Inj. herceptin hylecta, 10mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,J9357,Valrubicin injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,J9358,Inj fam-trastu deru-nxki 1mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,J9371,"Inj, vincristine sul lip 1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,J9395,"Injection, fulvestrant",Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,518.96,518.96,,,,,,
Molina Medicaid,CPT,J9400,"Inj, ziv-aflibercept, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Molina Medicaid,CPT,J9600,Porfimer sodium injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,L8604,Dextranomer/hyaluronic acid,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,L8605,Inj bulking agent anal canal,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,L8607,Inj vocal cord bulking agent,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,M0239,Bamlanivimab-xxxx infusion,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Molina Medicaid,CPT,M0243,Casirivi and imdevi infusion,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Molina Medicaid,CPT,P2028,Cephalin floculation test,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,P2029,Congo red blood test,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,P2031,Hair analysis,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,P2033,Blood thymol turbidity,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,P2038,Blood mucoprotein,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,P3000,Screen pap by tech w md supv,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Molina Medicaid,CPT,P3001,Screening pap smear by phys,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Molina Medicaid,CPT,P7001,Culture bacterial urine,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,P9010,Whole blood for transfusion,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,P9011,Blood split unit,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,P9012,Cryoprecipitate each unit,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,P9016,Rbc leukocytes reduced,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,P9017,Plasma 1 donor frz w/in 8 hr,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,P9019,"Platelets, each unit",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,P9020,Plaelet rich plasma unit,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,P9021,Red blood cells unit,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,P9022,Washed red blood cells unit,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,P9023,"Frozen plasma, pooled, sd",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,P9031,Platelets leukocytes reduced,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,P9032,"Platelets, irradiated",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,P9033,Platelets leukoreduced irrad,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,P9034,"Platelets, pheresis",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,P9035,Platelet pheres leukoreduced,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,P9036,Platelet pheresis irradiated,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,P9037,Plate pheres leukoredu irrad,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,P9038,Rbc irradiated,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,P9039,Rbc deglycerolized,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,P9040,Rbc leukoreduced irradiated,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,P9041,"Albumin (human),5%, 50ml",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,P9043,"Plasma protein fract,5%,50ml",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,P9044,Cryoprecipitatereducedplasma,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,P9045,"Albumin (human), 5%, 250 ml",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,P9046,"Albumin (human), 25%, 20 ml",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,P9047,"Albumin (human), 25%, 50ml",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,P9048,"Plasmaprotein fract,5%,250ml",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,P9050,"Granulocytes, pheresis unit",Hematology,Per Unit,"$1,474.66 ",OP,"1,474.66","1,474.66",,,,,,
Molina Medicaid,CPT,P9051,"Blood, l/r, cmv-neg",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,P9052,"Platelets, hla-m, l/r, unit",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,P9053,"Plt, pher, l/r cmv-neg, irr",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,P9054,"Blood, l/r, froz/degly/wash",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,P9055,"Plt, aph/pher, l/r, cmv-neg",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,P9056,"Blood, l/r, irradiated",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,P9057,"Rbc, frz/deg/wsh, l/r, irrad",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,P9058,"Rbc, l/r, cmv-neg, irrad",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,P9059,"Plasma, frz between 8-24hour",Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,P9060,Fr frz plasma donor retested,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,P9070,Pathogen reduced plasma pool,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,P9071,Pathogen reduced plasma sing,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,P9072,Plate path red/rapid bac tes,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,P9073,Platelets pheresis path redu,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,P9099,Blood component/product noc,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,P9100,Pathogen test for platelets,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,Q0035,Cardiokymography,Cardiology,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,
Molina Medicaid,CPT,Q0081,Infusion ther other than che,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Molina Medicaid,CPT,Q0084,Chemotherapy by infusion,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Molina Medicaid,CPT,Q0085,Chemo by both infusion and o,General Medicine,Per Unit,$178.41 ,OP,178.41,178.41,,,,,,
Molina Medicaid,CPT,Q0091,Obtaining screen pap smear,Pathology,Per Unit,$13.31 ,OP,13.31,13.31,,,,,,
Molina Medicaid,CPT,Q0111,Wet mounts/ w preparations,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,Q0112,Potassium hydroxide preps,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,Q0113,Pinworm examinations,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,Q0114,Fern test,Laboratory,Per Unit,$2.86 ,OP,2.86,2.86,,,,,,
Molina Medicaid,CPT,Q0115,Post-coital mucous exam,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,Q0138,"Ferumoxytol, non-esrd",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,Q0139,"Ferumoxytol, esrd use",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,Q0239,Bamlanivimab-xxxx,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Molina Medicaid,CPT,Q0243,Casirivimab and imdevimab,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Molina Medicaid,CPT,Q0515,Sermorelin acetate injection,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,518.96,518.96,,,,,,
Molina Medicaid,CPT,Q2017,"Teniposide, 50 mg",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Molina Medicaid,CPT,Q2028,"Inj, sculptra, 0.5mg",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q2034,Agriflu vaccine,Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,Q2035,"Afluria vacc, 3 yrs & >, im",Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,Q2036,"Flulaval vacc, 3 yrs & >, im",Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,Q2037,"Fluvirin vacc, 3 yrs & >, im",Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,Q2038,"Fluzone vacc, 3 yrs & >, im",Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,Q2039,"Influenza virus vaccine, nos",Preventive Care,Per Unit,$12.53 ,OP,12.53,12.53,,,,,,
Molina Medicaid,CPT,Q2040,Tisagenlecleucel car-pos t,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,Q2043,Sipuleucel-t auto cd54+,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,Q2049,Imported lipodox inj,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,Q2050,Doxorubicin inj 10mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Molina Medicaid,CPT,Q3014,Telehealth facility fee,Ancillary Services,Per Unit,$8.33 ,OP,8.33,8.33,,,,,,
Molina Medicaid,CPT,Q3027,Inj beta interferon im 1 mcg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Molina Medicaid,CPT,Q3028,Inj beta interferon sq 1 mcg,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,Q4074,Iloprost non-comp unit dose,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,Q4081,"Epoetin alfa, 100 units esrd",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,Q4100,"Skin substitute, nos",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4101,Apligraf,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4102,Oasis wound matrix,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4103,Oasis burn matrix,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4104,Integra bmwd,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4105,Integra drt or omnigraft,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4106,Dermagraft,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4107,Graftjacket,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4108,Integra matrix,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4110,Primatrix,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4111,Gammagraft,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4112,Cymetra injectable,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4113,Graftjacket xpress,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4114,Integra flowable wound matri,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4115,Alloskin,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4116,Alloderm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4117,Hyalomatrix,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4118,Matristem micromatrix,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4119,Matristem wound matrix,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4120,Matristem burn matrix,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4121,Theraskin,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4122,"Dermacell, awm, porous sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4123,Alloskin,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4124,Oasis tri-layer wound matrix,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4125,Arthroflex,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4126,Memoderm/derma/tranz/integup,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4127,Talymed,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4128,Flexhd/allopatchhd/matrixhd,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4129,Unite biomatrix,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4130,Strattice tm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4131,Epifix or epicord,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4132,"Grafix core, grafixpl core",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4133,Grafix stravix prime pl sqcm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4134,Hmatrix,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4135,Mediskin,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4136,Ezderm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4137,Amnioexcel biodexcel 1sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4138,"Biodfence dryflex, 1cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4139,"Amnio or biodmatrix, inj 1cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4140,Biodfence 1cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4141,"Alloskin ac, 1 cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4142,Xcm biologic tiss matrix 1cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4143,"Repriza, 1cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4145,"Epifix, inj, 1mg",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4146,"Tensix, 1cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4147,Architect ecm px fx 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4148,Neox neox rt or clarix cord,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4149,"Excellagen, 0.1 cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4150,Allowrap ds or dry 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4151,"Amnioband, guardian 1 sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4152,Dermapure 1 square cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4153,"Dermavest, plurivest sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4154,Biovance 1 square cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4155,Neoxflo or clarixflo 1 mg,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4156,Neox 100 or clarix 100,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4157,Revitalon 1 square cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4158,"Kerecis omega3, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4159,Affinity1 square cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4160,Nushield 1 square cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4161,Bio-connekt per square cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4162,"Wndex flw, bioskn flw, 0.5cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4163,"Woundex, bioskin, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4164,"Helicoll, per square cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4165,"Keramatrix, kerasorb sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4166,"Cytal, per square centimeter",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4167,"Truskin, per sq centimeter",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4168,"Amnioband, 1 mg",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4169,"Artacent wound, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4170,"Cygnus, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4171,"Interfyl, 1 mg",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4172,Puraply or puraply am,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4173,Palingen or palingen xplus,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4174,Palingen or promatrx,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4175,Miroderm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4176,"Neopatch or therion, 1 sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4177,"Floweramnioflo, 0.1 cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4178,"Floweramniopatch, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4179,"Flowerderm, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4180,"Revita, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4181,"Amnio wound, per square cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4182,"Transcyte, per sq centimeter",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4183,"Surgigraft, 1 sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4184,Cellesta or duo per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4185,Cellesta flowab amnion 0.5cc,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4186,Epifix 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4187,Epicord 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4188,Amnioarmor 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4189,"Artacent ac, 1 mg",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4190,Artacent ac 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4191,Restorigin 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4192,"Restorigin, 1 cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4193,Coll-e-derm 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4194,Novachor 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4195,Puraply 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4196,Puraply am 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4197,Puraply xt 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4198,Genesis amnio membrane 1sqcm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4200,Skin te 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4201,Matrion 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4202,"Keroxx (2.5g/cc), 1cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4203,"Derma-gide, 1 sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4204,Xwrap 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4205,Membrane graft or wrap sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4206,Fluid flow or fluid gf 1 cc,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4208,Novafix per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4209,Surgraft per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4210,Axolotl graf dualgraf sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4211,Amnion bio or axobio sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4212,"Allogen, per cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4213,"Ascent, 0.5 mg",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4214,Cellesta cord per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4215,"Axolotl ambient, cryo 0.1 mg",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4216,Artacent cord per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4217,Woundfix biowound plus xplus,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4218,Surgicord per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4219,Surgigraft dual per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4220,"Bellacell hd, surederm sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4221,Amniowrap2 per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4222,"Progenamatrix, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4226,Myown harv prep proc sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4227,Amniocore per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4228,"Bionextpatch, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4229,Cogenex amnio memb per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4230,Cogenex flow amnion 0.5 cc,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4231,"Corplex p, per cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4232,"Corplex, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4233,Surfactor /nudyn per 0.5 cc,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4234,"Xcellerate, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4235,Amniorepair or altiply sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4236,Carepatch per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4237,"Cryo-cord, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4238,"Derm-maxx, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4239,Amnio-maxx or lite per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4240,Corecyte topical only 0.5 cc,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4241,"Polycyte, topical only 0.5cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4242,"Amniocyte plus, per 0.5 cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4244,"Procenta, per 200 mg",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4245,"Amniotext, per cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4246,"Coretext or protext, per cc",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4247,"Amniotext patch, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4248,Dermacyte amn mem allo sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4249,"Amniply, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4250,Amnioamp-mp per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4254,Novafix dl per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q4255,"Reguard, topical use per sq",DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,Q5101,"Injection, zarxio",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,Q5102,"Inj., infliximab biosimilar",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Molina Medicaid,CPT,Q5103,"Injection, inflectra",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Molina Medicaid,CPT,Q5104,"Injection, renflexis",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Molina Medicaid,CPT,Q5105,Inj retacrit esrd on dialysi,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,Q5106,Inj retacrit non-esrd use,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,Q5107,Inj mvasi 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,Q5108,"Injection, fulphila",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,Q5109,"Injection, ixifi, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,Q5110,Nivestym,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,182.12,182.12,,,,,,
Molina Medicaid,CPT,Q5111,"Injection, udenyca 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,Q5112,Inj ontruzant 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,Q5113,Inj herzuma 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,Q5114,Inj ogivri 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,Q5115,Inj truxima 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,Q5116,"Inj., trazimera, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,Q5117,"Inj., kanjinti, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,Q5118,"Inj., zirabev, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,Q5119,"Inj ruxience, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,Q5120,Inj pegfilgrastim-bmez 0.5mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,Q5121,"Inj. avsola, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"1,236.31","1,236.31",,,,,,
Molina Medicaid,CPT,Q5122,"Inj, nyvepria",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"1,836.04","1,836.04",,,,,,
Molina Medicaid,CPT,Q9975,Factor VIII FC Fusion Recomb,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"2,528.43","2,528.43",,,,,,
Molina Medicaid,CPT,Q9979,"Injection, Alemtuzumab",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Molina Medicaid,CPT,Q9980,"Genvisc, inj, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Molina Medicaid,CPT,Q9984,Kyleena,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,Q9987,Pathogen test for platelets,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,Q9988,Platelet pheresis path reduc,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,Q9989,"Ustekinumab IV Inj, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Molina Medicaid,CPT,Q9991,Buprenorph xr 100 mg or less,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,Q9992,Buprenorphine xr over 100 mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,814.32,814.32,,,,,,
Molina Medicaid,CPT,Q9993,"Inj., triamcinolone ext rel",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,Q9995,"inj. emicizumab-kxwh, 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"10,767.37","10,767.37",,,,,,
Molina Medicaid,CPT,S0013,"Esketamine, nasal spray",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Molina Medicaid,CPT,S0040,"Injection, ticarcillin disod",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,855.06,855.06,,,,,,
Molina Medicaid,CPT,S0088,Imatinib 100 mg,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Molina Medicaid,CPT,S0126,Inj follitropin alfa 75 iu,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,S0132,Inj ganirelix acetat 250 mcg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Molina Medicaid,CPT,S0140,"Saquinavir, 200 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Molina Medicaid,CPT,S0142,Colistimethate inh sol mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Molina Medicaid,CPT,S0145,Peg interferon alfa-2a/180,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,S0148,Peg interferon alfa-2b/10,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Molina Medicaid,CPT,S0155,Epoprostenol dilutant,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,99.44,99.44,,,,,,
Molina Medicaid,CPT,S0166,Inj olanzapine 2.5mg,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,S0175,Flutamide 125 mg,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,100.71,100.71,,,,,,
Molina Medicaid,CPT,S0178,Lomustine 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,233.27,233.27,,,,,,
Molina Medicaid,CPT,S0190,"Mifepristone, oral, 200 mg",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,45.71,45.71,,,,,,
Molina Medicaid,CPT,S0195,Pneumo vaccine 5-9 yrs,Preventive Care,Per Unit,$52.77 ,OP,52.77,52.77,,,,,,
Molina Medicaid,CPT,S0199,Med abortion inc all ex drug,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Molina Medicaid,CPT,S0201,Partial hospitalization serv,Behavioral Health,Per Unit,$220.60 ,OP,220.6,220.6,,,,,,
Molina Medicaid,CPT,S0220,Medical conference by physic,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,S0221,"Medical conference, 60 min",Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,S0250,Comp geriatr assmt team,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,S0257,End of life counseling,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,S0271,Home hospice case 30 days,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,S0280,"Medical home, initial plan",Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,S0281,"Medical home, maintenance",Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,S0311,Comp mgmt care coord adv ill,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,S0315,Disease management program,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,S0316,Follow-up/reassessment,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,S0340,Lifestyle mod 1st stage,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,S0353,Cancer treatmentplan initial,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,S0354,Cancer treatment plan change,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,S0390,Rout foot care per visit,General Surgery,Per Unit,$46.77 ,OP,46.77,46.77,,,,,,
Molina Medicaid,CPT,S0395,Impression casting ft,Orthopedics,Per Unit,$185.40 ,OP,185.4,185.4,,,,,,
Molina Medicaid,CPT,S0592,Comp cont lens eval,Ophthalmology,Per Unit,$27.36 ,OP,27.36,27.36,,,,,,
Molina Medicaid,CPT,S0601,Screening proctoscopy,Preventive Care,Per Unit,$387.00 ,OP,387,387,,,,,,
Molina Medicaid,CPT,S0618,Audiometry for hearing aid,Otolaryngology,Per Unit,$78.72 ,OP,78.72,78.72,,,,,,
Molina Medicaid,CPT,S0800,Laser in situ keratomileusis,Ophthalmology Surgery,Per Unit,$751.45 ,OP,751.45,751.45,,,,,,
Molina Medicaid,CPT,S0810,Photorefractive keratectomy,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Molina Medicaid,CPT,S0812,Phototherap keratect,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"1,197.94","1,197.94",,,,,,
Molina Medicaid,CPT,S2066,Breast gap flap reconst,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
Molina Medicaid,CPT,S2067,"Breast ""stacked"" diep/gap",General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
Molina Medicaid,CPT,S2068,Breast diep or siea flap,General Surgery,Per Unit,"$2,963.62 ",OP,"2,963.62","2,963.62",,,,,,
Molina Medicaid,CPT,S2083,Adjustment gastric band,Gastroenterology,Per Unit,$119.18 ,OP,119.18,119.18,,,,,,
Molina Medicaid,CPT,S2112,Knee arthroscp harv,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,S2202,Echosclerotherapy,Vascular Surgery,Per Unit,$500.46 ,OP,500.46,500.46,,,,,,
Molina Medicaid,CPT,S2225,Myringotomy laser-assist,Otolaryngology Surgery,Per Unit,$729.78 ,OP,729.78,729.78,,,,,,
Molina Medicaid,CPT,S2230,Implant semi-imp hear,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,S2235,Implant auditory brain imp,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,S2260,Induced abortion 17-24 weeks,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Molina Medicaid,CPT,S2265,Induced abortion 25-28 wks,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Molina Medicaid,CPT,S2266,Induced abortion 29-31 wks,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Molina Medicaid,CPT,S2267,Induced abortion 32 or more,Obstetrics,Per Unit,$983.66 ,OP,983.66,983.66,,,,,,
Molina Medicaid,CPT,S2300,"Arthroscopy, shoulder, surgi",Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"1,170.79","1,170.79",,,,,,
Molina Medicaid,CPT,S2340,Chemodenervation of abductor,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,S2341,Chemodenerv adduct vocal,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"1,283.26","1,283.26",,,,,,
Molina Medicaid,CPT,S2342,Nasal endoscop po debrid,Otolaryngology Surgery,Per Unit,$230.30 ,OP,230.3,230.3,,,,,,
Molina Medicaid,CPT,S2400,Fetal surg congen hernia,Obstetrics,Per Unit,$139.58 ,OP,139.58,139.58,,,,,,
Molina Medicaid,CPT,S2401,Fetal surg urin trac obstr,Obstetrics,Per Unit,$482.07 ,OP,482.07,482.07,,,,,,
Molina Medicaid,CPT,S2402,Fetal surg cong cyst malf,Obstetrics,Per Unit,$482.07 ,OP,482.07,482.07,,,,,,
Molina Medicaid,CPT,S2403,Fetal surg pulmon sequest,Obstetrics,Per Unit,$482.07 ,OP,482.07,482.07,,,,,,
Molina Medicaid,CPT,S2404,Fetal surg myelomeningo,Obstetrics,Per Unit,$482.07 ,OP,482.07,482.07,,,,,,
Molina Medicaid,CPT,S2405,Fetal surg sacrococ teratoma,Obstetrics,Per Unit,$139.58 ,OP,139.58,139.58,,,,,,
Molina Medicaid,CPT,S2409,Fetal surg noc,Obstetrics,Per Unit,$139.58 ,OP,139.58,139.58,,,,,,
Molina Medicaid,CPT,S2411,Fetoscop laser ther ttts,Obstetrics,Per Unit,$139.58 ,OP,139.58,139.58,,,,,,
Molina Medicaid,CPT,S3620,Newborn metabolic screening,Laboratory,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,
Molina Medicaid,CPT,S3630,Eosinophil blood count,Laboratory,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,
Molina Medicaid,CPT,S3645,Hiv-1 antibody testing of or,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,S3650,"Saliva test, hormone level;",Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,S3652,"Saliva test, hormone level;",Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,S3655,Antisperm antibodies test,Laboratory,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,
Molina Medicaid,CPT,S3708,Gastrointestinal fat absorpt,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,S3721,Pca3 testing,Laboratory,Per Unit,$6.42 ,OP,6.42,6.42,,,,,,
Molina Medicaid,CPT,S3722,Dose optimization auc - 5fu,Laboratory,Per Unit,$7.38 ,OP,7.38,7.38,,,,,,
Molina Medicaid,CPT,S3800,Genetic testing als,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,S3840,Dna analysis ret-oncogene,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,S3841,Gene test retinoblastoma,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,S3842,Gene test hippel-lindau,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,S3844,Dna analysis deafness,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,S3845,Gene test alpha-thalassemia,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,S3846,Gene test beta-thalassemia,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,S3849,Gene test niemann-pick,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,S3850,Gene test sickle cell,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,S3852,Dna analysis apoe alzheimer,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,S3853,Gene test myo musclr dyst,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,S3854,Gene profile panel breast,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,S3861,Genetic test brugada,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,S3865,Comp genet test hyp cardiomy,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,S3866,Spec gene test hyp cardiomy,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,S3870,Cgh test developmental delay,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,S3890,Fecal dna analysis,Laboratory,Per Unit,$22.80 ,OP,22.8,22.8,,,,,,
Molina Medicaid,CPT,S3900,Surface emg,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,S3902,Ballistocardiogram,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,S3904,Masters two step,Cardiology,Per Unit,$80.87 ,OP,80.87,80.87,,,,,,
Molina Medicaid,CPT,S4011,Ivf package,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Molina Medicaid,CPT,S4013,Compl gift case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Molina Medicaid,CPT,S4014,Compl zift case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Molina Medicaid,CPT,S4015,Complete ivf nos case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Molina Medicaid,CPT,S4016,Frozen ivf case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Molina Medicaid,CPT,S4017,Ivf canc a stim case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Molina Medicaid,CPT,S4018,F emb trns canc case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Molina Medicaid,CPT,S4020,Ivf canc a aspir case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Molina Medicaid,CPT,S4021,Ivf canc p aspir case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Molina Medicaid,CPT,S4022,Asst oocyte fert case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Molina Medicaid,CPT,S4023,Incompl donor egg case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Molina Medicaid,CPT,S4025,Donor serv ivf case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Molina Medicaid,CPT,S4026,Procure donor sperm,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Molina Medicaid,CPT,S4027,Store prev froz embryos,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Molina Medicaid,CPT,S4028,Microsurg epi sperm asp,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Molina Medicaid,CPT,S4030,Sperm procure init visit,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Molina Medicaid,CPT,S4031,Sperm procure subs visit,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Molina Medicaid,CPT,S4035,Stimulated iui case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Molina Medicaid,CPT,S4037,Cryo embryo transf case rate,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Molina Medicaid,CPT,S4040,Monit store cryo embryo 30 d,Obstetrics,Per Unit,$175.09 ,OP,175.09,175.09,,,,,,
Molina Medicaid,CPT,S4042,Ovulation mgmt per cycle,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,S4981,Insert levonorgestrel ius,Gynecology,Per Unit,$102.34 ,OP,102.34,102.34,,,,,,
Molina Medicaid,CPT,S4989,Contracept iud,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,191.26,191.26,,,,,,
Molina Medicaid,CPT,S5180,Hh respiratory thrpy in eval,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
Molina Medicaid,CPT,S5181,Hh respiratory thrpy nos/day,Pulmonary,Per Unit,$138.31 ,OP,138.31,138.31,,,,,,
Molina Medicaid,CPT,S8032,Low dose CT lung screening,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Molina Medicaid,CPT,S8035,Magnetic source imaging,Diagnostic Radiology,Per Unit,$133.33 ,OP,133.33,133.33,,,,,,
Molina Medicaid,CPT,S8037,Mrcp,Interventional Radiology,Per Unit,$224.69 ,OP,224.69,224.69,,,,,,
Molina Medicaid,CPT,S8055,Us guidance fetal reduct,Interventional Radiology,Per Unit,$63.29 ,OP,63.29,63.29,,,,,,
Molina Medicaid,CPT,S8080,Scintimammography,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,239.98,239.98,,,,,,
Molina Medicaid,CPT,S8092,Electron beam computed tomog,Diagnostic Radiology,Per Unit,$79.18 ,OP,79.18,79.18,,,,,,
Molina Medicaid,CPT,S8110,Peak expiratory flow rate (p,Pulmonary,Per Unit,$42.64 ,OP,42.64,42.64,,,,,,
Molina Medicaid,CPT,S8930,Auricular electrostimulation,Neurology,Per Unit,$187.24 ,OP,187.24,187.24,,,,,,
Molina Medicaid,CPT,S8940,Hippotherapy per session,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,S8948,Low-level laser trmt 15 min,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,S8950,"Complex lymphedema therapy,",Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,S8990,Pt or manip for maint,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,S9015,Automated eeg monitoring,Neurology,Per Unit,$147.66 ,OP,147.66,147.66,,,,,,
Molina Medicaid,CPT,S9024,Paranasal sinus ultrasound,Diagnostic Radiology,Per Unit,$86.73 ,OP,86.73,86.73,,,,,,
Molina Medicaid,CPT,S9061,Medical supplies and equipme,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,S9090,Vertebral axial decompressio,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,S9098,Home phototherapy visit,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,S9128,"Speech therapy, in the home,",Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Molina Medicaid,CPT,S9129,"Occupational therapy, in the",Rehabilitation,Per Unit,$306.55 ,OP,306.55,306.55,,,,,,
Molina Medicaid,CPT,S9131,Pt in the home per diem,Rehabilitation,Per Unit,$192.71 ,OP,192.71,192.71,,,,,,
Molina Medicaid,CPT,S9140,"Diabetic management program,",Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Molina Medicaid,CPT,S9141,"Diabetic management program,",Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Molina Medicaid,CPT,S9145,Insulin pump initiation,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Molina Medicaid,CPT,S9152,"Speech therapy, re-eval",Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Molina Medicaid,CPT,S9211,Home mgmt gest hypertension,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,S9213,Hm preeclamp per diem,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,S9214,Hm gest dm per diem,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,S9335,Ht hemodialysis diem,Nephrology,Per Unit,$540.95 ,OP,540.95,540.95,,,,,,
Molina Medicaid,CPT,S9339,Hit periton dialysis diem,Nephrology,Per Unit,$540.95 ,OP,540.95,540.95,,,,,,
Molina Medicaid,CPT,S9370,Ht inj antiemetic diem,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,S9372,Ht inj anticoag diem,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,S9445,Pt education noc individ,Preventive Care,Per Unit,$20.58 ,OP,20.58,20.58,,,,,,
Molina Medicaid,CPT,S9446,Pt education noc group,Preventive Care,Per Unit,$26.23 ,OP,26.23,26.23,,,,,,
Molina Medicaid,CPT,S9452,Nutrition class,Preventive Care,Per Unit,$26.23 ,OP,26.23,26.23,,,,,,
Molina Medicaid,CPT,S9453,Smoking cessation class,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Molina Medicaid,CPT,S9455,"Diabetic management program,",Preventive Care,Per Unit,$26.23 ,OP,26.23,26.23,,,,,,
Molina Medicaid,CPT,S9465,"Diabetic management program,",Ancillary Services,Per Unit,$100.15 ,OP,100.15,100.15,,,,,,
Molina Medicaid,CPT,S9470,"Nutritional counseling, diet",Ancillary Services,Per Unit,$100.15 ,OP,100.15,100.15,,,,,,
Molina Medicaid,CPT,S9472,Cardiac rehabilitation progr,Rehabilitation,Per Unit,$274.82 ,OP,274.82,274.82,,,,,,
Molina Medicaid,CPT,S9473,Pulmonary rehabilitation pro,Rehabilitation,Per Unit,$73.11 ,OP,73.11,73.11,,,,,,
Molina Medicaid,CPT,S9475,Ambulatory setting substance,Behavioral Health,Per Unit,$220.60 ,OP,220.6,220.6,,,,,,
Molina Medicaid,CPT,S9476,Vestibular rehab per diem,Rehabilitation,Per Unit,$142.44 ,OP,142.44,142.44,,,,,,
Molina Medicaid,CPT,S9480,Intensive outpatient psychia,Behavioral Health,Per Unit,$339.88 ,OP,339.88,339.88,,,,,,
Molina Medicaid,CPT,S9482,Family stabilization 15 min,Behavioral Health,Per Unit,$89.14 ,OP,89.14,89.14,,,,,,
Molina Medicaid,CPT,S9484,Crisis intervention per hour,Behavioral Health,Per Unit,$135.70 ,OP,135.7,135.7,,,,,,
Molina Medicaid,CPT,S9485,Crisis intervention mental h,Behavioral Health,Per Unit,$220.60 ,OP,220.6,220.6,,,,,,
Molina Medicaid,CPT,S9537,Ht hem horm inj diem,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,S9538,Hit blood products diem,Hematology,Per Unit,$378.53 ,OP,378.53,378.53,,,,,,
Molina Medicaid,CPT,S9558,Ht inj growth horm diem,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,S9559,Hit inj interferon diem,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,S9560,Ht inj hormone diem,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,S9562,Ht inj palivizumab diem,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,T1006,Family/couple counseling,Behavioral Health,Per Unit,$89.14 ,OP,89.14,89.14,,,,,,
Molina Medicaid,CPT,T1007,Treatment plan development,Behavioral Health,Per Unit,$94.47 ,OP,94.47,94.47,,,,,,
Molina Medicaid,CPT,T1012,Alcohol/substance abuse skil,Behavioral Health,Per Unit,$48.15 ,OP,48.15,48.15,,,,,,
Molina Medicaid,CPT,T1016,Case management,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,T1017,Targeted case management,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,T1023,Program intake assessment,Behavioral Health,Per Unit,$70.18 ,OP,70.18,70.18,,,,,,
Molina Medicaid,CPT,T1040,Comm bh clinic svc per diem,Behavioral Health,Per Unit,$220.60 ,OP,220.6,220.6,,,,,,
Molina Medicaid,CPT,T2022,"Case management, per month",Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,T2023,Targeted case mgmt per month,Ancillary Services,Per Unit,$69.37 ,OP,69.37,69.37,,,,,,
Molina Medicaid,CPT,U0001,2019-ncov diagnostic p,Laboratory,Per Unit,$15.25 ,OP,15.25,15.25,,,,,,
Molina Medicaid,CPT,U0002,Covid-19 lab test non-cdc,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,U0005,Infec agen detec ampli probe,Laboratory,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
Molina Medicaid,CPT,V2785,Corneal tissue processing,Ophthalmology,Per Unit,"$1,390.89 ",OP,"1,390.89","1,390.89",,,,,,
Molina Medicaid,CPT,V2790,Amniotic membrane,DME and Supplies,Per Unit,$263.49 ,OP,263.49,263.49,,,,,,
Molina Medicaid,CPT,V5362,Speech screening,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,V5363,Language screening,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Molina Medicaid,CPT,V5364,Dysphagia screening,Rehabilitation,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,
Multiplan/PHCS,DRG,MS-001,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W MCC,,Relative Weights,"$557,099.42 ",IP,"17,718.00","557,099.42",,,,,,
Multiplan/PHCS,DRG,MS-002,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W/O MCC,,Relative Weights,"$282,516.19 ",IP,"17,718.00","282,516.19",,,,,,
Multiplan/PHCS,DRG,MS-003,ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITH MAJOR O.R. PROCEDURES,,Relative Weights,"$382,110.62 ",IP,"111,577.60","382,110.62",,,,,,
Multiplan/PHCS,DRG,MS-004,TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES,,Relative Weights,"$232,723.01 ",IP,"69,628.33","232,723.01",,,,,,
Multiplan/PHCS,DRG,MS-005,LIVER TRANSPLANT W MCC OR INTESTINAL TRANSPLANT,,Relative Weights,"$207,904.03 ",IP,"59,773.19","207,904.03",,,,,,
Multiplan/PHCS,DRG,MS-006,LIVER TRANSPLANT W/O MCC,,Relative Weights,"$98,217.50 ",IP,"27,427.34","98,217.50",,,,,,
Multiplan/PHCS,DRG,MS-007,LUNG TRANSPLANT,,Relative Weights,"$217,451.81 ",IP,"67,628.10","217,451.81",,,,,,
Multiplan/PHCS,DRG,MS-008,SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,,Relative Weights,"$113,220.58 ",IP,"31,730.89","113,220.58",,,,,,
Multiplan/PHCS,DRG,MS-010,PANCREAS TRANSPLANT,,Relative Weights,"$80,158.18 ",IP,"2,420.00","80,158.18",,,,,,
Multiplan/PHCS,DRG,MS-011,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC,,Relative Weights,"$99,667.01 ",IP,"2,420.00","99,667.01",,,,,,
Multiplan/PHCS,DRG,MS-012,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC,,Relative Weights,"$76,083.84 ",IP,"2,420.00","76,083.84",,,,,,
Multiplan/PHCS,DRG,MS-013,TRACHEOSTOMY FOR FACE -  MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC,,Relative Weights,"$48,894.05 ",IP,"2,420.00","48,894.05",,,,,,
Multiplan/PHCS,DRG,MS-014,ALLOGENEIC BONE MARROW TRANSPLANT,,Relative Weights,"$257,136.77 ",IP,"2,420.00","257,136.77",,,,,,
Multiplan/PHCS,DRG,MS-016,AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,,Relative Weights,"$138,805.63 ",IP,"2,420.00","138,805.63",,,,,,
Multiplan/PHCS,DRG,MS-017,AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,,Relative Weights,"$89,659.58 ",IP,"2,420.00","89,659.58",,,,,,
Multiplan/PHCS,DRG,MS-020,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,,Relative Weights,"$218,151.36 ",IP,"2,420.00","218,151.36",,,,,,
Multiplan/PHCS,DRG,MS-021,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,,Relative Weights,"$166,797.79 ",IP,"2,420.00","166,797.79",,,,,,
Multiplan/PHCS,DRG,MS-022,INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W/O CC/MCC,,Relative Weights,"$99,425.09 ",IP,"2,420.00","99,425.09",,,,,,
Multiplan/PHCS,DRG,MS-023,CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX CNS PDX W MCC OR CHEMO IMPLANT,,Relative Weights,"$113,240.74 ",IP,"2,420.00","113,240.74",,,,,,
Multiplan/PHCS,DRG,MS-024,CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,,Relative Weights,"$80,972.64 ",IP,"2,420.00","80,972.64",,,,,,
Multiplan/PHCS,DRG,MS-025,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,,Relative Weights,"$88,593.12 ",IP,"2,420.00","88,593.12",,,,,,
Multiplan/PHCS,DRG,MS-026,CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC,,Relative Weights,"$61,403.33 ",IP,"2,420.00","61,403.33",,,,,,
Multiplan/PHCS,DRG,MS-027,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$48,317.47 ",IP,"2,420.00","48,317.47",,,,,,
Multiplan/PHCS,DRG,MS-028,SPINAL PROCEDURES WITH MCC,,Relative Weights,"$112,702.46 ",IP,"2,420.00","112,702.46",,,,,,
Multiplan/PHCS,DRG,MS-029,SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,,Relative Weights,"$64,653.12 ",IP,"2,420.00","64,653.12",,,,,,
Multiplan/PHCS,DRG,MS-030,SPINAL PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$45,805.54 ",IP,"2,420.00","45,805.54",,,,,,
Multiplan/PHCS,DRG,MS-031,VENTRICULAR SHUNT PROCEDURES WITH MCC,,Relative Weights,"$88,189.92 ",IP,"2,420.00","88,189.92",,,,,,
Multiplan/PHCS,DRG,MS-032,VENTRICULAR SHUNT PROCEDURES WITH CC,,Relative Weights,"$44,192.74 ",IP,"2,420.00","44,192.74",,,,,,
Multiplan/PHCS,DRG,MS-033,VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$34,290.14 ",IP,"2,420.00","34,290.14",,,,,,
Multiplan/PHCS,DRG,MS-034,CAROTID ARTERY STENT PROCEDURE W MCC,,Relative Weights,"$75,674.59 ",IP,"2,420.00","75,674.59",,,,,,
Multiplan/PHCS,DRG,MS-035,CAROTID ARTERY STENT PROCEDURES WITH CC,,Relative Weights,"$46,412.35 ",IP,"2,420.00","46,412.35",,,,,,
Multiplan/PHCS,DRG,MS-036,CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$35,300.16 ",IP,"2,420.00","35,300.16",,,,,,
Multiplan/PHCS,DRG,MS-037,EXTRACRANIAL PROCEDURES WITH MCC,,Relative Weights,"$65,384.93 ",IP,"2,420.00","65,384.93",,,,,,
Multiplan/PHCS,DRG,MS-038,EXTRACRANIAL PROCEDURES WITH CC,,Relative Weights,"$33,772.03 ",IP,"2,420.00","33,772.03",,,,,,
Multiplan/PHCS,DRG,MS-039,EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$22,807.01 ",IP,"2,420.00","22,807.01",,,,,,
Multiplan/PHCS,DRG,MS-040,PERIPHERAL- CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC,,Relative Weights,"$79,438.46 ",IP,"2,420.00","79,438.46",,,,,,
Multiplan/PHCS,DRG,MS-041,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W CC OR PERIPH NEUROSTIM,,Relative Weights,"$47,809.44 ",IP,"2,420.00","47,809.44",,,,,,
Multiplan/PHCS,DRG,MS-042,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W/O CC/MCC,,Relative Weights,"$37,261.73 ",IP,"2,420.00","37,261.73",,,,,,
Multiplan/PHCS,DRG,MS-052,SPINAL DISORDERS AND INJURIES WITH CC/MCC,,Relative Weights,"$32,838.62 ",IP,"2,420.00","32,838.62",,,,,,
Multiplan/PHCS,DRG,MS-053,SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,,Relative Weights,"$19,476.58 ",IP,"2,420.00","19,476.58",,,,,,
Multiplan/PHCS,DRG,MS-054,NERVOUS SYSTEM NEOPLASMS WITH MCC,,Relative Weights,"$27,016.42 ",IP,"2,420.00","27,016.42",,,,,,
Multiplan/PHCS,DRG,MS-055,NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,,Relative Weights,"$19,877.76 ",IP,"2,420.00","19,877.76",,,,,,
Multiplan/PHCS,DRG,MS-056,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,,Relative Weights,"$44,198.78 ",IP,"2,420.00","44,198.78",,,,,,
Multiplan/PHCS,DRG,MS-057,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,,Relative Weights,"$24,409.73 ",IP,"2,420.00","24,409.73",,,,,,
Multiplan/PHCS,DRG,MS-058,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,,Relative Weights,"$39,406.75 ",IP,"2,420.00","39,406.75",,,,,,
Multiplan/PHCS,DRG,MS-059,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,,Relative Weights,"$21,984.48 ",IP,"2,420.00","21,984.48",,,,,,
Multiplan/PHCS,DRG,MS-060,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,,Relative Weights,"$17,775.07 ",IP,"2,420.00","17,775.07",,,,,,
Multiplan/PHCS,DRG,MS-061,ISCHEMIC STROKE -  PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC,,Relative Weights,"$56,316.96 ",IP,"2,420.00","56,316.96",,,,,,
Multiplan/PHCS,DRG,MS-062,ISCHEMIC STROKE -  PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC,,Relative Weights,"$40,545.79 ",IP,"2,420.00","40,545.79",,,,,,
Multiplan/PHCS,DRG,MS-063,ISCHEMIC STROKE- PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC,,Relative Weights,"$33,884.93 ",IP,"2,420.00","33,884.93",,,,,,
Multiplan/PHCS,DRG,MS-064,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,,Relative Weights,"$37,795.97 ",IP,"2,420.00","37,795.97",,,,,,
Multiplan/PHCS,DRG,MS-065,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC,,Relative Weights,"$20,718.43 ",IP,"2,420.00","20,718.43",,,,,,
Multiplan/PHCS,DRG,MS-066,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,,Relative Weights,"$14,454.72 ",IP,"2,420.00","14,454.72",,,,,,
Multiplan/PHCS,DRG,MS-067,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,,Relative Weights,"$29,524.32 ",IP,"2,420.00","29,524.32",,,,,,
Multiplan/PHCS,DRG,MS-068,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,,Relative Weights,"$18,212.54 ",IP,"2,420.00","18,212.54",,,,,,
Multiplan/PHCS,DRG,MS-069,TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,,Relative Weights,"$15,730.85 ",IP,"2,420.00","15,730.85",,,,,,
Multiplan/PHCS,DRG,MS-070,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC,,Relative Weights,"$33,725.66 ",IP,"2,420.00","33,725.66",,,,,,
Multiplan/PHCS,DRG,MS-071,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC,,Relative Weights,"$20,053.15 ",IP,"2,420.00","20,053.15",,,,,,
Multiplan/PHCS,DRG,MS-072,NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,,Relative Weights,"$14,888.16 ",IP,"2,420.00","14,888.16",,,,,,
Multiplan/PHCS,DRG,MS-073,CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,,Relative Weights,"$28,538.50 ",IP,"2,420.00","28,538.50",,,,,,
Multiplan/PHCS,DRG,MS-074,CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,,Relative Weights,"$19,920.10 ",IP,"2,420.00","19,920.10",,,,,,
Multiplan/PHCS,DRG,MS-075,VIRAL MENINGITIS WITH CC/MCC,,Relative Weights,"$32,421.31 ",IP,"2,420.00","32,421.31",,,,,,
Multiplan/PHCS,DRG,MS-076,VIRAL MENINGITIS WITHOUT CC/MCC,,Relative Weights,"$18,194.40 ",IP,"2,420.00","18,194.40",,,,,,
Multiplan/PHCS,DRG,MS-077,HYPERTENSIVE ENCEPHALOPATHY WITH MCC,,Relative Weights,"$31,096.80 ",IP,"2,420.00","31,096.80",,,,,,
Multiplan/PHCS,DRG,MS-078,HYPERTENSIVE ENCEPHALOPATHY WITH CC,,Relative Weights,"$19,393.92 ",IP,"2,420.00","19,393.92",,,,,,
Multiplan/PHCS,DRG,MS-079,HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC,,Relative Weights,"$14,940.58 ",IP,"2,420.00","14,940.58",,,,,,
Multiplan/PHCS,DRG,MS-080,NONTRAUMATIC STUPOR & COMA W MCC,,Relative Weights,"$38,632.61 ",IP,"2,420.00","38,632.61",,,,,,
Multiplan/PHCS,DRG,MS-081,NONTRAUMATIC STUPOR & COMA W/O MCC,,Relative Weights,"$17,722.66 ",IP,"2,420.00","17,722.66",,,,,,
Multiplan/PHCS,DRG,MS-082,TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,,Relative Weights,"$45,396.29 ",IP,"2,420.00","45,396.29",,,,,,
Multiplan/PHCS,DRG,MS-083,TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,,Relative Weights,"$26,423.71 ",IP,"2,420.00","26,423.71",,,,,,
Multiplan/PHCS,DRG,MS-084,TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,,Relative Weights,"$18,089.57 ",IP,"2,420.00","18,089.57",,,,,,
Multiplan/PHCS,DRG,MS-085,TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,,Relative Weights,"$45,275.33 ",IP,"2,420.00","45,275.33",,,,,,
Multiplan/PHCS,DRG,MS-086,TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,,Relative Weights,"$24,954.05 ",IP,"2,420.00","24,954.05",,,,,,
Multiplan/PHCS,DRG,MS-087,TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,,Relative Weights,"$16,918.27 ",IP,"2,420.00","16,918.27",,,,,,
Multiplan/PHCS,DRG,MS-088,CONCUSSION WITH MCC,,Relative Weights,"$28,004.26 ",IP,"2,420.00","28,004.26",,,,,,
Multiplan/PHCS,DRG,MS-089,CONCUSSION WITH CC,,Relative Weights,"$19,883.81 ",IP,"2,420.00","19,883.81",,,,,,
Multiplan/PHCS,DRG,MS-090,CONCUSSION WITHOUT CC/MCC,,Relative Weights,"$17,101.73 ",IP,"2,420.00","17,101.73",,,,,,
Multiplan/PHCS,DRG,MS-091,OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,,Relative Weights,"$31,552.42 ",IP,"2,420.00","31,552.42",,,,,,
Multiplan/PHCS,DRG,MS-092,OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,,Relative Weights,"$19,476.58 ",IP,"2,420.00","19,476.58",,,,,,
Multiplan/PHCS,DRG,MS-093,OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,,Relative Weights,"$15,345.79 ",IP,"2,420.00","15,345.79",,,,,,
Multiplan/PHCS,DRG,MS-094,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,,Relative Weights,"$72,269.57 ",IP,"2,420.00","72,269.57",,,,,,
Multiplan/PHCS,DRG,MS-095,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,,Relative Weights,"$48,527.14 ",IP,"2,420.00","48,527.14",,,,,,
Multiplan/PHCS,DRG,MS-096,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,,Relative Weights,"$45,603.94 ",IP,"2,420.00","45,603.94",,,,,,
Multiplan/PHCS,DRG,MS-097,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,,Relative Weights,"$72,090.14 ",IP,"2,420.00","72,090.14",,,,,,
Multiplan/PHCS,DRG,MS-098,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,,Relative Weights,"$39,412.80 ",IP,"2,420.00","39,412.80",,,,,,
Multiplan/PHCS,DRG,MS-099,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,,Relative Weights,"$25,853.18 ",IP,"2,420.00","25,853.18",,,,,,
Multiplan/PHCS,DRG,MS-100,SEIZURES WITH MCC,,Relative Weights,"$36,695.23 ",IP,"2,420.00","36,695.23",,,,,,
Multiplan/PHCS,DRG,MS-101,SEIZURES WITHOUT MCC,,Relative Weights,"$17,799.26 ",IP,"2,420.00","17,799.26",,,,,,
Multiplan/PHCS,DRG,MS-102,HEADACHES WITH MCC,,Relative Weights,"$24,042.82 ",IP,"2,420.00","24,042.82",,,,,,
Multiplan/PHCS,DRG,MS-103,HEADACHES W/O MCC,,Relative Weights,"$16,117.92 ",IP,"2,420.00","16,117.92",,,,,,
Multiplan/PHCS,DRG,MS-113,ORBITAL PROCEDURES WITH CC/MCC,,Relative Weights,"$42,983.14 ",IP,"2,420.00","42,983.14",,,,,,
Multiplan/PHCS,DRG,MS-114,ORBITAL PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$24,006.53 ",IP,"2,420.00","24,006.53",,,,,,
Multiplan/PHCS,DRG,MS-115,EXTRAOCULAR PROCEDURES EXCEPT ORBIT,,Relative Weights,"$29,957.76 ",IP,"2,420.00","29,957.76",,,,,,
Multiplan/PHCS,DRG,MS-116,INTRAOCULAR PROCEDURES W CC/MCC,,Relative Weights,"$38,122.56 ",IP,"2,420.00","38,122.56",,,,,,
Multiplan/PHCS,DRG,MS-117,INTRAOCULAR PROCEDURES W/O CC/MCC,,Relative Weights,"$22,109.47 ",IP,"2,420.00","22,109.47",,,,,,
Multiplan/PHCS,DRG,MS-121,ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,,Relative Weights,"$25,558.85 ",IP,"2,420.00","25,558.85",,,,,,
Multiplan/PHCS,DRG,MS-122,ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,,Relative Weights,"$15,575.62 ",IP,"2,420.00","15,575.62",,,,,,
Multiplan/PHCS,DRG,MS-123,NEUROLOGICAL EYE DISORDERS,,Relative Weights,"$15,740.93 ",IP,"2,420.00","15,740.93",,,,,,
Multiplan/PHCS,DRG,MS-124,OTHER DISORDERS OF THE EYE WITH MCC,,Relative Weights,"$28,010.30 ",IP,"2,420.00","28,010.30",,,,,,
Multiplan/PHCS,DRG,MS-125,OTHER DISORDERS OF THE EYE WITHOUT MCC,,Relative Weights,"$15,914.30 ",IP,"2,420.00","15,914.30",,,,,,
Multiplan/PHCS,DRG,MS-129,MAJOR HEAD & NECK PROCEDURES W CC/MCC OR MAJOR DEVICE,,Relative Weights,"$46,152.29 ",IP,"21,710.46","46,152.29",,,,,,
Multiplan/PHCS,DRG,MS-130,MAJOR HEAD & NECK PROCEDURES W/O CC/MCC,,Relative Weights,"$29,143.30 ",IP,"13,709.28","29,143.30",,,,,,
Multiplan/PHCS,DRG,MS-131,CRANIAL/FACIAL PROCEDURES W CC/MCC,,Relative Weights,"$54,216.29 ",IP,"25,503.84","54,216.29",,,,,,
Multiplan/PHCS,DRG,MS-132,CRANIAL/FACIAL PROCEDURES W/O CC/MCC,,Relative Weights,"$32,044.32 ",IP,"15,073.94","32,044.32",,,,,,
Multiplan/PHCS,DRG,MS-133,OTHER EAR - NOSE - MOUTH & THROAT O.R. PROCEDURES W CC/MCC,,Relative Weights,"$43,281.50 ",IP,"20,360.02","43,281.50",,,,,,
Multiplan/PHCS,DRG,MS-134,OTHER EAR - NOSE - MOUTH & THROAT O.R. PROCEDURES W/O CC/MCC,,Relative Weights,"$24,375.46 ",IP,"11,466.44","24,375.46",,,,,,
Multiplan/PHCS,DRG,MS-135,SINUS AND MASTOID PROCEDURES WITH CC/MCC,,Relative Weights,"$46,057.54 ",IP,"2,420.00","46,057.54",,,,,,
Multiplan/PHCS,DRG,MS-136,SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$23,990.40 ",IP,"2,420.00","23,990.40",,,,,,
Multiplan/PHCS,DRG,MS-137,MOUTH PROCEDURES WITH CC/MCC,,Relative Weights,"$26,879.33 ",IP,"2,420.00","26,879.33",,,,,,
Multiplan/PHCS,DRG,MS-138,MOUTH PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$17,365.82 ",IP,"2,420.00","17,365.82",,,,,,
Multiplan/PHCS,DRG,MS-139,SALIVARY GLAND PROCEDURES,,Relative Weights,"$24,883.49 ",IP,"2,420.00","24,883.49",,,,,,
Multiplan/PHCS,DRG,MS-146,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH MCC,,Relative Weights,"$38,880.58 ",IP,"2,420.00","38,880.58",,,,,,
Multiplan/PHCS,DRG,MS-147,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH CC,,Relative Weights,"$25,016.54 ",IP,"2,420.00","25,016.54",,,,,,
Multiplan/PHCS,DRG,MS-148,EAR - NOSE - MOUTH & THROAT MALIGNANCY W/O CC/MCC,,Relative Weights,"$15,329.66 ",IP,"2,420.00","15,329.66",,,,,,
Multiplan/PHCS,DRG,MS-149,DYSEQUILIBRIUM,,Relative Weights,"$14,726.88 ",IP,"2,420.00","14,726.88",,,,,,
Multiplan/PHCS,DRG,MS-150,EPISTAXIS WITH MCC,,Relative Weights,"$26,036.64 ",IP,"2,420.00","26,036.64",,,,,,
Multiplan/PHCS,DRG,MS-151,EPISTAXIS WITHOUT MCC,,Relative Weights,"$14,093.86 ",IP,"2,420.00","14,093.86",,,,,,
Multiplan/PHCS,DRG,MS-152,OTITIS MEDIA AND URI WITH MCC,,Relative Weights,"$20,946.24 ",IP,"2,420.00","20,946.24",,,,,,
Multiplan/PHCS,DRG,MS-153,OTITIS MEDIA AND URI WITHOUT MCC,,Relative Weights,"$14,241.02 ",IP,"2,420.00","14,241.02",,,,,,
Multiplan/PHCS,DRG,MS-154,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH MCC,,Relative Weights,"$28,969.92 ",IP,"2,420.00","28,969.92",,,,,,
Multiplan/PHCS,DRG,MS-155,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH CC,,Relative Weights,"$18,166.18 ",IP,"2,420.00","18,166.18",,,,,,
Multiplan/PHCS,DRG,MS-156,OTHER EAR -  NOSE -  MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC,,Relative Weights,"$13,194.72 ",IP,"2,420.00","13,194.72",,,,,,
Multiplan/PHCS,DRG,MS-157,DENTAL AND ORAL DISEASES WITH MCC,,Relative Weights,"$31,508.06 ",IP,"2,420.00","31,508.06",,,,,,
Multiplan/PHCS,DRG,MS-158,DENTAL AND ORAL DISEASES WITH CC,,Relative Weights,"$17,470.66 ",IP,"2,420.00","17,470.66",,,,,,
Multiplan/PHCS,DRG,MS-159,DENTAL AND ORAL DISEASES WITHOUT CC/MCC,,Relative Weights,"$13,565.66 ",IP,"2,420.00","13,565.66",,,,,,
Multiplan/PHCS,DRG,MS-163,MAJOR CHEST PROCEDURES WITH MCC,,Relative Weights,"$98,253.79 ",IP,"2,420.00","98,253.79",,,,,,
Multiplan/PHCS,DRG,MS-164,MAJOR CHEST PROCEDURES WITH CC,,Relative Weights,"$51,037.06 ",IP,"2,420.00","51,037.06",,,,,,
Multiplan/PHCS,DRG,MS-165,MAJOR CHEST PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$37,279.87 ",IP,"2,420.00","37,279.87",,,,,,
Multiplan/PHCS,DRG,MS-166,OTHER RESP SYSTEM O.R. PROCEDURES W MCC,,Relative Weights,"$75,210.91 ",IP,"2,420.00","75,210.91",,,,,,
Multiplan/PHCS,DRG,MS-167,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,,Relative Weights,"$38,594.30 ",IP,"2,420.00","38,594.30",,,,,,
Multiplan/PHCS,DRG,MS-168,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$26,746.27 ",IP,"2,420.00","26,746.27",,,,,,
Multiplan/PHCS,DRG,MS-175,PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,,Relative Weights,"$29,119.10 ",IP,"2,420.00","29,119.10",,,,,,
Multiplan/PHCS,DRG,MS-176,PULMONARY EMBOLISM WITHOUT MCC,,Relative Weights,"$17,103.74 ",IP,"2,420.00","17,103.74",,,,,,
Multiplan/PHCS,DRG,MS-177,RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC,,Relative Weights,"$38,126.59 ",IP,"2,420.00","38,126.59",,,,,,
Multiplan/PHCS,DRG,MS-178,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,,Relative Weights,"$25,064.93 ",IP,"2,420.00","25,064.93",,,,,,
Multiplan/PHCS,DRG,MS-179,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,,Relative Weights,"$17,460.58 ",IP,"2,420.00","17,460.58",,,,,,
Multiplan/PHCS,DRG,MS-180,RESPIRATORY NEOPLASMS WITH MCC,,Relative Weights,"$34,773.98 ",IP,"2,420.00","34,773.98",,,,,,
Multiplan/PHCS,DRG,MS-181,RESPIRATORY NEOPLASMS WITH CC,,Relative Weights,"$23,224.32 ",IP,"2,420.00","23,224.32",,,,,,
Multiplan/PHCS,DRG,MS-182,RESPIRATORY NEOPLASMS WITHOUT CC/MCC,,Relative Weights,"$16,990.85 ",IP,"2,420.00","16,990.85",,,,,,
Multiplan/PHCS,DRG,MS-183,MAJOR CHEST TRAUMA WITH MCC,,Relative Weights,"$30,425.47 ",IP,"2,420.00","30,425.47",,,,,,
Multiplan/PHCS,DRG,MS-184,MAJOR CHEST TRAUMA WITH CC,,Relative Weights,"$20,526.91 ",IP,"2,420.00","20,526.91",,,,,,
Multiplan/PHCS,DRG,MS-185,MAJOR CHEST TRAUMA W/O CC/MCC,,Relative Weights,"$14,797.44 ",IP,"2,420.00","14,797.44",,,,,,
Multiplan/PHCS,DRG,MS-186,PLEURAL EFFUSION WITH MCC,,Relative Weights,"$31,104.86 ",IP,"2,420.00","31,104.86",,,,,,
Multiplan/PHCS,DRG,MS-187,PLEURAL EFFUSION WITH CC,,Relative Weights,"$20,722.46 ",IP,"2,420.00","20,722.46",,,,,,
Multiplan/PHCS,DRG,MS-188,PLEURAL EFFUSION WITHOUT CC/MCC,,Relative Weights,"$14,734.94 ",IP,"2,420.00","14,734.94",,,,,,
Multiplan/PHCS,DRG,MS-189,PULMONARY EDEMA AND RESPIRATORY FAILURE,,Relative Weights,"$24,508.51 ",IP,"2,420.00","24,508.51",,,,,,
Multiplan/PHCS,DRG,MS-190,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,,Relative Weights,"$23,063.04 ",IP,"2,420.00","23,063.04",,,,,,
Multiplan/PHCS,DRG,MS-191,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,,Relative Weights,"$17,998.85 ",IP,"2,420.00","17,998.85",,,,,,
Multiplan/PHCS,DRG,MS-192,CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC,,Relative Weights,"$14,297.47 ",IP,"2,420.00","14,297.47",,,,,,
Multiplan/PHCS,DRG,MS-193,SIMPLE PNEUMONIA & PLEURISY W MCC,,Relative Weights,"$26,883.36 ",IP,"2,420.00","26,883.36",,,,,,
Multiplan/PHCS,DRG,MS-194,SIMPLE PNEUMONIA AND PLEURISY WITH CC,,Relative Weights,"$17,914.18 ",IP,"2,420.00","17,914.18",,,,,,
Multiplan/PHCS,DRG,MS-195,SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,,Relative Weights,"$13,751.14 ",IP,"2,420.00","13,751.14",,,,,,
Multiplan/PHCS,DRG,MS-196,INTERSTITIAL LUNG DISEASE WITH MCC,,Relative Weights,"$33,776.06 ",IP,"2,420.00","33,776.06",,,,,,
Multiplan/PHCS,DRG,MS-197,INTERSTITIAL LUNG DISEASE WITH CC,,Relative Weights,"$20,593.44 ",IP,"2,420.00","20,593.44",,,,,,
Multiplan/PHCS,DRG,MS-198,INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,,Relative Weights,"$15,220.80 ",IP,"2,420.00","15,220.80",,,,,,
Multiplan/PHCS,DRG,MS-199,PNEUMOTHORAX WITH MCC,,Relative Weights,"$36,169.06 ",IP,"2,420.00","36,169.06",,,,,,
Multiplan/PHCS,DRG,MS-200,PNEUMOTHORAX WITH CC,,Relative Weights,"$21,815.14 ",IP,"2,420.00","21,815.14",,,,,,
Multiplan/PHCS,DRG,MS-201,PNEUMOTHORAX WITHOUT CC/MCC,,Relative Weights,"$14,474.88 ",IP,"2,420.00","14,474.88",,,,,,
Multiplan/PHCS,DRG,MS-202,BRONCHITIS AND ASTHMA WITH CC/MCC,,Relative Weights,"$19,111.68 ",IP,"2,420.00","19,111.68",,,,,,
Multiplan/PHCS,DRG,MS-203,BRONCHITIS AND ASTHMA WITHOUT CC/MCC,,Relative Weights,"$13,987.01 ",IP,"2,420.00","13,987.01",,,,,,
Multiplan/PHCS,DRG,MS-204,RESPIRATORY SIGNS AND SYMPTOMS,,Relative Weights,"$16,380.00 ",IP,"2,420.00","16,380.00",,,,,,
Multiplan/PHCS,DRG,MS-205,OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,,Relative Weights,"$32,945.47 ",IP,"2,420.00","32,945.47",,,,,,
Multiplan/PHCS,DRG,MS-206,OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,,Relative Weights,"$17,589.60 ",IP,"2,420.00","17,589.60",,,,,,
Multiplan/PHCS,DRG,MS-207,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS,,Relative Weights,"$115,629.70 ",IP,"2,420.00","115,629.70",,,,,,
Multiplan/PHCS,DRG,MS-208,RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,,Relative Weights,"$50,079.46 ",IP,"2,420.00","50,079.46",,,,,,
Multiplan/PHCS,DRG,MS-215,OTHER HEART ASSIST SYSTEM IMPLANT,,Relative Weights,"$259,783.78 ",IP,"61,661.88","259,783.78",,,,,,
Multiplan/PHCS,DRG,MS-216,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,,Relative Weights,"$202,454.78 ",IP,"58,630.29","202,454.78",,,,,,
Multiplan/PHCS,DRG,MS-217,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,,Relative Weights,"$134,096.26 ",IP,"37,864.14","134,096.26",,,,,,
Multiplan/PHCS,DRG,MS-218,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,,Relative Weights,"$108,892.22 ",IP,"35,678.79","108,892.22",,,,,,
Multiplan/PHCS,DRG,MS-219,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,,Relative Weights,"$158,056.42 ",IP,"47,057.01","158,056.42",,,,,,
Multiplan/PHCS,DRG,MS-220,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,,Relative Weights,"$106,966.94 ",IP,"31,567.37","106,966.94",,,,,,
Multiplan/PHCS,DRG,MS-221,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,,Relative Weights,"$92,659.39 ",IP,"26,746.97","92,659.39",,,,,,
Multiplan/PHCS,DRG,MS-222,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITH MCC,,Relative Weights,"$168,227.14 ",IP,"46,434.46","168,227.14",,,,,,
Multiplan/PHCS,DRG,MS-223,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITHOUT MCC,,Relative Weights,"$121,018.46 ",IP,"33,864.27","121,018.46",,,,,,
Multiplan/PHCS,DRG,MS-224,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITH MCC,,Relative Weights,"$149,107.39 ",IP,"43,912.13","149,107.39",,,,,,
Multiplan/PHCS,DRG,MS-225,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITHOUT MCC,,Relative Weights,"$113,879.81 ",IP,"32,808.39","113,879.81",,,,,,
Multiplan/PHCS,DRG,MS-226,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITH MCC,,Relative Weights,"$134,824.03 ",IP,"25,420.00","134,824.03",,,,,,
Multiplan/PHCS,DRG,MS-227,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,,Relative Weights,"$105,420.67 ",IP,"25,420.00","105,420.67",,,,,,
Multiplan/PHCS,DRG,MS-228,OTHER CARDIOTHORACIC PROCEDURES WITH MCC,,Relative Weights,"$126,731.81 ",IP,"31,129.37","126,731.81",,,,,,
Multiplan/PHCS,DRG,MS-229,OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,,Relative Weights,"$82,754.78 ",IP,"20,096.88","82,754.78",,,,,,
Multiplan/PHCS,DRG,MS-231,CORONARY BYPASS W PTCA W MCC,,Relative Weights,"$165,543.84 ",IP,"50,901.53","165,543.84",,,,,,
Multiplan/PHCS,DRG,MS-232,CORONARY BYPASS W PTCA W/O MCC,,Relative Weights,"$120,687.84 ",IP,"34,770.65","120,687.84",,,,,,
Multiplan/PHCS,DRG,MS-233,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,,Relative Weights,"$156,621.02 ",IP,"42,365.00","156,621.02",,,,,,
Multiplan/PHCS,DRG,MS-234,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,,Relative Weights,"$104,959.01 ",IP,"31,162.65","104,959.01",,,,,,
Multiplan/PHCS,DRG,MS-235,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,,Relative Weights,"$118,633.54 ",IP,"32,351.00","118,633.54",,,,,,
Multiplan/PHCS,DRG,MS-236,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,,Relative Weights,"$81,226.66 ",IP,"23,926.80","81,226.66",,,,,,
Multiplan/PHCS,DRG,MS-239,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,,Relative Weights,"$94,141.15 ",IP,"2,420.00","94,141.15",,,,,,
Multiplan/PHCS,DRG,MS-240,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,,Relative Weights,"$55,641.60 ",IP,"2,420.00","55,641.60",,,,,,
Multiplan/PHCS,DRG,MS-241,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,,Relative Weights,"$30,568.61 ",IP,"2,420.00","30,568.61",,,,,,
Multiplan/PHCS,DRG,MS-242,PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,,Relative Weights,"$74,815.78 ",IP,"15,407.00","74,815.78",,,,,,
Multiplan/PHCS,DRG,MS-243,PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,,Relative Weights,"$50,992.70 ",IP,"14,708.24","50,992.70",,,,,,
Multiplan/PHCS,DRG,MS-244,PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,,Relative Weights,"$41,840.06 ",IP,"12,049.83","41,840.06",,,,,,
Multiplan/PHCS,DRG,MS-245,AICD GENERATOR PROCEDURES,,Relative Weights,"$104,989.25 ",IP,"15,407.00","104,989.25",,,,,,
Multiplan/PHCS,DRG,MS-246,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,,Relative Weights,"$63,963.65 ",IP,"18,246.15","63,963.65",,,,,,
Multiplan/PHCS,DRG,MS-247,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITHOUT MCC,,Relative Weights,"$41,019.55 ",IP,"11,523.64","41,019.55",,,,,,
Multiplan/PHCS,DRG,MS-248,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,,Relative Weights,"$62,425.44 ",IP,"18,467.49","62,425.44",,,,,,
Multiplan/PHCS,DRG,MS-249,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITHOUT MCC,,Relative Weights,"$38,638.66 ",IP,"10,942.55","38,638.66",,,,,,
Multiplan/PHCS,DRG,MS-250,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT CORONARY ARTERY STENT WITH MCC,,Relative Weights,"$51,410.02 ",IP,"14,727.51","51,410.02",,,,,,
Multiplan/PHCS,DRG,MS-251,PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W/O MCC,,Relative Weights,"$33,929.28 ",IP,"2,420.00","33,929.28",,,,,,
Multiplan/PHCS,DRG,MS-252,OTHER VASCULAR PROCEDURES W MCC,,Relative Weights,"$66,132.86 ",IP,"2,420.00","66,132.86",,,,,,
Multiplan/PHCS,DRG,MS-253,OTHER VASCULAR PROCEDURES WITH CC,,Relative Weights,"$52,549.06 ",IP,"2,420.00","52,549.06",,,,,,
Multiplan/PHCS,DRG,MS-254,OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$36,693.22 ",IP,"2,420.00","36,693.22",,,,,,
Multiplan/PHCS,DRG,MS-255,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,,Relative Weights,"$53,415.94 ",IP,"2,420.00","53,415.94",,,,,,
Multiplan/PHCS,DRG,MS-256,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,,Relative Weights,"$34,604.64 ",IP,"2,420.00","34,604.64",,,,,,
Multiplan/PHCS,DRG,MS-257,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,,Relative Weights,"$22,869.50 ",IP,"2,420.00","22,869.50",,,,,,
Multiplan/PHCS,DRG,MS-258,CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,,Relative Weights,"$61,663.39 ",IP,"11,861.00","61,663.39",,,,,,
Multiplan/PHCS,DRG,MS-259,CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,,Relative Weights,"$41,985.22 ",IP,"11,861.00","41,985.22",,,,,,
Multiplan/PHCS,DRG,MS-260,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,,Relative Weights,"$74,583.94 ",IP,"10,167.00","74,583.94",,,,,,
Multiplan/PHCS,DRG,MS-261,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,,Relative Weights,"$39,281.76 ",IP,"10,167.00","39,281.76",,,,,,
Multiplan/PHCS,DRG,MS-262,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,,Relative Weights,"$33,820.42 ",IP,"9,964.34","33,820.42",,,,,,
Multiplan/PHCS,DRG,MS-263,VEIN LIGATION AND STRIPPING,,Relative Weights,"$47,559.46 ",IP,"2,420.00","47,559.46",,,,,,
Multiplan/PHCS,DRG,MS-264,OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,,Relative Weights,"$65,278.08 ",IP,"2,420.00","65,278.08",,,,,,
Multiplan/PHCS,DRG,MS-265,AICD LEAD PROCEDURES,,Relative Weights,"$62,925.41 ",IP,"2,420.00","62,925.41",,,,,,
Multiplan/PHCS,DRG,MS-266,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,,Relative Weights,"$143,567.42 ",IP,"41,160.28","143,567.42",,,,,,
Multiplan/PHCS,DRG,MS-267,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,,Relative Weights,"$114,420.10 ",IP,"32,692.75","114,420.10",,,,,,
Multiplan/PHCS,DRG,MS-268,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,,Relative Weights,"$136,737.22 ",IP,"32,968.00","136,737.22",,,,,,
Multiplan/PHCS,DRG,MS-269,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,,Relative Weights,"$86,010.62 ",IP,"25,200.52","86,010.62",,,,,,
Multiplan/PHCS,DRG,MS-270,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,,Relative Weights,"$103,021.63 ",IP,"30,292.48","103,021.63",,,,,,
Multiplan/PHCS,DRG,MS-271,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,,Relative Weights,"$71,527.68 ",IP,"20,822.21","71,527.68",,,,,,
Multiplan/PHCS,DRG,MS-272,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$52,442.21 ",IP,"15,699.88","52,442.21",,,,,,
Multiplan/PHCS,DRG,MS-273,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,,Relative Weights,"$74,799.65 ",IP,"16,176.00","74,799.65",,,,,,
Multiplan/PHCS,DRG,MS-274,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,,Relative Weights,"$63,701.57 ",IP,"16,176.00","63,701.57",,,,,,
Multiplan/PHCS,DRG,MS-280,ACUTE MYOCARDIAL INFARCTION - DISCHARGED ALIVE W MCC,,Relative Weights,"$32,878.94 ",IP,"2,420.00","32,878.94",,,,,,
Multiplan/PHCS,DRG,MS-281,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITH CC,,Relative Weights,"$19,528.99 ",IP,"2,420.00","19,528.99",,,,,,
Multiplan/PHCS,DRG,MS-282,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITHOUT CC/MCC,,Relative Weights,"$14,876.06 ",IP,"2,420.00","14,876.06",,,,,,
Multiplan/PHCS,DRG,MS-283,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH MCC,,Relative Weights,"$36,281.95 ",IP,"2,420.00","36,281.95",,,,,,
Multiplan/PHCS,DRG,MS-284,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH CC,,Relative Weights,"$14,622.05 ",IP,"2,420.00","14,622.05",,,,,,
Multiplan/PHCS,DRG,MS-285,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITHOUT CC/MCC,,Relative Weights,"$10,438.85 ",IP,"2,420.00","10,438.85",,,,,,
Multiplan/PHCS,DRG,MS-286,CIRCULATORY DISORDERS EXCEPT AMI- WITH CARDIAC CATHETERIZATION WITH MCC,,Relative Weights,"$44,299.58 ",IP,"2,420.00","44,299.58",,,,,,
Multiplan/PHCS,DRG,MS-287,CIRCULATORY DISORDERS EXCEPT AMI -  WITH CARDIAC CATHETERIZATION WITHOUT MCC,,Relative Weights,"$23,228.35 ",IP,"6,512.27","23,228.35",,,,,,
Multiplan/PHCS,DRG,MS-288,ACUTE & SUBACUTE ENDOCARDITIS W MCC,,Relative Weights,"$53,573.18 ",IP,"2,420.00","53,573.18",,,,,,
Multiplan/PHCS,DRG,MS-289,ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,,Relative Weights,"$33,542.21 ",IP,"9,181.00","33,542.21",,,,,,
Multiplan/PHCS,DRG,MS-290,ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,,Relative Weights,"$20,172.10 ",IP,"2,420.00","20,172.10",,,,,,
Multiplan/PHCS,DRG,MS-291,HEART FAILURE AND SHOCK WITH MCC,,Relative Weights,"$27,131.33 ",IP,"2,420.00","27,131.33",,,,,,
Multiplan/PHCS,DRG,MS-292,HEART FAILURE AND SHOCK WITH CC,,Relative Weights,"$18,254.88 ",IP,"2,420.00","18,254.88",,,,,,
Multiplan/PHCS,DRG,MS-293,HEART FAILURE AND SHOCK WITHOUT CC/MCC,,Relative Weights,"$13,210.85 ",IP,"2,420.00","13,210.85",,,,,,
Multiplan/PHCS,DRG,MS-294,DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC,,Relative Weights,"$25,641.50 ",IP,"2,420.00","25,641.50",,,,,,
Multiplan/PHCS,DRG,MS-295,DEEP VEIN THROMBOPHLEBITIS W/O CC/MCC,,Relative Weights,"$11,632.32 ",IP,"2,420.00","11,632.32",,,,,,
Multiplan/PHCS,DRG,MS-296,CARDIAC ARREST - UNEXPLAINED W MCC,,Relative Weights,"$31,659.26 ",IP,"2,420.00","31,659.26",,,,,,
Multiplan/PHCS,DRG,MS-297,CARDIAC ARREST- UNEXPLAINED WITH CC,,Relative Weights,"$14,575.68 ",IP,"2,420.00","14,575.68",,,,,,
Multiplan/PHCS,DRG,MS-298,CARDIAC ARREST- UNEXPLAINED WITHOUT CC/MCC,,Relative Weights,"$10,144.51 ",IP,"2,420.00","10,144.51",,,,,,
Multiplan/PHCS,DRG,MS-299,PERIPHERAL VASCULAR DISORDERS WITH MCC,,Relative Weights,"$29,225.95 ",IP,"2,420.00","29,225.95",,,,,,
Multiplan/PHCS,DRG,MS-300,PERIPHERAL VASCULAR DISORDERS WITH CC,,Relative Weights,"$20,716.42 ",IP,"2,420.00","20,716.42",,,,,,
Multiplan/PHCS,DRG,MS-301,PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,,Relative Weights,"$14,632.13 ",IP,"2,420.00","14,632.13",,,,,,
Multiplan/PHCS,DRG,MS-302,ATHEROSCLEROSIS WITH MCC,,Relative Weights,"$22,222.37 ",IP,"2,420.00","22,222.37",,,,,,
Multiplan/PHCS,DRG,MS-303,ATHEROSCLEROSIS WITHOUT MCC,,Relative Weights,"$13,622.11 ",IP,"2,420.00","13,622.11",,,,,,
Multiplan/PHCS,DRG,MS-304,HYPERTENSION WITH MCC,,Relative Weights,"$22,004.64 ",IP,"2,420.00","22,004.64",,,,,,
Multiplan/PHCS,DRG,MS-305,HYPERTENSION WITHOUT MCC,,Relative Weights,"$14,747.04 ",IP,"2,420.00","14,747.04",,,,,,
Multiplan/PHCS,DRG,MS-306,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,,Relative Weights,"$28,516.32 ",IP,"2,420.00","28,516.32",,,,,,
Multiplan/PHCS,DRG,MS-307,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,,Relative Weights,"$17,785.15 ",IP,"2,420.00","17,785.15",,,,,,
Multiplan/PHCS,DRG,MS-308,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,,Relative Weights,"$23,944.03 ",IP,"2,420.00","23,944.03",,,,,,
Multiplan/PHCS,DRG,MS-309,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,,Relative Weights,"$15,247.01 ",IP,"2,420.00","15,247.01",,,,,,
Multiplan/PHCS,DRG,MS-310,CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC,,Relative Weights,"$11,275.49 ",IP,"2,420.00","11,275.49",,,,,,
Multiplan/PHCS,DRG,MS-311,ANGINA PECTORIS,,Relative Weights,"$13,809.60 ",IP,"2,420.00","13,809.60",,,,,,
Multiplan/PHCS,DRG,MS-312,SYNCOPE AND COLLAPSE,,Relative Weights,"$16,462.66 ",IP,"2,420.00","16,462.66",,,,,,
Multiplan/PHCS,DRG,MS-313,CHEST PAIN,,Relative Weights,"$14,420.45 ",IP,"2,420.00","14,420.45",,,,,,
Multiplan/PHCS,DRG,MS-314,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,,Relative Weights,"$40,914.72 ",IP,"2,420.00","40,914.72",,,,,,
Multiplan/PHCS,DRG,MS-315,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,,Relative Weights,"$19,563.26 ",IP,"2,420.00","19,563.26",,,,,,
Multiplan/PHCS,DRG,MS-316,OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,,Relative Weights,"$14,962.75 ",IP,"2,420.00","14,962.75",,,,,,
Multiplan/PHCS,DRG,MS-319,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,,Relative Weights,"$82,670.11 ",IP,"2,420.00","82,670.11",,,,,,
Multiplan/PHCS,DRG,MS-320,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,,Relative Weights,"$47,329.63 ",IP,"2,420.00","47,329.63",,,,,,
Multiplan/PHCS,DRG,MS-326,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC,,Relative Weights,"$106,253.28 ",IP,"2,420.00","106,253.28",,,,,,
Multiplan/PHCS,DRG,MS-327,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC,,Relative Weights,"$51,869.66 ",IP,"2,420.00","51,869.66",,,,,,
Multiplan/PHCS,DRG,MS-328,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$31,752.00 ",IP,"2,420.00","31,752.00",,,,,,
Multiplan/PHCS,DRG,MS-329,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,,Relative Weights,"$98,929.15 ",IP,"2,420.00","98,929.15",,,,,,
Multiplan/PHCS,DRG,MS-330,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,,Relative Weights,"$50,940.29 ",IP,"2,420.00","50,940.29",,,,,,
Multiplan/PHCS,DRG,MS-331,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$34,054.27 ",IP,"2,420.00","34,054.27",,,,,,
Multiplan/PHCS,DRG,MS-332,RECTAL RESECTION WITH MCC,,Relative Weights,"$70,396.70 ",IP,"2,420.00","70,396.70",,,,,,
Multiplan/PHCS,DRG,MS-333,RECTAL RESECTION WITH CC,,Relative Weights,"$45,626.11 ",IP,"2,420.00","45,626.11",,,,,,
Multiplan/PHCS,DRG,MS-334,RECTAL RESECTION WITHOUT CC/MCC,,Relative Weights,"$31,052.45 ",IP,"2,420.00","31,052.45",,,,,,
Multiplan/PHCS,DRG,MS-335,PERITONEAL ADHESIOLYSIS WITH MCC,,Relative Weights,"$81,549.22 ",IP,"2,420.00","81,549.22",,,,,,
Multiplan/PHCS,DRG,MS-336,PERITONEAL ADHESIOLYSIS WITH CC,,Relative Weights,"$45,686.59 ",IP,"2,420.00","45,686.59",,,,,,
Multiplan/PHCS,DRG,MS-337,PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,,Relative Weights,"$33,056.35 ",IP,"2,420.00","33,056.35",,,,,,
Multiplan/PHCS,DRG,MS-338,APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,,Relative Weights,"$58,667.62 ",IP,"2,420.00","58,667.62",,,,,,
Multiplan/PHCS,DRG,MS-339,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W CC,,Relative Weights,"$34,596.58 ",IP,"2,420.00","34,596.58",,,,,,
Multiplan/PHCS,DRG,MS-340,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC/MCC,,Relative Weights,"$24,948.00 ",IP,"2,420.00","24,948.00",,,,,,
Multiplan/PHCS,DRG,MS-341,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,,Relative Weights,"$51,571.30 ",IP,"2,420.00","51,571.30",,,,,,
Multiplan/PHCS,DRG,MS-342,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH CC,,Relative Weights,"$32,463.65 ",IP,"2,420.00","32,463.65",,,,,,
Multiplan/PHCS,DRG,MS-343,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,,Relative Weights,"$23,216.26 ",IP,"2,420.00","23,216.26",,,,,,
Multiplan/PHCS,DRG,MS-344,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,,Relative Weights,"$60,381.22 ",IP,"2,420.00","60,381.22",,,,,,
Multiplan/PHCS,DRG,MS-345,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,,Relative Weights,"$32,927.33 ",IP,"2,420.00","32,927.33",,,,,,
Multiplan/PHCS,DRG,MS-346,MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$25,859.23 ",IP,"2,420.00","25,859.23",,,,,,
Multiplan/PHCS,DRG,MS-347,ANAL AND STOMAL PROCEDURES WITH MCC,,Relative Weights,"$53,149.82 ",IP,"2,420.00","53,149.82",,,,,,
Multiplan/PHCS,DRG,MS-348,ANAL AND STOMAL PROCEDURES WITH CC,,Relative Weights,"$28,411.49 ",IP,"2,420.00","28,411.49",,,,,,
Multiplan/PHCS,DRG,MS-349,ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$19,774.94 ",IP,"2,420.00","19,774.94",,,,,,
Multiplan/PHCS,DRG,MS-350,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,,Relative Weights,"$49,176.29 ",IP,"2,420.00","49,176.29",,,,,,
Multiplan/PHCS,DRG,MS-351,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,,Relative Weights,"$29,399.33 ",IP,"2,420.00","29,399.33",,,,,,
Multiplan/PHCS,DRG,MS-352,INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$21,708.29 ",IP,"2,420.00","21,708.29",,,,,,
Multiplan/PHCS,DRG,MS-353,HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,,Relative Weights,"$59,812.70 ",IP,"2,420.00","59,812.70",,,,,,
Multiplan/PHCS,DRG,MS-354,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W CC,,Relative Weights,"$34,717.54 ",IP,"2,420.00","34,717.54",,,,,,
Multiplan/PHCS,DRG,MS-355,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W/O CC/MCC,,Relative Weights,"$27,667.58 ",IP,"2,420.00","27,667.58",,,,,,
Multiplan/PHCS,DRG,MS-356,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,,Relative Weights,"$82,196.35 ",IP,"2,420.00","82,196.35",,,,,,
Multiplan/PHCS,DRG,MS-357,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,,Relative Weights,"$45,368.06 ",IP,"2,420.00","45,368.06",,,,,,
Multiplan/PHCS,DRG,MS-358,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$27,653.47 ",IP,"2,420.00","27,653.47",,,,,,
Multiplan/PHCS,DRG,MS-368,MAJOR ESOPHAGEAL DISORDERS WITH MCC,,Relative Weights,"$38,376.58 ",IP,"2,420.00","38,376.58",,,,,,
Multiplan/PHCS,DRG,MS-369,MAJOR ESOPHAGEAL DISORDERS WITH CC,,Relative Weights,"$21,432.10 ",IP,"2,420.00","21,432.10",,,,,,
Multiplan/PHCS,DRG,MS-370,MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,,Relative Weights,"$15,065.57 ",IP,"2,420.00","15,065.57",,,,,,
Multiplan/PHCS,DRG,MS-371,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,,Relative Weights,"$34,786.08 ",IP,"2,420.00","34,786.08",,,,,,
Multiplan/PHCS,DRG,MS-372,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,,Relative Weights,"$20,613.60 ",IP,"2,420.00","20,613.60",,,,,,
Multiplan/PHCS,DRG,MS-373,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,,Relative Weights,"$14,954.69 ",IP,"2,420.00","14,954.69",,,,,,
Multiplan/PHCS,DRG,MS-374,DIGESTIVE MALIGNANCY WITH MCC,,Relative Weights,"$40,269.60 ",IP,"2,420.00","40,269.60",,,,,,
Multiplan/PHCS,DRG,MS-375,DIGESTIVE MALIGNANCY WITH CC,,Relative Weights,"$24,339.17 ",IP,"2,420.00","24,339.17",,,,,,
Multiplan/PHCS,DRG,MS-376,DIGESTIVE MALIGNANCY WITHOUT CC/MCC,,Relative Weights,"$20,186.21 ",IP,"2,420.00","20,186.21",,,,,,
Multiplan/PHCS,DRG,MS-377,GASTROINTESTINAL HEMORRHAGE WITH MCC,,Relative Weights,"$35,681.18 ",IP,"2,420.00","35,681.18",,,,,,
Multiplan/PHCS,DRG,MS-378,GASTROINTESTINAL HEMORRHAGE WITH CC,,Relative Weights,"$19,920.10 ",IP,"2,420.00","19,920.10",,,,,,
Multiplan/PHCS,DRG,MS-379,GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,,Relative Weights,"$13,017.31 ",IP,"2,420.00","13,017.31",,,,,,
Multiplan/PHCS,DRG,MS-380,COMPLICATED PEPTIC ULCER WITH MCC,,Relative Weights,"$38,054.02 ",IP,"2,420.00","38,054.02",,,,,,
Multiplan/PHCS,DRG,MS-381,COMPLICATED PEPTIC ULCER WITH CC,,Relative Weights,"$21,706.27 ",IP,"2,420.00","21,706.27",,,,,,
Multiplan/PHCS,DRG,MS-382,COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,,Relative Weights,"$15,954.62 ",IP,"2,420.00","15,954.62",,,,,,
Multiplan/PHCS,DRG,MS-383,UNCOMPLICATED PEPTIC ULCER WITH MCC,,Relative Weights,"$26,738.21 ",IP,"2,420.00","26,738.21",,,,,,
Multiplan/PHCS,DRG,MS-384,UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,,Relative Weights,"$17,543.23 ",IP,"2,420.00","17,543.23",,,,,,
Multiplan/PHCS,DRG,MS-385,INFLAMMATORY BOWEL DISEASE WITH MCC,,Relative Weights,"$32,463.65 ",IP,"2,420.00","32,463.65",,,,,,
Multiplan/PHCS,DRG,MS-386,INFLAMMATORY BOWEL DISEASE W CC,,Relative Weights,"$19,861.63 ",IP,"2,420.00","19,861.63",,,,,,
Multiplan/PHCS,DRG,MS-387,INFLAMMATORY BOWEL DISEASE W/O CC/MCC,,Relative Weights,"$14,126.11 ",IP,"2,420.00","14,126.11",,,,,,
Multiplan/PHCS,DRG,MS-388,GASTROINTESTINAL OBSTRUCTION WITH MCC,,Relative Weights,"$30,746.02 ",IP,"2,420.00","30,746.02",,,,,,
Multiplan/PHCS,DRG,MS-389,GASTROINTESTINAL OBSTRUCTION WITH CC,,Relative Weights,"$16,928.35 ",IP,"2,420.00","16,928.35",,,,,,
Multiplan/PHCS,DRG,MS-390,GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,,Relative Weights,"$11,684.74 ",IP,"2,420.00","11,684.74",,,,,,
Multiplan/PHCS,DRG,MS-391,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC,,Relative Weights,"$24,897.60 ",IP,"2,420.00","24,897.60",,,,,,
Multiplan/PHCS,DRG,MS-392,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC,,Relative Weights,"$15,351.84 ",IP,"2,420.00","15,351.84",,,,,,
Multiplan/PHCS,DRG,MS-393,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,,Relative Weights,"$32,749.92 ",IP,"2,420.00","32,749.92",,,,,,
Multiplan/PHCS,DRG,MS-394,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,,Relative Weights,"$18,912.10 ",IP,"2,420.00","18,912.10",,,,,,
Multiplan/PHCS,DRG,MS-395,OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,,Relative Weights,"$13,192.70 ",IP,"2,420.00","13,192.70",,,,,,
Multiplan/PHCS,DRG,MS-405,PANCREAS- LIVER AND SHUNT PROCEDURES WITH MCC,,Relative Weights,"$109,412.35 ",IP,"2,420.00","109,412.35",,,,,,
Multiplan/PHCS,DRG,MS-406,PANCREAS -  LIVER AND SHUNT PROCEDURES WITH CC,,Relative Weights,"$56,264.54 ",IP,"2,420.00","56,264.54",,,,,,
Multiplan/PHCS,DRG,MS-407,PANCREAS -  LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$42,059.81 ",IP,"2,420.00","42,059.81",,,,,,
Multiplan/PHCS,DRG,MS-408,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,,Relative Weights,"$71,842.18 ",IP,"2,420.00","71,842.18",,,,,,
Multiplan/PHCS,DRG,MS-409,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,,Relative Weights,"$48,259.01 ",IP,"2,420.00","48,259.01",,,,,,
Multiplan/PHCS,DRG,MS-410,BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W/O CC/MCC,,Relative Weights,"$33,465.60 ",IP,"2,420.00","33,465.60",,,,,,
Multiplan/PHCS,DRG,MS-411,CHOLECYSTECTOMY W C.D.E. W MCC,,Relative Weights,"$77,220.86 ",IP,"2,420.00","77,220.86",,,,,,
Multiplan/PHCS,DRG,MS-412,CHOLECYSTECTOMY WITH C.D.E. WITH CC,,Relative Weights,"$47,920.32 ",IP,"2,420.00","47,920.32",,,,,,
Multiplan/PHCS,DRG,MS-413,CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,,Relative Weights,"$32,604.77 ",IP,"2,420.00","32,604.77",,,,,,
Multiplan/PHCS,DRG,MS-414,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,,Relative Weights,"$68,874.62 ",IP,"2,420.00","68,874.62",,,,,,
Multiplan/PHCS,DRG,MS-415,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,,Relative Weights,"$41,362.27 ",IP,"2,420.00","41,362.27",,,,,,
Multiplan/PHCS,DRG,MS-416,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,,Relative Weights,"$27,222.05 ",IP,"2,420.00","27,222.05",,,,,,
Multiplan/PHCS,DRG,MS-417,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,,Relative Weights,"$48,599.71 ",IP,"2,420.00","48,599.71",,,,,,
Multiplan/PHCS,DRG,MS-418,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,,Relative Weights,"$33,645.02 ",IP,"2,420.00","33,645.02",,,,,,
Multiplan/PHCS,DRG,MS-419,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,,Relative Weights,"$26,345.09 ",IP,"2,420.00","26,345.09",,,,,,
Multiplan/PHCS,DRG,MS-420,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,,Relative Weights,"$69,245.57 ",IP,"2,420.00","69,245.57",,,,,,
Multiplan/PHCS,DRG,MS-421,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,,Relative Weights,"$37,118.59 ",IP,"2,420.00","37,118.59",,,,,,
Multiplan/PHCS,DRG,MS-422,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$28,314.72 ",IP,"2,420.00","28,314.72",,,,,,
Multiplan/PHCS,DRG,MS-423,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,,Relative Weights,"$85,442.11 ",IP,"2,420.00","85,442.11",,,,,,
Multiplan/PHCS,DRG,MS-424,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,,Relative Weights,"$45,388.22 ",IP,"2,420.00","45,388.22",,,,,,
Multiplan/PHCS,DRG,MS-425,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES W/O CC/MCC,,Relative Weights,"$29,463.84 ",IP,"2,420.00","29,463.84",,,,,,
Multiplan/PHCS,DRG,MS-432,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,,Relative Weights,"$36,759.74 ",IP,"2,420.00","36,759.74",,,,,,
Multiplan/PHCS,DRG,MS-433,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,,Relative Weights,"$20,805.12 ",IP,"2,420.00","20,805.12",,,,,,
Multiplan/PHCS,DRG,MS-434,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,,Relative Weights,"$12,900.38 ",IP,"2,420.00","12,900.38",,,,,,
Multiplan/PHCS,DRG,MS-435,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,,Relative Weights,"$34,213.54 ",IP,"2,420.00","34,213.54",,,,,,
Multiplan/PHCS,DRG,MS-436,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,,Relative Weights,"$22,694.11 ",IP,"2,420.00","22,694.11",,,,,,
Multiplan/PHCS,DRG,MS-437,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,,Relative Weights,"$17,698.46 ",IP,"2,420.00","17,698.46",,,,,,
Multiplan/PHCS,DRG,MS-438,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,,Relative Weights,"$33,028.13 ",IP,"2,420.00","33,028.13",,,,,,
Multiplan/PHCS,DRG,MS-439,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,,Relative Weights,"$17,079.55 ",IP,"2,420.00","17,079.55",,,,,,
Multiplan/PHCS,DRG,MS-440,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,,Relative Weights,"$12,410.50 ",IP,"2,420.00","12,410.50",,,,,,
Multiplan/PHCS,DRG,MS-441,DISORDERS OF LIVER EXCEPT MALIGNANCY- CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC,,Relative Weights,"$37,306.08 ",IP,"2,420.00","37,306.08",,,,,,
Multiplan/PHCS,DRG,MS-442,DISORDERS OF LIVER EXCEPT MALIGNANCY -  CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC,,Relative Weights,"$18,817.34 ",IP,"2,420.00","18,817.34",,,,,,
Multiplan/PHCS,DRG,MS-443,DISORDERS OF LIVER EXCEPT MALIGNANCY -  CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC,,Relative Weights,"$13,714.85 ",IP,"2,420.00","13,714.85",,,,,,
Multiplan/PHCS,DRG,MS-444,DISORDERS OF THE BILIARY TRACT WITH MCC,,Relative Weights,"$32,782.18 ",IP,"2,420.00","32,782.18",,,,,,
Multiplan/PHCS,DRG,MS-445,DISORDERS OF THE BILIARY TRACT WITH CC,,Relative Weights,"$21,661.92 ",IP,"2,420.00","21,661.92",,,,,,
Multiplan/PHCS,DRG,MS-446,DISORDERS OF THE BILIARY TRACT W/O CC/MCC,,Relative Weights,"$16,384.03 ",IP,"2,420.00","16,384.03",,,,,,
Multiplan/PHCS,DRG,MS-453,COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W MCC,,Relative Weights,"$189,645.12 ",IP,"2,420.00","189,645.12",,,,,,
Multiplan/PHCS,DRG,MS-454,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC,,Relative Weights,"$123,480.00 ",IP,"2,420.00","123,480.00",,,,,,
Multiplan/PHCS,DRG,MS-455,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CC/MCC,,Relative Weights,"$97,036.13 ",IP,"2,420.00","97,036.13",,,,,,
Multiplan/PHCS,DRG,MS-456,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH MCC,,Relative Weights,"$183,076.99 ",IP,"2,420.00","183,076.99",,,,,,
Multiplan/PHCS,DRG,MS-457,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH CC,,Relative Weights,"$131,308.13 ",IP,"2,420.00","131,308.13",,,,,,
Multiplan/PHCS,DRG,MS-458,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC,,Relative Weights,"$94,629.02 ",IP,"2,420.00","94,629.02",,,,,,
Multiplan/PHCS,DRG,MS-459,SPINAL FUSION EXCEPT CERVICAL WITH MCC,,Relative Weights,"$138,136.32 ",IP,"21,658.00","138,136.32",,,,,,
Multiplan/PHCS,DRG,MS-460,SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,,Relative Weights,"$79,841.66 ",IP,"21,658.00","79,841.66",,,,,,
Multiplan/PHCS,DRG,MS-461,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,,Relative Weights,"$108,436.61 ",IP,"2,420.00","108,436.61",,,,,,
Multiplan/PHCS,DRG,MS-462,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,,Relative Weights,"$63,229.82 ",IP,"2,420.00","63,229.82",,,,,,
Multiplan/PHCS,DRG,MS-463,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,,Relative Weights,"$105,392.45 ",IP,"2,420.00","105,392.45",,,,,,
Multiplan/PHCS,DRG,MS-464,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,,Relative Weights,"$59,526.43 ",IP,"2,420.00","59,526.43",,,,,,
Multiplan/PHCS,DRG,MS-465,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,,Relative Weights,"$38,610.43 ",IP,"2,420.00","38,610.43",,,,,,
Multiplan/PHCS,DRG,MS-466,REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,,Relative Weights,"$102,797.86 ",IP,"2,420.00","102,797.86",,,,,,
Multiplan/PHCS,DRG,MS-467,REVISION OF HIP OR KNEE REPLACEMENT W CC,,Relative Weights,"$70,803.94 ",IP,"2,420.00","70,803.94",,,,,,
Multiplan/PHCS,DRG,MS-468,REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,,Relative Weights,"$56,691.94 ",IP,"2,420.00","56,691.94",,,,,,
Multiplan/PHCS,DRG,MS-469,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,,Relative Weights,"$63,300.38 ",IP,"2,420.00","63,300.38",,,,,,
Multiplan/PHCS,DRG,MS-470,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,,Relative Weights,"$39,682.94 ",IP,"2,420.00","39,682.94",,,,,,
Multiplan/PHCS,DRG,MS-471,CERVICAL SPINAL FUSION WITH MCC,,Relative Weights,"$100,687.10 ",IP,"15,407.00","100,687.10",,,,,,
Multiplan/PHCS,DRG,MS-472,CERVICAL SPINAL FUSION WITH CC,,Relative Weights,"$61,316.64 ",IP,"15,407.00","61,316.64",,,,,,
Multiplan/PHCS,DRG,MS-473,CERVICAL SPINAL FUSION WITHOUT CC/MCC,,Relative Weights,"$50,649.98 ",IP,"14,827.96","50,649.98",,,,,,
Multiplan/PHCS,DRG,MS-474,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,,Relative Weights,"$78,117.98 ",IP,"2,420.00","78,117.98",,,,,,
Multiplan/PHCS,DRG,MS-475,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,,Relative Weights,"$42,356.16 ",IP,"2,420.00","42,356.16",,,,,,
Multiplan/PHCS,DRG,MS-476,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,,Relative Weights,"$23,480.35 ",IP,"2,420.00","23,480.35",,,,,,
Multiplan/PHCS,DRG,MS-477,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,,Relative Weights,"$65,626.85 ",IP,"2,420.00","65,626.85",,,,,,
Multiplan/PHCS,DRG,MS-478,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,,Relative Weights,"$46,712.74 ",IP,"2,420.00","46,712.74",,,,,,
Multiplan/PHCS,DRG,MS-479,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,,Relative Weights,"$35,929.15 ",IP,"2,420.00","35,929.15",,,,,,
Multiplan/PHCS,DRG,MS-480,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,,Relative Weights,"$60,852.96 ",IP,"2,420.00","60,852.96",,,,,,
Multiplan/PHCS,DRG,MS-481,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,,Relative Weights,"$42,090.05 ",IP,"2,420.00","42,090.05",,,,,,
Multiplan/PHCS,DRG,MS-482,HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC,,Relative Weights,"$33,169.25 ",IP,"2,420.00","33,169.25",,,,,,
Multiplan/PHCS,DRG,MS-483,MAJOR JOINT & LIMB REATTACHMENT PROC OF UPPER EXTREMITY W CC/MCC,,Relative Weights,"$48,224.74 ",IP,"2,420.00","48,224.74",,,,,,
Multiplan/PHCS,DRG,MS-485,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,,Relative Weights,"$66,104.64 ",IP,"2,420.00","66,104.64",,,,,,
Multiplan/PHCS,DRG,MS-486,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,,Relative Weights,"$43,356.10 ",IP,"2,420.00","43,356.10",,,,,,
Multiplan/PHCS,DRG,MS-487,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,,Relative Weights,"$32,401.15 ",IP,"2,420.00","32,401.15",,,,,,
Multiplan/PHCS,DRG,MS-488,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,,Relative Weights,"$39,699.07 ",IP,"2,420.00","39,699.07",,,,,,
Multiplan/PHCS,DRG,MS-489,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,,Relative Weights,"$25,381.44 ",IP,"2,420.00","25,381.44",,,,,,
Multiplan/PHCS,DRG,MS-492,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH MCC,,Relative Weights,"$69,457.25 ",IP,"2,420.00","69,457.25",,,,,,
Multiplan/PHCS,DRG,MS-493,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH CC,,Relative Weights,"$46,408.32 ",IP,"2,420.00","46,408.32",,,,,,
Multiplan/PHCS,DRG,MS-494,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITHOUT CC/MCC,,Relative Weights,"$36,517.82 ",IP,"2,420.00","36,517.82",,,,,,
Multiplan/PHCS,DRG,MS-495,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,,Relative Weights,"$69,201.22 ",IP,"2,420.00","69,201.22",,,,,,
Multiplan/PHCS,DRG,MS-496,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,,Relative Weights,"$41,136.48 ",IP,"2,420.00","41,136.48",,,,,,
Multiplan/PHCS,DRG,MS-497,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,,Relative Weights,"$29,621.09 ",IP,"2,420.00","29,621.09",,,,,,
Multiplan/PHCS,DRG,MS-498,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,,Relative Weights,"$49,353.70 ",IP,"2,420.00","49,353.70",,,,,,
Multiplan/PHCS,DRG,MS-499,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,,Relative Weights,"$23,202.14 ",IP,"2,420.00","23,202.14",,,,,,
Multiplan/PHCS,DRG,MS-500,SOFT TISSUE PROCEDURES WITH MCC,,Relative Weights,"$60,786.43 ",IP,"2,420.00","60,786.43",,,,,,
Multiplan/PHCS,DRG,MS-501,SOFT TISSUE PROCEDURES WITH CC,,Relative Weights,"$33,828.48 ",IP,"2,420.00","33,828.48",,,,,,
Multiplan/PHCS,DRG,MS-502,SOFT TISSUE PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$26,625.31 ",IP,"2,420.00","26,625.31",,,,,,
Multiplan/PHCS,DRG,MS-503,FOOT PROCEDURES WITH MCC,,Relative Weights,"$54,766.66 ",IP,"2,420.00","54,766.66",,,,,,
Multiplan/PHCS,DRG,MS-504,FOOT PROCEDURES WITH CC,,Relative Weights,"$35,007.84 ",IP,"2,420.00","35,007.84",,,,,,
Multiplan/PHCS,DRG,MS-505,FOOT PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$33,899.04 ",IP,"2,420.00","33,899.04",,,,,,
Multiplan/PHCS,DRG,MS-506,MAJOR THUMB OR JOINT PROCEDURES,,Relative Weights,"$26,986.18 ",IP,"2,420.00","26,986.18",,,,,,
Multiplan/PHCS,DRG,MS-507,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W CC/MCC,,Relative Weights,"$42,336.00 ",IP,"2,420.00","42,336.00",,,,,,
Multiplan/PHCS,DRG,MS-508,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W/O CC/MCC,,Relative Weights,"$31,417.34 ",IP,"2,420.00","31,417.34",,,,,,
Multiplan/PHCS,DRG,MS-509,ARTHROSCOPY,,Relative Weights,"$28,056.67 ",IP,"2,420.00","28,056.67",,,,,,
Multiplan/PHCS,DRG,MS-510,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH MCC,,Relative Weights,"$56,206.08 ",IP,"2,420.00","56,206.08",,,,,,
Multiplan/PHCS,DRG,MS-511,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH CC,,Relative Weights,"$37,985.47 ",IP,"2,420.00","37,985.47",,,,,,
Multiplan/PHCS,DRG,MS-512,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$30,518.21 ",IP,"2,420.00","30,518.21",,,,,,
Multiplan/PHCS,DRG,MS-513,HAND OR WRIST PROCEDURES- EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC,,Relative Weights,"$31,794.34 ",IP,"2,420.00","31,794.34",,,,,,
Multiplan/PHCS,DRG,MS-514,HAND OR WRIST PROCEDURES -  EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$21,506.69 ",IP,"2,420.00","21,506.69",,,,,,
Multiplan/PHCS,DRG,MS-515,OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W MCC,,Relative Weights,"$63,584.64 ",IP,"2,420.00","63,584.64",,,,,,
Multiplan/PHCS,DRG,MS-516,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,,Relative Weights,"$39,092.26 ",IP,"2,420.00","39,092.26",,,,,,
Multiplan/PHCS,DRG,MS-517,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$28,532.45 ",IP,"2,420.00","28,532.45",,,,,,
Multiplan/PHCS,DRG,MS-518,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,,Relative Weights,"$68,717.38 ",IP,"10,289.00","68,717.38",,,,,,
Multiplan/PHCS,DRG,MS-519,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,,Relative Weights,"$38,479.39 ",IP,"10,289.00","38,479.39",,,,,,
Multiplan/PHCS,DRG,MS-520,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,,Relative Weights,"$26,974.08 ",IP,"8,282.98","26,974.08",,,,,,
Multiplan/PHCS,DRG,MS-533,FRACTURES OF FEMUR WITH MCC,,Relative Weights,"$29,421.50 ",IP,"2,420.00","29,421.50",,,,,,
Multiplan/PHCS,DRG,MS-534,FRACTURES OF FEMUR WITHOUT MCC,,Relative Weights,"$15,680.45 ",IP,"2,420.00","15,680.45",,,,,,
Multiplan/PHCS,DRG,MS-535,FRACTURES OF HIP AND PELVIS WITH MCC,,Relative Weights,"$24,738.34 ",IP,"2,420.00","24,738.34",,,,,,
Multiplan/PHCS,DRG,MS-536,FRACTURES OF HIP AND PELVIS WITHOUT MCC,,Relative Weights,"$15,291.36 ",IP,"2,420.00","15,291.36",,,,,,
Multiplan/PHCS,DRG,MS-537,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITH CC/MCC,,Relative Weights,"$18,363.74 ",IP,"2,420.00","18,363.74",,,,,,
Multiplan/PHCS,DRG,MS-538,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITHOUT CC/MCC,,Relative Weights,"$14,535.36 ",IP,"2,420.00","14,535.36",,,,,,
Multiplan/PHCS,DRG,MS-539,OSTEOMYELITIS WITH MCC,,Relative Weights,"$38,005.63 ",IP,"2,420.00","38,005.63",,,,,,
Multiplan/PHCS,DRG,MS-540,OSTEOMYELITIS WITH CC,,Relative Weights,"$26,208.00 ",IP,"2,420.00","26,208.00",,,,,,
Multiplan/PHCS,DRG,MS-541,OSTEOMYELITIS WITHOUT CC/MCC,,Relative Weights,"$18,279.07 ",IP,"2,420.00","18,279.07",,,,,,
Multiplan/PHCS,DRG,MS-542,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,,Relative Weights,"$36,787.97 ",IP,"2,420.00","36,787.97",,,,,,
Multiplan/PHCS,DRG,MS-543,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,,Relative Weights,"$21,295.01 ",IP,"2,420.00","21,295.01",,,,,,
Multiplan/PHCS,DRG,MS-544,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,,Relative Weights,"$15,289.34 ",IP,"2,420.00","15,289.34",,,,,,
Multiplan/PHCS,DRG,MS-545,CONNECTIVE TISSUE DISORDERS WITH MCC,,Relative Weights,"$50,964.48 ",IP,"2,420.00","50,964.48",,,,,,
Multiplan/PHCS,DRG,MS-546,CONNECTIVE TISSUE DISORDERS WITH CC,,Relative Weights,"$24,260.54 ",IP,"2,420.00","24,260.54",,,,,,
Multiplan/PHCS,DRG,MS-547,CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,,Relative Weights,"$16,331.62 ",IP,"2,420.00","16,331.62",,,,,,
Multiplan/PHCS,DRG,MS-548,SEPTIC ARTHRITIS WITH MCC,,Relative Weights,"$39,983.33 ",IP,"2,420.00","39,983.33",,,,,,
Multiplan/PHCS,DRG,MS-549,SEPTIC ARTHRITIS W CC,,Relative Weights,"$24,052.90 ",IP,"2,420.00","24,052.90",,,,,,
Multiplan/PHCS,DRG,MS-550,SEPTIC ARTHRITIS W/O CC/MCC,,Relative Weights,"$17,418.24 ",IP,"2,420.00","17,418.24",,,,,,
Multiplan/PHCS,DRG,MS-551,MEDICAL BACK PROBLEMS WITH MCC,,Relative Weights,"$32,042.30 ",IP,"2,420.00","32,042.30",,,,,,
Multiplan/PHCS,DRG,MS-552,MEDICAL BACK PROBLEMS WITHOUT MCC,,Relative Weights,"$18,383.90 ",IP,"2,420.00","18,383.90",,,,,,
Multiplan/PHCS,DRG,MS-553,BONE DISEASES AND ARTHROPATHIES WITH MCC,,Relative Weights,"$25,915.68 ",IP,"2,420.00","25,915.68",,,,,,
Multiplan/PHCS,DRG,MS-554,BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,,Relative Weights,"$15,869.95 ",IP,"2,420.00","15,869.95",,,,,,
Multiplan/PHCS,DRG,MS-555,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,,Relative Weights,"$26,516.45 ",IP,"2,420.00","26,516.45",,,,,,
Multiplan/PHCS,DRG,MS-556,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,,Relative Weights,"$15,962.69 ",IP,"2,420.00","15,962.69",,,,,,
Multiplan/PHCS,DRG,MS-557,TENDONITIS -  MYOSITIS AND BURSITIS WITH MCC,,Relative Weights,"$29,397.31 ",IP,"2,420.00","29,397.31",,,,,,
Multiplan/PHCS,DRG,MS-558,TENDONITIS- MYOSITIS AND BURSITIS WITHOUT MCC,,Relative Weights,"$17,365.82 ",IP,"2,420.00","17,365.82",,,,,,
Multiplan/PHCS,DRG,MS-559,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,,Relative Weights,"$36,324.29 ",IP,"2,420.00","36,324.29",,,,,,
Multiplan/PHCS,DRG,MS-560,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,,Relative Weights,"$21,036.96 ",IP,"2,420.00","21,036.96",,,,,,
Multiplan/PHCS,DRG,MS-561,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,,Relative Weights,"$15,067.58 ",IP,"2,420.00","15,067.58",,,,,,
Multiplan/PHCS,DRG,MS-562,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITH MCC,,Relative Weights,"$27,157.54 ",IP,"2,420.00","27,157.54",,,,,,
Multiplan/PHCS,DRG,MS-563,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITHOUT MCC,,Relative Weights,"$17,216.64 ",IP,"2,420.00","17,216.64",,,,,,
Multiplan/PHCS,DRG,MS-564,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,,Relative Weights,"$30,481.92 ",IP,"2,420.00","30,481.92",,,,,,
Multiplan/PHCS,DRG,MS-565,OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W CC,,Relative Weights,"$19,766.88 ",IP,"2,420.00","19,766.88",,,,,,
Multiplan/PHCS,DRG,MS-566,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,,Relative Weights,"$15,275.23 ",IP,"2,420.00","15,275.23",,,,,,
Multiplan/PHCS,DRG,MS-570,SKIN DEBRIDEMENT WITH MCC,,Relative Weights,"$57,923.71 ",IP,"2,420.00","57,923.71",,,,,,
Multiplan/PHCS,DRG,MS-571,SKIN DEBRIDEMENT WITH CC,,Relative Weights,"$33,713.57 ",IP,"2,420.00","33,713.57",,,,,,
Multiplan/PHCS,DRG,MS-572,SKIN DEBRIDEMENT WITHOUT CC/MCC,,Relative Weights,"$22,613.47 ",IP,"2,420.00","22,613.47",,,,,,
Multiplan/PHCS,DRG,MS-573,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,,Relative Weights,"$107,156.45 ",IP,"2,420.00","107,156.45",,,,,,
Multiplan/PHCS,DRG,MS-574,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,,Relative Weights,"$62,935.49 ",IP,"2,420.00","62,935.49",,,,,,
Multiplan/PHCS,DRG,MS-575,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS W/O CC/MCC,,Relative Weights,"$35,421.12 ",IP,"2,420.00","35,421.12",,,,,,
Multiplan/PHCS,DRG,MS-576,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,,Relative Weights,"$97,759.87 ",IP,"2,420.00","97,759.87",,,,,,
Multiplan/PHCS,DRG,MS-577,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,,Relative Weights,"$48,698.50 ",IP,"2,420.00","48,698.50",,,,,,
Multiplan/PHCS,DRG,MS-578,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,,Relative Weights,"$32,808.38 ",IP,"2,420.00","32,808.38",,,,,,
Multiplan/PHCS,DRG,MS-579,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC,,Relative Weights,"$60,199.78 ",IP,"2,420.00","60,199.78",,,,,,
Multiplan/PHCS,DRG,MS-580,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC,,Relative Weights,"$32,431.39 ",IP,"2,420.00","32,431.39",,,,,,
Multiplan/PHCS,DRG,MS-581,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$25,296.77 ",IP,"2,420.00","25,296.77",,,,,,
Multiplan/PHCS,DRG,MS-582,MASTECTOMY FOR MALIGNANCY WITH CC/MCC,,Relative Weights,"$31,826.59 ",IP,"2,420.00","31,826.59",,,,,,
Multiplan/PHCS,DRG,MS-583,MASTECTOMY FOR MALIGNANCY W/O CC/MCC,,Relative Weights,"$29,461.82 ",IP,"2,420.00","29,461.82",,,,,,
Multiplan/PHCS,DRG,MS-584,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC,,Relative Weights,"$36,860.54 ",IP,"2,420.00","36,860.54",,,,,,
Multiplan/PHCS,DRG,MS-585,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$34,217.57 ",IP,"2,420.00","34,217.57",,,,,,
Multiplan/PHCS,DRG,MS-592,SKIN ULCERS WITH MCC,,Relative Weights,"$35,971.49 ",IP,"2,420.00","35,971.49",,,,,,
Multiplan/PHCS,DRG,MS-593,SKIN ULCERS WITH CC,,Relative Weights,"$23,139.65 ",IP,"2,420.00","23,139.65",,,,,,
Multiplan/PHCS,DRG,MS-594,SKIN ULCERS WITHOUT CC/MCC,,Relative Weights,"$16,323.55 ",IP,"2,420.00","16,323.55",,,,,,
Multiplan/PHCS,DRG,MS-595,MAJOR SKIN DISORDERS WITH MCC,,Relative Weights,"$40,977.22 ",IP,"2,420.00","40,977.22",,,,,,
Multiplan/PHCS,DRG,MS-596,MAJOR SKIN DISORDERS W/O MCC,,Relative Weights,"$19,637.86 ",IP,"2,420.00","19,637.86",,,,,,
Multiplan/PHCS,DRG,MS-597,MALIGNANT BREAST DISORDERS W MCC,,Relative Weights,"$34,128.86 ",IP,"2,420.00","34,128.86",,,,,,
Multiplan/PHCS,DRG,MS-598,MALIGNANT BREAST DISORDERS WITH CC,,Relative Weights,"$21,946.18 ",IP,"2,420.00","21,946.18",,,,,,
Multiplan/PHCS,DRG,MS-599,MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,,Relative Weights,"$14,019.26 ",IP,"2,420.00","14,019.26",,,,,,
Multiplan/PHCS,DRG,MS-600,NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,,Relative Weights,"$19,337.47 ",IP,"2,420.00","19,337.47",,,,,,
Multiplan/PHCS,DRG,MS-601,NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,,Relative Weights,"$12,475.01 ",IP,"2,420.00","12,475.01",,,,,,
Multiplan/PHCS,DRG,MS-602,CELLULITIS WITH MCC,,Relative Weights,"$28,824.77 ",IP,"2,420.00","28,824.77",,,,,,
Multiplan/PHCS,DRG,MS-603,CELLULITIS WITHOUT MCC,,Relative Weights,"$17,004.96 ",IP,"2,420.00","17,004.96",,,,,,
Multiplan/PHCS,DRG,MS-604,TRAUMA TO THE SKIN -  SUBCUTANEOUS TISSUE AND BREAST WITH MCC,,Relative Weights,"$29,524.32 ",IP,"2,420.00","29,524.32",,,,,,
Multiplan/PHCS,DRG,MS-605,TRAUMA TO THE SKIN- SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC,,Relative Weights,"$17,654.11 ",IP,"2,420.00","17,654.11",,,,,,
Multiplan/PHCS,DRG,MS-606,MINOR SKIN DISORDERS WITH MCC,,Relative Weights,"$30,149.28 ",IP,"2,420.00","30,149.28",,,,,,
Multiplan/PHCS,DRG,MS-607,MINOR SKIN DISORDERS WITHOUT MCC,,Relative Weights,"$16,654.18 ",IP,"2,420.00","16,654.18",,,,,,
Multiplan/PHCS,DRG,MS-614,ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,,Relative Weights,"$49,055.33 ",IP,"2,420.00","49,055.33",,,,,,
Multiplan/PHCS,DRG,MS-615,ADRENAL & PITUITARY PROCEDURES W/O CC/MCC,,Relative Weights,"$29,919.46 ",IP,"2,420.00","29,919.46",,,,,,
Multiplan/PHCS,DRG,MS-616,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,,Relative Weights,"$80,656.13 ",IP,"2,420.00","80,656.13",,,,,,
Multiplan/PHCS,DRG,MS-617,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH CC,,Relative Weights,"$41,354.21 ",IP,"2,420.00","41,354.21",,,,,,
Multiplan/PHCS,DRG,MS-618,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,,Relative Weights,"$25,290.72 ",IP,"2,420.00","25,290.72",,,,,,
Multiplan/PHCS,DRG,MS-619,O.R. PROCEDURES FOR OBESITY WITH MCC,,Relative Weights,"$62,062.56 ",IP,"2,420.00","62,062.56",,,,,,
Multiplan/PHCS,DRG,MS-620,O.R. PROCEDURES FOR OBESITY WITH CC,,Relative Weights,"$36,179.14 ",IP,"2,420.00","36,179.14",,,,,,
Multiplan/PHCS,DRG,MS-621,O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,,Relative Weights,"$31,691.52 ",IP,"2,420.00","31,691.52",,,,,,
Multiplan/PHCS,DRG,MS-622,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,,Relative Weights,"$76,114.08 ",IP,"2,420.00","76,114.08",,,,,,
Multiplan/PHCS,DRG,MS-623,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE -  NUTRITIONAL AND METABOLIC DISORDERS WITH CC,,Relative Weights,"$39,364.42 ",IP,"2,420.00","39,364.42",,,,,,
Multiplan/PHCS,DRG,MS-624,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,,Relative Weights,"$22,216.32 ",IP,"2,420.00","22,216.32",,,,,,
Multiplan/PHCS,DRG,MS-625,THYROID- PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC,,Relative Weights,"$58,970.02 ",IP,"2,420.00","58,970.02",,,,,,
Multiplan/PHCS,DRG,MS-626,THYROID -  PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC,,Relative Weights,"$33,925.25 ",IP,"2,420.00","33,925.25",,,,,,
Multiplan/PHCS,DRG,MS-627,THYROID -  PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$23,016.67 ",IP,"2,420.00","23,016.67",,,,,,
Multiplan/PHCS,DRG,MS-628,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC,,Relative Weights,"$74,376.29 ",IP,"2,420.00","74,376.29",,,,,,
Multiplan/PHCS,DRG,MS-629,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC,,Relative Weights,"$46,827.65 ",IP,"2,420.00","46,827.65",,,,,,
Multiplan/PHCS,DRG,MS-630,OTHER ENDOCRINE - NUTRIT & METAB O.R. PROC W/O CC/MCC,,Relative Weights,"$29,207.81 ",IP,"2,420.00","29,207.81",,,,,,
Multiplan/PHCS,DRG,MS-637,DIABETES WITH MCC,,Relative Weights,"$27,935.71 ",IP,"2,420.00","27,935.71",,,,,,
Multiplan/PHCS,DRG,MS-638,DIABETES WITH CC,,Relative Weights,"$17,823.46 ",IP,"2,420.00","17,823.46",,,,,,
Multiplan/PHCS,DRG,MS-639,DIABETES WITHOUT CC/MCC,,Relative Weights,"$12,362.11 ",IP,"2,420.00","12,362.11",,,,,,
Multiplan/PHCS,DRG,MS-640,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITH MCC,,Relative Weights,"$24,478.27 ",IP,"2,420.00","24,478.27",,,,,,
Multiplan/PHCS,DRG,MS-641,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITHOUT MCC,,Relative Weights,"$15,253.06 ",IP,"2,420.00","15,253.06",,,,,,
Multiplan/PHCS,DRG,MS-642,INBORN AND OTHER DISORDERS OF METABOLISM,,Relative Weights,"$24,510.53 ",IP,"2,420.00","24,510.53",,,,,,
Multiplan/PHCS,DRG,MS-643,ENDOCRINE DISORDERS WITH MCC,,Relative Weights,"$32,770.08 ",IP,"2,420.00","32,770.08",,,,,,
Multiplan/PHCS,DRG,MS-644,ENDOCRINE DISORDERS WITH CC,,Relative Weights,"$20,726.50 ",IP,"2,420.00","20,726.50",,,,,,
Multiplan/PHCS,DRG,MS-645,ENDOCRINE DISORDERS WITHOUT CC/MCC,,Relative Weights,"$15,426.43 ",IP,"2,420.00","15,426.43",,,,,,
Multiplan/PHCS,DRG,MS-652,KIDNEY TRANSPLANT,,Relative Weights,"$68,239.58 ",IP,"2,420.00","68,239.58",,,,,,
Multiplan/PHCS,DRG,MS-653,MAJOR BLADDER PROCEDURES WITH MCC,,Relative Weights,"$111,615.84 ",IP,"2,420.00","111,615.84",,,,,,
Multiplan/PHCS,DRG,MS-654,MAJOR BLADDER PROCEDURES WITH CC,,Relative Weights,"$56,693.95 ",IP,"2,420.00","56,693.95",,,,,,
Multiplan/PHCS,DRG,MS-655,MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$41,577.98 ",IP,"2,420.00","41,577.98",,,,,,
Multiplan/PHCS,DRG,MS-656,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,,Relative Weights,"$65,733.70 ",IP,"2,420.00","65,733.70",,,,,,
Multiplan/PHCS,DRG,MS-657,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,,Relative Weights,"$38,993.47 ",IP,"2,420.00","38,993.47",,,,,,
Multiplan/PHCS,DRG,MS-658,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,,Relative Weights,"$31,649.18 ",IP,"2,420.00","31,649.18",,,,,,
Multiplan/PHCS,DRG,MS-659,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,,Relative Weights,"$54,024.77 ",IP,"2,420.00","54,024.77",,,,,,
Multiplan/PHCS,DRG,MS-660,KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC,,Relative Weights,"$28,641.31 ",IP,"2,420.00","28,641.31",,,,,,
Multiplan/PHCS,DRG,MS-661,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,,Relative Weights,"$21,976.42 ",IP,"2,420.00","21,976.42",,,,,,
Multiplan/PHCS,DRG,MS-662,MINOR BLADDER PROCEDURES WITH MCC,,Relative Weights,"$63,800.35 ",IP,"2,420.00","63,800.35",,,,,,
Multiplan/PHCS,DRG,MS-663,MINOR BLADDER PROCEDURES WITH CC,,Relative Weights,"$30,711.74 ",IP,"2,420.00","30,711.74",,,,,,
Multiplan/PHCS,DRG,MS-664,MINOR BLADDER PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$22,309.06 ",IP,"2,420.00","22,309.06",,,,,,
Multiplan/PHCS,DRG,MS-665,PROSTATECTOMY WITH MCC,,Relative Weights,"$59,844.96 ",IP,"2,420.00","59,844.96",,,,,,
Multiplan/PHCS,DRG,MS-666,PROSTATECTOMY WITH CC,,Relative Weights,"$35,665.06 ",IP,"2,420.00","35,665.06",,,,,,
Multiplan/PHCS,DRG,MS-667,PROSTATECTOMY W/O CC/MCC,,Relative Weights,"$18,924.19 ",IP,"2,420.00","18,924.19",,,,,,
Multiplan/PHCS,DRG,MS-668,TRANSURETHRAL PROCEDURES W MCC,,Relative Weights,"$56,212.13 ",IP,"2,420.00","56,212.13",,,,,,
Multiplan/PHCS,DRG,MS-669,TRANSURETHRAL PROCEDURES WITH CC,,Relative Weights,"$31,161.31 ",IP,"2,420.00","31,161.31",,,,,,
Multiplan/PHCS,DRG,MS-670,TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$19,730.59 ",IP,"2,420.00","19,730.59",,,,,,
Multiplan/PHCS,DRG,MS-671,URETHRAL PROCEDURES WITH CC/MCC,,Relative Weights,"$36,844.42 ",IP,"2,420.00","36,844.42",,,,,,
Multiplan/PHCS,DRG,MS-672,URETHRAL PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$20,829.31 ",IP,"2,420.00","20,829.31",,,,,,
Multiplan/PHCS,DRG,MS-673,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,,Relative Weights,"$72,063.94 ",IP,"2,420.00","72,063.94",,,,,,
Multiplan/PHCS,DRG,MS-674,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,,Relative Weights,"$49,275.07 ",IP,"2,420.00","49,275.07",,,,,,
Multiplan/PHCS,DRG,MS-675,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$32,901.12 ",IP,"2,420.00","32,901.12",,,,,,
Multiplan/PHCS,DRG,MS-682,RENAL FAILURE WITH MCC,,Relative Weights,"$29,796.48 ",IP,"2,420.00","29,796.48",,,,,,
Multiplan/PHCS,DRG,MS-683,RENAL FAILURE WITH CC,,Relative Weights,"$18,089.57 ",IP,"2,420.00","18,089.57",,,,,,
Multiplan/PHCS,DRG,MS-684,RENAL FAILURE WITHOUT CC/MCC,,Relative Weights,"$12,404.45 ",IP,"2,420.00","12,404.45",,,,,,
Multiplan/PHCS,DRG,MS-686,KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,,Relative Weights,"$35,402.98 ",IP,"2,420.00","35,402.98",,,,,,
Multiplan/PHCS,DRG,MS-687,KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,,Relative Weights,"$21,220.42 ",IP,"2,420.00","21,220.42",,,,,,
Multiplan/PHCS,DRG,MS-688,KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,,Relative Weights,"$15,549.41 ",IP,"2,420.00","15,549.41",,,,,,
Multiplan/PHCS,DRG,MS-689,KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,,Relative Weights,"$22,550.98 ",IP,"2,420.00","22,550.98",,,,,,
Multiplan/PHCS,DRG,MS-690,KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,,Relative Weights,"$15,942.53 ",IP,"2,420.00","15,942.53",,,,,,
Multiplan/PHCS,DRG,MS-693,URINARY STONES WITH MCC,,Relative Weights,"$27,282.53 ",IP,"2,420.00","27,282.53",,,,,,
Multiplan/PHCS,DRG,MS-694,URINARY STONES WITHOUT MCC,,Relative Weights,"$14,926.46 ",IP,"2,420.00","14,926.46",,,,,,
Multiplan/PHCS,DRG,MS-695,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,,Relative Weights,"$23,633.57 ",IP,"2,420.00","23,633.57",,,,,,
Multiplan/PHCS,DRG,MS-696,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,,Relative Weights,"$13,696.70 ",IP,"2,420.00","13,696.70",,,,,,
Multiplan/PHCS,DRG,MS-697,URETHRAL STRICTURE,,Relative Weights,"$19,633.82 ",IP,"2,420.00","19,633.82",,,,,,
Multiplan/PHCS,DRG,MS-698,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,,Relative Weights,"$32,630.98 ",IP,"2,420.00","32,630.98",,,,,,
Multiplan/PHCS,DRG,MS-699,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,,Relative Weights,"$20,819.23 ",IP,"2,420.00","20,819.23",,,,,,
Multiplan/PHCS,DRG,MS-700,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,,Relative Weights,"$14,952.67 ",IP,"2,420.00","14,952.67",,,,,,
Multiplan/PHCS,DRG,MS-707,MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,,Relative Weights,"$37,697.18 ",IP,"2,420.00","37,697.18",,,,,,
Multiplan/PHCS,DRG,MS-708,MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$29,272.32 ",IP,"2,420.00","29,272.32",,,,,,
Multiplan/PHCS,DRG,MS-709,PENIS PROCEDURES W CC/MCC,,Relative Weights,"$48,496.90 ",IP,"2,420.00","48,496.90",,,,,,
Multiplan/PHCS,DRG,MS-710,PENIS PROCEDURES W/O CC/MCC,,Relative Weights,"$30,961.73 ",IP,"2,420.00","30,961.73",,,,,,
Multiplan/PHCS,DRG,MS-711,TESTES PROCEDURES WITH CC/MCC,,Relative Weights,"$43,206.91 ",IP,"2,420.00","43,206.91",,,,,,
Multiplan/PHCS,DRG,MS-712,TESTES PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$20,567.23 ",IP,"2,420.00","20,567.23",,,,,,
Multiplan/PHCS,DRG,MS-713,TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,,Relative Weights,"$29,473.92 ",IP,"2,420.00","29,473.92",,,,,,
Multiplan/PHCS,DRG,MS-714,TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,,Relative Weights,"$18,454.46 ",IP,"2,420.00","18,454.46",,,,,,
Multiplan/PHCS,DRG,MS-715,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,,Relative Weights,"$43,071.84 ",IP,"2,420.00","43,071.84",,,,,,
Multiplan/PHCS,DRG,MS-716,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,,Relative Weights,"$29,544.48 ",IP,"2,420.00","29,544.48",,,,,,
Multiplan/PHCS,DRG,MS-717,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,,Relative Weights,"$35,568.29 ",IP,"2,420.00","35,568.29",,,,,,
Multiplan/PHCS,DRG,MS-718,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,,Relative Weights,"$24,583.10 ",IP,"2,420.00","24,583.10",,,,,,
Multiplan/PHCS,DRG,MS-722,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH MCC,,Relative Weights,"$36,386.78 ",IP,"2,420.00","36,386.78",,,,,,
Multiplan/PHCS,DRG,MS-723,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH CC,,Relative Weights,"$22,325.18 ",IP,"2,420.00","22,325.18",,,,,,
Multiplan/PHCS,DRG,MS-724,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,,Relative Weights,"$11,902.46 ",IP,"2,420.00","11,902.46",,,,,,
Multiplan/PHCS,DRG,MS-725,BENIGN PROSTATIC HYPERTROPHY WITH MCC,,Relative Weights,"$25,308.86 ",IP,"2,420.00","25,308.86",,,,,,
Multiplan/PHCS,DRG,MS-726,BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,,Relative Weights,"$15,416.35 ",IP,"2,420.00","15,416.35",,,,,,
Multiplan/PHCS,DRG,MS-727,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,,Relative Weights,"$28,774.37 ",IP,"2,420.00","28,774.37",,,,,,
Multiplan/PHCS,DRG,MS-728,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,,Relative Weights,"$16,178.40 ",IP,"2,420.00","16,178.40",,,,,,
Multiplan/PHCS,DRG,MS-729,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,,Relative Weights,"$21,649.82 ",IP,"2,420.00","21,649.82",,,,,,
Multiplan/PHCS,DRG,MS-730,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,,Relative Weights,"$12,733.06 ",IP,"2,420.00","12,733.06",,,,,,
Multiplan/PHCS,DRG,MS-734,PELVIC EVISCERATION -  RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC,,Relative Weights,"$44,188.70 ",IP,"2,420.00","44,188.70",,,,,,
Multiplan/PHCS,DRG,MS-735,PELVIC EVISCERATION -  RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC,,Relative Weights,"$27,703.87 ",IP,"2,420.00","27,703.87",,,,,,
Multiplan/PHCS,DRG,MS-736,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,,Relative Weights,"$87,109.34 ",IP,"2,420.00","87,109.34",,,,,,
Multiplan/PHCS,DRG,MS-737,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,,Relative Weights,"$40,059.94 ",IP,"2,420.00","40,059.94",,,,,,
Multiplan/PHCS,DRG,MS-738,UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY W/O CC/MCC,,Relative Weights,"$27,798.62 ",IP,"2,420.00","27,798.62",,,,,,
Multiplan/PHCS,DRG,MS-739,UTERINE -ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W MCC,,Relative Weights,"$75,489.12 ",IP,"2,420.00","75,489.12",,,,,,
Multiplan/PHCS,DRG,MS-740,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,,Relative Weights,"$35,983.58 ",IP,"2,420.00","35,983.58",,,,,,
Multiplan/PHCS,DRG,MS-741,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,,Relative Weights,"$26,802.72 ",IP,"2,420.00","26,802.72",,,,,,
Multiplan/PHCS,DRG,MS-742,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,,Relative Weights,"$34,060.32 ",IP,"2,420.00","34,060.32",,,,,,
Multiplan/PHCS,DRG,MS-743,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,,Relative Weights,"$23,153.76 ",IP,"2,420.00","23,153.76",,,,,,
Multiplan/PHCS,DRG,MS-744,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC,,Relative Weights,"$35,088.48 ",IP,"2,420.00","35,088.48",,,,,,
Multiplan/PHCS,DRG,MS-745,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC,,Relative Weights,"$21,476.45 ",IP,"2,420.00","21,476.45",,,,,,
Multiplan/PHCS,DRG,MS-746,VAGINA -  CERVIX AND VULVA PROCEDURES WITH CC/MCC,,Relative Weights,"$32,880.96 ",IP,"2,420.00","32,880.96",,,,,,
Multiplan/PHCS,DRG,MS-747,VAGINA- CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$18,793.15 ",IP,"2,420.00","18,793.15",,,,,,
Multiplan/PHCS,DRG,MS-748,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,,Relative Weights,"$26,645.47 ",IP,"2,420.00","26,645.47",,,,,,
Multiplan/PHCS,DRG,MS-749,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,,Relative Weights,"$52,258.75 ",IP,"2,420.00","52,258.75",,,,,,
Multiplan/PHCS,DRG,MS-750,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$26,836.99 ",IP,"2,420.00","26,836.99",,,,,,
Multiplan/PHCS,DRG,MS-754,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH MCC,,Relative Weights,"$35,519.90 ",IP,"2,420.00","35,519.90",,,,,,
Multiplan/PHCS,DRG,MS-755,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH CC,,Relative Weights,"$20,639.81 ",IP,"2,420.00","20,639.81",,,,,,
Multiplan/PHCS,DRG,MS-756,MALIGNANCY - FEMALE REPRODUCTIVE SYSTEM W/O CC/MCC,,Relative Weights,"$17,676.29 ",IP,"2,420.00","17,676.29",,,,,,
Multiplan/PHCS,DRG,MS-757,INFECTIONS - FEMALE REPRODUCTIVE SYSTEM W MCC,,Relative Weights,"$28,633.25 ",IP,"2,420.00","28,633.25",,,,,,
Multiplan/PHCS,DRG,MS-758,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITH CC,,Relative Weights,"$19,462.46 ",IP,"2,420.00","19,462.46",,,,,,
Multiplan/PHCS,DRG,MS-759,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,,Relative Weights,"$13,311.65 ",IP,"2,420.00","13,311.65",,,,,,
Multiplan/PHCS,DRG,MS-760,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,,Relative Weights,"$18,194.40 ",IP,"2,420.00","18,194.40",,,,,,
Multiplan/PHCS,DRG,MS-761,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,,Relative Weights,"$11,398.46 ",IP,"2,420.00","11,398.46",,,,,,
Multiplan/PHCS,DRG,MS-768,VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C,,Relative Weights,"$20,311.20 ",IP,"2,420.00","20,311.20",,,,,,
Multiplan/PHCS,DRG,MS-769,POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,,Relative Weights,"$29,090.88 ",IP,"2,420.00","29,090.88",,,,,,
Multiplan/PHCS,DRG,MS-770,ABORTION WITH D&C- ASPIRATION CURETTAGE OR HYSTEROTOMY,,Relative Weights,"$15,851.81 ",IP,"2,420.00","15,851.81",,,,,,
Multiplan/PHCS,DRG,MS-776,POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,,Relative Weights,"$14,311.58 ",IP,"2,420.00","14,311.58",,,,,,
Multiplan/PHCS,DRG,MS-779,ABORTION WITHOUT D&C,,Relative Weights,"$23,018.69 ",IP,"2,420.00","23,018.69",,,,,,
Multiplan/PHCS,DRG,MS-783,CESAREAN SECTION WITH STERILIZATION WITH MCC,,Relative Weights,"$43,239.17 ",IP,"2,420.00","43,239.17",,,,,,
Multiplan/PHCS,DRG,MS-784,CESAREAN SECTION WITH STERILIZATION WITH CC,,Relative Weights,"$21,071.23 ",IP,"2,420.00","21,071.23",,,,,,
Multiplan/PHCS,DRG,MS-785,CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,,Relative Weights,"$17,305.34 ",IP,"2,420.00","17,305.34",,,,,,
Multiplan/PHCS,DRG,MS-786,CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,,Relative Weights,"$34,564.32 ",IP,"2,420.00","34,564.32",,,,,,
Multiplan/PHCS,DRG,MS-787,CESAREAN SECTION WITHOUT STERILIZATION WITH CC,,Relative Weights,"$21,077.28 ",IP,"2,420.00","21,077.28",,,,,,
Multiplan/PHCS,DRG,MS-788,CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,,Relative Weights,"$18,268.99 ",IP,"2,420.00","18,268.99",,,,,,
Multiplan/PHCS,DRG,MS-789,NEONATES- DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY,,Relative Weights,"$34,070.40 ",IP,"2,420.00","34,070.40",,,,,,
Multiplan/PHCS,DRG,MS-790,EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME- NEONATE,,Relative Weights,"$112,351.68 ",IP,"2,420.00","112,351.68",,,,,,
Multiplan/PHCS,DRG,MS-791,PREMATURITY W MAJOR PROBLEMS,,Relative Weights,"$76,732.99 ",IP,"2,420.00","76,732.99",,,,,,
Multiplan/PHCS,DRG,MS-792,PREMATURITY W/O MAJOR PROBLEMS,,Relative Weights,"$46,297.44 ",IP,"2,420.00","46,297.44",,,,,,
Multiplan/PHCS,DRG,MS-793,FULL TERM NEONATE WITH MAJOR PROBLEMS,,Relative Weights,"$78,819.55 ",IP,"2,420.00","78,819.55",,,,,,
Multiplan/PHCS,DRG,MS-794,NEONATE WITH OTHER SIGNIFICANT PROBLEMS,,Relative Weights,"$27,897.41 ",IP,"2,420.00","27,897.41",,,,,,
Multiplan/PHCS,DRG,MS-795,NORMAL NEWBORN,,Relative Weights,"$3,775.97 ",IP,"1,113.70","3,775.97",,,,,,
Multiplan/PHCS,DRG,MS-796,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,,Relative Weights,"$39,761.57 ",IP,"2,420.00","39,761.57",,,,,,
Multiplan/PHCS,DRG,MS-797,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,,Relative Weights,"$17,394.05 ",IP,"2,420.00","17,394.05",,,,,,
Multiplan/PHCS,DRG,MS-798,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,,Relative Weights,"$17,394.05 ",IP,"2,420.00","17,394.05",,,,,,
Multiplan/PHCS,DRG,MS-799,SPLENECTOMY WITH MCC,,Relative Weights,"$99,677.09 ",IP,"2,420.00","99,677.09",,,,,,
Multiplan/PHCS,DRG,MS-800,SPLENECTOMY WITH CC,,Relative Weights,"$57,294.72 ",IP,"2,420.00","57,294.72",,,,,,
Multiplan/PHCS,DRG,MS-801,SPLENECTOMY WITHOUT CC/MCC,,Relative Weights,"$37,763.71 ",IP,"2,420.00","37,763.71",,,,,,
Multiplan/PHCS,DRG,MS-802,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,,Relative Weights,"$63,552.38 ",IP,"2,420.00","63,552.38",,,,,,
Multiplan/PHCS,DRG,MS-803,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,,Relative Weights,"$35,917.06 ",IP,"2,420.00","35,917.06",,,,,,
Multiplan/PHCS,DRG,MS-804,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,,Relative Weights,"$27,470.02 ",IP,"2,420.00","27,470.02",,,,,,
Multiplan/PHCS,DRG,MS-805,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,,Relative Weights,"$20,980.51 ",IP,"2,420.00","20,980.51",,,,,,
Multiplan/PHCS,DRG,MS-806,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,,Relative Weights,"$14,297.47 ",IP,"2,420.00","14,297.47",,,,,,
Multiplan/PHCS,DRG,MS-807,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,,Relative Weights,"$12,636.29 ",IP,"2,420.00","12,636.29",,,,,,
Multiplan/PHCS,DRG,MS-808,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,,Relative Weights,"$42,932.74 ",IP,"2,420.00","42,932.74",,,,,,
Multiplan/PHCS,DRG,MS-809,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,,Relative Weights,"$24,512.54 ",IP,"2,420.00","24,512.54",,,,,,
Multiplan/PHCS,DRG,MS-810,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,,Relative Weights,"$18,857.66 ",IP,"2,420.00","18,857.66",,,,,,
Multiplan/PHCS,DRG,MS-811,RED BLOOD CELL DISORDERS WITH MCC,,Relative Weights,"$27,020.45 ",IP,"2,420.00","27,020.45",,,,,,
Multiplan/PHCS,DRG,MS-812,RED BLOOD CELL DISORDERS WITHOUT MCC,,Relative Weights,"$17,553.31 ",IP,"2,420.00","17,553.31",,,,,,
Multiplan/PHCS,DRG,MS-813,COAGULATION DISORDERS,,Relative Weights,"$31,957.63 ",IP,"2,420.00","31,957.63",,,,,,
Multiplan/PHCS,DRG,MS-814,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,,Relative Weights,"$35,261.86 ",IP,"2,420.00","35,261.86",,,,,,
Multiplan/PHCS,DRG,MS-815,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,,Relative Weights,"$20,418.05 ",IP,"2,420.00","20,418.05",,,,,,
Multiplan/PHCS,DRG,MS-816,RETICULOENDOTHELIAL & IMMUNITY DISORDERS W/O CC/MCC,,Relative Weights,"$14,432.54 ",IP,"2,420.00","14,432.54",,,,,,
Multiplan/PHCS,DRG,MS-817,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,,Relative Weights,"$50,726.59 ",IP,"2,420.00","50,726.59",,,,,,
Multiplan/PHCS,DRG,MS-818,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,,Relative Weights,"$25,681.82 ",IP,"2,420.00","25,681.82",,,,,,
Multiplan/PHCS,DRG,MS-819,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$16,085.66 ",IP,"2,420.00","16,085.66",,,,,,
Multiplan/PHCS,DRG,MS-820,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,,Relative Weights,"$115,248.67 ",IP,"2,420.00","115,248.67",,,,,,
Multiplan/PHCS,DRG,MS-821,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,,Relative Weights,"$45,003.17 ",IP,"2,420.00","45,003.17",,,,,,
Multiplan/PHCS,DRG,MS-822,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$25,490.30 ",IP,"2,420.00","25,490.30",,,,,,
Multiplan/PHCS,DRG,MS-823,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,,Relative Weights,"$85,280.83 ",IP,"2,420.00","85,280.83",,,,,,
Multiplan/PHCS,DRG,MS-824,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,,Relative Weights,"$46,874.02 ",IP,"2,420.00","46,874.02",,,,,,
Multiplan/PHCS,DRG,MS-825,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$27,306.72 ",IP,"2,420.00","27,306.72",,,,,,
Multiplan/PHCS,DRG,MS-826,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,,Relative Weights,"$101,102.40 ",IP,"2,420.00","101,102.40",,,,,,
Multiplan/PHCS,DRG,MS-827,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,,Relative Weights,"$46,694.59 ",IP,"2,420.00","46,694.59",,,,,,
Multiplan/PHCS,DRG,MS-828,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$33,288.19 ",IP,"2,420.00","33,288.19",,,,,,
Multiplan/PHCS,DRG,MS-829,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,,Relative Weights,"$63,300.38 ",IP,"2,420.00","63,300.38",,,,,,
Multiplan/PHCS,DRG,MS-830,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$27,796.61 ",IP,"2,420.00","27,796.61",,,,,,
Multiplan/PHCS,DRG,MS-831,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,,Relative Weights,"$21,742.56 ",IP,"2,420.00","21,742.56",,,,,,
Multiplan/PHCS,DRG,MS-832,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,,Relative Weights,"$14,424.48 ",IP,"2,420.00","14,424.48",,,,,,
Multiplan/PHCS,DRG,MS-833,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$10,727.14 ",IP,"2,420.00","10,727.14",,,,,,
Multiplan/PHCS,DRG,MS-834,ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W MCC,,Relative Weights,"$117,784.80 ",IP,"2,420.00","117,784.80",,,,,,
Multiplan/PHCS,DRG,MS-835,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC,,Relative Weights,"$40,888.51 ",IP,"2,420.00","40,888.51",,,,,,
Multiplan/PHCS,DRG,MS-836,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$26,562.82 ",IP,"2,420.00","26,562.82",,,,,,
Multiplan/PHCS,DRG,MS-837,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,,Relative Weights,"$120,774.53 ",IP,"2,420.00","120,774.53",,,,,,
Multiplan/PHCS,DRG,MS-838,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,,Relative Weights,"$44,108.06 ",IP,"2,420.00","44,108.06",,,,,,
Multiplan/PHCS,DRG,MS-839,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,,Relative Weights,"$25,728.19 ",IP,"2,420.00","25,728.19",,,,,,
Multiplan/PHCS,DRG,MS-840,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,,Relative Weights,"$64,415.23 ",IP,"2,420.00","64,415.23",,,,,,
Multiplan/PHCS,DRG,MS-841,LYMPHOMA & NON-ACUTE LEUKEMIA W CC,,Relative Weights,"$32,491.87 ",IP,"2,420.00","32,491.87",,,,,,
Multiplan/PHCS,DRG,MS-842,LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,,Relative Weights,"$23,115.46 ",IP,"2,420.00","23,115.46",,,,,,
Multiplan/PHCS,DRG,MS-843,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,,Relative Weights,"$38,461.25 ",IP,"2,420.00","38,461.25",,,,,,
Multiplan/PHCS,DRG,MS-844,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,,Relative Weights,"$24,353.28 ",IP,"2,420.00","24,353.28",,,,,,
Multiplan/PHCS,DRG,MS-845,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,,Relative Weights,"$17,456.54 ",IP,"2,420.00","17,456.54",,,,,,
Multiplan/PHCS,DRG,MS-846,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,,Relative Weights,"$52,952.26 ",IP,"2,420.00","52,952.26",,,,,,
Multiplan/PHCS,DRG,MS-847,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,,Relative Weights,"$26,528.54 ",IP,"2,420.00","26,528.54",,,,,,
Multiplan/PHCS,DRG,MS-848,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,,Relative Weights,"$19,785.02 ",IP,"2,420.00","19,785.02",,,,,,
Multiplan/PHCS,DRG,MS-849,RADIOTHERAPY,,Relative Weights,"$42,856.13 ",IP,"2,420.00","42,856.13",,,,,,
Multiplan/PHCS,DRG,MS-853,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,,Relative Weights,"$102,787.78 ",IP,"2,420.00","102,787.78",,,,,,
Multiplan/PHCS,DRG,MS-854,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,,Relative Weights,"$43,569.79 ",IP,"2,420.00","43,569.79",,,,,,
Multiplan/PHCS,DRG,MS-855,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$32,322.53 ",IP,"2,420.00","32,322.53",,,,,,
Multiplan/PHCS,DRG,MS-856,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,,Relative Weights,"$89,222.11 ",IP,"2,420.00","89,222.11",,,,,,
Multiplan/PHCS,DRG,MS-857,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,,Relative Weights,"$40,991.33 ",IP,"2,420.00","40,991.33",,,,,,
Multiplan/PHCS,DRG,MS-858,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$27,748.22 ",IP,"2,420.00","27,748.22",,,,,,
Multiplan/PHCS,DRG,MS-862,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W MCC,,Relative Weights,"$37,308.10 ",IP,"2,420.00","37,308.10",,,,,,
Multiplan/PHCS,DRG,MS-863,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W/O MCC,,Relative Weights,"$19,918.08 ",IP,"2,420.00","19,918.08",,,,,,
Multiplan/PHCS,DRG,MS-864,FEVER AND INFLAMMATORY CONDITIONS,,Relative Weights,"$17,083.58 ",IP,"2,420.00","17,083.58",,,,,,
Multiplan/PHCS,DRG,MS-865,VIRAL ILLNESS WITH MCC,,Relative Weights,"$28,088.93 ",IP,"2,420.00","28,088.93",,,,,,
Multiplan/PHCS,DRG,MS-866,VIRAL ILLNESS WITHOUT MCC,,Relative Weights,"$16,504.99 ",IP,"2,420.00","16,504.99",,,,,,
Multiplan/PHCS,DRG,MS-867,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,,Relative Weights,"$44,053.63 ",IP,"2,420.00","44,053.63",,,,,,
Multiplan/PHCS,DRG,MS-868,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,,Relative Weights,"$22,115.52 ",IP,"2,420.00","22,115.52",,,,,,
Multiplan/PHCS,DRG,MS-869,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,,Relative Weights,"$14,968.80 ",IP,"2,420.00","14,968.80",,,,,,
Multiplan/PHCS,DRG,MS-870,SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,,Relative Weights,"$127,497.89 ",IP,"2,420.00","127,497.89",,,,,,
Multiplan/PHCS,DRG,MS-871,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,,Relative Weights,"$37,624.61 ",IP,"2,420.00","37,624.61",,,,,,
Multiplan/PHCS,DRG,MS-872,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,,Relative Weights,"$20,952.29 ",IP,"2,420.00","20,952.29",,,,,,
Multiplan/PHCS,DRG,MS-876,O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,,Relative Weights,"$73,382.40 ",IP,"2,420.00","73,382.40",,,,,,
Multiplan/PHCS,DRG,MS-880,ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,,Relative Weights,"$17,275.10 ",IP,"2,420.00","17,275.10",,,,,,
Multiplan/PHCS,DRG,MS-881,DEPRESSIVE NEUROSES,,Relative Weights,"$16,517.09 ",IP,"2,420.00","16,517.09",,,,,,
Multiplan/PHCS,DRG,MS-882,NEUROSES EXCEPT DEPRESSIVE,,Relative Weights,"$15,922.37 ",IP,"2,420.00","15,922.37",,,,,,
Multiplan/PHCS,DRG,MS-883,DISORDERS OF PERSONALITY & IMPULSE CONTROL,,Relative Weights,"$26,945.86 ",IP,"2,420.00","26,945.86",,,,,,
Multiplan/PHCS,DRG,MS-884,ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,,Relative Weights,"$28,990.08 ",IP,"2,420.00","28,990.08",,,,,,
Multiplan/PHCS,DRG,MS-885,PSYCHOSES,,Relative Weights,"$24,502.46 ",IP,"2,420.00","24,502.46",,,,,,
Multiplan/PHCS,DRG,MS-886,BEHAVIORAL AND DEVELOPMENTAL DISORDERS,,Relative Weights,"$27,127.30 ",IP,"2,420.00","27,127.30",,,,,,
Multiplan/PHCS,DRG,MS-887,OTHER MENTAL DISORDER DIAGNOSES,,Relative Weights,"$21,936.10 ",IP,"2,420.00","21,936.10",,,,,,
Multiplan/PHCS,DRG,MS-894,ALCOHOL- DRUG ABUSE OR DEPENDENCE- LEFT AMA,,Relative Weights,"$11,700.86 ",IP,"2,420.00","11,700.86",,,,,,
Multiplan/PHCS,DRG,MS-895,ALCOHOL- DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY,,Relative Weights,"$32,798.30 ",IP,"2,420.00","32,798.30",,,,,,
Multiplan/PHCS,DRG,MS-896,ALCOHOL -  DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC,,Relative Weights,"$34,669.15 ",IP,"2,420.00","34,669.15",,,,,,
Multiplan/PHCS,DRG,MS-897,ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC,,Relative Weights,"$16,567.49 ",IP,"2,420.00","16,567.49",,,,,,
Multiplan/PHCS,DRG,MS-901,WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,,Relative Weights,"$87,236.35 ",IP,"2,420.00","87,236.35",,,,,,
Multiplan/PHCS,DRG,MS-902,WOUND DEBRIDEMENTS FOR INJURIES WITH CC,,Relative Weights,"$39,652.70 ",IP,"2,420.00","39,652.70",,,,,,
Multiplan/PHCS,DRG,MS-903,WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,,Relative Weights,"$23,063.04 ",IP,"2,420.00","23,063.04",,,,,,
Multiplan/PHCS,DRG,MS-904,SKIN GRAFTS FOR INJURIES WITH CC/MCC,,Relative Weights,"$71,313.98 ",IP,"2,420.00","71,313.98",,,,,,
Multiplan/PHCS,DRG,MS-905,SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,,Relative Weights,"$33,554.30 ",IP,"2,420.00","33,554.30",,,,,,
Multiplan/PHCS,DRG,MS-906,HAND PROCEDURES FOR INJURIES,,Relative Weights,"$35,096.54 ",IP,"2,420.00","35,096.54",,,,,,
Multiplan/PHCS,DRG,MS-907,OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,,Relative Weights,"$80,430.34 ",IP,"2,420.00","80,430.34",,,,,,
Multiplan/PHCS,DRG,MS-908,OTHER O.R. PROCEDURES FOR INJURIES WITH CC,,Relative Weights,"$41,592.10 ",IP,"2,420.00","41,592.10",,,,,,
Multiplan/PHCS,DRG,MS-909,OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,,Relative Weights,"$26,584.99 ",IP,"2,420.00","26,584.99",,,,,,
Multiplan/PHCS,DRG,MS-913,TRAUMATIC INJURY WITH MCC,,Relative Weights,"$29,762.21 ",IP,"2,420.00","29,762.21",,,,,,
Multiplan/PHCS,DRG,MS-914,TRAUMATIC INJURY WITHOUT MCC,,Relative Weights,"$17,371.87 ",IP,"2,420.00","17,371.87",,,,,,
Multiplan/PHCS,DRG,MS-915,ALLERGIC REACTIONS WITH MCC,,Relative Weights,"$34,253.86 ",IP,"2,420.00","34,253.86",,,,,,
Multiplan/PHCS,DRG,MS-916,ALLERGIC REACTIONS WITHOUT MCC,,Relative Weights,"$12,765.31 ",IP,"2,420.00","12,765.31",,,,,,
Multiplan/PHCS,DRG,MS-917,POISONING & TOXIC EFFECTS OF DRUGS W MCC,,Relative Weights,"$29,498.11 ",IP,"2,420.00","29,498.11",,,,,,
Multiplan/PHCS,DRG,MS-918,POISONING & TOXIC EFFECTS OF DRUGS W/O MCC,,Relative Weights,"$15,805.44 ",IP,"2,420.00","15,805.44",,,,,,
Multiplan/PHCS,DRG,MS-919,COMPLICATIONS OF TREATMENT WITH MCC,,Relative Weights,"$36,798.05 ",IP,"2,420.00","36,798.05",,,,,,
Multiplan/PHCS,DRG,MS-920,COMPLICATIONS OF TREATMENT WITH CC,,Relative Weights,"$20,311.20 ",IP,"2,420.00","20,311.20",,,,,,
Multiplan/PHCS,DRG,MS-921,COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,,Relative Weights,"$13,922.50 ",IP,"2,420.00","13,922.50",,,,,,
Multiplan/PHCS,DRG,MS-922,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC,,Relative Weights,"$32,328.58 ",IP,"2,420.00","32,328.58",,,,,,
Multiplan/PHCS,DRG,MS-923,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC,,Relative Weights,"$17,448.48 ",IP,"2,420.00","17,448.48",,,,,,
Multiplan/PHCS,DRG,MS-927,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,,Relative Weights,"$402,060.96 ",IP,"2,420.00","402,060.96",,,,,,
Multiplan/PHCS,DRG,MS-928,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,,Relative Weights,"$124,889.18 ",IP,"2,420.00","124,889.18",,,,,,
Multiplan/PHCS,DRG,MS-929,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,,Relative Weights,"$59,300.64 ",IP,"2,420.00","59,300.64",,,,,,
Multiplan/PHCS,DRG,MS-933,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,,Relative Weights,"$63,306.43 ",IP,"2,420.00","63,306.43",,,,,,
Multiplan/PHCS,DRG,MS-934,FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,,Relative Weights,"$36,485.57 ",IP,"2,420.00","36,485.57",,,,,,
Multiplan/PHCS,DRG,MS-935,NON-EXTENSIVE BURNS,,Relative Weights,"$38,955.17 ",IP,"2,420.00","38,955.17",,,,,,
Multiplan/PHCS,DRG,MS-939,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,,Relative Weights,"$73,672.70 ",IP,"2,420.00","73,672.70",,,,,,
Multiplan/PHCS,DRG,MS-940,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,,Relative Weights,"$45,799.49 ",IP,"2,420.00","45,799.49",,,,,,
Multiplan/PHCS,DRG,MS-941,O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W/O CC/MCC,,Relative Weights,"$38,922.91 ",IP,"2,420.00","38,922.91",,,,,,
Multiplan/PHCS,DRG,MS-945,REHABILITATION WITH CC/MCC,,Relative Weights,"$29,338.85 ",IP,"2,420.00","29,338.85",,,,,,
Multiplan/PHCS,DRG,MS-946,REHABILITATION WITHOUT CC/MCC,,Relative Weights,"$21,913.92 ",IP,"2,420.00","21,913.92",,,,,,
Multiplan/PHCS,DRG,MS-947,SIGNS AND SYMPTOMS WITH MCC,,Relative Weights,"$24,137.57 ",IP,"2,420.00","24,137.57",,,,,,
Multiplan/PHCS,DRG,MS-948,SIGNS AND SYMPTOMS WITHOUT MCC,,Relative Weights,"$15,716.74 ",IP,"2,420.00","15,716.74",,,,,,
Multiplan/PHCS,DRG,MS-949,AFTERCARE WITH CC/MCC,,Relative Weights,"$21,952.22 ",IP,"2,420.00","21,952.22",,,,,,
Multiplan/PHCS,DRG,MS-950,AFTERCARE WITHOUT CC/MCC,,Relative Weights,"$14,936.54 ",IP,"2,420.00","14,936.54",,,,,,
Multiplan/PHCS,DRG,MS-951,OTHER FACTORS INFLUENCING HEALTH STATUS,,Relative Weights,"$11,823.84 ",IP,"2,420.00","11,823.84",,,,,,
Multiplan/PHCS,DRG,MS-955,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$122,582.88 ",IP,"2,420.00","122,582.88",,,,,,
Multiplan/PHCS,DRG,MS-956,LIMB REATTACHMENT- HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$79,093.73 ",IP,"2,420.00","79,093.73",,,,,,
Multiplan/PHCS,DRG,MS-957,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,,Relative Weights,"$151,879.39 ",IP,"2,420.00","151,879.39",,,,,,
Multiplan/PHCS,DRG,MS-958,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,,Relative Weights,"$84,488.54 ",IP,"2,420.00","84,488.54",,,,,,
Multiplan/PHCS,DRG,MS-959,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,,Relative Weights,"$56,458.08 ",IP,"2,420.00","56,458.08",,,,,,
Multiplan/PHCS,DRG,MS-963,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,,Relative Weights,"$54,938.02 ",IP,"2,420.00","54,938.02",,,,,,
Multiplan/PHCS,DRG,MS-964,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,,Relative Weights,"$30,108.96 ",IP,"2,420.00","30,108.96",,,,,,
Multiplan/PHCS,DRG,MS-965,OTHER MULTIPLE SIGNIFICANT TRAUMA W/O CC/MCC,,Relative Weights,"$18,488.74 ",IP,"2,420.00","18,488.74",,,,,,
Multiplan/PHCS,DRG,MS-969,HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,,Relative Weights,"$116,982.43 ",IP,"2,420.00","116,982.43",,,,,,
Multiplan/PHCS,DRG,MS-970,HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,,Relative Weights,"$58,806.72 ",IP,"2,420.00","58,806.72",,,,,,
Multiplan/PHCS,DRG,MS-974,HIV WITH MAJOR RELATED CONDITION WITH MCC,,Relative Weights,"$53,905.82 ",IP,"2,420.00","53,905.82",,,,,,
Multiplan/PHCS,DRG,MS-975,HIV WITH MAJOR RELATED CONDITION WITH CC,,Relative Weights,"$27,054.72 ",IP,"2,420.00","27,054.72",,,,,,
Multiplan/PHCS,DRG,MS-976,HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,,Relative Weights,"$18,430.27 ",IP,"2,420.00","18,430.27",,,,,,
Multiplan/PHCS,DRG,MS-977,HIV WITH OR WITHOUT OTHER RELATED CONDITION,,Relative Weights,"$26,218.08 ",IP,"2,420.00","26,218.08",,,,,,
Multiplan/PHCS,DRG,MS-981,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,,Relative Weights,"$90,532.51 ",IP,"2,420.00","90,532.51",,,,,,
Multiplan/PHCS,DRG,MS-982,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,,Relative Weights,"$49,152.10 ",IP,"2,420.00","49,152.10",,,,,,
Multiplan/PHCS,DRG,MS-983,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,,Relative Weights,"$33,003.94 ",IP,"2,420.00","33,003.94",,,,,,
Multiplan/PHCS,DRG,MS-987,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,,Relative Weights,"$67,207.39 ",IP,"2,420.00","67,207.39",,,,,,
Multiplan/PHCS,DRG,MS-988,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,,Relative Weights,"$34,640.93 ",IP,"2,420.00","34,640.93",,,,,,
Multiplan/PHCS,DRG,MS-989,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,,Relative Weights,"$23,232.38 ",IP,"2,420.00","23,232.38",,,,,,
UHC Comm,DRG,MS-001,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W MCC,,Relative Weights,"$391,323.66 ",IP,"17,718.00","557,099.42",,,,,,
UHC Comm,DRG,MS-002,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W/O MCC,,Relative Weights,"$198,448.01 ",IP,"17,718.00","282,516.19",,,,,,
UHC Comm,DRG,MS-003,ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITH MAJOR O.R. PROCEDURES,,Relative Weights,"$268,406.18 ",IP,"111,577.60","382,110.62",,,,,,
UHC Comm,DRG,MS-004,TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES,,Relative Weights,"$163,471.75 ",IP,"69,628.33","232,723.01",,,,,,
UHC Comm,DRG,MS-005,LIVER TRANSPLANT W MCC OR INTESTINAL TRANSPLANT,,Relative Weights,"$146,038.14 ",IP,"59,773.19","207,904.03",,,,,,
UHC Comm,DRG,MS-006,LIVER TRANSPLANT W/O MCC,,Relative Weights,"$68,990.98 ",IP,"27,427.34","98,217.50",,,,,,
UHC Comm,DRG,MS-007,LUNG TRANSPLANT,,Relative Weights,"$152,744.79 ",IP,"67,628.10","217,451.81",,,,,,
UHC Comm,DRG,MS-008,SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,,Relative Weights,"$79,529.59 ",IP,"31,730.89","113,220.58",,,,,,
UHC Comm,DRG,MS-010,PANCREAS TRANSPLANT,,Relative Weights,"$56,305.55 ",IP,"2,420.00","80,158.18",,,,,,
UHC Comm,DRG,MS-011,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC,,Relative Weights,"$70,009.15 ",IP,"2,420.00","99,667.01",,,,,,
UHC Comm,DRG,MS-012,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC,,Relative Weights,"$53,443.61 ",IP,"2,420.00","76,083.84",,,,,,
UHC Comm,DRG,MS-013,TRACHEOSTOMY FOR FACE -  MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC,,Relative Weights,"$34,344.67 ",IP,"2,420.00","48,894.05",,,,,,
UHC Comm,DRG,MS-014,ALLOGENEIC BONE MARROW TRANSPLANT,,Relative Weights,"$180,620.72 ",IP,"2,420.00","257,136.77",,,,,,
UHC Comm,DRG,MS-016,AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,,Relative Weights,"$97,501.32 ",IP,"2,420.00","138,805.63",,,,,,
UHC Comm,DRG,MS-017,AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,,Relative Weights,"$62,979.63 ",IP,"2,420.00","89,659.58",,,,,,
UHC Comm,DRG,MS-020,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,,Relative Weights,"$153,236.18 ",IP,"2,420.00","218,151.36",,,,,,
UHC Comm,DRG,MS-021,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,,Relative Weights,"$117,163.87 ",IP,"2,420.00","166,797.79",,,,,,
UHC Comm,DRG,MS-022,INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W/O CC/MCC,,Relative Weights,"$69,839.22 ",IP,"2,420.00","99,425.09",,,,,,
UHC Comm,DRG,MS-023,CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX CNS PDX W MCC OR CHEMO IMPLANT,,Relative Weights,"$79,543.75 ",IP,"2,420.00","113,240.74",,,,,,
UHC Comm,DRG,MS-024,CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,,Relative Weights,"$56,877.66 ",IP,"2,420.00","80,972.64",,,,,,
UHC Comm,DRG,MS-025,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,,Relative Weights,"$62,230.51 ",IP,"2,420.00","88,593.12",,,,,,
UHC Comm,DRG,MS-026,CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC,,Relative Weights,"$43,131.57 ",IP,"2,420.00","61,403.33",,,,,,
UHC Comm,DRG,MS-027,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$33,939.67 ",IP,"2,420.00","48,317.47",,,,,,
UHC Comm,DRG,MS-028,SPINAL PROCEDURES WITH MCC,,Relative Weights,"$79,165.65 ",IP,"2,420.00","112,702.46",,,,,,
UHC Comm,DRG,MS-029,SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,,Relative Weights,"$45,414.33 ",IP,"2,420.00","64,653.12",,,,,,
UHC Comm,DRG,MS-030,SPINAL PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$32,175.21 ",IP,"2,420.00","45,805.54",,,,,,
UHC Comm,DRG,MS-031,VENTRICULAR SHUNT PROCEDURES WITH MCC,,Relative Weights,"$61,947.29 ",IP,"2,420.00","88,189.92",,,,,,
UHC Comm,DRG,MS-032,VENTRICULAR SHUNT PROCEDURES WITH CC,,Relative Weights,"$31,042.33 ",IP,"2,420.00","44,192.74",,,,,,
UHC Comm,DRG,MS-033,VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$24,086.44 ",IP,"2,420.00","34,290.14",,,,,,
UHC Comm,DRG,MS-034,CAROTID ARTERY STENT PROCEDURE W MCC,,Relative Weights,"$53,156.15 ",IP,"2,420.00","75,674.59",,,,,,
UHC Comm,DRG,MS-035,CAROTID ARTERY STENT PROCEDURES WITH CC,,Relative Weights,"$32,601.45 ",IP,"2,420.00","46,412.35",,,,,,
UHC Comm,DRG,MS-036,CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$24,795.91 ",IP,"2,420.00","35,300.16",,,,,,
UHC Comm,DRG,MS-037,EXTRACRANIAL PROCEDURES WITH MCC,,Relative Weights,"$45,928.37 ",IP,"2,420.00","65,384.93",,,,,,
UHC Comm,DRG,MS-038,EXTRACRANIAL PROCEDURES WITH CC,,Relative Weights,"$23,722.51 ",IP,"2,420.00","33,772.03",,,,,,
UHC Comm,DRG,MS-039,EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$16,020.34 ",IP,"2,420.00","22,807.01",,,,,,
UHC Comm,DRG,MS-040,PERIPHERAL- CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC,,Relative Weights,"$55,800.00 ",IP,"2,420.00","79,438.46",,,,,,
UHC Comm,DRG,MS-041,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W CC OR PERIPH NEUROSTIM,,Relative Weights,"$33,582.81 ",IP,"2,420.00","47,809.44",,,,,,
UHC Comm,DRG,MS-042,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W/O CC/MCC,,Relative Weights,"$26,173.78 ",IP,"2,420.00","37,261.73",,,,,,
UHC Comm,DRG,MS-052,SPINAL DISORDERS AND INJURIES WITH CC/MCC,,Relative Weights,"$23,066.85 ",IP,"2,420.00","32,838.62",,,,,,
UHC Comm,DRG,MS-053,SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,,Relative Weights,"$13,680.94 ",IP,"2,420.00","19,476.58",,,,,,
UHC Comm,DRG,MS-054,NERVOUS SYSTEM NEOPLASMS WITH MCC,,Relative Weights,"$18,977.16 ",IP,"2,420.00","27,016.42",,,,,,
UHC Comm,DRG,MS-055,NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,,Relative Weights,"$13,962.75 ",IP,"2,420.00","19,877.76",,,,,,
UHC Comm,DRG,MS-056,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,,Relative Weights,"$31,046.58 ",IP,"2,420.00","44,198.78",,,,,,
UHC Comm,DRG,MS-057,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,,Relative Weights,"$17,146.14 ",IP,"2,420.00","24,409.73",,,,,,
UHC Comm,DRG,MS-058,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,,Relative Weights,"$27,680.51 ",IP,"2,420.00","39,406.75",,,,,,
UHC Comm,DRG,MS-059,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,,Relative Weights,"$15,442.57 ",IP,"2,420.00","21,984.48",,,,,,
UHC Comm,DRG,MS-060,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,,Relative Weights,"$12,485.75 ",IP,"2,420.00","17,775.07",,,,,,
UHC Comm,DRG,MS-061,ISCHEMIC STROKE -  PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC,,Relative Weights,"$39,558.75 ",IP,"2,420.00","56,316.96",,,,,,
UHC Comm,DRG,MS-062,ISCHEMIC STROKE -  PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC,,Relative Weights,"$28,480.60 ",IP,"2,420.00","40,545.79",,,,,,
UHC Comm,DRG,MS-063,ISCHEMIC STROKE- PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC,,Relative Weights,"$23,801.81 ",IP,"2,420.00","33,884.93",,,,,,
UHC Comm,DRG,MS-064,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,,Relative Weights,"$26,549.04 ",IP,"2,420.00","37,795.97",,,,,,
UHC Comm,DRG,MS-065,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC,,Relative Weights,"$14,553.26 ",IP,"2,420.00","20,718.43",,,,,,
UHC Comm,DRG,MS-066,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,,Relative Weights,"$10,153.44 ",IP,"2,420.00","14,454.72",,,,,,
UHC Comm,DRG,MS-067,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,,Relative Weights,"$20,738.78 ",IP,"2,420.00","29,524.32",,,,,,
UHC Comm,DRG,MS-068,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,,Relative Weights,"$12,793.05 ",IP,"2,420.00","18,212.54",,,,,,
UHC Comm,DRG,MS-069,TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,,Relative Weights,"$11,049.83 ",IP,"2,420.00","15,730.85",,,,,,
UHC Comm,DRG,MS-070,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC,,Relative Weights,"$23,689.94 ",IP,"2,420.00","33,725.66",,,,,,
UHC Comm,DRG,MS-071,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC,,Relative Weights,"$14,085.95 ",IP,"2,420.00","20,053.15",,,,,,
UHC Comm,DRG,MS-072,NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,,Relative Weights,"$10,457.90 ",IP,"2,420.00","14,888.16",,,,,,
UHC Comm,DRG,MS-073,CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,,Relative Weights,"$20,046.31 ",IP,"2,420.00","28,538.50",,,,,,
UHC Comm,DRG,MS-074,CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,,Relative Weights,"$13,992.48 ",IP,"2,420.00","19,920.10",,,,,,
UHC Comm,DRG,MS-075,VIRAL MENINGITIS WITH CC/MCC,,Relative Weights,"$22,773.72 ",IP,"2,420.00","32,421.31",,,,,,
UHC Comm,DRG,MS-076,VIRAL MENINGITIS WITHOUT CC/MCC,,Relative Weights,"$12,780.30 ",IP,"2,420.00","18,194.40",,,,,,
UHC Comm,DRG,MS-077,HYPERTENSIVE ENCEPHALOPATHY WITH MCC,,Relative Weights,"$21,843.34 ",IP,"2,420.00","31,096.80",,,,,,
UHC Comm,DRG,MS-078,HYPERTENSIVE ENCEPHALOPATHY WITH CC,,Relative Weights,"$13,622.88 ",IP,"2,420.00","19,393.92",,,,,,
UHC Comm,DRG,MS-079,HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC,,Relative Weights,"$10,494.72 ",IP,"2,420.00","14,940.58",,,,,,
UHC Comm,DRG,MS-080,NONTRAUMATIC STUPOR & COMA W MCC,,Relative Weights,"$27,136.72 ",IP,"2,420.00","38,632.61",,,,,,
UHC Comm,DRG,MS-081,NONTRAUMATIC STUPOR & COMA W/O MCC,,Relative Weights,"$12,448.94 ",IP,"2,420.00","17,722.66",,,,,,
UHC Comm,DRG,MS-082,TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,,Relative Weights,"$31,887.74 ",IP,"2,420.00","45,396.29",,,,,,
UHC Comm,DRG,MS-083,TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,,Relative Weights,"$18,560.82 ",IP,"2,420.00","26,423.71",,,,,,
UHC Comm,DRG,MS-084,TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,,Relative Weights,"$12,706.67 ",IP,"2,420.00","18,089.57",,,,,,
UHC Comm,DRG,MS-085,TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,,Relative Weights,"$31,802.77 ",IP,"2,420.00","45,275.33",,,,,,
UHC Comm,DRG,MS-086,TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,,Relative Weights,"$17,528.49 ",IP,"2,420.00","24,954.05",,,,,,
UHC Comm,DRG,MS-087,TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,,Relative Weights,"$11,883.91 ",IP,"2,420.00","16,918.27",,,,,,
UHC Comm,DRG,MS-088,CONCUSSION WITH MCC,,Relative Weights,"$19,671.05 ",IP,"2,420.00","28,004.26",,,,,,
UHC Comm,DRG,MS-089,CONCUSSION WITH CC,,Relative Weights,"$13,966.99 ",IP,"2,420.00","19,883.81",,,,,,
UHC Comm,DRG,MS-090,CONCUSSION WITHOUT CC/MCC,,Relative Weights,"$12,012.78 ",IP,"2,420.00","17,101.73",,,,,,
UHC Comm,DRG,MS-091,OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,,Relative Weights,"$22,163.38 ",IP,"2,420.00","31,552.42",,,,,,
UHC Comm,DRG,MS-092,OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,,Relative Weights,"$13,680.94 ",IP,"2,420.00","19,476.58",,,,,,
UHC Comm,DRG,MS-093,OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,,Relative Weights,"$10,779.35 ",IP,"2,420.00","15,345.79",,,,,,
UHC Comm,DRG,MS-094,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,,Relative Weights,"$50,764.35 ",IP,"2,420.00","72,269.57",,,,,,
UHC Comm,DRG,MS-095,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,,Relative Weights,"$34,086.94 ",IP,"2,420.00","48,527.14",,,,,,
UHC Comm,DRG,MS-096,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,,Relative Weights,"$32,033.60 ",IP,"2,420.00","45,603.94",,,,,,
UHC Comm,DRG,MS-097,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,,Relative Weights,"$50,638.32 ",IP,"2,420.00","72,090.14",,,,,,
UHC Comm,DRG,MS-098,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,,Relative Weights,"$27,684.76 ",IP,"2,420.00","39,412.80",,,,,,
UHC Comm,DRG,MS-099,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,,Relative Weights,"$18,160.07 ",IP,"2,420.00","25,853.18",,,,,,
UHC Comm,DRG,MS-100,SEIZURES WITH MCC,,Relative Weights,"$25,775.85 ",IP,"2,420.00","36,695.23",,,,,,
UHC Comm,DRG,MS-101,SEIZURES WITHOUT MCC,,Relative Weights,"$12,502.75 ",IP,"2,420.00","17,799.26",,,,,,
UHC Comm,DRG,MS-102,HEADACHES WITH MCC,,Relative Weights,"$16,888.41 ",IP,"2,420.00","24,042.82",,,,,,
UHC Comm,DRG,MS-103,HEADACHES W/O MCC,,Relative Weights,"$11,321.72 ",IP,"2,420.00","16,117.92",,,,,,
UHC Comm,DRG,MS-113,ORBITAL PROCEDURES WITH CC/MCC,,Relative Weights,"$30,192.67 ",IP,"2,420.00","42,983.14",,,,,,
UHC Comm,DRG,MS-114,ORBITAL PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$16,862.92 ",IP,"2,420.00","24,006.53",,,,,,
UHC Comm,DRG,MS-115,EXTRAOCULAR PROCEDURES EXCEPT ORBIT,,Relative Weights,"$21,043.25 ",IP,"2,420.00","29,957.76",,,,,,
UHC Comm,DRG,MS-116,INTRAOCULAR PROCEDURES W CC/MCC,,Relative Weights,"$26,778.45 ",IP,"2,420.00","38,122.56",,,,,,
UHC Comm,DRG,MS-117,INTRAOCULAR PROCEDURES W/O CC/MCC,,Relative Weights,"$15,530.37 ",IP,"2,420.00","22,109.47",,,,,,
UHC Comm,DRG,MS-121,ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,,Relative Weights,"$17,953.32 ",IP,"2,420.00","25,558.85",,,,,,
UHC Comm,DRG,MS-122,ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,,Relative Weights,"$10,940.79 ",IP,"2,420.00","15,575.62",,,,,,
UHC Comm,DRG,MS-123,NEUROLOGICAL EYE DISORDERS,,Relative Weights,"$11,056.91 ",IP,"2,420.00","15,740.93",,,,,,
UHC Comm,DRG,MS-124,OTHER DISORDERS OF THE EYE WITH MCC,,Relative Weights,"$19,675.29 ",IP,"2,420.00","28,010.30",,,,,,
UHC Comm,DRG,MS-125,OTHER DISORDERS OF THE EYE WITHOUT MCC,,Relative Weights,"$11,178.69 ",IP,"2,420.00","15,914.30",,,,,,
UHC Comm,DRG,MS-129,MAJOR HEAD & NECK PROCEDURES W CC/MCC OR MAJOR DEVICE,,Relative Weights,"$32,418.78 ",IP,"21,710.46","46,152.29",,,,,,
UHC Comm,DRG,MS-130,MAJOR HEAD & NECK PROCEDURES W/O CC/MCC,,Relative Weights,"$20,471.14 ",IP,"13,709.28","29,143.30",,,,,,
UHC Comm,DRG,MS-131,CRANIAL/FACIAL PROCEDURES W CC/MCC,,Relative Weights,"$38,083.18 ",IP,"25,503.84","54,216.29",,,,,,
UHC Comm,DRG,MS-132,CRANIAL/FACIAL PROCEDURES W/O CC/MCC,,Relative Weights,"$22,508.91 ",IP,"15,073.94","32,044.32",,,,,,
UHC Comm,DRG,MS-133,OTHER EAR - NOSE - MOUTH & THROAT O.R. PROCEDURES W CC/MCC,,Relative Weights,"$30,402.25 ",IP,"20,360.02","43,281.50",,,,,,
UHC Comm,DRG,MS-134,OTHER EAR - NOSE - MOUTH & THROAT O.R. PROCEDURES W/O CC/MCC,,Relative Weights,"$17,122.07 ",IP,"11,466.44","24,375.46",,,,,,
UHC Comm,DRG,MS-135,SINUS AND MASTOID PROCEDURES WITH CC/MCC,,Relative Weights,"$32,352.22 ",IP,"2,420.00","46,057.54",,,,,,
UHC Comm,DRG,MS-136,SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$16,851.59 ",IP,"2,420.00","23,990.40",,,,,,
UHC Comm,DRG,MS-137,MOUTH PROCEDURES WITH CC/MCC,,Relative Weights,"$18,880.86 ",IP,"2,420.00","26,879.33",,,,,,
UHC Comm,DRG,MS-138,MOUTH PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$12,198.29 ",IP,"2,420.00","17,365.82",,,,,,
UHC Comm,DRG,MS-139,SALIVARY GLAND PROCEDURES,,Relative Weights,"$17,478.92 ",IP,"2,420.00","24,883.49",,,,,,
UHC Comm,DRG,MS-146,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH MCC,,Relative Weights,"$27,310.90 ",IP,"2,420.00","38,880.58",,,,,,
UHC Comm,DRG,MS-147,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH CC,,Relative Weights,"$17,572.38 ",IP,"2,420.00","25,016.54",,,,,,
UHC Comm,DRG,MS-148,EAR - NOSE - MOUTH & THROAT MALIGNANCY W/O CC/MCC,,Relative Weights,"$10,768.02 ",IP,"2,420.00","15,329.66",,,,,,
UHC Comm,DRG,MS-149,DYSEQUILIBRIUM,,Relative Weights,"$10,344.61 ",IP,"2,420.00","14,726.88",,,,,,
UHC Comm,DRG,MS-150,EPISTAXIS WITH MCC,,Relative Weights,"$18,288.93 ",IP,"2,420.00","26,036.64",,,,,,
UHC Comm,DRG,MS-151,EPISTAXIS WITHOUT MCC,,Relative Weights,"$9,899.96 ",IP,"2,420.00","14,093.86",,,,,,
UHC Comm,DRG,MS-152,OTITIS MEDIA AND URI WITH MCC,,Relative Weights,"$14,713.28 ",IP,"2,420.00","20,946.24",,,,,,
UHC Comm,DRG,MS-153,OTITIS MEDIA AND URI WITHOUT MCC,,Relative Weights,"$10,003.33 ",IP,"2,420.00","14,241.02",,,,,,
UHC Comm,DRG,MS-154,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH MCC,,Relative Weights,"$20,349.36 ",IP,"2,420.00","28,969.92",,,,,,
UHC Comm,DRG,MS-155,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH CC,,Relative Weights,"$12,760.48 ",IP,"2,420.00","18,166.18",,,,,,
UHC Comm,DRG,MS-156,OTHER EAR -  NOSE -  MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC,,Relative Weights,"$9,268.37 ",IP,"2,420.00","13,194.72",,,,,,
UHC Comm,DRG,MS-157,DENTAL AND ORAL DISEASES WITH MCC,,Relative Weights,"$22,132.23 ",IP,"2,420.00","31,508.06",,,,,,
UHC Comm,DRG,MS-158,DENTAL AND ORAL DISEASES WITH CC,,Relative Weights,"$12,271.92 ",IP,"2,420.00","17,470.66",,,,,,
UHC Comm,DRG,MS-159,DENTAL AND ORAL DISEASES WITHOUT CC/MCC,,Relative Weights,"$9,528.94 ",IP,"2,420.00","13,565.66",,,,,,
UHC Comm,DRG,MS-163,MAJOR CHEST PROCEDURES WITH MCC,,Relative Weights,"$69,016.47 ",IP,"2,420.00","98,253.79",,,,,,
UHC Comm,DRG,MS-164,MAJOR CHEST PROCEDURES WITH CC,,Relative Weights,"$35,849.99 ",IP,"2,420.00","51,037.06",,,,,,
UHC Comm,DRG,MS-165,MAJOR CHEST PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$26,186.52 ",IP,"2,420.00","37,279.87",,,,,,
UHC Comm,DRG,MS-166,OTHER RESP SYSTEM O.R. PROCEDURES W MCC,,Relative Weights,"$52,830.44 ",IP,"2,420.00","75,210.91",,,,,,
UHC Comm,DRG,MS-167,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,,Relative Weights,"$27,109.82 ",IP,"2,420.00","38,594.30",,,,,,
UHC Comm,DRG,MS-168,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$18,787.40 ",IP,"2,420.00","26,746.27",,,,,,
UHC Comm,DRG,MS-175,PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,,Relative Weights,"$20,454.15 ",IP,"2,420.00","29,119.10",,,,,,
UHC Comm,DRG,MS-176,PULMONARY EMBOLISM WITHOUT MCC,,Relative Weights,"$12,014.19 ",IP,"2,420.00","17,103.74",,,,,,
UHC Comm,DRG,MS-177,RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC,,Relative Weights,"$26,781.28 ",IP,"2,420.00","38,126.59",,,,,,
UHC Comm,DRG,MS-178,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,,Relative Weights,"$17,606.37 ",IP,"2,420.00","25,064.93",,,,,,
UHC Comm,DRG,MS-179,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,,Relative Weights,"$12,264.84 ",IP,"2,420.00","17,460.58",,,,,,
UHC Comm,DRG,MS-180,RESPIRATORY NEOPLASMS WITH MCC,,Relative Weights,"$24,426.31 ",IP,"2,420.00","34,773.98",,,,,,
UHC Comm,DRG,MS-181,RESPIRATORY NEOPLASMS WITH CC,,Relative Weights,"$16,313.47 ",IP,"2,420.00","23,224.32",,,,,,
UHC Comm,DRG,MS-182,RESPIRATORY NEOPLASMS WITHOUT CC/MCC,,Relative Weights,"$11,934.89 ",IP,"2,420.00","16,990.85",,,,,,
UHC Comm,DRG,MS-183,MAJOR CHEST TRAUMA WITH MCC,,Relative Weights,"$21,371.78 ",IP,"2,420.00","30,425.47",,,,,,
UHC Comm,DRG,MS-184,MAJOR CHEST TRAUMA WITH CC,,Relative Weights,"$14,418.73 ",IP,"2,420.00","20,526.91",,,,,,
UHC Comm,DRG,MS-185,MAJOR CHEST TRAUMA W/O CC/MCC,,Relative Weights,"$10,394.17 ",IP,"2,420.00","14,797.44",,,,,,
UHC Comm,DRG,MS-186,PLEURAL EFFUSION WITH MCC,,Relative Weights,"$21,849.01 ",IP,"2,420.00","31,104.86",,,,,,
UHC Comm,DRG,MS-187,PLEURAL EFFUSION WITH CC,,Relative Weights,"$14,556.09 ",IP,"2,420.00","20,722.46",,,,,,
UHC Comm,DRG,MS-188,PLEURAL EFFUSION WITHOUT CC/MCC,,Relative Weights,"$10,350.27 ",IP,"2,420.00","14,734.94",,,,,,
UHC Comm,DRG,MS-189,PULMONARY EDEMA AND RESPIRATORY FAILURE,,Relative Weights,"$17,215.53 ",IP,"2,420.00","24,508.51",,,,,,
UHC Comm,DRG,MS-190,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,,Relative Weights,"$16,200.18 ",IP,"2,420.00","23,063.04",,,,,,
UHC Comm,DRG,MS-191,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,,Relative Weights,"$12,642.94 ",IP,"2,420.00","17,998.85",,,,,,
UHC Comm,DRG,MS-192,CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC,,Relative Weights,"$10,042.98 ",IP,"2,420.00","14,297.47",,,,,,
UHC Comm,DRG,MS-193,SIMPLE PNEUMONIA & PLEURISY W MCC,,Relative Weights,"$18,883.69 ",IP,"2,420.00","26,883.36",,,,,,
UHC Comm,DRG,MS-194,SIMPLE PNEUMONIA AND PLEURISY WITH CC,,Relative Weights,"$12,583.46 ",IP,"2,420.00","17,914.18",,,,,,
UHC Comm,DRG,MS-195,SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,,Relative Weights,"$9,659.22 ",IP,"2,420.00","13,751.14",,,,,,
UHC Comm,DRG,MS-196,INTERSTITIAL LUNG DISEASE WITH MCC,,Relative Weights,"$23,725.34 ",IP,"2,420.00","33,776.06",,,,,,
UHC Comm,DRG,MS-197,INTERSTITIAL LUNG DISEASE WITH CC,,Relative Weights,"$14,465.46 ",IP,"2,420.00","20,593.44",,,,,,
UHC Comm,DRG,MS-198,INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,,Relative Weights,"$10,691.56 ",IP,"2,420.00","15,220.80",,,,,,
UHC Comm,DRG,MS-199,PNEUMOTHORAX WITH MCC,,Relative Weights,"$25,406.25 ",IP,"2,420.00","36,169.06",,,,,,
UHC Comm,DRG,MS-200,PNEUMOTHORAX WITH CC,,Relative Weights,"$15,323.62 ",IP,"2,420.00","21,815.14",,,,,,
UHC Comm,DRG,MS-201,PNEUMOTHORAX WITHOUT CC/MCC,,Relative Weights,"$10,167.60 ",IP,"2,420.00","14,474.88",,,,,,
UHC Comm,DRG,MS-202,BRONCHITIS AND ASTHMA WITH CC/MCC,,Relative Weights,"$13,424.63 ",IP,"2,420.00","19,111.68",,,,,,
UHC Comm,DRG,MS-203,BRONCHITIS AND ASTHMA WITHOUT CC/MCC,,Relative Weights,"$9,824.90 ",IP,"2,420.00","13,987.01",,,,,,
UHC Comm,DRG,MS-204,RESPIRATORY SIGNS AND SYMPTOMS,,Relative Weights,"$11,505.81 ",IP,"2,420.00","16,380.00",,,,,,
UHC Comm,DRG,MS-205,OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,,Relative Weights,"$23,141.91 ",IP,"2,420.00","32,945.47",,,,,,
UHC Comm,DRG,MS-206,OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,,Relative Weights,"$12,355.47 ",IP,"2,420.00","17,589.60",,,,,,
UHC Comm,DRG,MS-207,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS,,Relative Weights,"$81,221.83 ",IP,"2,420.00","115,629.70",,,,,,
UHC Comm,DRG,MS-208,RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,,Relative Weights,"$35,177.34 ",IP,"2,420.00","50,079.46",,,,,,
UHC Comm,DRG,MS-215,OTHER HEART ASSIST SYSTEM IMPLANT,,Relative Weights,"$182,480.06 ",IP,"61,661.88","259,783.78",,,,,,
UHC Comm,DRG,MS-216,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,,Relative Weights,"$142,210.43 ",IP,"58,630.29","202,454.78",,,,,,
UHC Comm,DRG,MS-217,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,,Relative Weights,"$94,193.31 ",IP,"37,864.14","134,096.26",,,,,,
UHC Comm,DRG,MS-218,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,,Relative Weights,"$76,489.23 ",IP,"35,678.79","108,892.22",,,,,,
UHC Comm,DRG,MS-219,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,,Relative Weights,"$111,023.66 ",IP,"47,057.01","158,056.42",,,,,,
UHC Comm,DRG,MS-220,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,,Relative Weights,"$75,136.85 ",IP,"31,567.37","106,966.94",,,,,,
UHC Comm,DRG,MS-221,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,,Relative Weights,"$65,086.79 ",IP,"26,746.97","92,659.39",,,,,,
UHC Comm,DRG,MS-222,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITH MCC,,Relative Weights,"$118,167.88 ",IP,"46,434.46","168,227.14",,,,,,
UHC Comm,DRG,MS-223,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITHOUT MCC,,Relative Weights,"$85,007.07 ",IP,"33,864.27","121,018.46",,,,,,
UHC Comm,DRG,MS-224,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITH MCC,,Relative Weights,"$104,737.59 ",IP,"43,912.13","149,107.39",,,,,,
UHC Comm,DRG,MS-225,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITHOUT MCC,,Relative Weights,"$79,992.66 ",IP,"32,808.39","113,879.81",,,,,,
UHC Comm,DRG,MS-226,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITH MCC,,Relative Weights,"$94,704.52 ",IP,"25,420.00","134,824.03",,,,,,
UHC Comm,DRG,MS-227,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,,Relative Weights,"$74,050.70 ",IP,"25,420.00","105,420.67",,,,,,
UHC Comm,DRG,MS-228,OTHER CARDIOTHORACIC PROCEDURES WITH MCC,,Relative Weights,"$89,020.29 ",IP,"31,129.37","126,731.81",,,,,,
UHC Comm,DRG,MS-229,OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,,Relative Weights,"$58,129.49 ",IP,"20,096.88","82,754.78",,,,,,
UHC Comm,DRG,MS-231,CORONARY BYPASS W PTCA W MCC,,Relative Weights,"$116,283.05 ",IP,"50,901.53","165,543.84",,,,,,
UHC Comm,DRG,MS-232,CORONARY BYPASS W PTCA W/O MCC,,Relative Weights,"$84,774.83 ",IP,"34,770.65","120,687.84",,,,,,
UHC Comm,DRG,MS-233,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,,Relative Weights,"$110,015.39 ",IP,"42,365.00","156,621.02",,,,,,
UHC Comm,DRG,MS-234,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,,Relative Weights,"$73,726.41 ",IP,"31,162.65","104,959.01",,,,,,
UHC Comm,DRG,MS-235,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,,Relative Weights,"$83,331.82 ",IP,"32,351.00","118,633.54",,,,,,
UHC Comm,DRG,MS-236,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,,Relative Weights,"$57,056.09 ",IP,"23,926.80","81,226.66",,,,,,
UHC Comm,DRG,MS-239,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,,Relative Weights,"$66,127.62 ",IP,"2,420.00","94,141.15",,,,,,
UHC Comm,DRG,MS-240,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,,Relative Weights,"$39,084.36 ",IP,"2,420.00","55,641.60",,,,,,
UHC Comm,DRG,MS-241,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,,Relative Weights,"$21,472.32 ",IP,"2,420.00","30,568.61",,,,,,
UHC Comm,DRG,MS-242,PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,,Relative Weights,"$52,552.89 ",IP,"15,407.00","74,815.78",,,,,,
UHC Comm,DRG,MS-243,PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,,Relative Weights,"$35,818.83 ",IP,"14,708.24","50,992.70",,,,,,
UHC Comm,DRG,MS-244,PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,,Relative Weights,"$29,389.74 ",IP,"12,049.83","41,840.06",,,,,,
UHC Comm,DRG,MS-245,AICD GENERATOR PROCEDURES,,Relative Weights,"$73,747.66 ",IP,"15,407.00","104,989.25",,,,,,
UHC Comm,DRG,MS-246,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,,Relative Weights,"$44,930.02 ",IP,"18,246.15","63,963.65",,,,,,
UHC Comm,DRG,MS-247,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITHOUT MCC,,Relative Weights,"$28,813.39 ",IP,"11,523.64","41,019.55",,,,,,
UHC Comm,DRG,MS-248,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,,Relative Weights,"$43,849.54 ",IP,"18,467.49","62,425.44",,,,,,
UHC Comm,DRG,MS-249,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITHOUT MCC,,Relative Weights,"$27,140.97 ",IP,"10,942.55","38,638.66",,,,,,
UHC Comm,DRG,MS-250,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT CORONARY ARTERY STENT WITH MCC,,Relative Weights,"$36,111.97 ",IP,"14,727.51","51,410.02",,,,,,
UHC Comm,DRG,MS-251,PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W/O MCC,,Relative Weights,"$23,832.96 ",IP,"2,420.00","33,929.28",,,,,,
UHC Comm,DRG,MS-252,OTHER VASCULAR PROCEDURES W MCC,,Relative Weights,"$46,453.74 ",IP,"2,420.00","66,132.86",,,,,,
UHC Comm,DRG,MS-253,OTHER VASCULAR PROCEDURES WITH CC,,Relative Weights,"$36,912.06 ",IP,"2,420.00","52,549.06",,,,,,
UHC Comm,DRG,MS-254,OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$25,774.44 ",IP,"2,420.00","36,693.22",,,,,,
UHC Comm,DRG,MS-255,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,,Relative Weights,"$37,520.99 ",IP,"2,420.00","53,415.94",,,,,,
UHC Comm,DRG,MS-256,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,,Relative Weights,"$24,307.36 ",IP,"2,420.00","34,604.64",,,,,,
UHC Comm,DRG,MS-257,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,,Relative Weights,"$16,064.24 ",IP,"2,420.00","22,869.50",,,,,,
UHC Comm,DRG,MS-258,CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,,Relative Weights,"$43,314.25 ",IP,"11,861.00","61,663.39",,,,,,
UHC Comm,DRG,MS-259,CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,,Relative Weights,"$29,491.70 ",IP,"11,861.00","41,985.22",,,,,,
UHC Comm,DRG,MS-260,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,,Relative Weights,"$52,390.04 ",IP,"10,167.00","74,583.94",,,,,,
UHC Comm,DRG,MS-261,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,,Relative Weights,"$27,592.71 ",IP,"10,167.00","39,281.76",,,,,,
UHC Comm,DRG,MS-262,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,,Relative Weights,"$23,756.49 ",IP,"9,964.34","33,820.42",,,,,,
UHC Comm,DRG,MS-263,VEIN LIGATION AND STRIPPING,,Relative Weights,"$33,407.22 ",IP,"2,420.00","47,559.46",,,,,,
UHC Comm,DRG,MS-264,OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,,Relative Weights,"$45,853.32 ",IP,"2,420.00","65,278.08",,,,,,
UHC Comm,DRG,MS-265,AICD LEAD PROCEDURES,,Relative Weights,"$44,200.73 ",IP,"2,420.00","62,925.41",,,,,,
UHC Comm,DRG,MS-266,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,,Relative Weights,"$100,846.15 ",IP,"41,160.28","143,567.42",,,,,,
UHC Comm,DRG,MS-267,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,,Relative Weights,"$80,372.17 ",IP,"32,692.75","114,420.10",,,,,,
UHC Comm,DRG,MS-268,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,,Relative Weights,"$96,048.40 ",IP,"32,968.00","136,737.22",,,,,,
UHC Comm,DRG,MS-269,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,,Relative Weights,"$60,416.49 ",IP,"25,200.52","86,010.62",,,,,,
UHC Comm,DRG,MS-270,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,,Relative Weights,"$72,365.54 ",IP,"30,292.48","103,021.63",,,,,,
UHC Comm,DRG,MS-271,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,,Relative Weights,"$50,243.23 ",IP,"20,822.21","71,527.68",,,,,,
UHC Comm,DRG,MS-272,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$36,837.01 ",IP,"15,699.88","52,442.21",,,,,,
UHC Comm,DRG,MS-273,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,,Relative Weights,"$52,541.56 ",IP,"16,176.00","74,799.65",,,,,,
UHC Comm,DRG,MS-274,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,,Relative Weights,"$44,745.93 ",IP,"16,176.00","63,701.57",,,,,,
UHC Comm,DRG,MS-280,ACUTE MYOCARDIAL INFARCTION - DISCHARGED ALIVE W MCC,,Relative Weights,"$23,095.17 ",IP,"2,420.00","32,878.94",,,,,,
UHC Comm,DRG,MS-281,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITH CC,,Relative Weights,"$13,717.76 ",IP,"2,420.00","19,528.99",,,,,,
UHC Comm,DRG,MS-282,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITHOUT CC/MCC,,Relative Weights,"$10,449.40 ",IP,"2,420.00","14,876.06",,,,,,
UHC Comm,DRG,MS-283,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH MCC,,Relative Weights,"$25,485.55 ",IP,"2,420.00","36,281.95",,,,,,
UHC Comm,DRG,MS-284,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH CC,,Relative Weights,"$10,270.97 ",IP,"2,420.00","14,622.05",,,,,,
UHC Comm,DRG,MS-285,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITHOUT CC/MCC,,Relative Weights,"$7,332.57 ",IP,"2,420.00","10,438.85",,,,,,
UHC Comm,DRG,MS-286,CIRCULATORY DISORDERS EXCEPT AMI- WITH CARDIAC CATHETERIZATION WITH MCC,,Relative Weights,"$31,117.38 ",IP,"2,420.00","44,299.58",,,,,,
UHC Comm,DRG,MS-287,CIRCULATORY DISORDERS EXCEPT AMI -  WITH CARDIAC CATHETERIZATION WITHOUT MCC,,Relative Weights,"$16,316.30 ",IP,"6,512.27","23,228.35",,,,,,
UHC Comm,DRG,MS-288,ACUTE & SUBACUTE ENDOCARDITIS W MCC,,Relative Weights,"$37,631.44 ",IP,"2,420.00","53,573.18",,,,,,
UHC Comm,DRG,MS-289,ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,,Relative Weights,"$23,561.07 ",IP,"9,181.00","33,542.21",,,,,,
UHC Comm,DRG,MS-290,ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,,Relative Weights,"$14,169.50 ",IP,"2,420.00","20,172.10",,,,,,
UHC Comm,DRG,MS-291,HEART FAILURE AND SHOCK WITH MCC,,Relative Weights,"$19,057.87 ",IP,"2,420.00","27,131.33",,,,,,
UHC Comm,DRG,MS-292,HEART FAILURE AND SHOCK WITH CC,,Relative Weights,"$12,822.79 ",IP,"2,420.00","18,254.88",,,,,,
UHC Comm,DRG,MS-293,HEART FAILURE AND SHOCK WITHOUT CC/MCC,,Relative Weights,"$9,279.70 ",IP,"2,420.00","13,210.85",,,,,,
UHC Comm,DRG,MS-294,DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC,,Relative Weights,"$18,011.38 ",IP,"2,420.00","25,641.50",,,,,,
UHC Comm,DRG,MS-295,DEEP VEIN THROMBOPHLEBITIS W/O CC/MCC,,Relative Weights,"$8,170.90 ",IP,"2,420.00","11,632.32",,,,,,
UHC Comm,DRG,MS-296,CARDIAC ARREST - UNEXPLAINED W MCC,,Relative Weights,"$22,238.43 ",IP,"2,420.00","31,659.26",,,,,,
UHC Comm,DRG,MS-297,CARDIAC ARREST- UNEXPLAINED WITH CC,,Relative Weights,"$10,238.40 ",IP,"2,420.00","14,575.68",,,,,,
UHC Comm,DRG,MS-298,CARDIAC ARREST- UNEXPLAINED WITHOUT CC/MCC,,Relative Weights,"$7,125.82 ",IP,"2,420.00","10,144.51",,,,,,
UHC Comm,DRG,MS-299,PERIPHERAL VASCULAR DISORDERS WITH MCC,,Relative Weights,"$20,529.20 ",IP,"2,420.00","29,225.95",,,,,,
UHC Comm,DRG,MS-300,PERIPHERAL VASCULAR DISORDERS WITH CC,,Relative Weights,"$14,551.84 ",IP,"2,420.00","20,716.42",,,,,,
UHC Comm,DRG,MS-301,PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,,Relative Weights,"$10,278.05 ",IP,"2,420.00","14,632.13",,,,,,
UHC Comm,DRG,MS-302,ATHEROSCLEROSIS WITH MCC,,Relative Weights,"$15,609.67 ",IP,"2,420.00","22,222.37",,,,,,
UHC Comm,DRG,MS-303,ATHEROSCLEROSIS WITHOUT MCC,,Relative Weights,"$9,568.59 ",IP,"2,420.00","13,622.11",,,,,,
UHC Comm,DRG,MS-304,HYPERTENSION WITH MCC,,Relative Weights,"$15,456.73 ",IP,"2,420.00","22,004.64",,,,,,
UHC Comm,DRG,MS-305,HYPERTENSION WITHOUT MCC,,Relative Weights,"$10,358.77 ",IP,"2,420.00","14,747.04",,,,,,
UHC Comm,DRG,MS-306,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,,Relative Weights,"$20,030.73 ",IP,"2,420.00","28,516.32",,,,,,
UHC Comm,DRG,MS-307,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,,Relative Weights,"$12,492.83 ",IP,"2,420.00","17,785.15",,,,,,
UHC Comm,DRG,MS-308,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,,Relative Weights,"$16,819.02 ",IP,"2,420.00","23,944.03",,,,,,
UHC Comm,DRG,MS-309,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,,Relative Weights,"$10,709.96 ",IP,"2,420.00","15,247.01",,,,,,
UHC Comm,DRG,MS-310,CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC,,Relative Weights,"$7,920.25 ",IP,"2,420.00","11,275.49",,,,,,
UHC Comm,DRG,MS-311,ANGINA PECTORIS,,Relative Weights,"$9,700.29 ",IP,"2,420.00","13,809.60",,,,,,
UHC Comm,DRG,MS-312,SYNCOPE AND COLLAPSE,,Relative Weights,"$11,563.87 ",IP,"2,420.00","16,462.66",,,,,,
UHC Comm,DRG,MS-313,CHEST PAIN,,Relative Weights,"$10,129.36 ",IP,"2,420.00","14,420.45",,,,,,
UHC Comm,DRG,MS-314,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,,Relative Weights,"$28,739.75 ",IP,"2,420.00","40,914.72",,,,,,
UHC Comm,DRG,MS-315,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,,Relative Weights,"$13,741.83 ",IP,"2,420.00","19,563.26",,,,,,
UHC Comm,DRG,MS-316,OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,,Relative Weights,"$10,510.29 ",IP,"2,420.00","14,962.75",,,,,,
UHC Comm,DRG,MS-319,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,,Relative Weights,"$58,070.01 ",IP,"2,420.00","82,670.11",,,,,,
UHC Comm,DRG,MS-320,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,,Relative Weights,"$33,245.78 ",IP,"2,420.00","47,329.63",,,,,,
UHC Comm,DRG,MS-326,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC,,Relative Weights,"$74,635.55 ",IP,"2,420.00","106,253.28",,,,,,
UHC Comm,DRG,MS-327,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC,,Relative Weights,"$36,434.84 ",IP,"2,420.00","51,869.66",,,,,,
UHC Comm,DRG,MS-328,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$22,303.58 ",IP,"2,420.00","31,752.00",,,,,,
UHC Comm,DRG,MS-329,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,,Relative Weights,"$69,490.86 ",IP,"2,420.00","98,929.15",,,,,,
UHC Comm,DRG,MS-330,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,,Relative Weights,"$35,782.01 ",IP,"2,420.00","50,940.29",,,,,,
UHC Comm,DRG,MS-331,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$23,920.76 ",IP,"2,420.00","34,054.27",,,,,,
UHC Comm,DRG,MS-332,RECTAL RESECTION WITH MCC,,Relative Weights,"$49,448.80 ",IP,"2,420.00","70,396.70",,,,,,
UHC Comm,DRG,MS-333,RECTAL RESECTION WITH CC,,Relative Weights,"$32,049.18 ",IP,"2,420.00","45,626.11",,,,,,
UHC Comm,DRG,MS-334,RECTAL RESECTION WITHOUT CC/MCC,,Relative Weights,"$21,812.19 ",IP,"2,420.00","31,052.45",,,,,,
UHC Comm,DRG,MS-335,PERITONEAL ADHESIOLYSIS WITH MCC,,Relative Weights,"$57,282.66 ",IP,"2,420.00","81,549.22",,,,,,
UHC Comm,DRG,MS-336,PERITONEAL ADHESIOLYSIS WITH CC,,Relative Weights,"$32,091.66 ",IP,"2,420.00","45,686.59",,,,,,
UHC Comm,DRG,MS-337,PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,,Relative Weights,"$23,219.79 ",IP,"2,420.00","33,056.35",,,,,,
UHC Comm,DRG,MS-338,APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,,Relative Weights,"$41,209.93 ",IP,"2,420.00","58,667.62",,,,,,
UHC Comm,DRG,MS-339,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W CC,,Relative Weights,"$24,301.69 ",IP,"2,420.00","34,596.58",,,,,,
UHC Comm,DRG,MS-340,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC/MCC,,Relative Weights,"$17,524.24 ",IP,"2,420.00","24,948.00",,,,,,
UHC Comm,DRG,MS-341,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,,Relative Weights,"$36,225.25 ",IP,"2,420.00","51,571.30",,,,,,
UHC Comm,DRG,MS-342,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH CC,,Relative Weights,"$22,803.46 ",IP,"2,420.00","32,463.65",,,,,,
UHC Comm,DRG,MS-343,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,,Relative Weights,"$16,307.81 ",IP,"2,420.00","23,216.26",,,,,,
UHC Comm,DRG,MS-344,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,,Relative Weights,"$42,413.61 ",IP,"2,420.00","60,381.22",,,,,,
UHC Comm,DRG,MS-345,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,,Relative Weights,"$23,129.16 ",IP,"2,420.00","32,927.33",,,,,,
UHC Comm,DRG,MS-346,MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$18,164.31 ",IP,"2,420.00","25,859.23",,,,,,
UHC Comm,DRG,MS-347,ANAL AND STOMAL PROCEDURES WITH MCC,,Relative Weights,"$37,334.06 ",IP,"2,420.00","53,149.82",,,,,,
UHC Comm,DRG,MS-348,ANAL AND STOMAL PROCEDURES WITH CC,,Relative Weights,"$19,957.10 ",IP,"2,420.00","28,411.49",,,,,,
UHC Comm,DRG,MS-349,ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$13,890.52 ",IP,"2,420.00","19,774.94",,,,,,
UHC Comm,DRG,MS-350,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,,Relative Weights,"$34,542.93 ",IP,"2,420.00","49,176.29",,,,,,
UHC Comm,DRG,MS-351,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,,Relative Weights,"$20,650.99 ",IP,"2,420.00","29,399.33",,,,,,
UHC Comm,DRG,MS-352,INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$15,248.56 ",IP,"2,420.00","21,708.29",,,,,,
UHC Comm,DRG,MS-353,HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,,Relative Weights,"$42,014.27 ",IP,"2,420.00","59,812.70",,,,,,
UHC Comm,DRG,MS-354,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W CC,,Relative Weights,"$24,386.66 ",IP,"2,420.00","34,717.54",,,,,,
UHC Comm,DRG,MS-355,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W/O CC/MCC,,Relative Weights,"$19,434.56 ",IP,"2,420.00","27,667.58",,,,,,
UHC Comm,DRG,MS-356,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,,Relative Weights,"$57,737.23 ",IP,"2,420.00","82,196.35",,,,,,
UHC Comm,DRG,MS-357,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,,Relative Weights,"$31,867.91 ",IP,"2,420.00","45,368.06",,,,,,
UHC Comm,DRG,MS-358,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$19,424.64 ",IP,"2,420.00","27,653.47",,,,,,
UHC Comm,DRG,MS-368,MAJOR ESOPHAGEAL DISORDERS WITH MCC,,Relative Weights,"$26,956.88 ",IP,"2,420.00","38,376.58",,,,,,
UHC Comm,DRG,MS-369,MAJOR ESOPHAGEAL DISORDERS WITH CC,,Relative Weights,"$15,054.56 ",IP,"2,420.00","21,432.10",,,,,,
UHC Comm,DRG,MS-370,MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,,Relative Weights,"$10,582.52 ",IP,"2,420.00","15,065.57",,,,,,
UHC Comm,DRG,MS-371,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,,Relative Weights,"$24,434.81 ",IP,"2,420.00","34,786.08",,,,,,
UHC Comm,DRG,MS-372,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,,Relative Weights,"$14,479.62 ",IP,"2,420.00","20,613.60",,,,,,
UHC Comm,DRG,MS-373,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,,Relative Weights,"$10,504.63 ",IP,"2,420.00","14,954.69",,,,,,
UHC Comm,DRG,MS-374,DIGESTIVE MALIGNANCY WITH MCC,,Relative Weights,"$28,286.60 ",IP,"2,420.00","40,269.60",,,,,,
UHC Comm,DRG,MS-375,DIGESTIVE MALIGNANCY WITH CC,,Relative Weights,"$17,096.58 ",IP,"2,420.00","24,339.17",,,,,,
UHC Comm,DRG,MS-376,DIGESTIVE MALIGNANCY WITHOUT CC/MCC,,Relative Weights,"$14,179.41 ",IP,"2,420.00","20,186.21",,,,,,
UHC Comm,DRG,MS-377,GASTROINTESTINAL HEMORRHAGE WITH MCC,,Relative Weights,"$25,063.55 ",IP,"2,420.00","35,681.18",,,,,,
UHC Comm,DRG,MS-378,GASTROINTESTINAL HEMORRHAGE WITH CC,,Relative Weights,"$13,992.48 ",IP,"2,420.00","19,920.10",,,,,,
UHC Comm,DRG,MS-379,GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,,Relative Weights,"$9,143.76 ",IP,"2,420.00","13,017.31",,,,,,
UHC Comm,DRG,MS-380,COMPLICATED PEPTIC ULCER WITH MCC,,Relative Weights,"$26,730.30 ",IP,"2,420.00","38,054.02",,,,,,
UHC Comm,DRG,MS-381,COMPLICATED PEPTIC ULCER WITH CC,,Relative Weights,"$15,247.15 ",IP,"2,420.00","21,706.27",,,,,,
UHC Comm,DRG,MS-382,COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,,Relative Weights,"$11,207.02 ",IP,"2,420.00","15,954.62",,,,,,
UHC Comm,DRG,MS-383,UNCOMPLICATED PEPTIC ULCER WITH MCC,,Relative Weights,"$18,781.73 ",IP,"2,420.00","26,738.21",,,,,,
UHC Comm,DRG,MS-384,UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,,Relative Weights,"$12,322.90 ",IP,"2,420.00","17,543.23",,,,,,
UHC Comm,DRG,MS-385,INFLAMMATORY BOWEL DISEASE WITH MCC,,Relative Weights,"$22,803.46 ",IP,"2,420.00","32,463.65",,,,,,
UHC Comm,DRG,MS-386,INFLAMMATORY BOWEL DISEASE W CC,,Relative Weights,"$13,951.42 ",IP,"2,420.00","19,861.63",,,,,,
UHC Comm,DRG,MS-387,INFLAMMATORY BOWEL DISEASE W/O CC/MCC,,Relative Weights,"$9,922.61 ",IP,"2,420.00","14,126.11",,,,,,
UHC Comm,DRG,MS-388,GASTROINTESTINAL OBSTRUCTION WITH MCC,,Relative Weights,"$21,596.94 ",IP,"2,420.00","30,746.02",,,,,,
UHC Comm,DRG,MS-389,GASTROINTESTINAL OBSTRUCTION WITH CC,,Relative Weights,"$11,890.99 ",IP,"2,420.00","16,928.35",,,,,,
UHC Comm,DRG,MS-390,GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,,Relative Weights,"$8,207.72 ",IP,"2,420.00","11,684.74",,,,,,
UHC Comm,DRG,MS-391,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC,,Relative Weights,"$17,488.84 ",IP,"2,420.00","24,897.60",,,,,,
UHC Comm,DRG,MS-392,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC,,Relative Weights,"$10,783.60 ",IP,"2,420.00","15,351.84",,,,,,
UHC Comm,DRG,MS-393,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,,Relative Weights,"$23,004.54 ",IP,"2,420.00","32,749.92",,,,,,
UHC Comm,DRG,MS-394,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,,Relative Weights,"$13,284.43 ",IP,"2,420.00","18,912.10",,,,,,
UHC Comm,DRG,MS-395,OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,,Relative Weights,"$9,266.96 ",IP,"2,420.00","13,192.70",,,,,,
UHC Comm,DRG,MS-405,PANCREAS- LIVER AND SHUNT PROCEDURES WITH MCC,,Relative Weights,"$76,854.58 ",IP,"2,420.00","109,412.35",,,,,,
UHC Comm,DRG,MS-406,PANCREAS -  LIVER AND SHUNT PROCEDURES WITH CC,,Relative Weights,"$39,521.93 ",IP,"2,420.00","56,264.54",,,,,,
UHC Comm,DRG,MS-407,PANCREAS -  LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$29,544.09 ",IP,"2,420.00","42,059.81",,,,,,
UHC Comm,DRG,MS-408,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,,Relative Weights,"$50,464.14 ",IP,"2,420.00","71,842.18",,,,,,
UHC Comm,DRG,MS-409,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,,Relative Weights,"$33,898.60 ",IP,"2,420.00","48,259.01",,,,,,
UHC Comm,DRG,MS-410,BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W/O CC/MCC,,Relative Weights,"$23,507.26 ",IP,"2,420.00","33,465.60",,,,,,
UHC Comm,DRG,MS-411,CHOLECYSTECTOMY W C.D.E. W MCC,,Relative Weights,"$54,242.29 ",IP,"2,420.00","77,220.86",,,,,,
UHC Comm,DRG,MS-412,CHOLECYSTECTOMY WITH C.D.E. WITH CC,,Relative Weights,"$33,660.70 ",IP,"2,420.00","47,920.32",,,,,,
UHC Comm,DRG,MS-413,CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,,Relative Weights,"$22,902.59 ",IP,"2,420.00","32,604.77",,,,,,
UHC Comm,DRG,MS-414,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,,Relative Weights,"$48,379.64 ",IP,"2,420.00","68,874.62",,,,,,
UHC Comm,DRG,MS-415,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,,Relative Weights,"$29,054.12 ",IP,"2,420.00","41,362.27",,,,,,
UHC Comm,DRG,MS-416,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,,Relative Weights,"$19,121.60 ",IP,"2,420.00","27,222.05",,,,,,
UHC Comm,DRG,MS-417,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,,Relative Weights,"$34,137.92 ",IP,"2,420.00","48,599.71",,,,,,
UHC Comm,DRG,MS-418,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,,Relative Weights,"$23,633.29 ",IP,"2,420.00","33,645.02",,,,,,
UHC Comm,DRG,MS-419,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,,Relative Weights,"$18,505.59 ",IP,"2,420.00","26,345.09",,,,,,
UHC Comm,DRG,MS-420,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,,Relative Weights,"$48,640.20 ",IP,"2,420.00","69,245.57",,,,,,
UHC Comm,DRG,MS-421,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,,Relative Weights,"$26,073.23 ",IP,"2,420.00","37,118.59",,,,,,
UHC Comm,DRG,MS-422,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$19,889.12 ",IP,"2,420.00","28,314.72",,,,,,
UHC Comm,DRG,MS-423,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,,Relative Weights,"$60,017.15 ",IP,"2,420.00","85,442.11",,,,,,
UHC Comm,DRG,MS-424,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,,Relative Weights,"$31,882.08 ",IP,"2,420.00","45,388.22",,,,,,
UHC Comm,DRG,MS-425,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES W/O CC/MCC,,Relative Weights,"$20,696.30 ",IP,"2,420.00","29,463.84",,,,,,
UHC Comm,DRG,MS-432,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,,Relative Weights,"$25,821.17 ",IP,"2,420.00","36,759.74",,,,,,
UHC Comm,DRG,MS-433,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,,Relative Weights,"$14,614.15 ",IP,"2,420.00","20,805.12",,,,,,
UHC Comm,DRG,MS-434,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,,Relative Weights,"$9,061.62 ",IP,"2,420.00","12,900.38",,,,,,
UHC Comm,DRG,MS-435,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,,Relative Weights,"$24,032.63 ",IP,"2,420.00","34,213.54",,,,,,
UHC Comm,DRG,MS-436,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,,Relative Weights,"$15,941.04 ",IP,"2,420.00","22,694.11",,,,,,
UHC Comm,DRG,MS-437,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,,Relative Weights,"$12,431.94 ",IP,"2,420.00","17,698.46",,,,,,
UHC Comm,DRG,MS-438,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,,Relative Weights,"$23,199.97 ",IP,"2,420.00","33,028.13",,,,,,
UHC Comm,DRG,MS-439,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,,Relative Weights,"$11,997.20 ",IP,"2,420.00","17,079.55",,,,,,
UHC Comm,DRG,MS-440,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,,Relative Weights,"$8,717.51 ",IP,"2,420.00","12,410.50",,,,,,
UHC Comm,DRG,MS-441,DISORDERS OF LIVER EXCEPT MALIGNANCY- CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC,,Relative Weights,"$26,204.93 ",IP,"2,420.00","37,306.08",,,,,,
UHC Comm,DRG,MS-442,DISORDERS OF LIVER EXCEPT MALIGNANCY -  CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC,,Relative Weights,"$13,217.88 ",IP,"2,420.00","18,817.34",,,,,,
UHC Comm,DRG,MS-443,DISORDERS OF LIVER EXCEPT MALIGNANCY -  CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC,,Relative Weights,"$9,633.73 ",IP,"2,420.00","13,714.85",,,,,,
UHC Comm,DRG,MS-444,DISORDERS OF THE BILIARY TRACT WITH MCC,,Relative Weights,"$23,027.20 ",IP,"2,420.00","32,782.18",,,,,,
UHC Comm,DRG,MS-445,DISORDERS OF THE BILIARY TRACT WITH CC,,Relative Weights,"$15,215.99 ",IP,"2,420.00","21,661.92",,,,,,
UHC Comm,DRG,MS-446,DISORDERS OF THE BILIARY TRACT W/O CC/MCC,,Relative Weights,"$11,508.64 ",IP,"2,420.00","16,384.03",,,,,,
UHC Comm,DRG,MS-453,COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W MCC,,Relative Weights,"$133,212.53 ",IP,"2,420.00","189,645.12",,,,,,
UHC Comm,DRG,MS-454,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC,,Relative Weights,"$86,736.13 ",IP,"2,420.00","123,480.00",,,,,,
UHC Comm,DRG,MS-455,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CC/MCC,,Relative Weights,"$68,161.14 ",IP,"2,420.00","97,036.13",,,,,,
UHC Comm,DRG,MS-456,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH MCC,,Relative Weights,"$128,598.87 ",IP,"2,420.00","183,076.99",,,,,,
UHC Comm,DRG,MS-457,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH CC,,Relative Weights,"$92,234.84 ",IP,"2,420.00","131,308.13",,,,,,
UHC Comm,DRG,MS-458,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC,,Relative Weights,"$66,470.32 ",IP,"2,420.00","94,629.02",,,,,,
UHC Comm,DRG,MS-459,SPINAL FUSION EXCEPT CERVICAL WITH MCC,,Relative Weights,"$97,031.17 ",IP,"21,658.00","138,136.32",,,,,,
UHC Comm,DRG,MS-460,SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,,Relative Weights,"$56,083.22 ",IP,"21,658.00","79,841.66",,,,,,
UHC Comm,DRG,MS-461,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,,Relative Weights,"$76,169.19 ",IP,"2,420.00","108,436.61",,,,,,
UHC Comm,DRG,MS-462,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,,Relative Weights,"$44,414.56 ",IP,"2,420.00","63,229.82",,,,,,
UHC Comm,DRG,MS-463,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,,Relative Weights,"$74,030.88 ",IP,"2,420.00","105,392.45",,,,,,
UHC Comm,DRG,MS-464,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,,Relative Weights,"$41,813.18 ",IP,"2,420.00","59,526.43",,,,,,
UHC Comm,DRG,MS-465,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,,Relative Weights,"$27,121.15 ",IP,"2,420.00","38,610.43",,,,,,
UHC Comm,DRG,MS-466,REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,,Relative Weights,"$72,208.36 ",IP,"2,420.00","102,797.86",,,,,,
UHC Comm,DRG,MS-467,REVISION OF HIP OR KNEE REPLACEMENT W CC,,Relative Weights,"$49,734.85 ",IP,"2,420.00","70,803.94",,,,,,
UHC Comm,DRG,MS-468,REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,,Relative Weights,"$39,822.15 ",IP,"2,420.00","56,691.94",,,,,,
UHC Comm,DRG,MS-469,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,,Relative Weights,"$44,464.12 ",IP,"2,420.00","63,300.38",,,,,,
UHC Comm,DRG,MS-470,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,,Relative Weights,"$27,874.51 ",IP,"2,420.00","39,682.94",,,,,,
UHC Comm,DRG,MS-471,CERVICAL SPINAL FUSION WITH MCC,,Relative Weights,"$70,725.70 ",IP,"15,407.00","100,687.10",,,,,,
UHC Comm,DRG,MS-472,CERVICAL SPINAL FUSION WITH CC,,Relative Weights,"$43,070.68 ",IP,"15,407.00","61,316.64",,,,,,
UHC Comm,DRG,MS-473,CERVICAL SPINAL FUSION WITHOUT CC/MCC,,Relative Weights,"$35,578.10 ",IP,"14,827.96","50,649.98",,,,,,
UHC Comm,DRG,MS-474,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,,Relative Weights,"$54,872.46 ",IP,"2,420.00","78,117.98",,,,,,
UHC Comm,DRG,MS-475,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,,Relative Weights,"$29,752.26 ",IP,"2,420.00","42,356.16",,,,,,
UHC Comm,DRG,MS-476,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,,Relative Weights,"$16,493.32 ",IP,"2,420.00","23,480.35",,,,,,
UHC Comm,DRG,MS-477,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,,Relative Weights,"$46,098.30 ",IP,"2,420.00","65,626.85",,,,,,
UHC Comm,DRG,MS-478,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,,Relative Weights,"$32,812.45 ",IP,"2,420.00","46,712.74",,,,,,
UHC Comm,DRG,MS-479,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,,Relative Weights,"$25,237.73 ",IP,"2,420.00","35,929.15",,,,,,
UHC Comm,DRG,MS-480,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,,Relative Weights,"$42,744.98 ",IP,"2,420.00","60,852.96",,,,,,
UHC Comm,DRG,MS-481,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,,Relative Weights,"$29,565.34 ",IP,"2,420.00","42,090.05",,,,,,
UHC Comm,DRG,MS-482,HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC,,Relative Weights,"$23,299.09 ",IP,"2,420.00","33,169.25",,,,,,
UHC Comm,DRG,MS-483,MAJOR JOINT & LIMB REATTACHMENT PROC OF UPPER EXTREMITY W CC/MCC,,Relative Weights,"$33,874.53 ",IP,"2,420.00","48,224.74",,,,,,
UHC Comm,DRG,MS-485,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,,Relative Weights,"$46,433.92 ",IP,"2,420.00","66,104.64",,,,,,
UHC Comm,DRG,MS-486,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,,Relative Weights,"$30,454.65 ",IP,"2,420.00","43,356.10",,,,,,
UHC Comm,DRG,MS-487,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,,Relative Weights,"$22,759.56 ",IP,"2,420.00","32,401.15",,,,,,
UHC Comm,DRG,MS-488,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,,Relative Weights,"$27,885.84 ",IP,"2,420.00","39,699.07",,,,,,
UHC Comm,DRG,MS-489,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,,Relative Weights,"$17,828.70 ",IP,"2,420.00","25,381.44",,,,,,
UHC Comm,DRG,MS-492,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH MCC,,Relative Weights,"$48,788.89 ",IP,"2,420.00","69,457.25",,,,,,
UHC Comm,DRG,MS-493,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH CC,,Relative Weights,"$32,598.62 ",IP,"2,420.00","46,408.32",,,,,,
UHC Comm,DRG,MS-494,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITHOUT CC/MCC,,Relative Weights,"$25,651.24 ",IP,"2,420.00","36,517.82",,,,,,
UHC Comm,DRG,MS-495,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,,Relative Weights,"$48,609.05 ",IP,"2,420.00","69,201.22",,,,,,
UHC Comm,DRG,MS-496,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,,Relative Weights,"$28,895.52 ",IP,"2,420.00","41,136.48",,,,,,
UHC Comm,DRG,MS-497,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,,Relative Weights,"$20,806.76 ",IP,"2,420.00","29,621.09",,,,,,
UHC Comm,DRG,MS-498,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,,Relative Weights,"$34,667.54 ",IP,"2,420.00","49,353.70",,,,,,
UHC Comm,DRG,MS-499,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,,Relative Weights,"$16,297.89 ",IP,"2,420.00","23,202.14",,,,,,
UHC Comm,DRG,MS-500,SOFT TISSUE PROCEDURES WITH MCC,,Relative Weights,"$42,698.25 ",IP,"2,420.00","60,786.43",,,,,,
UHC Comm,DRG,MS-501,SOFT TISSUE PROCEDURES WITH CC,,Relative Weights,"$23,762.16 ",IP,"2,420.00","33,828.48",,,,,,
UHC Comm,DRG,MS-502,SOFT TISSUE PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$18,702.43 ",IP,"2,420.00","26,625.31",,,,,,
UHC Comm,DRG,MS-503,FOOT PROCEDURES WITH MCC,,Relative Weights,"$38,469.77 ",IP,"2,420.00","54,766.66",,,,,,
UHC Comm,DRG,MS-504,FOOT PROCEDURES WITH CC,,Relative Weights,"$24,590.58 ",IP,"2,420.00","35,007.84",,,,,,
UHC Comm,DRG,MS-505,FOOT PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$23,811.72 ",IP,"2,420.00","33,899.04",,,,,,
UHC Comm,DRG,MS-506,MAJOR THUMB OR JOINT PROCEDURES,,Relative Weights,"$18,955.91 ",IP,"2,420.00","26,986.18",,,,,,
UHC Comm,DRG,MS-507,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W CC/MCC,,Relative Weights,"$29,738.10 ",IP,"2,420.00","42,336.00",,,,,,
UHC Comm,DRG,MS-508,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W/O CC/MCC,,Relative Weights,"$22,068.50 ",IP,"2,420.00","31,417.34",,,,,,
UHC Comm,DRG,MS-509,ARTHROSCOPY,,Relative Weights,"$19,707.86 ",IP,"2,420.00","28,056.67",,,,,,
UHC Comm,DRG,MS-510,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH MCC,,Relative Weights,"$39,480.87 ",IP,"2,420.00","56,206.08",,,,,,
UHC Comm,DRG,MS-511,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH CC,,Relative Weights,"$26,682.16 ",IP,"2,420.00","37,985.47",,,,,,
UHC Comm,DRG,MS-512,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$21,436.92 ",IP,"2,420.00","30,518.21",,,,,,
UHC Comm,DRG,MS-513,HAND OR WRIST PROCEDURES- EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC,,Relative Weights,"$22,333.31 ",IP,"2,420.00","31,794.34",,,,,,
UHC Comm,DRG,MS-514,HAND OR WRIST PROCEDURES -  EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$15,106.95 ",IP,"2,420.00","21,506.69",,,,,,
UHC Comm,DRG,MS-515,OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W MCC,,Relative Weights,"$44,663.79 ",IP,"2,420.00","63,584.64",,,,,,
UHC Comm,DRG,MS-516,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,,Relative Weights,"$27,459.60 ",IP,"2,420.00","39,092.26",,,,,,
UHC Comm,DRG,MS-517,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$20,042.06 ",IP,"2,420.00","28,532.45",,,,,,
UHC Comm,DRG,MS-518,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,,Relative Weights,"$48,269.18 ",IP,"10,289.00","68,717.38",,,,,,
UHC Comm,DRG,MS-519,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,,Relative Weights,"$27,029.10 ",IP,"10,289.00","38,479.39",,,,,,
UHC Comm,DRG,MS-520,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,,Relative Weights,"$18,947.42 ",IP,"8,282.98","26,974.08",,,,,,
UHC Comm,DRG,MS-533,FRACTURES OF FEMUR WITH MCC,,Relative Weights,"$20,666.56 ",IP,"2,420.00","29,421.50",,,,,,
UHC Comm,DRG,MS-534,FRACTURES OF FEMUR WITHOUT MCC,,Relative Weights,"$11,014.43 ",IP,"2,420.00","15,680.45",,,,,,
UHC Comm,DRG,MS-535,FRACTURES OF HIP AND PELVIS WITH MCC,,Relative Weights,"$17,376.96 ",IP,"2,420.00","24,738.34",,,,,,
UHC Comm,DRG,MS-536,FRACTURES OF HIP AND PELVIS WITHOUT MCC,,Relative Weights,"$10,741.12 ",IP,"2,420.00","15,291.36",,,,,,
UHC Comm,DRG,MS-537,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITH CC/MCC,,Relative Weights,"$12,899.25 ",IP,"2,420.00","18,363.74",,,,,,
UHC Comm,DRG,MS-538,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITHOUT CC/MCC,,Relative Weights,"$10,210.08 ",IP,"2,420.00","14,535.36",,,,,,
UHC Comm,DRG,MS-539,OSTEOMYELITIS WITH MCC,,Relative Weights,"$26,696.32 ",IP,"2,420.00","38,005.63",,,,,,
UHC Comm,DRG,MS-540,OSTEOMYELITIS WITH CC,,Relative Weights,"$18,409.30 ",IP,"2,420.00","26,208.00",,,,,,
UHC Comm,DRG,MS-541,OSTEOMYELITIS WITHOUT CC/MCC,,Relative Weights,"$12,839.78 ",IP,"2,420.00","18,279.07",,,,,,
UHC Comm,DRG,MS-542,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,,Relative Weights,"$25,840.99 ",IP,"2,420.00","36,787.97",,,,,,
UHC Comm,DRG,MS-543,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,,Relative Weights,"$14,958.26 ",IP,"2,420.00","21,295.01",,,,,,
UHC Comm,DRG,MS-544,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,,Relative Weights,"$10,739.70 ",IP,"2,420.00","15,289.34",,,,,,
UHC Comm,DRG,MS-545,CONNECTIVE TISSUE DISORDERS WITH MCC,,Relative Weights,"$35,799.01 ",IP,"2,420.00","50,964.48",,,,,,
UHC Comm,DRG,MS-546,CONNECTIVE TISSUE DISORDERS WITH CC,,Relative Weights,"$17,041.35 ",IP,"2,420.00","24,260.54",,,,,,
UHC Comm,DRG,MS-547,CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,,Relative Weights,"$11,471.83 ",IP,"2,420.00","16,331.62",,,,,,
UHC Comm,DRG,MS-548,SEPTIC ARTHRITIS WITH MCC,,Relative Weights,"$28,085.51 ",IP,"2,420.00","39,983.33",,,,,,
UHC Comm,DRG,MS-549,SEPTIC ARTHRITIS W CC,,Relative Weights,"$16,895.49 ",IP,"2,420.00","24,052.90",,,,,,
UHC Comm,DRG,MS-550,SEPTIC ARTHRITIS W/O CC/MCC,,Relative Weights,"$12,235.10 ",IP,"2,420.00","17,418.24",,,,,,
UHC Comm,DRG,MS-551,MEDICAL BACK PROBLEMS WITH MCC,,Relative Weights,"$22,507.49 ",IP,"2,420.00","32,042.30",,,,,,
UHC Comm,DRG,MS-552,MEDICAL BACK PROBLEMS WITHOUT MCC,,Relative Weights,"$12,913.42 ",IP,"2,420.00","18,383.90",,,,,,
UHC Comm,DRG,MS-553,BONE DISEASES AND ARTHROPATHIES WITH MCC,,Relative Weights,"$18,203.97 ",IP,"2,420.00","25,915.68",,,,,,
UHC Comm,DRG,MS-554,BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,,Relative Weights,"$11,147.54 ",IP,"2,420.00","15,869.95",,,,,,
UHC Comm,DRG,MS-555,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,,Relative Weights,"$18,625.96 ",IP,"2,420.00","26,516.45",,,,,,
UHC Comm,DRG,MS-556,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,,Relative Weights,"$11,212.68 ",IP,"2,420.00","15,962.69",,,,,,
UHC Comm,DRG,MS-557,TENDONITIS -  MYOSITIS AND BURSITIS WITH MCC,,Relative Weights,"$20,649.57 ",IP,"2,420.00","29,397.31",,,,,,
UHC Comm,DRG,MS-558,TENDONITIS- MYOSITIS AND BURSITIS WITHOUT MCC,,Relative Weights,"$12,198.29 ",IP,"2,420.00","17,365.82",,,,,,
UHC Comm,DRG,MS-559,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,,Relative Weights,"$25,515.29 ",IP,"2,420.00","36,324.29",,,,,,
UHC Comm,DRG,MS-560,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,,Relative Weights,"$14,777.00 ",IP,"2,420.00","21,036.96",,,,,,
UHC Comm,DRG,MS-561,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,,Relative Weights,"$10,583.93 ",IP,"2,420.00","15,067.58",,,,,,
UHC Comm,DRG,MS-562,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITH MCC,,Relative Weights,"$19,076.28 ",IP,"2,420.00","27,157.54",,,,,,
UHC Comm,DRG,MS-563,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITHOUT MCC,,Relative Weights,"$12,093.49 ",IP,"2,420.00","17,216.64",,,,,,
UHC Comm,DRG,MS-564,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,,Relative Weights,"$21,411.43 ",IP,"2,420.00","30,481.92",,,,,,
UHC Comm,DRG,MS-565,OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W CC,,Relative Weights,"$13,884.86 ",IP,"2,420.00","19,766.88",,,,,,
UHC Comm,DRG,MS-566,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,,Relative Weights,"$10,729.79 ",IP,"2,420.00","15,275.23",,,,,,
UHC Comm,DRG,MS-570,SKIN DEBRIDEMENT WITH MCC,,Relative Weights,"$40,687.39 ",IP,"2,420.00","57,923.71",,,,,,
UHC Comm,DRG,MS-571,SKIN DEBRIDEMENT WITH CC,,Relative Weights,"$23,681.44 ",IP,"2,420.00","33,713.57",,,,,,
UHC Comm,DRG,MS-572,SKIN DEBRIDEMENT WITHOUT CC/MCC,,Relative Weights,"$15,884.39 ",IP,"2,420.00","22,613.47",,,,,,
UHC Comm,DRG,MS-573,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,,Relative Weights,"$75,269.96 ",IP,"2,420.00","107,156.45",,,,,,
UHC Comm,DRG,MS-574,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,,Relative Weights,"$44,207.81 ",IP,"2,420.00","62,935.49",,,,,,
UHC Comm,DRG,MS-575,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS W/O CC/MCC,,Relative Weights,"$24,880.88 ",IP,"2,420.00","35,421.12",,,,,,
UHC Comm,DRG,MS-576,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,,Relative Weights,"$68,669.52 ",IP,"2,420.00","97,759.87",,,,,,
UHC Comm,DRG,MS-577,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,,Relative Weights,"$34,207.31 ",IP,"2,420.00","48,698.50",,,,,,
UHC Comm,DRG,MS-578,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,,Relative Weights,"$23,045.61 ",IP,"2,420.00","32,808.38",,,,,,
UHC Comm,DRG,MS-579,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC,,Relative Weights,"$42,286.16 ",IP,"2,420.00","60,199.78",,,,,,
UHC Comm,DRG,MS-580,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC,,Relative Weights,"$22,780.80 ",IP,"2,420.00","32,431.39",,,,,,
UHC Comm,DRG,MS-581,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$17,769.22 ",IP,"2,420.00","25,296.77",,,,,,
UHC Comm,DRG,MS-582,MASTECTOMY FOR MALIGNANCY WITH CC/MCC,,Relative Weights,"$22,355.97 ",IP,"2,420.00","31,826.59",,,,,,
UHC Comm,DRG,MS-583,MASTECTOMY FOR MALIGNANCY W/O CC/MCC,,Relative Weights,"$20,694.89 ",IP,"2,420.00","29,461.82",,,,,,
UHC Comm,DRG,MS-584,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC,,Relative Weights,"$25,891.97 ",IP,"2,420.00","36,860.54",,,,,,
UHC Comm,DRG,MS-585,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$24,035.47 ",IP,"2,420.00","34,217.57",,,,,,
UHC Comm,DRG,MS-592,SKIN ULCERS WITH MCC,,Relative Weights,"$25,267.47 ",IP,"2,420.00","35,971.49",,,,,,
UHC Comm,DRG,MS-593,SKIN ULCERS WITH CC,,Relative Weights,"$16,254.00 ",IP,"2,420.00","23,139.65",,,,,,
UHC Comm,DRG,MS-594,SKIN ULCERS WITHOUT CC/MCC,,Relative Weights,"$11,466.16 ",IP,"2,420.00","16,323.55",,,,,,
UHC Comm,DRG,MS-595,MAJOR SKIN DISORDERS WITH MCC,,Relative Weights,"$28,783.65 ",IP,"2,420.00","40,977.22",,,,,,
UHC Comm,DRG,MS-596,MAJOR SKIN DISORDERS W/O MCC,,Relative Weights,"$13,794.23 ",IP,"2,420.00","19,637.86",,,,,,
UHC Comm,DRG,MS-597,MALIGNANT BREAST DISORDERS W MCC,,Relative Weights,"$23,973.16 ",IP,"2,420.00","34,128.86",,,,,,
UHC Comm,DRG,MS-598,MALIGNANT BREAST DISORDERS WITH CC,,Relative Weights,"$15,415.66 ",IP,"2,420.00","21,946.18",,,,,,
UHC Comm,DRG,MS-599,MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,,Relative Weights,"$9,847.56 ",IP,"2,420.00","14,019.26",,,,,,
UHC Comm,DRG,MS-600,NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,,Relative Weights,"$13,583.23 ",IP,"2,420.00","19,337.47",,,,,,
UHC Comm,DRG,MS-601,NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,,Relative Weights,"$8,762.83 ",IP,"2,420.00","12,475.01",,,,,,
UHC Comm,DRG,MS-602,CELLULITIS WITH MCC,,Relative Weights,"$20,247.40 ",IP,"2,420.00","28,824.77",,,,,,
UHC Comm,DRG,MS-603,CELLULITIS WITHOUT MCC,,Relative Weights,"$11,944.80 ",IP,"2,420.00","17,004.96",,,,,,
UHC Comm,DRG,MS-604,TRAUMA TO THE SKIN -  SUBCUTANEOUS TISSUE AND BREAST WITH MCC,,Relative Weights,"$20,738.78 ",IP,"2,420.00","29,524.32",,,,,,
UHC Comm,DRG,MS-605,TRAUMA TO THE SKIN- SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC,,Relative Weights,"$12,400.79 ",IP,"2,420.00","17,654.11",,,,,,
UHC Comm,DRG,MS-606,MINOR SKIN DISORDERS WITH MCC,,Relative Weights,"$21,177.78 ",IP,"2,420.00","30,149.28",,,,,,
UHC Comm,DRG,MS-607,MINOR SKIN DISORDERS WITHOUT MCC,,Relative Weights,"$11,698.40 ",IP,"2,420.00","16,654.18",,,,,,
UHC Comm,DRG,MS-614,ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,,Relative Weights,"$34,457.96 ",IP,"2,420.00","49,055.33",,,,,,
UHC Comm,DRG,MS-615,ADRENAL & PITUITARY PROCEDURES W/O CC/MCC,,Relative Weights,"$21,016.34 ",IP,"2,420.00","29,919.46",,,,,,
UHC Comm,DRG,MS-616,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,,Relative Weights,"$56,655.33 ",IP,"2,420.00","80,656.13",,,,,,
UHC Comm,DRG,MS-617,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH CC,,Relative Weights,"$29,048.46 ",IP,"2,420.00","41,354.21",,,,,,
UHC Comm,DRG,MS-618,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,,Relative Weights,"$17,764.97 ",IP,"2,420.00","25,290.72",,,,,,
UHC Comm,DRG,MS-619,O.R. PROCEDURES FOR OBESITY WITH MCC,,Relative Weights,"$43,594.64 ",IP,"2,420.00","62,062.56",,,,,,
UHC Comm,DRG,MS-620,O.R. PROCEDURES FOR OBESITY WITH CC,,Relative Weights,"$25,413.33 ",IP,"2,420.00","36,179.14",,,,,,
UHC Comm,DRG,MS-621,O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,,Relative Weights,"$22,261.09 ",IP,"2,420.00","31,691.52",,,,,,
UHC Comm,DRG,MS-622,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,,Relative Weights,"$53,464.86 ",IP,"2,420.00","76,114.08",,,,,,
UHC Comm,DRG,MS-623,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE -  NUTRITIONAL AND METABOLIC DISORDERS WITH CC,,Relative Weights,"$27,650.77 ",IP,"2,420.00","39,364.42",,,,,,
UHC Comm,DRG,MS-624,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,,Relative Weights,"$15,605.42 ",IP,"2,420.00","22,216.32",,,,,,
UHC Comm,DRG,MS-625,THYROID- PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC,,Relative Weights,"$41,422.34 ",IP,"2,420.00","58,970.02",,,,,,
UHC Comm,DRG,MS-626,THYROID -  PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC,,Relative Weights,"$23,830.13 ",IP,"2,420.00","33,925.25",,,,,,
UHC Comm,DRG,MS-627,THYROID -  PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$16,167.61 ",IP,"2,420.00","23,016.67",,,,,,
UHC Comm,DRG,MS-628,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC,,Relative Weights,"$52,244.18 ",IP,"2,420.00","74,376.29",,,,,,
UHC Comm,DRG,MS-629,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC,,Relative Weights,"$32,893.17 ",IP,"2,420.00","46,827.65",,,,,,
UHC Comm,DRG,MS-630,OTHER ENDOCRINE - NUTRIT & METAB O.R. PROC W/O CC/MCC,,Relative Weights,"$20,516.46 ",IP,"2,420.00","29,207.81",,,,,,
UHC Comm,DRG,MS-637,DIABETES WITH MCC,,Relative Weights,"$19,622.90 ",IP,"2,420.00","27,935.71",,,,,,
UHC Comm,DRG,MS-638,DIABETES WITH CC,,Relative Weights,"$12,519.74 ",IP,"2,420.00","17,823.46",,,,,,
UHC Comm,DRG,MS-639,DIABETES WITHOUT CC/MCC,,Relative Weights,"$8,683.53 ",IP,"2,420.00","12,362.11",,,,,,
UHC Comm,DRG,MS-640,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITH MCC,,Relative Weights,"$17,194.29 ",IP,"2,420.00","24,478.27",,,,,,
UHC Comm,DRG,MS-641,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITHOUT MCC,,Relative Weights,"$10,714.21 ",IP,"2,420.00","15,253.06",,,,,,
UHC Comm,DRG,MS-642,INBORN AND OTHER DISORDERS OF METABOLISM,,Relative Weights,"$17,216.94 ",IP,"2,420.00","24,510.53",,,,,,
UHC Comm,DRG,MS-643,ENDOCRINE DISORDERS WITH MCC,,Relative Weights,"$23,018.71 ",IP,"2,420.00","32,770.08",,,,,,
UHC Comm,DRG,MS-644,ENDOCRINE DISORDERS WITH CC,,Relative Weights,"$14,558.92 ",IP,"2,420.00","20,726.50",,,,,,
UHC Comm,DRG,MS-645,ENDOCRINE DISORDERS WITHOUT CC/MCC,,Relative Weights,"$10,836.00 ",IP,"2,420.00","15,426.43",,,,,,
UHC Comm,DRG,MS-652,KIDNEY TRANSPLANT,,Relative Weights,"$47,933.57 ",IP,"2,420.00","68,239.58",,,,,,
UHC Comm,DRG,MS-653,MAJOR BLADDER PROCEDURES WITH MCC,,Relative Weights,"$78,402.38 ",IP,"2,420.00","111,615.84",,,,,,
UHC Comm,DRG,MS-654,MAJOR BLADDER PROCEDURES WITH CC,,Relative Weights,"$39,823.56 ",IP,"2,420.00","56,693.95",,,,,,
UHC Comm,DRG,MS-655,MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$29,205.65 ",IP,"2,420.00","41,577.98",,,,,,
UHC Comm,DRG,MS-656,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,,Relative Weights,"$46,173.36 ",IP,"2,420.00","65,733.70",,,,,,
UHC Comm,DRG,MS-657,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,,Relative Weights,"$27,390.21 ",IP,"2,420.00","38,993.47",,,,,,
UHC Comm,DRG,MS-658,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,,Relative Weights,"$22,231.35 ",IP,"2,420.00","31,649.18",,,,,,
UHC Comm,DRG,MS-659,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,,Relative Weights,"$37,948.65 ",IP,"2,420.00","54,024.77",,,,,,
UHC Comm,DRG,MS-660,KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC,,Relative Weights,"$20,118.53 ",IP,"2,420.00","28,641.31",,,,,,
UHC Comm,DRG,MS-661,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,,Relative Weights,"$15,436.91 ",IP,"2,420.00","21,976.42",,,,,,
UHC Comm,DRG,MS-662,MINOR BLADDER PROCEDURES WITH MCC,,Relative Weights,"$44,815.32 ",IP,"2,420.00","63,800.35",,,,,,
UHC Comm,DRG,MS-663,MINOR BLADDER PROCEDURES WITH CC,,Relative Weights,"$21,572.87 ",IP,"2,420.00","30,711.74",,,,,,
UHC Comm,DRG,MS-664,MINOR BLADDER PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$15,670.56 ",IP,"2,420.00","22,309.06",,,,,,
UHC Comm,DRG,MS-665,PROSTATECTOMY WITH MCC,,Relative Weights,"$42,036.93 ",IP,"2,420.00","59,844.96",,,,,,
UHC Comm,DRG,MS-666,PROSTATECTOMY WITH CC,,Relative Weights,"$25,052.23 ",IP,"2,420.00","35,665.06",,,,,,
UHC Comm,DRG,MS-667,PROSTATECTOMY W/O CC/MCC,,Relative Weights,"$13,292.93 ",IP,"2,420.00","18,924.19",,,,,,
UHC Comm,DRG,MS-668,TRANSURETHRAL PROCEDURES W MCC,,Relative Weights,"$39,485.12 ",IP,"2,420.00","56,212.13",,,,,,
UHC Comm,DRG,MS-669,TRANSURETHRAL PROCEDURES WITH CC,,Relative Weights,"$21,888.66 ",IP,"2,420.00","31,161.31",,,,,,
UHC Comm,DRG,MS-670,TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$13,859.37 ",IP,"2,420.00","19,730.59",,,,,,
UHC Comm,DRG,MS-671,URETHRAL PROCEDURES WITH CC/MCC,,Relative Weights,"$25,880.64 ",IP,"2,420.00","36,844.42",,,,,,
UHC Comm,DRG,MS-672,URETHRAL PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$14,631.15 ",IP,"2,420.00","20,829.31",,,,,,
UHC Comm,DRG,MS-673,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,,Relative Weights,"$50,619.91 ",IP,"2,420.00","72,063.94",,,,,,
UHC Comm,DRG,MS-674,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,,Relative Weights,"$34,612.32 ",IP,"2,420.00","49,275.07",,,,,,
UHC Comm,DRG,MS-675,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$23,110.75 ",IP,"2,420.00","32,901.12",,,,,,
UHC Comm,DRG,MS-682,RENAL FAILURE WITH MCC,,Relative Weights,"$20,929.96 ",IP,"2,420.00","29,796.48",,,,,,
UHC Comm,DRG,MS-683,RENAL FAILURE WITH CC,,Relative Weights,"$12,706.67 ",IP,"2,420.00","18,089.57",,,,,,
UHC Comm,DRG,MS-684,RENAL FAILURE WITHOUT CC/MCC,,Relative Weights,"$8,713.26 ",IP,"2,420.00","12,404.45",,,,,,
UHC Comm,DRG,MS-686,KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,,Relative Weights,"$24,868.13 ",IP,"2,420.00","35,402.98",,,,,,
UHC Comm,DRG,MS-687,KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,,Relative Weights,"$14,905.87 ",IP,"2,420.00","21,220.42",,,,,,
UHC Comm,DRG,MS-688,KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,,Relative Weights,"$10,922.38 ",IP,"2,420.00","15,549.41",,,,,,
UHC Comm,DRG,MS-689,KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,,Relative Weights,"$15,840.49 ",IP,"2,420.00","22,550.98",,,,,,
UHC Comm,DRG,MS-690,KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,,Relative Weights,"$11,198.52 ",IP,"2,420.00","15,942.53",,,,,,
UHC Comm,DRG,MS-693,URINARY STONES WITH MCC,,Relative Weights,"$19,164.08 ",IP,"2,420.00","27,282.53",,,,,,
UHC Comm,DRG,MS-694,URINARY STONES WITHOUT MCC,,Relative Weights,"$10,484.80 ",IP,"2,420.00","14,926.46",,,,,,
UHC Comm,DRG,MS-695,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,,Relative Weights,"$16,600.94 ",IP,"2,420.00","23,633.57",,,,,,
UHC Comm,DRG,MS-696,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,,Relative Weights,"$9,620.98 ",IP,"2,420.00","13,696.70",,,,,,
UHC Comm,DRG,MS-697,URETHRAL STRICTURE,,Relative Weights,"$13,791.40 ",IP,"2,420.00","19,633.82",,,,,,
UHC Comm,DRG,MS-698,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,,Relative Weights,"$22,920.99 ",IP,"2,420.00","32,630.98",,,,,,
UHC Comm,DRG,MS-699,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,,Relative Weights,"$14,624.06 ",IP,"2,420.00","20,819.23",,,,,,
UHC Comm,DRG,MS-700,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,,Relative Weights,"$10,503.21 ",IP,"2,420.00","14,952.67",,,,,,
UHC Comm,DRG,MS-707,MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,,Relative Weights,"$26,479.65 ",IP,"2,420.00","37,697.18",,,,,,
UHC Comm,DRG,MS-708,MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$20,561.77 ",IP,"2,420.00","29,272.32",,,,,,
UHC Comm,DRG,MS-709,PENIS PROCEDURES W CC/MCC,,Relative Weights,"$34,065.70 ",IP,"2,420.00","48,496.90",,,,,,
UHC Comm,DRG,MS-710,PENIS PROCEDURES W/O CC/MCC,,Relative Weights,"$21,748.46 ",IP,"2,420.00","30,961.73",,,,,,
UHC Comm,DRG,MS-711,TESTES PROCEDURES WITH CC/MCC,,Relative Weights,"$30,349.86 ",IP,"2,420.00","43,206.91",,,,,,
UHC Comm,DRG,MS-712,TESTES PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$14,447.05 ",IP,"2,420.00","20,567.23",,,,,,
UHC Comm,DRG,MS-713,TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,,Relative Weights,"$20,703.38 ",IP,"2,420.00","29,473.92",,,,,,
UHC Comm,DRG,MS-714,TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,,Relative Weights,"$12,962.98 ",IP,"2,420.00","18,454.46",,,,,,
UHC Comm,DRG,MS-715,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,,Relative Weights,"$30,254.98 ",IP,"2,420.00","43,071.84",,,,,,
UHC Comm,DRG,MS-716,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,,Relative Weights,"$20,752.95 ",IP,"2,420.00","29,544.48",,,,,,
UHC Comm,DRG,MS-717,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,,Relative Weights,"$24,984.25 ",IP,"2,420.00","35,568.29",,,,,,
UHC Comm,DRG,MS-718,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,,Relative Weights,"$17,267.92 ",IP,"2,420.00","24,583.10",,,,,,
UHC Comm,DRG,MS-722,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH MCC,,Relative Weights,"$25,559.19 ",IP,"2,420.00","36,386.78",,,,,,
UHC Comm,DRG,MS-723,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH CC,,Relative Weights,"$15,681.89 ",IP,"2,420.00","22,325.18",,,,,,
UHC Comm,DRG,MS-724,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,,Relative Weights,"$8,360.65 ",IP,"2,420.00","11,902.46",,,,,,
UHC Comm,DRG,MS-725,BENIGN PROSTATIC HYPERTROPHY WITH MCC,,Relative Weights,"$17,777.72 ",IP,"2,420.00","25,308.86",,,,,,
UHC Comm,DRG,MS-726,BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,,Relative Weights,"$10,828.92 ",IP,"2,420.00","15,416.35",,,,,,
UHC Comm,DRG,MS-727,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,,Relative Weights,"$20,212.00 ",IP,"2,420.00","28,774.37",,,,,,
UHC Comm,DRG,MS-728,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,,Relative Weights,"$11,364.20 ",IP,"2,420.00","16,178.40",,,,,,
UHC Comm,DRG,MS-729,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,,Relative Weights,"$15,207.50 ",IP,"2,420.00","21,649.82",,,,,,
UHC Comm,DRG,MS-730,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,,Relative Weights,"$8,944.09 ",IP,"2,420.00","12,733.06",,,,,,
UHC Comm,DRG,MS-734,PELVIC EVISCERATION -  RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC,,Relative Weights,"$31,039.50 ",IP,"2,420.00","44,188.70",,,,,,
UHC Comm,DRG,MS-735,PELVIC EVISCERATION -  RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC,,Relative Weights,"$19,460.05 ",IP,"2,420.00","27,703.87",,,,,,
UHC Comm,DRG,MS-736,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,,Relative Weights,"$61,188.26 ",IP,"2,420.00","87,109.34",,,,,,
UHC Comm,DRG,MS-737,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,,Relative Weights,"$28,139.32 ",IP,"2,420.00","40,059.94",,,,,,
UHC Comm,DRG,MS-738,UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY W/O CC/MCC,,Relative Weights,"$19,526.60 ",IP,"2,420.00","27,798.62",,,,,,
UHC Comm,DRG,MS-739,UTERINE -ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W MCC,,Relative Weights,"$53,025.86 ",IP,"2,420.00","75,489.12",,,,,,
UHC Comm,DRG,MS-740,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,,Relative Weights,"$25,275.97 ",IP,"2,420.00","35,983.58",,,,,,
UHC Comm,DRG,MS-741,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,,Relative Weights,"$18,827.05 ",IP,"2,420.00","26,802.72",,,,,,
UHC Comm,DRG,MS-742,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,,Relative Weights,"$23,925.01 ",IP,"2,420.00","34,060.32",,,,,,
UHC Comm,DRG,MS-743,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,,Relative Weights,"$16,263.91 ",IP,"2,420.00","23,153.76",,,,,,
UHC Comm,DRG,MS-744,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC,,Relative Weights,"$24,647.22 ",IP,"2,420.00","35,088.48",,,,,,
UHC Comm,DRG,MS-745,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC,,Relative Weights,"$15,085.71 ",IP,"2,420.00","21,476.45",,,,,,
UHC Comm,DRG,MS-746,VAGINA -  CERVIX AND VULVA PROCEDURES WITH CC/MCC,,Relative Weights,"$23,096.59 ",IP,"2,420.00","32,880.96",,,,,,
UHC Comm,DRG,MS-747,VAGINA- CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$13,200.88 ",IP,"2,420.00","18,793.15",,,,,,
UHC Comm,DRG,MS-748,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,,Relative Weights,"$18,716.59 ",IP,"2,420.00","26,645.47",,,,,,
UHC Comm,DRG,MS-749,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,,Relative Weights,"$36,708.14 ",IP,"2,420.00","52,258.75",,,,,,
UHC Comm,DRG,MS-750,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$18,851.12 ",IP,"2,420.00","26,836.99",,,,,,
UHC Comm,DRG,MS-754,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH MCC,,Relative Weights,"$24,950.27 ",IP,"2,420.00","35,519.90",,,,,,
UHC Comm,DRG,MS-755,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH CC,,Relative Weights,"$14,498.03 ",IP,"2,420.00","20,639.81",,,,,,
UHC Comm,DRG,MS-756,MALIGNANCY - FEMALE REPRODUCTIVE SYSTEM W/O CC/MCC,,Relative Weights,"$12,416.36 ",IP,"2,420.00","17,676.29",,,,,,
UHC Comm,DRG,MS-757,INFECTIONS - FEMALE REPRODUCTIVE SYSTEM W MCC,,Relative Weights,"$20,112.87 ",IP,"2,420.00","28,633.25",,,,,,
UHC Comm,DRG,MS-758,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITH CC,,Relative Weights,"$13,671.03 ",IP,"2,420.00","19,462.46",,,,,,
UHC Comm,DRG,MS-759,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,,Relative Weights,"$9,350.51 ",IP,"2,420.00","13,311.65",,,,,,
UHC Comm,DRG,MS-760,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,,Relative Weights,"$12,780.30 ",IP,"2,420.00","18,194.40",,,,,,
UHC Comm,DRG,MS-761,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,,Relative Weights,"$8,006.63 ",IP,"2,420.00","11,398.46",,,,,,
UHC Comm,DRG,MS-768,VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C,,Relative Weights,"$14,267.21 ",IP,"2,420.00","20,311.20",,,,,,
UHC Comm,DRG,MS-769,POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,,Relative Weights,"$20,434.32 ",IP,"2,420.00","29,090.88",,,,,,
UHC Comm,DRG,MS-770,ABORTION WITH D&C- ASPIRATION CURETTAGE OR HYSTEROTOMY,,Relative Weights,"$11,134.79 ",IP,"2,420.00","15,851.81",,,,,,
UHC Comm,DRG,MS-776,POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,,Relative Weights,"$10,052.89 ",IP,"2,420.00","14,311.58",,,,,,
UHC Comm,DRG,MS-779,ABORTION WITHOUT D&C,,Relative Weights,"$16,169.03 ",IP,"2,420.00","23,018.69",,,,,,
UHC Comm,DRG,MS-783,CESAREAN SECTION WITH STERILIZATION WITH MCC,,Relative Weights,"$30,372.51 ",IP,"2,420.00","43,239.17",,,,,,
UHC Comm,DRG,MS-784,CESAREAN SECTION WITH STERILIZATION WITH CC,,Relative Weights,"$14,801.08 ",IP,"2,420.00","21,071.23",,,,,,
UHC Comm,DRG,MS-785,CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,,Relative Weights,"$12,155.80 ",IP,"2,420.00","17,305.34",,,,,,
UHC Comm,DRG,MS-786,CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,,Relative Weights,"$24,279.03 ",IP,"2,420.00","34,564.32",,,,,,
UHC Comm,DRG,MS-787,CESAREAN SECTION WITHOUT STERILIZATION WITH CC,,Relative Weights,"$14,805.33 ",IP,"2,420.00","21,077.28",,,,,,
UHC Comm,DRG,MS-788,CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,,Relative Weights,"$12,832.70 ",IP,"2,420.00","18,268.99",,,,,,
UHC Comm,DRG,MS-789,NEONATES- DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY,,Relative Weights,"$23,932.09 ",IP,"2,420.00","34,070.40",,,,,,
UHC Comm,DRG,MS-790,EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME- NEONATE,,Relative Weights,"$78,919.25 ",IP,"2,420.00","112,351.68",,,,,,
UHC Comm,DRG,MS-791,PREMATURITY W MAJOR PROBLEMS,,Relative Weights,"$53,899.60 ",IP,"2,420.00","76,732.99",,,,,,
UHC Comm,DRG,MS-792,PREMATURITY W/O MAJOR PROBLEMS,,Relative Weights,"$32,520.74 ",IP,"2,420.00","46,297.44",,,,,,
UHC Comm,DRG,MS-793,FULL TERM NEONATE WITH MAJOR PROBLEMS,,Relative Weights,"$55,365.26 ",IP,"2,420.00","78,819.55",,,,,,
UHC Comm,DRG,MS-794,NEONATE WITH OTHER SIGNIFICANT PROBLEMS,,Relative Weights,"$19,595.99 ",IP,"2,420.00","27,897.41",,,,,,
UHC Comm,DRG,MS-795,NORMAL NEWBORN,,Relative Weights,"$2,652.36 ",IP,"1,113.70","3,775.97",,,,,,
UHC Comm,DRG,MS-796,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,,Relative Weights,"$27,929.74 ",IP,"2,420.00","39,761.57",,,,,,
UHC Comm,DRG,MS-797,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,,Relative Weights,"$12,218.11 ",IP,"2,420.00","17,394.05",,,,,,
UHC Comm,DRG,MS-798,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,,Relative Weights,"$12,218.11 ",IP,"2,420.00","17,394.05",,,,,,
UHC Comm,DRG,MS-799,SPLENECTOMY WITH MCC,,Relative Weights,"$70,016.23 ",IP,"2,420.00","99,677.09",,,,,,
UHC Comm,DRG,MS-800,SPLENECTOMY WITH CC,,Relative Weights,"$40,245.56 ",IP,"2,420.00","57,294.72",,,,,,
UHC Comm,DRG,MS-801,SPLENECTOMY WITHOUT CC/MCC,,Relative Weights,"$26,526.39 ",IP,"2,420.00","37,763.71",,,,,,
UHC Comm,DRG,MS-802,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,,Relative Weights,"$44,641.14 ",IP,"2,420.00","63,552.38",,,,,,
UHC Comm,DRG,MS-803,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,,Relative Weights,"$25,229.24 ",IP,"2,420.00","35,917.06",,,,,,
UHC Comm,DRG,MS-804,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,,Relative Weights,"$19,295.78 ",IP,"2,420.00","27,470.02",,,,,,
UHC Comm,DRG,MS-805,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,,Relative Weights,"$14,737.35 ",IP,"2,420.00","20,980.51",,,,,,
UHC Comm,DRG,MS-806,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,,Relative Weights,"$10,042.98 ",IP,"2,420.00","14,297.47",,,,,,
UHC Comm,DRG,MS-807,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,,Relative Weights,"$8,876.11 ",IP,"2,420.00","12,636.29",,,,,,
UHC Comm,DRG,MS-808,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,,Relative Weights,"$30,157.27 ",IP,"2,420.00","42,932.74",,,,,,
UHC Comm,DRG,MS-809,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,,Relative Weights,"$17,218.36 ",IP,"2,420.00","24,512.54",,,,,,
UHC Comm,DRG,MS-810,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,,Relative Weights,"$13,246.20 ",IP,"2,420.00","18,857.66",,,,,,
UHC Comm,DRG,MS-811,RED BLOOD CELL DISORDERS WITH MCC,,Relative Weights,"$18,979.99 ",IP,"2,420.00","27,020.45",,,,,,
UHC Comm,DRG,MS-812,RED BLOOD CELL DISORDERS WITHOUT MCC,,Relative Weights,"$12,329.98 ",IP,"2,420.00","17,553.31",,,,,,
UHC Comm,DRG,MS-813,COAGULATION DISORDERS,,Relative Weights,"$22,448.02 ",IP,"2,420.00","31,957.63",,,,,,
UHC Comm,DRG,MS-814,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,,Relative Weights,"$24,769.01 ",IP,"2,420.00","35,261.86",,,,,,
UHC Comm,DRG,MS-815,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,,Relative Weights,"$14,342.26 ",IP,"2,420.00","20,418.05",,,,,,
UHC Comm,DRG,MS-816,RETICULOENDOTHELIAL & IMMUNITY DISORDERS W/O CC/MCC,,Relative Weights,"$10,137.86 ",IP,"2,420.00","14,432.54",,,,,,
UHC Comm,DRG,MS-817,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,,Relative Weights,"$35,631.91 ",IP,"2,420.00","50,726.59",,,,,,
UHC Comm,DRG,MS-818,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,,Relative Weights,"$18,039.70 ",IP,"2,420.00","25,681.82",,,,,,
UHC Comm,DRG,MS-819,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$11,299.06 ",IP,"2,420.00","16,085.66",,,,,,
UHC Comm,DRG,MS-820,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,,Relative Weights,"$80,954.19 ",IP,"2,420.00","115,248.67",,,,,,
UHC Comm,DRG,MS-821,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,,Relative Weights,"$31,611.60 ",IP,"2,420.00","45,003.17",,,,,,
UHC Comm,DRG,MS-822,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$17,905.17 ",IP,"2,420.00","25,490.30",,,,,,
UHC Comm,DRG,MS-823,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,,Relative Weights,"$59,903.86 ",IP,"2,420.00","85,280.83",,,,,,
UHC Comm,DRG,MS-824,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,,Relative Weights,"$32,925.74 ",IP,"2,420.00","46,874.02",,,,,,
UHC Comm,DRG,MS-825,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$19,181.07 ",IP,"2,420.00","27,306.72",,,,,,
UHC Comm,DRG,MS-826,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,,Relative Weights,"$71,017.42 ",IP,"2,420.00","101,102.40",,,,,,
UHC Comm,DRG,MS-827,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,,Relative Weights,"$32,799.71 ",IP,"2,420.00","46,694.59",,,,,,
UHC Comm,DRG,MS-828,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$23,382.64 ",IP,"2,420.00","33,288.19",,,,,,
UHC Comm,DRG,MS-829,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,,Relative Weights,"$44,464.12 ",IP,"2,420.00","63,300.38",,,,,,
UHC Comm,DRG,MS-830,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$19,525.19 ",IP,"2,420.00","27,796.61",,,,,,
UHC Comm,DRG,MS-831,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,,Relative Weights,"$15,272.64 ",IP,"2,420.00","21,742.56",,,,,,
UHC Comm,DRG,MS-832,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,,Relative Weights,"$10,132.20 ",IP,"2,420.00","14,424.48",,,,,,
UHC Comm,DRG,MS-833,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$7,535.07 ",IP,"2,420.00","10,727.14",,,,,,
UHC Comm,DRG,MS-834,ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W MCC,,Relative Weights,"$82,735.64 ",IP,"2,420.00","117,784.80",,,,,,
UHC Comm,DRG,MS-835,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC,,Relative Weights,"$28,721.34 ",IP,"2,420.00","40,888.51",,,,,,
UHC Comm,DRG,MS-836,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$18,658.53 ",IP,"2,420.00","26,562.82",,,,,,
UHC Comm,DRG,MS-837,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,,Relative Weights,"$84,835.72 ",IP,"2,420.00","120,774.53",,,,,,
UHC Comm,DRG,MS-838,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,,Relative Weights,"$30,982.85 ",IP,"2,420.00","44,108.06",,,,,,
UHC Comm,DRG,MS-839,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,,Relative Weights,"$18,072.27 ",IP,"2,420.00","25,728.19",,,,,,
UHC Comm,DRG,MS-840,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,,Relative Weights,"$45,247.23 ",IP,"2,420.00","64,415.23",,,,,,
UHC Comm,DRG,MS-841,LYMPHOMA & NON-ACUTE LEUKEMIA W CC,,Relative Weights,"$22,823.28 ",IP,"2,420.00","32,491.87",,,,,,
UHC Comm,DRG,MS-842,LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,,Relative Weights,"$16,237.00 ",IP,"2,420.00","23,115.46",,,,,,
UHC Comm,DRG,MS-843,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,,Relative Weights,"$27,016.36 ",IP,"2,420.00","38,461.25",,,,,,
UHC Comm,DRG,MS-844,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,,Relative Weights,"$17,106.49 ",IP,"2,420.00","24,353.28",,,,,,
UHC Comm,DRG,MS-845,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,,Relative Weights,"$12,262.01 ",IP,"2,420.00","17,456.54",,,,,,
UHC Comm,DRG,MS-846,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,,Relative Weights,"$37,195.28 ",IP,"2,420.00","52,952.26",,,,,,
UHC Comm,DRG,MS-847,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,,Relative Weights,"$18,634.46 ",IP,"2,420.00","26,528.54",,,,,,
UHC Comm,DRG,MS-848,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,,Relative Weights,"$13,897.61 ",IP,"2,420.00","19,785.02",,,,,,
UHC Comm,DRG,MS-849,RADIOTHERAPY,,Relative Weights,"$30,103.45 ",IP,"2,420.00","42,856.13",,,,,,
UHC Comm,DRG,MS-853,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,,Relative Weights,"$72,201.27 ",IP,"2,420.00","102,787.78",,,,,,
UHC Comm,DRG,MS-854,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,,Relative Weights,"$30,604.75 ",IP,"2,420.00","43,569.79",,,,,,
UHC Comm,DRG,MS-855,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$22,704.33 ",IP,"2,420.00","32,322.53",,,,,,
UHC Comm,DRG,MS-856,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,,Relative Weights,"$62,672.34 ",IP,"2,420.00","89,222.11",,,,,,
UHC Comm,DRG,MS-857,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,,Relative Weights,"$28,793.56 ",IP,"2,420.00","40,991.33",,,,,,
UHC Comm,DRG,MS-858,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,,Relative Weights,"$19,491.20 ",IP,"2,420.00","27,748.22",,,,,,
UHC Comm,DRG,MS-862,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W MCC,,Relative Weights,"$26,206.35 ",IP,"2,420.00","37,308.10",,,,,,
UHC Comm,DRG,MS-863,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W/O MCC,,Relative Weights,"$13,991.07 ",IP,"2,420.00","19,918.08",,,,,,
UHC Comm,DRG,MS-864,FEVER AND INFLAMMATORY CONDITIONS,,Relative Weights,"$12,000.03 ",IP,"2,420.00","17,083.58",,,,,,
UHC Comm,DRG,MS-865,VIRAL ILLNESS WITH MCC,,Relative Weights,"$19,730.52 ",IP,"2,420.00","28,088.93",,,,,,
UHC Comm,DRG,MS-866,VIRAL ILLNESS WITHOUT MCC,,Relative Weights,"$11,593.61 ",IP,"2,420.00","16,504.99",,,,,,
UHC Comm,DRG,MS-867,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,,Relative Weights,"$30,944.62 ",IP,"2,420.00","44,053.63",,,,,,
UHC Comm,DRG,MS-868,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,,Relative Weights,"$15,534.62 ",IP,"2,420.00","22,115.52",,,,,,
UHC Comm,DRG,MS-869,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,,Relative Weights,"$10,514.54 ",IP,"2,420.00","14,968.80",,,,,,
UHC Comm,DRG,MS-870,SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,,Relative Weights,"$89,558.41 ",IP,"2,420.00","127,497.89",,,,,,
UHC Comm,DRG,MS-871,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,,Relative Weights,"$26,428.67 ",IP,"2,420.00","37,624.61",,,,,,
UHC Comm,DRG,MS-872,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,,Relative Weights,"$14,717.53 ",IP,"2,420.00","20,952.29",,,,,,
UHC Comm,DRG,MS-876,O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,,Relative Weights,"$51,546.04 ",IP,"2,420.00","73,382.40",,,,,,
UHC Comm,DRG,MS-880,ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,,Relative Weights,"$12,134.56 ",IP,"2,420.00","17,275.10",,,,,,
UHC Comm,DRG,MS-881,DEPRESSIVE NEUROSES,,Relative Weights,"$11,602.11 ",IP,"2,420.00","16,517.09",,,,,,
UHC Comm,DRG,MS-882,NEUROSES EXCEPT DEPRESSIVE,,Relative Weights,"$11,184.36 ",IP,"2,420.00","15,922.37",,,,,,
UHC Comm,DRG,MS-883,DISORDERS OF PERSONALITY & IMPULSE CONTROL,,Relative Weights,"$18,927.59 ",IP,"2,420.00","26,945.86",,,,,,
UHC Comm,DRG,MS-884,ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,,Relative Weights,"$20,363.52 ",IP,"2,420.00","28,990.08",,,,,,
UHC Comm,DRG,MS-885,PSYCHOSES,,Relative Weights,"$17,211.28 ",IP,"2,420.00","24,502.46",,,,,,
UHC Comm,DRG,MS-886,BEHAVIORAL AND DEVELOPMENTAL DISORDERS,,Relative Weights,"$19,055.04 ",IP,"2,420.00","27,127.30",,,,,,
UHC Comm,DRG,MS-887,OTHER MENTAL DISORDER DIAGNOSES,,Relative Weights,"$15,408.58 ",IP,"2,420.00","21,936.10",,,,,,
UHC Comm,DRG,MS-894,ALCOHOL- DRUG ABUSE OR DEPENDENCE- LEFT AMA,,Relative Weights,"$8,219.04 ",IP,"2,420.00","11,700.86",,,,,,
UHC Comm,DRG,MS-895,ALCOHOL- DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY,,Relative Weights,"$23,038.53 ",IP,"2,420.00","32,798.30",,,,,,
UHC Comm,DRG,MS-896,ALCOHOL -  DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC,,Relative Weights,"$24,352.67 ",IP,"2,420.00","34,669.15",,,,,,
UHC Comm,DRG,MS-897,ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC,,Relative Weights,"$11,637.51 ",IP,"2,420.00","16,567.49",,,,,,
UHC Comm,DRG,MS-901,WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,,Relative Weights,"$61,277.48 ",IP,"2,420.00","87,236.35",,,,,,
UHC Comm,DRG,MS-902,WOUND DEBRIDEMENTS FOR INJURIES WITH CC,,Relative Weights,"$27,853.27 ",IP,"2,420.00","39,652.70",,,,,,
UHC Comm,DRG,MS-903,WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,,Relative Weights,"$16,200.18 ",IP,"2,420.00","23,063.04",,,,,,
UHC Comm,DRG,MS-904,SKIN GRAFTS FOR INJURIES WITH CC/MCC,,Relative Weights,"$50,093.12 ",IP,"2,420.00","71,313.98",,,,,,
UHC Comm,DRG,MS-905,SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,,Relative Weights,"$23,569.57 ",IP,"2,420.00","33,554.30",,,,,,
UHC Comm,DRG,MS-906,HAND PROCEDURES FOR INJURIES,,Relative Weights,"$24,652.88 ",IP,"2,420.00","35,096.54",,,,,,
UHC Comm,DRG,MS-907,OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,,Relative Weights,"$56,496.73 ",IP,"2,420.00","80,430.34",,,,,,
UHC Comm,DRG,MS-908,OTHER O.R. PROCEDURES FOR INJURIES WITH CC,,Relative Weights,"$29,215.56 ",IP,"2,420.00","41,592.10",,,,,,
UHC Comm,DRG,MS-909,OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,,Relative Weights,"$18,674.11 ",IP,"2,420.00","26,584.99",,,,,,
UHC Comm,DRG,MS-913,TRAUMATIC INJURY WITH MCC,,Relative Weights,"$20,905.88 ",IP,"2,420.00","29,762.21",,,,,,
UHC Comm,DRG,MS-914,TRAUMATIC INJURY WITHOUT MCC,,Relative Weights,"$12,202.53 ",IP,"2,420.00","17,371.87",,,,,,
UHC Comm,DRG,MS-915,ALLERGIC REACTIONS WITH MCC,,Relative Weights,"$24,060.96 ",IP,"2,420.00","34,253.86",,,,,,
UHC Comm,DRG,MS-916,ALLERGIC REACTIONS WITHOUT MCC,,Relative Weights,"$8,966.75 ",IP,"2,420.00","12,765.31",,,,,,
UHC Comm,DRG,MS-917,POISONING & TOXIC EFFECTS OF DRUGS W MCC,,Relative Weights,"$20,720.38 ",IP,"2,420.00","29,498.11",,,,,,
UHC Comm,DRG,MS-918,POISONING & TOXIC EFFECTS OF DRUGS W/O MCC,,Relative Weights,"$11,102.22 ",IP,"2,420.00","15,805.44",,,,,,
UHC Comm,DRG,MS-919,COMPLICATIONS OF TREATMENT WITH MCC,,Relative Weights,"$25,848.07 ",IP,"2,420.00","36,798.05",,,,,,
UHC Comm,DRG,MS-920,COMPLICATIONS OF TREATMENT WITH CC,,Relative Weights,"$14,267.21 ",IP,"2,420.00","20,311.20",,,,,,
UHC Comm,DRG,MS-921,COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,,Relative Weights,"$9,779.59 ",IP,"2,420.00","13,922.50",,,,,,
UHC Comm,DRG,MS-922,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC,,Relative Weights,"$22,708.58 ",IP,"2,420.00","32,328.58",,,,,,
UHC Comm,DRG,MS-923,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC,,Relative Weights,"$12,256.35 ",IP,"2,420.00","17,448.48",,,,,,
UHC Comm,DRG,MS-927,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,,Relative Weights,"$282,419.90 ",IP,"2,420.00","402,060.96",,,,,,
UHC Comm,DRG,MS-928,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,,Relative Weights,"$87,725.98 ",IP,"2,420.00","124,889.18",,,,,,
UHC Comm,DRG,MS-929,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,,Relative Weights,"$41,654.58 ",IP,"2,420.00","59,300.64",,,,,,
UHC Comm,DRG,MS-933,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,,Relative Weights,"$44,468.37 ",IP,"2,420.00","63,306.43",,,,,,
UHC Comm,DRG,MS-934,FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,,Relative Weights,"$25,628.58 ",IP,"2,420.00","36,485.57",,,,,,
UHC Comm,DRG,MS-935,NON-EXTENSIVE BURNS,,Relative Weights,"$27,363.30 ",IP,"2,420.00","38,955.17",,,,,,
UHC Comm,DRG,MS-939,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,,Relative Weights,"$51,749.96 ",IP,"2,420.00","73,672.70",,,,,,
UHC Comm,DRG,MS-940,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,,Relative Weights,"$32,170.96 ",IP,"2,420.00","45,799.49",,,,,,
UHC Comm,DRG,MS-941,O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W/O CC/MCC,,Relative Weights,"$27,340.64 ",IP,"2,420.00","38,922.91",,,,,,
UHC Comm,DRG,MS-945,REHABILITATION WITH CC/MCC,,Relative Weights,"$20,608.50 ",IP,"2,420.00","29,338.85",,,,,,
UHC Comm,DRG,MS-946,REHABILITATION WITHOUT CC/MCC,,Relative Weights,"$15,393.01 ",IP,"2,420.00","21,913.92",,,,,,
UHC Comm,DRG,MS-947,SIGNS AND SYMPTOMS WITH MCC,,Relative Weights,"$16,954.97 ",IP,"2,420.00","24,137.57",,,,,,
UHC Comm,DRG,MS-948,SIGNS AND SYMPTOMS WITHOUT MCC,,Relative Weights,"$11,039.92 ",IP,"2,420.00","15,716.74",,,,,,
UHC Comm,DRG,MS-949,AFTERCARE WITH CC/MCC,,Relative Weights,"$15,419.91 ",IP,"2,420.00","21,952.22",,,,,,
UHC Comm,DRG,MS-950,AFTERCARE WITHOUT CC/MCC,,Relative Weights,"$10,491.88 ",IP,"2,420.00","14,936.54",,,,,,
UHC Comm,DRG,MS-951,OTHER FACTORS INFLUENCING HEALTH STATUS,,Relative Weights,"$8,305.43 ",IP,"2,420.00","11,823.84",,,,,,
UHC Comm,DRG,MS-955,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$86,105.96 ",IP,"2,420.00","122,582.88",,,,,,
UHC Comm,DRG,MS-956,LIMB REATTACHMENT- HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$55,557.85 ",IP,"2,420.00","79,093.73",,,,,,
UHC Comm,DRG,MS-957,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,,Relative Weights,"$106,684.73 ",IP,"2,420.00","151,879.39",,,,,,
UHC Comm,DRG,MS-958,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,,Relative Weights,"$59,347.33 ",IP,"2,420.00","84,488.54",,,,,,
UHC Comm,DRG,MS-959,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,,Relative Weights,"$39,657.88 ",IP,"2,420.00","56,458.08",,,,,,
UHC Comm,DRG,MS-963,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,,Relative Weights,"$38,590.14 ",IP,"2,420.00","54,938.02",,,,,,
UHC Comm,DRG,MS-964,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,,Relative Weights,"$21,149.45 ",IP,"2,420.00","30,108.96",,,,,,
UHC Comm,DRG,MS-965,OTHER MULTIPLE SIGNIFICANT TRAUMA W/O CC/MCC,,Relative Weights,"$12,987.05 ",IP,"2,420.00","18,488.74",,,,,,
UHC Comm,DRG,MS-969,HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,,Relative Weights,"$82,172.03 ",IP,"2,420.00","116,982.43",,,,,,
UHC Comm,DRG,MS-970,HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,,Relative Weights,"$41,307.64 ",IP,"2,420.00","58,806.72",,,,,,
UHC Comm,DRG,MS-974,HIV WITH MAJOR RELATED CONDITION WITH MCC,,Relative Weights,"$37,865.10 ",IP,"2,420.00","53,905.82",,,,,,
UHC Comm,DRG,MS-975,HIV WITH MAJOR RELATED CONDITION WITH CC,,Relative Weights,"$19,004.06 ",IP,"2,420.00","27,054.72",,,,,,
UHC Comm,DRG,MS-976,HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,,Relative Weights,"$12,945.99 ",IP,"2,420.00","18,430.27",,,,,,
UHC Comm,DRG,MS-977,HIV WITH OR WITHOUT OTHER RELATED CONDITION,,Relative Weights,"$18,416.38 ",IP,"2,420.00","26,218.08",,,,,,
UHC Comm,DRG,MS-981,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,,Relative Weights,"$63,592.80 ",IP,"2,420.00","90,532.51",,,,,,
UHC Comm,DRG,MS-982,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,,Relative Weights,"$34,525.93 ",IP,"2,420.00","49,152.10",,,,,,
UHC Comm,DRG,MS-983,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,,Relative Weights,"$23,182.97 ",IP,"2,420.00","33,003.94",,,,,,
UHC Comm,DRG,MS-987,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,,Relative Weights,"$47,208.53 ",IP,"2,420.00","67,207.39",,,,,,
UHC Comm,DRG,MS-988,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,,Relative Weights,"$24,332.85 ",IP,"2,420.00","34,640.93",,,,,,
UHC Comm,DRG,MS-989,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,,Relative Weights,"$16,319.14 ",IP,"2,420.00","23,232.38",,,,,,
UHC Comm,ExceptRevenue,118,Rehab,Rehabilitation,Per Diem,"$2,013.00 ",IP,"2,013.00","2,013.00",,,,,,
UHC Comm,ExceptRevenue,128,Rehab,Rehabilitation,Per Diem,"$2,013.00 ",IP,"2,013.00","2,013.00",,,,,,
UHC Comm,ExceptRevenue,138,Rehab,Rehabilitation,Per Diem,"$2,013.00 ",IP,"2,013.00","2,013.00",,,,,,
UHC Comm,ExceptRevenue,148,Rehab,Rehabilitation,Per Diem,"$2,013.00 ",IP,"2,013.00","2,013.00",,,,,,
UHC Comm,ExceptRevenue,158,Rehab,Rehabilitation,Per Diem,"$2,013.00 ",IP,"2,013.00","2,013.00",,,,,,
UHC Comm,ExceptCPT,61796,Srs cranial lesion simple,,Straight Discount,70.60%,OP,,,,,,,,
UHC Comm,ExceptCPT,61797,Srs cran les simple addl,,Straight Discount,70.60%,OP,,,,,,,,
UHC Comm,ExceptCPT,61798,Srs cranial lesion complex,,Straight Discount,70.60%,OP,,,,,,,,
UHC Comm,ExceptCPT,61799,Srs cran les complex addl,,Straight Discount,70.60%,OP,,,,,,,,
UHC Comm,ExceptCPT,61800,Apply srs headframe add-on,,Straight Discount,70.60%,OP,,,,,,,,
UHC Comm,ExceptCPT,63620,Srs spinal lesion,,Straight Discount,70.60%,OP,,,,,,,,
UHC Comm,ExceptCPT,63621,Srs spinal lesion addl,,Straight Discount,70.60%,OP,,,,,,,,
UHC Comm,ExceptCPT,77371,Srs multisource,,Straight Discount,70.60%,OP,,,,,,,,
UHC Comm,ExceptCPT,77372,Srs linear based,,Straight Discount,70.60%,OP,,,,,,,,
UHC Comm,RevenueCode,350,CT Scan,CT Scan,Per Case,"$1,700.00 ",OP,600,"1,700.00",,,,,,
UHC Comm,RevenueCode,351,CT Scan: Head,CT Scan,Per Case,"$1,700.00 ",OP,600,"1,700.00",,,,,,
UHC Comm,RevenueCode,352,CT Scan: Body,CT Scan,Per Case,"$1,700.00 ",OP,600,"1,700.00",,,,,,
UHC Comm,RevenueCode,359,CT Scan: Other CT scans,CT Scan,Per Case,"$1,700.00 ",OP,600,"1,700.00",,,,,,
UHC Comm,RevenueCode,450,Emergency Room,ER,Straight Discount,70.60%,OP,,,,,,,,
UHC Comm,RevenueCode,451,Emergency Room: EM/EMTALA,ER,Straight Discount,70.60%,OP,,,,,,,,
UHC Comm,RevenueCode,452,Emergency Room: ER/ Beyond EMTALA,ER,Straight Discount,70.60%,OP,,,,,,,,
UHC Comm,RevenueCode,456,Emergency Room: Urgent care,ER,Straight Discount,70.60%,OP,,,,,,,,
UHC Comm,RevenueCode,459,Emergency Room: Other emergency room,ER,Straight Discount,70.60%,OP,,,,,,,,
UHC Comm,RevenueCode,610,Magnetic Resonance Tech. (MRT),Magnetic Resonance Imagine,Per Case,"$2,200.00 ",OP,"1,200.00","2,200.00",,,,,,
UHC Comm,RevenueCode,611,Magnetic Resonance Tech. (MRT): Brain (incl. Brainstem),Magnetic Resonance Imagine,Per Case,"$2,200.00 ",OP,"1,200.00","2,200.00",,,,,,
UHC Comm,RevenueCode,612,Magnetic Resonance Tech. (MRT): Spinal cord (incl. spine),Magnetic Resonance Imagine,Per Case,"$2,200.00 ",OP,"1,200.00","2,200.00",,,,,,
UHC Comm,RevenueCode,614,Magnetic Resonance Tech. (MRT): MRI - Other,Magnetic Resonance Imagine,Per Case,"$2,200.00 ",OP,"1,200.00","2,200.00",,,,,,
UHC Comm,RevenueCode,616,Magnetic Resonance Tech. (MRT): MRA - Lower Ext,Magnetic Resonance Imagine,Per Case,"$2,200.00 ",OP,"1,200.00","2,200.00",,,,,,
UHC Comm,RevenueCode,618,Magnetic Resonance Tech. (MRT): MRA - Other,Magnetic Resonance Imagine,Per Case,"$2,200.00 ",OP,"1,200.00","2,200.00",,,,,,
UHC Comm,RevenueCode,619,Magnetic Resonance Tech. (MRT): Other MRI,Magnetic Resonance Imagine,Per Case,"$2,200.00 ",OP,"1,200.00","2,200.00",,,,,,
UHC Comm,RevenueCode,762,Treatment/Observation Room: Observation room,Observation,Straight Discount,70.60%,OP,,,,,,,,
UHC Comm,,,,All Other,Straight Discount,70.60%,OP,,,,,,,,
UHC MCR ADV,DRG,MS-001,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W MCC,Surgical,Relative Weights,"$168,855.33 ",IP,"17,718.00","557,099.42",,,,,,
UHC MCR ADV,DRG,MS-002,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W/O MCC,Surgical,Relative Weights,"$87,426.55 ",IP,"17,718.00","282,516.19",,,,,,
UHC MCR ADV,DRG,MS-003,ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITH MAJOR O.R. PROCEDURES,Surgical,Relative Weights,"$111,577.60 ",IP,"111,577.60","382,110.62",,,,,,
UHC MCR ADV,DRG,MS-004,TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES,Surgical,Relative Weights,"$69,628.33 ",IP,"69,628.33","232,723.01",,,,,,
UHC MCR ADV,DRG,MS-005,LIVER TRANSPLANT W MCC OR INTESTINAL TRANSPLANT,Surgical,Relative Weights,"$59,773.19 ",IP,"59,773.19","207,904.03",,,,,,
UHC MCR ADV,DRG,MS-006,LIVER TRANSPLANT W/O MCC,Surgical,Relative Weights,"$27,427.34 ",IP,"27,427.34","98,217.50",,,,,,
UHC MCR ADV,DRG,MS-007,LUNG TRANSPLANT,Surgical,Relative Weights,"$67,628.10 ",IP,"67,628.10","217,451.81",,,,,,
UHC MCR ADV,DRG,MS-008,SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,Surgical,Relative Weights,"$31,730.89 ",IP,"31,730.89","113,220.58",,,,,,
UHC MCR ADV,DRG,MS-010,PANCREAS TRANSPLANT,Surgical,Relative Weights,"$21,141.08 ",IP,"2,420.00","80,158.18",,,,,,
UHC MCR ADV,DRG,MS-011,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC,Surgical,Relative Weights,"$29,325.37 ",IP,"2,420.00","99,667.01",,,,,,
UHC MCR ADV,DRG,MS-012,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC,Surgical,Relative Weights,"$22,383.85 ",IP,"2,420.00","76,083.84",,,,,,
UHC MCR ADV,DRG,MS-013,TRACHEOSTOMY FOR FACE -  MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC,Surgical,Relative Weights,"$15,907.20 ",IP,"2,420.00","48,894.05",,,,,,
UHC MCR ADV,DRG,MS-014,ALLOGENEIC BONE MARROW TRANSPLANT,Surgical,Relative Weights,"$62,354.51 ",IP,"2,420.00","257,136.77",,,,,,
UHC MCR ADV,DRG,MS-016,AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,Surgical,Relative Weights,"$39,340.51 ",IP,"2,420.00","138,805.63",,,,,,
UHC MCR ADV,DRG,MS-017,AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,Surgical,Relative Weights,"$28,357.66 ",IP,"2,420.00","89,659.58",,,,,,
UHC MCR ADV,DRG,MS-018,CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,Medical,Relative Weights,"$218,711.49 ",IP,"2,420.00","218,711.49",,,,,,
UHC MCR ADV,DRG,MS-019,SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,Surgical,Relative Weights,"$39,009.97 ",IP,"2,420.00","39,009.97",,,,,,
UHC MCR ADV,DRG,MS-020,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,Surgical,Relative Weights,"$60,368.88 ",IP,"2,420.00","218,151.36",,,,,,
UHC MCR ADV,DRG,MS-021,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,Surgical,Relative Weights,"$44,054.63 ",IP,"2,420.00","166,797.79",,,,,,
UHC MCR ADV,DRG,MS-022,INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W/O CC/MCC,Surgical,Relative Weights,"$28,282.33 ",IP,"2,420.00","99,425.09",,,,,,
UHC MCR ADV,DRG,MS-023,CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX CNS PDX W MCC OR CHEMO IMPLANT,Surgical,Relative Weights,"$33,124.34 ",IP,"2,420.00","113,240.74",,,,,,
UHC MCR ADV,DRG,MS-024,CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,Surgical,Relative Weights,"$23,004.07 ",IP,"2,420.00","80,972.64",,,,,,
UHC MCR ADV,DRG,MS-025,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$26,265.17 ",IP,"2,420.00","88,593.12",,,,,,
UHC MCR ADV,DRG,MS-026,CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC,Surgical,Relative Weights,"$17,882.32 ",IP,"2,420.00","61,403.33",,,,,,
UHC MCR ADV,DRG,MS-027,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$14,683.71 ",IP,"2,420.00","48,317.47",,,,,,
UHC MCR ADV,DRG,MS-028,SPINAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$34,007.36 ",IP,"2,420.00","112,702.46",,,,,,
UHC MCR ADV,DRG,MS-029,SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,Surgical,Relative Weights,"$19,253.57 ",IP,"2,420.00","64,653.12",,,,,,
UHC MCR ADV,DRG,MS-030,SPINAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$13,763.89 ",IP,"2,420.00","45,805.54",,,,,,
UHC MCR ADV,DRG,MS-031,VENTRICULAR SHUNT PROCEDURES WITH MCC,Surgical,Relative Weights,"$25,531.07 ",IP,"2,420.00","88,189.92",,,,,,
UHC MCR ADV,DRG,MS-032,VENTRICULAR SHUNT PROCEDURES WITH CC,Surgical,Relative Weights,"$12,944.53 ",IP,"2,420.00","44,192.74",,,,,,
UHC MCR ADV,DRG,MS-033,VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,057.78 ",IP,"2,420.00","34,290.14",,,,,,
UHC MCR ADV,DRG,MS-034,CAROTID ARTERY STENT PROCEDURE W MCC,Surgical,Relative Weights,"$23,232.41 ",IP,"2,420.00","75,674.59",,,,,,
UHC MCR ADV,DRG,MS-035,CAROTID ARTERY STENT PROCEDURES WITH CC,Surgical,Relative Weights,"$13,664.03 ",IP,"2,420.00","46,412.35",,,,,,
UHC MCR ADV,DRG,MS-036,CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,817.58 ",IP,"2,420.00","35,300.16",,,,,,
UHC MCR ADV,DRG,MS-037,EXTRACRANIAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$19,141.44 ",IP,"2,420.00","65,384.93",,,,,,
UHC MCR ADV,DRG,MS-038,EXTRACRANIAL PROCEDURES WITH CC,Surgical,Relative Weights,"$9,687.52 ",IP,"2,420.00","33,772.03",,,,,,
UHC MCR ADV,DRG,MS-039,EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,652.43 ",IP,"2,420.00","22,807.01",,,,,,
UHC MCR ADV,DRG,MS-040,PERIPHERAL- CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC,Surgical,Relative Weights,"$22,570.73 ",IP,"2,420.00","79,438.46",,,,,,
UHC MCR ADV,DRG,MS-041,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W CC OR PERIPH NEUROSTIM,Surgical,Relative Weights,"$13,722.43 ",IP,"2,420.00","47,809.44",,,,,,
UHC MCR ADV,DRG,MS-042,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W/O CC/MCC,Surgical,Relative Weights,"$11,103.16 ",IP,"2,420.00","37,261.73",,,,,,
UHC MCR ADV,DRG,MS-052,SPINAL DISORDERS AND INJURIES WITH CC/MCC,Medical,Relative Weights,"$10,824.58 ",IP,"2,420.00","32,838.62",,,,,,
UHC MCR ADV,DRG,MS-053,SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,Medical,Relative Weights,"$6,636.66 ",IP,"2,420.00","19,476.58",,,,,,
UHC MCR ADV,DRG,MS-054,NERVOUS SYSTEM NEOPLASMS WITH MCC,Medical,Relative Weights,"$7,990.98 ",IP,"2,420.00","27,016.42",,,,,,
UHC MCR ADV,DRG,MS-055,NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,Medical,Relative Weights,"$6,100.55 ",IP,"2,420.00","19,877.76",,,,,,
UHC MCR ADV,DRG,MS-056,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,Medical,Relative Weights,"$12,820.72 ",IP,"2,420.00","44,198.78",,,,,,
UHC MCR ADV,DRG,MS-057,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,Medical,Relative Weights,"$7,402.30 ",IP,"2,420.00","24,409.73",,,,,,
UHC MCR ADV,DRG,MS-058,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,Medical,Relative Weights,"$10,148.89 ",IP,"2,420.00","39,406.75",,,,,,
UHC MCR ADV,DRG,MS-059,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,Medical,Relative Weights,"$6,583.52 ",IP,"2,420.00","21,984.48",,,,,,
UHC MCR ADV,DRG,MS-060,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,Medical,Relative Weights,"$5,359.44 ",IP,"2,420.00","17,775.07",,,,,,
UHC MCR ADV,DRG,MS-061,ISCHEMIC STROKE -  PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC,Medical,Relative Weights,"$16,884.83 ",IP,"2,420.00","56,316.96",,,,,,
UHC MCR ADV,DRG,MS-062,ISCHEMIC STROKE -  PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC,Medical,Relative Weights,"$11,611.83 ",IP,"2,420.00","40,545.79",,,,,,
UHC MCR ADV,DRG,MS-063,ISCHEMIC STROKE- PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC,Medical,Relative Weights,"$9,984.78 ",IP,"2,420.00","33,884.93",,,,,,
UHC MCR ADV,DRG,MS-064,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,Medical,Relative Weights,"$11,206.52 ",IP,"2,420.00","37,795.97",,,,,,
UHC MCR ADV,DRG,MS-065,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC,Medical,Relative Weights,"$5,956.88 ",IP,"2,420.00","20,718.43",,,,,,
UHC MCR ADV,DRG,MS-066,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,Medical,Relative Weights,"$4,155.80 ",IP,"2,420.00","14,454.72",,,,,,
UHC MCR ADV,DRG,MS-067,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,Medical,Relative Weights,"$8,326.78 ",IP,"2,420.00","29,524.32",,,,,,
UHC MCR ADV,DRG,MS-068,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,Medical,Relative Weights,"$5,191.24 ",IP,"2,420.00","18,212.54",,,,,,
UHC MCR ADV,DRG,MS-069,TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,Medical,Relative Weights,"$4,596.73 ",IP,"2,420.00","15,730.85",,,,,,
UHC MCR ADV,DRG,MS-070,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC,Medical,Relative Weights,"$9,808.99 ",IP,"2,420.00","33,725.66",,,,,,
UHC MCR ADV,DRG,MS-071,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC,Medical,Relative Weights,"$5,908.99 ",IP,"2,420.00","20,053.15",,,,,,
UHC MCR ADV,DRG,MS-072,NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$4,506.79 ",IP,"2,420.00","14,888.16",,,,,,
UHC MCR ADV,DRG,MS-073,CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,Medical,Relative Weights,"$8,485.05 ",IP,"2,420.00","28,538.50",,,,,,
UHC MCR ADV,DRG,MS-074,CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,Medical,Relative Weights,"$5,951.04 ",IP,"2,420.00","19,920.10",,,,,,
UHC MCR ADV,DRG,MS-075,VIRAL MENINGITIS WITH CC/MCC,Medical,Relative Weights,"$9,501.81 ",IP,"2,420.00","32,421.31",,,,,,
UHC MCR ADV,DRG,MS-076,VIRAL MENINGITIS WITHOUT CC/MCC,Medical,Relative Weights,"$5,751.89 ",IP,"2,420.00","18,194.40",,,,,,
UHC MCR ADV,DRG,MS-077,HYPERTENSIVE ENCEPHALOPATHY WITH MCC,Medical,Relative Weights,"$8,952.25 ",IP,"2,420.00","31,096.80",,,,,,
UHC MCR ADV,DRG,MS-078,HYPERTENSIVE ENCEPHALOPATHY WITH CC,Medical,Relative Weights,"$5,547.49 ",IP,"2,420.00","19,393.92",,,,,,
UHC MCR ADV,DRG,MS-079,HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC,Medical,Relative Weights,"$4,256.25 ",IP,"2,420.00","14,940.58",,,,,,
UHC MCR ADV,DRG,MS-080,NONTRAUMATIC STUPOR & COMA W MCC,Medical,Relative Weights,"$12,237.30 ",IP,"2,420.00","38,632.61",,,,,,
UHC MCR ADV,DRG,MS-081,NONTRAUMATIC STUPOR & COMA W/O MCC,Medical,Relative Weights,"$4,515.55 ",IP,"2,420.00","17,722.66",,,,,,
UHC MCR ADV,DRG,MS-082,TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,Medical,Relative Weights,"$13,221.35 ",IP,"2,420.00","45,396.29",,,,,,
UHC MCR ADV,DRG,MS-083,TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,Medical,Relative Weights,"$7,849.06 ",IP,"2,420.00","26,423.71",,,,,,
UHC MCR ADV,DRG,MS-084,TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,Medical,Relative Weights,"$5,288.77 ",IP,"2,420.00","18,089.57",,,,,,
UHC MCR ADV,DRG,MS-085,TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,Medical,Relative Weights,"$13,500.51 ",IP,"2,420.00","45,275.33",,,,,,
UHC MCR ADV,DRG,MS-086,TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,Medical,Relative Weights,"$7,443.18 ",IP,"2,420.00","24,954.05",,,,,,
UHC MCR ADV,DRG,MS-087,TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,Medical,Relative Weights,"$5,043.49 ",IP,"2,420.00","16,918.27",,,,,,
UHC MCR ADV,DRG,MS-088,CONCUSSION WITH MCC,Medical,Relative Weights,"$8,498.48 ",IP,"2,420.00","28,004.26",,,,,,
UHC MCR ADV,DRG,MS-089,CONCUSSION WITH CC,Medical,Relative Weights,"$6,210.92 ",IP,"2,420.00","19,883.81",,,,,,
UHC MCR ADV,DRG,MS-090,CONCUSSION WITHOUT CC/MCC,Medical,Relative Weights,"$4,990.93 ",IP,"2,420.00","17,101.73",,,,,,
UHC MCR ADV,DRG,MS-091,OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,Medical,Relative Weights,"$9,640.80 ",IP,"2,420.00","31,552.42",,,,,,
UHC MCR ADV,DRG,MS-092,OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,Medical,Relative Weights,"$5,775.25 ",IP,"2,420.00","19,476.58",,,,,,
UHC MCR ADV,DRG,MS-093,OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,Medical,Relative Weights,"$4,568.11 ",IP,"2,420.00","15,345.79",,,,,,
UHC MCR ADV,DRG,MS-094,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,Medical,Relative Weights,"$21,245.62 ",IP,"2,420.00","72,269.57",,,,,,
UHC MCR ADV,DRG,MS-095,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,Medical,Relative Weights,"$14,642.83 ",IP,"2,420.00","48,527.14",,,,,,
UHC MCR ADV,DRG,MS-096,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,Medical,Relative Weights,"$13,623.15 ",IP,"2,420.00","45,603.94",,,,,,
UHC MCR ADV,DRG,MS-097,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,Medical,Relative Weights,"$21,961.03 ",IP,"2,420.00","72,090.14",,,,,,
UHC MCR ADV,DRG,MS-098,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,Medical,Relative Weights,"$12,337.16 ",IP,"2,420.00","39,412.80",,,,,,
UHC MCR ADV,DRG,MS-099,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,Medical,Relative Weights,"$8,187.20 ",IP,"2,420.00","25,853.18",,,,,,
UHC MCR ADV,DRG,MS-100,SEIZURES WITH MCC,Medical,Relative Weights,"$10,958.32 ",IP,"2,420.00","36,695.23",,,,,,
UHC MCR ADV,DRG,MS-101,SEIZURES WITHOUT MCC,Medical,Relative Weights,"$5,188.32 ",IP,"2,420.00","17,799.26",,,,,,
UHC MCR ADV,DRG,MS-102,HEADACHES WITH MCC,Medical,Relative Weights,"$6,734.19 ",IP,"2,420.00","24,042.82",,,,,,
UHC MCR ADV,DRG,MS-103,HEADACHES W/O MCC,Medical,Relative Weights,"$4,844.34 ",IP,"2,420.00","16,117.92",,,,,,
UHC MCR ADV,DRG,MS-113,ORBITAL PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$12,815.47 ",IP,"2,420.00","42,983.14",,,,,,
UHC MCR ADV,DRG,MS-114,ORBITAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,454.10 ",IP,"2,420.00","24,006.53",,,,,,
UHC MCR ADV,DRG,MS-115,EXTRAOCULAR PROCEDURES EXCEPT ORBIT,Surgical,Relative Weights,"$8,506.66 ",IP,"2,420.00","29,957.76",,,,,,
UHC MCR ADV,DRG,MS-116,INTRAOCULAR PROCEDURES W CC/MCC,Surgical,Relative Weights,"$10,995.11 ",IP,"2,420.00","38,122.56",,,,,,
UHC MCR ADV,DRG,MS-117,INTRAOCULAR PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$6,080.69 ",IP,"2,420.00","22,109.47",,,,,,
UHC MCR ADV,DRG,MS-121,ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,Medical,Relative Weights,"$6,953.20 ",IP,"2,420.00","25,558.85",,,,,,
UHC MCR ADV,DRG,MS-122,ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,Medical,Relative Weights,"$3,769.77 ",IP,"2,420.00","15,575.62",,,,,,
UHC MCR ADV,DRG,MS-123,NEUROLOGICAL EYE DISORDERS,Medical,Relative Weights,"$4,478.17 ",IP,"2,420.00","15,740.93",,,,,,
UHC MCR ADV,DRG,MS-124,OTHER DISORDERS OF THE EYE WITH MCC,Medical,Relative Weights,"$8,187.79 ",IP,"2,420.00","28,010.30",,,,,,
UHC MCR ADV,DRG,MS-125,OTHER DISORDERS OF THE EYE WITHOUT MCC,Medical,Relative Weights,"$4,888.14 ",IP,"2,420.00","15,914.30",,,,,,
UHC MCR ADV,DRG,MS-135,SINUS AND MASTOID PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$12,518.21 ",IP,"2,420.00","46,057.54",,,,,,
UHC MCR ADV,DRG,MS-136,SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,332.22 ",IP,"2,420.00","23,990.40",,,,,,
UHC MCR ADV,DRG,MS-137,MOUTH PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$8,816.77 ",IP,"2,420.00","26,879.33",,,,,,
UHC MCR ADV,DRG,MS-138,MOUTH PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$5,002.03 ",IP,"2,420.00","17,365.82",,,,,,
UHC MCR ADV,DRG,MS-139,SALIVARY GLAND PROCEDURES,Surgical,Relative Weights,"$7,207.24 ",IP,"2,420.00","24,883.49",,,,,,
UHC MCR ADV,DRG,MS-140,MAJOR HEAD AND NECK PROCEDURES WITH MCC,Medical,Relative Weights,"$23,231.24 ",IP,"2,420.00","23,231.24",,,,,,
UHC MCR ADV,DRG,MS-141,MAJOR HEAD AND NECK PROCEDURES WITH CC,Medical,Relative Weights,"$12,883.80 ",IP,"2,420.00","12,883.80",,,,,,
UHC MCR ADV,DRG,MS-142,MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,Medical,Relative Weights,"$9,373.91 ",IP,"2,420.00","9,373.91",,,,,,
UHC MCR ADV,DRG,MS-143,OTHER EAR- NOSE- MOUTH AND THROAT O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$17,402.26 ",IP,"2,420.00","17,402.26",,,,,,
UHC MCR ADV,DRG,MS-144,HERNIA PROCEDURES AGE 0-17,Surgical,Relative Weights,"$10,287.30 ",IP,"2,420.00","10,287.30",,,,,,
UHC MCR ADV,DRG,MS-145,OTHER EAR -  NOSE -  MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC,Medical,Relative Weights,"$7,151.76 ",IP,"2,420.00","7,151.76",,,,,,
UHC MCR ADV,DRG,MS-146,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH MCC,Medical,Relative Weights,"$11,920.18 ",IP,"2,420.00","38,880.58",,,,,,
UHC MCR ADV,DRG,MS-147,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH CC,Medical,Relative Weights,"$7,598.52 ",IP,"2,420.00","25,016.54",,,,,,
UHC MCR ADV,DRG,MS-148,EAR - NOSE - MOUTH & THROAT MALIGNANCY W/O CC/MCC,Medical,Relative Weights,"$4,596.14 ",IP,"2,420.00","15,329.66",,,,,,
UHC MCR ADV,DRG,MS-149,DYSEQUILIBRIUM,Medical,Relative Weights,"$4,304.14 ",IP,"2,420.00","14,726.88",,,,,,
UHC MCR ADV,DRG,MS-150,EPISTAXIS WITH MCC,Medical,Relative Weights,"$7,752.70 ",IP,"2,420.00","26,036.64",,,,,,
UHC MCR ADV,DRG,MS-151,EPISTAXIS WITHOUT MCC,Medical,Relative Weights,"$4,312.31 ",IP,"2,420.00","14,093.86",,,,,,
UHC MCR ADV,DRG,MS-152,OTITIS MEDIA AND URI WITH MCC,Medical,Relative Weights,"$6,310.20 ",IP,"2,420.00","20,946.24",,,,,,
UHC MCR ADV,DRG,MS-153,OTITIS MEDIA AND URI WITHOUT MCC,Medical,Relative Weights,"$4,165.14 ",IP,"2,420.00","14,241.02",,,,,,
UHC MCR ADV,DRG,MS-154,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH MCC,Medical,Relative Weights,"$9,033.43 ",IP,"2,420.00","28,969.92",,,,,,
UHC MCR ADV,DRG,MS-155,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH CC,Medical,Relative Weights,"$5,311.55 ",IP,"2,420.00","18,166.18",,,,,,
UHC MCR ADV,DRG,MS-156,OTHER EAR -  NOSE -  MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$3,845.11 ",IP,"2,420.00","13,194.72",,,,,,
UHC MCR ADV,DRG,MS-157,DENTAL AND ORAL DISEASES WITH MCC,Medical,Relative Weights,"$9,205.13 ",IP,"2,420.00","31,508.06",,,,,,
UHC MCR ADV,DRG,MS-158,DENTAL AND ORAL DISEASES WITH CC,Medical,Relative Weights,"$5,257.24 ",IP,"2,420.00","17,470.66",,,,,,
UHC MCR ADV,DRG,MS-159,DENTAL AND ORAL DISEASES WITHOUT CC/MCC,Medical,Relative Weights,"$3,872.56 ",IP,"2,420.00","13,565.66",,,,,,
UHC MCR ADV,DRG,MS-163,MAJOR CHEST PROCEDURES WITH MCC,Surgical,Relative Weights,"$29,240.10 ",IP,"2,420.00","98,253.79",,,,,,
UHC MCR ADV,DRG,MS-164,MAJOR CHEST PROCEDURES WITH CC,Surgical,Relative Weights,"$15,508.91 ",IP,"2,420.00","51,037.06",,,,,,
UHC MCR ADV,DRG,MS-165,MAJOR CHEST PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$11,193.09 ",IP,"2,420.00","37,279.87",,,,,,
UHC MCR ADV,DRG,MS-166,OTHER RESP SYSTEM O.R. PROCEDURES W MCC,Surgical,Relative Weights,"$21,745.53 ",IP,"2,420.00","75,210.91",,,,,,
UHC MCR ADV,DRG,MS-167,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$10,621.35 ",IP,"2,420.00","38,594.30",,,,,,
UHC MCR ADV,DRG,MS-168,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,909.80 ",IP,"2,420.00","26,746.27",,,,,,
UHC MCR ADV,DRG,MS-175,PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,Medical,Relative Weights,"$9,028.76 ",IP,"2,420.00","29,119.10",,,,,,
UHC MCR ADV,DRG,MS-176,PULMONARY EMBOLISM WITHOUT MCC,Medical,Relative Weights,"$5,184.82 ",IP,"2,420.00","17,103.74",,,,,,
UHC MCR ADV,DRG,MS-177,RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC,Medical,Relative Weights,"$10,798.89 ",IP,"2,420.00","38,126.59",,,,,,
UHC MCR ADV,DRG,MS-178,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,Medical,Relative Weights,"$7,053.65 ",IP,"2,420.00","25,064.93",,,,,,
UHC MCR ADV,DRG,MS-179,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,Medical,Relative Weights,"$5,096.64 ",IP,"2,420.00","17,460.58",,,,,,
UHC MCR ADV,DRG,MS-180,RESPIRATORY NEOPLASMS WITH MCC,Medical,Relative Weights,"$10,161.15 ",IP,"2,420.00","34,773.98",,,,,,
UHC MCR ADV,DRG,MS-181,RESPIRATORY NEOPLASMS WITH CC,Medical,Relative Weights,"$6,541.47 ",IP,"2,420.00","23,224.32",,,,,,
UHC MCR ADV,DRG,MS-182,RESPIRATORY NEOPLASMS WITHOUT CC/MCC,Medical,Relative Weights,"$4,625.34 ",IP,"2,420.00","16,990.85",,,,,,
UHC MCR ADV,DRG,MS-183,MAJOR CHEST TRAUMA WITH MCC,Medical,Relative Weights,"$9,104.10 ",IP,"2,420.00","30,425.47",,,,,,
UHC MCR ADV,DRG,MS-184,MAJOR CHEST TRAUMA WITH CC,Medical,Relative Weights,"$6,078.94 ",IP,"2,420.00","20,526.91",,,,,,
UHC MCR ADV,DRG,MS-185,MAJOR CHEST TRAUMA W/O CC/MCC,Medical,Relative Weights,"$4,525.48 ",IP,"2,420.00","14,797.44",,,,,,
UHC MCR ADV,DRG,MS-186,PLEURAL EFFUSION WITH MCC,Medical,Relative Weights,"$9,015.91 ",IP,"2,420.00","31,104.86",,,,,,
UHC MCR ADV,DRG,MS-187,PLEURAL EFFUSION WITH CC,Medical,Relative Weights,"$6,032.22 ",IP,"2,420.00","20,722.46",,,,,,
UHC MCR ADV,DRG,MS-188,PLEURAL EFFUSION WITHOUT CC/MCC,Medical,Relative Weights,"$4,260.34 ",IP,"2,420.00","14,734.94",,,,,,
UHC MCR ADV,DRG,MS-189,PULMONARY EDEMA AND RESPIRATORY FAILURE,Medical,Relative Weights,"$7,160.52 ",IP,"2,420.00","24,508.51",,,,,,
UHC MCR ADV,DRG,MS-190,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,Medical,Relative Weights,"$6,570.67 ",IP,"2,420.00","23,063.04",,,,,,
UHC MCR ADV,DRG,MS-191,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,Medical,Relative Weights,"$5,164.38 ",IP,"2,420.00","17,998.85",,,,,,
UHC MCR ADV,DRG,MS-192,CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC,Medical,Relative Weights,"$4,062.36 ",IP,"2,420.00","14,297.47",,,,,,
UHC MCR ADV,DRG,MS-193,SIMPLE PNEUMONIA & PLEURISY W MCC,Medical,Relative Weights,"$7,662.18 ",IP,"2,420.00","26,883.36",,,,,,
UHC MCR ADV,DRG,MS-194,SIMPLE PNEUMONIA AND PLEURISY WITH CC,Medical,Relative Weights,"$5,045.24 ",IP,"2,420.00","17,914.18",,,,,,
UHC MCR ADV,DRG,MS-195,SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,Medical,Relative Weights,"$3,888.32 ",IP,"2,420.00","13,751.14",,,,,,
UHC MCR ADV,DRG,MS-196,INTERSTITIAL LUNG DISEASE WITH MCC,Medical,Relative Weights,"$10,153.56 ",IP,"2,420.00","33,776.06",,,,,,
UHC MCR ADV,DRG,MS-197,INTERSTITIAL LUNG DISEASE WITH CC,Medical,Relative Weights,"$5,880.96 ",IP,"2,420.00","20,593.44",,,,,,
UHC MCR ADV,DRG,MS-198,INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,Medical,Relative Weights,"$4,341.51 ",IP,"2,420.00","15,220.80",,,,,,
UHC MCR ADV,DRG,MS-199,PNEUMOTHORAX WITH MCC,Medical,Relative Weights,"$10,453.74 ",IP,"2,420.00","36,169.06",,,,,,
UHC MCR ADV,DRG,MS-200,PNEUMOTHORAX WITH CC,Medical,Relative Weights,"$6,286.84 ",IP,"2,420.00","21,815.14",,,,,,
UHC MCR ADV,DRG,MS-201,PNEUMOTHORAX WITHOUT CC/MCC,Medical,Relative Weights,"$4,144.12 ",IP,"2,420.00","14,474.88",,,,,,
UHC MCR ADV,DRG,MS-202,BRONCHITIS AND ASTHMA WITH CC/MCC,Medical,Relative Weights,"$5,647.36 ",IP,"2,420.00","19,111.68",,,,,,
UHC MCR ADV,DRG,MS-203,BRONCHITIS AND ASTHMA WITHOUT CC/MCC,Medical,Relative Weights,"$4,128.93 ",IP,"2,420.00","13,987.01",,,,,,
UHC MCR ADV,DRG,MS-204,RESPIRATORY SIGNS AND SYMPTOMS,Medical,Relative Weights,"$4,634.69 ",IP,"2,420.00","16,380.00",,,,,,
UHC MCR ADV,DRG,MS-205,OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,Medical,Relative Weights,"$9,839.36 ",IP,"2,420.00","32,945.47",,,,,,
UHC MCR ADV,DRG,MS-206,OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,Medical,Relative Weights,"$5,174.31 ",IP,"2,420.00","17,589.60",,,,,,
UHC MCR ADV,DRG,MS-207,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS,Medical,Relative Weights,"$33,499.27 ",IP,"2,420.00","115,629.70",,,,,,
UHC MCR ADV,DRG,MS-208,RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,Medical,Relative Weights,"$14,861.83 ",IP,"2,420.00","50,079.46",,,,,,
UHC MCR ADV,DRG,MS-215,OTHER HEART ASSIST SYSTEM IMPLANT,Surgical,Relative Weights,"$61,661.88 ",IP,"61,661.88","259,783.78",,,,,,
UHC MCR ADV,DRG,MS-216,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$58,630.29 ",IP,"58,630.29","202,454.78",,,,,,
UHC MCR ADV,DRG,MS-217,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,Surgical,Relative Weights,"$37,864.14 ",IP,"37,864.14","134,096.26",,,,,,
UHC MCR ADV,DRG,MS-218,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,Surgical,Relative Weights,"$35,678.79 ",IP,"35,678.79","108,892.22",,,,,,
UHC MCR ADV,DRG,MS-219,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$47,057.01 ",IP,"47,057.01","158,056.42",,,,,,
UHC MCR ADV,DRG,MS-220,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,Surgical,Relative Weights,"$31,567.37 ",IP,"31,567.37","106,966.94",,,,,,
UHC MCR ADV,DRG,MS-221,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,Surgical,Relative Weights,"$26,746.97 ",IP,"26,746.97","92,659.39",,,,,,
UHC MCR ADV,DRG,MS-222,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITH MCC,Surgical,Relative Weights,"$46,434.46 ",IP,"46,434.46","168,227.14",,,,,,
UHC MCR ADV,DRG,MS-223,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITHOUT MCC,Surgical,Relative Weights,"$33,864.27 ",IP,"33,864.27","121,018.46",,,,,,
UHC MCR ADV,DRG,MS-224,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITH MCC,Surgical,Relative Weights,"$43,912.13 ",IP,"43,912.13","149,107.39",,,,,,
UHC MCR ADV,DRG,MS-225,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITHOUT MCC,Surgical,Relative Weights,"$32,808.39 ",IP,"32,808.39","113,879.81",,,,,,
UHC MCR ADV,DRG,MS-226,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$38,340.11 ",IP,"25,420.00","134,824.03",,,,,,
UHC MCR ADV,DRG,MS-227,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Surgical,Relative Weights,"$30,439.07 ",IP,"25,420.00","105,420.67",,,,,,
UHC MCR ADV,DRG,MS-228,OTHER CARDIOTHORACIC PROCEDURES WITH MCC,Surgical,Relative Weights,"$31,129.37 ",IP,"31,129.37","126,731.81",,,,,,
UHC MCR ADV,DRG,MS-229,OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$20,096.88 ",IP,"20,096.88","82,754.78",,,,,,
UHC MCR ADV,DRG,MS-231,CORONARY BYPASS W PTCA W MCC,Surgical,Relative Weights,"$50,901.53 ",IP,"50,901.53","165,543.84",,,,,,
UHC MCR ADV,DRG,MS-232,CORONARY BYPASS W PTCA W/O MCC,Surgical,Relative Weights,"$34,770.65 ",IP,"34,770.65","120,687.84",,,,,,
UHC MCR ADV,DRG,MS-233,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,Surgical,Relative Weights,"$46,266.85 ",IP,"42,365.00","156,621.02",,,,,,
UHC MCR ADV,DRG,MS-234,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,Surgical,Relative Weights,"$31,162.65 ",IP,"31,162.65","104,959.01",,,,,,
UHC MCR ADV,DRG,MS-235,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,Surgical,Relative Weights,"$35,648.42 ",IP,"32,351.00","118,633.54",,,,,,
UHC MCR ADV,DRG,MS-236,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Surgical,Relative Weights,"$23,926.80 ",IP,"23,926.80","81,226.66",,,,,,
UHC MCR ADV,DRG,MS-239,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,Surgical,Relative Weights,"$28,125.81 ",IP,"2,420.00","94,141.15",,,,,,
UHC MCR ADV,DRG,MS-240,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,Surgical,Relative Weights,"$16,286.81 ",IP,"2,420.00","55,641.60",,,,,,
UHC MCR ADV,DRG,MS-241,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,Surgical,Relative Weights,"$9,299.74 ",IP,"2,420.00","30,568.61",,,,,,
UHC MCR ADV,DRG,MS-242,PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,Surgical,Relative Weights,"$21,769.47 ",IP,"15,407.00","74,815.78",,,,,,
UHC MCR ADV,DRG,MS-243,PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,Surgical,Relative Weights,"$14,708.24 ",IP,"14,708.24","50,992.70",,,,,,
UHC MCR ADV,DRG,MS-244,PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,Surgical,Relative Weights,"$12,049.83 ",IP,"12,049.83","41,840.06",,,,,,
UHC MCR ADV,DRG,MS-245,AICD GENERATOR PROCEDURES,Surgical,Relative Weights,"$31,640.37 ",IP,"15,407.00","104,989.25",,,,,,
UHC MCR ADV,DRG,MS-246,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Surgical,Relative Weights,"$18,246.15 ",IP,"18,246.15","63,963.65",,,,,,
UHC MCR ADV,DRG,MS-247,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITHOUT MCC,Surgical,Relative Weights,"$11,523.64 ",IP,"11,523.64","41,019.55",,,,,,
UHC MCR ADV,DRG,MS-248,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Surgical,Relative Weights,"$18,467.49 ",IP,"18,467.49","62,425.44",,,,,,
UHC MCR ADV,DRG,MS-249,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITHOUT MCC,Surgical,Relative Weights,"$10,942.55 ",IP,"10,942.55","38,638.66",,,,,,
UHC MCR ADV,DRG,MS-250,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT CORONARY ARTERY STENT WITH MCC,Surgical,Relative Weights,"$14,727.51 ",IP,"14,727.51","51,410.02",,,,,,
UHC MCR ADV,DRG,MS-251,PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W/O MCC,Surgical,Relative Weights,"$9,685.18 ",IP,"2,420.00","33,929.28",,,,,,
UHC MCR ADV,DRG,MS-252,OTHER VASCULAR PROCEDURES W MCC,Surgical,Relative Weights,"$19,422.35 ",IP,"2,420.00","66,132.86",,,,,,
UHC MCR ADV,DRG,MS-253,OTHER VASCULAR PROCEDURES WITH CC,Surgical,Relative Weights,"$15,497.23 ",IP,"2,420.00","52,549.06",,,,,,
UHC MCR ADV,DRG,MS-254,OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,605.00 ",IP,"2,420.00","36,693.22",,,,,,
UHC MCR ADV,DRG,MS-255,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,Surgical,Relative Weights,"$14,806.35 ",IP,"2,420.00","53,415.94",,,,,,
UHC MCR ADV,DRG,MS-256,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,Surgical,Relative Weights,"$9,602.26 ",IP,"2,420.00","34,604.64",,,,,,
UHC MCR ADV,DRG,MS-257,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$6,804.86 ",IP,"2,420.00","22,869.50",,,,,,
UHC MCR ADV,DRG,MS-258,CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,Surgical,Relative Weights,"$18,501.95 ",IP,"11,861.00","61,663.39",,,,,,
UHC MCR ADV,DRG,MS-259,CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,Surgical,Relative Weights,"$12,201.09 ",IP,"11,861.00","41,985.22",,,,,,
UHC MCR ADV,DRG,MS-260,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,Surgical,Relative Weights,"$20,833.31 ",IP,"10,167.00","74,583.94",,,,,,
UHC MCR ADV,DRG,MS-261,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,Surgical,Relative Weights,"$11,644.53 ",IP,"10,167.00","39,281.76",,,,,,
UHC MCR ADV,DRG,MS-262,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,Surgical,Relative Weights,"$9,964.34 ",IP,"9,964.34","33,820.42",,,,,,
UHC MCR ADV,DRG,MS-263,VEIN LIGATION AND STRIPPING,Surgical,Relative Weights,"$13,509.27 ",IP,"2,420.00","47,559.46",,,,,,
UHC MCR ADV,DRG,MS-264,OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,Surgical,Relative Weights,"$19,001.28 ",IP,"2,420.00","65,278.08",,,,,,
UHC MCR ADV,DRG,MS-265,AICD LEAD PROCEDURES,Surgical,Relative Weights,"$19,654.78 ",IP,"2,420.00","62,925.41",,,,,,
UHC MCR ADV,DRG,MS-266,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,Surgical,Relative Weights,"$41,160.28 ",IP,"41,160.28","143,567.42",,,,,,
UHC MCR ADV,DRG,MS-267,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$32,692.75 ",IP,"32,692.75","114,420.10",,,,,,
UHC MCR ADV,DRG,MS-268,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,Surgical,Relative Weights,"$40,666.21 ",IP,"32,968.00","136,737.22",,,,,,
UHC MCR ADV,DRG,MS-269,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,Surgical,Relative Weights,"$25,200.52 ",IP,"25,200.52","86,010.62",,,,,,
UHC MCR ADV,DRG,MS-270,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,Surgical,Relative Weights,"$30,292.48 ",IP,"30,292.48","103,021.63",,,,,,
UHC MCR ADV,DRG,MS-271,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,Surgical,Relative Weights,"$20,822.21 ",IP,"20,822.21","71,527.68",,,,,,
UHC MCR ADV,DRG,MS-272,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$15,699.88 ",IP,"15,699.88","52,442.21",,,,,,
UHC MCR ADV,DRG,MS-273,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,Surgical,Relative Weights,"$22,348.22 ",IP,"16,176.00","74,799.65",,,,,,
UHC MCR ADV,DRG,MS-274,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$19,194.00 ",IP,"16,176.00","63,701.57",,,,,,
UHC MCR ADV,DRG,MS-280,ACUTE MYOCARDIAL INFARCTION - DISCHARGED ALIVE W MCC,Medical,Relative Weights,"$9,384.42 ",IP,"2,420.00","32,878.94",,,,,,
UHC MCR ADV,DRG,MS-281,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITH CC,Medical,Relative Weights,"$5,434.78 ",IP,"2,420.00","19,528.99",,,,,,
UHC MCR ADV,DRG,MS-282,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITHOUT CC/MCC,Medical,Relative Weights,"$4,240.48 ",IP,"2,420.00","14,876.06",,,,,,
UHC MCR ADV,DRG,MS-283,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH MCC,Medical,Relative Weights,"$10,889.99 ",IP,"2,420.00","36,281.95",,,,,,
UHC MCR ADV,DRG,MS-284,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH CC,Medical,Relative Weights,"$4,224.71 ",IP,"2,420.00","14,622.05",,,,,,
UHC MCR ADV,DRG,MS-285,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITHOUT CC/MCC,Medical,Relative Weights,"$2,889.09 ",IP,"2,420.00","10,438.85",,,,,,
UHC MCR ADV,DRG,MS-286,CIRCULATORY DISORDERS EXCEPT AMI- WITH CARDIAC CATHETERIZATION WITH MCC,Medical,Relative Weights,"$12,476.16 ",IP,"2,420.00","44,299.58",,,,,,
UHC MCR ADV,DRG,MS-287,CIRCULATORY DISORDERS EXCEPT AMI -  WITH CARDIAC CATHETERIZATION WITHOUT MCC,Medical,Relative Weights,"$6,512.27 ",IP,"6,512.27","23,228.35",,,,,,
UHC MCR ADV,DRG,MS-288,ACUTE & SUBACUTE ENDOCARDITIS W MCC,Medical,Relative Weights,"$15,682.94 ",IP,"2,420.00","53,573.18",,,,,,
UHC MCR ADV,DRG,MS-289,ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,Medical,Relative Weights,"$9,598.75 ",IP,"9,181.00","33,542.21",,,,,,
UHC MCR ADV,DRG,MS-290,ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,Medical,Relative Weights,"$5,997.18 ",IP,"2,420.00","20,172.10",,,,,,
UHC MCR ADV,DRG,MS-291,HEART FAILURE AND SHOCK WITH MCC,Medical,Relative Weights,"$7,406.97 ",IP,"2,420.00","27,131.33",,,,,,
UHC MCR ADV,DRG,MS-292,HEART FAILURE AND SHOCK WITH CC,Medical,Relative Weights,"$5,042.91 ",IP,"2,420.00","18,254.88",,,,,,
UHC MCR ADV,DRG,MS-293,HEART FAILURE AND SHOCK WITHOUT CC/MCC,Medical,Relative Weights,"$3,445.06 ",IP,"2,420.00","13,210.85",,,,,,
UHC MCR ADV,DRG,MS-294,DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC,Medical,Relative Weights,"$7,491.65 ",IP,"2,420.00","25,641.50",,,,,,
UHC MCR ADV,DRG,MS-295,DEEP VEIN THROMBOPHLEBITIS W/O CC/MCC,Medical,Relative Weights,"$5,747.22 ",IP,"2,420.00","11,632.32",,,,,,
UHC MCR ADV,DRG,MS-296,CARDIAC ARREST - UNEXPLAINED W MCC,Medical,Relative Weights,"$9,316.09 ",IP,"2,420.00","31,659.26",,,,,,
UHC MCR ADV,DRG,MS-297,CARDIAC ARREST- UNEXPLAINED WITH CC,Medical,Relative Weights,"$4,128.93 ",IP,"2,420.00","14,575.68",,,,,,
UHC MCR ADV,DRG,MS-298,CARDIAC ARREST- UNEXPLAINED WITHOUT CC/MCC,Medical,Relative Weights,"$2,854.63 ",IP,"2,420.00","10,144.51",,,,,,
UHC MCR ADV,DRG,MS-299,PERIPHERAL VASCULAR DISORDERS WITH MCC,Medical,Relative Weights,"$8,950.50 ",IP,"2,420.00","29,225.95",,,,,,
UHC MCR ADV,DRG,MS-300,PERIPHERAL VASCULAR DISORDERS WITH CC,Medical,Relative Weights,"$6,095.87 ",IP,"2,420.00","20,716.42",,,,,,
UHC MCR ADV,DRG,MS-301,PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$4,339.76 ",IP,"2,420.00","14,632.13",,,,,,
UHC MCR ADV,DRG,MS-302,ATHEROSCLEROSIS WITH MCC,Medical,Relative Weights,"$6,393.72 ",IP,"2,420.00","22,222.37",,,,,,
UHC MCR ADV,DRG,MS-303,ATHEROSCLEROSIS WITHOUT MCC,Medical,Relative Weights,"$3,957.24 ",IP,"2,420.00","13,622.11",,,,,,
UHC MCR ADV,DRG,MS-304,HYPERTENSION WITH MCC,Medical,Relative Weights,"$6,406.57 ",IP,"2,420.00","22,004.64",,,,,,
UHC MCR ADV,DRG,MS-305,HYPERTENSION WITHOUT MCC,Medical,Relative Weights,"$4,321.07 ",IP,"2,420.00","14,747.04",,,,,,
UHC MCR ADV,DRG,MS-306,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,Medical,Relative Weights,"$8,803.33 ",IP,"2,420.00","28,516.32",,,,,,
UHC MCR ADV,DRG,MS-307,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,Medical,Relative Weights,"$5,083.20 ",IP,"2,420.00","17,785.15",,,,,,
UHC MCR ADV,DRG,MS-308,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,Medical,Relative Weights,"$7,013.35 ",IP,"2,420.00","23,944.03",,,,,,
UHC MCR ADV,DRG,MS-309,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,Medical,Relative Weights,"$4,382.98 ",IP,"2,420.00","15,247.01",,,,,,
UHC MCR ADV,DRG,MS-310,CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC,Medical,Relative Weights,"$3,265.77 ",IP,"2,420.00","11,275.49",,,,,,
UHC MCR ADV,DRG,MS-311,ANGINA PECTORIS,Medical,Relative Weights,"$4,079.29 ",IP,"2,420.00","13,809.60",,,,,,
UHC MCR ADV,DRG,MS-312,SYNCOPE AND COLLAPSE,Medical,Relative Weights,"$4,898.07 ",IP,"2,420.00","16,462.66",,,,,,
UHC MCR ADV,DRG,MS-313,CHEST PAIN,Medical,Relative Weights,"$4,213.03 ",IP,"2,420.00","14,420.45",,,,,,
UHC MCR ADV,DRG,MS-314,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,Medical,Relative Weights,"$12,174.81 ",IP,"2,420.00","40,914.72",,,,,,
UHC MCR ADV,DRG,MS-315,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,Medical,Relative Weights,"$5,684.73 ",IP,"2,420.00","19,563.26",,,,,,
UHC MCR ADV,DRG,MS-316,OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$4,224.71 ",IP,"2,420.00","14,962.75",,,,,,
UHC MCR ADV,DRG,MS-319,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,Surgical,Relative Weights,"$25,216.87 ",IP,"2,420.00","82,670.11",,,,,,
UHC MCR ADV,DRG,MS-320,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$14,048.89 ",IP,"2,420.00","47,329.63",,,,,,
UHC MCR ADV,DRG,MS-326,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$31,047.60 ",IP,"2,420.00","106,253.28",,,,,,
UHC MCR ADV,DRG,MS-327,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC,Surgical,Relative Weights,"$14,978.05 ",IP,"2,420.00","51,869.66",,,,,,
UHC MCR ADV,DRG,MS-328,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$9,734.83 ",IP,"2,420.00","31,752.00",,,,,,
UHC MCR ADV,DRG,MS-329,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Surgical,Relative Weights,"$28,535.79 ",IP,"2,420.00","98,929.15",,,,,,
UHC MCR ADV,DRG,MS-330,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Surgical,Relative Weights,"$14,888.11 ",IP,"2,420.00","50,940.29",,,,,,
UHC MCR ADV,DRG,MS-331,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$9,989.45 ",IP,"2,420.00","34,054.27",,,,,,
UHC MCR ADV,DRG,MS-332,RECTAL RESECTION WITH MCC,Surgical,Relative Weights,"$24,303.48 ",IP,"2,420.00","70,396.70",,,,,,
UHC MCR ADV,DRG,MS-333,RECTAL RESECTION WITH CC,Surgical,Relative Weights,"$12,505.36 ",IP,"2,420.00","45,626.11",,,,,,
UHC MCR ADV,DRG,MS-334,RECTAL RESECTION WITHOUT CC/MCC,Surgical,Relative Weights,"$9,394.35 ",IP,"2,420.00","31,052.45",,,,,,
UHC MCR ADV,DRG,MS-335,PERITONEAL ADHESIOLYSIS WITH MCC,Surgical,Relative Weights,"$22,855.14 ",IP,"2,420.00","81,549.22",,,,,,
UHC MCR ADV,DRG,MS-336,PERITONEAL ADHESIOLYSIS WITH CC,Surgical,Relative Weights,"$13,381.37 ",IP,"2,420.00","45,686.59",,,,,,
UHC MCR ADV,DRG,MS-337,PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$9,561.96 ",IP,"2,420.00","33,056.35",,,,,,
UHC MCR ADV,DRG,MS-338,APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$16,336.45 ",IP,"2,420.00","58,667.62",,,,,,
UHC MCR ADV,DRG,MS-339,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W CC,Surgical,Relative Weights,"$9,912.95 ",IP,"2,420.00","34,596.58",,,,,,
UHC MCR ADV,DRG,MS-340,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC/MCC,Surgical,Relative Weights,"$7,173.37 ",IP,"2,420.00","24,948.00",,,,,,
UHC MCR ADV,DRG,MS-341,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$13,563.00 ",IP,"2,420.00","51,571.30",,,,,,
UHC MCR ADV,DRG,MS-342,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH CC,Surgical,Relative Weights,"$8,368.25 ",IP,"2,420.00","32,463.65",,,,,,
UHC MCR ADV,DRG,MS-343,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$6,474.31 ",IP,"2,420.00","23,216.26",,,,,,
UHC MCR ADV,DRG,MS-344,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Surgical,Relative Weights,"$16,459.67 ",IP,"2,420.00","60,381.22",,,,,,
UHC MCR ADV,DRG,MS-345,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Surgical,Relative Weights,"$9,220.31 ",IP,"2,420.00","32,927.33",,,,,,
UHC MCR ADV,DRG,MS-346,MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,448.43 ",IP,"2,420.00","25,859.23",,,,,,
UHC MCR ADV,DRG,MS-347,ANAL AND STOMAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$14,394.04 ",IP,"2,420.00","53,149.82",,,,,,
UHC MCR ADV,DRG,MS-348,ANAL AND STOMAL PROCEDURES WITH CC,Surgical,Relative Weights,"$7,873.01 ",IP,"2,420.00","28,411.49",,,,,,
UHC MCR ADV,DRG,MS-349,ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$5,719.19 ",IP,"2,420.00","19,774.94",,,,,,
UHC MCR ADV,DRG,MS-350,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,Surgical,Relative Weights,"$14,336.22 ",IP,"2,420.00","49,176.29",,,,,,
UHC MCR ADV,DRG,MS-351,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,Surgical,Relative Weights,"$8,717.48 ",IP,"2,420.00","29,399.33",,,,,,
UHC MCR ADV,DRG,MS-352,INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,449.78 ",IP,"2,420.00","21,708.29",,,,,,
UHC MCR ADV,DRG,MS-353,HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,Surgical,Relative Weights,"$17,665.65 ",IP,"2,420.00","59,812.70",,,,,,
UHC MCR ADV,DRG,MS-354,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W CC,Surgical,Relative Weights,"$10,423.37 ",IP,"2,420.00","34,717.54",,,,,,
UHC MCR ADV,DRG,MS-355,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W/O CC/MCC,Surgical,Relative Weights,"$7,943.67 ",IP,"2,420.00","27,667.58",,,,,,
UHC MCR ADV,DRG,MS-356,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$25,157.89 ",IP,"2,420.00","82,196.35",,,,,,
UHC MCR ADV,DRG,MS-357,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$13,248.22 ",IP,"2,420.00","45,368.06",,,,,,
UHC MCR ADV,DRG,MS-358,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,878.85 ",IP,"2,420.00","27,653.47",,,,,,
UHC MCR ADV,DRG,MS-368,MAJOR ESOPHAGEAL DISORDERS WITH MCC,Medical,Relative Weights,"$11,382.90 ",IP,"2,420.00","38,376.58",,,,,,
UHC MCR ADV,DRG,MS-369,MAJOR ESOPHAGEAL DISORDERS WITH CC,Medical,Relative Weights,"$6,290.93 ",IP,"2,420.00","21,432.10",,,,,,
UHC MCR ADV,DRG,MS-370,MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$4,368.96 ",IP,"2,420.00","15,065.57",,,,,,
UHC MCR ADV,DRG,MS-371,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,Medical,Relative Weights,"$10,110.34 ",IP,"2,420.00","34,786.08",,,,,,
UHC MCR ADV,DRG,MS-372,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,Medical,Relative Weights,"$6,011.19 ",IP,"2,420.00","20,613.60",,,,,,
UHC MCR ADV,DRG,MS-373,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,Medical,Relative Weights,"$4,348.52 ",IP,"2,420.00","14,954.69",,,,,,
UHC MCR ADV,DRG,MS-374,DIGESTIVE MALIGNANCY WITH MCC,Medical,Relative Weights,"$12,110.57 ",IP,"2,420.00","40,269.60",,,,,,
UHC MCR ADV,DRG,MS-375,DIGESTIVE MALIGNANCY WITH CC,Medical,Relative Weights,"$7,052.48 ",IP,"2,420.00","24,339.17",,,,,,
UHC MCR ADV,DRG,MS-376,DIGESTIVE MALIGNANCY WITHOUT CC/MCC,Medical,Relative Weights,"$5,249.65 ",IP,"2,420.00","20,186.21",,,,,,
UHC MCR ADV,DRG,MS-377,GASTROINTESTINAL HEMORRHAGE WITH MCC,Medical,Relative Weights,"$10,519.15 ",IP,"2,420.00","35,681.18",,,,,,
UHC MCR ADV,DRG,MS-378,GASTROINTESTINAL HEMORRHAGE WITH CC,Medical,Relative Weights,"$5,802.12 ",IP,"2,420.00","19,920.10",,,,,,
UHC MCR ADV,DRG,MS-379,GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,Medical,Relative Weights,"$3,721.30 ",IP,"2,420.00","13,017.31",,,,,,
UHC MCR ADV,DRG,MS-380,COMPLICATED PEPTIC ULCER WITH MCC,Medical,Relative Weights,"$11,017.89 ",IP,"2,420.00","38,054.02",,,,,,
UHC MCR ADV,DRG,MS-381,COMPLICATED PEPTIC ULCER WITH CC,Medical,Relative Weights,"$6,186.39 ",IP,"2,420.00","21,706.27",,,,,,
UHC MCR ADV,DRG,MS-382,COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,Medical,Relative Weights,"$4,488.68 ",IP,"2,420.00","15,954.62",,,,,,
UHC MCR ADV,DRG,MS-383,UNCOMPLICATED PEPTIC ULCER WITH MCC,Medical,Relative Weights,"$7,665.69 ",IP,"2,420.00","26,738.21",,,,,,
UHC MCR ADV,DRG,MS-384,UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,Medical,Relative Weights,"$5,214.02 ",IP,"2,420.00","17,543.23",,,,,,
UHC MCR ADV,DRG,MS-385,INFLAMMATORY BOWEL DISEASE WITH MCC,Medical,Relative Weights,"$9,474.36 ",IP,"2,420.00","32,463.65",,,,,,
UHC MCR ADV,DRG,MS-386,INFLAMMATORY BOWEL DISEASE W CC,Medical,Relative Weights,"$5,811.46 ",IP,"2,420.00","19,861.63",,,,,,
UHC MCR ADV,DRG,MS-387,INFLAMMATORY BOWEL DISEASE W/O CC/MCC,Medical,Relative Weights,"$4,173.90 ",IP,"2,420.00","14,126.11",,,,,,
UHC MCR ADV,DRG,MS-388,GASTROINTESTINAL OBSTRUCTION WITH MCC,Medical,Relative Weights,"$8,845.38 ",IP,"2,420.00","30,746.02",,,,,,
UHC MCR ADV,DRG,MS-389,GASTROINTESTINAL OBSTRUCTION WITH CC,Medical,Relative Weights,"$4,807.55 ",IP,"2,420.00","16,928.35",,,,,,
UHC MCR ADV,DRG,MS-390,GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,Medical,Relative Weights,"$3,405.35 ",IP,"2,420.00","11,684.74",,,,,,
UHC MCR ADV,DRG,MS-391,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC,Medical,Relative Weights,"$7,295.42 ",IP,"2,420.00","24,897.60",,,,,,
UHC MCR ADV,DRG,MS-392,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC,Medical,Relative Weights,"$4,472.33 ",IP,"2,420.00","15,351.84",,,,,,
UHC MCR ADV,DRG,MS-393,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,Medical,Relative Weights,"$9,701.54 ",IP,"2,420.00","32,749.92",,,,,,
UHC MCR ADV,DRG,MS-394,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,Medical,Relative Weights,"$5,494.93 ",IP,"2,420.00","18,912.10",,,,,,
UHC MCR ADV,DRG,MS-395,OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$3,804.81 ",IP,"2,420.00","13,192.70",,,,,,
UHC MCR ADV,DRG,MS-405,PANCREAS- LIVER AND SHUNT PROCEDURES WITH MCC,Surgical,Relative Weights,"$33,508.03 ",IP,"2,420.00","109,412.35",,,,,,
UHC MCR ADV,DRG,MS-406,PANCREAS -  LIVER AND SHUNT PROCEDURES WITH CC,Surgical,Relative Weights,"$16,824.68 ",IP,"2,420.00","56,264.54",,,,,,
UHC MCR ADV,DRG,MS-407,PANCREAS -  LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$12,369.28 ",IP,"2,420.00","42,059.81",,,,,,
UHC MCR ADV,DRG,MS-408,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,Surgical,Relative Weights,"$21,917.23 ",IP,"2,420.00","71,842.18",,,,,,
UHC MCR ADV,DRG,MS-409,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,Surgical,Relative Weights,"$12,359.94 ",IP,"2,420.00","48,259.01",,,,,,
UHC MCR ADV,DRG,MS-410,BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W/O CC/MCC,Surgical,Relative Weights,"$9,158.99 ",IP,"2,420.00","33,465.60",,,,,,
UHC MCR ADV,DRG,MS-411,CHOLECYSTECTOMY W C.D.E. W MCC,Surgical,Relative Weights,"$21,920.73 ",IP,"2,420.00","77,220.86",,,,,,
UHC MCR ADV,DRG,MS-412,CHOLECYSTECTOMY WITH C.D.E. WITH CC,Surgical,Relative Weights,"$13,300.78 ",IP,"2,420.00","47,920.32",,,,,,
UHC MCR ADV,DRG,MS-413,CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,Surgical,Relative Weights,"$10,108.59 ",IP,"2,420.00","32,604.77",,,,,,
UHC MCR ADV,DRG,MS-414,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,Surgical,Relative Weights,"$21,189.55 ",IP,"2,420.00","68,874.62",,,,,,
UHC MCR ADV,DRG,MS-415,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,Surgical,Relative Weights,"$11,865.29 ",IP,"2,420.00","41,362.27",,,,,,
UHC MCR ADV,DRG,MS-416,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,Surgical,Relative Weights,"$8,306.34 ",IP,"2,420.00","27,222.05",,,,,,
UHC MCR ADV,DRG,MS-417,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,Surgical,Relative Weights,"$14,158.10 ",IP,"2,420.00","48,599.71",,,,,,
UHC MCR ADV,DRG,MS-418,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,Surgical,Relative Weights,"$9,863.89 ",IP,"2,420.00","33,645.02",,,,,,
UHC MCR ADV,DRG,MS-419,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,Surgical,Relative Weights,"$7,681.45 ",IP,"2,420.00","26,345.09",,,,,,
UHC MCR ADV,DRG,MS-420,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,Surgical,Relative Weights,"$20,536.63 ",IP,"2,420.00","69,245.57",,,,,,
UHC MCR ADV,DRG,MS-421,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,Surgical,Relative Weights,"$11,139.95 ",IP,"2,420.00","37,118.59",,,,,,
UHC MCR ADV,DRG,MS-422,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,489.14 ",IP,"2,420.00","28,314.72",,,,,,
UHC MCR ADV,DRG,MS-423,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$24,445.98 ",IP,"2,420.00","85,442.11",,,,,,
UHC MCR ADV,DRG,MS-424,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$13,339.32 ",IP,"2,420.00","45,388.22",,,,,,
UHC MCR ADV,DRG,MS-425,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$9,009.49 ",IP,"2,420.00","29,463.84",,,,,,
UHC MCR ADV,DRG,MS-432,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,Medical,Relative Weights,"$10,984.02 ",IP,"2,420.00","36,759.74",,,,,,
UHC MCR ADV,DRG,MS-433,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,Medical,Relative Weights,"$6,014.70 ",IP,"2,420.00","20,805.12",,,,,,
UHC MCR ADV,DRG,MS-434,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Medical,Relative Weights,"$3,624.94 ",IP,"2,420.00","12,900.38",,,,,,
UHC MCR ADV,DRG,MS-435,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,Medical,Relative Weights,"$10,239.99 ",IP,"2,420.00","34,213.54",,,,,,
UHC MCR ADV,DRG,MS-436,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,Medical,Relative Weights,"$6,549.65 ",IP,"2,420.00","22,694.11",,,,,,
UHC MCR ADV,DRG,MS-437,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,Medical,Relative Weights,"$5,232.13 ",IP,"2,420.00","17,698.46",,,,,,
UHC MCR ADV,DRG,MS-438,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,Medical,Relative Weights,"$9,331.28 ",IP,"2,420.00","33,028.13",,,,,,
UHC MCR ADV,DRG,MS-439,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,Medical,Relative Weights,"$4,936.03 ",IP,"2,420.00","17,079.55",,,,,,
UHC MCR ADV,DRG,MS-440,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,Medical,Relative Weights,"$3,540.84 ",IP,"2,420.00","12,410.50",,,,,,
UHC MCR ADV,DRG,MS-441,DISORDERS OF LIVER EXCEPT MALIGNANCY- CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC,Medical,Relative Weights,"$10,976.43 ",IP,"2,420.00","37,306.08",,,,,,
UHC MCR ADV,DRG,MS-442,DISORDERS OF LIVER EXCEPT MALIGNANCY -  CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC,Medical,Relative Weights,"$5,431.27 ",IP,"2,420.00","18,817.34",,,,,,
UHC MCR ADV,DRG,MS-443,DISORDERS OF LIVER EXCEPT MALIGNANCY -  CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Medical,Relative Weights,"$3,873.14 ",IP,"2,420.00","13,714.85",,,,,,
UHC MCR ADV,DRG,MS-444,DISORDERS OF THE BILIARY TRACT WITH MCC,Medical,Relative Weights,"$9,762.27 ",IP,"2,420.00","32,782.18",,,,,,
UHC MCR ADV,DRG,MS-445,DISORDERS OF THE BILIARY TRACT WITH CC,Medical,Relative Weights,"$6,292.68 ",IP,"2,420.00","21,661.92",,,,,,
UHC MCR ADV,DRG,MS-446,DISORDERS OF THE BILIARY TRACT W/O CC/MCC,Medical,Relative Weights,"$4,769.01 ",IP,"2,420.00","16,384.03",,,,,,
UHC MCR ADV,DRG,MS-453,COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W MCC,Surgical,Relative Weights,"$53,658.63 ",IP,"2,420.00","189,645.12",,,,,,
UHC MCR ADV,DRG,MS-454,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC,Surgical,Relative Weights,"$35,584.18 ",IP,"2,420.00","123,480.00",,,,,,
UHC MCR ADV,DRG,MS-455,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CC/MCC,Surgical,Relative Weights,"$27,923.16 ",IP,"2,420.00","97,036.13",,,,,,
UHC MCR ADV,DRG,MS-456,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH MCC,Surgical,Relative Weights,"$50,224.67 ",IP,"2,420.00","183,076.99",,,,,,
UHC MCR ADV,DRG,MS-457,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH CC,Surgical,Relative Weights,"$37,936.56 ",IP,"2,420.00","131,308.13",,,,,,
UHC MCR ADV,DRG,MS-458,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC,Surgical,Relative Weights,"$29,244.77 ",IP,"2,420.00","94,629.02",,,,,,
UHC MCR ADV,DRG,MS-459,SPINAL FUSION EXCEPT CERVICAL WITH MCC,Surgical,Relative Weights,"$39,324.16 ",IP,"21,658.00","138,136.32",,,,,,
UHC MCR ADV,DRG,MS-460,SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,Surgical,Relative Weights,"$22,955.59 ",IP,"21,658.00","79,841.66",,,,,,
UHC MCR ADV,DRG,MS-461,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,Surgical,Relative Weights,"$35,517.60 ",IP,"2,420.00","108,436.61",,,,,,
UHC MCR ADV,DRG,MS-462,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,Surgical,Relative Weights,"$18,346.02 ",IP,"2,420.00","63,229.82",,,,,,
UHC MCR ADV,DRG,MS-463,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,Surgical,Relative Weights,"$31,362.97 ",IP,"2,420.00","105,392.45",,,,,,
UHC MCR ADV,DRG,MS-464,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,Surgical,Relative Weights,"$17,379.49 ",IP,"2,420.00","59,526.43",,,,,,
UHC MCR ADV,DRG,MS-465,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$10,769.69 ",IP,"2,420.00","38,610.43",,,,,,
UHC MCR ADV,DRG,MS-466,REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,Surgical,Relative Weights,"$31,219.30 ",IP,"2,420.00","102,797.86",,,,,,
UHC MCR ADV,DRG,MS-467,REVISION OF HIP OR KNEE REPLACEMENT W CC,Surgical,Relative Weights,"$20,892.88 ",IP,"2,420.00","70,803.94",,,,,,
UHC MCR ADV,DRG,MS-468,REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,Surgical,Relative Weights,"$16,366.23 ",IP,"2,420.00","56,691.94",,,,,,
UHC MCR ADV,DRG,MS-469,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,Surgical,Relative Weights,"$18,021.90 ",IP,"2,420.00","63,300.38",,,,,,
UHC MCR ADV,DRG,MS-470,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,Surgical,Relative Weights,"$11,097.90 ",IP,"2,420.00","39,682.94",,,,,,
UHC MCR ADV,DRG,MS-471,CERVICAL SPINAL FUSION WITH MCC,Surgical,Relative Weights,"$29,315.44 ",IP,"15,407.00","100,687.10",,,,,,
UHC MCR ADV,DRG,MS-472,CERVICAL SPINAL FUSION WITH CC,Surgical,Relative Weights,"$17,833.84 ",IP,"15,407.00","61,316.64",,,,,,
UHC MCR ADV,DRG,MS-473,CERVICAL SPINAL FUSION WITHOUT CC/MCC,Surgical,Relative Weights,"$14,827.96 ",IP,"14,827.96","50,649.98",,,,,,
UHC MCR ADV,DRG,MS-474,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,Surgical,Relative Weights,"$23,804.74 ",IP,"2,420.00","78,117.98",,,,,,
UHC MCR ADV,DRG,MS-475,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,Surgical,Relative Weights,"$12,826.56 ",IP,"2,420.00","42,356.16",,,,,,
UHC MCR ADV,DRG,MS-476,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$6,776.24 ",IP,"2,420.00","23,480.35",,,,,,
UHC MCR ADV,DRG,MS-477,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Surgical,Relative Weights,"$19,616.24 ",IP,"2,420.00","65,626.85",,,,,,
UHC MCR ADV,DRG,MS-478,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Surgical,Relative Weights,"$13,773.24 ",IP,"2,420.00","46,712.74",,,,,,
UHC MCR ADV,DRG,MS-479,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Surgical,Relative Weights,"$10,567.62 ",IP,"2,420.00","35,929.15",,,,,,
UHC MCR ADV,DRG,MS-480,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,Surgical,Relative Weights,"$17,670.91 ",IP,"2,420.00","60,852.96",,,,,,
UHC MCR ADV,DRG,MS-481,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,Surgical,Relative Weights,"$12,241.39 ",IP,"2,420.00","42,090.05",,,,,,
UHC MCR ADV,DRG,MS-482,HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC,Surgical,Relative Weights,"$9,611.60 ",IP,"2,420.00","33,169.25",,,,,,
UHC MCR ADV,DRG,MS-483,MAJOR JOINT & LIMB REATTACHMENT PROC OF UPPER EXTREMITY W CC/MCC,Surgical,Relative Weights,"$13,932.67 ",IP,"2,420.00","48,224.74",,,,,,
UHC MCR ADV,DRG,MS-485,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,Surgical,Relative Weights,"$19,912.33 ",IP,"2,420.00","66,104.64",,,,,,
UHC MCR ADV,DRG,MS-486,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,Surgical,Relative Weights,"$12,552.66 ",IP,"2,420.00","43,356.10",,,,,,
UHC MCR ADV,DRG,MS-487,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Surgical,Relative Weights,"$9,578.90 ",IP,"2,420.00","32,401.15",,,,,,
UHC MCR ADV,DRG,MS-488,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,Surgical,Relative Weights,"$11,538.24 ",IP,"2,420.00","39,699.07",,,,,,
UHC MCR ADV,DRG,MS-489,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Surgical,Relative Weights,"$7,581.59 ",IP,"2,420.00","25,381.44",,,,,,
UHC MCR ADV,DRG,MS-492,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH MCC,Surgical,Relative Weights,"$20,265.07 ",IP,"2,420.00","69,457.25",,,,,,
UHC MCR ADV,DRG,MS-493,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH CC,Surgical,Relative Weights,"$13,582.85 ",IP,"2,420.00","46,408.32",,,,,,
UHC MCR ADV,DRG,MS-494,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITHOUT CC/MCC,Surgical,Relative Weights,"$10,814.07 ",IP,"2,420.00","36,517.82",,,,,,
UHC MCR ADV,DRG,MS-495,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,Surgical,Relative Weights,"$21,268.98 ",IP,"2,420.00","69,201.22",,,,,,
UHC MCR ADV,DRG,MS-496,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,Surgical,Relative Weights,"$11,600.73 ",IP,"2,420.00","41,136.48",,,,,,
UHC MCR ADV,DRG,MS-497,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,Surgical,Relative Weights,"$8,476.87 ",IP,"2,420.00","29,621.09",,,,,,
UHC MCR ADV,DRG,MS-498,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,Surgical,Relative Weights,"$15,089.01 ",IP,"2,420.00","49,353.70",,,,,,
UHC MCR ADV,DRG,MS-499,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,Surgical,Relative Weights,"$7,002.25 ",IP,"2,420.00","23,202.14",,,,,,
UHC MCR ADV,DRG,MS-500,SOFT TISSUE PROCEDURES WITH MCC,Surgical,Relative Weights,"$18,626.93 ",IP,"2,420.00","60,786.43",,,,,,
UHC MCR ADV,DRG,MS-501,SOFT TISSUE PROCEDURES WITH CC,Surgical,Relative Weights,"$10,244.08 ",IP,"2,420.00","33,828.48",,,,,,
UHC MCR ADV,DRG,MS-502,SOFT TISSUE PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,783.66 ",IP,"2,420.00","26,625.31",,,,,,
UHC MCR ADV,DRG,MS-503,FOOT PROCEDURES WITH MCC,Surgical,Relative Weights,"$15,421.31 ",IP,"2,420.00","54,766.66",,,,,,
UHC MCR ADV,DRG,MS-504,FOOT PROCEDURES WITH CC,Surgical,Relative Weights,"$10,366.14 ",IP,"2,420.00","35,007.84",,,,,,
UHC MCR ADV,DRG,MS-505,FOOT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,366.14 ",IP,"2,420.00","33,899.04",,,,,,
UHC MCR ADV,DRG,MS-506,MAJOR THUMB OR JOINT PROCEDURES,Surgical,Relative Weights,"$8,664.34 ",IP,"2,420.00","26,986.18",,,,,,
UHC MCR ADV,DRG,MS-507,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W CC/MCC,Surgical,Relative Weights,"$12,035.82 ",IP,"2,420.00","42,336.00",,,,,,
UHC MCR ADV,DRG,MS-508,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$8,232.76 ",IP,"2,420.00","31,417.34",,,,,,
UHC MCR ADV,DRG,MS-509,ARTHROSCOPY,Surgical,Relative Weights,"$9,849.29 ",IP,"2,420.00","28,056.67",,,,,,
UHC MCR ADV,DRG,MS-510,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH MCC,Surgical,Relative Weights,"$16,023.42 ",IP,"2,420.00","56,206.08",,,,,,
UHC MCR ADV,DRG,MS-511,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH CC,Surgical,Relative Weights,"$11,489.77 ",IP,"2,420.00","37,985.47",,,,,,
UHC MCR ADV,DRG,MS-512,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$9,078.40 ",IP,"2,420.00","30,518.21",,,,,,
UHC MCR ADV,DRG,MS-513,HAND OR WRIST PROCEDURES- EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$9,180.60 ",IP,"2,420.00","31,794.34",,,,,,
UHC MCR ADV,DRG,MS-514,HAND OR WRIST PROCEDURES -  EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$5,834.82 ",IP,"2,420.00","21,506.69",,,,,,
UHC MCR ADV,DRG,MS-515,OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W MCC,Surgical,Relative Weights,"$18,341.35 ",IP,"2,420.00","63,584.64",,,,,,
UHC MCR ADV,DRG,MS-516,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$11,462.90 ",IP,"2,420.00","39,092.26",,,,,,
UHC MCR ADV,DRG,MS-517,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,165.60 ",IP,"2,420.00","28,532.45",,,,,,
UHC MCR ADV,DRG,MS-518,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,Surgical,Relative Weights,"$20,947.77 ",IP,"10,289.00","68,717.38",,,,,,
UHC MCR ADV,DRG,MS-519,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,Surgical,Relative Weights,"$11,446.55 ",IP,"10,289.00","38,479.39",,,,,,
UHC MCR ADV,DRG,MS-520,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,Surgical,Relative Weights,"$8,282.98 ",IP,"8,282.98","26,974.08",,,,,,
UHC MCR ADV,DRG,MS-521,HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,Surgical,Relative Weights,"$17,906.85 ",IP,"2,420.00","17,906.85",,,,,,
UHC MCR ADV,DRG,MS-522,HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,Surgical,Relative Weights,"$12,786.27 ",IP,"2,420.00","12,786.27",,,,,,
UHC MCR ADV,DRG,MS-533,FRACTURES OF FEMUR WITH MCC,Medical,Relative Weights,"$8,270.72 ",IP,"2,420.00","29,421.50",,,,,,
UHC MCR ADV,DRG,MS-534,FRACTURES OF FEMUR WITHOUT MCC,Medical,Relative Weights,"$4,614.83 ",IP,"2,420.00","15,680.45",,,,,,
UHC MCR ADV,DRG,MS-535,FRACTURES OF HIP AND PELVIS WITH MCC,Medical,Relative Weights,"$7,199.65 ",IP,"2,420.00","24,738.34",,,,,,
UHC MCR ADV,DRG,MS-536,FRACTURES OF HIP AND PELVIS WITHOUT MCC,Medical,Relative Weights,"$4,506.79 ",IP,"2,420.00","15,291.36",,,,,,
UHC MCR ADV,DRG,MS-537,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITH CC/MCC,Medical,Relative Weights,"$5,462.81 ",IP,"2,420.00","18,363.74",,,,,,
UHC MCR ADV,DRG,MS-538,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITHOUT CC/MCC,Medical,Relative Weights,"$4,223.54 ",IP,"2,420.00","14,535.36",,,,,,
UHC MCR ADV,DRG,MS-539,OSTEOMYELITIS WITH MCC,Medical,Relative Weights,"$11,374.72 ",IP,"2,420.00","38,005.63",,,,,,
UHC MCR ADV,DRG,MS-540,OSTEOMYELITIS WITH CC,Medical,Relative Weights,"$7,601.45 ",IP,"2,420.00","26,208.00",,,,,,
UHC MCR ADV,DRG,MS-541,OSTEOMYELITIS WITHOUT CC/MCC,Medical,Relative Weights,"$4,924.35 ",IP,"2,420.00","18,279.07",,,,,,
UHC MCR ADV,DRG,MS-542,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,Medical,Relative Weights,"$10,565.87 ",IP,"2,420.00","36,787.97",,,,,,
UHC MCR ADV,DRG,MS-543,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,Medical,Relative Weights,"$6,104.05 ",IP,"2,420.00","21,295.01",,,,,,
UHC MCR ADV,DRG,MS-544,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,Medical,Relative Weights,"$4,541.83 ",IP,"2,420.00","15,289.34",,,,,,
UHC MCR ADV,DRG,MS-545,CONNECTIVE TISSUE DISORDERS WITH MCC,Medical,Relative Weights,"$14,618.30 ",IP,"2,420.00","50,964.48",,,,,,
UHC MCR ADV,DRG,MS-546,CONNECTIVE TISSUE DISORDERS WITH CC,Medical,Relative Weights,"$7,054.81 ",IP,"2,420.00","24,260.54",,,,,,
UHC MCR ADV,DRG,MS-547,CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$4,868.29 ",IP,"2,420.00","16,331.62",,,,,,
UHC MCR ADV,DRG,MS-548,SEPTIC ARTHRITIS WITH MCC,Medical,Relative Weights,"$11,976.83 ",IP,"2,420.00","39,983.33",,,,,,
UHC MCR ADV,DRG,MS-549,SEPTIC ARTHRITIS W CC,Medical,Relative Weights,"$7,299.51 ",IP,"2,420.00","24,052.90",,,,,,
UHC MCR ADV,DRG,MS-550,SEPTIC ARTHRITIS W/O CC/MCC,Medical,Relative Weights,"$5,132.84 ",IP,"2,420.00","17,418.24",,,,,,
UHC MCR ADV,DRG,MS-551,MEDICAL BACK PROBLEMS WITH MCC,Medical,Relative Weights,"$9,504.14 ",IP,"2,420.00","32,042.30",,,,,,
UHC MCR ADV,DRG,MS-552,MEDICAL BACK PROBLEMS WITHOUT MCC,Medical,Relative Weights,"$5,509.53 ",IP,"2,420.00","18,383.90",,,,,,
UHC MCR ADV,DRG,MS-553,BONE DISEASES AND ARTHROPATHIES WITH MCC,Medical,Relative Weights,"$7,425.66 ",IP,"2,420.00","25,915.68",,,,,,
UHC MCR ADV,DRG,MS-554,BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,Medical,Relative Weights,"$4,628.26 ",IP,"2,420.00","15,869.95",,,,,,
UHC MCR ADV,DRG,MS-555,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Medical,Relative Weights,"$7,992.15 ",IP,"2,420.00","26,516.45",,,,,,
UHC MCR ADV,DRG,MS-556,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,Medical,Relative Weights,"$4,722.87 ",IP,"2,420.00","15,962.69",,,,,,
UHC MCR ADV,DRG,MS-557,TENDONITIS -  MYOSITIS AND BURSITIS WITH MCC,Medical,Relative Weights,"$8,170.85 ",IP,"2,420.00","29,397.31",,,,,,
UHC MCR ADV,DRG,MS-558,TENDONITIS- MYOSITIS AND BURSITIS WITHOUT MCC,Medical,Relative Weights,"$5,030.64 ",IP,"2,420.00","17,365.82",,,,,,
UHC MCR ADV,DRG,MS-559,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Medical,Relative Weights,"$10,893.50 ",IP,"2,420.00","36,324.29",,,,,,
UHC MCR ADV,DRG,MS-560,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Medical,Relative Weights,"$6,283.92 ",IP,"2,420.00","21,036.96",,,,,,
UHC MCR ADV,DRG,MS-561,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Medical,Relative Weights,"$4,627.68 ",IP,"2,420.00","15,067.58",,,,,,
UHC MCR ADV,DRG,MS-562,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITH MCC,Medical,Relative Weights,"$8,245.02 ",IP,"2,420.00","27,157.54",,,,,,
UHC MCR ADV,DRG,MS-563,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITHOUT MCC,Medical,Relative Weights,"$5,093.72 ",IP,"2,420.00","17,216.64",,,,,,
UHC MCR ADV,DRG,MS-564,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,Medical,Relative Weights,"$8,897.94 ",IP,"2,420.00","30,481.92",,,,,,
UHC MCR ADV,DRG,MS-565,OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W CC,Medical,Relative Weights,"$5,894.39 ",IP,"2,420.00","19,766.88",,,,,,
UHC MCR ADV,DRG,MS-566,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$4,391.15 ",IP,"2,420.00","15,275.23",,,,,,
UHC MCR ADV,DRG,MS-570,SKIN DEBRIDEMENT WITH MCC,Surgical,Relative Weights,"$16,595.75 ",IP,"2,420.00","57,923.71",,,,,,
UHC MCR ADV,DRG,MS-571,SKIN DEBRIDEMENT WITH CC,Surgical,Relative Weights,"$9,550.86 ",IP,"2,420.00","33,713.57",,,,,,
UHC MCR ADV,DRG,MS-572,SKIN DEBRIDEMENT WITHOUT CC/MCC,Surgical,Relative Weights,"$6,449.78 ",IP,"2,420.00","22,613.47",,,,,,
UHC MCR ADV,DRG,MS-573,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,Surgical,Relative Weights,"$32,348.77 ",IP,"2,420.00","107,156.45",,,,,,
UHC MCR ADV,DRG,MS-574,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,Surgical,Relative Weights,"$18,959.81 ",IP,"2,420.00","62,935.49",,,,,,
UHC MCR ADV,DRG,MS-575,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS W/O CC/MCC,Surgical,Relative Weights,"$10,297.22 ",IP,"2,420.00","35,421.12",,,,,,
UHC MCR ADV,DRG,MS-576,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,Surgical,Relative Weights,"$29,572.40 ",IP,"2,420.00","97,759.87",,,,,,
UHC MCR ADV,DRG,MS-577,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,Surgical,Relative Weights,"$14,889.86 ",IP,"2,420.00","48,698.50",,,,,,
UHC MCR ADV,DRG,MS-578,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,Surgical,Relative Weights,"$9,316.09 ",IP,"2,420.00","32,808.38",,,,,,
UHC MCR ADV,DRG,MS-579,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC,Surgical,Relative Weights,"$18,366.46 ",IP,"2,420.00","60,199.78",,,,,,
UHC MCR ADV,DRG,MS-580,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC,Surgical,Relative Weights,"$10,096.33 ",IP,"2,420.00","32,431.39",,,,,,
UHC MCR ADV,DRG,MS-581,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,040.62 ",IP,"2,420.00","25,296.77",,,,,,
UHC MCR ADV,DRG,MS-582,MASTECTOMY FOR MALIGNANCY WITH CC/MCC,Surgical,Relative Weights,"$9,595.83 ",IP,"2,420.00","31,826.59",,,,,,
UHC MCR ADV,DRG,MS-583,MASTECTOMY FOR MALIGNANCY W/O CC/MCC,Surgical,Relative Weights,"$9,002.48 ",IP,"2,420.00","29,461.82",,,,,,
UHC MCR ADV,DRG,MS-584,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$10,726.47 ",IP,"2,420.00","36,860.54",,,,,,
UHC MCR ADV,DRG,MS-585,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,159.40 ",IP,"2,420.00","34,217.57",,,,,,
UHC MCR ADV,DRG,MS-592,SKIN ULCERS WITH MCC,Medical,Relative Weights,"$9,894.84 ",IP,"2,420.00","35,971.49",,,,,,
UHC MCR ADV,DRG,MS-593,SKIN ULCERS WITH CC,Medical,Relative Weights,"$6,661.19 ",IP,"2,420.00","23,139.65",,,,,,
UHC MCR ADV,DRG,MS-594,SKIN ULCERS WITHOUT CC/MCC,Medical,Relative Weights,"$4,765.50 ",IP,"2,420.00","16,323.55",,,,,,
UHC MCR ADV,DRG,MS-595,MAJOR SKIN DISORDERS WITH MCC,Medical,Relative Weights,"$11,776.52 ",IP,"2,420.00","40,977.22",,,,,,
UHC MCR ADV,DRG,MS-596,MAJOR SKIN DISORDERS W/O MCC,Medical,Relative Weights,"$5,809.13 ",IP,"2,420.00","19,637.86",,,,,,
UHC MCR ADV,DRG,MS-597,MALIGNANT BREAST DISORDERS W MCC,Medical,Relative Weights,"$9,601.09 ",IP,"2,420.00","34,128.86",,,,,,
UHC MCR ADV,DRG,MS-598,MALIGNANT BREAST DISORDERS WITH CC,Medical,Relative Weights,"$6,499.42 ",IP,"2,420.00","21,946.18",,,,,,
UHC MCR ADV,DRG,MS-599,MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$3,921.03 ",IP,"2,420.00","14,019.26",,,,,,
UHC MCR ADV,DRG,MS-600,NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,Medical,Relative Weights,"$5,821.97 ",IP,"2,420.00","19,337.47",,,,,,
UHC MCR ADV,DRG,MS-601,NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$4,010.97 ",IP,"2,420.00","12,475.01",,,,,,
UHC MCR ADV,DRG,MS-602,CELLULITIS WITH MCC,Medical,Relative Weights,"$8,468.11 ",IP,"2,420.00","28,824.77",,,,,,
UHC MCR ADV,DRG,MS-603,CELLULITIS WITHOUT MCC,Medical,Relative Weights,"$4,985.09 ",IP,"2,420.00","17,004.96",,,,,,
UHC MCR ADV,DRG,MS-604,TRAUMA TO THE SKIN -  SUBCUTANEOUS TISSUE AND BREAST WITH MCC,Medical,Relative Weights,"$8,631.05 ",IP,"2,420.00","29,524.32",,,,,,
UHC MCR ADV,DRG,MS-605,TRAUMA TO THE SKIN- SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC,Medical,Relative Weights,"$5,278.85 ",IP,"2,420.00","17,654.11",,,,,,
UHC MCR ADV,DRG,MS-606,MINOR SKIN DISORDERS WITH MCC,Medical,Relative Weights,"$8,830.78 ",IP,"2,420.00","30,149.28",,,,,,
UHC MCR ADV,DRG,MS-607,MINOR SKIN DISORDERS WITHOUT MCC,Medical,Relative Weights,"$4,836.75 ",IP,"2,420.00","16,654.18",,,,,,
UHC MCR ADV,DRG,MS-614,ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$13,956.03 ",IP,"2,420.00","49,055.33",,,,,,
UHC MCR ADV,DRG,MS-615,ADRENAL & PITUITARY PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$9,198.12 ",IP,"2,420.00","29,919.46",,,,,,
UHC MCR ADV,DRG,MS-616,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Surgical,Relative Weights,"$23,162.92 ",IP,"2,420.00","80,656.13",,,,,,
UHC MCR ADV,DRG,MS-617,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Surgical,Relative Weights,"$11,854.19 ",IP,"2,420.00","41,354.21",,,,,,
UHC MCR ADV,DRG,MS-618,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$7,610.79 ",IP,"2,420.00","25,290.72",,,,,,
UHC MCR ADV,DRG,MS-619,O.R. PROCEDURES FOR OBESITY WITH MCC,Surgical,Relative Weights,"$17,880.57 ",IP,"2,420.00","62,062.56",,,,,,
UHC MCR ADV,DRG,MS-620,O.R. PROCEDURES FOR OBESITY WITH CC,Surgical,Relative Weights,"$10,294.30 ",IP,"2,420.00","36,179.14",,,,,,
UHC MCR ADV,DRG,MS-621,O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,Surgical,Relative Weights,"$9,327.19 ",IP,"2,420.00","31,691.52",,,,,,
UHC MCR ADV,DRG,MS-622,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Surgical,Relative Weights,"$21,111.30 ",IP,"2,420.00","76,114.08",,,,,,
UHC MCR ADV,DRG,MS-623,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE -  NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Surgical,Relative Weights,"$10,929.71 ",IP,"2,420.00","39,364.42",,,,,,
UHC MCR ADV,DRG,MS-624,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Surgical,Relative Weights,"$6,417.66 ",IP,"2,420.00","22,216.32",,,,,,
UHC MCR ADV,DRG,MS-625,THYROID- PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC,Surgical,Relative Weights,"$16,586.99 ",IP,"2,420.00","58,970.02",,,,,,
UHC MCR ADV,DRG,MS-626,THYROID -  PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC,Surgical,Relative Weights,"$9,653.06 ",IP,"2,420.00","33,925.25",,,,,,
UHC MCR ADV,DRG,MS-627,THYROID -  PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,907.64 ",IP,"2,420.00","23,016.67",,,,,,
UHC MCR ADV,DRG,MS-628,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$21,487.98 ",IP,"2,420.00","74,376.29",,,,,,
UHC MCR ADV,DRG,MS-629,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$13,696.73 ",IP,"2,420.00","46,827.65",,,,,,
UHC MCR ADV,DRG,MS-630,OTHER ENDOCRINE - NUTRIT & METAB O.R. PROC W/O CC/MCC,Surgical,Relative Weights,"$8,230.42 ",IP,"2,420.00","29,207.81",,,,,,
UHC MCR ADV,DRG,MS-637,DIABETES WITH MCC,Medical,Relative Weights,"$8,039.45 ",IP,"2,420.00","27,935.71",,,,,,
UHC MCR ADV,DRG,MS-638,DIABETES WITH CC,Medical,Relative Weights,"$5,135.76 ",IP,"2,420.00","17,823.46",,,,,,
UHC MCR ADV,DRG,MS-639,DIABETES WITHOUT CC/MCC,Medical,Relative Weights,"$3,560.11 ",IP,"2,420.00","12,362.11",,,,,,
UHC MCR ADV,DRG,MS-640,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITH MCC,Medical,Relative Weights,"$7,187.97 ",IP,"2,420.00","24,478.27",,,,,,
UHC MCR ADV,DRG,MS-641,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITHOUT MCC,Medical,Relative Weights,"$4,404.59 ",IP,"2,420.00","15,253.06",,,,,,
UHC MCR ADV,DRG,MS-642,INBORN AND OTHER DISORDERS OF METABOLISM,Medical,Relative Weights,"$7,532.53 ",IP,"2,420.00","24,510.53",,,,,,
UHC MCR ADV,DRG,MS-643,ENDOCRINE DISORDERS WITH MCC,Medical,Relative Weights,"$9,739.50 ",IP,"2,420.00","32,770.08",,,,,,
UHC MCR ADV,DRG,MS-644,ENDOCRINE DISORDERS WITH CC,Medical,Relative Weights,"$5,955.71 ",IP,"2,420.00","20,726.50",,,,,,
UHC MCR ADV,DRG,MS-645,ENDOCRINE DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$4,488.68 ",IP,"2,420.00","15,426.43",,,,,,
UHC MCR ADV,DRG,MS-650,KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,Neonate,Relative Weights,"$26,401.24 ",IP,"2,420.00","26,401.24",,,,,,
UHC MCR ADV,DRG,MS-651,KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,Neonate,Relative Weights,"$21,598.94 ",IP,"2,420.00","21,598.94",,,,,,
UHC MCR ADV,DRG,MS-652,KIDNEY TRANSPLANT,Surgical,Relative Weights,"$18,601.23 ",IP,"2,420.00","68,239.58",,,,,,
UHC MCR ADV,DRG,MS-653,MAJOR BLADDER PROCEDURES WITH MCC,Surgical,Relative Weights,"$31,882.15 ",IP,"2,420.00","111,615.84",,,,,,
UHC MCR ADV,DRG,MS-654,MAJOR BLADDER PROCEDURES WITH CC,Surgical,Relative Weights,"$16,952.58 ",IP,"2,420.00","56,693.95",,,,,,
UHC MCR ADV,DRG,MS-655,MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$12,149.11 ",IP,"2,420.00","41,577.98",,,,,,
UHC MCR ADV,DRG,MS-656,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,Surgical,Relative Weights,"$19,184.65 ",IP,"2,420.00","65,733.70",,,,,,
UHC MCR ADV,DRG,MS-657,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,Surgical,Relative Weights,"$11,298.80 ",IP,"2,420.00","38,993.47",,,,,,
UHC MCR ADV,DRG,MS-658,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,Surgical,Relative Weights,"$9,215.06 ",IP,"2,420.00","31,649.18",,,,,,
UHC MCR ADV,DRG,MS-659,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,Surgical,Relative Weights,"$15,571.98 ",IP,"2,420.00","54,024.77",,,,,,
UHC MCR ADV,DRG,MS-660,KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC,Surgical,Relative Weights,"$8,427.82 ",IP,"2,420.00","28,641.31",,,,,,
UHC MCR ADV,DRG,MS-661,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,Surgical,Relative Weights,"$6,212.09 ",IP,"2,420.00","21,976.42",,,,,,
UHC MCR ADV,DRG,MS-662,MINOR BLADDER PROCEDURES WITH MCC,Surgical,Relative Weights,"$17,154.06 ",IP,"2,420.00","63,800.35",,,,,,
UHC MCR ADV,DRG,MS-663,MINOR BLADDER PROCEDURES WITH CC,Surgical,Relative Weights,"$9,341.20 ",IP,"2,420.00","30,711.74",,,,,,
UHC MCR ADV,DRG,MS-664,MINOR BLADDER PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,913.48 ",IP,"2,420.00","22,309.06",,,,,,
UHC MCR ADV,DRG,MS-665,PROSTATECTOMY WITH MCC,Surgical,Relative Weights,"$17,763.76 ",IP,"2,420.00","59,844.96",,,,,,
UHC MCR ADV,DRG,MS-666,PROSTATECTOMY WITH CC,Surgical,Relative Weights,"$10,159.98 ",IP,"2,420.00","35,665.06",,,,,,
UHC MCR ADV,DRG,MS-667,PROSTATECTOMY W/O CC/MCC,Surgical,Relative Weights,"$5,825.48 ",IP,"2,420.00","18,924.19",,,,,,
UHC MCR ADV,DRG,MS-668,TRANSURETHRAL PROCEDURES W MCC,Surgical,Relative Weights,"$16,389.01 ",IP,"2,420.00","56,212.13",,,,,,
UHC MCR ADV,DRG,MS-669,TRANSURETHRAL PROCEDURES WITH CC,Surgical,Relative Weights,"$9,130.96 ",IP,"2,420.00","31,161.31",,,,,,
UHC MCR ADV,DRG,MS-670,TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$5,714.52 ",IP,"2,420.00","19,730.59",,,,,,
UHC MCR ADV,DRG,MS-671,URETHRAL PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$10,402.93 ",IP,"2,420.00","36,844.42",,,,,,
UHC MCR ADV,DRG,MS-672,URETHRAL PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,718.43 ",IP,"2,420.00","20,829.31",,,,,,
UHC MCR ADV,DRG,MS-673,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,Surgical,Relative Weights,"$20,255.14 ",IP,"2,420.00","72,063.94",,,,,,
UHC MCR ADV,DRG,MS-674,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,Surgical,Relative Weights,"$13,918.07 ",IP,"2,420.00","49,275.07",,,,,,
UHC MCR ADV,DRG,MS-675,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$10,247.58 ",IP,"2,420.00","32,901.12",,,,,,
UHC MCR ADV,DRG,MS-682,RENAL FAILURE WITH MCC,Medical,Relative Weights,"$8,600.68 ",IP,"2,420.00","29,796.48",,,,,,
UHC MCR ADV,DRG,MS-683,RENAL FAILURE WITH CC,Medical,Relative Weights,"$5,135.18 ",IP,"2,420.00","18,089.57",,,,,,
UHC MCR ADV,DRG,MS-684,RENAL FAILURE WITHOUT CC/MCC,Medical,Relative Weights,"$3,550.18 ",IP,"2,420.00","12,404.45",,,,,,
UHC MCR ADV,DRG,MS-686,KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,Medical,Relative Weights,"$10,951.90 ",IP,"2,420.00","35,402.98",,,,,,
UHC MCR ADV,DRG,MS-687,KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,Medical,Relative Weights,"$6,132.67 ",IP,"2,420.00","21,220.42",,,,,,
UHC MCR ADV,DRG,MS-688,KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,Medical,Relative Weights,"$4,005.13 ",IP,"2,420.00","15,549.41",,,,,,
UHC MCR ADV,DRG,MS-689,KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,Medical,Relative Weights,"$6,507.01 ",IP,"2,420.00","22,550.98",,,,,,
UHC MCR ADV,DRG,MS-690,KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,Medical,Relative Weights,"$4,637.02 ",IP,"2,420.00","15,942.53",,,,,,
UHC MCR ADV,DRG,MS-693,URINARY STONES WITH MCC,Medical,Relative Weights,"$7,799.42 ",IP,"2,420.00","27,282.53",,,,,,
UHC MCR ADV,DRG,MS-694,URINARY STONES WITHOUT MCC,Medical,Relative Weights,"$4,503.87 ",IP,"2,420.00","14,926.46",,,,,,
UHC MCR ADV,DRG,MS-695,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,Medical,Relative Weights,"$6,644.26 ",IP,"2,420.00","23,633.57",,,,,,
UHC MCR ADV,DRG,MS-696,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,Medical,Relative Weights,"$4,040.75 ",IP,"2,420.00","13,696.70",,,,,,
UHC MCR ADV,DRG,MS-697,URETHRAL STRICTURE,Medical,Relative Weights,"$5,835.99 ",IP,"2,420.00","19,633.82",,,,,,
UHC MCR ADV,DRG,MS-698,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,Medical,Relative Weights,"$9,406.03 ",IP,"2,420.00","32,630.98",,,,,,
UHC MCR ADV,DRG,MS-699,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,Medical,Relative Weights,"$5,997.76 ",IP,"2,420.00","20,819.23",,,,,,
UHC MCR ADV,DRG,MS-700,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$4,359.62 ",IP,"2,420.00","14,952.67",,,,,,
UHC MCR ADV,DRG,MS-707,MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$11,225.80 ",IP,"2,420.00","37,697.18",,,,,,
UHC MCR ADV,DRG,MS-708,MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,708.72 ",IP,"2,420.00","29,272.32",,,,,,
UHC MCR ADV,DRG,MS-709,PENIS PROCEDURES W CC/MCC,Surgical,Relative Weights,"$13,525.04 ",IP,"2,420.00","48,496.90",,,,,,
UHC MCR ADV,DRG,MS-710,PENIS PROCEDURES W/O CC/MCC,Surgical,Relative Weights,"$9,353.47 ",IP,"2,420.00","30,961.73",,,,,,
UHC MCR ADV,DRG,MS-711,TESTES PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$12,448.71 ",IP,"2,420.00","43,206.91",,,,,,
UHC MCR ADV,DRG,MS-712,TESTES PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,190.48 ",IP,"2,420.00","20,567.23",,,,,,
UHC MCR ADV,DRG,MS-713,TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,Surgical,Relative Weights,"$8,721.57 ",IP,"2,420.00","29,473.92",,,,,,
UHC MCR ADV,DRG,MS-714,TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,Surgical,Relative Weights,"$5,424.26 ",IP,"2,420.00","18,454.46",,,,,,
UHC MCR ADV,DRG,MS-715,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,Surgical,Relative Weights,"$11,806.30 ",IP,"2,420.00","43,071.84",,,,,,
UHC MCR ADV,DRG,MS-716,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$7,450.77 ",IP,"2,420.00","29,544.48",,,,,,
UHC MCR ADV,DRG,MS-717,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,Surgical,Relative Weights,"$10,515.64 ",IP,"2,420.00","35,568.29",,,,,,
UHC MCR ADV,DRG,MS-718,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$7,210.16 ",IP,"2,420.00","24,583.10",,,,,,
UHC MCR ADV,DRG,MS-722,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH MCC,Medical,Relative Weights,"$10,001.72 ",IP,"2,420.00","36,386.78",,,,,,
UHC MCR ADV,DRG,MS-723,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH CC,Medical,Relative Weights,"$6,376.78 ",IP,"2,420.00","22,325.18",,,,,,
UHC MCR ADV,DRG,MS-724,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Medical,Relative Weights,"$3,784.95 ",IP,"2,420.00","11,902.46",,,,,,
UHC MCR ADV,DRG,MS-725,BENIGN PROSTATIC HYPERTROPHY WITH MCC,Medical,Relative Weights,"$7,507.42 ",IP,"2,420.00","25,308.86",,,,,,
UHC MCR ADV,DRG,MS-726,BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,Medical,Relative Weights,"$4,349.11 ",IP,"2,420.00","15,416.35",,,,,,
UHC MCR ADV,DRG,MS-727,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,Medical,Relative Weights,"$8,298.75 ",IP,"2,420.00","28,774.37",,,,,,
UHC MCR ADV,DRG,MS-728,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,Medical,Relative Weights,"$4,705.35 ",IP,"2,420.00","16,178.40",,,,,,
UHC MCR ADV,DRG,MS-729,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,Medical,Relative Weights,"$5,883.88 ",IP,"2,420.00","21,649.82",,,,,,
UHC MCR ADV,DRG,MS-730,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$3,322.42 ",IP,"2,420.00","12,733.06",,,,,,
UHC MCR ADV,DRG,MS-734,PELVIC EVISCERATION -  RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC,Surgical,Relative Weights,"$12,990.08 ",IP,"2,420.00","44,188.70",,,,,,
UHC MCR ADV,DRG,MS-735,PELVIC EVISCERATION -  RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC,Surgical,Relative Weights,"$8,255.53 ",IP,"2,420.00","27,703.87",,,,,,
UHC MCR ADV,DRG,MS-736,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,Surgical,Relative Weights,"$24,882.82 ",IP,"2,420.00","87,109.34",,,,,,
UHC MCR ADV,DRG,MS-737,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,Surgical,Relative Weights,"$12,019.46 ",IP,"2,420.00","40,059.94",,,,,,
UHC MCR ADV,DRG,MS-738,UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY W/O CC/MCC,Surgical,Relative Weights,"$8,619.37 ",IP,"2,420.00","27,798.62",,,,,,
UHC MCR ADV,DRG,MS-739,UTERINE -ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W MCC,Surgical,Relative Weights,"$22,332.46 ",IP,"2,420.00","75,489.12",,,,,,
UHC MCR ADV,DRG,MS-740,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,Surgical,Relative Weights,"$10,521.48 ",IP,"2,420.00","35,983.58",,,,,,
UHC MCR ADV,DRG,MS-741,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$7,474.72 ",IP,"2,420.00","26,802.72",,,,,,
UHC MCR ADV,DRG,MS-742,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,Surgical,Relative Weights,"$10,033.84 ",IP,"2,420.00","34,060.32",,,,,,
UHC MCR ADV,DRG,MS-743,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,Surgical,Relative Weights,"$6,615.64 ",IP,"2,420.00","23,153.76",,,,,,
UHC MCR ADV,DRG,MS-744,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC,Surgical,Relative Weights,"$10,485.28 ",IP,"2,420.00","35,088.48",,,,,,
UHC MCR ADV,DRG,MS-745,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC,Surgical,Relative Weights,"$6,832.89 ",IP,"2,420.00","21,476.45",,,,,,
UHC MCR ADV,DRG,MS-746,VAGINA -  CERVIX AND VULVA PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$9,411.29 ",IP,"2,420.00","32,880.96",,,,,,
UHC MCR ADV,DRG,MS-747,VAGINA- CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$5,484.42 ",IP,"2,420.00","18,793.15",,,,,,
UHC MCR ADV,DRG,MS-748,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,Surgical,Relative Weights,"$7,870.09 ",IP,"2,420.00","26,645.47",,,,,,
UHC MCR ADV,DRG,MS-749,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$15,848.80 ",IP,"2,420.00","52,258.75",,,,,,
UHC MCR ADV,DRG,MS-750,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,548.71 ",IP,"2,420.00","26,836.99",,,,,,
UHC MCR ADV,DRG,MS-754,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH MCC,Medical,Relative Weights,"$10,665.15 ",IP,"2,420.00","35,519.90",,,,,,
UHC MCR ADV,DRG,MS-755,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH CC,Medical,Relative Weights,"$6,595.20 ",IP,"2,420.00","20,639.81",,,,,,
UHC MCR ADV,DRG,MS-756,MALIGNANCY - FEMALE REPRODUCTIVE SYSTEM W/O CC/MCC,Medical,Relative Weights,"$5,363.53 ",IP,"2,420.00","17,676.29",,,,,,
UHC MCR ADV,DRG,MS-757,INFECTIONS - FEMALE REPRODUCTIVE SYSTEM W MCC,Medical,Relative Weights,"$8,904.37 ",IP,"2,420.00","28,633.25",,,,,,
UHC MCR ADV,DRG,MS-758,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITH CC,Medical,Relative Weights,"$5,663.12 ",IP,"2,420.00","19,462.46",,,,,,
UHC MCR ADV,DRG,MS-759,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Medical,Relative Weights,"$3,991.11 ",IP,"2,420.00","13,311.65",,,,,,
UHC MCR ADV,DRG,MS-760,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,Medical,Relative Weights,"$5,373.46 ",IP,"2,420.00","18,194.40",,,,,,
UHC MCR ADV,DRG,MS-761,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$3,450.32 ",IP,"2,420.00","11,398.46",,,,,,
UHC MCR ADV,DRG,MS-768,VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C,Surgical,Relative Weights,"$6,830.55 ",IP,"2,420.00","20,311.20",,,,,,
UHC MCR ADV,DRG,MS-769,POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,Surgical,Relative Weights,"$9,446.91 ",IP,"2,420.00","29,090.88",,,,,,
UHC MCR ADV,DRG,MS-770,ABORTION WITH D&C- ASPIRATION CURETTAGE OR HYSTEROTOMY,Surgical,Relative Weights,"$5,196.50 ",IP,"2,420.00","15,851.81",,,,,,
UHC MCR ADV,DRG,MS-776,POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,Medical,Relative Weights,"$4,523.14 ",IP,"2,420.00","14,311.58",,,,,,
UHC MCR ADV,DRG,MS-779,ABORTION WITHOUT D&C,Medical,Relative Weights,"$6,184.64 ",IP,"2,420.00","23,018.69",,,,,,
UHC MCR ADV,DRG,MS-783,CESAREAN SECTION WITH STERILIZATION WITH MCC,C-Section,Relative Weights,"$10,949.56 ",IP,"2,420.00","43,239.17",,,,,,
UHC MCR ADV,DRG,MS-784,CESAREAN SECTION WITH STERILIZATION WITH CC,C-Section,Relative Weights,"$6,400.14 ",IP,"2,420.00","21,071.23",,,,,,
UHC MCR ADV,DRG,MS-785,CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,C-Section,Relative Weights,"$5,354.18 ",IP,"2,420.00","17,305.34",,,,,,
UHC MCR ADV,DRG,MS-786,CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,C-Section,Relative Weights,"$9,311.42 ",IP,"2,420.00","34,564.32",,,,,,
UHC MCR ADV,DRG,MS-787,CESAREAN SECTION WITHOUT STERILIZATION WITH CC,C-Section,Relative Weights,"$6,216.18 ",IP,"2,420.00","21,077.28",,,,,,
UHC MCR ADV,DRG,MS-788,CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,C-Section,Relative Weights,"$5,182.48 ",IP,"2,420.00","18,268.99",,,,,,
UHC MCR ADV,DRG,MS-789,NEONATES- DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY,Medical,Relative Weights,"$10,044.93 ",IP,"2,420.00","34,070.40",,,,,,
UHC MCR ADV,DRG,MS-790,EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME- NEONATE,Medical,Relative Weights,"$33,125.50 ",IP,"2,420.00","112,351.68",,,,,,
UHC MCR ADV,DRG,MS-791,PREMATURITY W MAJOR PROBLEMS,Medical,Relative Weights,"$22,623.29 ",IP,"2,420.00","76,732.99",,,,,,
UHC MCR ADV,DRG,MS-792,PREMATURITY W/O MAJOR PROBLEMS,Medical,Relative Weights,"$13,650.60 ",IP,"2,420.00","46,297.44",,,,,,
UHC MCR ADV,DRG,MS-793,FULL TERM NEONATE WITH MAJOR PROBLEMS,Medical,Relative Weights,"$23,238.84 ",IP,"2,420.00","78,819.55",,,,,,
UHC MCR ADV,DRG,MS-794,NEONATE WITH OTHER SIGNIFICANT PROBLEMS,Medical,Relative Weights,"$8,225.17 ",IP,"2,420.00","27,897.41",,,,,,
UHC MCR ADV,DRG,MS-795,NORMAL NEWBORN,Medical,Relative Weights,"$1,113.70 ",IP,"1,113.70","3,775.97",,,,,,
UHC MCR ADV,DRG,MS-796,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,Vaginal Delivery,Relative Weights,"$6,253.56 ",IP,"2,420.00","39,761.57",,,,,,
UHC MCR ADV,DRG,MS-797,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,Vaginal Delivery,Relative Weights,"$5,369.37 ",IP,"2,420.00","17,394.05",,,,,,
UHC MCR ADV,DRG,MS-798,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,Vaginal Delivery,Relative Weights,"$4,832.66 ",IP,"2,420.00","17,394.05",,,,,,
UHC MCR ADV,DRG,MS-799,SPLENECTOMY WITH MCC,Surgical,Relative Weights,"$30,061.22 ",IP,"2,420.00","99,677.09",,,,,,
UHC MCR ADV,DRG,MS-800,SPLENECTOMY WITH CC,Surgical,Relative Weights,"$17,251.01 ",IP,"2,420.00","57,294.72",,,,,,
UHC MCR ADV,DRG,MS-801,SPLENECTOMY WITHOUT CC/MCC,Surgical,Relative Weights,"$9,834.69 ",IP,"2,420.00","37,763.71",,,,,,
UHC MCR ADV,DRG,MS-802,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,Surgical,Relative Weights,"$21,676.62 ",IP,"2,420.00","63,552.38",,,,,,
UHC MCR ADV,DRG,MS-803,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,Surgical,Relative Weights,"$11,017.31 ",IP,"2,420.00","35,917.06",,,,,,
UHC MCR ADV,DRG,MS-804,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,Surgical,Relative Weights,"$7,976.96 ",IP,"2,420.00","27,470.02",,,,,,
UHC MCR ADV,DRG,MS-805,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,Vaginal Delivery,Relative Weights,"$6,014.70 ",IP,"2,420.00","20,980.51",,,,,,
UHC MCR ADV,DRG,MS-806,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,Vaginal Delivery,Relative Weights,"$4,290.12 ",IP,"2,420.00","14,297.47",,,,,,
UHC MCR ADV,DRG,MS-807,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,Vaginal Delivery,Relative Weights,"$3,751.08 ",IP,"2,420.00","12,636.29",,,,,,
UHC MCR ADV,DRG,MS-808,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,Medical,Relative Weights,"$12,765.24 ",IP,"2,420.00","42,932.74",,,,,,
UHC MCR ADV,DRG,MS-809,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,Medical,Relative Weights,"$7,144.75 ",IP,"2,420.00","24,512.54",,,,,,
UHC MCR ADV,DRG,MS-810,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,Medical,Relative Weights,"$5,616.40 ",IP,"2,420.00","18,857.66",,,,,,
UHC MCR ADV,DRG,MS-811,RED BLOOD CELL DISORDERS WITH MCC,Medical,Relative Weights,"$8,055.22 ",IP,"2,420.00","27,020.45",,,,,,
UHC MCR ADV,DRG,MS-812,RED BLOOD CELL DISORDERS WITHOUT MCC,Medical,Relative Weights,"$5,141.02 ",IP,"2,420.00","17,553.31",,,,,,
UHC MCR ADV,DRG,MS-813,COAGULATION DISORDERS,Medical,Relative Weights,"$9,023.50 ",IP,"2,420.00","31,957.63",,,,,,
UHC MCR ADV,DRG,MS-814,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,Medical,Relative Weights,"$11,047.67 ",IP,"2,420.00","35,261.86",,,,,,
UHC MCR ADV,DRG,MS-815,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,Medical,Relative Weights,"$5,801.53 ",IP,"2,420.00","20,418.05",,,,,,
UHC MCR ADV,DRG,MS-816,RETICULOENDOTHELIAL & IMMUNITY DISORDERS W/O CC/MCC,Medical,Relative Weights,"$3,860.88 ",IP,"2,420.00","14,432.54",,,,,,
UHC MCR ADV,DRG,MS-817,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$13,471.89 ",IP,"2,420.00","50,726.59",,,,,,
UHC MCR ADV,DRG,MS-818,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$7,941.34 ",IP,"2,420.00","25,681.82",,,,,,
UHC MCR ADV,DRG,MS-819,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$5,765.32 ",IP,"2,420.00","16,085.66",,,,,,
UHC MCR ADV,DRG,MS-820,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$33,239.97 ",IP,"2,420.00","115,248.67",,,,,,
UHC MCR ADV,DRG,MS-821,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$12,586.54 ",IP,"2,420.00","45,003.17",,,,,,
UHC MCR ADV,DRG,MS-822,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,308.86 ",IP,"2,420.00","25,490.30",,,,,,
UHC MCR ADV,DRG,MS-823,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,Surgical,Relative Weights,"$26,290.86 ",IP,"2,420.00","85,280.83",,,,,,
UHC MCR ADV,DRG,MS-824,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,Surgical,Relative Weights,"$13,808.28 ",IP,"2,420.00","46,874.02",,,,,,
UHC MCR ADV,DRG,MS-825,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,184.87 ",IP,"2,420.00","27,306.72",,,,,,
UHC MCR ADV,DRG,MS-826,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$29,460.27 ",IP,"2,420.00","101,102.40",,,,,,
UHC MCR ADV,DRG,MS-827,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$14,603.70 ",IP,"2,420.00","46,694.59",,,,,,
UHC MCR ADV,DRG,MS-828,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$9,776.29 ",IP,"2,420.00","33,288.19",,,,,,
UHC MCR ADV,DRG,MS-829,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,Surgical,Relative Weights,"$18,737.31 ",IP,"2,420.00","63,300.38",,,,,,
UHC MCR ADV,DRG,MS-830,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,655.00 ",IP,"2,420.00","27,796.61",,,,,,
UHC MCR ADV,DRG,MS-831,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,Medical,Relative Weights,"$6,551.40 ",IP,"2,420.00","21,742.56",,,,,,
UHC MCR ADV,DRG,MS-832,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,Medical,Relative Weights,"$4,545.33 ",IP,"2,420.00","14,424.48",,,,,,
UHC MCR ADV,DRG,MS-833,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,Medical,Relative Weights,"$3,136.12 ",IP,"2,420.00","10,727.14",,,,,,
UHC MCR ADV,DRG,MS-834,ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W MCC,Medical,Relative Weights,"$35,345.32 ",IP,"2,420.00","117,784.80",,,,,,
UHC MCR ADV,DRG,MS-835,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC,Medical,Relative Weights,"$12,344.17 ",IP,"2,420.00","40,888.51",,,,,,
UHC MCR ADV,DRG,MS-836,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Medical,Relative Weights,"$6,853.33 ",IP,"2,420.00","26,562.82",,,,,,
UHC MCR ADV,DRG,MS-837,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,Medical,Relative Weights,"$33,284.35 ",IP,"2,420.00","120,774.53",,,,,,
UHC MCR ADV,DRG,MS-838,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,Medical,Relative Weights,"$13,199.74 ",IP,"2,420.00","44,108.06",,,,,,
UHC MCR ADV,DRG,MS-839,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Medical,Relative Weights,"$8,685.36 ",IP,"2,420.00","25,728.19",,,,,,
UHC MCR ADV,DRG,MS-840,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,Medical,Relative Weights,"$18,807.97 ",IP,"2,420.00","64,415.23",,,,,,
UHC MCR ADV,DRG,MS-841,LYMPHOMA & NON-ACUTE LEUKEMIA W CC,Medical,Relative Weights,"$9,470.27 ",IP,"2,420.00","32,491.87",,,,,,
UHC MCR ADV,DRG,MS-842,LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,Medical,Relative Weights,"$6,406.57 ",IP,"2,420.00","23,115.46",,,,,,
UHC MCR ADV,DRG,MS-843,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,Medical,Relative Weights,"$11,140.53 ",IP,"2,420.00","38,461.25",,,,,,
UHC MCR ADV,DRG,MS-844,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,Medical,Relative Weights,"$6,915.82 ",IP,"2,420.00","24,353.28",,,,,,
UHC MCR ADV,DRG,MS-845,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$4,957.64 ",IP,"2,420.00","17,456.54",,,,,,
UHC MCR ADV,DRG,MS-846,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,Medical,Relative Weights,"$15,609.94 ",IP,"2,420.00","52,952.26",,,,,,
UHC MCR ADV,DRG,MS-847,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,Medical,Relative Weights,"$7,802.93 ",IP,"2,420.00","26,528.54",,,,,,
UHC MCR ADV,DRG,MS-848,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Medical,Relative Weights,"$6,028.71 ",IP,"2,420.00","19,785.02",,,,,,
UHC MCR ADV,DRG,MS-849,RADIOTHERAPY,Medical,Relative Weights,"$14,562.82 ",IP,"2,420.00","42,856.13",,,,,,
UHC MCR ADV,DRG,MS-853,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$29,012.34 ",IP,"2,420.00","102,787.78",,,,,,
UHC MCR ADV,DRG,MS-854,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$12,393.81 ",IP,"2,420.00","43,569.79",,,,,,
UHC MCR ADV,DRG,MS-855,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,875.75 ",IP,"2,420.00","32,322.53",,,,,,
UHC MCR ADV,DRG,MS-856,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$27,237.54 ",IP,"2,420.00","89,222.11",,,,,,
UHC MCR ADV,DRG,MS-857,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,Surgical,Relative Weights,"$12,278.18 ",IP,"2,420.00","40,991.33",,,,,,
UHC MCR ADV,DRG,MS-858,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Relative Weights,"$7,940.17 ",IP,"2,420.00","27,748.22",,,,,,
UHC MCR ADV,DRG,MS-862,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W MCC,Medical,Relative Weights,"$11,076.88 ",IP,"2,420.00","37,308.10",,,,,,
UHC MCR ADV,DRG,MS-863,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W/O MCC,Medical,Relative Weights,"$5,906.65 ",IP,"2,420.00","19,918.08",,,,,,
UHC MCR ADV,DRG,MS-864,FEVER AND INFLAMMATORY CONDITIONS,Medical,Relative Weights,"$5,118.83 ",IP,"2,420.00","17,083.58",,,,,,
UHC MCR ADV,DRG,MS-865,VIRAL ILLNESS WITH MCC,Medical,Relative Weights,"$8,630.47 ",IP,"2,420.00","28,088.93",,,,,,
UHC MCR ADV,DRG,MS-866,VIRAL ILLNESS WITHOUT MCC,Medical,Relative Weights,"$4,899.83 ",IP,"2,420.00","16,504.99",,,,,,
UHC MCR ADV,DRG,MS-867,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,Medical,Relative Weights,"$13,064.84 ",IP,"2,420.00","44,053.63",,,,,,
UHC MCR ADV,DRG,MS-868,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,Medical,Relative Weights,"$6,225.52 ",IP,"2,420.00","22,115.52",,,,,,
UHC MCR ADV,DRG,MS-869,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,Medical,Relative Weights,"$4,254.50 ",IP,"2,420.00","14,968.80",,,,,,
UHC MCR ADV,DRG,MS-870,SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,Medical,Relative Weights,"$37,604.26 ",IP,"2,420.00","127,497.89",,,,,,
UHC MCR ADV,DRG,MS-871,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,Medical,Relative Weights,"$10,933.79 ",IP,"2,420.00","37,624.61",,,,,,
UHC MCR ADV,DRG,MS-872,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,Medical,Relative Weights,"$5,993.67 ",IP,"2,420.00","20,952.29",,,,,,
UHC MCR ADV,DRG,MS-876,O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,Surgical,Relative Weights,"$19,085.37 ",IP,"2,420.00","73,382.40",,,,,,
UHC MCR ADV,DRG,MS-880,ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,Medical,Relative Weights,"$5,048.75 ",IP,"2,420.00","17,275.10",,,,,,
UHC MCR ADV,DRG,MS-881,DEPRESSIVE NEUROSES,Medical,Relative Weights,"$4,683.74 ",IP,"2,420.00","16,517.09",,,,,,
UHC MCR ADV,DRG,MS-882,NEUROSES EXCEPT DEPRESSIVE,Medical,Relative Weights,"$4,809.89 ",IP,"2,420.00","15,922.37",,,,,,
UHC MCR ADV,DRG,MS-883,DISORDERS OF PERSONALITY & IMPULSE CONTROL,Medical,Relative Weights,"$9,237.83 ",IP,"2,420.00","26,945.86",,,,,,
UHC MCR ADV,DRG,MS-884,ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,Medical,Relative Weights,"$8,452.34 ",IP,"2,420.00","28,990.08",,,,,,
UHC MCR ADV,DRG,MS-885,PSYCHOSES,Medical,Relative Weights,"$7,238.19 ",IP,"2,420.00","24,502.46",,,,,,
UHC MCR ADV,DRG,MS-886,BEHAVIORAL AND DEVELOPMENTAL DISORDERS,Medical,Relative Weights,"$7,146.50 ",IP,"2,420.00","27,127.30",,,,,,
UHC MCR ADV,DRG,MS-887,OTHER MENTAL DISORDER DIAGNOSES,Medical,Relative Weights,"$6,306.12 ",IP,"2,420.00","21,936.10",,,,,,
UHC MCR ADV,DRG,MS-894,ALCOHOL- DRUG ABUSE OR DEPENDENCE- LEFT AMA,Medical,Relative Weights,"$3,206.20 ",IP,"2,420.00","11,700.86",,,,,,
UHC MCR ADV,DRG,MS-895,ALCOHOL- DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY,Medical,Relative Weights,"$9,339.45 ",IP,"2,420.00","32,798.30",,,,,,
UHC MCR ADV,DRG,MS-896,ALCOHOL -  DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC,Medical,Relative Weights,"$10,397.09 ",IP,"2,420.00","34,669.15",,,,,,
UHC MCR ADV,DRG,MS-897,ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC,Medical,Relative Weights,"$4,829.74 ",IP,"2,420.00","16,567.49",,,,,,
UHC MCR ADV,DRG,MS-901,WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,Surgical,Relative Weights,"$24,929.54 ",IP,"2,420.00","87,236.35",,,,,,
UHC MCR ADV,DRG,MS-902,WOUND DEBRIDEMENTS FOR INJURIES WITH CC,Surgical,Relative Weights,"$11,471.66 ",IP,"2,420.00","39,652.70",,,,,,
UHC MCR ADV,DRG,MS-903,WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,Surgical,Relative Weights,"$6,630.24 ",IP,"2,420.00","23,063.04",,,,,,
UHC MCR ADV,DRG,MS-904,SKIN GRAFTS FOR INJURIES WITH CC/MCC,Surgical,Relative Weights,"$21,765.97 ",IP,"2,420.00","71,313.98",,,,,,
UHC MCR ADV,DRG,MS-905,SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,Surgical,Relative Weights,"$9,636.13 ",IP,"2,420.00","33,554.30",,,,,,
UHC MCR ADV,DRG,MS-906,HAND PROCEDURES FOR INJURIES,Surgical,Relative Weights,"$10,534.33 ",IP,"2,420.00","35,096.54",,,,,,
UHC MCR ADV,DRG,MS-907,OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,Surgical,Relative Weights,"$23,057.79 ",IP,"2,420.00","80,430.34",,,,,,
UHC MCR ADV,DRG,MS-908,OTHER O.R. PROCEDURES FOR INJURIES WITH CC,Surgical,Relative Weights,"$11,974.50 ",IP,"2,420.00","41,592.10",,,,,,
UHC MCR ADV,DRG,MS-909,OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,Surgical,Relative Weights,"$8,006.75 ",IP,"2,420.00","26,584.99",,,,,,
UHC MCR ADV,DRG,MS-913,TRAUMATIC INJURY WITH MCC,Medical,Relative Weights,"$9,569.55 ",IP,"2,420.00","29,762.21",,,,,,
UHC MCR ADV,DRG,MS-914,TRAUMATIC INJURY WITHOUT MCC,Medical,Relative Weights,"$5,179.56 ",IP,"2,420.00","17,371.87",,,,,,
UHC MCR ADV,DRG,MS-915,ALLERGIC REACTIONS WITH MCC,Medical,Relative Weights,"$9,925.21 ",IP,"2,420.00","34,253.86",,,,,,
UHC MCR ADV,DRG,MS-916,ALLERGIC REACTIONS WITHOUT MCC,Medical,Relative Weights,"$3,845.11 ",IP,"2,420.00","12,765.31",,,,,,
UHC MCR ADV,DRG,MS-917,POISONING & TOXIC EFFECTS OF DRUGS W MCC,Medical,Relative Weights,"$8,634.55 ",IP,"2,420.00","29,498.11",,,,,,
UHC MCR ADV,DRG,MS-918,POISONING & TOXIC EFFECTS OF DRUGS W/O MCC,Medical,Relative Weights,"$4,623.01 ",IP,"2,420.00","15,805.44",,,,,,
UHC MCR ADV,DRG,MS-919,COMPLICATIONS OF TREATMENT WITH MCC,Medical,Relative Weights,"$10,769.69 ",IP,"2,420.00","36,798.05",,,,,,
UHC MCR ADV,DRG,MS-920,COMPLICATIONS OF TREATMENT WITH CC,Medical,Relative Weights,"$5,983.74 ",IP,"2,420.00","20,311.20",,,,,,
UHC MCR ADV,DRG,MS-921,COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,Medical,Relative Weights,"$4,075.79 ",IP,"2,420.00","13,922.50",,,,,,
UHC MCR ADV,DRG,MS-922,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC,Medical,Relative Weights,"$9,275.21 ",IP,"2,420.00","32,328.58",,,,,,
UHC MCR ADV,DRG,MS-923,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC,Medical,Relative Weights,"$5,488.50 ",IP,"2,420.00","17,448.48",,,,,,
UHC MCR ADV,DRG,MS-927,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,Surgical,Relative Weights,"$123,174.83 ",IP,"2,420.00","402,060.96",,,,,,
UHC MCR ADV,DRG,MS-928,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,Surgical,Relative Weights,"$38,145.05 ",IP,"2,420.00","124,889.18",,,,,,
UHC MCR ADV,DRG,MS-929,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,Surgical,Relative Weights,"$17,601.41 ",IP,"2,420.00","59,300.64",,,,,,
UHC MCR ADV,DRG,MS-933,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,Medical,Relative Weights,"$13,215.51 ",IP,"2,420.00","63,306.43",,,,,,
UHC MCR ADV,DRG,MS-934,FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,Medical,Relative Weights,"$11,335.01 ",IP,"2,420.00","36,485.57",,,,,,
UHC MCR ADV,DRG,MS-935,NON-EXTENSIVE BURNS,Medical,Relative Weights,"$11,288.29 ",IP,"2,420.00","38,955.17",,,,,,
UHC MCR ADV,DRG,MS-939,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,Surgical,Relative Weights,"$19,707.93 ",IP,"2,420.00","73,672.70",,,,,,
UHC MCR ADV,DRG,MS-940,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,Surgical,Relative Weights,"$12,970.23 ",IP,"2,420.00","45,799.49",,,,,,
UHC MCR ADV,DRG,MS-941,O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W/O CC/MCC,Surgical,Relative Weights,"$11,231.05 ",IP,"2,420.00","38,922.91",,,,,,
UHC MCR ADV,DRG,MS-945,REHABILITATION WITH CC/MCC,Medical,Relative Weights,"$8,654.41 ",IP,"2,420.00","29,338.85",,,,,,
UHC MCR ADV,DRG,MS-946,REHABILITATION WITHOUT CC/MCC,Medical,Relative Weights,"$6,577.10 ",IP,"2,420.00","21,913.92",,,,,,
UHC MCR ADV,DRG,MS-947,SIGNS AND SYMPTOMS WITH MCC,Medical,Relative Weights,"$6,973.05 ",IP,"2,420.00","24,137.57",,,,,,
UHC MCR ADV,DRG,MS-948,SIGNS AND SYMPTOMS WITHOUT MCC,Medical,Relative Weights,"$4,596.73 ",IP,"2,420.00","15,716.74",,,,,,
UHC MCR ADV,DRG,MS-949,AFTERCARE WITH CC/MCC,Medical,Relative Weights,"$6,481.90 ",IP,"2,420.00","21,952.22",,,,,,
UHC MCR ADV,DRG,MS-950,AFTERCARE WITHOUT CC/MCC,Medical,Relative Weights,"$4,322.83 ",IP,"2,420.00","14,936.54",,,,,,
UHC MCR ADV,DRG,MS-951,OTHER FACTORS INFLUENCING HEALTH STATUS,Medical,Relative Weights,"$3,268.11 ",IP,"2,420.00","11,823.84",,,,,,
UHC MCR ADV,DRG,MS-955,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,Surgical,Relative Weights,"$36,730.00 ",IP,"2,420.00","122,582.88",,,,,,
UHC MCR ADV,DRG,MS-956,LIMB REATTACHMENT- HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,Surgical,Relative Weights,"$22,484.30 ",IP,"2,420.00","79,093.73",,,,,,
UHC MCR ADV,DRG,MS-957,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Surgical,Relative Weights,"$43,338.63 ",IP,"2,420.00","151,879.39",,,,,,
UHC MCR ADV,DRG,MS-958,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,Surgical,Relative Weights,"$24,561.61 ",IP,"2,420.00","84,488.54",,,,,,
UHC MCR ADV,DRG,MS-959,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,Surgical,Relative Weights,"$15,979.04 ",IP,"2,420.00","56,458.08",,,,,,
UHC MCR ADV,DRG,MS-963,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Medical,Relative Weights,"$15,942.83 ",IP,"2,420.00","54,938.02",,,,,,
UHC MCR ADV,DRG,MS-964,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,Medical,Relative Weights,"$8,712.23 ",IP,"2,420.00","30,108.96",,,,,,
UHC MCR ADV,DRG,MS-965,OTHER MULTIPLE SIGNIFICANT TRAUMA W/O CC/MCC,Medical,Relative Weights,"$5,329.07 ",IP,"2,420.00","18,488.74",,,,,,
UHC MCR ADV,DRG,MS-969,HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,Surgical,Relative Weights,"$34,175.55 ",IP,"2,420.00","116,982.43",,,,,,
UHC MCR ADV,DRG,MS-970,HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,Surgical,Relative Weights,"$17,454.24 ",IP,"2,420.00","58,806.72",,,,,,
UHC MCR ADV,DRG,MS-974,HIV WITH MAJOR RELATED CONDITION WITH MCC,Medical,Relative Weights,"$15,712.73 ",IP,"2,420.00","53,905.82",,,,,,
UHC MCR ADV,DRG,MS-975,HIV WITH MAJOR RELATED CONDITION WITH CC,Medical,Relative Weights,"$7,487.56 ",IP,"2,420.00","27,054.72",,,,,,
UHC MCR ADV,DRG,MS-976,HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,Medical,Relative Weights,"$5,545.74 ",IP,"2,420.00","18,430.27",,,,,,
UHC MCR ADV,DRG,MS-977,HIV WITH OR WITHOUT OTHER RELATED CONDITION,Medical,Relative Weights,"$7,734.01 ",IP,"2,420.00","26,218.08",,,,,,
UHC MCR ADV,DRG,MS-981,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$26,949.04 ",IP,"2,420.00","90,532.51",,,,,,
UHC MCR ADV,DRG,MS-982,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Surgical,Relative Weights,"$14,813.94 ",IP,"2,420.00","49,152.10",,,,,,
UHC MCR ADV,DRG,MS-983,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$9,649.56 ",IP,"2,420.00","33,003.94",,,,,,
UHC MCR ADV,DRG,MS-987,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Relative Weights,"$19,131.51 ",IP,"2,420.00","67,207.39",,,,,,
UHC MCR ADV,DRG,MS-988,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Surgical,Relative Weights,"$9,965.51 ",IP,"2,420.00","34,640.93",,,,,,
UHC MCR ADV,DRG,MS-989,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Surgical,Relative Weights,"$6,561.91 ",IP,"2,420.00","23,232.38",,,,,,
UHC MCR ADV,CPT,176,Anesth pharyngeal surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,211,Anesth cran surg hemotoma,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,214,Anesth skull drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,215,Anesth skull repair/fract,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,524,Anesth chest drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,540,Anesth chest surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,542,Anesthesia removal pleura,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,546,Anesth lung chest wall surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,560,Anesth heart surg w/o pump,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,561,Anesth heart surg <1 yr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,562,Anesth hrt surg w/pmp age 1+,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,567,Anesth cabg w/pump,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,580,Anesth heart/lung transplnt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,632,Anesth removal of nerves,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,792,Anesth hemorr/excise liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,794,Anesth pancreas removal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,796,Anesth for liver transplant,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,844,Anesth pelvis surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,846,Anesth hysterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,848,Anesth pelvic organ surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,864,Anesth removal of bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,866,Anesth removal of adrenal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,868,Anesth kidney transplant,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,882,Anesth major vein ligation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,908,Anesth removal of prostate,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,932,Anesth amputation of penis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,934,Anesth penis nodes removal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,936,Anesth penis nodes removal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,1272,Anesth femoral artery surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,1442,Anesth knee artery surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,1444,Anesth knee artery repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,1502,Anesth lwr leg embolectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,1652,Anesth shoulder vessel surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,1654,Anesth shoulder vessel surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,1656,Anesth arm-leg vessel surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,1990,Support for organ donor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,10005,Fna bx w/us gdn 1st les,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,10007,Fna bx w/fluor gdn 1st les,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,10009,Fna bx w/ct gdn 1st les,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,10011,Fna bx w/mr gdn 1st les,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,10021,Fna bx w/o img gdn 1st les,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,10030,Guide cathet fluid drainage,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,10035,Perq dev soft tiss 1st imag,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,10040,Acne surgery,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,10060,Drainage of skin abscess,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,10061,Drainage of skin abscess,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,10080,Drainage of pilonidal cyst,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,10081,Drainage of pilonidal cyst,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,10120,Remove foreign body,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,10121,Remove foreign body,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,10140,Drainage of hematoma/fluid,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,10160,Puncture drainage of lesion,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,10180,Complex drainage wound,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,11000,Debride infected skin,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,11004,Debride genitalia & perineum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,11005,Debride abdom wall,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,11006,Debride genit/per/abdom wall,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,11008,Remove mesh from abd wall,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,11010,Debride skin at fx site,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,11011,Debride skin musc at fx site,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,11012,Deb skin bone at fx site,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,11042,Deb subq tissue 20 sq cm/<,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,11043,Deb musc/fascia 20 sq cm/<,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,11044,Deb bone 20 sq cm/<,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,11055,Trim skin lesion,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,11056,Trim skin lesions 2 to 4,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,11057,Trim skin lesions over 4,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,11102,Tangntl bx skin single les,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,11104,Punch bx skin single lesion,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,11106,Incal bx skn single les,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,11200,Removal of skin tags <w/15,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,11300,Shave skin lesion 0.5 cm/<,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,11301,Shave skin lesion 0.6-1.0 cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,11302,Shave skin lesion 1.1-2.0 cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,11303,Shave skin lesion >2.0 cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,11305,Shave skin lesion 0.5 cm/<,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,11306,Shave skin lesion 0.6-1.0 cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,11307,Shave skin lesion 1.1-2.0 cm,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,11308,Shave skin lesion >2.0 cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,11310,Shave skin lesion 0.5 cm/<,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,11311,Shave skin lesion 0.6-1.0 cm,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,11312,Shave skin lesion 1.1-2.0 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,11313,Shave skin lesion >2.0 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,11400,Exc tr-ext b9+marg 0.5 cm<,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,11401,Exc tr-ext b9+marg 0.6-1 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,11402,Exc tr-ext b9+marg 1.1-2 cm,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,11403,Exc tr-ext b9+marg 2.1-3cm,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,11404,Exc tr-ext b9+marg 3.1-4 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,11406,Exc tr-ext b9+marg >4.0 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,11420,Exc h-f-nk-sp b9+marg 0.5/<,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,11421,Exc h-f-nk-sp b9+marg 0.6-1,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,11422,Exc h-f-nk-sp b9+marg 1.1-2,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,11423,Exc h-f-nk-sp b9+marg 2.1-3,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,11424,Exc h-f-nk-sp b9+marg 3.1-4,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,11426,Exc h-f-nk-sp b9+marg >4 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,11440,Exc face-mm b9+marg 0.5 cm/<,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,11441,Exc face-mm b9+marg 0.6-1 cm,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,11442,Exc face-mm b9+marg 1.1-2 cm,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,11443,Exc face-mm b9+marg 2.1-3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,11444,Exc face-mm b9+marg 3.1-4 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,11446,Exc face-mm b9+marg >4 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,11450,Removal sweat gland lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,11451,Removal sweat gland lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,11462,Removal sweat gland lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,11463,Removal sweat gland lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,11470,Removal sweat gland lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,11471,Removal sweat gland lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,11600,Exc tr-ext mal+marg 0.5 cm/<,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,11601,Exc tr-ext mal+marg 0.6-1 cm,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,11602,Exc tr-ext mal+marg 1.1-2 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,11603,Exc tr-ext mal+marg 2.1-3 cm,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,11604,Exc tr-ext mal+marg 3.1-4 cm,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,11606,Exc tr-ext mal+marg >4 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,11620,Exc h-f-nk-sp mal+marg 0.5/<,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,11621,Exc s/n/h/f/g mal+mrg 0.6-1,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,11622,Exc s/n/h/f/g mal+mrg 1.1-2,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,11623,Exc s/n/h/f/g mal+mrg 2.1-3,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,11624,Exc s/n/h/f/g mal+mrg 3.1-4,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,11626,Exc s/n/h/f/g mal+mrg >4 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,11640,Exc f/e/e/n/l mal+mrg 0.5cm<,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,11641,Exc f/e/e/n/l mal+mrg 0.6-1,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,11642,Exc f/e/e/n/l mal+mrg 1.1-2,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,11643,Exc f/e/e/n/l mal+mrg 2.1-3,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,11644,Exc f/e/e/n/l mal+mrg 3.1-4,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,11646,Exc f/e/e/n/l mal+mrg >4 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,11719,Trim nail(s) any number,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
UHC MCR ADV,CPT,11720,Debride nail 1-5,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
UHC MCR ADV,CPT,11721,Debride nail 6 or more,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
UHC MCR ADV,CPT,11730,Removal of nail plate,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,11740,Drain blood from under nail,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
UHC MCR ADV,CPT,11750,Removal of nail bed,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,11755,Biopsy nail unit,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,11760,Repair of nail bed,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,11762,Reconstruction of nail bed,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,11765,Excision of nail fold toe,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,11770,Remove pilonidal cyst simple,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,11771,Remove pilonidal cyst exten,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,11772,Remove pilonidal cyst compl,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,11900,Inject skin lesions </w 7,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,11901,Inject skin lesions >7,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,11920,Correct skin color 6.0 cm/<,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,11921,Correct skn color 6.1-20.0cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,11950,Tx contour defects 1 cc/<,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,11951,Tx contour defects 1.1-5.0cc,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,11952,Tx contour defects 5.1-10cc,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,11954,Tx contour defects >10.0 cc,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,11960,Insert tissue expander(s),APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
UHC MCR ADV,CPT,11970,Rplcmt tiss xpndr perm implt,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,11971,Rmvl tis xpndr wo insj implt,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,11976,Remove contraceptive capsule,APC 5071,RVU Per Case,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,11980,Implant hormone pellet(s),APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
UHC MCR ADV,CPT,11981,Insert drug implant device,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
UHC MCR ADV,CPT,11982,Remove drug implant device,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
UHC MCR ADV,CPT,11983,Remove/insert drug implant,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
UHC MCR ADV,CPT,12001,Rpr s/n/ax/gen/trnk 2.5cm/<,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,12002,Rpr s/n/ax/gen/trnk2.6-7.5cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,12004,Rpr s/n/ax/gen/trk7.6-12.5cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,12005,Rpr s/n/a/gen/trk12.6-20.0cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,12006,Rpr s/n/a/gen/trk20.1-30.0cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,12007,Rpr s/n/ax/gen/trnk >30.0 cm,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,12011,Rpr f/e/e/n/l/m 2.5 cm/<,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,12013,Rpr f/e/e/n/l/m 2.6-5.0 cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,12014,Rpr f/e/e/n/l/m 5.1-7.5 cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,12015,Rpr f/e/e/n/l/m 7.6-12.5 cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,12016,Rpr fe/e/en/l/m 12.6-20.0 cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,12017,Rpr fe/e/en/l/m 20.1-30.0 cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,12018,Rpr f/e/e/n/l/m >30.0 cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,12020,Closure of split wound,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,12021,Closure of split wound,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,12031,Intmd rpr s/a/t/ext 2.5 cm/<,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,12032,Intmd rpr s/a/t/ext 2.6-7.5,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,12034,Intmd rpr s/tr/ext 7.6-12.5,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,12035,Intmd rpr s/a/t/ext 12.6-20,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,12036,Intmd rpr s/a/t/ext 20.1-30,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,12037,Intmd rpr s/tr/ext >30.0 cm,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,12041,Intmd rpr n-hf/genit 2.5cm/<,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,12042,Intmd rpr n-hf/genit2.6-7.5,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,12044,Intmd rpr n-hf/genit7.6-12.5,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,12045,Intmd rpr n-hf/genit12.6-20,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,12046,Intmd rpr n-hf/genit20.1-30,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,12047,Intmd rpr n-hf/genit >30.0cm,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,12051,Intmd rpr face/mm 2.5 cm/<,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,12052,Intmd rpr face/mm 2.6-5.0 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,12053,Intmd rpr face/mm 5.1-7.5 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,12054,Intmd rpr face/mm 7.6-12.5cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,12055,Intmd rpr face/mm 12.6-20 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,12056,Intmd rpr face/mm 20.1-30.0,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,12057,Intmd rpr face/mm >30.0 cm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,13100,Cmplx rpr trunk 1.1-2.5 cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,13101,Cmplx rpr trunk 2.6-7.5 cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,13120,Cmplx rpr s/a/l 1.1-2.5 cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,13121,Cmplx rpr s/a/l 2.6-7.5 cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,13131,Cmplx rpr f/c/c/m/n/ax/g/h/f,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,13132,Cmplx rpr f/c/c/m/n/ax/g/h/f,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,13151,Cmplx rpr e/n/e/l 1.1-2.5 cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,13152,Cmplx rpr e/n/e/l 2.6-7.5 cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,13160,Late closure of wound,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,14000,Tis trnfr trunk 10 sq cm/<,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,14001,Tis trnfr trunk 10.1-30sqcm,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,14020,Tis trnfr s/a/l 10 sq cm/<,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,14021,Tis trnfr s/a/l 10.1-30 sqcm,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,14040,Tis trnfr f/c/c/m/n/a/g/h/f,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,14041,Tis trnfr f/c/c/m/n/a/g/h/f,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,14060,Tis trnfr e/n/e/l 10 sq cm/<,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,14061,Tis trnfr e/n/e/l10.1-30sqcm,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,14301,Tis trnfr any 30.1-60 sq cm,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
UHC MCR ADV,CPT,14350,Filleted finger/toe flap,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,15002,Wound prep trk/arm/leg,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,15004,Wound prep f/n/hf/g,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,15040,Harvest cultured skin graft,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,15050,Skin pinch graft,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,15100,Skin splt grft trnk/arm/leg,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,15110,Epidrm autogrft trnk/arm/leg,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,15115,Epidrm a-grft face/nck/hf/g,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,15120,Skn splt a-grft fac/nck/hf/g,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
UHC MCR ADV,CPT,15130,Derm autograft trnk/arm/leg,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,15135,Derm autograft face/nck/hf/g,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
UHC MCR ADV,CPT,15150,Cult skin grft t/arm/leg,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,15155,Cult skin graft f/n/hf/g,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
UHC MCR ADV,CPT,15200,Skin full graft trunk,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,15220,Skin full graft sclp/arm/leg,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,15240,Skin full grft face/genit/hf,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,15260,Skin full graft een & lips,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,15271,Skin sub graft trnk/arm/leg,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,15273,Skin sub grft t/arm/lg child,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
UHC MCR ADV,CPT,15275,Skin sub graft face/nk/hf/g,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,15277,Skn sub grft f/n/hf/g child,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,15570,Skin pedicle flap trunk,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,15572,Skin pedicle flap arms/legs,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
UHC MCR ADV,CPT,15574,Pedcle fh/ch/ch/m/n/ax/g/h/f,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,15576,Pedicle e/n/e/l/ntroral,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,15600,Delay flap trunk,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
UHC MCR ADV,CPT,15610,Delay flap arms/legs,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,15620,Delay flap f/c/c/n/ax/g/h/f,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,15630,Delay flap eye/nos/ear/lip,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,15650,Transfer skin pedicle flap,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,15730,Mdfc flap w/prsrv vasc pedcl,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
UHC MCR ADV,CPT,15731,Forehead flap w/vasc pedicle,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
UHC MCR ADV,CPT,15733,Musc myoq/fscq flp h&n pedcl,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","9,201.00",,,,,,
UHC MCR ADV,CPT,15734,Muscle-skin graft trunk,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
UHC MCR ADV,CPT,15736,Muscle-skin graft arm,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,15738,Muscle-skin graft leg,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
UHC MCR ADV,CPT,15740,Island pedicle flap graft,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,15750,Neurovascular pedicle flap,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
UHC MCR ADV,CPT,15756,Free myo/skin flap microvasc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,15757,Free skin flap microvasc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,15758,Free fascial flap microvasc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,15760,Composite skin graft,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,15769,Grfg autol soft tiss dir exc,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
UHC MCR ADV,CPT,15770,Derma-fat-fascia graft,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
UHC MCR ADV,CPT,15771,Grfg autol fat lipo 50 cc/<,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
UHC MCR ADV,CPT,15773,Grfg autol fat lipo 25 cc/<,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,15775,Hair trnspl 1-15 punch grfts,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,15776,Hair trnspl >15 punch grafts,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,15780,Dermabrasion total face,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,15781,Dermabrasion segmental face,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,15782,Dermabrasion other than face,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,15783,Dermabrasion suprfl any site,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,15786,Abrasion lesion single,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,15788,Chemical peel face epiderm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,15789,Chemical peel face dermal,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,15792,Chemical peel nonfacial,APC 5053,RVU Per Case,$536.39 ,OP,536.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,15793,Chemical peel nonfacial,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,15819,Plastic surgery neck,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,15820,Revision of lower eyelid,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,15821,Revision of lower eyelid,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,15822,Revision of upper eyelid,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,15823,Revision of upper eyelid,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,15824,Removal of forehead wrinkles,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,15825,Removal of neck wrinkles,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
UHC MCR ADV,CPT,15826,Removal of brow wrinkles,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
UHC MCR ADV,CPT,15828,Removal of face wrinkles,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
UHC MCR ADV,CPT,15829,Removal of skin wrinkles,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
UHC MCR ADV,CPT,15830,Exc skin abd,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,15832,Excise excessive skin thigh,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,15833,Excise excessive skin leg,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,15834,Excise excessive skin hip,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,15835,Excise excessive skin buttck,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,15836,Excise excessive skin arm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,15837,Excise excess skin arm/hand,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,15838,Excise excess skin fat pad,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,15839,Excise excess skin & tissue,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,15840,Nerve palsy fascial graft,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
UHC MCR ADV,CPT,15841,Nerve palsy muscle graft,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
UHC MCR ADV,CPT,15842,Nerve palsy microsurg graft,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,15845,Skin and muscle repair face,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
UHC MCR ADV,CPT,15850,Remove sutures same surgeon,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,15851,Remove sutures diff surgeon,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,15852,Dressing change not for burn,APC 5053,RVU Per Case,$536.39 ,OP,536.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,15860,Test for blood flow in graft,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
UHC MCR ADV,CPT,15876,Suction lipectomy head&neck,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
UHC MCR ADV,CPT,15877,Suction lipectomy trunk,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
UHC MCR ADV,CPT,15878,Suction lipectomy upr extrem,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,15879,Suction lipectomy lwr extrem,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
UHC MCR ADV,CPT,15920,Removal of tail bone ulcer,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,15922,Removal of tail bone ulcer,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
UHC MCR ADV,CPT,15931,Remove sacrum pressure sore,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,15933,Remove sacrum pressure sore,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,15934,Remove sacrum pressure sore,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
UHC MCR ADV,CPT,15935,Remove sacrum pressure sore,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
UHC MCR ADV,CPT,15936,Remove sacrum pressure sore,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,15937,Remove sacrum pressure sore,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,15940,Remove hip pressure sore,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,15941,Remove hip pressure sore,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,15944,Remove hip pressure sore,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
UHC MCR ADV,CPT,15945,Remove hip pressure sore,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,15946,Remove hip pressure sore,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,15950,Remove thigh pressure sore,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,15951,Remove thigh pressure sore,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,15952,Remove thigh pressure sore,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,15953,Remove thigh pressure sore,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
UHC MCR ADV,CPT,15956,Remove thigh pressure sore,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,15958,Remove thigh pressure sore,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
UHC MCR ADV,CPT,15999,Removal of pressure sore,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,16000,Initial treatment of burn(s),APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,16020,Dress/debrid p-thick burn s,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,16025,Dress/debrid p-thick burn m,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,16030,Dress/debrid p-thick burn l,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,16035,Incision of burn scab initi,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,16036,Escharotomy addl incision,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,17000,Destruct premalg lesion,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,17004,Destroy premal lesions 15/>,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,17106,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,17107,Destruction of skin lesions,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,17108,Destruction of skin lesions,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,17110,Destruct b9 lesion 1-14,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,17111,Destruct lesion 15 or more,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,17250,Chem caut of granltj tissue,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,17260,Destruction of skin lesions,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,17261,Destruction of skin lesions,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,17262,Destruction of skin lesions,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,17263,Destruction of skin lesions,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,17264,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,17266,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,17270,Destruction of skin lesions,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,17271,Destruction of skin lesions,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,17272,Destruction of skin lesions,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,17273,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,17274,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,17276,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,17280,Destruction of skin lesions,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,17281,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,17282,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,17283,Destruction of skin lesions,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,17284,Destruction of skin lesions,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,17286,Destruction of skin lesions,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,17311,Mohs 1 stage h/n/hf/g,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,17313,Mohs 1 stage t/a/l,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,17340,Cryotherapy of skin,APC 5732,RVU Per Case,$34.63 ,OP,34.63,"4,314.00",,,,,,
UHC MCR ADV,CPT,17360,Skin peel therapy,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,17380,Hair removal by electrolysis,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,17999,Skin tissue procedure,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,19000,Drainage of breast lesion,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,19020,Incision of breast lesion,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,19081,Bx breast 1st lesion strtctc,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,19083,Bx breast 1st lesion us imag,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,19085,Bx breast 1st lesion mr imag,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,19100,Bx breast percut w/o image,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,19101,Biopsy of breast open,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
UHC MCR ADV,CPT,19105,Cryosurg ablate fa each,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
UHC MCR ADV,CPT,19110,Nipple exploration,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
UHC MCR ADV,CPT,19112,Excise breast duct fistula,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
UHC MCR ADV,CPT,19120,Removal of breast lesion,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
UHC MCR ADV,CPT,19125,Excision breast lesion,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
UHC MCR ADV,CPT,19281,Perq device breast 1st imag,APC 5071,RVU Per Case,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,19283,Perq dev breast 1st strtctc,APC 5071,RVU Per Case,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,19285,Perq dev breast 1st us imag,APC 5071,RVU Per Case,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,19287,Perq dev breast 1st mr guide,APC 5071,RVU Per Case,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,19296,Place po breast cath for rad,APC 5093,RVU Per Case,"$9,128.05 ",OP,"4,314.00","9,128.05",,,,,,
UHC MCR ADV,CPT,19298,Place breast rad tube/caths,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
UHC MCR ADV,CPT,19300,Removal of breast tissue,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","9,201.00",,,,,,
UHC MCR ADV,CPT,19301,Partial mastectomy,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
UHC MCR ADV,CPT,19302,P-mastectomy w/ln removal,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
UHC MCR ADV,CPT,19303,Mast simple complete,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
UHC MCR ADV,CPT,19305,Mast radical,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,19306,Mast rad urban type,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,19307,Mast mod rad,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,19316,Suspension of breast,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
UHC MCR ADV,CPT,19318,Breast reduction,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,19325,Breast augmentation w/implt,APC 5093,RVU Per Case,"$9,128.05 ",OP,"4,314.00","9,128.05",,,,,,
UHC MCR ADV,CPT,19328,Rmvl intact breast implant,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
UHC MCR ADV,CPT,19330,Rmvl ruptured breast implant,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
UHC MCR ADV,CPT,19340,Insj breast implt sm d mast,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,19342,Insj/rplcmt brst implt sep d,APC 5093,RVU Per Case,"$9,128.05 ",OP,"4,314.00","9,128.05",,,,,,
UHC MCR ADV,CPT,19350,Breast reconstruction,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
UHC MCR ADV,CPT,19355,Correct inverted nipple(s),APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
UHC MCR ADV,CPT,19357,Tiss xpndr plmt brst rcnstj,APC 5094,RVU Per Case,"$15,276.83 ",OP,"4,140.35","15,276.83",,,,,,
UHC MCR ADV,CPT,19361,Brst rcnstj latsms drsi flap,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,19364,Brst rcnstj free flap,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,19367,Brst rcnstj 1 pdcl tram flap,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,19368,Brst rcnstj 1pdcl tram anast,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,19369,Brst rcnstj 2 pdcl tram flap,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,19370,Revj peri-implt capsule brst,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
UHC MCR ADV,CPT,19371,Peri-implt capslc brst compl,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
UHC MCR ADV,CPT,19380,Revj reconstructed breast,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
UHC MCR ADV,CPT,19396,Design custom breast implant,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
UHC MCR ADV,CPT,19499,Breast surgery procedure,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
UHC MCR ADV,CPT,20100,Explore wound neck,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,20101,Explore wound chest,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,20102,Explore wound abdomen,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,20103,Explore wound extremity,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,20150,Excise epiphyseal bar,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,20200,Muscle biopsy,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,20205,Deep muscle biopsy,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,20206,Needle biopsy muscle,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,20220,Bone biopsy trocar/needle,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,20225,Bone biopsy trocar/needle,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,20240,Bone biopsy open superficial,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,20245,Bone biopsy open deep,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,20250,Open bone biopsy,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,20251,Open bone biopsy,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,20500,Injection of sinus tract,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,20520,Removal of foreign body,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,20525,Removal of foreign body,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,20526,Ther injection carp tunnel,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
UHC MCR ADV,CPT,20527,Inj dupuytren cord w/enzyme,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
UHC MCR ADV,CPT,20550,Inj tendon sheath/ligament,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
UHC MCR ADV,CPT,20551,Inj tendon origin/insertion,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
UHC MCR ADV,CPT,20552,Inj trigger point 1/2 muscl,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
UHC MCR ADV,CPT,20553,Inject trigger points 3/>,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
UHC MCR ADV,CPT,20555,Place ndl musc/tis for rt,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,20560,Ndl insj w/o njx 1 or 2 musc,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,"4,314.00",,,,,,
UHC MCR ADV,CPT,20561,Ndl insj w/o njx 3+ musc,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,"4,314.00",,,,,,
UHC MCR ADV,CPT,20600,Drain/inj joint/bursa w/o us,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
UHC MCR ADV,CPT,20604,Drain/inj joint/bursa w/us,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
UHC MCR ADV,CPT,20605,Drain/inj joint/bursa w/o us,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
UHC MCR ADV,CPT,20606,Drain/inj joint/bursa w/us,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,20610,Drain/inj joint/bursa w/o us,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
UHC MCR ADV,CPT,20611,Drain/inj joint/bursa w/us,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
UHC MCR ADV,CPT,20612,Aspirate/inj ganglion cyst,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
UHC MCR ADV,CPT,20615,Treatment of bone cyst,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,20650,Insert and remove bone pin,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,20660,Apply rem fixation device,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,20661,Application of head brace,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,20662,Application of pelvis brace,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,20663,Application of thigh brace,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,20664,Application of halo,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,20665,Removal of fixation device,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
UHC MCR ADV,CPT,20670,Removal of support implant,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,20680,Removal of support implant,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,20690,Apply bone fixation device,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,20692,Apply bone fixation device,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,20693,Adjust bone fixation device,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,20694,Remove bone fixation device,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,20696,Comp multiplane ext fixation,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,20697,Comp ext fixate strut change,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,20802,Replantation arm complete,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,20805,Replant forearm complete,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,20808,Replantation hand complete,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,20816,Replantation digit complete,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,20822,Replantation digit complete,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,20824,Replantation thumb complete,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,20827,Replantation thumb complete,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,20838,Replantation foot complete,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,20900,Removal of bone for graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,20902,Removal of bone for graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,20910,Remove cartilage for graft,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,20912,Remove cartilage for graft,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
UHC MCR ADV,CPT,20920,Removal of fascia for graft,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,20922,Removal of fascia for graft,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,20924,Removal of tendon for graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,20950,Fluid pressure muscle,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,20955,Fibula bone graft microvasc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,20956,Iliac bone graft microvasc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,20957,Mt bone graft microvasc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,20962,Other bone graft microvasc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,20969,Bone/skin graft microvasc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,20970,Bone/skin graft iliac crest,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,20972,Bone/skin graft metatarsal,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,20973,Bone/skin graft great toe,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,20974,Electrical bone stimulation,Physician,Per Unit,$50.41 ,OP,50.41,"4,314.00",,,,,,
UHC MCR ADV,CPT,20979,Us bone stimulation,APC 5731,RVU Per Case,$25.25 ,OP,25.25,"4,314.00",,,,,,
UHC MCR ADV,CPT,20982,Ablate bone tumor(s) perq,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,20983,Ablate bone tumor(s) perq,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,20999,Musculoskeletal surgery,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,21010,Incision of jaw joint,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,21011,Exc face les sc <2 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,21012,Exc face les sbq 2 cm/>,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,21013,Exc face tum deep < 2 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,21014,Exc face tum deep 2 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,21015,Resect face/scalp tum < 2 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,21016,Resect face/scalp tum 2 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,21025,Excision of bone lower jaw,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21026,Excision of facial bone(s),APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21029,Contour of face bone lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,21030,Excise max/zygoma b9 tumor,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21031,Remove exostosis mandible,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,21032,Remove exostosis maxilla,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,21034,Excise max/zygoma mal tumor,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21040,Excise mandible lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,21044,Removal of jaw bone lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21045,Extensive jaw surgery,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21046,Remove mandible cyst complex,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21047,Excise lwr jaw cyst w/repair,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21048,Remove maxilla cyst complex,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21049,Excis uppr jaw cyst w/repair,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21050,Removal of jaw joint,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21060,Remove jaw joint cartilage,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21070,Remove coronoid process,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21073,Mnpj of tmj w/anesth,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,21076,Prepare face/oral prosthesis,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,21077,Prepare face/oral prosthesis,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21079,Prepare face/oral prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,21080,Prepare face/oral prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,21081,Prepare face/oral prosthesis,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21082,Prepare face/oral prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,21083,Prepare face/oral prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,21084,Prepare face/oral prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,21085,Prepare face/oral prosthesis,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
UHC MCR ADV,CPT,21086,Prepare face/oral prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,21087,Prepare face/oral prosthesis,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21088,Prepare face/oral prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,21089,Prepare face/oral prosthesis,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
UHC MCR ADV,CPT,21100,Maxillofacial fixation,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21110,Interdental fixation,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,21120,Reconstruction of chin,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21121,Reconstruction of chin,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,21122,Reconstruction of chin,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21123,Reconstruction of chin,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,21125,Augmentation lower jaw bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21127,Augmentation lower jaw bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21137,Reduction of forehead,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,21138,Reduction of forehead,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21139,Reduction of forehead,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21141,Lefort i-1 piece w/o graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21142,Lefort i-2 piece w/o graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21143,Lefort i-3/> piece w/o graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21145,Lefort i-1 piece w/ graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21146,Lefort i-2 piece w/ graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21147,Lefort i-3/> piece w/ graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21150,Lefort ii anterior intrusion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21151,Lefort ii w/bone grafts,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21154,Lefort iii w/o lefort i,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21155,Lefort iii w/ lefort i,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21159,Lefort iii w/fhdw/o lefort i,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21160,Lefort iii w/fhd w/ lefort i,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21172,Reconstruct orbit/forehead,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21175,Reconstruct orbit/forehead,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21179,Reconstruct entire forehead,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21180,Reconstruct entire forehead,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21181,Contour cranial bone lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21182,Reconstruct cranial bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21183,Reconstruct cranial bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21184,Reconstruct cranial bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21188,Reconstruction of midface,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21193,Reconst lwr jaw w/o graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,21194,Reconst lwr jaw w/graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21195,Reconst lwr jaw w/o fixation,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21196,Reconst lwr jaw w/fixation,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21198,Reconstr lwr jaw segment,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21199,Reconstr lwr jaw w/advance,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21206,Reconstruct upper jaw bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21208,Augmentation of facial bones,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21209,Reduction of facial bones,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21210,Face bone graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21215,Lower jaw bone graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21230,Rib cartilage graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21235,Ear cartilage graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21240,Reconstruction of jaw joint,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21242,Reconstruction of jaw joint,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21243,Reconstruction of jaw joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,21244,Reconstruction of lower jaw,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21245,Reconstruction of jaw,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21246,Reconstruction of jaw,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21247,Reconstruct lower jaw bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21248,Reconstruction of jaw,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21249,Reconstruction of jaw,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21255,Reconstruct lower jaw bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21256,Reconstruction of orbit,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21260,Revise eye sockets,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21261,Revise eye sockets,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21263,Revise eye sockets,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21267,Revise eye sockets,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21268,Revise eye sockets,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21270,Augmentation cheek bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21275,Revision orbitofacial bones,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21280,Revision of eyelid,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,21282,Revision of eyelid,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,21295,Revision of jaw muscle/bone,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,21296,Revision of jaw muscle/bone,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,21299,Cranio/maxillofacial surgery,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
UHC MCR ADV,CPT,21310,Closed tx nose fx w/o manj,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,21315,Closed tx nose fx w/o stablj,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,21320,Closed tx nose fx w/ stablj,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,21325,Open tx nose fx uncomplicatd,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,21330,Open tx nose fx w/skele fixj,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21335,Open tx nose & septal fx,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,21336,Open tx septal fx w/wo stabj,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,21337,Closed tx septal&nose fx,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,21338,Open nasoethmoid fx w/o fixj,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21339,Open nasoethmoid fx w/ fixj,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21340,Perq tx nasoethmoid fx,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,21343,Open tx dprsd front sinus fx,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21344,Open tx compl front sinus fx,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21345,Closed tx nose/jaw fx,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,21346,Opn tx nasomax fx w/fixj,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21347,Opn tx nasomax fx multple,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21348,Opn tx nasomax fx w/graft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21355,Perq tx malar fracture,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,21356,Opn tx dprsd zygomatic arch,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21360,Opn tx dprsd malar fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21365,Opn tx complx malar fx,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21366,Opn tx complx malar w/grft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21385,Opn tx orbit fx transantral,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21386,Opn tx orbit fx periorbital,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21387,Opn tx orbit fx combined,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21390,Opn tx orbit periorbtl implt,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21395,Opn tx orbit periorbt w/grft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21400,Closed tx orbit w/o manipulj,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,21401,Closed tx orbit w/manipulj,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,21406,Opn tx orbit fx w/o implant,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21407,Opn tx orbit fx w/implant,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21408,Opn tx orbit fx w/bone grft,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21421,Treat mouth roof fracture,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,21422,Treat mouth roof fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21423,Treat mouth roof fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21431,Treat craniofacial fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21432,Treat craniofacial fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21433,Treat craniofacial fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21435,Treat craniofacial fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21436,Treat craniofacial fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21440,Treat dental ridge fracture,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,21445,Treat dental ridge fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21450,Treat lower jaw fracture,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,21451,Treat lower jaw fracture,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,21452,Treat lower jaw fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21453,Treat lower jaw fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21454,Treat lower jaw fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21461,Treat lower jaw fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21462,Treat lower jaw fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,21465,Treat lower jaw fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21470,Treat lower jaw fracture,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21480,Reset dislocated jaw,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,21485,Reset dislocated jaw,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,21490,Repair dislocated jaw,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,21497,Interdental wiring,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,21499,Head surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
UHC MCR ADV,CPT,21501,Drain neck/chest lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,21502,Drain chest lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,21510,Drainage of bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,21550,Biopsy of neck/chest,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,21552,Exc neck les sc 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,21554,Exc neck tum deep 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,21555,Exc neck les sc < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,21556,Exc neck tum deep < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,21557,Resect neck thorax tumor<5cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,21558,Resect neck tumor 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,21600,Partial removal of rib,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,21601,Exc chest wall tumor w/ribs,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,21602,Exc ch wal tum w/o lymphadec,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,21603,Exc ch wal tum w/lymphadec,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,21610,Partial removal of rib,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,21615,Removal of rib,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,21616,Removal of rib and nerves,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,21620,Partial removal of sternum,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,21627,Sternal debridement,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,21630,Extensive sternum surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,21632,Extensive sternum surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,21685,Hyoid myotomy & suspension,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,21700,Revision of neck muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,21705,Revision of neck muscle/rib,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,21720,Revision of neck muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,21725,Revision of neck muscle,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,21740,Reconstruction of sternum,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,21742,Repair stern/nuss w/o scope,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,21743,Repair sternum/nuss w/scope,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,21750,Repair of sternum separation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,21811,Optx of rib fx w/fixj scope,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,21812,Treatment of rib fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,21813,Treatment of rib fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,21820,Treat sternum fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,21825,Treat sternum fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,21899,Neck/chest surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
UHC MCR ADV,CPT,21920,Biopsy soft tissue of back,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,21925,Biopsy soft tissue of back,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,21930,Exc back les sc < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,21931,Exc back les sc 3 cm/>,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,21932,Exc back tum deep < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,21933,Exc back tum deep 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,21935,Resect back tum < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,21936,Resect back tum 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,22010,I&d p-spine c/t/cerv-thor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,22015,I&d abscess p-spine l/s/ls,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,22100,Remove part of neck vertebra,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,22101,Remove part thorax vertebra,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,22102,Remove part lumbar vertebra,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,22110,Remove part of neck vertebra,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,22112,Remove part thorax vertebra,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,22114,Remove part lumbar vertebra,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,22206,Incis spine 3 column thorac,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,22207,Incis spine 3 column lumbar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,22210,Incis 1 vertebral seg cerv,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,22212,Incis 1 vertebral seg thorac,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,22214,Incis 1 vertebral seg lumbar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,22220,Incis w/discectomy cervical,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,22222,Incis w/discectomy thoracic,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,22224,Incis w/discectomy lumbar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,22310,Closed tx vert fx w/o manj,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,22315,Closed tx vert fx w/manj,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,22318,Treat odontoid fx w/o graft,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,22319,Treat odontoid fx w/graft,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,22325,Treat spine fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,22326,Treat neck spine fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,22327,Treat thorax spine fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,22505,Manipulation of spine,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,22510,Perq cervicothoracic inject,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","15,496.26",,,,,,
UHC MCR ADV,CPT,22511,Perq lumbosacral injection,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","9,201.00",,,,,,
UHC MCR ADV,CPT,22513,Perq vertebral augmentation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,22514,Perq vertebral augmentation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,22532,Lat thorax spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,22533,Lat lumbar spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,22548,Neck spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,22551,Neck spine fuse&remov bel c2,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
UHC MCR ADV,CPT,22554,Neck spine fusion,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,22556,Thorax spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,22558,Lumbar spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,22586,Prescrl fuse w/ instr l5-s1,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,22590,Spine & skull spinal fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,22595,Neck spinal fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,22600,Neck spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,22610,Thorax spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,22612,Lumbar spine fusion,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,22630,Lumbar spine fusion,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,22633,Lumbar spine fusion combined,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,22800,Post fusion </6 vert seg,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,22802,Post fusion 7-12 vert seg,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,22804,Post fusion 13/> vert seg,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,22808,Ant fusion 2-3 vert seg,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,22810,Ant fusion 4-7 vert seg,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,22812,Ant fusion 8/> vert seg,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,22818,Kyphectomy 1-2 segments,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,22819,Kyphectomy 3 or more,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,22830,Exploration of spinal fusion,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,22849,Reinsert spinal fixation,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,22850,Remove spine fixation device,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,22852,Remove spine fixation device,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,22855,Remove spine fixation device,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,22856,Cerv artific diskectomy,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,140.35","16,238.16",,,,,,
UHC MCR ADV,CPT,22857,Lumbar artif diskectomy,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,22861,Revise cerv artific disc,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,22862,Revise lumbar artif disc,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,22864,Remove cerv artif disc,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,22865,Remove lumb artif disc,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,22867,Insj stablj dev w/dcmprn,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,22869,Insj stablj dev w/o dcmprn,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,22899,Spine surgery procedure,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,22900,Exc abdl tum deep < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,22901,Exc abdl tum deep 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,22902,Exc abd les sc < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,22903,Exc abd les sc 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,22904,Radical resect abd tumor<5cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,22905,Rad resect abd tumor 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,22999,Abdomen surgery procedure,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,23000,Removal of calcium deposits,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,23020,Release shoulder joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,23030,Drain shoulder lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,23031,Drain shoulder bursa,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,23035,Drain shoulder bone lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,23040,Exploratory shoulder surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,23044,Exploratory shoulder surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,23065,Biopsy shoulder tissues,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,23066,Biopsy shoulder tissues,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,23071,Exc shoulder les sc 3 cm/>,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,23073,Exc shoulder tum deep 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,23075,Exc shoulder les sc < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,23076,Exc shoulder tum deep < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,23077,Resect shoulder tumor < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,23078,Resect shoulder tumor 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,23100,Biopsy of shoulder joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,23101,Shoulder joint surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,23105,Remove shoulder joint lining,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,23106,Incision of collarbone joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,23107,Explore treat shoulder joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,23120,Partial removal collar bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,23125,Removal of collar bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,23130,Remove shoulder bone part,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,23140,Removal of bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,23145,Removal of bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,23146,Removal of bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,23150,Removal of humerus lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,23155,Removal of humerus lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,23156,Removal of humerus lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,23170,Remove collar bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,23172,Remove shoulder blade lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,23174,Remove humerus lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,23180,Remove collar bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,23182,Remove shoulder blade lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,23184,Remove humerus lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,23190,Partial removal of scapula,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,23195,Removal of head of humerus,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,23200,Resect clavicle tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,23210,Resect scapula tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,23220,Resect prox humerus tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,23330,Remove shoulder foreign body,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,23333,Remove shoulder fb deep,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,23334,Shoulder prosthesis removal,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,23335,Shoulder prosthesis removal,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,23395,Muscle transfer shoulder/arm,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,23397,Muscle transfers,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,23400,Fixation of shoulder blade,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,23405,Incision of tendon & muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,23406,Incise tendon(s) & muscle(s),APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,23410,Repair rotator cuff acute,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,23412,Repair rotator cuff chronic,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,23415,Release of shoulder ligament,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,23420,Repair of shoulder,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,23430,Repair biceps tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,23440,Remove/transplant tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,23450,Repair shoulder capsule,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,23455,Repair shoulder capsule,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,23460,Repair shoulder capsule,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,23462,Repair shoulder capsule,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,23465,Repair shoulder capsule,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,23466,Repair shoulder capsule,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,23470,Reconstruct shoulder joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,23472,Reconstruct shoulder joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,23473,Revis reconst shoulder joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,23474,Revis reconst shoulder joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,23480,Revision of collar bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,23485,Revision of collar bone,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,23490,Reinforce clavicle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,23491,Reinforce shoulder bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,23500,Treat clavicle fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,23505,Treat clavicle fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,23515,Treat clavicle fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,23520,Treat clavicle dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,23525,Treat clavicle dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,23530,Treat clavicle dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,23532,Treat clavicle dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,23540,Treat clavicle dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,23545,Treat clavicle dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,23550,Treat clavicle dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,23552,Treat clavicle dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,23570,Treat shoulder blade fx,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,23575,Treat shoulder blade fx,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,23585,Treat scapula fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,23600,Treat humerus fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,23605,Treat humerus fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,23615,Treat humerus fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
UHC MCR ADV,CPT,23616,Treat humerus fracture,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,23620,Treat humerus fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,23625,Treat humerus fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,23630,Treat humerus fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,23650,Treat shoulder dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,23655,Treat shoulder dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,23660,Treat shoulder dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,23665,Treat dislocation/fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,23670,Treat dislocation/fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,23675,Treat dislocation/fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,23680,Treat dislocation/fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,23700,Fixation of shoulder,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,23800,Fusion of shoulder joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,23802,Fusion of shoulder joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,23900,Amputation of arm & girdle,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,23920,Amputation at shoulder joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,23921,Amputation follow-up surgery,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,23929,Shoulder surgery procedure,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,23930,Drainage of arm lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,23931,Drainage of arm bursa,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,23935,Drain arm/elbow bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,24000,Exploratory elbow surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,24006,Release elbow joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,24065,Biopsy arm/elbow soft tissue,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,24066,Biopsy arm/elbow soft tissue,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,24071,Exc arm/elbow les sc 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,24073,Ex arm/elbow tum deep 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,24075,Exc arm/elbow les sc < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,24076,Ex arm/elbow tum deep < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,24077,Resect arm/elbow tum < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,24079,Resect arm/elbow tum 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,24100,Biopsy elbow joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,24101,Explore/treat elbow joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,24102,Remove elbow joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,24105,Removal of elbow bursa,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,24110,Remove humerus lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,24115,Remove/graft bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,24116,Remove/graft bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,24120,Remove elbow lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,24125,Remove/graft bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,24126,Remove/graft bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,24130,Removal of head of radius,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,24134,Removal of arm bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,24136,Remove radius bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,24138,Remove elbow bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,24140,Partial removal of arm bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,24145,Partial removal of radius,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,24147,Partial removal of elbow,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,24149,Radical resection of elbow,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,24150,Resect distal humerus tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,24152,Resect radius tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,24155,Removal of elbow joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,24160,Remove elbow joint implant,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,24164,Remove radius head implant,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,24200,Removal of arm foreign body,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,24201,Removal of arm foreign body,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,24300,Manipulate elbow w/anesth,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,24301,Muscle/tendon transfer,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,24305,Arm tendon lengthening,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,24310,Revision of arm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,24320,Repair of arm tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,24330,Revision of arm muscles,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,24331,Revision of arm muscles,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,24332,Tenolysis triceps,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,24340,Repair of biceps tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,24341,Repair arm tendon/muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,24342,Repair of ruptured tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,24343,Repr elbow lat ligmnt w/tiss,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,24344,Reconstruct elbow lat ligmnt,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,24345,Repr elbw med ligmnt w/tissu,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,24346,Reconstruct elbow med ligmnt,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,24357,Repair elbow perc,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,24358,Repair elbow w/deb open,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,24359,Repair elbow deb/attch open,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,24360,Reconstruct elbow joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,24361,Reconstruct elbow joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,24362,Reconstruct elbow joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,24363,Replace elbow joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,24365,Reconstruct head of radius,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,24366,Reconstruct head of radius,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,24370,Revise reconst elbow joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,24371,Revise reconst elbow joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,24400,Revision of humerus,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,24410,Revision of humerus,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,24420,Revision of humerus,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,24430,Repair of humerus,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,24435,Repair humerus with graft,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,24470,Revision of elbow joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,24495,Decompression of forearm,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,24498,Reinforce humerus,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,24500,Treat humerus fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,24505,Treat humerus fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,24515,Treat humerus fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
UHC MCR ADV,CPT,24516,Treat humerus fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,24530,Treat humerus fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,24535,Treat humerus fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,24538,Treat humerus fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,24545,Treat humerus fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
UHC MCR ADV,CPT,24546,Treat humerus fracture,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,24560,Treat humerus fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,24565,Treat humerus fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,24566,Treat humerus fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,24575,Treat humerus fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,24576,Treat humerus fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,24577,Treat humerus fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,24579,Treat humerus fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,24582,Treat humerus fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,24586,Treat elbow fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,24587,Treat elbow fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,24600,Treat elbow dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,24605,Treat elbow dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,24615,Treat elbow dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,24620,Treat elbow fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,24635,Treat elbow fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,24640,Treat elbow dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,24650,Treat radius fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,24655,Treat radius fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,24665,Treat radius fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,24666,Treat radius fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
UHC MCR ADV,CPT,24670,Treat ulnar fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,24675,Treat ulnar fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,24685,Treat ulnar fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,24800,Fusion of elbow joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,24802,Fusion/graft of elbow joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,24900,Amputation of upper arm,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,24920,Amputation of upper arm,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,24925,Amputation follow-up surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,24930,Amputation follow-up surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,24931,Amputate upper arm & implant,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,24935,Revision of amputation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,24940,Revision of upper arm,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,24999,Upper arm/elbow surgery,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,25000,Incision of tendon sheath,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,25001,Incise flexor carpi radialis,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25020,Decompress forearm 1 space,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,25023,Decompress forearm 1 space,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25024,Decompress forearm 2 spaces,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25025,Decompress forearm 2 spaces,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,25028,Drainage of forearm lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25031,Drainage of forearm bursa,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,25035,Treat forearm bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,25040,Explore/treat wrist joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25065,Biopsy forearm soft tissues,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,25066,Biopsy forearm soft tissues,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,25071,Exc forearm les sc 3 cm/>,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,25073,Exc forearm tum deep 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,25075,Exc forearm les sc < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,25076,Exc forearm tum deep < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,25077,Resect forearm/wrist tum<3cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,25078,Resect forarm/wrist tum 3cm>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,25085,Incision of wrist capsule,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25100,Biopsy of wrist joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25101,Explore/treat wrist joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25105,Remove wrist joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25107,Remove wrist joint cartilage,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25109,Excise tendon forearm/wrist,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25110,Remove wrist tendon lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,25111,Remove wrist tendon lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,25112,Reremove wrist tendon lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,25115,Remove wrist/forearm lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,25116,Remove wrist/forearm lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25118,Excise wrist tendon sheath,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,25119,Partial removal of ulna,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25120,Removal of forearm lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25125,Remove/graft forearm lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,25126,Remove/graft forearm lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25130,Removal of wrist lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25135,Remove & graft wrist lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,25136,Remove & graft wrist lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,25145,Remove forearm bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25150,Partial removal of ulna,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25151,Partial removal of radius,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","9,201.00",,,,,,
UHC MCR ADV,CPT,25170,Resect radius/ulnar tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,25210,Removal of wrist bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25215,Removal of wrist bones,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25230,Partial removal of radius,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25240,Partial removal of ulna,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25248,Remove forearm foreign body,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,25250,Removal of wrist prosthesis,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,25251,Removal of wrist prosthesis,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25259,Manipulate wrist w/anesthes,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,25260,Repair forearm tendon/muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25263,Repair forearm tendon/muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,25265,Repair forearm tendon/muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25270,Repair forearm tendon/muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25272,Repair forearm tendon/muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25274,Repair forearm tendon/muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25275,Repair forearm tendon sheath,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25280,Revise wrist/forearm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25290,Incise wrist/forearm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25295,Release wrist/forearm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25300,Fusion of tendons at wrist,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25301,Fusion of tendons at wrist,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25310,Transplant forearm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25312,Transplant forearm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25315,Revise palsy hand tendon(s),APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,25316,Revise palsy hand tendon(s),APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,25320,Repair/revise wrist joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,25332,Revise wrist joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25335,Realignment of hand,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25337,Reconstruct ulna/radioulnar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,25350,Revision of radius,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,25355,Revision of radius,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25360,Revision of ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,25365,Revise radius & ulna,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,25370,Revise radius or ulna,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25375,Revise radius & ulna,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25390,Shorten radius or ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,25391,Lengthen radius or ulna,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,25392,Shorten radius & ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,25393,Lengthen radius & ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,25394,Repair carpal bone shorten,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25400,Repair radius or ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,25405,Repair/graft radius or ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,25415,Repair radius & ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,25420,Repair/graft radius & ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,25425,Repair/graft radius or ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,25426,Repair/graft radius & ulna,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25430,Vasc graft into carpal bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25431,Repair nonunion carpal bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,25440,Repair/graft wrist bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,25441,Reconstruct wrist joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,25442,Reconstruct wrist joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,25443,Reconstruct wrist joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,25444,Reconstruct wrist joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,25445,Reconstruct wrist joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,25446,Wrist replacement,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,25447,Repair wrist joints,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25449,Remove wrist joint implant,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,25450,Revision of wrist joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25455,Revision of wrist joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25490,Reinforce radius,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,25491,Reinforce ulna,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,25492,Reinforce radius and ulna,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25500,Treat fracture of radius,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,25505,Treat fracture of radius,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,25515,Treat fracture of radius,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,25520,Treat fracture of radius,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,25525,Treat fracture of radius,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,25526,Treat fracture of radius,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,25530,Treat fracture of ulna,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,25535,Treat fracture of ulna,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,25545,Treat fracture of ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,25560,Treat fracture radius & ulna,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,25565,Treat fracture radius & ulna,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,25574,Treat fracture radius & ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,25575,Treat fracture radius/ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,25600,Treat fracture radius/ulna,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,25605,Treat fracture radius/ulna,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,25606,Treat fx distal radial,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25607,Treat fx rad extra-articul,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,25608,Treat fx rad intra-articul,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,25609,Treat fx radial 3+ frag,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,25622,Treat wrist bone fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,25624,Treat wrist bone fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,25628,Treat wrist bone fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,25630,Treat wrist bone fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,25635,Treat wrist bone fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,25645,Treat wrist bone fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25650,Treat wrist bone fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,25651,Pin ulnar styloid fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25652,Treat fracture ulnar styloid,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,25660,Treat wrist dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,25670,Treat wrist dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,25671,Pin radioulnar dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25675,Treat wrist dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,25676,Treat wrist dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,25680,Treat wrist fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,25685,Treat wrist fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,25690,Treat wrist dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,25695,Treat wrist dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,25800,Fusion of wrist joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,25805,Fusion/graft of wrist joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,25810,Fusion/graft of wrist joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,25820,Fusion of hand bones,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,25825,Fuse hand bones with graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,25830,Fusion radioulnar jnt/ulna,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,25900,Amputation of forearm,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,25905,Amputation of forearm,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,25907,Amputation follow-up surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25909,Amputation follow-up surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,25915,Amputation of forearm,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,25920,Amputate hand at wrist,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,25922,Amputate hand at wrist,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,25924,Amputation follow-up surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,25927,Amputation of hand,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25929,Amputation follow-up surgery,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,25931,Amputation follow-up surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,25999,Forearm or wrist surgery,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,26010,Drainage of finger abscess,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,26011,Drainage of finger abscess,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,26020,Drain hand tendon sheath,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26025,Drainage of palm bursa,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26030,Drainage of palm bursas,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26034,Treat hand bone lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,26035,Decompress fingers/hand,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26037,Decompress fingers/hand,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26040,Release palm contracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,26045,Release palm contracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26055,Incise finger tendon sheath,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,26060,Incision of finger tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,26070,Explore/treat hand joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,26075,Explore/treat finger joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26080,Explore/treat finger joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,26100,Biopsy hand joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26105,Biopsy finger joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26110,Biopsy finger joint lining,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,26111,Exc hand les sc 1.5 cm/>,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,26113,Exc hand tum deep 1.5 cm/>,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,26115,Exc hand les sc < 1.5 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,26116,Exc hand tum deep < 1.5 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,26117,Rad resect hand tumor < 3 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,26118,Rad resect hand tumor 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,26121,Release palm contracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26123,Release palm contracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26130,Remove wrist joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26135,Revise finger joint each,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26140,Revise finger joint each,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,26145,Tendon excision palm/finger,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,26160,Remove tendon sheath lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,26170,Removal of palm tendon each,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,26180,Removal of finger tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,26185,Remove finger bone,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,26200,Remove hand bone lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,26205,Remove/graft bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,26210,Removal of finger lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,26215,Remove/graft finger lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26230,Partial removal of hand bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26235,Partial removal finger bone,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,26236,Partial removal finger bone,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,26250,Extensive hand surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26260,Resect prox finger tumor,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26262,Resect distal finger tumor,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,26320,Removal of implant from hand,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,26340,Manipulate finger w/anesth,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,26341,Manipulat palm cord post inj,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,26350,Repair finger/hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26352,Repair/graft hand tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,26356,Repair finger/hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26357,Repair finger/hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26358,Repair/graft hand tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,26370,Repair finger/hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","9,201.00",,,,,,
UHC MCR ADV,CPT,26372,Repair/graft hand tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,26373,Repair finger/hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26390,Revise hand/finger tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,26392,Repair/graft hand tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,26410,Repair hand tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,26412,Repair/graft hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26415,Excision hand/finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26416,Graft hand or finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26418,Repair finger tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,26420,Repair/graft finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26426,Repair finger/hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26428,Repair/graft finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26432,Repair finger tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,26433,Repair finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26434,Repair/graft finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26437,Realignment of tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26440,Release palm/finger tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,26442,Release palm & finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26445,Release hand/finger tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26449,Release forearm/hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26450,Incision of palm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26455,Incision of finger tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,26460,Incise hand/finger tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,26471,Fusion of finger tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26474,Fusion of finger tendons,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,26476,Tendon lengthening,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26477,Tendon shortening,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26478,Lengthening of hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26479,Shortening of hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26480,Transplant hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26483,Transplant/graft hand tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26485,Transplant palm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26489,Transplant/graft palm tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26490,Revise thumb tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26492,Tendon transfer with graft,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26494,Hand tendon/muscle transfer,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26496,Revise thumb tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26497,Finger tendon transfer,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26498,Finger tendon transfer,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26499,Revision of finger,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26500,Hand tendon reconstruction,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,26502,Hand tendon reconstruction,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26508,Release thumb contracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26510,Thumb tendon transfer,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26516,Fusion of knuckle joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26517,Fusion of knuckle joints,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26518,Fusion of knuckle joints,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,26520,Release knuckle contracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26525,Release finger contracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,26530,Revise knuckle joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,26531,Revise knuckle with implant,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,26535,Revise finger joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26536,Revise/implant finger joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,26540,Repair hand joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26541,Repair hand joint with graft,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26542,Repair hand joint with graft,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26545,Reconstruct finger joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26546,Repair nonunion hand,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,26548,Reconstruct finger joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26550,Construct thumb replacement,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26551,Great toe-hand transfer,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,26553,Single transfer toe-hand,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,26554,Double transfer toe-hand,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,26555,Positional change of finger,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,26556,Toe joint transfer,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,26560,Repair of web finger,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,26561,Repair of web finger,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26562,Repair of web finger,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26565,Correct metacarpal flaw,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26567,Correct finger deformity,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26568,Lengthen metacarpal/finger,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,26580,Repair hand deformity,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26587,Reconstruct extra finger,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26590,Repair finger deformity,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,26591,Repair muscles of hand,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26593,Release muscles of hand,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26596,Excision constricting tissue,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26600,Treat metacarpal fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,26605,Treat metacarpal fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,26607,Treat metacarpal fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26608,Treat metacarpal fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26615,Treat metacarpal fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26641,Treat thumb dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,26645,Treat thumb fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,26650,Treat thumb fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26665,Treat thumb fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26670,Treat hand dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,26675,Treat hand dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,26676,Pin hand dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26685,Treat hand dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26686,Treat hand dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26700,Treat knuckle dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,26705,Treat knuckle dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,26706,Pin knuckle dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26715,Treat knuckle dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26720,Treat finger fracture each,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,26725,Treat finger fracture each,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,26727,Treat finger fracture each,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26735,Treat finger fracture each,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26740,Treat finger fracture each,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,26742,Treat finger fracture each,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,26746,Treat finger fracture each,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26750,Treat finger fracture each,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,26755,Treat finger fracture each,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,26756,Pin finger fracture each,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26765,Treat finger fracture each,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26770,Treat finger dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,26775,Treat finger dislocation,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
UHC MCR ADV,CPT,26776,Pin finger dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26785,Treat finger dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26820,Thumb fusion with graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,26841,Fusion of thumb,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,26842,Thumb fusion with graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,26843,Fusion of hand joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,26844,Fusion/graft of hand joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,26850,Fusion of knuckle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,26852,Fusion of knuckle with graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,26860,Fusion of finger joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26862,Fusion/graft of finger joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26910,Amputate metacarpal bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26951,Amputation of finger/thumb,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26952,Amputation of finger/thumb,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26989,Hand/finger surgery,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,26990,Drainage of pelvis lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,26991,Drainage of pelvis bursa,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,26992,Drainage of bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27000,Incision of hip tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,27001,Incision of hip tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27003,Incision of hip tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27005,Incision of hip tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27006,Incision of hip tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27025,Incision of hip/thigh fascia,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27027,Buttock fasciotomy,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27030,Drainage of hip joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27033,Exploration of hip joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27035,Denervation of hip joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27036,Excision of hip joint/muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27040,Biopsy of soft tissues,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,27041,Biopsy of soft tissues,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,27043,Exc hip pelvis les sc 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,27045,Exc hip/pelv tum deep 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,27047,Exc hip/pelvis les sc < 3 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,27048,Exc hip/pelv tum deep < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,27049,Resect hip/pelv tum < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,27050,Biopsy of sacroiliac joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,27052,Biopsy of hip joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,27054,Removal of hip joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27057,Buttock fasciotomy w/dbrdmt,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,27059,Resect hip/pelv tum 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,27060,Removal of ischial bursa,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27062,Remove femur lesion/bursa,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27065,Remove hip bone les super,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27066,Remove hip bone les deep,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27067,Remove/graft hip bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27070,Part remove hip bone super,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27071,Part removal hip bone deep,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27075,Resect hip tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27076,Resect hip tum incl acetabul,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27077,Resect hip tum w/innom bone,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,27078,Rsect hip tum incl femur,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,27080,Removal of tail bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27086,Remove hip foreign body,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,27087,Remove hip foreign body,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27090,Removal of hip prosthesis,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,27091,Removal of hip prosthesis,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,27097,Revision of hip tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27098,Transfer tendon to pelvis,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27100,Transfer of abdominal muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27105,Transfer of spinal muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27110,Transfer of iliopsoas muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27111,Transfer of iliopsoas muscle,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27120,Reconstruction of hip socket,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,27122,Reconstruction of hip socket,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,27125,Partial hip replacement,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,27130,Total hip arthroplasty,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,27132,Total hip arthroplasty,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,27134,Revise hip joint replacement,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,27137,Revise hip joint replacement,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,27138,Revise hip joint replacement,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,27140,Transplant femur ridge,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,27146,Incision of hip bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27147,Revision of hip bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27151,Incision of hip bones,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27156,Revision of hip bones,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27158,Revision of pelvis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27161,Incision of neck of femur,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27165,Incision/fixation of femur,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27170,Repair/graft femur head/neck,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27175,Treat slipped epiphysis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27176,Treat slipped epiphysis,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,27177,Treat slipped epiphysis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27178,Treat slipped epiphysis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27179,Revise head/neck of femur,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27181,Treat slipped epiphysis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27185,Revision of femur epiphysis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27187,Reinforce hip bones,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27197,Clsd tx pelvic ring fx,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,27198,Clsd tx pelvic ring fx,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,27200,Treat tail bone fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,27202,Treat tail bone fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27220,Treat hip socket fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,27222,Treat hip socket fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,27226,Treat hip wall fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27227,Treat hip fracture(s),APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27228,Treat hip fracture(s),APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27230,Treat thigh fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,27232,Treat thigh fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,27235,Treat thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27236,Treat thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27238,Treat thigh fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,27240,Treat thigh fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,27244,Treat thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27245,Treat thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27246,Treat thigh fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,27248,Treat thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27250,Treat hip dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,27252,Treat hip dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,27253,Treat hip dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27254,Treat hip dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27256,Treat hip dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,27257,Treat hip dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,27258,Treat hip dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27259,Treat hip dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27265,Treat hip dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,27266,Treat hip dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,27267,Cltx thigh fx,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27268,Cltx thigh fx w/mnpj,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27269,Optx thigh fx,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,27275,Manipulation of hip joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,27279,Arthrodesis sacroiliac joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,27280,Fusion of sacroiliac joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,27282,Fusion of pubic bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,27284,Fusion of hip joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,27286,Fusion of hip joint,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,27290,Amputation of leg at hip,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,27295,Amputation of leg at hip,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,27299,Pelvis/hip joint surgery,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,27301,Drain thigh/knee lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,27303,Drainage of bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27305,Incise thigh tendon & fascia,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27306,Incision of thigh tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27307,Incision of thigh tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27310,Exploration of knee joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27323,Biopsy thigh soft tissues,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,27324,Biopsy thigh soft tissues,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,27325,Neurectomy hamstring,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,27326,Neurectomy popliteal,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,27327,Exc thigh/knee les sc < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,27328,Exc thigh/knee tum deep <5cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,27329,Resect thigh/knee tum < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,27330,Biopsy knee joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27331,Explore/treat knee joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27332,Removal of knee cartilage,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27333,Removal of knee cartilage,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27334,Remove knee joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27335,Remove knee joint lining,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27337,Exc thigh/knee les sc 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,27339,Exc thigh/knee tum dep 5cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,27340,Removal of kneecap bursa,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27345,Removal of knee cyst,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27347,Remove knee cyst,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27350,Removal of kneecap,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27355,Remove femur lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27356,Remove femur lesion/graft,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,27357,Remove femur lesion/graft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27360,Partial removal leg bone(s),APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27364,Resect thigh/knee tum 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,27365,Resect femur/knee tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27372,Removal of foreign body,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,27380,Repair of kneecap tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27381,Repair/graft kneecap tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27385,Repair of thigh muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27386,Repair/graft of thigh muscle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27390,Incision of thigh tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27391,Incision of thigh tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27392,Incision of thigh tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27393,Lengthening of thigh tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27394,Lengthening of thigh tendons,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27395,Lengthening of thigh tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27396,Transplant of thigh tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27397,Transplants of thigh tendons,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27400,Revise thigh muscles/tendons,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27403,Repair of knee cartilage,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27405,Repair of knee ligament,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,27407,Repair of knee ligament,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,27409,Repair of knee ligaments,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,27412,Autochondrocyte implant knee,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27415,Osteochondral knee allograft,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,27416,Osteochondral knee autograft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27418,Repair degenerated kneecap,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27420,Revision of unstable kneecap,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27422,Revision of unstable kneecap,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27424,Revision/removal of kneecap,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27425,Lat retinacular release open,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27427,Reconstruction knee,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,27428,Reconstruction knee,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
UHC MCR ADV,CPT,27429,Reconstruction knee,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
UHC MCR ADV,CPT,27430,Revision of thigh muscles,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27435,Incision of knee joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27437,Revise kneecap,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27438,Revise kneecap with implant,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,27440,Revision of knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,27441,Revision of knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,27442,Revision of knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,27443,Revision of knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,27445,Revision of knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,27446,Revision of knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
UHC MCR ADV,CPT,27447,Total knee arthroplasty,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,27448,Incision of thigh,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27450,Incision of thigh,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27454,Realignment of thigh bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27455,Realignment of knee,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27457,Realignment of knee,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27465,Shortening of thigh bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27466,Lengthening of thigh bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27468,Shorten/lengthen thighs,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27470,Repair of thigh,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27472,Repair/graft of thigh,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27475,Surgery to stop leg growth,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27477,Surgery to stop leg growth,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27479,Surgery to stop leg growth,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27485,Surgery to stop leg growth,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27486,Revise/replace knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,27487,Revise/replace knee joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,27488,Removal of knee prosthesis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27495,Reinforce thigh,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27496,Decompression of thigh/knee,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27497,Decompression of thigh/knee,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27498,Decompression of thigh/knee,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,27499,Decompression of thigh/knee,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27500,Treatment of thigh fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,27501,Treatment of thigh fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,27502,Treatment of thigh fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,27503,Treatment of thigh fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,27506,Treatment of thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27507,Treatment of thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27508,Treatment of thigh fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,27509,Treatment of thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27510,Treatment of thigh fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,27511,Treatment of thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27513,Treatment of thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27514,Treatment of thigh fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27516,Treat thigh fx growth plate,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,27517,Treat thigh fx growth plate,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,27519,Treat thigh fx growth plate,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27520,Treat kneecap fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,27524,Treat kneecap fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27530,Treat knee fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,27532,Treat knee fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27535,Treat knee fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27536,Treat knee fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27538,Treat knee fracture(s),APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,27540,Treat knee fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27550,Treat knee dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,27552,Treat knee dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,27556,Treat knee dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27557,Treat knee dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27558,Treat knee dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27560,Treat kneecap dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,27562,Treat kneecap dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,27566,Treat kneecap dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27570,Fixation of knee joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,27580,Fusion of knee,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,27590,Amputate leg at thigh,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,27591,Amputate leg at thigh,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,27592,Amputate leg at thigh,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,27594,Amputation follow-up surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27596,Amputation follow-up surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27598,Amputate lower leg at knee,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,27599,Leg surgery procedure,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,27600,Decompression of lower leg,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27601,Decompression of lower leg,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27602,Decompression of lower leg,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27603,Drain lower leg lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,27604,Drain lower leg bursa,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27605,Incision of achilles tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,27606,Incision of achilles tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27607,Treat lower leg bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27610,Explore/treat ankle joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27612,Exploration of ankle joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27613,Biopsy lower leg soft tissue,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,27614,Biopsy lower leg soft tissue,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,27615,Resect leg/ankle tum < 5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,27616,Resect leg/ankle tum 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,27618,Exc leg/ankle tum < 3 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,27619,Exc leg/ankle tum deep <5 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,27620,Explore/treat ankle joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27625,Remove ankle joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27626,Remove ankle joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27630,Removal of tendon lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27632,Exc leg/ankle les sc 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,27634,Exc leg/ankle tum dep 5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,27635,Remove lower leg bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27637,Remove/graft leg bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27638,Remove/graft leg bone lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27640,Partial removal of tibia,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27641,Partial removal of fibula,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27645,Resect tibia tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27646,Resect fibula tumor,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27647,Resect talus/calcaneus tum,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27650,Repair achilles tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27652,Repair/graft achilles tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,27654,Repair of achilles tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,27656,Repair leg fascia defect,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27658,Repair of leg tendon each,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27659,Repair of leg tendon each,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27664,Repair of leg tendon each,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27665,Repair of leg tendon each,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27675,Repair lower leg tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27676,Repair lower leg tendons,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27680,Release of lower leg tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27681,Release of lower leg tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27685,Revision of lower leg tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27686,Revise lower leg tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27687,Revision of calf tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27690,Revise lower leg tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27691,Revise lower leg tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,27695,Repair of ankle ligament,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27696,Repair of ankle ligaments,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27698,Repair of ankle ligament,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27700,Revision of ankle joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27702,Reconstruct ankle joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,27703,Reconstruction ankle joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,27704,Removal of ankle implant,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27705,Incision of tibia,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27707,Incision of fibula,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27709,Incision of tibia & fibula,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,27712,Realignment of lower leg,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,27715,Revision of lower leg,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,27720,Repair of tibia,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27722,Repair/graft of tibia,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27724,Repair/graft of tibia,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,27725,Repair of lower leg,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27726,Repair fibula nonunion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,27727,Repair of lower leg,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27730,Repair of tibia epiphysis,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27732,Repair of fibula epiphysis,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27734,Repair lower leg epiphyses,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27740,Repair of leg epiphyses,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27742,Repair of leg epiphyses,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27745,Reinforce tibia,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27750,Treatment of tibia fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,27752,Treatment of tibia fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,27756,Treatment of tibia fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27758,Treatment of tibia fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
UHC MCR ADV,CPT,27759,Treatment of tibia fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,27760,Cltx medial ankle fx,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,27762,Cltx med ankle fx w/mnpj,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,27766,Optx medial ankle fx,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27767,Cltx post ankle fx,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,27768,Cltx post ankle fx w/mnpj,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,27769,Optx post ankle fx,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27780,Treatment of fibula fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,27781,Treatment of fibula fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,27784,Treatment of fibula fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27786,Treatment of ankle fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,27788,Treatment of ankle fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,27792,Treatment of ankle fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27808,Treatment of ankle fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,27810,Treatment of ankle fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,27814,Treatment of ankle fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,27816,Treatment of ankle fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,27818,Treatment of ankle fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,27822,Treatment of ankle fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27823,Treatment of ankle fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27824,Treat lower leg fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,27825,Treat lower leg fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,27826,Treat lower leg fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27827,Treat lower leg fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,27828,Treat lower leg fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
UHC MCR ADV,CPT,27829,Treat lower leg joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27830,Treat lower leg dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,27831,Treat lower leg dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27832,Treat lower leg dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27840,Treat ankle dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,27842,Treat ankle dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,27846,Treat ankle dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27848,Treat ankle dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27860,Fixation of ankle joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27870,Fusion of ankle joint open,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
UHC MCR ADV,CPT,27871,Fusion of tibiofibular joint,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
UHC MCR ADV,CPT,27880,Amputation of lower leg,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,27881,Amputation of lower leg,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27882,Amputation of lower leg,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27884,Amputation follow-up surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27886,Amputation follow-up surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27888,Amputation of foot at ankle,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,27889,Amputation of foot at ankle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27892,Decompression of leg,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27893,Decompression of leg,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,27894,Decompression of leg,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,27899,Leg/ankle surgery procedure,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,28001,Drainage of bursa of foot,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,28002,Treatment of foot infection,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,28003,Treatment of foot infection,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28005,Treat foot bone lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28008,Incision of foot fascia,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28010,Incision of toe tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,28011,Incision of toe tendons,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,28020,Exploration of foot joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28022,Exploration of foot joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28024,Exploration of toe joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,28035,Decompression of tibia nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,28039,Exc foot/toe tum sc 1.5 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,28041,Exc foot/toe tum dep 1.5cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,28043,Exc foot/toe tum sc < 1.5 cm,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,28045,Exc foot/toe tum deep <1.5cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,28046,Resect foot/toe tumor < 3 cm,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,28047,Resect foot/toe tumor 3 cm/>,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,28050,Biopsy of foot joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28052,Biopsy of foot joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28054,Biopsy of toe joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28055,Neurectomy foot,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,28060,Partial removal foot fascia,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28062,Removal of foot fascia,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28070,Removal of foot joint lining,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,28072,Removal of foot joint lining,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28080,Removal of foot lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,28086,Excise foot tendon sheath,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28088,Excise foot tendon sheath,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28090,Removal of foot lesion,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,28092,Removal of toe lesions,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,28100,Removal of ankle/heel lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28102,Remove/graft foot lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,28103,Remove/graft foot lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,28104,Removal of foot lesion,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28106,Remove/graft foot lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,28107,Remove/graft foot lesion,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,28108,Removal of toe lesions,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,28110,Part removal of metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28111,Part removal of metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28112,Part removal of metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28113,Part removal of metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28114,Removal of metatarsal heads,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28116,Revision of foot,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28118,Removal of heel bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28119,Removal of heel spur,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28120,Part removal of ankle/heel,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28122,Partial removal of foot bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28124,Partial removal of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28126,Partial removal of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28130,Removal of ankle bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,28140,Removal of metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28150,Removal of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28153,Partial removal of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28160,Partial removal of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28171,Resect tarsal tumor,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28173,Resect metatarsal tumor,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28175,Resect phalanx of toe tumor,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,28190,Removal of foot foreign body,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,28192,Removal of foot foreign body,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,28193,Removal of foot foreign body,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,28200,Repair of foot tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28202,Repair/graft of foot tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,28208,Repair of foot tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28210,Repair/graft of foot tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,28220,Release of foot tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,28222,Release of foot tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28225,Release of foot tendon,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28226,Release of foot tendons,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28230,Incision of foot tendon(s),APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,28232,Incision of toe tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,28234,Incision of foot tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,28238,Revision of foot tendon,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,28240,Release of big toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28250,Revision of foot fascia,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28260,Release of midfoot joint,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28261,Revision of foot tendon,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,28262,Revision of foot and ankle,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,28264,Release of midfoot joint,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,28270,Release of foot contracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28272,Release of toe joint each,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,28280,Fusion of toes,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28285,Repair of hammertoe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28286,Repair of hammertoe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28288,Partial removal of foot bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28289,Corrj halux rigdus w/o implt,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28291,Corrj halux rigdus w/implt,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,28292,Correction hallux valgus,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28295,Correction hallux valgus,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28296,Correction hallux valgus,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28297,Correction hallux valgus,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,28298,Correction hallux valgus,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,28299,Correction hallux valgus,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,28300,Incision of heel bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,28302,Incision of ankle bone,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,28304,Incision of midfoot bones,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,28305,Incise/graft midfoot bones,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,28306,Incision of metatarsal,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,28307,Incision of metatarsal,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,28308,Incision of metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28309,Incision of metatarsals,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,28310,Revision of big toe,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,28312,Revision of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28313,Repair deformity of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28315,Removal of sesamoid bone,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28320,Repair of foot bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,28322,Repair of metatarsals,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,28340,Resect enlarged toe tissue,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28341,Resect enlarged toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28344,Repair extra toe(s),APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28345,Repair webbed toe(s),APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,28360,Reconstruct cleft foot,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,28400,Treatment of heel fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,28405,Treatment of heel fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,28406,Treatment of heel fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,28415,Treat heel fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,28420,Treat/graft heel fracture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,28430,Treatment of ankle fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,28435,Treatment of ankle fracture,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,28436,Treatment of ankle fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,28445,Treat ankle fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,28446,Osteochondral talus autogrft,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,28450,Treat midfoot fracture each,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,28455,Treat midfoot fracture each,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,28456,Treat midfoot fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,28465,Treat midfoot fracture each,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,28470,Treat metatarsal fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,28475,Treat metatarsal fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,28476,Treat metatarsal fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28485,Treat metatarsal fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,28490,Treat big toe fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,28495,Treat big toe fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,28496,Treat big toe fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28505,Treat big toe fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28510,Treatment of toe fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,28515,Treatment of toe fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,28525,Treat toe fracture,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28530,Treat sesamoid bone fracture,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,28531,Treat sesamoid bone fracture,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,28540,Treat foot dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,28545,Treat foot dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28546,Treat foot dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,28555,Repair foot dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,28570,Treat foot dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,28575,Treat foot dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28576,Treat foot dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,28585,Repair foot dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,28600,Treat foot dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,28605,Treat foot dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,28606,Treat foot dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28615,Repair foot dislocation,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,28630,Treat toe dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,28635,Treat toe dislocation,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,28636,Treat toe dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28645,Repair toe dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28660,Treat toe dislocation,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,28665,Treat toe dislocation,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
UHC MCR ADV,CPT,28666,Treat toe dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28675,Repair of toe dislocation,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28705,Fusion of foot bones,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,28715,Fusion of foot bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
UHC MCR ADV,CPT,28725,Fusion of foot bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
UHC MCR ADV,CPT,28730,Fusion of foot bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
UHC MCR ADV,CPT,28735,Fusion of foot bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,28737,Revision of foot bones,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,28740,Fusion of foot bones,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,28750,Fusion of big toe joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,28755,Fusion of big toe joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,28760,Fusion of big toe joint,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,28800,Amputation of midfoot,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28805,Amputation thru metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28810,Amputation toe & metatarsal,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28820,Amputation of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28825,Partial amputation of toe,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,28890,Hi enrgy eswt plantar fascia,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,28899,Foot/toes surgery procedure,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,29000,Application of body cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
UHC MCR ADV,CPT,29010,Application of body cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
UHC MCR ADV,CPT,29015,Application of body cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
UHC MCR ADV,CPT,29035,Application of body cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
UHC MCR ADV,CPT,29040,Application of body cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
UHC MCR ADV,CPT,29044,Application of body cast,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,29046,Application of body cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
UHC MCR ADV,CPT,29049,Application of figure eight,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
UHC MCR ADV,CPT,29055,Application of shoulder cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
UHC MCR ADV,CPT,29058,Application of shoulder cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
UHC MCR ADV,CPT,29065,Application of long arm cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
UHC MCR ADV,CPT,29075,Application of forearm cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
UHC MCR ADV,CPT,29085,Apply hand/wrist cast,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,29086,Apply finger cast,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,29105,Apply long arm splint,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,29125,Apply forearm splint,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
UHC MCR ADV,CPT,29126,Apply forearm splint,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
UHC MCR ADV,CPT,29130,Application of finger splint,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
UHC MCR ADV,CPT,29131,Application of finger splint,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
UHC MCR ADV,CPT,29200,Strapping of chest,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,29240,Strapping of shoulder,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
UHC MCR ADV,CPT,29260,Strapping of elbow or wrist,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
UHC MCR ADV,CPT,29280,Strapping of hand or finger,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
UHC MCR ADV,CPT,29305,Application of hip cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
UHC MCR ADV,CPT,29325,Application of hip casts,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
UHC MCR ADV,CPT,29345,Application of long leg cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
UHC MCR ADV,CPT,29355,Application of long leg cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
UHC MCR ADV,CPT,29358,Apply long leg cast brace,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
UHC MCR ADV,CPT,29365,Application of long leg cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
UHC MCR ADV,CPT,29405,Apply short leg cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
UHC MCR ADV,CPT,29425,Apply short leg cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
UHC MCR ADV,CPT,29435,Apply short leg cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
UHC MCR ADV,CPT,29440,Addition of walker to cast,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,29445,Apply rigid leg cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
UHC MCR ADV,CPT,29450,Application of leg cast,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,29505,Application long leg splint,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,29515,Application lower leg splint,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,29520,Strapping of hip,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
UHC MCR ADV,CPT,29530,Strapping of knee,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
UHC MCR ADV,CPT,29540,Strapping of ankle and/or ft,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,29550,Strapping of toes,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
UHC MCR ADV,CPT,29580,Application of paste boot,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,29581,Apply multlay comprs lwr leg,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,29584,Appl multlay comprs arm/hand,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,29700,Removal/revision of cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
UHC MCR ADV,CPT,29705,Removal/revision of cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
UHC MCR ADV,CPT,29710,Removal/revision of cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
UHC MCR ADV,CPT,29720,Repair of body cast,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,29730,Windowing of cast,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,29740,Wedging of cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
UHC MCR ADV,CPT,29750,Wedging of clubfoot cast,APC 5102,RVU Per Unit,$246.80 ,OP,246.8,"4,314.00",,,,,,
UHC MCR ADV,CPT,29799,Casting/strapping procedure,APC 5101,RVU Per Unit,$144.47 ,OP,144.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,29800,Jaw arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,29804,Jaw arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,29805,Sho arthrs dx +- synovial bx,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,29806,Sho arthrs srg capsulorpaphy,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,29807,Sho arthrs srg rpr slap les,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,29819,Sho arthrs srg rmvl loose/fb,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,29820,Sho arthrs srg prtl synvct,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,29821,Sho arthrs srg compl synvct,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,29822,Sho arthrs srg lmtd dbrdmt,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,29823,Sho arthrs srg xtnsv dbrdmt,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,29824,Sho arthrs srg dstl claviclc,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,29825,Sho arthrs srg lss&rescj ads,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,29827,Sho arthrs srg rt8tr cuf rpr,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,29828,Sho arthrs srg bicp tenodsis,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,29830,Elbow arthroscopy,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,29834,Elbow arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,29835,Elbow arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,29836,Elbow arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,29837,Elbow arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,29838,Elbow arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,29840,Wrist arthroscopy,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,29843,Wrist arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,29844,Wrist arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,29845,Wrist arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,29846,Wrist arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,29847,Wrist arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,29848,Wrist endoscopy/surgery,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,29850,Knee arthroscopy/surgery,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,29851,Knee arthroscopy/surgery,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,29855,Tibial arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,29856,Tibial arthroscopy/surgery,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,29860,Hip arthroscopy dx,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,29861,Hip arthro w/fb removal,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,29862,Hip arthr0 w/debridement,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,29863,Hip arthr0 w/synovectomy,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,29866,Autgrft implnt knee w/scope,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,29867,Allgrft implnt knee w/scope,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,29868,Meniscal trnspl knee w/scpe,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,29870,Knee arthroscopy dx,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,29871,Knee arthroscopy/drainage,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,29873,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,29874,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,29875,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,29876,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,29877,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,29879,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,29880,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,29881,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,29882,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,29883,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,29884,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,29885,Knee arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,29886,Knee arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,29887,Knee arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,29888,Knee arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,29889,Knee arthroscopy/surgery,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,140.35","12,601.93",,,,,,
UHC MCR ADV,CPT,29891,Ankle arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,29892,Ankle arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,29893,Scope plantar fasciotomy,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,29894,Ankle arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,29895,Ankle arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,29897,Ankle arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,29898,Ankle arthroscopy/surgery,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,29899,Ankle arthroscopy/surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,29900,Mcp joint arthroscopy dx,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,29901,Mcp joint arthroscopy surg,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,29902,Mcp joint arthroscopy surg,APC 5112,RVU Per Case,"$1,424.82 ",OP,"1,424.82","4,314.00",,,,,,
UHC MCR ADV,CPT,29904,Subtalar arthro w/fb rmvl,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,29905,Subtalar arthro w/exc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,29906,Subtalar arthro w/deb,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,29907,Subtalar arthro w/fusion,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,29914,Hip arthro w/femoroplasty,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,29915,Hip arthro acetabuloplasty,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,29916,Hip arthro w/labral repair,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,29999,Arthroscopy of joint,APC 5111,RVU Per Unit,$211.00 ,OP,211,"4,314.00",,,,,,
UHC MCR ADV,CPT,30000,Drainage of nose lesion,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
UHC MCR ADV,CPT,30020,Drainage of nose lesion,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,30100,Intranasal biopsy,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,30110,Removal of nose polyp(s),APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,30115,Removal of nose polyp(s),APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,30117,Removal of intranasal lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,30118,Removal of intranasal lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,30120,Revision of nose,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,30124,Removal of nose lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,30125,Removal of nose lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,30130,Excise inferior turbinate,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,30140,Resect inferior turbinate,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,30150,Partial removal of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,30160,Removal of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,30200,Injection treatment of nose,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,30210,Nasal sinus therapy,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,30220,Insert nasal septal button,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,30300,Remove nasal foreign body,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
UHC MCR ADV,CPT,30310,Remove nasal foreign body,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,30320,Remove nasal foreign body,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,30400,Reconstruction of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,30410,Reconstruction of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,30420,Reconstruction of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,30430,Revision of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,30435,Revision of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,30450,Revision of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,30460,Revision of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,30462,Revision of nose,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,30465,Repair nasal stenosis,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,30468,Rpr nsl vlv collapse w/implt,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,30520,Repair of nasal septum,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,30540,Repair nasal defect,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,30545,Repair nasal defect,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,30560,Release of nasal adhesions,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,30580,Repair upper jaw fistula,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,30600,Repair mouth/nose fistula,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,30620,Intranasal reconstruction,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,30630,Repair nasal septum defect,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,30801,Ablate inf turbinate superf,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,30802,Ablate inf turbinate submuc,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,30901,Control of nosebleed,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
UHC MCR ADV,CPT,30903,Control of nosebleed,APC 5734,RVU Per Unit,$114.56 ,OP,114.56,"4,314.00",,,,,,
UHC MCR ADV,CPT,30905,Control of nosebleed,APC 5734,RVU Per Unit,$114.56 ,OP,114.56,"4,314.00",,,,,,
UHC MCR ADV,CPT,30906,Repeat control of nosebleed,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
UHC MCR ADV,CPT,30915,Ligation nasal sinus artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,30920,Ligation upper jaw artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,30930,Ther fx nasal inf turbinate,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,30999,Nasal surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
UHC MCR ADV,CPT,31000,Irrigation maxillary sinus,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
UHC MCR ADV,CPT,31002,Irrigation sphenoid sinus,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,31020,Exploration maxillary sinus,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,31030,Exploration maxillary sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,31032,Explore sinus remove polyps,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,31040,Exploration behind upper jaw,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,31050,Exploration sphenoid sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,31051,Sphenoid sinus surgery,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,31070,Exploration of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,31075,Exploration of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,31080,Removal of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,31081,Removal of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,31084,Removal of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,31085,Removal of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,31086,Removal of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,31087,Removal of frontal sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,31090,Exploration of sinuses,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,31200,Removal of ethmoid sinus,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,31201,Removal of ethmoid sinus,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,31205,Removal of ethmoid sinus,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,31225,Removal of upper jaw,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,31230,Removal of upper jaw,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,31231,Nasal endoscopy dx,APC 5151,RVU Per Unit,$168.23 ,OP,168.23,"4,314.00",,,,,,
UHC MCR ADV,CPT,31233,Nsl/sins ndsc dx max sinusc,APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
UHC MCR ADV,CPT,31235,Nsl/sins ndsc dx sphn sinusc,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
UHC MCR ADV,CPT,31237,Nasal/sinus endoscopy surg,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
UHC MCR ADV,CPT,31238,Nasal/sinus endoscopy surg,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
UHC MCR ADV,CPT,31239,Nasal/sinus endoscopy surg,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
UHC MCR ADV,CPT,31240,Nasal/sinus endoscopy surg,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
UHC MCR ADV,CPT,31241,Nsl/sins ndsc w/artery lig,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
UHC MCR ADV,CPT,31253,Nsl/sins ndsc total,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,31254,Nsl/sins ndsc w/prtl ethmdct,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
UHC MCR ADV,CPT,31255,Nsl/sins ndsc w/tot ethmdct,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,31256,Exploration maxillary sinus,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
UHC MCR ADV,CPT,31257,Nsl/sins ndsc tot w/sphendt,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,31259,Nsl/sins ndsc sphn tiss rmvl,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,31267,Endoscopy maxillary sinus,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
UHC MCR ADV,CPT,31276,Nsl/sins ndsc frnt tiss rmvl,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,31287,Nasal/sinus endoscopy surg,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,31288,Nasal/sinus endoscopy surg,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,31290,Nasal/sinus endoscopy surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,31291,Nasal/sinus endoscopy surg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,31292,Nsl/sins ndsc med/inf dcmprn,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
UHC MCR ADV,CPT,31293,Nsl/sins ndsc med&inf dcmprn,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
UHC MCR ADV,CPT,31294,Nsl/sins ndsc surg on dcmprn,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
UHC MCR ADV,CPT,31295,Nsl/sins ndsc surg max sins,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
UHC MCR ADV,CPT,31296,Nsl/sins ndsc surg frnt sins,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,31297,Nsl/sins ndsc surg sphn sins,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
UHC MCR ADV,CPT,31298,Nsl/sins ndsc surg frnt&sphn,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,31299,Sinus surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
UHC MCR ADV,CPT,31300,Removal of larynx lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,31360,Removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,31365,Removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,31367,Partial removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,31368,Partial removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,31370,Partial removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,31375,Partial removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,31380,Partial removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,31382,Partial removal of larynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,31390,Removal of larynx & pharynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,31395,Reconstruct larynx & pharynx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,31400,Revision of larynx,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,31420,Removal of epiglottis,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,31500,Insert emergency airway,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
UHC MCR ADV,CPT,31502,Change of windpipe airway,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
UHC MCR ADV,CPT,31505,Diagnostic laryngoscopy,APC 5151,RVU Per Unit,$168.23 ,OP,168.23,"4,314.00",,,,,,
UHC MCR ADV,CPT,31510,Laryngoscopy with biopsy,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
UHC MCR ADV,CPT,31511,Remove foreign body larynx,APC 5151,RVU Per Unit,$168.23 ,OP,168.23,"4,314.00",,,,,,
UHC MCR ADV,CPT,31512,Removal of larynx lesion,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
UHC MCR ADV,CPT,31513,Injection into vocal cord,APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
UHC MCR ADV,CPT,31515,Laryngoscopy for aspiration,APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
UHC MCR ADV,CPT,31520,Dx laryngoscopy newborn,APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
UHC MCR ADV,CPT,31525,Dx laryngoscopy excl nb,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
UHC MCR ADV,CPT,31526,Dx laryngoscopy w/oper scope,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
UHC MCR ADV,CPT,31527,Laryngoscopy for treatment,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
UHC MCR ADV,CPT,31528,Laryngoscopy and dilation,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
UHC MCR ADV,CPT,31529,Laryngoscopy and dilation,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
UHC MCR ADV,CPT,31530,Laryngoscopy w/fb removal,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
UHC MCR ADV,CPT,31531,Laryngoscopy w/fb & op scope,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
UHC MCR ADV,CPT,31535,Laryngoscopy w/biopsy,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
UHC MCR ADV,CPT,31536,Laryngoscopy w/bx & op scope,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
UHC MCR ADV,CPT,31540,Laryngoscopy w/exc of tumor,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
UHC MCR ADV,CPT,31541,Larynscop w/tumr exc + scope,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
UHC MCR ADV,CPT,31545,Remove vc lesion w/scope,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
UHC MCR ADV,CPT,31546,Remove vc lesion scope/graft,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
UHC MCR ADV,CPT,31551,Laryngoplasty laryngeal sten,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,31552,Laryngoplasty laryngeal sten,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,31553,Laryngoplasty laryngeal sten,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,31554,Laryngoplasty laryngeal sten,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,31560,Laryngoscop w/arytenoidectom,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
UHC MCR ADV,CPT,31561,Larynscop remve cart + scop,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
UHC MCR ADV,CPT,31570,Laryngoscope w/vc inj,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
UHC MCR ADV,CPT,31571,Laryngoscop w/vc inj + scope,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
UHC MCR ADV,CPT,31572,Largsc w/laser dstrj les,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
UHC MCR ADV,CPT,31573,Largsc w/ther injection,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
UHC MCR ADV,CPT,31574,Largsc w/njx augmentation,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
UHC MCR ADV,CPT,31575,Diagnostic laryngoscopy,APC 5151,RVU Per Unit,$168.23 ,OP,168.23,"4,314.00",,,,,,
UHC MCR ADV,CPT,31576,Laryngoscopy with biopsy,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
UHC MCR ADV,CPT,31577,Largsc w/rmvl foreign bdy(s),APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
UHC MCR ADV,CPT,31578,Largsc w/removal lesion,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
UHC MCR ADV,CPT,31579,Laryngoscopy telescopic,APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
UHC MCR ADV,CPT,31580,Laryngoplasty laryngeal web,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,31584,Laryngoplasty fx rdctj fixj,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,31587,Laryngoplasty cricoid split,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,31590,Reinnervate larynx,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,31591,Laryngoplasty medialization,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,31592,Cricotracheal resection,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,31599,Larynx surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
UHC MCR ADV,CPT,31600,Incision of windpipe,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,31601,Incision of windpipe,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,31603,Incision of windpipe,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,31605,Incision of windpipe,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
UHC MCR ADV,CPT,31610,Incision of windpipe,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,31611,Surgery/speech prosthesis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,31612,Puncture/clear windpipe,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,31613,Repair windpipe opening,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,31614,Repair windpipe opening,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,31615,Visualization of windpipe,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,31622,Dx bronchoscope/wash,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
UHC MCR ADV,CPT,31623,Dx bronchoscope/brush,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
UHC MCR ADV,CPT,31624,Dx bronchoscope/lavage,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
UHC MCR ADV,CPT,31625,Bronchoscopy w/biopsy(s),APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
UHC MCR ADV,CPT,31626,Bronchoscopy w/markers,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
UHC MCR ADV,CPT,31628,Bronchoscopy/lung bx each,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
UHC MCR ADV,CPT,31629,Bronchoscopy/needle bx each,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
UHC MCR ADV,CPT,31630,Bronchoscopy dilate/fx repr,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
UHC MCR ADV,CPT,31631,Bronchoscopy dilate w/stent,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
UHC MCR ADV,CPT,31634,Bronch w/balloon occlusion,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
UHC MCR ADV,CPT,31635,Bronchoscopy w/fb removal,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
UHC MCR ADV,CPT,31636,Bronchoscopy bronch stents,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
UHC MCR ADV,CPT,31638,Bronchoscopy revise stent,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
UHC MCR ADV,CPT,31640,Bronchoscopy w/tumor excise,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
UHC MCR ADV,CPT,31641,Bronchoscopy treat blockage,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
UHC MCR ADV,CPT,31643,Diag bronchoscope/catheter,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
UHC MCR ADV,CPT,31645,Brnchsc w/ther aspir 1st,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
UHC MCR ADV,CPT,31646,Brnchsc w/ther aspir sbsq,APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
UHC MCR ADV,CPT,31647,Bronchial valve init insert,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
UHC MCR ADV,CPT,31648,Bronchial valve remov init,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
UHC MCR ADV,CPT,31649,Bronchial valve remov addl,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
UHC MCR ADV,CPT,31652,Bronch ebus samplng 1/2 node,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
UHC MCR ADV,CPT,31653,Bronch ebus samplng 3/> node,APC 5154,RVU Per Case,"$3,170.26 ",OP,"3,170.26","4,314.00",,,,,,
UHC MCR ADV,CPT,31660,Bronch thermoplsty 1 lobe,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
UHC MCR ADV,CPT,31661,Bronch thermoplsty 2/> lobes,APC 5155,RVU Per Case,"$5,958.54 ",OP,"4,314.00","5,958.54",,,,,,
UHC MCR ADV,CPT,31717,Bronchial brush biopsy,APC 5152,RVU Per Unit,$385.29 ,OP,385.29,"4,314.00",,,,,,
UHC MCR ADV,CPT,31720,Clearance of airways,APC 5791,RVU Per Case,$192.26 ,OP,192.26,"4,314.00",,,,,,
UHC MCR ADV,CPT,31725,Clearance of airways,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,31730,Intro windpipe wire/tube,APC 5153,RVU Per Case,"$1,531.28 ",OP,"1,531.28","4,314.00",,,,,,
UHC MCR ADV,CPT,31750,Repair of windpipe,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,31755,Repair of windpipe,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,31760,Repair of windpipe,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,31766,Reconstruction of windpipe,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,31770,Repair/graft of bronchus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,31775,Reconstruct bronchus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,31780,Reconstruct windpipe,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,31781,Reconstruct windpipe,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,31785,Remove windpipe lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,31786,Remove windpipe lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,31800,Repair of windpipe injury,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,31805,Repair of windpipe injury,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,31820,Closure of windpipe lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,31825,Repair of windpipe defect,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,31830,Revise windpipe scar,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,31899,Airways surgical procedure,APC 5151,RVU Per Unit,$168.23 ,OP,168.23,"4,314.00",,,,,,
UHC MCR ADV,CPT,32035,Thoracostomy w/rib resection,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32036,Thoracostomy w/flap drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32096,Open wedge/bx lung infiltr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32097,Open wedge/bx lung nodule,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32098,Open biopsy of lung pleura,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32100,Exploration of chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32110,Explore/repair chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32120,Re-exploration of chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32124,Explore chest free adhesions,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32140,Removal of lung lesion(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32141,Remove/treat lung lesions,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32150,Removal of lung lesion(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32151,Remove lung foreign body,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32160,Open chest heart massage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32200,Drain open lung lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32215,Treat chest lining,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32220,Release of lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32225,Partial release of lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32310,Removal of chest lining,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32320,Free/remove chest lining,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32400,Needle biopsy chest lining,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,32408,Core ndl bx lng/med perq,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,32440,Remove lung pneumonectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32442,Sleeve pneumonectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32445,Removal of lung extrapleural,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32480,Partial removal of lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32482,Bilobectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32484,Segmentectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32486,Sleeve lobectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32488,Completion pneumonectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32491,Lung volume reduction,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32501,Repair bronchus add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32503,Resect apical lung tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32504,Resect apical lung tum/chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32505,Wedge resect of lung initial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32506,Wedge resect of lung add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32507,Wedge resect of lung diag,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32540,Removal of lung lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32550,Insert pleural cath,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
UHC MCR ADV,CPT,32551,Insertion of chest tube,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
UHC MCR ADV,CPT,32552,Remove lung catheter,APC 5181,RVU Per Case,$554.25 ,OP,554.25,"4,314.00",,,,,,
UHC MCR ADV,CPT,32553,Ins mark thor for rt perq,APC 5613,RVU Per Unit,"$1,291.62 ",OP,"1,291.62","4,314.00",,,,,,
UHC MCR ADV,CPT,32554,Aspirate pleura w/o imaging,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
UHC MCR ADV,CPT,32555,Aspirate pleura w/ imaging,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
UHC MCR ADV,CPT,32556,Insert cath pleura w/o image,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,32557,Insert cath pleura w/ image,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
UHC MCR ADV,CPT,32560,Treat pleurodesis w/agent,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
UHC MCR ADV,CPT,32561,Lyse chest fibrin init day,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
UHC MCR ADV,CPT,32562,Lyse chest fibrin subq day,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
UHC MCR ADV,CPT,32601,Thoracoscopy diagnostic,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,32604,Thoracoscopy wbx sac,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,32606,Thoracoscopy w/bx med space,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,32607,Thoracoscopy w/bx infiltrate,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,32608,Thoracoscopy w/bx nodule,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,32609,Thoracoscopy w/bx pleura,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,32650,Thoracoscopy w/pleurodesis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32651,Thoracoscopy remove cortex,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32652,Thoracoscopy rem totl cortex,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32653,Thoracoscopy remov fb/fibrin,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32654,Thoracoscopy contrl bleeding,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32655,Thoracoscopy resect bullae,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32656,Thoracoscopy w/pleurectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32658,Thoracoscopy w/sac fb remove,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32659,Thoracoscopy w/sac drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32661,Thoracoscopy w/pericard exc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32662,Thoracoscopy w/mediast exc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32663,Thoracoscopy w/lobectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32664,Thoracoscopy w/ th nrv exc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32665,Thoracoscop w/esoph musc exc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32666,Thoracoscopy w/wedge resect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32667,Thoracoscopy w/w resect addl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32668,Thoracoscopy w/w resect diag,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32669,Thoracoscopy remove segment,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32670,Thoracoscopy bilobectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32671,Thoracoscopy pneumonectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32672,Thoracoscopy for lvrs,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32673,Thoracoscopy w/thymus resect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32674,Thoracoscopy lymph node exc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32800,Repair lung hernia,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32810,Close chest after drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32815,Close bronchial fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32820,Reconstruct injured chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32850,Donor pneumonectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32851,Lung transplant single,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32852,Lung transplant with bypass,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32853,Lung transplant double,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32854,Lung transplant with bypass,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32855,Prepare donor lung single,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32856,Prepare donor lung double,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32900,Removal of rib(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32905,Revise & repair chest wall,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32906,Revise & repair chest wall,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32940,Revision of lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32960,Therapeutic pneumothorax,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
UHC MCR ADV,CPT,32994,Ablate pulm tumor perq crybl,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,32997,Total lung lavage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,32998,Ablate pulm tumor perq rf,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,32999,Chest surgery procedure,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
UHC MCR ADV,CPT,33016,Pericardiocentesis w/imaging,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
UHC MCR ADV,CPT,33017,Prcrd drg 6yr+ w/o cgen car,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33018,Prcrd drg 0-5yr or w/anomly,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33019,Perq prcrd drg insj cath ct,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33020,Incision of heart sac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33025,Incision of heart sac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33030,Partial removal of heart sac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33031,Partial removal of heart sac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33050,Resect heart sac lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33120,Removal of heart lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33130,Removal of heart lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33140,Heart revascularize (tmr),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33141,Heart tmr w/other procedure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33202,Insert epicard eltrd open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33203,Insert epicard eltrd endo,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33206,Insert heart pm atrial,APC 5223,RVU Per Case,"$10,642.67 ",OP,"4,314.00","10,642.67",,,,,,
UHC MCR ADV,CPT,33207,Insert heart pm ventricular,APC 5223,RVU Per Case,"$10,642.67 ",OP,"4,314.00","10,642.67",,,,,,
UHC MCR ADV,CPT,33208,Insrt heart pm atrial & vent,APC 5223,RVU Per Case,"$10,642.67 ",OP,"4,314.00","10,642.67",,,,,,
UHC MCR ADV,CPT,33210,Insert electrd/pm cath sngl,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
UHC MCR ADV,CPT,33211,Insert card electrodes dual,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
UHC MCR ADV,CPT,33212,Insert pulse gen sngl lead,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
UHC MCR ADV,CPT,33213,Insert pulse gen dual leads,APC 5223,RVU Per Case,"$10,642.67 ",OP,"4,314.00","10,642.67",,,,,,
UHC MCR ADV,CPT,33214,Upgrade of pacemaker system,APC 5223,RVU Per Case,"$10,642.67 ",OP,"4,314.00","10,642.67",,,,,,
UHC MCR ADV,CPT,33215,Reposition pacing-defib lead,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,33216,Insert 1 electrode pm-defib,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
UHC MCR ADV,CPT,33217,Insert 2 electrode pm-defib,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
UHC MCR ADV,CPT,33218,Repair lead pace-defib one,APC 5221,RVU Per Unit,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
UHC MCR ADV,CPT,33220,Repair lead pace-defib dual,APC 5221,RVU Per Unit,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
UHC MCR ADV,CPT,33221,Insert pulse gen mult leads,APC 5224,RVU Per Case,"$19,045.26 ",OP,"4,314.00","19,045.26",,,,,,
UHC MCR ADV,CPT,33222,Relocation pocket pacemaker,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,33223,Relocate pocket for defib,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,33224,Insert pacing lead & connect,APC 5223,RVU Per Case,"$10,642.67 ",OP,"4,314.00","10,642.67",,,,,,
UHC MCR ADV,CPT,33226,Reposition l ventric lead,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,33227,Remove&replace pm gen singl,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
UHC MCR ADV,CPT,33228,Remv&replc pm gen dual lead,APC 5223,RVU Per Case,"$10,642.67 ",OP,"4,140.35","10,642.67",,,,,,
UHC MCR ADV,CPT,33229,Remv&replc pm gen mult leads,APC 5224,RVU Per Case,"$19,045.26 ",OP,"4,314.00","19,045.26",,,,,,
UHC MCR ADV,CPT,33230,Insrt pulse gen w/dual leads,APC 5231,RVU Per Case,"$23,577.44 ",OP,"4,314.00","23,577.44",,,,,,
UHC MCR ADV,CPT,33231,Insrt pulse gen w/mult leads,APC 5232,RVU Per Case,"$33,604.66 ",OP,"4,314.00","33,604.66",,,,,,
UHC MCR ADV,CPT,33233,Removal of pm generator,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
UHC MCR ADV,CPT,33234,Removal of pacemaker system,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
UHC MCR ADV,CPT,33235,Removal pacemaker electrode,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
UHC MCR ADV,CPT,33236,Remove electrode/thoracotomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33237,Remove electrode/thoracotomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33238,Remove electrode/thoracotomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33240,Insrt pulse gen w/singl lead,APC 5231,RVU Per Case,"$23,577.44 ",OP,"4,140.35","23,577.44",,,,,,
UHC MCR ADV,CPT,33241,Remove pulse generator,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
UHC MCR ADV,CPT,33243,Remove eltrd/thoracotomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33244,Remove elctrd transvenously,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
UHC MCR ADV,CPT,33249,Insj/rplcmt defib w/lead(s),APC 5232,RVU Per Case,"$33,604.66 ",OP,"4,140.35","33,604.66",,,,,,
UHC MCR ADV,CPT,33250,Ablate heart dysrhythm focus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33251,Ablate heart dysrhythm focus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33254,Ablate atria lmtd,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33255,Ablate atria w/o bypass ext,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33256,Ablate atria w/bypass exten,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33257,Ablate atria lmtd add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33258,Ablate atria x10sv add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33259,Ablate atria w/bypass add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33261,Ablate heart dysrhythm focus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33262,Rmvl& replc pulse gen 1 lead,APC 5231,RVU Per Case,"$23,577.44 ",OP,"4,314.00","23,577.44",,,,,,
UHC MCR ADV,CPT,33263,Rmvl & rplcmt dfb gen 2 lead,APC 5231,RVU Per Case,"$23,577.44 ",OP,"4,140.35","23,577.44",,,,,,
UHC MCR ADV,CPT,33264,Rmvl & rplcmt dfb gen mlt ld,APC 5232,RVU Per Case,"$33,604.66 ",OP,"4,314.00","33,604.66",,,,,,
UHC MCR ADV,CPT,33265,Ablate atria lmtd endo,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33266,Ablate atria x10sv endo,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33270,Ins/rep subq defibrillator,APC 5232,RVU Per Case,"$33,604.66 ",OP,"4,314.00","33,604.66",,,,,,
UHC MCR ADV,CPT,33271,Insj subq impltbl dfb elctrd,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
UHC MCR ADV,CPT,33272,Rmvl of subq defibrillator,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
UHC MCR ADV,CPT,33273,Repos prev impltbl subq dfb,APC 5221,RVU Per Unit,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
UHC MCR ADV,CPT,33274,Tcat insj/rpl perm ldls pm,APC 5194,RVU Per Case,"$16,438.60 ",OP,"4,314.00","16,438.60",,,,,,
UHC MCR ADV,CPT,33275,Tcat rmvl perm ldls pm w/img,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,33285,Insj subq car rhythm mntr,APC 5222,RVU Per Case,"$8,342.69 ",OP,"4,314.00","8,342.69",,,,,,
UHC MCR ADV,CPT,33286,Rmvl subq car rhythm mntr,APC 5071,RVU Per Case,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,33289,Tcat impl wrls p-art prs snr,APC 5200,RVU Per Case,"$29,487.35 ",OP,"4,314.00","29,487.35",,,,,,
UHC MCR ADV,CPT,33300,Repair of heart wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33305,Repair of heart wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33310,Exploratory heart surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33315,Exploratory heart surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33320,Repair major blood vessel(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33321,Repair major vessel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33322,Repair major blood vessel(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33330,Insert major vessel graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33335,Insert major vessel graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33340,Perq clsr tcat l atr apndge,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33361,Replace aortic valve perq,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33362,Replace aortic valve open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33363,Replace aortic valve open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33364,Replace aortic valve open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33365,Replace aortic valve open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33366,Trcath replace aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33367,Replace aortic valve w/byp,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33368,Replace aortic valve w/byp,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33369,Replace aortic valve w/byp,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33390,Valvuloplasty aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33391,Valvuloplasty aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33404,Prepare heart-aorta conduit,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33405,Replacement aortic valve opn,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33406,Replacement aortic valve opn,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33410,Replacement aortic valve opn,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33411,Replacement of aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33412,Replacement of aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33413,Replacement of aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33414,Repair of aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33415,Revision subvalvular tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33416,Revise ventricle muscle,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33417,Repair of aortic valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33418,Repair tcat mitral valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33420,Revision of mitral valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33422,Revision of mitral valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33425,Repair of mitral valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33426,Repair of mitral valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33427,Repair of mitral valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33430,Replacement of mitral valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33440,Rplcmt a-valve tlcj autol pv,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33460,Revision of tricuspid valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33463,Valvuloplasty tricuspid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33464,Valvuloplasty tricuspid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33465,Replace tricuspid valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33468,Revision of tricuspid valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33470,Revision of pulmonary valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33471,Valvotomy pulmonary valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33474,Revision of pulmonary valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33475,Replacement pulmonary valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33476,Revision of heart chamber,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33477,Implant tcat pulm vlv perq,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33478,Revision of heart chamber,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33496,Repair prosth valve clot,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33500,Repair heart vessel fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33501,Repair heart vessel fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33502,Coronary artery correction,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33503,Coronary artery graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33504,Coronary artery graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33505,Repair artery w/tunnel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33506,Repair artery translocation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33507,Repair art intramural,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33510,Cabg vein single,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33511,Cabg vein two,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33512,Cabg vein three,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33513,Cabg vein four,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33514,Cabg vein five,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33516,Cabg vein six or more,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33517,Cabg artery-vein single,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33518,Cabg artery-vein two,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33519,Cabg artery-vein three,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33521,Cabg artery-vein four,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33522,Cabg artery-vein five,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33523,Cabg art-vein six or more,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33530,Coronary artery bypass/reop,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33533,Cabg arterial single,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33534,Cabg arterial two,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33535,Cabg arterial three,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33536,Cabg arterial four or more,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33542,Removal of heart lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33545,Repair of heart damage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33548,Restore/remodel ventricle,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33572,Open coronary endarterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33600,Closure of valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33602,Closure of valve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33606,Anastomosis/artery-aorta,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33608,Repair anomaly w/conduit,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33610,Repair by enlargement,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33611,Repair double ventricle,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33612,Repair double ventricle,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33615,Repair modified fontan,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33617,Repair single ventricle,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33619,Repair single ventricle,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33620,Apply r&l pulm art bands,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33621,Transthor cath for stent,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33622,Redo compl cardiac anomaly,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33641,Repair heart septum defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33645,Revision of heart veins,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33647,Repair heart septum defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33660,Repair of heart defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33665,Repair of heart defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33670,Repair of heart chambers,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33675,Close mult vsd,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33676,Close mult vsd w/resection,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33677,Cl mult vsd w/rem pul band,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33681,Repair heart septum defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33684,Repair heart septum defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33688,Repair heart septum defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33690,Reinforce pulmonary artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33692,Repair of heart defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33694,Repair of heart defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33697,Repair of heart defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33702,Repair of heart defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33710,Repair of heart defects,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33720,Repair of heart defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33722,Repair of heart defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33724,Repair venous anomaly,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33726,Repair pul venous stenosis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33730,Repair heart-vein defect(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33732,Repair heart-vein defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33735,Revision of heart chamber,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33736,Revision of heart chamber,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33737,Revision of heart chamber,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33741,Tas congenital car anomal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33745,Tis cgen car anomal 1st shnt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33746,Tis cgen car anomal ea addl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33750,Major vessel shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33755,Major vessel shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33762,Major vessel shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33764,Major vessel shunt & graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33766,Major vessel shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33767,Major vessel shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33768,Cavopulmonary shunting,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33770,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33771,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33774,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33775,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33776,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33777,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33778,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33779,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33780,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33781,Repair great vessels defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33782,Nikaidoh proc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33783,Nikaidoh proc w/ostia implt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33786,Repair arterial trunk,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33788,Revision of pulmonary artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33800,Aortic suspension,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33802,Repair vessel defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33803,Repair vessel defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33813,Repair septal defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33814,Repair septal defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33820,Revise major vessel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33822,Revise major vessel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33824,Revise major vessel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33840,Remove aorta constriction,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33845,Remove aorta constriction,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33851,Remove aorta constriction,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33852,Repair septal defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33853,Repair septal defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33858,As-aort grf f/aortic dsj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33859,As-aort grf f/ds oth/thn dsj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33863,Ascending aortic graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33864,Ascending aortic graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33871,Transvrs a-arch grf hypthrm,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33875,Thoracic aortic graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33877,Thoracoabdominal graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33880,Endovasc taa repr incl subcl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33881,Endovasc taa repr w/o subcl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33883,Insert endovasc prosth taa,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33884,Endovasc prosth taa add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33886,Endovasc prosth delayed,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33889,Artery transpose/endovas taa,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33891,Car-car bp grft/endovas taa,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33910,Remove lung artery emboli,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33915,Remove lung artery emboli,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33916,Surgery of great vessel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33917,Repair pulmonary artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33920,Repair pulmonary atresia,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33922,Transect pulmonary artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33924,Remove pulmonary shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33925,Rpr pul art unifocal w/o cpb,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33926,Repr pul art unifocal w/cpb,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33927,Impltj tot rplcmt hrt sys,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33928,Rmvl & rplcmt tot hrt sys,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33929,Rmvl rplcmt hrt sys f/trnspl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33930,Removal of donor heart/lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33933,Prepare donor heart/lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33935,Transplantation heart/lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33940,Removal of donor heart,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33944,Prepare donor heart,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33945,Transplantation of heart,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33946,Ecmo/ecls initiation venous,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33947,Ecmo/ecls initiation artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33948,Ecmo/ecls daily mgmt-venous,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33949,Ecmo/ecls daily mgmt artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33951,Ecmo/ecls insj prph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33952,Ecmo/ecls insj prph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33953,Ecmo/ecls insj prph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33954,Ecmo/ecls insj prph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33955,Ecmo/ecls insj ctr cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33956,Ecmo/ecls insj ctr cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33957,Ecmo/ecls repos perph cnula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33958,Ecmo/ecls repos perph cnula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33959,Ecmo/ecls repos perph cnula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33962,Ecmo/ecls repos perph cnula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33963,Ecmo/ecls repos perph cnula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33964,Ecmo/ecls repos perph cnula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33965,Ecmo/ecls rmvl perph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33966,Ecmo/ecls rmvl prph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33967,Insert i-aort percut device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33968,Remove aortic assist device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33969,Ecmo/ecls rmvl perph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33970,Aortic circulation assist,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33971,Aortic circulation assist,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33973,Insert balloon device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33974,Remove intra-aortic balloon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33975,Implant ventricular device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33976,Implant ventricular device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33977,Remove ventricular device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33978,Remove ventricular device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33979,Insert intracorporeal device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33980,Remove intracorporeal device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33981,Replace vad pump ext,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33982,Replace vad intra w/o bp,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33983,Replace vad intra w/bp,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33984,Ecmo/ecls rmvl prph cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33985,Ecmo/ecls rmvl ctr cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33986,Ecmo/ecls rmvl ctr cannula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33987,Artery expos/graft artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33988,Insertion of left heart vent,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33989,Removal of left heart vent,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33990,Insj perq vad l hrt arterial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33991,Insj perq vad l hrt artl&ven,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33992,Rmvl perq left heart vad,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33993,Reposg perq r/l hrt vad,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33995,Insj perq vad r hrt venous,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33997,Rmvl perq right heart vad,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,33999,Cardiac surgery procedure,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
UHC MCR ADV,CPT,34001,Removal of artery clot,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,34051,Removal of artery clot,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,34101,Removal of artery clot,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,34111,Removal of arm artery clot,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,34151,Removal of artery clot,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,34201,Removal of artery clot,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,34203,Removal of leg artery clot,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,34401,Removal of vein clot,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,34421,Removal of vein clot,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,34451,Removal of vein clot,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,34471,Removal of vein clot,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
UHC MCR ADV,CPT,34490,Removal of vein clot,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,34501,Repair valve femoral vein,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,34502,Reconstruct vena cava,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,34510,Transposition of vein valve,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,34520,Cross-over vein graft,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,34530,Leg vein fusion,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,34701,Evasc rpr a-ao ndgft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,34702,Evasc rpr a-ao ndgft rpt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,34703,Evasc rpr a-unilac ndgft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,34704,Evasc rpr a-unilac ndgft rpt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,34705,Evac rpr a-biiliac ndgft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,34706,Evasc rpr a-biiliac rpt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,34707,Evasc rpr ilio-iliac ndgft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,34708,Evasc rpr ilio-iliac rpt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,34709,Plmt xtn prosth evasc rpr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,34710,Dlyd plmt xtn prosth 1st vsl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,34711,Dlyd plmt xtn prosth ea addl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,34712,Tcat dlvr enhncd fixj dev,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,34717,Evasc rpr a-iliac ndgft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,34718,Evasc rpr n/a a-iliac ndgft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,34808,Endovas iliac a device addon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,34812,Opn fem art expos,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,34813,Femoral endovas graft add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,34820,Opn iliac art expos,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,34830,Open aortic tube prosth repr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,34831,Open aortoiliac prosth repr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,34832,Open aortofemor prosth repr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,34833,Opn ilac art expos cndt crtj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,34834,Opn brach art expos,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,34841,Endovasc visc aorta 1 graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,34842,Endovasc visc aorta 2 graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,34843,Endovasc visc aorta 3 graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,34844,Endovasc visc aorta 4 graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,34845,Visc & infraren abd 1 prosth,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,34846,Visc & infraren abd 2 prosth,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,34847,Visc & infraren abd 3 prosth,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,34848,Visc & infraren abd 4+ prost,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35001,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35002,Repair artery rupture neck,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35005,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35011,Repair defect of artery,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,35013,Repair artery rupture arm,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35021,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35022,Repair artery rupture chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35045,Repair defect of arm artery,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,35081,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35082,Repair artery rupture aorta,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35091,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35092,Repair artery rupture aorta,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35102,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35103,Repair artery rupture aorta,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35111,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35112,Repair artery rupture spleen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35121,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35122,Repair artery rupture belly,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35131,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35132,Repair artery rupture groin,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35141,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35142,Repair artery rupture thigh,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35151,Repair defect of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35152,Repair ruptd popliteal art,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35180,Repair blood vessel lesion,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
UHC MCR ADV,CPT,35182,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35184,Repair blood vessel lesion,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,35188,Repair blood vessel lesion,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,35189,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35190,Repair blood vessel lesion,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,35201,Repair blood vessel lesion,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,35206,Repair blood vessel lesion,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,35207,Repair blood vessel lesion,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,35211,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35216,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35221,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35226,Repair blood vessel lesion,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,35231,Repair blood vessel lesion,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,35236,Repair blood vessel lesion,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,35241,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35246,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35251,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35256,Repair blood vessel lesion,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,35261,Repair blood vessel lesion,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,35266,Repair blood vessel lesion,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,35271,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35276,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35281,Repair blood vessel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35286,Repair blood vessel lesion,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,35301,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35302,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35303,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35304,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35305,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35306,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35311,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35321,Rechanneling of artery,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,35331,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35341,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35351,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35355,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35361,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35363,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35371,Rechanneling of artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35372,Rechanneling of artery,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,35390,Reoperation carotid add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35400,Angioscopy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35501,Art byp grft ipsilat carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35506,Art byp grft subclav-carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35508,Art byp grft carotid-vertbrl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35509,Art byp grft contral carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35510,Art byp grft carotid-brchial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35511,Art byp grft subclav-subclav,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35512,Art byp grft subclav-brchial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35515,Art byp grft subclav-vertbrl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35516,Art byp grft subclav-axilary,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35518,Art byp grft axillary-axilry,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35521,Art byp grft axill-femoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35522,Art byp grft axill-brachial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35523,Art byp grft brchl-ulnr-rdl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35525,Art byp grft brachial-brchl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35526,Art byp grft aor/carot/innom,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35531,Art byp grft aorcel/aormesen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35533,Art byp grft axill/fem/fem,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35535,Art byp grft hepatorenal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35536,Art byp grft splenorenal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35537,Art byp grft aortoiliac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35538,Art byp grft aortobi-iliac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35539,Art byp grft aortofemoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35540,Art byp grft aortbifemoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35556,Art byp grft fem-popliteal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35558,Art byp grft fem-femoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35560,Art byp grft aortorenal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35563,Art byp grft ilioiliac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35565,Art byp grft iliofemoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35566,Art byp fem-ant-post tib/prl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35570,Art byp tibial-tib/peroneal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35571,Art byp pop-tibl-prl-other,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35583,Vein byp grft fem-popliteal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35585,Vein byp fem-tibial peroneal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35587,Vein byp pop-tibl peroneal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35600,Harvest art for cabg add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35601,Art byp common ipsi carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35606,Art byp carotid-subclavian,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35612,Art byp subclav-subclavian,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35616,Art byp subclav-axillary,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35621,Art byp axillary-femoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35623,Art byp axillary-pop-tibial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35626,Art byp aorsubcl/carot/innom,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35631,Art byp aor-celiac-msn-renal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35632,Art byp ilio-celiac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35633,Art byp ilio-mesenteric,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35634,Art byp iliorenal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35636,Art byp spenorenal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35637,Art byp aortoiliac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35638,Art byp aortobi-iliac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35642,Art byp carotid-vertebral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35645,Art byp subclav-vertebrl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35646,Art byp aortobifemoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35647,Art byp aortofemoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35650,Art byp axillary-axillary,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35654,Art byp axill-fem-femoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35656,Art byp femoral-popliteal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35661,Art byp femoral-femoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35663,Art byp ilioiliac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35665,Art byp iliofemoral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35666,Art byp fem-ant-post tib/prl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35671,Art byp pop-tibl-prl-other,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35681,Composite byp grft pros&vein,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35682,Composite byp grft 2 veins,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35683,Composite byp grft 3/> segmt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35691,Art trnsposj vertbrl carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35693,Art trnsposj subclavian,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35694,Art trnsposj subclav carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35695,Art trnsposj carotid subclav,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35697,Reimplant artery each,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35700,Reoperation bypass graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35701,Expl n/flwd surg neck art,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35702,Expl n/flwd surg uxtr art,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35703,Expl n/flwd surg lxtr art,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35800,Explore neck vessels,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,35820,Explore chest vessels,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35840,Explore abdominal vessels,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35860,Explore limb vessels,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,35870,Repair vessel graft defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35875,Removal of clot in graft,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,35876,Removal of clot in graft,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,35879,Revise graft w/vein,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,35881,Revise graft w/vein,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,35883,Revise graft w/nonauto graft,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,35884,Revise graft w/vein,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,35901,Excision graft neck,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35903,Excision graft extremity,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,35905,Excision graft thorax,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,35907,Excision graft abdomen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,36002,Pseudoaneurysm injection trt,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
UHC MCR ADV,CPT,36221,Place cath thoracic aorta,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,36222,Place cath carotid/inom art,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,36223,Place cath carotid/inom art,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,36224,Place cath carotd art,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,36225,Place cath subclavian art,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,36226,Place cath vertebral art,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,36251,Ins cath ren art 1st unilat,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,36252,Ins cath ren art 1st bilat,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,36253,Ins cath ren art 2nd+ unilat,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,36254,Ins cath ren art 2nd+ bilat,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,36260,Insertion of infusion pump,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,36261,Revision of infusion pump,APC 5221,RVU Per Unit,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
UHC MCR ADV,CPT,36262,Removal of infusion pump,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","4,314.00",,,,,,
UHC MCR ADV,CPT,36415,Routine venipuncture,Lab Services,Per Unit,$3.00 ,OP,3,"4,314.00",,,,,,
UHC MCR ADV,CPT,36420,Vein access cutdown < 1 yr,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
UHC MCR ADV,CPT,36425,Vein access cutdown > 1 yr,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
UHC MCR ADV,CPT,36430,Blood transfusion service,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
UHC MCR ADV,CPT,36440,Bl push transfuse 2 yr/<,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
UHC MCR ADV,CPT,36450,Bl exchange/transfuse nb,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
UHC MCR ADV,CPT,36455,Bl exchange/transfuse non-nb,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
UHC MCR ADV,CPT,36456,Prtl exchange transfuse nb,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
UHC MCR ADV,CPT,36460,Transfusion service fetal,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
UHC MCR ADV,CPT,36465,Njx noncmpnd sclrsnt 1 vein,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,36466,Njx noncmpnd sclrsnt mlt vn,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,36468,Njx sclrsnt spider veins,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,36470,Njx sclrsnt 1 incmptnt vein,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,36471,Njx sclrsnt mlt incmptnt vn,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,36473,Endovenous mchnchem 1st vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,36475,Endovenous rf 1st vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,36478,Endovenous laser 1st vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,36482,Endoven ther chem adhes 1st,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,36511,Apheresis wbc,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
UHC MCR ADV,CPT,36512,Apheresis rbc,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
UHC MCR ADV,CPT,36513,Apheresis platelets,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
UHC MCR ADV,CPT,36514,Apheresis plasma,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
UHC MCR ADV,CPT,36516,Apheresis immunoads slctv,APC 5243,RVU Per Unit,"$4,131.87 ",OP,"4,131.87","4,314.00",,,,,,
UHC MCR ADV,CPT,36522,Photopheresis,APC 5243,RVU Per Unit,"$4,131.87 ",OP,"4,131.87","4,314.00",,,,,,
UHC MCR ADV,CPT,36555,Insert non-tunnel cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,36556,Insert non-tunnel cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,36557,Insert tunneled cv cath,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,36558,Insert tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,36560,Insert tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,36561,Insert tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,36563,Insert tunneled cv cath,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,36565,Insert tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,36566,Insert tunneled cv cath,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,36568,Insj picc <5 yr w/o imaging,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
UHC MCR ADV,CPT,36569,Insj picc 5 yr+ w/o imaging,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
UHC MCR ADV,CPT,36570,Insert picvad cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,36571,Insert picvad cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,36572,Insj picc rs&i <5 yr,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
UHC MCR ADV,CPT,36573,Insj picc rs&i 5 yr+,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
UHC MCR ADV,CPT,36575,Repair tunneled cv cath,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
UHC MCR ADV,CPT,36576,Repair tunneled cv cath,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
UHC MCR ADV,CPT,36578,Replace tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,36580,Replace cvad cath,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
UHC MCR ADV,CPT,36581,Replace tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,36582,Replace tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,36583,Replace tunneled cv cath,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,36584,Compl rplcmt picc rs&i,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
UHC MCR ADV,CPT,36585,Replace picvad cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,36589,Removal tunneled cv cath,APC 5181,RVU Per Case,$554.25 ,OP,554.25,"4,314.00",,,,,,
UHC MCR ADV,CPT,36590,Removal tunneled cv cath,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
UHC MCR ADV,CPT,36591,Draw blood off venous device,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
UHC MCR ADV,CPT,36592,Collect blood from picc,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
UHC MCR ADV,CPT,36593,Declot vascular device,APC 5694,RVU Per Unit,$318.00 ,OP,318,"4,314.00",,,,,,
UHC MCR ADV,CPT,36595,Mech remov tunneled cv cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,36596,Mech remov tunneled cv cath,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
UHC MCR ADV,CPT,36597,Reposition venous catheter,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
UHC MCR ADV,CPT,36598,Inj w/fluor eval cv device,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,"4,314.00",,,,,,
UHC MCR ADV,CPT,36600,Withdrawal of arterial blood,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
UHC MCR ADV,CPT,36640,Insertion catheter artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,36660,Insertion catheter artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,36680,Insert needle bone cavity,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
UHC MCR ADV,CPT,36800,Insertion of cannula,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,36810,Insertion of cannula,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,36815,Insertion of cannula,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,36818,Av fuse uppr arm cephalic,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,36819,Av fuse uppr arm basilic,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,36820,Av fusion/forearm vein,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,36821,Av fusion direct any site,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","9,201.00",,,,,,
UHC MCR ADV,CPT,36823,Insertion of cannula(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,36825,Artery-vein autograft,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,36830,Artery-vein nonautograft,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,36831,Open thrombect av fistula,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,36832,Av fistula revision open,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,36833,Av fistula revision,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,36835,Artery to vein shunt,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,36838,Dist revas ligation hemo,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,36860,External cannula declotting,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
UHC MCR ADV,CPT,36861,Cannula declotting,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,36901,Intro cath dialysis circuit,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,438.93","4,314.00",,,,,,
UHC MCR ADV,CPT,36902,Intro cath dialysis circuit,APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,314.00","5,072.43",,,,,,
UHC MCR ADV,CPT,36903,Intro cath dialysis circuit,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
UHC MCR ADV,CPT,36904,Thrmbc/nfs dialysis circuit,APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,314.00","5,072.43",,,,,,
UHC MCR ADV,CPT,36905,Thrmbc/nfs dialysis circuit,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
UHC MCR ADV,CPT,36906,Thrmbc/nfs dialysis circuit,APC 5194,RVU Per Case,"$16,438.60 ",OP,"4,140.35","16,438.60",,,,,,
UHC MCR ADV,CPT,37140,Revision of circulation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,37145,Revision of circulation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,37160,Revision of circulation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,37180,Revision of circulation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,37181,Splice spleen/kidney veins,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,37182,Insert hepatic shunt (tips),APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
UHC MCR ADV,CPT,37183,Remove hepatic shunt (tips),APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,314.00","5,072.43",,,,,,
UHC MCR ADV,CPT,37184,Prim art m-thrmbc 1st vsl,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
UHC MCR ADV,CPT,37187,Venous mech thrombectomy,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
UHC MCR ADV,CPT,37188,Ven mechnl thrmbc repeat tx,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,37191,Ins endovas vena cava filtr,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,37192,Redo endovas vena cava filtr,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,37193,Rem endovas vena cava filter,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,37195,Thrombolytic therapy stroke,APC 5694,RVU Per Unit,$318.00 ,OP,318,"4,314.00",,,,,,
UHC MCR ADV,CPT,37197,Remove intrvas foreign body,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,37200,Transcatheter biopsy,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,37211,Thrombolytic art therapy,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,37212,Thrombolytic venous therapy,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,37213,Thromblytic art/ven therapy,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,37214,Cessj therapy cath removal,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,37215,Transcath stent cca w/eps,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,37217,Stent placemt retro carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,37218,Stent placemt ante carotid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,37220,Iliac revasc,APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,314.00","5,072.43",,,,,,
UHC MCR ADV,CPT,37221,Iliac revasc w/stent,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
UHC MCR ADV,CPT,37224,Fem/popl revas w/tla,APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,314.00","5,072.43",,,,,,
UHC MCR ADV,CPT,37225,Fem/popl revas w/ather,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
UHC MCR ADV,CPT,37226,Fem/popl revasc w/stent,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
UHC MCR ADV,CPT,37227,Fem/popl revasc stnt & ather,APC 5194,RVU Per Case,"$16,438.60 ",OP,"4,314.00","16,438.60",,,,,,
UHC MCR ADV,CPT,37228,Tib/per revasc w/tla,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
UHC MCR ADV,CPT,37229,Tib/per revasc w/ather,APC 5194,RVU Per Case,"$16,438.60 ",OP,"4,314.00","16,438.60",,,,,,
UHC MCR ADV,CPT,37230,Tib/per revasc w/stent,APC 5194,RVU Per Case,"$16,438.60 ",OP,"4,314.00","16,438.60",,,,,,
UHC MCR ADV,CPT,37231,Tib/per revasc stent & ather,APC 5194,RVU Per Case,"$16,438.60 ",OP,"4,314.00","16,438.60",,,,,,
UHC MCR ADV,CPT,37236,Open/perq place stent 1st,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
UHC MCR ADV,CPT,37238,Open/perq place stent same,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
UHC MCR ADV,CPT,37241,Vasc embolize/occlude venous,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
UHC MCR ADV,CPT,37242,Vasc embolize/occlude artery,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
UHC MCR ADV,CPT,37243,Vasc embolize/occlude organ,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
UHC MCR ADV,CPT,37244,Vasc embolize/occlude bleed,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
UHC MCR ADV,CPT,37246,Trluml balo angiop 1st art,APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,314.00","5,072.43",,,,,,
UHC MCR ADV,CPT,37248,Trluml balo angiop 1st vein,APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,314.00","5,072.43",,,,,,
UHC MCR ADV,CPT,37500,Endoscopy ligate perf veins,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,37501,Vascular endoscopy procedure,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
UHC MCR ADV,CPT,37565,Ligation of neck vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,37600,Ligation of neck artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,37605,Ligation of neck artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,37606,Ligation of neck artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,37607,Ligation of a-v fistula,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,37609,Temporal artery procedure,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,37615,Ligation of neck artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,37616,Ligation of chest artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,37617,Ligation of abdomen artery,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,37618,Ligation of extremity artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,37619,Ligation of inf vena cava,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,37650,Revision of major vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,37660,Revision of major vein,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,37700,Revise leg vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,37718,Ligate/strip short leg vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,37722,Ligate/strip long leg vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,37735,Removal of leg veins/lesion,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,37760,Ligate leg veins radical,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,37761,Ligate leg veins open,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,37765,Stab phleb veins xtr 10-20,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,37766,Phleb veins - extrem 20+,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,37780,Revision of leg vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,37785,Ligate/divide/excise vein,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,37788,Revascularization penis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,37790,Penile venous occlusion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,37799,Vascular surgery procedure,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,"4,314.00",,,,,,
UHC MCR ADV,CPT,38100,Removal of spleen total,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,38101,Removal of spleen partial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,38102,Removal of spleen total,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,38115,Repair of ruptured spleen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,38120,Laparoscopy splenectomy,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
UHC MCR ADV,CPT,38129,Laparoscope proc spleen,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,38206,Harvest auto stem cells,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
UHC MCR ADV,CPT,38207,Cryopreserve stem cells,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
UHC MCR ADV,CPT,38208,Thaw preserved stem cells,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
UHC MCR ADV,CPT,38209,Wash harvest stem cells,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
UHC MCR ADV,CPT,38210,T-cell depletion of harvest,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
UHC MCR ADV,CPT,38211,Tumor cell deplete of harvst,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
UHC MCR ADV,CPT,38212,Rbc depletion of harvest,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
UHC MCR ADV,CPT,38213,Platelet deplete of harvest,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
UHC MCR ADV,CPT,38214,Volume deplete of harvest,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
UHC MCR ADV,CPT,38215,Harvest stem cell concentrte,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
UHC MCR ADV,CPT,38220,Dx bone marrow aspirations,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,38221,Dx bone marrow biopsies,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,38222,Dx bone marrow bx & aspir,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,38230,Bone marrow harvest allogen,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
UHC MCR ADV,CPT,38232,Bone marrow harvest autolog,APC 5243,RVU Per Unit,"$4,131.87 ",OP,"4,131.87","4,314.00",,,,,,
UHC MCR ADV,CPT,38240,Transplt allo hct/donor,APC 5244,RVU Per Case,"$32,580.57 ",OP,"4,314.00","32,580.57",,,,,,
UHC MCR ADV,CPT,38241,Transplt autol hct/donor,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
UHC MCR ADV,CPT,38242,Transplt allo lymphocytes,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
UHC MCR ADV,CPT,38243,Transplj hematopoietic boost,APC 5242,RVU Per Unit,"$1,394.95 ",OP,"1,394.95","4,314.00",,,,,,
UHC MCR ADV,CPT,38300,Drainage lymph node lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,38305,Drainage lymph node lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,38308,Incision of lymph channels,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
UHC MCR ADV,CPT,38380,Thoracic duct procedure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,38381,Thoracic duct procedure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,38382,Thoracic duct procedure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,38500,Biopsy/removal lymph nodes,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
UHC MCR ADV,CPT,38505,Needle biopsy lymph nodes,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,38510,Biopsy/removal lymph nodes,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
UHC MCR ADV,CPT,38520,Biopsy/removal lymph nodes,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
UHC MCR ADV,CPT,38525,Biopsy/removal lymph nodes,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
UHC MCR ADV,CPT,38530,Biopsy/removal lymph nodes,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
UHC MCR ADV,CPT,38531,Open bx/exc inguinofem nodes,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
UHC MCR ADV,CPT,38542,Explore deep node(s) neck,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,38550,Removal neck/armpit lesion,APC 5091,RVU Per Case,"$3,231.37 ",OP,"3,231.37","4,314.00",,,,,,
UHC MCR ADV,CPT,38555,Removal neck/armpit lesion,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
UHC MCR ADV,CPT,38562,Removal pelvic lymph nodes,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
UHC MCR ADV,CPT,38564,Removal abdomen lymph nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,38570,Laparoscopy lymph node biop,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,38571,Laparoscopy lymphadenectomy,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,38572,Laparoscopy lymphadenectomy,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,38573,Laps pelvic lymphadec,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,38589,Laparoscope proc lymphatic,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,38700,Removal of lymph nodes neck,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
UHC MCR ADV,CPT,38720,Removal of lymph nodes neck,APC 5093,RVU Per Case,"$9,128.05 ",OP,"4,314.00","9,128.05",,,,,,
UHC MCR ADV,CPT,38724,Removal of lymph nodes neck,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,38740,Remove armpit lymph nodes,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,38745,Remove armpit lymph nodes,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,38746,Remove thoracic lymph nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,38747,Remove abdominal lymph nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,38760,Remove groin lymph nodes,APC 5092,RVU Per Case,"$5,662.99 ",OP,"4,314.00","5,662.99",,,,,,
UHC MCR ADV,CPT,38765,Remove groin lymph nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,38770,Remove pelvis lymph nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,38780,Remove abdomen lymph nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,38792,Ra tracer id of sentinl node,APC 5591,RVU Per Case,$385.91 ,OP,385.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,38999,Blood/lymph system procedure,APC 5241,RVU Per Unit,$406.32 ,OP,406.32,"4,314.00",,,,,,
UHC MCR ADV,CPT,39000,Exploration of chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,39010,Exploration of chest,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,39200,Resect mediastinal cyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,39220,Resect mediastinal tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,39401,Mediastinoscpy w/medstnl bx,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,39402,Mediastinoscpy w/lmph nod bx,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,39499,Chest procedure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,39501,Repair diaphragm laceration,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,39503,Repair of diaphragm hernia,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,39540,Repair of diaphragm hernia,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,39541,Repair of diaphragm hernia,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,39545,Revision of diaphragm,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,39560,Resect diaphragm simple,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,39561,Resect diaphragm complex,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,39599,Diaphragm surgery procedure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,40490,Biopsy of lip,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
UHC MCR ADV,CPT,40500,Partial excision of lip,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,40510,Partial excision of lip,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,40520,Partial excision of lip,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,40525,Reconstruct lip with flap,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,40527,Reconstruct lip with flap,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,40530,Partial removal of lip,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,40650,Repair lip,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,40652,Repair lip,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,40654,Repair lip,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,40700,Repair cleft lip/nasal,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,40701,Repair cleft lip/nasal,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,40702,Repair cleft lip/nasal,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,40720,Repair cleft lip/nasal,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,40761,Repair cleft lip/nasal,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,40799,Lip surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
UHC MCR ADV,CPT,40800,Drainage of mouth lesion,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,40801,Drainage of mouth lesion,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,40804,Removal foreign body mouth,APC 5301,RVU Per Case,$828.48 ,OP,828.48,"4,314.00",,,,,,
UHC MCR ADV,CPT,40805,Removal foreign body mouth,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,40806,Incision of lip fold,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,40808,Biopsy of mouth lesion,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,40810,Excision of mouth lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,40812,Excise/repair mouth lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,40814,Excise/repair mouth lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,40816,Excision of mouth lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,40818,Excise oral mucosa for graft,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,40819,Excise lip or cheek fold,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,40820,Treatment of mouth lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,40830,Repair mouth laceration,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
UHC MCR ADV,CPT,40831,Repair mouth laceration,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,40840,Reconstruction of mouth,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,40842,Reconstruction of mouth,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,40843,Reconstruction of mouth,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,40844,Reconstruction of mouth,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,40845,Reconstruction of mouth,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,40899,Mouth surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
UHC MCR ADV,CPT,41000,Drainage of mouth lesion,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,41005,Drainage of mouth lesion,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
UHC MCR ADV,CPT,41006,Drainage of mouth lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,41007,Drainage of mouth lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,41008,Drainage of mouth lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,41009,Drainage of mouth lesion,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,41010,Incision of tongue fold,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,41015,Drainage of mouth lesion,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,41016,Drainage of mouth lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,41017,Drainage of mouth lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,41018,Drainage of mouth lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,41019,Place needles h&n for rt,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,41100,Biopsy of tongue,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,41105,Biopsy of tongue,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,41108,Biopsy of floor of mouth,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,41110,Excision of tongue lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,41112,Excision of tongue lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,41113,Excision of tongue lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,41114,Excision of tongue lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,41115,Excision of tongue fold,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,41116,Excision of mouth lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,41120,Partial removal of tongue,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,41130,Partial removal of tongue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,41135,Tongue and neck surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,41140,Removal of tongue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,41145,Tongue removal neck surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,41150,Tongue mouth jaw surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,41153,Tongue mouth neck surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,41155,Tongue jaw & neck surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,41250,Repair tongue laceration,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
UHC MCR ADV,CPT,41251,Repair tongue laceration,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
UHC MCR ADV,CPT,41252,Repair tongue laceration,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
UHC MCR ADV,CPT,41510,Tongue to lip surgery,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,41512,Tongue suspension,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,41520,Reconstruction tongue fold,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,41530,Tongue base vol reduction,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,41599,Tongue and mouth surgery,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
UHC MCR ADV,CPT,41800,Drainage of gum lesion,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
UHC MCR ADV,CPT,41805,Removal foreign body gum,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,41806,Removal foreign body jawbone,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,41820,Excision gum each quadrant,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,41821,Excision of gum flap,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,41822,Excision of gum lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,41823,Excision of gum lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,41825,Excision of gum lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,41826,Excision of gum lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,41827,Excision of gum lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,41828,Excision of gum lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,41830,Removal of gum tissue,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,41850,Treatment of gum lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,41870,Gum graft,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,41872,Repair gum,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,41874,Repair tooth socket,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,41899,Dental surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
UHC MCR ADV,CPT,42000,Drainage mouth roof lesion,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
UHC MCR ADV,CPT,42100,Biopsy roof of mouth,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,42104,Excision lesion mouth roof,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,42106,Excision lesion mouth roof,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,42107,Excision lesion mouth roof,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,42120,Remove palate/lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,42140,Excision of uvula,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,42145,Repair palate pharynx/uvula,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,42160,Treatment mouth roof lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,42180,Repair palate,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,42182,Repair palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,42200,Reconstruct cleft palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,42205,Reconstruct cleft palate,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,42210,Reconstruct cleft palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,42215,Reconstruct cleft palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,42220,Reconstruct cleft palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,42225,Reconstruct cleft palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,42226,Lengthening of palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,42227,Lengthening of palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,42235,Repair palate,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,42260,Repair nose to lip fistula,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,42280,Preparation palate mold,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,42281,Insertion palate prosthesis,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,42299,Palate/uvula surgery,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
UHC MCR ADV,CPT,42300,Drainage of salivary gland,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,42305,Drainage of salivary gland,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,42310,Drainage of salivary gland,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,42320,Drainage of salivary gland,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,42330,Removal of salivary stone,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,42335,Removal of salivary stone,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,42340,Removal of salivary stone,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,42400,Biopsy of salivary gland,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,42405,Biopsy of salivary gland,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,42408,Excision of salivary cyst,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,42409,Drainage of salivary cyst,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,42410,Excise parotid gland/lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,42415,Excise parotid gland/lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,42420,Excise parotid gland/lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,42425,Excise parotid gland/lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,42426,Excise parotid gland/lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,42440,Excise submaxillary gland,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,42450,Excise sublingual gland,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,42500,Repair salivary duct,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,42505,Repair salivary duct,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,42507,Parotid duct diversion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,42509,Parotid duct diversion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,42510,Parotid duct diversion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,42600,Closure of salivary fistula,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,42650,Dilation of salivary duct,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,42660,Dilation of salivary duct,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,42665,Ligation of salivary duct,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,42699,Salivary surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
UHC MCR ADV,CPT,42700,Drainage of tonsil abscess,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
UHC MCR ADV,CPT,42720,Drainage of throat abscess,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,42725,Drainage of throat abscess,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,42800,Biopsy of throat,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,42804,Biopsy of upper nose/throat,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,42806,Biopsy of upper nose/throat,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,42808,Excise pharynx lesion,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,42809,Remove pharynx foreign body,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
UHC MCR ADV,CPT,42810,Excision of neck cyst,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,42815,Excision of neck cyst,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,42820,Remove tonsils and adenoids,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,42821,Remove tonsils and adenoids,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,42825,Removal of tonsils,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,42826,Removal of tonsils,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,42830,Removal of adenoids,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,42831,Removal of adenoids,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,42835,Removal of adenoids,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,42836,Removal of adenoids,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,42842,Extensive surgery of throat,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,42844,Extensive surgery of throat,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,42845,Extensive surgery of throat,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,42860,Excision of tonsil tags,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,42870,Excision of lingual tonsil,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,42890,Partial removal of pharynx,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,42892,Revision of pharyngeal walls,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,42894,Revision of pharyngeal walls,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,42900,Repair throat wound,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,42950,Reconstruction of throat,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,42953,Repair throat esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,42955,Surgical opening of throat,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,42960,Control throat bleeding,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,42961,Control throat bleeding,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,42962,Control throat bleeding,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,42970,Control nose/throat bleeding,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
UHC MCR ADV,CPT,42971,Control nose/throat bleeding,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,42972,Control nose/throat bleeding,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,42999,Throat surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
UHC MCR ADV,CPT,43020,Incision of esophagus,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,43030,Throat muscle surgery,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,43045,Incision of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43100,Excision of esophagus lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43101,Excision of esophagus lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43107,Removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43108,Removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43112,Esphg tot w/thrcm,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43113,Removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43116,Partial removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43117,Partial removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43118,Partial removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43121,Partial removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43122,Partial removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43123,Partial removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43124,Removal of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43130,Removal of esophagus pouch,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,43135,Removal of esophagus pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43180,Esophagoscopy rigid trnso,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,43191,Esophagoscopy rigid trnso dx,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,43192,Esophagoscp rig trnso inject,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,43193,Esophagoscp rig trnso biopsy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,43194,Esophagoscp rig trnso rem fb,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,43195,Esophagoscopy rigid balloon,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
UHC MCR ADV,CPT,43196,Esophagoscp guide wire dilat,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
UHC MCR ADV,CPT,43197,Esophagoscopy flex dx brush,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
UHC MCR ADV,CPT,43198,Esophagosc flex trnsn biopsy,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
UHC MCR ADV,CPT,43200,Esophagoscopy flexible brush,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
UHC MCR ADV,CPT,43201,Esoph scope w/submucous inj,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,43202,Esophagoscopy flex biopsy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,43204,Esoph scope w/sclerosis inj,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,43205,Esophagus endoscopy/ligation,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,43206,Esoph optical endomicroscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,43210,Egd esophagogastrc fndoplsty,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
UHC MCR ADV,CPT,43211,Esophagoscop mucosal resect,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,43212,Esophagoscop stent placement,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
UHC MCR ADV,CPT,43213,Esophagoscopy retro balloon,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,43214,Esophagosc dilate balloon 30,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,43215,Esophagoscopy flex remove fb,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,43216,Esophagoscopy lesion removal,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,43217,Esophagoscopy snare les remv,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,43220,Esophagoscopy balloon <30mm,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,43226,Esoph endoscopy dilation,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,43227,Esophagoscopy control bleed,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,43229,Esophagoscopy lesion ablate,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
UHC MCR ADV,CPT,43231,Esophagoscop ultrasound exam,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,43232,Esophagoscopy w/us needle bx,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,43233,Egd balloon dil esoph30 mm/>,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,43235,Egd diagnostic brush wash,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
UHC MCR ADV,CPT,43236,Uppr gi scope w/submuc inj,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
UHC MCR ADV,CPT,43237,Endoscopic us exam esoph,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,43238,Egd us fine needle bx/aspir,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,43239,Egd biopsy single/multiple,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
UHC MCR ADV,CPT,43240,Egd w/transmural drain cyst,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
UHC MCR ADV,CPT,43241,Egd tube/cath insertion,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,43242,Egd us fine needle bx/aspir,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,43243,Egd injection varices,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,43244,Egd varices ligation,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,43245,Egd dilate stricture,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,43246,Egd place gastrostomy tube,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,43247,Egd remove foreign body,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
UHC MCR ADV,CPT,43248,Egd guide wire insertion,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
UHC MCR ADV,CPT,43249,Esoph egd dilation <30 mm,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,43250,Egd cautery tumor polyp,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,43251,Egd remove lesion snare,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,43252,Egd optical endomicroscopy,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
UHC MCR ADV,CPT,43253,Egd us transmural injxn/mark,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,43254,Egd endo mucosal resection,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,43255,Egd control bleeding any,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,43257,Egd w/thrml txmnt gerd,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
UHC MCR ADV,CPT,43259,Egd us exam duodenum/jejunum,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,43260,Ercp w/specimen collection,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
UHC MCR ADV,CPT,43261,Endo cholangiopancreatograph,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
UHC MCR ADV,CPT,43262,Endo cholangiopancreatograph,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
UHC MCR ADV,CPT,43263,Ercp sphincter pressure meas,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
UHC MCR ADV,CPT,43264,Ercp remove duct calculi,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
UHC MCR ADV,CPT,43265,Ercp lithotripsy calculi,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
UHC MCR ADV,CPT,43266,Egd endoscopic stent place,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
UHC MCR ADV,CPT,43270,Egd lesion ablation,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,43274,Ercp duct stent placement,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
UHC MCR ADV,CPT,43275,Ercp remove forgn body duct,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
UHC MCR ADV,CPT,43276,Ercp stent exchange w/dilate,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
UHC MCR ADV,CPT,43277,Ercp ea duct/ampulla dilate,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
UHC MCR ADV,CPT,43278,Ercp lesion ablate w/dilate,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
UHC MCR ADV,CPT,43279,Lap myotomy heller,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43280,Laparoscopy fundoplasty,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
UHC MCR ADV,CPT,43281,Lap paraesophag hern repair,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
UHC MCR ADV,CPT,43282,Lap paraesoph her rpr w/mesh,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
UHC MCR ADV,CPT,43283,Lap esoph lengthening,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43284,Laps esophgl sphnctr agmntj,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
UHC MCR ADV,CPT,43285,Rmvl esophgl sphnctr dev,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,43286,Esphg tot w/laps moblj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43287,Esphg dstl 2/3 w/laps moblj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43288,Esphg thrsc moblj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43289,Laparoscope proc esoph,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,43300,Repair of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43305,Repair esophagus and fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43310,Repair of esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43312,Repair esophagus and fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43313,Esophagoplasty congenital,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43314,Tracheo-esophagoplasty cong,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43320,Fuse esophagus & stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43325,Revise esophagus & stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43327,Esoph fundoplasty lap,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43328,Esoph fundoplasty thor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43330,Esophagomyotomy abdominal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43331,Esophagomyotomy thoracic,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43332,Transab esoph hiat hern rpr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43333,Transab esoph hiat hern rpr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43334,Transthor diaphrag hern rpr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43335,Transthor diaphrag hern rpr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43336,Thorabd diaphr hern repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43337,Thorabd diaphr hern repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43338,Esoph lengthening,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43340,Fuse esophagus & intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43341,Fuse esophagus & intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43351,Surgical opening esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43352,Surgical opening esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43360,Gastrointestinal repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43361,Gastrointestinal repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43400,Ligate esophagus veins,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43405,Ligate/staple esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43410,Repair esophagus wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43415,Repair esophagus wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43420,Repair esophagus opening,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,43425,Repair esophagus opening,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43450,Dilate esophagus 1/mult pass,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
UHC MCR ADV,CPT,43453,Dilate esophagus,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,43460,Pressure treatment esophagus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43496,Free jejunum flap microvasc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43499,Esophagus surgery procedure,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
UHC MCR ADV,CPT,43500,Surgical opening of stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43501,Surgical repair of stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43502,Surgical repair of stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43510,Surgical opening of stomach,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
UHC MCR ADV,CPT,43520,Incision of pyloric muscle,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43605,Biopsy of stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43610,Excision of stomach lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43611,Excision of stomach lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43620,Removal of stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43621,Removal of stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43622,Removal of stomach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43631,Removal of stomach partial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43632,Removal of stomach partial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43633,Removal of stomach partial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43634,Removal of stomach partial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43635,Removal of stomach partial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43640,Vagotomy & pylorus repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43641,Vagotomy & pylorus repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43644,Lap gastric bypass/roux-en-y,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43645,Lap gastr bypass incl smll i,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43647,Lap impl electrode antrum,APC 5463,RVU Per Case,"$11,498.23 ",OP,"4,314.00","11,498.23",,,,,,
UHC MCR ADV,CPT,43648,Lap revise/remv eltrd antrum,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,43651,Laparoscopy vagus nerve,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,43652,Laparoscopy vagus nerve,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,43653,Laparoscopy gastrostomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,43659,Laparoscope proc stom,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,43752,Nasal/orogastric w/tube plmt,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
UHC MCR ADV,CPT,43753,Tx gastro intub w/asp,APC 5722,RVU Per Case,$270.61 ,OP,270.61,"4,314.00",,,,,,
UHC MCR ADV,CPT,43754,Dx gastr intub w/asp spec,APC 5722,RVU Per Case,$270.61 ,OP,270.61,"4,314.00",,,,,,
UHC MCR ADV,CPT,43755,Dx gastr intub w/asp specs,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,"4,314.00",,,,,,
UHC MCR ADV,CPT,43756,Dx duod intub w/asp spec,APC 5301,RVU Per Case,$828.48 ,OP,828.48,"4,314.00",,,,,,
UHC MCR ADV,CPT,43757,Dx duod intub w/asp specs,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
UHC MCR ADV,CPT,43761,Reposition gastrostomy tube,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
UHC MCR ADV,CPT,43762,Rplc gtube no revj trc,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
UHC MCR ADV,CPT,43763,Rplc gtube revj gstrst trc,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
UHC MCR ADV,CPT,43770,Lap place gastr adj device,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,43771,Lap revise gastr adj device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43772,Lap rmvl gastr adj device,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
UHC MCR ADV,CPT,43773,Lap replace gastr adj device,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,43774,Lap rmvl gastr adj all parts,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
UHC MCR ADV,CPT,43775,Lap sleeve gastrectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43800,Reconstruction of pylorus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43810,Fusion of stomach and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43820,Fusion of stomach and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43825,Fusion of stomach and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43830,Place gastrostomy tube,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,43831,Place gastrostomy tube,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
UHC MCR ADV,CPT,43832,Place gastrostomy tube,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43840,Repair of stomach lesion,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
UHC MCR ADV,CPT,43843,Gastroplasty w/o v-band,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43845,Gastroplasty duodenal switch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43846,Gastric bypass for obesity,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43847,Gastric bypass incl small i,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43848,Revision gastroplasty,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43850,Revise stomach-bowel fusion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43855,Revise stomach-bowel fusion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43860,Revise stomach-bowel fusion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43865,Revise stomach-bowel fusion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43870,Repair stomach opening,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
UHC MCR ADV,CPT,43880,Repair stomach-bowel fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43881,Impl/redo electrd antrum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43882,Revise/remove electrd antrum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,43886,Revise gastric port open,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
UHC MCR ADV,CPT,43887,Remove gastric port open,APC 5054,RVU Per Case,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,43888,Change gastric port open,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
UHC MCR ADV,CPT,43999,Stomach surgery procedure,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
UHC MCR ADV,CPT,44005,Freeing of bowel adhesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44010,Incision of small bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44015,Insert needle cath bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44020,Explore small intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44021,Decompress small bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44025,Incision of large bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44050,Reduce bowel obstruction,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44055,Correct malrotation of bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44100,Biopsy of bowel,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
UHC MCR ADV,CPT,44110,Excise intestine lesion(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44111,Excision of bowel lesion(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44120,Removal of small intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44121,Removal of small intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44125,Removal of small intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44126,Enterectomy w/o taper cong,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44127,Enterectomy w/taper cong,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44128,Enterectomy cong add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44130,Bowel to bowel fusion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44132,Enterectomy cadaver donor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44133,Enterectomy live donor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44135,Intestine transplnt cadaver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44136,Intestine transplant live,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44137,Remove intestinal allograft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44139,Mobilization of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44140,Partial removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44141,Partial removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44143,Partial removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44144,Partial removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44145,Partial removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44146,Partial removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44147,Partial removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44150,Removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44151,Removal of colon/ileostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44155,Removal of colon/ileostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44156,Removal of colon/ileostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44157,Colectomy w/ileoanal anast,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44158,Colectomy w/neo-rectum pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44160,Removal of colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44180,Lap enterolysis,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,44186,Lap jejunostomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,44187,Lap ileo/jejuno-stomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44188,Lap colostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44202,Lap enterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44203,Lap resect s/intestine addl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44204,Laparo partial colectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44205,Lap colectomy part w/ileum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44206,Lap part colectomy w/stoma,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44207,L colectomy/coloproctostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44208,L colectomy/coloproctostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44210,Laparo total proctocolectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44211,Lap colectomy w/proctectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44212,Laparo total proctocolectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44213,Lap mobil splenic fl add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44227,Lap close enterostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44238,Laparoscope proc intestine,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,44300,Open bowel to skin,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,44310,Ileostomy/jejunostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44312,Revision of ileostomy,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
UHC MCR ADV,CPT,44314,Revision of ileostomy,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
UHC MCR ADV,CPT,44316,Devise bowel pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44320,Colostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44322,Colostomy with biopsies,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44340,Revision of colostomy,APC 5055,RVU Per Unit,"$3,604.28 ",OP,"3,604.28","4,314.00",,,,,,
UHC MCR ADV,CPT,44345,Revision of colostomy,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
UHC MCR ADV,CPT,44346,Revision of colostomy,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
UHC MCR ADV,CPT,44360,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,44361,Small bowel endoscopy/biopsy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,44363,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,44364,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,44365,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,44366,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,44369,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,44370,Small bowel endoscopy/stent,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
UHC MCR ADV,CPT,44372,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,44373,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,44376,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,44377,Small bowel endoscopy/biopsy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,44378,Small bowel endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,44379,S bowel endoscope w/stent,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
UHC MCR ADV,CPT,44380,Small bowel endoscopy br/wa,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
UHC MCR ADV,CPT,44381,Small bowel endoscopy br/wa,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,44382,Small bowel endoscopy,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
UHC MCR ADV,CPT,44384,Small bowel endoscopy,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
UHC MCR ADV,CPT,44385,Endoscopy of bowel pouch,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
UHC MCR ADV,CPT,44386,Endoscopy bowel pouch/biop,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
UHC MCR ADV,CPT,44388,Colonoscopy thru stoma spx,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
UHC MCR ADV,CPT,44389,Colonoscopy with biopsy,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,44390,Colonoscopy for foreign body,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
UHC MCR ADV,CPT,44391,Colonoscopy for bleeding,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,44392,Colonoscopy & polypectomy,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,44394,Colonoscopy w/snare,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,44401,Colonoscopy with ablation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,44402,Colonoscopy w/stent plcmt,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
UHC MCR ADV,CPT,44403,Colonoscopy w/resection,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,44404,Colonoscopy w/injection,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,44405,Colonoscopy w/dilation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,44406,Colonoscopy w/ultrasound,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,44407,Colonoscopy w/ndl aspir/bx,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,44408,Colonoscopy w/decompression,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
UHC MCR ADV,CPT,44500,Intro gastrointestinal tube,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
UHC MCR ADV,CPT,44602,Suture small intestine,APC 5303,RVU Per Case,"$3,152.63 ",OP,"3,152.63","4,314.00",,,,,,
UHC MCR ADV,CPT,44603,Suture small intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44604,Suture large intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44605,Repair of bowel lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44615,Intestinal stricturoplasty,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44620,Repair bowel opening,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44625,Repair bowel opening,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44626,Repair bowel opening,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44640,Repair bowel-skin fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44650,Repair bowel fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44660,Repair bowel-bladder fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44661,Repair bowel-bladder fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44680,Surgical revision intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44700,Suspend bowel w/prosthesis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44715,Prepare donor intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44720,Prep donor intestine/venous,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44721,Prep donor intestine/artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44799,Unlisted px small intestine,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
UHC MCR ADV,CPT,44800,Excision of bowel pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44820,Excision of mesentery lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44850,Repair of mesentery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44899,Bowel surgery procedure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44900,Drain appendix abscess open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44950,Appendectomy,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
UHC MCR ADV,CPT,44960,Appendectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,44970,Laparoscopy appendectomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,44979,Laparoscope proc app,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,45000,Drainage of pelvic abscess,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,45005,Drainage of rectal abscess,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,45020,Drainage of rectal abscess,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,45100,Biopsy of rectum,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,45108,Removal of anorectal lesion,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,45110,Removal of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,45111,Partial removal of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,45112,Removal of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,45113,Partial proctectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,45114,Partial removal of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,45116,Partial removal of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,45119,Remove rectum w/reservoir,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,45120,Removal of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,45121,Removal of rectum and colon,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,45123,Partial proctectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,45126,Pelvic exenteration,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,45130,Excision of rectal prolapse,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,45135,Excision of rectal prolapse,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,45136,Excise ileoanal reservior,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,45150,Excision of rectal stricture,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,45160,Excision of rectal lesion,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,45171,Exc rect tum transanal part,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,45172,Exc rect tum transanal full,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,45190,Destruction rectal tumor,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,45300,Proctosigmoidoscopy dx,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
UHC MCR ADV,CPT,45303,Proctosigmoidoscopy dilate,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,45305,Proctosigmoidoscopy w/bx,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,45307,Proctosigmoidoscopy fb,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,45308,Proctosigmoidoscopy removal,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,45309,Proctosigmoidoscopy removal,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,45315,Proctosigmoidoscopy removal,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,45317,Proctosigmoidoscopy bleed,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,45320,Proctosigmoidoscopy ablate,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,45321,Proctosigmoidoscopy volvul,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,45327,Proctosigmoidoscopy w/stent,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
UHC MCR ADV,CPT,45330,Diagnostic sigmoidoscopy,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
UHC MCR ADV,CPT,45331,Sigmoidoscopy and biopsy,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
UHC MCR ADV,CPT,45332,Sigmoidoscopy w/fb removal,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,45333,Sigmoidoscopy & polypectomy,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
UHC MCR ADV,CPT,45334,Sigmoidoscopy for bleeding,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,45335,Sigmoidoscopy w/submuc inj,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
UHC MCR ADV,CPT,45337,Sigmoidoscopy & decompress,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
UHC MCR ADV,CPT,45338,Sigmoidoscopy w/tumr remove,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,45340,Sig w/tndsc balloon dilation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,45341,Sigmoidoscopy w/ultrasound,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
UHC MCR ADV,CPT,45342,Sigmoidoscopy w/us guide bx,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,45346,Sigmoidoscopy w/ablation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,45347,Sigmoidoscopy w/plcmt stent,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
UHC MCR ADV,CPT,45349,Sigmoidoscopy w/resection,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,45350,Sgmdsc w/band ligation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,45378,Diagnostic colonoscopy,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
UHC MCR ADV,CPT,45379,Colonoscopy w/fb removal,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,45380,Colonoscopy and biopsy,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,45381,Colonoscopy submucous njx,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,45382,Colonoscopy w/control bleed,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,45384,Colonoscopy w/lesion removal,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,45385,Colonoscopy w/lesion removal,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,45386,Colonoscopy w/balloon dilat,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,45388,Colonoscopy w/ablation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,45389,Colonoscopy w/stent plcmt,APC 5331,RVU Per Case,"$5,145.78 ",OP,"4,314.00","5,145.78",,,,,,
UHC MCR ADV,CPT,45390,Colonoscopy w/resection,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,45391,Colonoscopy w/endoscope us,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,45392,Colonoscopy w/endoscopic fnb,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,45393,Colonoscopy w/decompression,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,45395,Lap removal of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,45397,Lap remove rectum w/pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,45398,Colonoscopy w/band ligation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,45399,Unlisted procedure colon,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
UHC MCR ADV,CPT,45400,Laparoscopic proc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,45402,Lap proctopexy w/sig resect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,45499,Laparoscope proc rectum,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,45500,Repair of rectum,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,45505,Repair of rectum,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,45520,Treatment of rectal prolapse,APC 5311,RVU Per Case,$812.16 ,OP,812.16,"4,314.00",,,,,,
UHC MCR ADV,CPT,45540,Correct rectal prolapse,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,45541,Correct rectal prolapse,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,45550,Repair rectum/remove sigmoid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,45560,Repair of rectocele,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,45562,Exploration/repair of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,45563,Exploration/repair of rectum,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,45800,Repair rect/bladder fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,45805,Repair fistula w/colostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,45820,Repair rectourethral fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,45825,Repair fistula w/colostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,45900,Reduction of rectal prolapse,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
UHC MCR ADV,CPT,45905,Dilation of anal sphincter,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,45910,Dilation of rectal narrowing,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,45915,Remove rectal obstruction,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,45990,Surg dx exam anorectal,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,45999,Rectum surgery procedure,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
UHC MCR ADV,CPT,46020,Placement of seton,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,46030,Removal of rectal marker,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,46040,Incision of rectal abscess,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,46045,Incision of rectal abscess,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,46050,Incision of anal abscess,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
UHC MCR ADV,CPT,46060,Incision of rectal abscess,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,46070,Incision of anal septum,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,46080,Incision of anal sphincter,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,46083,Incise external hemorrhoid,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
UHC MCR ADV,CPT,46200,Removal of anal fissure,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,46220,Excise anal ext tag/papilla,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,46221,Ligation of hemorrhoid(s),APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
UHC MCR ADV,CPT,46230,Removal of anal tags,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,46250,Remove ext hem groups 2+,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,46255,Remove int/ext hem 1 group,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,46257,Remove in/ex hem grp & fiss,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,46258,Remove in/ex hem grp w/fistu,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,46260,Remove in/ex hem groups 2+,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,46261,Remove in/ex hem grps & fiss,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,46262,Remove in/ex hem grps w/fist,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,46270,Remove anal fist subq,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,46275,Remove anal fist inter,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,46280,Remove anal fist complex,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,46285,Remove anal fist 2 stage,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,46288,Repair anal fistula,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,46320,Removal of hemorrhoid clot,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,46500,Injection into hemorrhoid(s),APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
UHC MCR ADV,CPT,46505,Chemodenervation anal musc,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,46600,Diagnostic anoscopy spx,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
UHC MCR ADV,CPT,46601,Diagnostic anoscopy,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
UHC MCR ADV,CPT,46604,Anoscopy and dilation,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,46606,Anoscopy and biopsy,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,46607,Diagnostic anoscopy & biopsy,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,46608,Anoscopy remove for body,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
UHC MCR ADV,CPT,46610,Anoscopy remove lesion,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,46611,Anoscopy,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
UHC MCR ADV,CPT,46612,Anoscopy remove lesions,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,46614,Anoscopy control bleeding,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,46615,Anoscopy,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,46700,Repair of anal stricture,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,46705,Repair of anal stricture,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,46706,Repr of anal fistula w/glue,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,46707,Repair anorectal fist w/plug,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,46710,Repr per/vag pouch sngl proc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,46712,Repr per/vag pouch dbl proc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,46715,Rep perf anoper fistu,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,46716,Rep perf anoper/vestib fistu,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,46730,Construction of absent anus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,46735,Construction of absent anus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,46740,Construction of absent anus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,46742,Repair of imperforated anus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,46744,Repair of cloacal anomaly,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,46746,Repair of cloacal anomaly,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,46748,Repair of cloacal anomaly,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,46750,Repair of anal sphincter,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,46751,Repair of anal sphincter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,46753,Reconstruction of anus,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,46754,Removal of suture from anus,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,46760,Repair of anal sphincter,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,46761,Repair of anal sphincter,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,46900,Destruction anal lesion(s),APC 5052,RVU Per Unit,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,46910,Destruction anal lesion(s),APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,46916,Cryosurgery anal lesion(s),APC 5051,RVU Per Unit,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,46917,Laser surgery anal lesions,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,46922,Excision of anal lesion(s),APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,46924,Destruction anal lesion(s),APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,46930,Destroy internal hemorrhoids,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,46940,Treatment of anal fissure,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,46942,Treatment of anal fissure,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
UHC MCR ADV,CPT,46945,Int hrhc lig 1 hroid w/o img,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,46946,Int hrhc lig 2+hroid w/o img,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,46947,Hemorrhoidopexy by stapling,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,46948,Int hrhc tranal dartlzj 2+,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","4,314.00",,,,,,
UHC MCR ADV,CPT,46999,Anus surgery procedure,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,"4,314.00",,,,,,
UHC MCR ADV,CPT,47000,Needle biopsy of liver,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,47010,Open drainage liver lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47015,Inject/aspirate liver cyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47100,Wedge biopsy of liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47120,Partial removal of liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47122,Extensive removal of liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47125,Partial removal of liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47130,Partial removal of liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47133,Removal of donor liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47135,Transplantation of liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47140,Partial removal donor liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47141,Partial removal donor liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47142,Partial removal donor liver,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47143,Prep donor liver whole,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47144,Prep donor liver 3-segment,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47145,Prep donor liver lobe split,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47146,Prep donor liver/venous,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47147,Prep donor liver/arterial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47300,Surgery for liver lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47350,Repair liver wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47360,Repair liver wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47361,Repair liver wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47362,Repair liver wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47370,Laparo ablate liver tumor rf,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
UHC MCR ADV,CPT,47371,Laparo ablate liver cryosurg,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
UHC MCR ADV,CPT,47379,Laparoscope procedure liver,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,47380,Open ablate liver tumor rf,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47381,Open ablate liver tumor cryo,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47382,Percut ablate liver rf,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,47383,Perq abltj lvr cryoablation,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,47399,Liver surgery procedure,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,47400,Incision of liver duct,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47420,Incision of bile duct,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47425,Incision of bile duct,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47460,Incise bile duct sphincter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47480,Incision of gallbladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47490,Incision of gallbladder,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
UHC MCR ADV,CPT,47531,Injection for cholangiogram,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
UHC MCR ADV,CPT,47532,Injection for cholangiogram,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
UHC MCR ADV,CPT,47533,Plmt biliary drainage cath,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
UHC MCR ADV,CPT,47534,Plmt biliary drainage cath,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
UHC MCR ADV,CPT,47535,Conversion ext bil drg cath,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
UHC MCR ADV,CPT,47536,Exchange biliary drg cath,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
UHC MCR ADV,CPT,47537,Removal biliary drg cath,APC 5301,RVU Per Case,$828.48 ,OP,828.48,"4,314.00",,,,,,
UHC MCR ADV,CPT,47538,Perq plmt bile duct stent,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,47539,Perq plmt bile duct stent,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,47540,Perq plmt bile duct stent,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,47541,Plmt access bil tree sm bwl,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
UHC MCR ADV,CPT,47550,Bile duct endoscopy add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47552,Biliary endo perq dx w/speci,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
UHC MCR ADV,CPT,47553,Biliary endoscopy thru skin,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
UHC MCR ADV,CPT,47554,Biliary endoscopy thru skin,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,47555,Biliary endoscopy thru skin,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
UHC MCR ADV,CPT,47556,Biliary endoscopy thru skin,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,47562,Laparoscopic cholecystectomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,47563,Laparo cholecystectomy/graph,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,47564,Laparo cholecystectomy/explr,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,47570,Laparo cholecystoenterostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47579,Laparoscope proc biliary,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,47600,Removal of gallbladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,47605,Removal of gallbladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,47610,Removal of gallbladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,47612,Removal of gallbladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,47620,Removal of gallbladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,47700,Exploration of bile ducts,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47701,Bile duct revision,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47711,Excision of bile duct tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47712,Excision of bile duct tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47715,Excision of bile duct cyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47720,Fuse gallbladder & bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47721,Fuse upper gi structures,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47740,Fuse gallbladder & bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47741,Fuse gallbladder & bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47760,Fuse bile ducts and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47765,Fuse liver ducts & bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47780,Fuse bile ducts and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47785,Fuse bile ducts and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47800,Reconstruction of bile ducts,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47801,Placement bile duct support,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47802,Fuse liver duct & intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47900,Suture bile duct injury,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,47999,Bile tract surgery procedure,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
UHC MCR ADV,CPT,48000,Drainage of abdomen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,48001,Placement of drain pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,48020,Removal of pancreatic stone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,48100,Biopsy of pancreas open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,48102,Needle biopsy pancreas,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,48105,Resect/debride pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,48120,Removal of pancreas lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,48140,Partial removal of pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,48145,Partial removal of pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,48146,Pancreatectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,48148,Removal of pancreatic duct,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,48150,Partial removal of pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,48152,Pancreatectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,48153,Pancreatectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,48154,Pancreatectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,48155,Removal of pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,48400,Injection intraop add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,48500,Surgery of pancreatic cyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,48510,Drain pancreatic pseudocyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,48520,Fuse pancreas cyst and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,48540,Fuse pancreas cyst and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,48545,Pancreatorrhaphy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,48547,Duodenal exclusion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,48548,Fuse pancreas and bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,48551,Prep donor pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,48552,Prep donor pancreas/venous,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,48554,Transpl allograft pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,48556,Removal allograft pancreas,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,48999,Pancreas surgery procedure,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,49000,Exploration of abdomen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,49002,Reopening of abdomen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,49010,Exploration behind abdomen,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
UHC MCR ADV,CPT,49013,Prpertl pel pack hemrrg trma,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,49014,Reexploration pelvic wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,49020,Drainage abdom abscess open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,49040,Drain open abdom abscess,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,49060,Drain open retroperi abscess,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,49062,Drain to peritoneal cavity,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,49082,Abd paracentesis,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
UHC MCR ADV,CPT,49083,Abd paracentesis w/imaging,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
UHC MCR ADV,CPT,49084,Peritoneal lavage,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
UHC MCR ADV,CPT,49180,Biopsy abdominal mass,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,49185,Sclerotx fluid collection,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,49203,Exc abd tum 5 cm or less,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,49204,Exc abd tum over 5 cm,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,49205,Exc abd tum over 10 cm,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,49215,Excise sacral spine tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,49250,Excision of umbilicus,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
UHC MCR ADV,CPT,49255,Removal of omentum,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
UHC MCR ADV,CPT,49320,Diag laparo separate proc,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,49321,Laparoscopy biopsy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,49322,Laparoscopy aspiration,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,49323,Laparo drain lymphocele,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,49324,Lap insert tunnel ip cath,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,49325,Lap revision perm ip cath,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,49329,Laparo proc abdm/per/oment,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,49402,Remove foreign body adbomen,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
UHC MCR ADV,CPT,49405,Image cath fluid colxn visc,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,49406,Image cath fluid peri/retro,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,49407,Image cath fluid trns/vgnl,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,49411,Ins mark abd/pel for rt perq,APC 5613,RVU Per Unit,"$1,291.62 ",OP,"1,291.62","4,314.00",,,,,,
UHC MCR ADV,CPT,49412,Ins device for rt guide open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,49418,Insert tun ip cath perc,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
UHC MCR ADV,CPT,49419,Insert tun ip cath w/port,APC 5184,RVU Per Case,"$4,881.61 ",OP,"4,314.00","4,881.61",,,,,,
UHC MCR ADV,CPT,49421,Ins tun ip cath for dial opn,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
UHC MCR ADV,CPT,49422,Remove tunneled ip cath,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,49423,Exchange drainage catheter,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,49425,Insert abdomen-venous drain,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,49426,Revise abdomen-venous shunt,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
UHC MCR ADV,CPT,49428,Ligation of shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,49429,Removal of shunt,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,314.00",,,,,,
UHC MCR ADV,CPT,49436,Embedded ip cath exit-site,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,49440,Place gastrostomy tube perc,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,49441,Place duod/jej tube perc,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,49442,Place cecostomy tube perc,APC 5312,RVU Per Unit,"$1,061.14 ",OP,"1,061.14","4,314.00",,,,,,
UHC MCR ADV,CPT,49446,Change g-tube to g-j perc,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","4,314.00",,,,,,
UHC MCR ADV,CPT,49450,Replace g/c tube perc,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
UHC MCR ADV,CPT,49451,Replace duod/jej tube perc,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
UHC MCR ADV,CPT,49452,Replace g-j tube perc,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
UHC MCR ADV,CPT,49460,Fix g/colon tube w/device,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
UHC MCR ADV,CPT,49465,Fluoro exam of g/colon tube,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"4,314.00",,,,,,
UHC MCR ADV,CPT,49491,Rpr hern preemie reduc,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,49492,Rpr ing hern premie blocked,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
UHC MCR ADV,CPT,49495,Rpr ing hernia baby reduc,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
UHC MCR ADV,CPT,49496,Rpr ing hernia baby blocked,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
UHC MCR ADV,CPT,49500,Rpr ing hernia init reduce,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
UHC MCR ADV,CPT,49501,Rpr ing hernia init blocked,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
UHC MCR ADV,CPT,49505,Prp i/hern init reduc >5 yr,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
UHC MCR ADV,CPT,49507,Prp i/hern init block >5 yr,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
UHC MCR ADV,CPT,49520,Rerepair ing hernia reduce,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
UHC MCR ADV,CPT,49521,Rerepair ing hernia blocked,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
UHC MCR ADV,CPT,49525,Repair ing hernia sliding,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
UHC MCR ADV,CPT,49540,Repair lumbar hernia,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,49550,Rpr rem hernia init reduce,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
UHC MCR ADV,CPT,49553,Rpr fem hernia init blocked,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
UHC MCR ADV,CPT,49555,Rerepair fem hernia reduce,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
UHC MCR ADV,CPT,49557,Rerepair fem hernia blocked,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
UHC MCR ADV,CPT,49560,Rpr ventral hern init reduc,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
UHC MCR ADV,CPT,49561,Rpr ventral hern init block,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
UHC MCR ADV,CPT,49565,Rerepair ventrl hern reduce,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,49566,Rerepair ventrl hern block,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,49570,Rpr epigastric hern reduce,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
UHC MCR ADV,CPT,49572,Rpr epigastric hern blocked,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
UHC MCR ADV,CPT,49580,Rpr umbil hern reduc < 5 yr,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
UHC MCR ADV,CPT,49582,Rpr umbil hern block < 5 yr,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
UHC MCR ADV,CPT,49585,Rpr umbil hern reduc > 5 yr,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
UHC MCR ADV,CPT,49587,Rpr umbil hern block > 5 yr,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
UHC MCR ADV,CPT,49590,Repair spigelian hernia,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
UHC MCR ADV,CPT,49600,Repair umbilical lesion,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
UHC MCR ADV,CPT,49605,Repair umbilical lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,49606,Repair umbilical lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,49610,Repair umbilical lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,49611,Repair umbilical lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,49650,Lap ing hernia repair init,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,49651,Lap ing hernia repair recur,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,49652,Lap vent/abd hernia repair,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,49653,Lap vent/abd hern proc comp,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,49654,Lap inc hernia repair,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,49655,Lap inc hern repair comp,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
UHC MCR ADV,CPT,49656,Lap inc hernia repair recur,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
UHC MCR ADV,CPT,49657,Lap inc hern recur comp,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
UHC MCR ADV,CPT,49659,Laparo proc hernia repair,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,49900,Repair of abdominal wall,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,49904,Omental flap extra-abdom,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,49905,Omental flap intra-abdom,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,49906,Free omental flap microvasc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,49999,Abdomen surgery procedure,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,"4,314.00",,,,,,
UHC MCR ADV,CPT,50010,Exploration of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50020,Renal abscess open drain,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,50040,Drainage of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50045,Exploration of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50060,Removal of kidney stone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50065,Incision of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50070,Incision of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50075,Removal of kidney stone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50080,Removal of kidney stone,APC 5376,RVU Per Case,"$8,450.70 ",OP,"4,314.00","8,450.70",,,,,,
UHC MCR ADV,CPT,50081,Removal of kidney stone,APC 5376,RVU Per Case,"$8,450.70 ",OP,"4,314.00","8,450.70",,,,,,
UHC MCR ADV,CPT,50100,Revise kidney blood vessels,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50120,Exploration of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50125,Explore and drain kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50130,Removal of kidney stone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50135,Exploration of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50200,Renal biopsy perq,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,50205,Renal biopsy open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50220,Remove kidney open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50225,Removal kidney open complex,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50230,Removal kidney open radical,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50234,Removal of kidney & ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50236,Removal of kidney & ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50240,Partial removal of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50250,Cryoablate renal mass open,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50280,Removal of kidney lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50290,Removal of kidney lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50300,Remove cadaver donor kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50320,Remove kidney living donor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50323,Prep cadaver renal allograft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50325,Prep donor renal graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50327,Prep renal graft/venous,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50328,Prep renal graft/arterial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50329,Prep renal graft/ureteral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50340,Removal of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50360,Transplantation of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50365,Transplantation of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50370,Remove transplanted kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50380,Reimplantation of kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50382,Change ureter stent percut,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,50384,Remove ureter stent percut,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,50385,Change stent via transureth,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,50386,Remove stent via transureth,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,50387,Change nephroureteral cath,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,50389,Remove renal tube w/fluoro,APC 5372,RVU Per Case,$588.17 ,OP,588.17,"4,314.00",,,,,,
UHC MCR ADV,CPT,50390,Drainage of kidney lesion,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,50391,Instll rx agnt into rnal tub,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
UHC MCR ADV,CPT,50396,Measure kidney pressure,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
UHC MCR ADV,CPT,50400,Revision of kidney/ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50405,Revision of kidney/ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50430,Njx px nfrosgrm &/urtrgrm,APC 5372,RVU Per Case,$588.17 ,OP,588.17,"4,314.00",,,,,,
UHC MCR ADV,CPT,50431,Njx px nfrosgrm &/urtrgrm,APC 5372,RVU Per Case,$588.17 ,OP,588.17,"4,314.00",,,,,,
UHC MCR ADV,CPT,50432,Plmt nephrostomy catheter,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,50433,Plmt nephroureteral catheter,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,50434,Convert nephrostomy catheter,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,50435,Exchange nephrostomy cath,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,50436,Dilat xst trc ndurlgc px,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,50437,Dilat xst trc new access rcs,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,50500,Repair of kidney wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50520,Close kidney-skin fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50525,Close nephrovisceral fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50526,Close nephrovisceral fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50540,Revision of horseshoe kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50541,Laparo ablate renal cyst,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,50542,Laparo ablate renal mass,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
UHC MCR ADV,CPT,50543,Laparo partial nephrectomy,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
UHC MCR ADV,CPT,50544,Laparoscopy pyeloplasty,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,50545,Laparo radical nephrectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50546,Laparoscopic nephrectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50547,Laparo removal donor kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50548,Laparo remove w/ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50549,Laparoscope proc renal,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,50551,Kidney endoscopy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,50553,Kidney endoscopy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,50555,Kidney endoscopy & biopsy,APC 5376,RVU Per Case,"$8,450.70 ",OP,"4,314.00","8,450.70",,,,,,
UHC MCR ADV,CPT,50557,Kidney endoscopy & treatment,APC 5376,RVU Per Case,"$8,450.70 ",OP,"4,314.00","8,450.70",,,,,,
UHC MCR ADV,CPT,50561,Kidney endoscopy & treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,50562,Renal scope w/tumor resect,APC 5376,RVU Per Case,"$8,450.70 ",OP,"4,314.00","8,450.70",,,,,,
UHC MCR ADV,CPT,50570,Kidney endoscopy,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,50572,Kidney endoscopy,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
UHC MCR ADV,CPT,50574,Kidney endoscopy & biopsy,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,50575,Kidney endoscopy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,50576,Kidney endoscopy & treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,50580,Kidney endoscopy & treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,50590,Fragmenting of kidney stone,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,50592,Perc rf ablate renal tumor,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,50593,Perc cryo ablate renal tum,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
UHC MCR ADV,CPT,50600,Exploration of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50605,Insert ureteral support,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50610,Removal of ureter stone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50620,Removal of ureter stone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50630,Removal of ureter stone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50650,Removal of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50660,Removal of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50686,Measure ureter pressure,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,"4,314.00",,,,,,
UHC MCR ADV,CPT,50688,Change of ureter tube/stent,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,50693,Plmt ureteral stent prq,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,50694,Plmt ureteral stent prq,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,50695,Plmt ureteral stent prq,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,50700,Revision of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50715,Release of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50722,Release of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50725,Release/revise ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50727,Revise ureter,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,50728,Revise ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50740,Fusion of ureter & kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50750,Fusion of ureter & kidney,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50760,Fusion of ureters,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50770,Splicing of ureters,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50780,Reimplant ureter in bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50782,Reimplant ureter in bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50783,Reimplant ureter in bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50785,Reimplant ureter in bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50800,Implant ureter in bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50810,Fusion of ureter & bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50815,Urine shunt to intestine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50820,Construct bowel bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50825,Construct bowel bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50830,Revise urine flow,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50840,Replace ureter by bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50845,Appendico-vesicostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50860,Transplant ureter to skin,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50900,Repair of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50920,Closure ureter/skin fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50930,Closure ureter/bowel fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50940,Release of ureter,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,50945,Laparoscopy ureterolithotomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,50947,Laparo new ureter/bladder,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,50948,Laparo new ureter/bladder,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
UHC MCR ADV,CPT,50949,Laparoscope proc ureter,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,50951,Endoscopy of ureter,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,50953,Endoscopy of ureter,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,50955,Ureter endoscopy & biopsy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,50957,Ureter endoscopy & treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,50961,Ureter endoscopy & treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,50970,Ureter endoscopy,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,50972,Ureter endoscopy & catheter,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,50974,Ureter endoscopy & biopsy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,50976,Ureter endoscopy & treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,50980,Ureter endoscopy & treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,51020,Incise & treat bladder,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,51030,Incise & treat bladder,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,51040,Incise & drain bladder,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,51045,Incise bladder/drain ureter,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,51050,Removal of bladder stone,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,51060,Removal of ureter stone,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,51065,Remove ureter calculus,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,51080,Drainage of bladder abscess,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,51100,Drain bladder by needle,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
UHC MCR ADV,CPT,51101,Drain bladder by trocar/cath,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"4,314.00",,,,,,
UHC MCR ADV,CPT,51102,Drain bl w/cath insertion,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,51500,Removal of bladder cyst,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,51520,Removal of bladder lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,51525,Removal of bladder lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,51530,Removal of bladder lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,51535,Repair of ureter lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,51550,Partial removal of bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,51555,Partial removal of bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,51565,Revise bladder & ureter(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,51570,Removal of bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,51575,Removal of bladder & nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,51580,Remove bladder/revise tract,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,51585,Removal of bladder & nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,51590,Remove bladder/revise tract,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,51595,Remove bladder/revise tract,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,51596,Remove bladder/create pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,51597,Removal of pelvic structures,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,51700,Irrigation of bladder,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
UHC MCR ADV,CPT,51701,Insert bladder catheter,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
UHC MCR ADV,CPT,51702,Insert temp bladder cath,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
UHC MCR ADV,CPT,51703,Insert bladder cath complex,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,"4,314.00",,,,,,
UHC MCR ADV,CPT,51705,Change of bladder tube,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
UHC MCR ADV,CPT,51710,Change of bladder tube,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
UHC MCR ADV,CPT,51715,Endoscopic injection/implant,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,51720,Treatment of bladder lesion,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
UHC MCR ADV,CPT,51725,Simple cystometrogram,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
UHC MCR ADV,CPT,51726,Complex cystometrogram,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
UHC MCR ADV,CPT,51727,Cystometrogram w/up,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
UHC MCR ADV,CPT,51728,Cystometrogram w/vp,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
UHC MCR ADV,CPT,51729,Cystometrogram w/vp&up,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
UHC MCR ADV,CPT,51736,Urine flow measurement,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
UHC MCR ADV,CPT,51741,Electro-uroflowmetry first,APC 5721,RVU Per Case,$142.80 ,OP,142.8,"4,314.00",,,,,,
UHC MCR ADV,CPT,51784,Anal/urinary muscle study,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,"4,314.00",,,,,,
UHC MCR ADV,CPT,51785,Anal/urinary muscle study,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
UHC MCR ADV,CPT,51792,Urinary reflex study,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
UHC MCR ADV,CPT,51798,Us urine capacity measure,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
UHC MCR ADV,CPT,51800,Revision of bladder/urethra,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,51820,Revision of urinary tract,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,51840,Attach bladder/urethra,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
UHC MCR ADV,CPT,51841,Attach bladder/urethra,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,51845,Repair bladder neck,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
UHC MCR ADV,CPT,51860,Repair of bladder wound,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,51865,Repair of bladder wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,51880,Repair of bladder opening,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,51900,Repair bladder/vagina lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,51920,Close bladder-uterus fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,51925,Hysterectomy/bladder repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,51940,Correction of bladder defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,51960,Revision of bladder & bowel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,51980,Construct bladder opening,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,51990,Laparo urethral suspension,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,51992,Laparo sling operation,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,51999,Laparoscope proc bla,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,52000,Cystoscopy,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
UHC MCR ADV,CPT,52001,Cystoscopy removal of clots,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,52005,Cystoscopy & ureter catheter,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,52007,Cystoscopy and biopsy,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,52010,Cystoscopy & duct catheter,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
UHC MCR ADV,CPT,52204,Cystoscopy w/biopsy(s),APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,52214,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,52224,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,52234,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,52235,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,52240,Cystoscopy and treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,52250,Cystoscopy and radiotracer,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,52260,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,52265,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,52270,Cystoscopy & revise urethra,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,52275,Cystoscopy & revise urethra,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,52276,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,52277,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,52281,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,52282,Cystoscopy implant stent,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,52283,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,52285,Cystoscopy and treatment,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
UHC MCR ADV,CPT,52287,Cystoscopy chemodenervation,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,52290,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,52300,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,52301,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,52305,Cystoscopy and treatment,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,52310,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,52315,Cystoscopy and treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,52317,Remove bladder stone,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,52318,Remove bladder stone,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,52320,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,52325,Cystoscopy stone removal,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,52327,Cystoscopy inject material,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,52330,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,52332,Cystoscopy and treatment,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,52334,Create passage to kidney,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,52341,Cysto w/ureter stricture tx,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,52342,Cysto w/up stricture tx,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,52343,Cysto w/renal stricture tx,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,52344,Cysto/uretero stricture tx,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,52345,Cysto/uretero w/up stricture,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,52346,Cystouretero w/renal strict,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,52351,Cystouretero & or pyeloscope,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,52352,Cystouretero w/stone remove,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,52353,Cystouretero w/lithotripsy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,52354,Cystouretero w/biopsy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,52355,Cystouretero w/excise tumor,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,52356,Cysto/uretero w/lithotripsy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,52400,Cystouretero w/congen repr,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,52402,Cystourethro cut ejacul duct,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,52450,Incision of prostate,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,52500,Revision of bladder neck,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,52601,Prostatectomy (turp),APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,52630,Remove prostate regrowth,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,52640,Relieve bladder contracture,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,52647,Laser surgery of prostate,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,52648,Laser surgery of prostate,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,52649,Prostate laser enucleation,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,52700,Drainage of prostate abscess,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,53000,Incision of urethra,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,53010,Incision of urethra,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,53020,Incision of urethra,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,53025,Incision of urethra,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,53040,Drainage of urethra abscess,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,53060,Drainage of urethra abscess,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,53080,Drainage of urinary leakage,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
UHC MCR ADV,CPT,53085,Drainage of urinary leakage,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,53200,Biopsy of urethra,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,53210,Removal of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,53215,Removal of urethra,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,53220,Treatment of urethra lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,53230,Removal of urethra lesion,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,53235,Removal of urethra lesion,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,53240,Surgery for urethra pouch,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,53250,Removal of urethra gland,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,53260,Treatment of urethra lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,53265,Treatment of urethra lesion,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,53270,Removal of urethra gland,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,53275,Repair of urethra defect,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,53400,Revise urethra stage 1,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,53405,Revise urethra stage 2,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,53410,Reconstruction of urethra,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,53415,Reconstruction of urethra,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,53420,Reconstruct urethra stage 1,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,53425,Reconstruct urethra stage 2,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,53430,Reconstruction of urethra,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,53431,Reconstruct urethra/bladder,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,53440,Male sling procedure,APC 5377,RVU Per Case,"$11,755.91 ",OP,"4,140.35","11,755.91",,,,,,
UHC MCR ADV,CPT,53442,Remove/revise male sling,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,53444,Insert tandem cuff,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,314.00","18,684.12",,,,,,
UHC MCR ADV,CPT,53445,Insert uro/ves nck sphincter,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,140.35","18,684.12",,,,,,
UHC MCR ADV,CPT,53446,Remove uro sphincter,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,53447,Remove/replace ur sphincter,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,314.00","18,684.12",,,,,,
UHC MCR ADV,CPT,53448,Remov/replc ur sphinctr comp,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,53449,Repair uro sphincter,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,53450,Revision of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,53460,Revision of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,53500,Urethrlys transvag w/ scope,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,53502,Repair of urethra injury,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,53505,Repair of urethra injury,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,53510,Repair of urethra injury,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,53515,Repair of urethra injury,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,53520,Repair of urethra defect,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,53600,Dilate urethra stricture,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
UHC MCR ADV,CPT,53601,Dilate urethra stricture,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
UHC MCR ADV,CPT,53605,Dilate urethra stricture,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,53620,Dilate urethra stricture,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
UHC MCR ADV,CPT,53621,Dilate urethra stricture,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
UHC MCR ADV,CPT,53660,Dilation of urethra,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,"4,314.00",,,,,,
UHC MCR ADV,CPT,53661,Dilation of urethra,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
UHC MCR ADV,CPT,53665,Dilation of urethra,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,53850,Prostatic microwave thermotx,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,53852,Prostatic rf thermotx,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,53854,Trurl dstrj prst8 tiss rf wv,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,53855,Insert prost urethral stent,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,53860,Transurethral rf treatment,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,53899,Urology surgery procedure,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
UHC MCR ADV,CPT,54000,Slitting of prepuce,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,54001,Slitting of prepuce,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,54015,Drain penis lesion,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,54050,Destruction penis lesion(s),APC 5052,RVU Per Case,$353.91 ,OP,353.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,54055,Destruction penis lesion(s),APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,54056,Cryosurgery penis lesion(s),APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,54057,Laser surg penis lesion(s),APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,54060,Excision of penis lesion(s),APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,54065,Destruction penis lesion(s),APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,54100,Biopsy of penis,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,54105,Biopsy of penis,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,54110,Treatment of penis lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,54111,Treat penis lesion graft,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,54112,Treat penis lesion graft,APC 5376,RVU Per Case,"$8,450.70 ",OP,"4,314.00","8,450.70",,,,,,
UHC MCR ADV,CPT,54115,Treatment of penis lesion,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,54120,Partial removal of penis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,54125,Removal of penis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,54130,Remove penis & nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,54135,Remove penis & nodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,54150,Circumcision w/regionl block,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,54160,Circumcision neonate,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,"4,314.00",,,,,,
UHC MCR ADV,CPT,54161,Circum 28 days or older,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,54162,Lysis penil circumic lesion,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,54163,Repair of circumcision,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,54164,Frenulotomy of penis,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,54200,Treatment of penis lesion,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
UHC MCR ADV,CPT,54205,Treatment of penis lesion,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,54220,Treatment of penis lesion,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
UHC MCR ADV,CPT,54231,Dynamic cavernosometry,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
UHC MCR ADV,CPT,54235,Penile injection,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
UHC MCR ADV,CPT,54240,Penis study,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"4,314.00",,,,,,
UHC MCR ADV,CPT,54250,Penis study,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
UHC MCR ADV,CPT,54300,Revision of penis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,54304,Revision of penis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,54308,Reconstruction of urethra,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,54312,Reconstruction of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,54316,Reconstruction of urethra,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,54318,Reconstruction of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,54322,Reconstruction of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,54324,Reconstruction of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,54326,Reconstruction of urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,54328,Revise penis/urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,54332,Revise penis/urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,54336,Revise penis/urethra,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,54340,Secondary urethral surgery,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,54344,Secondary urethral surgery,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,54348,Secondary urethral surgery,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,54352,Reconstruct urethra/penis,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,54360,Penis plastic surgery,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,54380,Repair penis,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,54385,Repair penis,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,54390,Repair penis and bladder,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,54400,Insert semi-rigid prosthesis,APC 5377,RVU Per Case,"$11,755.91 ",OP,"4,314.00","11,755.91",,,,,,
UHC MCR ADV,CPT,54401,Insert self-contd prosthesis,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,314.00","18,684.12",,,,,,
UHC MCR ADV,CPT,54405,Insert multi-comp penis pros,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,140.35","18,684.12",,,,,,
UHC MCR ADV,CPT,54406,Remove muti-comp penis pros,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,54408,Repair multi-comp penis pros,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,54410,Remove/replace penis prosth,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,140.35","18,684.12",,,,,,
UHC MCR ADV,CPT,54411,Remov/replc penis pros comp,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,314.00","18,684.12",,,,,,
UHC MCR ADV,CPT,54415,Remove self-contd penis pros,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,54416,Remv/repl penis contain pros,APC 5378,RVU Per Case,"$18,684.12 ",OP,"4,314.00","18,684.12",,,,,,
UHC MCR ADV,CPT,54417,Remv/replc penis pros compl,APC 5377,RVU Per Case,"$11,755.91 ",OP,"4,314.00","11,755.91",,,,,,
UHC MCR ADV,CPT,54420,Revision of penis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,54430,Revision of penis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,54435,Revision of penis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,54437,Repair corporeal tear,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,54438,Replantation of penis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,54440,Repair of penis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,54450,Preputial stretching,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
UHC MCR ADV,CPT,54500,Biopsy of testis,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,54505,Biopsy of testis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,54512,Excise lesion testis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,54520,Removal of testis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,54522,Orchiectomy partial,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,54530,Removal of testis,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
UHC MCR ADV,CPT,54535,Extensive testis surgery,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,54550,Exploration for testis,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
UHC MCR ADV,CPT,54560,Exploration for testis,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,54600,Reduce testis torsion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,54620,Suspension of testis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,54640,Orchiopexy ingun/scrot appr,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
UHC MCR ADV,CPT,54650,Orchiopexy (fowler-stephens),APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
UHC MCR ADV,CPT,54660,Revision of testis,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,54670,Repair testis injury,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,54680,Relocation of testis(es),APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,54690,Laparoscopy orchiectomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,54692,Laparoscopy orchiopexy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,54699,Laparoscope proc testis,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,54700,Drainage of scrotum,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,54800,Biopsy of epididymis,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,54830,Remove epididymis lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,54840,Remove epididymis lesion,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,54860,Removal of epididymis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,54861,Removal of epididymis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,54865,Explore epididymis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,54900,Fusion of spermatic ducts,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,54901,Fusion of spermatic ducts,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,55000,Drainage of hydrocele,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,55040,Removal of hydrocele,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
UHC MCR ADV,CPT,55041,Removal of hydroceles,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
UHC MCR ADV,CPT,55060,Repair of hydrocele,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,55100,Drainage of scrotum abscess,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,55110,Explore scrotum,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,55120,Removal of scrotum lesion,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,55150,Removal of scrotum,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,55175,Revision of scrotum,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,55180,Revision of scrotum,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,55200,Incision of sperm duct,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,55250,Removal of sperm duct(s),APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,55400,Repair of sperm duct,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,55500,Removal of hydrocele,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,55520,Removal of sperm cord lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,55530,Revise spermatic cord veins,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,55535,Revise spermatic cord veins,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","4,314.00",,,,,,
UHC MCR ADV,CPT,55540,Revise hernia & sperm veins,APC 5341,RVU Per Case,"$3,257.65 ",OP,"3,257.65","9,201.00",,,,,,
UHC MCR ADV,CPT,55550,Laparo ligate spermatic vein,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,55559,Laparo proc spermatic cord,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,55600,Incise sperm duct pouch,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,55605,Incise sperm duct pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,55650,Remove sperm duct pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,55680,Remove sperm pouch lesion,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,55700,Biopsy of prostate,APC 5373,RVU Per Case,"$1,834.80 ",OP,"1,834.80","4,314.00",,,,,,
UHC MCR ADV,CPT,55705,Biopsy of prostate,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,55706,Prostate saturation sampling,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,55720,Drainage of prostate abscess,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,55725,Drainage of prostate abscess,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,55801,Removal of prostate,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,55810,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,55812,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,55815,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,55821,Removal of prostate,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,55831,Removal of prostate,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,55840,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,55842,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,55845,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,55860,Surgical exposure prostate,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,55862,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,55865,Extensive prostate surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,55866,Laparo radical prostatectomy,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
UHC MCR ADV,CPT,55870,Electroejaculation,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
UHC MCR ADV,CPT,55873,Cryoablate prostate,APC 5376,RVU Per Case,"$8,450.70 ",OP,"4,314.00","8,450.70",,,,,,
UHC MCR ADV,CPT,55874,Tprnl plmt biodegrdabl matrl,APC 5375,RVU Per Unit,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,55875,Transperi needle place pros,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,55876,Place rt device/marker pros,APC 5613,RVU Per Unit,"$1,291.62 ",OP,"1,291.62","4,314.00",,,,,,
UHC MCR ADV,CPT,55880,Abltj mal prst8 tiss hifu,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,314.00","4,516.83",,,,,,
UHC MCR ADV,CPT,55899,Genital surgery procedure,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,"4,314.00",,,,,,
UHC MCR ADV,CPT,55920,Place needles pelvic for rt,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
UHC MCR ADV,CPT,55970,Sex transformation m to f,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
UHC MCR ADV,CPT,55980,Sex transformation f to m,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","4,314.00",,,,,,
UHC MCR ADV,CPT,56405,I & d of vulva/perineum,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
UHC MCR ADV,CPT,56420,Drainage of gland abscess,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
UHC MCR ADV,CPT,56440,Surgery for vulva lesion,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,56441,Lysis of labial lesion(s),APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,56442,Hymenotomy,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,56501,Destroy vulva lesions sim,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,56515,Destroy vulva lesion/s compl,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","4,314.00",,,,,,
UHC MCR ADV,CPT,56605,Biopsy of vulva/perineum,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
UHC MCR ADV,CPT,56620,Partial removal of vulva,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,56625,Complete removal of vulva,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,56630,Extensive vulva surgery,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
UHC MCR ADV,CPT,56631,Extensive vulva surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,56632,Extensive vulva surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,56633,Extensive vulva surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,56634,Extensive vulva surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,56637,Extensive vulva surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,56640,Extensive vulva surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,56700,Partial removal of hymen,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,56740,Remove vagina gland lesion,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,56800,Repair of vagina,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,56805,Repair clitoris,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,56810,Repair of perineum,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,56820,Exam of vulva w/scope,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
UHC MCR ADV,CPT,56821,Exam/biopsy of vulva w/scope,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
UHC MCR ADV,CPT,57000,Exploration of vagina,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,57010,Drainage of pelvic abscess,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,57020,Drainage of pelvic fluid,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
UHC MCR ADV,CPT,57022,I & d vaginal hematoma pp,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,57023,I & d vag hematoma non-ob,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,57061,Destroy vag lesions simple,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,57065,Destroy vag lesions complex,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,57100,Biopsy of vagina,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
UHC MCR ADV,CPT,57105,Biopsy of vagina,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,57106,Remove vagina wall partial,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,57107,Remove vagina tissue part,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,57109,Vaginectomy partial w/nodes,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,57110,Remove vagina wall complete,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,57111,Remove vagina tissue compl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,57120,Closure of vagina,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
UHC MCR ADV,CPT,57130,Remove vagina lesion,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,57135,Remove vagina lesion,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,57150,Treat vagina infection,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
UHC MCR ADV,CPT,57155,Insert uteri tandem/ovoids,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
UHC MCR ADV,CPT,57156,Ins vag brachytx device,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
UHC MCR ADV,CPT,57160,Insert pessary/other device,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
UHC MCR ADV,CPT,57170,Fitting of diaphragm/cap,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
UHC MCR ADV,CPT,57180,Treat vaginal bleeding,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
UHC MCR ADV,CPT,57200,Repair of vagina,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,57210,Repair vagina/perineum,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,57220,Revision of urethra,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
UHC MCR ADV,CPT,57230,Repair of urethral lesion,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,57240,Anterior colporrhaphy,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
UHC MCR ADV,CPT,57250,Repair rectum & vagina,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
UHC MCR ADV,CPT,57260,Cmbn ant pst colprhy,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
UHC MCR ADV,CPT,57265,Cmbn ap colprhy w/ntrcl rpr,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
UHC MCR ADV,CPT,57268,Repair of bowel bulge,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
UHC MCR ADV,CPT,57270,Repair of bowel pouch,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,57280,Suspension of vagina,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,57282,Colpopexy extraperitoneal,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,57283,Colpopexy intraperitoneal,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,57284,Repair paravag defect open,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
UHC MCR ADV,CPT,57285,Repair paravag defect vag,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,57287,Revise/remove sling repair,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,57288,Repair bladder defect,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,57289,Repair bladder & vagina,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,314.00","6,952.74",,,,,,
UHC MCR ADV,CPT,57291,Construction of vagina,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
UHC MCR ADV,CPT,57292,Construct vagina with graft,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
UHC MCR ADV,CPT,57295,Revise vag graft via vagina,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,57296,Revise vag graft open abd,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,57300,Repair rectum-vagina fistula,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,57305,Repair rectum-vagina fistula,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,57307,Fistula repair & colostomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,57308,Fistula repair transperine,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,57310,Repair urethrovaginal lesion,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,314.00","6,952.74",,,,,,
UHC MCR ADV,CPT,57311,Repair urethrovaginal lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,57320,Repair bladder-vagina lesion,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
UHC MCR ADV,CPT,57330,Repair bladder-vagina lesion,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,314.00","6,952.74",,,,,,
UHC MCR ADV,CPT,57335,Repair vagina,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
UHC MCR ADV,CPT,57400,Dilation of vagina,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,57410,Pelvic examination,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,57415,Remove vaginal foreign body,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,57420,Exam of vagina w/scope,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
UHC MCR ADV,CPT,57421,Exam/biopsy of vag w/scope,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
UHC MCR ADV,CPT,57423,Repair paravag defect lap,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,314.00","9,115.38",,,,,,
UHC MCR ADV,CPT,57425,Laparoscopy surg colpopexy,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,57426,Revise prosth vag graft lap,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,314.00","6,952.74",,,,,,
UHC MCR ADV,CPT,57452,Exam of cervix w/scope,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
UHC MCR ADV,CPT,57454,Bx/curett of cervix w/scope,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
UHC MCR ADV,CPT,57455,Biopsy of cervix w/scope,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
UHC MCR ADV,CPT,57456,Endocerv curettage w/scope,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
UHC MCR ADV,CPT,57460,Bx of cervix w/scope leep,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,57461,Conz of cervix w/scope leep,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,57500,Biopsy of cervix,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
UHC MCR ADV,CPT,57505,Endocervical curettage,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
UHC MCR ADV,CPT,57510,Cauterization of cervix,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,57511,Cryocautery of cervix,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
UHC MCR ADV,CPT,57513,Laser surgery of cervix,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,57520,Conization of cervix,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,57522,Conization of cervix,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,57530,Removal of cervix,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
UHC MCR ADV,CPT,57531,Removal of cervix radical,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,57540,Removal of residual cervix,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,57545,Remove cervix/repair pelvis,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,57550,Removal of residual cervix,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
UHC MCR ADV,CPT,57555,Remove cervix/repair vagina,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
UHC MCR ADV,CPT,57556,Remove cervix repair bowel,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
UHC MCR ADV,CPT,57558,D&c of cervical stump,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,57700,Revision of cervix,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,57720,Revision of cervix,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,57800,Dilation of cervical canal,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,58100,Biopsy of uterus lining,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
UHC MCR ADV,CPT,58120,Dilation and curettage,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,58140,Myomectomy abdom method,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,58145,Myomectomy vag method,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","9,201.00",,,,,,
UHC MCR ADV,CPT,58146,Myomectomy abdom complex,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,58150,Total hysterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,58152,Total hysterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,58180,Partial hysterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,58200,Extensive hysterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,58210,Extensive hysterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,58240,Removal of pelvis contents,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,58260,Vaginal hysterectomy,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
UHC MCR ADV,CPT,58262,Vag hyst including t/o,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
UHC MCR ADV,CPT,58263,Vag hyst w/t/o & vag repair,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
UHC MCR ADV,CPT,58267,Vag hyst w/urinary repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,58270,Vag hyst w/enterocele repair,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
UHC MCR ADV,CPT,58275,Hysterectomy/revise vagina,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,58280,Hysterectomy/revise vagina,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,58285,Extensive hysterectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,58290,Vag hyst complex,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,314.00","6,952.74",,,,,,
UHC MCR ADV,CPT,58291,Vag hyst incl t/o complex,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
UHC MCR ADV,CPT,58292,Vag hyst t/o & repair compl,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,314.00","6,952.74",,,,,,
UHC MCR ADV,CPT,58294,Vag hyst w/enterocele compl,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
UHC MCR ADV,CPT,58301,Remove intrauterine device,APC 5412,RVU Per Case,$288.05 ,OP,288.05,"4,314.00",,,,,,
UHC MCR ADV,CPT,58321,Artificial insemination,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
UHC MCR ADV,CPT,58322,Artificial insemination,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
UHC MCR ADV,CPT,58323,Sperm washing,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
UHC MCR ADV,CPT,58345,Reopen fallopian tube,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,58346,Insert heyman uteri capsule,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
UHC MCR ADV,CPT,58350,Reopen fallopian tube,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
UHC MCR ADV,CPT,58353,Endometr ablate thermal,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
UHC MCR ADV,CPT,58356,Endometrial cryoablation,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
UHC MCR ADV,CPT,58400,Suspension of uterus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,58410,Suspension of uterus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,58520,Repair of ruptured uterus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,58540,Revision of uterus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,58541,Lsh uterus 250 g or less,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,58542,Lsh w/t/o ut 250 g or less,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,58543,Lsh uterus above 250 g,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,58544,Lsh w/t/o uterus above 250 g,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,58545,Laparoscopic myomectomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,58546,Laparo-myomectomy complex,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,58548,Lap radical hyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,58550,Laparo-asst vag hysterectomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,58552,Laparo-vag hyst incl t/o,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,58553,Laparo-vag hyst complex,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,58554,Laparo-vag hyst w/t/o compl,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,58555,Hysteroscopy dx sep proc,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,58558,Hysteroscopy biopsy,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","9,201.00",,,,,,
UHC MCR ADV,CPT,58559,Hysteroscopy lysis,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,58560,Hysteroscopy resect septum,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,58561,Hysteroscopy remove myoma,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,58562,Hysteroscopy remove fb,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,58563,Hysteroscopy ablation,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
UHC MCR ADV,CPT,58565,Hysteroscopy sterilization,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,58570,Tlh uterus 250 g or less,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,58571,Tlh w/t/o 250 g or less,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,58572,Tlh uterus over 250 g,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,58573,Tlh w/t/o uterus over 250 g,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,58575,Laps tot hyst resj mal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,58578,Laparo proc uterus,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,58579,Hysteroscope procedure,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
UHC MCR ADV,CPT,58600,Division of fallopian tube,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,58605,Division of fallopian tube,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,58611,Ligate oviduct(s) add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,58615,Occlude fallopian tube(s),APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,58660,Laparoscopy lysis,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,58661,Laparoscopy remove adnexa,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,58662,Laparoscopy excise lesions,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,58670,Laparoscopy tubal cautery,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,58671,Laparoscopy tubal block,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,58672,Laparoscopy fimbrioplasty,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,58673,Laparoscopy salpingostomy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,58674,Laps abltj uterine fibroids,APC 5362,RVU Per Case,"$9,115.38 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,58679,Laparo proc oviduct-ovary,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,58700,Removal of fallopian tube,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,58720,Removal of ovary/tube(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,58740,Adhesiolysis tube ovary,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,58750,Repair oviduct,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,58752,Revise ovarian tube(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,58760,Fimbrioplasty,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,58770,Create new tubal opening,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,58800,Drainage of ovarian cyst(s),APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,58805,Drainage of ovarian cyst(s),APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,58820,Drain ovary abscess open,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,58822,Drain ovary abscess percut,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,58825,Transposition ovary(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,58900,Biopsy of ovary(s),APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,58920,Partial removal of ovary(s),APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,314.00","6,952.74",,,,,,
UHC MCR ADV,CPT,58925,Removal of ovarian cyst(s),APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
UHC MCR ADV,CPT,58940,Removal of ovary(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,58943,Removal of ovary(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,58950,Resect ovarian malignancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,58951,Resect ovarian malignancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,58952,Resect ovarian malignancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,58953,Tah rad dissect for debulk,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,58954,Tah rad debulk/lymph remove,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,58956,Bso omentectomy w/tah,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,58957,Resect recurrent gyn mal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,58958,Resect recur gyn mal w/lym,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,58960,Exploration of abdomen,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,58970,Retrieval of oocyte,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
UHC MCR ADV,CPT,58974,Transfer of embryo,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
UHC MCR ADV,CPT,58976,Transfer of embryo,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
UHC MCR ADV,CPT,58999,Genital surgery procedure,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
UHC MCR ADV,CPT,59000,Amniocentesis diagnostic,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
UHC MCR ADV,CPT,59001,Amniocentesis therapeutic,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
UHC MCR ADV,CPT,59012,Fetal cord puncture prenatal,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
UHC MCR ADV,CPT,59015,Chorion biopsy,APC 5413,RVU Per Unit,$648.18 ,OP,648.18,"4,314.00",,,,,,
UHC MCR ADV,CPT,59020,Fetal contract stress test,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
UHC MCR ADV,CPT,59025,Fetal non-stress test,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
UHC MCR ADV,CPT,59030,Fetal scalp blood sample,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
UHC MCR ADV,CPT,59070,Transabdom amnioinfus w/us,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
UHC MCR ADV,CPT,59072,Umbilical cord occlud w/us,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
UHC MCR ADV,CPT,59074,Fetal fluid drainage w/us,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
UHC MCR ADV,CPT,59076,Fetal shunt placement w/us,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
UHC MCR ADV,CPT,59100,Remove uterus lesion,APC 5415,RVU Per Case,"$4,512.36 ",OP,"4,314.00","4,512.36",,,,,,
UHC MCR ADV,CPT,59120,Treat ectopic pregnancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,59121,Treat ectopic pregnancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,59130,Treat ectopic pregnancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,59135,Treat ectopic pregnancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,59136,Treat ectopic pregnancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,59140,Treat ectopic pregnancy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,59150,Treat ectopic pregnancy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,59151,Treat ectopic pregnancy,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,59160,D & c after delivery,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,59200,Insert cervical dilator,APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
UHC MCR ADV,CPT,59300,Episiotomy or vaginal repair,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,59320,Revision of cervix,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,59325,Revision of cervix,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,59350,Repair of uterus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,59409,Obstetrical care,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,59412,Antepartum manipulation,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,59414,Deliver placenta,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,59514,Cesarean delivery only,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,59525,Remove uterus after cesarean,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,59612,Vbac delivery only,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,59620,Attempted vbac delivery only,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,59812,Treatment of miscarriage,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,59820,Care of miscarriage,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,59821,Treatment of miscarriage,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,59830,Treat uterus infection,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,59840,Abortion,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,59841,Abortion,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,59850,Abortion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,59851,Abortion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,59852,Abortion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,59855,Abortion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,59856,Abortion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,59857,Abortion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,59866,Abortion (mpr),APC 5412,RVU Per Unit,$288.05 ,OP,288.05,"4,314.00",,,,,,
UHC MCR ADV,CPT,59870,Evacuate mole of uterus,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,59871,Remove cerclage suture,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","4,314.00",,,,,,
UHC MCR ADV,CPT,59897,Fetal invas px w/us,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
UHC MCR ADV,CPT,59898,Laparo proc ob care/deliver,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,59899,Maternity care procedure,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,"4,314.00",,,,,,
UHC MCR ADV,CPT,60000,Drain thyroid/tongue cyst,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,60100,Biopsy of thyroid,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,60200,Remove thyroid lesion,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,60210,Partial thyroid excision,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,60212,Partial thyroid excision,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,60220,Partial removal of thyroid,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,60225,Partial removal of thyroid,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,60240,Removal of thyroid,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,60252,Removal of thyroid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,60254,Extensive thyroid surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,60260,Repeat thyroid surgery,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,60270,Removal of thyroid,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,60271,Removal of thyroid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,60280,Remove thyroid duct lesion,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,60281,Remove thyroid duct lesion,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,60300,Aspir/inj thyroid cyst,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,60500,Explore parathyroid glands,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,60502,Re-explore parathyroids,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,60505,Explore parathyroid glands,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,60520,Removal of thymus gland,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,60521,Removal of thymus gland,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,60522,Removal of thymus gland,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,60540,Explore adrenal gland,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,60545,Explore adrenal gland,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,60600,Remove carotid body lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,60605,Remove carotid body lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,60650,Laparoscopy adrenalectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,60659,Laparo proc endocrine,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,60699,Endocrine surgery procedure,APC 5361,RVU Per Case,"$5,178.44 ",OP,"4,314.00","5,178.44",,,,,,
UHC MCR ADV,CPT,61000,Remove cranial cavity fluid,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,61001,Remove cranial cavity fluid,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,61020,Remove brain cavity fluid,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
UHC MCR ADV,CPT,61026,Injection into brain canal,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,61050,Remove brain canal fluid,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
UHC MCR ADV,CPT,61055,Injection into brain canal,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
UHC MCR ADV,CPT,61070,Brain canal shunt procedure,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,61105,Twist drill hole,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61107,Drill skull for implantation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61108,Drill skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61120,Burr hole for puncture,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61140,Pierce skull for biopsy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61150,Pierce skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61151,Pierce skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61154,Pierce skull & remove clot,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61156,Pierce skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61210,Pierce skull implant device,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61215,Insert brain-fluid device,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
UHC MCR ADV,CPT,61250,Pierce skull & explore,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61253,Pierce skull & explore,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61304,Open skull for exploration,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61305,Open skull for exploration,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61312,Open skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61313,Open skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61314,Open skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61315,Open skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61316,Implt cran bone flap to abdo,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61320,Open skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61321,Open skull for drainage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61322,Decompressive craniotomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61323,Decompressive lobectomy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61330,Decompress eye socket,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,61333,Explore orbit/remove lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61340,Subtemporal decompression,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61343,Incise skull (press relief),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61345,Relieve cranial pressure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61450,Incise skull for surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61458,Incise skull for brain wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61460,Incise skull for surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61500,Removal of skull lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61501,Remove infected skull bone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61510,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61512,Remove brain lining lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61514,Removal of brain abscess,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61516,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61517,Implt brain chemotx add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61518,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61519,Remove brain lining lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61520,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61521,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61522,Removal of brain abscess,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61524,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61526,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61530,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61531,Implant brain electrodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61533,Implant brain electrodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61534,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61535,Remove brain electrodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61536,Removal of brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61537,Removal of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61538,Removal of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61539,Removal of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61540,Removal of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61541,Incision of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61543,Removal of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61544,Remove & treat brain lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61545,Excision of brain tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61546,Removal of pituitary gland,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61548,Removal of pituitary gland,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61550,Release of skull seams,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61552,Release of skull seams,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61556,Incise skull/sutures,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61557,Incise skull/sutures,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61558,Excision of skull/sutures,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61559,Excision of skull/sutures,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61563,Excision of skull tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61564,Excision of skull tumor,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61566,Removal of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61567,Incision of brain tissue,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61570,Remove foreign body brain,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61571,Incise skull for brain wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61575,Skull base/brainstem surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61576,Skull base/brainstem surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61580,Craniofacial approach skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61581,Craniofacial approach skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61582,Craniofacial approach skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61583,Craniofacial approach skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61584,Orbitocranial approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61585,Orbitocranial approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61586,Resect nasopharynx skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61590,Infratemporal approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61591,Infratemporal approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61592,Orbitocranial approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61595,Transtemporal approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61596,Transcochlear approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61597,Transcondylar approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61598,Transpetrosal approach/skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61600,Resect/excise cranial lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61601,Resect/excise cranial lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61605,Resect/excise cranial lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61606,Resect/excise cranial lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61607,Resect/excise cranial lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61608,Resect/excise cranial lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61611,Transect artery sinus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61613,Remove aneurysm sinus,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61615,Resect/excise lesion skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61616,Resect/excise lesion skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61618,Repair dura,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61619,Repair dura,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61623,Endovasc tempory vessel occl,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
UHC MCR ADV,CPT,61624,Transcath occlusion cns,APC 5194,RVU Per Case,"$16,438.60 ",OP,"4,314.00","16,438.60",,,,,,
UHC MCR ADV,CPT,61626,Transcath occlusion non-cns,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,314.00","10,277.14",,,,,,
UHC MCR ADV,CPT,61630,Intracranial angioplasty,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61635,Intracran angioplsty w/stent,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61645,Perq art m-thrombect &/nfs,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61650,Evasc prlng admn rx agnt 1st,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61651,Evasc prlng admn rx agnt add,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61680,Intracranial vessel surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61682,Intracranial vessel surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61684,Intracranial vessel surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61686,Intracranial vessel surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61690,Intracranial vessel surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61692,Intracranial vessel surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61697,Brain aneurysm repr complx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61698,Brain aneurysm repr complx,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61700,Brain aneurysm repr simple,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61702,Inner skull vessel surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61703,Clamp neck artery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61705,Revise circulation to head,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61708,Revise circulation to head,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61710,Revise circulation to head,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61711,Fusion of skull arteries,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61720,Incise skull/brain surgery,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
UHC MCR ADV,CPT,61735,Incise skull/brain surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61750,Incise skull/brain biopsy,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61751,Brain biopsy w/ct/mr guide,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61760,Implant brain electrodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61770,Incise skull for treatment,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
UHC MCR ADV,CPT,61790,Treat trigeminal nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,61791,Treat trigeminal tract,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,61850,Implant neuroelectrodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61860,Implant neuroelectrodes,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61863,Implant neuroelectrode,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61864,Implant neuroelectrde addl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61867,Implant neuroelectrode,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61868,Implant neuroelectrde addl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,61880,Revise/remove neuroelectrode,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","4,314.00",,,,,,
UHC MCR ADV,CPT,61885,Insrt/redo neurostim 1 array,APC 5464,RVU Per Case,"$20,957.35 ",OP,"4,140.35","20,957.35",,,,,,
UHC MCR ADV,CPT,61886,Implant neurostim arrays,APC 5465,RVU Per Case,"$30,131.14 ",OP,"4,314.00","30,131.14",,,,,,
UHC MCR ADV,CPT,61888,Revise/remove neuroreceiver,APC 5463,RVU Per Case,"$11,498.23 ",OP,"4,314.00","11,498.23",,,,,,
UHC MCR ADV,CPT,62000,Treat skull fracture,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,62005,Treat skull fracture,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,62010,Treatment of head injury,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,62100,Repair brain fluid leakage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,62115,Reduction of skull defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,62117,Reduction of skull defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,62120,Repair skull cavity lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,62121,Incise skull repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,62140,Repair of skull defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,62141,Repair of skull defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,62142,Remove skull plate/flap,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,62143,Replace skull plate/flap,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,62145,Repair of skull & brain,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,62146,Repair of skull with graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,62147,Repair of skull with graft,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,62148,Retr bone flap to fix skull,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,62161,Dissect brain w/scope,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,62162,Remove colloid cyst w/scope,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,62164,Remove brain tumor w/scope,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,62165,Remove pituit tumor w/scope,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,62180,Establish brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,62190,Establish brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,62192,Establish brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,62194,Replace/irrigate catheter,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,62200,Establish brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,62201,Brain cavity shunt w/scope,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,62220,Establish brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,62223,Establish brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,62225,Replace/irrigate catheter,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
UHC MCR ADV,CPT,62230,Replace/revise brain shunt,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
UHC MCR ADV,CPT,62252,Csf shunt reprogram,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,"4,314.00",,,,,,
UHC MCR ADV,CPT,62256,Remove brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,62258,Replace brain cavity shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,62263,Epidural lysis mult sessions,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
UHC MCR ADV,CPT,62264,Epidural lysis on single day,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
UHC MCR ADV,CPT,62267,Interdiscal perq aspir dx,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,62268,Drain spinal cord cyst,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
UHC MCR ADV,CPT,62269,Needle biopsy spinal cord,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,62270,Dx lmbr spi pnxr,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,62272,Ther spi pnxr drg csf,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,62273,Inject epidural patch,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,62280,Treat spinal cord lesion,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
UHC MCR ADV,CPT,62281,Treat spinal cord lesion,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
UHC MCR ADV,CPT,62282,Treat spinal canal lesion,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
UHC MCR ADV,CPT,62287,Percutaneous diskectomy,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,62292,Njx chemonucleolysis lmbr,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,62294,Injection into spinal artery,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
UHC MCR ADV,CPT,62302,Myelography lumbar injection,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"4,314.00",,,,,,
UHC MCR ADV,CPT,62303,Myelography lumbar injection,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"4,314.00",,,,,,
UHC MCR ADV,CPT,62304,Myelography lumbar injection,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"4,314.00",,,,,,
UHC MCR ADV,CPT,62305,Myelography lumbar injection,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"4,314.00",,,,,,
UHC MCR ADV,CPT,62320,Njx interlaminar crv/thrc,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,62321,Njx interlaminar crv/thrc,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,62322,Njx interlaminar lmbr/sac,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,62323,Njx interlaminar lmbr/sac,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,62324,Njx interlaminar crv/thrc,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
UHC MCR ADV,CPT,62325,Njx interlaminar crv/thrc,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
UHC MCR ADV,CPT,62326,Njx interlaminar lmbr/sac,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
UHC MCR ADV,CPT,62327,Njx interlaminar lmbr/sac,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
UHC MCR ADV,CPT,62328,Dx lmbr spi pnxr w/fluor/ct,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,62329,Ther spi pnxr csf fluor/ct,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,62350,Implant spinal canal cath,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
UHC MCR ADV,CPT,62351,Implant spinal canal cath,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,62355,Remove spinal canal catheter,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,62360,Insert spine infusion device,APC 5471,RVU Per Case,"$17,429.07 ",OP,"4,314.00","17,429.07",,,,,,
UHC MCR ADV,CPT,62361,Implant spine infusion pump,APC 5471,RVU Per Case,"$17,429.07 ",OP,"4,314.00","17,429.07",,,,,,
UHC MCR ADV,CPT,62362,Implant spine infusion pump,APC 5471,RVU Per Case,"$17,429.07 ",OP,"4,140.35","17,429.07",,,,,,
UHC MCR ADV,CPT,62365,Remove spine infusion device,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
UHC MCR ADV,CPT,62367,Analyze spine infus pump,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,"4,314.00",,,,,,
UHC MCR ADV,CPT,62368,Analyze sp inf pump w/reprog,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,"4,314.00",,,,,,
UHC MCR ADV,CPT,62369,Anal sp inf pmp w/reprg&fill,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,"4,314.00",,,,,,
UHC MCR ADV,CPT,62370,Anl sp inf pmp w/mdreprg&fil,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,"4,314.00",,,,,,
UHC MCR ADV,CPT,62380,Ndsc dcmprn 1 ntrspc lumbar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,63001,Remove spine lamina 1/2 crvl,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,63003,Remove spine lamina 1/2 thrc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,63005,Remove spine lamina 1/2 lmbr,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,63011,Remove spine lamina 1/2 scrl,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,63012,Remove lamina/facets lumbar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,63015,Remove spine lamina >2 crvcl,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,63016,Remove spine lamina >2 thrc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,63017,Remove spine lamina >2 lmbr,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,63020,Neck spine disk surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,63030,Low back disk surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,63040,Laminotomy single cervical,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,63042,Laminotomy single lumbar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,63045,Remove spine lamina 1 crvl,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,63046,Remove spine lamina 1 thrc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,63047,Remove spine lamina 1 lmbr,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,63050,Cervical laminoplsty 2/> seg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63051,C-laminoplasty w/graft/plate,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63055,Decompress spinal cord thrc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,63056,Decompress spinal cord lmbr,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,63064,Decompress spinal cord thrc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,63075,Neck spine disk surgery,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,63077,Spine disk surgery thorax,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63078,Spine disk surgery thorax,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63081,Remove vert body dcmprn crvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63082,Remove vertebral body add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63085,Remove vert body dcmprn thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63086,Remove vertebral body add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63087,Remov vertbr dcmprn thrclmbr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63088,Remove vertebral body add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63090,Remove vert body dcmprn lmbr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63091,Remove vertebral body add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63101,Remove vert body dcmprn thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63102,Remove vert body dcmprn lmbr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63103,Remove vertebral body add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63170,Incise spinal cord tract(s),APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63172,Drainage of spinal cyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63173,Drainage of spinal cyst,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63185,Incise spine nrv half segmnt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63190,Incise spine nrv >2 segmnts,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63191,Incise spine accessory nerve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63194,Incise spine & cord cervical,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63195,Incise spine & cord thoracic,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63196,Incise spine&cord 2 trx crvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63197,Incise spine&cord 2 trx thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63198,Incise spin&cord 2 stgs crvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63199,Incise spin&cord 2 stgs thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63200,Release spinal cord lumbar,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63250,Revise spinal cord vsls crvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63251,Revise spinal cord vsls thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63252,Revise spine cord vsl thrlmb,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63265,Excise intraspinl lesion crv,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,63266,Excise intrspinl lesion thrc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,63267,Excise intrspinl lesion lmbr,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,63268,Excise intrspinl lesion scrl,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,63270,Excise intrspinl lesion crvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63271,Excise intrspinl lesion thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63272,Excise intrspinl lesion lmbr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63273,Excise intrspinl lesion scrl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63275,Bx/exc xdrl spine lesn crvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63276,Bx/exc xdrl spine lesn thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63277,Bx/exc xdrl spine lesn lmbr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63278,Bx/exc xdrl spine lesn scrl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63280,Bx/exc idrl spine lesn crvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63281,Bx/exc idrl spine lesn thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63282,Bx/exc idrl spine lesn lmbr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63283,Bx/exc idrl spine lesn scrl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63285,Bx/exc idrl imed lesn cervl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63286,Bx/exc idrl imed lesn thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63287,Bx/exc idrl imed lesn thrlmb,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63290,Bx/exc xdrl/idrl lsn any lvl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63295,Repair laminectomy defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63300,Remove vert xdrl body crvcl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63301,Remove vert xdrl body thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63302,Remove vert xdrl body thrlmb,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63303,Remov vert xdrl bdy lmbr/sac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63304,Remove vert idrl body crvcl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63305,Remove vert idrl body thrc,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63306,Remov vert idrl bdy thrclmbr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63307,Remov vert idrl bdy lmbr/sac,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63308,Remove vertebral body add-on,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63600,Remove spinal cord lesion,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,63610,Stimulation of spinal cord,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,63650,Implant neuroelectrodes,APC 5462,RVU Per Case,"$6,304.35 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,63655,Implant neuroelectrodes,APC 5464,RVU Per Case,"$20,957.35 ",OP,"4,140.35","20,957.35",,,,,,
UHC MCR ADV,CPT,63661,Remove spine eltrd perq aray,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,63662,Remove spine eltrd plate,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","4,314.00",,,,,,
UHC MCR ADV,CPT,63663,Revise spine eltrd perq aray,APC 5462,RVU Per Case,"$6,304.35 ",OP,"4,314.00","6,304.35",,,,,,
UHC MCR ADV,CPT,63664,Revise spine eltrd plate,APC 5463,RVU Per Case,"$11,498.23 ",OP,"4,314.00","11,498.23",,,,,,
UHC MCR ADV,CPT,63685,Insrt/redo spine n generator,APC 5465,RVU Per Case,"$30,131.14 ",OP,"4,140.35","30,131.14",,,,,,
UHC MCR ADV,CPT,63688,Revise/remove neuroreceiver,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","4,314.00",,,,,,
UHC MCR ADV,CPT,63700,Repair of spinal herniation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63702,Repair of spinal herniation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63704,Repair of spinal herniation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63706,Repair of spinal herniation,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63707,Repair spinal fluid leakage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63709,Repair spinal fluid leakage,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63710,Graft repair of spine defect,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63740,Install spinal shunt,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,63741,Install spinal shunt,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
UHC MCR ADV,CPT,63744,Revision of spinal shunt,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
UHC MCR ADV,CPT,63746,Removal of spinal shunt,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,64400,Njx aa&/strd trigeminal nrv,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
UHC MCR ADV,CPT,64405,Njx aa&/strd gr ocpl nrv,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
UHC MCR ADV,CPT,64408,Njx aa&/strd vagus nrv,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
UHC MCR ADV,CPT,64415,Njx aa&/strd brach plexus,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
UHC MCR ADV,CPT,64416,Njx aa&/strd brach plex nfs,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
UHC MCR ADV,CPT,64417,Njx aa&/strd axillary nrv,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
UHC MCR ADV,CPT,64418,Njx aa&/strd sprscap nrv,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,64420,Njx aa&/strd ntrcost nrv 1,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,64421,Njx aa&/strd ntrcost nrv ea,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
UHC MCR ADV,CPT,64425,Njx aa&/strd ii ih nerves,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,64430,Njx aa&/strd pudendal nerve,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
UHC MCR ADV,CPT,64435,Njx aa&/strd paracrv nrv,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,64445,Njx aa&/strd sciatic nerve,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,64446,Njx aa&/strd sciatic nrv nfs,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
UHC MCR ADV,CPT,64447,Njx aa&/strd femoral nerve,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,64448,Njx aa&/strd fem nerve nfs,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
UHC MCR ADV,CPT,64449,Njx aa&/strd lmbr plex nfs,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
UHC MCR ADV,CPT,64450,Njx aa&/strd other pn/branch,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,64451,Njx aa&/strd nrv nrvtg si jt,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,64454,Njx aa&/strd gnclr nrv brnch,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,64455,Njx aa&/strd pltr com dg nrv,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
UHC MCR ADV,CPT,64461,Pvb thoracic single inj site,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,64463,Pvb thoracic cont infusion,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,64479,Njx aa&/strd tfrm epi c/t 1,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
UHC MCR ADV,CPT,64483,Njx aa&/strd tfrm epi l/s 1,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
UHC MCR ADV,CPT,64490,Inj paravert f jnt c/t 1 lev,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
UHC MCR ADV,CPT,64493,Inj paravert f jnt l/s 1 lev,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
UHC MCR ADV,CPT,64505,N block spenopalatine gangl,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
UHC MCR ADV,CPT,64510,N block stellate ganglion,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
UHC MCR ADV,CPT,64517,N block inj hypogas plxs,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
UHC MCR ADV,CPT,64520,N block lumbar/thoracic,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
UHC MCR ADV,CPT,64530,N block inj celiac pelus,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
UHC MCR ADV,CPT,64553,Implant neuroelectrodes,APC 5463,RVU Per Case,"$11,498.23 ",OP,"4,314.00","11,498.23",,,,,,
UHC MCR ADV,CPT,64555,Implant neuroelectrodes,APC 5462,RVU Per Case,"$6,304.35 ",OP,"4,314.00","6,304.35",,,,,,
UHC MCR ADV,CPT,64561,Implant neuroelectrodes,APC 5462,RVU Per Case,"$6,304.35 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,64566,Neuroeltrd stim post tibial,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
UHC MCR ADV,CPT,64568,Inc for vagus n elect impl,APC 5465,RVU Per Case,"$30,131.14 ",OP,"4,140.35","30,131.14",,,,,,
UHC MCR ADV,CPT,64569,Revise/repl vagus n eltrd,APC 5463,RVU Per Case,"$11,498.23 ",OP,"4,314.00","11,498.23",,,,,,
UHC MCR ADV,CPT,64570,Remove vagus n eltrd,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
UHC MCR ADV,CPT,64575,Implant neuroelectrodes,APC 5463,RVU Per Case,"$11,498.23 ",OP,"4,314.00","11,498.23",,,,,,
UHC MCR ADV,CPT,64580,Implant neuroelectrodes,APC 5464,RVU Per Case,"$20,957.35 ",OP,"4,314.00","20,957.35",,,,,,
UHC MCR ADV,CPT,64581,Implant neuroelectrodes,APC 5462,RVU Per Case,"$6,304.35 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,64585,Revise/remove neuroelectrode,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","4,314.00",,,,,,
UHC MCR ADV,CPT,64590,Insrt/redo pn/gastr stimul,APC 5464,RVU Per Case,"$20,957.35 ",OP,"4,140.35","20,957.35",,,,,,
UHC MCR ADV,CPT,64595,Revise/rmv pn/gastr stimul,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","4,314.00",,,,,,
UHC MCR ADV,CPT,64600,Injection treatment of nerve,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
UHC MCR ADV,CPT,64605,Injection treatment of nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,64610,Injection treatment of nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,64611,Chemodenerv saliv glands,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
UHC MCR ADV,CPT,64612,Destroy nerve face muscle,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
UHC MCR ADV,CPT,64615,Chemodenerv musc migraine,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
UHC MCR ADV,CPT,64616,Chemodenerv musc neck dyston,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
UHC MCR ADV,CPT,64617,Chemodener muscle larynx emg,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
UHC MCR ADV,CPT,64620,Injection treatment of nerve,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
UHC MCR ADV,CPT,64624,Dstrj nulyt agt gnclr nrv,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,64625,Rf abltj nrv nrvtg si jt,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,64630,Injection treatment of nerve,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
UHC MCR ADV,CPT,64632,N block inj common digit,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
UHC MCR ADV,CPT,64633,Destroy cerv/thor facet jnt,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,64635,Destroy lumb/sac facet jnt,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,64640,Injection treatment of nerve,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
UHC MCR ADV,CPT,64642,Chemodenerv 1 extremity 1-4,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,64644,Chemodenerv 1 extrem 5/> mus,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,64646,Chemodenerv trunk musc 1-5,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,64647,Chemodenerv trunk musc 6/>,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,"4,314.00",,,,,,
UHC MCR ADV,CPT,64650,Chemodenerv eccrine glands,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
UHC MCR ADV,CPT,64653,Chemodenerv eccrine glands,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
UHC MCR ADV,CPT,64680,Injection treatment of nerve,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
UHC MCR ADV,CPT,64681,Injection treatment of nerve,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,"4,314.00",,,,,,
UHC MCR ADV,CPT,64702,Revise finger/toe nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,64704,Revise hand/foot nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,64708,Revise arm/leg nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,64712,Revision of sciatic nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,64713,Revision of arm nerve(s),APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,64714,Revise low back nerve(s),APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,64716,Revision of cranial nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,64718,Revise ulnar nerve at elbow,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,64719,Revise ulnar nerve at wrist,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,64721,Carpal tunnel surgery,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,64722,Relieve pressure on nerve(s),APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,64726,Release foot/toe nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,64732,Incision of brow nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,64734,Incision of cheek nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,64736,Incision of chin nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,64738,Incision of jaw nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,64740,Incision of tongue nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,64742,Incision of facial nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,64744,Incise nerve back of head,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,64746,Incise diaphragm nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,64755,Incision of stomach nerves,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,64760,Incision of vagus nerve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,64763,Incise hip/thigh nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,64766,Incise hip/thigh nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,64771,Sever cranial nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,64772,Incision of spinal nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,64774,Remove skin nerve lesion,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,64776,Remove digit nerve lesion,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,64782,Remove limb nerve lesion,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,64784,Remove nerve lesion,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,64786,Remove sciatic nerve lesion,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
UHC MCR ADV,CPT,64788,Remove skin nerve lesion,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,64790,Removal of nerve lesion,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,64792,Removal of nerve lesion,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
UHC MCR ADV,CPT,64795,Biopsy of nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,64802,Sympathectomy cervical,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,64804,Remove sympathetic nerves,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,64809,Remove sympathetic nerves,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,64818,Remove sympathetic nerves,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,64820,Sympathectomy digital artery,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,64821,Remove sympathetic nerves,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,64822,Remove sympathetic nerves,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,64823,Sympathectomy supfc palmar,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","4,314.00",,,,,,
UHC MCR ADV,CPT,64831,Repair of digit nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,64834,Repair of hand or foot nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
UHC MCR ADV,CPT,64835,Repair of hand or foot nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
UHC MCR ADV,CPT,64836,Repair of hand or foot nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
UHC MCR ADV,CPT,64840,Repair of leg nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
UHC MCR ADV,CPT,64856,Repair/transpose nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
UHC MCR ADV,CPT,64857,Repair arm/leg nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
UHC MCR ADV,CPT,64858,Repair sciatic nerve,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,64861,Repair of arm nerves,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","4,314.00",,,,,,
UHC MCR ADV,CPT,64862,Repair of low back nerves,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
UHC MCR ADV,CPT,64864,Repair of facial nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
UHC MCR ADV,CPT,64865,Repair of facial nerve,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
UHC MCR ADV,CPT,64866,Fusion of facial/other nerve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,64868,Fusion of facial/other nerve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,64885,Nerve graft head/neck </4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
UHC MCR ADV,CPT,64886,Nerve graft head/neck >4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
UHC MCR ADV,CPT,64890,Nerve graft hand/foot </4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
UHC MCR ADV,CPT,64891,Nerve graft hand/foot >4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
UHC MCR ADV,CPT,64892,Nerve graft arm/leg <4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
UHC MCR ADV,CPT,64893,Nerve graft arm/leg >4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
UHC MCR ADV,CPT,64895,Nerve graft hand/foot </4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
UHC MCR ADV,CPT,64896,Nerve graft hand/foot >4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
UHC MCR ADV,CPT,64897,Nerve graft arm/leg </4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
UHC MCR ADV,CPT,64898,Nerve graft arm/leg >4 cm,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
UHC MCR ADV,CPT,64905,Nerve pedicle transfer,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
UHC MCR ADV,CPT,64907,Nerve pedicle transfer,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
UHC MCR ADV,CPT,64910,Nerve repair w/allograft,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
UHC MCR ADV,CPT,64911,Neurorraphy w/vein autograft,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
UHC MCR ADV,CPT,64912,Nrv rpr w/nrv algrft 1st,APC 5432,RVU Per Case,"$5,833.22 ",OP,"4,314.00","5,833.22",,,,,,
UHC MCR ADV,CPT,64999,Nervous system surgery,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,"4,314.00",,,,,,
UHC MCR ADV,CPT,65091,Revise eye,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,65093,Revise eye with implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,65101,Removal of eye,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,65103,Remove eye/insert implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,65105,Remove eye/attach implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,65110,Removal of eye,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,65112,Remove eye/revise socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,65114,Remove eye/revise socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,65125,Revise ocular implant,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,65130,Insert ocular implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,65135,Insert ocular implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,65140,Attach ocular implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,65150,Revise ocular implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,65155,Reinsert ocular implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,65175,Removal of ocular implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,65205,Remove foreign body from eye,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
UHC MCR ADV,CPT,65210,Remove foreign body from eye,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
UHC MCR ADV,CPT,65220,Remove foreign body from eye,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
UHC MCR ADV,CPT,65222,Remove foreign body from eye,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
UHC MCR ADV,CPT,65235,Remove foreign body from eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,65260,Remove foreign body from eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,65265,Remove foreign body from eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,65270,Repair of eye wound,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,65272,Repair of eye wound,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,65273,Repair of eye wound,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,65275,Repair of eye wound,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,65280,Repair of eye wound,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
UHC MCR ADV,CPT,65285,Repair of eye wound,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
UHC MCR ADV,CPT,65286,Repair of eye wound,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,65290,Repair of eye socket wound,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,65400,Removal of eye lesion,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
UHC MCR ADV,CPT,65410,Biopsy of cornea,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,65420,Removal of eye lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,65426,Removal of eye lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,65430,Corneal smear,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
UHC MCR ADV,CPT,65435,Curette/treat cornea,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
UHC MCR ADV,CPT,65436,Curette/treat cornea,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,65450,Treatment of corneal lesion,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
UHC MCR ADV,CPT,65600,Revision of cornea,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,65710,Corneal transplant,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
UHC MCR ADV,CPT,65730,Corneal transplant,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","9,201.00",,,,,,
UHC MCR ADV,CPT,65750,Corneal transplant,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
UHC MCR ADV,CPT,65755,Corneal transplant,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
UHC MCR ADV,CPT,65756,Corneal trnspl endothelial,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","9,201.00",,,,,,
UHC MCR ADV,CPT,65770,Revise cornea with implant,APC 5493,RVU Per Case,"$7,506.93 ",OP,"4,314.00","7,506.93",,,,,,
UHC MCR ADV,CPT,65772,Correction of astigmatism,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
UHC MCR ADV,CPT,65775,Correction of astigmatism,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,65778,Cover eye w/membrane,APC 5502,RVU Per Case,$828.42 ,OP,828.42,"4,314.00",,,,,,
UHC MCR ADV,CPT,65779,Cover eye w/membrane suture,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,65780,Ocular reconst transplant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,65781,Ocular reconst transplant,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
UHC MCR ADV,CPT,65782,Ocular reconst transplant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,65785,Impltj ntrstrml crnl rng seg,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
UHC MCR ADV,CPT,65800,Drainage of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,65810,Drainage of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,65815,Drainage of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,65820,Relieve inner eye pressure,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
UHC MCR ADV,CPT,65850,Incision of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,65855,Trabeculoplasty laser surg,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
UHC MCR ADV,CPT,65860,Incise inner eye adhesions,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
UHC MCR ADV,CPT,65865,Incise inner eye adhesions,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,65870,Incise inner eye adhesions,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,65875,Incise inner eye adhesions,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,65880,Incise inner eye adhesions,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
UHC MCR ADV,CPT,65900,Remove eye lesion,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,65920,Remove implant of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,65930,Remove blood clot from eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,66020,Injection treatment of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,66030,Injection treatment of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,66130,Remove eye lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,66150,Glaucoma surgery,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
UHC MCR ADV,CPT,66155,Glaucoma surgery,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
UHC MCR ADV,CPT,66160,Glaucoma surgery,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,66170,Glaucoma surgery,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,66172,Incision of eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,66174,Translum dil eye canal,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
UHC MCR ADV,CPT,66175,Trnslum dil eye canal w/stnt,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
UHC MCR ADV,CPT,66179,Aqueous shunt eye w/o graft,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
UHC MCR ADV,CPT,66180,Aqueous shunt eye w/graft,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","9,201.00",,,,,,
UHC MCR ADV,CPT,66183,Insert ant drainage device,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
UHC MCR ADV,CPT,66184,Revision of aqueous shunt,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,66185,Revise aqueous shunt eye,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,66225,Repair/graft eye lesion,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
UHC MCR ADV,CPT,66250,Follow-up surgery of eye,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,66500,Incision of iris,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,66505,Incision of iris,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,66600,Remove iris and lesion,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
UHC MCR ADV,CPT,66605,Removal of iris,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,66625,Removal of iris,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,66630,Removal of iris,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,66635,Removal of iris,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,66680,Repair iris & ciliary body,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,66682,Repair iris & ciliary body,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,66700,Destruction ciliary body,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,66710,Ciliary transsleral therapy,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,66711,Ecp ciliary body destruction,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,66720,Destruction ciliary body,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,66740,Destruction ciliary body,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,66761,Revision of iris,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
UHC MCR ADV,CPT,66762,Revision of iris,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
UHC MCR ADV,CPT,66770,Removal of inner eye lesion,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
UHC MCR ADV,CPT,66820,Incision secondary cataract,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,66821,After cataract laser surgery,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
UHC MCR ADV,CPT,66825,Reposition intraocular lens,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,66830,Removal of lens lesion,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,66840,Removal of lens material,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,66850,Removal of lens material,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,66852,Removal of lens material,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
UHC MCR ADV,CPT,66920,Extraction of lens,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,66930,Extraction of lens,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
UHC MCR ADV,CPT,66940,Extraction of lens,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,66982,Xcapsl ctrc rmvl cplx wo ecp,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,66983,Cataract surg w/iol 1 stage,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,66984,Xcapsl ctrc rmvl w/o ecp,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,66985,Insert lens prosthesis,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,66986,Exchange lens prosthesis,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,66987,Xcapsl ctrc rmvl cplx w/ecp,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
UHC MCR ADV,CPT,66988,Xcapsl ctrc rmvl w/ecp,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
UHC MCR ADV,CPT,66999,Eye surgery procedure,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,67005,Partial removal of eye fluid,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,67010,Partial removal of eye fluid,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,67015,Release of eye fluid,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,67025,Replace eye fluid,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,67027,Implant eye drug system,APC 5494,RVU Per Case,"$15,359.39 ",OP,"4,314.00","15,359.39",,,,,,
UHC MCR ADV,CPT,67028,Injection eye drug,APC 5694,RVU Per Unit,$318.00 ,OP,318,"4,314.00",,,,,,
UHC MCR ADV,CPT,67030,Incise inner eye strands,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,67031,Laser surgery eye strands,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
UHC MCR ADV,CPT,67036,Removal of inner eye fluid,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
UHC MCR ADV,CPT,67039,Laser treatment of retina,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
UHC MCR ADV,CPT,67040,Laser treatment of retina,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
UHC MCR ADV,CPT,67041,Vit for macular pucker,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
UHC MCR ADV,CPT,67042,Vit for macular hole,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
UHC MCR ADV,CPT,67043,Vit for membrane dissect,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
UHC MCR ADV,CPT,67101,Repair detached retina crtx,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,67105,Repair detached retina pc,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
UHC MCR ADV,CPT,67107,Repair detached retina,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
UHC MCR ADV,CPT,67108,Repair detached retina,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","9,201.00",,,,,,
UHC MCR ADV,CPT,67110,Repair detached retina,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,67113,Repair retinal detach cplx,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","9,201.00",,,,,,
UHC MCR ADV,CPT,67115,Release encircling material,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,314.00",,,,,,
UHC MCR ADV,CPT,67120,Remove eye implant material,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,67121,Remove eye implant material,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,67141,Treatment of retina,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
UHC MCR ADV,CPT,67145,Treatment of retina,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
UHC MCR ADV,CPT,67208,Treatment of retinal lesion,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
UHC MCR ADV,CPT,67210,Treatment of retinal lesion,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
UHC MCR ADV,CPT,67218,Treatment of retinal lesion,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,67220,Treatment of choroid lesion,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
UHC MCR ADV,CPT,67221,Ocular photodynamic ther,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
UHC MCR ADV,CPT,67227,Dstrj extensive retinopathy,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,67228,Treatment x10sv retinopathy,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
UHC MCR ADV,CPT,67229,Tr retinal les preterm inf,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,"4,314.00",,,,,,
UHC MCR ADV,CPT,67250,Reinforce eye wall,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,67255,Reinforce/graft eye wall,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,67299,Eye surgery procedure,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,67311,Revise eye muscle,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,67312,Revise two eye muscles,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,67314,Revise eye muscle,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,67316,Revise two eye muscles,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,67318,Revise eye muscle(s),APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,67343,Release eye tissue,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,67345,Destroy nerve of eye muscle,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
UHC MCR ADV,CPT,67346,Biopsy eye muscle,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,67399,Unlisted px extraocular musc,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
UHC MCR ADV,CPT,67400,Explore/biopsy eye socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,67405,Explore/drain eye socket,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,67412,Explore/treat eye socket,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,67413,Explore/treat eye socket,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,67414,Explr/decompress eye socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,67415,Aspiration orbital contents,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,67420,Explore/treat eye socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,67430,Explore/treat eye socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,67440,Explore/drain eye socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,67445,Explr/decompress eye socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,67450,Explore/biopsy eye socket,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,67500,Inject/treat eye socket,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
UHC MCR ADV,CPT,67505,Inject/treat eye socket,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
UHC MCR ADV,CPT,67515,Inject/treat eye socket,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
UHC MCR ADV,CPT,67550,Insert eye socket implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,67560,Revise eye socket implant,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,67570,Decompress optic nerve,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,67599,Orbit surgery procedure,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
UHC MCR ADV,CPT,67700,Drainage of eyelid abscess,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
UHC MCR ADV,CPT,67710,Incision of eyelid,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
UHC MCR ADV,CPT,67715,Incision of eyelid fold,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,67800,Remove eyelid lesion,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
UHC MCR ADV,CPT,67801,Remove eyelid lesions,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
UHC MCR ADV,CPT,67805,Remove eyelid lesions,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
UHC MCR ADV,CPT,67808,Remove eyelid lesion(s),APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,67810,Biopsy eyelid & lid margin,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
UHC MCR ADV,CPT,67820,Revise eyelashes,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
UHC MCR ADV,CPT,67825,Revise eyelashes,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
UHC MCR ADV,CPT,67830,Revise eyelashes,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
UHC MCR ADV,CPT,67835,Revise eyelashes,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,67840,Remove eyelid lesion,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
UHC MCR ADV,CPT,67850,Treat eyelid lesion,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
UHC MCR ADV,CPT,67875,Closure of eyelid by suture,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
UHC MCR ADV,CPT,67880,Revision of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,67882,Revision of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,67900,Repair brow defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,67901,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,67902,Repair eyelid defect,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,67903,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,67904,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,67906,Repair eyelid defect,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,67908,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,67909,Revise eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,67911,Revise eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,67912,Correction eyelid w/implant,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,67914,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,67915,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,67916,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,67917,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,67921,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,67922,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,67923,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,67924,Repair eyelid defect,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,67930,Repair eyelid wound,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,67935,Repair eyelid wound,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,67938,Remove eyelid foreign body,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
UHC MCR ADV,CPT,67950,Revision of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,67961,Revision of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,67966,Revision of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,67971,Reconstruction of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,67973,Reconstruction of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,67974,Reconstruction of eyelid,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,67975,Reconstruction of eyelid,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,67999,Revision of eyelid,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
UHC MCR ADV,CPT,68020,Incise/drain eyelid lining,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
UHC MCR ADV,CPT,68040,Treatment of eyelid lesions,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
UHC MCR ADV,CPT,68100,Biopsy of eyelid lining,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,68110,Remove eyelid lining lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,68115,Remove eyelid lining lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,68130,Remove eyelid lining lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,68135,Remove eyelid lining lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,68200,Treat eyelid by injection,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
UHC MCR ADV,CPT,68320,Revise/graft eyelid lining,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,68325,Revise/graft eyelid lining,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,68326,Revise/graft eyelid lining,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,68328,Revise/graft eyelid lining,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,68330,Revise eyelid lining,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","4,314.00",,,,,,
UHC MCR ADV,CPT,68335,Revise/graft eyelid lining,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,68340,Separate eyelid adhesions,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,68360,Revise eyelid lining,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,68362,Revise eyelid lining,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,68371,Harvest eye tissue alograft,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,68399,Eyelid lining surgery,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
UHC MCR ADV,CPT,68400,Incise/drain tear gland,APC 5502,RVU Per Unit,$828.42 ,OP,828.42,"4,314.00",,,,,,
UHC MCR ADV,CPT,68420,Incise/drain tear sac,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,68440,Incise tear duct opening,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
UHC MCR ADV,CPT,68500,Removal of tear gland,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,68505,Partial removal tear gland,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,68510,Biopsy of tear gland,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,68520,Removal of tear sac,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,68525,Biopsy of tear sac,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,68530,Clearance of tear duct,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
UHC MCR ADV,CPT,68540,Remove tear gland lesion,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,68550,Remove tear gland lesion,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,68700,Repair tear ducts,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,68705,Revise tear duct opening,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
UHC MCR ADV,CPT,68720,Create tear sac drain,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,68745,Create tear duct drain,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,68750,Create tear duct drain,APC 5504,RVU Per Case,"$3,382.53 ",OP,"3,382.53","4,314.00",,,,,,
UHC MCR ADV,CPT,68760,Close tear duct opening,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
UHC MCR ADV,CPT,68761,Close tear duct opening,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
UHC MCR ADV,CPT,68770,Close tear system fistula,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,68801,Dilate tear duct opening,APC 5735,RVU Per Case,$276.53 ,OP,276.53,"4,314.00",,,,,,
UHC MCR ADV,CPT,68810,Probe nasolacrimal duct,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
UHC MCR ADV,CPT,68811,Probe nasolacrimal duct,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,68815,Probe nasolacrimal duct,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,68816,Probe nl duct w/balloon,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","4,314.00",,,,,,
UHC MCR ADV,CPT,68840,Explore/irrigate tear ducts,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
UHC MCR ADV,CPT,68899,Tear duct system surgery,APC 5501,RVU Per Unit,$267.38 ,OP,267.38,"4,314.00",,,,,,
UHC MCR ADV,CPT,69000,Drain external ear lesion,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,69005,Drain external ear lesion,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,69020,Drain outer ear canal lesion,APC 5071,RVU Per Unit,$636.47 ,OP,636.47,"4,314.00",,,,,,
UHC MCR ADV,CPT,69100,Biopsy of external ear,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
UHC MCR ADV,CPT,69105,Biopsy of external ear canal,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,69110,Remove external ear partial,APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,69120,Removal of external ear,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,69140,Remove ear canal lesion(s),APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,69145,Remove ear canal lesion(s),APC 5073,RVU Per Case,"$2,425.27 ",OP,"2,425.27","4,314.00",,,,,,
UHC MCR ADV,CPT,69150,Extensive ear canal surgery,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,69155,Extensive ear/neck surgery,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,69200,Clear outer ear canal,APC 5734,RVU Per Case,$114.56 ,OP,114.56,"4,314.00",,,,,,
UHC MCR ADV,CPT,69205,Clear outer ear canal,APC 5072,RVU Per Case,"$1,439.81 ",OP,"1,439.81","4,314.00",,,,,,
UHC MCR ADV,CPT,69209,Remove impacted ear wax uni,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
UHC MCR ADV,CPT,69210,Remove impacted ear wax uni,APC 5733,RVU Per Case,$56.95 ,OP,56.95,"4,314.00",,,,,,
UHC MCR ADV,CPT,69220,Clean out mastoid cavity,APC 5051,RVU Per Case,$183.73 ,OP,183.73,"4,314.00",,,,,,
UHC MCR ADV,CPT,69222,Clean out mastoid cavity,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,69300,Revise external ear,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,69310,Rebuild outer ear canal,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,69320,Rebuild outer ear canal,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,69399,Outer ear surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
UHC MCR ADV,CPT,69420,Incision of eardrum,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
UHC MCR ADV,CPT,69421,Incision of eardrum,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,69424,Remove ventilating tube,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,69433,Create eardrum opening,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,"4,314.00",,,,,,
UHC MCR ADV,CPT,69436,Create eardrum opening,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,69440,Exploration of middle ear,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,69450,Eardrum revision,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,69501,Mastoidectomy,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,69502,Mastoidectomy,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,69505,Remove mastoid structures,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,69511,Extensive mastoid surgery,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,69530,Extensive mastoid surgery,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,69535,Remove part of temporal bone,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,69540,Remove ear lesion,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,69550,Remove ear lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,69552,Remove ear lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,69554,Remove ear lesion,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,69601,Mastoid surgery revision,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,69602,Mastoid surgery revision,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,69603,Mastoid surgery revision,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,69604,Mastoid surgery revision,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,69610,Repair of eardrum,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,69620,Repair of eardrum,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,69631,Repair eardrum structures,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,69632,Rebuild eardrum structures,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,69633,Rebuild eardrum structures,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,69635,Repair eardrum structures,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,69636,Rebuild eardrum structures,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,69637,Rebuild eardrum structures,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,69641,Revise middle ear & mastoid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,69642,Revise middle ear & mastoid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,69643,Revise middle ear & mastoid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,69644,Revise middle ear & mastoid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,69645,Revise middle ear & mastoid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,69646,Revise middle ear & mastoid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,69650,Release middle ear bone,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,69660,Revise middle ear bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,69661,Revise middle ear bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,69662,Revise middle ear bone,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,69666,Repair middle ear structures,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,69667,Repair middle ear structures,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,69670,Remove mastoid air cells,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,69676,Remove middle ear nerve,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,69700,Close mastoid fistula,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,69705,Nps surg dilat eust tube uni,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,69706,Nps surg dilat eust tube bi,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,69711,Remove/repair hearing aid,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,69714,Implant temple bone w/stimul,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,69715,Temple bne implnt w/stimulat,APC 5116,RVU Per Case,"$16,238.16 ",OP,"4,314.00","16,238.16",,,,,,
UHC MCR ADV,CPT,69717,Temple bone implant revision,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,314.00","6,411.04",,,,,,
UHC MCR ADV,CPT,69718,Revise temple bone implant,APC 5115,RVU Per Case,"$12,601.93 ",OP,"4,314.00","12,601.93",,,,,,
UHC MCR ADV,CPT,69720,Release facial nerve,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,69725,Release facial nerve,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,69740,Repair facial nerve,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,69745,Repair facial nerve,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,69799,Middle ear surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
UHC MCR ADV,CPT,69801,Incise inner ear,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","4,314.00",,,,,,
UHC MCR ADV,CPT,69805,Explore inner ear,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,69806,Explore inner ear,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,69905,Remove inner ear,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,69910,Remove inner ear & mastoid,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,69915,Incise inner ear nerve,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","4,314.00",,,,,,
UHC MCR ADV,CPT,69930,Implant cochlear device,APC 5166,RVU Per Case,"$35,230.37 ",OP,"4,140.35","35,230.37",,,,,,
UHC MCR ADV,CPT,69949,Inner ear surgery procedure,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
UHC MCR ADV,CPT,69950,Incise inner ear nerve,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,314.00","8,948.83",,,,,,
UHC MCR ADV,CPT,69955,Release facial nerve,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,69960,Release inner ear canal,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,69970,Remove inner ear lesion,APC 5165,RVU Per Case,"$5,204.66 ",OP,"4,314.00","5,204.66",,,,,,
UHC MCR ADV,CPT,69979,Temporal bone surgery,APC 5161,RVU Per Unit,$216.54 ,OP,216.54,"4,314.00",,,,,,
UHC MCR ADV,CPT,70010,Contrast x-ray of brain,APC 5572,RVU Per Case,$376.70 ,OP,376.7,899.79,,,,,,
UHC MCR ADV,CPT,70015,Contrast x-ray of brain,APC 5573,RVU Per Case,$731.85 ,OP,731.85,735.85,,,,,,
UHC MCR ADV,CPT,70030,X-ray eye for foreign body,APC 5521,RVU Per Case,$82.79 ,OP,82.79,144.88,,,,,,
UHC MCR ADV,CPT,70100,X-ray exam of jaw <4views,APC 5521,RVU Per Case,$82.79 ,OP,82.79,156.32,,,,,,
UHC MCR ADV,CPT,70110,X-ray exam of jaw 4/> views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,202.07,,,,,,
UHC MCR ADV,CPT,70120,X-ray exam of mastoids,APC 5522,RVU Per Case,$111.51 ,OP,111.51,171.58,,,,,,
UHC MCR ADV,CPT,70130,X-ray exam of mastoids,APC 5522,RVU Per Case,$111.51 ,OP,111.51,282.14,,,,,,
UHC MCR ADV,CPT,70134,X-ray exam of middle ear,APC 5524,RVU Per Case,$494.15 ,OP,244.01,494.15,,,,,,
UHC MCR ADV,CPT,70140,X-ray exam of facial bones,APC 5521,RVU Per Case,$82.79 ,OP,82.79,156.32,,,,,,
UHC MCR ADV,CPT,70150,X-ray exam of facial bones,APC 5522,RVU Per Case,$111.51 ,OP,111.51,221.14,,,,,,
UHC MCR ADV,CPT,70160,X-ray exam of nasal bones,APC 5521,RVU Per Case,$82.79 ,OP,82.79,163.95,,,,,,
UHC MCR ADV,CPT,70170,X-ray exam of tear duct,APC 5523,RVU Per Case,$235.49 ,OP,235.49,274.51,,,,,,
UHC MCR ADV,CPT,70190,X-ray exam of eye sockets,APC 5521,RVU Per Case,$82.79 ,OP,82.79,183.02,,,,,,
UHC MCR ADV,CPT,70200,X-ray exam of eye sockets,APC 5522,RVU Per Case,$111.51 ,OP,111.51,228.77,,,,,,
UHC MCR ADV,CPT,70210,X-ray exam of sinuses,APC 5521,RVU Per Case,$82.79 ,OP,82.79,156.32,,,,,,
UHC MCR ADV,CPT,70220,X-ray exam of sinuses,APC 5521,RVU Per Case,$82.79 ,OP,82.79,202.07,,,,,,
UHC MCR ADV,CPT,70240,X-ray exam pituitary saddle,APC 5521,RVU Per Case,$82.79 ,OP,82.79,148.69,,,,,,
UHC MCR ADV,CPT,70250,X-ray exam of skull,APC 5522,RVU Per Case,$111.51 ,OP,111.51,186.82,,,,,,
UHC MCR ADV,CPT,70260,X-ray exam of skull,APC 5522,RVU Per Case,$111.51 ,OP,111.51,251.64,,,,,,
UHC MCR ADV,CPT,70300,X-ray exam of teeth,APC 5521,RVU Per Case,$82.79 ,OP,76.26,82.79,,,,,,
UHC MCR ADV,CPT,70310,X-ray exam of teeth,APC 5523,RVU Per Case,$235.49 ,OP,235.49,235.49,,,,,,
UHC MCR ADV,CPT,70320,Full mouth x-ray of teeth,APC 5523,RVU Per Case,$235.49 ,OP,235.49,247.83,,,,,,
UHC MCR ADV,CPT,70328,X-ray exam of jaw joint,APC 5521,RVU Per Case,$82.79 ,OP,82.79,152.51,,,,,,
UHC MCR ADV,CPT,70330,X-ray exam of jaw joints,APC 5521,RVU Per Case,$82.79 ,OP,82.79,244.01,,,,,,
UHC MCR ADV,CPT,70332,X-ray exam of jaw joint,APC 5523,RVU Per Case,$235.49 ,OP,235.49,446.08,,,,,,
UHC MCR ADV,CPT,70336,Magnetic image jaw joint,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
UHC MCR ADV,CPT,70350,X-ray head for orthodontia,APC 5521,RVU Per Case,$82.79 ,OP,82.79,106.76,,,,,,
UHC MCR ADV,CPT,70355,Panoramic x-ray of jaws,APC 5521,RVU Per Case,$82.79 ,OP,82.79,122,,,,,,
UHC MCR ADV,CPT,70360,X-ray exam of neck,APC 5521,RVU Per Case,$82.79 ,OP,82.79,137.25,,,,,,
UHC MCR ADV,CPT,70370,Throat x-ray & fluoroscopy,APC 5521,RVU Per Case,$82.79 ,OP,82.79,381.27,,,,,,
UHC MCR ADV,CPT,70371,Speech evaluation complex,APC 5523,RVU Per Case,$235.49 ,OP,235.49,510.9,,,,,,
UHC MCR ADV,CPT,70380,X-ray exam of salivary gland,APC 5521,RVU Per Case,$82.79 ,OP,82.79,190.64,,,,,,
UHC MCR ADV,CPT,70390,X-ray exam of salivary duct,APC 5523,RVU Per Case,$235.49 ,OP,235.49,235.49,,,,,,
UHC MCR ADV,CPT,70450,Ct head/brain w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
UHC MCR ADV,CPT,70460,Ct head/brain w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
UHC MCR ADV,CPT,70470,Ct head/brain w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
UHC MCR ADV,CPT,70480,Ct orbit/ear/fossa w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
UHC MCR ADV,CPT,70481,Ct orbit/ear/fossa w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
UHC MCR ADV,CPT,70482,Ct orbit/ear/fossa w/o&w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
UHC MCR ADV,CPT,70486,Ct maxillofacial w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
UHC MCR ADV,CPT,70487,Ct maxillofacial w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
UHC MCR ADV,CPT,70488,Ct maxillofacial w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
UHC MCR ADV,CPT,70490,Ct soft tissue neck w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
UHC MCR ADV,CPT,70491,Ct soft tissue neck w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
UHC MCR ADV,CPT,70492,Ct sft tsue nck w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
UHC MCR ADV,CPT,70496,Ct angiography head,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
UHC MCR ADV,CPT,70498,Ct angiography neck,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
UHC MCR ADV,CPT,70540,Mri orbit/face/neck w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
UHC MCR ADV,CPT,70542,Mri orbit/face/neck w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
UHC MCR ADV,CPT,70543,Mri orbt/fac/nck w/o &w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
UHC MCR ADV,CPT,70544,Mr angiography head w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
UHC MCR ADV,CPT,70545,Mr angiography head w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
UHC MCR ADV,CPT,70546,Mr angiograph head w/o&w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
UHC MCR ADV,CPT,70547,Mr angiography neck w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
UHC MCR ADV,CPT,70548,Mr angiography neck w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
UHC MCR ADV,CPT,70549,Mr angiograph neck w/o&w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
UHC MCR ADV,CPT,70551,Mri brain stem w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
UHC MCR ADV,CPT,70552,Mri brain stem w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
UHC MCR ADV,CPT,70553,Mri brain stem w/o & w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
UHC MCR ADV,CPT,70554,Fmri brain by tech,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
UHC MCR ADV,CPT,70555,Fmri brain by phys/psych,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,507.00",,,,,,
UHC MCR ADV,CPT,70557,Mri brain w/o dye,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,149.44",,,,,,
UHC MCR ADV,CPT,70558,Mri brain w/dye,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,"1,609.22",,,,,,
UHC MCR ADV,CPT,70559,Mri brain w/o & w/dye,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,"1,609.22",,,,,,
UHC MCR ADV,CPT,71045,X-ray exam chest 1 view,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,152.51,,,,,,
UHC MCR ADV,CPT,71046,X-ray exam chest 2 views,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,167.76,,,,,,
UHC MCR ADV,CPT,71047,X-ray exam chest 3 views,APC 5521,RVU Per Case,$82.79 ,OP,82.79,240.2,,,,,,
UHC MCR ADV,CPT,71048,X-ray exam chest 4+ views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,240.2,,,,,,
UHC MCR ADV,CPT,71100,X-ray exam ribs uni 2 views,APC 5521,RVU Per Case,$82.79 ,OP,82.79,171.58,,,,,,
UHC MCR ADV,CPT,71101,X-ray exam unilat ribs/chest,APC 5522,RVU Per Case,$111.51 ,OP,111.51,202.07,,,,,,
UHC MCR ADV,CPT,71110,X-ray exam ribs bil 3 views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,213.51,,,,,,
UHC MCR ADV,CPT,71111,X-ray exam ribs/chest4/> vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,270.71,,,,,,
UHC MCR ADV,CPT,71120,X-ray exam breastbone 2/>vws,APC 5521,RVU Per Case,$82.79 ,OP,82.79,171.58,,,,,,
UHC MCR ADV,CPT,71130,X-ray strenoclavic jt 3/>vws,APC 5521,RVU Per Case,$82.79 ,OP,82.79,194.45,,,,,,
UHC MCR ADV,CPT,71250,Ct thorax dx c-,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
UHC MCR ADV,CPT,71260,Ct thorax dx c+,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
UHC MCR ADV,CPT,71270,Ct thorax dx c-/c+,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
UHC MCR ADV,CPT,71271,Ct thorax lung cancer scr c-,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,927,,,,,,
UHC MCR ADV,CPT,71275,Ct angiography chest,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
UHC MCR ADV,CPT,71550,Mri chest w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
UHC MCR ADV,CPT,71551,Mri chest w/dye,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"1,609.22",,,,,,
UHC MCR ADV,CPT,71552,Mri chest w/o & w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
UHC MCR ADV,CPT,72020,X-ray exam of spine 1 view,APC 5521,RVU Per Case,$82.79 ,OP,82.79,122,,,,,,
UHC MCR ADV,CPT,72040,X-ray exam neck spine 2-3 vw,APC 5521,RVU Per Case,$82.79 ,OP,82.79,190.64,,,,,,
UHC MCR ADV,CPT,72050,X-ray exam neck spine 4/5vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,293.57,,,,,,
UHC MCR ADV,CPT,72052,X-ray exam neck spine 6/>vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,339.33,,,,,,
UHC MCR ADV,CPT,72070,X-ray exam thorac spine 2vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,175.39,,,,,,
UHC MCR ADV,CPT,72072,X-ray exam thorac spine 3vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,202.07,,,,,,
UHC MCR ADV,CPT,72074,X-ray exam thorac spine4/>vw,APC 5522,RVU Per Case,$111.51 ,OP,111.51,236.38,,,,,,
UHC MCR ADV,CPT,72080,X-ray exam thoracolmb 2/> vw,APC 5521,RVU Per Case,$82.79 ,OP,82.79,183.02,,,,,,
UHC MCR ADV,CPT,72081,X-ray exam entire spi 1 vw,APC 5521,RVU Per Case,$82.79 ,OP,82.79,354.58,,,,,,
UHC MCR ADV,CPT,72082,X-ray exam entire spi 2/3 vw,APC 5522,RVU Per Case,$111.51 ,OP,111.51,354.58,,,,,,
UHC MCR ADV,CPT,72083,X-ray exam entire spi 4/5 vw,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,354.58,,,,,,
UHC MCR ADV,CPT,72084,X-ray exam entire spi 6/> vw,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,354.58,,,,,,
UHC MCR ADV,CPT,72100,X-ray exam l-s spine 2/3 vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,202.07,,,,,,
UHC MCR ADV,CPT,72110,X-ray exam l-2 spine 4/>vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,301.2,,,,,,
UHC MCR ADV,CPT,72114,X-ray exam l-s spine bending,APC 5522,RVU Per Case,$111.51 ,OP,111.51,362.21,,,,,,
UHC MCR ADV,CPT,72120,X-ray bend only l-s spine,APC 5522,RVU Per Case,$111.51 ,OP,111.51,251.64,,,,,,
UHC MCR ADV,CPT,72125,Ct neck spine w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
UHC MCR ADV,CPT,72126,Ct neck spine w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,965.53,,,,,,
UHC MCR ADV,CPT,72127,Ct neck spine w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
UHC MCR ADV,CPT,72128,Ct chest spine w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
UHC MCR ADV,CPT,72129,Ct chest spine w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
UHC MCR ADV,CPT,72130,Ct chest spine w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
UHC MCR ADV,CPT,72131,Ct lumbar spine w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
UHC MCR ADV,CPT,72132,Ct lumbar spine w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,965.53,,,,,,
UHC MCR ADV,CPT,72133,Ct lumbar spine w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
UHC MCR ADV,CPT,72141,Mri neck spine w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
UHC MCR ADV,CPT,72142,Mri neck spine w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
UHC MCR ADV,CPT,72146,Mri chest spine w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
UHC MCR ADV,CPT,72147,Mri chest spine w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
UHC MCR ADV,CPT,72148,Mri lumbar spine w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
UHC MCR ADV,CPT,72149,Mri lumbar spine w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
UHC MCR ADV,CPT,72156,Mri neck spine w/o & w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
UHC MCR ADV,CPT,72157,Mri chest spine w/o & w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
UHC MCR ADV,CPT,72158,Mri lumbar spine w/o & w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
UHC MCR ADV,CPT,72170,X-ray exam of pelvis,APC 5522,RVU Per Case,$111.51 ,OP,111.51,133.45,,,,,,
UHC MCR ADV,CPT,72190,X-ray exam of pelvis,APC 5522,RVU Per Case,$111.51 ,OP,111.51,205.88,,,,,,
UHC MCR ADV,CPT,72191,Ct angiograph pelv w/o&w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
UHC MCR ADV,CPT,72192,Ct pelvis w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
UHC MCR ADV,CPT,72193,Ct pelvis w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
UHC MCR ADV,CPT,72194,Ct pelvis w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
UHC MCR ADV,CPT,72195,Mri pelvis w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
UHC MCR ADV,CPT,72196,Mri pelvis w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
UHC MCR ADV,CPT,72197,Mri pelvis w/o & w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
UHC MCR ADV,CPT,72200,X-ray exam si joints,APC 5522,RVU Per Case,$111.51 ,OP,111.51,148.69,,,,,,
UHC MCR ADV,CPT,72202,X-ray exam si joints 3/> vws,APC 5522,RVU Per Case,$111.51 ,OP,111.51,183.02,,,,,,
UHC MCR ADV,CPT,72220,X-ray exam sacrum tailbone,APC 5521,RVU Per Case,$82.79 ,OP,82.79,156.32,,,,,,
UHC MCR ADV,CPT,72240,Myelography neck spine,APC 5573,RVU Per Case,$731.85 ,OP,731.85,842.61,,,,,,
UHC MCR ADV,CPT,72255,Myelography thoracic spine,APC 5573,RVU Per Case,$731.85 ,OP,731.85,766.35,,,,,,
UHC MCR ADV,CPT,72265,Myelography l-s spine,APC 5573,RVU Per Case,$731.85 ,OP,731.85,781.61,,,,,,
UHC MCR ADV,CPT,72270,Myelogphy 2/> spine regions,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"1,216.24",,,,,,
UHC MCR ADV,CPT,72285,Discography cerv/thor spine,APC 5431,RVU Per Case,"$1,795.30 ",OP,976.05,"1,795.30",,,,,,
UHC MCR ADV,CPT,72295,X-ray of lower spine disk,APC 5431,RVU Per Case,"$1,795.30 ",OP,873.11,"1,795.30",,,,,,
UHC MCR ADV,CPT,73000,X-ray exam of collar bone,APC 5521,RVU Per Case,$82.79 ,OP,82.79,141.07,,,,,,
UHC MCR ADV,CPT,73010,X-ray exam of shoulder blade,APC 5522,RVU Per Case,$111.51 ,OP,111.51,144.88,,,,,,
UHC MCR ADV,CPT,73020,X-ray exam of shoulder,APC 5521,RVU Per Case,$82.79 ,OP,82.79,122,,,,,,
UHC MCR ADV,CPT,73030,X-ray exam of shoulder,APC 5521,RVU Per Case,$82.79 ,OP,82.79,163.95,,,,,,
UHC MCR ADV,CPT,73040,Contrast x-ray of shoulder,APC 5572,RVU Per Case,$376.70 ,OP,376.7,552.84,,,,,,
UHC MCR ADV,CPT,73050,X-ray exam of shoulders,APC 5521,RVU Per Case,$82.79 ,OP,82.79,186.82,,,,,,
UHC MCR ADV,CPT,73060,X-ray exam of humerus,APC 5521,RVU Per Case,$82.79 ,OP,82.79,152.51,,,,,,
UHC MCR ADV,CPT,73070,X-ray exam of elbow,APC 5521,RVU Per Case,$82.79 ,OP,82.79,137.25,,,,,,
UHC MCR ADV,CPT,73080,X-ray exam of elbow,APC 5521,RVU Per Case,$82.79 ,OP,82.79,179.2,,,,,,
UHC MCR ADV,CPT,73085,Contrast x-ray of elbow,APC 5572,RVU Per Case,$376.70 ,OP,376.7,503.28,,,,,,
UHC MCR ADV,CPT,73090,X-ray exam of forearm,APC 5521,RVU Per Case,$82.79 ,OP,82.79,137.25,,,,,,
UHC MCR ADV,CPT,73092,X-ray exam of arm infant,APC 5522,RVU Per Case,$111.51 ,OP,111.51,141.07,,,,,,
UHC MCR ADV,CPT,73100,X-ray exam of wrist,APC 5521,RVU Per Case,$82.79 ,OP,82.79,144.88,,,,,,
UHC MCR ADV,CPT,73110,X-ray exam of wrist,APC 5521,RVU Per Case,$82.79 ,OP,82.79,171.58,,,,,,
UHC MCR ADV,CPT,73115,Contrast x-ray of wrist,APC 5572,RVU Per Case,$376.70 ,OP,376.7,526.16,,,,,,
UHC MCR ADV,CPT,73120,X-ray exam of hand,APC 5522,RVU Per Case,$111.51 ,OP,111.51,137.25,,,,,,
UHC MCR ADV,CPT,73130,X-ray exam of hand,APC 5521,RVU Per Case,$82.79 ,OP,82.79,156.32,,,,,,
UHC MCR ADV,CPT,73140,X-ray exam of finger(s),APC 5521,RVU Per Case,$82.79 ,OP,82.79,160.13,,,,,,
UHC MCR ADV,CPT,73200,Ct upper extremity w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
UHC MCR ADV,CPT,73201,Ct upper extremity w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,965.53,,,,,,
UHC MCR ADV,CPT,73202,Ct uppr extremity w/o&w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
UHC MCR ADV,CPT,73206,Ct angio upr extrm w/o&w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
UHC MCR ADV,CPT,73218,Mri upper extremity w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
UHC MCR ADV,CPT,73219,Mri upper extremity w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
UHC MCR ADV,CPT,73220,Mri uppr extremity w/o&w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
UHC MCR ADV,CPT,73221,Mri joint upr extrem w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
UHC MCR ADV,CPT,73222,Mri joint upr extrem w/dye,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"1,609.22",,,,,,
UHC MCR ADV,CPT,73223,Mri joint upr extr w/o&w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
UHC MCR ADV,CPT,73501,X-ray exam hip uni 1 view,APC 5521,RVU Per Case,$82.79 ,OP,82.79,129.64,,,,,,
UHC MCR ADV,CPT,73502,X-ray exam hip uni 2-3 views,APC 5521,RVU Per Case,$82.79 ,OP,82.79,198.25,,,,,,
UHC MCR ADV,CPT,73503,X-ray exam hip uni 4/> views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,198.25,,,,,,
UHC MCR ADV,CPT,73521,X-ray exam hips bi 2 views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,202.07,,,,,,
UHC MCR ADV,CPT,73522,X-ray exam hips bi 3-4 views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,202.07,,,,,,
UHC MCR ADV,CPT,73523,X-ray exam hips bi 5/> views,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,202.07,,,,,,
UHC MCR ADV,CPT,73525,Contrast x-ray of hip,APC 5572,RVU Per Case,$376.70 ,OP,376.7,503.28,,,,,,
UHC MCR ADV,CPT,73551,X-ray exam of femur 1,APC 5521,RVU Per Case,$82.79 ,OP,82.79,148.69,,,,,,
UHC MCR ADV,CPT,73552,X-ray exam of femur 2/>,APC 5521,RVU Per Case,$82.79 ,OP,82.79,148.69,,,,,,
UHC MCR ADV,CPT,73560,X-ray exam of knee 1 or 2,APC 5521,RVU Per Case,$82.79 ,OP,82.79,144.88,,,,,,
UHC MCR ADV,CPT,73562,X-ray exam of knee 3,APC 5521,RVU Per Case,$82.79 ,OP,82.79,186.82,,,,,,
UHC MCR ADV,CPT,73564,X-ray exam knee 4 or more,APC 5522,RVU Per Case,$111.51 ,OP,111.51,205.88,,,,,,
UHC MCR ADV,CPT,73565,X-ray exam of knees,APC 5521,RVU Per Case,$82.79 ,OP,82.79,152.51,,,,,,
UHC MCR ADV,CPT,73580,Contrast x-ray of knee joint,APC 5572,RVU Per Case,$376.70 ,OP,376.7,625.29,,,,,,
UHC MCR ADV,CPT,73590,X-ray exam of lower leg,APC 5521,RVU Per Case,$82.79 ,OP,82.79,137.25,,,,,,
UHC MCR ADV,CPT,73592,X-ray exam of leg infant,APC 5521,RVU Per Case,$82.79 ,OP,82.79,141.07,,,,,,
UHC MCR ADV,CPT,73600,X-ray exam of ankle,APC 5521,RVU Per Case,$82.79 ,OP,82.79,137.25,,,,,,
UHC MCR ADV,CPT,73610,X-ray exam of ankle,APC 5521,RVU Per Case,$82.79 ,OP,82.79,156.32,,,,,,
UHC MCR ADV,CPT,73615,Contrast x-ray of ankle,APC 5572,RVU Per Case,$376.70 ,OP,376.7,376.7,,,,,,
UHC MCR ADV,CPT,73620,X-ray exam of foot,APC 5521,RVU Per Case,$82.79 ,OP,82.79,133.45,,,,,,
UHC MCR ADV,CPT,73630,X-ray exam of foot,APC 5521,RVU Per Case,$82.79 ,OP,82.79,156.32,,,,,,
UHC MCR ADV,CPT,73650,X-ray exam of heel,APC 5521,RVU Per Case,$82.79 ,OP,82.79,137.25,,,,,,
UHC MCR ADV,CPT,73660,X-ray exam of toe(s),APC 5521,RVU Per Case,$82.79 ,OP,82.79,141.07,,,,,,
UHC MCR ADV,CPT,73700,Ct lower extremity w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
UHC MCR ADV,CPT,73701,Ct lower extremity w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
UHC MCR ADV,CPT,73702,Ct lwr extremity w/o&w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
UHC MCR ADV,CPT,73706,Ct angio lwr extr w/o&w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
UHC MCR ADV,CPT,73718,Mri lower extremity w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
UHC MCR ADV,CPT,73719,Mri lower extremity w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
UHC MCR ADV,CPT,73720,Mri lwr extremity w/o&w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
UHC MCR ADV,CPT,73721,Mri jnt of lwr extre w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
UHC MCR ADV,CPT,73722,Mri joint of lwr extr w/dye,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"1,609.22",,,,,,
UHC MCR ADV,CPT,73723,Mri joint lwr extr w/o&w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
UHC MCR ADV,CPT,74018,X-ray exam abdomen 1 view,APC 5521,RVU Per Case,$82.79 ,OP,82.79,137.25,,,,,,
UHC MCR ADV,CPT,74019,X-ray exam abdomen 2 views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,194.45,,,,,,
UHC MCR ADV,CPT,74021,X-ray exam abdomen 3+ views,APC 5522,RVU Per Case,$111.51 ,OP,111.51,205.88,,,,,,
UHC MCR ADV,CPT,74022,X-ray exam complete abdomen,APC 5522,RVU Per Case,$111.51 ,OP,111.51,251.64,,,,,,
UHC MCR ADV,CPT,74150,Ct abdomen w/o dye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
UHC MCR ADV,CPT,74160,Ct abdomen w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
UHC MCR ADV,CPT,74170,Ct abdomen w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
UHC MCR ADV,CPT,74174,Ct angio abd&pelv w/o&w/dye,APC 5572,RVU Per Unit,$376.70 ,OP,376.7,965.53,,,,,,
UHC MCR ADV,CPT,74175,Ct angio abdom w/o & w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
UHC MCR ADV,CPT,74176,Ct abd & pelvis w/o contrast,APC 5523,RVU Per Case,$235.49 ,OP,235.49,927,,,,,,
UHC MCR ADV,CPT,74177,Ct abd & pelv w/contrast,APC 5572,RVU Per Case,$376.70 ,OP,376.7,965.53,,,,,,
UHC MCR ADV,CPT,74178,Ct abd & pelv 1/> regns,APC 5572,RVU Per Case,$376.70 ,OP,376.7,927,,,,,,
UHC MCR ADV,CPT,74181,Mri abdomen w/o dye,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
UHC MCR ADV,CPT,74182,Mri abdomen w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
UHC MCR ADV,CPT,74183,Mri abdomen w/o & w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
UHC MCR ADV,CPT,74190,X-ray exam of peritoneum,APC 5524,RVU Per Case,$494.15 ,OP,400.34,494.15,,,,,,
UHC MCR ADV,CPT,74210,X-ray xm phrnx&/crv esoph c+,APC 5571,RVU Per Case,$182.72 ,OP,182.72,182.72,,,,,,
UHC MCR ADV,CPT,74220,X-ray xm esophagus 1cntrst,APC 5571,RVU Per Case,$182.72 ,OP,182.72,446.08,,,,,,
UHC MCR ADV,CPT,74221,X-ray xm esophagus 2cntrst,APC 5571,RVU Per Case,$182.72 ,OP,182.72,446.08,,,,,,
UHC MCR ADV,CPT,74230,X-ray xm swlng funcj c+,APC 5571,RVU Per Case,$182.72 ,OP,182.72,457.52,,,,,,
UHC MCR ADV,CPT,74240,X-ray xm upr gi trc 1cntrst,APC 5571,RVU Per Case,$182.72 ,OP,182.72,552.84,,,,,,
UHC MCR ADV,CPT,74246,X-ray xm upr gi trc 2cntrst,APC 5571,RVU Per Case,$182.72 ,OP,182.72,632.91,,,,,,
UHC MCR ADV,CPT,74250,X-ray xm sm int 1cntrst std,APC 5571,RVU Per Case,$182.72 ,OP,182.72,518.52,,,,,,
UHC MCR ADV,CPT,74251,X-ray xm sm int 2cntrst std,APC 5571,RVU Per Case,$182.72 ,OP,182.72,"1,593.72",,,,,,
UHC MCR ADV,CPT,74261,Ct colonography dx,APC 5522,RVU Per Case,$111.51 ,OP,111.51,927,,,,,,
UHC MCR ADV,CPT,74262,Ct colonography dx w/dye,APC 5571,RVU Per Case,$182.72 ,OP,182.72,182.72,,,,,,
UHC MCR ADV,CPT,74270,X-ray xm colon 1cntrst std,APC 5571,RVU Per Case,$182.72 ,OP,182.72,747.28,,,,,,
UHC MCR ADV,CPT,74280,X-ray xm colon 2cntrst std,APC 5571,RVU Per Case,$182.72 ,OP,182.72,"1,029.43",,,,,,
UHC MCR ADV,CPT,74283,Ther nma rdctj intus/obstrcj,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,182.72,,,,,,
UHC MCR ADV,CPT,74290,Contrast x-ray gallbladder,APC 5571,RVU Per Case,$182.72 ,OP,182.72,331.7,,,,,,
UHC MCR ADV,CPT,74400,Urography iv +-kub tomog,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,568.09,,,,,,
UHC MCR ADV,CPT,74410,Urography nfs drip&/bolus,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,598.59,,,,,,
UHC MCR ADV,CPT,74415,Urography nfs drip&/bls w/nf,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,682.47,,,,,,
UHC MCR ADV,CPT,74420,Urography rtrgr +-kub,APC 5572,RVU Per Unit,$376.70 ,OP,376.7,659.6,,,,,,
UHC MCR ADV,CPT,74425,Urography antegrade rs&i,APC 5572,RVU Per Case,$376.70 ,OP,366.02,376.7,,,,,,
UHC MCR ADV,CPT,74430,Contrast x-ray bladder,APC 5572,RVU Per Case,$376.70 ,OP,376.7,404.14,,,,,,
UHC MCR ADV,CPT,74440,X-ray male genital tract,APC 5523,RVU Per Case,$235.49 ,OP,235.49,434.65,,,,,,
UHC MCR ADV,CPT,74445,X-ray exam of penis,APC 5522,RVU Per Case,$111.51 ,OP,111.51,545.21,,,,,,
UHC MCR ADV,CPT,74450,X-ray urethra/bladder,APC 5523,RVU Per Case,$235.49 ,OP,235.49,396.52,,,,,,
UHC MCR ADV,CPT,74455,X-ray urethra/bladder,APC 5523,RVU Per Case,$235.49 ,OP,235.49,472.78,,,,,,
UHC MCR ADV,CPT,74470,X-ray exam of kidney lesion,APC 5524,RVU Per Case,$494.15 ,OP,400.34,494.15,,,,,,
UHC MCR ADV,CPT,74485,Dilation urtr/urt rs&i,APC 5373,RVU Per Case,"$1,834.80 ",OP,629.1,"1,834.80",,,,,,
UHC MCR ADV,CPT,74710,X-ray measurement of pelvis,APC 5521,RVU Per Case,$82.79 ,OP,82.79,232.58,,,,,,
UHC MCR ADV,CPT,74712,Mri fetal sngl/1st gestation,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,507.00",,,,,,
UHC MCR ADV,CPT,74740,X-ray female genital tract,APC 5523,RVU Per Case,$235.49 ,OP,235.49,404.14,,,,,,
UHC MCR ADV,CPT,74775,X-ray exam of perineum,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,457.52,,,,,,
UHC MCR ADV,CPT,75557,Cardiac mri for morph,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
UHC MCR ADV,CPT,75559,Cardiac mri w/stress img,APC 5524,RVU Per Case,$494.15 ,OP,494.15,"1,507.00",,,,,,
UHC MCR ADV,CPT,75561,Cardiac mri for morph w/dye,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,609.22",,,,,,
UHC MCR ADV,CPT,75563,Card mri w/stress img & dye,APC 5573,RVU Per Case,$731.85 ,OP,731.85,"1,609.22",,,,,,
UHC MCR ADV,CPT,75571,Ct hrt w/o dye w/ca test,APC 5521,RVU Per Case,$82.79 ,OP,82.79,927,,,,,,
UHC MCR ADV,CPT,75572,Ct hrt w/3d image,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,927,,,,,,
UHC MCR ADV,CPT,75573,Ct hrt w/3d image congen,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,927,,,,,,
UHC MCR ADV,CPT,75574,Ct angio hrt w/3d image,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,927,,,,,,
UHC MCR ADV,CPT,75600,Contrast exam thoracic aorta,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,742.41","2,928.39",,,,,,
UHC MCR ADV,CPT,75605,Contrast exam thoracic aorta,APC 5184,RVU Per Case,"$4,881.61 ",OP,"1,506.03","4,881.61",,,,,,
UHC MCR ADV,CPT,75625,Contrast exam abdominl aorta,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,486.95","2,928.39",,,,,,
UHC MCR ADV,CPT,75630,X-ray aorta leg arteries,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","2,928.39",,,,,,
UHC MCR ADV,CPT,75635,Ct angio abdominal arteries,APC 5571,RVU Per Case,$182.72 ,OP,182.72,965.53,,,,,,
UHC MCR ADV,CPT,75705,Artery x-rays spine,APC 5184,RVU Per Case,"$4,881.61 ",OP,"1,826.28","4,881.61",,,,,,
UHC MCR ADV,CPT,75710,Artery x-rays arm/leg,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,567.02","2,928.39",,,,,,
UHC MCR ADV,CPT,75716,Artery x-rays arms/legs,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,730.97","2,928.39",,,,,,
UHC MCR ADV,CPT,75726,Artery x-rays abdomen,APC 5184,RVU Per Case,"$4,881.61 ",OP,"1,547.95","4,881.61",,,,,,
UHC MCR ADV,CPT,75731,Artery x-rays adrenal gland,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,601.33","2,928.39",,,,,,
UHC MCR ADV,CPT,75733,Artery x-rays adrenals,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,795.78","2,928.39",,,,,,
UHC MCR ADV,CPT,75736,Artery x-rays pelvis,APC 5184,RVU Per Case,"$4,881.61 ",OP,"1,563.20","4,881.61",,,,,,
UHC MCR ADV,CPT,75741,Artery x-rays lung,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,506.03","2,928.39",,,,,,
UHC MCR ADV,CPT,75743,Artery x-rays lungs,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,635.64","2,928.39",,,,,,
UHC MCR ADV,CPT,75746,Artery x-rays lung,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,517.46","2,928.39",,,,,,
UHC MCR ADV,CPT,75756,Artery x-rays chest,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,601.33","2,928.39",,,,,,
UHC MCR ADV,CPT,75801,Lymph vessel x-ray arm/leg,APC 5181,RVU Per Case,$554.25 ,OP,554.25,"1,281.07",,,,,,
UHC MCR ADV,CPT,75803,Lymph vessel x-ray arms/legs,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,437.39","1,438.93",,,,,,
UHC MCR ADV,CPT,75805,Lymph vessel x-ray trunk,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,483.14","2,928.39",,,,,,
UHC MCR ADV,CPT,75807,Lymph vessel x-ray trunk,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,582.28","2,928.39",,,,,,
UHC MCR ADV,CPT,75809,Nonvascular shunt x-ray,APC 5522,RVU Per Case,$111.51 ,OP,111.51,446.08,,,,,,
UHC MCR ADV,CPT,75810,Vein x-ray spleen/liver,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,836.65","2,928.39",,,,,,
UHC MCR ADV,CPT,75820,Vein x-ray arm/leg,APC 5182,RVU Per Case,"$1,438.93 ",OP,610.03,"1,438.93",,,,,,
UHC MCR ADV,CPT,75822,Vein x-ray arms/legs,APC 5182,RVU Per Case,"$1,438.93 ",OP,747.28,"1,438.93",,,,,,
UHC MCR ADV,CPT,75825,Vein x-ray trunk,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,441.20","2,928.39",,,,,,
UHC MCR ADV,CPT,75827,Vein x-ray chest,APC 5182,RVU Per Case,"$1,438.93 ",OP,"1,433.58","1,438.93",,,,,,
UHC MCR ADV,CPT,75831,Vein x-ray kidney,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,456.44","2,928.39",,,,,,
UHC MCR ADV,CPT,75833,Vein x-ray kidneys,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,608.95","2,928.39",,,,,,
UHC MCR ADV,CPT,75840,Vein x-ray adrenal gland,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,445.01","2,928.39",,,,,,
UHC MCR ADV,CPT,75842,Vein x-ray adrenal glands,APC 5184,RVU Per Case,"$4,881.61 ",OP,"1,616.58","4,881.61",,,,,,
UHC MCR ADV,CPT,75860,Vein x-ray neck,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,479.33","2,928.39",,,,,,
UHC MCR ADV,CPT,75870,Vein x-ray skull,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,467.89","2,928.39",,,,,,
UHC MCR ADV,CPT,75872,Vein x-ray skull epidural,APC 5181,RVU Per Case,$554.25 ,OP,554.25,"1,608.95",,,,,,
UHC MCR ADV,CPT,75880,Vein x-ray eye socket,APC 5181,RVU Per Case,$554.25 ,OP,554.25,613.85,,,,,,
UHC MCR ADV,CPT,75885,Vein x-ray liver w/hemodynam,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,536.51","2,928.39",,,,,,
UHC MCR ADV,CPT,75887,Vein x-ray liver w/o hemodyn,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,547.95","2,928.39",,,,,,
UHC MCR ADV,CPT,75889,Vein x-ray liver w/hemodynam,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,456.44","2,928.39",,,,,,
UHC MCR ADV,CPT,75891,Vein x-ray liver,APC 5183,RVU Per Case,"$2,928.39 ",OP,"1,456.44","2,928.39",,,,,,
UHC MCR ADV,CPT,75893,Venous sampling by catheter,APC 5184,RVU Per Case,"$4,881.61 ",OP,"1,296.32","4,881.61",,,,,,
UHC MCR ADV,CPT,75898,Follow-up angiography,APC 5183,RVU Per Case,"$2,928.39 ",OP,655.78,"2,928.39",,,,,,
UHC MCR ADV,CPT,75956,Xray endovasc thor ao repr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,75957,Xray endovasc thor ao repr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,597.52","8,948.83",,,,,,
UHC MCR ADV,CPT,75958,Xray place prox ext thor ao,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,052.29","8,948.83",,,,,,
UHC MCR ADV,CPT,75959,Xray place dist ext thor ao,APC 5881,RVU Per Case,"$8,948.83 ",OP,926.48,"8,948.83",,,,,,
UHC MCR ADV,CPT,76000,Fluoroscopy <1 hr phys/qhp,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,495.65,,,,,,
UHC MCR ADV,CPT,76010,X-ray nose to rectum,APC 5521,RVU Per Case,$82.79 ,OP,82.79,144.88,,,,,,
UHC MCR ADV,CPT,76080,X-ray exam of fistula,APC 5524,RVU Per Case,$494.15 ,OP,331.7,494.15,,,,,,
UHC MCR ADV,CPT,76098,X-ray exam surgical specimen,APC 5524,RVU Per Case,$494.15 ,OP,102.95,494.15,,,,,,
UHC MCR ADV,CPT,76100,X-ray exam of body section,APC 5522,RVU Per Case,$111.51 ,OP,111.51,690.1,,,,,,
UHC MCR ADV,CPT,76101,Complex body section x-ray,APC 5522,RVU Per Case,$111.51 ,OP,111.51,949.36,,,,,,
UHC MCR ADV,CPT,76102,Complex body section x-rays,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,111.51,,,,,,
UHC MCR ADV,CPT,76120,Cine/video x-rays,APC 5522,RVU Per Case,$111.51 ,OP,111.51,392.7,,,,,,
UHC MCR ADV,CPT,76145,Med physic dos eval rad exps,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,129.83,,,,,,
UHC MCR ADV,CPT,76380,Cat scan follow-up study,APC 5521,RVU Per Case,$82.79 ,OP,82.79,689.66,,,,,,
UHC MCR ADV,CPT,76390,Mr spectroscopy,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,"1,507.00",,,,,,
UHC MCR ADV,CPT,76391,Mr elastography,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
UHC MCR ADV,CPT,76496,Fluoroscopic procedure,APC 5521,RVU Per Case,$82.79 ,OP,82.79,82.79,,,,,,
UHC MCR ADV,CPT,76497,Ct procedure,APC 5521,RVU Per Case,$82.79 ,OP,82.79,927,,,,,,
UHC MCR ADV,CPT,76498,Mri procedure,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,"1,507.00",,,,,,
UHC MCR ADV,CPT,76499,Radiographic procedure,APC 5521,RVU Per Case,$82.79 ,OP,82.79,82.79,,,,,,
UHC MCR ADV,CPT,76506,Echo exam of head,APC 5522,RVU Per Case,$111.51 ,OP,111.51,602.41,,,,,,
UHC MCR ADV,CPT,76510,Oph us dx b-scan&quan a-scan,APC 5734,RVU Per Case,$114.56 ,OP,114.56,751.1,,,,,,
UHC MCR ADV,CPT,76511,Oph us dx quan a-scan only,APC 5522,RVU Per Case,$111.51 ,OP,111.51,495.65,,,,,,
UHC MCR ADV,CPT,76512,Oph us dx b-scan,APC 5522,RVU Per Case,$111.51 ,OP,111.51,468.96,,,,,,
UHC MCR ADV,CPT,76513,Oph us dx ant sgm us uni/bi,APC 5522,RVU Per Case,$111.51 ,OP,111.51,438.47,,,,,,
UHC MCR ADV,CPT,76514,Echo exam of eye thickness,APC 5731,RVU Per Case,$25.25 ,OP,25.25,64.82,,,,,,
UHC MCR ADV,CPT,76516,Echo exam of eye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,346.96,,,,,,
UHC MCR ADV,CPT,76519,Echo exam of eye,APC 5522,RVU Per Case,$111.51 ,OP,111.51,369.83,,,,,,
UHC MCR ADV,CPT,76529,Echo exam of eye,APC 5521,RVU Per Case,$82.79 ,OP,82.79,354.58,,,,,,
UHC MCR ADV,CPT,76536,Us exam of head and neck,APC 5522,RVU Per Case,$111.51 ,OP,111.51,594.77,,,,,,
UHC MCR ADV,CPT,76604,Us exam chest,APC 5522,RVU Per Case,$111.51 ,OP,111.51,446.08,,,,,,
UHC MCR ADV,CPT,76641,Ultrasound breast complete,APC 5522,RVU Per Case,$111.51 ,OP,111.51,174.71,,,,,,
UHC MCR ADV,CPT,76642,Ultrasound breast limited,APC 5521,RVU Per Case,$82.79 ,OP,82.79,174.71,,,,,,
UHC MCR ADV,CPT,76700,Us exam abdom complete,APC 5522,RVU Per Case,$111.51 ,OP,111.51,739.67,,,,,,
UHC MCR ADV,CPT,76705,Echo exam of abdomen,APC 5522,RVU Per Case,$111.51 ,OP,111.51,537.6,,,,,,
UHC MCR ADV,CPT,76706,Us abdl aorta screen aaa,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,575.73,,,,,,
UHC MCR ADV,CPT,76770,Us exam abdo back wall comp,APC 5522,RVU Per Case,$111.51 ,OP,111.51,678.66,,,,,,
UHC MCR ADV,CPT,76775,Us exam abdo back wall lim,APC 5522,RVU Per Case,$111.51 ,OP,111.51,602.41,,,,,,
UHC MCR ADV,CPT,76776,Us exam k transpl w/doppler,APC 5522,RVU Per Case,$111.51 ,OP,111.51,751.1,,,,,,
UHC MCR ADV,CPT,76800,Us exam spinal canal,APC 5522,RVU Per Case,$111.51 ,OP,111.51,632.91,,,,,,
UHC MCR ADV,CPT,76801,Ob us < 14 wks single fetus,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,712.98,,,,,,
UHC MCR ADV,CPT,76805,Ob us >= 14 wks sngl fetus,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,789.23,,,,,,
UHC MCR ADV,CPT,76811,Ob us detailed sngl fetus,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,204.81",,,,,,
UHC MCR ADV,CPT,76813,Ob us nuchal meas 1 gest,APC 5522,RVU Per Case,$111.51 ,OP,111.51,667.22,,,,,,
UHC MCR ADV,CPT,76815,Ob us limited fetus(s),APC 5522,RVU Per Case,$111.51 ,OP,111.51,472.78,,,,,,
UHC MCR ADV,CPT,76816,Ob us follow-up per fetus,APC 5522,RVU Per Case,$111.51 ,OP,111.51,571.91,,,,,,
UHC MCR ADV,CPT,76817,Transvaginal us obstetric,APC 5522,RVU Per Case,$111.51 ,OP,111.51,560.47,,,,,,
UHC MCR ADV,CPT,76818,Fetal biophys profile w/nst,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,625.29,,,,,,
UHC MCR ADV,CPT,76819,Fetal biophys profil w/o nst,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,526.16,,,,,,
UHC MCR ADV,CPT,76820,Umbilical artery echo,APC 5522,RVU Per Case,$111.51 ,OP,111.51,297.39,,,,,,
UHC MCR ADV,CPT,76821,Middle cerebral artery echo,APC 5522,RVU Per Case,$111.51 ,OP,111.51,510.9,,,,,,
UHC MCR ADV,CPT,76825,Echo exam of fetal heart,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,067.55",,,,,,
UHC MCR ADV,CPT,76826,Echo exam of fetal heart,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,587.16,,,,,,
UHC MCR ADV,CPT,76827,Echo exam of fetal heart,APC 5522,RVU Per Case,$111.51 ,OP,111.51,381.27,,,,,,
UHC MCR ADV,CPT,76828,Echo exam of fetal heart,APC 5522,RVU Per Case,$111.51 ,OP,111.51,282.14,,,,,,
UHC MCR ADV,CPT,76830,Transvaginal us non-ob,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,651.97,,,,,,
UHC MCR ADV,CPT,76831,Echo exam uterus,APC 5523,RVU Per Case,$235.49 ,OP,235.49,621.47,,,,,,
UHC MCR ADV,CPT,76856,Us exam pelvic complete,APC 5522,RVU Per Case,$111.51 ,OP,111.51,655.78,,,,,,
UHC MCR ADV,CPT,76857,Us exam pelvic limited,APC 5522,RVU Per Case,$111.51 ,OP,111.51,518.52,,,,,,
UHC MCR ADV,CPT,76870,Us exam scrotum,APC 5522,RVU Per Case,$111.51 ,OP,111.51,621.47,,,,,,
UHC MCR ADV,CPT,76872,Us transrectal,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,735.85,,,,,,
UHC MCR ADV,CPT,76873,Echograp trans r pros study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,934.12,,,,,,
UHC MCR ADV,CPT,76881,Us compl joint r-t w/img,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,644.34,,,,,,
UHC MCR ADV,CPT,76882,Us lmtd jt/nonvasc xtr strux,APC 5522,RVU Per Case,$111.51 ,OP,111.51,644.34,,,,,,
UHC MCR ADV,CPT,76885,Us exam infant hips dynamic,APC 5521,RVU Per Case,$82.79 ,OP,82.79,701.54,,,,,,
UHC MCR ADV,CPT,76886,Us exam infant hips static,APC 5521,RVU Per Case,$82.79 ,OP,82.79,518.52,,,,,,
UHC MCR ADV,CPT,76936,Echo guide for artery repair,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,654.72",,,,,,
UHC MCR ADV,CPT,76975,Gi endoscopic ultrasound,APC 5523,RVU Per Case,$235.49 ,OP,235.49,529.96,,,,,,
UHC MCR ADV,CPT,76977,Us bone density measure,APC 5522,RVU Per Unit,$111.51 ,OP,80.07,111.51,,,,,,
UHC MCR ADV,CPT,76978,Us trgt dyn mbubb 1st les,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,182.72,,,,,,
UHC MCR ADV,CPT,76981,Use parenchyma,APC 5522,RVU Per Case,$111.51 ,OP,111.51,111.51,,,,,,
UHC MCR ADV,CPT,76982,Use 1st target lesion,APC 5522,RVU Per Case,$111.51 ,OP,111.51,111.51,,,,,,
UHC MCR ADV,CPT,76999,Echo examination procedure,APC 5521,RVU Per Case,$82.79 ,OP,82.79,82.79,,,,,,
UHC MCR ADV,CPT,77046,Mri breast c- unilateral,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
UHC MCR ADV,CPT,77047,Mri breast c- bilateral,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
UHC MCR ADV,CPT,77053,X-ray of mammary duct,APC 5523,RVU Per Case,$235.49 ,OP,235.49,411.78,,,,,,
UHC MCR ADV,CPT,77054,X-ray of mammary ducts,APC 5523,RVU Per Case,$235.49 ,OP,235.49,235.49,,,,,,
UHC MCR ADV,CPT,77063,Breast tomosynthesis bi,Physician,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
UHC MCR ADV,CPT,77065,Dx mammo incl cad uni,Physician,Per Unit,$83.47 ,OP,83.47,275.87,,,,,,
UHC MCR ADV,CPT,77066,Dx mammo incl cad bi,Physician,Per Unit,$106.70 ,OP,106.7,275.87,,,,,,
UHC MCR ADV,CPT,77067,Scr mammo bi incl cad,Physician,Per Unit,$88.24 ,OP,88.24,275.87,,,,,,
UHC MCR ADV,CPT,77071,X-ray stress view,APC 5521,RVU Per Case,$82.79 ,OP,82.79,205.88,,,,,,
UHC MCR ADV,CPT,77072,X-rays for bone age,APC 5522,RVU Per Case,$111.51 ,OP,111.51,122,,,,,,
UHC MCR ADV,CPT,77073,X-rays bone length studies,APC 5522,RVU Per Case,$111.51 ,OP,111.51,198.25,,,,,,
UHC MCR ADV,CPT,77074,X-rays bone survey limited,APC 5522,RVU Per Case,$111.51 ,OP,111.51,358.39,,,,,,
UHC MCR ADV,CPT,77075,X-rays bone survey complete,APC 5522,RVU Per Case,$111.51 ,OP,111.51,514.72,,,,,,
UHC MCR ADV,CPT,77076,X-rays bone survey infant,APC 5522,RVU Per Case,$111.51 ,OP,111.51,476.6,,,,,,
UHC MCR ADV,CPT,77077,Joint survey single view,APC 5522,RVU Per Case,$111.51 ,OP,111.51,224.95,,,,,,
UHC MCR ADV,CPT,77078,Ct bone density axial,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,927,,,,,,
UHC MCR ADV,CPT,77080,Dxa bone density axial,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,537.6,,,,,,
UHC MCR ADV,CPT,77081,Dxa bone density/peripheral,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,167.76,,,,,,
UHC MCR ADV,CPT,77084,Magnetic image bone marrow,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,507.00",,,,,,
UHC MCR ADV,CPT,77085,Dxa bone density study,APC 5522,RVU Per Case,$111.51 ,OP,111.51,111.51,,,,,,
UHC MCR ADV,CPT,77086,Fracture assessment via dxa,APC 5521,RVU Per Case,$82.79 ,OP,82.79,213.51,,,,,,
UHC MCR ADV,CPT,77280,Set radiation therapy field,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,964.61,,,,,,
UHC MCR ADV,CPT,77285,Set radiation therapy field,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,"1,662.33",,,,,,
UHC MCR ADV,CPT,77290,Set radiation therapy field,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,"2,558.32",,,,,,
UHC MCR ADV,CPT,77295,3-d radiotherapy plan,APC 5613,RVU Per Unit,"$1,291.62 ",OP,"1,291.62","3,736.44",,,,,,
UHC MCR ADV,CPT,77299,Radiation therapy planning,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,129.83,,,,,,
UHC MCR ADV,CPT,77300,Radiation therapy dose plan,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,388.89,,,,,,
UHC MCR ADV,CPT,77301,Radiotherapy dose plan imrt,APC 5613,RVU Per Unit,"$1,291.62 ",OP,"1,291.62","11,205.50",,,,,,
UHC MCR ADV,CPT,77306,Telethx isodose plan simple,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,392.7,,,,,,
UHC MCR ADV,CPT,77307,Telethx isodose plan cplx,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,777.79,,,,,,
UHC MCR ADV,CPT,77316,Brachytx isodose plan simple,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,747.28,,,,,,
UHC MCR ADV,CPT,77317,Brachytx isodose intermed,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,"1,059.93",,,,,,
UHC MCR ADV,CPT,77318,Brachytx isodose complex,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,"1,456.44",,,,,,
UHC MCR ADV,CPT,77321,Special teletx port plan,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,659.6,,,,,,
UHC MCR ADV,CPT,77331,Special radiation dosimetry,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,320.27,,,,,,
UHC MCR ADV,CPT,77332,Radiation treatment aid(s),APC 5611,RVU Per Unit,$129.83 ,OP,129.83,407.96,,,,,,
UHC MCR ADV,CPT,77333,Radiation treatment aid(s),APC 5611,RVU Per Unit,$129.83 ,OP,129.83,369.83,,,,,,
UHC MCR ADV,CPT,77334,Radiation treatment aid(s),APC 5612,RVU Per Unit,$346.58 ,OP,346.58,869.3,,,,,,
UHC MCR ADV,CPT,77336,Radiation physics consult,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,343.14,,,,,,
UHC MCR ADV,CPT,77338,Design mlc device for imrt,APC 5612,RVU Per Unit,$346.58 ,OP,346.58,346.58,,,,,,
UHC MCR ADV,CPT,77370,Radiation physics consult,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,629.1,,,,,,
UHC MCR ADV,CPT,77371,Srs multisource,APC 5627,RVU Per Case,"$7,954.01 ",OP,"6,969.60","7,954.01",,,,,,
UHC MCR ADV,CPT,77372,Srs linear based,APC 5627,RVU Per Case,"$7,954.01 ",OP,"4,148.22","7,954.01",,,,,,
UHC MCR ADV,CPT,77373,Sbrt delivery,APC 5626,RVU Per Unit,"$1,774.17 ",OP,"1,774.17","13,221.44",,,,,,
UHC MCR ADV,CPT,77385,Ntsty modul rad tx dlvr smpl,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"1,379.33",,,,,,
UHC MCR ADV,CPT,77386,Ntsty modul rad tx dlvr cplx,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"1,379.33",,,,,,
UHC MCR ADV,CPT,77399,External radiation dosimetry,APC 5611,RVU Per Unit,$129.83 ,OP,129.83,129.83,,,,,,
UHC MCR ADV,CPT,77401,Radiation treatment delivery,APC 5621,RVU Per Unit,$123.36 ,OP,123.36,183.02,,,,,,
UHC MCR ADV,CPT,77402,Radiation treatment delivery,APC 5621,RVU Per Unit,$123.36 ,OP,123.36,123.36,,,,,,
UHC MCR ADV,CPT,77407,Radiation treatment delivery,APC 5622,RVU Per Unit,$247.32 ,OP,247.32,247.32,,,,,,
UHC MCR ADV,CPT,77412,Radiation treatment delivery,APC 5622,RVU Per Unit,$247.32 ,OP,247.32,"1,067.55",,,,,,
UHC MCR ADV,CPT,77423,Neutron beam tx complex,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"1,235.32",,,,,,
UHC MCR ADV,CPT,77424,Io rad tx delivery by x-ray,APC 5627,RVU Per Case,"$7,954.01 ",OP,"7,954.01","7,954.01",,,,,,
UHC MCR ADV,CPT,77425,Io rad tx deliver by elctrns,APC 5627,RVU Per Case,"$7,954.01 ",OP,"7,954.01","7,954.01",,,,,,
UHC MCR ADV,CPT,77470,Special radiation treatment,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"1,509.83",,,,,,
UHC MCR ADV,CPT,77520,Proton trmt simple w/o comp,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,555.2,,,,,,
UHC MCR ADV,CPT,77522,Proton trmt simple w/comp,APC 5625,RVU Per Unit,"$1,328.18 ",OP,"1,328.18","1,328.18",,,,,,
UHC MCR ADV,CPT,77523,Proton trmt intermediate,APC 5625,RVU Per Unit,"$1,328.18 ",OP,"1,328.18","1,328.18",,,,,,
UHC MCR ADV,CPT,77525,Proton treatment complex,APC 5625,RVU Per Unit,"$1,328.18 ",OP,"1,328.18","1,328.18",,,,,,
UHC MCR ADV,CPT,77600,Hyperthermia treatment,APC 5622,RVU Per Unit,$247.32 ,OP,247.32,"1,902.54",,,,,,
UHC MCR ADV,CPT,77605,Hyperthermia treatment,APC 5624,RVU Per Unit,$724.98 ,OP,724.98,"3,397.11",,,,,,
UHC MCR ADV,CPT,77610,Hyperthermia treatment,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"3,156.91",,,,,,
UHC MCR ADV,CPT,77615,Hyperthermia treatment,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"4,464.67",,,,,,
UHC MCR ADV,CPT,77620,Hyperthermia treatment,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"2,013.11",,,,,,
UHC MCR ADV,CPT,77750,Infuse radioactive materials,APC 5622,RVU Per Unit,$247.32 ,OP,247.32,"1,730.97",,,,,,
UHC MCR ADV,CPT,77761,Apply intrcav radiat simple,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"1,803.41",,,,,,
UHC MCR ADV,CPT,77762,Apply intrcav radiat interm,APC 5623,RVU Per Unit,$555.20 ,OP,555.2,"2,463.00",,,,,,
UHC MCR ADV,CPT,77763,Apply intrcav radiat compl,APC 5624,RVU Per Unit,$724.98 ,OP,724.98,724.98,,,,,,
UHC MCR ADV,CPT,77767,Hdr rdncl skn surf brachytx,APC 5622,RVU Per Unit,$247.32 ,OP,247.32,247.32,,,,,,
UHC MCR ADV,CPT,77768,Hdr rdncl skn surf brachytx,APC 5622,RVU Per Unit,$247.32 ,OP,247.32,247.32,,,,,,
UHC MCR ADV,CPT,77770,Hdr rdncl ntrstl/icav brchtx,APC 5624,RVU Per Unit,$724.98 ,OP,724.98,964.61,,,,,,
UHC MCR ADV,CPT,77771,Hdr rdncl ntrstl/icav brchtx,APC 5624,RVU Per Unit,$724.98 ,OP,724.98,"2,882.39",,,,,,
UHC MCR ADV,CPT,77772,Hdr rdncl ntrstl/icav brchtx,APC 5624,RVU Per Unit,$724.98 ,OP,724.98,"4,285.47",,,,,,
UHC MCR ADV,CPT,77778,Apply interstit radiat compl,APC 5624,RVU Per Unit,$724.98 ,OP,724.98,"4,209.21",,,,,,
UHC MCR ADV,CPT,77789,Apply surf ldr radionuclide,APC 5621,RVU Per Unit,$123.36 ,OP,123.36,533.78,,,,,,
UHC MCR ADV,CPT,77799,Radium/radioisotope therapy,APC 5621,RVU Per Unit,$123.36 ,OP,123.36,123.36,,,,,,
UHC MCR ADV,CPT,78012,Thyroid uptake measurement,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,453.71,,,,,,
UHC MCR ADV,CPT,78013,Thyroid imaging w/blood flow,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,884.55,,,,,,
UHC MCR ADV,CPT,78014,Thyroid imaging w/blood flow,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,105.68",,,,,,
UHC MCR ADV,CPT,78015,Thyroid met imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,044.69",,,,,,
UHC MCR ADV,CPT,78016,Thyroid met imaging/studies,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,578.46",,,,,,
UHC MCR ADV,CPT,78018,Thyroid met imaging body,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,616.58",,,,,,
UHC MCR ADV,CPT,78070,Parathyroid planar imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,884.55,,,,,,
UHC MCR ADV,CPT,78071,Parathyrd planar w/wo subtrj,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,884.55,,,,,,
UHC MCR ADV,CPT,78072,Parathyrd planar w/spect&ct,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,884.55,,,,,,
UHC MCR ADV,CPT,78075,Adrenal cortex & medulla img,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","2,085.54",,,,,,
UHC MCR ADV,CPT,78099,Endocrine nuclear procedure,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
UHC MCR ADV,CPT,78102,Bone marrow imaging ltd,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
UHC MCR ADV,CPT,78103,Bone marrow imaging mult,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,109.50",,,,,,
UHC MCR ADV,CPT,78104,Bone marrow imaging body,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,273.44",,,,,,
UHC MCR ADV,CPT,78110,Plasma volume single,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,336.39",,,,,,
UHC MCR ADV,CPT,78111,Plasma volume multiple,APC 5593,RVU Per Unit,"$1,336.39 ",OP,518.52,"1,336.39",,,,,,
UHC MCR ADV,CPT,78120,Red cell mass single,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
UHC MCR ADV,CPT,78121,Red cell mass multiple,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,552.84,,,,,,
UHC MCR ADV,CPT,78122,Blood volume,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,701.54,,,,,,
UHC MCR ADV,CPT,78130,Red cell survival study,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,793.05,,,,,,
UHC MCR ADV,CPT,78140,Red cell sequestration,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,781.61,,,,,,
UHC MCR ADV,CPT,78185,Spleen imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
UHC MCR ADV,CPT,78191,Platelet survival,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,067.55",,,,,,
UHC MCR ADV,CPT,78195,Lymph system imaging,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,704.28",,,,,,
UHC MCR ADV,CPT,78199,Blood/lymph nuclear exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
UHC MCR ADV,CPT,78201,Liver imaging,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,884.55,,,,,,
UHC MCR ADV,CPT,78202,Liver imaging with flow,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,014.17",,,,,,
UHC MCR ADV,CPT,78215,Liver and spleen imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,941.74,,,,,,
UHC MCR ADV,CPT,78216,Liver & spleen image/flow,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,728.23,,,,,,
UHC MCR ADV,CPT,78226,Hepatobiliary system imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,570.83",,,,,,
UHC MCR ADV,CPT,78227,Hepatobil syst image w/drug,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,570.83",,,,,,
UHC MCR ADV,CPT,78230,Salivary gland imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,804.48,,,,,,
UHC MCR ADV,CPT,78231,Serial salivary imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,697.72,,,,,,
UHC MCR ADV,CPT,78232,Salivary gland function exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,712.98,,,,,,
UHC MCR ADV,CPT,78258,Esophageal motility study,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,113.30",,,,,,
UHC MCR ADV,CPT,78261,Gastric mucosa imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,242.94",,,,,,
UHC MCR ADV,CPT,78262,Gastroesophageal reflux exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,227.68",,,,,,
UHC MCR ADV,CPT,78264,Gastric emptying imag study,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,403.08",,,,,,
UHC MCR ADV,CPT,78265,Gastric emptying imag study,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,403.08",,,,,,
UHC MCR ADV,CPT,78266,Gastric emptying imag study,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,403.08",,,,,,
UHC MCR ADV,CPT,78267,Breath tst attain/anal c-14,Lab Services,Per Unit,$11.06 ,OP,11.06,11.06,,,,,,
UHC MCR ADV,CPT,78268,Breath test analysis c-14,Lab Services,Per Unit,$94.41 ,OP,94.41,301.2,,,,,,
UHC MCR ADV,CPT,78278,Acute gi blood loss imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
UHC MCR ADV,CPT,78282,Gi protein loss exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,407.96,,,,,,
UHC MCR ADV,CPT,78290,Meckels divert exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,498.39",,,,,,
UHC MCR ADV,CPT,78291,Leveen/shunt patency exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,227.68",,,,,,
UHC MCR ADV,CPT,78299,Gi nuclear procedure,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
UHC MCR ADV,CPT,78300,Bone imaging limited area,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,869.3,,,,,,
UHC MCR ADV,CPT,78305,Bone imaging multiple areas,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,155.24",,,,,,
UHC MCR ADV,CPT,78306,Bone imaging whole body,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,281.07",,,,,,
UHC MCR ADV,CPT,78315,Bone imaging 3 phase,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,692.84",,,,,,
UHC MCR ADV,CPT,78399,Musculoskeletal nuclear exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
UHC MCR ADV,CPT,78414,Non-imaging heart function,APC 5592,RVU Per Unit,$500.81 ,OP,377.46,500.81,,,,,,
UHC MCR ADV,CPT,78428,Cardiac shunt imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,998.92,,,,,,
UHC MCR ADV,CPT,78429,Myocrd img pet 1 std w/ct,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,240.30",,,,,,
UHC MCR ADV,CPT,78430,Myocrd img pet rst/strs w/ct,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,217.42",,,,,,
UHC MCR ADV,CPT,78431,Myocrd img pet rst&strs ct,APC 1522,RVU Per Unit,"$2,302.98 ",OP,"2,150.30","7,339.44",,,,,,
UHC MCR ADV,CPT,78432,Myocrd img pet 2rtracer,APC 1523,RVU Per Unit,"$2,814.64 ",OP,"2,628.05","8,030.21",,,,,,
UHC MCR ADV,CPT,78433,Myocrd img pet 2rtracer ct,APC 1523,RVU Per Unit,"$2,814.64 ",OP,"2,628.05","8,778.55",,,,,,
UHC MCR ADV,CPT,78445,Vascular flow imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,838.79,,,,,,
UHC MCR ADV,CPT,78451,Ht muscle image spect sing,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","2,116.06",,,,,,
UHC MCR ADV,CPT,78452,Ht muscle image spect mult,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","3,343.73",,,,,,
UHC MCR ADV,CPT,78453,Ht muscle image planar sing,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,631.84",,,,,,
UHC MCR ADV,CPT,78454,Ht musc image planar mult,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,772.90",,,,,,
UHC MCR ADV,CPT,78456,Acute venous thrombus image,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,784.34",,,,,,
UHC MCR ADV,CPT,78457,Venous thrombosis imaging,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,964.61,,,,,,
UHC MCR ADV,CPT,78458,Ven thrombosis images bilat,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,078.99",,,,,,
UHC MCR ADV,CPT,78459,Myocrd img pet single study,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","7,240.30",,,,,,
UHC MCR ADV,CPT,78466,Heart infarct image,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,922.67,,,,,,
UHC MCR ADV,CPT,78468,Heart infarct image (ef),APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,166.68",,,,,,
UHC MCR ADV,CPT,78469,Heart infarct image (3d),APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,338.26",,,,,,
UHC MCR ADV,CPT,78472,Gated heart planar single,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,368.75",,,,,,
UHC MCR ADV,CPT,78473,Gated heart multiple,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,872.03",,,,,,
UHC MCR ADV,CPT,78481,Heart first pass single,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,201.00",,,,,,
UHC MCR ADV,CPT,78483,Heart first pass multiple,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,700.46",,,,,,
UHC MCR ADV,CPT,78491,Myocrd img pet 1std rst/strs,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,217.42",,,,,,
UHC MCR ADV,CPT,78492,Myocrd img pet mlt rst&strs,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,339.44",,,,,,
UHC MCR ADV,CPT,78494,Heart image spect,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,486.95",,,,,,
UHC MCR ADV,CPT,78499,Cardiovascular nuclear exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
UHC MCR ADV,CPT,78579,Lung ventilation imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,155.24",,,,,,
UHC MCR ADV,CPT,78580,Lung perfusion imaging,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,071.37",,,,,,
UHC MCR ADV,CPT,78582,Lung ventilat&perfus imaging,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,769.09",,,,,,
UHC MCR ADV,CPT,78597,Lung perfusion differential,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,906.36",,,,,,
UHC MCR ADV,CPT,78598,Lung perf&ventilat diferentl,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,906.36",,,,,,
UHC MCR ADV,CPT,78599,Respiratory nuclear exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
UHC MCR ADV,CPT,78600,Brain image < 4 views,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,888.36,,,,,,
UHC MCR ADV,CPT,78601,Brain image w/flow < 4 views,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,059.93",,,,,,
UHC MCR ADV,CPT,78605,Brain image 4+ views,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,991.29,,,,,,
UHC MCR ADV,CPT,78606,Brain image w/flow 4 + views,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,540.33",,,,,,
UHC MCR ADV,CPT,78608,Brain imaging (pet),APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,209.80",,,,,,
UHC MCR ADV,CPT,78610,Brain flow imaging only,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,888.36,,,,,,
UHC MCR ADV,CPT,78630,Cerebrospinal fluid scan,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,647.08",,,,,,
UHC MCR ADV,CPT,78635,Csf ventriculography,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,475.51",,,,,,
UHC MCR ADV,CPT,78645,Csf shunt evaluation,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,502.21",,,,,,
UHC MCR ADV,CPT,78650,Csf leakage imaging,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,601.33",,,,,,
UHC MCR ADV,CPT,78660,Nuclear exam of tear flow,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,831.17,,,,,,
UHC MCR ADV,CPT,78699,Nervous system nuclear exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
UHC MCR ADV,CPT,78700,Kidney imaging morphol,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,884.55,,,,,,
UHC MCR ADV,CPT,78701,Kidney imaging with flow,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,056.11",,,,,,
UHC MCR ADV,CPT,78707,K flow/funct image w/o drug,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,235.32",,,,,,
UHC MCR ADV,CPT,78708,K flow/funct image w/drug,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,014.17",,,,,,
UHC MCR ADV,CPT,78709,K flow/funct image multiple,APC 5592,RVU Per Unit,$500.81 ,OP,500.81,"1,795.78",,,,,,
UHC MCR ADV,CPT,78725,Kidney function study,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,518.52,,,,,,
UHC MCR ADV,CPT,78740,Ureteral reflux study,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,040.87",,,,,,
UHC MCR ADV,CPT,78761,Testicular imaging w/flow,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,052.29",,,,,,
UHC MCR ADV,CPT,78799,Genitourinary nuclear exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
UHC MCR ADV,CPT,78800,Rp loclzj tum 1 area 1 d img,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,949.36,,,,,,
UHC MCR ADV,CPT,78801,Rp loclzj tum 2+area 1+d img,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"1,265.81",,,,,,
UHC MCR ADV,CPT,78802,Rp loclzj tum whbdy 1 d img,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,654.72",,,,,,
UHC MCR ADV,CPT,78803,Rp loclzj tum spect 1 area,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,826.28",,,,,,
UHC MCR ADV,CPT,78804,Rp loclzj tum whbdy 2+d img,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","2,870.96",,,,,,
UHC MCR ADV,CPT,78808,Iv inj ra drug dx study,APC 5591,RVU Per Case,$385.91 ,OP,385.91,385.91,,,,,,
UHC MCR ADV,CPT,78811,Pet image ltd area,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,336.39",,,,,,
UHC MCR ADV,CPT,78812,Pet image skull-thigh,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,347.07",,,,,,
UHC MCR ADV,CPT,78813,Pet image full body,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,354.67",,,,,,
UHC MCR ADV,CPT,78814,Pet image w/ct lmtd,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,404.24",,,,,,
UHC MCR ADV,CPT,78815,Pet image w/ct skull-thigh,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,446.19",,,,,,
UHC MCR ADV,CPT,78816,Pet image w/ct full body,APC 5594,RVU Per Unit,"$1,514.86 ",OP,"1,514.86","7,461.44",,,,,,
UHC MCR ADV,CPT,78830,Rp loclzj tum spect w/ct 1,APC 5593,RVU Per Unit,"$1,336.39 ",OP,927,"2,600.43",,,,,,
UHC MCR ADV,CPT,78831,Rp loclzj tum spect 2 areas,APC 5593,RVU Per Unit,"$1,336.39 ",OP,927,"3,860.65",,,,,,
UHC MCR ADV,CPT,78832,Rp loclzj tum spect w/ct 2,APC 5594,RVU Per Unit,"$1,514.86 ",OP,927,"5,097.10",,,,,,
UHC MCR ADV,CPT,78999,Nuclear diagnostic exam,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,385.91,,,,,,
UHC MCR ADV,CPT,79005,Nuclear rx oral admin,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,800.67,,,,,,
UHC MCR ADV,CPT,79101,Nuclear rx iv admin,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,896,,,,,,
UHC MCR ADV,CPT,79200,Nuclear rx intracav admin,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,911.23,,,,,,
UHC MCR ADV,CPT,79300,Nuclr rx interstit colloid,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,724.42,,,,,,
UHC MCR ADV,CPT,79403,Hematopoietic nuclear tx,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,"1,132.37",,,,,,
UHC MCR ADV,CPT,79440,Nuclear rx intra-articular,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,838.79,,,,,,
UHC MCR ADV,CPT,79445,Nuclear rx intra-arterial,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,"1,162.87",,,,,,
UHC MCR ADV,CPT,79999,Nuclear medicine therapy,APC 5661,RVU Per Unit,$255.45 ,OP,255.45,255.45,,,,,,
UHC MCR ADV,CPT,80047,Metabolic panel ionized ca,Lab Services,Per Unit,$13.73 ,OP,13.73,41.94,,,,,,
UHC MCR ADV,CPT,80048,Metabolic panel total ca,Lab Services,Per Unit,$8.46 ,OP,8.46,132.19,,,,,,
UHC MCR ADV,CPT,80051,Electrolyte panel,Lab Services,Per Unit,$7.01 ,OP,7.01,34.31,,,,,,
UHC MCR ADV,CPT,80053,Comprehen metabolic panel,Lab Services,Per Unit,$10.56 ,OP,10.56,172.42,,,,,,
UHC MCR ADV,CPT,80055,Obstetric panel,Lab Services,Per Unit,$47.81 ,OP,47.81,301.2,,,,,,
UHC MCR ADV,CPT,80061,Lipid panel,Lab Services,Per Unit,$13.39 ,OP,13.39,68.63,,,,,,
UHC MCR ADV,CPT,80069,Renal function panel,Lab Services,Per Unit,$8.68 ,OP,8.68,38.13,,,,,,
UHC MCR ADV,CPT,80074,Acute hepatitis panel,Lab Services,Per Unit,$47.63 ,OP,47.63,213.51,,,,,,
UHC MCR ADV,CPT,80076,Hepatic function panel,Lab Services,Per Unit,$8.17 ,OP,8.17,126.44,,,,,,
UHC MCR ADV,CPT,80081,Obstetric panel,Lab Services,Per Unit,$74.86 ,OP,74.86,74.86,,,,,,
UHC MCR ADV,CPT,80143,Drug assay acetaminophen,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,
UHC MCR ADV,CPT,80145,Drug assay adalimumab,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,
UHC MCR ADV,CPT,80150,Assay of amikacin,Lab Services,Per Unit,$15.08 ,OP,15.08,49.56,,,,,,
UHC MCR ADV,CPT,80151,Drug assay amiodarone,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,
UHC MCR ADV,CPT,80155,Drug assay caffeine,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,
UHC MCR ADV,CPT,80156,Assay carbamazepine total,Lab Services,Per Unit,$14.57 ,OP,14.57,64.82,,,,,,
UHC MCR ADV,CPT,80157,Assay carbamazepine free,Lab Services,Per Unit,$13.25 ,OP,13.25,57.19,,,,,,
UHC MCR ADV,CPT,80158,Drug assay cyclosporine,Lab Services,Per Unit,$18.05 ,OP,18.05,80.07,,,,,,
UHC MCR ADV,CPT,80159,Drug assay clozapine,Lab Services,Per Unit,$20.15 ,OP,20.15,20.15,,,,,,
UHC MCR ADV,CPT,80161,Asy carbamazepin 10-11-epxid,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,
UHC MCR ADV,CPT,80162,Assay of digoxin total,Lab Services,Per Unit,$13.28 ,OP,13.28,61,,,,,,
UHC MCR ADV,CPT,80163,Assay of digoxin free,Lab Services,Per Unit,$13.28 ,OP,13.28,61,,,,,,
UHC MCR ADV,CPT,80164,Assay dipropylacetic acd tot,Lab Services,Per Unit,$13.54 ,OP,13.54,61,,,,,,
UHC MCR ADV,CPT,80165,Dipropylacetic acid free,Lab Services,Per Unit,$13.54 ,OP,13.54,61,,,,,,
UHC MCR ADV,CPT,80167,Drug assay felbamate,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,
UHC MCR ADV,CPT,80168,Assay of ethosuximide,Lab Services,Per Unit,$16.34 ,OP,16.34,72.44,,,,,,
UHC MCR ADV,CPT,80169,Drug assay everolimus,Lab Services,Per Unit,$13.73 ,OP,13.73,13.73,,,,,,
UHC MCR ADV,CPT,80170,Assay of gentamicin,Lab Services,Per Unit,$16.38 ,OP,16.38,72.44,,,,,,
UHC MCR ADV,CPT,80171,Drug screen quant gabapentin,Lab Services,Per Unit,$21.67 ,OP,21.67,21.67,,,,,,
UHC MCR ADV,CPT,80173,Assay of haloperidol,Lab Services,Per Unit,$15.78 ,OP,15.78,15.78,,,,,,
UHC MCR ADV,CPT,80175,Drug screen quan lamotrigine,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,
UHC MCR ADV,CPT,80176,Assay of lidocaine,Lab Services,Per Unit,$14.69 ,OP,14.69,64.82,,,,,,
UHC MCR ADV,CPT,80177,Drug scrn quan levetiracetam,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,
UHC MCR ADV,CPT,80178,Assay of lithium,Lab Services,Per Unit,$6.61 ,OP,6.61,30.51,,,,,,
UHC MCR ADV,CPT,80179,Drug assay salicylate,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,
UHC MCR ADV,CPT,80180,Drug scrn quan mycophenolate,Lab Services,Per Unit,$18.05 ,OP,18.05,18.05,,,,,,
UHC MCR ADV,CPT,80181,Drug assay flecainide,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,
UHC MCR ADV,CPT,80183,Drug scrn quant oxcarbazepin,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,
UHC MCR ADV,CPT,80184,Assay of phenobarbital,Lab Services,Per Unit,$15.30 ,OP,15.3,49.56,,,,,,
UHC MCR ADV,CPT,80185,Assay of phenytoin total,Lab Services,Per Unit,$13.25 ,OP,13.25,57.19,,,,,,
UHC MCR ADV,CPT,80186,Assay of phenytoin free,Lab Services,Per Unit,$13.76 ,OP,13.76,61,,,,,,
UHC MCR ADV,CPT,80187,Drug assay posaconazole,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,
UHC MCR ADV,CPT,80188,Assay of primidone,Lab Services,Per Unit,$16.59 ,OP,16.59,72.44,,,,,,
UHC MCR ADV,CPT,80189,Drug assay itraconzaole,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,
UHC MCR ADV,CPT,80190,Assay of procainamide,Lab Services,Per Unit,$60.00 ,OP,60,76.26,,,,,,
UHC MCR ADV,CPT,80192,Assay of procainamide,Lab Services,Per Unit,$16.75 ,OP,16.75,76.26,,,,,,
UHC MCR ADV,CPT,80193,Drug assay leflunomide,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,
UHC MCR ADV,CPT,80194,Assay of quinidine,Lab Services,Per Unit,$14.60 ,OP,14.6,64.82,,,,,,
UHC MCR ADV,CPT,80195,Assay of sirolimus,Lab Services,Per Unit,$13.73 ,OP,13.73,61,,,,,,
UHC MCR ADV,CPT,80197,Assay of tacrolimus,Lab Services,Per Unit,$13.73 ,OP,13.73,61,,,,,,
UHC MCR ADV,CPT,80198,Assay of theophylline,Lab Services,Per Unit,$14.14 ,OP,14.14,64.82,,,,,,
UHC MCR ADV,CPT,80199,Drug screen quant tiagabine,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,
UHC MCR ADV,CPT,80200,Assay of tobramycin,Lab Services,Per Unit,$16.13 ,OP,16.13,49.56,,,,,,
UHC MCR ADV,CPT,80201,Assay of topiramate,Lab Services,Per Unit,$11.92 ,OP,11.92,53.38,,,,,,
UHC MCR ADV,CPT,80202,Assay of vancomycin,Lab Services,Per Unit,$13.54 ,OP,13.54,61,,,,,,
UHC MCR ADV,CPT,80203,Drug screen quant zonisamide,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,
UHC MCR ADV,CPT,80204,Drug assay methotrexate,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,
UHC MCR ADV,CPT,80210,Drug assay rufinamide,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,
UHC MCR ADV,CPT,80230,Drug assay infliximab,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,
UHC MCR ADV,CPT,80235,Drug assay lacosamide,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,
UHC MCR ADV,CPT,80280,Drug assay vedolizumab,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,
UHC MCR ADV,CPT,80285,Drug assay voriconazole,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,
UHC MCR ADV,CPT,80299,Quantitative assay drug,Lab Services,Per Unit,$18.64 ,OP,18.64,61,,,,,,
UHC MCR ADV,CPT,80305,Drug test prsmv dir opt obs,Lab Services,Per Unit,$12.60 ,OP,12.6,64.82,,,,,,
UHC MCR ADV,CPT,80306,Drug test prsmv instrmnt,Lab Services,Per Unit,$17.14 ,OP,17.14,64.82,,,,,,
UHC MCR ADV,CPT,80307,Drug test prsmv chem anlyzr,Lab Services,Per Unit,$62.14 ,OP,62.14,62.14,,,,,,
UHC MCR ADV,CPT,80400,Acth stimulation panel,Lab Services,Per Unit,$32.62 ,OP,32.62,144.88,,,,,,
UHC MCR ADV,CPT,80402,Acth stimulation panel,Lab Services,Per Unit,$86.96 ,OP,86.96,388.89,,,,,,
UHC MCR ADV,CPT,80406,Acth stimulation panel,Lab Services,Per Unit,$78.26 ,OP,78.26,346.96,,,,,,
UHC MCR ADV,CPT,80408,Aldosterone suppression eval,Lab Services,Per Unit,$125.50 ,OP,125.5,560.47,,,,,,
UHC MCR ADV,CPT,80410,Calcitonin stimul panel,Lab Services,Per Unit,$80.37 ,OP,80.37,358.39,,,,,,
UHC MCR ADV,CPT,80412,Crh stimulation panel,Lab Services,Per Unit,$801.62 ,OP,801.62,"1,467.89",,,,,,
UHC MCR ADV,CPT,80414,Testosterone response panel,Lab Services,Per Unit,$51.64 ,OP,51.64,228.77,,,,,,
UHC MCR ADV,CPT,80415,Tot estradiol response panel,Lab Services,Per Unit,$55.89 ,OP,55.89,99.13,,,,,,
UHC MCR ADV,CPT,80416,Renin stimulation panel,Lab Services,Per Unit,$209.32 ,OP,209.32,587.16,,,,,,
UHC MCR ADV,CPT,80417,Renin stimulation panel,Lab Services,Per Unit,$43.99 ,OP,43.99,194.45,,,,,,
UHC MCR ADV,CPT,80418,Pituitary evaluation panel,Lab Services,Per Unit,$579.48 ,OP,579.48,"2,573.58",,,,,,
UHC MCR ADV,CPT,80420,Dexamethasone panel,Lab Services,Per Unit,$161.88 ,OP,161.88,320.27,,,,,,
UHC MCR ADV,CPT,80422,Glucagon tolerance panel,Lab Services,Per Unit,$46.07 ,OP,46.07,205.88,,,,,,
UHC MCR ADV,CPT,80424,Glucagon tolerance panel,Lab Services,Per Unit,$50.50 ,OP,50.5,224.95,,,,,,
UHC MCR ADV,CPT,80426,Gonadotropin hormone panel,Lab Services,Per Unit,$148.41 ,OP,148.41,659.6,,,,,,
UHC MCR ADV,CPT,80428,Growth hormone panel,Lab Services,Per Unit,$66.70 ,OP,66.7,289.76,,,,,,
UHC MCR ADV,CPT,80430,Growth hormone panel,Lab Services,Per Unit,$129.33 ,OP,129.33,343.14,,,,,,
UHC MCR ADV,CPT,80432,Insulin suppression panel,Lab Services,Per Unit,$165.61 ,OP,165.61,602.41,,,,,,
UHC MCR ADV,CPT,80434,Insulin tolerance panel,Lab Services,Per Unit,$285.03 ,OP,285.03,449.9,,,,,,
UHC MCR ADV,CPT,80435,Insulin tolerance panel,Lab Services,Per Unit,$103.00 ,OP,103,449.9,,,,,,
UHC MCR ADV,CPT,80436,Metyrapone panel,Lab Services,Per Unit,$91.16 ,OP,91.16,301.2,,,,,,
UHC MCR ADV,CPT,80438,Trh stimulation panel,Lab Services,Per Unit,$50.41 ,OP,50.41,224.95,,,,,,
UHC MCR ADV,CPT,80439,Trh stimulation panel,Lab Services,Per Unit,$67.21 ,OP,67.21,297.39,,,,,,
UHC MCR ADV,CPT,80500,Lab pathology consultation,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
UHC MCR ADV,CPT,80502,Lab pathology consultation,APC 5672,RVU Per Case,$152.64 ,OP,152.64,320.27,,,,,,
UHC MCR ADV,CPT,81000,Urinalysis nonauto w/scope,Lab Services,Per Unit,$4.02 ,OP,4.02,15.26,,,,,,
UHC MCR ADV,CPT,81001,Urinalysis auto w/scope,Lab Services,Per Unit,$3.17 ,OP,3.17,15.26,,,,,,
UHC MCR ADV,CPT,81002,Urinalysis nonauto w/o scope,Lab Services,Per Unit,$3.48 ,OP,3.48,11.44,,,,,,
UHC MCR ADV,CPT,81003,Urinalysis auto w/o scope,Lab Services,Per Unit,$2.25 ,OP,2.25,11.44,,,,,,
UHC MCR ADV,CPT,81005,Urinalysis,Lab Services,Per Unit,$2.17 ,OP,2.17,11.44,,,,,,
UHC MCR ADV,CPT,81007,Urine screen for bacteria,Lab Services,Per Unit,$29.98 ,OP,11.44,29.98,,,,,,
UHC MCR ADV,CPT,81015,Microscopic exam of urine,Lab Services,Per Unit,$3.05 ,OP,3.05,15.26,,,,,,
UHC MCR ADV,CPT,81020,Urinalysis glass test,Lab Services,Per Unit,$4.70 ,OP,4.7,15.26,,,,,,
UHC MCR ADV,CPT,81025,Urine pregnancy test,Lab Services,Per Unit,$8.61 ,OP,8.61,30.51,,,,,,
UHC MCR ADV,CPT,81050,Urinalysis volume measure,Lab Services,Per Unit,$3.64 ,OP,3.64,11.44,,,,,,
UHC MCR ADV,CPT,81105,Hpa-1 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
UHC MCR ADV,CPT,81106,Hpa-2 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
UHC MCR ADV,CPT,81107,Hpa-3 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
UHC MCR ADV,CPT,81108,Hpa-4 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
UHC MCR ADV,CPT,81109,Hpa-5 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
UHC MCR ADV,CPT,81110,Hpa-6 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
UHC MCR ADV,CPT,81111,Hpa-9 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
UHC MCR ADV,CPT,81112,Hpa-15 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
UHC MCR ADV,CPT,81120,Idh1 common variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,
UHC MCR ADV,CPT,81121,Idh2 common variants,Lab Services,Per Unit,$295.79 ,OP,295.79,295.79,,,,,,
UHC MCR ADV,CPT,81161,Dmd dup/delet analysis,Lab Services,Per Unit,$279.00 ,OP,279,279,,,,,,
UHC MCR ADV,CPT,81162,Brca1&2 gen full seq dup/del,Lab Services,Per Unit,"$1,824.88 ",OP,"1,824.88","1,824.88",,,,,,
UHC MCR ADV,CPT,81163,Brca1&2 gene full seq alys,Lab Services,Per Unit,$468.00 ,OP,468,468,,,,,,
UHC MCR ADV,CPT,81164,Brca1&2 gen ful dup/del alys,Lab Services,Per Unit,$584.23 ,OP,584.23,584.23,,,,,,
UHC MCR ADV,CPT,81165,Brca1 gene full seq alys,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,
UHC MCR ADV,CPT,81166,Brca1 gene full dup/del alys,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,
UHC MCR ADV,CPT,81167,Brca2 gene full dup/del alys,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,
UHC MCR ADV,CPT,81168,Ccnd1/igh translocation alys,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,
UHC MCR ADV,CPT,81170,Abl1 gene,Lab Services,Per Unit,$300.00 ,OP,300,300,,,,,,
UHC MCR ADV,CPT,81171,Aff2 gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
UHC MCR ADV,CPT,81172,Aff2 gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
UHC MCR ADV,CPT,81173,Ar gene full gene sequence,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,
UHC MCR ADV,CPT,81174,Ar gene known famil variant,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
UHC MCR ADV,CPT,81175,Asxl1 full gene sequence,Lab Services,Per Unit,$676.50 ,OP,676.5,676.5,,,,,,
UHC MCR ADV,CPT,81176,Asxl1 gene target seq alys,Lab Services,Per Unit,$241.90 ,OP,241.9,241.9,,,,,,
UHC MCR ADV,CPT,81177,Atn1 gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
UHC MCR ADV,CPT,81178,Atxn1 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
UHC MCR ADV,CPT,81179,Atxn2 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
UHC MCR ADV,CPT,81180,Atxn3 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
UHC MCR ADV,CPT,81181,Atxn7 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
UHC MCR ADV,CPT,81182,Atxn8os gen detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
UHC MCR ADV,CPT,81183,Atxn10 gene detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
UHC MCR ADV,CPT,81184,Cacna1a gen detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
UHC MCR ADV,CPT,81185,Cacna1a gene full gene seq,Lab Services,Per Unit,$846.27 ,OP,846.27,846.27,,,,,,
UHC MCR ADV,CPT,81186,Cacna1a gen known famil vrnt,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
UHC MCR ADV,CPT,81187,Cnbp gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
UHC MCR ADV,CPT,81188,Cstb gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
UHC MCR ADV,CPT,81189,Cstb gene full gene sequence,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
UHC MCR ADV,CPT,81190,Cstb gene known famil vrnt,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
UHC MCR ADV,CPT,81191,Ntrk1 translocation analysis,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,
UHC MCR ADV,CPT,81192,Ntrk2 translocation analysis,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,
UHC MCR ADV,CPT,81193,Ntrk3 translocation analysis,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,
UHC MCR ADV,CPT,81194,Ntrk translocation analysis,Lab Services,Per Unit,$518.28 ,OP,518.28,518.28,,,,,,
UHC MCR ADV,CPT,81200,Aspa gene,Lab Services,Per Unit,$47.25 ,OP,47.25,47.25,,,,,,
UHC MCR ADV,CPT,81201,Apc gene full sequence,Lab Services,Per Unit,$780.00 ,OP,780,780,,,,,,
UHC MCR ADV,CPT,81202,Apc gene known fam variants,Lab Services,Per Unit,$280.00 ,OP,280,280,,,,,,
UHC MCR ADV,CPT,81203,Apc gene dup/delet variants,Lab Services,Per Unit,$200.00 ,OP,200,200,,,,,,
UHC MCR ADV,CPT,81204,Ar gene charac alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
UHC MCR ADV,CPT,81205,Bckdhb gene,Lab Services,Per Unit,$94.99 ,OP,94.99,94.99,,,,,,
UHC MCR ADV,CPT,81206,Bcr/abl1 gene major bp,Lab Services,Per Unit,$163.96 ,OP,163.96,163.96,,,,,,
UHC MCR ADV,CPT,81207,Bcr/abl1 gene minor bp,Lab Services,Per Unit,$144.84 ,OP,144.84,144.84,,,,,,
UHC MCR ADV,CPT,81208,Bcr/abl1 gene other bp,Lab Services,Per Unit,$214.62 ,OP,214.62,214.62,,,,,,
UHC MCR ADV,CPT,81209,Blm gene,Lab Services,Per Unit,$39.31 ,OP,39.31,39.31,,,,,,
UHC MCR ADV,CPT,81210,Braf gene,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,
UHC MCR ADV,CPT,81212,Brca1&2 185&5385&6174 vrnt,Lab Services,Per Unit,$440.00 ,OP,440,440,,,,,,
UHC MCR ADV,CPT,81215,Brca1 gene known famil vrnt,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,
UHC MCR ADV,CPT,81216,Brca2 gene full seq alys,Lab Services,Per Unit,$185.12 ,OP,185.12,185.12,,,,,,
UHC MCR ADV,CPT,81217,Brca2 gene known famil vrnt,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,
UHC MCR ADV,CPT,81218,Cebpa gene full sequence,Lab Services,Per Unit,$241.90 ,OP,241.9,241.9,,,,,,
UHC MCR ADV,CPT,81219,Calr gene com variants,Lab Services,Per Unit,$121.63 ,OP,121.63,121.63,,,,,,
UHC MCR ADV,CPT,81220,Cftr gene com variants,Lab Services,Per Unit,$556.60 ,OP,556.6,556.6,,,,,,
UHC MCR ADV,CPT,81221,Cftr gene known fam variants,Lab Services,Per Unit,$97.22 ,OP,97.22,97.22,,,,,,
UHC MCR ADV,CPT,81222,Cftr gene dup/delet variants,Lab Services,Per Unit,$435.07 ,OP,435.07,435.07,,,,,,
UHC MCR ADV,CPT,81223,Cftr gene full sequence,Lab Services,Per Unit,$499.00 ,OP,499,499,,,,,,
UHC MCR ADV,CPT,81224,Cftr gene intron poly t,Lab Services,Per Unit,$168.75 ,OP,168.75,168.75,,,,,,
UHC MCR ADV,CPT,81225,Cyp2c19 gene com variants,Lab Services,Per Unit,$291.36 ,OP,291.36,291.36,,,,,,
UHC MCR ADV,CPT,81226,Cyp2d6 gene com variants,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,
UHC MCR ADV,CPT,81227,Cyp2c9 gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
UHC MCR ADV,CPT,81228,Cytogen micrarray copy nmbr,Lab Services,Per Unit,$900.00 ,OP,900,900,,,,,,
UHC MCR ADV,CPT,81229,Cytogen m array copy no&snp,Lab Services,Per Unit,"$1,160.00 ",OP,"1,160.00","1,160.00",,,,,,
UHC MCR ADV,CPT,81230,Cyp3a4 gene common variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
UHC MCR ADV,CPT,81231,Cyp3a5 gene common variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
UHC MCR ADV,CPT,81232,Dpyd gene common variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
UHC MCR ADV,CPT,81233,Btk gene common variants,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,
UHC MCR ADV,CPT,81234,Dmpk gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
UHC MCR ADV,CPT,81235,Egfr gene com variants,Lab Services,Per Unit,$324.58 ,OP,324.58,324.58,,,,,,
UHC MCR ADV,CPT,81236,Ezh2 gene full gene sequence,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,
UHC MCR ADV,CPT,81237,Ezh2 gene common variants,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,
UHC MCR ADV,CPT,81238,F9 full gene sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,
UHC MCR ADV,CPT,81239,Dmpk gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
UHC MCR ADV,CPT,81240,F2 gene,Lab Services,Per Unit,$65.69 ,OP,65.69,65.69,,,,,,
UHC MCR ADV,CPT,81241,F5 gene,Lab Services,Per Unit,$73.37 ,OP,73.37,73.37,,,,,,
UHC MCR ADV,CPT,81242,Fancc gene,Lab Services,Per Unit,$36.62 ,OP,36.62,36.62,,,,,,
UHC MCR ADV,CPT,81243,Fmr1 gene detection,Lab Services,Per Unit,$57.04 ,OP,57.04,57.04,,,,,,
UHC MCR ADV,CPT,81244,Fmr1 gene charac alleles,Lab Services,Per Unit,$44.89 ,OP,44.89,44.89,,,,,,
UHC MCR ADV,CPT,81245,Flt3 gene,Lab Services,Per Unit,$165.51 ,OP,165.51,165.51,,,,,,
UHC MCR ADV,CPT,81246,Flt3 gene analysis,Lab Services,Per Unit,$83.00 ,OP,83,83,,,,,,
UHC MCR ADV,CPT,81247,G6pd gene alys cmn variant,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
UHC MCR ADV,CPT,81248,G6pd known familial variant,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,
UHC MCR ADV,CPT,81249,G6pd full gene sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,
UHC MCR ADV,CPT,81250,G6pc gene,Lab Services,Per Unit,$58.49 ,OP,58.49,58.49,,,,,,
UHC MCR ADV,CPT,81251,Gba gene,Lab Services,Per Unit,$47.25 ,OP,47.25,47.25,,,,,,
UHC MCR ADV,CPT,81252,Gjb2 gene full sequence,Lab Services,Per Unit,$101.12 ,OP,101.12,101.12,,,,,,
UHC MCR ADV,CPT,81253,Gjb2 gene known fam variants,Lab Services,Per Unit,$61.52 ,OP,61.52,61.52,,,,,,
UHC MCR ADV,CPT,81254,Gjb6 gene com variants,Lab Services,Per Unit,$35.00 ,OP,35,35,,,,,,
UHC MCR ADV,CPT,81255,Hexa gene,Lab Services,Per Unit,$51.45 ,OP,51.45,51.45,,,,,,
UHC MCR ADV,CPT,81256,Hfe gene,Lab Services,Per Unit,$65.36 ,OP,65.36,65.36,,,,,,
UHC MCR ADV,CPT,81257,Hba1/hba2 gene,Lab Services,Per Unit,$102.26 ,OP,102.26,102.26,,,,,,
UHC MCR ADV,CPT,81258,Hba1/hba2 gene fam vrnt,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,
UHC MCR ADV,CPT,81259,Hba1/hba2 full gene sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,
UHC MCR ADV,CPT,81260,Ikbkap gene,Lab Services,Per Unit,$39.31 ,OP,39.31,39.31,,,,,,
UHC MCR ADV,CPT,81261,Igh gene rearrange amp meth,Lab Services,Per Unit,$197.99 ,OP,197.99,197.99,,,,,,
UHC MCR ADV,CPT,81262,Igh gene rearrang dir probe,Lab Services,Per Unit,$68.55 ,OP,68.55,68.55,,,,,,
UHC MCR ADV,CPT,81263,Igh vari regional mutation,Lab Services,Per Unit,$294.52 ,OP,294.52,294.52,,,,,,
UHC MCR ADV,CPT,81264,Igk rearrangeabn clonal pop,Lab Services,Per Unit,$172.73 ,OP,172.73,172.73,,,,,,
UHC MCR ADV,CPT,81265,Str markers specimen anal,Lab Services,Per Unit,$233.07 ,OP,233.07,233.07,,,,,,
UHC MCR ADV,CPT,81266,Str markers spec anal addl,Lab Services,Per Unit,$304.81 ,OP,304.81,304.81,,,,,,
UHC MCR ADV,CPT,81267,Chimerism anal no cell selec,Lab Services,Per Unit,$207.46 ,OP,207.46,207.46,,,,,,
UHC MCR ADV,CPT,81268,Chimerism anal w/cell select,Lab Services,Per Unit,$260.79 ,OP,260.79,260.79,,,,,,
UHC MCR ADV,CPT,81269,Hba1/hba2 gene dup/del vrnts,Lab Services,Per Unit,$202.40 ,OP,202.4,202.4,,,,,,
UHC MCR ADV,CPT,81270,Jak2 gene,Lab Services,Per Unit,$91.66 ,OP,91.66,91.66,,,,,,
UHC MCR ADV,CPT,81271,Htt gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
UHC MCR ADV,CPT,81272,Kit gene targeted seq analys,Lab Services,Per Unit,$329.51 ,OP,329.51,329.51,,,,,,
UHC MCR ADV,CPT,81273,Kit gene analys d816 variant,Lab Services,Per Unit,$124.87 ,OP,124.87,124.87,,,,,,
UHC MCR ADV,CPT,81274,Htt gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
UHC MCR ADV,CPT,81275,Kras gene variants exon 2,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,
UHC MCR ADV,CPT,81276,Kras gene addl variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,
UHC MCR ADV,CPT,81277,Cytogenomic neo microra alys,Lab Services,Per Unit,"$1,160.00 ",OP,"1,160.00","1,160.00",,,,,,
UHC MCR ADV,CPT,81278,Igh@/bcl2 translocation alys,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,
UHC MCR ADV,CPT,81279,Jak2 gene trgt sequence alys,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
UHC MCR ADV,CPT,81283,Ifnl3 gene,Lab Services,Per Unit,$73.37 ,OP,73.37,73.37,,,,,,
UHC MCR ADV,CPT,81284,Fxn gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
UHC MCR ADV,CPT,81285,Fxn gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
UHC MCR ADV,CPT,81286,Fxn gene full gene sequence,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
UHC MCR ADV,CPT,81287,Mgmt gene prmtr mthyltn alys,Lab Services,Per Unit,$124.64 ,OP,124.64,124.64,,,,,,
UHC MCR ADV,CPT,81288,Mlh1 gene,Lab Services,Per Unit,$192.32 ,OP,192.32,192.32,,,,,,
UHC MCR ADV,CPT,81289,Fxn gene known famil variant,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
UHC MCR ADV,CPT,81290,Mcoln1 gene,Lab Services,Per Unit,$39.31 ,OP,39.31,39.31,,,,,,
UHC MCR ADV,CPT,81291,Mthfr gene,Lab Services,Per Unit,$65.34 ,OP,65.34,65.34,,,,,,
UHC MCR ADV,CPT,81292,Mlh1 gene full seq,Lab Services,Per Unit,$675.40 ,OP,675.4,675.4,,,,,,
UHC MCR ADV,CPT,81293,Mlh1 gene known variants,Lab Services,Per Unit,$331.00 ,OP,331,331,,,,,,
UHC MCR ADV,CPT,81294,Mlh1 gene dup/delete variant,Lab Services,Per Unit,$202.40 ,OP,202.4,202.4,,,,,,
UHC MCR ADV,CPT,81295,Msh2 gene full seq,Lab Services,Per Unit,$381.70 ,OP,381.7,381.7,,,,,,
UHC MCR ADV,CPT,81296,Msh2 gene known variants,Lab Services,Per Unit,$337.73 ,OP,337.73,337.73,,,,,,
UHC MCR ADV,CPT,81297,Msh2 gene dup/delete variant,Lab Services,Per Unit,$213.30 ,OP,213.3,213.3,,,,,,
UHC MCR ADV,CPT,81298,Msh6 gene full seq,Lab Services,Per Unit,$641.85 ,OP,641.85,641.85,,,,,,
UHC MCR ADV,CPT,81299,Msh6 gene known variants,Lab Services,Per Unit,$308.00 ,OP,308,308,,,,,,
UHC MCR ADV,CPT,81300,Msh6 gene dup/delete variant,Lab Services,Per Unit,$238.00 ,OP,238,238,,,,,,
UHC MCR ADV,CPT,81301,Microsatellite instability,Lab Services,Per Unit,$348.56 ,OP,348.56,348.56,,,,,,
UHC MCR ADV,CPT,81302,Mecp2 gene full seq,Lab Services,Per Unit,$527.87 ,OP,527.87,527.87,,,,,,
UHC MCR ADV,CPT,81303,Mecp2 gene known variant,Lab Services,Per Unit,$120.00 ,OP,120,120,,,,,,
UHC MCR ADV,CPT,81304,Mecp2 gene dup/delet variant,Lab Services,Per Unit,$150.00 ,OP,150,150,,,,,,
UHC MCR ADV,CPT,81305,Myd88 gene p.leu265pro vrnt,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,
UHC MCR ADV,CPT,81306,Nudt15 gene common variants,Lab Services,Per Unit,$291.36 ,OP,291.36,291.36,,,,,,
UHC MCR ADV,CPT,81307,Palb2 gene full gene seq,Lab Services,Per Unit,$676.50 ,OP,676.5,676.5,,,,,,
UHC MCR ADV,CPT,81308,Palb2 gene known famil vrnt,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,
UHC MCR ADV,CPT,81309,Pik3ca gene trgt seq alys,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
UHC MCR ADV,CPT,81310,Npm1 gene,Lab Services,Per Unit,$246.52 ,OP,246.52,246.52,,,,,,
UHC MCR ADV,CPT,81311,Nras gene variants exon 2&3,Lab Services,Per Unit,$295.79 ,OP,295.79,295.79,,,,,,
UHC MCR ADV,CPT,81312,Pabpn1 gene detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
UHC MCR ADV,CPT,81313,Pca3/klk3 antigen,Lab Services,Per Unit,$255.05 ,OP,255.05,255.05,,,,,,
UHC MCR ADV,CPT,81314,Pdgfra gene,Lab Services,Per Unit,$329.51 ,OP,329.51,329.51,,,,,,
UHC MCR ADV,CPT,81315,Pml/raralpha com breakpoints,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,
UHC MCR ADV,CPT,81316,Pml/raralpha 1 breakpoint,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,
UHC MCR ADV,CPT,81317,Pms2 gene full seq analysis,Lab Services,Per Unit,$676.50 ,OP,676.5,676.5,,,,,,
UHC MCR ADV,CPT,81318,Pms2 known familial variants,Lab Services,Per Unit,$331.00 ,OP,331,331,,,,,,
UHC MCR ADV,CPT,81319,Pms2 gene dup/delet variants,Lab Services,Per Unit,$203.50 ,OP,203.5,203.5,,,,,,
UHC MCR ADV,CPT,81320,Plcg2 gene common variants,Lab Services,Per Unit,$291.36 ,OP,291.36,291.36,,,,,,
UHC MCR ADV,CPT,81321,Pten gene full sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,
UHC MCR ADV,CPT,81322,Pten gene known fam variant,Lab Services,Per Unit,$46.60 ,OP,46.6,46.6,,,,,,
UHC MCR ADV,CPT,81323,Pten gene dup/delet variant,Lab Services,Per Unit,$300.00 ,OP,300,300,,,,,,
UHC MCR ADV,CPT,81324,Pmp22 gene dup/delet,Lab Services,Per Unit,$758.36 ,OP,758.36,758.36,,,,,,
UHC MCR ADV,CPT,81325,Pmp22 gene full sequence,Lab Services,Per Unit,$769.58 ,OP,769.58,769.58,,,,,,
UHC MCR ADV,CPT,81326,Pmp22 gene known fam variant,Lab Services,Per Unit,$46.60 ,OP,46.6,46.6,,,,,,
UHC MCR ADV,CPT,81327,Sept9 gen prmtr mthyltn alys,Lab Services,Per Unit,$192.00 ,OP,192,192,,,,,,
UHC MCR ADV,CPT,81328,Slco1b1 gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
UHC MCR ADV,CPT,81329,Smn1 gene dos/deletion alys,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
UHC MCR ADV,CPT,81330,Smpd1 gene common variants,Lab Services,Per Unit,$47.00 ,OP,47,47,,,,,,
UHC MCR ADV,CPT,81331,Snrpn/ube3a gene,Lab Services,Per Unit,$51.07 ,OP,51.07,51.07,,,,,,
UHC MCR ADV,CPT,81332,Serpina1 gene,Lab Services,Per Unit,$43.65 ,OP,43.65,43.65,,,,,,
UHC MCR ADV,CPT,81333,Tgfbi gene common variants,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
UHC MCR ADV,CPT,81334,Runx1 gene targeted seq alys,Lab Services,Per Unit,$329.51 ,OP,329.51,329.51,,,,,,
UHC MCR ADV,CPT,81335,Tpmt gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
UHC MCR ADV,CPT,81336,Smn1 gene full gene sequence,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,
UHC MCR ADV,CPT,81337,Smn1 gen nown famil seq vrnt,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
UHC MCR ADV,CPT,81338,Mpl gene common variants,Lab Services,Per Unit,$150.33 ,OP,150.33,150.33,,,,,,
UHC MCR ADV,CPT,81339,Mpl gene seq alys exon 10,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
UHC MCR ADV,CPT,81340,Trb@ gene rearrange amplify,Lab Services,Per Unit,$208.92 ,OP,208.92,208.92,,,,,,
UHC MCR ADV,CPT,81341,Trb@ gene rearrange dirprobe,Lab Services,Per Unit,$49.59 ,OP,49.59,49.59,,,,,,
UHC MCR ADV,CPT,81342,Trg gene rearrangement anal,Lab Services,Per Unit,$201.50 ,OP,201.5,201.5,,,,,,
UHC MCR ADV,CPT,81343,Ppp2r2b gen detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
UHC MCR ADV,CPT,81344,Tbp gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
UHC MCR ADV,CPT,81345,Tert gene targeted seq alys,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
UHC MCR ADV,CPT,81346,Tyms gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
UHC MCR ADV,CPT,81347,Sf3b1 gene common variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,
UHC MCR ADV,CPT,81348,Srsf2 gene common variants,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,
UHC MCR ADV,CPT,81350,Ugt1a1 gene common variants,Lab Services,Per Unit,$234.00 ,OP,234,234,,,,,,
UHC MCR ADV,CPT,81351,Tp53 gene full gene sequence,Lab Services,Per Unit,$641.85 ,OP,641.85,641.85,,,,,,
UHC MCR ADV,CPT,81352,Tp53 gene trgt sequence alys,Lab Services,Per Unit,$329.51 ,OP,329.51,329.51,,,,,,
UHC MCR ADV,CPT,81353,Tp53 gene known famil vrnt,Lab Services,Per Unit,$308.00 ,OP,308,308,,,,,,
UHC MCR ADV,CPT,81355,Vkorc1 gene,Lab Services,Per Unit,$88.20 ,OP,88.2,88.2,,,,,,
UHC MCR ADV,CPT,81357,U2af1 gene common variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,
UHC MCR ADV,CPT,81360,Zrsr2 gene common variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,
UHC MCR ADV,CPT,81361,Hbb gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
UHC MCR ADV,CPT,81362,Hbb gene known fam variant,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,
UHC MCR ADV,CPT,81363,Hbb gene dup/del variants,Lab Services,Per Unit,$202.40 ,OP,202.4,202.4,,,,,,
UHC MCR ADV,CPT,81364,Hbb full gene sequence,Lab Services,Per Unit,$324.58 ,OP,324.58,324.58,,,,,,
UHC MCR ADV,CPT,81370,Hla i & ii typing lr,Lab Services,Per Unit,$402.12 ,OP,402.12,402.12,,,,,,
UHC MCR ADV,CPT,81371,Hla i & ii type verify lr,Lab Services,Per Unit,$404.52 ,OP,404.52,404.52,,,,,,
UHC MCR ADV,CPT,81372,Hla i typing complete lr,Lab Services,Per Unit,$403.59 ,OP,403.59,403.59,,,,,,
UHC MCR ADV,CPT,81373,Hla i typing 1 locus lr,Lab Services,Per Unit,$127.43 ,OP,127.43,127.43,,,,,,
UHC MCR ADV,CPT,81374,Hla i typing 1 antigen lr,Lab Services,Per Unit,$74.33 ,OP,74.33,74.33,,,,,,
UHC MCR ADV,CPT,81375,Hla ii typing ag equiv lr,Lab Services,Per Unit,$220.74 ,OP,220.74,220.74,,,,,,
UHC MCR ADV,CPT,81376,Hla ii typing 1 locus lr,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,
UHC MCR ADV,CPT,81377,Hla ii type 1 ag equiv lr,Lab Services,Per Unit,$94.74 ,OP,94.74,94.74,,,,,,
UHC MCR ADV,CPT,81378,Hla i & ii typing hr,Lab Services,Per Unit,$345.57 ,OP,345.57,345.57,,,,,,
UHC MCR ADV,CPT,81379,Hla i typing complete hr,Lab Services,Per Unit,$335.38 ,OP,335.38,335.38,,,,,,
UHC MCR ADV,CPT,81380,Hla i typing 1 locus hr,Lab Services,Per Unit,$177.25 ,OP,177.25,177.25,,,,,,
UHC MCR ADV,CPT,81381,Hla i typing 1 allele hr,Lab Services,Per Unit,$169.90 ,OP,169.9,169.9,,,,,,
UHC MCR ADV,CPT,81382,Hla ii typing 1 loc hr,Lab Services,Per Unit,$123.68 ,OP,123.68,123.68,,,,,,
UHC MCR ADV,CPT,81383,Hla ii typing 1 allele hr,Lab Services,Per Unit,$109.13 ,OP,109.13,109.13,,,,,,
UHC MCR ADV,CPT,81400,Mopath procedure level 1,Lab Services,Per Unit,$63.96 ,OP,63.96,63.96,,,,,,
UHC MCR ADV,CPT,81401,Mopath procedure level 2,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,
UHC MCR ADV,CPT,81402,Mopath procedure level 3,Lab Services,Per Unit,$150.33 ,OP,150.33,150.33,,,,,,
UHC MCR ADV,CPT,81403,Mopath procedure level 4,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
UHC MCR ADV,CPT,81404,Mopath procedure level 5,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
UHC MCR ADV,CPT,81405,Mopath procedure level 6,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,
UHC MCR ADV,CPT,81406,Mopath procedure level 7,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,
UHC MCR ADV,CPT,81407,Mopath procedure level 8,Lab Services,Per Unit,$846.27 ,OP,846.27,846.27,,,,,,
UHC MCR ADV,CPT,81408,Mopath procedure level 9,Lab Services,Per Unit,"$2,000.00 ",OP,"2,000.00","2,000.00",,,,,,
UHC MCR ADV,CPT,81410,Aortic dysfunction/dilation,Lab Services,Per Unit,$504.00 ,OP,504,504,,,,,,
UHC MCR ADV,CPT,81411,Aortic dysfunction/dilation,Lab Services,Per Unit,"$1,350.19 ",OP,"1,350.19","1,350.19",,,,,,
UHC MCR ADV,CPT,81412,Ashkenazi jewish assoc dis,Lab Services,Per Unit,"$2,448.56 ",OP,"2,448.56","2,448.56",,,,,,
UHC MCR ADV,CPT,81413,Car ion chnnlpath inc 10 gns,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,
UHC MCR ADV,CPT,81414,Car ion chnnlpath inc 2 gns,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,
UHC MCR ADV,CPT,81415,Exome sequence analysis,Lab Services,Per Unit,"$4,780.00 ",OP,"4,780.00","4,780.00",,,,,,
UHC MCR ADV,CPT,81416,Exome sequence analysis,Lab Services,Per Unit,"$12,000.00 ",OP,"12,000.00","12,000.00",,,,,,
UHC MCR ADV,CPT,81417,Exome re-evaluation,Lab Services,Per Unit,$320.00 ,OP,320,320,,,,,,
UHC MCR ADV,CPT,81419,Epilepsy gen seq alys panel,Lab Services,Per Unit,"$2,448.56 ",OP,"2,448.56","2,448.56",,,,,,
UHC MCR ADV,CPT,81420,Fetal chrmoml aneuploidy,Lab Services,Per Unit,$759.05 ,OP,759.05,759.05,,,,,,
UHC MCR ADV,CPT,81422,Fetal chrmoml microdeltj,Lab Services,Per Unit,$759.05 ,OP,759.05,759.05,,,,,,
UHC MCR ADV,CPT,81425,Genome sequence analysis,Lab Services,Per Unit,"$5,031.20 ",OP,"5,031.20","5,031.20",,,,,,
UHC MCR ADV,CPT,81426,Genome sequence analysis,Lab Services,Per Unit,"$2,709.95 ",OP,"2,709.95","2,709.95",,,,,,
UHC MCR ADV,CPT,81427,Genome re-evaluation,Lab Services,Per Unit,"$2,337.65 ",OP,"2,337.65","2,337.65",,,,,,
UHC MCR ADV,CPT,81430,Hearing loss sequence analys,Lab Services,Per Unit,"$1,625.00 ",OP,"1,625.00","1,625.00",,,,,,
UHC MCR ADV,CPT,81431,Hearing loss dup/del analys,Lab Services,Per Unit,$679.57 ,OP,679.57,679.57,,,,,,
UHC MCR ADV,CPT,81432,Hrdtry brst ca-rlatd dsordrs,Lab Services,Per Unit,$679.05 ,OP,679.05,679.05,,,,,,
UHC MCR ADV,CPT,81433,Hrdtry brst ca-rlatd dsordrs,Lab Services,Per Unit,$438.93 ,OP,438.93,438.93,,,,,,
UHC MCR ADV,CPT,81434,Hereditary retinal disorders,Lab Services,Per Unit,$597.91 ,OP,597.91,597.91,,,,,,
UHC MCR ADV,CPT,81435,Hereditary colon ca dsordrs,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,
UHC MCR ADV,CPT,81436,Hereditary colon ca dsordrs,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,
UHC MCR ADV,CPT,81437,Heredtry nurondcrn tum dsrdr,Lab Services,Per Unit,$438.93 ,OP,438.93,438.93,,,,,,
UHC MCR ADV,CPT,81438,Heredtry nurondcrn tum dsrdr,Lab Services,Per Unit,$438.93 ,OP,438.93,438.93,,,,,,
UHC MCR ADV,CPT,81439,Hrdtry cardmypy gene panel,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,
UHC MCR ADV,CPT,81440,Mitochondrial gene,Lab Services,Per Unit,"$3,324.00 ",OP,"3,324.00","3,324.00",,,,,,
UHC MCR ADV,CPT,81442,Noonan spectrum disorders,Lab Services,Per Unit,"$2,143.60 ",OP,"2,143.60","2,143.60",,,,,,
UHC MCR ADV,CPT,81443,Genetic tstg severe inh cond,Lab Services,Per Unit,"$2,448.56 ",OP,"2,448.56","2,448.56",,,,,,
UHC MCR ADV,CPT,81445,Targeted genomic seq analys,Lab Services,Per Unit,$597.91 ,OP,597.91,597.91,,,,,,
UHC MCR ADV,CPT,81448,Hrdtry perph neurphy panel,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,
UHC MCR ADV,CPT,81450,Targeted genomic seq analys,Lab Services,Per Unit,$759.53 ,OP,759.53,759.53,,,,,,
UHC MCR ADV,CPT,81455,Targeted genomic seq analys,Lab Services,Per Unit,"$2,919.60 ",OP,"2,919.60","2,919.60",,,,,,
UHC MCR ADV,CPT,81460,Whole mitochondrial genome,Lab Services,Per Unit,"$1,287.00 ",OP,"1,287.00","1,287.00",,,,,,
UHC MCR ADV,CPT,81465,Whole mitochondrial genome,Lab Services,Per Unit,$936.00 ,OP,936,936,,,,,,
UHC MCR ADV,CPT,81470,X-linked intellectual dblt,Lab Services,Per Unit,$914.00 ,OP,914,914,,,,,,
UHC MCR ADV,CPT,81471,X-linked intellectual dblt,Lab Services,Per Unit,$914.00 ,OP,914,914,,,,,,
UHC MCR ADV,CPT,81490,Autoimmune rheumatoid arthr,Lab Services,Per Unit,$840.65 ,OP,840.65,840.65,,,,,,
UHC MCR ADV,CPT,81493,Cor artery disease mrna,Lab Services,Per Unit,"$1,050.00 ",OP,"1,050.00","1,050.00",,,,,,
UHC MCR ADV,CPT,81500,Onco (ovar) two proteins,Lab Services,Per Unit,$260.50 ,OP,91.51,260.5,,,,,,
UHC MCR ADV,CPT,81503,Onco (ovar) five proteins,Lab Services,Per Unit,$897.00 ,OP,91.51,897,,,,,,
UHC MCR ADV,CPT,81504,Oncology tissue of origin,Lab Services,Per Unit,$520.00 ,OP,520,520,,,,,,
UHC MCR ADV,CPT,81506,Endo assay seven anal,Lab Services,Per Unit,$68.92 ,OP,57.19,68.92,,,,,,
UHC MCR ADV,CPT,81507,Fetal aneuploidy trisom risk,Lab Services,Per Unit,$795.00 ,OP,795,795,,,,,,
UHC MCR ADV,CPT,81508,Ftl cgen abnor two proteins,Lab Services,Per Unit,$54.30 ,OP,54.3,144.88,,,,,,
UHC MCR ADV,CPT,81509,Ftl cgen abnor 3 proteins,Lab Services,Per Unit,"$1,487.37 ",OP,213.51,"1,487.37",,,,,,
UHC MCR ADV,CPT,81510,Ftl cgen abnor three anal,Lab Services,Per Unit,$55.54 ,OP,55.54,202.07,,,,,,
UHC MCR ADV,CPT,81511,Ftl cgen abnor four anal,Lab Services,Per Unit,$153.50 ,OP,153.5,270.71,,,,,,
UHC MCR ADV,CPT,81512,Ftl cgen abnor five anal,Lab Services,Per Unit,$69.52 ,OP,69.52,270.71,,,,,,
UHC MCR ADV,CPT,81513,Nfct ds bv rna vag flu alg,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
UHC MCR ADV,CPT,81514,Nfct ds bv&vaginitis dna alg,Lab Services,Per Unit,$262.99 ,OP,262.99,262.99,,,,,,
UHC MCR ADV,CPT,81518,Onc brst mrna 11 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
UHC MCR ADV,CPT,81519,Oncology breast mrna,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
UHC MCR ADV,CPT,81520,Onc breast mrna 58 genes,Lab Services,Per Unit,"$2,510.21 ",OP,"2,510.21","2,510.21",,,,,,
UHC MCR ADV,CPT,81521,Onc breast mrna 70 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
UHC MCR ADV,CPT,81522,Onc breast mrna 12 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
UHC MCR ADV,CPT,81525,Oncology colon mrna,Lab Services,Per Unit,"$3,116.00 ",OP,"3,116.00","3,116.00",,,,,,
UHC MCR ADV,CPT,81528,Oncology colorectal scr,Lab Services,Per Unit,$508.87 ,OP,508.87,508.87,,,,,,
UHC MCR ADV,CPT,81529,Onc cutan mlnma mrna 31 gene,Lab Services,Per Unit,"$7,193.00 ",OP,"7,193.00","7,193.00",,,,,,
UHC MCR ADV,CPT,81535,Oncology gynecologic,Lab Services,Per Unit,$579.46 ,OP,579.46,579.46,,,,,,
UHC MCR ADV,CPT,81536,Oncology gynecologic,Lab Services,Per Unit,$177.56 ,OP,177.56,177.56,,,,,,
UHC MCR ADV,CPT,81538,Oncology lung,Lab Services,Per Unit,"$2,871.00 ",OP,"2,871.00","2,871.00",,,,,,
UHC MCR ADV,CPT,81539,Oncology prostate prob score,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
UHC MCR ADV,CPT,81540,Oncology tum unknown origin,Lab Services,Per Unit,"$3,750.00 ",OP,"3,750.00","3,750.00",,,,,,
UHC MCR ADV,CPT,81541,Onc prostate mrna 46 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
UHC MCR ADV,CPT,81542,Onc prostate mrna 22 cnt gen,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
UHC MCR ADV,CPT,81546,Onc thyr mrna 10-196 gen alg,Lab Services,Per Unit,"$3,600.00 ",OP,"3,600.00","3,600.00",,,,,,
UHC MCR ADV,CPT,81551,Onc prostate 3 genes,Lab Services,Per Unit,"$2,030.00 ",OP,"2,030.00","2,030.00",,,,,,
UHC MCR ADV,CPT,81552,Onc uveal mlnma mrna 15 gene,Lab Services,Per Unit,"$7,776.00 ",OP,"7,776.00","7,776.00",,,,,,
UHC MCR ADV,CPT,81554,Pulm ds ipf mrna 190 gen alg,Lab Services,Per Unit,"$5,500.00 ",OP,"5,500.00","5,500.00",,,,,,
UHC MCR ADV,CPT,81595,Cardiology hrt trnspl mrna,Lab Services,Per Unit,"$3,240.00 ",OP,"3,240.00","3,240.00",,,,,,
UHC MCR ADV,CPT,81596,Nfct ds chrnc hcv 6 assays,Lab Services,Per Unit,$72.19 ,OP,72.19,72.19,,,,,,
UHC MCR ADV,CPT,82009,Test for acetone/ketones,Lab Services,Per Unit,$4.52 ,OP,4.52,19.07,,,,,,
UHC MCR ADV,CPT,82010,Acetone assay,Lab Services,Per Unit,$8.17 ,OP,8.17,41.94,,,,,,
UHC MCR ADV,CPT,82013,Acetylcholinesterase assay,Lab Services,Per Unit,$12.29 ,OP,12.29,12.29,,,,,,
UHC MCR ADV,CPT,82016,Acylcarnitines qual,Lab Services,Per Unit,$16.49 ,OP,16.49,61,,,,,,
UHC MCR ADV,CPT,82017,Acylcarnitines quant,Lab Services,Per Unit,$16.87 ,OP,16.87,76.26,,,,,,
UHC MCR ADV,CPT,82024,Assay of acth,Lab Services,Per Unit,$38.62 ,OP,38.62,171.58,,,,,,
UHC MCR ADV,CPT,82030,Assay of adp & amp,Lab Services,Per Unit,$25.80 ,OP,25.8,99.13,,,,,,
UHC MCR ADV,CPT,82040,Assay of serum albumin,Lab Services,Per Unit,$4.95 ,OP,4.95,22.88,,,,,,
UHC MCR ADV,CPT,82042,Other source albumin quan ea,Lab Services,Per Unit,$7.78 ,OP,7.78,26.7,,,,,,
UHC MCR ADV,CPT,82043,Ur albumin quantitative,Lab Services,Per Unit,$5.78 ,OP,5.78,26.7,,,,,,
UHC MCR ADV,CPT,82044,Ur albumin semiquantitative,Lab Services,Per Unit,$6.23 ,OP,6.23,22.88,,,,,,
UHC MCR ADV,CPT,82045,Albumin ischemia modified,Lab Services,Per Unit,$33.94 ,OP,33.94,125.82,,,,,,
UHC MCR ADV,CPT,82075,Assay of breath ethanol,Lab Services,Per Unit,$30.00 ,OP,30,45.74,,,,,,
UHC MCR ADV,CPT,82077,Assay spec xcp ur&breath ia,Lab Services,Per Unit,$17.27 ,OP,17.27,17.27,,,,,,
UHC MCR ADV,CPT,82085,Assay of aldolase,Lab Services,Per Unit,$9.71 ,OP,9.71,41.94,,,,,,
UHC MCR ADV,CPT,82088,Assay of aldosterone,Lab Services,Per Unit,$40.75 ,OP,40.75,183.02,,,,,,
UHC MCR ADV,CPT,82103,Alpha-1-antitrypsin total,Lab Services,Per Unit,$13.44 ,OP,13.44,61,,,,,,
UHC MCR ADV,CPT,82104,Alpha-1-antitrypsin pheno,Lab Services,Per Unit,$14.46 ,OP,14.46,64.82,,,,,,
UHC MCR ADV,CPT,82105,Alpha-fetoprotein serum,Lab Services,Per Unit,$16.77 ,OP,16.77,76.26,,,,,,
UHC MCR ADV,CPT,82106,Alpha-fetoprotein amniotic,Lab Services,Per Unit,$17.00 ,OP,17,76.26,,,,,,
UHC MCR ADV,CPT,82107,Alpha-fetoprotein l3,Lab Services,Per Unit,$64.41 ,OP,64.41,209.7,,,,,,
UHC MCR ADV,CPT,82108,Assay of aluminum,Lab Services,Per Unit,$25.48 ,OP,25.48,114.39,,,,,,
UHC MCR ADV,CPT,82120,Amines vaginal fluid qual,Lab Services,Per Unit,$5.99 ,OP,5.99,19.07,,,,,,
UHC MCR ADV,CPT,82127,Amino acid single qual,Lab Services,Per Unit,$14.18 ,OP,14.18,61,,,,,,
UHC MCR ADV,CPT,82128,Amino acids mult qual,Lab Services,Per Unit,$13.87 ,OP,13.87,61,,,,,,
UHC MCR ADV,CPT,82131,Amino acids single quant,Lab Services,Per Unit,$22.98 ,OP,22.98,76.26,,,,,,
UHC MCR ADV,CPT,82135,Assay aminolevulinic acid,Lab Services,Per Unit,$16.45 ,OP,16.45,64.82,,,,,,
UHC MCR ADV,CPT,82136,Amino acids quant 2-5,Lab Services,Per Unit,$19.61 ,OP,19.61,76.26,,,,,,
UHC MCR ADV,CPT,82139,Amino acids quan 6 or more,Lab Services,Per Unit,$16.87 ,OP,16.87,16.87,,,,,,
UHC MCR ADV,CPT,82140,Assay of ammonia,Lab Services,Per Unit,$14.57 ,OP,14.57,64.82,,,,,,
UHC MCR ADV,CPT,82143,Amniotic fluid scan,Lab Services,Per Unit,$9.35 ,OP,9.35,30.51,,,,,,
UHC MCR ADV,CPT,82150,Assay of amylase,Lab Services,Per Unit,$6.48 ,OP,6.48,34.31,,,,,,
UHC MCR ADV,CPT,82154,Androstanediol glucuronide,Lab Services,Per Unit,$28.83 ,OP,28.83,28.83,,,,,,
UHC MCR ADV,CPT,82157,Assay of androstenedione,Lab Services,Per Unit,$29.28 ,OP,29.28,129.64,,,,,,
UHC MCR ADV,CPT,82160,Assay of androsterone,Lab Services,Per Unit,$25.55 ,OP,25.55,110.57,,,,,,
UHC MCR ADV,CPT,82163,Assay of angiotensin ii,Lab Services,Per Unit,$20.52 ,OP,20.52,91.51,,,,,,
UHC MCR ADV,CPT,82164,Angiotensin i enzyme test,Lab Services,Per Unit,$14.60 ,OP,14.6,64.82,,,,,,
UHC MCR ADV,CPT,82172,Assay of apolipoprotein,Lab Services,Per Unit,$21.09 ,OP,21.09,68.63,,,,,,
UHC MCR ADV,CPT,82175,Assay of arsenic,Lab Services,Per Unit,$18.97 ,OP,18.97,83.87,,,,,,
UHC MCR ADV,CPT,82180,Assay of ascorbic acid,Lab Services,Per Unit,$9.89 ,OP,9.89,9.89,,,,,,
UHC MCR ADV,CPT,82190,Atomic absorption,Lab Services,Per Unit,$15.90 ,OP,15.9,64.82,,,,,,
UHC MCR ADV,CPT,82232,Assay of beta-2 protein,Lab Services,Per Unit,$16.18 ,OP,16.18,72.44,,,,,,
UHC MCR ADV,CPT,82239,Bile acids total,Lab Services,Per Unit,$17.12 ,OP,17.12,76.26,,,,,,
UHC MCR ADV,CPT,82240,Bile acids cholylglycine,Lab Services,Per Unit,$26.58 ,OP,26.58,64.82,,,,,,
UHC MCR ADV,CPT,82247,Bilirubin total,Lab Services,Per Unit,$5.02 ,OP,5.02,26.7,,,,,,
UHC MCR ADV,CPT,82248,Bilirubin direct,Lab Services,Per Unit,$5.02 ,OP,5.02,26.7,,,,,,
UHC MCR ADV,CPT,82252,Fecal bilirubin test,Lab Services,Per Unit,$4.56 ,OP,4.56,19.07,,,,,,
UHC MCR ADV,CPT,82261,Assay of biotinidase,Lab Services,Per Unit,$16.87 ,OP,16.87,76.26,,,,,,
UHC MCR ADV,CPT,82270,Occult blood feces,Lab Services,Per Unit,$4.38 ,OP,4.38,15.26,,,,,,
UHC MCR ADV,CPT,82271,Occult blood other sources,Lab Services,Per Unit,$5.32 ,OP,5.32,15.26,,,,,,
UHC MCR ADV,CPT,82272,Occult bld feces 1-3 tests,Lab Services,Per Unit,$4.23 ,OP,4.23,15.26,,,,,,
UHC MCR ADV,CPT,82274,Assay test for blood fecal,Lab Services,Per Unit,$15.92 ,OP,15.92,80.07,,,,,,
UHC MCR ADV,CPT,82286,Assay of bradykinin,Lab Services,Per Unit,$5.16 ,OP,5.16,30.51,,,,,,
UHC MCR ADV,CPT,82300,Assay of cadmium,Lab Services,Per Unit,$23.64 ,OP,23.64,102.95,,,,,,
UHC MCR ADV,CPT,82306,Vitamin d 25 hydroxy,Lab Services,Per Unit,$29.60 ,OP,29.6,356.68,,,,,,
UHC MCR ADV,CPT,82308,Assay of calcitonin,Lab Services,Per Unit,$26.79 ,OP,26.79,118.19,,,,,,
UHC MCR ADV,CPT,82310,Assay of calcium,Lab Services,Per Unit,$5.16 ,OP,5.16,22.88,,,,,,
UHC MCR ADV,CPT,82330,Assay of calcium,Lab Services,Per Unit,$13.68 ,OP,13.68,61,,,,,,
UHC MCR ADV,CPT,82331,Calcium infusion test,Lab Services,Per Unit,$13.34 ,OP,13.34,22.88,,,,,,
UHC MCR ADV,CPT,82340,Assay of calcium in urine,Lab Services,Per Unit,$6.03 ,OP,6.03,26.7,,,,,,
UHC MCR ADV,CPT,82355,Calculus analysis qual,Lab Services,Per Unit,$11.58 ,OP,11.58,53.38,,,,,,
UHC MCR ADV,CPT,82360,Calculus assay quant,Lab Services,Per Unit,$12.87 ,OP,12.87,45.74,,,,,,
UHC MCR ADV,CPT,82365,Calculus spectroscopy,Lab Services,Per Unit,$12.90 ,OP,12.9,45.74,,,,,,
UHC MCR ADV,CPT,82370,X-ray assay calculus,Lab Services,Per Unit,$12.52 ,OP,12.52,45.74,,,,,,
UHC MCR ADV,CPT,82373,Assay c-d transfer measure,Lab Services,Per Unit,$18.06 ,OP,18.06,80.07,,,,,,
UHC MCR ADV,CPT,82374,Assay blood carbon dioxide,Lab Services,Per Unit,$4.88 ,OP,4.88,22.88,,,,,,
UHC MCR ADV,CPT,82375,Assay carboxyhb quant,Lab Services,Per Unit,$12.32 ,OP,12.32,26.7,,,,,,
UHC MCR ADV,CPT,82376,Assay carboxyhb qual,Lab Services,Per Unit,$14.07 ,OP,14.07,26.7,,,,,,
UHC MCR ADV,CPT,82378,Carcinoembryonic antigen,Lab Services,Per Unit,$18.96 ,OP,18.96,83.87,,,,,,
UHC MCR ADV,CPT,82379,Assay of carnitine,Lab Services,Per Unit,$16.87 ,OP,16.87,76.26,,,,,,
UHC MCR ADV,CPT,82380,Assay of carotene,Lab Services,Per Unit,$9.22 ,OP,9.22,41.94,,,,,,
UHC MCR ADV,CPT,82382,Assay urine catecholamines,Lab Services,Per Unit,$27.30 ,OP,27.3,76.26,,,,,,
UHC MCR ADV,CPT,82383,Assay blood catecholamines,Lab Services,Per Unit,$29.08 ,OP,29.08,110.57,,,,,,
UHC MCR ADV,CPT,82384,Assay three catecholamines,Lab Services,Per Unit,$25.25 ,OP,25.25,110.57,,,,,,
UHC MCR ADV,CPT,82387,Assay of cathepsin-d,Lab Services,Per Unit,$18.06 ,OP,18.06,91.51,,,,,,
UHC MCR ADV,CPT,82390,Assay of ceruloplasmin,Lab Services,Per Unit,$10.74 ,OP,10.74,49.56,,,,,,
UHC MCR ADV,CPT,82397,Chemiluminescent assay,Lab Services,Per Unit,$14.12 ,OP,14.12,64.82,,,,,,
UHC MCR ADV,CPT,82415,Assay of chloramphenicol,Lab Services,Per Unit,$12.67 ,OP,12.67,57.19,,,,,,
UHC MCR ADV,CPT,82435,Assay of blood chloride,Lab Services,Per Unit,$4.60 ,OP,4.6,19.07,,,,,,
UHC MCR ADV,CPT,82436,Assay of urine chloride,Lab Services,Per Unit,$5.75 ,OP,5.75,22.88,,,,,,
UHC MCR ADV,CPT,82438,Assay other fluid chlorides,Lab Services,Per Unit,$5.00 ,OP,5,5,,,,,,
UHC MCR ADV,CPT,82441,Test for chlorohydrocarbons,Lab Services,Per Unit,$6.01 ,OP,6.01,26.7,,,,,,
UHC MCR ADV,CPT,82465,Assay bld/serum cholesterol,Lab Services,Per Unit,$4.35 ,OP,4.35,22.88,,,,,,
UHC MCR ADV,CPT,82480,Assay serum cholinesterase,Lab Services,Per Unit,$7.87 ,OP,7.87,34.31,,,,,,
UHC MCR ADV,CPT,82482,Assay rbc cholinesterase,Lab Services,Per Unit,$9.81 ,OP,9.81,34.31,,,,,,
UHC MCR ADV,CPT,82485,Assay chondroitin sulfate,Lab Services,Per Unit,$20.65 ,OP,20.65,91.51,,,,,,
UHC MCR ADV,CPT,82495,Assay of chromium,Lab Services,Per Unit,$20.28 ,OP,20.28,91.51,,,,,,
UHC MCR ADV,CPT,82507,Assay of citrate,Lab Services,Per Unit,$27.80 ,OP,27.8,57.19,,,,,,
UHC MCR ADV,CPT,82523,Collagen crosslinks,Lab Services,Per Unit,$18.68 ,OP,18.68,95.32,,,,,,
UHC MCR ADV,CPT,82525,Assay of copper,Lab Services,Per Unit,$12.41 ,OP,12.41,53.38,,,,,,
UHC MCR ADV,CPT,82528,Assay of corticosterone,Lab Services,Per Unit,$22.52 ,OP,22.52,99.13,,,,,,
UHC MCR ADV,CPT,82530,Cortisol free,Lab Services,Per Unit,$16.71 ,OP,16.71,76.26,,,,,,
UHC MCR ADV,CPT,82533,Total cortisol,Lab Services,Per Unit,$16.30 ,OP,16.3,72.44,,,,,,
UHC MCR ADV,CPT,82540,Assay of creatine,Lab Services,Per Unit,$4.64 ,OP,4.64,19.07,,,,,,
UHC MCR ADV,CPT,82542,Col chromotography qual/quan,Lab Services,Per Unit,$24.09 ,OP,24.09,80.07,,,,,,
UHC MCR ADV,CPT,82550,Assay of ck (cpk),Lab Services,Per Unit,$6.51 ,OP,6.51,30.51,,,,,,
UHC MCR ADV,CPT,82552,Assay of cpk in blood,Lab Services,Per Unit,$13.39 ,OP,13.39,61,,,,,,
UHC MCR ADV,CPT,82553,Creatine mb fraction,Lab Services,Per Unit,$11.55 ,OP,11.55,49.56,,,,,,
UHC MCR ADV,CPT,82554,Creatine isoforms,Lab Services,Per Unit,$11.87 ,OP,11.87,53.38,,,,,,
UHC MCR ADV,CPT,82565,Assay of creatinine,Lab Services,Per Unit,$5.12 ,OP,5.12,22.88,,,,,,
UHC MCR ADV,CPT,82570,Assay of urine creatinine,Lab Services,Per Unit,$5.18 ,OP,5.18,26.7,,,,,,
UHC MCR ADV,CPT,82575,Creatinine clearance test,Lab Services,Per Unit,$9.46 ,OP,9.46,41.94,,,,,,
UHC MCR ADV,CPT,82585,Assay of cryofibrinogen,Lab Services,Per Unit,$14.14 ,OP,14.14,38.13,,,,,,
UHC MCR ADV,CPT,82595,Assay of cryoglobulin,Lab Services,Per Unit,$6.47 ,OP,6.47,30.51,,,,,,
UHC MCR ADV,CPT,82600,Assay of cyanide,Lab Services,Per Unit,$19.40 ,OP,19.4,19.4,,,,,,
UHC MCR ADV,CPT,82607,Vitamin b-12,Lab Services,Per Unit,$15.08 ,OP,15.08,68.63,,,,,,
UHC MCR ADV,CPT,82608,B-12 binding capacity,Lab Services,Per Unit,$14.32 ,OP,14.32,14.32,,,,,,
UHC MCR ADV,CPT,82610,Cystatin c,Lab Services,Per Unit,$18.52 ,OP,18.52,61,,,,,,
UHC MCR ADV,CPT,82615,Test for urine cystines,Lab Services,Per Unit,$9.55 ,OP,9.55,38.13,,,,,,
UHC MCR ADV,CPT,82626,Dehydroepiandrosterone,Lab Services,Per Unit,$25.27 ,OP,25.27,114.39,,,,,,
UHC MCR ADV,CPT,82627,Dehydroepiandrosterone,Lab Services,Per Unit,$22.23 ,OP,22.23,99.13,,,,,,
UHC MCR ADV,CPT,82633,Desoxycorticosterone,Lab Services,Per Unit,$30.98 ,OP,30.98,122,,,,,,
UHC MCR ADV,CPT,82634,Deoxycortisol,Lab Services,Per Unit,$29.28 ,OP,29.28,76.26,,,,,,
UHC MCR ADV,CPT,82638,Assay of dibucaine number,Lab Services,Per Unit,$12.25 ,OP,12.25,53.38,,,,,,
UHC MCR ADV,CPT,82642,Dihydrotestosterone,Lab Services,Per Unit,$29.28 ,OP,29.28,114.39,,,,,,
UHC MCR ADV,CPT,82652,Vit d 1 25-dihydroxy,Lab Services,Per Unit,$38.50 ,OP,38.5,171.58,,,,,,
UHC MCR ADV,CPT,82656,Pancreatic elastase fecal,Lab Services,Per Unit,$11.53 ,OP,11.53,11.53,,,,,,
UHC MCR ADV,CPT,82657,Enzyme cell activity,Lab Services,Per Unit,$22.17 ,OP,22.17,80.07,,,,,,
UHC MCR ADV,CPT,82658,Enzyme cell activity ra,Lab Services,Per Unit,$44.03 ,OP,44.03,44.03,,,,,,
UHC MCR ADV,CPT,82664,Electrophoretic test,Lab Services,Per Unit,$61.50 ,OP,61.5,122,,,,,,
UHC MCR ADV,CPT,82668,Assay of erythropoietin,Lab Services,Per Unit,$18.79 ,OP,18.79,83.87,,,,,,
UHC MCR ADV,CPT,82670,Assay of total estradiol,Lab Services,Per Unit,$27.94 ,OP,27.94,49.56,,,,,,
UHC MCR ADV,CPT,82671,Assay of estrogens,Lab Services,Per Unit,$32.30 ,OP,32.3,114.39,,,,,,
UHC MCR ADV,CPT,82672,Assay of estrogen,Lab Services,Per Unit,$21.70 ,OP,21.7,95.32,,,,,,
UHC MCR ADV,CPT,82677,Assay of estriol,Lab Services,Per Unit,$24.18 ,OP,24.18,49.56,,,,,,
UHC MCR ADV,CPT,82679,Assay of estrone,Lab Services,Per Unit,$24.95 ,OP,24.95,57.19,,,,,,
UHC MCR ADV,CPT,82681,Assay dir meas fr estradiol,Lab Services,Per Unit,$27.94 ,OP,27.94,27.94,,,,,,
UHC MCR ADV,CPT,82693,Assay of ethylene glycol,Lab Services,Per Unit,$14.90 ,OP,14.9,64.82,,,,,,
UHC MCR ADV,CPT,82696,Assay of etiocholanolone,Lab Services,Per Unit,$26.24 ,OP,26.24,64.82,,,,,,
UHC MCR ADV,CPT,82705,Fats/lipids feces qual,Lab Services,Per Unit,$5.10 ,OP,5.1,5.1,,,,,,
UHC MCR ADV,CPT,82710,Fats/lipids feces quant,Lab Services,Per Unit,$16.80 ,OP,16.8,16.8,,,,,,
UHC MCR ADV,CPT,82715,Assay of fecal fat,Lab Services,Per Unit,$22.97 ,OP,15.26,22.97,,,,,,
UHC MCR ADV,CPT,82725,Assay of blood fatty acids,Lab Services,Per Unit,$18.77 ,OP,18.77,18.77,,,,,,
UHC MCR ADV,CPT,82726,Long chain fatty acids,Lab Services,Per Unit,$19.75 ,OP,19.75,80.07,,,,,,
UHC MCR ADV,CPT,82728,Assay of ferritin,Lab Services,Per Unit,$13.63 ,OP,13.63,61,,,,,,
UHC MCR ADV,CPT,82731,Assay of fetal fibronectin,Lab Services,Per Unit,$64.41 ,OP,64.41,236.38,,,,,,
UHC MCR ADV,CPT,82735,Assay of fluoride,Lab Services,Per Unit,$18.54 ,OP,18.54,83.87,,,,,,
UHC MCR ADV,CPT,82746,Assay of folic acid serum,Lab Services,Per Unit,$14.70 ,OP,14.7,64.82,,,,,,
UHC MCR ADV,CPT,82747,Assay of folic acid rbc,Lab Services,Per Unit,$17.65 ,OP,17.65,76.26,,,,,,
UHC MCR ADV,CPT,82757,Assay of semen fructose,Lab Services,Per Unit,$17.34 ,OP,17.34,76.26,,,,,,
UHC MCR ADV,CPT,82759,Assay of rbc galactokinase,Lab Services,Per Unit,$21.48 ,OP,21.48,95.32,,,,,,
UHC MCR ADV,CPT,82760,Assay of galactose,Lab Services,Per Unit,$11.20 ,OP,11.2,49.56,,,,,,
UHC MCR ADV,CPT,82775,Assay galactose transferase,Lab Services,Per Unit,$21.07 ,OP,21.07,80.07,,,,,,
UHC MCR ADV,CPT,82776,Galactose transferase test,Lab Services,Per Unit,$11.74 ,OP,11.74,26.7,,,,,,
UHC MCR ADV,CPT,82777,Galectin-3,Lab Services,Per Unit,$44.25 ,OP,44.25,44.25,,,,,,
UHC MCR ADV,CPT,82784,Assay iga/igd/igg/igm each,Lab Services,Per Unit,$9.30 ,OP,9.3,41.94,,,,,,
UHC MCR ADV,CPT,82785,Assay of ige,Lab Services,Per Unit,$16.46 ,OP,16.46,72.44,,,,,,
UHC MCR ADV,CPT,82787,Igg 1 2 3 or 4 each,Lab Services,Per Unit,$8.02 ,OP,8.02,34.31,,,,,,
UHC MCR ADV,CPT,82800,Blood ph,Lab Services,Per Unit,$11.00 ,OP,11,30.51,,,,,,
UHC MCR ADV,CPT,82803,Blood gases any combination,Lab Services,Per Unit,$26.07 ,OP,26.07,61,,,,,,
UHC MCR ADV,CPT,82805,Blood gases w/o2 saturation,Lab Services,Per Unit,$78.77 ,OP,78.77,141.07,,,,,,
UHC MCR ADV,CPT,82810,Blood gases o2 sat only,Lab Services,Per Unit,$9.77 ,OP,9.77,9.77,,,,,,
UHC MCR ADV,CPT,82820,Hemoglobin-oxygen affinity,Lab Services,Per Unit,$13.34 ,OP,13.34,49.56,,,,,,
UHC MCR ADV,CPT,82930,Gastric analy w/ph ea spec,Lab Services,Per Unit,$6.71 ,OP,6.71,6.71,,,,,,
UHC MCR ADV,CPT,82938,Gastrin test,Lab Services,Per Unit,$17.69 ,OP,17.69,80.07,,,,,,
UHC MCR ADV,CPT,82941,Assay of gastrin,Lab Services,Per Unit,$17.63 ,OP,17.63,80.07,,,,,,
UHC MCR ADV,CPT,82943,Assay of glucagon,Lab Services,Per Unit,$14.29 ,OP,14.29,34.31,,,,,,
UHC MCR ADV,CPT,82945,Glucose other fluid,Lab Services,Per Unit,$3.93 ,OP,3.93,19.07,,,,,,
UHC MCR ADV,CPT,82946,Glucagon tolerance test,Lab Services,Per Unit,$17.77 ,OP,17.77,68.63,,,,,,
UHC MCR ADV,CPT,82947,Assay glucose blood quant,Lab Services,Per Unit,$3.93 ,OP,3.93,19.07,,,,,,
UHC MCR ADV,CPT,82948,Reagent strip/blood glucose,Lab Services,Per Unit,$5.04 ,OP,5.04,15.26,,,,,,
UHC MCR ADV,CPT,82950,Glucose test,Lab Services,Per Unit,$4.75 ,OP,4.75,22.88,,,,,,
UHC MCR ADV,CPT,82951,Glucose tolerance test (gtt),Lab Services,Per Unit,$12.87 ,OP,12.87,64.82,,,,,,
UHC MCR ADV,CPT,82952,Gtt-added samples,Lab Services,Per Unit,$3.92 ,OP,3.92,19.07,,,,,,
UHC MCR ADV,CPT,82955,Assay of g6pd enzyme,Lab Services,Per Unit,$9.70 ,OP,9.7,41.94,,,,,,
UHC MCR ADV,CPT,82960,Test for g6pd enzyme,Lab Services,Per Unit,$6.05 ,OP,6.05,6.05,,,,,,
UHC MCR ADV,CPT,82962,Glucose blood test,Lab Services,Per Unit,$3.28 ,OP,3.28,11.44,,,,,,
UHC MCR ADV,CPT,82963,Assay of glucosidase,Lab Services,Per Unit,$21.48 ,OP,21.48,80.07,,,,,,
UHC MCR ADV,CPT,82965,Assay of gdh enzyme,Lab Services,Per Unit,$13.15 ,OP,13.15,34.31,,,,,,
UHC MCR ADV,CPT,82977,Assay of ggt,Lab Services,Per Unit,$7.20 ,OP,7.2,34.31,,,,,,
UHC MCR ADV,CPT,82978,Assay of glutathione,Lab Services,Per Unit,$15.45 ,OP,15.45,64.82,,,,,,
UHC MCR ADV,CPT,82979,Assay rbc glutathione,Lab Services,Per Unit,$9.44 ,OP,9.44,30.51,,,,,,
UHC MCR ADV,CPT,82985,Assay of glycated protein,Lab Services,Per Unit,$16.76 ,OP,16.76,76.26,,,,,,
UHC MCR ADV,CPT,83001,Assay of gonadotropin (fsh),Lab Services,Per Unit,$18.58 ,OP,18.58,91.51,,,,,,
UHC MCR ADV,CPT,83002,Assay of gonadotropin (lh),Lab Services,Per Unit,$18.52 ,OP,18.52,91.51,,,,,,
UHC MCR ADV,CPT,83003,Assay growth hormone (hgh),Lab Services,Per Unit,$16.67 ,OP,16.67,72.44,,,,,,
UHC MCR ADV,CPT,83006,Growth stimulation gene 2,Lab Services,Per Unit,$75.60 ,OP,75.6,75.6,,,,,,
UHC MCR ADV,CPT,83009,H pylori (c-13) blood,Lab Services,Per Unit,$67.36 ,OP,67.36,301.2,,,,,,
UHC MCR ADV,CPT,83010,Assay of haptoglobin quant,Lab Services,Per Unit,$12.58 ,OP,12.58,57.19,,,,,,
UHC MCR ADV,CPT,83012,Assay of haptoglobins,Lab Services,Per Unit,$26.89 ,OP,26.89,72.44,,,,,,
UHC MCR ADV,CPT,83013,H pylori (c-13) breath,Lab Services,Per Unit,$67.36 ,OP,67.36,301.2,,,,,,
UHC MCR ADV,CPT,83014,H pylori drug admin,Lab Services,Per Unit,$7.86 ,OP,7.86,34.31,,,,,,
UHC MCR ADV,CPT,83015,Heavy metal qual any anal,Lab Services,Per Unit,$20.94 ,OP,20.94,83.87,,,,,,
UHC MCR ADV,CPT,83018,Heavy metal quant each nes,Lab Services,Per Unit,$21.96 ,OP,21.96,99.13,,,,,,
UHC MCR ADV,CPT,83020,Hemoglobin electrophoresis,Lab Services,Per Unit,$12.87 ,OP,12.87,45.74,,,,,,
UHC MCR ADV,CPT,83021,Hemoglobin chromotography,Lab Services,Per Unit,$18.06 ,OP,18.06,80.07,,,,,,
UHC MCR ADV,CPT,83026,Hemoglobin copper sulfate,Lab Services,Per Unit,$4.01 ,OP,4.01,4.01,,,,,,
UHC MCR ADV,CPT,83030,Fetal hemoglobin chemical,Lab Services,Per Unit,$10.74 ,OP,10.74,10.74,,,,,,
UHC MCR ADV,CPT,83033,Fetal hemoglobin assay qual,Lab Services,Per Unit,$8.00 ,OP,8,8,,,,,,
UHC MCR ADV,CPT,83036,Glycosylated hemoglobin test,Lab Services,Per Unit,$9.71 ,OP,9.71,49.56,,,,,,
UHC MCR ADV,CPT,83037,Glycosylated hb home device,Lab Services,Per Unit,$9.71 ,OP,9.71,41.94,,,,,,
UHC MCR ADV,CPT,83045,Blood methemoglobin test,Lab Services,Per Unit,$6.49 ,OP,6.49,22.88,,,,,,
UHC MCR ADV,CPT,83050,Blood methemoglobin assay,Lab Services,Per Unit,$8.20 ,OP,8.2,15.26,,,,,,
UHC MCR ADV,CPT,83051,Assay of plasma hemoglobin,Lab Services,Per Unit,$7.31 ,OP,7.31,7.31,,,,,,
UHC MCR ADV,CPT,83060,Blood sulfhemoglobin assay,Lab Services,Per Unit,$8.80 ,OP,8.8,15.26,,,,,,
UHC MCR ADV,CPT,83065,Assay of hemoglobin heat,Lab Services,Per Unit,$9.00 ,OP,9,15.26,,,,,,
UHC MCR ADV,CPT,83068,Hemoglobin stability screen,Lab Services,Per Unit,$9.47 ,OP,9.47,9.47,,,,,,
UHC MCR ADV,CPT,83069,Assay of urine hemoglobin,Lab Services,Per Unit,$3.95 ,OP,3.95,7.62,,,,,,
UHC MCR ADV,CPT,83070,Assay of hemosiderin qual,Lab Services,Per Unit,$4.75 ,OP,4.75,15.26,,,,,,
UHC MCR ADV,CPT,83080,Assay of b hexosaminidase,Lab Services,Per Unit,$16.87 ,OP,16.87,76.26,,,,,,
UHC MCR ADV,CPT,83088,Assay of histamine,Lab Services,Per Unit,$29.53 ,OP,29.53,129.64,,,,,,
UHC MCR ADV,CPT,83090,Assay of homocystine,Lab Services,Per Unit,$17.92 ,OP,17.92,76.26,,,,,,
UHC MCR ADV,CPT,83150,Assay of homovanillic acid,Lab Services,Per Unit,$22.41 ,OP,22.41,87.69,,,,,,
UHC MCR ADV,CPT,83491,Assay of corticosteroids 17,Lab Services,Per Unit,$17.90 ,OP,17.9,76.26,,,,,,
UHC MCR ADV,CPT,83497,Assay of 5-hiaa,Lab Services,Per Unit,$12.90 ,OP,12.9,57.19,,,,,,
UHC MCR ADV,CPT,83498,Assay of progesterone 17-d,Lab Services,Per Unit,$27.17 ,OP,27.17,122,,,,,,
UHC MCR ADV,CPT,83500,Assay free hydroxyproline,Lab Services,Per Unit,$22.65 ,OP,22.65,99.13,,,,,,
UHC MCR ADV,CPT,83505,Assay total hydroxyproline,Lab Services,Per Unit,$24.30 ,OP,24.3,106.76,,,,,,
UHC MCR ADV,CPT,83516,Immunoassay nonantibody,Lab Services,Per Unit,$11.53 ,OP,11.53,49.56,,,,,,
UHC MCR ADV,CPT,83518,Immunoassay dipstick,Lab Services,Per Unit,$9.64 ,OP,9.64,9.64,,,,,,
UHC MCR ADV,CPT,83519,Ria nonantibody,Lab Services,Per Unit,$18.40 ,OP,18.4,61,,,,,,
UHC MCR ADV,CPT,83520,Immunoassay quant nos nonab,Lab Services,Per Unit,$17.27 ,OP,17.27,57.19,,,,,,
UHC MCR ADV,CPT,83525,Assay of insulin,Lab Services,Per Unit,$11.43 ,OP,11.43,49.56,,,,,,
UHC MCR ADV,CPT,83527,Assay of insulin,Lab Services,Per Unit,$12.95 ,OP,12.95,57.19,,,,,,
UHC MCR ADV,CPT,83528,Assay of intrinsic factor,Lab Services,Per Unit,$19.82 ,OP,19.82,72.44,,,,,,
UHC MCR ADV,CPT,83540,Assay of iron,Lab Services,Per Unit,$6.47 ,OP,6.47,30.51,,,,,,
UHC MCR ADV,CPT,83550,Iron binding test,Lab Services,Per Unit,$8.74 ,OP,8.74,38.13,,,,,,
UHC MCR ADV,CPT,83570,Assay of idh enzyme,Lab Services,Per Unit,$8.85 ,OP,8.85,38.13,,,,,,
UHC MCR ADV,CPT,83582,Assay of ketogenic steroids,Lab Services,Per Unit,$15.47 ,OP,15.47,15.47,,,,,,
UHC MCR ADV,CPT,83586,Assay 17- ketosteroids,Lab Services,Per Unit,$12.80 ,OP,12.8,57.19,,,,,,
UHC MCR ADV,CPT,83593,Fractionation ketosteroids,Lab Services,Per Unit,$28.50 ,OP,28.5,118.19,,,,,,
UHC MCR ADV,CPT,83605,Assay of lactic acid,Lab Services,Per Unit,$11.57 ,OP,11.57,53.38,,,,,,
UHC MCR ADV,CPT,83615,Lactate (ld) (ldh) enzyme,Lab Services,Per Unit,$6.04 ,OP,6.04,26.7,,,,,,
UHC MCR ADV,CPT,83625,Assay of ldh enzymes,Lab Services,Per Unit,$12.79 ,OP,12.79,49.56,,,,,,
UHC MCR ADV,CPT,83630,Lactoferrin fecal (qual),Lab Services,Per Unit,$19.70 ,OP,19.7,87.69,,,,,,
UHC MCR ADV,CPT,83631,Lactoferrin fecal (quant),Lab Services,Per Unit,$19.63 ,OP,19.63,87.69,,,,,,
UHC MCR ADV,CPT,83632,Placental lactogen,Lab Services,Per Unit,$20.22 ,OP,20.22,91.51,,,,,,
UHC MCR ADV,CPT,83633,Test urine for lactose,Lab Services,Per Unit,$11.25 ,OP,11.25,22.88,,,,,,
UHC MCR ADV,CPT,83655,Assay of lead,Lab Services,Per Unit,$12.11 ,OP,12.11,53.38,,,,,,
UHC MCR ADV,CPT,83661,L/s ratio fetal lung,Lab Services,Per Unit,$21.99 ,OP,21.99,99.13,,,,,,
UHC MCR ADV,CPT,83662,Foam stability fetal lung,Lab Services,Per Unit,$18.91 ,OP,18.91,83.87,,,,,,
UHC MCR ADV,CPT,83663,Fluoro polarize fetal lung,Lab Services,Per Unit,$18.91 ,OP,18.91,83.87,,,,,,
UHC MCR ADV,CPT,83664,Lamellar bdy fetal lung,Lab Services,Per Unit,$19.32 ,OP,19.32,83.87,,,,,,
UHC MCR ADV,CPT,83670,Assay of lap enzyme,Lab Services,Per Unit,$9.81 ,OP,9.81,41.94,,,,,,
UHC MCR ADV,CPT,83690,Assay of lipase,Lab Services,Per Unit,$6.89 ,OP,6.89,61.5,,,,,,
UHC MCR ADV,CPT,83695,Assay of lipoprotein(a),Lab Services,Per Unit,$14.32 ,OP,14.32,57.19,,,,,,
UHC MCR ADV,CPT,83698,Assay lipoprotein pla2,Lab Services,Per Unit,$46.31 ,OP,46.31,125.82,,,,,,
UHC MCR ADV,CPT,83700,Lipopro bld electrophoretic,Lab Services,Per Unit,$11.26 ,OP,11.26,49.56,,,,,,
UHC MCR ADV,CPT,83701,Lipoprotein bld hr fraction,Lab Services,Per Unit,$33.86 ,OP,33.86,110.57,,,,,,
UHC MCR ADV,CPT,83704,Lipoprotein bld quan part,Lab Services,Per Unit,$34.19 ,OP,34.19,141.07,,,,,,
UHC MCR ADV,CPT,83718,Assay of lipoprotein,Lab Services,Per Unit,$8.19 ,OP,8.19,41.94,,,,,,
UHC MCR ADV,CPT,83719,Assay of blood lipoprotein,Lab Services,Per Unit,$12.75 ,OP,12.75,53.38,,,,,,
UHC MCR ADV,CPT,83721,Assay of blood lipoprotein,Lab Services,Per Unit,$10.50 ,OP,10.5,41.94,,,,,,
UHC MCR ADV,CPT,83722,Lipoprtn dir meas sd ldl chl,Lab Services,Per Unit,$34.19 ,OP,34.19,141.07,,,,,,
UHC MCR ADV,CPT,83727,Assay of lrh hormone,Lab Services,Per Unit,$17.19 ,OP,17.19,76.26,,,,,,
UHC MCR ADV,CPT,83735,Assay of magnesium,Lab Services,Per Unit,$6.70 ,OP,6.7,34.31,,,,,,
UHC MCR ADV,CPT,83775,Assay malate dehydrogenase,Lab Services,Per Unit,$7.37 ,OP,7.37,34.31,,,,,,
UHC MCR ADV,CPT,83785,Assay of manganese,Lab Services,Per Unit,$26.65 ,OP,26.65,110.57,,,,,,
UHC MCR ADV,CPT,83789,Mass spectrometry qual/quan,Lab Services,Per Unit,$24.11 ,OP,24.11,80.07,,,,,,
UHC MCR ADV,CPT,83825,Assay of mercury,Lab Services,Per Unit,$16.26 ,OP,16.26,72.44,,,,,,
UHC MCR ADV,CPT,83835,Assay of metanephrines,Lab Services,Per Unit,$16.94 ,OP,16.94,76.26,,,,,,
UHC MCR ADV,CPT,83857,Assay of methemalbumin,Lab Services,Per Unit,$10.74 ,OP,10.74,49.56,,,,,,
UHC MCR ADV,CPT,83861,Microfluid analy tears,Lab Services,Per Unit,$22.48 ,OP,22.48,22.48,,,,,,
UHC MCR ADV,CPT,83864,Mucopolysaccharides,Lab Services,Per Unit,$28.50 ,OP,28.5,87.69,,,,,,
UHC MCR ADV,CPT,83872,Assay synovial fluid mucin,Lab Services,Per Unit,$5.86 ,OP,5.86,26.7,,,,,,
UHC MCR ADV,CPT,83873,Assay of csf protein,Lab Services,Per Unit,$17.20 ,OP,17.2,72.44,,,,,,
UHC MCR ADV,CPT,83874,Assay of myoglobin,Lab Services,Per Unit,$12.92 ,OP,12.92,57.19,,,,,,
UHC MCR ADV,CPT,83876,Assay myeloperoxidase,Lab Services,Per Unit,$50.86 ,OP,50.86,57.19,,,,,,
UHC MCR ADV,CPT,83880,Assay of natriuretic peptide,Lab Services,Per Unit,$39.26 ,OP,39.26,245.98,,,,,,
UHC MCR ADV,CPT,83883,Assay nephelometry not spec,Lab Services,Per Unit,$13.60 ,OP,13.6,61,,,,,,
UHC MCR ADV,CPT,83885,Assay of nickel,Lab Services,Per Unit,$24.51 ,OP,24.51,45.74,,,,,,
UHC MCR ADV,CPT,83915,Assay of nucleotidase,Lab Services,Per Unit,$11.15 ,OP,11.15,11.15,,,,,,
UHC MCR ADV,CPT,83916,Oligoclonal bands,Lab Services,Per Unit,$27.39 ,OP,27.39,87.69,,,,,,
UHC MCR ADV,CPT,83918,Organic acids total quant,Lab Services,Per Unit,$23.60 ,OP,23.6,72.44,,,,,,
UHC MCR ADV,CPT,83919,Organic acids qual each,Lab Services,Per Unit,$16.45 ,OP,16.45,16.45,,,,,,
UHC MCR ADV,CPT,83921,Organic acid single quant,Lab Services,Per Unit,$21.21 ,OP,21.21,72.44,,,,,,
UHC MCR ADV,CPT,83930,Assay of blood osmolality,Lab Services,Per Unit,$6.61 ,OP,6.61,26.7,,,,,,
UHC MCR ADV,CPT,83935,Assay of urine osmolality,Lab Services,Per Unit,$6.82 ,OP,6.82,30.51,,,,,,
UHC MCR ADV,CPT,83937,Assay of osteocalcin,Lab Services,Per Unit,$29.85 ,OP,29.85,133.45,,,,,,
UHC MCR ADV,CPT,83945,Assay of oxalate,Lab Services,Per Unit,$14.45 ,OP,14.45,57.19,,,,,,
UHC MCR ADV,CPT,83950,Oncoprotein her-2/neu,Lab Services,Per Unit,$64.41 ,OP,64.41,209.7,,,,,,
UHC MCR ADV,CPT,83951,Oncoprotein dcp,Lab Services,Per Unit,$64.41 ,OP,64.41,209.7,,,,,,
UHC MCR ADV,CPT,83970,Assay of parathormone,Lab Services,Per Unit,$41.28 ,OP,41.28,183.02,,,,,,
UHC MCR ADV,CPT,83986,Assay ph body fluid nos,Lab Services,Per Unit,$3.58 ,OP,3.58,19.07,,,,,,
UHC MCR ADV,CPT,83987,Exhaled breath condensate,Lab Services,Per Unit,$3.58 ,OP,3.58,3.58,,,,,,
UHC MCR ADV,CPT,83993,Assay for calprotectin fecal,Lab Services,Per Unit,$19.63 ,OP,19.63,87.69,,,,,,
UHC MCR ADV,CPT,84030,Assay of blood pku,Lab Services,Per Unit,$5.50 ,OP,5.5,26.7,,,,,,
UHC MCR ADV,CPT,84035,Assay of phenylketones,Lab Services,Per Unit,$3.98 ,OP,3.98,15.26,,,,,,
UHC MCR ADV,CPT,84060,Assay acid phosphatase,Lab Services,Per Unit,$7.64 ,OP,7.64,34.31,,,,,,
UHC MCR ADV,CPT,84066,Assay prostate phosphatase,Lab Services,Per Unit,$9.66 ,OP,9.66,41.94,,,,,,
UHC MCR ADV,CPT,84075,Assay alkaline phosphatase,Lab Services,Per Unit,$5.18 ,OP,5.18,26.7,,,,,,
UHC MCR ADV,CPT,84078,Assay alkaline phosphatase,Lab Services,Per Unit,$8.26 ,OP,8.26,34.31,,,,,,
UHC MCR ADV,CPT,84080,Assay alkaline phosphatases,Lab Services,Per Unit,$14.78 ,OP,14.78,64.82,,,,,,
UHC MCR ADV,CPT,84081,Assay phosphatidylglycerol,Lab Services,Per Unit,$16.52 ,OP,16.52,72.44,,,,,,
UHC MCR ADV,CPT,84085,Assay of rbc pg6d enzyme,Lab Services,Per Unit,$9.44 ,OP,9.44,30.51,,,,,,
UHC MCR ADV,CPT,84087,Assay phosphohexose enzymes,Lab Services,Per Unit,$10.73 ,OP,10.73,45.74,,,,,,
UHC MCR ADV,CPT,84100,Assay of phosphorus,Lab Services,Per Unit,$4.74 ,OP,4.74,22.88,,,,,,
UHC MCR ADV,CPT,84105,Assay of urine phosphorus,Lab Services,Per Unit,$5.78 ,OP,5.78,22.88,,,,,,
UHC MCR ADV,CPT,84106,Test for porphobilinogen,Lab Services,Per Unit,$5.82 ,OP,5.82,19.07,,,,,,
UHC MCR ADV,CPT,84110,Assay of porphobilinogen,Lab Services,Per Unit,$8.44 ,OP,8.44,38.13,,,,,,
UHC MCR ADV,CPT,84112,Eval amniotic fluid protein,Lab Services,Per Unit,$98.11 ,OP,98.11,98.11,,,,,,
UHC MCR ADV,CPT,84119,Test urine for porphyrins,Lab Services,Per Unit,$13.36 ,OP,13.36,13.36,,,,,,
UHC MCR ADV,CPT,84120,Assay of urine porphyrins,Lab Services,Per Unit,$14.71 ,OP,14.71,64.82,,,,,,
UHC MCR ADV,CPT,84126,Assay of feces porphyrins,Lab Services,Per Unit,$39.11 ,OP,39.11,114.39,,,,,,
UHC MCR ADV,CPT,84132,Assay of serum potassium,Lab Services,Per Unit,$4.76 ,OP,4.76,22.88,,,,,,
UHC MCR ADV,CPT,84133,Assay of urine potassium,Lab Services,Per Unit,$4.73 ,OP,4.73,19.07,,,,,,
UHC MCR ADV,CPT,84134,Assay of prealbumin,Lab Services,Per Unit,$14.59 ,OP,14.59,64.82,,,,,,
UHC MCR ADV,CPT,84135,Assay of pregnanediol,Lab Services,Per Unit,$21.27 ,OP,21.27,57.19,,,,,,
UHC MCR ADV,CPT,84138,Assay of pregnanetriol,Lab Services,Per Unit,$21.05 ,OP,21.05,83.87,,,,,,
UHC MCR ADV,CPT,84140,Assay of pregnenolone,Lab Services,Per Unit,$20.67 ,OP,20.67,91.51,,,,,,
UHC MCR ADV,CPT,84143,Assay of 17-hydroxypregneno,Lab Services,Per Unit,$22.81 ,OP,22.81,102.95,,,,,,
UHC MCR ADV,CPT,84144,Assay of progesterone,Lab Services,Per Unit,$20.86 ,OP,20.86,91.51,,,,,,
UHC MCR ADV,CPT,84145,Procalcitonin (pct),Lab Services,Per Unit,$27.22 ,OP,27.22,27.22,,,,,,
UHC MCR ADV,CPT,84146,Assay of prolactin,Lab Services,Per Unit,$19.38 ,OP,19.38,87.69,,,,,,
UHC MCR ADV,CPT,84150,Assay of prostaglandin,Lab Services,Per Unit,$41.77 ,OP,41.77,41.77,,,,,,
UHC MCR ADV,CPT,84152,Assay of psa complexed,Lab Services,Per Unit,$18.39 ,OP,18.39,80.07,,,,,,
UHC MCR ADV,CPT,84153,Assay of psa total,Lab Services,Per Unit,$18.39 ,OP,18.39,80.07,,,,,,
UHC MCR ADV,CPT,84154,Assay of psa free,Lab Services,Per Unit,$18.39 ,OP,18.39,80.07,,,,,,
UHC MCR ADV,CPT,84155,Assay of protein serum,Lab Services,Per Unit,$3.67 ,OP,3.67,15.26,,,,,,
UHC MCR ADV,CPT,84156,Assay of protein urine,Lab Services,Per Unit,$3.67 ,OP,3.67,15.26,,,,,,
UHC MCR ADV,CPT,84157,Assay of protein other,Lab Services,Per Unit,$4.00 ,OP,4,19.07,,,,,,
UHC MCR ADV,CPT,84160,Assay of protein any source,Lab Services,Per Unit,$5.61 ,OP,5.61,22.88,,,,,,
UHC MCR ADV,CPT,84163,Pappa serum,Lab Services,Per Unit,$15.05 ,OP,15.05,68.63,,,,,,
UHC MCR ADV,CPT,84165,Protein e-phoresis serum,Lab Services,Per Unit,$10.74 ,OP,10.74,49.56,,,,,,
UHC MCR ADV,CPT,84166,Protein e-phoresis/urine/csf,Lab Services,Per Unit,$17.83 ,OP,17.83,80.07,,,,,,
UHC MCR ADV,CPT,84181,Western blot test,Lab Services,Per Unit,$17.03 ,OP,17.03,118.19,,,,,,
UHC MCR ADV,CPT,84182,Protein western blot test,Lab Services,Per Unit,$29.21 ,OP,29.21,129.64,,,,,,
UHC MCR ADV,CPT,84202,Assay rbc protoporphyrin,Lab Services,Per Unit,$14.35 ,OP,14.35,64.82,,,,,,
UHC MCR ADV,CPT,84203,Test rbc protoporphyrin,Lab Services,Per Unit,$9.74 ,OP,9.74,38.13,,,,,,
UHC MCR ADV,CPT,84206,Assay of proinsulin,Lab Services,Per Unit,$26.69 ,OP,26.69,80.07,,,,,,
UHC MCR ADV,CPT,84207,Assay of vitamin b-6,Lab Services,Per Unit,$28.10 ,OP,28.1,125.82,,,,,,
UHC MCR ADV,CPT,84210,Assay of pyruvate,Lab Services,Per Unit,$14.48 ,OP,14.48,49.56,,,,,,
UHC MCR ADV,CPT,84220,Assay of pyruvate kinase,Lab Services,Per Unit,$9.44 ,OP,9.44,41.94,,,,,,
UHC MCR ADV,CPT,84228,Assay of quinine,Lab Services,Per Unit,$11.63 ,OP,11.63,53.38,,,,,,
UHC MCR ADV,CPT,84233,Assay of estrogen,Lab Services,Per Unit,$87.88 ,OP,87.88,209.7,,,,,,
UHC MCR ADV,CPT,84234,Assay of progesterone,Lab Services,Per Unit,$64.88 ,OP,64.88,183.02,,,,,,
UHC MCR ADV,CPT,84235,Assay of endocrine hormone,Lab Services,Per Unit,$71.23 ,OP,71.23,163.95,,,,,,
UHC MCR ADV,CPT,84238,Assay nonendocrine receptor,Lab Services,Per Unit,$36.57 ,OP,36.57,163.95,,,,,,
UHC MCR ADV,CPT,84244,Assay of renin,Lab Services,Per Unit,$21.99 ,OP,21.99,99.13,,,,,,
UHC MCR ADV,CPT,84252,Assay of vitamin b-2,Lab Services,Per Unit,$20.24 ,OP,20.24,20.24,,,,,,
UHC MCR ADV,CPT,84255,Assay of selenium,Lab Services,Per Unit,$25.53 ,OP,25.53,114.39,,,,,,
UHC MCR ADV,CPT,84260,Assay of serotonin,Lab Services,Per Unit,$30.98 ,OP,30.98,30.98,,,,,,
UHC MCR ADV,CPT,84270,Assay of sex hormone globul,Lab Services,Per Unit,$21.73 ,OP,21.73,95.32,,,,,,
UHC MCR ADV,CPT,84275,Assay of sialic acid,Lab Services,Per Unit,$13.44 ,OP,13.44,13.44,,,,,,
UHC MCR ADV,CPT,84285,Assay of silica,Lab Services,Per Unit,$25.21 ,OP,25.21,38.13,,,,,,
UHC MCR ADV,CPT,84295,Assay of serum sodium,Lab Services,Per Unit,$4.81 ,OP,4.81,22.88,,,,,,
UHC MCR ADV,CPT,84300,Assay of urine sodium,Lab Services,Per Unit,$5.06 ,OP,5.06,22.88,,,,,,
UHC MCR ADV,CPT,84302,Assay of sweat sodium,Lab Services,Per Unit,$4.86 ,OP,4.86,22.88,,,,,,
UHC MCR ADV,CPT,84305,Assay of somatomedin,Lab Services,Per Unit,$21.26 ,OP,21.26,95.32,,,,,,
UHC MCR ADV,CPT,84307,Assay of somatostatin,Lab Services,Per Unit,$18.28 ,OP,18.28,80.07,,,,,,
UHC MCR ADV,CPT,84311,Spectrophotometry,Lab Services,Per Unit,$8.10 ,OP,8.1,30.51,,,,,,
UHC MCR ADV,CPT,84315,Body fluid specific gravity,Lab Services,Per Unit,$3.28 ,OP,3.28,11.44,,,,,,
UHC MCR ADV,CPT,84375,Chromatogram assay sugars,Lab Services,Per Unit,$39.00 ,OP,39,39,,,,,,
UHC MCR ADV,CPT,84376,Sugars single qual,Lab Services,Per Unit,$5.50 ,OP,5.5,22.88,,,,,,
UHC MCR ADV,CPT,84377,Sugars multiple qual,Lab Services,Per Unit,$5.50 ,OP,5.5,22.88,,,,,,
UHC MCR ADV,CPT,84378,Sugars single quant,Lab Services,Per Unit,$11.53 ,OP,11.53,49.56,,,,,,
UHC MCR ADV,CPT,84379,Sugars multiple quant,Lab Services,Per Unit,$11.53 ,OP,11.53,49.56,,,,,,
UHC MCR ADV,CPT,84392,Assay of urine sulfate,Lab Services,Per Unit,$5.49 ,OP,5.49,22.88,,,,,,
UHC MCR ADV,CPT,84402,Assay of free testosterone,Lab Services,Per Unit,$25.47 ,OP,25.47,114.39,,,,,,
UHC MCR ADV,CPT,84403,Assay of total testosterone,Lab Services,Per Unit,$25.81 ,OP,25.81,114.39,,,,,,
UHC MCR ADV,CPT,84410,Testosterone bioavailable,Lab Services,Per Unit,$51.28 ,OP,51.28,51.28,,,,,,
UHC MCR ADV,CPT,84425,Assay of vitamin b-1,Lab Services,Per Unit,$21.23 ,OP,21.23,95.32,,,,,,
UHC MCR ADV,CPT,84430,Assay of thiocyanate,Lab Services,Per Unit,$11.63 ,OP,11.63,53.38,,,,,,
UHC MCR ADV,CPT,84431,Thromboxane urine,Lab Services,Per Unit,$35.11 ,OP,35.11,35.11,,,,,,
UHC MCR ADV,CPT,84432,Assay of thyroglobulin,Lab Services,Per Unit,$16.06 ,OP,16.06,72.44,,,,,,
UHC MCR ADV,CPT,84436,Assay of total thyroxine,Lab Services,Per Unit,$6.87 ,OP,6.87,30.51,,,,,,
UHC MCR ADV,CPT,84437,Assay of neonatal thyroxine,Lab Services,Per Unit,$6.47 ,OP,6.47,30.51,,,,,,
UHC MCR ADV,CPT,84439,Assay of free thyroxine,Lab Services,Per Unit,$9.02 ,OP,9.02,41.94,,,,,,
UHC MCR ADV,CPT,84442,Assay of thyroid activity,Lab Services,Per Unit,$14.78 ,OP,14.78,64.82,,,,,,
UHC MCR ADV,CPT,84443,Assay thyroid stim hormone,Lab Services,Per Unit,$16.80 ,OP,16.8,76.26,,,,,,
UHC MCR ADV,CPT,84445,Assay of tsi globulin,Lab Services,Per Unit,$50.86 ,OP,50.86,224.95,,,,,,
UHC MCR ADV,CPT,84446,Assay of vitamin e,Lab Services,Per Unit,$14.18 ,OP,14.18,64.82,,,,,,
UHC MCR ADV,CPT,84449,Assay of transcortin,Lab Services,Per Unit,$18.00 ,OP,18,80.07,,,,,,
UHC MCR ADV,CPT,84450,Transferase (ast) (sgot),Lab Services,Per Unit,$5.18 ,OP,5.18,22.88,,,,,,
UHC MCR ADV,CPT,84460,Alanine amino (alt) (sgpt),Lab Services,Per Unit,$5.30 ,OP,5.3,26.7,,,,,,
UHC MCR ADV,CPT,84466,Assay of transferrin,Lab Services,Per Unit,$12.76 ,OP,12.76,57.19,,,,,,
UHC MCR ADV,CPT,84478,Assay of triglycerides,Lab Services,Per Unit,$5.74 ,OP,5.74,30.51,,,,,,
UHC MCR ADV,CPT,84479,Assay of thyroid (t3 or t4),Lab Services,Per Unit,$6.47 ,OP,6.47,30.51,,,,,,
UHC MCR ADV,CPT,84480,Assay triiodothyronine (t3),Lab Services,Per Unit,$14.18 ,OP,14.18,49.56,,,,,,
UHC MCR ADV,CPT,84481,Free assay (ft-3),Lab Services,Per Unit,$16.94 ,OP,16.94,49.56,,,,,,
UHC MCR ADV,CPT,84482,T3 reverse,Lab Services,Per Unit,$15.76 ,OP,15.76,68.63,,,,,,
UHC MCR ADV,CPT,84484,Assay of troponin quant,Lab Services,Per Unit,$12.47 ,OP,12.47,92.24,,,,,,
UHC MCR ADV,CPT,84485,Assay duodenal fluid trypsin,Lab Services,Per Unit,$7.20 ,OP,7.2,7.2,,,,,,
UHC MCR ADV,CPT,84488,Test feces for trypsin,Lab Services,Per Unit,$7.30 ,OP,7.3,34.31,,,,,,
UHC MCR ADV,CPT,84490,Assay of feces for trypsin,Lab Services,Per Unit,$9.93 ,OP,9.93,26.7,,,,,,
UHC MCR ADV,CPT,84510,Assay of tyrosine,Lab Services,Per Unit,$10.63 ,OP,10.63,45.74,,,,,,
UHC MCR ADV,CPT,84512,Assay of troponin qual,Lab Services,Per Unit,$10.09 ,OP,10.09,34.31,,,,,,
UHC MCR ADV,CPT,84520,Assay of urea nitrogen,Lab Services,Per Unit,$3.95 ,OP,3.95,19.07,,,,,,
UHC MCR ADV,CPT,84525,Urea nitrogen semi-quant,Lab Services,Per Unit,$5.13 ,OP,5.13,15.26,,,,,,
UHC MCR ADV,CPT,84540,Assay of urine/urea-n,Lab Services,Per Unit,$5.56 ,OP,5.56,22.88,,,,,,
UHC MCR ADV,CPT,84545,Urea-n clearance test,Lab Services,Per Unit,$7.20 ,OP,7.2,19.07,,,,,,
UHC MCR ADV,CPT,84550,Assay of blood/uric acid,Lab Services,Per Unit,$4.52 ,OP,4.52,19.07,,,,,,
UHC MCR ADV,CPT,84560,Assay of urine/uric acid,Lab Services,Per Unit,$5.08 ,OP,5.08,22.88,,,,,,
UHC MCR ADV,CPT,84577,Assay of feces/urobilinogen,Lab Services,Per Unit,$16.80 ,OP,16.8,57.19,,,,,,
UHC MCR ADV,CPT,84578,Test urine urobilinogen,Lab Services,Per Unit,$4.47 ,OP,4.47,15.26,,,,,,
UHC MCR ADV,CPT,84580,Assay of urine urobilinogen,Lab Services,Per Unit,$9.55 ,OP,9.55,19.07,,,,,,
UHC MCR ADV,CPT,84583,Assay of urine urobilinogen,Lab Services,Per Unit,$6.05 ,OP,6.05,22.88,,,,,,
UHC MCR ADV,CPT,84585,Assay of urine vma,Lab Services,Per Unit,$15.50 ,OP,15.5,68.63,,,,,,
UHC MCR ADV,CPT,84586,Assay of vip,Lab Services,Per Unit,$35.33 ,OP,35.33,156.32,,,,,,
UHC MCR ADV,CPT,84588,Assay of vasopressin,Lab Services,Per Unit,$33.94 ,OP,33.94,125.82,,,,,,
UHC MCR ADV,CPT,84590,Assay of vitamin a,Lab Services,Per Unit,$11.61 ,OP,11.61,53.38,,,,,,
UHC MCR ADV,CPT,84591,Assay of nos vitamin,Lab Services,Per Unit,$17.06 ,OP,17.06,53.38,,,,,,
UHC MCR ADV,CPT,84597,Assay of vitamin k,Lab Services,Per Unit,$13.72 ,OP,13.72,49.56,,,,,,
UHC MCR ADV,CPT,84600,Assay of volatiles,Lab Services,Per Unit,$17.11 ,OP,17.11,72.44,,,,,,
UHC MCR ADV,CPT,84620,Xylose tolerance test,Lab Services,Per Unit,$12.91 ,OP,12.91,38.13,,,,,,
UHC MCR ADV,CPT,84630,Assay of zinc,Lab Services,Per Unit,$11.39 ,OP,11.39,49.56,,,,,,
UHC MCR ADV,CPT,84681,Assay of c-peptide,Lab Services,Per Unit,$20.81 ,OP,20.81,91.51,,,,,,
UHC MCR ADV,CPT,84702,Chorionic gonadotropin test,Lab Services,Per Unit,$15.05 ,OP,15.05,76.26,,,,,,
UHC MCR ADV,CPT,84703,Chorionic gonadotropin assay,Lab Services,Per Unit,$7.52 ,OP,7.52,38.13,,,,,,
UHC MCR ADV,CPT,84704,Hcg free betachain test,Lab Services,Per Unit,$15.29 ,OP,15.29,68.63,,,,,,
UHC MCR ADV,CPT,84830,Ovulation tests,Lab Services,Per Unit,$12.70 ,OP,12.7,49.56,,,,,,
UHC MCR ADV,CPT,85002,Bleeding time test,Lab Services,Per Unit,$4.82 ,OP,4.82,22.88,,,,,,
UHC MCR ADV,CPT,85004,Automated diff wbc count,Lab Services,Per Unit,$6.47 ,OP,6.47,34.31,,,,,,
UHC MCR ADV,CPT,85007,Bl smear w/diff wbc count,Lab Services,Per Unit,$3.80 ,OP,3.8,19.07,,,,,,
UHC MCR ADV,CPT,85008,Bl smear w/o diff wbc count,Lab Services,Per Unit,$3.43 ,OP,3.43,19.07,,,,,,
UHC MCR ADV,CPT,85009,Manual diff wbc count b-coat,Lab Services,Per Unit,$5.07 ,OP,5.07,19.07,,,,,,
UHC MCR ADV,CPT,85013,Spun microhematocrit,Lab Services,Per Unit,$7.00 ,OP,7,7,,,,,,
UHC MCR ADV,CPT,85014,Hematocrit,Lab Services,Per Unit,$2.37 ,OP,2.37,11.44,,,,,,
UHC MCR ADV,CPT,85018,Hemoglobin,Lab Services,Per Unit,$2.37 ,OP,2.37,11.44,,,,,,
UHC MCR ADV,CPT,85025,Complete cbc w/auto diff wbc,Lab Services,Per Unit,$7.77 ,OP,7.77,67.65,,,,,,
UHC MCR ADV,CPT,85027,Complete cbc automated,Lab Services,Per Unit,$6.47 ,OP,6.47,34.31,,,,,,
UHC MCR ADV,CPT,85032,Manual cell count each,Lab Services,Per Unit,$4.31 ,OP,4.31,22.88,,,,,,
UHC MCR ADV,CPT,85041,Automated rbc count,Lab Services,Per Unit,$3.02 ,OP,3.02,11.44,,,,,,
UHC MCR ADV,CPT,85044,Manual reticulocyte count,Lab Services,Per Unit,$4.31 ,OP,4.31,4.31,,,,,,
UHC MCR ADV,CPT,85045,Automated reticulocyte count,Lab Services,Per Unit,$3.99 ,OP,3.99,19.07,,,,,,
UHC MCR ADV,CPT,85046,Reticyte/hgb concentrate,Lab Services,Per Unit,$5.57 ,OP,5.57,26.7,,,,,,
UHC MCR ADV,CPT,85048,Automated leukocyte count,Lab Services,Per Unit,$2.54 ,OP,2.54,11.44,,,,,,
UHC MCR ADV,CPT,85049,Automated platelet count,Lab Services,Per Unit,$4.48 ,OP,4.48,22.88,,,,,,
UHC MCR ADV,CPT,85055,Reticulated platelet assay,Lab Services,Per Unit,$35.74 ,OP,35.74,61,,,,,,
UHC MCR ADV,CPT,85097,Bone marrow interpretation,APC 5674,RVU Per Case,$671.45 ,OP,438.47,671.45,,,,,,
UHC MCR ADV,CPT,85130,Chromogenic substrate assay,Lab Services,Per Unit,$11.89 ,OP,11.89,53.38,,,,,,
UHC MCR ADV,CPT,85170,Blood clot retraction,Lab Services,Per Unit,$16.30 ,OP,16.3,16.3,,,,,,
UHC MCR ADV,CPT,85175,Blood clot lysis time,Lab Services,Per Unit,$20.37 ,OP,19.07,20.37,,,,,,
UHC MCR ADV,CPT,85210,Clot factor ii prothrom spec,Lab Services,Per Unit,$12.98 ,OP,12.98,64.82,,,,,,
UHC MCR ADV,CPT,85220,Blooc clot factor v test,Lab Services,Per Unit,$17.65 ,OP,17.65,80.07,,,,,,
UHC MCR ADV,CPT,85230,Clot factor vii proconvertin,Lab Services,Per Unit,$17.90 ,OP,17.9,80.07,,,,,,
UHC MCR ADV,CPT,85240,Clot factor viii ahg 1 stage,Lab Services,Per Unit,$17.90 ,OP,17.9,80.07,,,,,,
UHC MCR ADV,CPT,85244,Clot factor viii reltd antgn,Lab Services,Per Unit,$20.42 ,OP,20.42,91.51,,,,,,
UHC MCR ADV,CPT,85245,Clot factor viii vw ristoctn,Lab Services,Per Unit,$22.94 ,OP,22.94,64.82,,,,,,
UHC MCR ADV,CPT,85246,Clot factor viii vw antigen,Lab Services,Per Unit,$22.94 ,OP,22.94,64.82,,,,,,
UHC MCR ADV,CPT,85247,Clot factor viii multimetric,Lab Services,Per Unit,$22.94 ,OP,22.94,22.94,,,,,,
UHC MCR ADV,CPT,85250,Clot factor ix ptc/chrstmas,Lab Services,Per Unit,$19.04 ,OP,19.04,83.87,,,,,,
UHC MCR ADV,CPT,85260,Clot factor x stuart-power,Lab Services,Per Unit,$17.90 ,OP,17.9,80.07,,,,,,
UHC MCR ADV,CPT,85270,Clot factor xi pta,Lab Services,Per Unit,$17.90 ,OP,17.9,80.07,,,,,,
UHC MCR ADV,CPT,85280,Clot factor xii hageman,Lab Services,Per Unit,$19.35 ,OP,19.35,87.69,,,,,,
UHC MCR ADV,CPT,85290,Clot factor xiii fibrin stab,Lab Services,Per Unit,$16.34 ,OP,16.34,72.44,,,,,,
UHC MCR ADV,CPT,85291,Clot factor xiii fibrin scrn,Lab Services,Per Unit,$9.11 ,OP,9.11,38.13,,,,,,
UHC MCR ADV,CPT,85292,Clot factor fletcher fact,Lab Services,Per Unit,$18.93 ,OP,18.93,83.87,,,,,,
UHC MCR ADV,CPT,85293,Clot factor wght kininogen,Lab Services,Per Unit,$18.93 ,OP,18.93,83.87,,,,,,
UHC MCR ADV,CPT,85300,Antithrombin iii activity,Lab Services,Per Unit,$11.85 ,OP,11.85,53.38,,,,,,
UHC MCR ADV,CPT,85301,Antithrombin iii antigen,Lab Services,Per Unit,$10.81 ,OP,10.81,49.56,,,,,,
UHC MCR ADV,CPT,85302,Clot inhibit prot c antigen,Lab Services,Per Unit,$12.01 ,OP,12.01,53.38,,,,,,
UHC MCR ADV,CPT,85303,Clot inhibit prot c activity,Lab Services,Per Unit,$13.84 ,OP,13.84,61,,,,,,
UHC MCR ADV,CPT,85305,Clot inhibit prot s total,Lab Services,Per Unit,$11.61 ,OP,11.61,53.38,,,,,,
UHC MCR ADV,CPT,85306,Clot inhibit prot s free,Lab Services,Per Unit,$15.32 ,OP,15.32,68.63,,,,,,
UHC MCR ADV,CPT,85307,Assay activated protein c,Lab Services,Per Unit,$15.32 ,OP,15.32,68.63,,,,,,
UHC MCR ADV,CPT,85335,Factor inhibitor test,Lab Services,Per Unit,$12.87 ,OP,12.87,12.87,,,,,,
UHC MCR ADV,CPT,85337,Thrombomodulin,Lab Services,Per Unit,$17.27 ,OP,17.27,45.74,,,,,,
UHC MCR ADV,CPT,85345,Coagulation time lee & white,Lab Services,Per Unit,$4.69 ,OP,4.69,4.69,,,,,,
UHC MCR ADV,CPT,85347,Coagulation time activated,Lab Services,Per Unit,$4.28 ,OP,4.28,15.26,,,,,,
UHC MCR ADV,CPT,85348,Coagulation time otr method,Lab Services,Per Unit,$4.49 ,OP,4.49,15.26,,,,,,
UHC MCR ADV,CPT,85360,Euglobulin lysis,Lab Services,Per Unit,$8.41 ,OP,8.41,38.13,,,,,,
UHC MCR ADV,CPT,85362,Fibrin degradation products,Lab Services,Per Unit,$6.89 ,OP,6.89,30.51,,,,,,
UHC MCR ADV,CPT,85366,Fibrinogen test,Lab Services,Per Unit,$80.46 ,OP,30.51,80.46,,,,,,
UHC MCR ADV,CPT,85370,Fibrinogen test,Lab Services,Per Unit,$12.43 ,OP,12.43,49.56,,,,,,
UHC MCR ADV,CPT,85378,Fibrin degrade semiquant,Lab Services,Per Unit,$9.72 ,OP,9.72,30.51,,,,,,
UHC MCR ADV,CPT,85379,Fibrin degradation quant,Lab Services,Per Unit,$10.18 ,OP,10.18,135.29,,,,,,
UHC MCR ADV,CPT,85380,Fibrin degradj d-dimer,Lab Services,Per Unit,$10.18 ,OP,10.18,45.74,,,,,,
UHC MCR ADV,CPT,85384,Fibrinogen activity,Lab Services,Per Unit,$9.72 ,OP,9.72,38.13,,,,,,
UHC MCR ADV,CPT,85385,Fibrinogen antigen,Lab Services,Per Unit,$14.46 ,OP,14.46,38.13,,,,,,
UHC MCR ADV,CPT,85390,Fibrinolysins screen i&r,Lab Services,Per Unit,$15.48 ,OP,15.48,38.13,,,,,,
UHC MCR ADV,CPT,85397,Clotting funct activity,Lab Services,Per Unit,$30.86 ,OP,30.86,30.86,,,,,,
UHC MCR ADV,CPT,85400,Fibrinolytic plasmin,Lab Services,Per Unit,$7.71 ,OP,7.71,38.13,,,,,,
UHC MCR ADV,CPT,85410,Fibrinolytic antiplasmin,Lab Services,Per Unit,$7.71 ,OP,7.71,34.31,,,,,,
UHC MCR ADV,CPT,85415,Fibrinolytic plasminogen,Lab Services,Per Unit,$17.19 ,OP,17.19,76.26,,,,,,
UHC MCR ADV,CPT,85420,Fibrinolytic plasminogen,Lab Services,Per Unit,$6.53 ,OP,6.53,6.53,,,,,,
UHC MCR ADV,CPT,85421,Fibrinolytic plasminogen,Lab Services,Per Unit,$10.18 ,OP,10.18,45.74,,,,,,
UHC MCR ADV,CPT,85441,Heinz bodies direct,Lab Services,Per Unit,$4.20 ,OP,4.2,19.07,,,,,,
UHC MCR ADV,CPT,85445,Heinz bodies induced,Lab Services,Per Unit,$6.82 ,OP,6.82,30.51,,,,,,
UHC MCR ADV,CPT,85460,Hemoglobin fetal,Lab Services,Per Unit,$7.73 ,OP,7.73,7.73,,,,,,
UHC MCR ADV,CPT,85461,Hemoglobin fetal,Lab Services,Per Unit,$9.36 ,OP,9.36,30.51,,,,,,
UHC MCR ADV,CPT,85475,Hemolysin acid,Lab Services,Per Unit,$8.87 ,OP,8.87,38.13,,,,,,
UHC MCR ADV,CPT,85520,Heparin assay,Lab Services,Per Unit,$13.09 ,OP,13.09,57.19,,,,,,
UHC MCR ADV,CPT,85525,Heparin neutralization,Lab Services,Per Unit,$11.84 ,OP,11.84,53.38,,,,,,
UHC MCR ADV,CPT,85530,Heparin-protamine tolerance,Lab Services,Per Unit,$13.09 ,OP,13.09,48.46,,,,,,
UHC MCR ADV,CPT,85536,Iron stain peripheral blood,Lab Services,Per Unit,$6.88 ,OP,6.88,30.51,,,,,,
UHC MCR ADV,CPT,85540,Wbc alkaline phosphatase,Lab Services,Per Unit,$8.60 ,OP,8.6,38.13,,,,,,
UHC MCR ADV,CPT,85547,Rbc mechanical fragility,Lab Services,Per Unit,$8.60 ,OP,8.6,11.44,,,,,,
UHC MCR ADV,CPT,85549,Muramidase,Lab Services,Per Unit,$18.75 ,OP,18.75,83.87,,,,,,
UHC MCR ADV,CPT,85555,Rbc osmotic fragility,Lab Services,Per Unit,$7.47 ,OP,7.47,30.51,,,,,,
UHC MCR ADV,CPT,85557,Rbc osmotic fragility,Lab Services,Per Unit,$13.36 ,OP,13.36,13.36,,,,,,
UHC MCR ADV,CPT,85576,Blood platelet aggregation,Lab Services,Per Unit,$24.91 ,OP,24.91,95.32,,,,,,
UHC MCR ADV,CPT,85597,Phospholipid pltlt neutraliz,Lab Services,Per Unit,$17.98 ,OP,17.98,80.07,,,,,,
UHC MCR ADV,CPT,85598,Hexagnal phosph pltlt neutrl,Lab Services,Per Unit,$17.98 ,OP,17.98,17.98,,,,,,
UHC MCR ADV,CPT,85610,Prothrombin time,Lab Services,Per Unit,$4.29 ,OP,4.29,19.07,,,,,,
UHC MCR ADV,CPT,85611,Prothrombin test,Lab Services,Per Unit,$3.94 ,OP,3.94,19.07,,,,,,
UHC MCR ADV,CPT,85612,Viper venom prothrombin time,Lab Services,Per Unit,$17.49 ,OP,17.49,17.49,,,,,,
UHC MCR ADV,CPT,85613,Russell viper venom diluted,Lab Services,Per Unit,$9.58 ,OP,9.58,41.94,,,,,,
UHC MCR ADV,CPT,85635,Reptilase test,Lab Services,Per Unit,$9.85 ,OP,9.85,19.07,,,,,,
UHC MCR ADV,CPT,85651,Rbc sed rate nonautomated,Lab Services,Per Unit,$4.27 ,OP,4.27,19.07,,,,,,
UHC MCR ADV,CPT,85652,Rbc sed rate automated,Lab Services,Per Unit,$2.70 ,OP,2.7,15.26,,,,,,
UHC MCR ADV,CPT,85660,Rbc sickle cell test,Lab Services,Per Unit,$5.51 ,OP,5.51,22.88,,,,,,
UHC MCR ADV,CPT,85670,Thrombin time plasma,Lab Services,Per Unit,$5.77 ,OP,5.77,26.7,,,,,,
UHC MCR ADV,CPT,85675,Thrombin time titer,Lab Services,Per Unit,$6.85 ,OP,6.85,30.51,,,,,,
UHC MCR ADV,CPT,85705,Thromboplastin inhibition,Lab Services,Per Unit,$9.63 ,OP,9.63,41.94,,,,,,
UHC MCR ADV,CPT,85730,Thromboplastin time partial,Lab Services,Per Unit,$6.01 ,OP,6.01,30.51,,,,,,
UHC MCR ADV,CPT,85732,Thromboplastin time partial,Lab Services,Per Unit,$6.47 ,OP,6.47,30.51,,,,,,
UHC MCR ADV,CPT,85810,Blood viscosity examination,Lab Services,Per Unit,$11.67 ,OP,11.67,53.38,,,,,,
UHC MCR ADV,CPT,86000,Agglutinins febrile antigen,Lab Services,Per Unit,$6.98 ,OP,6.98,6.98,,,,,,
UHC MCR ADV,CPT,86001,Allergen specific igg,Lab Services,Per Unit,$7.82 ,OP,7.82,22.88,,,,,,
UHC MCR ADV,CPT,86003,Allg spec ige crude xtrc ea,Lab Services,Per Unit,$5.22 ,OP,5.22,22.88,,,,,,
UHC MCR ADV,CPT,86005,Allg spec ige multiallg scr,Lab Services,Per Unit,$7.97 ,OP,7.97,7.97,,,,,,
UHC MCR ADV,CPT,86008,Allg spec ige recomb ea,Lab Services,Per Unit,$17.93 ,OP,17.93,80.07,,,,,,
UHC MCR ADV,CPT,86021,Wbc antibody identification,Lab Services,Per Unit,$15.05 ,OP,15.05,68.63,,,,,,
UHC MCR ADV,CPT,86022,Platelet antibodies,Lab Services,Per Unit,$18.37 ,OP,18.37,64.82,,,,,,
UHC MCR ADV,CPT,86023,Immunoglobulin assay,Lab Services,Per Unit,$12.46 ,OP,12.46,57.19,,,,,,
UHC MCR ADV,CPT,86038,Antinuclear antibodies,Lab Services,Per Unit,$12.09 ,OP,12.09,53.38,,,,,,
UHC MCR ADV,CPT,86039,Antinuclear antibodies (ana),Lab Services,Per Unit,$11.16 ,OP,11.16,49.56,,,,,,
UHC MCR ADV,CPT,86060,Antistreptolysin o titer,Lab Services,Per Unit,$7.30 ,OP,7.3,34.31,,,,,,
UHC MCR ADV,CPT,86063,Antistreptolysin o screen,Lab Services,Per Unit,$5.77 ,OP,5.77,26.7,,,,,,
UHC MCR ADV,CPT,86077,Phys blood bank serv xmatch,APC 5731,RVU Per Case,$25.25 ,OP,25.25,244.01,,,,,,
UHC MCR ADV,CPT,86078,Phys blood bank serv reactj,APC 5672,RVU Per Case,$152.64 ,OP,152.64,247.83,,,,,,
UHC MCR ADV,CPT,86079,Phys blood bank serv authrj,APC 5671,RVU Per Case,$50.92 ,OP,50.92,251.64,,,,,,
UHC MCR ADV,CPT,86140,C-reactive protein,Lab Services,Per Unit,$5.18 ,OP,5.18,22.88,,,,,,
UHC MCR ADV,CPT,86141,C-reactive protein hs,Lab Services,Per Unit,$12.95 ,OP,12.95,57.19,,,,,,
UHC MCR ADV,CPT,86146,Beta-2 glycoprotein antibody,Lab Services,Per Unit,$25.45 ,OP,25.45,114.39,,,,,,
UHC MCR ADV,CPT,86147,Cardiolipin antibody ea ig,Lab Services,Per Unit,$25.45 ,OP,25.45,114.39,,,,,,
UHC MCR ADV,CPT,86148,Anti-phospholipid antibody,Lab Services,Per Unit,$16.07 ,OP,16.07,72.44,,,,,,
UHC MCR ADV,CPT,86152,Cell enumeration & id,Lab Services,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,
UHC MCR ADV,CPT,86155,Chemotaxis assay,Lab Services,Per Unit,$15.99 ,OP,15.99,72.44,,,,,,
UHC MCR ADV,CPT,86156,Cold agglutinin screen,Lab Services,Per Unit,$8.07 ,OP,8.07,30.51,,,,,,
UHC MCR ADV,CPT,86157,Cold agglutinin titer,Lab Services,Per Unit,$8.06 ,OP,8.06,34.31,,,,,,
UHC MCR ADV,CPT,86160,Complement antigen,Lab Services,Per Unit,$12.00 ,OP,12,53.38,,,,,,
UHC MCR ADV,CPT,86161,Complement/function activity,Lab Services,Per Unit,$12.00 ,OP,12,53.38,,,,,,
UHC MCR ADV,CPT,86162,Complement total (ch50),Lab Services,Per Unit,$20.32 ,OP,20.32,91.51,,,,,,
UHC MCR ADV,CPT,86171,Complement fixation each,Lab Services,Per Unit,$10.01 ,OP,10.01,45.74,,,,,,
UHC MCR ADV,CPT,86200,Ccp antibody,Lab Services,Per Unit,$12.95 ,OP,12.95,57.19,,,,,,
UHC MCR ADV,CPT,86215,Deoxyribonuclease antibody,Lab Services,Per Unit,$13.25 ,OP,13.25,57.19,,,,,,
UHC MCR ADV,CPT,86225,Dna antibody native,Lab Services,Per Unit,$13.74 ,OP,13.74,61,,,,,,
UHC MCR ADV,CPT,86226,Dna antibody single strand,Lab Services,Per Unit,$12.11 ,OP,12.11,53.38,,,,,,
UHC MCR ADV,CPT,86235,Nuclear antigen antibody,Lab Services,Per Unit,$17.93 ,OP,17.93,80.07,,,,,,
UHC MCR ADV,CPT,86255,Fluorescent antibody screen,Lab Services,Per Unit,$12.05 ,OP,12.05,53.38,,,,,,
UHC MCR ADV,CPT,86256,Fluorescent antibody titer,Lab Services,Per Unit,$12.05 ,OP,12.05,53.38,,,,,,
UHC MCR ADV,CPT,86277,Growth hormone antibody,Lab Services,Per Unit,$15.74 ,OP,15.74,68.63,,,,,,
UHC MCR ADV,CPT,86280,Hemagglutination inhibition,Lab Services,Per Unit,$8.19 ,OP,8.19,8.19,,,,,,
UHC MCR ADV,CPT,86294,Immunoassay tumor qual,Lab Services,Per Unit,$25.57 ,OP,25.57,80.07,,,,,,
UHC MCR ADV,CPT,86300,Immunoassay tumor ca 15-3,Lab Services,Per Unit,$20.81 ,OP,20.81,91.51,,,,,,
UHC MCR ADV,CPT,86301,Immunoassay tumor ca 19-9,Lab Services,Per Unit,$20.81 ,OP,20.81,91.51,,,,,,
UHC MCR ADV,CPT,86304,Immunoassay tumor ca 125,Lab Services,Per Unit,$20.81 ,OP,20.81,91.51,,,,,,
UHC MCR ADV,CPT,86305,Human epididymis protein 4,Lab Services,Per Unit,$20.81 ,OP,20.81,20.81,,,,,,
UHC MCR ADV,CPT,86308,Heterophile antibody screen,Lab Services,Per Unit,$5.18 ,OP,5.18,26.7,,,,,,
UHC MCR ADV,CPT,86309,Heterophile antibody titer,Lab Services,Per Unit,$6.47 ,OP,6.47,30.51,,,,,,
UHC MCR ADV,CPT,86310,Heterophile antibody absrbj,Lab Services,Per Unit,$7.37 ,OP,7.37,7.37,,,,,,
UHC MCR ADV,CPT,86316,Immunoassay tumor other,Lab Services,Per Unit,$20.81 ,OP,20.81,91.51,,,,,,
UHC MCR ADV,CPT,86317,Immunoassay infectious agent,Lab Services,Per Unit,$14.99 ,OP,14.99,68.63,,,,,,
UHC MCR ADV,CPT,86318,Ia infectious agent antibody,Lab Services,Per Unit,$18.09 ,OP,18.09,64.82,,,,,,
UHC MCR ADV,CPT,86320,Serum immunoelectrophoresis,Lab Services,Per Unit,$29.92 ,OP,29.92,99.13,,,,,,
UHC MCR ADV,CPT,86325,Other immunoelectrophoresis,Lab Services,Per Unit,$23.13 ,OP,23.13,99.13,,,,,,
UHC MCR ADV,CPT,86327,Immunoelectrophoresis assay,Lab Services,Per Unit,$29.92 ,OP,29.92,72.44,,,,,,
UHC MCR ADV,CPT,86328,Ia nfct ab sarscov2 covid19,Lab Services,Per Unit,$45.23 ,OP,45.23,64.82,,,,,,
UHC MCR ADV,CPT,86329,Immunodiffusion nes,Lab Services,Per Unit,$14.05 ,OP,14.05,14.05,,,,,,
UHC MCR ADV,CPT,86331,Immunodiffusion ouchterlony,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
UHC MCR ADV,CPT,86332,Immune complex assay,Lab Services,Per Unit,$24.37 ,OP,24.37,106.76,,,,,,
UHC MCR ADV,CPT,86334,Immunofix e-phoresis serum,Lab Services,Per Unit,$22.34 ,OP,22.34,99.13,,,,,,
UHC MCR ADV,CPT,86335,Immunfix e-phorsis/urine/csf,Lab Services,Per Unit,$29.35 ,OP,29.35,129.64,,,,,,
UHC MCR ADV,CPT,86336,Inhibin a,Lab Services,Per Unit,$15.59 ,OP,15.59,68.63,,,,,,
UHC MCR ADV,CPT,86337,Insulin antibodies,Lab Services,Per Unit,$21.41 ,OP,21.41,95.32,,,,,,
UHC MCR ADV,CPT,86340,Intrinsic factor antibody,Lab Services,Per Unit,$15.08 ,OP,15.08,68.63,,,,,,
UHC MCR ADV,CPT,86341,Islet cell antibody,Lab Services,Per Unit,$23.57 ,OP,23.57,87.69,,,,,,
UHC MCR ADV,CPT,86343,Leukocyte histamine release,Lab Services,Per Unit,$12.46 ,OP,12.46,57.19,,,,,,
UHC MCR ADV,CPT,86344,Leukocyte phagocytosis,Lab Services,Per Unit,$10.39 ,OP,10.39,34.31,,,,,,
UHC MCR ADV,CPT,86352,Cell function assay w/stim,Lab Services,Per Unit,$135.86 ,OP,135.86,135.86,,,,,,
UHC MCR ADV,CPT,86353,Lymphocyte transformation,Lab Services,Per Unit,$49.03 ,OP,49.03,217.32,,,,,,
UHC MCR ADV,CPT,86355,B cells total count,Lab Services,Per Unit,$37.73 ,OP,37.73,167.76,,,,,,
UHC MCR ADV,CPT,86356,Mononuclear cell antigen,Lab Services,Per Unit,$26.78 ,OP,26.78,61,,,,,,
UHC MCR ADV,CPT,86357,Nk cells total count,Lab Services,Per Unit,$37.73 ,OP,37.73,167.76,,,,,,
UHC MCR ADV,CPT,86359,T cells total count,Lab Services,Per Unit,$37.73 ,OP,37.73,167.76,,,,,,
UHC MCR ADV,CPT,86360,T cell absolute count/ratio,Lab Services,Per Unit,$46.98 ,OP,46.98,209.7,,,,,,
UHC MCR ADV,CPT,86361,T cell absolute count,Lab Services,Per Unit,$26.78 ,OP,26.78,61,,,,,,
UHC MCR ADV,CPT,86367,Stem cells total count,Lab Services,Per Unit,$77.78 ,OP,77.78,167.76,,,,,,
UHC MCR ADV,CPT,86376,Microsomal antibody each,Lab Services,Per Unit,$14.55 ,OP,14.55,64.82,,,,,,
UHC MCR ADV,CPT,86382,Neutralization test viral,Lab Services,Per Unit,$16.91 ,OP,16.91,76.26,,,,,,
UHC MCR ADV,CPT,86384,Nitroblue tetrazolium dye,Lab Services,Per Unit,$13.61 ,OP,13.61,13.61,,,,,,
UHC MCR ADV,CPT,86386,Nuclear matrix protein 22,Lab Services,Per Unit,$21.78 ,OP,21.78,21.78,,,,,,
UHC MCR ADV,CPT,86403,Particle agglut antbdy scrn,Lab Services,Per Unit,$11.54 ,OP,11.54,26.7,,,,,,
UHC MCR ADV,CPT,86406,Particle agglut antbdy titr,Lab Services,Per Unit,$10.64 ,OP,10.64,45.74,,,,,,
UHC MCR ADV,CPT,86408,Neutrlzg antb sarscov2 scr,Lab Services,Per Unit,$42.13 ,OP,42.13,42.13,,,,,,
UHC MCR ADV,CPT,86409,Neutrlzg antb sarscov2 titer,Lab Services,Per Unit,$105.33 ,OP,105.33,105.33,,,,,,
UHC MCR ADV,CPT,86413,Sars-cov-2 antb quantitative,Lab Services,Per Unit,$51.43 ,OP,51.43,51.43,,,,,,
UHC MCR ADV,CPT,86430,Rheumatoid factor test qual,Lab Services,Per Unit,$6.14 ,OP,6.14,26.7,,,,,,
UHC MCR ADV,CPT,86431,Rheumatoid factor quant,Lab Services,Per Unit,$5.67 ,OP,5.67,26.7,,,,,,
UHC MCR ADV,CPT,86480,Tb test cell immun measure,Lab Services,Per Unit,$61.98 ,OP,61.98,274.51,,,,,,
UHC MCR ADV,CPT,86481,Tb ag response t-cell susp,Lab Services,Per Unit,$100.00 ,OP,100,100,,,,,,
UHC MCR ADV,CPT,86485,Skin test candida,APC 5731,RVU Per Case,$25.25 ,OP,25.25,61,,,,,,
UHC MCR ADV,CPT,86486,Skin test nos antigen,APC 5731,RVU Per Case,$25.25 ,OP,25.25,30.51,,,,,,
UHC MCR ADV,CPT,86490,Coccidioidomycosis skin test,APC 5733,RVU Per Case,$56.95 ,OP,38.13,56.95,,,,,,
UHC MCR ADV,CPT,86510,Histoplasmosis skin test,APC 5733,RVU Per Case,$56.95 ,OP,38.13,56.95,,,,,,
UHC MCR ADV,CPT,86580,Tb intradermal test,APC 5731,RVU Per Case,$25.25 ,OP,25.25,38.13,,,,,,
UHC MCR ADV,CPT,86590,Streptokinase antibody,Lab Services,Per Unit,$12.66 ,OP,12.66,49.56,,,,,,
UHC MCR ADV,CPT,86592,Syphilis test non-trep qual,Lab Services,Per Unit,$4.27 ,OP,4.27,19.07,,,,,,
UHC MCR ADV,CPT,86593,Syphilis test non-trep quant,Lab Services,Per Unit,$4.40 ,OP,4.4,19.07,,,,,,
UHC MCR ADV,CPT,86602,Antinomyces antibody,Lab Services,Per Unit,$10.18 ,OP,10.18,45.74,,,,,,
UHC MCR ADV,CPT,86603,Adenovirus antibody,Lab Services,Per Unit,$12.87 ,OP,12.87,12.87,,,,,,
UHC MCR ADV,CPT,86606,Aspergillus antibody,Lab Services,Per Unit,$15.05 ,OP,15.05,68.63,,,,,,
UHC MCR ADV,CPT,86609,Bacterium antibody,Lab Services,Per Unit,$12.88 ,OP,12.88,57.19,,,,,,
UHC MCR ADV,CPT,86611,Bartonella antibody,Lab Services,Per Unit,$10.18 ,OP,10.18,45.74,,,,,,
UHC MCR ADV,CPT,86612,Blastomyces antibody,Lab Services,Per Unit,$12.90 ,OP,12.9,57.19,,,,,,
UHC MCR ADV,CPT,86615,Bordetella antibody,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
UHC MCR ADV,CPT,86617,Lyme disease antibody,Lab Services,Per Unit,$15.49 ,OP,15.49,68.63,,,,,,
UHC MCR ADV,CPT,86618,Lyme disease antibody,Lab Services,Per Unit,$17.03 ,OP,17.03,83.87,,,,,,
UHC MCR ADV,CPT,86619,Borrelia antibody,Lab Services,Per Unit,$13.38 ,OP,13.38,61,,,,,,
UHC MCR ADV,CPT,86622,Brucella antibody,Lab Services,Per Unit,$8.93 ,OP,8.93,38.13,,,,,,
UHC MCR ADV,CPT,86625,Campylobacter antibody,Lab Services,Per Unit,$13.12 ,OP,13.12,57.19,,,,,,
UHC MCR ADV,CPT,86628,Candida antibody,Lab Services,Per Unit,$12.01 ,OP,12.01,53.38,,,,,,
UHC MCR ADV,CPT,86631,Chlamydia antibody,Lab Services,Per Unit,$11.82 ,OP,11.82,53.38,,,,,,
UHC MCR ADV,CPT,86632,Chlamydia igm antibody,Lab Services,Per Unit,$12.68 ,OP,12.68,57.19,,,,,,
UHC MCR ADV,CPT,86635,Coccidioides antibody,Lab Services,Per Unit,$11.47 ,OP,11.47,49.56,,,,,,
UHC MCR ADV,CPT,86638,Q fever antibody,Lab Services,Per Unit,$12.12 ,OP,12.12,53.38,,,,,,
UHC MCR ADV,CPT,86641,Cryptococcus antibody,Lab Services,Per Unit,$14.41 ,OP,14.41,64.82,,,,,,
UHC MCR ADV,CPT,86644,Cmv antibody,Lab Services,Per Unit,$14.39 ,OP,14.39,64.82,,,,,,
UHC MCR ADV,CPT,86645,Cmv antibody igm,Lab Services,Per Unit,$16.85 ,OP,16.85,76.26,,,,,,
UHC MCR ADV,CPT,86648,Diphtheria antibody,Lab Services,Per Unit,$15.21 ,OP,15.21,68.63,,,,,,
UHC MCR ADV,CPT,86651,Encephalitis californ antbdy,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
UHC MCR ADV,CPT,86652,Encephaltis east eqne anbdy,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
UHC MCR ADV,CPT,86653,Encephaltis st louis antbody,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
UHC MCR ADV,CPT,86654,Encephaltis west eqne antbdy,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
UHC MCR ADV,CPT,86658,Enterovirus antibody,Lab Services,Per Unit,$13.03 ,OP,13.03,57.19,,,,,,
UHC MCR ADV,CPT,86663,Epstein-barr antibody,Lab Services,Per Unit,$13.12 ,OP,13.12,57.19,,,,,,
UHC MCR ADV,CPT,86664,Epstein-barr nuclear antigen,Lab Services,Per Unit,$15.29 ,OP,15.29,68.63,,,,,,
UHC MCR ADV,CPT,86665,Epstein-barr capsid vca,Lab Services,Per Unit,$18.14 ,OP,18.14,80.07,,,,,,
UHC MCR ADV,CPT,86666,Ehrlichia antibody,Lab Services,Per Unit,$10.18 ,OP,10.18,45.74,,,,,,
UHC MCR ADV,CPT,86668,Francisella tularensis,Lab Services,Per Unit,$14.16 ,OP,14.16,45.74,,,,,,
UHC MCR ADV,CPT,86671,Fungus nes antibody,Lab Services,Per Unit,$12.25 ,OP,12.25,53.38,,,,,,
UHC MCR ADV,CPT,86674,Giardia lamblia antibody,Lab Services,Per Unit,$14.72 ,OP,14.72,14.72,,,,,,
UHC MCR ADV,CPT,86677,Helicobacter pylori antibody,Lab Services,Per Unit,$16.85 ,OP,16.85,64.82,,,,,,
UHC MCR ADV,CPT,86682,Helminth antibody,Lab Services,Per Unit,$13.01 ,OP,13.01,57.19,,,,,,
UHC MCR ADV,CPT,86684,Hemophilus influenza antibdy,Lab Services,Per Unit,$15.84 ,OP,15.84,72.44,,,,,,
UHC MCR ADV,CPT,86687,Htlv-i antibody,Lab Services,Per Unit,$9.09 ,OP,9.09,38.13,,,,,,
UHC MCR ADV,CPT,86688,Htlv-ii antibody,Lab Services,Per Unit,$14.00 ,OP,14,61,,,,,,
UHC MCR ADV,CPT,86689,Htlv/hiv confirmj antibody,Lab Services,Per Unit,$19.35 ,OP,19.35,87.69,,,,,,
UHC MCR ADV,CPT,86692,Hepatitis delta agent antbdy,Lab Services,Per Unit,$17.16 ,OP,17.16,76.26,,,,,,
UHC MCR ADV,CPT,86694,Herpes simplex nes antbdy,Lab Services,Per Unit,$14.39 ,OP,14.39,64.82,,,,,,
UHC MCR ADV,CPT,86695,Herpes simplex type 1 test,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
UHC MCR ADV,CPT,86696,Herpes simplex type 2 test,Lab Services,Per Unit,$19.35 ,OP,19.35,87.69,,,,,,
UHC MCR ADV,CPT,86698,Histoplasma antibody,Lab Services,Per Unit,$13.79 ,OP,13.79,57.19,,,,,,
UHC MCR ADV,CPT,86701,Hiv-1antibody,Lab Services,Per Unit,$8.89 ,OP,8.89,38.13,,,,,,
UHC MCR ADV,CPT,86702,Hiv-2 antibody,Lab Services,Per Unit,$13.52 ,OP,13.52,61,,,,,,
UHC MCR ADV,CPT,86703,Hiv-1/hiv-2 1 result antbdy,Lab Services,Per Unit,$13.71 ,OP,13.71,61,,,,,,
UHC MCR ADV,CPT,86704,Hep b core antibody total,Lab Services,Per Unit,$12.05 ,OP,12.05,53.38,,,,,,
UHC MCR ADV,CPT,86705,Hep b core antibody igm,Lab Services,Per Unit,$11.77 ,OP,11.77,53.38,,,,,,
UHC MCR ADV,CPT,86706,Hep b surface antibody,Lab Services,Per Unit,$10.74 ,OP,10.74,49.56,,,,,,
UHC MCR ADV,CPT,86707,Hepatitis be antibody,Lab Services,Per Unit,$11.57 ,OP,11.57,53.38,,,,,,
UHC MCR ADV,CPT,86708,Hepatitis a antibody,Lab Services,Per Unit,$12.39 ,OP,12.39,53.38,,,,,,
UHC MCR ADV,CPT,86709,Hepatitis a igm antibody,Lab Services,Per Unit,$11.26 ,OP,11.26,49.56,,,,,,
UHC MCR ADV,CPT,86710,Influenza virus antibody,Lab Services,Per Unit,$13.55 ,OP,13.55,68.63,,,,,,
UHC MCR ADV,CPT,86711,John cunningham antibody,Lab Services,Per Unit,$16.89 ,OP,16.89,16.89,,,,,,
UHC MCR ADV,CPT,86713,Legionella antibody,Lab Services,Per Unit,$15.30 ,OP,15.3,68.63,,,,,,
UHC MCR ADV,CPT,86717,Leishmania antibody,Lab Services,Per Unit,$12.25 ,OP,12.25,53.38,,,,,,
UHC MCR ADV,CPT,86720,Leptospira antibody,Lab Services,Per Unit,$16.20 ,OP,16.2,57.19,,,,,,
UHC MCR ADV,CPT,86723,Listeria monocytogenes,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,
UHC MCR ADV,CPT,86727,Lymph choriomeningitis ab,Lab Services,Per Unit,$12.87 ,OP,12.87,57.19,,,,,,
UHC MCR ADV,CPT,86732,Mucormycosis antibody,Lab Services,Per Unit,$15.00 ,OP,15,57.19,,,,,,
UHC MCR ADV,CPT,86735,Mumps antibody,Lab Services,Per Unit,$13.05 ,OP,13.05,57.19,,,,,,
UHC MCR ADV,CPT,86738,Mycoplasma antibody,Lab Services,Per Unit,$13.24 ,OP,13.24,57.19,,,,,,
UHC MCR ADV,CPT,86741,Neisseria meningitidis,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
UHC MCR ADV,CPT,86744,Nocardia antibody,Lab Services,Per Unit,$15.99 ,OP,15.99,57.19,,,,,,
UHC MCR ADV,CPT,86747,Parvovirus antibody,Lab Services,Per Unit,$15.03 ,OP,15.03,68.63,,,,,,
UHC MCR ADV,CPT,86750,Malaria antibody,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
UHC MCR ADV,CPT,86753,Protozoa antibody nos,Lab Services,Per Unit,$12.39 ,OP,12.39,53.38,,,,,,
UHC MCR ADV,CPT,86756,Respiratory virus antibody,Lab Services,Per Unit,$15.89 ,OP,15.89,57.19,,,,,,
UHC MCR ADV,CPT,86757,Rickettsia antibody,Lab Services,Per Unit,$19.35 ,OP,19.35,87.69,,,,,,
UHC MCR ADV,CPT,86759,Rotavirus antibody,Lab Services,Per Unit,$18.23 ,OP,18.23,57.19,,,,,,
UHC MCR ADV,CPT,86762,Rubella antibody,Lab Services,Per Unit,$14.39 ,OP,14.39,64.82,,,,,,
UHC MCR ADV,CPT,86765,Rubeola antibody,Lab Services,Per Unit,$12.88 ,OP,12.88,57.19,,,,,,
UHC MCR ADV,CPT,86768,Salmonella antibody,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,
UHC MCR ADV,CPT,86769,Sars-cov-2 covid-19 antibody,Lab Services,Per Unit,$42.13 ,OP,42.13,57.19,,,,,,
UHC MCR ADV,CPT,86771,Shigella antibody,Lab Services,Per Unit,$24.48 ,OP,24.48,57.19,,,,,,
UHC MCR ADV,CPT,86774,Tetanus antibody,Lab Services,Per Unit,$14.80 ,OP,14.8,64.82,,,,,,
UHC MCR ADV,CPT,86777,Toxoplasma antibody,Lab Services,Per Unit,$14.39 ,OP,14.39,64.82,,,,,,
UHC MCR ADV,CPT,86778,Toxoplasma antibody igm,Lab Services,Per Unit,$14.41 ,OP,14.41,64.82,,,,,,
UHC MCR ADV,CPT,86780,Treponema pallidum,Lab Services,Per Unit,$13.24 ,OP,13.24,13.24,,,,,,
UHC MCR ADV,CPT,86784,Trichinella antibody,Lab Services,Per Unit,$12.56 ,OP,12.56,12.56,,,,,,
UHC MCR ADV,CPT,86787,Varicella-zoster antibody,Lab Services,Per Unit,$12.88 ,OP,12.88,57.19,,,,,,
UHC MCR ADV,CPT,86788,West nile virus ab igm,Lab Services,Per Unit,$16.85 ,OP,16.85,76.26,,,,,,
UHC MCR ADV,CPT,86789,West nile virus antibody,Lab Services,Per Unit,$14.39 ,OP,14.39,64.82,,,,,,
UHC MCR ADV,CPT,86790,Virus antibody nos,Lab Services,Per Unit,$12.88 ,OP,12.88,57.19,,,,,,
UHC MCR ADV,CPT,86793,Yersinia antibody,Lab Services,Per Unit,$13.19 ,OP,13.19,57.19,,,,,,
UHC MCR ADV,CPT,86794,Zika virus igm antibody,Lab Services,Per Unit,$16.85 ,OP,16.85,16.85,,,,,,
UHC MCR ADV,CPT,86800,Thyroglobulin antibody,Lab Services,Per Unit,$15.91 ,OP,15.91,72.44,,,,,,
UHC MCR ADV,CPT,86803,Hepatitis c ab test,Lab Services,Per Unit,$14.27 ,OP,14.27,64.82,,,,,,
UHC MCR ADV,CPT,86804,Hep c ab test confirm,Lab Services,Per Unit,$15.49 ,OP,15.49,68.63,,,,,,
UHC MCR ADV,CPT,86805,Lymphocytotoxicity assay,Lab Services,Per Unit,$189.51 ,OP,189.51,232.58,,,,,,
UHC MCR ADV,CPT,86806,Lymphocytotoxicity assay,Lab Services,Per Unit,$47.59 ,OP,47.59,213.51,,,,,,
UHC MCR ADV,CPT,86807,Cytotoxic antibody screening,Lab Services,Per Unit,$78.65 ,OP,78.65,175.39,,,,,,
UHC MCR ADV,CPT,86808,Cytotoxic antibody screening,Lab Services,Per Unit,$29.68 ,OP,29.68,133.45,,,,,,
UHC MCR ADV,CPT,86812,Hla typing a b or c,Lab Services,Per Unit,$25.81 ,OP,25.81,114.39,,,,,,
UHC MCR ADV,CPT,86813,Hla typing a b or c,Lab Services,Per Unit,$58.00 ,OP,58,247.83,,,,,,
UHC MCR ADV,CPT,86816,Hla typing dr/dq,Lab Services,Per Unit,$30.17 ,OP,30.17,102.95,,,,,,
UHC MCR ADV,CPT,86817,Hla typing dr/dq,Lab Services,Per Unit,$106.14 ,OP,106.14,247.83,,,,,,
UHC MCR ADV,CPT,86821,Lymphocyte culture mixed,Lab Services,Per Unit,$36.56 ,OP,36.56,251.64,,,,,,
UHC MCR ADV,CPT,86825,Hla x-math non-cytotoxic,Lab Services,Per Unit,$109.49 ,OP,109.49,109.49,,,,,,
UHC MCR ADV,CPT,86826,Hla x-match noncytotoxc addl,Lab Services,Per Unit,$36.53 ,OP,36.53,36.53,,,,,,
UHC MCR ADV,CPT,86828,Hla class i&ii antibody qual,Lab Services,Per Unit,$64.19 ,OP,64.19,64.19,,,,,,
UHC MCR ADV,CPT,86829,Hla class i/ii antibody qual,Lab Services,Per Unit,$64.19 ,OP,64.19,64.19,,,,,,
UHC MCR ADV,CPT,86830,Hla class i phenotype qual,Lab Services,Per Unit,$95.52 ,OP,95.52,95.52,,,,,,
UHC MCR ADV,CPT,86831,Hla class ii phenotype qual,Lab Services,Per Unit,$81.88 ,OP,81.88,81.88,,,,,,
UHC MCR ADV,CPT,86832,Hla class i high defin qual,Lab Services,Per Unit,$323.75 ,OP,323.75,323.75,,,,,,
UHC MCR ADV,CPT,86833,Hla class ii high defin qual,Lab Services,Per Unit,$325.80 ,OP,325.8,325.8,,,,,,
UHC MCR ADV,CPT,86834,Hla class i semiquant panel,Lab Services,Per Unit,$357.56 ,OP,357.56,357.56,,,,,,
UHC MCR ADV,CPT,86835,Hla class ii semiquant panel,Lab Services,Per Unit,$322.96 ,OP,322.96,322.96,,,,,,
UHC MCR ADV,CPT,86850,Rbc antibody screen,APC 5671,RVU Per Case,$50.92 ,OP,50.92,76.26,,,,,,
UHC MCR ADV,CPT,86860,Rbc antibody elution,APC 5672,RVU Per Case,$152.64 ,OP,91.51,152.64,,,,,,
UHC MCR ADV,CPT,86870,Rbc antibody identification,APC 5673,RVU Per Case,$298.05 ,OP,141.07,298.05,,,,,,
UHC MCR ADV,CPT,86880,Coombs test direct,APC 5733,RVU Per Case,$56.95 ,OP,22.88,56.95,,,,,,
UHC MCR ADV,CPT,86885,Coombs test indirect qual,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
UHC MCR ADV,CPT,86886,Coombs test indirect titer,APC 5672,RVU Per Case,$152.64 ,OP,22.88,152.64,,,,,,
UHC MCR ADV,CPT,86890,Autologous blood process,APC 5672,RVU Per Case,$152.64 ,OP,152.64,308.83,,,,,,
UHC MCR ADV,CPT,86891,Autologous blood op salvage,APC 5674,RVU Per Case,$671.45 ,OP,480.4,671.45,,,,,,
UHC MCR ADV,CPT,86900,Blood typing serologic abo,APC 5734,RVU Per Case,$114.56 ,OP,11.44,114.56,,,,,,
UHC MCR ADV,CPT,86901,Blood typing serologic rh(d),APC 5732,RVU Per Case,$34.63 ,OP,22.88,34.63,,,,,,
UHC MCR ADV,CPT,86902,Blood type antigen donor ea,APC 5673,RVU Per Case,$298.05 ,OP,41.94,298.05,,,,,,
UHC MCR ADV,CPT,86904,Blood typing patient serum,APC 5732,RVU Per Case,$34.63 ,OP,34.63,41.94,,,,,,
UHC MCR ADV,CPT,86905,Blood typing rbc antigens,APC 5673,RVU Per Case,$298.05 ,OP,15.26,298.05,,,,,,
UHC MCR ADV,CPT,86906,Bld typing serologic rh phnt,APC 5732,RVU Per Case,$34.63 ,OP,34.31,34.63,,,,,,
UHC MCR ADV,CPT,86920,Compatibility test spin,APC 5672,RVU Per Case,$152.64 ,OP,125.82,152.64,,,,,,
UHC MCR ADV,CPT,86921,Compatibility test incubate,APC 5672,RVU Per Case,$152.64 ,OP,102.95,152.64,,,,,,
UHC MCR ADV,CPT,86922,Compatibility test antiglob,APC 5672,RVU Per Case,$152.64 ,OP,118.19,152.64,,,,,,
UHC MCR ADV,CPT,86923,Compatibility test electric,APC 5672,RVU Per Case,$152.64 ,OP,91.51,152.64,,,,,,
UHC MCR ADV,CPT,86927,Plasma fresh frozen,APC 5672,RVU Per Unit,$152.64 ,OP,49.56,152.64,,,,,,
UHC MCR ADV,CPT,86930,Frozen blood prep,APC 5673,RVU Per Case,$298.05 ,OP,298.05,385.09,,,,,,
UHC MCR ADV,CPT,86931,Frozen blood thaw,APC 5673,RVU Per Case,$298.05 ,OP,289.76,298.05,,,,,,
UHC MCR ADV,CPT,86932,Frozen blood freeze/thaw,APC 5732,RVU Per Case,$34.63 ,OP,34.63,385.09,,,,,,
UHC MCR ADV,CPT,86940,Hemolysins/agglutinins auto,Lab Services,Per Unit,$8.77 ,OP,8.77,38.13,,,,,,
UHC MCR ADV,CPT,86941,Hemolysins/agglutinins,Lab Services,Per Unit,$12.11 ,OP,12.11,53.38,,,,,,
UHC MCR ADV,CPT,86945,Blood product/irradiation,APC 5732,RVU Per Case,$34.63 ,OP,34.63,110.57,,,,,,
UHC MCR ADV,CPT,86950,Leukacyte transfusion,APC 5672,RVU Per Case,$152.64 ,OP,152.64,240.2,,,,,,
UHC MCR ADV,CPT,86960,Vol reduction of blood/prod,APC 5672,RVU Per Case,$152.64 ,OP,110.57,152.64,,,,,,
UHC MCR ADV,CPT,86965,Pooling blood platelets,APC 5672,RVU Per Case,$152.64 ,OP,95.32,152.64,,,,,,
UHC MCR ADV,CPT,86970,Rbc pretx incubatj w/chemicl,APC 5732,RVU Per Case,$34.63 ,OP,34.63,76.26,,,,,,
UHC MCR ADV,CPT,86971,Rbc pretx incubatj w/enzymes,APC 5673,RVU Per Case,$298.05 ,OP,298.05,298.05,,,,,,
UHC MCR ADV,CPT,86972,Rbc pretx incubatj w/density,APC 5672,RVU Per Case,$152.64 ,OP,122,152.64,,,,,,
UHC MCR ADV,CPT,86975,Rbc serum pretx incubj drugs,APC 5735,RVU Per Case,$276.53 ,OP,102.95,276.53,,,,,,
UHC MCR ADV,CPT,86976,Rbc serum pretx id dilution,APC 5731,RVU Per Case,$25.25 ,OP,25.25,118.19,,,,,,
UHC MCR ADV,CPT,86977,Rbc serum pretx incubj/inhib,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
UHC MCR ADV,CPT,86978,Rbc pretreatment serum,APC 5732,RVU Per Case,$34.63 ,OP,34.63,102.95,,,,,,
UHC MCR ADV,CPT,86985,Split blood or products,APC 5672,RVU Per Case,$152.64 ,OP,76.26,152.64,,,,,,
UHC MCR ADV,CPT,86999,Transfusion procedure,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
UHC MCR ADV,CPT,87003,Small animal inoculation,Lab Services,Per Unit,$16.84 ,OP,16.84,76.26,,,,,,
UHC MCR ADV,CPT,87015,Specimen infect agnt concntj,Lab Services,Per Unit,$6.68 ,OP,6.68,30.51,,,,,,
UHC MCR ADV,CPT,87040,Blood culture for bacteria,Lab Services,Per Unit,$10.32 ,OP,10.32,45.74,,,,,,
UHC MCR ADV,CPT,87045,Feces culture aerobic bact,Lab Services,Per Unit,$9.44 ,OP,9.44,41.94,,,,,,
UHC MCR ADV,CPT,87046,Stool cultr aerobic bact ea,Lab Services,Per Unit,$9.44 ,OP,9.44,41.94,,,,,,
UHC MCR ADV,CPT,87070,Culture othr specimn aerobic,Lab Services,Per Unit,$8.62 ,OP,8.62,41.94,,,,,,
UHC MCR ADV,CPT,87071,Culture aerobic quant other,Lab Services,Per Unit,$9.89 ,OP,9.89,41.94,,,,,,
UHC MCR ADV,CPT,87073,Culture bacteria anaerobic,Lab Services,Per Unit,$9.66 ,OP,9.66,41.94,,,,,,
UHC MCR ADV,CPT,87075,Cultr bacteria except blood,Lab Services,Per Unit,$9.47 ,OP,9.47,41.94,,,,,,
UHC MCR ADV,CPT,87076,Culture anaerobe ident each,Lab Services,Per Unit,$8.08 ,OP,8.08,19.07,,,,,,
UHC MCR ADV,CPT,87077,Culture aerobic identify,Lab Services,Per Unit,$8.08 ,OP,8.08,22.88,,,,,,
UHC MCR ADV,CPT,87081,Culture screen only,Lab Services,Per Unit,$6.63 ,OP,6.63,34.31,,,,,,
UHC MCR ADV,CPT,87084,Culture of specimen by kit,Lab Services,Per Unit,$27.07 ,OP,22.88,27.07,,,,,,
UHC MCR ADV,CPT,87086,Urine culture/colony count,Lab Services,Per Unit,$8.07 ,OP,8.07,41.94,,,,,,
UHC MCR ADV,CPT,87088,Urine bacteria culture,Lab Services,Per Unit,$8.09 ,OP,8.09,41.94,,,,,,
UHC MCR ADV,CPT,87101,Skin fungi culture,Lab Services,Per Unit,$7.71 ,OP,7.71,34.31,,,,,,
UHC MCR ADV,CPT,87102,Fungus isolation culture,Lab Services,Per Unit,$8.41 ,OP,8.41,38.13,,,,,,
UHC MCR ADV,CPT,87103,Blood fungus culture,Lab Services,Per Unit,$20.46 ,OP,20.46,41.94,,,,,,
UHC MCR ADV,CPT,87106,Fungi identification yeast,Lab Services,Per Unit,$10.32 ,OP,10.32,45.74,,,,,,
UHC MCR ADV,CPT,87107,Fungi identification mold,Lab Services,Per Unit,$10.32 ,OP,10.32,45.74,,,,,,
UHC MCR ADV,CPT,87109,Mycoplasma,Lab Services,Per Unit,$15.39 ,OP,15.39,68.63,,,,,,
UHC MCR ADV,CPT,87110,Chlamydia culture,Lab Services,Per Unit,$19.60 ,OP,19.6,87.69,,,,,,
UHC MCR ADV,CPT,87116,Mycobacteria culture,Lab Services,Per Unit,$10.80 ,OP,10.8,49.56,,,,,,
UHC MCR ADV,CPT,87118,Mycobacteric identification,Lab Services,Per Unit,$14.61 ,OP,14.61,49.56,,,,,,
UHC MCR ADV,CPT,87140,Culture type immunofluoresc,Lab Services,Per Unit,$5.57 ,OP,5.57,26.7,,,,,,
UHC MCR ADV,CPT,87143,Culture typing glc/hplc,Lab Services,Per Unit,$12.52 ,OP,12.52,57.19,,,,,,
UHC MCR ADV,CPT,87147,Culture type immunologic,Lab Services,Per Unit,$5.18 ,OP,5.18,22.88,,,,,,
UHC MCR ADV,CPT,87149,Dna/rna direct probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
UHC MCR ADV,CPT,87150,Dna/rna amplified probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,
UHC MCR ADV,CPT,87152,Culture type pulse field gel,Lab Services,Per Unit,$7.74 ,OP,7.74,22.88,,,,,,
UHC MCR ADV,CPT,87153,Dna/rna sequencing,Lab Services,Per Unit,$115.36 ,OP,115.36,115.36,,,,,,
UHC MCR ADV,CPT,87158,Culture typing added method,Lab Services,Per Unit,$7.74 ,OP,7.74,7.74,,,,,,
UHC MCR ADV,CPT,87164,Dark field examination,Lab Services,Per Unit,$10.74 ,OP,10.74,49.56,,,,,,
UHC MCR ADV,CPT,87166,Dark field examination,Lab Services,Per Unit,$11.30 ,OP,11.3,49.56,,,,,,
UHC MCR ADV,CPT,87168,Macroscopic exam arthropod,Lab Services,Per Unit,$4.27 ,OP,4.27,19.07,,,,,,
UHC MCR ADV,CPT,87169,Macroscopic exam parasite,Lab Services,Per Unit,$4.31 ,OP,4.31,19.07,,,,,,
UHC MCR ADV,CPT,87172,Pinworm exam,Lab Services,Per Unit,$4.27 ,OP,4.27,22.88,,,,,,
UHC MCR ADV,CPT,87176,Tissue homogenization cultr,Lab Services,Per Unit,$5.88 ,OP,5.88,26.7,,,,,,
UHC MCR ADV,CPT,87177,Ova and parasites smears,Lab Services,Per Unit,$8.90 ,OP,8.9,41.94,,,,,,
UHC MCR ADV,CPT,87181,Microbe susceptible diffuse,Lab Services,Per Unit,$4.75 ,OP,4.75,22.88,,,,,,
UHC MCR ADV,CPT,87184,Microbe susceptible disk,Lab Services,Per Unit,$7.48 ,OP,7.48,34.31,,,,,,
UHC MCR ADV,CPT,87185,Microbe susceptible enzyme,Lab Services,Per Unit,$4.75 ,OP,4.75,22.88,,,,,,
UHC MCR ADV,CPT,87186,Microbe susceptible mic,Lab Services,Per Unit,$8.65 ,OP,8.65,38.13,,,,,,
UHC MCR ADV,CPT,87187,Microbe susceptible mlc,Lab Services,Per Unit,$40.17 ,OP,40.17,45.74,,,,,,
UHC MCR ADV,CPT,87188,Microbe suscept macrobroth,Lab Services,Per Unit,$6.64 ,OP,6.64,30.51,,,,,,
UHC MCR ADV,CPT,87190,Microbe suscept mycobacteri,Lab Services,Per Unit,$7.31 ,OP,7.31,26.7,,,,,,
UHC MCR ADV,CPT,87197,Bactericidal level serum,Lab Services,Per Unit,$15.02 ,OP,15.02,68.63,,,,,,
UHC MCR ADV,CPT,87205,Smear gram stain,Lab Services,Per Unit,$4.27 ,OP,4.27,22.88,,,,,,
UHC MCR ADV,CPT,87206,Smear fluorescent/acid stai,Lab Services,Per Unit,$5.39 ,OP,5.39,26.7,,,,,,
UHC MCR ADV,CPT,87207,Smear special stain,Lab Services,Per Unit,$5.99 ,OP,5.99,41.94,,,,,,
UHC MCR ADV,CPT,87209,Smear complex stain,Lab Services,Per Unit,$17.98 ,OP,17.98,80.07,,,,,,
UHC MCR ADV,CPT,87210,Smear wet mount saline/ink,Lab Services,Per Unit,$5.82 ,OP,5.82,22.88,,,,,,
UHC MCR ADV,CPT,87220,Tissue exam for fungi,Lab Services,Per Unit,$4.27 ,OP,4.27,22.88,,,,,,
UHC MCR ADV,CPT,87230,Assay toxin or antitoxin,Lab Services,Per Unit,$19.74 ,OP,19.74,87.69,,,,,,
UHC MCR ADV,CPT,87250,Virus inoculate eggs/animal,Lab Services,Per Unit,$19.56 ,OP,19.56,87.69,,,,,,
UHC MCR ADV,CPT,87252,Virus inoculation tissue,Lab Services,Per Unit,$26.07 ,OP,26.07,102.95,,,,,,
UHC MCR ADV,CPT,87253,Virus inoculate tissue addl,Lab Services,Per Unit,$20.20 ,OP,20.2,91.51,,,,,,
UHC MCR ADV,CPT,87254,Virus inoculation shell via,Lab Services,Per Unit,$19.56 ,OP,19.56,87.69,,,,,,
UHC MCR ADV,CPT,87255,Genet virus isolate hsv,Lab Services,Per Unit,$33.86 ,OP,33.86,152.51,,,,,,
UHC MCR ADV,CPT,87260,Adenovirus ag if,Lab Services,Per Unit,$14.43 ,OP,14.43,14.43,,,,,,
UHC MCR ADV,CPT,87265,Pertussis ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
UHC MCR ADV,CPT,87267,Enterovirus antibody dfa,Lab Services,Per Unit,$13.42 ,OP,13.42,53.38,,,,,,
UHC MCR ADV,CPT,87269,Giardia ag if,Lab Services,Per Unit,$13.61 ,OP,13.61,53.38,,,,,,
UHC MCR ADV,CPT,87270,Chlamydia trachomatis ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
UHC MCR ADV,CPT,87271,Cytomegalovirus dfa,Lab Services,Per Unit,$13.42 ,OP,13.42,53.38,,,,,,
UHC MCR ADV,CPT,87272,Cryptosporidium ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
UHC MCR ADV,CPT,87273,Herpes simplex 2 ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,
UHC MCR ADV,CPT,87274,Herpes simplex 1 ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,
UHC MCR ADV,CPT,87275,Influenza b ag if,Lab Services,Per Unit,$12.25 ,OP,12.25,53.38,,,,,,
UHC MCR ADV,CPT,87276,Influenza a ag if,Lab Services,Per Unit,$16.07 ,OP,16.07,53.38,,,,,,
UHC MCR ADV,CPT,87278,Legion pneumophilia ag if,Lab Services,Per Unit,$15.60 ,OP,15.6,53.38,,,,,,
UHC MCR ADV,CPT,87279,Parainfluenza ag if,Lab Services,Per Unit,$16.43 ,OP,16.43,53.38,,,,,,
UHC MCR ADV,CPT,87280,Respiratory syncytial ag if,Lab Services,Per Unit,$13.42 ,OP,13.42,53.38,,,,,,
UHC MCR ADV,CPT,87281,Pneumocystis carinii ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
UHC MCR ADV,CPT,87283,Rubeola ag if,Lab Services,Per Unit,$60.80 ,OP,53.38,60.8,,,,,,
UHC MCR ADV,CPT,87285,Treponema pallidum ag if,Lab Services,Per Unit,$12.18 ,OP,12.18,53.38,,,,,,
UHC MCR ADV,CPT,87290,Varicella zoster ag if,Lab Services,Per Unit,$13.42 ,OP,13.42,53.38,,,,,,
UHC MCR ADV,CPT,87299,Antibody detection nos if,Lab Services,Per Unit,$16.10 ,OP,16.1,53.38,,,,,,
UHC MCR ADV,CPT,87300,Ag detection polyval if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,
UHC MCR ADV,CPT,87301,Adenovirus ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
UHC MCR ADV,CPT,87305,Aspergillus ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
UHC MCR ADV,CPT,87320,Chylmd trach ag ia,Lab Services,Per Unit,$15.00 ,OP,15,53.38,,,,,,
UHC MCR ADV,CPT,87324,Clostridium ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
UHC MCR ADV,CPT,87327,Cryptococcus neoform ag ia,Lab Services,Per Unit,$13.42 ,OP,13.42,53.38,,,,,,
UHC MCR ADV,CPT,87328,Cryptosporidium ag ia,Lab Services,Per Unit,$13.82 ,OP,13.82,53.38,,,,,,
UHC MCR ADV,CPT,87329,Giardia ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
UHC MCR ADV,CPT,87332,Cytomegalovirus ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
UHC MCR ADV,CPT,87335,E coli 0157 ag ia,Lab Services,Per Unit,$12.66 ,OP,12.66,53.38,,,,,,
UHC MCR ADV,CPT,87336,Entamoeb hist dispr ag ia,Lab Services,Per Unit,$16.00 ,OP,16,53.38,,,,,,
UHC MCR ADV,CPT,87337,Entamoeb hist group ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
UHC MCR ADV,CPT,87338,Hpylori stool ag ia,Lab Services,Per Unit,$14.38 ,OP,14.38,64.82,,,,,,
UHC MCR ADV,CPT,87339,H pylori ag ia,Lab Services,Per Unit,$16.00 ,OP,16,53.38,,,,,,
UHC MCR ADV,CPT,87340,Hepatitis b surface ag ia,Lab Services,Per Unit,$10.33 ,OP,10.33,45.74,,,,,,
UHC MCR ADV,CPT,87341,Hepatitis b surface ag ia,Lab Services,Per Unit,$10.33 ,OP,10.33,45.74,,,,,,
UHC MCR ADV,CPT,87350,Hepatitis be ag ia,Lab Services,Per Unit,$11.53 ,OP,11.53,49.56,,,,,,
UHC MCR ADV,CPT,87380,Hepatitis delta agent ag ia,Lab Services,Per Unit,$18.36 ,OP,18.36,72.44,,,,,,
UHC MCR ADV,CPT,87385,Histoplasma capsul ag ia,Lab Services,Per Unit,$13.25 ,OP,13.25,53.38,,,,,,
UHC MCR ADV,CPT,87389,Hiv-1 ag w/hiv-1&2 ab ag ia,Lab Services,Per Unit,$24.08 ,OP,24.08,24.08,,,,,,
UHC MCR ADV,CPT,87390,Hiv-1 ag ia,Lab Services,Per Unit,$24.06 ,OP,24.06,24.06,,,,,,
UHC MCR ADV,CPT,87391,Hiv-2 ag ia,Lab Services,Per Unit,$21.90 ,OP,21.9,80.07,,,,,,
UHC MCR ADV,CPT,87400,Influenza a/b each ag ia,Lab Services,Per Unit,$14.13 ,OP,14.13,61,,,,,,
UHC MCR ADV,CPT,87420,Resp syncytial virus ag ia,Lab Services,Per Unit,$13.91 ,OP,13.91,53.38,,,,,,
UHC MCR ADV,CPT,87425,Rotavirus ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
UHC MCR ADV,CPT,87426,Sarscov coronavirus ag ia,Lab Services,Per Unit,$35.33 ,OP,35.33,35.33,,,,,,
UHC MCR ADV,CPT,87427,Shiga-like toxin ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,53.38,,,,,,
UHC MCR ADV,CPT,87428,Sarscov & inf vir a&b ag ia,Lab Services,Per Unit,$63.59 ,OP,63.59,63.59,,,,,,
UHC MCR ADV,CPT,87430,Strep a ag ia,Lab Services,Per Unit,$16.81 ,OP,16.81,61,,,,,,
UHC MCR ADV,CPT,87449,Nos each organism ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,61,,,,,,
UHC MCR ADV,CPT,87451,Polyvalent mult org ea ag ia,Lab Services,Per Unit,$10.51 ,OP,10.51,41.94,,,,,,
UHC MCR ADV,CPT,87471,Bartonella dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,
UHC MCR ADV,CPT,87472,Bartonella dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
UHC MCR ADV,CPT,87475,Lyme dis dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
UHC MCR ADV,CPT,87476,Lyme dis dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
UHC MCR ADV,CPT,87480,Candida dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,99.13,,,,,,
UHC MCR ADV,CPT,87481,Candida dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
UHC MCR ADV,CPT,87482,Candida dna quant,Lab Services,Per Unit,$55.74 ,OP,55.74,186.82,,,,,,
UHC MCR ADV,CPT,87483,Cns dna amp probe type 12-25,Lab Services,Per Unit,$416.78 ,OP,416.78,416.78,,,,,,
UHC MCR ADV,CPT,87485,Chylmd pneum dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
UHC MCR ADV,CPT,87486,Chylmd pneum dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
UHC MCR ADV,CPT,87487,Chylmd pneum dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
UHC MCR ADV,CPT,87490,Chylmd trach dna dir probe,Lab Services,Per Unit,$22.75 ,OP,22.75,99.13,,,,,,
UHC MCR ADV,CPT,87491,Chylmd trach dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
UHC MCR ADV,CPT,87492,Chylmd trach dna quant,Lab Services,Per Unit,$53.47 ,OP,53.47,156.32,,,,,,
UHC MCR ADV,CPT,87493,C diff amplified probe,Lab Services,Per Unit,$37.27 ,OP,37.27,37.27,,,,,,
UHC MCR ADV,CPT,87495,Cytomeg dna dir probe,Lab Services,Per Unit,$30.03 ,OP,30.03,30.03,,,,,,
UHC MCR ADV,CPT,87496,Cytomeg dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
UHC MCR ADV,CPT,87497,Cytomeg dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
UHC MCR ADV,CPT,87498,Enterovirus probe&revrs trns,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
UHC MCR ADV,CPT,87500,Vanomycin dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
UHC MCR ADV,CPT,87501,Influenza dna amp prob 1+,Lab Services,Per Unit,$51.31 ,OP,51.31,51.31,,,,,,
UHC MCR ADV,CPT,87502,Influenza dna amp probe,Lab Services,Per Unit,$95.80 ,OP,95.8,95.8,,,,,,
UHC MCR ADV,CPT,87503,Influenza dna amp prob addl,Lab Services,Per Unit,$29.22 ,OP,29.22,29.22,,,,,,
UHC MCR ADV,CPT,87505,Nfct agent detection gi,Lab Services,Per Unit,$128.29 ,OP,128.29,128.29,,,,,,
UHC MCR ADV,CPT,87506,Iadna-dna/rna probe tq 6-11,Lab Services,Per Unit,$262.99 ,OP,262.99,262.99,,,,,,
UHC MCR ADV,CPT,87507,Iadna-dna/rna probe tq 12-25,Lab Services,Per Unit,$416.78 ,OP,416.78,416.78,,,,,,
UHC MCR ADV,CPT,87510,Gardner vag dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,99.13,,,,,,
UHC MCR ADV,CPT,87511,Gardner vag dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
UHC MCR ADV,CPT,87512,Gardner vag dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,186.82,,,,,,
UHC MCR ADV,CPT,87516,Hepatitis b dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
UHC MCR ADV,CPT,87517,Hepatitis b dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
UHC MCR ADV,CPT,87520,Hepatitis c rna dir probe,Lab Services,Per Unit,$31.22 ,OP,31.22,87.69,,,,,,
UHC MCR ADV,CPT,87521,Hepatitis c probe&rvrs trnsc,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
UHC MCR ADV,CPT,87522,Hepatitis c revrs trnscrpj,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
UHC MCR ADV,CPT,87525,Hepatitis g dna dir probe,Lab Services,Per Unit,$29.80 ,OP,29.8,87.69,,,,,,
UHC MCR ADV,CPT,87526,Hepatitis g dna amp probe,Lab Services,Per Unit,$39.26 ,OP,39.26,156.32,,,,,,
UHC MCR ADV,CPT,87527,Hepatitis g dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,186.82,,,,,,
UHC MCR ADV,CPT,87528,Hsv dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
UHC MCR ADV,CPT,87529,Hsv dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
UHC MCR ADV,CPT,87530,Hsv dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
UHC MCR ADV,CPT,87531,Hhv-6 dna dir probe,Lab Services,Per Unit,$58.00 ,OP,58,87.69,,,,,,
UHC MCR ADV,CPT,87532,Hhv-6 dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,
UHC MCR ADV,CPT,87533,Hhv-6 dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,186.82,,,,,,
UHC MCR ADV,CPT,87534,Hiv-1 dna dir probe,Lab Services,Per Unit,$21.92 ,OP,21.92,87.69,,,,,,
UHC MCR ADV,CPT,87535,Hiv-1 probe&reverse trnscrpj,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
UHC MCR ADV,CPT,87536,Hiv-1 quant&revrse trnscrpj,Lab Services,Per Unit,$85.10 ,OP,85.1,377.46,,,,,,
UHC MCR ADV,CPT,87537,Hiv-2 dna dir probe,Lab Services,Per Unit,$21.92 ,OP,21.92,87.69,,,,,,
UHC MCR ADV,CPT,87538,Hiv-2 probe&revrse trnscripj,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
UHC MCR ADV,CPT,87539,Hiv-2 quant&revrse trnscripj,Lab Services,Per Unit,$58.62 ,OP,58.62,190.64,,,,,,
UHC MCR ADV,CPT,87540,Legion pneumo dna dir prob,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
UHC MCR ADV,CPT,87541,Legion pneumo dna amp prob,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
UHC MCR ADV,CPT,87542,Legion pneumo dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,186.82,,,,,,
UHC MCR ADV,CPT,87550,Mycobacteria dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
UHC MCR ADV,CPT,87551,Mycobacteria dna amp probe,Lab Services,Per Unit,$48.24 ,OP,48.24,156.32,,,,,,
UHC MCR ADV,CPT,87552,Mycobacteria dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
UHC MCR ADV,CPT,87555,M.tuberculo dna dir probe,Lab Services,Per Unit,$26.88 ,OP,26.88,87.69,,,,,,
UHC MCR ADV,CPT,87556,M.tuberculo dna amp probe,Lab Services,Per Unit,$41.68 ,OP,41.68,156.32,,,,,,
UHC MCR ADV,CPT,87557,M.tuberculo dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
UHC MCR ADV,CPT,87560,M.avium-intra dna dir prob,Lab Services,Per Unit,$27.29 ,OP,27.29,87.69,,,,,,
UHC MCR ADV,CPT,87561,M.avium-intra dna amp prob,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
UHC MCR ADV,CPT,87562,M.avium-intra dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
UHC MCR ADV,CPT,87563,M. genitalium amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
UHC MCR ADV,CPT,87580,M.pneumon dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
UHC MCR ADV,CPT,87581,M.pneumon dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
UHC MCR ADV,CPT,87582,M.pneumon dna quant,Lab Services,Per Unit,$302.62 ,OP,186.82,302.62,,,,,,
UHC MCR ADV,CPT,87590,N.gonorrhoeae dna dir prob,Lab Services,Per Unit,$26.88 ,OP,26.88,99.13,,,,,,
UHC MCR ADV,CPT,87591,N.gonorrhoeae dna amp prob,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
UHC MCR ADV,CPT,87592,N.gonorrhoeae dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,
UHC MCR ADV,CPT,87623,Hpv low-risk types,Lab Services,Per Unit,$35.09 ,OP,35.09,93.87,,,,,,
UHC MCR ADV,CPT,87624,Hpv high-risk types,Lab Services,Per Unit,$35.09 ,OP,35.09,93.87,,,,,,
UHC MCR ADV,CPT,87625,Hpv types 16 & 18 only,Lab Services,Per Unit,$40.55 ,OP,40.55,93.87,,,,,,
UHC MCR ADV,CPT,87631,Resp virus 3-5 targets,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
UHC MCR ADV,CPT,87632,Resp virus 6-11 targets,Lab Services,Per Unit,$218.06 ,OP,218.06,218.06,,,,,,
UHC MCR ADV,CPT,87633,Resp virus 12-25 targets,Lab Services,Per Unit,$416.78 ,OP,416.78,416.78,,,,,,
UHC MCR ADV,CPT,87634,Rsv dna/rna amp probe,Lab Services,Per Unit,$70.20 ,OP,70.2,70.2,,,,,,
UHC MCR ADV,CPT,87635,Sars-cov-2 covid-19 amp prb,Lab Services,Per Unit,$51.31 ,OP,51.31,51.31,,,,,,
UHC MCR ADV,CPT,87636,Sarscov2 & inf a&b amp prb,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
UHC MCR ADV,CPT,87637,Sarscov2&inf a&b&rsv amp prb,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
UHC MCR ADV,CPT,87640,Staph a dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
UHC MCR ADV,CPT,87641,Mr-staph dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
UHC MCR ADV,CPT,87650,Strep a dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
UHC MCR ADV,CPT,87651,Strep a dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
UHC MCR ADV,CPT,87652,Strep a dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,186.82,,,,,,
UHC MCR ADV,CPT,87653,Strep b dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,
UHC MCR ADV,CPT,87660,Trichomonas vagin dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,87.69,,,,,,
UHC MCR ADV,CPT,87661,Trichomonas vaginalis amplif,Lab Services,Per Unit,$35.09 ,OP,35.09,87.69,,,,,,
UHC MCR ADV,CPT,87662,Zika virus dna/rna amp probe,Lab Services,Per Unit,$51.31 ,OP,51.31,51.31,,,,,,
UHC MCR ADV,CPT,87797,Detect agent nos dna dir,Lab Services,Per Unit,$30.03 ,OP,30.03,99.13,,,,,,
UHC MCR ADV,CPT,87798,Detect agent nos dna amp,Lab Services,Per Unit,$35.09 ,OP,35.09,156.32,,,,,,
UHC MCR ADV,CPT,87799,Detect agent nos dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,190.64,,,,,,
UHC MCR ADV,CPT,87800,Detect agnt mult dna direc,Lab Services,Per Unit,$43.67 ,OP,43.67,179.2,,,,,,
UHC MCR ADV,CPT,87801,Detect agnt mult dna ampli,Lab Services,Per Unit,$70.20 ,OP,70.2,312.64,,,,,,
UHC MCR ADV,CPT,87802,Strep b assay w/optic,Lab Services,Per Unit,$12.73 ,OP,12.73,61,,,,,,
UHC MCR ADV,CPT,87803,Clostridium toxin a w/optic,Lab Services,Per Unit,$16.00 ,OP,16,61,,,,,,
UHC MCR ADV,CPT,87804,Influenza assay w/optic,Lab Services,Per Unit,$16.55 ,OP,16.55,61,,,,,,
UHC MCR ADV,CPT,87806,Hiv w/hiv1&2 antb w/optic,Lab Services,Per Unit,$32.77 ,OP,32.77,61,,,,,,
UHC MCR ADV,CPT,87807,Rsv assay w/optic,Lab Services,Per Unit,$13.10 ,OP,13.1,53.38,,,,,,
UHC MCR ADV,CPT,87808,Trichomonas assay w/optic,Lab Services,Per Unit,$15.29 ,OP,15.29,61,,,,,,
UHC MCR ADV,CPT,87809,Adenovirus assay w/optic,Lab Services,Per Unit,$21.76 ,OP,21.76,53.38,,,,,,
UHC MCR ADV,CPT,87810,Chylmd trach assay w/optic,Lab Services,Per Unit,$35.29 ,OP,35.29,53.38,,,,,,
UHC MCR ADV,CPT,87811,Sars-cov-2 covid19 w/optic,Lab Services,Per Unit,$41.38 ,OP,41.38,41.38,,,,,,
UHC MCR ADV,CPT,87850,N. gonorrhoeae assay w/optic,Lab Services,Per Unit,$24.56 ,OP,24.56,53.38,,,,,,
UHC MCR ADV,CPT,87880,Strep a assay w/optic,Lab Services,Per Unit,$16.53 ,OP,16.53,61,,,,,,
UHC MCR ADV,CPT,87899,Agent nos assay w/optic,Lab Services,Per Unit,$16.07 ,OP,16.07,61,,,,,,
UHC MCR ADV,CPT,87900,Phenotype infect agent drug,Lab Services,Per Unit,$130.35 ,OP,130.35,518.52,,,,,,
UHC MCR ADV,CPT,87901,Genotype dna hiv reverse t,Lab Services,Per Unit,$257.45 ,OP,257.45,"1,147.62",,,,,,
UHC MCR ADV,CPT,87902,Genotype dna/rna hep c,Lab Services,Per Unit,$257.45 ,OP,257.45,"1,147.62",,,,,,
UHC MCR ADV,CPT,87903,Phenotype dna hiv w/culture,Lab Services,Per Unit,$488.66 ,OP,488.66,488.66,,,,,,
UHC MCR ADV,CPT,87904,Phenotype dna hiv w/clt add,Lab Services,Per Unit,$26.07 ,OP,26.07,26.07,,,,,,
UHC MCR ADV,CPT,87905,Sialidase enzyme assay,Lab Services,Per Unit,$12.22 ,OP,12.22,53.38,,,,,,
UHC MCR ADV,CPT,87906,Genotype dna/rna hiv,Lab Services,Per Unit,$128.73 ,OP,128.73,128.73,,,,,,
UHC MCR ADV,CPT,87910,Genotype cytomegalovirus,Lab Services,Per Unit,$257.45 ,OP,257.45,257.45,,,,,,
UHC MCR ADV,CPT,87912,Genotype dna hepatitis b,Lab Services,Per Unit,$257.45 ,OP,257.45,257.45,,,,,,
UHC MCR ADV,CPT,88104,Cytopath fl nongyn smears,APC 5732,RVU Per Case,$34.63 ,OP,34.63,175.39,,,,,,
UHC MCR ADV,CPT,88106,Cytopath fl nongyn filter,APC 5731,RVU Per Case,$25.25 ,OP,25.25,247.83,,,,,,
UHC MCR ADV,CPT,88108,Cytopath concentrate tech,APC 5732,RVU Per Case,$34.63 ,OP,34.63,228.77,,,,,,
UHC MCR ADV,CPT,88112,Cytopath cell enhance tech,APC 5671,RVU Per Case,$50.92 ,OP,50.92,232.58,,,,,,
UHC MCR ADV,CPT,88120,Cytp urne 3-5 probes ea spec,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
UHC MCR ADV,CPT,88121,Cytp urine 3-5 probes cmptr,APC 5673,RVU Per Case,$298.05 ,OP,298.05,298.05,,,,,,
UHC MCR ADV,CPT,88125,Forensic cytopathology,APC 5671,RVU Per Case,$50.92 ,OP,45.74,50.92,,,,,,
UHC MCR ADV,CPT,88130,Sex chromatin identification,Lab Services,Per Unit,$17.98 ,OP,17.98,68.63,,,,,,
UHC MCR ADV,CPT,88140,Sex chromatin identification,Lab Services,Per Unit,$7.99 ,OP,7.99,34.31,,,,,,
UHC MCR ADV,CPT,88142,Cytopath c/v thin layer,Lab Services,Per Unit,$20.26 ,OP,20.26,91.51,,,,,,
UHC MCR ADV,CPT,88143,Cytopath c/v thin layer redo,Lab Services,Per Unit,$23.04 ,OP,23.04,91.51,,,,,,
UHC MCR ADV,CPT,88147,Cytopath c/v automated,Lab Services,Per Unit,$50.56 ,OP,45.74,50.56,,,,,,
UHC MCR ADV,CPT,88148,Cytopath c/v auto rescreen,Lab Services,Per Unit,$16.00 ,OP,16,45.74,,,,,,
UHC MCR ADV,CPT,88150,Cytopath c/v manual,Lab Services,Per Unit,$15.15 ,OP,15.15,45.74,,,,,,
UHC MCR ADV,CPT,88152,Cytopath c/v auto redo,Lab Services,Per Unit,$27.64 ,OP,27.64,45.74,,,,,,
UHC MCR ADV,CPT,88153,Cytopath c/v redo,Lab Services,Per Unit,$24.03 ,OP,24.03,45.74,,,,,,
UHC MCR ADV,CPT,88155,Cytopath c/v index add-on,Lab Services,Per Unit,$14.65 ,OP,14.65,26.7,,,,,,
UHC MCR ADV,CPT,88160,Cytopath smear other source,APC 5731,RVU Per Case,$25.25 ,OP,25.25,141.07,,,,,,
UHC MCR ADV,CPT,88161,Cytopath smear other source,APC 5731,RVU Per Case,$25.25 ,OP,25.25,152.51,,,,,,
UHC MCR ADV,CPT,88162,Cytopath smear other source,APC 5671,RVU Per Case,$50.92 ,OP,50.92,205.88,,,,,,
UHC MCR ADV,CPT,88164,Cytopath tbs c/v manual,Lab Services,Per Unit,$15.15 ,OP,15.15,45.74,,,,,,
UHC MCR ADV,CPT,88165,Cytopath tbs c/v redo,Lab Services,Per Unit,$42.22 ,OP,42.22,45.74,,,,,,
UHC MCR ADV,CPT,88166,Cytopath tbs c/v auto redo,Lab Services,Per Unit,$15.15 ,OP,15.15,45.74,,,,,,
UHC MCR ADV,CPT,88167,Cytopath tbs c/v select,Lab Services,Per Unit,$15.15 ,OP,15.15,45.74,,,,,,
UHC MCR ADV,CPT,88172,Cytp dx eval fna 1st ea site,APC 5672,RVU Per Case,$152.64 ,OP,118.19,152.64,,,,,,
UHC MCR ADV,CPT,88173,Cytopath eval fna report,APC 5671,RVU Per Case,$50.92 ,OP,50.92,327.9,,,,,,
UHC MCR ADV,CPT,88174,Cytopath c/v auto in fluid,Lab Services,Per Unit,$25.37 ,OP,25.37,95.32,,,,,,
UHC MCR ADV,CPT,88175,Cytopath c/v auto fluid redo,Lab Services,Per Unit,$26.61 ,OP,26.61,118.19,,,,,,
UHC MCR ADV,CPT,88182,Cell marker study,APC 5671,RVU Per Case,$50.92 ,OP,50.92,339.33,,,,,,
UHC MCR ADV,CPT,88184,Flowcytometry/ tc 1 marker,APC 5673,RVU Per Case,$298.05 ,OP,298.05,404.14,,,,,,
UHC MCR ADV,CPT,88199,Cytopathology procedure,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
UHC MCR ADV,CPT,88230,Tissue culture lymphocyte,Lab Services,Per Unit,$116.49 ,OP,116.49,518.52,,,,,,
UHC MCR ADV,CPT,88233,Tissue culture skin/biopsy,Lab Services,Per Unit,$140.73 ,OP,140.73,625.29,,,,,,
UHC MCR ADV,CPT,88235,Tissue culture placenta,Lab Services,Per Unit,$150.30 ,OP,150.3,655.78,,,,,,
UHC MCR ADV,CPT,88237,Tissue culture bone marrow,Lab Services,Per Unit,$143.75 ,OP,143.75,564.29,,,,,,
UHC MCR ADV,CPT,88239,Tissue culture tumor,Lab Services,Per Unit,$147.52 ,OP,147.52,655.78,,,,,,
UHC MCR ADV,CPT,88240,Cell cryopreserve/storage,Lab Services,Per Unit,$13.07 ,OP,13.07,45.74,,,,,,
UHC MCR ADV,CPT,88241,Frozen cell preparation,Lab Services,Per Unit,$12.09 ,OP,12.09,45.74,,,,,,
UHC MCR ADV,CPT,88245,Chromosome analysis 20-25,Lab Services,Per Unit,$173.17 ,OP,173.17,648.16,,,,,,
UHC MCR ADV,CPT,88248,Chromosome analysis 50-100,Lab Services,Per Unit,$173.17 ,OP,173.17,770.16,,,,,,
UHC MCR ADV,CPT,88249,Chromosome analysis 100,Lab Services,Per Unit,$173.17 ,OP,173.17,770.16,,,,,,
UHC MCR ADV,CPT,88261,Chromosome analysis 5,Lab Services,Per Unit,$264.34 ,OP,264.34,785.42,,,,,,
UHC MCR ADV,CPT,88262,Chromosome analysis 15-20,Lab Services,Per Unit,$125.49 ,OP,125.49,556.65,,,,,,
UHC MCR ADV,CPT,88263,Chromosome analysis 45,Lab Services,Per Unit,$150.29 ,OP,150.29,671.03,,,,,,
UHC MCR ADV,CPT,88264,Chromosome analysis 20-25,Lab Services,Per Unit,$144.61 ,OP,144.61,556.65,,,,,,
UHC MCR ADV,CPT,88267,Chromosome analys placenta,Lab Services,Per Unit,$188.57 ,OP,188.57,800.67,,,,,,
UHC MCR ADV,CPT,88269,Chromosome analys amniotic,Lab Services,Per Unit,$173.66 ,OP,173.66,739.67,,,,,,
UHC MCR ADV,CPT,88271,Cytogenetics dna probe,Lab Services,Per Unit,$21.42 ,OP,21.42,64.82,,,,,,
UHC MCR ADV,CPT,88272,Cytogenetics 3-5,Lab Services,Per Unit,$40.70 ,OP,40.7,114.39,,,,,,
UHC MCR ADV,CPT,88273,Cytogenetics 10-30,Lab Services,Per Unit,$34.81 ,OP,34.81,144.88,,,,,,
UHC MCR ADV,CPT,88274,Cytogenetics 25-99,Lab Services,Per Unit,$42.38 ,OP,42.38,156.32,,,,,,
UHC MCR ADV,CPT,88275,Cytogenetics 100-300,Lab Services,Per Unit,$51.19 ,OP,51.19,179.2,,,,,,
UHC MCR ADV,CPT,88280,Chromosome karyotype study,Lab Services,Per Unit,$33.47 ,OP,33.47,110.57,,,,,,
UHC MCR ADV,CPT,88283,Chromosome banding study,Lab Services,Per Unit,$68.60 ,OP,68.6,68.6,,,,,,
UHC MCR ADV,CPT,88285,Chromosome count additional,Lab Services,Per Unit,$26.91 ,OP,26.91,83.87,,,,,,
UHC MCR ADV,CPT,88289,Chromosome study additional,Lab Services,Per Unit,$34.43 ,OP,34.43,129.64,,,,,,
UHC MCR ADV,CPT,88299,Cytogenetic study,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
UHC MCR ADV,CPT,88300,Surgical path gross,APC 5731,RVU Per Case,$25.25 ,OP,25.25,99.13,,,,,,
UHC MCR ADV,CPT,88302,Tissue exam by pathologist,APC 5731,RVU Per Case,$25.25 ,OP,25.25,217.32,,,,,,
UHC MCR ADV,CPT,88304,Tissue exam by pathologist,APC 5671,RVU Per Case,$50.92 ,OP,50.92,263.08,,,,,,
UHC MCR ADV,CPT,88305,Tissue exam by pathologist,APC 5671,RVU Per Case,$50.92 ,OP,50.92,362.21,,,,,,
UHC MCR ADV,CPT,88307,Tissue exam by pathologist,APC 5673,RVU Per Case,$298.05 ,OP,298.05,671.03,,,,,,
UHC MCR ADV,CPT,88309,Tissue exam by pathologist,APC 5674,RVU Per Case,$671.45 ,OP,671.45,911.23,,,,,,
UHC MCR ADV,CPT,88312,Special stains group 1,APC 5671,RVU Per Case,$50.92 ,OP,50.92,366.02,,,,,,
UHC MCR ADV,CPT,88313,Special stains group 2,APC 5732,RVU Per Case,$34.63 ,OP,34.63,308.83,,,,,,
UHC MCR ADV,CPT,88319,Enzyme histochemistry,APC 5674,RVU Per Case,$671.45 ,OP,568.09,671.45,,,,,,
UHC MCR ADV,CPT,88321,Microslide consultation,APC 5732,RVU Per Case,$34.63 ,OP,34.63,438.47,,,,,,
UHC MCR ADV,CPT,88323,Microslide consultation,APC 5671,RVU Per Case,$50.92 ,OP,50.92,289.76,,,,,,
UHC MCR ADV,CPT,88325,Comprehensive review of data,APC 5672,RVU Per Case,$152.64 ,OP,152.64,949.36,,,,,,
UHC MCR ADV,CPT,88329,Path consult introp,APC 5732,RVU Per Case,$34.63 ,OP,34.63,247.83,,,,,,
UHC MCR ADV,CPT,88331,Path consult intraop 1 bloc,APC 5672,RVU Per Case,$152.64 ,OP,152.51,152.64,,,,,,
UHC MCR ADV,CPT,88333,Intraop cyto path consult 1,APC 5674,RVU Per Case,$671.45 ,OP,163.95,671.45,,,,,,
UHC MCR ADV,CPT,88342,Immunohisto antb 1st stain,APC 5672,RVU Per Case,$152.64 ,OP,152.64,297.39,,,,,,
UHC MCR ADV,CPT,88344,Immunohisto antibody slide,APC 5673,RVU Per Case,$298.05 ,OP,297.39,298.05,,,,,,
UHC MCR ADV,CPT,88346,Immunofluor antb 1st stain,APC 5673,RVU Per Case,$298.05 ,OP,293.57,298.05,,,,,,
UHC MCR ADV,CPT,88348,Electron microscopy,APC 5674,RVU Per Case,$671.45 ,OP,671.45,"2,794.70",,,,,,
UHC MCR ADV,CPT,88355,Analysis skeletal muscle,APC 5672,RVU Per Case,$152.64 ,OP,152.64,777.79,,,,,,
UHC MCR ADV,CPT,88356,Analysis nerve,APC 5671,RVU Per Case,$50.92 ,OP,50.92,766.35,,,,,,
UHC MCR ADV,CPT,88358,Analysis tumor,APC 5672,RVU Per Case,$152.64 ,OP,152.64,171.58,,,,,,
UHC MCR ADV,CPT,88360,Tumor immunohistochem/manual,APC 5672,RVU Per Case,$152.64 ,OP,152.64,335.53,,,,,,
UHC MCR ADV,CPT,88361,Tumor immunohistochem/comput,APC 5673,RVU Per Case,$298.05 ,OP,298.05,484.22,,,,,,
UHC MCR ADV,CPT,88362,Nerve teasing preparations,APC 5674,RVU Per Case,$671.45 ,OP,671.45,793.05,,,,,,
UHC MCR ADV,CPT,88363,Xm archive tissue molec anal,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
UHC MCR ADV,CPT,88365,Insitu hybridization (fish),APC 5672,RVU Per Case,$152.64 ,OP,152.64,499.47,,,,,,
UHC MCR ADV,CPT,88366,Insitu hybridization (fish),APC 5673,RVU Per Case,$298.05 ,OP,298.05,499.47,,,,,,
UHC MCR ADV,CPT,88367,Insitu hybridization auto,APC 5673,RVU Per Case,$298.05 ,OP,298.05,907.42,,,,,,
UHC MCR ADV,CPT,88368,Insitu hybridization manual,APC 5673,RVU Per Case,$298.05 ,OP,298.05,747.28,,,,,,
UHC MCR ADV,CPT,88374,M/phmtrc alys ishquant/semiq,APC 5672,RVU Per Case,$152.64 ,OP,152.64,907.42,,,,,,
UHC MCR ADV,CPT,88377,M/phmtrc alys ishquant/semiq,APC 5672,RVU Per Case,$152.64 ,OP,152.64,747.28,,,,,,
UHC MCR ADV,CPT,88399,Surgical pathology procedure,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
UHC MCR ADV,CPT,88720,Bilirubin total transcut,Lab Services,Per Unit,$5.02 ,OP,5.02,22.88,,,,,,
UHC MCR ADV,CPT,88738,Hgb quant transcutaneous,Lab Services,Per Unit,$5.02 ,OP,5.02,5.02,,,,,,
UHC MCR ADV,CPT,88740,Transcutaneous carboxyhb,Lab Services,Per Unit,$9.37 ,OP,9.37,22.88,,,,,,
UHC MCR ADV,CPT,88741,Transcutaneous methb,Lab Services,Per Unit,$9.37 ,OP,9.37,22.88,,,,,,
UHC MCR ADV,CPT,89049,Chct for mal hyperthermia,APC 5672,RVU Per Case,$152.64 ,OP,152.64,"1,201.00",,,,,,
UHC MCR ADV,CPT,89050,Body fluid cell count,Lab Services,Per Unit,$4.72 ,OP,4.72,22.88,,,,,,
UHC MCR ADV,CPT,89051,Body fluid cell count,Lab Services,Per Unit,$5.60 ,OP,5.6,26.7,,,,,,
UHC MCR ADV,CPT,89055,Leukocyte assessment fecal,Lab Services,Per Unit,$4.27 ,OP,4.27,22.88,,,,,,
UHC MCR ADV,CPT,89060,Exam synovial fluid crystals,Lab Services,Per Unit,$7.33 ,OP,7.33,30.51,,,,,,
UHC MCR ADV,CPT,89125,Specimen fat stain,Lab Services,Per Unit,$5.88 ,OP,5.88,11.44,,,,,,
UHC MCR ADV,CPT,89160,Exam feces for meat fibers,Lab Services,Per Unit,$4.85 ,OP,4.85,15.26,,,,,,
UHC MCR ADV,CPT,89190,Nasal smear for eosinophils,Lab Services,Per Unit,$5.79 ,OP,5.79,22.88,,,,,,
UHC MCR ADV,CPT,89220,Sputum specimen collection,APC 5672,RVU Per Case,$152.64 ,OP,80.07,152.64,,,,,,
UHC MCR ADV,CPT,89230,Collect sweat for test,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
UHC MCR ADV,CPT,89240,Pathology lab procedure,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
UHC MCR ADV,CPT,89250,Cultr oocyte/embryo <4 days,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
UHC MCR ADV,CPT,89251,Cultr oocyte/embryo <4 days,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
UHC MCR ADV,CPT,89253,Embryo hatching,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
UHC MCR ADV,CPT,89254,Oocyte identification,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
UHC MCR ADV,CPT,89255,Prepare embryo for transfer,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
UHC MCR ADV,CPT,89257,Sperm identification,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
UHC MCR ADV,CPT,89258,Cryopreservation embryo(s),APC 5674,RVU Per Case,$671.45 ,OP,671.45,671.45,,,,,,
UHC MCR ADV,CPT,89259,Cryopreservation sperm,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
UHC MCR ADV,CPT,89260,Sperm isolation simple,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
UHC MCR ADV,CPT,89261,Sperm isolation complex,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
UHC MCR ADV,CPT,89264,Identify sperm tissue,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
UHC MCR ADV,CPT,89268,Insemination of oocytes,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
UHC MCR ADV,CPT,89272,Extended culture of oocytes,APC 5674,RVU Per Case,$671.45 ,OP,671.45,671.45,,,,,,
UHC MCR ADV,CPT,89280,Assist oocyte fertilization,APC 5674,RVU Per Case,$671.45 ,OP,671.45,671.45,,,,,,
UHC MCR ADV,CPT,89281,Assist oocyte fertilization,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
UHC MCR ADV,CPT,89290,Biopsy oocyte polar body,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
UHC MCR ADV,CPT,89291,Biopsy oocyte polar body,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
UHC MCR ADV,CPT,89300,Semen analysis w/huhner,Lab Services,Per Unit,$9.84 ,OP,9.84,45.74,,,,,,
UHC MCR ADV,CPT,89310,Semen analysis w/count,Lab Services,Per Unit,$8.61 ,OP,8.61,30.51,,,,,,
UHC MCR ADV,CPT,89320,Semen anal vol/count/mot,Lab Services,Per Unit,$12.31 ,OP,12.31,49.56,,,,,,
UHC MCR ADV,CPT,89321,Semen anal sperm detection,Lab Services,Per Unit,$12.05 ,OP,12.05,49.56,,,,,,
UHC MCR ADV,CPT,89322,Semen anal strict criteria,Lab Services,Per Unit,$15.50 ,OP,15.5,61,,,,,,
UHC MCR ADV,CPT,89325,Sperm antibody test,Lab Services,Per Unit,$10.67 ,OP,10.67,10.67,,,,,,
UHC MCR ADV,CPT,89329,Sperm evaluation test,Lab Services,Per Unit,$19.59 ,OP,19.59,91.51,,,,,,
UHC MCR ADV,CPT,89330,Evaluation cervical mucus,Lab Services,Per Unit,$10.38 ,OP,10.38,45.74,,,,,,
UHC MCR ADV,CPT,89331,Retrograde ejaculation anal,Lab Services,Per Unit,$19.59 ,OP,19.59,83.87,,,,,,
UHC MCR ADV,CPT,89335,Cryopreserve testicular tiss,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
UHC MCR ADV,CPT,89337,Cryopreservation oocyte(s),APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
UHC MCR ADV,CPT,89342,Storage/year embryo(s),APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
UHC MCR ADV,CPT,89343,Storage/year sperm/semen,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
UHC MCR ADV,CPT,89344,Storage/year reprod tissue,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
UHC MCR ADV,CPT,89346,Storage/year oocyte(s),APC 5673,RVU Per Case,$298.05 ,OP,298.05,298.05,,,,,,
UHC MCR ADV,CPT,89352,Thawing cryopresrved embryo,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
UHC MCR ADV,CPT,89353,Thawing cryopresrved sperm,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
UHC MCR ADV,CPT,89354,Thaw cryoprsvrd reprod tiss,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
UHC MCR ADV,CPT,89356,Thawing cryopresrved oocyte,APC 5672,RVU Per Case,$152.64 ,OP,152.64,152.64,,,,,,
UHC MCR ADV,CPT,89398,Unlisted reprod med lab proc,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
UHC MCR ADV,CPT,90371,Hep b ig im,APC 1630,Per Unit,$130.31 ,OP,130.31,735.85,,,,,,
UHC MCR ADV,CPT,90375,Rabies ig im/sc,APC 9133,Per Unit,$267.30 ,OP,267.3,617.65,,,,,,
UHC MCR ADV,CPT,90376,Rabies ig heat treated,APC 9134,Per Unit,$287.38 ,OP,287.38,617.65,,,,,,
UHC MCR ADV,CPT,90378,Rsv mab im 50mg,APC 9003,Per Unit,"$1,185.67 ",OP,"1,185.67","3,154.20",,,,,,
UHC MCR ADV,CPT,90385,Rh ig minidose im,APC 9063,Per Unit,$151.41 ,OP,151.41,202.07,,,,,,
UHC MCR ADV,CPT,90396,Varicella-zoster ig im,APC 9135,Per Unit,"$1,965.97 ",OP,495.65,"1,965.97",,,,,,
UHC MCR ADV,CPT,90471,Immunization admin,APC 5692,RVU Per Case,$63.42 ,OP,57.19,63.42,,,,,,
UHC MCR ADV,CPT,90473,Immune admin oral/nasal,APC 5692,RVU Per Case,$63.42 ,OP,57.19,63.42,,,,,,
UHC MCR ADV,CPT,90630,Flu vacc iiv4 no preserv id,Other,Straight Discount,29.70%,OP,,,,,,,,
UHC MCR ADV,CPT,90653,Iiv adjuvant vaccine im,Other,Straight Discount,29.70%,OP,,,,,,,,
UHC MCR ADV,CPT,90654,Flu vacc iiv3 no preserv id,Other,Straight Discount,29.70%,OP,,,,,,,,
UHC MCR ADV,CPT,90655,Iiv3 vacc no prsv 0.25 ml im,Other,Straight Discount,29.70%,OP,68.63,68.63,,,,,,
UHC MCR ADV,CPT,90656,Iiv3 vacc no prsv 0.5 ml im,Other,Straight Discount,29.70%,OP,76.26,76.26,,,,,,
UHC MCR ADV,CPT,90657,Iiv3 vaccine splt 0.25 ml im,Other,Straight Discount,29.70%,OP,110.57,110.57,,,,,,
UHC MCR ADV,CPT,90660,Laiv3 vaccine intranasal,Other,Straight Discount,29.70%,OP,122,122,,,,,,
UHC MCR ADV,CPT,90661,Cciiv3 vac no prsv 0.5 ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
UHC MCR ADV,CPT,90662,Iiv no prsv increased ag im,Other,Straight Discount,29.70%,OP,,,,,,,,
UHC MCR ADV,CPT,90670,Pcv13 vaccine im,Other,Straight Discount,29.70%,OP,,,,,,,,
UHC MCR ADV,CPT,90672,Laiv4 vaccine intranasal,Other,Straight Discount,29.70%,OP,,,,,,,,
UHC MCR ADV,CPT,90673,Riv3 vaccine no preserv im,Other,Straight Discount,29.70%,OP,,,,,,,,
UHC MCR ADV,CPT,90674,Cciiv4 vac no prsv 0.5 ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
UHC MCR ADV,CPT,90675,Rabies vaccine im,APC 9139,Per Unit,$327.53 ,OP,327.53,945.56,,,,,,
UHC MCR ADV,CPT,90676,Rabies vaccine id,APC 9140,Per Unit,$189.63 ,OP,189.63,945.56,,,,,,
UHC MCR ADV,CPT,90677,Pcv20 vaccine im,Other,Straight Discount,29.70%,OP,,,,,,,,
UHC MCR ADV,CPT,90682,Riv4 vacc recombinant dna im,Other,Straight Discount,29.70%,OP,,,,,,,,
UHC MCR ADV,CPT,90685,Iiv4 vacc no prsv 0.25 ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
UHC MCR ADV,CPT,90686,Iiv4 vacc no prsv 0.5 ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
UHC MCR ADV,CPT,90687,Iiv4 vaccine splt 0.25 ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
UHC MCR ADV,CPT,90688,Iiv4 vaccine splt 0.5 ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
UHC MCR ADV,CPT,90689,Vacc iiv4 no prsrv 0.25ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
UHC MCR ADV,CPT,90694,Vacc aiiv4 no prsrv 0.5ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
UHC MCR ADV,CPT,90732,Ppsv23 vacc 2 yrs+ subq/im,Other,Straight Discount,29.70%,OP,228.77,228.77,,,,,,
UHC MCR ADV,CPT,90739,Hepb vacc 2 dose adult im,Other,Straight Discount,29.70%,OP,,,,,,,,
UHC MCR ADV,CPT,90740,Hepb vacc 3 dose immunsup im,Other,Straight Discount,29.70%,OP,"1,029.43","1,029.43",,,,,,
UHC MCR ADV,CPT,90743,Hepb vacc 2 dose adolesc im,Other,Straight Discount,29.70%,OP,141.07,141.07,,,,,,
UHC MCR ADV,CPT,90744,Hepb vacc 3 dose ped/adol im,Other,Straight Discount,29.70%,OP,141.07,141.07,,,,,,
UHC MCR ADV,CPT,90746,Hepb vaccine 3 dose adult im,Other,Straight Discount,29.70%,OP,369.83,369.83,,,,,,
UHC MCR ADV,CPT,90747,Hepb vacc 4 dose immunsup im,Other,Straight Discount,29.70%,OP,"1,029.43","1,029.43",,,,,,
UHC MCR ADV,CPT,90756,Cciiv4 vacc abx free im,Other,Straight Discount,29.70%,OP,,,,,,,,
UHC MCR ADV,CPT,90791,Psych diagnostic evaluation,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,789.23,,,,,,
UHC MCR ADV,CPT,90792,Psych diag eval w/med srvcs,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,789.23,,,,,,
UHC MCR ADV,CPT,90832,Psytx w pt 30 minutes,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,331.7,,,,,,
UHC MCR ADV,CPT,90834,Psytx w pt 45 minutes,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,480.4,,,,,,
UHC MCR ADV,CPT,90837,Psytx w pt 60 minutes,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,705.35,,,,,,
UHC MCR ADV,CPT,90839,Psytx crisis initial 60 min,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,136.74,,,,,,
UHC MCR ADV,CPT,90845,Psychoanalysis,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,423.22,,,,,,
UHC MCR ADV,CPT,90846,Family psytx w/o pt 50 min,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,449.9,,,,,,
UHC MCR ADV,CPT,90847,Family psytx w/pt 50 min,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,583.35,,,,,,
UHC MCR ADV,CPT,90849,Multiple family group psytx,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,171.58,,,,,,
UHC MCR ADV,CPT,90853,Group psychotherapy,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,368.97,,,,,,
UHC MCR ADV,CPT,90865,Narcosynthesis,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,808.29,,,,,,
UHC MCR ADV,CPT,90867,Tcranial magn stim tx plan,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
UHC MCR ADV,CPT,90868,Tcranial magn stim tx deli,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
UHC MCR ADV,CPT,90869,Tcran magn stim redetemine,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
UHC MCR ADV,CPT,90870,Electroconvulsive therapy,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,709.16,,,,,,
UHC MCR ADV,CPT,90880,Hypnotherapy,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,545.21,,,,,,
UHC MCR ADV,CPT,90899,Psychiatric service/therapy,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
UHC MCR ADV,CPT,90901,Biofeedback train any meth,Physician,Per Unit,$19.59 ,OP,19.59,19.59,,,,,,
UHC MCR ADV,CPT,90912,Bfb training 1st 15 min,Physician,Per Unit,$43.33 ,OP,43.33,476.6,,,,,,
UHC MCR ADV,CPT,90913,Bfb training ea addl 15 min,Physician,Per Unit,$24.51 ,OP,24.51,264.78,,,,,,
UHC MCR ADV,CPT,90935,Hemodialysis one evaluation,APC 5401,RVU Per Unit,$669.60 ,OP,373.65,669.6,,,,,,
UHC MCR ADV,CPT,90945,Dialysis one evaluation,APC 5024,RVU Per Unit,$372.22 ,OP,372.22,388.89,,,,,,
UHC MCR ADV,CPT,91010,Esophagus motility study,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
UHC MCR ADV,CPT,91020,Gastric motility studies,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,"1,265.81",,,,,,
UHC MCR ADV,CPT,91022,Duodenal motility study,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,"1,044.69",,,,,,
UHC MCR ADV,CPT,91030,Acid perfusion of esophagus,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,754.91,,,,,,
UHC MCR ADV,CPT,91034,Gastroesophageal reflux test,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
UHC MCR ADV,CPT,91035,G-esoph reflx tst w/electrod,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
UHC MCR ADV,CPT,91037,Esoph imped function test,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
UHC MCR ADV,CPT,91038,Esoph imped funct test > 1hr,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
UHC MCR ADV,CPT,91040,Esoph balloon distension tst,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
UHC MCR ADV,CPT,91065,Breath hydrogen/methane test,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
UHC MCR ADV,CPT,91110,Gi tract capsule endoscopy,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,828.48,,,,,,
UHC MCR ADV,CPT,91111,Esophageal capsule endoscopy,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,828.48,,,,,,
UHC MCR ADV,CPT,91112,Gi wireless capsule measure,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,828.48,,,,,,
UHC MCR ADV,CPT,91117,Colon motility 6 hr study,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,272.35,,,,,,
UHC MCR ADV,CPT,91120,Rectal sensation test,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
UHC MCR ADV,CPT,91122,Anal pressure record,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,272.35,,,,,,
UHC MCR ADV,CPT,91132,Electrogastrography,APC 5722,RVU Per Unit,$270.61 ,OP,244.01,270.61,,,,,,
UHC MCR ADV,CPT,91133,Electrogastrography w/test,APC 5734,RVU Per Case,$114.56 ,OP,114.56,312.64,,,,,,
UHC MCR ADV,CPT,91200,Liver elastography,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
UHC MCR ADV,CPT,91299,Gastroenterology procedure,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
UHC MCR ADV,CPT,91300,Sarscov2 vac 30mcg/0.3ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
UHC MCR ADV,CPT,91301,Sarscov2 vac 100mcg/0.5ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
UHC MCR ADV,CPT,91303,Sarscov2 vac ad26 .5ml im,Other,Straight Discount,29.70%,OP,,,,,,,,
UHC MCR ADV,CPT,92002,Eye exam new patient,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,354.58,,,,,,
UHC MCR ADV,CPT,92004,Eye exam new patient,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,663.41,,,,,,
UHC MCR ADV,CPT,92012,Eye exam establish patient,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,373.65,,,,,,
UHC MCR ADV,CPT,92014,Eye exam&tx estab pt 1/>vst,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,545.21,,,,,,
UHC MCR ADV,CPT,92018,New eye exam & treatment,APC 5503,RVU Per Case,"$2,049.05 ",OP,671.03,"2,049.05",,,,,,
UHC MCR ADV,CPT,92019,Eye exam & treatment,APC 5503,RVU Per Case,"$2,049.05 ",OP,331.7,"2,049.05",,,,,,
UHC MCR ADV,CPT,92020,Special eye evaluation,APC 5734,RVU Per Case,$114.56 ,OP,114.56,125.82,,,,,,
UHC MCR ADV,CPT,92025,Corneal topography,APC 5733,RVU Per Case,$56.95 ,OP,56.95,167.76,,,,,,
UHC MCR ADV,CPT,92060,Special eye evaluation,APC 5733,RVU Per Case,$56.95 ,OP,56.95,285.96,,,,,,
UHC MCR ADV,CPT,92065,Orthoptic/pleoptic training,APC 5733,RVU Per Case,$56.95 ,OP,56.95,224.95,,,,,,
UHC MCR ADV,CPT,92081,Visual field examination(s),APC 5733,RVU Per Case,$56.95 ,OP,56.95,255.45,,,,,,
UHC MCR ADV,CPT,92082,Visual field examination(s),APC 5733,RVU Per Case,$56.95 ,OP,56.95,339.33,,,,,,
UHC MCR ADV,CPT,92083,Visual field examination(s),APC 5734,RVU Per Case,$114.56 ,OP,114.56,385.09,,,,,,
UHC MCR ADV,CPT,92132,Cmptr ophth dx img ant segmt,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
UHC MCR ADV,CPT,92133,Cmptr ophth img optic nerve,APC 5733,RVU Per Case,$56.95 ,OP,56.95,224.95,,,,,,
UHC MCR ADV,CPT,92134,Cptr ophth dx img post segmt,APC 5733,RVU Per Case,$56.95 ,OP,56.95,224.95,,,,,,
UHC MCR ADV,CPT,92136,Ophthalmic biometry,APC 5734,RVU Per Case,$114.56 ,OP,114.56,411.78,,,,,,
UHC MCR ADV,CPT,92145,Corneal hysteresis deter,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
UHC MCR ADV,CPT,92201,Opscpy extnd rta draw uni/bi,APC 5733,RVU Per Case,$56.95 ,OP,56.95,118.19,,,,,,
UHC MCR ADV,CPT,92202,Opscpy extnd on/mac draw,APC 5733,RVU Per Case,$56.95 ,OP,56.95,76.37,,,,,,
UHC MCR ADV,CPT,92227,Img rta detcj/mntr ds staff,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
UHC MCR ADV,CPT,92228,Img rta detc/mntr ds phy/qhp,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
UHC MCR ADV,CPT,92229,Img rta detc/mntr ds poc aly,APC 5733,RVU Per Unit,$56.95 ,OP,56.95,56.95,,,,,,
UHC MCR ADV,CPT,92230,Eye exam with photos,APC 5723,RVU Per Case,$499.16 ,OP,289.76,499.16,,,,,,
UHC MCR ADV,CPT,92235,Fluorescein angrph uni/bi,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,629.1,,,,,,
UHC MCR ADV,CPT,92240,Icg angiography uni/bi,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,162.87",,,,,,
UHC MCR ADV,CPT,92242,Fluorescein icg angiography,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,791.98",,,,,,
UHC MCR ADV,CPT,92250,Eye exam with photos,APC 5734,RVU Per Case,$114.56 ,OP,114.56,346.96,,,,,,
UHC MCR ADV,CPT,92260,Ophthalmoscopy/dynamometry,APC 5732,RVU Per Case,$34.63 ,OP,34.63,87.69,,,,,,
UHC MCR ADV,CPT,92265,Eye muscle evaluation,APC 5733,RVU Per Case,$56.95 ,OP,56.95,381.27,,,,,,
UHC MCR ADV,CPT,92270,Electro-oculography,APC 5734,RVU Per Case,$114.56 ,OP,114.56,438.47,,,,,,
UHC MCR ADV,CPT,92273,Full field erg w/i&r,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,648.16,,,,,,
UHC MCR ADV,CPT,92274,Multifocal erg w/i&r,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,386.03,,,,,,
UHC MCR ADV,CPT,92283,Color vision examination,APC 5733,RVU Per Case,$56.95 ,OP,56.95,224.95,,,,,,
UHC MCR ADV,CPT,92284,Dark adaptation eye exam,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
UHC MCR ADV,CPT,92285,Eye photography,APC 5733,RVU Per Case,$56.95 ,OP,56.95,205.88,,,,,,
UHC MCR ADV,CPT,92286,Internal eye photography,APC 5734,RVU Per Case,$114.56 ,OP,114.56,583.35,,,,,,
UHC MCR ADV,CPT,92287,Internal eye photography,APC 5734,RVU Per Case,$114.56 ,OP,114.56,549.03,,,,,,
UHC MCR ADV,CPT,92311,Contact lens fitting,APC 5735,RVU Per Case,$276.53 ,OP,276.53,449.9,,,,,,
UHC MCR ADV,CPT,92312,Contact lens fitting,APC 5734,RVU Per Case,$114.56 ,OP,114.56,510.9,,,,,,
UHC MCR ADV,CPT,92313,Contact lens fitting,APC 5734,RVU Per Case,$114.56 ,OP,114.56,434.65,,,,,,
UHC MCR ADV,CPT,92315,Rx cntact lens aphakia 1 eye,APC 5734,RVU Per Case,$114.56 ,OP,114.56,312.64,,,,,,
UHC MCR ADV,CPT,92316,Rx cntact lens aphakia 2 eye,APC 5734,RVU Per Case,$114.56 ,OP,114.56,411.78,,,,,,
UHC MCR ADV,CPT,92317,Rx corneoscleral cntact lens,APC 5732,RVU Per Case,$34.63 ,OP,34.63,324.09,,,,,,
UHC MCR ADV,CPT,92325,Modification of contact lens,APC 5734,RVU Per Case,$114.56 ,OP,114.56,141.07,,,,,,
UHC MCR ADV,CPT,92326,Replacement of contact lens,APC 5733,RVU Per Case,$56.95 ,OP,56.95,205.88,,,,,,
UHC MCR ADV,CPT,92352,Fit aphakia spectcl monofocl,APC 5733,RVU Per Case,$56.95 ,OP,56.95,198.25,,,,,,
UHC MCR ADV,CPT,92353,Fit aphakia spectcl multifoc,APC 5733,RVU Per Case,$56.95 ,OP,56.95,232.58,,,,,,
UHC MCR ADV,CPT,92354,Fit spectacles single system,APC 5732,RVU Per Case,$34.63 ,OP,34.63,510.9,,,,,,
UHC MCR ADV,CPT,92355,Fit spectacles compound lens,APC 5732,RVU Per Case,$34.63 ,OP,34.63,285.96,,,,,,
UHC MCR ADV,CPT,92358,Aphakia prosth service temp,APC 5733,RVU Per Case,$56.95 ,OP,56.95,102.95,,,,,,
UHC MCR ADV,CPT,92371,Repair & adjust spectacles,APC 5733,RVU Per Case,$56.95 ,OP,56.95,76.26,,,,,,
UHC MCR ADV,CPT,92499,Eye service or procedure,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
UHC MCR ADV,CPT,92502,Ear and throat examination,APC 5162,RVU Per Unit,$462.91 ,OP,462.91,526.16,,,,,,
UHC MCR ADV,CPT,92507,Speech/hearing therapy,Physician,Per Unit,$75.75 ,OP,75.75,354.58,,,,,,
UHC MCR ADV,CPT,92508,Speech/hearing therapy,Physician,Per Unit,$23.07 ,OP,23.07,171.58,,,,,,
UHC MCR ADV,CPT,92511,Nasopharyngoscopy,APC 5151,RVU Per Unit,$168.23 ,OP,168.23,842.61,,,,,,
UHC MCR ADV,CPT,92512,Nasal function studies,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,331.7,,,,,,
UHC MCR ADV,CPT,92516,Facial nerve function test,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
UHC MCR ADV,CPT,92517,Vemp test i&r cervical,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
UHC MCR ADV,CPT,92518,Vemp test i&r ocular,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
UHC MCR ADV,CPT,92519,Vemp tst i&r cervical&ocular,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
UHC MCR ADV,CPT,92520,Laryngeal function studies,APC 5734,RVU Per Case,$114.56 ,OP,114.56,339.33,,,,,,
UHC MCR ADV,CPT,92521,Evaluation of speech fluency,Physician,Per Unit,$132.47 ,OP,132.47,857.86,,,,,,
UHC MCR ADV,CPT,92522,Evaluate speech production,Physician,Per Unit,$111.22 ,OP,111.22,857.86,,,,,,
UHC MCR ADV,CPT,92523,Speech sound lang comprehen,Physician,Per Unit,$227.69 ,OP,227.69,857.86,,,,,,
UHC MCR ADV,CPT,92524,Behavral qualit analys voice,Physician,Per Unit,$108.89 ,OP,108.89,857.86,,,,,,
UHC MCR ADV,CPT,92526,Oral function therapy,Physician,Per Unit,$83.51 ,OP,83.51,453.71,,,,,,
UHC MCR ADV,CPT,92537,Caloric vstblr test w/rec,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,163.95,,,,,,
UHC MCR ADV,CPT,92538,Caloric vstblr test w/rec,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,163.95,,,,,,
UHC MCR ADV,CPT,92540,Basic vestibular evaluation,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
UHC MCR ADV,CPT,92541,Spontaneous nystagmus test,APC 5734,RVU Per Case,$114.56 ,OP,114.56,335.53,,,,,,
UHC MCR ADV,CPT,92542,Positional nystagmus test,APC 5734,RVU Per Case,$114.56 ,OP,114.56,346.96,,,,,,
UHC MCR ADV,CPT,92544,Optokinetic nystagmus test,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,282.14,,,,,,
UHC MCR ADV,CPT,92545,Oscillating tracking test,APC 5722,RVU Per Unit,$270.61 ,OP,263.08,270.61,,,,,,
UHC MCR ADV,CPT,92546,Sinusoidal rotational test,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,468.96,,,,,,
UHC MCR ADV,CPT,92548,Cdp-sot 6 cond w/i&r,APC 5734,RVU Per Case,$114.56 ,OP,114.56,556.65,,,,,,
UHC MCR ADV,CPT,92549,Cdp-sot 6 cond w/i&r mct&adt,APC 5734,RVU Per Case,$114.56 ,OP,114.56,556.65,,,,,,
UHC MCR ADV,CPT,92550,Tympanometry & reflex thresh,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
UHC MCR ADV,CPT,92552,Pure tone audiometry air,APC 5734,RVU Per Case,$114.56 ,OP,114.56,129.64,,,,,,
UHC MCR ADV,CPT,92553,Audiometry air & bone,APC 5721,RVU Per Case,$142.80 ,OP,142.8,175.39,,,,,,
UHC MCR ADV,CPT,92555,Speech threshold audiometry,APC 5732,RVU Per Case,$34.63 ,OP,34.63,99.13,,,,,,
UHC MCR ADV,CPT,92556,Speech audiometry complete,APC 5733,RVU Per Case,$56.95 ,OP,56.95,152.51,,,,,,
UHC MCR ADV,CPT,92557,Comprehensive hearing test,APC 5721,RVU Per Case,$142.80 ,OP,142.8,278.32,,,,,,
UHC MCR ADV,CPT,92561,Bekesy audiometry diagnosis,APC 5734,RVU Per Case,$114.56 ,OP,114.56,171.58,,,,,,
UHC MCR ADV,CPT,92562,Loudness balance test,APC 5721,RVU Per Case,$142.80 ,OP,137.25,142.8,,,,,,
UHC MCR ADV,CPT,92563,Tone decay hearing test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,125.82,,,,,,
UHC MCR ADV,CPT,92564,Sisi hearing test,APC 5731,RVU Per Case,$25.25 ,OP,25.25,122,,,,,,
UHC MCR ADV,CPT,92565,Stenger test pure tone,APC 5732,RVU Per Case,$34.63 ,OP,34.63,80.07,,,,,,
UHC MCR ADV,CPT,92567,Tympanometry,APC 5732,RVU Per Case,$34.63 ,OP,34.63,110.57,,,,,,
UHC MCR ADV,CPT,92568,Acoustic refl threshold tst,APC 5732,RVU Per Case,$34.63 ,OP,34.63,110.57,,,,,,
UHC MCR ADV,CPT,92570,Acoustic immitance testing,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
UHC MCR ADV,CPT,92571,Filtered speech hearing test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,102.95,,,,,,
UHC MCR ADV,CPT,92572,Staggered spondaic word test,APC 5721,RVU Per Case,$142.80 ,OP,99.13,142.8,,,,,,
UHC MCR ADV,CPT,92575,Sensorineural acuity test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,202.07,,,,,,
UHC MCR ADV,CPT,92576,Synthetic sentence test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,129.64,,,,,,
UHC MCR ADV,CPT,92577,Stenger test speech,APC 5723,RVU Per Case,$499.16 ,OP,114.39,499.16,,,,,,
UHC MCR ADV,CPT,92579,Visual audiometry (vra),APC 5721,RVU Per Case,$142.80 ,OP,142.8,259.27,,,,,,
UHC MCR ADV,CPT,92582,Conditioning play audiometry,APC 5721,RVU Per Case,$142.80 ,OP,142.8,247.83,,,,,,
UHC MCR ADV,CPT,92583,Select picture audiometry,APC 5733,RVU Per Case,$56.95 ,OP,56.95,205.88,,,,,,
UHC MCR ADV,CPT,92584,Electrocochleography,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,427.03,,,,,,
UHC MCR ADV,CPT,92587,Evoked auditory test limited,APC 5722,RVU Per Unit,$270.61 ,OP,244.01,270.61,,,,,,
UHC MCR ADV,CPT,92588,Evoked auditory tst complete,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,385.09,,,,,,
UHC MCR ADV,CPT,92596,Ear protector evaluation,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
UHC MCR ADV,CPT,92597,Oral speech device eval,Physician,Per Unit,$70.53 ,OP,70.53,583.35,,,,,,
UHC MCR ADV,CPT,92601,Cochlear implt f/up exam <7,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
UHC MCR ADV,CPT,92602,Reprogram cochlear implt <7,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
UHC MCR ADV,CPT,92603,Cochlear implt f/up exam 7/>,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
UHC MCR ADV,CPT,92604,Reprogram cochlear implt 7/>,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
UHC MCR ADV,CPT,92607,Ex for speech device rx 1hr,Physician,Per Unit,$122.72 ,OP,122.72,804.48,,,,,,
UHC MCR ADV,CPT,92608,Ex for speech device rx addl,Physician,Per Unit,$49.31 ,OP,49.31,163.95,,,,,,
UHC MCR ADV,CPT,92609,Use of speech device service,Physician,Per Unit,$102.45 ,OP,102.45,430.83,,,,,,
UHC MCR ADV,CPT,92610,Evaluate swallowing function,Physician,Per Unit,$69.06 ,OP,69.06,423.22,,,,,,
UHC MCR ADV,CPT,92611,Motion fluoroscopy/swallow,Physician,Per Unit,$90.57 ,OP,90.57,461.34,,,,,,
UHC MCR ADV,CPT,92612,Endoscopy swallow (fees) vid,Physician,Per Unit,$65.56 ,OP,65.56,796.85,,,,,,
UHC MCR ADV,CPT,92614,Laryngoscopic sensory vid,Physician,Per Unit,$64.93 ,OP,64.93,709.16,,,,,,
UHC MCR ADV,CPT,92616,Fees w/laryngeal sense test,Physician,Per Unit,$97.82 ,OP,97.82,972.25,,,,,,
UHC MCR ADV,CPT,92620,Auditory function 60 min,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
UHC MCR ADV,CPT,92625,Tinnitus assessment,APC 5721,RVU Per Case,$142.80 ,OP,142.8,293.57,,,,,,
UHC MCR ADV,CPT,92626,Eval aud funcj 1st hour,APC 5721,RVU Per Case,$142.80 ,OP,142.8,407.96,,,,,,
UHC MCR ADV,CPT,92640,Aud brainstem implt programg,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,385.09,,,,,,
UHC MCR ADV,CPT,92651,Aep hearing status deter i&r,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
UHC MCR ADV,CPT,92652,Aep thrshld est mlt freq i&r,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
UHC MCR ADV,CPT,92653,Aep neurodiagnostic i&r,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
UHC MCR ADV,CPT,92700,Ent procedure/service,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
UHC MCR ADV,CPT,92920,Prq cardiac angioplast 1 art,APC 5192,RVU Per Case,"$5,072.43 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,92924,Prq card angio/athrect 1 art,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
UHC MCR ADV,CPT,92928,Prq card stent w/angio 1 vsl,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
UHC MCR ADV,CPT,92933,Prq card stent/ath/angio,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
UHC MCR ADV,CPT,92937,Prq revasc byp graft 1 vsl,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
UHC MCR ADV,CPT,92941,Prq card revasc mi 1 vsl,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,92943,Prq card revasc chronic 1vsl,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
UHC MCR ADV,CPT,92950,Heart/lung resuscitation cpr,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,567.02",,,,,,
UHC MCR ADV,CPT,92953,Temporary external pacing,APC 5781,RVU Per Unit,$575.01 ,OP,575.01,575.01,,,,,,
UHC MCR ADV,CPT,92960,Cardioversion electric ext,APC 5781,RVU Per Unit,$575.01 ,OP,575.01,"1,460.26",,,,,,
UHC MCR ADV,CPT,92961,Cardioversion electric int,APC 5781,RVU Per Unit,$575.01 ,OP,575.01,"1,513.64",,,,,,
UHC MCR ADV,CPT,92970,Cardioassist internal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,040.87","8,948.83",,,,,,
UHC MCR ADV,CPT,92971,Cardioassist external,APC 5881,RVU Per Case,"$8,948.83 ",OP,590.97,"8,948.83",,,,,,
UHC MCR ADV,CPT,92975,Dissolve clot heart vessel,APC 5881,RVU Per Case,"$8,948.83 ",OP,"2,367.69","8,948.83",,,,,,
UHC MCR ADV,CPT,92977,Dissolve clot heart vessel,APC 5694,RVU Per Unit,$318.00 ,OP,318,850.23,,,,,,
UHC MCR ADV,CPT,92986,Revision of aortic valve,APC 5192,RVU Per Case,"$5,072.43 ",OP,"5,072.43","8,048.60",,,,,,
UHC MCR ADV,CPT,92987,Revision of mitral valve,APC 5193,RVU Per Case,"$10,277.14 ",OP,"8,338.36","10,277.14",,,,,,
UHC MCR ADV,CPT,92990,Revision of pulmonary valve,APC 5193,RVU Per Case,"$10,277.14 ",OP,"6,409.14","10,277.14",,,,,,
UHC MCR ADV,CPT,92997,Pul art balloon repr percut,APC 5193,RVU Per Case,"$10,277.14 ",OP,"4,140.35","10,277.14",,,,,,
UHC MCR ADV,CPT,93005,Electrocardiogram tracing,APC 5733,RVU Per Case,$56.95 ,OP,56.95,72.44,,,,,,
UHC MCR ADV,CPT,93017,Cardiovascular stress test,APC 5722,RVU Per Case,$270.61 ,OP,270.61,362.21,,,,,,
UHC MCR ADV,CPT,93024,Cardiac drug stress test,APC 5735,RVU Per Case,$276.53 ,OP,276.53,712.98,,,,,,
UHC MCR ADV,CPT,93025,Microvolt t-wave assess,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,"1,246.76",,,,,,
UHC MCR ADV,CPT,93041,Rhythm ecg tracing,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
UHC MCR ADV,CPT,93050,Art pressure waveform analys,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
UHC MCR ADV,CPT,93225,Ecg monit/reprt up to 48 hrs,APC 5734,RVU Per Case,$114.56 ,OP,114.56,224.95,,,,,,
UHC MCR ADV,CPT,93226,Ecg monit/reprt up to 48 hrs,APC 5734,RVU Per Case,$114.56 ,OP,114.56,926.48,,,,,,
UHC MCR ADV,CPT,93229,Remote 30 day ecg tech supp,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
UHC MCR ADV,CPT,93242,Ext ecg>48hr<7d recording,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
UHC MCR ADV,CPT,93243,Ext ecg>48hr<7d scan a/r,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
UHC MCR ADV,CPT,93246,Ext ecg>7d<15d recording,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
UHC MCR ADV,CPT,93247,Ext ecg>7d<15d scan a/r,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
UHC MCR ADV,CPT,93260,Prgrmg dev eval impltbl sys,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
UHC MCR ADV,CPT,93261,Interrogate subq defib,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
UHC MCR ADV,CPT,93270,Remote 30 day ecg rev/report,APC 5741,RVU Per Case,$38.02 ,OP,38.02,137.25,,,,,,
UHC MCR ADV,CPT,93271,Ecg/monitoring and analysis,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,"1,281.07",,,,,,
UHC MCR ADV,CPT,93278,Ecg/signal-averaged,APC 5733,RVU Per Case,$56.95 ,OP,56.95,251.64,,,,,,
UHC MCR ADV,CPT,93279,Prgrmg dev eval pm/ldls pm,APC 5741,RVU Per Case,$38.02 ,OP,38.02,327.9,,,,,,
UHC MCR ADV,CPT,93280,Pm device progr eval dual,APC 5741,RVU Per Case,$38.02 ,OP,38.02,381.27,,,,,,
UHC MCR ADV,CPT,93281,Pm device progr eval multi,APC 5741,RVU Per Case,$38.02 ,OP,38.02,446.08,,,,,,
UHC MCR ADV,CPT,93282,Prgrmg eval implantable dfb,APC 5741,RVU Per Case,$38.02 ,OP,38.02,415.59,,,,,,
UHC MCR ADV,CPT,93283,Prgrmg eval implantable dfb,APC 5741,RVU Per Case,$38.02 ,OP,38.02,503.28,,,,,,
UHC MCR ADV,CPT,93284,Prgrmg eval implantable dfb,APC 5741,RVU Per Case,$38.02 ,OP,38.02,587.16,,,,,,
UHC MCR ADV,CPT,93285,Prgrmg dev eval scrms ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,282.14,,,,,,
UHC MCR ADV,CPT,93288,Interrog evl pm/ldls pm ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,255.45,,,,,,
UHC MCR ADV,CPT,93289,Interrog device eval heart,APC 5741,RVU Per Case,$38.02 ,OP,38.02,385.09,,,,,,
UHC MCR ADV,CPT,93290,Interrog dev eval icpms ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,190.64,,,,,,
UHC MCR ADV,CPT,93291,Interrog dev eval scrms ip,APC 5731,RVU Per Case,$25.25 ,OP,25.25,244.01,,,,,,
UHC MCR ADV,CPT,93292,Wcd device interrogate,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
UHC MCR ADV,CPT,93293,Pm phone r-strip device eval,APC 5741,RVU Per Case,$38.02 ,OP,38.02,366.02,,,,,,
UHC MCR ADV,CPT,93296,Rem interrog evl pm/ids,APC 5741,RVU Per Case,$38.02 ,OP,38.02,213.51,,,,,,
UHC MCR ADV,CPT,93303,Echo transthoracic,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,292.50",,,,,,
UHC MCR ADV,CPT,93304,Echo transthoracic,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,796.85,,,,,,
UHC MCR ADV,CPT,93306,Tte w/doppler complete,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,593.72",,,,,,
UHC MCR ADV,CPT,93307,Tte w/o doppler complete,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,056.11",,,,,,
UHC MCR ADV,CPT,93308,Tte f-up or lmtd,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,667.22,,,,,,
UHC MCR ADV,CPT,93312,Echo transesophageal,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,921.59",,,,,,
UHC MCR ADV,CPT,93313,Echo transesophageal,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,494.15,,,,,,
UHC MCR ADV,CPT,93315,Echo transesophageal,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,738.59",,,,,,
UHC MCR ADV,CPT,93316,Echo transesophageal,APC 5524,RVU Per Unit,$494.15 ,OP,259.27,494.15,,,,,,
UHC MCR ADV,CPT,93318,Echo transesophageal intraop,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,330.63",,,,,,
UHC MCR ADV,CPT,93350,Stress tte only,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,239.13",,,,,,
UHC MCR ADV,CPT,93351,Stress tte complete,APC 5524,RVU Per Unit,$494.15 ,OP,494.15,"1,635.64",,,,,,
UHC MCR ADV,CPT,93451,Right heart cath,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
UHC MCR ADV,CPT,93452,Left hrt cath w/ventrclgrphy,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
UHC MCR ADV,CPT,93453,R&l hrt cath w/ventriclgrphy,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
UHC MCR ADV,CPT,93454,Coronary artery angio s&i,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","2,966.62",,,,,,
UHC MCR ADV,CPT,93455,Coronary art/grft angio s&i,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","2,966.62",,,,,,
UHC MCR ADV,CPT,93456,R hrt coronary artery angio,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
UHC MCR ADV,CPT,93457,R hrt art/grft angio,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
UHC MCR ADV,CPT,93458,L hrt artery/ventricle angio,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
UHC MCR ADV,CPT,93459,L hrt art/grft angio,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
UHC MCR ADV,CPT,93460,R&l hrt art/ventricle angio,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
UHC MCR ADV,CPT,93461,R&l hrt art/ventricle angio,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
UHC MCR ADV,CPT,93503,Insert/place heart catheter,APC 5182,RVU Per Case,"$1,438.93 ",OP,651.97,"1,438.93",,,,,,
UHC MCR ADV,CPT,93505,Biopsy of heart lining,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","4,346.47",,,,,,
UHC MCR ADV,CPT,93530,Rt heart cath congenital,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","9,201.00",,,,,,
UHC MCR ADV,CPT,93531,R & l heart cath congenital,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","16,124.56",,,,,,
UHC MCR ADV,CPT,93532,R & l heart cath congenital,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","16,600.26",,,,,,
UHC MCR ADV,CPT,93533,R & l heart cath congenital,APC 5191,RVU Per Case,"$2,966.62 ",OP,"2,966.62","16,111.09",,,,,,
UHC MCR ADV,CPT,93580,Transcath closure of asd,APC 5194,RVU Per Case,"$16,438.60 ",OP,"5,905.86","16,438.60",,,,,,
UHC MCR ADV,CPT,93581,Transcath closure of vsd,APC 5194,RVU Per Case,"$16,438.60 ",OP,"7,739.77","16,438.60",,,,,,
UHC MCR ADV,CPT,93582,Perq transcath closure pda,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
UHC MCR ADV,CPT,93583,Perq transcath septal reduxn,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,93590,Perq transcath cls mitral,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
UHC MCR ADV,CPT,93591,Perq transcath cls aortic,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
UHC MCR ADV,CPT,93600,Bundle of his recording,APC 5212,RVU Per Case,"$6,220.22 ",OP,"6,220.22","6,220.22",,,,,,
UHC MCR ADV,CPT,93602,Intra-atrial recording,APC 5212,RVU Per Case,"$6,220.22 ",OP,968.43,"6,220.22",,,,,,
UHC MCR ADV,CPT,93603,Right ventricular recording,APC 5211,RVU Per Case,"$1,138.72 ",OP,"1,117.12","1,138.72",,,,,,
UHC MCR ADV,CPT,93610,Intra-atrial pacing,APC 5212,RVU Per Case,"$6,220.22 ",OP,"1,323.01","6,220.22",,,,,,
UHC MCR ADV,CPT,93612,Intraventricular pacing,APC 5212,RVU Per Case,"$6,220.22 ",OP,"1,376.38","6,220.22",,,,,,
UHC MCR ADV,CPT,93615,Esophageal recording,APC 5211,RVU Per Case,"$1,138.72 ",OP,392.7,"1,138.72",,,,,,
UHC MCR ADV,CPT,93616,Esophageal recording,APC 5211,RVU Per Case,"$1,138.72 ",OP,"1,138.72","1,138.72",,,,,,
UHC MCR ADV,CPT,93618,Heart rhythm pacing,APC 5211,RVU Per Case,"$1,138.72 ",OP,"1,138.72","2,367.69",,,,,,
UHC MCR ADV,CPT,93619,Electrophysiology evaluation,APC 5212,RVU Per Case,"$6,220.22 ",OP,"4,312.16","6,220.22",,,,,,
UHC MCR ADV,CPT,93620,Electrophysiology evaluation,APC 5212,RVU Per Case,"$6,220.22 ",OP,"5,112.83","6,220.22",,,,,,
UHC MCR ADV,CPT,93624,Electrophysiologic study,APC 5212,RVU Per Case,"$6,220.22 ",OP,"2,051.24","6,220.22",,,,,,
UHC MCR ADV,CPT,93642,Electrophysiology evaluation,APC 5211,RVU Per Case,"$1,138.72 ",OP,"1,138.72","2,775.65",,,,,,
UHC MCR ADV,CPT,93650,Ablate heart dysrhythm focus,APC 5212,RVU Per Case,"$6,220.22 ",OP,"3,488.62","6,220.22",,,,,,
UHC MCR ADV,CPT,93653,Ep & ablate supravent arrhyt,APC 5213,RVU Per Case,"$21,964.94 ",OP,"10,420.09","21,964.94",,,,,,
UHC MCR ADV,CPT,93654,Ep & ablate ventric tachy,APC 5213,RVU Per Case,"$21,964.94 ",OP,"10,889.05","21,964.94",,,,,,
UHC MCR ADV,CPT,93656,Tx atrial fib pulm vein isol,APC 5213,RVU Per Case,"$21,964.94 ",OP,"10,420.09","21,964.94",,,,,,
UHC MCR ADV,CPT,93660,Tilt table evaluation,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,983.68,,,,,,
UHC MCR ADV,CPT,93668,Peripheral vascular rehab,APC 5733,RVU Per Unit,$56.95 ,OP,56.95,99.13,,,,,,
UHC MCR ADV,CPT,93701,Bioimpedance cv analysis,APC 5734,RVU Per Case,$114.56 ,OP,114.56,198.25,,,,,,
UHC MCR ADV,CPT,93702,Bis xtracell fluid analysis,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
UHC MCR ADV,CPT,93724,Analyze pacemaker system,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,"1,948.29",,,,,,
UHC MCR ADV,CPT,93740,Temperature gradient studies,APC 5721,RVU Per Case,$142.80 ,OP,57.19,142.8,,,,,,
UHC MCR ADV,CPT,93745,Set-up cardiovert-defibrill,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,278.82,,,,,,
UHC MCR ADV,CPT,93750,Interrogation vad in person,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,102.65,,,,,,
UHC MCR ADV,CPT,93786,Ambl bp mntr w/sw rec only,APC 5734,RVU Per Case,$114.56 ,OP,114.56,171.58,,,,,,
UHC MCR ADV,CPT,93788,Ambl bp mntr w/sw a/r,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
UHC MCR ADV,CPT,93797,Cardiac rehab,APC 5771,RVU Per Unit,$118.77 ,OP,102.95,118.77,,,,,,
UHC MCR ADV,CPT,93798,Cardiac rehab/monitor,APC 5771,RVU Per Unit,$118.77 ,OP,118.77,148.69,,,,,,
UHC MCR ADV,CPT,93799,Cardiovascular procedure,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
UHC MCR ADV,CPT,93880,Extracranial bilat study,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,239.13",,,,,,
UHC MCR ADV,CPT,93882,Extracranial uni/ltd study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,815.92,,,,,,
UHC MCR ADV,CPT,93886,Intracranial complete study,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,483.14",,,,,,
UHC MCR ADV,CPT,93888,Intracranial limited study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,"1,010.37",,,,,,
UHC MCR ADV,CPT,93890,Tcd vasoreactivity study,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,307.75",,,,,,
UHC MCR ADV,CPT,93892,Tcd emboli detect w/o inj,APC 5522,RVU Per Case,$111.51 ,OP,111.51,"1,425.95",,,,,,
UHC MCR ADV,CPT,93893,Tcd emboli detect w/inj,APC 5522,RVU Per Case,$111.51 ,OP,111.51,"1,422.14",,,,,,
UHC MCR ADV,CPT,93922,Upr/l xtremity art 2 levels,APC 5734,RVU Per Case,$114.56 ,OP,114.56,594.77,,,,,,
UHC MCR ADV,CPT,93923,Upr/lxtr art stdy 3+ lvls,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,922.67,,,,,,
UHC MCR ADV,CPT,93924,Lwr xtr vasc stdy bilat,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,136.19",,,,,,
UHC MCR ADV,CPT,93925,Lower extremity study,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,525.07",,,,,,
UHC MCR ADV,CPT,93926,Lower extremity study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,976.05,,,,,,
UHC MCR ADV,CPT,93930,Upper extremity study,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,223.88",,,,,,
UHC MCR ADV,CPT,93931,Upper extremity study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,815.92,,,,,,
UHC MCR ADV,CPT,93970,Extremity study,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,273.44",,,,,,
UHC MCR ADV,CPT,93971,Extremity study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,842.61,,,,,,
UHC MCR ADV,CPT,93975,Vascular study,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,367.82,,,,,,
UHC MCR ADV,CPT,93976,Vascular study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,"1,082.81",,,,,,
UHC MCR ADV,CPT,93978,Vascular study,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,197.20",,,,,,
UHC MCR ADV,CPT,93979,Vascular study,APC 5522,RVU Per Case,$111.51 ,OP,111.51,823.54,,,,,,
UHC MCR ADV,CPT,93980,Penile vascular study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,934.12,,,,,,
UHC MCR ADV,CPT,93981,Penile vascular study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,667.22,,,,,,
UHC MCR ADV,CPT,93985,Dup-scan hemo compl bi std,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,136.19",,,,,,
UHC MCR ADV,CPT,93986,Dup-scan hemo compl uni std,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,646.72,,,,,,
UHC MCR ADV,CPT,93990,Doppler flow testing,APC 5522,RVU Per Case,$111.51 ,OP,111.51,956.99,,,,,,
UHC MCR ADV,CPT,93998,Noninvas vasc dx study proc,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
UHC MCR ADV,CPT,94002,Vent mgmt inpat init day,APC 5801,RVU Per Unit,$496.58 ,OP,496.58,541.4,,,,,,
UHC MCR ADV,CPT,94003,Vent mgmt inpat subq day,APC 5801,RVU Per Unit,$496.58 ,OP,496.58,496.58,,,,,,
UHC MCR ADV,CPT,94010,Breathing capacity test,APC 5721,RVU Per Case,$142.80 ,OP,142.8,209.7,,,,,,
UHC MCR ADV,CPT,94011,Spirometry up to 2 yrs old,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
UHC MCR ADV,CPT,94012,Spirmtry w/brnchdil inf-2 yr,APC 5722,RVU Per Case,$270.61 ,OP,270.61,270.61,,,,,,
UHC MCR ADV,CPT,94013,Meas lung vol thru 2 yrs,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
UHC MCR ADV,CPT,94014,Patient recorded spirometry,APC 5735,RVU Per Case,$276.53 ,OP,276.53,301.2,,,,,,
UHC MCR ADV,CPT,94015,Patient recorded spirometry,APC 5722,RVU Per Case,$270.61 ,OP,148.69,270.61,,,,,,
UHC MCR ADV,CPT,94016,Review patient spirometry,Physician,Per Unit,$24.70 ,OP,24.7,152.51,,,,,,
UHC MCR ADV,CPT,94060,Evaluation of wheezing,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,369.83,,,,,,
UHC MCR ADV,CPT,94070,Evaluation of wheezing,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,392.7,,,,,,
UHC MCR ADV,CPT,94150,Vital capacity test,APC 5721,RVU Per Case,$142.80 ,OP,141.07,142.8,,,,,,
UHC MCR ADV,CPT,94200,Lung function test (mbc/mvv),APC 5733,RVU Per Case,$56.95 ,OP,56.95,144.88,,,,,,
UHC MCR ADV,CPT,94375,Respiratory flow volume loop,APC 5722,RVU Per Case,$270.61 ,OP,232.58,270.61,,,,,,
UHC MCR ADV,CPT,94450,Hypoxia response curve,APC 5722,RVU Per Case,$270.61 ,OP,270.61,316.46,,,,,,
UHC MCR ADV,CPT,94452,Hast w/report,APC 5734,RVU Per Case,$114.56 ,OP,114.56,346.96,,,,,,
UHC MCR ADV,CPT,94453,Hast w/oxygen titrate,APC 5734,RVU Per Case,$114.56 ,OP,114.56,461.34,,,,,,
UHC MCR ADV,CPT,94610,Surfactant admin thru tube,APC 5791,RVU Per Case,$192.26 ,OP,192.26,438.47,,,,,,
UHC MCR ADV,CPT,94617,Exercise tst brncspsm w/ecg,APC 5734,RVU Per Case,$114.56 ,OP,114.56,465.15,,,,,,
UHC MCR ADV,CPT,94618,Pulmonary stress testing,APC 5734,RVU Per Case,$114.56 ,OP,114.56,465.15,,,,,,
UHC MCR ADV,CPT,94619,Exercise tst brncspsm wo ecg,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
UHC MCR ADV,CPT,94621,Cardiopulm exercise testing,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,017.99",,,,,,
UHC MCR ADV,CPT,94640,Airway inhalation treatment,APC 5791,RVU Per Case,$192.26 ,OP,87.69,192.26,,,,,,
UHC MCR ADV,CPT,94642,Aerosol inhalation treatment,APC 5791,RVU Per Case,$192.26 ,OP,192.26,255.45,,,,,,
UHC MCR ADV,CPT,94644,Cbt 1st hour,APC 5734,RVU Per Case,$114.56 ,OP,114.56,217.32,,,,,,
UHC MCR ADV,CPT,94660,Pos airway pressure cpap,APC 5791,RVU Per Case,$192.26 ,OP,192.26,346.96,,,,,,
UHC MCR ADV,CPT,94662,Neg press ventilation cnp,APC 5801,RVU Per Unit,$496.58 ,OP,221.14,496.58,,,,,,
UHC MCR ADV,CPT,94664,Evaluate pt use of inhaler,APC 5791,RVU Per Case,$192.26 ,OP,99.13,192.26,,,,,,
UHC MCR ADV,CPT,94667,Chest wall manipulation,APC 5734,RVU Per Case,$114.56 ,OP,114.56,137.25,,,,,,
UHC MCR ADV,CPT,94668,Chest wall manipulation,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
UHC MCR ADV,CPT,94669,Mechanical chest wall oscill,APC 5791,RVU Per Case,$192.26 ,OP,192.26,192.26,,,,,,
UHC MCR ADV,CPT,94680,Exhaled air analysis o2,APC 5721,RVU Per Case,$142.80 ,OP,142.8,369.83,,,,,,
UHC MCR ADV,CPT,94681,Exhaled air analysis o2/co2,APC 5722,RVU Per Case,$270.61 ,OP,270.61,270.61,,,,,,
UHC MCR ADV,CPT,94690,Exhaled air analysis,APC 5733,RVU Per Case,$56.95 ,OP,56.95,320.27,,,,,,
UHC MCR ADV,CPT,94726,Pulm funct tst plethysmograp,APC 5722,RVU Per Case,$270.61 ,OP,270.61,282.14,,,,,,
UHC MCR ADV,CPT,94727,Pulm function test by gas,APC 5721,RVU Per Case,$142.80 ,OP,142.8,221.14,,,,,,
UHC MCR ADV,CPT,94728,Airwy resist by oscillometry,APC 5722,RVU Per Case,$270.61 ,OP,270.61,282.14,,,,,,
UHC MCR ADV,CPT,94762,Measure blood oxygen level,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,202.07,,,,,,
UHC MCR ADV,CPT,94772,Breath recording infant,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
UHC MCR ADV,CPT,94775,Ped home apnea rec hk-up,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
UHC MCR ADV,CPT,94776,Ped home apnea rec downld,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
UHC MCR ADV,CPT,94780,Cars/bd tst inft-12mo 60 min,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
UHC MCR ADV,CPT,94799,Pulmonary service/procedure,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
UHC MCR ADV,CPT,95004,Percut allergy skin tests,APC 5724,RVU Per Case,$941.27 ,OP,30.51,941.27,,,,,,
UHC MCR ADV,CPT,95012,Exhaled nitric oxide meas,APC 5732,RVU Per Case,$34.63 ,OP,34.63,102.95,,,,,,
UHC MCR ADV,CPT,95017,Perq & icut allg test venoms,APC 5731,RVU Per Case,$25.25 ,OP,25.25,87.69,,,,,,
UHC MCR ADV,CPT,95018,Perq&ic allg test drugs/biol,APC 5732,RVU Per Case,$34.63 ,OP,34.63,87.69,,,,,,
UHC MCR ADV,CPT,95024,Icut allergy test drug/bug,APC 5733,RVU Per Case,$56.95 ,OP,38.13,56.95,,,,,,
UHC MCR ADV,CPT,95027,Icut allergy titrate-airborn,APC 5731,RVU Per Case,$25.25 ,OP,25.25,26.7,,,,,,
UHC MCR ADV,CPT,95028,Icut allergy test-delayed,APC 5732,RVU Per Case,$34.63 ,OP,34.63,57.19,,,,,,
UHC MCR ADV,CPT,95044,Allergy patch tests,APC 5724,RVU Per Case,$941.27 ,OP,34.31,941.27,,,,,,
UHC MCR ADV,CPT,95052,Photo patch test,APC 5733,RVU Per Case,$56.95 ,OP,38.13,56.95,,,,,,
UHC MCR ADV,CPT,95056,Photosensitivity tests,APC 5734,RVU Per Case,$114.56 ,OP,114.56,179.2,,,,,,
UHC MCR ADV,CPT,95060,Eye allergy tests,APC 5734,RVU Per Case,$114.56 ,OP,114.56,122,,,,,,
UHC MCR ADV,CPT,95065,Nose allergy test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,110.57,,,,,,
UHC MCR ADV,CPT,95070,Bronchial allergy tests,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
UHC MCR ADV,CPT,95076,Ingest challenge ini 120 min,APC 5723,RVU Per Unit,$499.16 ,OP,320.27,499.16,,,,,,
UHC MCR ADV,CPT,95115,Immunotherapy one injection,APC 5691,RVU Per Case,$40.93 ,OP,40.93,57.19,,,,,,
UHC MCR ADV,CPT,95117,Immunotherapy injections,APC 5691,RVU Per Case,$40.93 ,OP,40.93,68.63,,,,,,
UHC MCR ADV,CPT,95144,Antigen therapy services,APC 5691,RVU Per Case,$40.93 ,OP,40.93,61,,,,,,
UHC MCR ADV,CPT,95145,Antigen therapy services,APC 5691,RVU Per Case,$40.93 ,OP,40.93,80.07,,,,,,
UHC MCR ADV,CPT,95146,Antigen therapy services,APC 5691,RVU Per Case,$40.93 ,OP,40.93,129.64,,,,,,
UHC MCR ADV,CPT,95147,Antigen therapy services,APC 5692,RVU Per Case,$63.42 ,OP,63.42,125.82,,,,,,
UHC MCR ADV,CPT,95148,Antigen therapy services,APC 5692,RVU Per Case,$63.42 ,OP,63.42,179.2,,,,,,
UHC MCR ADV,CPT,95149,Antigen therapy services,APC 5692,RVU Per Case,$63.42 ,OP,63.42,232.58,,,,,,
UHC MCR ADV,CPT,95165,Antigen therapy services,APC 5691,RVU Per Case,$40.93 ,OP,40.93,61,,,,,,
UHC MCR ADV,CPT,95170,Antigen therapy services,APC 5691,RVU Per Case,$40.93 ,OP,40.93,49.56,,,,,,
UHC MCR ADV,CPT,95180,Rapid desensitization,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
UHC MCR ADV,CPT,95199,Allergy immunology services,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
UHC MCR ADV,CPT,95249,Cont gluc mntr pt prov eqp,APC 5733,RVU Per Unit,$56.95 ,OP,56.95,686.28,,,,,,
UHC MCR ADV,CPT,95250,Cont gluc mntr phys/qhp eqp,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,686.28,,,,,,
UHC MCR ADV,CPT,95700,Eeg cont rec w/vid eeg tech,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
UHC MCR ADV,CPT,95705,Eeg w/o vid 2-12 hr unmntr,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
UHC MCR ADV,CPT,95706,Eeg wo vid 2-12hr intmt mntr,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
UHC MCR ADV,CPT,95707,Eeg w/o vid 2-12hr cont mntr,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
UHC MCR ADV,CPT,95708,Eeg wo vid ea 12-26hr unmntr,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
UHC MCR ADV,CPT,95709,Eeg w/o vid ea 12-26hr intmt,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
UHC MCR ADV,CPT,95710,Eeg w/o vid ea 12-26hr cont,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
UHC MCR ADV,CPT,95711,Veeg 2-12 hr unmonitored,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
UHC MCR ADV,CPT,95712,Veeg 2-12 hr intmt mntr,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
UHC MCR ADV,CPT,95713,Veeg 2-12 hr cont mntr,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
UHC MCR ADV,CPT,95714,Veeg ea 12-26 hr unmntr,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
UHC MCR ADV,CPT,95715,Veeg ea 12-26hr intmt mntr,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
UHC MCR ADV,CPT,95716,Veeg ea 12-26hr cont mntr,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,941.27,,,,,,
UHC MCR ADV,CPT,95782,Polysom <6 yrs 4/> paramtrs,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"4,472.29",,,,,,
UHC MCR ADV,CPT,95783,Polysom <6 yrs cpap/bilvl,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"4,472.29",,,,,,
UHC MCR ADV,CPT,95800,Slp stdy unattended,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
UHC MCR ADV,CPT,95801,Slp stdy unatnd w/anal,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
UHC MCR ADV,CPT,95803,Actigraphy testing,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
UHC MCR ADV,CPT,95805,Multiple sleep latency test,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,"2,249.49",,,,,,
UHC MCR ADV,CPT,95806,Sleep study unatt&resp efft,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,413.8,,,,,,
UHC MCR ADV,CPT,95807,Sleep study attended,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,"2,638.38",,,,,,
UHC MCR ADV,CPT,95808,Polysom any age 1-3> param,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,941.27,,,,,,
UHC MCR ADV,CPT,95810,Polysom 6/> yrs 4/> param,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"1,103.46",,,,,,
UHC MCR ADV,CPT,95811,Polysom 6/>yrs cpap 4/> parm,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"1,103.46",,,,,,
UHC MCR ADV,CPT,95812,Eeg 41-60 minutes,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,242.94",,,,,,
UHC MCR ADV,CPT,95813,Eeg extnd mntr 61-119 min,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,521.26",,,,,,
UHC MCR ADV,CPT,95816,Eeg awake and drowsy,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,139.99",,,,,,
UHC MCR ADV,CPT,95819,Eeg awake and asleep,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,223.88",,,,,,
UHC MCR ADV,CPT,95822,Eeg coma or sleep only,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,"1,223.88",,,,,,
UHC MCR ADV,CPT,95824,Eeg cerebral death only,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,503.28,,,,,,
UHC MCR ADV,CPT,95836,Ecog impltd brn npgt <30 d,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
UHC MCR ADV,CPT,95851,Range of motion measurements,Physician,Per Unit,$7.59 ,OP,7.59,83.87,,,,,,
UHC MCR ADV,CPT,95852,Range of motion measurements,Physician,Per Unit,$5.52 ,OP,5.52,64.82,,,,,,
UHC MCR ADV,CPT,95857,Cholinesterase challenge,APC 5722,RVU Per Unit,$270.61 ,OP,209.7,270.61,,,,,,
UHC MCR ADV,CPT,95860,Muscle test one limb,APC 5734,RVU Per Case,$114.56 ,OP,114.56,423.22,,,,,,
UHC MCR ADV,CPT,95861,Muscle test 2 limbs,APC 5734,RVU Per Case,$114.56 ,OP,114.56,613.85,,,,,,
UHC MCR ADV,CPT,95863,Muscle test 3 limbs,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,732.04,,,,,,
UHC MCR ADV,CPT,95864,Muscle test 4 limbs,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,850.23,,,,,,
UHC MCR ADV,CPT,95865,Muscle test larynx,APC 5734,RVU Per Case,$114.56 ,OP,114.56,439,,,,,,
UHC MCR ADV,CPT,95866,Muscle test hemidiaphragm,APC 5721,RVU Per Case,$142.80 ,OP,142.8,480.4,,,,,,
UHC MCR ADV,CPT,95867,Muscle test cran nerv unilat,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,369.83,,,,,,
UHC MCR ADV,CPT,95868,Muscle test cran nerve bilat,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,503.28,,,,,,
UHC MCR ADV,CPT,95869,Muscle test thor paraspinal,APC 5721,RVU Per Case,$142.80 ,OP,142.8,236.38,,,,,,
UHC MCR ADV,CPT,95870,Muscle test nonparaspinal,APC 5734,RVU Per Case,$114.56 ,OP,114.56,228.77,,,,,,
UHC MCR ADV,CPT,95872,Muscle test one fiber,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,635.69,,,,,,
UHC MCR ADV,CPT,95875,Limb exercise test,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,364.88,,,,,,
UHC MCR ADV,CPT,95905,Motor &/ sens nrve cndj test,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
UHC MCR ADV,CPT,95907,Nvr cndj tst 1-2 studies,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
UHC MCR ADV,CPT,95908,Nrv cndj tst 3-4 studies,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
UHC MCR ADV,CPT,95909,Nrv cndj tst 5-6 studies,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
UHC MCR ADV,CPT,95910,Nrv cndj test 7-8 studies,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
UHC MCR ADV,CPT,95911,Nrv cndj test 9-10 studies,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
UHC MCR ADV,CPT,95912,Nrv cndj test 11-12 studies,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
UHC MCR ADV,CPT,95913,Nrv cndj test 13/> studies,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
UHC MCR ADV,CPT,95921,Autonomic nrv parasym inervj,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,282.21,,,,,,
UHC MCR ADV,CPT,95922,Autonomic nrv adrenrg inervj,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
UHC MCR ADV,CPT,95923,Autonomic nrv syst funj test,APC 5734,RVU Per Case,$114.56 ,OP,114.56,447.55,,,,,,
UHC MCR ADV,CPT,95924,Ans parasymp & symp w/tilt,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
UHC MCR ADV,CPT,95925,Somatosensory testing,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,461.8,,,,,,
UHC MCR ADV,CPT,95926,Somatosensory testing,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,602.41,,,,,,
UHC MCR ADV,CPT,95927,Somatosensory testing,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,621.47,,,,,,
UHC MCR ADV,CPT,95928,C motor evoked uppr limbs,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,964.61,,,,,,
UHC MCR ADV,CPT,95929,C motor evoked lwr limbs,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,"1,017.99",,,,,,
UHC MCR ADV,CPT,95930,Visual ep test cns w/i&r,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,537.6,,,,,,
UHC MCR ADV,CPT,95933,Blink reflex test,APC 5733,RVU Per Case,$56.95 ,OP,56.95,339.33,,,,,,
UHC MCR ADV,CPT,95937,Neuromuscular junction test,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,305.01,,,,,,
UHC MCR ADV,CPT,95938,Somatosensory testing,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
UHC MCR ADV,CPT,95939,C motor evoked upr&lwr limbs,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,941.27,,,,,,
UHC MCR ADV,CPT,95943,Parasymp&symp hrt rate test,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
UHC MCR ADV,CPT,95954,Eeg monitoring/giving drugs,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,"1,277.26",,,,,,
UHC MCR ADV,CPT,95958,Eeg monitoring/function test,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"1,982.60",,,,,,
UHC MCR ADV,CPT,95961,Electrode stimulation brain,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"1,265.81",,,,,,
UHC MCR ADV,CPT,95965,Meg spontaneous,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"10,992.00",,,,,,
UHC MCR ADV,CPT,95966,Meg evoked single,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,"5,455.97",,,,,,
UHC MCR ADV,CPT,95970,Alys npgt w/o prgrmg,APC 5734,RVU Per Case,$114.56 ,OP,114.56,255.45,,,,,,
UHC MCR ADV,CPT,95971,Alys smpl sp/pn npgt w/prgrm,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,297.39,,,,,,
UHC MCR ADV,CPT,95972,Alys cplx sp/pn npgt w/prgrm,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,533.78,,,,,,
UHC MCR ADV,CPT,95976,Alys smpl cn npgt prgrmg,APC 5741,RVU Per Unit,$38.02 ,OP,38.02,657.7,,,,,,
UHC MCR ADV,CPT,95977,Alys cplx cn npgt prgrmg,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,876.92,,,,,,
UHC MCR ADV,CPT,95981,Io anal gast n-stim subsq,APC 5734,RVU Per Case,$114.56 ,OP,114.56,144.88,,,,,,
UHC MCR ADV,CPT,95982,Io ga n-stim subsq w/reprog,APC 5741,RVU Per Case,$38.02 ,OP,38.02,224.95,,,,,,
UHC MCR ADV,CPT,95983,Alys brn npgt prgrmg 15 min,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,260.22,,,,,,
UHC MCR ADV,CPT,95990,Spin/brain pump refil & main,APC 5694,RVU Per Unit,$318.00 ,OP,312.64,318,,,,,,
UHC MCR ADV,CPT,95991,Spin/brain pump refil & main,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,453.71,,,,,,
UHC MCR ADV,CPT,95992,Canalith repositioning proc,Physician,Per Unit,$36.73 ,OP,36.73,36.73,,,,,,
UHC MCR ADV,CPT,95999,Neurological procedure,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
UHC MCR ADV,CPT,96000,Motion analysis video/3d,APC 5723,RVU Per Unit,$499.16 ,OP,449.9,499.16,,,,,,
UHC MCR ADV,CPT,96001,Motion test w/ft press meas,APC 5724,RVU Per Unit,$941.27 ,OP,526.16,941.27,,,,,,
UHC MCR ADV,CPT,96002,Dynamic surface emg,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
UHC MCR ADV,CPT,96003,Dynamic fine wire emg,APC 5722,RVU Per Case,$270.61 ,OP,91.51,270.61,,,,,,
UHC MCR ADV,CPT,96105,Assessment of aphasia,Physician,Per Unit,$98.92 ,OP,98.92,419.4,,,,,,
UHC MCR ADV,CPT,96112,Devel tst phys/qhp 1st hr,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,693.9,,,,,,
UHC MCR ADV,CPT,96116,Nubhvl xm phys/qhp 1st hr,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,518.52,,,,,,
UHC MCR ADV,CPT,96125,Cognitive test by hc pro,Physician,Per Unit,$103.76 ,OP,103.76,510.9,,,,,,
UHC MCR ADV,CPT,96127,Brief emotional/behav assmt,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
UHC MCR ADV,CPT,96130,Psycl tst eval phys/qhp 1st,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,438.47,,,,,,
UHC MCR ADV,CPT,96132,Nrpsyc tst eval phys/qhp 1st,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,583.35,,,,,,
UHC MCR ADV,CPT,96136,Psycl/nrpsyc tst phy/qhp 1st,APC 5734,RVU Per Unit,$114.56 ,OP,114.56,219.24,,,,,,
UHC MCR ADV,CPT,96138,Psycl/nrpsyc tech 1st,APC 5735,RVU Per Unit,$276.53 ,OP,133.45,276.53,,,,,,
UHC MCR ADV,CPT,96146,Psycl/nrpsyc tst auto result,APC 5731,RVU Per Unit,$25.25 ,OP,18.8,25.25,,,,,,
UHC MCR ADV,CPT,96156,Hlth bhv assmt/reassessment,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,526.34,,,,,,
UHC MCR ADV,CPT,96158,Hlth bhv ivntj indiv 1st 30,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,236.39,,,,,,
UHC MCR ADV,CPT,96160,Pt-focused hlth risk assmt,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
UHC MCR ADV,CPT,96161,Caregiver health risk assmt,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
UHC MCR ADV,CPT,96164,Hlth bhv ivntj grp 1st 30,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,61.03,,,,,,
UHC MCR ADV,CPT,96167,Hlth bhv ivntj fam 1st 30,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,236.39,,,,,,
UHC MCR ADV,CPT,96360,Hydration iv infusion init,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,293.57,,,,,,
UHC MCR ADV,CPT,96361,Hydrate iv infusion add-on,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,122.99,,,,,,
UHC MCR ADV,CPT,96365,Ther/proph/diag iv inf init,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,354.58,,,,,,
UHC MCR ADV,CPT,96366,Ther/proph/diag iv inf addon,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,114.39,,,,,,
UHC MCR ADV,CPT,96367,Tx/proph/dg addl seq iv inf,APC 5692,RVU Per Unit,$63.42 ,OP,63.42,179.2,,,,,,
UHC MCR ADV,CPT,96369,Sc ther infusion up to 1 hr,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,758.72,,,,,,
UHC MCR ADV,CPT,96370,Sc ther infusion addl hr,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,83.87,,,,,,
UHC MCR ADV,CPT,96371,Sc ther infusion reset pump,APC 5692,RVU Per Case,$63.42 ,OP,63.42,366.02,,,,,,
UHC MCR ADV,CPT,96372,Ther/proph/diag inj sc/im,APC 5692,RVU Per Case,$63.42 ,OP,63.42,106.76,,,,,,
UHC MCR ADV,CPT,96373,Ther/proph/diag inj ia,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,208.24,,,,,,
UHC MCR ADV,CPT,96374,Ther/proph/diag inj iv push,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,278.32,,,,,,
UHC MCR ADV,CPT,96375,Tx/pro/dx inj new drug addon,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,202.94,,,,,,
UHC MCR ADV,CPT,96377,Applicaton on-body injector,APC 5691,RVU Per Case,$40.93 ,OP,40.93,40.93,,,,,,
UHC MCR ADV,CPT,96379,Ther/prop/diag inj/inf proc,APC 5691,RVU Per Case,$40.93 ,OP,40.93,40.93,,,,,,
UHC MCR ADV,CPT,96401,Chemo anti-neopl sq/im,APC 5692,RVU Per Case,$63.42 ,OP,63.42,377.46,,,,,,
UHC MCR ADV,CPT,96402,Chemo hormon antineopl sq/im,APC 5692,RVU Per Case,$63.42 ,OP,63.42,205.88,,,,,,
UHC MCR ADV,CPT,96405,Chemo intralesional up to 7,APC 5692,RVU Per Case,$63.42 ,OP,63.42,468.96,,,,,,
UHC MCR ADV,CPT,96406,Chemo intralesional over 7,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,648.16,,,,,,
UHC MCR ADV,CPT,96409,Chemo iv push sngl drug,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,629.1,,,,,,
UHC MCR ADV,CPT,96411,Chemo iv push addl drug,APC 5692,RVU Per Unit,$63.42 ,OP,63.42,362.21,,,,,,
UHC MCR ADV,CPT,96413,Chemo iv infusion 1 hr,APC 5694,RVU Per Unit,$318.00 ,OP,133.34,318,,,,,,
UHC MCR ADV,CPT,96415,Chemo iv infusion addl hr,APC 5692,RVU Per Unit,$63.42 ,OP,63.42,202.07,,,,,,
UHC MCR ADV,CPT,96416,Chemo prolong infuse w/pump,APC 5694,RVU Per Unit,$318.00 ,OP,318,926.48,,,,,,
UHC MCR ADV,CPT,96417,Chemo iv infus each addl seq,APC 5692,RVU Per Unit,$63.42 ,OP,63.42,427.03,,,,,,
UHC MCR ADV,CPT,96420,Chemo ia push tecnique,APC 5694,RVU Per Unit,$318.00 ,OP,318,613.85,,,,,,
UHC MCR ADV,CPT,96422,Chemo ia infusion up to 1 hr,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,979.86,,,,,,
UHC MCR ADV,CPT,96423,Chemo ia infuse each addl hr,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,434.65,,,,,,
UHC MCR ADV,CPT,96425,Chemotherapy infusion method,APC 5694,RVU Per Unit,$318.00 ,OP,318,968.43,,,,,,
UHC MCR ADV,CPT,96440,Chemotherapy intracavitary,APC 5694,RVU Per Unit,$318.00 ,OP,318,"3,339.91",,,,,,
UHC MCR ADV,CPT,96446,Chemotx admn prtl cavity,APC 5694,RVU Per Unit,$318.00 ,OP,318,318,,,,,,
UHC MCR ADV,CPT,96450,Chemotherapy into cns,APC 5694,RVU Per Unit,$318.00 ,OP,318,"1,159.06",,,,,,
UHC MCR ADV,CPT,96521,Refill/maint portable pump,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,716.79,,,,,,
UHC MCR ADV,CPT,96522,Refill/maint pump/resvr syst,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,610.03,,,,,,
UHC MCR ADV,CPT,96523,Irrig drug delivery device,APC 5733,RVU Per Case,$56.95 ,OP,56.95,141.07,,,,,,
UHC MCR ADV,CPT,96542,Chemotherapy injection,APC 5693,RVU Per Unit,$208.24 ,OP,208.24,751.1,,,,,,
UHC MCR ADV,CPT,96549,Chemotherapy unspecified,APC 5691,RVU Per Case,$40.93 ,OP,40.93,40.93,,,,,,
UHC MCR ADV,CPT,96567,Pdt dstr prmlg les skn,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
UHC MCR ADV,CPT,96573,Pdt dstr prmlg les phys/qhp,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
UHC MCR ADV,CPT,96574,Dbrdmt prmlg les w/pdt,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
UHC MCR ADV,CPT,96900,Ultraviolet light therapy,APC 5732,RVU Per Case,$34.63 ,OP,34.63,114.39,,,,,,
UHC MCR ADV,CPT,96910,Photochemotherapy with uv-b,APC 5733,RVU Per Case,$56.95 ,OP,56.95,335.53,,,,,,
UHC MCR ADV,CPT,96912,Photochemotherapy with uv-a,APC 5733,RVU Per Case,$56.95 ,OP,56.95,430.83,,,,,,
UHC MCR ADV,CPT,96913,Photochemotherapy uv-a or b,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,651.97,,,,,,
UHC MCR ADV,CPT,96920,Laser tx skin < 250 sq cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
UHC MCR ADV,CPT,96921,Laser tx skin 250-500 sq cm,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
UHC MCR ADV,CPT,96922,Laser tx skin >500 sq cm,APC 5052,RVU Per Case,$353.91 ,OP,353.91,"1,307.75",,,,,,
UHC MCR ADV,CPT,96999,Dermatological procedure,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
UHC MCR ADV,CPT,97012,Mechanical traction therapy,Physician,Per Unit,$14.55 ,OP,14.55,68.63,,,,,,
UHC MCR ADV,CPT,97016,Vasopneumatic device therapy,Physician,Per Unit,$11.78 ,OP,11.78,72.44,,,,,,
UHC MCR ADV,CPT,97018,Paraffin bath therapy,Physician,Per Unit,$5.69 ,OP,5.69,5.69,,,,,,
UHC MCR ADV,CPT,97022,Whirlpool therapy,Physician,Per Unit,$17.16 ,OP,17.16,83.87,,,,,,
UHC MCR ADV,CPT,97024,Diathermy eg microwave,Physician,Per Unit,$6.96 ,OP,6.96,26.7,,,,,,
UHC MCR ADV,CPT,97026,Infrared therapy,Physician,Per Unit,$6.32 ,OP,6.32,26.7,,,,,,
UHC MCR ADV,CPT,97028,Ultraviolet therapy,Physician,Per Unit,$7.98 ,OP,7.98,7.98,,,,,,
UHC MCR ADV,CPT,97032,Electrical stimulation,Physician,Per Unit,$14.55 ,OP,14.55,76.26,,,,,,
UHC MCR ADV,CPT,97033,Electric current therapy,Physician,Per Unit,$19.67 ,OP,19.67,114.39,,,,,,
UHC MCR ADV,CPT,97034,Contrast bath therapy,Physician,Per Unit,$14.42 ,OP,14.42,68.63,,,,,,
UHC MCR ADV,CPT,97035,Ultrasound therapy,Physician,Per Unit,$14.10 ,OP,14.1,53.38,,,,,,
UHC MCR ADV,CPT,97036,Hydrotherapy,Physician,Per Unit,$33.09 ,OP,33.09,118.19,,,,,,
UHC MCR ADV,CPT,97110,Therapeutic exercises,Physician,Per Unit,$29.26 ,OP,29.26,133.45,,,,,,
UHC MCR ADV,CPT,97112,Neuromuscular reeducation,Physician,Per Unit,$33.86 ,OP,33.86,137.25,,,,,,
UHC MCR ADV,CPT,97113,Aquatic therapy/exercises,Physician,Per Unit,$36.67 ,OP,36.67,160.13,,,,,,
UHC MCR ADV,CPT,97116,Gait training therapy,Physician,Per Unit,$29.26 ,OP,29.26,114.39,,,,,,
UHC MCR ADV,CPT,97124,Massage therapy,Physician,Per Unit,$28.22 ,OP,28.22,106.76,,,,,,
UHC MCR ADV,CPT,97129,Ther ivntj 1st 15 min,Physician,Per Unit,$23.04 ,OP,23.04,114.39,,,,,,
UHC MCR ADV,CPT,97130,Ther ivntj ea addl 15 min,Physician,Per Unit,$22.35 ,OP,22.35,110.97,,,,,,
UHC MCR ADV,CPT,97140,Manual therapy 1/> regions,Physician,Per Unit,$26.97 ,OP,26.97,122,,,,,,
UHC MCR ADV,CPT,97150,Group therapeutic procedures,Physician,Per Unit,$17.53 ,OP,17.53,83.87,,,,,,
UHC MCR ADV,CPT,97151,Bhv id assmt by phys/qhp,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
UHC MCR ADV,CPT,97152,Bhv id suprt assmt by 1 tech,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
UHC MCR ADV,CPT,97153,Adaptive behavior tx by tech,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
UHC MCR ADV,CPT,97154,Grp adapt bhv tx by tech,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
UHC MCR ADV,CPT,97155,Adapt behavior tx phys/qhp,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
UHC MCR ADV,CPT,97156,Fam adapt bhv tx gdn phy/qhp,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
UHC MCR ADV,CPT,97157,Mult fam adapt bhv tx gdn,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
UHC MCR ADV,CPT,97158,Grp adapt bhv tx by phy/qhp,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
UHC MCR ADV,CPT,97161,Pt eval low complex 20 min,Physician,Per Unit,$98.12 ,OP,98.12,330.81,,,,,,
UHC MCR ADV,CPT,97162,Pt eval mod complex 30 min,Physician,Per Unit,$98.12 ,OP,98.12,331.7,,,,,,
UHC MCR ADV,CPT,97163,Pt eval high complex 45 min,Physician,Per Unit,$98.12 ,OP,98.12,331.7,,,,,,
UHC MCR ADV,CPT,97164,Pt re-eval est plan care,Physician,Per Unit,$66.97 ,OP,66.97,175.39,,,,,,
UHC MCR ADV,CPT,97165,Ot eval low complex 30 min,Physician,Per Unit,$95.26 ,OP,95.26,354.58,,,,,,
UHC MCR ADV,CPT,97166,Ot eval mod complex 45 min,Physician,Per Unit,$95.26 ,OP,95.26,354.58,,,,,,
UHC MCR ADV,CPT,97167,Ot eval high complex 60 min,Physician,Per Unit,$95.26 ,OP,95.26,354.58,,,,,,
UHC MCR ADV,CPT,97168,Ot re-eval est plan care,Physician,Per Unit,$64.11 ,OP,64.11,202.07,,,,,,
UHC MCR ADV,CPT,97530,Therapeutic activities,Physician,Per Unit,$37.50 ,OP,37.5,137.25,,,,,,
UHC MCR ADV,CPT,97533,Sensory integration,Physician,Per Unit,$57.03 ,OP,57.03,122,,,,,,
UHC MCR ADV,CPT,97535,Self care mngment training,Physician,Per Unit,$32.44 ,OP,32.44,137.25,,,,,,
UHC MCR ADV,CPT,97537,Community/work reintegration,Physician,Per Unit,$31.26 ,OP,31.26,125.82,,,,,,
UHC MCR ADV,CPT,97542,Wheelchair mngment training,Physician,Per Unit,$31.58 ,OP,31.58,125.82,,,,,,
UHC MCR ADV,CPT,97597,Rmvl devital tis 20 cm/<,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,282.14,,,,,,
UHC MCR ADV,CPT,97602,Wound(s) care non-selective,APC 5051,RVU Per Case,$183.73 ,OP,171.58,183.73,,,,,,
UHC MCR ADV,CPT,97605,Neg press wound tx <=50 cm,APC 5051,RVU Per Case,$183.73 ,OP,163.95,183.73,,,,,,
UHC MCR ADV,CPT,97606,Neg press wound tx >50 cm,APC 5052,RVU Per Case,$353.91 ,OP,175.39,353.91,,,,,,
UHC MCR ADV,CPT,97607,Neg press wnd tx <=50 sq cm,APC 5052,RVU Per Unit,$353.91 ,OP,163.95,353.91,,,,,,
UHC MCR ADV,CPT,97608,Neg press wound tx >50 cm,APC 5052,RVU Per Unit,$353.91 ,OP,175.39,353.91,,,,,,
UHC MCR ADV,CPT,97610,Low frequency non-thermal us,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
UHC MCR ADV,CPT,97750,Physical performance test,Physician,Per Unit,$33.07 ,OP,33.07,137.25,,,,,,
UHC MCR ADV,CPT,97755,Assistive technology assess,Physician,Per Unit,$37.42 ,OP,37.42,156.32,,,,,,
UHC MCR ADV,CPT,97760,Orthotic mgmt&traing 1st enc,Physician,Per Unit,$47.55 ,OP,47.55,152.51,,,,,,
UHC MCR ADV,CPT,97761,Prosthetic traing 1st enc,Physician,Per Unit,$40.55 ,OP,40.55,133.45,,,,,,
UHC MCR ADV,CPT,97763,Orthc/prostc mgmt sbsq enc,Physician,Per Unit,$51.94 ,OP,51.94,160.13,,,,,,
UHC MCR ADV,CPT,97802,Medical nutrition indiv in,Physician,Per Unit,$30.75 ,OP,30.75,148.69,,,,,,
UHC MCR ADV,CPT,97803,Med nutrition indiv subseq,Physician,Per Unit,$31.17 ,OP,31.17,129.64,,,,,,
UHC MCR ADV,CPT,97804,Medical nutrition group,Physician,Per Unit,$16.45 ,OP,16.45,64.82,,,,,,
UHC MCR ADV,CPT,97810,Acupunct w/o stimul 15 min,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,186.82,,,,,,
UHC MCR ADV,CPT,97813,Acupunct w/stimul 15 min,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,198.25,,,,,,
UHC MCR ADV,CPT,98925,Osteopath manj 1-2 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,141.07,,,,,,
UHC MCR ADV,CPT,98926,Osteopath manj 3-4 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,27.17,,,,,,
UHC MCR ADV,CPT,98927,Osteopath manj 5-6 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,251.64,,,,,,
UHC MCR ADV,CPT,98928,Osteopath manj 7-8 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,297.39,,,,,,
UHC MCR ADV,CPT,98929,Osteopath manj 9-10 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,343.14,,,,,,
UHC MCR ADV,CPT,98940,Chiropract manj 1-2 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,125.82,,,,,,
UHC MCR ADV,CPT,98941,Chiropract manj 3-4 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,171.58,,,,,,
UHC MCR ADV,CPT,98942,Chiropractic manj 5 regions,APC 5811,RVU Per Case,$27.17 ,OP,27.17,224.95,,,,,,
UHC MCR ADV,CPT,98966,Hc pro phone call 5-10 min,Physician,Per Unit,$12.73 ,OP,12.73,61,,,,,,
UHC MCR ADV,CPT,98967,Hc pro phone call 11-20 min,Physician,Per Unit,$25.14 ,OP,25.14,118.19,,,,,,
UHC MCR ADV,CPT,98968,Hc pro phone call 21-30 min,Physician,Per Unit,$37.46 ,OP,37.46,171.58,,,,,,
UHC MCR ADV,CPT,98970,Qnhp ol dig assmt&mgmt 5-10,Physician,Per Unit,$11.36 ,OP,11.36,11.36,,,,,,
UHC MCR ADV,CPT,98971,Qnhp ol dig assmt&mgmt 11-20,Physician,Per Unit,$20.31 ,OP,20.31,20.31,,,,,,
UHC MCR ADV,CPT,98972,Qnhp ol dig assmt&mgmt 21+,Physician,Per Unit,$32.41 ,OP,32.41,32.41,,,,,,
UHC MCR ADV,CPT,99170,Anogenital exam child w imag,APC 5411,RVU Per Unit,$174.29 ,OP,174.29,663.41,,,,,,
UHC MCR ADV,CPT,99184,Hypothermia ill neonate,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,99190,Special pump services,APC 5881,RVU Per Case,"$8,948.83 ",OP,"2,299.05","8,948.83",,,,,,
UHC MCR ADV,CPT,99191,Special pump services,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,612.76","8,948.83",,,,,,
UHC MCR ADV,CPT,99192,Special pump services,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,151.42","8,948.83",,,,,,
UHC MCR ADV,CPT,99195,Phlebotomy,APC 5734,RVU Per Case,$114.56 ,OP,114.56,331.7,,,,,,
UHC MCR ADV,CPT,99281,Emergency dept visit,APC 5021,RVU Per Case,$74.29 ,OP,74.29,245.98,,,,,,
UHC MCR ADV,CPT,99282,Emergency dept visit,APC 5022,RVU Per Case,$134.66 ,OP,134.66,368.97,,,,,,
UHC MCR ADV,CPT,99283,Emergency dept visit,APC 5023,RVU Per Case,$237.00 ,OP,237,737.94,,,,,,
UHC MCR ADV,CPT,99284,Emergency dept visit,APC 5024,RVU Per Case,$372.22 ,OP,372.22,"1,291.40",,,,,,
UHC MCR ADV,CPT,99285,Emergency dept visit,APC 5025,RVU Per Case,$534.29 ,OP,534.29,"1,967.84",,,,,,
UHC MCR ADV,CPT,99291,Critical care first hour,APC 5041,RVU Per Case,$708.83 ,OP,708.83,"1,197.20",,,,,,
UHC MCR ADV,CPT,99356,Prolng svc i/p/obs 1st hour,APC 5881,RVU Per Case,"$8,948.83 ",OP,499.47,"8,948.83",,,,,,
UHC MCR ADV,CPT,99357,Prolng svc i/p/obs ea addl,APC 5881,RVU Per Case,"$8,948.83 ",OP,507.08,"8,948.83",,,,,,
UHC MCR ADV,CPT,99406,Behav chng smoking 3-10 min,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,64.82,,,,,,
UHC MCR ADV,CPT,99407,Behav chng smoking > 10 min,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,125.82,,,,,,
UHC MCR ADV,CPT,99453,Rem mntr physiol param setup,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,121.51,,,,,,
UHC MCR ADV,CPT,99454,Rem mntr physiol param dev,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
UHC MCR ADV,CPT,99460,Init nb em per day hosp,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,305.01,,,,,,
UHC MCR ADV,CPT,99462,Sbsq nb em per day hosp,APC 5881,RVU Per Case,"$8,948.83 ",OP,160.13,"8,948.83",,,,,,
UHC MCR ADV,CPT,99463,Same day nb discharge,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,404.14,,,,,,
UHC MCR ADV,CPT,99465,Nb resuscitation,APC 5781,RVU Per Unit,$575.01 ,OP,575.01,781.61,,,,,,
UHC MCR ADV,CPT,99468,Neonate crit care initial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,510.41","8,948.83",,,,,,
UHC MCR ADV,CPT,99469,Neonate crit care subsq,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,936.85","8,948.83",,,,,,
UHC MCR ADV,CPT,99471,Ped critical care initial,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,049.07","8,948.83",,,,,,
UHC MCR ADV,CPT,99472,Ped critical care subsq,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,982.60","8,948.83",,,,,,
UHC MCR ADV,CPT,99473,Self-meas bp pt educaj/train,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
UHC MCR ADV,CPT,99475,Ped crit care age 2-5 init,APC 5881,RVU Per Case,"$8,948.83 ",OP,"2,790.89","8,948.83",,,,,,
UHC MCR ADV,CPT,99476,Ped crit care age 2-5 subsq,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,643.28","8,948.83",,,,,,
UHC MCR ADV,CPT,99477,Init day hosp neonate care,APC 5881,RVU Per Case,"$8,948.83 ",OP,"1,734.78","8,948.83",,,,,,
UHC MCR ADV,CPT,99478,Ic lbw inf < 1500 gm subsq,APC 5881,RVU Per Case,"$8,948.83 ",OP,716.79,"8,948.83",,,,,,
UHC MCR ADV,CPT,99479,Ic lbw inf 1500-2500 g subsq,APC 5881,RVU Per Case,"$8,948.83 ",OP,629.1,"8,948.83",,,,,,
UHC MCR ADV,CPT,99480,Ic inf pbw 2501-5000 g subsq,APC 5881,RVU Per Case,"$8,948.83 ",OP,606.21,"8,948.83",,,,,,
UHC MCR ADV,CPT,99483,Assmt & care pln pt cog imp,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
UHC MCR ADV,CPT,99484,Care mgmt svc bhvl hlth cond,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
UHC MCR ADV,CPT,99487,Cplx chrnc care 1st 60 min,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,136.74,,,,,,
UHC MCR ADV,CPT,99490,Chrnc care mgmt svc 1st 20,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
UHC MCR ADV,CPT,99492,1st psyc collab care mgmt,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
UHC MCR ADV,CPT,99493,Sbsq psyc collab care mgmt,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
UHC MCR ADV,CPT,99495,Trans care mgmt 14 day disch,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,121.51,,,,,,
UHC MCR ADV,CPT,99496,Trans care mgmt 7 day disch,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,121.51,,,,,,
UHC MCR ADV,CPT,99497,Advncd care plan 30 min,APC 5822,RVU Per Case,$76.62 ,OP,76.62,76.62,,,,,,
UHC MCR ADV,CPT,0001A,Adm sarscov2 30mcg/0.3ml 1st,APC 9397,RVU Per Unit,$40.93 ,OP,40.93,40.93,,,,,,
UHC MCR ADV,CPT,0001U,Rbc dna hea 35 ag 11 bld grp,Lab Services,Per Unit,$720.00 ,OP,720,720,,,,,,
UHC MCR ADV,CPT,0002A,Adm sarscov2 30mcg/0.3ml 2nd,APC 9398,RVU Per Unit,$40.93 ,OP,40.93,40.93,,,,,,
UHC MCR ADV,CPT,0002M,Liver dis 10 assays w/ash,Lab Services,Per Unit,$503.40 ,OP,503.4,503.4,,,,,,
UHC MCR ADV,CPT,0002U,Onc clrct 3 ur metab alg plp,Lab Services,Per Unit,$25.00 ,OP,25,25,,,,,,
UHC MCR ADV,CPT,0003A,Adm sarscov2 30mcg/0.3ml 3rd,APC 9398,RVU Per Unit,$40.93 ,OP,40.93,40.93,,,,,,
UHC MCR ADV,CPT,0003M,Liver dis 10 assays w/nash,Lab Services,Per Unit,$503.40 ,OP,503.4,503.4,,,,,,
UHC MCR ADV,CPT,0003U,Onc ovar 5 prtn ser alg scor,Lab Services,Per Unit,$950.00 ,OP,950,950,,,,,,
UHC MCR ADV,CPT,0004M,Scoliosis dna alys,Lab Services,Per Unit,$79.00 ,OP,79,79,,,,,,
UHC MCR ADV,CPT,0005U,Onco prst8 3 gene ur alg,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
UHC MCR ADV,CPT,0006M,Onc hep gene risk classifier,Lab Services,Per Unit,$150.00 ,OP,150,150,,,,,,
UHC MCR ADV,CPT,0007M,Onc gastro 51 gene nomogram,Lab Services,Per Unit,$375.00 ,OP,375,375,,,,,,
UHC MCR ADV,CPT,0007U,Rx test prsmv ur w/def conf,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
UHC MCR ADV,CPT,0008U,Hpylori detcj abx rstnc dna,Lab Services,Per Unit,$597.91 ,OP,597.91,597.91,,,,,,
UHC MCR ADV,CPT,0009U,Onc brst ca erbb2 amp/nonamp,Lab Services,Per Unit,$107.00 ,OP,107,107,,,,,,
UHC MCR ADV,CPT,0010U,Nfct ds strn typ whl gen seq,Lab Services,Per Unit,$427.26 ,OP,427.26,427.26,,,,,,
UHC MCR ADV,CPT,0011A,Adm sarscov2 100mcg/0.5ml1st,APC 9397,RVU Per Unit,$40.93 ,OP,40.93,40.93,,,,,,
UHC MCR ADV,CPT,0011M,Onc prst8 ca mrna 12 gen alg,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
UHC MCR ADV,CPT,0011U,Rx mntr lc-ms/ms oral fluid,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
UHC MCR ADV,CPT,0012A,Adm sarscov2 100mcg/0.5ml2nd,APC 9398,RVU Per Unit,$40.93 ,OP,40.93,40.93,,,,,,
UHC MCR ADV,CPT,0012M,Onc mrna 5 gen rsk urthl ca,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
UHC MCR ADV,CPT,0012U,Germln do gene reargmt detcj,Lab Services,Per Unit,"$2,515.60 ",OP,"2,515.60","2,515.60",,,,,,
UHC MCR ADV,CPT,0013A,Adm sarscov2 100mcg/0.5ml3rd,APC 9398,RVU Per Unit,$40.93 ,OP,40.93,40.93,,,,,,
UHC MCR ADV,CPT,0013M,Onc mrna 5 gen recr urthl ca,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
UHC MCR ADV,CPT,0013U,Onc sld org neo gene reargmt,Lab Services,Per Unit,"$2,515.60 ",OP,"2,515.60","2,515.60",,,,,,
UHC MCR ADV,CPT,0014M,Liver ds alys 3 bmrk srm alg,Lab Services,Per Unit,$176.19 ,OP,176.19,176.19,,,,,,
UHC MCR ADV,CPT,0014U,Hem hmtlmf neo gene reargmt,Lab Services,Per Unit,"$2,515.60 ",OP,"2,515.60","2,515.60",,,,,,
UHC MCR ADV,CPT,0016U,Onc hmtlmf neo rna bcr/abl1,Lab Services,Per Unit,$163.96 ,OP,163.96,163.96,,,,,,
UHC MCR ADV,CPT,0017U,Onc hmtlmf neo jak2 mut dna,Lab Services,Per Unit,$91.66 ,OP,91.66,91.66,,,,,,
UHC MCR ADV,CPT,0018U,Onc thyr 10 microrna seq alg,Lab Services,Per Unit,"$3,002.09 ",OP,"3,002.09","3,002.09",,,,,,
UHC MCR ADV,CPT,0019U,Onc rna tiss predict alg,Lab Services,Per Unit,"$3,675.00 ",OP,"3,675.00","3,675.00",,,,,,
UHC MCR ADV,CPT,0021U,Onc prst8 detcj 8 autoantb,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
UHC MCR ADV,CPT,0022U,Trgt gen seq dna&rna 23 gene,Lab Services,Per Unit,"$1,950.00 ",OP,"1,950.00","1,950.00",,,,,,
UHC MCR ADV,CPT,0023U,Onc aml dna detcj/nondetcj,Lab Services,Per Unit,$248.51 ,OP,248.51,248.51,,,,,,
UHC MCR ADV,CPT,0024U,Glyca nuc mr spectrsc quan,Lab Services,Per Unit,$34.19 ,OP,34.19,34.19,,,,,,
UHC MCR ADV,CPT,0025U,Tenofovir liq chrom ur quan,Lab Services,Per Unit,$85.77 ,OP,85.77,85.77,,,,,,
UHC MCR ADV,CPT,0026U,Onc thyr dna&mrna 112 genes,Lab Services,Per Unit,"$3,600.00 ",OP,"3,600.00","3,600.00",,,,,,
UHC MCR ADV,CPT,0027U,Jak2 gene trgt seq alys,Lab Services,Per Unit,$121.91 ,OP,121.91,121.91,,,,,,
UHC MCR ADV,CPT,0029U,Rx metab advrs trgt seq alys,Lab Services,Per Unit,$742.27 ,OP,742.27,742.27,,,,,,
UHC MCR ADV,CPT,0030U,Rx metab warf trgt seq alys,Lab Services,Per Unit,$134.13 ,OP,134.13,134.13,,,,,,
UHC MCR ADV,CPT,0031A,Adm sarscov2 vac ad26 .5ml,APC 9398,RVU Per Unit,$40.93 ,OP,40.93,40.93,,,,,,
UHC MCR ADV,CPT,0031U,Cyp1a2 gene,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
UHC MCR ADV,CPT,0032U,Comt gene,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,
UHC MCR ADV,CPT,0033U,Htr2a htr2c genes,Lab Services,Per Unit,$349.62 ,OP,349.62,349.62,,,,,,
UHC MCR ADV,CPT,0034U,Tpmt nudt15 genes,Lab Services,Per Unit,$466.17 ,OP,466.17,466.17,,,,,,
UHC MCR ADV,CPT,0035U,Neuro csf prion prtn qual,Lab Services,Per Unit,$540.99 ,OP,540.99,540.99,,,,,,
UHC MCR ADV,CPT,0036U,Xome tum & nml spec seq alys,Lab Services,Per Unit,"$4,780.00 ",OP,"4,780.00","4,780.00",,,,,,
UHC MCR ADV,CPT,0037U,Trgt gen seq dna 324 genes,Lab Services,Per Unit,"$3,500.00 ",OP,"3,500.00","3,500.00",,,,,,
UHC MCR ADV,CPT,0038U,Vitamin d srm microsamp quan,Lab Services,Per Unit,$29.60 ,OP,29.6,29.6,,,,,,
UHC MCR ADV,CPT,0039U,Dna antb 2strand hi avidity,Lab Services,Per Unit,$13.74 ,OP,13.74,13.74,,,,,,
UHC MCR ADV,CPT,0040U,Bcr/abl1 gene major bp quan,Lab Services,Per Unit,$409.90 ,OP,409.9,409.9,,,,,,
UHC MCR ADV,CPT,0041U,B brgdrferi antb 5 prtn igm,Lab Services,Per Unit,$17.21 ,OP,17.21,17.21,,,,,,
UHC MCR ADV,CPT,0042U,B brgdrferi antb 12 prtn igg,Lab Services,Per Unit,$17.21 ,OP,17.21,17.21,,,,,,
UHC MCR ADV,CPT,0043U,Tbrf b grp antb 4 prtn igm,Lab Services,Per Unit,$14.86 ,OP,14.86,14.86,,,,,,
UHC MCR ADV,CPT,0044U,Tbrf b grp antb 4 prtn igg,Lab Services,Per Unit,$14.86 ,OP,14.86,14.86,,,,,,
UHC MCR ADV,CPT,0045U,Onc brst dux carc is 12 gene,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
UHC MCR ADV,CPT,0046U,Flt3 gene itd variants quan,Lab Services,Per Unit,$407.43 ,OP,407.43,407.43,,,,,,
UHC MCR ADV,CPT,0047U,Onc prst8 mrna 17 gene alg,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,
UHC MCR ADV,CPT,0048U,Onc sld org neo dna 468 gene,Lab Services,Per Unit,"$2,919.60 ",OP,"2,919.60","2,919.60",,,,,,
UHC MCR ADV,CPT,0049U,Npm1 gene analysis quan,Lab Services,Per Unit,$407.43 ,OP,407.43,407.43,,,,,,
UHC MCR ADV,CPT,0050U,Trgt gen seq dna 194 genes,Lab Services,Per Unit,"$2,916.60 ",OP,"2,916.60","2,916.60",,,,,,
UHC MCR ADV,CPT,0051U,Rx mntr lc-ms/ms ur 31 pnl,Lab Services,Per Unit,$193.71 ,OP,193.71,193.71,,,,,,
UHC MCR ADV,CPT,0052U,Lpoprtn bld w/5 maj classes,Lab Services,Per Unit,$33.86 ,OP,33.86,33.86,,,,,,
UHC MCR ADV,CPT,0053U,Onc prst8 ca fish alys 4 gen,Lab Services,Per Unit,"$2,030.00 ",OP,"2,030.00","2,030.00",,,,,,
UHC MCR ADV,CPT,0054U,Rx mntr 14+ drugs & sbsts,Lab Services,Per Unit,$148.96 ,OP,148.96,148.96,,,,,,
UHC MCR ADV,CPT,0055U,Card hrt trnspl 96 dna seq,Lab Services,Per Unit,"$3,240.00 ",OP,"3,240.00","3,240.00",,,,,,
UHC MCR ADV,CPT,0056U,Hem aml dna gene reargmt,Lab Services,Per Unit,"$2,515.60 ",OP,"2,515.60","2,515.60",,,,,,
UHC MCR ADV,CPT,0058U,Onc merkel cll carc srm quan,Lab Services,Per Unit,$322.96 ,OP,322.96,322.96,,,,,,
UHC MCR ADV,CPT,0059U,Onc merkel cll carc srm +/-,Lab Services,Per Unit,$322.96 ,OP,322.96,322.96,,,,,,
UHC MCR ADV,CPT,0060U,Twn zyg gen seq alys chrms2,Lab Services,Per Unit,$759.05 ,OP,759.05,759.05,,,,,,
UHC MCR ADV,CPT,0061U,Tc meas 5 bmrk sfdi m-s alys,Lab Services,Per Unit,$25.10 ,OP,25.1,25.1,,,,,,
UHC MCR ADV,CPT,0062U,Ai sle igg&igm alys 80 bmrk,Lab Services,Per Unit,$380.72 ,OP,380.72,380.72,,,,,,
UHC MCR ADV,CPT,0063U,Neuro autism 32 amines alg,Lab Services,Per Unit,$750.00 ,OP,750,750,,,,,,
UHC MCR ADV,CPT,0064U,Antb tp total&rpr ia qual,Lab Services,Per Unit,$31.33 ,OP,31.33,31.33,,,,,,
UHC MCR ADV,CPT,0065U,Syfls tst nontreponemal antb,Lab Services,Per Unit,$18.09 ,OP,18.09,18.09,,,,,,
UHC MCR ADV,CPT,0066U,Pamg-1 ia cervico-vag fluid,Lab Services,Per Unit,$15.29 ,OP,15.29,15.29,,,,,,
UHC MCR ADV,CPT,0067U,Onc brst imhchem prfl 4 bmrk,Lab Services,Per Unit,"$1,897.00 ",OP,"1,897.00","1,897.00",,,,,,
UHC MCR ADV,CPT,0068U,Candida species pnl amp prb,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
UHC MCR ADV,CPT,0069U,Onc clrct microrna mir-31-3p,Lab Services,Per Unit,$380.00 ,OP,380,380,,,,,,
UHC MCR ADV,CPT,0070U,Cyp2d6 gen com&slct rar vrnt,Lab Services,Per Unit,$676.37 ,OP,676.37,676.37,,,,,,
UHC MCR ADV,CPT,0071T,Us leiomyomata ablate <200,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","2,684.38",,,,,,
UHC MCR ADV,CPT,0071U,Cyp2d6 full gene sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,
UHC MCR ADV,CPT,0072T,Us leiomyomata ablate >200,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","2,684.38",,,,,,
UHC MCR ADV,CPT,0072U,Cyp2d6 gen cyp2d6-2d7 hybrid,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,
UHC MCR ADV,CPT,0073U,Cyp2d6 gen cyp2d7-2d6 hybrid,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,
UHC MCR ADV,CPT,0074U,Cyp2d6 nonduplicated gene,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,
UHC MCR ADV,CPT,0075T,Perq stent/chest vert art,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,0075U,Cyp2d6 5' gene dup/mlt,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,
UHC MCR ADV,CPT,0076T,S&i stent/chest vert art,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,0076U,Cyp2d6 3' gene dup/mlt,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,
UHC MCR ADV,CPT,0077U,Ig paraprotein qual bld/ur,Lab Services,Per Unit,$43.43 ,OP,43.43,43.43,,,,,,
UHC MCR ADV,CPT,0078U,Pain mgt opi use gnotyp pnl,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,
UHC MCR ADV,CPT,0080U,Onc lng 5 clin rsk factr alg,Lab Services,Per Unit,"$3,520.00 ",OP,"3,520.00","3,520.00",,,,,,
UHC MCR ADV,CPT,0082U,Rx test def 90+ rx/sbsts ur,Lab Services,Per Unit,$246.92 ,OP,246.92,246.92,,,,,,
UHC MCR ADV,CPT,0083U,Onc rspse chemo cntrst tomog,Lab Services,Per Unit,$167.35 ,OP,167.35,167.35,,,,,,
UHC MCR ADV,CPT,0084U,Rbc dna gnotyp 10 bld groups,Lab Services,Per Unit,$720.00 ,OP,720,720,,,,,,
UHC MCR ADV,CPT,0086U,Nfct ds bact&fng org id 6+,Lab Services,Per Unit,$200.00 ,OP,200,200,,,,,,
UHC MCR ADV,CPT,0087U,Crd hrt trnspl mrna 1283 gen,Lab Services,Per Unit,"$3,159.42 ",OP,"3,159.42","3,159.42",,,,,,
UHC MCR ADV,CPT,0088U,Trnsplj kdn algrft rej 1494,Lab Services,Per Unit,"$3,159.42 ",OP,"3,159.42","3,159.42",,,,,,
UHC MCR ADV,CPT,0089U,Onc mlnma prame & linc00518,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
UHC MCR ADV,CPT,0090U,Onc cutan mlnma mrna 23 gene,Lab Services,Per Unit,"$1,755.00 ",OP,"1,755.00","1,755.00",,,,,,
UHC MCR ADV,CPT,0092U,Onc lng 3 prtn bmrk plsm alg,Lab Services,Per Unit,"$2,488.00 ",OP,"2,488.00","2,488.00",,,,,,
UHC MCR ADV,CPT,0093U,Rx mntr 65 com drugs urine,Lab Services,Per Unit,$62.14 ,OP,62.14,62.14,,,,,,
UHC MCR ADV,CPT,0094U,Genome rapid sequence alys,Lab Services,Per Unit,"$7,582.20 ",OP,"7,582.20","7,582.20",,,,,,
UHC MCR ADV,CPT,0095U,Inflm ee elisa alys alg,Lab Services,Per Unit,$771.98 ,OP,771.98,771.98,,,,,,
UHC MCR ADV,CPT,0096U,Hpv hi risk types male urine,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,
UHC MCR ADV,CPT,0097U,Gi pathogen 22 targets,Lab Services,Per Unit,$363.04 ,OP,363.04,363.04,,,,,,
UHC MCR ADV,CPT,0101T,Extracorp shockwv tx hi enrg,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","2,896.40",,,,,,
UHC MCR ADV,CPT,0102T,Extracorp shockwv tx anesth,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","2,896.40",,,,,,
UHC MCR ADV,CPT,0105U,Neph ckd mult eclia tum nec,Lab Services,Per Unit,$950.00 ,OP,950,950,,,,,,
UHC MCR ADV,CPT,0106T,Touch quant sensory test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
UHC MCR ADV,CPT,0106U,Gstr emptg 7 timed brth spec,Lab Services,Per Unit,$874.49 ,OP,874.49,874.49,,,,,,
UHC MCR ADV,CPT,0107T,Vibrate quant sensory test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
UHC MCR ADV,CPT,0107U,C diff tox ag detcj ia stool,Lab Services,Per Unit,$16.00 ,OP,16,16,,,,,,
UHC MCR ADV,CPT,0108T,Cool quant sensory test,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
UHC MCR ADV,CPT,0108U,Gi barrett esoph 9 prtn bmrk,Lab Services,Per Unit,"$2,513.25 ",OP,"2,513.25","2,513.25",,,,,,
UHC MCR ADV,CPT,0109T,Heat quant sensory test,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
UHC MCR ADV,CPT,0109U,Id aspergillus dna 4 species,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
UHC MCR ADV,CPT,0110T,Nos quant sensory test,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
UHC MCR ADV,CPT,0110U,Rx mntr 1+oral onc rx&sbsts,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,
UHC MCR ADV,CPT,0111U,Onc colon ca kras&nras alys,Lab Services,Per Unit,$682.29 ,OP,682.29,682.29,,,,,,
UHC MCR ADV,CPT,0112U,Iadi 16s&18s rrna genes,Lab Services,Per Unit,$356.13 ,OP,356.13,356.13,,,,,,
UHC MCR ADV,CPT,0113U,Onc prst8 pca3&tmprss2-erg,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
UHC MCR ADV,CPT,0114U,Gi barretts esoph vim&ccna1,Lab Services,Per Unit,"$1,938.01 ",OP,"1,938.01","1,938.01",,,,,,
UHC MCR ADV,CPT,0115U,Respir iadna 18 viral&2 bact,Lab Services,Per Unit,$275.35 ,OP,275.35,275.35,,,,,,
UHC MCR ADV,CPT,0116U,Rx mntr nzm ia 35+oral flu,Lab Services,Per Unit,$246.92 ,OP,246.92,246.92,,,,,,
UHC MCR ADV,CPT,0117U,Pain mgmt 11 endogenous anal,Lab Services,Per Unit,$840.65 ,OP,840.65,840.65,,,,,,
UHC MCR ADV,CPT,0118U,Trnsplj don-drv cll-fr dna,Lab Services,Per Unit,"$2,753.25 ",OP,"2,753.25","2,753.25",,,,,,
UHC MCR ADV,CPT,0119U,Crd ceramides liq chrom plsm,Lab Services,Per Unit,$83.76 ,OP,83.76,83.76,,,,,,
UHC MCR ADV,CPT,0120U,Onc b cll lymphm mrna 58 gen,Lab Services,Per Unit,"$2,510.21 ",OP,"2,510.21","2,510.21",,,,,,
UHC MCR ADV,CPT,0121U,Sc dis vcam-1 whole blood,Lab Services,Per Unit,$509.20 ,OP,509.2,509.2,,,,,,
UHC MCR ADV,CPT,0122U,Sc dis p-selectin whl blood,Lab Services,Per Unit,$526.23 ,OP,526.23,526.23,,,,,,
UHC MCR ADV,CPT,0123U,Mchnl fragility rbc prflg,Lab Services,Per Unit,$357.63 ,OP,357.63,357.63,,,,,,
UHC MCR ADV,CPT,0130U,Hered colon ca do mrna pnl,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,
UHC MCR ADV,CPT,0131U,Hered brst ca rltd do pnl 13,Lab Services,Per Unit,$710.00 ,OP,710,710,,,,,,
UHC MCR ADV,CPT,0132U,Hered ova ca rltd do pnl 17,Lab Services,Per Unit,$741.64 ,OP,741.64,741.64,,,,,,
UHC MCR ADV,CPT,0133U,Hered prst8 ca rltd do 11,Lab Services,Per Unit,$690.29 ,OP,690.29,690.29,,,,,,
UHC MCR ADV,CPT,0134U,Hered pan ca mrna pnl 18 gen,Lab Services,Per Unit,$748.39 ,OP,748.39,748.39,,,,,,
UHC MCR ADV,CPT,0135U,Hered gyn ca mrna pnl 12 gen,Lab Services,Per Unit,$700.56 ,OP,700.56,700.56,,,,,,
UHC MCR ADV,CPT,0136U,Atm mrna seq alys,Lab Services,Per Unit,$407.43 ,OP,407.43,407.43,,,,,,
UHC MCR ADV,CPT,0137U,Palb2 mrna seq alys,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,
UHC MCR ADV,CPT,0138U,Brca1 brca2 mrna seq alys,Lab Services,Per Unit,$468.33 ,OP,468.33,468.33,,,,,,
UHC MCR ADV,CPT,0145U,Drug assay 65+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
UHC MCR ADV,CPT,0146U,Drug assay 80+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
UHC MCR ADV,CPT,0147U,Drug assay 85+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
UHC MCR ADV,CPT,0148U,Drug assay 100+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
UHC MCR ADV,CPT,0149U,Drug assay 60+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
UHC MCR ADV,CPT,0150U,Drug assay 120+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
UHC MCR ADV,CPT,0154U,Onc urthl ca rna fgfr3 gene,Lab Services,Per Unit,$482.14 ,OP,482.14,482.14,,,,,,
UHC MCR ADV,CPT,0155U,Onc brst ca dna pik3ca gene,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
UHC MCR ADV,CPT,0166U,Liver ds 10 biochem asy srm,Lab Services,Per Unit,$503.40 ,OP,503.4,503.4,,,,,,
UHC MCR ADV,CPT,0167U,Chornc gonadotropin hcg ia,Lab Services,Per Unit,$7.52 ,OP,7.52,7.52,,,,,,
UHC MCR ADV,CPT,0169U,Nudt15&tpmt gene com vrnt,Lab Services,Per Unit,$466.17 ,OP,466.17,466.17,,,,,,
UHC MCR ADV,CPT,0170U,Neuro asd rna next gen seq,Lab Services,Per Unit,"$1,755.00 ",OP,"1,755.00","1,755.00",,,,,,
UHC MCR ADV,CPT,0172U,Onc sld tum alys brca1 brca2,Lab Services,Per Unit,"$3,030.00 ",OP,"3,030.00","3,030.00",,,,,,
UHC MCR ADV,CPT,0176U,Cdtb&vinculin igg antb ia,Lab Services,Per Unit,$64.19 ,OP,64.19,64.19,,,,,,
UHC MCR ADV,CPT,0177U,Onc brst ca dna pik3ca 11,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
UHC MCR ADV,CPT,0181U,Co gnotyp aqp1 exon 1,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
UHC MCR ADV,CPT,0182U,Crom gnotyp cd55 exons 1-10,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,
UHC MCR ADV,CPT,0183U,Di gnotyp slc4a1 exon 19,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
UHC MCR ADV,CPT,0184T,Exc rectal tumor endoscopic,APC 5331,RVU Per Case,"$5,145.78 ",OP,"5,145.78","5,145.78",,,,,,
UHC MCR ADV,CPT,0184U,Do gnotyp art4 exon 2,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
UHC MCR ADV,CPT,0185U,Fut1 gnotyp fut1 exon 4,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
UHC MCR ADV,CPT,0186U,Fut2 gnotyp fut2 exon 2,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
UHC MCR ADV,CPT,0187U,Fy gnotyp ackr1 exons 1-2,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
UHC MCR ADV,CPT,0188U,Ge gnotyp gypc exons 1-4,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
UHC MCR ADV,CPT,0189U,Gypa gnotyp ntrns 1 5 exon 2,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
UHC MCR ADV,CPT,0190U,Gypb gnotyp ntrns 1 5 seux 3,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
UHC MCR ADV,CPT,0191T,Insert ant segment drain int,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,009.10",,,,,,
UHC MCR ADV,CPT,0191U,In gnotyp cd44 exons 2 3 6,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
UHC MCR ADV,CPT,0192U,Jk gnotyp slc14a1 exon 9,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
UHC MCR ADV,CPT,0193U,Jr gnotyp abcg2 exons 2-26,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,
UHC MCR ADV,CPT,0194U,Kel gnotyp kel exon 8,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
UHC MCR ADV,CPT,0195U,Klf1 targeted sequencing,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,
UHC MCR ADV,CPT,0196U,Lu gnotyp bcam exon 3,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
UHC MCR ADV,CPT,0197U,Lw gnotyp icam4 exon 1,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
UHC MCR ADV,CPT,0198T,Ocular blood flow measure,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
UHC MCR ADV,CPT,0198U,Rhd&rhce gntyp rhd1-10&rhce5,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,
UHC MCR ADV,CPT,0199U,Sc gnotyp ermap exons 4 12,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
UHC MCR ADV,CPT,0200T,Perq sacral augmt unilat inj,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
UHC MCR ADV,CPT,0200U,Xk gnotyp xk exons 1-3,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,
UHC MCR ADV,CPT,0201T,Perq sacral augmt bilat inj,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
UHC MCR ADV,CPT,0201U,Yt gnotyp ache exon 2,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,
UHC MCR ADV,CPT,0202T,Post vert arthrplst 1 lumbar,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
UHC MCR ADV,CPT,0202U,Nfct ds 22 trgt sars-cov-2,Lab Services,Per Unit,$416.78 ,OP,416.78,416.78,,,,,,
UHC MCR ADV,CPT,0203U,Ai ibd mrna xprsn prfl 17,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,
UHC MCR ADV,CPT,0204U,Onc thyr mrna xprsn alys 593,Lab Services,Per Unit,"$2,919.60 ",OP,"2,919.60","2,919.60",,,,,,
UHC MCR ADV,CPT,0205U,Oph amd alys 3 gene variants,Lab Services,Per Unit,$47.00 ,OP,47,47,,,,,,
UHC MCR ADV,CPT,0207T,Clear eyelid gland w/heat,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
UHC MCR ADV,CPT,0208T,Audiometry air only,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
UHC MCR ADV,CPT,0209T,Audiometry air & bone,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
UHC MCR ADV,CPT,0210T,Speech audiometry threshold,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
UHC MCR ADV,CPT,0210U,Syphilis tst antb ia quan,Lab Services,Per Unit,$18.63 ,OP,18.63,18.63,,,,,,
UHC MCR ADV,CPT,0211T,Speech audiom thresh & recog,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
UHC MCR ADV,CPT,0212T,Compre audiometry evaluation,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
UHC MCR ADV,CPT,0213T,Njx paravert w/us cer/thor,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,841.63,,,,,,
UHC MCR ADV,CPT,0216T,Njx paravert w/us lumb/sac,APC 5443,RVU Per Unit,$841.63 ,OP,841.63,841.63,,,,,,
UHC MCR ADV,CPT,0218U,Neuro musc dys dmd seq alys,Lab Services,Per Unit,"$2,279.00 ",OP,"2,279.00","2,279.00",,,,,,
UHC MCR ADV,CPT,0219T,Plmt post facet implt cerv,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
UHC MCR ADV,CPT,0220T,Plmt post facet implt thor,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
UHC MCR ADV,CPT,0221T,Plmt post facet implt lumb,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
UHC MCR ADV,CPT,0224U,Antibody sars-cov-2 titer(s),Lab Services,Per Unit,$42.13 ,OP,42.13,42.13,,,,,,
UHC MCR ADV,CPT,0226U,Svnt sarscov2 elisa plsm srm,Lab Services,Per Unit,$42.28 ,OP,42.28,42.28,,,,,,
UHC MCR ADV,CPT,0232T,Njx platelet plasma,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
UHC MCR ADV,CPT,0234T,Trluml perip athrc renal art,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
UHC MCR ADV,CPT,0235T,Trluml perip athrc visceral,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,0236T,Trluml perip athrc abd aorta,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
UHC MCR ADV,CPT,0237T,Trluml perip athrc brchiocph,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
UHC MCR ADV,CPT,0238T,Trluml perip athrc iliac art,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
UHC MCR ADV,CPT,0239U,Trgt gen seq alys pnl 311+,Lab Services,Per Unit,"$3,500.00 ",OP,"3,500.00","3,500.00",,,,,,
UHC MCR ADV,CPT,0240U,Nfct ds vir resp rna 3 trgt,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
UHC MCR ADV,CPT,0241U,Nfct ds vir resp rna 4 trgt,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,
UHC MCR ADV,CPT,0242U,Trgt gen seq alys pnl 55-74,Lab Services,Per Unit,"$5,000.00 ",OP,"5,000.00","5,000.00",,,,,,
UHC MCR ADV,CPT,0253T,Insert aqueous drain device,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,009.10",,,,,,
UHC MCR ADV,CPT,0263T,Im b1 mrw cel ther cmpl,APC 5243,RVU Per Unit,"$4,131.87 ",OP,"4,131.87","4,131.87",,,,,,
UHC MCR ADV,CPT,0264T,Im b1 mrw cel ther xcl hrvst,APC 5243,RVU Per Unit,"$4,131.87 ",OP,"4,131.87","4,131.87",,,,,,
UHC MCR ADV,CPT,0265T,Im b1 mrw cel ther hrvst onl,APC 5243,RVU Per Unit,"$4,131.87 ",OP,"4,131.87","4,131.87",,,,,,
UHC MCR ADV,CPT,0266T,Implt/rpl crtd sns dev total,APC 5465,RVU Per Case,"$30,131.14 ",OP,"30,131.14","30,131.14",,,,,,
UHC MCR ADV,CPT,0267T,Implt/rpl crtd sns dev lead,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
UHC MCR ADV,CPT,0268T,Implt/rpl crtd sns dev gen,APC 5465,RVU Per Case,"$30,131.14 ",OP,"30,131.14","30,131.14",,,,,,
UHC MCR ADV,CPT,0269T,Rev/remvl crtd sns dev total,APC 5432,RVU Per Case,"$5,833.22 ",OP,"5,833.22","5,833.22",,,,,,
UHC MCR ADV,CPT,0270T,Rev/remvl crtd sns dev lead,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
UHC MCR ADV,CPT,0271T,Rev/remvl crtd sns dev gen,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
UHC MCR ADV,CPT,0272T,Interrogate crtd sns dev,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
UHC MCR ADV,CPT,0273T,Interrogate crtd sns w/pgrmg,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
UHC MCR ADV,CPT,0274T,Perq lamot/lam crv/thrc,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
UHC MCR ADV,CPT,0275T,Perq lamot/lam lumbar,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
UHC MCR ADV,CPT,0278T,Tempr,APC 5721,RVU Per Case,$142.80 ,OP,142.8,142.8,,,,,,
UHC MCR ADV,CPT,0308T,Insj ocular telescope prosth,APC 5495,RVU Per Case,"$21,250.81 ",OP,"21,250.81","21,250.81",,,,,,
UHC MCR ADV,CPT,0312T,Laps impltj nstim vagus,APC 5465,RVU Per Case,"$30,131.14 ",OP,"30,131.14","30,131.14",,,,,,
UHC MCR ADV,CPT,0313T,Laps rmvl nstim array vagus,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
UHC MCR ADV,CPT,0314T,Laps rmvl vgl arry&pls gen,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
UHC MCR ADV,CPT,0315T,Rmvl vagus nerve pls gen,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
UHC MCR ADV,CPT,0316T,Replc vagus nerve pls gen,APC 5465,RVU Per Case,"$30,131.14 ",OP,"30,131.14","30,131.14",,,,,,
UHC MCR ADV,CPT,0317T,Elec alys vagus nrv pls gen,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
UHC MCR ADV,CPT,0330T,Tear film img uni/bi w/i&r,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
UHC MCR ADV,CPT,0331T,Heart symp image plnr,APC 5593,RVU Per Unit,"$1,336.39 ",OP,922.67,"1,336.39",,,,,,
UHC MCR ADV,CPT,0332T,Heart symp image plnr spect,APC 5593,RVU Per Unit,"$1,336.39 ",OP,"1,336.39","1,338.26",,,,,,
UHC MCR ADV,CPT,0335T,Insj sinus tarsi implant,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
UHC MCR ADV,CPT,0338T,Trnscth renal symp denrv unl,APC 5192,RVU Per Case,"$5,072.43 ",OP,"5,072.43","5,072.43",,,,,,
UHC MCR ADV,CPT,0339T,Trnscth renal symp denrv bil,APC 5192,RVU Per Case,"$5,072.43 ",OP,"5,072.43","5,072.43",,,,,,
UHC MCR ADV,CPT,0342T,Thxp apheresis w/hdl delip,APC 5243,RVU Per Unit,"$4,131.87 ",OP,"4,131.87","4,131.87",,,,,,
UHC MCR ADV,CPT,0345T,Transcath mtral vlve repair,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,0347T,Ins bone device for rsa,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
UHC MCR ADV,CPT,0348T,Rsa spine exam,APC 5522,RVU Per Case,$111.51 ,OP,111.51,111.51,,,,,,
UHC MCR ADV,CPT,0349T,Rsa upper extr exam,APC 5522,RVU Per Case,$111.51 ,OP,111.51,111.51,,,,,,
UHC MCR ADV,CPT,0350T,Rsa lower extr exam,APC 5521,RVU Per Case,$82.79 ,OP,82.79,82.79,,,,,,
UHC MCR ADV,CPT,0355T,Gi tract capsule endoscopy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","1,662.91",,,,,,
UHC MCR ADV,CPT,0356T,Insrt drug device for iop,APC 5692,RVU Per Case,$63.42 ,OP,63.42,63.42,,,,,,
UHC MCR ADV,CPT,0358T,Bia whole body,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
UHC MCR ADV,CPT,0362T,Bhv id suprt assmt ea 15 min,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
UHC MCR ADV,CPT,0373T,Adapt bhv tx ea 15 min,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
UHC MCR ADV,CPT,0379T,Vis field assmnt tech suppt,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
UHC MCR ADV,CPT,0394T,Hdr elctrnc skn surf brchytx,APC 5622,RVU Per Unit,$247.32 ,OP,247.32,247.32,,,,,,
UHC MCR ADV,CPT,0395T,Hdr elctr ntrst/ntrcv brchtx,APC 5624,RVU Per Unit,$724.98 ,OP,724.98,724.98,,,,,,
UHC MCR ADV,CPT,0398T,Mrgfus strtctc les abltj,APC 5463,RVU Per Case,"$11,498.23 ",OP,"11,498.23","11,498.23",,,,,,
UHC MCR ADV,CPT,0402T,Colgn cross-link crn med sep,APC 5503,RVU Per Case,"$2,049.05 ",OP,"2,049.05","2,049.05",,,,,,
UHC MCR ADV,CPT,0404T,Trnscrv uterin fibroid abltj,APC 5416,RVU Per Case,"$6,952.74 ",OP,"4,140.35","9,201.00",,,,,,
UHC MCR ADV,CPT,0408T,Insj/rplc cardiac modulj sys,APC 5231,RVU Per Case,"$23,577.44 ",OP,"23,577.44","23,577.44",,,,,,
UHC MCR ADV,CPT,0409T,Insj/rplc car modulj pls gn,APC 5231,RVU Per Case,"$23,577.44 ",OP,"23,577.44","23,577.44",,,,,,
UHC MCR ADV,CPT,0410T,Insj/rplc car modulj atr elt,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
UHC MCR ADV,CPT,0411T,Insj/rplc car modulj vnt elt,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
UHC MCR ADV,CPT,0412T,Rmvl cardiac modulj pls gen,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
UHC MCR ADV,CPT,0413T,Rmvl car modulj tranvns elt,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
UHC MCR ADV,CPT,0414T,Rmvl & rpl car modulj pls gn,APC 5231,RVU Per Case,"$23,577.44 ",OP,"23,577.44","23,577.44",,,,,,
UHC MCR ADV,CPT,0415T,Repos car modulj tranvns elt,APC 5181,RVU Per Unit,$554.25 ,OP,554.25,554.25,,,,,,
UHC MCR ADV,CPT,0416T,Reloc skin pocket pls gen,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","1,755.36",,,,,,
UHC MCR ADV,CPT,0417T,Prgrmg eval cardiac modulj,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
UHC MCR ADV,CPT,0418T,Interro eval cardiac modulj,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
UHC MCR ADV,CPT,0419T,Dstrj neurofibroma xtnsv,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,536.39,,,,,,
UHC MCR ADV,CPT,0420T,Dstrj neurofibroma xtnsv,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,536.39,,,,,,
UHC MCR ADV,CPT,0421T,Waterjet prostate abltj cmpl,APC 5376,RVU Per Case,"$8,450.70 ",OP,"8,450.70","8,450.70",,,,,,
UHC MCR ADV,CPT,0422T,Tactile breast img uni/bi,APC 5521,RVU Per Case,$82.79 ,OP,82.79,82.79,,,,,,
UHC MCR ADV,CPT,0424T,Insj/rplc nstim apnea compl,APC 5465,RVU Per Case,"$30,131.14 ",OP,"30,131.14","30,131.14",,,,,,
UHC MCR ADV,CPT,0425T,Insj/rplc nstim apnea sen ld,APC 5463,RVU Per Case,"$11,498.23 ",OP,"11,498.23","11,498.23",,,,,,
UHC MCR ADV,CPT,0426T,Insj/rplc nstim apnea stm ld,APC 5463,RVU Per Case,"$11,498.23 ",OP,"11,498.23","11,498.23",,,,,,
UHC MCR ADV,CPT,0427T,Insj/rplc nstim apnea pls gn,APC 5465,RVU Per Case,"$30,131.14 ",OP,"30,131.14","30,131.14",,,,,,
UHC MCR ADV,CPT,0428T,Rmvl nstim apnea pls gen,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
UHC MCR ADV,CPT,0429T,Rmvl nstim apnea sen ld,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
UHC MCR ADV,CPT,0430T,Rmvl nstim apnea stimj ld,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
UHC MCR ADV,CPT,0431T,Rmvl/rplc nstim apnea pls gn,APC 5465,RVU Per Case,"$30,131.14 ",OP,"30,131.14","30,131.14",,,,,,
UHC MCR ADV,CPT,0432T,Repos nstim apnea stimj ld,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
UHC MCR ADV,CPT,0433T,Repos nstim apnea sensing ld,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
UHC MCR ADV,CPT,0434T,Interro eval npgs apnea,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,102.65,,,,,,
UHC MCR ADV,CPT,0435T,Prgrmg eval npgs apnea 1 ses,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,102.65,,,,,,
UHC MCR ADV,CPT,0436T,Prgrmg eval npgs apnea study,APC 5724,RVU Per Unit,$941.27 ,OP,941.27,941.27,,,,,,
UHC MCR ADV,CPT,0440T,Abltj perc uxtr/perph nrv,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","1,795.30",,,,,,
UHC MCR ADV,CPT,0441T,Abltj perc lxtr/perph nrv,APC 5431,RVU Per Case,"$1,795.30 ",OP,"1,795.30","1,795.30",,,,,,
UHC MCR ADV,CPT,0442T,Abltj perc plex/trncl nrv,APC 5432,RVU Per Case,"$5,833.22 ",OP,"5,833.22","5,833.22",,,,,,
UHC MCR ADV,CPT,0446T,Insj impltbl glucose sensor,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","1,755.36",,,,,,
UHC MCR ADV,CPT,0447T,Rmvl impltbl glucose sensor,APC 5051,RVU Per Case,$183.73 ,OP,183.73,183.73,,,,,,
UHC MCR ADV,CPT,0448T,Remvl insj impltbl gluc sens,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","1,755.36",,,,,,
UHC MCR ADV,CPT,0449T,Insj aqueous drain dev 1st,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,009.10",,,,,,
UHC MCR ADV,CPT,0451T,Insj/rplcmt aortic ventr sys,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,0452T,Insj/rplcmt dev vasc seal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,0453T,Insj/rplcmt mech-elec ntrfce,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
UHC MCR ADV,CPT,0454T,Insj/rplcmt subq electrode,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
UHC MCR ADV,CPT,0455T,Remvl aortic ventr cmpl sys,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,0456T,Remvl aortic dev vasc seal,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,0457T,Remvl mech-elec skin ntrfce,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
UHC MCR ADV,CPT,0458T,Remvl subq electrode,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
UHC MCR ADV,CPT,0459T,Relocaj rplcmt aortic ventr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,0460T,Repos aortic ventr dev eltrd,APC 5221,RVU Per Unit,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
UHC MCR ADV,CPT,0461T,Repos aortic contrpulsj dev,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,0462T,Prgrmg eval aortic ventr sys,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,278.82,,,,,,
UHC MCR ADV,CPT,0463T,Interrog aortic ventr sys,APC 5743,RVU Per Unit,$278.82 ,OP,278.82,278.82,,,,,,
UHC MCR ADV,CPT,0464T,Visual ep test for glaucoma,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
UHC MCR ADV,CPT,0465T,Supchrdl njx rx w/o supply,APC 5694,RVU Per Unit,$318.00 ,OP,318,318,,,,,,
UHC MCR ADV,CPT,0467T,Revj/rplmnt ch respir eltrd,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
UHC MCR ADV,CPT,0468T,Rmvl ch wal respir eltrd/ra,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
UHC MCR ADV,CPT,0472T,Prgrmg io rta eltrd ra,APC 5743,RVU Per Case,$278.82 ,OP,278.82,278.82,,,,,,
UHC MCR ADV,CPT,0473T,Reprgrmg io rta eltrd ra,APC 5742,RVU Per Case,$102.65 ,OP,102.65,102.65,,,,,,
UHC MCR ADV,CPT,0476T,Rec ftl car sgl elec tr data,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
UHC MCR ADV,CPT,0477T,Rec ftl car sgl xrtj alys,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
UHC MCR ADV,CPT,0479T,Fxjl abl lsr 1st 100 sq cm,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,536.39,,,,,,
UHC MCR ADV,CPT,0481T,Njx autol wbc concentrate,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
UHC MCR ADV,CPT,0483T,Tmvi percutaneous approach,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,0484T,Tmvi transthoracic exposure,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,0485T,Oct mid ear i&r unilateral,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
UHC MCR ADV,CPT,0486T,Oct mid ear i&r bilateral,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
UHC MCR ADV,CPT,0487T,Trvg biomchn mapg w/reprt,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
UHC MCR ADV,CPT,0491T,Abl lsr opn wnd 1st 20 sqcm,APC 5052,RVU Per Unit,$353.91 ,OP,353.91,353.91,,,,,,
UHC MCR ADV,CPT,0494T,Prep & cannulj cdvr don lung,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,0495T,Mntr cdvr don lng 1st 2 hrs,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,0496T,Mntr cdvr don lng ea addl hr,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,0497T,Xtrnl pt act ecg in-off conn,APC 5741,RVU Per Case,$38.02 ,OP,38.02,"1,574.64",,,,,,
UHC MCR ADV,CPT,0499T,Cysto f/urtl strix/stenosis,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","3,148.08",,,,,,
UHC MCR ADV,CPT,0503T,Cor ffr alys gnrj ffr mdl,APC 1511,RVU Per Unit,$972.67 ,OP,908.19,972.67,,,,,,
UHC MCR ADV,CPT,0505T,Ev fempop artl revsc,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
UHC MCR ADV,CPT,0506T,Mac pgmt opt dns meas hfp,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
UHC MCR ADV,CPT,0507T,Near ifr 2img mibmn glnd i&r,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
UHC MCR ADV,CPT,0508T,Pls echo us b1 dns meas tib,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,111.51,,,,,,
UHC MCR ADV,CPT,0509T,Pattern erg w/i&r,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,386.03,,,,,,
UHC MCR ADV,CPT,0510T,Rmvl sinus tarsi implant,APC 5113,RVU Per Case,"$2,896.40 ",OP,"2,896.40","2,896.40",,,,,,
UHC MCR ADV,CPT,0511T,Rmvl&rinsj sinus tarsi implt,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
UHC MCR ADV,CPT,0512T,Esw integ wnd hlg 1st wnd,APC 5051,RVU Per Unit,$183.73 ,OP,183.73,183.73,,,,,,
UHC MCR ADV,CPT,0515T,Insj wcs lv compl sys,APC 5231,RVU Per Case,"$23,577.44 ",OP,"23,577.44","23,577.44",,,,,,
UHC MCR ADV,CPT,0516T,Insj wcs lv eltrd only,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
UHC MCR ADV,CPT,0517T,Insj wcs lv pg compnt,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
UHC MCR ADV,CPT,0518T,Rmvl pg compnt wcs,APC 5221,RVU Per Unit,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
UHC MCR ADV,CPT,0519T,Rmvl & rplcmt pg compnt wcs,APC 5221,RVU Per Unit,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
UHC MCR ADV,CPT,0520T,Rmvl&rplcmt pg wcs new eltrd,APC 5231,RVU Per Case,"$23,577.44 ",OP,"23,577.44","23,577.44",,,,,,
UHC MCR ADV,CPT,0521T,Interrog dev eval wcs ip,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
UHC MCR ADV,CPT,0522T,Prgrmg dev eval wcs ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
UHC MCR ADV,CPT,0524T,Ev cath dir chem abltj w/img,APC 5183,RVU Per Case,"$2,928.39 ",OP,"2,928.39","2,928.39",,,,,,
UHC MCR ADV,CPT,0525T,Insj/rplcmt compl iims,APC 5223,RVU Per Case,"$10,642.67 ",OP,"10,642.67","10,642.67",,,,,,
UHC MCR ADV,CPT,0526T,Insj/rplcmt iims eltrd only,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
UHC MCR ADV,CPT,0527T,Insj/rplcmt iims implt mntr,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
UHC MCR ADV,CPT,0528T,Prgrmg dev eval iims ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
UHC MCR ADV,CPT,0529T,Interrog dev eval iims ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
UHC MCR ADV,CPT,0530T,Removal complete iims,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
UHC MCR ADV,CPT,0531T,Removal iims electrode only,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
UHC MCR ADV,CPT,0532T,Removal iims implt mntr only,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
UHC MCR ADV,CPT,0534T,Cont rec mvmt do setup&train,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
UHC MCR ADV,CPT,0535T,Cont rec mvmt do reprt cnfig,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
UHC MCR ADV,CPT,0540T,Car-t cll admn autologous,APC 5694,RVU Per Unit,$318.00 ,OP,318,318,,,,,,
UHC MCR ADV,CPT,0541T,Myocardial imaging mcg,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
UHC MCR ADV,CPT,0543T,Ta mv rpr w/artif chord tend,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,0544T,Tcat mv annulus rcnstj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,0545T,Tcat tv annulus rcnstj,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,0548T,Tprnl balo cntnc dev bi,APC 5377,RVU Per Case,"$11,755.91 ",OP,"11,755.91","11,755.91",,,,,,
UHC MCR ADV,CPT,0549T,Tprnl balo cntnc dev uni,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,516.83","4,516.83",,,,,,
UHC MCR ADV,CPT,0550T,Tprnl balo cntnc dev rmvl ea,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","3,148.08",,,,,,
UHC MCR ADV,CPT,0551T,Tprnl balo cntnc dev adjmt,APC 5371,RVU Per Unit,$272.35 ,OP,272.35,272.35,,,,,,
UHC MCR ADV,CPT,0555T,B1 str&fx rsk transmis data,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,25.25,,,,,,
UHC MCR ADV,CPT,0556T,B1 str & fx rsk assessment,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,235.49,,,,,,
UHC MCR ADV,CPT,0558T,Ct scan f/biomchn ct alys,APC 5521,RVU Per Unit,$82.79 ,OP,82.79,927,,,,,,
UHC MCR ADV,CPT,0559T,Antmc mdl 3d print 1st cmpnt,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
UHC MCR ADV,CPT,0561T,Antmc guide 3d print 1st gd,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
UHC MCR ADV,CPT,0563T,Evac meibomian glnd heat bi,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
UHC MCR ADV,CPT,0564T,Onc chemo rx cytotox csc 14,APC 5671,RVU Per Case,$50.92 ,OP,50.92,50.92,,,,,,
UHC MCR ADV,CPT,0565T,Autol cell implt adps hrvg,APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
UHC MCR ADV,CPT,0566T,Autol cell implt adps njx,APC 5441,RVU Per Unit,$267.26 ,OP,267.26,267.26,,,,,,
UHC MCR ADV,CPT,0569T,Ttvr perq appr 1st prosth,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,0570T,Ttvr perq ea addl prosth,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,0571T,Insj/rplcmt icds ss eltrd,APC 5232,RVU Per Case,"$33,604.66 ",OP,"33,604.66","33,604.66",,,,,,
UHC MCR ADV,CPT,0572T,Insertion ss dfb electrode,APC 5222,RVU Per Case,"$8,342.69 ",OP,"8,342.69","8,342.69",,,,,,
UHC MCR ADV,CPT,0573T,Removal ss dfb electrode,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
UHC MCR ADV,CPT,0574T,Repos prev ss impl dfb eltrd,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
UHC MCR ADV,CPT,0575T,Prgrmg dev eval icds ss ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
UHC MCR ADV,CPT,0576T,Interrog dev eval icds ss ip,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
UHC MCR ADV,CPT,0577T,Ephys eval icds ss,APC 5211,RVU Per Case,"$1,138.72 ",OP,"1,138.72","2,775.65",,,,,,
UHC MCR ADV,CPT,0579T,Rem interrog dev icds tech,APC 5741,RVU Per Case,$38.02 ,OP,38.02,213.51,,,,,,
UHC MCR ADV,CPT,0580T,Rmvl ss impl dfb pg only,APC 5221,RVU Per Case,"$3,520.60 ",OP,"3,520.60","3,520.60",,,,,,
UHC MCR ADV,CPT,0583T,Tmpst auto tube dlvr sys,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","1,384.33",,,,,,
UHC MCR ADV,CPT,0584T,Perq islet cell transplant,APC 5881,RVU Per Case,"$8,948.83 ",OP,"2,508.76","8,948.83",,,,,,
UHC MCR ADV,CPT,0585T,Laps islet cell transplant,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,254.96","8,948.83",,,,,,
UHC MCR ADV,CPT,0586T,Open islet cell transplant,APC 5881,RVU Per Case,"$8,948.83 ",OP,"6,965.79","8,948.83",,,,,,
UHC MCR ADV,CPT,0587T,Perq impltj/rplcmt isdns ptn,APC 5462,RVU Per Case,"$6,304.35 ",OP,"6,304.35","6,304.35",,,,,,
UHC MCR ADV,CPT,0588T,Revision/removal isdns ptn,APC 5461,RVU Per Case,"$3,351.68 ",OP,"3,351.68","3,351.68",,,,,,
UHC MCR ADV,CPT,0589T,Elec alys smpl prgrmg iins,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,255.45,,,,,,
UHC MCR ADV,CPT,0590T,Elec alys cplx prgrmg iins,APC 5742,RVU Per Unit,$102.65 ,OP,102.65,255.45,,,,,,
UHC MCR ADV,CPT,0594T,Osteot hum xtrnl lngth dev,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
UHC MCR ADV,CPT,0596T,Temp fml iu vlv-pmp 1st insj,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,588.17,,,,,,
UHC MCR ADV,CPT,0597T,Temp fml iu valve-pmp rplcmt,APC 5372,RVU Per Unit,$588.17 ,OP,588.17,588.17,,,,,,
UHC MCR ADV,CPT,0598T,Ncntc r-t fluor wnd img 1st,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
UHC MCR ADV,CPT,0600T,Ire abltj 1+tum organ perq,APC 5362,RVU Per Case,"$9,115.38 ",OP,"9,115.38","9,115.38",,,,,,
UHC MCR ADV,CPT,0601T,Ire abltj 1+tumors open,APC 5362,RVU Per Case,"$9,115.38 ",OP,"9,115.38","9,115.38",,,,,,
UHC MCR ADV,CPT,0604T,Rem oct rta dev setup&educaj,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,121.51,,,,,,
UHC MCR ADV,CPT,0605T,Rem oct rta techl sprt min 8,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
UHC MCR ADV,CPT,0607T,Rem mntr pulm flu mntr setup,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,121.51,,,,,,
UHC MCR ADV,CPT,0608T,Rem mntr pulm flu mntr alys,APC 5741,RVU Per Unit,$38.02 ,OP,38.02,38.02,,,,,,
UHC MCR ADV,CPT,0609T,Mrs disc pain acquisj data,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
UHC MCR ADV,CPT,0611T,Mrs disc pain alg alys data,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,"1,507.00",,,,,,
UHC MCR ADV,CPT,0614T,Rmvl&rplcmt ss impl dfb pg,APC 5231,RVU Per Case,"$23,577.44 ",OP,"23,577.44","23,577.44",,,,,,
UHC MCR ADV,CPT,0615T,Eye mvmt alys w/o calbrj i&r,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
UHC MCR ADV,CPT,0616T,Insertion of iris prosthesis,APC 5491,RVU Per Case,"$2,127.64 ",OP,"2,127.64","2,127.64",,,,,,
UHC MCR ADV,CPT,0617T,Insj iris prosth w/rmvl&insj,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,009.10",,,,,,
UHC MCR ADV,CPT,0618T,Insj iris prosth sec io lens,APC 5492,RVU Per Case,"$4,009.10 ",OP,"4,009.10","4,009.10",,,,,,
UHC MCR ADV,CPT,0619T,Cysto w/prst8 commissurotomy,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,516.83","4,516.83",,,,,,
UHC MCR ADV,CPT,0620T,Evasc ven artlz tibl/prnl vn,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
UHC MCR ADV,CPT,0627T,Perq njx algc fluor lmbr 1st,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
UHC MCR ADV,CPT,0629T,Perq njx algc ct lmbr 1st,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
UHC MCR ADV,CPT,0631T,Tc vis lit hyperspectral img,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
UHC MCR ADV,CPT,0632T,Perq tcat us abltj nrv p-art,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
UHC MCR ADV,CPT,0633T,Ct breast w/3d uni c-,APC 5522,RVU Per Case,$111.51 ,OP,111.51,111.51,,,,,,
UHC MCR ADV,CPT,0634T,Ct breast w/3d uni c+,APC 5571,RVU Per Case,$182.72 ,OP,182.72,182.72,,,,,,
UHC MCR ADV,CPT,0635T,Ct breast w/3d uni c-/c+,APC 5571,RVU Per Case,$182.72 ,OP,182.72,182.72,,,,,,
UHC MCR ADV,CPT,0636T,Ct breast w/3d bi c-,APC 5523,RVU Per Case,$235.49 ,OP,235.49,235.49,,,,,,
UHC MCR ADV,CPT,0637T,Ct breast w/3d bi c+,APC 5572,RVU Per Case,$376.70 ,OP,376.7,376.7,,,,,,
UHC MCR ADV,CPT,0638T,Ct breast w/3d bi c-/c+,APC 5572,RVU Per Case,$376.70 ,OP,376.7,376.7,,,,,,
UHC MCR ADV,CPT,0641T,Ncntc nr ifr spctrsc wnd img,APC 5732,RVU Per Unit,$34.63 ,OP,34.63,34.63,,,,,,
UHC MCR ADV,CPT,0644T,Tcat rmvl/dblk icar mas perq,APC 5192,RVU Per Case,"$5,072.43 ",OP,"5,072.43","5,072.43",,,,,,
UHC MCR ADV,CPT,0647T,Insj gtube perq mag gastrpxy,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","1,662.91",,,,,,
UHC MCR ADV,CPT,0648T,Quan mr alys tiss w/o mri,APC 5523,RVU Per Unit,$235.49 ,OP,235.49,235.49,,,,,,
UHC MCR ADV,CPT,0650T,Prgrmg dev eval scrms remote,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
UHC MCR ADV,CPT,0651T,Mag ctrld capsule endoscopy,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,828.48,,,,,,
UHC MCR ADV,CPT,0652T,Egd flx transnasal dx br/wa,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,828.48,,,,,,
UHC MCR ADV,CPT,0653T,Egd flx transnasal bx 1/ml,APC 5301,RVU Per Unit,$828.48 ,OP,828.48,828.48,,,,,,
UHC MCR ADV,CPT,0654T,Egd flx transnasal tube/cath,APC 5302,RVU Per Case,"$1,662.91 ",OP,"1,662.91","1,662.91",,,,,,
UHC MCR ADV,CPT,0655T,Tprnl focal abltj mal prst8,APC 5374,RVU Per Case,"$3,148.08 ",OP,"3,148.08","3,148.08",,,,,,
UHC MCR ADV,CPT,0656T,Vrt bdy tethering ant,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,0657T,Vrt bdy tethering ant 8+ seg,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,0658T,Elec impd spectrsc 1+skn les,APC 5733,RVU Per Unit,$56.95 ,OP,56.95,56.95,,,,,,
UHC MCR ADV,CPT,0659T,Tcat intra-c nfs supersat o2,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,0662T,Scalp cool 1st meas&calbrj,APC 5732,RVU Per Unit,$34.63 ,OP,34.63,34.63,,,,,,
UHC MCR ADV,CPT,A0425,Ground mileage,Ambulance,Per Unit,$7.47 ,OP,7.47,7.47,,,,,,
UHC MCR ADV,CPT,A0426,Als 1,Ambulance,Per Case,$231.98 ,OP,231.98,"2,249.49",,,,,,
UHC MCR ADV,CPT,A0427,Als1-emergency,Ambulance,Per Case,$231.98 ,OP,231.98,"2,287.62",,,,,,
UHC MCR ADV,CPT,A0428,Bls,Ambulance,Per Case,$231.98 ,OP,231.98,231.98,,,,,,
UHC MCR ADV,CPT,A0429,Bls-emergency,Ambulance,Per Case,$231.98 ,OP,231.98,"1,883.47",,,,,,
UHC MCR ADV,CPT,A0430,Fixed wing air transport,Ambulance,Per Case,"$3,147.91 ",OP,"3,147.91","3,147.91",,,,,,
UHC MCR ADV,CPT,A0431,Rotary wing air transport,Ambulance,Per Case,"$3,659.92 ",OP,"3,659.92","3,659.92",,,,,,
UHC MCR ADV,CPT,A0432,Pi volunteer ambulance co,Ambulance,Per Case,$231.98 ,OP,231.98,231.98,,,,,,
UHC MCR ADV,CPT,A0433,Als 2,Ambulance,Per Case,$231.98 ,OP,231.98,"2,859.52",,,,,,
UHC MCR ADV,CPT,A0434,Specialty care transport,Ambulance,Per Case,$231.98 ,OP,231.98,"6,100.31",,,,,,
UHC MCR ADV,CPT,A0435,Fixed wing air mileage,Ambulance,Per Unit,$8.93 ,OP,8.93,8.93,,,,,,
UHC MCR ADV,CPT,A0436,Rotary wing air mileage,Ambulance,Per Unit,$23.83 ,OP,23.83,23.83,,,,,,
UHC MCR ADV,CPT,A4563,Vag inser rectal control sys,Durable Medical Equipment,Per Unit,"$1,372.71 ",OP,"1,372.71","1,372.71",,,,,,
UHC MCR ADV,CPT,A9513,Lutetium lu 177 dotatat ther,APC 9067,Per Unit,$274.33 ,OP,274.33,274.33,,,,,,
UHC MCR ADV,CPT,A9517,I131 iodide cap- rx,APC 1064,Per Unit,$20.12 ,OP,20.12,32.18,,,,,,
UHC MCR ADV,CPT,A9527,Iodine i-125 sodium iodide,APC 2632,Per Unit,$30.66 ,OP,30.66,30.66,,,,,,
UHC MCR ADV,CPT,A9530,I131 iodide sol- rx,APC 1150,Per Unit,$13.34 ,OP,13.34,13.34,,,,,,
UHC MCR ADV,CPT,A9543,Y90 ibritumomab- rx,APC 1643,Per Unit,"$59,793.85 ",OP,"59,793.85","59,793.85",,,,,,
UHC MCR ADV,CPT,A9563,P32 na phosphate,APC 1675,Per Unit,$458.34 ,OP,458.34,458.34,,,,,,
UHC MCR ADV,CPT,A9590,Iodine i-131 iobenguane 1mci,APC 9339,Per Unit,$320.12 ,OP,320.12,320.12,,,,,,
UHC MCR ADV,CPT,A9591,Fluoroestradiol f 18,APC 9370,Per Unit,$644.83 ,OP,644.83,644.83,,,,,,
UHC MCR ADV,CPT,A9592,Copper cu 64 dotatate diag,APC 9383,Per Unit,$918.21 ,OP,918.21,918.21,,,,,,
UHC MCR ADV,CPT,A9593,Gallium ga-68 psma-11 ucsf,APC 9409,Per Unit,$732.86 ,OP,732.86,732.86,,,,,,
UHC MCR ADV,CPT,A9594,Gallium ga-68 psma-11- ucla,APC 9410,Per Unit,$717.55 ,OP,717.55,717.55,,,,,,
UHC MCR ADV,CPT,A9600,Sr89 strontium,APC 0701,Per Unit,"$3,975.00 ",OP,"3,975.00","4,407.46",,,,,,
UHC MCR ADV,CPT,A9604,Sm 153 lexidronam,APC 1295,Per Unit,"$17,259.85 ",OP,"17,259.85","17,259.85",,,,,,
UHC MCR ADV,CPT,A9606,Radium ra223 dichloride ther,APC 1745,Per Unit,$145.65 ,OP,145.65,145.65,,,,,,
UHC MCR ADV,CPT,C1052,Hemostatic agent- gi- topic,APC 2031,Straight Discount,29.70%,OP,,,,,,,,
UHC MCR ADV,CPT,C1062,Intravertebral fx aug impl,APC 2032,Straight Discount,29.70%,OP,,,,,,,,
UHC MCR ADV,CPT,C1716,Brachytx- non-str- gold-198,APC 2645,Per Unit,$330.76 ,OP,330.76,330.76,,,,,,
UHC MCR ADV,CPT,C1717,Brachytx- non-str-hdr ir-192,APC 2646,Per Unit,$383.90 ,OP,383.9,383.9,,,,,,
UHC MCR ADV,CPT,C1719,Brachytx- ns- non-hdrir-192,APC 2647,Per Unit,$323.97 ,OP,323.97,323.97,,,,,,
UHC MCR ADV,CPT,C1734,Orth/devic/drug bn/bn-tis/bn,APC 2026,Straight Discount,29.70%,OP,,,,,,,,
UHC MCR ADV,CPT,C1748,Endoscope- single- ugi,APC 2029,Straight Discount,29.70%,OP,,,,,,,,
UHC MCR ADV,CPT,C1761,Cath- trans intra litho/coro,APC 2033,Straight Discount,29.70%,OP,,,,,,,,
UHC MCR ADV,CPT,C1823,Gen- neuro- trans sen/stim,APC 2993,Straight Discount,29.70%,OP,,,,,,,,
UHC MCR ADV,CPT,C1824,Generator- ccm- implant,APC 2024,Straight Discount,29.70%,OP,,,,,,,,
UHC MCR ADV,CPT,C1825,Gen- neuro- carot sinus baro,APC 2030,Straight Discount,29.70%,OP,,,,,,,,
UHC MCR ADV,CPT,C1831,Personalized interbody cage,APC 2034,Straight Discount,29.70%,OP,,,,,,,,
UHC MCR ADV,CPT,C1839,Iris prosthesis,APC 2028,Straight Discount,29.70%,OP,,,,,,,,
UHC MCR ADV,CPT,C1982,Cath- pressure-valve-occlu,APC 2025,Straight Discount,29.70%,OP,,,,,,,,
UHC MCR ADV,CPT,C2596,Probe- robotic- water-jet,APC 2027,Straight Discount,29.70%,OP,,,,,,,,
UHC MCR ADV,CPT,C2616,Brachytx- non-str-yttrium-90,APC 2616,Per Unit,"$19,955.81 ",OP,"19,955.81","19,955.81",,,,,,
UHC MCR ADV,CPT,C2634,Brachytx- non-str- ha- i-125,APC 2634,Per Unit,$169.87 ,OP,169.87,169.87,,,,,,
UHC MCR ADV,CPT,C2635,Brachytx- non-str- ha- p-103,APC 2635,Per Unit,$52.25 ,OP,52.25,52.25,,,,,,
UHC MCR ADV,CPT,C2636,Brachy linear- non-str-p-103,APC 2636,Per Unit,$36.02 ,OP,36.02,36.02,,,,,,
UHC MCR ADV,CPT,C2638,Brachytx- stranded- i-125,APC 2638,Per Unit,$42.90 ,OP,42.9,42.9,,,,,,
UHC MCR ADV,CPT,C2639,Brachytx- non-stranded-i-125,APC 2639,Per Unit,$39.11 ,OP,39.11,39.11,,,,,,
UHC MCR ADV,CPT,C2640,Brachytx- stranded- p-103,APC 2640,Per Unit,$100.65 ,OP,100.65,100.65,,,,,,
UHC MCR ADV,CPT,C2641,Brachytx- non-stranded-p-103,APC 2641,Per Unit,$79.72 ,OP,79.72,79.72,,,,,,
UHC MCR ADV,CPT,C2642,Brachytx- stranded- c-131,APC 2642,Per Unit,$82.43 ,OP,82.43,82.43,,,,,,
UHC MCR ADV,CPT,C2643,Brachytx- non-stranded-c-131,APC 2643,Per Unit,$92.16 ,OP,92.16,92.16,,,,,,
UHC MCR ADV,CPT,C2645,Brachytx planar- p-103,APC 2648,Per Unit,$5.38 ,OP,5.38,5.38,,,,,,
UHC MCR ADV,CPT,C2698,Brachytx- stranded- nos,APC 2698,Per Unit,$42.90 ,OP,42.9,42.9,,,,,,
UHC MCR ADV,CPT,C2699,Brachytx- non-stranded- nos,APC 2699,Per Unit,$36.02 ,OP,36.02,36.02,,,,,,
UHC MCR ADV,CPT,C5271,Low cost skin substitute app,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,536.39,,,,,,
UHC MCR ADV,CPT,C5273,Low cost skin substitute app,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","1,755.36",,,,,,
UHC MCR ADV,CPT,C5275,Low cost skin substitute app,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,536.39,,,,,,
UHC MCR ADV,CPT,C5277,Low cost skin substitute app,APC 5053,RVU Per Unit,$536.39 ,OP,536.39,536.39,,,,,,
UHC MCR ADV,CPT,C8900,Mra w/cont- abd,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
UHC MCR ADV,CPT,C8901,Mra w/o cont- abd,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
UHC MCR ADV,CPT,C8902,Mra w/o fol w/cont- abd,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
UHC MCR ADV,CPT,C8903,Mri w/cont- breast-  uni,APC 5571,RVU Per Case,$182.72 ,OP,182.72,"1,507.00",,,,,,
UHC MCR ADV,CPT,C8905,Mri w/o fol w/cont- brst- un,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
UHC MCR ADV,CPT,C8906,Mri w/cont- breast-  bi,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
UHC MCR ADV,CPT,C8908,Mri w/o fol w/cont- breast-,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
UHC MCR ADV,CPT,C8909,Mra w/cont- chest,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
UHC MCR ADV,CPT,C8910,Mra w/o cont- chest,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
UHC MCR ADV,CPT,C8911,Mra w/o fol w/cont- chest,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
UHC MCR ADV,CPT,C8912,Mra w/cont- lwr ext,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
UHC MCR ADV,CPT,C8913,Mra w/o cont- lwr ext,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
UHC MCR ADV,CPT,C8914,Mra w/o fol w/cont- lwr ext,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
UHC MCR ADV,CPT,C8918,Mra w/cont- pelvis,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
UHC MCR ADV,CPT,C8919,Mra w/o cont- pelvis,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
UHC MCR ADV,CPT,C8920,Mra w/o fol w/cont- pelvis,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
UHC MCR ADV,CPT,C8921,Tte w or w/o fol w/cont- com,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
UHC MCR ADV,CPT,C8922,Tte w or w/o fol w/cont- f/u,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
UHC MCR ADV,CPT,C8923,2d tte w or w/o fol w/con-co,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
UHC MCR ADV,CPT,C8924,2d tte w or w/o fol w/con-fu,APC 5572,RVU Per Unit,$376.70 ,OP,376.7,376.7,,,,,,
UHC MCR ADV,CPT,C8925,2d tee w or w/o fol w/con-in,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
UHC MCR ADV,CPT,C8926,Tee w or w/o fol w/cont-cong,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
UHC MCR ADV,CPT,C8927,Tee w or w/o fol w/cont- mon,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
UHC MCR ADV,CPT,C8928,Tte w or w/o fol w/con-stres,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
UHC MCR ADV,CPT,C8929,Tte w or wo fol wcon-doppler,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
UHC MCR ADV,CPT,C8930,Tte w or w/o contr- cont ecg,APC 5573,RVU Per Unit,$731.85 ,OP,731.85,731.85,,,,,,
UHC MCR ADV,CPT,C8931,Mra- w/dye- spinal canal,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
UHC MCR ADV,CPT,C8932,Mra- w/o dye- spinal canal,APC 5523,RVU Per Case,$235.49 ,OP,235.49,"1,507.00",,,,,,
UHC MCR ADV,CPT,C8933,Mra- w/o&w/dye- spinal canal,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
UHC MCR ADV,CPT,C8934,Mra- w/dye- upper extremity,APC 5572,RVU Per Case,$376.70 ,OP,376.7,"1,507.00",,,,,,
UHC MCR ADV,CPT,C8935,Mra- w/o dye- upper extr,APC 5523,RVU Per Case,$235.49 ,OP,235.49,235.49,,,,,,
UHC MCR ADV,CPT,C8936,Mra- w/o&w/dye- upper extr,APC 5572,RVU Per Case,$376.70 ,OP,376.7,376.7,,,,,,
UHC MCR ADV,CPT,C8957,Prolonged iv inf- req pump,APC 5694,RVU Per Unit,$318.00 ,OP,318,318,,,,,,
UHC MCR ADV,CPT,C9046,Cocaine hcl nasal solution,APC 9307,Per Unit,$1.33 ,OP,1.33,1.33,,,,,,
UHC MCR ADV,CPT,C9047,Injection- caplacizumab-yhdp,APC 9199,Per Unit,$691.29 ,OP,691.29,691.29,,,,,,
UHC MCR ADV,CPT,C9067,Gallium ga-68 dotatoc,APC 9323,Per Unit,$8.64 ,OP,8.64,8.64,,,,,,
UHC MCR ADV,CPT,C9081,Idecabtagene car pos t,APC 9422,Per Unit,"$432,085.00 ",OP,"432,085.00","432,085.00",,,,,,
UHC MCR ADV,CPT,C9082,Inj dostarlimab-gxly- 100 mg,APC 9423,Per Unit,"$2,136.09 ",OP,"2,136.09","2,136.09",,,,,,
UHC MCR ADV,CPT,C9083,Inj- amivantamab-vmjw- 10 mg,APC 9424,Per Unit,$87.89 ,OP,87.89,87.89,,,,,,
UHC MCR ADV,CPT,C9084,loncastuximab-lpyl- 0.1 mg,APC 9425,Per Unit,$242.05 ,OP,242.05,242.05,,,,,,
UHC MCR ADV,CPT,C9248,Inj- clevidipine butyrate,APC 9087,Per Unit,$2.91 ,OP,2.91,2.91,,,,,,
UHC MCR ADV,CPT,C9250,Artiss fibrin sealant,APC 1848,Per Unit,$156.84 ,OP,156.84,156.84,,,,,,
UHC MCR ADV,CPT,C9257,Bevacizumab injection,APC 1281,Per Unit,$1.76 ,OP,1.76,1.76,,,,,,
UHC MCR ADV,CPT,C9460,Injection- cangrelor,APC 9460,Per Unit,$16.32 ,OP,16.32,16.32,,,,,,
UHC MCR ADV,CPT,C9462,Injection- delafloxacin,APC 9462,Per Unit,$0.37 ,OP,0.37,0.37,,,,,,
UHC MCR ADV,CPT,C9482,Sotalol hydrochloride iv,APC 9482,Per Unit,$17.58 ,OP,17.58,17.58,,,,,,
UHC MCR ADV,CPT,C9488,Conivaptan hcl,APC 9488,Per Unit,$43.94 ,OP,43.94,43.94,,,,,,
UHC MCR ADV,CPT,C9600,Perc drug-el cor stent sing,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
UHC MCR ADV,CPT,C9602,Perc d-e cor stent ather s,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
UHC MCR ADV,CPT,C9604,Perc d-e cor revasc t cabg s,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
UHC MCR ADV,CPT,C9606,Perc d-e cor revasc w ami s,APC 5881,RVU Per Case,"$8,948.83 ",OP,"8,948.83","8,948.83",,,,,,
UHC MCR ADV,CPT,C9607,Perc d-e cor revasc chro sin,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
UHC MCR ADV,CPT,C9725,Place endorectal app,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,812.16,,,,,,
UHC MCR ADV,CPT,C9727,Insert palate implants,APC 5163,RVU Per Case,"$1,384.33 ",OP,"1,384.33","1,384.33",,,,,,
UHC MCR ADV,CPT,C9728,Place device/marker- non pro,APC 5613,RVU Per Unit,"$1,291.62 ",OP,"1,291.62","1,291.62",,,,,,
UHC MCR ADV,CPT,C9733,Non-ophthalmic fva,APC 5572,RVU Per Case,$376.70 ,OP,376.7,376.7,,,,,,
UHC MCR ADV,CPT,C9734,U/s trtmt- not leiomyomata,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
UHC MCR ADV,CPT,C9739,Cystoscopy prostatic imp 1-3,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,516.83","4,516.83",,,,,,
UHC MCR ADV,CPT,C9740,Cysto impl 4 or more,APC 5376,RVU Per Case,"$8,450.70 ",OP,"8,450.70","8,450.70",,,,,,
UHC MCR ADV,CPT,C9752,Intraosseous des lumb/sacrum,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
UHC MCR ADV,CPT,C9757,Spine/lumbar disk surgery,APC 5115,RVU Per Case,"$12,601.93 ",OP,"12,601.93","12,601.93",,,,,,
UHC MCR ADV,CPT,C9761,Cysto- litho- vacuum kidney,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,516.83","4,516.83",,,,,,
UHC MCR ADV,CPT,C9762,Cardiac mri seg dys strain,APC 5524,RVU Per Case,$494.15 ,OP,494.15,494.15,,,,,,
UHC MCR ADV,CPT,C9763,Cardiac mri seg dys stress,APC 5524,RVU Per Case,$494.15 ,OP,494.15,494.15,,,,,,
UHC MCR ADV,CPT,C9764,Revasc intravasc lithotripsy,APC 5192,RVU Per Case,"$5,072.43 ",OP,"5,072.43","5,072.43",,,,,,
UHC MCR ADV,CPT,C9765,Revasc intra lithotrip-stent,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
UHC MCR ADV,CPT,C9766,Revasc intra lithotrip-ather,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
UHC MCR ADV,CPT,C9767,Revasc lithotrip-stent-ather,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
UHC MCR ADV,CPT,C9769,Cysto w/temp pros implant,APC 5375,RVU Per Case,"$4,516.83 ",OP,"4,516.83","4,516.83",,,,,,
UHC MCR ADV,CPT,C9771,Nsl/sins cryo post nasal tis,APC 5164,RVU Per Case,"$2,800.20 ",OP,"2,800.20","2,800.20",,,,,,
UHC MCR ADV,CPT,C9772,Revasc lithotrip tibi/perone,APC 5193,RVU Per Case,"$10,277.14 ",OP,"10,277.14","10,277.14",,,,,,
UHC MCR ADV,CPT,C9773,Revasc lithotr-stent tib/per,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
UHC MCR ADV,CPT,C9774,Revasc lithotr-ather tib/per,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
UHC MCR ADV,CPT,C9775,Revasc lith-sten-ath tib/per,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
UHC MCR ADV,CPT,C9778,Colpopexy- min/inv- ex-perit,APC 5414,RVU Per Case,"$2,684.38 ",OP,"2,684.38","2,684.38",,,,,,
UHC MCR ADV,CPT,C9779,ESD endoscopy or colonoscopy,APC 5313,RVU Per Case,"$2,500.37 ",OP,"2,500.37","2,500.37",,,,,,
UHC MCR ADV,CPT,C9780,Insert cv cath inf & sup app,APC 1534,RVU Per Unit,"$8,442.89 ",OP,"7,883.19","8,442.89",,,,,,
UHC MCR ADV,CPT,C9803,Hopd covid-19 spec collect,APC 5731,RVU Per Case,$25.25 ,OP,25.25,25.25,,,,,,
UHC MCR ADV,CPT,D0150,Comprehensve oral evaluation,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D0240,Intraoral occlusal film,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D0250,Extraoral 2d project image,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D0251,Extraoral posterior image,APC 5521,RVU Per Case,$82.79 ,OP,82.79,82.79,,,,,,
UHC MCR ADV,CPT,D0270,Dental bitewing single image,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D0272,Dental bitewings two images,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D0274,Bitewings four images,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D0277,Vert bitewings 7 to 8 images,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D0460,Pulp vitality test,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D0600,Non-ionizing diag proc,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D1510,Space maintainer fxd unilat,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D1516,Fixed bilat space maint- max,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D1517,Fixed bilat space maint- man,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D1520,Remove unilat space maintain,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D1526,Remove bilat space main- max,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D1527,Remove bilat space main- man,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D1551,Recement space maint - max,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D1552,Recement space maint - man,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D1553,Recement unilat space maint,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D1575,Dist space maint- fixed unil,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D2999,Dental unspec restorative pr,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D3460,Endodontic endosseous implan,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D3999,Endodontic procedure,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D4260,Osseous surgery 4 or more,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D4263,Bone replce graft first site,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D4264,Bone replce graft each add,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D4268,Surgical revision procedure,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D4270,Pedicle soft tissue graft pr,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D4273,Auto tissue graft 1st tooth,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D4355,Full mouth debridement,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D4381,Localized delivery antimicro,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D5911,Facial moulage sectional,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D5912,Facial moulage complete,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D5983,Radiation applicator,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D5984,Radiation shield,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D5985,Radiation cone locator,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D5987,Commissure splint,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D6920,Dental connector bar,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D7111,Extraction coronal remnants,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D7140,Extraction erupted tooth/exr,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D7210,Rem imp tooth w mucoper flp,APC 5871,RVU Per Unit,"$1,426.03 ",OP,953.17,"1,426.03",,,,,,
UHC MCR ADV,CPT,D7220,Impact tooth remov soft tiss,APC 5871,RVU Per Unit,"$1,426.03 ",OP,953.17,"1,426.03",,,,,,
UHC MCR ADV,CPT,D7230,Impact tooth remov part bony,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,391.64","1,426.03",,,,,,
UHC MCR ADV,CPT,D7240,Impact tooth remov comp bony,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,715.71",,,,,,
UHC MCR ADV,CPT,D7241,Impact tooth rem bony w/comp,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","2,001.67",,,,,,
UHC MCR ADV,CPT,D7250,Tooth root removal,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D7260,Oral antral fistula closure,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D7261,Primary closure sinus perf,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D7291,Transseptal fiberotomy,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D7940,Reshaping bone orthognathic,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D9930,Treatment of complications,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D9944,Occ guard- hard- full arch,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D9945,Occ guard- soft- full arch,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D9946,Occ guard- hard- part arch,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D9950,Occlusion analysis,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D9951,Limited occlusal adjustment,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,D9952,Complete occlusal adjustment,APC 5871,RVU Per Unit,"$1,426.03 ",OP,"1,426.03","1,426.03",,,,,,
UHC MCR ADV,CPT,G0008,Admin influenza virus vac,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,57.19,,,,,,
UHC MCR ADV,CPT,G0009,Admin pneumococcal vaccine,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,57.19,,,,,,
UHC MCR ADV,CPT,G0010,Admin hepatitis b vaccine,APC 5691,RVU Per Unit,$40.93 ,OP,40.93,57.19,,,,,,
UHC MCR ADV,CPT,G0027,Semen analysis,Lab Services,Per Unit,$6.50 ,OP,6.5,34.31,,,,,,
UHC MCR ADV,CPT,G0101,Ca screen-pelvic/breast exam,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,186.82,,,,,,
UHC MCR ADV,CPT,G0103,Psa screening,Lab Services,Per Unit,$19.31 ,OP,19.31,80.07,,,,,,
UHC MCR ADV,CPT,G0104,Ca screen-flexi sigmoidscope,APC 5311,RVU Per Unit,$812.16 ,OP,678.66,812.16,,,,,,
UHC MCR ADV,CPT,G0105,Colorectal scrn- hi risk ind,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,812.16,,,,,,
UHC MCR ADV,CPT,G0106,Colon ca screen-barium enema,APC 5571,RVU Per Unit,$182.72 ,OP,182.72,"1,090.43",,,,,,
UHC MCR ADV,CPT,G0108,Diab manage trn  per indiv,Physician,Per Unit,$54.47 ,OP,54.47,125.82,,,,,,
UHC MCR ADV,CPT,G0109,Diab manage trn ind/group,Physician,Per Unit,$15.18 ,OP,15.18,72.44,,,,,,
UHC MCR ADV,CPT,G0117,Glaucoma scrn hgh risk direc,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,232.58,,,,,,
UHC MCR ADV,CPT,G0118,Glaucoma scrn hgh risk direc,APC 5732,RVU Per Unit,$34.63 ,OP,34.63,160.13,,,,,,
UHC MCR ADV,CPT,G0120,Colon ca scrn- barium enema,APC 5572,RVU Per Unit,$376.70 ,OP,376.7,"1,090.43",,,,,,
UHC MCR ADV,CPT,G0121,Colon ca scrn not hi rsk ind,APC 5311,RVU Per Unit,$812.16 ,OP,812.16,812.16,,,,,,
UHC MCR ADV,CPT,G0123,Screen cerv/vag thin layer,Lab Services,Per Unit,$20.26 ,OP,20.26,91.51,,,,,,
UHC MCR ADV,CPT,G0127,Trim nail(s),APC 5733,RVU Per Case,$56.95 ,OP,56.95,56.95,,,,,,
UHC MCR ADV,CPT,G0129,Partial hosp prog service,APC 5853,RVU Per Case,$266.56 ,OP,266.56,266.56,,,,,,
UHC MCR ADV,CPT,G0130,Single energy x-ray study,APC 5522,RVU Per Unit,$111.51 ,OP,111.51,171.58,,,,,,
UHC MCR ADV,CPT,G0143,Scr c/v cyto-thinlayer-rescr,Lab Services,Per Unit,$27.05 ,OP,27.05,91.51,,,,,,
UHC MCR ADV,CPT,G0144,Scr c/v cyto-thinlayer-rescr,Lab Services,Per Unit,$43.97 ,OP,43.97,95.32,,,,,,
UHC MCR ADV,CPT,G0145,Scr c/v cyto-thinlayer-rescr,Lab Services,Per Unit,$26.49 ,OP,26.49,118.19,,,,,,
UHC MCR ADV,CPT,G0147,Scr c/v cyto- automated sys,Lab Services,Per Unit,$15.15 ,OP,15.15,45.74,,,,,,
UHC MCR ADV,CPT,G0148,Scr c/v cyto- autosys- rescr,Lab Services,Per Unit,$31.94 ,OP,31.94,45.74,,,,,,
UHC MCR ADV,CPT,G0166,Extrnl counterpulse- per tx,APC 5734,RVU Per Case,$114.56 ,OP,114.56,114.56,,,,,,
UHC MCR ADV,CPT,G0175,Opps service-sched team conf,APC 5024,RVU Per Unit,$372.22 ,OP,372.22,392.7,,,,,,
UHC MCR ADV,CPT,G0176,Opps/php-activity therapy,APC 5853,RVU Per Case,$266.56 ,OP,266.56,266.56,,,,,,
UHC MCR ADV,CPT,G0186,Dstry eye lesn-fdr vssl tech,APC 5481,RVU Per Unit,$515.61 ,OP,515.61,515.61,,,,,,
UHC MCR ADV,CPT,G0235,Pet not otherwise specified,APC 5591,RVU Per Unit,$385.91 ,OP,385.91,"7,236.50",,,,,,
UHC MCR ADV,CPT,G0237,Therapeutic procd strg endur,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,61,,,,,,
UHC MCR ADV,CPT,G0238,Oth resp proc- indiv,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,64.82,,,,,,
UHC MCR ADV,CPT,G0239,Oth resp proc- group,APC 5732,RVU Per Unit,$34.63 ,OP,34.63,64.82,,,,,,
UHC MCR ADV,CPT,G0245,Initial foot exam pt lops,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,339.33,,,,,,
UHC MCR ADV,CPT,G0246,Followup eval of foot pt lop,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,198.25,,,,,,
UHC MCR ADV,CPT,G0247,Routine footcare pt w lops,APC 5051,RVU Per Case,$183.73 ,OP,183.73,232.58,,,,,,
UHC MCR ADV,CPT,G0248,Demonstrate use home inr mon,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,804.48,,,,,,
UHC MCR ADV,CPT,G0249,Provide inr test mater/equip,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,686.28,,,,,,
UHC MCR ADV,CPT,G0257,Unsched dialysis esrd pt hos,APC 5401,RVU Per Unit,$669.60 ,OP,669.6,669.6,,,,,,
UHC MCR ADV,CPT,G0260,Inj for sacroiliac jt anesth,APC 5442,RVU Per Unit,$649.39 ,OP,649.39,649.39,,,,,,
UHC MCR ADV,CPT,G0270,Mnt subs tx for change dx,Physician,Per Unit,$26.49 ,OP,26.49,122,,,,,,
UHC MCR ADV,CPT,G0271,Group mnt 2 or more 30 mins,Physician,Per Unit,$13.98 ,OP,13.98,68.63,,,,,,
UHC MCR ADV,CPT,G0276,Pild/placebo control clin tr,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,411.04",,,,,,
UHC MCR ADV,CPT,G0277,Hbot- full body chamber- 30m,APC 5061,RVU Per Unit,$122.06 ,OP,122.06,122.06,,,,,,
UHC MCR ADV,CPT,G0279,Tomosynthesis- mammo,Physician,Per Unit,$23.23 ,OP,23.23,23.23,,,,,,
UHC MCR ADV,CPT,G0281,Elec stim unattend for press,Physician,Per Unit,$12.74 ,OP,12.74,61,,,,,,
UHC MCR ADV,CPT,G0283,Elec stim other than wound,Physician,Per Unit,$12.74 ,OP,12.74,61,,,,,,
UHC MCR ADV,CPT,G0293,Non-cov surg proc-clin trial,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
UHC MCR ADV,CPT,G0294,Non-cov proc- clinical trial,APC 5732,RVU Per Case,$34.63 ,OP,34.63,34.63,,,,,,
UHC MCR ADV,CPT,G0296,Visit to determ ldct elig,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
UHC MCR ADV,CPT,G0302,Pre-op service lvrs complete,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
UHC MCR ADV,CPT,G0303,Pre-op service lvrs 10-15dos,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,270.61,,,,,,
UHC MCR ADV,CPT,G0304,Pre-op service lvrs 1-9 dos,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
UHC MCR ADV,CPT,G0305,Post op service lvrs min 6,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
UHC MCR ADV,CPT,G0306,Cbc/diffwbc w/o platelet,Lab Services,Per Unit,$7.77 ,OP,7.77,34.31,,,,,,
UHC MCR ADV,CPT,G0307,Cbc without platelet,Lab Services,Per Unit,$6.47 ,OP,6.47,30.51,,,,,,
UHC MCR ADV,CPT,G0328,Fecal blood scrn immunoassay,Lab Services,Per Unit,$18.05 ,OP,18.05,72.44,,,,,,
UHC MCR ADV,CPT,G0329,Electromagntic tx for ulcers,Physician,Per Unit,$10.46 ,OP,10.46,45.74,,,,,,
UHC MCR ADV,CPT,G0341,Percutaneous islet celltrans,APC 5881,RVU Per Case,"$8,948.83 ",OP,"2,508.76","8,948.83",,,,,,
UHC MCR ADV,CPT,G0342,Laparoscopy islet cell trans,APC 5881,RVU Per Case,"$8,948.83 ",OP,"4,254.96","8,948.83",,,,,,
UHC MCR ADV,CPT,G0343,Laparotomy islet cell transp,APC 5881,RVU Per Case,"$8,948.83 ",OP,"6,965.79","8,948.83",,,,,,
UHC MCR ADV,CPT,G0379,Direct refer hospital observ,APC 5025,RVU Per Case,$534.29 ,OP,534.29,534.29,,,,,,
UHC MCR ADV,CPT,G0380,Lev 1 hosp type b ed visit,APC 5031,RVU Per Case,$72.19 ,OP,72.19,72.19,,,,,,
UHC MCR ADV,CPT,G0381,Lev 2 hosp type b ed visit,APC 5032,RVU Per Case,$97.63 ,OP,97.63,97.63,,,,,,
UHC MCR ADV,CPT,G0382,Lev 3 hosp type b ed visit,APC 5033,RVU Per Case,$185.19 ,OP,185.19,185.19,,,,,,
UHC MCR ADV,CPT,G0383,Lev 4 hosp type b ed visit,APC 5034,RVU Per Case,$233.92 ,OP,233.92,233.92,,,,,,
UHC MCR ADV,CPT,G0384,Lev 5 hosp type b ed visit,APC 5035,RVU Per Case,$325.81 ,OP,325.81,325.81,,,,,,
UHC MCR ADV,CPT,G0390,Trauma respons w/hosp criti,APC 5045,RVU Per Unit,$964.64 ,OP,964.64,964.64,,,,,,
UHC MCR ADV,CPT,G0396,Alcohol/subs interv 15-30mn,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,163.95,,,,,,
UHC MCR ADV,CPT,G0397,Alcohol/subs interv >30 min,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,136.74,,,,,,
UHC MCR ADV,CPT,G0398,Home sleep test/type 2 porta,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,367.82,,,,,,
UHC MCR ADV,CPT,G0399,Home sleep test/type 3 porta,APC 5721,RVU Per Unit,$142.80 ,OP,142.8,142.8,,,,,,
UHC MCR ADV,CPT,G0400,Home sleep test/type 4 porta,APC 5722,RVU Per Unit,$270.61 ,OP,270.61,367.82,,,,,,
UHC MCR ADV,CPT,G0402,Initial preventive exam,APC 5012,RVU Per Unit,$121.51 ,OP,121.51,491.83,,,,,,
UHC MCR ADV,CPT,G0404,Ekg tracing for initial prev,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,25.25,,,,,,
UHC MCR ADV,CPT,G0410,Grp psych partial hosp 45-50,APC 5853,RVU Per Case,$266.56 ,OP,266.56,266.56,,,,,,
UHC MCR ADV,CPT,G0411,Inter active grp psych parti,APC 5853,RVU Per Case,$266.56 ,OP,266.56,266.56,,,,,,
UHC MCR ADV,CPT,G0412,Open tx iliac spine uni/bil,APC 5114,RVU Per Case,"$6,411.04 ",OP,"4,510.41","6,411.04",,,,,,
UHC MCR ADV,CPT,G0413,Pelvic ring fracture uni/bil,APC 5114,RVU Per Case,"$6,411.04 ",OP,"6,411.04","6,527.33",,,,,,
UHC MCR ADV,CPT,G0414,Pelvic ring fx treat int fix,APC 5115,RVU Per Case,"$12,601.93 ",OP,"6,161.31","12,601.93",,,,,,
UHC MCR ADV,CPT,G0415,Open tx post pelvic fxcture,APC 5115,RVU Per Case,"$12,601.93 ",OP,"8,452.74","12,601.93",,,,,,
UHC MCR ADV,CPT,G0416,Prostate biopsy- any mthd,APC 5673,RVU Per Case,$298.05 ,OP,298.05,"3,297.99",,,,,,
UHC MCR ADV,CPT,G0420,Ed svc ckd ind per session,Physician,Per Unit,$111.79 ,OP,111.79,111.79,,,,,,
UHC MCR ADV,CPT,G0421,Ed svc ckd grp per session,Physician,Per Unit,$26.73 ,OP,26.73,26.73,,,,,,
UHC MCR ADV,CPT,G0422,Intens cardiac rehab w/exerc,APC 5771,RVU Per Unit,$118.77 ,OP,118.77,118.77,,,,,,
UHC MCR ADV,CPT,G0423,Intens cardiac rehab no exer,APC 5771,RVU Per Unit,$118.77 ,OP,118.77,118.77,,,,,,
UHC MCR ADV,CPT,G0424,Pulmonary rehab w exer,APC 5733,RVU Per Unit,$56.95 ,OP,56.95,56.95,,,,,,
UHC MCR ADV,CPT,G0429,Dermal filler injection(s),APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","1,755.36",,,,,,
UHC MCR ADV,CPT,G0432,Eia hiv-1/hiv-2 screen,Lab Services,Per Unit,$19.57 ,OP,19.57,19.57,,,,,,
UHC MCR ADV,CPT,G0433,Elisa hiv-1/hiv-2 screen,Lab Services,Per Unit,$18.29 ,OP,18.29,18.29,,,,,,
UHC MCR ADV,CPT,G0435,Oral hiv-1/hiv-2 screen,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,
UHC MCR ADV,CPT,G0438,Ppps- initial visit,Physician,Per Unit,$163.74 ,OP,163.74,163.74,,,,,,
UHC MCR ADV,CPT,G0439,Ppps- subseq visit,Physician,Per Unit,$129.00 ,OP,129,129,,,,,,
UHC MCR ADV,CPT,G0442,Annual alcohol screen 15 min,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
UHC MCR ADV,CPT,G0443,Brief alcohol misuse counsel,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
UHC MCR ADV,CPT,G0444,Depression screen annual,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
UHC MCR ADV,CPT,G0445,High inten beh couns std 30m,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
UHC MCR ADV,CPT,G0446,Intens behave ther cardio dx,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
UHC MCR ADV,CPT,G0447,Behavior counsel obesity 15m,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
UHC MCR ADV,CPT,G0451,Devlopment test interpt&rep,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
UHC MCR ADV,CPT,G0455,Fecal microbiota prep instil,APC 5301,RVU Per Case,$828.48 ,OP,828.48,828.48,,,,,,
UHC MCR ADV,CPT,G0460,Autologous prp for ulcers,APC 5054,RVU Per Unit,"$1,755.36 ",OP,"1,755.36","1,755.36",,,,,,
UHC MCR ADV,CPT,G0463,Hospital outpt clinic visit,APC 5012,RVU Per Case,$121.51 ,OP,95.32,121.51,,,,,,
UHC MCR ADV,CPT,G0471,Ven blood coll snf/hha,Lab Services,Per Unit,$5.00 ,OP,5,5,,,,,,
UHC MCR ADV,CPT,G0472,Hep c screen high risk/other,Lab Services,Per Unit,$46.35 ,OP,46.35,46.35,,,,,,
UHC MCR ADV,CPT,G0473,Group behave couns 2-10,APC 5821,RVU Per Unit,$26.84 ,OP,26.84,26.84,,,,,,
UHC MCR ADV,CPT,G0475,Hiv combination assay,Lab Services,Per Unit,$24.08 ,OP,24.08,24.08,,,,,,
UHC MCR ADV,CPT,G0476,Hpv combo assay ca screen,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,
UHC MCR ADV,CPT,G0480,Drug test def 1-7 classes,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,
UHC MCR ADV,CPT,G0481,Drug test def 8-14 classes,Lab Services,Per Unit,$156.59 ,OP,156.59,156.59,,,,,,
UHC MCR ADV,CPT,G0482,Drug test def 15-21 classes,Lab Services,Per Unit,$198.74 ,OP,198.74,198.74,,,,,,
UHC MCR ADV,CPT,G0483,Drug test def 22+ classes,Lab Services,Per Unit,$246.92 ,OP,246.92,246.92,,,,,,
UHC MCR ADV,CPT,G0498,Chemo extend iv infus w/pump,APC 5694,RVU Per Unit,$318.00 ,OP,318,318,,,,,,
UHC MCR ADV,CPT,G0499,Hepb screen high risk indiv,Lab Services,Per Unit,$28.27 ,OP,28.27,28.27,,,,,,
UHC MCR ADV,CPT,G0516,Insert drug del implant- >=4,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
UHC MCR ADV,CPT,G0517,Remove drug implant,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
UHC MCR ADV,CPT,G0518,Remove w insert drug implant,APC 5735,RVU Per Case,$276.53 ,OP,276.53,276.53,,,,,,
UHC MCR ADV,CPT,G0659,Drug test def simple all cl,Lab Services,Per Unit,$62.14 ,OP,62.14,62.14,,,,,,
UHC MCR ADV,CPT,G2000,Blinded conv. tx mdd clin tr,APC 5723,RVU Per Unit,$499.16 ,OP,499.16,499.16,,,,,,
UHC MCR ADV,CPT,G2011,Alcohol/sub misuse assess,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,25.25,,,,,,
UHC MCR ADV,CPT,G2065,Clin mang h risk dx 30,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
UHC MCR ADV,CPT,G2066,Inter devc remote 30d,APC 5741,RVU Per Case,$38.02 ,OP,38.02,38.02,,,,,,
UHC MCR ADV,CPT,G2082,Visit esketamine 56m or less,APC 1508,RVU Per Unit,$665.67 ,OP,621.54,665.67,,,,,,
UHC MCR ADV,CPT,G2083,Visit esketamine- > 56m,APC 1511,RVU Per Unit,$972.67 ,OP,972.67,972.67,,,,,,
UHC MCR ADV,CPT,G2086,Off base opioid tx 70min,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,136.74,,,,,,
UHC MCR ADV,CPT,G2087,Off base opioid tx- 60 m,APC 5823,RVU Per Unit,$136.74 ,OP,136.74,136.74,,,,,,
UHC MCR ADV,CPT,G2170,Avf by tissue w thermal e,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
UHC MCR ADV,CPT,G2171,Avf use magnetic/art/ven,APC 5194,RVU Per Case,"$16,438.60 ",OP,"16,438.60","16,438.60",,,,,,
UHC MCR ADV,CPT,G2214,Init/sub psych care m 1st 30,APC 5822,RVU Per Unit,$76.62 ,OP,76.62,76.62,,,,,,
UHC MCR ADV,CPT,G2250,Remot img sub by pt- non e/m,Physician,Per Unit,$9.24 ,OP,9.24,9.24,,,,,,
UHC MCR ADV,CPT,G2251,Brief chkin- 5-10- non-e/m,Physician,Per Unit,$13.05 ,OP,13.05,13.05,,,,,,
UHC MCR ADV,CPT,G2252,Brief chkin by md/qhp- 11-20,Physician,Per Unit,$25.14 ,OP,25.14,25.14,,,,,,
UHC MCR ADV,CPT,J0121,Inj.- omadacycline- 1 mg,APC 9311,Per Unit,$3.30 ,OP,3.3,3.3,,,,,,
UHC MCR ADV,CPT,J0129,Abatacept injection,APC 9230,Per Unit,$45.27 ,OP,45.27,73.44,,,,,,
UHC MCR ADV,CPT,J0135,Adalimumab injection,APC 1083,Per Unit,"$1,581.57 ",OP,"1,581.57","1,581.57",,,,,,
UHC MCR ADV,CPT,J0178,Aflibercept injection,APC 1420,Per Unit,$917.94 ,OP,917.94,917.94,,,,,,
UHC MCR ADV,CPT,J0179,Inj- brolucizumab-dbll- 1 mg,APC 9340,Per Unit,$312.01 ,OP,312.01,312.01,,,,,,
UHC MCR ADV,CPT,J0180,Agalsidase beta injection,APC 9208,Per Unit,$198.14 ,OP,198.14,508.92,,,,,,
UHC MCR ADV,CPT,J0185,Inj.- aprepitant- 1 mg,APC 9463,Per Unit,$1.69 ,OP,1.69,1.69,,,,,,
UHC MCR ADV,CPT,J0202,Injection- alemtuzumab,APC 1809,Per Unit,"$2,086.32 ",OP,277.19,"2,086.32",,,,,,
UHC MCR ADV,CPT,J0207,Amifostine,APC 7000,Per Unit,"$1,135.69 ",OP,"1,135.69","1,985.16",,,,,,
UHC MCR ADV,CPT,J0220,Alglucosidase alfa injection,APC 9234,Per Unit,$117.07 ,OP,117.07,474.68,,,,,,
UHC MCR ADV,CPT,J0221,Lumizyme injection,APC 1413,Per Unit,$180.35 ,OP,180.35,180.35,,,,,,
UHC MCR ADV,CPT,J0222,Inj.- patisiran- 0.1 mg,APC 9180,Per Unit,$97.75 ,OP,97.75,97.75,,,,,,
UHC MCR ADV,CPT,J0223,Inj givosiran 0.5 mg,APC 9343,Per Unit,$106.76 ,OP,106.76,106.76,,,,,,
UHC MCR ADV,CPT,J0224,Inj. lumasiran- 0.5 mg,APC 9407,Per Unit,$302.30 ,OP,302.3,302.3,,,,,,
UHC MCR ADV,CPT,J0256,Alpha 1 proteinase inhibitor,APC 0901,Per Unit,$4.54 ,OP,4.54,7.9,,,,,,
UHC MCR ADV,CPT,J0257,Glassia injection,APC 1415,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,
UHC MCR ADV,CPT,J0287,Amphotericin b lipid complex,APC 9024,Per Unit,$9.50 ,OP,9.5,49.56,,,,,,
UHC MCR ADV,CPT,J0289,Amphotericin b liposome inj,APC 0736,Per Unit,$28.75 ,OP,28.75,118.19,,,,,,
UHC MCR ADV,CPT,J0291,Inj.- plazomicin- 5 mg,APC 9183,Per Unit,$3.05 ,OP,3.05,3.05,,,,,,
UHC MCR ADV,CPT,J0300,Amobarbital 125 mg inj,APC 1341,Per Unit,$125.22 ,OP,30.51,125.22,,,,,,
UHC MCR ADV,CPT,J0390,Chloroquine injection,APC 9352,Per Unit,$165.22 ,OP,83.87,165.22,,,,,,
UHC MCR ADV,CPT,J0401,Inj aripiprazole ext rel 1mg,APC 1468,Per Unit,$6.01 ,OP,6.01,7.62,,,,,,
UHC MCR ADV,CPT,J0475,Baclofen 10 mg injection,APC 9032,Per Unit,$177.43 ,OP,177.43,826.29,,,,,,
UHC MCR ADV,CPT,J0480,Basiliximab,APC 1683,Per Unit,"$4,013.08 ",OP,"4,013.08","7,724.52",,,,,,
UHC MCR ADV,CPT,J0485,Belatacept injection,APC 9286,Per Unit,$3.80 ,OP,3.8,3.8,,,,,,
UHC MCR ADV,CPT,J0490,Belimumab injection,APC 1353,Per Unit,$47.57 ,OP,47.57,47.57,,,,,,
UHC MCR ADV,CPT,J0517,Inj.- benralizumab- 1 mg,APC 9466,Per Unit,$170.80 ,OP,170.8,170.8,,,,,,
UHC MCR ADV,CPT,J0558,Peng benzathine/procaine inj,APC 9088,Per Unit,$11.79 ,OP,11.79,11.79,,,,,,
UHC MCR ADV,CPT,J0561,Penicillin g benzathine inj,APC 1829,Per Unit,$14.95 ,OP,14.95,14.95,,,,,,
UHC MCR ADV,CPT,J0565,Inj- bezlotoxumab- 10 mg,APC 9490,Per Unit,$39.77 ,OP,39.77,39.77,,,,,,
UHC MCR ADV,CPT,J0570,Buprenorphine implant 74.2mg,APC 9058,Per Unit,"$1,311.75 ",OP,209.7,"1,311.75",,,,,,
UHC MCR ADV,CPT,J0584,Injection- burosumab-twza 1m,APC 9187,Per Unit,$369.11 ,OP,369.11,369.11,,,,,,
UHC MCR ADV,CPT,J0585,Injection-onabotulinumtoxina,APC 0902,Per Unit,$6.09 ,OP,6.09,6.09,,,,,,
UHC MCR ADV,CPT,J0586,Abobotulinumtoxina,APC 1289,Per Unit,$8.41 ,OP,8.41,8.41,,,,,,
UHC MCR ADV,CPT,J0587,Inj- rimabotulinumtoxinb,APC 9018,Per Unit,$12.05 ,OP,12.05,39.5,,,,,,
UHC MCR ADV,CPT,J0588,Incobotulinumtoxin a,APC 9278,Per Unit,$5.05 ,OP,5.05,5.05,,,,,,
UHC MCR ADV,CPT,J0594,Busulfan injection,APC 1178,Per Unit,$1.71 ,OP,1.71,61,,,,,,
UHC MCR ADV,CPT,J0596,Injection- ruconest,APC 9445,Per Unit,$29.97 ,OP,29.97,29.97,,,,,,
UHC MCR ADV,CPT,J0597,C-1 esterase- berinert,APC 9269,Per Unit,$57.39 ,OP,57.39,57.39,,,,,,
UHC MCR ADV,CPT,J0598,C-1 esterase- cinryze,APC 9251,Per Unit,$58.93 ,OP,58.93,58.93,,,,,,
UHC MCR ADV,CPT,J0599,Inj.- haegarda 10 units,APC 9015,Per Unit,$10.25 ,OP,10.25,10.25,,,,,,
UHC MCR ADV,CPT,J0600,Edetate calcium disodium inj,APC 1274,Per Unit,"$5,708.59 ",OP,362.21,"5,708.59",,,,,,
UHC MCR ADV,CPT,J0630,Calcitonin salmon injection,APC 1433,Per Unit,"$3,100.79 ",OP,191.13,"3,100.79",,,,,,
UHC MCR ADV,CPT,J0638,Canakinumab injection,APC 1311,Per Unit,$115.61 ,OP,115.61,115.61,,,,,,
UHC MCR ADV,CPT,J0641,Inj levoleucovorin nos 0.5mg,APC 1236,Per Unit,$0.09 ,OP,0.09,0.09,,,,,,
UHC MCR ADV,CPT,J0642,Injection- khapzory- 0.5 mg,APC 9334,Per Unit,$1.86 ,OP,1.86,1.86,,,,,,
UHC MCR ADV,CPT,J0691,Inj lefamulin 1 mg,APC 9332,Per Unit,$0.72 ,OP,0.72,0.72,,,,,,
UHC MCR ADV,CPT,J0695,Inj ceftolozane tazobactam,APC 9452,Per Unit,$6.64 ,OP,6.64,6.64,,,,,,
UHC MCR ADV,CPT,J0699,Inj- cefiderocol- 10 mg,APC 9426,Per Unit,$2.01 ,OP,2.01,2.01,,,,,,
UHC MCR ADV,CPT,J0712,Ceftaroline fosamil inj,APC 1824,Per Unit,$3.51 ,OP,3.51,3.51,,,,,,
UHC MCR ADV,CPT,J0714,Ceftazidime and avibactam,APC 1825,Per Unit,$92.39 ,OP,92.39,92.39,,,,,,
UHC MCR ADV,CPT,J0716,Centruroides immune f(ab),APC 1431,Per Unit,"$5,190.15 ",OP,"5,190.15","5,190.15",,,,,,
UHC MCR ADV,CPT,J0717,Certolizumab pegol inj 1mg,APC 1474,Per Unit,$6.27 ,OP,6.27,6.27,,,,,,
UHC MCR ADV,CPT,J0740,Cidofovir injection,APC 9033,Per Unit,$563.76 ,OP,563.76,"3,694.50",,,,,,
UHC MCR ADV,CPT,J0741,Inj- cabote rilpivir 2mg 3mg,APC 9414,Per Unit,$20.56 ,OP,20.56,20.56,,,,,,
UHC MCR ADV,CPT,J0742,Inj imip 4 cilas 4 releb 2mg,APC 9362,Per Unit,$2.32 ,OP,2.32,2.32,,,,,,
UHC MCR ADV,CPT,J0745,Inj codeine phosphate /30 mg,APC 9393,Per Unit,$135.64 ,OP,7.62,135.64,,,,,,
UHC MCR ADV,CPT,J0775,Collagenase- clost hist inj,APC 1340,Per Unit,$56.66 ,OP,56.66,56.66,,,,,,
UHC MCR ADV,CPT,J0791,Inj crizanlizumab-tmca 5mg,APC 9359,Per Unit,$123.29 ,OP,123.29,123.29,,,,,,
UHC MCR ADV,CPT,J0795,Corticorelin ovine triflutal,APC 1684,Per Unit,$9.67 ,OP,9.67,22.88,,,,,,
UHC MCR ADV,CPT,J0840,Crotalidae poly immune fab,APC 9274,Per Unit,"$2,743.36 ",OP,"2,743.36","2,743.36",,,,,,
UHC MCR ADV,CPT,J0841,Inj crotalidae im f(ab)2 eq,APC 9188,Per Unit,"$1,189.81 ",OP,"1,189.81","1,189.81",,,,,,
UHC MCR ADV,CPT,J0850,Cytomegalovirus imm iv /vial,APC 0903,Per Unit,"$1,538.70 ",OP,"1,538.70","4,266.40",,,,,,
UHC MCR ADV,CPT,J0875,Injection- dalbavancin,APC 1823,Per Unit,$15.89 ,OP,15.89,15.89,,,,,,
UHC MCR ADV,CPT,J0881,Darbepoetin alfa- non-esrd,APC 1685,Per Unit,$3.15 ,OP,3.15,15.26,,,,,,
UHC MCR ADV,CPT,J0882,Darbepoetin alfa- esrd use,APC 1482,Per Unit,$3.15 ,OP,3.15,15.26,,,,,,
UHC MCR ADV,CPT,J0883,Argatroban nonesrd use 1mg,APC 1859,Per Unit,$1.20 ,OP,1.2,1.2,,,,,,
UHC MCR ADV,CPT,J0884,Argatroban esrd dialysis 1mg,APC 9065,Per Unit,$1.20 ,OP,1.2,1.2,,,,,,
UHC MCR ADV,CPT,J0885,Epoetin alfa- non-esrd,APC 1686,Per Unit,$8.15 ,OP,8.15,45.74,,,,,,
UHC MCR ADV,CPT,J0888,Epoetin beta non esrd,APC 9077,Per Unit,$1.51 ,OP,1.51,1.51,,,,,,
UHC MCR ADV,CPT,J0894,Decitabine injection,APC 9231,Per Unit,$3.45 ,OP,3.45,3.45,,,,,,
UHC MCR ADV,CPT,J0896,Inj luspatercept-aamt 0.25mg,APC 9347,Per Unit,$36.85 ,OP,36.85,36.85,,,,,,
UHC MCR ADV,CPT,J0897,Denosumab injection,APC 9272,Per Unit,$21.19 ,OP,21.19,21.19,,,,,,
UHC MCR ADV,CPT,J1095,Injection- dexamethasone 9%,APC 9172,Per Unit,$1.04 ,OP,1.04,1.04,,,,,,
UHC MCR ADV,CPT,J1096,Dexametha opth insert 0.1 mg,APC 9308,Per Unit,$133.30 ,OP,133.3,133.3,,,,,,
UHC MCR ADV,CPT,J1162,Digoxin immune fab (ovine),APC 1687,Per Unit,"$4,128.19 ",OP,"2,344.81","4,128.19",,,,,,
UHC MCR ADV,CPT,J1190,Dexrazoxane hcl injection,APC 0726,Per Unit,$192.33 ,OP,192.33,"1,849.16",,,,,,
UHC MCR ADV,CPT,J1201,Inj. cetirizine hcl 0.5mg,APC 9361,Per Unit,$15.38 ,OP,15.38,15.38,,,,,,
UHC MCR ADV,CPT,J1212,Dimethyl sulfoxide 50% 50 ml,APC 1832,Per Unit,$637.11 ,OP,339.33,637.11,,,,,,
UHC MCR ADV,CPT,J1290,Ecallantide injection,APC 9263,Per Unit,$503.88 ,OP,503.88,503.88,,,,,,
UHC MCR ADV,CPT,J1300,Eculizumab injection,APC 9236,Per Unit,$229.23 ,OP,229.23,679.45,,,,,,
UHC MCR ADV,CPT,J1301,Injection- edaravone- 1 mg,APC 9493,Per Unit,$20.51 ,OP,20.51,20.51,,,,,,
UHC MCR ADV,CPT,J1303,Inj.- ravulizumab-cwvz 10 mg,APC 9312,Per Unit,$224.68 ,OP,224.68,224.68,,,,,,
UHC MCR ADV,CPT,J1305,Inj- evinacumab-dgnb- 5mg,APC 9416,Per Unit,$165.63 ,OP,165.63,165.63,,,,,,
UHC MCR ADV,CPT,J1322,Elosulfase alfa- injection,APC 1480,Per Unit,$250.33 ,OP,250.33,250.33,,,,,,
UHC MCR ADV,CPT,J1364,Erythro lactobionate /500 mg,APC 1669,Per Unit,$77.75 ,OP,38.13,77.75,,,,,,
UHC MCR ADV,CPT,J1410,Inj estrogen conjugate 25 mg,APC 9038,Per Unit,$341.46 ,OP,341.46,381.27,,,,,,
UHC MCR ADV,CPT,J1426,Injection- casimersen- 10 mg,APC 9412,Per Unit,$166.47 ,OP,166.47,166.47,,,,,,
UHC MCR ADV,CPT,J1427,Inj. viltolarsen,APC 9386,Per Unit,$59.05 ,OP,59.05,59.05,,,,,,
UHC MCR ADV,CPT,J1429,Inj golodirsen 10 mg,APC 9356,Per Unit,$166.21 ,OP,166.21,166.21,,,,,,
UHC MCR ADV,CPT,J1430,Ethanolamine oleate 100 mg,APC 1688,Per Unit,$444.10 ,OP,444.1,728.23,,,,,,
UHC MCR ADV,CPT,J1437,Inj. fe derisomaltose 10 mg,APC 9388,Per Unit,$24.87 ,OP,24.87,24.87,,,,,,
UHC MCR ADV,CPT,J1438,Etanercept injection,APC 1608,Per Unit,$790.78 ,OP,714.31,790.78,,,,,,
UHC MCR ADV,CPT,J1439,Inj ferric carboxymaltos 1mg,APC 9441,Per Unit,$1.12 ,OP,1.12,1.12,,,,,,
UHC MCR ADV,CPT,J1442,Inj filgrastim excl biosimil,APC 1469,Per Unit,$0.97 ,OP,0.97,3.09,,,,,,
UHC MCR ADV,CPT,J1447,Inj tbo filgrastim 1 microg,APC 1748,Per Unit,$0.46 ,OP,0.46,3.1,,,,,,
UHC MCR ADV,CPT,J1448,Injection- trilaciclib- 1mg,APC 9415,Per Unit,$4.97 ,OP,4.97,4.97,,,,,,
UHC MCR ADV,CPT,J1451,Fomepizole- 15 mg,APC 1689,Per Unit,$5.98 ,OP,5.98,49.56,,,,,,
UHC MCR ADV,CPT,J1453,Fosaprepitant injection,APC 9242,Per Unit,$0.24 ,OP,0.24,7.62,,,,,,
UHC MCR ADV,CPT,J1454,Inj fosnetupitant- palonoset,APC 9099,Per Unit,$571.22 ,OP,571.22,571.22,,,,,,
UHC MCR ADV,CPT,J1455,Foscarnet sodium injection,APC 1849,Per Unit,$72.86 ,OP,49.56,72.86,,,,,,
UHC MCR ADV,CPT,J1458,Galsulfase injection,APC 9224,Per Unit,$411.92 ,OP,411.92,"1,289.57",,,,,,
UHC MCR ADV,CPT,J1459,Inj ivig privigen 500 mg,APC 1214,Per Unit,$44.48 ,OP,44.48,143.18,,,,,,
UHC MCR ADV,CPT,J1460,Gamma globulin 1 cc inj,APC 1850,Per Unit,$44.13 ,OP,44.13,61,,,,,,
UHC MCR ADV,CPT,J1554,Inj. asceniv,APC 9392,Per Unit,$481.77 ,OP,481.77,481.77,,,,,,
UHC MCR ADV,CPT,J1555,Inj cuvitru- 100 mg,APC 9034,Per Unit,$14.50 ,OP,14.5,14.5,,,,,,
UHC MCR ADV,CPT,J1556,Inj- imm glob bivigam- 500mg,APC 9130,Per Unit,$70.49 ,OP,70.49,70.49,,,,,,
UHC MCR ADV,CPT,J1557,Gammaplex injection,APC 9270,Per Unit,$48.53 ,OP,48.53,48.53,,,,,,
UHC MCR ADV,CPT,J1558,Inj. xembify- 100 mg,APC 9372,Per Unit,$13.61 ,OP,13.61,13.61,,,,,,
UHC MCR ADV,CPT,J1559,Hizentra injection,APC 1312,Per Unit,$11.58 ,OP,11.58,11.58,,,,,,
UHC MCR ADV,CPT,J1560,Gamma globulin > 10 cc inj,APC 1851,Per Unit,$441.31 ,OP,441.31,621.47,,,,,,
UHC MCR ADV,CPT,J1561,Gamunex-c/gammaked,APC 0948,Per Unit,$48.22 ,OP,48.22,158.91,,,,,,
UHC MCR ADV,CPT,J1566,Immune globulin- powder,APC 2731,Per Unit,$65.49 ,OP,65.49,152.51,,,,,,
UHC MCR ADV,CPT,J1568,Octagam injection,APC 0943,Per Unit,$41.63 ,OP,41.63,41.63,,,,,,
UHC MCR ADV,CPT,J1569,Gammagard liquid injection,APC 0944,Per Unit,$44.49 ,OP,44.49,171.58,,,,,,
UHC MCR ADV,CPT,J1571,Hepagam b im injection,APC 0946,Per Unit,$70.94 ,OP,70.94,213.51,,,,,,
UHC MCR ADV,CPT,J1572,Flebogamma injection,APC 0947,Per Unit,$36.80 ,OP,36.8,171.58,,,,,,
UHC MCR ADV,CPT,J1573,Hepagam b intravenous- inj,APC 1138,Per Unit,$71.24 ,OP,71.24,213.51,,,,,,
UHC MCR ADV,CPT,J1575,Hyqvia 100mg immuneglobulin,APC 1826,Per Unit,$15.16 ,OP,15.16,15.16,,,,,,
UHC MCR ADV,CPT,J1595,Injection glatiramer acetate,APC 1015,Per Unit,$141.29 ,OP,141.29,298.68,,,,,,
UHC MCR ADV,CPT,J1602,Golimumab for iv use 1mg,APC 1475,Per Unit,$16.82 ,OP,16.82,16.82,,,,,,
UHC MCR ADV,CPT,J1610,Glucagon hydrochloride/1 mg,APC 9042,Per Unit,$171.74 ,OP,171.74,343.14,,,,,,
UHC MCR ADV,CPT,J1628,Inj.- guselkumab- 1 mg,APC 9029,Per Unit,$82.56 ,OP,82.56,82.56,,,,,,
UHC MCR ADV,CPT,J1632,Inj.- brexanolone- 1 mg,APC 9333,Per Unit,$74.65 ,OP,74.65,74.65,,,,,,
UHC MCR ADV,CPT,J1640,Hemin- 1 mg,APC 1690,Per Unit,$26.64 ,OP,26.64,38.13,,,,,,
UHC MCR ADV,CPT,J1670,Tetanus immune globulin inj,APC 1670,Per Unit,$441.70 ,OP,441.7,"1,040.87",,,,,,
UHC MCR ADV,CPT,J1726,Makena- 10 mg,APC 9074,Per Unit,$16.82 ,OP,16.82,16.82,,,,,,
UHC MCR ADV,CPT,J1729,Inj hydroxyprogst capoat nos,APC 9318,Per Unit,$21.54 ,OP,21.54,21.54,,,,,,
UHC MCR ADV,CPT,J1738,Inj. meloxicam 1 mg,APC 9371,Per Unit,$3.18 ,OP,3.18,3.18,,,,,,
UHC MCR ADV,CPT,J1740,Ibandronate sodium injection,APC 9229,Per Unit,$37.09 ,OP,37.09,674.85,,,,,,
UHC MCR ADV,CPT,J1742,Ibutilide fumarate injection,APC 9044,Per Unit,$205.06 ,OP,205.06,"1,898.73",,,,,,
UHC MCR ADV,CPT,J1744,Icatibant injection,APC 1443,Per Unit,$204.96 ,OP,204.96,204.96,,,,,,
UHC MCR ADV,CPT,J1745,Infliximab not biosimil 10mg,APC 7043,Per Unit,$39.53 ,OP,39.53,301.32,,,,,,
UHC MCR ADV,CPT,J1746,Inj.- ibalizumab-uiyk- 10 mg,APC 9189,Per Unit,$66.39 ,OP,66.39,66.39,,,,,,
UHC MCR ADV,CPT,J1750,Inj iron dextran,APC 1237,Per Unit,$15.84 ,OP,15.84,15.84,,,,,,
UHC MCR ADV,CPT,J1786,Imuglucerase injection,APC 1327,Per Unit,$44.05 ,OP,44.05,44.05,,,,,,
UHC MCR ADV,CPT,J1823,Inj. inebilizumab-cdon- 1 mg,APC 9394,Per Unit,$458.21 ,OP,458.21,458.21,,,,,,
UHC MCR ADV,CPT,J1826,Interferon beta-1a inj,APC 1852,Per Unit,"$2,293.85 ",OP,"2,293.85","2,293.85",,,,,,
UHC MCR ADV,CPT,J1830,Interferon beta-1b / .25 mg,APC 0910,Per Unit,$406.24 ,OP,406.24,538.7,,,,,,
UHC MCR ADV,CPT,J1833,Injection- isavuconazonium,APC 9456,Per Unit,$0.83 ,OP,0.83,0.83,,,,,,
UHC MCR ADV,CPT,J1930,Lanreotide injection,APC 9237,Per Unit,$67.64 ,OP,67.64,129.64,,,,,,
UHC MCR ADV,CPT,J1931,Laronidase injection,APC 9209,Per Unit,$34.75 ,OP,34.75,95.46,,,,,,
UHC MCR ADV,CPT,J1943,Inj.- aristada initio- 1 mg,APC 9179,Per Unit,$3.05 ,OP,3.05,3.05,,,,,,
UHC MCR ADV,CPT,J1944,Aripirazole lauroxil 1 mg,APC 9470,Per Unit,$2.99 ,OP,2.99,2.99,,,,,,
UHC MCR ADV,CPT,J1950,Leuprolide acetate /3.75 mg,APC 0800,Per Unit,"$1,406.37 ",OP,"1,406.37","1,525.07",,,,,,
UHC MCR ADV,CPT,J1951,Inj fensolvi 0.25 mg,APC 9419,Per Unit,$126.28 ,OP,126.28,126.28,,,,,,
UHC MCR ADV,CPT,J2182,Injection- mepolizumab- 1mg,APC 9473,Per Unit,$28.29 ,OP,28.29,28.29,,,,,,
UHC MCR ADV,CPT,J2186,Inj.- meropenem- vaborbactam,APC 9178,Per Unit,$1.76 ,OP,1.76,1.76,,,,,,
UHC MCR ADV,CPT,J2248,Micafungin sodium injection,APC 9227,Per Unit,$0.97 ,OP,0.97,0.97,,,,,,
UHC MCR ADV,CPT,J2265,Minocycline hydrochloride,APC 1853,Per Unit,$2.00 ,OP,2,2,,,,,,
UHC MCR ADV,CPT,J2278,Ziconotide injection,APC 1694,Per Unit,$8.69 ,OP,8.69,30.51,,,,,,
UHC MCR ADV,CPT,J2315,Naltrexone- depot form,APC 0759,Per Unit,$3.53 ,OP,3.53,3.53,,,,,,
UHC MCR ADV,CPT,J2323,Natalizumab injection,APC 9126,Per Unit,$23.24 ,OP,23.24,103.45,,,,,,
UHC MCR ADV,CPT,J2326,Inj- nusinersen- 0.1mg,APC 9489,Per Unit,"$1,122.13 ",OP,"1,122.13","1,122.13",,,,,,
UHC MCR ADV,CPT,J2350,Injection- ocrelizumab- 1 mg,APC 9494,Per Unit,$58.29 ,OP,58.29,58.29,,,,,,
UHC MCR ADV,CPT,J2353,Octreotide injection- depot,APC 1207,Per Unit,$205.37 ,OP,205.37,408.99,,,,,,
UHC MCR ADV,CPT,J2357,Omalizumab injection,APC 9300,Per Unit,$37.67 ,OP,37.67,70.74,,,,,,
UHC MCR ADV,CPT,J2358,Olanzapine long-acting inj,APC 1331,Per Unit,$2.91 ,OP,2.91,2.91,,,,,,
UHC MCR ADV,CPT,J2406,Injection- oritavancin 10 mg,APC 9427,Per Unit,$41.92 ,OP,41.92,41.92,,,,,,
UHC MCR ADV,CPT,J2407,Injection- oritavancin,APC 1660,Per Unit,$23.63 ,OP,23.63,23.63,,,,,,
UHC MCR ADV,CPT,J2425,Palifermin injection,APC 1696,Per Unit,$23.93 ,OP,23.93,23.93,,,,,,
UHC MCR ADV,CPT,J2426,Paliperidone palmitate inj,APC 9255,Per Unit,$12.66 ,OP,12.66,12.66,,,,,,
UHC MCR ADV,CPT,J2502,Inj- pasireotide long acting,APC 9454,Per Unit,$359.03 ,OP,359.03,359.03,,,,,,
UHC MCR ADV,CPT,J2504,Pegademase bovine- 25 iu,APC 1739,Per Unit,$4.06 ,OP,4.06,"1,098.07",,,,,,
UHC MCR ADV,CPT,J2505,Injection- pegfilgrastim 6mg,APC 9119,Per Unit,"$2,221.63 ",OP,"2,221.63","10,481.09",,,,,,
UHC MCR ADV,CPT,J2507,Pegloticase injection,APC 9281,Per Unit,"$2,960.91 ",OP,"2,960.91","2,960.91",,,,,,
UHC MCR ADV,CPT,J2515,Pentobarbital sodium inj,APC 1854,Per Unit,$26.41 ,OP,26.41,26.41,,,,,,
UHC MCR ADV,CPT,J2547,Injection- peramivir,APC 9451,Per Unit,$1.68 ,OP,1.68,1.68,,,,,,
UHC MCR ADV,CPT,J2560,Phenobarbital sodium inj,APC 9069,Per Unit,$40.22 ,OP,40.22,40.22,,,,,,
UHC MCR ADV,CPT,J2562,Plerixafor injection,APC 9252,Per Unit,$382.85 ,OP,382.85,382.85,,,,,,
UHC MCR ADV,CPT,J2597,Inj desmopressin acetate,APC 1440,Per Unit,$9.40 ,OP,9.4,9.4,,,,,,
UHC MCR ADV,CPT,J2724,Protein c concentrate,APC 1139,Per Unit,$15.13 ,OP,15.13,61,,,,,,
UHC MCR ADV,CPT,J2760,Phentolaine mesylate inj,APC 1458,Per Unit,$416.00 ,OP,255.45,416,,,,,,
UHC MCR ADV,CPT,J2770,Quinupristin/dalfopristin,APC 2770,Per Unit,$444.67 ,OP,444.67,712.98,,,,,,
UHC MCR ADV,CPT,J2778,Ranibizumab injection,APC 9233,Per Unit,$318.47 ,OP,318.47,318.47,,,,,,
UHC MCR ADV,CPT,J2783,Rasburicase,APC 0738,Per Unit,$315.06 ,OP,315.06,804.48,,,,,,
UHC MCR ADV,CPT,J2786,Injection- reslizumab- 1mg,APC 9481,Per Unit,$10.11 ,OP,10.11,10.11,,,,,,
UHC MCR ADV,CPT,J2792,Rho(d) immune globulin h- sd,APC 1609,Per Unit,$31.42 ,OP,31.42,80.07,,,,,,
UHC MCR ADV,CPT,J2794,Inj risperdal consta- 0.5 mg,APC 9125,Per Unit,$11.04 ,OP,11.04,19.71,,,,,,
UHC MCR ADV,CPT,J2796,Romiplostim injection,APC 9245,Per Unit,$83.47 ,OP,83.47,83.47,,,,,,
UHC MCR ADV,CPT,J2798,Inj.- perseris- 0.5 mg,APC 9181,Per Unit,$10.69 ,OP,10.69,10.69,,,,,,
UHC MCR ADV,CPT,J2820,Sargramostim injection,APC 0731,Per Unit,$51.55 ,OP,51.55,122,,,,,,
UHC MCR ADV,CPT,J2840,Inj sebelipase alfa 1 mg,APC 9478,Per Unit,$539.91 ,OP,539.91,539.91,,,,,,
UHC MCR ADV,CPT,J2850,Inj secretin synthetic human,APC 1700,Per Unit,$34.78 ,OP,34.78,129.64,,,,,,
UHC MCR ADV,CPT,J2860,Injection- siltuximab,APC 9455,Per Unit,$124.09 ,OP,124.09,124.09,,,,,,
UHC MCR ADV,CPT,J2941,Somatropin injection,APC 9319,Per Unit,$36.54 ,OP,36.54,226.93,,,,,,
UHC MCR ADV,CPT,J2993,Reteplase injection,APC 9005,Per Unit,"$2,506.51 ",OP,"2,506.51","4,712.48",,,,,,
UHC MCR ADV,CPT,J2997,Alteplase recombinant,APC 7048,Per Unit,$87.75 ,OP,87.75,163.95,,,,,,
UHC MCR ADV,CPT,J3031,Inj.- fremanezumab-vfrm 1 mg,APC 9197,Per Unit,$2.34 ,OP,2.34,2.34,,,,,,
UHC MCR ADV,CPT,J3032,Inj. eptinezumab-jjmr 1 mg,APC 9357,Per Unit,$15.64 ,OP,15.64,15.64,,,,,,
UHC MCR ADV,CPT,J3060,Inj- taliglucerase alfa 10 u,APC 9294,Per Unit,$41.32 ,OP,41.32,41.32,,,,,,
UHC MCR ADV,CPT,J3090,Inj tedizolid phosphate,APC 1662,Per Unit,$1.60 ,OP,1.6,1.6,,,,,,
UHC MCR ADV,CPT,J3095,Telavancin injection,APC 9258,Per Unit,$6.16 ,OP,6.16,6.16,,,,,,
UHC MCR ADV,CPT,J3101,Tenecteplase injection,APC 9002,Per Unit,$134.74 ,OP,134.74,202.07,,,,,,
UHC MCR ADV,CPT,J3111,Inj. romosozumab-aqqg 1 mg,APC 9327,Per Unit,$9.34 ,OP,9.34,9.34,,,,,,
UHC MCR ADV,CPT,J3145,Testosterone undecanoate 1mg,APC 9078,Per Unit,$1.63 ,OP,1.63,1.63,,,,,,
UHC MCR ADV,CPT,J3240,Thyrotropin injection,APC 9108,Per Unit,"$1,837.25 ",OP,"1,837.25","3,617.49",,,,,,
UHC MCR ADV,CPT,J3241,Inj. teprotumumab-trbw 10 mg,APC 9355,Per Unit,$315.88 ,OP,315.88,315.88,,,,,,
UHC MCR ADV,CPT,J3243,Tigecycline injection,APC 9228,Per Unit,$1.12 ,OP,1.12,3.82,,,,,,
UHC MCR ADV,CPT,J3245,Inj.- tildrakizumab- 1 mg,APC 9306,Per Unit,$134.08 ,OP,134.08,134.08,,,,,,
UHC MCR ADV,CPT,J3246,Tirofiban hcl,APC 7041,Per Unit,$3.83 ,OP,3.83,3.83,,,,,,
UHC MCR ADV,CPT,J3262,Tocilizumab injection,APC 9264,Per Unit,$5.55 ,OP,5.55,5.55,,,,,,
UHC MCR ADV,CPT,J3285,Treprostinil injection,APC 1701,Per Unit,$59.68 ,OP,59.68,238.44,,,,,,
UHC MCR ADV,CPT,J3304,Inj triamcinolone ace xr 1mg,APC 9469,Per Unit,$17.75 ,OP,17.75,17.75,,,,,,
UHC MCR ADV,CPT,J3315,Triptorelin pamoate,APC 9122,Per Unit,$379.90 ,OP,379.9,379.9,,,,,,
UHC MCR ADV,CPT,J3316,Inj.- triptorelin xr 3.75 mg,APC 9016,Per Unit,"$3,120.11 ",OP,"3,120.11","3,120.11",,,,,,
UHC MCR ADV,CPT,J3357,Ustekinumab sub cu inj- 1 mg,APC 9261,Per Unit,$176.65 ,OP,176.65,176.65,,,,,,
UHC MCR ADV,CPT,J3358,Ustekinumab- iv inject- 1 mg,APC 9487,Per Unit,$11.68 ,OP,11.68,11.68,,,,,,
UHC MCR ADV,CPT,J3380,Injection- vedolizumab,APC 1489,Per Unit,$21.28 ,OP,21.28,21.28,,,,,,
UHC MCR ADV,CPT,J3385,Velaglucerase alfa,APC 9271,Per Unit,$359.29 ,OP,359.29,359.29,,,,,,
UHC MCR ADV,CPT,J3396,Verteporfin injection,APC 1203,Per Unit,$11.25 ,OP,11.25,37.64,,,,,,
UHC MCR ADV,CPT,J3398,Inj luxturna 1 billion vec g,APC 9070,Per Unit,"$2,953.71 ",OP,"2,953.71","2,953.71",,,,,,
UHC MCR ADV,CPT,J7168,Prothrombin complex kcentra,APC 9132,Per Unit,$1.99 ,OP,1.99,1.99,,,,,,
UHC MCR ADV,CPT,J7169,Inj andexxa- 10 mg,APC 9198,Per Unit,$289.93 ,OP,289.93,289.93,,,,,,
UHC MCR ADV,CPT,J7170,Inj.- emicizumab-kxwh 0.5 mg,APC 9257,Per Unit,$48.88 ,OP,48.88,48.88,,,,,,
UHC MCR ADV,CPT,J7175,Inj- factor x- (human)- 1iu,APC 1857,Per Unit,$8.20 ,OP,8.2,8.2,,,,,,
UHC MCR ADV,CPT,J7178,Inj human fibrinogen con nos,APC 1478,Per Unit,$1.30 ,OP,1.3,1.3,,,,,,
UHC MCR ADV,CPT,J7179,Vonvendi inj 1 iu vwf:rco,APC 9059,Per Unit,$1.85 ,OP,1.85,1.85,,,,,,
UHC MCR ADV,CPT,J7180,Factor xiii anti-hem factor,APC 1416,Per Unit,$9.14 ,OP,9.14,9.14,,,,,,
UHC MCR ADV,CPT,J7181,Factor xiii recomb a-subunit,APC 1746,Per Unit,$15.87 ,OP,15.87,15.87,,,,,,
UHC MCR ADV,CPT,J7182,Factor viii recomb novoeight,APC 1856,Per Unit,$1.51 ,OP,1.51,1.51,,,,,,
UHC MCR ADV,CPT,J7183,Wilate injection,APC 1352,Per Unit,$1.16 ,OP,1.16,1.16,,,,,,
UHC MCR ADV,CPT,J7185,Xyntha inj,APC 1268,Per Unit,$1.33 ,OP,1.33,1.33,,,,,,
UHC MCR ADV,CPT,J7186,Antihemophilic viii/vwf comp,APC 1213,Per Unit,$1.14 ,OP,1.14,3.82,,,,,,
UHC MCR ADV,CPT,J7187,Humate-p- inj,APC 1704,Per Unit,$1.26 ,OP,1.26,2.98,,,,,,
UHC MCR ADV,CPT,J7188,Factor viii recomb obizur,APC 1827,Per Unit,$3.19 ,OP,3.19,3.19,,,,,,
UHC MCR ADV,CPT,J7189,Factor viia recomb novoseven,APC 1705,Per Unit,$2.33 ,OP,2.33,2.33,,,,,,
UHC MCR ADV,CPT,J7190,Factor viii,APC 0925,Per Unit,$1.12 ,OP,1.12,3.02,,,,,,
UHC MCR ADV,CPT,J7192,Factor viii recombinant nos,APC 0927,Per Unit,$1.43 ,OP,1.43,3.85,,,,,,
UHC MCR ADV,CPT,J7193,Factor ix non-recombinant,APC 0931,Per Unit,$1.17 ,OP,1.17,3.36,,,,,,
UHC MCR ADV,CPT,J7194,Factor ix complex,APC 0928,Per Unit,$1.54 ,OP,1.54,2.52,,,,,,
UHC MCR ADV,CPT,J7195,Factor ix recombinant nos,APC 0932,Per Unit,$1.61 ,OP,1.61,3.57,,,,,,
UHC MCR ADV,CPT,J7197,Antithrombin iii injection,APC 1263,Per Unit,$3.20 ,OP,3.2,10.61,,,,,,
UHC MCR ADV,CPT,J7198,Anti-inhibitor,APC 0929,Per Unit,$2.21 ,OP,2.21,5.2,,,,,,
UHC MCR ADV,CPT,J7200,Factor ix recombinan rixubis,APC 1467,Per Unit,$1.54 ,OP,1.54,1.54,,,,,,
UHC MCR ADV,CPT,J7201,Factor ix alprolix recomb,APC 1486,Per Unit,$3.28 ,OP,3.28,3.28,,,,,,
UHC MCR ADV,CPT,J7202,Factor ix idelvion inj,APC 9171,Per Unit,$4.59 ,OP,4.59,4.59,,,,,,
UHC MCR ADV,CPT,J7203,Factor ix recomb gly rebinyn,APC 9468,Per Unit,$4.23 ,OP,4.23,4.23,,,,,,
UHC MCR ADV,CPT,J7204,Inj recombin esperoct per iu,APC 9354,Per Unit,$2.23 ,OP,2.23,2.23,,,,,,
UHC MCR ADV,CPT,J7205,Factor viii fc fusion recomb,APC 1656,Per Unit,$2.15 ,OP,2.15,2.15,,,,,,
UHC MCR ADV,CPT,J7207,Factor viii pegylated recomb,APC 1844,Per Unit,$1.92 ,OP,1.92,1.92,,,,,,
UHC MCR ADV,CPT,J7208,Inj. jivi 1 iu,APC 9299,Per Unit,$2.10 ,OP,2.1,2.1,,,,,,
UHC MCR ADV,CPT,J7209,Factor viii nuwiq recomb 1iu,APC 1846,Per Unit,$1.24 ,OP,1.24,1.24,,,,,,
UHC MCR ADV,CPT,J7210,Inj- afstyla- 1 i.u.,APC 9043,Per Unit,$1.36 ,OP,1.36,1.36,,,,,,
UHC MCR ADV,CPT,J7211,Inj- kovaltry- 1 i.u.,APC 9075,Per Unit,$1.24 ,OP,1.24,1.24,,,,,,
UHC MCR ADV,CPT,J7212,Factor viia recomb sevenfact,APC 9395,Per Unit,$2.27 ,OP,2.27,2.27,,,,,,
UHC MCR ADV,CPT,J7308,Aminolevulinic acid hcl top,APC 7308,Per Unit,$392.48 ,OP,392.48,392.48,,,,,,
UHC MCR ADV,CPT,J7311,Inj.- retisert- 0.01 mg,APC 9225,Per Unit,$339.00 ,OP,339,"93,937.12",,,,,,
UHC MCR ADV,CPT,J7312,Dexamethasone intra implant,APC 9256,Per Unit,$199.69 ,OP,199.69,199.69,,,,,,
UHC MCR ADV,CPT,J7313,Inj.- iluvien- 0.01 mg,APC 9450,Per Unit,$490.95 ,OP,490.95,490.95,,,,,,
UHC MCR ADV,CPT,J7314,Inj.- yutiq- 0.01 mg,APC 9328,Per Unit,$513.16 ,OP,513.16,513.16,,,,,,
UHC MCR ADV,CPT,J7316,Inj- ocriplasmin- 0.125 mg,APC 9298,Per Unit,"$1,046.93 ",OP,"1,046.93","1,046.93",,,,,,
UHC MCR ADV,CPT,J7318,Inj- durolane 1 mg,APC 9174,Per Unit,$17.23 ,OP,17.23,17.23,,,,,,
UHC MCR ADV,CPT,J7320,Genvisc 850- inj- 1mg,APC 9079,Per Unit,$16.92 ,OP,16.92,16.92,,,,,,
UHC MCR ADV,CPT,J7322,Hymovis injection 1 mg,APC 9471,Per Unit,$31.67 ,OP,31.67,903.6,,,,,,
UHC MCR ADV,CPT,J7323,Euflexxa inj per dose,APC 0875,Per Unit,$138.82 ,OP,138.82,590.67,,,,,,
UHC MCR ADV,CPT,J7324,Orthovisc inj per dose,APC 0877,Per Unit,$148.74 ,OP,148.74,880.74,,,,,,
UHC MCR ADV,CPT,J7325,Synvisc or synvisc-one,APC 0874,Per Unit,$11.24 ,OP,11.24,11.24,,,,,,
UHC MCR ADV,CPT,J7326,Gel-one,APC 1417,Per Unit,"$1,219.00 ",OP,"1,219.00","1,219.00",,,,,,
UHC MCR ADV,CPT,J7327,Monovisc inj per dose,APC 1747,Per Unit,$762.80 ,OP,762.8,762.8,,,,,,
UHC MCR ADV,CPT,J7328,Gelsyn-3 injection 0.1 mg,APC 1862,Per Unit,$2.18 ,OP,2.18,2.18,,,,,,
UHC MCR ADV,CPT,J7329,Inj- trivisc 1 mg,APC 9196,Per Unit,$19.12 ,OP,19.12,19.12,,,,,,
UHC MCR ADV,CPT,J7331,Synojoynt- inj.- 1 mg,APC 9337,Per Unit,$18.02 ,OP,18.02,18.02,,,,,,
UHC MCR ADV,CPT,J7336,Capsaicin 8% patch,APC 9071,Per Unit,$3.23 ,OP,3.23,3.23,,,,,,
UHC MCR ADV,CPT,J7340,Carbidopa levodopa ent 100ml,APC 9320,Per Unit,$211.70 ,OP,211.7,211.7,,,,,,
UHC MCR ADV,CPT,J7342,Ciprofloxacin otic susp 6 mg,APC 9479,Per Unit,$29.98 ,OP,29.98,29.98,,,,,,
UHC MCR ADV,CPT,J7345,Aminolevulinic acid- 10% gel,APC 9301,Per Unit,$1.59 ,OP,1.59,1.59,,,,,,
UHC MCR ADV,CPT,J7351,Inj bimatoprost itc imp1mcg,APC 9351,Per Unit,$205.63 ,OP,205.63,205.63,,,,,,
UHC MCR ADV,CPT,J7352,Afamelanotide implant- 1 mg,APC 9396,Per Unit,"$3,218.90 ",OP,"3,218.90","3,218.90",,,,,,
UHC MCR ADV,CPT,J7402,Mometasone sinus sinuva,APC 9346,Per Unit,$10.56 ,OP,10.56,10.56,,,,,,
UHC MCR ADV,CPT,J7501,Azathioprine parenteral,APC 0887,Per Unit,$245.02 ,OP,245.02,442.27,,,,,,
UHC MCR ADV,CPT,J7504,Lymphocyte immune globulin,APC 0890,Per Unit,"$2,355.53 ",OP,"2,245.67","2,355.53",,,,,,
UHC MCR ADV,CPT,J7511,Antithymocyte globuln rabbit,APC 9104,Per Unit,$837.42 ,OP,837.42,"1,807.23",,,,,,
UHC MCR ADV,CPT,J7525,Tacrolimus injection,APC 9006,Per Unit,$219.33 ,OP,219.33,540.46,,,,,,
UHC MCR ADV,CPT,J8560,Etoposide oral 50 mg,APC 0802,Per Unit,$75.63 ,OP,75.63,75.63,,,,,,
UHC MCR ADV,CPT,J8655,Oral netupitant- palonosetro,APC 9448,Per Unit,$315.59 ,OP,315.59,315.59,,,,,,
UHC MCR ADV,CPT,J8670,Rolapitant- oral- 1mg,APC 1761,Per Unit,$1.75 ,OP,1.75,1.75,,,,,,
UHC MCR ADV,CPT,J9015,Aldesleukin injection,APC 0807,Per Unit,"$3,795.26 ",OP,"3,795.26","3,795.26",,,,,,
UHC MCR ADV,CPT,J9017,Arsenic trioxide injection,APC 9012,Per Unit,$13.11 ,OP,13.11,179.2,,,,,,
UHC MCR ADV,CPT,J9019,Erwinaze injection,APC 9289,Per Unit,$427.27 ,OP,427.27,427.27,,,,,,
UHC MCR ADV,CPT,J9022,Inj- atezolizumab-10 mg,APC 9483,Per Unit,$79.75 ,OP,79.75,79.75,,,,,,
UHC MCR ADV,CPT,J9023,Injection- avelumab- 10 mg,APC 9491,Per Unit,$86.19 ,OP,86.19,86.19,,,,,,
UHC MCR ADV,CPT,J9025,Azacitidine injection,APC 1709,Per Unit,$0.93 ,OP,0.93,22.88,,,,,,
UHC MCR ADV,CPT,J9027,Clofarabine injection,APC 1710,Per Unit,$53.15 ,OP,53.15,564.29,,,,,,
UHC MCR ADV,CPT,J9032,Injection- belinostat- 10mg,APC 1658,Per Unit,$42.77 ,OP,42.77,42.77,,,,,,
UHC MCR ADV,CPT,J9033,Inj.- treanda 1 mg,APC 9243,Per Unit,$22.01 ,OP,22.01,91.51,,,,,,
UHC MCR ADV,CPT,J9034,Inj.- bendeka 1 mg,APC 1861,Per Unit,$19.65 ,OP,19.65,19.65,,,,,,
UHC MCR ADV,CPT,J9035,Bevacizumab injection,APC 9214,Per Unit,$70.41 ,OP,70.41,278.32,,,,,,
UHC MCR ADV,CPT,J9036,Inj. belrapzo/bendamustine,APC 9313,Per Unit,$21.47 ,OP,21.47,21.47,,,,,,
UHC MCR ADV,CPT,J9037,Inj belantamab mafodont blmf,APC 9384,Per Unit,$42.78 ,OP,42.78,42.78,,,,,,
UHC MCR ADV,CPT,J9039,Injection- blinatumomab,APC 9449,Per Unit,$123.88 ,OP,123.88,123.88,,,,,,
UHC MCR ADV,CPT,J9041,Inj.- velcade 0.1 mg,APC 9207,Per Unit,$45.16 ,OP,45.16,175.39,,,,,,
UHC MCR ADV,CPT,J9042,Brentuximab vedotin inj,APC 9287,Per Unit,$189.34 ,OP,189.34,189.34,,,,,,
UHC MCR ADV,CPT,J9043,Cabazitaxel injection,APC 9276,Per Unit,$189.00 ,OP,189,189,,,,,,
UHC MCR ADV,CPT,J9044,Inj- bortezomib- nos- 0.1 mg,APC 9192,Per Unit,$18.31 ,OP,18.31,18.31,,,,,,
UHC MCR ADV,CPT,J9047,Injection- carfilzomib- 1 mg,APC 9295,Per Unit,$41.10 ,OP,41.1,41.1,,,,,,
UHC MCR ADV,CPT,J9050,Carmustine injection,APC 0812,Per Unit,"$1,234.46 ",OP,"1,234.46","1,234.46",,,,,,
UHC MCR ADV,CPT,J9055,Cetuximab injection,APC 9215,Per Unit,$66.71 ,OP,66.71,240.2,,,,,,
UHC MCR ADV,CPT,J9057,Inj.- copanlisib- 1 mg,APC 9030,Per Unit,$80.96 ,OP,80.96,80.96,,,,,,
UHC MCR ADV,CPT,J9065,Inj cladribine per 1 mg,APC 0858,Per Unit,$18.02 ,OP,18.02,144.88,,,,,,
UHC MCR ADV,CPT,J9070,Cyclophosphamide 100 mg inj,APC 1408,Per Unit,$29.15 ,OP,19.07,29.15,,,,,,
UHC MCR ADV,CPT,J9119,Inj.- cemiplimab-rwlc- 1 mg,APC 9304,Per Unit,$27.54 ,OP,27.54,27.54,,,,,,
UHC MCR ADV,CPT,J9120,Dactinomycin injection,APC 0752,Per Unit,$890.64 ,OP,890.64,"2,634.57",,,,,,
UHC MCR ADV,CPT,J9144,Daratumumab- hyaluronidase,APC 9378,Per Unit,$45.10 ,OP,45.1,45.1,,,,,,
UHC MCR ADV,CPT,J9145,Injection- daratumumab 10 mg,APC 9476,Per Unit,$57.55 ,OP,57.55,57.55,,,,,,
UHC MCR ADV,CPT,J9150,Daunorubicin injection,APC 0820,Per Unit,$40.36 ,OP,40.36,80.07,,,,,,
UHC MCR ADV,CPT,J9153,Inj daunorubicin- cytarabine,APC 9302,Per Unit,$202.60 ,OP,202.6,202.6,,,,,,
UHC MCR ADV,CPT,J9155,Degarelix injection,APC 1296,Per Unit,$4.12 ,OP,4.12,4.12,,,,,,
UHC MCR ADV,CPT,J9173,Inj.- durvalumab- 10 mg,APC 9492,Per Unit,$76.86 ,OP,76.86,76.86,,,,,,
UHC MCR ADV,CPT,J9176,Injection- elotuzumab- 1mg,APC 9477,Per Unit,$6.77 ,OP,6.77,6.77,,,,,,
UHC MCR ADV,CPT,J9177,Inj enfort vedo-ejfv 0.25mg,APC 9364,Per Unit,$30.17 ,OP,30.17,30.17,,,,,,
UHC MCR ADV,CPT,J9179,Eribulin mesylate injection,APC 1426,Per Unit,$123.93 ,OP,123.93,123.93,,,,,,
UHC MCR ADV,CPT,J9198,Inj. infugem- 100 mg,APC 9387,Per Unit,$34.00 ,OP,34,34,,,,,,
UHC MCR ADV,CPT,J9202,Goserelin acetate implant,APC 0810,Per Unit,$525.21 ,OP,525.21,915.04,,,,,,
UHC MCR ADV,CPT,J9203,Gemtuzumab ozogamicin 0.1 mg,APC 9495,Per Unit,$207.99 ,OP,207.99,207.99,,,,,,
UHC MCR ADV,CPT,J9204,Inj mogamulizumab-kpkc- 1 mg,APC 9182,Per Unit,$210.05 ,OP,210.05,210.05,,,,,,
UHC MCR ADV,CPT,J9205,Inj irinotecan liposome 1 mg,APC 9474,Per Unit,$57.20 ,OP,57.2,57.2,,,,,,
UHC MCR ADV,CPT,J9207,Ixabepilone injection,APC 9240,Per Unit,$112.12 ,OP,112.12,308.83,,,,,,
UHC MCR ADV,CPT,J9210,Inj.- emapalumab-lzsg- 1 mg,APC 9310,Per Unit,$376.03 ,OP,376.03,376.03,,,,,,
UHC MCR ADV,CPT,J9214,Interferon alfa-2b inj,APC 0836,Per Unit,$33.24 ,OP,33.24,72.44,,,,,,
UHC MCR ADV,CPT,J9217,Leuprolide acetate suspnsion,APC 9217,Per Unit,$139.09 ,OP,139.09,987.49,,,,,,
UHC MCR ADV,CPT,J9223,Inj. lurbinectedin- 0.1 mg,APC 9389,Per Unit,$174.03 ,OP,174.03,174.03,,,,,,
UHC MCR ADV,CPT,J9225,Vantas implant,APC 1711,Per Unit,"$5,166.29 ",OP,"5,166.29","7,613.94",,,,,,
UHC MCR ADV,CPT,J9226,Supprelin la implant,APC 1142,Per Unit,"$43,467.03 ",OP,"43,467.03","71,949.32",,,,,,
UHC MCR ADV,CPT,J9227,Inj. isatuximab-irfc 10 mg,APC 9377,Per Unit,$67.60 ,OP,67.6,67.6,,,,,,
UHC MCR ADV,CPT,J9228,Ipilimumab injection,APC 9284,Per Unit,$158.65 ,OP,158.65,158.65,,,,,,
UHC MCR ADV,CPT,J9229,Inj inotuzumab ozogam 0.1 mg,APC 9028,Per Unit,"$2,371.62 ",OP,"2,371.62","2,371.62",,,,,,
UHC MCR ADV,CPT,J9230,Mechlorethamine hcl inj,APC 0751,Per Unit,$11.74 ,OP,11.74,712.98,,,,,,
UHC MCR ADV,CPT,J9245,Inj melpha hydroch nos 50 mg,APC 0840,Per Unit,$208.41 ,OP,208.41,"7,888.46",,,,,,
UHC MCR ADV,CPT,J9246,Inj.- evomela- 1 mg,APC 9375,Per Unit,$18.20 ,OP,18.2,18.2,,,,,,
UHC MCR ADV,CPT,J9247,Inj- melphalan flufenami 1mg,APC 9417,Per Unit,$499.86 ,OP,499.86,499.86,,,,,,
UHC MCR ADV,CPT,J9261,Nelarabine injection,APC 0825,Per Unit,$155.90 ,OP,155.9,488.04,,,,,,
UHC MCR ADV,CPT,J9262,Inj- omacetaxine mep- 0.01mg,APC 9297,Per Unit,$3.30 ,OP,3.3,3.3,,,,,,
UHC MCR ADV,CPT,J9264,Paclitaxel protein bound,APC 1712,Per Unit,$14.08 ,OP,14.08,45.74,,,,,,
UHC MCR ADV,CPT,J9266,Pegaspargase injection,APC 0843,Per Unit,"$21,561.05 ",OP,"12,715.34","21,561.05",,,,,,
UHC MCR ADV,CPT,J9268,Pentostatin injection,APC 0844,Per Unit,"$1,880.67 ",OP,"1,880.67","7,030.61",,,,,,
UHC MCR ADV,CPT,J9269,Inj. tagraxofusp-erzs 10 mcg,APC 9309,Per Unit,$290.37 ,OP,290.37,290.37,,,,,,
UHC MCR ADV,CPT,J9270,Plicamycin (mithramycin) inj,APC 9093,Per Unit,$115.40 ,OP,115.4,385.09,,,,,,
UHC MCR ADV,CPT,J9271,Inj pembrolizumab,APC 1490,Per Unit,$52.75 ,OP,52.75,52.75,,,,,,
UHC MCR ADV,CPT,J9280,Mitomycin injection,APC 1232,Per Unit,$38.63 ,OP,38.63,76.26,,,,,,
UHC MCR ADV,CPT,J9281,Mitomycin instillation,APC 9374,Per Unit,$281.88 ,OP,281.88,281.88,,,,,,
UHC MCR ADV,CPT,J9285,Inj- olaratumab- 10 mg,APC 9485,Per Unit,$52.07 ,OP,52.07,52.07,,,,,,
UHC MCR ADV,CPT,J9293,Mitoxantrone hydrochl / 5 mg,APC 0864,Per Unit,$26.29 ,OP,26.29,392.7,,,,,,
UHC MCR ADV,CPT,J9295,Injection- necitumumab- 1 mg,APC 9475,Per Unit,$5.74 ,OP,5.74,5.74,,,,,,
UHC MCR ADV,CPT,J9299,Injection- nivolumab,APC 9453,Per Unit,$28.86 ,OP,28.86,28.86,,,,,,
UHC MCR ADV,CPT,J9301,Obinutuzumab inj,APC 1476,Per Unit,$64.54 ,OP,64.54,64.54,,,,,,
UHC MCR ADV,CPT,J9302,Ofatumumab injection,APC 9260,Per Unit,$63.96 ,OP,63.96,63.96,,,,,,
UHC MCR ADV,CPT,J9303,Panitumumab injection,APC 9235,Per Unit,$130.38 ,OP,130.38,130.38,,,,,,
UHC MCR ADV,CPT,J9305,Inj. pemetrexed nos 10mg,APC 9213,Per Unit,$74.93 ,OP,74.93,232.58,,,,,,
UHC MCR ADV,CPT,J9306,Injection- pertuzumab- 1 mg,APC 1471,Per Unit,$13.56 ,OP,13.56,13.56,,,,,,
UHC MCR ADV,CPT,J9307,Pralatrexate injection,APC 9259,Per Unit,$314.84 ,OP,314.84,314.84,,,,,,
UHC MCR ADV,CPT,J9308,Injection- ramucirumab,APC 1488,Per Unit,$62.69 ,OP,62.69,62.69,,,,,,
UHC MCR ADV,CPT,J9309,Inj- polatuzumab vedotin 1mg,APC 9331,Per Unit,$113.57 ,OP,113.57,113.57,,,,,,
UHC MCR ADV,CPT,J9311,Inj rituximab- hyaluronidase,APC 9467,Per Unit,$37.94 ,OP,37.94,37.94,,,,,,
UHC MCR ADV,CPT,J9312,Inj.- rituximab- 10 mg,APC 9186,Per Unit,$86.94 ,OP,86.94,86.94,,,,,,
UHC MCR ADV,CPT,J9313,Inj.- lumoxiti- 0.01 mg,APC 9305,Per Unit,$23.39 ,OP,23.39,23.39,,,,,,
UHC MCR ADV,CPT,J9316,Pertuzu- trastuzu- 10 mg,APC 9390,Per Unit,$72.15 ,OP,72.15,72.15,,,,,,
UHC MCR ADV,CPT,J9317,Sacituzumab govitecan-hziy,APC 9376,Per Unit,$30.35 ,OP,30.35,30.35,,,,,,
UHC MCR ADV,CPT,J9318,Inj romidepsin non-lyo 0.1mg,APC 9428,Per Unit,$33.91 ,OP,33.91,33.91,,,,,,
UHC MCR ADV,CPT,J9319,Inj romidepsin lyophil 0.1mg,APC 9429,Per Unit,$33.68 ,OP,33.68,33.68,,,,,,
UHC MCR ADV,CPT,J9320,Streptozocin injection,APC 0850,Per Unit,$348.51 ,OP,348.51,"1,372.57",,,,,,
UHC MCR ADV,CPT,J9325,Inj talimogene laherparepvec,APC 9472,Per Unit,$57.26 ,OP,57.26,57.26,,,,,,
UHC MCR ADV,CPT,J9328,Temozolomide injection,APC 9253,Per Unit,$10.41 ,OP,10.41,10.41,,,,,,
UHC MCR ADV,CPT,J9330,Temsirolimus injection,APC 1168,Per Unit,$38.25 ,OP,38.25,38.25,,,,,,
UHC MCR ADV,CPT,J9340,Thiotepa injection,APC 0851,Per Unit,$305.84 ,OP,305.84,446.08,,,,,,
UHC MCR ADV,CPT,J9348,Inj. naxitamab-gqgk- 1 mg,APC 9408,Per Unit,$539.07 ,OP,539.07,539.07,,,,,,
UHC MCR ADV,CPT,J9349,Inj.- tafasitamab-cxix,APC 9385,Per Unit,$12.62 ,OP,12.62,12.62,,,,,,
UHC MCR ADV,CPT,J9352,Injection trabectedin 0.1mg,APC 9480,Per Unit,$325.03 ,OP,325.03,325.03,,,,,,
UHC MCR ADV,CPT,J9353,Inj. margetuximab-cmkb- 5 mg,APC 9418,Per Unit,$42.99 ,OP,42.99,42.99,,,,,,
UHC MCR ADV,CPT,J9354,Inj- ado-trastuzumab emt 1mg,APC 9131,Per Unit,$34.18 ,OP,34.18,34.18,,,,,,
UHC MCR ADV,CPT,J9355,Inj trastuzumab excl biosimi,APC 1613,Per Unit,$89.81 ,OP,89.81,238.1,,,,,,
UHC MCR ADV,CPT,J9356,Inj. herceptin hylecta- 10mg,APC 9314,Per Unit,$71.85 ,OP,71.85,71.85,,,,,,
UHC MCR ADV,CPT,J9357,Valrubicin injection,APC 1235,Per Unit,"$1,425.37 ",OP,"1,425.37","1,795.78",,,,,,
UHC MCR ADV,CPT,J9358,Inj fam-trastu deru-nxki 1mg,APC 9353,Per Unit,$24.27 ,OP,24.27,24.27,,,,,,
UHC MCR ADV,CPT,J9371,Inj- vincristine sul lip 1mg,APC 1466,Per Unit,"$3,370.23 ",OP,28.22,"3,370.23",,,,,,
UHC MCR ADV,CPT,J9395,Injection- fulvestrant,APC 9120,Per Unit,$15.98 ,OP,15.98,396.52,,,,,,
UHC MCR ADV,CPT,J9400,Inj- ziv-aflibercept- 1mg,APC 9296,Per Unit,$8.42 ,OP,8.42,8.42,,,,,,
UHC MCR ADV,CPT,J9600,Porfimer sodium injection,APC 0856,Per Unit,"$21,856.35 ",OP,"13,169.04","21,856.35",,,,,,
UHC MCR ADV,CPT,K0672,Removable soft interface le,Durable Medical Equipment,Per Unit,$85.14 ,OP,85.14,85.14,,,,,,
UHC MCR ADV,CPT,L0112,Cranial cervical orthosis,Durable Medical Equipment,Per Unit,"$1,404.96 ",OP,"1,404.96","4,830.68",,,,,,
UHC MCR ADV,CPT,L0113,Cranial cervical torticollis,Durable Medical Equipment,Per Unit,$286.27 ,OP,286.27,286.27,,,,,,
UHC MCR ADV,CPT,L0120,Cerv flex n/adj foam pre ots,Durable Medical Equipment,Per Unit,$26.55 ,OP,26.55,91.51,,,,,,
UHC MCR ADV,CPT,L0130,Flex thermoplastic collar mo,Durable Medical Equipment,Per Unit,$153.23 ,OP,153.23,526.16,,,,,,
UHC MCR ADV,CPT,L0140,Cervical semi-rigid adjustab,Durable Medical Equipment,Per Unit,$60.09 ,OP,60.09,205.88,,,,,,
UHC MCR ADV,CPT,L0150,Cerv semi-rig adj molded chn,Durable Medical Equipment,Per Unit,$107.45 ,OP,107.45,369.83,,,,,,
UHC MCR ADV,CPT,L0160,Cerv sr wire occ/man pre ots,Durable Medical Equipment,Per Unit,$156.89 ,OP,156.89,541.4,,,,,,
UHC MCR ADV,CPT,L0170,Cervical collar molded to pt,Durable Medical Equipment,Per Unit,$807.10 ,OP,807.1,"2,775.65",,,,,,
UHC MCR ADV,CPT,L0172,Cerv col sr foam 2pc pre ots,Durable Medical Equipment,Per Unit,$142.17 ,OP,142.17,488.04,,,,,,
UHC MCR ADV,CPT,L0174,Cerv sr 2pc thor ext pre ots,Durable Medical Equipment,Per Unit,$279.55 ,OP,279.55,960.8,,,,,,
UHC MCR ADV,CPT,L0180,Cer post col occ/man sup adj,Durable Medical Equipment,Per Unit,$452.88 ,OP,452.88,"1,559.39",,,,,,
UHC MCR ADV,CPT,L0190,Cerv collar supp adj cerv ba,Durable Medical Equipment,Per Unit,$534.12 ,OP,534.12,"1,837.71",,,,,,
UHC MCR ADV,CPT,L0200,Cerv col supp adj bar & thor,Durable Medical Equipment,Per Unit,$619.54 ,OP,619.54,"2,131.30",,,,,,
UHC MCR ADV,CPT,L0220,Thor rib belt custom fabrica,Durable Medical Equipment,Per Unit,$129.68 ,OP,129.68,446.08,,,,,,
UHC MCR ADV,CPT,L0450,Tlso flex trunk/thor pre ots,Durable Medical Equipment,Per Unit,$128.11 ,OP,128.11,560.47,,,,,,
UHC MCR ADV,CPT,L0454,Tlso trnk sj-t9 pre cst,Durable Medical Equipment,Per Unit,$348.14 ,OP,348.14,"1,197.20",,,,,,
UHC MCR ADV,CPT,L0455,Tlso flex trnk sj-t9 pre ots,Durable Medical Equipment,Per Unit,$249.16 ,OP,249.16,249.16,,,,,,
UHC MCR ADV,CPT,L0456,Tlso flex trnk sj-ss pre cst,Durable Medical Equipment,Per Unit,$998.38 ,OP,998.38,"3,435.25",,,,,,
UHC MCR ADV,CPT,L0457,Tlso flex trnk sj-ss pre ots,Durable Medical Equipment,Per Unit,$714.52 ,OP,714.52,714.52,,,,,,
UHC MCR ADV,CPT,L0458,Tlso 2mod symphis-xipho pre,Durable Medical Equipment,Per Unit,$895.27 ,OP,895.27,"3,080.66",,,,,,
UHC MCR ADV,CPT,L0460,Tlso 2 shl symphys-stern cst,Durable Medical Equipment,Per Unit,"$1,007.68 ",OP,"1,007.68","3,465.73",,,,,,
UHC MCR ADV,CPT,L0462,Tlso 3mod sacro-scap pre,Durable Medical Equipment,Per Unit,"$1,253.37 ",OP,"1,253.37","4,312.16",,,,,,
UHC MCR ADV,CPT,L0464,Tlso 4mod sacro-scap pre,Durable Medical Equipment,Per Unit,"$1,492.13 ",OP,"1,492.13","5,131.88",,,,,,
UHC MCR ADV,CPT,L0466,Tlso r fram soft ant pre cst,Durable Medical Equipment,Per Unit,$380.86 ,OP,380.86,"1,311.56",,,,,,
UHC MCR ADV,CPT,L0467,Tlso r fram soft pre ots,Durable Medical Equipment,Per Unit,$277.04 ,OP,277.04,277.04,,,,,,
UHC MCR ADV,CPT,L0468,Tlso rig fram pelvic pre cst,Durable Medical Equipment,Per Unit,$477.29 ,OP,477.29,"1,643.28",,,,,,
UHC MCR ADV,CPT,L0469,Tlso rig fram pelvic pre ots,Durable Medical Equipment,Per Unit,$351.00 ,OP,351,351,,,,,,
UHC MCR ADV,CPT,L0470,Tlso rigid frame pre subclav,Durable Medical Equipment,Per Unit,$660.47 ,OP,660.47,"2,272.36",,,,,,
UHC MCR ADV,CPT,L0472,Tlso rigid frame hyperex pre,Durable Medical Equipment,Per Unit,$406.41 ,OP,406.41,"1,399.26",,,,,,
UHC MCR ADV,CPT,L0480,Tlso rigid plastic custom fa,Durable Medical Equipment,Per Unit,"$1,516.23 ",OP,"1,516.23","5,215.77",,,,,,
UHC MCR ADV,CPT,L0482,Tlso rigid lined custom fab,Durable Medical Equipment,Per Unit,"$1,693.64 ",OP,"1,693.64","5,825.80",,,,,,
UHC MCR ADV,CPT,L0484,Tlso rigid plastic cust fab,Durable Medical Equipment,Per Unit,"$1,829.06 ",OP,"1,829.06","6,290.94",,,,,,
UHC MCR ADV,CPT,L0486,Tlso rigidlined cust fab two,Durable Medical Equipment,Per Unit,"$2,054.11 ",OP,"2,054.11","7,064.92",,,,,,
UHC MCR ADV,CPT,L0488,Tlso rigid lined pre one pie,Durable Medical Equipment,Per Unit,"$1,007.68 ",OP,"1,007.68","3,465.73",,,,,,
UHC MCR ADV,CPT,L0490,Tlso rigid plastic pre one,Durable Medical Equipment,Per Unit,$283.96 ,OP,283.96,976.05,,,,,,
UHC MCR ADV,CPT,L0491,Tlso 2 piece rigid shell,Durable Medical Equipment,Per Unit,$770.93 ,OP,770.93,"2,649.83",,,,,,
UHC MCR ADV,CPT,L0492,Tlso 3 piece rigid shell,Durable Medical Equipment,Per Unit,$502.01 ,OP,502.01,"1,727.15",,,,,,
UHC MCR ADV,CPT,L0621,Sio flex pelvic/sacr pre ots,Durable Medical Equipment,Per Unit,$67.68 ,OP,67.68,446.08,,,,,,
UHC MCR ADV,CPT,L0622,Sio flex pelvisacral custom,Durable Medical Equipment,Per Unit,$268.31 ,OP,268.31,"1,384.01",,,,,,
UHC MCR ADV,CPT,L0623,Sio rig pnl pelv/sac pre ots,Durable Medical Equipment,Per Unit,$126.95 ,OP,126.95,126.95,,,,,,
UHC MCR ADV,CPT,L0625,Lo flex l1-below l5 pre ots,Durable Medical Equipment,Per Unit,$39.58 ,OP,39.58,285.96,,,,,,
UHC MCR ADV,CPT,L0626,Lo sag rig pnl stays pre cst,Durable Medical Equipment,Per Unit,$78.25 ,OP,78.25,404.14,,,,,,
UHC MCR ADV,CPT,L0627,Lo sag ri an/pos pnl pre cst,Durable Medical Equipment,Per Unit,$412.59 ,OP,412.59,"2,127.49",,,,,,
UHC MCR ADV,CPT,L0628,Lso flex no ri stays pre ots,Durable Medical Equipment,Per Unit,$60.27 ,OP,60.27,434.65,,,,,,
UHC MCR ADV,CPT,L0630,Lso r post pnl sj-t9 pre cst,Durable Medical Equipment,Per Unit,$162.59 ,OP,162.59,838.79,,,,,,
UHC MCR ADV,CPT,L0631,Lso sag r an/pos pnl pre cst,Durable Medical Equipment,Per Unit,"$1,030.49 ",OP,"1,030.49","5,314.90",,,,,,
UHC MCR ADV,CPT,L0633,Lso sc r pos/lat pnl pre cst,Durable Medical Equipment,Per Unit,$287.85 ,OP,287.85,"1,483.14",,,,,,
UHC MCR ADV,CPT,L0635,Lso sagit rigid panel prefab,Durable Medical Equipment,Per Unit,"$1,003.05 ",OP,"1,003.05","5,173.83",,,,,,
UHC MCR ADV,CPT,L0636,Lso sagittal rigid panel cus,Durable Medical Equipment,Per Unit,"$1,360.98 ",OP,"1,360.98","7,019.17",,,,,,
UHC MCR ADV,CPT,L0637,Lso sc r ant/pos pnl pre cst,Durable Medical Equipment,Per Unit,"$1,300.47 ",OP,"1,300.47","6,710.34",,,,,,
UHC MCR ADV,CPT,L0638,Lso sag-coronal panel custom,Durable Medical Equipment,Per Unit,"$1,323.97 ",OP,"1,323.97","6,828.54",,,,,,
UHC MCR ADV,CPT,L0639,Lso s/c shell/panel prefab,Durable Medical Equipment,Per Unit,"$1,300.47 ",OP,"1,300.47","6,710.34",,,,,,
UHC MCR ADV,CPT,L0640,Lso s/c shell/panel custom,Durable Medical Equipment,Per Unit,"$1,050.39 ",OP,"1,050.39","5,417.84",,,,,,
UHC MCR ADV,CPT,L0641,Lo rig pos pnl l1-l5 pre ots,Durable Medical Equipment,Per Unit,$56.00 ,OP,56,56,,,,,,
UHC MCR ADV,CPT,L0642,Lo sag ri an/pos pnl pre ots,Durable Medical Equipment,Per Unit,$295.35 ,OP,295.35,295.35,,,,,,
UHC MCR ADV,CPT,L0643,Lso sag ctr rigi pos pre ots,Durable Medical Equipment,Per Unit,$116.37 ,OP,116.37,116.37,,,,,,
UHC MCR ADV,CPT,L0648,Lso sag r an/pos pnl pre ots,Durable Medical Equipment,Per Unit,$737.61 ,OP,737.61,737.61,,,,,,
UHC MCR ADV,CPT,L0649,Lso sc r pos/lat pnl pre ots,Durable Medical Equipment,Per Unit,$206.04 ,OP,206.04,206.04,,,,,,
UHC MCR ADV,CPT,L0650,Lso sc r ant/pos pnl pre ots,Durable Medical Equipment,Per Unit,$880.49 ,OP,880.49,880.49,,,,,,
UHC MCR ADV,CPT,L0651,Lso sag-co shell pnl pre ots,Durable Medical Equipment,Per Unit,$880.49 ,OP,880.49,880.49,,,,,,
UHC MCR ADV,CPT,L0700,Ctlso a-p-l control molded,Durable Medical Equipment,Per Unit,"$1,998.37 ",OP,"1,998.37","6,874.29",,,,,,
UHC MCR ADV,CPT,L0710,Ctlso a-p-l control w/ inter,Durable Medical Equipment,Per Unit,"$2,196.75 ",OP,"2,196.75","7,552.94",,,,,,
UHC MCR ADV,CPT,L0810,Halo cervical into jckt vest,Durable Medical Equipment,Per Unit,"$2,683.14 ",OP,"2,683.14","9,226.72",,,,,,
UHC MCR ADV,CPT,L0820,Halo cervical into body jack,Durable Medical Equipment,Per Unit,"$2,110.65 ",OP,"2,110.65","7,259.37",,,,,,
UHC MCR ADV,CPT,L0830,Halo cerv into milwaukee typ,Durable Medical Equipment,Per Unit,"$3,229.60 ",OP,"3,229.60","11,106.37",,,,,,
UHC MCR ADV,CPT,L0859,Mri compatible system,Durable Medical Equipment,Per Unit,"$1,143.45 ",OP,"1,143.45","3,930.89",,,,,,
UHC MCR ADV,CPT,L0861,Halo repl liner/interface,Durable Medical Equipment,Per Unit,$216.37 ,OP,216.37,743.48,,,,,,
UHC MCR ADV,CPT,L0970,Tlso corset front,Durable Medical Equipment,Per Unit,$107.27 ,OP,107.27,369.83,,,,,,
UHC MCR ADV,CPT,L0972,Lso corset front,Durable Medical Equipment,Per Unit,$97.64 ,OP,97.64,335.53,,,,,,
UHC MCR ADV,CPT,L0974,Tlso full corset,Durable Medical Equipment,Per Unit,$175.42 ,OP,175.42,602.41,,,,,,
UHC MCR ADV,CPT,L0976,Lso full corset,Durable Medical Equipment,Per Unit,$150.09 ,OP,150.09,150.09,,,,,,
UHC MCR ADV,CPT,L0978,Axillary crutch extension,Durable Medical Equipment,Per Unit,$188.90 ,OP,188.9,648.16,,,,,,
UHC MCR ADV,CPT,L0980,Peroneal straps pair pre ots,Durable Medical Equipment,Per Unit,$17.15 ,OP,17.15,57.19,,,,,,
UHC MCR ADV,CPT,L0982,Stocking sup grips 4 pre ots,Durable Medical Equipment,Per Unit,$15.70 ,OP,15.7,53.38,,,,,,
UHC MCR ADV,CPT,L0984,Protect body sock ea pre ots,Durable Medical Equipment,Per Unit,$67.93 ,OP,67.93,232.58,,,,,,
UHC MCR ADV,CPT,L1000,Ctlso milwauke initial model,Durable Medical Equipment,Per Unit,"$2,035.53 ",OP,"2,035.53","7,000.10",,,,,,
UHC MCR ADV,CPT,L1005,Tension based scoliosis orth,Durable Medical Equipment,Per Unit,"$3,212.88 ",OP,"3,212.88","11,049.19",,,,,,
UHC MCR ADV,CPT,L1010,Ctlso axilla sling,Durable Medical Equipment,Per Unit,$83.99 ,OP,83.99,289.76,,,,,,
UHC MCR ADV,CPT,L1020,Kyphosis pad,Durable Medical Equipment,Per Unit,$108.17 ,OP,108.17,373.65,,,,,,
UHC MCR ADV,CPT,L1025,Kyphosis pad floating,Durable Medical Equipment,Per Unit,$156.06 ,OP,156.06,537.6,,,,,,
UHC MCR ADV,CPT,L1030,Lumbar bolster pad,Durable Medical Equipment,Per Unit,$78.60 ,OP,78.6,270.71,,,,,,
UHC MCR ADV,CPT,L1040,Lumbar or lumbar rib pad,Durable Medical Equipment,Per Unit,$89.00 ,OP,89,305.01,,,,,,
UHC MCR ADV,CPT,L1050,Sternal pad,Durable Medical Equipment,Per Unit,$100.72 ,OP,100.72,346.96,,,,,,
UHC MCR ADV,CPT,L1060,Thoracic pad,Durable Medical Equipment,Per Unit,$108.72 ,OP,108.72,373.65,,,,,,
UHC MCR ADV,CPT,L1070,Trapezius sling,Durable Medical Equipment,Per Unit,$112.62 ,OP,112.62,388.89,,,,,,
UHC MCR ADV,CPT,L1080,Outrigger,Durable Medical Equipment,Per Unit,$52.52 ,OP,52.52,179.2,,,,,,
UHC MCR ADV,CPT,L1085,Outrigger bil w/ vert extens,Durable Medical Equipment,Per Unit,$175.83 ,OP,175.83,606.21,,,,,,
UHC MCR ADV,CPT,L1090,Lumbar sling,Durable Medical Equipment,Per Unit,$101.01 ,OP,101.01,346.96,,,,,,
UHC MCR ADV,CPT,L1100,Ring flange plastic/leather,Durable Medical Equipment,Per Unit,$190.64 ,OP,190.64,655.78,,,,,,
UHC MCR ADV,CPT,L1110,Ring flange plas/leather mol,Durable Medical Equipment,Per Unit,$319.63 ,OP,319.63,"1,098.07",,,,,,
UHC MCR ADV,CPT,L1120,Covers for upright each,Durable Medical Equipment,Per Unit,$38.18 ,OP,38.18,129.64,,,,,,
UHC MCR ADV,CPT,L1200,Furnsh initial orthosis only,Durable Medical Equipment,Per Unit,"$1,796.37 ",OP,"1,796.37","6,176.57",,,,,,
UHC MCR ADV,CPT,L1210,Lateral thoracic extension,Durable Medical Equipment,Per Unit,$245.60 ,OP,245.6,846.41,,,,,,
UHC MCR ADV,CPT,L1220,Anterior thoracic extension,Durable Medical Equipment,Per Unit,$239.05 ,OP,239.05,823.54,,,,,,
UHC MCR ADV,CPT,L1230,Milwaukee type superstructur,Durable Medical Equipment,Per Unit,$669.67 ,OP,669.67,"2,302.87",,,,,,
UHC MCR ADV,CPT,L1240,Lumbar derotation pad,Durable Medical Equipment,Per Unit,$91.29 ,OP,91.29,312.64,,,,,,
UHC MCR ADV,CPT,L1250,Anterior asis pad,Durable Medical Equipment,Per Unit,$79.39 ,OP,79.39,274.51,,,,,,
UHC MCR ADV,CPT,L1260,Anterior thoracic derotation,Durable Medical Equipment,Per Unit,$94.68 ,OP,94.68,324.09,,,,,,
UHC MCR ADV,CPT,L1270,Abdominal pad,Durable Medical Equipment,Per Unit,$83.20 ,OP,83.2,285.96,,,,,,
UHC MCR ADV,CPT,L1280,Rib gusset (elastic) each,Durable Medical Equipment,Per Unit,$87.71 ,OP,87.71,301.2,,,,,,
UHC MCR ADV,CPT,L1290,Lateral trochanteric pad,Durable Medical Equipment,Per Unit,$78.00 ,OP,78,266.89,,,,,,
UHC MCR ADV,CPT,L1300,Body jacket mold to patient,Durable Medical Equipment,Per Unit,"$1,730.06 ",OP,"1,730.06","5,951.62",,,,,,
UHC MCR ADV,CPT,L1310,Post-operative body jacket,Durable Medical Equipment,Per Unit,"$1,802.00 ",OP,"1,802.00","6,195.63",,,,,,
UHC MCR ADV,CPT,L1600,Ho flex frejka w/cov pre cst,Durable Medical Equipment,Per Unit,$129.35 ,OP,129.35,446.08,,,,,,
UHC MCR ADV,CPT,L1610,Ho frejka cov only pre cst,Durable Medical Equipment,Per Unit,$54.94 ,OP,54.94,190.64,,,,,,
UHC MCR ADV,CPT,L1620,Ho flex pavlik harns pre cst,Durable Medical Equipment,Per Unit,$157.73 ,OP,157.73,541.4,,,,,,
UHC MCR ADV,CPT,L1630,Abduct control hip semi-flex,Durable Medical Equipment,Per Unit,$212.06 ,OP,212.06,728.23,,,,,,
UHC MCR ADV,CPT,L1640,Pelv band/spread bar thigh c,Durable Medical Equipment,Per Unit,$475.20 ,OP,475.2,"1,635.64",,,,,,
UHC MCR ADV,CPT,L1650,Ho abduction hip adjustable,Durable Medical Equipment,Per Unit,$247.55 ,OP,247.55,850.23,,,,,,
UHC MCR ADV,CPT,L1652,Ho bi thighcuffs w sprdr bar,Durable Medical Equipment,Per Unit,$357.83 ,OP,357.83,"1,231.50",,,,,,
UHC MCR ADV,CPT,L1660,Ho abduction static plastic,Durable Medical Equipment,Per Unit,$181.40 ,OP,181.4,625.29,,,,,,
UHC MCR ADV,CPT,L1680,Pelvic & hip control thigh c,Durable Medical Equipment,Per Unit,"$1,143.62 ",OP,"1,143.62","3,934.69",,,,,,
UHC MCR ADV,CPT,L1685,Post-op hip abduct custom fa,Durable Medical Equipment,Per Unit,"$1,116.47 ",OP,"1,116.47","3,839.39",,,,,,
UHC MCR ADV,CPT,L1686,Ho post-op hip abduction,Durable Medical Equipment,Per Unit,$940.60 ,OP,940.6,"3,233.17",,,,,,
UHC MCR ADV,CPT,L1690,Combination bilateral ho,Durable Medical Equipment,Per Unit,"$1,941.15 ",OP,"1,941.15","6,676.03",,,,,,
UHC MCR ADV,CPT,L1700,Leg perthes orth toronto typ,Durable Medical Equipment,Per Unit,"$1,561.78 ",OP,"1,561.78","5,372.08",,,,,,
UHC MCR ADV,CPT,L1710,Legg perthes orth newington,Durable Medical Equipment,Per Unit,"$1,988.75 ",OP,"1,988.75","6,839.98",,,,,,
UHC MCR ADV,CPT,L1720,Legg perthes orthosis trilat,Durable Medical Equipment,Per Unit,"$1,480.82 ",OP,"1,480.82","5,093.76",,,,,,
UHC MCR ADV,CPT,L1730,Legg perthes orth scottish r,Durable Medical Equipment,Per Unit,"$1,250.14 ",OP,"1,250.14","4,300.73",,,,,,
UHC MCR ADV,CPT,L1755,Legg perthes patten bottom t,Durable Medical Equipment,Per Unit,"$1,797.35 ",OP,"1,797.35","6,180.39",,,,,,
UHC MCR ADV,CPT,L1810,Ko elastic with joints,Durable Medical Equipment,Per Unit,$103.34 ,OP,103.34,103.34,,,,,,
UHC MCR ADV,CPT,L1812,Ko elastic w/joints pre ots,Durable Medical Equipment,Per Unit,$81.50 ,OP,81.5,81.5,,,,,,
UHC MCR ADV,CPT,L1820,Ko elas w/ condyle pads & jo,Durable Medical Equipment,Per Unit,$142.66 ,OP,142.66,142.66,,,,,,
UHC MCR ADV,CPT,L1830,Ko immob canvas long pre ots,Durable Medical Equipment,Per Unit,$71.04 ,OP,71.04,285.96,,,,,,
UHC MCR ADV,CPT,L1831,Knee orth pos locking joint,Durable Medical Equipment,Per Unit,$295.44 ,OP,295.44,"1,017.99",,,,,,
UHC MCR ADV,CPT,L1832,Ko adj jnt pos r sup pre cst,Durable Medical Equipment,Per Unit,$691.44 ,OP,691.44,"2,379.12",,,,,,
UHC MCR ADV,CPT,L1833,Ko adj jnt pos r sup pre ots,Durable Medical Equipment,Per Unit,$534.19 ,OP,534.19,534.19,,,,,,
UHC MCR ADV,CPT,L1834,Ko w/0 joint rigid molded to,Durable Medical Equipment,Per Unit,$728.61 ,OP,728.61,"2,504.94",,,,,,
UHC MCR ADV,CPT,L1836,Ko rigid w/o joints pre ots,Durable Medical Equipment,Per Unit,$104.41 ,OP,104.41,104.41,,,,,,
UHC MCR ADV,CPT,L1840,Ko derot ant cruciate custom,Durable Medical Equipment,Per Unit,$944.00 ,OP,944,"3,248.41",,,,,,
UHC MCR ADV,CPT,L1843,Ko single upright pre cst,Durable Medical Equipment,Per Unit,$900.70 ,OP,900.7,"3,095.90",,,,,,
UHC MCR ADV,CPT,L1844,Ko w/adj jt rot cntrl molded,Durable Medical Equipment,Per Unit,"$1,528.66 ",OP,"1,528.66","5,257.70",,,,,,
UHC MCR ADV,CPT,L1845,Ko double upright pre cst,Durable Medical Equipment,Per Unit,$840.88 ,OP,840.88,840.88,,,,,,
UHC MCR ADV,CPT,L1846,Ko w adj flex/ext rotat mold,Durable Medical Equipment,Per Unit,"$1,174.51 ",OP,"1,174.51","1,174.51",,,,,,
UHC MCR ADV,CPT,L1847,Ko dbl upright w/air pre cst,Durable Medical Equipment,Per Unit,$577.37 ,OP,577.37,"1,986.41",,,,,,
UHC MCR ADV,CPT,L1848,Ko dbl upright w/air pre ots,Durable Medical Equipment,Per Unit,$577.37 ,OP,577.37,577.37,,,,,,
UHC MCR ADV,CPT,L1850,Ko swedish type pre ots,Durable Medical Equipment,Per Unit,$234.85 ,OP,234.85,983.68,,,,,,
UHC MCR ADV,CPT,L1851,Ko single upright prefab ots,Durable Medical Equipment,Per Unit,$702.11 ,OP,702.11,702.11,,,,,,
UHC MCR ADV,CPT,L1852,Ko double upright prefab ots,Durable Medical Equipment,Per Unit,$665.20 ,OP,665.2,665.2,,,,,,
UHC MCR ADV,CPT,L1860,Ko supracondylar socket mold,Durable Medical Equipment,Per Unit,"$1,251.75 ",OP,"1,251.75","4,304.53",,,,,,
UHC MCR ADV,CPT,L1900,Afo sprng wir drsflx calf bd,Durable Medical Equipment,Per Unit,$286.39 ,OP,286.39,983.68,,,,,,
UHC MCR ADV,CPT,L1902,Afo ankle gauntlet pre ots,Durable Medical Equipment,Per Unit,$74.93 ,OP,74.93,259.27,,,,,,
UHC MCR ADV,CPT,L1904,Afo molded ankle gauntlet,Durable Medical Equipment,Per Unit,$453.09 ,OP,453.09,"1,559.39",,,,,,
UHC MCR ADV,CPT,L1906,Afo multilig ank sup pre ots,Durable Medical Equipment,Per Unit,$112.88 ,OP,112.88,388.89,,,,,,
UHC MCR ADV,CPT,L1907,Afo supramalleolar custom,Durable Medical Equipment,Per Unit,$564.86 ,OP,564.86,"1,944.48",,,,,,
UHC MCR ADV,CPT,L1910,Afo sing bar clasp attach sh,Durable Medical Equipment,Per Unit,$281.51 ,OP,281.51,968.43,,,,,,
UHC MCR ADV,CPT,L1920,Afo sing upright w/ adjust s,Durable Medical Equipment,Per Unit,$412.37 ,OP,412.37,"1,418.32",,,,,,
UHC MCR ADV,CPT,L1930,Afo plastic,Durable Medical Equipment,Per Unit,$252.89 ,OP,252.89,869.3,,,,,,
UHC MCR ADV,CPT,L1932,Afo rig ant tib prefab tcf/=,Durable Medical Equipment,Per Unit,$895.75 ,OP,895.75,"3,080.66",,,,,,
UHC MCR ADV,CPT,L1940,Afo molded to patient plasti,Durable Medical Equipment,Per Unit,$488.84 ,OP,488.84,"1,681.40",,,,,,
UHC MCR ADV,CPT,L1945,Afo molded plas rig ant tib,Durable Medical Equipment,Per Unit,"$1,126.77 ",OP,"1,126.77","3,873.69",,,,,,
UHC MCR ADV,CPT,L1950,Afo spiral molded to pt plas,Durable Medical Equipment,Per Unit,$772.00 ,OP,772,"2,653.63",,,,,,
UHC MCR ADV,CPT,L1951,Afo spiral prefabricated,Durable Medical Equipment,Per Unit,$843.02 ,OP,843.02,"2,897.65",,,,,,
UHC MCR ADV,CPT,L1960,Afo pos solid ank plastic mo,Durable Medical Equipment,Per Unit,$622.25 ,OP,622.25,"2,138.93",,,,,,
UHC MCR ADV,CPT,L1970,Afo plastic molded w/ankle j,Durable Medical Equipment,Per Unit,$694.78 ,OP,694.78,"2,390.56",,,,,,
UHC MCR ADV,CPT,L1971,Afo w/ankle joint- prefab,Durable Medical Equipment,Per Unit,$470.55 ,OP,470.55,"1,616.58",,,,,,
UHC MCR ADV,CPT,L1980,Afo sing solid stirrup calf,Durable Medical Equipment,Per Unit,$405.31 ,OP,405.31,"1,395.45",,,,,,
UHC MCR ADV,CPT,L1990,Afo doub solid stirrup calf,Durable Medical Equipment,Per Unit,$469.10 ,OP,469.1,"1,612.76",,,,,,
UHC MCR ADV,CPT,L2000,Kafo sing fre stirr thi/calf,Durable Medical Equipment,Per Unit,"$1,122.95 ",OP,"1,122.95","3,862.25",,,,,,
UHC MCR ADV,CPT,L2005,Kafo sng/dbl mechanical act,Durable Medical Equipment,Per Unit,"$4,113.39 ",OP,"4,113.39","14,145.09",,,,,,
UHC MCR ADV,CPT,L2010,Kafo sng solid stirrup w/o j,Durable Medical Equipment,Per Unit,$875.89 ,OP,875.89,"3,012.03",,,,,,
UHC MCR ADV,CPT,L2020,Kafo dbl solid stirrup band/,Durable Medical Equipment,Per Unit,"$1,106.22 ",OP,"1,106.22","3,805.07",,,,,,
UHC MCR ADV,CPT,L2030,Kafo dbl solid stirrup w/o j,Durable Medical Equipment,Per Unit,"$1,087.33 ",OP,"1,087.33","3,740.26",,,,,,
UHC MCR ADV,CPT,L2034,Kafo pla sin up w/wo k/a cus,Durable Medical Equipment,Per Unit,"$2,039.24 ",OP,"2,039.24","7,011.54",,,,,,
UHC MCR ADV,CPT,L2035,Kafo plastic pediatric size,Durable Medical Equipment,Per Unit,$173.91 ,OP,173.91,598.59,,,,,,
UHC MCR ADV,CPT,L2036,Kafo plas doub free knee mol,Durable Medical Equipment,Per Unit,"$1,861.04 ",OP,"1,861.04","6,401.51",,,,,,
UHC MCR ADV,CPT,L2037,Kafo plas sing free knee mol,Durable Medical Equipment,Per Unit,"$1,664.67 ",OP,"1,664.67","5,726.65",,,,,,
UHC MCR ADV,CPT,L2038,Kafo w/o joint multi-axis an,Durable Medical Equipment,Per Unit,"$1,341.97 ",OP,"1,341.97","4,613.36",,,,,,
UHC MCR ADV,CPT,L2040,Hkafo torsion bil rot straps,Durable Medical Equipment,Per Unit,$203.08 ,OP,203.08,697.72,,,,,,
UHC MCR ADV,CPT,L2050,Hkafo torsion cable hip pelv,Durable Medical Equipment,Per Unit,$489.17 ,OP,489.17,"1,681.40",,,,,,
UHC MCR ADV,CPT,L2060,Hkafo torsion ball bearing j,Durable Medical Equipment,Per Unit,$611.86 ,OP,611.86,"2,104.61",,,,,,
UHC MCR ADV,CPT,L2070,Hkafo torsion unilat rot str,Durable Medical Equipment,Per Unit,$155.80 ,OP,155.8,537.6,,,,,,
UHC MCR ADV,CPT,L2080,Hkafo unilat torsion cable,Durable Medical Equipment,Per Unit,$374.61 ,OP,374.61,"1,288.69",,,,,,
UHC MCR ADV,CPT,L2090,Hkafo unilat torsion ball br,Durable Medical Equipment,Per Unit,$499.12 ,OP,499.12,"1,715.71",,,,,,
UHC MCR ADV,CPT,L2106,Afo tib fx cast plaster mold,Durable Medical Equipment,Per Unit,$791.23 ,OP,791.23,"2,722.27",,,,,,
UHC MCR ADV,CPT,L2108,Afo tib fx cast molded to pt,Durable Medical Equipment,Per Unit,"$1,154.03 ",OP,"1,154.03","3,969.02",,,,,,
UHC MCR ADV,CPT,L2112,Afo tibial fracture soft,Durable Medical Equipment,Per Unit,$506.43 ,OP,506.43,"1,742.41",,,,,,
UHC MCR ADV,CPT,L2114,Afo tib fx semi-rigid,Durable Medical Equipment,Per Unit,$634.33 ,OP,634.33,634.33,,,,,,
UHC MCR ADV,CPT,L2116,Afo tibial fracture rigid,Durable Medical Equipment,Per Unit,$773.69 ,OP,773.69,773.69,,,,,,
UHC MCR ADV,CPT,L2126,Kafo fem fx cast thermoplas,Durable Medical Equipment,Per Unit,"$1,281.77 ",OP,"1,281.77","4,407.46",,,,,,
UHC MCR ADV,CPT,L2128,Kafo fem fx cast molded to p,Durable Medical Equipment,Per Unit,"$1,609.47 ",OP,"1,609.47","5,536.03",,,,,,
UHC MCR ADV,CPT,L2132,Kafo femoral fx cast soft,Durable Medical Equipment,Per Unit,$976.92 ,OP,976.92,"3,358.99",,,,,,
UHC MCR ADV,CPT,L2134,Kafo fem fx cast semi-rigid,Durable Medical Equipment,Per Unit,"$1,156.80 ",OP,"1,156.80","3,976.64",,,,,,
UHC MCR ADV,CPT,L2136,Kafo femoral fx cast rigid,Durable Medical Equipment,Per Unit,"$1,265.95 ",OP,"1,265.95","4,354.09",,,,,,
UHC MCR ADV,CPT,L2180,Plas shoe insert w ank joint,Durable Medical Equipment,Per Unit,$133.08 ,OP,133.08,457.52,,,,,,
UHC MCR ADV,CPT,L2182,Drop lock knee,Durable Medical Equipment,Per Unit,$114.71 ,OP,114.71,392.7,,,,,,
UHC MCR ADV,CPT,L2184,Limited motion knee joint,Durable Medical Equipment,Per Unit,$116.27 ,OP,116.27,400.34,,,,,,
UHC MCR ADV,CPT,L2186,Adj motion knee jnt lerman t,Durable Medical Equipment,Per Unit,$154.63 ,OP,154.63,529.96,,,,,,
UHC MCR ADV,CPT,L2188,Quadrilateral brim,Durable Medical Equipment,Per Unit,$281.10 ,OP,281.1,968.43,,,,,,
UHC MCR ADV,CPT,L2190,Waist belt,Durable Medical Equipment,Per Unit,$85.62 ,OP,85.62,293.57,,,,,,
UHC MCR ADV,CPT,L2192,Pelvic band & belt thigh fla,Durable Medical Equipment,Per Unit,$334.67 ,OP,334.67,"1,151.42",,,,,,
UHC MCR ADV,CPT,L2200,Limited ankle motion ea jnt,Durable Medical Equipment,Per Unit,$50.44 ,OP,50.44,175.39,,,,,,
UHC MCR ADV,CPT,L2210,Dorsiflexion assist each joi,Durable Medical Equipment,Per Unit,$63.09 ,OP,63.09,217.32,,,,,,
UHC MCR ADV,CPT,L2220,Dorsi & plantar flex ass/res,Durable Medical Equipment,Per Unit,$81.22 ,OP,81.22,278.32,,,,,,
UHC MCR ADV,CPT,L2230,Split flat caliper stirr & p,Durable Medical Equipment,Per Unit,$96.02 ,OP,96.02,331.7,,,,,,
UHC MCR ADV,CPT,L2232,Rocker bottom- contact afo,Durable Medical Equipment,Per Unit,$97.51 ,OP,97.51,335.53,,,,,,
UHC MCR ADV,CPT,L2240,Round caliper and plate atta,Durable Medical Equipment,Per Unit,$95.58 ,OP,95.58,327.9,,,,,,
UHC MCR ADV,CPT,L2250,Foot plate molded stirrup at,Durable Medical Equipment,Per Unit,$335.30 ,OP,335.3,"1,151.42",,,,,,
UHC MCR ADV,CPT,L2260,Reinforced solid stirrup,Durable Medical Equipment,Per Unit,$188.16 ,OP,188.16,648.16,,,,,,
UHC MCR ADV,CPT,L2265,Long tongue stirrup,Durable Medical Equipment,Per Unit,$134.94 ,OP,134.94,465.15,,,,,,
UHC MCR ADV,CPT,L2270,Varus/valgus strap padded/li,Durable Medical Equipment,Per Unit,$61.87 ,OP,61.87,213.51,,,,,,
UHC MCR ADV,CPT,L2275,Plastic mod low ext pad/line,Durable Medical Equipment,Per Unit,$130.85 ,OP,130.85,449.9,,,,,,
UHC MCR ADV,CPT,L2280,Molded inner boot,Durable Medical Equipment,Per Unit,$566.69 ,OP,566.69,"1,948.29",,,,,,
UHC MCR ADV,CPT,L2300,Abduction bar jointed adjust,Durable Medical Equipment,Per Unit,$252.72 ,OP,252.72,869.3,,,,,,
UHC MCR ADV,CPT,L2310,Abduction bar-straight,Durable Medical Equipment,Per Unit,$115.47 ,OP,115.47,396.52,,,,,,
UHC MCR ADV,CPT,L2320,Non-molded lacer,Durable Medical Equipment,Per Unit,$193.64 ,OP,193.64,667.22,,,,,,
UHC MCR ADV,CPT,L2330,Lacer molded to patient mode,Durable Medical Equipment,Per Unit,$368.55 ,OP,368.55,"1,265.81",,,,,,
UHC MCR ADV,CPT,L2335,Anterior swing band,Durable Medical Equipment,Per Unit,$282.18 ,OP,282.18,972.25,,,,,,
UHC MCR ADV,CPT,L2340,Pre-tibial shell molded to p,Durable Medical Equipment,Per Unit,$419.50 ,OP,419.5,"1,441.20",,,,,,
UHC MCR ADV,CPT,L2350,Prosthetic type socket molde,Durable Medical Equipment,Per Unit,$836.35 ,OP,836.35,"2,874.78",,,,,,
UHC MCR ADV,CPT,L2360,Extended steel shank,Durable Medical Equipment,Per Unit,$51.76 ,OP,51.76,179.2,,,,,,
UHC MCR ADV,CPT,L2370,Patten bottom,Durable Medical Equipment,Per Unit,$321.26 ,OP,321.26,"1,105.68",,,,,,
UHC MCR ADV,CPT,L2375,Torsion ank & half solid sti,Durable Medical Equipment,Per Unit,$123.52 ,OP,123.52,423.22,,,,,,
UHC MCR ADV,CPT,L2380,Torsion straight knee joint,Durable Medical Equipment,Per Unit,$129.54 ,OP,129.54,446.08,,,,,,
UHC MCR ADV,CPT,L2385,Straight knee joint heavy du,Durable Medical Equipment,Per Unit,$147.50 ,OP,147.5,507.08,,,,,,
UHC MCR ADV,CPT,L2387,Add le poly knee custom kafo,Durable Medical Equipment,Per Unit,$191.63 ,OP,191.63,659.6,,,,,,
UHC MCR ADV,CPT,L2390,Offset knee joint each,Durable Medical Equipment,Per Unit,$102.75 ,OP,102.75,354.58,,,,,,
UHC MCR ADV,CPT,L2395,Offset knee joint heavy duty,Durable Medical Equipment,Per Unit,$146.86 ,OP,146.86,503.28,,,,,,
UHC MCR ADV,CPT,L2397,Suspension sleeve lower ext,Durable Medical Equipment,Per Unit,$122.52 ,OP,122.52,423.22,,,,,,
UHC MCR ADV,CPT,L2405,Knee joint drop lock ea jnt,Durable Medical Equipment,Per Unit,$87.52 ,OP,87.52,301.2,,,,,,
UHC MCR ADV,CPT,L2415,Knee joint cam lock each joi,Durable Medical Equipment,Per Unit,$121.95 ,OP,121.95,419.4,,,,,,
UHC MCR ADV,CPT,L2425,Knee disc/dial lock/adj flex,Durable Medical Equipment,Per Unit,$143.90 ,OP,143.9,495.65,,,,,,
UHC MCR ADV,CPT,L2430,Knee jnt ratchet lock ea jnt,Durable Medical Equipment,Per Unit,$143.90 ,OP,143.9,495.65,,,,,,
UHC MCR ADV,CPT,L2492,Knee lift loop drop lock rin,Durable Medical Equipment,Per Unit,$117.74 ,OP,117.74,404.14,,,,,,
UHC MCR ADV,CPT,L2500,Thi/glut/ischia wgt bearing,Durable Medical Equipment,Per Unit,$314.13 ,OP,314.13,"1,078.99",,,,,,
UHC MCR ADV,CPT,L2510,Th/wght bear quad-lat brim m,Durable Medical Equipment,Per Unit,$809.60 ,OP,809.6,"2,783.26",,,,,,
UHC MCR ADV,CPT,L2520,Th/wght bear quad-lat brim c,Durable Medical Equipment,Per Unit,$539.56 ,OP,539.56,"1,856.79",,,,,,
UHC MCR ADV,CPT,L2525,Th/wght bear nar m-l brim mo,Durable Medical Equipment,Per Unit,"$1,144.16 ",OP,"1,144.16","3,934.69",,,,,,
UHC MCR ADV,CPT,L2526,Th/wght bear nar m-l brim cu,Durable Medical Equipment,Per Unit,$642.90 ,OP,642.9,"2,211.37",,,,,,
UHC MCR ADV,CPT,L2530,Thigh/wght bear lacer non-mo,Durable Medical Equipment,Per Unit,$240.74 ,OP,240.74,827.35,,,,,,
UHC MCR ADV,CPT,L2540,Thigh/wght bear lacer molded,Durable Medical Equipment,Per Unit,$455.54 ,OP,455.54,"1,567.02",,,,,,
UHC MCR ADV,CPT,L2550,Thigh/wght bear high roll cu,Durable Medical Equipment,Per Unit,$341.55 ,OP,341.55,"1,174.31",,,,,,
UHC MCR ADV,CPT,L2570,Hip clevis type 2 posit jnt,Durable Medical Equipment,Per Unit,$447.07 ,OP,447.07,"1,536.51",,,,,,
UHC MCR ADV,CPT,L2580,Pelvic control pelvic sling,Durable Medical Equipment,Per Unit,$435.62 ,OP,435.62,"1,498.39",,,,,,
UHC MCR ADV,CPT,L2600,Hip clevis/thrust bearing fr,Durable Medical Equipment,Per Unit,$214.10 ,OP,214.1,735.85,,,,,,
UHC MCR ADV,CPT,L2610,Hip clevis/thrust bearing lo,Durable Medical Equipment,Per Unit,$236.58 ,OP,236.58,812.11,,,,,,
UHC MCR ADV,CPT,L2620,Pelvic control hip heavy dut,Durable Medical Equipment,Per Unit,$250.96 ,OP,250.96,861.67,,,,,,
UHC MCR ADV,CPT,L2622,Hip joint adjustable flexion,Durable Medical Equipment,Per Unit,$319.42 ,OP,319.42,"1,098.07",,,,,,
UHC MCR ADV,CPT,L2624,Hip adj flex ext abduct cont,Durable Medical Equipment,Per Unit,$391.68 ,OP,391.68,"1,345.89",,,,,,
UHC MCR ADV,CPT,L2627,Plastic mold recipro hip & c,Durable Medical Equipment,Per Unit,"$2,145.41 ",OP,"2,145.41","7,377.56",,,,,,
UHC MCR ADV,CPT,L2628,Metal frame recipro hip & ca,Durable Medical Equipment,Per Unit,"$1,572.54 ",OP,"1,572.54","5,406.41",,,,,,
UHC MCR ADV,CPT,L2630,Pelvic control band & belt u,Durable Medical Equipment,Per Unit,$232.43 ,OP,232.43,800.67,,,,,,
UHC MCR ADV,CPT,L2640,Pelvic control band & belt b,Durable Medical Equipment,Per Unit,$315.42 ,OP,315.42,"1,086.62",,,,,,
UHC MCR ADV,CPT,L2650,Pelv & thor control gluteal,Durable Medical Equipment,Per Unit,$138.91 ,OP,138.91,476.6,,,,,,
UHC MCR ADV,CPT,L2660,Thoracic control thoracic ba,Durable Medical Equipment,Per Unit,$179.86 ,OP,179.86,617.65,,,,,,
UHC MCR ADV,CPT,L2670,Thorac cont paraspinal uprig,Durable Medical Equipment,Per Unit,$160.11 ,OP,160.11,549.03,,,,,,
UHC MCR ADV,CPT,L2680,Thorac cont lat support upri,Durable Medical Equipment,Per Unit,$146.88 ,OP,146.88,503.28,,,,,,
UHC MCR ADV,CPT,L2750,Plating chrome/nickel pr bar,Durable Medical Equipment,Per Unit,$78.45 ,OP,78.45,270.71,,,,,,
UHC MCR ADV,CPT,L2755,Carbon graphite lamination,Durable Medical Equipment,Per Unit,$131.16 ,OP,131.16,449.9,,,,,,
UHC MCR ADV,CPT,L2760,Extension per extension per,Durable Medical Equipment,Per Unit,$57.03 ,OP,57.03,194.45,,,,,,
UHC MCR ADV,CPT,L2768,Ortho sidebar disconnect,Durable Medical Equipment,Per Unit,$130.78 ,OP,130.78,449.9,,,,,,
UHC MCR ADV,CPT,L2780,Non-corrosive finish,Durable Medical Equipment,Per Unit,$63.53 ,OP,63.53,217.32,,,,,,
UHC MCR ADV,CPT,L2785,Drop lock retainer each,Durable Medical Equipment,Per Unit,$29.75 ,OP,29.75,102.95,,,,,,
UHC MCR ADV,CPT,L2795,Knee control full kneecap,Durable Medical Equipment,Per Unit,$82.32 ,OP,82.32,282.14,,,,,,
UHC MCR ADV,CPT,L2800,Knee cap medial or lateral p,Durable Medical Equipment,Per Unit,$101.09 ,OP,101.09,101.09,,,,,,
UHC MCR ADV,CPT,L2810,Knee control condylar pad,Durable Medical Equipment,Per Unit,$81.98 ,OP,81.98,282.14,,,,,,
UHC MCR ADV,CPT,L2820,Soft interface below knee se,Durable Medical Equipment,Per Unit,$81.51 ,OP,81.51,282.14,,,,,,
UHC MCR ADV,CPT,L2830,Soft interface above knee se,Durable Medical Equipment,Per Unit,$88.18 ,OP,88.18,305.01,,,,,,
UHC MCR ADV,CPT,L2840,Tibial length sock fx or equ,Durable Medical Equipment,Per Unit,$43.30 ,OP,43.3,148.69,,,,,,
UHC MCR ADV,CPT,L2850,Femoral lgth sock fx or equa,Durable Medical Equipment,Per Unit,$60.72 ,OP,60.72,209.7,,,,,,
UHC MCR ADV,CPT,L3000,Ft insert ucb berkeley shell,Durable Medical Equipment,Per Unit,$315.34 ,OP,315.34,"1,082.81",,,,,,
UHC MCR ADV,CPT,L3001,Foot insert remov molded spe,Durable Medical Equipment,Per Unit,$132.78 ,OP,132.78,686.28,,,,,,
UHC MCR ADV,CPT,L3002,Foot insert plastazote or eq,Durable Medical Equipment,Per Unit,$162.12 ,OP,162.12,834.98,,,,,,
UHC MCR ADV,CPT,L3003,Foot insert silicone gel eac,Durable Medical Equipment,Per Unit,$174.89 ,OP,174.89,903.6,,,,,,
UHC MCR ADV,CPT,L3010,Foot longitudinal arch suppo,Durable Medical Equipment,Per Unit,$174.89 ,OP,174.89,903.6,,,,,,
UHC MCR ADV,CPT,L3020,Foot longitud/metatarsal sup,Durable Medical Equipment,Per Unit,$199.16 ,OP,199.16,"1,025.61",,,,,,
UHC MCR ADV,CPT,L3030,Foot arch support remov prem,Durable Medical Equipment,Per Unit,$76.59 ,OP,76.59,"1,239.13",,,,,,
UHC MCR ADV,CPT,L3031,Foot lamin/prepreg composite,Durable Medical Equipment,Per Unit,$122.94 ,OP,122.94,"1,334.45",,,,,,
UHC MCR ADV,CPT,L3040,Ft arch suprt premold longit,Durable Medical Equipment,Per Unit,$47.25 ,OP,47.25,163.95,,,,,,
UHC MCR ADV,CPT,L3050,Foot arch supp premold metat,Durable Medical Equipment,Per Unit,$47.25 ,OP,47.25,163.95,,,,,,
UHC MCR ADV,CPT,L3060,Foot arch supp longitud/meta,Durable Medical Equipment,Per Unit,$74.04 ,OP,74.04,255.45,,,,,,
UHC MCR ADV,CPT,L3070,Arch suprt att to sho longit,Durable Medical Equipment,Per Unit,$31.91 ,OP,31.91,110.57,,,,,,
UHC MCR ADV,CPT,L3080,Arch supp att to shoe metata,Durable Medical Equipment,Per Unit,$31.91 ,OP,31.91,110.57,,,,,,
UHC MCR ADV,CPT,L3090,Arch supp att to shoe long/m,Durable Medical Equipment,Per Unit,$40.86 ,OP,40.86,141.07,,,,,,
UHC MCR ADV,CPT,L3100,Hallus-valgus nt dyn pre ots,Durable Medical Equipment,Per Unit,$43.43 ,OP,43.43,148.69,,,,,,
UHC MCR ADV,CPT,L3140,Abduction rotation bar shoe,Durable Medical Equipment,Per Unit,$89.37 ,OP,89.37,308.83,,,,,,
UHC MCR ADV,CPT,L3150,Abduct rotation bar w/o shoe,Durable Medical Equipment,Per Unit,$81.72 ,OP,81.72,282.14,,,,,,
UHC MCR ADV,CPT,L3170,Foot plas heel stabi pre ots,Durable Medical Equipment,Per Unit,$51.06 ,OP,51.06,175.39,,,,,,
UHC MCR ADV,CPT,L3224,Woman's shoe oxford brace,Durable Medical Equipment,Per Unit,$67.83 ,OP,67.83,232.58,,,,,,
UHC MCR ADV,CPT,L3225,Man's shoe oxford brace,Durable Medical Equipment,Per Unit,$74.09 ,OP,74.09,255.45,,,,,,
UHC MCR ADV,CPT,L3300,Sho lift taper to metatarsal,Durable Medical Equipment,Per Unit,$52.35 ,OP,52.35,179.2,,,,,,
UHC MCR ADV,CPT,L3310,Shoe lift elev heel/sole neo,Durable Medical Equipment,Per Unit,$81.72 ,OP,81.72,282.14,,,,,,
UHC MCR ADV,CPT,L3330,Lifts elevation metal extens,Durable Medical Equipment,Per Unit,$568.10 ,OP,568.1,"1,952.10",,,,,,
UHC MCR ADV,CPT,L3332,Shoe lifts tapered to one-ha,Durable Medical Equipment,Per Unit,$74.04 ,OP,74.04,255.45,,,,,,
UHC MCR ADV,CPT,L3334,Shoe lifts elevation heel /i,Durable Medical Equipment,Per Unit,$38.28 ,OP,38.28,133.45,,,,,,
UHC MCR ADV,CPT,L3340,Shoe wedge sach,Durable Medical Equipment,Per Unit,$85.56 ,OP,85.56,293.57,,,,,,
UHC MCR ADV,CPT,L3350,Shoe heel wedge,Durable Medical Equipment,Per Unit,$22.96 ,OP,22.96,80.07,,,,,,
UHC MCR ADV,CPT,L3360,Shoe sole wedge outside sole,Durable Medical Equipment,Per Unit,$35.74 ,OP,35.74,122,,,,,,
UHC MCR ADV,CPT,L3370,Shoe sole wedge between sole,Durable Medical Equipment,Per Unit,$49.79 ,OP,49.79,171.58,,,,,,
UHC MCR ADV,CPT,L3380,Shoe clubfoot wedge,Durable Medical Equipment,Per Unit,$49.79 ,OP,49.79,171.58,,,,,,
UHC MCR ADV,CPT,L3390,Shoe outflare wedge,Durable Medical Equipment,Per Unit,$49.79 ,OP,49.79,171.58,,,,,,
UHC MCR ADV,CPT,L3400,Shoe metatarsal bar wedge ro,Durable Medical Equipment,Per Unit,$40.86 ,OP,40.86,141.07,,,,,,
UHC MCR ADV,CPT,L3410,Shoe metatarsal bar between,Durable Medical Equipment,Per Unit,$93.19 ,OP,93.19,320.27,,,,,,
UHC MCR ADV,CPT,L3420,Full sole/heel wedge btween,Durable Medical Equipment,Per Unit,$54.90 ,OP,54.9,190.64,,,,,,
UHC MCR ADV,CPT,L3430,Sho heel count plast reinfor,Durable Medical Equipment,Per Unit,$160.86 ,OP,160.86,552.84,,,,,,
UHC MCR ADV,CPT,L3440,Heel leather reinforced,Durable Medical Equipment,Per Unit,$76.59 ,OP,76.59,263.08,,,,,,
UHC MCR ADV,CPT,L3450,Shoe heel sach cushion type,Durable Medical Equipment,Per Unit,$105.93 ,OP,105.93,105.93,,,,,,
UHC MCR ADV,CPT,L3455,Shoe heel new leather standa,Durable Medical Equipment,Per Unit,$40.86 ,OP,40.86,141.07,,,,,,
UHC MCR ADV,CPT,L3460,Shoe heel new rubber standar,Durable Medical Equipment,Per Unit,$34.49 ,OP,34.49,118.19,,,,,,
UHC MCR ADV,CPT,L3465,Shoe heel thomas with wedge,Durable Medical Equipment,Per Unit,$58.76 ,OP,58.76,202.07,,,,,,
UHC MCR ADV,CPT,L3470,Shoe heel thomas extend to b,Durable Medical Equipment,Per Unit,$62.54 ,OP,62.54,213.51,,,,,,
UHC MCR ADV,CPT,L3480,Shoe heel pad & depress for,Durable Medical Equipment,Per Unit,$62.54 ,OP,62.54,213.51,,,,,,
UHC MCR ADV,CPT,L3500,Ortho shoe add leather insol,Durable Medical Equipment,Per Unit,$29.35 ,OP,29.35,99.13,,,,,,
UHC MCR ADV,CPT,L3510,Orthopedic shoe add rub insl,Durable Medical Equipment,Per Unit,$29.35 ,OP,29.35,99.13,,,,,,
UHC MCR ADV,CPT,L3520,O shoe add felt w leath insl,Durable Medical Equipment,Per Unit,$31.91 ,OP,31.91,110.57,,,,,,
UHC MCR ADV,CPT,L3530,Ortho shoe add half sole,Durable Medical Equipment,Per Unit,$31.91 ,OP,31.91,110.57,,,,,,
UHC MCR ADV,CPT,L3540,Ortho shoe add full sole,Durable Medical Equipment,Per Unit,$51.06 ,OP,51.06,175.39,,,,,,
UHC MCR ADV,CPT,L3550,O shoe add standard toe tap,Durable Medical Equipment,Per Unit,$8.97 ,OP,8.97,30.51,,,,,,
UHC MCR ADV,CPT,L3560,O shoe add horseshoe toe tap,Durable Medical Equipment,Per Unit,$22.96 ,OP,22.96,80.07,,,,,,
UHC MCR ADV,CPT,L3570,O shoe add instep extension,Durable Medical Equipment,Per Unit,$85.56 ,OP,85.56,293.57,,,,,,
UHC MCR ADV,CPT,L3580,O shoe add instep velcro clo,Durable Medical Equipment,Per Unit,$65.11 ,OP,65.11,224.95,,,,,,
UHC MCR ADV,CPT,L3590,O shoe convert to sof counte,Durable Medical Equipment,Per Unit,$53.63 ,OP,53.63,183.02,,,,,,
UHC MCR ADV,CPT,L3595,Ortho shoe add march bar,Durable Medical Equipment,Per Unit,$42.10 ,OP,42.1,144.88,,,,,,
UHC MCR ADV,CPT,L3600,Trans shoe calip plate exist,Durable Medical Equipment,Per Unit,$76.59 ,OP,76.59,263.08,,,,,,
UHC MCR ADV,CPT,L3610,Trans shoe caliper plate new,Durable Medical Equipment,Per Unit,$100.86 ,OP,100.86,346.96,,,,,,
UHC MCR ADV,CPT,L3620,Trans shoe solid stirrup exi,Durable Medical Equipment,Per Unit,$76.59 ,OP,76.59,263.08,,,,,,
UHC MCR ADV,CPT,L3630,Trans shoe solid stirrup new,Durable Medical Equipment,Per Unit,$100.86 ,OP,100.86,346.96,,,,,,
UHC MCR ADV,CPT,L3640,Shoe dennis browne splint bo,Durable Medical Equipment,Per Unit,$43.43 ,OP,43.43,148.69,,,,,,
UHC MCR ADV,CPT,L3650,So 8 abd restraint pre ots,Durable Medical Equipment,Per Unit,$65.83 ,OP,65.83,224.95,,,,,,
UHC MCR ADV,CPT,L3660,So 8 ab rstr can/web pre ots,Durable Medical Equipment,Per Unit,$94.40 ,OP,94.4,324.09,,,,,,
UHC MCR ADV,CPT,L3670,So acro/clav can web pre ots,Durable Medical Equipment,Per Unit,$103.86 ,OP,103.86,358.39,,,,,,
UHC MCR ADV,CPT,L3671,So cap design w/o jnts cf,Durable Medical Equipment,Per Unit,$823.17 ,OP,823.17,"2,832.83",,,,,,
UHC MCR ADV,CPT,L3674,So airplane w/wo joint cf,Durable Medical Equipment,Per Unit,"$1,079.87 ",OP,"1,079.87","1,079.87",,,,,,
UHC MCR ADV,CPT,L3675,So vest canvas/web pre ots,Durable Medical Equipment,Per Unit,$160.35 ,OP,160.35,552.84,,,,,,
UHC MCR ADV,CPT,L3702,Eo w/o joints cf,Durable Medical Equipment,Per Unit,$263.81 ,OP,263.81,907.42,,,,,,
UHC MCR ADV,CPT,L3710,Eo elas w/metal jnts pre ots,Durable Medical Equipment,Per Unit,$130.45 ,OP,130.45,449.9,,,,,,
UHC MCR ADV,CPT,L3720,Forearm/arm cuffs free motio,Durable Medical Equipment,Per Unit,$624.22 ,OP,624.22,"2,146.54",,,,,,
UHC MCR ADV,CPT,L3730,Forearm/arm cuffs ext/flex a,Durable Medical Equipment,Per Unit,$827.96 ,OP,827.96,"2,848.08",,,,,,
UHC MCR ADV,CPT,L3740,Cuffs adj lock w/ active con,Durable Medical Equipment,Per Unit,$981.62 ,OP,981.62,"3,374.24",,,,,,
UHC MCR ADV,CPT,L3760,Eo adj jt prefab custom fit,Durable Medical Equipment,Per Unit,$456.89 ,OP,456.89,"1,570.83",,,,,,
UHC MCR ADV,CPT,L3761,Eo- adj lock joint prefab ot,Durable Medical Equipment,Per Unit,$456.89 ,OP,456.89,456.89,,,,,,
UHC MCR ADV,CPT,L3762,Eo rigid w/o joints pre ots,Durable Medical Equipment,Per Unit,$98.22 ,OP,98.22,339.33,,,,,,
UHC MCR ADV,CPT,L3763,Ewho rigid w/o jnts cf,Durable Medical Equipment,Per Unit,$683.66 ,OP,683.66,"2,352.44",,,,,,
UHC MCR ADV,CPT,L3764,Ewho w/joint(s) cf,Durable Medical Equipment,Per Unit,$715.47 ,OP,715.47,"2,459.19",,,,,,
UHC MCR ADV,CPT,L3765,Ewhfo rigid w/o jnts cf,Durable Medical Equipment,Per Unit,"$1,171.43 ",OP,"1,171.43","4,030.02",,,,,,
UHC MCR ADV,CPT,L3766,Ewhfo w/joint(s) cf,Durable Medical Equipment,Per Unit,"$1,240.47 ",OP,"1,240.47","4,266.40",,,,,,
UHC MCR ADV,CPT,L3806,Whfo w/joint(s) custom fab,Durable Medical Equipment,Per Unit,$414.97 ,OP,414.97,"1,425.95",,,,,,
UHC MCR ADV,CPT,L3807,Whfo w/o joints pre cst,Durable Medical Equipment,Per Unit,$228.43 ,OP,228.43,785.42,,,,,,
UHC MCR ADV,CPT,L3808,Whfo- rigid w/o joints,Durable Medical Equipment,Per Unit,$325.43 ,OP,325.43,"1,120.94",,,,,,
UHC MCR ADV,CPT,L3809,Whfo w/o joints pre ots,Durable Medical Equipment,Per Unit,$228.43 ,OP,228.43,228.43,,,,,,
UHC MCR ADV,CPT,L3900,Hinge extension/flex wrist/f,Durable Medical Equipment,Per Unit,"$1,479.93 ",OP,"1,479.93","5,089.95",,,,,,
UHC MCR ADV,CPT,L3901,Hinge ext/flex wrist finger,Durable Medical Equipment,Per Unit,"$1,939.53 ",OP,"1,939.53","6,668.40",,,,,,
UHC MCR ADV,CPT,L3904,Whfo electric custom fitted,Durable Medical Equipment,Per Unit,"$3,083.64 ",OP,"3,083.64","10,603.11",,,,,,
UHC MCR ADV,CPT,L3905,Who w/nontorsion jnt(s) cf,Durable Medical Equipment,Per Unit,$905.97 ,OP,905.97,"3,114.97",,,,,,
UHC MCR ADV,CPT,L3906,Who w/o joints cf,Durable Medical Equipment,Per Unit,$462.97 ,OP,462.97,"1,593.72",,,,,,
UHC MCR ADV,CPT,L3908,Who cock-up nonmolde pre ots,Durable Medical Equipment,Per Unit,$66.98 ,OP,66.98,228.77,,,,,,
UHC MCR ADV,CPT,L3912,Hfo flexion glove pre ots,Durable Medical Equipment,Per Unit,$96.25 ,OP,96.25,331.7,,,,,,
UHC MCR ADV,CPT,L3913,Hfo w/o joints cf,Durable Medical Equipment,Per Unit,$247.41 ,OP,247.41,850.23,,,,,,
UHC MCR ADV,CPT,L3915,Who nontorsion jnts pre cst,Durable Medical Equipment,Per Unit,$485.63 ,OP,485.63,"1,669.97",,,,,,
UHC MCR ADV,CPT,L3916,Who nontorsion jnts pre ots,Durable Medical Equipment,Per Unit,$485.63 ,OP,485.63,485.63,,,,,,
UHC MCR ADV,CPT,L3917,Metacarp fx orthosis pre cst,Durable Medical Equipment,Per Unit,$96.47 ,OP,96.47,331.7,,,,,,
UHC MCR ADV,CPT,L3918,Metacarp fx orthosis pre ots,Durable Medical Equipment,Per Unit,$96.47 ,OP,96.47,96.47,,,,,,
UHC MCR ADV,CPT,L3919,Ho w/o joints cf,Durable Medical Equipment,Per Unit,$247.41 ,OP,247.41,850.23,,,,,,
UHC MCR ADV,CPT,L3921,Hfo w/joint(s) cf,Durable Medical Equipment,Per Unit,$293.46 ,OP,293.46,"1,010.37",,,,,,
UHC MCR ADV,CPT,L3923,Hfo without joints pre cst,Durable Medical Equipment,Per Unit,$88.25 ,OP,88.25,305.01,,,,,,
UHC MCR ADV,CPT,L3924,Hfo without joints pre ots,Durable Medical Equipment,Per Unit,$88.25 ,OP,88.25,88.25,,,,,,
UHC MCR ADV,CPT,L3925,Fo pip dip jnt/sprng pre ots,Durable Medical Equipment,Per Unit,$60.01 ,OP,60.01,205.88,,,,,,
UHC MCR ADV,CPT,L3927,Fo pip dip no jt spr pre ots,Durable Medical Equipment,Per Unit,$31.98 ,OP,31.98,110.57,,,,,,
UHC MCR ADV,CPT,L3929,Hfo nontorsion jnts pre cst,Durable Medical Equipment,Per Unit,$83.44 ,OP,83.44,285.96,,,,,,
UHC MCR ADV,CPT,L3930,Hfo nontorsion jnts pre ots,Durable Medical Equipment,Per Unit,$83.44 ,OP,83.44,83.44,,,,,,
UHC MCR ADV,CPT,L3931,Whfo nontorsion joint prefab,Durable Medical Equipment,Per Unit,$190.48 ,OP,190.48,655.78,,,,,,
UHC MCR ADV,CPT,L3933,Fo w/o joints cf,Durable Medical Equipment,Per Unit,$194.93 ,OP,194.93,671.03,,,,,,
UHC MCR ADV,CPT,L3935,Fo nontorsion joint cf,Durable Medical Equipment,Per Unit,$201.82 ,OP,201.82,693.9,,,,,,
UHC MCR ADV,CPT,L3960,Sewho airplan desig abdu pos,Durable Medical Equipment,Per Unit,$728.64 ,OP,728.64,"2,504.94",,,,,,
UHC MCR ADV,CPT,L3961,Sewho cap design w/o jnts cf,Durable Medical Equipment,Per Unit,"$1,534.92 ",OP,"1,534.92","5,280.58",,,,,,
UHC MCR ADV,CPT,L3962,Sewho erbs palsey design abd,Durable Medical Equipment,Per Unit,$659.00 ,OP,659,"2,264.75",,,,,,
UHC MCR ADV,CPT,L3967,Sewho airplane w/o jnts cf,Durable Medical Equipment,Per Unit,"$1,812.20 ",OP,"1,812.20","6,233.76",,,,,,
UHC MCR ADV,CPT,L3971,Sewho cap design w/jnt(s) cf,Durable Medical Equipment,Per Unit,"$1,720.20 ",OP,"1,720.20","5,917.29",,,,,,
UHC MCR ADV,CPT,L3973,Sewho airplane w/jnt(s) cf,Durable Medical Equipment,Per Unit,"$1,812.20 ",OP,"1,812.20","6,233.76",,,,,,
UHC MCR ADV,CPT,L3975,Sewhfo cap design w/o jnt cf,Durable Medical Equipment,Per Unit,"$1,534.92 ",OP,"1,534.92","5,280.58",,,,,,
UHC MCR ADV,CPT,L3976,Sewhfo airplane w/o jnts cf,Durable Medical Equipment,Per Unit,"$1,534.92 ",OP,"1,534.92","5,280.58",,,,,,
UHC MCR ADV,CPT,L3977,Sewhfo cap desgn w/jnt(s) cf,Durable Medical Equipment,Per Unit,"$1,720.20 ",OP,"1,720.20","5,917.29",,,,,,
UHC MCR ADV,CPT,L3978,Sewhfo airplane w/jnt(s) cf,Durable Medical Equipment,Per Unit,"$1,812.20 ",OP,"1,812.20","6,233.76",,,,,,
UHC MCR ADV,CPT,L3980,Up ext fx orthos humeral nos,Durable Medical Equipment,Per Unit,$353.43 ,OP,353.43,"1,216.24",,,,,,
UHC MCR ADV,CPT,L3981,Ue fx orth shoul cap forearm,Durable Medical Equipment,Per Unit,$919.57 ,OP,919.57,919.57,,,,,,
UHC MCR ADV,CPT,L3982,Upper ext fx orthosis rad/ul,Durable Medical Equipment,Per Unit,$358.87 ,OP,358.87,"1,235.32",,,,,,
UHC MCR ADV,CPT,L3984,Upper ext fx orthosis wrist,Durable Medical Equipment,Per Unit,$316.13 ,OP,316.13,"1,086.62",,,,,,
UHC MCR ADV,CPT,L3995,Sock fracture or equal each,Durable Medical Equipment,Per Unit,$37.51 ,OP,37.51,129.64,,,,,,
UHC MCR ADV,CPT,L4000,Repl girdle milwaukee orth,Durable Medical Equipment,Per Unit,"$1,326.47 ",OP,"1,326.47","4,559.97",,,,,,
UHC MCR ADV,CPT,L4010,Replace trilateral socket br,Durable Medical Equipment,Per Unit,$806.25 ,OP,806.25,"2,771.83",,,,,,
UHC MCR ADV,CPT,L4020,Replace quadlat socket brim,Durable Medical Equipment,Per Unit,$968.52 ,OP,968.52,"3,332.30",,,,,,
UHC MCR ADV,CPT,L4030,Replace socket brim cust fit,Durable Medical Equipment,Per Unit,$615.47 ,OP,615.47,"2,116.06",,,,,,
UHC MCR ADV,CPT,L4040,Replace molded thigh lacer,Durable Medical Equipment,Per Unit,$416.80 ,OP,416.8,"1,433.58",,,,,,
UHC MCR ADV,CPT,L4045,Replace non-molded thigh lac,Durable Medical Equipment,Per Unit,$307.89 ,OP,307.89,"1,059.93",,,,,,
UHC MCR ADV,CPT,L4050,Replace molded calf lacer,Durable Medical Equipment,Per Unit,$412.80 ,OP,412.8,"1,418.32",,,,,,
UHC MCR ADV,CPT,L4055,Replace non-molded calf lace,Durable Medical Equipment,Per Unit,$250.92 ,OP,250.92,861.67,,,,,,
UHC MCR ADV,CPT,L4060,Replace high roll cuff,Durable Medical Equipment,Per Unit,$326.17 ,OP,326.17,"1,120.94",,,,,,
UHC MCR ADV,CPT,L4070,Replace prox & dist upright,Durable Medical Equipment,Per Unit,$264.15 ,OP,264.15,907.42,,,,,,
UHC MCR ADV,CPT,L4080,Repl met band kafo-afo prox,Durable Medical Equipment,Per Unit,$99.72 ,OP,99.72,343.14,,,,,,
UHC MCR ADV,CPT,L4090,Repl met band kafo-afo calf/,Durable Medical Equipment,Per Unit,$84.84 ,OP,84.84,293.57,,,,,,
UHC MCR ADV,CPT,L4100,Repl leath cuff kafo prox th,Durable Medical Equipment,Per Unit,$101.94 ,OP,101.94,350.76,,,,,,
UHC MCR ADV,CPT,L4110,Repl leath cuff kafo-afo cal,Durable Medical Equipment,Per Unit,$79.60 ,OP,79.6,274.51,,,,,,
UHC MCR ADV,CPT,L4130,Replace pretibial shell,Durable Medical Equipment,Per Unit,$481.14 ,OP,481.14,"1,654.72",,,,,,
UHC MCR ADV,CPT,L4350,Ankle control ortho pre ots,Durable Medical Equipment,Per Unit,$97.13 ,OP,97.13,335.53,,,,,,
UHC MCR ADV,CPT,L4360,Pneumat walking boot pre cst,Durable Medical Equipment,Per Unit,$259.89 ,OP,259.89,892.18,,,,,,
UHC MCR ADV,CPT,L4361,Pneuma/vac walk boot pre ots,Durable Medical Equipment,Per Unit,$259.89 ,OP,259.89,259.89,,,,,,
UHC MCR ADV,CPT,L4370,Pneum full leg splnt pre ots,Durable Medical Equipment,Per Unit,$236.26 ,OP,236.26,812.11,,,,,,
UHC MCR ADV,CPT,L4386,Non-pneum walk boot pre cst,Durable Medical Equipment,Per Unit,$159.16 ,OP,159.16,549.03,,,,,,
UHC MCR ADV,CPT,L4387,Non-pneum walk boot pre ots,Durable Medical Equipment,Per Unit,$159.16 ,OP,159.16,159.16,,,,,,
UHC MCR ADV,CPT,L4392,Replace afo soft interface,Durable Medical Equipment,Per Unit,$23.62 ,OP,23.62,80.07,,,,,,
UHC MCR ADV,CPT,L4394,Replace foot drop spint,Durable Medical Equipment,Per Unit,$17.23 ,OP,17.23,61,,,,,,
UHC MCR ADV,CPT,L4396,Static or dynami afo pre cst,Durable Medical Equipment,Per Unit,$168.46 ,OP,168.46,579.53,,,,,,
UHC MCR ADV,CPT,L4397,Static or dynami afo pre ots,Durable Medical Equipment,Per Unit,$168.46 ,OP,168.46,168.46,,,,,,
UHC MCR ADV,CPT,L4398,Foot drop splint pre ots,Durable Medical Equipment,Per Unit,$77.54 ,OP,77.54,266.89,,,,,,
UHC MCR ADV,CPT,L4631,Afo- walk boot type- cus fab,Durable Medical Equipment,Per Unit,"$1,479.79 ",OP,"1,479.79","1,479.79",,,,,,
UHC MCR ADV,CPT,L5000,Sho insert w arch toe filler,Durable Medical Equipment,Per Unit,$576.42 ,OP,576.42,"1,982.60",,,,,,
UHC MCR ADV,CPT,L5010,Mold socket ank hgt w/ toe f,Durable Medical Equipment,Per Unit,"$1,610.60 ",OP,"1,610.60","5,539.84",,,,,,
UHC MCR ADV,CPT,L5020,Tibial tubercle hgt w/ toe f,Durable Medical Equipment,Per Unit,"$2,523.29 ",OP,"2,523.29","8,677.68",,,,,,
UHC MCR ADV,CPT,L5050,Ank symes mold sckt sach ft,Durable Medical Equipment,Per Unit,"$2,755.91 ",OP,"2,755.91","9,478.35",,,,,,
UHC MCR ADV,CPT,L5060,Symes met fr leath socket ar,Durable Medical Equipment,Per Unit,"$3,397.24 ",OP,"3,397.24","11,682.09",,,,,,
UHC MCR ADV,CPT,L5100,Molded socket shin sach foot,Durable Medical Equipment,Per Unit,"$2,744.12 ",OP,"2,744.12","9,436.43",,,,,,
UHC MCR ADV,CPT,L5105,Plast socket jts/thgh lacer,Durable Medical Equipment,Per Unit,"$3,872.55 ",OP,"3,872.55","13,317.74",,,,,,
UHC MCR ADV,CPT,L5150,Mold sckt ext knee shin sach,Durable Medical Equipment,Per Unit,"$4,305.35 ",OP,"4,305.35","14,804.69",,,,,,
UHC MCR ADV,CPT,L5160,Mold socket bent knee shin s,Durable Medical Equipment,Per Unit,"$4,727.07 ",OP,"4,727.07","16,257.32",,,,,,
UHC MCR ADV,CPT,L5200,Kne sing axis fric shin sach,Durable Medical Equipment,Per Unit,"$3,656.04 ",OP,"3,656.04","12,574.26",,,,,,
UHC MCR ADV,CPT,L5210,No knee/ankle joints w/ ft b,Durable Medical Equipment,Per Unit,"$2,902.89 ",OP,"2,902.89","9,981.64",,,,,,
UHC MCR ADV,CPT,L5220,No knee joint with artic ali,Durable Medical Equipment,Per Unit,"$3,197.74 ",OP,"3,197.74","10,995.81",,,,,,
UHC MCR ADV,CPT,L5230,Fem focal defic constant fri,Durable Medical Equipment,Per Unit,"$4,796.11 ",OP,"4,796.11","16,493.71",,,,,,
UHC MCR ADV,CPT,L5250,Hip canad sing axi cons fric,Durable Medical Equipment,Per Unit,"$5,623.57 ",OP,"5,623.57","19,341.79",,,,,,
UHC MCR ADV,CPT,L5270,Tilt table locking hip sing,Durable Medical Equipment,Per Unit,"$6,265.76 ",OP,"6,265.76","21,549.33",,,,,,
UHC MCR ADV,CPT,L5280,Hemipelvect canad sing axis,Durable Medical Equipment,Per Unit,"$6,090.55 ",OP,"6,090.55","20,946.94",,,,,,
UHC MCR ADV,CPT,L5301,Bk mold socket sach ft endo,Durable Medical Equipment,Per Unit,"$2,694.66 ",OP,"2,694.66","9,268.66",,,,,,
UHC MCR ADV,CPT,L5312,Knee disart- sach ft- endo,Durable Medical Equipment,Per Unit,"$4,245.62 ",OP,"4,245.62","4,245.62",,,,,,
UHC MCR ADV,CPT,L5321,Ak open end sach,Durable Medical Equipment,Per Unit,"$3,593.24 ",OP,"3,593.24","12,356.94",,,,,,
UHC MCR ADV,CPT,L5331,Hip disart canadian sach ft,Durable Medical Equipment,Per Unit,"$5,262.80 ",OP,"5,262.80","18,098.85",,,,,,
UHC MCR ADV,CPT,L5341,Hemipelvectomy canadian sach,Durable Medical Equipment,Per Unit,"$5,594.28 ",OP,"5,594.28","19,238.85",,,,,,
UHC MCR ADV,CPT,L5400,Postop dress & 1 cast chg bk,Durable Medical Equipment,Per Unit,"$1,604.68 ",OP,"1,604.68","5,516.97",,,,,,
UHC MCR ADV,CPT,L5410,Postop dsg bk ea add cast ch,Durable Medical Equipment,Per Unit,$443.32 ,OP,443.32,"1,525.07",,,,,,
UHC MCR ADV,CPT,L5420,Postop dsg & 1 cast chg ak/d,Durable Medical Equipment,Per Unit,"$2,026.64 ",OP,"2,026.64","6,969.60",,,,,,
UHC MCR ADV,CPT,L5430,Postop dsg ak ea add cast ch,Durable Medical Equipment,Per Unit,$550.12 ,OP,550.12,"1,891.10",,,,,,
UHC MCR ADV,CPT,L5450,Postop app non-wgt bear dsg,Durable Medical Equipment,Per Unit,$475.67 ,OP,475.67,"1,635.64",,,,,,
UHC MCR ADV,CPT,L5460,Postop app non-wgt bear dsg,Durable Medical Equipment,Per Unit,$623.89 ,OP,623.89,"2,146.54",,,,,,
UHC MCR ADV,CPT,L5500,Init bk ptb plaster direct,Durable Medical Equipment,Per Unit,"$1,483.19 ",OP,"1,483.19","5,101.39",,,,,,
UHC MCR ADV,CPT,L5505,Init ak ischal plstr direct,Durable Medical Equipment,Per Unit,"$2,086.44 ",OP,"2,086.44","7,175.49",,,,,,
UHC MCR ADV,CPT,L5510,Prep bk ptb plaster molded,Durable Medical Equipment,Per Unit,"$1,771.18 ",OP,"1,771.18","6,092.69",,,,,,
UHC MCR ADV,CPT,L5520,Perp bk ptb thermopls direct,Durable Medical Equipment,Per Unit,"$1,587.65 ",OP,"1,587.65","5,459.77",,,,,,
UHC MCR ADV,CPT,L5530,Prep bk ptb thermopls molded,Durable Medical Equipment,Per Unit,"$2,087.07 ",OP,"2,087.07","7,179.30",,,,,,
UHC MCR ADV,CPT,L5535,Prep bk ptb open end socket,Durable Medical Equipment,Per Unit,"$1,945.59 ",OP,"1,945.59","6,691.29",,,,,,
UHC MCR ADV,CPT,L5540,Prep bk ptb laminated socket,Durable Medical Equipment,Per Unit,"$2,060.66 ",OP,"2,060.66","7,087.80",,,,,,
UHC MCR ADV,CPT,L5560,Prep ak ischial plast molded,Durable Medical Equipment,Per Unit,"$2,348.01 ",OP,"2,348.01","8,075.28",,,,,,
UHC MCR ADV,CPT,L5570,Prep ak ischial direct form,Durable Medical Equipment,Per Unit,"$2,278.83 ",OP,"2,278.83","7,838.89",,,,,,
UHC MCR ADV,CPT,L5580,Prep ak ischial thermo mold,Durable Medical Equipment,Per Unit,"$2,828.36 ",OP,"2,828.36","9,726.18",,,,,,
UHC MCR ADV,CPT,L5585,Prep ak ischial open end,Durable Medical Equipment,Per Unit,"$3,312.24 ",OP,"3,312.24","11,392.33",,,,,,
UHC MCR ADV,CPT,L5590,Prep ak ischial laminated,Durable Medical Equipment,Per Unit,"$2,948.85 ",OP,"2,948.85","10,141.77",,,,,,
UHC MCR ADV,CPT,L5595,Hip disartic sach thermopls,Durable Medical Equipment,Per Unit,"$4,608.29 ",OP,"4,608.29","15,849.36",,,,,,
UHC MCR ADV,CPT,L5600,Hip disart sach laminat mold,Durable Medical Equipment,Per Unit,"$5,244.91 ",OP,"5,244.91","18,037.85",,,,,,
UHC MCR ADV,CPT,L5610,Above knee hydracadence,Durable Medical Equipment,Per Unit,"$2,529.59 ",OP,"2,529.59","8,700.56",,,,,,
UHC MCR ADV,CPT,L5611,Ak 4 bar link w/fric swing,Durable Medical Equipment,Per Unit,"$1,611.13 ",OP,"1,611.13","5,539.84",,,,,,
UHC MCR ADV,CPT,L5613,Ak 4 bar ling w/hydraul swig,Durable Medical Equipment,Per Unit,"$2,450.64 ",OP,"2,450.64","8,429.87",,,,,,
UHC MCR ADV,CPT,L5614,4-bar link above knee w/swng,Durable Medical Equipment,Per Unit,"$1,697.23 ",OP,"1,697.23","5,837.23",,,,,,
UHC MCR ADV,CPT,L5616,Ak univ multiplex sys frict,Durable Medical Equipment,Per Unit,"$1,477.66 ",OP,"1,477.66","5,082.32",,,,,,
UHC MCR ADV,CPT,L5617,Ak/bk self-aligning unit ea,Durable Medical Equipment,Per Unit,$562.74 ,OP,562.74,"1,936.85",,,,,,
UHC MCR ADV,CPT,L5618,Test socket symes,Durable Medical Equipment,Per Unit,$336.06 ,OP,336.06,"1,155.24",,,,,,
UHC MCR ADV,CPT,L5620,Test socket below knee,Durable Medical Equipment,Per Unit,$298.16 ,OP,298.16,"1,025.61",,,,,,
UHC MCR ADV,CPT,L5622,Test socket knee disarticula,Durable Medical Equipment,Per Unit,$401.70 ,OP,401.7,"1,380.19",,,,,,
UHC MCR ADV,CPT,L5624,Test socket above knee,Durable Medical Equipment,Per Unit,$401.54 ,OP,401.54,"1,380.19",,,,,,
UHC MCR ADV,CPT,L5626,Test socket hip disarticulat,Durable Medical Equipment,Per Unit,$635.70 ,OP,635.7,"2,184.67",,,,,,
UHC MCR ADV,CPT,L5628,Test socket hemipelvectomy,Durable Medical Equipment,Per Unit,$643.74 ,OP,643.74,"2,215.19",,,,,,
UHC MCR ADV,CPT,L5629,Below knee acrylic socket,Durable Medical Equipment,Per Unit,$317.79 ,OP,317.79,"1,094.25",,,,,,
UHC MCR ADV,CPT,L5630,Syme typ expandabl wall sckt,Durable Medical Equipment,Per Unit,$552.17 ,OP,552.17,"1,898.73",,,,,,
UHC MCR ADV,CPT,L5631,Ak/knee disartic acrylic soc,Durable Medical Equipment,Per Unit,$439.37 ,OP,439.37,"1,509.83",,,,,,
UHC MCR ADV,CPT,L5632,Symes type ptb brim design s,Durable Medical Equipment,Per Unit,$270.81 ,OP,270.81,930.3,,,,,,
UHC MCR ADV,CPT,L5634,Symes type poster opening so,Durable Medical Equipment,Per Unit,$338.66 ,OP,338.66,"1,162.87",,,,,,
UHC MCR ADV,CPT,L5636,Symes type medial opening so,Durable Medical Equipment,Per Unit,$258.86 ,OP,258.86,888.36,,,,,,
UHC MCR ADV,CPT,L5637,Below knee total contact,Durable Medical Equipment,Per Unit,$385.17 ,OP,385.17,"1,323.01",,,,,,
UHC MCR ADV,CPT,L5638,Below knee leather socket,Durable Medical Equipment,Per Unit,$648.87 ,OP,648.87,"2,230.43",,,,,,
UHC MCR ADV,CPT,L5639,Below knee wood socket,Durable Medical Equipment,Per Unit,"$1,121.15 ",OP,"1,121.15","3,854.63",,,,,,
UHC MCR ADV,CPT,L5640,Knee disarticulat leather so,Durable Medical Equipment,Per Unit,$736.94 ,OP,736.94,"2,535.44",,,,,,
UHC MCR ADV,CPT,L5642,Above knee leather socket,Durable Medical Equipment,Per Unit,$683.11 ,OP,683.11,"2,348.62",,,,,,
UHC MCR ADV,CPT,L5643,Hip flex inner socket ext fr,Durable Medical Equipment,Per Unit,"$2,014.84 ",OP,"2,014.84","6,927.67",,,,,,
UHC MCR ADV,CPT,L5644,Above knee wood socket,Durable Medical Equipment,Per Unit,$590.63 ,OP,590.63,"2,032.17",,,,,,
UHC MCR ADV,CPT,L5645,Bk flex inner socket ext fra,Durable Medical Equipment,Per Unit,$979.82 ,OP,979.82,"3,370.43",,,,,,
UHC MCR ADV,CPT,L5646,Below knee cushion socket,Durable Medical Equipment,Per Unit,$620.93 ,OP,620.93,"2,135.11",,,,,,
UHC MCR ADV,CPT,L5647,Below knee suction socket,Durable Medical Equipment,Per Unit,$795.44 ,OP,795.44,"2,733.70",,,,,,
UHC MCR ADV,CPT,L5648,Above knee cushion socket,Durable Medical Equipment,Per Unit,$733.68 ,OP,733.68,"2,524.00",,,,,,
UHC MCR ADV,CPT,L5649,Isch containmt/narrow m-l so,Durable Medical Equipment,Per Unit,"$2,465.24 ",OP,"2,465.24","8,479.43",,,,,,
UHC MCR ADV,CPT,L5650,Tot contact ak/knee disart s,Durable Medical Equipment,Per Unit,$488.17 ,OP,488.17,"1,677.58",,,,,,
UHC MCR ADV,CPT,L5651,Ak flex inner socket ext fra,Durable Medical Equipment,Per Unit,"$1,430.29 ",OP,"1,430.29","4,918.37",,,,,,
UHC MCR ADV,CPT,L5652,Suction susp ak/knee disart,Durable Medical Equipment,Per Unit,$435.97 ,OP,435.97,"1,498.39",,,,,,
UHC MCR ADV,CPT,L5653,Knee disart expand wall sock,Durable Medical Equipment,Per Unit,$680.24 ,OP,680.24,"2,341.00",,,,,,
UHC MCR ADV,CPT,L5654,Socket insert symes,Durable Medical Equipment,Per Unit,$394.33 ,OP,394.33,"1,357.32",,,,,,
UHC MCR ADV,CPT,L5655,Socket insert below knee,Durable Medical Equipment,Per Unit,$284.71 ,OP,284.71,979.86,,,,,,
UHC MCR ADV,CPT,L5656,Socket insert knee articulat,Durable Medical Equipment,Per Unit,$432.53 ,OP,432.53,"1,486.95",,,,,,
UHC MCR ADV,CPT,L5658,Socket insert above knee,Durable Medical Equipment,Per Unit,$456.55 ,OP,456.55,"1,570.83",,,,,,
UHC MCR ADV,CPT,L5661,Multi-durometer symes,Durable Medical Equipment,Per Unit,$655.04 ,OP,655.04,"2,253.31",,,,,,
UHC MCR ADV,CPT,L5665,Multi-durometer below knee,Durable Medical Equipment,Per Unit,$582.36 ,OP,582.36,"2,001.67",,,,,,
UHC MCR ADV,CPT,L5666,Below knee cuff suspension,Durable Medical Equipment,Per Unit,$77.11 ,OP,77.11,266.89,,,,,,
UHC MCR ADV,CPT,L5668,Bk molded distal cushion,Durable Medical Equipment,Per Unit,$114.86 ,OP,114.86,396.52,,,,,,
UHC MCR ADV,CPT,L5670,Bk molded supracondylar susp,Durable Medical Equipment,Per Unit,$271.35 ,OP,271.35,934.12,,,,,,
UHC MCR ADV,CPT,L5671,Bk/ak locking mechanism,Durable Medical Equipment,Per Unit,$497.40 ,OP,497.4,"1,711.89",,,,,,
UHC MCR ADV,CPT,L5672,Bk removable medial brim sus,Durable Medical Equipment,Per Unit,$359.07 ,OP,359.07,"1,235.32",,,,,,
UHC MCR ADV,CPT,L5673,Socket insert w lock mech,Durable Medical Equipment,Per Unit,$790.52 ,OP,790.52,"2,718.45",,,,,,
UHC MCR ADV,CPT,L5676,Bk knee joints single axis p,Durable Medical Equipment,Per Unit,$362.36 ,OP,362.36,"1,246.76",,,,,,
UHC MCR ADV,CPT,L5677,Bk knee joints polycentric p,Durable Medical Equipment,Per Unit,$554.97 ,OP,554.97,"1,910.16",,,,,,
UHC MCR ADV,CPT,L5678,Bk joint covers pair,Durable Medical Equipment,Per Unit,$39.70 ,OP,39.7,137.25,,,,,,
UHC MCR ADV,CPT,L5679,Socket insert w/o lock mech,Durable Medical Equipment,Per Unit,$658.75 ,OP,658.75,"2,264.75",,,,,,
UHC MCR ADV,CPT,L5680,Bk thigh lacer non-molded,Durable Medical Equipment,Per Unit,$304.37 ,OP,304.37,"1,048.50",,,,,,
UHC MCR ADV,CPT,L5681,Intl custm cong/latyp insert,Durable Medical Equipment,Per Unit,"$1,323.02 ",OP,"1,323.02","4,548.54",,,,,,
UHC MCR ADV,CPT,L5682,Bk thigh lacer glut/ischia m,Durable Medical Equipment,Per Unit,$625.37 ,OP,625.37,"2,150.36",,,,,,
UHC MCR ADV,CPT,L5683,Initial custom socket insert,Durable Medical Equipment,Per Unit,"$1,323.02 ",OP,"1,323.02","4,548.54",,,,,,
UHC MCR ADV,CPT,L5684,Bk fork strap,Durable Medical Equipment,Per Unit,$48.13 ,OP,48.13,163.95,,,,,,
UHC MCR ADV,CPT,L5685,Below knee sus/seal sleeve,Durable Medical Equipment,Per Unit,$128.85 ,OP,128.85,442.27,,,,,,
UHC MCR ADV,CPT,L5686,Bk back check,Durable Medical Equipment,Per Unit,$57.89 ,OP,57.89,198.25,,,,,,
UHC MCR ADV,CPT,L5688,Bk waist belt webbing,Durable Medical Equipment,Per Unit,$61.48 ,OP,61.48,209.7,,,,,,
UHC MCR ADV,CPT,L5690,Bk waist belt padded and lin,Durable Medical Equipment,Per Unit,$125.50 ,OP,125.5,430.83,,,,,,
UHC MCR ADV,CPT,L5692,Ak pelvic control belt light,Durable Medical Equipment,Per Unit,$132.88 ,OP,132.88,457.52,,,,,,
UHC MCR ADV,CPT,L5694,Ak pelvic control belt pad/l,Durable Medical Equipment,Per Unit,$181.41 ,OP,181.41,625.29,,,,,,
UHC MCR ADV,CPT,L5695,Ak sleeve susp neoprene/equa,Durable Medical Equipment,Per Unit,$163.08 ,OP,163.08,560.47,,,,,,
UHC MCR ADV,CPT,L5696,Ak/knee disartic pelvic join,Durable Medical Equipment,Per Unit,$196.99 ,OP,196.99,678.66,,,,,,
UHC MCR ADV,CPT,L5697,Ak/knee disartic pelvic band,Durable Medical Equipment,Per Unit,$93.55 ,OP,93.55,320.27,,,,,,
UHC MCR ADV,CPT,L5698,Ak/knee disartic silesian ba,Durable Medical Equipment,Per Unit,$120.01 ,OP,120.01,411.78,,,,,,
UHC MCR ADV,CPT,L5699,Shoulder harness,Durable Medical Equipment,Per Unit,$205.11 ,OP,205.11,705.35,,,,,,
UHC MCR ADV,CPT,L5700,Replace socket below knee,Durable Medical Equipment,Per Unit,"$3,085.07 ",OP,"3,085.07","10,610.72",,,,,,
UHC MCR ADV,CPT,L5701,Replace socket above knee,Durable Medical Equipment,Per Unit,"$3,827.32 ",OP,"3,827.32","13,161.41",,,,,,
UHC MCR ADV,CPT,L5702,Replace socket hip,Durable Medical Equipment,Per Unit,"$4,823.75 ",OP,"4,823.75","16,589.03",,,,,,
UHC MCR ADV,CPT,L5703,Symes ankle w/o (sach) foot,Durable Medical Equipment,Per Unit,"$2,537.43 ",OP,"2,537.43","8,727.25",,,,,,
UHC MCR ADV,CPT,L5704,Custom shape cover bk,Durable Medical Equipment,Per Unit,$629.03 ,OP,629.03,"2,161.80",,,,,,
UHC MCR ADV,CPT,L5705,Custom shape cover ak,Durable Medical Equipment,Per Unit,"$1,153.25 ",OP,"1,153.25","3,965.20",,,,,,
UHC MCR ADV,CPT,L5706,Custom shape cvr knee disart,Durable Medical Equipment,Per Unit,"$1,124.85 ",OP,"1,124.85","3,869.89",,,,,,
UHC MCR ADV,CPT,L5707,Custom shape cvr hip disart,Durable Medical Equipment,Per Unit,"$1,511.27 ",OP,"1,511.27","5,196.70",,,,,,
UHC MCR ADV,CPT,L5710,Kne-shin exo sng axi mnl loc,Durable Medical Equipment,Per Unit,$359.65 ,OP,359.65,"1,235.32",,,,,,
UHC MCR ADV,CPT,L5711,Knee-shin exo mnl lock ultra,Durable Medical Equipment,Per Unit,$603.60 ,OP,603.6,"2,074.10",,,,,,
UHC MCR ADV,CPT,L5712,Knee-shin exo frict swg & st,Durable Medical Equipment,Per Unit,$430.88 ,OP,430.88,"1,483.14",,,,,,
UHC MCR ADV,CPT,L5714,Knee-shin exo variable frict,Durable Medical Equipment,Per Unit,$438.43 ,OP,438.43,"1,506.03",,,,,,
UHC MCR ADV,CPT,L5716,Knee-shin exo mech stance ph,Durable Medical Equipment,Per Unit,$866.93 ,OP,866.93,"2,981.52",,,,,,
UHC MCR ADV,CPT,L5718,Knee-shin exo frct swg & sta,Durable Medical Equipment,Per Unit,$927.01 ,OP,927.01,"3,187.41",,,,,,
UHC MCR ADV,CPT,L5722,Knee-shin pneum swg frct exo,Durable Medical Equipment,Per Unit,"$1,127.32 ",OP,"1,127.32","3,877.51",,,,,,
UHC MCR ADV,CPT,L5724,Knee-shin exo fluid swing ph,Durable Medical Equipment,Per Unit,"$1,737.57 ",OP,"1,737.57","5,974.48",,,,,,
UHC MCR ADV,CPT,L5726,Knee-shin ext jnts fld swg e,Durable Medical Equipment,Per Unit,"$2,068.65 ",OP,"2,068.65","7,114.49",,,,,,
UHC MCR ADV,CPT,L5728,Knee-shin fluid swg & stance,Durable Medical Equipment,Per Unit,"$2,424.23 ",OP,"2,424.23","8,338.36",,,,,,
UHC MCR ADV,CPT,L5780,Knee-shin pneum/hydra pneum,Durable Medical Equipment,Per Unit,"$1,334.72 ",OP,"1,334.72","4,590.49",,,,,,
UHC MCR ADV,CPT,L5781,Lower limb pros vacuum pump,Durable Medical Equipment,Per Unit,"$4,024.33 ",OP,"4,024.33","13,840.07",,,,,,
UHC MCR ADV,CPT,L5782,Hd low limb pros vacuum pump,Durable Medical Equipment,Per Unit,"$4,242.55 ",OP,"4,242.55","14,591.17",,,,,,
UHC MCR ADV,CPT,L5785,Exoskeletal bk ultralt mater,Durable Medical Equipment,Per Unit,$519.54 ,OP,519.54,"1,788.15",,,,,,
UHC MCR ADV,CPT,L5790,Exoskeletal ak ultra-light m,Durable Medical Equipment,Per Unit,$749.83 ,OP,749.83,"2,577.38",,,,,,
UHC MCR ADV,CPT,L5795,Exoskel hip ultra-light mate,Durable Medical Equipment,Per Unit,"$1,073.66 ",OP,"1,073.66","3,690.70",,,,,,
UHC MCR ADV,CPT,L5810,Endoskel knee-shin mnl lock,Durable Medical Equipment,Per Unit,$572.04 ,OP,572.04,"1,967.35",,,,,,
UHC MCR ADV,CPT,L5811,Endo knee-shin mnl lck ultra,Durable Medical Equipment,Per Unit,$789.42 ,OP,789.42,"2,714.64",,,,,,
UHC MCR ADV,CPT,L5812,Endo knee-shin frct swg & st,Durable Medical Equipment,Per Unit,$594.07 ,OP,594.07,"2,043.61",,,,,,
UHC MCR ADV,CPT,L5814,Endo knee-shin hydral swg ph,Durable Medical Equipment,Per Unit,"$3,735.37 ",OP,"3,735.37","12,844.96",,,,,,
UHC MCR ADV,CPT,L5816,Endo knee-shin polyc mch sta,Durable Medical Equipment,Per Unit,$850.43 ,OP,850.43,"2,924.33",,,,,,
UHC MCR ADV,CPT,L5818,Endo knee-shin frct swg & st,Durable Medical Equipment,Per Unit,$960.30 ,OP,960.3,"3,301.79",,,,,,
UHC MCR ADV,CPT,L5822,Endo knee-shin pneum swg frc,Durable Medical Equipment,Per Unit,"$1,761.65 ",OP,"1,761.65","6,058.37",,,,,,
UHC MCR ADV,CPT,L5824,Endo knee-shin fluid swing p,Durable Medical Equipment,Per Unit,"$1,665.27 ",OP,"1,665.27","5,726.65",,,,,,
UHC MCR ADV,CPT,L5826,Miniature knee joint,Durable Medical Equipment,Per Unit,"$3,140.97 ",OP,"3,140.97","10,801.35",,,,,,
UHC MCR ADV,CPT,L5828,Endo knee-shin fluid swg/sta,Durable Medical Equipment,Per Unit,"$2,963.78 ",OP,"2,963.78","10,191.33",,,,,,
UHC MCR ADV,CPT,L5830,Endo knee-shin pneum/swg pha,Durable Medical Equipment,Per Unit,"$1,998.37 ",OP,"1,998.37","6,874.29",,,,,,
UHC MCR ADV,CPT,L5840,Multi-axial knee/shin system,Durable Medical Equipment,Per Unit,"$3,922.28 ",OP,"3,922.28","13,489.32",,,,,,
UHC MCR ADV,CPT,L5845,Knee-shin sys stance flexion,Durable Medical Equipment,Per Unit,"$1,802.73 ",OP,"1,802.73","6,199.43",,,,,,
UHC MCR ADV,CPT,L5848,Knee-shin sys hydraul stance,Durable Medical Equipment,Per Unit,"$1,081.55 ",OP,"1,081.55","3,721.19",,,,,,
UHC MCR ADV,CPT,L5850,Endo ak/hip knee extens assi,Durable Medical Equipment,Per Unit,$127.92 ,OP,127.92,438.47,,,,,,
UHC MCR ADV,CPT,L5855,Mech hip extension assist,Durable Medical Equipment,Per Unit,$308.82 ,OP,308.82,"1,063.73",,,,,,
UHC MCR ADV,CPT,L5856,Elec knee-shin swing/stance,Durable Medical Equipment,Per Unit,"$24,144.68 ",OP,"24,144.68","83,036.63",,,,,,
UHC MCR ADV,CPT,L5857,Elec knee-shin swing only,Durable Medical Equipment,Per Unit,"$8,567.44 ",OP,"8,567.44","29,464.49",,,,,,
UHC MCR ADV,CPT,L5858,Stance phase only,Durable Medical Equipment,Per Unit,"$18,692.70 ",OP,"18,692.70","64,285.82",,,,,,
UHC MCR ADV,CPT,L5859,Knee-shin pro flex/ext cont,Durable Medical Equipment,Per Unit,"$14,593.21 ",OP,"14,593.21","14,593.21",,,,,,
UHC MCR ADV,CPT,L5910,Endo below knee alignable sy,Durable Medical Equipment,Per Unit,$362.17 ,OP,362.17,"1,246.76",,,,,,
UHC MCR ADV,CPT,L5920,Endo ak/hip alignable system,Durable Medical Equipment,Per Unit,$530.58 ,OP,530.58,"1,826.28",,,,,,
UHC MCR ADV,CPT,L5925,Above knee manual lock,Durable Medical Equipment,Per Unit,$336.00 ,OP,336,"1,155.24",,,,,,
UHC MCR ADV,CPT,L5930,High activity knee frame,Durable Medical Equipment,Per Unit,"$3,385.39 ",OP,"3,385.39","11,643.96",,,,,,
UHC MCR ADV,CPT,L5940,Endo bk ultra-light material,Durable Medical Equipment,Per Unit,$501.60 ,OP,501.6,"1,723.33",,,,,,
UHC MCR ADV,CPT,L5950,Endo ak ultra-light material,Durable Medical Equipment,Per Unit,$777.99 ,OP,777.99,"2,676.51",,,,,,
UHC MCR ADV,CPT,L5960,Endo hip ultra-light materia,Durable Medical Equipment,Per Unit,"$1,163.29 ",OP,"1,163.29","3,999.51",,,,,,
UHC MCR ADV,CPT,L5961,Endo poly hip- pneu/hyd/rot,Durable Medical Equipment,Per Unit,"$4,800.88 ",OP,"4,800.88","4,800.88",,,,,,
UHC MCR ADV,CPT,L5962,Below knee flex cover system,Durable Medical Equipment,Per Unit,$587.78 ,OP,587.78,"2,020.72",,,,,,
UHC MCR ADV,CPT,L5964,Above knee flex cover system,Durable Medical Equipment,Per Unit,"$1,127.47 ",OP,"1,127.47","3,877.51",,,,,,
UHC MCR ADV,CPT,L5966,Hip flexible cover system,Durable Medical Equipment,Per Unit,"$1,452.38 ",OP,"1,452.38","4,994.63",,,,,,
UHC MCR ADV,CPT,L5968,Multiaxial ankle w dorsiflex,Durable Medical Equipment,Per Unit,"$3,654.91 ",OP,"3,654.91","12,570.45",,,,,,
UHC MCR ADV,CPT,L5970,Foot external keel sach foot,Durable Medical Equipment,Per Unit,$218.47 ,OP,218.47,751.1,,,,,,
UHC MCR ADV,CPT,L5971,Sach foot- replacement,Durable Medical Equipment,Per Unit,$218.47 ,OP,218.47,751.1,,,,,,
UHC MCR ADV,CPT,L5972,Flexible keel foot,Durable Medical Equipment,Per Unit,$397.97 ,OP,397.97,"1,368.75",,,,,,
UHC MCR ADV,CPT,L5973,Ank-foot sys dors-plant flex,Durable Medical Equipment,Per Unit,"$17,757.02 ",OP,"17,757.02","17,757.02",,,,,,
UHC MCR ADV,CPT,L5974,Foot single axis ankle/foot,Durable Medical Equipment,Per Unit,$233.03 ,OP,233.03,800.67,,,,,,
UHC MCR ADV,CPT,L5975,Combo ankle/foot prosthesis,Durable Medical Equipment,Per Unit,$466.28 ,OP,466.28,"1,605.15",,,,,,
UHC MCR ADV,CPT,L5976,Energy storing foot,Durable Medical Equipment,Per Unit,$591.07 ,OP,591.07,"2,032.17",,,,,,
UHC MCR ADV,CPT,L5978,Ft prosth multiaxial ankl/ft,Durable Medical Equipment,Per Unit,$313.20 ,OP,313.2,"1,078.99",,,,,,
UHC MCR ADV,CPT,L5979,Multi-axial ankle/ft prosth,Durable Medical Equipment,Per Unit,"$2,507.69 ",OP,"2,507.69","8,624.30",,,,,,
UHC MCR ADV,CPT,L5980,Flex foot system,Durable Medical Equipment,Per Unit,"$3,820.69 ",OP,"3,820.69","13,138.54",,,,,,
UHC MCR ADV,CPT,L5981,Flex-walk sys low ext prosth,Durable Medical Equipment,Per Unit,"$3,431.91 ",OP,"3,431.91","11,804.09",,,,,,
UHC MCR ADV,CPT,L5982,Exoskeletal axial rotation u,Durable Medical Equipment,Per Unit,$644.71 ,OP,644.71,"2,218.98",,,,,,
UHC MCR ADV,CPT,L5984,Endoskeletal axial rotation,Durable Medical Equipment,Per Unit,$646.71 ,OP,646.71,"2,222.79",,,,,,
UHC MCR ADV,CPT,L5985,Lwr ext dynamic prosth pylon,Durable Medical Equipment,Per Unit,$284.02 ,OP,284.02,976.05,,,,,,
UHC MCR ADV,CPT,L5986,Multi-axial rotation unit,Durable Medical Equipment,Per Unit,$780.11 ,OP,780.11,"2,684.14",,,,,,
UHC MCR ADV,CPT,L5987,Shank ft w vert load pylon,Durable Medical Equipment,Per Unit,"$7,235.38 ",OP,"7,235.38","24,881.63",,,,,,
UHC MCR ADV,CPT,L5988,Vertical shock reducing pylo,Durable Medical Equipment,Per Unit,"$2,009.25 ",OP,"2,009.25","6,908.59",,,,,,
UHC MCR ADV,CPT,L5990,User adjustable heel height,Durable Medical Equipment,Per Unit,"$1,824.64 ",OP,"1,824.64","6,275.69",,,,,,
UHC MCR ADV,CPT,L6000,Part hand thumb rem,Durable Medical Equipment,Per Unit,"$1,771.55 ",OP,"1,771.55","6,092.69",,,,,,
UHC MCR ADV,CPT,L6010,Part hand little/ring,Durable Medical Equipment,Per Unit,"$1,971.44 ",OP,"1,971.44","6,778.98",,,,,,
UHC MCR ADV,CPT,L6020,Part hand no fingers,Durable Medical Equipment,Per Unit,"$1,838.05 ",OP,"1,838.05","6,321.45",,,,,,
UHC MCR ADV,CPT,L6026,Part hand myo exclu term dev,Durable Medical Equipment,Per Unit,"$4,375.03 ",OP,"4,375.03","4,375.03",,,,,,
UHC MCR ADV,CPT,L6050,Wrst mld sck flx hng tri pad,Durable Medical Equipment,Per Unit,"$2,500.12 ",OP,"2,500.12","8,597.63",,,,,,
UHC MCR ADV,CPT,L6055,Wrst mold sock w/exp interfa,Durable Medical Equipment,Per Unit,"$3,189.04 ",OP,"3,189.04","10,969.11",,,,,,
UHC MCR ADV,CPT,L6100,Elb mold sock flex hinge pad,Durable Medical Equipment,Per Unit,"$2,530.04 ",OP,"2,530.04","8,700.56",,,,,,
UHC MCR ADV,CPT,L6110,Elbow mold sock suspension t,Durable Medical Equipment,Per Unit,"$2,676.61 ",OP,"2,676.61","9,203.84",,,,,,
UHC MCR ADV,CPT,L6120,Elbow mold doub splt soc ste,Durable Medical Equipment,Per Unit,"$3,027.26 ",OP,"3,027.26","10,412.46",,,,,,
UHC MCR ADV,CPT,L6130,Elbow stump activated lock h,Durable Medical Equipment,Per Unit,"$3,193.82 ",OP,"3,193.82","10,984.37",,,,,,
UHC MCR ADV,CPT,L6200,Elbow mold outsid lock hinge,Durable Medical Equipment,Per Unit,"$3,290.01 ",OP,"3,290.01","11,316.08",,,,,,
UHC MCR ADV,CPT,L6205,Elbow molded w/ expand inter,Durable Medical Equipment,Per Unit,"$4,538.50 ",OP,"4,538.50","15,609.16",,,,,,
UHC MCR ADV,CPT,L6250,Elbow inter loc elbow forarm,Durable Medical Equipment,Per Unit,"$3,236.79 ",OP,"3,236.79","11,133.06",,,,,,
UHC MCR ADV,CPT,L6300,Shlder disart int lock elbow,Durable Medical Equipment,Per Unit,"$4,464.43 ",OP,"4,464.43","15,353.72",,,,,,
UHC MCR ADV,CPT,L6310,Shoulder passive restor comp,Durable Medical Equipment,Per Unit,"$4,046.04 ",OP,"4,046.04","13,916.32",,,,,,
UHC MCR ADV,CPT,L6320,Shoulder passive restor cap,Durable Medical Equipment,Per Unit,"$2,108.67 ",OP,"2,108.67","7,251.74",,,,,,
UHC MCR ADV,CPT,L6350,Thoracic intern lock elbow,Durable Medical Equipment,Per Unit,"$4,891.63 ",OP,"4,891.63","16,821.60",,,,,,
UHC MCR ADV,CPT,L6360,Thoracic passive restor comp,Durable Medical Equipment,Per Unit,"$4,246.80 ",OP,"4,246.80","14,606.43",,,,,,
UHC MCR ADV,CPT,L6370,Thoracic passive restor cap,Durable Medical Equipment,Per Unit,"$2,462.85 ",OP,"2,462.85","8,471.79",,,,,,
UHC MCR ADV,CPT,L6380,Postop dsg cast chg wrst/elb,Durable Medical Equipment,Per Unit,"$1,424.44 ",OP,"1,424.44","4,899.32",,,,,,
UHC MCR ADV,CPT,L6382,Postop dsg cast chg elb dis/,Durable Medical Equipment,Per Unit,"$1,695.74 ",OP,"1,695.74","5,833.42",,,,,,
UHC MCR ADV,CPT,L6384,Postop dsg cast chg shlder/t,Durable Medical Equipment,Per Unit,"$2,145.20 ",OP,"2,145.20","7,377.56",,,,,,
UHC MCR ADV,CPT,L6386,Postop ea cast chg & realign,Durable Medical Equipment,Per Unit,$470.24 ,OP,470.24,"1,616.58",,,,,,
UHC MCR ADV,CPT,L6388,Postop applicat rigid dsg on,Durable Medical Equipment,Per Unit,$517.85 ,OP,517.85,"1,780.53",,,,,,
UHC MCR ADV,CPT,L6400,Below elbow prosth tiss shap,Durable Medical Equipment,Per Unit,"$2,736.86 ",OP,"2,736.86","9,413.54",,,,,,
UHC MCR ADV,CPT,L6450,Elb disart prosth tiss shap,Durable Medical Equipment,Per Unit,"$3,576.94 ",OP,"3,576.94","12,299.74",,,,,,
UHC MCR ADV,CPT,L6500,Above elbow prosth tiss shap,Durable Medical Equipment,Per Unit,"$3,512.48 ",OP,"3,512.48","12,078.62",,,,,,
UHC MCR ADV,CPT,L6550,Shldr disar prosth tiss shap,Durable Medical Equipment,Per Unit,"$4,549.39 ",OP,"4,549.39","15,647.29",,,,,,
UHC MCR ADV,CPT,L6570,Scap thorac prosth tiss shap,Durable Medical Equipment,Per Unit,"$5,078.79 ",OP,"5,078.79","17,465.96",,,,,,
UHC MCR ADV,CPT,L6580,Wrist/elbow bowden cable mol,Durable Medical Equipment,Per Unit,"$2,030.62 ",OP,"2,030.62","6,984.85",,,,,,
UHC MCR ADV,CPT,L6582,Wrist/elbow bowden cbl dir f,Durable Medical Equipment,Per Unit,"$1,705.44 ",OP,"1,705.44","5,863.93",,,,,,
UHC MCR ADV,CPT,L6584,Elbow fair lead cable molded,Durable Medical Equipment,Per Unit,"$2,525.30 ",OP,"2,525.30","8,685.31",,,,,,
UHC MCR ADV,CPT,L6586,Elbow fair lead cable dir fo,Durable Medical Equipment,Per Unit,"$2,250.20 ",OP,"2,250.20","7,739.77",,,,,,
UHC MCR ADV,CPT,L6588,Shdr fair lead cable molded,Durable Medical Equipment,Per Unit,"$3,583.73 ",OP,"3,583.73","12,326.44",,,,,,
UHC MCR ADV,CPT,L6590,Shdr fair lead cable direct,Durable Medical Equipment,Per Unit,"$3,123.36 ",OP,"3,123.36","10,740.36",,,,,,
UHC MCR ADV,CPT,L6600,Polycentric hinge pair,Durable Medical Equipment,Per Unit,$228.13 ,OP,228.13,785.42,,,,,,
UHC MCR ADV,CPT,L6605,Single pivot hinge pair,Durable Medical Equipment,Per Unit,$234.81 ,OP,234.81,808.29,,,,,,
UHC MCR ADV,CPT,L6610,Flexible metal hinge pair,Durable Medical Equipment,Per Unit,$221.98 ,OP,221.98,762.54,,,,,,
UHC MCR ADV,CPT,L6611,Additional switch- ext power,Durable Medical Equipment,Per Unit,$414.10 ,OP,414.1,"1,425.95",,,,,,
UHC MCR ADV,CPT,L6615,Disconnect locking wrist uni,Durable Medical Equipment,Per Unit,$215.48 ,OP,215.48,739.67,,,,,,
UHC MCR ADV,CPT,L6616,Disconnect insert locking wr,Durable Medical Equipment,Per Unit,$64.86 ,OP,64.86,224.95,,,,,,
UHC MCR ADV,CPT,L6620,Flexion/extension wrist unit,Durable Medical Equipment,Per Unit,$376.69 ,OP,376.69,"1,296.32",,,,,,
UHC MCR ADV,CPT,L6621,Flex/ext wrist w/wo friction,Durable Medical Equipment,Per Unit,"$2,300.54 ",OP,"2,300.54","7,911.34",,,,,,
UHC MCR ADV,CPT,L6623,Spring-ass rot wrst w/ latch,Durable Medical Equipment,Per Unit,$717.59 ,OP,717.59,"2,466.81",,,,,,
UHC MCR ADV,CPT,L6624,Flex/ext/rotation wrist unit,Durable Medical Equipment,Per Unit,"$3,787.86 ",OP,"3,787.86","13,027.98",,,,,,
UHC MCR ADV,CPT,L6625,Rotation wrst w/ cable lock,Durable Medical Equipment,Per Unit,$531.84 ,OP,531.84,"1,830.09",,,,,,
UHC MCR ADV,CPT,L6628,Quick disconn hook adapter o,Durable Medical Equipment,Per Unit,$572.47 ,OP,572.47,"1,967.35",,,,,,
UHC MCR ADV,CPT,L6629,Lamination collar w/ couplin,Durable Medical Equipment,Per Unit,$195.07 ,OP,195.07,671.03,,,,,,
UHC MCR ADV,CPT,L6630,Stainless steel any wrist,Durable Medical Equipment,Per Unit,$287.35 ,OP,287.35,987.49,,,,,,
UHC MCR ADV,CPT,L6632,Latex suspension sleeve each,Durable Medical Equipment,Per Unit,$64.97 ,OP,64.97,224.95,,,,,,
UHC MCR ADV,CPT,L6635,Lift assist for elbow,Durable Medical Equipment,Per Unit,$207.68 ,OP,207.68,712.98,,,,,,
UHC MCR ADV,CPT,L6637,Nudge control elbow lock,Durable Medical Equipment,Per Unit,$406.60 ,OP,406.6,"1,399.26",,,,,,
UHC MCR ADV,CPT,L6638,Elec lock on manual pw elbow,Durable Medical Equipment,Per Unit,"$2,515.20 ",OP,"2,515.20","8,651.00",,,,,,
UHC MCR ADV,CPT,L6640,Shoulder abduction joint pai,Durable Medical Equipment,Per Unit,$338.63 ,OP,338.63,"1,162.87",,,,,,
UHC MCR ADV,CPT,L6641,Excursion amplifier pulley t,Durable Medical Equipment,Per Unit,$197.18 ,OP,197.18,678.66,,,,,,
UHC MCR ADV,CPT,L6642,Excursion amplifier lever ty,Durable Medical Equipment,Per Unit,$289.92 ,OP,289.92,998.92,,,,,,
UHC MCR ADV,CPT,L6645,Shoulder flexion-abduction j,Durable Medical Equipment,Per Unit,$366.21 ,OP,366.21,"1,258.19",,,,,,
UHC MCR ADV,CPT,L6646,Multipo locking shoulder jnt,Durable Medical Equipment,Per Unit,"$3,172.24 ",OP,"3,172.24","10,908.12",,,,,,
UHC MCR ADV,CPT,L6647,Shoulder lock actuator,Durable Medical Equipment,Per Unit,$522.26 ,OP,522.26,"1,795.78",,,,,,
UHC MCR ADV,CPT,L6648,Ext pwrd shlder lock/unlock,Durable Medical Equipment,Per Unit,"$3,271.71 ",OP,"3,271.71","11,251.26",,,,,,
UHC MCR ADV,CPT,L6650,Shoulder universal joint,Durable Medical Equipment,Per Unit,$397.20 ,OP,397.2,"1,364.94",,,,,,
UHC MCR ADV,CPT,L6655,Standard control cable extra,Durable Medical Equipment,Per Unit,$77.05 ,OP,77.05,263.08,,,,,,
UHC MCR ADV,CPT,L6660,Heavy duty control cable,Durable Medical Equipment,Per Unit,$103.11 ,OP,103.11,354.58,,,,,,
UHC MCR ADV,CPT,L6665,Teflon or equal cable lining,Durable Medical Equipment,Per Unit,$46.05 ,OP,46.05,160.13,,,,,,
UHC MCR ADV,CPT,L6670,Hook to hand cable adapter,Durable Medical Equipment,Per Unit,$47.96 ,OP,47.96,163.95,,,,,,
UHC MCR ADV,CPT,L6672,Harness chest/shlder saddle,Durable Medical Equipment,Per Unit,$220.08 ,OP,220.08,758.72,,,,,,
UHC MCR ADV,CPT,L6675,Harness figure of 8 sing con,Durable Medical Equipment,Per Unit,$120.09 ,OP,120.09,411.78,,,,,,
UHC MCR ADV,CPT,L6676,Harness figure of 8 dual con,Durable Medical Equipment,Per Unit,$125.64 ,OP,125.64,430.83,,,,,,
UHC MCR ADV,CPT,L6677,Ue triple control harness,Durable Medical Equipment,Per Unit,$298.35 ,OP,298.35,"1,025.61",,,,,,
UHC MCR ADV,CPT,L6680,Test sock wrist disart/bel e,Durable Medical Equipment,Per Unit,$309.33 ,OP,309.33,"1,063.73",,,,,,
UHC MCR ADV,CPT,L6682,Test sock elbw disart/above,Durable Medical Equipment,Per Unit,$342.01 ,OP,342.01,"1,178.12",,,,,,
UHC MCR ADV,CPT,L6684,Test socket shldr disart/tho,Durable Medical Equipment,Per Unit,$464.75 ,OP,464.75,"1,597.52",,,,,,
UHC MCR ADV,CPT,L6686,Suction socket,Durable Medical Equipment,Per Unit,$689.63 ,OP,689.63,"2,371.49",,,,,,
UHC MCR ADV,CPT,L6687,Frame typ socket bel elbow/w,Durable Medical Equipment,Per Unit,$576.80 ,OP,576.8,"1,982.60",,,,,,
UHC MCR ADV,CPT,L6688,Frame typ sock above elb/dis,Durable Medical Equipment,Per Unit,$638.36 ,OP,638.36,"2,196.11",,,,,,
UHC MCR ADV,CPT,L6689,Frame typ socket shoulder di,Durable Medical Equipment,Per Unit,$760.81 ,OP,760.81,"2,615.51",,,,,,
UHC MCR ADV,CPT,L6690,Frame typ sock interscap-tho,Durable Medical Equipment,Per Unit,$895.74 ,OP,895.74,"3,080.66",,,,,,
UHC MCR ADV,CPT,L6691,Removable insert each,Durable Medical Equipment,Per Unit,$353.58 ,OP,353.58,"1,216.24",,,,,,
UHC MCR ADV,CPT,L6692,Silicone gel insert or equal,Durable Medical Equipment,Per Unit,$643.25 ,OP,643.25,"2,211.37",,,,,,
UHC MCR ADV,CPT,L6693,Lockingelbow forearm cntrbal,Durable Medical Equipment,Per Unit,"$2,855.43 ",OP,"2,855.43","9,821.50",,,,,,
UHC MCR ADV,CPT,L6694,Elbow socket ins use w/lock,Durable Medical Equipment,Per Unit,$790.52 ,OP,790.52,"2,718.45",,,,,,
UHC MCR ADV,CPT,L6695,Elbow socket ins use w/o lck,Durable Medical Equipment,Per Unit,$658.75 ,OP,658.75,"2,264.75",,,,,,
UHC MCR ADV,CPT,L6696,Cus elbo skt in for con/atyp,Durable Medical Equipment,Per Unit,"$1,323.02 ",OP,"1,323.02","4,548.54",,,,,,
UHC MCR ADV,CPT,L6697,Cus elbo skt in not con/atyp,Durable Medical Equipment,Per Unit,"$1,323.02 ",OP,"1,323.02","4,548.54",,,,,,
UHC MCR ADV,CPT,L6698,Below/above elbow lock mech,Durable Medical Equipment,Per Unit,$497.40 ,OP,497.4,"1,711.89",,,,,,
UHC MCR ADV,CPT,L6703,Term dev- passive hand mitt,Durable Medical Equipment,Per Unit,$351.79 ,OP,351.79,"1,208.62",,,,,,
UHC MCR ADV,CPT,L6704,Term dev- sport/rec/work att,Durable Medical Equipment,Per Unit,$679.06 ,OP,679.06,"2,337.18",,,,,,
UHC MCR ADV,CPT,L6706,Term dev mech hook vol open,Durable Medical Equipment,Per Unit,$421.40 ,OP,421.4,"1,448.82",,,,,,
UHC MCR ADV,CPT,L6707,Term dev mech hook vol close,Durable Medical Equipment,Per Unit,"$1,490.70 ",OP,"1,490.70","5,128.07",,,,,,
UHC MCR ADV,CPT,L6708,Term dev mech hand vol open,Durable Medical Equipment,Per Unit,$985.41 ,OP,985.41,"3,389.47",,,,,,
UHC MCR ADV,CPT,L6709,Term dev mech hand vol close,Durable Medical Equipment,Per Unit,"$1,398.55 ",OP,"1,398.55","4,811.61",,,,,,
UHC MCR ADV,CPT,L6711,Ped term dev- hook- vol open,Durable Medical Equipment,Per Unit,$676.19 ,OP,676.19,"2,325.74",,,,,,
UHC MCR ADV,CPT,L6712,Ped term dev- hook- vol clos,Durable Medical Equipment,Per Unit,"$1,245.05 ",OP,"1,245.05","4,281.66",,,,,,
UHC MCR ADV,CPT,L6713,Ped term dev- hand- vol open,Durable Medical Equipment,Per Unit,"$1,571.33 ",OP,"1,571.33","5,402.59",,,,,,
UHC MCR ADV,CPT,L6714,Ped term dev- hand- vol clos,Durable Medical Equipment,Per Unit,"$1,330.91 ",OP,"1,330.91","4,579.05",,,,,,
UHC MCR ADV,CPT,L6715,Term device- multi art digit,Durable Medical Equipment,Per Unit,"$3,175.42 ",OP,"3,175.42","3,175.42",,,,,,
UHC MCR ADV,CPT,L6721,Hook/hand- hvy dty- vol open,Durable Medical Equipment,Per Unit,"$2,365.59 ",OP,"2,365.59","8,136.28",,,,,,
UHC MCR ADV,CPT,L6722,Hook/hand- hvy dty- vol clos,Durable Medical Equipment,Per Unit,"$2,039.28 ",OP,"2,039.28","7,011.54",,,,,,
UHC MCR ADV,CPT,L6805,Term dev modifier wrist unit,Durable Medical Equipment,Per Unit,$385.75 ,OP,385.75,"1,326.82",,,,,,
UHC MCR ADV,CPT,L6810,Term dev precision pinch dev,Durable Medical Equipment,Per Unit,$205.07 ,OP,205.07,705.35,,,,,,
UHC MCR ADV,CPT,L6880,Elec hand ind art digits,Durable Medical Equipment,Per Unit,"$24,030.68 ",OP,"24,030.68","24,030.68",,,,,,
UHC MCR ADV,CPT,L6881,Term dev auto grasp feature,Durable Medical Equipment,Per Unit,"$4,111.91 ",OP,"4,111.91","14,141.27",,,,,,
UHC MCR ADV,CPT,L6882,Microprocessor control uplmb,Durable Medical Equipment,Per Unit,"$3,119.08 ",OP,"3,119.08","10,725.10",,,,,,
UHC MCR ADV,CPT,L6883,Replc sockt below e/w disa,Durable Medical Equipment,Per Unit,"$1,997.96 ",OP,"1,997.96","6,870.47",,,,,,
UHC MCR ADV,CPT,L6884,Replc sockt above elbow disa,Durable Medical Equipment,Per Unit,"$2,733.67 ",OP,"2,733.67","9,402.10",,,,,,
UHC MCR ADV,CPT,L6885,Replc sockt shldr dis/interc,Durable Medical Equipment,Per Unit,"$4,246.80 ",OP,"4,246.80","14,606.43",,,,,,
UHC MCR ADV,CPT,L6890,Prefab glove for term device,Durable Medical Equipment,Per Unit,$200.88 ,OP,200.88,690.1,,,,,,
UHC MCR ADV,CPT,L6895,Custom glove for term device,Durable Medical Equipment,Per Unit,$671.68 ,OP,671.68,"2,310.49",,,,,,
UHC MCR ADV,CPT,L6900,Hand restorat thumb/1 finger,Durable Medical Equipment,Per Unit,"$1,950.52 ",OP,"1,950.52","6,706.52",,,,,,
UHC MCR ADV,CPT,L6905,Hand restoration multiple fi,Durable Medical Equipment,Per Unit,"$1,930.47 ",OP,"1,930.47","6,637.91",,,,,,
UHC MCR ADV,CPT,L6910,Hand restoration no fingers,Durable Medical Equipment,Per Unit,"$1,897.78 ",OP,"1,897.78","6,527.33",,,,,,
UHC MCR ADV,CPT,L6915,Hand restoration replacmnt g,Durable Medical Equipment,Per Unit,$815.40 ,OP,815.4,"2,806.14",,,,,,
UHC MCR ADV,CPT,L6920,Wrist disarticul switch ctrl,Durable Medical Equipment,Per Unit,"$8,425.39 ",OP,"8,425.39","28,976.47",,,,,,
UHC MCR ADV,CPT,L6925,Wrist disart myoelectronic c,Durable Medical Equipment,Per Unit,"$9,001.12 ",OP,"9,001.12","30,955.25",,,,,,
UHC MCR ADV,CPT,L6930,Below elbow switch control,Durable Medical Equipment,Per Unit,"$8,114.82 ",OP,"8,114.82","27,908.91",,,,,,
UHC MCR ADV,CPT,L6935,Below elbow myoelectronic ct,Durable Medical Equipment,Per Unit,"$8,958.82 ",OP,"8,958.82","30,810.37",,,,,,
UHC MCR ADV,CPT,L6940,Elbow disarticulation switch,Durable Medical Equipment,Per Unit,"$10,478.90 ",OP,"10,478.90","36,037.57",,,,,,
UHC MCR ADV,CPT,L6945,Elbow disart myoelectronic c,Durable Medical Equipment,Per Unit,"$11,690.57 ",OP,"11,690.57","40,204.84",,,,,,
UHC MCR ADV,CPT,L6950,Above elbow switch control,Durable Medical Equipment,Per Unit,"$10,459.47 ",OP,"10,459.47","35,972.77",,,,,,
UHC MCR ADV,CPT,L6955,Above elbow myoelectronic ct,Durable Medical Equipment,Per Unit,"$12,129.70 ",OP,"12,129.70","41,714.68",,,,,,
UHC MCR ADV,CPT,L6960,Shldr disartic switch contro,Durable Medical Equipment,Per Unit,"$12,759.97 ",OP,"12,759.97","43,884.09",,,,,,
UHC MCR ADV,CPT,L6965,Shldr disartic myoelectronic,Durable Medical Equipment,Per Unit,"$15,116.16 ",OP,"15,116.16","51,986.07",,,,,,
UHC MCR ADV,CPT,L6970,Interscapular-thor switch ct,Durable Medical Equipment,Per Unit,"$16,180.17 ",OP,"16,180.17","55,646.26",,,,,,
UHC MCR ADV,CPT,L6975,Interscap-thor myoelectronic,Durable Medical Equipment,Per Unit,"$17,834.37 ",OP,"17,834.37","61,334.79",,,,,,
UHC MCR ADV,CPT,L7007,Adult electric hand,Durable Medical Equipment,Per Unit,"$3,673.63 ",OP,"3,673.63","12,635.27",,,,,,
UHC MCR ADV,CPT,L7008,Pediatric electric hand,Durable Medical Equipment,Per Unit,"$5,696.71 ",OP,"5,696.71","19,593.43",,,,,,
UHC MCR ADV,CPT,L7009,Adult electric hook,Durable Medical Equipment,Per Unit,"$3,758.57 ",OP,"3,758.57","12,925.03",,,,,,
UHC MCR ADV,CPT,L7040,Prehensile actuator,Durable Medical Equipment,Per Unit,"$3,059.23 ",OP,"3,059.23","10,519.22",,,,,,
UHC MCR ADV,CPT,L7045,Pediatric electric hook,Durable Medical Equipment,Per Unit,"$1,616.29 ",OP,"1,616.29","5,558.92",,,,,,
UHC MCR ADV,CPT,L7170,Electronic elbow hosmer swit,Durable Medical Equipment,Per Unit,"$6,050.00 ",OP,"6,050.00","20,805.87",,,,,,
UHC MCR ADV,CPT,L7180,Electronic elbow sequential,Durable Medical Equipment,Per Unit,"$39,141.46 ",OP,"39,141.46","134,610.92",,,,,,
UHC MCR ADV,CPT,L7181,Electronic elbo simultaneous,Durable Medical Equipment,Per Unit,"$40,299.84 ",OP,"40,299.84","138,595.19",,,,,,
UHC MCR ADV,CPT,L7185,Electron elbow adolescent sw,Durable Medical Equipment,Per Unit,"$6,360.51 ",OP,"6,360.51","21,873.42",,,,,,
UHC MCR ADV,CPT,L7186,Electron elbow child switch,Durable Medical Equipment,Per Unit,"$10,692.92 ",OP,"10,692.92","36,773.42",,,,,,
UHC MCR ADV,CPT,L7190,Elbow adolescent myoelectron,Durable Medical Equipment,Per Unit,"$8,439.80 ",OP,"8,439.80","29,026.03",,,,,,
UHC MCR ADV,CPT,L7191,Elbow child myoelectronic ct,Durable Medical Equipment,Per Unit,"$11,247.26 ",OP,"11,247.26","38,679.77",,,,,,
UHC MCR ADV,CPT,L7259,Electronic wrist rotator any,Durable Medical Equipment,Per Unit,"$4,121.94 ",OP,"4,121.94","4,121.94",,,,,,
UHC MCR ADV,CPT,L7360,Six volt bat otto bock/eq ea,Durable Medical Equipment,Per Unit,$266.08 ,OP,266.08,915.04,,,,,,
UHC MCR ADV,CPT,L7362,Battery chrgr six volt otto,Durable Medical Equipment,Per Unit,$290.68 ,OP,290.68,998.92,,,,,,
UHC MCR ADV,CPT,L7364,Twelve volt battery utah/equ,Durable Medical Equipment,Per Unit,$514.33 ,OP,514.33,"1,769.09",,,,,,
UHC MCR ADV,CPT,L7366,Battery chrgr 12 volt utah/e,Durable Medical Equipment,Per Unit,$707.34 ,OP,707.34,"2,432.50",,,,,,
UHC MCR ADV,CPT,L7367,Replacemnt lithium ionbatter,Durable Medical Equipment,Per Unit,$391.59 ,OP,391.59,"1,345.89",,,,,,
UHC MCR ADV,CPT,L7368,Lithium ion battery charger,Durable Medical Equipment,Per Unit,$507.61 ,OP,507.61,"1,746.22",,,,,,
UHC MCR ADV,CPT,L7400,Add ue prost be/wd- ultlite,Durable Medical Equipment,Per Unit,$308.25 ,OP,308.25,"1,059.93",,,,,,
UHC MCR ADV,CPT,L7401,Add ue prost a/e ultlite mat,Durable Medical Equipment,Per Unit,$345.06 ,OP,345.06,"1,185.76",,,,,,
UHC MCR ADV,CPT,L7402,Add ue prost s/d ultlite mat,Durable Medical Equipment,Per Unit,$372.68 ,OP,372.68,"1,281.07",,,,,,
UHC MCR ADV,CPT,L7403,Add ue prost b/e acrylic,Durable Medical Equipment,Per Unit,$370.41 ,OP,370.41,"1,273.44",,,,,,
UHC MCR ADV,CPT,L7404,Add ue prost a/e acrylic,Durable Medical Equipment,Per Unit,$559.06 ,OP,559.06,"1,921.59",,,,,,
UHC MCR ADV,CPT,L7405,Add ue prost s/d acrylic,Durable Medical Equipment,Per Unit,$731.10 ,OP,731.1,"2,512.57",,,,,,
UHC MCR ADV,CPT,L7700,Pros soc insert gasket/seal,Durable Medical Equipment,Per Unit,$150.48 ,OP,150.48,150.48,,,,,,
UHC MCR ADV,CPT,L8000,Mastectomy bra,Durable Medical Equipment,Per Unit,$42.59 ,OP,42.59,144.88,,,,,,
UHC MCR ADV,CPT,L8001,Breast prosthesis bra & form,Durable Medical Equipment,Per Unit,$126.18 ,OP,126.18,434.65,,,,,,
UHC MCR ADV,CPT,L8002,Brst prsth bra & bilat form,Durable Medical Equipment,Per Unit,$165.94 ,OP,165.94,571.91,,,,,,
UHC MCR ADV,CPT,L8015,Ext breastprosthesis garment,Durable Medical Equipment,Per Unit,$60.29 ,OP,60.29,205.88,,,,,,
UHC MCR ADV,CPT,L8020,Mastectomy form,Durable Medical Equipment,Per Unit,$227.40 ,OP,227.4,781.61,,,,,,
UHC MCR ADV,CPT,L8030,Breast prosthes w/o adhesive,Durable Medical Equipment,Per Unit,$351.55 ,OP,351.55,"1,208.62",,,,,,
UHC MCR ADV,CPT,L8031,Breast prosthesis w adhesive,Durable Medical Equipment,Per Unit,$351.55 ,OP,351.55,351.55,,,,,,
UHC MCR ADV,CPT,L8032,Reusable nipple prosthesis,Durable Medical Equipment,Per Unit,$39.39 ,OP,39.39,39.39,,,,,,
UHC MCR ADV,CPT,L8035,Custom breast prosthesis,Durable Medical Equipment,Per Unit,"$3,684.79 ",OP,"3,684.79","12,673.39",,,,,,
UHC MCR ADV,CPT,L8040,Nasal prosthesis,Durable Medical Equipment,Per Unit,"$2,493.50 ",OP,"2,493.50","8,574.74",,,,,,
UHC MCR ADV,CPT,L8041,Midfacial prosthesis,Durable Medical Equipment,Per Unit,"$3,005.20 ",OP,"3,005.20","10,336.21",,,,,,
UHC MCR ADV,CPT,L8042,Orbital prosthesis,Durable Medical Equipment,Per Unit,"$3,376.62 ",OP,"3,376.62","11,613.47",,,,,,
UHC MCR ADV,CPT,L8043,Upper facial prosthesis,Durable Medical Equipment,Per Unit,"$3,781.84 ",OP,"3,781.84","13,005.10",,,,,,
UHC MCR ADV,CPT,L8044,Hemi-facial prosthesis,Durable Medical Equipment,Per Unit,"$4,187.02 ",OP,"4,187.02","14,400.54",,,,,,
UHC MCR ADV,CPT,L8045,Auricular prosthesis,Durable Medical Equipment,Per Unit,"$3,278.72 ",OP,"3,278.72","11,274.13",,,,,,
UHC MCR ADV,CPT,L8046,Partial facial prosthesis,Durable Medical Equipment,Per Unit,"$2,701.33 ",OP,"2,701.33","9,291.53",,,,,,
UHC MCR ADV,CPT,L8047,Nasal septal prosthesis,Durable Medical Equipment,Per Unit,"$1,384.42 ",OP,"1,384.42","4,762.05",,,,,,
UHC MCR ADV,CPT,L8300,Truss single w/ standard pad,Durable Medical Equipment,Per Unit,$84.35 ,OP,84.35,289.76,,,,,,
UHC MCR ADV,CPT,L8310,Truss double w/ standard pad,Durable Medical Equipment,Per Unit,$149.44 ,OP,149.44,514.72,,,,,,
UHC MCR ADV,CPT,L8320,Truss addition to std pad wa,Durable Medical Equipment,Per Unit,$62.00 ,OP,62,213.51,,,,,,
UHC MCR ADV,CPT,L8330,Truss add to std pad scrotal,Durable Medical Equipment,Per Unit,$49.37 ,OP,49.37,171.58,,,,,,
UHC MCR ADV,CPT,L8400,Sheath below knee,Durable Medical Equipment,Per Unit,$15.74 ,OP,15.74,53.38,,,,,,
UHC MCR ADV,CPT,L8410,Sheath above knee,Durable Medical Equipment,Per Unit,$20.72 ,OP,20.72,72.44,,,,,,
UHC MCR ADV,CPT,L8415,Sheath upper limb,Durable Medical Equipment,Per Unit,$21.44 ,OP,21.44,72.44,,,,,,
UHC MCR ADV,CPT,L8417,Pros sheath/sock w gel cushn,Durable Medical Equipment,Per Unit,$75.64 ,OP,75.64,259.27,,,,,,
UHC MCR ADV,CPT,L8420,Prosthetic sock multi ply bk,Durable Medical Equipment,Per Unit,$20.98 ,OP,20.98,72.44,,,,,,
UHC MCR ADV,CPT,L8430,Prosthetic sock multi ply ak,Durable Medical Equipment,Per Unit,$23.76 ,OP,23.76,80.07,,,,,,
UHC MCR ADV,CPT,L8435,Pros sock multi ply upper lm,Durable Medical Equipment,Per Unit,$22.58 ,OP,22.58,76.26,,,,,,
UHC MCR ADV,CPT,L8440,Shrinker below knee,Durable Medical Equipment,Per Unit,$46.88 ,OP,46.88,160.13,,,,,,
UHC MCR ADV,CPT,L8460,Shrinker above knee,Durable Medical Equipment,Per Unit,$66.65 ,OP,66.65,228.77,,,,,,
UHC MCR ADV,CPT,L8465,Shrinker upper limb,Durable Medical Equipment,Per Unit,$61.60 ,OP,61.6,213.51,,,,,,
UHC MCR ADV,CPT,L8470,Pros sock single ply bk,Durable Medical Equipment,Per Unit,$6.67 ,OP,6.67,22.88,,,,,,
UHC MCR ADV,CPT,L8480,Pros sock single ply ak,Durable Medical Equipment,Per Unit,$9.20 ,OP,9.2,30.51,,,,,,
UHC MCR ADV,CPT,L8485,Pros sock single ply upper l,Durable Medical Equipment,Per Unit,$12.39 ,OP,12.39,41.94,,,,,,
UHC MCR ADV,CPT,L8500,Artificial larynx,Durable Medical Equipment,Per Unit,$661.87 ,OP,661.87,"2,276.18",,,,,,
UHC MCR ADV,CPT,L8501,Tracheostomy speaking valve,Durable Medical Equipment,Per Unit,$120.80 ,OP,120.8,415.59,,,,,,
UHC MCR ADV,CPT,L8507,Trach-esoph voice pros pt in,Durable Medical Equipment,Per Unit,$42.11 ,OP,42.11,144.88,,,,,,
UHC MCR ADV,CPT,L8509,Trach-esoph voice pros md in,Durable Medical Equipment,Per Unit,$109.85 ,OP,109.85,377.46,,,,,,
UHC MCR ADV,CPT,L8510,Voice amplifier,Durable Medical Equipment,Per Unit,$254.17 ,OP,254.17,873.11,,,,,,
UHC MCR ADV,CPT,L8511,Indwelling trach insert,Durable Medical Equipment,Per Unit,$73.14 ,OP,73.14,251.64,,,,,,
UHC MCR ADV,CPT,L8512,Gel cap for trach voice pros,Durable Medical Equipment,Per Unit,$2.19 ,OP,2.19,7.62,,,,,,
UHC MCR ADV,CPT,L8513,Trach pros cleaning device,Durable Medical Equipment,Per Unit,$5.22 ,OP,5.22,19.07,,,,,,
UHC MCR ADV,CPT,L8514,Repl trach puncture dilator,Durable Medical Equipment,Per Unit,$94.85 ,OP,94.85,327.9,,,,,,
UHC MCR ADV,CPT,L8515,Gel cap app device for trach,Durable Medical Equipment,Per Unit,$63.49 ,OP,63.49,217.32,,,,,,
UHC MCR ADV,CPT,L8615,Coch implant headset replace,Durable Medical Equipment,Per Unit,$453.62 ,OP,453.62,"1,559.39",,,,,,
UHC MCR ADV,CPT,L8616,Coch implant microphone repl,Durable Medical Equipment,Per Unit,$105.64 ,OP,105.64,362.21,,,,,,
UHC MCR ADV,CPT,L8617,Coch implant trans coil repl,Durable Medical Equipment,Per Unit,$92.27 ,OP,92.27,92.27,,,,,,
UHC MCR ADV,CPT,L8618,Coch implant tran cable repl,Durable Medical Equipment,Per Unit,$26.38 ,OP,26.38,91.51,,,,,,
UHC MCR ADV,CPT,L8619,Coch imp ext proc/contr rplc,Durable Medical Equipment,Per Unit,"$8,454.02 ",OP,"8,454.02","29,075.59",,,,,,
UHC MCR ADV,CPT,L8621,Repl zinc air battery,Durable Medical Equipment,Per Unit,$0.62 ,OP,0.62,3.82,,,,,,
UHC MCR ADV,CPT,L8622,Repl alkaline battery,Durable Medical Equipment,Per Unit,$0.32 ,OP,0.32,1.9,,,,,,
UHC MCR ADV,CPT,L8623,Lith ion batt cid-non-earlvl,Durable Medical Equipment,Per Unit,$65.06 ,OP,65.06,65.06,,,,,,
UHC MCR ADV,CPT,L8624,Lith ion batt cid- ear level,Durable Medical Equipment,Per Unit,$162.20 ,OP,162.2,556.65,,,,,,
UHC MCR ADV,CPT,L8625,Charger coch impl/aoi battry,Durable Medical Equipment,Per Unit,$189.97 ,OP,189.97,189.97,,,,,,
UHC MCR ADV,CPT,L8627,Cid ext speech process repl,Durable Medical Equipment,Per Unit,"$7,175.59 ",OP,"7,175.59","7,175.59",,,,,,
UHC MCR ADV,CPT,L8628,Cid ext controller repl,Durable Medical Equipment,Per Unit,"$1,278.42 ",OP,"1,278.42","1,278.42",,,,,,
UHC MCR ADV,CPT,L8629,Cid transmit coil and cable,Durable Medical Equipment,Per Unit,$180.09 ,OP,180.09,180.09,,,,,,
UHC MCR ADV,CPT,L8681,Pt prgrm for implt neurostim,Durable Medical Equipment,Per Unit,"$1,147.11 ",OP,"1,147.11","3,946.14",,,,,,
UHC MCR ADV,CPT,L8683,Radiofq trsmtr for implt neu,Durable Medical Equipment,Per Unit,"$5,420.03 ",OP,"5,420.03","18,640.24",,,,,,
UHC MCR ADV,CPT,L8684,Radiof trsmtr implt scrl neu,Durable Medical Equipment,Per Unit,$850.48 ,OP,850.48,"2,924.33",,,,,,
UHC MCR ADV,CPT,L8689,External recharg sys intern,Durable Medical Equipment,Per Unit,"$1,734.92 ",OP,"1,734.92","5,966.87",,,,,,
UHC MCR ADV,CPT,L8691,Aoi snd proc repl excl actua,Durable Medical Equipment,Per Unit,"$1,732.10 ",OP,"1,732.10","9,222.90",,,,,,
UHC MCR ADV,CPT,L8693,Aud osseo dev- abutment,Durable Medical Equipment,Per Unit,"$1,525.09 ",OP,"1,525.09","1,525.09",,,,,,
UHC MCR ADV,CPT,L8694,Aoi transducer/actuator repl,Durable Medical Equipment,Per Unit,$949.85 ,OP,949.85,949.85,,,,,,
UHC MCR ADV,CPT,L8695,External recharg sys extern,Durable Medical Equipment,Per Unit,$16.77 ,OP,16.77,57.19,,,,,,
UHC MCR ADV,CPT,L8696,Ext antenna phren nerve stim,Durable Medical Equipment,Per Unit,$217.98 ,OP,217.98,217.98,,,,,,
UHC MCR ADV,CPT,M0201,Covid-19 vaccine home admin,APC 1494,RVU Per Unit,$36.33 ,OP,36.33,36.33,,,,,,
UHC MCR ADV,CPT,M0240,Casiri and imdev repeat,APC 1506,RVU Per Unit,$461.00 ,OP,430.44,461,,,,,,
UHC MCR ADV,CPT,M0241,Casiri and imdev repeat hm,APC 1509,RVU Per Unit,$768.00 ,OP,768,768,,,,,,
UHC MCR ADV,CPT,M0243,Casirivi and imdevi inj,APC 1506,RVU Per Unit,$461.00 ,OP,461,461,,,,,,
UHC MCR ADV,CPT,M0244,Casirivi and imdevi inj hm,APC 1509,RVU Per Unit,$768.00 ,OP,717.08,768,,,,,,
UHC MCR ADV,CPT,M0245,Bamlan and etesev infusion,APC 1506,RVU Per Unit,$461.00 ,OP,430.44,461,,,,,,
UHC MCR ADV,CPT,M0246,Bamlan and etesev infus home,APC 1509,RVU Per Unit,$768.00 ,OP,717.08,768,,,,,,
UHC MCR ADV,CPT,M0247,Sotrovimab infusion,APC 1506,RVU Per Unit,$461.00 ,OP,430.44,461,,,,,,
UHC MCR ADV,CPT,M0248,Sotrovimab inf- home admin,APC 1509,RVU Per Unit,$768.00 ,OP,717.08,768,,,,,,
UHC MCR ADV,CPT,M0249,Adm tocilizu covid-19 1st,APC 1506,RVU Per Unit,$461.00 ,OP,430.44,461,,,,,,
UHC MCR ADV,CPT,M0250,Adm tocilizu covid-19 2nd,APC 1506,RVU Per Unit,$461.00 ,OP,430.44,461,,,,,,
UHC MCR ADV,CPT,P2028,Cephalin floculation test,Lab Services,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,
UHC MCR ADV,CPT,P2029,Congo red blood test,Lab Services,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,
UHC MCR ADV,CPT,P2033,Blood thymol turbidity,Lab Services,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,
UHC MCR ADV,CPT,P2038,Blood mucoprotein,Lab Services,Per Unit,$4.95 ,OP,4.95,22.88,,,,,,
UHC MCR ADV,CPT,P3000,Screen pap by tech w md supv,Lab Services,Per Unit,$15.15 ,OP,15.15,45.74,,,,,,
UHC MCR ADV,CPT,P9010,Whole blood for transfusion,APC 9510,Per Unit,$172.22 ,OP,172.22,172.22,,,,,,
UHC MCR ADV,CPT,P9011,Blood split unit,APC 9520,Per Unit,$169.28 ,OP,169.28,169.28,,,,,,
UHC MCR ADV,CPT,P9012,Cryoprecipitate each unit,APC 9511,Per Unit,$91.59 ,OP,91.59,91.59,,,,,,
UHC MCR ADV,CPT,P9016,Rbc leukocytes reduced,APC 9512,Per Unit,$216.23 ,OP,216.23,216.23,,,,,,
UHC MCR ADV,CPT,P9017,Plasma 1 donor frz w/in 8 hr,APC 9508,Per Unit,$94.81 ,OP,94.81,94.81,,,,,,
UHC MCR ADV,CPT,P9019,Platelets- each unit,APC 9515,Per Unit,$81.77 ,OP,81.77,81.77,,,,,,
UHC MCR ADV,CPT,P9020,Plaelet rich plasma unit,APC 9516,Per Unit,$229.41 ,OP,229.41,229.41,,,,,,
UHC MCR ADV,CPT,P9021,Red blood cells unit,APC 9517,Per Unit,$157.87 ,OP,157.87,157.87,,,,,,
UHC MCR ADV,CPT,P9022,Washed red blood cells unit,APC 9518,Per Unit,$435.72 ,OP,435.72,435.72,,,,,,
UHC MCR ADV,CPT,P9023,Frozen plasma- pooled- sd,APC 9509,Per Unit,$102.26 ,OP,102.26,102.26,,,,,,
UHC MCR ADV,CPT,P9025,Plasma cryo redu path each,APC 9538,Per Unit,$75.36 ,OP,75.36,75.36,,,,,,
UHC MCR ADV,CPT,P9026,Cryo fib comp path redu each,APC 9539,Per Unit,$91.59 ,OP,91.59,91.59,,,,,,
UHC MCR ADV,CPT,P9031,Platelets leukocytes reduced,APC 9526,Per Unit,$171.96 ,OP,171.96,171.96,,,,,,
UHC MCR ADV,CPT,P9032,Platelets- irradiated,APC 9500,Per Unit,$162.52 ,OP,162.52,162.52,,,,,,
UHC MCR ADV,CPT,P9033,Platelets leukoreduced irrad,APC 9521,Per Unit,$244.54 ,OP,244.54,244.54,,,,,,
UHC MCR ADV,CPT,P9034,Platelets- pheresis,APC 9507,Per Unit,$371.63 ,OP,371.63,371.63,,,,,,
UHC MCR ADV,CPT,P9035,Platelet pheres leukoreduced,APC 9501,Per Unit,$558.38 ,OP,558.38,558.38,,,,,,
UHC MCR ADV,CPT,P9036,Platelet pheresis irradiated,APC 9502,Per Unit,$693.83 ,OP,693.83,693.83,,,,,,
UHC MCR ADV,CPT,P9037,Plate pheres leukoredu irrad,APC 9530,Per Unit,$708.10 ,OP,708.1,708.1,,,,,,
UHC MCR ADV,CPT,P9038,Rbc irradiated,APC 9505,Per Unit,$194.21 ,OP,194.21,194.21,,,,,,
UHC MCR ADV,CPT,P9039,Rbc deglycerolized,APC 9504,Per Unit,$500.86 ,OP,500.86,500.86,,,,,,
UHC MCR ADV,CPT,P9040,Rbc leukoreduced irradiated,APC 9522,Per Unit,$298.86 ,OP,298.86,298.86,,,,,,
UHC MCR ADV,CPT,P9041,Albumin (human)-5%- 50ml,APC 0961,Per Unit,$10.49 ,OP,10.49,10.49,,,,,,
UHC MCR ADV,CPT,P9043,Plasma protein fract-5%-50ml,APC 9514,Per Unit,$9.16 ,OP,9.16,106.76,,,,,,
UHC MCR ADV,CPT,P9044,Cryoprecipitatereducedplasma,APC 9523,Per Unit,$75.36 ,OP,75.36,75.36,,,,,,
UHC MCR ADV,CPT,P9045,Albumin (human)- 5%- 250 ml,APC 0963,Per Unit,$52.45 ,OP,52.45,274.51,,,,,,
UHC MCR ADV,CPT,P9046,Albumin (human)- 25%- 20 ml,APC 0964,Per Unit,$20.98 ,OP,20.98,129.64,,,,,,
UHC MCR ADV,CPT,P9047,Albumin (human)- 25%- 50ml,APC 0965,Per Unit,$52.45 ,OP,52.45,255.45,,,,,,
UHC MCR ADV,CPT,P9048,Plasmaprotein fract-5%-250ml,APC 9519,Per Unit,$183.92 ,OP,183.92,198.25,,,,,,
UHC MCR ADV,CPT,P9051,Blood- l/r- cmv-neg,APC 9524,Per Unit,$243.44 ,OP,243.44,243.44,,,,,,
UHC MCR ADV,CPT,P9052,Platelets- hla-m- l/r- unit,APC 9525,Per Unit,$923.57 ,OP,923.57,923.57,,,,,,
UHC MCR ADV,CPT,P9053,Plt- pher- l/r cmv-neg- irr,APC 9531,Per Unit,$513.08 ,OP,513.08,513.08,,,,,,
UHC MCR ADV,CPT,P9054,Blood- l/r- froz/degly/wash,APC 9527,Per Unit,$356.39 ,OP,356.39,356.39,,,,,,
UHC MCR ADV,CPT,P9055,Plt- aph/pher- l/r- cmv-neg,APC 9528,Per Unit,$550.63 ,OP,550.63,550.63,,,,,,
UHC MCR ADV,CPT,P9056,Blood- l/r- irradiated,APC 9529,Per Unit,$176.83 ,OP,176.83,176.83,,,,,,
UHC MCR ADV,CPT,P9057,Rbc- frz/deg/wsh- l/r- irrad,APC 9532,Per Unit,$298.91 ,OP,298.91,298.91,,,,,,
UHC MCR ADV,CPT,P9058,Rbc- l/r- cmv-neg- irrad,APC 9533,Per Unit,$279.73 ,OP,279.73,279.73,,,,,,
UHC MCR ADV,CPT,P9059,Plasma- frz between 8-24hour,APC 9513,Per Unit,$81.61 ,OP,81.61,81.61,,,,,,
UHC MCR ADV,CPT,P9060,Fr frz plasma donor retested,APC 9503,Per Unit,$74.65 ,OP,74.65,74.65,,,,,,
UHC MCR ADV,CPT,P9070,Pathogen reduced plasma pool,APC 9534,Per Unit,$60.91 ,OP,60.91,60.91,,,,,,
UHC MCR ADV,CPT,P9071,Pathogen reduced plasma sing,APC 9535,Per Unit,$140.88 ,OP,140.88,140.88,,,,,,
UHC MCR ADV,CPT,P9073,Platelets pheresis path redu,APC 9536,Per Unit,$669.72 ,OP,669.72,669.72,,,,,,
UHC MCR ADV,CPT,P9099,Blood component/product noc,APC 9537,Per Unit,$9.16 ,OP,9.16,9.16,,,,,,
UHC MCR ADV,CPT,P9100,Pathogen test for platelets,APC 5732,RVU Per Unit,$34.63 ,OP,34.63,34.63,,,,,,
UHC MCR ADV,CPT,P9612,Catheterize for urine spec,Lab Services,Per Unit,$3.00 ,OP,3,3,,,,,,
UHC MCR ADV,CPT,Q0035,Cardiokymography,APC 5732,RVU Per Case,$34.63 ,OP,34.63,106.76,,,,,,
UHC MCR ADV,CPT,Q0091,Obtaining screen pap smear,APC 5731,RVU Per Unit,$25.25 ,OP,25.25,205.88,,,,,,
UHC MCR ADV,CPT,Q0111,Wet mounts/ w preparations,Lab Services,Per Unit,$15.15 ,OP,15.15,15.15,,,,,,
UHC MCR ADV,CPT,Q0112,Potassium hydroxide preps,Lab Services,Per Unit,$5.83 ,OP,5.83,22.88,,,,,,
UHC MCR ADV,CPT,Q0113,Pinworm examinations,Lab Services,Per Unit,$4.27 ,OP,4.27,26.7,,,,,,
UHC MCR ADV,CPT,Q0114,Fern test,Lab Services,Per Unit,$9.74 ,OP,9.74,34.31,,,,,,
UHC MCR ADV,CPT,Q0115,Post-coital mucous exam,Lab Services,Per Unit,$25.00 ,OP,25,49.56,,,,,,
UHC MCR ADV,CPT,Q0138,Ferumoxytol- non-esrd,APC 1297,Per Unit,$1.00 ,OP,1,1,,,,,,
UHC MCR ADV,CPT,Q0139,Ferumoxytol- esrd use,APC 1485,Per Unit,$1.00 ,OP,1,1,,,,,,
UHC MCR ADV,CPT,Q0240,Casirivi and imdevi 600 mg,Other,Straight Discount,29.70%,OP,,,,,,,,
UHC MCR ADV,CPT,Q0243,Casirivimab and imdevimab,Other,Straight Discount,29.70%,OP,,,,,,,,
UHC MCR ADV,CPT,Q0244,Casirivi and imdevi 1200 mg,Other,Straight Discount,29.70%,OP,,,,,,,,
UHC MCR ADV,CPT,Q0245,Bamlanivimab and etesevima,Other,Straight Discount,29.70%,OP,,,,,,,,
UHC MCR ADV,CPT,Q0247,Sotrovimab,Other,Straight Discount,29.70%,OP,,,,,,,,
UHC MCR ADV,CPT,Q0249,Tocilizumab for covid-19,Other,Straight Discount,29.70%,OP,,,,,,,,
UHC MCR ADV,CPT,Q0477,Pwr module pt cable lvad rpl,Durable Medical Equipment,Per Unit,$780.34 ,OP,780.34,780.34,,,,,,
UHC MCR ADV,CPT,Q0478,Power adapter- combo vad,Durable Medical Equipment,Per Unit,$184.82 ,OP,184.82,184.82,,,,,,
UHC MCR ADV,CPT,Q0479,Power module combo vad- rep,Durable Medical Equipment,Per Unit,"$12,073.17 ",OP,"12,073.17","12,073.17",,,,,,
UHC MCR ADV,CPT,Q0480,Driver pneumatic vad- rep,Durable Medical Equipment,Per Unit,"$90,585.51 ",OP,"90,585.51","311,531.29",,,,,,
UHC MCR ADV,CPT,Q0481,Microprcsr cu elec vad- rep,Durable Medical Equipment,Per Unit,"$14,614.95 ",OP,"14,614.95","50,262.72",,,,,,
UHC MCR ADV,CPT,Q0482,Microprcsr cu combo vad- rep,Durable Medical Equipment,Per Unit,"$4,577.67 ",OP,"4,577.67","15,742.60",,,,,,
UHC MCR ADV,CPT,Q0483,Monitor elec vad- rep,Durable Medical Equipment,Per Unit,"$18,857.93 ",OP,"18,857.93","64,853.90",,,,,,
UHC MCR ADV,CPT,Q0484,Monitor elec or comb vad rep,Durable Medical Equipment,Per Unit,"$3,662.14 ",OP,"3,662.14","12,593.32",,,,,,
UHC MCR ADV,CPT,Q0485,Monitor cable elec vad- rep,Durable Medical Equipment,Per Unit,$353.60 ,OP,353.6,"1,216.24",,,,,,
UHC MCR ADV,CPT,Q0486,Mon cable elec/pneum vad rep,Durable Medical Equipment,Per Unit,$294.28 ,OP,294.28,"1,010.37",,,,,,
UHC MCR ADV,CPT,Q0487,Leads any type vad- rep only,Durable Medical Equipment,Per Unit,$343.31 ,OP,343.31,"1,181.94",,,,,,
UHC MCR ADV,CPT,Q0489,Pwr pck base combo vad- rep,Durable Medical Equipment,Per Unit,"$16,348.80 ",OP,"16,348.80","56,225.77",,,,,,
UHC MCR ADV,CPT,Q0490,Emr pwr source elec vad- rep,Durable Medical Equipment,Per Unit,$707.17 ,OP,707.17,"2,432.50",,,,,,
UHC MCR ADV,CPT,Q0491,Emr pwr source combo vad rep,Durable Medical Equipment,Per Unit,"$1,111.75 ",OP,"1,111.75","3,824.13",,,,,,
UHC MCR ADV,CPT,Q0492,Emr pwr cbl elec vad- rep,Durable Medical Equipment,Per Unit,$89.58 ,OP,89.58,308.83,,,,,,
UHC MCR ADV,CPT,Q0493,Emr pwr cbl combo vad- rep,Durable Medical Equipment,Per Unit,$255.02 ,OP,255.02,876.92,,,,,,
UHC MCR ADV,CPT,Q0494,Emr hd pmp elec/combo- rep,Durable Medical Equipment,Per Unit,$215.79 ,OP,215.79,743.48,,,,,,
UHC MCR ADV,CPT,Q0495,Charger elec/combo vad- rep,Durable Medical Equipment,Per Unit,"$4,201.23 ",OP,"4,201.23","14,450.10",,,,,,
UHC MCR ADV,CPT,Q0496,Battery elec/combo vad- rep,Durable Medical Equipment,Per Unit,"$1,507.90 ",OP,"1,507.90","5,185.26",,,,,,
UHC MCR ADV,CPT,Q0497,Bat clps elec/comb vad- rep,Durable Medical Equipment,Per Unit,$470.84 ,OP,470.84,"1,620.40",,,,,,
UHC MCR ADV,CPT,Q0498,Holster elec/combo vad- rep,Durable Medical Equipment,Per Unit,$516.61 ,OP,516.61,"1,776.71",,,,,,
UHC MCR ADV,CPT,Q0499,Belt/vest elec/combo vad rep,Durable Medical Equipment,Per Unit,$167.86 ,OP,167.86,575.73,,,,,,
UHC MCR ADV,CPT,Q0500,Filters elec/combo vad- rep,Durable Medical Equipment,Per Unit,$30.69 ,OP,30.69,106.76,,,,,,
UHC MCR ADV,CPT,Q0501,Shwr cov elec/combo vad- rep,Durable Medical Equipment,Per Unit,$513.63 ,OP,513.63,"1,765.27",,,,,,
UHC MCR ADV,CPT,Q0502,Mobility cart pneum vad- rep,Durable Medical Equipment,Per Unit,$653.97 ,OP,653.97,"2,249.49",,,,,,
UHC MCR ADV,CPT,Q0503,Battery pneum vad replacemnt,Durable Medical Equipment,Per Unit,"$1,307.87 ",OP,"1,307.87","4,498.98",,,,,,
UHC MCR ADV,CPT,Q0504,Pwr adpt pneum vad- rep veh,Durable Medical Equipment,Per Unit,$690.16 ,OP,690.16,"2,375.30",,,,,,
UHC MCR ADV,CPT,Q0506,Lith-ion batt elec/pneum vad,Durable Medical Equipment,Per Unit,$859.04 ,OP,859.04,859.04,,,,,,
UHC MCR ADV,CPT,Q2017,Teniposide- 50 mg,APC 7035,Per Unit,"$2,645.71 ",OP,"1,582.28","2,645.71",,,,,,
UHC MCR ADV,CPT,Q2026,Radiesse injection,APC 9094,Per Unit,$257.37 ,OP,257.37,257.37,,,,,,
UHC MCR ADV,CPT,Q2028,Inj- sculptra- 0.5mg,APC 9095,Per Unit,$2.49 ,OP,2.49,2.49,,,,,,
UHC MCR ADV,CPT,Q2034,Agriflu vaccine,Other,Straight Discount,29.70%,OP,,,,,,,,
UHC MCR ADV,CPT,Q2035,Afluria vacc- 3 yrs & >- im,Other,Straight Discount,29.70%,OP,,,,,,,,
UHC MCR ADV,CPT,Q2036,Flulaval vacc- 3 yrs & >- im,Other,Straight Discount,29.70%,OP,,,,,,,,
UHC MCR ADV,CPT,Q2037,Fluvirin vacc- 3 yrs & >- im,Other,Straight Discount,29.70%,OP,,,,,,,,
UHC MCR ADV,CPT,Q2038,Fluzone vacc- 3 yrs & >- im,Other,Straight Discount,29.70%,OP,,,,,,,,
UHC MCR ADV,CPT,Q2039,Influenza virus vaccine- nos,Other,Straight Discount,29.70%,OP,,,,,,,,
UHC MCR ADV,CPT,Q2041,Axicabtagene ciloleucel car+,APC 9035,Per Unit,"$395,380.00 ",OP,"395,380.00","395,380.00",,,,,,
UHC MCR ADV,CPT,Q2042,Tisagenlecleucel car-pos t,APC 9194,Per Unit,"$434,337.60 ",OP,"434,337.60","434,337.60",,,,,,
UHC MCR ADV,CPT,Q2043,Sipuleucel-t auto cd54+,APC 9273,Per Unit,"$53,017.58 ",OP,"53,017.58","53,017.58",,,,,,
UHC MCR ADV,CPT,Q2049,Imported lipodox inj,APC 1421,Per Unit,$311.04 ,OP,311.04,311.04,,,,,,
UHC MCR ADV,CPT,Q2050,Doxorubicin inj 10mg,APC 7046,Per Unit,$234.03 ,OP,234.03,"1,719.01",,,,,,
UHC MCR ADV,CPT,Q2053,Brexucabtagene car pos t,APC 9391,Per Unit,"$395,380.00 ",OP,"395,380.00","395,380.00",,,,,,
UHC MCR ADV,CPT,Q2054,Lisocabtagene mara car pos t,APC 9413,Per Unit,"$422,609.00 ",OP,"422,609.00","422,609.00",,,,,,
UHC MCR ADV,CPT,Q3027,Inj beta interferon im 1 mcg,APC 1472,Per Unit,$55.29 ,OP,55.29,74.17,,,,,,
UHC MCR ADV,CPT,Q5101,Injection- zarxio,APC 1822,Per Unit,$0.32 ,OP,0.32,0.32,,,,,,
UHC MCR ADV,CPT,Q5103,Injection- inflectra,APC 1847,Per Unit,$41.19 ,OP,41.19,41.19,,,,,,
UHC MCR ADV,CPT,Q5104,Injection- renflexis,APC 9036,Per Unit,$38.79 ,OP,38.79,38.79,,,,,,
UHC MCR ADV,CPT,Q5106,Inj retacrit non-esrd use,APC 9097,Per Unit,$8.66 ,OP,8.66,8.66,,,,,,
UHC MCR ADV,CPT,Q5107,Inj mvasi 10 mg,APC 9329,Per Unit,$44.56 ,OP,44.56,44.56,,,,,,
UHC MCR ADV,CPT,Q5108,Injection- fulphila,APC 9173,Per Unit,$211.19 ,OP,211.19,211.19,,,,,,
UHC MCR ADV,CPT,Q5110,Nivestym,APC 9193,Per Unit,$0.33 ,OP,0.33,0.33,,,,,,
UHC MCR ADV,CPT,Q5111,Injection- udenyca 0.5 mg,APC 9195,Per Unit,$222.38 ,OP,222.38,222.38,,,,,,
UHC MCR ADV,CPT,Q5112,Inj ontruzant 10 mg,APC 9382,Per Unit,$66.55 ,OP,66.55,66.55,,,,,,
UHC MCR ADV,CPT,Q5113,Inj herzuma 10 mg,APC 9349,Per Unit,$57.30 ,OP,57.3,57.3,,,,,,
UHC MCR ADV,CPT,Q5114,Inj ogivri 10 mg,APC 9341,Per Unit,$59.91 ,OP,59.91,59.91,,,,,,
UHC MCR ADV,CPT,Q5115,Inj truxima 10 mg,APC 9336,Per Unit,$60.58 ,OP,60.58,60.58,,,,,,
UHC MCR ADV,CPT,Q5116,Inj.- trazimera- 10 mg,APC 9350,Per Unit,$59.93 ,OP,59.93,59.93,,,,,,
UHC MCR ADV,CPT,Q5117,Inj.- kanjinti- 10 mg,APC 9330,Per Unit,$53.18 ,OP,53.18,53.18,,,,,,
UHC MCR ADV,CPT,Q5118,Inj.- zirabev- 10 mg,APC 9348,Per Unit,$52.37 ,OP,52.37,52.37,,,,,,
UHC MCR ADV,CPT,Q5119,Inj ruxience- 10 mg,APC 9367,Per Unit,$58.80 ,OP,58.8,58.8,,,,,,
UHC MCR ADV,CPT,Q5120,Inj pegfilgrastim-bmez 0.5mg,APC 9345,Per Unit,$245.43 ,OP,245.43,245.43,,,,,,
UHC MCR ADV,CPT,Q5121,Inj. avsola- 10 mg,APC 9381,Per Unit,$47.12 ,OP,47.12,47.12,,,,,,
UHC MCR ADV,CPT,Q5122,Inj- nyvepria,APC 9406,Per Unit,$284.69 ,OP,284.69,284.69,,,,,,
UHC MCR ADV,CPT,Q5123,Inj. riabni- 10 mg,APC 9411,Per Unit,$72.23 ,OP,72.23,72.23,,,,,,
UHC MCR ADV,CPT,Q9968,Visualization adjunct,APC 1446,Per Unit,$6.73 ,OP,6.73,6.73,,,,,,
UHC MCR ADV,CPT,Q9969,Non-heu tc-99m add-on/dose,APC 1442,Per Unit,$10.00 ,OP,10,10,,,,,,
UHC MCR ADV,CPT,Q9991,Buprenorph xr 100 mg or less,APC 9073,Per Unit,"$1,796.80 ",OP,"1,796.80","1,796.80",,,,,,
UHC MCR ADV,CPT,Q9992,Buprenorphine xr over 100 mg,APC 9239,Per Unit,"$1,796.80 ",OP,"1,796.80","1,796.80",,,,,,
UHC MCR ADV,CPT,U0001,2019-ncov diagnostic p,Lab Services,Per Unit,$35.91 ,OP,35.91,35.91,,,,,,
UHC MCR ADV,CPT,U0002,Covid-19 lab test non-cdc,Lab Services,Per Unit,$51.31 ,OP,51.31,51.31,,,,,,
UHC MCR ADV,CPT,U0003,Cov-19 amp prb hgh thruput,Lab Services,Per Unit,$75.00 ,OP,75,75,,,,,,
UHC MCR ADV,CPT,U0004,Cov-19 test non-cdc hgh thru,Lab Services,Per Unit,$75.00 ,OP,75,75,,,,,,
UHC MCR ADV,CPT,U0005,Infec agen detec ampli probe,Lab Services,Per Unit,$25.00 ,OP,25,25,,,,,,
UHC MCR ADV,CPT,V2020,Vision svcs frames purchases,Durable Medical Equipment,Per Unit,$75.22 ,OP,75.22,388.89,,,,,,
UHC MCR ADV,CPT,V2100,Lens spher single plano 4.00,Durable Medical Equipment,Per Unit,$46.49 ,OP,46.49,240.2,,,,,,
UHC MCR ADV,CPT,V2101,Single visn sphere 4.12-7.00,Durable Medical Equipment,Per Unit,$44.67 ,OP,44.67,228.77,,,,,,
UHC MCR ADV,CPT,V2102,Singl visn sphere 7.12-20.00,Durable Medical Equipment,Per Unit,$77.24 ,OP,77.24,400.34,,,,,,
UHC MCR ADV,CPT,V2103,Spherocylindr 4.00d/12-2.00d,Durable Medical Equipment,Per Unit,$39.13 ,OP,39.13,202.07,,,,,,
UHC MCR ADV,CPT,V2104,Spherocylindr 4.00d/2.12-4d,Durable Medical Equipment,Per Unit,$40.34 ,OP,40.34,209.7,,,,,,
UHC MCR ADV,CPT,V2105,Spherocylinder 4.00d/4.25-6d,Durable Medical Equipment,Per Unit,$47.98 ,OP,47.98,247.83,,,,,,
UHC MCR ADV,CPT,V2106,Spherocylinder 4.00d/>6.00d,Durable Medical Equipment,Per Unit,$53.15 ,OP,53.15,274.51,,,,,,
UHC MCR ADV,CPT,V2107,Spherocylinder 4.25d/12-2d,Durable Medical Equipment,Per Unit,$47.33 ,OP,47.33,244.01,,,,,,
UHC MCR ADV,CPT,V2108,Spherocylinder 4.25d/2.12-4d,Durable Medical Equipment,Per Unit,$47.46 ,OP,47.46,244.01,,,,,,
UHC MCR ADV,CPT,V2109,Spherocylinder 4.25d/4.25-6d,Durable Medical Equipment,Per Unit,$66.10 ,OP,66.1,339.33,,,,,,
UHC MCR ADV,CPT,V2110,Spherocylinder 4.25d/over 6d,Durable Medical Equipment,Per Unit,$53.39 ,OP,53.39,274.51,,,,,,
UHC MCR ADV,CPT,V2111,Spherocylindr 7.25d/.25-2.25,Durable Medical Equipment,Per Unit,$64.70 ,OP,64.7,335.53,,,,,,
UHC MCR ADV,CPT,V2112,Spherocylindr 7.25d/2.25-4d,Durable Medical Equipment,Per Unit,$73.09 ,OP,73.09,377.46,,,,,,
UHC MCR ADV,CPT,V2113,Spherocylindr 7.25d/4.25-6d,Durable Medical Equipment,Per Unit,$73.91 ,OP,73.91,381.27,,,,,,
UHC MCR ADV,CPT,V2114,Spherocylinder over 12.00d,Durable Medical Equipment,Per Unit,$87.57 ,OP,87.57,453.71,,,,,,
UHC MCR ADV,CPT,V2115,Lens lenticular bifocal,Durable Medical Equipment,Per Unit,$88.27 ,OP,88.27,453.71,,,,,,
UHC MCR ADV,CPT,V2118,Lens aniseikonic single,Durable Medical Equipment,Per Unit,$96.05 ,OP,96.05,495.65,,,,,,
UHC MCR ADV,CPT,V2121,Lenticular lens- single,Durable Medical Equipment,Per Unit,$86.61 ,OP,86.61,446.08,,,,,,
UHC MCR ADV,CPT,V2200,Lens spher bifoc plano 4.00d,Durable Medical Equipment,Per Unit,$52.35 ,OP,52.35,270.71,,,,,,
UHC MCR ADV,CPT,V2201,Lens sphere bifocal 4.12-7.0,Durable Medical Equipment,Per Unit,$56.09 ,OP,56.09,289.76,,,,,,
UHC MCR ADV,CPT,V2202,Lens sphere bifocal 7.12-20.,Durable Medical Equipment,Per Unit,$69.53 ,OP,69.53,358.39,,,,,,
UHC MCR ADV,CPT,V2203,Lens sphcyl bifocal 4.00d/.1,Durable Medical Equipment,Per Unit,$53.92 ,OP,53.92,278.32,,,,,,
UHC MCR ADV,CPT,V2204,Lens sphcy bifocal 4.00d/2.1,Durable Medical Equipment,Per Unit,$55.48 ,OP,55.48,285.96,,,,,,
UHC MCR ADV,CPT,V2205,Lens sphcy bifocal 4.00d/4.2,Durable Medical Equipment,Per Unit,$61.51 ,OP,61.51,316.46,,,,,,
UHC MCR ADV,CPT,V2206,Lens sphcy bifocal 4.00d/ove,Durable Medical Equipment,Per Unit,$72.21 ,OP,72.21,373.65,,,,,,
UHC MCR ADV,CPT,V2207,Lens sphcy bifocal 4.25-7d/.,Durable Medical Equipment,Per Unit,$61.03 ,OP,61.03,316.46,,,,,,
UHC MCR ADV,CPT,V2208,Lens sphcy bifocal 4.25-7/2.,Durable Medical Equipment,Per Unit,$59.97 ,OP,59.97,308.83,,,,,,
UHC MCR ADV,CPT,V2209,Lens sphcy bifocal 4.25-7/4.,Durable Medical Equipment,Per Unit,$70.40 ,OP,70.4,362.21,,,,,,
UHC MCR ADV,CPT,V2210,Lens sphcy bifocal 4.25-7/ov,Durable Medical Equipment,Per Unit,$75.86 ,OP,75.86,392.7,,,,,,
UHC MCR ADV,CPT,V2211,Lens sphcy bifo 7.25-12/.25-,Durable Medical Equipment,Per Unit,$73.85 ,OP,73.85,381.27,,,,,,
UHC MCR ADV,CPT,V2212,Lens sphcyl bifo 7.25-12/2.2,Durable Medical Equipment,Per Unit,$77.30 ,OP,77.3,400.34,,,,,,
UHC MCR ADV,CPT,V2213,Lens sphcyl bifo 7.25-12/4.2,Durable Medical Equipment,Per Unit,$81.28 ,OP,81.28,419.4,,,,,,
UHC MCR ADV,CPT,V2214,Lens sphcyl bifocal over 12.,Durable Medical Equipment,Per Unit,$84.95 ,OP,84.95,438.47,,,,,,
UHC MCR ADV,CPT,V2215,Lens lenticular bifocal,Durable Medical Equipment,Per Unit,$106.06 ,OP,106.06,549.03,,,,,,
UHC MCR ADV,CPT,V2218,Lens aniseikonic bifocal,Durable Medical Equipment,Per Unit,$108.09 ,OP,108.09,556.65,,,,,,
UHC MCR ADV,CPT,V2219,Lens bifocal seg width over,Durable Medical Equipment,Per Unit,$49.86 ,OP,49.86,255.45,,,,,,
UHC MCR ADV,CPT,V2220,Lens bifocal add over 3.25d,Durable Medical Equipment,Per Unit,$44.28 ,OP,44.28,228.77,,,,,,
UHC MCR ADV,CPT,V2221,Lenticular lens- bifocal,Durable Medical Equipment,Per Unit,$88.33 ,OP,88.33,457.52,,,,,,
UHC MCR ADV,CPT,V2300,Lens sphere trifocal 4.00d,Durable Medical Equipment,Per Unit,$71.57 ,OP,71.57,369.83,,,,,,
UHC MCR ADV,CPT,V2301,Lens sphere trifocal 4.12-7.,Durable Medical Equipment,Per Unit,$87.77 ,OP,87.77,453.71,,,,,,
UHC MCR ADV,CPT,V2302,Lens sphere trifocal 7.12-20,Durable Medical Equipment,Per Unit,$82.00 ,OP,82,423.22,,,,,,
UHC MCR ADV,CPT,V2303,Lens sphcy trifocal 4.0/.12-,Durable Medical Equipment,Per Unit,$68.89 ,OP,68.89,354.58,,,,,,
UHC MCR ADV,CPT,V2304,Lens sphcy trifocal 4.0/2.25,Durable Medical Equipment,Per Unit,$69.70 ,OP,69.7,358.39,,,,,,
UHC MCR ADV,CPT,V2305,Lens sphcy trifocal 4.0/4.25,Durable Medical Equipment,Per Unit,$77.86 ,OP,77.86,400.34,,,,,,
UHC MCR ADV,CPT,V2306,Lens sphcyl trifocal 4.00/>6,Durable Medical Equipment,Per Unit,$80.17 ,OP,80.17,411.78,,,,,,
UHC MCR ADV,CPT,V2307,Lens sphcy trifocal 4.25-7/.,Durable Medical Equipment,Per Unit,$76.33 ,OP,76.33,392.7,,,,,,
UHC MCR ADV,CPT,V2308,Lens sphc trifocal 4.25-7/2.,Durable Medical Equipment,Per Unit,$83.26 ,OP,83.26,430.83,,,,,,
UHC MCR ADV,CPT,V2309,Lens sphc trifocal 4.25-7/4.,Durable Medical Equipment,Per Unit,$87.13 ,OP,87.13,449.9,,,,,,
UHC MCR ADV,CPT,V2310,Lens sphc trifocal 4.25-7/>6,Durable Medical Equipment,Per Unit,$91.01 ,OP,91.01,468.96,,,,,,
UHC MCR ADV,CPT,V2311,Lens sphc trifo 7.25-12/.25-,Durable Medical Equipment,Per Unit,$105.08 ,OP,105.08,541.4,,,,,,
UHC MCR ADV,CPT,V2312,Lens sphc trifo 7.25-12/2.25,Durable Medical Equipment,Per Unit,$96.32 ,OP,96.32,495.65,,,,,,
UHC MCR ADV,CPT,V2313,Lens sphc trifo 7.25-12/4.25,Durable Medical Equipment,Per Unit,$105.15 ,OP,105.15,541.4,,,,,,
UHC MCR ADV,CPT,V2314,Lens sphcyl trifocal over 12,Durable Medical Equipment,Per Unit,$107.48 ,OP,107.48,552.84,,,,,,
UHC MCR ADV,CPT,V2315,Lens lenticular trifocal,Durable Medical Equipment,Per Unit,$119.32 ,OP,119.32,613.85,,,,,,
UHC MCR ADV,CPT,V2318,Lens aniseikonic trifocal,Durable Medical Equipment,Per Unit,$146.68 ,OP,146.68,754.91,,,,,,
UHC MCR ADV,CPT,V2319,Lens trifocal seg width > 28,Durable Medical Equipment,Per Unit,$66.22 ,OP,66.22,343.14,,,,,,
UHC MCR ADV,CPT,V2320,Lens trifocal add over 3.25d,Durable Medical Equipment,Per Unit,$69.85 ,OP,69.85,362.21,,,,,,
UHC MCR ADV,CPT,V2321,Lenticular lens- trifocal,Durable Medical Equipment,Per Unit,$117.61 ,OP,117.61,606.21,,,,,,
UHC MCR ADV,CPT,V2410,Lens variab asphericity sing,Durable Medical Equipment,Per Unit,$102.83 ,OP,102.83,529.96,,,,,,
UHC MCR ADV,CPT,V2430,Lens variable asphericity bi,Durable Medical Equipment,Per Unit,$108.84 ,OP,108.84,560.47,,,,,,
UHC MCR ADV,CPT,V2500,Contact lens pmma spherical,Durable Medical Equipment,Per Unit,$92.01 ,OP,92.01,92.01,,,,,,
UHC MCR ADV,CPT,V2501,Cntct lens pmma-toric/prism,Durable Medical Equipment,Per Unit,$130.56 ,OP,130.56,674.85,,,,,,
UHC MCR ADV,CPT,V2502,Contact lens pmma bifocal,Durable Medical Equipment,Per Unit,$176.91 ,OP,176.91,911.23,,,,,,
UHC MCR ADV,CPT,V2503,Cntct lens pmma color vision,Durable Medical Equipment,Per Unit,$170.87 ,OP,170.87,880.74,,,,,,
UHC MCR ADV,CPT,V2510,Cntct gas permeable sphericl,Durable Medical Equipment,Per Unit,$122.68 ,OP,122.68,632.91,,,,,,
UHC MCR ADV,CPT,V2511,Cntct toric prism ballast,Durable Medical Equipment,Per Unit,$181.84 ,OP,181.84,937.93,,,,,,
UHC MCR ADV,CPT,V2512,Cntct lens gas permbl bifocl,Durable Medical Equipment,Per Unit,$209.31 ,OP,209.31,"1,078.99",,,,,,
UHC MCR ADV,CPT,V2513,Contact lens extended wear,Durable Medical Equipment,Per Unit,$210.87 ,OP,210.87,"1,086.62",,,,,,
UHC MCR ADV,CPT,V2520,Contact lens hydrophilic,Durable Medical Equipment,Per Unit,$122.25 ,OP,122.25,629.1,,,,,,
UHC MCR ADV,CPT,V2521,Cntct lens hydrophilic toric,Durable Medical Equipment,Per Unit,$242.09 ,OP,242.09,"1,250.57",,,,,,
UHC MCR ADV,CPT,V2522,Cntct lens hydrophil bifocl,Durable Medical Equipment,Per Unit,$177.16 ,OP,177.16,915.04,,,,,,
UHC MCR ADV,CPT,V2523,Cntct lens hydrophil extend,Durable Medical Equipment,Per Unit,$186.00 ,OP,186,960.8,,,,,,
UHC MCR ADV,CPT,V2530,Contact lens gas impermeable,Durable Medical Equipment,Per Unit,$297.37 ,OP,297.37,"1,532.70",,,,,,
UHC MCR ADV,CPT,V2531,Contact lens gas permeable,Durable Medical Equipment,Per Unit,$544.58 ,OP,544.58,"2,809.96",,,,,,
UHC MCR ADV,CPT,V2623,Plastic eye prosth custom,Durable Medical Equipment,Per Unit,$942.94 ,OP,942.94,"4,864.99",,,,,,
UHC MCR ADV,CPT,V2624,Polishing artifical eye,Durable Medical Equipment,Per Unit,$60.88 ,OP,60.88,312.64,,,,,,
UHC MCR ADV,CPT,V2625,Enlargemnt of eye prosthesis,Durable Medical Equipment,Per Unit,$482.12 ,OP,482.12,"2,485.87",,,,,,
UHC MCR ADV,CPT,V2626,Reduction of eye prosthesis,Durable Medical Equipment,Per Unit,$199.51 ,OP,199.51,"1,029.43",,,,,,
UHC MCR ADV,CPT,V2627,Scleral cover shell,Durable Medical Equipment,Per Unit,"$1,430.28 ",OP,"1,430.28","7,377.56",,,,,,
UHC MCR ADV,CPT,V2628,Fabrication & fitting,Durable Medical Equipment,Per Unit,$304.24 ,OP,304.24,"1,570.83",,,,,,
UHC MCR ADV,CPT,V2700,Balance lens,Durable Medical Equipment,Per Unit,$44.84 ,OP,44.84,232.58,,,,,,
UHC MCR ADV,CPT,V2710,Glass/plastic slab off prism,Durable Medical Equipment,Per Unit,$73.51 ,OP,73.51,377.46,,,,,,
UHC MCR ADV,CPT,V2715,Prism lens/es,Durable Medical Equipment,Per Unit,$14.41 ,OP,14.41,72.44,,,,,,
UHC MCR ADV,CPT,V2718,Fresnell prism press-on lens,Durable Medical Equipment,Per Unit,$31.12 ,OP,31.12,160.13,,,,,,
UHC MCR ADV,CPT,V2730,Special base curve,Durable Medical Equipment,Per Unit,$26.06 ,OP,26.06,133.45,,,,,,
UHC MCR ADV,CPT,V2744,Tint photochromatic lens/es,Durable Medical Equipment,Per Unit,$17.83 ,OP,17.83,91.51,,,,,,
UHC MCR ADV,CPT,V2745,Tint- any color/solid/grad,Durable Medical Equipment,Per Unit,$10.27 ,OP,10.27,53.38,,,,,,
UHC MCR ADV,CPT,V2750,Anti-reflective coating,Durable Medical Equipment,Per Unit,$20.02 ,OP,20.02,102.95,,,,,,
UHC MCR ADV,CPT,V2755,Uv lens/es,Durable Medical Equipment,Per Unit,$16.76 ,OP,16.76,87.69,,,,,,
UHC MCR ADV,CPT,V2770,Occluder lens/es,Durable Medical Equipment,Per Unit,$19.52 ,OP,19.52,99.13,,,,,,
UHC MCR ADV,CPT,V2780,Oversize lens/es,Durable Medical Equipment,Per Unit,$12.53 ,OP,12.53,64.82,,,,,,
UHC MCR ADV,CPT,V2782,Lens- 1.54-1.65 p/1.60-1.79g,Durable Medical Equipment,Per Unit,$64.75 ,OP,64.75,335.53,,,,,,
UHC MCR ADV,CPT,V2783,Lens- >= 1.66 p/>=1.80 g,Durable Medical Equipment,Per Unit,$73.02 ,OP,73.02,377.46,,,,,,
UHC MCR ADV,CPT,V2784,Lens polycarb or equal,Durable Medical Equipment,Per Unit,$47.48 ,OP,47.48,244.01,,,,,,
UHC MCR ADV,CPT,V2785,Corneal tissue processing,Other,Straight Discount,29.70%,OP,,,,,,,,